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Friday Health Plans
2018
lowercase italics = Generic drugsUPPERCASE = Brand name drugs
Formulary TiersT1 = Preferred GenericT2 = Preferred BrandT3 = Non Preferred Generic and BrandT4 = Specialty
RestrictionsPA = Prior AuthorizationST = Step Therapy
Drug Name Formulary Tiers Restrictions
ALTERNATIVE THERAPY
ALTERNATIVE THERAPY - ANDROGENIC AGENTS
prasterone (dhea), micro(bulk) T3
ALTERNATIVE THERAPY - ANTIARTHRITICS
LIMBREL T3
LIMBREL250 T3
LIMBREL500 T3
ALTERNATIVE THERAPY - ESTROGENIC AGENTS
VP-GSTN T1
FOSTEUM T3
FOSTEUM PLUS T3
ALTERNATIVE THERAPY - UNCLASSIFIED
epigallocatechin gallate(bulk) T1
creatine (bulk) T3
s-adenosylmeth sulf tos (bulk) T3
CERENX T3
ENTERAGAM T3
NUMOISYN T3
VAYACOG T3
VAYARIN T3
ANALGESIC, ANTI-INFLAMMATORY OR ANTIPYRETIC
ANALGESIC - CENTRAL ALPHA-2 RECEPTOR AGONISTS
clonidine (pf) T1
ANALGESIC - NEUROLYSIS AGENTS
ethanol (ethyl alcohol) T1
ANALGESIC - NEURONAL (N)-TYPE CALCIUM CHANNEL BLOCKERS (NCCBS)
PRIALT T4 PA
ANALGESIC NARCOTIC AGONISTS
alfentanil T1
codeine sulfate T1
fentanyl citrate (pf) T1
fentanyl citrate buccal lozenge on a handle 1,600 mcg T1 PA
fentanyl citrate-0.9%nacl (pf) T1
fentanyl transdermal patch 72 hour 37.5 mcg/hour, 62.5 mcg/hour, 87.5 mcg/hour
T1
hydromorph(pf)-ropiv-0.9% nacl T1
hydromorphone (pf) T1
hydromorphone (pf)-0.9% nacl T1
hydromorphone in 0.9 % nacl T1
hydromorphone injection T1
2018
1
Drug Name Formulary Tiers Restrictions
hydromorphone intravenous T1
hydromorphone oral liquid T1
hydromorphone oral tablet T1
hydromorphone oral tablet extended release 24 hr 16 mg, 32 mg T1
hydromorphone rectal T1
levorphanol tartrate T1
meperidine T1
meperidine (pf) T1
meperidine (pf) in 0.9 % nacl T1
methadone T1
morphine (pf) T1
morphine (pf) in 0.9 % nacl T1
morphine (pf) in dextrose 5 % T1
morphine concentrate T1
morphine in 0.9 % nacl T1
morphine injection T1
morphine intramuscular T1
morphine intravenous T1
morphine oral capsule, er multiphase 24 hr T1
morphine oral capsule,extend.release pellets 100 mg T1
morphine oral solution T1
morphine oral tablet T1
morphine oral tablet extended release T1
morphine rectal T1
oxycodone oral capsule T1
oxycodone oral solution T1
oxycodone oral tablet T1
oxycodone oral tablet,oral only,ext.rel.12 hr T1
oxymorphone T1
tramadol T1
HYSINGLA ER T2
NUCYNTA T2
OXYCONTIN T2
fentanyl citrate buccal lozenge on a handle 200 mcg, 400 mcg T3 PA
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
T3
hydromorphone oral tablet extended release 24 hr 12 mg, 8 mg T3
morphine oral capsule,extend.release pellets 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg
T3
oxycodone oral concentrate T3
oxycodone oral syringe T3
ABSTRAL SUBLINGUAL TABLET 100 MCG, 200 MCG, 300 MCG, 400 MCG, 600 MCG
T3 PA
ACTIQ T3 PA
ARYMO ER T3 ST
ASTRAMORPH-PF T3
CONZIP T3
DEMEROL T3
2018
2
Drug Name Formulary Tiers Restrictions
DEMEROL (PF) T3
EMBEDA T3 ST
EXALGO ER T3 ST
INFUMORPH P/F T3
LAZANDA T3 PA
MORPHABOND ER T3 ST
NUCYNTA ER T3 ST
OPANA T3
XTAMPZA ER T3 ST
ZOHYDRO ER T3 ST
fentanyl citrate buccal lozenge on a handle 1,200 mcg, 600 mcg, 800 mcg
T4 PA
ABSTRAL SUBLINGUAL TABLET 800 MCG T4 PA
FENTORA T4 PA
SUBSYS T4 PA
ANALGESIC NARCOTIC CODEINE COMBINATIONS
acetaminophen-codeine T1
butalbital-acetaminop-caf-cod T1
ASCOMP WITH CODEINE T1
FIORINAL-CODEINE #3 T1
CAPITAL WITH CODEINE T3
ANALGESIC NARCOTIC DIHYDROCODEINE COMBINATIONS
aspirin-caffeine-dihydrocodein T1
TREZIX T3
ANALGESIC NARCOTIC DIHYDROCODEINE, NON-SALICYLATE ANALGESIC,XANTHINE
TREZIX T3
ANALGESIC NARCOTIC DIHYDROCODEINE, SALICYLATE ANALGESIC, XANTHINE COMB
aspirin-caffeine-dihydrocodein T1
ANALGESIC NARCOTIC FENTANYL COMBINATIONS
fentanyl (pf)-bupivacaine-nacl T1
ANALGESIC NARCOTIC HYDROCODONE AND NON-SALICYLATE COMBINATIONS
hydrocodone-acetaminophen T1
LORTAB ELIXIR T1
ANALGESIC NARCOTIC HYDROCODONE AND NSAID COMBINATIONS
hydrocodone-ibuprofen T1
ANALGESIC NARCOTIC HYDROCODONE COMBINATIONS
hydrocodone-acetaminophen T1
hydrocodone-ibuprofen T1
LORTAB ELIXIR T1
ANALGESIC NARCOTIC HYDROMORPHONE COMBINATIONS
hydromorphone-bupiv (pf)-nacl T1
ANALGESIC NARCOTIC OXYCODONE AND NON-SALICYLATE COMBINATIONS
oxycodone-acetaminophen T1
ENDOCET T1
2018
3
Drug Name Formulary Tiers Restrictions
ANALGESIC NARCOTIC OXYCODONE AND NSAID COMBINATIONS
ibuprofen-oxycodone T1
ANALGESIC NARCOTIC OXYCODONE AND SALICYLATE COMBINATIONS
oxycodone-aspirin T1
ANALGESIC NARCOTIC OXYCODONE COMBINATIONS
ibuprofen-oxycodone T1
oxycodone-acetaminophen T1
oxycodone-aspirin T1
ENDOCET T1
ANALGESIC NARCOTIC PARTIAL-MIXED AGONISTS
buprenorphine T1
buprenorphine hcl T1
butorphanol tartrate injection solution 1 mg/ml T1
butorphanol tartrate nasal T1
pentazocine-naloxone T1
BELBUCA T2 PA
butorphanol tartrate injection solution 2 mg/ml T3
nalbuphine T3
BUPRENEX T3
TALWIN T3
ANALGESIC NARCOTIC TRAMADOL AND NON-SALICYLATE COMBINATIONS
tramadol-acetaminophen T1
ANALGESIC NARCOTIC TRAMADOL COMBINATIONS
tramadol-acetaminophen T1
ANALGESIC OR ANTIPYRETIC NON-NARCOTIC
OFIRMEV T3
ANALGESIC OR ANTIPYRETIC NON-NARCOTIC/SEDATIVE COMBINATIONS
butalbital-acetaminophen T1
butalbital-acetaminophen-caff T1
FIORICET T1
ZEBUTAL T3
ANTI-INFLAMMATORY - INTERLEUKIN-1 BETA BLOCKERS
ILARIS (PF) T4 PA
ANTI-INFLAMMATORY - INTERLEUKIN-1 RECEPTOR ANTAGONIST
ARCALYST T4 PA
ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITING AGNTS,NON-SEIECTIVE
ENBREL T4
ENBREL SURECLICK T4
ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITING AGNTS,TNF-ALPHA SEL
CIMZIA T4 ST
CIMZIA POWDER FOR RECONST T4 ST
CIMZIA STARTER KIT T4 ST
HUMIRA T4
2018
4
Drug Name Formulary Tiers Restrictions
HUMIRA PEDIATRIC CROHN'S START T4
HUMIRA PEN T4
HUMIRA PEN CROHN'S-UC-HS START T4
HUMIRA PEN PSORIASIS-UVEITIS T4
REMICADE T4 ST
RENFLEXIS T4 PA
SIMPONI T4 ST
SIMPONI ARIA T4 ST
DMARD - ANTIMALARIALS
hydroxychloroquine T1
DMARD - ANTIMETABOLITES
methotrexate sodium T1
XATMEP T2 PA
OTREXUP (PF) T3
RASUVO (PF) T3 ST
TREXALL T3
DMARD - ANTINFLAMMATORY, SELECT. COSTIMULATION MODULATOR,T-CELL INHIB.
ORENCIA T4 ST
ORENCIA (WITH MALTOSE) T4 ST
ORENCIA CLICKJECT T4 ST
DMARD - B CELL TARGETED AGENTS
RITUXAN T4 PA
DMARD - GOLD COMPOUNDS
RIDAURA T2
DMARD - IMMUNOSUPPRESSIVES
azathioprine T1
cyclophosphamide intravenous recon soln 500 mg T1
cyclosporine T1
cyclosporine modified T1
mycophenolate mofetil T1
CELLCEPT T3
CELLCEPT INTRAVENOUS T3
cyclophosphamide intravenous recon soln 1 gram, 2 gram T4
cyclophosphamide oral T4
AZASAN T4
DMARD - INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA)
KINERET T4 ST
DMARD - INTERLEUKIN-6 (IL-6) RECEPTOR INHIBITORS, MONOCLONAL ANTIBODY
ACTEMRA T4 ST
KEVZARA T4 PA
DMARD - JANUS KINASE (JAK) INHIBITORS
XELJANZ T4 ST
XELJANZ XR T4 ST
DMARD - OTHER
minocycline T1
sulfasalazine T1
2018
5
Drug Name Formulary Tiers Restrictions
DEPEN TITRATABS T3
CUPRIMINE T4
DMARD - PHOSPHODIESTERASE-4 (PDE4) INHIBITORS
OTEZLA T4 ST
OTEZLA STARTER T4 ST
DMARD - PYRIMIDINE SYNTHESIS INHIBITORS
leflunomide T1
IMMUNOMODULATOR B-LYMPHOCYTE STIMULATOR (BLYS)-SPECIFIC INHIBITOR MCAB
BENLYSTA T4 PA
NSAID ANALGESIC AND PROSTAGLANDIN ANALOG COMBINATIONS
diclofenac-misoprostol T3
NSAID ANALGESIC AND TOPICAL IRRITANT COUNTER-IRRITANT COMBINATIONS
COMFORT PAC-IBUPROFEN T1
COMFORT PAC-MELOXICAM T3
COMFORT PAC-NAPROXEN T3
NSAID ANALGESIC, CYCLOOXYGENASE-2 (COX-2) SELECTIVE INHIBITORS
celecoxib T1
CELEBREX T3
NSAID ANALGESICS (COX NON-SPECIFIC) - ANTHRANILIC ACID DERIVATIVES
meclofenamate T1
mefenamic acid T3
NSAID ANALGESICS (COX NON-SPECIFIC) - OTHER
ketorolac T1
nabumetone T1
sulindac T1
tolmetin T1
NSAID ANALGESICS (COX NON-SPECIFIC) - OXICAM DERIVATIVES
meloxicam T1
piroxicam T1
NSAID ANALGESICS (COX NON-SPECIFIC) - PHENYLACETIC ACID DERIVATIVES
diclofenac potassium T3
diclofenac sodium T3
CAMBIA T3 PA
DYLOJECT T3
ZORVOLEX T3 ST
NSAID ANALGESICS (COX NON-SPECIFIC) - PROPIONIC ACID DERIVATIVES
fenoprofen T1
flurbiprofen T1
ibuprofen T1
ketoprofen T1
naproxen T1
naproxen sodium T1
oxaprozin T1
2018
6
Drug Name Formulary Tiers Restrictions
FENORTHO T1
CALDOLOR T3
NALFON T3
NAPRELAN CR T3
NSAID ANALGESICS, (COX NON-SPECIFIC) - INDOLE ACETIC ACID DERIVATIVES
etodolac T1
indomethacin T1
INDOCIN T3
TIVORBEX T3 ST
SALICYLATE ANALGESIC AND SEDATIVE COMBINATIONS
butalbital-aspirin-caffeine T1
SALICYLATE ANALGESIC COMBINATIONS
choline,magnesium salicylate T3
SALICYLATE ANALGESICS
diflunisal T1
salsalate T1
ANESTHETICS
GENERAL ANESTHETIC - INHALANT VOLATILE
isoflurane T1
sevoflurane T1
SUPRANE T3
GENERAL ANESTHETIC - PARENTERAL, ARYLCYCLOHEXYLAMINES
ketamine T1
ketamine in 0.9 % sod chloride T1
GENERAL ANESTHETIC - PARENTERAL, BARBITURATES
BREVITAL T3
GENERAL ANESTHETIC - PARENTERAL, BENZODIAZEPINES
midazolam injection solution 1 mg/ml T1
midazolam (pf) T3
midazolam injection solution 5 mg/ml T3
GENERAL ANESTHETIC - PARENTERAL, OTHERS
etomidate T1
AMIDATE T3
GENERAL ANESTHETIC - PARENTERAL, PHENOL DERIVATIVES
propofol T1
GENERAL ANESTHETIC ADJUNCTS - NARCOTIC
fentanyl citrate (pf) T1
sufentanil citrate T1
ULTIVA T3
GENERAL ANESTHETIC ADJUNCTS - NEUROLEPTIC, BUTYROPHENONE DERIVATIVE
droperidol T1
LOCAL ANESTHETIC - AMIDES
bupivacaine T1
bupivacaine (pf) T1
bupivacaine in nacl(pf) T1
2018
7
Drug Name Formulary Tiers Restrictions
bupivacaine-dextrose-water(pf) T1
lidocaine (pf) in d7.5w T1
lidocaine (pf) T1
lidocaine hcl T1
lidocaine hcl(pf) in 0.9% nacl T1
mepivacaine (pf) T1
ropivacaine (pf) T1
POLOCAINE-MPF INJECTION SOLUTION 10 MG/ML (1 %), 15 MG/ML (1.5 %)
T1
XYLOCAINE-MPF T1
lidocaine T3
CARBOCAINE T3
CARBOCAINE (PF) T3
CITANEST PLAIN DENTAL T3
EXPAREL (PF) T3
NAROPIN (PF) T3
POLOCAINE T3
POLOCAINE-MPF INJECTION SOLUTION 20 MG/ML (2 %) T3
LOCAL ANESTHETIC - ESTERS
tetracaine hcl (pf) T1
NESACAINE T3
LOCAL ANESTHETIC - SYMPATHOMIMETIC COMBINATIONS
bupivacaine-epinephrine T1
bupivacaine-epinephrine (pf) T1
lidocaine-epinephrine T1
lidocaine-epinephrine bit T1
SENSORCAINE-MPF/EPINEPHRINE T1
ARTICADENT DENTAL T3
XYLOCAINE-MPF/EPINEPHRINE T3
ANORECTAL PREPARATIONS
ANAL FISSURE PAIN/TREATMENT AGENTS - NITRATES
RECTIV T3
ANORECTAL - GLUCOCORTICOIDS
hydrocortisone acetate T1
ANUCORT-HC T1
PROCTO-PAK T1
PROCTOZONE-HC T1
PROCTOCORT T3
ANORECTAL - HEMORRHOIDAL RECTAL GLUCOCORTICOID-LOCAL ANESTHETIC COMB
hydrocortisone-pramoxine T1
lidocaine hcl-hydrocortison ac T1
lidocaine-hydrocortisone-aloe T1
PROCTOFOAM HC T2
ANA-LEX KIT T3
PROCORT T3
ZYPRAM T3
2018
8
Drug Name Formulary Tiers Restrictions
ANTIDOTES AND OTHER REVERSAL AGENTS
ANTIDOTE - ACETAMINOPHEN POISONING
acetylcysteine T1
acetylcysteine (bulk) T1
ANTIDOTE - ALCOHOL DEHYDROGENASE ENZYME INHIBITOR
fomepizole T1
ANTIDOTE - ANTICHOLINESTERASE AGENTS
physostigmine salicylate T1
ANTIDOTE - ANTICHOLINESTERASE AND MUSCARINIC ANTAGONIST COMBINATIONS
ENLON-PLUS T3
ANTIDOTE - CHOLINESTERASE REACTIVATING AGENT
pralidoxime T1
PROTOPAM CHLORIDE T3
ANTIDOTE - CHOLINESTERASE REACTIVATING AGENT AND MUSCARINIC ANTAGONIST
DUODOTE T3
ANTIDOTE - CYANIDE POISONING
sodium nitrite T1
sodium thiosulfate T1
CYANOKIT T3
NITHIODOTE T3
ANTIDOTE - DIGITALIS GLYCOSIDE TOXICITY AGENTS
DIGIFAB T3
ANTIDOTE - METHEMOGLOBINEMIA
methylene blue (antidote) T1
ANTIDOTE OTHERS
GALZIN T3
BENZODIAZEPINE REVERSAL AGENTS - BENZODIAZEPINE ANTAGONISTS
flumazenil T1
CHELATING AGENTS - COPPER
DEPEN TITRATABS T3
CUPRIMINE T4 PA
SYPRINE T4
CHELATING AGENTS - IRON
deferoxamine T1
JADENU SPRINKLE T3 PA
EXJADE T4 PA
FERRIPROX T4 PA
JADENU T4 PA
CHELATING AGENTS - LEAD POISONING
CHEMET T2
BAL IN OIL T3
CHELATING AGENTS - OTHERS
betadex (bulk) T1
BAL IN OIL T3
CA-DTPA T3
2018
9
Drug Name Formulary Tiers Restrictions
ZN-DTPA T3
EMETICS
ipecac T1
MU-OPIOID RECEPTOR ANTAGONISTS, PERIPHERALLY-ACTING
MOVANTIK T2
ENTEREG T3
RELISTOR T3 PA
OPIATE/NARCOTIC REVERSAL AGENTS - OPIATE ANTAGONISTS
naloxone T1
naltrexone T1
NARCAN T2
REVERSAL AGENTS - HEPARIN ANTAGONISTS
protamine T1
ANTI-INFECTIVE AGENTS
AMEBICIDES
paromomycin T1
AMINOGLYCOSIDE ANTIBIOTIC
amikacin T1
gentamicin T1
gentamicin (bulk) T1
gentamicin in nacl (iso-osm) T1
gentamicin sulfate (ped) (pf) T1
gentamicin sulfate (pf) T1
neomycin T1
streptomycin T1
tobramycin in 0.9 % nacl T1
tobramycin sulfate T1
AMINOPENICILLIN ANTIBIOTIC
amoxicillin T1
ampicillin T1
ampicillin sodium T1
MOXATAG T3
AMINOPENICILLIN ANTIBIOTIC - BETA-LACTAMASE INHIBITOR COMBINATIONS
amoxicillin-pot clavulanate T1
ampicillin-sulbactam T1
AUGMENTIN T2
ANTHELMINTIC AGENTS - BENZIMIDAZOLE DERIVATIVES
ALBENZA T2
ANTHELMINTIC AGENTS OTHER
ivermectin T1
BILTRICIDE T2
STROMECTOL T3
ANTIBACTERIAL FOLATE ANTAGONIST - OTHER COMBINATIONS
sulfamethoxazole-trimethoprim T1
2018
10
Drug Name Formulary Tiers Restrictions
ANTIBACTERIAL FOLATE ANTAGONIST OTHERS
trimethoprim T1
PRIMSOL T3
ANTIFUNGAL - ALLYLAMINES
terbinafine hcl T1
ANTIFUNGAL - AMPHOTERIC POLYENE MACROLIDES
amphotericin b T1
nystatin T1
ABELCET T3
AMBISOME T3
ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)
caspofungin T1
CANCIDAS T3
ERAXIS(WATER DILUENT) T3
MYCAMINE T3
ANTIFUNGAL - IMIDAZOLES
ketoconazole T1
ORAVIG T3
ANTIFUNGAL - TRIAZOLES
fluconazole T1
fluconazole in dextrose(iso-o) T1
fluconazole in nacl (iso-osm) T1
voriconazole intravenous T1
voriconazole oral suspension for reconstitution T1
CRESEMBA T2 PA
NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) T2
itraconazole T3
voriconazole oral tablet T3
NOXAFIL INTRAVENOUS T3
NOXAFIL ORAL SUSPENSION T3
ONMEL T3
SPORANOX T3 PA
SPORANOX PULSEPAK T3 PA
VFEND T3
ANTIFUNGAL OTHER
flucytosine T1
griseofulvin microsize oral suspension T1
griseofulvin microsize oral tablet T3
griseofulvin ultramicrosize T3
ANTI-INFECTIVE IMMUNOLOGIC ADJUVANTS - INTERFERONS
ACTIMMUNE T4 PA
ANTILEPROTIC - IMMUNOMODULATORS
THALOMID T4 PA
ANTILEPROTIC - SULFONE AGENTS
dapsone T1
2018
11
Drug Name Formulary Tiers Restrictions
ANTIMALARIAL COMBINATIONS
atovaquone-proguanil T1
COARTEM T2
ANTIMALARIALS
chloroquine phosphate T1
hydroxychloroquine T1
mefloquine T1
primaquine T1
quinine sulfate T1
ANTIPROTOZOAL AGENTS - OTHER
ALINIA T2 PA
MEPRON T3
IMPAVIDO T4 PA
ANTIPROTOZOAL-ANTIBACTERIAL 1ST GENERATION 2-METHYL-5-NITROIMIDAZOLE
metronidazole T1
metronidazole (bulk) T1
metronidazole in nacl (iso-os) T1
FLAGYL T3
ANTIPROTOZOAL-ANTIBACTERIAL 2ND GENERATION 2-METHYL-5-NITROIMIDAZOLE
tinidazole T1
TINDAMAX T2
ANTIRETROVIRAL - CCR5 CO-RECEPTOR ANTAGONIST
SELZENTRY T2
ANTIRETROVIRAL - HIV-1 FUSION INHIBITORS
FUZEON T4
ANTIRETROVIRAL - HIV-1 INTEGRASE STRAND TRANSFER INHIBITORS
ISENTRESS T2
ISENTRESS HD T2
TIVICAY ORAL TABLET 10 MG, 25 MG T2
TIVICAY ORAL TABLET 50 MG T4
ANTIRETROVIRAL - NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIB (NNRTI)
nevirapine oral suspension T1
nevirapine oral tablet T1
SUSTIVA T2
nevirapine oral tablet extended release 24 hr T3
EDURANT T3
INTELENCE T3
VIRAMUNE T3
VIRAMUNE XR T3
RESCRIPTOR T4
ANTIRETROVIRAL - NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir oral solution T1
didanosine T1
lamivudine oral solution T1
2018
12
Drug Name Formulary Tiers Restrictions
stavudine T1
zidovudine T1
abacavir oral tablet T3
lamivudine oral tablet T3
EMTRIVA T3
EPIVIR T3
RETROVIR T3
ZIAGEN T3
VIDEX 2 GRAM PEDIATRIC T4
VIDEX 4 GRAM PEDIATRIC T4
ANTIRETROVIRAL - NUCLEOTIDE ANALOG REVERSE TRANSCRIPTASE INHIBITORS
VIREAD ORAL POWDER T3
VIREAD ORAL TABLET T4
ANTIRETROVIRAL COMBINATIONS - NRTI'S
lamivudine-zidovudine T3
abacavir-lamivudine T4
abacavir-lamivudine-zidovudine T4
EPZICOM T4
TRIZIVIR T4
ANTIRETROVIRAL COMBINATIONS - NUCLEOSIDE AND NUCLEOTIDE ANALOG RTIS
DESCOVY T4
TRUVADA T4
ANTIRETROVIRAL COMBINATIONS - PROTEASE INHIBITORS
EVOTAZ T4
KALETRA T4
PREZCOBIX T4
ANTIRETROVIRAL COMBINATIONS-NUCLEOSIDE ANALOGS AND INTEGRASE INHIBITOR
TRIUMEQ T4
ANTIRETROVIRAL- NUCLEOSIDE AND NUCLEOTIDE ANALOGS,INTEGRASE INHIBITORS
GENVOYA T4
STRIBILD T4
ANTIRETROVIRAL-NUCLEOSIDE, NUCLEOTIDE ANALOGS AND NON-NUCLEOSIDE RTI
COMPLERA T3
ATRIPLA T4
ODEFSEY T4
ANTITUBERCULAR - AMINOBENZOIC ACID ANALOGS
PASER T3
ANTITUBERCULAR - CYCLIC PEPTIDE ANTIBIOTICS
CAPASTAT T3
ANTITUBERCULAR - D-ALANINE ANALOGS
cycloserine T1
ANTITUBERCULAR - DIARYLQUINOLINE ANTIBIOTICS
SIRTURO T4 PA
ANTITUBERCULAR - ISONICOTINIC ACID DERIVATIVES
isoniazid T1
2018
13
Drug Name Formulary Tiers Restrictions
ANTITUBERCULAR - NIACINAMIDE DERIVATIVES
pyrazinamide T1
ANTITUBERCULAR - RIFAMYCIN AND DERIVATIVES
rifabutin T1
rifampin oral T1
rifampin intravenous T3
MYCOBUTIN T3
PRIFTIN T3
ANTITUBERCULAR AGENTS OTHER
ethambutol T1
TRECATOR T3
ANTITUBERCULAR COMBINATIONS
RIFAMATE T3
RIFATER T3
CARBAPENEM ANTIBIOTIC COMBINATIONS
imipenem-cilastatin T3
PRIMAXIN IV T3
CARBAPENEM ANTIBIOTICS (THIENAMYCINS)
doripenem T1
meropenem T1
meropenem-0.9% sodium chloride T1
INVANZ T3
CEPHALOSPORIN ANTIBIOTIC AND BETA-LACTAMASE INHIBITOR COMBINATIONS
ZERBAXA T3 PA
AVYCAZ T4
CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION
cefadroxil T1
cefazolin T1
cefazolin in dextrose (iso-os) T1
cefazolin in sterile water T1
cephalexin T1
CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION
cefaclor oral suspension for reconstitution T1
cefaclor oral tablet extended release 12 hr T1
cefotetan T1
cefotetan in dextrose, iso-osm T1
cefoxitin T1
cefoxitin in dextrose, iso-osm T1
cefprozil T1
cefuroxime axetil T1
cefuroxime sodium T1
cefaclor oral capsule T3
MEFOXIN IN DEXTROSE (ISO-OSM) T3
ZINACEF T3
ZINACEF IN STERILE WATER T3
CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION
cefdinir T1
2018
14
Drug Name Formulary Tiers Restrictions
cefditoren pivoxil T1
cefotaxime T1
cefpodoxime T1
ceftazidime T1
ceftazidime in d5w T1
ceftriaxone T1
ceftriaxone in dextrose,iso-os T1
TAZICEF T1
cefixime T3
CEDAX T3
CLAFORAN T3
FORTAZ T3
FORTAZ IN DEXTROSE 5 % T3
SPECTRACEF T3
SUPRAX T3
CEPHALOSPORIN ANTIBIOTICS - 4TH GENERATION
cefepime T1
cefepime in dextrose 5 % T1
cefepime in dextrose,iso-osm T1
MAXIPIME T3
CEPHALOSPORIN ANTIBIOTICS - 5TH GENERATION
TEFLARO T3
CHLORAMPHENICOL ANTIBIOTICS AND DERIVATIVES - SINGLE AGENTS
chloramphenicol sod succinate T1
CMV ANTIVIRAL AGENT - INORGANIC PYROPHOSPHATE ANALOGS
foscarnet T4
CMV ANTIVIRAL AGENT - NUCLEOSIDE ANALOGS
valganciclovir T1 PA
ganciclovir sodium T4
CMV ANTIVIRAL AGENT - NUCLEOTIDE ANALOGS
cidofovir T1
CYCLIC LIPOPEPTIDE ANTIBIOTICS
daptomycin T4
FLUOROQUINOLONE ANTIBIOTICS
ciprofloxacin T1
ciprofloxacin hcl T1
ciprofloxacin in 5 % dextrose T1
ciprofloxacin lactate T1
levofloxacin in d5w T1
levofloxacin oral tablet T1
moxifloxacin T1
ofloxacin T1
CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 250 MG/5 ML
T1
moxifloxacin hcl (bulk) T2
CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 500 MG/5 ML
T2
2018
15
Drug Name Formulary Tiers Restrictions
levofloxacin intravenous T3
levofloxacin oral solution T3
moxifloxacin-sod.ace,sul-water T3
AVELOX T3
AVELOX IN NACL (ISO-OSMOTIC) T3
BAXDELA T3 PA
GLYCOPEPTIDE ANTIBIOTICS
vancomycin T1
vancomycin in 0.9% sodium cl T1
vancomycin in dextrose 5 % T1
GLYCYLCYCLINE ANTIBIOTICS
TYGACIL T3
HEPATITIS B TREATMENT- NUCLEOSIDE ANALOGS (ANTIVIRAL)
entecavir T1
BARACLUDE ORAL TABLET T2
EPIVIR HBV T3
BARACLUDE ORAL SOLUTION T4
HEPATITIS B TREATMENT- NUCLEOTIDE ANALOGS (ANTIVIRAL)
adefovir T1
HEPSERA T4
HEPATITIS C - INTERFERONS
PEGASYS T4 PA
PEGASYS PROCLICK T4 PA
PEGINTRON T4 PA
HEPATITIS C - NS5A INHIBITOR AND NS3/4A PROTEASE INHIBITOR COMBINATION
MAVYRET T4 PA
HEPATITIS C - NS5A, NS3/4A PROTEASE, NUCLEO.NS5B POLYMERASE INHIB COMB
VOSEVI T4 PA
HEPATITIS C - NS5B POLYMERASE AND NS5A INHIBITOR COMBINATIONS
EPCLUSA T4 PA
HEPATITIS C - NUCLEOS(T)IDE ANALOG NS5B POLYMERASE INHIBITORS
SOVALDI T4 PA
HEPATITIS C - NUCLEOSIDE ANALOGS
ribavirin oral tablet T3
MODERIBA T3
RIBASPHERE T3
ribavirin oral capsule T4
REBETOL T4
RIBASPHERE RIBAPAK T4
HERPES ANTIVIRAL AGENT - PURINE ANALOGS
acyclovir oral capsule T1
acyclovir oral tablet T1
acyclovir sodium intravenous recon soln 500 mg T1
valacyclovir T1
2018
16
Drug Name Formulary Tiers Restrictions
acyclovir oral suspension T3
acyclovir sodium intravenous recon soln 1,000 mg T3
acyclovir sodium intravenous solution T3
SITAVIG T3
HERPES ANTIVIRAL AGENT - THYMIDINE ANALOGS
famciclovir T1
INFLUENZA ANTIVIRAL AGENTS - NEURAMINIDASE INHIBITORS
oseltamivir T1
RELENZA DISKHALER T3
TAMIFLU T3
INFLUENZA-A ANTIVIRAL AGENTS
rimantadine T1
LINCOSAMIDE ANTIBIOTICS
clindamycin hcl T1
clindamycin in 5 % dextrose T1
clindamycin palmitate hcl T1
clindamycin phosphate T1
CLIN SINGLE USE T3
LINCOCIN T3
LIPOGLYCOPEPTIDE ANTIBIOTICS
DALVANCE T2 PA
ORBACTIV T2 PA
MACROLIDES
azithromycin T1
clarithromycin T1
erythromycin ethylsuccinate oral tablet T1
erythromycin oral tablet T1
ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG
T1
erythromycin ethylsuccinate oral suspension for reconstitution T3
erythromycin oral capsule,delayed release(dr/ec) T3
ERYPED 400 T3
ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 250 MG, 500 MG
T3
ERYTHROCIN T3
ERYTHROCIN (AS STEARATE) T3
PCE T3
ZMAX T3
DIFICID T4 PA
MISC ANTI-INFECTIVE
NEBUPENT T2
PENTAM T3
MONOBACTAM ANTIBIOTICS
aztreonam injection recon soln 2 gram T1
aztreonam injection recon soln 1 gram T3
AZACTAM IN DEXTROSE (ISO-OSM) T3
2018
17
Drug Name Formulary Tiers Restrictions
OXAZOLIDINONE ANTIBIOTICS
linezolid oral T1
linezolid intravenous T3
linezolid-0.9% sodium chloride T3
ZYVOX T3
SIVEXTRO T4 PA
PENICILLIN ANTIBIOTIC - NATURAL
penicillin g pot in dextrose T1
penicillin g potassium T1
penicillin g procaine T1
penicillin g sodium T1
penicillin v potassium T1
BICILLIN L-A T3
PENICILLIN ANTIBIOTIC - PENICILLINASE-RESISTANT
dicloxacillin T1
nafcillin in dextrose iso-osm T1
nafcillin injection recon soln 10 gram, 2 gram T1
nafcillin intravenous T1
oxacillin in dextrose(iso-osm) T1
oxacillin injection recon soln 1 gram, 10 gram T1
oxacillin intravenous recon soln 1 gram T1
nafcillin injection recon soln 1 gram T3
oxacillin injection recon soln 2 gram T3
oxacillin intravenous recon soln 2 gram T3
PENICILLIN ANTIBIOTIC, EXTENDED-SPECTRUM AND BETA-LACTAMASE INHIB COMB
piperacillin-tazobactam T1
ZOSYN IN DEXTROSE (ISO-OSM) T3
PENICILLIN NATURAL ANTIBIOTIC COMBINATIONS - EXTENDED RELEASE
BICILLIN C-R T3
POLYMYXINS AND DERIVATIVES - SINGLE AGENTS
bacitracin T1
polymyxin b sulfate T1
colistin (colistimethate na) T3
PROTEASE INHIBITORS (NON-PEPTIDIC) ANTIRETROVIRAL
PREZISTA ORAL SUSPENSION T2
PREZISTA ORAL TABLET 150 MG, 75 MG, 800 MG T2
APTIVUS T3
PREZISTA ORAL TABLET 600 MG T4
PROTEASE INHIBITORS (PEPTIDIC) ANTIRETROVIRAL
fosamprenavir T1
NORVIR T2
REYATAZ ORAL CAPSULE 150 MG, 300 MG T2
REYATAZ ORAL POWDER IN PACKET T2
INVIRASE T3
LEXIVA T3
CRIXIVAN T4
2018
18
Drug Name Formulary Tiers Restrictions
REYATAZ ORAL CAPSULE 200 MG T4
VIRACEPT T4
RIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICS
rifabutin T1
rifampin oral T1
XIFAXAN T2 PA
rifampin intravenous T3
MYCOBUTIN T3
PRIFTIN T3
STREPTOGRAMIN ANTIBIOTICS
SYNERCID T3
SULFONAMIDE ANTIBIOTIC
sulfadiazine T1
TETRACYCLINE AND TETRACYCLINE ANTIBIOTIC COMBINATIONS
AVIDOXY DK T3
TETRACYCLINE ANTIBIOTICS
demeclocycline T1
doxycycline hyclate oral capsule T1
doxycycline hyclate oral tablet T1
doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg
T1
doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg T1
doxycycline monohydrate oral capsule,ir - delay rel,biphase T1
doxycycline monohydrate oral suspension for reconstitution T1
doxycycline monohydrate oral tablet T1
minocycline T1
doxycycline hyclate oral tablet,delayed release (dr/ec) 200 mg, 50 mg
T3 PA
doxycycline monohydrate oral capsule 150 mg T3
tetracycline T3
DORYX MPC T3 ST
MINOCIN T3
MONODOX T3
MORGIDOX T3 ST
MORGIDOX 1X100 T3 ST
MORGIDOX 2X100 T3 ST
ORACEA T3 ST
VIBRAMYCIN T3
ANTINEOPLASTICS
ANP - HUMAN VASCULAR ENDOTHELIAL GROWTH FACTOR INHIB REC-MC ANTIBODY
AVASTIN T4 PA
ANP-PLATELET-DERIVED GROWTH FACTOR RECEPTOR (PDGFR) ALPHA BLOCKER MC
LARTRUVO T4 PA
ANTINEOPLASIC-EPIDERM.GROWTH FACTOR-EGFR (ERBB1),HER-2 (ERBB2)R.INHIB
TYKERB T4 PA
2018
19
Drug Name Formulary Tiers Restrictions
ANTINEOPLASTIC - CYP17 (17 ALPHA-HYDROXYLASE/C17,20-LYASE) INHIBITOR
ZYTIGA T4 PA
ANTINEOPLASTIC - 1ST GENERATION EGFR TYROSINE KINASE INHIBITOR
TARCEVA T4 PA
ANTINEOPLASTIC - 2ND GENERATION EGFR TYROSINE KINASE INHIBITOR
GILOTRIF T4 PA
NERLYNX T4 PA
ANTINEOPLASTIC - 3RD GENERATION EGFR TYROSINE KINASE INHIBITOR
TAGRISSO T4 PA
ANTINEOPLASTIC - ALKYLATING AGENT - ALKYL SULFONATES
MYLERAN T2
busulfan T4 PA
ANTINEOPLASTIC - ALKYLATING AGENT - ETHYLENIMINES AND METHYLMELAMINES
thiotepa T4 PA
HEXALEN T4
TEPADINA T4 PA
ANTINEOPLASTIC - ALKYLATING AGENT - METHYLHYDRAZINES
MATULANE T4
ANTINEOPLASTIC - ALKYLATING AGENT - NITROGEN MUSTARD WITH RESCUE AGENT
ifosfamide-mesna T4
ANTINEOPLASTIC - ALKYLATING AGENT - NITROGEN MUSTARDS
cyclophosphamide intravenous recon soln 500 mg T1
melphalan T1
LEUKERAN T2
ifosfamide intravenous recon soln 1 gram T3
ALKERAN T3
cyclophosphamide intravenous recon soln 1 gram, 2 gram T4
cyclophosphamide oral T4
ifosfamide intravenous recon soln 3 gram T4
ifosfamide intravenous solution T4
melphalan hcl T4
MUSTARGEN T4
ANTINEOPLASTIC - ALKYLATING AGENT - NITROSOUREAS
GLIADEL WAFER T3
BICNU T4
ANTINEOPLASTIC - ALKYLATING AGENT - OTHER
BENDEKA T4 PA
TREANDA T4 PA
ANTINEOPLASTIC - ALKYLATING AGENT - TETRAHYDROISOQUINOLINES
YONDELIS T4
ANTINEOPLASTIC - ALKYLATING AGENT - TRIAZENES
dacarbazine T4
2018
20
Drug Name Formulary Tiers Restrictions
temozolomide T4
TEMODAR T4 PA
ANTINEOPLASTIC - ANAPLASTIC LYMPHOMA KINASE (ALK) INHIBITORS
ALECENSA T4 PA
ALUNBRIG T4 PA
ANTINEOPLASTIC - ANTIADRENALS
LYSODREN T2
ANTINEOPLASTIC - ANTIANDROGENS
bicalutamide T1
flutamide T1
NILANDRON T4
XTANDI T4 PA
ZYTIGA T4 PA
ANTINEOPLASTIC - ANTIBIOTIC AND ANTIMETABOLITE COMBINATIONS
VYXEOS T4 PA
ANTINEOPLASTIC - ANTIBODY-DRUG CONJUGATES (ADCS)
ADCETRIS T4 PA
BESPONSA T4 PA
KADCYLA T4 PA
ANTINEOPLASTIC - ANTI-GD2 GANGLIOSIDE MONOCLONAL ANTIBODY
UNITUXIN T4 PA
ANTINEOPLASTIC - ANTIMETABOLITE - FOLIC ACID ANALOGS
methotrexate sodium T1
methotrexate sodium (pf) T1
XATMEP T2 PA
TREXALL T3
ALIMTA T4 PA
FOLOTYN T4 PA
ANTINEOPLASTIC - ANTIMETABOLITE - PURINE ANALOGS
mercaptopurine T1
fludarabine intravenous recon soln T3
cladribine T4
clofarabine T4 PA
fludarabine intravenous solution T4
ARRANON T4
CLOLAR T4
PURIXAN T4
TABLOID T4
ANTINEOPLASTIC - ANTIMETABOLITE - PYRIMIDINE ANALOGS
capecitabine T1
cytarabine T1
cytarabine (pf) T1
gemcitabine intravenous recon soln 2 gram, 200 mg T1
gemcitabine intravenous solution T1
2018
21
Drug Name Formulary Tiers Restrictions
fluorouracil (bulk) T3
gemcitabine intravenous recon soln 1 gram T3
decitabine T4
floxuridine T4
fluorouracil T4
VIDAZA T4
XELODA T4 PA
ANTINEOPLASTIC - ANTIMETABOLITE - UREA DERIVATIVES
hydroxyurea T1
ANTINEOPLASTIC - ANTIMETABOLITES - PYRIMIDINE ANALOG COMBINATIONS
LONSURF T4 PA
ANTINEOPLASTIC - ANTI-SLAMF7 MONOCLONAL ANTIBODY AGENTS
EMPLICITI T4 PA
ANTINEOPLASTIC - AROMATASE INHIBITORS
anastrozole T1
letrozole T1
exemestane T3
ANTINEOPLASTIC - ARSENIC COMPOUNDS
TRISENOX T4
ANTINEOPLASTIC - ASPARAGINASE ENZYME THERAPY AGENTS
ERWINAZE T4 PA
ANTINEOPLASTIC - B-CELL LYMPHOMA-2 (BCL-2) INHIBITORS
VENCLEXTA T4 PA
VENCLEXTA STARTING PACK T4 PA
ANTINEOPLASTIC - BRAF KINASE INHIBITORS
TAFINLAR T4 PA
ZELBORAF T4 PA
ANTINEOPLASTIC - BRUTON'S TYROSINE KINASE (BTK) INHIBITOR
IMBRUVICA T4 PA
ANTINEOPLASTIC - CD20 SPECIFIC RECOMBINANT MONOCLONAL ANTIBODY AGENTS
ARZERRA T4 PA
GAZYVA T4 PA
RITUXAN T4 PA
RITUXAN HYCELA T4 PA
ANTINEOPLASTIC - CD38 SPECIFIC RECOMBINANT MONOCLONAL ANTIBODY AGENTS
DARZALEX T4 PA
ANTINEOPLASTIC - CYCLIN-DEPENDENT KINASE (CDK) 4/6 INHIBITORS
IBRANCE T4 PA
KISQALI T4 PA
ANTINEOPLASTIC - CYTOTOXIC T-LYMPHOCYTE ANTIGEN (CTLA-4),R-MC ANTIBODY
YERVOY T4 PA
2018
22
Drug Name Formulary Tiers Restrictions
ANTINEOPLASTIC - EPIPODOPHYLLOTOXINS
etoposide T4
teniposide T4
ETOPOPHOS T4
ANTINEOPLASTIC - EPOTHILONES AND ANALOGS
IXEMPRA T4 PA
ANTINEOPLASTIC - ESTROGEN RECEPTOR ANTAGONIST
FASLODEX T4
ANTINEOPLASTIC - ESTROGENS
EMCYT T4
ANTINEOPLASTIC - HALICHONDRIN B ANALOGS, MICROTUBULE INHIBITORS
HALAVEN T4 PA
ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITOR
ERIVEDGE T4 PA
ODOMZO T4 PA
ANTINEOPLASTIC - HISTONE DEACETYLASE (HDAC) INHIBITORS
BELEODAQ T4 PA
FARYDAK T4 PA
ISTODAX T4 PA
ZOLINZA T4 PA
ANTINEOPLASTIC - IMMUNOTHERAPY, THERAPEUTIC VACCINES
PROVENGE T4 PA
ANTINEOPLASTIC - IMMUNOTHERAPY, VIRUS-BASED
IMLYGIC T4
ANTINEOPLASTIC - INTERFERONS
INTRON A T4
SYLATRON T4 PA
ANTINEOPLASTIC - INTERLEUKIN-6 (IL-6) INHIBITORS, MONOCLONAL ANTIBODY
SYLVANT T4 PA
ANTINEOPLASTIC - INTERLEUKINS
PROLEUKIN T4
ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS
JAKAFI T4 PA
ANTINEOPLASTIC - KINASE INHIBITOR AND AROMATASE INHIBITOR COMBINATION
KISQALI FEMARA CO-PACK T4 PA
ANTINEOPLASTIC - LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS
leuprolide T4
ELIGARD T4
ELIGARD (3 MONTH) T4
ELIGARD (4 MONTH) T4
ELIGARD (6 MONTH) T4
LUPRON DEPOT T4
LUPRON DEPOT (3 MONTH) T4
LUPRON DEPOT (4 MONTH) T4
2018
23
Drug Name Formulary Tiers Restrictions
LUPRON DEPOT (6 MONTH) T4
TRELSTAR T4
ZOLADEX T4
ANTINEOPLASTIC - LHRH (GNRH) ANTAGONIST PITUITARY SUPPRESSANTS
FIRMAGON KIT W DILUENT SYRINGE T4
ANTINEOPLASTIC - MAST CELL STABILIZERS
cromolyn T3
ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORS
COTELLIC T4 PA
ANTINEOPLASTIC - MONOCLONAL ANTIBODIES FOR RADIOPHARMACEUTICAL THERAPY
ZEVALIN (Y-90) T4 PA
ANTINEOPLASTIC - MTOR KINASE INHIBITORS
AFINITOR T4 PA
AFINITOR DISPERZ T4 PA
TORISEL T4 PA
ANTINEOPLASTIC - MULTIKINASE INHIBITORS
CABOMETYX T4 PA
COMETRIQ T4 PA
ICLUSIG T4 PA
NEXAVAR T4 PA
STIVARGA T4 PA
ANTINEOPLASTIC - MUTANT ISOCITRATE DEHYDROGENASE 2 (MIDH2) INHIBITORS
IDHIFA T4 PA
ANTINEOPLASTIC - OTHER
TICE BCG T2
ANTINEOPLASTIC - PAN-CLASS I PI3K INHIBITORS
ALIQOPA T4 PA
ANTINEOPLASTIC - PHOTOSENSITIZERS
UVADEX T3
PHOTOFRIN T4 PA
ANTINEOPLASTIC - PI3K-DELTA INHIBITORS
ZYDELIG T4 PA
ANTINEOPLASTIC - PLATINUM COMPLEXES
oxaliplatin intravenous solution 100 mg/20 ml T3
carboplatin T4
cisplatin T4
oxaliplatin intravenous recon soln T4
oxaliplatin intravenous solution 50 mg/10 ml (5 mg/ml) T4
ANTINEOPLASTIC - POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS
LYNPARZA T4 PA
RUBRACA T4 PA
ZEJULA T4 PA
ANTINEOPLASTIC - PROGESTINS
megestrol T1
DEPO-PROVERA T4
2018
24
Drug Name Formulary Tiers Restrictions
ANTINEOPLASTIC - PROTEASOME ENZYME INHIBITORS
KYPROLIS T4 PA
NINLARO T4 PA
VELCADE T4 PA
ANTINEOPLASTIC - PROTEIN-TYROSINE KINASE INHIBITORS
BOSULIF T4 PA
CAPRELSA T4 PA
GLEEVEC T4 PA
IMBRUVICA T4 PA
INLYTA T4 PA
LENVIMA T4 PA
OFEV T4 PA
RYDAPT T4 PA
SPRYCEL T4 PA
SUTENT T4 PA
TASIGNA T4 PA
VOTRIENT T4 PA
ANTINEOPLASTIC - RADIOPHARMACEUTICALS
METASTRON T3
HICON T4
XOFIGO T4 PA
ANTINEOPLASTIC - RETINOIDS
tretinoin (chemotherapy) T1
ANTINEOPLASTIC - SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)
tamoxifen T1
FARESTON T3
SOLTAMOX T3
ANTINEOPLASTIC - SELECTIVE RETINOID X RECEPTOR AGONISTS
bexarotene T4 PA
TARGRETIN T4 PA
ANTINEOPLASTIC - TAXANES
DOCEFREZ T3
docetaxel T4
paclitaxel T4
ABRAXANE T4
JEVTANA T4 PA
ANTINEOPLASTIC - THALIDOMIDE ANALOGS
POMALYST T4 PA
REVLIMID T4 PA
THALOMID T4 PA
ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS
irinotecan T1
topotecan T4
CAMPTOSAR T4
HYCAMTIN T4
ONIVYDE T4 PA
2018
25
Drug Name Formulary Tiers Restrictions
ANTINEOPLASTIC - VASC ENDOTHELIAL GROWTH FACTOR RECEPTOR (VEGFR) ANTAG
CYRAMZA T4 PA
ANTINEOPLASTIC - VINCA ALKALOIDS AND ANALOGS
vinorelbine T1
vinblastine T4
vincristine T4
MARQIBO T4
ANTINEOPLASTIC ANTIBIOTIC - ANTHRACYCLINES
daunorubicin T3
doxorubicin T4
doxorubicin, peg-liposomal T4
epirubicin T4
idarubicin T4
mitoxantrone T4
VALSTAR T4
ANTINEOPLASTIC ANTIBIOTIC - OTHERS
bleomycin T4
mitomycin T4
ZANOSAR T4 PA
ANTINEOPLASTIC -CEPHALOTAXINES
SYNRIBO T4 PA
ANTINEOPLASTIC-ANTI-PROGRAMMED CELL DEATH LIGAND-1 (PD-L1) MC ANTIB.
BAVENCIO T4 PA
TECENTRIQ T4 PA
ANTINEOPLASTIC-ANTI-PROGRAMMED CELL DEATH RECEPTOR-1 (PD-1) MC ANTIB.
KEYTRUDA T4 PA
OPDIVO T4 PA
ANTINEOPLASTIC-CD22 SPECIFIC ANTIBODY / CYTOTOXIC ANTIBIOTIC CONJUGATE
BESPONSA T4 PA
ANTINEOPLASTIC-CD30 DIRECTED ANTIBODY-MICROTUBULE DISRUPTING CONJUGATE
ADCETRIS T4 PA
ANTINEOPLASTIC-HER2 TARGETED ANTIBODY-MICROTUBULE INHIBITOR CONJUGATE
KADCYLA INTRAVENOUS RECON SOLN 100 MG T4
KADCYLA INTRAVENOUS RECON SOLN 160 MG T4 PA
ANTINEOPLASTIC-VASC ENDOTHELIAL GROWTH FAC(VEGF-A,B AND PLGF)INHIBITOR
ZALTRAP T4 PA
BISPECIFIC CD19-DIRECTED CD3 T-CELL ENGAGER, MONOCLONAL ANTIBODY
BLINCYTO T4 PA
CARDIAC PROTECTIVE AGENTS USED IN CONJUNCTION WITH CHEMOTHERAPY
dexrazoxane hcl T1
EPIDERMAL GROWTH FACTOR RECEPT (HER-2) SUBDOMAIN II BLOCKER, REC-MC AB
PERJETA T4 PA
2018
26
Drug Name Formulary Tiers Restrictions
EPIDERMAL GROWTH FACTOR RECEPT BLOCKER (HER-1 TYPE), REC-MC ANTIBODY
ERBITUX T4 PA
PORTRAZZA T4 PA
VECTIBIX T4 PA
EPIDERMAL GROWTH FACTOR RECEPT BLOCKER (HER-2 TYPE), REC-MC ANTIBODY
HERCEPTIN T4
METHOTREXATE RESCUE AGENTS
leucovorin calcium injection recon soln 50 mg, 500 mg T1
leucovorin calcium oral T1
leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg T3
FUSILEV T3
VORAXAZE T4
METHOTREXATE RESCUE AGENTS - CARBOXYPEPTIDASE G2 TYPE
VORAXAZE T4
METHOTREXATE RESCUE AGENTS - FOLIC ACID ANTAGONIST TYPE
leucovorin calcium injection recon soln 50 mg, 500 mg T1
leucovorin calcium oral T1
levoleucovorin intravenous recon soln T1
leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg T3
FUSILEV T3
levoleucovorin intravenous solution T4
URINARY TRACT PROTECTIVE AGENTS USED IN CONJUNCTION WITH CHEMOTHERAPY
mesna T1
amifostine crystalline T4
MESNEX T4
ANTISEPTICS AND DISINFECTANTS
ANTISEPTIC - ALCOHOLS
alcohol swabs T1
ANTISEPTIC - IODINE/IODOPHORES
IODOFLEX T3
IODOSORB T3
ANTISEPTIC - OTHERS
formaldehyde T1
glutaraldehyde T3
FORMADON T3
FORMA-RAY T3
ANTISEPTIC - PHENOL DERIVATIVES
phenol T1
DISINFECTANTS - ALDEHYDES
FORMADON T3
BIOLOGICALS
ALLERGENIC EXTRACT OTHERS
CANDIN T3
ALLERGENIC EXTRACTS - GRASS POLLEN
GRASTEK T3 PA
2018
27
Drug Name Formulary Tiers Restrictions
ORALAIR T3 PA
ALLERGENIC EXTRACTS - WEED POLLEN
RAGWITEK T3 PA
ANTIVIRAL MONOCLONAL ANTIBODIES
SYNAGIS T4 PA
HEPATITIS A AND HEPATITIS B VACCINE COMBINATIONS
TWINRIX (PF) T2
HEPATITIS A VACCINE - SINGLE AGENTS
HAVRIX (PF) T2
VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML T2
VAQTA (PF) INTRAMUSCULAR SYRINGE T2
VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML
T3
HEPATITIS B VACCINE COMBINATIONS
PEDIARIX (PF) T2
HEPATITIS B VACCINES - SINGLE AGENTS
ENGERIX-B (PF) T2
ENGERIX-B PEDIATRIC (PF) T2
RECOMBIVAX HB (PF) T2
IMMUNE GLOBULIN - CYTOMEGALOVIRUS (CMV)
CYTOGAM T4
IMMUNE GLOBULIN - GAMMA GLOBULIN (IGG), HUMAN
BIVIGAM T4 PA
CARIMUNE NF NANOFILTERED T4 PA
CUVITRU T4 PA
FLEBOGAMMA DIF T4 PA
GAMASTAN S/D T4 PA
GAMMAGARD LIQUID T4 PA
GAMMAGARD S-D (IGA < 1 MCG/ML) T4 PA
GAMMAKED T4 PA
GAMMAPLEX T4 PA
GAMMAPLEX (WITH SORBITOL) T4 PA
GAMUNEX-C T4 PA
HIZENTRA T4 PA
HYQVIA T4 PA
HYQVIA IG COMPONENT T4 PA
OCTAGAM T4 PA
PRIVIGEN T4 PA
IMMUNE GLOBULIN - HEPATITIS B
HEPAGAM B T4
HYPERHEP B S/D T4
HYPERHEP B S-D NEONATAL T4
NABI-HB T4
IMMUNE GLOBULIN - RABIES
HYPERRAB S/D (PF) T4
IMOGAM RABIES-HT (PF) T4
IMMUNE GLOBULIN - RHO(D)
HYPERRHO S/D T4
2018
28
Drug Name Formulary Tiers Restrictions
MICRHOGAM ULTRA-FILTERED PLUS T4
RHOGAM ULTRA-FILTERED PLUS T4
RHOPHYLAC T4
WINRHO SDF T4
IMMUNE GLOBULIN - TETANUS
HYPERTET S/D (PF) T4
IMMUNE GLOBULIN - VARICELLA-ZOSTER
VARIZIG T2
IMMUNE SERUMS
ATGAM T4
THYMOGLOBULIN T4
IMMUNE SERUMS - BOTULINUM ANTITOXINS
botulism antitoxin heptavalent T1
LIVE VACCINES
bcg vaccine, live (pf) T1
FLUMIST QUAD 2017-2018 T2
M-M-R II (PF) T2
PROQUAD (PF) T2
ROTARIX T2
ROTATEQ VACCINE T2
TICE BCG T2
VARIVAX (PF) T2
VIVOTIF BERNA VACCINE T2
YF-VAX (PF) T2
ZOSTAVAX (PF) T2
IMLYGIC T4 PA
TOXOID VACCINE COMBINATIONS
tetanus,diphtheria tox ped(pf) T1
tetanus-diphtheria toxoids-td T1
ADACEL(TDAP ADOLESN/ADULT)(PF) T2
BOOSTRIX TDAP T2
DAPTACEL (DTAP PEDIATRIC) (PF) T2
INFANRIX (DTAP) (PF) T2
KINRIX (PF) T2
PEDIARIX (PF) T2
PENTACEL DTAP-IPV COMPNT (PF) T2
TENIVAC (PF) T2
VACCINE BACTERIAL - GRAM NEGATIVE BACILLI (NON-ENTERIC)
ACTHIB (PF) T2
PEDVAX HIB (PF) T2
TYPHIM VI T2
VIVOTIF BERNA VACCINE T2
VACCINE BACTERIAL - GRAM NEGATIVE COCCI
MENACTRA (PF) T2
MENOMUNE - A/C/Y/W-135 T2
MENOMUNE - A/C/Y/W-135 (PF) T2
MENVEO A-C-Y-W-135-DIP (PF) T3
2018
29
Drug Name Formulary Tiers Restrictions
VACCINE BACTERIAL - GRAM NEGATIVE COCCI AND BACILLI
MENHIBRIX (PF) T2
VACCINE BACTERIAL - GRAM POSITIVE COCCI
PNEUMOVAX 23 T2
PREVNAR 13 (PF) T2
VACCINE BACTERIAL - MENINGOCOCCAL GROUP B VACCINES
TRUMENBA T2
BEXSERO T4
VACCINE BACTERIAL - OTHER
bcg vaccine, live (pf) T1
VACCINE BACTERIAL - TOXIN-PRODUCING BACILLI
BIOTHRAX T2
VAXCHORA VACCINE T2
VACCINE MIXED COMBINATIONS (BACTERIAL AND VIRAL)
PENTACEL (PF) T2
VACCINE VIRAL - HUMAN PAPILLOMAVIRUS (HPV) VACCINES
GARDASIL 9 (PF) T2
VACCINE VIRAL - INFLUENZA A AND B
AFLURIA 2017-2018 T2
AFLURIA 2017-2018 (PF) T2
AFLURIA QUAD 2017-2018 T2
AFLURIA QUAD 2017-2018 (PF) T2
FLUAD 2017-2018 (65 YR UP)(PF) T2
FLUARIX QUAD 2017-2018 (PF) T2
FLUBLOK 2017-2018 (PF) T2
FLUBLOK QUAD 2017-2018 (PF) T2
FLUCELVAX QUAD 2017-2018 T2
FLUCELVAX QUAD 2017-2018 (PF) T2
FLULAVAL QUAD 2017-2018 T2
FLULAVAL QUAD 2017-2018 (PF) T2
FLUMIST QUAD 2017-2018 T2
FLUVIRIN 2017-2018 T2
FLUVIRIN 2017-2018 (PF) T2
FLUZONE HIGH-DOSE 2017-18 (PF) T2
FLUZONE INTRADERM QUAD 2017-18 T2
FLUZONE QUAD 2017-2018 T2
FLUZONE QUAD 2017-2018 (PF) T2
FLUZONE QUAD PEDI 2017-18 (PF) T2
VACCINE VIRAL - JAPANESE ENCEPHALITIS
IXIARO (PF) T3
VACCINE VIRAL - MEASLES
M-M-R II (PF) T2
PROQUAD (PF) T2
VACCINE VIRAL - MUMPS AND RELATED
M-M-R II (PF) T2
PROQUAD (PF) T2
2018
30
Drug Name Formulary Tiers Restrictions
VACCINE VIRAL - POLIOMYELITIS
IPOL T2
VACCINE VIRAL - RABIES
IMOVAX RABIES VACCINE (PF) T2
RABAVERT (PF) T2
VACCINE VIRAL - ROTAVIRUS
ROTARIX T2
ROTATEQ VACCINE T2
VACCINE VIRAL - RUBELLA
M-M-R II (PF) T2
PROQUAD (PF) T2
VACCINE VIRAL - VARICELLA
PROQUAD (PF) T2
VARIVAX (PF) T2
ZOSTAVAX (PF) T2
VACCINE VIRAL - YELLOW FEVER
YF-VAX (PF) T2
VACCINE VIRAL COMBINATIONS
M-M-R II (PF) T2
PROQUAD (PF) T2
CARDIOVASCULAR THERAPY AGENTS
ACE INHIBITOR AND CALCIUM CHANNEL BLOCKER COMBINATIONS
amlodipine-benazepril T1
trandolapril-verapamil T1
PRESTALIA T3
TARKA T3
ACE INHIBITOR AND DIURETIC COMBINATIONS
benazepril-hydrochlorothiazide T1
captopril-hydrochlorothiazide T1
enalapril-hydrochlorothiazide T1
fosinopril-hydrochlorothiazide T1
lisinopril-hydrochlorothiazide T1
moexipril-hydrochlorothiazide T1
quinapril-hydrochlorothiazide T1
ACE INHIBITORS
benazepril T1
captopril T1
enalapril maleate T1
enalaprilat T1
fosinopril T1
lisinopril T1
moexipril T1
perindopril erbumine T1
quinapril T1
ramipril T1
trandolapril T1
EPANED T3
2018
31
Drug Name Formulary Tiers Restrictions
QBRELIS T3 PA
ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone T1
spironolactone T1
ALPHA-BETA BLOCKERS
carvedilol T1
labetalol T1
COREG CR T2
ANGIOTENSIN II RECEPTOR BLOCKER (ARB)-CALCIUM CHANNEL BLOCKER COMB.
amlodipine-olmesartan T1
amlodipine-valsartan T1
telmisartan-amlodipine T1
AZOR T3
EXFORGE T3
TWYNSTA T3
ANGIOTENSIN II RECEPTOR BLOCKER (ARB)-CALCIUM CHANNEL BLOCKER-DIURETIC
amlodipine-valsartan-hcthiazid T1
olmesartan-amlodipin-hcthiazid T1
EXFORGE HCT T3
TRIBENZOR T3
ANGIOTENSIN II RECEPTOR BLOCKER (ARB)-DIURETIC COMBINATIONS
candesartan-hydrochlorothiazid T1
irbesartan-hydrochlorothiazide T1
losartan-hydrochlorothiazide T1
olmesartan-hydrochlorothiazide T1
telmisartan-hydrochlorothiazid T1
valsartan-hydrochlorothiazide T1
BENICAR HCT T3
EDARBYCLOR T3 ST
MICARDIS HCT T3
ANGIOTENSIN II RECEPTOR BLOCKER-NEPRILYSIN INHIBITOR COMB. (ARNI)
ENTRESTO T2
ANGIOTENSIN II RECEPTOR BLOCKERS (ARBS)
candesartan T1
eprosartan T1
irbesartan T1
losartan T1
olmesartan T1
telmisartan T1
valsartan T1
AVAPRO T3
BENICAR T3
EDARBI T3 ST
MICARDIS T3
2018
32
Drug Name Formulary Tiers Restrictions
ANTIANGINAL - CORONARY VASODILATORS (NITRATES)
isosorbide dinitrate T1
isosorbide mononitrate T1
nitroglycerin in 5 % dextrose T1
nitroglycerin intravenous T1
nitroglycerin oral T1
nitroglycerin sublingual T1
nitroglycerin transdermal T1
NITROLINGUAL T2
nitroglycerin translingual T3
GONITRO T3
ISORDIL T3
NITRO-BID T3
NITRO-DUR T3
ANTIANGINAL AND ANTI-ISCHEMIC AGENTS, NON-HEMODYNAMIC
RANEXA T2
ANTIARRHYTHMIC - CLASS IA
disopyramide phosphate T1
procainamide T1
quinidine gluconate injection T1
quinidine sulfate T1
quinidine gluconate oral T3
NORPACE CR T3
ANTIARRHYTHMIC - CLASS IB
lidocaine (pf) T1
lidocaine in 5 % dextrose (pf) T1
mexiletine T1
phenytoin sodium T1
XYLOCAINE (CARDIAC) (PF) T3
ANTIARRHYTHMIC - CLASS IC
flecainide T1
propafenone oral tablet T1
propafenone oral capsule,extended release 12 hr T3
ANTIARRHYTHMIC - CLASS II
esmolol T1
sotalol T1
SOTALOL AF T1
BREVIBLOC IN NACL (ISO-OSM) T3
SOTYLIZE T3
ANTIARRHYTHMIC - CLASS III
amiodarone T1
amiodarone in dextrose 5 % T1
ibutilide fumarate T1
MULTAQ T2
dofetilide T3
NEXTERONE T3
2018
33
Drug Name Formulary Tiers Restrictions
ANTIARRHYTHMIC - CLASS IV
diltiazem hcl T1
verapamil T1
ANTIARRHYTHMIC OTHERS
adenosine T1
ANTIHYPERLIPIDEMIC - APOLIPOPROTEIN B-100 SYNTHESIS INHIBITOR
KYNAMRO T4 PA
ANTIHYPERLIPIDEMIC - BILE ACID SEQUESTRANTS
cholestyramine (with sugar) T1
colestipol T1
CHOLESTYRAMINE LIGHT T1
PREVALITE T1
WELCHOL T2
COLESTID FLAVORED T3
QUESTRAN LIGHT T3
ANTIHYPERLIPIDEMIC - FIBRIC ACID DERIVATIVES
fenofibrate T1
fenofibrate micronized T1
fenofibrate nanocrystallized T1
fenofibric acid T1
fenofibric acid (choline) T1
gemfibrozil T1
FENOGLIDE ORAL TABLET 40 MG T2
TRIGLIDE T2
FENOGLIDE ORAL TABLET 120 MG T3
LIPOFEN T3
ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS (STATINS)
atorvastatin T1
fluvastatin T1 ST
lovastatin T1
pravastatin T1
rosuvastatin T1
simvastatin T1
ALTOPREV T2
LIVALO T2 ST
FLOLIPID T3 PA
LESCOL XL T3
ANTIHYPERLIPIDEMIC - NICOTINIC ACID DERIVATIVES
niacin T1
NIACOR T3
NIASPAN EXTENDED-RELEASE T3
ANTIHYPERLIPIDEMIC - SELECTIVE CHOLESTEROL ABSORPTION INHIBITOR
ezetimibe T1 ST
ANTIHYPERLIPIDEMIC AGENTS - DIETARY SOURCE
TRIKLO T1
omega-3 acid ethyl esters T3
2018
34
Drug Name Formulary Tiers Restrictions
LOVAZA T3
VASCEPA T3
ANTIHYPERLIPIDEMIC AGENTS - DIETARY SOURCE COMBINATIONS
vitamin e T1
CARDIOVID PLUS T3
LIPOCHOL PLUS T3
VASCAZEN T3
VAYAROL T3
ANTIHYPERLIPIDEMIC HMG COA REDUCT INHIB AND CALCIUM CHANNEL BLOCKER
amlodipine-atorvastatin T1
ANTIHYPERLIPIDEMIC-HMG COA REDUCT INHIB AND CHOLESTEROL ABSORP INHIBIT
ezetimibe-simvastatin T1
ANTIHYPERLIPIDEMIC-MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP)INHIB
JUXTAPID T4 PA
ANTI-PCSK9 MONOCLONAL ANTIBODIES
PRALUENT PEN T4 PA
REPATHA PUSHTRONEX T4 PA
REPATHA SURECLICK T4 PA
REPATHA SYRINGE T4 PA
BETA BLOCKERS CARDIAC SELECTIVE
atenolol T1
betaxolol T1
bisoprolol fumarate T1
esmolol T1
metoprolol succinate T1
metoprolol tartrate T1
BYSTOLIC T2
BREVIBLOC IN NACL (ISO-OSM) T3
BETA BLOCKERS CARDIAC SELECTIVE, INTRINSIC SYMPATHOMIMETIC ACTIVITY
acebutolol T1
BETA BLOCKERS NON-CARDIAC SELECT., INTRINSIC SYMPATHOMIMETIC ACTIVITY
pindolol T1
LEVATOL T3
BETA BLOCKERS NON-CARDIAC SELECTIVE
nadolol T1
propranolol T1
sotalol T1
timolol maleate T1
SOTALOL AF T1
HEMANGEOL T3
INNOPRAN XL T3
SOTYLIZE T3
BRADYKININ B2 RECEPTOR ANTAGONISTS
FIRAZYR T4 PA
2018
35
Drug Name Formulary Tiers Restrictions
CALCIUM CHANNEL BLOCKERS - BENZOTHIAZEPINES
diltiazem hcl T1
diltiazem hcl in 0.9% nacl T1
CARTIA XT T1
TAZTIA XT T1
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG
T2
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG
T3
CALCIUM CHANNEL BLOCKERS - DIHYDROPYRIDINES
amlodipine T1
felodipine T1
nicardipine intravenous syringe T1
nifedipine T1
isradipine T3
nicardipine intravenous solution T3
nicardipine oral T3
nisoldipine T3
CARDENE IV IN DEXTROSE T3
CARDENE IV IN SODIUM CHLORIDE T3
CLEVIPREX T3
CALCIUM CHANNEL BLOCKERS - DIHYDROPYRIDINES - CEREBROVASCULAR SPECIFIC
nimodipine T1
NYMALIZE T3 PA
CALCIUM CHANNEL BLOCKERS - PHENYLAKYLAMINES
verapamil T1
CARDIAC INOTROPES - PHOSPHODIESTERASE INHIBITORS
milrinone T1
milrinone in 5 % dextrose T1
CARDIAC SELECTIVE BETA BLOCKER-THIAZIDE DIURETIC AND RELATED COMB.
atenolol-chlorthalidone T1
bisoprolol-hydrochlorothiazide T1
metoprolol ta-hydrochlorothiaz T1
CARDIOVASCULAR SYMPATHOMIMETIC - ANAPHYLAXIS THERAPY SINGLE AGENTS
epinephrine T1
ADYPHREN T1
ADRENALIN T3
CARDIOVASCULAR SYMPATHOMIMETIC - BETA-ADRENERGIC AGONISTS
ISUPREL T3
CARDIOVASCULAR SYMPATHOMIMETICS
dobutamine T1
dobutamine in d5w T1
dopamine T1
dopamine in 5 % dextrose T1
ephedrine sulfate T1
ephedrine sulfate-0.9%nacl(pf) T1
2018
36
Drug Name Formulary Tiers Restrictions
epinephrine T1
midodrine T1
norepinephrine bitartrate T1
phenylephrine hcl T1
phenylephrine hcl in 0.9% nacl intravenous solution 40 mg/250 ml (160 mcg/ml)
T1
phenylephrine hcl in 0.9% nacl intravenous syringe T1
phenylephrine hcl in 0.9% nacl intravenous solution 50 mg/250 ml (200 mcg/ml)
T3
ADRENALIN T3
VAZCULEP T3
NORTHERA T4 PA
CENTRAL ALPHA-2 AGONISTS-THIAZIDE DIURETIC AND RELATED COMB.
methyldopa-hydrochlorothiazide T1
CLORPRES T3
CENTRAL ALPHA-2 RECEPTOR AGONISTS
clonidine T1
clonidine hcl T1
guanfacine T1
methyldopa T1
methyldopate T1
CATAPRES-TTS-1 T3
CATAPRES-TTS-2 T3
CATAPRES-TTS-3 T3
DIGITALIS GLYCOSIDES
digoxin T1
LANOXIN T3
DIRECT ACTING VASODILATORS
hydralazine oral T1
hydralazine injection T3
minoxidil T3
DIURETIC - ALDOSTERONE RECEPTOR ANTAGONIST, NON-SELECTIVE
spironolactone T1
DIURETIC - ALDOSTERONE RECEPTOR ANTAGONIST, SELECTIVE
eplerenone T1
DIURETIC - ARGININE VASOPRESSIN V1A/V2 RECEPTOR ANTAGONISTS
VAPRISOL T3
DIURETIC - CARBONIC ANHYDRASE INHIBITORS
acetazolamide T1
acetazolamide sodium T1
methazolamide T1
DIURETIC - INORGANIC SALT
ammonium chloride T1
DIURETIC - LOOP
bumetanide T1
ethacrynate sodium T1
2018
37
Drug Name Formulary Tiers Restrictions
furosemide T1
torsemide T1
EDECRIN T3 PA
SODIUM EDECRIN T3
DIURETIC - OSMOTIC
mannitol 10 % T1
mannitol 20 % T1
mannitol 25 % T1
mannitol 5 % T1
OSMITROL 15 % T3
DIURETIC - POTASSIUM SPARING
amiloride T1
DYRENIUM T3
DIURETIC - POTASSIUM SPARING-THIAZIDE AND RELATED COMBINATIONS
amiloride-hydrochlorothiazide T1
spironolacton-hydrochlorothiaz T1
triamterene-hydrochlorothiazid T1
ALDACTAZIDE T3
DIURETIC - SELECTIVE ARGININE VASOPRESSIN V2 RECEPTOR ANTAGONISTS
SAMSCA T4 PA
DIURETIC - THIAZIDES AND RELATED
chlorothiazide T1
chlorthalidone T1
hydrochlorothiazide T1
indapamide T1
methyclothiazide T1
metolazone T1
chlorothiazide sodium T3
DIURIL T3
DOPAMINE D1 RECEPTOR AGONISTS, ANTIHYPERTENSIVE
CORLOPAM T3
GANGLIONIC BLOCKING, NON-DEPOLARIZING
VECAMYL T1
HYPERPOLARIZATION-ACTIVATED CYCLIC NUCLEOTIDE-GATED CHANNEL INHIBITORS
CORLANOR T3 ST
MUSCARINIC RECEPTOR ANTAGONISTS (ANTICHOLINERGIC)
atropine T1
atropine (bulk) T1
ATROPEN T3
NON-CARDIAC SELECTIVE BETA BLOCKER-THIAZIDE DIURETIC AND RELATED COMB.
nadolol-bendroflumethiazide T1
propranolol-hydrochlorothiazid T1
PAH AGENTS - SELECTIVE PROSTACYCLIN RECEPTOR (IP) AGONISTS
UPTRAVI T4 PA
2018
38
Drug Name Formulary Tiers Restrictions
PATENT DUCTUS ARTERIOSUS (PDA) TREATMENT AGENTS , NSAID-TYPE
indomethacin sodium T1
PATENT DUCTUS ARTERIOSUS (PDA) TREATMENT AGENTS, PROSTAGLANDIN-TYPE
alprostadil T1
PROSTIN VR PEDIATRIC T3
PERIPHERAL ALPHA-1 RECEPTOR BLOCKERS
doxazosin T1
prazosin T1
terazosin T1
doxazosin mesylate (bulk) T3
CARDURA XL T3
phenoxybenzamine T4 PA
DIBENZYLINE T4 PA
PERIPHERAL VASODILATORS, SINGLE AGENTS
isoxsuprine T1
papaverine T1
PHEOCHROMOCYTOMA, AGENTS TO TREAT
DEMSER T2
PLASMA KALLIKREIN INHIBITOR AGENTS
KALBITOR T4 PA
PULMONARY ANTIHYPERTENSIVE AGENTS - PROSTACYCLIN-TYPE
epoprostenol (glycine) T1 PA
ORENITRAM T4 PA
REMODULIN T4 PA
TYVASO T4 PA
TYVASO INSTITUTIONAL START KIT T4 PA
TYVASO REFILL KIT T4 PA
TYVASO STARTER KIT T4 PA
VELETRI T4 PA
VENTAVIS T4 PA
PULMONARY ANTIHYPERTENSIVE AGENTS-SOLUBLE GUANYLATE CYCLASE STIMULATOR
ADEMPAS T4 PA
PULMONARY ARTERIAL HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS
LETAIRIS T4 PA
OPSUMIT T4 PA
TRACLEER T4 PA
PULMONARY ARTERIAL HYPERTENSION AGENTS-SELECTIVE CGMP-PDE5 INHIBITORS
sildenafil T4 PA
ADCIRCA T4 PA
REVATIO T4 PA
RENIN INHIBITOR, DIRECT
TEKTURNA T2
RENIN INHIBITOR, DIRECT AND DIURETIC COMBINATIONS
TEKTURNA HCT T2
2018
39
Drug Name Formulary Tiers Restrictions
SCLEROSING AGENTS
ASCLERA T3
SOTRADECOL T3
VARITHENA T3
ETHAMOLIN T4
VASOACTIVE NATRIURETIC PEPTIDES
NATRECOR T3
VASODILATOR COMBINATIONS
BIDIL T2
CENTRAL NERVOUS SYSTEM AGENTS
ANTIANXIETY AGENT - ANTIHISTAMINE TYPE
hydroxyzine hcl T1
hydroxyzine pamoate T1
ANTIANXIETY AGENT - BENZODIAZEPINES
alprazolam T1
chlordiazepoxide hcl T1
clonazepam T1
clorazepate dipotassium T1
diazepam T1
lorazepam T1
oxazepam T1
ALPRAZOLAM INTENSOL T1
DIAZEPAM INTENSOL T1
ANTIANXIETY AGENT - DICARBAMATE TYPE
meprobamate T1
ANTIANXIETY AGENT - NON-BENZODIAZEPINE
buspirone T1
ANTICONVULSANT - AMPA-TYPE GLUTAMATE RECEPTOR ANTAGONISTS
FYCOMPA ORAL SUSPENSION T3 PA; ST
FYCOMPA ORAL TABLET T3 ST
ANTICONVULSANT - BARBITURATES AND DERIVATIVES
phenobarbital T1
phenobarbital sodium T1
primidone T1
ANTICONVULSANT - BENZODIAZEPINES
clonazepam T1
diazepam T1
ONFI T3 PA
ANTICONVULSANT - CARBAMATES
felbamate oral suspension T1
felbamate oral tablet T3
ANTICONVULSANT - CARBOXYLIC ACID DERIVATIVES
divalproex T1
valproic acid T1
valproic acid (as sodium salt) T1
valproate sodium T3
2018
40
Drug Name Formulary Tiers Restrictions
ANTICONVULSANT - FUNCTIONALIZED AMINO ACID
VIMPAT T3 ST
ANTICONVULSANT - GABA ANALOGS
gabapentin T1
LYRICA T2
ANTICONVULSANT - GABA RE-UPTAKE INHIBITOR, NIPECOTIC ACID DERIVATIVES
GABITRIL T2
tiagabine T3
ANTICONVULSANT - GABA TRANSAMINASE (GABA-T) INHIBITOR
vigabatrin T4 PA
SABRIL T4 PA
ANTICONVULSANT - HYDANTOINS
fosphenytoin T1
phenytoin T1
phenytoin sodium T1
phenytoin sodium extended T1
DILANTIN T2
PEGANONE T2
ANTICONVULSANT - IMINOSTILBENE DERIVATIVES
carbamazepine T1
oxcarbazepine oral tablet T1
oxcarbazepine oral suspension T3
APTIOM T3 ST
EQUETRO T3
OXTELLAR XR T3 ST
TEGRETOL XR T3
TRILEPTAL T3
ANTICONVULSANT - MONOSACCHARIDE DERIVATIVES
topiramate T1
topiramate (bulk) T2
QUDEXY XR T3 ST
ANTICONVULSANT - PHENYLTRIAZINE DERIVATIVES
lamotrigine oral tablet T1
lamotrigine oral tablet disintegrating, dose pk T1
lamotrigine oral tablet, chewable dispersible T1
lamotrigine oral tablets,dose pack T1
LAMICTAL ODT T2
LAMICTAL XR STARTER (BLUE) T2
LAMICTAL XR STARTER (GREEN) T2
LAMICTAL XR STARTER (ORANGE) T2
lamotrigine oral tablet extended release 24hr T3
lamotrigine oral tablet,disintegrating T3
LAMICTAL ODT STARTER (BLUE) T3
LAMICTAL ODT STARTER (GREEN) T3
LAMICTAL ODT STARTER (ORANGE) T3
2018
41
Drug Name Formulary Tiers Restrictions
ANTICONVULSANT - PYRROLIDINE DERIVATIVES
levetiracetam oral T1
levetiracetam in nacl (iso-os) T3
levetiracetam intravenous T3
BRIVIACT T3 ST
SPRITAM T3 PA
ANTICONVULSANT - SUCCINIMIDES
ethosuximide T1
CELONTIN T2
ANTICONVULSANT - SULFONAMIDE DERIVATIVES
zonisamide T1
ANTICONVULSANT - TRIAZOLE DERIVATIVES
BANZEL T2
ANTIDEPRESSANT - ALPHA-2 RECEPTOR ANTAGONISTS (NASSA)
mirtazapine T1
ANTIDEPRESSANT - MAO INHIBITOR NONSELECTIVE AND IRREVERSIBLE-TYPES A,B
phenelzine T1
tranylcypromine T3
EMSAM T3
MARPLAN T3
ANTIDEPRESSANT - SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)
citalopram T1
escitalopram oxalate T1
fluoxetine T1
fluvoxamine oral tablet T1
paroxetine hcl T1
sertraline T1
fluvoxamine oral capsule,extended release 24hr T3
PEXEVA T3
ANTIDEPRESSANT - SEROTONIN-2 ANTAGONIST-REUPTAKE INHIBITORS (SARIS)
nefazodone oral tablet 100 mg, 150 mg, 200 mg T1
trazodone T1
nefazodone oral tablet 250 mg, 50 mg T3
ANTIDEPRESSANT - SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)
desvenlafaxine T1
desvenlafaxine fumarate T1
desvenlafaxine succinate T1
duloxetine T1
venlafaxine T1
duloxetine hcl (bulk) T2
CYMBALTA T3
FETZIMA T3 ST
KHEDEZLA T3 ST
SAVELLA T3 ST
2018
42
Drug Name Formulary Tiers Restrictions
ANTIDEPRESSANT - SSRI AND 5HT1A PARTIAL AGONIST
VIIBRYD T3 ST
ANTIDEPRESSANT - SSRI AND SEROTONIN (5-HT) RECEPTOR MODULATOR
TRINTELLIX T3 ST
ANTIDEPRESSANT - TRICYCLIC AND ANTIPSYCHOTIC, PHENOTHIAZINE COMB
perphenazine-amitriptyline T1
ANTIDEPRESSANT - TRICYCLIC-BENZODIAZEPINE COMBINATIONS
amitriptyline-chlordiazepoxide T1
ANTIDEPRESSANT- SSRI AND ATYPICAL ANTIPSYCH,DOPAMINE,SEROTONIN ANTAGON
olanzapine-fluoxetine T3
ANTIDEPRESSANT-NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIBITORS (NDRIS)
bupropion hcl T1
FORFIVO XL T3 ST
ANTIDEPRESSANT-TRICYCLICS AND RELATED (NON-SELECT REUPTAKE INHIBITORS)
amitriptyline T1
amoxapine T1
clomipramine T1 PA
desipramine T1
doxepin T1
imipramine hcl T1
imipramine pamoate T1
maprotiline T1
nortriptyline T1
protriptyline T1
SURMONTIL T3
ANTIPARKINSON - DOPAMINERGIC-PERIPH COMT-DOPA-DECARBOXYLASE INHIB COMB
carbidopa-levodopa-entacapone T1
ANTIPARKINSON - DOPAMINERG-PERIPHERAL DOPA-DECARBOXYLASE INHIBIT COMB
carbidopa-levodopa T1
RYTARY T3
ANTIPARKINSON ADJUVANT - CENTRAL/PERIPHERAL COMT INHIBITORS
TASMAR T3 PA
tolcapone T4 PA
ANTIPARKINSON ADJUVANT - PERIPHERAL COMT INHIBITORS
entacapone T1
ANTIPARKINSON ADJUVANT - PERIPHERAL DOPA-DECARBOXYLASE INHIBITORS
LODOSYN T2
ANTIPARKINSON THERAPY - ANTICHOLINERGIC AGENTS
benztropine T1
trihexyphenidyl T1
2018
43
Drug Name Formulary Tiers Restrictions
ANTIPARKINSON THERAPY - ERGOT ALKALOIDS AND DERIVATIVES
bromocriptine T3
ANTIPARKINSON THERAPY - MONOAMINE OXIDASE INHIBITOR(MAO-B)
rasagiline T1
selegiline hcl T1
XADAGO T3 PA
ZELAPAR T3
ANTIPARKINSON THERAPY - NON-ERGOT DOPAMINE AGONIST AGENTS
amantadine hcl T1
pramipexole oral tablet T1
ropinirole T1
MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR 3.75 MG, 4.5 MG
T2
pramipexole oral tablet extended release 24 hr T3
MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR 0.375 MG, 0.75 MG, 1.5 MG, 2.25 MG, 3 MG
T3
NEUPRO T3 ST
APOKYN T4 PA
GOCOVRI T4 PA
ANTIPSYCHOTIC - ATYP DOPAMINE-SEROTONIN ANTAG DIBENZO-OXEPINO PYRROLES
SAPHRIS (BLACK CHERRY) T3 ST
ANTIPSYCHOTIC - ATYPICAL DOPAMINE-SEROTONIN ANTAG- BENZISOTHIAZOLONES
ziprasidone hcl T1
LATUDA T2 ST
GEODON T3
ANTIPSYCHOTIC - ATYPICAL DOPAMINE-SEROTONIN ANTAG- BENZISOXAZOLE DERIV
paliperidone T1
risperidone T1
FANAPT T3 ST
INVEGA T3 ST
INVEGA SUSTENNA T4
INVEGA TRINZA T4
RISPERDAL CONSTA T4
ANTIPSYCHOTIC - ATYPICAL DOPAMINE-SEROTONIN ANTAG-DIBENZODIAZEPINE DER
clozapine oral tablet T1
clozapine oral tablet,disintegrating 12.5 mg, 150 mg, 200 mg T1
clozapine oral tablet,disintegrating 100 mg, 25 mg T3
FAZACLO T3
VERSACLOZ T3
ANTIPSYCHOTIC - BUTYROPHENONE DERIVATIVES
haloperidol T1
haloperidol decanoate T1
haloperidol lactate T1
2018
44
Drug Name Formulary Tiers Restrictions
ANTIPSYCHOTIC - DIBENZOXAZEPINE DERIVATIVES
loxapine succinate T1
ADASUVE T3
ANTIPSYCHOTIC - DIPHENYLBUTYLPIPERIDINE DERIVATIVES
pimozide T3
ORAP T3
ANTIPSYCHOTIC - PHENOTHIAZINES, ALIPHATIC
chlorpromazine injection T1
chlorpromazine oral T3
ANTIPSYCHOTIC - PHENOTHIAZINES, PIPERAZINE
fluphenazine hcl oral concentrate T1
fluphenazine hcl oral tablet 1 mg, 10 mg, 5 mg T1
perphenazine T1
prochlorperazine maleate T1
trifluoperazine T1
fluphenazine hcl injection T2
fluphenazine hcl oral elixir T2
fluphenazine hcl oral tablet 2.5 mg T2
ANTIPSYCHOTIC - PHENOTHIAZINES, PIPERIDINE
thioridazine T1
ANTIPSYCHOTIC - THIOXANTHENES
thiothixene T1
ANTIPSYCHOTIC -ATYPICAL DOPAMINE-SEROTONIN ANTAG-DIBENZOTHIAZEPINE DER
quetiapine oral tablet T1
quetiapine oral tablet extended release 24 hr 400 mg T1
quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 300 mg, 50 mg
T3
ANTIPSYCHOTIC -ATYPICAL DOPAMINE-SEROTONIN ANTAG-THIENOBENZODIAZEPINES
olanzapine T1
ZYPREXA RELPREVV T4
ANTIPSYCHOTIC-ATYP SELECTIVE SEROTONIN 5-HT2A INVERSE AGONISTS (SSIA)
NUPLAZID T3 ST
ANTIPSYCHOTIC-ATYPICAL,D2 RECEPTOR PARTIAL AGONIST-5HT SEROTONIN MIXED
aripiprazole oral solution T1
aripiprazole oral tablet,disintegrating T1
aripiprazole oral tablet T3
REXULTI T3 ST
ABILIFY MAINTENA T4
ARISTADA T4
ATTENTION DEFICIT-HYPERACT. DISORDER (ADHD)- ALPHA-2 RECEPTOR AGONIST
clonidine hcl T3
guanfacine T3
INTUNIV ER T3
KAPVAY T3
2018
45
Drug Name Formulary Tiers Restrictions
ATTENTION DEFICIT-HYPERACTIVITY (ADHD) THERAPY, STIMULANT-TYPE
dexmethylphenidate oral tablet T1
dextroamphetamine T1
dextroamphetamine-amphetamine T1
methylphenidate hcl oral capsule,er biphasic 50-50 30 mg, 60 mg T1
methylphenidate hcl oral tablet T1
methylphenidate hcl oral tablet extended release 24hr T1
methylphenidate hcl oral tablet,chewable T1
DAYTRANA T2 ST
VYVANSE T2
dexmethylphenidate oral capsule,er biphasic 50-50 T3
methylphenidate hcl oral capsule, er biphasic 30-70 T3
methylphenidate hcl oral capsule,er biphasic 50-50 20 mg, 40 mg T3
methylphenidate hcl oral solution T3
methylphenidate hcl oral tablet extended release T3
ADDERALL T3
APTENSIO XR T3 ST
COTEMPLA XR-ODT T3 PA
DYANAVEL XR T3 ST
EVEKEO T3
FOCALIN XR T3
METADATE ER T3
MYDAYIS T3 PA
QUILLICHEW ER T3
QUILLIVANT XR T3 ST
RITALIN LA T3
ZENZEDI T3
ATTENTION DEFICIT-HYPERACTIVITY DISORDER (ADHD) THERAPY, NRI-TYPE
atomoxetine T1
STRATTERA T3
BENZODIAZEPINES
amitriptyline-chlordiazepoxide T1
chlordiazepoxide-clidinium T1
diazepam T1
lorazepam T1
DIAZEPAM INTENSOL T1
ONFI T3 PA
BIPOLAR THERAPY AGENTS - ANTICONVULSANT TYPE
carbamazepine T1
divalproex T1
lamotrigine T1
valproic acid T1
valproic acid (as sodium salt) T1
LAMICTAL ODT T2
EQUETRO T3
LAMICTAL ODT STARTER (BLUE) T3
2018
46
Drug Name Formulary Tiers Restrictions
LAMICTAL ODT STARTER (GREEN) T3
LAMICTAL ODT STARTER (ORANGE) T3
BIPOLAR THERAPY AGENTS - ATYPICAL ANTIPSYCHOTICS
aripiprazole oral solution T1
aripiprazole oral tablet,disintegrating T1
olanzapine T1
quetiapine oral tablet T1
quetiapine oral tablet extended release 24 hr 400 mg T1
risperidone T1
ziprasidone hcl T1
aripiprazole oral tablet T3
quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 300 mg, 50 mg
T3
GEODON T3
SAPHRIS (BLACK CHERRY) T3 ST
VRAYLAR T3 ST
BIPOLAR THERAPY AGENTS - LITHIUM
lithium carbonate T1
lithium citrate T3
CNS STIMULANT - AMPHETAMINE COMBINATIONS
dextroamphetamine-amphetamine T1
ADDERALL T3
ADZENYS XR-ODT T3 ST
DYANAVEL XR T3 ST
MYDAYIS T3 PA
CNS STIMULANT - AMPHETAMINES
dextroamphetamine T1
DEXEDRINE SPANSULE T1
EVEKEO T3 ST
ZENZEDI T3 ST
CNS STIMULANT - ANALEPTICS
caffeine citrate T1
caffeine-sodium benzoate T1
doxapram T1
FIBROMYALGIA AGENTS - GABA ANALOGS
LYRICA T2
FIBROMYALGIA AGENTS - SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS)
duloxetine T1
duloxetine hcl (bulk) T2
CYMBALTA T3
SAVELLA T3 ST
HSDD AGENTS-MIXED SEROTONIN AGONIST/ANTAGONISTS
ADDYI T3 PA
HYPNOTICS - MELATONIN M1/M2 RECEPTOR AGONISTS
ROZEREM T3
HETLIOZ T4 PA
2018
47
Drug Name Formulary Tiers Restrictions
MIGRAINE THERAPY - ANALGESIC-VASOCONSTRICTORS
isomethepten-caf-acetaminophen T1
PRODRIN T3
MIGRAINE THERAPY - ANALGESIC-VASOCONSTRICTOR-SEDATIVE COMBINATIONS
isometh-dichloral-acetaminophn T1
MIGRAINE THERAPY - CARBOXYLIC ACID DERIVATIVES
divalproex T1
MIGRAINE THERAPY - ERGOT ALKALOIDS AND DERIVATIVES
dihydroergotamine T1
MIGRAINE THERAPY - ERGOT COMBINATIONS
MIGERGOT T1
CAFERGOT T3
MIGRAINE THERAPY - SELECTIVE SEROTONIN AGONISTS 5-HT(1)
eletriptan hbr T1
naratriptan T1
rizatriptan T1
sumatriptan succinate oral T1
zolmitriptan T1
almotriptan malate T3
frovatriptan T3
sumatriptan T3
sumatriptan succinate subcutaneous T3
AMERGE T3
AXERT T3
FROVA T3
IMITREX T3
MAXALT T3
MAXALT-MLT T3
ONZETRA XSAIL T3 PA
RELPAX T3 ST
SUMAVEL DOSEPRO T3 ST
ZEMBRACE SYMTOUCH T3 PA
ZOMIG T3
ZOMIG ZMT T3
MIGRAINE THERAPY - SEROTONIN AGONIST 5-HT(1) AND NSAID COMB.
TREXIMET T3 ST
MOVEMENT DISORDER DRUG THERAPY
tetrabenazine T4
AUSTEDO T4 PA
INGREZZA T4 PA
XENAZINE T4
MOVEMENT DISORDER THERAPY - HUNTINGTON'S DISEASE
tetrabenazine T4
AUSTEDO T4 PA
XENAZINE T4 PA
2018
48
Drug Name Formulary Tiers Restrictions
MOVEMENT DISORDER THERAPY - RESTLESS LEGS SYNDROME
HORIZANT T3 ST
MOVEMENT DISORDER THERAPY - TARDIVE DYSKINESIA
INGREZZA T4 PA
NARCOLEPSY AND CATAPLEXY THERAPY AGENTS - SEDATIVE-TYPE
XYREM T4 PA
NARCOLEPSY THERAPY AGENTS - NON-SYMPATHOMIMETIC
armodafinil T3 PA
modafinil T3 PA
NUVIGIL T3 PA
NARCOLEPSY THERAPY AGENTS - STIMULANT-TYPE, PIPERADINE DERIVATIVE
methylphenidate hcl oral tablet T1
methylphenidate hcl oral solution T3
NARCOLEPSY THERAPY AGENTS- STIMULANT-TYPE,SYMPATHOMIMETIC,AMPHETAMINES
dextroamphetamine T1
ADDERALL T3
ZENZEDI T3
PSEUDOBULBAR AFFECT (PBA) AGENTS, NMDA ANTAGONISTS TYPE
NUEDEXTA T2 PA
SEDATIVE-HYPNOTIC - BARBITURATES
phenobarbital T1
phenobarbital sodium T1
AMYTAL T3
BUTISOL T3
SECONAL SODIUM T3
SEDATIVE-HYPNOTIC - BENZODIAZEPINES
estazolam T1
flurazepam T1
lorazepam T1
midazolam T1
quazepam T1
temazepam T1
triazolam T1
SEDATIVE-HYPNOTIC - GABA-RECEPTOR MODULATORS
eszopiclone T1
zaleplon T1
zolpidem T1
EDLUAR T3
LUNESTA T3
ZOLPIMIST T3
SEDATIVE-HYPNOTIC - OREXIN RECEPTOR ANTAGONIST
BELSOMRA T3 ST
2018
49
Drug Name Formulary Tiers Restrictions
SEDATIVE-HYPNOTIC - SELECTIVE ALPHA2-ADRENORECEPTOR AGONISTS
dexmedetomidine T1
PRECEDEX T3
PRECEDEX IN 0.9 % SODIUM CHLOR INTRAVENOUS SOLUTION 200 MCG/50 ML (4 MCG/ML), 400 MCG/100 ML (4 MCG/ML)
T3
PRECEDEX IN 0.9 % SODIUM CHLOR INTRAVENOUS SOLUTION 80 MCG/20 ML (4 MCG/ML)
T4
SEDATIVE-HYPNOTIC - TRICYCLIC ANTIDEPRESSANT TYPE
SILENOR T2
CHEMICAL DEPENDENCY, AGENTS TO TREAT
AGENTS FOR NARCOTIC WITHDRAWAL
buprenorphine hcl T1 ST
buprenorphine-naloxone T3 PA
BUNAVAIL T3 PA
SUBOXONE T3 PA
ZUBSOLV T3 PA
ALCOHOL ABSTINENCE THERAPY - GLUTAMATE AND GABA SYSTEM TYPE
acamprosate T1
ALCOHOL ABSTINENCE THERAPY - OPIOID RECEPTOR ANTAGONIST-TYPE
VIVITROL T4
ALCOHOL DETERRENTS
disulfiram T1
SMOKING DETERRENTS - NE AND DOPAMINE REUPTAKE INHIBITOR (NDRI)-TYPE
bupropion hcl T1
SMOKING DETERRENTS - NICOTINE-TYPE
nicotine (polacrilex) T1
NICOTROL T2
NICOTROL NS T2
SMOKING DETERRENTS - NICOTINIC RECEPTOR PARTIAL AGONIST, ALPHA4BETA2
CHANTIX T2
CHANTIX CONTINUING MONTH BOX T2
CHANTIX STARTING MONTH BOX T2
CHEMICALS-PHARMACEUTICAL ADJUVANTS
BULK CHEMICALS
belladonna tincture (bulk) T1
alprostadil (bulk) T3
fluorouracil (bulk) T3
prasterone (dhea), micro(bulk) T3
CHEMICALS - ACIDS
glycolic acid (bulk) T1
hydrochloric acid (bulk) T3
CHEMICALS - BASES
sodium hydroxide (bulk) T1
CHEMICALS - CRYOPRESERVATIVE AGENTS
CRYOSERV T3
2018
50
Drug Name Formulary Tiers Restrictions
CHEMICALS - SOLVENTS
ethyl alcohol (bulk) T1
sodium succinate T1
MURI-LUBE T3
PHARMACEUTICAL ADJUVANT - ANTICORROSIVE AGENTS
butylated hydroxytoluene T1
sodium bisulfite T1
PHARMACEUTICAL ADJUVANT - FLAVORING AGENTS
banana creme flavor (bulk) T1
ethyl acetate T1
PHARMACEUTICAL ADJUVANT - INHALATION VEHICLES
sodium chloride T1
HYPER-SAL T3
NEBUSAL T3
PHARMACEUTICAL ADJUVANT - ORAL VEHICLES
sorbitol T1
PHARMACEUTICAL ADJUVANT - PARENTERAL VEHICLES
BACTERIOSTATIC WATER(PARABENS) T3
DILUENT FOR EPOPROSTENOL/FLOLA T3
PHARMACEUTICAL ADJUVANT - SUSPENDING AGENTS
oleic acid T1
PHARMACEUTICAL ADJUVANT - TABLETING
cellulose (bulk) T1
lactose (bulk) T1
magnesium stearate T1
COGNITIVE DISORDER THERAPY
ALZHEIMER'S DISEASE THERAPY - CHOLINESTERASE INHIBITORS
donepezil oral tablet 10 mg, 5 mg T1
donepezil oral tablet,disintegrating T1
galantamine T1
rivastigmine tartrate T1
donepezil oral tablet 23 mg T3
rivastigmine T3
EXELON T3
ALZHEIMER'S DISEASE THERAPY - NMDA RECEPTOR ANTAGONISTS
memantine T1
memantine hcl (bulk) T2
NAMENDA XR T2
NAMENDA T3
NAMENDA TITRATION PAK T3
ALZHEIMER'S THX - NMDA RECEPTOR ANTAG. AND CHOLINESTERASE INHIB. COMB
NAMZARIC T3
COGNITIVE DISORDER THERAPY - CEREBRAL VASODILATORS
ergoloid T1
2018
51
Drug Name Formulary Tiers Restrictions
CONTRACEPTIVES
CONTRACEPTIVE INJECTABLE - PROGESTIN
medroxyprogesterone T1
DEPO-SUBQ PROVERA 104 T3
CONTRACEPTIVE INTRAUTERINE - COPPER IUD
PARAGARD T 380A T3
CONTRACEPTIVE INTRAUTERINE - PROGESTERONE IUD
KYLEENA T3
LILETTA T3
MIRENA T3
SKYLA T3
CONTRACEPTIVE ORAL - BIPHASIC
DAYSEE T1
KARIVA (28) T1
VIORELE (28) T1
AMETHIA T3
AMETHIA LO T3
AZURETTE (28) T3
CAMRESE T3
CAMRESE LO T3
LOSEASONIQUE T3
MIRCETTE (28) T3
SEASONIQUE T3
CONTRACEPTIVE ORAL - MONOPHASIC
desogestrel-ethinyl estradiol T1
drospirenone-e.estradiol-lm.fa T1
drospirenone-ethinyl estradiol T1
ethynodiol diac-eth estradiol T1
levonorgestrel-ethinyl estrad oral tablet T1
mibelas 24 fe T1
noreth-ethinyl estradiol-iron T1
norethindrone-e.estradiol-iron T1
norgestimate-ethinyl estradiol T1
AMETHYST T1
APRI T1
AVIANE T1
BRIELLYN T1
CYCLAFEM 1/35 (28) T1
ELINEST T1
EMOQUETTE T1
GIANVI (28) T1
GILDAGIA T1
ISIBLOOM T1
JOLESSA T1
JUNEL 1.5/30 (21) T1
JUNEL 1/20 (21) T1
JUNEL FE 1.5/30 (28) T1
2018
52
Drug Name Formulary Tiers Restrictions
JUNEL FE 1/20 (28) T1
KELNOR 1/35 (28) T1
LILLOW T1
LORYNA (28) T1
MELODETTA 24 FE T1
MICROGESTIN FE 1.5/30 (28) T1
MICROGESTIN FE 1/20 (28) T1
MONONESSA (28) T1
NORTREL 0.5/35 (28) T1
NORTREL 1/35 (21) T1
NORTREL 1/35 (28) T1
OCELLA T1
ORSYTHIA T1
PHILITH T1
PIRMELLA T1
QUASENSE T1
RAJANI T1
SPRINTEC (28) T1
SRONYX T1
ZARAH T1
ZOVIA 1/35E (28) T1
ZOVIA 1/50E (28) T1
SAFYRAL T2
TAYTULLA T2
levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month T3
ALTAVERA (28) T3
BALZIVA (28) T3
BREVICON (28) T3
CRYSELLE (28) T3
DELYLA (28) T3
FALMINA (28) T3
GENERESS FE T3
INTROVALE T3
KURVELO T3
LARIN 1.5/30 (21) T3
LARIN 1/20 (21) T3
LARIN FE 1.5/30 (28) T3
LARIN FE 1/20 (28) T3
LESSINA T3
LEVORA-28 T3
LOESTRIN 1.5/30 (21) T3
LOESTRIN 1/20 (21) T3
LOESTRIN FE 1.5/30 (28-DAY) T3
LOESTRIN FE 1/20 (28-DAY) T3
LOW-OGESTREL (28) T3
LUTERA (28) T3
MARLISSA T3
2018
53
Drug Name Formulary Tiers Restrictions
MICROGESTIN 1.5/30 (21) T3
MICROGESTIN 1/20 (21) T3
NECON 0.5/35 (28) T3
NECON 1/50 (28) T3
OGESTREL (28) T3
ORTHO-CYCLEN (28) T3
ORTHO-NOVUM 1/35 (28) T3
OVCON-35 (28) T3
PORTIA T3
PREVIFEM T3
RECLIPSEN (28) T3
SYEDA T3
VESTURA (28) T3
WYMZYA FE T3
YASMIN (28) T3
YAZ (28) T3
ZENCHENT (28) T3
CONTRACEPTIVE ORAL - PROGESTIN
CAMILA T1
HEATHER T1
NORLYDA T1
ERRIN T3
JOLIVETTE T3
NORA-BE T3
ORTHO MICRONOR T3
CONTRACEPTIVE ORAL - QUADRAPHASIC
FAYOSIM T1
RIVELSA T1
NATAZIA T3
QUARTETTE T3
CONTRACEPTIVE ORAL - TRIPHASIC
norgestimate-ethinyl estradiol T1
ALYACEN 7/7/7 (28) T1
ARANELLE (28) T1
CAZIANT (28) T1
CYCLAFEM 7/7/7 (28) T1
DASETTA 7/7/7 (28) T1
LEVONEST (28) T1
MYZILRA T1
NECON 7/7/7 (28) T1
NORTREL 7/7/7 (28) T1
TILIA FE T1
TRI FEMYNOR T1
TRINESSA (28) T1
TRI-PREVIFEM (28) T1
TRI-SPRINTEC (28) T1
CYCLESSA (28) T3
2018
54
Drug Name Formulary Tiers Restrictions
ENPRESSE T3
ESTROSTEP FE-28 T3
LEENA 28 T3
ORTHO TRI-CYCLEN (28) T3
ORTHO TRI-CYCLEN LO (28) T3
ORTHO-NOVUM 7/7/7 (28) T3
TRI-LEGEST FE T3
TRI-NORINYL (28) T3
TRIVORA (28) T3
VELIVET TRIPHASIC REGIMEN (28) T3
CONTRACEPTIVE TRANSDERMAL COMBINATIONS
XULANE T1
CONTRACEPTIVE TRANSDERMAL COMBINATIONS - ESTROGEN AND PROGESTIN COMB.
XULANE T1
CONTRACEPTIVES - INTRAVAGINAL, SYSTEMIC
NUVARING T2
CONTRACEPTIVES - INTRAVAGINAL, SYSTEMIC - ESTROGEN AND PROGESTIN COMB.
NUVARING T2
EMERGENCY CONTRACEPTIVES
MY WAY T1
NEXT CHOICE ONE DOSE T1
ELLA T3
EMERGENCY CONTRACEPTIVES - PROGESTERONE AGONIST/ANTAGONIST TYPE
ELLA T3
EMERGENCY CONTRACEPTIVES - PROGESTIN TYPE
MY WAY T1
NEXT CHOICE ONE DOSE T1
DERMATOLOGICAL
ACNE THERAPY SYSTEMIC - RETINOIDS AND DERIVATIVES
CLARAVIS T3 ST
MYORISAN T3 ST
ZENATANE T3 ST
ACNE THERAPY SYSTEMIC - TETRACYCLINES
minocycline T1
ACNE THERAPY TOPICAL - ANTI-INFECTIVE
clindamycin phosphate T1
erythromycin with ethanol T1
metronidazole T1
AZELEX T2
azelaic acid (bulk) T3
sulfacetamide sodium (acne) T3
ACZONE T3 ST
CLINDAGEL T3 ST
FINACEA T3
NORITATE T3
2018
55
Drug Name Formulary Tiers Restrictions
ACNE THERAPY TOPICAL - ANTI-INFECTIVE COMBINATIONS OTHER
CLINDACIN ETZ T3
CLINDACIN PAC T3
ACNE THERAPY TOPICAL - ANTI-INFECTIVE-KERATOLYTIC COMBINATIONS
erythromycin-benzoyl peroxide T1
sulfacetamide sodium-sulfur T1
sulfacetamide sod-sulfur-urea T1
sulfacetamide-sulfur-cleansr23 T1
sulfact na-sul-avobnz-otn-ocsa T1
clindamycin-benzoyl peroxide topical gel 1.2 %(1 % base) -5 % T3
clindamycin-benzoyl peroxide topical gel 1-5 % T3 ST
clindamycin-benzoyl peroxide topical gel with pump T3 ST
ACANYA T3 ST
AKTIPAK T3 PA
AVAR T3
AVAR LS T3
AVAR-E LS T3
BENZACLIN T3 ST
BENZACLIN PUMP T3 ST
NEUAC T3
NEUAC KIT T3
PLEXION T3
SUMADAN XLT T3
SUMAXIN CP T3
ACNE THERAPY TOPICAL - ANTI-INFECTIVE-RETINOID COMBINATIONS
clindamycin-tretinoin T3
VELTIN T3
ZIANA T3 ST
ACNE THERAPY TOPICAL - KERATOLYTIC
benzoyl peroxide topical cleanser T1
benzoyl peroxide topical foam T1
benzoyl peroxide topical gel 2.5 % T1
potassium hydroxide T1
BP WASH ACNE TREATMENT T1
benzoyl peroxide topical gel 5 % T3
BENZEFOAM T3
BENZEFOAM ULTRA T3
BENZEPRO T3
BENZEPRO (MICROSPHERES) T3
BP FOAM T3
BP WASH T3
BPO T3
INOVA T3
PACNEX HP T3
PACNEX LP T3
2018
56
Drug Name Formulary Tiers Restrictions
RIAX T3
ACNE THERAPY TOPICAL - KERATOLYTIC COMBINATIONS OTHER
INOVA 4-1 T3
INOVA 8-2 T3
ACNE THERAPY TOPICAL - KERATOLYTIC MIXTURES
NUOX T3
ACNE THERAPY TOPICAL - KERATOLYTIC-GLUCOCORTICOID COMBINATIONS
VANOXIDE-HC T3
ACNE THERAPY TOPICAL - RETINOID COMBINATIONS OTHER
adapalene-benzoyl peroxide T1
EPIDUO FORTE T2
EPIDUO T3
ACNE THERAPY TOPICAL - RETINOIDS AND DERIVATIVES
adapalene T1
tretinoin T3
tretinoin microspheres T3
AVITA T3
DIFFERIN T3 ST
FABIOR T3 ST
RETIN-A T3 ST
RETIN-A MICRO T3 ST
RETIN-A MICRO PUMP T3 ST
TRETIN-X T3 ST
TRETIN-X CREAM KIT T3 ST
ANTIPSORIATIC - VITAMIN D ANALOG - GLUCOCORTICOID COMBINATIONS
calcipotriene-betamethasone T3
TACLONEX T3
ANTIPSORIATIC AGENTS - INTERLEUKIN 12 AND IL-23 INHIBITORS,MC ANTIBODY
STELARA T4 ST
ANTIPSORIATIC AGENTS - INTERLEUKIN-23 (IL-23) ANTAGONIST, MC ANTIBODY
TREMFYA T4 PA
ANTIPSORIATIC AGENTS-INTERLEUKIN-17 (IL-17) ANTAGONIST, MC ANTIBODY
COSENTYX T4 ST
COSENTYX (2 SYRINGES) T4 ST
COSENTYX PEN T4 ST
COSENTYX PEN (2 PENS) T4 ST
SILIQ T4 ST
TALTZ AUTOINJECTOR T4 ST
TALTZ AUTOINJECTOR (2 PACK) T4 ST
TALTZ AUTOINJECTOR (3 PACK) T4 ST
TALTZ SYRINGE T4 ST
TALTZ SYRINGE (2 PACK) T4 ST
TALTZ SYRINGE (3 PACK) T4 ST
2018
57
Drug Name Formulary Tiers Restrictions
DERMATITIS OR ECZEMA AGENTS, SYSTEMIC-INTERLEUKIN-4 (IL-4RA) ANTAG.MAB
DUPIXENT T4 PA
DERMATITIS OR ECZEMA AGENTS, TOPICAL - PHOSPHODIESTERASE-4 INHIBITORS
EUCRISA T2 ST
DERMATOLOGICAL - ANTIBACTERIAL AMINOGLYCOSIDES
gentamicin T1
DERMATOLOGICAL - ANTIBACTERIAL AND ANTIFUNGAL AGENTS
ALOQUIN T3
DERMATOLOGICAL - ANTIBACTERIAL OTHER
mupirocin T1
mupirocin calcium T1
silver nitrate T1
NORMLGEL AG T1
CENTANY AT T3
SILVRSTAT T3
DERMATOLOGICAL - ANTIBACTERIAL PLEUROMUTILIN DERIVATIVES
ALTABAX T3
DERMATOLOGICAL - ANTIBACTERIAL SULFONAMIDES
sulfacetamide sodium-sulfur T1
DERMATOLOGICAL - ANTIBACTERIAL,ANTIFUNGAL AGENT WITH GLUCOCORTICOID
ALA-QUIN T3
DERMASORB AF COMPLETE KIT T3
VYTONE T3
DERMATOLOGICAL - ANTIBACTERIAL-GLUCOCORTICOID COMBINATIONS
CORTISPORIN T3
NEO-SYNALAR T3
NEO-SYNALAR KIT T3
DERMATOLOGICAL - ANTIFUNGAL ALLYLAMINES
naftifine T3
NAFTIN T3
DERMATOLOGICAL - ANTIFUNGAL AMPHOTERIC POLYENE MACROLIDES
nystatin T1
DERMATOLOGICAL - ANTIFUNGAL BENZYLAMINES
MENTAX T3
DERMATOLOGICAL - ANTIFUNGAL COMBINATIONS OTHER
EXODERM T1
DERMATOLOGICAL - ANTIFUNGAL HYDROXYPYRIDINONE
ciclopirox T1
ciclopirox-ure-camph-menth-euc T1
CICLODAN KIT T3
DERMATOLOGICAL - ANTIFUNGAL IMIDAZOLE AND RELATED AGENTS
clotrimazole T1
ketoconazole topical cream T1
2018
58
Drug Name Formulary Tiers Restrictions
ketoconazole topical shampoo T1
oxiconazole T1
econazole T3
ketoconazole topical foam T3
ERTACZO T3
EXELDERM T3
EXTINA T3
LUZU T3
OXISTAT T3 PA
VUSION T3
XOLEGEL T3
DERMATOLOGICAL - ANTIFUNGAL MIXTURES
TRIPLE DYE T3
DERMATOLOGICAL - ANTIFUNGAL-GLUCOCORTICOID COMBINATIONS
clotrimazole-betamethasone T1
iodoquinol-hc T1
nystatin-triamcinolone T1
DERMATOLOGICAL - ANTIFUNGALS OTHER
triacetin T1
DERMATOLOGICAL - ANTINEOPLASTIC ALKYLATING AGENTS
VALCHLOR T4 PA
DERMATOLOGICAL - ANTINEOPLASTIC ANTIMETABOLITES
fluorouracil topical cream 0.5 % T1
CARAC T3
TOLAK T3
fluorouracil topical cream 5 % T4
fluorouracil topical solution T4
DERMATOLOGICAL - ANTINEOPLASTIC OR PREMALIG. LESIONS -DITERPENE ESTERS
PICATO T2
DERMATOLOGICAL - ANTINEOPLASTIC RETINOIDS
PANRETIN T4 PA
DERMATOLOGICAL - ANTINEOPLASTIC SELECTIVE RETINOID X RECEPTOR AGONIST
TARGRETIN T4
DERMATOLOGICAL - ANTIPERSPIRANTS
XERAC AC T3
DERMATOLOGICAL - ANTIPSORIATIC AGENTS SYSTEMIC, PHOTOSENSITIZING
OXSORALEN ULTRA T2
DERMATOLOGICAL - ANTIPSORIATIC AGENTS SYSTEMIC, VITAMIN A DERIVATIVES
acitretin oral capsule 17.5 mg T1
acitretin oral capsule 10 mg, 25 mg T3
DERMATOLOGICAL - ANTIPSORIATIC AGENTS TOPICAL
calcipotriene scalp T1
calcitriol T1
tazarotene T1
2018
59
Drug Name Formulary Tiers Restrictions
TAZORAC T2
calcipotriene topical T3
DOVONEX T3
DRITHOCREME HP T3
SORILUX T3
ZITHRANOL T3
DERMATOLOGICAL - ANTIPSORIATICS SYSTEMIC, PHOSPHODIESTERASE 4 INHIB.
OTEZLA T4 ST
OTEZLA STARTER T4 ST
DERMATOLOGICAL - ANTISEBORRHEIC
selenium sulfide T1
sulfacetamide sodium T1
OVACE PLUS SHAMPOO T2
LOUTREX T3
OVACE PLUS T3
OVACE PLUS WASH T3
PROMISEB T3
PROMISEB COMPLETE T3
SELRX T3
TERSI FOAM T3
DERMATOLOGICAL - ANTIVIRAL, HERPES
ZOVIRAX T2
acyclovir T3
DENAVIR T3
DERMATOLOGICAL - BURN PRODUCTS ANTI-INFECTIVE
silver sulfadiazine T1
SULFAMYLON T3
DERMATOLOGICAL - CALCINEURIN INHIBITORS
ELIDEL T2 ST
tacrolimus T3
PROTOPIC T3
DERMATOLOGICAL - DEPIGMENTING AGENTS
hydroquinone T1
hydroquinone microspheres T1
DERMATOLOGICAL - DEPIGMENTING COMBINATIONS
OBAGI NU-DERM SUNFADER T3
OBAGI-C CLARIFYING SERUM T3
OBAGI-C THERAPY NIGHT T3
TRI-LUMA T3
DERMATOLOGICAL - EMOLLIENT COMBINATIONS OTHER
HPR PLUS-MB HYDROGEL T1
MB HYDROGEL T1
MB HYDROGEL (CYCLOMETHICONE) T1
DERMATOLOGICAL - EMOLLIENT MIXTURES
AVO CREAM T1
EMULSION SB T1
HPR T1
2018
60
Drug Name Formulary Tiers Restrictions
HPR PLUS T1
PRUCLAIR T1
PRUMYX T1
PRUTECT T1
SONAFINE T1
ATOPICLAIR T3
ATRAPRO CP T3
BIAFINE EMULSION T3
ELETONE T3
EPICERAM T3
HYLATOPIC T3
HYLATOPICPLUS T3
LOUTREX T3
NEOSALUS T3
PRESERA T3
PROMISEB T3
PROMISEB COMPLETE T3
RADIGEL ACEMANNAN HYDROGEL T3
XCLAIR T3
DERMATOLOGICAL - EMOLLIENTS
ammonium lactate T1
urea T1
GORDONS UREA T3
DERMATOLOGICAL - ENZYMES
SANTYL T3
DERMATOLOGICAL - GLUCOCORTICOID
alclometasone T1
amcinonide T1
betamethasone dipropionate T1
betamethasone valerate topical cream T1
betamethasone valerate topical lotion T1
betamethasone valerate topical ointment T1
betamethasone, augmented T1
desonide T1
diflorasone T1
fluocinolone T1
fluocinolone and shower cap T1
fluocinonide T1
fluticasone T1
halobetasol propionate T1
hydrocortisone T1
hydrocortisone butyrate T1
hydrocortisone valerate T1
hydrocortisone-pramoxine T1
mometasone T1
prednicarbate T1
triamcinolone acetonide topical cream T1
2018
61
Drug Name Formulary Tiers Restrictions
triamcinolone acetonide topical lotion T1
triamcinolone acetonide topical ointment T1
FLUOCINONIDE-E T1
PROCTO-PAK T1
PROCTOZONE-HC T1
SCALACORT T1
TRIDERM T1
CAPEX T2
betamethasone valerate topical foam T3
clobetasol T3
clobetasol-emollient T3
desoximetasone T3
flurandrenolide T3
triamcinolone acetonide topical aerosol T3
ALA-SCALP T3
CLOBEX T3
CLODAN T3
CLODERM T3
CORDRAN T3
CORMAX T3
DESONATE T3
HALOG T3
KENALOG T3
PANDEL T3
PREPARATION H HYDROCORTISONE T3
PROCTOCORT T3
SCALACORT DK T3
TEXACORT T3
TOPICORT T3
TRIANEX T3
VANOS T3
VERDESO T3
DERMATOLOGICAL - GLUCOCORTICOID-EMOLLIENT COMBINATIONS
hydrocortisone-min oil-wht pet T1
DERMASORB TA COMPLETE KIT T3
SYNALAR CREAM KIT T3
SYNALAR OINTMENT KIT T3
ULTRAVATE X T3
DERMATOLOGICAL - GLUCOCORTICOID-LOCAL ANESTHETIC COMBINATIONS
hydrocortisone-pramoxine T1
lidocaine hcl-hydrocortison ac T1
PRAMOSONE E T2
PRAMOSONE TOPICAL LOTION T2
PRAMOSONE TOPICAL OINTMENT T2
EPIFOAM T3
PRAMOSONE TOPICAL CREAM T3
2018
62
Drug Name Formulary Tiers Restrictions
DERMATOLOGICAL - GLUCOCORTICOID-SKIN CLEANSER COMBINATIONS
AQUA GLYCOLIC HC T3
CLODAN KIT T3
DERMASORB HC COMPLETE KIT T3
SYNALAR TS T3
DERMATOLOGICAL - IMMUNOMODULATOR - CATECHINS - GENITAL WART/HPV TX
VEREGEN T3
DERMATOLOGICAL - IMMUNOMODULATOR - IMIDAZOQUINOLINAMINES
imiquimod T1
DERMATOLOGICAL - IMMUNOMODULATOR - INTERFERONS
ALFERON N T4
DERMATOLOGICAL - KERATOLYTIC COMBINATIONS OTHER
URAMAXIN GT T3
DERMATOLOGICAL - KERATOLYTIC-ANTIMITOTIC COMBINATIONS
silver nitrate applicators T1
SALVAX DUO PLUS T3
DERMATOLOGICAL - KERATOLYTIC-ANTIMITOTIC SINGLE AGENTS
podofilox T1
salicylic acid T1
salicylic acid er-ceramides T1
trichloroacetic acid T1
urea topical cream T1
urea topical gel T1
urea topical lotion T1
BP-50% UREA T1
UMECTA T1
CONDYLOX T2
urea topical foam T3
BENSAL HP T3
HYDRO 40 T3
KERAFOAM T3
KERALAC T3
KERALYT SCALP COMPLETE T3
PODOCON T3
TRI-CHLOR T3
URAMAXIN T3
URAMAXIN GT T3
UTOPIC T3
DERMATOLOGICAL - KERATOPLASTIC TAR PRODUCTS
coal tar T1
DERMATOLOGICAL - LIVER DERIVATIVE COMPLEX
NEXAVIR T3
DERMATOLOGICAL - LOCAL ANESTHETIC COMBINATIONS
lidocaine-prilocaine T1
2018
63
Drug Name Formulary Tiers Restrictions
CETACAINE T3
CETACAINE ANESTHETIC T3
LENZAPATCH T3
PUROXCIN T3
DERMATOLOGICAL - LOCAL ANESTHETIC GAS COMBINATIONS
PAIN EASE T3
SPRAY AND STRETCH T3
DERMATOLOGICAL - LOCAL ANESTHETIC GAS SINGLE AGENTS
ethyl chloride T1
DERMATOLOGICAL - MISCELLANEOUS SINGLE AGENTS
PYROGALLIC ACID T3
DERMATOLOGICAL - NSAID SINGLE AGENTS
diclofenac sodium T3
FLECTOR T3 ST
PENNSAID T3 ST
VOLTAREN T3
DERMATOLOGICAL - ORNITHINE DECARBOXYLASE (ODC) INHIBITORS
VANIQA T3
DERMATOLOGICAL - PHOTODYNAMIC THERAPY AGENTS TOPICAL
aminolevulinic acid hcl (bulk) T2
LEVULAN T3
DERMATOLOGICAL - PROTECTANT COMBINATIONS
HYGEL T1
PR CREAM T1
BEAU RX T3
RADIAPLEXRX T3
DERMATOLOGICAL - PROTECTANTS
white petrolatum T3
BIONECT T3
NUVAIL T3
DERMATOLOGICAL - RETINOIDS (VITAMIN A DERIVATIVES) - TOPICAL COSMETIC
tretinoin (emollient) T3
RENOVA T3
DERMATOLOGICAL - ROSACEA THERAPY, SYSTEMIC
ORACEA T3 ST
DERMATOLOGICAL - ROSACEA THERAPY, TOPICAL
metronidazole T1
sulfacetamide sod-sulfur-urea T1
sulfact na-sul-avobnz-otn-ocsa T1
AZELEX T2
FINACEA T3
MIRVASO T3
RHOFADE T3
ROSADAN T3
2018
64
Drug Name Formulary Tiers Restrictions
SOOLANTRA T3
SUMADAN XLT T3
DERMATOLOGICAL - TISSUE/WOUND ADHESIVES - FIBRIN SEALANTS
ARTISS T3
DERMATOLOGICAL - TOPICAL LOCAL ANESTHETIC AMIDES
lidocaine hcl T1
lidocaine-tetracaine T1
lidocaine T3
LIDODERM T3
LIDOPIN T3
LIDORX T3
PLIAGLIS T3
REGENECARE T3
REGENECARE WITH ALOE T3
SYNERA T3
DERMATOLOGICAL - TOPICAL LOCAL ANESTHETIC ESTERS
cocaine T1
ANACAINE T3
PONTOCAINE T3
DERMATOLOGICAL IRRITANTS-COUNTER-IRRITANT COMBINATIONS
MEDROX (WITHOUT METHYL SALICY) T3
DERMATOLOGICAL IRRITANTS-COUNTER-IRRITANT SINGLE AGENTS
methyl salicylate T1
QUTENZA T4
HAIR GROWTH, TOPICAL HYPERTRICHOTIC AGENTS, EYELASHES
LATISSE T3
HUMAN CELLULAR REGENERATIVE TISSUE MATRIX
EPIFIX AMNIOTIC MEMBRANE T3
GRAFIX CORE T3
GRAFIX PRIME T3
NAIL PROTECTIVES
GENADUR T3
GENADUR (WITH LEXINAL) T3
SCABICIDE AND PEDICULICIDE COMBINATIONS
LYCELLE T3
SCABICIDE AND PEDICULICIDE SINGLE AGENTS
lindane T1
permethrin T1
spinosad T1
EURAX T2
ULESFIA T2
malathion T3
SKLICE T3
SKIN REPLACEMENT, LIVE TISSUE DRESSINGS
APLIGRAF T3
2018
65
Drug Name Formulary Tiers Restrictions
DERMAGRAFT T3
WOUND CARE - CLEANSER COMBINATIONS
ATRAPRO DERMAL SPRAY T3
WOUND CARE - DRESSINGS
MEDIHONEY (HONEY) T3
WOUND CARE COMBINATIONS OTHER
RADIGEL ACEMANNAN HYDROGEL T3
DIAGNOSTIC AGENTS
CONTRAST MEDIA - BARIUM
LIQUID E-Z PAQUE T1
ENTERO VU T3
E-Z DISK T3
E-Z-CAT DRY T3
E-Z-HD BARIUM T3
E-Z-PAQUE T3
E-Z-PASTE T3
LIQUID POLIBAR PLUS T3
POLIBAR ACB T3
READI-CAT 2 T3
TAGITOL V T3
VARIBAR HONEY T3
VARIBAR NECTAR T3
VARIBAR PUDDING T3
VARIBAR THIN HONEY T3
VARIBAR THIN LIQUID T3
VOLUMEN T3
CONTRAST MEDIA - IODINATED IONIC
MD-GASTROVIEW T1
CONRAY T3
CONRAY 43 T3
CONRAY-30 T3
CYSTO-CONRAY II T3
CYSTOGRAFIN T3
CYSTOGRAFIN-DILUTE T3
GASTROGRAFIN T3
MD-76 R T3
SINOGRAFIN T3
CONTRAST MEDIA - IODINATED NONIONIC
ISOVUE-200 T3
ISOVUE-250 T3
ISOVUE-300 T3
ISOVUE-370 T3
ISOVUE-M 200 T3
ISOVUE-M 300 T3
OMNIPAQUE 140 T3
OMNIPAQUE 180 T3
OMNIPAQUE 240 T3
2018
66
Drug Name Formulary Tiers Restrictions
OMNIPAQUE 300 T3
OMNIPAQUE 350 T3
OPTIRAY 300 T3
OPTIRAY 320 T3
OPTIRAY 350 T3
ULTRAVIST T3
VISIPAQUE T3
CONTRAST MEDIA - MAGNETIC RESONANCE GADOLINIUM COMPLEXES
DOTAREM T3
EOVIST T3
GADAVIST T3
MAGNEVIST T3
MULTIHANCE T3
MULTIHANCE MULTIPACK T3
OMNISCAN T3
OMNISCAN PREFILL PLUS T3
OPTIMARK T3
PROHANCE T3
PROHANCE MULTIPACK T3
CONTRAST MEDIA - MAGNETIC RESONANCE IRON COMPOUNDS
FERIDEX IV T3
GASTROMARK T3
CONTRAST MEDIA - ULTRASOUND AGENTS
DEFINITY T3
OPTISON T3
DIAGNOSTIC - OTHER
SITZMARKS T3
DIAGNOSTIC BIOLOGICALS
APLISOL T3
TUBERSOL T3
DIAGNOSTIC DRUGS - CARDIOVASCULAR
dipyridamole T1
ADENOSCAN T3
LEXISCAN T3
DIAGNOSTIC DRUGS - GASTROINTESTINAL RADIOLOGICAL ADJUNCT
GLUCAGEN DIAGNOSTIC KIT T2
DIAGNOSTIC DRUGS - IN VIVO OTHER
isosulfan blue T1
KINEVAC T3
DIAGNOSTIC DRUGS - METABOLIC FUNCTION
CHIRHOSTIM T3
METOPIRONE T3
R-GENE 10 T3
DIAGNOSTIC DRUGS - PITUITARY FUNCTION
cosyntropin T1
ACTHREL T3
2018
67
Drug Name Formulary Tiers Restrictions
DIAGNOSTIC DRUGS - PULMONARY
PROVOCHOLINE T3
DIAGNOSTIC DRUGS - RENAL FUNCTION
INDIGO CARMINE T3
DIAGNOSTIC DRUGS - THYROID FUNCTION
THYROGEN T3
DIAGNOSTIC RADIOPHARMACEUTICALS - BONE OR SKELETAL IMAGING
kit prep of tc-99m-sod pyroph T1
kit prep tc-99m-medronate sod T1
DRAXIMAGE MDP-25 T3
DIAGNOSTIC RADIOPHARMACEUTICALS - BRAIN, AMYLOID PLAQUE IMAGING
AMYVID T3
DIAGNOSTIC RADIOPHARMACEUTICALS - CEREBRAL PERFUSION IMAGING
CERETEC T3
INDIUM IN-111 DTPA T3
DIAGNOSTIC RADIOPHARMACEUTICALS - DOPAMINE TRANSPORTER (DAT) IMAGING
DATSCAN T3
DIAGNOSTIC RADIOPHARMACEUTICALS - ENDOCRINE
ADREVIEW T3
OCTREOSCAN T3
DIAGNOSTIC RADIOPHARMACEUTICALS - HEPATOBILIARY IMAGING
kit prep of tc-99m-mebrofenin T1
DIAGNOSTIC RADIOPHARMACEUTICALS - MISC.
kit for tc 99m-sod thiosulfate T1
DIAGNOSTIC RADIOPHARMACEUTICALS - MYOCARDIAL PERFUSION IMAGING
kit for tc 99m-sestamibi no.1 T1
kit prep of tc-99m-sod pyroph T1
thallous chloride tl-201 T1
DIAGNOSTIC RADIOPHARMACEUTICALS - PROSTATIC
PROSTASCINT T3
DIAGNOSTIC RADIOPHARMACEUTICALS - PULMONARY PERFUSION IMAGING
DRAXIMAGE MAA T3
DIAGNOSTIC RADIOPHARMACEUTICALS - RADIOLABELING AUTOLOGOUS LEUKOCYTES
indium in-111 oxyquinoline T1
DIAGNOSTIC RADIOPHARMACEUTICALS - RADIOLABELING REAGENTS
INDICLOR T3
DIAGNOSTIC RADIOPHARMACEUTICALS - RENAL IMAGING
DMSA T3
DRAXIMAGE DTPA T3
DIAGNOSTIC SKIN TESTS
PRE-PEN T3
2018
68
Drug Name Formulary Tiers Restrictions
DRUGS TO TREAT ERECTILE DYSFUNCTION
ERECTILE DYSFUNCTION (ED) DRUGS - PROSTAGLANDINS
CAVERJECT T4
ERECTILE DYSFUNCTION (ED) DRUGS-SEL.CGMP PHOSPHODIESTERASE TYPE5 INHIB
CIALIS ORAL TABLET 2.5 MG, 5 MG T2 PA
CIALIS ORAL TABLET 20 MG T2
EATING DISORDER THERAPY
ANOREXIANTS
diethylpropion T1
phendimetrazine tartrate oral capsule, extended release T1
benzphetamine T3
phendimetrazine tartrate oral tablet T3
REGIMEX T3
APPETITE STIMULANTS - CANNABINOIDS
dronabinol T3 PA
SYNDROS T4 PA
APPETITE STIMULANTS - PROGESTIN HORMONE TYPE
megestrol T1
MEGACE ES T3
ELECTROLYTE BALANCE-NUTRITIONAL PRODUCTS
AMINO ACIDS, SINGLE INGREDIENT, ORAL (NON-INJECTABLE)
ENDARI T3 PA
NUTRESTORE T3
B-COMPLEX VITAMIN COMBINATIONS
FOLBEE PLUS T1
MYNEPHROCAPS T1
RENAL CAPS T1
RENO CAPS T1
TRIPHROCAPS T1
VIRT-VITE PLUS T1
CARDIOTEK-RX (BIOPERINE) T3
DIALYVITE T3
DIALYVITE 3000 T3
DIALYVITE SUPREME D T3
LYSIPLEX PLUS T3
SUPER B/C T3
SUPERVITE T3
B-COMPLEX VITAMINS
B COMPLEX 100 T3
PODIAPN T3
B-COMPLEX VITAMINS AND COMBINATIONS
RENA-VITE RX T1
VOL-CARE RX T1
DIALYVITE T3
NEPHPLEX RX T3
NEPHRO-VITE RX T3
2018
69
Drug Name Formulary Tiers Restrictions
BIOFLAVONOID COMBINATIONS
VASCULERA T3
DEXTROSE AND LACTATED RINGER'S SOLUTIONS
dextrose 5 %-lactated ringers T1
DEXTROSE AND SODIUM CHLORIDE SOLUTIONS
d10 %-0.45 % sodium chloride T1
d2.5 %-0.45 % sodium chloride T1
d5 % and 0.9 % sodium chloride T1
d5 %-0.45 % sodium chloride T1
dextrose 10 % and 0.2 % nacl T1
dextrose 5%-0.2 % sod chloride T1
dextrose 5%-0.3 % sod.chloride T1
DEXTROSE SOLUTIONS
dextrose 10 % in water (d10w) T1
dextrose 20 % in water (d20w) T1
dextrose 25 % in water (d25w) T1
dextrose 30 % in water (d30w) T1
dextrose 40 % in water (d40w) T1
dextrose 5 % in water (d5w) T1
dextrose 50 % in water (d50w) T1
dextrose 70 % in water (d70w) T1
DEXTROSE SOLUTIONS, CONCENTRATED
dextrose 20 % in water (d20w) T1
dextrose 25 % in water (d25w) T1
dextrose 30 % in water (d30w) T1
dextrose 40 % in water (d40w) T1
dextrose 50 % in water (d50w) T1
dextrose 70 % in water (d70w) T1
DIETARY PRODUCT - DIETARY SUPPLEMENTS
VP-ZEL T1
TOZAL T3
DIETARY PRODUCT - SWEETENERS
saccharin T3
DILUENTS - SODIUM CHLORIDE
sodium chloride 0.9 % T1
SWABFLUSH T3
DILUENTS - STERILE WATER FOR INJECTION
water for inject, bacteriostat T1
water for injection, sterile T1
DILUENTS - VACCINE DILUENTS
DILUENT FOR ACTHIB T2
DILUENT FOR HIBERIX T2
DILUENT FOR IMOVAX T2
DILUENT FOR MENHIBRIX T2
DILUENT FOR MENOMUNE T2
DILUENT FOR MENOMUNE (PF) T2
DILUENT FOR RABAVERT T2
2018
70
Drug Name Formulary Tiers Restrictions
DILUENT FOR ROTARIX T2
DILUENT FOR YF-VAX (1 DOSE) T2
DILUENT FOR YF-VAX (5 DOSE) T2
DILUENT-MERCK LIVE VIRUS VACC T2
ELECTROLYTE DEPLETERS - ION EXCHANGE RESIN
sodium polystyrene sulfonate T1
KIONEX (WITH SORBITOL) T1
SPS (WITH SORBITOL) T1
VELTASSA T2
GERIATRIC VITAMINS
REQ49+ T3
IRRIGATION SOLUTIONS
lactated ringers T1
ringer's T1
water for irrigation, sterile T1
PHYSIOLYTE T3
PHYSIOSOL IRRIGATION T3
MINERALS AND ELECTROLYTES - BICARBONATE PRODUCING OR CONTAINING AGENTS
sodium acetate T1
sodium bicarbonate T1
sodium lactate T1
NEUT T3
THAM T3
MINERALS AND ELECTROLYTES - CALCIUM REPLACEMENT
calcium acetate T1
calcium chloride T1
calcium gluconate T1
calcium gluconate in 0.9% nacl T1
calcium gluconate in d5w T1
MINERALS AND ELECTROLYTES - CALCIUM REPLACEMENT COMBINATIONS
CALCIUM-FOLIC ACID-VITAMIN D T1
TL G-FOL OS T1
FOLGARD OS T3
MINERALS AND ELECTROLYTES - ELECTROLYTES AND DEXTROSE
dextrose 5 % in ringer's T1
electrolyte-48 in d5w T1
ELLIOTTS B (PF) T3
IONOSOL-B IN D5W T3
IONOSOL-MB IN D5W T3
ISOLYTE-P IN 5 % DEXTROSE T3
NORMOSOL-M IN 5 % DEXTROSE T3
NORMOSOL-R IN 5 % DEXTROSE T3
PLASMA-LYTE-56 IN 5 % DEXTROSE T3
MINERALS AND ELECTROLYTES - IODINE
LUGOLS T1
2018
71
Drug Name Formulary Tiers Restrictions
STRONG IODINE T1
IODOPEN T3
SSKI T3
MINERALS AND ELECTROLYTES - IRON
sodium ferric gluconat-sucrose T1
FERAHEME T3
ICAR-C PLUS T3
INFED T3
INJECTAFER T3
VENOFER T4
MINERALS AND ELECTROLYTES - IRON COMBINATIONS
CENTRATEX T1
CORVITA 150 T1
FEROCON T1
FERRAPLUS 90 T1
FERREX 150 FORTE T1
FERREX 150 FORTE PLUS T1
FERREX 28 T1
FERROCITE PLUS T1
FOLIVANE-F T1
FOLIVANE-PLUS T1
HEMATINIC PLUS VIT/MINERALS T1
HEMATINIC/FOLIC ACID T1
HEMATOGEN FA T1
HEMATOGEN FORTE T1
HEMETAB T1
IFEREX 150 FORTE T1
MULTIGEN T1
MULTIGEN FOLIC T1
MULTIGEN PLUS T1
POLY-IRON 150 FORTE T1
TARON FORTE T1
TL ICON T1
TL-HEM 150 T1
TRIGELS-F FORTE T1
ACTIVE FE T3
BIFERA RX T3
FERRALET 90 DUAL-IRON DELIVERY T3
FUSION PLUS T3
HEMATOGEN T3
HEMATRON-AF T3
HEMOCYTE-F T3
HEMOCYTE-PLUS T3
INTEGRA F T3
INTEGRA PLUS T3
MAXFE (FOLATE-DOCUSATE) T3
NEPHRON FA T3
2018
72
Drug Name Formulary Tiers Restrictions
OB COMPLETE T3
OB COMPLETE PREMIER T3
PROFERRIN-FORTE T3
SIDEROL T3
MINERALS AND ELECTROLYTES - MAGNESIUM
magnesium chloride T1
magnesium sulfate T1
magnesium sulfate in d5w T1
magnesium sulfate in lr T1
magnesium sulfate in water T1
magnesium glycinate (bulk) T3
MINERALS AND ELECTROLYTES - MANGANESE
manganese chloride T1
MINERALS AND ELECTROLYTES - PARENTERAL ELECTROLYTE COMBINATIONS
HYPERLYTE CR T3
ISOLYTE S PH 7.4 T3
ISOLYTE-S T3
NORMOSOL-R T3
NORMOSOL-R PH 7.4 T3
NUTRILYTE T3
PLASMA-LYTE 148 T3
PLASMA-LYTE A T3
TPN ELECTROLYTES T3
TPN ELECTROLYTES II T3
MINERALS AND ELECTROLYTES - PHOSPHATE
potassium phosphate m-/d-basic T1
sodium phosphate T1
sodium phosphate in 0.9 % nacl T1
GLYCOPHOS T3
PHOSPHA 250 NEUTRAL T3
MINERALS AND ELECTROLYTES - POTASSIUM COMBINATIONS
potassium bicarb and chloride T1
MINERALS AND ELECTROLYTES - POTASSIUM FOR INJECTION
potassium acetate T1
potassium chlorid-d5-0.45%nacl T1
potassium chloride T1
potassium chloride in 0.9%nacl T1
potassium chloride in 5 % dex T1
potassium chloride in lr-d5 T1
potassium chloride-0.45 % nacl T1
potassium chloride-d5-0.2%nacl T1
potassium chloride-d5-0.3%nacl T1
potassium chloride-d5-0.9%nacl T1
MINERALS AND ELECTROLYTES - POTASSIUM, ORAL
potassium bicarb-citric acid T1
2018
73
Drug Name Formulary Tiers Restrictions
potassium chloride T1
EFFER-K T2
KLOR-CON T3
KLOR-CON M15 T3
KLOR-CON/25 T3
MINERALS AND ELECTROLYTES - TRACE MINERAL COMBINATIONS
MULTITRACE-4 T1
MULTITRACE-4 CONCENTRATE T1
MULTITRACE-4 NEONATAL T1
MULTITRACE-5 T1
MULTITRACE-5 CONCENTRATE T1
ADDAMEL N T3
MULTITRACE-4 PEDIATRIC T3
PEDITRACE T3
TRACE ELEMENTS 4/PEDIATRIC T3
MINERALS AND ELECTROLYTES - TRACE MINERALS
chromium chloride T1
selenium T1
COPPER CHLORIDE T1
chromium polynicotinate (bulk) T3
MINERALS AND ELECTROLYTES - ZINC
zinc chloride T1
zinc sulfate T1
MULTIVITAMIN AND MINERAL COMBINATIONS
ADVANCED AM-PM T1
V-C FORTE T1
VIC-FORTE T1
BACMIN T3
CORVITE FREE T3
DIALYVITE 5000 T3
NICOMIDE T3
NUTRICAP T3
OCUVEL T3
PROTECT IRON T3
REQ49+ T3
STROVITE FORTE T3
STROVITE ONE T3
UDAMIN SP T3
VITAL-D RX T3
MULTIVITAMINS
L-METHYL-MC T1
METAFOLBIC T1
PUREVIT DUALFE PLUS T1
SE-TAN PLUS T1
VIT 3 T1
ANIMI-3 WITH VITAMIN D T3
2018
74
Drug Name Formulary Tiers Restrictions
CEREFOLIN T3
DIALYVITE 800 WITH IRON T3
FORTAVIT T3
INFUVITE ADULT T3
M.V.I. ADULT T3
TANDEM PLUS T3
NUTRITIONAL PRODUCT - MEDICAL CONDITION SPECIFIC FORMULATION
ENDARI T3 PA
NUTRESTORE T3
NUTRITIONAL PRODUCT - MSUD SPECIFIC FORMULATION
CAMINO PRO 15 PE MSUD T3
NUTRITIONAL PRODUCT - NUTRITIONAL THERAPY
VITAL HIGH PROTEIN T3
NUTRITIONAL PRODUCT - PHENYLKETONURIA (PKU) SPECIFIC FORMULATION
PHENYLADE GMP T3
PKU EASY MICROTABS T3
PKU PERIFLEX JUNIOR PLUS T3
NUTRITIONAL PRODUCT - TYROSINEMIA SPECIFIC FORMULATION
TYLACTIN RESTORE 10 PE T3
TYLACTIN RTD 15 PE T3
TYR ANAMIX NEXT T3
PARENTERAL NUTRITION - AMINO ACID AND DEXTROSE COMBINATIONS
CLINIMIX 5%/D15W SULFITE FREE T3
CLINIMIX 5%/D25W SULFITE-FREE T3
CLINIMIX 2.75%/D5W SULFIT FREE T3
CLINIMIX 4.25%/D10W SULF FREE T3
CLINIMIX 4.25%/D5W SULFIT FREE T3
CLINIMIX 4.25%-D20W SULF-FREE T3
CLINIMIX 4.25%-D25W SULF-FREE T3
CLINIMIX 5%-D20W(SULFITE-FREE) T3
PARENTERAL NUTRITION - AMINO ACID AND ELECTROLYTES COMBINATION
AMINOSYN 7 % WITH ELECTROLYTES T3
AMINOSYN 8.5 %-ELECTROLYTES T3
AMINOSYN II 8.5 %-ELECTROLYTES T3
PARENTERAL NUTRITION - AMINO ACID SOLUTIONS
cysteine (l-cysteine) T1
CLINISOL SF 15 % T1
AMINO ACIDS 15 % T3
AMINOSYN 10 % T3
AMINOSYN 3.5 % T3
AMINOSYN 7 % T3
AMINOSYN 8.5 % T3
AMINOSYN II 10 % T3
AMINOSYN II 15 % T3
2018
75
Drug Name Formulary Tiers Restrictions
AMINOSYN M 3.5 % T3
AMINOSYN-HBC 7% T3
AMINOSYN-PF 10 % T3
AMINOSYN-PF 7 % (SULFITE-FREE) T3
CLINIMIX E 2.75%/D10W SUL FREE T3
CLINIMIX E 2.75%/D5W SULF FREE T3
CLINIMIX E 4.25%/D10W SUL FREE T3
CLINIMIX E 4.25%/D25W SUL FREE T3
CLINIMIX E 4.25%/D5W SULF FREE T3
CLINIMIX E 5%/D15W SULFIT FREE T3
CLINIMIX E 5%/D20W SULFIT FREE T3
CLINIMIX E 5%/D25W SULFIT FREE T3
FREAMINE HBC 6.9 % T3
FREAMINE III 10 % T3
HEPATAMINE 8% T3
NEPHRAMINE 5.4 % T3
PREMASOL 10 % T3
PREMASOL 6 % T3
PROCALAMINE 3% T3
PROSOL 20 % T3
TRAVASOL 10 % T3
TROPHAMINE 10 % T3
TROPHAMINE 6% T3
PARENTERAL NUTRITION - AMINO ACID, DEXTROSE, E-LYTES AND FAT EMUL COMB
KABIVEN T3
PERIKABIVEN T3
PARENTERAL NUTRITION - INTRAVENOUS FAT EMULSIONS
INTRALIPID T3
LIPOSYN II T3
LIPOSYN III T3
NUTRILIPID T3
PEDIATRIC VITAMINS
MVW COMPLETE FORMUL PEDIATRIC T1
INFUVITE PEDIATRIC T3
M.V.I. PEDIATRIC T3
MVW COMPLETE FORMULATION D3000 T3
PEDIATRIC VITAMINS WITH FLUORIDE AND MINERALS COMBINATIONS
TRI-VIT WITH FLUORIDE AND IRON T3
PEDIATRIC VITAMINS WITH FLUORIDE COMBINATIONS
MULTIVITAMIN WITH FLUORIDE T1
MULTI-VITAMIN WITH FLUORIDE T1
MULTIVITAMINS WITH FLUORIDE T1
TRIPLE VITAMIN WITH FLUORIDE T1
TRI-VITAMIN WITH FLUORIDE T1
VITAMINS A,C,D AND FLUORIDE T1
ESCAVITE T3
2018
76
Drug Name Formulary Tiers Restrictions
ESCAVITE D T3
FLORIVA (FLUORIDE-VITAMIN D3) T3
MVC-FLUORIDE T3
POLY-VI-FLOR T3
POLY-VI-FLOR WITH IRON T3
QUFLORA FE (FERROUS SULFATE) T3
QUFLORA PEDIATRIC DROPS T3
TEXAVITE LQ T3
TRI-VI-FLOR T3
PRENATAL VITAMINS AND MINERALS
C-NATE DHA T1
COMPLETE NATAL DHA T1
COMPLETENATE T1
ELITE OB WITH DHA T1
ELITE-OB 400 T1
EXTRA-VIRT PLUS DHA T1
FOLIVANE-OB T1
HEMENATAL OB T1
HEMENATAL OB + DHA T1
LEVOMEFOLATE DHA T1
MYNATAL ADVANCE T1
MYNATAL ORAL TABLET T1
MYNATAL PLUS T1
MYNATAL-Z T1
MYNATE 90 PLUS T1
OBSTETRIX DHA T1
PNV OB+DHA T1
PNV-DHA T1
PNV-DHA + DOCUSATE T1
PNV-OMEGA T1
PNV-SELECT T1
PR NATAL 400 T1
PR NATAL 400 EC T1
PR NATAL 430 T1
PR NATAL 430 EC T1
PRENA1 TRUE T1
PRENAISSANCE T1
PRENAISSANCE PLUS T1
PRENATAL 19 (WITH DOCUSATE) T1
PRENATAL LOW IRON T1
PRENATAL PLUS T1
PRENATAL PLUS (CALCIUM CARB) T1
PRENATAL-U T1
RELNATE DHA T1
SE-NATAL 19 T1
SE-NATAL 19 (WITH DOCUSATE) T1
TARON-C DHA T1
2018
77
Drug Name Formulary Tiers Restrictions
TARON-PREX PRENATAL-DHA T1
TL-SELECT T1
TRIADVANCE T1
TRINATAL GT T1
TRINATAL RX 1 T1
TRIVEEN-DUO DHA T1
TRIVEEN-ONE T1
TRIVEEN-PRX RNF T1
TRUST NATAL DHA T1
ULTIMATECARE ONE T1
ULTIMATECARE ONE NF T1
VEMAVITE-PRX-2 T1
VENA-BAL DHA T1
VINACAL T1
VINATE GT T1
VINATE II T1
VINATE M T1
VINATE ONE T1
VINATE PN CARE T1
VINATE ULTRA T1
VIRT-PN T1
VIRT-PN DHA T1
VIRT-PN PLUS T1
VIRT-SELECT T1
VOL-NATE T1
VOL-TAB RX T1
VP-CH PLUS T1
VP-CH-PNV T1
VP-HEME ONE T1
VP-PNV-DHA T1
ZATEAN-CH T1
ZATEAN-PN DHA T1
ZATEAN-PN PLUS T1
ATABEX EC T3
BAL-CARE DHA T3
BAL-CARE DHA ESSENTIAL T3
CITRANATAL (DUAL-IRON) T3
CITRANATAL 90 DHA (ALGAL OIL) T3
CITRANATAL ASSURE T3
CITRANATAL B-CALM (FE GLUC) T3
CITRANATAL DHA (ALGAL OIL) T3
CONCEPT DHA T3
CONCEPT OB T3
DUET DHA BALANCED T3
DUET DHA WITH OMEGA-3 T3
FOCALGIN CA T3
MARNATAL-F T3
2018
78
Drug Name Formulary Tiers Restrictions
MYNATAL ORAL CAPSULE T3
NESTABS T3
NESTABS ABC T3
NESTABS DHA T3
OB COMPLETE T3
OB COMPLETE WITH DHA T3
OBSTETRIX EC T3
OBTREX DHA T3
O-CAL FA T3
O-CAL PRENATAL T3
PREFERA-OB PLUS DHA T3
PRENATA T3
PRENATABS FA T3
PRENATABS RX T3
PRENATAL 19 T3
PROVIDA DHA T3
PROVIDA OB T3
PUREFE OB PLUS T3
PUREFE PLUS T3
SELECT-OB (FOLIC ACID) T3
SELECT-OB + DHA T3
TRICARE T3
TRICARE PRENATAL DHA ONE T3
TRINATE T3
VINATE CARE T3
VITAFOL GUMMIES T3
VITAFOL-OB+DHA T3
VIVA DHA T3
PRENATAL VITAMINS WITHOUT IRON
VP-GGR-B6 T1
ZINGIBER T1
RINGER'S AND LACTATED RINGER'S SOLUTIONS
lactated ringers T1
ringer's T1
SODIUM CHLORIDE FLUSHES
sodium chloride 0.9 % T1
SWABFLUSH T3
SODIUM CHLORIDE SOLUTIONS, CONCENTRATED
sodium chloride T1
sodium chloride 3 % T1
sodium chloride 5 % T1
SODIUM CHLORIDE, PARENTERAL
sodium chloride T1
sodium chloride 0.45 % T1
sodium chloride 0.9 % T1
sodium chloride 3 % T1
sodium chloride 5 % T1
2018
79
Drug Name Formulary Tiers Restrictions
SWABFLUSH T3
STERILE WATER FOR INJECTION
water for injection, sterile T1
VITAMINS - A
AQUASOL A T3
VITAMINS - B PREPARATION COMBINATIONS
folic acid-vit b6-vit b12 T1
FABB T1
FOLBIC RF T1
LMTHF-PYRIDOXINE-CYANOCOBALAMN T1
TL GARD RX T1
FOLGARD RX T3
FOLTX T3
NEURIN-SL T3
VITA-RESPA T3
VITAMINS - B-1, THIAMINE AND DERIVATIVES
thiamine hcl (vitamin b1) T1
VITAMINS - B-12 AND FOLIC ACID COMBINATIONS
FOLTRATE T3
VITAMINS - B-12, CYANOCOBALAMIN AND DERIVATIVES
cyanocobalamin (vitamin b-12) T1
hydroxocobalamin T1
PHYSICIANS EZ USE B-12 T1
B-12 COMPLIANCE T3
ELIGEN B12 T3
NASCOBAL T3 ST
NEURIN-SL T3
VITAMINS - B-3, NIACIN AND DERIVATIVES
niacin T1
niacinamide (bulk) T1
VITAMINS - B-6, PYRIDOXINE AND DERIVATIVES
pyridoxine (vitamin b6) T1
VITAMINS - C, ASCORBIC ACID AND DERIVATIVES
ascorbic acid (vitamin c) T1
VITAMINS - D DERIVATIVES
calcitriol T1
ergocalciferol (vitamin d2) T1
calcitriol (bulk) T2
VITAL-D RX T3
VITAMINS - E
vitamin e T1
wheat germ oil T1
NATURAL MIXED TOCOPHEROLS T3
VITAMINS - FOLIC ACID AND DERIVATIVES
folic acid T1
levomefolate calcium T1
METHYLTETRAHYDROFOLIC ACID T2
DEPLIN (ALGAL OIL) T3
2018
80
Drug Name Formulary Tiers Restrictions
L-METHYLFOLATE FORTE T3
VITAMINS - FOLIC ACID COMBINATIONS
folic acid-vit b6-vit b12 T1
FABB T1
TL GARD RX T1
FOLGARD RX T3
PURALOR CI T3
VITA-RESPA T3
VITAMINS - K, PHYTONADIONE AND DERIVATIVES
phytonadione (vit k1) (bulk) T1
phytonadione (vitamin k1) T1
VITAMIN K T1
VITAMIN K1 T1
VITAMINS - PABA
POTABA T3
ENDOCRINE
ABORTIFACIENTS OR CERVICAL RIPENING AGENTS - PROSTAGLANDIN ANALOGS
CERVIDIL T3
HEMABATE T3
PREPIDIL T3
PROSTIN E2 T3
ABORTIFACIENTS- PROGESTERONE RECEPTOR ANTAGONIST
MIFEPREX T3
ADRENOCORTICOTROPHIC HORMONES
ACTHAR H.P. T4 PA
AGENTS TO TREAT HYPOGLYCEMIA (HYPERGLYCEMICS)
glucagon hcl T1
GLUCAGEN HYPOKIT T2
GLUCAGON EMERGENCY KIT (HUMAN) T2
PROGLYCEM T3
ANABOLIC STEROID - SINGLE AGENTS
oxandrolone T3
ANADROL-50 T3
ANDROGEN - SINGLE AGENTS
methyltestosterone T1
testosterone T1
testosterone (bulk) T1
testosterone cypionate T1
testosterone enanthate T1
ANDROGEL T2
ANDRODERM T3 ST
AVEED T3 ST
AXIRON T3 ST
DEPO-TESTOSTERONE T3 ST
FORTESTA T3 ST
NATESTO T3 ST
2018
81
Drug Name Formulary Tiers Restrictions
STRIANT T3 ST
TESTIM T3 ST
VOGELXO T3 ST
ANTIDIURETIC AND VASOPRESSOR HORMONES
desmopressin T1 PA
vasopressin T1
VASOSTRICT T3
STIMATE T4
ANTIHYPERGLYCEMIC - ALPHA-GLUCOSIDASE INHIBITORS
acarbose T1
miglitol T3
ANTIHYPERGLYCEMIC - DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS
alogliptin T1
TRADJENTA T2
JANUVIA T3 ST
NESINA T3 ST
ONGLYZA T3 ST
ANTIHYPERGLYCEMIC - DOPAMINE RECEPTOR AGONISTS
CYCLOSET T3
ANTIHYPERGLYCEMIC - GLUCOCORTICOID (CORTISOL) RECEPTOR BLOCKER (GR-II)
KORLYM T4 PA
ANTIHYPERGLYCEMIC - MEGLITINIDE ANALOG AND BIGUANIDE COMBINATIONS
repaglinide-metformin T1
ANTIHYPERGLYCEMIC - MEGLITINIDE ANALOGS
nateglinide T1
repaglinide T1
ANTIHYPERGLYCEMIC - SGLT-2 INHIBITOR AND BIGUANIDE COMBINATIONS
INVOKAMET T2
INVOKAMET XR T2
SYNJARDY T2
SYNJARDY XR T2
XIGDUO XR T3 ST
ANTIHYPERGLYCEMIC - SGLT-2 INHIBITOR AND DPP-4 INHIBITOR COMBINATIONS
GLYXAMBI T2
ANTIHYPERGLYCEMIC - SODIUM GLUCOSE COTRANSPORTER-2 (SGLT2) INHIBITORS
INVOKANA T2
JARDIANCE T2
FARXIGA T3 ST
ANTIHYPERGLYCEMIC - SULFONYLUREA AND BIGUANIDE COMBINATIONS
glipizide-metformin T1
glyburide-metformin T1
ANTIHYPERGLYCEMIC - SULFONYLUREA DERIVATIVES
chlorpropamide T1
2018
82
Drug Name Formulary Tiers Restrictions
glimepiride T1
glipizide T1
glyburide T1
glyburide micronized T1
tolazamide T1
tolbutamide T1
ANTIHYPERGLYCEMIC - THIAZOLIDINEDIONE AND BIGUANIDE COMBINATIONS
ACTOPLUS MET XR T3
AVANDAMET T4
ANTIHYPERGLYCEMIC - THIAZOLIDINEDIONE AND SULFONYLUREA COMBINATIONS
pioglitazone-glimepiride T1
ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPE
SYMLINPEN 120 T3 PA
SYMLINPEN 60 T3 PA
ANTIHYPERGLYCEMIC, INCRETIN MIMETIC,GLP-1 RECEPTOR AGONIST ANALOG-TYPE
TRULICITY T2 ST
VICTOZA 2-PAK T2 ST
VICTOZA 3-PAK T2 ST
ADLYXIN T3 ST
BYDUREON T3 ST
BYETTA T3 ST
TANZEUM T3 ST
ANTIHYPERGLYCEMIC-DIPEPTIDYL PEPTIDASE-4 INHIBIT AND THIAZOLIDINEDIONE
alogliptin-pioglitazone T1
OSENI T3 ST
ANTIHYPERGLYCEMIC-DIPEPTIDYL PEPTIDASE-4(DPP-4)INHIBITOR AND BIGUANIDE
alogliptin-metformin T1
JENTADUETO T2
JENTADUETO XR T2
JANUMET T3 ST
JANUMET XR T3 ST
KAZANO T3 ST
KOMBIGLYZE XR T3 ST
ANTIHYPERGLYCEMIC-INSULIN, LONG ACTING AND GLP-1 RECEPTOR AGONIST COMB
SOLIQUA 100/33 T2 ST
ANTITHYROID AGENTS, THIONAMIDES - IMIDAZOLE DERIVATIVES
methimazole T1
ANTITHYROID AGENTS, THIONAMIDES - THIOURACIL DERIVATIVES
propylthiouracil T1
BONE FORMATION STIMULATING AGENTS - PARATHYROID HORMONE REL PEPTIDES
TYMLOS T4 PA
2018
83
Drug Name Formulary Tiers Restrictions
BONE FORMATION STIMULATING AGENTS - PARATHYROID HORMONE-TYPE
FORTEO T4 PA
BONE RESORPTION INHIBITORS - BISPHOSPHONATE AND VITAMIN D COMBINATIONS
FOSAMAX PLUS D T2
BONE RESORPTION INHIBITORS - BISPHOSPHONATES
alendronate T1
etidronate disodium T1
ibandronate T1
risedronate oral tablet,delayed release (dr/ec) T1
risedronate oral tablet T3
zoledronic acid-mannitol-water T3
ACTONEL T3
ATELVIA T3
BINOSTO T3
BONIVA T3
pamidronate T4
zoledronic acid T4
zoledronic ac-mannitol-0.9nacl T4 PA
CALCIMIMETIC, PARATHYROID CALCIUM RECEPTOR SENSITIVITY ENHANCER
SENSIPAR T4
CALCITONINS
calcitonin (salmon) T1
MIACALCIN T3
ESTROGEN AND PROGESTIN WITH ANTIMINERALOCORTICOID ACTIVITY,COMBINATION
ANGELIQ T3
ESTROGEN AND SELECTIVE ESTROGEN RECEPTOR MODULATOR (SERM) COMBINATIONS
DUAVEE T2
ESTROGEN-ANDROGEN
estrogens-methyltestosterone T1
ESTROGEN-PROGESTIN
estradiol-norethindrone acet T1
norethindrone ac-eth estradiol T1
AMABELZ T1
JINTELI T1
COMBIPATCH T2
PREMPHASE T2
PREMPRO T2
CLIMARA PRO T3
FEMHRT LOW DOSE T3
PREFEST T3
ESTROGENS
estradiol T1
estradiol valerate T1
estropipate T1
2018
84
Drug Name Formulary Tiers Restrictions
ALORA T2
DIVIGEL T2
EVAMIST T2
MINIVELLE T2
PREMARIN ORAL T2
CLIMARA T3
DEPO-ESTRADIOL T3
ELESTRIN T3
ESTROGEL T3
MENEST T3
MENOSTAR T3
PREMARIN INJECTION T3
VIVELLE-DOT T3
FERTILITY ENHANCER - LUTEAL PHASE SUPPORTING, PROGESTERONE-TYPE
ENDOMETRIN T3
FERTILITY ENHANCER - OVULATION STIMULANT - SYNTHETIC (NON-FSH)
clomiphene citrate T1
FOLLICLE-STIMULATING AND LUTEINIZING HORMONES
MENOPUR T4
FOLLICLE-STIMULATING HORMONE (FSH)
BRAVELLE T4
FOLLISTIM AQ T4 ST
GONAL-F T4
GONAL-F RFF T4
GLUCOCORTICOID SALT COMBINATIONS
betamethasone acet,sod phos T1
GLUCOCORTICOIDS
cortisone T1
dexamethasone T1
dexamethasone in 0.9 % sod chl T1
dexamethasone sodium phos (pf) T1
dexamethasone sodium phosphate T1
hydrocortisone T1
methylprednisolone T1
methylprednisolone acetate T1
methylprednisolone sodium succ T1
prednisolone T1
prednisolone sodium phosphate T1
prednisone T1
DEXAMETHASONE INTENSOL T1
MILLIPRED DP T1
PREDNISONE INTENSOL T1
triamcinolone hexaceton (bulk) T3
ARISTOSPAN INTRA-ARTICULAR T3
ARISTOSPAN INTRALESIONAL T3
DEPO-MEDROL T3
2018
85
Drug Name Formulary Tiers Restrictions
KENALOG T3
MEDROL T3
MILLIPRED T3
ORAPRED ODT T3
SOLU-CORTEF T3
SOLU-CORTEF (PF) T3
SOLU-MEDROL T3
SOLU-MEDROL (PF) T3
VERIPRED 20 T3
ZODEX T3
EMFLAZA T4 PA
GONADOTROPIN INHIBITOR PITUITARY SUPPRESSANTS
danazol T1
GROWTH HORMONE RECEPTOR ANTAGONISTS
SOMAVERT T4 PA
GROWTH HORMONE RELEASING HORMONES (GHRH)
EGRIFTA T4 PA
GROWTH HORMONES
NORDITROPIN FLEXPRO T4 PA
HUMAN CHORIONIC GONADOTROPIN (HCG)
chorionic gonadotropin, human T3
NOVAREL INTRAMUSCULAR RECON SOLN 10,000 UNIT T3
PREGNYL T3
NOVAREL INTRAMUSCULAR RECON SOLN 5,000 UNIT T4
HUMAN INSULINS - FIXED COMBINATIONS
NOVOLIN 70/30 T2
HUMAN INSULINS - INTERMEDIATE ACTING
NOVOLIN N T2
HUMAN INSULINS - SHORT ACTING
NOVOLIN R T2
INSULIN ANALOGS - FIXED COMBINATIONS
NOVOLOG MIX 70-30 T2
NOVOLOG MIX 70-30 FLEXPEN T2
INSULIN ANALOGS - LONG ACTING
LANTUS T2
LANTUS SOLOSTAR T2
LEVEMIR T2
LEVEMIR FLEXTOUCH T2
TOUJEO SOLOSTAR T2
TRESIBA FLEXTOUCH U-100 T2
TRESIBA FLEXTOUCH U-200 T2
INSULIN ANALOGS - RAPID ACTING
NOVOLOG T2
NOVOLOG FLEXPEN T2
NOVOLOG PENFILL T2
INSULIN RESPONSE ENHANCERS - BIGUANIDES
metformin T1
RIOMET T3
2018
86
Drug Name Formulary Tiers Restrictions
INSULIN RESPONSE ENHANCERS - THIAZOLIDINEDIONES (PPAR-GAMMA AGONISTS)
pioglitazone T1
AVANDIA T4
INSULIN-LIKE GROWTH FACTOR-1 (IGF-1)
INCRELEX T4 PA
LEPTIN HORMONE ANALOGS
MYALEPT T4 PA
LHRH (GNRH) AGONIST ANALOG PIT SUPPRES - CENTRAL PRECOCIOUS PUBERTY
LUPRON DEPOT-PED T4
LUPRON DEPOT-PED (3 MONTH) T4
TRIPTODUR T4
LHRH (GNRH) AGONIST ANALOG PITUITARY SUPP. AND PROGESTIN COMB.
LUPANETA PACK (1 MONTH) T4
LUPANETA PACK (3 MONTH) T4
LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS
LUPRON DEPOT T4
LUPRON DEPOT (3 MONTH) T4
SYNAREL T4
LHRH (GNRH) ANTAGONISTS
ganirelix T4
CETROTIDE T4
MENOPAUSAL SYMPTOMS SUPPRESSANT-SELECTIVE ESTROGEN RECEPTOR MODULATORS
OSPHENA T3
MENOPAUSAL SYMPTOMS SUPPRESSANT-SSRI ANTIDEPRESSANT TYPE
paroxetine mesylate T1
BRISDELLE T3 ST
MENOPAUSAL SYMPTOMS SUPRESSANT - HORMONAL AGENTS
INTRAROSA T3
MINERALOCORTICOIDS
fludrocortisone T1
OXYTOCIC - ERGOT ALKALOIDS
methylergonovine T1
OXYTOCIC - OXYTOCIN AND ANALOGS
oxytocin T1
oxytocin in dextrose 5 % in lr T1
PARATHYROID HORMONES
NATPARA T4 PA
PROGESTINS
medroxyprogesterone T1
norethindrone acetate T1
progesterone T1
progesterone micronized T1
hydroxyprogesterone caproate T4 PA
MAKENA T4 PA
2018
87
Drug Name Formulary Tiers Restrictions
PROLACTIN INHIBITOR - ERGOT DERIVATIVE DOPAMINE RECEPTOR AGONISTS
cabergoline T1
RANK LIGAND (RANKL) INHIBITOR, MC ANTIBODY
PROLIA T4 PA
XGEVA T4 PA
SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)
raloxifene T1
EVISTA T3
SOMATOSTATIC AGENTS
octreotide acetate T3
SANDOSTATIN LAR DEPOT T4 PA
SIGNIFOR T4 PA
SIGNIFOR LAR T4 PA
SOMATULINE DEPOT T4 PA
THYROID HORMONE COMBINATIONS - SYNTHETIC T3 AND T4
THYROLAR-1 T3
THYROLAR-1/2 T3
THYROLAR-1/4 T3
THYROLAR-2 T3
THYROLAR-3 T3
THYROID HORMONES - ANIMAL SOURCE (PORCINE)
ARMOUR THYROID T3
NATURE-THROID T3
NP THYROID T3
WESTHROID T3
WP THYROID T3
THYROID HORMONES - SYNTHETIC T3 (TRIIODOTHYRONINE)
liothyronine oral T1
liothyronine intravenous T3
THYROID HORMONES - SYNTHETIC T4 (THYROXINE)
levothyroxine T1
LEVOXYL T2
SYNTHROID T2
TIROSINT T3
ENZYMES
ENZYMES
HYLENEX T3
VITRASE T3
HYQVIA HY COMPONENT T4 PA
GASTROINTESTINAL THERAPY AGENTS
ANTACID - ALUMINUM
aluminum hydroxide gel T1
ANTIDIARRHEAL - ANTIPERISTALTIC AGENTS
opium tincture T1
paregoric T1
2018
88
Drug Name Formulary Tiers Restrictions
ANTIDIARRHEAL - GASTROINTESTINAL CHLORIDE CHANNEL INHIBITORS
MYTESI T3
ANTIDIARRHEAL - TRYPTOPHAN HYDROXYLASE INHIBITOR
XERMELO T4 PA
ANTIDIARRHEAL ANTIPERISTALTIC-ANTICHOLINERGIC COMBINATIONS
diphenoxylate-atropine T1
MOTOFEN T2
ANTIEMETIC - ANTICHOLINERGICS
scopolamine base T1
TRANSDERM-SCOP T3
ANTIEMETIC - ANTIHISTAMINES
dimenhydrinate T1
meclizine T1
ANTIEMETIC - CANNABINOIDS
dronabinol T3 PA
CESAMET T3
SYNDROS T4 PA
ANTIEMETIC - DOPAMINE (D2)/5-HT3 ANTAGONISTS
trimethobenzamide T3
ANTIEMETIC - PHENOTHIAZINES
prochlorperazine T1
prochlorperazine maleate T1
promethazine T1
prochlorperazine edisylate T3
PROMETHEGAN T3
ANTIEMETIC - SELECTIVE SEROTONIN 5-HT3 ANTAGONISTS
granisetron (pf) T1
granisetron hcl T1
ondansetron T1
ondansetron hcl T1
ondansetron hcl (pf) T1
ondansetron in 0.9 % sod chlor T1
ALOXI T3
ANZEMET T3
SANCUSO T3
SUSTOL T3
ZUPLENZ T3
ANTIEMETIC - SUBSTANCE P-NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS
aprepitant T1
EMEND T2
EMEND (FOSAPREPITANT) T2
VARUBI T3
ANTIEMETIC - SUBSTANCE P-NEUROKININ 1 AND 5-HT3 RECEPT ANTAGONIST COMB
AKYNZEO T3
2018
89
Drug Name Formulary Tiers Restrictions
BILE ACIDS
CHOLBAM ORAL CAPSULE 250 MG T3 PA
CHOLBAM ORAL CAPSULE 50 MG T4 PA
CHRONIC IIDOPATHIC CONST. AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS
LINZESS T2
TRULANCE T3
COLONIC ACIDIFIER (AMMONIA INHIBITOR)
lactulose T1
DIGESTIVE ENZYME MIXTURES
CREON T2
PANCREAZE T2
ZENPEP T2
PERTZYE T3
VIOKACE T3
DIGESTIVE ENZYMES
SUCRAID T4 PA
GALLSTONE SOLUBILIZING (LITHOLYSIS) AGENTS
ursodiol oral capsule T1
ursodiol oral tablet T3
CHENODAL T4 ST
GASTRIC ACID SECRETION REDUCERS - HISTAMINE H2-RECEPTOR ANTAGONISTS
cimetidine T1
cimetidine hcl T1
famotidine T1
famotidine (pf) T1
famotidine (pf)-nacl (iso-os) T1
nizatidine T1
ranitidine hcl T1
GASTRIC ACID SECRETION REDUCING AGENTS - PROTON PUMP INHIBITORS (PPIS)
pantoprazole T1
rabeprazole T1
NEXIUM PACKET T2
PREVACID SOLUTAB T2
esomeprazole magnesium T3
esomeprazole sodium T3
ACIPHEX T3
ACIPHEX SPRINKLE T3
DEXILANT T3
NEXIUM IV T3
PRILOSEC T3
PROTONIX T3
GASTRIC MUCOSA - CYTOPROTECTIVE PROSTAGLANDIN ANALOGS
misoprostol T1
2018
90
Drug Name Formulary Tiers Restrictions
GASTROINTESTINAL PROKINETIC AGENTS - D2 ANTAGONIST/5-HT4 AGONISTS
metoclopramide hcl injection T1
metoclopramide hcl oral solution T1
metoclopramide hcl oral tablet T1
metoclopramide hcl oral tablet,disintegrating 5 mg T1
metoclopramide hcl oral tablet,disintegrating 10 mg T3
GI ANTISPASMODIC - BELLADONNA ALKALOIDS
atropine T1
atropine (bulk) T1
belladonna tincture (bulk) T1
hyoscyamine sulfate T1
scopolamine hbr T1
methscopolamine T3
LEVSIN T3
SYMAX DUOTAB T3
GI ANTISPASMODIC - QUATERNARY AMMONIUM COMPOUNDS
glycopyrrolate intravenous T1
glycopyrrolate oral T1
propantheline T1
glycopyrrolate injection T3
GI ANTISPASMODIC - SYNTHETIC TERTIARY AMINES
dicyclomine T1
BENTYL T3
GI ANTISPASMODIC AND BENZODIAZEPINE COMBINATIONS
chlordiazepoxide-clidinium T1
GI ANTISPASMODIC COMBINATIONS OTHER
belladonna alkaloids-opium T1
chlordiazepoxide-clidinium T1
BELLADONNA-OPIUM T1
phenobarb-hyoscy-atropine-scop T3
DONNATAL T3
IBS AGENT - GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATOR AGENTS
AMITIZA T2
IBS AGENT - GUANYLATE CYCLASE-C (GC-C) AGONISTS
LINZESS T2
IBS AGENT - MIXED OPIOID RECEPTOR AGONIST AND ANTAGONIST
VIBERZI T2 PA
IBS AGENT - SELECTIVE 5-HT3 RECEPTOR ANTAGONISTS
LOTRONEX T3
INFLAMMATORY BOWEL AGENT - INTERLEUKIN-12 AND IL-23 INHIBITORS, MC AB
STELARA T4 ST
INFLAMMATORY BOWEL AGENT - AMINOSALICYLATES AND RELATED AGENTS
balsalazide T1
mesalamine oral T1
2018
91
Drug Name Formulary Tiers Restrictions
sulfasalazine T1
APRISO T2
CANASA T2
DELZICOL T2
LIALDA T2
PENTASA T2
mesalamine rectal T3
mesalamine with cleansing wipe T3
DIPENTUM T3
GIAZO T3
INFLAMMATORY BOWEL AGENT - GLUCOCORTICOIDS
hydrocortisone T1
CORTIFOAM T2
budesonide T3
UCERIS T3
INFLAMMATORY BOWEL AGENT - INTEGRIN RECEPTOR ANTAGONIST, MC ANTIBODY
ENTYVIO T4 ST
INFLAMMATORY BOWEL AGENT - TUMOR NECROSIS FACTOR ALPHA BLOCKERS
CIMZIA T4 ST
CIMZIA POWDER FOR RECONST T4 ST
CIMZIA STARTER KIT T4 ST
HUMIRA T4
HUMIRA PEDIATRIC CROHN'S START T4
REMICADE T4 ST
RENFLEXIS T4 PA
IRRITABLE BOWEL SYNDROME (IBS) AGENTS
alosetron T1 PA
AMITIZA T2
LINZESS T2
VIBERZI T2 PA
LOTRONEX T3
KERATINOCYTE GROWTH FACTOR (KGF)
KEPIVANCE T4 PA
LAXATIVE - SALINE AND OSMOTIC
lactulose T1
polyethylene glycol 3350 T1
sorbitol T1
KRISTALOSE T2
LAXATIVE - SALINE/OSMOTIC MIXTURES
peg 3350-electrolytes T1
peg-electrolyte soln T1
GOLYTELY ORAL POWDER IN PACKET T2
GOLYTELY ORAL RECON SOLN T3
MOVIPREP T3
OSMOPREP T3
SUPREP BOWEL PREP KIT T3
2018
92
Drug Name Formulary Tiers Restrictions
LAXATIVE - STIMULANT AND SALINE/OSMOTIC COMBINATIONS
PREPOPIK T3
PEPTIC ULCER - GASTRIC LUMEN ADHERENT CYTOPROTECTIVES
sucralfate T1
CARAFATE T2
PEPTIC ULCER - TREATMENT OF H. PYLORI: ANTIBIOTIC-BISMUTH COMBINATIONS
PYLERA T2
PEPTIC ULCER-TREATMENT H. PYLORI-PROTON PUMP INHIBITOR AND ANTIBIOTICS
amoxicil-clarithromy-lansopraz T3
OMECLAMOX-PAK T3
PREVPAC T3
SHORT BOWEL SYNDROME (SBS) - GLUCAGON-LIKE PEPTIDE-2 (GLP-2) ANALOG
GATTEX 30-VIAL T3 PA
GATTEX ONE-VIAL T3 PA
SHORT BOWEL SYNDROME (SBS) AGENTS
octreotide acetate T3
ENDARI T3 PA
NUTRESTORE T3
SANDOSTATIN LAR DEPOT T4
GENITOURINARY THERAPY
BPH AGENT- 5-ALPHA REDUCTASE INHIB AND ALPHA-1 ADRENOCEPTOR ANTAG COMB
dutasteride-tamsulosin T3
JALYN T3
CYSTINOSIS THERAPY (CYSTINE DEPLETING AGENTS)
CYSTAGON T4
PROCYSBI T4 PA
G.U. IRRIGANTS
acetic acid T1
glycine urologic solution T1
sorbitol T1
sorbitol-mannitol T1
RESECTISOL T3
G.U. IRRIGANTS - ANTI-INFECTIVE
neomycin-polymyxin b gu T1
INTERSTITIAL CYSTITIS AGENTS
ELMIRON T2
RIMSO-50 T3
KIDNEY STONE AGENTS
THIOLA T4 PA
OVERACTIVE BLADDER AGENTS - BETA -3 ADRENERGIC RECEPTOR AGONIST
MYRBETRIQ T2
PHOSPHATE BINDERS
calcium acetate T1
sevelamer carbonate T1
2018
93
Drug Name Formulary Tiers Restrictions
FOSRENOL ORAL POWDER IN PACKET T2
RENAGEL T2
RENVELA T2
AURYXIA T3
FOSRENOL ORAL TABLET,CHEWABLE T3
MAGNEBIND 400 T3
PHOSLYRA T3
PHOSPHATE BINDERS - IRON-BASED
AURYXIA T3
PROSTATIC HYPERTROPHY AGENT - ALPHA-1-ADRENOCEPTOR ANTAGONISTS
alfuzosin T1
tamsulosin T1
RAPAFLO T3
PROSTATIC HYPERTROPHY AGENT - TYPE II 5-ALPHA REDUCTASE INHIBITORS
finasteride T1
PROSTATIC HYPERTROPHY AGENT-SEL.CGMP PHOSPHODIESTERASE TYPE5 INHIBITOR
CIALIS T2 PA
PROSTATIC HYPERTROPHY AGENT-TYPE I AND II 5-ALPHA REDUCTASE INHIBITORS
dutasteride T3
AVODART T3
URINARY ACIDIFIER - OTHERS
ammonium chloride T1
URINARY ACIDIFIER - PHOSPHATES
K-PHOS NO 2 T3
K-PHOS ORIGINAL T3
PHOSPHA 250 NEUTRAL T3
URINARY ALKALINIZER - CITRATES
potassium citrate T1
sodium citrate-citric acid T1
CYTRA-3 T1
SHOHL'S MODIFIED T1
TRICITRATES T1
UROCIT-K 15 T2
CYTRA K CRYSTALS T3
CYTRA-K T3
ORACIT T3
UROCIT-K 10 T3
UROCIT-K 5 T3
URINARY ANALGESICS
phenazopyridine T1
URINARY ANTIBACTERIAL - METHENAMINE AND SALTS
methenamine hippurate T1
methenamine mandelate T1
UROQID-ACID NO.2 T3
2018
94
Drug Name Formulary Tiers Restrictions
URINARY ANTIBACTERIAL - NITROFURAN DERIVATIVES
MACRODANTIN T1
nitrofurantoin T3
nitrofurantoin macrocrystal T3
nitrofurantoin monohyd/m-cryst T3
URINARY ANTIBACTERIAL - QUINOLONES
ciprofloxacin (mixture) T1
URINARY ANTIBACTERIALS OTHER
MONUROL T3
URINARY ANTI-INFECTIVE METHENAMINE-ANTISPAS-ANALG COMBINATIONS
HYOPHEN T1
PHOSPHASAL T1
UR N-C T1
URIN DS T1
URO-MP T1
USTELL T1
URELLE T3
URETRON D-S T3
URIBEL T3
URINARY ANTI-INFECTIVE METHENAMINE-ANTISPASMODIC COMBINATIONS
URYL T1
UROGESIC-BLUE T3
URINARY ANTISPASMODIC - ANTICHOL., M(3) MUSCARINIC SELECTIVE (BLADDER)
VESICARE T2
darifenacin T3
URINARY ANTISPASMODIC - SMOOTH MUSCLE RELAXANTS
flavoxate T1
oxybutynin chloride T1
tolterodine T1
trospium T1
DETROL LA ORAL CAPSULE,EXTENDED RELEASE 24HR 4 MG
T2
DETROL LA ORAL CAPSULE,EXTENDED RELEASE 24HR 2 MG
T3
GELNIQUE T3 ST
TOVIAZ T3 ST
URINARY RETENTION THERAPY - PARASYMPATHOMIMETIC AGENTS
bethanechol chloride T1
GOUT AND HYPERURICEMIA THERAPY
GOUT ACUTE THERAPY - ANTIMITOTICS
colchicine T1
COLCRYS T3
MITIGARE T3
GOUT AND HYPERURICEMIA - ANTIMITOTIC-URICOSURIC COMBINATIONS
probenecid-colchicine T1
2018
95
Drug Name Formulary Tiers Restrictions
HYPERURICEMIA THERAPY - URATE-OXIDASE ENZYME-TYPE
ELITEK T4
KRYSTEXXA T4
HYPERURICEMIA THERAPY - URIC ACID TRANSPORTER 1 (URAT1) INHIBITORS
ZURAMPIC T3 ST
HYPERURICEMIA THERAPY - URICOSURICS
probenecid T1
HYPERURICEMIA THERAPY - XANTHINE OXIDASE INHIBITORS
allopurinol T1
ULORIC T2 ST
allopurinol sodium T3
HEMATOLOGICAL AGENTS
ANTICOAGULANTS - CITRATE-BASED
anticoag citrate phos dextrose T1
ACD T3
ACD-A T3
TRICITRASOL T3
ANTICOAGULANTS - COUMARIN
warfarin T1
ANTIPORPHYRIA FACTORS
PANHEMATIN T4 PA
C1 ESTERASE INHIBITOR AGENTS
BERINERT T4 PA
CINRYZE T4 PA
HAEGARDA T4 PA
RUCONEST T4 PA
CXCR4 CHEMOKINE RECEPTOR ANTAGONISTS
MOZOBIL T4
DIRECT FACTOR XA INHIBITORS
ELIQUIS T2
XARELTO T2
BEVYXXA T3 PA
SAVAYSA T3
ERYTHROPOIETINS
ARANESP (IN POLYSORBATE) T4
EPOGEN T4
MIRCERA T4
PROCRIT T4
FACTOR IX COMPLEX (PROTHROMBIN COMPLEX CONCENTRATE) PREPARATIONS
KCENTRA T4
GRANULOCYTE COLONY-STIMULATING FACTOR (G-CSF)
GRANIX T4
NEULASTA T4
NEUPOGEN T4
ZARXIO T4 PA
2018
96
Drug Name Formulary Tiers Restrictions
GRANULOCYTE-MACROPHAGE COLONY-STIMULATING FACTOR (GM-CSF)
LEUKINE T4
HEMATORHEOLOGIC AGENTS
pentoxifylline T3
HEMOSTATIC SYSTEMIC - ANTIFIBRINOLYTIC AGENTS
aminocaproic acid T1
tranexamic acid intravenous T1
tranexamic acid oral T3
RIASTAP T4
HEMOSTATIC TOPICAL AGENTS
AVITENE FLOUR T1
SYRINGE AVITENE T1
ULTRAFOAM T1
ASTRINGYN T3
AVITENE T3
ENDO AVITENE T3
GELFILM T3
GELFOAM T3
GELFOAM COMPRESSED SIZE 100 T3
GELFOAM SPONGE SIZE 100 T3
GELFOAM SPONGE SIZE 12-7MM T3
GELFOAM SPONGE SIZE 200 T3
GELFOAM SPONGE SIZE 50 T3
MONSEL'S T3
RECOTHROM T3
RECOTHROM SPRAY KIT T3
THROMBI-GEL T3
THROMBIN-JMI T3
THROMBI-PAD T3
HEMOSTATIC TOPICAL COMBINATIONS
TACHOSIL T3
TISSEEL VHSD T4
HEPARIN FLUSH FORMULATIONS
heparin (porcine) in 0.9% nacl T1
heparin (porcine) in nacl (pf) T1
heparin flush(porcine)-0.9nacl T1
heparin lock flush (porcine) T1
heparin, porcine (pf) T1
HEP FLUSH-10 (PF) T1
HEPARINS
heparin (porcine) T1
heparin (porcine) (bulk) T1
heparin (porcine) in 0.9% nacl T1
heparin (porcine) in 5 % dex T1
heparin (porcine) in nacl (pf) T1
heparin flush(porcine)-0.9nacl T1
heparin lock flush (porcine) T1
2018
97
Drug Name Formulary Tiers Restrictions
heparin(porcine) in 0.45% nacl T1
heparin, porcine (pf) T1
HEP FLUSH-10 (PF) T1
HUMAN ALBUMIN
albumin, human 25 % T1
albumin, human 5 % T1
PLASBUMIN 5 % T3
HUMAN MONOCLONAL ANTIBODY COMPLEMENT (C5) INHIBITORS
SOLIRIS T4
INDIRECT FACTOR XA INHIBITORS
fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml
T1
fondaparinux subcutaneous syringe 2.5 mg/0.5 ml T3
LOW MOLECULAR WEIGHT HEPARINS
enoxaparin subcutaneous syringe 150 mg/ml T1
FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML
T1
enoxaparin subcutaneous solution T3
enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml
T3
FRAGMIN SUBCUTANEOUS SYRINGE 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML
T4
PLASMA EXPANDERS
hetastarch 6 % in 0.9 % nacl T1
HEXTEND T3
LMD 10 % IN 0.9 % SODIUM CHLOR T3
LMD 10 % IN 5 % DEXTROSE T3
VOLUVEN 6 % T3
PLASMA FRACTIONS
OCTAPLAS (BLOOD GROUP A) T4
OCTAPLAS (BLOOD GROUP AB) T4
OCTAPLAS (BLOOD GROUP B) T4
OCTAPLAS (BLOOD GROUP O) T4
PLASMANATE T4
PLASMA PROTEINS WHICH FACILITATE ANTICOAGULATION
ATRYN T4
THROMBATE III T4
PLATELET AGGREGATION INHIB - CYCLOPENTYL-TRIAZOLO-PYRIMIDINES (CPTPS)
BRILINTA T2
PLATELET AGGREGATION INHIBITOR COMBINATIONS
aspirin-dipyridamole T1
PLATELET AGGREGATION INHIBITORS - GLYCOPROTEIN IIB/IIIA RECEPTOR INHIB
AGGRASTAT IN SODIUM CHLORIDE T3
INTEGRILIN T3
2018
98
Drug Name Formulary Tiers Restrictions
PLATELET AGGREGATION INHIBITORS - MONOCLONAL AGENTS
REOPRO T4
PLATELET AGGREGATION INHIBITORS - PHOSPHODIESTERASE III INHIBITORS
cilostazol T1
PLATELET AGGREGATION INHIBITORS - QUINAZOLINE AGENTS
anagrelide T1
PLATELET AGGREGATION INHIBITORS - THIENOPYRIDINE AGENTS
clopidogrel T1
prasugrel T1
ticlopidine T1
EFFIENT T2
PLATELET AGGREGATION INHIB-PDESTERASE AND ADENOSINE DEAMINASE INHIBITR
dipyridamole T1
PLATELET AGGREGATION INHIB-PROTEASE-ACTIV.RECEPTOR-1(PAR-1) ANTAGONIST
ZONTIVITY T3 ST
PROTEIN C PREPARATIONS
CEPROTIN (BLUE BAR) T3
CEPROTIN (GREEN BAR) T3
SICKLE CELL ANEMIA AGENTS
DROXIA T2
ENDARI T3 PA
NUTRESTORE T3
THROMBIN INHIBITOR - SELECTIVE DIRECT AND REVERSIBLE
argatroban T1
argatroban in 0.9 % sod chlor intravenous solution T1
argatroban in nacl (iso-os) T1
PRADAXA T3
argatroban in 0.9 % sod chlor intravenous parenteral solution T4
THROMBIN INHIBITOR - SELECTIVE DIRECT AND REVERSIBLE - HIRUDIN TYPE
bivalirudin T1
ANGIOMAX T3
IPRIVASK T3
THROMBOLYTIC - TISSUE PLASMINOGEN ACTIVATORS
ACTIVASE T3
CATHFLO ACTIVASE T4
TNKASE T4
THROMBOPOIETIN RECEPTOR AGONISTS
NPLATE T4
PROMACTA T4 PA
HEPATOBILIARY SYSTEM TREATMENT AGENTS
FARNESOID X RECEPTOR (FXR) AGONIST, BILE ACID ANALOG
OCALIVA T4 PA
2018
99
Drug Name Formulary Tiers Restrictions
IMMUNOSUPPRESSIVE AGENTS
IMMUNOSUPPRESSIVE - CALCINEURIN INHIBITORS
cyclosporine T1
cyclosporine (bulk) T1
cyclosporine modified T1
tacrolimus T1
ASTAGRAF XL T3
ENVARSUS XR T3
PROGRAF T3
IMMUNOSUPPRESSIVE - INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS
mycophenolate mofetil T1
mycophenolate sodium T3
CELLCEPT T3
CELLCEPT INTRAVENOUS T3
MYFORTIC T3
IMMUNOSUPPRESSIVE - MAMMALIAN TARGET OF RAPAMYCIN (MTOR) INHIBITORS
RAPAMUNE ORAL TABLET 0.5 MG T2
sirolimus oral tablet 0.5 mg, 1 mg T3
ZORTRESS T3 PA
sirolimus oral tablet 2 mg T4
RAPAMUNE ORAL SOLUTION T4
RAPAMUNE ORAL TABLET 1 MG, 2 MG T4
IMMUNOSUPPRESSIVE - MONOCLONAL ANTIBODIES
SIMULECT T4
IMMUNOSUPPRESSIVE - PURINE ANALOGS
azathioprine T1
AZASAN T4
IMMUNOSUPPRESSIVE - SELECTIVE T-CELL COSTIMULATION BLOCKER
NULOJIX T4
LOCOMOTOR SYSTEM
AGENTS TO TREAT PERIODIC PARALYSIS - CARBONIC ANHYDRASE INHIBITORS
KEVEYIS T4 PA
ALS AGENT - BENZATHIAZOLES
riluzole T4
ANTIMYASTHENIC AGENT - REVERSIBLE CHOLINESTERASE INHIBITORS
neostigmine methylsulfate intravenous syringe T1
pyridostigmine bromide oral tablet T1
MESTINON T2
pyridostigmine bromide oral tablet extended release T3
MESTINON TIMESPAN T3
REGONOL T3
neostigmine methylsulfate intravenous solution T4
ANTIMYASTHENIC AGENTS OTHER
guanidine T1
2018
100
Drug Name Formulary Tiers Restrictions
DUCHENNE MUSCULAR DYSTROPHY - EXON SKIPPING ANTISENSE OLIGONUCLEOTIDE
EXONDYS 51 T4 PA
MUSCULOSKELETAL THERAPY AGENT - JOINT TISSUE REPLACEMENT
CARTICEL T3
MUSCULOSKELETAL THERAPY AGENT - VISCOSUPPLEMENTS
EUFLEXXA T4
SYNVISC T4
SYNVISC-ONE T4
MUSCULOSKELETAL TX AGENT-JOINT CONTRACTURE THERAPY, COLLAGENASE ENZYME
XIAFLEX T4 PA
NEUROMUSCULAR BLOCKER - DEPOLARIZING AGENTS
succinylcholine chloride T1
QUELICIN T3
NEUROMUSCULAR BLOCKER - NEUROTOXINS
BOTOX T4 PA
DYSPORT T4 PA
MYOBLOC T4 PA
XEOMIN T4 PA
NEUROMUSCULAR BLOCKER - NONDEPOLARIZING AGENTS
atracurium T1
cisatracurium T1
pancuronium T1
rocuronium T1
vecuronium bromide T1
SKELETAL MUSCLE RELAXANT - ANALGESIC SALICYLATE COMBINATIONS
carisoprodol-aspirin T1
SKELETAL MUSCLE RELAXANT - CENTRAL MUSCLE RELAXANTS
baclofen T1
chlorzoxazone T1
cyclobenzaprine T1
metaxalone T1
methocarbamol T1
orphenadrine citrate T1
tizanidine T1
carisoprodol T3
GABLOFEN T3
LIORESAL T3
LORZONE T3
ROBAXIN T3
SKELETAL MUSCLE RELAXANT - DIRECT MUSCLE RELAXANTS
dantrolene T1
REVONTO T1
DANTRIUM T3
2018
101
Drug Name Formulary Tiers Restrictions
RYANODEX T3
SKELETAL MUSCLE RELAXANT - NARCOTIC ANALGESIC COMBINATIONS
carisoprodol-asa-codeine T1
SKELETAL MUSCLE RELAXANT AND TOPICAL IRRITANT COUNTER-IRRITANT COMB.
COMFORT PAC-CYCLOBENZAPRINE T3
COMFORT PAC-TIZANIDINE T3
SKELETAL MUSCLE RELAXANT, SALICYLATE, AND NARCOTIC ANALGESIC COMB.
carisoprodol-asa-codeine T1
MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT (DME)
MEDICAL SUPPLIES AND DME - BLOOD GLUCOSE TESTS
FREESTYLE INSULINX T2
FREESTYLE INSULINX TEST STRIPS T2
FREESTYLE LITE STRIPS T2
FREESTYLE TEST T2
PRECISION XTRA TEST T2
MEDICAL SUPPLIES AND DME - GLUCOSE MONITORING TEST SUPPLIES
blood glucose contrl hi,normal T1
lancets T1
lancing device T1
lancing device with lancets T1
MEDICAL SUPPLIES AND DME - INSULIN NEEDLES-SYRINGES AND ADMIN SUPPLIES
insulin syr/ndl u100 half mark T1
insulin syringe needleless T1
insulin syringe-needle u-100 T1
insulin syringes (disposable) T1
pen needle, diabetic T1
BD ULTRA-FINE MICRO PEN NEEDLE T2
MEDICAL SUPPLIES AND DME - NEEDLES AND SYRINGES
huber safety needles (disp.) T1
needle (disp) 16 g T1
needle (disp) 18 g T1
needle (disp) 19 g T1
needle (disp) 23 gauge T1
needles, huber disposable T1
safety needles T1
syringe (disposable) T1
syringe (reusable) T1
syringe with needle T1
syringe with needle, safety T1
tuberculin-allergy syringes T1
MEDICAL SUPPLIES AND DME - TISSUE BULKING IMPLANTS
SCULPTRA T3
SOLESTA T4
2018
102
Drug Name Formulary Tiers Restrictions
MEDICAL SUPPLY, FDB SUPERSET
MEDICAL SUPPLY, FDB SUPERSET
blood glucose contrl hi,normal T1
huber safety needles (disp.) T1
insulin syr/ndl u100 half mark T1
insulin syringe needleless T1
insulin syringe-needle u-100 T1
insulin syringes (disposable) T1
lancets T1
lancing device T1
lancing device with lancets T1
needle (disp) 16 g T1
needle (disp) 18 g T1
needle (disp) 19 g T1
needle (disp) 23 gauge T1
needles, huber disposable T1
pen needle, diabetic T1
safety needles T1
syringe (disposable) T1
syringe (reusable) T1
syringe with needle T1
syringe with needle, safety T1
tuberculin-allergy syringes T1
BD ULTRA-FINE MICRO PEN NEEDLE T2
PRECISION XTRA TEST T2
METABOLIC DISEASE ENZYME REPLACEMENT AGENTS
METABOLIC DISEASE ENZYME REPLACEMENT, FABRY'S DISEASE
FABRAZYME T4 PA
METABOLIC DISEASE ENZYME REPLACEMENT, GAUCHER'S DISEASE
CEREZYME T4
ELELYSO T4
VPRIV T4
METABOLIC DISEASE ENZYME REPLACEMENT, HYPOPHOSPHATASIA
STRENSIQ T4 PA
METABOLIC DISEASE ENZYME REPLACEMENT, MUCOPOLYSACCHARIDOSIS
ALDURAZYME T4
ELAPRASE T4
NAGLAZYME T4
VIMIZIM T4
METABOLIC DISEASE ENZYME REPLACEMENT, POMPE DISEASE
LUMIZYME T4
METABOLIC DX ENZYME REPLACEMENT, SEVERE COMBINED IMMUNE DEFICIENCY
ADAGEN T4
2018
103
Drug Name Formulary Tiers Restrictions
METABOLIC MODIFIERS
HYPERPARATHYROID TREATMENT AGENTS - VITAMIN D ANALOG-TYPE
doxercalciferol intravenous T1
paricalcitol oral T1
HECTOROL ORAL T2
doxercalciferol oral T3
paricalcitol hemodialysis port injection T3
paricalcitol intravenous T3
HECTOROL INTRAVENOUS T3
RAYALDEE T3 PA
ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML T3
ZEMPLAR ORAL T3
ZEMPLAR INTRAVENOUS SOLUTION 5 MCG/ML T4
METABOLIC MODIFIER - CARNITINE REPLENISHER AGENTS
levocarnitine T1
levocarnitine (with sugar) T1
CARNITOR (SUGAR-FREE) T3
METABOLIC MODIFIER - GAUCHER'S DISEASE, TYPE-1, SUBSTRATE REDUCTION TX
CERDELGA T4 PA
ZAVESCA T4 PA
METABOLIC MODIFIER - HEREDITARY TYROSINEMIA TREATMENT AGENTS
ORFADIN ORAL SUSPENSION T2
NITYR T4 PA
ORFADIN ORAL CAPSULE T4
METABOLIC MODIFIER - HOMOCYSTINURIA TREATMENT AGENTS
CYSTADANE T4
METABOLIC MODIFIER - UREA CYCLE DISORDER AGENTS-CONJUGATING AGENTS
sodium benzoate-sod phenylacet T1
sodium phenylbutyrate T1
BUPHENYL T2
RAVICTI T4 PA
METABOLIC MODIFIER-CARBAMOYL PHOSPHATE SYNTHETASE 1 (CPS 1) ACTIVATOR
CARBAGLU T4
PHARMACOENHANCER - CYTOCHROME P450 INHIBITORS
TYBOST T2
PHENYLKETONURIA(PKU) TX AGENTS - COFACTOR OF PHENYLALANINE HYDROXYLASE
KUVAN T4 PA
MOUTH-THROAT-DENTAL - PREPARATIONS
DENTAL PRODUCT - FLUORIDE PREPARATIONS
fluoride (sodium) T1
FLURA-DROPS T1
FLUORABON T2
FLUOR-A-DAY (WITH XYLITOL) ORAL TABLET,CHEWABLE 0.25 MG F (0.55 MG)-236.79MG
T2
2018
104
Drug Name Formulary Tiers Restrictions
FLORIVA (FLUORIDE-VITAMIN D3) T3
FLUOR-A-DAY T3
FLUOR-A-DAY (WITH XYLITOL) ORAL TABLET,CHEWABLE 1 MG F (2.2 MG)-236.79 MG
T3
PREVIDENT 5000 DRY MOUTH T3
PREVIDENT 5000 PLUS T3
PREVIDENT 5000 SENSITIVE T3
DENTAL PRODUCT - LOCAL ANESTHETICS
bupivacaine-epinephrine bitart T1
lidocaine-epinephrine bit T1
mepivacaine (pf) T1
ARTICADENT DENTAL T3
CITANEST PLAIN DENTAL T3
MOUTH AND THROAT - ANTIFUNGALS
clotrimazole T1
nystatin T1
MOUTH AND THROAT - ANTI-INFECTIVE MIXTURES
DEBACTEROL T3
MOUTH AND THROAT - ANTI-INFECTIVE-LOCAL ANESTHETIC COMBINATIONS
BUCALSEP T3
MOUTH AND THROAT - ANTISEPTICS
chlorhexidine gluconate T1
MOUTH AND THROAT - ARTIFICIAL SALIVA
AQUORAL T3
CAPHOSOL T3
NEUTRASAL T3
NUMOISYN T3
MOUTH AND THROAT - GLUCOCORTICOIDS
triamcinolone acetonide T1
MOUTH AND THROAT - LOCAL ANESTHETIC AMIDES
lidocaine hcl T1
ADVANCED DNA MEDICATED COLLECT T3
MOUTH AND THROAT - MUCOSITIS-STOMATITIS AGENTS
EPISIL T3
GELCLAIR T3
GELX T3
ORAMAGICRX T3
MUGARD T4
MOUTH AND THROAT - PROTECTANTS
GELX T3
MUGARD T4
MOUTH AND THROAT - SALIVA STIMULANTS
pilocarpine hcl T1
cevimeline T3
PERIODONTAL PRODUCT - TETRACYCLINE-TYPE, COLLAGENASE INHIBITORS
doxycycline hyclate T1
2018
105
Drug Name Formulary Tiers Restrictions
THERAPY FOR DROOLING- PRIMARY OR SECONDARY SIALORRHEA-ANTICHOLINERGIC
CUVPOSA T3
MULTIPLE SCLEROSIS AGENTS
LEUKOCYTE ADHESION INHIBITORS, ALPHA4-MEDIATED, IGG4K MC ANTIBODY
TYSABRI T4 PA
MULTIPLE SCLEROSIS AGENT - CD20 SPECIFIC MONOCLONAL ANTIBODY
OCREVUS T4 PA
MULTIPLE SCLEROSIS AGENT - INTERFERONS
AVONEX T4
AVONEX (WITH ALBUMIN) T4
BETASERON T4 PA
EXTAVIA T4 PA; ST
PLEGRIDY T4
REBIF (WITH ALBUMIN) T4 ST
REBIF REBIDOSE T4 ST
REBIF TITRATION PACK T4 ST
MULTIPLE SCLEROSIS AGENT - OTHERS
COPAXONE T4
TECFIDERA T4
MULTIPLE SCLEROSIS AGENT - POTASSIUM CHANNEL BLOCKER
AMPYRA T4 PA
MULTIPLE SCLEROSIS AGENT - PYRIMIDINE SYNTHESIS INHIBITORS
AUBAGIO T4 ST
MULTIPLE SCLEROSIS AGENT - SPHINGOSINE 1-PHOSPHATE RECEPTOR MODULATOR
GILENYA T4 ST
MULTIPLE SCLEROSIS AGENT-INTERLEUKIN-2 RECEPTOR MODULATOR, MC ANTIBODY
ZINBRYTA T4 ST
OPHTHALMIC AGENTS
ARTIFICIAL TEARS AND LUBRICANT SINGLE AGENTS
LACRISERT T2
MIOTICS - CHOLINESTERASE INHIBITORS
PHOSPHOLINE IODIDE T2
MIOTICS - DIRECT ACTING
pilocarpine hcl T1
MIOCHOL-E T3
MIOSTAT T3
MYDRIATIC AND CYCLOPLEGIC COMBINATIONS
CYCLOMYDRIL T3
PAREMYD T3
OPHTHALMIC - ADRENERGIC-CARBONIC ANHYDRASE INHIBITOR COMBINATIONS
SIMBRINZA T3
2018
106
Drug Name Formulary Tiers Restrictions
OPHTHALMIC - ANTIBACTERIAL-GLUCOCORTICOID COMBINATIONS
neomycin-bacitracin-poly-hc T1
neomycin-polymyxin b-dexameth T1
neomycin-polymyxin-hc T1
sulfacetamide-prednisolone T1
tobramycin-dexamethasone T1
BLEPHAMIDE S.O.P. T2
TOBRADEX T2
TOBRADEX ST T2
ZYLET T2
BLEPHAMIDE T3
PRED-G T3
PRED-G S.O.P. T3
OPHTHALMIC - ANTICHOLINERGICS
atropine T1
cyclopentolate T1
homatropine hbr T1
tropicamide T1
CYCLOGYL T3
OPHTHALMIC - ANTIFIBROTIC AGENTS
MITOSOL T3
OPHTHALMIC - ANTIHISTAMINES
azelastine T1
epinastine T1
olopatadine T1
BEPREVE T3
EMADINE T3
LASTACAFT T3
PATADAY T3
PATANOL T3
PAZEO T3
OPHTHALMIC - ANTI-INFLAMMATORY, GLUCOCORTICOIDS
dexamethasone sodium phosphate T1
fluorometholone T1
prednisolone acetate T1
prednisolone sodium phosphate T1
ALREX T2
FML S.O.P. T2
LOTEMAX OPHTHALMIC (EYE) DROPS,GEL T2
LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION T2
PRED MILD T2
DUREZOL T3
FLAREX T3
FML FORTE T3
ILUVIEN T3
LOTEMAX OPHTHALMIC (EYE) OINTMENT T3
2018
107
Drug Name Formulary Tiers Restrictions
MAXIDEX T3
TRIESENCE (PF) T3
OZURDEX T4
RETISERT T4
OPHTHALMIC - ANTI-INFLAMMATORY, IMMUNOMODULATORS
RESTASIS T2
RESTASIS MULTIDOSE T2
OPHTHALMIC - ANTI-INFLAMMATORY, NSAIDS
bromfenac T1
diclofenac sodium T1
flurbiprofen sodium T1
ketorolac T1
ACUVAIL (PF) T3
BROMSITE T3
ILEVRO T3
NEVANAC T3
PROLENSA T3
OPHTHALMIC - BETA BLOCKERS-ADRENERGIC COMBINATIONS
COMBIGAN T3
OPHTHALMIC - BETA BLOCKERS-CARBONIC ANHYDRASE INHIBITOR COMBINATIONS
dorzolamide-timolol T1
COSOPT (PF) T3
OPHTHALMIC - CARBONIC ANHYDRASE INHIBITORS
dorzolamide T1
AZOPT T2
OPHTHALMIC - CYSTINE DEPLETING AGENTS
CYSTARAN T4 PA
OPHTHALMIC - DECONGESTANTS
phenylephrine hcl T1
OPHTHALMIC - DIAGNOSTIC AGENTS
fluorescein (bulk) T1
fluorescein-proparacaine T1
FLUORESCITE T1
FUL-GLO OPHTHALMIC (EYE) STRIP 1 MG T1
AK-FLUOR T3
FLUCAINE T3
FUL-GLO OPHTHALMIC (EYE) STRIP 0.6 MG T3
OPHTHALMIC - INTRAOCULAR PRESSURE REDUCING AGENTS, BETA-BLOCKERS
betaxolol T1
carteolol T1
levobunolol T1
metipranolol T1
timolol maleate T1
BETOPTIC S T2
BETIMOL T3
2018
108
Drug Name Formulary Tiers Restrictions
ISTALOL T3
TIMOPTIC OCUDOSE (PF) T3
OPHTHALMIC - IRRIGATION SOLUTIONS
BSS PLUS T3
OPHTHALMIC - LOCAL ANESTHETIC ESTERS
proparacaine T1
tetracaine hcl T1
tetracaine hcl (pf) T1
TETRAVISC T3
TETRAVISC FORTE T3
OPHTHALMIC - LOCAL ANESTHETIC, AMIDES
AKTEN (PF) T3
OPHTHALMIC - MACULAR DEGENERATION, AGE-RELATED, THERAPY AGENTS
EYLEA T4 PA
LUCENTIS T4 PA
MACUGEN T4 PA
OPHTHALMIC - MAST CELL STABILIZERS
cromolyn T1
ALOCRIL T3
ALOMIDE T3
OPHTHALMIC - PHOTODYNAMIC THERAPY AGENTS
VISUDYNE T4
OPHTHALMIC - SURGICAL AID COMBINATIONS
DISCOVISC T3
DUOVISC VISCO ELASTIC T3
VISCOAT T3
OPHTHALMIC - SURGICAL AIDS OTHER
OCUCOAT T1
CELLUGEL T3
GELFILM T3
MEMBRANEBLUE T3
VISIONBLUE T3
OPHTHALMIC - VISCOELASTIC AGENTS
AMVISC T4
AMVISC PLUS T4
PROVISC T4
OPHTHALMIC ANTIBACTERIAL MIXTURES
bacitracin-polymyxin b T1
neomycin-bacitracin-polymyxin T1
neomycin-polymyxin-gramicidin T1
polymyxin b sulf-trimethoprim T1
OPHTHALMIC ANTIBIOTIC - AMINOGLYCOSIDES
gentamicin T1
tobramycin T1
TOBREX T2
2018
109
Drug Name Formulary Tiers Restrictions
OPHTHALMIC ANTIBIOTIC - DEHYDROPEPTIDASE INHIBITORS
bacitracin T1
OPHTHALMIC ANTIBIOTIC - FLUOROQUINOLONES
ciprofloxacin hcl T1
levofloxacin T1
moxifloxacin T1
ofloxacin T1
BESIVANCE T2
CILOXAN T2
MOXEZA T3
VIGAMOX T3
ZYMAXID T3
OPHTHALMIC ANTIBIOTIC - MACROLIDES
erythromycin T1
AZASITE T3
OPHTHALMIC ANTIBIOTIC - SULFONAMIDES
sulfacetamide sodium T1
OPHTHALMIC ANTIFUNGALS
NATACYN T3
OPHTHALMIC ANTIVIRALS
trifluridine T1
ZIRGAN T3
OPHTHALMIC-INTRAOCULAR PRESS. REDUCING, SEL. ALPHA ADRENERGIC AGONISTS
apraclonidine T1
brimonidine T1
ALPHAGAN P T2
IOPIDINE T3
OPHTHALMIC-INTRAOCULAR PRESSURE REDUCING AGENTS, PROSTAGLANDIN ANALOGS
bimatoprost T1
latanoprost T1
LUMIGAN T2
TRAVATAN Z T2
ZIOPTAN (PF) T3
SELECTIVE VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) ANTAGONISTS
MACUGEN T4 PA
VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF-A) RECEPTOR ANTAGONISTS
LUCENTIS T4 PA
VASCULAR ENDOTHELIAL GROWTH FACTOR(VEGF-A AND PLGF)RECEPTOR INHIBITORS
EYLEA T4 PA
ORGAN PRESERVATION SOLUTIONS
CARDIOPLEGIC SOLUTIONS
cardioplegic soln T1
2018
110
Drug Name Formulary Tiers Restrictions
OTIC
OTIC - ANTI-INFECTIVE-GLUCOCORTICOID COMBINATIONS
neomycin-polymyxin-hc T1
CIPRODEX T2
CIPRO HC T3
OTIC - ANTI-INFECTIVES OTHER
acetic acid T1
OTIC - FLUOROQUINOLONES
ciprofloxacin hcl T1
ofloxacin T1
OTIC - GLUCOCORTICOIDS
fluocinolone acetonide oil T1
hydrocortisone-acetic acid T1
OTIC - PINNA COMBINATIONS
CORTANE-B T3
PROSTAGLANDINS
PROSTAGLANDINS
alprostadil (bulk) T3
RENAL REPLACEMENT THERAPY
HEMODIALYSIS AND HEMOFILTRATE SOLUTIONS
PRISMASOL B22GK T3
PRISMASOL BGK T3
PRISMASOL BK T3
PERITONEAL DIALYSIS SOLUTIONS
DELFLEX WITH 2.5 % DEXTROSE T3
DELFLEX-LC/1.5% DEXTROSE T3
DELFLEX-LC/2.5% DEXTROSE T3
DELFLEX-LC/4.25% DEXTROSE T3
DELFLEX-SM WITH 1.5% DEXTROSE T3
DIANEAL LOW CALCIUM/1.5% DEX T3
DIANEAL LOW CALCIUM/4.25% DEX T3
DIANEAL PD-2 WITH 2.5 % DEX T3
DIANEAL PD-2 WITH 4.25 % DEX T3
DIANEAL WITH 1.5% DEXTROSE T3
DIANEAL WITH 2.5 % DEXTROSE T3
DIANEAL WITH 4.25 % DEXTROSE T3
EXTRANEAL 7.5 % T3
RESPIRATORY THERAPY AGENTS
1ST GENERATION ANTIHISTAMINE-DECONGESTANT COMBINATIONS
CENTERGY T1
PROMETHAZINE VC T1
1ST GENERATION ANTIHISTAMINE-DECONGESTANT-ANTICHOLINERGIC COMBINATIONS
RESPA-AR T3
2ND GENERATION ANTIHISTAMINE-DECONGESTANT COMBINATIONS
CLARINEX-D 12 HOUR T3
SEMPREX-D T3
2018
111
Drug Name Formulary Tiers Restrictions
ANTIHISTAMINE - 1ST GENERATION - ETHANOLAMINES
carbinoxamine maleate T1
clemastine T1
diphenhydramine hcl T1
KARBINAL ER T3
ANTIHISTAMINE - 1ST GENERATION - ETHYLENEDIAMINES
tripelennamine (bulk) T1
ANTIHISTAMINE - 1ST GENERATION - PHENOTHIAZINES
promethazine T1
ANTIHISTAMINE - 1ST GENERATION - PIPERIDINES
cyproheptadine T1
ANTIHISTAMINES - 1ST GENERATION
carbinoxamine maleate T1
clemastine T1
cyproheptadine T1
diphenhydramine hcl T1
promethazine T1
KARBINAL ER T3
ANTIHISTAMINES - 2ND GENERATION
desloratadine oral tablet,disintegrating 2.5 mg T1
levocetirizine T1
loratadine, micronized (bulk) T2
desloratadine oral tablet T3
desloratadine oral tablet,disintegrating 5 mg T3
CLARINEX T3
ANTIHISTAMINES - 2ND GENERATION - PIPERAZINES
levocetirizine T1
ALL DAY ALLERGY (CETIRIZINE) T3
ANTIHISTAMINES - 2ND GENERATION - PIPERIDINES
desloratadine oral tablet,disintegrating 2.5 mg T1
loratadine, micronized (bulk) T2
desloratadine oral tablet T3
desloratadine oral tablet,disintegrating 5 mg T3
CLARINEX T3
ANTITUSSIVES - NONNARCOTIC
benzonatate T1
ZONATUSS T3
ASTHMA THERAPY - 5-LIPOXYGENASE INHIBITORS
ZYFLO T3
ASTHMA THERAPY - ALPHA/BETA ADRENERGIC AGENTS
epinephrine T1
ASTHMA THERAPY - INHALED CORTICOSTEROIDS (GLUCOCORTICOIDS)
ARNUITY ELLIPTA T2
ASMANEX HFA T2
ASMANEX TWISTHALER T2
FLOVENT DISKUS T2
FLOVENT HFA T2
2018
112
Drug Name Formulary Tiers Restrictions
PULMICORT FLEXHALER T2
QVAR T2
budesonide T3
AEROSPAN T3
ALVESCO T3
PULMICORT T3
ASTHMA THERAPY - LEUKOTRIENE RECEPTOR ANTAGONISTS
montelukast oral tablet T1
montelukast oral tablet,chewable T1
zafirlukast T1
montelukast oral granules in packet T3
ASTHMA THERAPY - MONOCLONAL ANTIBODIES TO IMMUNOGLOBULIN E (IGE)
XOLAIR T4 PA
ASTHMA THERAPY - XANTHINES
aminophylline T1
aminophylline (bulk) T1
theophylline T1
theophylline in dextrose 5 % T1
THEO-24 T3
ASTHMA THERAPY- MONOCLONAL ANTIBODY - INTERLEUKIN-5 (IL-5) ANTAGONISTS
CINQAIR T4 PA
NUCALA T4 PA
ASTHMA/COPD - PHOSPHODIESTERASE-4 (PDE4) INHIBITORS
DALIRESP T3 ST
ASTHMA/COPD - ANTICHOLINERGIC AGENTS, INHALED LONG ACTING
INCRUSE ELLIPTA T2
SPIRIVA RESPIMAT T2
SPIRIVA WITH HANDIHALER T2
TUDORZA PRESSAIR T3 ST
ASTHMA/COPD - ANTICHOLINERGIC AGENTS, INHALED SHORT ACTING
ATROVENT HFA T2
ASTHMA/COPD - BETA 2-ADRENERGIC AGENTS, INHALED, ULTRA-LONG ACTING
STRIVERDI RESPIMAT T2
ARCAPTA NEOHALER T3 ST
ASTHMA/COPD THERAPY - BETA 2-ADRENERGIC AGENTS, INHALED, LONG ACTING
PERFOROMIST T2
SEREVENT DISKUS T2
BROVANA T3
ASTHMA/COPD THERAPY - BETA 2-ADRENERGIC AGENTS, INHALED, SHORT ACTING
albuterol sulfate T1
levalbuterol hcl T1
levalbuterol tartrate T1
2018
113
Drug Name Formulary Tiers Restrictions
VENTOLIN HFA T2
PROAIR HFA T3 ST
PROAIR RESPICLICK T3 ST
PROVENTIL HFA T3 ST
ASTHMA/COPD THERAPY - BETA ADRENERGIC AGENTS
metaproterenol T1
terbutaline subcutaneous T1
albuterol sulfate T3
terbutaline oral T3
ASTHMA/COPD THERAPY - BETA ADRENERGIC-ANTICHOLINERGIC COMBINATIONS
ipratropium-albuterol T1
ANORO ELLIPTA T2
COMBIVENT RESPIMAT T2
STIOLTO RESPIMAT T2
BEVESPI AEROSPHERE T3 ST
ASTHMA/COPD THERAPY - BETA ADRENERGIC-GLUCOCORTICOID COMBINATIONS
fluticasone-salmeterol T1
ADVAIR DISKUS T2
ADVAIR HFA T2
BREO ELLIPTA T2
SYMBICORT T2
AIRDUO RESPICLICK T3
DULERA T3 ST
CYSTIC FIBROSIS - INHALED AMINOGLYCOSIDES
BETHKIS T3
tobramycin in 0.225 % nacl T4
tobramycin with nebulizer T4 PA
KITABIS PAK T4 PA
TOBI T4 PA
TOBI PODHALER T4 PA
CYSTIC FIBROSIS - INHALED MONOBACTAMS
CAYSTON T2 PA
CYSTIC FIBROSIS-TRANSMEMBRANE CONDUCTANCE REGULATOR (CFTR) POTENTIATOR
KALYDECO T4 PA
CYSTIC FIB-TRANSMEMB CONDUCT. REG.(CFTR) POTENTIATOR AND CORRECTOR CMB
ORKAMBI T4 PA
ELASTASE INHIBITORS
ARALAST NP T4
GLASSIA T4
PROLASTIN-C T4
ZEMAIRA T4
LUNG SURFACTANTS
CUROSURF T3
INFASURF T3
SURFAXIN T3
2018
114
Drug Name Formulary Tiers Restrictions
SURVANTA T3
MUCOLYTICS
acetylcysteine T1
acetylcysteine (bulk) T1
PULMOZYME T4
NARCOTIC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT COMBINATIONS
CAPCOF T3
PROMETHAZINE VC-CODEINE T3
ZUTRIPRO T3
NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE COMBINATIONS
hydrocodone-chlorpheniramine T1
promethazine-codeine T1
TUSSICAPS T2
TUZISTRA XR T3
VITUZ T3
NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATIONS
hydrocodone-homatropine T1
NARCOTIC ANTITUSSIVE-DECONGESTANT COMBINATIONS
REZIRA T3
NARCOTIC ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMBINATIONS
HYCOFENIX T3
NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATIONS
codeine-guaifenesin T1
M-CLEAR WC T1
RELCOF C T1
OBREDON T3
NASAL ANTIBIOTICS
BACTROBAN NASAL T3
NASAL ANTICHOLINERGICS
ipratropium bromide T1
NASAL ANTIHISTAMINES
azelastine T1
olopatadine T3
ASTEPRO T3
PATANASE T3
NASAL CORTICOSTEROIDS
mometasone T3
NASAL SYMPATHOMIMETIC DECONGESTANTS (INTRANASAL)
ADRENALIN T3
TYZINE T3
NON-NARC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT COMBINATIONS
CENTERGY DM T1
brompheniramin-phenylephrin-dm T3
BROMFED DM T3
2018
115
Drug Name Formulary Tiers Restrictions
NON-NARCOTIC ANTITUSSIVE-ANTIHISTAMINE COMBINATIONS
promethazine-dm T1
NON-NARCOTIC ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMBINATIONS
TUSNEL PEDIATRIC T3
PLEURAL SCLEROSING AGENTS
sterile talc T1
SCLEROSOL INTRAPLEURAL T3
PULMONARY FIBROSIS TREATMENT AGENTS - ANTIFIBROTIC THERAPY
ESBRIET T4 PA
PULMONARY FIBROSIS TREATMENT AGENTS - MULTIKINASE INHIBITORS
OFEV T4 PA
VAGINAL PRODUCTS
VAGINAL ANTIBACTERIAL - LINCOSAMIDES
clindamycin phosphate T1
CLINDESSE T2
CLEOCIN T3
VAGINAL ANTIFUNGAL - IMIDAZOLES
GYNAZOLE-1 T1
MICONAZOLE-3 T1
VAGINAL ANTIFUNGAL - TRIAZOLES
terconazole T1
VAGINAL ANTIPROTOZOAL-ANTIBACTERIAL - NITROIMIDAZOLE DERIVATIVES
metronidazole T1
NUVESSA T3
VAGINAL ANTISEPTIC MIXTURES
RELAGARD T1
FEM PH T3
VAGINAL ESTROGENS
estradiol T1
ESTRACE T2
ESTRING T2
FEMRING T3
PREMARIN T3
VAGIFEM T3
YUVAFEM T3
VAGINAL PROGESTINS
CRINONE T2
2018
116
Indexabacavir ................................................... 12, 13abacavir-lamivudine ...................................... 13abacavir-lamivudine-zidovudine ....................13ABELCET......................................................11ABILIFY MAINTENA..................................45ABRAXANE................................................. 25ABSTRAL................................................... 2, 3acamprosate ................................................... 50ACANYA.......................................................56acarbose ......................................................... 82ACD............................................................... 96ACD-A........................................................... 96acebutolol .......................................................35acetaminophen-codeine ................................... 3acetazolamide .................................................37acetazolamide sodium .................................... 37acetic acid .............................................. 93, 111acetylcysteine ........................................... 9, 115acetylcysteine (bulk) .................................9, 115ACIPHEX...................................................... 90ACIPHEX SPRINKLE.................................. 90acitretin .......................................................... 59ACTEMRA...................................................... 5ACTHAR H.P. ............................................... 81ACTHIB (PF) .................................................29ACTHREL..................................................... 67ACTIMMUNE............................................... 11ACTIQ............................................................. 2ACTIVASE....................................................99ACTIVE FE................................................... 72ACTONEL..................................................... 84ACTOPLUS MET XR................................... 83ACUVAIL (PF) ............................................108acyclovir .............................................16, 17, 60acyclovir sodium ...................................... 16, 17ACZONE....................................................... 55ADACEL(TDAP ADOLESN/ADULT)(PF) .29ADAGEN.....................................................103adapalene ....................................................... 57adapalene-benzoyl peroxide .......................... 57ADASUVE.....................................................45ADCETRIS.............................................. 21, 26ADCIRCA......................................................39ADDAMEL N................................................74ADDERALL...................................... 46, 47, 49ADDYI...........................................................47adefovir .......................................................... 16ADEMPAS.....................................................39ADENOSCAN............................................... 67adenosine ....................................................... 34ADLYXIN..................................................... 83ADRENALIN.................................. 36, 37, 115ADREVIEW.................................................. 68ADVAIR DISKUS.......................................114ADVAIR HFA............................................. 114ADVANCED AM-PM...................................74ADVANCED DNA MEDICATED COLLECT....................................................105ADYPHREN..................................................36ADZENYS XR-ODT.....................................47AEROSPAN.................................................113AFINITOR..................................................... 24AFINITOR DISPERZ....................................24AFLURIA 2017-2018.................................... 30AFLURIA 2017-2018 (PF) ............................30AFLURIA QUAD 2017-2018....................... 30AFLURIA QUAD 2017-2018 (PF) ............... 30AGGRASTAT IN SODIUM CHLORIDE.... 98AIRDUO RESPICLICK.............................. 114
AK-FLUOR................................................. 108AKTEN (PF) ................................................ 109AKTIPAK...................................................... 56AKYNZEO.................................................... 89ALA-QUIN.................................................... 58ALA-SCALP..................................................62ALBENZA..................................................... 10albumin, human 25 % .................................... 98albumin, human 5 % ...................................... 98albuterol sulfate ................................... 113, 114alclometasone .................................................61alcohol swabs .................................................27ALDACTAZIDE........................................... 38ALDURAZYME..........................................103ALECENSA...................................................21alendronate .................................................... 84alfentanil .......................................................... 1ALFERON N................................................. 63alfuzosin ......................................................... 94ALIMTA........................................................ 21ALINIA..........................................................12ALIQOPA...................................................... 24ALKERAN.....................................................20ALL DAY ALLERGY (CETIRIZINE) .......112allopurinol ......................................................96allopurinol sodium ......................................... 96almotriptan malate .........................................48ALOCRIL.................................................... 109alogliptin ........................................................ 82alogliptin-metformin ...................................... 83alogliptin-pioglitazone ................................... 83ALOMIDE................................................... 109ALOQUIN..................................................... 58ALORA..........................................................85alosetron .........................................................92ALOXI........................................................... 89ALPHAGAN P............................................ 110alprazolam ..................................................... 40ALPRAZOLAM INTENSOL........................40alprostadil ...................................................... 39alprostadil (bulk) ....................................50, 111ALREX........................................................ 107ALTABAX.....................................................58ALTAVERA (28) .......................................... 53ALTOPREV...................................................34aluminum hydroxide gel .................................88ALUNBRIG................................................... 21ALVESCO................................................... 113ALYACEN 7/7/7 (28) ....................................54AMABELZ.................................................... 84amantadine hcl ...............................................44AMBISOME.................................................. 11amcinonide ..................................................... 61AMERGE.......................................................48AMETHIA..................................................... 52AMETHIA LO...............................................52AMETHYST..................................................52AMIDATE....................................................... 7amifostine crystalline ..................................... 27amikacin ......................................................... 10amiloride ........................................................ 38amiloride-hydrochlorothiazide ...................... 38AMINO ACIDS 15 %....................................75aminocaproic acid ..........................................97aminolevulinic acid hcl (bulk) ........................64aminophylline ...............................................113aminophylline (bulk) .................................... 113AMINOSYN 10 %.........................................75AMINOSYN 3.5 %........................................75
AMINOSYN 7 %...........................................75AMINOSYN 7 % WITH ELECTROLYTES......................................... 75AMINOSYN 8.5 %........................................75AMINOSYN 8.5 %-ELECTROLYTES........ 75AMINOSYN II 10 %..................................... 75AMINOSYN II 15 %..................................... 75AMINOSYN II 8.5 %-ELECTROLYTES.... 75AMINOSYN M 3.5 %................................... 76AMINOSYN-HBC 7%.................................. 76AMINOSYN-PF 10 %................................... 76AMINOSYN-PF 7 % (SULFITE-FREE) ...... 76amiodarone .................................................... 33amiodarone in dextrose 5 % .......................... 33AMITIZA.................................................91, 92amitriptyline ................................................... 43amitriptyline-chlordiazepoxide ................ 43, 46amlodipine ......................................................36amlodipine-atorvastatin ................................. 35amlodipine-benazepril ................................... 31amlodipine-olmesartan .................................. 32amlodipine-valsartan ..................................... 32amlodipine-valsartan-hcthiazid ..................... 32ammonium chloride ..................................37, 94ammonium lactate .......................................... 61amoxapine ...................................................... 43amoxicil-clarithromy-lansopraz .....................93amoxicillin ......................................................10amoxicillin-pot clavulanate ............................10amphotericin b ............................................... 11ampicillin ....................................................... 10ampicillin sodium ...........................................10ampicillin-sulbactam ......................................10AMPYRA.....................................................106AMVISC...................................................... 109AMVISC PLUS........................................... 109AMYTAL.......................................................49AMYVID....................................................... 68ANACAINE...................................................65ANADROL-50...............................................81anagrelide ...................................................... 99ANA-LEX KIT................................................ 8anastrozole ..................................................... 22ANDRODERM..............................................81ANDROGEL..................................................81ANGELIQ......................................................84ANGIOMAX................................................. 99ANIMI-3 WITH VITAMIN D.......................74ANORO ELLIPTA...................................... 114anticoag citrate phos dextrose ....................... 96ANUCORT-HC............................................... 8ANZEMET.....................................................89APLIGRAF.................................................... 65APLISOL....................................................... 67APOKYN....................................................... 44apraclonidine ............................................... 110aprepitant ....................................................... 89APRI ...............................................................52APRISO......................................................... 92APTENSIO XR..............................................46APTIOM........................................................ 41APTIVUS.......................................................18AQUA GLYCOLIC HC................................ 63AQUASOL A.................................................80AQUORAL.................................................. 105ARALAST NP............................................. 114ARANELLE (28) ...........................................54ARANESP (IN POLYSORBATE) ................96ARCALYST.....................................................4
117
ARCAPTA NEOHALER............................ 113argatroban ..................................................... 99argatroban in 0.9 % sod chlor ....................... 99argatroban in nacl (iso-os) ............................ 99aripiprazole ..............................................45, 47ARISTADA................................................... 45ARISTOSPAN INTRA-ARTICULAR..........85ARISTOSPAN INTRALESIONAL.............. 85armodafinil .....................................................49ARMOUR THYROID................................... 88ARNUITY ELLIPTA.................................. 112ARRANON....................................................21ARTICADENT DENTAL....................... 8, 105ARTISS..........................................................65ARYMO ER.....................................................2ARZERRA..................................................... 22ASCLERA..................................................... 40ASCOMP WITH CODEINE........................... 3ascorbic acid (vitamin c) ................................80ASMANEX HFA.........................................112ASMANEX TWISTHALER....................... 112aspirin-caffeine-dihydrocodein ........................3aspirin-dipyridamole ......................................98ASTAGRAF XL.......................................... 100ASTEPRO....................................................115ASTRAMORPH-PF.........................................2ASTRINGYN.................................................97ATABEX EC................................................. 78ATELVIA...................................................... 84atenolol ...........................................................35atenolol-chlorthalidone ..................................36ATGAM......................................................... 29atomoxetine .................................................... 46ATOPICLAIR................................................61atorvastatin .................................................... 34atovaquone-proguanil ....................................12atracurium ....................................................101ATRAPRO CP............................................... 61ATRAPRO DERMAL SPRAY..................... 66ATRIPLA.......................................................13ATROPEN..................................................... 38atropine ............................................ 38, 91, 107atropine (bulk) ..........................................38, 91ATROVENT HFA....................................... 113ATRYN..........................................................98AUBAGIO................................................... 106AUGMENTIN............................................... 10AURYXIA..................................................... 94AUSTEDO..................................................... 48AVANDAMET..............................................83AVANDIA..................................................... 87AVAPRO....................................................... 32AVAR............................................................ 56AVAR LS.......................................................56AVAR-E LS...................................................56AVASTIN...................................................... 19AVEED.......................................................... 81AVELOX....................................................... 16AVELOX IN NACL (ISO-OSMOTIC) .........16AVIANE........................................................ 52AVIDOXY DK.............................................. 19AVITA........................................................... 57AVITENE...................................................... 97AVITENE FLOUR........................................ 97AVO CREAM................................................60AVODART.................................................... 94AVONEX.....................................................106AVONEX (WITH ALBUMIN)................... 106AVYCAZ....................................................... 14AXERT.......................................................... 48
AXIRON........................................................ 81AZACTAM IN DEXTROSE (ISO-OSM).....17AZASAN................................................. 5, 100AZASITE..................................................... 110azathioprine ............................................. 5, 100azelaic acid (bulk) ..........................................55azelastine ..............................................107, 115AZELEX.................................................. 55, 64azithromycin ...................................................17AZOPT.........................................................108AZOR.............................................................32aztreonam .......................................................17AZURETTE (28) ........................................... 52B COMPLEX 100..........................................69B-12 COMPLIANCE.....................................80bacitracin ............................................... 18, 110bacitracin-polymyxin b ................................ 109baclofen ........................................................101BACMIN........................................................74BACTERIOSTATIC WATER(PARABENS) ..................................51BACTROBAN NASAL...............................115BAL IN OIL.....................................................9BAL-CARE DHA.......................................... 78BAL-CARE DHA ESSENTIAL....................78balsalazide ..................................................... 91BALZIVA (28) .............................................. 53banana creme flavor (bulk) ............................51BANZEL........................................................42BARACLUDE............................................... 16BAVENCIO................................................... 26BAXDELA.....................................................16bcg vaccine, live (pf) ................................ 29, 30BD ULTRA-FINE MICRO PEN NEEDLE.............................................................. 102, 103BEAU RX...................................................... 64BELBUCA....................................................... 4BELEODAQ.................................................. 23belladonna alkaloids-opium ...........................91belladonna tincture (bulk) ........................50, 91BELLADONNA-OPIUM.............................. 91BELSOMRA..................................................49benazepril .......................................................31benazepril-hydrochlorothiazide ..................... 31BENDEKA.....................................................20BENICAR...................................................... 32BENICAR HCT............................................. 32BENLYSTA.....................................................6BENSAL HP.................................................. 63BENTYL........................................................91BENZACLIN................................................. 56BENZACLIN PUMP..................................... 56BENZEFOAM............................................... 56BENZEFOAM ULTRA.................................56BENZEPRO................................................... 56BENZEPRO (MICROSPHERES) ................. 56benzonatate .................................................. 112benzoyl peroxide ............................................ 56benzphetamine ................................................69benztropine .....................................................43BEPREVE....................................................107BERINERT.................................................... 96BESIVANCE............................................... 110BESPONSA............................................. 21, 26betadex (bulk) ...................................................9betamethasone acet,sod phos .........................85betamethasone dipropionate .......................... 61betamethasone valerate ............................61, 62betamethasone, augmented ............................ 61BETASERON.............................................. 106
betaxolol .................................................35, 108bethanechol chloride ......................................95BETHKIS.....................................................114BETIMOL....................................................108BETOPTIC S ............................................... 108BEVESPI AEROSPHERE...........................114BEVYXXA.................................................... 96bexarotene ......................................................25BEXSERO..................................................... 30BIAFINE EMULSION.................................. 61bicalutamide ...................................................21BICILLIN C-R...............................................18BICILLIN L-A...............................................18BICNU........................................................... 20BIDIL............................................................. 40BIFERA RX...................................................72BILTRICIDE................................................. 10bimatoprost .................................................. 110BINOSTO...................................................... 84BIONECT...................................................... 64BIOTHRAX................................................... 30bisoprolol fumarate ........................................35bisoprolol-hydrochlorothiazide ..................... 36bivalirudin ......................................................99BIVIGAM...................................................... 28bleomycin ....................................................... 26BLEPHAMIDE............................................107BLEPHAMIDE S.O.P. .................................107BLINCYTO................................................... 26blood glucose contrl hi,normal ............ 102, 103BONIVA........................................................ 84BOOSTRIX TDAP........................................ 29BOSULIF....................................................... 25BOTOX........................................................101botulism antitoxin heptavalent ....................... 29BP FOAM...................................................... 56BP WASH...................................................... 56BP WASH ACNE TREATMENT.................56BP-50% UREA.............................................. 63BPO................................................................56BRAVELLE...................................................85BREO ELLIPTA..........................................114BREVIBLOC IN NACL (ISO-OSM)......33, 35BREVICON (28) ............................................53BREVITAL......................................................7BRIELLYN....................................................52BRILINTA..................................................... 98brimonidine .................................................. 110BRISDELLE.................................................. 87BRIVIACT.....................................................42BROMFED DM...........................................115bromfenac .....................................................108bromocriptine .................................................44brompheniramin-phenylephrin-dm .............. 115BROMSITE................................................. 108BROVANA..................................................113BSS PLUS....................................................109BUCALSEP................................................. 105budesonide ............................................. 92, 113bumetanide ..................................................... 37BUNAVAIL...................................................50BUPHENYL................................................ 104bupivacaine ...................................................... 7bupivacaine (pf) ............................................... 7bupivacaine in nacl(pf) .................................... 7bupivacaine-dextrose-water(pf) ....................... 8bupivacaine-epinephrine ..................................8bupivacaine-epinephrine (pf) ...........................8bupivacaine-epinephrine bitart ....................105BUPRENEX.....................................................4
118
buprenorphine ..................................................4buprenorphine hcl ...................................... 4, 50buprenorphine-naloxone ................................50bupropion hcl ........................................... 43, 50buspirone ........................................................40busulfan ..........................................................20butalbital-acetaminop-caf-cod .........................3butalbital-acetaminophen ................................ 4butalbital-acetaminophen-caff ......................... 4butalbital-aspirin-caffeine ............................... 7BUTISOL.......................................................49butorphanol tartrate .........................................4butylated hydroxytoluene ............................... 51BYDUREON................................................. 83BYETTA........................................................83BYSTOLIC.................................................... 35cabergoline .....................................................88CABOMETYX.............................................. 24CA-DTPA........................................................ 9CAFERGOT...................................................48caffeine citrate ................................................47caffeine-sodium benzoate ...............................47calcipotriene .............................................59, 60calcipotriene-betamethasone ......................... 57calcitonin (salmon) ........................................ 84calcitriol ................................................... 59, 80calcitriol (bulk) .............................................. 80calcium acetate ........................................ 71, 93calcium chloride .............................................71calcium gluconate .......................................... 71calcium gluconate in 0.9% nacl .....................71calcium gluconate in d5w .............................. 71CALCIUM-FOLIC ACID-VITAMIN D....... 71CALDOLOR....................................................7CAMBIA..........................................................6CAMILA........................................................54CAMINO PRO 15 PE MSUD....................... 75CAMPTOSAR............................................... 25CAMRESE.....................................................52CAMRESE LO.............................................. 52CANASA....................................................... 92CANCIDAS................................................... 11candesartan ....................................................32candesartan-hydrochlorothiazid ....................32CANDIN........................................................ 27CAPASTAT................................................... 13CAPCOF...................................................... 115capecitabine ................................................... 21CAPEX...........................................................62CAPHOSOL.................................................105CAPITAL WITH CODEINE...........................3CAPRELSA................................................... 25captopril ......................................................... 31captopril-hydrochlorothiazide ....................... 31CARAC..........................................................59CARAFATE...................................................93CARBAGLU................................................104carbamazepine ......................................... 41, 46carbidopa-levodopa ....................................... 43carbidopa-levodopa-entacapone ................... 43carbinoxamine maleate ................................ 112CARBOCAINE................................................8CARBOCAINE (PF) ........................................8carboplatin ..................................................... 24CARDENE IV IN DEXTROSE.................... 36CARDENE IV IN SODIUM CHLORIDE.... 36cardioplegic soln ..........................................110CARDIOTEK-RX (BIOPERINE) ................. 69CARDIOVID PLUS...................................... 35CARDIZEM LA............................................ 36
CARDURA XL..............................................39CARIMUNE NF NANOFILTERED.............28carisoprodol ................................................. 101carisoprodol-asa-codeine ............................ 102carisoprodol-aspirin .................................... 101CARNITOR (SUGAR-FREE) .....................104carteolol ....................................................... 108CARTIA XT.................................................. 36CARTICEL.................................................. 101carvedilol ....................................................... 32caspofungin .................................................... 11CATAPRES-TTS-1 ....................................... 37CATAPRES-TTS-2 ....................................... 37CATAPRES-TTS-3 ....................................... 37CATHFLO ACTIVASE................................ 99CAVERJECT................................................. 69CAYSTON...................................................114CAZIANT (28) .............................................. 54CEDAX..........................................................15cefaclor ...........................................................14cefadroxil ....................................................... 14cefazolin ......................................................... 14cefazolin in dextrose (iso-os) ......................... 14cefazolin in sterile water ................................ 14cefdinir ........................................................... 14cefditoren pivoxil ............................................15cefepime ......................................................... 15cefepime in dextrose 5 % ............................... 15cefepime in dextrose,iso-osm ......................... 15cefixime .......................................................... 15cefotaxime ...................................................... 15cefotetan ......................................................... 14cefotetan in dextrose, iso-osm ........................14cefoxitin ..........................................................14cefoxitin in dextrose, iso-osm .........................14cefpodoxime ................................................... 15cefprozil ..........................................................14ceftazidime ..................................................... 15ceftazidime in d5w ..........................................15ceftriaxone ......................................................15ceftriaxone in dextrose,iso-os ........................ 15cefuroxime axetil ............................................ 14cefuroxime sodium ......................................... 14CELEBREX..................................................... 6celecoxib ...........................................................6CELLCEPT..............................................5, 100CELLCEPT INTRAVENOUS................ 5, 100CELLUGEL................................................. 109cellulose (bulk) ...............................................51CELONTIN....................................................42CENTANY AT.............................................. 58CENTERGY................................................ 111CENTERGY DM.........................................115CENTRATEX................................................72cephalexin ...................................................... 14CEPROTIN (BLUE BAR).............................99CEPROTIN (GREEN BAR)..........................99CERDELGA................................................ 104CEREFOLIN..................................................75CERENX..........................................................1CERETEC......................................................68CEREZYME................................................ 103CERVIDIL..................................................... 81CESAMET..................................................... 89CETACAINE................................................. 64CETACAINE ANESTHETIC....................... 64CETROTIDE................................................. 87cevimeline .....................................................105CHANTIX......................................................50CHANTIX CONTINUING MONTH BOX.. 50
CHANTIX STARTING MONTH BOX........50CHEMET......................................................... 9CHENODAL..................................................90CHIRHOSTIM...............................................67chloramphenicol sod succinate ......................15chlordiazepoxide hcl ...................................... 40chlordiazepoxide-clidinium ......................46, 91chlorhexidine gluconate ...............................105chloroquine phosphate ...................................12chlorothiazide .................................................38chlorothiazide sodium .................................... 38chlorpromazine .............................................. 45chlorpropamide ..............................................82chlorthalidone ................................................ 38chlorzoxazone ...............................................101CHOLBAM....................................................90cholestyramine (with sugar) ...........................34CHOLESTYRAMINE LIGHT...................... 34choline,magnesium salicylate .......................... 7chorionic gonadotropin, human .....................86chromium chloride ......................................... 74chromium polynicotinate (bulk) ..................... 74CIALIS.....................................................69, 94CICLODAN KIT........................................... 58ciclopirox ....................................................... 58ciclopirox-ure-camph-menth-euc ...................58cidofovir ......................................................... 15cilostazol ........................................................ 99CILOXAN....................................................110cimetidine ....................................................... 90cimetidine hcl ................................................. 90CIMZIA..................................................... 4, 92CIMZIA POWDER FOR RECONST........4, 92CIMZIA STARTER KIT........................... 4, 92CINQAIR..................................................... 113CINRYZE...................................................... 96CIPRO............................................................15CIPRO HC................................................... 111CIPRODEX..................................................111ciprofloxacin .................................................. 15ciprofloxacin (mixture) .................................. 95ciprofloxacin hcl ............................ 15, 110, 111ciprofloxacin in 5 % dextrose ........................ 15ciprofloxacin lactate ...................................... 15cisatracurium ............................................... 101cisplatin ..........................................................24citalopram ...................................................... 42CITANEST PLAIN DENTAL.................8, 105CITRANATAL (DUAL-IRON).................... 78CITRANATAL 90 DHA (ALGAL OIL) .......78CITRANATAL ASSURE..............................78CITRANATAL B-CALM (FE GLUC)......... 78CITRANATAL DHA (ALGAL OIL) ............78cladribine ....................................................... 21CLAFORAN.................................................. 15CLARAVIS....................................................55CLARINEX................................................. 112CLARINEX-D 12 HOUR............................111clarithromycin ................................................17clemastine .....................................................112CLEOCIN.................................................... 116CLEVIPREX..................................................36CLIMARA..................................................... 85CLIMARA PRO............................................ 84CLIN SINGLE USE.......................................17CLINDACIN ETZ......................................... 56CLINDACIN PAC.........................................56CLINDAGEL.................................................55clindamycin hcl .............................................. 17clindamycin in 5 % dextrose .......................... 17
119
clindamycin palmitate hcl .............................. 17clindamycin phosphate .....................17, 55, 116clindamycin-benzoyl peroxide ........................56clindamycin-tretinoin ..................................... 56CLINDESSE................................................ 116CLINIMIX 5%/D15W SULFITE FREE...... 75CLINIMIX 5%/D25W SULFITE-FREE...... 75CLINIMIX 2.75%/D5W SULFIT FREE.......75CLINIMIX 4.25%/D10W SULF FREE.........75CLINIMIX 4.25%/D5W SULFIT FREE.......75CLINIMIX 4.25%-D20W SULF-FREE........ 75CLINIMIX 4.25%-D25W SULF-FREE........ 75CLINIMIX 5%-D20W(SULFITE-FREE) ..... 75CLINIMIX E 2.75%/D10W SUL FREE....... 76CLINIMIX E 2.75%/D5W SULF FREE....... 76CLINIMIX E 4.25%/D10W SUL FREE....... 76CLINIMIX E 4.25%/D25W SUL FREE....... 76CLINIMIX E 4.25%/D5W SULF FREE....... 76CLINIMIX E 5%/D15W SULFIT FREE...... 76CLINIMIX E 5%/D20W SULFIT FREE...... 76CLINIMIX E 5%/D25W SULFIT FREE...... 76CLINISOL SF 15 %.......................................75clobetasol ....................................................... 62clobetasol-emollient ....................................... 62CLOBEX........................................................62CLODAN....................................................... 62CLODAN KIT............................................... 63CLODERM.................................................... 62clofarabine ..................................................... 21CLOLAR........................................................21clomiphene citrate ..........................................85clomipramine ................................................. 43clonazepam .....................................................40clonidine .........................................................37clonidine (pf) .................................................... 1clonidine hcl .............................................37, 45clopidogrel ..................................................... 99clorazepate dipotassium .................................40CLORPRES................................................... 37clotrimazole ............................................58, 105clotrimazole-betamethasone .......................... 59clozapine ........................................................ 44C-NATE DHA............................................... 77coal tar ........................................................... 63COARTEM.................................................... 12cocaine ........................................................... 65codeine sulfate ..................................................1codeine-guaifenesin ..................................... 115colchicine ....................................................... 95COLCRYS..................................................... 95COLESTID FLAVORED.............................. 34colestipol ........................................................ 34colistin (colistimethate na) .............................18COMBIGAN................................................108COMBIPATCH............................................. 84COMBIVENT RESPIMAT......................... 114COMETRIQ...................................................24COMFORT PAC-CYCLOBENZAPRINE..102COMFORT PAC-IBUPROFEN...................... 6COMFORT PAC-MELOXICAM....................6COMFORT PAC-NAPROXEN...................... 6COMFORT PAC-TIZANIDINE................. 102COMPLERA..................................................13COMPLETE NATAL DHA.......................... 77COMPLETENATE........................................77CONCEPT DHA............................................78CONCEPT OB...............................................78CONDYLOX................................................. 63CONRAY.......................................................66CONRAY 43..................................................66
CONRAY-30................................................. 66CONZIP........................................................... 2COPAXONE................................................106COPPER CHLORIDE................................... 74CORDRAN.................................................... 62COREG CR....................................................32CORLANOR..................................................38CORLOPAM................................................. 38CORMAX...................................................... 62CORTANE-B...............................................111CORTIFOAM................................................ 92cortisone .........................................................85CORTISPORIN............................................. 58CORVITA 150 ...............................................72CORVITE FREE............................................74COSENTYX.................................................. 57COSENTYX (2 SYRINGES) ........................ 57COSENTYX PEN..........................................57COSENTYX PEN (2 PENS) ......................... 57COSOPT (PF) .............................................. 108cosyntropin .....................................................67COTELLIC.................................................... 24COTEMPLA XR-ODT.................................. 46creatine (bulk) .................................................. 1CREON.......................................................... 90CRESEMBA.................................................. 11CRINONE....................................................116CRIXIVAN.................................................... 18cromolyn .................................................24, 109CRYOSERV.................................................. 50CRYSELLE (28) ............................................53CUPRIMINE................................................6, 9CUROSURF.................................................114CUVITRU......................................................28CUVPOSA................................................... 106cyanocobalamin (vitamin b-12) ..................... 80CYANOKIT.....................................................9CYCLAFEM 1/35 (28) .................................. 52CYCLAFEM 7/7/7 (28) ................................. 54CYCLESSA (28) ............................................54cyclobenzaprine ........................................... 101CYCLOGYL................................................107CYCLOMYDRIL........................................ 106cyclopentolate .............................................. 107cyclophosphamide ......................................5, 20cycloserine ..................................................... 13CYCLOSET................................................... 82cyclosporine ............................................. 5, 100cyclosporine (bulk) .......................................100cyclosporine modified .............................. 5, 100CYMBALTA........................................... 42, 47cyproheptadine .............................................112CYRAMZA....................................................26CYSTADANE............................................. 104CYSTAGON..................................................93CYSTARAN................................................ 108cysteine (l-cysteine) ........................................75CYSTO-CONRAY II .....................................66CYSTOGRAFIN............................................66CYSTOGRAFIN-DILUTE............................66cytarabine .......................................................21cytarabine (pf) ................................................21CYTOGAM................................................... 28CYTRA K CRYSTALS.................................94CYTRA-3.......................................................94CYTRA-K......................................................94d10 %-0.45 % sodium chloride ......................70d2.5 %-0.45 % sodium chloride .....................70d5 % and 0.9 % sodium chloride ................... 70d5 %-0.45 % sodium chloride ........................70
dacarbazine ....................................................20DALIRESP...................................................113DALVANCE..................................................17danazol ........................................................... 86DANTRIUM................................................ 101dantrolene .................................................... 101dapsone .......................................................... 11DAPTACEL (DTAP PEDIATRIC) (PF) .......29daptomycin ..................................................... 15darifenacin ..................................................... 95DARZALEX.................................................. 22DASETTA 7/7/7 (28) .....................................54DATSCAN.....................................................68daunorubicin .................................................. 26DAYSEE........................................................52DAYTRANA................................................. 46DEBACTEROL........................................... 105decitabine ....................................................... 22deferoxamine ....................................................9DEFINITY..................................................... 67DELFLEX WITH 2.5 % DEXTROSE........ 111DELFLEX-LC/1.5% DEXTROSE.............. 111DELFLEX-LC/2.5% DEXTROSE.............. 111DELFLEX-LC/4.25% DEXTROSE............ 111DELFLEX-SM WITH 1.5% DEXTROSE.. 111DELYLA (28) ................................................ 53DELZICOL.................................................... 92demeclocycline ............................................... 19DEMEROL...................................................... 2DEMEROL (PF) .............................................. 3DEMSER....................................................... 39DENAVIR......................................................60DEPEN TITRATABS..................................6, 9DEPLIN (ALGAL OIL) .................................80DEPO-ESTRADIOL......................................85DEPO-MEDROL........................................... 85DEPO-PROVERA......................................... 24DEPO-SUBQ PROVERA 104.......................52DEPO-TESTOSTERONE............................. 81DERMAGRAFT............................................ 66DERMASORB AF COMPLETE KIT...........58DERMASORB HC COMPLETE KIT.......... 63DERMASORB TA COMPLETE KIT...........62DESCOVY.....................................................13desipramine ....................................................43desloratadine ................................................112desmopressin ..................................................82desogestrel-ethinyl estradiol .......................... 52DESONATE...................................................62desonide ......................................................... 61desoximetasone .............................................. 62desvenlafaxine ................................................42desvenlafaxine fumarate ................................ 42desvenlafaxine succinate ................................42DETROL LA..................................................95dexamethasone ............................................... 85dexamethasone in 0.9 % sod chl .................... 85DEXAMETHASONE INTENSOL............... 85dexamethasone sodium phos (pf) ................... 85dexamethasone sodium phosphate ......... 85, 107DEXEDRINE SPANSULE............................47DEXILANT................................................... 90dexmedetomidine ............................................50dexmethylphenidate ........................................46dexrazoxane hcl ..............................................26dextroamphetamine ............................46, 47, 49dextroamphetamine-amphetamine ........... 46, 47dextrose 10 % and 0.2 % nacl ........................70dextrose 10 % in water (d10w) ...................... 70dextrose 20 % in water (d20w) ...................... 70
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dextrose 25 % in water (d25w) ...................... 70dextrose 30 % in water (d30w) ...................... 70dextrose 40 % in water (d40w) ...................... 70dextrose 5 % in ringer's ................................. 71dextrose 5 % in water (d5w) .......................... 70dextrose 5 %-lactated ringers ........................ 70dextrose 5%-0.2 % sod chloride .................... 70dextrose 5%-0.3 % sod.chloride .................... 70dextrose 50 % in water (d50w) ...................... 70dextrose 70 % in water (d70w) ...................... 70DIALYVITE.................................................. 69DIALYVITE 3000......................................... 69DIALYVITE 5000......................................... 74DIALYVITE 800 WITH IRON.....................75DIALYVITE SUPREME D...........................69DIANEAL LOW CALCIUM/1.5% DEX....111DIANEAL LOW CALCIUM/4.25% DEX..111DIANEAL PD-2 WITH 2.5 % DEX........... 111DIANEAL PD-2 WITH 4.25 % DEX......... 111DIANEAL WITH 1.5% DEXTROSE......... 111DIANEAL WITH 2.5 % DEXTROSE........ 111DIANEAL WITH 4.25 % DEXTROSE...... 111diazepam .................................................. 40, 46DIAZEPAM INTENSOL........................ 40, 46DIBENZYLINE............................................. 39diclofenac potassium ........................................6diclofenac sodium .............................. 6, 64, 108diclofenac-misoprostol .....................................6dicloxacillin ....................................................18dicyclomine .................................................... 91didanosine ...................................................... 12diethylpropion ................................................ 69DIFFERIN......................................................57DIFICID......................................................... 17diflorasone ..................................................... 61diflunisal ...........................................................7DIGIFAB......................................................... 9digoxin ............................................................37dihydroergotamine ......................................... 48DILANTIN.....................................................41diltiazem hcl ............................................. 34, 36diltiazem hcl in 0.9% nacl ..............................36DILUENT FOR ACTHIB..............................70DILUENT FOR EPOPROSTENOL/FLOLA........................... 51DILUENT FOR HIBERIX............................ 70DILUENT FOR IMOVAX............................ 70DILUENT FOR MENHIBRIX......................70DILUENT FOR MENOMUNE..................... 70DILUENT FOR MENOMUNE (PF) .............70DILUENT FOR RABAVERT....................... 70DILUENT FOR ROTARIX...........................71DILUENT FOR YF-VAX (1 DOSE) ............ 71DILUENT FOR YF-VAX (5 DOSE) ............ 71DILUENT-MERCK LIVE VIRUS VACC....71dimenhydrinate ...............................................89DIPENTUM................................................... 92diphenhydramine hcl ....................................112diphenoxylate-atropine .................................. 89dipyridamole ............................................ 67, 99DISCOVISC.................................................109disopyramide phosphate ................................ 33disulfiram ....................................................... 50DIURIL.......................................................... 38divalproex ...........................................40, 46, 48DIVIGEL....................................................... 85DMSA............................................................ 68dobutamine .....................................................36dobutamine in d5w ......................................... 36DOCEFREZ................................................... 25
docetaxel ........................................................ 25dofetilide .........................................................33donepezil ........................................................ 51DONNATAL................................................. 91dopamine ........................................................36dopamine in 5 % dextrose ..............................36doripenem .......................................................14DORYX MPC................................................ 19dorzolamide ..................................................108dorzolamide-timolol ..................................... 108DOTAREM....................................................67DOVONEX....................................................60doxapram ....................................................... 47doxazosin ........................................................39doxazosin mesylate (bulk) .............................. 39doxepin ........................................................... 43doxercalciferol ............................................. 104doxorubicin .................................................... 26doxorubicin, peg-liposomal ........................... 26doxycycline hyclate ................................ 19, 105doxycycline monohydrate ...............................19DRAXIMAGE DTPA....................................68DRAXIMAGE MAA.....................................68DRAXIMAGE MDP-25................................ 68DRITHOCREME HP.....................................60dronabinol ................................................69, 89droperidol .........................................................7drospirenone-e.estradiol-lm.fa .......................52drospirenone-ethinyl estradiol .......................52DROXIA........................................................ 99DUAVEE....................................................... 84DUET DHA BALANCED.............................78DUET DHA WITH OMEGA-3.....................78DULERA..................................................... 114duloxetine ................................................. 42, 47duloxetine hcl (bulk) .................................42, 47DUODOTE...................................................... 9DUOVISC VISCO ELASTIC..................... 109DUPIXENT....................................................58DUREZOL................................................... 107dutasteride ......................................................94dutasteride-tamsulosin ................................... 93DYANAVEL XR.....................................46, 47DYLOJECT..................................................... 6DYRENIUM.................................................. 38DYSPORT................................................... 101econazole ........................................................59EDARBI.........................................................32EDARBYCLOR.............................................32EDECRIN...................................................... 38EDLUAR....................................................... 49EDURANT.....................................................12EFFER-K....................................................... 74EFFIENT........................................................99EGRIFTA.......................................................86ELAPRASE................................................. 103electrolyte-48 in d5w ......................................71ELELYSO....................................................103ELESTRIN.....................................................85ELETONE......................................................61eletriptan hbr ..................................................48ELIDEL..........................................................60ELIGARD...................................................... 23ELIGARD (3 MONTH).................................23ELIGARD (4 MONTH).................................23ELIGARD (6 MONTH).................................23ELIGEN B12..................................................80ELINEST....................................................... 52ELIQUIS........................................................ 96ELITE OB WITH DHA.................................77
ELITEK..........................................................96ELITE-OB 400...............................................77ELLA............................................................. 55ELLIOTTS B (PF) ......................................... 71ELMIRON..................................................... 93EMADINE................................................... 107EMBEDA.........................................................3EMCYT..........................................................23EMEND......................................................... 89EMEND (FOSAPREPITANT)...................... 89EMFLAZA.....................................................86EMOQUETTE............................................... 52EMPLICITI ....................................................22EMSAM......................................................... 42EMTRIVA..................................................... 13EMULSION SB............................................. 60enalapril maleate ........................................... 31enalaprilat ......................................................31enalapril-hydrochlorothiazide ....................... 31ENBREL.......................................................... 4ENBREL SURECLICK...................................4ENDARI.......................................69, 75, 93, 99ENDO AVITENE.......................................... 97ENDOCET................................................... 3, 4ENDOMETRIN............................................. 85ENGERIX-B (PF) .......................................... 28ENGERIX-B PEDIATRIC (PF) .................... 28ENLON-PLUS................................................. 9enoxaparin ..................................................... 98ENPRESSE.................................................... 55entacapone ..................................................... 43entecavir .........................................................16ENTERAGAM.................................................1ENTEREG..................................................... 10ENTERO VU................................................. 66ENTRESTO................................................... 32ENTYVIO......................................................92ENVARSUS XR.......................................... 100EOVIST......................................................... 67EPANED........................................................31EPCLUSA......................................................16ephedrine sulfate ............................................ 36ephedrine sulfate-0.9%nacl(pf) ......................36EPICERAM................................................... 61EPIDUO......................................................... 57EPIDUO FORTE........................................... 57EPIFIX AMNIOTIC MEMBRANE.............. 65EPIFOAM...................................................... 62epigallocatechin gallate(bulk) ......................... 1epinastine ..................................................... 107epinephrine .......................................36, 37, 112epirubicin ....................................................... 26EPISIL..........................................................105EPIVIR...........................................................13EPIVIR HBV................................................. 16eplerenone ................................................32, 37EPOGEN........................................................96epoprostenol (glycine) ....................................39eprosartan ...................................................... 32EPZICOM...................................................... 13EQUETRO............................................... 41, 46ERAXIS(WATER DILUENT) ...................... 11ERBITUX...................................................... 27ergocalciferol (vitamin d2) ............................ 80ergoloid .......................................................... 51ERIVEDGE....................................................23ERRIN............................................................54ERTACZO..................................................... 59ERWINAZE...................................................22ERYPED 400................................................. 17
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ERY-TAB...................................................... 17ERYTHROCIN..............................................17ERYTHROCIN (AS STEARATE) ................17erythromycin .......................................... 17, 110erythromycin ethylsuccinate .......................... 17erythromycin with ethanol ............................. 55erythromycin-benzoyl peroxide ......................56ESBRIET..................................................... 116ESCAVITE.................................................... 76ESCAVITE D................................................ 77escitalopram oxalate ...................................... 42esmolol ..................................................... 33, 35esomeprazole magnesium .............................. 90esomeprazole sodium ..................................... 90estazolam ........................................................49ESTRACE....................................................116estradiol ................................................. 84, 116estradiol valerate ........................................... 84estradiol-norethindrone acet ..........................84ESTRING.....................................................116ESTROGEL................................................... 85estrogens-methyltestosterone ......................... 84estropipate ......................................................84ESTROSTEP FE-28 .......................................55eszopiclone ..................................................... 49ethacrynate sodium ........................................ 37ethambutol ......................................................14ETHAMOLIN................................................40ethanol (ethyl alcohol) ..................................... 1ethosuximide ...................................................42ethyl acetate ................................................... 51ethyl alcohol (bulk) ........................................ 51ethyl chloride ..................................................64ethynodiol diac-eth estradiol ......................... 52etidronate disodium ........................................84etodolac ............................................................7etomidate ..........................................................7ETOPOPHOS.................................................23etoposide ........................................................ 23EUCRISA.......................................................58EUFLEXXA.................................................101EURAX..........................................................65EVAMIST......................................................85EVEKEO..................................................46, 47EVISTA......................................................... 88EVOTAZ........................................................13EXALGO ER................................................... 3EXELDERM..................................................59EXELON........................................................51exemestane ..................................................... 22EXFORGE..................................................... 32EXFORGE HCT............................................ 32EXJADE...........................................................9EXODERM....................................................58EXONDYS 51 ..............................................101EXPAREL (PF) ................................................8EXTAVIA....................................................106EXTINA.........................................................59EXTRANEAL 7.5 %................................... 111EXTRA-VIRT PLUS DHA........................... 77EYLEA.................................................109, 110E-Z DISK....................................................... 66E-Z-CAT DRY...............................................66ezetimibe .........................................................34ezetimibe-simvastatin ..................................... 35E-Z-HD BARIUM......................................... 66E-Z-PAQUE...................................................66E-Z-PASTE....................................................66FABB....................................................... 80, 81FABIOR......................................................... 57
FABRAZYME............................................. 103FALMINA (28) ..............................................53famciclovir ..................................................... 17famotidine .......................................................90famotidine (pf) ................................................90famotidine (pf)-nacl (iso-os) ......................... 90FANAPT........................................................ 44FARESTON................................................... 25FARXIGA......................................................82FARYDAK.................................................... 23FASLODEX...................................................23FAYOSIM......................................................54FAZACLO..................................................... 44felbamate ........................................................40felodipine ........................................................36FEM PH....................................................... 116FEMHRT LOW DOSE..................................84FEMRING....................................................116fenofibrate ...................................................... 34fenofibrate micronized ................................... 34fenofibrate nanocrystallized ...........................34fenofibric acid ................................................ 34fenofibric acid (choline) .................................34FENOGLIDE................................................. 34fenoprofen ........................................................ 6FENORTHO.................................................... 7fentanyl .........................................................1, 2fentanyl (pf)-bupivacaine-nacl .........................3fentanyl citrate ......................................... 1, 2, 3fentanyl citrate (pf) .......................................1, 7fentanyl citrate-0.9%nacl (pf) .......................... 1FENTORA....................................................... 3FERAHEME.................................................. 72FERIDEX IV..................................................67FEROCON..................................................... 72FERRALET 90 DUAL-IRON DELIVERY.. 72FERRAPLUS 90 ............................................ 72FERREX 150 FORTE....................................72FERREX 150 FORTE PLUS.........................72FERREX 28 ................................................... 72FERRIPROX....................................................9FERROCITE PLUS....................................... 72FETZIMA...................................................... 42FINACEA................................................ 55, 64finasteride .......................................................94FIORICET........................................................4FIORINAL-CODEINE #3 ............................... 3FIRAZYR.......................................................35FIRMAGON KIT W DILUENT SYRINGE. 24FLAGYL........................................................12FLAREX...................................................... 107flavoxate ......................................................... 95FLEBOGAMMA DIF....................................28flecainide ........................................................33FLECTOR......................................................64FLOLIPID......................................................34FLORIVA (FLUORIDE-VITAMIN D3)................................................................ 77, 105FLOVENT DISKUS.................................... 112FLOVENT HFA.......................................... 112floxuridine ...................................................... 22FLUAD 2017-2018 (65 YR UP)(PF) .............30FLUARIX QUAD 2017-2018 (PF) ............... 30FLUBLOK 2017-2018 (PF) ...........................30FLUBLOK QUAD 2017-2018 (PF) .............. 30FLUCAINE..................................................108FLUCELVAX QUAD 2017-2018................. 30FLUCELVAX QUAD 2017-2018 (PF) .........30fluconazole ..................................................... 11fluconazole in dextrose(iso-o) ........................11
fluconazole in nacl (iso-osm) ......................... 11flucytosine ...................................................... 11fludarabine ..................................................... 21fludrocortisone ............................................... 87FLULAVAL QUAD 2017-2018....................30FLULAVAL QUAD 2017-2018 (PF) ............30flumazenil ......................................................... 9FLUMIST QUAD 2017-2018..................29, 30fluocinolone ....................................................61fluocinolone acetonide oil ............................111fluocinolone and shower cap ......................... 61fluocinonide ....................................................61FLUOCINONIDE-E...................................... 62FLUORABON............................................. 104FLUOR-A-DAY.......................................... 105FLUOR-A-DAY (WITH XYLITOL) ..104, 105fluorescein (bulk) ......................................... 108fluorescein-proparacaine .............................108FLUORESCITE........................................... 108fluoride (sodium) ..........................................104fluorometholone ........................................... 107fluorouracil .............................................. 22, 59fluorouracil (bulk) ....................................22, 50fluoxetine ........................................................42fluphenazine hcl ............................................. 45FLURA-DROPS.......................................... 104flurandrenolide ...............................................62flurazepam ......................................................49flurbiprofen ...................................................... 6flurbiprofen sodium ......................................108flutamide .........................................................21fluticasone ...................................................... 61fluticasone-salmeterol ..................................114fluvastatin .......................................................34FLUVIRIN 2017-2018...................................30FLUVIRIN 2017-2018 (PF) ...........................30fluvoxamine .................................................... 42FLUZONE HIGH-DOSE 2017-18 (PF) ........ 30FLUZONE INTRADERM QUAD 2017-18 ..30FLUZONE QUAD 2017-2018.......................30FLUZONE QUAD 2017-2018 (PF) .............. 30FLUZONE QUAD PEDI 2017-18 (PF) .........30FML FORTE................................................107FML S.O.P. .................................................. 107FOCALGIN CA.............................................78FOCALIN XR................................................46FOLBEE PLUS..............................................69FOLBIC RF....................................................80FOLGARD OS...............................................71FOLGARD RX........................................ 80, 81folic acid .........................................................80folic acid-vit b6-vit b12 ............................ 80, 81FOLIVANE-F................................................ 72FOLIVANE-OB.............................................77FOLIVANE-PLUS.........................................72FOLLISTIM AQ............................................ 85FOLOTYN..................................................... 21FOLTRATE................................................... 80FOLTX...........................................................80fomepizole ........................................................ 9fondaparinux .................................................. 98FORFIVO XL................................................ 43FORMADON.................................................27formaldehyde ..................................................27FORMA-RAY................................................27FORTAVIT....................................................75FORTAZ........................................................ 15FORTAZ IN DEXTROSE 5 %......................15FORTEO........................................................ 84FORTESTA................................................... 81
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FOSAMAX PLUS D..................................... 84fosamprenavir ................................................ 18foscarnet .........................................................15fosinopril ........................................................ 31fosinopril-hydrochlorothiazide ...................... 31fosphenytoin ................................................... 41FOSRENOL................................................... 94FOSTEUM....................................................... 1FOSTEUM PLUS............................................ 1FRAGMIN..................................................... 98FREAMINE HBC 6.9 %................................76FREAMINE III 10 %.....................................76FREESTYLE INSULINX............................102FREESTYLE INSULINX TEST STRIPS...102FREESTYLE LITE STRIPS........................102FREESTYLE TEST.....................................102FROVA.......................................................... 48frovatriptan .................................................... 48FUL-GLO.....................................................108furosemide ......................................................38FUSILEV....................................................... 27FUSION PLUS.............................................. 72FUZEON........................................................12FYCOMPA.................................................... 40gabapentin ......................................................41GABITRIL..................................................... 41GABLOFEN................................................ 101GADAVIST................................................... 67galantamine ....................................................51GALZIN...........................................................9GAMASTAN S/D..........................................28GAMMAGARD LIQUID..............................28GAMMAGARD S-D (IGA < 1 MCG/ML) ...28GAMMAKED................................................28GAMMAPLEX..............................................28GAMMAPLEX (WITH SORBITOL) ........... 28GAMUNEX-C............................................... 28ganciclovir sodium .........................................15ganirelix ......................................................... 87GARDASIL 9 (PF) ........................................ 30GASTROGRAFIN.........................................66GASTROMARK............................................67GATTEX 30-VIAL........................................93GATTEX ONE-VIAL....................................93GAZYVA.......................................................22GELCLAIR..................................................105GELFILM.............................................. 97, 109GELFOAM.................................................... 97GELFOAM COMPRESSED SIZE 100 .........97GELFOAM SPONGE SIZE 100................... 97GELFOAM SPONGE SIZE 12-7MM...........97GELFOAM SPONGE SIZE 200................... 97GELFOAM SPONGE SIZE 50 ..................... 97GELNIQUE................................................... 95GELX........................................................... 105gemcitabine .............................................. 21, 22gemfibrozil ..................................................... 34GENADUR.................................................... 65GENADUR (WITH LEXINAL) ....................65GENERESS FE..............................................53gentamicin ........................................10, 58, 109gentamicin (bulk) ........................................... 10gentamicin in nacl (iso-osm) ..........................10gentamicin sulfate (ped) (pf) .......................... 10gentamicin sulfate (pf) ................................... 10GENVOYA....................................................13GEODON.................................................44, 47GIANVI (28) ..................................................52GIAZO........................................................... 92GILDAGIA.................................................... 52
GILENYA....................................................106GILOTRIF..................................................... 20GLASSIA.....................................................114GLEEVEC..................................................... 25GLIADEL WAFER....................................... 20glimepiride ..................................................... 83glipizide ..........................................................83glipizide-metformin ........................................ 82GLUCAGEN DIAGNOSTIC KIT.................67GLUCAGEN HYPOKIT............................... 81GLUCAGON EMERGENCY KIT (HUMAN)......................................................81glucagon hcl ...................................................81glutaraldehyde ............................................... 27glyburide ........................................................ 83glyburide micronized ......................................83glyburide-metformin .......................................82glycine urologic solution ................................93glycolic acid (bulk) .........................................50GLYCOPHOS................................................73glycopyrrolate ................................................ 91GLYXAMBI.................................................. 82GOCOVRI..................................................... 44GOLYTELY.................................................. 92GONAL-F...................................................... 85GONAL-F RFF.............................................. 85GONITRO......................................................33GORDONS UREA........................................ 61GRAFIX CORE............................................. 65GRAFIX PRIME............................................65granisetron (pf) .............................................. 89granisetron hcl ............................................... 89GRANIX........................................................ 96GRASTEK..................................................... 27griseofulvin microsize .................................... 11griseofulvin ultramicrosize ............................ 11guanfacine ................................................37, 45guanidine ......................................................100GYNAZOLE-1 .............................................116HAEGARDA................................................. 96HALAVEN.................................................... 23halobetasol propionate .................................. 61HALOG..........................................................62haloperidol ..................................................... 44haloperidol decanoate ....................................44haloperidol lactate ......................................... 44HAVRIX (PF) ................................................ 28HEATHER..................................................... 54HECTOROL................................................ 104HEMABATE................................................. 81HEMANGEOL.............................................. 35HEMATINIC PLUS VIT/MINERALS......... 72HEMATINIC/FOLIC ACID..........................72HEMATOGEN.............................................. 72HEMATOGEN FA........................................ 72HEMATOGEN FORTE.................................72HEMATRON-AF...........................................72HEMENATAL OB........................................ 77HEMENATAL OB + DHA........................... 77HEMETAB.................................................... 72HEMOCYTE-F..............................................72HEMOCYTE-PLUS...................................... 72HEP FLUSH-10 (PF) ............................... 97, 98HEPAGAM B................................................ 28heparin (porcine) ........................................... 97heparin (porcine) (bulk) .................................97heparin (porcine) in 0.9% nacl ...................... 97heparin (porcine) in 5 % dex ......................... 97heparin (porcine) in nacl (pf) .........................97heparin flush(porcine)-0.9nacl ...................... 97
heparin lock flush (porcine) ...........................97heparin(porcine) in 0.45% nacl ..................... 98heparin, porcine (pf) ................................ 97, 98HEPATAMINE 8%....................................... 76HEPSERA......................................................16HERCEPTIN..................................................27hetastarch 6 % in 0.9 % nacl ......................... 98HETLIOZ.......................................................47HEXALEN.....................................................20HEXTEND.....................................................98HICON........................................................... 25HIZENTRA....................................................28homatropine hbr ...........................................107HORIZANT................................................... 49HPR................................................................60HPR PLUS..................................................... 61HPR PLUS-MB HYDROGEL.......................60huber safety needles (disp.) ..................102, 103HUMIRA................................................... 4, 92HUMIRA PEDIATRIC CROHN'S START.................................................................... 5, 92HUMIRA PEN.................................................5HUMIRA PEN CROHN'S-UC-HS START....5HUMIRA PEN PSORIASIS-UVEITIS........... 5HYCAMTIN.................................................. 25HYCOFENIX...............................................115hydralazine .....................................................37HYDRO 40.................................................... 63hydrochloric acid (bulk) .................................50hydrochlorothiazide ....................................... 38hydrocodone-acetaminophen ........................... 3hydrocodone-chlorpheniramine ...................115hydrocodone-homatropine ........................... 115hydrocodone-ibuprofen ....................................3hydrocortisone ................................... 61, 85, 92hydrocortisone acetate .....................................8hydrocortisone butyrate ................................. 61hydrocortisone valerate ................................. 61hydrocortisone-acetic acid ...........................111hydrocortisone-min oil-wht pet ......................62hydrocortisone-pramoxine ................... 8, 61, 62hydromorph(pf)-ropiv-0.9% nacl .....................1hydromorphone ............................................ 1, 2hydromorphone (pf) ......................................... 1hydromorphone (pf)-0.9% nacl ........................1hydromorphone in 0.9 % nacl ..........................1hydromorphone-bupiv (pf)-nacl .......................3hydroquinone ................................................. 60hydroquinone microspheres ...........................60hydroxocobalamin ..........................................80hydroxychloroquine ................................... 5, 12hydroxyprogesterone caproate ...................... 87hydroxyurea ................................................... 22hydroxyzine hcl .............................................. 40hydroxyzine pamoate ......................................40HYGEL.......................................................... 64HYLATOPIC................................................. 61HYLATOPICPLUS....................................... 61HYLENEX.....................................................88HYOPHEN.....................................................95hyoscyamine sulfate ....................................... 91HYPERHEP B S/D........................................ 28HYPERHEP B S-D NEONATAL................. 28HYPERLYTE CR.......................................... 73HYPERRAB S/D (PF) ................................... 28HYPERRHO S/D...........................................28HYPER-SAL..................................................51HYPERTET S/D (PF) ....................................29HYQVIA........................................................28HYQVIA HY COMPONENT....................... 88
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HYQVIA IG COMPONENT.........................28HYSINGLA ER............................................... 2ibandronate .................................................... 84IBRANCE...................................................... 22ibuprofen .......................................................... 6ibuprofen-oxycodone ........................................4ibutilide fumarate ...........................................33ICAR-C PLUS............................................... 72ICLUSIG........................................................24idarubicin ....................................................... 26IDHIFA.......................................................... 24IFEREX 150 FORTE..................................... 72ifosfamide ....................................................... 20ifosfamide-mesna ........................................... 20ILARIS (PF) .....................................................4ILEVRO....................................................... 108ILUVIEN..................................................... 107IMBRUVICA...........................................22, 25imipenem-cilastatin ........................................14imipramine hcl ............................................... 43imipramine pamoate ...................................... 43imiquimod .......................................................63IMITREX....................................................... 48IMLYGIC.................................................23, 29IMOGAM RABIES-HT (PF) .........................28IMOVAX RABIES VACCINE (PF) ............. 31IMPAVIDO....................................................12INCRELEX....................................................87INCRUSE ELLIPTA................................... 113indapamide .....................................................38INDICLOR.....................................................68INDIGO CARMINE...................................... 68INDIUM IN-111 DTPA.................................68indium in-111 oxyquinoline ........................... 68INDOCIN.........................................................7indomethacin ....................................................7indomethacin sodium ..................................... 39INFANRIX (DTAP) (PF) .............................. 29INFASURF.................................................. 114INFED............................................................72INFUMORPH P/F ............................................3INFUVITE ADULT.......................................75INFUVITE PEDIATRIC............................... 76INGREZZA..............................................48, 49INJECTAFER................................................ 72INLYTA.........................................................25INNOPRAN XL.............................................35INOVA...........................................................56INOVA 4-1 .................................................... 57INOVA 8-2 .................................................... 57insulin syr/ndl u100 half mark ............. 102, 103insulin syringe needleless .....................102, 103insulin syringe-needle u-100 ................102, 103insulin syringes (disposable) ................102, 103INTEGRA F...................................................72INTEGRA PLUS........................................... 72INTEGRILIN................................................. 98INTELENCE..................................................12INTRALIPID................................................. 76INTRAROSA.................................................87INTRON A.....................................................23INTROVALE.................................................53INTUNIV ER.................................................45INVANZ........................................................ 14INVEGA........................................................ 44INVEGA SUSTENNA.................................. 44INVEGA TRINZA.........................................44INVIRASE..................................................... 18INVOKAMET............................................... 82INVOKAMET XR.........................................82
INVOKANA.................................................. 82IODOFLEX....................................................27IODOPEN...................................................... 72iodoquinol-hc ................................................. 59IODOSORB................................................... 27IONOSOL-B IN D5W................................... 71IONOSOL-MB IN D5W................................71IOPIDINE.................................................... 110ipecac ............................................................. 10IPOL...............................................................31ipratropium bromide .................................... 115ipratropium-albuterol .................................. 114IPRIVASK..................................................... 99irbesartan ....................................................... 32irbesartan-hydrochlorothiazide ..................... 32irinotecan ....................................................... 25ISENTRESS...................................................12ISENTRESS HD............................................ 12ISIBLOOM.................................................... 52isoflurane ......................................................... 7ISOLYTE S PH 7.4 ........................................73ISOLYTE-P IN 5 % DEXTROSE................. 71ISOLYTE-S................................................... 73isometh-dichloral-acetaminophn ................... 48isomethepten-caf-acetaminophen ...................48isoniazid ......................................................... 13ISORDIL........................................................33isosorbide dinitrate ........................................ 33isosorbide mononitrate .................................. 33isosulfan blue ................................................. 67ISOVUE-200..................................................66ISOVUE-250..................................................66ISOVUE-300..................................................66ISOVUE-370..................................................66ISOVUE-M 200............................................. 66ISOVUE-M 300............................................. 66isoxsuprine ..................................................... 39isradipine ....................................................... 36ISTALOL..................................................... 109ISTODAX...................................................... 23ISUPREL....................................................... 36itraconazole ....................................................11ivermectin .......................................................10IXEMPRA......................................................23IXIARO (PF) ..................................................30JADENU.......................................................... 9JADENU SPRINKLE...................................... 9JAKAFI ..........................................................23JALYN........................................................... 93JANUMET..................................................... 83JANUMET XR.............................................. 83JANUVIA...................................................... 82JARDIANCE................................................. 82JENTADUETO..............................................83JENTADUETO XR....................................... 83JEVTANA......................................................25JINTELI ......................................................... 84JOLESSA....................................................... 52JOLIVETTE...................................................54JUNEL 1.5/30 (21) .........................................52JUNEL 1/20 (21) ............................................52JUNEL FE 1.5/30 (28) ................................... 52JUNEL FE 1/20 (28) ...................................... 53JUXTAPID.....................................................35KABIVEN......................................................76KADCYLA.............................................. 21, 26KALBITOR................................................... 39KALETRA..................................................... 13KALYDECO................................................114KAPVAY....................................................... 45
KARBINAL ER...........................................112KARIVA (28) ................................................ 52KAZANO.......................................................83KCENTRA.....................................................96KELNOR 1/35 (28) ........................................53KENALOG.............................................. 62, 86KEPIVANCE................................................. 92KERAFOAM................................................. 63KERALAC.....................................................63KERALYT SCALP COMPLETE................. 63ketamine ........................................................... 7ketamine in 0.9 % sod chloride ........................7ketoconazole .......................................11, 58, 59ketoprofen .........................................................6ketorolac ...................................................6, 108KEVEYIS.....................................................100KEVZARA.......................................................5KEYTRUDA..................................................26KHEDEZLA.................................................. 42KINERET.........................................................5KINEVAC......................................................67KINRIX (PF) ..................................................29KIONEX (WITH SORBITOL) ......................71KISQALI ........................................................22KISQALI FEMARA CO-PACK................... 23kit for tc 99m-sestamibi no.1 ..........................68kit for tc 99m-sod thiosulfate ......................... 68kit prep of tc-99m-mebrofenin ........................68kit prep of tc-99m-sod pyroph ........................68kit prep tc-99m-medronate sod ...................... 68KITABIS PAK.............................................114KLOR-CON................................................... 74KLOR-CON M15.......................................... 74KLOR-CON/25..............................................74KOMBIGLYZE XR.......................................83KORLYM...................................................... 82K-PHOS NO 2 ............................................... 94K-PHOS ORIGINAL.....................................94KRISTALOSE............................................... 92KRYSTEXXA............................................... 96KURVELO.....................................................53KUVAN....................................................... 104KYLEENA.....................................................52KYNAMRO................................................... 34KYPROLIS.................................................... 25labetalol ......................................................... 32LACRISERT................................................106lactated ringers ........................................ 71, 79lactose (bulk) ..................................................51lactulose ................................................... 90, 92LAMICTAL ODT....................................41, 46LAMICTAL ODT STARTER (BLUE) ...41, 46LAMICTAL ODT STARTER (GREEN) 41, 47LAMICTAL ODT STARTER (ORANGE).................................................................. 41, 47LAMICTAL XR STARTER (BLUE) ............41LAMICTAL XR STARTER (GREEN).........41LAMICTAL XR STARTER (ORANGE)..... 41lamivudine ................................................12, 13lamivudine-zidovudine ................................... 13lamotrigine ............................................... 41, 46lancets .................................................. 102, 103lancing device ...................................... 102, 103lancing device with lancets .................. 102, 103LANOXIN..................................................... 37LANTUS........................................................86LANTUS SOLOSTAR.................................. 86LARIN 1.5/30 (21) .........................................53LARIN 1/20 (21) ............................................53LARIN FE 1.5/30 (28) ................................... 53
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LARIN FE 1/20 (28) ...................................... 53LARTRUVO..................................................19LASTACAFT...............................................107latanoprost ................................................... 110LATISSE........................................................65LATUDA....................................................... 44LAZANDA...................................................... 3LEENA 28......................................................55leflunomide .......................................................6LENVIMA..................................................... 25LENZAPATCH............................................. 64LESCOL XL.................................................. 34LESSINA....................................................... 53LETAIRIS......................................................39letrozole ..........................................................22leucovorin calcium .........................................27LEUKERAN.................................................. 20LEUKINE...................................................... 97leuprolide ....................................................... 23levalbuterol hcl ............................................ 113levalbuterol tartrate ..................................... 113LEVATOL..................................................... 35LEVEMIR......................................................86LEVEMIR FLEXTOUCH............................. 86levetiracetam ..................................................42levetiracetam in nacl (iso-os) .........................42levobunolol ...................................................108levocarnitine .................................................104levocarnitine (with sugar) ............................104levocetirizine ................................................ 112levofloxacin ...................................... 15, 16, 110levofloxacin in d5w ........................................ 15levoleucovorin ................................................27levomefolate calcium ......................................80LEVOMEFOLATE DHA.............................. 77LEVONEST (28) ........................................... 54levonorgestrel-ethinyl estrad ................... 52, 53LEVORA-28.................................................. 53levorphanol tartrate ......................................... 2levothyroxine ..................................................88LEVOXYL.....................................................88LEVSIN......................................................... 91LEVULAN.....................................................64LEXISCAN....................................................67LEXIVA.........................................................18LIALDA.........................................................92lidocaine .....................................................8, 65lidocaine (pf) in d7.5w .................................... 8lidocaine (pf) .............................................. 8, 33lidocaine hcl .......................................8, 65, 105lidocaine hcl(pf) in 0.9% nacl ..........................8lidocaine hcl-hydrocortison ac .................. 8, 62lidocaine in 5 % dextrose (pf) ........................ 33lidocaine-epinephrine ...................................... 8lidocaine-epinephrine bit ......................... 8, 105lidocaine-hydrocortisone-aloe ......................... 8lidocaine-prilocaine ....................................... 63lidocaine-tetracaine ....................................... 65LIDODERM...................................................65LIDOPIN........................................................65LIDORX.........................................................65LILETTA....................................................... 52LILLOW........................................................ 53LIMBREL........................................................ 1LIMBREL250.................................................. 1LIMBREL500.................................................. 1LINCOCIN.....................................................17lindane ............................................................65linezolid ..........................................................18linezolid-0.9% sodium chloride ..................... 18
LINZESS............................................90, 91, 92LIORESAL.................................................. 101liothyronine .................................................... 88LIPOCHOL PLUS......................................... 35LIPOFEN....................................................... 34LIPOSYN II ................................................... 76LIPOSYN III ..................................................76LIQUID E-Z PAQUE.................................... 66LIQUID POLIBAR PLUS............................. 66lisinopril ......................................................... 31lisinopril-hydrochlorothiazide ....................... 31lithium carbonate ........................................... 47lithium citrate .................................................47LIVALO.........................................................34LMD 10 % IN 0.9 % SODIUM CHLOR.......98LMD 10 % IN 5 % DEXTROSE................... 98L-METHYLFOLATE FORTE...................... 81L-METHYL-MC............................................74LMTHF-PYRIDOXINE-CYANOCOBALAMN...................................80LODOSYN.....................................................43LOESTRIN 1.5/30 (21) ..................................53LOESTRIN 1/20 (21) .....................................53LOESTRIN FE 1.5/30 (28-DAY)..................53LOESTRIN FE 1/20 (28-DAY).....................53LONSURF..................................................... 22loratadine, micronized (bulk) .......................112lorazepam ...........................................40, 46, 49LORTAB ELIXIR............................................3LORYNA (28) ............................................... 53LORZONE................................................... 101losartan .......................................................... 32losartan-hydrochlorothiazide .........................32LOSEASONIQUE......................................... 52LOTEMAX.................................................. 107LOTRONEX............................................ 91, 92LOUTREX............................................... 60, 61lovastatin ........................................................34LOVAZA....................................................... 35LOW-OGESTREL (28) ................................. 53loxapine succinate ..........................................45LUCENTIS.......................................... 109, 110LUGOLS........................................................71LUMIGAN...................................................110LUMIZYME................................................ 103LUNESTA..................................................... 49LUPANETA PACK (1 MONTH)..................87LUPANETA PACK (3 MONTH)..................87LUPRON DEPOT....................................23, 87LUPRON DEPOT (3 MONTH).............. 23, 87LUPRON DEPOT (4 MONTH).................... 23LUPRON DEPOT (6 MONTH).................... 24LUPRON DEPOT-PED.................................87LUPRON DEPOT-PED (3 MONTH)............87LUTERA (28) ................................................ 53LUZU............................................................. 59LYCELLE......................................................65LYNPARZA.................................................. 24LYRICA...................................................41, 47LYSIPLEX PLUS.......................................... 69LYSODREN.................................................. 21M.V.I. ADULT.............................................. 75M.V.I. PEDIATRIC....................................... 76MACRODANTIN..........................................95MACUGEN......................................... 109, 110MAGNEBIND 400........................................ 94magnesium chloride ....................................... 73magnesium glycinate (bulk) ........................... 73magnesium stearate ........................................51magnesium sulfate ..........................................73
magnesium sulfate in d5w .............................. 73magnesium sulfate in lr .................................. 73magnesium sulfate in water ............................73MAGNEVIST................................................ 67MAKENA...................................................... 87malathion ....................................................... 65manganese chloride ....................................... 73mannitol 10 % ................................................ 38mannitol 20 % ................................................ 38mannitol 25 % ................................................ 38mannitol 5 % .................................................. 38maprotiline ..................................................... 43MARLISSA................................................... 53MARNATAL-F............................................. 78MARPLAN.................................................... 42MARQIBO.....................................................26MATULANE................................................. 20MAVYRET....................................................16MAXALT.......................................................48MAXALT-MLT.............................................48MAXFE (FOLATE-DOCUSATE) ................ 72MAXIDEX...................................................108MAXIPIME................................................... 15MB HYDROGEL.......................................... 60MB HYDROGEL (CYCLOMETHICONE)..60M-CLEAR WC............................................ 115MD-76 R........................................................ 66MD-GASTROVIEW..................................... 66meclizine .........................................................89meclofenamate ................................................. 6MEDIHONEY (HONEY)..............................66MEDROL.......................................................86MEDROX (WITHOUT METHYL SALICY) ........................................................65medroxyprogesterone ...............................52, 87mefenamic acid ................................................ 6mefloquine ......................................................12MEFOXIN IN DEXTROSE (ISO-OSM)...... 14MEGACE ES................................................. 69megestrol ..................................................24, 69MELODETTA 24 FE.....................................53meloxicam ........................................................ 6melphalan .......................................................20melphalan hcl .................................................20memantine ...................................................... 51memantine hcl (bulk) ......................................51MEMBRANEBLUE.................................... 109MENACTRA (PF) ......................................... 29MENEST........................................................85MENHIBRIX (PF) .........................................30MENOMUNE - A/C/Y/W-135......................29MENOMUNE - A/C/Y/W-135 (PF) ..............29MENOPUR.................................................... 85MENOSTAR..................................................85MENTAX.......................................................58MENVEO A-C-Y-W-135-DIP (PF) .............. 29meperidine ........................................................2meperidine (pf) .................................................2meperidine (pf) in 0.9 % nacl ...........................2mepivacaine (pf) .......................................8, 105meprobamate ..................................................40MEPRON....................................................... 12mercaptopurine .............................................. 21meropenem ..................................................... 14meropenem-0.9% sodium chloride ................ 14mesalamine ...............................................91, 92mesalamine with cleansing wipe ....................92mesna ............................................................. 27MESNEX....................................................... 27MESTINON................................................. 100
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MESTINON TIMESPAN............................ 100METADATE ER............................................46METAFOLBIC.............................................. 74metaproterenol ............................................. 114METASTRON............................................... 25metaxalone ................................................... 101metformin ....................................................... 86methadone ........................................................ 2methazolamide ............................................... 37methenamine hippurate ..................................94methenamine mandelate .................................94methimazole ................................................... 83methocarbamol .............................................101methotrexate sodium .................................. 5, 21methotrexate sodium (pf) ............................... 21methscopolamine ............................................91methyclothiazide .............................................38methyl salicylate .............................................65methyldopa ..................................................... 37methyldopa-hydrochlorothiazide ................... 37methyldopate .................................................. 37methylene blue (antidote) .................................9methylergonovine ........................................... 87methylphenidate hcl ................................. 46, 49methylprednisolone ........................................ 85methylprednisolone acetate ............................85methylprednisolone sodium succ ................... 85methyltestosterone ..........................................81METHYLTETRAHYDROFOLIC ACID......80metipranolol ................................................. 108metoclopramide hcl ........................................91metolazone ..................................................... 38METOPIRONE..............................................67metoprolol succinate ...................................... 35metoprolol ta-hydrochlorothiaz ..................... 36metoprolol tartrate .........................................35metronidazole .............................12, 55, 64, 116metronidazole (bulk) ...................................... 12metronidazole in nacl (iso-os) ........................12mexiletine ....................................................... 33MIACALCIN................................................. 84mibelas 24 fe .................................................. 52MICARDIS.................................................... 32MICARDIS HCT........................................... 32MICONAZOLE-3........................................116MICRHOGAM ULTRA-FILTERED PLUS. 29MICROGESTIN 1.5/30 (21) ..........................54MICROGESTIN 1/20 (21) .............................54MICROGESTIN FE 1.5/30 (28) ....................53MICROGESTIN FE 1/20 (28) .......................53midazolam .................................................. 7, 49midazolam (pf) ................................................. 7midodrine ....................................................... 37MIFEPREX....................................................81MIGERGOT...................................................48miglitol ........................................................... 82MILLIPRED.................................................. 86MILLIPRED DP............................................ 85milrinone ........................................................ 36milrinone in 5 % dextrose .............................. 36MINIVELLE..................................................85MINOCIN...................................................... 19minocycline .......................................... 5, 19, 55minoxidil .........................................................37MIOCHOL-E............................................... 106MIOSTAT....................................................106MIRAPEX ER................................................44MIRCERA..................................................... 96MIRCETTE (28) ............................................ 52MIRENA........................................................52
mirtazapine .....................................................42MIRVASO..................................................... 64misoprostol .....................................................90MITIGARE.................................................... 95mitomycin ....................................................... 26MITOSOL....................................................107mitoxantrone .................................................. 26M-M-R II (PF) ................................... 29, 30, 31modafinil ........................................................ 49MODERIBA.................................................. 16moexipril ........................................................ 31moexipril-hydrochlorothiazide .......................31mometasone ............................................61, 115MONODOX...................................................19MONONESSA (28) ....................................... 53MONSEL'S .................................................... 97montelukast .................................................. 113MONUROL................................................... 95MORGIDOX..................................................19MORGIDOX 1X100......................................19MORGIDOX 2X100......................................19MORPHABOND ER....................................... 3morphine .......................................................... 2morphine (pf) ....................................................2morphine (pf) in 0.9 % nacl ............................. 2morphine (pf) in dextrose 5 % ..........................2morphine concentrate ...................................... 2morphine in 0.9 % nacl .................................... 2MOTOFEN.................................................... 89MOVANTIK..................................................10MOVIPREP................................................... 92MOXATAG................................................... 10MOXEZA.....................................................110moxifloxacin ........................................... 15, 110moxifloxacin hcl (bulk) ...................................15moxifloxacin-sod.ace,sul-water ..................... 16MOZOBIL..................................................... 96MUGARD....................................................105MULTAQ.......................................................33MULTIGEN...................................................72MULTIGEN FOLIC...................................... 72MULTIGEN PLUS........................................ 72MULTIHANCE............................................. 67MULTIHANCE MULTIPACK.....................67MULTITRACE-4 ...........................................74MULTITRACE-4 CONCENTRATE............ 74MULTITRACE-4 NEONATAL....................74MULTITRACE-4 PEDIATRIC.....................74MULTITRACE-5 ...........................................74MULTITRACE-5 CONCENTRATE............ 74MULTIVITAMIN WITH FLUORIDE......... 76MULTI-VITAMIN WITH FLUORIDE........ 76MULTIVITAMINS WITH FLUORIDE....... 76mupirocin ....................................................... 58mupirocin calcium ..........................................58MURI-LUBE................................................. 51MUSTARGEN...............................................20MVC-FLUORIDE......................................... 77MVW COMPLETE FORMUL PEDIATRIC...................................................76MVW COMPLETE FORMULATION D3000.............................................................76MY WAY.......................................................55MYALEPT.....................................................87MYCAMINE................................................. 11MYCOBUTIN......................................... 14, 19mycophenolate mofetil ............................. 5, 100mycophenolate sodium .................................100MYDAYIS............................................... 46, 47MYFORTIC................................................. 100
MYLERAN....................................................20MYNATAL..............................................77, 79MYNATAL ADVANCE............................... 77MYNATAL PLUS.........................................77MYNATAL-Z................................................77MYNATE 90 PLUS.......................................77MYNEPHROCAPS....................................... 69MYOBLOC..................................................101MYORISAN.................................................. 55MYRBETRIQ................................................ 93MYTESI .........................................................89MYZILRA..................................................... 54NABI-HB....................................................... 28nabumetone ...................................................... 6nadolol ........................................................... 35nadolol-bendroflumethiazide ......................... 38nafcillin .......................................................... 18nafcillin in dextrose iso-osm .......................... 18naftifine .......................................................... 58NAFTIN......................................................... 58NAGLAZYME............................................ 103nalbuphine ........................................................4NALFON......................................................... 7naloxone ......................................................... 10naltrexone .......................................................10NAMENDA................................................... 51NAMENDA TITRATION PAK....................51NAMENDA XR.............................................51NAMZARIC.................................................. 51NAPRELAN CR.............................................. 7naproxen ...........................................................6naproxen sodium .............................................. 6naratriptan ..................................................... 48NARCAN.......................................................10NAROPIN (PF) ................................................8NASCOBAL.................................................. 80NATACYN.................................................. 110NATAZIA......................................................54nateglinide ......................................................82NATESTO..................................................... 81NATPARA.....................................................87NATRECOR.................................................. 40NATURAL MIXED TOCOPHEROLS.........80NATURE-THROID....................................... 88NEBUPENT...................................................17NEBUSAL..................................................... 51NECON 0.5/35 (28) ....................................... 54NECON 1/50 (28) .......................................... 54NECON 7/7/7 (28) ......................................... 54needle (disp) 16 g .................................102, 103needle (disp) 18 g .................................102, 103needle (disp) 19 g .................................102, 103needle (disp) 23 gauge ......................... 102, 103needles, huber disposable .................... 102, 103nefazodone ..................................................... 42neomycin ........................................................ 10neomycin-bacitracin-poly-hc ....................... 107neomycin-bacitracin-polymyxin ...................109neomycin-polymyxin b gu ...............................93neomycin-polymyxin b-dexameth .................107neomycin-polymyxin-gramicidin ..................109neomycin-polymyxin-hc ....................... 107, 111NEOSALUS...................................................61neostigmine methylsulfate ............................ 100NEO-SYNALAR........................................... 58NEO-SYNALAR KIT....................................58NEPHPLEX RX.............................................69NEPHRAMINE 5.4 %................................... 76NEPHRON FA...............................................72NEPHRO-VITE RX.......................................69
126
NERLYNX.....................................................20NESACAINE................................................... 8NESINA......................................................... 82NESTABS......................................................79NESTABS ABC.............................................79NESTABS DHA............................................ 79NEUAC..........................................................56NEUAC KIT.................................................. 56NEULASTA...................................................96NEUPOGEN.................................................. 96NEUPRO........................................................44NEURIN-SL...................................................80NEUT............................................................. 71NEUTRASAL..............................................105NEVANAC.................................................. 108nevirapine .......................................................12NEXAVAR.................................................... 24NEXAVIR......................................................63NEXIUM IV.................................................. 90NEXIUM PACKET....................................... 90NEXT CHOICE ONE DOSE........................ 55NEXTERONE................................................33niacin ........................................................34, 80niacinamide (bulk) ......................................... 80NIACOR........................................................ 34NIASPAN EXTENDED-RELEASE............. 34nicardipine ..................................................... 36NICOMIDE....................................................74nicotine (polacrilex) .......................................50NICOTROL................................................... 50NICOTROL NS............................................. 50nifedipine ........................................................36NILANDRON................................................21nimodipine ......................................................36NINLARO......................................................25nisoldipine ......................................................36NITHIODOTE................................................. 9NITRO-BID................................................... 33NITRO-DUR..................................................33nitrofurantoin ................................................. 95nitrofurantoin macrocrystal ...........................95nitrofurantoin monohyd/m-cryst .................... 95nitroglycerin ...................................................33nitroglycerin in 5 % dextrose .........................33NITROLINGUAL..........................................33NITYR......................................................... 104nizatidine ........................................................90NORA-BE......................................................54NORDITROPIN FLEXPRO..........................86norepinephrine bitartrate ...............................37noreth-ethinyl estradiol-iron ..........................52norethindrone acetate .................................... 87norethindrone ac-eth estradiol .......................84norethindrone-e.estradiol-iron ...................... 52norgestimate-ethinyl estradiol ................. 52, 54NORITATE....................................................55NORLYDA.................................................... 54NORMLGEL AG...........................................58NORMOSOL-M IN 5 % DEXTROSE..........71NORMOSOL-R............................................. 73NORMOSOL-R IN 5 % DEXTROSE...........71NORMOSOL-R PH 7.4 ................................. 73NORPACE CR...............................................33NORTHERA..................................................37NORTREL 0.5/35 (28) .................................. 53NORTREL 1/35 (21) ..................................... 53NORTREL 1/35 (28) ..................................... 53NORTREL 7/7/7 (28) .................................... 54nortriptyline ................................................... 43NORVIR........................................................ 18
NOVAREL.....................................................86NOVOLIN 70/30 ........................................... 86NOVOLIN N..................................................86NOVOLIN R..................................................86NOVOLOG....................................................86NOVOLOG FLEXPEN................................. 86NOVOLOG MIX 70-30 .................................86NOVOLOG MIX 70-30 FLEXPEN.............. 86NOVOLOG PENFILL...................................86NOXAFIL...................................................... 11NP THYROID................................................88NPLATE........................................................ 99NUCALA..................................................... 113NUCYNTA...................................................... 2NUCYNTA ER................................................ 3NUEDEXTA..................................................49NULOJIX.....................................................100NUMOISYN............................................ 1, 105NUOX............................................................ 57NUPLAZID....................................................45NUTRESTORE............................69, 75, 93, 99NUTRICAP....................................................74NUTRILIPID................................................. 76NUTRILYTE................................................. 73NUVAIL........................................................ 64NUVARING.................................................. 55NUVESSA................................................... 116NUVIGIL....................................................... 49NYMALIZE...................................................36nystatin ............................................. 11, 58, 105nystatin-triamcinolone ................................... 59OB COMPLETE...................................... 73, 79OB COMPLETE PREMIER..........................73OB COMPLETE WITH DHA.......................79OBAGI NU-DERM SUNFADER................. 60OBAGI-C CLARIFYING SERUM............... 60OBAGI-C THERAPY NIGHT...................... 60OBREDON.................................................. 115OBSTETRIX DHA........................................ 77OBSTETRIX EC............................................79OBTREX DHA.............................................. 79O-CAL FA..................................................... 79O-CAL PRENATAL......................................79OCALIVA......................................................99OCELLA........................................................53OCREVUS................................................... 106OCTAGAM................................................... 28OCTAPLAS (BLOOD GROUP A) ............... 98OCTAPLAS (BLOOD GROUP AB) ............ 98OCTAPLAS (BLOOD GROUP B) ............... 98OCTAPLAS (BLOOD GROUP O) ............... 98OCTREOSCAN............................................. 68octreotide acetate .....................................88, 93OCUCOAT.................................................. 109OCUVEL....................................................... 74ODEFSEY......................................................13ODOMZO...................................................... 23OFEV..................................................... 25, 116OFIRMEV........................................................4ofloxacin .........................................15, 110, 111OGESTREL (28) ............................................54olanzapine ................................................ 45, 47olanzapine-fluoxetine ..................................... 43oleic acid ........................................................ 51olmesartan ......................................................32olmesartan-amlodipin-hcthiazid .................... 32olmesartan-hydrochlorothiazide ....................32olopatadine ...........................................107, 115OMECLAMOX-PAK.................................... 93omega-3 acid ethyl esters ...............................34
OMNIPAQUE 140.........................................66OMNIPAQUE 180.........................................66OMNIPAQUE 240.........................................66OMNIPAQUE 300.........................................67OMNIPAQUE 350.........................................67OMNISCAN.................................................. 67OMNISCAN PREFILL PLUS.......................67ondansetron ....................................................89ondansetron hcl ..............................................89ondansetron hcl (pf) ....................................... 89ondansetron in 0.9 % sod chlor ..................... 89ONFI ........................................................ 40, 46ONGLYZA.................................................... 82ONIVYDE..................................................... 25ONMEL......................................................... 11ONZETRA XSAIL........................................ 48OPANA............................................................3OPDIVO.........................................................26opium tincture ................................................ 88OPSUMIT...................................................... 39OPTIMARK...................................................67OPTIRAY 300............................................... 67OPTIRAY 320............................................... 67OPTIRAY 350............................................... 67OPTISON.......................................................67ORACEA................................................. 19, 64ORACIT.........................................................94ORALAIR......................................................28ORAMAGICRX.......................................... 105ORAP............................................................. 45ORAPRED ODT............................................86ORAVIG........................................................ 11ORBACTIV................................................... 17ORENCIA........................................................5ORENCIA (WITH MALTOSE) ......................5ORENCIA CLICKJECT..................................5ORENITRAM................................................39ORFADIN....................................................104ORKAMBI...................................................114orphenadrine citrate .................................... 101ORSYTHIA................................................... 53ORTHO MICRONOR................................... 54ORTHO TRI-CYCLEN (28) ......................... 55ORTHO TRI-CYCLEN LO (28) ................... 55ORTHO-CYCLEN (28) .................................54ORTHO-NOVUM 1/35 (28) ..........................54ORTHO-NOVUM 7/7/7 (28) .........................55oseltamivir ......................................................17OSENI............................................................83OSMITROL 15 %..........................................38OSMOPREP...................................................92OSPHENA..................................................... 87OTEZLA.................................................... 6, 60OTEZLA STARTER................................. 6, 60OTREXUP (PF) ............................................... 5OVACE PLUS............................................... 60OVACE PLUS SHAMPOO...........................60OVACE PLUS WASH.................................. 60OVCON-35 (28) ............................................ 54oxacillin ..........................................................18oxacillin in dextrose(iso-osm) ........................18oxaliplatin ...................................................... 24oxandrolone ................................................... 81oxaprozin ..........................................................6oxazepam ........................................................40oxcarbazepine ................................................ 41oxiconazole .....................................................59OXISTAT.......................................................59OXSORALEN ULTRA................................. 59OXTELLAR XR............................................ 41
127
oxybutynin chloride ........................................95oxycodone .........................................................2oxycodone-acetaminophen ...........................3, 4oxycodone-aspirin ............................................4OXYCONTIN..................................................2oxymorphone ....................................................2oxytocin .......................................................... 87oxytocin in dextrose 5 % in lr ........................ 87OZURDEX...................................................108paclitaxel ........................................................25PACNEX HP..................................................56PACNEX LP.................................................. 56PAIN EASE................................................... 64paliperidone ................................................... 44pamidronate ................................................... 84PANCREAZE................................................ 90pancuronium ................................................ 101PANDEL........................................................62PANHEMATIN............................................. 96PANRETIN....................................................59pantoprazole ...................................................90papaverine ......................................................39PARAGARD T 380A.................................... 52paregoric ........................................................88PAREMYD.................................................. 106paricalcitol ................................................... 104paromomycin ..................................................10paroxetine hcl .................................................42paroxetine mesylate ........................................87PASER........................................................... 13PATADAY...................................................107PATANASE.................................................115PATANOL................................................... 107PAZEO.........................................................107PCE................................................................ 17PEDIARIX (PF) .......................................28, 29PEDITRACE..................................................74PEDVAX HIB (PF) ....................................... 29peg 3350-electrolytes ..................................... 92PEGANONE.................................................. 41PEGASYS......................................................16PEGASYS PROCLICK................................. 16peg-electrolyte soln ........................................ 92PEGINTRON................................................. 16pen needle, diabetic ..............................102, 103penicillin g pot in dextrose .............................18penicillin g potassium .................................... 18penicillin g procaine ...................................... 18penicillin g sodium ......................................... 18penicillin v potassium .....................................18PENNSAID....................................................64PENTACEL (PF) ........................................... 30PENTACEL DTAP-IPV COMPNT (PF) ...... 29PENTAM....................................................... 17PENTASA......................................................92pentazocine-naloxone .......................................4pentoxifylline ..................................................97PERFOROMIST.......................................... 113PERIKABIVEN............................................. 76perindopril erbumine ..................................... 31PERJETA....................................................... 26permethrin ......................................................65perphenazine .................................................. 45perphenazine-amitriptyline ............................ 43PERTZYE...................................................... 90PEXEVA........................................................42phenazopyridine ............................................. 94phendimetrazine tartrate ................................69phenelzine .......................................................42phenobarb-hyoscy-atropine-scop ...................91
phenobarbital ........................................... 40, 49phenobarbital sodium .............................. 40, 49phenol .............................................................27phenoxybenzamine ......................................... 39PHENYLADE GMP...................................... 75phenylephrine hcl ...................................37, 108phenylephrine hcl in 0.9% nacl ......................37phenytoin ........................................................41phenytoin sodium ..................................... 33, 41phenytoin sodium extended ............................ 41PHILITH........................................................ 53PHOSLYRA...................................................94PHOSPHA 250 NEUTRAL.....................73, 94PHOSPHASAL..............................................95PHOSPHOLINE IODIDE............................106PHOTOFRIN................................................. 24PHYSICIANS EZ USE B-12 .........................80PHYSIOLYTE............................................... 71PHYSIOSOL IRRIGATION......................... 71physostigmine salicylate .................................. 9phytonadione (vit k1) (bulk) ...........................81phytonadione (vitamin k1) ............................. 81PICATO......................................................... 59pilocarpine hcl ..................................... 105, 106pimozide ......................................................... 45pindolol .......................................................... 35pioglitazone ....................................................87pioglitazone-glimepiride ................................ 83piperacillin-tazobactam ................................. 18PIRMELLA....................................................53piroxicam ......................................................... 6PKU EASY MICROTABS............................75PKU PERIFLEX JUNIOR PLUS.................. 75PLASBUMIN 5 %......................................... 98PLASMA-LYTE 148 .....................................73PLASMA-LYTE A........................................ 73PLASMA-LYTE-56 IN 5 % DEXTROSE.... 71PLASMANATE.............................................98PLEGRIDY..................................................106PLEXION.......................................................56PLIAGLIS......................................................65PNEUMOVAX 23......................................... 30PNV OB+DHA.............................................. 77PNV-DHA......................................................77PNV-DHA + DOCUSATE............................ 77PNV-OMEGA................................................77PNV-SELECT................................................77PODIAPN...................................................... 69PODOCON.................................................... 63podofilox .........................................................63POLIBAR ACB............................................. 66POLOCAINE................................................... 8POLOCAINE-MPF..........................................8polyethylene glycol 3350 ................................92POLY-IRON 150 FORTE............................. 72polymyxin b sulfate .........................................18polymyxin b sulf-trimethoprim ..................... 109POLY-VI-FLOR............................................ 77POLY-VI-FLOR WITH IRON......................77POMALYST.................................................. 25PONTOCAINE.............................................. 65PORTIA......................................................... 54PORTRAZZA................................................ 27POTABA........................................................81potassium acetate ...........................................73potassium bicarb and chloride .......................73potassium bicarb-citric acid .......................... 73potassium chlorid-d5-0.45%nacl ................... 73potassium chloride ................................... 73, 74potassium chloride in 0.9%nacl .....................73
potassium chloride in 5 % dex ....................... 73potassium chloride in lr-d5 ............................ 73potassium chloride-0.45 % nacl .....................73potassium chloride-d5-0.2%nacl ................... 73potassium chloride-d5-0.3%nacl ................... 73potassium chloride-d5-0.9%nacl ................... 73potassium citrate ............................................ 94potassium hydroxide ...................................... 56potassium phosphate m-/d-basic ....................73PR CREAM....................................................64PR NATAL 400............................................. 77PR NATAL 400 EC....................................... 77PR NATAL 430............................................. 77PR NATAL 430 EC....................................... 77PRADAXA.................................................... 99pralidoxime ...................................................... 9PRALUENT PEN.......................................... 35pramipexole ....................................................44PRAMOSONE............................................... 62PRAMOSONE E............................................62prasterone (dhea), micro(bulk) .................. 1, 50prasugrel ........................................................ 99pravastatin ..................................................... 34prazosin ..........................................................39PRECEDEX................................................... 50PRECEDEX IN 0.9 % SODIUM CHLOR.... 50PRECISION XTRA TEST...................102, 103PRED MILD................................................ 107PRED-G....................................................... 107PRED-G S.O.P. ............................................107prednicarbate ................................................. 61prednisolone ...................................................85prednisolone acetate .................................... 107prednisolone sodium phosphate .............85, 107prednisone ......................................................85PREDNISONE INTENSOL.......................... 85PREFERA-OB PLUS DHA...........................79PREFEST....................................................... 84PREGNYL..................................................... 86PREMARIN........................................... 85, 116PREMASOL 10 %......................................... 76PREMASOL 6 %........................................... 76PREMPHASE................................................ 84PREMPRO..................................................... 84PRENA1 TRUE............................................. 77PRENAISSANCE..........................................77PRENAISSANCE PLUS............................... 77PRENATA..................................................... 79PRENATABS FA.......................................... 79PRENATABS RX..........................................79PRENATAL 19 ..............................................79PRENATAL 19 (WITH DOCUSATE) ......... 77PRENATAL LOW IRON..............................77PRENATAL PLUS........................................ 77PRENATAL PLUS (CALCIUM CARB)...... 77PRENATAL-U...............................................77PREPARATION H HYDROCORTISONE...62PRE-PEN....................................................... 68PREPIDIL...................................................... 81PREPOPIK.....................................................93PRESERA...................................................... 61PRESTALIA.................................................. 31PREVACID SOLUTAB................................ 90PREVALITE..................................................34PREVIDENT 5000 DRY MOUTH............. 105PREVIDENT 5000 PLUS............................105PREVIDENT 5000 SENSITIVE................. 105PREVIFEM....................................................54PREVNAR 13 (PF) ........................................30PREVPAC......................................................93
128
PREZCOBIX................................................. 13PREZISTA..................................................... 18PRIALT............................................................1PRIFTIN...................................................14, 19PRILOSEC.....................................................90primaquine ..................................................... 12PRIMAXIN IV...............................................14primidone ....................................................... 40PRIMSOL...................................................... 11PRISMASOL B22GK..................................111PRISMASOL BGK......................................111PRISMASOL BK.........................................111PRIVIGEN..................................................... 28PROAIR HFA.............................................. 114PROAIR RESPICLICK............................... 114probenecid ......................................................96probenecid-colchicine ....................................95procainamide ................................................. 33PROCALAMINE 3%.................................... 76prochlorperazine ............................................89prochlorperazine edisylate .............................89prochlorperazine maleate ........................ 45, 89PROCORT....................................................... 8PROCRIT.......................................................96PROCTOCORT......................................... 8, 62PROCTOFOAM HC........................................8PROCTO-PAK...........................................8, 62PROCTOZONE-HC.................................. 8, 62PROCYSBI .................................................... 93PRODRIN...................................................... 48PROFERRIN-FORTE....................................73progesterone ...................................................87progesterone micronized ................................87PROGLYCEM............................................... 81PROGRAF................................................... 100PROHANCE.................................................. 67PROHANCE MULTIPACK..........................67PROLASTIN-C............................................114PROLENSA................................................. 108PROLEUKIN................................................. 23PROLIA......................................................... 88PROMACTA................................................. 99promethazine ..........................................89, 112PROMETHAZINE VC................................ 111PROMETHAZINE VC-CODEINE............. 115promethazine-codeine .................................. 115promethazine-dm ..........................................116PROMETHEGAN......................................... 89PROMISEB..............................................60, 61PROMISEB COMPLETE........................60, 61propafenone ................................................... 33propantheline ................................................. 91proparacaine ................................................109propofol ............................................................7propranolol .................................................... 35propranolol-hydrochlorothiazid .................... 38propylthiouracil ............................................. 83PROQUAD (PF) ................................ 29, 30, 31PROSOL 20 %............................................... 76PROSTASCINT.............................................68PROSTIN E2..................................................81PROSTIN VR PEDIATRIC...........................39protamine ....................................................... 10PROTECT IRON........................................... 74PROTONIX................................................... 90PROTOPAM CHLORIDE...............................9PROTOPIC.................................................... 60protriptyline ................................................... 43PROVENGE.................................................. 23PROVENTIL HFA...................................... 114
PROVIDA DHA............................................ 79PROVIDA OB............................................... 79PROVISC.....................................................109PROVOCHOLINE.........................................68PRUCLAIR....................................................61PRUMYX.......................................................61PRUTECT......................................................61PULMICORT...............................................113PULMICORT FLEXHALER...................... 113PULMOZYME............................................ 115PURALOR CI ................................................ 81PUREFE OB PLUS....................................... 79PUREFE PLUS.............................................. 79PUREVIT DUALFE PLUS........................... 74PURIXAN......................................................21PUROXCIN................................................... 64PYLERA........................................................ 93pyrazinamide ..................................................14pyridostigmine bromide ............................... 100pyridoxine (vitamin b6) ..................................80PYROGALLIC ACID....................................64QBRELIS....................................................... 32QUARTETTE................................................ 54QUASENSE...................................................53quazepam ....................................................... 49QUDEXY XR................................................ 41QUELICIN...................................................101QUESTRAN LIGHT..................................... 34quetiapine .................................................45, 47QUFLORA FE (FERROUS SULFATE) .......77QUFLORA PEDIATRIC DROPS................. 77QUILLICHEW ER........................................ 46QUILLIVANT XR.........................................46quinapril .........................................................31quinapril-hydrochlorothiazide ....................... 31quinidine gluconate ........................................33quinidine sulfate .............................................33quinine sulfate ................................................ 12QUTENZA.....................................................65QVAR.......................................................... 113RABAVERT (PF) .......................................... 31rabeprazole .................................................... 90RADIAPLEXRX........................................... 64RADIGEL ACEMANNAN HYDROGEL.................................................................. 61, 66RAGWITEK.................................................. 28RAJANI......................................................... 53raloxifene ....................................................... 88ramipril .......................................................... 31RANEXA....................................................... 33ranitidine hcl .................................................. 90RAPAFLO..................................................... 94RAPAMUNE............................................... 100rasagiline ....................................................... 44RASUVO (PF) ................................................. 5RAVICTI ..................................................... 104RAYALDEE................................................ 104READI-CAT 2 ............................................... 66REBETOL......................................................16REBIF (WITH ALBUMIN) .........................106REBIF REBIDOSE......................................106REBIF TITRATION PACK........................ 106RECLIPSEN (28) ...........................................54RECOMBIVAX HB (PF) .............................. 28RECOTHROM...............................................97RECOTHROM SPRAY KIT......................... 97RECTIV........................................................... 8REGENECARE............................................. 65REGENECARE WITH ALOE...................... 65REGIMEX..................................................... 69
REGONOL...................................................100RELAGARD................................................116RELCOF C...................................................115RELENZA DISKHALER..............................17RELISTOR.....................................................10RELNATE DHA............................................77RELPAX........................................................ 48REMICADE...............................................5, 92REMODULIN................................................39RENAGEL..................................................... 94RENAL CAPS............................................... 69RENA-VITE RX............................................69RENFLEXIS.............................................. 5, 92RENO CAPS..................................................69RENOVA....................................................... 64RENVELA..................................................... 94REOPRO........................................................99repaglinide ..................................................... 82repaglinide-metformin ................................... 82REPATHA PUSHTRONEX..........................35REPATHA SURECLICK.............................. 35REPATHA SYRINGE...................................35REQ49+................................................... 71, 74RESCRIPTOR............................................... 12RESECTISOL................................................93RESPA-AR.................................................. 111RESTASIS................................................... 108RESTASIS MULTIDOSE........................... 108RETIN-A........................................................57RETIN-A MICRO..........................................57RETIN-A MICRO PUMP..............................57RETISERT................................................... 108RETROVIR....................................................13REVATIO...................................................... 39REVLIMID.................................................... 25REVONTO...................................................101REXULTI .......................................................45REYATAZ............................................... 18, 19REZIRA....................................................... 115R-GENE 10 .................................................... 67RHOFADE.....................................................64RHOGAM ULTRA-FILTERED PLUS.........29RHOPHYLAC............................................... 29RIASTAP....................................................... 97RIAX..............................................................57RIBASPHERE............................................... 16RIBASPHERE RIBAPAK.............................16ribavirin ......................................................... 16RIDAURA....................................................... 5rifabutin ....................................................14, 19RIFAMATE................................................... 14rifampin ....................................................14, 19RIFATER....................................................... 14riluzole ......................................................... 100rimantadine .................................................... 17RIMSO-50......................................................93ringer's ..................................................... 71, 79RIOMET........................................................ 86risedronate ..................................................... 84RISPERDAL CONSTA.................................44risperidone ............................................... 44, 47RITALIN LA................................................. 46RITUXAN..................................................5, 22RITUXAN HYCELA.................................... 22rivastigmine ....................................................51rivastigmine tartrate ...................................... 51RIVELSA.......................................................54rizatriptan .......................................................48ROBAXIN................................................... 101rocuronium ...................................................101
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ropinirole ....................................................... 44ropivacaine (pf) ................................................8ROSADAN.................................................... 64rosuvastatin ....................................................34ROTARIX................................................29, 31ROTATEQ VACCINE............................ 29, 31ROZEREM.....................................................47RUBRACA.................................................... 24RUCONEST...................................................96RYANODEX............................................... 102RYDAPT........................................................25RYTARY....................................................... 43SABRIL......................................................... 41saccharin ........................................................70s-adenosylmeth sulf tos (bulk) ..........................1safety needles ....................................... 102, 103SAFYRAL..................................................... 53salicylic acid .................................................. 63salicylic acid er-ceramides ............................ 63salsalate ........................................................... 7SALVAX DUO PLUS................................... 63SAMSCA....................................................... 38SANCUSO..................................................... 89SANDOSTATIN LAR DEPOT...............88, 93SANTYL........................................................61SAPHRIS (BLACK CHERRY)...............44, 47SAVAYSA.....................................................96SAVELLA............................................... 42, 47SCALACORT................................................62SCALACORT DK......................................... 62SCLEROSOL INTRAPLEURAL................116scopolamine base ........................................... 89scopolamine hbr .............................................91SCULPTRA................................................. 102SEASONIQUE...............................................52SECONAL SODIUM.................................... 49SELECT-OB (FOLIC ACID) ........................ 79SELECT-OB + DHA..................................... 79selegiline hcl .................................................. 44selenium ......................................................... 74selenium sulfide ..............................................60SELRX........................................................... 60SELZENTRY.................................................12SEMPREX-D............................................... 111SE-NATAL 19 ............................................... 77SE-NATAL 19 (WITH DOCUSATE) ...........77SENSIPAR.....................................................84SENSORCAINE-MPF/EPINEPHRINE..........8SEREVENT DISKUS..................................113sertraline ........................................................ 42SE-TAN PLUS...............................................74sevelamer carbonate ...................................... 93sevoflurane ....................................................... 7SHOHL'S MODIFIED...................................94SIDEROL.......................................................73SIGNIFOR..................................................... 88SIGNIFOR LAR............................................ 88sildenafil .........................................................39SILENOR.......................................................50SILIQ............................................................. 57silver nitrate ................................................... 58silver nitrate applicators ................................63silver sulfadiazine .......................................... 60SILVRSTAT.................................................. 58SIMBRINZA................................................106SIMPONI......................................................... 5SIMPONI ARIA.............................................. 5SIMULECT..................................................100simvastatin ..................................................... 34SINOGRAFIN............................................... 66
sirolimus .......................................................100SIRTURO.......................................................13SITAVIG........................................................17SITZMARKS................................................. 67SIVEXTRO....................................................18SKLICE..........................................................65SKYLA.......................................................... 52sodium acetate ................................................71sodium benzoate-sod phenylacet ..................104sodium bicarbonate ........................................71sodium bisulfite .............................................. 51sodium chloride ........................................51, 79sodium chloride 0.45 % ................................. 79sodium chloride 0.9 % ............................. 70, 79sodium chloride 3 % ...................................... 79sodium chloride 5 % ...................................... 79sodium citrate-citric acid ............................... 94SODIUM EDECRIN......................................38sodium ferric gluconat-sucrose ......................72sodium hydroxide (bulk) .................................50sodium lactate ................................................ 71sodium nitrite ................................................... 9sodium phenylbutyrate ................................. 104sodium phosphate ...........................................73sodium phosphate in 0.9 % nacl .................... 73sodium polystyrene sulfonate ......................... 71sodium succinate ............................................ 51sodium thiosulfate ............................................ 9SOLESTA.................................................... 102SOLIQUA 100/33 .......................................... 83SOLIRIS.........................................................98SOLTAMOX................................................. 25SOLU-CORTEF.............................................86SOLU-CORTEF (PF) .................................... 86SOLU-MEDROL........................................... 86SOLU-MEDROL (PF) ...................................86SOMATULINE DEPOT................................88SOMAVERT..................................................86SONAFINE....................................................61SOOLANTRA............................................... 65sorbitol ............................................... 51, 92, 93sorbitol-mannitol ............................................93SORILUX...................................................... 60sotalol .......................................................33, 35SOTALOL AF......................................... 33, 35SOTRADECOL............................................. 40SOTYLIZE...............................................33, 35SOVALDI...................................................... 16SPECTRACEF...............................................15spinosad ......................................................... 65SPIRIVA RESPIMAT................................. 113SPIRIVA WITH HANDIHALER............... 113spironolactone ..........................................32, 37spironolacton-hydrochlorothiaz .....................38SPORANOX.................................................. 11SPORANOX PULSEPAK.............................11SPRAY AND STRETCH.............................. 64SPRINTEC (28) ............................................. 53SPRITAM...................................................... 42SPRYCEL...................................................... 25SPS (WITH SORBITOL) .............................. 71SRONYX....................................................... 53SSKI ............................................................... 72stavudine ........................................................ 13STELARA................................................57, 91sterile talc .....................................................116STIMATE...................................................... 82STIOLTO RESPIMAT................................ 114STIVARGA................................................... 24STRATTERA.................................................46
STRENSIQ...................................................103streptomycin ................................................... 10STRIANT.......................................................82STRIBILD......................................................13STRIVERDI RESPIMAT............................ 113STROMECTOL............................................. 10STRONG IODINE.........................................72STROVITE FORTE.......................................74STROVITE ONE........................................... 74SUBOXONE..................................................50SUBSYS...........................................................3succinylcholine chloride .............................. 101SUCRAID...................................................... 90sucralfate ........................................................93sufentanil citrate .............................................. 7sulfacetamide sodium .............................60, 110sulfacetamide sodium (acne) ..........................55sulfacetamide sodium-sulfur .................... 56, 58sulfacetamide sod-sulfur-urea ..................56, 64sulfacetamide-prednisolone ......................... 107sulfacetamide-sulfur-cleansr23 ......................56sulfact na-sul-avobnz-otn-ocsa ................ 56, 64sulfadiazine .................................................... 19sulfamethoxazole-trimethoprim ..................... 10SULFAMYLON............................................ 60sulfasalazine ...............................................5, 92sulindac ............................................................ 6SUMADAN XLT.....................................56, 65sumatriptan .................................................... 48sumatriptan succinate .................................... 48SUMAVEL DOSEPRO................................. 48SUMAXIN CP............................................... 56SUPER B/C....................................................69SUPERVITE.................................................. 69SUPRANE....................................................... 7SUPRAX........................................................15SUPREP BOWEL PREP KIT........................92SURFAXIN..................................................114SURMONTIL................................................ 43SURVANTA................................................115SUSTIVA.......................................................12SUSTOL.........................................................89SUTENT........................................................ 25SWABFLUSH................................... 70, 79, 80SYEDA.......................................................... 54SYLATRON.................................................. 23SYLVANT..................................................... 23SYMAX DUOTAB........................................91SYMBICORT.............................................. 114SYMLINPEN 120..........................................83SYMLINPEN 60 ............................................83SYNAGIS...................................................... 28SYNALAR CREAM KIT..............................62SYNALAR OINTMENT KIT....................... 62SYNALAR TS............................................... 63SYNAREL..................................................... 87SYNDROS............................................... 69, 89SYNERA........................................................65SYNERCID....................................................19SYNJARDY...................................................82SYNJARDY XR............................................ 82SYNRIBO...................................................... 26SYNTHROID.................................................88SYNVISC.....................................................101SYNVISC-ONE........................................... 101SYPRINE......................................................... 9syringe (disposable) ............................. 102, 103syringe (reusable) ................................ 102, 103SYRINGE AVITENE.................................... 97syringe with needle ...............................102, 103
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syringe with needle, safety ................... 102, 103TABLOID...................................................... 21TACHOSIL....................................................97TACLONEX.................................................. 57tacrolimus ...............................................60, 100TAFINLAR....................................................22TAGITOL V.................................................. 66TAGRISSO.................................................... 20TALTZ AUTOINJECTOR............................ 57TALTZ AUTOINJECTOR (2 PACK)...........57TALTZ AUTOINJECTOR (3 PACK)...........57TALTZ SYRINGE.........................................57TALTZ SYRINGE (2 PACK)....................... 57TALTZ SYRINGE (3 PACK)....................... 57TALWIN..........................................................4TAMIFLU......................................................17tamoxifen ........................................................25tamsulosin ...................................................... 94TANDEM PLUS............................................75TANZEUM.................................................... 83TARCEVA.....................................................20TARGRETIN........................................... 25, 59TARKA..........................................................31TARON FORTE............................................ 72TARON-C DHA............................................ 77TARON-PREX PRENATAL-DHA.............. 78TASIGNA...................................................... 25TASMAR....................................................... 43TAYTULLA.................................................. 53tazarotene .......................................................59TAZICEF....................................................... 15TAZORAC.....................................................60TAZTIA XT...................................................36TECENTRIQ................................................. 26TECFIDERA................................................106TEFLARO......................................................15TEGRETOL XR............................................ 41TEKTURNA.................................................. 39TEKTURNA HCT......................................... 39telmisartan ..................................................... 32telmisartan-amlodipine .................................. 32telmisartan-hydrochlorothiazid ..................... 32temazepam ......................................................49TEMODAR....................................................21temozolomide ................................................. 21teniposide ....................................................... 23TENIVAC (PF) .............................................. 29TEPADINA....................................................20terazosin ......................................................... 39terbinafine hcl ................................................ 11terbutaline .................................................... 114terconazole ................................................... 116TERSI FOAM................................................ 60TESTIM......................................................... 82testosterone .................................................... 81testosterone (bulk) ..........................................81testosterone cypionate ....................................81testosterone enanthate ....................................81tetanus,diphtheria tox ped(pf) ........................ 29tetanus-diphtheria toxoids-td ......................... 29tetrabenazine ..................................................48tetracaine hcl ................................................109tetracaine hcl (pf) .....................................8, 109tetracycline .....................................................19TETRAVISC................................................109TETRAVISC FORTE.................................. 109TEXACORT.................................................. 62TEXAVITE LQ..............................................77thallous chloride tl-201 ..................................68THALOMID............................................ 11, 25
THAM............................................................71THEO-24......................................................113theophylline ..................................................113theophylline in dextrose 5 % ........................113thiamine hcl (vitamin b1) ............................... 80THIOLA.........................................................93thioridazine .................................................... 45thiotepa ...........................................................20thiothixene ......................................................45THROMBATE III ..........................................98THROMBI-GEL............................................ 97THROMBIN-JMI...........................................97THROMBI-PAD............................................97THYMOGLOBULIN.....................................29THYROGEN..................................................68THYROLAR-1...............................................88THYROLAR-1/2 ........................................... 88THYROLAR-1/4 ........................................... 88THYROLAR-2...............................................88THYROLAR-3...............................................88tiagabine .........................................................41TICE BCG................................................24, 29ticlopidine .......................................................99TILIA FE........................................................54timolol maleate .......................................35, 108TIMOPTIC OCUDOSE (PF) .......................109TINDAMAX..................................................12tinidazole ........................................................12TIROSINT..................................................... 88TISSEEL VHSD............................................ 97TIVICAY....................................................... 12TIVORBEX..................................................... 7tizanidine ......................................................101TL GARD RX..........................................80, 81TL G-FOL OS................................................71TL ICON........................................................ 72TL-HEM 150..................................................72TL-SELECT...................................................78TNKASE........................................................99TOBI ............................................................ 114TOBI PODHALER...................................... 114TOBRADEX................................................107TOBRADEX ST.......................................... 107tobramycin ................................................... 109tobramycin in 0.225 % nacl ......................... 114tobramycin in 0.9 % nacl ............................... 10tobramycin sulfate ..........................................10tobramycin with nebulizer ............................114tobramycin-dexamethasone ......................... 107TOBREX......................................................109TOLAK.......................................................... 59tolazamide ...................................................... 83tolbutamide .....................................................83tolcapone ........................................................43tolmetin .............................................................6tolterodine ...................................................... 95TOPICORT.................................................... 62topiramate ...................................................... 41topiramate (bulk) ............................................41topotecan ........................................................25TORISEL....................................................... 24torsemide ........................................................38TOUJEO SOLOSTAR...................................86TOVIAZ.........................................................95TOZAL...........................................................70TPN ELECTROLYTES.................................73TPN ELECTROLYTES II ............................. 73TRACE ELEMENTS 4/PEDIATRIC............74TRACLEER................................................... 39TRADJENTA.................................................82
tramadol ........................................................... 2tramadol-acetaminophen ................................. 4trandolapril .................................................... 31trandolapril-verapamil ...................................31tranexamic acid ..............................................97TRANSDERM-SCOP....................................89tranylcypromine ............................................. 42TRAVASOL 10 %......................................... 76TRAVATAN Z............................................ 110trazodone ........................................................42TREANDA.....................................................20TRECATOR...................................................14TRELSTAR................................................... 24TREMFYA.....................................................57TRESIBA FLEXTOUCH U-100................... 86TRESIBA FLEXTOUCH U-200................... 86tretinoin ..........................................................57tretinoin (chemotherapy) ................................25tretinoin (emollient) ....................................... 64tretinoin microspheres ................................... 57TRETIN-X..................................................... 57TRETIN-X CREAM KIT.............................. 57TREXALL................................................. 5, 21TREXIMET................................................... 48TREZIX........................................................... 3TRI FEMYNOR.............................................54triacetin .......................................................... 59TRIADVANCE..............................................78triamcinolone acetonide ...................61, 62, 105triamcinolone hexaceton (bulk) ..................... 85triamterene-hydrochlorothiazid ..................... 38TRIANEX...................................................... 62triazolam ........................................................ 49TRIBENZOR................................................. 32TRICARE.......................................................79TRICARE PRENATAL DHA ONE..............79TRI-CHLOR.................................................. 63trichloroacetic acid ........................................ 63TRICITRASOL..............................................96TRICITRATES.............................................. 94TRIDERM......................................................62TRIESENCE (PF) ........................................ 108trifluoperazine ................................................45trifluridine .................................................... 110TRIGELS-F FORTE...................................... 72TRIGLIDE..................................................... 34trihexyphenidyl ...............................................43TRIKLO......................................................... 34TRI-LEGEST FE........................................... 55TRILEPTAL.................................................. 41TRI-LUMA.................................................... 60trimethobenzamide ......................................... 89trimethoprim ...................................................11TRINATAL GT............................................. 78TRINATAL RX 1 .......................................... 78TRINATE.......................................................79TRINESSA (28) .............................................54TRI-NORINYL (28) ...................................... 55TRINTELLIX................................................ 43tripelennamine (bulk) ...................................112TRIPHROCAPS.............................................69TRIPLE DYE.................................................59TRIPLE VITAMIN WITH FLUORIDE........76TRI-PREVIFEM (28) .................................... 54TRIPTODUR................................................. 87TRISENOX....................................................22TRI-SPRINTEC (28) ..................................... 54TRIUMEQ..................................................... 13TRIVEEN-DUO DHA...................................78TRIVEEN-ONE............................................. 78
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TRIVEEN-PRX RNF.....................................78TRI-VI-FLOR................................................ 77TRI-VIT WITH FLUORIDE AND IRON.....76TRI-VITAMIN WITH FLUORIDE.............. 76TRIVORA (28) .............................................. 55TRIZIVIR.......................................................13TROPHAMINE 10 %.................................... 76TROPHAMINE 6%....................................... 76tropicamide .................................................. 107trospium ......................................................... 95TRULANCE.................................................. 90TRULICITY...................................................83TRUMENBA................................................. 30TRUST NATAL DHA...................................78TRUVADA.................................................... 13tuberculin-allergy syringes .................. 102, 103TUBERSOL................................................... 67TUDORZA PRESSAIR...............................113TUSNEL PEDIATRIC................................ 116TUSSICAPS.................................................115TUZISTRA XR............................................115TWINRIX (PF) .............................................. 28TWYNSTA.................................................... 32TYBOST...................................................... 104TYGACIL...................................................... 16TYKERB........................................................19TYLACTIN RESTORE 10 PE...................... 75TYLACTIN RTD 15 PE................................ 75TYMLOS....................................................... 83TYPHIM VI ................................................... 29TYR ANAMIX NEXT...................................75TYSABRI.....................................................106TYVASO....................................................... 39TYVASO INSTITUTIONAL START KIT...39TYVASO REFILL KIT................................. 39TYVASO STARTER KIT............................. 39TYZINE....................................................... 115UCERIS......................................................... 92UDAMIN SP..................................................74ULESFIA....................................................... 65ULORIC.........................................................96ULTIMATECARE ONE............................... 78ULTIMATECARE ONE NF......................... 78ULTIVA...........................................................7ULTRAFOAM...............................................97ULTRAVATE X............................................62ULTRAVIST................................................. 67UMECTA.......................................................63UNITUXIN.................................................... 21UPTRAVI...................................................... 38UR N-C.......................................................... 95URAMAXIN..................................................63URAMAXIN GT........................................... 63urea .......................................................... 61, 63URELLE........................................................ 95URETRON D-S............................................. 95URIBEL......................................................... 95URIN DS........................................................95UROCIT-K 10 ................................................94UROCIT-K 15 ................................................94UROCIT-K 5 ..................................................94UROGESIC-BLUE........................................95URO-MP........................................................ 95UROQID-ACID NO.2 ................................... 94ursodiol .......................................................... 90URYL.............................................................95USTELL.........................................................95UTOPIC......................................................... 63UVADEX.......................................................24VAGIFEM................................................... 116
valacyclovir ....................................................16VALCHLOR..................................................59valganciclovir .................................................15valproate sodium ............................................40valproic acid ............................................ 40, 46valproic acid (as sodium salt) ..................40, 46valsartan .........................................................32valsartan-hydrochlorothiazide .......................32VALSTAR..................................................... 26vancomycin .....................................................16vancomycin in 0.9% sodium cl .......................16vancomycin in dextrose 5 % ...........................16VANIQA........................................................64VANOS..........................................................62VANOXIDE-HC............................................57VAPRISOL.................................................... 37VAQTA (PF) ..................................................28VARIBAR HONEY.......................................66VARIBAR NECTAR.....................................66VARIBAR PUDDING...................................66VARIBAR THIN HONEY............................ 66VARIBAR THIN LIQUID............................ 66VARITHENA................................................ 40VARIVAX (PF) ....................................... 29, 31VARIZIG....................................................... 29VARUBI........................................................ 89VASCAZEN.................................................. 35VASCEPA..................................................... 35VASCULERA................................................70vasopressin .....................................................82VASOSTRICT............................................... 82VAXCHORA VACCINE.............................. 30VAYACOG......................................................1VAYARIN....................................................... 1VAYAROL.................................................... 35VAZCULEP...................................................37V-C FORTE................................................... 74VECAMYL....................................................38VECTIBIX..................................................... 27vecuronium bromide .................................... 101VELCADE..................................................... 25VELETRI ....................................................... 39VELIVET TRIPHASIC REGIMEN (28) ...... 55VELTASSA................................................... 71VELTIN......................................................... 56VEMAVITE-PRX-2...................................... 78VENA-BAL DHA..........................................78VENCLEXTA................................................22VENCLEXTA STARTING PACK............... 22venlafaxine ..................................................... 42VENOFER..................................................... 72VENTAVIS....................................................39VENTOLIN HFA........................................ 114verapamil ................................................. 34, 36VERDESO..................................................... 62VEREGEN..................................................... 63VERIPRED 20 ............................................... 86VERSACLOZ................................................ 44VESICARE.................................................... 95VESTURA (28) ..............................................54VFEND.......................................................... 11VIBERZI ..................................................91, 92VIBRAMYCIN..............................................19VIC-FORTE...................................................74VICTOZA 2-PAK..........................................83VICTOZA 3-PAK..........................................83VIDAZA........................................................ 22VIDEX 2 GRAM PEDIATRIC..................... 13VIDEX 4 GRAM PEDIATRIC..................... 13vigabatrin ....................................................... 41
VIGAMOX.................................................. 110VIIBRYD....................................................... 43VIMIZIM..................................................... 103VIMPAT........................................................ 41VINACAL......................................................78VINATE CARE............................................. 79VINATE GT.................................................. 78VINATE II ..................................................... 78VINATE M.................................................... 78VINATE ONE................................................78VINATE PN CARE....................................... 78VINATE ULTRA.......................................... 78vinblastine ...................................................... 26vincristine .......................................................26vinorelbine ..................................................... 26VIOKACE......................................................90VIORELE (28) ...............................................52VIRACEPT.................................................... 19VIRAMUNE.................................................. 12VIRAMUNE XR............................................12VIREAD.........................................................13VIRT-PN........................................................78VIRT-PN DHA.............................................. 78VIRT-PN PLUS............................................. 78VIRT-SELECT.............................................. 78VIRT-VITE PLUS......................................... 69VISCOAT.................................................... 109VISIONBLUE..............................................109VISIPAQUE...................................................67VISUDYNE................................................. 109VIT 3 .............................................................. 74VITAFOL GUMMIES...................................79VITAFOL-OB+DHA.....................................79VITAL HIGH PROTEIN...............................75VITAL-D RX...........................................74, 80vitamin e ...................................................35, 80VITAMIN K.................................................. 81VITAMIN K1................................................ 81VITAMINS A,C,D AND FLUORIDE.......... 76VITA-RESPA.......................................... 80, 81VITRASE.......................................................88VITUZ..........................................................115VIVA DHA.................................................... 79VIVELLE-DOT............................................. 85VIVITROL.....................................................50VIVOTIF BERNA VACCINE...................... 29VOGELXO.................................................... 82VOL-CARE RX.............................................69VOL-NATE................................................... 78VOL-TAB RX................................................78VOLTAREN.................................................. 64VOLUMEN....................................................66VOLUVEN 6 %............................................. 98VORAXAZE..................................................27voriconazole ................................................... 11VOSEVI......................................................... 16VOTRIENT....................................................25VP-CH PLUS.................................................78VP-CH-PNV.................................................. 78VP-GGR-B6...................................................79VP-GSTN.........................................................1VP-HEME ONE.............................................78VP-PNV-DHA............................................... 78VPRIV..........................................................103VP-ZEL..........................................................70VRAYLAR.................................................... 47VUSION.........................................................59VYTONE....................................................... 58VYVANSE.....................................................46VYXEOS....................................................... 21
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warfarin ..........................................................96water for inject, bacteriostat ..........................70water for injection, sterile ........................70, 80water for irrigation, sterile ............................ 71WELCHOL.................................................... 34WESTHROID................................................ 88wheat germ oil ................................................80white petrolatum ............................................ 64WINRHO SDF...............................................29WP THYROID...............................................88WYMZYA FE................................................54XADAGO...................................................... 44XARELTO..................................................... 96XATMEP................................................... 5, 21XCLAIR.........................................................61XELJANZ........................................................ 5XELJANZ XR..................................................5XELODA....................................................... 22XENAZINE................................................... 48XEOMIN......................................................101XERAC AC....................................................59XERMELO.................................................... 89XGEVA..........................................................88XIAFLEX.....................................................101XIFAXAN......................................................19XIGDUO XR................................................. 82XOFIGO.........................................................25XOLAIR.......................................................113XOLEGEL..................................................... 59XTAMPZA ER................................................ 3XTANDI........................................................ 21XULANE....................................................... 55XYLOCAINE (CARDIAC) (PF) ...................33XYLOCAINE-MPF......................................... 8XYLOCAINE-MPF/EPINEPHRINE.............. 8XYREM......................................................... 49YASMIN (28) ................................................ 54YAZ (28) ........................................................54YERVOY....................................................... 22YF-VAX (PF) .......................................... 29, 31YONDELIS....................................................20YUVAFEM..................................................116zafirlukast .....................................................113zaleplon .......................................................... 49ZALTRAP......................................................26ZANOSAR.....................................................26ZARAH..........................................................53ZARXIO.........................................................96ZATEAN-CH.................................................78ZATEAN-PN DHA........................................78ZATEAN-PN PLUS...................................... 78ZAVESCA................................................... 104ZEBUTAL....................................................... 4ZEJULA......................................................... 24ZELAPAR......................................................44ZELBORAF................................................... 22ZEMAIRA................................................... 114ZEMBRACE SYMTOUCH.......................... 48ZEMPLAR................................................... 104ZENATANE.................................................. 55ZENCHENT (28) ...........................................54ZENPEP......................................................... 90ZENZEDI...........................................46, 47, 49ZERBAXA.....................................................14ZEVALIN (Y-90) .......................................... 24ZIAGEN.........................................................13ZIANA........................................................... 56zidovudine ...................................................... 13ZINACEF.......................................................14ZINACEF IN STERILE WATER................. 14
ZINBRYTA................................................. 106zinc chloride ...................................................74zinc sulfate ......................................................74ZINGIBER..................................................... 79ZIOPTAN (PF) ............................................ 110ziprasidone hcl ......................................... 44, 47ZIRGAN.......................................................110ZITHRANOL.................................................60ZMAX............................................................17ZN-DTPA.......................................................10ZODEX.......................................................... 86ZOHYDRO ER................................................ 3ZOLADEX.....................................................24zoledronic acid ...............................................84zoledronic acid-mannitol-water .....................84zoledronic ac-mannitol-0.9nacl ..................... 84ZOLINZA...................................................... 23zolmitriptan .................................................... 48zolpidem ......................................................... 49ZOLPIMIST...................................................49ZOMIG...........................................................48ZOMIG ZMT................................................. 48ZONATUSS.................................................112zonisamide ......................................................42ZONTIVITY.................................................. 99ZORTRESS..................................................100ZORVOLEX.................................................... 6ZOSTAVAX (PF) .................................... 29, 31ZOSYN IN DEXTROSE (ISO-OSM)........... 18ZOVIA 1/35E (28) ......................................... 53ZOVIA 1/50E (28) ......................................... 53ZOVIRAX......................................................60ZUBSOLV..................................................... 50ZUPLENZ......................................................89ZURAMPIC................................................... 96ZUTRIPRO.................................................. 115ZYDELIG...................................................... 24ZYFLO.........................................................112ZYLET......................................................... 107ZYMAXID...................................................110ZYPRAM......................................................... 8ZYPREXA RELPREVV................................45ZYTIGA...................................................20, 21ZYVOX..........................................................18
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