akamai advantage 2019 formulary · akamai advantage premier limits the amount of the drug that hmsa...

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

Premier MAPD (PPO)

List of Covered DrugsFormulary ID 00019312, version 18

This formulary was updated on 12/01/2019. For more recent information or other questions, please contact HMSA at 948-6000 on Oahu or 1 (800) 660-4672 toll-free. TTY users, call 711. Telephone hours are 8 a.m. to 8 p.m., seven days a week or visit http://www.hmsa.com/advantage.

H3832_5042_8700_16676_12_C

2019Formulary

HMSA Akamai Advantage

http://www.hmsa.com/advantage

Note to existing members: This formulary has changed since last year. Please review this docu-ment to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means HMSA. When it refers to “plan” or “our plan,” it means HMSA Akamai Advantage Premier.

This document includes a list of the drugs (formulary) for our plan which is current as of December 1, 2019. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year.

What is the HMSA Akamai Advantage Premier Formulary?A formulary is a list of covered drugs selected by HMSA Akamai Advantage Premier in consultation with a team of health care providers, which rep-resents the prescription therapies believed to be a necessary part of a quality treatment program. HMSA Akamai Advantage Premier will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an HMSA Akamai Advantage Premier net-work pharmacy, and other plan rules are followed. For more information on how to fill your prescrip-tions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce cov-erage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available or when new adverse informa-tion about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the

coverage year. We feel it is important that you have continued access for the remainder of the cover-age year to the formulary drugs that were avail-able when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, add prior authorization, quantity limits, and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective or at the time the member re-quests a refill of the drug, at which time the mem-ber will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufac-turer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of Decem-ber 1, 2019. To get updated information about the drugs covered by HMSA Akamai Advantage Pre-mier, please contact us. Our contact information appears on the front and back cover pages. We will inform members of any formulary changes to this comprehensive formulary by mail.

How do I use the formulary? There are two ways to find your drug within the formulary:

Medical ConditionThe formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 45. The Index provides an al-phabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage

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information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?HMSA Akamai Advantage Premier covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. General-ly, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?Some covered drugs may have additional require-ments or limits on coverage. These requirements and limits may include:

• Prior Authorization: HMSA Akamai Advantage Premier requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from HMSA Akamai Advantage Premier before you fill your prescriptions. If you don’t get approval, HMSA Akamai Advantage Premier may not cover the drug.

• Quantity Limits: For certain drugs, HMSA Akamai Advantage Premier limits the amount of the drug that HMSA Akamai Advantage Premier will cover. For example, HMSA Akamai Advan-tage Premier provides 30 tablets per prescription for simvastatin. This may be in addition to a stan-dard one-month or three-month supply.

• Step Therapy: In some cases, HMSA Akamai Advantage Premier requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, HMSA Akamai Advantage Premier may not cover Drug B unless you try Drug A first. If Drug A does not work for you, HMSA Akamai Advantage Premier will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restric-tions. You may also ask us to send you a copy.

Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask HMSA Akamai Advantage Premier to make an exception to these restrictions or limits or for a list of other similar drugs that may treat your health condition. See the section, “How do I request an exception to the HMSA Akamai Advan-tage Premier formulary?” on this page for informa-tion about how to request an exception.

What if my drug is not on the formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact our Customer Relations department and ask if your drug is covered. If you learn that HMSA Akamai Advantage Premier does not cover your drug, you have two options:

• You can ask Customer Relations for a list of similar drugs that are covered by HMSA Akamai Advantage Premier. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by HMSA Akamai Advantage Premier.

• You can ask HMSA Akamai Advantage Premier to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the HMSA Akamai Advantage Premier Formulary?You can ask HMSA Akamai Advantage Premier to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain

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drugs, HMSA Akamai Advantage Premier limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, HMSA Akamai Advantage Premier will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug, or additional utiliza-tion restrictions would not be as effective in treat-ing your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering, or uti-lization restriction exception. When you request a formulary, tiering, or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s sup-porting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formu-lary but your ability to get it is limited. For exam-ple, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to deter-mine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs

even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care (LTC) facility, we will allow you to refill your prescrip-tion until we have provided you with a 31-day transition supply consistent with the dispensing increment (unless you have a prescription writ-ten for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Transition policyNew members in our Plan may be taking drugs that aren’t on our formulary or that are subject to certain restrictions, such as prior authorization. Current members may also be affected by changes in our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. See the section, “How do I request an exception to HMSA Akamai Advantage Premier formulary?” to learn more about how to request an exception. Please contact Customer Relations if your drug is not on our formulary, is subject to certain restrictions such as prior authorization, and you need to switch to a different drug that we cover or request a formulary exception. During the period of time members are talking to their doctors to determine a course of action, we may provide a temporary supply of a non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in our plan. If you are a current member affected by a formulary change from one year to the next, we will provide you with the opportunity to request a formulary exception in advance for the following year.

When a member goes to a network pharmacy and we provide a temporary supply of a drug that isn’t on our formulary or that has coverage restrictions or limits (but is otherwise considered a Part D drug), we will cover a 30-day supply (unless the prescription is written for fewer days). After we

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cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transi-tion policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.

If a new member is a resident of a long-term care facility (like a nursing home), we will also cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our plan. If the resident has been enrolled in our plan for more than 90 days and needs a drug that isn’t on our formulary or is subject to other restrictions, such as dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.

Current members are also eligible to receive a transition fill under certain conditions. If a current member enters a long-term care (LTC) facility or is in an LTC facility and requires an emergency supply of non-formulary drugs, we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). We will cover more than one refill of these drugs for these members for the first 90 days. A member may experience a change in their level of care at an inpatient hospital facility or skilled nursing facility which results in non-coverage of drugs previously covered by Medicare Part D. For current members experiencing a level of care change, we will also cover a temporary 31-day transition supply as outlined above.

Please note that our transition policy applies only to those drugs that are Part D drugs and bought at a network pharmacy. The transition policy can’t be used to buy a non-Part D drug or a drug out-of-network, unless you qualify for out-of-network access.

For more informationFor more detailed information about your HMSA Akamai Advantage Premier prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about HMSA Akamai Advantage Premier, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1 (800) MEDICARE [1 (800) 633-4227] 24 hours a day/seven days a week. TTY users should call 1 (877) 486-2048. Or visit http://www.medicare.gov.

HMSA Akamai Advantage Premier FormularyThis formulary includes all qualified Medicare prescription drugs that are covered by HMSA Akamai Advantage Premier.

Your plan also includes enhanced drug coverage of generics and non-preferred brands in the following drug categories:

• Drugs when used for the relief of cough or cold symptoms

• Prescription vitamins

If you have questions regarding whether or not your prescription is covered, please call our Customer Relations department.

These enhanced drugs are not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for these drugs do not count toward your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any additional help to pay for these drugs.

The formulary that begins on page 1 provides coverage information about the drugs covered by HMSA Akamai Advantage Premier. If you have trouble finding your drug in the list, turn to the Index that begins on page 45.

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

The information in the requirements/limits column tells you if HMSA Akamai Advantage Premier has any special requirements for coverage of your drug.

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Drug tier index:

Tier 1 - Preferred Generic

Tier 2 - Generic

Tier 3 - Preferred Brand

Tier 4 - Non-Preferred Drug

Tier 5 - Specialty Tier

Please refer to the Summary of Benefits or Evidence of Coverage for the specific copayment or coinsurance amount associated with each tier.

Abbreviations used in this FormularyPA – Prior Authorization: Requires that you or your physician receive approval from HMSA Akamai Advantage Premier before we will cover your prescription.

QL – Quantity Limits: A limit on the amount of the drug that HMSA Akamai Advantage Premier will cover.

ST – Step Therapy: Requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.

M – Mail Order: These drugs are available through HMSA’s mail order pharmacy, CVS Caremark.

B/D – B or D: This drug may be covered under Medicare Part B or D depending upon the circum-stances. Information may need to be submitted describing the use and setting of the drug to make the determination. For more information, please call Customer Relations.

LA – Limited Availability: This prescription may be available only at certain pharmacies. For more information, please call Customer Relations.

Prescription drugs can be shipped to your home from the HMSA Akamai Advantage Premier Mail Order pharmacy. Usually a mail-order pharmacy order will get to you in no more than 14 days after the pharmacy receives the order. If your drugs do not arrive within this timeframe, please call 1 (855) 479-3659 toll-free, 24 hours a day, seven days a week; TTY users, call 711. You can also choose to sign up for our optional automatic delivery program by calling these numbers.

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - Available at mail-order B/D - Covered under Medicare B or D LA - Limited Access

1

Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol tab 1 M

colchicine w/ probenecid 2 M

COLCRYS QL (120 tabs / 30 days)

3 QL M

DUZALLO 4 M ST

febuxostat 2 M ST

MITIGARE QL (60 caps / 30 days)

3 QL M

probenecid 2 M

ULORIC 3 M ST

NSAIDS celecoxib CAPS 50mg

QL (240 caps / 30 days) 2 QL M

celecoxib CAPS 100mg QL (120 caps / 30 days)

2 QL M


2 QL M


2 QL M

diclofenac potassium QL (120 tabs / 30 days)

2 QL M

diclofenac sodium TB24; TBEC

2 M

diclofenac w/ misoprostol 2 M

diflunisal TABS 2 M

etodolac 2 M

etodolac er 2 M

fenoprofen calcium CAPS 400mg

2 M

fenoprofen calcium TABS 2 M

flurbiprofen TABS 2 M

ibu tab 600mg 1 M

ibu tab 800mg 1 M

ibuprofen SUSP 2 M

ibuprofen TABS 400mg, 600mg, 800mg

1 M

ketoprofen CAPS; CP24 2 M

meloxicam tabs 1 M

nabumetone TABS 2 M

naproxen TABS 1 M

naproxen dr 1 M

naproxen sodium TABS 275mg, 550mg

2 M

oxaprozin 2 M

piroxicam CAPS 2 M

sulindac TABS 1 M

tolmetin sodium 2 M

Drug Name Drug Tier

Requirements/Limits

OPIOID ANALGESICS acetaminophen w/ codeine 300-15mg

QL (400 tabs / 30 days)

2 QL M

acetaminophen w/ codeine 300-30mg


2 QL M

acetaminophen w/ codeine 300-60mg


2 QL M

acetaminophen w/ codeine soln

QL (2700 mL / 30 days)

2 QL M

acetaminophen-caff-dihydrocod

QL (300 caps / 30 days)

2 QL M

BELBUCA QL (60 buccal films / 30 days)

4 QL M PA

buprenorphine patch QL (4 patches / 28 days)

2 QL M PA

butorphanol nasal spray QL (10 mL / 30 days)

2 QL M

butorphanol tartrate SOLN 4 M

BUTRANS QL (4 patches / 28 days)

3 QL M PA

dvorah QL (300 tabs / 30 days)

2 QL M

nalbuphine hcl SOLN 4 M

tramadol hcl CP24 QL (30 caps / 30 days)

2 QL M PA

tramadol hcl er TB24 QL (30 tabs / 30 days)

2 QL M PA

tramadol hcl er (biphasic) 100mg


2 QL M PA



2 QL M PA



2 QL M PA

tramadol hcl tab 50 mg QL (240 tabs / 30 days)

2 QL M

tramadol-acetaminophen QL (240 tabs / 30 days)

2 QL M

trezix QL (300 caps / 30 days)

2 QL M


2

Drug Name Drug Tier

Requirements/Limits

OPIOID ANALGESICS, CII ABSTRAL

QL (120 tabs / 30 days) 5 QL M PA

ARYMO ER 15mg, 30mg QL (90 tabs / 30 days)

4 QL M PA

ARYMO ER 60mg QL (90 tabs / 30 days)

5 QL M PA

codeine sulfate QL (180 tabs / 30 days)

2 QL M

EMBEDA CAP 20-0.8MG QL (60 caps / 30 days)

4 QL M PA


4 QL M PA

EMBEDA CAP 50-2MG QL (60 caps / 30 days)

4 QL M PA


4 QL M PA


4 QL M PA

EMBEDA CAP 100-4MG QL (60 caps / 30 days)

5 QL M PA

endocet 2.5-325mg QL (360 tabs / 30 days)

2 QL M

endocet 5-325mg QL (360 tabs / 30 days)

2 QL M

endocet 7.5-325mg QL (240 tabs / 30 days)

2 QL M

endocet 10-325mg QL (180 tabs / 30 days)

2 QL M

fentanyl citrate LPOP QL (120 lozenges / 30 days)

5 QL M PA

fentanyl citrate TABS QL (120 tabs / 30 days)

5 QL M PA

fentanyl patch 12 mcg/hr QL (10 patches / 30 days)

2 QL M PA


2 QL M PA


2 QL M PA


2 QL M PA


2 QL M PA

Drug Name Drug Tier

Requirements/Limits

FENTORA QL (120 tabs / 30 days)

5 QL M PA

hydrocodone-acetaminophen 2.5-325mg


2 QL M

hydrocodone-acetaminophen 5-300mg


2 QL M



2 QL M



2 QL M

hydrocodone-acetaminophen 7.5-325 mg/15ml

QL (2700 mL / 30 days)

2 QL M



2 QL M



2 QL M

hydrocodone-acetaminophen tab 10-325mg


2 QL M

hydrocodone-ibuprofen tab 5-200mg


2 QL M

hydrocodone-ibuprofen tab 7.5-200 mg


2 QL M

hydrocodone-ibuprofen tab 10-200mg


2 QL M

hydromorphone hcl LIQD QL (600 mL / 30 days)

2 QL M

hydromorphone hcl SOLN 4 B/D M

hydromorphone hcl TABS QL (180 tabs / 30 days)

2 QL M

HYDROMORPHONE HYDROCHLORI SOLN 1mg/ml, 2mg/ml, 4mg/ml

4 B/D M

hydromorphone tab 8mg er QL (30 tabs / 30 days)

2 QL M PA


2 QL M PA


5 QL M PA

hydromorphone tabs 32mg er QL (30 tabs / 30 days)

5 QL M PA


3

Drug Name Drug Tier

Requirements/Limits

HYSINGLA ER QL (30 tabs / 30 days)

3 QL M PA

KADIAN 40mg, 200mg QL (60 caps / 30 days)

5 QL M PA

LAZANDA QL (30 bottles / 30 days)

5 QL M PA

levorphanol tartrate TABS 2mg


5 QL M

lorcet hd tab 10-325mg QL (180 tabs / 30 days)

2 QL M

lorcet plus tab 7.5-325 QL (180 tabs / 30 days)

2 QL M

lorcet tab 5-325mg QL (240 tabs / 30 days)

2 QL M

methadone hcl SOLN 5mg/5ml, 10mg/5ml

QL (450 mL / 30 days)

2 QL M PA

methadone hcl SOLN 10mg/ml

2 M

methadone hcl 5mg QL (90 tabs / 30 days)

2 QL M PA

methadone hcl 10mg QL (90 tabs / 30 days)

2 QL M PA

methadone hcl intensol QL (90 mL / 30 days)

2 QL M PA

MORPHABOND ER 15mg, 30mg


4 QL M PA

MORPHABOND ER 60mg, 100mg


5 QL M PA

morphine sul inj 1mg/ml 4 B/D M

morphine sulfate CP24 10mg, 20mg, 30mg, 40mg, 50mg, 60mg, 80mg


2 QL M PA

morphine sulfate CP24 100mg


5 QL M PA

MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml

4 B/D M

morphine sulfate SOLN 4mg/ml, 8mg/ml, 10mg/ml

4 B/D M

morphine sulfate TABS 15mg


2 QL M

Drug Name Drug Tier

Requirements/Limits

morphine sulfate TABS 30mg


2 QL M

morphine sulfate beads QL (30 caps / 30 days)

2 QL M PA

morphine sulfate ext-rel tab 15mg, 30mg, 60mg, 100mg


2 QL M PA

morphine sulfate ext-rel tab 200mg


2 QL M PA

morphine sulfate oral soln 10mg/5ml

QL (900 mL / 30 days)

2 QL M


QL (750 mL / 30 days)

2 QL M


QL (180 mL / 30 days)

2 QL M

NUCYNTA 50mg, 75mg QL (180 tabs / 30 days)

4 QL M

NUCYNTA 100mg QL (180 tabs / 30 days)

5 QL M

NUCYNTA ER 50mg, 100mg, 200mg, 250mg


3 QL M PA

NUCYNTA ER 150mg QL (90 tabs / 30 days)

3 QL M PA

OXAYDO 5mg QL (540 tabs / 30 days)

4 QL M

OXAYDO 7.5mg QL (360 tabs / 30 days)

4 QL M

oxycodone hcl CAPS QL (180 caps / 30 days)

2 QL M

oxycodone hcl CONC QL (180 mL / 30 days)

2 QL M

oxycodone hcl SOLN QL (900 mL / 30 days)

2 QL M

oxycodone hcl TABS QL (180 tabs / 30 days)

2 QL M

oxycodone w/ acetaminophen 2.5-325mg


2 QL M

oxycodone w/ acetaminophen 5-325mg


2 QL M

oxycodone w/ acetaminophen 7.5-325mg


2 QL M


4

Drug Name Drug Tier

Requirements/Limits

oxycodone w/ acetaminophen 10-325mg


2 QL M

oxycodone-aspirin QL (360 tabs / 30 days)

2 QL M

oxycodone-ibuprofen QL (120 tabs / 30 days)

2 QL M

OXYCONTIN 10mg, 15mg, 20mg, 30mg, 40mg


4 QL M PA

OXYCONTIN 60mg, 80mg QL (60 tabs / 30 days)

5 QL M PA

oxymorphone tab QL (180 tabs / 30 days)

2 QL M

SUBSYS SPRAY 100MCG QL (120 sprays / 30 days)

5 QL M PA


5 QL M PA


5 QL M PA


5 QL M PA


5 QL M PA


5 QL M PA


5 QL M PA

vicodin es QL (180 tabs / 30 days)

2 QL M

vicodin hp QL (180 tabs / 30 days)

2 QL M

XTAMPZA ER 9mg, 13.5mg, 18mg, 27mg


4 QL M PA

XTAMPZA ER 36mg QL (240 caps / 30 days)

5 QL M PA

ZOHYDRO ER (ABUSE DETERRENT)


4 QL M PA

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) 2 B/D M

Drug Name Drug Tier

Requirements/Limits

lidocaine inj 0.5% 2 B/D M

lidocaine inj 1% 2 B/D M

lidocaine inj 1.5% preservative free (pf)

2 B/D M

lidocaine inj 2% preservative free (pf)

2 B/D M

lidocaine inj 4% preservative free (pf)

2 M

ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 2 M

ARIKAYCE 5 LA PA

BETHKIS 5 PA

gentamicin in saline 2 M

gentamicin sulfate SOLN 2 M

neomycin sulfate TABS 2 M

paromomycin sulfate CAPS 2 M

streptomycin sulfate SOLR 5 M

SULFADIAZINE TABS 4 M

TOBI PODHALER 5 LA PA

tobramycin NEBU 5 PA

tobramycin inj 1.2 gm/30ml 2 M

tobramycin inj 1.2gm 5 M

tobramycin inj 10mg/ml 2 M

tobramycin inj 40mg/ml 2 M

tobramycin inj 80mg/2ml 2 M

ZEMDRI 5 M

ANTI-INFECTIVES - MISCELLANEOUS albendazole TABS 5 M

ALINIA 5 M

atovaquone SUSP 5 M

AZACTAM INJ 4 M

aztreonam 2 M

CAYSTON 5 LA PA

clindamycin hcl CAPS 2 M

clindamycin phosphate in d5w 2 M

CLINDAMYCIN PHOSPHATE IN NACL

4 M

clindamycin phosphate inj 2 M

clindamycin soln 75mg/5ml 2 M

colistimethate sodium SOLR 2 M

DALVANCE 5 M

dapsone TABS 2 M

DAPTOMYCIN 350mg 5 M

daptomycin 350mg, 500mg 5 M

EMVERM 5 M

ertapenem sodium 2 M

FIRVANQ 4 M

imipenem-cilastatin 2 M


5

Drug Name Drug Tier

Requirements/Limits

ivermectin TABS 2 M

linezolid in sodium chloride 4 M

linezolid inj 2 M

linezolid susp 5 M

linezolid tab 600mg 5 M

meropenem 2 M

MEROPENEM/SODIUM CHLORIDE

4 M

methenamine hippurate 2 M

metronidazole CAPS 2 M

METRONIDAZOLE SOLN 3 M

metronidazole TABS 1 M

metronidazole inj 2 M

NEBUPENT 4 B/D M

nitrofurantoin SUSP PA applies if 70 years and older after a 90 day supply in a calendar year

4 M PA

nitrofurantoin macrocrystal PA applies if 70 years and older after a 90 day supply in a calendar year

3 M PA

nitrofurantoin monohyd macro PA applies if 70 years and older after a 90 day supply in a calendar year

3 M PA

ORBACTIV 5 M

PENTAM 300 4 M

pentamidine isethionate 2 M

polymyxin b sulfate SOLR 2 M

praziquantel TABS 2 M

SIVEXTRO 5 M

SOLOSEC 4 M

sulfamethoxazole-trimethop ds

1 M

sulfamethoxazole-trimethoprim inj

2 M

sulfamethoxazole-trimethoprim susp

2 M

sulfamethoxazole-trimethoprim tab 400-80mg

1 M

SYNERCID 5 M

tigecycline 5 M

trimethoprim TABS 1 M

VABOMERE 4 M

vancomycin hcl CAPS 125mg

2 M

vancomycin hcl CAPS 250mg

5 M

Drug Name Drug Tier

Requirements/Limits

vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg

2 M

VANCOMYCIN HYDROCHLORIDE SOLR

4 M

VANCOMYCIN IN NACL 4 M

VANCOMYCIN INJ 250MG 4 M

VIBATIV 5 M

XIFAXAN TAB 200MG QL (9 tabs / 30 days)

5 QL M

ANTIFUNGALS ABELCET 5 B/D M

AMBISOME 5 B/D M

amphotericin b SOLR 2 B/D M

caspofungin acetate 5 M

CRESEMBA 5 M

ERAXIS 5 M

fluconazole SUSR 2 M

fluconazole TABS 50mg, 100mg, 200mg

2 M

fluconazole TABS 150mg 1 M

fluconazole inj nacl 200 2 M

fluconazole inj nacl 400 2 M

flucytosine CAPS 5 M

griseofulvin microsize 2 M

griseofulvin ultramicrosize 2 M

itraconazole CAPS 2 M PA

itraconazole SOLN 5 M

ketoconazole TABS 2 M PA

MYCAMINE 5 M

NOXAFIL SOLN 5 M

NOXAFIL SUSP QL (630 mL / 30 days)

5 QL M

NOXAFIL TBEC QL (93 tabs / 30 days)

5 QL M

nystatin TABS 2 M

posaconazole QL (93 tabs / 30 days)

5 QL M

terbinafine hcl TABS QL (90 tabs / year)

1 QL M

TOLSURA 5 M PA

voriconazole SUSR; TABS 5 M

voriconazole inj 200mg 2 M

ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg

2 M

atovaquone-proguanil hcl tab 250-100 mg

2 M

chloroquine phosphate TABS

2 M


6

Drug Name Drug Tier

Requirements/Limits

COARTEM 4 M

mefloquine hcl 2 M

primaquine phosphate 26.3mg

2 M

PRIMAQUINE PHOSPHATE 26.3mg

3 M

quinine sulfate CAPS 2 M PA

ANTIRETROVIRAL AGENTS abacavir sulfate 2 M

APTIVUS 5 M

atazanavir sulfate 5 M

CRIXIVAN 4 M

didanosine 2 M

EDURANT 5 M

efavirenz CAPS 50mg 2 M

efavirenz CAPS 200mg 5 M

efavirenz TABS 5 M

EMTRIVA 3 M

fosamprenavir tab 700 mg 5 M

FUZEON 5

INTELENCE 25mg 4 M

INTELENCE 100mg, 200mg 5 M

INVIRASE 5 M

ISENTRESS CHEW 25mg 3 M

ISENTRESS CHEW 100mg 5 M

ISENTRESS PACK 3 M

ISENTRESS TABS 5 M

ISENTRESS HD 5 M

lamivudine 2 M

LEXIVA SUSP 4 M

nevirapine susp 50 mg/5ml 2 M

nevirapine tab 100mg er 2 M

nevirapine tab 200mg 2 M

nevirapine tab 400mg er 2 M

NORVIR PACK 4 M

NORVIR SOLN 4 M

PIFELTRO 5 M

PREZISTA SUSP QL (400 mL / 30 days)

5 QL M

PREZISTA TABS 75mg QL (480 tabs / 30 days)

3 QL M


5 QL M


5 QL M


5 QL M

RESCRIPTOR 4 M

REYATAZ PACK 5 M

Drug Name Drug Tier

Requirements/Limits

ritonavir 2 M

SELZENTRY SOLN 5 M

SELZENTRY TABS 25mg 4 M

SELZENTRY TABS 75mg, 150mg, 300mg

5 M

stavudine 2 M

tenofovir disoproxil fumarate 5 M

TIVICAY 10mg 3 M

TIVICAY 25mg, 50mg 5 M

TROGARZO 5 LA

TYBOST 4 M

VIDEX EC 125mg 4 M

VIDEX PEDIATRIC 4 M

VIRACEPT 5 M

VIRAMUNE SUSP 4 M

VIREAD POWD 5 M

VIREAD TABS 150mg, 200mg, 250mg

5 M

zidovudine cap 100mg 2 M

zidovudine syp 50mg/5ml 2 M

zidovudine tab 300mg 2 M

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine 2 M

abacavir sulfate-lamivudine-zidovudine

5 M

ATRIPLA 5 M

BIKTARVY 5 M

CIMDUO 5 M

COMPLERA 5 M

DELSTRIGO 5 M

DESCOVY 5 M

DOVATO 5 M

EVOTAZ 5 M

GENVOYA 5 M

JULUCA 5 M

KALETRA TAB 100-25MG 4 M

KALETRA TAB 200-50MG 5 M

lamivudine-zidovudine 2 M

lopinavir-ritonavir 2 M

ODEFSEY 5 M

PREZCOBIX 5 M

STRIBILD 5 M

SYMFI 5 M

SYMFI LO 5 M

SYMTUZA 5 M

TEMIXYS 5 M

TRIUMEQ 5 M


7

Drug Name Drug Tier

Requirements/Limits

TRUVADA TAB 100-150 QL (60 tabs / 30 days)

5 QL M


5 QL M


5 QL M


5 QL M

ANTITUBERCULAR AGENTS cycloserine CAPS 5 M

ethambutol hcl TABS 2 M

isoniazid SYRP 2 M

isoniazid tabs 1 M

PASER D/R 4 M

PRIFTIN 4 M

pyrazinamide TABS 2 M

rifabutin 2 M

RIFAMATE 4 M

rifampin CAPS; SOLR 2 M

RIFATER 4 M

SIRTURO 5 M LA PA

TRECATOR 4 M

ANTIVIRALS acyclovir CAPS; TABS 1 M

acyclovir SUSP 2 M

acyclovir sodium 2 B/D M

adefovir dipivoxil 5 M

BARACLUDE SOLN 5 M

cidofovir 5 M

entecavir 5 M

EPCLUSA 5 PA

EPIVIR HBV SOLN 4 M

famciclovir 2 M

GANCICLOVIR INJ 500MG/10ML

4 B/D M

ganciclovir sodium 2 B/D M

HARVONI TAB 90-400MG 5 PA

lamivudine (hbv) 2 M

MAVYRET 5 PA

oseltamivir phosphate CAPS; SUSR

2 M

PEGASYS 5 PA

PEGASYS PROCLICK 5 PA

PREVYMIS 5 M

RELENZA DISKHALER 3 M

ribavirin 200mg 2

rimantadine hydrochloride 2 M

valacyclovir hcl TABS 2 M

valganciclovir hcl 5 M

Drug Name Drug Tier

Requirements/Limits

VEMLIDY 5 M

VOSEVI 5 PA

XOFLUZA 4 M

ZEPATIER 5 PA

CEPHALOSPORINS AVYCAZ 5 M

cefaclor 2 M

CEFACLOR ER TAB 500MG 4 M

cefadroxil CAPS 1 M

cefadroxil SUSR; TABS 2 M

CEFAZOLIN IN DEXTROSE 2GM/100ML-4%

3 M

cefazolin inj 2 M

cefazolin sodium SOLR 1gm 2 M

CEFAZOLIN SODIUM 1 GM/50ML

3 M

cefdinir 2 M

CEFEPIME 1GM SOLN 4 M

CEFEPIME 2GM SOLN 4 M

cefepime inj 1gm 2 M

cefepime inj 2gm 2 M

CEFEPIME/DEXTROSE 4 M

cefixime cap 400mg 2 M

cefixime susr 2 M

cefotaxime sodium 1gm, 500mg

2 M

cefotetan disodium 2 M

CEFOXITIN SODIUM 4 M

cefoxitin sodium 1gm, 2gm, 10gm

2 M

cefpodoxime proxetil 2 M

cefprozil 2 M

ceftazidime SOLR 2 M

CEFTAZIDIME/DEXTROSE 4 M

ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

2 M

cefuroxime axetil 2 M

cefuroxime sodium 2 M

cephalexin CAPS 250mg, 500mg

1 M

cephalexin CAPS 750mg 2 M

cephalexin SUSR 2 M

cephalexin TABS 2 M

MAXIPIME 4 M

SUPRAX CHEW 4 M

SUPRAX SUSR 500mg/5ml 3 M

tazicef SOLR 2 M

TEFLARO 5 M


8

Drug Name Drug Tier

Requirements/Limits

ZERBAXA 5 M

ERYTHROMYCINS/MACROLIDES azithromycin PACK; SOLR; SUSR

2 M

azithromycin TABS 1 M

clarithromycin SUSR; TABS; TB24

2 M

DIFICID 5 M

e.e.s 400 2 M

ery-tab 2 M

ERYPED 400 5 M

ERYTHROCIN LACTOBIONATE

4 M

erythrocin stearate 2 M

erythromycin base 2 M

erythromycin cap 250mg ec 2 M

erythromycin ethylsuccinate SUSR 200mg/5ml

2 M

erythromycin ethylsuccinate SUSR 400mg/5ml

5 M

erythromycin ethylsuccinate TABS

2 M

erythromycin tab ec 2 M

FLUOROQUINOLONES BAXDELA 5 M

ciprofloxacin SUSR 2 M

ciprofloxacin hcl TABS 100mg

2 M

ciprofloxacin hcl TABS 250mg, 500mg, 750mg

1 M

ciprofloxacin in d5w 2 M

levofloxacin SOLN 2 M

levofloxacin TABS 1 M

levofloxacin in d5w 2 M

MOXIFLOXACIN HCL SOLN 4 M

moxifloxacin hcl TABS 2 M

moxifloxacin hcl in sodium chloride

2 M

PENICILLINS amoxicillin CAPS; SUSR; TABS

1 M

amoxicillin CHEW 2 M

amoxicillin & pot clavulanate 2 M

ampicillin & sulbactam sodium 2 M

ampicillin cap 500mg 2 M

ampicillin inj 2 M

ampicillin sodium 2 M

AUGMENTIN SUSP 125MG/5ML

4 M

Drug Name Drug Tier

Requirements/Limits

BACTOCILL INJ DEX 1GM 4 M

BACTOCILL INJ DEX 2GM 4 M

BICILLIN C-R 4 M

BICILLIN L-A 4 M

dicloxacillin sodium 2 M

NAFCILLIN IN DEXTROSE 4 M

nafcillin sodium 1gm, 2gm 2 M

nafcillin sodium 10gm 5 M

NAFCILLIN SODIUM FOR INJ 10GM

4 M

oxacillin sodium 1gm, 2gm 2 M

oxacillin sodium 10gm 5 M

PENICILLIN G POT IN DEXTROSE 1MU

4 M


4 M


4 M

PENICILLIN G PROCAINE 4 M

penicillin g sodium 2 M

penicillin v potassium SOLR 2 M

penicillin v potassium TABS 1 M

penicilln gk inj 5mu 2 M

penicilln gk inj 20mu 2 M

pfizerpen-g inj 5mu 2 M

pfizerpen-g inj 20mu 2 M

piper/tazoba inj 2-0.25gm 2 M





ZOSYN SOLN 4 M

TETRACYCLINES demeclocycline hcl 2 M

doxy 100 2 M

doxycycline (monohydrate) 2 M

doxycycline hyclate CAPS 2 M

doxycycline hyclate SOLR 2 M

doxycycline hyclate TABS 20mg, 100mg

2 M

doxycycline hyclate TBEC 2 M

doxycycline hyclate tab 75 mg dr

2 M


2 M


2 M

minocycline hcl CAPS; TABS

2 M


9

Drug Name Drug Tier

Requirements/Limits

minocycline tab 45mg er 2 M



mondoxyne nl cap 75mg 2 M

mondoxyne nl cap 100mg 2 M

morgidox cap 1x50mg 2 M

tetracycline hcl CAPS 2 M

VIBRAMYCIN SYRP 4 M

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA 5 B/D

cyclophosphamide CAPS 2 B/D M

cyclophosphamide SOLR 5 B/D M

dacarbazine 100mg 2 B/D M

EMCYT 4 M

GLEOSTINE 4 M

IFEX INJ 3GM 4 B/D M

ifosfamide inj 1gm/20ml 2 B/D M

IFOSFAMIDE INJ 3GM 4 B/D M

ifosfamide inj 3gm/60ml 2 B/D M

LEUKERAN 5 M

TREANDA 5 B/D M

ANTHRACYCLINES adriamycin SOLN 2 B/D M

doxorubicin hcl 2 B/D M

doxorubicin hcl liposomal 5 B/D M

epirubicin hcl 2 B/D M

ANTIBIOTICS bleomycin sulfate 2 B/D M

mitomycin SOLR 5 B/D M

ANTIMETABOLITES adrucil 2 B/D M

ALIMTA 5 B/D M

azacitidine 5 B/D M

cytarabine 2 B/D M

decitabine 5 B/D M

fludarabine phosphate 2 B/D M

fluorouracil SOLN 2 B/D M

gemcitabine inj soln 2 B/D M

gemcitabine inj solr 2 B/D M

INFUGEM 5 B/D M

mercaptopurine TABS 2 M

methotrexate sodium inj 2 B/D M

NIPENT 5 B/D M

PURIXAN 5

TABLOID 4 M

ANTIMITOTIC, TAXOIDS ABRAXANE 5 B/D M

Drug Name Drug Tier

Requirements/Limits

docetaxel CONC 20mg/ml, 80mg/4ml, 160mg/8ml

5 B/D M

DOCETAXEL CONC 80mg/4ml, 160mg/8ml, 200mg/10ml

5 B/D M

docetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

5 B/D M

DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

5 B/D M

paclitaxel 2 B/D M

TAXOTERE 80mg/4ml 5 B/D M

ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 2 B/D M

vincristine sulfate 2 B/D M

vinorelbine tartrate 2 B/D M

BIOLOGIC RESPONSE MODIFIERS ARZERRA 5 B/D M

AVASTIN 5 M LA PA

BELEODAQ 5 PA

BESPONSA 5 LA PA

BORTEZOMIB 5 M PA

DAURISMO 5 LA PA

ERBITUX 5 B/D M

ERIVEDGE 5 LA PA

FARYDAK 5 LA PA

HERCEPTIN 5 M PA

HERCEPTIN HYLECTA 5 M PA

IBRANCE 5 LA PA

IDHIFA 5 LA PA

KADCYLA 5 B/D M

KEYTRUDA SOLN 5 PA

KEYTRUDA SOLR 5 M PA

KISQALI 5 PA

KISQALI FEMARA 200 DOSE 5 PA



LIBTAYO 5 LA PA

LYNPARZA 5 LA PA

MYLOTARG 5 LA PA

NINLARO 5 PA

ODOMZO 5 LA PA

PERJETA 5 M PA

POTELIGEO 5 LA PA

RITUXAN 5 M LA PA

RITUXAN HYCELA 5 LA PA

RUBRACA 5 LA PA

TALZENNA 5 LA PA

TECENTRIQ 5 LA PA


10

Drug Name Drug Tier

Requirements/Limits

temsirolimus 5 B/D M

TIBSOVO 5 LA PA

TORISEL 5 B/D M

VECTIBIX 5 B/D M

VELCADE 5 M PA

VENCLEXTA 10mg, 50mg 4 LA PA

VENCLEXTA 100mg 5 LA PA

VENCLEXTA STARTING PACK

5 LA PA

VERZENIO 5 LA PA

YERVOY 5 M PA

ZEJULA 5 LA PA

ZOLINZA 5 PA

HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate 5 PA

anastrozole TABS 2 M

bicalutamide 2 M

DEPO-PROVERA INJ 400/ML 4 B/D M

ELIGARD INJ 7.5MG 4 B/D

ELIGARD INJ 22.5MG 4 B/D

ELIGARD INJ 30MG 4 B/D

ELIGARD INJ 45MG 4 B/D

ERLEADA 5 LA PA

exemestane 2 M

FASLODEX 5 B/D M

FIRMAGON 80mg 4 B/D

FIRMAGON 120mg 5 B/D

flutamide 2 M

fulvestrant 5 B/D M

hydroxyprogesterone caproate (antineoplastic)

5 B/D M

letrozole TABS 2 M

leuprolide inj 1mg/0.2 2 PA

LUPRON DEPOT (1-MONTH) 5 PA

LUPRON DEPOT INJ 11.25MG (3-MONTH)

5 PA

LUPRON DEPOT INJ 22.5MG (3-MONTH)

5 PA

LUPRON DEPOT INJ 30MG (4-MONTH)

5 PA

LYSODREN 3 M

megestrol ac sus 40mg/ml 4 M

megestrol ac tab 20mg 3 M

megestrol ac tab 40mg 3 M

megestrol sus 625mg/5ml 4 M PA

nilutamide 5 M

NUBEQA 5 LA PA

SOLTAMOX 5 M

tamoxifen citrate TABS 1 M

Drug Name Drug Tier

Requirements/Limits

toremifene citrate 5 M

TRELSTAR MIXJECT 5 PA

XTANDI 5 LA PA

ZYTIGA 500mg 5 LA PA

IMMUNOMODULATORS POMALYST 5 LA PA

REVLIMID 5 LA PA

THALOMID 5 PA

KINASE INHIBITORS AFINITOR

QL (30 tabs / 30 days) 5 QL PA

AFINITOR DISPERZ 2mg QL (150 tabs / 30 days)

5 QL PA


5 QL PA


5 QL PA

ALECENSA 5 LA PA

ALIQOPA 5 LA PA

ALUNBRIG 5 LA PA

BALVERSA 5 LA PA

BOSULIF 5 PA

BRAFTOVI 5 LA PA

CABOMETYX QL (30 tabs / 30 days)

5 QL LA PA

CALQUENCE 5 LA PA

CAPRELSA 5 LA PA

COMETRIQ 5 LA PA

COPIKTRA 5 LA PA

COTELLIC 5 LA PA

erlotinib hcl 25mg QL (90 tabs / 30 days)

5 QL PA

erlotinib hcl 100mg, 150mg QL (30 tabs / 30 days)

5 QL PA

GILOTRIF TAB 20MG 5 LA PA



ICLUSIG 5 LA PA

imatinib mesylate 100mg QL (90 tabs / 30 days)

5 QL PA

imatinib mesylate 400mg QL (60 tabs / 30 days)

5 QL PA

IMBRUVICA 5 LA PA

INLYTA 1mg QL (180 tabs / 30 days)

5 QL LA PA

INLYTA 5mg QL (120 tabs / 30 days)

5 QL LA PA

INREBIC 5 LA PA

IRESSA 5 LA PA


11

Drug Name Drug Tier

Requirements/Limits

JAKAFI QL (60 tabs / 30 days)

5 QL LA PA

LENVIMA 4 MG DAILY DOSE 5 LA PA

LENVIMA 8 MG DAILY DOSE 5 LA PA

LENVIMA 10 MG DAILY DOSE

5 LA PA

LENVIMA 12MG DAILY DOSE

5 LA PA


5 LA PA


5 LA PA


5 LA PA


5 LA PA

LORBRENA 5 LA PA

MEKINIST 5 LA PA

MEKTOVI 5 LA PA

NERLYNX 5 LA PA

NEXAVAR 5 LA PA

PIQRAY 200MG DAILY DOSE

5 PA


5 PA


5 PA

ROZLYTREK 5 LA PA

RYDAPT 5 PA

SPRYCEL 5 PA

STIVARGA 5 LA PA

SUTENT 5 PA

TAFINLAR 5 LA PA

TAGRISSO 5 LA PA

TARCEVA 25mg QL (90 tabs / 30 days)

5 QL LA PA

TARCEVA 100mg, 150mg QL (30 tabs / 30 days)

5 QL LA PA

TASIGNA 5 PA

TURALIO 5 LA PA

TYKERB 5 LA PA

VITRAKVI 5 LA PA

VIZIMPRO 5 LA PA

VOTRIENT 5 LA PA

XALKORI 5 LA PA

XOSPATA 5 LA PA

ZELBORAF 5 LA PA

ZYDELIG 5 LA PA

ZYKADIA 5 LA PA

Drug Name Drug Tier

Requirements/Limits

MISCELLANEOUS bexarotene 5 PA

HALAVEN 5 B/D M

hydroxyurea CAPS 2 M

IXEMPRA KIT 5 B/D M

LONSURF 5 PA

MATULANE 5 M LA

SYLATRON KIT 200MCG 5 M PA



SYNRIBO 5 PA

tretinoin CAPS 5 M

XPOVIO 60 MG ONCE WEEKLY

5 LA PA


5 LA PA

XPOVIO 80 MG TWICE WEEKLY

5 LA PA


5 LA PA

PLATINUM-BASED AGENTS carboplatin 2 B/D M

cisplatin SOLN 2 B/D M

oxaliplatin inj 50mg 5 B/D M

oxaliplatin inj 50mg/10ml 2 B/D M

oxaliplatin inj 100mg 5 B/D M

oxaliplatin inj 100mg/20ml 2 B/D M

PROTECTIVE AGENTS dexrazoxane hcl 5 B/D M

ELITEK 5 B/D M

KHAPZORY 5 B/D M

leucovorin calcium SOLR 2 B/D M

leucovorin calcium TABS 2 M

leucovorin calcium solr 2 B/D M

levoleucovorin calcium 175mg/17.5ml

5 B/D M

levoleucovorin calcium 250mg/25ml

2 B/D M

levoleucovorin calcium 50mg 5 B/D M

MESNEX TABS 5 M

TOPOISOMERASE INHIBITORS etoposide SOLN 2 B/D M

irinotecan hcl 2 B/D M

ONIVYDE 5 B/D

toposar 2 B/D M

topotecan hcl 5 B/D M

TOPOTECAN INJ 4MG/4ML 5 B/D M


12

Drug Name Drug Tier

Requirements/Limits

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl

1 M

benazepril & hydrochlorothiazide

1 M

captopril & hydrochlorothiazide

1 M

enalapril maleate & hydrochlorothiazide

1 M

fosinopril sodium & hydrochlorothiazide

1 M

lisinopril & hydrochlorothiazide 1 M

quinapril-hydrochlorothiazide 1 M

trandolapril-verapamil hcl 1 M

ACE INHIBITORS benazepril hcl TABS 1 M

captopril TABS 1 M

enalapril maleate TABS 1 M

EPANED 5 M

fosinopril sodium 1 M

lisinopril TABS 1 M

moexipril hcl 1 M

perindopril erbumine 1 M

QBRELIS 5 M

quinapril hcl 1 M

ramipril 1 M

trandolapril 1 M

ALDOSTERONE RECEPTOR ANTAGONISTS CAROSPIR 4 M

eplerenone 2 M

spironolactone TABS 1 M

ALPHA BLOCKERS doxazosin mesylate TABS 2 M

prazosin hcl 2 M

terazosin hcl 1 M

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil

1 M

amlodipine besylate-valsartan tab 5-160 mg

1 M


1 M


1 M

Drug Name Drug Tier

Requirements/Limits


1 M

amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg

1 M

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg

1 M

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg

1 M


1 M


1 M

candesartan cilexetil-hydrochlorothiazide

1 M

EDARBYCLOR 4 M

ENTRESTO 3 M

irbesartan-hydrochlorothiazide 1 M

losartan-hydrochlorothiazide 1 M

olmesartan medoxomil-amlodipine-hydrochlorothiazide

1 M

olmesartan medoxomil-hydrochlorothiazide

1 M

telmisartan-amlodipine 1 M

telmisartan-hydrochlorothiazide

1 M

valsartan-hydrochlorothiazide 1 M

ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil 1 M

EDARBI 4 M

eprosartan mesylate 1 M

irbesartan 1 M

losartan potassium 1 M

olmesartan medoxomil TABS

1 M

telmisartan 1 M

valsartan 1 M

ANTIARRHYTHMICS amiodarone hcl soln 2 M

amiodarone tab 100mg 2 M



disopyramide phosphate 4 M

dofetilide 2 M

flecainide acetate 2 M

mexiletine hcl 2 M

MULTAQ 4 M


13

Drug Name Drug Tier

Requirements/Limits

NORPACE CR 4 M

pacerone 100mg, 400mg 2 M

pacerone 200mg 1 M

propafenone hcl 2 M

propafenone hcl 12hr 2 M

quinidine gluconate 2 M

quinidine sulfate 2 M

sorine 2 M

sotalol hcl 2 M

sotalol hcl (afib/afl) 2 M

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 5 M ST

atorvastatin calcium TABS 1 M

FLOLIPID 4 M ST

fluvastatin sodium cap 20 mg 1 M

fluvastatin sodium cap 40 mg 1 M

fluvastatin sodium tab sr 24 hr 80 mg

1 M

LIVALO 4 M ST

lovastatin 1 M

pravastatin sodium 1 M

rosuvastatin calcium 1 M

simvastatin TABS 5mg, 10mg, 20mg, 40mg

1 M

simvastatin TABS 80mg QL (30 tabs / 30 days)

1 QL M

ZYPITAMAG 4 M ST

ANTILIPEMICS, MISCELLANEOUS ANTARA 4 M

cholestyramine 2 M

cholestyramine light 2 M

choline fenofibrate 2 M

colesevelam hcl 2 M

colestipol hcl gran 2 M

colestipol hcl pack 2 M

colestipol hcl tabs 2 M

ezetimibe 2 M

ezetimibe-simvastatin 1 M

fenofibrate CAPS 2 M

fenofibrate TABS 40mg, 48mg, 54mg, 145mg, 160mg

2 M

fenofibrate TABS 120mg 5 M

fenofibrate micronized 2 M

fenofibric acid 2 M

gemfibrozil TABS 1 M

JUXTAPID 5 LA PA

KYNAMRO 5 M PA

niacin (antihyperlipidemic) 2 M

Drug Name Drug Tier

Requirements/Limits

niacin er (antihyperlipidemic) 2 M

niacor 2 M

omega-3-acid ethyl esters 2 M PA

PRALUENT Lower cost version - Tier 4

5 M PA

prevalite 2 M

TRIGLIDE 4 M

VASCEPA 4 M

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone 2 M

bisoprolol & hydrochlorothiazide

1 M

DUTOPROL 4 M

metoprolol & hctz tab 50-25mg

2 M


2 M


2 M

nadolol & bendroflumethiazide 2 M

propranolol & hydrochlorothiazide

2 M

BETA-BLOCKERS acebutolol hcl CAPS 2 M

atenolol TABS 1 M

betaxolol hcl 2 M

bisoprolol fumarate 2 M

BYSTOLIC 4 M

carvedilol 1 M

carvedilol er 2 M

KAPSPARGO SPRINKLE 4 M

labetalol hcl SOLN; TABS 2 M

metoprolol succinate 2 M

metoprolol tartrate SOCT 2 M

metoprolol tartrate SOLN 2 M

metoprolol tartrate TABS 25mg, 50mg, 100mg

1 M

nadolol TABS 2 M

pindolol 2 M

propranolol hcl er 2 M

propranolol inj 1mg/ml 2 M

propranolol oral sol 2 M

propranolol tab 2 M

SOTYLIZE 4 M

timolol maleate TABS 2 M


14

Drug Name Drug Tier

Requirements/Limits

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate-atorvastatin calcium

1 M

CALCIUM CHANNEL BLOCKERS amlodipine besylate TABS 1 M

CARDIZEM LA 120mg 4 M

cartia xt 2 M

dilt-xr cap 2 M

diltiazem cap 180mg cd 2 M



diltiazem cap er/12hr 2 M

diltiazem er tab 180mg 2 M





diltiazem hcl TABS 2 M

diltiazem hcl coated beads cap sr 24hr

2 M

diltiazem hcl extended release beads cap sr

2 M

diltiazem inj 2 M

felodipine 2 M

isradipine 2 M

matzim la 2 M

nicardipine hcl CAPS 2 M

nifedipine TB24 2 M

nifedipine er 2 M

nimodipine CAPS 5 M

nisoldipine 2 M

NYMALIZE 5 M

taztia xt 2 M

verapamil hcl CP24; SOLN 2 M

verapamil hcl TABS; TBCR 1 M

DIGITALIS GLYCOSIDES digitek .25mg

PA if 70 years and older 2 M PA

digitek .125mg QL (30 tabs / 30 days)

2 QL M

digox 125mcg QL (30 tabs / 30 days)

2 QL M

digox 250mcg PA if 70 years and older

2 M PA

digoxin TABS 125mcg QL (30 tabs / 30 days)

2 QL M

digoxin TABS 250mcg PA if 70 years and older

2 M PA

Drug Name Drug Tier

Requirements/Limits

digoxin inj 2 M

digoxin sol 50mcg/ml PA if 70 years and older

2 M PA

LANOXIN PEDIATRIC 4 M

LANOXIN TABS 62.5 MCG QL (60 tabs / 30 days)

4 QL M

DIRECT RENIN INHIBITORS/COMBINATIONS aliskiren fumarate 2 M

TEKTURNA 4 M

TEKTURNA HCT 4 M

DIURETICS acetazolamide CP12; TABS 2 M

ALDACTAZIDE TAB 50/50 4 M

amiloride & hydrochlorothiazide

2 M

amiloride hcl TABS 2 M

bumetanide 2 M

chlorothiazide tabs 2 M

chlorthalidone 2 M

DIURIL SUS 250/5ML 4 M

DYRENIUM 4 M

ethacrynic acid 5 M

furosemide SOLN; TABS 1 M

furosemide inj 2 M

furosemide oral soln 8 mg/ml 1 M

hydrochlorothiazide CAPS; TABS

1 M

indapamide 2 M

methazolamide TABS 2 M

methyclothiazide 2 M

metolazone 2 M

spironolactone & hydrochlorothiazide

2 M

torsemide tabs 2 M

triamt/hctz cap 37.5-25 1 M

triamterene CAPS 2 M

triamterene & hydrochlorothiazide tabs

1 M

MISCELLANEOUS BIDIL 3 M

clonidine hcl TABS 1 M

clonidine hcl ptwk 2 M

CORLANOR SOLN 4 M

CORLANOR TABS 4 M

DEMSER 5 M PA

hydralazine hcl SOLN; TABS 2 M

KEVEYIS 5 PA

midodrine hcl 2 M


15

Drug Name Drug Tier

Requirements/Limits

minoxidil TABS 2 M

NORTHERA 5 LA PA

phenoxybenzamine hcl CAPS

5 M PA

ranolazine 2 M

VYNDAQEL 5 LA PA

NITRATES DILATRATE SR 4 M

ISORDIL TITRADOSE 40mg 5 M

isosorbide dinitrate 2 M

isosorbide dinitrate er 2 M

isosorbide mononitrate 1 M

isosorbide mononitrate er 2 M

minitran 2 M

NITRO-BID 3 M

NITRO-DUR .3mg/hr, .8mg/hr

4 M

nitroglycerin SOLN .4mg/spray

2 M

nitroglycerin SUBL 2 M

nitroglycerin td patch 2 M

PULMONARY ARTERIAL HYPERTENSION ADEMPAS 5 LA PA

alyq 5 PA

ambrisentan 5 LA PA

bosentan 5 LA PA

OPSUMIT 5 LA PA

ORENITRAM TAB 0.25MG 5 LA PA


ORENITRAM TAB 1MG 5 LA PA


ORENITRAM TAB 5MG 5 LA PA

REMODULIN 5 LA PA

REVATIO SUSR 5 PA

sildenafil citrate sus 10mg/ml (pulmonary hypertension)

5 PA

sildenafil citrate tab 20 mg (pulmonary hypertension)

2 PA

tadalafil (pulmonary hypertension)

5 PA

TRACLEER 5 LA PA

treprostinil 5 LA PA

TYVASO 5 PA

UPTRAVI 5 LA PA

VENTAVIS 5 PA

CENTRAL NERVOUS SYSTEM ANTIANXIETY ALPRAZOLAM CONC

QL (300 mL / 30 days) 4 QL M

Drug Name Drug Tier

Requirements/Limits

alprazolam TABS QL (150 tabs / 30 days)

2 QL M

buspirone hcl TABS 2 M

fluvoxamine maleate 2 M

fluvoxamine maleate er 100mg


2 QL M

fluvoxamine maleate er 150mg


2 QL M

lorazepam SOLN 2 M

lorazepam TABS QL (150 tabs / 30 days)

2 QL M

lorazepam intensol QL (150 mL / 30 days)

2 QL M

ANTICONVULSANTS APTIOM 5 M

BANZEL SUS 40MG/ML 5 M PA

BANZEL TAB 200MG 5 M PA

BANZEL TAB 400MG 5 M PA

BRIVIACT INJ 50MG/5ML 4 M PA

BRIVIACT SOL 10MG/ML 5 M PA

BRIVIACT TAB 10MG 5 M PA





carbamazepine CHEW; CP12; SUSP; TABS; TB12

2 M

CELONTIN 4 M

clobazam 2 M PA

clonazepam TABS 2mg QL (300 tabs / 30 days)

2 QL M

clonazepam TABS .5mg, 1mg


2 QL M

clonazepam TBDP 2mg QL (300 tabs / 30 days)

2 QL M

clonazepam TBDP .125mg, .25mg, .5mg, 1mg


2 QL M

clorazepate dipotassium QL (180 tabs / 30 days)

PA if 65 years and older

2 QL M PA

DIASTAT ACUDIAL 4 M

DIASTAT PEDIATRIC 4 M

diazepam TABS QL (120 tabs / 30 days)


2 QL M PA

diazepam gel 2 M


16

Drug Name Drug Tier

Requirements/Limits

diazepam inj 2 M

diazepam intensol QL (240 mL / 30 days)


2 QL M PA

diazepam oral soln 1 mg/ml QL (1200 mL / 30 days)


2 QL M PA

DILANTIN CAP 30MG 3 M

DILANTIN CAP 100MG 3 M

DILANTIN CHEW TAB 50MG 3 M

DILANTIN-125 SUSP 4 M

divalproex sodium CSDR; TB24; TBEC

2 M

EPIDIOLEX QL (600 mL / 30 days)

5 QL LA PA

epitol 2 M

ethosuximide CAPS; SOLN 2 M

felbamate SUSP 5 M

felbamate TABS 2 M

FYCOMPA SUSP 5 M PA

FYCOMPA TABS 2mg 4 M PA

FYCOMPA TABS 4mg, 6mg, 8mg, 10mg, 12mg

5 M PA

gabapentin CAPS 100mg QL (1080 caps / 30 days)

1 QL M


1 QL M


1 QL M

gabapentin SOLN QL (2160 mL / 30 days)

2 QL M

gabapentin TABS 600mg QL (180 tabs / 30 days)

2 QL M

gabapentin TABS 800mg QL (120 tabs / 30 days)

2 QL M

LAMICTAL ODT KIT 4 M

LAMICTAL XR KIT 4 M

lamotrigine CHEW; KIT; TB24; TBDP

2 M

lamotrigine TABS 1 M

levetiracetam SOLN; TABS; TB24

2 M

levetiracetam in sodium chloride

2 M

levetiracetam oral soln 100 mg/ml

2 M

LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg


3 QL M

Drug Name Drug Tier

Requirements/Limits

LYRICA CAPS 200mg QL (90 caps / 30 days)

3 QL M

LYRICA CAPS 225mg, 300mg


3 QL M

LYRICA SOLN QL (946 mL / 30 days)

3 QL M

NAYZILAM 4 M

oxcarbazepine 2 M

OXTELLAR XR 150mg, 300mg

4 M

OXTELLAR XR 600mg 5 M

PEGANONE 4 M

phenobarbital ELIX PA if 70 years and older

4 M PA

phenobarbital TABS PA if 70 years and older

3 M PA

PHENOBARBITAL SODIUM SOLN 65mg/ml


4 M PA

phenobarbital sodium SOLN 130mg/ml


4 M PA

PHENYTEK 3 M

phenytoin CHEW; SUSP 2 M

phenytoin sodium extended 2 M

phenytoin sodium inj 50mg/ml 2 M

pregabalin CAPS 25mg, 50mg, 75mg, 100mg, 150mg


2 QL M

pregabalin CAPS 200mg QL (90 caps / 30 days)

2 QL M

pregabalin CAPS 225mg, 300mg


2 QL M

pregabalin SOLN QL (946 mL / 30 days)

2 QL M

primidone TABS 2 M

roweepra 2 M

roweepra xr 2 M

SPRITAM 4 M

subvenite starter kit 2 M

subvenite tab 1 M

SYMPAZAN 5mg 4 M PA

SYMPAZAN 10mg, 20mg 5 M PA

tiagabine hcl 2 M

topiramate CPSP; CS24 2 M

topiramate TABS 1 M

TROKENDI XR 25mg, 50mg, 100mg

4 M


17

Drug Name Drug Tier

Requirements/Limits

TROKENDI XR 200mg 5 M

valproate sodium SOLN 2 M

valproic acid CAPS 2 M

vigabatrin powd pack 500mg QL (180 packets / 30 days)

5 QL LA PA

vigabatrin tab 500mg QL (180 tabs / 30 days)

5 QL LA PA

vigadrone QL (180 packets / 30 days)

5 QL LA PA

VIMPAT 50mg 4 M

VIMPAT 100mg, 150mg, 200mg

5 M

VIMPAT INJ 200MG/20ML 5 M

VIMPAT SOL 10MG/ML 5 M

zonisamide CAPS 2 M

ANTIDEMENTIA donepezil odt 5mg 2 M

donepezil odt 10mg 2 M

donepezil tab hcl 23mg 2 M

donepezil tabs 5mg 2 M

donepezil tabs 10mg 2 M

galantamine hydrobromide 2 M

galantamine hydrobromide er 2 M

memantine hcl cp24 PA if < 30 yrs

2 M PA

memantine soln PA if < 30 yrs

2 M PA

memantine tabs PA if < 30 yrs

2 M PA

NAMZARIC 4 M

rivastigmine tartrate 2 M

rivastigmine td patch 24hr 4.6 mg/24hr

2 M


2 M


2 M

ANTIDEPRESSANTS amitriptyline hcl TABS 3 M

amoxapine 3 M

APLENZIN 5 M

bupropion hcl TABS 2 M

bupropion hcl TB12 2 M

bupropion hcl TB24 150mg, 300mg

2 M

bupropion hcl TB24 450mg QL (30 tabs / 30 days)

2 QL M

Drug Name Drug Tier

Requirements/Limits

citalopram hydrobromide SOLN

2 M

citalopram hydrobromide TABS

1 M

clomipramine hcl CAPS 4 M PA

desipramine hcl TABS 4 M

desvenlafaxine succinate 2 M PA

doxepin hcl CAPS; CONC 3 M

duloxetine hcl CPEP 20mg QL (180 caps / 30 days)

2 QL M


2 QL M


2 QL M

EMSAM 5 M PA

escitalopram oxalate SOLN 2 M

escitalopram oxalate TABS 1 M

FETZIMA 4 M PA

FETZIMA TITRATION PACK 4 M PA

fluoxetine cap 10mg 1 M



fluoxetine hcl CPDR; SOLN; TABS

2 M

imipramine hcl TABS 3 M

imipramine pamoate 4 M

maprotiline hcl 2 M

MARPLAN 4 M

mirtazapine TABS 1 M

mirtazapine TBDP 2 M

nefazodone hcl 2 M

nortriptyline hcl CAPS 2 M

nortriptyline hcl SOLN 4 M

paroxetine er tab QL (60 tabs / 30 days)

4 QL M

paroxetine hcl tabs 2 M

PAXIL SUSP 4 M

PEXEVA 10mg, 30mg QL (60 tabs / 30 days)

4 QL M

PEXEVA 20mg, 40mg QL (30 tabs / 30 days)

4 QL M

phenelzine sulfate TABS 2 M

protriptyline hcl 4 M

sertraline hcl CONC 2 M

sertraline hcl TABS 1 M

tranylcypromine sulfate 2 M

trazodone hcl TABS 50mg, 100mg, 150mg

1 M

trazodone hcl TABS 300mg 2 M


18

Drug Name Drug Tier

Requirements/Limits

trimipramine maleate CAPS 4 M

TRINTELLIX 4 M

venlafaxine cap er 1 M

venlafaxine tab 2 M

VIIBRYD STARTER PACK 4 M

VIIBRYD TAB 4 M

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS


amantadine hcl SYRP; TABS

2 M

APOKYN QL (20 cartridges / 30 days)

5 QL LA PA

benztropine mesylate inj 2 M

benztropine mesylate tab 0.5mg


3 M PA

benztropine mesylate tab 1mg PA if 70 years and older

3 M PA

benztropine mesylate tab 2mg PA if 70 years and older

3 M PA

bromocriptine mesylate CAPS; TABS

2 M

carbidopa TABS 5 M

carbidopa-levodopa 2 M

carbidopa/levodopa/entacapone

2 M

DUOPA 5 B/D

entacapone 2 M

GOCOVRI QL (60 caps / 30 days)

5 QL M LA PA

INBRIJA 5 LA PA

NEUPRO 4 M

OSMOLEX ER QL (30 tabs / 30 days)

4 QL M PA

pramipexole dihydrochloride 2 M

pramipexole tab 0.5mg 2 M


pramipexole tab 0.75 er 2 M





pramipexole tab 1.5mg er 2 M

pramipexole tab 1mg 2 M


pramipexole tab 3mg 2 M


Drug Name Drug Tier

Requirements/Limits

rasagiline mesylate TABS 2 M

ropinirole tab 0.5mg 2 M

ropinirole tab 0.25mg 2 M

ropinirole tab 1mg 2 M


ropinirole tab 2mg er 2 M








RYTARY 4 M

selegiline hcl CAPS; TABS 2 M

trihexyphenidyl hcl PA if 70 years and older

3 M PA

XADAGO 5 M

ZELAPAR 5 M

ANTIPSYCHOTICS ABILIFY MAINTENA

QL (1 injection / 28 days)

5 QL M

aripiprazole odt QL (60 tabs / 30 days)

5 QL M

aripiprazole oral solution 1 mg/ml

QL (900 mL / 30 days)

5 QL M

aripiprazole tab QL (30 tabs / 30 days)

2 QL M

ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml


5 QL M

ARISTADA 1064mg/3.9ml QL (1 injection / 56 days)

5 QL M

ARISTADA INITIO 5 M

chlorpromazine hcl TABS 2 M

CHLORPROMAZINE INJ 4 M

clozapine odt 12.5mg, 25mg 2 M PA

clozapine odt 100mg QL (270 tabs / 30 days)

2 QL M PA


2 QL M PA


5 QL M PA

clozapine tab 25mg 2 M

clozapine tab 50mg 2 M


19

Drug Name Drug Tier

Requirements/Limits

clozapine tab 100mg QL (270 tabs / 30 days)

2 QL M

clozapine tab 200mg QL (135 tabs / 30 days)

2 QL M

FANAPT QL (60 tabs / 30 days)

4 QL M

FANAPT TITRATION PACK 4 M

fluphenazine decanoate SOLN

2 M

fluphenazine hcl 2 M

GEODON INJ QL (6 mL / 3 days)

4 QL M

haloperidol TABS 2 M

haloperidol conc 2mg/ml 2 M

haloperidol decanoate SOLN 2 M

haloperidol lactate inj 5mg/ml 2 M

INVEGA SUST INJ 39 MG/0.25 ML


4 QL M



5 QL M



5 QL M

INVEGA SUST INJ 156MG/ML


5 QL M



5 QL M

INVEGA TRINZA QL (1 injection / 90 days)

5 QL M

LATUDA 20mg, 60mg, 80mg QL (60 tabs / 30 days)

4 QL M

LATUDA 40mg, 120mg QL (30 tabs / 30 days)

4 QL M

loxapine succinate 2 M

molindone hcl 2 M

NUPLAZID CAPS QL (30 caps / 30 days)

5 QL LA PA

NUPLAZID TABS 10MG QL (30 tabs / 30 days)

5 QL LA PA

Drug Name Drug Tier

Requirements/Limits

NUPLAZID TABS 17MG QL (60 tabs / 30 days)

5 QL LA PA

olanzapine SOLR QL (3 vials / 1 day)

2 QL M

olanzapine TABS 2.5mg QL (240 tabs / 30 days)

2 QL M

olanzapine TABS 5mg QL (120 tabs / 30 days)

2 QL M

olanzapine TABS 7.5mg, 15mg, 20mg


2 QL M

olanzapine TABS 10mg QL (60 tabs / 30 days)

2 QL M

olanzapine odt 5mg, 15mg, 20mg


2 QL M

olanzapine odt 10mg QL (60 tabs / 30 days)

2 QL M

paliperidone 1.5mg, 3mg, 9mg


5 QL M

paliperidone 6mg QL (60 tabs / 30 days)

5 QL M

perphenazine TABS 2 M

PERSERIS QL (1 injection / 30 days)

5 QL M

pimozide 2 M

quetiapine fumarate TABS 2 M

quetiapine fumarate TB24 50mg, 300mg, 400mg


2 QL M

quetiapine fumarate TB24 150mg, 200mg


2 QL M

REXULTI 1mg QL (90 tabs / 30 days)

5 QL M

REXULTI 2mg QL (60 tabs / 30 days)

5 QL M

REXULTI 3mg, 4mg QL (30 tabs / 30 days)

5 QL M

REXULTI .5mg QL (180 tabs / 30 days)

5 QL M

REXULTI .25mg QL (360 tabs / 30 days)

5 QL M

RISPERDAL INJ 12.5MG QL (2 injections / 28 days)

4 QL M


20

Drug Name Drug Tier

Requirements/Limits

RISPERDAL INJ 25MG QL (2 injections / 28 days)

4 QL M

RISPERDAL INJ 37.5MG QL (2 injections / 28 days)

5 QL M

RISPERDAL INJ 50MG QL (2 injections / 28 days)

5 QL M

risperidone SOLN QL (240 mL / 30 days)

2 QL M

risperidone TABS 2 M

risperidone odt .5mg QL (90 tabs / 30 days)

2 QL M

risperidone odt .25mg, 1mg, 2mg, 3mg, 4mg


2 QL M

SAPHRIS 2.5mg QL (240 tabs / 30 days)

4 QL M

SAPHRIS 5mg QL (120 tabs / 30 days)

4 QL M

SAPHRIS 10mg QL (60 tabs / 30 days)

4 QL M

thioridazine hcl TABS 2 M

thiothixene 2 M

trifluoperazine hcl 2 M

VERSACLOZ QL (600 mL / 30 days)

5 QL M PA

VRAYLAR 1.5mg QL (60 caps / 30 days)

5 QL M PA

VRAYLAR 3mg, 4.5mg, 6mg QL (30 caps / 30 days)

5 QL M PA

VRAYLAR THERAPY PACK 4 M PA

ziprasidone hcl QL (60 caps / 30 days)

2 QL M

ZYPREXA RELPREVV 300mg

QL (2 vials / 28 days)

5 QL M PA

ZYPREXA RELPREVV 405mg

QL (1 vial / 28 days)

5 QL M PA

ZYPREXA RELPREVV INJ 210MG

QL (2 vials / 28 days)

4 QL M PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER ADZENYS ER SUS 1.25MG

QL (450 ml / 30 days) 4 QL M

Drug Name Drug Tier

Requirements/Limits

ADZENYS XR-ODT 3.1mg, 6.3mg, 9.4mg


4 QL M

ADZENYS XR-ODT 12.5mg, 15.7mg, 18.8mg


4 QL M

amphetamine cap 10mg er QL (90 caps / 30 days)

2 QL M


2 QL M


2 QL M


2 QL M


2 QL M

amphetamine-dextroamphetamine cap sr 24hr 5 mg


2 QL M

amphetamine-dextroamphetamine tab 5 mg


2 QL M

amphetamine-dextroamphetamine tab 7.5 mg


2 QL M



2 QL M

amphetamine-dextroamphetamine tab 12.5 mg


2 QL M



2 QL M



2 QL M



2 QL M

APTENSIO XR 10mg, 15mg, 20mg, 30mg


4 QL M

APTENSIO XR 40mg, 50mg, 60mg


4 QL M

atomoxetine hcl 10mg, 18mg, 25mg


2 QL M

atomoxetine hcl 40mg QL (60 caps / 30 days)

2 QL M


21

Drug Name Drug Tier

Requirements/Limits

atomoxetine hcl 60mg, 80mg, 100mg


2 QL M

COTEMPLA XR-ODT QL (60 tabs / 30 days)

4 QL M

DAYTRANA QL (30 patches / 30 days)

4 QL M

dexmethylphenidate hcl CP24 5mg, 10mg, 15mg, 20mg


2 QL M

dexmethylphenidate hcl CP24 25mg, 30mg, 35mg, 40mg


2 QL M

dexmethylphenidate hcl TABS 2.5mg, 5mg


2 QL M

dexmethylphenidate hcl TABS 10mg


2 QL M

DYANAVEL XR QL (240 ml / 30 days)

4 QL M

guanfacine er (adhd) PA if 70 years and older

3 M PA

metadate er tab 20mg QL (90 tabs / 30 days)

2 QL M

methylphenidate hcl CHEW QL (180 tabs / 30 days)

2 QL M

methylphenidate hcl CP24 10mg, 20mg, 30mg


2 QL M

methylphenidate hcl CP24 40mg, 60mg


2 QL M

methylphenidate hcl CPCR 10mg, 20mg, 30mg


2 QL M

methylphenidate hcl CPCR 40mg, 50mg, 60mg


2 QL M

methylphenidate hcl SOLN 5mg/5ml

QL (1800 mL / 30 days)

2 QL M

methylphenidate hcl SOLN 10mg/5ml

QL (900 mL / 30 days)

2 QL M

methylphenidate hcl TABS 5mg, 10mg


2 QL M

Drug Name Drug Tier

Requirements/Limits

methylphenidate hcl TABS 20mg


2 QL M

methylphenidate hcl TB24 QL (60 tabs / 30 days)

2 QL M

methylphenidate hcl TBCR 18mg, 27mg, 36mg


2 QL M

methylphenidate hcl TBCR 54mg


2 QL M

methylphenidate hcl 72mg er QL (30 tabs / 30 days)

2 QL M

methylphenidate hcl er 27mg, 36mg


2 QL M

methylphenidate hcl er 54mg QL (30 tabs / 30 days)

2 QL M

methylphenidate tab 10mg er QL (90 tabs / 30 days)

2 QL M

methylphenidate tab 20mg er QL (90 tabs / 30 days)

2 QL M

MYDAYIS CAP 12.5MG QL (60 caps / 30 days)

4 QL M

MYDAYIS CAP 25MG QL (60 caps / 30 days)

4 QL M

MYDAYIS CAP 37.5MG QL (30 caps / 30 days)

4 QL M

MYDAYIS CAP 50MG QL (30 caps / 30 days)

4 QL M

QUILLICHEW ER 20mg, 30mg


4 QL M

QUILLICHEW ER 40mg QL (30 tabs / 30 days)

4 QL M

QUILLIVANT XR QL (360 mL / 30 days)

4 QL M

relexxii QL (30 tabs / 30 days)

2 QL M

VYVANSE CAPS 10mg, 20mg, 30mg


4 QL M

VYVANSE CAPS 40mg, 50mg, 60mg, 70mg


4 QL M

VYVANSE CHEW 10mg, 20mg, 30mg


4 QL M


22

Drug Name Drug Tier

Requirements/Limits

VYVANSE CHEW 40mg, 50mg, 60mg


4 QL M

HYPNOTICS HETLIOZ 5 LA PA

SILENOR 3mg QL (60 tabs / 30 days)

3 QL M

SILENOR 6mg QL (30 tabs / 30 days)

3 QL M

temazepam 7.5mg QL (30 caps / 30 days)

PA applies if 65 years and older after a 90 day supply in a calendar year

2 QL M PA

temazepam 15mg QL (60 caps / 30 days)


2 QL M PA

zolpidem tartrate TABS QL (30 tabs / 30 days)


2 QL M PA

MIGRAINE AIMOVIG

QL (1 pen / 30 days) 3 QL M PA

almotriptan malate QL (12 tabs / 30 days)

2 QL M

dihydroergotamine mesylate inj 1 mg/ml

5 M

dihydroergotamine mesylate nasal

QL (8 mL / 30 days)

5 QL M

eletriptan hydrobromide QL (12 tabs / 30 days)

2 QL M

EMGALITY SOAJ QL (2 pens / 30 days)

3 QL M PA

EMGALITY SOSY 120mg/ml QL (2 syringes / 30 days)

3 QL M PA

ergotamine w/ caffeine 2 M

frovatriptan succinate QL (18 tabs / 30 days)

2 QL M

naratriptan hcl QL (12 tabs / 30 days)

2 QL M

ONZETRA XSAIL QL (16 nosepieces / 30 days)

4 QL M ST

Drug Name Drug Tier

Requirements/Limits

rizatriptan benzoate QL (18 tabs / 30 days)

2 QL M

rizatriptan benzoate odt QL (18 tabs / 30 days)

2 QL M

sumatriptan inj 4mg/0.5ml QL (18 injections / 30 days)

2 QL M

sumatriptan inj 6mg/0.5ml QL (12 injections / 30 days)

2 QL M

sumatriptan succinate SOLN 5mg/act

QL (24 inhalers / 30 days)

2 QL M

sumatriptan succinate SOLN 20mg/act


2 QL M

sumatriptan succinate TABS QL (12 tabs / 30 days)

2 QL M

sumatriptan-naproxen sodium QL (9 tabs / 30 days)

2 QL M

TREXIMET TAB 10-60MG QL (9 tabs / 30 days)

5 QL M

ZEMBRACE SYMTOUCH QL (24 pens / 30 days)

5 QL M ST

zolmitriptan TABS QL (12 tabs / 30 days)

2 QL M

zolmitriptan odt QL (12 tabs / 30 days)

2 QL M

ZOMIG NASAL SPRAY QL (12 inhalers / 30 days)

4 QL M ST

MISCELLANEOUS AUSTEDO 6mg

QL (60 tabs / 30 days) 5 QL LA PA

AUSTEDO 9mg, 12mg QL (120 tabs / 30 days)

5 QL LA PA

EQUETRO 4 M

GRALISE 300mg QL (180 tabs / 30 days)

4 QL M PA

GRALISE 600mg QL (90 tabs / 30 days)

4 QL M PA

GRALISE STARTER 4 M PA

HORIZANT 4 M PA

INGREZZA CAPS QL (30 caps / 30 days)

5 QL PA

INGREZZA CPPK QL (28 caps / 28 days)

5 QL PA


23

Drug Name Drug Tier

Requirements/Limits

lithium carbonate CAPS; TABS

1 M

lithium carbonate TBCR 2 M

LITHIUM SOLN 8MEQ/5ML 4 M

LYRICA CR 82.5mg, 165mg QL (90 tabs / 30 days)

3 QL M PA

LYRICA CR 330mg QL (60 tabs / 30 days)

3 QL M PA

NUEDEXTA QL (60 caps / 30 days)

4 QL M PA

paroxetine mesylate (vasomotor)


4 QL M

pyridostigmine bromide SOLN

5 M

pyridostigmine bromide TBCR

2 M

pyridostigmine tab 60mg 2 M

riluzole 2 M

SAVELLA 12.5mg QL (480 tabs / 30 days)

4 QL M

SAVELLA 25mg QL (240 tabs / 30 days)

4 QL M


4 QL M


4 QL M

SAVELLA TITRATION PACK 4 M

tetrabenazine 12.5mg QL (240 tabs / 30 days)

5 QL PA

tetrabenazine 25mg QL (120 tabs / 30 days)

5 QL PA

TIGLUTIK QL (600 mL / 30 days)

5 QL M PA

MULTIPLE SCLEROSIS AGENTS BETASERON

QL (14 syringes / 28 days)

5 QL PA

dalfampridine 5 PA

GILENYA CAP 0.5MG QL (28 caps / 28 days)

5 QL PA

glatiramer acetate 20mg/ml QL (30 syringes / 30 days)

5 QL PA

glatiramer acetate 40mg/ml QL (12 syringes / 28 days)

5 QL PA

glatopa 20mg/ml QL (30 syringes / 30 days)

5 QL PA

Drug Name Drug Tier

Requirements/Limits

glatopa 40mg/ml QL (12 syringes / 28 days)

5 QL PA

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 2 M

BOTOX 5 M PA

cyclobenzaprine hcl TABS 5mg, 10mg


3 M PA

dantrolene sodium CAPS 2 M

tizanidine 2 M

XEOMIN INJ 50 UNITS 4 M PA



NARCOLEPSY/CATAPLEXY armodafinil 50mg

QL (90 tabs / 30 days) 2 QL M PA

armodafinil 150mg, 200mg, 250mg


2 QL M PA

modafinil 100mg QL (30 tabs / 30 days)

2 QL M PA

modafinil 200mg QL (60 tabs / 30 days)

2 QL M PA

XYREM QL (540 mL / 30 days)

5 QL LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium 2 M

BUNAVAIL MIS 2.1-0.3MG QL (90 films / 30 days)

4 QL M

BUNAVAIL MIS 4.2-0.7MG QL (90 films / 30 days)

4 QL M

BUNAVAIL MIS 6.3-1MG QL (60 films / 30 days)

4 QL M

buprenorphine hcl SUBL QL (90 tabs / 30 days)

2 QL M PA

buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg

QL (90 films / 30 days)

2 QL M

buprenorphine hcl-naloxone hcl dihydrate 4-1mg


2 QL M



2 QL M



2 QL M


24

Drug Name Drug Tier

Requirements/Limits

buprenorphine hcl-naloxone hcl sl


2 QL M

bupropion hcl (smoking deterrent)

2 M

CHANTIX 4 M PA

CHANTIX CONTINUING MONTH

4 M PA

CHANTIX STARTER PACK 4 M PA

disulfiram TABS 2 M

fluoxetine hcl (pmdd) (generic of SARAFEM)

2 M

LUCEMYRA QL (228 tabs / 14 days)

5 QL M PA

naloxone inj 0.4mg/ml 2 M

naloxone inj 1mg/ml 2 M

naltrexone hcl TABS 2 M

NARCAN 3 M

NICOTROL INHALER 4 M

NICOTROL NS 4 M

VIVITROL 5 M

ZUBSOLV SUB 0.7-0.18MG QL (90 tabs / 30 days)

4 QL M


4 QL M


4 QL M


4 QL M


4 QL M


4 QL M

ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 5 M PA

ANDRODERM QL (30 patches / 30 days)

4 QL M PA

oxandrolone TABS 2 M PA

STRIANT QL (60 buccal systems / 30 days)

4 QL M PA

testosterone GEL 1%, 25mg/2.5gm, 50mg/5gm

QL (300 grams / 30 days)

2 QL M PA

Drug Name Drug Tier

Requirements/Limits

testosterone GEL 1.62%, 20.25mg/1.25gm, 40.5mg/2.5gm

QL (150 grams / 30 days)

2 QL M PA

testosterone GEL 10mg/act QL (120 grams / 30 days)

2 QL M PA

testosterone cypionate SOLN

2 M PA

testosterone enanthate SOLN

2 M PA

testosterone td soln 30 mg/act QL (180 mL / 30 days)

2 QL M PA

ANTIDIABETICS, INJECTABLE ADMELOG 4 M

ADMELOG SOLOSTAR 4 M

ALCOHOL SWABS 3 M

APIDRA 4 M

APIDRA SOLOSTAR 4 M

BASAGLAR KWIKPEN 3 M

BD ULTRAFINE INSULIN SYRINGE

3 M

BD ULTRAFINE/NANO PEN NEEDLES

3 M

BYDUREON BCISE QL (4 pens / 28 days)

3 QL M

BYDUREON INJ QL (4 vials / 28 days)

3 QL M

BYDUREON PEN QL (4 pens / 28 days)

3 QL M

BYETTA QL (1 pen / 30 days)

4 QL M

FIASP 3 M

FIASP FLEXTOUCH 3 M

GAUZE PADS 2X2 3 M

HUMALOG 4 M

HUMALOG JUNIOR KWIKPEN

4 M

HUMALOG KWIKPEN 4 M

HUMALOG MIX 50/50 4 M

HUMALOG MIX 50/50 KWIKPEN

4 M

HUMALOG MIX 75/25 4 M

HUMALOG MIX 75/25 KWIKPEN

4 M

HUMULIN 70/30 4 M

HUMULIN 70/30 KWIKPEN 4 M

HUMULIN N 4 M

HUMULIN N KWIKPEN 4 M


25

Drug Name Drug Tier

Requirements/Limits

HUMULIN R 4 M

HUMULIN R U-500 (CONCENTRATE)

5 B/D M

HUMULIN R U-500 KWIKPEN 5 M

INSULIN LISPRO 4 M

INSULIN LISPRO KWIKPEN 4 M

INSULIN PEN NEEDLES 3 M

INSULIN SAFETY NEEDLES 3 M

INSULIN SYRINGES 3 M

LEVEMIR 3 M

LEVEMIR FLEXTOUCH 3 M

NOVOLIN 70/30 3 M

NOVOLIN 70/30 FLEXPEN 3 M

NOVOLIN 70/30 FLEXPEN RELION

4 M

NOVOLIN 70/30 RELION 4 M

NOVOLIN N 3 M

NOVOLIN N RELION 4 M

NOVOLIN R 3 M

NOVOLIN R RELION 4 M

NOVOLOG 3 M

NOVOLOG 70/30 FLEXPEN 3 M

NOVOLOG FLEXPEN 3 M

NOVOLOG MIX 70/30 3 M

NOVOLOG PENFILL 3 M

OZEMPIC INJ 0.25 OR 0.5MG/DOSE

QL (1 pen / 28 days)

3 QL M

OZEMPIC INJ 1MG/DOSE QL (2 pens / 28 days)

3 QL M

SOLIQUA 100/33 QL (10 pens / 30 days)

3 QL M

SYMLINPEN 60 5 M PA

SYMLINPEN 120 5 M PA

TRESIBA FLEXTOUCH 3 M

TRESIBA INJ 3 M

TRULICITY QL (4 pens / 28 days)

3 QL M

VICTOZA QL (3 pens / 30 days)

3 QL M

XULTOPHY 100/3.6 QL (5 pens / 30 days)

3 QL M

ANTIDIABETICS, ORAL acarbose TABS 2 M

alogliptin benzoate 6.25mg QL (120 tabs / 30 days)

1 QL M

alogliptin benzoate 12.5mg QL (60 tabs / 30 days)

1 QL M

Drug Name Drug Tier

Requirements/Limits

alogliptin benzoate 25mg QL (30 tabs / 30 days)

1 QL M

alogliptin-metformin hcl QL (60 tabs / 30 days)

1 QL M

alogliptin-pioglitazone 12.5-15mg


1 QL M



1 QL M



1 QL M

alogliptin-pioglitazone 25-15mg


1 QL M



1 QL M



1 QL M

FARXIGA 5mg QL (60 tabs / 30 days)

3 QL M

FARXIGA 10mg QL (30 tabs / 30 days)

3 QL M

glimepiride 1mg QL (240 tabs / 30 days)

1 QL M


1 QL M


1 QL M

glipizide TABS 5mg QL (240 tabs / 30 days)

1 QL M

glipizide TABS 10mg QL (120 tabs / 30 days)

1 QL M

glipizide er 2.5mg QL (240 tabs / 30 days)

1 QL M

glipizide er 5mg QL (120 tabs / 30 days)

1 QL M

glipizide er 10mg QL (60 tabs / 30 days)

1 QL M

glipizide xl 2.5mg QL (240 tabs / 30 days)

1 QL M

glipizide xl 5mg QL (120 tabs / 30 days)

1 QL M

glipizide xl 10mg QL (60 tabs / 30 days)

1 QL M


26

Drug Name Drug Tier

Requirements/Limits

glipizide-metformin 2.5-250 mg


1 QL M

glipizide-metformin 2.5-500 mg


1 QL M

glipizide-metformin 5-500mg QL (120 tabs / 30 days)

1 QL M

GLYXAMBI QL (30 tabs / 30 days)

4 QL M

INVOKAMET TAB 50-500MG QL (120 tabs / 30 days)

4 QL M

INVOKAMET TAB 50-1000MG


4 QL M



4 QL M



4 QL M

INVOKAMET XR TAB 50-500MG


4 QL M



4 QL M



4 QL M



4 QL M

INVOKANA TAB 100MG QL (90 tabs / 30 days)

4 QL M

INVOKANA TAB 300MG QL (30 tabs / 30 days)

4 QL M

JANUMET QL (60 tabs / 30 days)

3 QL M

JANUMET XR TAB 50-500MG


3 QL M

JANUMET XR TAB 50-1000 QL (60 tabs / 30 days)

3 QL M

JANUMET XR TAB 100-1000 QL (30 tabs / 30 days)

3 QL M

JANUVIA QL (30 tabs / 30 days)

3 QL M

JARDIANCE 10mg QL (60 tabs / 30 days)

3 QL M

Drug Name Drug Tier

Requirements/Limits

JARDIANCE 25mg QL (30 tabs / 30 days)

3 QL M

JENTADUETO QL (60 tabs / 30 days)

3 QL M

JENTADUETO TAB XR 2.5-1000 MG


3 QL M

JENTADUETO TAB XR 5-1000 MG


3 QL M

KOMBIGLYZE XR 2.5-1000MG


4 QL M

KOMBIGLYZE XR 5-500MG QL (30 tabs / 30 days)

4 QL M

KOMBIGLYZE XR 5-1000MG QL (30 tabs / 30 days)

4 QL M

metformin er 500mg QL (120 tabs / 30 days)

(generic of GLUCOPHAGE XR)

1 QL M

metformin er 750mg QL (60 tabs / 30 days)

(generic of GLUCOPHAGE XR)

1 QL M

metformin hcl TABS 500mg QL (150 tabs / 30 days)

1 QL M


1 QL M


1 QL M

miglitol 2 M

nateglinide QL (90 tabs / 30 days)

1 QL M

ONGLYZA QL (30 tabs / 30 days)

4 QL M

pioglitazone hcl QL (30 tabs / 30 days)

1 QL M

pioglitazone hcl-glimepiride QL (30 tabs / 30 days)

1 QL M

pioglitazone hcl-metformin hcl QL (90 tabs / 30 days)

1 QL M

QTERN QL (30 tabs / 30 days)

4 QL M

repaglinide 2mg QL (240 tabs / 30 days)

1 QL M

repaglinide .5mg, 1mg QL (120 tabs / 30 days)

1 QL M

repaglinide-metformin hcl QL (150 tabs / 30 days)

1 QL M


27

Drug Name Drug Tier

Requirements/Limits

RIOMET QL (946 mL / 30 days)

4 QL M

SEGLUROMET TAB 2.5-500MG


4 QL M



4 QL M



4 QL M



4 QL M

STEGLATRO 5mg QL (90 tabs / 30 days)

4 QL M

STEGLATRO 15mg QL (30 tabs / 30 days)

4 QL M

STEGLUJAN QL (30 tabs / 30 days)

4 QL M

SYNJARDY TAB 5-500MG QL (120 tabs / 30 days)

3 QL M

SYNJARDY TAB 5-1000MG QL (60 tabs / 30 days)

3 QL M

SYNJARDY TAB 12.5-500MG QL (60 tabs / 30 days)

3 QL M

SYNJARDY TAB 12.5-1000MG


3 QL M

SYNJARDY XR TAB 5-1000MG


3 QL M



3 QL M

SYNJARDY XR TAB 12.5-1000MG


3 QL M



3 QL M

TRADJENTA QL (30 tabs / 30 days)

3 QL M

XIGDUO XR TAB 2.5-1000MG


3 QL M

XIGDUO XR TAB 5-500MG QL (60 tabs / 30 days)

3 QL M


3 QL M

Drug Name Drug Tier

Requirements/Limits


3 QL M


3 QL M

BISPHOSPHONATES alendronate sodium SOLN 2 M

alendronate sodium TABS 1 M

BINOSTO 4 M ST

FOSAMAX PLUS D 4 M ST

ibandronate sodium QL (1 injection / 90 days)

2 B/D QL M

ibandronate tab 150mg 2 B/D M

PAMIDRONATE DISODIUM 6mg/ml

3 B/D M

pamidronate disodium 30mg/10ml, 90mg/10ml

2 B/D M

pamidronate inj 30mg 2 B/D M

pamidronate inj 90mg 2 B/D M

risedronate sodium 2 M

zoledronic acid inj 5mg/100ml 2 B/D

zoledronic inj 4mg/5ml 2 B/D

ZOLEDRONIC INJ 4MG/100ML

4 B/D

CALCIUM RECEPTOR AGONISTS cinacalcet hcl 5 B/D

SENSIPAR 5 B/D

CHELATING AGENTS CHEMET 4 M

deferasirox 5 PA

DEPEN TITRATABS 5 M

FERRIPROX 5 LA PA

JADENU 5 LA PA

JADENU SPRINKLE 5 LA PA

kionex sus 15gm/60ml 2 M

LOKELMA 3 M

sodium polystyrene sulfonate powder

2 M

sodium polystyrene sulfonate susp

2 M

sps susp 15gm/60ml 2 M

trientine hcl 5 M PA

VELTASSA 5 M LA

CONTRACEPTIVES altavera tab 2 M

alyacen 1/35 2 M

amethia 2 M

amethia lo 2 M

apri 2 M


28

Drug Name Drug Tier

Requirements/Limits

aranelle 2 M

ashlyna 2 M

aubra 2 M

aviane 2 M

balziva 2 M

bekyree 2 M

blisovi 24 fe 2 M

blisovi fe 1.5/30 2 M

briellyn 2 M

camila 2 M

camrese lo tab 2 M

caziant pak 2 M

cryselle-28 2 M

cyclafem 1/35 2 M

cyclafem 7/7/7 2 M

cyred tab 2 M

dasetta 1/35 2 M

dasetta 7/7/7 2 M

deblitane 2 M

delyla 2 M

DEPO-SUBQ PROVERA 104 4 M

desogestrel & ethinyl estradiol 2 M

desogestrel-ethinyl estradiol (biphasic)

2 M

drospirenone-ethinyl estradiol 2 M

drospirenone-ethinyl estradiol-levomefolate calcium

2 M

ELLA 4 M

emoquette 2 M

enpresse-28 2 M

enskyce 2 M

errin 2 M

estarylla tab 0.25-35 2 M

ethynodiol diacet & eth estrad 2 M

ethynodiol tab 1-50 2 M

falmina 2 M

fayosim 2 M

femynor 2 M

gianvi tab 3-0.02mg 2 M

hailey 24 fe 2 M

heather 2 M

incassia 2 M

introvale 2 M

isibloom 2 M

jasmiel 2 M

jolessa tab 0.15-0.03 mg 2 M

jolivette 2 M

juleber 2 M

junel 1.5/30 2 M

Drug Name Drug Tier

Requirements/Limits

junel 1/20 2 M

junel fe 1.5/30 2 M

junel fe 1/20 2 M

junel fe 24 2 M

kaitlib fe 2 M

kariva 2 M

kelnor 1/35 2 M

kelnor 1/50 2 M

kurvelo 2 M

larin 1.5/30 2 M

larin 1/20 2 M

larin fe 1.5/30 2 M

larin fe 1/20 2 M

larissia tab 2 M

layolis fe chw 2 M

leena tab 2 M

lessina 2 M

levonest 2 M

levonor/ethi tab 2 M

levonorgestrel & eth estradiol 2 M

levonorgestrel-ethinyl estradiol (91-day)

2 M

levonorgestrel-ethinyl estradiol (continuous)

2 M

levora 0.15/30-28 2 M

LO LOESTRIN FE 4 M

lomedia 24 fe 2 M

loryna 2 M

low-ogestrel 2 M

lutera 2 M

lyza 2 M

marlissa 2 M

medroxyprogesterone acetate (contraceptive)

2 M

melodetta 24 fe 2 M

mibelas 24 fe 2 M

microgestin 1.5/30 2 M

microgestin 1/20 2 M

microgestin fe 1.5/30 2 M

microgestin fe 1/20 2 M

mili 2 M

mono-linyah tab 0.25-35 2 M

myzilra 2 M

NATAZIA 4 M

necon 0.5/35-28 2 M

necon 7/7/7 2 M

nikki 2 M

nora-be tab 2 M

norethin acet & estrad-fe 2 M


29

Drug Name Drug Tier

Requirements/Limits

norethindrone & ethinyl estradiol-fe

2 M

norethindrone (contraceptive) 2 M

norethindrone acet & eth estra 2 M

norgest/ethi tab 0.25/35 2 M

norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg

2 M

norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg

2 M

norlyroc 2 M

nortrel 0.5/35 (28) 2 M

nortrel 1/35 2 M

nortrel 7/7/7 2 M

NUVARING 4 M

ocella tab 3-0.03mg 2 M

ogestrel 2 M

orsythia 2 M

philith 2 M

pimtrea 2 M

pirmella 1/35 2 M

portia-28 2 M

previfem 2 M

quasense 2 M

reclipsen 2 M

rivelsa 2 M

setlakin tab 2 M

sharobel 2 M

SLYND 4 M

sprintec 28 2 M

sronyx 2 M

syeda 2 M

tarina 24 fe 2 M

tarina fe 1/20 2 M

TAYTULLA 4 M

tilia fe 2 M

tri-estarylla 2 M

tri-legest fe 2 M

tri-linyah 2 M

tri-lo- tab marzia 2 M

tri-lo-estarylla 2 M

tri-lo-sprintec 2 M

tri-mili 2 M

tri-previfem 2 M

tri-sprintec 2 M

tri-vylibra 2 M

Drug Name Drug Tier

Requirements/Limits

tri-vylibra lo 2 M

trinessa 2 M

trinessa lo 2 M

trivora-28 2 M

tulana 2 M

tydemy 2 M

velivet 2 M

vienva 2 M

viorele 2 M

vyfemla 2 M

vylibra 2 M

wymzya fe 2 M

xulane dis 150-35 2 M

zarah 2 M

zovia 1/35e 2 M

ENDOMETRIOSIS danazol CAPS 2 M

LUPANETA PACK 5 PA

ORILISSA 5 M PA

SYNAREL 5 M

ENZYME REPLACEMENTS ALDURAZYME 5 LA PA

CARBAGLU 5 LA PA

CERDELGA 5 PA

CEREZYME 5 LA PA

CYSTADANE 5 LA

CYSTAGON 4 LA PA

ELAPRASE 5 LA PA

ELELYSO 5 PA

FABRAZYME 5 LA PA

GALAFOLD 5 LA PA

KUVAN 5 LA PA

levocarnitine (metabolic modifiers)

2 B/D M

LUMIZYME 5 LA PA

miglustat 5 PA

NAGLAZYME 5 LA PA

NITYR 5 LA PA

ORFADIN 5 LA PA

PALYNZIQ 5 LA PA

PROCYSBI 5 LA PA

RAVICTI 5 LA PA

sodium phenylbutyrate 5 PA

VIMIZIM 5 PA

VPRIV 5 PA

ESTROGENS ALORA 4 M

DELESTROGEN 10mg/ml 4 M

DEPO-ESTRADIOL 4 M


30

Drug Name Drug Tier

Requirements/Limits

dotti 3 M

estradiol PTTW; PTWK 3 M

estradiol TABS 2 M

estradiol vaginal cream 2 M

estradiol vaginal tab 2 M

estradiol valerate OIL 2 M

ESTRING 4 M

FEMRING 4 M

fyavolv 3 M

IMVEXXY MAINTENANCE PACK

4 M PA

IMVEXXY STARTER PACK 4 M PA

jinteli 3 M

MENOSTAR 4 M

MINIVELLE 4 M

norethindrone acetate-ethinyl estradiol

3 M

PREMARIN SOLR 4 M

PREMARIN CREAM 4 M

yuvafem vaginal tablet 10 mcg 2 M

GLUCOCORTICOIDS cortisone acetate TABS 2 M

DEPO-MEDROL 20mg/ml 4 B/D M

DEXAMETHASONE CONC 4 M

dexamethasone ELIX; SOLN 2 M

dexamethasone TABS 1 M

dexamethasone sodium phosphate

2 M

fludrocortisone acetate TABS

2 M

hydrocortisone TABS 2 M

MEDROL TAB 2MG 4 B/D M

methylpr ss inj 2 B/D M

methylpred pak 4mg 2 M

methylpred tab 4mg 2 B/D M




methylprednisolone acetate 2 B/D M

MILLIPRED DP 4 M

MILLIPRED TAB 4 B/D M

pred sod pho sol 5mg/5ml 2 B/D M

prednisolone sodium phosphate

2 B/D M

prednisolone sol 15mg/5ml 2 B/D M

prednisolone sol 25mg/5ml 2 B/D M

PREDNISONE CON 5MG/ML 4 B/D M

prednisone pak 5mg 2 M

prednisone pak 10mg 2 M

Drug Name Drug Tier

Requirements/Limits

prednisone sol 5mg/5ml 2 B/D M

prednisone tab 1mg 1 B/D M

prednisone tab 2.5mg 1 B/D M





SOLU-CORTEF 100MG 4 M




SOLU-MEDROL 2gm 4 B/D M

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 3 M

GLUCAGON EMERGENCY KIT

3 M

PROGLYCEM SUS 50MG/ML 4 M

MISCELLANEOUS AFREZZA 4unit, 8unit 4 M

AFREZZA 12unit 5 M

AFREZZA 4/8/12UNITS 5 M

AFREZZA 4/8UNITS 4 M

AFREZZA 8/12 UNITS 5 M

cabergoline 2 M

calcitonin (salmon) nasal spray

2 B/D M

CHORIONIC GONADOTROPIN SOLR

4 PA

EGRIFTA 1MG 5 LA PA

EVENITY 5 PA

FORTEO 5 PA

GENOTROPIN 5 PA

GENOTROPIN MINIQUICK .2mg

3 PA

GENOTROPIN MINIQUICK .4mg, .6mg, .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg

5 PA

HUMATROPE 5 PA

HUMATROPE COMBO PACK 5 PA

INCRELEX 5 LA PA

JYNARQUE 5 LA PA

KORLYM 5 LA PA

LUPRON DEP-PED INJ 7.5MG

5 PA

LUPRON DEP-PED INJ 11.25MG (3-MONTH)

5 PA

LUPRON DEPOT-PED (1-MONTH

5 PA


31

Drug Name Drug Tier

Requirements/Limits

LUPRON DEPOT-PED (3-MONTH

5 PA

methergine 5 M PA

methylergonovine maleate TABS

5 M PA

MIACALCIN INJ 200U/ML 5 B/D M

NATPARA 5 PA

NORDITROPIN FLEXPRO 5 PA

NOVAREL 4 PA

NUTROPIN AQ NUSPIN 5 5 LA PA



octreotide acetate 50mcg/ml, 200mcg/ml

2 PA

octreotide acetate 500mcg/ml, 1000mcg/ml

5 PA

octreotide inj 100mcg/ml 2 PA

OMNITROPE 5.8MG 5 LA PA

OMNITROPE 5MG 5 LA PA

OMNITROPE 10MG 5 LA PA

OSPHENA 4 M PA

PREGNYL W/DILUENT BENZYL

4 PA

PROLIA QL (1 injection / 180 days)

4 QL

raloxifene hcl 2 M

SAIZEN 5 LA PA

SAIZENPREP RECONSTITUTION

5 LA PA

SAMSCA 5 PA

SANDOSTATIN LAR DEPOT 5 PA

SEROSTIM 5 LA PA

SIGNIFOR 5 LA PA

SIGNIFOR LAR 5 LA PA

SOMATULINE DEPOT 5 PA

SOMAVERT 5 LA PA

TYMLOS 5 PA

XGEVA 5 PA

ZOMACTON 5mg 4 PA

ZOMACTON 10mg 5 PA

ZORBTIVE 5 PA

PHOSPHATE BINDER AGENTS AURYXIA 5 M PA

calcium acetate (phosphate binder)

2 M

FOSRENOL PACK 5 M

lanthanum chew tab 5 M

PHOSLYRA 4 M

Drug Name Drug Tier

Requirements/Limits

sevelamer carbonate PACK 5 M

sevelamer carbonate TABS 2 M

sevelamer tabs 400 mg 2 M

sevelamer tabs 800mg 2 M

VELPHORO 5 M

PROGESTINS CRINONE 4 M PA

medroxyprogesterone acetate 1 M

norethindrone acetate TABS 2 M

progesterone micronized CAPS

2 M

THYROID AGENTS levo-t 2 M

levothyroxine sodium TABS 1 M

levoxyl 2 M

liothyronine sodium TABS 2 M

methimazole TABS 1 M

propylthiouracil TABS 2 M

SYNTHROID 3 M

TIROSINT 4 M

TIROSINT-SOL 4 M

unithroid 2 M

VASOPRESSINS desmopressin acetate TABS 2 M

desmopressin acetate spray 2 M

desmopressin acetate spray refrigerated

2 M

desmopressin inj 4mcg/ml 2 M

STIMATE 5

GASTROINTESTINAL ANTIEMETICS AKYNZEO CAPS 4 B/D M

AKYNZEO SOLR 4 M

aprepitant 2 B/D M

aprepitant pak 80mg & 125mg 2 B/D M

CESAMET QL (60 caps / 30 days)

5 B/D QL M

CINVANTI 4 M

compro supp 2 M

dronabinol QL (60 caps / 30 days)

2 B/D QL M

EMEND SOLR 4 M

EMEND SUSR 4 B/D M

fosaprepitant dimeglumine 2 M

granisetron hcl SOLN 2 M

granisetron hcl TABS 2 B/D M

meclizine hcl TABS 2 M

metoclopramide hcl SOLN; TBDP

2 M


32

Drug Name Drug Tier

Requirements/Limits

metoclopramide hcl TABS 1 M

metoclopramide hcl inj 2 M

METOCLOPRAMIDE ODT 4 M

ondansetron hcl TABS 2 B/D M

ondansetron hcl inj 2 M

ondansetron hcl oral soln 2 B/D M

ondansetron odt 2 B/D M

palonosetron hcl 2 M

PALONOSETRON HYDROCHLORID

4 M

palonosetron hydrochlorid sosy

2 M

phenadoz PA if 70 years and older

4 M PA

prochlorperazine inj 2 M

prochlorperazine maleate TABS

1 M

prochlorperazine supp 2 M

promethazine hcl SUPP PA if 70 years and older

4 M PA

promethazine hcl SYRP; TABS


2 M PA

promethazine hcl inj PA if 70 years and older

4 M PA

promethegan PA if 70 years and older

4 M PA

SANCUSO QL (4 patches / 28 days)

5 QL M

scopolamine patch QL (10 patches / 30 days)


4 QL M PA

SUSTOL 4 M

SYNDROS QL (120 mL / 30 days)

5 B/D QL M

TRANSDERM-SCOP QL (10 patches / 30 days)


4 QL M PA

VARUBI INJ 4 M

VARUBI TAB 90MG 4 B/D M

ZUPLENZ 4 B/D M

ANTISPASMODICS atropine sulfate SOSY .25mg/5ml, 1mg/10ml

4 M

CUVPOSA 4 M

dicyclomine hcl cap 10mg 3 M

dicyclomine hcl inj 4 M

Drug Name Drug Tier

Requirements/Limits

dicyclomine hcl soln 10mg/5ml

4 M

dicyclomine hcl tab 20mg 3 M

GLYCATE 4 M

glycopyrrolate SOLN 2 M

GLYCOPYRROLATE SOSY .2mg/ml, .4mg/2ml

4 M

glycopyrrolate tab 1mg 2 M

glycopyrrolate tab 2mg 2 M

methscopolamine bromide TABS

2 M

H2-RECEPTOR ANTAGONISTS cimetidine TABS 2 M

cimetidine sol 300/5ml 2 M

famotidine SUSR 2 M

famotidine TABS 20mg, 40mg

1 M

famotidine in nacl 2 M

famotidine inj 2 M

nizatidine 2 M

ranitidine hcl CAPS 2 M

ranitidine hcl SYRP 2 M

ranitidine hcl TABS 150mg, 300mg

1 M

ranitidine hcl inj 2 M

ranitidine inj 2 M

INFLAMMATORY BOWEL DISEASE APRISO 3 M

balsalazide disodium 2 M

budesonide CPEP; TB24 5 M

colocort 2 M

DELZICOL 4 M

DIPENTUM 5 M

ENTYVIO 5 PA

hydrocortisone (enema) 2 M

mesalamine CPDR; SUPP; TBEC

2 M

mesalamine enema 2 M

mesalamine w/ cleanser 2 M

PENTASA 250mg 4 M

PENTASA 500mg 5 M

SFROWASA 5 M

sulfasalazine dr 2 M

sulfasalazine ir 2 M

UCERISFOAM 4 M

LAXATIVES CLENPIQ 4 M

constulose 2 M

enulose 2 M


33

Drug Name Drug Tier

Requirements/Limits

gavilyte-c 2 M

gavilyte-g 2 M

gavilyte-n/flavor pack 2 M

generlac 2 M

GOLYTELY 3 M

KRISTALOSE 4 M

lactulose SOLN 2 M

lactulose (encephalopathy) 2 M

MOVIPREP 4 M

NULYTELY/FLAVOR PACKS 3 M

OSMOPREP 4 M

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

2 M

peg 3350-potassium chloride-sod bicarbonate-sod chloride

2 M

PLENVU 4 M

PREPOPIK 4 M

SUPREP BOWEL PREP KIT 4 M

trilyte 2 M

MISCELLANEOUS alosetron hcl 5 M PA

AMITIZA 3 M

amoxicillin-clarithromycin w/ lansoprazole

2 M

CARAFATE SUSP 4 M

cromolyn sodium (mastocytosis)

5 M

diphenoxylate w/ atropine LIQD

4 M

diphenoxylate w/ atropine TABS

3 M

GATTEX 5 LA PA

LINZESS 3 M

loperamide hcl CAPS 2 M

misoprostol TABS 2 M

MOTEGRITY 4 M

MOVANTIK 3 M

OMECLAMOX-PAK 4 M

PYLERA 5 M

RELISTOR 5 M PA

SUCRAID 5 M LA

sucralfate TABS 2 M

SYMPROIC 3 M

TRULANCE 4 M

ursodiol CAPS; TABS 2 M

VIBERZI 5 M PA

XIFAXAN TAB 550MG 5 M PA

Drug Name Drug Tier

Requirements/Limits

PANCREATIC ENZYMES CREON 3 M

PANCREAZE 4 M

PERTZYE 4 M

VIOKACE 10 4 M

VIOKACE 20 5 M

ZENPEP 4 M

PROTON PUMP INHIBITORS DEXILANT


esomeprazole magnesium QL (30 caps / 30 days)

2 QL M

esomeprazole sodium inj 2 M

lansoprazole CPDR QL (30 caps / 30 days)

2 QL M

lansoprazole TBDD QL (30 tabs / 30 days)

2 QL M

NEXIUM GRA 2.5MG DR 4 M

NEXIUM GRA 5MG DR 4 M

NEXIUM GRA 10MG DR QL (30 packets / 30 days)

4 QL M


4 QL M


4 QL M

omeprazole cap 10mg 1 M



pantoprazole sodium SOLR 2 M

pantoprazole sodium TBEC 1 M

PRILOSEC 3 M

PROTONIX PACK QL (30 packets / 30 days)

4 QL M

rabeprazole sodium QL (30 tabs / 30 days)

2 QL M

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl 2 M

CARDURA XL 4 M ST

dutasteride CAPS 2 M

dutasteride-tamsulosin hcl 2 M

finasteride TABS 5mg 1 M

silodosin 2 M

tamsulosin hcl 2 M


34

Drug Name Drug Tier

Requirements/Limits

MISCELLANEOUS bethanechol chloride TABS 2 M

ELMIRON 5 M

INTRAROSA 4 M PA

potassium citrate (alkalinizer) er tabs

2 M

URINARY ANTISPASMODICS darifenacin hydrobromide 2 M

GELNIQUE PUMP 4 M ST

MYRBETRIQ 4 M

oxybutynin chloride SYRP; TABS; TB24

2 M

OXYTROL 4 M ST

solifenacin succinate 2 M

tolterodine tartrate er 2 M

tolterodine tartrate tab 1 mg 2 M

tolterodine tartrate tab 2 mg 2 M

TOVIAZ 3 M

trospium chloride 2 M

trospium chloride er 2 M

VAGINAL ANTI-INFECTIVES AVC 4 M

CLEOCIN VAG SUPP 100MG 4 M

clindamycin cre 2% vag 2 M

CLINDESSE 4 M

metronidazole vaginal 2 M

miconazole 3 sup 200mg 2 M

terconazole vaginal 2 M

vandazole 2 M

HEMATOLOGIC ANTICOAGULANTS BEVYXXA 4 M

COUMADIN 3 M

ELIQUIS STARTER PACK 3 M

ELIQUIS TAB 2.5MG 3 M

ELIQUIS TAB 5MG 3 M

enoxaparin sodium 2 M

fondaparinux sodium 2.5mg/0.5ml

2 M

fondaparinux sodium 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml

5 M

FRAGMIN 2500unit/0.2ml, 5000unit/0.2ml

4 M

Drug Name Drug Tier

Requirements/Limits

FRAGMIN 7500unit/0.3ml, 10000unit/ml, 12500unit/0.5ml, 15000unit/0.6ml, 18000unt/0.72ml, 95000unit/3.8ml

5 M

heparin sod (porcine) in d5w 3 M

heparin sod inj 1000u/ml 2 B/D M

heparin sod inj 5000u/0.5ml 2 B/D M




HEPARIN SODIUM INJ 5000 U/0.5ML

4 B/D M

HEPARIN SODIUM/NACL 0.45%

3 M

jantoven 1 M

PRADAXA 4 M

SAVAYSA 4 M

warfarin sodium 1 M

XARELTO 3 M

XARELTO STARTER PACK 3 M

HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE SOLN 25mcg/ml, 40mcg/ml

3 PA

ARANESP ALBUMIN FREE SOLN 60mcg/ml, 100mcg/ml, 200mcg/ml, 300mcg/ml

5 PA

ARANESP ALBUMIN FREE SOSY 10mcg/0.4ml, 25mcg/0.42ml, 40mcg/0.4ml

3 PA

ARANESP ALBUMIN FREE SOSY 60mcg/0.3ml, 100mcg/0.5ml, 150mcg/0.3ml, 200mcg/0.4ml, 300mcg/0.6ml, 500mcg/ml

5 PA

EPOGEN 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

4 PA

EPOGEN 20000unit/ml 5 PA

GRANIX 5 PA

LEUKINE 5 PA

MOZOBIL 5 PA

NEULASTA 5 PA

NEULASTA ONPRO KIT 5 PA

NEUPOGEN 5 PA

PROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

3 PA


35

Drug Name Drug Tier

Requirements/Limits

PROCRIT 20000unit/ml, 40000unit/ml

5 PA

RETACRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

4 PA

RETACRIT 40000unit/ml 5 M PA

MISCELLANEOUS anagrelide hcl 2 M

BERINERT QL (24 boxes / 30 days)

5 QL LA PA

cilostazol 2 M

CINRYZE QL (20 vials / 30 days)

5 QL LA PA

DOPTELET 5 LA PA

DROXIA 3 M

ENDARI 5 LA PA

FIRAZYR QL (9 syringes / 30 days)

5 QL PA

HAEGARDA 2000unit QL (30 vials / 30 days)

5 QL LA PA

HAEGARDA 3000unit QL (20 vials / 30 days)

5 QL LA PA

icatibant acetate QL (9 syringes / 30 days)

5 QL PA

MULPLETA 5 PA

pentoxifylline TBCR 2 M

PROMACTA PACK QL (360 packets / 30 days)

5 QL LA PA

PROMACTA TABS 12.5mg QL (360 tabs / 30 days)

5 QL LA PA

PROMACTA TABS 25mg QL (180 tabs / 30 days)

5 QL LA PA


5 QL LA PA


5 QL LA PA

RUCONEST 5 PA

TAKHZYRO QL (2 vials / 28 days)

5 QL LA PA

tranexamic acid SOLN; TABS

2 M

PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole 2 M

BRILINTA 3 M

clopidogrel tab 75mg 1 M

clopidogrel tab 300mg 2 M

prasugrel hcl 2 M

Drug Name Drug Tier

Requirements/Limits

YOSPRALA 4 M

ZONTIVITY 4 M

IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) HUMIRA 10mg/0.1ml, 20mg/0.2ml

QL (2 injections / 28 days)

5 QL PA

HUMIRA 40mg/0.4ml QL (6 injections / 28 days)

5 QL PA

HUMIRA INJ 10MG/0.2ML QL (2 syringes / 28 days)

5 QL PA

HUMIRA KIT 20MG/0.4ML QL (2 syringes / 28 days)

5 QL PA

HUMIRA KIT 40MG/0.8ML QL (6 syringes / 28 days)

5 QL PA

HUMIRA PEDIATRIC CROHNS DISEASE

5 PA

HUMIRA PEN QL (6 pens / 28 days)

5 QL PA

HUMIRA PEN CD/UC/HS STARTER

5 PA

HUMIRA PEN INJ CD/UC/HS STARTER

5 PA

HUMIRA PEN INJ PS/UV STARTER

5 PA

HUMIRA PEN-PS/UV STARTER

5 PA

hydroxychloroquine sulfate 1 M

leflunomide TABS 2 M

methotrexate sodium tabs 2 M

REMICADE 5 PA

TREXALL 4 B/D M

XATMEP 4 B/D M

XELJANZ QL (60 tabs / 30 days)

5 QL PA

XELJANZ XR QL (30 tabs / 30 days)

5 QL PA

IMMUNOGLOBULINS BIVIGAM 5 PA

CARIMUNE NANOFILTERED 12gm

5 PA

FLEBOGAMMA DIF 5 PA

GAMASTAN S/D 3 B/D

GAMMAGARD LIQUID 5 PA


36

Drug Name Drug Tier

Requirements/Limits

GAMMAGARD S/D 5 PA

GAMMAKED 5 PA

GAMMAPLEX 5 PA

GAMMAPLEX 10GM/100ML 5 PA

GAMUNEX-C 5 PA

OCTAGAM 5 PA

PANZYGA 5 PA

PRIVIGEN 5 PA

IMMUNOMODULATORS ACTIMMUNE 5 LA PA

ARCALYST 5 PA

INTRON-A INJ 10MU 5 B/D M




ORALAIR 4 M PA

IMMUNOSUPPRESSANTS ASTAGRAF XL 5mg 5 B/D M

ASTAGRAF XL .5mg, 1mg 4 B/D M

ATGAM 5 B/D M

AZASAN 4 B/D M

azathioprine TABS 2 B/D M

BENLYSTA 5 PA

cyclosporine CAPS; SOLN 2 B/D M

cyclosporine modified (for microemulsion)

2 B/D M

ENVARSUS XR 4 B/D M

gengraf 2 B/D M

mycophenolate mofetil CAPS; TABS

2 B/D M

mycophenolate mofetil SUSR

5 B/D M

mycophenolate sodium tbec 2 B/D M

NULOJIX 5 B/D M

PROGRAF PACK 4 B/D M

RAPAMUNE SOLN 5 B/D M

SANDIMMUNE SOLN 3 B/D M

sirolimus SOLN 5 B/D M

sirolimus TABS 2mg 5 B/D M

sirolimus TABS .5mg, 1mg 2 B/D M

tacrolimus CAPS 2 B/D M

ZORTRESS TAB 0.5MG 5 B/D M



ZORTRESS TAB 1MG 5 B/D M

VACCINES ACTHIB 3

ADACEL 3

Drug Name Drug Tier

Requirements/Limits

BCG VACCINE 3

BEXSERO 3

BOOSTRIX 3

DAPTACEL 3

DIPHTHERIA/TETANUS TOXOID

3 B/D

ENGERIX-B SUSP 3 B/D

GARDASIL 9 3

HAVRIX 3

HIBERIX 3

IMOVAX RABIES (H.D.C.V.) 3 B/D

INFANRIX 3

IPOL INACTIVATED IPV 3

IXIARO 3

KINRIX 3

M-M-R II 3 M

MENACTRA 3

MENVEO 3

PEDIARIX 3

PEDVAX HIB 3

PENTACEL 3

PROQUAD 3

QUADRACEL 3

RABAVERT 3 B/D

RECOMBIVAX HB 3 B/D

ROTARIX 3

ROTATEQ 3

SHINGRIX QL (2 vials per lifetime)

3 QL

TDVAX 3 B/D

TENIVAC 3 B/D

TRUMENBA 3

TWINRIX INJ 3

TYPHIM VI 3

VAQTA 3

VARIVAX 3

YF-VAX 3

ZOSTAVAX QL (1 vial per lifetime)

3 QL

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES klor-con 8 2 M

klor-con 10 2 M

klor-con m10 2 M

klor-con m15 3 M

klor-con m20 2 M

klor-con pak 20meq 2 M


37

Drug Name Drug Tier

Requirements/Limits

klor-con spr cap 8meq 2 M

klor-con spr cap 10meq 2 M

magnesium sulfate SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

3 M

MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

3 M

MAGNESIUM SULFATE IN D5W

3 M

magnesium sulfate in dextrose

3 M

magnesium sulfate inj 50% 3 M

potassium chloride PACK 2 M

potassium chloride SOLN 10%, 20%

2 M

potassium chloride TBCR 2 M

potassium chloride caps er 2 M

potassium chloride microencapsulated crystals er

2 M

potassium chloride tab cr 10 meq

2 M

sodium chloride SOLN 2.5meq/ml

2 M

sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln

2 M

tpn electrolytes 4 B/D M

IV NUTRITION AMINOSYN II INJ 10% 4 B/D M

AMINOSYN-PF 7% 4 B/D M

AMINOSYN-PF INJ 10% 4 B/D M

CLINIMIX 4.25%/DEXTROSE 5%

4 B/D M


4 B/D M


4 B/D M

CLINIMIX 5%/DEXTROSE 15%

4 B/D M


4 B/D M


4 B/D M

CLINIMIX E 2.75%/DEXTROSE 5%

4 B/D M

CLINIMIX E 4.25%/D10 4 B/D M

CLINIMIX E 4.25%/DEXTROSE 5%

4 B/D M

Drug Name Drug Tier

Requirements/Limits

CLINIMIX E 5%/DEXTROSE 15%

4 B/D M

CLINIMIX E 5%/DEXTROSE 20%

4 B/D M

clinisol sf 15% 2 B/D M

CLINOLIPID 4 B/D M

FREAMINE HBC 6.9% 4 B/D M

FREAMINE III 4 B/D M

hepatamine 4 B/D M

INTRALIPID 30% 4 B/D M

INTRALIPID INJ 20% 4 B/D M

NEPHRAMINE 4 B/D M

NUTRILIPID INJ 20% 4 B/D M

plenamine 2 B/D M

premasol 6% 2 B/D M

PREMASOL 10% 4 B/D M

PROCALAMINE 4 B/D M

PROSOL 4 B/D M

SMOFLIPID 4 B/D M

TRAVASOL 4 B/D M

TROPHAMINE INJ 10% 4 B/D M

IV REPLACEMENT SOLUTIONS dextrose SOLN 2 M

dextrose 2.5%/nacl 0.45% 2 M

dextrose 5% 2 M

DEXTROSE 5% /ELECTROLYTE

3 M

dextrose 5%/nacl 0.2% 2 M

DEXTROSE 5%/NACL 0.3% 4 M





dextrose 5%/potassium chl 2 M

dextrose 10% flex contain 2 M

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

3 M


dextrose in lactated ringers 2 M

ELECTROLYTE-R IN DEXTROSE

4 M

IONOSOL-MB/DEXTROSE 5%

4 M

ISOLYTE P 4 M

ISOLYTE S 4 M

kcl0.15%/d5w/nacl0.2% 2 M

KCL 0.3%/D5W/LR 4 M

KCL 0.3%/D5W/NACL 0.9% 4 M

kcl 0.3%/d5w/nacl 0.45% 2 M


38

Drug Name Drug Tier

Requirements/Limits

KCL 0.15%/D5W/LR 4 M

kcl 0.15%/d5w/nacl 0.9% 2 M

KCL 0.15%/D5W/NACL 0.225%

3 M

kcl 0.075%/d5w/nacl 0.45% 2 M

kcl/d5w/nacl inj 0.22%/0.45% 2 M

kcl/d5w/nacl inj .15/.33% 2 M

kcl/d5w/nacl inj .15/.45% 2 M

kcl/nacl inj 0.15%-0.9% 2 M

lactated ringer's 2 M

NORMOSOL-M IN D5W 4 M

NORMOSOL-R 4 M

PLASMA-LYTE A 4 M

PLASMA-LYTE-148 4 M

pot chloride inj 2meq/ml 2 M

potassium chloride SOLN 2meq/ml

2 M

POTASSIUM CHLORIDE SOLN .4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

2 M

potassium chloride 0.3%/d 2 M

potassium chloride in nacl 2 M

sodium chloride SOLN .9%, 3%, 5%

2 M

sodium chloride 0.45% 2 M

VITAMINS calcitriol CAPS; SOLN 2 B/D M

calcitriol inj 2 B/D M

doxercalciferol CAPS 2 B/D M

M-NATAL PLUS 3 M

paricalcitol CAPS 2 B/D M

PNV FOLIC ACID + IRON MUL

3 M

PRENATAL 3 M

PRENATAL PLUS 3 M

PRENATAL PLUS LOW IRON 3 M

RAYALDEE 5 M

TRICARE 3 M

OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 2 M

BLEPHAMIDE 4 M

neomycin-polymy-dexameth 2 M

neomycin-polymyxin-hc (ophth)

2 M

PRED-G 4 M

PRED-G S.O.P. 4 M

Drug Name Drug Tier

Requirements/Limits

sulfacetamide sod-prednisolone

2 M

TOBRADEX OINT 3 M

TOBRADEX ST 3 M

tobramycin-dexamethasone 2 M

ZYLET 3 M

ANTI-INFECTIVES AZASITE 4 M

bacitracin (ophthalmic) 2 M

bacitracin-polymyxin b (ophth) 2 M

BESIVANCE 3 M

CILOXAN OIN 0.3% OP 3 M

ciprofloxacin hcl (ophth) 1 M

erythromycin (ophth) 1 M

gatifloxacin (ophth) 2 M

gentak 2 M

gentamicin sulfate soln (ophth)

1 M

levofloxacin (ophth) 2 M

MOXEZA 3 M

moxifloxacin hcl (ophth) 2 M

NATACYN 4 M

neomycin-bacitracin zn-polymyxin

2 M

neomycin-polymyxin-gramicidin

2 M

ofloxacin (ophth) 2 M

polymyxin b-trimethoprim 1 M

sulfacetamide sodium (ophth) 2 M

tobramycin (ophth) 1 M

TOBREX OINT 0.3% 4 M

trifluridine 2 M

ZIRGAN 4 M

ANTI-INFLAMMATORIES ACUVAIL 4 M

ALREX 3 M

bromfenac sodium (ophth) 2 M

BROMSITE 4 M

dexamethasone sodium phosphate (ophth)

2 M

diclofenac sodium (ophth) 2 M

DUREZOL 3 M

FLAREX 4 M

fluorometholone (ophth) 2 M

flurbiprofen sodium 2 M

FML 4 M

FML FORTE 4 M

ILEVRO 3 M

INVELTYS 4 M


39

Drug Name Drug Tier

Requirements/Limits

ketorolac tromethamine (ophth)

2 M

LOTEMAX 3 M

LOTEMAX SM 4 M

loteprednol etabonate 2 M

MAXIDEX 4 M

PRED MILD 4 M

prednisolone acetate (ophth) 2 M

PREDNISOLONE SODIUM PHOSPHATE (OPHTH)

3 M

PROLENSA 3 M

ANTIALLERGICS ALOCRIL 4 M

ALOMIDE 4 M

azelastine drop 0.05% 2 M

BEPREVE 3 M

cromolyn sodium (ophth) 1 M

epinastine hcl (ophth) 2 M

LASTACAFT 4 M

olopatadine hcl 0.1% 2 M

olopatadine hcl 0.2% 2 M

PAZEO 3 M

ANTIGLAUCOMA ALPHAGAN P 0.1% 3 M

AZOPT 3 M

betaxolol hcl (ophth) 2 M

BETIMOL 4 M

BETOPTIC-S 3 M

brimonidine sol 0.2% 1 M

brimonidine sol 0.15% 2 M

carteolol hcl (ophth) 2 M

COMBIGAN 3 M

dorzolamide hcl 2 M

dorzolamide hcl-timolol maleate

2 M

latanoprost SOLN 1 M

levobunolol hcl 2 M

LUMIGAN 3 M

PHOSPHOLINE IODIDE 4 M

pilocarpine hcl SOLN 2 M

RHOPRESSA 3 M

ROCKLATAN 4 M

SIMBRINZA SUS 1-0.2% 3 M

timolol maleate (ophth) soln 1 M

timolol maleate gel 2 M

timolol maleate ophth soln 0.5% (once-daily)

2 M

TIMOPTIC OCUDOSE 4 M

TRAVATAN Z 3 M

Drug Name Drug Tier

Requirements/Limits

VYZULTA 4 M ST

XELPROS 4 M ST

ZIOPTAN 4 M ST

MISCELLANEOUS ATROPINE SULFATE SOLN 1%

3 M

CYSTARAN 5 LA PA

LACRISERT 4 M

proparacaine hcl SOLN 2 M

RESTASIS 3 M

RESTASIS MULTIDOSE 3 M

XIIDRA 4 M

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPT AER 62.5-25

QL (60 blisters / 30 days)

3 QL M

BEVESPI AEROSPHERE QL (1 inhaler / 30 days)

3 QL M

COMBIVENT RESPIMAT QL (2 inhalers / 30 days)

4 QL M

ipratropium-albuterol 2 B/D M

STIOLTO RESPIMAT QL (1 inhaler / 30 days)

4 QL M

STIOLTO RESPIMAT (INSTITUTIONAL PACK)


4 QL M

TRELEGY ELLIPTA QL (60 blisters / 30 days)

3 QL M

UTIBRON NEOHALER QL (60 caps / 30 days)

4 QL M

ANTICHOLINERGICS ATROVENT HFA

QL (2 inhalers / 30 days) 4 QL M

INCRUSE ELLIPTA QL (30 blisters / 30 days)

3 QL M

ipratropium bromide (nasal) 2 M

ipratropium sol inhal 2 B/D M

LONHALA MAGNAIR REFILL KIT

5 M

LONHALA MAGNAIR STARTER KIT

5 M

SEEBRI NEOHALER QL (60 caps / 30 days)

4 QL M

SPIRIVA HANDIHALER QL (30 caps / 30 days)

4 QL M


40

Drug Name Drug Tier

Requirements/Limits

SPIRIVA RESPIMAT 1.25MCG/ACT

QL (1 inhaler / 30 days)

4 QL M

SPIRIVA RESPIMAT 2.5MCG/ACT

QL (1 inhaler / 30 days)

4 QL M

SPIRIVA RESPIMAT 2.5MCG/ACT (INSTITUTIONAL PACK)


4 QL M

TUDORZA PRESSAIR QL (1 inhaler / 30 days)

4 QL M

TUDORZA PRESSAIR (INSTITUTIONAL PACK)


4 QL M

YUPELRI 5 B/D M

ANTIHISTAMINE COMBINATIONS CLARINEX-D TAB 2.5-120 4 M

DYMISTA SPR 137-50 QL (1 bottle / 30 days)

4 QL M

SEMPREX-D 4 M

ANTIHISTAMINES azelastine spr 0.1% 2 M

azelastine spr 0.15% 2 M

cetirizine syrup 1 M

CLARINEX SYRP 4 M

cyproheptadine hcl SYRP; TABS


3 M PA

desloratadine 2 M

diphenhydramine hcl inj 50mg/ml

2 M

hydroxyzine hcl SYRP PA if 70 years and older

3 M PA

hydroxyzine hcl TABS PA if 70 years and older

2 M PA

hydroxyzine hcl inj PA if 70 years and older

4 M PA

hydroxyzine pamoate CAPS PA if 70 years and older

2 M PA

levocetirizine soln 2.5mg/5ml 2 M

levocetirizine tab 5 mg 2 M

olopatadine hcl (nasal) 2 M

BETA AGONISTS albuterol sulfate AERS 108mcg/act

QL (2 inhalers / 30 days) (generic of Proair HFA)

2 QL M

Drug Name Drug Tier

Requirements/Limits

albuterol sulfate AERS 108mcg/act

QL (2 inhalers / 30 days) (generic of Proventil HFA)

2 QL M

albuterol sulfate AERS 108mcg/act

QL (2 inhalers / 30 days) (generic of Ventolin HFA)

2 QL M

albuterol sulfate NEBU 2 B/D M

albuterol sulfate SYRP 2 M

albuterol sulfate TABS 2 M

albuterol sulfate er 2 M

ARCAPTA NEOHALER QL (30 caps / 30 days)

4 QL M

BROVANA 5 B/D M

levalbuterol hcl NEBU 2 B/D M

levalbuterol hcl soln nebu conc 1.25 mg/0.5ml

2 B/D M

levalbuterol tartrate hfa QL (2 inhalers / 30 days)

2 QL M

PERFOROMIST 5 B/D M

PROAIR RESPICLICK QL (2 inhalers / 30 days)

4 QL M

PROVENTIL HFA QL (2 inhalers / 30 days)

4 QL M

SEREVENT DISKUS QL (60 inhalations / 30 days)

3 QL M

STRIVERDI RESPIMAT QL (1 inhaler / 30 days)

4 QL M

terbutaline sulfate SOLN 5 M

terbutaline sulfate TABS 2 M

VENTOLIN HFA QL (2 inhalers / 30 days)

3 QL M

LEUKOTRIENE MODULATORS montelukast sodium CHEW; PACK; TABS

2 M

zafirlukast 2 M

MAST CELL STABILIZERS cromolyn sodium NEBU 2 B/D M

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

2 B/D M

ARALAST NP 5 LA PA

CINQAIR 5 LA PA

DALIRESP 4 M

ELIXOPHYLLIN 4 M

epinephrine (anaphylaxis) .15mg/0.3ml, .3mg/0.3ml

(generic of EpiPen)

2 M


41

Drug Name Drug Tier

Requirements/Limits

epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml

(generic of Adrenaclick)

2 M

ESBRIET 5 PA

FASENRA INJ 30MG/ML 5 LA PA

GLASSIA 5 LA PA

KALYDECO 5 PA

NUCALA 5 LA PA

OFEV 5 PA

ORKAMBI 5 PA

PROLASTIN-C 5 LA PA

PULMOZYME 5 PA

SYMDEKO 5 LA PA

SYMJEPI 4 M

THEO-24 4 M

theophylline sol 80/15ml 2 M

theophylline tb12 300 mg 2 M

theophylline tb12 450 mg 2 M

theophylline tb24 2 M

XOLAIR 5 LA PA

ZEMAIRA 5 LA PA

NASAL STEROIDS BECONASE AQ


flunisolide (nasal) QL (3 bottles / 30 days)

2 QL M

fluticasone propionate (nasal) QL (1 bottle / 30 days)

2 QL M

mometasone furoate (nasal) QL (2 inhalers / 30 days)

2 QL M

OMNARIS QL (1 inhaler / 30 days)

4 QL M

QNASL QL (1 inhaler / 30 days)

4 QL M

QNASL CHILDRENS QL (1 inhaler / 30 days)

4 QL M

XHANCE QL (32 mL / 30 days)

4 QL M

ZETONNA QL (1 inhaler / 30 days)

4 QL M

STEROID INHALANTS ALVESCO


ARNUITY ELLIPTA QL (30 inhalations / 30 days)

3 QL M

ASMANEX QL (2 inhalers / 30 days)

4 QL M

ASMANEX HFA 100mcg/act QL (2 inhalers / 30 days)

4 QL M

Drug Name Drug Tier

Requirements/Limits

ASMANEX HFA 200mcg/act QL (1 inhaler / 30 days)

4 QL M

budesonide (inhalation) 2 B/D M

FLOVENT DISKUS 50mcg/blist, 100mcg/blist

QL (120 inhalations / 30 days)

3 QL M

FLOVENT DISKUS 250mcg/blist


3 QL M

FLOVENT HFA QL (2 inhalers / 30 days)

3 QL M

PULMICORT FLEXHALER QL (2 inhalers / 30 days)

4 QL M

QVAR REDIHALER QL (2 inhalers / 30 days)

4 QL M

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS


3 QL M

ADVAIR HFA QL (1 inhaler / 30 days)

3 QL M

BREO ELLIPTA QL (60 blisters / 30 days)

3 QL M

DULERA QL (1 inhaler / 30 days)

4 QL M

SYMBICORT QL (1 inhaler / 30 days)

3 QL M

TOPICAL DERMATOLOGY, ACNE ACZONE 7.5% 4 M

adapalene CREA; GEL 2 M

ADAPALENE SOLN 4 M

adapalene-benzoyl peroxide gel 0.1-2.5%

2 M

AKTIPAK 4 M

ALTRENO 4 M PA

amnesteem 2 M PA

avita 2 M PA

AZELEX 4 M

benzoyl peroxide-erythromycin

2 M

claravis 2 M PA

clindacin-p 2 M

CLINDAGEL 5 M

clindamycin phosphate (topical)

2 M


42

Drug Name Drug Tier

Requirements/Limits

clindamycin phosphate-benzoyl peroxide

2 M

clindamycin phosphate-benzoyl peroxide (refrigerate)

2 M

clindamycin phosphate-tretinoin

2 M

dapsone gel 5% 2 M

DIFFERIN LOTN 4 M

EPIDUO FORTE 4 M

ery pad 2% 2 M

erythromycin (acne aid) 2 M

isotretinoin CAPS 2 M PA

myorisan 2 M PA

neuac gel 1.2-5% 2 M

ONEXTON 4 M

RETIN-A MICRO .06% 5 M PA

RETIN-A MICRO PUMP .08%

5 M PA

sulfacetamide sodium (acne) 2 M

tretinoin CREA; GEL 2 M PA

tretinoin microsphere 2 M PA

zenatane 2 M PA

DERMATOLOGY, ANTIBIOTICS CENTANY 4 M

CORTISPORIN 4 M

gentamicin sulfate (topical) 2 M

mupirocin OINT 1 M

mupirocin calcium (topical) 2 M

silver sulfadiazine CREA 2 M

ssd 2 M

SULFAMYLON CREA 4 M

XEPI 4 M

DERMATOLOGY, ANTIFUNGALS ciclopirox GEL 2 M

ciclopirox cre 0.77% 2 M

ciclopirox shampoo 1% 2 M

ciclopirox sus 0.77% 2 M

clotrimazole (topical) 2 M

clotrimazole w/ betamethasone

2 M

ERTACZO 5 M

EXELDERM 4 M

ketoconazole (topical) 2 M

luliconazole 2 M

MENTAX 4 M

naftifine hcl 2 M

NAFTIN GEL 4 M

nyamyc 2 M

Drug Name Drug Tier

Requirements/Limits

nystatin (topical) 2 M

nystatin pow 100000 2 M

nystop 2 M

oxiconazole nitrate 2 M

OXISTAT LOTN 4 M

DERMATOLOGY, ANTIPSORIATICS acitretin 5 M PA

calcipotriene CREA; OINT QL (120 gm / 30 days)

2 QL M PA

calcipotriene SOLN QL (120 mL / 30 days)

2 QL M PA

calcitrene QL (120 gm / 30 days)

2 QL M PA

calcitriol OINT 2 M

methoxsalen rapid 5 M

tazarotene CREA 2 M PA

TAZORAC CREA .05% 4 M PA

TAZORAC GEL 4 M PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 1 M

selenium sulfide LOTN 1 M

DERMATOLOGY, CORTICOSTEROIDS ala-cort 1 M

alclometasone dipropionate 2 M

beser LOTN 2 M

betamethasone dipropionate (topical)

2 M

betamethasone dipropionate augmented

2 M

betamethasone valerate CREA; FOAM; LOTN; OINT

2 M

BRYHALI 4 M

calcipotriene/betamethasone 2 M PA

CAPEX 4 M

clocortolone pivalate 2 M

CORDRAN TAPE 4 M

DESONATE 4 M

desonide CREA; LOTN; OINT

2 M

desoximetasone LIQD 2 M

ENSTILAR 4 M PA

fluocinolone acetonide CREA; OIL; OINT; SOLN

2 M

fluocinolone acetonide oil body

2 M

fluocinonide CREA .05% 2 M

fluocinonide GEL 2 M

fluocinonide OINT 2 M

fluocinonide SOLN 2 M


43

Drug Name Drug Tier

Requirements/Limits

fluocinonide emulsified base 2 M

flurandrenolide 2 M

fluticasone propionate CREA; LOTN; OINT

2 M

halcinonide 2 M

halobetasol propionate CREA; OINT

2 M

HALOBETASOL PROPIONATE FOAM

5 M

HALOG 4 M

hydrocortisone (topical) CREA

1 M

hydrocortisone (topical) LOTN

2 M

hydrocortisone (topical) OINT 2.5%

1 M

hydrocortisone butyrate cream 0.1%

2 M

hydrocortisone butyrate lotion 0.1%

2 M

hydrocortisone butyrate oint 0.1%

2 M

hydrocortisone valerate 2 M

LEXETTE 5 M

MICORT-HC 4 M

mometasone furoate CREA; OINT; SOLN

2 M

nolix 2 M

PANDEL 5 M

prednicarbate 2 M

SERNIVO 5 M

TACLONEX SUSP 5 M PA

TEXACORT 4 M

triamcinolone acetonide (topical) AERS; LOTN

2 M

triamcinolone acetonide (topical) CREA; OINT

1 M

TRIANEX 4 M

ULTRAVATE LOTN 5 M

DERMATOLOGY, LOCAL ANESTHETICS glydo

QL (30 mL / 30 days) 2 QL M PA

lidocaine OINT QL (50 grams / 30 days)

2 QL M PA

lidocaine PTCH 2 M PA

lidocaine hcl GEL QL (30 mL / 30 days)

2 QL M PA

lidocaine hcl SOLN 4% QL (50 mL / 30 days)

2 QL M PA

Drug Name Drug Tier

Requirements/Limits

lidocaine-prilocaine QL (30 grams / 30 days)

2 QL M PA

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir topical CREA 5 M

acyclovir topical OINT 2 M

ammonium lactate CREA; LOTN

2 M

azelaic acid GEL 2 M

CONDYLOX 4 M

CORTIFOAM 4 M

DENAVIR 5 M

diclofenac sodium (topical) 1% gel

2 M PA

diclofenac sodium (topical) 1.5% soln

2 M PA

doxycycline (rosacea) 2 M

EUCRISA 4 M PA

FINACEA AER 15% 4 M

fluorouracil (topical) CREA 5%

2 M

fluorouracil (topical) SOLN 2 M

imiquimod CREA 3.75% 5 M

imiquimod CREA 5% 2 M

metronidazole (topical) 2 M

NORITATE 5 M

PANRETIN 5 M

PENNSAID 5 M PA

PICATO .05% QL (2 tubes / 30 days)

3 QL M

PICATO .015% QL (3 tubes / 30 days)

3 QL M

podofilox SOLN 2 M

procto-med hc 2 M

procto-pak 2 M

proctosol hc 2.5 % 2 M

proctozone-hc 2 M

RECTIV 4 M

rosadan cre 0.75% 2 M

SOOLANTRA 4 M

tacrolimus (topical) 2 M

TARGRETIN GEL 5 PA

VALCHLOR 5 LA PA

XERESE 5 M

ZYCLARA 5 M

ZYCLARA PUMP 5 M

DERMATOLOGY, SCABICIDES AND PEDICULIDES crotan 2 M


44

Drug Name Drug Tier

Requirements/Limits

EURAX 4 M

malathion 2 M

NATROBA 4 M

permethrin cre 5% 2 M

SKLICE 4 M

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 2 M

neomycin/polymyxin b gu 2 M

REGRANEX 5 M PA

SANTYL 4 M

sodium chlor sol 0.9% irr 2 M

water for irrigation, sterile 2 M

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl 2 M

chlorhexidine gluconate (mouth-throat)

1 M

clotrimazole LOZG 2 M

lidocaine hcl (mouth-throat) 2 M

nystatin (mouth-throat) 2 M

ORAVIG 5 M

paroex sol 0.12% 1 M

periogard 1 M

pilocarpine hcl (oral) 2 M

triamcinolone acetonide (mouth)

2 M

OTIC acetic acid (otic) 2 M

acetic acid sol/hc 2 M

CIPRO HC 4 M

CIPRODEX 3 M

ciprofloxacin hcl (otic) 2 M

COLY-MYCIN S 4 M

CORTISPORIN-TC 4 M

flac 2 M

fluocinolone acetonide (otic) 2 M

neomycin-polymyxin-hc (otic) 2 M

ofloxacin (otic) 2 M

OTOVEL 4 M

45

Index A abacavir sulfate ...................6 abacavir sulfate-lamivudine.6 abacavir sulfate-lamivudine-zidovudine ..........................................6 ABELCET............................5 ABILIFY MAINTENA ......... 18 abiraterone acetate ........... 10 ABRAXANE ........................9 ABSTRAL............................2 acamprosate calcium ........ 23 acarbose ........................... 25 acebutolol hcl .................... 13 acetaminophen w/ codeine 300-15mg ............................1 acetaminophen w/ codeine 300-30mg ............................1 acetaminophen w/ codeine 300-60mg ............................1 acetaminophen w/ codeine soln .....................................1 acetaminophen-caff-dihydrocod ........................................1 acetazolamide ................... 14 acetic acid ......................... 44 acetic acid (otic) ................ 44 acetic acid sol/hc ............... 44 acetylcysteine ................... 40 acitretin ............................. 42 ACTHIB ............................. 36 ACTIMMUNE .................... 36 ACUVAIL........................... 38 acyclovir ..............................7 acyclovir sodium .................7 acyclovir topical ................. 43 ACZONE ........................... 41 ADACEL............................ 36 adapalene ......................... 41 ADAPALENE .................... 41 adapalene-benzoyl peroxide gel 0.1-2.5% ...................... 41 adefovir dipivoxil .................7 ADEMPAS ........................ 15 ADMELOG ........................ 24 ADMELOG SOLOSTAR.... 24 adriamycin...........................9 adrucil .................................9 ADVAIR DISKUS .............. 41

ADVAIR HFA .................... 41 ADZENYS ER SUS 1.25MG .......................................... 20 ADZENYS XR-ODT .......... 20 AFINITOR ......................... 10 AFINITOR DISPERZ......... 10 AFREZZA ......................... 30 AFREZZA 4/8/12UNITS .... 30 AFREZZA 4/8UNITS ......... 30 AFREZZA 8/12 UNITS ...... 30 AIMOVIG .......................... 22 AKTIPAK ........................... 41 AKYNZEO ......................... 31 ala-cort .............................. 42 albendazole ........................ 4 albuterol sulfate ................ 40 albuterol sulfate er ............ 40 alclometasone dipropionate .......................................... 42 ALCOHOL SWABS ........... 24 ALDACTAZIDE TAB 50/50 .......................................... 14 ALDURAZYME ................. 29 ALECENSA ....................... 10 alendronate sodium .......... 27 alfuzosin hcl ...................... 33 ALIMTA ............................... 9 ALINIA ................................ 4 ALIQOPA .......................... 10 aliskiren fumarate ............. 14 allopurinol tab ..................... 1 almotriptan malate ............ 22 ALOCRIL .......................... 39 alogliptin benzoate ............ 25 alogliptin-metformin hcl ..... 25 alogliptin-pioglitazone 12.5-15mg ......................... 25 alogliptin-pioglitazone 12.5-30mg ......................... 25 alogliptin-pioglitazone 12.5-45mg ......................... 25 alogliptin-pioglitazone 25-15mg ............................ 25 alogliptin-pioglitazone 25-30mg ............................ 25 alogliptin-pioglitazone 25-45mg ............................ 25 ALOMIDE .......................... 39 ALORA .............................. 29

alosetron hcl ..................... 33 ALPHAGAN P 0.1% .......... 39 alprazolam ........................ 15 ALPRAZOLAM.................. 15 ALREX .............................. 38 altavera tab ....................... 27 ALTOPREV ...................... 13 ALTRENO ......................... 41 ALUNBRIG ....................... 10 ALVESCO ......................... 41 alyacen 1/35 ..................... 27 alyq ................................... 15 amantadine hcl ................. 18 AMBISOME ........................ 5 ambrisentan ...................... 15 amethia ............................. 27 amethia lo ......................... 27 amikacin sulfate .................. 4 amiloride & hydrochlorothiazide ........... 14 amiloride hcl ..................... 14 AMINOSYN II INJ 10% ..... 37 AMINOSYN-PF 7% ........... 37 AMINOSYN-PF INJ 10% .. 37 amiodarone hcl soln .......... 12 amiodarone tab 100mg ..... 12 amiodarone tab 200mg ..... 12 amiodarone tab 400mg ..... 12 AMITIZA ........................... 33 amitriptyline hcl ................. 17 amlodipine besylate .......... 14 amlodipine besylate-atorvastatin calcium.......................................... 14 amlodipine besylate-benazepril hcl ..... 12 amlodipine besylate-olmesartan medoxomil ........................ 12 amlodipine besylate-valsartan tab 10-160 mg ........................ 12 amlodipine besylate-valsartan tab 10-320 mg ........................ 12 amlodipine besylate-valsartan tab 5-160 mg ..................................... 12 amlodipine

46

besylate-valsartan tab 5-320 mg ..................................... 12 amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg .......................................... 12 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg .......................................... 12 amlodipine-valsartan-hydrochlorothiazide 10-320-25mg .......................................... 12 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg .......................................... 12 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg . 12 ammonium lactate ............. 43 amnesteem ....................... 41 amoxapine ........................ 17 amoxicillin ...........................8 amoxicillin & pot clavulanate ............................................8 amoxicillin-clarithromycin w/ lansoprazole ...................... 33 amphetamine cap 10mg er .......................................... 20 amphetamine cap 15mg er .......................................... 20 amphetamine cap 20mg er .......................................... 20 amphetamine cap 25mg er .......................................... 20 amphetamine cap 30mg er .......................................... 20 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 20 amphetamine-dextroamphetamine tab 10 mg ............... 20 amphetamine-dextroamphetamine tab 12.5 mg ............ 20 amphetamine-dextroamphetamine tab 15 mg ............... 20 amphetamine-dextroamphetamine tab 20 mg ............... 20 amphetamine-dextroamphetamine tab 30 mg ............... 20 amphetamine-dextroamphetamine tab 5 mg ................. 20 amphetamine-dextroamphetamine tab 7.5 mg .............. 20

amphotericin b .................... 5 ampicillin & sulbactam sodium ................................ 8 ampicillin cap 500mg .......... 8 ampicillin inj ........................ 8 ampicillin sodium ................ 8 ANADROL-50 ................... 24 anagrelide hcl ................... 35 anastrozole ....................... 10 ANDRODERM .................. 24 ANORO ELLIPT AER 62.5-25 .............................. 39 ANTARA ........................... 13 APIDRA ............................ 24 APIDRA SOLOSTAR ........ 24 APLENZIN ........................ 17 APOKYN ........................... 18 aprepitant .......................... 31 aprepitant pak 80mg & 125mg ............................... 31 apri .................................... 27 APRISO ............................ 32 APTENSIO XR .................. 20 APTIOM ............................ 15 APTIVUS ............................ 6 ARALAST NP ................... 40 aranelle ............................. 28 ARANESP ALBUMIN FREE .......................................... 34 ARCALYST ....................... 36 ARCAPTA NEOHALER .... 40 ARIKAYCE .......................... 4 aripiprazole odt ................. 18 aripiprazole oral solution 1 mg/ml ................................ 18 aripiprazole tab ................. 18 ARISTADA ........................ 18 ARISTADA INITIO ............ 18 armodafinil ........................ 23 ARNUITY ELLIPTA ........... 41 ARYMO ER ......................... 2 ARZERRA ........................... 9 ashlyna ............................. 28 ASMANEX ........................ 41 ASMANEX HFA ................ 41 aspirin-dipyridamole .......... 35 ASTAGRAF XL ................. 36 atazanavir sulfate ................ 6 atenolol ............................. 13 atenolol & chlorthalidone ... 13

ATGAM ............................. 36 atomoxetine hcl........... 20, 21 atorvastatin calcium .......... 13 atovaquone ......................... 4 atovaquone-proguanil hcl tab 250-100 mg ........................ 5 atovaquone-proguanil hcl tab 62.5-25 mg ......................... 5 ATRIPLA ............................. 6 atropine sulfate ................. 32 ATROPINE SULFATE ...... 39 ATROVENT HFA .............. 39 aubra ................................ 28 AUGMENTIN SUSP 125MG/5ML ........................ 8 AURYXIA .......................... 31 AUSTEDO ........................ 22 AVASTIN ............................ 9 AVC .................................. 34 aviane ............................... 28 avita .................................. 41 AVYCAZ ............................. 7 azacitidine ........................... 9 AZACTAM INJ .................... 4 AZASAN ........................... 36 AZASITE ........................... 38 azathioprine ...................... 36 azelaic acid ....................... 43 azelastine drop 0.05% ...... 39 azelastine spr 0.1% .......... 40 azelastine spr 0.15% ........ 40 AZELEX ............................ 41 azithromycin ....................... 8 AZOPT .............................. 39 aztreonam ........................... 4 B bacitracin (ophthalmic) ...... 38 bacitracin-polymyxin b (ophth) .............................. 38 bacitracin-poly-neomycin-hc.......................................... 38 baclofen ............................ 23 BACTOCILL INJ DEX 1GM 8 BACTOCILL INJ DEX 2GM 8 balsalazide disodium ........ 32 BALVERSA ....................... 10 balziva .............................. 28 BANZEL SUS 40MG/ML ... 15 BANZEL TAB 200MG ....... 15 BANZEL TAB 400MG ....... 15

47

BARACLUDE ......................7 BASAGLAR KWIKPEN ..... 24 BAXDELA ...........................8 BCG VACCINE ................. 36 BD ULTRAFINE INSULIN SYRINGE .......................... 24 BD ULTRAFINE/NANO PEN NEEDLES ......................... 24 BECONASE AQ ................ 41 bekyree ............................. 28 BELBUCA ...........................1 BELEODAQ ........................9 benazepril & hydrochlorothiazide ........... 12 benazepril hcl .................... 12 BENDEKA ...........................9 BENLYSTA ....................... 36 benzoyl peroxide-erythromycin ...... 41 benztropine mesylate inj ... 18 benztropine mesylate tab 0.5mg ................................ 18 benztropine mesylate tab 1mg ................................... 18 benztropine mesylate tab 2mg ................................... 18 BEPREVE ......................... 39 BERINERT ........................ 35 beser ................................. 42 BESIVANCE ..................... 38 BESPONSA ........................9 betamethasone dipropionate (topical) ............................. 42 betamethasone dipropionate augmented ........................ 42 betamethasone valerate ... 42 BETASERON .................... 23 betaxolol hcl ...................... 13 betaxolol hcl (ophth) .......... 39 bethanechol chloride ......... 34 BETHKIS.............................4 BETIMOL .......................... 39 BETOPTIC-S .................... 39 BEVESPI AEROSPHERE . 39 BEVYXXA ......................... 34 bexarotene ........................ 11 BEXSERO......................... 36 bicalutamide ...................... 10 BICILLIN C-R ......................8 BICILLIN L-A .......................8

BIDIL ................................. 14 BIKTARVY .......................... 6 BINOSTO .......................... 27 bisoprolol & hydrochlorothiazide ........... 13 bisoprolol fumarate ........... 13 BIVIGAM ........................... 35 bleomycin sulfate ................ 9 BLEPHAMIDE ................... 38 blisovi 24 fe ....................... 28 blisovi fe 1.5/30 ................. 28 BOOSTRIX ....................... 36 BORTEZOMIB .................... 9 bosentan ........................... 15 BOSULIF .......................... 10 BOTOX ............................. 23 BRAFTOVI ........................ 10 BREO ELLIPTA ................ 41 briellyn .............................. 28 BRILINTA .......................... 35 brimonidine sol 0.15%....... 39 brimonidine sol 0.2%......... 39 BRIVIACT INJ 50MG/5ML 15 BRIVIACT SOL 10MG/ML 15 BRIVIACT TAB 100MG ..... 15 BRIVIACT TAB 10MG....... 15 BRIVIACT TAB 25MG....... 15 BRIVIACT TAB 50MG....... 15 BRIVIACT TAB 75MG....... 15 bromfenac sodium (ophth) 38 bromocriptine mesylate ..... 18 BROMSITE ....................... 38 BROVANA ........................ 40 BRYHALI .......................... 42 budesonide ....................... 32 budesonide (inhalation) ..... 41 bumetanide ....................... 14 BUNAVAIL MIS 2.1-0.3MG .......................................... 23 BUNAVAIL MIS 4.2-0.7MG .......................................... 23 BUNAVAIL MIS 6.3-1MG .. 23 buprenorphine hcl ............. 23 buprenorphine hcl-naloxone hcl dihydrate 12-3mg ........ 23 buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg ....... 23 buprenorphine hcl-naloxone hcl dihydrate 4-1mg .......... 23 buprenorphine hcl-naloxone

hcl dihydrate 8-2mg .......... 23 buprenorphine hcl-naloxone hcl sl ................................. 24 buprenorphine patch ........... 1 bupropion hcl .................... 17 bupropion hcl (smoking deterrent) .......................... 24 buspirone hcl .................... 15 butorphanol nasal spray ..... 1 butorphanol tartrate ............ 1 BUTRANS .......................... 1 BYDUREON BCISE .......... 24 BYDUREON INJ ............... 24 BYDUREON PEN ............. 24 BYETTA ............................ 24 BYSTOLIC ........................ 13 C cabergoline ....................... 30 CABOMETYX ................... 10 calcipotriene ..................... 42 calcipotriene/betamethasone.......................................... 42 calcitonin (salmon) nasal spray ................................. 30 calcitrene .......................... 42 calcitriol ....................... 38, 42 calcitriol inj ........................ 38 calcium acetate (phosphate binder) .............................. 31 CALQUENCE ................... 10 camila ............................... 28 camrese lo tab .................. 28 candesartan cilexetil ......... 12 candesartan cilexetil-hydrochlorothiazide.......................................... 12 CAPEX ............................. 42 CAPRELSA ...................... 10 captopril ............................ 12 captopril & hydrochlorothiazide ........... 12 CARAFATE ...................... 33 CARBAGLU ...................... 29 carbamazepine ................. 15 carbidopa .......................... 18 carbidopa/levodopa/entacapone .................................... 18 carbidopa-levodopa .......... 18 carboplatin ........................ 11 CARDIZEM LA.................. 14

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CARDURA XL ................... 33 CARIMUNE NANOFILTERED .............. 35 CAROSPIR ....................... 12 carteolol hcl (ophth) .......... 39 cartia xt ............................. 14 carvedilol ........................... 13 carvedilol er ....................... 13 caspofungin acetate ............5 CAYSTON ...........................4 caziant pak ........................ 28 cefaclor ...............................7 CEFACLOR ER TAB 500MG ............................................7 cefadroxil.............................7 CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ..................7 cefazolin inj .........................7 cefazolin sodium .................7 CEFAZOLIN SODIUM 1 GM/50ML ............................7 cefdinir ................................7 CEFEPIME 1GM SOLN ......7 CEFEPIME 2GM SOLN ......7 cefepime inj 1gm .................7 cefepime inj 2gm .................7 CEFEPIME/DEXTROSE .....7 cefixime cap 400mg ............7 cefixime susr .......................7 cefotaxime sodium ..............7 cefotetan disodium ..............7 cefoxitin sodium ..................7 CEFOXITIN SODIUM .........7 cefpodoxime proxetil ...........7 cefprozil...............................7 ceftazidime ..........................7 CEFTAZIDIME/DEXTROSE ............................................7 ceftriaxone sodium ..............7 cefuroxime axetil .................7 cefuroxime sodium ..............7 celecoxib .............................1 CELONTIN ........................ 15 CENTANY ......................... 42 cephalexin ...........................7 CERDELGA ...................... 29 CEREZYME ...................... 29 CESAMET ......................... 31 cetirizine syrup .................. 40 cevimeline hcl ................... 44

CHANTIX .......................... 24 CHANTIX CONTINUING MONTH ............................. 24 CHANTIX STARTER PACK .......................................... 24 CHEMET ........................... 27 chlorhexidine gluconate (mouth-throat) ................... 44 chloroquine phosphate........ 5 chlorothiazide tabs ............ 14 chlorpromazine hcl ............ 18 CHLORPROMAZINE INJ .. 18 chlorthalidone ................... 14 cholestyramine .................. 13 cholestyramine light .......... 13 choline fenofibrate ............ 13 CHORIONIC GONADOTROPIN ............ 30 ciclopirox ........................... 42 ciclopirox cre 0.77% .......... 42 ciclopirox shampoo 1% ..... 42 ciclopirox sus 0.77% ......... 42 cidofovir .............................. 7 cilostazol ........................... 35 CILOXAN OIN 0.3% OP ... 38 CIMDUO ............................. 6 cimetidine .......................... 32 cimetidine sol 300/5ml ...... 32 cinacalcet hcl .................... 27 CINQAIR ........................... 40 CINRYZE .......................... 35 CINVANTI ......................... 31 CIPRO HC ........................ 44 CIPRODEX ....................... 44 ciprofloxacin ........................ 8 ciprofloxacin hcl .................. 8 ciprofloxacin hcl (ophth) .... 38 ciprofloxacin hcl (otic) ....... 44 ciprofloxacin in d5w ............ 8 cisplatin ............................. 11 citalopram hydrobromide .. 17 claravis .............................. 41 CLARINEX ........................ 40 CLARINEX-D TAB 2.5-120 .......................................... 40 clarithromycin ...................... 8 CLENPIQ .......................... 32 CLEOCIN VAG SUPP 100MG .............................. 34 clindacin-p ......................... 41

CLINDAGEL ..................... 41 clindamycin cre 2% vag .... 34 clindamycin hcl ................... 4 clindamycin phosphate (topical) ............................. 41 clindamycin phosphate in d5w ..................................... 4 CLINDAMYCIN PHOSPHATE IN NACL ...... 4 clindamycin phosphate inj ... 4 clindamycin phosphate-benzoyl peroxide.......................................... 42 clindamycin phosphate-benzoyl peroxide (refrigerate) ....................... 42 clindamycin phosphate-tretinoin ........... 42 clindamycin soln 75mg/5ml . 4 CLINDESSE ..................... 34 CLINIMIX 4.25%/DEXTROSE 10% ... 37 CLINIMIX 4.25%/DEXTROSE 25% ... 37 CLINIMIX 4.25%/DEXTROSE 5% ..... 37 CLINIMIX 5%/DEXTROSE 15% .................................. 37 CLINIMIX 5%/DEXTROSE 20% .................................. 37 CLINIMIX 5%/DEXTROSE 25% .................................. 37 CLINIMIX E 2.75%/DEXTROSE 5% ..... 37 CLINIMIX E 4.25%/D10 .... 37 CLINIMIX E 4.25%/DEXTROSE 5% ..... 37 CLINIMIX E 5%/DEXTROSE 15% .................................. 37 CLINIMIX E 5%/DEXTROSE 20% .................................. 37 clinisol sf 15% ................... 37 CLINOLIPID ...................... 37 clobazam .......................... 15 clocortolone pivalate ......... 42 clomipramine hcl ............... 17 clonazepam ...................... 15 clonidine hcl ...................... 14 clonidine hcl ptwk.............. 14 clopidogrel tab 300mg ...... 35

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clopidogrel tab 75mg ......... 35 clorazepate dipotassium ... 15 clotrimazole ....................... 44 clotrimazole (topical) ......... 42 clotrimazole w/ betamethasone ................. 42 clozapine odt ..................... 18 clozapine tab 100mg ......... 19 clozapine tab 200mg ......... 19 clozapine tab 25mg ........... 18 clozapine tab 50mg ........... 18 COARTEM ..........................6 codeine sulfate ....................2 colchicine w/ probenecid .....1 COLCRYS ...........................1 colesevelam hcl ................ 13 colestipol hcl gran ............. 13 colestipol hcl pack ............. 13 colestipol hcl tabs .............. 13 colistimethate sodium .........4 colocort ............................. 32 COLY-MYCIN S ................ 44 COMBIGAN ...................... 39 COMBIVENT RESPIMAT . 39 COMETRIQ ....................... 10 COMPLERA ........................6 compro supp ..................... 31 CONDYLOX ...................... 43 constulose ......................... 32 COPIKTRA ........................ 10 CORDRAN ........................ 42 CORLANOR SOLN ........... 14 CORLANOR TABS ........... 14 CORTIFOAM .................... 43 cortisone acetate ............... 30 CORTISPORIN ................. 42 CORTISPORIN-TC ........... 44 COTELLIC ........................ 10 COTEMPLA XR-ODT ....... 21 COUMADIN ...................... 34 CREON ............................. 33 CRESEMBA ........................5 CRINONE ......................... 31 CRIXIVAN ...........................6 cromolyn sodium ............... 40 cromolyn sodium (mastocytosis) ................... 33 cromolyn sodium (ophth) .. 39 crotan ................................ 43 cryselle-28......................... 28

CUVPOSA ........................ 32 cyclafem 1/35 .................... 28 cyclafem 7/7/7 ................... 28 cyclobenzaprine hcl .......... 23 cyclophosphamide .............. 9 cycloserine .......................... 7 cyclosporine ...................... 36 cyclosporine modified (for microemulsion) ................. 36 cyproheptadine hcl ............ 40 cyred tab ........................... 28 CYSTADANE .................... 29 CYSTAGON ...................... 29 CYSTARAN ...................... 39 cytarabine ........................... 9 D dacarbazine ........................ 9 dalfampridine .................... 23 DALIRESP ........................ 40 DALVANCE ........................ 4 danazol ............................. 29 dantrolene sodium ............ 23 dapsone .............................. 4 dapsone gel 5% ................ 42 DAPTACEL ....................... 36 daptomycin ......................... 4 DAPTOMYCIN .................... 4 darifenacin hydrobromide . 34 dasetta 1/35 ...................... 28 dasetta 7/7/7 ..................... 28 DAURISMO ........................ 9 DAYTRANA ...................... 21 deblitane ........................... 28 decitabine ........................... 9 deferasirox ........................ 27 DELESTROGEN ............... 29 DELSTRIGO ....................... 6 delyla ................................ 28 DELZICOL ........................ 32 demeclocycline hcl .............. 8 DEMSER .......................... 14 DENAVIR .......................... 43 DEPEN TITRATABS ......... 27 DEPO-ESTRADIOL .......... 29 DEPO-MEDROL ............... 30 DEPO-PROVERA INJ 400/ML .............................. 10 DEPO-SUBQ PROVERA 104 .................................... 28 DESCOVY .......................... 6

desipramine hcl................. 17 desloratadine .................... 40 desmopressin acetate ....... 31 desmopressin acetate spray.......................................... 31 desmopressin acetate spray refrigerated ....................... 31 desmopressin inj 4mcg/ml 31 desogestrel & ethinyl estradiol ............................ 28 desogestrel-ethinyl estradiol (biphasic) .......................... 28 DESONATE ...................... 42 desonide ........................... 42 desoximetasone................ 42 desvenlafaxine succinate .. 17 dexamethasone ................ 30 DEXAMETHASONE ......... 30 dexamethasone sodium phosphate ......................... 30 dexamethasone sodium phosphate (ophth)............. 38 DEXILANT ........................ 33 dexmethylphenidate hcl .... 21 dexrazoxane hcl................ 11 dextrose ............................ 37 dextrose 10% flex contain . 37 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%.......................................... 37 dextrose 10%/nacl 0.45% . 37 dextrose 2.5%/nacl 0.45% 37 dextrose 5% ...................... 37 DEXTROSE 5% /ELECTROLYTE ............... 37 dextrose 5%/nacl 0.2% ..... 37 dextrose 5%/nacl 0.225% . 37 DEXTROSE 5%/NACL 0.3%.......................................... 37 dextrose 5%/nacl 0.33% ... 37 dextrose 5%/nacl 0.45% ... 37 dextrose 5%/nacl 0.9% ..... 37 dextrose 5%/potassium chl.......................................... 37 dextrose in lactated ringers.......................................... 37 DIASTAT ACUDIAL .......... 15 DIASTAT PEDIATRIC ...... 15 diazepam .......................... 15 diazepam gel .................... 15

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diazepam inj ...................... 16 diazepam intensol ............. 16 diazepam oral soln 1 mg/ml .......................................... 16 diclofenac potassium ..........1 diclofenac sodium ...............1 diclofenac sodium (ophth) . 38 diclofenac sodium (topical) 1% gel ............................... 43 diclofenac sodium (topical) 1.5% soln .......................... 43 diclofenac w/ misoprostol ....1 dicloxacillin sodium .............8 dicyclomine hcl cap 10mg . 32 dicyclomine hcl inj ............. 32 dicyclomine hcl soln 10mg/5ml .......................... 32 dicyclomine hcl tab 20mg .. 32 didanosine...........................6 DIFFERIN ......................... 42 DIFICID ...............................8 diflunisal ..............................1 digitek ............................... 14 digox ................................. 14 digoxin .............................. 14 digoxin inj .......................... 14 digoxin sol 50mcg/ml ........ 14 dihydroergotamine mesylate inj 1 mg/ml ......................... 22 dihydroergotamine mesylate nasal ................................. 22 DILANTIN CAP 100MG .... 16 DILANTIN CAP 30MG ...... 16 DILANTIN CHEW TAB 50MG ................................ 16 DILANTIN-125 SUSP ........ 16 DILATRATE SR ................ 15 diltiazem cap 180mg cd .... 14 diltiazem cap 240mg cd .... 14 diltiazem cap 360mg cd .... 14 diltiazem cap er/12hr ......... 14 diltiazem er tab 180mg ...... 14 diltiazem er tab 240mg ...... 14 diltiazem er tab 300mg ...... 14 diltiazem er tab 360mg ...... 14 diltiazem er tab 420mg ...... 14 diltiazem hcl ...................... 14 diltiazem hcl coated beads cap sr 24hr ........................ 14 diltiazem hcl extended

release beads cap sr......... 14 diltiazem inj ....................... 14 dilt-xr cap .......................... 14 DIPENTUM ....................... 32 diphenhydramine hcl inj 50mg/ml ............................ 40 diphenoxylate w/ atropine . 33 DIPHTHERIA/TETANUS TOXOID ............................ 36 disopyramide phosphate ... 12 disulfiram .......................... 24 DIURIL SUS 250/5ML ....... 14 divalproex sodium ............. 16 docetaxel ............................ 9 DOCETAXEL ...................... 9 dofetilide ........................... 12 donepezil odt 10mg .......... 17 donepezil odt 5mg ............ 17 donepezil tab hcl 23mg ..... 17 donepezil tabs 10mg ......... 17 donepezil tabs 5mg ........... 17 DOPTELET ....................... 35 dorzolamide hcl ................. 39 dorzolamide hcl-timolol maleate ............................. 39 dotti ................................... 30 DOVATO ............................. 6 doxazosin mesylate .......... 12 doxepin hcl ........................ 17 doxercalciferol ................... 38 doxorubicin hcl .................... 9 doxorubicin hcl liposomal .... 9 doxy 100 ............................. 8 doxycycline (monohydrate) . 8 doxycycline (rosacea) ....... 43 doxycycline hyclate ............. 8 doxycycline hyclate tab 100 mg dr................................... 8 doxycycline hyclate tab 150 mg dr................................... 8 doxycycline hyclate tab 75 mg dr................................... 8 dronabinol ......................... 31 drospirenone-ethinyl estradiol ............................ 28 drospirenone-ethinyl estradiol-levomefolate calcium .............................. 28 DROXIA ............................ 35 DULERA ........................... 41

duloxetine hcl .................... 17 DUOPA ............................. 18 DUREZOL ........................ 38 dutasteride ........................ 33 dutasteride-tamsulosin hcl 33 DUTOPROL ...................... 13 DUZALLO ........................... 1 dvorah ................................. 1 DYANAVEL XR................. 21 DYMISTA SPR 137-50 ..... 40 DYRENIUM ...................... 14 E e.e.s 400 ............................. 8 EDARBI ............................ 12 EDARBYCLOR ................. 12 EDURANT .......................... 6 efavirenz ............................. 6 EGRIFTA 1MG ................. 30 ELAPRASE ....................... 29 ELECTROLYTE-R IN DEXTROSE ...................... 37 ELELYSO ......................... 29 eletriptan hydrobromide .... 22 ELIGARD INJ 22.5MG ...... 10 ELIGARD INJ 30MG ......... 10 ELIGARD INJ 45MG ......... 10 ELIGARD INJ 7.5MG ........ 10 ELIQUIS STARTER PACK.......................................... 34 ELIQUIS TAB 2.5MG ........ 34 ELIQUIS TAB 5MG ........... 34 ELITEK ............................. 11 ELIXOPHYLLIN ................ 40 ELLA ................................. 28 ELMIRON ......................... 34 EMBEDA CAP 100-4MG .... 2 EMBEDA CAP 20-0.8MG ... 2 EMBEDA CAP 30-1.2MG ... 2 EMBEDA CAP 50-2MG ...... 2 EMBEDA CAP 60-2.4MG ... 2 EMBEDA CAP 80-3.2MG ... 2 EMCYT ............................... 9 EMEND ............................. 31 EMGALITY ....................... 22 emoquette ......................... 28 EMSAM ............................ 17 EMTRIVA ............................ 6 EMVERM ............................ 4 enalapril maleate .............. 12 enalapril maleate &

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hydrochlorothiazide ........... 12 ENDARI ............................ 35 endocet 10-325mg ..............2 endocet 2.5-325mg .............2 endocet 5-325mg ................2 endocet 7.5-325mg .............2 ENGERIX-B ...................... 36 enoxaparin sodium ............ 34 enpresse-28 ...................... 28 enskyce ............................. 28 ENSTILAR ........................ 42 entacapone ....................... 18 entecavir .............................7 ENTRESTO ...................... 12 ENTYVIO .......................... 32 enulose ............................. 32 ENVARSUS XR ................ 36 EPANED ........................... 12 EPCLUSA ...........................7 EPIDIOLEX ....................... 16 EPIDUO FORTE ............... 42 epinastine hcl (ophth) ........ 39 epinephrine (anaphylaxis) 40, 41 epirubicin hcl .......................9 epitol ................................. 16 EPIVIR HBV ........................7 eplerenone ........................ 12 EPOGEN........................... 34 eprosartan mesylate ......... 12 EQUETRO ........................ 22 ERAXIS ...............................5 ERBITUX ............................9 ergotamine w/ caffeine ...... 22 ERIVEDGE .........................9 ERLEADA ......................... 10 erlotinib hcl ........................ 10 errin ................................... 28 ERTACZO ......................... 42 ertapenem sodium ..............4 ery pad 2% ........................ 42 ERYPED 400 ......................8 ery-tab .................................8 ERYTHROCIN LACTOBIONATE ................8 erythrocin stearate ..............8 erythromycin (acne aid) .... 42 erythromycin (ophth) ......... 38 erythromycin base ...............8 erythromycin cap 250mg ec 8

erythromycin ethylsuccinate 8 erythromycin tab ec ............ 8 ESBRIET .......................... 41 escitalopram oxalate ......... 17 esomeprazole magnesium 33 esomeprazole sodium inj .. 33 estarylla tab 0.25-35 ......... 28 estradiol ............................ 30 estradiol vaginal cream ..... 30 estradiol vaginal tab .......... 30 estradiol valerate .............. 30 ESTRING .......................... 30 ethacrynic acid .................. 14 ethambutol hcl .................... 7 ethosuximide ..................... 16 ethynodiol diacet & eth estrad ................................ 28 ethynodiol tab 1-50 ........... 28 etodolac .............................. 1 etodolac er .......................... 1 etoposide .......................... 11 EUCRISA .......................... 43 EURAX ............................. 44 EVENITY .......................... 30 EVOTAZ ............................. 6 EXELDERM ...................... 42 exemestane ...................... 10 ezetimibe .......................... 13 ezetimibe-simvastatin ....... 13 F FABRAZYME .................... 29 falmina .............................. 28 famciclovir ........................... 7 famotidine ......................... 32 famotidine in nacl .............. 32 famotidine inj ..................... 32 FANAPT ............................ 19 FANAPT TITRATION PACK .......................................... 19 FARXIGA .......................... 25 FARYDAK ........................... 9 FASENRA INJ 30MG/ML .. 41 FASLODEX ....................... 10 fayosim ............................. 28 febuxostat ........................... 1 felbamate .......................... 16 felodipine .......................... 14 FEMRING ......................... 30 femynor ............................. 28 fenofibrate ......................... 13

fenofibrate micronized ...... 13 fenofibric acid ................... 13 fenoprofen calcium ............. 1 fentanyl citrate .................... 2 fentanyl patch 100 mcg/hr .. 2 fentanyl patch 12 mcg/hr .... 2 fentanyl patch 25 mcg/hr .... 2 fentanyl patch 50 mcg/hr .... 2 fentanyl patch 75 mcg/hr .... 2 FENTORA .......................... 2 FERRIPROX ..................... 27 FETZIMA .......................... 17 FETZIMA TITRATION PACK.......................................... 17 FIASP ............................... 24 FIASP FLEXTOUCH ......... 24 FINACEA AER 15% .......... 43 finasteride ......................... 33 FIRAZYR .......................... 35 FIRMAGON ...................... 10 FIRVANQ ............................ 4 flac .................................... 44 FLAREX ............................ 38 FLEBOGAMMA DIF .......... 35 flecainide acetate .............. 12 FLOLIPID .......................... 13 FLOVENT DISKUS ........... 41 FLOVENT HFA ................. 41 fluconazole ......................... 5 fluconazole inj nacl 200 ...... 5 fluconazole inj nacl 400 ...... 5 flucytosine ........................... 5 fludarabine phosphate ........ 9 fludrocortisone acetate ..... 30 flunisolide (nasal) .............. 41 fluocinolone acetonide ...... 42 fluocinolone acetonide (otic).......................................... 44 fluocinolone acetonide oil body .................................. 42 fluocinonide ...................... 42 fluocinonide emulsified base.......................................... 43 fluorometholone (ophth) .... 38 fluorouracil .......................... 9 fluorouracil (topical) .......... 43 fluoxetine cap 10mg .......... 17 fluoxetine cap 20mg .......... 17 fluoxetine cap 40mg .......... 17 fluoxetine hcl ..................... 17

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fluoxetine hcl (pmdd) ......... 24 fluphenazine decanoate .... 19 fluphenazine hcl ................ 19 flurandrenolide .................. 43 flurbiprofen ..........................1 flurbiprofen sodium ........... 38 flutamide ........................... 10 fluticasone propionate ....... 43 fluticasone propionate (nasal) ............................... 41 fluvastatin sodium cap 20 mg .......................................... 13 fluvastatin sodium cap 40 mg .......................................... 13 fluvastatin sodium tab sr 24 hr 80 mg ............................ 13 fluvoxamine maleate ......... 15 fluvoxamine maleate er ..... 15 FML ................................... 38 FML FORTE ...................... 38 fondaparinux sodium ......... 34 FORTEO ........................... 30 FOSAMAX PLUS D .......... 27 fosamprenavir tab 700 mg ..6 fosaprepitant dimeglumine 31 fosinopril sodium ............... 12 fosinopril sodium & hydrochlorothiazide ........... 12 FOSRENOL ...................... 31 FRAGMIN ......................... 34 FREAMINE HBC 6.9% ...... 37 FREAMINE III ................... 37 frovatriptan succinate ........ 22 fulvestrant ......................... 10 furosemide ........................ 14 furosemide inj .................... 14 furosemide oral soln 8 mg/ml .......................................... 14 FUZEON .............................6 fyavolv ............................... 30 FYCOMPA ........................ 16 G gabapentin ........................ 16 GALAFOLD ....................... 29 galantamine hydrobromide 17 galantamine hydrobromide er ....................................... 17 GAMASTAN S/D ............... 35 GAMMAGARD LIQUID ..... 35 GAMMAGARD S/D ........... 36

GAMMAKED ..................... 36 GAMMAPLEX ................... 36 GAMMAPLEX 10GM/100ML .......................................... 36 GAMUNEX-C .................... 36 GANCICLOVIR INJ 500MG/10ML ...................... 7 ganciclovir sodium .............. 7 GARDASIL 9 ..................... 36 gatifloxacin (ophth) ........... 38 GATTEX ........................... 33 GAUZE PADS 2X2 ........... 24 gavilyte-c ........................... 33 gavilyte-g .......................... 33 gavilyte-n/flavor pack ........ 33 GELNIQUE PUMP ............ 34 gemcitabine inj soln ............ 9 gemcitabine inj solr ............. 9 gemfibrozil ........................ 13 generlac ............................ 33 gengraf .............................. 36 GENOTROPIN .................. 30 GENOTROPIN MINIQUICK .......................................... 30 gentak ............................... 38 gentamicin in saline ............ 4 gentamicin sulfate ............... 4 gentamicin sulfate (topical) .......................................... 42 gentamicin sulfate soln (ophth) .............................. 38 GENVOYA .......................... 6 GEODON INJ ................... 19 gianvi tab 3-0.02mg .......... 28 GILENYA CAP 0.5MG ...... 23 GILOTRIF TAB 20MG....... 10 GILOTRIF TAB 30MG....... 10 GILOTRIF TAB 40MG....... 10 GLASSIA .......................... 41 glatiramer acetate 20mg/ml .......................................... 23 glatiramer acetate 40mg/ml .......................................... 23 glatopa .............................. 23 GLEOSTINE ....................... 9 glimepiride ........................ 25 glipizide ............................. 25 glipizide er ......................... 25 glipizide xl ......................... 25 glipizide-metformin 2.5-250

mg ..................................... 26 glipizide-metformin 2.5-500 mg ..................................... 26 glipizide-metformin 5-500mg.......................................... 26 GLUCAGEN HYPOKIT ..... 30 GLUCAGON EMERGENCY KIT .................................... 30 GLYCATE ......................... 32 glycopyrrolate ................... 32 GLYCOPYRROLATE ....... 32 glycopyrrolate tab 1mg ..... 32 glycopyrrolate tab 2mg ..... 32 glydo ................................. 43 GLYXAMBI ....................... 26 GOCOVRI ......................... 18 GOLYTELY ....................... 33 GRALISE .......................... 22 GRALISE STARTER ........ 22 granisetron hcl .................. 31 GRANIX ............................ 34 griseofulvin microsize ......... 5 griseofulvin ultramicrosize .. 5 guanfacine er (adhd) ......... 21 H HAEGARDA ..................... 35 hailey 24 fe ....................... 28 HALAVEN ......................... 11 halcinonide ....................... 43 halobetasol propionate ..... 43 HALOBETASOL PROPIONATE .................. 43 HALOG ............................. 43 haloperidol ........................ 19 haloperidol conc 2mg/ml ... 19 haloperidol decanoate ...... 19 haloperidol lactate inj 5mg/ml.......................................... 19 HARVONI TAB 90-400MG . 7 HAVRIX ............................ 36 heather ............................. 28 heparin sod (porcine) in d5w.......................................... 34 heparin sod inj 10000u/ml . 34 heparin sod inj 1000u/ml ... 34 heparin sod inj 20000u/ml . 34 heparin sod inj 5000u/0.5ml.......................................... 34 heparin sod inj 5000u/ml ... 34 HEPARIN SODIUM INJ

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5000 U/0.5ML ................... 34 HEPARIN SODIUM/NACL 0.45% ................................ 34 hepatamine ....................... 37 HERCEPTIN .......................9 HERCEPTIN HYLECTA ......9 HETLIOZ ........................... 22 HIBERIX............................ 36 HORIZANT ........................ 22 HUMALOG ........................ 24 HUMALOG JUNIOR KWIKPEN ......................... 24 HUMALOG KWIKPEN ...... 24 HUMALOG MIX 50/50 ...... 24 HUMALOG MIX 50/50 KWIKPEN ......................... 24 HUMALOG MIX 75/25 ...... 24 HUMALOG MIX 75/25 KWIKPEN ......................... 24 HUMATROPE ................... 30 HUMATROPE COMBO PACK ................................ 30 HUMIRA ............................ 35 HUMIRA INJ 10MG/0.2ML 35 HUMIRA KIT 20MG/0.4ML 35 HUMIRA KIT 40MG/0.8ML 35 HUMIRA PEDIATRIC CROHNS DISEASE .......... 35 HUMIRA PEN ................... 35 HUMIRA PEN CD/UC/HS STARTER ......................... 35 HUMIRA PEN INJ CD/UC/HS STARTER ....... 35 HUMIRA PEN INJ PS/UV STARTER ......................... 35 HUMIRA PEN-PS/UV STARTER ......................... 35 HUMULIN 70/30 ................ 24 HUMULIN 70/30 KWIKPEN .......................................... 24 HUMULIN N ...................... 24 HUMULIN N KWIKPEN..... 24 HUMULIN R ...................... 25 HUMULIN R U-500 (CONCENTRATE) ............ 25 HUMULIN R U-500 KWIKPEN ......................... 25 hydralazine hcl .................. 14 hydrochlorothiazide ........... 14 hydrocodone-acetaminophen

10-300mg ............................ 2 hydrocodone-acetaminophen 2.5-325mg ........................... 2 hydrocodone-acetaminophen 5-300mg .............................. 2 hydrocodone-acetaminophen 5-325mg .............................. 2 hydrocodone-acetaminophen 7.5-300mg ........................... 2 hydrocodone-acetaminophen 7.5-325 mg/15ml ................. 2 hydrocodone-acetaminophen 7.5-325mg ........................... 2 hydrocodone-acetaminophen tab 10-325mg ...................... 2 hydrocodone-ibuprofen tab 10-200mg ............................ 2 hydrocodone-ibuprofen tab 5-200mg .............................. 2 hydrocodone-ibuprofen tab 7.5-200 mg .......................... 2 hydrocortisone .................. 30 hydrocortisone (enema) .... 32 hydrocortisone (topical) ..... 43 hydrocortisone butyrate cream 0.1% ....................... 43 hydrocortisone butyrate lotion 0.1% ........................ 43 hydrocortisone butyrate oint 0.1%.................................. 43 hydrocortisone valerate..... 43 hydromorphone hcl ............. 2 HYDROMORPHONE HYDROCHLORI ................. 2 hydromorphone tab 12mg er ............................................ 2 hydromorphone tab 16mg er ............................................ 2 hydromorphone tab 8mg er . 2 hydromorphone tabs 32mg er ........................................ 2 hydroxychloroquine sulfate .......................................... 35 hydroxyprogesterone caproate (antineoplastic) ... 10 hydroxyurea ...................... 11 hydroxyzine hcl ................. 40 hydroxyzine hcl inj ............ 40 hydroxyzine pamoate ........ 40 HYSINGLA ER .................... 3

I ibandronate sodium .......... 27 ibandronate tab 150mg ..... 27 IBRANCE ............................ 9 ibu tab 600mg ..................... 1 ibu tab 800mg ..................... 1 ibuprofen ............................. 1 icatibant acetate................ 35 ICLUSIG ........................... 10 IDHIFA ................................ 9 IFEX INJ 3GM .................... 9 ifosfamide inj 1gm/20ml ...... 9 IFOSFAMIDE INJ 3GM ....... 9 ifosfamide inj 3gm/60ml ...... 9 ILEVRO ............................ 38 imatinib mesylate .............. 10 IMBRUVICA ...................... 10 imipenem-cilastatin ............. 4 imipramine hcl .................. 17 imipramine pamoate ......... 17 imiquimod ......................... 43 IMOVAX RABIES (H.D.C.V.).......................................... 36 IMVEXXY MAINTENANCE PACK ................................ 30 IMVEXXY STARTER PACK.......................................... 30 INBRIJA ............................ 18 incassia ............................. 28 INCRELEX ........................ 30 INCRUSE ELLIPTA .......... 39 indapamide ....................... 14 INFANRIX ......................... 36 INFUGEM ........................... 9 INGREZZA ....................... 22 INLYTA ............................. 10 INREBIC ........................... 10 INSULIN LISPRO ............. 25 INSULIN LISPRO KWIKPEN.......................................... 25 INSULIN PEN NEEDLES . 25 INSULIN SAFETY NEEDLES ......................... 25 INSULIN SYRINGES ........ 25 INTELENCE ....................... 6 INTRALIPID 30% .............. 37 INTRALIPID INJ 20% ....... 37 INTRAROSA ..................... 34 INTRON-A INJ 10MU ....... 36 INTRON-A INJ 18MU ....... 36

54

INTRON-A INJ 25MU ........ 36 INTRON-A INJ 50MU ........ 36 introvale ............................ 28 INVEGA SUST INJ 117 MG/0.75 ML ...................... 19 INVEGA SUST INJ 156MG/ML ........................ 19 INVEGA SUST INJ 234 MG/1.5 ML ........................ 19 INVEGA SUST INJ 39 MG/0.25 ML ...................... 19 INVEGA SUST INJ 78 MG/0.5 ML ........................ 19 INVEGA TRINZA .............. 19 INVELTYS......................... 38 INVIRASE ...........................6 INVOKAMET TAB 150-1000MG ..................... 26 INVOKAMET TAB 150-500MG ....................... 26 INVOKAMET TAB 50-1000MG ....................... 26 INVOKAMET TAB 50-500MG ......................... 26 INVOKAMET XR TAB 150-1000MG ..................... 26 INVOKAMET XR TAB 150-500MG ....................... 26 INVOKAMET XR TAB 50-1000MG ....................... 26 INVOKAMET XR TAB 50-500MG ......................... 26 INVOKANA TAB 100MG ... 26 INVOKANA TAB 300MG ... 26 IONOSOL-MB/DEXTROSE 5% ..................................... 37 IPOL INACTIVATED IPV .. 36 ipratropium bromide (nasal) .......................................... 39 ipratropium sol inhal .......... 39 ipratropium-albuterol ......... 39 irbesartan .......................... 12 irbesartan-hydrochlorothiazide ........................................ 12 IRESSA ............................. 10 irinotecan hcl ..................... 11 ISENTRESS ........................6 ISENTRESS HD .................6 isibloom ............................. 28 ISOLYTE P ....................... 37

ISOLYTE S ....................... 37 isoniazid .............................. 7 isoniazid tabs ...................... 7 ISORDIL TITRADOSE ...... 15 isosorbide dinitrate ............ 15 isosorbide dinitrate er........ 15 isosorbide mononitrate...... 15 isosorbide mononitrate er . 15 isotretinoin ........................ 42 isradipine .......................... 14 itraconazole ........................ 5 ivermectin ........................... 5 IXEMPRA KIT ................... 11 IXIARO .............................. 36 J JADENU ........................... 27 JADENU SPRINKLE ......... 27 JAKAFI .............................. 11 jantoven ............................ 34 JANUMET ......................... 26 JANUMET XR TAB 100-1000 ........................... 26 JANUMET XR TAB 50-1000 .......................................... 26 JANUMET XR TAB 50-500MG ......................... 26 JANUVIA ........................... 26 JARDIANCE ..................... 26 jasmiel ............................... 28 JENTADUETO .................. 26 JENTADUETO TAB XR 2.5-1000 MG ..................... 26 JENTADUETO TAB XR 5-1000 MG ........................ 26 jinteli.................................. 30 jolessa tab 0.15-0.03 mg ... 28 jolivette .............................. 28 juleber ............................... 28 JULUCA .............................. 6 junel 1.5/30 ....................... 28 junel 1/20 .......................... 28 junel fe 1.5/30 ................... 28 junel fe 1/20 ...................... 28 junel fe 24 ......................... 28 JUXTAPID ........................ 13 JYNARQUE ...................... 30 K KADCYLA ........................... 9 KADIAN .............................. 3 kaitlib fe ............................. 28

KALETRA TAB 100-25MG . 6 KALETRA TAB 200-50MG . 6 KALYDECO ...................... 41 KAPSPARGO SPRINKLE 13 kariva ................................ 28 kcl 0.075%/d5w/nacl 0.45%.......................................... 38 KCL 0.15%/D5W/LR ......... 38 KCL 0.15%/D5W/NACL 0.225% ............................. 38 kcl 0.15%/d5w/nacl 0.9% .. 38 KCL 0.3%/D5W/LR ........... 37 kcl 0.3%/d5w/nacl 0.45% .. 37 KCL 0.3%/D5W/NACL 0.9%.......................................... 37 kcl/d5w/nacl inj .15/.33% .. 38 kcl/d5w/nacl inj .15/.45% .. 38 kcl/d5w/nacl inj 0.22%/0.45%.......................................... 38 kcl/nacl inj 0.15%-0.9% ..... 38 kcl0.15%/d5w/nacl0.2% .... 37 kelnor 1/35 ........................ 28 kelnor 1/50 ........................ 28 ketoconazole ...................... 5 ketoconazole (topical) ....... 42 ketoconazole shampoo ..... 42 ketoprofen ........................... 1 ketorolac tromethamine (ophth) .............................. 39 KEVEYIS .......................... 14 KEYTRUDA ........................ 9 KHAPZORY ...................... 11 KINRIX .............................. 36 kionex sus 15gm/60ml ...... 27 KISQALI .............................. 9 KISQALI FEMARA 200 DOSE ................................. 9 KISQALI FEMARA 400 DOSE ................................. 9 KISQALI FEMARA 600 DOSE ................................. 9 klor-con 10 ........................ 36 klor-con 8 .......................... 36 klor-con m10 ..................... 36 klor-con m15 ..................... 36 klor-con m20 ..................... 36 klor-con pak 20meq .......... 36 klor-con spr cap 10meq .... 37 klor-con spr cap 8meq ...... 37 KOMBIGLYZE XR

55

2.5-1000MG ...................... 26 KOMBIGLYZE XR 5-1000MG ......................... 26 KOMBIGLYZE XR 5-500MG .......................................... 26 KORLYM ........................... 30 KRISTALOSE ................... 33 kurvelo .............................. 28 KUVAN ............................. 29 KYNAMRO ........................ 13 L labetalol hcl ....................... 13 LACRISERT ...................... 39 lactated ringer's ................. 38 lactulose ............................ 33 lactulose (encephalopathy) .......................................... 33 LAMICTAL ODT ................ 16 LAMICTAL XR .................. 16 lamivudine ...........................6 lamivudine (hbv) ..................7 lamivudine-zidovudine ........6 lamotrigine ........................ 16 LANOXIN PEDIATRIC ...... 14 LANOXIN TABS 62.5 MCG .......................................... 14 lansoprazole ...................... 33 lanthanum chew tab .......... 31 larin 1.5/30 ........................ 28 larin 1/20 ........................... 28 larin fe 1.5/30 .................... 28 larin fe 1/20 ....................... 28 larissia tab ......................... 28 LASTACAFT ..................... 39 latanoprost ........................ 39 LATUDA ............................ 19 layolis fe chw ..................... 28 LAZANDA ...........................3 leena tab ........................... 28 leflunomide ........................ 35 LENVIMA 10 MG DAILY DOSE ................................ 11 LENVIMA 12MG DAILY DOSE ................................ 11 LENVIMA 14 MG DAILY DOSE ................................ 11 LENVIMA 18 MG DAILY DOSE ................................ 11 LENVIMA 20 MG DAILY DOSE ................................ 11

LENVIMA 24 MG DAILY DOSE ................................ 11 LENVIMA 4 MG DAILY DOSE ................................ 11 LENVIMA 8 MG DAILY DOSE ................................ 11 lessina ............................... 28 letrozole ............................ 10 leucovorin calcium ............ 11 leucovorin calcium solr...... 11 LEUKERAN ........................ 9 LEUKINE .......................... 34 leuprolide inj 1mg/0.2 ........ 10 levalbuterol hcl .................. 40 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml .......... 40 levalbuterol tartrate hfa ..... 40 LEVEMIR .......................... 25 LEVEMIR FLEXTOUCH ... 25 levetiracetam .................... 16 levetiracetam in sodium chloride ............................. 16 levetiracetam oral soln 100 mg/ml ................................ 16 levobunolol hcl .................. 39 levocarnitine (metabolic modifiers) .......................... 29 levocetirizine soln 2.5mg/5ml .......................................... 40 levocetirizine tab 5 mg ...... 40 levofloxacin ......................... 8 levofloxacin (ophth) ........... 38 levofloxacin in d5w .............. 8 levoleucovorin calcium ...... 11 levoleucovorin calcium 50mg .......................................... 11 levonest ............................ 28 levonor/ethi tab ................. 28 levonorgestrel & eth estradiol .......................................... 28 levonorgestrel-ethinyl estradiol (91-day) .............. 28 levonorgestrel-ethinyl estradiol (continuous)........ 28 levora 0.15/30-28 .............. 28 levorphanol tartrate ............. 3 levo-t ................................. 31 levothyroxine sodium ........ 31 levoxyl ............................... 31 LEXETTE .......................... 43

LEXIVA ............................... 6 LIBTAYO ............................ 9 lidocaine ........................... 43 lidocaine hcl ...................... 43 lidocaine hcl (local anesth.) 4 lidocaine hcl (mouth-throat).......................................... 44 lidocaine inj 0.5% ................ 4 lidocaine inj 1% ................... 4 lidocaine inj 1.5% preservative free (pf) ........... 4 lidocaine inj 2% preservative free (pf) ............................... 4 lidocaine inj 4% preservative free (pf) ............................... 4 lidocaine-prilocaine ........... 43 linezolid in sodium chloride . 5 linezolid inj .......................... 5 linezolid susp ...................... 5 linezolid tab 600mg ............. 5 LINZESS ........................... 33 liothyronine sodium ........... 31 lisinopril ............................. 12 lisinopril & hydrochlorothiazide ........... 12 lithium carbonate .............. 23 LITHIUM SOLN 8MEQ/5ML.......................................... 23 LIVALO ............................. 13 LO LOESTRIN FE ............ 28 LOKELMA ......................... 27 lomedia 24 fe .................... 28 LONHALA MAGNAIR REFILL KIT ....................... 39 LONHALA MAGNAIR STARTER KIT .................. 39 LONSURF ........................ 11 loperamide hcl .................. 33 lopinavir-ritonavir ................ 6 lorazepam ......................... 15 lorazepam intensol ............ 15 LORBRENA ...................... 11 lorcet hd tab 10-325mg ....... 3 lorcet plus tab 7.5-325 ........ 3 lorcet tab 5-325mg .............. 3 loryna ................................ 28 losartan potassium ............ 12 losartan-hydrochlorothiazide.......................................... 12 LOTEMAX ........................ 39

56

LOTEMAX SM .................. 39 loteprednol etabonate ....... 39 lovastatin ........................... 13 low-ogestrel ....................... 28 loxapine succinate ............ 19 LUCEMYRA ...................... 24 luliconazole ....................... 42 LUMIGAN.......................... 39 LUMIZYME ....................... 29 LUPANETA PACK ............ 29 LUPRON DEPOT (1-MONTH) ....................... 10 LUPRON DEPOT INJ 11.25MG (3-MONTH) ....... 10 LUPRON DEPOT INJ 22.5MG (3-MONTH) ......... 10 LUPRON DEPOT INJ 30MG (4-MONTH) ....................... 10 LUPRON DEPOT-PED (1-MONTH ........................ 30 LUPRON DEPOT-PED (3-MONTH ........................ 31 LUPRON DEP-PED INJ 11.25MG (3-MONTH) ....... 30 LUPRON DEP-PED INJ 7.5MG ............................... 30 lutera ................................. 28 LYNPARZA .........................9 LYRICA ............................. 16 LYRICA CR ....................... 23 LYSODREN ...................... 10 lyza ................................... 28 M magnesium sulfate ............ 37 MAGNESIUM SULFATE ... 37 MAGNESIUM SULFATE IN D5W .................................. 37 magnesium sulfate in dextrose ............................ 37 magnesium sulfate inj 50% .......................................... 37 malathion .......................... 44 maprotiline hcl ................... 17 marlissa............................. 28 MARPLAN ......................... 17 MATULANE ...................... 11 matzim la........................... 14 MAVYRET ...........................7 MAXIDEX .......................... 39 MAXIPIME ..........................7

meclizine hcl ..................... 31 MEDROL TAB 2MG .......... 30 medroxyprogesterone acetate .............................. 31 medroxyprogesterone acetate (contraceptive) ..... 28 mefloquine hcl ..................... 6 megestrol ac sus 40mg/ml 10 megestrol ac tab 20mg ..... 10 megestrol ac tab 40mg ..... 10 megestrol sus 625mg/5ml . 10 MEKINIST ......................... 11 MEKTOVI .......................... 11 melodetta 24 fe ................. 28 meloxicam tabs ................... 1 memantine hcl cp24 .......... 17 memantine soln ................ 17 memantine tabs ................ 17 MENACTRA ...................... 36 MENOSTAR ..................... 30 MENTAX ........................... 42 MENVEO .......................... 36 mercaptopurine ................... 9 meropenem ......................... 5 MEROPENEM/SODIUM CHLORIDE ......................... 5 mesalamine ...................... 32 mesalamine enema .......... 32 mesalamine w/ cleanser ... 32 MESNEX ........................... 11 metadate er tab 20mg ....... 21 metformin er ...................... 26 metformin hcl .................... 26 methadone hcl .................... 3 methadone hcl 10mg .......... 3 methadone hcl 5mg ............ 3 methadone hcl intensol ....... 3 methazolamide ................. 14 methenamine hippurate ...... 5 methergine ........................ 31 methimazole ..................... 31 methotrexate sodium inj ...... 9 methotrexate sodium tabs . 35 methoxsalen rapid ............ 42 methscopolamine bromide 32 methyclothiazide ............... 14 methylergonovine maleate 31 methylphenidate hcl .......... 21 methylphenidate hcl 72mg er .......................................... 21

methylphenidate hcl er ...... 21 methylphenidate tab 10mg er.......................................... 21 methylphenidate tab 20mg er.......................................... 21 methylpr ss inj ................... 30 methylpred pak 4mg ......... 30 methylpred tab 16mg ........ 30 methylpred tab 32mg ........ 30 methylpred tab 4mg .......... 30 methylpred tab 8mg .......... 30 methylprednisolone acetate.......................................... 30 metoclopramide hcl ..... 31, 32 metoclopramide hcl inj ...... 32 METOCLOPRAMIDE ODT.......................................... 32 metolazone ....................... 14 metoprolol & hctz tab 100-25mg ......................... 13 metoprolol & hctz tab 100-50mg ......................... 13 metoprolol & hctz tab 50-25mg ........................... 13 metoprolol succinate ......... 13 metoprolol tartrate............. 13 metronidazole ..................... 5 METRONIDAZOLE ............. 5 metronidazole (topical) ..... 43 metronidazole inj................. 5 metronidazole vaginal ....... 34 mexiletine hcl .................... 12 MIACALCIN INJ 200U/ML 31 mibelas 24 fe .................... 28 miconazole 3 sup 200mg .. 34 MICORT-HC ..................... 43 microgestin 1.5/30 ............ 28 microgestin 1/20 ............... 28 microgestin fe 1.5/30 ........ 28 microgestin fe 1/20 ........... 28 midodrine hcl .................... 14 miglitol .............................. 26 miglustat ........................... 29 mili .................................... 28 MILLIPRED DP ................. 30 MILLIPRED TAB ............... 30 minitran ............................. 15 MINIVELLE ....................... 30 minocycline hcl ................... 8 minocycline tab 135mg er ... 9

57

minocycline tab 45mg er .....9 minocycline tab 90mg er .....9 minoxidil ............................ 15 mirtazapine ....................... 17 misoprostol ........................ 33 MITIGARE ...........................1 mitomycin ............................9 M-M-R II ............................ 36 M-NATAL PLUS ................ 38 modafinil............................ 23 moexipril hcl ...................... 12 molindone hcl .................... 19 mometasone furoate ......... 43 mometasone furoate (nasal) .......................................... 41 mondoxyne nl cap 100mg ...9 mondoxyne nl cap 75mg .....9 mono-linyah tab 0.25-35 ... 28 montelukast sodium .......... 40 morgidox cap 1x50mg .........9 MORPHABOND ER ............3 morphine sul inj 1mg/ml ......3 morphine sulfate .................3 MORPHINE SULFATE .......3 morphine sulfate beads .......3 morphine sulfate ext-rel tab.3 morphine sulfate oral soln 100mg/5ml ..........................3 morphine sulfate oral soln 10mg/5ml ............................3 morphine sulfate oral soln 20mg/5ml ............................3 MOTEGRITY ..................... 33 MOVANTIK ....................... 33 MOVIPREP ....................... 33 MOXEZA ........................... 38 moxifloxacin hcl ...................8 MOXIFLOXACIN HCL .........8 moxifloxacin hcl (ophth) .... 38 moxifloxacin hcl in sodium chloride ...............................8 MOZOBIL .......................... 34 MULPLETA ....................... 35 MULTAQ ........................... 12 mupirocin .......................... 42 mupirocin calcium (topical) 42 MYCAMINE .........................5 mycophenolate mofetil ...... 36 mycophenolate sodium tbec .......................................... 36

MYDAYIS CAP 12.5MG .... 21 MYDAYIS CAP 25MG....... 21 MYDAYIS CAP 37.5MG .... 21 MYDAYIS CAP 50MG....... 21 MYLOTARG ........................ 9 myorisan ........................... 42 MYRBETRIQ .................... 34 myzilra .............................. 28 N nabumetone ........................ 1 nadolol .............................. 13 nadolol & bendroflumethiazide ......... 13 NAFCILLIN IN DEXTROSE 8 nafcillin sodium ................... 8 NAFCILLIN SODIUM FOR INJ 10GM ............................ 8 naftifine hcl ........................ 42 NAFTIN ............................. 42 NAGLAZYME .................... 29 nalbuphine hcl ..................... 1 naloxone inj 0.4mg/ml ....... 24 naloxone inj 1mg/ml .......... 24 naltrexone hcl ................... 24 NAMZARIC ....................... 17 naproxen ............................. 1 naproxen dr ......................... 1 naproxen sodium ................ 1 naratriptan hcl ................... 22 NARCAN ........................... 24 NATACYN ......................... 38 NATAZIA ........................... 28 nateglinide ........................ 26 NATPARA ......................... 31 NATROBA ........................ 44 NAYZILAM ........................ 16 NEBUPENT ........................ 5 necon 0.5/35-28 ................ 28 necon 7/7/7 ....................... 28 nefazodone hcl ................. 17 neomycin sulfate ................. 4 neomycin/polymyxin b gu .. 44 neomycin-bacitracin zn-polymyxin ..................... 38 neomycin-polymy-dexameth .......................................... 38 neomycin-polymyxin-gramicidin ..................................... 38 neomycin-polymyxin-hc (ophth) .............................. 38

neomycin-polymyxin-hc (otic).......................................... 44 NEPHRAMINE .................. 37 NERLYNX ......................... 11 neuac gel 1.2-5% .............. 42 NEULASTA ....................... 34 NEULASTA ONPRO KIT .. 34 NEUPOGEN ..................... 34 NEUPRO .......................... 18 nevirapine susp 50 mg/5ml . 6 nevirapine tab 100mg er ..... 6 nevirapine tab 200mg ......... 6 nevirapine tab 400mg er ..... 6 NEXAVAR ........................ 11 NEXIUM GRA 10MG DR .. 33 NEXIUM GRA 2.5MG DR . 33 NEXIUM GRA 20MG DR .. 33 NEXIUM GRA 40MG DR .. 33 NEXIUM GRA 5MG DR .... 33 niacin (antihyperlipidemic) 13 niacin er (antihyperlipidemic).......................................... 13 niacor ................................ 13 nicardipine hcl ................... 14 NICOTROL INHALER ....... 24 NICOTROL NS ................. 24 nifedipine .......................... 14 nifedipine er ...................... 14 nikki .................................. 28 nilutamide ......................... 10 nimodipine ........................ 14 NINLARO ............................ 9 NIPENT .............................. 9 nisoldipine ......................... 14 NITRO-BID ....................... 15 NITRO-DUR ..................... 15 nitrofurantoin ....................... 5 nitrofurantoin macrocrystal . 5 nitrofurantoin monohyd macro .................................. 5 nitroglycerin ...................... 15 nitroglycerin td patch ......... 15 NITYR ............................... 29 nizatidine .......................... 32 nolix .................................. 43 nora-be tab ....................... 28 NORDITROPIN FLEXPRO.......................................... 31 norethin acet & estrad-fe .. 28 norethindrone & ethinyl

58

estradiol-fe ........................ 29 norethindrone (contraceptive) .................. 29 norethindrone acet & eth estra .................................. 29 norethindrone acetate ....... 31 norethindrone acetate-ethinyl estradiol ............................ 30 norgest/ethi tab 0.25/35 .... 29 norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ............................. 29 norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg ............................. 29 NORITATE ........................ 43 norlyroc ............................. 29 NORMOSOL-M IN D5W ... 38 NORMOSOL-R ................. 38 NORPACE CR .................. 13 NORTHERA ...................... 15 nortrel 0.5/35 (28) ............. 29 nortrel 1/35 ........................ 29 nortrel 7/7/7 ....................... 29 nortriptyline hcl .................. 17 NORVIR PACK ...................6 NORVIR SOLN ...................6 NOVAREL ......................... 31 NOVOLIN 70/30 ................ 25 NOVOLIN 70/30 FLEXPEN .......................................... 25 NOVOLIN 70/30 FLEXPEN RELION............................. 25 NOVOLIN 70/30 RELION.. 25 NOVOLIN N ...................... 25 NOVOLIN N RELION ........ 25 NOVOLIN R ...................... 25 NOVOLIN R RELION ........ 25 NOVOLOG ........................ 25 NOVOLOG 70/30 FLEXPEN .......................................... 25 NOVOLOG FLEXPEN ...... 25 NOVOLOG MIX 70/30 ...... 25 NOVOLOG PENFILL ........ 25 NOXAFIL.............................5 NUBEQA ........................... 10 NUCALA ........................... 41 NUCYNTA ...........................3

NUCYNTA ER .................... 3 NUEDEXTA ...................... 23 NULOJIX ........................... 36 NULYTELY/FLAVOR PACKS .............................. 33 NUPLAZID CAPS ............. 19 NUPLAZID TABS 10MG ... 19 NUPLAZID TABS 17MG ... 19 NUTRILIPID INJ 20% ....... 37 NUTROPIN AQ NUSPIN 10 .......................................... 31 NUTROPIN AQ NUSPIN 20 .......................................... 31 NUTROPIN AQ NUSPIN 5 31 NUVARING ....................... 29 nyamyc ............................. 42 NYMALIZE ........................ 14 nystatin ............................... 5 nystatin (mouth-throat) ...... 44 nystatin (topical) ................ 42 nystatin pow 100000 ......... 42 nystop ............................... 42 O ocella tab 3-0.03mg .......... 29 OCTAGAM ........................ 36 octreotide acetate ............. 31 octreotide inj 100mcg/ml ... 31 ODEFSEY ........................... 6 ODOMZO ............................ 9 OFEV ................................ 41 ofloxacin (ophth) ............... 38 ofloxacin (otic) ................... 44 ogestrel ............................. 29 olanzapine ........................ 19 olanzapine odt .................. 19 olmesartan medoxomil ...... 12 olmesartan medoxomil-amlodipine-hydrochlorothiazide .................... 12 olmesartan medoxomil-hydrochlorothiazide ...................................... 12 olopatadine hcl (nasal) ...... 40 olopatadine hcl 0.1% ........ 39 olopatadine hcl 0.2% ........ 39 OMECLAMOX-PAK .......... 33 omega-3-acid ethyl esters . 13 omeprazole cap 10mg ...... 33 omeprazole cap 20mg ...... 33 omeprazole cap 40mg ...... 33

OMNARIS ......................... 41 OMNITROPE 10MG ......... 31 OMNITROPE 5.8MG ........ 31 OMNITROPE 5MG ........... 31 ondansetron hcl ................ 32 ondansetron hcl inj............ 32 ondansetron hcl oral soln .. 32 ondansetron odt ................ 32 ONEXTON ........................ 42 ONGLYZA ........................ 26 ONIVYDE ......................... 11 ONZETRA XSAIL ............. 22 OPSUMIT ......................... 15 ORALAIR .......................... 36 ORAVIG ............................ 44 ORBACTIV ......................... 5 ORENITRAM TAB 0.125MG.......................................... 15 ORENITRAM TAB 0.25MG.......................................... 15 ORENITRAM TAB 1MG ... 15 ORENITRAM TAB 2.5MG 15 ORENITRAM TAB 5MG ... 15 ORFADIN ......................... 29 ORILISSA ......................... 29 ORKAMBI ......................... 41 orsythia ............................. 29 oseltamivir phosphate ......... 7 OSMOLEX ER .................. 18 OSMOPREP ..................... 33 OSPHENA ........................ 31 OTOVEL ........................... 44 oxacillin sodium .................. 8 oxaliplatin inj 100mg ......... 11 oxaliplatin inj 100mg/20ml 11 oxaliplatin inj 50mg ........... 11 oxaliplatin inj 50mg/10ml .. 11 oxandrolone ...................... 24 oxaprozin ............................ 1 OXAYDO ............................ 3 oxcarbazepine .................. 16 oxiconazole nitrate ............ 42 OXISTAT .......................... 42 OXTELLAR XR ................. 16 oxybutynin chloride ........... 34 oxycodone hcl ..................... 3 oxycodone w/ acetaminophen 10-325mg .. 4 oxycodone w/ acetaminophen 2.5-325mg . 3

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oxycodone w/ acetaminophen 5-325mg ....3 oxycodone w/ acetaminophen 7.5-325mg .3 oxycodone-aspirin ...............4 oxycodone-ibuprofen ..........4 OXYCONTIN .......................4 oxymorphone tab ................4 OXYTROL ......................... 34 OZEMPIC INJ 0.25 OR 0.5MG/DOSE .................... 25 OZEMPIC INJ 1MG/DOSE .......................................... 25 P pacerone ........................... 13 paclitaxel .............................9 paliperidone ...................... 19 palonosetron hcl ................ 32 PALONOSETRON HYDROCHLORID ............. 32 palonosetron hydrochlorid sosy .................................. 32 PALYNZIQ ........................ 29 pamidronate disodium ....... 27 PAMIDRONATE DISODIUM .......................................... 27 pamidronate inj 30mg ....... 27 pamidronate inj 90mg ....... 27 PANCREAZE .................... 33 PANDEL............................ 43 PANRETIN ........................ 43 pantoprazole sodium ......... 33 PANZYGA ......................... 36 paricalcitol ......................... 38 paroex sol 0.12% .............. 44 paromomycin sulfate ...........4 paroxetine er tab ............... 17 paroxetine hcl tabs ............ 17 paroxetine mesylate (vasomotor) ....................... 23 PASER D/R .........................7 PAXIL ................................ 17 PAZEO .............................. 39 PEDIARIX ......................... 36 PEDVAX HIB .................... 36 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........... 33 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 33

PEGANONE ..................... 16 PEGASYS ........................... 7 PEGASYS PROCLICK ....... 7 PENICILLIN G POT IN DEXTROSE 1MU ............... 8 PENICILLIN G POT IN DEXTROSE 2MU ............... 8 PENICILLIN G POT IN DEXTROSE 3MU ............... 8 PENICILLIN G PROCAINE . 8 penicillin g sodium .............. 8 penicillin v potassium .......... 8 penicilln gk inj 20mu ........... 8 penicilln gk inj 5mu ............. 8 PENNSAID ....................... 43 PENTACEL ....................... 36 PENTAM 300 ...................... 5 pentamidine isethionate ...... 5 PENTASA ......................... 32 pentoxifylline ..................... 35 PERFOROMIST ............... 40 perindopril erbumine ......... 12 periogard ........................... 44 PERJETA ............................ 9 permethrin cre 5% ............ 44 perphenazine .................... 19 PERSERIS ........................ 19 PERTZYE ......................... 33 PEXEVA ........................... 17 pfizerpen-g inj 20mu ........... 8 pfizerpen-g inj 5mu ............. 8 phenadoz .......................... 32 phenelzine sulfate ............. 17 phenobarbital .................... 16 phenobarbital sodium........ 16 PHENOBARBITAL SODIUM .......................................... 16 phenoxybenzamine hcl ..... 15 PHENYTEK ...................... 16 phenytoin .......................... 16 phenytoin sodium extended .......................................... 16 phenytoin sodium inj 50mg/ml ............................ 16 philith ................................ 29 PHOSLYRA ...................... 31 PHOSPHOLINE IODIDE ... 39 PICATO ............................ 43 PIFELTRO .......................... 6 pilocarpine hcl ................... 39

pilocarpine hcl (oral) ......... 44 pimozide ........................... 19 pimtrea .............................. 29 pindolol ............................. 13 pioglitazone hcl ................. 26 pioglitazone hcl-glimepiride.......................................... 26 pioglitazone hcl-metformin hcl ..................................... 26 piper/tazoba inj 12-1.5gm ... 8 piper/tazoba inj 2-0.25gm ... 8 piper/tazoba inj 3-0.375gm . 8 piper/tazoba inj 36-4.5gm ... 8 piper/tazoba inj 4-0.5gm ..... 8 PIQRAY 200MG DAILY DOSE ............................... 11 PIQRAY 250MG DAILY DOSE ............................... 11 PIQRAY 300MG DAILY DOSE ............................... 11 pirmella 1/35 ..................... 29 piroxicam ............................ 1 PLASMA-LYTE A.............. 38 PLASMA-LYTE-148 .......... 38 plenamine ......................... 37 PLENVU ........................... 33 PNV FOLIC ACID + IRON MUL .................................. 38 podofilox ........................... 43 polymyxin b sulfate ............. 5 polymyxin b-trimethoprim .. 38 POMALYST ...................... 10 portia-28 ........................... 29 posaconazole ..................... 5 pot chloride inj 2meq/ml .... 38 potassium chloride ...... 37, 38 POTASSIUM CHLORIDE . 38 potassium chloride 0.3%/d 38 potassium chloride caps er.......................................... 37 potassium chloride in nacl 38 potassium chloride microencapsulated crystals er ...................................... 37 potassium chloride tab cr 10 meq ................................... 37 potassium citrate (alkalinizer) er tabs ............................... 34 POTELIGEO ....................... 9 PRADAXA ........................ 34

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PRALUENT ....................... 13 pramipexole dihydrochloride .......................................... 18 pramipexole tab 0.125mg . 18 pramipexole tab 0.25mg ... 18 pramipexole tab 0.375mg . 18 pramipexole tab 0.5mg ..... 18 pramipexole tab 0.75 er .... 18 pramipexole tab 0.75mg ... 18 pramipexole tab 1.5mg ..... 18 pramipexole tab 1.5mg er . 18 pramipexole tab 1mg ........ 18 pramipexole tab 2.25mg ... 18 pramipexole tab 3mg ........ 18 pramipexole tab 4.5mg ..... 18 prasugrel hcl ..................... 35 pravastatin sodium ............ 13 praziquantel ........................5 prazosin hcl ....................... 12 PRED MILD ...................... 39 pred sod pho sol 5mg/5ml . 30 PRED-G ............................ 38 PRED-G S.O.P. ................ 38 prednicarbate .................... 43 prednisolone acetate (ophth) .......................................... 39 prednisolone sodium phosphate ......................... 30 PREDNISOLONE SODIUM PHOSPHATE (OPHTH) .... 39 prednisolone sol 15mg/5ml .......................................... 30 prednisolone sol 25mg/5ml .......................................... 30 PREDNISONE CON 5MG/ML ............................ 30 prednisone pak 10mg ....... 30 prednisone pak 5mg ......... 30 prednisone sol 5mg/5ml .... 30 prednisone tab 10mg ........ 30 prednisone tab 1mg .......... 30 prednisone tab 2.5mg ....... 30 prednisone tab 20mg ........ 30 prednisone tab 50mg ........ 30 prednisone tab 5mg .......... 30 pregabalin ......................... 16 PREGNYL W/DILUENT BENZYL ............................ 31 PREMARIN ....................... 30 PREMARIN CREAM ......... 30

PREMASOL 10% .............. 37 premasol 6% ..................... 37 PRENATAL ....................... 38 PRENATAL PLUS ............ 38 PRENATAL PLUS LOW IRON ................................. 38 PREPOPIK ....................... 33 prevalite ............................ 13 previfem ............................ 29 PREVYMIS ......................... 7 PREZCOBIX ....................... 6 PREZISTA .......................... 6 PRIFTIN .............................. 7 PRILOSEC ........................ 33 primaquine phosphate ........ 6 PRIMAQUINE PHOSPHATE ............................................ 6 primidone .......................... 16 PRIVIGEN ......................... 36 PROAIR RESPICLICK ...... 40 probenecid .......................... 1 PROCALAMINE ................ 37 prochlorperazine inj .......... 32 prochlorperazine maleate . 32 prochlorperazine supp ...... 32 PROCRIT .................... 34, 35 procto-med hc ................... 43 procto-pak ......................... 43 proctosol hc 2.5 % ............ 43 proctozone-hc ................... 43 PROCYSBI ....................... 29 progesterone micronized .. 31 PROGLYCEM SUS 50MG/ML .......................... 30 PROGRAF ........................ 36 PROLASTIN-C .................. 41 PROLENSA ...................... 39 PROLIA ............................. 31 PROMACTA ..................... 35 promethazine hcl .............. 32 promethazine hcl inj .......... 32 promethegan ..................... 32 propafenone hcl ................ 13 propafenone hcl 12hr ........ 13 proparacaine hcl ............... 39 propranolol & hydrochlorothiazide ........... 13 propranolol hcl er .............. 13 propranolol inj 1mg/ml....... 13 propranolol oral sol ........... 13

propranolol tab .................. 13 propylthiouracil ................. 31 PROQUAD ....................... 36 PROSOL ........................... 37 PROTONIX ....................... 33 protriptyline hcl ................. 17 PROVENTIL HFA ............. 40 PULMICORT FLEXHALER.......................................... 41 PULMOZYME ................... 41 PURIXAN ............................ 9 PYLERA ........................... 33 pyrazinamide ...................... 7 pyridostigmine bromide ..... 23 pyridostigmine tab 60mg ... 23 Q QBRELIS .......................... 12 QNASL ............................. 41 QNASL CHILDRENS ........ 41 QTERN ............................. 26 QUADRACEL ................... 36 quasense .......................... 29 quetiapine fumarate .......... 19 QUILLICHEW ER ............. 21 QUILLIVANT XR ............... 21 quinapril hcl ...................... 12 quinapril-hydrochlorothiazide.......................................... 12 quinidine gluconate ........... 13 quinidine sulfate ................ 13 quinine sulfate .................... 6 QVAR REDIHALER .......... 41 R RABAVERT ...................... 36 rabeprazole sodium .......... 33 raloxifene hcl .................... 31 ramipril .............................. 12 ranitidine hcl ..................... 32 ranitidine hcl inj ................. 32 ranitidine inj ...................... 32 ranolazine ......................... 15 RAPAMUNE ..................... 36 rasagiline mesylate ........... 18 RAVICTI ........................... 29 RAYALDEE ...................... 38 reclipsen ........................... 29 RECOMBIVAX HB ............ 36 RECTIV ............................ 43 REGRANEX ..................... 44 RELENZA DISKHALER ...... 7

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relexxii ............................... 21 RELISTOR ........................ 33 REMICADE ....................... 35 REMODULIN .................... 15 repaglinide ........................ 26 repaglinide-metformin hcl .. 26 RESCRIPTOR ....................6 RESTASIS ........................ 39 RESTASIS MULTIDOSE .. 39 RETACRIT ........................ 35 RETIN-A MICRO ............... 42 RETIN-A MICRO PUMP ... 42 REVATIO .......................... 15 REVLIMID ......................... 10 REXULTI ........................... 19 REYATAZ ...........................6 RHOPRESSA ................... 39 ribavirin 200mg ...................7 rifabutin ...............................7 RIFAMATE ..........................7 rifampin ...............................7 RIFATER.............................7 riluzole .............................. 23 rimantadine hydrochloride ...7 RIOMET ............................ 27 risedronate sodium ........... 27 RISPERDAL INJ 12.5MG.. 19 RISPERDAL INJ 25MG .... 20 RISPERDAL INJ 37.5MG.. 20 RISPERDAL INJ 50MG .... 20 risperidone ........................ 20 risperidone odt .................. 20 ritonavir ...............................6 RITUXAN ............................9 RITUXAN HYCELA .............9 rivastigmine tartrate .......... 17 rivastigmine td patch 24hr 13.3 mg/24hr ..................... 17 rivastigmine td patch 24hr 4.6 mg/24hr ....................... 17 rivastigmine td patch 24hr 9.5 mg/24hr ....................... 17 rivelsa ............................... 29 rizatriptan benzoate .......... 22 rizatriptan benzoate odt .... 22 ROCKLATAN .................... 39 ropinirole tab 0.25mg ........ 18 ropinirole tab 0.5mg .......... 18 ropinirole tab 12mg er ....... 18 ropinirole tab 1mg ............. 18

ropinirole tab 2mg ............. 18 ropinirole tab 2mg er ......... 18 ropinirole tab 3mg ............. 18 ropinirole tab 4mg ............. 18 ropinirole tab 4mg er ......... 18 ropinirole tab 5mg ............. 18 ropinirole tab 6mg er ......... 18 ropinirole tab 8mg er ......... 18 rosadan cre 0.75% ............ 43 rosuvastatin calcium ......... 13 ROTARIX .......................... 36 ROTATEQ ........................ 36 roweepra ........................... 16 roweepra xr ....................... 16 ROZLYTREK .................... 11 RUBRACA .......................... 9 RUCONEST ...................... 35 RYDAPT ........................... 11 RYTARY ........................... 18 S SAIZEN ............................. 31 SAIZENPREP RECONSTITUTION .......... 31 SAMSCA ........................... 31 SANCUSO ........................ 32 SANDIMMUNE SOLN....... 36 SANDOSTATIN LAR DEPOT ............................. 31 SANTYL ............................ 44 SAPHRIS .......................... 20 SAVAYSA ......................... 34 SAVELLA .......................... 23 SAVELLA TITRATION PACK ................................ 23 scopolamine patch ............ 32 SEEBRI NEOHALER ........ 39 SEGLUROMET TAB 2.5-1000MG ...................... 27 SEGLUROMET TAB 2.5-500MG ........................ 27 SEGLUROMET TAB 7.5-1000MG ...................... 27 SEGLUROMET TAB 7.5-500MG ........................ 27 selegiline hcl ..................... 18 selenium sulfide ................ 42 SELZENTRY ....................... 6 SEMPREX-D .................... 40 SENSIPAR ........................ 27 SEREVENT DISKUS ........ 40

SERNIVO ......................... 43 SEROSTIM ....................... 31 sertraline hcl ..................... 17 setlakin tab ....................... 29 sevelamer carbonate ........ 31 sevelamer tabs 400 mg .... 31 sevelamer tabs 800mg ..... 31 SFROWASA ..................... 32 sharobel ............................ 29 SHINGRIX ........................ 36 SIGNIFOR ........................ 31 SIGNIFOR LAR ................ 31 sildenafil citrate sus 10mg/ml (pulmonary hypertension) . 15 sildenafil citrate tab 20 mg (pulmonary hypertension) . 15 SILENOR .......................... 22 silodosin ............................ 33 silver sulfadiazine ............. 42 SIMBRINZA SUS 1-0.2% . 39 simvastatin ........................ 13 sirolimus ........................... 36 SIRTURO ........................... 7 SIVEXTRO ......................... 5 SKLICE ............................. 44 SLYND .............................. 29 SMOFLIPID ...................... 37 sodium chlor sol 0.9% irr .. 44 sodium chloride........... 37, 38 sodium chloride 0.45% ..... 38 sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln ........ 37 sodium phenylbutyrate ...... 29 sodium polystyrene sulfonate powder .............................. 27 sodium polystyrene sulfonate susp .................................. 27 solifenacin succinate ......... 34 SOLIQUA 100/33 .............. 25 SOLOSEC .......................... 5 SOLTAMOX ...................... 10 SOLU-CORTEF 1000MG . 30 SOLU-CORTEF 100MG ... 30 SOLU-CORTEF 250MG ... 30 SOLU-CORTEF 500MG ... 30 SOLU-MEDROL ............... 30 SOMATULINE DEPOT ..... 31 SOMAVERT ..................... 31 SOOLANTRA ................... 43 sorine ................................ 13

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sotalol hcl .......................... 13 sotalol hcl (afib/afl) ............ 13 SOTYLIZE ......................... 13 SPIRIVA HANDIHALER .... 39 SPIRIVA RESPIMAT 1.25MCG/ACT .................. 40 SPIRIVA RESPIMAT 2.5MCG/ACT .................... 40 SPIRIVA RESPIMAT 2.5MCG/ACT (INSTITUTIONAL PACK) .. 40 spironolactone ................... 12 spironolactone & hydrochlorothiazide ........... 14 sprintec 28 ........................ 29 SPRITAM .......................... 16 SPRYCEL ......................... 11 sps susp 15gm/60ml ......... 27 sronyx ............................... 29 ssd .................................... 42 stavudine.............................6 STEGLATRO .................... 27 STEGLUJAN ..................... 27 STIMATE .......................... 31 STIOLTO RESPIMAT ....... 39 STIOLTO RESPIMAT (INSTITUTIONAL PACK) .. 39 STIVARGA ........................ 11 streptomycin sulfate ............4 STRIANT........................... 24 STRIBILD ............................6 STRIVERDI RESPIMAT.... 40 SUBSYS SPRAY 100MCG .4 SUBSYS SPRAY 1200MCG ............................................4 SUBSYS SPRAY 1600MCG ............................................4 SUBSYS SPRAY 200MCG .4 SUBSYS SPRAY 400MCG .4 SUBSYS SPRAY 600MCG .4 SUBSYS SPRAY 800MCG .4 subvenite starter kit ........... 16 subvenite tab ..................... 16 SUCRAID .......................... 33 sucralfate .......................... 33 sulfacetamide sodium (acne) .......................................... 42 sulfacetamide sodium (ophth) .............................. 38 sulfacetamide

sod-prednisolone .............. 38 SULFADIAZINE .................. 4 sulfamethoxazole-trimethop ds ........................................ 5 sulfamethoxazole-trimethoprim inj .................................... 5 sulfamethoxazole-trimethoprim susp ................................ 5 sulfamethoxazole-trimethoprim tab 400-80mg .................. 5 SULFAMYLON ................. 42 sulfasalazine dr ................. 32 sulfasalazine ir .................. 32 sulindac ............................... 1 sumatriptan inj 4mg/0.5ml . 22 sumatriptan inj 6mg/0.5ml . 22 sumatriptan succinate ....... 22 sumatriptan-naproxen sodium .............................. 22 SUPRAX ............................. 7 SUPREP BOWEL PREP KIT .......................................... 33 SUSTOL ........................... 32 SUTENT ........................... 11 syeda ................................ 29 SYLATRON KIT 200MCG . 11 SYLATRON KIT 300MCG . 11 SYLATRON KIT 600MCG . 11 SYMBICORT .................... 41 SYMDEKO ........................ 41 SYMFI ................................. 6 SYMFI LO ........................... 6 SYMJEPI .......................... 41 SYMLINPEN 120 .............. 25 SYMLINPEN 60 ................ 25 SYMPAZAN ...................... 16 SYMPROIC ....................... 33 SYMTUZA ........................... 6 SYNAREL ......................... 29 SYNDROS ........................ 32 SYNERCID ......................... 5 SYNJARDY TAB 12.5-1000MG .................... 27 SYNJARDY TAB 12.5-500MG ...................... 27 SYNJARDY TAB 5-1000MG .......................................... 27 SYNJARDY TAB 5-500MG .......................................... 27 SYNJARDY XR TAB

10-1000MG ....................... 27 SYNJARDY XR TAB 12.5-1000MG .................... 27 SYNJARDY XR TAB 25-1000MG ....................... 27 SYNJARDY XR TAB 5-1000MG ......................... 27 SYNRIBO ......................... 11 SYNTHROID .................... 31 T TABLOID ............................ 9 TACLONEX ...................... 43 tacrolimus ......................... 36 tacrolimus (topical) ............ 43 tadalafil (pulmonary hypertension) .................... 15 TAFINLAR ........................ 11 TAGRISSO ....................... 11 TAKHZYRO ...................... 35 TALZENNA ......................... 9 tamoxifen citrate ............... 10 tamsulosin hcl ................... 33 TARCEVA ......................... 11 TARGRETIN ..................... 43 tarina 24 fe ........................ 29 tarina fe 1/20 ..................... 29 TASIGNA .......................... 11 TAXOTERE ........................ 9 TAYTULLA ....................... 29 tazarotene ......................... 42 tazicef ................................. 7 TAZORAC ........................ 42 taztia xt ............................. 14 TDVAX .............................. 36 TECENTRIQ ....................... 9 TEFLARO ........................... 7 TEKTURNA ...................... 14 TEKTURNA HCT .............. 14 telmisartan ........................ 12 telmisartan-amlodipine ...... 12 telmisartan-hydrochlorothiazide ...................................... 12 temazepam ....................... 22 TEMIXYS ............................ 6 temsirolimus ..................... 10 TENIVAC .......................... 36 tenofovir disoproxil fumarate............................................ 6 terazosin hcl ..................... 12 terbinafine hcl ..................... 5

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terbutaline sulfate .............. 40 terconazole vaginal ........... 34 testosterone ...................... 24 testosterone cypionate ...... 24 testosterone enanthate ..... 24 testosterone td soln 30 mg/act ............................... 24 tetrabenazine .................... 23 tetracycline hcl ....................9 TEXACORT ...................... 43 THALOMID ....................... 10 THEO-24 ........................... 41 theophylline sol 80/15ml ... 41 theophylline tb12 300 mg .. 41 theophylline tb12 450 mg .. 41 theophylline tb24 ............... 41 thioridazine hcl .................. 20 thiothixene......................... 20 tiagabine hcl ...................... 16 TIBSOVO .......................... 10 tigecycline ...........................5 TIGLUTIK .......................... 23 tilia fe ................................ 29 timolol maleate .................. 13 timolol maleate (ophth) soln .......................................... 39 timolol maleate gel ............ 39 timolol maleate ophth soln 0.5% (once-daily) .............. 39 TIMOPTIC OCUDOSE ...... 39 TIROSINT ......................... 31 TIROSINT-SOL ................. 31 TIVICAY ..............................6 tizanidine ........................... 23 TOBI PODHALER ...............4 TOBRADEX ...................... 38 TOBRADEX ST ................. 38 tobramycin ..........................4 tobramycin (ophth) ............ 38 tobramycin inj 1.2 gm/30ml .4 tobramycin inj 1.2gm ...........4 tobramycin inj 10mg/ml .......4 tobramycin inj 40mg/ml .......4 tobramycin inj 80mg/2ml .....4 tobramycin-dexamethasone .......................................... 38 TOBREX OINT 0.3% ........ 38 tolmetin sodium ...................1 TOLSURA ...........................5 tolterodine tartrate er ......... 34

tolterodine tartrate tab 1 mg .......................................... 34 tolterodine tartrate tab 2 mg .......................................... 34 topiramate ......................... 16 toposar .............................. 11 topotecan hcl .................... 11 TOPOTECAN INJ 4MG/4ML .......................................... 11 toremifene citrate .............. 10 TORISEL .......................... 10 torsemide tabs .................. 14 TOVIAZ ............................. 34 tpn electrolytes .................. 37 TRACLEER ....................... 15 TRADJENTA ..................... 27 tramadol hcl ........................ 1 tramadol hcl er .................... 1 tramadol hcl er (biphasic) 100mg ................................. 1 tramadol hcl er (biphasic) 200mg ................................. 1 tramadol hcl er (biphasic) 300mg ................................. 1 tramadol hcl tab 50 mg ....... 1 tramadol-acetaminophen .... 1 trandolapril ........................ 12 trandolapril-verapamil hcl .. 12 tranexamic acid ................. 35 TRANSDERM-SCOP ........ 32 tranylcypromine sulfate ..... 17 TRAVASOL ....................... 37 TRAVATAN Z ................... 39 trazodone hcl .................... 17 TREANDA ........................... 9 TRECATOR ........................ 7 TRELEGY ELLIPTA .......... 39 TRELSTAR MIXJECT ....... 10 treprostinil ......................... 15 TRESIBA FLEXTOUCH .... 25 TRESIBA INJ .................... 25 tretinoin ....................... 11, 42 tretinoin microsphere ........ 42 TREXALL .......................... 35 TREXIMET TAB 10-60MG 22 trezix ................................... 1 triamcinolone acetonide (mouth) ............................. 44 triamcinolone acetonide (topical) ............................. 43

triamt/hctz cap 37.5-25 ..... 14 triamterene ....................... 14 triamterene & hydrochlorothiazide tabs ... 14 TRIANEX .......................... 43 TRICARE .......................... 38 trientine hcl ....................... 27 tri-estarylla ........................ 29 trifluoperazine hcl.............. 20 trifluridine .......................... 38 TRIGLIDE ......................... 13 trihexyphenidyl hcl ............ 18 tri-legest fe ........................ 29 tri-linyah ............................ 29 tri-lo- tab marzia ................ 29 tri-lo-estarylla .................... 29 tri-lo-sprintec ..................... 29 trilyte ................................. 33 trimethoprim ........................ 5 tri-mili ................................ 29 trimipramine maleate ........ 18 trinessa ............................. 29 trinessa lo ......................... 29 TRINTELLIX ..................... 18 tri-previfem ........................ 29 tri-sprintec ......................... 29 TRIUMEQ ........................... 6 trivora-28 .......................... 29 tri-vylibra ........................... 29 tri-vylibra lo ....................... 29 TROGARZO ....................... 6 TROKENDI XR ........... 16, 17 TROPHAMINE INJ 10% ... 37 trospium chloride .............. 34 trospium chloride er .......... 34 TRULANCE ...................... 33 TRULICITY ....................... 25 TRUMENBA ..................... 36 TRUVADA TAB 100-150 .... 7 TRUVADA TAB 133-200 .... 7 TRUVADA TAB 167-250 .... 7 TRUVADA TAB 200-300 .... 7 TUDORZA PRESSAIR ..... 40 TUDORZA PRESSAIR (INSTITUTIONAL PACK) .. 40 tulana ................................ 29 TURALIO .......................... 11 TWINRIX INJ .................... 36 TYBOST ............................. 6 tydemy .............................. 29

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TYKERB............................ 11 TYMLOS ........................... 31 TYPHIM VI ........................ 36 TYVASO ........................... 15 U UCERISFOAM .................. 32 ULORIC ..............................1 ULTRAVATE LOTN .......... 43 unithroid ............................ 31 UPTRAVI .......................... 15 ursodiol ............................. 33 UTIBRON NEOHALER ..... 39 V VABOMERE ........................5 valacyclovir hcl ....................7 VALCHLOR ....................... 43 valganciclovir hcl .................7 valproate sodium ............... 17 valproic acid ...................... 17 valsartan ........................... 12 valsartan-hydrochlorothiazide ........................................ 12 vancomycin hcl ...................5 VANCOMYCIN HYDROCHLORIDE ............5 VANCOMYCIN IN NACL.....5 VANCOMYCIN INJ 250MG.5 vandazole.......................... 34 VAQTA .............................. 36 VARIVAX .......................... 36 VARUBI INJ ...................... 32 VARUBI TAB 90MG .......... 32 VASCEPA ......................... 13 VECTIBIX.......................... 10 VELCADE ......................... 10 velivet ................................ 29 VELPHORO ...................... 31 VELTASSA ....................... 27 VEMLIDY ............................7 VENCLEXTA ..................... 10 VENCLEXTA STARTING PACK ................................ 10 venlafaxine cap er ............. 18 venlafaxine tab .................. 18 VENTAVIS ........................ 15 VENTOLIN HFA ................ 40 verapamil hcl ..................... 14 VERSACLOZ .................... 20 VERZENIO ........................ 10 VIBATIV ..............................5

VIBERZI ............................ 33 VIBRAMYCIN ..................... 9 vicodin es ............................ 4 vicodin hp ............................ 4 VICTOZA .......................... 25 VIDEX EC ........................... 6 VIDEX PEDIATRIC ............. 6 vienva ............................... 29 vigabatrin powd pack 500mg .......................................... 17 vigabatrin tab 500mg ........ 17 vigadrone .......................... 17 VIIBRYD STARTER PACK .......................................... 18 VIIBRYD TAB ................... 18 VIMIZIM ............................ 29 VIMPAT ............................ 17 VIMPAT INJ 200MG/20ML 17 VIMPAT SOL 10MG/ML .... 17 vinblastine sulfate ............... 9 vincristine sulfate ................ 9 vinorelbine tartrate .............. 9 VIOKACE 10 ..................... 33 VIOKACE 20 ..................... 33 viorele ............................... 29 VIRACEPT .......................... 6 VIRAMUNE ......................... 6 VIREAD .............................. 6 VITRAKVI ......................... 11 VIVITROL ......................... 24 VIZIMPRO ........................ 11 voriconazole ........................ 5 voriconazole inj 200mg ....... 5 VOSEVI .............................. 7 VOTRIENT ........................ 11 VPRIV ............................... 29 VRAYLAR ......................... 20 VRAYLAR THERAPY PACK .......................................... 20 vyfemla ............................. 29 vylibra ............................... 29 VYNDAQEL ...................... 15 VYVANSE ................... 21, 22 VYZULTA .......................... 39 W warfarin sodium ................ 34 water for irrigation, sterile 44 wymzya fe ......................... 29 X XADAGO .......................... 18

XALKORI .......................... 11 XARELTO ......................... 34 XARELTO STARTER PACK.......................................... 34 XATMEP ........................... 35 XELJANZ .......................... 35 XELJANZ XR .................... 35 XELPROS ......................... 39 XEOMIN INJ 100 UNITS .. 23 XEOMIN INJ 200 UNITS .. 23 XEOMIN INJ 50 UNITS .... 23 XEPI ................................. 42 XERESE ........................... 43 XGEVA ............................. 31 XHANCE ........................... 41 XIFAXAN TAB 200MG ........ 5 XIFAXAN TAB 550MG ...... 33 XIGDUO XR TAB 10-1000MG ....................... 27 XIGDUO XR TAB 10-500MG.......................................... 27 XIGDUO XR TAB 2.5-1000MG ...................... 27 XIGDUO XR TAB 5-1000MG.......................................... 27 XIGDUO XR TAB 5-500MG.......................................... 27 XIIDRA .............................. 39 XOFLUZA ........................... 7 XOLAIR ............................ 41 XOSPATA ......................... 11 XPOVIO 100 MG ONCE WEEKLY ........................... 11 XPOVIO 60 MG ONCE WEEKLY ........................... 11 XPOVIO 80 MG ONCE WEEKLY ........................... 11 XPOVIO 80 MG TWICE WEEKLY ........................... 11 XTAMPZA ER ..................... 4 XTANDI ............................ 10 xulane dis 150-35 ............. 29 XULTOPHY 100/3.6 ......... 25 XYREM ............................. 23 Y YERVOY ........................... 10 YF-VAX ............................. 36 YOSPRALA ...................... 35 YUPELRI .......................... 40 yuvafem vaginal tablet 10

65

mcg ................................... 30 Z zafirlukast .......................... 40 zarah ................................. 29 ZEJULA............................. 10 ZELAPAR.......................... 18 ZELBORAF ....................... 11 ZEMAIRA .......................... 41 ZEMBRACE SYMTOUCH . 22 ZEMDRI ..............................4 zenatane ........................... 42 ZENPEP............................ 33 ZEPATIER ..........................7 ZERBAXA ...........................8 ZETONNA ......................... 41 zidovudine cap 100mg ........6 zidovudine syp 50mg/5ml ...6 zidovudine tab 300mg .........6 ZIOPTAN .......................... 39 ziprasidone hcl .................. 20 ZIRGAN ............................ 38 ZOHYDRO ER (ABUSE DETERRENT) .....................4

zoledronic acid inj 5mg/100ml ........................ 27 ZOLEDRONIC INJ 4MG/100ML ...................... 27 zoledronic inj 4mg/5ml ...... 27 ZOLINZA ........................... 10 zolmitriptan ....................... 22 zolmitriptan odt ................. 22 zolpidem tartrate ............... 22 ZOMACTON ..................... 31 ZOMIG NASAL SPRAY .... 22 zonisamide ........................ 17 ZONTIVITY ....................... 35 ZORBTIVE ........................ 31 ZORTRESS TAB 0.25MG . 36 ZORTRESS TAB 0.5MG ... 36 ZORTRESS TAB 0.75MG . 36 ZORTRESS TAB 1MG ...... 36 ZOSTAVAX ....................... 36 ZOSYN ............................... 8 zovia 1/35e ....................... 29 ZUBSOLV SUB 0.7-0.18MG .......................................... 24

ZUBSOLV SUB 1.4-0.36MG.......................................... 24 ZUBSOLV SUB 11.4-2.9MG.......................................... 24 ZUBSOLV SUB 2.9-0.71MG.......................................... 24 ZUBSOLV SUB 5.7-1.4MG.......................................... 24 ZUBSOLV SUB 8.6-2.1MG.......................................... 24 ZUPLENZ ......................... 32 ZYCLARA ......................... 43 ZYCLARA PUMP .............. 43 ZYDELIG .......................... 11 ZYKADIA .......................... 11 ZYLET .............................. 38 ZYPITAMAG ..................... 13 ZYPREXA RELPREVV ..... 20 ZYPREXA RELPREVV INJ 210MG .............................. 20 ZYTIGA ............................. 10

HAWAI‘I MEDICAL SERVICE ASSOCIATIONhmsa.com/advantage

HMSA Akamai Advantage is a PPO plan with a Medicare contract. Enrollment in HMSA Akamai Advantage depends on contract renewal.

This formulary was updated on 12/01/2019. For more recent information or other questions, please contact HMSA at:

(00) 8700-16676 December12.19 LG


PHONECall 8 a.m. to 8 p.m., seven days a week

948-6000 on Oahu 1 (800) 660-4672 toll-freeTTY users, call 711

ONLINEhttp://www.hmsa.com/advantage

HMSA CENTERSConvenient evening and Saturday hours:

HMSA Center @ Honolulu818 Keeaumoku St.Monday - Friday, 8 a.m. - 5 p.m. | Saturday, 9 a.m. - 2 p.m.

HMSA Center @ Pearl CityPearl City Gateway | 1132 Kuala St., Suite 400 Monday - Friday, 9 a.m. - 6 p.m. | Saturday, 9 a.m. - 2 p.m.

HMSA Center @ HiloWaiakea Center | 303A E. Makaala St.

Monday - Friday, 9 a.m. - 6 p.m. | Saturday, 9 a.m. - 2 p.m.

HMSA Center @ KahuluiPuunene Shopping Center | 70 Hookele St.

Monday - Friday, 9 a.m. - 6 p.m. | Saturday, 9 a.m. - 2 p.m.

OFFICESVisit your local HMSA office Monday through Friday, 8 a.m. - 4 p.m.:

Kailua-Kona, Hawaii Island | 75-1029 Henry St., Suite 301 | Phone: 329-5291Lihue, Kauai | 4366 Kukui Grove St., Suite 103 | Phone: 245-3393



akamai advantage 2019 formulary · akamai advantage premier limits the amount of the drug that hmsa...

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