Fidelis Care 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN H3328_FC 15054 CMS Accepted 00016378. Version 2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. This document includes the list of the drugs (formulary) for our plan which is current as of 01/01/2016. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year. Fidelis Care is an HMO plan with a Medicare contract. Enrollment in Fidelis Care depends on contract renewal. Fidelis Care is a Coordinated Care plan with a Medicare contract and a contract with the New York State Department of Health Medicaid program. Enrollment in Fidelis Care depends on contract renewal. This information is available for free in other languages. Please contact our Member Services number at 1-800-247-1447 for additional information. (TTY users should call 1-800-695-8544). Hours are 8:00 a.m. to 8:00 p.m. seven days a week from October 1 to February 14, and Monday through Friday, 8:00 a.m. to 8:00 p.m. from February 15 through September 30. Member Services also has free language interpreter services available for non-English speakers. Esta información está disponible de forma gratuita en otros idiomas. Por favor comuníquese con nuestro número de Servicios al Socio al 1-800-247-1447 para obtener información adicional. Los usuarios con deficiencia auditiva (TTY) deberán llamar al 1-800-695-8544. El horario de atención es de 8:00 a.m. a 8:00 p.m. los siete días de la semana desde el 1 de octubre hasta el 14 de febrero, y de lunes a viernes, de 8:a.m. hasta las 8:00 p.m. desde el 15 de febrero hasta el 30 de septiembre. Servicios al Socio también tiene servicios gratuitos de intérprete disponibles para personas que no hablan inglés. 1 What is the Fidelis Care Formulary? A formulary is a list of covered drugs selected by Fidelis Care in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Fidelis Care will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Fidelis Care network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 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 ava ilable when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enc losed formulary is current as of 01/01/2016. To get updated information about the drugs covered by Fidelis Care, please contact us. Our contact information appears on the front and back cover pages. To get updated information about the drugs covered by Fidelis Care, please visit our Web site at www.fideliscare.org or call Member Services at 1-800-247-1447. Hours are 8:00 a.m. to 8:00 p.m. seven days a week from October 1 to February 14, and Monday through Friday, 8:00 a.m. to 8:00 p.m. from February 15 through September 30. TTY/TDD users should call 1-800-695-8544. We will mail you updated information about our formulary in the event that there are mid-year non-maintenance formulary changes. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 12. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular”. If you know what your drug is used for, look for the category name in the list that begins on page number 12. Then look under the category name for your drug. 2 Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 76. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Fidelis Care covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Fidelis Care requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Fidelis Care before you fill your prescriptions. If you don’t get approval, Fidelis Care may not cover the drug. Quantity Limits: For certain drugs, Fidelis Care limits the amount of the drug that Fidelis Care will cover. For example, Fidelis Care provides 30 pills per prescription for ROZEREM. This may be in addition to a standard one-month or three-month supply. Step The rapy: In some cases, Fidelis Care requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Fidelis Care may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Fidelis Care will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 12. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line a document that explains our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Fidelis Care to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Fidelis Care’s formulary?” on page 4 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that Fidelis Care does not cover your drug, you have two options: 3 You can ask Member Services for a list of similar drugs that are covered by Fidelis Care. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Fidelis Care. You can ask Fidelis Care to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Fidelis Care’s Formulary? You can ask Fidelis Care to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred brand or specialty tier you can ask us to cover it at the cost-sharing amount that applies to drugs in our preferred brand tier. If your drug is in our non-preferred generic tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in our preferred generic tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Fidelis Care limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Fidelis Care will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary exception. When you request a formulary exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. 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 yo ur drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when 4 you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 34-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. For more information For more detailed information about your Fidelis Care prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Fidelis Care, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov. Fidelis Care’s Formulary The formulary below provides coverage information about the drugs covered by Fidelis Care. If you have trouble finding your drug in the list, turn to the Index that begins on page 76. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., BICILLIN) and generic drugs are listed in lower-case italics (e.g., ampicillin). The information in the Requirements/Limits column tells you if Fidelis Care has any special requirements for coverage of your drug. For example, “PA” means prior authorization is required. (This means that you will need to get approval from Fidelis Care before you fill your prescriptions); "ST" means that step therapy is required. (This means you may be required to try certain drugs for your medical condition before we will cover another drug for that condition); “QL” means that quantity limits apply (Fidelis Care limits the amount of the drug that Fidelis Care will cover); “B/D” means that the drug is covered under Part B and Part D of Medicare (Fidelis Care will determine whether a particular prescription is covered under Part B or Part D). 5 Fidelis Care Formulario 2016 (Lista de medicamentos cubiertos) POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN H3328_FC 15054_SP CMS Aceptado 00016378. Version 2 Nota para socios actuales: Hubo cambios en este formulario durante el último año. Lea este documento para asegurarse de que siga conteniendo los medicamentos que toma. Este documento incluye la lista de los medicamentos (formulario) para nuestro plan, que está vigente al 1 de enero del 2016. Para obtener un formulario actualizado, por favor póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, aparecen en la portada y contraportada. Usted generalmente debe utilizar farmacias de la red para utilizar su beneficio de medicamentos con receta médica. Los beneficios, la lista de medicamentos, la red farmacéutica, y/o los copagos/coaseguros pueden variar el 1 de enero de 2016, y de vez en cuando durante el año. Fidelis Care es un plan HMO con un contrato de Medicare. La inscripción en Fidelis Care depende de la renovación del contrato. Fidelis Care es un plan de Cuidado Coordinado con un contrato de Medicare y un contrato con el programa del Departamento de Salud de Medicaid del Estado de Nueva York. La inscripción en Fidelis Care depende de la renovación del contrato. Esta información está disponible de forma gratuita en otros idiomas. Por favor comuníquese con nuestro número de Servicios al Socio al 1-800-247-1447 para obtener información adicional. (Los usuarios de TTY deben llamar al 1-800-695-8544). El horario de atención es de 8:00 a.m. a 8:00 p.m. los siete días de la semana desde el 1 de octubre hasta el 14 de febrero, y de lunes a viernes, de 8:00 a.m. a 8:00 p.m. desde el 15 de febrero hasta el 30 de septiembre. Servicios al Socio también tiene servicios gratuitos de intérprete disponibles para personas que no hablan inglés. This information is available for free in other languages. Please contact our Member Services number at 1-800-247-1447 for additional information. (TTY users should call 1-800-695-8544). Hours are 8:00 a.m. to 8:00 p.m. seven days a week from October 1 to February 14, and Monday through Friday, 8:00 a.m. to 8:00 p.m. from February 15 through September 30. Member Services also has free language interpreter services available for non-English speakers. 6 ¿Qué es el formulario de Fidelis Care? Un formulario es una lista de medicamentos cubiertos seleccionados por Fidelis Care con el asesoramiento de un equipo de proveedores de cuidados de la salud, la cual representa las terapias con medicamentos recetados consideradas una parte necesaria de un programa de tratamiento de calidad. Fidelis Care cubrirá, generalmente, los medicamentos incluidos en nuestro formulario, siempre y cuando el medicamento sea médicamente necesario, la receta se surta en una farmacia de la red de Fidelis Care y se cumplan otras reglas del plan. Para obtener más información sobre cómo surtir sus recetas, lea su Comprobante de cobertura. ¿Puede cambiar el formulario? En general, si está tomando un medicamento incluido en nuestro formulario 2016 que estaba cubierto a principio de año, no discontinuaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2016, salvo cuando haya un nuevo medicamento genérico menos costoso disponible o cuando se haya publicado nueva información adversa sobre la seguridad o efectividad de un medicamento. Otro tipo de cambios de formulario, tales como quitar un medicamento de nuestro formulario, no afectará a los socios que actualmente estén tomando el medicamento. Seguirá disponible con el mismo costo compartido para los socios que estén tomando tal medicamento durante el resto del año de cobertura. Creemos que es importante que tenga un acceso continuado durante el resto del año de cobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, salvo en situaciones en las que pueda ahorrar dinero adicional o en caso de que nosotros podamos afianzar su seguridad. Si quitamos medicamentos de nuestro formulario, o, con autorización previa, aumentamos los límites de cantidades y/o hacemos restricciones a terapias escalonadas sobre un medicamento o pasamos un medicamento a un nivel mayor de costos compartidos, debemos notificar del cambio a los socios afectados, al menos, 60 días antes de que el cambio entre en vigencia o al momento en que el socio solicite un nuevo surtido del medicamento, momento en el cual el socio recibirá un suministro del medicamento para 60 días. Si la Administración de Alimentos y Medicamentos (Food and Drug Administration, FDA) considera que un medicamento que está en nuestro formulario es inseguro o si el fabricante del medicamento retira el medicamento del mercado, inmediatamente retiraremos el medicamento de nuestro formulario y daremos aviso a los socios que toman dicho medicamento. El formulario adjunto está vigente desde el 01/01/2016. Para recibir información actualizada sobre los medicamentos con cobertura de Fidelis Care, visite nuestro sitio web en www.fideliscare.org o llame a Servicios al Socio al 1-800-247-1447. El horario de atención es de 8:00 a.m. a 8:00 p.m. los siete días de la semana desde el 1 de octubre hasta el 14 de febrero, y de lunes a viernes, de 8:00 a.m. a 8:00 p.m. desde el 15 de febrero hasta el 30 de septiembre. Los usuarios de TTY/TDD deben llamar al 1-800-695-8544. Le enviaremos por correo información actualizada sobre nuestro formulario en caso de que haya cambios a mitad de año en el formulario, no vinculados con el mantenimiento. ¿Cómo uso el formulario? 7 Hay dos maneras de encontrar un medicamento en el formulario: Afección médica El formulario comienza a partir de la página 12. Los medicamentos del formulario están agrupados en categorías que dependen del tipo de afección médica para cuyo tratamiento se utilizan. Por ejemplo, los medicamentos usados para tratar una afección cardiac a se enumeran en la categoría Cardiovascular. Si sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que comienza en la página número 12. Después, busque su medicamento en el nombre de la categoría. Listado alfabético Si no está seguro(a) en qué categoría buscar, debe buscar su medicamento en el índice que empieza en la página 76. El índice proporciona un listado alfabético de todos los medicamentos incluidos en este documento. En el Índice, se incluyen los medicamentos de marca y los medicamentos genéricos. Busque en el índice para encontrar su medicamento. Al lado del medicamento, verá el número de página donde puede encontrar la información de cobertura. Vaya a la página indicada en el índice y busque el nombre de su medicamento en la primera columna de la lista. ¿Qué son los medicamentos genéricos? Fidelis Care cubre tanto medicamentos de marca como medicamentos genéricos. Un medicamento genérico está aprobado por la FDA cuando tiene el mismo ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos cuestan menos que los de marca. ¿Hay alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites en la cobertura. Entre los requisitos y límites se pueden incluir: Autorización previa: Fidelis Care le exige (o su médico) que obtenga autorización previa para determinados medicamentos. Esto significa que usted deberá tener la autorización previa de Fidelis Care para surtir sus recetas. Si usted no tiene la aprobación, Fidelis Care no podrá cubrir el medicamento. Límites en la cantidad: en el caso de determinados medicamentos, Fidelis Care limita la cantidad de medicamento que cubrirá. Por ejemplo, Fidelis Care proporciona 30 pastillas por receta para ROZEREM. Esto puede proporcionarse además de un suministro estándar de uno o tres meses. Terapia escalonada: en algunos casos, Fidelis Care exige que usted primero pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa condición. Por ejemplo, si un Medicamento A y también un Medicamento B tratan su afección médica, Fidelis Care quizás no cubra el Medicamento B a menos que usted primero trate el Medicamento A. Si el Medicamento A no funciona en su caso, Fidelis Care cubrirá entonces el Medicamento B. 8 Puede averiguar si su medicamento tiene algún requisito adicional o límites consultando el formulario que comienza en la página 12. También puede obtener más información sobre las restricciones aplicadas a determinados medicamentos cubiertos a través de nuestro sitio web. Hemos publicado en línea un documento que explica nuestras restricciones de autorización previa y terapia escalonada. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha en que actualizamos por ultima vez el formulario, aparecen en la portada y contraportada. Puede pedirle a Fidelis Care que haga una excepción a estas restricciones o límites. Consulte la sección “¿Cómo solicito una excepción al formulario de Fidelis Care?” en la página para obtener más información sobre cómo solicitar una excepción. ¿Qué sucede en caso de que mi medicamento no esté en el formulario? Si su medicamento no está incluido en este formulario, primero deberá contactarse con Servicios al Socio y preguntar si su medicamento no tiene cobertura. Si se entera de que Fidelis Care no cubre su medicamento, tiene dos opciones: Puede pedirle a Servicios al Socio una lista de medicamentos similares que estén cubiertos por Fidelis Care. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por Fidelis Care. Puede pedirle a Fidelis Care que haga una excepción y que cubra el medicamento. Consulte la información a continuación para saber cómo solicitar una excepción. ¿Cómo solicito una excepción al formulario de Fidelis Care? Puede pedirle a Fidelis Care que haga una excepción a nuestras reglas de cobertura. Hay varios tipos de excepciones que puede solicitarnos. Puede pedirnos que cubramos un medicamento aunque no esté en nuestro formulario. Puede pedirnos que desestimemos las restricciones o límites de cobertura que aplican a su medicamento. Por ejemplo, en el caso de determinados medicamentos, Fidelis Care limita la cantidad de medicamento que cubrirá. Si su medicamento tiene un límite de cantidad, puede pedirnos que no consideremos el límite y que cubramos una mayor cantidad. Puede pedirnos que le brindemos un nivel mayor de cobertura en su medicamento. Si su medicamento está incluido en nuestro nivel de medicamentos de marca no preferida o de especialidades, puede pedirnos que lo cubramos según el monto de costo compartido que aplica a los medicamentos que están en el nivel de medicamentos de marca preferida. Si su medicamento está incluido en el nivel de medicamentos de marca no preferida, puede pedirnos que lo cubramos según el monto de costo compartido que aplica a los medicamentos que están en el nivel de medicamentos genéricos preferidos. Esto reduciría el monto que debe pagar por el medicamento. Tenga en cuenta que si aceptamos su solicitud de cubrir un medicamento que no está en el formulario, no podrá pedirnos un mayor nivel de cobertura para el medicamento. En general, Fidelis Care sólo aprobará su solicitud de hacer una excepción si el medicamento alternativo está incluido en el formulario del plan, si es un medicamento del nivel más bajo o si las 9 restricciones de utilización adicionales no resultaran tan efectivas para tratar su afección y/o le provocaran efectos médicos adversos. Deberá comunicarse con nosotros para solicitar una excepción a una decisión de cobertura inicial con respecto al formulario. Cuando vaya a solicitar una excepción al formulario, deberá presentar una declaración de su médico para avalar la solicitud. En general, debemos tomar una decisión en un plazo de 72 horas después de recibir la declaración de aval del médico o persona que emitió la receta. Puede solicitar una excepción urgente (rápida) si usted o su médico creen que su salud podría verse gravemente afectada por esperar 72 horas para recibir una decisión. Si aceptamos acelerar el trámite tal como lo solicitara usted, debemos tomar una decisión en no más de 24 horas después de que recibamos la declaración de aval del médico o persona que emitió la receta. ¿Qué hago antes de hablar con mi médico acerca de cambiar el medicamento que tomo o solicitar una excepción? Ya sea si usted es un nuevo socio o un socio actual de nuestro plan, puede que esté tomando medicamentos que no estén en nuestro formulario. O puede que esté tomando un medicamento que está en nuestro formulario, pero su capacidad de obtenerlo es limitada. Por ejemplo, puede que necesite una autorización previa nuestra antes de poder surtir su receta. Deberá hablar con su médico para decidir si debería pasar a tomar otro medicamento adecuado que esté cubierto por nosotros o solicitar una excepción al formulario para que cubramos el medicamento que toma. Mientras habla con su médico para determinar la acción adecuada para usted, podemos cubrir su medicamento en determinados casos durante los primeros 90 días de su membresía en nuestro plan. Para cada uno de sus medicamentos que no esté en nuestro formulario o si su capacidad de obtener sus medicamentos es limitada, cubriremos temporalmente un suministro de 30 días (a menos que tenga una receta escrita por menos días) cuando vaya a una farmacia de la red. Después de su primer suministro de 30 días, no pagaremos estos medicamentos, aunque sea socio del plan desde hace menos de 90 días. Si usted reside en un centro de cuidados a largo plazo, le permitiremos surtir su receta hasta que le hayamos brindado un suministro de transición para 93 días, consistente con el incremento de la entrega, (a menos que tenga una receta escrita por menos días). Cubriremos más de un surtido de estos medicamentos durante los primeros 90 días de su membresía en el plan. Si necesita un medicamento que no está en nuestro formulario o si su capacidad de obtener sus medicamentos es limitada, pero hace más de 90 días es socio del plan, cubriremos un suministro de emergencia por 34 días para dicho medicamento (a menos que tenga una receta por menos días) mientras intenta conseguir una excepción al formulario. Para mayor información Para obtener información más detallada sobre la cobertura de medicamentos con receta de Fidelis Care, consulte su Comprobante de cobertura y otros materiales del plan. Si tiene preguntas sobre Fidelis Care, por favor llame a Servicios al Socio al 1-800-247-1447, el horario de atención es de 8:00 a.m. a 8:00 p.m. los siete días de la semana desde el 1 de octubre hasta el 14 de febrero, y de lunes a viernes, de 8:00 a.m. a 8:00 p.m. desde el 15 de febrero hasta el 30 de septiembre. Los usuarios de TTY/TDD deben llamar al 1-800-695-8544. O visitar www.fideliscare.org. Si tiene consultas generales sobre la cobertura de medicamentos con receta médica de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227) las 24 horas del día/los 7 días de la 10 semana. Los usuarios de TTY/TDD deben llamar al 1-877-486-2048. O visítenos en http://www.medicare.gov. Formulario de Fidelis Care El formulario a continuación proporciona información de la cobertura sobre algunos medicamentos cubiertos por Fidelis Care. Si le resulta difícil encontrar su medicamento en la lista, pase al Índice que comienza en la página 76. La primera columna del cuadro enumera los nombres de los medicamentos. Los medicamentos de marca están en mayúscula (por ej., BICILLIN) y los medicamentos genéricos están en minúscula y cursiva (por ej., ampicilina). La información que se encuentra en la columna Requisitos/Límites indica si Fidelis Care tiene algún requisito especial de cobertura para el medicamento. Por ejemplo, “PA” significa que se requiere autorización previa. (Esto significa que deberá obtener la aprobación de Fidelis Care antes de que pueda surtir las recetas); “ST” significa que se exige terapia escalonada. (Esto significa que le pueden solicitar que intente con ciertos medicamentos para su afección médica antes de que cubramos otro medicamento para esa condición); “QL” significa que se aplican límites de cantidad (Fidelis Care limita la cantidad de medicamento que Fidelis Care cubrirá); “B/D” significa que el medicamento tiene cobertura de Parte B y Parte D de Medicare (Fidelis Care determinará si una receta en particular tiene cobertura de Parte B o Parte D). 11 BG_CY16_5T_PERFORMANCE eff 01/01/2016 Drug Name Drug Tier Requirements/Limits ANALGESICS GOUT allopurinol tab ALOPRIM colchicine w/ probenecid COLCRYS probenecid ULORIC MISCELLANEOUS diclofenac w/ misoprostol DUEXIS VIMOVO NSAIDS celecoxib CAPS diclofenac potassium diclofenac sodium TB24; TBEC diflunisal etodolac etodolac er fenoprofen calcium TABS flurbiprofen TABS ibuprofen SUSP ibuprofen TABS 400mg, 600mg, 800mg ketoprofen CAPS; CP24 mefenamic acid CAPS MELOXICAM SUSP meloxicam tabs nabumetone TABS NAPRELAN 375mg, 750mg naproxen SUSP naproxen TABS; TBEC naproxen sodium TABS 275mg, 550mg naproxen sodium TB24 375mg NAPROXEN SODIUM TB24 500mg oxaprozin piroxicam CAPS sulindac TABS tolmetin sodium ZIPSOR ZORVOLEX OPIOID ANALGESICS acetaminophen w/ codeine SOLN acetaminophen w/ codeine TABS acetaminophen-caff-dihydrocod 1 4 2 3 2 3 QL (120 tabs / 30 days) ST 2 5 5 2 2 2 2 2 2 2 2 2 1 2 2 2 1 2 5 2 1 1 5 5 2 2 1 2 4 4 2 2 2 QL (5000 mL / 30 days) QL (400 tabs / 30 days) QL (360 caps / 30 days) 12 Drug Name Drug Tier Requirements/Limits ASPIRIN-CAFFEINE-DIHYDROCODEINE CAP2 QL (360 caps / 30 days) 356.4-30-16 MG butorphanol nasal spray 2 QL (10 mL / 30 days) butorphanol tartrate SOLN 2 BUTRANS 5mcg/hr 3 QL (16 patches / 28 days) BUTRANS 7.5mcg/hr, 10mcg/hr 3 QL (8 patches / 28 days) BUTRANS 15mcg/hr, 20mcg/hr 3 QL (4 patches / 28 days) capital and codeine 4 QL (5000 mL / 30 days) CONZIP 100mg 4 QL (90 caps / 30 days) CONZIP 200mg 4 QL (60 caps / 30 days) CONZIP 300mg 4 QL (30 caps / 30 days) nalbuphine hcl SOLN 2 TRAMADOL HCL CP24 100mg 2 QL (90 caps / 30 days) TRAMADOL HCL CP24 200mg 2 QL (60 caps / 30 days) TRAMADOL HCL CP24 300mg 2 QL (30 caps / 30 days) tramadol hcl er TB24 100mg 2 QL (90 tabs / 30 days) tramadol hcl er TB24 200mg 2 QL (30 tabs / 30 days) TRAMADOL HCL ER TB24 300mg 2 QL (30 tabs / 30 days) tramadol hcl er (biphasic) 100mg 2 QL (90 tabs / 30 days) tramadol hcl er (biphasic) 200mg 2 QL (30 tabs / 30 days) tramadol hcl er (biphasic) 300mg 2 QL (30 tabs / 30 days) tramadol hcl tab 50 mg 2 QL (240 tabs / 30 days) tramadol-acetaminophen 2 QL (240 tabs / 30 days) trezix 4 QL (360 caps / 30 days) OPIOID ANALGESICS, CII ABSTRAL 5 CODEINE SULFATE 15mg CODEINE SULFATE 30mg CODEINE SULFATE 60mg DILAUDID-HP INJ 250MG DURAMORPH EMBEDA endocet ENDODAN TAB fentanyl citrate LPOP 2 2 2 4 2 4 2 2 5 fentanyl patch 12 mcg/hr 2 fentanyl patch 25 mcg/hr 2 fentanyl patch 50 mcg/hr 2 fentanyl patch 75 mcg/hr 2 QL (120 tabs / 30 days), PA QL (720 tabs / 30 days) QL (360 tabs / 30 days) QL (180 tabs / 30 days) B/D B/D QL (60 caps / 30 days) QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (120 lozenges / 30 days), PA QL (10 patches / 30 days) QL (10 patches / 30 days) QL (10 patches / 30 days), PA QL (10 patches / 30 days), PA 13 Drug Name fentanyl patch 100 mcg/hr FENTORA Drug Tier Requirements/Limits 2 QL (10 patches / 30 days), PA 5 QL (120 tabs / 30 days), PA 2 QL (360 tabs / 30 days) 2 QL (400 tabs / 30 days) 2 QL (360 tabs / 30 days) 2 QL (400 tabs / 30 days) 2 QL (5400 mL / 30 days) hydrocodone-acetaminophen 2.5-325mg hydrocodone-acetaminophen 5-300mg hydrocodone-acetaminophen 5-325mg hydrocodone-acetaminophen 7.5-300mg hydrocodone-acetaminophen 7.5-325 mg/15ml hydrocodone-acetaminophen 7.5-325mg 2 hydrocodone-acetaminophen 10-300mg 2 hydrocodone-acetaminophen tab 10-325mg2 hydrocodone-ibuprofen tab 2.5-200mg 2 hydrocodone-ibuprofen tab 5-200mg 2 hydrocodone-ibuprofen tab 7.5-200 mg 2 hydrocodone-ibuprofen tab 10-200mg 2 hydromorphone hcl LIQD 2 HYDROMORPHONE HCL SOLN 1mg/ml, 2 2mg/ml, 4mg/ml hydromorphone hcl SOLN 500mg/50ml 2 hydromorphone hcl TABS 2 hydromorphone tab 8mg er 2 hydromorphone tab 12mg er 2 hydromorphone tab 16mg er 5 HYDROMORPHONE TABS 32MG 5 HYSINGLA ER 20mg, 30mg, 40mg, 60mg 4 HYSINGLA ER 80mg, 100mg, 120mg 5 ibudone tab 5-200mg 2 ibudone tab 10-200mg 2 INFUMORPH 200 4 INFUMORPH 500 4 KADIAN 40mg, 200mg 5 LAZANDA 5 levorphanol tartrate TABS lorcet hd tab 10-325mg lorcet plus tab 7.5-325 lorcet tab 5-325mg lortab tab 5-325mg lortab tab 7.5-325 lortab tab 10-325mg methadone hcl CONC methadone hcl SOLN methadone hcl TABS METHADONE INJ 10MG/ML MORPHINE SUL 20MG/ML ORAL SOL 2 2 2 2 2 2 2 2 2 2 4 2 QL QL QL QL QL QL QL (360 tabs / (400 tabs / (360 tabs / (150 tabs / (150 tabs / (150 tabs / (150 tabs / 30 days) 30 days) 30 days) 30 days) 30 days) 30 days) 30 days) B/D B/D QL (270 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL (150 tabs / 30 days) QL (150 tabs / 30 days) B/D B/D QL (60 caps / 30 days) QL (30 bottles / 30 days), PA QL (180 tabs / 30 days) QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (120 mL / 30 days) QL (600 mL / 30 days) QL (240 tabs / 30 days) 14 Drug Name Drug Tier Requirements/Limits morphine sulfate CP24 10mg, 20mg, 2 QL (60 caps / 30 days) 30mg, 50mg, 60mg morphine sulfate CP24 80mg, 100mg 5 QL (60 caps / 30 days) MORPHINE SULFATE SOLN 1mg/ml, 2 B/D 2mg/ml, 4mg/ml, 8mg/ml, 10mg/ml, 15mg/ml MORPHINE SULFATE SOLN 10mg/5ml, 2 20mg/5ml morphine sulfate SOLN .5mg/ml, 1mg/ml 2 B/D MORPHINE SULFATE TABS 2 QL (180 tabs / 30 days) morphine sulfate beads 2 QL (60 caps / 30 days) morphine sulfate ext-rel tab 15mg, 30mg,2 QL (90 tabs / 30 days) 60mg, 100mg morphine sulfate ext-rel tab 200mg 2 QL (60 tabs / 30 days) NUCYNTA 50mg 4 QL (360 tabs / 30 days) NUCYNTA 75mg 4 QL (240 tabs / 30 days) NUCYNTA 100mg 4 QL (180 tabs / 30 days) NUCYNTA ER 50mg, 100mg 4 QL (120 tabs / 30 days) NUCYNTA ER 150mg, 200mg, 250mg 4 QL (60 tabs / 30 days) OPANA ER (CRUSH RESISTANT 5mg, 4 QL (120 tabs / 30 days) 7.5mg, 10mg, 15mg, 20mg OPANA ER (CRUSH RESISTANT 30mg, 5 QL (120 tabs / 30 days) 40mg oxycodone hcl CAPS 2 QL (180 caps / 30 days) oxycodone hcl CONC 2 OXYCODONE HCL SOLN 2 oxycodone hcl TABS 2 QL (180 tabs / 30 days) oxycodone w/ acetaminophen 2.5-325mg 2 QL (360 tabs / 30 days) oxycodone w/ acetaminophen 5-325mg 2 QL (360 tabs / 30 days) oxycodone w/ acetaminophen 7.5-325mg 2 QL (360 tabs / 30 days) oxycodone w/ acetaminophen 10-325mg 2 QL (360 tabs / 30 days) oxycodone-aspirin 2 QL (360 tabs / 30 days) oxycodone-ibuprofen 2 QL (28 tabs / 30 days) OXYCONTIN 10mg, 15mg, 20mg, 30mg, 4 QL (120 tabs / 30 days) 40mg OXYCONTIN 60mg, 80mg 5 QL (120 tabs / 30 days) oxymorphone hcl TABS 2 QL (180 tabs / 30 days) reprexain tab 10-200mg 2 QL (150 tabs / 30 days) roxicet soln 3 QL (1800 mL / 30 days) roxicet tab 5-325mg 2 QL (360 tabs / 30 days) SUBSYS 5 QL (120 sprays / 30 days), PA vicodin 2 QL (400 tabs / 30 days) vicodin es 2 QL (400 tabs / 30 days) vicodin hp 2 QL (400 tabs / 30 days) XARTEMIS XR 4 QL (120 tabs / 30 days) xylon tab 10-200mg 2 QL (150 tabs / 30 days) zamicet 2 QL (5400 mL / 30 days) 15 Drug Name Drug Tier Requirements/Limits ZOHYDRO ER (ABUSE DETERRENT) 10mg,4 QL (120 caps / 30 days) 15mg, 20mg ZOHYDRO ER (ABUSE DETERRENT) 30mg,4 QL (60 caps / 30 days) 40mg, 50mg ANESTHETICS LOCAL ANESTHETICS lidocaine lidocaine lidocaine lidocaine lidocaine lidocaine hcl (local anesth.) hcl (local anesth.) inj 0.5% inj 1% inj 1.5% inj 2% 4% .5%, 1% 2 2 2 2 2 2 B/D B/D B/D B/D B/D ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN BETHKIS gentamicin in saline gentamicin sulfate SOLN neomycin sulfate TABS paromomycin sulfate CAPS streptomycin sulfate SOLR sulfadiazine TABS TOBI PODHALER tobramycin NEBU tobramycin sulfate SOLN; SOLR tobramycin sulfate in saline ANTI-INFECTIVES - MISCELLANEOUS ALBENZA ALINIA atovaquone SUSP AZACTAM/DEX INJ 1GM AZACTAM/DEX INJ 2GM aztreonam BILTRICIDE CAYSTON clindamycin hcl CAPS clindamycin palmitate hydrochloride clindamycin phosphate SOLN clindamycin phosphate in d5w colistimethate sodium SOLR CUBICIN DALVANCE dapsone TABS DARAPRIM DORIBAX FLAGYL ER 2 5 2 2 2 2 2 4 5 5 2 3 4 4 5 4 5 2 3 5 1 2 2 2 2 5 5 2 4 4 4 B/D, NM NM, LA, PA B/D, NM NM, LA, PA 16 Drug Name imipenem-cilastatin INVANZ ivermectin TABS linezolid SOLN LINEZOLID TABS MACRODANTIN 25mg Drug Tier Requirements/Limits 2 4 2 5 5 4 PA; PA applies if 65 years and older after a 90 day supply in a calendar year meropenem 2 methenamine hippurate 2 METRO IV 3 metronidazole CAPS 2 metronidazole TABS 1 metronidazole inj 2 NEBUPENT 4 B/D nitrofurantoin SUSP 2 PA; PA applies if 65 years and older after a 90 day supply in a calendar year nitrofurantoin macrocrystal 25mg 4 PA; 90 day limit per calendar year if 65 years and older nitrofurantoin macrocrystal 50mg, 100mg 4 PA; PA applies if 65 years and older after a 90 day supply in a calendar year nitrofurantoin monohyd macro 4 PA; PA applies if 65 years and older after a 90 day supply in a calendar year PENTAM 300 4 polymyxin b sulfate SOLR 2 PRIMSOL SOL 50MG/5ML 4 SIVEXTRO 5 sulfamethoxazole-trimethop SUSP 2 sulfamethoxazole-trimethop TABS 1 sulfamethoxazole-trimethoprim inj 2 SYNERCID 5 trimethoprim TABS 1 TYGACIL 5 vancomycin hcl CAPS 5 vancomycin hcl SOLR 2 XIFAXAN TAB 200MG 5 ZYVOX SUSR; TABS 5 ANTIFUNGALS ABELCET AMBISOME AMPHOTEC amphotericin b SOLR CANCIDAS 5 5 4 2 5 B/D B/D B/D B/D 17 Drug Name CRESEMBA ERAXIS fluconazole SUSR; TABS fluconazole in dextrose fluconazole in nacl flucytosine CAPS griseofulvin microsize griseofulvin ultramicrosize itraconazole CAPS ketoconazole TABS LAMISIL PACK MYCAMINE NOXAFIL nystatin TABS ONMEL SPORANOX SOL 10MG/ML terbinafine hcl TABS voriconazole SUSR; TABS voriconazole inj 200mg Drug Tier Requirements/Limits 5 5 2 2 2 5 2 2 2 PA 2 PA 4 5 5 2 5 PA 5 1 QL (90 tabs / 365 days) 5 2 ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg atovaquone-proguanil hcl tab 250-100 mg chloroquine phosphate TABS COARTEM mefloquine hcl PRIMAQUINE PHOSPHATE quinine sulfate CAPS 2 2 2 4 2 3 2 PA ANTIRETROVIRAL AGENTS abacavir sulfate APTIVUS CRIXIVAN didanosine EDURANT EMTRIVA FUZEON INTELENCE 25mg INTELENCE 100mg, 200mg INVIRASE ISENTRESS CHEW 25mg ISENTRESS CHEW 100mg ISENTRESS PACK ISENTRESS TABS lamivudine LEXIVA SUSP LEXIVA TABS NEVIRAPINE SUSP 2 5 4 2 5 3 5 4 5 5 3 5 3 5 2 4 5 2 NM 18 Drug Name nevirapine TABS; TB24 NORVIR PREZISTA SUSP PREZISTA TABS 75mg, 150mg PREZISTA TABS 600mg, 800mg RESCRIPTOR RETROVIR IV INFUSION REYATAZ SELZENTRY stavudine SUSTIVA CAPS SUSTIVA TABS TIVICAY TYBOST VIDEX PEDIATRIC VIRACEPT VIRAMUNE XR 100mg VIREAD VITEKTA ZIAGEN SOLN zidovudine Drug Tier Requirements/Limits 2 3 5 3 5 4 3 5 5 2 3 5 5 3 4 5 4 5 5 3 2 ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine ATRIPLA COMPLERA EPZICOM EVOTAZ KALETRA SOL KALETRA TAB 100-25MG KALETRA TAB 200-50MG lamivudine-zidovudine PREZCOBIX STRIBILD TRIUMEQ TRUVADA ANTITUBERCULAR AGENTS CAPASTAT SULFATE cycloserine CAPS ethambutol hcl TABS isoniazid SOLN; SYRP isoniazid tabs paser d/r PRIFTIN pyrazinamide rifabutin rifamate 5 5 5 5 5 5 3 5 5 5 5 5 5 QL (30 tabs / 30 days) 4 5 2 2 1 3 4 2 2 4 19 Drug Name rifampin CAPS; SOLR RIFATER SIRTURO TRECATOR Drug Tier Requirements/Limits 2 4 5 LA, PA 4 ANTIVIRALS acyclovir CAPS; TABS acyclovir SUSP acyclovir sodium SOLN acyclovir sodium SOLR 500mg adefovir dipivoxil BARACLUDE SOLN cidofovir entecavir EPIVIR HBV SOLN famciclovir TABS foscarnet sodium ganciclovir inj 500mg HARVONI lamivudine (hbv) moderiba pak MISC moderiba pak TABS 400mg MODERIBA PAK TABS 600mg moderiba tab 200mg PEG-INTRON PEG-INTRON REDIPEN PEGINTRON 80mcg/0.5ml, 120mcg/0.5ml, 150mcg/0.5ml REBETOL SOLN RELENZA DISKHALER ribapak mis 600/day ribasphere CAPS ribasphere TABS 200mg, 400mg ribasphere TABS 600mg ribasphere ribapak 800 ribasphere ribapak 1000 ribasphere ribapak 1200 ribavirin 200mg rimantadine hydrochloride SOVALDI TAMIFLU TYZEKA valacyclovir hcl TABS VALCYTE SOLR valganciclovir hcl CEPHALOSPORINS AVYCAZ 1 2 2 2 5 3 5 5 4 2 2 2 5 2 5 5 5 2 5 5 5 5 3 5 2 2 5 5 5 5 2 2 5 3 5 2 5 5 B/D B/D B/D NM, PA NM NM NM NM NM, PA NM, PA NM, PA NM NM NM NM NM NM NM NM NM NM, PA 5 20 Drug Name Drug Tier Requirements/Limits CEDAX SUSR 90mg/5ml 4 cefaclor 2 cefaclor er tab 500mg 3 cefadroxil CAPS 1 cefadroxil SUSR; TABS 2 cefazolin inj 2 cefazolin sodium 1gm, 20gm 2 cefazolin/dextrose 3 cefdinir 2 CEFEPIME 1GM SOLN 4 CEFEPIME 2GM SOLN 4 CEFEPIME HCL AND DEXTROSE 4 cefepime inj 1gm 2 cefepime inj 2gm 2 cefixime 2 cefotaxime sodium 1gm, 2gm, 500mg 2 cefotetan disodium 4 cefoxitin sodium 2 CEFOXITIN SODIUM IN DEXTROSE 4 cefpodoxime proxetil 2 cefprozil 2 ceftazidime 2 CEFTAZIDIME/DEXTROSE 4 CEFTIBUTEN 2 CEFTIN SUSR 4 ceftriaxone sodium SOLR 1gm, 2gm, 2 10gm, 250mg, 500mg cefuroxime axetil 2 cefuroxime sodium 1.5gm, 7.5gm, 750mg2 cephalexin CAPS 250mg, 500mg 1 cephalexin CAPS 750mg 2 cephalexin SUSR 2 cephalexin TABS 2 claforan 1gm, 2gm 4 FORTAZ SOLN 4 FORTAZ SOLR 500mg 4 MAXIPIME 4 SUPRAX CAPS 3 suprax CHEW 4 SUPRAX SUSR 500mg/5ml 3 tazicef SOLR 2 tazicef vial 2 TEFLARO 4 ZERBAXA 5 ZINACEF SOLR 750mg 4 ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 2 21 Drug Name azithromycin SOLR 500mg azithromycin SUSR azithromycin TABS clarithromycin SUSR; TABS; TB24 DIFICID e.e.s. 400 tab 400mg E.E.S. GRANULES ery-tab ERYPED 200 ERYPED 400 erythrocin lactobionate 500mg erythrocin stearate erythromycin base erythromycin cap 250mg ec erythromycin ethylsuccinate PCE ZMAX FLUOROQUINOLONES AVELOX SOLN ciprofloxacin SOLN 200mg/20ml ciprofloxacin SUSR ciprofloxacin er ciprofloxacin hcl TABS ciprofloxacin in d5w ciprofloxacn inj 400mg/40ml FACTIVE levofloxacin SOLN levofloxacin TABS levofloxacin in d5w MOXIFLOXACIN HCL SOLN moxifloxacin hcl TABS PENICILLINS amoxicillin amoxicillin & pot clavulanate ampicillin & sulbactam sodium ampicillin cap 250mg ampicillin cap 500 mg ampicillin inj ampicillin sodium ampicillin susp AUGMENTIN SUSR BACTOCILL INJ DEX 1GM BACTOCILL INJ DEX 2GM BICILLIN C-R BICILLIN L-A dicloxacillin sodium Drug Tier Requirements/Limits 2 2 1 2 5 2 4 2 4 4 4 2 2 2 2 4 4 4 2 2 2 1 2 2 4 2 1 2 4 2 1 2 2 1 1 2 2 2 4 4 5 4 4 2 22 Drug Name nafcillin sodium 1gm nafcillin sodium 2gm, 10gm NALLPEN ISO-OSMOTIC IN DE NALLPEN/DEXTROSE oxacillin sodium 1gm, 2gm oxacillin sodium 10gm PENICILLIN G POT IN DEXTROSE PENICILLIN G POTASSIUM IN penicillin g procaine penicillin g sodium penicillin v potassium penicilln gk inj 5mu penicilln gk inj 20mu pfizerpen g inj 5mu pfizerpen-g inj 20mu piperacillin sodium-tazobactam sodium ZOSYN SOLN TETRACYCLINES demeclocycline hcl doxy doxycycline (monohydrate) doxycycline hyclate CAPS; SOLR; TABS; TBEC minocycline hcl CAPS; TABS; TB24 SOLODYN TETRACYCLINE HCL CAPS VIBRAMYCIN SYRP ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU BUSULFEX CYCLOPHOSPHAMIDE CAPS cyclophosphamide SOLR 1gm, 500mg cyclophosphamide SOLR 2gm dacarbazine EMCYT GLEOSTINE 10mg, 40mg, 100mg HEXALEN IFEX INJ 3GM ifosfamide inj 1gm ifosfamide inj 1gm/20ml IFOSFAMIDE INJ 3GM ifosfamide inj 3gm/60ml LEUKERAN LOMUSTINE melphalan hcl Drug Tier Requirements/Limits 2 5 4 4 2 5 4 4 3 2 1 2 2 2 2 2 4 2 2 2 2 2 5 2 4 4 5 4 5 2 2 4 4 5 4 2 2 4 2 4 2 5 B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D 23 Drug Name MUSTARGEN TREANDA ZANOSAR Drug Tier Requirements/Limits 4 B/D 5 B/D, NM 4 B/D ANTHRACYCLINES adriamyc inj 50mg 2 daunorubicin hcl 2 doxorubicin hcl 50mg 2 doxorubicin hcl liposomal inj (for iv infusion)5 2 mg/ml doxorubicin inj 50mg 2 epirubicin inj 50mg/25ml 2 epirubicin inj 200mg 2 idarubicin hcl 5 ANTIBIOTICS bleomycin sulfate COSMEGEN mitomycin SOLR B/D B/D B/D B/D B/D B/D B/D B/D 2 5 2 B/D B/D B/D 2 5 5 5 5 5 2 5 2 2 5 5 2 2 5 5 4 B/D B/D B/D B/D, NM B/D B/D B/D B/D, NM B/D B/D B/D B/D 5 5 5 2 5 B/D B/D B/D B/D B/D 5 2 B/D B/D 3 B/D ANTIMETABOLITES adrucil ALIMTA ARRANON azacitidine cladribine CLOLAR cytarabine inj decitabine fludarabine phosphate fluorouracil SOLN GEMCITABINE gemcitabine hcl mercaptopurine TABS methotrexate sodium inj NIPENT PURIXAN TABLOID B/D B/D ANTIMITOTIC, TAXOIDS ABRAXANE DOCETAXEL CONC 20mg/ml, 80mg/4ml docetaxel CONC 140mg/7ml DOCETAXEL SOLN 20mg/2ml DOCETAXEL SOLN 160mg/16ml, 200mg/20ml DOCETAXEL SOLN 80MG/8ML paclitaxel ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 24 Drug Name vincasar vincristine sulfate vinorelbine tartrate BIOLOGIC RESPONSE MODIFIERS ARZERRA AVASTIN BELEODAQ ERBITUX ERIVEDGE FARYDAK HERCEPTIN IBRANCE ISTODAX KADCYLA KEYTRUDA LYNPARZA PERJETA PROLEUKIN RITUXAN TORISEL VECTIBIX VELCADE YERVOY ZOLINZA Drug Tier Requirements/Limits 2 B/D 2 B/D 2 B/D 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 B/D, NM B/D, NM, LA NM, PA B/D, NM NM, LA, PA NM, LA, PA B/D, NM NM, LA, PA B/D, NM B/D, NM NM, PA NM, LA, PA NM, PA B/D, NM NM, LA, PA B/D, NM B/D, NM B/D, NM NM, PA NM, PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS bicalutamide DEPO-PROVERA INJ 400/ML ELIGARD INJ 7.5MG ELIGARD INJ 22.5MG ELIGARD INJ 30MG ELIGARD INJ 45MG exemestane FARESTON FASLODEX FIRMAGON 80mg FIRMAGON 120mg flutamide letrozole TABS leuprolide acetate KIT LUPRON DEP INJ 11.25MG LUPRON DEP-PED INJ 7.5MG LUPRON DEP-PED INJ 11.25MG LUPRON DEP-PED INJ 15MG LUPRON DEP-PED INJ 30MG (3-MONTH) LUPRON DEPOT 3.75mg, 7.5mg 2 2 4 4 4 4 4 2 5 5 4 5 2 2 2 5 5 5 5 5 5 B/D B/D, B/D, B/D, B/D, NM NM NM NM B/D B/D, NM B/D, NM NM, NM, NM, NM, NM, NM, NM, PA PA PA PA PA PA PA 25 Drug Name LUPRON DEPOT INJ 22.5MG (3-MONTH) LUPRON DEPOT INJ 30MG (3-MONTH) LYSODREN MEGACE ES megestrol ac sus 40mg/ml megestrol ac tab 20mg megestrol ac tab 40mg MEGESTROL SUS 625MG/5ML NILANDRON SOLTAMOX tamoxifen citrate TABS TRELSTAR MIXJECT XTANDI ZYTIGA KINASE INHIBITORS AFINITOR AFINITOR DISPERZ BOSULIF CAPRELSA COMETRIQ GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG GLEEVEC ICLUSIG IMBRUVICA CAP 140MG INLYTA IRESSA JAKAFI LENVIMA 10MG DAILY DOSE LENVIMA 14MG DAILY DOSE LENVIMA 20MG DAILY DOSE LENVIMA 24MG DAILY DOSE MEKINIST NEXAVAR SPRYCEL STIVARGA SUTENT TAFINLAR TARCEVA TASIGNA TYKERB VOTRIENT XALKORI Drug Tier Requirements/Limits 5 NM, PA 5 NM, PA 3 5 PA 4 PA; PA if 65 years and older 4 PA; PA if 65 years and older 4 PA; PA if 65 years and older 5 PA 5 4 1 5 NM, PA 5 NM, LA, PA 5 NM, LA, PA 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, PA PA PA LA, LA, LA, LA, LA, PA LA, LA, LA, LA, LA, LA, LA, LA, LA, LA, LA, PA LA, PA LA, LA, PA LA, LA, LA, PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA 26 Drug Name ZELBORAF ZYDELIG ZYKADIA MISCELLANEOUS bexarotene DROXIA HALAVEN hydroxyurea CAPS IXEMPRA KIT LONSURF MATULANE mitoxantrone hcl ODOMZO POMALYST SYLATRON KIT 200MCG SYLATRON KIT 300MCG SYLATRON KIT 600MCG SYNRIBO TARGRETIN CAPS tretinoin CAPS TRISENOX UVADEX Drug Tier Requirements/Limits 5 NM, LA, PA 5 NM, LA, PA 5 NM, LA, PA 5 3 5 2 5 5 5 2 5 5 5 5 5 5 5 5 5 4 NM, PA 2 2 5 5 B/D B/D B/D B/D 5 5 5 5 5 2 2 2 2 5 2 5 B/D B/D B/D B/D, NM B/D B/D B/D 4 4 2 2 2 B/D B/D B/D B/D B/D B/D, NM B/D, NM NM, LA, PA LA B/D, NM NM, PA NM, LA, PA NM, PA NM, PA NM, PA NM, PA NM, PA B/D B/D PLATINUM-BASED AGENTS carboplatin cisplatin ELOXATIN oxaliplatin PROTECTIVE AGENTS amifostine crystalline dexrazoxane 250mg ELITEK FUSILEV KEPIVANCE leucovor ca inj leucovorin calcium SOLR leucovorin calcium TABS leucovorin calcium 500 mg levoleucovorin calcium mesna MESNEX TABS B/D B/D, NM B/D TOPOISOMERASE INHIBITORS CAMPTOSAR 300mg/15ml ETOPOPHOS etoposide SOLN 500mg/25ml irinotecan inj 40mg/2ml irinotecan inj 100/5ml 27 Drug Name irinotecan inj 500mg/25ml toposar 1gm/50ml topotecan hcl SOLR Drug Tier Requirements/Limits 2 B/D 2 B/D 5 B/D CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl benazepril & hydrochlorothiazide captopril & hydrochlorothiazide enalapril maleate & hydrochlorothiazide fosinopril sodium & hydrochlorothiazide lisinopril & hydrochlorothiazide moexipril-hydrochlorothiazide quinapril-hydrochlorothiazide trandolapril-verapamil hcl 1 1 1 1 1 1 1 1 1 ACE INHIBITORS benazepril hcl TABS captopril TABS enalapril maleate TABS fosinopril sodium lisinopril TABS moexipril hcl perindopril erbumine quinapril hcl ramipril trandolapril 1 1 1 1 1 1 1 1 1 1 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone spironolactone TABS ALPHA BLOCKERS doxazosin mesylate prazosin hcl terazosin hcl 2 1 2 2 1 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan tab 5-160 mg amlodipine besylate-valsartan tab 5-320 mg amlodipine besylate-valsartan tab 10-160 mg amlodipine besylate-valsartan tab 10-320 mg amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg amlodipine-valsartan-hydrochlorothiazide 5-160-25mg 1 1 1 1 1 1 28 Drug Name amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg amlodipine-valsartan-hydrochlorothiazide 10-160-25mg amlodipine-valsartan-hydrochlorothiazide 10-320-25mg AZOR BENICAR HCT candesartan cilexetil-hydrochlorothiazide EDARBYCLOR ENTRESTO irbesartan-hydrochlorothiazide losartan-hydrochlorothiazide telmisartan-amlodipine telmisartan-hydrochlorothiazide TEVETEN HCT TRIBENZOR valsartan-hydrochlorothiazide Drug Tier Requirements/Limits 1 1 1 3 3 1 4 4 1 1 1 1 4 3 1 PA ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR candesartan cilexetil EDARBI eprosartan mesylate irbesartan losartan potassium telmisartan valsartan ANTIARRHYTHMICS 3 1 4 1 1 1 1 1 amiodarone hcl SOLN amiodarone hcl TABS 100mg, 400mg amiodarone hcl TABS 200mg amiodarone inj 50mg/ml disopyramide phosphate 2 2 1 2 4 flecainide acetate mexiletine hcl MULTAQ NORPACE CR 2 2 4 4 pacerone 100mg, 400mg pacerone 200mg propafenone hcl propafenone hcl 12hr quinidine gluconate TBCR quinidine sulfate TABS sorine sotalol hcl 2 1 2 2 2 2 2 1 PA; PA if 65 years and older PA; PA if 65 years and older 29 Drug Name sotalol hcl (afib/afl) TIKOSYN Drug Tier Requirements/Limits 2 4 NM ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV atorvastatin calcium TABS CRESTOR fluvastatin sodium cap 20 mg fluvastatin sodium cap 40 mg fluvastatin sodium tab sr 24 hr 80 mg LESCOL XL LIVALO lovastatin pravastatin sodium simvastatin TABS 5mg, 10mg, 20mg, 40mg simvastatin TABS 80mg ANTILIPEMICS, MISCELLANEOUS ADVICOR ANTARA cholestyramine cholestyramine light choline fenofibrate colestipol hcl FENOFIBRATE CAPS FENOFIBRATE TABS 40mg, 120mg fenofibrate TABS 48mg, 54mg, 145mg, 160mg fenofibrate micronized FENOFIBRIC ACID FENOGLIDE gemfibrozil TABS JUXTAPID KYNAMRO LIPTRUZET niacin er (antihyperlipidemic) niacor omega-3-acid ethyl esters prevalite SIMCOR TRIGLIDE VASCEPA VYTORIN WELCHOL ZETIA TAB 10MG 4 1 3 1 1 1 4 4 1 1 1 1 QL (30 tabs / 30 days) 4 4 2 2 2 2 2 2 2 2 2 4 1 5 5 4 2 2 2 2 4 4 4 4 3 3 NM, LA, PA NM, PA ST ST BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone 2 30 Drug Name bisoprolol & hydrochlorothiazide DUTOPROL metoprolol & hctz tab 50-25mg metoprolol & hctz tab 100-25mg metoprolol & hctz tab 100-50mg nadolol & bendroflumethiazide propranolol & hydrochlorothiazide BETA-BLOCKERS acebutolol hcl CAPS atenolol TABS betaxolol hcl bisoprolol fumarate BYSTOLIC carvedilol COREG CR labetalol hcl SOLN; TABS metoprolol succinate metoprolol tartrate SOLN metoprolol tartrate TABS nadolol TABS pindolol propranolol hcl er propranolol inj 1mg/ml propranolol sol propranolol tab SOTYLIZE timolol maleate TABS Drug Tier Requirements/Limits 1 4 2 2 2 2 2 1 1 2 2 4 1 4 2 2 2 1 2 2 2 2 2 1 5 2 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate/atorv CALCIUM CHANNEL BLOCKERS afeditab cr amlodipine besylate TABS CARDIZEM LA 120mg cartia xt dilt-xr cap diltiazem cap 120mg/24hr diltiazem cap 240mg/24hr diltiazem cap er/12hr diltiazem hcl TABS diltiazem hcl coated beads diltiazem hcl er diltiazem hcl extended release beads diltiazem inj 25mg/5ml diltiazem inj 50/10ml diltiazem inj 100mg diltiazem inj 125/25ml 1 2 1 4 2 2 2 2 2 1 2 2 2 2 2 4 2 31 Drug Name diltzac felodipine isradipine matzim la nicardipine hcl CAPS nifedical nifedipine TB24 nifedipine er nimodipine CAPS nisoldipine NYMALIZE taztia xt verapamil hcl CP24 100mg, 120mg, 180mg, 200mg, 240mg, 300mg VERAPAMIL HCL CP24 360mg verapamil hcl SOLN verapamil hcl TABS verapamil hcl TBCR DIGITALIS GLYCOSIDES Drug Tier Requirements/Limits 2 2 2 2 2 2 2 2 5 2 5 2 2 2 2 1 1 digitek .25mg 2 digitek .125mg digox 125mcg digox 250mcg 2 2 2 digoxin 125mcg digoxin 250mcg 2 2 digoxin inj DIGOXIN SOL 50MCG/ML 2 2 LANOXIN LANOXIN 4 4 TABS 62.5mcg TABS 187.5mcg LANOXIN PEDIATRIC 4 PA; PA if 65 years and older QL (30 tabs / 30 days) QL (30 tabs / 30 days) PA; PA if 65 years and older QL (30 tabs / 30 days) PA; PA if 65 years and older PA; PA if 65 years and older QL (60 tabs / 30 days) PA; PA if 65 years and older DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA TEKTURNA HCT DIURETICS acetazolamide CP12; TABS acetazolamide sodium ALDACTAZIDE TAB 50/50 amiloride & hydrochlorothiazide amiloride hcl bumetanide chlorothiazide tabs chlorthalidone 25mg, 50mg 3 3 2 2 4 1 2 2 2 2 32 Drug Name DIURIL SUS 250/5ML DYRENIUM EDECRIN furosemide SOLN; TABS furosemide inj 10mg/ml FUROSEMIDE INJ 10mg/ml furosemide oral soln 8 mg/ml hydrochlorothiazide CAPS; TABS indapamide methazolamide TABS methyclothiazide metolazone spironolactone & hydrochlorothiazide torsemide inj 50mg/5ml torsemide tabs triamt/hctz cap 37.5-25 triamt/hctz cap 50-25mg triamt/hctz tab 37.5-25 triamt/hctz tab 75-50mg Drug Tier Requirements/Limits 4 4 4 1 2 2 1 1 1 2 2 2 2 2 1 1 1 1 1 MISCELLANEOUS BIDIL clonidine hcl PTWK clonidine hcl TABS clorpres CORLANOR DEMSER DIBENZYLINE hydralazine hcl SOLN; TABS midodrine hcl minoxidil TABS phenoxybenzamine hcl CAPS RANEXA 3 2 1 2 4 5 5 2 2 2 5 3 NITRATES DILATRATE SR ISORDIL TITRADOSE 40mg isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er minitran nitro-bid NITRO-DUR .3mg/hr, .8mg/hr nitroglycerin .4mg/spray NITROGLYCERIN LINGUAL nitroglycerin patches NITROSTAT 4 4 2 2 1 1 2 3 4 2 2 2 3 33 Drug Name Drug Tier Requirements/Limits PULMONARY ARTERIAL HYPERTENSION ADCIRCA 5 ADEMPAS 5 LETAIRIS 5 OPSUMIT 5 ORENITRAM TAB 0.25MG 5 ORENITRAM TAB 0.125MG 4 ORENITRAM TAB 1MG 5 ORENITRAM TAB 2.5MG 5 REMODULIN 5 REVATIO SUSR 5 sildenafil citrate (pulmonary hypertension) 2 TABS TRACLEER 5 TYVASO 5 VENTAVIS 5 NM, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA B/D, NM, LA NM, PA NM, PA NM, LA, PA B/D, NM B/D, NM CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam CONC alprazolam TABS 1mg alprazolam TABS 2mg alprazolam TABS .5mg alprazolam TABS .25mg buspirone hcl TABS fluvoxamine maleate 25mg, 50mg fluvoxamine maleate 100mg fluvoxamine maleate er 100mg fluvoxamine maleate er 150mg lorazepam CONC lorazepam SOLN lorazepam TABS ANTICONVULSANTS APTIOM 200mg APTIOM 400mg, 600mg, 800mg BANZEL SUS 40MG/ML BANZEL TAB 200MG BANZEL TAB 400MG carbamazepine CHEW; CP12; SUSP; TABS; TB12 CELONTIN clonazepam TABS 1mg clonazepam TABS 2mg clonazepam TABS .5mg clonazepam TBDP 1mg clonazepam TBDP 2mg clonazepam TBDP .5mg 2 1 1 1 1 2 2 2 2 2 2 2 1 4 5 5 4 5 2 4 1 1 1 2 2 2 QL QL QL QL QL (300 mL / 30 days) (120 tabs / 30 days) (150 tabs / 30 days) (240 tabs / 30 days) (480 tabs / 30 days) QL (45 tabs / 30 days) QL (90 caps / 30 days) QL (60 caps / 30 days) QL (150 mL / 30 days) QL (150 tabs / 30 days) PA PA PA QL QL QL QL QL QL (120 tabs / (300 tabs / (240 tabs / (120 tabs / (300 tabs / (240 tabs / 30 days) 30 days) 30 days) 30 days) 30 days) 30 days) 34 Drug Name clonazepam TBDP .25mg clonazepam TBDP .125mg clorazepate dipotassium 3.75mg, 7.5mg Drug Tier Requirements/Limits 2 QL (480 tabs / 30 days) 2 QL (960 tabs / 30 days) 2 QL (120 tabs / 30 days), PA clorazepate dipotassium 15mg 2 QL (180 tabs / 30 days), PA diazepam CONC 2 QL (240 mL / 30 days), PA diazepam SOLN 1mg/ml 2 QL (1200 mL / 30 days), PA diazepam SOLN 5mg/ml 2 diazepam TABS 1 QL (120 tabs / 30 days), PA DIAZEPAM GEL (ANTICONVULSANT) 2 dilantin 3 DILANTIN-125 3 divalproex sodium 2 epitol 2 ethosuximide CAPS; SOLN 2 felbamate SUSP 5 felbamate TABS 2 FYCOMPA 4 PA gabapentin CAPS 100mg 1 QL (1080 caps / 30 days) gabapentin CAPS 300mg 1 QL (360 caps / 30 days) gabapentin CAPS 400mg 1 QL (270 caps / 30 days) gabapentin SOLN 2 QL (2160 mL / 30 days) gabapentin TABS 600mg 2 QL (180 tabs / 30 days) gabapentin TABS 800mg 2 QL (120 tabs / 30 days) GABITRIL 12mg, 16mg 4 LAMICTAL ODT KIT 4 LAMICTAL STARTER 4 LAMICTAL XR KIT 4 lamotrigine CHEW; TB24; TBDP 2 lamotrigine TABS 1 levetiracetam SOLN; TABS; TB24 2 LEVETIRACETAM IV 4 levetiracetam oral soln 100 mg/ml 2 LYRICA CAPS 25mg, 50mg, 75mg, 100mg,3 QL (120 caps / 30 days) 150mg LYRICA CAPS 200mg 3 QL (90 caps / 30 days) LYRICA CAPS 225mg, 300mg 3 QL (60 caps / 30 days) LYRICA SOLN 3 QL (946 mL / 30 days) ONFI SUSP 5 PA ONFI TABS 10mg 4 PA ONFI TABS 20mg 5 PA oxcarbazepine 2 OXTELLAR XR 4 35 Drug Name PEGANONE phenobarbital ELIX; TABS PHENOBARBITAL SODIUM 65mg/ml phenobarbital sodium 130mg/ml phenytek phenytoin CHEW; SUSP phenytoin inj 50mg/ml phenytoin sodium extended POTIGA 50mg POTIGA 200mg POTIGA 300mg, 400mg primidone TABS SABRIL PACK SABRIL TABS TEGRETOL TEGRETOL-XR tiagabine hcl topiramate CPSP TOPIRAMATE CS24 topiramate TABS TROKENDI XR 25mg, 50mg, 100mg TROKENDI XR 200mg valproate sodium SOLN; SYRP valproic acid CAPS VIMPAT SOLN VIMPAT TABS 50mg VIMPAT TABS 100mg, 150mg, 200mg zonisamide CAPS ANTIDEMENTIA donepezil odt 5mg donepezil odt 10mg donepezil tab hcl 23mg donepezil tabs 5mg donepezil tabs 10mg EXELON PATCHES galantamine hydrobromide galantamine hydrobromide er memantine hcl NAMENDA SOL 10MG/5ML NAMENDA TAB NAMENDA XR NAMENDA XR TITRATION PACK Drug Tier Requirements/Limits 4 4 PA; PA if 65 years and older 4 PA; PA if 65 years and older 4 PA; PA if 65 years and older 3 2 2 2 4 5 QL (180 tabs / 30 days) 5 QL (90 tabs / 30 days) 2 5 QL (180 packets / 30 days), NM, LA, PA 5 QL (180 tabs / 30 days), NM, LA, PA 4 4 2 2 2 1 4 5 2 2 4 4 5 2 2 2 2 2 2 2 2 2 2 3 4 4 4 PA; PA; PA; PA; PA; PA PA PA PA PA if if if if if < < < < < 30 yrs 30 yrs 30 yrs 30 yrs 30 yrs 36 Drug Name NAMZARIC rivastigmine tartrate ANTIDEPRESSANTS amitriptyline hcl TABS Drug Tier Requirements/Limits 4 2 4 amoxapine APLENZIN BRINTELLIX bupropion hcl TABS; TB12; TB24 citalopram hydrobromide SOLN citalopram hydrobromide TABS clomipramine hcl CAPS 2 5 4 2 2 1 4 desipramine hcl TABS doxepin hcl CAPS; CONC 2 4 duloxetine hcl CPEP 20mg, 30mg, 60mg EMSAM escitalopram oxalate FETZIMA FETZIMA TITRATION PACK fluoxetine cap 10mg fluoxetine cap 20mg fluoxetine cap 40mg fluoxetine hcl CPDR fluoxetine hcl SOLN fluoxetine hcl TABS 10mg, 20mg FLUOXETINE HCL TABS 60mg FORFIVO XL imipramine hcl TABS 2 5 2 4 4 1 1 1 2 2 2 4 4 4 imipramine pamoate 4 maprotiline hcl MARPLAN mirtazapine TABS mirtazapine TBDP nefazodone hcl nortriptyline hcl CAPS nortriptyline hcl SOLN paroxetine er tab paroxetine hcl tabs PAXIL SUSP PEXEVA phenelzine sulfate TABS PRISTIQ protriptyline hcl 2 4 1 2 2 1 2 2 1 4 4 2 3 2 PA; PA if 65 years and older PA; PA if 65 years and older PA; PA if 65 years and older PA QL (30 tabs / 30 days) PA; PA if 65 years and older PA; PA if 65 years and older 37 Drug Name sertraline hcl sertraline hcl SURMONTIL Drug Tier Requirements/Limits CONC 2 TABS 1 4 PA; PA if 65 years and older tranylcypromine sulfate 2 trazodone hcl TABS 50mg, 100mg, 150mg1 trazodone hcl TABS 300mg 2 trimipramine maleate CAPS 4 PA; PA if 65 years and older venlafaxine cap er 2 venlafaxine hcl 2 venlafaxine tab 2 VENLAFAXINE TAB 225MG ER 2 venlafaxine tab er 2 VIIBRYD 4 VIIBRYD STARTER PACK 4 ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS APOKYN AZILECT BENZTROPINE MESYLATE SOLN benztropine mesylate TABS 2 5 3 2 4 bromocriptine mesylate CAPS; TABS carbidopa TABS carbidopa-levodopa CARBIDOPA/LEVODOPA/ENTACAPONE DUOPA ENTACAPONE MIRAPEX .75mg MIRAPEX ER .375mg, 2.25mg, 3mg, 3.75mg, 4.5mg NEUPRO pramipexole dihydrochloride ropinirole hydrochloride RYTARY selegiline hcl CAPS; TABS ZELAPAR 2 5 2 2 4 2 4 4 NM, LA, PA PA; PA if 65 years and older B/D, NM 4 2 2 4 2 5 ANTIPSYCHOTICS ABILIFY DISCMELT TAB 10MG ABILIFY MAINTENA aripiprazole odt aripiprazole oral solution 1 mg/ml aripiprazole tabs chlorpromaz inj 25mg/ml chlorpromazine hcl TABS clozapine TABS 25mg, 50mg 5 5 5 5 5 4 2 2 QL (60 tabs / 30 days) QL (1 injection / 28 days) QL (60 tabs / 30 days) QL (900ml / 30 days) QL (30 tabs / 30 days) 38 Drug Name clozapine TABS 100mg clozapine TABS 200mg CLOZAPINE TBDP 150mg CLOZAPINE TBDP 200mg CLOZAPINE ODT 12.5mg, 25mg CLOZAPINE ODT 100mg FANAPT FANAPT TITRATION PACK FAZACLO 150mg FAZACLO 200mg fluphenazine decanoate SOLN fluphenazine hcl GEODON INJ haloperidol TABS haloperidol decanoate SOLN haloperidol lactate haloperidol lactate inj 5 mg/ml INVEGA 1.5mg, 3mg, 9mg INVEGA 6mg INVEGA SUST INJ 39 MG/0.25 ML INVEGA SUST INJ 78 MG/0.5 ML INVEGA SUST INJ 117 MG/0.75 ML INVEGA SUST INJ 156MG/ML INVEGA SUST INJ 234 MG/1.5 ML INVEGA TRINZA LATUDA 20mg LATUDA 40mg, 120mg LATUDA 60mg, 80mg loxapine succinate olanzapine SOLR olanzapine TABS 2.5mg, 5mg, 7.5mg olanzapine TABS 10mg, 15mg, 20mg olanzapine odt 5mg olanzapine odt 10mg, 15mg, 20mg ORAP paliperidone 1.5mg, 3mg, 9mg paliperidone 6mg perphenazine TABS pimozide quetiapine fumarate Drug Tier Requirements/Limits 2 QL (270 tabs / 30 days) 2 QL (135 tabs / 30 days) 5 QL (180 tabs / 30 days), PA 5 QL (135 tabs / 30 days), PA 2 PA 2 QL (270 tabs / 30 days), PA 4 QL (60 tabs / 30 days), ST 4 ST 5 QL (180 tabs / 30 days), PA 5 QL (135 tabs / 30 days), PA 2 2 4 QL (6 mL / 3 days) 2 2 2 2 4 QL (30 tabs / 30 days) 4 QL (60 tabs / 30 days) 4 QL (1 injection / 28 days) 5 QL (1 injection / 28 days) 5 QL (1 injection / 28 days) 5 QL (1 injection / 28 days) 5 QL (1 injection / 28 days) 5 QL (1 syringe / 90 days) 4 QL (240 tabs / 30 days) 4 QL (30 tabs / 30 days) 4 QL (60 tabs / 30 days) 2 2 QL (3 vials / 1 day) 2 QL (30 tabs / 30 days) 2 QL (60 tabs / 30 days) 2 QL (30 tabs / 30 days) 2 QL (60 tabs / 30 days) 4 2 QL (30 tabs / 30 days) 2 QL (60 tabs / 30 days) 2 2 2 QL (90 tabs / 30 days) 39 Drug Name REXULTI 1mg REXULTI 2mg REXULTI 3mg, 4mg REXULTI .5mg REXULTI .25mg RISPERDAL INJ 12.5MG RISPERDAL INJ 25MG RISPERDAL INJ 37.5MG RISPERDAL INJ 50MG risperidone SOLN risperidone TABS 1mg, 2mg, 3mg risperidone TABS 4mg risperidone TABS .25mg, .5mg risperidone odt 1mg, 2mg, 3mg risperidone odt 4mg risperidone odt .25mg, .5mg SAPHRIS 2.5mg SAPHRIS 5mg SAPHRIS 10mg SEROQUEL XR 50mg SEROQUEL XR 150mg, 200mg SEROQUEL XR 300mg, 400mg thioridazine hcl TABS thiothixene trifluoperazine hcl VERSACLOZ ziprasidone hcl 20mg, 40mg ziprasidone hcl 60mg, 80mg ZYPREXA RELPREVV 300mg ZYPREXA RELPREVV 405mg ZYPREXA RELPREVV INJ 210MG Drug Tier Requirements/Limits 5 QL (90 tabs / 30 days), ST 5 QL (60 tabs / 30 days), ST 5 QL (30 tabs / 30 days), ST 5 QL (180 tabs / 30 days), ST 5 QL (360 tabs / 30 days), ST 4 QL (2 injections / 28 days) 4 QL (2 injections / 28 days) 5 QL (2 injections / 28 days) 5 QL (2 injections / 28 days) 2 QL (240 mL / 30 days) 2 QL (60 tabs / 30 days) 2 QL (120 tabs / 30 days) 2 QL (90 tabs / 30 days) 2 QL (60 tabs / 30 days) 2 QL (120 tabs / 30 days) 2 QL (90 tabs / 30 days) 4 QL (240 tabs / 30 days) 4 QL (120 tabs / 30 days) 4 QL (60 tabs / 30 days) 4 QL (120 tabs / 30 days) 4 QL (30 tabs / 30 days) 4 QL (60 tabs / 30 days) 4 PA; PA if 65 years and older 2 2 5 QL (600 mL / 30 days), PA 2 QL (60 caps / 30 days) 2 QL (90 caps / 30 days) 5 QL (2 vials / 28 days), PA 5 QL (1 vial / 28 days), PA 5 QL (2 vials / 28 days), PA ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine cap amphetamine cap amphetamine cap amphetamine cap amphetamine cap 10mg er 15mg er 20mg er 25mg er 30mg er 2 2 2 2 2 QL QL QL QL QL (90 caps (30 caps (30 caps (30 caps (30 caps / / / / / 30 days) 30 days) 30 days) 30 days) 30 days) 40 Drug Name Drug Tier Requirements/Limits amphetamine-dextroamphetamine cap sr 2 QL (90 caps / 30 days) 24hr 5 mg amphetamine-dextroamphetamine tab 5 2 QL (360 tabs / 30 days) mg amphetamine-dextroamphetamine tab 7.5 2 QL (240 tabs / 30 days) mg amphetamine-dextroamphetamine tab 10 2 QL (180 tabs / 30 days) mg amphetamine-dextroamphetamine tab 12.52 QL (144 tabs / 30 days) mg amphetamine-dextroamphetamine tab 15 2 QL (120 tabs / 30 days) mg amphetamine-dextroamphetamine tab 20 2 QL (90 tabs / 30 days) mg amphetamine-dextroamphetamine tab 30 2 QL (60 tabs / 30 days) mg APTENSIO XR 10mg, 15mg, 20mg, 30mg 4 QL (60 caps / 30 days) APTENSIO XR 40mg, 50mg, 60mg 4 QL (30 caps / 30 days) DAYTRANA 4 QL (30 patches / 30 days) guanfacine hcl (adhd) 4 PA; PA if 65 years and older metadate er tab 20mg 2 QL (90 tabs / 30 days) methylphenidate hcl CHEW 2 QL (180 tabs / 30 days) methylphenidate hcl CP24 20mg, 30mg 2 QL (60 caps / 30 days) methylphenidate hcl CP24 40mg 2 QL (30 caps / 30 days) methylphenidate hcl CPCR 10mg, 20mg, 2 QL (60 caps / 30 days) 30mg methylphenidate hcl CPCR 40mg, 50mg, 2 QL (30 caps / 30 days) 60mg methylphenidate hcl SOLN 5mg/5ml 2 QL (1800 mL / 30 days) methylphenidate hcl SOLN 10mg/5ml 2 QL (900 mL / 30 days) methylphenidate hcl TABS 5mg, 10mg 2 QL (180 tabs / 30 days) methylphenidate hcl TABS 20mg 2 QL (90 tabs / 30 days) methylphenidate hcl TB24 2 QL (60 tabs / 30 days) methylphenidate hcl TBCR 2 QL (90 tabs / 30 days) methylphenidate hcl er TB24 27mg, 36mg2 QL (60 tabs / 30 days) methylphenidate hcl er TB24 54mg 2 QL (30 tabs / 30 days) QUILLIVANT XR 4 QL (360 mL / 30 days) RITALIN LA 10mg 4 QL (180 tabs / 30 days) RITALIN LA 60mg 4 QL (30 caps / 30 days) STRATTERA 10mg, 18mg, 25mg 4 QL (120 caps / 30 days) STRATTERA 40mg 4 QL (60 caps / 30 days) STRATTERA 60mg, 80mg, 100mg 4 QL (30 caps / 30 days) VYVANSE 10mg, 20mg, 30mg 4 QL (60 caps / 30 days) VYVANSE 40mg, 50mg, 60mg, 70mg 4 QL (30 caps / 30 days) HYPNOTICS HETLIOZ 5 NM, LA, PA 41 Drug Name ROZEREM SILENOR 3mg SILENOR 6mg temazepam 7.5mg temazepam 15mg zolpidem tartrate TABS MIGRAINE Drug Tier Requirements/Limits 4 QL (30 tabs / 30 days) 3 QL (60 tabs / 30 days) 3 QL (30 tabs / 30 days) 2 QL (30 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year 2 QL (60 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year 4 QL (30 tabs / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year almotriptan malate ALSUMA 2 4 AXERT 4 cafergot tab 1-100mg dihydroergotamine mesylate 1mg/ml DIHYDROERGOTAMINE MESYLATE 4mg/ml ergomar FROVA TAB 2.5MG 4 2 5 migergot naratriptan hcl RELPAX rizatriptan benzoate SUMATRIPTAN INJ 4MG/0.5ML 5 2 3 2 2 4 4 sumatriptan inj 6mg/0.5ml SOAJ; SOLN; 2 SOSY SUMATRIPTAN INJ 6MG/0.5ML SOCT 2 SUMATRIPTAN SUCCINATE SOLN 5mg/act2 SUMATRIPTAN SUCCINATE SOLN 20mg/act sumatriptan succinate TABS SUMAVEL DOSEPRO 2 TREXIMET zolmitriptan TABS zolmitriptan odt 5 2 2 2 5 QL (12 tabs / 30 days) QL (12 injections / 30 days), ST QL (12 tabs / 30 days), ST QL (8 mL / 30 days) QL (18 tabs / 30 days), ST QL (9 tabs / 30 days) QL (12 tabs / 30 days) QL (18 tabs / 30 days) QL (12 injections / 30 days) QL (12 injections / 30 days) QL (12 injections / 30 days) QL (24 inhalers / 30 days) QL (12 inhalers / 30 days) QL (9 tabs / 30 days) QL (12 injections / 30 days) QL (9 tabs / 30 days), ST QL (12 tabs / 30 days) QL (12 tabs / 30 days) 42 Drug Name ZOMIG NASAL SPRAY Drug Tier Requirements/Limits 4 QL (12 inhalers / 30 days) MISCELLANEOUS BRISDELLE EQUETRO GRALISE 300mg GRALISE 600mg GRALISE STARTER HORIZANT lithium carbonate CAPS; TABS lithium carbonate TBCR LITHIUM SOLN 8MEQ/5ML MESTINON SYRUP MESTINON TIMESPAN NUEDEXTA pyridostigmine bromide TABS; TBCR riluzole SAVELLA 12.5mg SAVELLA 25mg SAVELLA 50mg SAVELLA 100mg SAVELLA TITRATION PACK tetrabenazine 12.5mg 4 4 3 3 3 4 1 2 3 4 4 3 2 2 4 4 4 4 4 5 tetrabenazine 25mg 5 XENAZINE 12.5mg 5 XENAZINE 25mg 5 MULTIPLE SCLEROSIS AGENTS AMPYRA AUBAGIO 5 5 AVONEX 5 AVONEX PEN 5 BETASERON 5 COPAXONE INJ 20MG/ML 5 COPAXONE INJ 40MG/ML 5 EXTAVIA 5 GILENYA CAP 0.5MG 5 QL (180 tabs / 30 days) QL (90 tabs / 30 days) PA QL QL QL QL (480 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) QL (240 tabs / NM, PA QL (120 tabs / NM, PA QL (240 tabs / NM, LA, PA QL (120 tabs / NM, LA, PA 30 days), 30 days), 30 days), 30 days), NM, LA, PA QL (30 tabs / 30 days), NM, LA, PA QL (4 injections / 28 days), NM, PA QL (4 injections / 28 days), NM, PA QL (14 syringes / 28 days), NM, PA QL (30 syringes / 30 days), NM, PA QL (12 syringes / 28 days), NM, PA QL (15 syringes / 30 days), NM, PA QL (28 caps / 28 days), NM, PA 43 Drug Name LEMTRADA PLEGRIDY SOPN PLEGRIDY SOSY PLEGRIDY STARTER PACK SOPN PLEGRIDY STARTER PACK SOSY REBIF REBIF REBIDOSE REBIF REBIDOSE TITRATION REBIF TITRATION PACK TECFIDERA CAP 120MG TECFIDERA CAP 240MG TECFIDERA MIS STARTER TYSABRI Drug Tier Requirements/Limits 5 NM, LA, PA 5 QL (2 pens / 28 days), NM, PA 5 QL (2 syringes / 28 days), NM, PA 5 QL (2 pens / 28 days), NM, PA 5 QL (2 syringes / 28 days), NM, PA 5 QL (6 mL / 28 days), NM, PA 5 QL (6 mL / 28 days), NM, PA 5 QL (6 mL boxes / 28 days), NM, PA 5 QL (6 mL / 30 days), NM, PA 5 QL (14 caps / 7 days), NM, LA, PA 5 QL (60 caps / 30 days), NM, LA, PA 5 NM, LA, PA 5 NM, LA, PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS BOTOX INJ 100UNIT BOTOX INJ 200UNIT dantrolene sodium CAPS tizanidine XEOMIN 50unit XEOMIN 100unit NARCOLEPSY/CATAPLEXY 2 5 5 2 2 4 5 modafinil 100mg 2 modafinil 200mg 5 NUVIGIL 50mg 4 NUVIGIL 150mg 4 NUVIGIL 200mg, 250mg 4 XYREM PSYCHOTHERAPEUTIC-MISC acamprosate calcium BUNAVAIL MIS 2.1-0.3MG 5 2 4 NM, PA NM, PA NM, PA NM, PA QL (30 tabs / 30 days), PA QL (60 tabs / 30 days), PA QL (150 tabs / 30 days), PA QL (60 tabs / 30 days), PA QL (30 tabs / 30 days), PA QL (540 mL / 30 days), LA, PA QL (120 buccal films / 30 days), PA 44 Drug Name BUNAVAIL MIS 4.2-0.7MG BUNAVAIL MIS 6.3-1MG buprenorphine hcl SUBL buprenorphine hcl-naloxone hcl sl buproban bupropion hcl (smoking deterrent) CHANTIX CHANTIX CONTINUING MONTH CHANTIX STARTER PACK disulfiram TABS naloxone hcl SOLN naltrexone hcl TABS NICOTROL INHALER NICOTROL NS SARAFEM SUBOXONE MIS 2-0.5MG SUBOXONE MIS 4-1MG SUBOXONE MIS 8-2MG SUBOXONE MIS 12-3MG VIVITROL ZUBSOLV SUB 1.4-0.36MG ZUBSOLV SUB 2.9-0.71MG ZUBSOLV SUB 5.7-1.4MG ZUBSOLV SUB 8.6-2.1MG ZUBSOLV SUB 11.4-2.9MG ENDOCRINE AND METABOLIC ANDROGENS Drug Tier Requirements/Limits 4 QL (120 buccal films / 30 days), PA 4 QL (60 buccal films / 30 days), PA 2 PA 2 QL (120 tabs / 30 days), PA 2 2 4 PA 4 PA 4 PA 2 2 2 4 4 4 4 QL (120 SL films / 30 days), PA 4 QL (120 SL films / 30 days), PA 4 QL (120 SL films / 30 days), PA 4 QL (60 SL films / 30 days), PA 5 NM 4 QL (120 tabs / 30 days), PA 4 QL (120 tabs / 30 days), PA 4 QL (120 tabs / 30 days), PA 4 QL (60 tabs / 30 days), PA 4 QL (60 tabs / 30 days), PA ANDRODERM 4 ANDROGEL 20.25mg/1.25gm, 40.5mg/2.5gm ANDROGEL 25mg/2.5gm 4 ANDROGEL 1% 4 4 QL (30 patches / 30 days), PA QL (150 grams / 30 days), PA QL (300 grams / 30 days), PA QL (300 grams / 30 days), PA 45 Drug Name ANDROGEL 1.62% ANDROGEL PUMP AXIRON depo-testosterone 100mg/ml FORTESTA oxandrolone oxandrolone STRIANT TABS 2.5mg TABS 10mg TESTIM testosterone cypionate SOLN testosterone enanthate SOLN VOGELXO VOGELXO PUMP ANTIDIABETICS, INJECTABLE ALCOHOL SWABS APIDRA APIDRA SOLOSTAR BYDUREON PEN BYDUREON SUSR BYETTA GAUZE PADS 2X2 HUMALOG HUMALOG KWIKPEN HUMALOG MIX 50/50 HUMALOG MIX 50/50 KWIKPEN HUMALOG MIX 75/25 HUMALOG MIX 75/25 KWIKPEN HUMULIN 70/30 HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 (CONCENTRATE) INSULIN PEN NEEDLES INSULIN SAFETY NEEDLES INSULIN SYRINGES LANTUS LANTUS SOLOSTAR LEVEMIR Drug Tier Requirements/Limits 4 QL (150 grams / 30 days), PA 4 QL (300 grams / 30 days), PA 3 QL (440 mL / 30 days), PA 4 PA 4 QL (120 grams / 30 days), PA 2 PA 5 PA 4 QL (60 buccal systems / 30 days), PA 4 QL (300 grams / 30 days), PA 2 PA 2 PA 4 QL (300 grams / 30 days), PA 4 QL (300 grams / 30 days), PA 3 4 4 3 3 4 3 4 4 4 4 4 4 4 4 4 4 4 5 3 3 3 3 3 3 QL (4 pens / 28 days) QL (4 vials / 28 days) QL (1 pen / 30 days) B/D 46 Drug Name LEVEMIR FLEXTOUCH NOVOLIN 70/30 NOVOLIN 70/30 RELION NOVOLIN N NOVOLIN N RELION NOVOLIN R NOVOLIN R RELION NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/30 NOVOLOG MIX 70/30 PREFILL NOVOLOG PENFILL SYMLINPEN 60 SYMLINPEN 120 TANZEUM TOUJEO SOLOSTAR TRULICITY VICTOZA ANTIDIABETICS, ORAL acarbose ACTOPLUS MET XR 15-1000MG ACTOPLUS MET XR 30-1000MG FARXIGA 5mg FARXIGA 10mg glimepiride 1mg glimepiride 2mg glimepiride 4mg glipizide TABS 5mg glipizide TABS 10mg glipizide er 2.5mg glipizide er 5mg glipizide er 10mg glipizide-metformin 2.5-250 mg glipizide-metformin 2.5-500 mg glipizide-metformin 5-500mg GLUMETZA 500mg GLUMETZA 1000mg GLYSET GLYXAMBI INVOKAMET TAB 50-500MG INVOKAMET TAB 50-1000 INVOKAMET TAB 150-500 INVOKAMET TAB 150-1000 INVOKANA TAB 100MG INVOKANA TAB 300MG JANUMET Drug Tier Requirements/Limits 3 3 4 3 4 3 4 3 3 3 3 3 4 PA 5 PA 4 QL (4 pens / 28 days) 3 4 QL (4 pens / 28 days) 3 QL (3 pens / 30 days) 2 4 4 3 3 1 1 1 1 1 1 1 1 1 1 1 4 4 4 4 3 3 3 3 3 3 3 QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL (60 tabs / 30 days) (30 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (120 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) QL QL QL QL QL QL QL QL (30 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (90 tabs / 30 days) (30 tabs / 30 days) (60 tabs / 30 days) 47 Drug Name JANUMET XR TAB 50-500MG JANUMET XR TAB 50-1000 JANUMET XR TAB 100-1000 JANUVIA JARDIANCE 10mg JARDIANCE 25mg JENTADUETO KAZANO KOMBIGLYZE XR 2.5-1000MG KOMBIGLYZE XR 5-500MG KOMBIGLYZE XR 5-1000MG metformin er 500mg metformin er 750mg metformin hcl TABS 500mg metformin hcl TABS 850mg metformin hcl TABS 1000mg metformin hcl TB24 500mg metformin hcl TB24 1000mg nateglinide NESINA 6.25mg NESINA 12.5mg NESINA 25mg ONGLYZA OSENI TAB 12.5-15MG OSENI TAB 12.5-30MG OSENI TAB 12.5-45MG OSENI TAB 25-15MG OSENI TAB 25-30MG OSENI TAB 25-45MG pioglitazone hcl pioglitazone hcl-glimepiride pioglitazone hcl-metformin hcl PRANDIMET repaglinide 2mg repaglinide .5mg, 1mg RIOMET TRADJENTA XIGDUO XR TAB 5-500MG XIGDUO XR TAB 5-1000MG XIGDUO XR TAB 10-500MG XIGDUO XR TAB 10-1000MG BISPHOSPHONATES alendronate sodium SOLN alendronate sodium TABS BINOSTO FOSAMAX PLUS D Drug Tier Requirements/Limits 3 QL (60 tabs / 30 days) 3 QL (60 tabs / 30 days) 3 QL (30 tabs / 30 days) 3 QL (30 tabs / 30 days) 4 QL (60 tabs / 30 days) 4 QL (30 tabs / 30 days) 3 QL (60 tabs / 30 days) 4 QL (60 tabs / 30 days) 4 QL (60 tabs / 30 days) 4 QL (30 tabs / 30 days) 4 QL (30 tabs / 30 days) 1 QL (120 tabs / 30 days) 1 QL (60 tabs / 30 days) 1 QL (150 tabs / 30 days) 1 QL (90 tabs / 30 days) 1 QL (75 tabs / 30 days) 1 QL (150 tabs / 30 days) 1 QL (75 tabs / 30 days) 1 QL (90 tabs / 30 days) 4 QL (120 tabs / 30 days) 4 QL (60 tabs / 30 days) 4 QL (30 tabs / 30 days) 4 QL (30 tabs / 30 days) 4 QL (60 tabs / 30 days) 4 QL (30 tabs / 30 days) 4 QL (30 tabs / 30 days) 4 QL (30 tabs / 30 days) 4 QL (30 tabs / 30 days) 4 QL (30 tabs / 30 days) 1 QL (30 tabs / 30 days) 1 QL (30 tabs / 30 days) 1 QL (90 tabs / 30 days) 4 QL (150 tabs / 30 days) 1 QL (240 tabs / 30 days) 1 QL (120 tabs / 30 days) 4 QL (946 mL / 30 days) 3 QL (30 tabs / 30 days) 3 QL (60 tabs / 30 days) 3 QL (60 tabs / 30 days) 3 QL (30 tabs / 30 days) 3 QL (30 tabs / 30 days) 2 1 4 4 QL (300 mL / 28 days) ST 48 Drug Name ibandronate sodium Drug Tier Requirements/Limits 2 B/D, QL (1 injection / 90 days) ibandronate tab 150mg 2 B/D pamidronate disodium SOLN 2 B/D RISEDRONATE SODIUM TABS 5mg, 30mg 2 risedronate sodium TABS 35mg, 150mg 2 risedronate sodium TBEC 2 zoledronic inj 4mg/5ml 2 B/D, NM zoledronic inj 5/100ml 2 B/D, NM ZOMETA SOLN 5 B/D, NM CALCIUM RECEPTOR AGONISTS SENSIPAR SENSIPAR 30mg 60mg, 90mg CHELATING AGENTS CHEMET DEPEN TITRATABS EXJADE FERRIPROX TABS JADENU kionex sodium polystyrene sulfonate sps susp 15gm/60ml SYPRINE ENDOMETRIOSIS danazol CAPS LUPANETA PACK SYNAREL ENZYME REPLACEMENTS ADAGEN ALDURAZYME CARBAGLU CERDELGA CEREZYME CYSTADANE CYSTAGON ELAPRASE ELELYSO FABRAZYME KUVAN levocarnitine (metabolic modifiers) LUMIZYME MYOZYME NAGLAZYME ORFADIN PROCYSBI RAVICTI 3 5 4 5 5 5 5 2 2 2 5 NM NM NM, LA, PA NM, LA, PA NM, PA 2 5 5 NM, PA 5 5 5 5 5 5 4 5 5 5 5 2 5 5 5 5 5 5 NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, B/D NM, NM, NM, NM, NM, NM, LA, LA, LA, PA LA, LA LA, LA, PA LA, LA, PA PA PA LA, LA, LA, LA, LA, PA PA PA PA PA PA PA PA PA PA PA 49 Drug Name sodium phenylbutyrate VIMIZIM VPRIV ZAVESCA Drug Tier Requirements/Limits 5 NM 5 NM, PA 5 NM, PA 5 NM, LA, PA ESTROGENS ALORA 4 DELESTROGEN 10mg/ml depo-estradiol estrace CREA estradiol PTTW; PTWK; TABS 4 4 4 4 estradiol valerate OIL ESTRING FEMRING jinteli 2 4 4 4 MENOSTAR 4 MINIVELLE 4 norethindrone acetate-ethinyl estradiol 4 PREMARIN CREAM PREMARIN INJ VAGIFEM 4 4 4 GLUCOCORTICOIDS a-hydrocort cortisone acetate TABS DEPO-MEDROL INJ 20MG/ML dexamethasone CONC; ELIX; SOLN dexamethasone TABS dexamethasone sodium phosphate dexpak taperpak 13 day FLO-PRED SUS fludrocortisone acetate TABS hydrocortisone TABS MEDROL TAB 2MG methylpr ace inj 40mg/ml methylpr ace inj 80mg/ml methylpr ss inj 1gm methylpr ss inj 40mg methylpr ss inj 125mg methylpred pak 4mg methylpred tab 4mg methylpred tab 8mg methylpred tab 16mg 2 2 4 2 1 2 4 4 2 2 4 2 2 2 2 2 2 2 2 2 PA; PA if 65 years and older PA; PA if 65 years and older PA; PA older PA; PA older PA; PA older PA; PA older if 65 years and if 65 years and if 65 years and if 65 years and B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D 50 Drug Name methylpred tab 32mg millipred pred sod pho sol 5mg/5ml prednisolone sodium phosphate prednisolone sol 15mg/5ml prednisolone sol 25mg/5ml prednisolone syrup 15 mg/5ml prednisone con 5mg/ml prednisone pak 5mg prednisone pak 10mg prednisone sol 5mg/5ml prednisone tab 1mg prednisone tab 2.5mg prednisone tab 5mg prednisone tab 10mg prednisone tab 20mg prednisone tab 50mg RAYOS TAB 1MG RAYOS TAB 2MG RAYOS TAB 5MG SOLU-CORTEF 100MG SOLU-CORTEF 250MG SOLU-CORTEF 500MG SOLU-CORTEF 1000MG SOLU-MEDROL INJ 2GM veripred GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT KORLYM PROGLYCEM SUS 50MG/ML HUMAN GROWTH HORMONES Drug Tier Requirements/Limits 2 B/D 4 B/D 2 B/D 2 B/D 2 B/D 2 B/D 1 B/D 3 B/D 2 B/D 2 B/D 2 B/D 1 B/D 1 B/D 1 B/D 1 B/D 1 B/D 1 B/D 5 B/D 5 B/D 5 B/D 4 4 4 4 4 B/D 4 B/D 3 3 5 4 GENOTROPIN 5 GENOTROPIN MINIQUICK .2mg 4 GENOTROPIN MINIQUICK .4mg, .6mg, 5 .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg HUMATROPE 5 HUMATROPE COMBO PACK 5 NORDITROPIN FLEXPRO 5 NORDITROPIN NORDIFLEX PEN 5 NUTROPIN AQ INJ 20MG/2ML 5 NUTROPIN AQ NUSPIN 5 5 NUTROPIN AQ PEN 5 OMNITROPE 5.8MG 5 OMNITROPE 5MG 5 NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, NM, NM, NM, NM, NM, NM, NM, NM, LA, LA, PA PA LA, LA, LA, LA, LA, PA PA PA PA PA PA PA 51 Drug Name OMNITROPE 10MG SAIZEN SAIZEN CLICK.EASY SEROSTIM ZOMACTON ZORBTIVE MISCELLANEOUS AFREZZA cabergoline calcitonin (salmon) nasal spray CHORIONIC GONADOTROPIN SOLR EGRIFTA 1mg FORTICAL SPR 200/ACT H.P. ACTHAR Drug Tier Requirements/Limits 5 NM, LA, PA 5 NM, LA, PA 5 NM, LA, PA 5 NM, LA, PA 5 NM, PA 5 NM, PA 4 2 2 2 5 3 5 INCRELEX 5 methylergonovine maleate TABS 2 MIACALCIN INJ 200U/ML 5 NOVAREL INJ 10000UNT 2 octreotide acetate 50mcg/ml, 100mcg/ml 2 octreotide acetate 200mcg/ml, 5 500mcg/ml, 1000mcg/ml PREGNYL W/DILUENT BENZYL 2 PROLIA 4 raloxifene hcl SAMSCA SANDOSTATIN LAR DEPOT SIGNIFOR SIGNIFOR LAR SOMATULINE DEPOT SOMAVERT XGEVA NM, PA NM, LA, PA QL (1.5 ml / 1 day), NM, LA, PA NM, LA, PA B/D NM, PA NM, PA NM, PA NM, PA QL (1 syringe / 180 days), NM 2 5 5 5 5 5 5 5 NM, NM, NM, NM, NM, NM, NM, 5 5 NM, PA NM, PA PA PA LA, PA LA, PA PA LA, PA PA PARATHYROID HORMONES FORTEO NATPARA PHOSPHATE BINDER AGENTS AURYXIA calcium acetate (phosphate binder) FOSRENOL PHOSLYRA RENAGEL 400mg RENAGEL 800mg RENVELA PAK RENVELA TAB 800MG VELPHORO 5 2 5 4 4 5 5 5 5 52 Drug Name Drug Tier Requirements/Limits PROGESTINS CRINONE medroxyprogesterone acetate norethindrone acetate TABS progesterone micronized CAPS THYROID AGENTS levothyroxine sodium TABS LEVOXYL liothyronine sodium SOLN; TABS methimazole TABS propylthiouracil TABS SYNTHROID TIROSINT UNITHROID 4 1 2 2 1 1 2 1 2 4 4 1 VASOPRESSINS DESMOPRESSIN ACETATE SOLN desmopressin acetate TABS desmopressin acetate inj desmopressin acetate spray desmopressin acetate spray refrigerated STIMATE 2 2 2 2 2 5 NM GASTROINTESTINAL ANTIEMETICS AKYNZEO ALOXI CESAMET 4 5 5 compro supp dronabinol 2.5mg, 5mg 2 2 dronabinol 5 10mg EMEND CAP 40MG EMEND CAP 80MG EMEND CAP 125MG EMEND PAK 80 & 125 granisetron hcl SOLN granisetron hcl TABS meclizine hcl TABS metoclopramide hcl SOLN; TABS metoclopramide hcl TBDP metoclopramide hcl inj 5 mg/ml ondansetron hcl TABS ondansetron hcl inj ondansetron hcl oral soln ondansetron odt 4 4 4 4 2 2 2 1 2 2 2 2 2 2 B/D B/D, QL (60 caps / 30 days) B/D, QL (60 caps / 30 days) B/D, QL (60 caps / 30 days) B/D B/D B/D B/D B/D B/D B/D B/D 53 Drug Name phenadoz phenergan SUPP prochlorperazine inj 5 mg/ml prochlorperazine maleate TABS prochlorperazine supp promethazine hcl SOLN; SUPP; SYRP; TABS promethegan SANCUSO TRANSDERM-SCOP ZUPLENZ ANTISPASMODICS ATROPINE SULFATE SOLN .05mg/ml, .1mg/ml BENTYL SOLN CANTIL CUVPOSA dicyclomine hcl CAPS; TABS dicyclomine hcl SOLN glycate glycopyrrolate SOLN; TABS methscopolamine bromide TABS H2-RECEPTOR ANTAGONISTS cimetidine TABS cimetidine sol 300/5ml famotidine SUSR famotidine TABS 20mg, 40mg famotidine inj nizatidine ranitidine hcl CAPS ranitidine hcl SOLN ranitidine hcl SYRP ranitidine hcl TABS 150mg, 300mg Drug Tier Requirements/Limits 4 PA; PA if 65 years and older 4 PA; PA if 65 years and older 2 1 2 4 PA; PA if 65 years and older 4 PA; PA if 65 years and older 5 QL (4 patches / 30 days) 4 QL (10 patches / 30 days), PA; PA if 65 years and older 5 B/D 2 4 4 4 1 2 4 2 2 2 2 2 1 2 2 2 2 2 1 INFLAMMATORY BOWEL DISEASE APRISO ASACOL HD balsalazide disodium budesonide CP24 CANASA colocort DELZICOL DIPENTUM 3 4 2 5 5 2 4 5 54 Drug Name ENTYVIO GIAZO HYDROCORTISONE (INTRARECTAL) LIALDA mesalamine enema PENTASA SF-ROWASA sulfasalazine dr sulfasalazine ir UCERIS FOAM UCERIS TB24 LAXATIVES COLYTE-FLAVOR PACKS constulose enulose gaviltye-g gavilyte-c gavilyte-h gavilyte-n generlac GOLYTELY kristalose lactulose lactulose (encephalopathy) MOVIPREP NULYTELY/FLAVOR PACKS OSMOPREP PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE peg 3350-potassium chloride-sod bicarbonate-sod chloride polyethylene glycol 3350 PACK; POWD PREPOPIK RELISTOR SUCLEAR SUPREP BOWEL PREP trilyte MISCELLANEOUS alosetron hcl AMITIZA amoxicillin-clarithromycin w/ lansoprazole CARAFATE SUSP cromolyn sodium (mastocytosis) diphenoxylate w/ atropine GATTEX LINZESS Drug Tier Requirements/Limits 5 NM, PA 5 2 4 2 4 5 2 2 4 5 4 2 2 1 1 2 2 2 3 3 2 2 4 3 4 1 2 2 4 5 4 4 2 5 3 2 4 5 2 5 3 PA PA NM, LA, PA 55 Drug Name loperamide hcl CAPS misoprostol TABS MOVANTIK OMECLAMOX-PAK PYLERA SUCRAID sucralfate TABS ursodiol CAPS; TABS XIFAXAN TAB 550MG Drug Tier Requirements/Limits 1 2 3 4 5 5 LA 2 2 5 PA PANCREATIC ENZYMES CREON PANCREAZE PERTZYE ULTRESA VIOKACE 10 VIOKACE 20 ZENPEP 3 4 4 4 4 5 4 PROTON PUMP INHIBITORS ACIPHEX SPR CAP 5MG ACIPHEX SPR CAP 10MG DEXILANT esomeprazole sodium inj lansoprazole CPDR NEXIUM CAP 20MG NEXIUM CAP 40MG NEXIUM GRA 2.5MG DR NEXIUM GRA 5MG DR NEXIUM GRA 10MG DR 4 4 3 2 2 2 2 3 3 3 NEXIUM GRA 20MG DR 3 NEXIUM GRA 40MG DR 3 omeprazole CPDR 10mg, 40mg omeprazole CPDR 20mg OMEPRAZOLE-SODIUM BICARBONATE pantoprazole sodium PREVACID SOLUTAB PRILOSEC PACK PROTONIX PACK 1 1 2 1 4 3 4 rabeprazole sodium ZEGERID PACK 2 4 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl QL (60 caps / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days) QL (30 packets / 30 days) QL (30 packets / 30 days) QL (30 packets / 30 days) QL (30 caps / 30 days) QL (60 caps / 30 days) QL (30 caps / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 packets / 30 days) QL (30 tabs / 30 days) QL (30 packets / 30 days) 2 56 Drug Name AVODART CARDURA XL dutasteride finasteride TABS 5mg JALYN RAPAFLO tamsulosin hcl MISCELLANEOUS bethanechol chloride TABS ELMIRON potassium citrate (alkalinizer) 15meq POTASSIUM CITRATE (ALKALINIZER) 540mg, 1080mg URINARY ANTISPASMODICS ENABLEX GELNIQUE MYRBETRIQ oxybutynin chloride SYRP oxybutynin chloride TABS; TB24 OXYTROL tolterodine tartrate er tolterodine tartrate tab 1 mg tolterodine tartrate tab 2 mg TOVIAZ trospium chloride trospium chloride er VESICARE Drug Tier Requirements/Limits 4 4 2 1 4 4 ST 2 2 4 2 2 4 4 4 1 2 4 2 2 2 3 2 2 4 ST ST VAGINAL ANTI-INFECTIVES AVC CLEOCIN VAG SUPP 100MG clindamycin cre 2% vag CLINDESSE metronidazole vaginal miconazole 3 sup 200mg NUVESSA terconazole vaginal VANDAZOLE zazole .4% ZAZOLE .8% 4 4 2 4 2 2 4 2 2 2 2 HEMATOLOGIC ANTICOAGULANTS COUMADIN ELIQUIS TAB 2.5MG ELIQUIS TAB 5MG 4 3 3 57 Drug Name Drug Tier Requirements/Limits enoxaparin sodium 30mg/0.3ml, 2 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 300mg/3ml enoxaparin sodium 100mg/ml, 5 120mg/0.8ml, 150mg/ml fondaparinux sodium 2.5mg/0.5ml 2 fondaparinux sodium 5mg/0.4ml, 5 7.5mg/0.6ml, 10mg/0.8ml FRAGMIN 2500unit/0.2ml, 4 5000unit/0.2ml FRAGMIN 7500unit/0.3ml, 10000unit/ml, 5 12500unit/0.5ml, 15000unit/0.6ml, 18000unt/0.72ml, 95000unit/3.8ml HEP SOD/NACL INJ 25000 3 HEPARIN (PORCINE) IN SODIUM CHLORIDE 3 100U/ML heparin sod inj 1000u/ml 2 B/D HEPARIN SOD INJ 2000U/ML 3 B/D HEPARIN SOD INJ 2500U/ML 3 B/D heparin sod inj 5000u/0.5ml 2 B/D heparin sod inj 5000u/ml 2 B/D heparin sod inj 10000u/ml 2 B/D heparin sod inj 20000u/ml 2 B/D HEPARIN SODIUM/D5W 3 HEPARIN SODIUM/NACL 0.45% 3 jantoven 1 PRADAXA 3 SAVAYSA 4 warfarin sodium 1 XARELTO 3 XARELTO STARTER PACK 3 HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE SOLN 3 10mcg/0.4ml, 25mcg/ml, 40mcg/ml, 60mcg/ml ARANESP ALBUMIN FREE SOLN 5 100mcg/ml, 150mcg/0.75ml, 200mcg/ml, 300mcg/ml ARANESP ALBUMIN FREE SOSY 3 25mcg/0.42ml, 40mcg/0.4ml, 60mcg/0.3ml ARANESP ALBUMIN FREE SOSY 5 100mcg/0.5ml, 150mcg/0.3ml, 200mcg/0.4ml, 300mcg/0.6ml, 500mcg/ml EPOGEN 2000unit/ml, 3000unit/ml, 4 4000unit/ml, 10000unit/ml EPOGEN 20000unit/ml 5 GRANIX 5 NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA NM, PA 58 Drug Name LEUKINE MIRCERA MOZOBIL NEULASTA NEULASTA DELIVERY KIT NEUMEGA NEUPOGEN PROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml PROCRIT 20000unit/ml, 40000unit/ml Drug Tier Requirements/Limits 5 NM, PA 4 NM, PA 5 NM, PA 5 NM, PA 5 NM, PA 5 NM 5 NM, PA 3 NM, PA 5 NM, PA anagrelide hcl cilostazol CINRYZE FIRAZYR pentoxifylline TBCR PROMACTA 12.5mg 2 2 5 5 2 5 NM, LA, PA NM, PA PROMACTA 25mg 5 PROMACTA 50mg 5 PROMACTA 75mg 5 RUCONEST tranexamic acid SOLN; TABS 5 2 MISCELLANEOUS QL (360 tabs / 30 days), NM, LA, PA QL (180 tabs / 30 days), NM, LA, PA QL (90 tabs / 30 days), NM, LA, PA QL (60 tabs / 30 days), NM, LA, PA NM, PA PLATELET AGGREGATION INHIBITORS AGGRENOX BRILINTA clopidogrel bisulfate 75mg clopidogrel bisulfate 300mg EFFIENT ZONTIVITY 2 3 1 2 4 4 IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA CIMZIA ENBREL ENBREL SURECLICK HUMIRA HUMIRA PEN HUMIRA PEN-CROHNS STARTER KIT HUMIRA PEN-PSORIASIS STARTER KIT hydroxychloroquine sulfate KINERET leflunomide TABS methotrexate sodium tabs 5 5 5 5 5 5 5 5 2 5 2 2 NM, NM, NM, NM, NM, NM, NM, NM, PA PA PA PA PA PA PA PA NM, PA 59 Drug Name ORENCIA OTEZLA REMICADE RHEUMATREX SIMPONI SIMPONI ARIA trexall XELJANZ Drug Tier Requirements/Limits 5 NM, PA 5 NM, PA 5 NM, PA 4 5 NM, PA 5 NM, PA 4 B/D 5 NM, PA IMMUNOGLOBULINS BIVIGAM CARIMUNE NANOFILTERED FLEBOGAMMA FLEBOGAMMA DIF GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S/D GAMMAGARD S/D IGA LESS TH GAMMAKED GAMMAPLEX 2.5gm/50ml, 5gm/100ml, 10gm/200ml GAMUNEX-C OCTAGAM 1gm/20ml, 2gm/20ml, 2.5gm/50ml, 5gm/100ml, 10gm/200ml, 25gm/500ml PRIVIGEN IMMUNOMODULATORS ACTIMMUNE ARCALYST GRASTEK INTRON-A INJ INTRON-A INJ INTRON-A INJ INTRON-A INJ RAGWITEK REVLIMID THALOMID 10MU 18MU 25MU 50MU IMMUNOSUPPRESSANTS ASTAGRAF XL 5mg ASTAGRAF XL .5mg, 1mg ATGAM azasan azathioprine TABS BENLYSTA CELLCEPT INTRAVENOUS cyclosporine CAPS; SOLN cyclosporine modified (for microemulsion) 5 5 5 5 3 5 5 5 5 5 NM, PA NM, PA NM, PA NM, PA B/D, NM NM, PA NM, PA NM, PA NM, PA NM, PA 5 5 NM, PA NM, PA 5 NM, PA 5 5 4 5 5 5 5 4 5 5 NM, LA, PA NM, PA PA B/D, NM B/D, NM B/D, NM B/D, NM PA NM, LA, PA NM, PA 5 4 5 4 2 5 4 2 2 B/D B/D B/D B/D B/D NM, PA B/D B/D B/D 60 Drug Name gengraf mycophenolate mofetil CAPS; TABS mycophenolate mofetil SUSR mycophenolate sodium 180mg mycophenolate sodium 360mg NEORAL NULOJIX PROGRAF CAPS 5mg PROGRAF CAPS .5mg, 1mg PROGRAF SOLN RAPAMUNE SOLN SANDIMMUNE SOLN SIMULECT 10mg SIMULECT 20mg SIROLIMUS TABS 2mg sirolimus TABS .5mg, 1mg tacrolimus CAPS 5mg tacrolimus CAPS .5mg, 1mg THYMOGLOBULIN ZORTRESS TAB 0.5MG ZORTRESS TAB 0.25MG ZORTRESS TAB 0.75MG Drug Tier Requirements/Limits 2 B/D 2 B/D 5 B/D 2 B/D 5 B/D 3 B/D 5 B/D 5 B/D 4 B/D 4 B/D 5 B/D 3 B/D 4 B/D 5 B/D 5 B/D 2 B/D 5 B/D 2 B/D 5 B/D 5 B/D 4 B/D 5 B/D VACCINES ACTHIB ADACEL BCG VACCINE BEXSERO BOOSTRIX CERVARIX COMVAX DAPTACEL DIPHTHERIA/TETANUS TOXOID ENGERIX-B SUSP GARDASIL GARDASIL 9 HAVRIX HIBERIX IMOVAX RABIES (H.D.C.V.) INFANRIX IPOL INACTIVATED IPV IXIARO KINRIX M-M-R II MENACTRA MENOMUNE-A/C/Y/W-135 MENVEO 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 B/D B/D 61 Drug Name PEDVAX HIB PROQUAD QUADRACEL RABAVERT RECOMBIVAX HB ROTARIX ROTATEQ SYNAGIS TENIVAC TETANUS/DIPHTHERIA TOXOID TRUMENBA TWINRIX INJ TYPHIM VI VAQTA VARIVAX YF-VAX ZOSTAVAX Drug Tier Requirements/Limits 3 3 3 3 3 B/D 3 3 5 NM 3 B/D 3 B/D 3 3 3 3 3 3 3 NUTRITIONAL/SUPPLEMENTS ELECTROLYTES ammonium chloride SOLN 4 KLOR-CON 8 2 KLOR-CON 10 2 klor-con m10 2 klor-con m15 2 klor-con m20 2 klor-con pow 20meq 2 klor-con spr cap 8meq 2 klor-con spr cap 10meq 2 MAGNESIUM SULFATE SOLN 2gm/50ml, 3 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml magnesium sulfate SOLN 50% 2 MAGNESIUM SULFATE IN D5W 3 MAGNESIUM SULFATE INJ 50% 2 POTASSIUM CHLORIDE SOLN 10%, 20% 2 potassium chloride TBCR 8meq 2 POTASSIUM CHLORIDE TBCR 20meq 2 potassium chloride caps er 2 potassium chloride microencapsulated 2 crystals cr POTASSIUM CHLORIDE TAB CR 10 MEQ 2 SODIUM CHLORIDE SOLN 2.5meq/ml 2 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F)2 MG/ML SOLN TPN ELECTROLYTES 4 IV NUTRITION AMINOSYN 4 B/D B/D 62 Drug Name AMINOSYN 7%/ELECTROLYTES AMINOSYN II AMINOSYN II 8.5%/ELECTROL AMINOSYN INJ 8.5/LYTE AMINOSYN M AMINOSYN-HBC AMINOSYN-PF 7% AMINOSYN-PF INJ 10% AMINOSYN-RF CLINIMIX 2.75%/DEXTROSE 5% CLINIMIX 4.25%/DEXTROSE 5% CLINIMIX 4.25%/DEXTROSE 10% CLINIMIX 4.25%/DEXTROSE 20% CLINIMIX 4.25%/DEXTROSE 25% CLINIMIX 5%/DEXTROSE 15% CLINIMIX 5%/DEXTROSE 20% CLINIMIX 5%/DEXTROSE 25% CLINIMIX E 2.75%/DEXTROSE 5% CLINIMIX E 2.75%/DEXTROSE 10% CLINIMIX E 4.25%/D10 CLINIMIX E 4.25%/DEXTROSE 5% CLINIMIX E 4.25%/DEXTROSE 25% CLINIMIX E 5%/DEXTROSE 15% CLINIMIX E 5%/DEXTROSE 20% CLINIMIX E 5%/DEXTROSE 25% clinisol 15 FREAMINE HBC 6.9% FREAMINE III HEPATAMINE INTRALIPID INJ 20% INTRALIPID INJ 30% LIPOSYN III NEPHRAMINE NUTRILIPID INJ 20% premasol 6% premasol 10% PROCALAMINE PROSOL TRAVASOL TROPHAMINE INJ 10% IV REPLACEMENT SOLUTIONS DEXTROSE DEXTROSE DEXTROSE DEXTROSE DEXTROSE SOLN 2.5%/NACL 0.45% 5% 5% /ELECTROLYTE 5%/LACTATED RING Drug Tier Requirements/Limits 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 2 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 2 B/D 4 B/D 4 B/D 4 B/D 4 B/D 4 B/D 2 2 2 3 2 63 Drug Name DEXTROSE 5%/NACL 0.2% DEXTROSE 5%/NACL 0.3% DEXTROSE 5%/NACL 0.9% DEXTROSE 5%/NACL 0.33% DEXTROSE 5%/NACL 0.45% DEXTROSE 5%/NACL 0.225% DEXTROSE 5%/POTASSIUM CHL DEXTROSE 10% FLEX CONTAIN DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% DEXTROSE 10%/NACL 0.45% ELECTROLYTE-R IN DEXTROSE IONOSOL-B/DEXTROSE 5% IONOSOL-MB/DEXTROSE 5% ISOLYTE P ISOLYTE S KCL0.15%/D5W/NACL0.2% KCL0.15%/D5W/NACL0.225% KCL 0.3%/D5W/LR IV LAC RI KCL 0.3%/D5W/NACL 0.9% KCL 0.3%/D5W/NACL 0.45% KCL 0.15%/D5W/LR KCL 0.15%/D5W/NACL 0.9% KCL 0.075%/D5W/NACL 0.45% KCL IN NACL INJ .15-0.45 KCL/D5W/NACL INJ 0.22%/0.45% KCL/D5W/NACL INJ .15/.33% KCL/D5W/NACL INJ .15/.45% KCL/NACL INJ 0.15%-0.9% LACTATED RINGERS VIAFLEX NORMOSOL-M IN D5W NORMOSOL-R PLASMA-LYTE A PLASMA-LYTE-56/D5W PLASMA-LYTE-148 pot chloride inj 2meq/ml POTASSIUM CHLORIDE SOLN .4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml POTASSIUM CHLORIDE 0.3%/D potassium chloride in nacl POTASSIUM CHLORIDE IN NACL RINGER'S SODIUM CHLORIDE SOLN .9%, 3%, 5% SODIUM CHLORIDE 0.45% VIA VITAMINS calcitriol CAPS; SOLN Drug Tier Requirements/Limits 2 2 2 2 2 2 2 2 3 2 4 4 4 4 4 2 3 4 2 2 4 2 2 2 2 2 2 2 2 2 4 4 4 4 2 2 2 2 2 2 2 2 2 B/D 64 Drug Name doxercalciferol CAPS 1mcg, 2.5mcg doxercalciferol CAPS .5mcg doxercalciferol SOLN HECTOROL SOLN 2mcg/ml paricalcitol CAPS PARICALCITOL SOLN PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) ZEMPLAR SOLN 2mcg/ml Drug Tier Requirements/Limits 5 B/D 2 B/D 2 B/D 4 B/D 2 B/D 2 B/D 2 4 B/D OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc blephamide OINT BLEPHAMIDE SUSP neomycin-polymy-dexameth neomycin-polymyxin-hc (ophth) PRED-G PRED-G S.O.P. sulfacetamide sod-prednisolone TOBRADEX OINT TOBRADEX ST tobramycin-dexamethasone ZYLET ANTI-INFECTIVES AZASITE bacitracin (ophthalmic) bacitracin-polymyxin b (ophth) BESIVANCE CILOXAN OIN 0.3% OP ciprofloxacin hcl (ophth) erythromycin (ophth) gatifloxacin (ophth) gentak gentamicin sulfate (ophth) OINT gentamicin sulfate (ophth) SOLN ilotycin levofloxacin (ophth) MOXEZA NATACYN neomycin-bacitracin zn-polymyxin neomycin-polymyxin-gramicidin ofloxacin (ophth) polymyxin b-trimethoprim sulfacet sod oin 10% op sulfacetamide sodium (ophth) tobramycin (ophth) 2 4 4 2 2 4 4 2 3 3 2 3 4 2 2 3 3 2 1 2 2 2 1 1 2 3 4 2 2 2 1 2 2 1 65 Drug Name TOBREX OINT 0.3% trifluridine SOLN VIGAMOX ZIRGAN Drug Tier Requirements/Limits 4 2 3 4 ANTI-INFLAMMATORIES ACUVAIL ALREX bromfenac sodium (ophth) BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) dexamethasone sodium phosphate (ophth) diclofenac sodium (ophth) DUREZOL FLAREX FLUOROMETHOLONE (OPHTH) flurbiprofen sodium FML FML FORTE ILEVRO ketorolac tromethamine (ophth) LOTEMAX MAXIDEX PRED MILD PREDNISOLONE ACETATE (OPHTH) prednisolone sodium phosphate (ophth) VEXOL ANTIALLERGICS ALOCRIL ALOMIDE azelastine drop 0.05% BEPREVE cromolyn sodium (ophth) EMADINE epinastine hcl (ophth) LASTACAFT PATADAY PATANOL PAZEO ANTIGLAUCOMA ALPHAGAN P 0.1% AZOPT betaxolol hcl (ophth) BETIMOL BETOPTIC-S brimonidine sol 0.2% BRIMONIDINE SOL 0.15% 4 3 2 2 2 2 3 4 2 1 4 4 3 2 3 3 4 2 3 4 4 4 2 3 1 4 2 4 3 4 3 3 3 2 4 3 1 2 66 Drug Name carteolol hcl (ophth) COMBIGAN COSOPT PF dorzolamide hcl dorzolamide hcl-timolol maleate ISTALOL latanoprost SOLN levobunolol hcl .5% LEVOBUNOLOL HCL .25% LUMIGAN metipranolol PHOSPHOLINE IODIDE PILOCARPINE HCL SOLN SIMBRINZA SUS 1-0.2% timolol maleate (ophth) TIMOLOL MALEATE GEL TIMOPTIC OCUDOSE TRAVATAN Z ZIOPTAN Drug Tier Requirements/Limits 1 3 4 2 2 3 1 2 2 3 2 4 2 3 1 2 4 3 4 ST MISCELLANEOUS LACRISERT naphazoline 0.1% PROLENSA proparacaine hcl SOLN RESTASIS 4 1 3 1 3 RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPT AER 62.5-25 3 COMBIVENT RESPIMAT ipratropium-albuterol STIOLTO RESPIMAT 4 2 4 ANTICHOLINERGICS ATROVENT HFA INCRUSE ELLIPTA ipratropium bromide (nasal) ipratropium sol inhal SPIRIVA HANDIHALER SPIRIVA RESPIMAT TUDORZA PRESSAIR TUDORZA PRESSAIR (INSTITUTIONAL PACK) ANTIHISTAMINE COMBINATIONS CLARINEX-D TAB 2.5-120 DYMISTA SPR 137-50 SEMPREX-D 4 3 2 2 4 4 4 4 4 4 4 QL (60 inhalations / 30 days) QL (2 inhalers / 30 days) B/D QL (1 inhaler / 30 days) QL (2 inhalers / 30 days) QL (1 inhaler / 30 days) B/D QL (30 caps / 30 days) QL (1 inhaler / 30 days) QL (1 inhaler / 30 days) QL (2 inhalers / 30 days) QL (1 bottle / 30 days) 67 Drug Name Drug Tier Requirements/Limits ANTIHISTAMINES ASTEPRO 3 azelastine spr 0.1% 2 azelastine spr 0.15% 2 cetirizine syrup 2 CLARINEX SYRP 4 desloratadine 2 diphenhydram inj 50mg/ml 2 hydroxyzine hcl SOLN 25mg/ml, 50mg/ml4 levocetirizine soln 2.5mg/5ml levocetirizine tab 5 mg olopatadine hcl (nasal) BETA AGONISTS PA; PA if 65 years and older 2 2 2 albuterol sulfate NEBU albuterol sulfate SYRP albuterol sulfate TABS albuterol sulfate er ARCAPTA NEOHALER BROVANA FORADIL AEROLIZER levalbuterol conc 1.25mg/0.5ml LEVALBUTEROL HCL NEBU 1.25mg/3ml levalbuterol hcl NEBU .31mg/3ml, .63mg/3ml PERFOROMIST PROAIR HFA PROAIR RESPICLICK PROVENTIL HFA SEREVENT DISKUS 2 1 2 2 4 4 4 2 2 2 B/D 4 4 4 4 3 STRIVERDI RESPIMAT terbutaline sulfate SOLN terbutaline sulfate TABS VENTOLIN HFA XOPENEX HFA 4 5 2 3 3 B/D QL (2 inhalers / 30 days) QL (2 inhalers / 30 days) QL (2 inhalers / 30 days) QL (60 inhalations / 30 days) QL (1 inhaler / 30 days) QL (30 caps / 30 days) B/D QL (60 caps / 30 days) B/D B/D B/D QL (2 inhalers / 30 days) QL (2 inhalers / 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium zafirlukast ZYFLO CR CHEW; PACK; TABS 2 2 5 MAST CELL STABILIZERS cromolyn sodium NEBU MISCELLANEOUS acetylcysteine SOLN 10%, 20% ARALAST NP AUVI-Q 2 B/D 2 5 3 B/D NM, LA, PA 68 Drug Name DALIRESP EPINEPHRINE SOAJ EPIPEN 2-PAK EPIPEN-JR 2-PAK ESBRIET GLASSIA KALYDECO OFEV ORKAMBI PROLASTIN-C PULMOZYME tyzine .05% XOLAIR ZEMAIRA Drug Tier Requirements/Limits 4 2 3 3 5 NM, PA 5 NM, LA, PA 5 NM, PA 5 NM, PA 5 NM, PA 5 NM, LA, PA 5 B/D, NM 4 5 NM, LA, PA 5 NM, LA, PA NASAL STEROIDS BECONASE AQ budesonide (nasal) flunisolide (nasal) fluticasone propionate (nasal) NASONEX OMNARIS QNASL QNASL CHILDRENS triamcinolone acetonide (nasal) VERAMYST ZETONNA 4 2 2 2 4 4 4 4 2 4 4 QL (2 inhalers / 30 days) QL (2 bottles / 30 days) QL (2 bottles / 30 days) QL (1 bottle / 30 days) QL (2 inhalers / 30 days) QL (1 inhaler / 30 days) QL (1 inhaler / 30 days) QL (1 inhaler / 30 days) QL (1 bottle / 30 days) QL (1 bottle / 30 days) QL (1 inhaler / 30 days) AEROSPAN ALVESCO ARNUITY ELLIPTA 4 4 3 ASMANEX ASMANEX HFA 100mcg/act ASMANEX HFA 200mcg/act budesonide (inhalation) FLOVENT DISKUS 50mcg/blist, 100mcg/blist FLOVENT DISKUS 250mcg/blist 4 4 4 2 3 FLOVENT HFA PULMICORT FLEXHALER PULMICORT INH SUSP 1MG/2ML QVAR 40mcg/act QVAR 80mcg/act 3 3 5 4 4 QL (2 inhalers / 30 days) QL (2 inhalers / 30 days) QL (30 inhalations / 30 days) QL (2 inhalers / 30 days) QL (2 inhalers / 30 days) QL (1 inhaler / 30 days) B/D QL (120 inhalations / 30 days) QL (240 inhalations / 30 days) QL (2 inhalers / 30 days) QL (2 inhalers / 30 days) B/D QL (1 inhaler / 30 days) QL (2 inhalers / 30 days) STEROID INHALANTS 3 STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS 3 QL (60 inhalations / 30 days) 69 Drug Name ADVAIR HFA BREO ELLIPTA DULERA SYMBICORT Drug Tier Requirements/Limits 3 QL (1 inhaler / 30 days) 3 QL (60 blisters / 30 days) 4 QL (1 inhaler / 30 days) 3 QL (1 inhaler / 30 days) XANTHINES aminophylline inj elixophyllin theo-24 theophylline TOPICAL DERMATOLOGY, ACNE ABSORICA ACANYA ACZONE adapalene CREA; GEL amnesteem ATRALIN AVITA AZELEX benzoyl peroxide-erythromycin claravis CLINDAGEL clindamax clindamycin phosphate (topical) clindamycin phosphate-benzoyl peroxide clindamycin phosphate-benzoyl peroxide (refrigerate) DIFFERIN LOTN EPIDUO EPIDUO FORTE ery pad 2% erythromycin (acne aid) FABIOR myorisan neuac gel 1.2-5% ONEXTON RETIN-A MICRO PUMP .08% sulfacetamide sodium (acne) tretin-x CREA tretinoin CREA TRETINOIN GEL .01% tretinoin GEL .025%, .05% TRETINOIN MICROSPHERE VELTIN zenatane ZIANA 2 4 4 2 5 4 4 2 2 4 2 4 2 2 4 2 2 2 2 4 4 4 2 2 4 2 2 4 4 2 4 2 2 2 2 4 2 4 70 Drug Name DERMATOLOGY, ANTIBIOTICS ALTABAX BACTROBAN NASAL CENTANY CORTISPORIN CREA; OINT gentamicin sulfate (topical) mupirocin OINT mupirocin calcium (topical) SILVER SULFADIAZINE CREA SSD SULFAMYLON CREA SULFAMYLON PACK Drug Tier Requirements/Limits 4 4 4 4 2 1 2 2 2 4 5 DERMATOLOGY, ANTIFUNGALS ciclopirox GEL ciclopirox cre 0.77% ciclopirox shampoo 1% ciclopirox sus 0.77% clotrimazole (topical) econazole nitrate CREA ERTACZO EXELDERM ketoconazole (topical) ketodan aer 2% LUZU MENTAX NAFTIFINE HCL NAFTIN nyamyc nystatin (topical) nystatin pow 100000 nystop OXISTAT 2 2 2 2 2 2 4 4 2 2 4 4 2 4 2 2 2 2 4 DERMATOLOGY, ANTIPRURITIC CORTIFOAM procto-pak proctosol hc 2.5 % proctozone hc PRUDOXIN CRE 5% DERMATOLOGY, ANTIPSORIATICS acitretin calcipotriene CREA; OINT; SOLN calcitrene oin 0.005% CALCITRIOL OINT COSENTYX COSENTYX SENSOREADY PEN methoxsalen rapid 4 2 2 2 2 5 2 2 2 5 5 5 PA NM, PA NM, PA 71 Drug Name 8-MOP SORILUX STELARA TAZORAC Drug Tier Requirements/Limits 4 4 5 NM, PA 4 PA DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo selenium sulfide LOTN 1 1 DERMATOLOGY, CORTICOSTEROIDS ala-cort 1 alclometasone dipropionate 2 amcinonide CREA; LOTN 2 amcinonide OINT 4 apexicon 2 apexicon e cream 4 betamethasone dipropionate (topical) 2 betamethasone dipropionate augmented 2 betamethasone valerate CREA; FOAM; 2 LOTN; OINT calcipotriene/betamethasone 5 CAPEX 4 clobetasol e cream 0.05% 2 clobetasol propionate CREA; FOAM; GEL; 2 LIQD; LOTN; OINT; SHAM; SOLN clobetasol propionate emulsion 2 CLOCORTOLONE PIVALATE 2 clodan sha 0.05% 2 CORDRAN TAPE 4 cormax 2 DESONATE 4 DESONIDE CREA 2 desonide LOTN; OINT 2 desoximetasone CREA 2 desoximetasone GEL 2 DESOXIMETASONE OINT .05% 2 desoximetasone OINT .25% 2 diflorasone diacetate 2 fluocinolone acetonide CREA; OIL; OINT; 2 SOLN fluocinonide CREA .1% 5 fluocinonide CREA .05% 2 fluocinonide GEL 2 fluocinonide OINT 2 fluocinonide SOLN 2 fluocinonide emulsified base 2 fluticasone propionate CREA; LOTN; OINT 2 halobetasol propionate 2 HALOG 4 72 Drug Name hydrocortisone (topical) CREA; OINT hydrocortisone (topical) LOTN hydrocortisone butyrate hydrocortisone butyrate hydrophilic lipo base hydrocortisone valerate LOCOID LOTN lokara mometasone furoate CREA; OINT; SOLN PANDEL PREDNICARBATE CREA prednicarbate OINT TACLONEX SUSP texacort TOPICORT SPRAY 0.25% triamcinolone acetonide (topical) AERS; LOTN triamcinolone acetonide (topical) CREA; OINT trianex triderm DERMATOLOGY, LOCAL ANESTHETICS lidocaine OINT lidocaine PTCH lidocaine hcl GEL lidocaine hcl SOLN 4% lidocaine-prilocaine SYNERA Drug Tier Requirements/Limits 1 2 2 2 2 4 2 2 4 2 2 5 4 4 2 1 4 1 2 2 2 1 2 4 PA B/D DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir topical ammonium lactate CREA; LOTN CONDYLOX GEL DENAVIR diclofenac sodium (actinic keratoses) diclofenac sodium (topical) DOXYCYCLINE (ROSACEA) ELIDEL FINACEA AER 15% FINACEA GEL 15% fluorouracil (topical) CREA 5% FLUOROURACIL (TOPICAL) CREA .5% fluorouracil (topical) SOLN imiquimod CREA laclotion lot 12% metronidazole (topical) NORITATE ORACEA 2 2 4 5 5 2 2 4 4 4 2 5 2 2 2 2 5 4 PA PA 73 Drug Name PANRETIN PENNSAID PICATO podofilox SOLN RECTIV rosadan cre 0.75% SOOLANTRA tacrolimus (topical) TARGRETIN GEL TOLAK VALCHLOR VOLTAREN GEL 1% XERESE ZOVIRAX CREA ZYCLARA Drug Tier Requirements/Limits 5 4 5 2 4 2 4 2 PA 5 NM, PA 4 5 NM, LA, PA 3 5 5 5 DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX malathion permethrin SKLICE 4 2 2 4 DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% neomycin/polymyxin b gu REGRANEX SANTYL SODIUM CHLORIDE 0.9% STERILE WATER IRRIGATION 1 2 5 4 1 2 PA MOUTH/THROAT/DENTAL AGENTS cevimeline hcl chlorhexidine gluconate (mouth-throat) clotrimazole TROC lidocaine hcl (mouth-throat) nystatin (mouth-throat) paroex sol 0.12% periogard soln 0.12% PILOCARPINE HCL (ORAL) 5mg pilocarpine hcl (oral) 7.5mg triamcinolone acetonide (mouth) OTIC acetasol hc acetic acid (otic) acetic acid sol/hc acetic acid-aluminum acetate CIPRO HC CIPRODEX COLY-MYCIN S 2 1 2 1 2 1 1 2 2 2 2 2 2 2 4 3 4 74 Drug Name CORTISPORIN-TC fluocinolone acetonide (otic) neomycin-polymyxin-hc (otic) ofloxacin (otic) Drug Tier Requirements/Limits 4 2 2 2 PART B DIABETIC METERS AND TEST STRIPS FREESTYLE FREESTYLE FREESTYLE PRECISION FREEDOM LITE KITS,STRIPS INSULINX KITS,STRIPS LITE KITS,STRIPS XTRA KITS,STRIPS 75 Index 8 8-MOP ........................................... 71 A abacavir sulfate .............................. 18 abacavir sulfate-lamivudine-zidovudine18 ABELCET........................................ 17 ABILIFY DISCMELT TAB 10MG ........... 38 ABILIFY MAINTENA.......................... 38 ABRAXANE ..................................... 24 ABSORICA ..................................... 69 ABSTRAL ....................................... 13 acamprosate calcium ....................... 44 ACANYA......................................... 69 acarbose........................................ 46 acebutolol hcl ................................. 30 acetaminophen w/ codeine................ 12 acetaminophen-caff-dihydrocod ......... 12 acetasol hc..................................... 74 acetazolamide ................................ 32 acetazolamide sodium ...................... 32 acetic acid...................................... 73 acetic acid (otic) ............................. 74 acetic acid sol/hc............................. 74 acetic acid-aluminum acetate ............ 74 acetylcysteine................................. 68 ACIPHEX SPR CAP 10MG................... 55 ACIPHEX SPR CAP 5MG .................... 55 acitretin......................................... 71 ACTEMRA....................................... 59 ACTHIB ......................................... 60 ACTIMMUNE ................................... 59 ACTOPLUS MET XR 15-1000MG.......... 46 ACTOPLUS MET XR 30-1000MG.......... 46 ACUVAIL........................................ 65 acyclovir........................................ 19 acyclovir sodium ............................. 19 acyclovir topical .............................. 73 ACZONE ........................................ 69 ADACEL ......................................... 60 ADAGEN ........................................ 49 adapalene ...................................... 69 ADCIRCA ....................................... 33 adefovir dipivoxil ............................. 19 ADEMPAS....................................... 33 adriamyc inj 50mg .......................... 23 adrucil........................................... 23 ADVAIR DISKUS.............................. 69 ADVAIR HFA ................................... 69 ADVICOR ....................................... 29 AEROSPAN ..................................... 69 afeditab cr ..................................... 31 AFINITOR ...................................... 25 AFINITOR DISPERZ ......................... 25 AFREZZA ....................................... 51 AGGRENOX .................................... 58 a-hydrocort .................................... 49 AKYNZEO....................................... 52 ala-cort ......................................... 71 ALBENZA ....................................... 16 albuterol sulfate .............................. 67 albuterol sulfate er .......................... 67 alclometasone dipropionate ............... 71 ALCOHOL SWABS ............................ 45 ALDACTAZIDE TAB 50/50 ................. 32 ALDURAZYME ................................. 49 alendronate sodium ......................... 48 alfuzosin hcl ................................... 56 ALIMTA ......................................... 23 ALINIA .......................................... 16 allopurinol tab ................................ 11 almotriptan malate .......................... 41 ALOCRIL ........................................ 65 ALOMIDE ....................................... 66 ALOPRIM ....................................... 11 ALORA .......................................... 49 alosetron hcl .................................. 55 ALOXI ........................................... 52 ALPHAGAN P 0.1% .......................... 66 alprazolam ..................................... 33 ALREX ........................................... 65 ALSUMA ........................................ 41 ALTABAX ....................................... 70 ALTOPREV...................................... 29 ALVESCO ....................................... 69 amantadine hcl ............................... 37 AMBISOME ..................................... 17 amcinonide .................................... 71 amifostine crystalline ....................... 27 amikacin sulfate .............................. 15 amiloride & hydrochlorothiazide ......... 32 amiloride hcl .................................. 32 aminophylline inj ............................. 69 AMINOSYN ..................................... 62 AMINOSYN 7%/ELECTROLYTES.......... 62 76 AMINOSYN II.................................. 62 AMINOSYN II 8.5%/ELECTROL .......... 62 AMINOSYN INJ 8.5/LYTE................... 62 AMINOSYN M.................................. 62 AMINOSYN-HBC .............................. 62 AMINOSYN-PF 7% ........................... 62 AMINOSYN-PF INJ 10% .................... 62 AMINOSYN-RF ................................ 62 amiodarone hcl ............................... 29 amiodarone inj 50mg/ml .................. 29 AMITIZA ........................................ 55 amitriptyline hcl .............................. 36 amlodipine besylate ......................... 31 amlodipine besylate/atorv................. 31 amlodipine besylate-benazepril hcl ..... 27 amlodipine besylate-valsartan tab 10-160 mg ............................................... 28 amlodipine besylate-valsartan tab 10-320 mg ............................................... 28 amlodipine besylate-valsartan tab 5-160 mg ............................................... 28 amlodipine besylate-valsartan tab 5-320 mg ............................................... 28 amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg .............................. 28 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg ................................. 28 amlodipine-valsartan-hydrochlorothiazide 10-320-25mg ................................. 28 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg ................................ 28 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg ................................... 28 ammonium chloride ......................... 61 ammonium lactate........................... 73 amnesteem .................................... 69 amoxapine ..................................... 36 amoxicillin ..................................... 22 amoxicillin & pot clavulanate ............. 22 amoxicillin-clarithromycin w/ lansoprazole .................................................... 55 amphetamine cap 10mg er ............... 40 amphetamine cap 15mg er ............... 40 amphetamine cap 20mg er ............... 40 amphetamine cap 25mg er ............... 40 amphetamine cap 30mg er ............... 40 amphetamine-dextroamphetamine cap sr 24hr 5 mg...................................... 40 amphetamine-dextroamphetamine tab 10 mg ............................................... 40 amphetamine-dextroamphetamine tab 12.5 mg ........................................ 40 amphetamine-dextroamphetamine tab 15 mg ............................................... 40 amphetamine-dextroamphetamine tab 20 mg ............................................... 40 amphetamine-dextroamphetamine tab 30 mg ............................................... 40 amphetamine-dextroamphetamine tab 5 mg ............................................... 40 amphetamine-dextroamphetamine tab 7.5 mg .......................................... 40 AMPHOTEC..................................... 17 amphotericin b ............................... 17 ampicillin & sulbactam sodium ........... 22 ampicillin cap 250mg ....................... 22 ampicillin cap 500 mg ...................... 22 ampicillin inj ................................... 22 ampicillin sodium ............................ 22 ampicillin susp ................................ 22 AMPYRA......................................... 43 anagrelide hcl ................................. 58 anastrozole .................................... 25 ANDRODERM .................................. 45 ANDROGEL..................................... 45 ANDROGEL 1% ............................... 45 ANDROGEL 1.62%........................... 45 ANDROGEL PUMP ............................ 45 ANORO ELLIPT AER 62.5-25 .............. 67 ANTARA......................................... 29 apexicon........................................ 71 apexicon e cream ............................ 71 APIDRA ......................................... 45 APIDRA SOLOSTAR .......................... 45 APLENZIN ...................................... 36 APOKYN......................................... 37 APRISO ......................................... 54 APTENSIO XR ................................. 40 APTIOM ......................................... 34 APTIVUS........................................ 18 ARALAST NP ................................... 68 ARANESP ALBUMIN FREE .................. 58 ARCALYST...................................... 59 ARCAPTA NEOHALER........................ 67 aripiprazole odt ............................... 38 aripiprazole oral solution 1 mg/ml ...... 38 77 aripiprazole tabs ............................. 38 ARNUITY ELLIPTA............................ 69 ARRANON ...................................... 23 ARZERRA ....................................... 24 ASACOL HD.................................... 54 ASMANEX ...................................... 69 ASMANEX HFA ................................ 69 ASPIRIN-CAFFEINE-DIHYDROCODEINE CAP 356.4-30-16 MG ....................... 12 ASTAGRAF XL ................................. 60 ASTEPRO ....................................... 67 atenolol ......................................... 30 atenolol & chlorthalidone .................. 30 ATGAM .......................................... 60 atorvastatin calcium ........................ 29 atovaquone .................................... 16 atovaquone-proguanil hcl tab 250-100 mg .................................................... 17 atovaquone-proguanil hcl tab 62.5-25 mg .................................................... 17 ATRALIN ........................................ 69 ATRIPLA ........................................ 19 ATROPINE SULFATE ......................... 53 ATROVENT HFA............................... 67 AUBAGIO ....................................... 43 AUGMENTIN ................................... 22 AURYXIA........................................ 52 AUVI-Q.......................................... 68 AVASTIN........................................ 24 AVC .............................................. 57 AVELOX ......................................... 21 AVITA ........................................... 69 AVODART ...................................... 56 AVONEX ........................................ 43 AVONEX PEN .................................. 43 AVYCAZ......................................... 20 AXERT ........................................... 41 AXIRON ......................................... 45 azacitidine ..................................... 23 AZACTAM/DEX INJ 1GM.................... 16 AZACTAM/DEX INJ 2GM.................... 16 azasan .......................................... 60 AZASITE ........................................ 64 azathioprine ................................... 60 azelastine drop 0.05% ..................... 66 azelastine spr 0.1% ......................... 67 azelastine spr 0.15% ....................... 67 AZELEX ......................................... 69 AZILECT ........................................ 37 azithromycin .................................. 21 AZITHROMYCIN .............................. 21 AZOPT........................................... 66 AZOR ............................................ 28 aztreonam ..................................... 16 B bacitracin (ophthalmic) .................... 64 bacitracin-polymyxin b (ophth) .......... 64 bacitracin-poly-neomycin-hc ............. 64 baclofen ........................................ 43 BACTOCILL INJ DEX 1GM.................. 22 BACTOCILL INJ DEX 2GM.................. 22 BACTROBAN NASAL ......................... 70 balsalazide disodium ........................ 54 BANZEL SUS 40MG/ML ..................... 34 BANZEL TAB 200MG ........................ 34 BANZEL TAB 400MG ........................ 34 BARACLUDE ................................... 19 BCG VACCINE ................................. 60 BECONASE AQ ................................ 68 BELEODAQ ..................................... 24 benazepril & hydrochlorothiazide........ 27 benazepril hcl ................................. 27 BENICAR ....................................... 28 BENICAR HCT ................................. 28 BENLYSTA...................................... 60 BENTYL ......................................... 53 benzoyl peroxide-erythromycin .......... 69 benztropine mesylate ....................... 37 BENZTROPINE MESYLATE ................. 37 BEPREVE ....................................... 66 BESIVANCE .................................... 64 betamethasone dipropionate (topical) . 71 betamethasone dipropionate augmented .................................................... 71 betamethasone valerate ................... 71 BETASERON ................................... 43 betaxolol hcl................................... 30 betaxolol hcl (ophth)........................ 66 bethanechol chloride ........................ 56 BETHKIS........................................ 15 BETIMOL ....................................... 66 BETOPTIC-S ................................... 66 bexarotene .................................... 26 BEXSERO ....................................... 60 bicalutamide................................... 25 BICILLIN C-R.................................. 22 78 BICILLIN L-A .................................. 22 BICNU ........................................... 23 BIDIL ............................................ 32 BILTRICIDE .................................... 16 BINOSTO ....................................... 48 bisoprolol & hydrochlorothiazide......... 30 bisoprolol fumarate.......................... 30 BIVIGAM........................................ 59 bleomycin sulfate ............................ 23 blephamide .................................... 64 BLEPHAMIDE .................................. 64 BOOSTRIX ..................................... 60 BOSULIF ........................................ 25 BOTOX INJ 100UNIT ........................ 43 BOTOX INJ 200UNIT ........................ 44 BREO ELLIPTA ................................ 69 BRILINTA....................................... 58 BRIMONIDINE SOL 0.15% ................ 66 brimonidine sol 0.2% ....................... 66 BRINTELLIX.................................... 36 BRISDELLE..................................... 42 bromfenac sodium (ophth)................ 65 BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) .................... 65 bromocriptine mesylate .................... 37 BROVANA ...................................... 67 budesonide .................................... 54 budesonide (inhalation) .................... 69 budesonide (nasal) .......................... 68 bumetanide .................................... 32 BUNAVAIL MIS 2.1-0.3MG ................ 44 BUNAVAIL MIS 4.2-0.7MG ................ 44 BUNAVAIL MIS 6.3-1MG ................... 44 buprenorphine hcl ........................... 44 buprenorphine hcl-naloxone hcl sl ...... 44 buproban ....................................... 44 bupropion hcl ................................. 36 bupropion hcl (smoking deterrent) ..... 44 buspirone hcl.................................. 34 BUSULFEX ..................................... 23 butorphanol nasal spray ................... 12 butorphanol tartrate ........................ 12 BUTRANS....................................... 12 BYDUREON .................................... 45 BYETTA ......................................... 46 BYSTOLIC ...................................... 30 C cabergoline .................................... 51 cafergot tab 1-100mg ...................... 41 calcipotriene................................... 71 calcipotriene/betamethasone ............. 71 calcitonin (salmon) nasal spray .......... 51 calcitrene oin 0.005% ...................... 71 calcitriol ........................................ 64 CALCITRIOL ................................... 71 calcium acetate (phosphate binder) .... 52 CAMPTOSAR ................................... 27 CANASA ........................................ 54 CANCIDAS ..................................... 17 candesartan cilexetil ........................ 28 candesartan cilexetil-hydrochlorothiazide .................................................... 28 CANTIL.......................................... 53 CAPASTAT SULFATE......................... 19 CAPEX ........................................... 71 capital and codeine ................................. 12 CAPRELSA...................................... 25 captopril ........................................ 27 captopril & hydrochlorothiazide .......... 27 CARAFATE...................................... 55 CARBAGLU ..................................... 49 carbamazepine ............................... 34 carbidopa....................................... 38 CARBIDOPA/LEVODOPA/ENTACAPONE 38 carbidopa-levodopa ......................... 38 carboplatin..................................... 27 CARDIZEM LA ................................. 31 CARDURA XL .................................. 56 CARIMUNE NANOFILTERED ............... 59 carteolol hcl (ophth) ........................ 66 cartia xt ........................................ 31 carvedilol ....................................... 30 CAYSTON....................................... 16 CEDAX .......................................... 20 cefaclor ......................................... 20 cefaclor er tab 500mg ...................... 20 cefadroxil....................................... 20 cefazolin inj.................................... 20 cefazolin sodium ............................. 20 cefazolin/dextrose ........................... 20 cefdinir.......................................... 20 CEFEPIME 1GM SOLN ....................... 20 CEFEPIME 2GM SOLN ....................... 20 CEFEPIME HCL AND DEXTROSE ......... 20 cefepime inj 1gm ............................ 20 79 cefepime inj 2gm ............................ 20 cefixime ........................................ 20 cefotaxime sodium .......................... 20 cefotetan disodium .......................... 20 cefoxitin sodium.............................. 20 CEFOXITIN SODIUM IN DEXTROSE ..... 20 cefpodoxime proxetil........................ 20 cefprozil ........................................ 20 ceftazidime .................................... 20 CEFTAZIDIME/DEXTROSE ................. 20 CEFTIBUTEN................................... 20 CEFTIN .......................................... 21 ceftriaxone sodium .......................... 21 cefuroxime axetil ............................ 21 cefuroxime sodium .......................... 21 celecoxib ....................................... 11 CELLCEPT INTRAVENOUS ................. 60 CELONTIN...................................... 34 CENTANY ....................................... 70 cephalexin ..................................... 21 CERDELGA ..................................... 49 CEREZYME ..................................... 49 CERVARIX ...................................... 60 CESAMET ....................................... 52 cetirizine syrup ............................... 67 cevimeline hcl................................. 74 CHANTIX ....................................... 44 CHANTIX CONTINUING MONTH.......... 44 CHANTIX STARTER PACK .................. 44 CHEMET ........................................ 48 chlorhexidine gluconate (mouth-throat) .................................................... 74 chloroquine phosphate ..................... 17 chlorothiazide tabs .......................... 32 chlorpromaz inj 25mg/ml.................. 38 chlorpromazine hcl .......................... 38 chlorthalidone................................. 32 cholestyramine ............................... 29 cholestyramine light ........................ 29 choline fenofibrate........................... 29 CHORIONIC GONADOTROPIN ............ 51 ciclopirox ....................................... 70 ciclopirox cre 0.77% ........................ 70 ciclopirox shampoo 1% .................... 70 ciclopirox sus 0.77%........................ 70 cidofovir ........................................ 19 cilostazol ....................................... 58 CILOXAN OIN 0.3% OP .................... 65 cimetidine ...................................... 53 cimetidine sol 300/5ml ..................... 54 CIMZIA.......................................... 59 CINRYZE........................................ 58 CIPRO HC ...................................... 74 CIPRODEX ..................................... 74 ciprofloxacin................................... 21 ciprofloxacin er ............................... 21 ciprofloxacin hcl .............................. 21 ciprofloxacin hcl (ophth) ................... 65 ciprofloxacin in d5w ......................... 22 ciprofloxacn inj 400mg/40ml ............. 22 cisplatin......................................... 27 citalopram hydrobromide .................. 36 cladribine....................................... 23 claforan ......................................... 21 claravis ......................................... 69 CLARINEX ...................................... 67 CLARINEX-D TAB 2.5-120 ................. 67 clarithromycin................................. 21 CLEOCIN VAG SUPP 100MG............... 57 CLINDAGEL .................................... 69 clindamax ...................................... 69 clindamycin cre 2% vag ................... 57 clindamycin hcl ............................... 16 clindamycin palmitate hydrochloride ... 16 clindamycin phosphate ..................... 16 clindamycin phosphate (topical)......... 69 clindamycin phosphate in d5w ........... 16 clindamycin phosphate-benzoyl peroxide .................................................... 69 clindamycin phosphate-benzoyl peroxide (refrigerate) ................................... 69 CLINDESSE .................................... 57 CLINIMIX 2.75%/DEXTROSE 5%........ 62 CLINIMIX 4.25%/DEXTROSE 10% ...... 62 CLINIMIX 4.25%/DEXTROSE 20% ...... 62 CLINIMIX 4.25%/DEXTROSE 25% ...... 62 CLINIMIX 4.25%/DEXTROSE 5%........ 62 CLINIMIX 5%/DEXTROSE 15% .......... 62 CLINIMIX 5%/DEXTROSE 20% .......... 62 CLINIMIX 5%/DEXTROSE 25% .......... 62 CLINIMIX E 2.75%/DEXTROSE 10% ... 62 CLINIMIX E 2.75%/DEXTROSE 5% ..... 62 CLINIMIX E 4.25%/D10.................... 62 CLINIMIX E 4.25%/DEXTROSE 25% ... 62 CLINIMIX E 4.25%/DEXTROSE 5% ..... 62 CLINIMIX E 5%/DEXTROSE 15%........ 62 80 CLINIMIX E 5%/DEXTROSE 20%........ 62 CLINIMIX E 5%/DEXTROSE 25%........ 62 clinisol 15 ...................................... 62 clobetasol e cream 0.05%................. 71 clobetasol propionate ....................... 71 clobetasol propionate emulsion .......... 71 CLOCORTOLONE PIVALATE ............... 71 clodan sha 0.05% ........................... 71 CLOLAR ......................................... 24 clomipramine hcl ............................. 36 clonazepam.................................... 34 clonidine hcl ................................... 32 clopidogrel bisulfate .................... 58, 59 clorazepate dipotassium ................... 34 clorpres ......................................... 33 clotrimazole ................................... 74 clotrimazole (topical) ....................... 70 clozapine ....................................... 38 CLOZAPINE .................................... 38 CLOZAPINE ODT ............................. 38 COARTEM ...................................... 18 codeine and capital .................................. 12 CODEINE SULFATE .......................... 13 colchicine w/ probenecid................... 11 COLCRYS ....................................... 11 colestipol hcl .................................. 29 colistimethate sodium ...................... 16 colocort ......................................... 54 COLY-MYCIN S................................ 74 COLYTE-FLAVOR PACKS ................... 54 COMBIGAN..................................... 66 COMBIVENT RESPIMAT..................... 67 COMETRIQ ..................................... 25 COMPLERA ..................................... 19 compro supp .................................. 52 COMVAX ........................................ 61 CONDYLOX..................................... 73 constulose ..................................... 54 CONZIP ......................................... 12 COPAXONE INJ 20MG/ML .................. 43 COPAXONE INJ 40MG/ML .................. 43 CORDRAN ...................................... 71 COREG CR ..................................... 30 CORLANOR..................................... 33 cormax.......................................... 72 CORTIFOAM ................................... 71 cortisone acetate............................. 50 CORTISPORIN ................................ 70 CORTISPORIN-TC ............................ 74 COSENTYX ..................................... 71 COSENTYX SENSOREADY PEN ........... 71 COSMEGEN .................................... 23 COSOPT PF .................................... 66 COUMADIN .................................... 57 CREON .......................................... 55 CRESEMBA ..................................... 17 CRESTOR ....................................... 29 CRINONE ....................................... 52 CRIXIVAN ...................................... 18 cromolyn sodium............................. 68 cromolyn sodium (mastocytosis) ........ 55 cromolyn sodium (ophth).................. 66 CUBICIN ........................................ 16 CUVPOSA....................................... 53 cyclophosphamide ........................... 23 CYCLOPHOSPHAMIDE....................... 23 cycloserine ..................................... 19 cyclosporine ................................... 60 cyclosporine modified (for microemulsion) .................................................... 60 CYSTADANE ................................... 49 CYSTAGON..................................... 49 cytarabine inj ................................. 24 D dacarbazine.................................... 23 DALIRESP ...................................... 68 DALVANCE ..................................... 16 danazol ......................................... 48 dantrolene sodium........................... 44 dapsone ........................................ 16 DAPTACEL...................................... 61 DARAPRIM ..................................... 16 daunorubicin hcl.............................. 23 DAYTRANA ..................................... 40 decitabine ...................................... 24 DELESTROGEN ............................... 49 DELZICOL ...................................... 54 demeclocycline hcl........................... 22 DEMSER ........................................ 33 DENAVIR ....................................... 73 DEPEN TITRATABS .......................... 48 depo-estradiol ................................ 49 DEPO-MEDROL INJ 20MG/ML............. 50 DEPO-PROVERA INJ 400/ML .............. 25 depo-testosterone ........................... 45 81 desipramine hcl .............................. 36 desloratadine.................................. 67 desmopressin acetate ...................... 52 DESMOPRESSIN ACETATE................. 52 desmopressin acetate inj .................. 52 desmopressin acetate spray .............. 52 desmopressin acetate spray refrigerated .................................................... 52 DESONATE ..................................... 72 desonide........................................ 72 DESONIDE ..................................... 72 desoximetasone .............................. 72 DESOXIMETASONE .......................... 72 dexamethasone .............................. 50 dexamethasone sodium phosphate ..... 50 dexamethasone sodium phosphate (ophth) ......................................... 65 DEXILANT ...................................... 55 dexpak taperpak 13 day ................... 50 dexrazoxane................................... 27 DEXTROSE ..................................... 63 DEXTROSE 10% FLEX CONTAIN ......... 63 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% ............................................ 63 DEXTROSE 10%/NACL 0.45% ........... 63 DEXTROSE 2.5%/NACL 0.45% .......... 63 DEXTROSE 5% ............................... 63 DEXTROSE 5% /ELECTROLYTE .......... 63 DEXTROSE 5%/LACTATED RING ........ 63 DEXTROSE 5%/NACL 0.2% ............... 63 DEXTROSE 5%/NACL 0.225% ........... 63 DEXTROSE 5%/NACL 0.3% ............... 63 DEXTROSE 5%/NACL 0.33% ............. 63 DEXTROSE 5%/NACL 0.45% ............. 63 DEXTROSE 5%/NACL 0.9% ............... 63 DEXTROSE 5%/POTASSIUM CHL ........ 63 diazepam....................................... 34 DIAZEPAM GEL (ANTICONVULSANT) ... 34 DIBENZYLINE ................................. 33 diclofenac potassium........................ 11 diclofenac sodium............................ 11 diclofenac sodium (actinic keratoses) .. 73 diclofenac sodium (ophth)................. 65 diclofenac sodium (topical) ............... 73 diclofenac w/ misoprostol ................. 11 dicloxacillin sodium.......................... 22 dicyclomine hcl ............................... 53 didanosine ..................................... 18 DIFFERIN ....................................... 70 DIFICID ......................................... 21 diflorasone diacetate........................ 72 diflunisal ........................................ 11 digitek........................................... 31 digox ....................................... 31, 32 digoxin .......................................... 32 digoxin inj...................................... 32 DIGOXIN SOL 50MCG/ML ................. 32 dihydroergotamine mesylate ............. 41 DIHYDROERGOTAMINE MESYLATE...... 41 dilantin.......................................... 34 DILANTIN-125 ................................ 34 DILATRATE SR ................................ 33 DILAUDID-HP INJ 250MG ................. 13 diltiazem cap 120mg/24hr ................ 31 diltiazem cap 240mg/24hr ................ 31 diltiazem cap er/12hr ....................... 31 diltiazem hcl ................................... 31 diltiazem hcl coated beads ................ 31 diltiazem hcl er ............................... 31 diltiazem hcl extended release beads .. 31 diltiazem inj 100mg ......................... 31 diltiazem inj 125/25ml ..................... 31 diltiazem inj 25mg/5ml .................... 31 diltiazem inj 50/10ml ....................... 31 dilt-xr cap ...................................... 31 diltzac ........................................... 31 DIPENTUM ..................................... 54 diphenhydram inj 50mg/ml ............... 67 diphenoxylate w/ atropine ................ 55 DIPHTHERIA/TETANUS TOXOID ......... 61 disopyramide phosphate ................... 29 disulfiram ...................................... 44 DIURIL SUS 250/5ML ....................... 32 divalproex sodium ........................... 34 docetaxel ....................................... 24 DOCETAXEL ................................... 24 DOCETAXEL SOLN 80MG/8ML ............ 24 donepezil odt 10mg ......................... 36 donepezil odt 5mg ........................... 36 donepezil tab hcl 23mg .................... 36 donepezil tabs 10mg........................ 36 donepezil tabs 5mg ......................... 36 DORIBAX ....................................... 16 dorzolamide hcl .............................. 66 dorzolamide hcl-timolol maleate ........ 66 doxazosin mesylate ......................... 28 82 doxepin hcl .................................... 36 doxercalciferol ................................ 64 doxorubicin hcl ............................... 23 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml............................ 23 doxorubicin inj 50mg ....................... 23 doxy ............................................. 22 doxycycline (monohydrate) ............... 22 DOXYCYCLINE (ROSACEA) ................ 73 doxycycline hyclate ......................... 22 dronabinol ..................................... 53 DROXIA ......................................... 26 DUEXIS ......................................... 11 DULERA ......................................... 69 duloxetine hcl ................................. 36 DUOPA .......................................... 38 DURAMORPH .................................. 13 DUREZOL....................................... 65 dutasteride .................................... 56 DUTOPROL..................................... 30 DYMISTA SPR 137-50 ...................... 67 DYRENIUM ..................................... 32 E e.e.s. 400 tab 400mg....................... 21 E.E.S. GRANULES ............................ 21 econazole nitrate............................. 70 EDARBI ......................................... 28 EDARBYCLOR ................................. 28 EDECRIN ....................................... 32 EDURANT....................................... 18 EFFIENT ........................................ 59 EGRIFTA ........................................ 51 ELAPRASE ...................................... 49 ELECTROLYTE-R IN DEXTROSE .......... 63 ELELYSO ........................................ 49 ELIDEL .......................................... 73 ELIGARD INJ 22.5MG ....................... 25 ELIGARD INJ 30MG.......................... 25 ELIGARD INJ 45MG.......................... 25 ELIGARD INJ 7.5MG......................... 25 ELIQUIS TAB 2.5MG ........................ 57 ELIQUIS TAB 5MG ........................... 57 ELITEK .......................................... 27 elixophyllin..................................... 69 ELMIRON ....................................... 56 ELOXATIN ...................................... 27 EMADINE ....................................... 66 EMBEDA ........................................ 13 EMCYT .......................................... 23 EMEND CAP 125MG ......................... 53 EMEND CAP 40MG ........................... 53 EMEND CAP 80MG ........................... 53 EMEND PAK 80 & 125 ...................... 53 EMSAM .......................................... 36 EMTRIVA ....................................... 18 ENABLEX ....................................... 56 enalapril maleate ............................ 27 enalapril maleate & hydrochlorothiazide .................................................... 27 ENBREL ......................................... 59 ENBREL SURECLICK......................... 59 endocet ......................................... 13 ENDODAN TAB................................ 13 ENGERIX-B .................................... 61 enoxaparin sodium .......................... 57 ENTACAPONE ................................. 38 entecavir ....................................... 19 ENTRESTO ..................................... 28 ENTYVIO........................................ 54 enulose ......................................... 54 EPIDUO ......................................... 70 EPIDUO FORTE ............................... 70 epinastine hcl (ophth) ...................... 66 EPINEPHRINE ................................. 68 EPIPEN 2-PAK................................. 68 EPIPEN-JR 2-PAK ............................ 68 epirubicin inj 200mg ........................ 23 epirubicin inj 50mg/25ml .................. 23 epitol ............................................ 34 EPIVIR HBV.................................... 19 eplerenone ..................................... 28 EPOGEN ........................................ 58 eprosartan mesylate ........................ 28 EPZICOM ....................................... 19 EQUETRO....................................... 42 ERAXIS ......................................... 17 ERBITUX........................................ 24 ergomar ........................................ 41 ERIVEDGE...................................... 24 ERTACZO ....................................... 70 ery pad 2% .................................... 70 ERYPED 200 ................................... 21 ERYPED 400 ................................... 21 ery-tab .......................................... 21 erythrocin lactobionate ..................... 21 erythrocin stearate .......................... 21 83 erythromycin (acne aid) ................... 70 erythromycin (ophth)....................... 65 erythromycin base........................... 21 erythromycin cap 250mg ec .............. 21 erythromycin ethylsuccinate .............. 21 ESBRIET ........................................ 68 escitalopram oxalate ........................ 36 esomeprazole sodium inj .................. 55 estrace .......................................... 49 estradiol ........................................ 49 estradiol valerate ............................ 49 ESTRING ....................................... 49 ethambutol hcl................................ 19 ethosuximide.................................. 34 etodolac ........................................ 11 etodolac er..................................... 11 ETOPOPHOS ................................... 27 etoposide ....................................... 27 EURAX .......................................... 73 EVOTAZ......................................... 19 EXELDERM ..................................... 70 EXELON PATCHES ........................... 36 exemestane ................................... 25 EXJADE ......................................... 48 EXTAVIA ........................................ 43 F FABIOR ......................................... 70 FABRAZYME ................................... 49 FACTIVE ........................................ 22 famciclovir ..................................... 19 famotidine ..................................... 54 famotidine inj ................................. 54 FANAPT ......................................... 38 FANAPT TITRATION PACK ................. 38 FARESTON ..................................... 25 FARXIGA........................................ 46 FARYDAK ....................................... 24 FASLODEX ..................................... 25 FAZACLO ....................................... 38 felbamate ...................................... 34 felodipine....................................... 31 FEMRING ....................................... 49 fenofibrate ..................................... 30 FENOFIBRATE ............................ 29, 30 fenofibrate micronized...................... 30 FENOFIBRIC ACID ........................... 30 FENOGLIDE .................................... 30 fenoprofen calcium .......................... 11 fentanyl citrate ............................... 13 fentanyl patch 100 mcg/hr................ 13 fentanyl patch 12 mcg/hr ................. 13 fentanyl patch 25 mcg/hr ................. 13 fentanyl patch 50 mcg/hr ................. 13 fentanyl patch 75 mcg/hr ................. 13 FENTORA ....................................... 13 FERRIPROX .................................... 48 FETZIMA ........................................ 36 FETZIMA TITRATION PACK................ 36 FINACEA AER 15% .......................... 73 FINACEA GEL 15% .......................... 73 finasteride ..................................... 56 FIRAZYR ........................................ 58 FIRMAGON ..................................... 25 FLAGYL ER ..................................... 16 FLAREX ......................................... 65 FLEBOGAMMA ................................. 59 FLEBOGAMMA DIF ........................... 59 flecainide acetate ............................ 29 FLO-PRED SUS................................ 50 FLOVENT DISKUS ............................ 69 FLOVENT HFA ................................. 69 fluconazole..................................... 17 fluconazole in dextrose ..................... 17 fluconazole in nacl ........................... 17 flucytosine ..................................... 17 fludarabine phosphate...................... 24 fludrocortisone acetate ..................... 50 flunisolide (nasal)............................ 68 fluocinolone acetonide ...................... 72 fluocinolone acetonide (otic).............. 74 fluocinonide.................................... 72 fluocinonide emulsified base .............. 72 FLUOROMETHOLONE (OPHTH) ........... 65 fluorouracil..................................... 24 fluorouracil (topical) ........................ 73 FLUOROURACIL (TOPICAL) ............... 73 fluoxetine cap 10mg ........................ 36 fluoxetine cap 20mg ........................ 36 fluoxetine cap 40mg ........................ 36 fluoxetine hcl.................................. 37 FLUOXETINE HCL ............................ 37 fluphenazine decanoate .................... 38 fluphenazine hcl .............................. 38 flurbiprofen .................................... 11 flurbiprofen sodium ......................... 65 flutamide ....................................... 25 84 fluticasone propionate ...................... 72 fluticasone propionate (nasal) ........... 68 fluvastatin sodium cap 20 mg ............ 29 fluvastatin sodium cap 40 mg ............ 29 fluvastatin sodium tab sr 24 hr 80 mg. 29 fluvoxamine maleate........................ 34 fluvoxamine maleate er .................... 34 FML .............................................. 65 FML FORTE..................................... 65 fondaparinux sodium ....................... 57 FORADIL AEROLIZER ....................... 67 FORFIVO XL ................................... 37 FORTAZ ......................................... 21 FORTEO......................................... 52 FORTESTA ..................................... 45 FORTICAL SPR 200/ACT ................... 51 FOSAMAX PLUS D............................ 48 foscarnet sodium............................. 19 fosinopril sodium............................. 27 fosinopril sodium & hydrochlorothiazide .................................................... 27 FOSRENOL ..................................... 52 FRAGMIN ....................................... 57 FREAMINE HBC 6.9% ....................... 62 FREAMINE III ................................. 62 FROVA TAB 2.5MG........................... 42 furosemide..................................... 32 furosemide inj ................................ 32 FUROSEMIDE INJ ............................ 32 furosemide oral soln 8 mg/ml ............ 32 FUSILEV ........................................ 27 FUZEON ........................................ 18 FYCOMPA....................................... 34 G gabapentin................................ 34, 35 GABITRIL....................................... 35 galantamine hydrobromide ............... 36 galantamine hydrobromide er ............ 36 GAMASTAN S/D .............................. 59 GAMMAGARD LIQUID ....................... 59 GAMMAGARD S/D............................ 59 GAMMAGARD S/D IGA LESS TH ......... 59 GAMMAKED .................................... 59 GAMMAPLEX ................................... 59 GAMUNEX-C ................................... 59 ganciclovir inj 500mg ....................... 19 GARDASIL...................................... 61 GARDASIL 9 ................................... 61 gatifloxacin (ophth) ......................... 65 GATTEX ......................................... 55 GAUZE PADS 2X2 ............................ 46 gaviltye-g ...................................... 54 gavilyte-c ...................................... 54 gavilyte-h ...................................... 54 gavilyte-n ...................................... 54 GELNIQUE ..................................... 56 GEMCITABINE ................................ 24 gemcitabine hcl............................... 24 gemfibrozil ..................................... 30 generlac ........................................ 54 gengraf ......................................... 60 GENOTROPIN ................................. 51 GENOTROPIN MINIQUICK ................. 51 gentak .......................................... 65 gentamicin in saline ......................... 15 gentamicin sulfate ........................... 15 gentamicin sulfate (ophth) ................ 65 gentamicin sulfate (topical)............... 70 GEODON INJ .................................. 38 GIAZO........................................... 54 GILENYA CAP 0.5MG ........................ 43 GILOTRIF TAB 20MG ........................ 25 GILOTRIF TAB 30MG ........................ 26 GILOTRIF TAB 40MG ........................ 26 GLASSIA........................................ 68 GLEEVEC ....................................... 26 GLEOSTINE .................................... 23 glimepiride ................................ 46, 47 glipizide ......................................... 47 glipizide er ..................................... 47 glipizide-metformin 2.5-250 mg ......... 47 glipizide-metformin 2.5-500 mg ......... 47 glipizide-metformin 5-500mg ............ 47 GLUCAGEN HYPOKIT........................ 51 GLUCAGON EMERGENCY KIT ............. 51 GLUMETZA ..................................... 47 glycate .......................................... 53 glycopyrrolate ................................ 53 GLYSET ......................................... 47 GLYXAMBI...................................... 47 GOLYTELY ...................................... 54 GRALISE ........................................ 42 GRALISE STARTER .......................... 42 granisetron hcl................................ 53 GRANIX ......................................... 58 GRASTEK ....................................... 59 85 griseofulvin microsize....................... 17 griseofulvin ultramicrosize ................ 17 guanfacine hcl (adhd) ...................... 40 H H.P. ACTHAR .................................. 51 HALAVEN ....................................... 26 halobetasol propionate ..................... 72 HALOG .......................................... 72 haloperidol ..................................... 38 haloperidol decanoate ...................... 38 haloperidol lactate ........................... 38 haloperidol lactate inj 5 mg/ml .......... 38 HARVONI ....................................... 19 HAVRIX ......................................... 61 HECTOROL ..................................... 64 HEP SOD/NACL INJ 25000 ................ 57 HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML ........................ 57 heparin sod inj 10000u/ml ................ 57 heparin sod inj 1000u/ml.................. 57 heparin sod inj 20000u/ml ................ 57 HEPARIN SOD INJ 2000U/ML ............. 57 HEPARIN SOD INJ 2500U/ML ............. 57 heparin sod inj 5000u/0.5ml ............. 57 heparin sod inj 5000u/ml.................. 57 HEPARIN SODIUM/D5W.................... 57 HEPARIN SODIUM/NACL 0.45% ......... 57 HEPATAMINE .................................. 63 HERCEPTIN .................................... 24 HETLIOZ........................................ 41 HEXALEN ....................................... 23 HIBERIX ........................................ 61 HORIZANT ..................................... 42 HUMALOG ...................................... 46 HUMALOG KWIKPEN ........................ 46 HUMALOG MIX 50/50 ....................... 46 HUMALOG MIX 50/50 KWIKPEN ......... 46 HUMALOG MIX 75/25 ....................... 46 HUMALOG MIX 75/25 KWIKPEN ......... 46 HUMATROPE................................... 51 HUMATROPE COMBO PACK ............... 51 HUMIRA......................................... 59 HUMIRA PEN .................................. 59 HUMIRA PEN-CROHNS STARTER KIT ... 59 HUMIRA PEN-PSORIASIS STARTER KIT 59 HUMULIN 70/30 .............................. 46 HUMULIN 70/30 KWIKPEN ................ 46 HUMULIN N .................................... 46 HUMULIN N KWIKPEN ...................... 46 HUMULIN R .................................... 46 HUMULIN R U-500 (CONCENTRATE) ... 46 hydralazine hcl ............................... 33 hydrochlorothiazide ......................... 32 hydrocodone-acetaminophen 10-300mg .................................................... 13 hydrocodone-acetaminophen 2.5-325mg .................................................... 13 hydrocodone-acetaminophen 5-300mg 13 hydrocodone-acetaminophen 5-325mg 13 hydrocodone-acetaminophen 7.5-300mg .................................................... 13 hydrocodone-acetaminophen 7.5-325 mg/15ml ....................................... 13 hydrocodone-acetaminophen 7.5-325mg .................................................... 13 hydrocodone-acetaminophen tab 10-325mg...................................... 13 hydrocodone-ibuprofen tab 10-200mg 13 hydrocodone-ibuprofen tab 2.5-200mg 13 hydrocodone-ibuprofen tab 5-200mg .. 13 hydrocodone-ibuprofen tab 7.5-200 mg .................................................... 13 hydrocortisone ................................ 50 HYDROCORTISONE (INTRARECTAL).... 54 hydrocortisone (topical).................... 72 hydrocortisone butyrate ................... 72 hydrocortisone butyrate hydrophilic lipo base ............................................. 72 hydrocortisone valerate .................... 72 hydromorphone hcl.......................... 13 HYDROMORPHONE HCL .................... 13 hydromorphone tab 12mg er ............. 13 hydromorphone tab 16mg er ............. 13 hydromorphone tab 8mg er .............. 13 HYDROMORPHONE TABS 32MG.......... 13 hydroxychloroquine sulfate ............... 59 hydroxyurea ................................... 26 hydroxyzine hcl............................... 67 HYSINGLA ER ............................ 13, 14 I ibandronate sodium ......................... 48 ibandronate tab 150mg .................... 48 IBRANCE ....................................... 24 ibudone tab 10-200mg ..................... 14 ibudone tab 5-200mg ...................... 14 ibuprofen .................................. 11, 12 86 ICLUSIG ........................................ 26 idarubicin hcl .................................. 23 IFEX INJ 3GM ................................. 23 ifosfamide inj 1gm........................... 23 ifosfamide inj 1gm/20ml ................... 23 IFOSFAMIDE INJ 3GM ...................... 23 ifosfamide inj 3gm/60ml ................... 23 ILEVRO.......................................... 65 ilotycin .......................................... 65 IMBRUVICA CAP 140MG ................... 26 imipenem-cilastatin ......................... 16 imipramine hcl ................................ 37 imipramine pamoate ........................ 37 imiquimod...................................... 73 IMOVAX RABIES (H.D.C.V.)............... 61 INCRELEX ...................................... 51 INCRUSE ELLIPTA ........................... 67 indapamide .................................... 32 INFANRIX ...................................... 61 INFUMORPH 200 ............................. 14 INFUMORPH 500 ............................. 14 INLYTA .......................................... 26 INSULIN PEN NEEDLES .................... 46 INSULIN SAFETY NEEDLES................ 46 INSULIN SYRINGES ......................... 46 INTELENCE .................................... 18 INTRALIPID INJ 20% ....................... 63 INTRALIPID INJ 30% ....................... 63 INTRON-A INJ 10MU ........................ 60 INTRON-A INJ 18MU ........................ 60 INTRON-A INJ 25MU ........................ 60 INTRON-A INJ 50MU ........................ 60 INVANZ ......................................... 16 INVEGA .................................... 38, 39 INVEGA SUST INJ 117 MG/0.75 ML .... 39 INVEGA SUST INJ 156MG/ML ............ 39 INVEGA SUST INJ 234 MG/1.5 ML ...... 39 INVEGA SUST INJ 39 MG/0.25 ML ...... 39 INVEGA SUST INJ 78 MG/0.5 ML ........ 39 INVEGA TRINZA .............................. 39 INVIRASE ...................................... 18 INVOKAMET TAB 150-1000 ............... 47 INVOKAMET TAB 150-500 ................. 47 INVOKAMET TAB 50-1000 ................. 47 INVOKAMET TAB 50-500MG .............. 47 INVOKANA TAB 100MG .................... 47 INVOKANA TAB 300MG .................... 47 IONOSOL-B/DEXTROSE 5% .............. 63 IONOSOL-MB/DEXTROSE 5% ............ 63 IPOL INACTIVATED IPV .................... 61 ipratropium bromide (nasal).............. 67 ipratropium sol inhal ........................ 67 ipratropium-albuterol ....................... 67 irbesartan ...................................... 28 irbesartan-hydrochlorothiazide .......... 28 IRESSA ......................................... 26 irinotecan inj 100/5ml ...................... 27 irinotecan inj 40mg/2ml ................... 27 irinotecan inj 500mg/25ml ................ 27 ISENTRESS .................................... 18 ISOLYTE P...................................... 63 ISOLYTE S ..................................... 63 isoniazid ........................................ 19 isoniazid tabs ................................. 19 ISORDIL TITRADOSE ....................... 33 isosorbide dinitrate .......................... 33 isosorbide dinitrate er ...................... 33 isosorbide mononitrate ..................... 33 isosorbide mononitrate er ................. 33 isradipine....................................... 31 ISTALOL ........................................ 66 ISTODAX ....................................... 24 itraconazole ................................... 17 ivermectin ..................................... 16 IXEMPRA KIT .................................. 26 IXIARO .......................................... 61 J JADENU ......................................... 48 JAKAFI .......................................... 26 JALYN ........................................... 56 jantoven ........................................ 57 JANUMET ....................................... 47 JANUMET XR TAB 100-1000 .............. 47 JANUMET XR TAB 50-1000 ................ 47 JANUMET XR TAB 50-500MG ............. 47 JANUVIA ........................................ 47 JARDIANCE .................................... 47 JENTADUETO .................................. 47 jinteli ............................................ 49 JUXTAPID ...................................... 30 K KADCYLA ....................................... 24 KADIAN ......................................... 14 KALETRA SOL ................................. 19 KALETRA TAB 100-25MG .................. 19 KALETRA TAB 200-50MG .................. 19 87 KALYDECO ..................................... 68 KAZANO ........................................ 47 KCL 0.075%/D5W/NACL 0.45% ......... 63 KCL 0.15%/D5W/LR ........................ 63 KCL 0.15%/D5W/NACL 0.9% ............ 63 KCL 0.3%/D5W/LR IV LAC RI ............ 63 KCL 0.3%/D5W/NACL 0.45% ............ 63 KCL 0.3%/D5W/NACL 0.9% .............. 63 KCL IN NACL INJ .15-0.45 ................ 63 KCL/D5W/NACL INJ .15/.33% ........... 63 KCL/D5W/NACL INJ .15/.45% ........... 63 KCL/D5W/NACL INJ 0.22%/0.45% ..... 63 KCL/NACL INJ 0.15%-0.9% .............. 63 KCL0.15%/D5W/NACL0.2% .............. 63 KCL0.15%/D5W/NACL0.225% ........... 63 KEPIVANCE .................................... 27 ketoconazole .................................. 17 ketoconazole (topical) ...................... 70 ketoconazole shampoo ..................... 71 ketodan aer 2% .............................. 70 ketoprofen ..................................... 12 ketorolac tromethamine (ophth) ........ 65 KEYTRUDA ..................................... 24 KINERET ........................................ 59 KINRIX .......................................... 61 kionex ........................................... 48 KLOR-CON 10 ................................. 61 KLOR-CON 8 .................................. 61 klor-con m10 .................................. 61 klor-con m15 .................................. 61 klor-con m20 .................................. 61 klor-con pow 20meq ........................ 61 klor-con spr cap 10meq.................... 61 klor-con spr cap 8meq ..................... 61 KOMBIGLYZE XR 2.5-1000MG ........... 47 KOMBIGLYZE XR 5-1000MG .............. 47 KOMBIGLYZE XR 5-500MG ................ 47 KORLYM ........................................ 51 kristalose ....................................... 54 KUVAN .......................................... 49 KYNAMRO ...................................... 30 L labetalol hcl.................................... 30 laclotion lot 12% ............................. 73 LACRISERT .................................... 66 LACTATED RINGERS VIAFLEX ............ 64 lactulose ........................................ 54 lactulose (encephalopathy) ............... 54 LAMICTAL ODT ............................... 35 LAMICTAL STARTER ......................... 35 LAMICTAL XR ................................. 35 LAMISIL ........................................ 17 lamivudine ..................................... 18 lamivudine (hbv) ............................. 19 lamivudine-zidovudine ..................... 19 lamotrigine .................................... 35 LANOXIN ....................................... 32 LANOXIN PEDIATRIC........................ 32 lansoprazole ................................... 55 LANTUS ......................................... 46 LANTUS SOLOSTAR ......................... 46 LASTACAFT .................................... 66 latanoprost .................................... 66 LATUDA ......................................... 39 LAZANDA ....................................... 14 leflunomide .................................... 59 LEMTRADA ..................................... 43 LENVIMA 10MG DAILY DOSE ............. 26 LENVIMA 14MG DAILY DOSE ............. 26 LENVIMA 20MG DAILY DOSE ............. 26 LENVIMA 24MG DAILY DOSE ............. 26 LESCOL XL ..................................... 29 LETAIRIS ....................................... 33 letrozole ........................................ 25 leucovor ca inj ................................ 27 leucovorin calcium ........................... 27 leucovorin calcium 500 mg................ 27 LEUKERAN ..................................... 23 LEUKINE ........................................ 58 leuprolide acetate............................ 25 levalbuterol conc 1.25mg/0.5ml ......... 67 levalbuterol hcl ............................... 67 LEVALBUTEROL HCL ........................ 67 LEVEMIR ........................................ 46 LEVEMIR FLEXTOUCH....................... 46 levetiracetam ................................. 35 LEVETIRACETAM IV ......................... 35 levetiracetam oral soln 100 mg/ml ..... 35 levobunolol hcl................................ 66 LEVOBUNOLOL HCL ......................... 66 levocarnitine (metabolic modifiers) ..... 49 levocetirizine soln 2.5mg/5ml ............ 67 levocetirizine tab 5 mg ..................... 67 levofloxacin.................................... 22 levofloxacin (ophth)......................... 65 levofloxacin in d5w .......................... 22 88 levoleucovorin calcium ..................... 27 levorphanol tartrate ......................... 14 levothyroxine sodium ....................... 52 LEVOXYL........................................ 52 LEXIVA .......................................... 18 LIALDA .......................................... 54 lidocaine ........................................ 72 lidocaine hcl ................................... 72 lidocaine hcl (local anesth.)............... 15 lidocaine hcl (mouth-throat).............. 74 lidocaine inj 0.5% ........................... 15 lidocaine inj 1% .............................. 15 lidocaine inj 1.5% ........................... 15 lidocaine inj 2% .............................. 15 lidocaine-prilocaine .......................... 72 linezolid......................................... 16 LINEZOLID..................................... 16 LINZESS ........................................ 55 liothyronine sodium ......................... 52 LIPOSYN III ................................... 63 LIPTRUZET..................................... 30 lisinopril ........................................ 27 lisinopril & hydrochlorothiazide .......... 27 lithium carbonate ............................ 42 LITHIUM SOLN 8MEQ/5ML ................ 42 LIVALO .......................................... 29 LOCOID ......................................... 72 lokara ........................................... 72 LOMUSTINE.................................... 23 LONSURF ....................................... 26 loperamide hcl ................................ 55 lorazepam...................................... 34 lorcet hd tab 10-325mg.................... 14 lorcet plus tab 7.5-325 ..................... 14 lorcet tab 5-325mg.......................... 14 lortab tab 10-325mg........................ 14 lortab tab 5-325mg ......................... 14 lortab tab 7.5-325 ........................... 14 losartan potassium .......................... 28 losartan-hydrochlorothiazide ............. 28 LOTEMAX ....................................... 65 lovastatin....................................... 29 loxapine succinate ........................... 39 LUMIGAN ....................................... 66 LUMIZYME ..................................... 49 LUPANETA PACK ............................. 48 LUPRON DEP INJ 11.25MG ................ 25 LUPRON DEPOT............................... 25 LUPRON DEPOT INJ 22.5MG (3-MONTH) .................................................... 25 LUPRON DEPOT INJ 30MG (3-MONTH) 25 LUPRON DEP-PED INJ 11.25MG ......... 25 LUPRON DEP-PED INJ 15MG .............. 25 LUPRON DEP-PED INJ 30MG (3-MONTH) .................................................... 25 LUPRON DEP-PED INJ 7.5MG ............. 25 LUZU ............................................ 70 LYNPARZA...................................... 24 LYRICA.......................................... 35 LYSODREN ..................................... 25 M MACRODANTIN ............................... 16 magnesium sulfate .......................... 62 MAGNESIUM SULFATE ...................... 62 MAGNESIUM SULFATE IN D5W .......... 62 MAGNESIUM SULFATE INJ 50% ......... 62 malathion ...................................... 73 maprotiline hcl ................................ 37 MARPLAN ....................................... 37 MATULANE ..................................... 26 matzim la ...................................... 31 MAXIDEX ....................................... 65 MAXIPIME ...................................... 21 meclizine hcl .................................. 53 MEDROL TAB 2MG ........................... 50 medroxyprogesterone acetate ........... 52 mefenamic acid............................... 12 mefloquine hcl ................................ 18 MEGACE ES .................................... 25 megestrol ac sus 40mg/ml ................ 25 megestrol ac tab 20mg .................... 25 megestrol ac tab 40mg .................... 25 MEGESTROL SUS 625MG/5ML ........... 25 MEKINIST ...................................... 26 MELOXICAM ................................... 12 meloxicam tabs............................... 12 melphalan hcl ................................. 23 memantine hcl ................................ 36 MENACTRA..................................... 61 MENOMUNE-A/C/Y/W-135................. 61 MENOSTAR .................................... 49 MENTAX ........................................ 70 MENVEO ........................................ 61 mercaptopurine .............................. 24 meropenem.................................... 16 mesalamine enema ......................... 54 89 mesna........................................... 27 MESNEX ........................................ 27 MESTINON SYRUP ........................... 42 MESTINON TIMESPAN ...................... 42 metadate er tab 20mg ..................... 40 metformin er .................................. 47 metformin hcl ................................. 47 methadone hcl ................................ 14 METHADONE INJ 10MG/ML ............... 14 methazolamide ............................... 32 methenamine hippurate ................... 16 methimazole .................................. 52 methotrexate sodium inj................... 24 methotrexate sodium tabs ................ 59 methoxsalen rapid........................... 71 methscopolamine bromide ................ 53 methyclothiazide ............................. 32 methylergonovine maleate ................ 51 methylphenidate hcl ................... 40, 41 methylphenidate hcl er..................... 41 methylpr ace inj 40mg/ml................. 50 methylpr ace inj 80mg/ml................. 50 methylpr ss inj 125mg ..................... 50 methylpr ss inj 1gm......................... 50 methylpr ss inj 40mg ....................... 50 methylpred pak 4mg........................ 50 methylpred tab 16mg ...................... 50 methylpred tab 32mg ...................... 50 methylpred tab 4mg ........................ 50 methylpred tab 8mg ........................ 50 metipranolol ................................... 66 metoclopramide hcl ......................... 53 metoclopramide hcl inj 5 mg/ml......... 53 metolazone .................................... 32 metoprolol & hctz tab 100-25mg ........ 30 metoprolol & hctz tab 100-50mg ........ 30 metoprolol & hctz tab 50-25mg ......... 30 metoprolol succinate ........................ 30 metoprolol tartrate .......................... 30 METRO IV ...................................... 16 metronidazole................................. 16 metronidazole (topical) .................... 73 metronidazole inj ............................ 16 metronidazole vaginal ...................... 57 mexiletine hcl ................................. 29 MIACALCIN INJ 200U/ML .................. 51 miconazole 3 sup 200mg .................. 57 midodrine hcl ................................. 33 migergot........................................ 42 millipred ........................................ 50 minitran ........................................ 33 MINIVELLE ..................................... 49 minocycline hcl ............................... 23 minoxidil........................................ 33 MIRAPEX ....................................... 38 MIRAPEX ER ................................... 38 MIRCERA ....................................... 58 mirtazapine .................................... 37 misoprostol .................................... 55 mitomycin...................................... 23 mitoxantrone hcl ............................. 26 M-M-R II........................................ 61 modafinil ....................................... 44 moderiba pak ................................. 19 MODERIBA PAK............................... 19 moderiba tab 200mg ....................... 19 moexipril hcl .................................. 27 moexipril-hydrochlorothiazide............ 27 mometasone furoate ........................ 72 montelukast sodium ........................ 68 MORPHINE SUL 20MG/ML ORAL SOL... 14 morphine sulfate ............................. 14 MORPHINE SULFATE ........................ 14 morphine sulfate beads .................... 14 morphine sulfate ext-rel tab .............. 14 MOVANTIK ..................................... 55 MOVIPREP...................................... 54 MOXEZA ........................................ 65 moxifloxacin hcl .............................. 22 MOXIFLOXACIN HCL ........................ 22 MOZOBIL ....................................... 58 MULTAQ ........................................ 29 mupirocin ...................................... 70 mupirocin calcium (topical) ............... 70 MUSTARGEN .................................. 23 MYCAMINE ..................................... 17 mycophenolate mofetil ..................... 60 mycophenolate sodium..................... 60 myorisan ....................................... 70 MYOZYME ...................................... 49 MYRBETRIQ.................................... 56 N nabumetone ................................... 12 nadolol .......................................... 30 nadolol & bendroflumethiazide ........... 30 nafcillin sodium ............................... 22 90 NAFTIFINE HCL ............................... 70 NAFTIN ......................................... 70 NAGLAZYME ................................... 49 nalbuphine hcl ................................ 12 NALLPEN ISO-OSMOTIC IN DE........... 22 NALLPEN/DEXTROSE........................ 22 naloxone hcl ................................... 44 naltrexone hcl................................. 44 NAMENDA SOL 10MG/5ML ................ 36 NAMENDA TAB ................................ 36 NAMENDA XR ................................. 36 NAMENDA XR TITRATION PACK ......... 36 NAMZARIC ..................................... 36 naphazoline 0.1% ........................... 66 NAPRELAN ..................................... 12 naproxen ....................................... 12 naproxen sodium ............................ 12 NAPROXEN SODIUM ........................ 12 naratriptan hcl ................................ 42 NASONEX ...................................... 68 NATACYN....................................... 65 nateglinide ..................................... 47 NATPARA ....................................... 52 NEBUPENT ..................................... 16 nefazodone hcl ............................... 37 neomycin sulfate ............................. 15 neomycin/polymyxin b gu ................. 73 neomycin-bacitracin zn-polymyxin...... 65 neomycin-polymy-dexameth ............. 64 neomycin-polymyxin-gramicidin......... 65 neomycin-polymyxin-hc (ophth) ........ 64 neomycin-polymyxin-hc (otic) ........... 74 NEORAL......................................... 60 NEPHRAMINE.................................. 63 NESINA ......................................... 47 neuac gel 1.2-5%............................ 70 NEULASTA ..................................... 58 NEULASTA DELIVERY KIT ................. 58 NEUMEGA ...................................... 58 NEUPOGEN .................................... 58 NEUPRO ........................................ 38 nevirapine...................................... 18 NEVIRAPINE ................................... 18 NEXAVAR ....................................... 26 NEXIUM CAP 20MG .......................... 55 NEXIUM CAP 40MG .......................... 55 NEXIUM GRA 10MG DR..................... 56 NEXIUM GRA 2.5MG DR.................... 55 NEXIUM GRA 20MG DR..................... 56 NEXIUM GRA 40MG DR..................... 56 NEXIUM GRA 5MG DR ...................... 55 niacin er (antihyperlipidemic) ............ 30 niacor ........................................... 30 nicardipine hcl ................................ 31 NICOTROL INHALER......................... 44 NICOTROL NS................................. 44 nifedical......................................... 31 nifedipine....................................... 31 nifedipine er ................................... 31 NILANDRON ................................... 25 nimodipine ..................................... 31 NIPENT.......................................... 24 nisoldipine ..................................... 31 nitro-bid ........................................ 33 NITRO-DUR .................................... 33 nitrofurantoin ................................. 16 nitrofurantoin macrocrystal ............... 16 nitrofurantoin monohyd macro........... 17 nitroglycerin ................................... 33 NITROGLYCERIN LINGUAL ................ 33 nitroglycerin patches........................ 33 NITROSTAT .................................... 33 nizatidine ....................................... 54 NORDITROPIN FLEXPRO ................... 51 NORDITROPIN NORDIFLEX PEN ......... 51 norethindrone acetate ...................... 52 norethindrone acetate-ethinyl estradiol49 NORITATE...................................... 73 NORMOSOL-M IN D5W ..................... 64 NORMOSOL-R ................................. 64 NORPACE CR .................................. 29 nortriptyline hcl .............................. 37 NORVIR ......................................... 18 NOVAREL INJ 10000UNT................... 51 NOVOLIN 70/30 .............................. 46 NOVOLIN 70/30 RELION ................... 46 NOVOLIN N .................................... 46 NOVOLIN N RELION ......................... 46 NOVOLIN R .................................... 46 NOVOLIN R RELION ......................... 46 NOVOLOG ...................................... 46 NOVOLOG FLEXPEN ......................... 46 NOVOLOG MIX 70/30 ....................... 46 NOVOLOG MIX 70/30 PREFILL ........... 46 NOVOLOG PENFILL .......................... 46 NOXAFIL........................................ 17 91 NUCYNTA....................................... 14 NUCYNTA ER .................................. 14 NUEDEXTA ..................................... 42 NULOJIX ........................................ 60 NULYTELY/FLAVOR PACKS ................ 54 NUTRILIPID INJ 20% ....................... 63 NUTROPIN AQ INJ 20MG/2ML ............ 51 NUTROPIN AQ NUSPIN 5 .................. 51 NUTROPIN AQ PEN .......................... 51 NUVESSA....................................... 57 NUVIGIL ........................................ 44 nyamyc ......................................... 71 NYMALIZE...................................... 31 nystatin......................................... 17 nystatin (mouth-throat) ................... 74 nystatin (topical)............................. 71 nystatin pow 100000 ....................... 71 nystop........................................... 71 O OCTAGAM ...................................... 59 octreotide acetate ........................... 51 ODOMZO ....................................... 26 OFEV ............................................ 68 ofloxacin (ophth)............................. 65 ofloxacin (otic)................................ 74 olanzapine ..................................... 39 olanzapine odt ................................ 39 olopatadine hcl (nasal) ..................... 67 OMECLAMOX-PAK ............................ 55 omega-3-acid ethyl esters ................ 30 omeprazole .................................... 56 OMEPRAZOLE-SODIUM BICARBONATE 56 OMNARIS....................................... 68 OMNITROPE 10MG........................... 51 OMNITROPE 5.8MG.......................... 51 OMNITROPE 5MG ............................ 51 ondansetron hcl .............................. 53 ondansetron hcl inj .......................... 53 ondansetron hcl oral soln.................. 53 ondansetron odt.............................. 53 ONEXTON ...................................... 70 ONFI ............................................. 35 ONGLYZA....................................... 47 ONMEL .......................................... 17 OPANA ER (CRUSH RESISTANT .......... 14 OPSUMIT ....................................... 33 ORACEA ........................................ 73 ORAP ............................................ 39 ORENCIA ....................................... 59 ORENITRAM TAB 0.125MG ................ 33 ORENITRAM TAB 0.25MG .................. 33 ORENITRAM TAB 1MG ...................... 33 ORENITRAM TAB 2.5MG ................... 33 ORFADIN ....................................... 49 ORKAMBI ....................................... 68 OSENI TAB 12.5-15MG ..................... 47 OSENI TAB 12.5-30MG ..................... 47 OSENI TAB 12.5-45MG ..................... 47 OSENI TAB 25-15MG ....................... 47 OSENI TAB 25-30MG ....................... 48 OSENI TAB 25-45MG ....................... 48 OSMOPREP..................................... 54 OTEZLA ......................................... 59 oxacillin sodium .............................. 22 oxaliplatin ...................................... 27 oxandrolone ................................... 45 oxaprozin....................................... 12 oxcarbazepine ................................ 35 OXISTAT........................................ 71 OXTELLAR XR ................................. 35 oxybutynin chloride ......................... 56 oxycodone hcl ................................ 14 OXYCODONE HCL ............................ 14 oxycodone w/ acetaminophen 10-325mg .................................................... 15 oxycodone w/ acetaminophen 2.5-325mg .................................................... 15 oxycodone w/ acetaminophen 5-325mg .................................................... 15 oxycodone w/ acetaminophen 7.5-325mg .................................................... 15 oxycodone-aspirin ........................... 15 oxycodone-ibuprofen ....................... 15 OXYCONTIN ................................... 15 oxymorphone hcl ............................ 15 OXYTROL ....................................... 56 P pacerone ....................................... 29 paclitaxel ....................................... 24 paliperidone ................................... 39 pamidronate disodium...................... 48 PANCREAZE ................................... 55 PANDEL ......................................... 72 PANRETIN ...................................... 73 pantoprazole sodium........................ 56 paricalcitol ..................................... 64 92 PARICALCITOL................................ 64 paroex sol 0.12% ............................ 74 paromomycin sulfate ....................... 15 paroxetine er tab ............................ 37 paroxetine hcl tabs .......................... 37 paser d/r ....................................... 19 PATADAY ....................................... 66 PATANOL ....................................... 66 PAXIL............................................ 37 PAZEO........................................... 66 PCE .............................................. 21 PEDVAX HIB ................................... 61 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE ................. 55 peg 3350-potassium chloride-sod bicarbonate-sod chloride .................. 55 PEGANONE..................................... 35 PEGINTRON.................................... 20 PEG-INTRON .................................. 20 PEG-INTRON REDIPEN ..................... 20 PENICILLIN G POT IN DEXTROSE ....... 22 PENICILLIN G POTASSIUM IN ............ 22 penicillin g procaine ......................... 22 penicillin g sodium........................... 22 penicillin v potassium ....................... 22 penicilln gk inj 20mu........................ 22 penicilln gk inj 5mu ......................... 22 PENNSAID ..................................... 73 PENTAM 300................................... 17 PENTASA ....................................... 54 pentoxifylline .................................. 58 PERFOROMIST ................................ 67 perindopril erbumine........................ 27 periogard soln 0.12%....................... 74 PERJETA ........................................ 24 permethrin ..................................... 73 perphenazine.................................. 39 PERTZYE........................................ 55 PEXEVA ......................................... 37 pfizerpen g inj 5mu ......................... 22 pfizerpen-g inj 20mu ....................... 22 phenadoz....................................... 53 phenelzine sulfate ........................... 37 phenergan ..................................... 53 phenobarbital ................................. 35 phenobarbital sodium....................... 35 PHENOBARBITAL SODIUM................. 35 phenoxybenzamine hcl ..................... 33 phenytek ....................................... 35 phenytoin ...................................... 35 phenytoin inj 50mg/ml ..................... 35 phenytoin sodium extended .............. 35 PHOSLYRA ..................................... 52 PHOSPHOLINE IODIDE ..................... 66 PICATO ......................................... 73 PILOCARPINE HCL ........................... 66 pilocarpine hcl (oral) ........................ 74 PILOCARPINE HCL (ORAL) ................ 74 pimozide........................................ 39 pindolol ......................................... 30 pioglitazone hcl ............................... 48 pioglitazone hcl-glimepiride ............... 48 pioglitazone hcl-metformin hcl ........... 48 piperacillin sodium-tazobactam sodium22 piroxicam....................................... 12 PLASMA-LYTE A .............................. 64 PLASMA-LYTE-148 ........................... 64 PLASMA-LYTE-56/D5W ..................... 64 PLEGRIDY ...................................... 43 PLEGRIDY STARTER PACK................. 43 podofilox ....................................... 73 polyethylene glycol 3350 .................. 55 polymyxin b sulfate ......................... 17 polymyxin b-trimethoprim ................ 65 POMALYST ..................................... 26 pot chloride inj 2meq/ml .................. 64 potassium chloride .......................... 62 POTASSIUM CHLORIDE ............... 62, 64 POTASSIUM CHLORIDE 0.3%/D ......... 64 potassium chloride caps er ................ 62 potassium chloride in nacl................. 64 POTASSIUM CHLORIDE IN NACL ........ 64 potassium chloride microencapsulated crystals cr...................................... 62 POTASSIUM CHLORIDE TAB CR 10 MEQ .................................................... 62 potassium citrate (alkalinizer) ........... 56 POTASSIUM CITRATE (ALKALINIZER) . 56 POTIGA ......................................... 35 PRADAXA ....................................... 57 pramipexole dihydrochloride.............. 38 PRANDIMET.................................... 48 pravastatin sodium .......................... 29 prazosin hcl.................................... 28 PRED MILD..................................... 65 pred sod pho sol 5mg/5ml ................ 50 93 PRED-G ......................................... 64 PRED-G S.O.P. ................................ 64 prednicarbate ................................. 72 PREDNICARBATE ............................. 72 PREDNISOLONE ACETATE (OPHTH) .... 65 prednisolone sodium phosphate ......... 50 prednisolone sodium phosphate (ophth) .................................................... 65 prednisolone sol 15mg/5ml ............... 50 prednisolone sol 25mg/5ml ............... 50 prednisolone syrup 15 mg/5ml .......... 50 prednisone con 5mg/ml .................... 50 prednisone pak 10mg ...................... 50 prednisone pak 5mg ........................ 50 prednisone sol 5mg/5ml ................... 50 prednisone tab 10mg ....................... 50 prednisone tab 1mg......................... 50 prednisone tab 2.5mg ...................... 50 prednisone tab 20mg ....................... 50 prednisone tab 50mg ....................... 50 prednisone tab 5mg......................... 50 PREGNYL W/DILUENT BENZYL ........... 51 PREMARIN CREAM ........................... 49 PREMARIN INJ ................................ 49 premasol 10% ................................ 63 premasol 6%.................................. 63 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)................................ 64 PREPOPIK ...................................... 55 PREVACID SOLUTAB ........................ 56 prevalite ........................................ 30 PREZCOBIX .................................... 19 PREZISTA ...................................... 18 PRIFTIN......................................... 19 PRILOSEC ...................................... 56 PRIMAQUINE PHOSPHATE ................. 18 primidone ...................................... 35 PRIMSOL SOL 50MG/5ML .................. 17 PRISTIQ ........................................ 37 PRIVIGEN ...................................... 59 PROAIR HFA ................................... 67 PROAIR RESPICLICK ........................ 68 probenecid ..................................... 11 PROCALAMINE ................................ 63 prochlorperazine inj 5 mg/ml............. 53 prochlorperazine maleate ................. 53 prochlorperazine supp ...................... 53 PROCRIT........................................ 58 procto-pak ..................................... 71 proctosol hc 2.5 % .......................... 71 proctozone hc ................................. 71 PROCYSBI ...................................... 49 progesterone micronized .................. 52 PROGLYCEM SUS 50MG/ML ............... 51 PROGRAF ....................................... 60 PROLASTIN-C ................................. 68 PROLENSA ..................................... 66 PROLEUKIN .................................... 24 PROLIA.......................................... 51 PROMACTA..................................... 58 promethazine hcl ............................ 53 promethegan.................................. 53 propafenone hcl .............................. 29 propafenone hcl 12hr ....................... 29 proparacaine hcl ............................. 66 propranolol & hydrochlorothiazide ...... 30 propranolol hcl er ............................ 30 propranolol inj 1mg/ml..................... 30 propranolol sol ................................ 30 propranolol tab ............................... 31 propylthiouracil ............................... 52 PROQUAD ...................................... 61 PROSOL......................................... 63 PROTONIX ..................................... 56 protriptyline hcl .............................. 37 PROVENTIL HFA .............................. 68 PRUDOXIN CRE 5% ......................... 71 PULMICORT FLEXHALER ................... 69 PULMICORT INH SUSP 1MG/2ML ........ 69 PULMOZYME ................................... 68 PURIXAN ....................................... 24 PYLERA ......................................... 55 pyrazinamide.................................. 19 pyridostigmine bromide .................... 42 Q QNASL .......................................... 68 QNASL CHILDRENS.......................... 68 QUADRACEL ................................... 61 quetiapine fumarate ........................ 39 QUILLIVANT XR .............................. 41 quinapril hcl ................................... 27 quinapril-hydrochlorothiazide ............ 27 quinidine gluconate ......................... 29 quinidine sulfate ............................. 29 quinine sulfate ................................ 18 QVAR ............................................ 69 94 R RABAVERT ..................................... 61 rabeprazole sodium ......................... 56 RAGWITEK ..................................... 60 raloxifene hcl.................................. 51 ramipril ......................................... 28 RANEXA......................................... 33 ranitidine hcl .................................. 54 RAPAFLO ....................................... 56 RAPAMUNE..................................... 60 RAVICTI ........................................ 49 RAYOS TAB 1MG ............................. 50 RAYOS TAB 2MG ............................. 50 RAYOS TAB 5MG ............................. 50 REBETOL ....................................... 20 REBIF............................................ 43 REBIF REBIDOSE ............................ 43 REBIF REBIDOSE TITRATION............. 43 REBIF TITRATION PACK.................... 43 RECOMBIVAX HB............................. 61 RECTIV.......................................... 73 REGRANEX ..................................... 73 RELENZA DISKHALER....................... 20 RELISTOR ...................................... 55 RELPAX ......................................... 42 REMICADE ..................................... 59 REMODULIN ................................... 33 RENAGEL ....................................... 52 RENVELA PAK ................................. 52 RENVELA TAB 800MG....................... 52 repaglinide ..................................... 48 reprexain tab 10-200mg ................... 15 RESCRIPTOR .................................. 18 RESTASIS ...................................... 66 RETIN-A MICRO PUMP ...................... 70 RETROVIR IV INFUSION ................... 18 REVATIO........................................ 33 REVLIMID ...................................... 60 REXULTI ........................................ 39 REYATAZ ....................................... 18 RHEUMATREX ................................. 59 ribapak mis 600/day ........................ 20 ribasphere ..................................... 20 ribasphere ribapak 1000 ................... 20 ribasphere ribapak 1200 ................... 20 ribasphere ribapak 800 .................... 20 ribavirin 200mg .............................. 20 rifabutin ........................................ 19 rifamate ........................................ 19 rifampin ........................................ 19 RIFATER ........................................ 19 riluzole .......................................... 42 rimantadine hydrochloride ................ 20 RINGER'S ...................................... 64 RIOMET ......................................... 48 risedronate sodium .......................... 48 RISEDRONATE SODIUM .................... 48 RISPERDAL INJ 12.5MG .................... 39 RISPERDAL INJ 25MG ...................... 39 RISPERDAL INJ 37.5MG .................... 39 RISPERDAL INJ 50MG ...................... 39 risperidone..................................... 39 risperidone odt ............................... 39 RITALIN LA .................................... 41 RITUXAN ....................................... 24 rivastigmine tartrate ........................ 36 rizatriptan benzoate......................... 42 ropinirole hydrochloride .................... 38 rosadan cre 0.75% .......................... 73 ROTARIX ....................................... 61 ROTATEQ ....................................... 61 roxicet soln .................................... 15 roxicet tab 5-325mg ........................ 15 ROZEREM ...................................... 41 RUCONEST..................................... 58 RYTARY ......................................... 38 S SABRIL.......................................... 35 SAIZEN ......................................... 51 SAIZEN CLICK.EASY ........................ 51 SAMSCA ........................................ 51 SANCUSO ...................................... 53 SANDIMMUNE SOLN ........................ 60 SANDOSTATIN LAR DEPOT................ 51 SANTYL ......................................... 73 SAPHRIS................................... 39, 40 SARAFEM ....................................... 44 SAVAYSA ....................................... 57 SAVELLA........................................ 42 SAVELLA TITRATION PACK................ 42 selegiline hcl .................................. 38 selenium sulfide .............................. 71 SELZENTRY .................................... 18 SEMPREX-D.................................... 67 SENSIPAR ...................................... 48 SEREVENT DISKUS .......................... 68 95 SEROQUEL XR ................................ 40 SEROSTIM ..................................... 51 sertraline hcl .................................. 37 SF-ROWASA ................................... 54 SIGNIFOR ...................................... 52 SIGNIFOR LAR ................................ 52 sildenafil citrate (pulmonary hypertension) ................................. 33 SILENOR........................................ 41 SILVER SULFADIAZINE..................... 70 SIMBRINZA SUS 1-0.2% .................. 66 SIMCOR......................................... 30 SIMPONI........................................ 59 SIMPONI ARIA ................................ 59 SIMULECT ...................................... 60 simvastatin .................................... 29 sirolimus........................................ 60 SIROLIMUS .................................... 60 SIRTURO ....................................... 19 SIVEXTRO ...................................... 17 SKLICE .......................................... 73 SODIUM CHLORIDE .................... 62, 64 SODIUM CHLORIDE 0.45% VIA.......... 64 SODIUM CHLORIDE 0.9% ................. 73 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN .............................. 62 sodium phenylbutyrate..................... 49 sodium polystyrene sulfonate ............ 48 SOLODYN ...................................... 23 SOLTAMOX..................................... 25 SOLU-CORTEF 1000MG .................... 50 SOLU-CORTEF 100MG ...................... 50 SOLU-CORTEF 250MG ...................... 50 SOLU-CORTEF 500MG ...................... 50 SOLU-MEDROL INJ 2GM ................... 50 SOMATULINE DEPOT........................ 52 SOMAVERT..................................... 52 SOOLANTRA ................................... 73 SORILUX ....................................... 71 sorine ........................................... 29 sotalol hcl ...................................... 29 sotalol hcl (afib/afl) ......................... 29 SOTYLIZE ...................................... 31 SOVALDI ....................................... 20 SPIRIVA HANDIHALER...................... 67 SPIRIVA RESPIMAT.......................... 67 spironolactone ................................ 28 spironolactone & hydrochlorothiazide .. 32 SPORANOX SOL 10MG/ML................. 17 SPRYCEL........................................ 26 sps susp 15gm/60ml........................ 48 SSD .............................................. 70 stavudine....................................... 18 STELARA ....................................... 71 STERILE WATER IRRIGATION ............ 74 STIMATE........................................ 52 STIOLTO RESPIMAT ......................... 67 STIVARGA...................................... 26 STRATTERA .................................... 41 streptomycin sulfate ........................ 15 STRIANT ........................................ 45 STRIBILD....................................... 19 STRIVERDI RESPIMAT ...................... 68 SUBOXONE MIS 12-3MG................... 44 SUBOXONE MIS 2-0.5MG.................. 44 SUBOXONE MIS 4-1MG .................... 44 SUBOXONE MIS 8-2MG .................... 44 SUBSYS......................................... 15 SUCLEAR ....................................... 55 SUCRAID ....................................... 55 sucralfate ...................................... 55 sulfacet sod oin 10% op ................... 65 sulfacetamide sodium (acne)............. 70 sulfacetamide sodium (ophth) ........... 65 sulfacetamide sod-prednisolone ......... 64 sulfadiazine .................................... 15 sulfamethoxazole-trimethop.............. 17 sulfamethoxazole-trimethoprim inj ..... 17 SULFAMYLON ................................. 70 sulfasalazine dr............................... 54 sulfasalazine ir................................ 54 sulindac ......................................... 12 SUMATRIPTAN INJ 4MG/0.5ML........... 42 sumatriptan inj 6mg/0.5ml ............... 42 SUMATRIPTAN INJ 6MG/0.5ML........... 42 sumatriptan succinate ...................... 42 SUMATRIPTAN SUCCINATE ............... 42 SUMAVEL DOSEPRO......................... 42 suprax........................................... 21 SUPRAX ......................................... 21 SUPREP BOWEL PREP ....................... 55 SURMONTIL ................................... 37 SUSTIVA........................................ 18 SUTENT ......................................... 26 SYLATRON KIT 200MCG ................... 26 SYLATRON KIT 300MCG ................... 26 96 SYLATRON KIT 600MCG ................... 26 SYMBICORT ................................... 69 SYMLINPEN 120 .............................. 46 SYMLINPEN 60................................ 46 SYNAGIS ....................................... 61 SYNAREL ....................................... 48 SYNERA ......................................... 73 SYNERCID...................................... 17 SYNRIBO ....................................... 26 SYNTHROID ................................... 52 SYPRINE ........................................ 48 T TABLOID........................................ 24 TACLONEX ..................................... 72 tacrolimus...................................... 60 tacrolimus (topical) ......................... 73 TAFINLAR ...................................... 26 TAMIFLU ........................................ 20 tamoxifen citrate ............................. 25 tamsulosin hcl ................................ 56 TANZEUM ...................................... 46 TARCEVA ....................................... 26 TARGRETIN ............................... 26, 73 TASIGNA ....................................... 26 tazicef ........................................... 21 tazicef vial ..................................... 21 TAZORAC....................................... 71 taztia xt......................................... 31 TECFIDERA CAP 120MG .................... 43 TECFIDERA CAP 240MG .................... 43 TECFIDERA MIS STARTER ................. 43 TEFLARO ....................................... 21 TEGRETOL ..................................... 35 TEGRETOL-XR................................. 35 TEKTURNA ..................................... 32 TEKTURNA HCT............................... 32 telmisartan .................................... 29 telmisartan-amlodipine..................... 28 telmisartan-hydrochlorothiazide ......... 28 temazepam .................................... 41 TENIVAC........................................ 61 terazosin hcl................................... 28 terbinafine hcl ................................ 17 terbutaline sulfate ........................... 68 terconazole vaginal.......................... 57 TESTIM ......................................... 45 testosterone cypionate ..................... 45 testosterone enanthate .................... 45 TETANUS/DIPHTHERIA TOXOID ......... 61 tetrabenazine ................................. 42 TETRACYCLINE HCL ......................... 23 TEVETEN HCT ................................. 28 texacort......................................... 72 THALOMID ..................................... 60 theo-24 ......................................... 69 theophylline ................................... 69 thioridazine hcl ............................... 40 thiothixene..................................... 40 THYMOGLOBULIN ............................ 60 tiagabine hcl................................... 35 TIKOSYN ....................................... 29 timolol maleate ............................... 31 timolol maleate (ophth).................... 66 TIMOLOL MALEATE GEL .................... 66 TIMOPTIC OCUDOSE ........................ 66 TIROSINT ...................................... 52 TIVICAY......................................... 18 tizanidine ....................................... 44 TOBI PODHALER ............................. 15 TOBRADEX ..................................... 64 TOBRADEX ST ................................ 64 tobramycin..................................... 15 tobramycin (ophth) ......................... 65 tobramycin sulfate........................... 15 tobramycin sulfate in saline............... 16 tobramycin-dexamethasone .............. 64 TOBREX OINT 0.3%......................... 65 TOLAK........................................... 73 tolmetin sodium .............................. 12 tolterodine tartrate er ...................... 56 tolterodine tartrate tab 1 mg ............. 56 tolterodine tartrate tab 2 mg ............. 56 TOPICORT SPRAY 0.25% .................. 72 topiramate ................................ 35, 36 TOPIRAMATE .................................. 35 toposar.......................................... 27 topotecan hcl.................................. 27 TORISEL ........................................ 24 torsemide inj 50mg/5ml ................... 32 torsemide tabs................................ 32 TOUJEO SOLOSTAR ......................... 46 TOVIAZ ......................................... 56 TPN ELECTROLYTES......................... 62 TRACLEER ...................................... 33 TRADJENTA .................................... 48 TRAMADOL HCL .............................. 12 97 tramadol hcl er ............................... 12 TRAMADOL HCL ER .......................... 12 tramadol hcl er (biphasic) 100mg....... 12 tramadol hcl er (biphasic) 200mg....... 12 tramadol hcl er (biphasic) 300mg....... 12 tramadol hcl tab 50 mg .................... 12 tramadol-acetaminophen .................. 12 trandolapril .................................... 28 trandolapril-verapamil hcl ................. 27 tranexamic acid .............................. 58 TRANSDERM-SCOP .......................... 53 tranylcypromine sulfate .................... 37 TRAVASOL ..................................... 63 TRAVATAN Z .................................. 66 trazodone hcl ................................. 37 TREANDA ....................................... 23 TRECATOR ..................................... 19 TRELSTAR MIXJECT ......................... 25 tretinoin ................................... 26, 70 TRETINOIN .................................... 70 TRETINOIN MICROSPHERE................ 70 tretin-x.......................................... 70 trexall ........................................... 59 TREXIMET ...................................... 42 trezix ............................................ 12 triamcinolone acetonide (mouth)........ 74 triamcinolone acetonide (nasal) ......... 68 triamcinolone acetonide (topical) ....... 72 triamt/hctz cap 37.5-25 ................... 32 triamt/hctz cap 50-25mg .................. 32 triamt/hctz tab 37.5-25 .................... 32 triamt/hctz tab 75-50mg .................. 32 trianex .......................................... 72 TRIBENZOR.................................... 28 triderm .......................................... 72 trifluoperazine hcl............................ 40 trifluridine ...................................... 65 TRIGLIDE....................................... 30 trilyte ............................................ 55 trimethoprim .................................. 17 trimipramine maleate....................... 37 TRISENOX...................................... 26 TRIUMEQ ....................................... 19 TROKENDI XR................................. 36 TROPHAMINE INJ 10% ..................... 63 trospium chloride ............................ 56 trospium chloride er......................... 56 TRULICITY ..................................... 46 TRUMENBA..................................... 61 TRUVADA....................................... 19 TUDORZA PRESSAIR ........................ 67 TUDORZA PRESSAIR (INSTITUTIONAL PACK) ........................................... 67 TWINRIX INJ .................................. 61 TYBOST ......................................... 18 TYGACIL ........................................ 17 TYKERB ......................................... 26 TYPHIM VI ..................................... 61 TYSABRI ........................................ 43 TYVASO ......................................... 33 TYZEKA ......................................... 20 tyzine............................................ 68 U UCERIS ......................................... 54 ULORIC ......................................... 11 ULTRESA ....................................... 55 UNITHROID.................................... 52 ursodiol ......................................... 55 UVADEX ........................................ 26 V VAGIFEM ....................................... 49 valacyclovir hcl ............................... 20 VALCHLOR ..................................... 73 VALCYTE........................................ 20 valganciclovir hcl............................. 20 valproate sodium ............................ 36 valproic acid................................... 36 valsartan ....................................... 29 valsartan-hydrochlorothiazide............ 28 vancomycin hcl ............................... 17 VANDAZOLE ................................... 57 VAQTA .......................................... 61 VARIVAX ....................................... 61 VASCEPA ....................................... 30 VECTIBIX....................................... 24 VELCADE ....................................... 24 VELPHORO ..................................... 52 VELTIN .......................................... 70 venlafaxine cap er ........................... 37 venlafaxine hcl................................ 37 venlafaxine tab ............................... 37 VENLAFAXINE TAB 225MG ER ............ 37 venlafaxine tab er ........................... 37 VENTAVIS ...................................... 33 VENTOLIN HFA ............................... 68 VERAMYST ..................................... 68 98 verapamil hcl.................................. 31 VERAPAMIL HCL .............................. 31 veripred ........................................ 50 VERSACLOZ ................................... 40 VESICARE ...................................... 56 VEXOL........................................... 65 VIBRAMYCIN .................................. 23 vicodin .......................................... 15 vicodin es ...................................... 15 vicodin hp ...................................... 15 VICTOZA ....................................... 46 VIDEX PEDIATRIC ........................... 18 VIGAMOX....................................... 65 VIIBRYD ........................................ 37 VIIBRYD STARTER PACK ................... 37 VIMIZIM ........................................ 49 VIMOVO ........................................ 11 VIMPAT ......................................... 36 vinblastine sulfate ........................... 24 vincasar ........................................ 24 vincristine sulfate ............................ 24 vinorelbine tartrate .......................... 24 VIOKACE 10 ................................... 55 VIOKACE 20 ................................... 55 VIRACEPT ...................................... 18 VIRAMUNE XR ................................ 18 VIREAD ......................................... 18 VITEKTA ........................................ 18 VIVITROL....................................... 45 VOGELXO ...................................... 45 VOGELXO PUMP .............................. 45 VOLTAREN GEL 1% ......................... 73 voriconazole ................................... 17 voriconazole inj 200mg .................... 17 VOTRIENT...................................... 26 VPRIV ........................................... 49 VYTORIN ....................................... 30 VYVANSE ....................................... 41 W warfarin sodium .............................. 57 WELCHOL ...................................... 30 X XALKORI........................................ 26 XARELTO ....................................... 57 XARELTO STARTER PACK .................. 58 XARTEMIS XR ................................. 15 XELJANZ ........................................ 59 XENAZINE...................................... 43 XEOMIN......................................... 44 XERESE ......................................... 73 XGEVA .......................................... 52 XIFAXAN TAB 200MG ....................... 17 XIFAXAN TAB 550MG ....................... 55 XIGDUO XR TAB 10-1000MG ............. 48 XIGDUO XR TAB 10-500MG............... 48 XIGDUO XR TAB 5-1000MG............... 48 XIGDUO XR TAB 5-500MG ................ 48 XOLAIR ......................................... 68 XOPENEX HFA................................. 68 XTANDI ......................................... 25 xylon tab 10-200mg ........................ 15 XYREM .......................................... 44 Y YERVOY ......................................... 24 YF-VAX.......................................... 61 Z zafirlukast ...................................... 68 zamicet ......................................... 15 ZANOSAR ...................................... 23 ZAVESCA ....................................... 49 zazole ........................................... 57 ZAZOLE ......................................... 57 ZEGERID ....................................... 56 ZELAPAR ....................................... 38 ZELBORAF ..................................... 26 ZEMAIRA ....................................... 68 ZEMPLAR ....................................... 64 zenatane ....................................... 70 ZENPEP ......................................... 55 ZERBAXA ....................................... 21 ZETIA TAB 10MG............................. 30 ZETONNA....................................... 68 ZIAGEN ......................................... 18 ZIANA ........................................... 70 zidovudine ..................................... 18 ZINACEF ........................................ 21 ZIOPTAN ....................................... 66 ziprasidone hcl................................ 40 ZIPSOR ......................................... 12 ZIRGAN ......................................... 65 ZMAX ............................................ 21 ZOHYDRO ER (ABUSE DETERRENT) .... 15 zoledronic inj 4mg/5ml..................... 48 zoledronic inj 5/100ml ..................... 48 ZOLINZA ....................................... 25 zolmitriptan.................................... 42 99 zolmitriptan odt .............................. 42 zolpidem tartrate ............................ 41 ZOMACTON .................................... 51 ZOMETA ........................................ 48 ZOMIG NASAL SPRAY....................... 42 zonisamide..................................... 36 ZONTIVITY..................................... 59 ZORBTIVE...................................... 51 ZORTRESS TAB 0.25MG ................... 60 ZORTRESS TAB 0.5MG ..................... 60 ZORTRESS TAB 0.75MG ................... 60 ZORVOLEX ..................................... 12 ZOSTAVAX ..................................... 61 ZOSYN .......................................... 22 ZOVIRAX ....................................... 73 ZUBSOLV SUB 1.4-0.36MG ............... 45 ZUBSOLV SUB 11.4-2.9MG ............... 45 ZUBSOLV SUB 2.9-0.71MG ............... 45 ZUBSOLV SUB 5.7-1.4MG ................. 45 ZUBSOLV SUB 8.6-2.1MG ................. 45 ZUPLENZ ....................................... 53 ZYCLARA ....................................... 73 ZYDELIG........................................ 26 ZYFLO CR ...................................... 68 ZYKADIA ....................................... 26 ZYLET ........................................... 64 ZYPREXA RELPREVV......................... 40 ZYPREXA RELPREVV INJ 210MG ......... 40 ZYTIGA ......................................... 25 ZYVOX .......................................... 17 This formulary was updated on 01/01/2016. This information is available for free in other languages. Please contact our Member Services number at 1-800-247-1447 for additional information. (TTY users should call 1-800-695-8544). Hours are 8:00 a.m. to 8:00 p.m. seven days a week from October 1 to February 14, and Monday through Friday, 8:00 a.m. to 8:00 p.m. from February 15 through September 30. Member Services also has free language interpreter services available for non-English speakers. Esta información está disponible de forma gratuita en otros idiomas. Por favor comuníquese con nuestro número de Servicios al Socio al 1-800-247-1447 para obtener información adicional. Los usuarios con deficiencia auditiva (TTY) deberán llamar al 1-800-695-8544. El horario de atención es de 8:00 a.m. a 8:00 p.m. los siete días de la semana desde el 1 de octubre hasta el 14 de febrero, y de lunes a viernes, de 8:a.m. hasta las 8:00 p.m. desde 100 el 15 de febrero hasta el 30 de septiembre. Servicios al Socio también tiene servicios gratuitos de intérprete disponibles para personas que no hablan inglés. Fidelis Care is an HMO plan with a Medicare contract. Enrollment in Fidelis Care depends on contract renewal. Fidelis Care is a Coordinated Care plan with a Medicare contract and a contract with the New York State Department of Health Medicaid program. Enrollment in Fidelis Care depends on contract renewal. H3328_FC 15054 CMS Accepted 00016378. Version 2 101
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