2017 list of covered drugs/formulary - aetna · 2016-12-13 · aetna better healthsm premier plan |...

Aetna Better HealthSM Premier Plan (Medicare-Medicaid Plan) is a health plan that contracts with Medicare and Michigan Medicaid to provide benefits of both programs to enrollees.

www.aetnabetterhealth.com/michigan

2017 List of Covered Drugs/FormularyAETNA BETTER HEALTHSM PREMIER PLAN

H8026_17_004_DRG_LST_FINAL ACCEPTEDUpdated 09/2016

www.aetnabetterhealth.com/michigan

Helpful information

Member Services1-855-676-5772 (TTY: 711)Representatives available 24 hours a day, 7 days a week

AddressAetna Better HealthSM Premier Plan1333 Gratiot Avenue, Suite 400Detroit, MI 48207

Personal information

My primary care provider’s (PCP) name and phone number

My care manager’s name and phone number

I

If you have questions, please call Aetna Better Health Premier Plan at 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/michigan MI-16-07-07

AETNA BETTER HEALTHSM PREMIER PLAN | 2017 List of Covered Drugs(Formulary)

This is a list of drugs that members can get in Aetna Better Health Premier Plan.

❖ Aetna Better Health Premier Plan is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees.

❖ The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.

❖ Benefits may change on January 1 of each year. You can always check Aetna Better Health Premier Plan’s up‑to‑date List of Covered Drugs online at www.aetnabetterhealth.com/michigan.

❖ Limitations, restrictions, and patient pay amounts may apply. This means that you may have to pay for some services and that you need to follow certain rules to have Aetna Better Health Premier Plan pay for your services. For more information, call Aetna Better Health Premier Plan Member Services or read the Aetna Better Health Premier Plan Member Handbook.

❖ You can get this information for free in other languages. Call 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

Puede obtener esta información en otros idiomas de manera gratuita. Llame al 1‑855‑676‑5772 (TTY: 711), las 24 horas del día, los 7 días de la semana. Esta llamada es gratuita.

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❖ You can also get this information for free in other formats, such as large print, braille, or audio. Call 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

❖ If you wish to make a standing request to receive all materials in a language other than English, or in an alternate format, you can call Aetna Better Health Premier Plan Member Services at 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week.

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Frequently Asked Questions (FAQ)Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.

1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.)

The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by Aetna Better Health Premier Plan. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

➨ Aetna Better Health Premier Plan will cover all medically necessary drugs on the Drug List if:

• your doctor or other prescriber says you need them to get better or stay healthy, and

• you fill the prescription at an Aetna Better Health Premier Plan network pharmacy.

➨ Aetna Better Health Premier Plan may have additional steps to access certain drugs (see question #5 below).

You can also see an up‑to‑date list of drugs that we cover on our website at www.aetnabetterhealth.com/michigan or call Member Services toll‑free at 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week.

2. Does the Drug List ever change?Yes. Aetna Better Health Premier Plan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if:

• a cheaper drug comes along that works as well as a drug on the Drug List now, or

• we learn that a drug is not safe.

We may also change our rules about drugs. For example, we could:

• Decide to require or not require prior approval for a drug. (Prior approval is permission from Aetna Better Health Premier Plan before you can get a drug.)

• Add or change the amount of a drug you can get (called “quantity limits”).

• Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

(For more information on these drug rules, see V.)

We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes.

➨ You can always check Aetna Better Health Premier Plan’s up to date Drug List online at www.aetnabetterhealth.com/michigan. You can also call Member Services to check the current Drug List at 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week.

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3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now?

If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60‑day supply of the drug before the change to the Drug List is made. You will be notified by mail if a drug list change will affect you. You can also search for your drug with the online searchable formulary tool as it is updated to reflect current coverage.

4. Whathappenswhenwefindoutadrugisnotsafe?If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. Please contact your doctor if a drug you are taking is removed from the drug list.

5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example:

• Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Aetna Better Health Premier Plan before you fill your prescription. If you don’t get approval, Aetna Better Health Premier Plan may not cover the drug.

• Quantity limits: Sometimes Aetna Better Health Premier Plan limits the amount of a drug you can get.

• Step therapy: Sometimes Aetna Better Health Premier Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your prescriber thinks the first drug doesn’t work for you, then we will cover the second.

You can find out if your drug has any additional requirements or limits by looking in the tables on pages 1‑89. You can also get more information by visiting our website at www.aetnabetterhealth.com/michigan. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.

You can also ask for an “exception” from these limits. Please see question 11 for more information on exceptions.

➨ If you are in a nursing home or other long‑term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31‑day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Aetna Better Health Premier Plan member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions.

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6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?

The List of Covered Drugs on page 1 has a column labeled “Necessary actions, restrictions, or limits on use.”

7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug.

We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60‑day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next.

8. HowcanyoufindadrugontheDrugList?There are two ways to find a drug:

• You can search alphabetically (if you know how to spell the drug), or

• You can search by medical condition.

To search alphabetically, go to the Alphabetical Listing section. You can find it beginning on page 90. Then look for the name of your drug in the list.

To search by medical condition, find the section labeled “List of drugs by medical condition” on 1. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions.

9. What if the drug you want to take is not on the Drug List?If you don’t see your drug on the Drug List, call Member Services at 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week and ask about it. If you learn that Aetna Better Health Premier Plan will not cover the drug, you can do one of these things:

• Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or

• You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions.

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10. What if you are a new Aetna Better Health Premier Plan member and can’tfindyourdrugontheDrugListorhaveaproblemgettingyourdrug?

We can help. We may cover a temporary 30‑day supply of your drug during the first 90 days you are a member of Aetna Better Health Premier Plan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception.

We will cover a 30‑day supply of your drug if:

• you are taking a drug that is not on our Drug List, or

• health plan rules do not let you get the amount ordered by your prescriber, or

• the drug requires prior approval by Aetna Better Health Premier Plan, or

• you are taking a drug that is part of a step therapy restriction.

If you live in a nursing home or other long‑term care facility, you may refill your prescription for as long as at least 91 days and up to 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception.

If you are a current member with change in level of care, we will cover a one‑time temporary 30‑day supply if you move from the hospital to a home setting and:

• you need a drug that is not on our drug list, and

• your ability to get the drug is limited

We will cover a one time temporary 31‑day supply (see the note below for exceptions) if you move into or out of a long‑term care setting and:

• you need a drug that is not on our drug list, and

• your ability to get the drug is limited

Note: Oral brand name solid dosage form such as tablets or capsules are limited to 14 day fills with exceptions as required by Medicare Part D rules. If your prescription is written for fewer than 31 days, we will pay for the smaller amount. During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.

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11. Can you ask for an exception to cover your drug?Yes. You can ask Aetna Better Health Premier Plan to make an exception to cover a drug that is not on the Drug List.

You can also ask us to change the rules on your drug.

• For example, Aetna Better Health Premier Plan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.

• Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.

12. How long does it take to get an exception?First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber’s supporting statement.

13. How can you ask for an exception?To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception.

14. What are generic drugs?Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well‑known names. Generic drugs are approved by the Food and Drug Administration (FDA).

Aetna Better Health Premier Plan covers both brand name drugs and generic drugs.

15. What are OTC drugs? OTC stands for “over‑the‑counter”. Aetna Better Health Premier Plan covers some OTC drugs when they are written as prescriptions by your provider.

You can read the Aetna Better Health Premier Plan Drug List to see what OTC drugs are covered.

16. Does Aetna Better Health Premier Plan cover OTC non‑drug products? Aetna Better Health Premier Plan covers some OTC non‑drug products when they are written as prescriptions by your provider.

You can read the Aetna Better Health Premier Plan Drug List to see what OTC non‑drug products are covered.

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17. What is your copay?As an Aetna Better Health Premier Plan member, you have no copays for prescription and OTC drugs as long as you follow Aetna Better Health Premier Plan’s rules.

18. What are drug tiers?Tiers are groups of drugs.

Tier 1: Part D prescription generic drug

Tier 2: Part D prescription brand name drugs

Tier 3: Non‑Part D prescription and over‑the‑counter drugs

All tiers have no copay.

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List of Covered DrugsThe list of covered drugs on the next page gives you information about the drugs covered by Aetna Better Health Premier Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 90.

The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., PRADAXA) and generic drugs are listed in lower‑case italics (e.g., amoxicillin).

The information in the necessary actions, restrictions, or limits on use column tells you if Aetna Better Health Premier Plan has any rules for covering your drug.

Note: The asterisk (*) next to a drug means the drug is not a “Part D drug.” These drugs have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Michigan Medicaid. If you or your prescriber disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at 1‑855‑676‑5772 (TTY: 711), 24 hours a day, 7 days a week. You can also read Chapter 9 in the Member Handbook to learn how to appeal a decision.

Here are the meanings of the codes used in the “Necessary action, restrictions, or limits on use” column:

(* ) = Non Medicare Part D drugs, or OTC items that are covered by Medicaid

B/D = Covered under Medicare B or D

PA = Prior Authorization QL = Quantity Limits ST = Step Therapy

MO = Available by mail order LA = Limited Access

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1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy MO - Available by Mail Order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Medicare Part D drugs or OTC items that are covered by MedicaidMI-15-08-24 Formulary ID 00017469 V5

MIMMPeffective01/01/2017

List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions.

Name of drug

What the drug will cost

you (tier

level)

Necessary actions,restrictions,

or limits on useANALGESICS‑DRUGS USED TO TREAT PAIN AND INFLAMMATION

Analgesics 8 hour pain relief $0 (3) *acetaminophen supp 650mg $0 (3) *arthritis pain $0 (3) *arthritis pain relief $0 (3) *ascomp/codeine $0 (1) QL (180 EA per 30 days) PAbutalbital/acetaminophen/caffeine/codeine caps 325mg; 50mg; 40mg; 30mg

$0 (1) QL (180 EA per 30 days) PA

butalbital/acetaminophen/caffeine/codeine caps 300mg; 50mg; 40mg; 30mg

$0 (1) QL (180 EA per 30 days) PA MO

butalbital/acetaminophen/caffeine caps $0 (1) QL (180 EA per 30 days) PAbutalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg

$0 (1) QL (180 EA per 30 days) PA

butalbital/aspirin/caffeine $0 (1) QL (180 EA per 30 days) PA MObutalbital/aspirin/caffeine/codeine $0 (1) QL (180 EA per 30 days) PAcapacet $0 (1) QL (180 EA per 30 days) PAesgic caps $0 (1) QL (180 EA per 30 days) PA MOgnp 8 hour pain reliever $0 (3) *gnp arthritis pain relief $0 (3) *hm arthritis pain relief $0 (3) *margesic $0 (1) QL (180 EA per 30 days) PA MOqc arthritis pain relief $0 (3) *sm 8 hour pain relief $0 (3) *sm arthritis pain relief $0 (3) *zebutal caps 325mg; 50mg; 40mg $0 (1) QL (180 EA per 30 days) PA MO

Nonsteroidal Anti-inflammatory Drugs all day pain relief $0 (3) *celecoxib caps 400mg $0 (1) QL (30 EA per 30 days)

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Name of drug


you (tier

level)


or limits on usecelecoxib caps 100mg, 200mg, 50mg $0 (1) QL (60 EA per 30 days)childrens ibuprofen susp 100mg/5ml $0 (3) *childs ibuprofen $0 (3) *diclofenac potassium $0 (1)diclofenac sodium dr $0 (1)diclofenac sodium er $0 (1)diflunisal tabs $0 (1)etodolac er tb24 600mg $0 (1)etodolac er tb24 400mg, 500mg $0 (1) MOetodolac tabs $0 (1)etodolac caps $0 (1) MOflurbiprofen tabs 100mg $0 (1)flurbiprofen tabs 50mg $0 (1) MOgnp all day pain relief $0 (3) *gnp childrens ibuprofen $0 (3) *gnp ibuprofen $0 (3) *hm ibuprofen infants $0 (3) *ibu-200 $0 (3) *ibuprofen childrens $0 (3) *ibuprofen junior strength $0 (3) *ibuprofen caps $0 (3) *ibuprofen susp 100mg/5ml $0 (1) MOibuprofen susp 100mg/5ml $0 (3) *ibuprofen tabs 400mg, 600mg, 800mg $0 (1)ibuprofen tabs 200mg $0 (3) *infants ibuprofen $0 (3) *ketoprofen er $0 (1) MOketoprofen caps $0 (1)meclofenamate sodium caps $0 (1) MOmeloxicam tabs $0 (1)meloxicam susp $0 (1) MOnabumetone $0 (1)naproxen dr tbec 375mg $0 (1)naproxen dr tbec 500mg $0 (1) MO

3


Name of drug


you (tier

level)


or limits on usenaproxen sodium tabs 275mg, 550mg $0 (1)naproxen tabs $0 (1)naproxen susp $0 (1) MOoxaprozin $0 (1)piroxicam caps 20mg $0 (1)piroxicam caps 10mg $0 (1) MOqc childrens ibuprofen $0 (3) *sb ibuprofen $0 (3) *sm ibuprofen caps $0 (3) *sm infants ibuprofen $0 (3) *sm naproxen sodium tabs $0 (3) *sulindac tabs 150mg $0 (1)sulindac tabs 200mg $0 (1) MOtolmetin sodium caps $0 (1) MOtolmetin sodium tabs 200mg $0 (1)tolmetin sodium tabs 600mg $0 (1) MOVOLTAREN $0 (2) QL (1000 GM per 30 days) MO

Opioid Analgesics, Long-acting fentanyl pt72 25mcg/hr, 50mcg/hr, 75mcg/hr $0 (1) QL (15 EA per 30 days)fentanyl pt72 100mcg/hr, 12mcg/hr, 37.5mcg/hr, 62.5mcg/hr, 87.5mcg/hr

$0 (1) QL (15 EA per 30 days) MO

methadone hcl inj $0 (1) PAmethadone hcl tabs $0 (1) QL (180 EA per 30 days) PAmethadone hcl oral soln $0 (1) QL (3000 ML per 30 days) PAmethadone hcl conc $0 (1) QL (360 ML per 30 days) PAmethadone hcl tbso $0 (1) QL (90 EA per 30 days) PAmethadose tbso $0 (1) QL (90 EA per 30 days) PAmorphine sulfate er cp24 120mg, 45mg, 75mg, 90mg $0 (1) QL (30 EA per 30 days) MOmorphine sulfate er cp24 100mg, 20mg, 30mg, 50mg, 60mg, 80mg

$0 (1) QL (60 EA per 30 days)

morphine sulfate er cp24 10mg, 30mg, 60mg $0 (1) QL (60 EA per 30 days) MOmorphine sulfate er tbcr 100mg, 200mg, 30mg, 60mg

$0 (1) QL (60 EA per 30 days)

morphine sulfate er tbcr 15mg $0 (1) QL (90 EA per 30 days)Opioid Analgesics, Short-acting

4


Name of drug


you (tier

level)


or limits on useacetaminophen/codeine #3 $0 (1) QL (180 EA per 30 days)acetaminophen/codeine soln $0 (1) QL (4500 ML per 30 days)acetaminophen/codeine tabs 300mg; 15mg, 300mg; 60mg

$0 (1) QL (180 EA per 30 days)

butalbital compound/codeine $0 (1) QL (180 EA per 30 days) PAcodeine sulfate tabs $0 (1) QL (180 EA per 30 days) MOduramorph $0 (1) B/Dendocet tabs 325mg; 2.5mg, 325mg; 5mg $0 (1) QL (180 EA per 30 days)endocet tabs 325mg; 10mg, 325mg; 7.5mg $0 (1) QL (180 EA per 30 days) MOendodan $0 (1) QL (180 EA per 30 days)fentanyl citrate oral transmucosal $0 (1) QL (120 EA per 30 days) PAhydrocodone bitartrate/acetaminophen soln 325mg/15ml; 7.5mg/15ml

$0 (1) QL (5550 ML per 30 days)

hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg

$0 (1) QL (180 EA per 30 days)

hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg

$0 (1) QL (180 EA per 30 days) MO

hydrocodone/acetaminophen tabs 325mg; 10mg $0 (1) QL (180 EA per 30 days)hydrocodone/acetaminophen tabs 325mg; 5mg, 325mg; 7.5mg

$0 (1) QL (180 EA per 30 days) MO

hydrocodone/ibuprofen tabs 10mg; 200mg, 5mg; 200mg

$0 (1) QL (150 EA per 30 days)

hydrocodone/ibuprofen tabs 2.5mg; 200mg, 7.5mg; 200mg

$0 (1) QL (150 EA per 30 days) MO

hydromorphone hcl tabs $0 (1) QL (180 EA per 30 days)hydromorphone hcl liqd $0 (1) QL (2400 ML per 30 days) MOhydromorphone hcl inj 10mg/ml, 1mg/ml, 2mg/ml, 50mg/5ml

$0 (1) B/D

hydromorphone hcl inj 4mg/ml $0 (1) B/D MOibudone tabs 5mg; 200mg $0 (1) QL (150 EA per 30 days) MOlorcet $0 (1) QL (180 EA per 30 days)lorcet hd $0 (1) QL (180 EA per 30 days)lorcet plus tabs 325mg; 7.5mg $0 (1) QL (180 EA per 30 days)lortab tabs 325mg; 5mg $0 (1) QL (180 EA per 30 days)lortab tabs 325mg; 10mg, 325mg; 7.5mg $0 (1) QL (180 EA per 30 days) MO

5


Name of drug


you (tier

level)


or limits on usemorphine sulfate inj 0.5mg/ml, 10mg/ml, 150mg/30ml, 15mg/ml, 1mg/ml, 25mg/ml, 2mg/ml, 4mg/ml, 50mg/ml, 5mg/ml, 8mg/ml

$0 (1) B/D

morphine sulfate inj 10mg/ml, 1mg/ml $0 (1) B/D MOmorphine sulfate oral soln 20mg/5ml $0 (1) QL (1020 ML per 30 days)morphine sulfate oral soln 100mg/5ml $0 (1) QL (180 ML per 30 days)morphine sulfate oral soln 10mg/5ml $0 (1) QL (1800 ML per 30 days)morphine sulfate tabs 30mg $0 (1) QL (180 EA per 30 days) MOmorphine sulfate tabs 15mg $0 (1) QL (60 EA per 30 days) MOnalbuphine hcl inj $0 (1) MOoxycodone hcl caps $0 (1) QL (180 EA per 30 days)oxycodone hcl conc $0 (1) QL (180 ML per 30 days)oxycodone hcl soln $0 (1) QL (5400 ML per 30 days)oxycodone hcl tabs 30mg $0 (1) QL (120 EA per 30 days)oxycodone hcl tabs 10mg, 15mg, 20mg $0 (1) QL (120 EA per 30 days) MOoxycodone hcl tabs 5mg $0 (1) QL (180 EA per 30 days)oxycodone/acetaminophen soln $0 (1) QL (1800 ML per 30 days)oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg

$0 (1) QL (180 EA per 30 days)

oxycodone/acetaminophen tabs 325mg; 7.5mg $0 (1) QL (180 EA per 30 days) MOoxycodone/aspirin $0 (1) QL (180 EA per 30 days)oxycodone/ibuprofen $0 (1) QL (120 EA per 30 days) MOreprexain tabs 10mg; 200mg $0 (1) QL (150 EA per 30 days) MOROXICET SOLN $0 (2) QL (1800 ML per 30 days)roxicet tabs $0 (1) QL (180 EA per 30 days)tramadol hcl tabs $0 (1) QL (240 EA per 30 days)tramadol hydrochloride/acetaminophen $0 (1) QL (240 EA per 30 days)vicodin es tabs 300mg; 7.5mg $0 (1) QL (180 EA per 30 days)vicodin tabs 300mg; 5mg $0 (1) QL (180 EA per 30 days)xylon $0 (1) QL (150 EA per 30 days)zamicet $0 (1) QL (5550 ML per 30 days) MO

ANESTHETICS‑DRUGS USED FOR NUMBINGLocal Anesthetics

glydo $0 (1) MOlidocaine hcl jelly gel 2% $0 (1)

6


Name of drug


you (tier

level)


or limits on uselidocaine hcl gel 2% $0 (1) MOlidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4% $0 (1)lidocaine hcl external soln 4% $0 (1)lidocaine hcl mouth/throat soln 4% $0 (1)lidocaine viscous $0 (1)lidocaine/prilocaine kit $0 (1)lidocaine/prilocaine crea $0 (1) MOlidocaine oint $0 (1)lidocaine ptch $0 (1) QL (90 EA per 30 days) PArelador pak plus $0 (1)

ANTI‑ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTSAlcohol Deterrents/Anti-craving

acamprosate calcium dr $0 (1) MOdisulfiram tabs $0 (1)naltrexone hcl tabs $0 (1)

Opioid Dependence Treatments buprenorphine hcl/naloxone hcl $0 (1) QL (90 EA per 30 days) PA MObuprenorphine hcl subl $0 (1) QL (90 EA per 30 days) PA MOSUBOXONE FILM 12MG; 3MG $0 (2) QL (60 EA per 30 days) PA MOSUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG, 8MG; 2MG


Opioid Reversal Agents EVZIO $0 (2) MOnaloxone hcl inj 0.4mg/ml $0 (1)naloxone hcl inj 1mg/ml $0 (1) MONARCAN $0 (2) MO

Smoking Cessation Agents buproban $0 (1) QL (60 EA per 30 days)bupropion hcl sr tb12 150mg $0 (1) QL (60 EA per 30 days) MOCHANTIX CONTINUING MONTH PAK $0 (2) QL (336 EA per 365 days)CHANTIX STARTING MONTH PAK $0 (2) QL (106 EA per 365 days) MOCHANTIX TABS 0.5MG, 1MG $0 (2) QL (336 EA per 365 days) MOgnp nicotine polacrilex gum 2mg $0 (3) *hm nicotine polacrilex lozg $0 (3) *hm nicotine polacrilex gum 2mg $0 (3) *

7


Name of drug


you (tier

level)


or limits on usenicotine polacrilex gum, lozg $0 (3) *nicotine transdermal system pt24 21mg/24hr $0 (3) *NICOTROL NS $0 (2) QL (40 ML per 30 days) MOsm nicotine polacrilex $0 (3) *sm nicotine gum, lozg $0 (3) *

ANTIBACTERIALS‑DRUGS USED TO TREAT INFECTIONSAminoglycosides

amikacin sulfate inj 500mg/2ml $0 (1)amikacin sulfate inj 1gm/4ml $0 (1) MOgentamicin sulfate pediatric $0 (1) MOgentamicin sulfate/0.9% sodium chloride inj 0.9mg/ml; 0.9%, 1.2mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9%, 2mg/ml; 0.9%

$0 (1)

gentamicin sulfate/0.9% sodium chloride inj 0.8mg/ml; 0.9%

$0 (1) MO

gentamicin sulfate inj 10mg/ml $0 (1)gentamicin sulfate inj 40mg/ml $0 (1) MOisotonic gentamicin inj 0.8mg/ml; 0.9% $0 (1)neomycin sulfate $0 (1) MOparomomycin sulfate $0 (1) MOstreptomycin sulfate inj $0 (1) MOtobramycin sulfate inj 1.2gm/30ml, 1.2gm, 10mg/ml, 40mg/ml, 80mg/2ml

$0 (1)

Antibacterials, Other baciim $0 (1)bacitracin inj 50000unit $0 (1) MOchloramphenicol sodium succinate $0 (1)clindamycin hcl caps 150mg, 300mg $0 (1)clindamycin hcl caps 75mg $0 (1) MOclindamycin palmitate hcl $0 (1)clindamycin phosphate add-vantage inj 900mg/6ml $0 (1)clindamycin phosphate in d5w $0 (1)clindamycin phosphate crea 2% $0 (1)clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, 9000mg/60ml, 900mg/6ml

$0 (1)

8


Name of drug


you (tier

level)


or limits on usecolistimethate sodium $0 (1) PACUBICIN $0 (2)DALVANCE $0 (2)ISOPROPYL ALCOHOL WIPES $0 (2)linezolid inj $0 (1) PAlinezolid susr $0 (1) QL (1800 ML per 28 days) PA

MOlinezolid tabs $0 (1) QL (56 EA per 28 days) PAmethenamine hippurate $0 (1)METRO IV $0 (2)metronidazole in nacl 0.79% $0 (1)metronidazole vaginal $0 (1)metronidazole caps 375mg $0 (1) MOmetronidazole tabs 250mg, 500mg $0 (1)nitrofurantoin macrocrystals $0 (1) PAnitrofurantoin monohydrate $0 (1) PAnitrofurantoin monohydrate/macrocrystals $0 (1) PAnitrofurantoin susp $0 (1) PASIVEXTRO INJ $0 (2)SIVEXTRO TABS $0 (2) MOSYNERCID $0 (2)tinidazole $0 (1)trimethoprim tabs $0 (1) MOTYGACIL $0 (2)vancomycin hcl in dextrose $0 (1)vancomycin hcl caps $0 (1) PAvancomycin hcl inj 1000mg, 10gm, 5000mg, 500mg, 750mg

$0 (1)

vandazole $0 (1) MOZYVOX SUSR $0 (2) QL (1800 ML per 28 days) PA

MOZYVOX TABS $0 (2) QL (56 EA per 28 days) PA MOZYVOX INJ 600MG/300ML $0 (2) PA

Beta-lactam, Cephalosporins cefaclor er $0 (1) MO

9


Name of drug


you (tier

level)


or limits on usecefaclor caps $0 (1) MOcefaclor susr 250mg/5ml, 375mg/5ml $0 (1)cefaclor susr 125mg/5ml $0 (1) MOcefadroxil caps, tabs $0 (1)cefadroxil susr 250mg/5ml $0 (1)cefadroxil susr 500mg/5ml $0 (1) MOcefazolin $0 (1)cefazolin sodium/dextrose $0 (1)cefazolin sodium inj 100gm, 10gm, 1gm, 1gm; 5%, 300gm, 500mg

$0 (1)

cefdinir $0 (1)cefditoren pivoxil tabs 400mg $0 (1)cefepime $0 (1)cefepime/dextrose $0 (1)cefixime $0 (1) MOcefotaxime sodium inj 10gm, 2gm, 500mg $0 (1)cefotaxime sodium inj 1gm $0 (1) MOcefotetan $0 (1)cefotetan/dextrose $0 (1)cefoxitin sodium $0 (1)cefpodoxime proxetil susr $0 (1) MOcefpodoxime proxetil tabs 200mg $0 (1)cefpodoxime proxetil tabs 100mg $0 (1) MOcefprozil $0 (1)ceftazidime $0 (1)ceftazidime/dextrose $0 (1)ceftriaxone in iso-osmotic dextrose $0 (1)ceftriaxone sodium inj 100gm, 10gm, 1gm, 250mg, 2gm, 500mg

$0 (1)

ceftriaxone sodium inj 2gm $0 (1) MOceftriaxone/dextrose $0 (1)cefuroxime axetil $0 (1)cefuroxime sodium inj 1.5gm, 225gm, 7.5gm, 75gm $0 (1)cefuroxime sodium inj 750mg $0 (1) MOcephalexin caps 250mg, 500mg $0 (1)

10


Name of drug


you (tier

level)


or limits on usecephalexin caps 750mg $0 (1) MOcephalexin susr $0 (1)cephalexin tabs $0 (1) MOSUPRAX CAPS $0 (2)SUPRAX CHEW 100MG $0 (2)SUPRAX CHEW 200MG $0 (2) MOSUPRAX SUSR 500MG/5ML $0 (2)tazicef inj 1gm, 2gm, 6gm $0 (1)TEFLARO $0 (2)

Beta-lactam, Other aztreonam $0 (1) MOimipenem/cilastatin $0 (1) MOINVANZ INJ 1GM $0 (2)meropenem $0 (1) MOmeropenem/sodium chloride $0 (1)

Beta-lactam, Penicillins amoxicillin/clavulanate potassium er $0 (1)amoxicillin/clavulanate potassium chew $0 (1) MOamoxicillin/clavulanate potassium susr 200mg/5ml; 28.5mg/5ml, 400mg/5ml; 57mg/5ml, 600mg/5ml; 42.9mg/5ml

$0 (1)

amoxicillin/clavulanate potassium susr 250mg/5ml; 62.5mg/5ml

$0 (1) MO

amoxicillin/clavulanate potassium tabs 500mg; 125mg, 875mg; 125mg

$0 (1)

amoxicillin/clavulanate potassium tabs 250mg; 125mg

$0 (1) MO

amoxicillin caps, susr $0 (1)amoxicillin chew $0 (1) MOamoxicillin tabs 875mg $0 (1)amoxicillin tabs 500mg $0 (1) MOampicillin sodium inj 10gm, 125mg, 1gm, 250mg, 2gm, 500mg

$0 (1)

ampicillin sodium inj 1gm $0 (1) MOampicillin-sulbactam $0 (1)

11


Name of drug


you (tier

level)


or limits on useampicillin caps $0 (1)ampicillin susr 125mg/5ml $0 (1)ampicillin susr 250mg/5ml $0 (1) MOBICILLIN L‑A $0 (2) MOdicloxacillin sodium $0 (1)nafcillin $0 (1)oxacillin sodium inj 10gm, 1gm $0 (1)oxacillin sodium inj 2gm $0 (1) MOpenicillin g potassium inj 5000000unit $0 (1)penicillin g potassium inj 20000000unit $0 (1) MOpenicillin g procaine $0 (1) MOpenicillin g sodium $0 (1)penicillin v potassium tabs $0 (1)penicillin v potassium solr 125mg/5ml $0 (1)penicillin v potassium solr 250mg/5ml $0 (1) MOpiperacillin sodium/ tazobactam sodium $0 (1)piperacillin sodium/tazobactam sodium $0 (1)piperacillin/tazobactam inj 36gm; 4.5gm, 4gm; 0.5gm $0 (1)

Macrolides azithromycin inj, tabs $0 (1)azithromycin pack, susr $0 (1) MOclarithromycin tabs $0 (1)clarithromycin susr $0 (1) MODIFICID $0 (2) MOERYTHROCIN LACTOBIONATE $0 (2)erythromycin base $0 (1) MOerythromycin ethylsuccinate tabs $0 (1) MOerythromycin stearate tabs $0 (1)erythromycin cpep 250mg $0 (1) MO

Quinolones ciprofloxacin er $0 (1) MOciprofloxacin hcl tabs 250mg, 500mg $0 (1)ciprofloxacin hcl tabs 100mg, 750mg $0 (1) MOciprofloxacin i.v.-in d5w $0 (1)

12


Name of drug


you (tier

level)


or limits on useciprofloxacin inj, otic soln, susr $0 (1) MOlevofloxacin in d5w $0 (1)levofloxacin inj 25mg/ml $0 (1)levofloxacin oral soln 25mg/ml $0 (1)levofloxacin tabs 250mg, 500mg, 750mg $0 (1)ofloxacin tabs 400mg $0 (1)

Sulfonamides sulfadiazine tabs $0 (1) MOsulfamethoxazole/trimethoprim ds $0 (1)sulfamethoxazole/trimethoprim inj, tabs $0 (1)sulfamethoxazole/trimethoprim susp $0 (1) MOsulfatrim pediatric $0 (1)

Tetracyclines doxy 100 $0 (1)doxycycline hyclate dr $0 (1)doxycycline hyclate caps 100mg $0 (1)doxycycline hyclate caps 50mg $0 (1) MOdoxycycline hyclate inj $0 (1)doxycycline hyclate tabs 100mg $0 (1)doxycycline hyclate tabs 20mg $0 (1) MOdoxycycline monohydrate caps 100mg $0 (1)doxycycline monohydrate caps 50mg $0 (1) MOdoxycycline monohydrate tabs 50mg, 75mg $0 (1)doxycycline monohydrate tabs 100mg, 150mg $0 (1) MOdoxycycline caps 150mg $0 (1)doxycycline caps 75mg $0 (1) MOdoxycycline susr $0 (1) MOminocycline hcl caps $0 (1)morgidox 1x100mg caps $0 (1)morgidox 2x100mg caps $0 (1)tetracycline hcl caps $0 (1) MO

ANTICONVULSANTS‑DRUGS USED TO TREAT SEIZURESAnticonvulsants, Other

APTIOM TABS 200MG, 400MG, 800MG $0 (2) QL (30 EA per 30 days) PA MO

13


Name of drug


you (tier

level)


or limits on useAPTIOM TABS 600MG $0 (2) QL (60 EA per 30 days) PA MOBRIVIACT TABS $0 (2) QL (60 EA per 30 days) PABRIVIACT INJ, ORAL SOLN $0 (2) QL (600 ML per 30 days) PAFYCOMPA SUSP $0 (2) QL (1020 ML per 30 days) PAFYCOMPA TABS 10MG, 12MG, 4MG, 6MG, 8MG $0 (2) QL (30 EA per 30 days) PA MOFYCOMPA TABS 2MG $0 (2) QL (60 EA per 30 days) PA MOlevetiracetam $0 (1)POTIGA TABS 50MG $0 (2) QL (270 EA per 30 days) MOPOTIGA TABS 200MG, 300MG, 400MG $0 (2) QL (90 EA per 30 days) MOSPRITAM TB3D 250MG, 500MG, 750MG $0 (2)SPRITAM TB3D 1000MG $0 (2) MO

Calcium Channel Modifying Agents CELONTIN $0 (2) MOethosuximide $0 (1)LYRICA SOLN $0 (2) QL (900 ML per 30 days) PA MOLYRICA CAPS 225MG, 300MG $0 (2) QL (60 EA per 30 days) PA MOLYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG


zonisamide $0 (1)Gamma-aminobutyric Acid (GABA) Augmenting Agents

clonazepam odt tbdp 1mg $0 (1) QL (120 EA per 30 days)clonazepam odt tbdp 2mg $0 (1) QL (300 EA per 30 days)clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg $0 (1) QL (90 EA per 30 days)clonazepam tabs 1mg $0 (1) QL (120 EA per 30 days)clonazepam tabs 2mg $0 (1) QL (300 EA per 30 days)clonazepam tabs 0.5mg $0 (1) QL (90 EA per 30 days)diazepam gel 10mg, 2.5mg, 20mg $0 (1) MOdivalproex sodium $0 (1)divalproex sodium dr $0 (1)divalproex sodium er $0 (1)gabapentin caps, soln, tabs $0 (1)GABITRIL TABS 12MG, 16MG $0 (2) MOONFI SUSP $0 (2) MOONFI TABS 10MG, 20MG $0 (2) MO

14


Name of drug


you (tier

level)


or limits on usephenobarbital elix $0 (1) QL (1500 ML per 30 days) PA

MOphenobarbital tabs 16.2mg, 32.4mg, 64.8mg, 97.2mg

$0 (1) QL (120 EA per 30 days) PA

phenobarbital tabs 100mg, 15mg, 30mg, 60mg $0 (1) QL (120 EA per 30 days) PA MOprimidone tabs $0 (1)SABRIL $0 (2) PAtiagabine hydrochloride $0 (1)valproate sodium inj $0 (1)valproic acid caps $0 (1)valproic acid syrp $0 (1) MO

Glutamate Reducing Agents felbamate $0 (1)lamotrigine titration $0 (1) MOlamotrigine chew, tabs $0 (1)topiramate cpsp 15mg $0 (1)topiramate cpsp 25mg $0 (1) MOtopiramate tabs $0 (1) MO

Sodium Channel Agents BANZEL $0 (2) PA MOcarbamazepine er cp12 $0 (1)carbamazepine er tb12 $0 (1) MOcarbamazepine chew, susp, tabs $0 (1)DILANTIN CAPS 30MG $0 (2) MOepitol $0 (1) MOfosphenytoin sodium $0 (1)oxcarbazepine tabs $0 (1)oxcarbazepine susp $0 (1) MOPEGANONE $0 (2) MOphenytoin sodium extended $0 (1)phenytoin sodium inj $0 (1)phenytoin susp $0 (1)phenytoin chew $0 (1) MOVIMPAT INJ $0 (2)VIMPAT ORAL SOLN $0 (2) MO

15


Name of drug


you (tier

level)


or limits on useVIMPAT TABS 50MG $0 (2) QL (180 EA per 30 days) MOVIMPAT TABS 100MG, 150MG, 200MG $0 (2) QL (60 EA per 30 days) MO

ANTIDEMENTIA AGENTS‑DRUGS USED TO TREAT DEMENTIA AND MEMORY LOSSAntidementia Agents, Other

ergoloid mesylates tabs $0 (1) PA MOCholinesterase Inhibitors

donepezil hcl tbdp $0 (1) QL (30 EA per 30 days)donepezil hcl tabs 23mg, 5mg $0 (1) QL (30 EA per 30 days)donepezil hcl tabs 10mg $0 (1) QL (60 EA per 30 days)galantamine hydrobromide soln $0 (1) QL (200 ML per 30 days) MOgalantamine hydrobromide cp24 $0 (1) QL (30 EA per 30 days)galantamine hydrobromide tabs $0 (1) QL (60 EA per 30 days)NAMZARIC $0 (2) QL (30 EA per 30 days) PA MOrivastigmine tartrate $0 (1) QL (60 EA per 30 days)rivastigmine transdermal system $0 (1) QL (30 EA per 30 days) MO

N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl $0 (1) QL (60 EA per 30 days) PAmemantine hcl titration pak $0 (1) QL (98 EA per 365 days) PA MOmemantine hydrochloride soln $0 (1) QL (360 ML per 30 days) PANAMENDA TITRATION PAK $0 (2) QL (98 EA per 365 days) PA MONAMENDA XR TITRATION PACK $0 (2) QL (56 EA per 365 days) PA MONAMENDA XR CP24 14MG $0 (2) QL (30 EA per 30 days) PANAMENDA XR CP24 21MG, 28MG, 7MG $0 (2) QL (30 EA per 30 days) PA MONAMENDA SOLN $0 (2) QL (360 ML per 30 days) PA MONAMENDA TABS $0 (2) QL (60 EA per 30 days) PA MO

ANTIDEPRESSANTS‑DRUGS USED TO TREAT DEPRESSIONAntidepressants, Other

bupropion hcl er $0 (1) QL (60 EA per 30 days)bupropion hcl sr tb12 100mg, 150mg, 200mg $0 (1) QL (60 EA per 30 days)bupropion hcl xl tb24 300mg $0 (1) QL (30 EA per 30 days)bupropion hcl xl tb24 150mg $0 (1) QL (30 EA per 30 days) MObupropion hcl tabs $0 (1) QL (180 EA per 30 days)mirtazapine $0 (1)mirtazapine odt $0 (1) QL (30 EA per 30 days) MOTRINTELLIX $0 (2) QL (30 EA per 30 days) PA

16


Name of drug


you (tier

level)


or limits on useMonoamine Oxidase Inhibitors

EMSAM $0 (2) QL (30 EA per 30 days) PA MOMARPLAN $0 (2) MOphenelzine sulfate $0 (1)tranylcypromine sulfate $0 (1) MO

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor

BRINTELLIX TABS 20MG $0 (2) QL (30 EA per 30 days) PABRINTELLIX TABS 10MG, 5MG $0 (2) QL (30 EA per 30 days) PA MOcitalopram hydrobromide soln $0 (1) QL (600 ML per 30 days)citalopram hydrobromide tabs 10mg $0 (1) QL (120 EA per 30 days)citalopram hydrobromide tabs 40mg $0 (1) QL (30 EA per 30 days)citalopram hydrobromide tabs 20mg $0 (1) QL (60 EA per 30 days)desvenlafaxine er tb24 100mg, 50mg $0 (1) QL (30 EA per 30 days) PAdesvenlafaxine er tb24 50mg $0 (1) QL (30 EA per 30 days) PA MOduloxetine hcl cpep 20mg, 60mg $0 (1) QL (60 EA per 30 days)duloxetine hcl cpep 40mg $0 (1) QL (60 EA per 30 days) MOduloxetine hcl cpep 30mg $0 (1) QL (90 EA per 30 days) MOescitalopram oxalate soln $0 (1) QL (600 ML per 30 days)escitalopram oxalate tabs 20mg $0 (1) QL (30 EA per 30 days)escitalopram oxalate tabs 10mg, 5mg $0 (1) QL (45 EA per 30 days)FETZIMA $0 (2) QL (30 EA per 30 days) PA MOFETZIMA TITRATION PACK $0 (2) QL (56 EA per 365 days) PA MOfluoxetine $0 (1) MOfluoxetine dr $0 (1) QL (4 EA per 28 days) MOfluoxetine hcl caps, soln $0 (1)fluoxetine hcl tabs 10mg, 20mg $0 (1)fluoxetine hcl tabs 60mg $0 (1) MOfluvoxamine maleate tabs 100mg, 50mg $0 (1)fluvoxamine maleate tabs 25mg $0 (1) MOmaprotiline hcl $0 (1) MOnefazodone hcl $0 (1) MOolanzapine/fluoxetine caps 25mg; 12mg, 25mg; 6mg, 50mg; 12mg, 50mg; 6mg

$0 (1) QL (30 EA per 30 days)

olanzapine/fluoxetine caps 25mg; 3mg $0 (1) QL (30 EA per 30 days) MO

17


Name of drug


you (tier

level)


or limits on useparoxetine hcl $0 (1)PAXIL SUSP $0 (2) MOPRISTIQ TB24 25MG $0 (2) QL (120 EA per 30 days) PA MOsertraline hcl conc, tabs $0 (1)trazodone hcl $0 (1)venlafaxine hcl $0 (1) MOvenlafaxine hcl er cp24 37.5mg, 75mg $0 (1) QL (30 EA per 30 days)venlafaxine hcl er cp24 150mg $0 (1) QL (60 EA per 30 days)venlafaxine hcl er tb24 37.5mg, 75mg $0 (1) QL (30 EA per 30 days)venlafaxine hcl er tb24 225mg $0 (1) QL (30 EA per 30 days) MOvenlafaxine hcl er tb24 150mg $0 (1) QL (60 EA per 30 days)VIIBRYD STARTER PACK $0 (2) QL (60 EA per 365 days) MOVIIBRYD TABS $0 (2) QL (30 EA per 30 days) MOVIIBRYD KIT $0 (2) QL (60 EA per 365 days)

Tricyclics amitriptyline hcl tabs 100mg, 25mg, 50mg, 75mg $0 (1) PAamitriptyline hcl tabs 10mg, 150mg $0 (1) PA MOamoxapine $0 (1) MOclomipramine hcl caps $0 (1) PAdesipramine hcl tabs 100mg, 150mg, 25mg, 50mg $0 (1)desipramine hcl tabs 10mg, 75mg $0 (1) MOdoxepin hcl caps 100mg, 10mg, 25mg, 50mg, 75mg $0 (1) PAdoxepin hcl caps 150mg $0 (1) PA MOdoxepin hcl conc $0 (1) PA MOimipramine hcl tabs $0 (1) PAnortriptyline hcl caps 10mg, 25mg, 75mg $0 (1)nortriptyline hcl caps 50mg $0 (1) MOnortriptyline hcl soln $0 (1) MOperphenazine/amitriptyline tabs 25mg; 4mg $0 (1)perphenazine/amitriptyline tabs 10mg; 2mg, 10mg; 4mg, 25mg; 2mg, 50mg; 4mg

$0 (1) MO

protriptyline hcl $0 (1)trimipramine maleate caps $0 (1) PA

ANTIEMETICS‑DRUGS FOR NAUSEA AND VOMITINGAntiemetics, Other

18


Name of drug


you (tier

level)


or limits on usemeclizine hcl tabs $0 (1)phenadoz supp 25mg $0 (1) PAphenadoz supp 12.5mg $0 (1) PA MOphenergan supp $0 (1) PApromethazine hcl supp 12.5mg, 50mg $0 (1) PApromethazine hcl supp 25mg $0 (1) PA MOpromethegan supp 12.5mg, 25mg $0 (1) PApromethegan supp 50mg $0 (1) PA MOTRANSDERM‑SCOP $0 (2) MO

Emetogenic Therapy Adjuncts dronabinol $0 (1) QL (60 EA per 30 days) PAEMEND CAPS 40MG $0 (2) QL (1 EA per 30 days) B/DEMEND CAPS 0, 125MG, 80MG $0 (2) QL (6 EA per 30 days) B/D MOgranisetron hcl tabs $0 (1) QL (60 EA per 30 days) B/Dondansetron hcl oral soln $0 (1) QL (900 ML per 30 days) B/D

MOondansetron hcl inj 40mg/20ml, 4mg/2ml $0 (1)ondansetron hcl inj 4mg/2ml $0 (1) MOondansetron hcl tabs 4mg, 8mg $0 (1) B/Dondansetron hcl tabs 24mg $0 (1) B/D MOondansetron odt tbdp 8mg $0 (1) B/Dondansetron odt tbdp 4mg $0 (1) B/D MO

ANTIFUNGALS‑DRUGS USED TO TREAT FUNGAL INFECTIONSAntifungals

ABELCET $0 (2) B/DAMBISOME $0 (2) B/Damphotericin b $0 (1) B/D MOCANCIDAS INJ 50MG $0 (2)CANCIDAS INJ 70MG $0 (2) MOciclodan $0 (1)ciclopirox nail lacquer $0 (1)ciclopirox olamine crea $0 (1)ciclopirox gel, susp $0 (1)ciclopirox sham $0 (1) MOclotrimazole/betamethasone dipropionate $0 (1)

19


Name of drug


you (tier

level)


or limits on useclotrimazole vaginal crea 1% $0 (3) *clotrimazole soln $0 (1)clotrimazole external crea, troc $0 (1) MOeconazole nitrate crea $0 (1) MOERAXIS $0 (2) PAfluconazole in dextrose $0 (1)fluconazole in nacl inj 100mg/50ml; 0.9%, 400mg/200ml; 0.9%

$0 (1)

fluconazole susr, tabs $0 (1)flucytosine $0 (1) MOgnp miconazole 3 $0 (3) *gnp terbinafine hydrochloride $0 (3) *griseofulvin microsize susp $0 (1)griseofulvin microsize tabs $0 (1) MOgriseofulvin ultramicrosize $0 (1)itraconazole caps $0 (1) PAketoconazole tabs $0 (1)ketoconazole crea, sham $0 (1) MOLAMISIL AT $0 (3) *miconazole 3 combo pack $0 (3) *miconazole 7 $0 (3) *NOXAFIL INJ $0 (2) PANOXAFIL SUSP, TBEC $0 (2) PA MOnyamyc $0 (1) MOnystatin crea, oint, powd, susp, tabs $0 (1)nystop $0 (1) MOqc 3 day vaginal cream $0 (3) *sm athletes foot crea $0 (3) *sm miconazole 3 $0 (3) *sm miconazole 7 crea $0 (3) *SPORANOX SOLN $0 (2) PA MOterbinafine hcl tabs $0 (1)terbinafine hcl crea $0 (3) *terconazole $0 (1) MOtioconazole-1 $0 (3) *

20


Name of drug


you (tier

level)


or limits on usevoriconazole inj, tabs $0 (1)voriconazole susr $0 (1) MOzazole $0 (1)

ANTIGOUT AGENTS‑ DRUGS USED TO TREAT GOUT Antigout Agents

allopurinol tabs 300mg $0 (1)allopurinol tabs 100mg $0 (1) MOcolchicine caps, tabs $0 (1) MOprobenecid/colchicine $0 (1)probenecid tabs $0 (1) MOULORIC $0 (2) ST MO

ANTIMIGRAINE AGENTS‑ DRUGS USED TO TREAT SEVERE HEADACHES Ergot Alkaloids

dihydroergotamine mesylate inj $0 (1) MOMIGERGOT $0 (2) QL (20 EA per 28 days) MO

Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan hcl $0 (1) QL (9 EA per 30 days)rizatriptan benzoate odt $0 (1) QL (12 EA per 30 days)rizatriptan benzoate tabs 5mg $0 (1) QL (12 EA per 30 days)rizatriptan benzoate tabs 10mg $0 (1) QL (12 EA per 30 days) MOsumatriptan succinate refill inj 6mg/0.5ml $0 (1) QL (4 ML per 30 days)sumatriptan succinate refill inj 4mg/0.5ml $0 (1) QL (4 ML per 30 days) MOsumatriptan succinate inj 6mg/0.5ml $0 (1) QL (4 ML per 30 days)sumatriptan succinate inj 4mg/0.5ml $0 (1) QL (4 ML per 30 days) MOsumatriptan succinate tabs 100mg, 50mg $0 (1) QL (9 EA per 30 days)sumatriptan succinate tabs 25mg $0 (1) QL (9 EA per 30 days) MOsumatriptan soln $0 (1) QL (12 EA per 30 days) MOzolmitriptan odt $0 (1) QL (6 EA per 30 days)zolmitriptan tabs $0 (1) QL (6 EA per 30 days)

ANTIMYASTHENIC AGENTS‑ DRUGS USED TO TREAT MYASTHENIA GRAVISParasympathomimetics

guanidine hcl $0 (1)MESTINON TIMESPAN $0 (2) MOMESTINON SYRP $0 (2) MO

21


Name of drug


you (tier

level)


or limits on usepyridostigmine bromide tabs, tbcr $0 (1)

ANTIMYCOBACTERIALS‑ DRUGS USED TO TREAT TUBERCULOSISAntimycobacterials, Other

dapsone tabs $0 (1) MOrifabutin $0 (1) MO

Antituberculars CAPASTAT SULFATE $0 (2)cycloserine $0 (1) MOethambutol hcl $0 (1) MOisoniazid inj $0 (1)isoniazid syrp $0 (1) MOisoniazid tabs 300mg $0 (1)isoniazid tabs 100mg $0 (1) MOPASER $0 (2) MOPRIFTIN $0 (2)pyrazinamide tabs $0 (1) MOrifampin caps, inj $0 (1)RIFATER $0 (2) MOSIRTURO $0 (2) QL (188 EA per 365 days) PATRECATOR $0 (2) MO

ANTINEOPLASTICS‑ DRUGS USED TO TREAT CANCERAlkylating Agents

ALKERAN TABS $0 (2) B/D MOBENDEKA $0 (2)BUSULFEX $0 (2)cyclophosphamide inj $0 (1)cyclophosphamide caps $0 (1) B/D MOGLEOSTINE CAPS 5MG $0 (2)HEXALEN $0 (2) MOLEUKERAN $0 (2) MOlomustine $0 (1)MATULANE $0 (2)melphalan hydrochloride $0 (1)MUSTARGEN $0 (2)

22


Name of drug


you (tier

level)


or limits on useTEMODAR INJ $0 (2) B/Dthiotepa $0 (1)TREANDA $0 (2)VALCHLOR $0 (2) PA LAYONDELIS $0 (2) PA

Antiandrogens bicalutamide $0 (1)flutamide $0 (1)NILANDRON $0 (2) MOXTANDI $0 (2) QL (120 EA per 30 days) PAZYTIGA $0 (2) QL (120 EA per 30 days) PA

Antiangiogenic Agents POMALYST $0 (2) QL (21 EA per 28 days) PAREVLIMID $0 (2) QL (30 EA per 30 days) PATHALOMID CAPS 100MG, 150MG, 50MG $0 (2) QL (28 EA per 28 days) PATHALOMID CAPS 200MG $0 (2) QL (56 EA per 28 days) PA

Antiestrogens/Modifiers EMCYT $0 (2) MOFARESTON $0 (2) MOSOLTAMOX $0 (2) PA MOtamoxifen citrate tabs 20mg $0 (1)tamoxifen citrate tabs 10mg $0 (1) MO

Antimetabolites DEPOCYT $0 (2)DROXIA $0 (2) MOhydroxyurea caps $0 (1)LONSURF TABS 6.14MG; 15MG $0 (2) QL (100 EA per 28 days) PALONSURF TABS 8.19MG; 20MG $0 (2) QL (80 EA per 28 days) PAmercaptopurine tabs $0 (1)PURIXAN $0 (2) PATABLOID $0 (2) MO

Antineoplastics, Other ABRAXANE $0 (2)adrucil $0 (1) B/D

23


Name of drug


you (tier

level)


or limits on useALIMTA $0 (2) PAamifostine $0 (1)ARRANON $0 (2)AVASTIN $0 (2) PAazacitidine $0 (1) PABELEODAQ $0 (2) PABICNU $0 (2)bleomycin sulfate $0 (1) B/Dcarboplatin $0 (1)cisplatin $0 (1)cladribine $0 (1) B/DCLOLAR $0 (2)COSMEGEN $0 (2)COTELLIC $0 (2) QL (63 EA per 28 days) PAcytarabine aqueous $0 (1) B/Ddacarbazine $0 (1)daunorubicin hcl $0 (1)decitabine $0 (1)dexrazoxane $0 (1)DOCEFREZ INJ 20MG $0 (2)docetaxel inj 140mg/7ml, 160mg/16ml, 160mg/8ml, 200mg/20ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml

$0 (1)

doxorubicin hcl $0 (1) B/Ddoxorubicin hcl liposome $0 (1)ELITEK $0 (2) PAepirubicin hcl inj 200mg/100ml, 50mg/25ml $0 (1)ERBITUX $0 (2) PAERWINAZE $0 (2) PAFARYDAK $0 (2) QL (6 EA per 21 days) PAFASLODEX $0 (2) PA MOfludarabine phosphate $0 (1)fluorouracil inj 2.5gm/50ml $0 (1) B/DFOLOTYN $0 (2)FUSILEV $0 (2)

24


Name of drug


you (tier

level)


or limits on usegemcitabine $0 (1)gemcitabine hcl $0 (1)HALAVEN $0 (2) PAHERCEPTIN $0 (2) PAIBRANCE $0 (2) QL (21 EA per 28 days) PAidarubicin hcl $0 (1)ifosfamide $0 (1)INTRON A W/DILUENT $0 (2) PAINTRON A INJ 10MU/ML, 18MU, 50MU, 6000000UNIT/ML

$0 (2) PA

irinotecan $0 (1)ISTODAX $0 (2) PAIXEMPRA KIT $0 (2) PAJEVTANA $0 (2) PAKADCYLA $0 (2) PAleucovorin calcium inj $0 (1)leucovorin calcium tabs 5mg $0 (1)leucovorin calcium tabs 10mg, 15mg, 25mg $0 (1) MOlevoleucovorin calcium $0 (1)levoleucovorin inj 250mg/25ml $0 (1)LYNPARZA $0 (2) QL (448 EA per 28 days) PA LAMARQIBO $0 (2) PA LAmesna $0 (1)MESNEX TABS $0 (2) MOmitomycin $0 (1)mitoxantrone hcl $0 (1)NINLARO $0 (2) QL (3 EA per 28 days) PANIPENT $0 (2)ODOMZO $0 (2) QL (30 EA per 30 days) PAONCASPAR $0 (2)oxaliplatin $0 (1)paclitaxel $0 (1)PERJETA $0 (2) PAPORTRAZZA $0 (2) PA LAPROLEUKIN $0 (2)

25


Name of drug


you (tier

level)


or limits on useSYLATRON $0 (2) PASYNRIBO $0 (2) PATAGRISSO $0 (2) QL (30 EA per 30 days) PA LATHERACYS $0 (2)TICE BCG $0 (2)TRISENOX $0 (2) PAUVADEX $0 (2)VALSTAR $0 (2)VECTIBIX $0 (2) PAVELCADE $0 (2) PAVENCLEXTA $0 (2) QL (120 EA per 30 days) PA LAVENCLEXTA STARTING PACK $0 (2) QL (84 EA per 365 days) PA LAvinblastine sulfate inj 1mg/ml $0 (1) B/Dvincasar pfs $0 (1) B/Dvincristine sulfate $0 (1) B/Dvinorelbine tartrate $0 (1)YERVOY $0 (2) PAZALTRAP $0 (2) PAZANOSAR $0 (2)ZOLINZA $0 (2) QL (120 EA per 30 days) PA

Aromatase Inhibitors, 3rd Generation anastrozole tabs $0 (1)exemestane $0 (1) MOletrozole $0 (1)

Enzyme Inhibitors etoposide inj $0 (1)toposar $0 (1)topotecan hcl $0 (1)ZYDELIG $0 (2) QL (60 EA per 30 days) PA LA

Molecular Target Inhibitors AFINITOR $0 (2) QL (30 EA per 30 days) PAAFINITOR DISPERZ $0 (2) QL (60 EA per 30 days) PAALECENSA $0 (2) QL (240 EA per 30 days) PABOSULIF $0 (2) PA

26


Name of drug


you (tier

level)


or limits on useCABOMETYX $0 (2) QL (30 EA per 30 days) PACAPRELSA TABS 300MG $0 (2) QL (30 EA per 30 days) PA LACAPRELSA TABS 100MG $0 (2) QL (60 EA per 30 days) PA LACOMETRIQ $0 (2) PA LAERIVEDGE $0 (2) QL (30 EA per 30 days) PAGILOTRIF $0 (2) QL (30 EA per 30 days) PA LAGLEEVEC TABS 400MG $0 (2) QL (60 EA per 30 days) PAGLEEVEC TABS 100MG $0 (2) QL (90 EA per 30 days) PAICLUSIG TABS 45MG $0 (2) QL (30 EA per 30 days) PA LAICLUSIG TABS 15MG $0 (2) QL (60 EA per 30 days) PA LAimatinib mesylate tabs 400mg $0 (1) QL (60 EA per 30 days) PAimatinib mesylate tabs 100mg $0 (1) QL (90 EA per 30 days) PAIMBRUVICA $0 (2) QL (120 EA per 30 days) PA LAINLYTA TABS 5MG $0 (2) QL (120 EA per 30 days) PAINLYTA TABS 1MG $0 (2) QL (240 EA per 30 days) PAIRESSA $0 (2) QL (30 EA per 30 days) PA LAJAKAFI $0 (2) QL (60 EA per 30 days) PALENVIMA 10 MG DAILY DOSE $0 (2) PA LALENVIMA 14 MG DAILY DOSE $0 (2) PA LALENVIMA 18 MG DAILY DOSE $0 (2) PALENVIMA 20 MG DAILY DOSE $0 (2) PA LALENVIMA 24 MG DAILY DOSE $0 (2) PA LALENVIMA 8 MG DAILY DOSE $0 (2) PAMEKINIST TABS 0.5MG $0 (2) QL (120 EA per 30 days) PAMEKINIST TABS 2MG $0 (2) QL (30 EA per 30 days) PANEXAVAR $0 (2) QL (120 EA per 30 days) PASPRYCEL TABS 100MG, 140MG $0 (2) QL (30 EA per 30 days) PASPRYCEL TABS 20MG, 50MG, 70MG, 80MG $0 (2) QL (60 EA per 30 days) PASTIVARGA $0 (2) QL (120 EA per 30 days) PASUTENT CAPS 25MG, 37.5MG, 50MG $0 (2) QL (30 EA per 30 days) PASUTENT CAPS 12.5MG $0 (2) QL (90 EA per 30 days) PATAFINLAR CAPS 75MG $0 (2) QL (120 EA per 30 days) PATAFINLAR CAPS 50MG $0 (2) QL (180 EA per 30 days) PATARCEVA TABS 25MG $0 (2) QL (60 EA per 30 days) PATARCEVA TABS 100MG, 150MG $0 (2) QL (90 EA per 30 days) PA

27


Name of drug


you (tier

level)


or limits on useTASIGNA $0 (2) QL (120 EA per 30 days) PATORISEL $0 (2)TYKERB $0 (2) QL (180 EA per 30 days) PAVOTRIENT $0 (2) QL (120 EA per 30 days) PAXALKORI $0 (2) QL (60 EA per 30 days) PAZELBORAF $0 (2) QL (240 EA per 30 days) PAZYKADIA $0 (2) QL (150 EA per 30 days) PA

Monoclonal Antibodies ARZERRA $0 (2) PABLINCYTO $0 (2) PACYRAMZA $0 (2) PA LADARZALEX $0 (2) PAEMPLICITI $0 (2) PAGAZYVA $0 (2) PAKEYTRUDA $0 (2) PAOPDIVO $0 (2) PARITUXAN $0 (2) PATECENTRIQ $0 (2) PA

Retinoids bexarotene $0 (1) PAPANRETIN $0 (2) MOTARGRETIN $0 (2) PAtretinoin caps 10mg $0 (1)

ANTIPARASITICS‑DRUGS USED TO TREAT MALARIA AND LICEAnthelmintics

ALBENZA $0 (2) MOivermectin tabs $0 (1) MO

Antiprotozoals ALINIA SUSR $0 (2)ALINIA TABS $0 (2) MOatovaquone $0 (1) PA MOatovaquone/proguanil hcl $0 (1)chloroquine phosphate tabs $0 (1)COARTEM $0 (2) MODARAPRIM $0 (2)

28


Name of drug


you (tier

level)


or limits on usehydroxychloroquine sulfate tabs $0 (1)mefloquine hcl $0 (1) MOMEPRON $0 (2) PA MONEBUPENT $0 (2) B/D MOPENTAM 300 $0 (2) MOprimaquine phosphate tabs $0 (1) MOquinine sulfate $0 (1) PA MO

Pediculicides/Scabicides gnp lice treatment liqd $0 (3) *lindane sham $0 (1)lindane lotn $0 (1) MOmalathion $0 (1) MOpermethrin crea $0 (1) MO

ANTIPARKINSON AGENTS‑ DRUGS USED TO TREAT PARKINSONS DISEASE Anticholinergics

benztropine mesylate inj $0 (1) PA MObenztropine mesylate tabs 2mg $0 (1) PAbenztropine mesylate tabs 0.5mg, 1mg $0 (1) PA MOtrihexyphenidyl hcl $0 (1) PA

Antiparkinson Agents, Other amantadine hcl caps, syrp $0 (1)amantadine hcl tabs $0 (1) MOentacapone $0 (1)

Dopamine Agonists APOKYN $0 (2) PAbromocriptine mesylate caps, tabs $0 (1)NEUPRO $0 (2) QL (30 EA per 30 days) MOpramipexole dihydrochloride $0 (1)ropinirole hcl $0 (1)

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors

carbidopa/levodopa $0 (1)carbidopa/levodopa er $0 (1)carbidopa/levodopa odt $0 (1) MO

29


Name of drug


you (tier

level)


or limits on usecarbidopa/levodopa/entacapone tabs 18.75mg; 200mg; 75mg, 25mg; 200mg; 100mg, 31.25mg; 200mg; 125mg, 37.5mg; 200mg; 150mg, 50mg; 200mg; 200mg

$0 (1)

carbidopa/levodopa/entacapone tabs 12.5mg; 200mg; 50mg

$0 (1) MO

carbidopa tabs $0 (1)Monoamine Oxidase B (MAO-B) Inhibitors

AZILECT $0 (2) QL (30 EA per 30 days) MOselegiline hcl tabs $0 (1)selegiline hcl caps $0 (1) MO

ANTIPSYCHOTICS‑ DRUGS USED TO TREAT PSYCHOSES AND SCHIZOPHRENIA1st Generation/Typical

chlorpromazine hcl inj $0 (1)chlorpromazine hcl tabs 100mg, 200mg, 25mg, 50mg

$0 (1)

chlorpromazine hcl tabs 10mg $0 (1) MOcompro $0 (1) MOfluphenazine decanoate inj $0 (1) MOfluphenazine hcl elix $0 (1)fluphenazine hcl conc, inj $0 (1) MOfluphenazine hcl tabs 10mg, 1mg, 5mg $0 (1)fluphenazine hcl tabs 2.5mg $0 (1) MOhaloperidol decanoate $0 (1)haloperidol lactate $0 (1)haloperidol conc $0 (1) MOhaloperidol tabs 0.5mg, 1mg, 20mg, 5mg $0 (1)haloperidol tabs 10mg, 2mg $0 (1) MOloxapine succinate caps 10mg, 50mg, 5mg $0 (1)loxapine succinate caps 25mg $0 (1) MOperphenazine tabs 4mg $0 (1)perphenazine tabs 16mg, 2mg, 8mg $0 (1) MOpimozide $0 (1) MOprochlorperazine $0 (1)prochlorperazine edisylate inj $0 (1) MO

30


Name of drug


you (tier

level)


or limits on useprochlorperazine maleate tabs $0 (1)thioridazine hcl tabs 10mg, 25mg, 50mg $0 (1) PAthioridazine hcl tabs 100mg $0 (1) PA MOthiothixene caps 1mg $0 (1)thiothixene caps 10mg, 2mg, 5mg $0 (1) MOtrifluoperazine hcl tabs 1mg $0 (1)trifluoperazine hcl tabs 10mg, 2mg, 5mg $0 (1) MO

2nd Generation/Atypical ABILIFY DISCMELT $0 (2) QL (60 EA per 30 days)ABILIFY MAINTENA $0 (2) MOABILIFY INJ $0 (2) MOABILIFY ORAL SOLN $0 (2) QL (900 ML per 30 days)aripiprazole odt tbdp 15mg $0 (1) QL (60 EA per 30 days)aripiprazole odt tbdp 10mg $0 (1) QL (60 EA per 30 days) MOaripiprazole tabs $0 (1) QL (30 EA per 30 days)aripiprazole soln $0 (1) QL (900 ML per 30 days)ARISTADA $0 (2)FANAPT TITRATION PACK $0 (2) QL (16 EA per 365 days) PAFANAPT TABS 10MG $0 (2) QL (60 EA per 30 days) PAFANAPT TABS 12MG, 1MG, 2MG, 4MG, 6MG, 8MG $0 (2) QL (60 EA per 30 days) PA MOGEODON INJ $0 (2) MOINVEGA SUSTENNA $0 (2)INVEGA TRINZA $0 (2)LATUDA TABS 40MG, 80MG $0 (2) QL (30 EA per 30 days) PALATUDA TABS 120MG, 20MG, 60MG $0 (2) QL (30 EA per 30 days) PA MONUPLAZID $0 (2) QL (60 EA per 30 days) PAolanzapine odt $0 (1) QL (30 EA per 30 days)olanzapine inj $0 (1) MOolanzapine tabs 10mg, 15mg, 20mg, 5mg, 7.5mg $0 (1) QL (30 EA per 30 days)olanzapine tabs 2.5mg $0 (1) QL (60 EA per 30 days)paliperidone er tb24 1.5mg, 3mg, 9mg $0 (1) QL (30 EA per 30 days)paliperidone er tb24 6mg $0 (1) QL (60 EA per 30 days)quetiapine fumarate tabs 200mg $0 (1) QL (120 EA per 30 days)quetiapine fumarate tabs 25mg $0 (1) QL (180 EA per 30 days)quetiapine fumarate tabs 300mg, 400mg $0 (1) QL (60 EA per 30 days)

31


Name of drug


you (tier

level)


or limits on usequetiapine fumarate tabs 100mg, 50mg $0 (1) QL (90 EA per 30 days)REXULTI $0 (2) QL (30 EA per 30 days) PA MORISPERDAL CONSTA $0 (2) MOrisperidone odt tbdp 4mg $0 (1) QL (120 EA per 30 days) MOrisperidone odt tbdp 1mg, 2mg $0 (1) QL (60 EA per 30 days)risperidone odt tbdp 0.5mg $0 (1) QL (90 EA per 30 days)risperidone odt tbdp 0.25mg, 3mg $0 (1) QL (90 EA per 30 days) MOrisperidone soln $0 (1)risperidone tabs 4mg $0 (1) QL (120 EA per 30 days)risperidone tabs 1mg, 2mg $0 (1) QL (60 EA per 30 days)risperidone tabs 0.25mg, 0.5mg, 3mg $0 (1) QL (90 EA per 30 days)SAPHRIS SUBL 10MG $0 (2) QL (60 EA per 30 days) PASAPHRIS SUBL 2.5MG, 5MG $0 (2) QL (60 EA per 30 days) PA MOVRAYLAR CPPK $0 (2) QL (14 EA per 365 days) PA MOVRAYLAR CAPS $0 (2) QL (30 EA per 30 days) PA MOziprasidone hcl caps 60mg, 80mg $0 (1) QL (60 EA per 30 days)ziprasidone hcl caps 20mg, 40mg $0 (1) QL (60 EA per 30 days) MOZYPREXA RELPREVV INJ 405MG $0 (2) QL (1 EA per 28 days)ZYPREXA RELPREVV INJ 210MG, 300MG $0 (2) QL (2 EA per 28 days)

Antipsychotics molindone hydrochloride tabs 25mg $0 (1) QL (270 EA per 30 days) MOmolindone hydrochloride tabs 10mg $0 (1) QL (60 EA per 30 days) MOmolindone hydrochloride tabs 5mg $0 (1) QL (90 EA per 30 days) MO

Treatment-Resistant clozapine $0 (1)clozapine odt $0 (1)FAZACLO TBDP 12.5MG, 150MG, 200MG $0 (2) PAVERSACLOZ $0 (2) PA

ANTISPASTICITY AGENTS ‑ DRUGS USED TO TREAT MUSCLE SPASMS Antispasticity Agents

baclofen tabs $0 (1)dantrolene sodium caps $0 (1) MOtizanidine hcl tabs $0 (1)

32


Name of drug


you (tier

level)


or limits on useANTIVIRALS‑ DRUGS USED TO TREAT VIRAL INFECTIONS, HEPATITIS AND HIV/AIDS INFECTIONS

Anti-cytomegalovirus (CMV) Agents ganciclovir inj $0 (1) B/DVALCYTE SOLR $0 (2) MOvalganciclovir $0 (1)

Anti-hepatitis B (HBV) Agents adefovir dipivoxil $0 (1) QL (30 EA per 30 days) MOBARACLUDE SOLN $0 (2) QL (630 ML per 30 days) MOentecavir $0 (1) QL (30 EA per 30 days)EPIVIR HBV SOLN $0 (2) MOlamivudine tabs 100mg $0 (1)TYZEKA $0 (2) QL (30 EA per 30 days) MO

Anti-hepatitis C (HCV) Agents HARVONI $0 (2) QL (30 EA per 30 days) PAmoderiba tabs $0 (1)PEG‑INTRON REDIPEN $0 (2) PAPEGINTRON $0 (2) PAribasphere caps $0 (1)ribasphere tabs 200mg $0 (1)ribavirin $0 (1)SOVALDI $0 (2) QL (28 EA per 28 days) PA

Anti-HIV Agents, Integrase Inhibitors (INSTI) ATRIPLA $0 (2) QL (30 EA per 30 days) MOGENVOYA $0 (2) QL (30 EA per 30 days) MOISENTRESS TABS $0 (2) QL (120 EA per 30 days) MOISENTRESS CHEW $0 (2) QL (180 EA per 30 days) MOISENTRESS PACK $0 (2) QL (300 EA per 30 days)TIVICAY TABS 10MG, 25MG $0 (2) QL (60 EA per 30 days)TIVICAY TABS 50MG $0 (2) QL (60 EA per 30 days) MOVITEKTA $0 (2) QL (30 EA per 30 days)

Anti-HIV Agents, Non-nucleoside Reverse Transcrip-tase Inhibitors (NNRTI)

COMPLERA $0 (2) QL (30 EA per 30 days) MOEDURANT $0 (2) QL (30 EA per 30 days) MOINTELENCE TABS 25MG $0 (2) QL (180 EA per 30 days)

33


Name of drug


you (tier

level)


or limits on useINTELENCE TABS 100MG, 200MG $0 (2) QL (60 EA per 30 days) MOnevirapine er tb24 400mg $0 (1)nevirapine er tb24 100mg $0 (1) MOnevirapine tabs $0 (1)nevirapine susp $0 (1) MOODEFSEY $0 (2) QL (30 EA per 30 days) MORESCRIPTOR $0 (2) MOSTRIBILD $0 (2) QL (30 EA per 30 days) MOSUSTIVA $0 (2) MOVIRAMUNE SUSP $0 (2) MO

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)

abacavir $0 (1)abacavir sulfate/lamivudine/zidovudine $0 (1) MODESCOVY $0 (2) QL (30 EA per 30 days) MOdidanosine cpdr 200mg, 250mg, 400mg $0 (1)didanosine cpdr 125mg $0 (1) MOEMTRIVA $0 (2) MOEPZICOM $0 (2) MOlamivudine/zidovudine $0 (1)lamivudine soln 10mg/ml $0 (1)lamivudine tabs 150mg, 300mg $0 (1)RETROVIR IV INFUSION $0 (2)stavudine caps 15mg, 20mg $0 (1)stavudine caps 30mg, 40mg $0 (1) MOstavudine solr $0 (1)TRIUMEQ $0 (2) QL (30 EA per 30 days) MOTRUVADA TABS 100MG; 150MG, 133MG; 200MG, 167MG; 250MG

$0 (2) QL (30 EA per 30 days)

TRUVADA TABS 200MG; 300MG $0 (2) QL (30 EA per 30 days) MOVIDEX PEDIATRIC SOLR 2GM $0 (2)VIDEX PEDIATRIC SOLR 4GM $0 (2) MOVIREAD $0 (2) MOZIAGEN SOLN $0 (2) MOzidovudine $0 (1) MO

34


Name of drug


you (tier

level)


or limits on useAnti-HIV Agents, Other

FUZEON $0 (2) QL (60 EA per 30 days)SELZENTRY TABS 300MG $0 (2) QL (120 EA per 30 days) MOSELZENTRY TABS 150MG $0 (2) QL (60 EA per 30 days) MOTYBOST $0 (2) QL (30 EA per 30 days) MO

Anti-HIV Agents, Protease Inhibitors APTIVUS SOLN $0 (2)APTIVUS CAPS $0 (2) MOCRIXIVAN $0 (2) MOEVOTAZ $0 (2) QL (30 EA per 30 days) MOINVIRASE $0 (2) MOKALETRA SOLN $0 (2) QL (390 ML per 30 days) MOKALETRA TABS 200MG; 50MG $0 (2) QL (120 EA per 30 days) MOKALETRA TABS 100MG; 25MG $0 (2) QL (240 EA per 30 days) MOLEXIVA $0 (2) MONORVIR $0 (2) MOPREZCOBIX $0 (2) QL (30 EA per 30 days) MOPREZISTA SUSP $0 (2) MOPREZISTA TABS 75MG $0 (2)PREZISTA TABS 150MG, 600MG, 800MG $0 (2) MOREYATAZ $0 (2) MOVIRACEPT $0 (2) MO

Anti-influenza Agents RELENZA DISKHALER $0 (2) QL (120 EA per 365 days) MOrimantadine hcl $0 (1) MOTAMIFLU SUSR $0 (2) QL (1080 ML per 365 days) MOTAMIFLU CAPS 30MG $0 (2) QL (168 EA per 365 days) MOTAMIFLU CAPS 45MG, 75MG $0 (2) QL (84 EA per 365 days) MO

Antiherpetic Agents acyclovir sodium inj 50mg/ml $0 (1) B/Dacyclovir sodium inj 500mg $0 (1) B/D MOacyclovir caps, susp, tabs $0 (1)acyclovir oint $0 (1) MODENAVIR $0 (2) MOfamciclovir tabs 125mg, 250mg $0 (1) QL (60 EA per 30 days) MO

35


Name of drug


you (tier

level)


or limits on usefamciclovir tabs 500mg $0 (1) QL (90 EA per 30 days) MOvalacyclovir hcl $0 (1)

Antivirals VIRAZOLE $0 (2)ZEPATIER $0 (2) QL (30 EA per 30 days) PA

ANXIOLYTICS‑ DRUGS USED TO TREAT ANXIETY Anxiolytics, Other

buspirone hcl tabs 10mg, 15mg, 5mg, 7.5mg $0 (1)buspirone hcl tabs 30mg $0 (1) MO

Benzodiazepines alprazolam tabs 0.25mg, 0.5mg $0 (1) QL (120 EA per 30 days)alprazolam tabs 1mg, 2mg $0 (1) QL (150 EA per 30 days)clorazepate dipotassium tabs 15mg $0 (1) QL (180 EA per 30 days)clorazepate dipotassium tabs 3.75mg, 7.5mg $0 (1) QL (90 EA per 30 days) MOdiazepam intensol $0 (1) MOdiazepam inj 5mg/ml $0 (1) QL (240 ML per 30 days)diazepam oral soln 1mg/ml $0 (1) QL (1200 ML per 30 days) MOdiazepam tabs 10mg, 2mg, 5mg $0 (1) QL (120 EA per 30 days)lorazepam intensol $0 (1) QL (150 ML per 30 days)lorazepam inj 2mg/ml, 4mg/ml $0 (1) QL (120 ML per 30 days)lorazepam tabs 0.5mg $0 (1) QL (120 EA per 30 days)lorazepam tabs 2mg $0 (1) QL (150 EA per 30 days)lorazepam tabs 1mg $0 (1) QL (180 EA per 30 days)

BIPOLAR AGENTS‑ DRUGS USED TO TREAT BIPOLAR DISORDERMood Stabilizers

EQUETRO $0 (2) MOlithium $0 (1) MOlithium carbonate er $0 (1)lithium carbonate caps, tabs $0 (1)

BLOOD GLUCOSE REGULATORS‑ DRUGS USED TO TREAT DIABETESAntidiabetic Agents

acarbose $0 (1)alogliptin $0 (1) QL (30 EA per 30 days) MOalogliptin/metformin hcl $0 (1) QL (60 EA per 30 days) MO

36


Name of drug


you (tier

level)


or limits on usealogliptin/pioglitazone $0 (1) QL (30 EA per 30 days) MOglimepiride $0 (1)glipizide er $0 (1)glipizide xl tb24 10mg $0 (1)glipizide xl tb24 2.5mg, 5mg $0 (1) MOglipizide/metformin hcl tabs 2.5mg; 250mg $0 (1)glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg

$0 (1) MO

glipizide tabs $0 (1)glyburide micronized tabs 3mg, 6mg $0 (1) PAglyburide micronized tabs 1.5mg $0 (1) PA MOglyburide/metformin hcl $0 (1) PAglyburide tabs 2.5mg, 5mg $0 (1) PAglyburide tabs 1.25mg $0 (1) PA MOINVOKAMET $0 (2) QL (60 EA per 30 days) MOINVOKANA TABS 300MG $0 (2) QL (30 EA per 30 days)INVOKANA TABS 100MG $0 (2) QL (60 EA per 30 days)JANUMET $0 (2) QL (60 EA per 30 days) MOJANUMET XR TB24 1000MG; 100MG, 500MG; 50MG

$0 (2) QL (30 EA per 30 days)

JANUMET XR TB24 1000MG; 50MG $0 (2) QL (60 EA per 30 days)JANUVIA TABS 100MG, 25MG $0 (2) QL (30 EA per 30 days)JANUVIA TABS 50MG $0 (2) QL (30 EA per 30 days) MOJENTADUETO $0 (2)JENTADUETO XR $0 (2)KORLYM $0 (2) QL (120 EA per 30 days) PA LAmetformin hcl er tb24 500mg, 750mg $0 (1)metformin hcl er tb24 1000mg, 500mg $0 (1) MOmetformin hcl tabs $0 (1)miglitol $0 (1) QL (90 EA per 30 days)nateglinide $0 (1)pioglitazone hcl $0 (1) QL (30 EA per 30 days)pioglitazone hcl-glimepiride $0 (1) QL (30 EA per 30 days) MOpioglitazone hcl/metformin hcl $0 (1) QL (90 EA per 30 days)repaglinide/metformin hydrochloride $0 (1) QL (150 EA per 30 days) MO

37


Name of drug


you (tier

level)


or limits on userepaglinide tabs 0.5mg, 1mg $0 (1) QL (120 EA per 30 days)repaglinide tabs 2mg $0 (1) QL (240 EA per 30 days)SYMLINPEN 120 $0 (2) QL (10.8 ML per 30 days) MOSYMLINPEN 60 $0 (2) QL (6 ML per 30 days) MOtolazamide $0 (1) MOtolbutamide $0 (1)TRADJENTA $0 (2)TRULICITY $0 (2) QL (2 ML per 28 days) MOVICTOZA $0 (2) QL (9 ML per 30 days) MO

Glycemic Agents GLUCAGEN HYPOKIT $0 (2) QL (4 EA per 30 days) MOGLUCAGON EMERGENCY KIT $0 (2) QL (4 EA per 30 days) MOPROGLYCEM $0 (2) MO

Insulins HUMALOG $0 (2) MOHUMALOG KWIKPEN $0 (2) MOHUMALOG MIX 50/50 $0 (2) MOHUMALOG MIX 50/50 KWIKPEN $0 (2) MOHUMALOG MIX 75/25 $0 (2) MOHUMALOG MIX 75/25 KWIKPEN $0 (2) MOHUMULIN 70/30 $0 (2) MOHUMULIN 70/30 KWIKPEN $0 (2)HUMULIN N $0 (2) MOHUMULIN N KWIKPEN $0 (2)HUMULIN R $0 (2) MOHUMULIN R U‑500 (CONCENTRATED) $0 (2) MOHUMULIN R U‑500 KWIKPEN $0 (2) MOLANTUS $0 (2) MOLANTUS SOLOSTAR $0 (2) MOLEVEMIR $0 (2) MOLEVEMIR FLEXTOUCH $0 (2) MONOVOLIN 70/30 $0 (2) MONOVOLIN 70/30 RELION $0 (2)NOVOLIN N $0 (2) MONOVOLIN N RELION $0 (2)

38


Name of drug


you (tier

level)


or limits on useNOVOLIN R $0 (2) MONOVOLIN R RELION $0 (2)NOVOLOG $0 (2) MONOVOLOG FLEXPEN $0 (2) MONOVOLOG MIX 70/30 $0 (2) MONOVOLOG MIX 70/30 PREFILLED FLEXPEN $0 (2) MONOVOLOG PENFILL $0 (2) MOTRESIBA FLEXTOUCH $0 (2) MO

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS‑ DRUGS USED TO TREAT BLOOD DISORDERS; ANTICOAGULANTS/BLOOD THINNERS

Anticoagulants enoxaparin sodium $0 (1)fondaparinux sodium $0 (1)heparin sodium/d5w $0 (1)heparin sodium/nacl 0.45% $0 (1)heparin sodium/nacl 0.9% $0 (1)heparin sodium/sodium chloride 0.9% $0 (1)heparin sodium/sodium chloride 0.9% premix $0 (1)heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml

$0 (1)

jantoven tabs 10mg, 2.5mg, 5mg $0 (1)jantoven tabs 1mg, 2mg, 3mg, 4mg, 6mg, 7.5mg $0 (1) MOPRADAXA $0 (2) QL (60 EA per 30 days) MOwarfarin sodium tabs $0 (1)XARELTO STARTER PACK $0 (2) QL (102 EA per 365 days) MOXARELTO TABS 10MG, 20MG $0 (2) QL (30 EA per 30 days)XARELTO TABS 15MG $0 (2) QL (60 EA per 30 days)

Blood Formation Modifiers anagrelide hydrochloride $0 (1) MOARANESP ALBUMIN FREE INJ 500MCG/ML $0 (2) QL (1 ML per 21 days) PAARANESP ALBUMIN FREE INJ 150MCG/0.3ML, 60MCG/0.3ML

$0 (2) QL (1.2 ML per 28 days) PA

ARANESP ALBUMIN FREE INJ 200MCG/0.4ML, 40MCG/0.4ML

$0 (2) QL (1.6 ML per 28 days) PA

ARANESP ALBUMIN FREE INJ 25MCG/0.42ML $0 (2) QL (1.68 ML per 28 days) PA

39


Name of drug


you (tier

level)


or limits on useARANESP ALBUMIN FREE INJ 100MCG/0.5ML $0 (2) QL (2 ML per 28 days) PAARANESP ALBUMIN FREE INJ 300MCG/0.6ML $0 (2) QL (2.4 ML per 28 days) PAARANESP ALBUMIN FREE INJ 150MCG/0.75ML $0 (2) QL (3 ML per 28 days) PAARANESP ALBUMIN FREE INJ 10MCG/0.4ML $0 (2) QL (3.2 ML per 28 days) PAARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 25MCG/ML, 300MCG/ML, 40MCG/ML, 60MCG/ML

$0 (2) QL (4 ML per 28 days) PA

LEUKINE INJ 250MCG $0 (2) PAMOZOBIL $0 (2) PANEUMEGA $0 (2) PANEUPOGEN $0 (2) PAPROCRIT INJ 10000UNIT/ML, 20000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

$0 (2) QL (12 ML per 28 days) PA

PROCRIT INJ 40000UNIT/ML $0 (2) QL (8 ML per 28 days) PAPROMACTA $0 (2) QL (30 EA per 30 days) PA

Coagulants tranexamic acid inj $0 (1)tranexamic acid tabs $0 (1) QL (30 EA per 5 days)

Platelet Modifying Agents aspirin/dipyridamole $0 (1) QL (60 EA per 30 days)BRILINTA $0 (2) QL (60 EA per 30 days) MOcilostazol $0 (1)clopidogrel tabs 300mg $0 (1) QL (2 EA per 365 days)clopidogrel tabs 75mg $0 (1) QL (30 EA per 30 days)EFFIENT $0 (2) QL (30 EA per 30 days)ticlopidine hcl $0 (1) PA

CARDIOVASCULAR AGENTS ‑ DRUGS USED TO TREAT HEART AND CIRCULATION CONDITIONS, HIGH BLOOD PRESSURE, HEART RHYTHM, HIGH CHOLESTEROL

Alpha-adrenergic Agonists clonidine hcl tabs $0 (1)clonidine hcl ptwk $0 (1) QL (8 EA per 28 days)midodrine hcl $0 (1)

Alpha-adrenergic Blocking Agents doxazosin $0 (1) MOdoxazosin mesylate tabs 8mg $0 (1)

40


Name of drug


you (tier

level)


or limits on usedoxazosin mesylate tabs 1mg, 2mg $0 (1) MOprazosin hcl $0 (1)terazosin hcl $0 (1)

Angiotensin II Receptor Antagonists candesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg, 32mg; 25mg

$0 (1) QL (30 EA per 30 days)

candesartan cilexetil/hydrochlorothiazide tabs 16mg; 12.5mg

$0 (1) QL (60 EA per 30 days)

candesartan cilexetil tabs 16mg, 32mg $0 (1) QL (30 EA per 30 days)candesartan cilexetil tabs 4mg, 8mg $0 (1) QL (30 EA per 30 days) MOEDARBI $0 (2) QL (30 EA per 30 days) MOEDARBYCLOR $0 (2) QL (30 EA per 30 days) MOENTRESTO $0 (2) QL (60 EA per 30 days) PA MOeprosartan mesylate $0 (1) QL (30 EA per 30 days) MOirbesartan $0 (1) QL (30 EA per 30 days)irbesartan/hydrochlorothiazide $0 (1) QL (30 EA per 30 days)losartan potassium/hydrochlorothiazide $0 (1) QL (30 EA per 30 days)losartan potassium tabs 100mg $0 (1) QL (30 EA per 30 days)losartan potassium tabs 25mg, 50mg $0 (1) QL (60 EA per 30 days)telmisartan $0 (1) QL (30 EA per 30 days)telmisartan/amlodipine $0 (1) QL (30 EA per 30 days) MOtelmisartan/hydrochlorothiazide $0 (1) QL (30 EA per 30 days)valsartan $0 (1)valsartan/hydrochlorothiazide $0 (1) QL (30 EA per 30 days)

Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl/hydrochlorothiazide $0 (1) MObenazepril hcl tabs $0 (1)captopril/hydrochlorothiazide $0 (1) MOcaptopril tabs 12.5mg, 25mg, 50mg $0 (1)captopril tabs 100mg $0 (1) MOenalapril maleate/hydrochlorothiazide $0 (1)enalapril maleate tabs $0 (1)fosinopril sodium/hydrochlorothiazide $0 (1)fosinopril sodium tabs 20mg, 40mg $0 (1)fosinopril sodium tabs 10mg $0 (1) MO

41


Name of drug


you (tier

level)


or limits on uselisinopril $0 (1)lisinopril/hydrochlorothiazide $0 (1)moexipril hcl tabs 15mg $0 (1)moexipril hcl tabs 7.5mg $0 (1) MOmoexipril/hydrochlorothiazide $0 (1) MOperindopril erbumine $0 (1)quinapril hcl tabs 10mg, 40mg $0 (1)quinapril hcl tabs 20mg, 5mg $0 (1) MOquinapril/hydrochlorothiazide $0 (1)ramipril caps 10mg, 2.5mg, 5mg $0 (1)ramipril caps 1.25mg $0 (1) MOtrandolapril $0 (1)trandolapril/verapamil hcl $0 (1) MOtrandolapril/verapamil hcl er $0 (1)

Antiarrhythmics amiodarone hcl tabs 200mg $0 (1)amiodarone hcl tabs 100mg, 400mg $0 (1) MOdisopyramide phosphate caps 150mg $0 (1) PAdisopyramide phosphate caps 100mg $0 (1) PA MOdofetilide $0 (1)flecainide acetate tabs 50mg $0 (1)flecainide acetate tabs 100mg, 150mg $0 (1) MOlidocaine hcl inj 10mg/ml, 20mg/ml $0 (1)mexiletine hcl $0 (1) MOMULTAQ $0 (2) MOpacerone tabs 100mg $0 (1)pacerone tabs 200mg, 400mg $0 (1) MOpropafenone hcl $0 (1)propafenone hcl er $0 (1)quinidine gluconate cr $0 (1) MOquinidine gluconate er $0 (1)quinidine sulfate tabs 300mg $0 (1)quinidine sulfate tabs 200mg $0 (1) MOsorine $0 (1)

42


Name of drug


you (tier

level)


or limits on usesotalol hcl (af) tabs 160mg, 80mg $0 (1)sotalol hcl (af) tabs 120mg $0 (1) MOsotalol hcl tabs 120mg, 160mg, 80mg $0 (1)sotalol hcl tabs 240mg $0 (1) MOTIKOSYN $0 (2)

Beta-adrenergic Blocking Agents acebutolol hcl caps $0 (1)atenolol/chlorthalidone tabs 50mg; 25mg $0 (1)atenolol/chlorthalidone tabs 100mg; 25mg $0 (1) MOatenolol tabs $0 (1)betaxolol hcl tabs 10mg, 20mg $0 (1) MObisoprolol fumarate $0 (1)bisoprolol fumarate/hydrochlorothiazide tabs 2.5mg; 6.25mg, 5mg; 6.25mg

$0 (1)

bisoprolol fumarate/hydrochlorothiazide tabs 10mg; 6.25mg

$0 (1) MO

carvedilol $0 (1)labetalol hcl inj, tabs $0 (1)metoprolol succinate er tb24 100mg, 25mg, 50mg $0 (1)metoprolol succinate er tb24 200mg $0 (1) MOmetoprolol tartrate inj $0 (1)metoprolol tartrate tabs 100mg, 25mg, 50mg $0 (1)metoprolol tartrate tabs 37.5mg, 75mg $0 (1) MOmetoprolol/hydrochlorothiazide $0 (1) MOnadolol/bendroflumethiazide $0 (1) MOnadolol tabs 40mg, 80mg $0 (1)nadolol tabs 20mg $0 (1) MOpindolol $0 (1) MOpropranolol hcl er $0 (1)propranolol hcl inj $0 (1)propranolol hcl oral soln $0 (1) MOpropranolol hcl tabs 80mg $0 (1)propranolol hcl tabs 10mg, 20mg, 40mg, 60mg $0 (1) MOpropranolol/hydrochlorothiazide $0 (1) MOtimolol maleate tabs 10mg, 20mg, 5mg $0 (1) MO

43


Name of drug


you (tier

level)


or limits on useCalcium Channel Blocking Agents

amlodipine besylate/atorvastatin calcium tabs 10mg; 20mg, 10mg; 40mg

$0 (1)

amlodipine besylate/atorvastatin calcium tabs 10mg; 10mg, 10mg; 80mg, 2.5mg; 10mg, 2.5mg; 20mg, 2.5mg; 40mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg, 5mg; 80mg

$0 (1) MO

amlodipine besylate/benazepril hydrochloride $0 (1) QL (30 EA per 30 days)amlodipine besylate/valsartan $0 (1) QL (30 EA per 30 days) MOamlodipine besylate tabs $0 (1)amlodipine/valsartan/hctz $0 (1) QL (30 EA per 30 days)cartia xt $0 (1)dilt-xr $0 (1)diltiazem cd $0 (1)diltiazem hcl cd $0 (1)diltiazem hcl er cp24 120mg, 180mg, 240mg, 300mg, 360mg, 420mg

$0 (1)

diltiazem hcl er cp24 180mg, 360mg $0 (1) MOdiltiazem hcl er tb24 $0 (1)diltiazem hcl er cp12 $0 (1) MOdiltiazem hcl inj 100mg, 125mg/25ml, 25mg/5ml, 50mg/10ml

$0 (1)

diltiazem hcl tabs 30mg, 60mg $0 (1)diltiazem hcl tabs 120mg, 90mg $0 (1) MOfelodipine er tb24 10mg $0 (1)felodipine er tb24 2.5mg, 5mg $0 (1) MOisradipine $0 (1) MOmatzim la $0 (1) MOnicardipine hcl caps 30mg $0 (1)nicardipine hcl caps 20mg $0 (1) MOnifedipine er tb24 30mg, 60mg, 90mg $0 (1)nifedipine er tb24 90mg $0 (1) MOnisoldipine $0 (1) MOnisoldipine er $0 (1) MOtaztia xt $0 (1)

44


Name of drug


you (tier

level)


or limits on useverapamil hcl er cp24 200mg $0 (1)verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg

$0 (1) MO

verapamil hcl er tbcr 120mg $0 (1)verapamil hcl er tbcr 180mg, 240mg $0 (1) MOverapamil hcl sr cp24 120mg, 180mg, 240mg $0 (1)verapamil hcl sr cp24 360mg $0 (1) MOverapamil hcl sr tbcr 240mg $0 (1)verapamil hcl inj, tabs $0 (1)

Cardiovascular Agents, Other CORLANOR $0 (2) PA MOdigitek $0 (1)digoxin inj, oral soln $0 (1) PA MOdigoxin tabs 125mcg $0 (1)digoxin tabs 250mcg $0 (1) PAdigox tabs 125mcg $0 (1)digox tabs 250mcg $0 (1) PANORTHERA $0 (2) PApentoxifylline cr $0 (1)pentoxifylline er $0 (1)PRALUENT $0 (2) QL (2 ML per 28 days) PARANEXA $0 (2) QL (60 EA per 30 days) MOREPATHA $0 (2) QL (3 ML per 28 days) PAREPATHA SURECLICK $0 (2) QL (3 ML per 28 days) PA

Diuretics, Carbonic Anhydrase Inhibitors acetazolamide er $0 (1)acetazolamide tabs 250mg $0 (1)acetazolamide tabs 125mg $0 (1) MOmethazolamide $0 (1) MO

Diuretics, Loop bumetanide tabs $0 (1)bumetanide inj $0 (1) MOfurosemide tabs $0 (1)furosemide oral soln $0 (1) MOfurosemide inj 10mg/ml $0 (1)

45


Name of drug


you (tier

level)


or limits on usetorsemide tabs 10mg, 20mg, 5mg $0 (1)torsemide tabs 100mg $0 (1) MO

Diuretics, Potassium-sparing amiloride hcl tabs $0 (1)amiloride/hydrochlorothiazide $0 (1)eplerenone $0 (1)spironolactone/hydrochlorothiazide $0 (1)spironolactone tabs $0 (1)triamterene/hydrochlorothiazide caps 25mg; 37.5mg $0 (1)triamterene/hydrochlorothiazide caps 25mg; 50mg $0 (1) MOtriamterene/hydrochlorothiazide tabs $0 (1)

Diuretics, Thiazide chlorothiazide $0 (1) MOchlorthalidone tabs 25mg $0 (1)chlorthalidone tabs 50mg $0 (1) MOhydrochlorothiazide caps $0 (1)hydrochlorothiazide tabs 25mg, 50mg $0 (1)hydrochlorothiazide tabs 12.5mg $0 (1) MOindapamide $0 (1)methyclothiazide tabs $0 (1) MOmetolazone $0 (1) MO

Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized $0 (1) MOfenofibrate caps 130mg, 43mg $0 (1)fenofibrate caps 150mg, 50mg $0 (1) MOfenofibrate tabs 145mg, 160mg, 48mg, 54mg $0 (1)fenofibrate tabs 120mg, 40mg $0 (1) MOfenofibric acid $0 (1) MOfenofibric acid dr $0 (1)gemfibrozil tabs $0 (1)

Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium $0 (1)fluvastatin sodium er $0 (1) QL (30 EA per 30 days) MOfluvastatin caps 40mg $0 (1)

46


Name of drug


you (tier

level)


or limits on usefluvastatin caps 20mg $0 (1) MOlovastatin $0 (1)pravastatin sodium tabs 10mg, 80mg $0 (1)pravastatin sodium tabs 20mg, 40mg $0 (1) MOrosuvastatin calcium tabs 10mg, 20mg, 5mg $0 (1) QL (30 EA per 30 days)rosuvastatin calcium tabs 40mg $0 (1) QL (30 EA per 30 days) MOsimvastatin tabs 10mg, 20mg, 40mg, 5mg $0 (1)simvastatin tabs 80mg $0 (1) QL (30 EA per 30 days)

Dyslipidemics, Other cholestyramine light $0 (1)cholestyramine pack $0 (1)cholestyramine powd $0 (1) MOcolestipol hcl tabs $0 (1)colestipol hcl gran, pack $0 (1) MOKYNAMRO $0 (2) PALOVAZA $0 (2) QL (120 EA per 30 days) ST MOniacin er $0 (1)omega-3-acid ethyl esters $0 (1) QL (120 EA per 30 days)prevalite $0 (1) MOVASCEPA $0 (2) MOZETIA $0 (2) QL (30 EA per 30 days) MO

Vasodilators, Direct-acting Arterial/Venous isosorbide dinitrate er $0 (1) MOisosorbide dinitrate tabs $0 (1)isosorbide mononitrate er $0 (1)isosorbide mononitrate tabs 20mg $0 (1)isosorbide mononitrate tabs 10mg $0 (1) MOminitran $0 (1)nitroglycerin lingual $0 (1)nitroglycerin transdermal pt24 0.1mg/hr, 0.4mg/hr, 0.6mg/hr

$0 (1)

nitroglycerin transdermal pt24 0.2mg/hr $0 (1) MOnitroglycerin inj $0 (1)NITROSTAT $0 (2) MO

Vasodilators, Direct-acting Arterial

47


Name of drug


you (tier

level)


or limits on usehydralazine hcl inj, tabs $0 (1)minoxidil tabs $0 (1)

CENTRAL NERVOUS SYSTEM AGENTS‑ DRUGS USED TO TREAT ADHD, MULTIPLE SCLEROSIS, CHOREA ASSOCIATED WITH HUNTINGTON DISEASE

Attention Deficit Hyperactivity Disorder Agents, Am-phetamines

amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg

$0 (1) QL (60 EA per 30 days) PA

amphetamine/dextroamphetamine tabs 1.875mg; 1.875mg; 1.875mg; 1.875mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg


amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg


dextroamphetamine sulfate tabs $0 (1) QL (180 EA per 30 days) PA MOdextroamphetamine sulfate soln $0 (1) QL (1800 ML per 30 days) PA

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

dexmethylphenidate hcl $0 (1) QL (60 EA per 30 days) PA MOguanfacine er $0 (1) QL (30 EA per 30 days)metadate er $0 (1) QL (90 EA per 30 days) PAmethylphenidate hcl er cp24 30mg $0 (1) QL (60 EA per 30 days) PA MOmethylphenidate hcl er tbcr 10mg, 20mg $0 (1) QL (90 EA per 30 days) PAmethylphenidate hcl sr $0 (1) QL (90 EA per 30 days) PAmethylphenidate hcl tabs $0 (1) PASTRATTERA CAPS 100MG, 80MG $0 (2) QL (30 EA per 30 days) PA MOSTRATTERA CAPS 10MG, 18MG, 25MG, 40MG, 60MG


Central Nervous System, Other NUEDEXTA $0 (2) QL (60 EA per 30 days) MOriluzole $0 (1)tetrabenazine tabs 25mg $0 (1) QL (120 EA per 30 days) PAtetrabenazine tabs 12.5mg $0 (1) QL (90 EA per 30 days) PA

Multiple Sclerosis Agents AMPYRA $0 (2) QL (60 EA per 30 days) PA

48


Name of drug


you (tier

level)


or limits on useCOPAXONE INJ 40MG/ML $0 (2) QL (12 ML per 28 days) PACOPAXONE INJ 20MG/ML $0 (2) QL (30 ML per 30 days) PAGILENYA $0 (2) QL (30 EA per 30 days) PAglatopa $0 (1) QL (30 ML per 30 days) PAREBIF $0 (2) QL (6 ML per 28 days) PAREBIF REBIDOSE $0 (2) QL (6 ML per 28 days) PAREBIF REBIDOSE TITRATION PACK $0 (2) QL (4.2 ML per 365 days) PAREBIF TITRATION PACK $0 (2) QL (8.4 ML per 365 days) PATYSABRI $0 (2) QL (15 ML per 28 days) PA

DENTAL AND ORAL AGENTSDental and Oral Agents

chlorhexidine gluconate oral rinse $0 (1)clinpro 5000 $0 (1) MOdentagel $0 (1) MOfluoridex daily defense $0 (1)oralone $0 (1)paroex $0 (1)periogard $0 (1) MOphos-flur $0 (1)pilocarpine hcl tabs 7.5mg $0 (1)pilocarpine hydrochloride $0 (1)sf $0 (1) MOtriamcinolone acetonide pste 0.1% $0 (1)triamcinolone in orabase $0 (1) MO

DERMATOLOGICAL AGENTS‑ ANTIPSORIATICS, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE, ACNE, WOUND CARE AGENTS, ANTIBIOTICS

Dermatological Agents 8‑MOP $0 (2)acitretin caps 10mg, 25mg $0 (1) PAacitretin caps 17.5mg $0 (1) PA MOALTABAX $0 (2)ammonium lactate crea, lotn $0 (1)amnesteem $0 (1)avita $0 (1) PA MOcalcipotriene $0 (1)

49


Name of drug


you (tier

level)


or limits on usecalcitrene $0 (1) MOclaravis $0 (1)clindacin etz pledgets $0 (1) MOclindacin-p $0 (1) MOclindamax $0 (1)clindamycin phosphate foam 1% $0 (1) MOclindamycin phosphate gel 1% $0 (1)clindamycin phosphate lotn 1% $0 (1)clindamycin phosphate external soln 1% $0 (1)clindamycin phosphate swab 1% $0 (1) MOclindamycin/benzoyl peroxide gel 5%; 1.2% $0 (1)clindamycin/benzoyl peroxide gel 5%; 1% $0 (1) MOdiclofenac sodium gel $0 (1) QL (1020 GM per 30 days) MOdoxepin hydrochloride $0 (1) MOELIDEL $0 (2) QL (60 GM per 30 days) ST MOery $0 (1) MOerythromycin/benzoyl peroxide $0 (1) MOerythromycin gel 2% $0 (1) MOerythromycin pads 2% $0 (1)erythromycin soln 2% $0 (1)fluocinolone acetonide body $0 (1) MOfluocinolone acetonide scalp $0 (1) MOfluorouracil crea 5% $0 (1)fluorouracil crea 0.5% $0 (1) MOfluorouracil external soln 2%, 5% $0 (1) MOgentamicin sulfate crea 0.1% $0 (1) MOgentamicin sulfate external oint 0.1% $0 (1) MOimiquimod crea $0 (1) MOmethoxsalen caps $0 (1)metronidazole crea 0.75% $0 (1)metronidazole gel 0.75% $0 (1)metronidazole gel 1% $0 (1) MOmetronidazole lotn 0.75% $0 (1)mupirocin calcium $0 (1)

50


Name of drug


you (tier

level)


or limits on usemupirocin oint $0 (1)mupirocin crea $0 (1) MOmyorisan $0 (1)neuac $0 (1) MOpodofilox soln $0 (1) MOREGRANEX $0 (2) QL (15 GM per 30 days) PA MOrosadan crea $0 (1)rosadan gel $0 (1) MOSANTYL $0 (2)selenium sulfide lotn $0 (1) MOsilver sulfadiazine $0 (1)sodium sulfacetamide lotn 10% $0 (1)ssd $0 (1)sulfacetamide sodium susp 10% $0 (1)SULFAMYLON $0 (2) MOTAZORAC $0 (2) MOtretinoin crea 0.025%, 0.05%, 0.1% $0 (1) PA MOtretinoin gel 0.01% $0 (1) PAtretinoin gel 0.025%, 0.05% $0 (1) PA MOzenatane $0 (1)ZONALON $0 (2) MO

ENZYME REPLACEMENT/MODIFIERS‑ DRUGS USED TO TREAT ENZYME DEFICIENCIES, PANCREATIC ENZYMES

Enzyme Replacement/Modifiers ADAGEN $0 (2) PA LAALDURAZYME $0 (2) PABUPHENYL TABS $0 (2) PACARBAGLU $0 (2) LACEREZYME $0 (2) PACREON CPEP 120000UNIT; 24000UNIT; 76000UNIT, 30000UNIT; 6000UNIT; 19000UNIT, 60000UNIT; 12000UNIT; 38000UNIT

$0 (2)

CREON CPEP 15000UNIT; 3000UNIT; 9500UNIT, 180000UNIT; 36000UNIT; 114000UNIT

$0 (2) MO

CYSTADANE $0 (2) LA

51


Name of drug


you (tier

level)


or limits on useCYSTAGON $0 (2) PAFABRAZYME $0 (2) PAKUVAN $0 (2) PALUMIZYME $0 (2)NAGLAZYME $0 (2) PAORFADIN CAPS 10MG, 2MG, 5MG $0 (2) PA LApancrelipase $0 (1)RAVICTI $0 (2) PAsodium phenylbutyrate powd $0 (1) PAVPRIV $0 (2) PAZAVESCA $0 (2) PA LAZENPEP $0 (2) MO

GASTROINTESTINAL‑ DRUGS USED TO TREAT STOMACH AND INTESTINAL DISORDERS, ANTI‑DIARRHEAL, LAXATIVES, ULCERS AND STOMACH ACID

Antispasmodics, Gastrointestinal dicyclomine hcl caps, soln, tabs $0 (1) PA MOglycopyrrolate tabs $0 (1) MOglycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml $0 (1)glycopyrrolate inj 4mg/20ml $0 (1) MOmethscopolamine bromide $0 (1)

Gastrointestinal Agents, Other anti-diarrheal tabs $0 (3) *cromolyn sodium conc 100mg/5ml $0 (1)diphenatol $0 (1)diphenoxylate/atropine tabs $0 (1)diphenoxylate/atropine liqd $0 (1) MOGATTEX $0 (2) PAgavilyte-h $0 (1) MOgnp loperamide hcl $0 (3) *loperamide hcl caps $0 (1)loperamide hcl liqd, susp $0 (3) *metoclopramide hcl oral soln, tabs $0 (1)metoclopramide hcl inj $0 (1) MOMOVANTIK $0 (2) QL (30 EA per 30 days) PA MOqc anti-diarrheal $0 (3) *

52


Name of drug


you (tier

level)


or limits on useRELISTOR $0 (2) PA MOsb anti-diarrhea $0 (3) *sm anti-diarrheal tabs $0 (3) *ursodiol caps, tabs $0 (1) MO

Histamine2 (H2) Receptor Antagonists acid reducer maximum strength tabs 20mg $0 (3) *acid reducer tabs 10mg, 75mg $0 (3) *cimetidine hcl $0 (1) MOcimetidine tabs 400mg $0 (1)cimetidine tabs 200mg, 300mg, 800mg $0 (1) MOdual action complete $0 (3) *famotidine premixed $0 (1)famotidine inj 200mg/20ml, 20mg/2ml, 40mg/4ml $0 (1)famotidine susr 40mg/5ml $0 (1) MOfamotidine tabs 20mg, 40mg $0 (1)gnp acid control 150 maximum strength $0 (3) *gnp acid reducer maximum strength $0 (3) *gnp acid reducer tabs 10mg $0 (3) *heartburn relief 150 maximum strength $0 (3) *heartburn relief maximum strength $0 (3) *heartburn relief tabs 10mg, 200mg $0 (3) *hm complete dual action $0 (3) *qc acid controller $0 (3) *qc acid controller maximum strength $0 (3) *ranitidine 150 maximum strength $0 (3) *ranitidine 75 $0 (3) *ranitidine hcl caps 150mg, 300mg $0 (1) MOranitidine hcl inj 150mg/6ml $0 (1)ranitidine hcl inj 50mg/2ml $0 (1) MOranitidine hcl syrp 15mg/ml $0 (1)ranitidine hcl tabs 150mg, 300mg $0 (1)sm acid reducer tabs 200mg, 75mg $0 (3) *

Irritable Bowel Syndrome Agents alosetron hydrochloride $0 (1) QL (60 EA per 30 days) MO

53


Name of drug


you (tier

level)


or limits on useAMITIZA $0 (2) QL (60 EA per 30 days) MOLINZESS $0 (2) QL (30 EA per 30 days) MO

Laxatives clearlax powd $0 (3) *constulose $0 (1)enulose $0 (1)gavilax powd $0 (3) *gavilyte-c $0 (1) MOgavilyte-g $0 (1) MOgavilyte-n/flavor pack $0 (1) MOgenerlac $0 (1)gnp clearlax $0 (3) *healthylax $0 (3) *lactulose soln 10gm/15ml $0 (1)MOVIPREP $0 (2) MOpeg 3350/electrolytes $0 (1)peg 3350 powd $0 (3) *peg-3350/electrolytes $0 (1) MOpeg-3350/nacl/na bicarbonate/kcl $0 (1)polyethylene glycol 3350 pack 0 $0 (1) MOpolyethylene glycol 3350 pack 0 $0 (3) *polyethylene glycol 3350 powd 0 $0 (1) MOpolyethylene glycol 3350 powd 0 $0 (3) *PREPOPIK $0 (2) MOsm clearlax $0 (3) *SUPREP BOWEL PREP $0 (2) MOtrilyte $0 (1) MO

Protectants CARAFATE SUSP $0 (2) MOmisoprostol $0 (1)sucralfate susp, tabs $0 (1)

Proton Pump Inhibitors esomeprazole magnesium $0 (1) QL (30 EA per 30 days)esomeprazole sodium $0 (1)

54


Name of drug


you (tier

level)


or limits on useomeprazole magnesium $0 (3) *omeprazole cpdr 20mg $0 (1)omeprazole cpdr 10mg $0 (1) QL (30 EA per 30 days)omeprazole cpdr 40mg $0 (1) QL (60 EA per 30 days)pantoprazole sodium tbec 20mg $0 (1) QL (30 EA per 30 days)pantoprazole sodium tbec 40mg $0 (1) QL (60 EA per 30 days)PRILOSEC OTC $0 (3) *qc omeprazole magnesium $0 (3) *

GENITOURINARY‑ VAGINAL ANTI‑INFECTIVES Antispasmodics, Urinary

darifenacin hydrobromide er $0 (1) QL (30 EA per 30 days)MYRBETRIQ $0 (2) QL (30 EA per 30 days)oxybutynin chloride er tb24 5mg $0 (1) QL (30 EA per 30 days)oxybutynin chloride er tb24 10mg $0 (1) QL (60 EA per 30 days)oxybutynin chloride er tb24 15mg $0 (1) QL (60 EA per 30 days) MOoxybutynin chloride tabs $0 (1) QL (120 EA per 30 days)oxybutynin chloride syrp $0 (1) QL (600 ML per 30 days)tolterodine tartrate $0 (1) QL (60 EA per 30 days)VESICARE $0 (2) QL (30 EA per 30 days) MO

Benign Prostatic Hypertrophy Agents alfuzosin hcl er $0 (1)dutasteride $0 (1) QL (30 EA per 30 days)dutasteride/tamsulosin hydrochloride $0 (1) QL (30 EA per 30 days) MOfinasteride tabs 5mg $0 (1)tamsulosin hcl $0 (1)

Genitourinary Agents, Other bethanechol chloride $0 (1)methylergonovine maleate $0 (1) MORENACIDIN SOLN 6.602GM/100ML; 0.198GM/100ML; 3.177GM/100ML

$0 (2) MO

sodium chloride 0.9% $0 (1)THIOLA $0 (2)

Phosphate Binders calcium acetate caps $0 (1)calcium acetate tabs 667mg $0 (1) MO

55


Name of drug


you (tier

level)


or limits on useFOSRENOL CHEW $0 (2) ST MOFOSRENOL PACK 750MG $0 (2) STFOSRENOL PACK 1000MG $0 (2) ST MORENVELA $0 (2) MOVELPHORO $0 (2) MO

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)‑ CORTICOSTEROID DRUGS THAT CAN BE USED FOR A VARIETY OF CONDITIONS SUCH AS INFLAMMATION

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

a-hydrocort $0 (1) MOala cort $0 (1)alclometasone dipropionate $0 (1)amcinonide $0 (1) MOaugmented betamethasone dipropionate crea, lotn $0 (1)augmented betamethasone dipropionate gel, oint $0 (1) MObaycadron $0 (1)betamethasone dipropionate lotn $0 (1)betamethasone dipropionate crea, oint $0 (1) MObetamethasone valerate lotn $0 (1)betamethasone valerate crea, foam, oint $0 (1) MObudesonide cpep 3mg $0 (1)clobetasol propionate e $0 (1) MOclobetasol propionate emollient foam $0 (1) MOclobetasol propionate foam 0.05% $0 (1)clobetasol propionate crea, gel, lotn, oint, sham $0 (1)clobetasol propionate liqd, soln $0 (1) MOclodan $0 (1) MOcolocort $0 (1) MOcormax scalp application $0 (1)cortisone acetate tabs $0 (1) MOdeltasone $0 (1)desonide crea, lotn $0 (1)desonide oint $0 (1) MOdesoximetasone crea 0.25% $0 (1)desoximetasone crea 0.05% $0 (1) MO

56


Name of drug


you (tier

level)


or limits on usedesoximetasone oint $0 (1)desoximetasone gel $0 (1) MODEXAMETHASONE INTENSOL $0 (2) MOdexamethasone sodium phosphate inj 10mg/ml, 20mg/5ml, 4mg/ml

$0 (1)

dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml

$0 (1) MO

dexamethasone elix $0 (1)dexamethasone soln, tabs $0 (1) MOdiflorasone diacetate $0 (1) MOfludrocortisone acetate tabs $0 (1)fluocinolone acetonide crea 0.01%, 0.025% $0 (1)fluocinolone acetonide oint 0.025% $0 (1)fluocinolone acetonide soln 0.01% $0 (1)fluocinonide-e $0 (1)fluocinonide crea 0.1% $0 (1)fluocinonide crea 0.05% $0 (1) MOfluocinonide oint, soln $0 (1)fluocinonide gel $0 (1) MOfluticasone propionate crea 0.05% $0 (1)fluticasone propionate lotn 0.05% $0 (1) MOfluticasone propionate oint 0.005% $0 (1) MOhalobetasol propionate crea $0 (1)halobetasol propionate oint $0 (1) MOhydrocortisone butyrate (lipophilic) $0 (1) MOhydrocortisone butyrate crea, oint, soln $0 (1) MOhydrocortisone in absorbase $0 (1)hydrocortisone valerate crea $0 (1)hydrocortisone valerate oint $0 (1) MOhydrocortisone crea 1%, 2.5% $0 (1)hydrocortisone enem, tabs $0 (1)hydrocortisone lotn 2.5% $0 (1)hydrocortisone oint 2.5% $0 (1)hydrocortisone oint 1% $0 (1) MOlokara $0 (1)

57


Name of drug


you (tier

level)


or limits on usemethylprednisolone acetate inj $0 (1)methylprednisolone dose pack $0 (1)methylprednisolone sodiumsuccinate $0 (1) MOmethylprednisolone tabs $0 (1)MILLIPRED $0 (2)MILLIPRED DP $0 (2) MOmometasone furoate oint, soln $0 (1)mometasone furoate crea $0 (1) MOprednicarbate crea $0 (1)prednicarbate oint $0 (1) MOprednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml

$0 (1) MO

prednisolone soln, syrp $0 (1)PREDNISONE INTENSOL $0 (2) MOprednisone soln $0 (1) MOprednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg $0 (1)prednisone tabs 50mg $0 (1) MOprednisone tbpk 10mg, 5mg $0 (1)procto-med hc $0 (1)procto-pak $0 (1) MOproctosol hc $0 (1) MOproctozone-hc $0 (1) MOtriamcinolone acetonide aers 0.147mg/gm $0 (1) MOtriamcinolone acetonide crea 0.1% $0 (1)triamcinolone acetonide crea 0.025%, 0.5% $0 (1) MOtriamcinolone acetonide lotn 0.025%, 0.1% $0 (1) MOtriamcinolone acetonide oint 0.025% $0 (1)triamcinolone acetonide oint 0.1%, 0.5% $0 (1) MOtriderm $0 (1) MO

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)‑ DRUGS USED TO REGULATE PITUITARY HORMONES, GROWTH HORMONES

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

desmopressin acetate inj, tabs $0 (1)desmopressin acetate nasal soln 0.01% $0 (1)

58


Name of drug


you (tier

level)


or limits on useEGRIFTA INJ 2MG $0 (2) QL (30 EA per 30 days) PAEGRIFTA INJ 1MG $0 (2) QL (60 EA per 30 days) PAH.P. ACTHAR $0 (2) PAINCRELEX $0 (2) PANORDITROPIN FLEXPRO $0 (2) PAOMNITROPE $0 (2) PAVASOSTRICT $0 (2)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)‑ BIRTH CONTROL, ENDOMETRIOSIS, ESTROGENS, MALE HORMONES

Anabolic Steroids ANADROL‑50 $0 (2) MOoxandrolone tabs 2.5mg $0 (1) QL (120 EA per 30 days) PA MOoxandrolone tabs 10mg $0 (1) QL (60 EA per 30 days) PA MO

Androgens ANDROGEL PUMP GEL 1.62% $0 (2) PA MOANDROGEL PUMP GEL 1% $0 (2) QL (300 GM per 30 days) PAANDROGEL GEL 20.25MG/1.25GM, 40.5MG/2.5GM

$0 (2) PA MO

ANDROGEL GEL 25MG/2.5GM, 50MG/5GM $0 (2) QL (300 GM per 30 days) PA MOdanazol caps $0 (1) MOtestosterone cypionate inj $0 (1) MOtestosterone enanthate inj $0 (1)testosterone gel 1%, 25mg/2.5gm $0 (1) QL (300 GM per 30 days) PA MO

Estrogens altavera $0 (1)alyacen 1/35 $0 (1)alyacen 7/7/7 tabs $0 (1)amethia $0 (1)amethia lo $0 (1)amethyst $0 (1)apri $0 (1)aranelle $0 (1)ashlyna $0 (1)aubra $0 (1)aviane $0 (1)

59


Name of drug


you (tier

level)


or limits on useazurette $0 (1)balziva $0 (1) MObekyree $0 (1)blisovi 24 fe $0 (1)blisovi fe 1.5/30 $0 (1)blisovi fe 1/20 $0 (1)briellyn $0 (1)camrese $0 (1)camrese lo $0 (1) MOcaziant $0 (1) MOchateal $0 (1)cryselle-28 $0 (1) MOcyclafem 1/35 $0 (1)cyclafem 7/7/7 $0 (1) MOcyred $0 (1)dasetta 1/35 $0 (1)dasetta 7/7/7 $0 (1)daysee $0 (1)delyla $0 (1)DEPO‑ESTRADIOL $0 (2) MOdesogestrel/ethinyl estradiol $0 (1)drospirenone/ethinyl estradiol tabs 3mg; 0.02mg $0 (1)drospirenone/ethinyl estradiol tabs 3mg; 0.03mg $0 (1) MOelinest $0 (1)emoquette $0 (1)enpresse-28 $0 (1)enskyce $0 (1)estarylla $0 (1)ESTRACE CREA $0 (2) MOestradiol/norethindrone acetate $0 (1) PAestradiol ptwk $0 (1) QL (4 EA per 28 days) PAestradiol pttw $0 (1) QL (8 EA per 28 days) PAestradiol tabs 2mg $0 (1) PAestradiol tabs 0.5mg, 1mg $0 (1) PA MO

60


Name of drug


you (tier

level)


or limits on usefalmina $0 (1)fyavolv $0 (1) PAgianvi $0 (1)gildagia $0 (1)gildess 1.5/30 $0 (1)gildess 1/20 $0 (1)gildess 24 fe $0 (1)gildess fe 1.5/30 $0 (1)gildess fe 1/20 $0 (1)introvale $0 (1)jinteli $0 (1) PA MOjolessa $0 (1)juleber $0 (1)junel 1.5/30 $0 (1)junel 1/20 $0 (1)junel fe 1.5/30 $0 (1) MOjunel fe 1/20 $0 (1) MOjunel fe 24 $0 (1)kaitlib fe $0 (1)kariva $0 (1)kelnor 1/35 $0 (1) MOkimidess $0 (1)kurvelo $0 (1)larin 1.5/30 $0 (1)larin 1/20 $0 (1)larin 24 fe $0 (1)larin fe 1.5/30 $0 (1)larin fe 1/20 $0 (1)layolis fe $0 (1) MOleena $0 (1) MOlessina $0 (1)levonest $0 (1)levonorgestrel and ethinyl estradiol tabs 0; 0 $0 (1)

61


Name of drug


you (tier

level)


or limits on uselevonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg

$0 (1) MO

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg

$0 (1)

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg $0 (1) MOlevora 0.15/30-28 $0 (1)lomedia 24 fe $0 (1)lopreeza $0 (1) PAloryna $0 (1) MOlow-ogestrel $0 (1)lutera $0 (1)marlissa $0 (1) MOMENEST $0 (2) PA MOmicrogestin 1.5/30 $0 (1)microgestin 1/20 $0 (1)microgestin 24 fe $0 (1)microgestin fe $0 (1)microgestin fe 1.5/30 $0 (1)mimvey $0 (1) PAmimvey lo $0 (1) PAmono-linyah $0 (1)mononessa $0 (1)myzilra $0 (1) MOnecon 0.5/35-28 $0 (1)necon 1/35 $0 (1)NECON 1/50‑28 $0 (2) MONECON 10/11‑28 $0 (2) MOnecon 7/7/7 $0 (1)nikki $0 (1)norethindrone & ethinyl estradiol ferrous fumarate $0 (1) MOnorethindrone acetate/ethinyl estradiol/ferrous fuma-rate

$0 (1)

norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg

$0 (1)

62


Name of drug


you (tier

level)


or limits on usenorethindrone acetate/ethinyl estradiol tabs 5mcg; 1mg

$0 (1) PA

norgestimate/ethinyl estradiol $0 (1)NORINYL 1+50 $0 (2) MOnortrel 0.5/35 (28) $0 (1) MOnortrel 1/35 $0 (1)nortrel 7/7/7 $0 (1)ocella $0 (1)OGESTREL $0 (2) MOorsythia $0 (1)philith $0 (1)pimtrea $0 (1)pirmella 1/35 $0 (1)pirmella 7/7/7 $0 (1)portia-28 $0 (1)previfem $0 (1) MOquasense $0 (1)reclipsen $0 (1)setlakin $0 (1)sprintec 28 $0 (1)sronyx $0 (1) MOsyeda $0 (1)tarina fe 1/20 $0 (1)tilia fe $0 (1)tri-estarylla $0 (1)tri-legest fe $0 (1) MOtri-linyah $0 (1)tri-lo-estarylla $0 (1)tri-lo-marzia $0 (1)tri-lo-sprintec $0 (1)tri-previfem $0 (1)tri-sprintec $0 (1) MOtrinessa $0 (1)trinessa lo $0 (1) MO

63


Name of drug


you (tier

level)


or limits on usetrivora-28 $0 (1)VAGIFEM $0 (2) MOvelivet $0 (1) MOvestura $0 (1)vienva $0 (1)viorele $0 (1) MOvyfemla $0 (1) MOwera $0 (1)wymzya fe $0 (1) MOzarah $0 (1)zenchent $0 (1)zenchent fe $0 (1)zovia 1/35e $0 (1)zovia 1/50e $0 (1) MO

Progesterone Agonists/Antagonists ELLA $0 (2)

Progestins camila $0 (1) MOdeblitane $0 (1)DEPO‑PROVERA $0 (2) MOerrin $0 (1) MOheather $0 (1) MOhydroxyprogesterone caproate inj $0 (1) PAjencycla $0 (1)jolivette $0 (1)levonorgestrel $0 (1)lyza $0 (1)medroxyprogesterone acetate inj $0 (1)medroxyprogesterone acetate tabs 5mg $0 (1)medroxyprogesterone acetate tabs 10mg, 2.5mg $0 (1) MOmegestrol acetate tabs $0 (1) PAmegestrol acetate susp 40mg/ml $0 (1) PAnora-be $0 (1)norethindrone acetate tabs $0 (1)

64


Name of drug


you (tier

level)


or limits on usenorethindrone tabs $0 (1)norlyroc $0 (1)progesterone inj $0 (1)progesterone caps $0 (1) MOsharobel $0 (1)

Selective Estrogen Receptor Modifying Agents raloxifene hydrochloride $0 (1)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) ‑ DRUGS USED TO REGULATE THYROID LEVELS

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

levothyroxine sodium inj $0 (1) MOlevothyroxine sodium tabs 100mcg, 112mcg, 125mcg, 150mcg, 25mcg, 50mcg, 75mcg, 88mcg

$0 (1)

levothyroxine sodium tabs 137mcg, 175mcg, 200mcg, 300mcg

$0 (1) MO

levoxyl tabs 100mcg, 112mcg, 150mcg, 50mcg, 75mcg, 88mcg

$0 (1)

levoxyl tabs 125mcg, 137mcg, 175mcg, 200mcg, 25mcg

$0 (1) MO

liothyronine sodium tabs $0 (1)SYNTHROID TABS 112MCG $0 (2)SYNTHROID TABS 100MCG, 125MCG, 137MCG, 150MCG, 175MCG, 200MCG, 25MCG, 300MCG, 50MCG, 75MCG, 88MCG

$0 (2) MO

THYROLAR‑1 $0 (2) MOTHYROLAR‑1/2 $0 (2) MOTHYROLAR‑1/4 $0 (2) MOTHYROLAR‑2 $0 (2) MOTHYROLAR‑3 $0 (2)unithroid tabs 200mcg $0 (1)unithroid tabs 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg

$0 (1) MO

65


Name of drug


you (tier

level)


or limits on useHORMONAL AGENTS, SUPPRESSANT (ADRENAL) ‑ DRUG(S) USED TO TREAT ADRENAL CORTICAL CANCER

Hormonal Agents, Suppressant (Adrenal) LYSODREN $0 (2) MO

HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) ‑ DRUGS USED TO TREAT HIGH CALCIUM LEVELS IN PEOPLE WITH CHRONIC KIDNEY DISEASE

Hormonal Agents, Suppressant (Parathyroid) SENSIPAR TABS 90MG $0 (2) QL (120 EA per 30 days)SENSIPAR TABS 30MG, 60MG $0 (2) QL (60 EA per 30 days)

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)‑ DRUGS USED TO TREAT PROSTATE CANCER AND OTHER CONDITIONS ASSOCIATED WITH AN OVERACTIVE PITUITARY GLAND

Hormonal Agents, Suppressant (Pituitary) cabergoline $0 (1)FIRMAGON $0 (2) PAleuprolide acetate inj $0 (1) PALUPRON DEPOT $0 (2) PALUPRON DEPOT‑PED $0 (2) PAoctreotide acetate $0 (1) PASIGNIFOR $0 (2) QL (60 ML per 30 days) PA LASOMATULINE DEPOT INJ 60MG/0.2ML $0 (2) QL (0.2 ML per 28 days) PASOMATULINE DEPOT INJ 90MG/0.3ML $0 (2) QL (0.3 ML per 28 days) PASOMATULINE DEPOT INJ 120MG/0.5ML $0 (2) QL (0.5 ML per 28 days) PASOMAVERT $0 (2) PASYNAREL $0 (2) MOTRELSTAR MIXJECT $0 (2) PAVANTAS $0 (2)ZOLADEX $0 (2)

HORMONAL AGENTS, SUPPRESSANT (THYROID) ‑ DRUGS USED TO LOWER THYROID LEVELSAntithyroid Agents

methimazole tabs $0 (1)propylthiouracil tabs $0 (1) MO

IMMUNOLOGICAL AGENTS‑ VACCINES, RHEUMATOID ARTHRITIS , IMMUNOGLOBULINS, IMMUNOMODULATORS, IMMUNOSUPPRESSANTS

Angioedema (HAE) Agents CINRYZE $0 (2) PA

66


Name of drug


you (tier

level)


or limits on useFIRAZYR $0 (2) QL (270 ML per 30 days) PA

Immune Suppressants azathioprine inj, tabs $0 (1) B/DCELLCEPT INTRAVENOUS $0 (2) B/Dcyclosporine modified caps 100mg, 25mg $0 (1) PAcyclosporine modified caps 50mg $0 (1) PA MOcyclosporine modified soln $0 (1) PAcyclosporine inj $0 (1) PAcyclosporine caps $0 (1) PA MOENBREL SURECLICK $0 (2) QL (7.84 ML per 28 days) PAENBREL INJ 25MG/0.5ML $0 (2) QL (4.08 ML per 28 days) PAENBREL INJ 50MG/ML $0 (2) QL (7.84 ML per 28 days) PAENBREL INJ 25MG $0 (2) QL (8 EA per 28 days) PAENVARSUS XR $0 (2) B/Dgengraf caps 100mg, 25mg $0 (1) PAgengraf soln $0 (1) PA MOhecoria $0 (1) B/DHUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK


HUMIRA PEN $0 (2) QL (6 EA per 28 days) PAHUMIRA PEN‑CROHNS DISEASESTARTER $0 (2) QL (6 EA per 28 days) PAHUMIRA PEN‑PSORIASIS STARTER $0 (2) QL (6 EA per 28 days) PAHUMIRA INJ 10MG/0.2ML, 20MG/0.4ML $0 (2) QL (2 EA per 28 days) PAHUMIRA INJ 40MG/0.8ML $0 (2) QL (6 EA per 28 days) PAmethotrexate sodium inj 1gm/40ml, 1gm, 250mg/10ml, 50mg/2ml

$0 (1)

methotrexate tabs $0 (1)mycophenolate mofetil caps, tabs $0 (1) B/Dmycophenolate mofetil susr $0 (1) B/D MONULOJIX $0 (2) PAOTREXUP INJ 10MG/0.4ML, 15MG/0.4ML, 17.5MG/0.4ML, 20MG/0.4ML, 22.5MG/0.4ML, 25MG/0.4ML, 7.5MG/0.4ML

$0 (2) ST

PROGRAF INJ $0 (2) B/DRAPAMUNE SOLN $0 (2) B/D MO

67


Name of drug


you (tier

level)


or limits on useRASUVO $0 (2) STREMICADE $0 (2) PASANDIMMUNE SOLN $0 (2) PA MOSIMULECT $0 (2) B/Dsirolimus tabs 0.5mg, 2mg $0 (1) B/Dsirolimus tabs 1mg $0 (1) B/D MOtacrolimus caps $0 (1) B/DXELJANZ $0 (2) QL (60 EA per 30 days) PAZORTRESS $0 (2) PA MO

Immunizing Agents, Passive ATGAM $0 (2) B/DFLEBOGAMMA DIF $0 (2) PAGAMASTAN S/D $0 (2) PAGAMMAGARD LIQUID $0 (2) PAGAMMAGARD S/D IGA LESS THAN 1MCG/ML $0 (2) PAGAMMAKED $0 (2) PAGAMMAPLEX $0 (2) PAGAMUNEX‑C $0 (2) PAOCTAGAM $0 (2) PATHYMOGLOBULIN $0 (2) B/D

Immunomodulators ACTIMMUNE $0 (2) PAARCALYST $0 (2) PABENLYSTA $0 (2) PAILARIS $0 (2) QL (2 EA per 28 days) PAleflunomide $0 (1)OTEZLA TBPK $0 (2) QL (110 EA per 365 days) PAOTEZLA TABS $0 (2) QL (60 EA per 30 days) PASYNAGIS $0 (2) PAXELJANZ XR $0 (2) QL (30 EA per 30 days) PA

Vaccines ACTHIB $0 (2)ADACEL $0 (2)bcg vaccine $0 (1)BEXSERO $0 (2)

68


Name of drug


you (tier

level)


or limits on useBOOSTRIX $0 (2)CERVARIX $0 (2)COMVAX $0 (2)DAPTACEL $0 (2)diphtheria/tetanus toxoids adsorbed pediatric $0 (1)ENGERIX‑B $0 (2) B/DGARDASIL $0 (2)GARDASIL 9 $0 (2)HAVRIX $0 (2)HIBERIX $0 (2)IMOVAX RABIES (H.D.C.V.) $0 (2) B/DINFANRIX $0 (2)IPOL INACTIVATED IPV $0 (2)IXIARO $0 (2)KINRIX $0 (2)M‑M‑R II $0 (2)MENACTRA $0 (2)MENHIBRIX $0 (2)MENOMUNE‑A/C/Y/W‑135 $0 (2)MENVEO $0 (2)PEDIARIX $0 (2)PEDVAX HIB $0 (2)PENTACEL $0 (2)PROQUAD $0 (2)QUADRACEL $0 (2)RABAVERT $0 (2) B/DRECOMBIVAX HB $0 (2) B/DROTARIX $0 (2)ROTATEQ $0 (2)TENIVAC $0 (2)tetanus/diphtheria toxoids-adsorbed $0 (1)TRUMENBA $0 (2)TWINRIX $0 (2)TYPHIM VI $0 (2)

69


Name of drug


you (tier

level)


or limits on useVAQTA $0 (2)VARIVAX $0 (2)YF‑VAX $0 (2)ZOSTAVAX $0 (2) QL (1 EA per 365 days)

INFLAMMATORY BOWEL DISEASE AGENTS DRUGS USED TO MANAGE DISORDERS IN THE COLON AND/OR INTESTINES

Aminosalicylates APRISO $0 (2) MOASACOL HD $0 (2) ST MObalsalazide disodium $0 (1) MODELZICOL $0 (2) ST MOLIALDA $0 (2) ST MOmesalamine enem, kit $0 (1)PENTASA $0 (2) ST MO

Sulfonamides sulfasalazine tabs, tbec $0 (1)

METABOLIC BONE DISEASE AGENTS‑ DRUGS USED TO TREAT BONE LOSSMetabolic Bone Disease Agents

alendronate sodium soln $0 (1) MOalendronate sodium tabs 10mg, 5mg $0 (1) QL (30 EA per 30 days)alendronate sodium tabs 40mg $0 (1) QL (30 EA per 30 days) MOalendronate sodium tabs 35mg, 70mg $0 (1) QL (4 EA per 28 days)calcitonin-salmon $0 (1) MOcalcitriol caps, inj $0 (1)calcitriol oral soln $0 (1) MOdoxercalciferol caps $0 (1)etidronate disodium $0 (1) MOFORTEO $0 (2) QL (2.4 ML per 28 days) PAMIACALCIN INJ $0 (2) MOpamidronate disodium $0 (1)paricalcitol $0 (1)PROLIA $0 (2) QL (1 ML per 180 days)risedronate sodium dr $0 (1) QL (4 EA per 28 days) MOrisedronate sodium tabs 150mg $0 (1) QL (1 EA per 28 days)risedronate sodium tabs 35mg $0 (1) QL (12 EA per 84 days)

70


Name of drug


you (tier

level)


or limits on userisedronate sodium tabs 30mg, 5mg $0 (1) QL (30 EA per 30 days) MOXGEVA $0 (2) PAzoledronic acid inj 4mg/5ml, 4mg, 5mg/100ml $0 (1)

MISCELLANEOUS THERAPEUTIC AGENTSMiscellaneous Therapeutic Agents

ALCOHOL PREP PADS $0 (2)FERRIPROX SOLN 100MG/ML $0 (2) PA LAGAUZE PADS 2”X2” $0 (2)INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2” $0 (2) MOINSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16” $0 (2)INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2” $0 (2) MOINSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16” $0 (2) MOINSUPEN 33GX4MM $0 (2) MONATPARA $0 (2) QL (2 EA per 28 days) PAORFADIN SUSP 4MG/ML $0 (2) PAPEN NEEDLE/ULTRAFINE/29G X 12.7MM $0 (2)SYLVANT $0 (2) PAV‑GO 20 $0 (2) MOV‑GO 30 $0 (2) MOV‑GO 40 $0 (2) MO

OPHTHALMIC AGENTS‑ DRUGS USED TO TREAT EYE ALLERGIES, INFECTIONS, INFLAMMATION, AND GLAUCOMA

Ophthalmic Prostaglandin and Prostamide Analogs COMBIGAN $0 (2) MOlatanoprost $0 (1)LUMIGAN $0 (2) MOTRAVATAN Z $0 (2) ST MOtravoprost $0 (1) MO

Ophthalmic Agents, Other ak-poly-bac $0 (1) MOatropine sulfate soln $0 (1) MOAZASITE $0 (2) MObacitracin/neomycin/polymyxin $0 (1)bacitracin/polymyxin b $0 (1) MObacitracin oint 500unit/gm $0 (1) MO

71


Name of drug


you (tier

level)


or limits on useBESIVANCE $0 (2) MOciprofloxacin hcl soln 0.3% $0 (1) MOCYSTARAN $0 (2) QL (60 ML per 28 days) LAerythromycin oint 5mg/gm $0 (1)gatifloxacin $0 (1)gentak $0 (1) MOgentamicin sulfate ophthalmic oint 0.3% $0 (1)gentamicin sulfate ophthalmic soln 0.3% $0 (1) MOilotycin $0 (1)levofloxacin ophthalmic soln 0.5% $0 (1) MOMOXEZA $0 (2) MOnaphazoline hcl $0 (1) MOneo-polycin $0 (1)neomycin/bacitracin/polymyxin $0 (1) MOneomycin/polymyxin/bacitracin/hydrocortisone $0 (1) MOneomycin/polymyxin/dexamethasone oint $0 (1)neomycin/polymyxin/dexamethasone susp $0 (1) MOneomycin/polymyxin/gramicidin $0 (1) MOneomycin/polymyxin/hydrocortisone ophthalmic susp 1%; 3.5mg/ml; 10000unit/ml

$0 (1) MO

ofloxacin ophthalmic soln 0.3% $0 (1)polycin $0 (1)polymyxin b sulfate/trimethoprim sulfate $0 (1) MOproparacaine hcl $0 (1)RESTASIS $0 (2) MOsodium sulfacetamide soln 10% $0 (1) MOsulfacetamide sodium/prednisolone sodium phosphate $0 (1)sulfacetamide sodium oint 10% $0 (1) MOsulfacetamide sodium soln 10% $0 (1)TOBRADEX $0 (2) MOTOBRADEX ST $0 (2) MOtobramycin sulfate ophthalmic soln 0.3% $0 (1) MOtobramycin/dexamethasone $0 (1) MOTOBREX $0 (2) MOtrifluridine $0 (1)

72


Name of drug


you (tier

level)


or limits on usetrimethoprim sulfate/polymyxin b sulfate $0 (1)triple antibiotic $0 (1)VIGAMOX $0 (2) MOZIRGAN $0 (2) MO

Ophthalmic Anti-allergy Agents azelastine hcl ophthalmic soln 0.05% $0 (1)cromolyn sodium soln 4% $0 (1) MOepinastine hcl $0 (1) MOolopatadine hcl ophthalmic soln 0.1% $0 (1)PATADAY $0 (2) MOPAZEO $0 (2) MO

Ophthalmic Anti-inflammatories ACUVAIL $0 (2) MOdexamethasone sodium phosphate ophthalmic soln 0.1%

$0 (1) MO

DUREZOL $0 (2) MOfluorometholone $0 (1) MOflurbiprofen sodium $0 (1) MOILEVRO $0 (2) MOketorolac tromethamine $0 (1)LOTEMAX $0 (2) MONEVANAC $0 (2) MOprednisolone acetate $0 (1)prednisolone sodium phosphate ophthalmic soln 1% $0 (1) MOPROLENSA $0 (2) MOZADITOR $0 (3) *

Ophthalmic Antiglaucoma Agents ALPHAGAN P SOLN 0.1% $0 (2) MOapraclonidine $0 (1) MOAZOPT $0 (2) MObetaxolol hcl soln 0.5% $0 (1) MOBETIMOL $0 (2) MOBETOPTIC‑S $0 (2) MObrimonidine tartrate $0 (1) MOcarteolol hcl $0 (1)

73


Name of drug


you (tier

level)


or limits on usedorzolamide hcl $0 (1) MOdorzolamide hcl/timolol maleate $0 (1) MOlevobunolol hcl $0 (1) MOmetipranolol $0 (1)PHOSPHOLINE IODIDE $0 (2)pilocarpine hcl soln 1%, 2%, 4% $0 (1) MOSIMBRINZA $0 (2) MOtimolol maleate ophthalmic gel forming $0 (1) MOtimolol maleate soln 0.25%, 0.5% $0 (1)

OTIC AGENTS‑ DRUGS USED TO TREAT CONDITIONS OF THE EAROtic Agents

acetasol hc $0 (1)acetic acid $0 (1)acetic acid/aluminum acetate $0 (1) MOantibiotic ear $0 (1)CIPRODEX $0 (2) MOfluocinolone acetonide oil 0.01% $0 (1) MOhydrocortisone/acetic acid $0 (1)neomycin/polymyxin/hc $0 (1) MOneomycin/polymyxin/hydrocortisone otic susp 1%; 3.5mg/ml; 10000unit/ml

$0 (1) MO

ofloxacin otic soln 0.3% $0 (1)RESPIRATORY TRACT/PULMONARY AGENTS‑ DRUGS USED TO TREAT ALLERGIES, ASTHMA, COPD, PULMONARY HYPERTENSION

Anti-inflammatories, Inhaled Corticosteroids ADVAIR DISKUS $0 (2) QL (60 EA per 30 days) MOADVAIR HFA $0 (2) QL (12 GM per 30 days) MOASMANEX HFA $0 (2) QL (13 GM per 30 days) MOASMANEX TWISTHALER 120 METERED DOSES $0 (2) QL (1 EA per 30 days) MOASMANEX TWISTHALER 14 METERED DOSES $0 (2) QL (2 EA per 28 days)ASMANEX TWISTHALER 30 METERED DOSES $0 (2) QL (1 EA per 30 days) MOASMANEX TWISTHALER 60 METERED DOSES $0 (2) QL (1 EA per 30 days) MOASMANEX TWISTHALER 7 METERED DOSES $0 (2) QL (4 EA per 28 days)BREO ELLIPTA $0 (2) QL (60 EA per 30 days) MO

74


Name of drug


you (tier

level)


or limits on usebudesonide inhalation susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml

$0 (1) B/D MO

budesonide nasal susp 32mcg/act $0 (1) QL (17.2 GM per 30 days)FLOVENT DISKUS AEPB 250MCG/BLIST $0 (2) QL (240 EA per 30 days) MOFLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST

$0 (2) QL (60 EA per 30 days) MO

FLOVENT HFA AERO 44MCG/ACT $0 (2) QL (21.2 GM per 30 days) MOFLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT $0 (2) QL (24 GM per 30 days) MOflunisolide $0 (1) MOfluticasone propionate susp 50mcg/act $0 (1) QL (16 GM per 30 days) MONASONEX $0 (2) QL (34 GM per 30 days) MOQVAR $0 (2) QL (17.4 GM per 30 days) MOtriamcinolone acetonide aero 55mcg/act $0 (1)

Antihistamines all day allergy childrens soln $0 (3) *all day allergy tabs $0 (3) *allergy relief tbdp $0 (3) *allergy relief tabs 10mg $0 (3) *allergy tbdp $0 (3) *allergy tabs 10mg $0 (3) *allerhist-1 $0 (3) *azelastine hcl nasal soln 0.15% $0 (1) MOazelastine hcl nasal soln 0.1% $0 (1) QL (30 ML per 25 days)cetirizine hcl allergy childrens $0 (3) *cetirizine hcl childrens soln 5mg/5ml $0 (3) *cetirizine hcl hives relief childrens $0 (3) *cetirizine hcl chew, tabs $0 (3) *childrens loratadine $0 (3) *chlorpheniramine maleate tbcr $0 (3) *clemastine fumarate tabs 2.68mg $0 (1) PAcyproheptadine hcl tabs $0 (1) PAdayhist allergy 12 hour relief $0 (3) *diphenhydramine hcl inj $0 (1) PAgnp all day allergy childrens syrp $0 (3) *gnp all day allergy childrens soln 5mg/5ml $0 (3) *

75


Name of drug


you (tier

level)


or limits on usegnp allergy relief for kids tbdp $0 (3) *gnp allergy relief tbdp $0 (3) *gnp dayhist allergy $0 (3) *gnp loratadine childrens $0 (3) *gnp loratadine tabs $0 (3) *goodsense all day allergy $0 (3) *hm all day allergy $0 (3) *hm allergy relief tbdp $0 (3) *hydroxyzine hcl tabs $0 (1) PAhydroxyzine hcl inj, syrp $0 (1) PA MOhydroxyzine pamoate caps 25mg, 50mg $0 (1) PAhydroxyzine pamoate caps 100mg $0 (1) PA MOlevocetirizine dihydrochloride tabs $0 (1) QL (30 EA per 30 days)levocetirizine dihydrochloride soln $0 (1) QL (300 ML per 30 days) MOloratadine childrens $0 (3) *loratadine hives relief $0 (3) *loratadine tabs $0 (3) *olopatadine hcl nasal soln 0.6% $0 (1) QL (30.5 GM per 30 days)promethazine hcl tabs 25mg $0 (1) PApromethazine hcl tabs 12.5mg, 50mg $0 (1) PA MOqc all day allergy $0 (3) *qc allergy relief $0 (3) *qc loratadine allergy relief $0 (3) *sb allergy tabs $0 (3) *sb loratadine tabs $0 (3) *sm all day allergy $0 (3) *sm all day allergy childrens soln 5mg/5ml $0 (3) *sm allergy relief loratadine $0 (3) *sm allergy relief tabs 1.34mg $0 (3) *sm loratadine allergy relief $0 (3) *sm loratadine syrp $0 (3) *

Antileukotrienes montelukast sodium $0 (1) QL (30 EA per 30 days)zafirlukast $0 (1) QL (60 EA per 30 days) MO

76


Name of drug


you (tier

level)


or limits on useBronchodilators, Anticholinergic

ANORO ELLIPTA $0 (2) QL (60 EA per 30 days) MOCOMBIVENT RESPIMAT $0 (2) QL (8 GM per 30 days) MOINCRUSE ELLIPTA $0 (2) QL (30 EA per 30 days) MOipratropium bromide/albuterol sulfate $0 (1) B/Dipratropium bromide nasal soln $0 (1)ipratropium bromide inhalation soln $0 (1) B/DSPIRIVA HANDIHALER $0 (2) QL (30 EA per 30 days) MOSPIRIVA RESPIMAT $0 (2) QL (4 GM per 30 days) MO

Bronchodilators, Sympathomimetic albuterol sulfate er $0 (1) MOalbuterol sulfate syrp $0 (1)albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml

$0 (1) B/D

albuterol sulfate nebu 0.5% $0 (1) B/D MOalbuterol sulfate tabs 4mg $0 (1)albuterol sulfate tabs 2mg $0 (1) MOARCAPTA NEOHALER $0 (2) QL (30 EA per 30 days) ST MOEPIPEN 2‑PAK $0 (2) QL (2 EA per 30 days) MOEPIPEN‑JR 2‑PAK $0 (2) QL (2 EA per 30 days) MOFORADIL AEROLIZER $0 (2) QL (60 EA per 30 days) MOlevalbuterol hcl nebu $0 (1) B/Dlevalbuterol nebu $0 (1) B/D MOmetaproterenol sulfate syrp, tabs $0 (1) MOPROAIR HFA $0 (2) QL (17 GM per 30 days) MOPROAIR RESPICLICK $0 (2) QL (2 EA per 30 days) MOSEREVENT DISKUS $0 (2) QL (60 EA per 30 days) ST MOSTRIVERDI RESPIMAT $0 (2) QL (4 GM per 30 days) MOterbutaline sulfate tabs $0 (1)VENTOLIN HFA $0 (2) QL (36 GM per 30 days) MO

Cystic Fibrosis Agents CAYSTON $0 (2) QL (84 ML per 56 days) LAKALYDECO PACK $0 (2) QL (56 EA per 28 days) PAKALYDECO TABS $0 (2) QL (60 EA per 30 days) PAORKAMBI $0 (2) QL (112 EA per 28 days) PA

77


Name of drug


you (tier

level)


or limits on usePULMOZYME $0 (2) B/DTOBI PODHALER $0 (2) QL (224 EA per 56 days)tobramycin $0 (1) QL (280 ML per 56 days) B/D

Mast Cell Stabilizers cromolyn sodium aers 5.2mg/act $0 (3) *cromolyn sodium nebu 20mg/2ml $0 (1) B/D MO

Phosphodiesterase Inhibitors, Airways Disease aminophylline $0 (1)DALIRESP $0 (2) QL (30 EA per 30 days) MOtheophylline $0 (1)theophylline cr tb12 200mg $0 (1)theophylline cr tb12 100mg $0 (1) MOtheophylline er tb24 $0 (1)theophylline er tb12 100mg, 200mg, 300mg $0 (1)theophylline er tb12 450mg $0 (1) MO

Pulmonary Antihypertensives ADEMPAS $0 (2) QL (90 EA per 30 days) PAepoprostenol sodium $0 (1) PA LALETAIRIS $0 (2) QL (30 EA per 30 days) PAOPSUMIT $0 (2) QL (30 EA per 30 days) PAREMODULIN $0 (2) PAsildenafil tabs $0 (1) QL (90 EA per 30 days) PATRACLEER $0 (2) QL (60 EA per 30 days) PAVENTAVIS $0 (2) PA

Respiratory Tract Agents, Other acetylcysteine inj $0 (1)acetylcysteine inhalation soln 10% $0 (1) B/Dacetylcysteine inhalation soln 20% $0 (1) B/D MOESBRIET $0 (2) QL (270 EA per 30 days) PAOFEV $0 (2) QL (60 EA per 30 days) PAPROLASTIN‑C $0 (2) PA LASTIOLTO RESPIMAT $0 (2) QL (4 GM per 30 days) MOTYZINE PEDIATRIC NASAL DROPS $0 (2)XOLAIR $0 (2) QL (6 EA per 28 days) PA

78


Name of drug


you (tier

level)


or limits on useZEMAIRA $0 (2) PA LA

SKELETAL MUSCLE RELAXANTS‑ DRUGS USED TO TREAT MUSCLE SPASMS Skeletal Muscle Relaxants

chlorzoxazone $0 (1) QL (180 EA per 30 days) PA MOcyclobenzaprine hcl tabs $0 (1) QL (90 EA per 30 days) PA

SLEEP DISORDER AGENTS‑ DRUGS USED TO TREAT INSOMNIA OR SLEEP DISORDERSGABA Receptor Modulators

zaleplon caps 5mg $0 (1) QL (30 EA per 30 days) PAzaleplon caps 10mg $0 (1) QL (60 EA per 30 days) PAzolpidem tartrate er $0 (1) QL (30 EA per 30 days) PAzolpidem tartrate tabs 10mg $0 (1) QL (30 EA per 30 days) PAzolpidem tartrate tabs 5mg $0 (1) QL (30 EA per 30 days) PA MO

Sleep Disorders, Other armodafinil $0 (1) QL (30 EA per 30 days) PAHETLIOZ $0 (2) QL (30 EA per 30 days) PA LAmodafinil tabs 100mg $0 (1) QL (30 EA per 30 days) PAmodafinil tabs 200mg $0 (1) QL (60 EA per 30 days) PAROZEREM $0 (2) QL (30 EA per 30 days)XYREM $0 (2) QL (540 ML per 30 days) PA

THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES, VITAMINS AND IV NUTRITIONElectrolyte/Mineral Modifiers

CUPRIMINE $0 (2) MODEPEN TITRATABS $0 (2) MOEXJADE $0 (2) PAFERRIPROX TABS 500MG $0 (2) PA LAfomepizole $0 (1)kionex $0 (1) MOlevocarnitine $0 (1)SAMSCA TABS 15MG $0 (2) QL (30 EA per 30 days) PASAMSCA TABS 30MG $0 (2) QL (60 EA per 30 days) PAsodium bicarbonate partial fill $0 (1) MOsodium bicarbonate inj 8.4% $0 (1) MOsodium polystyrene sulfonate $0 (1)sps $0 (1)

79


Name of drug


you (tier

level)


or limits on useSYPRINE $0 (2) MO

Electrolyte/Mineral Replacement AMINOSYN $0 (2) B/DAMINOSYN 7%/ELECTROLYTES $0 (2) B/Daminosyn 8.5%/electrolytes $0 (1) B/Daminosyn ii 8.5%/electrolytes $0 (1) B/DAMINOSYN II INJ 50.3MEQ/L; 695MG/100ML; 713MG/100ML; 490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML; 462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML; 209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L; 280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML, 61.1MEQ/L; 844MG/100ML; 865MG/100ML; 595MG/100ML; 627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML; 850MG/100ML; 893MG/100ML; 146MG/100ML; 253MG/100ML; 614MG/100ML; 450MG/100ML; 33.3MEQ/L; 340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML, 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 44.4MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML

$0 (2) B/D

AMINOSYN M $0 (2) B/DAMINOSYN‑HBC $0 (2) B/DAMINOSYN‑PF $0 (2) B/DAMINOSYN‑PF 7% $0 (2) B/DAMINOSYN‑RF $0 (2) B/Dcalcium chloride $0 (1)calcium gluconate inj $0 (1)citric acid/sodium citrate $0 (1)clinisol sf 15% $0 (1) B/Ddextrose 10%/nacl 0.45% $0 (1)dextrose 5% /electrolyte #48 viaflex $0 (1)

80


Name of drug


you (tier

level)


or limits on usedextrose 10% $0 (1) B/Ddextrose 10% flex container $0 (1) B/Ddextrose 10%/nacl 0.2% $0 (1)dextrose 2.5%/sodium chloride 0.45% $0 (1)dextrose 20% $0 (1) B/Ddextrose 25% $0 (1) B/Ddextrose 30% $0 (1) B/Ddextrose 40% $0 (1) B/Ddextrose 5% $0 (1) MOdextrose 5%/lactated ringers $0 (1)dextrose 5%/nacl 0.2% $0 (1)dextrose 5%/nacl 0.225% $0 (1)dextrose 5%/nacl 0.3% $0 (1)dextrose 5%/nacl 0.33% $0 (1)dextrose 5%/nacl 0.45% $0 (1)dextrose 5%/nacl 0.9% $0 (1)dextrose 5%/potassium chloride 0.15% $0 (1)dextrose 50% $0 (1) B/Ddextrose 70% $0 (1) B/DFLORIVA LIQD 0.25MG/ML; 400UNIT/ML $0 (2) MOfluor-a-day soln $0 (1)fluoride chew 1.1mg, 2.2mg $0 (1)fluoride chew 0.25mg $0 (1) MOfluoritab chew 0.5mg, 1mg $0 (1)fluoritab soln $0 (1)FLURA‑DROPS SOLN 0.25MG/DROP $0 (2) MOFREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML

$0 (2) B/D

hepatamine $0 (1) B/D

81


Name of drug


you (tier

level)


or limits on useINTRALIPID INJ 30GM/100ML $0 (2) B/Dintralipid inj 20gm/100ml $0 (1) B/Dk-sol $0 (1)KABIVEN $0 (2) B/Dkcl 0.075%/d5w/nacl 0.45% $0 (1)kcl 0.15%/d5w/lr $0 (1)kcl 0.15%/d5w/nacl 0.2% $0 (1)kcl 0.15%/d5w/nacl 0.225% $0 (1)kcl 0.15%/d5w/nacl 0.45% $0 (1)kcl 0.15%/d5w/nacl 0.9% $0 (1)kcl 0.3%/d5w/lr iv lac ring $0 (1)kcl 0.3%/d5w/nacl 0.45% $0 (1)kcl 0.3%/d5w/nacl 0.9% $0 (1)klor-con $0 (1)klor-con 10 $0 (1)KLOR‑CON 25 $0 (2)klor-con 8 $0 (1)klor-con m10 $0 (1)KLOR‑CON M15 $0 (2) MOklor-con m20 $0 (1)klor-con sprinkle $0 (1)klor-con/ef $0 (1) MOlactated ringers dextrose 5% viaflex $0 (1)lactated ringers viaflex $0 (1)ludent $0 (1) MOmagnesium sulfate inj $0 (1)NEPHRAMINE $0 (2) B/Dnutrilipid $0 (1) B/DPERIKABIVEN $0 (2) B/Dplenamine $0 (1) B/Dpotassium chloride 0.15% /nacl 0.45% viaflex $0 (1)potassium chloride 0.15% d5w/nacl 0.33% $0 (1)potassium chloride 0.15% d5w/nacl 0.45% $0 (1)potassium chloride 0.15% d5w/nacl 0.45% viaflex $0 (1)

82


Name of drug


you (tier

level)


or limits on usepotassium chloride 0.15% nacl 0.9% $0 (1)potassium chloride 0.15%/nacl 0.9% $0 (1)potassium chloride 0.22% d5w/nacl 0.45% $0 (1)potassium chloride 0.224%d5w/nacl 0.45% viaflex $0 (1)potassium chloride 0.3%/ nacl 0.9% $0 (1)potassium chloride 0.3%/d5w $0 (1)potassium chloride cr tbcr 10meq, 20meq $0 (1)potassium chloride er cpcr $0 (1)potassium chloride er tbcr 10meq, 20meq, 8meq $0 (1)potassium chloride er tbcr 20meq $0 (1) MOpotassium chloride sr $0 (1)potassium chloride oral soln $0 (1)potassium chloride inj 10meq/100ml, 10meq/50ml, 20meq/100ml, 2meq/ml, 40meq/100ml

$0 (1)

potassium chloride inj 0.4meq/ml $0 (1) MOpotassium citrate er tbcr 15meq $0 (1)potassium citrate er tbcr 1080mg, 540mg $0 (1) MOPREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML

$0 (2) B/D

premasol inj 56meq/l; 320mg/100ml; 730mg/100ml; 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml

$0 (1) B/D

ringers injection $0 (1)sodium chloride 0.45% viaflex $0 (1)sodium chloride inj 0.9%, 5% $0 (1)sodium chloride inj 2.5meq/ml, 3% $0 (1) MOsodium fluoride chew 0.5mg, 1.1mg $0 (1)

83


Name of drug


you (tier

level)


or limits on usesodium fluoride soln $0 (1)sodium phosphate $0 (1)sterile water irrigation $0 (1)tpn electrolytes $0 (1) B/DTRAVASOL $0 (2) B/DTROPHAMINE INJ 97MEQ/L; 0.54GM/100ML; 1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML

$0 (2) B/D

vitamins a/d/c/fluoride $0 (1)Vitamins

ACTIVE OB $0 (2)BAL‑CARE DHA $0 (2)CALCIUM PNV $0 (2)CITRANATAL 90 DHA $0 (2) MOCITRANATAL ASSURE $0 (2) MOCITRANATAL B‑CALM $0 (2) MOCITRANATAL DHA $0 (2) MOCITRANATAL RX TABS 120MG; 125MG; 400UNIT; 2MG; 30UNIT; 50MG; 1MG; 27MG; 20MG; 150MCG; 20MG; 3.4MG; 3MG; 25MG

$0 (2)

completenate $0 (1) MOCONCEPT DHA $0 (2) MOCONCEPT OB $0 (2) MODUET DHA 400 $0 (2) MODUET DHA BALANCED MISC 120MG; 2800UNIT; 215MG; 640UNIT; 55MG; 1.8MG; 12MCG; 0; 0; 0; 1MG; 25MG; 0; 25MG; 20MG; 267MG; 0; 210MCG; 50MG; 2MG; 0; 65MCG; 1.5MG; 15MG; 25MG

$0 (2) MO

elite-ob $0 (1) MOENBRACE HR $0 (2) MO

84


Name of drug


you (tier

level)


or limits on useESCAVITE D $0 (2)ESCAVITE LQ $0 (2)EXTRA‑VIRT PLUS DHA $0 (2)floriva chew 75mg; 0; 40mcg; 600unit; 1mg; 6mcg; 262mcg; 0; 15mg; 1.8mg; 1.5mg; 0.25mg; 1.3mg; 20unit; 2000unit; 5mg

$0 (1)

FOCALGIN 90 DHA $0 (2)FOCALGIN CA $0 (2) MOFOLCAL DHA $0 (2)FOLCAPS OMEGA 3 $0 (2)FOLET ONE $0 (2) MOFOLIVANE‑OB $0 (2)FOLIVANE‑PRX DHA NF $0 (2)HEMENATAL OB $0 (2) MOHEMENATAL OB + DHA $0 (2) MOinatal advance $0 (1)inatal ultra $0 (1)MARNATAL‑F $0 (2) MOmult-vitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.5mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1.05mg; 2500unit; 15unit

$0 (1) MO

multi vitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 1mg; 1.05mg; 15unit; 2500unit

$0 (1)

multi-vit/fluoride soln 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml

$0 (1)

multi-vit/iron/fluoride soln 35mg/ml; 400unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml

$0 (1)

multi-vitamin/fluoride/iron soln 35mg/ml; 400unit/ml; 5unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 1500unit/ml

$0 (1)

multi-vitamin/fluoride soln 35mg/ml; 400unit/ml; 2mcg/ml; 5unit/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 0.5mg/ml; 1500unit/ml

$0 (1)

85


Name of drug


you (tier

level)


or limits on usemultivitamin with fluoride chew 60mg; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.25mg; 1.05mg; 2500unit; 400unit; 15unit, 60mg; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.5mg; 1.05mg; 2500unit; 400unit; 15unit

$0 (1)

mvc-fluoride $0 (1) MONATACHEW CHEW 120MG; 2700UNIT; 400UNIT; 12MCG; 0; 0; 1MG; 28MG; 20MG; 10MG; 3MG; 0; 2MG; 20UNIT

$0 (2)

NATALVIRT 90 DHA $0 (2)NATALVIRT CA $0 (2)NATELLE ONE $0 (2) MONESTABS $0 (2) MONESTABS ABC $0 (2) MONESTABS DHA $0 (2) MONEXA PLUS $0 (2) MONIVA‑PLUS $0 (2)O‑CAL PRENATAL $0 (2) MOOB COMPLETE GOLD $0 (2) MOOB COMPLETE ONE $0 (2) MOOB COMPLETE PETITE $0 (2) MOOB COMPLETE PREMIER $0 (2) MOOB COMPLETE/DHA $0 (2) MOOB COMPLETE TABS $0 (2) MOPAIRE OB $0 (2) MOPNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID

$0 (2)

PNV FOLIC ACID + IRON MULTIVITAMIN $0 (2)PNV OB+DHA $0 (2)pnv prenatal plus multivitamin $0 (1) MOpnv tabs 29-1 $0 (1)pnv-dha $0 (1) MOpnv-select $0 (1) MOPNV‑VP‑U $0 (2)poly-vitamin/fluoride chew $0 (1)

86


Name of drug


you (tier

level)


or limits on usepoly-vitamin/fluoride soln 35mg/ml; 50mcg/ml; 2mcg/ml; 0.25mg/ml; 8mg/ml; 3mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 1500unit/ml; 400unit/ml; 5unit/ml

$0 (1)

pr natal 400 $0 (1)PREFERA OB $0 (2)PREFERA OB + DHA MISC 30MCG; 10MG; 400UNIT; 0.8MG; 12MCG; 200MG; 2.5MG; 1MG; 6MG; 0.5MG; 17MG; 203MG; 28MG; 250MCG; 50MG; 1.6MG; 65MCG; 1.5MG; 10UNIT; 4.5MG

$0 (2)

PREFERAOB +DHA $0 (2) MOPREFERAOB ONE $0 (2)PRENAISSANCE $0 (2) MOPRENAISSANCE PLUS $0 (2) MOPRENATA $0 (2) MOprenatabs fa $0 (1) MOprenatal 19 chew 100mg; 1000unit; 200mg; 7mg; 400unit; 12mcg; 29mg; 1mg; 15mg; 20mg; 3mg; 3mg; 30unit; 20mg

$0 (1)

prenatal 19 tabs 100mg; 1000unit; 200mg; 7mg; 400unit; 12mcg; 25mg; 29mg; 1mg; 15mg; 20mg; 3mg; 3mg; 30unit; 20mg

$0 (1)

PRENATAL PLUS $0 (2)prenatal plus iron tabs 120mg; 0; 200mg; 400unit; 2mg; 12mcg; 1mg; 29mg; 20mg; 10mg; 3mg; 1.84mg; 22unit; 4000unit; 25mg

$0 (1)

PRENATE AM $0 (2) MOPRENATE DHA CAPS 90MG; 145MG; 220UNIT; 13MCG; 300MG; 28MG; 400MCG; 600MCG; 50MG; 26MG; 10UNIT

$0 (2)

PRENATE ELITE TABS 75MG; 2600UNIT; 330MCG; 100MG; 6MG; 450UNIT; 1.5MG; 13MCG; 26MG; 400MCG; 150MCG; 600MCG; 25MG; 21MG; 21MG; 3.5MG; 3MG; 10UNIT; 15MG

$0 (2)

PRENATE ELITE TABS 600MCG; 75MG; 2600UNIT; 330MCG; 155MG; 600UNIT; 1.5MG; 13MCG; 20MG; 400MCG; 25MG; 21MG; 150MCG; 21MG; 3.5MG; 3MG; 40UNIT; 15MG

$0 (2) MO

87


Name of drug


you (tier

level)


or limits on usePRENATE ENHANCE $0 (2) MOPRENATE ESSENTIAL CAPS 90MG; 280MCG; 145MG; 220UNIT; 13MCG; 300MG; 40MG; 29MG; 0; 400MCG; 600MCG; 50MG; 150MCG; 26MG; 10UNIT

$0 (2)

PRENATE ESSENTIAL CAPS 600MCG; 90MG; 280MCG; 155MG; 220UNIT; 13MCG; 300MG; 40MG; 18MG; 400MCG; 50MG; 150MCG; 26MG; 10UNIT

$0 (2) MO

PRENATE MINI CAPS 60MG; 280MCG; 100MG; 220UNIT; 13MCG; 350MG; 400MCG; 29MG; 600MCG; 25MG; 150MCG; 26MG; 10UNIT; 25MG

$0 (2)

PRENATE MINI CAPS 600MCG; 60MG; 280MCG; 80MG; 1000UNIT; 13MCG; 350MG; 0; 400MCG; 18MG; 0; 25MG; 150MCG; 26MG; 10UNIT; 25MG

$0 (2) MO

PRENATE PIXIE $0 (2) MOPRENATE RESTORE $0 (2) MOPRENATE STAR $0 (2) MOPREPLUS TABS 120MG; 0; 200MG; 400UNIT; 2MG; 12MCG; 27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG; 22MG; 4000UNIT; 25MG

$0 (2)

PREQUE 10 $0 (2) MOPRETAB $0 (2)PROVIDA DHA $0 (2)PROVIDA OB $0 (2) MOPUREFE OB PLUS $0 (2)QUFLORA PEDIATRIC SOLN 45MG/ML; 400UNIT/ML; 1MG/ML; 3MCG/ML; 81MCG/ML; 150MCG/ML; 12MG/ML; 2MG/ML; 1MG/ML; 1MG/ML; 0.5MG/ML; 1MG/ML; 1100UNIT/ML; 12UNIT/ML

$0 (2)

QUFLORA PEDIATRIC SOLN 35MG/ML; 400UNIT/ML; 1MG/ML; 2MCG/ML; 35MCG/ML; 65MCG/ML; 10MG/ML; 0.8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.25MG/ML; 0.5MG/ML; 1000UNIT/ML; 5UNIT/ML

$0 (2) MO

RELNATE DHA $0 (2) MOse-natal 19 $0 (1) MOSELECT‑OB+DHA $0 (2) MO

88


Name of drug


you (tier

level)


or limits on useSELECT‑OB CHEW 60MG; 0; 400UNIT; 5MCG; 1MG; 25MG; 15MG; 29MG; 2.5MG; 1.8MG; 1.6MG; 30UNIT; 1700UNIT; 15MG

$0 (2)

SELECT‑OB CHEW 60MG; 0; 400UNIT; 5MCG; 0.4MG; 0.6MG; 25MG; 15MG; 29MG; 2.5MG; 1.8MG; 0; 1.6MG; 30UNIT; 1700UNIT; 15MG

$0 (2) MO

TARON‑BC $0 (2)TARON‑PREX $0 (2) MOthrivite rx $0 (1)TL FOLATE $0 (2)TL‑CARE DHA $0 (2)TL‑SELECT $0 (2)tri-vit/fluoride $0 (1) MOtri-vit/fluoride/iron $0 (1) MOtri-vitamin/fluoride $0 (1)triadvance $0 (1)tricare $0 (1) MOTRICARE PRENATAL COMPLEAT $0 (2) MOTRICARE PRENATAL DHA ONE $0 (2)TRINATAL GT $0 (2) MOtrinatal rx 1 $0 (1) MOtriple-vitamin/fluoride $0 (1)TRISTART DHA $0 (2) MOTRIVEEN‑DUO DHA $0 (2) MOTRIVEEN‑PRX RNF $0 (2)ultimatecare one nf $0 (1) MOVEMAVITE‑PRX 2 $0 (2) MOVENA‑BAL DHA $0 (2) MOVIRT‑ADVANCE $0 (2) MOVIRT‑C DHA $0 (2)VIRT‑CARE ONE $0 (2)VIRT‑PN $0 (2) MOVIRT‑PN DHA CAPS 85MG; 140MG; 200UNIT; 12MCG; 300MG; 27MG; 400MCG; 600MCG; 45MG; 25MG; 10UNIT

$0 (2)

89


Name of drug


you (tier

level)


or limits on useVIRT‑PN PLUS $0 (2) MOVIRT‑SELECT $0 (2)VITAFOL FE+ $0 (2) MOVITAFOL GUMMIES $0 (2)VITAFOL ULTRA $0 (2) MOVITAFOL‑NANO $0 (2) MOVITAFOL‑OB $0 (2) MOVITAFOL‑OB+DHA $0 (2) MOVITAFOL‑ONE $0 (2) MOVITAMEDMD ONE RX/QUATREFOLIC $0 (2) MOVITAMEDMD PLUS RX/QUATRE FOLIC $0 (2) MOvitamins a/c/d/fluoride $0 (1) MOVOL‑NATE $0 (2) MOVOL‑PLUS $0 (2) MOVP CH ULTRA $0 (2)VP‑CH PLUS $0 (2)VP‑CH‑PNV $0 (2)VP‑GGR‑B6 PRENATAL $0 (2) MOVP‑HEME OB $0 (2)VP‑HEME ONE $0 (2)VP‑PNV‑DHA $0 (2) MOZATEAN‑CH $0 (2) MOZATEAN‑PN $0 (2)ZATEAN‑PN DHA $0 (2) MOZATEAN‑PN PLUS $0 (2) MO

90

Drug Name Page # Drug Name Page #

Index of Drugs8 hour pain relief ...................................................................... 18‑MOP ..............................................................................48abacavir ....................................................................................33abacavir sulfate/lamivudine/zidovudine ..........................33ABELCET ..........................................................................18ABILIFY DISCMELT ..........................................................30ABILIFY INJ .......................................................................30ABILIFY MAINTENA .......................................................30ABILIFY ORAL SOLN ......................................................30ABRAXANE ......................................................................22acamprosate calcium dr ......................................................... 6acarbose ...................................................................................35acebutolol hcl caps .................................................................42acetaminophen/codeine #3 .................................................. 4acetaminophen/codeine soln ................................................ 4acetaminophen/codeine tabs 300mg; 15mg, 300mg; 60mg ........................................................................................... 4acetaminophen supp 650mg ............................................... 1acetasol hc ...............................................................................73acetazolamide er ....................................................................44acetazolamide tabs 125mg .................................................44acetazolamide tabs 250mg .................................................44acetic acid .................................................................................73acetic acid/aluminum acetate .............................................73acetylcysteine inhalation soln 10% ...................................77acetylcysteine inhalation soln 20% ...................................77acetylcysteine inj .....................................................................77acid reducer maximum strength tabs 20mg ...................52acid reducer tabs 10mg, 75mg ..........................................52acitretin caps 10mg, 25mg .................................................48acitretin caps 17.5mg ...........................................................48ACTHIB .............................................................................67ACTIMMUNE ...................................................................67ACTIVE OB .......................................................................83ACUVAIL ...........................................................................72acyclovir caps, susp, tabs ......................................................34acyclovir oint............................................................................34acyclovir sodium inj 50mg/ml .............................................34acyclovir sodium inj 500mg ................................................34ADACEL ............................................................................67ADAGEN ...........................................................................50adefovir dipivoxil .....................................................................32ADEMPAS .........................................................................77adrucil........................................................................................22ADVAIR DISKUS ...............................................................73

ADVAIR HFA .....................................................................73AFINITOR ..........................................................................25AFINITOR DISPERZ .........................................................25a-hydrocort ..............................................................................55ak-poly-bac .............................................................................70ala cort ......................................................................................55ALBENZA .........................................................................27albuterol sulfate er .................................................................76albuterol sulfate nebu 0.5% .................................................76albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml ............................................................................76albuterol sulfate syrp .............................................................76albuterol sulfate tabs 2mg ...................................................76albuterol sulfate tabs 4mg ...................................................76alclometasone dipropionate ................................................55ALCOHOL PREP PADS ...................................................70ALDURAZYME .................................................................50ALECENSA .......................................................................25alendronate sodium soln ......................................................69alendronate sodium tabs 10mg, 5mg ..............................69alendronate sodium tabs 35mg, 70mg ...........................69alendronate sodium tabs 40mg .........................................69alfuzosin hcl er ........................................................................54ALIMTA .............................................................................23ALINIA SUSR ....................................................................27ALINIA TABS ....................................................................27ALKERAN TABS ...............................................................21all day allergy childrens soln ................................................74all day allergy tabs ..................................................................74all day pain relief ....................................................................... 1allergy relief tabs 10mg ........................................................74allergy relief tbdp ....................................................................74allergy tabs 10mg ..................................................................74allergy tbdp ..............................................................................74allerhist-1 .................................................................................74allopurinol tabs 100mg ........................................................20allopurinol tabs 300mg ........................................................20alogliptin ...................................................................................35alogliptin/metformin hcl.......................................................35alogliptin/pioglitazone ..........................................................36alosetron hydrochloride .......................................................52ALPHAGAN P SOLN 0.1% ............................................72alprazolam tabs 0.25mg, 0.5mg .......................................35alprazolam tabs 1mg, 2mg ..................................................35ALTABAX...........................................................................48

91


altavera .....................................................................................58alyacen 1/35 ...........................................................................58alyacen 7/7/7 tabs .................................................................58amantadine hcl caps, syrp ....................................................28amantadine hcl tabs ..............................................................28AMBISOME ......................................................................18amcinonide ..............................................................................55amethia .....................................................................................58amethia lo ................................................................................58amethyst ...................................................................................58amifostine ................................................................................23amikacin sulfate inj 1gm/4ml ............................................... 7amikacin sulfate inj 500mg/2ml .......................................... 7amiloride hcl tabs ...................................................................45amiloride/hydrochlorothiazide ...........................................45aminophylline ..........................................................................77AMINOSYN ......................................................................79AMINOSYN 7%/ELECTROLYTES .................................79aminosyn 8.5%/electrolytes ................................................79AMINOSYN‑HBC ............................................................79aminosyn ii 8.5%/electrolytes .............................................79AMINOSYN II INJ 50.3MEQ/L; 695MG/100ML; 713MG/100ML; 490MG/100ML; 517MG/100ML; 350MG/100ML; 210MG/100ML; 462MG/100ML; 700MG/100ML; 735MG/100ML; 120MG/100ML; 209MG/100ML; 505MG/100ML; 371MG/100ML; 31.3MEQ/L; 280MG/100ML; 140MG/100ML; 189MG/100ML; 350MG/100ML, 61.1MEQ/L; 844MG/100ML; 865MG/100ML; 595MG/100ML; 627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML; 850MG/100ML; 893MG/100ML; 146MG/100ML; 253MG/100ML; 614MG/100ML; 450MG/100ML; 33.3MEQ/L; 340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML, 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 44.4MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML ..............................................................79AMINOSYN M ..................................................................79AMINOSYN‑PF ................................................................79AMINOSYN‑PF 7% ........................................................79AMINOSYN‑RF ................................................................79amiodarone hcl tabs 100mg, 400mg ..............................41amiodarone hcl tabs 200mg ...............................................41

AMITIZA ...........................................................................53amitriptyline hcl tabs 10mg, 150mg ................................17amitriptyline hcl tabs 100mg, 25mg, 50mg, 75mg .....17amlodipine besylate/atorvastatin calcium tabs 10mg; 10mg, 10mg; 80mg, 2.5mg; 10mg, 2.5mg; 20mg, 2.5mg; 40mg, 5mg; 10mg, 5mg; 20mg, 5mg; 40mg, 5mg; 80mg ..............................................................................43amlodipine besylate/atorvastatin calcium tabs 10mg; 20mg, 10mg; 40mg ..............................................................43amlodipine besylate/benazepril hydrochloride ..............43amlodipine besylate tabs ......................................................43amlodipine besylate/valsartan ............................................43amlodipine/valsartan/hctz ...................................................43ammonium lactate crea, lotn ..............................................48amnesteem ..............................................................................48amoxapine ................................................................................17amoxicillin caps, susr .............................................................10amoxicillin chew ......................................................................10amoxicillin/clavulanate potassium chew ..........................10amoxicillin/clavulanate potassium er ................................10amoxicillin/clavulanate potassium susr 200mg/5ml; 28.5mg/5ml, 400mg/5ml; 57mg/5ml, 600mg/5ml; 42.9mg/5ml ............................................................................10amoxicillin/clavulanate potassium susr 250mg/5ml; 62.5mg/5ml ............................................................................10amoxicillin/clavulanate potassium tabs 250mg; 125mg .10amoxicillin/clavulanate potassium tabs 500mg; 125mg, 875mg; 125mg ......................................................................10amoxicillin tabs 500mg ........................................................10amoxicillin tabs 875mg ........................................................10amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg; 1.25mg; 1.25mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg, 7.5mg; 7.5mg; 7.5mg; 7.5mg ...........................................................47amphetamine/dextroamphetamine tabs 1.875mg; 1.875mg; 1.875mg; 1.875mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg ..............................................................47amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg; 5mg ............................................................................................47amphotericin b ........................................................................18ampicillin caps .........................................................................11ampicillin sodium inj 1gm ....................................................10ampicillin sodium inj 10gm, 125mg, 1gm, 250mg, 2gm, 500mg ......................................................................................10ampicillin-sulbactam ............................................................10ampicillin susr 125mg/5ml .................................................11

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ampicillin susr 250mg/5ml .................................................11AMPYRA ...........................................................................47ANADROL‑50 .................................................................58anagrelide hydrochloride .....................................................38anastrozole tabs ......................................................................25ANDROGEL GEL 20.25MG/1.25GM, 40.5MG/2.5GM 58ANDROGEL GEL 25MG/2.5GM, 50MG/5GM ..........58ANDROGEL PUMP GEL 1% ..........................................58ANDROGEL PUMP GEL 1.62% ....................................58ANORO ELLIPTA .............................................................76antibiotic ear ............................................................................73anti-diarrheal tabs .................................................................51APOKYN ...........................................................................28apraclonidine ...........................................................................72apri .............................................................................................58APRISO .............................................................................69APTIOM TABS 200MG, 400MG, 800MG ..................12APTIOM TABS 600MG ..................................................13APTIVUS CAPS ................................................................34APTIVUS SOLN ...............................................................34aranelle .....................................................................................58ARANESP ALBUMIN FREE INJ 10MCG/0.4ML .........39ARANESP ALBUMIN FREE INJ 25MCG/0.42ML ......38ARANESP ALBUMIN FREE INJ 100MCG/0.5ML ......39ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 25MCG/ML, 300MCG/ML, 40MCG/ML, 60MCG/ML ..............................................................39ARANESP ALBUMIN FREE INJ 150MCG/0.3ML, 60MCG/0.3ML ................................................................38ARANESP ALBUMIN FREE INJ 150MCG/0.75ML ....39ARANESP ALBUMIN FREE INJ 200MCG/0.4ML, 40MCG/0.4ML ................................................................38ARANESP ALBUMIN FREE INJ 300MCG/0.6ML ......39ARANESP ALBUMIN FREE INJ 500MCG/ML ............38ARCALYST ........................................................................67ARCAPTA NEOHALER ....................................................76aripiprazole odt tbdp 10mg.................................................30aripiprazole odt tbdp 15mg.................................................30aripiprazole soln .....................................................................30aripiprazole tabs .....................................................................30ARISTADA .........................................................................30armodafinil ...............................................................................78ARRANON........................................................................23arthritis pain .............................................................................. 1arthritis pain relief .................................................................... 1ARZERRA ..........................................................................27

ASACOL HD .....................................................................69ascomp/codeine........................................................................ 1ashlyna ......................................................................................58ASMANEX HFA ................................................................73ASMANEX TWISTHALER 7 METERED DOSES ..........73ASMANEX TWISTHALER 14 METERED DOSES ........73ASMANEX TWISTHALER 30 METERED DOSES ........73ASMANEX TWISTHALER 60 METERED DOSES ........73ASMANEX TWISTHALER 120 METERED DOSES .....73aspirin/dipyridamole .............................................................39atenolol/chlorthalidone tabs 50mg; 25mg .....................42atenolol/chlorthalidone tabs 100mg; 25mg ..................42atenolol tabs ............................................................................42ATGAM ..............................................................................67atorvastatin calcium ..............................................................45atovaquone ..............................................................................27atovaquone/proguanil hcl ....................................................27ATRIPLA ............................................................................32atropine sulfate soln ..............................................................70aubra .........................................................................................58augmented betamethasone dipropionate crea, lotn .....55augmented betamethasone dipropionate gel, oint .......55AVASTIN ...........................................................................23aviane ........................................................................................58avita ...........................................................................................48azacitidine ................................................................................23AZASITE ............................................................................70azathioprine inj, tabs .............................................................66azelastine hcl nasal soln 0.1% ............................................74azelastine hcl nasal soln 0.15% ..........................................74azelastine hcl ophthalmic soln 0.05% ..............................72AZILECT ............................................................................29azithromycin inj, tabs ............................................................11azithromycin pack, susr ........................................................11AZOPT ..............................................................................72aztreonam ................................................................................10azurette .....................................................................................59baciim .......................................................................................... 7bacitracin inj 50000unit ........................................................ 7bacitracin/neomycin/polymyxin .........................................70bacitracin oint 500unit/gm .................................................70bacitracin/polymyxin b ..........................................................70baclofen tabs ...........................................................................31BAL‑CARE DHA ..............................................................83balsalazide disodium .............................................................69balziva .......................................................................................59BANZEL ............................................................................14

93


BARACLUDE SOLN ........................................................32baycadron ................................................................................55bcg vaccine ...............................................................................67bekyree ......................................................................................59BELEODAQ ......................................................................23benazepril hcl/hydrochlorothiazide ...................................40benazepril hcl tabs .................................................................40BENDEKA .........................................................................21BENLYSTA .........................................................................67benztropine mesylate inj .......................................................28benztropine mesylate tabs 0.5mg, 1mg ...........................28benztropine mesylate tabs 2mg .........................................28BESIVANCE ......................................................................71betamethasone dipropionate crea, oint ...........................55betamethasone dipropionate lotn .....................................55betamethasone valerate crea, foam, oint ........................55betamethasone valerate lotn ..............................................55betaxolol hcl soln 0.5% .........................................................72betaxolol hcl tabs 10mg, 20mg ..........................................42bethanechol chloride .............................................................54BETIMOL ..........................................................................72BETOPTIC‑S ....................................................................72bexarotene ................................................................................27BEXSERO ..........................................................................67bicalutamide ............................................................................22BICILLIN L‑A ....................................................................11BICNU ...............................................................................23bisoprolol fumarate ...............................................................42bisoprolol fumarate/hydrochlorothiazide tabs 2.5mg; 6.25mg, 5mg; 6.25mg .........................................................42bisoprolol fumarate/hydrochlorothiazide tabs 10mg; 6.25mg .....................................................................................42bleomycin sulfate....................................................................23BLINCYTO ........................................................................27blisovi 24 fe ..............................................................................59blisovi fe 1.5/30 ......................................................................59blisovi fe 1/20 .........................................................................59BOOSTRIX ........................................................................68BOSULIF ...........................................................................25BREO ELLIPTA .................................................................73briellyn .......................................................................................59BRILINTA ..........................................................................39brimonidine tartrate ..............................................................72BRINTELLIX TABS 10MG, 5MG ....................................16BRINTELLIX TABS 20MG ...............................................16BRIVIACT INJ, ORAL SOLN ...........................................13BRIVIACT TABS ...............................................................13

bromocriptine mesylate caps, tabs ....................................28budesonide cpep 3mg ...........................................................55budesonide inhalation susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml ..................................................................................74budesonide nasal susp 32mcg/act ....................................74bumetanide inj ........................................................................44bumetanide tabs .....................................................................44BUPHENYL TABS ............................................................50buprenorphine hcl/naloxone hcl ........................................... 6buprenorphine hcl subl ........................................................... 6buproban .................................................................................... 6bupropion hcl er ......................................................................15bupropion hcl sr tb12 100mg, 150mg, 200mg ...........15bupropion hcl sr tb12 150mg .............................................. 6bupropion hcl tabs .................................................................15bupropion hcl xl tb24 150mg .............................................15bupropion hcl xl tb24 300mg .............................................15buspirone hcl tabs 10mg, 15mg, 5mg, 7.5mg ..............35buspirone hcl tabs 30mg......................................................35BUSULFEX ........................................................................21butalbital/acetaminophen/caffeine caps ............................ 1butalbital/acetaminophen/caffeine/codeine caps 300mg; 50mg; 40mg; 30mg ................................................................ 1butalbital/acetaminophen/caffeine/codeine caps 325mg; 50mg; 40mg; 30mg ................................................................ 1butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg ........................................................................................... 1butalbital/aspirin/caffeine ...................................................... 1butalbital/aspirin/caffeine/codeine ...................................... 1butalbital compound/codeine ............................................... 4cabergoline ..............................................................................65CABOMETYX ...................................................................26calcipotriene ............................................................................48calcitonin-salmon ..................................................................69calcitrene ..................................................................................49calcitriol caps, inj ....................................................................69calcitriol oral soln ...................................................................69calcium acetate caps .............................................................54calcium acetate tabs 667mg ...............................................54calcium chloride......................................................................79calcium gluconate inj .............................................................79CALCIUM PNV .................................................................83camila ........................................................................................63camrese.....................................................................................59camrese lo ................................................................................59CANCIDAS INJ 50MG .....................................................18CANCIDAS INJ 70MG .....................................................18

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candesartan cilexetil/hydrochlorothiazide tabs 16mg; 12.5mg .....................................................................................40candesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg, 32mg; 25mg ..........................................................40candesartan cilexetil tabs 4mg, 8mg .................................40candesartan cilexetil tabs 16mg, 32mg ...........................40capacet ........................................................................................ 1CAPASTAT SULFATE .......................................................21CAPRELSA TABS 100MG ..............................................26CAPRELSA TABS 300MG ..............................................26captopril/hydrochlorothiazide ............................................40captopril tabs 12.5mg, 25mg, 50mg ...............................40captopril tabs 100mg ...........................................................40CARAFATE SUSP .............................................................53CARBAGLU ......................................................................50carbamazepine chew, susp, tabs .........................................14carbamazepine er cp12 ........................................................14carbamazepine er tb12 ........................................................14carbidopa/levodopa ..............................................................28carbidopa/levodopa/entacapone tabs 12.5mg; 200mg; 50mg .........................................................................................29carbidopa/levodopa/entacapone tabs 18.75mg; 200mg; 75mg, 25mg; 200mg; 100mg, 31.25mg; 200mg; 125mg, 37.5mg; 200mg; 150mg, 50mg; 200mg; 200mg ......................................................................................29carbidopa/levodopa er ..........................................................28carbidopa/levodopa odt .......................................................28carbidopa tabs ........................................................................29carboplatin ...............................................................................23carteolol hcl..............................................................................72cartia xt .....................................................................................43carvedilol ..................................................................................42CAYSTON .........................................................................76caziant .......................................................................................59cefaclor caps .............................................................................. 9cefaclor er ................................................................................... 8cefaclor susr 125mg/5ml ...................................................... 9cefaclor susr 250mg/5ml, 375mg/5ml ............................ 9cefadroxil caps, tabs ................................................................. 9cefadroxil susr 250mg/5ml ................................................... 9cefadroxil susr 500mg/5ml ................................................... 9cefazolin ...................................................................................... 9cefazolin sodium/dextrose ...................................................... 9cefazolin sodium inj 100gm, 10gm, 1gm, 1gm; 5%, 300gm, 500mg ........................................................................ 9cefdinir ........................................................................................ 9cefditoren pivoxil tabs 400mg .............................................. 9

cefepime ..................................................................................... 9cefepime/dextrose .................................................................... 9cefixime ....................................................................................... 9cefotaxime sodium inj 1gm .................................................... 9cefotaxime sodium inj 10gm, 2gm, 500mg ...................... 9cefotetan ..................................................................................... 9cefotetan/dextrose ................................................................... 9cefoxitin sodium ........................................................................ 9cefpodoxime proxetil susr ....................................................... 9cefpodoxime proxetil tabs 100mg ....................................... 9cefpodoxime proxetil tabs 200mg ....................................... 9cefprozil ...................................................................................... 9ceftazidime ................................................................................. 9ceftazidime/dextrose ............................................................... 9ceftriaxone/dextrose ................................................................ 9ceftriaxone in iso-osmotic dextrose ..................................... 9ceftriaxone sodium inj 2gm ................................................... 9ceftriaxone sodium inj 100gm, 10gm, 1gm, 250mg, 2gm, 500mg ............................................................................. 9cefuroxime axetil ....................................................................... 9cefuroxime sodium inj 1.5gm, 225gm, 7.5gm, 75gm ... 9cefuroxime sodium inj 750mg .............................................. 9celecoxib caps 100mg, 200mg, 50mg .............................. 2celecoxib caps 400mg ............................................................ 1CELLCEPT INTRAVENOUS ............................................66CELONTIN ........................................................................13cephalexin caps 250mg, 500mg ......................................... 9cephalexin caps 750mg........................................................10cephalexin susr ........................................................................10cephalexin tabs........................................................................10CEREZYME .......................................................................50CERVARIX .........................................................................68cetirizine hcl allergy childrens .............................................74cetirizine hcl chew, tabs .........................................................74cetirizine hcl childrens soln 5mg/5ml ...............................74cetirizine hcl hives relief childrens ......................................74CHANTIX CONTINUING MONTH PAK ......................... 6CHANTIX STARTING MONTH PAK ................................ 6CHANTIX TABS 0.5MG, 1MG ......................................... 6chateal .......................................................................................59childrens ibuprofen susp 100mg/5ml ................................ 2childrens loratadine ...............................................................74childs ibuprofen ........................................................................ 2chloramphenicol sodium succinate ..................................... 7chlorhexidine gluconate oral rinse .....................................48chloroquine phosphate tabs ................................................27chlorothiazide ..........................................................................45

95


chlorpheniramine maleate tbcr ..........................................74chlorpromazine hcl inj ...........................................................29chlorpromazine hcl tabs 10mg ..........................................29chlorpromazine hcl tabs 100mg, 200mg, 25mg, 50mg .29chlorthalidone tabs 25mg ...................................................45chlorthalidone tabs 50mg ...................................................45chlorzoxazone ..........................................................................78cholestyramine light ..............................................................46cholestyramine pack..............................................................46cholestyramine powd ............................................................46ciclodan .....................................................................................18ciclopirox gel, susp ..................................................................18ciclopirox nail lacquer ............................................................18ciclopirox olamine crea .........................................................18ciclopirox sham .......................................................................18cilostazol ...................................................................................39cimetidine hcl ..........................................................................52cimetidine tabs 200mg, 300mg, 800mg ........................52cimetidine tabs 400mg ........................................................52CINRYZE ...........................................................................65CIPRODEX ........................................................................73ciprofloxacin er ........................................................................11ciprofloxacin hcl soln 0.3% ..................................................71ciprofloxacin hcl tabs 100mg, 750mg .............................11ciprofloxacin hcl tabs 250mg, 500mg .............................11ciprofloxacin inj, otic soln, susr ............................................12ciprofloxacin i.v.-in d5w .........................................................11cisplatin .....................................................................................23citalopram hydrobromide soln............................................16citalopram hydrobromide tabs 10mg ...............................16citalopram hydrobromide tabs 20mg ...............................16citalopram hydrobromide tabs 40mg ...............................16CITRANATAL 90 DHA ....................................................83CITRANATAL ASSURE ....................................................83CITRANATAL B‑CALM ...................................................83CITRANATAL DHA ..........................................................83CITRANATAL RX TABS 120MG; 125MG; 400UNIT; 2MG; 30UNIT; 50MG; 1MG; 27MG; 20MG; 150MCG; 20MG; 3.4MG; 3MG; 25MG ........................................83citric acid/sodium citrate ......................................................79cladribine ..................................................................................23claravis ......................................................................................49clarithromycin susr ................................................................11clarithromycin tabs ................................................................11clearlax powd ...........................................................................53clemastine fumarate tabs 2.68mg ....................................74

clindacin etz pledgets ............................................................49clindacin-p ...............................................................................49clindamax .................................................................................49clindamycin/benzoyl peroxide gel 5%; 1% .......................49clindamycin/benzoyl peroxide gel 5%; 1.2% ...................49clindamycin hcl caps 75mg ................................................... 7clindamycin hcl caps 150mg, 300mg ................................ 7clindamycin palmitate hcl ...................................................... 7clindamycin phosphate add-vantage inj 900mg/6ml ... 7clindamycin phosphate crea 2% .......................................... 7clindamycin phosphate external soln 1% .........................49clindamycin phosphate foam 1% ......................................49clindamycin phosphate gel 1% ...........................................49clindamycin phosphate in d5w ............................................. 7clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, 9000mg/60ml, 900mg/6ml ...................... 7clindamycin phosphate lotn 1% .........................................49clindamycin phosphate swab 1% .......................................49clinisol sf 15% .........................................................................79clinpro 5000 ............................................................................48clobetasol propionate crea, gel, lotn, oint, sham ............55clobetasol propionate e ........................................................55clobetasol propionate emollient foam ..............................55clobetasol propionate foam 0.05% ...................................55clobetasol propionate liqd, soln ..........................................55clodan ........................................................................................55CLOLAR ............................................................................23clomipramine hcl caps ..........................................................17clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg .........13clonazepam odt tbdp 1mg ...................................................13clonazepam odt tbdp 2mg ...................................................13clonazepam tabs 0.5mg .......................................................13clonazepam tabs 1mg ...........................................................13clonazepam tabs 2mg ...........................................................13clonidine hcl ptwk ...................................................................39clonidine hcl tabs ....................................................................39clopidogrel tabs 75mg ..........................................................39clopidogrel tabs 300mg .......................................................39clorazepate dipotassium tabs 3.75mg, 7.5mg ...............35clorazepate dipotassium tabs 15mg .................................35clotrimazole/betamethasone dipropionate .....................18clotrimazole external crea, troc ..........................................19clotrimazole soln ....................................................................19clotrimazole vaginal crea 1% ..............................................19clozapine ...................................................................................31clozapine odt ...........................................................................31COARTEM ........................................................................27

96


codeine sulfate tabs ................................................................. 4colchicine caps, tabs ..............................................................20colestipol hcl gran, pack .......................................................46colestipol hcl tabs ...................................................................46colistimethate sodium ............................................................. 8colocort .....................................................................................55COMBIGAN .....................................................................70COMBIVENT RESPIMAT ................................................76COMETRIQ.......................................................................26COMPLERA ......................................................................32completenate ...........................................................................83compro ......................................................................................29COMVAX ...........................................................................68CONCEPT DHA ...............................................................83CONCEPT OB ..................................................................83constulose ................................................................................53COPAXONE INJ 20MG/ML ............................................48COPAXONE INJ 40MG/ML ............................................48CORLANOR .....................................................................44cormax scalp application ......................................................55cortisone acetate tabs ...........................................................55COSMEGEN .....................................................................23COTELLIC .........................................................................23CREON CPEP 15000UNIT; 3000UNIT; 9500UNIT, 180000UNIT; 36000UNIT; 114000UNIT .................50CREON CPEP 120000UNIT; 24000UNIT; 76000UNIT, 30000UNIT; 6000UNIT; 19000UNIT, 60000UNIT; 12000UNIT; 38000UNIT ..............................................50CRIXIVAN .........................................................................34cromolyn sodium aers 5.2mg/act ......................................77cromolyn sodium conc 100mg/5ml .................................51cromolyn sodium nebu 20mg/2ml ...................................77cromolyn sodium soln 4% ....................................................72cryselle-28 ...............................................................................59CUBICIN ............................................................................. 8CUPRIMINE ......................................................................78cyclafem 1/35 .........................................................................59cyclafem 7/7/7 .......................................................................59cyclobenzaprine hcl tabs ......................................................78cyclophosphamide caps .......................................................21cyclophosphamide inj ...........................................................21cycloserine ...............................................................................21cyclosporine caps ...................................................................66cyclosporine inj .......................................................................66cyclosporine modified caps 50mg .....................................66cyclosporine modified caps 100mg, 25mg .....................66cyclosporine modified soln ..................................................66

cyproheptadine hcl tabs .......................................................74CYRAMZA ........................................................................27cyred ..........................................................................................59CYSTADANE .....................................................................50CYSTAGON ......................................................................51CYSTARAN .......................................................................71cytarabine aqueous ...............................................................23dacarbazine .............................................................................23DALIRESP .........................................................................77DALVANCE ......................................................................... 8danazol caps ............................................................................58dantrolene sodium caps .......................................................31dapsone tabs ...........................................................................21DAPTACEL ........................................................................68DARAPRIM .......................................................................27darifenacin hydrobromide er ...............................................54DARZALEX .......................................................................27dasetta 1/35 ............................................................................59dasetta 7/7/7 ..........................................................................59daunorubicin hcl .....................................................................23dayhist allergy 12 hour relief ...............................................74daysee .......................................................................................59deblitane ...................................................................................63decitabine .................................................................................23deltasone ..................................................................................55delyla .........................................................................................59DELZICOL .........................................................................69DENAVIR ...........................................................................34dentagel ....................................................................................48DEPEN TITRATABS .........................................................78DEPOCYT .........................................................................22DEPO‑ESTRADIOL .........................................................59DEPO‑PROVERA ............................................................63DESCOVY ..........................................................................33desipramine hcl tabs 10mg, 75mg ...................................17desipramine hcl tabs 100mg, 150mg, 25mg, 50mg ...17desmopressin acetate inj, tabs ............................................57desmopressin acetate nasal soln 0.01% ..........................57desogestrel/ethinyl estradiol ...............................................59desonide crea, lotn .................................................................55desonide oint ...........................................................................55desoximetasone crea 0.05% ...............................................55desoximetasone crea 0.25% ...............................................55desoximetasone gel ................................................................56desoximetasone oint ..............................................................56desvenlafaxine er tb24 50mg .............................................16desvenlafaxine er tb24 100mg, 50mg .............................16

97


dexamethasone elix................................................................56DEXAMETHASONE INTENSOL ....................................56dexamethasone sodium phosphate inj 10mg/ml, 20mg/5ml, 4mg/ml ..............................................................56dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml ..........................................................................56dexamethasone sodium phosphate ophthalmic soln 0.1% ..........................................................................................72dexamethasone soln, tabs ....................................................56dexmethylphenidate hcl ........................................................47dexrazoxane .............................................................................23dextroamphetamine sulfate soln ........................................47dextroamphetamine sulfate tabs........................................47dextrose 2.5%/sodium chloride 0.45% ............................80dextrose 5% .............................................................................80dextrose 5% /electrolyte #48 viaflex ................................79dextrose 5%/lactated ringers ..............................................80dextrose 5%/nacl 0.2% .........................................................80dextrose 5%/nacl 0.3% .........................................................80dextrose 5%/nacl 0.9% .........................................................80dextrose 5%/nacl 0.33% ......................................................80dextrose 5%/nacl 0.45% ......................................................80dextrose 5%/nacl 0.225% ...................................................80dextrose 5%/potassium chloride 0.15% ..........................80dextrose 10% ..........................................................................80dextrose 10% flex container ................................................80dextrose 10%/nacl 0.2% ......................................................80dextrose 10%/nacl 0.45% ..................................................79dextrose 20% ..........................................................................80dextrose 25% ..........................................................................80dextrose 30% ..........................................................................80dextrose 40% ..........................................................................80dextrose 50% ..........................................................................80dextrose 70% ..........................................................................80diazepam gel 10mg, 2.5mg, 20mg ...................................13diazepam inj 5mg/ml ............................................................35diazepam intensol ..................................................................35diazepam oral soln 1mg/ml .................................................35diazepam tabs 10mg, 2mg, 5mg .......................................35diclofenac potassium .............................................................. 2diclofenac sodium dr ............................................................... 2diclofenac sodium er ............................................................... 2diclofenac sodium gel ............................................................49dicloxacillin sodium ................................................................11dicyclomine hcl caps, soln, tabs ..........................................51didanosine cpdr 125mg .......................................................33didanosine cpdr 200mg, 250mg, 400mg ......................33

DIFICID ..............................................................................11diflorasone diacetate .............................................................56diflunisal tabs ............................................................................. 2digitek ........................................................................................44digoxin inj, oral soln ...............................................................44digoxin tabs 125mcg .............................................................44digoxin tabs 250mcg .............................................................44digox tabs 125mcg ................................................................44digox tabs 250mcg ................................................................44dihydroergotamine mesylate inj .........................................20DILANTIN CAPS 30MG .................................................14diltiazem cd ..............................................................................43diltiazem hcl cd .......................................................................43diltiazem hcl er cp12 .............................................................43diltiazem hcl er cp24 120mg, 180mg, 240mg, 300mg, 360mg, 420mg ......................................................................43diltiazem hcl er cp24 180mg, 360mg .............................43diltiazem hcl er tb24 ..............................................................43diltiazem hcl inj 100mg, 125mg/25ml, 25mg/5ml, 50mg/10ml .............................................................................43diltiazem hcl tabs 30mg, 60mg ..........................................43diltiazem hcl tabs 120mg, 90mg .......................................43dilt-xr .........................................................................................43diphenatol ................................................................................51diphenhydramine hcl inj .......................................................74diphenoxylate/atropine liqd .................................................51diphenoxylate/atropine tabs ................................................51diphtheria/tetanus toxoids adsorbed pediatric ...............68disopyramide phosphate caps 100mg .............................41disopyramide phosphate caps 150mg .............................41disulfiram tabs ........................................................................... 6divalproex sodium ..................................................................13divalproex sodium dr .............................................................13divalproex sodium er ..............................................................13DOCEFREZ INJ 20MG ....................................................23docetaxel inj 140mg/7ml, 160mg/16ml, 160mg/8ml, 200mg/20ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml ................................................................................23dofetilide ...................................................................................41donepezil hcl tabs 10mg ......................................................15donepezil hcl tabs 23mg, 5mg ...........................................15donepezil hcl tbdp ..................................................................15dorzolamide hcl ......................................................................73dorzolamide hcl/timolol maleate .......................................73doxazosin ..................................................................................39doxazosin mesylate tabs 1mg, 2mg...................................40doxazosin mesylate tabs 8mg .............................................39

98


doxepin hcl caps 100mg, 10mg, 25mg, 50mg, 75mg 17doxepin hcl caps 150mg ......................................................17doxepin hcl conc .....................................................................17doxepin hydrochloride ...........................................................49doxercalciferol caps................................................................69doxorubicin hcl ........................................................................23doxorubicin hcl liposome ......................................................23doxy 100 ...................................................................................12doxycycline caps 75mg .........................................................12doxycycline caps 150mg ......................................................12doxycycline hyclate caps 50mg ..........................................12doxycycline hyclate caps 100mg ........................................12doxycycline hyclate dr ............................................................12doxycycline hyclate inj ...........................................................12doxycycline hyclate tabs 20mg ...........................................12doxycycline hyclate tabs 100mg ........................................12doxycycline monohydrate caps 50mg ..............................12doxycycline monohydrate caps 100mg ...........................12doxycycline monohydrate tabs 50mg, 75mg .................12doxycycline monohydrate tabs 100mg, 150mg ............12doxycycline susr ......................................................................12dronabinol ................................................................................18drospirenone/ethinyl estradiol tabs 3mg; 0.02mg ........59drospirenone/ethinyl estradiol tabs 3mg; 0.03mg ........59DROXIA .............................................................................22dual action complete .............................................................52DUET DHA 400 ...............................................................83DUET DHA BALANCED MISC 120MG; 2800UNIT; 215MG; 640UNIT; 55MG; 1.8MG; 12MCG; 0; 0; 0; 1MG; 25MG; 0; 25MG; 20MG; 267MG; 0; 210MCG; 50MG; 2MG; 0; 65MCG; 1.5MG; 15MG; 25MG ......83duloxetine hcl cpep 20mg, 60mg ......................................16duloxetine hcl cpep 30mg ....................................................16duloxetine hcl cpep 40mg ....................................................16duramorph ................................................................................. 4DUREZOL .........................................................................72dutasteride ...............................................................................54dutasteride/tamsulosin hydrochloride ..............................54econazole nitrate crea ...........................................................19EDARBI..............................................................................40EDARBYCLOR ..................................................................40EDURANT .........................................................................32EFFIENT ............................................................................39EGRIFTA INJ 1MG ............................................................58EGRIFTA INJ 2MG ............................................................58ELIDEL ...............................................................................49elinest ........................................................................................59

ELITEK ...............................................................................23elite-ob ......................................................................................83ELLA ..................................................................................63EMCYT ..............................................................................22EMEND CAPS 0, 125MG, 80MG .................................18EMEND CAPS 40MG......................................................18emoquette ................................................................................59EMPLICITI .........................................................................27EMSAM .............................................................................16EMTRIVA ...........................................................................33enalapril maleate/hydrochlorothiazide ............................40enalapril maleate tabs ...........................................................40ENBRACE HR ...................................................................83ENBREL INJ 25MG ..........................................................66ENBREL INJ 25MG/0.5ML ............................................66ENBREL INJ 50MG/ML ..................................................66ENBREL SURECLICK .......................................................66endocet tabs 325mg; 2.5mg, 325mg; 5mg ..................... 4endocet tabs 325mg; 10mg, 325mg; 7.5mg .................. 4endodan ...................................................................................... 4ENGERIX‑B ......................................................................68enoxaparin sodium.................................................................38enpresse-28 ............................................................................59enskyce ......................................................................................59entacapone ..............................................................................28entecavir ...................................................................................32ENTRESTO .......................................................................40enulose ......................................................................................53ENVARSUS XR .................................................................66epinastine hcl ..........................................................................72EPIPEN 2‑PAK .................................................................76EPIPEN‑JR 2‑PAK ............................................................76epirubicin hcl inj 200mg/100ml, 50mg/25ml ..............23epitol ..........................................................................................14EPIVIR HBV SOLN ...........................................................32eplerenone ...............................................................................45epoprostenol sodium .............................................................77eprosartan mesylate ..............................................................40EPZICOM ..........................................................................33EQUETRO .........................................................................35ERAXIS ..............................................................................19ERBITUX ............................................................................23ergoloid mesylates tabs ........................................................15ERIVEDGE .........................................................................26errin............................................................................................63ERWINAZE .......................................................................23ery ...............................................................................................49

99


ERYTHROCIN LACTOBIONATE ....................................11erythromycin base .................................................................11erythromycin/benzoyl peroxide ..........................................49erythromycin cpep 250mg ..................................................11erythromycin ethylsuccinate tabs ......................................11erythromycin gel 2% .............................................................49erythromycin oint 5mg/gm .................................................71erythromycin pads 2% ..........................................................49erythromycin soln 2% ...........................................................49erythromycin stearate tabs ..................................................11ESBRIET ............................................................................77ESCAVITE D......................................................................84ESCAVITE LQ ...................................................................84escitalopram oxalate soln .....................................................16escitalopram oxalate tabs 10mg, 5mg .............................16escitalopram oxalate tabs 20mg ........................................16esgic caps ................................................................................... 1esomeprazole magnesium ...................................................53esomeprazole sodium ...........................................................53estarylla .....................................................................................59ESTRACE CREA ...............................................................59estradiol/norethindrone acetate ........................................59estradiol pttw ...........................................................................59estradiol ptwk ..........................................................................59estradiol tabs 0.5mg, 1mg ...................................................59estradiol tabs 2mg .................................................................59ethambutol hcl ........................................................................21ethosuximide ...........................................................................13etidronate disodium ...............................................................69etodolac caps ............................................................................. 2etodolac er tb24 400mg, 500mg ....................................... 2etodolac er tb24 600mg ........................................................ 2etodolac tabs ............................................................................. 2etoposide inj .............................................................................25EVOTAZ .............................................................................34EVZIO .................................................................................. 6exemestane ..............................................................................25EXJADE ..............................................................................78EXTRA‑VIRT PLUS DHA ................................................84FABRAZYME.....................................................................51falmina ......................................................................................60famciclovir tabs 125mg, 250mg .......................................34famciclovir tabs 500mg .......................................................35famotidine inj 200mg/20ml, 20mg/2ml, 40mg/4ml .52famotidine premixed..............................................................52famotidine susr 40mg/5ml .................................................52famotidine tabs 20mg, 40mg .............................................52

FANAPT TABS 10MG .....................................................30FANAPT TABS 12MG, 1MG, 2MG, 4MG, 6MG, 8MG ...30FANAPT TITRATION PACK ............................................30FARESTON........................................................................22FARYDAK ..........................................................................23FASLODEX ........................................................................23FAZACLO TBDP 12.5MG, 150MG, 200MG ..............31felbamate .................................................................................14felodipine er tb24 2.5mg, 5mg ..........................................43felodipine er tb24 10mg ......................................................43fenofibrate caps 130mg, 43mg .........................................45fenofibrate caps 150mg, 50mg .........................................45fenofibrate micronized ..........................................................45fenofibrate tabs 120mg, 40mg ..........................................45fenofibrate tabs 145mg, 160mg, 48mg, 54mg ............45fenofibric acid ..........................................................................45fenofibric acid dr .....................................................................45fentanyl citrate oral transmucosal ....................................... 4fentanyl pt72 25mcg/hr, 50mcg/hr, 75mcg/hr ............... 3fentanyl pt72 100mcg/hr, 12mcg/hr, 37.5mcg/hr, 62.5mcg/hr, 87.5mcg/hr ....................................................... 3FERRIPROX SOLN 100MG/ML.....................................70FERRIPROX TABS 500MG .............................................78FETZIMA ...........................................................................16FETZIMA TITRATION PACK ...........................................16finasteride tabs 5mg ..............................................................54FIRAZYR ............................................................................66FIRMAGON ......................................................................65FLEBOGAMMA DIF ........................................................67flecainide acetate tabs 50mg ..............................................41flecainide acetate tabs 100mg, 150mg ...........................41floriva chew 75mg; 0; 40mcg; 600unit; 1mg; 6mcg; 262mcg; 0; 15mg; 1.8mg; 1.5mg; 0.25mg; 1.3mg; 20unit; 2000unit; 5mg ........................................................84FLORIVA LIQD 0.25MG/ML; 400UNIT/ML ...............80FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST .................................................................................74FLOVENT DISKUS AEPB 250MCG/BLIST ..................74FLOVENT HFA AERO 44MCG/ACT .............................74FLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT 74fluconazole in dextrose ..........................................................19fluconazole in nacl inj 100mg/50ml; 0.9%, 400mg/200ml; 0.9% ...........................................................19fluconazole susr, tabs .............................................................19flucytosine ................................................................................19fludarabine phosphate ..........................................................23

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fludrocortisone acetate tabs ................................................56flunisolide .................................................................................74fluocinolone acetonide body ...............................................49fluocinolone acetonide crea 0.01%, 0.025% .................56fluocinolone acetonide oil 0.01% ......................................73fluocinolone acetonide oint 0.025% .................................56fluocinolone acetonide scalp ...............................................49fluocinolone acetonide soln 0.01% ...................................56fluocinonide crea 0.1% .........................................................56fluocinonide crea 0.05% ......................................................56fluocinonide-e .........................................................................56fluocinonide gel .......................................................................56fluocinonide oint, soln ...........................................................56fluor-a-day soln ......................................................................80fluoride chew 0.25mg ...........................................................80fluoride chew 1.1mg, 2.2mg ...............................................80fluoridex daily defense ...........................................................48fluoritab chew 0.5mg, 1mg .................................................80fluoritab soln ............................................................................80fluorometholone .....................................................................72fluorouracil crea 0.5% ...........................................................49fluorouracil crea 5% ..............................................................49fluorouracil external soln 2%, 5% ......................................49fluorouracil inj 2.5gm/50ml ................................................23fluoxetine ..................................................................................16fluoxetine dr .............................................................................16fluoxetine hcl caps, soln ........................................................16fluoxetine hcl tabs 10mg, 20mg .........................................16fluoxetine hcl tabs 60mg ......................................................16fluphenazine decanoate inj ..................................................29fluphenazine hcl conc, inj .....................................................29fluphenazine hcl elix ...............................................................29fluphenazine hcl tabs 2.5mg ...............................................29fluphenazine hcl tabs 10mg, 1mg, 5mg ..........................29FLURA‑DROPS SOLN 0.25MG/DROP .......................80flurbiprofen sodium ...............................................................72flurbiprofen tabs 50mg........................................................... 2flurbiprofen tabs 100mg ........................................................ 2flutamide ...................................................................................22fluticasone propionate crea 0.05% ...................................56fluticasone propionate lotn 0.05% ....................................56fluticasone propionate oint 0.005% .................................56fluticasone propionate susp 50mcg/act ...........................74fluvastatin caps 20mg ...........................................................46fluvastatin caps 40mg ...........................................................45fluvastatin sodium er .............................................................45fluvoxamine maleate tabs 25mg ........................................16

fluvoxamine maleate tabs 100mg, 50mg ........................16FOCALGIN 90 DHA ........................................................84FOCALGIN CA .................................................................84FOLCAL DHA ...................................................................84FOLCAPS OMEGA 3 .......................................................84FOLET ONE ......................................................................84FOLIVANE‑OB .................................................................84FOLIVANE‑PRX DHA NF ................................................84FOLOTYN ..........................................................................23fomepizole ................................................................................78fondaparinux sodium ............................................................38FORADIL AEROLIZER .....................................................76FORTEO ............................................................................69fosinopril sodium/hydrochlorothiazide ............................40fosinopril sodium tabs 10mg ..............................................40fosinopril sodium tabs 20mg, 40mg .................................40fosphenytoin sodium .............................................................14FOSRENOL CHEW ..........................................................55FOSRENOL PACK 750MG .............................................55FOSRENOL PACK 1000MG...........................................55FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML 80furosemide inj 10mg/ml .......................................................44furosemide oral soln ..............................................................44furosemide tabs ......................................................................44FUSILEV ............................................................................23FUZEON ............................................................................34fyavolv .......................................................................................60FYCOMPA SUSP ..............................................................13FYCOMPA TABS 2MG ....................................................13FYCOMPA TABS 10MG, 12MG, 4MG, 6MG, 8MG ...13gabapentin caps, soln, tabs ..................................................13GABITRIL TABS 12MG, 16MG .....................................13galantamine hydrobromide cp24 ......................................15galantamine hydrobromide soln ........................................15galantamine hydrobromide tabs ........................................15GAMASTAN S/D .............................................................67GAMMAGARD LIQUID ..................................................67GAMMAGARD S/D IGA LESS THAN 1MCG/ML ......67GAMMAKED ....................................................................67GAMMAPLEX ..................................................................67GAMUNEX‑C ...................................................................67

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ganciclovir inj ...........................................................................32GARDASIL ........................................................................68GARDASIL 9 .....................................................................68gatifloxacin ...............................................................................71GATTEX .............................................................................51GAUZE PADS 2”X2” .......................................................70gavilax powd ............................................................................53gavilyte-c ..................................................................................53gavilyte-g ..................................................................................53gavilyte-h ..................................................................................51gavilyte-n/flavor pack ...........................................................53GAZYVA ............................................................................27gemcitabine .............................................................................24gemcitabine hcl .......................................................................24gemfibrozil tabs.......................................................................45generlac ....................................................................................53gengraf caps 100mg, 25mg ...............................................66gengraf soln .............................................................................66gentak ........................................................................................71gentamicin sulfate/0.9% sodium chloride inj 0.8mg/ml; 0.9% ............................................................................................ 7gentamicin sulfate/0.9% sodium chloride inj 0.9mg/ml; 0.9%, 1.2mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9%, 2mg/ml; 0.9% .................................. 7gentamicin sulfate crea 0.1% ..............................................49gentamicin sulfate external oint 0.1% ..............................49gentamicin sulfate inj 10mg/ml ........................................... 7gentamicin sulfate inj 40mg/ml ........................................... 7gentamicin sulfate ophthalmic oint 0.3% ........................71gentamicin sulfate ophthalmic soln 0.3% .......................71gentamicin sulfate pediatric .................................................. 7GENVOYA .........................................................................32GEODON INJ ....................................................................30gianvi .........................................................................................60gildagia......................................................................................60gildess 1.5/30 .........................................................................60gildess 1/20 .............................................................................60gildess 24 fe .............................................................................60gildess fe 1.5/30 .....................................................................60gildess fe 1/20 ........................................................................60GILENYA ...........................................................................48GILOTRIF ...........................................................................26glatopa ......................................................................................48GLEEVEC TABS 100MG .................................................26GLEEVEC TABS 400MG .................................................26GLEOSTINE CAPS 5MG .................................................21glimepiride ...............................................................................36

glipizide er ................................................................................36glipizide/metformin hcl tabs 2.5mg; 250mg ..................36glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg ......................................................................................36glipizide tabs ............................................................................36glipizide xl tb24 2.5mg, 5mg ..............................................36glipizide xl tb24 10mg ..........................................................36GLUCAGEN HYPOKIT ....................................................37GLUCAGON EMERGENCY KIT .....................................37glyburide/metformin hcl .......................................................36glyburide micronized tabs 1.5mg.......................................36glyburide micronized tabs 3mg, 6mg ...............................36glyburide tabs 1.25mg ..........................................................36glyburide tabs 2.5mg, 5mg .................................................36glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml ....51glycopyrrolate inj 4mg/20ml ..............................................51glycopyrrolate tabs .................................................................51glydo ............................................................................................ 5gnp 8 hour pain reliever .......................................................... 1gnp acid control 150 maximum strength ........................52gnp acid reducer maximum strength ................................52gnp acid reducer tabs 10mg................................................52gnp all day allergy childrens soln 5mg/5ml .....................74gnp all day allergy childrens syrp........................................74gnp all day pain relief............................................................... 2gnp allergy relief for kids tbdp .............................................75gnp allergy relief tbdp ............................................................75gnp arthritis pain relief ............................................................ 1gnp childrens ibuprofen .......................................................... 2gnp clearlax ..............................................................................53gnp dayhist allergy .................................................................75gnp ibuprofen ............................................................................ 2gnp lice treatment liqd ..........................................................28gnp loperamide hcl ................................................................51gnp loratadine childrens .......................................................75gnp loratadine tabs ................................................................75gnp miconazole 3 ...................................................................19gnp nicotine polacrilex gum 2mg ......................................... 6gnp terbinafine hydrochloride.............................................19goodsense all day allergy ......................................................75granisetron hcl tabs ...............................................................18griseofulvin microsize susp ..................................................19griseofulvin microsize tabs ...................................................19griseofulvin ultramicrosize ...................................................19guanfacine er ...........................................................................47guanidine hcl ...........................................................................20HALAVEN .........................................................................24

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halobetasol propionate crea ................................................56halobetasol propionate oint ................................................56haloperidol conc .....................................................................29haloperidol decanoate ..........................................................29haloperidol lactate .................................................................29haloperidol tabs 0.5mg, 1mg, 20mg, 5mg .....................29haloperidol tabs 10mg, 2mg...............................................29HARVONI .........................................................................32HAVRIX .............................................................................68healthylax .................................................................................53heartburn relief 150 maximum strength .........................52heartburn relief maximum strength ..................................52heartburn relief tabs 10mg, 200mg .................................52heather ......................................................................................63hecoria ......................................................................................66HEMENATAL OB .............................................................84HEMENATAL OB + DHA ................................................84heparin sodium/d5w .............................................................38heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml .............38heparin sodium/nacl 0.9% ..................................................38heparin sodium/nacl 0.45% ................................................38heparin sodium/sodium chloride 0.9% ............................38heparin sodium/sodium chloride 0.9% premix ..............38hepatamine ..............................................................................80HERCEPTIN ......................................................................24HETLIOZ ...........................................................................78HEXALEN .........................................................................21HIBERIX .............................................................................68hm all day allergy ....................................................................75hm allergy relief tbdp .............................................................75hm arthritis pain relief ............................................................. 1hm complete dual action ......................................................52hm ibuprofen infants ............................................................... 2hm nicotine polacrilex gum 2mg .......................................... 6hm nicotine polacrilex lozg ..................................................... 6H.P. ACTHAR ....................................................................58HUMALOG .......................................................................37HUMALOG KWIKPEN ....................................................37HUMALOG MIX 50/50 ..................................................37HUMALOG MIX 50/50 KWIKPEN ................................37HUMALOG MIX 75/25 ..................................................37HUMALOG MIX 75/25 KWIKPEN ................................37HUMIRA INJ 10MG/0.2ML, 20MG/0.4ML ................66HUMIRA INJ 40MG/0.8ML ...........................................66HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK ..................................................................................66

HUMIRA PEN ...................................................................66HUMIRA PEN‑CROHNS DISEASESTARTER ...............66HUMIRA PEN‑PSORIASIS STARTER ...........................66HUMULIN 70/30 ............................................................37HUMULIN 70/30 KWIKPEN .........................................37HUMULIN N .....................................................................37HUMULIN N KWIKPEN ..................................................37HUMULIN R .....................................................................37HUMULIN R U‑500 (CONCENTRATED) .....................37HUMULIN R U‑500 KWIKPEN .....................................37hydralazine hcl inj, tabs .........................................................47hydrochlorothiazide caps .....................................................45hydrochlorothiazide tabs 12.5mg .....................................45hydrochlorothiazide tabs 25mg, 50mg ...........................45hydrocodone/acetaminophen tabs 325mg; 5mg, 325mg; 7.5mg ......................................................................... 4hydrocodone/acetaminophen tabs 325mg; 10mg ......... 4hydrocodone bitartrate/acetaminophen soln 325mg/15ml; 7.5mg/15ml ................................................. 4hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg ................................. 4hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg .......................................................................................... 4hydrocodone/ibuprofen tabs 2.5mg; 200mg, 7.5mg; 200mg ........................................................................................ 4hydrocodone/ibuprofen tabs 10mg; 200mg, 5mg; 200mg ........................................................................................ 4hydrocortisone/acetic acid ...................................................73hydrocortisone butyrate crea, oint, soln ...........................56hydrocortisone butyrate (lipophilic) ...................................56hydrocortisone crea 1%, 2.5% ...........................................56hydrocortisone enem, tabs ..................................................56hydrocortisone in absorbase ...............................................56hydrocortisone lotn 2.5%.....................................................56hydrocortisone oint 1% ........................................................56hydrocortisone oint 2.5%.....................................................56hydrocortisone valerate crea ...............................................56hydrocortisone valerate oint ................................................56hydromorphone hcl inj 4mg/ml ........................................... 4hydromorphone hcl inj 10mg/ml, 1mg/ml, 2mg/ml, 50mg/5ml .................................................................................. 4hydromorphone hcl liqd ......................................................... 4hydromorphone hcl tabs ........................................................ 4hydroxychloroquine sulfate tabs .........................................28hydroxyprogesterone caproate inj .....................................63hydroxyurea caps ....................................................................22hydroxyzine hcl inj, syrp ........................................................75

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hydroxyzine hcl tabs ...............................................................75hydroxyzine pamoate caps 25mg, 50mg ........................75hydroxyzine pamoate caps 100mg ...................................75IBRANCE ..........................................................................24ibu-200 ...................................................................................... 2ibudone tabs 5mg; 200mg .................................................... 4ibuprofen caps........................................................................... 2ibuprofen childrens .................................................................. 2ibuprofen junior strength ....................................................... 2ibuprofen susp 100mg/5ml .................................................. 2ibuprofen susp 100mg/5ml .................................................. 2ibuprofen tabs 200mg ............................................................ 2ibuprofen tabs 400mg, 600mg, 800mg ........................... 2ICLUSIG TABS 15MG .....................................................26ICLUSIG TABS 45MG .....................................................26idarubicin hcl ...........................................................................24ifosfamide .................................................................................24ILARIS ................................................................................67ILEVRO ..............................................................................72ilotycin .......................................................................................71imatinib mesylate tabs 100mg ...........................................26imatinib mesylate tabs 400mg ...........................................26IMBRUVICA ......................................................................26imipenem/cilastatin ...............................................................10imipramine hcl tabs ...............................................................17imiquimod crea .......................................................................49IMOVAX RABIES (H.D.C.V.) ............................................68inatal advance .........................................................................84inatal ultra ................................................................................84INCRELEX .........................................................................58INCRUSE ELLIPTA ...........................................................76indapamide ..............................................................................45INFANRIX ..........................................................................68infants ibuprofen ...................................................................... 2INLYTA TABS 1MG ..........................................................26INLYTA TABS 5MG ..........................................................26INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2” 70INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16” 70INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2” .70INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16” ..70INSUPEN 33GX4MM .....................................................70INTELENCE TABS 25MG ...............................................32INTELENCE TABS 100MG, 200MG ............................33intralipid inj 20gm/100ml ...................................................81INTRALIPID INJ 30GM/100ML ....................................81INTRON A INJ 10MU/ML, 18MU, 50MU, 6000000UNIT/ML .........................................................24

INTRON A W/DILUENT ..................................................24introvale ....................................................................................60INVANZ INJ 1GM .............................................................10INVEGA SUSTENNA .......................................................30INVEGA TRINZA ..............................................................30INVIRASE ..........................................................................34INVOKAMET ....................................................................36INVOKANA TABS 100MG .............................................36INVOKANA TABS 300MG .............................................36IPOL INACTIVATED IPV .................................................68ipratropium bromide/albuterol sulfate .............................76ipratropium bromide inhalation soln ................................76ipratropium bromide nasal soln .........................................76irbesartan .................................................................................40irbesartan/hydrochlorothiazide ..........................................40IRESSA ..............................................................................26irinotecan .................................................................................24ISENTRESS CHEW ..........................................................32ISENTRESS PACK ............................................................32ISENTRESS TABS .............................................................32isoniazid inj...............................................................................21isoniazid syrp ...........................................................................21isoniazid tabs 100mg ............................................................21isoniazid tabs 300mg ............................................................21ISOPROPYL ALCOHOL WIPES ....................................... 8isosorbide dinitrate er ............................................................46isosorbide dinitrate tabs .......................................................46isosorbide mononitrate er ....................................................46isosorbide mononitrate tabs 10mg ...................................46isosorbide mononitrate tabs 20mg ...................................46isotonic gentamicin inj 0.8mg/ml; 0.9% ............................ 7isradipine ..................................................................................43ISTODAX ...........................................................................24itraconazole caps ....................................................................19ivermectin tabs ........................................................................27IXEMPRA KIT ...................................................................24IXIARO ..............................................................................68JAKAFI ...............................................................................26jantoven tabs 1mg, 2mg, 3mg, 4mg, 6mg, 7.5mg .......38jantoven tabs 10mg, 2.5mg, 5mg .....................................38JANUMET .........................................................................36JANUMET XR TB24 1000MG; 50MG .........................36JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG 36JANUVIA TABS 50MG ....................................................36JANUVIA TABS 100MG, 25MG ....................................36jencycla .....................................................................................63

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JENTADUETO ...................................................................36JENTADUETO XR .............................................................36JEVTANA ...........................................................................24jinteli ..........................................................................................60jolessa ........................................................................................60jolivette ......................................................................................63juleber ........................................................................................60junel 1.5/30 .............................................................................60junel 1/20 .................................................................................60junel fe 1.5/30 ........................................................................60junel fe 1/20 ............................................................................60junel fe 24.................................................................................60KABIVEN ...........................................................................81KADCYLA .........................................................................24kaitlib fe .....................................................................................60KALETRA SOLN ..............................................................34KALETRA TABS 100MG; 25MG ...................................34KALETRA TABS 200MG; 50MG ...................................34KALYDECO PACK .............................................................76KALYDECO TABS .............................................................76kariva .........................................................................................60kcl 0.3%/d5w/lr iv lac ring ....................................................81kcl 0.3%/d5w/nacl 0.9% ......................................................81kcl 0.3%/d5w/nacl 0.45% ....................................................81kcl 0.15%/d5w/lr ....................................................................81kcl 0.15%/d5w/nacl 0.2% ....................................................81kcl 0.15%/d5w/nacl 0.9% ....................................................81kcl 0.15%/d5w/nacl 0.45% .................................................81kcl 0.15%/d5w/nacl 0.225% ..............................................81kcl 0.075%/d5w/nacl 0.45% ..............................................81kelnor 1/35 ..............................................................................60ketoconazole crea, sham ......................................................19ketoconazole tabs ...................................................................19ketoprofen caps ........................................................................ 2ketoprofen er ............................................................................. 2ketorolac tromethamine .......................................................72KEYTRUDA .......................................................................27kimidess ....................................................................................60KINRIX ...............................................................................68kionex ........................................................................................78klor-con ....................................................................................81klor-con 8 .................................................................................81klor-con 10 ..............................................................................81KLOR‑CON 25.................................................................81klor-con/ef ...............................................................................81klor-con m10 ..........................................................................81KLOR‑CON M15 .............................................................81

klor-con m20 ..........................................................................81klor-con sprinkle .....................................................................81KORLYM ............................................................................36k-sol ...........................................................................................81kurvelo .......................................................................................60KUVAN ..............................................................................51KYNAMRO ........................................................................46labetalol hcl inj, tabs ..............................................................42lactated ringers dextrose 5% viaflex ..................................81lactated ringers viaflex ..........................................................81lactulose soln 10gm/15ml ..................................................53LAMISIL AT .......................................................................19lamivudine soln 10mg/ml ....................................................33lamivudine tabs 100mg .......................................................32lamivudine tabs 150mg, 300mg .......................................33lamivudine/zidovudine ..........................................................33lamotrigine chew, tabs ..........................................................14lamotrigine titration ..............................................................14LANTUS ............................................................................37LANTUS SOLOSTAR .......................................................37larin 1.5/30 .............................................................................60larin 1/20 .................................................................................60larin 24 fe .................................................................................60larin fe 1.5/30 .........................................................................60larin fe 1/20 .............................................................................60latanoprost ...............................................................................70LATUDA TABS 40MG, 80MG .......................................30LATUDA TABS 120MG, 20MG, 60MG .......................30layolis fe ....................................................................................60leena ..........................................................................................60leflunomide ..............................................................................67LENVIMA 8 MG DAILY DOSE ........................................26LENVIMA 10 MG DAILY DOSE .....................................26LENVIMA 14 MG DAILY DOSE .....................................26LENVIMA 18 MG DAILY DOSE .....................................26LENVIMA 20 MG DAILY DOSE .....................................26LENVIMA 24 MG DAILY DOSE .....................................26lessina ........................................................................................60LETAIRIS ...........................................................................77letrozole ....................................................................................25leucovorin calcium inj ............................................................24leucovorin calcium tabs 5mg ..............................................24leucovorin calcium tabs 10mg, 15mg, 25mg ................24LEUKERAN .......................................................................21LEUKINE INJ 250MCG....................................................39leuprolide acetate inj..............................................................65levalbuterol hcl nebu .............................................................76

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levalbuterol nebu ....................................................................76LEVEMIR ...........................................................................37LEVEMIR FLEXTOUCH ...................................................37levetiracetam ...........................................................................13levobunolol hcl ........................................................................73levocarnitine ............................................................................78levocetirizine dihydrochloride soln ....................................75levocetirizine dihydrochloride tabs ....................................75levofloxacin in d5w .................................................................12levofloxacin inj 25mg/ml ......................................................12levofloxacin ophthalmic soln 0.5% ....................................71levofloxacin oral soln 25mg/ml ..........................................12levofloxacin tabs 250mg, 500mg, 750mg .....................12levoleucovorin calcium..........................................................24levoleucovorin inj 250mg/25ml ........................................24levonest .....................................................................................60levonorgestrel ..........................................................................63levonorgestrel and ethinyl estradiol tabs 0; 0 .................60levonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg 61levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg 61levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg ....................................................................61levora 0.15/30-28 ................................................................61levothyroxine sodium inj .......................................................64levothyroxine sodium tabs 100mcg, 112mcg, 125mcg, 150mcg, 25mcg, 50mcg, 75mcg, 88mcg......................64levothyroxine sodium tabs 137mcg, 175mcg, 200mcg, 300mcg ....................................................................................64levoxyl tabs 100mcg, 112mcg, 150mcg, 50mcg, 75mcg, 88mcg .......................................................................................64levoxyl tabs 125mcg, 137mcg, 175mcg, 200mcg, 25mcg .......................................................................................64LEXIVA ..............................................................................34LIALDA ..............................................................................69lidocaine hcl external soln 4% ............................................... 6lidocaine hcl gel 2% ................................................................. 6lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4% ......................... 6lidocaine hcl inj 10mg/ml, 20mg/ml .................................41lidocaine hcl jelly gel 2% ......................................................... 5lidocaine hcl mouth/throat soln 4% .................................... 6lidocaine oint ............................................................................. 6lidocaine/prilocaine crea ........................................................ 6lidocaine/prilocaine kit ............................................................ 6lidocaine ptch ............................................................................ 6lidocaine viscous ....................................................................... 6lindane lotn ..............................................................................28

lindane sham ...........................................................................28linezolid inj .................................................................................. 8linezolid susr .............................................................................. 8linezolid tabs .............................................................................. 8LINZESS ............................................................................53liothyronine sodium tabs ......................................................64lisinopril ....................................................................................41lisinopril/hydrochlorothiazide .............................................41lithium .......................................................................................35lithium carbonate caps, tabs ...............................................35lithium carbonate er ..............................................................35lokara .........................................................................................56lomedia 24 fe ..........................................................................61lomustine ..................................................................................21LONSURF TABS 6.14MG; 15MG .................................22LONSURF TABS 8.19MG; 20MG .................................22loperamide hcl caps ...............................................................51loperamide hcl liqd, susp ......................................................51lopreeza.....................................................................................61loratadine childrens ...............................................................75loratadine hives relief ............................................................75loratadine tabs ........................................................................75lorazepam inj 2mg/ml, 4mg/ml ..........................................35lorazepam intensol .................................................................35lorazepam tabs 0.5mg ..........................................................35lorazepam tabs 1mg ..............................................................35lorazepam tabs 2mg ..............................................................35lorcet ............................................................................................ 4lorcet hd ...................................................................................... 4lorcet plus tabs 325mg; 7.5mg ............................................ 4lortab tabs 325mg; 5mg ........................................................ 4lortab tabs 325mg; 10mg, 325mg; 7.5mg ...................... 4loryna ........................................................................................61losartan potassium/hydrochlorothiazide .........................40losartan potassium tabs 25mg, 50mg .............................40losartan potassium tabs 100mg ........................................40LOTEMAX .........................................................................72lovastatin ..................................................................................46LOVAZA ............................................................................46low-ogestrel .............................................................................61loxapine succinate caps 10mg, 50mg, 5mg ...................29loxapine succinate caps 25mg ............................................29ludent ........................................................................................81LUMIGAN .........................................................................70LUMIZYME .......................................................................51LUPRON DEPOT .............................................................65LUPRON DEPOT‑PED ....................................................65

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lutera ..........................................................................................61LYNPARZA ........................................................................24LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG ..................................................................13LYRICA CAPS 225MG, 300MG ....................................13LYRICA SOLN ...................................................................13LYSODREN .......................................................................65lyza .............................................................................................63magnesium sulfate inj ...........................................................81malathion .................................................................................28maprotiline hcl ........................................................................16margesic ..................................................................................... 1marlissa.....................................................................................61MARNATAL‑F...................................................................84MARPLAN ........................................................................16MARQIBO.........................................................................24MATULANE ......................................................................21matzim la ..................................................................................43meclizine hcl tabs ...................................................................18meclofenamate sodium caps ................................................ 2medroxyprogesterone acetate inj .......................................63medroxyprogesterone acetate tabs 5mg .........................63medroxyprogesterone acetate tabs 10mg, 2.5mg ........63mefloquine hcl .........................................................................28megestrol acetate susp 40mg/ml ......................................63megestrol acetate tabs ..........................................................63MEKINIST TABS 0.5MG .................................................26MEKINIST TABS 2MG .....................................................26meloxicam susp......................................................................... 2meloxicam tabs ......................................................................... 2melphalan hydrochloride .....................................................21memantine hcl ........................................................................15memantine hcl titration pak ................................................15memantine hydrochloride soln ...........................................15MENACTRA .....................................................................68MENEST ............................................................................61MENHIBRIX ......................................................................68MENOMUNE‑A/C/Y/W‑135 .......................................68MENVEO ...........................................................................68MEPRON ..........................................................................28mercaptopurine tabs .............................................................22meropenem .............................................................................10meropenem/sodium chloride ..............................................10mesalamine enem, kit ...........................................................69mesna ........................................................................................24MESNEX TABS .................................................................24MESTINON SYRP ............................................................20

MESTINON TIMESPAN ..................................................20metadate er ..............................................................................47metaproterenol sulfate syrp, tabs .......................................76metformin hcl er tb24 500mg, 750mg ...........................36metformin hcl er tb24 1000mg, 500mg ........................36metformin hcl tabs .................................................................36methadone hcl conc ................................................................ 3methadone hcl inj ..................................................................... 3methadone hcl oral soln ......................................................... 3methadone hcl tabs ................................................................. 3methadone hcl tbso ................................................................. 3methadose tbso ........................................................................ 3methazolamide .......................................................................44methenamine hippurate ......................................................... 8methimazole tabs ...................................................................65methotrexate sodium inj 1gm/40ml, 1gm, 250mg/10ml, 50mg/2ml ................................................................................66methotrexate tabs ..................................................................66methoxsalen caps ...................................................................49methscopolamine bromide ..................................................51methyclothiazide tabs ...........................................................45methylergonovine maleate ..................................................54methylphenidate hcl er cp24 30mg ..................................47methylphenidate hcl er tbcr 10mg, 20mg .......................47methylphenidate hcl sr ..........................................................47methylphenidate hcl tabs .....................................................47methylprednisolone acetate inj ...........................................57methylprednisolone dose pack ...........................................57methylprednisolone sodiumsuccinate ..............................57methylprednisolone tabs ......................................................57metipranolol ............................................................................73metoclopramide hcl inj .........................................................51metoclopramide hcl oral soln, tabs ....................................51metolazone ..............................................................................45metoprolol/hydrochlorothiazide ........................................42metoprolol succinate er tb24 100mg, 25mg, 50mg ...42metoprolol succinate er tb24 200mg ...............................42metoprolol tartrate inj ...........................................................42metoprolol tartrate tabs 37.5mg, 75mg..........................42metoprolol tartrate tabs 100mg, 25mg, 50mg .............42METRO IV ........................................................................... 8metronidazole caps 375mg .................................................. 8metronidazole crea 0.75% ..................................................49metronidazole gel 0.75% .....................................................49metronidazole gel 1% ...........................................................49metronidazole in nacl 0.79% ................................................ 8metronidazole lotn 0.75% ...................................................49

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metronidazole tabs 250mg, 500mg................................... 8metronidazole vaginal ............................................................. 8mexiletine hcl ...........................................................................41MIACALCIN INJ ................................................................69miconazole 3 combo pack ...................................................19miconazole 7 ...........................................................................19microgestin 1.5/30 ................................................................61microgestin 1/20 ...................................................................61microgestin 24 fe ...................................................................61microgestin fe ..........................................................................61microgestin fe 1.5/30 ...........................................................61midodrine hcl ..........................................................................39MIGERGOT .......................................................................20miglitol ......................................................................................36MILLIPRED .......................................................................57MILLIPRED DP .................................................................57mimvey ......................................................................................61mimvey lo .................................................................................61minitran ....................................................................................46minocycline hcl caps ..............................................................12minoxidil tabs...........................................................................47mirtazapine ..............................................................................15mirtazapine odt .......................................................................15misoprostol ..............................................................................53mitomycin ................................................................................24mitoxantrone hcl .....................................................................24M‑M‑R II ...........................................................................68modafinil tabs 100mg ..........................................................78modafinil tabs 200mg ..........................................................78moderiba tabs .........................................................................32moexipril hcl tabs 7.5mg ......................................................41moexipril hcl tabs 15mg .......................................................41moexipril/hydrochlorothiazide............................................41molindone hydrochloride tabs 5mg ..................................31molindone hydrochloride tabs 10mg ...............................31molindone hydrochloride tabs 25mg ...............................31mometasone furoate crea ....................................................57mometasone furoate oint, soln ...........................................57mono-linyah ............................................................................61mononessa ...............................................................................61montelukast sodium ..............................................................75morgidox 1x100mg caps .....................................................12morgidox 2x100mg caps .....................................................12morphine sulfate er cp24 10mg, 30mg, 60mg ............... 3morphine sulfate er cp24 100mg, 20mg, 30mg, 50mg, 60mg, 80mg ............................................................................. 3morphine sulfate er cp24 120mg, 45mg, 75mg, 90mg 3

morphine sulfate er tbcr 15mg ............................................. 3morphine sulfate er tbcr 100mg, 200mg, 30mg, 60mg 3morphine sulfate inj 0.5mg/ml, 10mg/ml, 150mg/30ml, 15mg/ml, 1mg/ml, 25mg/ml, 2mg/ml, 4mg/ml, 50mg/ml, 5mg/ml, 8mg/ml ............................................................... 5morphine sulfate inj 10mg/ml, 1mg/ml ............................. 5morphine sulfate oral soln 10mg/5ml ............................... 5morphine sulfate oral soln 20mg/5ml ............................... 5morphine sulfate oral soln 100mg/5ml ............................. 5morphine sulfate tabs 15mg ................................................. 5morphine sulfate tabs 30mg ................................................. 5MOVANTIK .......................................................................51MOVIPREP .......................................................................53MOXEZA ...........................................................................71MOZOBIL..........................................................................39MULTAQ ...........................................................................41multi vitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 1mg; 1.05mg; 15unit; 2500unit ..................................................................................84multi-vitamin/fluoride/iron soln 35mg/ml; 400unit/ml; 5unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 1500unit/ml ...............................84multi-vitamin/fluoride soln 35mg/ml; 400unit/ml; 2mcg/ml; 5unit/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 0.5mg/ml; 1500unit/ml .......................................................84multivitamin with fluoride chew 60mg; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.25mg; 1.05mg; 2500unit; 400unit; 15unit, 60mg; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.5mg; 1.05mg; 2500unit; 400unit; 15unit ........................................................................................85multi-vit/fluoride soln 35mg/ml; 400unit/ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml .........................................................84multi-vit/iron/fluoride soln 35mg/ml; 400unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml ....................................84mult-vitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.5mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1.05mg; 2500unit; 15unit ...................................................................84mupirocin calcium..................................................................49mupirocin crea ........................................................................50mupirocin oint .........................................................................50MUSTARGEN ...................................................................21mvc-fluoride ............................................................................85mycophenolate mofetil caps, tabs .....................................66mycophenolate mofetil susr ................................................66myorisan ...................................................................................50

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MYRBETRIQ .....................................................................54myzilra .......................................................................................61nabumetone .............................................................................. 2nadolol/bendroflumethiazide .............................................42nadolol tabs 20mg .................................................................42nadolol tabs 40mg, 80mg ...................................................42nafcillin ......................................................................................11NAGLAZYME ...................................................................51nalbuphine hcl inj ..................................................................... 5naloxone hcl inj 0.4mg/ml ...................................................... 6naloxone hcl inj 1mg/ml ......................................................... 6naltrexone hcl tabs ................................................................... 6NAMENDA SOLN ...........................................................15NAMENDA TABS .............................................................15NAMENDA TITRATION PAK ..........................................15NAMENDA XR CP24 14MG ..........................................15NAMENDA XR CP24 21MG, 28MG, 7MG .................15NAMENDA XR TITRATION PACK .................................15NAMZARIC ......................................................................15naphazoline hcl .......................................................................71naproxen dr tbec 375mg........................................................ 2naproxen dr tbec 500mg........................................................ 2naproxen sodium tabs 275mg, 550mg ............................. 3naproxen susp ........................................................................... 3naproxen tabs ............................................................................ 3naratriptan hcl ........................................................................20NARCAN ............................................................................. 6NASONEX ........................................................................74NATACHEW CHEW 120MG; 2700UNIT; 400UNIT; 12MCG; 0; 0; 1MG; 28MG; 20MG; 10MG; 3MG; 0; 2MG; 20UNIT ..................................................................85NATALVIRT 90 DHA ........................................................85NATALVIRT CA .................................................................85nateglinide ................................................................................36NATELLE ONE .................................................................85NATPARA .........................................................................70NEBUPENT ......................................................................28necon 0.5/35-28 ...................................................................61necon 1/35 ..............................................................................61NECON 1/50‑28 ............................................................61necon 7/7/7 ............................................................................61NECON 10/11‑28 ..........................................................61nefazodone hcl ........................................................................16neomycin/bacitracin/polymyxin .........................................71neomycin/polymyxin/bacitracin/hydrocortisone ...........71neomycin/polymyxin/dexamethasone oint ......................71neomycin/polymyxin/dexamethasone susp .....................71

neomycin/polymyxin/gramicidin ........................................71neomycin/polymyxin/hc .......................................................73neomycin/polymyxin/hydrocortisone ophthalmic susp 1%; 3.5mg/ml; 10000unit/ml ............................................71neomycin/polymyxin/hydrocortisone otic susp 1%; 3.5mg/ml; 10000unit/ml ....................................................73neomycin sulfate....................................................................... 7neo-polycin ..............................................................................71NEPHRAMINE .................................................................81NESTABS ..........................................................................85NESTABS ABC .................................................................85NESTABS DHA .................................................................85neuac .........................................................................................50NEUMEGA ........................................................................39NEUPOGEN .....................................................................39NEUPRO ...........................................................................28NEVANAC .........................................................................72nevirapine er tb24 100mg ..................................................33nevirapine er tb24 400mg ..................................................33nevirapine susp .......................................................................33nevirapine tabs ........................................................................33NEXA PLUS ......................................................................85NEXAVAR ..........................................................................26niacin er ....................................................................................46nicardipine hcl caps 20mg ...................................................43nicardipine hcl caps 30mg ...................................................43nicotine polacrilex gum, lozg ................................................. 7nicotine transdermal system pt24 21mg/24hr ............... 7NICOTROL NS ................................................................... 7nifedipine er tb24 30mg, 60mg, 90mg ...........................43nifedipine er tb24 90mg ......................................................43nikki ............................................................................................61NILANDRON ....................................................................22NINLARO ..........................................................................24NIPENT .............................................................................24nisoldipine ................................................................................43nisoldipine er ...........................................................................43nitrofurantoin macrocrystals ................................................ 8nitrofurantoin monohydrate ................................................. 8nitrofurantoin monohydrate/macrocrystals ..................... 8nitrofurantoin susp .................................................................. 8nitroglycerin inj .......................................................................46nitroglycerin lingual ...............................................................46nitroglycerin transdermal pt24 0.1mg/hr, 0.4mg/hr, 0.6mg/hr ..................................................................................46nitroglycerin transdermal pt24 0.2mg/hr .......................46NITROSTAT.......................................................................46

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NIVA‑PLUS .......................................................................85nora-be .....................................................................................63NORDITROPIN FLEXPRO ..............................................58norethindrone acetate/ethinyl estradiol/ferrous fumarate 61norethindrone acetate/ethinyl estradiol tabs 5mcg; 1mg 62norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg ............................................................................................61norethindrone acetate tabs .................................................63norethindrone & ethinyl estradiol ferrous fumarate .....61norethindrone tabs ................................................................64norgestimate/ethinyl estradiol ............................................62NORINYL 1+50 ...............................................................62norlyroc .....................................................................................64NORTHERA ......................................................................44nortrel 0.5/35 (28) ................................................................62nortrel 1/35 .............................................................................62nortrel 7/7/7 ...........................................................................62nortriptyline hcl caps 10mg, 25mg, 75mg .....................17nortriptyline hcl caps 50mg ................................................17nortriptyline hcl soln ..............................................................17NORVIR .............................................................................34NOVOLIN 70/30 .............................................................37NOVOLIN 70/30 RELION .............................................37NOVOLIN N .....................................................................37NOVOLIN N RELION ......................................................37NOVOLIN R ......................................................................38NOVOLIN R RELION .......................................................38NOVOLOG........................................................................38NOVOLOG FLEXPEN ......................................................38NOVOLOG MIX 70/30 ...................................................38NOVOLOG MIX 70/30 PREFILLED FLEXPEN ............38NOVOLOG PENFILL .......................................................38NOXAFIL INJ .....................................................................19NOXAFIL SUSP, TBEC .....................................................19NUEDEXTA .......................................................................47NULOJIX ............................................................................66NUPLAZID ........................................................................30nutrilipid ...................................................................................81nyamyc ......................................................................................19nystatin crea, oint, powd, susp, tabs ..................................19nystop ........................................................................................19OB COMPLETE/DHA .....................................................85OB COMPLETE GOLD ...................................................85OB COMPLETE ONE ......................................................85OB COMPLETE PETITE ..................................................85

OB COMPLETE PREMIER ..............................................85OB COMPLETE TABS .....................................................85O‑CAL PRENATAL ..........................................................85ocella .........................................................................................62OCTAGAM .......................................................................67octreotide acetate ..................................................................65ODEFSEY ..........................................................................33ODOMZO .........................................................................24OFEV .................................................................................77ofloxacin ophthalmic soln 0.3% .........................................71ofloxacin otic soln 0.3% ........................................................73ofloxacin tabs 400mg ...........................................................12OGESTREL .......................................................................62olanzapine/fluoxetine caps 25mg; 3mg ...........................16olanzapine/fluoxetine caps 25mg; 12mg, 25mg; 6mg, 50mg; 12mg, 50mg; 6mg ...................................................16olanzapine inj ..........................................................................30olanzapine odt .........................................................................30olanzapine tabs 2.5mg .........................................................30olanzapine tabs 10mg, 15mg, 20mg, 5mg, 7.5mg ......30olopatadine hcl nasal soln 0.6% .........................................75olopatadine hcl ophthalmic soln 0.1% .............................72omega-3-acid ethyl esters ..................................................46omeprazole cpdr 10mg ........................................................54omeprazole cpdr 20mg ........................................................54omeprazole cpdr 40mg ........................................................54omeprazole magnesium .......................................................54OMNITROPE ....................................................................58ONCASPAR ......................................................................24ondansetron hcl inj 4mg/2ml .............................................18ondansetron hcl inj 40mg/20ml, 4mg/2ml....................18ondansetron hcl oral soln .....................................................18ondansetron hcl tabs 4mg, 8mg ........................................18ondansetron hcl tabs 24mg ................................................18ondansetron odt tbdp 4mg .................................................18ondansetron odt tbdp 8mg .................................................18ONFI SUSP .......................................................................13ONFI TABS 10MG, 20MG .............................................13OPDIVO ............................................................................27OPSUMIT ..........................................................................77oralone ......................................................................................48ORFADIN CAPS 10MG, 2MG, 5MG ............................51ORFADIN SUSP 4MG/ML ..............................................70ORKAMBI .........................................................................76orsythia .....................................................................................62OTEZLA TABS ..................................................................67OTEZLA TBPK ..................................................................67

110


OTREXUP INJ 10MG/0.4ML, 15MG/0.4ML, 17.5MG/0.4ML, 20MG/0.4ML, 22.5MG/0.4ML, 25MG/0.4ML, 7.5MG/0.4ML ......................................66oxacillin sodium inj 2gm .......................................................11oxacillin sodium inj 10gm, 1gm ..........................................11oxaliplatin .................................................................................24oxandrolone tabs 2.5mg ......................................................58oxandrolone tabs 10mg .......................................................58oxaprozin .................................................................................... 3oxcarbazepine susp ................................................................14oxcarbazepine tabs.................................................................14oxybutynin chloride er tb24 5mg .......................................54oxybutynin chloride er tb24 10mg ....................................54oxybutynin chloride er tb24 15mg ....................................54oxybutynin chloride syrp .......................................................54oxybutynin chloride tabs .......................................................54oxycodone/acetaminophen soln ........................................... 5oxycodone/acetaminophen tabs 325mg; 7.5mg ............ 5oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg ............................................................... 5oxycodone/aspirin .................................................................... 5oxycodone hcl caps .................................................................. 5oxycodone hcl conc .................................................................. 5oxycodone hcl soln ................................................................... 5oxycodone hcl tabs 5mg ......................................................... 5oxycodone hcl tabs 10mg, 15mg, 20mg ........................... 5oxycodone hcl tabs 30mg ...................................................... 5oxycodone/ibuprofen .............................................................. 5pacerone tabs 100mg...........................................................41pacerone tabs 200mg, 400mg ..........................................41paclitaxel ...................................................................................24PAIRE OB ..........................................................................85paliperidone er tb24 1.5mg, 3mg, 9mg ..........................30paliperidone er tb24 6mg ....................................................30pamidronate disodium ..........................................................69pancrelipase.............................................................................51PANRETIN ........................................................................27pantoprazole sodium tbec 20mg .......................................54pantoprazole sodium tbec 40mg .......................................54paricalcitol ................................................................................69paroex ........................................................................................48paromomycin sulfate............................................................... 7paroxetine hcl ..........................................................................17PASER ................................................................................21PATADAY ...........................................................................72PAXIL SUSP ......................................................................17PAZEO ...............................................................................72

PEDIARIX ..........................................................................68PEDVAX HIB .....................................................................68peg 3350/electrolytes ...........................................................53peg-3350/electrolytes ..........................................................53peg-3350/nacl/na bicarbonate/kcl ..................................53peg 3350 powd ......................................................................53PEGANONE......................................................................14PEGINTRON .....................................................................32PEG‑INTRON REDIPEN .................................................32penicillin g potassium inj 5000000unit ...........................11penicillin g potassium inj 20000000unit ........................11penicillin g procaine ...............................................................11penicillin g sodium .................................................................11penicillin v potassium solr 125mg/5ml ............................11penicillin v potassium solr 250mg/5ml ............................11penicillin v potassium tabs ...................................................11PEN NEEDLE/ULTRAFINE/29G X 12.7MM................70PENTACEL ........................................................................68PENTAM 300 ...................................................................28PENTASA ..........................................................................69pentoxifylline cr .......................................................................44pentoxifylline er .......................................................................44PERIKABIVEN ..................................................................81perindopril erbumine.............................................................41periogard ..................................................................................48PERJETA ............................................................................24permethrin crea ......................................................................28perphenazine/amitriptyline tabs 10mg; 2mg, 10mg; 4mg, 25mg; 2mg, 50mg; 4mg ...........................................17perphenazine/amitriptyline tabs 25mg; 4mg .................17perphenazine tabs 4mg ........................................................29perphenazine tabs 16mg, 2mg, 8mg ...............................29phenadoz supp 12.5mg .......................................................18phenadoz supp 25mg ...........................................................18phenelzine sulfate ...................................................................16phenergan supp ......................................................................18phenobarbital elix ...................................................................14phenobarbital tabs 16.2mg, 32.4mg, 64.8mg, 97.2mg .14phenobarbital tabs 100mg, 15mg, 30mg, 60mg .........14phenytoin chew .......................................................................14phenytoin sodium extended .................................................14phenytoin sodium inj .............................................................14phenytoin susp ........................................................................14philith.........................................................................................62phos-flur ...................................................................................48PHOSPHOLINE IODIDE .................................................73

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pilocarpine hcl soln 1%, 2%, 4% ........................................73pilocarpine hcl tabs 7.5mg ..................................................48pilocarpine hydrochloride ....................................................48pimozide ...................................................................................29pimtrea ......................................................................................62pindolol .....................................................................................42pioglitazone hcl .......................................................................36pioglitazone hcl-glimepiride ................................................36pioglitazone hcl/metformin hcl ...........................................36piperacillin sodium/ tazobactam sodium .........................11piperacillin sodium/tazobactam sodium ..........................11piperacillin/tazobactam inj 36gm; 4.5gm, 4gm; 0.5gm ...11pirmella 1/35 ..........................................................................62pirmella 7/7/7 ........................................................................62piroxicam caps 10mg .............................................................. 3piroxicam caps 20mg .............................................................. 3plenamine ................................................................................81pnv-dha ....................................................................................85PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID ..85PNV FOLIC ACID + IRON MULTIVITAMIN ..................85PNV OB+DHA ..................................................................85pnv prenatal plus multivitamin ...........................................85pnv-select .................................................................................85pnv tabs 29-1 .........................................................................85PNV‑VP‑U ........................................................................85podofilox soln ..........................................................................50polycin .......................................................................................71polyethylene glycol 3350 pack 0 .......................................53polyethylene glycol 3350 pack 0 .......................................53polyethylene glycol 3350 powd 0 ......................................53polyethylene glycol 3350 powd 0 ......................................53polymyxin b sulfate/trimethoprim sulfate ........................71poly-vitamin/fluoride chew ..................................................85poly-vitamin/fluoride soln 35mg/ml; 50mcg/ml; 2mcg/ml; 0.25mg/ml; 8mg/ml; 3mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 1500unit/ml; 400unit/ml; 5unit/ml ............86POMALYST .......................................................................22portia-28 ..................................................................................62PORTRAZZA ....................................................................24potassium chloride 0.3%/d5w ............................................82potassium chloride 0.3%/ nacl 0.9% ................................82potassium chloride 0.15% d5w/nacl 0.33% ..................81potassium chloride 0.15% d5w/nacl 0.45% ..................81potassium chloride 0.15% d5w/nacl 0.45% viaflex .....81potassium chloride 0.15% nacl 0.9% ...............................82

potassium chloride 0.15%/nacl 0.9% ..............................82potassium chloride 0.15% /nacl 0.45% viaflex ..............81potassium chloride 0.22% d5w/nacl 0.45% ..................82potassium chloride 0.224%d5w/nacl 0.45% viaflex ...82potassium chloride cr tbcr 10meq, 20meq .....................82potassium chloride er cpcr ...................................................82potassium chloride er tbcr 10meq, 20meq, 8meq ........82potassium chloride er tbcr 20meq.....................................82potassium chloride inj 0.4meq/ml .....................................82potassium chloride inj 10meq/100ml, 10meq/50ml, 20meq/100ml, 2meq/ml, 40meq/100ml ......................82potassium chloride oral soln................................................82potassium chloride sr ............................................................82potassium citrate er tbcr 15meq ........................................82potassium citrate er tbcr 1080mg, 540mg ....................82POTIGA TABS 50MG ......................................................13POTIGA TABS 200MG, 300MG, 400MG ...................13PRADAXA .........................................................................38PRALUENT .......................................................................44pramipexole dihydrochloride ...............................................28pravastatin sodium tabs 10mg, 80mg .............................46pravastatin sodium tabs 20mg, 40mg .............................46prazosin hcl ..............................................................................40prednicarbate crea .................................................................57prednicarbate oint ..................................................................57prednisolone acetate .............................................................72prednisolone sodium phosphate ophthalmic soln 1% .72prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml ...........................................................57prednisolone soln, syrp .........................................................57PREDNISONE INTENSOL ..............................................57prednisone soln .......................................................................57prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg ........57prednisone tabs 50mg ..........................................................57prednisone tbpk 10mg, 5mg ...............................................57PREFERA OB ....................................................................86PREFERAOB +DHA .........................................................86PREFERA OB + DHA MISC 30MCG; 10MG; 400UNIT; 0.8MG; 12MCG; 200MG; 2.5MG; 1MG; 6MG; 0.5MG; 17MG; 203MG; 28MG; 250MCG; 50MG; 1.6MG; 65MCG; 1.5MG; 10UNIT; 4.5MG ...............................86PREFERAOB ONE ...........................................................86PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML;

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34MG/100ML; 152MG/100ML ..................................82premasol inj 56meq/l; 320mg/100ml; 730mg/100ml; 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml ........................................82PRENAISSANCE ..............................................................86PRENAISSANCE PLUS ...................................................86PRENATA ..........................................................................86prenatabs fa .............................................................................86prenatal 19 chew 100mg; 1000unit; 200mg; 7mg; 400unit; 12mcg; 29mg; 1mg; 15mg; 20mg; 3mg; 3mg; 30unit; 20mg ..........................................................................86prenatal 19 tabs 100mg; 1000unit; 200mg; 7mg; 400unit; 12mcg; 25mg; 29mg; 1mg; 15mg; 20mg; 3mg; 3mg; 30unit; 20mg ....................................................86PRENATAL PLUS .............................................................86prenatal plus iron tabs 120mg; 0; 200mg; 400unit; 2mg; 12mcg; 1mg; 29mg; 20mg; 10mg; 3mg; 1.84mg; 22unit; 4000unit; 25mg ......................................................86PRENATE AM ...................................................................86PRENATE DHA CAPS 90MG; 145MG; 220UNIT; 13MCG; 300MG; 28MG; 400MCG; 600MCG; 50MG; 26MG; 10UNIT ...............................................................86PRENATE ELITE TABS 75MG; 2600UNIT; 330MCG; 100MG; 6MG; 450UNIT; 1.5MG; 13MCG; 26MG; 400MCG; 150MCG; 600MCG; 25MG; 21MG; 21MG; 3.5MG; 3MG; 10UNIT; 15MG ......................................86PRENATE ELITE TABS 600MCG; 75MG; 2600UNIT; 330MCG; 155MG; 600UNIT; 1.5MG; 13MCG; 20MG; 400MCG; 25MG; 21MG; 150MCG; 21MG; 3.5MG; 3MG; 40UNIT; 15MG ....................................................86PRENATE ENHANCE ......................................................87PRENATE ESSENTIAL CAPS 90MG; 280MCG; 145MG; 220UNIT; 13MCG; 300MG; 40MG; 29MG; 0; 400MCG; 600MCG; 50MG; 150MCG; 26MG; 10UNIT 87PRENATE ESSENTIAL CAPS 600MCG; 90MG; 280MCG; 155MG; 220UNIT; 13MCG; 300MG; 40MG; 18MG; 400MCG; 50MG; 150MCG; 26MG; 10UNIT .............................................................................87PRENATE MINI CAPS 60MG; 280MCG; 100MG; 220UNIT; 13MCG; 350MG; 400MCG; 29MG; 600MCG; 25MG; 150MCG; 26MG; 10UNIT; 25MG 87PRENATE MINI CAPS 600MCG; 60MG; 280MCG;

80MG; 1000UNIT; 13MCG; 350MG; 0; 400MCG; 18MG; 0; 25MG; 150MCG; 26MG; 10UNIT; 25MG 87PRENATE PIXIE ................................................................87PRENATE RESTORE ........................................................87PRENATE STAR ................................................................87PREPLUS TABS 120MG; 0; 200MG; 400UNIT; 2MG; 12MCG; 27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG; 22MG; 4000UNIT; 25MG .............................................87PREPOPIK .........................................................................53PREQUE 10 ......................................................................87PRETAB .............................................................................87prevalite ....................................................................................46previfem ....................................................................................62PREZCOBIX ......................................................................34PREZISTA SUSP ...............................................................34PREZISTA TABS 75MG ...................................................34PREZISTA TABS 150MG, 600MG, 800MG ................34PRIFTIN .............................................................................21PRILOSEC OTC ................................................................54primaquine phosphate tabs .................................................28primidone tabs ........................................................................14PRISTIQ TB24 25MG .....................................................17pr natal 400 .............................................................................86PROAIR HFA .....................................................................76PROAIR RESPICLICK .......................................................76probenecid/colchicine ...........................................................20probenecid tabs ......................................................................20prochlorperazine ....................................................................29prochlorperazine edisylate inj .............................................29prochlorperazine maleate tabs ...........................................30PROCRIT INJ 10000UNIT/ML, 20000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML ........39PROCRIT INJ 40000UNIT/ML .......................................39procto-med hc ........................................................................57procto-pak ...............................................................................57proctosol hc .............................................................................57proctozone-hc .........................................................................57progesterone caps ..................................................................64progesterone inj ......................................................................64PROGLYCEM ....................................................................37PROGRAF INJ ...................................................................66PROLASTIN‑C .................................................................77PROLENSA .......................................................................72PROLEUKIN......................................................................24PROLIA .............................................................................69PROMACTA ......................................................................39promethazine hcl supp 12.5mg, 50mg............................18

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promethazine hcl supp 25mg .............................................18promethazine hcl tabs 12.5mg, 50mg .............................75promethazine hcl tabs 25mg ..............................................75promethegan supp 12.5mg, 25mg ...................................18promethegan supp 50mg ....................................................18propafenone hcl ......................................................................41propafenone hcl er .................................................................41proparacaine hcl .....................................................................71propranolol hcl er ...................................................................42propranolol hcl inj ..................................................................42propranolol hcl oral soln .......................................................42propranolol hcl tabs 10mg, 20mg, 40mg, 60mg .........42propranolol hcl tabs 80mg ..................................................42propranolol/hydrochlorothiazide .......................................42propylthiouracil tabs ..............................................................65PROQUAD ........................................................................68protriptyline hcl .......................................................................17PROVIDA DHA .................................................................87PROVIDA OB ....................................................................87PULMOZYME ...................................................................77PUREFE OB PLUS ............................................................87PURIXAN ..........................................................................22pyrazinamide tabs ..................................................................21pyridostigmine bromide tabs, tbcr .....................................21qc 3 day vaginal cream .........................................................19qc acid controller ....................................................................52qc acid controller maximum strength ...............................52qc all day allergy .....................................................................75qc allergy relief ........................................................................75qc anti-diarrheal.....................................................................51qc arthritis pain relief .............................................................. 1qc childrens ibuprofen ............................................................. 3qc loratadine allergy relief ....................................................75qc omeprazole magnesium .................................................54QUADRACEL ...................................................................68quasense ...................................................................................62quetiapine fumarate tabs 25mg ........................................30quetiapine fumarate tabs 100mg, 50mg ........................31quetiapine fumarate tabs 200mg......................................30quetiapine fumarate tabs 300mg, 400mg .....................30QUFLORA PEDIATRIC SOLN 35MG/ML; 400UNIT/ML; 1MG/ML; 2MCG/ML; 35MCG/ML; 65MCG/ML; 10MG/ML; 0.8MG/ML; 0.4MG/ML; 0.6MG/ML; 0.25MG/ML; 0.5MG/ML; 1000UNIT/ML; 5UNIT/ML ..87QUFLORA PEDIATRIC SOLN 45MG/ML; 400UNIT/ML; 1MG/ML; 3MCG/ML; 81MCG/ML; 150MCG/ML;

12MG/ML; 2MG/ML; 1MG/ML; 1MG/ML; 0.5MG/ML; 1MG/ML; 1100UNIT/ML; 12UNIT/ML ...............87quinapril hcl tabs 10mg, 40mg ..........................................41quinapril hcl tabs 20mg, 5mg .............................................41quinapril/hydrochlorothiazide ............................................41quinidine gluconate cr ...........................................................41quinidine gluconate er ...........................................................41quinidine sulfate tabs 200mg .............................................41quinidine sulfate tabs 300mg .............................................41quinine sulfate .........................................................................28QVAR .................................................................................74RABAVERT .......................................................................68raloxifene hydrochloride .......................................................64ramipril caps 1.25mg ............................................................41ramipril caps 10mg, 2.5mg, 5mg ......................................41RANEXA............................................................................44ranitidine 75 ............................................................................52ranitidine 150 maximum strength ....................................52ranitidine hcl caps 150mg, 300mg ...................................52ranitidine hcl inj 50mg/2ml .................................................52ranitidine hcl inj 150mg/6ml ..............................................52ranitidine hcl syrp 15mg/ml ................................................52ranitidine hcl tabs 150mg, 300mg ...................................52RAPAMUNE SOLN ..........................................................66RASUVO ...........................................................................67RAVICTI .............................................................................51REBIF .................................................................................48REBIF REBIDOSE .............................................................48REBIF REBIDOSE TITRATION PACK .............................48REBIF TITRATION PACK .................................................48reclipsen ....................................................................................62RECOMBIVAX HB ............................................................68REGRANEX .......................................................................50relador pak plus ........................................................................ 6RELENZA DISKHALER ....................................................34RELISTOR .........................................................................52RELNATE DHA .................................................................87REMICADE .......................................................................67REMODULIN ....................................................................77RENACIDIN SOLN 6.602GM/100ML; 0.198GM/100ML; 3.177GM/100ML ........................54RENVELA ..........................................................................55repaglinide/metformin hydrochloride ..............................36repaglinide tabs 0.5mg, 1mg ..............................................37repaglinide tabs 2mg .............................................................37REPATHA ..........................................................................44REPATHA SURECLICK ....................................................44

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reprexain tabs 10mg; 200mg ............................................... 5RESCRIPTOR ....................................................................33RESTASIS ..........................................................................71RETROVIR IV INFUSION .................................................33REVLIMID .........................................................................22REXULTI ............................................................................31REYATAZ ...........................................................................34ribasphere caps .......................................................................32ribasphere tabs 200mg ........................................................32ribavirin .....................................................................................32rifabutin ....................................................................................21rifampin caps, inj ....................................................................21RIFATER .............................................................................21riluzole .......................................................................................47rimantadine hcl .......................................................................34ringers injection ......................................................................82risedronate sodium dr ...........................................................69risedronate sodium tabs 30mg, 5mg ................................70risedronate sodium tabs 35mg ..........................................69risedronate sodium tabs 150mg ........................................69RISPERDAL CONSTA ......................................................31risperidone odt tbdp 0.5mg ................................................31risperidone odt tbdp 0.25mg, 3mg ...................................31risperidone odt tbdp 1mg, 2mg .........................................31risperidone odt tbdp 4mg ....................................................31risperidone soln ......................................................................31risperidone tabs 0.25mg, 0.5mg, 3mg ............................31risperidone tabs 1mg, 2mg .................................................31risperidone tabs 4mg ............................................................31RITUXAN ..........................................................................27rivastigmine tartrate ..............................................................15rivastigmine transdermal system .......................................15rizatriptan benzoate odt .......................................................20rizatriptan benzoate tabs 5mg ............................................20rizatriptan benzoate tabs 10mg .........................................20ropinirole hcl ............................................................................28rosadan crea ............................................................................50rosadan gel...............................................................................50rosuvastatin calcium tabs 10mg, 20mg, 5mg ................46rosuvastatin calcium tabs 40mg ........................................46ROTARIX ...........................................................................68ROTATEQ ..........................................................................68ROXICET SOLN .................................................................. 5roxicet tabs ................................................................................. 5ROZEREM .........................................................................78SABRIL ..............................................................................14SAMSCA TABS 15MG ....................................................78

SAMSCA TABS 30MG ....................................................78SANDIMMUNE SOLN ....................................................67SANTYL.............................................................................50SAPHRIS SUBL 2.5MG, 5MG ........................................31SAPHRIS SUBL 10MG ....................................................31sb allergy tabs ..........................................................................75sb anti-diarrhea ......................................................................52sb ibuprofen ............................................................................... 3sb loratadine tabs ...................................................................75SELECT‑OB CHEW 60MG; 0; 400UNIT; 5MCG; 0.4MG; 0.6MG; 25MG; 15MG; 29MG; 2.5MG; 1.8MG; 0; 1.6MG; 30UNIT; 1700UNIT; 15MG ........88SELECT‑OB CHEW 60MG; 0; 400UNIT; 5MCG; 1MG; 25MG; 15MG; 29MG; 2.5MG; 1.8MG; 1.6MG; 30UNIT; 1700UNIT; 15MG ..........................................88SELECT‑OB+DHA ...........................................................87selegiline hcl caps ...................................................................29selegiline hcl tabs ....................................................................29selenium sulfide lotn ..............................................................50SELZENTRY TABS 150MG .............................................34SELZENTRY TABS 300MG .............................................34se-natal 19 ..............................................................................87SENSIPAR TABS 30MG, 60MG .....................................65SENSIPAR TABS 90MG ..................................................65SEREVENT DISKUS .........................................................76sertraline hcl conc, tabs ........................................................17setlakin ......................................................................................62sf .................................................................................................48sharobel ....................................................................................64SIGNIFOR..........................................................................65sildenafil tabs ...........................................................................77silver sulfadiazine ...................................................................50SIMBRINZA ......................................................................73SIMULECT ........................................................................67simvastatin tabs 10mg, 20mg, 40mg, 5mg ...................46simvastatin tabs 80mg .........................................................46sirolimus tabs 0.5mg, 2mg ..................................................67sirolimus tabs 1mg .................................................................67SIRTURO ...........................................................................21SIVEXTRO INJ ..................................................................... 8SIVEXTRO TABS ................................................................ 8sm 8 hour pain relief ................................................................ 1sm acid reducer tabs 200mg, 75mg .................................52sm all day allergy ....................................................................75sm all day allergy childrens soln 5mg/5ml ......................75sm allergy relief loratadine ...................................................75sm allergy relief tabs 1.34mg ..............................................75

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sm anti-diarrheal tabs ..........................................................52sm arthritis pain relief ............................................................. 1sm athletes foot crea .............................................................19sm clearlax ...............................................................................53sm ibuprofen caps .................................................................... 3sm infants ibuprofen ............................................................... 3sm loratadine allergy relief ...................................................75sm loratadine syrp ..................................................................75sm miconazole 3 .....................................................................19sm miconazole 7 crea ...........................................................19sm naproxen sodium tabs ...................................................... 3sm nicotine gum, lozg .............................................................. 7sm nicotine polacrilex .............................................................. 7sodium bicarbonate inj 8.4% ..............................................78sodium bicarbonate partial fill ............................................78sodium chloride 0.9% ...........................................................54sodium chloride 0.45% viaflex ............................................82sodium chloride inj 0.9%, 5% .............................................82sodium chloride inj 2.5meq/ml, 3% ..................................82sodium fluoride chew 0.5mg, 1.1mg ................................82sodium fluoride soln ..............................................................83sodium phenylbutyrate powd ..............................................51sodium phosphate..................................................................83sodium polystyrene sulfonate .............................................78sodium sulfacetamide lotn 10% .........................................50sodium sulfacetamide soln 10% ........................................71SOLTAMOX .......................................................................22SOMATULINE DEPOT INJ 60MG/0.2ML ....................65SOMATULINE DEPOT INJ 90MG/0.3ML ....................65SOMATULINE DEPOT INJ 120MG/0.5ML .................65SOMAVERT ......................................................................65sorine .........................................................................................41sotalol hcl (af) tabs 120mg ..................................................42sotalol hcl (af) tabs 160mg, 80mg ....................................42sotalol hcl tabs 120mg, 160mg, 80mg ...........................42sotalol hcl tabs 240mg .........................................................42SOVALDI ...........................................................................32SPIRIVA HANDIHALER ...................................................76SPIRIVA RESPIMAT .........................................................76spironolactone/hydrochlorothiazide .................................45spironolactone tabs ...............................................................45SPORANOX SOLN ..........................................................19sprintec 28 ...............................................................................62SPRITAM TB3D 250MG, 500MG, 750MG ................13SPRITAM TB3D 1000MG ..............................................13SPRYCEL TABS 20MG, 50MG, 70MG, 80MG ...........26SPRYCEL TABS 100MG, 140MG .................................26

sps ..............................................................................................78sronyx ........................................................................................62ssd ..............................................................................................50stavudine caps 15mg, 20mg ..............................................33stavudine caps 30mg, 40mg ..............................................33stavudine solr...........................................................................33sterile water irrigation ...........................................................83STIOLTO RESPIMAT ........................................................77STIVARGA ........................................................................26STRATTERA CAPS 10MG, 18MG, 25MG, 40MG, 60MG ................................................................................47STRATTERA CAPS 100MG, 80MG ..............................47streptomycin sulfate inj ........................................................... 7STRIBILD ...........................................................................33STRIVERDI RESPIMAT ....................................................76SUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG, 8MG; 2MG .................................................................................... 6SUBOXONE FILM 12MG; 3MG ...................................... 6sucralfate susp, tabs ...............................................................53sulfacetamide sodium oint 10% .........................................71sulfacetamide sodium/prednisolone sodium phosphate ..71sulfacetamide sodium soln 10% ........................................71sulfacetamide sodium susp 10% .......................................50sulfadiazine tabs .....................................................................12sulfamethoxazole/trimethoprim ds ...................................12sulfamethoxazole/trimethoprim inj, tabs .........................12sulfamethoxazole/trimethoprim susp ...............................12SULFAMYLON..................................................................50sulfasalazine tabs, tbec .........................................................69sulfatrim pediatric ..................................................................12sulindac tabs 150mg............................................................... 3sulindac tabs 200mg............................................................... 3sumatriptan soln ....................................................................20sumatriptan succinate inj 4mg/0.5ml ..............................20sumatriptan succinate inj 6mg/0.5ml ..............................20sumatriptan succinate refill inj 4mg/0.5ml .....................20sumatriptan succinate refill inj 6mg/0.5ml .....................20sumatriptan succinate tabs 25mg .....................................20sumatriptan succinate tabs 100mg, 50mg .....................20SUPRAX CAPS .................................................................10SUPRAX CHEW 100MG ................................................10SUPRAX CHEW 200MG ................................................10SUPRAX SUSR 500MG/5ML ........................................10SUPREP BOWEL PREP ...................................................53SUSTIVA............................................................................33SUTENT CAPS 12.5MG .................................................26

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SUTENT CAPS 25MG, 37.5MG, 50MG ......................26syeda ..........................................................................................62SYLATRON .......................................................................25SYLVANT ...........................................................................70SYMLINPEN 60 ...............................................................37SYMLINPEN 120 .............................................................37SYNAGIS ...........................................................................67SYNAREL ..........................................................................65SYNERCID .......................................................................... 8SYNRIBO...........................................................................25SYNTHROID TABS 100MCG, 125MCG, 137MCG, 150MCG, 175MCG, 200MCG, 25MCG, 300MCG, 50MCG, 75MCG, 88MCG .............................................64SYNTHROID TABS 112MCG .........................................64SYPRINE ............................................................................79TABLOID ...........................................................................22tacrolimus caps .......................................................................67TAFINLAR CAPS 50MG .................................................26TAFINLAR CAPS 75MG .................................................26TAGRISSO .........................................................................25TAMIFLU CAPS 30MG ...................................................34TAMIFLU CAPS 45MG, 75MG ......................................34TAMIFLU SUSR ................................................................34tamoxifen citrate tabs 10mg ...............................................22tamoxifen citrate tabs 20mg ...............................................22tamsulosin hcl .........................................................................54TARCEVA TABS 25MG ...................................................26TARCEVA TABS 100MG, 150MG ................................26TARGRETIN ......................................................................27tarina fe 1/20 ..........................................................................62TARON‑BC .......................................................................88TARON‑PREX ..................................................................88TASIGNA ...........................................................................27tazicef inj 1gm, 2gm, 6gm ...................................................10TAZORAC .........................................................................50taztia xt ......................................................................................43TECENTRIQ ......................................................................27TEFLARO ..........................................................................10telmisartan ...............................................................................40telmisartan/amlodipine ........................................................40telmisartan/hydrochlorothiazide........................................40TEMODAR INJ ..................................................................22TENIVAC ...........................................................................68terazosin hcl .............................................................................40terbinafine hcl crea ................................................................19terbinafine hcl tabs ................................................................19terbutaline sulfate tabs..........................................................76

terconazole ...............................................................................19testosterone cypionate inj ....................................................58testosterone enanthate inj ...................................................58testosterone gel 1%, 25mg/2.5gm ...................................58tetanus/diphtheria toxoids-adsorbed ................................68tetrabenazine tabs 12.5mg .................................................47tetrabenazine tabs 25mg .....................................................47tetracycline hcl caps ..............................................................12THALOMID CAPS 100MG, 150MG, 50MG ...............22THALOMID CAPS 200MG ............................................22theophylline .............................................................................77theophylline cr tb12 100mg ...............................................77theophylline cr tb12 200mg ...............................................77theophylline er tb12 100mg, 200mg, 300mg ..............77theophylline er tb12 450mg ...............................................77theophylline er tb24 ..............................................................77THERACYS .......................................................................25THIOLA .............................................................................54thioridazine hcl tabs 10mg, 25mg, 50mg .......................30thioridazine hcl tabs 100mg ...............................................30thiotepa .....................................................................................22thiothixene caps 1mg ............................................................30thiothixene caps 10mg, 2mg, 5mg ...................................30thrivite rx ...................................................................................88THYMOGLOBULIN .........................................................67THYROLAR‑1 ..................................................................64THYROLAR‑1/2 ..............................................................64THYROLAR‑1/4 ..............................................................64THYROLAR‑2 ..................................................................64THYROLAR‑3 ..................................................................64tiagabine hydrochloride ........................................................14TICE BCG ..........................................................................25ticlopidine hcl ..........................................................................39TIKOSYN ...........................................................................42tilia fe .........................................................................................62timolol maleate ophthalmic gel forming ..........................73timolol maleate soln 0.25%, 0.5% ....................................73timolol maleate tabs 10mg, 20mg, 5mg .........................42tinidazole .................................................................................... 8tioconazole-1 ..........................................................................19TIVICAY TABS 10MG, 25MG ........................................32TIVICAY TABS 50MG ......................................................32tizanidine hcl tabs ...................................................................31TL‑CARE DHA .................................................................88TL FOLATE ........................................................................88TL‑SELECT .......................................................................88TOBI PODHALER ............................................................77

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TOBRADEX .......................................................................71TOBRADEX ST .................................................................71tobramycin ...............................................................................77tobramycin/dexamethasone ................................................71tobramycin sulfate inj 1.2gm/30ml, 1.2gm, 10mg/ml, 40mg/ml, 80mg/2ml .............................................................. 7tobramycin sulfate ophthalmic soln 0.3% .......................71TOBREX ............................................................................71tolazamide ................................................................................37tolbutamide ..............................................................................37tolmetin sodium caps .............................................................. 3tolmetin sodium tabs 200mg ............................................... 3tolmetin sodium tabs 600mg ............................................... 3tolterodine tartrate .................................................................54topiramate cpsp 15mg .........................................................14topiramate cpsp 25mg .........................................................14topiramate tabs .......................................................................14toposar ......................................................................................25topotecan hcl ...........................................................................25TORISEL ............................................................................27torsemide tabs 10mg, 20mg, 5mg ...................................45torsemide tabs 100mg .........................................................45tpn electrolytes ........................................................................83TRACLEER ........................................................................77TRADJENTA ......................................................................37tramadol hcl tabs ...................................................................... 5tramadol hydrochloride/acetaminophen ........................... 5trandolapril ..............................................................................41trandolapril/verapamil hcl ...................................................41trandolapril/verapamil hcl er...............................................41tranexamic acid inj .................................................................39tranexamic acid tabs ..............................................................39TRANSDERM‑SCOP.......................................................18tranylcypromine sulfate ........................................................16TRAVASOL .......................................................................83TRAVATAN Z ....................................................................70travoprost .................................................................................70trazodone hcl ...........................................................................17TREANDA .........................................................................22TRECATOR ........................................................................21TRELSTAR MIXJECT ........................................................65TRESIBA FLEXTOUCH ...................................................38tretinoin caps 10mg ..............................................................27tretinoin crea 0.025%, 0.05%, 0.1% ................................50tretinoin gel 0.01% ................................................................50tretinoin gel 0.025%, 0.05% ..............................................50triadvance.................................................................................88

triamcinolone acetonide aero 55mcg/act .......................74triamcinolone acetonide aers 0.147mg/gm ...................57triamcinolone acetonide crea 0.1% ..................................57triamcinolone acetonide crea 0.025%, 0.5% .................57triamcinolone acetonide lotn 0.025%, 0.1% .................57triamcinolone acetonide oint 0.1%, 0.5% .......................57triamcinolone acetonide oint 0.025% ..............................57triamcinolone acetonide pste 0.1% ...................................48triamcinolone in orabase .....................................................48triamterene/hydrochlorothiazide caps 25mg; 37.5mg 45triamterene/hydrochlorothiazide caps 25mg; 50mg ...45triamterene/hydrochlorothiazide tabs ..............................45tricare ........................................................................................88TRICARE PRENATAL COMPLEAT .................................88TRICARE PRENATAL DHA ONE ...................................88triderm ......................................................................................57tri-estarylla ..............................................................................62trifluoperazine hcl tabs 1mg ................................................30trifluoperazine hcl tabs 10mg, 2mg, 5mg .......................30trifluridine .................................................................................71trihexyphenidyl hcl .................................................................28tri-legest fe ...............................................................................62tri-linyah ...................................................................................62tri-lo-estarylla .........................................................................62tri-lo-marzia ............................................................................62tri-lo-sprintec ..........................................................................62trilyte ..........................................................................................53trimethoprim sulfate/polymyxin b sulfate ........................72trimethoprim tabs .................................................................... 8trimipramine maleate caps ..................................................17TRINATAL GT ...................................................................88trinatal rx 1 ...............................................................................88trinessa ......................................................................................62trinessa lo .................................................................................62TRINTELLIX ......................................................................15triple antibiotic ........................................................................72triple-vitamin/fluoride ...........................................................88tri-previfem ..............................................................................62TRISENOX .........................................................................25tri-sprintec ...............................................................................62TRISTART DHA ................................................................88TRIUMEQ ..........................................................................33TRIVEEN‑DUO DHA.......................................................88TRIVEEN‑PRX RNF..........................................................88tri-vitamin/fluoride ................................................................88tri-vit/fluoride ..........................................................................88tri-vit/fluoride/iron.................................................................88

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trivora-28 ................................................................................63TROPHAMINE INJ 97MEQ/L; 0.54GM/100ML; 1.2GM/100ML; 0.32GM/100ML; 0; 0; 0.5GM/100ML; 0.36GM/100ML; 0.48GM/100ML; 0.82GM/100ML; 1.4GM/100ML; 1.2GM/100ML; 0.34GM/100ML; 0.48GM/100ML; 0.68GM/100ML; 0.38GM/100ML; 5MEQ/L; 0.025GM/100ML; 0.42GM/100ML; 0.2GM/100ML; 0.24GM/100ML; 0.78GM/100ML .............................................................83TRULICITY ........................................................................37TRUMENBA .....................................................................68TRUVADA TABS 100MG; 150MG, 133MG; 200MG, 167MG; 250MG .............................................................33TRUVADA TABS 200MG; 300MG ...............................33TWINRIX ...........................................................................68TYBOST ............................................................................34TYGACIL ............................................................................. 8TYKERB .............................................................................27TYPHIM VI ........................................................................68TYSABRI ............................................................................48TYZEKA .............................................................................32TYZINE PEDIATRIC NASAL DROPS .............................77ULORIC .............................................................................20ultimatecare one nf ................................................................88unithroid tabs 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg .......................................................................................64unithroid tabs 200mcg .........................................................64ursodiol caps, tabs ..................................................................52UVADEX ............................................................................25VAGIFEM ..........................................................................63valacyclovir hcl ........................................................................35VALCHLOR .......................................................................22VALCYTE SOLR ................................................................32valganciclovir ...........................................................................32valproate sodium inj ..............................................................14valproic acid caps ...................................................................14valproic acid syrp ....................................................................14valsartan ...................................................................................40valsartan/hydrochlorothiazide ............................................40VALSTAR ...........................................................................25vancomycin hcl caps ................................................................ 8vancomycin hcl in dextrose .................................................... 8vancomycin hcl inj 1000mg, 10gm, 5000mg, 500mg, 750mg ........................................................................................ 8vandazole ................................................................................... 8VANTAS ............................................................................65

VAQTA ...............................................................................69VARIVAX ...........................................................................69VASCEPA ..........................................................................46VASOSTRICT ....................................................................58VECTIBIX ...........................................................................25VELCADE ..........................................................................25velivet .........................................................................................63VELPHORO ......................................................................55VEMAVITE‑PRX 2 ...........................................................88VENA‑BAL DHA .............................................................88VENCLEXTA .....................................................................25VENCLEXTA STARTING PACK ......................................25venlafaxine hcl .........................................................................17venlafaxine hcl er cp24 37.5mg, 75mg ...........................17venlafaxine hcl er cp24 150mg ..........................................17venlafaxine hcl er tb24 37.5mg, 75mg ............................17venlafaxine hcl er tb24 150mg ..........................................17venlafaxine hcl er tb24 225mg ..........................................17VENTAVIS .........................................................................77VENTOLIN HFA ...............................................................76verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg ......................................................................................44verapamil hcl er cp24 200mg ............................................44verapamil hcl er tbcr 120mg ...............................................44verapamil hcl er tbcr 180mg, 240mg ..............................44verapamil hcl inj, tabs ............................................................44verapamil hcl sr cp24 120mg, 180mg, 240mg ............44verapamil hcl sr cp24 360mg.............................................44verapamil hcl sr tbcr 240mg ...............................................44VERSACLOZ .....................................................................31VESICARE .........................................................................54vestura .......................................................................................63V‑GO 20 ...........................................................................70V‑GO 30 ...........................................................................70V‑GO 40 ...........................................................................70vicodin es tabs 300mg; 7.5mg ............................................. 5vicodin tabs 300mg; 5mg ...................................................... 5VICTOZA ...........................................................................37VIDEX PEDIATRIC SOLR 2GM ......................................33VIDEX PEDIATRIC SOLR 4GM ......................................33vienva ........................................................................................63VIGAMOX .........................................................................72VIIBRYD KIT ......................................................................17VIIBRYD STARTER PACK ................................................17VIIBRYD TABS ..................................................................17VIMPAT INJ .......................................................................14VIMPAT ORAL SOLN ......................................................14

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VIMPAT TABS 50MG ......................................................15VIMPAT TABS 100MG, 150MG, 200MG ....................15vinblastine sulfate inj 1mg/ml .............................................25vincasar pfs ..............................................................................25vincristine sulfate ....................................................................25vinorelbine tartrate ................................................................25viorele ........................................................................................63VIRACEPT .........................................................................34VIRAMUNE SUSP ............................................................33VIRAZOLE .........................................................................35VIREAD .............................................................................33VIRT‑ADVANCE...............................................................88VIRT‑CARE ONE..............................................................88VIRT‑C DHA .....................................................................88VIRT‑PN ............................................................................88VIRT‑PN DHA CAPS 85MG; 140MG; 200UNIT; 12MCG; 300MG; 27MG; 400MCG; 600MCG; 45MG; 25MG; 10UNIT ...............................................................88VIRT‑PN PLUS .................................................................89VIRT‑SELECT ...................................................................89VITAFOL FE+ ....................................................................89VITAFOL GUMMIES ........................................................89VITAFOL‑NANO ..............................................................89VITAFOL‑OB ....................................................................89VITAFOL‑OB+DHA .........................................................89VITAFOL‑ONE .................................................................89VITAFOL ULTRA ..............................................................89VITAMEDMD ONE RX/QUATREFOLIC ........................89VITAMEDMD PLUS RX/QUATRE FOLIC ......................89vitamins a/c/d/fluoride ..........................................................89vitamins a/d/c/fluoride ..........................................................83VITEKTA ............................................................................32VOL‑NATE ........................................................................89VOL‑PLUS ........................................................................89VOLTAREN .......................................................................... 3voriconazole inj, tabs .............................................................20voriconazole susr ....................................................................20VOTRIENT ........................................................................27VP‑CH PLUS ....................................................................89VP‑CH‑PNV .....................................................................89VP CH ULTRA ...................................................................89VP‑GGR‑B6 PRENATAL ................................................89VP‑HEME OB ..................................................................89VP‑HEME ONE ................................................................89VP‑PNV‑DHA ..................................................................89VPRIV ................................................................................51VRAYLAR CAPS ...............................................................31

VRAYLAR CPPK ...............................................................31vyfemla ......................................................................................63warfarin sodium tabs .............................................................38wera ...........................................................................................63wymzya fe .................................................................................63XALKORI ...........................................................................27XARELTO STARTER PACK ..............................................38XARELTO TABS 10MG, 20MG ......................................38XARELTO TABS 15MG ...................................................38XELJANZ ...........................................................................67XELJANZ XR ......................................................................67XGEVA ...............................................................................70XOLAIR ..............................................................................77XTANDI .............................................................................22xylon ............................................................................................. 5XYREM ..............................................................................78YERVOY .............................................................................25YF‑VAX ..............................................................................69YONDELIS ........................................................................22ZADITOR ...........................................................................72zafirlukast .................................................................................75zaleplon caps 5mg .................................................................78zaleplon caps 10mg...............................................................78ZALTRAP...........................................................................25zamicet ........................................................................................ 5ZANOSAR .........................................................................25zarah ..........................................................................................63ZATEAN‑CH ....................................................................89ZATEAN‑PN .....................................................................89ZATEAN‑PN DHA ...........................................................89ZATEAN‑PN PLUS ..........................................................89ZAVESCA ..........................................................................51zazole .........................................................................................20zebutal caps 325mg; 50mg; 40mg ..................................... 1ZELBORAF ........................................................................27ZEMAIRA ..........................................................................78zenatane ...................................................................................50zenchent ...................................................................................63zenchent fe ...............................................................................63ZENPEP .............................................................................51ZEPATIER ..........................................................................35ZETIA .................................................................................46ZIAGEN SOLN .................................................................33zidovudine ................................................................................33ziprasidone hcl caps 20mg, 40mg ....................................31ziprasidone hcl caps 60mg, 80mg ....................................31ZIRGAN .............................................................................72

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ZOLADEX..........................................................................65zoledronic acid inj 4mg/5ml, 4mg, 5mg/100ml ...........70ZOLINZA ...........................................................................25zolmitriptan odt ......................................................................20zolmitriptan tabs .....................................................................20zolpidem tartrate er ...............................................................78zolpidem tartrate tabs 5mg .................................................78zolpidem tartrate tabs 10mg ..............................................78ZONALON ........................................................................50zonisamide ...............................................................................13ZORTRESS ........................................................................67ZOSTAVAX ........................................................................69zovia 1/35e ..............................................................................63zovia 1/50e ..............................................................................63ZYDELIG ...........................................................................25ZYKADIA ...........................................................................27ZYPREXA RELPREVV INJ 210MG, 300MG .................31ZYPREXA RELPREVV INJ 405MG .................................31ZYTIGA ..............................................................................22ZYVOX INJ 600MG/300ML ............................................. 8ZYVOX SUSR ...................................................................... 8ZYVOX TABS....................................................................... 8

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AETNA BETTER HEALTH PREMIER PLAN 1333 Gratiot Avenue, Suite 400 Detroit, MI 48207

Aetna, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Aetna, Inc. does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Aetna, Inc.:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic

formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

o Qualified interpreters o Information written in other languages

If you need these services, contact Aetna Medicaid Civil Rights Coordinator If you believe that Aetna, Inc. has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Aetna Medicaid Civil Rights Coordinator, 4500 Cotton Center Blvd., Phoenix, AZ 85040, 1-888-234-7358, TTY 711, 860-900-7667, [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Aetna Medicaid Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

122

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-385-4104 (TTY: 711).

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-385-4104 (TTY: 711).

Arabic:

Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-385-4104 (TTY: 711)。

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Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-800-385-4104 (TTY: 711).

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-385-4104 (TTY: 711) 번으로 전화해 주십시오.

Bengali: লক্ষ্য করুনঃ যদি আপনি বাংলা, কথা বলতে পারেন, তাহলে নিঃখরচায় ভাষা সহায়তা পরিষেবা উপলব্ধ আছে। ফোন করুন 1-800-385-4104 (TTY: 711)।

Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-385-4104 (TTY: 711).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-385-4104 (TTY: 711).

Italian: ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-385-4104 (TTY: 711).

Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-385-4104 (TTY: 711) まで、お電話にてご連絡ください。

Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-385-4104 (телетайп: 711).

Serbo-Croatian (Serbian): OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-800-385-4104 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711).

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-385-4104 (TTY: 711).

MI-16-07-07

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