2016 List of CoveredDRUGS - · PDF file2016 List of CoveredDRUGS (Formulary) ... Medicare Approved Formulary File ID 00016011, Version 20 ... 5 5 You can find out if

2016 List of Covered

DRUGS(Formulary)

UnitedHealthcare Connected® (Medicare-Medicaid Plan)

Toll-Free 1-800-256-6533, TTY 7-1-1

8 a.m. to 8 p.m. Central Time, Monday to Friday

www.UHCCommunityPlan.com

www.myuhc.com/CommunityPlan

Medicare Approved Formulary File ID 00016011, Version 20

H7833_150629_154123_FINAL10 Last updated November 1, 2016

If you have questions, please call UnitedHealthcare Connected at 1-800-256-6533, TTY 7-1-1,

8 a.m. to 8 p.m. Central Time, Monday to Friday. The call is free. For more information, visit

www.UHCCommunityPlan.com.

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UnitedHealthcare Connected® (Medicare-Medicaid Plan)

2016 List of Covered Drugs (Formulary)

This is a list of drugs that members can get in UnitedHealthcare Connected.

UnitedHealthcare Connected® (Medicare-Medicaid Plan) is a health plan that contracts

with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees.

The List of Covered Drugs and/or pharmacy and provider networks may change

throughout the year. We will send you a notice before we make a change that affects you.

Benefits and/or co-payments may change on January 1 of each year.

You can always check UnitedHealthcare Connected’s up-to-date List of Covered Drugs

online at www.UHCCommunityPlan.com.

Limitations, co-payments, and restrictions may apply. For more information, call

UnitedHealthcare Connected Member Services or read the UnitedHealthcare Connected

Member Handbook.

Copays for prescription drugs may vary based on the level of Extra Help you receive.

Please contact the plan for more details.

You can get this information for free in other formats, such as large print, braille or audio.

Call 1-800-256-6533, TTY 7-1-1. The call is free.

You can get this information for free in other languages. Call 1-800-256-6533, TTY 7-1-1.

The call is free.

Usted puede obtener esta información de forma gratuita en otros idiomas. Llame al

1-800-256-6533, TTY 7-1-1. Las llamadas son gratuitas.




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Frequently Asked Questions (FAQ)

Find answers here to questions you have about this List of Covered Drugs. You can read

all of the FAQ to learn more, or look for a question and answer.

1 What prescription drugs are on the List of Covered Drugs? (We call the

List of Covered Drugs the “Drug List” for short.)

The drugs on the List of Covered Drugs that starts on page 9 are the drugs covered by UnitedHealthcare Connected. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

® .UnitedHealthcare Connected will cover all medically necessary drugs on the Drug

List if:

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

and

·you fill the prescription at a UnitedHealthcare Connected network pharmacy.

® UnitedHealthcare Connected may have additional steps to access certain drugs

(see question #5 below).

You can also see an up-to-date list of drugs that we cover on our website at

www.UHCCommunityPlan.com or call Member Services at 1-800-256-6533, TTY

7-1-1.

2 Does the Drug List ever change?

Yes. UnitedHealthcare Connected may add or remove drugs on the Drug List during

the year. Generally, the Drug List will only change if:

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

·we learn that a drug is not safe.

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

·Decide to require or not require prior approval for a drug. (Prior approval is

permission from UnitedHealthcare Connected before you can get a drug.)

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

·Add or change step therapy restrictions on a drug. (Step therapy means you must

try one drug before we will cover another drug.)

(For more information on these drug rules, see pages 4, 5 and 9.)




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We will tell you when a Medicare Part D drug you are taking is removed from the

Drug List. We will also tell you when we change our rules for covering a Medicare

Part D drug. Questions 3, 4, and 7 below have more information on what happens

when the Drug List changes.

® You can always check UnitedHealthcare Connected’s up-to-date Drug List online

at www.UHCCommunityPlan.com. You can also call Member Services to check

the current Drug List at 1-800-256-6533, TTY 7-1-1.

3 What happens when a cheaper drug comes along that works as well as

a drug on the Drug List now?

If you are taking a Medicare Part D drug that is removed because a cheaper drug that

works just as well comes along, we will tell you. We will tell you at least 60 days

before we remove it from the Drug List or when you ask for a refill. Then you can get

a 60-day supply of the drug before the change to the Drug List is made. You will

receive a letter letting you know about the change. Contact your doctor or other

prescriber to make sure this cheaper drug will work for you.

4 What happens when we find out a drug is not safe?

If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we

will take it off the Drug List right away. We will also send you a letter telling you that.

Contact your doctor or other prescriber and ask about your other options.

5 Are there any restrictions or limits on drug coverage? Or are there any

required actions to take in order to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In

some cases you must do something before you can get the drug. For example:

·Prior approval (or prior authorization): For some drugs, you or your doctor or

other prescriber must get approval from UnitedHealthcare Connected before you

fill your prescription. If you don’t get approval, UnitedHealthcare Connected may

not cover the drug.

·Quantity limits: Sometimes UnitedHealthcare Connected limits the amount of a

drug you can get.

· Step therapy: Sometimes UnitedHealthcare Connected requires you to do step

therapy. This means you will have to try drugs in a certain order for your medical

condition. You might have to try one drug before we will cover another drug. If

your doctor thinks the first drug doesn’t work for you, then we will cover the

second.




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You can find out if your drug has any additional requirements or limits by looking in the tables on pages 10 - 117. You can also get more information by visiting our website

at www.UHCCommunityPlan.com. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.

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

information on exceptions.

® If you are in a nursing home or other long-term care facility and need a drug that

is not on the Drug List, or if you cannot easily get the drug you need, we can help.

We will cover a 31-day emergency supply of the drug you need (unless you have a

prescription for fewer days), whether or not you are a new UnitedHealthcare

Connected member. This will give you time to talk to your doctor or other

prescriber. He or she can help you decide if there is a similar drug on the Drug List

you can take instead or whether to request an exception. Please see question 11 for

more information about exceptions.

6 How will you know if the drug you want has limitations or if there are

required actions to take to get the drug?

The List of Covered Drugs on pages 10 - 117 has a column labeled “Necessary actions, restrictions, or limits on use.”

7 What happens if we change our rules on how we cover some drugs?

For example, if we add prior authorization (approval), quantity limits,

and/or step therapy restrictions on a drug.

We will tell you if we add prior approval, quantity limits, and/or step therapy

restrictions on a drug. We will tell you at least 60 days before the restriction is added

or when you next ask for a refill. Then, you can get a 60-day supply of the drug before

the change to the Drug List is made. This gives you time to talk to your doctor or

other prescriber about what to do next.

8 How can you find a drug on the Drug List?

There are two ways to find a drug:

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

·You can search by medical condition.




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To search alphabetically, go to the Alphabetical Listing section. You can find it after the “List of Covered Drugs” section. Find the name of your drug. The page number where you can find the drug will be next to it.

To search by medical condition, find the section labeled “List of drugs by medical condition” on pages 10 - 117. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions.

9 What if the drug you want to take is not on the Drug List?

If you don’t see your drug on the Drug List, call Member Services at 1-800-256-6533,

TTY 7-1-1 and ask about it. If you learn that UnitedHealthcare Connected will not

cover the drug, you can do one of these things:

·Ask Member Services for a list of drugs like the one you want to take. Then show

the list to your doctor or other prescriber. He or she can prescribe a drug on the

Drug List that is like the one you want to take. Or

·You can ask the health plan to make an exception to cover your drug. Please see

question 11 for more information about exceptions.

10 What if you are a new UnitedHealthcare Connected member and can’t

find your drug on the Drug List or have a problem getting your drug?

We can help. We may cover a temporary 30-day supply of your drug during the first

90 days you are a member of UnitedHealthcare Connected. This will give you time

to talk to your doctor or other prescriber. He or she can help you decide if there is a

similar drug on the Drug List you can take instead or whether to request an

exception.

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

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

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

· the drug requires prior approval by UnitedHealthcare Connected, or

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




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If you live in a nursing home or other long-term care facility, you may refill your

prescription for as long as 91 and may be up to 98 days. You may refill the drug

multiple times during your first 90 days in the plan. This gives your prescriber time

to change your drugs to ones on the Drug List or ask for an exception.

You may have an unplanned transition, like a hospital discharge or a change in your

level of care, after the first 90 days of your plan membership. If this happens and

your doctor prescribes a drug that’s not on the drug list, or if it’s difficult for you to

get your drugs, you are required to use your plan’s exception process. You may ask

for a one-time emergency supply of up to 30 days to give you time to talk to your

doctor about other treatment options or to try to get a formulary exception.

11 Can you ask for an exception to cover your drug?

Yes. You can ask UnitedHealthcare Connected to make an exception to cover a drug

that is not on the Drug List.

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

·For example, UnitedHealthcare Connected may limit the amount of a drug we

will cover. If your drug has a limit, you can ask us to change the limit and cover

more.

·Other examples: You can ask us to drop step therapy restrictions or prior

approval requirements.

12 How long does it take to get an exception?

First, we must receive a statement from your prescriber supporting your request for

an exception. After we receive the statement, we will give you a decision on your

exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72

hours for a decision, you can ask for an expedited exception. This is a faster

decision. If your prescriber supports your request, we will give you a decision within

24 hours of receiving your prescriber’s supporting statement.

13 How can you ask for an exception?

To ask for an exception, call Member Services. A Member Services representative

will work with you and your provider to help you ask for an exception.

14 What are generic drugs?

Generic drugs are made up of the same active ingredients as brand name drugs.

They usually cost less than the brand name drug and usually don’t have well-known

names. Generic drugs are approved by the Food and Drug Administration (FDA).

UnitedHealthcare Connected covers both brand name drugs and generic drugs.

15 What are OTC drugs?

OTC stands for “over-the-counter”. UnitedHealthcare Connected covers some OTC

drugs when they are written as prescriptions by your provider.

You can read the UnitedHealthcare Connected Drug List to see what OTC drugs are

covered.

16 Does UnitedHealthcare Connected cover OTC non-drug products?

UnitedHealthcare Connected covers some OTC non-drug products when they are

written as prescriptions by your provider.

You can read the UnitedHealthcare Connected Drug List to see what OTC non-drug

products are covered.

17 What is your co-pay?

You can read the UnitedHealthcare Connected Drug List to learn about the co-pay

for each drug.

UnitedHealthcare Connected members living in nursing homes or other long-term

care facilities will have no co-pays. Some members getting long-term care in the

community will also have no co-pays.

Co-pays are listed by tiers. Tiers are groups of drugs with the same co-pay.

·Tier 1 drugs have a lower co-pay. They are generic drugs. The co-pay will be from

$1.20 to $2.95, depending on your income.

·Tier 2 drugs have a higher co-pay. They are brand name drugs. The co-pay will

be from $3.60 to $7.40, depending on your income.

·Tier 3 drugs have a co-pay of $0. They are OTCs/Non-Part D drugs.




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9For Track Refered Purpose

List of Covered Drugs

The List of Covered Drugs that begins on the next page gives you information about the drugs covered by UnitedHealthcare Connected. If you have trouble finding your drug in the list, turn to the Index that begins on page 118.

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

The information in the “Necessary actions, restrictions, or limits on use” column tells you if UnitedHealthcare Connected has any rules for covering your drug.

Utilization Management Restrictions

PA - Prior approval (or prior authorization)

For some drugs, you or your doctor or other prescriber must get approval from

UnitedHealthcare Connected before you fill your prescription. If you don’t get approval,

UnitedHealthcare Connected may not cover the drug.

QL - Quantity limits

Sometimes UnitedHealthcare Connected limits the amount of a drug you can get.

ST - Step therapy

Sometimes UnitedHealthcare Connected requires you to do step therapy. This means you will

have to try drugs in a certain order for your medical condition. You might have to try one drug

before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then

we will cover the second.

Other Special Requirements for Coverage

B/D - Medicare Part B or Part D

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and

outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to

provide the plan with more information about how this drug will be used to make sure it’s

correctly covered by Medicare.

HRM - High Risk Medication

This drug is known as a high risk medication (HRM) for Medicare members 65 and older. This

drug may cause side effects if taken on a regular basis. We suggest you talk with your doctor

to see if an alternative drug is available to treat your condition.

Note: If you are 65 or older, you may need to get a prior authorization (PA) or formulary

exception from the health plan before the plan will cover a high risk medication (HRM). If you

are under 65, the prior authorization (PA) will not apply to you until the first time you get your

prescription filled after turning 65.

LA - Limited Access

Drugs are considered “limited access” if the FDA says the drug can be given out only by

certain facilities or doctors. These drugs may require extra handling, provider coordination or

patient education that can’t be done at a network pharmacy.

You can find information on what the symbols and abbreviations in this table mean by going to

page 9.

CAPITALIZED = brand name drug lower-case italics = generic drug

* For OTCs/Non-Part D Drugs. These drugs require a prescription in order to be covered by the plan.

1For Track Refered Purpose101


Note: The asterisk (*) next to a drug means the drug is not a “Part D drug.” The amount

you pay when you fill a prescription for this drug does not count towards your total drug

costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In

addition, if you are receiving Extra Help to pay for your prescriptions, you will not get any

Extra Help to pay for these drugs. These drugs also have different rules for appeals. An

appeal is a formal way of asking us to review a coverage decision and to change it if you

think we made a mistake. For example, we might decide that a drug that you want is not

covered or is no longer covered by Medicare or Medicaid. If you or your doctor disagrees

with our decision, you can appeal. To ask for instructions on how to appeal, call Member

Services at 1-800-256-6533, TTY 7-1-1. You can also read the Member Handbook to learn

how to appeal a decision.

Name of drugWhat the drug

will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Analgesics

Analgesics

Acephen

acephen (suppository)* $0 (Tier 3) QLAcetaminophen

acetaminophen (325mg tablet)* $0 (Tier 3) QLChildrens Mapap Rapid Tabs

childrens mapap rapid tabs (tablet dispersible)* $0 (Tier 3)Childrens Pain Reliever

childrens pain reliever (tablet dispersible)* $0 (Tier 3)Childrens Silapap

childrens silapap (160mg/5ml liquid)* $0 (Tier 3) QLED-APAP

ed-apap (liquid)* $0 (Tier 3) QLElixSure Fever/Pain

elixsure fever/pain (gel)* $0 (Tier 3)GNP Arthritis Pain Relief

gnp arthritis pain relief (tablet extended-release)* $0 (Tier 3) QLGNP Pain Relief

gnp pain relief (tablet)* $0 (Tier 3) QLGNP Pain Relief Extra Strength

gnp pain relief extra strength (tablet)* $0 (Tier 3) QLGoodsense Pain & Fever Childrens

goodsense pain & fever childrens (suspension)* $0 (Tier 3) QLInfants Silapap

infants silapap (80mg/0.8ml oral solution)* $0 (Tier 3) QLJunior Mapap

junior mapap (tablet dispersible)* $0 (Tier 3)Mapap

mapap (160mg/5ml liquid, 325mg tablet, 500mg tablet,

500mg capsule, 80mg tablet chewable)*$0 (Tier 3) QL


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will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMapap Acetaminophen Extra Strength

mapap acetaminophen extra strength (500mg/15ml

liquid)*$0 (Tier 3) QL

Mapap Arthritis Pain

mapap arthritis pain (tablet extended-release)* $0 (Tier 3) QLMapap Childrens

mapap childrens (160mg/5ml suspension)* $0 (Tier 3) QLMapap Childrens

mapap childrens (80mg tablet dispersible)* $0 (Tier 3)Nortemp

nortemp (suspension)* $0 (Tier 3) QLNortemp Infants

nortemp infants (suspension)* $0 (Tier 3) QLPain & Fever

pain & fever (tablet)* $0 (Tier 3) QLPain & Fever Childrens

pain & fever childrens (160mg/5ml oral solution, 160mg/

5ml suspension)*$0 (Tier 3) QL

Pain & Fever Extra Strength

pain & fever extra strength (tablet)* $0 (Tier 3) QLPain Relief Childrens

pain relief childrens (suspension)* $0 (Tier 3) QLPain Relief Extra Strength

pain relief extra strength (tablet)* $0 (Tier 3) QLQC Arthritis Pain Relief

qc arthritis pain relief (tablet extended-release)* $0 (Tier 3) QLQC Non-Aspirin Extra Strength

qc non-aspirin extra strength (tablet)* $0 (Tier 3) QLQ-PAP

q-pap (160mg/5ml liquid, 325mg tablet)* $0 (Tier 3) QLQ-PAP Childrens

q-pap childrens (suspension)* $0 (Tier 3) QLQ-PAP Extra Strength

q-pap extra strength (tablet)* $0 (Tier 3) QLQ-PAP Infants

q-pap infants (oral solution)* $0 (Tier 3) QLSM Pain Reliever

sm pain reliever (tablet)* $0 (Tier 3) QLSM Pain Reliever Childrens

sm pain reliever childrens (suspension)* $0 (Tier 3) QLSM Pain Reliever Extra Strength

sm pain reliever extra strength (tablet)* $0 (Tier 3) QL

Nonsteroidal Anti-inflammatory Drugs

Added Strength Headache Relief

added strength headache relief (tablet)* $0 (Tier 3)Adult Aspirin EC Low Strength

adult aspirin ec low strength (tablet delayed-release)* $0 (Tier 3) QLAll Day Pain Relief

all day pain relief (tablet)* $0 (Tier 3) QLAll Day Relief

all day relief (tablet)* $0 (Tier 3) QLAspirin

aspirin (325mg tablet, 325mg tablet delayed-release,

81mg tablet delayed-release, 81mg tablet chewable)*$0 (Tier 3) QL

Aspirin Adult Low Strength

aspirin adult low strength (tablet chewable)* $0 (Tier 3) QLAspirin EC

aspirin ec (tablet delayed-release)* $0 (Tier 3) QLAspirin EC Low Dose

aspirin ec low dose (tablet delayed-release)* $0 (Tier 3) QLAspirin Low Dose

aspirin low dose (tablet chewable)* $0 (Tier 3) QLAspir-Low

aspir-low (tablet delayed-release)* $0 (Tier 3) QLChildrens Aspirin

childrens aspirin (tablet chewable)* $0 (Tier 3) QLCongestion Relief

congestion relief (tablet)* $0 (Tier 3) QLDiclofenac Potassium

diclofenac potassium (tablet immediate-release) $1.20-$2.95 (Tier 1)


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will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useDiclofenac Sodium

diclofenac sodium (1% gel) $1.20-$2.95 (Tier 1) PADiclofenac Sodium DR

diclofenac sodium dr (tablet delayed-release) $1.20-$2.95 (Tier 1)Diclofenac Sodium ER

diclofenac sodium er (tablet extended-release 24 hour) $1.20-$2.95 (Tier 1)Diflunisal

diflunisal (tablet) $1.20-$2.95 (Tier 1)Effervescent Pain Relief

effervescent pain relief (tablet effervescent)* $0 (Tier 3)Enteric Coated Aspirin

enteric coated aspirin (tablet delayed-release)* $0 (Tier 3) QLEtodolac

etodolac (200mg capsule, 300mg capsule, 400mg tablet

immediate-release, 500mg tablet immediate-release)$1.20-$2.95 (Tier 1)

Flector

FLECTOR (PATCH) $3.60-$7.40 (Tier 2) PA, QLFlurbiprofen

flurbiprofen (tablet) $1.20-$2.95 (Tier 1)GNP Adult Aspirin Low Strength

gnp adult aspirin low strength (tablet chewable)* $0 (Tier 3) QLGNP Aspirin

gnp aspirin (tablet)* $0 (Tier 3) QLGNP Ibuprofen

gnp ibuprofen (otc only) (200mg tablet)* $0 (Tier 3) QLGNP Ibuprofen Junior Strength

gnp ibuprofen junior strength (otc only) (100mg tablet

chewable)*$0 (Tier 3) QL

Ibu-Drops

ibu-drops (otc only) (suspension)* $0 (Tier 3) QLIbu-Drops Infants

ibu-drops infants (otc only) (suspension)* $0 (Tier 3) QLIbuprofen

ibuprofen (otc only) (200mg capsule, 200mg tablet)* $0 (Tier 3) QLIbuprofen

ibuprofen (rx only) (100mg/5ml suspension, 400mg

tablet, 600mg tablet, 800mg tablet)$1.20-$2.95 (Tier 1)

Ibu-Profen Cold/Sinus

ibu-profen cold/sinus (tablet)* $0 (Tier 3)Ibuprofen Junior Strength

ibuprofen junior strength (otc only) (100mg tablet

chewable)*$0 (Tier 3) QL

Infants Ibuprofen

infants ibuprofen (otc only) (50mg/1.25ml suspension)* $0 (Tier 3) QLKetoprofen

ketoprofen (capsule immediate-release) $1.20-$2.95 (Tier 1)Ketorolac Tromethamine

ketorolac tromethamine (15mg/ml injection, 30mg/ml

injection, 60mg/2ml injection)$1.20-$2.95 (Tier 1)

Medi-Profen

medi-profen (tablet)* $0 (Tier 3) QLMeloxicam

meloxicam (15mg tablet, 7.5mg tablet) $1.20-$2.95 (Tier 1)Meloxicam

MELOXICAM (7.5MG/5ML SUSPENSION) $3.60-$7.40 (Tier 2)Migraine Formula

migraine formula (tablet)* $0 (Tier 3)


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will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMobisyl

mobisyl (cream)* $0 (Tier 3)Naproxen

naproxen (rx only) (125mg/5ml suspension, 250mg

tablet immediate-release, 375mg tablet immediate-

release, 500mg tablet immediate-release)

$1.20-$2.95 (Tier 1)

Naproxen DR

naproxen dr (rx only) (375mg tablet delayed-release,

500mg tablet delayed-release) (generic ec-naprosyn)$1.20-$2.95 (Tier 1)

Naproxen Sodium

naproxen sodium (otc only) (220mg tablet immediate-

release)*$0 (Tier 3) QL

Naproxen Sodium

naproxen sodium (rx only) (275mg tablet immediate-

release, 550mg tablet immediate-release)$1.20-$2.95 (Tier 1)

QC Aspirin

qc aspirin (tablet)* $0 (Tier 3) QLQC Aspirin Low Dose

qc aspirin low dose (tablet delayed-release)* $0 (Tier 3) QLQC Headache Relief

qc headache relief (tablet)* $0 (Tier 3)QC Ibuprofen

qc ibuprofen (otc only) (200mg capsule, 200mg tablet)* $0 (Tier 3) QLQC Naproxen Sodium

qc naproxen sodium (otc only) (220mg tablet immediate-


SM Aspirin

sm aspirin (tablet)* $0 (Tier 3) QLSM Aspirin EC Low Strength

sm aspirin ec low strength (tablet delayed-release)* $0 (Tier 3) QLSM Childrens Aspirin

sm childrens aspirin (tablet chewable)* $0 (Tier 3) QLSM Ibuprofen

sm ibuprofen (otc only) (200mg tablet)* $0 (Tier 3) QLSulindac

sulindac (tablet) $1.20-$2.95 (Tier 1)Voltaren

VOLTAREN (GEL) $3.60-$7.40 (Tier 2) PA

Opioid Analgesics, Long-actingEmbeda

EMBEDA (CAPSULE EXTENDED-RELEASE) $3.60-$7.40 (Tier 2) QLFentanyl

fentanyl (100mcg/hr patch 72 hour, 12mcg/hr patch 72

hour, 25mcg/hr patch 72 hour, 50mcg/hr patch 72 hour,

75mcg/hr patch 72 hour)

$1.20-$2.95 (Tier 1) QL

Hydromorphone HCl ER

hydromorphone hcl er (12mg tablet extended-release 24

hour abuse-deterrent, 16mg tablet extended-release 24

hour abuse-deterrent, 8mg tablet extended-release 24

hour abuse-deterrent)

$1.20-$2.95 (Tier 1) QL

Hydromorphone HCl ER

HYDROMORPHONE HCL ER (32MG TABLET

EXTENDED-RELEASE 24 HOUR ABUSE-

DETERRENT)

$3.60-$7.40 (Tier 2) QL

Levorphanol Tartrate

levorphanol tartrate (tablet) $1.20-$2.95 (Tier 1) QLMethadone HCl

methadone hcl (10mg tablet, 5mg tablet, 10mg/5ml oral

solution, 5mg/5ml oral solution)$1.20-$2.95 (Tier 1) QL

Methadone HCl

METHADONE HCL (10MG/ML INJECTION) $3.60-$7.40 (Tier 2)


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will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMorphine Sulfate ER

morphine sulfate er (tablet extended-release) (generic ms

contin)$1.20-$2.95 (Tier 1) QL

Nucynta ER

NUCYNTA ER (TABLET EXTENDED-RELEASE 12

HOUR)$3.60-$7.40 (Tier 2) QL

Opioid Analgesics, Short-actingAbstral

ABSTRAL (TABLET SUBLINGUAL) $3.60-$7.40 (Tier 2) PA, QLAcetaminophen/Codeine

acetaminophen/codeine (120mg-12mg/5ml oral

solution, 300mg-15mg tablet, 300mg-30mg tablet,

300mg-60mg tablet)

$1.20-$2.95 (Tier 1) QL

Butorphanol Tartrate

butorphanol tartrate (10mg/ml nasal solution) $1.20-$2.95 (Tier 1) QLButorphanol Tartrate

butorphanol tartrate (1mg/ml injection, 2mg/ml injection) $1.20-$2.95 (Tier 1)Codeine Sulfate

codeine sulfate (tablet) $1.20-$2.95 (Tier 1) QLDuramorph

DURAMORPH (INJECTION) $3.60-$7.40 (Tier 2)Endocet

endocet (tablet) $1.20-$2.95 (Tier 1) QLHydrocodone Bitartrate/Acetaminophen

hydrocodone bitartrate/acetaminophen (7.5mg-325mg/

15ml oral solution)$1.20-$2.95 (Tier 1) QL

Hydrocodone/Acetaminophen

hydrocodone/acetaminophen (10mg-325mg tablet,

2.5mg-325mg tablet, 5mg-325mg tablet, 7.5mg-325mg

tablet)

$1.20-$2.95 (Tier 1) QL

Hydrocodone/Ibuprofen

hydrocodone/ibuprofen (7.5mg-200mg tablet) $1.20-$2.95 (Tier 1) QLHydromorphone HCl

hydromorphone hcl (1mg/ml liquid, 2mg tablet

immediate-release, 4mg tablet immediate-release, 8mg

tablet immediate-release)

$1.20-$2.95 (Tier 1) QL

Hydromorphone HCl

HYDROMORPHONE HCL (2MG/ML INJECTION) $3.60-$7.40 (Tier 2)Hydromorphone HCl

hydromorphone hcl (500mg/50ml injection) $1.20-$2.95 (Tier 1)Lorcet

lorcet (tablet) $1.20-$2.95 (Tier 1) QLLorcet HD

lorcet hd (tablet) $1.20-$2.95 (Tier 1) QLLorcet Plus

lorcet plus (tablet) $1.20-$2.95 (Tier 1) QLLortab

lortab (tablet) $1.20-$2.95 (Tier 1) QLMorphine Sulfate

morphine sulfate (100mg/5ml oral solution, 10mg/5ml

oral solution, 20mg/5ml oral solution)$1.20-$2.95 (Tier 1) QL


15


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMorphine Sulfate

MORPHINE SULFATE (10MG/ML INJECTION,

2MG/ML INJECTION, 4MG/ML INJECTION,

8MG/ML INJECTION)

$3.60-$7.40 (Tier 2)

Morphine Sulfate

MORPHINE SULFATE (15MG TABLET

IMMEDIATE-RELEASE, 30MG TABLET

IMMEDIATE-RELEASE)

$3.60-$7.40 (Tier 2) QL

Nalbuphine HCl

nalbuphine hcl (injection) $1.20-$2.95 (Tier 1)Oxycodone HCl

oxycodone hcl (100mg/5ml concentrate, 10mg tablet

immediate-release, 15mg tablet immediate-release,

20mg tablet immediate-release, 30mg tablet immediate-

release, 5mg tablet immediate-release, 5mg/5ml oral

solution)

$1.20-$2.95 (Tier 1) QL

Oxycodone/Acetaminophen

oxycodone/acetaminophen (10mg-325mg tablet,

2.5mg-325mg tablet, 5mg-325mg tablet, 7.5mg-325mg

tablet)

$1.20-$2.95 (Tier 1) QL

Oxycodone/Aspirin

oxycodone/aspirin (tablet) $1.20-$2.95 (Tier 1) QLOxycodone/Ibuprofen

oxycodone/ibuprofen (tablet) $1.20-$2.95 (Tier 1) QLTramadol HCl

tramadol hcl (tablet immediate-release) $1.20-$2.95 (Tier 1) QLTramadol HCl/Acetaminophen

tramadol hcl/acetaminophen (tablet) $1.20-$2.95 (Tier 1) QLTrezix

trezix (capsule) $1.20-$2.95 (Tier 1) QL

Anesthetics

Local Anesthetics

Lidocaine

lidocaine (otc only) (cream)* $0 (Tier 3) QLLidocaine

lidocaine (rx only) (5% ointment) $1.20-$2.95 (Tier 1)Lidocaine

lidocaine (rx only) (5% patch) $1.20-$2.95 (Tier 1) PA, QLLidocaine HCl

lidocaine hcl (rx only) (0.5% injection, 2% injection) $1.20-$2.95 (Tier 1) B/D, PALidocaine HCl

lidocaine hcl (rx only) (4% external solution) $1.20-$2.95 (Tier 1)Lidocaine HCl

lidocaine hcl (rx only) (2% gel) $1.20-$2.95 (Tier 1)Lidocaine Viscous

lidocaine viscous (rx only) (2% solution) $1.20-$2.95 (Tier 1)Lidocaine/Prilocaine

lidocaine/prilocaine (cream) $1.20-$2.95 (Tier 1)

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-craving

Acamprosate Calcium DR

acamprosate calcium dr (tablet delayed-release) $1.20-$2.95 (Tier 1)Disulfiram

disulfiram (tablet) $1.20-$2.95 (Tier 1)Naltrexone HCl

naltrexone hcl (tablet) $1.20-$2.95 (Tier 1)Vivitrol

VIVITROL (INJECTION) $3.60-$7.40 (Tier 2) PA


page 9.




16


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Opioid Dependence Treatments

Buprenorphine HCl

buprenorphine hcl (0.3mg/ml injection) $1.20-$2.95 (Tier 1)Buprenorphine HCl

buprenorphine hcl (2mg tablet sublingual, 8mg tablet

sublingual)$1.20-$2.95 (Tier 1) QL

Buprenorphine HCl/Naloxone HCl

buprenorphine hcl/naloxone hcl (tablet sublingual) $1.20-$2.95 (Tier 1) PA, QLNaloxone HCl

naloxone hcl (injection) $1.20-$2.95 (Tier 1)Narcan

NARCAN (LIQUID) $3.60-$7.40 (Tier 2)Suboxone

SUBOXONE (FILM) $3.60-$7.40 (Tier 2) PA, QL

Smoking Cessation AgentsBupropion HCl SR

bupropion hcl sr (150mg tablet extended-release 12

hour)$1.20-$2.95 (Tier 1)

Chantix

CHANTIX (TABLET) $3.60-$7.40 (Tier 2)Chantix Continuing Month Pak

CHANTIX CONTINUING MONTH PAK (TABLET) $3.60-$7.40 (Tier 2)Chantix Starting Month Pak

CHANTIX STARTING MONTH PAK (TABLET) $3.60-$7.40 (Tier 2)NicoDerm CQ

nicoderm cq (patch 24 hour)* $0 (Tier 3) QLNICOrelief

nicorelief (gum)* $0 (Tier 3) QLNicorette

nicorette (2mg gum, 4mg gum, 2mg lozenge, 4mg

lozenge)*$0 (Tier 3) QL

Nicorette Mini

nicorette mini (lozenge)* $0 (Tier 3) QLNicorette Starter Kit

nicorette starter kit (gum)* $0 (Tier 3) QLNicotine Polacrilex

nicotine polacrilex (2mg gum, 4mg gum, 2mg lozenge,

4mg lozenge)*$0 (Tier 3) QL

Nicotine Transdermal System

nicotine transdermal system (patch 24 hour)* $0 (Tier 3) QLNicotrol Inhaler

NICOTROL INHALER $3.60-$7.40 (Tier 2)

Antibacterials

Aminoglycosides

Amikacin Sulfate

amikacin sulfate (injection) $1.20-$2.95 (Tier 1)Bethkis

BETHKIS (NEBULIZED SOLUTION) $3.60-$7.40 (Tier 2) B/D, PA


17


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useGentak

gentak (ophthalmic ointment) $1.20-$2.95 (Tier 1)Gentamicin Sulfate

gentamicin sulfate (0.1% cream, 0.1% ointment, 0.3%

ophthalmic ointment, 0.3% ophthalmic solution, 10mg/

ml injection, 40mg/ml injection)

$1.20-$2.95 (Tier 1)

Gentamicin Sulfate/0.9% Sodium Chloride

gentamicin sulfate/0.9% sodium chloride (injection) $1.20-$2.95 (Tier 1)Isotonic Gentamicin

isotonic gentamicin (injection) $1.20-$2.95 (Tier 1)Neomycin Sulfate

neomycin sulfate (tablet) $1.20-$2.95 (Tier 1)Paromomycin Sulfate

paromomycin sulfate (capsule) $1.20-$2.95 (Tier 1)Streptomycin Sulfate

streptomycin sulfate (injection) $1.20-$2.95 (Tier 1)TOBI

TOBI (NEBULIZED SOLUTION) $3.60-$7.40 (Tier 2) B/D, PATOBI Podhaler

TOBI PODHALER (CAPSULE) $3.60-$7.40 (Tier 2) PATobradex

TOBRADEX (OPHTHALMIC OINTMENT) $3.60-$7.40 (Tier 2)Tobramycin

tobramycin (nebulized solution) $1.20-$2.95 (Tier 1) B/D, PATobramycin Sulfate

tobramycin sulfate (0.3% ophthalmic solution, 10mg/ml

injection, 80mg/2ml injection)$1.20-$2.95 (Tier 1)

Tobrex

TOBREX (0.3% OPHTHALMIC OINTMENT) $3.60-$7.40 (Tier 2)

Antibacterials, Other

BACiiM

baciim (injection) $1.20-$2.95 (Tier 1)Bacitracin

bacitracin (otc only) (ointment)* $0 (Tier 3) QLBacitracin

bacitracin (rx only) (50000unit injection, 500unit/gm

ophthalmic ointment)$1.20-$2.95 (Tier 1)

Bacitracin Zinc

bacitracin zinc (otc only) (ointment)* $0 (Tier 3)Bacitracin/Neomycin/Polymyxin

bacitracin/neomycin/polymyxin (otc only) (ointment)* $0 (Tier 3) QLBactroban Nasal

BACTROBAN NASAL (OINTMENT) $3.60-$7.40 (Tier 2) PAChloramphenicol Sodium Succinate

chloramphenicol sodium succinate (injection) $1.20-$2.95 (Tier 1)Clindamycin HCl

clindamycin hcl (capsule immediate-release) $1.20-$2.95 (Tier 1)Clindamycin Palmitate HCl

clindamycin palmitate hcl (oral solution) $1.20-$2.95 (Tier 1)Clindamycin Phosphate

clindamycin phosphate (2% cream, 600mg/4ml injection) $1.20-$2.95 (Tier 1)Clindamycin Phosphate in D5W

clindamycin phosphate in d5w (injection) $1.20-$2.95 (Tier 1)Colistimethate Sodium

colistimethate sodium (injection) $1.20-$2.95 (Tier 1)Cubicin

CUBICIN (INJECTION) $3.60-$7.40 (Tier 2)Dalvance

DALVANCE (INJECTION) $3.60-$7.40 (Tier 2) PALincocin

LINCOCIN (INJECTION) $3.60-$7.40 (Tier 2)Lincomycin HCl

lincomycin hcl (injection) $1.20-$2.95 (Tier 1)Linezolid

linezolid (100mg/5ml suspension, 600mg/300ml

injection)$1.20-$2.95 (Tier 1) PA

Linezolid

LINEZOLID (600MG TABLET) $3.60-$7.40 (Tier 2) PA, QLMethenamine Hippurate

methenamine hippurate (tablet) $1.20-$2.95 (Tier 1)


page 9.




18


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMetronidazole

metronidazole (0.75% cream, 0.75% gel, 1% gel, 0.75%

lotion, 250mg tablet immediate-release, 500mg tablet

immediate-release, 375mg capsule immediate-release)

$1.20-$2.95 (Tier 1)

Metronidazole in NaCl 0.79%

metronidazole in nacl 0.79% (injection) $1.20-$2.95 (Tier 1)Metronidazole Vaginal

metronidazole vaginal (gel) $1.20-$2.95 (Tier 1)Mupirocin

mupirocin (2% ointment) $1.20-$2.95 (Tier 1)Neomycin/Polymyxin B Sulfates

neomycin/polymyxin b sulfates (rx only) (irrigation

solution)$1.20-$2.95 (Tier 1)

Nitrofurantoin

nitrofurantoin (suspension) $1.20-$2.95 (Tier 1)Nitrofurantoin Macrocrystals

nitrofurantoin macrocrystals (100mg capsule, 50mg

capsule) (generic macrodantin)$1.20-$2.95 (Tier 1)

Nitrofurantoin Monohydrate 100mg Capsule

nitrofurantoin monohydrate 100mg capsule (generic

macrobid)$1.20-$2.95 (Tier 1)

Polymyxin B Sulfate

polymyxin b sulfate (injection) $1.20-$2.95 (Tier 1)Povidone-Iodine

povidone-iodine (otc only) (10% external solution, 10%

ointment)*$0 (Tier 3)

QC Povidone Iodine

qc povidone iodine (otc only) (external solution)* $0 (Tier 3)Synercid

SYNERCID (INJECTION) $3.60-$7.40 (Tier 2)Tinidazole

tinidazole (tablet) $1.20-$2.95 (Tier 1)Trimethoprim

trimethoprim (tablet) $1.20-$2.95 (Tier 1)Triple Antibiotic

triple antibiotic (ointment)* $0 (Tier 3) QLTriple Antibiotic Plus

triple antibiotic plus (ointment)* $0 (Tier 3) QLTygacil

TYGACIL (INJECTION) $3.60-$7.40 (Tier 2)Vancocin HCl

VANCOCIN HCL (CAPSULE) $3.60-$7.40 (Tier 2) PAVancomycin HCl

vancomycin hcl (1000mg injection, 10gm injection,

500mg injection)$1.20-$2.95 (Tier 1)

Vancomycin HCl

vancomycin hcl (125mg capsule, 250mg capsule) $1.20-$2.95 (Tier 1) PAVandazole

VANDAZOLE (GEL) $3.60-$7.40 (Tier 2)Xifaxan

XIFAXAN (TABLET) $3.60-$7.40 (Tier 2) PAZyvox

ZYVOX (100MG/5ML SUSPENSION, 600MG/

300ML INJECTION)$3.60-$7.40 (Tier 2) PA


19


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Beta-lactam, CephalosporinsCefaclor

cefaclor (250mg capsule immediate-release, 500mg

capsule immediate-release)$1.20-$2.95 (Tier 1)

Cefadroxil

cefadroxil (250mg/5ml suspension, 500mg/5ml

suspension, 500mg capsule)$1.20-$2.95 (Tier 1)

Cefazolin Sodium

cefazolin sodium (10gm injection, 1gm injection, 500mg

injection, 1gm/50ml injection)$1.20-$2.95 (Tier 1)

Cefdinir

cefdinir (125mg/5ml suspension, 250mg/5ml

suspension, 300mg capsule)$1.20-$2.95 (Tier 1)

Cefepime

cefepime (1gm injection, 2gm injection) $1.20-$2.95 (Tier 1)Cefepime/Dextrose

CEFEPIME/DEXTROSE (1GM/50ML INJECTION,

2GM/50ML INJECTION)$3.60-$7.40 (Tier 2)

Cefixime

cefixime (suspension) $1.20-$2.95 (Tier 1)Cefotaxime Sodium

cefotaxime sodium (injection) $1.20-$2.95 (Tier 1)Cefotetan

cefotetan (injection) $1.20-$2.95 (Tier 1)Cefoxitin Sodium

cefoxitin sodium (10gm injection, 1gm injection, 2gm

injection)$1.20-$2.95 (Tier 1)

Cefoxitin Sodium

CEFOXITIN SODIUM (1GM-4% INJECTION,

2GM-2.2% INJECTION)$3.60-$7.40 (Tier 2)

Cefpodoxime Proxetil

cefpodoxime proxetil (100mg tablet, 200mg tablet,

100mg/5ml suspension, 50mg/5ml suspension)$1.20-$2.95 (Tier 1)

Cefprozil

cefprozil (125mg/5ml suspension, 250mg/5ml

suspension, 250mg tablet, 500mg tablet)$1.20-$2.95 (Tier 1)

Ceftazidime

ceftazidime (injection) $1.20-$2.95 (Tier 1)Ceftazidime/Dextrose

CEFTAZIDIME/DEXTROSE (INJECTION) $3.60-$7.40 (Tier 2)Ceftriaxone Sodium

ceftriaxone sodium (10gm injection, 1gm injection, 2gm

injection, 250mg injection, 500mg injection)$1.20-$2.95 (Tier 1)

Cefuroxime Axetil

cefuroxime axetil (tablet) $1.20-$2.95 (Tier 1)Cefuroxime Sodium

cefuroxime sodium (injection) $1.20-$2.95 (Tier 1)Cephalexin

cephalexin (125mg/5ml suspension, 250mg/5ml

suspension, 250mg capsule, 500mg capsule, 750mg

capsule)

$1.20-$2.95 (Tier 1)

Fortaz

FORTAZ (1GM INJECTION, 2GM INJECTION,

2GM INJECTION, 6GM INJECTION)$3.60-$7.40 (Tier 2)

Suprax

suprax (100mg tablet chewable, 200mg tablet chewable,

100mg/5ml suspension, 200mg/5ml suspension)$1.20-$2.95 (Tier 1)

Suprax

SUPRAX (400MG CAPSULE, 500MG/5ML

SUSPENSION)$3.60-$7.40 (Tier 2)

Tazicef

tazicef (injection) $1.20-$2.95 (Tier 1)


page 9.




20


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useZerbaxa

ZERBAXA (INJECTION) $3.60-$7.40 (Tier 2) PA

Beta-lactam, OtherAzactam in Iso-Osmotic Dextrose

AZACTAM IN ISO-OSMOTIC DEXTROSE

(INJECTION)$3.60-$7.40 (Tier 2)

Aztreonam

aztreonam (injection) $1.20-$2.95 (Tier 1)Doribax

DORIBAX (INJECTION) $3.60-$7.40 (Tier 2)Imipenem/Cilastatin

imipenem/cilastatin (injection) $1.20-$2.95 (Tier 1)Invanz

INVANZ (INJECTION) $3.60-$7.40 (Tier 2)Meropenem

meropenem (injection) $1.20-$2.95 (Tier 1)

Beta-lactam, PenicillinsAmoxicillin

amoxicillin (capsule, oral suspension, tablet, tablet

chewable)$1.20-$2.95 (Tier 1)

Amoxicillin/Clavulanate Potassium

amoxicillin/clavulanate potassium (oral suspension, tablet

chewable, tablet immediate-release) (generic augmentin)$1.20-$2.95 (Tier 1)

Amoxicillin/Clavulanate Potassium ER

amoxicillin/clavulanate potassium er (tablet extended-

release 12 hour)$1.20-$2.95 (Tier 1)

Ampicillin

ampicillin (125mg/5ml suspension, 250mg/5ml

suspension, 250mg capsule, 500mg capsule)$1.20-$2.95 (Tier 1)

Ampicillin Sodium

ampicillin sodium (10gm injection, 125mg injection, 1gm


Ampicillin-Sulbactam

ampicillin-sulbactam (10gm-5gm injection, 1gm-0.5gm

injection, 2gm-1gm injection)$1.20-$2.95 (Tier 1)

Bactocill in Dextrose

BACTOCILL IN DEXTROSE (INJECTION) $3.60-$7.40 (Tier 2)Bicillin C-R

BICILLIN C-R (INJECTION) $3.60-$7.40 (Tier 2)Bicillin L-A

BICILLIN L-A (INJECTION) $3.60-$7.40 (Tier 2)Dicloxacillin Sodium

dicloxacillin sodium (capsule) $1.20-$2.95 (Tier 1)Nafcillin in Dextrose

NAFCILLIN IN DEXTROSE (INJECTION) $3.60-$7.40 (Tier 2)Nafcillin Sodium

nafcillin sodium (injection) $1.20-$2.95 (Tier 1)Oxacillin Sodium

oxacillin sodium (injection) $1.20-$2.95 (Tier 1)Penicillin G Potassium

penicillin g potassium (injection) $1.20-$2.95 (Tier 1)


21


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on usePenicillin G Procaine

penicillin g procaine (injection) $1.20-$2.95 (Tier 1)Penicillin G Sodium

penicillin g sodium (injection) $1.20-$2.95 (Tier 1)Penicillin V Potassium

penicillin v potassium (125mg/5ml oral solution, 250mg/

5ml oral solution, 250mg tablet, 500mg tablet)$1.20-$2.95 (Tier 1)

Piperacillin/Tazobactam

piperacillin/tazobactam (injection) $1.20-$2.95 (Tier 1)

MacrolidesAzithromycin

azithromycin (100mg/5ml oral suspension, 200mg/5ml

oral suspension, 250mg tablet, 500mg tablet, 600mg

tablet, 500mg injection)

$1.20-$2.95 (Tier 1)

Clarithromycin

clarithromycin (125mg/5ml suspension, 250mg/5ml

suspension, 250mg tablet, 500mg tablet)$1.20-$2.95 (Tier 1)

Clarithromycin ER

clarithromycin er (tablet extended-release 24 hour) $1.20-$2.95 (Tier 1)Dificid

DIFICID (TABLET) $3.60-$7.40 (Tier 2) PAE.E.S. 400

e.e.s. 400 (tablet) $1.20-$2.95 (Tier 1)E.E.S. Granules

E.E.S. GRANULES (SUSPENSION) $3.60-$7.40 (Tier 2)EryPed 200

ERYPED 200 (SUSPENSION) $3.60-$7.40 (Tier 2)EryPed 400

ERYPED 400 (SUSPENSION) $3.60-$7.40 (Tier 2)Ery-Tab

ery-tab (tablet delayed-release) $1.20-$2.95 (Tier 1)Erythrocin Lactobionate

erythrocin lactobionate (injection) $1.20-$2.95 (Tier 1)Erythromycin

erythromycin (250mg capsule delayed-release, 5mg/gm

ophthalmic ointment)$1.20-$2.95 (Tier 1)

Erythromycin Base

erythromycin base (tablet) $1.20-$2.95 (Tier 1)Erythromycin Ethylsuccinate

erythromycin ethylsuccinate (tablet) $1.20-$2.95 (Tier 1)Ilotycin

ilotycin (ophthalmic ointment) $1.20-$2.95 (Tier 1)Zmax

ZMAX (SUSPENSION) $3.60-$7.40 (Tier 2)

QuinolonesAvelox

AVELOX (400MG/250ML-0.8% INJECTION) $3.60-$7.40 (Tier 2)Ciprofloxacin

ciprofloxacin (250mg/5ml suspension, 500mg/5ml

suspension, 400mg/40ml injection)$1.20-$2.95 (Tier 1)

Ciprofloxacin ER

ciprofloxacin er (tablet extended-release 24 hour) $1.20-$2.95 (Tier 1)Ciprofloxacin HCl

ciprofloxacin hcl (0.3% ophthalmic solution, 100mg


release, 500mg tablet immediate-release, 750mg tablet

immediate-release)

$1.20-$2.95 (Tier 1)

Ciprofloxacin I.V. in D5W

ciprofloxacin i.v. in d5w (injection) $1.20-$2.95 (Tier 1)Levofloxacin

levofloxacin (0.5% ophthalmic solution, 250mg tablet,

500mg tablet, 750mg tablet, 25mg/ml injection, 25mg/

ml oral solution)

$1.20-$2.95 (Tier 1)


page 9.




22


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useLevofloxacin in D5W

levofloxacin in d5w (injection) $1.20-$2.95 (Tier 1)Moxeza

MOXEZA (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2)Moxifloxacin HCl

moxifloxacin hcl (400mg tablet) $1.20-$2.95 (Tier 1)Moxifloxacin HCl

MOXIFLOXACIN HCL (400MG/250ML

INJECTION)$3.60-$7.40 (Tier 2)

Ofloxacin

ofloxacin (0.3% ophthalmic solution, 0.3% otic solution,

400mg tablet)$1.20-$2.95 (Tier 1)

Sulfonamides

Silver Sulfadiazine

silver sulfadiazine (cream) $1.20-$2.95 (Tier 1)Sodium Sulfacetamide

sodium sulfacetamide (ophthalmic solution) $1.20-$2.95 (Tier 1)SSD

SSD (CREAM) $3.60-$7.40 (Tier 2)Sulfacetamide Sodium

sulfacetamide sodium (ophthalmic ointment) $1.20-$2.95 (Tier 1)Sulfadiazine

sulfadiazine (tablet) $1.20-$2.95 (Tier 1)Sulfamethoxazole/Trimethoprim

sulfamethoxazole/trimethoprim (200mg-40mg/5ml

suspension, 400mg-80mg tablet, 400mg-80mg/5ml

injection)

$1.20-$2.95 (Tier 1)

Sulfamethoxazole/Trimethoprim DS

sulfamethoxazole/trimethoprim ds (tablet) $1.20-$2.95 (Tier 1)

Tetracyclines

Demeclocycline HCl

demeclocycline hcl (tablet) $1.20-$2.95 (Tier 1)Doxy 100

doxy 100 (injection) $1.20-$2.95 (Tier 1)Doxycycline

doxycycline (150mg capsule immediate-release, 75mg

capsule immediate-release, 25mg/5ml suspension)$1.20-$2.95 (Tier 1)

Doxycycline Hyclate

doxycycline hyclate (100mg capsule immediate-release,

50mg capsule immediate-release, 100mg injection,


release)

$1.20-$2.95 (Tier 1)

Doxycycline Monohydrate

doxycycline monohydrate (100mg capsule, 50mg

capsule, 100mg tablet, 150mg tablet, 50mg tablet,

75mg tablet)

$1.20-$2.95 (Tier 1)


23


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMinocycline HCl

minocycline hcl (100mg capsule immediate-release,

50mg capsule immediate-release, 75mg capsule

immediate-release)

$1.20-$2.95 (Tier 1)

Tetracycline HCl

TETRACYCLINE HCL (CAPSULE) $3.60-$7.40 (Tier 2)Vibramycin

VIBRAMYCIN (50MG/5ML SYRUP) $3.60-$7.40 (Tier 2)

Anticonvulsants

Anticonvulsants, OtherBRIVIACT

BRIVIACT (100MG TABLET, 10MG TABLET,

25MG TABLET, 50MG TABLET, 75MG TABLET,

10MG/ML ORAL SOLUTION, 50MG/5ML

INJECTION)

$3.60-$7.40 (Tier 2) QL

Fycompa

FYCOMPA (TABLET, ORAL SUSPENSION) $3.60-$7.40 (Tier 2)Levetiracetam

levetiracetam (1000mg tablet immediate-release, 250mg


release, 750mg tablet immediate-release, 100mg/ml oral

solution, 500mg/5ml injection)

$1.20-$2.95 (Tier 1)

Levetiracetam

LEVETIRACETAM (1000MG/100ML INJECTION,

1500MG/100ML INJECTION, 500MG/100ML

INJECTION)

$3.60-$7.40 (Tier 2)

Levetiracetam ER

levetiracetam er (tablet extended-release 24 hour) $1.20-$2.95 (Tier 1)Potiga

POTIGA (TABLET) $3.60-$7.40 (Tier 2) QLRoweepra

roweepra (tablet) $1.20-$2.95 (Tier 1)Spritam

SPRITAM (TABLET DISINTEGRATING SOLUBLE) $3.60-$7.40 (Tier 2)

Calcium Channel Modifying AgentsCelontin

CELONTIN (CAPSULE) $3.60-$7.40 (Tier 2)Ethosuximide

ethosuximide (250mg capsule, 250mg/5ml oral solution) $1.20-$2.95 (Tier 1)Zonisamide

zonisamide (capsule) $1.20-$2.95 (Tier 1)

Gamma-aminobutyric Acid (GABA) Augmenting AgentsDiastat AcuDial

DIASTAT ACUDIAL (GEL) $3.60-$7.40 (Tier 2)Diastat Pediatric

DIASTAT PEDIATRIC (GEL) $3.60-$7.40 (Tier 2)Diazepam

DIAZEPAM (10MG GEL, 2.5MG GEL, 20MG GEL) $3.60-$7.40 (Tier 2)Divalproex Sodium

divalproex sodium (capsule sprinkle delayed-release) $1.20-$2.95 (Tier 1)Divalproex Sodium DR

divalproex sodium dr (tablet delayed-release) $1.20-$2.95 (Tier 1)Divalproex Sodium ER

divalproex sodium er (tablet extended-release 24 hour) $1.20-$2.95 (Tier 1)Gabapentin

gabapentin (100mg capsule, 300mg capsule, 400mg

capsule, 250mg/5ml oral solution, 600mg tablet, 800mg

tablet)

$1.20-$2.95 (Tier 1)


page 9.




24


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useGabitril

GABITRIL (12MG TABLET, 16MG TABLET) $3.60-$7.40 (Tier 2) QLOnfi

ONFI (10MG TABLET, 20MG TABLET) $3.60-$7.40 (Tier 2) QLOnfi

ONFI (2.5MG/ML SUSPENSION) $3.60-$7.40 (Tier 2)Phenobarbital

phenobarbital (100mg tablet, 15mg tablet, 16.2mg

tablet, 30mg tablet, 32.4mg tablet, 60mg tablet, 64.8mg

tablet, 97.2mg tablet, 20mg/5ml elixir)

$1.20-$2.95 (Tier 1)

Primidone

primidone (tablet) $1.20-$2.95 (Tier 1)Sabril

SABRIL (500MG PACKET, 500MG TABLET) $3.60-$7.40 (Tier 2) PA, QL, LATiagabine HCl

tiagabine hcl (tablet) $1.20-$2.95 (Tier 1)Valproate Sodium

valproate sodium (100mg/ml injection) $1.20-$2.95 (Tier 1)Valproic Acid

valproic acid (250mg capsule, 250mg/5ml syrup) $1.20-$2.95 (Tier 1)

Glutamate Reducing AgentsFelbamate

felbamate (400mg tablet, 600mg tablet, 600mg/5ml

suspension)$1.20-$2.95 (Tier 1)

Felbatol

FELBATOL (600MG/5ML SUSPENSION) $3.60-$7.40 (Tier 2)Lamotrigine

lamotrigine (100mg tablet immediate-release, 150mg


release, 25mg tablet immediate-release, 25mg tablet

chewable, 5mg tablet chewable)

$1.20-$2.95 (Tier 1)

Topiramate

topiramate (100mg tablet immediate-release, 200mg

tablet immediate-release, 25mg tablet immediate-release,

50mg tablet immediate-release, 15mg capsule sprinkle

immediate-release, 25mg capsule sprinkle immediate-

release)

$1.20-$2.95 (Tier 1)

Sodium Channel AgentsAptiom

APTIOM (TABLET) $3.60-$7.40 (Tier 2) QLBanzel

BANZEL (200MG TABLET, 400MG TABLET,

40MG/ML SUSPENSION)$3.60-$7.40 (Tier 2)

Carbamazepine

carbamazepine (100mg tablet chewable, 100mg/5ml

suspension, 200mg tablet immediate-release)$1.20-$2.95 (Tier 1)


25


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useCarbamazepine ER

carbamazepine er (capsule extended-release 12 hour,

tablet extended-release 12 hour)$1.20-$2.95 (Tier 1)

Dilantin

dilantin (capsule) $1.20-$2.95 (Tier 1)Dilantin INFATABS

dilantin infatabs (tablet chewable) $1.20-$2.95 (Tier 1)Epitol

epitol (tablet) $1.20-$2.95 (Tier 1)Fosphenytoin Sodium

fosphenytoin sodium (injection) $1.20-$2.95 (Tier 1)Oxcarbazepine

oxcarbazepine (150mg tablet, 300mg tablet, 600mg

tablet, 300mg/5ml suspension)$1.20-$2.95 (Tier 1)

Peganone

PEGANONE (TABLET) $3.60-$7.40 (Tier 2)Phenytek

phenytek (capsule) $1.20-$2.95 (Tier 1)Phenytoin

phenytoin (125mg/5ml suspension, 50mg tablet


Phenytoin Sodium

phenytoin sodium (injection) $1.20-$2.95 (Tier 1)Phenytoin Sodium Extended

phenytoin sodium extended (capsule) $1.20-$2.95 (Tier 1)Tegretol-XR

TEGRETOL-XR (100MG TABLET EXTENDED-

RELEASE 12 HOUR)$3.60-$7.40 (Tier 2)

Vimpat

VIMPAT (100MG TABLET, 150MG TABLET,

200MG TABLET, 50MG TABLET, 10MG/ML

ORAL SOLUTION)

$3.60-$7.40 (Tier 2) QL

Vimpat

VIMPAT (200MG/20ML INJECTION) $3.60-$7.40 (Tier 2) PA

Antidementia Agents

Cholinesterase InhibitorsDonepezil HCl

donepezil hcl (10mg tablet immediate-release, 5mg

tablet immediate-release)$1.20-$2.95 (Tier 1) QL

Donepezil HCl ODT

donepezil hcl odt (tablet dispersible) $1.20-$2.95 (Tier 1) QLExelon

EXELON (PATCH 24 HOUR) $3.60-$7.40 (Tier 2) QL, STRivastigmine Tartrate

rivastigmine tartrate (capsule immediate-release) $1.20-$2.95 (Tier 1) QLRivastigmine Transdermal System

rivastigmine transdermal system (patch 24 hour) $1.20-$2.95 (Tier 1) QL, ST

N-methyl-D-aspartate (NMDA) Receptor AntagonistMemantine HCl

memantine hcl (10mg tablet, 5mg tablet, 2mg/ml oral

solution)$1.20-$2.95 (Tier 1) PA, QL

Memantine HCl Titration Pak

MEMANTINE HCL TITRATION PAK (TABLET) $3.60-$7.40 (Tier 2) PANamenda

NAMENDA (10MG/5ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) PA, QLNamenda XR

NAMENDA XR (CAPSULE EXTENDED-RELEASE

24 HOUR)$3.60-$7.40 (Tier 2) PA, QL

Namenda XR Titration Pack

NAMENDA XR TITRATION PACK (CAPSULE

EXTENDED-RELEASE 24 HOUR)$3.60-$7.40 (Tier 2) PA, QL


page 9.




26


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Antidepressants

Antidepressants, Other

Bupropion HCl

bupropion hcl (tablet immediate-release) $1.20-$2.95 (Tier 1)Bupropion HCl SR

bupropion hcl sr (tablet extended-release 12 hour) $1.20-$2.95 (Tier 1)Bupropion HCl XL

bupropion hcl xl (tablet extended-release 24 hour) $1.20-$2.95 (Tier 1)Mirtazapine

mirtazapine (tablet immediate-release) $1.20-$2.95 (Tier 1)Mirtazapine ODT

mirtazapine odt (tablet dispersible) $1.20-$2.95 (Tier 1)

Monoamine Oxidase InhibitorsEmsam

EMSAM (PATCH 24 HOUR) $3.60-$7.40 (Tier 2) QLMarplan

MARPLAN (TABLET) $3.60-$7.40 (Tier 2)Phenelzine Sulfate

phenelzine sulfate (tablet) $1.20-$2.95 (Tier 1)Tranylcypromine Sulfate

tranylcypromine sulfate (tablet) $1.20-$2.95 (Tier 1)

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine

Reuptake Inhibitors)Citalopram HBr

citalopram hbr (10mg tablet, 20mg tablet, 40mg tablet,

10mg/5ml oral solution)$1.20-$2.95 (Tier 1)

Escitalopram Oxalate

escitalopram oxalate (10mg tablet, 20mg tablet, 5mg

tablet, 5mg/5ml oral solution)$1.20-$2.95 (Tier 1)

Fetzima

FETZIMA (CAPSULE EXTENDED-RELEASE 24

HOUR)$3.60-$7.40 (Tier 2) QL, ST

Fetzima Titration Pack

FETZIMA TITRATION PACK (CAPSULE

EXTENDED-RELEASE 24 HOUR THERAPY PACK)$3.60-$7.40 (Tier 2) ST

Fluoxetine DR

fluoxetine dr (capsule delayed-release) $1.20-$2.95 (Tier 1)Fluoxetine HCl

fluoxetine hcl (10mg capsule immediate-release, 20mg

capsule immediate-release, 40mg capsule immediate-

release, 20mg/5ml oral solution)

$1.20-$2.95 (Tier 1)

Fluvoxamine Maleate

fluvoxamine maleate (tablet) $1.20-$2.95 (Tier 1)Maprotiline HCl

maprotiline hcl (tablet) $1.20-$2.95 (Tier 1)Nefazodone HCl

nefazodone hcl (tablet) $1.20-$2.95 (Tier 1)


27


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useParoxetine HCl

paroxetine hcl (tablet immediate-release) $1.20-$2.95 (Tier 1)Paxil

PAXIL (10MG/5ML SUSPENSION) $3.60-$7.40 (Tier 2)Pristiq

PRISTIQ (TABLET EXTENDED-RELEASE 24

HOUR)$3.60-$7.40 (Tier 2) QL

Sertraline HCl

sertraline hcl (100mg tablet, 25mg tablet, 50mg tablet,

20mg/ml concentrate)$1.20-$2.95 (Tier 1)

Trazodone HCl

trazodone hcl (tablet) $1.20-$2.95 (Tier 1)Trintellix

TRINTELLIX (TABLET) $3.60-$7.40 (Tier 2) QLVenlafaxine HCl

venlafaxine hcl (tablet immediate-release) $1.20-$2.95 (Tier 1)Venlafaxine HCl ER

venlafaxine hcl er (150mg capsule extended-release 24

hour, 37.5mg capsule extended-release 24 hour, 75mg

capsule extended-release 24 hour)

$1.20-$2.95 (Tier 1)

Viibryd

VIIBRYD (TABLET) $3.60-$7.40 (Tier 2) QLViibryd Starter Pack

VIIBRYD STARTER PACK (KIT) $3.60-$7.40 (Tier 2) QL

Tricyclics

Amitriptyline HCl

amitriptyline hcl (tablet) $1.20-$2.95 (Tier 1)Amoxapine

amoxapine (tablet) $1.20-$2.95 (Tier 1)Clomipramine HCl

clomipramine hcl (capsule) $1.20-$2.95 (Tier 1)Desipramine HCl

desipramine hcl (tablet) $1.20-$2.95 (Tier 1)Doxepin HCl

doxepin hcl (100mg capsule, 10mg capsule, 150mg

capsule, 25mg capsule, 50mg capsule, 75mg capsule,

10mg/ml concentrate)

$1.20-$2.95 (Tier 1)

Imipramine HCl

imipramine hcl (tablet) $1.20-$2.95 (Tier 1)Imipramine Pamoate

imipramine pamoate (capsule) $1.20-$2.95 (Tier 1)Nortriptyline HCl

nortriptyline hcl (10mg capsule, 25mg capsule, 50mg

capsule, 75mg capsule, 10mg/5ml oral solution)$1.20-$2.95 (Tier 1)

Protriptyline HCl

protriptyline hcl (tablet) $1.20-$2.95 (Tier 1)Surmontil

SURMONTIL (CAPSULE) $3.60-$7.40 (Tier 2)Trimipramine Maleate

trimipramine maleate (capsule) $1.20-$2.95 (Tier 1)

Antiemetics

Antiemetics, Other

Anti-Nausea

anti-nausea (oral solution)* $0 (Tier 3)Compro

compro (suppository) $1.20-$2.95 (Tier 1)Dimenhydrinate

dimenhydrinate (tablet)* $0 (Tier 3)Formula EM

formula em (oral solution)* $0 (Tier 3)Hydroxyzine Pamoate

hydroxyzine pamoate (capsule) $1.20-$2.95 (Tier 1)Meclizine HCl

meclizine hcl (rx only) (tablet) $1.20-$2.95 (Tier 1)


page 9.




28


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMetoclopramide HCl

metoclopramide hcl (10mg tablet, 5mg tablet, 5mg/5ml

oral solution, 5mg/ml injection)$1.20-$2.95 (Tier 1)

Perphenazine

perphenazine (tablet) $1.20-$2.95 (Tier 1)Prochlorperazine

prochlorperazine (suppository) $1.20-$2.95 (Tier 1)Prochlorperazine Edisylate

prochlorperazine edisylate (injection) $1.20-$2.95 (Tier 1)Prochlorperazine Maleate

prochlorperazine maleate (tablet) $1.20-$2.95 (Tier 1)Transderm-Scop

TRANSDERM-SCOP (PATCH 72 HOUR) $3.60-$7.40 (Tier 2)Travel Sickness

travel sickness (25mg tablet chewable)* $0 (Tier 3) QLTravel Sickness

travel sickness (50mg tablet)* $0 (Tier 3)

Emetogenic Therapy AdjunctsAloxi

ALOXI (INJECTION) $3.60-$7.40 (Tier 2)Anzemet

ANZEMET (100MG TABLET, 50MG TABLET) $3.60-$7.40 (Tier 2) B/D, PACesamet

CESAMET (CAPSULE) $3.60-$7.40 (Tier 2) PADronabinol

dronabinol (capsule) $1.20-$2.95 (Tier 1) PA, QLEmend

EMEND (PACK, 125MG CAPSULE, 40MG

CAPSULE, 80MG CAPSULE, 125MG

SUSPENSION)

$3.60-$7.40 (Tier 2) PA

Emend

EMEND (150MG INJECTION) $3.60-$7.40 (Tier 2)Granisetron HCl

granisetron hcl (0.1mg/ml injection, 1mg/ml injection) $1.20-$2.95 (Tier 1)Granisetron HCl

granisetron hcl (1mg tablet) $1.20-$2.95 (Tier 1) B/D, PA, QLOndansetron HCl

ondansetron hcl (24mg tablet, 4mg tablet, 8mg tablet,

4mg/5ml oral solution)$1.20-$2.95 (Tier 1) B/D, PA

Ondansetron HCl

ondansetron hcl (4mg/2ml injection) $1.20-$2.95 (Tier 1)Ondansetron ODT

ondansetron odt (tablet dispersible) $1.20-$2.95 (Tier 1) B/D, PASancuso

SANCUSO (PATCH) $3.60-$7.40 (Tier 2)

Antifungals

AntifungalsAbelcet

ABELCET (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAAmBisome

AMBISOME (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA


29


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useAmphotericin B

amphotericin b (injection) $1.20-$2.95 (Tier 1) B/D, PAAncobon

ANCOBON (CAPSULE) $3.60-$7.40 (Tier 2)Antifungal

antifungal (1% aerosol, 1% cream, 2% cream)* $0 (Tier 3)Anti-Fungal Powder

anti-fungal powder* $0 (Tier 3)Cancidas

CANCIDAS (INJECTION) $3.60-$7.40 (Tier 2)Ciclopirox

ciclopirox (0.77% gel, 0.77% suspension, 1% shampoo) $1.20-$2.95 (Tier 1)Ciclopirox Nail Lacquer

ciclopirox nail lacquer (external solution) $1.20-$2.95 (Tier 1)Ciclopirox Olamine

ciclopirox olamine (cream) $1.20-$2.95 (Tier 1)Clotrimazole

clotrimazole (otc only) (cream)* $0 (Tier 3) QLClotrimazole

clotrimazole (rx only) (1% cream, 1% external solution,

10mg troche)$1.20-$2.95 (Tier 1)

Econazole Nitrate

econazole nitrate (cream) $1.20-$2.95 (Tier 1)Eraxis

ERAXIS (INJECTION) $3.60-$7.40 (Tier 2)Fluconazole

fluconazole (100mg tablet, 150mg tablet, 200mg tablet,

50mg tablet, 10mg/ml suspension, 40mg/ml

suspension)

$1.20-$2.95 (Tier 1)

Fluconazole in Dextrose

fluconazole in dextrose (injection) $1.20-$2.95 (Tier 1)Fluconazole in NaCl

fluconazole in nacl (injection) $1.20-$2.95 (Tier 1)Flucytosine

flucytosine (capsule) $1.20-$2.95 (Tier 1)Fungoid Tincture

fungoid tincture (external solution)* $0 (Tier 3)Griseofulvin Microsize

griseofulvin microsize (125mg/5ml suspension, 500mg

tablet)$1.20-$2.95 (Tier 1)

Griseofulvin Ultramicrosize

griseofulvin ultramicrosize (tablet) $1.20-$2.95 (Tier 1)Itraconazole

itraconazole (capsule) $1.20-$2.95 (Tier 1) PA, QLJublia

JUBLIA (EXTERNAL SOLUTION) $3.60-$7.40 (Tier 2)Ketoconazole

ketoconazole (2% cream, 2% foam, 2% shampoo,

200mg tablet)$1.20-$2.95 (Tier 1)

Mentax

MENTAX (CREAM) $3.60-$7.40 (Tier 2)Miconazole 3

miconazole 3 (rx only) (suppository) $1.20-$2.95 (Tier 1)Miconazole 7

miconazole 7 (otc only) (100mg suppository, 2% vaginal

cream)*$0 (Tier 3)

Miconazole Nitrate

miconazole nitrate (otc only) (100mg suppository, 2%

vaginal cream)*$0 (Tier 3) QL

Miconazole Nitrate

miconazole nitrate (otc only) (2% topical cream)* $0 (Tier 3)Mycamine

MYCAMINE (INJECTION) $3.60-$7.40 (Tier 2)Natacyn

NATACYN (SUSPENSION) $3.60-$7.40 (Tier 2)Noxafil

NOXAFIL (100MG TABLET DELAYED-RELEASE) $3.60-$7.40 (Tier 2) PANoxafil

NOXAFIL (40MG/ML SUSPENSION) $3.60-$7.40 (Tier 2)Nyamyc

nyamyc (powder) $1.20-$2.95 (Tier 1)


page 9.




30


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useNystatin

nystatin (cream, ointment, powder, suspension, tablet) $1.20-$2.95 (Tier 1)Nystop

nystop (powder) $1.20-$2.95 (Tier 1)ONMEL

ONMEL (TABLET) $3.60-$7.40 (Tier 2) PAQC Tolnaftate

qc tolnaftate (cream)* $0 (Tier 3)SM Miconazole 7

sm miconazole 7 (otc only) (cream)* $0 (Tier 3)Sporanox

SPORANOX (10MG/ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) PATerbinafine HCl

terbinafine hcl (otc only) (cream)* $0 (Tier 3)Terbinafine HCl

terbinafine hcl (rx only) (tablet) $1.20-$2.95 (Tier 1)Terconazole

terconazole (0.4% cream, 0.8% cream, 80mg

suppository)$1.20-$2.95 (Tier 1)

Tioconazole-1

tioconazole-1 (ointment)* $0 (Tier 3)Tolnaftate

tolnaftate (1% cream, 1% powder)* $0 (Tier 3)Vfend

VFEND (200MG TABLET, 50MG TABLET, 40MG/

ML SUSPENSION)$3.60-$7.40 (Tier 2)

Voriconazole

voriconazole (200mg injection, 200mg tablet, 50mg

tablet, 40mg/ml suspension)$1.20-$2.95 (Tier 1)

Zazole

ZAZOLE (CREAM) $3.60-$7.40 (Tier 2)Zeasorb-AF

zeasorb-af (powder)* $0 (Tier 3)

Antigout Agents

Antigout Agents

Allopurinol

allopurinol (tablet) $1.20-$2.95 (Tier 1)Colchicine

COLCHICINE (0.6MG TABLET) (GENERIC

COLCRYS)$3.60-$7.40 (Tier 2) QL

Colcrys

COLCRYS (TABLET) $3.60-$7.40 (Tier 2) QLProbenecid

probenecid (tablet) $1.20-$2.95 (Tier 1)Probenecid/Colchicine

probenecid/colchicine (tablet) $1.20-$2.95 (Tier 1)Uloric

ULORIC (TABLET) $3.60-$7.40 (Tier 2) ST

Antimigraine Agents


31


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Ergot Alkaloids

Dihydroergotamine Mesylate

dihydroergotamine mesylate (1mg/ml injection) $1.20-$2.95 (Tier 1)Migergot

migergot (suppository) $1.20-$2.95 (Tier 1)

Serotonin (5-HT) 1b/1d Receptor Agonists

Naratriptan HCl

naratriptan hcl (tablet) $1.20-$2.95 (Tier 1) QLRizatriptan Benzoate

rizatriptan benzoate (tablet immediate-release) $1.20-$2.95 (Tier 1) QLRizatriptan Benzoate ODT

rizatriptan benzoate odt (tablet dispersible) $1.20-$2.95 (Tier 1) QLSumatriptan

SUMATRIPTAN (NASAL SOLUTION) $3.60-$7.40 (Tier 2) QLSumatriptan Succinate

sumatriptan succinate (100mg tablet, 25mg tablet, 50mg

tablet, 6mg/0.5ml injection)$1.20-$2.95 (Tier 1) QL

Sumatriptan Succinate

SUMATRIPTAN SUCCINATE (4MG/0.5ML

SOLUTION AUTO INJECTOR)$3.60-$7.40 (Tier 2) QL

Sumatriptan Succinate Refill

SUMATRIPTAN SUCCINATE REFILL (4MG/0.5ML

INJECTION)$3.60-$7.40 (Tier 2) QL


sumatriptan succinate refill (6mg/0.5ml injection) $1.20-$2.95 (Tier 1) QLSumavel DosePro

SUMAVEL DOSEPRO (INJECTION) $3.60-$7.40 (Tier 2)

Antimyasthenic Agents

ParasympathomimeticsGuanidine HCl

GUANIDINE HCL (TABLET) $1.20-$2.95 (Tier 1)Mestinon

MESTINON (60MG/5ML SYRUP) $3.60-$7.40 (Tier 2)Mestinon Timespan

MESTINON TIMESPAN (TABLET EXTENDED-

RELEASE)$3.60-$7.40 (Tier 2)

Pyridostigmine Bromide

pyridostigmine bromide (180mg tablet extended-release,

60mg tablet)$1.20-$2.95 (Tier 1)

Antimycobacterials

Antimycobacterials, Other

Dapsone

dapsone (tablet) $1.20-$2.95 (Tier 1)Rifabutin

rifabutin (capsule) $1.20-$2.95 (Tier 1)

AntitubercularsCapastat Sulfate

CAPASTAT SULFATE (INJECTION) $3.60-$7.40 (Tier 2)Ethambutol HCl

ethambutol hcl (tablet) $1.20-$2.95 (Tier 1)Isoniazid

isoniazid (100mg tablet, 300mg tablet, 100mg/ml

injection, 50mg/5ml syrup)$1.20-$2.95 (Tier 1)

Paser

paser (packet) $1.20-$2.95 (Tier 1)


page 9.




32


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on usePriftin

PRIFTIN (TABLET) $3.60-$7.40 (Tier 2)Pyrazinamide

pyrazinamide (tablet) $1.20-$2.95 (Tier 1)Rifampin

rifampin (150mg capsule, 300mg capsule, 600mg


Rifater

RIFATER (TABLET) $3.60-$7.40 (Tier 2)Sirturo

SIRTURO (TABLET) $3.60-$7.40 (Tier 2) PATrecator

TRECATOR (TABLET) $3.60-$7.40 (Tier 2)

Antineoplastics

Alkylating AgentsBiCNU

BICNU (INJECTION) $3.60-$7.40 (Tier 2)Busulfex

BUSULFEX (INJECTION) $3.60-$7.40 (Tier 2)Cyclophosphamide

CYCLOPHOSPHAMIDE (CAPSULE) $3.60-$7.40 (Tier 2) B/D, PADacarbazine

dacarbazine (injection) $1.20-$2.95 (Tier 1)Gleostine

GLEOSTINE (CAPSULE) $3.60-$7.40 (Tier 2)Hexalen

HEXALEN (CAPSULE) $3.60-$7.40 (Tier 2) PAIfosfamide

ifosfamide (injection) $1.20-$2.95 (Tier 1)Leukeran

LEUKERAN (TABLET) $3.60-$7.40 (Tier 2)Matulane

MATULANE (CAPSULE) $3.60-$7.40 (Tier 2) LAMelphalan HCl

melphalan hcl (injection) $1.20-$2.95 (Tier 1)Mustargen

MUSTARGEN (INJECTION) $3.60-$7.40 (Tier 2)Treanda

TREANDA (INJECTION) $3.60-$7.40 (Tier 2) PAValchlor

VALCHLOR (GEL) $3.60-$7.40 (Tier 2) PA, LAYondelis

YONDELIS (INJECTION) $3.60-$7.40 (Tier 2) PAZanosar

ZANOSAR (INJECTION) $3.60-$7.40 (Tier 2)

Antiandrogens

Bicalutamide

bicalutamide (tablet) $1.20-$2.95 (Tier 1)Flutamide

flutamide (capsule) $1.20-$2.95 (Tier 1)Nilandron

NILANDRON (TABLET) $3.60-$7.40 (Tier 2)


33


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useNilutamide

nilutamide (tablet) $1.20-$2.95 (Tier 1)Xtandi

XTANDI (CAPSULE) $3.60-$7.40 (Tier 2) PA, QLZytiga

ZYTIGA (TABLET) $3.60-$7.40 (Tier 2) PA, QL

Antiangiogenic AgentsPomalyst

POMALYST (CAPSULE) $3.60-$7.40 (Tier 2) PARevlimid

REVLIMID (CAPSULE) $3.60-$7.40 (Tier 2) PA, LAThalomid

THALOMID (CAPSULE) $3.60-$7.40 (Tier 2) PA

Antiestrogens/ModifiersEmcyt

EMCYT (CAPSULE) $3.60-$7.40 (Tier 2)Fareston

FARESTON (TABLET) $3.60-$7.40 (Tier 2)Faslodex

FASLODEX (INJECTION) $3.60-$7.40 (Tier 2)Soltamox

SOLTAMOX (ORAL SOLUTION) $3.60-$7.40 (Tier 2)Tamoxifen Citrate

tamoxifen citrate (tablet) $1.20-$2.95 (Tier 1)

Antimetabolites

Adrucil

adrucil (injection) $1.20-$2.95 (Tier 1) B/D, PAAlimta

ALIMTA (INJECTION) $3.60-$7.40 (Tier 2) PACladribine

cladribine (injection) $1.20-$2.95 (Tier 1) B/D, PAClolar

CLOLAR (INJECTION) $3.60-$7.40 (Tier 2)Cytarabine Aqueous

cytarabine aqueous (injection) $1.20-$2.95 (Tier 1) B/D, PADroxia

DROXIA (CAPSULE) $3.60-$7.40 (Tier 2)Elitek

ELITEK (INJECTION) $3.60-$7.40 (Tier 2)Fluorouracil

fluorouracil (2.5gm/50ml injection) $1.20-$2.95 (Tier 1) B/D, PAFolotyn

FOLOTYN (INJECTION) $3.60-$7.40 (Tier 2)Gemcitabine HCl

gemcitabine hcl (injection) $1.20-$2.95 (Tier 1)Gemzar

GEMZAR (INJECTION) $3.60-$7.40 (Tier 2)Hydroxyurea

hydroxyurea (capsule) $1.20-$2.95 (Tier 1)Lonsurf

LONSURF (TABLET) $3.60-$7.40 (Tier 2) PA, QLMercaptopurine

mercaptopurine (tablet) $1.20-$2.95 (Tier 1)Nipent

NIPENT (INJECTION) $3.60-$7.40 (Tier 2)Purixan

PURIXAN (SUSPENSION) $3.60-$7.40 (Tier 2) PATabloid

TABLOID (TABLET) $3.60-$7.40 (Tier 2) PA

Antineoplastics, OtherAbraxane

ABRAXANE (INJECTION) $3.60-$7.40 (Tier 2) PAAlecensa

ALECENSA (CAPSULE) $3.60-$7.40 (Tier 2) PA, QLAmifostine

amifostine (injection) $1.20-$2.95 (Tier 1)


page 9.




34


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useArranon

ARRANON (INJECTION) $3.60-$7.40 (Tier 2)Azacitidine

azacitidine (injection) $1.20-$2.95 (Tier 1) PABeleodaq

BELEODAQ (INJECTION) $3.60-$7.40 (Tier 2) PABleomycin Sulfate

bleomycin sulfate (injection) $1.20-$2.95 (Tier 1) B/D, PACarboplatin

carboplatin (injection) $1.20-$2.95 (Tier 1)Cisplatin

cisplatin (injection) $1.20-$2.95 (Tier 1)Cosmegen

COSMEGEN (INJECTION) $3.60-$7.40 (Tier 2)Dacogen

DACOGEN (INJECTION) $3.60-$7.40 (Tier 2)Daunorubicin HCl

daunorubicin hcl (injection) $1.20-$2.95 (Tier 1)Decitabine

decitabine (injection) $1.20-$2.95 (Tier 1)Dexrazoxane

dexrazoxane (injection) $1.20-$2.95 (Tier 1) PADocefrez

DOCEFREZ (INJECTION) $3.60-$7.40 (Tier 2)Docetaxel

docetaxel (80mg/4ml injection) $1.20-$2.95 (Tier 1)Docetaxel

DOCETAXEL (80MG/8ML INJECTION) $3.60-$7.40 (Tier 2)Doxil

DOXIL (INJECTION) $3.60-$7.40 (Tier 2)Doxorubicin HCl

doxorubicin hcl (injection) $1.20-$2.95 (Tier 1) B/D, PADoxorubicin HCl Liposome

doxorubicin hcl liposome (injection) $1.20-$2.95 (Tier 1)Epirubicin HCl

epirubicin hcl (injection) $1.20-$2.95 (Tier 1)Erwinaze

ERWINAZE (INJECTION) $3.60-$7.40 (Tier 2)Farydak

FARYDAK (CAPSULE) $3.60-$7.40 (Tier 2) PAFludarabine Phosphate

fludarabine phosphate (injection) $1.20-$2.95 (Tier 1)Fusilev

FUSILEV (INJECTION) $3.60-$7.40 (Tier 2)Halaven

HALAVEN (INJECTION) $3.60-$7.40 (Tier 2) PAIbrance

IBRANCE (CAPSULE) $3.60-$7.40 (Tier 2) PA, QLIdarubicin HCl

idarubicin hcl (injection) $1.20-$2.95 (Tier 1)Irinotecan

irinotecan (injection) $1.20-$2.95 (Tier 1)Istodax

ISTODAX (INJECTION) $3.60-$7.40 (Tier 2) PAIxempra Kit

IXEMPRA KIT (INJECTION) $3.60-$7.40 (Tier 2)Jevtana

JEVTANA (INJECTION) $3.60-$7.40 (Tier 2) PA


35


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useLeucovorin Calcium

leucovorin calcium (100mg injection, 350mg injection,

10mg tablet, 15mg tablet, 25mg tablet, 5mg tablet)$1.20-$2.95 (Tier 1)

Levoleucovorin Calcium

levoleucovorin calcium (injection) $1.20-$2.95 (Tier 1)Lynparza

LYNPARZA (CAPSULE) $3.60-$7.40 (Tier 2) PA, QLMesna

mesna (injection) $1.20-$2.95 (Tier 1)Mesnex

MESNEX (400MG TABLET) $3.60-$7.40 (Tier 2)Mitomycin

mitomycin (injection) $1.20-$2.95 (Tier 1)Mitoxantrone HCl

mitoxantrone hcl (injection) $1.20-$2.95 (Tier 1)Ninlaro

NINLARO (CAPSULE) $3.60-$7.40 (Tier 2) PA, QLOncaspar

ONCASPAR (INJECTION) $3.60-$7.40 (Tier 2)Oxaliplatin

oxaliplatin (injection) $1.20-$2.95 (Tier 1)Paclitaxel

paclitaxel (injection) $1.20-$2.95 (Tier 1)Proleukin

PROLEUKIN (INJECTION) $3.60-$7.40 (Tier 2) PASynribo

SYNRIBO (INJECTION) $3.60-$7.40 (Tier 2) PATaxotere

TAXOTERE (INJECTION) $3.60-$7.40 (Tier 2)Thiotepa

thiotepa (injection) $1.20-$2.95 (Tier 1)Trisenox

TRISENOX (INJECTION) $3.60-$7.40 (Tier 2)Velcade

VELCADE (INJECTION) $3.60-$7.40 (Tier 2) PAVenclexta

VENCLEXTA (TABLET) $3.60-$7.40 (Tier 2) PA, QLVenclexta Starting Pack

VENCLEXTA STARTING PACK (TABLET

THERAPY PACK)$3.60-$7.40 (Tier 2) PA

Vidaza

VIDAZA (INJECTION) $3.60-$7.40 (Tier 2) PAVinblastine Sulfate

vinblastine sulfate (injection) $1.20-$2.95 (Tier 1) B/D, PAVincasar PFS

vincasar pfs (injection) $1.20-$2.95 (Tier 1) B/D, PAVincristine Sulfate

vincristine sulfate (injection) $1.20-$2.95 (Tier 1) B/D, PAVinorelbine Tartrate

vinorelbine tartrate (injection) $1.20-$2.95 (Tier 1)Zaltrap

ZALTRAP (INJECTION) $3.60-$7.40 (Tier 2) PAZolinza

ZOLINZA (CAPSULE) $3.60-$7.40 (Tier 2) PAZydelig

ZYDELIG (TABLET) $3.60-$7.40 (Tier 2) PA, QLZykadia

ZYKADIA (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL

Aromatase Inhibitors, 3rd Generation

Anastrozole

anastrozole (tablet) $1.20-$2.95 (Tier 1)Exemestane

exemestane (tablet) $1.20-$2.95 (Tier 1)Letrozole

letrozole (tablet) $1.20-$2.95 (Tier 1)

Enzyme InhibitorsEtopophos

ETOPOPHOS (INJECTION) $3.60-$7.40 (Tier 2)


page 9.




36


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useEtoposide

etoposide (injection) $1.20-$2.95 (Tier 1)Hycamtin

HYCAMTIN (INJECTION) $3.60-$7.40 (Tier 2)Toposar

toposar (injection) $1.20-$2.95 (Tier 1)Topotecan HCl

topotecan hcl (injection) $1.20-$2.95 (Tier 1)

Molecular Target InhibitorsAfinitor

AFINITOR (TABLET) $3.60-$7.40 (Tier 2) PAAfinitor Disperz

AFINITOR DISPERZ (TABLET SOLUBLE) $3.60-$7.40 (Tier 2) PABosulif

BOSULIF (TABLET) $3.60-$7.40 (Tier 2) PACabometyx

CABOMETYX (TABLET) $3.60-$7.40 (Tier 2) PA, QLCaprelsa

CAPRELSA (TABLET) $3.60-$7.40 (Tier 2) PA, LACometriq

COMETRIQ (KIT) $3.60-$7.40 (Tier 2) PACotellic

COTELLIC (TABLET) $3.60-$7.40 (Tier 2) PA, QL, LAErivedge

ERIVEDGE (CAPSULE) $3.60-$7.40 (Tier 2) PAGilotrif

GILOTRIF (TABLET) $3.60-$7.40 (Tier 2) PAIclusig

ICLUSIG (15MG TABLET) $3.60-$7.40 (Tier 2) PA, LAIclusig

ICLUSIG (45MG TABLET) $3.60-$7.40 (Tier 2) PAImatinib Mesylate

imatinib mesylate (tablet) $1.20-$2.95 (Tier 1) PAImbruvica

IMBRUVICA (CAPSULE) $3.60-$7.40 (Tier 2) PAInlyta

INLYTA (TABLET) $3.60-$7.40 (Tier 2) PAIressa

IRESSA (TABLET) $3.60-$7.40 (Tier 2) PA, QLJakafi

JAKAFI (TABLET) $3.60-$7.40 (Tier 2) PA, LALenvima

LENVIMA (CAPSULE THERAPY PACK) $3.60-$7.40 (Tier 2) PAMekinist

MEKINIST (TABLET) $3.60-$7.40 (Tier 2) PANexavar

NEXAVAR (TABLET) $3.60-$7.40 (Tier 2) PAOdomzo

ODOMZO (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL, LASprycel

SPRYCEL (TABLET) $3.60-$7.40 (Tier 2) PAStivarga

STIVARGA (TABLET) $3.60-$7.40 (Tier 2) PASutent

SUTENT (CAPSULE) $3.60-$7.40 (Tier 2) PATafinlar

TAFINLAR (CAPSULE) $3.60-$7.40 (Tier 2) PA


37


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useTarceva

TARCEVA (TABLET) $3.60-$7.40 (Tier 2) PATasigna

TASIGNA (CAPSULE) $3.60-$7.40 (Tier 2) PATykerb

TYKERB (TABLET) $3.60-$7.40 (Tier 2) PAVotrient

VOTRIENT (TABLET) $3.60-$7.40 (Tier 2) PAXalkori

XALKORI (CAPSULE) $3.60-$7.40 (Tier 2) PA, LAZelboraf

ZELBORAF (TABLET) $3.60-$7.40 (Tier 2) PA

Monoclonal AntibodiesAvastin

AVASTIN (INJECTION) $3.60-$7.40 (Tier 2) PACyramza

CYRAMZA (INJECTION) $3.60-$7.40 (Tier 2) PADarzalex

DARZALEX (INJECTION) $3.60-$7.40 (Tier 2) PA, LAEmpliciti

EMPLICITI (INJECTION) $3.60-$7.40 (Tier 2) PAErbitux

ERBITUX (INJECTION) $3.60-$7.40 (Tier 2) PAHerceptin

HERCEPTIN (INJECTION) $3.60-$7.40 (Tier 2) PAKadcyla

KADCYLA (INJECTION) $3.60-$7.40 (Tier 2) PAKeytruda

KEYTRUDA (INJECTION) $3.60-$7.40 (Tier 2) PAOpdivo

OPDIVO (INJECTION) $3.60-$7.40 (Tier 2) PAPerjeta

PERJETA (INJECTION) $3.60-$7.40 (Tier 2) PARituxan

RITUXAN (INJECTION) $3.60-$7.40 (Tier 2) PASylvant

SYLVANT (INJECTION) $3.60-$7.40 (Tier 2) PATagrisso

TAGRISSO (TABLET) $3.60-$7.40 (Tier 2) PA, QL, LATecentriq

TECENTRIQ (INJECTION) $3.60-$7.40 (Tier 2) PAVectibix

VECTIBIX (INJECTION) $3.60-$7.40 (Tier 2) PAYervoy

YERVOY (INJECTION) $3.60-$7.40 (Tier 2) PA

Retinoids

Bexarotene

bexarotene (capsule) $1.20-$2.95 (Tier 1) PAPanretin

PANRETIN (GEL) $3.60-$7.40 (Tier 2) PATargretin

TARGRETIN (1% GEL, 75MG CAPSULE) $3.60-$7.40 (Tier 2) PATretinoin

tretinoin (10mg capsule) $1.20-$2.95 (Tier 1)

Antiparasitics

AnthelminticsAlbenza

ALBENZA (TABLET) $3.60-$7.40 (Tier 2)Biltricide

BILTRICIDE (TABLET) $3.60-$7.40 (Tier 2)Ivermectin

ivermectin (tablet) $1.20-$2.95 (Tier 1)

Antiprotozoals


page 9.




38


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useAlinia

ALINIA (100MG/5ML SUSPENSION, 500MG

TABLET)$3.60-$7.40 (Tier 2)

Atovaquone

atovaquone (suspension) $1.20-$2.95 (Tier 1)Atovaquone/Proguanil HCl

atovaquone/proguanil hcl (tablet) (generic malarone) $1.20-$2.95 (Tier 1)Chloroquine Phosphate

chloroquine phosphate (tablet) $1.20-$2.95 (Tier 1)Coartem

COARTEM (TABLET) $3.60-$7.40 (Tier 2)DARAPRIM

DARAPRIM (TABLET) $3.60-$7.40 (Tier 2)Hydroxychloroquine Sulfate

hydroxychloroquine sulfate (tablet) $1.20-$2.95 (Tier 1)Mefloquine HCl

mefloquine hcl (tablet) $1.20-$2.95 (Tier 1)Mepron

MEPRON (SUSPENSION) $3.60-$7.40 (Tier 2)Nebupent

NEBUPENT (INHALATION SOLUTION) $3.60-$7.40 (Tier 2) B/D, PAPentam 300

PENTAM 300 (INJECTION) $3.60-$7.40 (Tier 2)Primaquine Phosphate

primaquine phosphate (tablet) $1.20-$2.95 (Tier 1)Quinine Sulfate

quinine sulfate (capsule) $1.20-$2.95 (Tier 1) PA

Pediculicides/Scabicides

Lindane

lindane (shampoo) $1.20-$2.95 (Tier 1)Malathion

malathion (lotion) $1.20-$2.95 (Tier 1)Permethrin

permethrin (otc only) (lotion)* $0 (Tier 3)Permethrin

permethrin (rx only) (cream) $1.20-$2.95 (Tier 1)

Antiparkinson Agents

AnticholinergicsBenztropine Mesylate

benztropine mesylate (0.5mg tablet, 1mg tablet, 2mg

tablet, 1mg/ml injection)$1.20-$2.95 (Tier 1)

Trihexyphenidyl HCl

trihexyphenidyl hcl (0.4mg/ml elixir, 2mg tablet, 5mg

tablet)$1.20-$2.95 (Tier 1)

Antiparkinson Agents, OtherAmantadine HCl

amantadine hcl (100mg capsule, 100mg tablet, 50mg/

5ml syrup)$1.20-$2.95 (Tier 1)


39


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useEntacapone

entacapone (tablet) $1.20-$2.95 (Tier 1)Tolcapone

tolcapone (tablet) $1.20-$2.95 (Tier 1)

Dopamine AgonistsApokyn

APOKYN (INJECTION) $3.60-$7.40 (Tier 2) PABromocriptine Mesylate

bromocriptine mesylate (2.5mg tablet, 5mg capsule) $1.20-$2.95 (Tier 1)Pramipexole Dihydrochloride

pramipexole dihydrochloride (tablet immediate-release) $1.20-$2.95 (Tier 1)Ropinirole HCl

ropinirole hcl (tablet immediate-release) $1.20-$2.95 (Tier 1)

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors

Carbidopa/Levodopa

carbidopa/levodopa (tablet immediate-release) $1.20-$2.95 (Tier 1)Carbidopa/Levodopa ER

carbidopa/levodopa er (tablet extended-release) $1.20-$2.95 (Tier 1)Carbidopa/Levodopa ODT

carbidopa/levodopa odt (tablet dispersible) $1.20-$2.95 (Tier 1)

Monoamine Oxidase B (MAO-B) InhibitorsAzilect

AZILECT (TABLET) $3.60-$7.40 (Tier 2)Selegiline HCl

selegiline hcl (5mg capsule, 5mg tablet) $1.20-$2.95 (Tier 1)Zelapar

ZELAPAR (TABLET DISPERSIBLE) $3.60-$7.40 (Tier 2)

Antipsychotics

1st Generation/TypicalChlorpromazine HCl

chlorpromazine hcl (100mg tablet, 10mg tablet, 200mg

tablet, 25mg tablet, 50mg tablet, 50mg/2ml injection)$1.20-$2.95 (Tier 1)

Fluphenazine Decanoate

fluphenazine decanoate (injection) $1.20-$2.95 (Tier 1)Fluphenazine HCl

fluphenazine hcl (10mg tablet, 1mg tablet, 2.5mg tablet,

5mg tablet, 2.5mg/5ml elixir, 2.5mg/ml injection, 5mg/ml

concentrate)

$1.20-$2.95 (Tier 1)

Haloperidol

haloperidol (0.5mg tablet, 10mg tablet, 1mg tablet,

20mg tablet, 2mg tablet, 5mg tablet, 2mg/ml

concentrate)

$1.20-$2.95 (Tier 1)

Haloperidol Decanoate

haloperidol decanoate (injection) $1.20-$2.95 (Tier 1)Haloperidol Lactate

haloperidol lactate (injection) $1.20-$2.95 (Tier 1)Loxapine Succinate

loxapine succinate (10mg capsule, 5mg capsule) $1.20-$2.95 (Tier 1) QLLoxapine Succinate

loxapine succinate (25mg capsule, 50mg capsule) $1.20-$2.95 (Tier 1)Molindone HCl

molindone hcl (tablet) $1.20-$2.95 (Tier 1)Orap

ORAP (TABLET) $3.60-$7.40 (Tier 2)Pimozide

pimozide (tablet) $1.20-$2.95 (Tier 1)Thioridazine HCl

thioridazine hcl (tablet) $1.20-$2.95 (Tier 1)Thiothixene

thiothixene (capsule) $1.20-$2.95 (Tier 1)Trifluoperazine HCl

trifluoperazine hcl (tablet) $1.20-$2.95 (Tier 1)


page 9.




40


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

2nd Generation/AtypicalAbilify Maintena

ABILIFY MAINTENA (INJECTION) $3.60-$7.40 (Tier 2)Aripiprazole

aripiprazole (tablet) $1.20-$2.95 (Tier 1) QLAripiprazole ODT

aripiprazole odt (tablet dispersible) $1.20-$2.95 (Tier 1) QLAristada

ARISTADA (INJECTION) $3.60-$7.40 (Tier 2)Fanapt

FANAPT (TABLET) $3.60-$7.40 (Tier 2) QL, STFanapt Titration Pack

FANAPT TITRATION PACK (TABLET) $3.60-$7.40 (Tier 2) STGeodon

GEODON (20MG INJECTION) $3.60-$7.40 (Tier 2)Invega

INVEGA (TABLET EXTENDED-RELEASE 24

HOUR)$3.60-$7.40 (Tier 2) QL

Invega Sustenna

INVEGA SUSTENNA (INJECTION) $3.60-$7.40 (Tier 2)Invega Trinza

INVEGA TRINZA (INJECTION) $3.60-$7.40 (Tier 2) PALatuda

LATUDA (TABLET) $3.60-$7.40 (Tier 2) QLNuplazid

NUPLAZID (TABLET) $3.60-$7.40 (Tier 2) PA, QLOlanzapine

olanzapine (10mg injection) $1.20-$2.95 (Tier 1)Olanzapine

olanzapine (10mg tablet immediate-release, 15mg tablet

immediate-release, 2.5mg tablet immediate-release,


release, 7.5mg tablet immediate-release)

$1.20-$2.95 (Tier 1) QL

Olanzapine ODT

olanzapine odt (tablet dispersible) $1.20-$2.95 (Tier 1) QLPaliperidone ER

paliperidone er (tablet extended-release 24 hour) $1.20-$2.95 (Tier 1) QLQuetiapine Fumarate

quetiapine fumarate (tablet immediate-release) $1.20-$2.95 (Tier 1) QLRexulti

REXULTI (TABLET) $3.60-$7.40 (Tier 2) QLRisperdal Consta

RISPERDAL CONSTA (INJECTION) $3.60-$7.40 (Tier 2)Risperidone

risperidone (0.25mg tablet immediate-release, 0.5mg



release, 4mg tablet immediate-release, 1mg/ml oral

solution)

$1.20-$2.95 (Tier 1)

Risperidone ODT

risperidone odt (tablet dispersible) $1.20-$2.95 (Tier 1)


41


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useSaphris

SAPHRIS (TABLET SUBLINGUAL) $3.60-$7.40 (Tier 2) QLSeroquel XR

SEROQUEL XR (TABLET EXTENDED-RELEASE

24 HOUR)$3.60-$7.40 (Tier 2) QL

Vraylar

VRAYLAR (1.5MG CAPSULE, 3MG CAPSULE,

4.5MG CAPSULE, 6MG CAPSULE)$3.60-$7.40 (Tier 2) QL, ST

Vraylar

VRAYLAR (CAPSULE THERAPY PACK) $3.60-$7.40 (Tier 2) STZiprasidone HCl

ziprasidone hcl (capsule) $1.20-$2.95 (Tier 1) QLZyprexa Relprevv

ZYPREXA RELPREVV (INJECTION) $3.60-$7.40 (Tier 2)

Treatment-Resistant

Clozapine

clozapine (tablet immediate-release) $1.20-$2.95 (Tier 1)Clozapine ODT

CLOZAPINE ODT (TABLET DISPERSIBLE) $3.60-$7.40 (Tier 2) QLFazaclo

FAZACLO (100MG TABLET DISPERSIBLE) $3.60-$7.40 (Tier 2) QLVersacloz

VERSACLOZ (SUSPENSION) $3.60-$7.40 (Tier 2)

Antivirals

Anti-cytomegalovirus (CMV) Agents

Cidofovir

cidofovir (injection) $1.20-$2.95 (Tier 1)Ganciclovir

ganciclovir (injection) $1.20-$2.95 (Tier 1) B/D, PAValcyte

VALCYTE (450MG TABLET, 50MG/ML ORAL

SOLUTION)$3.60-$7.40 (Tier 2)

Valganciclovir

valganciclovir (tablet) $1.20-$2.95 (Tier 1)Zirgan

ZIRGAN (GEL) $3.60-$7.40 (Tier 2)

Anti-hepatitis B (HBV) Agents

Adefovir Dipivoxil

adefovir dipivoxil (tablet) $1.20-$2.95 (Tier 1)Baraclude

BARACLUDE (0.05MG/ML ORAL SOLUTION) $3.60-$7.40 (Tier 2)Entecavir

entecavir (tablet) $1.20-$2.95 (Tier 1)Epivir HBV

EPIVIR HBV (5MG/ML ORAL SOLUTION) $3.60-$7.40 (Tier 2)Hepsera

HEPSERA (TABLET) $3.60-$7.40 (Tier 2)Lamivudine

lamivudine (100mg tablet) $1.20-$2.95 (Tier 1)Tyzeka

TYZEKA (TABLET) $3.60-$7.40 (Tier 2)

Anti-hepatitis C (HCV) AgentsDaklinza

DAKLINZA (TABLET) $3.60-$7.40 (Tier 2) PA, QLEpclusa

EPCLUSA (TABLET) $3.60-$7.40 (Tier 2) PA, QLHarvoni

HARVONI (TABLET) $3.60-$7.40 (Tier 2) PA, QLIntron A

INTRON A (INJECTION) $3.60-$7.40 (Tier 2) PAIntron A w/Diluent

INTRON A W/DILUENT (INJECTION) $3.60-$7.40 (Tier 2) PA


page 9.




42


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useOlysio

OLYSIO (CAPSULE) $3.60-$7.40 (Tier 2) PA, QLPegasys

PEGASYS (INJECTION) $3.60-$7.40 (Tier 2) PAPegasys ProClick

PEGASYS PROCLICK (INJECTION) $3.60-$7.40 (Tier 2) PAPegIntron

PEGINTRON (INJECTION) $3.60-$7.40 (Tier 2) PAPegIntron REDIPEN

PEGINTRON REDIPEN (INJECTION) $3.60-$7.40 (Tier 2) PARibasphere

ribasphere (200mg capsule, 200mg tablet, 400mg

tablet, 600mg tablet)$1.20-$2.95 (Tier 1)

Ribavirin

ribavirin (200mg capsule, 200mg tablet) $1.20-$2.95 (Tier 1)Sovaldi

SOVALDI (TABLET) $3.60-$7.40 (Tier 2) PA, QLSylatron

SYLATRON (INJECTION) $3.60-$7.40 (Tier 2) PAZepatier

ZEPATIER (TABLET) $3.60-$7.40 (Tier 2) PA, QL

Antiherpetic AgentsAcyclovir

acyclovir (200mg capsule, 200mg/5ml suspension,

400mg tablet, 800mg tablet)$1.20-$2.95 (Tier 1)

Acyclovir Sodium

acyclovir sodium (injection) $1.20-$2.95 (Tier 1) B/D, PAFamciclovir

famciclovir (tablet) $1.20-$2.95 (Tier 1) QLTrifluridine

trifluridine (ophthalmic solution) $1.20-$2.95 (Tier 1)Valacyclovir HCl

valacyclovir hcl (tablet) $1.20-$2.95 (Tier 1) QL

Anti-HIV Agents, Integrase Inhibitors (INSTI) Evotaz

EVOTAZ (TABLET) $3.60-$7.40 (Tier 2) QLGenvoya

GENVOYA (TABLET) $3.60-$7.40 (Tier 2) QLIsentress

ISENTRESS (100MG PACKET, 100MG TABLET

CHEWABLE, 25MG TABLET CHEWABLE, 400MG

TABLET)

$3.60-$7.40 (Tier 2) QL

Prezcobix

PREZCOBIX (TABLET) $3.60-$7.40 (Tier 2) QLStribild

STRIBILD (TABLET) $3.60-$7.40 (Tier 2) QLTivicay

TIVICAY (25MG TABLET, 50MG TABLET) $3.60-$7.40 (Tier 2) QLTriumeq

TRIUMEQ (TABLET) $3.60-$7.40 (Tier 2) QLTybost

TYBOST (TABLET) $3.60-$7.40 (Tier 2) QL


43


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useVitekta

VITEKTA (TABLET) $3.60-$7.40 (Tier 2) QL

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)Atripla

ATRIPLA (TABLET) $3.60-$7.40 (Tier 2) QLComplera

COMPLERA (TABLET) $3.60-$7.40 (Tier 2) QLEdurant

EDURANT (TABLET) $3.60-$7.40 (Tier 2) QLIntelence

INTELENCE (TABLET) $3.60-$7.40 (Tier 2) QLNevirapine

nevirapine (200mg tablet immediate-release) $1.20-$2.95 (Tier 1) QLNevirapine

NEVIRAPINE (50MG/5ML SUSPENSION) $3.60-$7.40 (Tier 2) QLNevirapine ER

nevirapine er (tablet extended-release 24 hour) $1.20-$2.95 (Tier 1) QLOdefsey

ODEFSEY (TABLET) $3.60-$7.40 (Tier 2) QLRescriptor

RESCRIPTOR (TABLET) $3.60-$7.40 (Tier 2) QLSustiva

SUSTIVA (200MG CAPSULE, 50MG CAPSULE,

600MG TABLET)$3.60-$7.40 (Tier 2) QL

Viramune

VIRAMUNE (50MG/5ML SUSPENSION) $3.60-$7.40 (Tier 2) QLViramune XR

VIRAMUNE XR (TABLET EXTENDED-RELEASE 24

HOUR)$3.60-$7.40 (Tier 2) QL

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

Abacavir

abacavir (tablet) $1.20-$2.95 (Tier 1) QLAbacavir Sulfate/Lamivudine/Zidovudine

abacavir sulfate/lamivudine/zidovudine (tablet) $1.20-$2.95 (Tier 1) QLCombivir

COMBIVIR (TABLET) $3.60-$7.40 (Tier 2) QLDescovy

DESCOVY (TABLET) $3.60-$7.40 (Tier 2) QLDidanosine

didanosine (capsule delayed-release) $1.20-$2.95 (Tier 1) QLEmtriva

EMTRIVA (10MG/ML ORAL SOLUTION, 200MG

CAPSULE)$3.60-$7.40 (Tier 2) QL

Epivir

EPIVIR (10MG/ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) QLEpzicom

EPZICOM (TABLET) $3.60-$7.40 (Tier 2) QLLamivudine

lamivudine (10mg/ml oral solution, 150mg tablet, 300mg

tablet)$1.20-$2.95 (Tier 1) QL

Lamivudine/Zidovudine

lamivudine/zidovudine (tablet) $1.20-$2.95 (Tier 1) QLRetrovir IV Infusion

RETROVIR IV INFUSION (INJECTION) $3.60-$7.40 (Tier 2)Stavudine

stavudine (15mg capsule, 20mg capsule, 30mg capsule,

40mg capsule, 1mg/ml oral solution)$1.20-$2.95 (Tier 1) QL

Trizivir

TRIZIVIR (TABLET) $3.60-$7.40 (Tier 2) QLTruvada

TRUVADA (TABLET) $3.60-$7.40 (Tier 2) QLVidex Pediatric

VIDEX PEDIATRIC (ORAL SOLUTION) $3.60-$7.40 (Tier 2) QL


page 9.




44


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useViread

VIREAD (150MG TABLET, 200MG TABLET,

250MG TABLET, 300MG TABLET, 40MG/GM

POWDER)

$3.60-$7.40 (Tier 2) QL

Ziagen

ZIAGEN (20MG/ML ORAL SOLUTION) $3.60-$7.40 (Tier 2) QLZidovudine

zidovudine (100mg capsule, 300mg tablet, 50mg/5ml

syrup)$1.20-$2.95 (Tier 1) QL

Anti-HIV Agents, OtherFuzeon

FUZEON (INJECTION) $3.60-$7.40 (Tier 2) QLSelzentry

SELZENTRY (TABLET) $3.60-$7.40 (Tier 2) QLTivicay

TIVICAY (10MG TABLET) $3.60-$7.40 (Tier 2) QL

Anti-HIV Agents, Protease InhibitorsAptivus

APTIVUS (100MG/ML ORAL SOLUTION, 250MG

CAPSULE)$3.60-$7.40 (Tier 2) QL

Crixivan

CRIXIVAN (CAPSULE) $3.60-$7.40 (Tier 2) QLInvirase

INVIRASE (200MG CAPSULE, 500MG TABLET) $3.60-$7.40 (Tier 2) QLKaletra

KALETRA (100MG-25MG TABLET, 200MG-50MG

TABLET, 400MG-100MG/5ML ORAL SOLUTION)$3.60-$7.40 (Tier 2) QL

Lexiva

LEXIVA (50MG/ML SUSPENSION, 700MG

TABLET)$3.60-$7.40 (Tier 2) QL

Norvir

NORVIR (100MG CAPSULE, 100MG TABLET,

80MG/ML ORAL SOLUTION)$3.60-$7.40 (Tier 2) QL

Prezista

PREZISTA (100MG/ML SUSPENSION, 150MG

TABLET, 600MG TABLET, 75MG TABLET,

800MG TABLET)

$3.60-$7.40 (Tier 2) QL

Reyataz

REYATAZ (150MG CAPSULE, 200MG CAPSULE,

300MG CAPSULE, 50MG PACKET)$3.60-$7.40 (Tier 2) QL

Viracept

VIRACEPT (TABLET) $3.60-$7.40 (Tier 2) QL

Anti-influenza AgentsRelenza Diskhaler

RELENZA DISKHALER (AEROSOL POWDER) $3.60-$7.40 (Tier 2) QL


45


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useRimantadine HCl

rimantadine hcl (tablet) $1.20-$2.95 (Tier 1)Tamiflu

TAMIFLU (30MG CAPSULE, 45MG CAPSULE,

75MG CAPSULE, 6MG/ML SUSPENSION)$3.60-$7.40 (Tier 2) QL

AntiviralsVirazole

VIRAZOLE (INHALATION SOLUTION) $3.60-$7.40 (Tier 2)

Anxiolytics

Anxiolytics, Other

Buspirone HCl

buspirone hcl (tablet) $1.20-$2.95 (Tier 1)Hydroxyzine HCl

hydroxyzine hcl (10mg tablet, 25mg tablet, 50mg tablet,

10mg/5ml syrup, 25mg/ml injection, 50mg/ml injection)$1.20-$2.95 (Tier 1)

Benzodiazepines

Alprazolam

alprazolam (tablet immediate-release) $1.20-$2.95 (Tier 1) QLChlordiazepoxide HCl

chlordiazepoxide hcl (capsule) $1.20-$2.95 (Tier 1)Clonazepam

clonazepam (tablet immediate-release) $1.20-$2.95 (Tier 1) QLClonazepam ODT

clonazepam odt (tablet dispersible) $1.20-$2.95 (Tier 1) QLClorazepate Dipotassium

clorazepate dipotassium (tablet) $1.20-$2.95 (Tier 1) QLDiazepam

diazepam (10mg tablet, 2mg tablet, 5mg tablet) $1.20-$2.95 (Tier 1) QLDiazepam

diazepam (1mg/ml oral solution) $1.20-$2.95 (Tier 1)Diazepam Intensol

diazepam intensol (5mg/ml concentrate) $1.20-$2.95 (Tier 1) QLLorazepam

lorazepam (tablet) $1.20-$2.95 (Tier 1) QLLorazepam Intensol

lorazepam intensol (2mg/ml concentrate) $1.20-$2.95 (Tier 1) QL

Bipolar Agents

Mood StabilizersEquetro

EQUETRO (CAPSULE EXTENDED-RELEASE 12

HOUR)$3.60-$7.40 (Tier 2)

Lithium

LITHIUM (ORAL SOLUTION) $3.60-$7.40 (Tier 2)Lithium Carbonate

lithium carbonate (150mg capsule immediate-release,

300mg capsule immediate-release, 600mg capsule

immediate-release, 300mg tablet immediate-release)

$1.20-$2.95 (Tier 1)

Lithium Carbonate ER

lithium carbonate er (tablet extended-release) $1.20-$2.95 (Tier 1)

Blood Glucose Regulators

Antidiabetic Agents

Acarbose

acarbose (tablet) $1.20-$2.95 (Tier 1) QLAvandia

AVANDIA (TABLET) $3.60-$7.40 (Tier 2) PA, QL


page 9.




46


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useBydureon Vial

BYDUREON VIAL (INJECTION) $3.60-$7.40 (Tier 2) QLBydureon Pen

BYDUREON PEN (INJECTION) $3.60-$7.40 (Tier 2) QLByetta

BYETTA (INJECTION) $3.60-$7.40 (Tier 2) QLCycloset

CYCLOSET (TABLET) $3.60-$7.40 (Tier 2) PA, QLFarxiga

FARXIGA (TABLET) $3.60-$7.40 (Tier 2) QLGlimepiride

glimepiride (tablet) $1.20-$2.95 (Tier 1) QLGlipizide

glipizide (tablet immediate-release) $1.20-$2.95 (Tier 1) QLGlipizide ER

glipizide er (tablet extended-release 24 hour) $1.20-$2.95 (Tier 1) QLGlipizide/Metformin HCl

glipizide/metformin hcl (tablet) $1.20-$2.95 (Tier 1) QLJardiance

JARDIANCE (TABLET) $3.60-$7.40 (Tier 2) QLJentadueto

JENTADUETO (TABLET) $3.60-$7.40 (Tier 2) QLJentadueto XR

JENTADUETO XR (TABLET EXTENDED-RELEASE

24 HOUR)$3.60-$7.40 (Tier 2) QL

Kombiglyze XR

KOMBIGLYZE XR (TABLET EXTENDED-RELEASE

24 HOUR)$3.60-$7.40 (Tier 2) QL

Metformin HCl

metformin hcl (tablet immediate-release) $1.20-$2.95 (Tier 1) QLMetformin HCl ER

metformin hcl er (1000mg tablet extended-release 24

hour) (generic fortamet), (500mg tablet extended-release

24 hour, 750mg tablet extended-release 24 hour)

(generic glucophage xr)

$1.20-$2.95 (Tier 1) QL

Nateglinide

nateglinide (tablet) $1.20-$2.95 (Tier 1) QLNesina

NESINA (TABLET) $3.60-$7.40 (Tier 2) QLOnglyza

ONGLYZA (TABLET) $3.60-$7.40 (Tier 2) QLPioglitazone HCl

pioglitazone hcl (tablet) $1.20-$2.95 (Tier 1) QLPioglitazone HCl/Glimepiride

pioglitazone hcl/glimepiride (tablet) $1.20-$2.95 (Tier 1) QLPioglitazone HCl/Metformin HCl

pioglitazone hcl/metformin hcl (tablet) $1.20-$2.95 (Tier 1) QLRepaglinide

repaglinide (tablet) $1.20-$2.95 (Tier 1) QLRepaglinide/Metformin HCl

repaglinide/metformin hcl (tablet) $1.20-$2.95 (Tier 1) QLRiomet

RIOMET (ORAL SOLUTION) $3.60-$7.40 (Tier 2) QLSymlinPen 120

SYMLINPEN 120 (INJECTION) $3.60-$7.40 (Tier 2) PA


47


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useSymlinPen 60

SYMLINPEN 60 (INJECTION) $3.60-$7.40 (Tier 2) PASynjardy

SYNJARDY (TABLET) $3.60-$7.40 (Tier 2) QLTradjenta

TRADJENTA (TABLET) $3.60-$7.40 (Tier 2) QLXigduo XR

XIGDUO XR (TABLET EXTENDED-RELEASE 24

HOUR)$3.60-$7.40 (Tier 2) QL

Glycemic AgentsGlucaGen HypoKit

GLUCAGEN HYPOKIT (INJECTION) $3.60-$7.40 (Tier 2)Glucagon Emergency Kit

GLUCAGON EMERGENCY KIT (INJECTION) $3.60-$7.40 (Tier 2)Glutose 15

glutose 15 (gel)* $0 (Tier 3)Proglycem

PROGLYCEM (SUSPENSION) $3.60-$7.40 (Tier 2)

InsulinsHumalog Cartridge

HUMALOG CARTRIDGE (INJECTION) $3.60-$7.40 (Tier 2)Humalog KwikPen

HUMALOG KWIKPEN (INJECTION) $3.60-$7.40 (Tier 2)Humalog Mix 50/50 KwikPen

HUMALOG MIX 50/50 KWIKPEN (INJECTION) $3.60-$7.40 (Tier 2)Humalog Mix 50/50 Vial

HUMALOG MIX 50/50 VIAL (INJECTION) $3.60-$7.40 (Tier 2)Humalog Mix 75/25 KwikPen

HUMALOG MIX 75/25 KWIKPEN (INJECTION) $3.60-$7.40 (Tier 2)Humalog Mix 75/25 Vial

HUMALOG MIX 75/25 VIAL (INJECTION) $3.60-$7.40 (Tier 2)Humalog Vial

HUMALOG VIAL (INJECTION) $3.60-$7.40 (Tier 2)Humulin 70/30 KwikPen

HUMULIN 70/30 KWIKPEN (INJECTION) $3.60-$7.40 (Tier 2)Humulin 70/30 Vial

HUMULIN 70/30 VIAL (INJECTION) $3.60-$7.40 (Tier 2)Humulin N KwikPen

HUMULIN N KWIKPEN (INJECTION) $3.60-$7.40 (Tier 2)Humulin N Vial

HUMULIN N VIAL (INJECTION) $3.60-$7.40 (Tier 2)Humulin R U-500 KwikPen

HUMULIN R U-500 KWIKPEN (INJECTION) $3.60-$7.40 (Tier 2)Humulin R U-500 Vial

HUMULIN R U-500 VIAL (CONCENTRATED)


Humulin R Vial

HUMULIN R VIAL (INJECTION) $3.60-$7.40 (Tier 2)Lantus SoloStar

LANTUS SOLOSTAR (INJECTION) $3.60-$7.40 (Tier 2)Lantus Vial

LANTUS VIAL (INJECTION) $3.60-$7.40 (Tier 2)Levemir FlexTouch

LEVEMIR FLEXTOUCH (INJECTION) $3.60-$7.40 (Tier 2)Levemir Vial

LEVEMIR VIAL (INJECTION) $3.60-$7.40 (Tier 2)Toujeo SoloStar

TOUJEO SOLOSTAR (INJECTION) $3.60-$7.40 (Tier 2)

Blood Products/Modifiers/Volume Expanders

AnticoagulantsCoumadin

COUMADIN (TABLET) $3.60-$7.40 (Tier 2)Eliquis

ELIQUIS (TABLET) $3.60-$7.40 (Tier 2) PA, QL


page 9.




48


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useEnoxaparin Sodium

enoxaparin sodium (injection) $1.20-$2.95 (Tier 1) QLFondaparinux Sodium

fondaparinux sodium (injection) $1.20-$2.95 (Tier 1)Heparin Sodium

heparin sodium (10000unit/ml injection, 20000unit/ml

injection, 5000unit/ml injection)$1.20-$2.95 (Tier 1)

Heparin Sodium

heparin sodium (1000unit/ml injection) $1.20-$2.95 (Tier 1) B/D, PAHeparin Sodium/D5W

HEPARIN SODIUM/D5W (INJECTION) $3.60-$7.40 (Tier 2)Jantoven

jantoven (tablet) $1.20-$2.95 (Tier 1)Pradaxa

PRADAXA (CAPSULE) $3.60-$7.40 (Tier 2) PA, QLWarfarin Sodium

warfarin sodium (tablet) $1.20-$2.95 (Tier 1)Xarelto

XARELTO (TABLET) $3.60-$7.40 (Tier 2) PA, QLXarelto Starter Pack

XARELTO STARTER PACK (TABLET THERAPY

PACK)$3.60-$7.40 (Tier 2) PA, QL

Blood Formation Modifiers

Anagrelide HCl

anagrelide hcl (capsule) $1.20-$2.95 (Tier 1)Aranesp Albumin Free

ARANESP ALBUMIN FREE (INJECTION) $3.60-$7.40 (Tier 2) PAGranix

GRANIX (INJECTION) $3.60-$7.40 (Tier 2) PALeukine

LEUKINE (INJECTION) $3.60-$7.40 (Tier 2) PAMozobil

MOZOBIL (INJECTION) $3.60-$7.40 (Tier 2) PANeulasta

NEULASTA (INJECTION) $3.60-$7.40 (Tier 2) PANeupogen

NEUPOGEN (INJECTION) $3.60-$7.40 (Tier 2) PAProcrit

PROCRIT (INJECTION) $3.60-$7.40 (Tier 2) PAPromacta

PROMACTA (TABLET) $3.60-$7.40 (Tier 2) PAZarxio

zarxio (injection) $3.60-$7.40 (Tier 2)

Blood Products/Modifiers/Volume ExpandersArgatroban

ARGATROBAN (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA

Coagulants

Tranexamic Acid

tranexamic acid (1000mg/10ml injection, 650mg tablet) $1.20-$2.95 (Tier 1)

Platelet Modifying Agents


49


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useAggrenox

AGGRENOX (CAPSULE EXTENDED-RELEASE 12

HOUR)$3.60-$7.40 (Tier 2) QL

Aspirin/Dipyridamole

ASPIRIN/DIPYRIDAMOLE (CAPSULE EXTENDED-

RELEASE 12 HOUR)$3.60-$7.40 (Tier 2) QL

Brilinta

BRILINTA (TABLET) $3.60-$7.40 (Tier 2) QLCilostazol

cilostazol (tablet) $1.20-$2.95 (Tier 1)Clopidogrel

clopidogrel (75mg tablet) $1.20-$2.95 (Tier 1) QLEffient

EFFIENT (TABLET) $3.60-$7.40 (Tier 2) QL

Cardiovascular Agents

Alpha-adrenergic AgonistsClonidine HCl

clonidine hcl (0.1mg tablet immediate-release, 0.2mg

tablet immediate-release, 0.3mg tablet immediate-

release, 0.1mg/24hr patch weekly, 0.2mg/24hr patch

weekly, 0.3mg/24hr patch weekly)

$1.20-$2.95 (Tier 1)

Methyldopa

methyldopa (tablet) $1.20-$2.95 (Tier 1)Methyldopate HCl

methyldopate hcl (injection) $1.20-$2.95 (Tier 1)Midodrine HCl

midodrine hcl (tablet) $1.20-$2.95 (Tier 1)

Alpha-adrenergic Blocking AgentsDibenzyline

DIBENZYLINE (CAPSULE) $3.60-$7.40 (Tier 2)Doxazosin Mesylate

doxazosin mesylate (tablet) $1.20-$2.95 (Tier 1)Phenoxybenzamine HCl

phenoxybenzamine hcl (capsule) $1.20-$2.95 (Tier 1)Prazosin HCl

prazosin hcl (capsule) $1.20-$2.95 (Tier 1)

Angiotensin II Receptor AntagonistsBenicar

BENICAR (TABLET) $3.60-$7.40 (Tier 2) QLCandesartan Cilexetil

candesartan cilexetil (tablet) $1.20-$2.95 (Tier 1) QLEprosartan Mesylate

eprosartan mesylate (tablet) $1.20-$2.95 (Tier 1) QLIrbesartan

irbesartan (tablet) $1.20-$2.95 (Tier 1) QLLosartan Potassium

losartan potassium (tablet) $1.20-$2.95 (Tier 1) QLTelmisartan

telmisartan (tablet) $1.20-$2.95 (Tier 1) QLValsartan

valsartan (tablet) $1.20-$2.95 (Tier 1) QL

Angiotensin-converting Enzyme (ACE) Inhibitors

Benazepril HCl

benazepril hcl (tablet) $1.20-$2.95 (Tier 1) QLCaptopril

captopril (tablet) $1.20-$2.95 (Tier 1) QLEnalapril Maleate

enalapril maleate (tablet) $1.20-$2.95 (Tier 1) QLEpaned

EPANED (ORAL SOLUTION) $3.60-$7.40 (Tier 2)


page 9.




50


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useFosinopril Sodium

fosinopril sodium (tablet) $1.20-$2.95 (Tier 1) QLLisinopril

lisinopril (tablet) $1.20-$2.95 (Tier 1) QLMoexipril HCl

moexipril hcl (tablet) $1.20-$2.95 (Tier 1) QLPerindopril Erbumine

perindopril erbumine (tablet) $1.20-$2.95 (Tier 1) QLQuinapril HCl

quinapril hcl (tablet) $1.20-$2.95 (Tier 1) QLRamipril

ramipril (capsule) $1.20-$2.95 (Tier 1) QLTrandolapril

trandolapril (tablet) $1.20-$2.95 (Tier 1) QL

Antiarrhythmics

Amiodarone HCl

amiodarone hcl (200mg tablet, 50mg/ml injection) $1.20-$2.95 (Tier 1)Dofetilide

dofetilide (capsule) $1.20-$2.95 (Tier 1)Flecainide Acetate

flecainide acetate (tablet) $1.20-$2.95 (Tier 1)Mexiletine HCl

mexiletine hcl (capsule) $1.20-$2.95 (Tier 1)Multaq

MULTAQ (TABLET) $3.60-$7.40 (Tier 2) QLPacerone

pacerone (200mg tablet) $1.20-$2.95 (Tier 1)Procainamide HCl

procainamide hcl (injection) $1.20-$2.95 (Tier 1)Propafenone HCl

propafenone hcl (tablet) $1.20-$2.95 (Tier 1)Propafenone HCl ER

propafenone hcl er (capsule extended-release 12 hour) $1.20-$2.95 (Tier 1)Quinidine Gluconate

QUINIDINE GLUCONATE (INJECTION) $3.60-$7.40 (Tier 2)Quinidine Gluconate CR

quinidine gluconate cr (tablet extended-release) $1.20-$2.95 (Tier 1)Quinidine Sulfate

quinidine sulfate (tablet) $1.20-$2.95 (Tier 1)Sotalol HCl

sotalol hcl (af) (tablet) $1.20-$2.95 (Tier 1)Sotalol HCl

sotalol hcl (tablet) $1.20-$2.95 (Tier 1)Tikosyn

TIKOSYN (CAPSULE) $3.60-$7.40 (Tier 2)

Beta-adrenergic Blocking Agents

Atenolol

atenolol (tablet) $1.20-$2.95 (Tier 1)Bystolic

BYSTOLIC (TABLET) $3.60-$7.40 (Tier 2) QLCarvedilol

carvedilol (tablet immediate-release) $1.20-$2.95 (Tier 1)Labetalol HCl

labetalol hcl (100mg tablet, 200mg tablet, 300mg tablet,

5mg/ml injection)$1.20-$2.95 (Tier 1)


51


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMetoprolol Succinate ER

metoprolol succinate er (tablet extended-release 24 hour) $1.20-$2.95 (Tier 1)Metoprolol Tartrate

metoprolol tartrate (100mg tablet immediate-release,


release, 1mg/ml injection)

$1.20-$2.95 (Tier 1)

Nadolol

nadolol (tablet) $1.20-$2.95 (Tier 1)Pindolol

pindolol (tablet) $1.20-$2.95 (Tier 1)Propranolol HCl

propranolol hcl (tablet immediate-release, 1mg/ml

injection, oral solution)$1.20-$2.95 (Tier 1)

Propranolol HCl ER

propranolol hcl er (capsule extended-release 24 hour) $1.20-$2.95 (Tier 1)Timolol Maleate

timolol maleate (10mg tablet, 20mg tablet, 5mg tablet) $1.20-$2.95 (Tier 1)

Calcium Channel Blocking Agents

Amlodipine Besylate

amlodipine besylate (tablet) $1.20-$2.95 (Tier 1)Cardene IV

CARDENE IV (INJECTION) $3.60-$7.40 (Tier 2)Cartia XT

cartia xt (capsule extended-release 24 hour) $1.20-$2.95 (Tier 1)Diltiazem CD

diltiazem cd (240mg capsule extended-release 24 hour)

(generic cardizem cd)$1.20-$2.95 (Tier 1)

Diltiazem HCl

diltiazem hcl (100mg injection, 50mg/10ml injection,

tablet immediate-release)$1.20-$2.95 (Tier 1)

Diltiazem HCl ER

diltiazem hcl er (120mg capsule extended-release 24

hour, 300mg capsule extended-release 24 hour) (generic

cardizem cd)

$1.20-$2.95 (Tier 1)

Dilt-XR

dilt-xr (capsule extended-release 24 hour) $1.20-$2.95 (Tier 1)Nicardipine HCl

nicardipine hcl (2.5mg/ml injection, 20mg capsule, 30mg

capsule)$1.20-$2.95 (Tier 1)

Nimodipine

nimodipine (capsule) $1.20-$2.95 (Tier 1)Verapamil HCl

verapamil hcl (120mg tablet immediate-release, 40mg


2.5mg/ml injection)

$1.20-$2.95 (Tier 1)

Verapamil HCl ER

verapamil hcl er (120mg tablet extended-release, 180mg

tablet extended-release, 240mg tablet extended-release)$1.20-$2.95 (Tier 1)

Cardiovascular Agents, Other

Amiloride/Hydrochlorothiazide

amiloride/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1)Amlodipine Besylate/Atorvastatin Calcium

amlodipine besylate/atorvastatin calcium (tablet) $1.20-$2.95 (Tier 1) QLAmlodipine Besylate/Benazepril HCl

amlodipine besylate/benazepril hcl (capsule) $1.20-$2.95 (Tier 1) QLAtenolol/Chlorthalidone

atenolol/chlorthalidone (tablet) $1.20-$2.95 (Tier 1)Benazepril HCl/Hydrochlorothiazide

benazepril hcl/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1) QLBenicar HCT

BENICAR HCT (TABLET) $3.60-$7.40 (Tier 2) QLCandesartan Cilexetil/Hydrochlorothiazide

candesartan cilexetil/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1) QL


page 9.




52


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useCaptopril/Hydrochlorothiazide

captopril/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1) QLDemser

DEMSER (CAPSULE) $3.60-$7.40 (Tier 2)Digitek

digitek (tablet) $1.20-$2.95 (Tier 1)Digoxin

DIGOXIN (0.05MG/ML ORAL SOLUTION) $3.60-$7.40 (Tier 2)Digoxin

digoxin (0.25mg/ml injection, 125mcg tablet, 250mcg

tablet)$1.20-$2.95 (Tier 1)

Enalapril Maleate/Hydrochlorothiazide

enalapril maleate/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1) QLEntresto

ENTRESTO (TABLET) $3.60-$7.40 (Tier 2) PA, QLFosinopril Sodium/Hydrochlorothiazide

fosinopril sodium/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1) QLIrbesartan/Hydrochlorothiazide

irbesartan/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1) QLLanoxin

LANOXIN (125MCG TABLET, 187.5MCG TABLET,

250MCG TABLET, 62.5MCG TABLET)$3.60-$7.40 (Tier 2)

Lisinopril/Hydrochlorothiazide

lisinopril/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1) QLLosartan Potassium/Hydrochlorothiazide

losartan potassium/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1) QLMethyldopa/Hydrochlorothiazide

methyldopa/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1)Metoprolol/Hydrochlorothiazide

metoprolol/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1)Moexipril/Hydrochlorothiazide

moexipril/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1) QLNorthera

NORTHERA (CAPSULE) $3.60-$7.40 (Tier 2) PA, QLPentoxifylline ER

pentoxifylline er (tablet extended-release) $1.20-$2.95 (Tier 1)Propranolol/Hydrochlorothiazide

propranolol/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1)Quinapril/Hydrochlorothiazide

quinapril/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1) QLRanexa

RANEXA (TABLET EXTENDED-RELEASE 12

HOUR)$3.60-$7.40 (Tier 2) QL

Spironolactone/Hydrochlorothiazide

spironolactone/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1)Telmisartan/Amlodipine

telmisartan/amlodipine (tablet) $1.20-$2.95 (Tier 1) QLTelmisartan/Hydrochlorothiazide

telmisartan/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1) QLTriamterene/Hydrochlorothiazide

triamterene/hydrochlorothiazide (capsule, tablet) $1.20-$2.95 (Tier 1)Valsartan/Hydrochlorothiazide

valsartan/hydrochlorothiazide (tablet) $1.20-$2.95 (Tier 1) QL

Diuretics, Carbonic Anhydrase Inhibitors


53


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useAcetazolamide

acetazolamide (tablet immediate-release) $1.20-$2.95 (Tier 1)Acetazolamide ER

acetazolamide er (capsule extended-release 12 hour) $1.20-$2.95 (Tier 1)Acetazolamide Sodium

acetazolamide sodium (injection) $1.20-$2.95 (Tier 1)

Diuretics, LoopBumetanide

bumetanide (0.25mg/ml injection, 0.5mg tablet, 1mg


Furosemide

furosemide (10mg/ml injection) $1.20-$2.95 (Tier 1) B/D, PAFurosemide

furosemide (10mg/ml oral solution, 8mg/ml oral solution,

20mg tablet, 40mg tablet, 80mg tablet)$1.20-$2.95 (Tier 1)

Torsemide

torsemide (tablet) $1.20-$2.95 (Tier 1)

Diuretics, Potassium-sparing

Amiloride HCl

amiloride hcl (tablet) $1.20-$2.95 (Tier 1)Eplerenone

eplerenone (tablet) $1.20-$2.95 (Tier 1)Spironolactone

spironolactone (tablet) $1.20-$2.95 (Tier 1)

Diuretics, Thiazide

Chlorothiazide

chlorothiazide (tablet) $1.20-$2.95 (Tier 1)Chlorothiazide Sodium

chlorothiazide sodium (injection) $1.20-$2.95 (Tier 1) B/D, PAChlorthalidone

chlorthalidone (tablet) $1.20-$2.95 (Tier 1)Diuril

DIURIL (SUSPENSION) $3.60-$7.40 (Tier 2)Hydrochlorothiazide

hydrochlorothiazide (12.5mg capsule, 12.5mg tablet,

25mg tablet, 50mg tablet)$1.20-$2.95 (Tier 1)

Indapamide

indapamide (tablet) $1.20-$2.95 (Tier 1)Methyclothiazide

methyclothiazide (tablet) $1.20-$2.95 (Tier 1)Metolazone

metolazone (tablet) $1.20-$2.95 (Tier 1)

Dyslipidemics, Fibric Acid DerivativesFenofibrate

fenofibrate (145mg tablet, 160mg tablet, 48mg tablet,

54mg tablet)$1.20-$2.95 (Tier 1)

Fenofibrate Micronized

fenofibrate micronized (capsule) $1.20-$2.95 (Tier 1)Fenofibric Acid

FENOFIBRIC ACID (TABLET) $3.60-$7.40 (Tier 2)Fenofibric Acid DR

fenofibric acid dr (capsule delayed-release) $1.20-$2.95 (Tier 1)Gemfibrozil

gemfibrozil (tablet) $1.20-$2.95 (Tier 1)

Dyslipidemics, HMG CoA Reductase Inhibitors

Atorvastatin Calcium

atorvastatin calcium (tablet) $1.20-$2.95 (Tier 1) QLCrestor

CRESTOR (TABLET) $3.60-$7.40 (Tier 2) QLFluvastatin

fluvastatin (capsule immediate-release) $1.20-$2.95 (Tier 1) QLLovastatin

lovastatin (tablet immediate-release) $1.20-$2.95 (Tier 1) QL


page 9.




54


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on usePravastatin Sodium

pravastatin sodium (tablet) $1.20-$2.95 (Tier 1) QLRosuvastatin Calcium

rosuvastatin calcium (tablet) $1.20-$2.95 (Tier 1) QLSimvastatin

simvastatin (tablet) $1.20-$2.95 (Tier 1) QL

Dyslipidemics, Other

Cholestyramine Light

cholestyramine light (4gm packet, 4gm/dose powder) $1.20-$2.95 (Tier 1)Colestipol HCl

colestipol hcl (1gm tablet, 5gm granules) $1.20-$2.95 (Tier 1)Juxtapid

JUXTAPID (CAPSULE) $3.60-$7.40 (Tier 2) PAKynamro

KYNAMRO (INJECTION) $3.60-$7.40 (Tier 2) PANiacin

niacin (otc only) (100mg tablet, 50mg tablet)* $0 (Tier 3) PANiacin

niacin (otc only) (500mg tablet)* $0 (Tier 3) PA, QLNiacin ER

niacin er (rx only) (tablet extended-release) $1.20-$2.95 (Tier 1)Niacor

niacor (tablet) $1.20-$2.95 (Tier 1)Omega-3-Acid Ethyl Esters

omega-3-acid ethyl esters (capsule) (generic lovaza) $1.20-$2.95 (Tier 1) QLPraluent

PRALUENT (INJECTION) $3.60-$7.40 (Tier 2) PA, QL, LAPrevalite

prevalite (powder) $1.20-$2.95 (Tier 1)RA Niacin

ra niacin (otc only) (100mg tablet)* $0 (Tier 3) PARA Niacin

ra niacin (otc only) (500mg tablet)* $0 (Tier 3) PA, QLRepatha

REPATHA (INJECTION) $3.60-$7.40 (Tier 2) PA, QLRepatha Pushtronex System

REPATHA PUSHTRONEX SYSTEM (SOLUTION

CARTRIDGE)$3.60-$7.40 (Tier 2) PA, QL

Repatha SureClick

REPATHA SURECLICK (INJECTION) $3.60-$7.40 (Tier 2) PA, QLVascepa

VASCEPA (CAPSULE) $3.60-$7.40 (Tier 2)Vytorin

VYTORIN (TABLET) $3.60-$7.40 (Tier 2) QLWelchol

WELCHOL (3.75GM PACKET, 625MG TABLET) $3.60-$7.40 (Tier 2)Zetia

ZETIA (TABLET) $3.60-$7.40 (Tier 2) QL

Vasodilators, Direct-acting ArterialHydralazine HCl

hydralazine hcl (100mg tablet, 10mg tablet, 25mg tablet,

50mg tablet, 20mg/ml injection)$1.20-$2.95 (Tier 1)

Minoxidil

minoxidil (tablet) $1.20-$2.95 (Tier 1)


55


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Vasodilators, Direct-acting Arterial/Venous

Isosorbide Dinitrate

isosorbide dinitrate (tablet immediate-release) $1.20-$2.95 (Tier 1)Isosorbide Dinitrate ER

isosorbide dinitrate er (tablet extended-release) $1.20-$2.95 (Tier 1)Isosorbide Mononitrate

isosorbide mononitrate (tablet immediate-release) $1.20-$2.95 (Tier 1)Isosorbide Mononitrate ER

isosorbide mononitrate er (tablet extended-release 24

hour)$1.20-$2.95 (Tier 1)

Minitran

minitran (patch 24 hour) $1.20-$2.95 (Tier 1)Nitro-Bid

nitro-bid (ointment) $1.20-$2.95 (Tier 1)Nitroglycerin

nitroglycerin (injection) $1.20-$2.95 (Tier 1)Nitroglycerin Lingual

nitroglycerin lingual (translingual solution) $1.20-$2.95 (Tier 1)Nitroglycerin Transdermal

nitroglycerin transdermal (patch 24 hour) $1.20-$2.95 (Tier 1)Nitrostat

NITROSTAT (TABLET SUBLINGUAL) $3.60-$7.40 (Tier 2)

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, AmphetaminesAmphetamine/Dextroamphetamine

amphetamine/dextroamphetamine (capsule extended-

release 24 hour, tablet immediate-release)$1.20-$2.95 (Tier 1) QL

Dexedrine

dexedrine (tablet) $1.20-$2.95 (Tier 1) QLDextroamphetamine Sulfate

dextroamphetamine sulfate (tablet immediate-release) $1.20-$2.95 (Tier 1) QL

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

Clonidine HCl ER

clonidine hcl er (tablet extended-release 12 hour) $1.20-$2.95 (Tier 1)Dexmethylphenidate HCl

dexmethylphenidate hcl (tablet immediate-release) $1.20-$2.95 (Tier 1) QLDexmethylphenidate HCl ER

dexmethylphenidate hcl er (capsule extended-release 24

hour)$1.20-$2.95 (Tier 1)

Guanfacine ER

guanfacine er (tablet extended-release 24 hour) $1.20-$2.95 (Tier 1)Methylphenidate HCl

methylphenidate hcl (10mg tablet immediate-release,


release) (generic ritalin), (10mg/5ml oral solution, 5mg/

5ml oral solution)

$1.20-$2.95 (Tier 1) QL

Methylphenidate HCl ER

methylphenidate hcl er (10mg tablet extended-release,

20mg tablet extended-release)$1.20-$2.95 (Tier 1) QL

Strattera

STRATTERA (CAPSULE) $3.60-$7.40 (Tier 2) QL, ST

Central Nervous System, OtherNamzaric

NAMZARIC (CAPSULE EXTENDED-RELEASE 24

HOUR)$3.60-$7.40 (Tier 2) PA, QL

Nuedexta

NUEDEXTA (CAPSULE) $3.60-$7.40 (Tier 2) PARilutek

RILUTEK (TABLET) $3.60-$7.40 (Tier 2)


page 9.




56


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useRiluzole

riluzole (tablet) $1.20-$2.95 (Tier 1)Tetrabenazine

tetrabenazine (tablet) $1.20-$2.95 (Tier 1) PA, QLXenazine

XENAZINE (TABLET) $3.60-$7.40 (Tier 2) PA, QL, LA

Fibromyalgia AgentsDuloxetine HCl

duloxetine hcl (20mg capsule delayed-release, 30mg

capsule delayed-release, 60mg capsule delayed-release)$1.20-$2.95 (Tier 1) QL

Lyrica

LYRICA (100MG CAPSULE, 150MG CAPSULE,

200MG CAPSULE, 225MG CAPSULE, 25MG

CAPSULE, 300MG CAPSULE, 50MG CAPSULE,

75MG CAPSULE, 20MG/ML ORAL SOLUTION)

$3.60-$7.40 (Tier 2) QL

Savella

SAVELLA (TABLET) $3.60-$7.40 (Tier 2)Savella Titration Pack

SAVELLA TITRATION PACK $3.60-$7.40 (Tier 2)

Multiple Sclerosis AgentsAmpyra

AMPYRA (TABLET EXTENDED-RELEASE 12

HOUR)$3.60-$7.40 (Tier 2) PA, QL

Aubagio

AUBAGIO (TABLET) $3.60-$7.40 (Tier 2) PA, QLAvonex

AVONEX (INJECTION) $3.60-$7.40 (Tier 2) PAAvonex Pen

AVONEX PEN (INJECTION) $3.60-$7.40 (Tier 2) PABetaseron

BETASERON (INJECTION) $3.60-$7.40 (Tier 2) PACopaxone

COPAXONE (INJECTION) $3.60-$7.40 (Tier 2) PAGilenya

GILENYA (CAPSULE) $3.60-$7.40 (Tier 2) PA, QLGlatopa

glatopa (injection) $1.20-$2.95 (Tier 1) PARebif

REBIF (INJECTION) $3.60-$7.40 (Tier 2) PARebif Rebidose

REBIF REBIDOSE (INJECTION) $3.60-$7.40 (Tier 2) PARebif Rebidose Titration Pack

REBIF REBIDOSE TITRATION PACK (INJECTION) $3.60-$7.40 (Tier 2) PARebif Titration Pack

REBIF TITRATION PACK (INJECTION) $3.60-$7.40 (Tier 2) PATecfidera

TECFIDERA (CAPSULE DELAYED-RELEASE) $3.60-$7.40 (Tier 2) PA, QLTecfidera Starter Pack

TECFIDERA STARTER PACK $3.60-$7.40 (Tier 2) PATysabri

TYSABRI (INJECTION) $3.60-$7.40 (Tier 2) PA


57


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Dental and Oral Agents

Dental and Oral Agents

Chlorhexidine Gluconate Oral Rinse

chlorhexidine gluconate oral rinse (solution) $1.20-$2.95 (Tier 1)Kepivance

KEPIVANCE (INJECTION) $3.60-$7.40 (Tier 2)Periogard

periogard (solution) $1.20-$2.95 (Tier 1)Pilocarpine HCl

pilocarpine hcl (5mg tablet, 7.5mg tablet) $1.20-$2.95 (Tier 1)Triamcinolone in Orabase

triamcinolone in orabase (paste) $1.20-$2.95 (Tier 1)

Dermatological Agents

Dermatological Agents8-MOP

8-MOP (CAPSULE) $3.60-$7.40 (Tier 2)Acitretin

acitretin (capsule) $1.20-$2.95 (Tier 1)Adapalene

adapalene (0.1% cream, 0.1% gel) $1.20-$2.95 (Tier 1)Ammonium Lactate

ammonium lactate (rx only) (12% cream, 12% lotion) $1.20-$2.95 (Tier 1)Anti-Itch

anti-itch (cream)* $0 (Tier 3)Anti-Itch Maximum Strength

anti-itch maximum strength (external solution)* $0 (Tier 3)Anu-Med

anu-med (suppository)* $0 (Tier 3)Aquabase

aquabase (ointment)* $0 (Tier 3)Avita

AVITA (0.025% CREAM, 0.025% GEL) $3.60-$7.40 (Tier 2) PABenzoyl Peroxide

benzoyl peroxide (otc only) (10% gel, 5% gel)* $0 (Tier 3) QLBenzoyl Peroxide

benzoyl peroxide (otc only) (2.5% gel)* $0 (Tier 3)Calcipotriene

calcipotriene (0.005% cream, 0.005% external solution) $1.20-$2.95 (Tier 1)Calcitriol

CALCITRIOL (3MCG/GM OINTMENT) $3.60-$7.40 (Tier 2)Caldyphen

caldyphen (lotion)* $0 (Tier 3)Carac

CARAC (CREAM) $3.60-$7.40 (Tier 2)Carmol 10

carmol 10 (lotion)* $0 (Tier 3)Carmol 20

carmol 20 (cream)* $0 (Tier 3)Claravis

claravis (capsule) $1.20-$2.95 (Tier 1) PAClindamycin Phosphate

clindamycin phosphate (1% external solution, 1% gel, 1%

lotion, 1% swab)$1.20-$2.95 (Tier 1)

Clindamycin/Benzoyl Peroxide

clindamycin/benzoyl peroxide (gel) (generic benzaclin) $1.20-$2.95 (Tier 1)Clotrimazole/Betamethasone Dipropionate

clotrimazole/betamethasone dipropionate (1%-0.05%

cream, 1%-0.05% lotion)$1.20-$2.95 (Tier 1)

Coats Aloe Vera

coats aloe vera (cream, liquid, 90% gel)* $0 (Tier 3)Coats Aloe Vera Liniment

coats aloe vera liniment (liquid)* $0 (Tier 3)Coats Aloe Vera Moisturizing Lotion

coats aloe vera moisturizing lotion* $0 (Tier 3)Dermabase Oil in Water

dermabase oil in water (cream)* $0 (Tier 3)


page 9.




58


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useDibucaine

dibucaine (ointment)* $0 (Tier 3)Diclofenac Sodium

diclofenac sodium (3% gel) $1.20-$2.95 (Tier 1) PADoxepin HCl

DOXEPIN HCL (CREAM) $3.60-$7.40 (Tier 2)Dr Smiths Diaper

dr smiths diaper (ointment)* $0 (Tier 3)Dr Smiths Diaper Rash Spray

dr smiths diaper rash spray (aerosol)* $0 (Tier 3) QLDr Smiths Rash + Skin

dr smiths rash + skin (aerosol)* $0 (Tier 3) QLElidel

ELIDEL (CREAM) $3.60-$7.40 (Tier 2) STEry

ery (2% pad) $1.20-$2.95 (Tier 1)Erythromycin

erythromycin (2% external solution, 2% gel) $1.20-$2.95 (Tier 1)Erythromycin/Benzoyl Peroxide

erythromycin/benzoyl peroxide (gel) $1.20-$2.95 (Tier 1)Fattibase

fattibase (ointment)* $0 (Tier 3)Fluorouracil

fluorouracil (2% external solution, 5% external solution,

5% cream)$1.20-$2.95 (Tier 1)

Hemorrhoid

hemorrhoid (suppository)* $0 (Tier 3)Hydrocream Base Water in Oil

hydrocream base water in oil (cream)* $0 (Tier 3)Imiquimod

imiquimod (cream) $1.20-$2.95 (Tier 1)Itch-X

itch-x (gel)* $0 (Tier 3)Major-Prep Hemorrhoidal

major-prep hemorrhoidal (ointment)* $0 (Tier 3) QLMedicated Body Powder

medicated body powder* $0 (Tier 3)Methoxsalen

methoxsalen (capsule) $1.20-$2.95 (Tier 1)Mirvaso

MIRVASO (GEL) $3.60-$7.40 (Tier 2) PAOxsoralen Ultra

OXSORALEN ULTRA (CAPSULE) $3.60-$7.40 (Tier 2)Picato

PICATO (GEL) $3.60-$7.40 (Tier 2)Podofilox

podofilox (external solution) $1.20-$2.95 (Tier 1)Polybase

polybase (ointment)* $0 (Tier 3)PRUDOXIN

PRUDOXIN (CREAM) $3.60-$7.40 (Tier 2)QC Anti-Itch Extra Strength

qc anti-itch extra strength (cream)* $0 (Tier 3)Regranex

REGRANEX (GEL) $3.60-$7.40 (Tier 2) PASantyl

SANTYL (OINTMENT) $3.60-$7.40 (Tier 2)Sarna

sarna (lotion)* $0 (Tier 3)


59


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useSelenium Sulfide

selenium sulfide (lotion) $1.20-$2.95 (Tier 1)Soriatane

SORIATANE (CAPSULE) $3.60-$7.40 (Tier 2)Tacrolimus

tacrolimus (0.03% ointment, 0.1% ointment) $1.20-$2.95 (Tier 1) STTazorac

TAZORAC (0.05% CREAM, 0.1% CREAM) $3.60-$7.40 (Tier 2) PAThera-Gesic

thera-gesic (cream)* $0 (Tier 3)Tretinoin

tretinoin (0.01% gel, 0.025% gel, 0.025% cream, 0.05%

cream, 0.1% cream)$1.20-$2.95 (Tier 1) PA

Tretinoin Microsphere

tretinoin microsphere (gel) $1.20-$2.95 (Tier 1) PATrixaicin

trixaicin (cream)* $0 (Tier 3)Trixaicin HP

trixaicin hp (cream)* $0 (Tier 3) QLUvadex

UVADEX (INJECTION) $3.60-$7.40 (Tier 2)Vitamin A & D

vitamin a & d (ointment)* $0 (Tier 3)White Petrolatum

white petrolatum (otc only) (gel)* $0 (Tier 3)Zinc Oxide

zinc oxide (otc only) (ointment)* $0 (Tier 3)Zyclara

ZYCLARA (CREAM) $3.60-$7.40 (Tier 2) PAZyclara Pump

ZYCLARA PUMP (CREAM) $3.60-$7.40 (Tier 2) PA

Enzyme Replacement/Modifiers

Enzyme Replacement/ModifiersAdagen

ADAGEN (INJECTION) $3.60-$7.40 (Tier 2) LAAldurazyme

ALDURAZYME (INJECTION) $3.60-$7.40 (Tier 2)Buphenyl

BUPHENYL (3GM/TSP POWDER, 500MG

TABLET)$3.60-$7.40 (Tier 2)

Cerezyme

CEREZYME (INJECTION) $3.60-$7.40 (Tier 2) PACreon

CREON (CAPSULE DELAYED-RELEASE) $3.60-$7.40 (Tier 2)Cystadane

CYSTADANE (POWDER) $3.60-$7.40 (Tier 2)Cystagon

CYSTAGON (CAPSULE) $3.60-$7.40 (Tier 2) LAElaprase

ELAPRASE (INJECTION) $3.60-$7.40 (Tier 2)Elelyso

ELELYSO (INJECTION) $3.60-$7.40 (Tier 2) PA, LAFabrazyme

FABRAZYME (INJECTION) $3.60-$7.40 (Tier 2)Kuvan

KUVAN (100MG PACKET, 500MG PACKET,

100MG TABLET SOLUBLE)$3.60-$7.40 (Tier 2)

Lumizyme

LUMIZYME (INJECTION) $3.60-$7.40 (Tier 2)Naglazyme

NAGLAZYME (INJECTION) $3.60-$7.40 (Tier 2)Orfadin

ORFADIN (CAPSULE, ORAL SUSPENSION) $3.60-$7.40 (Tier 2) LAProcysbi

PROCYSBI (CAPSULE DELAYED-RELEASE) $3.60-$7.40 (Tier 2)RAVICTI

RAVICTI (LIQUID) $3.60-$7.40 (Tier 2)


page 9.




60


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useSodium Phenylbutyrate

sodium phenylbutyrate (powder) $1.20-$2.95 (Tier 1)Strensiq

STRENSIQ (INJECTION) $3.60-$7.40 (Tier 2) PA, LASucraid

SUCRAID (ORAL SOLUTION) $3.60-$7.40 (Tier 2) LAVPRIV

VPRIV (INJECTION) $3.60-$7.40 (Tier 2) PAZavesca

ZAVESCA (CAPSULE) $3.60-$7.40 (Tier 2) PA, LAZenpep

ZENPEP (CAPSULE DELAYED-RELEASE) $3.60-$7.40 (Tier 2)

Gastrointestinal Agents

Antispasmodics, GastrointestinalAtropine Sulfate

ATROPINE SULFATE (INJECTION) $3.60-$7.40 (Tier 2)Cuvposa

CUVPOSA (ORAL SOLUTION) $3.60-$7.40 (Tier 2)Dicyclomine HCl

dicyclomine hcl (10mg capsule, 10mg/5ml oral solution,

20mg tablet)$1.20-$2.95 (Tier 1)

Glycopyrrolate

glycopyrrolate (4mg/20ml injection) $1.20-$2.95 (Tier 1)Methscopolamine Bromide

methscopolamine bromide (tablet) $1.20-$2.95 (Tier 1)

Gastrointestinal Agents, Other

Acid Gone

acid gone (suspension)* $0 (Tier 3)Actidose/Sorbitol

actidose/sorbitol (liquid)* $0 (Tier 3)Almacone

almacone (200mg-200mg-25mg tablet chewable,

200mg-200mg-20mg/5ml suspension)*$0 (Tier 3) QL

Almacone Double Strength

almacone double strength (suspension)* $0 (Tier 3) QLAluminum Hydroxide

aluminum hydroxide (suspension)* $0 (Tier 3)Antacid

antacid (tablet chewable)* $0 (Tier 3)Antacid Extra Strength

antacid extra strength (tablet chewable)* $0 (Tier 3)Antacid Maximum Strength

antacid maximum strength (suspension)* $0 (Tier 3) QLAntacid Plus Anti-Gas Relief

antacid plus anti-gas relief (suspension)* $0 (Tier 3) QLAntacid/Simethicone

antacid/simethicone (suspension)* $0 (Tier 3) QLAntacid/Simethicone Double Strength

antacid/simethicone double strength (suspension)* $0 (Tier 3) QLAnti-Diarrheal

anti-diarrheal (tablet)* $0 (Tier 3)


61


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useBismatrol

bismatrol (262mg tablet chewable, 262mg/15ml

suspension)*$0 (Tier 3)

Bismatrol Maximum Strength

bismatrol maximum strength (suspension)* $0 (Tier 3)Calcium Antacid

calcium antacid (tablet chewable)* $0 (Tier 3) QLCalcium Antacid Extra Strength

calcium antacid extra strength (tablet chewable)* $0 (Tier 3)Calcium Carbonate

calcium carbonate (500mg tablet chewable, 648mg

tablet)*$0 (Tier 3) PA

Cal-Gest Antacid

cal-gest antacid (tablet chewable)* $0 (Tier 3) QLChenodal

chenodal (tablet) $1.20-$2.95 (Tier 1)Chewable Antacid

chewable antacid (tablet chewable)* $0 (Tier 3)Cholbam

CHOLBAM (CAPSULE) $3.60-$7.40 (Tier 2) PACoats Aloe Vera Juice Drink

coats aloe vera juice drink (liquid)* $0 (Tier 3)Cromolyn Sodium

cromolyn sodium (rx only) (100mg/5ml concentrate) $1.20-$2.95 (Tier 1)CVS Laxative Dietary Supplement

cvs laxative dietary supplement (tablet)* $0 (Tier 3) PACVS Magnesium

cvs magnesium (500mg tablet)* $0 (Tier 3) PADiocto

diocto (50mg/5ml liquid, 60mg/15ml syrup)* $0 (Tier 3) QLDiphenoxylate/Atropine

diphenoxylate/atropine (2.5mg-0.025mg tablet,

2.5mg-0.025mg/5ml liquid)$1.20-$2.95 (Tier 1)

Docu

docu (liquid)* $0 (Tier 3) QLDocusol Kids

docusol kids (enema)* $0 (Tier 3) QLDocusol Mini

docusol mini (enema)* $0 (Tier 3) QLEnemeez Mini

enemeez mini (enema)* $0 (Tier 3)Gas Relief

gas relief (180mg capsule, 20mg/0.3ml suspension,

80mg tablet chewable)*$0 (Tier 3)

Gas Relief

gas relief (80mg tablet chewable)* $0 (Tier 3) QLGas Relief Extra Strength

gas relief extra strength (capsule)* $0 (Tier 3)Gas Relief Maximum Strength

gas relief maximum strength (tablet chewable)* $0 (Tier 3) QLGattex

GATTEX (INJECTION) $3.60-$7.40 (Tier 2) PAGNP Antacid Anti-Gas

gnp antacid anti-gas (suspension)* $0 (Tier 3) QLGNP Masanti Maximum Strength

gnp masanti maximum strength (suspension)* $0 (Tier 3) QLGNP Masanti Regular Strength

gnp masanti regular strength (suspension)* $0 (Tier 3) QLInfants Gas Relief

infants gas relief (suspension)* $0 (Tier 3)Infants Simethicone

infants simethicone (suspension)* $0 (Tier 3)Kao-Tin

kao-tin (262mg/15ml suspension)* $0 (Tier 3)Loperamide HCl

loperamide hcl (otc only) (1mg/5ml liquid)* $0 (Tier 3)Loperamide HCl

loperamide hcl (otc only) (1mg/7.5ml suspension)* $0 (Tier 3) QLLoperamide HCl

loperamide hcl (rx only) (2mg capsule) $1.20-$2.95 (Tier 1)Magnesium

magnesium (otc only) (500mg tablet)* $0 (Tier 3) PA


page 9.




62


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMagnesium Oxide

magnesium oxide (otc only) (241.3mg tablet)* $0 (Tier 3) QLMagnesium Oxide

magnesium oxide (otc only) (400mg tablet)* $0 (Tier 3)Magnesium Oxide

magnesium oxide (otc only) (420mg tablet)* $0 (Tier 3) PAMedi-Bismuth

medi-bismuth (tablet chewable)* $0 (Tier 3)Mi-Acid

mi-acid (suspension)* $0 (Tier 3) QLMi-Acid Gas Relief

mi-acid gas relief (tablet chewable)* $0 (Tier 3)Mi-Acid Maximum Strength

mi-acid maximum strength (suspension)* $0 (Tier 3) QLMilk of Magnesia Concentrate

milk of magnesia concentrate (suspension)* $0 (Tier 3)Mintox Maximum Strength

mintox maximum strength (suspension)* $0 (Tier 3) QLMYTAB GAS

mytab gas (tablet chewable)* $0 (Tier 3)MYTAB GAS Maximum Strength

mytab gas maximum strength (tablet chewable)* $0 (Tier 3)Ocaliva

OCALIVA (TABLET) $3.60-$7.40 (Tier 2) PA, QLPink Bismuth

pink bismuth (tablet chewable)* $0 (Tier 3)QC Anti-Diarrheal

qc anti-diarrheal (tablet)* $0 (Tier 3)RA Magnesium

ra magnesium (capsule)* $0 (Tier 3) PARelistor

RELISTOR (INJECTION) $3.60-$7.40 (Tier 2) PARulox

rulox (suspension)* $0 (Tier 3) QLSerostim

SEROSTIM (INJECTION) $3.60-$7.40 (Tier 2) PASilace

silace (150mg/15ml liquid)* $0 (Tier 3) QLSilace

silace (60mg/15ml syrup)* $0 (Tier 3)Simethicone

simethicone (180mg capsule, 40mg/0.6ml suspension)* $0 (Tier 3)SM Antacid Anti-Gas

sm antacid anti-gas (suspension)* $0 (Tier 3) QLSM Antacid Anti-Gas Extra Strength

sm antacid anti-gas extra strength (suspension)* $0 (Tier 3) QLSM Anti-Diarrheal

sm anti-diarrheal (tablet)* $0 (Tier 3)SM Calcium Antacid Extra Strength

sm calcium antacid extra strength (tablet chewable)* $0 (Tier 3)SM Stomach Relief

sm stomach relief (tablet chewable)* $0 (Tier 3)SM Stomach Relief Maximum Strength

sm stomach relief maximum strength (suspension)* $0 (Tier 3)Sodium Bicarbonate

sodium bicarbonate (tablet)* $0 (Tier 3)Ursodiol

ursodiol (250mg tablet, 500mg tablet, 300mg capsule) $1.20-$2.95 (Tier 1)Zorbtive

ZORBTIVE (INJECTION) $3.60-$7.40 (Tier 2) PA


63


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Histamine2 (H2) Receptor Antagonists

Cimetidine

cimetidine (rx only) (tablet) $1.20-$2.95 (Tier 1)Cimetidine HCl

cimetidine hcl (rx only) (oral solution) $1.20-$2.95 (Tier 1)Famotidine

famotidine (otc only) (10mg tablet)* $0 (Tier 3) QLFamotidine

famotidine (rx only) (20mg tablet, 40mg tablet, 20mg/

2ml injection)$1.20-$2.95 (Tier 1)

Famotidine Premixed

famotidine premixed (rx only) (injection) $1.20-$2.95 (Tier 1)Ranitidine 75

ranitidine 75 (otc only) (75mg tablet)* $0 (Tier 3) QLRanitidine HCl

ranitidine hcl (150mg capsule, 300mg capsule, 150mg


Irritable Bowel Syndrome Agents

Alosetron HCl

alosetron hcl (tablet) $1.20-$2.95 (Tier 1) PAAmitiza

AMITIZA (CAPSULE) $3.60-$7.40 (Tier 2) QLLinzess

LINZESS (CAPSULE) $3.60-$7.40 (Tier 2) QL

Laxatives

Bisac-Evac

bisac-evac (suppository)* $0 (Tier 3) QLBisacodyl EC

bisacodyl ec (tablet delayed-release)* $0 (Tier 3)Biscolax

biscolax (suppository)* $0 (Tier 3) QLColace

colace (capsule)* $0 (Tier 3) QLConstulose

constulose (oral solution) $1.20-$2.95 (Tier 1)Doc-Q-Lace

doc-q-lace (capsule)* $0 (Tier 3) QLDoc-Q-Lax

doc-q-lax (tablet)* $0 (Tier 3)Docusate Sodium & Senna Stimulant Laxative/Stool Softener

docusate sodium & senna stimulant laxative/stool

softener (tablet)*$0 (Tier 3)

Docusate Sodium

docusate sodium (otc only) (capsule)* $0 (Tier 3) QLDocusol Plus Mini-Enema

docusol plus mini-enema* $0 (Tier 3) QLDOK

dok (100mg capsule, 250mg capsule)* $0 (Tier 3) QLDOK

dok (100mg tablet)* $0 (Tier 3)DOK PLUS

dok plus (tablet)* $0 (Tier 3)Enema Ready-To-Use

enema ready-to-use* $0 (Tier 3) QLEnemeez Plus

enemeez plus (enema)* $0 (Tier 3)Enulose

enulose (oral solution) $1.20-$2.95 (Tier 1)Fiber Laxative

fiber laxative (0.52gm capsule, 625mg tablet)* $0 (Tier 3)Fiber Tabs

fiber tabs (tablet)* $0 (Tier 3)Fiber-Lax

fiber-lax (tablet)* $0 (Tier 3)Fleet Pediatric

fleet pediatric (enema)* $0 (Tier 3)


page 9.




64


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useGaviLyte-C

gavilyte-c (oral solution) $1.20-$2.95 (Tier 1)GaviLyte-G

gavilyte-g (oral solution) $1.20-$2.95 (Tier 1)GaviLyte-H

gavilyte-h (kit) $1.20-$2.95 (Tier 1)GaviLyte-N/Flavor Pack

gavilyte-n/flavor pack (oral solution) $1.20-$2.95 (Tier 1)Generlac

generlac (oral solution) $1.20-$2.95 (Tier 1)Gentle Laxative

gentle laxative (tablet delayed-release)* $0 (Tier 3)GNP Enema

gnp enema* $0 (Tier 3)GNP Milk of Magnesia

gnp milk of magnesia (suspension)* $0 (Tier 3)GNP Natural Fiber

gnp natural fiber (powder)* $0 (Tier 3)Kao-Tin

kao-tin (240mg capsule)* $0 (Tier 3)Konsyl

konsyl (powder)* $0 (Tier 3)Lactulose

lactulose (oral solution) $1.20-$2.95 (Tier 1)Laxative

laxative (10mg suppository)* $0 (Tier 3) QLLaxative

laxative (25mg tablet)* $0 (Tier 3)Laxative with Senna

laxative with senna (tablet)* $0 (Tier 3)Medi-Natural

medi-natural (tablet)* $0 (Tier 3)Milk of Magnesia

milk of magnesia (suspension)* $0 (Tier 3)Mineral Oil

mineral oil* $0 (Tier 3)Natural Fiber Therapy

natural fiber therapy (powder)* $0 (Tier 3)PEG-3350/Electrolytes

peg-3350/electrolytes (oral solution) (generic golytely) $1.20-$2.95 (Tier 1)PEG-3350/NaCl/Na Bicarbonate/KCl

PEG-3350/NACL/NA BICARBONATE/KCL (ORAL

SOLUTION) (GENERIC NULYTELY)$3.60-$7.40 (Tier 2)

Polyethylene Glycol 3350 Powder

polyethylene glycol 3350 powder (rx only) (generic

miralax)$1.20-$2.95 (Tier 1)

QC Gentle Laxative

qc gentle laxative (5mg tablet delayed-release)* $0 (Tier 3) QLQC Milk of Magnesia

qc milk of magnesia (suspension)* $0 (Tier 3)QC Stool Softener Plus Laxative

qc stool softener plus laxative (tablet)* $0 (Tier 3)Reguloid

reguloid (capsule)* $0 (Tier 3)Sani-Supp Adult

sani-supp adult (suppository)* $0 (Tier 3) QLSani-Supp Pediatric

sani-supp pediatric (suppository)* $0 (Tier 3) QL


65


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useSenexon

senexon (8.6mg tablet)* $0 (Tier 3)Senexon

senexon (8.8mg/5ml liquid)* $0 (Tier 3) QLSenna

senna (8.6mg tablet)* $0 (Tier 3)Senna

senna (8.8mg/5ml syrup)* $0 (Tier 3) QLSenna Lax

senna lax (tablet)* $0 (Tier 3)Senna Plus

senna plus (tablet)* $0 (Tier 3) QLSennalax-S

sennalax-s (tablet)* $0 (Tier 3)Sennosides/Docusate Sodium

sennosides/docusate sodium (tablet)* $0 (Tier 3) QLSM Fiber

sm fiber (powder)* $0 (Tier 3)SM Milk of Magnesia

sm milk of magnesia (suspension)* $0 (Tier 3)Stimulant Laxative

stimulant laxative (tablet delayed-release)* $0 (Tier 3)Stool Softener

stool softener (capsule)* $0 (Tier 3) QLStool Softener Extra Strength

stool softener extra strength (capsule)* $0 (Tier 3) QLStool Softener Laxative DC

stool softener laxative dc (capsule)* $0 (Tier 3)Suprep Bowel Prep

SUPREP BOWEL PREP (ORAL SOLUTION) $3.60-$7.40 (Tier 2)TriLyte

trilyte (oral solution) $1.20-$2.95 (Tier 1)

ProtectantsCarafate

CARAFATE (1GM/10ML SUSPENSION) $3.60-$7.40 (Tier 2)Misoprostol

misoprostol (tablet) $1.20-$2.95 (Tier 1)Sucralfate

sucralfate (tablet) $1.20-$2.95 (Tier 1)

Proton Pump InhibitorsEsomeprazole Magnesium

esomeprazole magnesium (rx only) (capsule delayed-

release) (generic nexium)$1.20-$2.95 (Tier 1) QL

Esomeprazole Sodium

esomeprazole sodium (rx only) (injection) $1.20-$2.95 (Tier 1)GNP Omeprazole

gnp omeprazole (otc only) (20mg tablet delayed-


Nexium

NEXIUM (RX ONLY) (10MG PACKET, 2.5MG

PACKET, 20MG PACKET, 40MG PACKET, 5MG

PACKET)

$3.60-$7.40 (Tier 2)

Nexium

NEXIUM (RX ONLY) (20MG CAPSULE DELAYED-

RELEASE, 40MG CAPSULE DELAYED-RELEASE)$3.60-$7.40 (Tier 2) QL

Omeprazole

omeprazole (otc only) (20mg tablet delayed-release)* $0 (Tier 3) QLOmeprazole

omeprazole (rx only) (10mg capsule delayed-release,

40mg capsule delayed-release)$1.20-$2.95 (Tier 1) QL

Omeprazole

omeprazole (rx only) (20mg capsule delayed-release) $1.20-$2.95 (Tier 1)Pantoprazole Sodium

pantoprazole sodium (tablet delayed-release) $1.20-$2.95 (Tier 1) QLPrilosec OTC

prilosec otc (20mg tablet delayed-release)* $0 (Tier 3) QL


page 9.




66


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Genitourinary Agents

Antispasmodics, UrinaryMyrbetriq

MYRBETRIQ (TABLET EXTENDED-RELEASE 24

HOUR)$3.60-$7.40 (Tier 2)

Oxybutynin Chloride

oxybutynin chloride (5mg tablet immediate-release, 5mg/

5ml syrup)$1.20-$2.95 (Tier 1)

Oxybutynin Chloride ER

oxybutynin chloride er (tablet extended-release 24 hour) $1.20-$2.95 (Tier 1) QLVesicare

VESICARE (TABLET) $3.60-$7.40 (Tier 2) QL

Benign Prostatic Hypertrophy Agents

Alfuzosin HCl ER

alfuzosin hcl er (tablet extended-release 24 hour) $1.20-$2.95 (Tier 1)Finasteride

finasteride (5mg tablet) (generic proscar) $1.20-$2.95 (Tier 1)Rapaflo

RAPAFLO (CAPSULE) $3.60-$7.40 (Tier 2) QLTamsulosin HCl

tamsulosin hcl (capsule) $1.20-$2.95 (Tier 1)Terazosin HCl

terazosin hcl (capsule) $1.20-$2.95 (Tier 1)

Genitourinary Agents, Other

AZO Tabs

azo tabs (tablet)* $0 (Tier 3)Bethanechol Chloride

bethanechol chloride (tablet) $1.20-$2.95 (Tier 1)Cuprimine

CUPRIMINE (CAPSULE) $3.60-$7.40 (Tier 2) STDepen Titratabs

DEPEN TITRATABS (TABLET) $3.60-$7.40 (Tier 2)Elmiron

ELMIRON (CAPSULE) $3.60-$7.40 (Tier 2)Lithostat

LITHOSTAT (TABLET) $3.60-$7.40 (Tier 2)

Phosphate Binders

Calcium Acetate

calcium acetate (capsule) $1.20-$2.95 (Tier 1)Eliphos

eliphos (tablet) $1.20-$2.95 (Tier 1)Fosrenol

FOSRENOL (1000MG PACKET, 750MG PACKET,

1000MG TABLET CHEWABLE, 500MG TABLET

CHEWABLE, 750MG TABLET CHEWABLE)

$3.60-$7.40 (Tier 2)


67


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on usePhosLo

PHOSLO (CAPSULE) $3.60-$7.40 (Tier 2)Phoslyra

PHOSLYRA (ORAL SOLUTION) $3.60-$7.40 (Tier 2)Renagel

RENAGEL (TABLET) $3.60-$7.40 (Tier 2) STRenvela

RENVELA (0.8GM PACKET, 2.4GM PACKET,

800MG TABLET)$3.60-$7.40 (Tier 2)

Velphoro

VELPHORO (TABLET CHEWABLE) $3.60-$7.40 (Tier 2)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

A-Hydrocort

a-hydrocort (injection) $1.20-$2.95 (Tier 1)Ala Cort

ala cort (cream) $1.20-$2.95 (Tier 1)Alclometasone Dipropionate

alclometasone dipropionate (0.05% cream, 0.05%

ointment)$1.20-$2.95 (Tier 1)

Augmented Betamethasone Dipropionate

augmented betamethasone dipropionate (0.05% gel,

0.05% lotion, 0.05% ointment)$1.20-$2.95 (Tier 1)

Betamethasone Dipropionate

betamethasone dipropionate (0.05% cream, 0.05%

lotion, 0.05% ointment)$1.20-$2.95 (Tier 1)

Betamethasone Valerate

betamethasone valerate (0.1% cream, 0.1% lotion, 0.1%


Clobetasol Propionate

clobetasol propionate (0.05% external solution, 0.05%

gel, 0.05% ointment, 0.05% shampoo)$1.20-$2.95 (Tier 1)

Clobetasol Propionate E

clobetasol propionate e (cream) $1.20-$2.95 (Tier 1)Cormax Scalp Application

cormax scalp application (external solution) $1.20-$2.95 (Tier 1)Cortisone Acetate

cortisone acetate (tablet) $1.20-$2.95 (Tier 1)Depo-Medrol

DEPO-MEDROL (20MG/ML INJECTION) $3.60-$7.40 (Tier 2)Desonide

desonide (0.05% ointment) $1.20-$2.95 (Tier 1)Desoximetasone

desoximetasone (0.05% cream, 0.25% cream) $1.20-$2.95 (Tier 1)Dexamethasone

dexamethasone (0.5mg tablet, 0.75mg tablet, 1.5mg

tablet, 1mg tablet, 2mg tablet, 4mg tablet, 6mg tablet,

0.5mg/5ml elixir)

$1.20-$2.95 (Tier 1)

Dexamethasone Intensol

dexamethasone intensol (1mg/ml concentrate) $1.20-$2.95 (Tier 1)Dexamethasone Sodium Phosphate

dexamethasone sodium phosphate (10mg/ml injection,

120mg/30ml injection)$1.20-$2.95 (Tier 1)

Fludrocortisone Acetate

fludrocortisone acetate (tablet) $1.20-$2.95 (Tier 1)Fluocinolone Acetonide

fluocinolone acetonide (0.01% cream, 0.025% cream,

0.01% external solution, 0.025% ointment)$1.20-$2.95 (Tier 1)

Fluocinonide

fluocinonide (0.05% cream, 0.05% external solution,

0.05% gel, 0.05% ointment)$1.20-$2.95 (Tier 1)

Fluocinonide-E

fluocinonide-e (cream) $1.20-$2.95 (Tier 1)


page 9.




68


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useFluticasone Propionate

fluticasone propionate (0.005% ointment, 0.05% cream) $1.20-$2.95 (Tier 1)Halobetasol Propionate

halobetasol propionate (0.05% cream, 0.05% ointment) $1.20-$2.95 (Tier 1)Hydro Skin Maximum Strength

hydro skin maximum strength (lotion)* $0 (Tier 3) QLHydrocortisone

hydrocortisone (otc only) (0.5% cream)* $0 (Tier 3) QLHydrocortisone

hydrocortisone (otc only) (0.5% ointment)* $0 (Tier 3)Hydrocortisone

hydrocortisone (rx only) (1% cream, 2.5% cream, 1%

ointment, 2.5% ointment, 10mg tablet, 20mg tablet, 5mg

tablet, 2.5% lotion)

$1.20-$2.95 (Tier 1)

Hydrocortisone Butyrate

hydrocortisone butyrate (rx only) (0.1% ointment) $1.20-$2.95 (Tier 1)Hydrocortisone Valerate

hydrocortisone valerate (rx only) (0.2% cream, 0.2%


Kenalog-10

KENALOG-10 (INJECTION) $3.60-$7.40 (Tier 2)Kenalog-40

KENALOG-40 (INJECTION) $3.60-$7.40 (Tier 2)Methylprednisolone

methylprednisolone (tablet) $1.20-$2.95 (Tier 1)Methylprednisolone Acetate

methylprednisolone acetate (injection) $1.20-$2.95 (Tier 1)Methylprednisolone Dose Pack

methylprednisolone dose pack (tablet therapy pack) $1.20-$2.95 (Tier 1)Methylprednisolone Sodium Succinate

methylprednisolone sodium succinate (injection) $1.20-$2.95 (Tier 1)Millipred

millipred (5mg tablet) $1.20-$2.95 (Tier 1)Mometasone Furoate

mometasone furoate (0.1% cream, 0.1% external

solution, 0.1% ointment)$1.20-$2.95 (Tier 1)

Prednicarbate

PREDNICARBATE (0.1% CREAM) $3.60-$7.40 (Tier 2)Prednicarbate

prednicarbate (0.1% ointment) $1.20-$2.95 (Tier 1)Prednisolone Sodium Phosphate

prednisolone sodium phosphate (15mg/5ml oral

solution, 25mg/5ml oral solution, 5mg/5ml oral solution)$1.20-$2.95 (Tier 1)

Prednisone

prednisone (10mg tablet therapy pack, 5mg tablet

therapy pack, 10mg tablet, 1mg tablet, 2.5mg tablet,

20mg tablet, 50mg tablet, 5mg tablet, 5mg/5ml oral

solution)

$1.20-$2.95 (Tier 1)

Prednisone Intensol

prednisone intensol (5mg/ml concentrate) $1.20-$2.95 (Tier 1)Solu-Cortef

SOLU-CORTEF (INJECTION) $3.60-$7.40 (Tier 2)Solu-Medrol

SOLU-MEDROL (2GM INJECTION) $3.60-$7.40 (Tier 2)


69


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useTriamcinolone Acetonide

triamcinolone acetonide (cream, lotion, ointment) $1.20-$2.95 (Tier 1)Triderm

triderm (cream) $1.20-$2.95 (Tier 1)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)Chorionic Gonadotropin

CHORIONIC GONADOTROPIN (INJECTION) $3.60-$7.40 (Tier 2) PADesmopressin Acetate

DESMOPRESSIN ACETATE (0.01% NASAL

RHINAL TUBE SOLUTION)$3.60-$7.40 (Tier 2)

Desmopressin Acetate

desmopressin acetate (0.01% nasal spray solution,

0.1mg tablet, 0.2mg tablet, 4mcg/ml injection)$1.20-$2.95 (Tier 1)

Genotropin

GENOTROPIN (12MG INJECTION, 5MG

INJECTION)$3.60-$7.40 (Tier 2) PA

Genotropin Miniquick

GENOTROPIN MINIQUICK (INJECTION) $3.60-$7.40 (Tier 2) PAHumatrope

HUMATROPE (INJECTION) $3.60-$7.40 (Tier 2) PAHumatrope Combo Pack

HUMATROPE COMBO PACK (INJECTION) $3.60-$7.40 (Tier 2) PAIncrelex

INCRELEX (INJECTION) $3.60-$7.40 (Tier 2) PANorditropin FlexPro

NORDITROPIN FLEXPRO (INJECTION) $3.60-$7.40 (Tier 2) PANovarel

NOVAREL (INJECTION) $3.60-$7.40 (Tier 2) PANutropin AQ

NUTROPIN AQ (INJECTION) $3.60-$7.40 (Tier 2) PAOmnitrope

OMNITROPE (INJECTION) $3.60-$7.40 (Tier 2) PAPregnyl w/Diluent Benzyl Alcohol/NaCl

PREGNYL W/DILUENT BENZYL ALCOHOL/

NACL (INJECTION)$3.60-$7.40 (Tier 2) PA

Saizen

SAIZEN (INJECTION) $3.60-$7.40 (Tier 2) PAZomacton

ZOMACTON (INJECTION) $3.60-$7.40 (Tier 2) PA

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)Korlym

KORLYM (TABLET) $3.60-$7.40 (Tier 2) PA, QL

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

AndrogensAnadrol-50

ANADROL-50 (TABLET) $3.60-$7.40 (Tier 2) PAAndroderm

ANDRODERM (PATCH 24 HOUR) $3.60-$7.40 (Tier 2) PA, QLAndroGel

ANDROGEL (1.62% PACKET) $3.60-$7.40 (Tier 2) PAAndroGel Pump

ANDROGEL PUMP (1.62% GEL) $3.60-$7.40 (Tier 2) PADanazol

danazol (capsule) $1.20-$2.95 (Tier 1)Oxandrolone

oxandrolone (tablet) $1.20-$2.95 (Tier 1) PA, QL


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70


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useTestosterone Cypionate

testosterone cypionate (injection) $1.20-$2.95 (Tier 1)Testosterone Enanthate

testosterone enanthate (injection) $1.20-$2.95 (Tier 1)

EstrogensAlora

ALORA (PATCH TWICE WEEKLY) $3.60-$7.40 (Tier 2)Amethia

amethia (tablet) $1.20-$2.95 (Tier 1)Amethyst

amethyst (tablet) $1.20-$2.95 (Tier 1)Apri

apri (tablet) $1.20-$2.95 (Tier 1)Aranelle

aranelle (tablet) $1.20-$2.95 (Tier 1)Ashlyna

ashlyna (tablet) $1.20-$2.95 (Tier 1)Aubra

aubra (tablet) $1.20-$2.95 (Tier 1)Aviane

aviane (tablet) $1.20-$2.95 (Tier 1)Balziva

balziva (tablet) $1.20-$2.95 (Tier 1)Bekyree

bekyree (tablet) $1.20-$2.95 (Tier 1)Blisovi 24 Fe

blisovi 24 fe (tablet) $1.20-$2.95 (Tier 1)Blisovi Fe 1.5/30

blisovi fe 1.5/30 (tablet) $1.20-$2.95 (Tier 1)Blisovi Fe 1/20

blisovi fe 1/20 (tablet) $1.20-$2.95 (Tier 1)Briellyn

briellyn (tablet) $1.20-$2.95 (Tier 1)Caziant

caziant (tablet) $1.20-$2.95 (Tier 1)Climara Pro

CLIMARA PRO (PATCH WEEKLY) $3.60-$7.40 (Tier 2)Cryselle-28

cryselle-28 (tablet) $1.20-$2.95 (Tier 1)Cyclafem

cyclafem (tablet) $1.20-$2.95 (Tier 1)Delyla

delyla (tablet) $1.20-$2.95 (Tier 1)Desogestrel/Ethinyl Estradiol

desogestrel/ethinyl estradiol (tablet) $1.20-$2.95 (Tier 1)Drospirenone/Ethinyl Estradiol

drospirenone/ethinyl estradiol (tablet) $1.20-$2.95 (Tier 1)Duavee

DUAVEE (TABLET) $3.60-$7.40 (Tier 2)Elestrin

ELESTRIN (GEL) $3.60-$7.40 (Tier 2)Emoquette

emoquette (tablet) $1.20-$2.95 (Tier 1)Enpresse-28

enpresse-28 (tablet) $1.20-$2.95 (Tier 1)


71


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useEstradiol

estradiol (0.025mg/24hr patch weekly, 0.05mg/24hr

patch weekly, 0.06mg/24hr patch weekly, 0.075mg/24hr

patch weekly, 0.1mg/24hr patch weekly, 37.5mcg/24hr

patch weekly, 0.5mg tablet, 1mg tablet, 2mg tablet)

$1.20-$2.95 (Tier 1)

Estradiol Valerate

estradiol valerate (injection) $1.20-$2.95 (Tier 1)Estring

ESTRING (RING) $3.60-$7.40 (Tier 2)Falmina

falmina (tablet) $1.20-$2.95 (Tier 1)Gianvi

gianvi (tablet) $1.20-$2.95 (Tier 1)Gildagia

gildagia (tablet) $1.20-$2.95 (Tier 1)Gildess 1.5/30

gildess 1.5/30 (tablet) $1.20-$2.95 (Tier 1)Gildess 24 Fe

gildess 24 fe (tablet) $1.20-$2.95 (Tier 1)Introvale

introvale (tablet) $1.20-$2.95 (Tier 1)Jinteli

jinteli (tablet) $1.20-$2.95 (Tier 1)Juleber

juleber (tablet) $1.20-$2.95 (Tier 1)Junel 1.5/30

junel 1.5/30 (tablet) $1.20-$2.95 (Tier 1)Junel 1/20

junel 1/20 (tablet) $1.20-$2.95 (Tier 1)Junel Fe 1.5/30

junel fe 1.5/30 (tablet) $1.20-$2.95 (Tier 1)Junel Fe 1/20

junel fe 1/20 (tablet) $1.20-$2.95 (Tier 1)Junel Fe 24

junel fe 24 (tablet) $1.20-$2.95 (Tier 1)Kaitlib Fe

kaitlib fe (tablet chewable) $1.20-$2.95 (Tier 1)Kariva

kariva (tablet) $1.20-$2.95 (Tier 1)Kelnor 1/35

kelnor 1/35 (tablet) $1.20-$2.95 (Tier 1)Kimidess

kimidess (tablet) $1.20-$2.95 (Tier 1)LARIN 1.5/30

larin 1.5/30 (tablet) $1.20-$2.95 (Tier 1)LARIN 1/20

larin 1/20 (tablet) $1.20-$2.95 (Tier 1)LARIN Fe 1.5/30

larin fe 1.5/30 (tablet) $1.20-$2.95 (Tier 1)LARIN Fe 1/20

larin fe 1/20 (tablet) $1.20-$2.95 (Tier 1)Larissia

larissia (tablet) $1.20-$2.95 (Tier 1)Layolis Fe

layolis fe (tablet chewable) $1.20-$2.95 (Tier 1)Lessina

lessina (tablet) $1.20-$2.95 (Tier 1)Levonest

levonest (tablet) $1.20-$2.95 (Tier 1)Levonorgestrel and Ethinyl Estradiol

levonorgestrel and ethinyl estradiol (rx only) (tablet) $1.20-$2.95 (Tier 1)Levonorgestrel/Ethinyl Estradiol

levonorgestrel/ethinyl estradiol (rx only) (tablet) $1.20-$2.95 (Tier 1)Levora 0.15/30-28

levora 0.15/30-28 (tablet) $1.20-$2.95 (Tier 1)Lomedia 24 Fe

lomedia 24 fe (tablet) $1.20-$2.95 (Tier 1)Loryna

loryna (tablet) $1.20-$2.95 (Tier 1)Low-Ogestrel

low-ogestrel (tablet) $1.20-$2.95 (Tier 1)Lutera

lutera (tablet) $1.20-$2.95 (Tier 1)


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72


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMarlissa

marlissa (tablet) $1.20-$2.95 (Tier 1)Menest

menest (tablet) $1.20-$2.95 (Tier 1)Microgestin 1.5/30

microgestin 1.5/30 (tablet) $1.20-$2.95 (Tier 1)Microgestin 1/20

microgestin 1/20 (tablet) $1.20-$2.95 (Tier 1)Microgestin Fe

microgestin fe (tablet) $1.20-$2.95 (Tier 1)Microgestin Fe 1.5/30

microgestin fe 1.5/30 (tablet) $1.20-$2.95 (Tier 1)MonoNessa

MONONESSA (TABLET) $3.60-$7.40 (Tier 2)Necon 0.5/35-28

necon 0.5/35-28 (tablet) $1.20-$2.95 (Tier 1)Necon 1/35

necon 1/35 (tablet) $1.20-$2.95 (Tier 1)Necon 1/50-28

NECON 1/50-28 (TABLET) $3.60-$7.40 (Tier 2)Necon 10/11-28

necon 10/11-28 (tablet) $1.20-$2.95 (Tier 1)Necon 7/7/7

NECON 7/7/7 (TABLET) $3.60-$7.40 (Tier 2)Nikki

nikki (tablet) $1.20-$2.95 (Tier 1)Norethindrone & Ethinyl Estradiol Ferrous Fumarate

norethindrone & ethinyl estradiol ferrous fumarate (tablet


Norethindrone Acetate/Ethinyl Estradiol/Ferrous Fumarate

norethindrone acetate/ethinyl estradiol/ferrous fumarate

(tablet)$1.20-$2.95 (Tier 1)

Norgestimate/Ethinyl Estradiol

norgestimate/ethinyl estradiol (tablet) $1.20-$2.95 (Tier 1)Nortrel 0.5/35

nortrel 0.5/35 (28) (tablet) $1.20-$2.95 (Tier 1)Nortrel 1/35

nortrel 1/35 (tablet) $1.20-$2.95 (Tier 1)Nortrel 7/7/7

nortrel 7/7/7 (tablet) $1.20-$2.95 (Tier 1)NuvaRing

NUVARING (RING) $3.60-$7.40 (Tier 2)Ocella

OCELLA (TABLET) $3.60-$7.40 (Tier 2)Ogestrel

ogestrel (tablet) $1.20-$2.95 (Tier 1)Orsythia

orsythia (tablet) $1.20-$2.95 (Tier 1)Pimtrea

pimtrea (tablet) $1.20-$2.95 (Tier 1)Pirmella 1/35

pirmella 1/35 (tablet) $1.20-$2.95 (Tier 1)Portia-28

portia-28 (tablet) $1.20-$2.95 (Tier 1)Premarin

PREMARIN (TABLET, VAGINAL CREAM) $3.60-$7.40 (Tier 2)Premphase

PREMPHASE (TABLET) $3.60-$7.40 (Tier 2)


73


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on usePrempro

PREMPRO (TABLET) $3.60-$7.40 (Tier 2)Previfem

previfem (tablet) $1.20-$2.95 (Tier 1)Quasense

quasense (tablet) $1.20-$2.95 (Tier 1)Reclipsen

reclipsen (tablet) $1.20-$2.95 (Tier 1)Setlakin

setlakin (tablet) $1.20-$2.95 (Tier 1)Sprintec 28

sprintec 28 (tablet) $1.20-$2.95 (Tier 1)Sronyx

sronyx (tablet) $1.20-$2.95 (Tier 1)Tarina Fe 1/20

tarina fe 1/20 (tablet) $1.20-$2.95 (Tier 1)Tri-Legest Fe

tri-legest fe (tablet) $1.20-$2.95 (Tier 1)Tri-Lo-Estarylla

tri-lo-estarylla (tablet) $1.20-$2.95 (Tier 1)Tri-Lo-Sprintec

tri-lo-sprintec (tablet) $1.20-$2.95 (Tier 1)Trinessa

TRINESSA (TABLET) $3.60-$7.40 (Tier 2)Tri-Previfem

tri-previfem (tablet) $1.20-$2.95 (Tier 1)Tri-Sprintec

tri-sprintec (tablet) $1.20-$2.95 (Tier 1)Trivora-28

trivora-28 (tablet) $1.20-$2.95 (Tier 1)Velivet

velivet (tablet) $1.20-$2.95 (Tier 1)Vestura

vestura (tablet) $1.20-$2.95 (Tier 1)Vienva

vienva (tablet) $1.20-$2.95 (Tier 1)Vyfemla

vyfemla (tablet) $1.20-$2.95 (Tier 1)WYMZYA Fe

WYMZYA FE (TABLET CHEWABLE) $3.60-$7.40 (Tier 2)Zenchent

zenchent (tablet) $1.20-$2.95 (Tier 1)Zenchent Fe

zenchent fe (tablet chewable) $1.20-$2.95 (Tier 1)Zovia 1/35E

zovia 1/35e (tablet) $1.20-$2.95 (Tier 1)Zovia 1/50E

zovia 1/50e (tablet) $1.20-$2.95 (Tier 1)

Progestins

Camila

camila (tablet) $1.20-$2.95 (Tier 1)Crinone

CRINONE (GEL) $3.60-$7.40 (Tier 2)Deblitane

deblitane (tablet) $1.20-$2.95 (Tier 1)Depo-Provera

DEPO-PROVERA (INJECTION) $3.60-$7.40 (Tier 2)Errin

errin (tablet) $1.20-$2.95 (Tier 1)Fallback Solo

fallback solo (tablet)* $0 (Tier 3) PA, QLHydroxyprogesterone Caproate

hydroxyprogesterone caproate (injection) $1.20-$2.95 (Tier 1) PAJolivette

JOLIVETTE (TABLET) $3.60-$7.40 (Tier 2)Lyza

lyza (tablet) $1.20-$2.95 (Tier 1)Makena

MAKENA (INJECTION) $3.60-$7.40 (Tier 2) PAMedroxyprogesterone Acetate

medroxyprogesterone acetate (10mg tablet, 2.5mg

tablet, 5mg tablet, 150mg/ml injection)$1.20-$2.95 (Tier 1)


page 9.




74


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMegace ES

MEGACE ES (SUSPENSION) $3.60-$7.40 (Tier 2)Megace Oral

MEGACE ORAL (SUSPENSION) $3.60-$7.40 (Tier 2)Megestrol Acetate

megestrol acetate (20mg tablet, 40mg tablet, 40mg/ml

suspension, 625mg/5ml suspension)$1.20-$2.95 (Tier 1)

My Way

my way (otc only) (tablet)* $0 (Tier 3) PA, QLNext Choice One Dose

next choice one dose (otc only) (tablet)* $0 (Tier 3) PA, QLNora-BE

NORA-BE (TABLET) $3.60-$7.40 (Tier 2)Norethindrone

norethindrone (tablet) $1.20-$2.95 (Tier 1)Norethindrone Acetate

norethindrone acetate (tablet) $1.20-$2.95 (Tier 1)Norlyroc

norlyroc (tablet) $1.20-$2.95 (Tier 1)Sharobel

sharobel (tablet) $1.20-$2.95 (Tier 1)

Selective Estrogen Receptor Modifying Agents

Raloxifene HCl

raloxifene hcl (tablet) $1.20-$2.95 (Tier 1) QL

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)Levothyroxine Sodium

LEVOTHYROXINE SODIUM (100MCG


Levothyroxine Sodium

levothyroxine sodium (tablet) $1.20-$2.95 (Tier 1)Levoxyl

LEVOXYL (TABLET) $3.60-$7.40 (Tier 2)Liothyronine Sodium

liothyronine sodium (10mcg/ml injection, 25mcg tablet,

50mcg tablet, 5mcg tablet)$1.20-$2.95 (Tier 1)

Synthroid

SYNTHROID (TABLET) $3.60-$7.40 (Tier 2)Thyrolar

THYROLAR (TABLET) $3.60-$7.40 (Tier 2)Unithroid

UNITHROID (TABLET) $3.60-$7.40 (Tier 2)

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)Lysodren

LYSODREN (TABLET) $3.60-$7.40 (Tier 2)


75


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Hormonal Agents, Suppressant (Parathyroid)

Hormonal Agents, Suppressant (Parathyroid)Sensipar

SENSIPAR (TABLET) $3.60-$7.40 (Tier 2) QL

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)

Cabergoline

cabergoline (tablet) $1.20-$2.95 (Tier 1)Egrifta

EGRIFTA (INJECTION) $3.60-$7.40 (Tier 2) PAFirmagon

FIRMAGON (INJECTION) $3.60-$7.40 (Tier 2) PALeuprolide Acetate

leuprolide acetate (injection) $1.20-$2.95 (Tier 1) PALupaneta Pack

LUPANETA PACK (KIT) $3.60-$7.40 (Tier 2) PALupron Depot

LUPRON DEPOT (INJECTION) $3.60-$7.40 (Tier 2) PALupron Depot-PED

LUPRON DEPOT-PED (INJECTION) $3.60-$7.40 (Tier 2) PAOctreotide Acetate

octreotide acetate (injection) $1.20-$2.95 (Tier 1) PASandostatin LAR Depot

SANDOSTATIN LAR DEPOT (INJECTION) $3.60-$7.40 (Tier 2) PASignifor

SIGNIFOR (INJECTION) $3.60-$7.40 (Tier 2) PASomatuline Depot

SOMATULINE DEPOT (INJECTION) $3.60-$7.40 (Tier 2) PASomavert

SOMAVERT (INJECTION) $3.60-$7.40 (Tier 2) PASynarel

SYNAREL (NASAL SOLUTION) $3.60-$7.40 (Tier 2)Trelstar Mixject

TRELSTAR MIXJECT (INJECTION) $3.60-$7.40 (Tier 2) PA

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

Methimazole

methimazole (tablet) $1.20-$2.95 (Tier 1)Propylthiouracil

propylthiouracil (tablet) $1.20-$2.95 (Tier 1)

Immunological Agents

Angioedema (HAE) Agents Berinert

BERINERT (INJECTION) $3.60-$7.40 (Tier 2) PA, LACinryze

CINRYZE (INJECTION) $3.60-$7.40 (Tier 2) PA, LAFirazyr

FIRAZYR (INJECTION) $3.60-$7.40 (Tier 2) PARuconest

RUCONEST (INJECTION) $3.60-$7.40 (Tier 2) PA

Immune Suppressants

Azathioprine

azathioprine (100mg injection, 50mg tablet) $1.20-$2.95 (Tier 1) B/D, PACellcept

CELLCEPT (200MG/ML SUSPENSION) $3.60-$7.40 (Tier 2) PACellcept Intravenous

CELLCEPT INTRAVENOUS (INJECTION) $3.60-$7.40 (Tier 2) PA


page 9.




76


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useCimzia

CIMZIA (INJECTION) $3.60-$7.40 (Tier 2) PACyclosporine

cyclosporine (100mg capsule, 25mg capsule) $1.20-$2.95 (Tier 1) B/D, PACyclosporine

cyclosporine (50mg/ml injection) $1.20-$2.95 (Tier 1)Cyclosporine Modified

cyclosporine modified (100mg capsule, 25mg capsule,

50mg capsule, 100mg/ml oral solution)$1.20-$2.95 (Tier 1) B/D, PA

Enbrel

ENBREL (INJECTION) $3.60-$7.40 (Tier 2) PAEnbrel SureClick

ENBREL SURECLICK (INJECTION) $3.60-$7.40 (Tier 2) PAGengraf

gengraf (100mg capsule, 25mg capsule, 100mg/ml oral

solution, 50mg capsule)$1.20-$2.95 (Tier 1) B/D, PA

Humira

HUMIRA (INJECTION) $3.60-$7.40 (Tier 2) PAHumira Pediatric Crohns Disease Starter Pack

HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK (INJECTION)$3.60-$7.40 (Tier 2) PA

Humira Pen

HUMIRA PEN (INJECTION) $3.60-$7.40 (Tier 2) PAHumira Pen Crohns Disease Starter Pack

HUMIRA PEN CROHNS DISEASE STARTER

PACK (INJECTION)$3.60-$7.40 (Tier 2) PA

Humira Pen-Psoriasis Starter

HUMIRA PEN-PSORIASIS STARTER (INJECTION) $3.60-$7.40 (Tier 2) PAKineret

KINERET (INJECTION) $3.60-$7.40 (Tier 2) PAMethotrexate

methotrexate (tablet) $1.20-$2.95 (Tier 1)Methotrexate Sodium

methotrexate sodium (injection) $1.20-$2.95 (Tier 1)Mycophenolate Mofetil

mycophenolate mofetil (200mg/ml suspension, 250mg

capsule, 500mg tablet)$1.20-$2.95 (Tier 1) PA

Mycophenolic Acid DR

mycophenolic acid dr (tablet delayed-release) $1.20-$2.95 (Tier 1) B/D, PANulojix

NULOJIX (INJECTION) $3.60-$7.40 (Tier 2) PAOrencia

ORENCIA (125MG/ML INJECTION, 250MG

INJECTION)$3.60-$7.40 (Tier 2) PA

Orencia Clickject

ORENCIA CLICKJECT (SOLUTION AUTO

INJECTOR)$3.60-$7.40 (Tier 2) PA

Prograf

PROGRAF (5MG/ML INJECTION) $3.60-$7.40 (Tier 2) PARapamune

RAPAMUNE (1MG TABLET, 2MG TABLET, 1MG/

ML ORAL SOLUTION)$3.60-$7.40 (Tier 2) B/D, PA


77


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useRemicade

REMICADE (INJECTION) $3.60-$7.40 (Tier 2) PASandimmune

SANDIMMUNE (100MG CAPSULE, 100MG/ML

ORAL SOLUTION)$3.60-$7.40 (Tier 2) B/D, PA

Simponi

SIMPONI (INJECTION) $3.60-$7.40 (Tier 2) PASimponi Aria

SIMPONI ARIA (INJECTION) $3.60-$7.40 (Tier 2) PASirolimus

sirolimus (tablet) $1.20-$2.95 (Tier 1) B/D, PAStelara

STELARA (INJECTION) $3.60-$7.40 (Tier 2) PATacrolimus

tacrolimus (0.5mg capsule, 1mg capsule, 5mg capsule) $1.20-$2.95 (Tier 1) PATorisel

TORISEL (INJECTION) $3.60-$7.40 (Tier 2)Trexall

trexall (tablet) $1.20-$2.95 (Tier 1)Xeljanz

XELJANZ (TABLET) $3.60-$7.40 (Tier 2) PA, QLXeljanz XR

XELJANZ XR (TABLET EXTENDED-RELEASE 24

HOUR)$3.60-$7.40 (Tier 2) PA, QL

Zinbryta

ZINBRYTA (SOLUTION PREFILLED SYRINGE) $3.60-$7.40 (Tier 2) PAZortress

ZORTRESS (TABLET) $3.60-$7.40 (Tier 2) PA

Immunizing Agents, PassiveAtgam

ATGAM (INJECTION) $3.60-$7.40 (Tier 2)BIVIGAM

BIVIGAM (INJECTION) $3.60-$7.40 (Tier 2) PACarimune Nanofiltered

CARIMUNE NANOFILTERED (INJECTION) $3.60-$7.40 (Tier 2) PAFlebogamma DIF

FLEBOGAMMA DIF (INJECTION) $3.60-$7.40 (Tier 2) PAGamastan S/D

GAMASTAN S/D (INJECTION) $3.60-$7.40 (Tier 2) PAGammagard Liquid

GAMMAGARD LIQUID (INJECTION) $3.60-$7.40 (Tier 2) PAGammaked

GAMMAKED (INJECTION) $3.60-$7.40 (Tier 2) PAGammaplex

GAMMAPLEX (INJECTION) $3.60-$7.40 (Tier 2) PAGamunex-C

GAMUNEX-C (INJECTION) $3.60-$7.40 (Tier 2) PAOctagam

OCTAGAM (INJECTION) $3.60-$7.40 (Tier 2) PAPrivigen

PRIVIGEN (INJECTION) $3.60-$7.40 (Tier 2) PAThymoglobulin

THYMOGLOBULIN (INJECTION) $3.60-$7.40 (Tier 2)Varizig

VARIZIG (INJECTION) $3.60-$7.40 (Tier 2)

ImmunomodulatorsActemra

ACTEMRA (162MG/0.9ML INJECTION, 200MG/

10ML INJECTION, 400MG/20ML INJECTION,

80MG/4ML INJECTION)

$3.60-$7.40 (Tier 2) PA

Actimmune

ACTIMMUNE (INJECTION) $3.60-$7.40 (Tier 2)Arcalyst

ARCALYST (INJECTION) $3.60-$7.40 (Tier 2) PA, LABenlysta

BENLYSTA (INJECTION) $3.60-$7.40 (Tier 2) PA


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78


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useIlaris

ILARIS (INJECTION) $3.60-$7.40 (Tier 2) PA, LALeflunomide

leflunomide (tablet) $1.20-$2.95 (Tier 1)Otezla

OTEZLA (TABLET THERAPY PACK, 30MG

TABLET)$3.60-$7.40 (Tier 2) PA

Ridaura

RIDAURA (CAPSULE) $3.60-$7.40 (Tier 2)Simulect

SIMULECT (INJECTION) $3.60-$7.40 (Tier 2)Synagis

SYNAGIS (INJECTION) $3.60-$7.40 (Tier 2) PA

VaccinesActHIB

ACTHIB (INJECTION) $3.60-$7.40 (Tier 2)Adacel

ADACEL (INJECTION) $3.60-$7.40 (Tier 2)BCG Vaccine

BCG VACCINE (INJECTION) $3.60-$7.40 (Tier 2)Bexsero

BEXSERO (INJECTION) $3.60-$7.40 (Tier 2)Boostrix

BOOSTRIX (INJECTION) $3.60-$7.40 (Tier 2)Cervarix

CERVARIX (INJECTION) $3.60-$7.40 (Tier 2)Daptacel

DAPTACEL (INJECTION) $3.60-$7.40 (Tier 2)Diphtheria/Tetanus Toxoids Adsorbed Pediatric

DIPHTHERIA/TETANUS TOXOIDS ADSORBED

PEDIATRIC (INJECTION)$3.60-$7.40 (Tier 2)

Engerix-B

ENGERIX-B (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAGardasil

GARDASIL (INJECTION) $3.60-$7.40 (Tier 2)Gardasil 9

GARDASIL 9 (INJECTION) $3.60-$7.40 (Tier 2)Havrix

HAVRIX (INJECTION) $3.60-$7.40 (Tier 2)Hiberix

HIBERIX (INJECTION) $3.60-$7.40 (Tier 2)Imovax Rabies

IMOVAX RABIES (H.D.C.V.) (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAInfanrix

INFANRIX (INJECTION) $3.60-$7.40 (Tier 2)IPOL Inactivated IPV

IPOL INACTIVATED IPV (INJECTION) $3.60-$7.40 (Tier 2)Ixiaro

IXIARO (INJECTION) $3.60-$7.40 (Tier 2)Menactra

MENACTRA (INJECTION) $3.60-$7.40 (Tier 2)MENHIBRIX

MENHIBRIX (INJECTION) $3.60-$7.40 (Tier 2)Menomune-A/C/Y/W-135

MENOMUNE-A/C/Y/W-135 (INJECTION) $3.60-$7.40 (Tier 2)


79


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMenveo

MENVEO (INJECTION) $3.60-$7.40 (Tier 2)M-M-R II

M-M-R II (INJECTION) $3.60-$7.40 (Tier 2)Pedvax HIB

PEDVAX HIB (INJECTION) $3.60-$7.40 (Tier 2)ProQuad

PROQUAD (INJECTION) $3.60-$7.40 (Tier 2)Quadracel

QUADRACEL (INJECTION) $3.60-$7.40 (Tier 2)Rabavert

RABAVERT (INJECTION) $3.60-$7.40 (Tier 2) B/D, PARecombivax HB

RECOMBIVAX HB (INJECTION) $3.60-$7.40 (Tier 2) B/D, PARotarix

ROTARIX (SUSPENSION) $3.60-$7.40 (Tier 2)RotaTeq

ROTATEQ (ORAL SOLUTION) $3.60-$7.40 (Tier 2)Tenivac

TENIVAC (INJECTION) $3.60-$7.40 (Tier 2)Tetanus/Diphtheria Toxoids-Adsorbed Adult

TETANUS/DIPHTHERIA TOXOIDS-ADSORBED

ADULT (INJECTION)$3.60-$7.40 (Tier 2)

Trumenba

TRUMENBA (INJECTION) $3.60-$7.40 (Tier 2)Twinrix

TWINRIX (INJECTION) $3.60-$7.40 (Tier 2)Typhim Vi

TYPHIM VI (INJECTION) $3.60-$7.40 (Tier 2)VAQTA

VAQTA (INJECTION) $3.60-$7.40 (Tier 2)Varivax

VARIVAX (INJECTION) $3.60-$7.40 (Tier 2)YF-Vax

YF-VAX (INJECTION) $3.60-$7.40 (Tier 2)Zostavax

ZOSTAVAX (INJECTION) $3.60-$7.40 (Tier 2) PA

Inflammatory Bowel Disease Agents

AminosalicylatesApriso

APRISO (CAPSULE EXTENDED-RELEASE 24

HOUR)$3.60-$7.40 (Tier 2) QL

Balsalazide Disodium

balsalazide disodium (capsule) $1.20-$2.95 (Tier 1)Canasa

CANASA (SUPPOSITORY) $3.60-$7.40 (Tier 2)Dipentum

DIPENTUM (CAPSULE) $3.60-$7.40 (Tier 2)Giazo

GIAZO (TABLET) $3.60-$7.40 (Tier 2)Lialda

LIALDA (TABLET DELAYED-RELEASE) $3.60-$7.40 (Tier 2) QLMesalamine

mesalamine (kit) $1.20-$2.95 (Tier 1)sfRowasa

SFROWASA (ENEMA) $3.60-$7.40 (Tier 2) QL

Glucocorticoids

Budesonide

budesonide (3mg capsule delayed-release) $1.20-$2.95 (Tier 1)Colocort

colocort (enema) $1.20-$2.95 (Tier 1)Entocort EC

ENTOCORT EC (CAPSULE DELAYED-RELEASE) $3.60-$7.40 (Tier 2)Hydrocortisone

HYDROCORTISONE (RX ONLY) (100MG/60ML

ENEMA)$3.60-$7.40 (Tier 2)


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80


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useProcto-Med HC

procto-med hc (cream) $1.20-$2.95 (Tier 1)Procto-Pak

procto-pak (cream) $1.20-$2.95 (Tier 1)Proctosol HC

proctosol hc (cream) $1.20-$2.95 (Tier 1)Proctozone-HC

proctozone-hc (cream) $1.20-$2.95 (Tier 1)Uceris

UCERIS (9MG TABLET EXTENDED-RELEASE 24

HOUR)$3.60-$7.40 (Tier 2) ST

SulfonamidesSulfasalazine

sulfasalazine (500mg tablet delayed-release, 500mg


Metabolic Bone Disease Agents

Metabolic Bone Disease AgentsAlendronate Sodium

alendronate sodium (10mg tablet, 35mg tablet, 40mg

tablet, 5mg tablet, 70mg tablet)$1.20-$2.95 (Tier 1) QL

Alendronate Sodium

alendronate sodium (70mg/75ml oral solution) $1.20-$2.95 (Tier 1)Binosto

BINOSTO (TABLET EFFERVESCENT) $3.60-$7.40 (Tier 2) QLCalcitonin-Salmon

calcitonin-salmon (nasal solution) $1.20-$2.95 (Tier 1)Calcitriol

calcitriol (0.25mcg capsule, 0.5mcg capsule, 1mcg/ml

injection, 1mcg/ml oral solution)$1.20-$2.95 (Tier 1) B/D, PA

Doxercalciferol

doxercalciferol (0.5mcg capsule, 1mcg capsule, 2.5mcg

capsule)$1.20-$2.95 (Tier 1) B/D, PA, QL

Doxercalciferol

doxercalciferol (4mcg/2ml injection) $1.20-$2.95 (Tier 1) B/D, PAEtidronate Disodium

etidronate disodium (tablet) $1.20-$2.95 (Tier 1)Forteo

FORTEO (INJECTION) $3.60-$7.40 (Tier 2) PA, QLMiacalcin

MIACALCIN (200UNIT/ML INJECTION) $3.60-$7.40 (Tier 2) PANatpara

NATPARA (INJECTION) $3.60-$7.40 (Tier 2) PAPamidronate Disodium

pamidronate disodium (injection) $1.20-$2.95 (Tier 1) B/D, PAParicalcitol

paricalcitol (1mcg capsule, 2mcg capsule) $1.20-$2.95 (Tier 1) B/D, PA, QLParicalcitol

PARICALCITOL (2MCG/ML INJECTION, 5MCG/

ML INJECTION)$3.60-$7.40 (Tier 2) B/D, PA


81


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useParicalcitol

paricalcitol (4mcg capsule) $1.20-$2.95 (Tier 1) B/D, PAProlia

PROLIA (INJECTION) $3.60-$7.40 (Tier 2) PARocaltrol

ROCALTROL (0.25MCG CAPSULE, 0.5MCG

CAPSULE, 1MCG/ML ORAL SOLUTION)$3.60-$7.40 (Tier 2) B/D, PA

Xgeva

XGEVA (INJECTION) $3.60-$7.40 (Tier 2) PAZemplar

ZEMPLAR (2MCG/ML INJECTION, 5MCG/ML

INJECTION)$3.60-$7.40 (Tier 2) B/D, PA

Zoledronic Acid

zoledronic acid (4mg/5ml injection) $1.20-$2.95 (Tier 1) B/D, PAZoledronic Acid

zoledronic acid (5mg/100ml injection) $1.20-$2.95 (Tier 1) PAZometa

ZOMETA (INJECTION) $3.60-$7.40 (Tier 2) B/D, PA

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agents

Alcohol Prep Pads

alcohol prep pads $1.20-$2.95 (Tier 1)Botox

BOTOX (INJECTION) $3.60-$7.40 (Tier 2) PA, QLFomepizole

fomepizole (injection) $1.20-$2.95 (Tier 1)Gauze

gauze (non-medicated 2x2) $1.20-$2.95 (Tier 1)Insulin Syringes, Needles

insulin syringes, needles $1.20-$2.95 (Tier 1)Iosat

iosat (tablet)* $0 (Tier 3) PAKanuma

KANUMA (INJECTION) $3.60-$7.40 (Tier 2) PAMethylergonovine Maleate

methylergonovine maleate (tablet) $1.20-$2.95 (Tier 1)Myalept

MYALEPT (INJECTION) $3.60-$7.40 (Tier 2) PAOne-Way Valved Expiratory Mouthpiece/Disposable

one-way valved expiratory mouthpiece/disposable* $0 (Tier 3) QLOne-Way Valved Inspiratory Mouthpiece/Disposable

one-way valved inspiratory mouthpiece/disposable* $0 (Tier 3) QLPanda Mask Large

panda mask large* $0 (Tier 3) QLPanda Mask Medium

panda mask medium* $0 (Tier 3) QLPanda Mask Small

panda mask small* $0 (Tier 3) QLPantothenic Acid

pantothenic acid (tablet)* $0 (Tier 3) PAPediatric Medium Mask

pediatric medium mask* $0 (Tier 3) QLPediatric Mouthpiece/Disposable

pediatric mouthpiece/disposable* $0 (Tier 3) QLPediatric Panda Mask

pediatric panda mask* $0 (Tier 3) QLPediatric Small Mask

pediatric small mask* $0 (Tier 3) QLPropylene Glycol

propylene glycol (otc only) (external solution)* $0 (Tier 3)Sidestream Pediatric Face Mask

sidestream pediatric face mask* $0 (Tier 3) QLSidestream Pediatric Face Mask/Tucker the Turtle

sidestream pediatric face mask/tucker the turtle* $0 (Tier 3) QLSilicone Mask for BreatheRite Chamber/Pediatric

silicone mask for breatherite chamber/pediatric* $0 (Tier 3) QLSterile Water Irrigation

STERILE WATER IRRIGATION (SOLUTION) $3.60-$7.40 (Tier 2)


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82


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useSuspendol-S

suspendol-s (liquid)* $0 (Tier 3)ThyroSafe

thyrosafe (tablet)* $0 (Tier 3) PAThyroShield

thyroshield (oral solution)* $0 (Tier 3) PA

Ophthalmic Agents

Ophthalmic Agents, Other

Akwa Tears

akwa tears (ointment)* $0 (Tier 3)Artificial Tears

artificial tears (ointment, ophthalmic solution)* $0 (Tier 3)Bacitracin/Polymyxin B

bacitracin/polymyxin b (rx only) (ophthalmic ointment) $1.20-$2.95 (Tier 1)Blephamide

BLEPHAMIDE (SUSPENSION) $3.60-$7.40 (Tier 2)Blephamide S.O.P.

blephamide s.o.p. (ointment) $1.20-$2.95 (Tier 1)Cystaran

CYSTARAN (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2)Eye Drops

eye drops (ophthalmic solution)* $0 (Tier 3) QLFreshkote

freshkote (ophthalmic solution)* $0 (Tier 3)Isopto Tears

isopto tears (ophthalmic solution)* $0 (Tier 3)Lacrisert

LACRISERT (INSERT) $3.60-$7.40 (Tier 2)Lastacaft

LASTACAFT (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2)Lubricating Plus Eye Drops

lubricating plus eye drops (ophthalmic solution)* $0 (Tier 3) QLLubrifresh P.M.

lubrifresh p.m. (ointment)* $0 (Tier 3)Muro 128

muro 128 (ophthalmic solution)* $0 (Tier 3)Natural Balance Tears

natural balance tears (ophthalmic solution)* $0 (Tier 3)Natures Tears

natures tears (ophthalmic solution)* $0 (Tier 3)Neomycin/Bacitracin/Polymyxin

neomycin/bacitracin/polymyxin (rx only) (ophthalmic


Neomycin/Polymyxin/Bacitracin/Hydrocortisone

neomycin/polymyxin/bacitracin/hydrocortisone (rx only)

(ophthalmic ointment)$1.20-$2.95 (Tier 1)

Neomycin/Polymyxin/Dexamethasone

neomycin/polymyxin/dexamethasone (0.1% ophthalmic

ointment, 0.1% ophthalmic suspension)$1.20-$2.95 (Tier 1)

Neomycin/Polymyxin/Gramicidin

neomycin/polymyxin/gramicidin (ophthalmic solution) $1.20-$2.95 (Tier 1)


83


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useNeomycin/Polymyxin/Hydrocortisone

neomycin/polymyxin/hydrocortisone (rx only) (1%

ophthalmic suspension)$1.20-$2.95 (Tier 1)

Opti-Clear

opti-clear (ophthalmic solution)* $0 (Tier 3) QLPolymyxin B Sulfate/Trimethoprim Sulfate

polymyxin b sulfate/trimethoprim sulfate (ophthalmic


Proparacaine HCl

proparacaine hcl (ophthalmic solution) $1.20-$2.95 (Tier 1)Puralube

puralube (ointment)* $0 (Tier 3)Refresh Celluvisc

refresh celluvisc (ophthalmic solution)* $0 (Tier 3)Refresh Lacri-Lube

refresh lacri-lube (42.5%-56.8% ointment)* $0 (Tier 3)Refresh Lacri-Lube

refresh lacri-lube (42.5%-56.8% ointment)* $0 (Tier 3) QLRefresh Plus

refresh plus (ophthalmic solution)* $0 (Tier 3)Restasis

RESTASIS (EMULSION) $3.60-$7.40 (Tier 2)Sodium Chloride

sodium chloride (otc only) (5% ointment, 5% ophthalmic

solution)*$0 (Tier 3)

Sulfacetamide Sodium/Prednisolone Sodium Phosphate

sulfacetamide sodium/prednisolone sodium phosphate

(ophthalmic solution)$1.20-$2.95 (Tier 1)

Tobradex ST

TOBRADEX ST (OPHTHALMIC SUSPENSION) $3.60-$7.40 (Tier 2)Tobramycin/Dexamethasone

tobramycin/dexamethasone (ophthalmic suspension) $1.20-$2.95 (Tier 1)

Ophthalmic Anti-allergy Agents

Azelastine HCl

azelastine hcl (0.05% ophthalmic solution) $1.20-$2.95 (Tier 1)Bepreve

BEPREVE (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2)Cromolyn Sodium

cromolyn sodium (rx only) (4% ophthalmic solution) $1.20-$2.95 (Tier 1)Epinastine HCl

epinastine hcl (ophthalmic solution) $1.20-$2.95 (Tier 1)Olopatadine HCl

olopatadine hcl (ophthalmic solution) $1.20-$2.95 (Tier 1)Pataday

PATADAY (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2)Patanol

PATANOL (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2)Pazeo

PAZEO (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2)

Ophthalmic Antiglaucoma AgentsAlphagan P

ALPHAGAN P (0.1% OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2)Apraclonidine

apraclonidine (ophthalmic solution) $1.20-$2.95 (Tier 1)Betaxolol HCl

betaxolol hcl (ophthalmic solution) $1.20-$2.95 (Tier 1)Brimonidine Tartrate

BRIMONIDINE TARTRATE (0.15% OPHTHALMIC


Brimonidine Tartrate

brimonidine tartrate (0.2% ophthalmic solution) $1.20-$2.95 (Tier 1)Carteolol HCl

carteolol hcl (ophthalmic solution) $1.20-$2.95 (Tier 1)Combigan

COMBIGAN (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2)Dorzolamide HCl

dorzolamide hcl (ophthalmic solution) $1.20-$2.95 (Tier 1)


page 9.




84


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useDorzolamide HCl/Timolol Maleate

dorzolamide hcl/timolol maleate (ophthalmic solution) $1.20-$2.95 (Tier 1)Levobunolol HCl

levobunolol hcl (ophthalmic solution) $1.20-$2.95 (Tier 1)Methazolamide

methazolamide (tablet) $1.20-$2.95 (Tier 1)Metipranolol

metipranolol (ophthalmic solution) $1.20-$2.95 (Tier 1)Phospholine Iodide

PHOSPHOLINE IODIDE (OPHTHALMIC


Pilocarpine HCl

PILOCARPINE HCL (1% OPHTHALMIC

SOLUTION, 2% OPHTHALMIC SOLUTION, 4%

OPHTHALMIC SOLUTION)

$3.60-$7.40 (Tier 2)

Timolol Maleate

timolol maleate (0.25% ophthalmic solution, 0.5%

ophthalmic solution)$1.20-$2.95 (Tier 1)

Timolol Maleate Ophthalmic Gel Forming

TIMOLOL MALEATE OPHTHALMIC GEL

FORMING (SOLUTION)$3.60-$7.40 (Tier 2)

Ophthalmic Anti-inflammatoriesDexamethasone Sodium Phosphate

dexamethasone sodium phosphate (0.1% ophthalmic


Diclofenac Sodium

diclofenac sodium (0.1% ophthalmic solution) $1.20-$2.95 (Tier 1)Durezol

DUREZOL (EMULSION) $3.60-$7.40 (Tier 2)Fluorometholone

FLUOROMETHOLONE (OPHTHALMIC


Flurbiprofen Sodium

flurbiprofen sodium (ophthalmic solution) $1.20-$2.95 (Tier 1)Ilevro

ILEVRO (SUSPENSION) $3.60-$7.40 (Tier 2)Ketorolac Tromethamine

ketorolac tromethamine (0.4% ophthalmic solution, 0.5%

ophthalmic solution)$1.20-$2.95 (Tier 1)

Lotemax

LOTEMAX (0.5% GEL, 0.5% OINTMENT, 0.5%


Nevanac

NEVANAC (SUSPENSION) $3.60-$7.40 (Tier 2)Prednisolone Acetate

PREDNISOLONE ACETATE (OPHTHALMIC



85


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on usePrednisolone Sodium Phosphate

prednisolone sodium phosphate (1% ophthalmic


Prolensa

PROLENSA (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2)

Ophthalmic Prostaglandin and Prostamide Analogs

Latanoprost

latanoprost (ophthalmic solution) $1.20-$2.95 (Tier 1)Lumigan

LUMIGAN (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2)Travatan Z

TRAVATAN Z (OPHTHALMIC SOLUTION) $3.60-$7.40 (Tier 2)Travoprost

travoprost (ophthalmic solution) $1.20-$2.95 (Tier 1)

Otic Agents

Otic Agents

Acetic Acid

acetic acid (otic solution) $1.20-$2.95 (Tier 1)Ear Drops

ear drops (otic solution)* $0 (Tier 3)Fluocinolone Acetonide

fluocinolone acetonide (0.01% otic oil) $1.20-$2.95 (Tier 1)Hydrocortisone/Acetic Acid

hydrocortisone/acetic acid (rx only) (otic solution) $1.20-$2.95 (Tier 1)Neomycin/Polymyxin/Hydrocortisone

neomycin/polymyxin/hydrocortisone (rx only) (1% otic

solution, 1% otic suspension)$1.20-$2.95 (Tier 1)

Respiratory Tract/Pulmonary Agents

Antihistamines

Aceta-Gesic

aceta-gesic (tablet)* $0 (Tier 3) QLAcetaminophen/Diphenhydramine

acetaminophen/diphenhydramine (tablet)* $0 (Tier 3) QLAla-Hist IR

ala-hist ir (tablet)* $0 (Tier 3)Ala-Hist PE

ala-hist pe (tablet)* $0 (Tier 3)Alavert

alavert (tablet)* $0 (Tier 3) QLAlavert Allergy/Sinus

alavert allergy/sinus (tablet extended-release 12 hour)* $0 (Tier 3) QLAll Day Allergy

all day allergy (tablet)* $0 (Tier 3) QLAll Day Allergy Childrens

all day allergy childrens (tablet chewable)* $0 (Tier 3) QLAll Day Allergy-D

all day allergy-d (tablet extended-release 12 hour)* $0 (Tier 3) QLAller-Chlor

aller-chlor (2mg/5ml syrup, 4mg tablet)* $0 (Tier 3) QLAllergy

allergy (10mg tablet dispersible, 10mg tablet, 4mg

tablet)*$0 (Tier 3) QL

Allergy Relief

allergy relief (tablet)* $0 (Tier 3) QLAllergy Relief Child

allergy relief child (syrup)* $0 (Tier 3) QLAllergy Relief D-24

allergy relief d-24 (tablet extended-release 24 hour)* $0 (Tier 3)Allerhist-1

allerhist-1 (tablet)* $0 (Tier 3) QLAzelastine HCl

azelastine hcl (0.1% nasal solution) $1.20-$2.95 (Tier 1) QL


page 9.




86


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useAzelastine HCl

azelastine hcl (0.15% nasal solution) $1.20-$2.95 (Tier 1)Banophen

banophen (12.5mg/5ml liquid, 50mg capsule)* $0 (Tier 3) QLBrotapp

brotapp (liquid)* $0 (Tier 3)Cetirizine HCl

cetirizine hcl (otc only) (10mg tablet chewable, 5mg

tablet chewable, 10mg tablet, 5mg tablet)*$0 (Tier 3) QL

Cetirizine HCl

cetirizine hcl (rx only) (syrup) $1.20-$2.95 (Tier 1)Cetirizine HCl/Pseudoephedrine HCl ER

cetirizine hcl/pseudoephedrine hcl er (otc only) (tablet

extended-release 12 hour)*$0 (Tier 3) QL

Childrens Loratadine

childrens loratadine (otc only) (5mg/5ml oral solution,

5mg/5ml syrup)*$0 (Tier 3) QL

Chlorpheniramine Maleate

chlorpheniramine maleate (otc only) (tablet extended-


Complete Allergy Medicine

complete allergy medicine (capsule)* $0 (Tier 3) QLCyproheptadine HCl

cyproheptadine hcl (rx only) (4mg tablet) $1.20-$2.95 (Tier 1)Dallergy

dallergy (1mg-5mg tablet, 1mg-2.5mg/ml liquid)* $0 (Tier 3) QLDimaphen Childrens

dimaphen childrens (elixir)* $0 (Tier 3)Diphenhist

diphenhist (12.5mg/5ml liquid, 25mg tablet)* $0 (Tier 3) QLDiphenhydramine HCl

diphenhydramine hcl (otc only) (capsule)* $0 (Tier 3) QLDiphenhydramine HCl

diphenhydramine hcl (rx only) (50mg/ml injection) $1.20-$2.95 (Tier 1) B/D, PAED A-Hist

ed a-hist (liquid)* $0 (Tier 3) QLED Chlorped

ed chlorped (liquid)* $0 (Tier 3)ED Chlorped D

ed chlorped d (liquid)* $0 (Tier 3)ED Chlorped Jr

ed chlorped jr (syrup)* $0 (Tier 3) QLED Chlortan

ed chlortan (tablet)* $0 (Tier 3) QLFexofenadine HCl

fexofenadine hcl (otc only) (tablet)* $0 (Tier 3) QLGNP All Day Allergy

gnp all day allergy (tablet)* $0 (Tier 3) QLGNP Allergy

gnp allergy (tablet)* $0 (Tier 3) QLGNP Dayhist Allergy

gnp dayhist allergy (tablet)* $0 (Tier 3) QLGNP Loratadine

gnp loratadine (otc only) (10mg tablet, 5mg/5ml syrup)* $0 (Tier 3) QLHistex

histex (syrup)* $0 (Tier 3) QLHistex PD

histex pd (liquid)* $0 (Tier 3) QL


87


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useJ-TAN D PD

j-tan d pd (liquid)* $0 (Tier 3)J-TAN PD

j-tan pd (liquid)* $0 (Tier 3)Levocetirizine Dihydrochloride

levocetirizine dihydrochloride (5mg tablet) $1.20-$2.95 (Tier 1) QLLodrane D

lodrane d (capsule)* $0 (Tier 3) QLLoHist-D

lohist-d (liquid)* $0 (Tier 3) QLLoHist-PEB

lohist-peb (liquid)* $0 (Tier 3)Loratadine

loratadine (otc only) (tablet)* $0 (Tier 3) QLLoratadine Allergy Relief

loratadine allergy relief (otc only) (tablet dispersible)* $0 (Tier 3) QLLoratadine Childrens

loratadine childrens (otc only) (5mg/5ml oral solution,

5mg/5ml syrup)*$0 (Tier 3) QL

Loratadine Hives Relief

loratadine hives relief (otc only) (oral solution)* $0 (Tier 3) QLLoratadine-D 12 Hour

loratadine-d 12 hour (otc only) (tablet extended-release

12 hour)*$0 (Tier 3) QL

Loratadine-D 24 Hour

loratadine-d 24 hour (otc only) (tablet extended-release)* $0 (Tier 3) QLLortuss LQ

lortuss lq (liquid)* $0 (Tier 3) QLMapap PM

mapap pm (tablet)* $0 (Tier 3)Medi-Phedryl

medi-phedryl (25mg capsule)* $0 (Tier 3) QLMedi-Sleep

medi-sleep (tablet)* $0 (Tier 3)Medi-Tabs PM Extra Strength

medi-tabs pm extra strength (tablet)* $0 (Tier 3)Nasopen PE

nasopen pe (liquid)* $0 (Tier 3) QLNight Time Sleep Aid

night time sleep aid (tablet)* $0 (Tier 3) QLNoHist-LQ

nohist-lq (liquid)* $0 (Tier 3) QLPain Reliever PM Extra Strength

pain reliever pm extra strength (tablet)* $0 (Tier 3) QLPhenadoz

phenadoz (suppository) $1.20-$2.95 (Tier 1)Phenergan

phenergan (12.5mg suppository, 25mg suppository) $1.20-$2.95 (Tier 1)Poly-Hist PD

poly-hist pd (liquid)* $0 (Tier 3) QLPromethazine HCl

promethazine hcl (12.5mg suppository, 25mg

suppository, 12.5mg tablet, 25mg tablet, 50mg tablet,

25mg/ml injection, 50mg/ml injection, 6.25mg/5ml

syrup)

$1.20-$2.95 (Tier 1)

Promethegan

promethegan (25mg suppository) $1.20-$2.95 (Tier 1)QC Loratadine Allergy Relief

qc loratadine allergy relief (otc only) (tablet)* $0 (Tier 3) QLQC Loratadine-D

qc loratadine-d (otc only) (tablet extended-release 24

hour)*$0 (Tier 3)

QC Non-Aspirin PM

qc non-aspirin pm (tablet)* $0 (Tier 3)Q-Dryl

q-dryl (capsule)* $0 (Tier 3) QLRescon

rescon (tablet)* $0 (Tier 3) QLRestfully Sleep

restfully sleep (tablet)* $0 (Tier 3) QL


page 9.




88


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useRu-Hist D

ru-hist d (tablet)* $0 (Tier 3) QLRymed

rymed (tablet)* $0 (Tier 3) QLRynex PE

rynex pe (elixir)* $0 (Tier 3)Rynex PSE

rynex pse (liquid)* $0 (Tier 3)Siladryl Allergy

siladryl allergy (liquid)* $0 (Tier 3) QLSM Allergy 4 Hour

sm allergy 4 hour (tablet)* $0 (Tier 3) QLSM Allergy Relief

sm allergy relief (1.34mg tablet, 25mg tablet, 25mg

capsule)*$0 (Tier 3) QL

SM Loratadine

sm loratadine (otc only) (syrup)* $0 (Tier 3) QLSM Lorata-Dine D

sm lorata-dine d (otc only) (tablet extended-release 24

hour)*$0 (Tier 3)

SM Pain Reliever PM Extra Strength

sm pain reliever pm extra strength (tablet)* $0 (Tier 3)SM Sleep Aid

sm sleep aid (tablet)* $0 (Tier 3)Sudogest Sinus & Allergy

sudogest sinus & allergy (tablet)* $0 (Tier 3) QLVanahist PD

vanahist pd (liquid)* $0 (Tier 3) QLVituz

vituz (oral solution)* $0 (Tier 3) QL

Anti-inflammatories, Inhaled CorticosteroidsArnuity Ellipta

ARNUITY ELLIPTA (AEROSOL POWDER) $3.60-$7.40 (Tier 2) QLBudesonide

budesonide (0.25mg/2ml suspension, 0.5mg/2ml

suspension, 1mg/2ml suspension)$1.20-$2.95 (Tier 1) B/D, PA

Flovent Diskus

FLOVENT DISKUS (AEROSOL POWDER) $3.60-$7.40 (Tier 2) QLFlovent HFA

FLOVENT HFA (AEROSOL) $3.60-$7.40 (Tier 2)Flunisolide

flunisolide (nasal solution) $1.20-$2.95 (Tier 1)Fluticasone Propionate

fluticasone propionate (50mcg/act suspension) $1.20-$2.95 (Tier 1)Mometasone Furoate

mometasone furoate (50mcg/act suspension) $1.20-$2.95 (Tier 1)Nasonex

NASONEX (SUSPENSION) $3.60-$7.40 (Tier 2)Pulmicort

PULMICORT (1MG/2ML SUSPENSION) $3.60-$7.40 (Tier 2) B/D, PA

Antileukotrienes


89


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMontelukast Sodium

montelukast sodium (10mg tablet, 4mg packet, 4mg

tablet chewable, 5mg tablet chewable)$1.20-$2.95 (Tier 1) QL

Zafirlukast

zafirlukast (tablet) $1.20-$2.95 (Tier 1) QLZyflo

ZYFLO (TABLET) $3.60-$7.40 (Tier 2) STZyflo CR

ZYFLO CR (TABLET EXTENDED-RELEASE 12

HOUR)$3.60-$7.40 (Tier 2) ST

Bronchodilators, AnticholinergicAtrovent HFA

ATROVENT HFA (AEROSOL SOLUTION) $3.60-$7.40 (Tier 2)Ipratropium Bromide

ipratropium bromide (0.02% inhalation solution) $1.20-$2.95 (Tier 1) B/D, PAIpratropium Bromide

ipratropium bromide (0.03% nasal solution, 0.06% nasal


Spiriva HandiHaler

SPIRIVA HANDIHALER (CAPSULE) $3.60-$7.40 (Tier 2) QLSpiriva Respimat

SPIRIVA RESPIMAT (AEROSOL SOLUTION) $3.60-$7.40 (Tier 2) QL

Bronchodilators, SympathomimeticAlbuterol Sulfate

albuterol sulfate (0.083% nebulized solution, 0.5%

nebulized solution, 0.63mg/3ml nebulized solution,

1.25mg/3ml nebulized solution)

$1.20-$2.95 (Tier 1) B/D, PA

Albuterol Sulfate

albuterol sulfate (2mg tablet immediate-release, 4mg


Brovana

BROVANA (NEBULIZED SOLUTION) $3.60-$7.40 (Tier 2) B/D, PAEpiPen

EPIPEN (INJECTION) $3.60-$7.40 (Tier 2)Levalbuterol

levalbuterol (nebulized solution) $1.20-$2.95 (Tier 1) B/D, PAMetaproterenol Sulfate

metaproterenol sulfate (10mg tablet, 20mg tablet, 10mg/

5ml syrup)$1.20-$2.95 (Tier 1)

Perforomist

PERFOROMIST (NEBULIZED SOLUTION) $3.60-$7.40 (Tier 2) B/D, PA, QLProAir HFA

PROAIR HFA (AEROSOL SOLUTION) $3.60-$7.40 (Tier 2)ProAir RespiClick

PROAIR RESPICLICK (AEROSOL POWDER) $3.60-$7.40 (Tier 2)S2

s2 (nebulized solution)* $0 (Tier 3)Serevent Diskus

SEREVENT DISKUS (AEROSOL POWDER) $3.60-$7.40 (Tier 2) QLTerbutaline Sulfate

terbutaline sulfate (1mg/ml injection) $1.20-$2.95 (Tier 1)

Cystic Fibrosis AgentsCayston

CAYSTON (INHALATION SOLUTION) $3.60-$7.40 (Tier 2) PA, LAKalydeco

KALYDECO (50MG PACKET, 75MG PACKET) $3.60-$7.40 (Tier 2) PA, QLOrkambi

ORKAMBI (TABLET) $3.60-$7.40 (Tier 2) PA, QL, LA

Mast Cell Stabilizers

Cromolyn Sodium

cromolyn sodium (otc only) (nasal aerosol solution)* $0 (Tier 3) QL


page 9.




90


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Phosphodiesterase Inhibitors, Airways Disease

Aminophylline

aminophylline (injection) $1.20-$2.95 (Tier 1)Daliresp

DALIRESP (TABLET) $3.60-$7.40 (Tier 2) PA, QLTheophylline

theophylline (oral solution) $1.20-$2.95 (Tier 1)Theophylline CR

theophylline cr (tablet extended-release 12 hour) $1.20-$2.95 (Tier 1)Theophylline ER

theophylline er (300mg tablet extended-release 12 hour,

450mg tablet extended-release 12 hour, 400mg tablet

extended-release 24 hour, 600mg tablet extended-

release 24 hour)

$1.20-$2.95 (Tier 1)

Pulmonary AntihypertensivesAdcirca

ADCIRCA (TABLET) $3.60-$7.40 (Tier 2) PA, QLAdempas

ADEMPAS (TABLET) $3.60-$7.40 (Tier 2) PALetairis

LETAIRIS (TABLET) $3.60-$7.40 (Tier 2) PA, LAOpsumit

OPSUMIT (TABLET) $3.60-$7.40 (Tier 2) PA, LAOrenitram

ORENITRAM (0.125MG TABLET EXTENDED-

RELEASE, 0.25MG TABLET EXTENDED-

RELEASE, 1MG TABLET EXTENDED-RELEASE)

$3.60-$7.40 (Tier 2) PA, QL

Orenitram

ORENITRAM (2.5MG TABLET EXTENDED-

RELEASE)$3.60-$7.40 (Tier 2) PA

Remodulin

REMODULIN (INJECTION) $3.60-$7.40 (Tier 2) PA, LARevatio

REVATIO (20MG TABLET) $3.60-$7.40 (Tier 2) PA, QLSildenafil

sildenafil (10mg/12.5ml injection) $1.20-$2.95 (Tier 1) PASildenafil

sildenafil (20mg tablet) (generic revatio) $1.20-$2.95 (Tier 1) PA, QLTracleer

TRACLEER (TABLET) $3.60-$7.40 (Tier 2) PA, QLTyvaso

TYVASO (INHALATION SOLUTION) $3.60-$7.40 (Tier 2) PAVentavis

VENTAVIS (INHALATION SOLUTION) $3.60-$7.40 (Tier 2) PA, LA

Respiratory Tract Agents, Other

12 Hour Decongestant

12 hour decongestant (tablet extended-release 12 hour)* $0 (Tier 3)Acetylcysteine

acetylcysteine (inhalation solution) $1.20-$2.95 (Tier 1) B/D, PA


91


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useAdvair Diskus

ADVAIR DISKUS (AEROSOL POWDER) $3.60-$7.40 (Tier 2) QLAdvair HFA

ADVAIR HFA (AEROSOL) $3.60-$7.40 (Tier 2)Alahist DM

alahist dm (liquid)* $0 (Tier 3)All-Nite Multi-Symptom Cold/Flu Relief

all-nite multi-symptom cold/flu relief (liquid)* $0 (Tier 3) QLAP-Hist DM

ap-hist dm (liquid)* $0 (Tier 3) QLAprodine

aprodine (tablet)* $0 (Tier 3) QLAralast NP

ARALAST NP (INJECTION) $3.60-$7.40 (Tier 2) PA, LABalamine DM

balamine dm (syrup)* $0 (Tier 3)Benzonatate

benzonatate (capsule)* $0 (Tier 3) QLBreo Ellipta

BREO ELLIPTA (AEROSOL POWDER) $3.60-$7.40 (Tier 2)Bromfed DM

bromfed dm (syrup)* $0 (Tier 3) QLBromphen/Pseudoephedrine HCl/Dextromethorphan HBr

bromphen/pseudoephedrine hcl/dextromethorphan hbr

(syrup)*$0 (Tier 3) QL

Brotapp DM

brotapp dm (liquid)* $0 (Tier 3)Cheratussin AC

cheratussin ac (syrup)* $0 (Tier 3) QLCheratussin DAC

cheratussin dac (oral solution)* $0 (Tier 3) QLChest Congestion Relief

chest congestion relief (tablet)* $0 (Tier 3)Chest Congestion Relief PE

chest congestion relief pe (tablet)* $0 (Tier 3) QLChildrens Silfedrine

childrens silfedrine (liquid)* $0 (Tier 3) QLChlo Tuss

chlo tuss (liquid)* $0 (Tier 3) QLChlo Tuss EX

chlo tuss ex (liquid)* $0 (Tier 3) QLCodeine/Guaifenesin

codeine/guaifenesin (oral solution)* $0 (Tier 3) QLCold/Cough DM Childrens

cold/cough dm childrens (elixir)* $0 (Tier 3)Cough DM

cough dm (suspension extended-release)* $0 (Tier 3) QLCough Syrup

cough syrup* $0 (Tier 3)Cromolyn Sodium

cromolyn sodium (rx only) (20mg/2ml nebulized solution) $1.20-$2.95 (Tier 1) B/D, PADay Time Multi-Symptom Cold/Flu Relief

day time multi-symptom cold/flu relief (capsule)* $0 (Tier 3) QLDeconex DMX

deconex dmx (tablet)* $0 (Tier 3)Deconex IR

deconex ir (tablet)* $0 (Tier 3)Deep Sea Nasal Spray

deep sea nasal spray (nasal solution)* $0 (Tier 3)Delsym

delsym (suspension extended-release)* $0 (Tier 3)Delsym Childrens Night Time Cough/Cold

delsym childrens night time cough/cold (liquid)* $0 (Tier 3)Delsym Cough + Chest Congestion DM

delsym cough + chest congestion dm (liquid)* $0 (Tier 3) QLDelsym Cough + Chest Congestion DM Childrens

delsym cough + chest congestion dm childrens (liquid)* $0 (Tier 3) QLDelsym Cough + Cold Daytime

delsym cough + cold daytime (liquid)* $0 (Tier 3) QLDelsym Cough + Cold Nighttime

delsym cough + cold nighttime (liquid)* $0 (Tier 3) QLDelsym Cough + Cold Nighttime Childrens

delsym cough + cold nighttime childrens (liquid)* $0 (Tier 3) QLDelsym Night Time Cough/Cold

delsym night time cough/cold (liquid)* $0 (Tier 3) QL


page 9.




92


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useDelsym Night Time Cough/Cold Childrens

delsym night time cough/cold childrens (liquid)* $0 (Tier 3) QLDelsym Night Time Multi-Symptom

delsym night time multi-symptom (liquid)* $0 (Tier 3)Dextromethorphan Polistirex

dextromethorphan polistirex (suspension extended-

release)*$0 (Tier 3)

Dimaphen DM Cold/Cough Childrens

dimaphen dm cold/cough childrens (elixir)* $0 (Tier 3)Duraflu

duraflu (tablet)* $0 (Tier 3)ED A-Hist

ed a-hist (4mg-10mg tablet)* $0 (Tier 3) QLED A-Hist DM

ed a-hist dm (liquid)* $0 (Tier 3) QLED A-Hist PSE

ed a-hist pse (tablet)* $0 (Tier 3) QLED Bron GP

ed bron gp (liquid)* $0 (Tier 3)EndaCof-C

endacof-c (liquid)* $0 (Tier 3) QLEndaCof-DM

endacof-dm (liquid)* $0 (Tier 3) QLEntsol Nasal Gel

entsol nasal gel* $0 (Tier 3)Esbriet

ESBRIET (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL, LAExefen-IR

exefen-ir (tablet)* $0 (Tier 3)Extra Action Cough

extra action cough (syrup)* $0 (Tier 3) QLGlassia

GLASSIA (INJECTION) $3.60-$7.40 (Tier 2) PA, LAGNP 12 Hour Nasal Spray

gnp 12 hour nasal spray (nasal solution)* $0 (Tier 3)GNP Tussin

gnp tussin (syrup)* $0 (Tier 3)GNP Tussin DM

gnp tussin dm (liquid)* $0 (Tier 3) QLGuaiatussin AC

guaiatussin ac (syrup)* $0 (Tier 3) QLGuaifenesin AC

guaifenesin ac (syrup)* $0 (Tier 3) QLGuaifenesin ER

guaifenesin er (tablet extended-release 12 hour)* $0 (Tier 3) QLGuaifenesin/Codeine

guaifenesin/codeine (oral solution)* $0 (Tier 3) QLHistex-DM

histex-dm (syrup)* $0 (Tier 3) QLHistex-PE

histex-pe (syrup)* $0 (Tier 3) QLHydrocodone Bitartrate/Chlorpheniramine Maleate/PSE

hydrocodone bitartrate/chlorpheniramine maleate/pse

(oral solution)*$0 (Tier 3) QL

Hydrocodone Bitartrate/Homatropine Methylbromide

hydrocodone bitartrate/homatropine methylbromide

(1.5mg-5mg tablet, 1.5mg-5mg/5ml syrup)*$0 (Tier 3) QL


93


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useHydrocodone Polistirex/Chlorpheniramine Polistirex

hydrocodone polistirex/chlorpheniramine polistirex

(suspension extended-release)*$0 (Tier 3) QL

Hydromet

hydromet (syrup)* $0 (Tier 3) QLIophen C-NR

iophen c-nr (liquid)* $0 (Tier 3) QLIophen DM-NR

iophen dm-nr (liquid)* $0 (Tier 3) QLIophen-NR

iophen-nr (liquid)* $0 (Tier 3)J-Max

j-max (syrup)* $0 (Tier 3)Kalydeco

KALYDECO (150MG TABLET) $3.60-$7.40 (Tier 2) PA, QLKidkare Cough/Cold

kidkare cough/cold (liquid)* $0 (Tier 3)Liquibid

liquibid (tablet)* $0 (Tier 3)LoHist-DM

lohist-dm (syrup)* $0 (Tier 3)LoHist-PEB-DM

lohist-peb-dm (liquid)* $0 (Tier 3)Lortuss DM

lortuss dm (liquid)* $0 (Tier 3) QLLortuss EX

lortuss ex (liquid)* $0 (Tier 3) QLMapap Cold Formula Multi-Symptom

mapap cold formula multi-symptom (tablet)* $0 (Tier 3)Mapap Sinus Maximum Strength Congestion and Pain

mapap sinus maximum strength congestion and pain

(tablet)*$0 (Tier 3)

Medi-Tussin DM Diabetic

medi-tussin dm diabetic (liquid)* $0 (Tier 3) QLM-END DMX

m-end dmx (liquid)* $0 (Tier 3) QLM-END Max D

m-end max d (liquid)* $0 (Tier 3) QLM-END WC

m-end wc (liquid)* $0 (Tier 3) QLMucaphed

mucaphed (tablet)* $0 (Tier 3) QLMucinex

mucinex (tablet extended-release 12 hour)* $0 (Tier 3) QLMucinex Chest Congestion Childrens

mucinex chest congestion childrens (liquid)* $0 (Tier 3) QLMucinex Childrens Cold Cough & Sore Throat

mucinex childrens cold cough & sore throat (liquid)* $0 (Tier 3) QLMucinex Childrens Multi-Symptom Cold & Fever

mucinex childrens multi-symptom cold & fever (liquid)* $0 (Tier 3) QLMucinex Childrens Multi-Symptom Cold

mucinex childrens multi-symptom cold (liquid)* $0 (Tier 3) QLMucinex Cold for Kids

mucinex cold for kids (liquid)* $0 (Tier 3)Mucinex Congestion & Cough Childrens

mucinex congestion & cough childrens (liquid)* $0 (Tier 3) QLMucinex Cough Childrens

mucinex cough childrens (liquid)* $0 (Tier 3) QLMucinex Cough for Kids

mucinex cough for kids (packet)* $0 (Tier 3)Mucinex D

mucinex d (tablet extended-release 12 hour)* $0 (Tier 3)Mucinex D Maximum Strength

mucinex d maximum strength (tablet extended-release

12 hour)*$0 (Tier 3)

Mucinex DM

mucinex dm (tablet extended-release 12 hour)* $0 (Tier 3) QLMucinex DM Maximum Strength

mucinex dm maximum strength (tablet extended-release

12 hour)*$0 (Tier 3)

Mucinex Fast-Max Cold & Sinus

mucinex fast-max cold & sinus (liquid)* $0 (Tier 3) QL


page 9.




94


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMucinex Fast-Max Cold Flu & Sore Throat

mucinex fast-max cold flu & sore throat (tablet, liquid)* $0 (Tier 3) QLMucinex Fast-Max Day Time/Night Time

mucinex fast-max day time/night time (liquid)* $0 (Tier 3) QLMucinex Fast-Max DM Max

mucinex fast-max dm max (liquid)* $0 (Tier 3) QLMucinex Fast-Max Night Time Cold & Flu

mucinex fast-max night time cold & flu (tablet, liquid)* $0 (Tier 3) QLMucinex Fast-Max Severe Cold

mucinex fast-max severe cold (liquid)* $0 (Tier 3) QLMucinex Fast-Max Severe Congestion & Cough

mucinex fast-max severe congestion & cough (tablet)* $0 (Tier 3) QLMucinex for Kids

mucinex for kids (packet)* $0 (Tier 3)Mucinex Multi-Symptom Cold Night Time Childrens

mucinex multi-symptom cold night time childrens

(liquid)*$0 (Tier 3) QL

Mucinex Nasal Spray Full Force

mucinex nasal spray full force (nasal solution)* $0 (Tier 3)Mucinex Stuffy Nose & Cold Childrens

mucinex stuffy nose & cold childrens (liquid)* $0 (Tier 3) QLMucus Relief

mucus relief (tablet)* $0 (Tier 3)Mucus Relief Sinus

mucus relief sinus (tablet)* $0 (Tier 3) QLMucus ER

mucus er (tablet extended-release 12 hour)* $0 (Tier 3) QLNasal Decongestant

nasal decongestant (1% nasal solution)* $0 (Tier 3)Nasal Decongestant

nasal decongestant (30mg/5ml syrup)* $0 (Tier 3) QLNasal Decongestant PE

nasal decongestant pe (tablet)* $0 (Tier 3)Nasal Decongestant Spray

nasal decongestant spray (nasal solution)* $0 (Tier 3)Nasal Spray X-Moist

nasal spray x-moist (nasal solution)* $0 (Tier 3)Night Time Multi-Symptom Cold/Flu Relief

night time multi-symptom cold/flu relief (capsule)* $0 (Tier 3) QLNinjaCof

ninjacof (liquid)* $0 (Tier 3) QLNinjaCof-A

ninjacof-a (liquid)* $0 (Tier 3) QLNinjaCof-XG

ninjacof-xg (liquid)* $0 (Tier 3) QLNoHist-DM

nohist-dm (liquid)* $0 (Tier 3) QLNorel AD

norel ad (tablet)* $0 (Tier 3) QLNorel CS

norel cs (liquid)* $0 (Tier 3) QLNRS Nasal Relief

nrs nasal relief (nasal solution)* $0 (Tier 3)Ofev

OFEV (CAPSULE) $3.60-$7.40 (Tier 2) PA, QL, LAOrgan-I NR

organ-i nr (tablet)* $0 (Tier 3) QLPain Relief Sinus PE Daytime

pain relief sinus pe daytime (tablet)* $0 (Tier 3)


95


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on usePediatric Cough/Cold

pediatric cough/cold (liquid)* $0 (Tier 3)Phenylephrine HCl/Pyrilamine Maleate

phenylephrine hcl/pyrilamine maleate (tablet)* $0 (Tier 3) QLPhenylhistine DH

phenylhistine dh (liquid)* $0 (Tier 3) QLPoly-Hist DM

poly-hist dm (liquid)* $0 (Tier 3) QLPoly-Vent DM

poly-vent dm (tablet)* $0 (Tier 3) QLPoly-Vent IR

poly-vent ir (tablet)* $0 (Tier 3) QLPro-Chlo

pro-chlo (liquid)* $0 (Tier 3) QLPro-Clear AC

pro-clear ac (syrup)* $0 (Tier 3)Prolastin-C

PROLASTIN-C (INJECTION) $3.60-$7.40 (Tier 2) PA, LAPromethazine VC/Codeine

promethazine vc/codeine (syrup)* $0 (Tier 3) PA, QLPromethazine/Codeine

promethazine/codeine (syrup)* $0 (Tier 3) PA, QLPromethazine/Dextromethorphan

promethazine/dextromethorphan (syrup)* $0 (Tier 3) PA, QLPromethazine-DM

promethazine-dm (syrup)* $0 (Tier 3) PA, QLPseudoephedrine HCl

pseudoephedrine hcl (tablet)* $0 (Tier 3) QLPulmozyme

PULMOZYME (INHALATION SOLUTION) $3.60-$7.40 (Tier 2) B/D, PAQC Cough/Sore Throat Nighttime

qc cough/sore throat nighttime (liquid)* $0 (Tier 3)QC Daytime Multi-Symptom Cold/Flu

qc daytime multi-symptom cold/flu (capsule)* $0 (Tier 3)QC Nighttime Cough

qc nighttime cough (liquid)* $0 (Tier 3)QC Suphedrine PE

qc suphedrine pe (tablet)* $0 (Tier 3)Q-Tussin

q-tussin (oral solution)* $0 (Tier 3)Q-Tussin DM

q-tussin dm (syrup)* $0 (Tier 3) QLRescon DM

rescon dm (syrup)* $0 (Tier 3)Rescon-GG

rescon-gg (liquid)* $0 (Tier 3)Respaire-30

respaire-30 (capsule)* $0 (Tier 3)Rezira

rezira (oral solution)* $0 (Tier 3)Robafen

robafen (syrup)* $0 (Tier 3)Robafen CF Cough & Cold

robafen cf cough & cold (syrup)* $0 (Tier 3)Robafen DM

robafen dm (syrup)* $0 (Tier 3) QLRobafen DM Cough Clear

robafen dm cough clear (syrup)* $0 (Tier 3) QLRynex DM

rynex dm (liquid)* $0 (Tier 3) QLSilphen DM Cough

silphen dm cough (syrup)* $0 (Tier 3)Siltussin DAS

siltussin das (liquid)* $0 (Tier 3)Siltussin DM DAS

siltussin dm das (liquid)* $0 (Tier 3) QLSiltussin SA

siltussin sa (syrup)* $0 (Tier 3)Siltussin-DM

siltussin-dm (syrup)* $0 (Tier 3) QLSM Nasal Decongestant Maximum Strength

sm nasal decongestant maximum strength (tablet)* $0 (Tier 3) QLSM Nasal Spray 12 Hour

sm nasal spray 12 hour (nasal solution)* $0 (Tier 3)


page 9.




96


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useSM Nasal Spray Pump Mist

sm nasal spray pump mist (nasal solution)* $0 (Tier 3)SM Tussin

sm tussin (syrup)* $0 (Tier 3)SM Tussin DM

sm tussin dm (syrup)* $0 (Tier 3) QLSM Tussin DM Cough/Chest Congestion

sm tussin dm cough/chest congestion (syrup)* $0 (Tier 3) QLStahist AD

stahist ad (25mg-60mg tablet, 25mg-60mg/5ml liquid)* $0 (Tier 3) QLStiolto Respimat

STIOLTO RESPIMAT (AEROSOL SOLUTION) $3.60-$7.40 (Tier 2) QLSudogest

sudogest (tablet)* $0 (Tier 3) QLSudogest 12 Hour

sudogest 12 hour (tablet extended-release)* $0 (Tier 3)Sudogest PE

sudogest pe (tablet)* $0 (Tier 3)Symbicort

SYMBICORT (AEROSOL) $3.60-$7.40 (Tier 2)Tussin

tussin (syrup)* $0 (Tier 3)Tussin DM

tussin dm (liquid, syrup)* $0 (Tier 3) QLTussin DM Clear

tussin dm clear (liquid)* $0 (Tier 3) QLTussionex Pennkinetic Extended-Release

tussionex pennkinetic extended-release (suspension

extended-release)*$0 (Tier 3) QL

Tyzine Pediatric Nasal Drops

tyzine pediatric nasal drops (nasal solution) $1.20-$2.95 (Tier 1)VanaCof

vanacof (liquid)* $0 (Tier 3)VanaCof DM

vanacof dm (liquid)* $0 (Tier 3) QLVanaCof-8

vanacof-8 (liquid)* $0 (Tier 3) QLVirtussin A/C

virtussin a/c (oral solution)* $0 (Tier 3) QLZemaira

ZEMAIRA (INJECTION) $3.60-$7.40 (Tier 2) PA, LAZonatuss

zonatuss (capsule)* $0 (Tier 3)Zutripro

zutripro (oral solution)* $0 (Tier 3)

Respiratory Tract/Pulmonary AgentsCombivent Respimat

COMBIVENT RESPIMAT (AEROSOL SOLUTION) $3.60-$7.40 (Tier 2)Ipratropium Bromide/Albuterol Sulfate

ipratropium bromide/albuterol sulfate (inhalation solution) $1.20-$2.95 (Tier 1) B/D, PAXolair

XOLAIR (INJECTION) $3.60-$7.40 (Tier 2) PA

Skeletal Muscle Relaxants


97


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on use

Skeletal Muscle Relaxants

Baclofen

baclofen (tablet) $1.20-$2.95 (Tier 1)Cyclobenzaprine HCl

cyclobenzaprine hcl (7.5mg tablet) $1.20-$2.95 (Tier 1) PA, HRMDantrolene Sodium

dantrolene sodium (capsule) $1.20-$2.95 (Tier 1)Gablofen

GABLOFEN (INJECTION) $3.60-$7.40 (Tier 2) B/D, PALioresal Intrathecal

LIORESAL INTRATHECAL (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAOrphenadrine Citrate

orphenadrine citrate (injection) $1.20-$2.95 (Tier 1)Tizanidine HCl

tizanidine hcl (2mg tablet, 4mg tablet) $1.20-$2.95 (Tier 1)

Sleep Disorder Agents

GABA Receptor Modulators

Temazepam

temazepam (capsule) $1.20-$2.95 (Tier 1) QLZaleplon

zaleplon (capsule) $1.20-$2.95 (Tier 1) QL, HRMZolpidem Tartrate

zolpidem tartrate (tablet immediate-release) $1.20-$2.95 (Tier 1) QL, HRM

Sleep Disorders, OtherBelsomra

BELSOMRA (TABLET) $3.60-$7.40 (Tier 2) QLHetlioz

HETLIOZ (CAPSULE) $3.60-$7.40 (Tier 2) PA, QLModafinil

modafinil (tablet) $1.20-$2.95 (Tier 1) PA, QLRozerem

ROZEREM (TABLET) $3.60-$7.40 (Tier 2) QLXyrem

XYREM (ORAL SOLUTION) $3.60-$7.40 (Tier 2) PA, QL, LA

Therapeutic Nutrients/Minerals/Electrolytes

Electrolyte/Mineral ModifiersChemet

CHEMET (CAPSULE) $3.60-$7.40 (Tier 2)Exjade

EXJADE (TABLET SOLUBLE) $3.60-$7.40 (Tier 2) PAFerriprox

FERRIPROX (100MG/ML ORAL SOLUTION,

500MG TABLET)$3.60-$7.40 (Tier 2) PA

Jadenu

JADENU (TABLET) $3.60-$7.40 (Tier 2) PAKionex

kionex (powder) $1.20-$2.95 (Tier 1)Samsca

SAMSCA (TABLET) $3.60-$7.40 (Tier 2) PA, QLSodium Polystyrene Sulfonate

sodium polystyrene sulfonate (suspension) $1.20-$2.95 (Tier 1)SPS

sps (suspension) $1.20-$2.95 (Tier 1)Syprine

SYPRINE (CAPSULE) $3.60-$7.40 (Tier 2) ST

Electrolyte/Mineral Replacement

Baby Darlings Pediatric Electrolyte

baby darlings pediatric electrolyte (solution)* $0 (Tier 3) QLCalcet Petites

calcet petites (tablet)* $0 (Tier 3) PA


page 9.




98


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useCalci-Chew

calci-chew (tablet chewable)* $0 (Tier 3) PA, QLCalcitrate

calcitrate (315mg-250unit tablet)* $0 (Tier 3) PA, QLCalcitrate

calcitrate (950mg tablet)* $0 (Tier 3) PACalcium

calcium (500mg tablet, 600mg tablet)* $0 (Tier 3) PA, QLCalcium

calcium (500mg-100unit-tablet chewable)* $0 (Tier 3) QLCalcium+D3

calcium+d3 (tablet)* $0 (Tier 3) PACalcium 500/D

calcium 500/d (200unit-500mg tablet)* $0 (Tier 3) PA, QLCalcium 500/D

calcium 500/d (400unit-500mg tablet chewable)* $0 (Tier 3) PACalcium 600

calcium 600 (tablet)* $0 (Tier 3) PA, QLCalcium 600+D

calcium 600+d (tablet)* $0 (Tier 3) PACalcium Carbonate

calcium carbonate (1250mg tablet, 600mg tablet)* $0 (Tier 3) PA, QLCalcium Carbonate

calcium carbonate (1250mg/5ml suspension)* $0 (Tier 3) QLCalcium Carbonate/D3

calcium carbonate/d3 (600mg-400unit tablet)* $0 (Tier 3) PA, QLCalcium Citrate Malate/Vitamin D

calcium citrate malate/vitamin d (250mg-100unit tablet)* $0 (Tier 3) PACalcium Citrate/Vitamin D

calcium citrate/vitamin d (315mg-200unit tablet)* $0 (Tier 3) PA, QLCalcium Citrate+D

calcium citrate+d (315mg-250unit tablet)* $0 (Tier 3) PACalcium Citrate+D

calcium citrate+d (200mg-125unit tablet)* $0 (Tier 3) PACalcium Gluconate

calcium gluconate (tablet)* $0 (Tier 3) PA, QLCalcium High Potency

calcium high potency (tablet)* $0 (Tier 3) PA, QLCalcium High Potency + Vitamin D

calcium high potency + vitamin d (tablet)* $0 (Tier 3) PA, QLCalcium Oyster Shell

calcium oyster shell (tablet)* $0 (Tier 3) PA, QLCalcium/Magnesium/Zinc

calcium/magnesium/zinc (tablet)* $0 (Tier 3) PACalcium/Vitamin D

calcium/vitamin d (500mg-200unit tablet,

600mg-200unit tablet, 600mg-400unit tablet)*$0 (Tier 3) PA, QL

Caltrate 600+D3 Soft Chews

caltrate 600+d3 soft chews (tablet chewable)* $0 (Tier 3) PACalvite P&D

calvite p&d (tablet)* $0 (Tier 3) PACarbaglu

CARBAGLU (TABLET) $3.60-$7.40 (Tier 2) LACitrus Calcium+D

citrus calcium+d (tablet)* $0 (Tier 3) PACoral Calcium

coral calcium (capsule)* $0 (Tier 3) PACVS Calcium

cvs calcium (tablet)* $0 (Tier 3) PA, QL


99


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useCVS Calcium 600 + D/Minerals

cvs calcium 600 + d/minerals (tablet)* $0 (Tier 3) PACVS Calcium 600+D

cvs calcium 600+d (tablet)* $0 (Tier 3) PA, QLCVS Calcium Carbonate

cvs calcium carbonate (tablet)* $0 (Tier 3) PA, QLCVS Calcium Chewables 600plus

cvs calcium chewables 600plus (tablet chewable)* $0 (Tier 3) PACVS Calcium Citrate+D

cvs calcium citrate+d (tablet)* $0 (Tier 3) PACVS Calcium Citrate+D/Magnesium

cvs calcium citrate+d/magnesium (tablet)* $0 (Tier 3) PA, QLCVS Calcium/Magnesium/Zinc

cvs calcium/magnesium/zinc (tablet)* $0 (Tier 3) PACVS Electrolyte Solution

cvs electrolyte solution (oral solution)* $0 (Tier 3) QLCVS Iron

cvs iron (27mg tablet)* $0 (Tier 3) PACVS Iron

cvs iron (325mg tablet)* $0 (Tier 3) PA, QLCVS Magnesium

cvs magnesium (250mg tablet)* $0 (Tier 3) PACVS Oyster Shell Calcium w/ Vitamin D

cvs oyster shell calcium w/ vitamin d (tablet)* $0 (Tier 3) PA, QLCVS Pediatric Electrolyte

cvs pediatric electrolyte (oral solution)* $0 (Tier 3) QLCVS Pediatric Electrolyte Freezer Pops

cvs pediatric electrolyte freezer pops (oral solution)* $0 (Tier 3) QLCVS Slow Release Iron

cvs slow release iron (tablet extended-release)* $0 (Tier 3) PACVS Zinc

cvs zinc (otc only) (tablet)* $0 (Tier 3) PA, QLDuofer

duofer (tablet)* $0 (Tier 3) PAEnfamil Enfalyte

enfamil enfalyte (oral solution)* $0 (Tier 3) QLEQL Pediatric Electrolyte

eql pediatric electrolyte (solution)* $0 (Tier 3) QLEZFE 200

ezfe 200 (capsule)* $0 (Tier 3) PA, QLFerate

ferate (tablet)* $0 (Tier 3) PAFergon

fergon (tablet)* $0 (Tier 3) PAFer-In-Sol

fer-in-sol (oral solution)* $0 (Tier 3) PA, QLFer-Iron

fer-iron (oral solution)* $0 (Tier 3) PA, QLFerosul

ferosul (elixir)* $0 (Tier 3) PAFerretts

ferretts (tablet)* $0 (Tier 3) PA, QLFerretts IPS

ferretts ips (oral solution)* $0 (Tier 3) PA, QLFerrex 150

ferrex 150 (150mg capsule)* $0 (Tier 3) PA, QLFerrimin 150

ferrimin 150 (tablet)* $0 (Tier 3) PAFerrous Drops

ferrous drops (oral solution)* $0 (Tier 3) PA, QLFerrous Fumarate 324

ferrous fumarate 324 (tablet)* $0 (Tier 3) PAFerrous Gluconate

ferrous gluconate (240mg tablet)* $0 (Tier 3) PAFerrous Gluconate

ferrous gluconate (324mg tablet, 325mg tablet)* $0 (Tier 3) PA, QLFerrous Sulfate

ferrous sulfate (140mg tablet extended-release, 220mg/

5ml elixir, 300mg/5ml syrup)*$0 (Tier 3) PA

Ferrous Sulfate

ferrous sulfate (15mg/ml oral solution, 324mg tablet

delayed-release, 325mg tablet delayed-release, 325mg

tablet immediate-release)*

$0 (Tier 3) PA, QL


page 9.




100


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useFerrousul

ferrousul (tablet)* $0 (Tier 3) PA, QLFolitab 500

folitab 500 (tablet extended-release)* $0 (Tier 3) PAGNP Calcium

gnp calcium (tablet)* $0 (Tier 3) PA, QLGNP Calcium 1200

gnp calcium 1200 (tablet chewable)* $0 (Tier 3) PAGNP Calcium 500/D

gnp calcium 500/d (tablet)* $0 (Tier 3) PA, QLGNP Calcium 500+D3

gnp calcium 500+d3 (tablet)* $0 (Tier 3) PAGNP Calcium 600/D

gnp calcium 600/d (tablet)* $0 (Tier 3) PAGNP Calcium 600+D Plus Minerals

gnp calcium 600+d plus minerals (tablet chewable)* $0 (Tier 3) PAGNP Calcium Citrate+D Maximum

gnp calcium citrate+d maximum (tablet)* $0 (Tier 3) PAGNP Calcium Citrate+D3

gnp calcium citrate+d3 (tablet)* $0 (Tier 3) PAGNP Calcium/Magnesium/Zinc

gnp calcium/magnesium/zinc (tablet)* $0 (Tier 3) PAGNP Calcuim/Vitamin D/Minerals

gnp calcuim/vitamin d/minerals (tablet chewable)* $0 (Tier 3) PAGNP Iron

gnp iron (200mg tablet, 45mg tablet extended-release)* $0 (Tier 3) PAGNP Magnesium

gnp magnesium (tablet)* $0 (Tier 3) PAGNP Pediatric Electrolyte

gnp pediatric electrolyte (oral solution)* $0 (Tier 3) QLGNP Zinc

gnp zinc (tablet)* $0 (Tier 3) PAHemocyte

hemocyte (tablet)* $0 (Tier 3) PAHM Pediatric Electrolyte

hm pediatric electrolyte (solution)* $0 (Tier 3) QLI.L.X. B-12

i.l.x. b-12 (elixir)* $0 (Tier 3) PAICAR Pediatric

icar pediatric (suspension)* $0 (Tier 3) PAIferex 150

iferex 150 (capsule)* $0 (Tier 3) PAIron

iron (otc only) (tablet)* $0 (Tier 3) PAIron Supplement Childrens

iron supplement childrens (oral solution)* $0 (Tier 3) PA, QLIsolyte-S

ISOLYTE-S (INJECTION) $3.60-$7.40 (Tier 2)Klor-Con 10

KLOR-CON 10 (TABLET EXTENDED-RELEASE) $3.60-$7.40 (Tier 2)Klor-Con 8

KLOR-CON 8 (TABLET EXTENDED-RELEASE) $3.60-$7.40 (Tier 2)Klor-Con M15

klor-con m15 (tablet extended-release) $1.20-$2.95 (Tier 1)Klor-Con M20

klor-con m20 (tablet extended-release) $1.20-$2.95 (Tier 1)Klor-Con Sprinkle

klor-con sprinkle (capsule extended-release) $1.20-$2.95 (Tier 1)KP Calcium/Magnesium/Zinc

kp calcium/magnesium/zinc (tablet)* $0 (Tier 3) PA


101


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useKP Ferrous Gluconate

kp ferrous gluconate (tablet)* $0 (Tier 3) PAKP Ferrous Sulfate

kp ferrous sulfate (tablet)* $0 (Tier 3) PA, QLK-Tab

K-TAB (10MEQ TABLET EXTENDED-RELEASE,

8MEQ TABLET EXTENDED-RELEASE)$3.60-$7.40 (Tier 2)

Liquid Calcium/D3

liquid calcium/d3 (capsule)* $0 (Tier 3) PALiquid Calcium/Vitamin D

liquid calcium/vitamin d (capsule)* $0 (Tier 3) PAMag-Delay

mag-delay (tablet extended-release)* $0 (Tier 3)Magnesium

magnesium (otc only) (250mg tablet)* $0 (Tier 3) PAMagnesium 27

magnesium 27 (otc only) (tablet)* $0 (Tier 3) PAMagnesium Elemental

magnesium elemental (otc only) (300mg capsule, 30mg

tablet)*$0 (Tier 3) PA

Magnesium Sulfate

MAGNESIUM SULFATE (1GM/2ML-50%


Magnesium Sulfate

magnesium sulfate (5gm/10ml-50% injection) $1.20-$2.95 (Tier 1)Mag-SR Plus Calcium

mag-sr plus calcium (tablet delayed-release)* $0 (Tier 3)Mag-Tab SR

mag-tab sr (otc only) (tablet extended-release)* $0 (Tier 3) PAMonocal

monocal (tablet)* $0 (Tier 3) PAMyferon 150

myferon 150 (capsule)* $0 (Tier 3) PANormosol-R

NORMOSOL-R (INJECTION) $3.60-$7.40 (Tier 2)NovaFerrum 125

novaferrum 125 (liquid)* $0 (Tier 3)NovaFerrum 50

novaferrum 50 (capsule)* $0 (Tier 3)NovaFerrum Pediatric Drops

novaferrum pediatric drops (liquid)* $0 (Tier 3)Nu-Iron 150

nu-iron 150 (capsule)* $0 (Tier 3) PAOralyte

oralyte (oral solution)* $0 (Tier 3) QLOralyte Freezer Pops

oralyte freezer pops (oral solution)* $0 (Tier 3) QLOrazinc

orazinc (110mg tablet)* $0 (Tier 3) PAOrazinc

orazinc (220mg capsule)* $0 (Tier 3) PA, QLOS-CAL

os-cal (tablet chewable)* $0 (Tier 3) PAOS-CAL Calcium+D3

os-cal calcium+d3 (tablet)* $0 (Tier 3) PA, QLOS-CAL Extra D3

os-cal extra d3 (tablet)* $0 (Tier 3) PAOsteo-Poretical

osteo-poretical (tablet)* $0 (Tier 3) PAOysco 500

oysco 500 (tablet)* $0 (Tier 3) PA, QLOysco 500+D

oysco 500+d (tablet)* $0 (Tier 3) PA, QLOysco 500+D

oysco 500+d (tablet chewable)* $0 (Tier 3) PAOysco D

oysco d (tablet)* $0 (Tier 3) PA, QLOyst-Cal-D 500

oyst-cal-d 500 (tablet)* $0 (Tier 3) PA, QLOyster Calcium

oyster calcium (tablet)* $0 (Tier 3) PA, QLOyster Shell Calcium

oyster shell calcium (tablet)* $0 (Tier 3) PA, QL


page 9.




102


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useOyster Shell Calcium+D

oyster shell calcium+d (tablet)* $0 (Tier 3) PAOyster Shell Calcium+D3

oyster shell calcium+d3 (tablet)* $0 (Tier 3) PAOyster Shell Calcium + Vitamin D

oyster shell calcium + vitamin d (tablet)* $0 (Tier 3) PA, QLOyster Shell Calcium 500+D

oyster shell calcium 500+d (tablet)* $0 (Tier 3) PA, QLOyster Shell Calcium Plus Vitamin D

oyster shell calcium plus vitamin d (tablet)* $0 (Tier 3) PA, QLOyster Shell Calcium/D

oyster shell calcium/d (tablet)* $0 (Tier 3) PA, QLOyster Shell/Vitamin D

oyster shell/vitamin d (tablet)* $0 (Tier 3) PA, QLPA Oyster Shell Calcium

pa oyster shell calcium (tablet)* $0 (Tier 3) PA, QLPedialyte

pedialyte (oral solution)* $0 (Tier 3) QLPedialyte Advanced Care

pedialyte advanced care (oral solution)* $0 (Tier 3) QLPedialyte Freezer Pops

pedialyte freezer pops (oral solution)* $0 (Tier 3) QLPedialyte Singles

pedialyte singles (oral solution)* $0 (Tier 3) QLPediatric Electrolyte

pediatric electrolyte (oral solution)* $0 (Tier 3) QLPediatric Electrolyte Freeze Pops

pediatric electrolyte freeze pops (solution)* $0 (Tier 3) QLPediatric Electrolyte Freezer Pops

pediatric electrolyte freezer pops (oral solution)* $0 (Tier 3) QLPediatric Electrolyte/Zinc

pediatric electrolyte/zinc (oral solution)* $0 (Tier 3) QLPhysiolyte

PHYSIOLYTE (IRRIGATION SOLUTION) $3.60-$7.40 (Tier 2)Physiosol Irrigation

PHYSIOSOL IRRIGATION (SOLUTION) $3.60-$7.40 (Tier 2)PIC 200

pic 200 (capsule)* $0 (Tier 3) PAPlasma-Lyte A

PLASMA-LYTE A (INJECTION) $3.60-$7.40 (Tier 2)Plasma-Lyte-148

PLASMA-LYTE-148 (INJECTION) $3.60-$7.40 (Tier 2)Poly-Iron 150

poly-iron 150 (capsule)* $0 (Tier 3) PA, QLPotassium Chloride

POTASSIUM CHLORIDE (10% ORAL SOLUTION,

20% ORAL SOLUTION)$3.60-$7.40 (Tier 2)

Potassium Chloride

POTASSIUM CHLORIDE (10MEQ/100ML

INJECTION, 20MEQ/100ML INJECTION, 40MEQ/

100ML INJECTION)

$3.60-$7.40 (Tier 2) B/D, PA

Potassium Chloride

potassium chloride (2meq/ml injection) $1.20-$2.95 (Tier 1) B/D, PAPotassium Chloride 0.15% /NaCl 0.45% Viaflex

potassium chloride 0.15% /nacl 0.45% viaflex (injection) $1.20-$2.95 (Tier 1) B/D, PA


103


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on usePotassium Chloride 0.15%/NaCl 0.9%

POTASSIUM CHLORIDE 0.15%/NACL 0.9%

(INJECTION)$3.60-$7.40 (Tier 2) B/D, PA

Potassium Chloride 0.3%/ NaCl 0.9%

POTASSIUM CHLORIDE 0.3%/ NACL 0.9%


Potassium Chloride ER

potassium chloride er (10meq capsule extended-release,

8meq capsule extended-release, 10meq

microencapsulated tablet extended-release, 20meq

microencapsulated tablet extended-release, 8meq tablet

extended-release)

$1.20-$2.95 (Tier 1)

Potassium Citrate ER

potassium citrate er (tablet extended-release) $1.20-$2.95 (Tier 1)ProFe

profe (capsule)* $0 (Tier 3) PAProferrin ES

proferrin es (tablet)* $0 (Tier 3) PAQC Calcium Fast Dissolution

qc calcium fast dissolution (tablet)* $0 (Tier 3) PA, QLQC Calcium/Minerals/Vitamin D

qc calcium/minerals/vitamin d (tablet)* $0 (Tier 3) PA, QLQC Ferrous Sulfate

qc ferrous sulfate (tablet)* $0 (Tier 3) PA, QLRA Calcium 600

ra calcium 600 (tablet)* $0 (Tier 3) PA, QLRA Calcium 600 Plus Vitamin D-3

ra calcium 600 plus vitamin d-3 (tablet)* $0 (Tier 3) PA, QLRA Calcium 600/Vitamin D/Minerals

ra calcium 600/vitamin d/minerals (tablet)* $0 (Tier 3) PA, QLRA Calcium Citrate Plus Vitamin D-3

ra calcium citrate plus vitamin d-3 (tablet)* $0 (Tier 3) PARA Calcium/Boron

ra calcium/boron (tablet)* $0 (Tier 3) PARA Calcium/Magnesium/Zinc/Copper

ra calcium/magnesium/zinc/copper (tablet)* $0 (Tier 3) PARA Coral Calcium

ra coral calcium (capsule)* $0 (Tier 3) PARA Hi Cal

ra hi cal (tablet)* $0 (Tier 3) PA, QLRA Hi-Cal Plus Vitamin D

ra hi-cal plus vitamin d (tablet)* $0 (Tier 3) PA, QLRA High Potency Iron

ra high potency iron (tablet)* $0 (Tier 3) PARA Iron

ra iron (otc only) (tablet)* $0 (Tier 3) PA, QLRA Natural Magnesium

ra natural magnesium (tablet)* $0 (Tier 3) PARA Oyster Shell Calcium/Vitamin D

ra oyster shell calcium/vitamin d (125unit-250mg tablet)* $0 (Tier 3) PARA Oyster Shell Calcium/Vitamin D

ra oyster shell calcium/vitamin d (tablet)* $0 (Tier 3) PA, QLRA Pediatric Electrolyte

ra pediatric electrolyte (oral solution)* $0 (Tier 3) QLRA Pediatric Electrolyte Freezer Pops

ra pediatric electrolyte freezer pops (oral solution)* $0 (Tier 3) QLRA Slow Release Iron

ra slow release iron (tablet extended-release)* $0 (Tier 3) PARA Zinc

ra zinc (tablet)* $0 (Tier 3) PARisacal-D

risacal-d (tablet)* $0 (Tier 3) PASB Pediatric Electrolyte

sb pediatric electrolyte (solution)* $0 (Tier 3) QLSelenium

selenium (otc only) (tablet extended-release)* $0 (Tier 3) PASlow-Mag

slow-mag (tablet delayed-release)* $0 (Tier 3) PASM Calcium 500/Vitamin D3

sm calcium 500/vitamin d3 (tablet)* $0 (Tier 3) PA


page 9.




104


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useSM Calcium 600/Vitamin D

sm calcium 600/vitamin d (tablet)* $0 (Tier 3) PASM Calcium Citrate with Vitamin D3

sm calcium citrate with vitamin d3 (tablet)* $0 (Tier 3) PASM Calcium/Magnesium/Zinc

sm calcium/magnesium/zinc (otc only) (tablet)* $0 (Tier 3) PASM Calcium/Vitamin D

sm calcium/vitamin d (tablet)* $0 (Tier 3) PA, QLSM Iron

sm iron (tablet)* $0 (Tier 3) PA, QLSM Magnesium

sm magnesium (tablet)* $0 (Tier 3) PASM Oyster Shell Calcium/Vitamin D

sm oyster shell calcium/vitamin d (tablet)* $0 (Tier 3) PASM Oyster Shell Calcium/Vitamin D3

sm oyster shell calcium/vitamin d3 (tablet)* $0 (Tier 3) PASM Pediatric Electrolyte

sm pediatric electrolyte (oral solution)* $0 (Tier 3) QLSM Slow Release Iron

sm slow release iron (tablet extended-release)* $0 (Tier 3) PASM Zinc

sm zinc (tablet)* $0 (Tier 3) PASodium Chloride

sodium chloride (rx only) (0.9% injection) $1.20-$2.95 (Tier 1)Sodium Chloride

SODIUM CHLORIDE (RX ONLY) (2.5MEQ/ML

INJECTION, 3% INJECTION, 5% INJECTION)$3.60-$7.40 (Tier 2)

Sodium Chloride 0.45% Viaflex

SODIUM CHLORIDE 0.45% VIAFLEX (INJECTION) $3.60-$7.40 (Tier 2)Sodium Chloride 0.9%

SODIUM CHLORIDE 0.9% (IRRIGATION


Sodium Fluoride

sodium fluoride (tablet) $1.20-$2.95 (Tier 1)Tandem

tandem (capsule)* $0 (Tier 3)Wee Care

wee care (suspension)* $0 (Tier 3) PAZinc

zinc (otc only) (tablet)* $0 (Tier 3) PAZinc 15

zinc 15 (tablet)* $0 (Tier 3) PAZinc Chelated

zinc chelated (tablet)* $0 (Tier 3) PA, QLZinc Gluconate

zinc gluconate (tablet)* $0 (Tier 3) PAZinc Sulfate

zinc sulfate (220mg capsule)* $0 (Tier 3) PA, QLZinc Sulfate

zinc sulfate (220mg tablet)* $0 (Tier 3) PAZinc/Vitamin C

zinc/vitamin c (lozenge)* $0 (Tier 3) PAZinc-220

zinc-220 (capsule)* $0 (Tier 3) PA, QL

Therapeutic Nutrients/Minerals/Electrolytes


105


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useAminosyn 7%/Electrolytes

AMINOSYN 7%/ELECTROLYTES (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAAminosyn 8.5%/Electrolytes

AMINOSYN 8.5%/ELECTROLYTES (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAAminosyn II

AMINOSYN II (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAAminosyn II 8.5%/Electrolytes

AMINOSYN II 8.5%/ELECTROLYTES (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAAminosyn M

AMINOSYN M (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAAminosyn-HBC

AMINOSYN-HBC (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAAminosyn-PF

AMINOSYN-PF (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAAminosyn-RF

AMINOSYN-RF (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAClinisol SF 15%

clinisol sf 15% (injection) $1.20-$2.95 (Tier 1) B/D, PADextrose 10% Flex Container

DEXTROSE 10% FLEX CONTAINER (INJECTION) $3.60-$7.40 (Tier 2)Dextrose 10%/NaCl 0.2%

DEXTROSE 10%/NACL 0.2% (INJECTION) $3.60-$7.40 (Tier 2)Dextrose 10%/NaCl 0.45%

DEXTROSE 10%/NACL 0.45% (INJECTION) $3.60-$7.40 (Tier 2)Dextrose 2.5%/NaCl 0.45%

DEXTROSE 2.5%/NACL 0.45% (INJECTION) $3.60-$7.40 (Tier 2)Dextrose 5%

DEXTROSE 5% (INJECTION) $3.60-$7.40 (Tier 2)Dextrose 5%/Lactated Ringers

DEXTROSE 5%/LACTATED RINGERS


Dextrose 5%/NaCl 0.2%





DEXTROSE 5%/NACL 0.9% (INJECTION) $3.60-$7.40 (Tier 2)Dextrose 5%/Potassium Chloride 0.15%

DEXTROSE 5%/POTASSIUM CHLORIDE 0.15%


FreAmine HBC 6.9%

FREAMINE HBC 6.9% (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAHepatAmine

HEPATAMINE (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAIntralipid

INTRALIPID (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAIonosol-B/Dextrose 5%

IONOSOL-B/DEXTROSE 5% (INJECTION) $3.60-$7.40 (Tier 2)Ionosol-MB/Dextrose 5%

IONOSOL-MB/DEXTROSE 5% (INJECTION) $3.60-$7.40 (Tier 2)Isolyte-P/Dextrose 5%

ISOLYTE-P/DEXTROSE 5% (INJECTION) $3.60-$7.40 (Tier 2)KCl 0.075%/D5W/NaCl 0.45%

KCL 0.075%/D5W/NACL 0.45% (INJECTION) $3.60-$7.40 (Tier 2)KCl 0.15%/D5W/LR

KCL 0.15%/D5W/LR (INJECTION) $3.60-$7.40 (Tier 2)KCl 0.15%/D5W/NaCl 0.2%

KCL 0.15%/D5W/NACL 0.2% (INJECTION) $3.60-$7.40 (Tier 2)KCl 0.15%/D5W/NaCl 0.225%




KCL 0.3%/D5W/NACL 0.9% (INJECTION) $3.60-$7.40 (Tier 2)Lactated Ringers Irrigation

LACTATED RINGERS IRRIGATION (SOLUTION) $3.60-$7.40 (Tier 2)


page 9.




106


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useLactated Ringers Viaflex

LACTATED RINGERS VIAFLEX (INJECTION) $3.60-$7.40 (Tier 2)Levocarnitine

levocarnitine (1gm/10ml oral solution, 200mg/ml

injection, 330mg tablet)$1.20-$2.95 (Tier 1) B/D, PA

Nephramine

NEPHRAMINE (INJECTION) $3.60-$7.40 (Tier 2) B/D, PANormosol-M in D5W

NORMOSOL-M IN D5W (INJECTION) $3.60-$7.40 (Tier 2)Normosol-R in D5W

NORMOSOL-R IN D5W (INJECTION) $3.60-$7.40 (Tier 2)NutreStore

NUTRESTORE (PACKET) $3.60-$7.40 (Tier 2)Nutrilipid

NUTRILIPID (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAPlasma-Lyte-56/D5W

PLASMA-LYTE-56/D5W (INJECTION) $3.60-$7.40 (Tier 2)Plenamine

plenamine (injection) $1.20-$2.95 (Tier 1) B/D, PAPotassium Chloride 0.15% D5W/NaCl 0.33%

POTASSIUM CHLORIDE 0.15% D5W/NACL

0.33% (INJECTION)$3.60-$7.40 (Tier 2)

Potassium Chloride 0.15% D5W/NaCl 0.45%


0.45% (INJECTION)$3.60-$7.40 (Tier 2)

Potassium Chloride 0.22% D5W/NaCl 0.45%


0.45% (INJECTION)$3.60-$7.40 (Tier 2)

Potassium Chloride 0.3%/D5W

POTASSIUM CHLORIDE 0.3%/D5W (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAPremasol

premasol (injection) $1.20-$2.95 (Tier 1) B/D, PAProcalamine

PROCALAMINE (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAProsol

PROSOL (INJECTION) $3.60-$7.40 (Tier 2) B/D, PARingers Injection

RINGERS INJECTION (INJECTION) $3.60-$7.40 (Tier 2)Ringers Irrigation

RINGERS IRRIGATION (SOLUTION) $3.60-$7.40 (Tier 2)Sodium Lactate

SODIUM LACTATE (INJECTION) $3.60-$7.40 (Tier 2)TPN Electrolytes

TPN ELECTROLYTES (INJECTION) $3.60-$7.40 (Tier 2)Travasol

TRAVASOL (INJECTION) $3.60-$7.40 (Tier 2) B/D, PATrophamine

TROPHAMINE (INJECTION) $3.60-$7.40 (Tier 2) B/D, PAVP-PNV-DHA

vp-pnv-dha (capsule) $1.20-$2.95 (Tier 1)

Vitamins

Acerola C 500

acerola c 500 (wafer)* $0 (Tier 3) PA


107


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useActical

actical (capsule)* $0 (Tier 3) PAAlba-Lybe NR

alba-lybe nr (liquid)* $0 (Tier 3) PAAnimal Shapes

animal shapes (tablet chewable)* $0 (Tier 3) PA, QLAnimal Shapes + Iron

animal shapes + iron (tablet chewable)* $0 (Tier 3) PA, QLApatate Forte

apatate forte (liquid)* $0 (Tier 3) PAApetex

apetex (elixir)* $0 (Tier 3) PAApetigen

apetigen (elixir)* $0 (Tier 3) PAApetigen-Plus

apetigen-plus (tablet, oral solution)* $0 (Tier 3) PAAquADEKs

aquadeks (tablet chewable)* $0 (Tier 3) PA, QLAquADEKs

aquadeks (capsule)* $0 (Tier 3) PAAqueous Vitamin D Infants

aqueous vitamin d infants (liquid)* $0 (Tier 3)Aqueous Vitamin E

aqueous vitamin e (oral solution)* $0 (Tier 3) PA, QLAscorbic Acid

ascorbic acid (otc only) (tablet)* $0 (Tier 3) PA, QLB Complex

b complex (capsule)* $0 (Tier 3) PAB Complex/Folic Acid

b complex/folic acid (otc only) (tablet)* $0 (Tier 3) PAB-6

b-6 (tablet)* $0 (Tier 3) PA, QLBalance B-100

balance b-100 (tablet)* $0 (Tier 3) PABalance B-50

balance b-50 (tablet)* $0 (Tier 3) PABalanced B-100

balanced b-100 (tablet)* $0 (Tier 3) PABalanced B-50

balanced b-50 (tablet)* $0 (Tier 3) PAB-Complex

b-complex (capsule)* $0 (Tier 3) PAB-Complex Formula 1

b-complex formula 1 (tablet)* $0 (Tier 3) PAB-Complex Plus Vitamin C

b-complex plus vitamin c (tablet)* $0 (Tier 3) PAB-Complex with B-12

b-complex with b-12 (tablet)* $0 (Tier 3) PABee Zee

bee zee (tablet)* $0 (Tier 3) PABeta Carotene

beta carotene (capsule)* $0 (Tier 3) PABiocal

biocal (capsule)* $0 (Tier 3) PABiotin

biotin (1000mcg tablet, 300mcg tablet, 5000mcg

capsule)*$0 (Tier 3) PA

C 1000/Bioflavonoids/Rosehips

c 1000/bioflavonoids/rosehips (capsule)* $0 (Tier 3) PAC 250

c 250 (tablet)* $0 (Tier 3) PA, QLC 500/Rose Hips

c 500/rose hips (tablet)* $0 (Tier 3) PA, QLC Complex

c complex (tablet extended-release)* $0 (Tier 3) PAC-1000/Rose Hips

c-1000/rose hips (tablet)* $0 (Tier 3) PA, QLC-500

c-500 (tablet chewable)* $0 (Tier 3) PA, QLCalcium & Magnesium

calcium & magnesium (tablet)* $0 (Tier 3) PACemill SR

cemill sr (tablet extended-release)* $0 (Tier 3) PA, QLCentamin

centamin (liquid)* $0 (Tier 3) PA, QL


page 9.




108


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useCentavite A-Z Complete Multivitamin/Minerals

centavite a-z complete multivitamin/minerals (tablet)* $0 (Tier 3) PA, QLCentrum

centrum

(60mg-300mcg-400unit-25mcg-6mcg-150mcg-9mg-2mg

-25mcg-20mg-10mg-2mg-1.7mg-1.1mg-1300unit-30unit-

3mg/15ml liquid)*

$0 (Tier 3) QL

Centrum

centrum

(60mg-300mcg-25mcg-6mcg-150mcg-9mg-2.5mg-25mc

g-20mg-10mg-2mg-1.7mg-1.5mg-2500unit-400unit-30un

it-3mg/15ml liquid)*

$0 (Tier 3) PA

Centrum

centrum (tablet chewable)* $0 (Tier 3) PA, QLCentrum Adults

centrum adults (tablet)* $0 (Tier 3) PA, QLCentrum Kids Complete

centrum kids complete (tablet chewable)* $0 (Tier 3) PA, QLCentrum Silver

centrum silver (tablet)* $0 (Tier 3) PA, QLCentrum Silver Ultra Womens

centrum silver ultra womens (tablet)* $0 (Tier 3) PA, QLCentrum Specialist Heart

centrum specialist heart (tablet)* $0 (Tier 3) PA, QLCentrum Ultra Mens

centrum ultra mens (tablet)* $0 (Tier 3) PA, QLCentrum Ultra Womens

centrum ultra womens (tablet)* $0 (Tier 3) PA, QLCerovite Advanced Formula

cerovite advanced formula (liquid)* $0 (Tier 3) PACerovite Advanced Formula

cerovite advanced formula (tablet)* $0 (Tier 3) PA, QLCerovite Jr

cerovite jr (tablet chewable)* $0 (Tier 3) PA, QLCertavite/Antioxidants

certavite/antioxidants (liquid)* $0 (Tier 3) PACertavite/Antioxidants

certavite/antioxidants (tablet)* $0 (Tier 3) PA, QLChewable Vite Childrens

chewable vite childrens (tablet chewable)* $0 (Tier 3) PA, QLChewable Vite with Iron/Childrens

chewable vite with iron/childrens (tablet chewable)* $0 (Tier 3) PA, QLChildrens Chewable Vitamins

childrens chewable vitamins (tablet chewable)* $0 (Tier 3) PA, QLChildrens Chewable Vitamins/Iron

childrens chewable vitamins/iron (tablet chewable)* $0 (Tier 3) PA, QLCompete

compete (tablet)* $0 (Tier 3) PA, QLComplete

complete (tablet)* $0 (Tier 3) PA, QLComplex B-100

complex b-100 (tablet extended-release)* $0 (Tier 3) PACVS B Complex Plus C

cvs b complex plus c (tablet)* $0 (Tier 3) PACVS B-12

cvs b-12 (liquid)* $0 (Tier 3) PA


109


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useCVS B-6

cvs b-6 (tablet)* $0 (Tier 3) PA, QLCVS Balanced B-100

cvs balanced b-100 (tablet)* $0 (Tier 3) PACVS Balanced B-50

cvs balanced b-50 (tablet)* $0 (Tier 3) PACVS Beta Carotene

cvs beta carotene (capsule)* $0 (Tier 3) PACVS Biotin

cvs biotin (capsule)* $0 (Tier 3) PACVS Biotin High Potency

cvs biotin high potency (tablet)* $0 (Tier 3) PACVS Calcium Soft Chews

cvs calcium soft chews (tablet chewable)* $0 (Tier 3) PACVS Childrens Chewable Complete

cvs childrens chewable complete (tablet chewable)* $0 (Tier 3) PA, QLCVS Childrens Chewable Multivitamin/Iron

cvs childrens chewable multivitamin/iron (tablet

chewable)*$0 (Tier 3) PA, QL

CVS Daily Energy

cvs daily energy (tablet)* $0 (Tier 3) PA, QLCVS Daily Multiple

cvs daily multiple (tablet)* $0 (Tier 3) PACVS Daily Multiple for Men

cvs daily multiple for men (tablet)* $0 (Tier 3) PA, QLCVS Daily Multiple for Men 50+

cvs daily multiple for men 50+ (tablet)* $0 (Tier 3) PA, QLCVS Daily Multiple for Women

cvs daily multiple for women (tablet)* $0 (Tier 3) PA, QLCVS Daily Multiple for Women 50+

cvs daily multiple for women 50+ (tablet)* $0 (Tier 3) PA, QLCVS Daily Multiple Plus Iron/Calcium/Zinc

cvs daily multiple plus iron/calcium/zinc (tablet)* $0 (Tier 3) PA, QLCVS E Oil

cvs e oil* $0 (Tier 3) PACVS Gummy Dinos

cvs gummy dinos (tablet chewable)* $0 (Tier 3) PA, QLCVS Hair Skin & Nails/Antioxidants

cvs hair skin & nails/antioxidants (tablet)* $0 (Tier 3) PACVS Spectravite Adult 50+

cvs spectravite adult 50+ (tablet)* $0 (Tier 3) PA, QLCVS Spectravite Advanced Formula

cvs spectravite advanced formula (tablet)* $0 (Tier 3) PA, QLCVS Spectravite Senior

cvs spectravite senior (tablet)* $0 (Tier 3) PA, QLCVS Spectravite Ultra Health Mens

cvs spectravite ultra health mens (tablet)* $0 (Tier 3) PA, QLCVS Spectravite Ultra Mens Health

cvs spectravite ultra mens health (tablet)* $0 (Tier 3) PA, QLCVS Spectravite Ultra Women

cvs spectravite ultra women (tablet)* $0 (Tier 3) PA, QLCVS Spectravite Ultra Womens Health

cvs spectravite ultra womens health (tablet)* $0 (Tier 3) PA, QLCVS Spectravite Ultra Womens Health Senior

cvs spectravite ultra womens health senior (tablet)* $0 (Tier 3) PA, QLCVS Stress Formula/Zinc

cvs stress formula/zinc (tablet)* $0 (Tier 3) PACVS Super B Complex/C

cvs super b complex/c (tablet)* $0 (Tier 3) PACVS Vitamin A

cvs vitamin a (capsule)* $0 (Tier 3) PA, QLCVS Vitamin B-12

cvs vitamin b-12 (tablet)* $0 (Tier 3) PACVS Vitamin B-12 TR

cvs vitamin b-12 tr (tablet extended-release)* $0 (Tier 3) PACVS Vitamin B-6

cvs vitamin b-6 (tablet)* $0 (Tier 3) PA, QLCVS Vitamin C

cvs vitamin c (1000mg tablet chewable, 500mg tablet

chewable, 1000mg tablet, 500mg tablet)*$0 (Tier 3) PA, QL

CVS Vitamin C/Rose Hips

cvs vitamin c/rose hips (tablet)* $0 (Tier 3) PA, QLCVS Vitamin E

cvs vitamin e (capsule)* $0 (Tier 3) PA


page 9.




110


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useDaily Multiple Vitamin/Iron

daily multiple vitamin/iron (tablet)* $0 (Tier 3) PA, QLDaily Multiple Vitamins

daily multiple vitamins (tablet)* $0 (Tier 3) PADaily Vitamins

daily vitamins (tablet)* $0 (Tier 3) PADaily Vite

daily vite (tablet)* $0 (Tier 3) PADaily Vite with Iron

daily vite with iron (tablet)* $0 (Tier 3) PA, QLDaily-Vite/Iron/Beta-Carotene

daily-vite/iron/beta-carotene (tablet)* $0 (Tier 3) PA, QLDialyvite 800

dialyvite 800 (tablet)* $0 (Tier 3) PA, QLDialyvite 800/Zinc

dialyvite 800/zinc (tablet)* $0 (Tier 3) PADialyvite 800/Zinc 15

dialyvite 800/zinc 15 (tablet)* $0 (Tier 3) PADino-Life

dino-life (tablet chewable)* $0 (Tier 3) PA, QLDino-Life with Extra C

dino-life with extra c (tablet chewable)* $0 (Tier 3) PA, QLDino-Life w/Iron & Zinc

dino-life w/iron & zinc (tablet chewable)* $0 (Tier 3) PADrisdol

drisdol (rx only) (50000unit capsule)* $0 (Tier 3) QLE-400

e-400 (capsule)* $0 (Tier 3) PAEcee Plus

ecee plus (tablet)* $0 (Tier 3) PAEQL One Daily Essential

eql one daily essential (tablet)* $0 (Tier 3) PAErgocalciferol

ergocalciferol (otc only) (oral solution)* $0 (Tier 3) QLFe C

fe c (tablet)* $0 (Tier 3) PAFolic Acid

folic acid (rx only) (1mg tablet)* $0 (Tier 3) QLFolic Acid

folic acid (rx only) (5mg/ml injection)* $0 (Tier 3)Foltabs 800

foltabs 800 (tablet)* $0 (Tier 3) PAFormula E 400

formula e 400 (capsule)* $0 (Tier 3) PAFosfree

fosfree (tablet)* $0 (Tier 3) PA, QLFruity C

fruity c (tablet chewable)* $0 (Tier 3) PA, QLFruity Chewables Multivitamin

fruity chewables multivitamin (tablet chewable)* $0 (Tier 3) PA, QLFull Spectrum B/Vitamin C

full spectrum b/vitamin c (tablet)* $0 (Tier 3) PA, QLGNP Animal Shapes

gnp animal shapes (tablet chewable)* $0 (Tier 3) PA, QLGNP Animal Shapes Plus Extra C

gnp animal shapes plus extra c (tablet chewable)* $0 (Tier 3) PA, QLGNP Animal Shapes Plus Iron

gnp animal shapes plus iron (tablet chewable)* $0 (Tier 3) PA, QLGNP B-50 Balanced

gnp b-50 balanced (tablet)* $0 (Tier 3) PA


111


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useGNP Century

gnp century (tablet)* $0 (Tier 3) QLGNP Century Adults 50+ Senior

gnp century adults 50+ senior (tablet)* $0 (Tier 3) QLGNP Century Cardio Health Formula

gnp century cardio health formula (tablet)* $0 (Tier 3) PA, QLGNP Century Ultimate Mens Complete

gnp century ultimate mens complete (tablet)* $0 (Tier 3) QLGNP Century Ultimate Womens Complete

gnp century ultimate womens complete (tablet)* $0 (Tier 3) QLGNP Century Ultimate Womens Senior Formula

gnp century ultimate womens senior formula (tablet)* $0 (Tier 3) QLGNP Childrens Chewables/Extra C

gnp childrens chewables/extra c (tablet chewable)* $0 (Tier 3) PA, QLGNP Childrens Chewables/Iron

gnp childrens chewables/iron (tablet chewable)* $0 (Tier 3) PA, QLGNP Essential One Daily

gnp essential one daily (tablet)* $0 (Tier 3) PAGNP Hair/Skin/Nails

gnp hair/skin/nails (tablet)* $0 (Tier 3) PA, QLGNP Little Ones Childrens

gnp little ones childrens (tablet chewable)* $0 (Tier 3) PA, QLGNP Mega Multi for Men

gnp mega multi for men (tablet)* $0 (Tier 3) PA, QLGNP Mega Multi for Women

gnp mega multi for women (tablet)* $0 (Tier 3) PA, QLGNP Niacin TR

gnp niacin tr (otc only) (tablet extended-release)* $0 (Tier 3) PAGNP One Daily Maximum

gnp one daily maximum (tablet)* $0 (Tier 3) PA, QLGNP One Daily Mens Health 50+

gnp one daily mens health 50+ (tablet)* $0 (Tier 3) PA, QLGNP One Daily Plus Iron

gnp one daily plus iron (tablet)* $0 (Tier 3) PA, QLGNP One Daily Womens Health 50+

gnp one daily womens health 50+ (tablet)* $0 (Tier 3) QLGNP Opti-Vitamins

gnp opti-vitamins (tablet)* $0 (Tier 3) PA, QLGNP Therapeutic-M

gnp therapeutic-m (tablet)* $0 (Tier 3) PA, QLGNP Vitamin A

gnp vitamin a (capsule)* $0 (Tier 3) PA, QLGNP Vitamin B-12

gnp vitamin b-12 (tablet)* $0 (Tier 3) PAGNP Vitamin B-12 TR

gnp vitamin b-12 tr (tablet extended-release)* $0 (Tier 3) PAGNP Vitamin B-6

gnp vitamin b-6 (tablet)* $0 (Tier 3) PA, QLGNP Vitamin C

gnp vitamin c (1000mg tablet, 250mg tablet, 500mg

tablet, 500mg tablet chewable, 500mg-tablet chewable)*$0 (Tier 3) PA, QL

GNP Vitamin C Drops

gnp vitamin c drops (lozenge)* $0 (Tier 3) PAGNP Vitamin C TR

gnp vitamin c tr (tablet extended-release)* $0 (Tier 3) PA, QLGNP Vitamin C w/Rose Hips

gnp vitamin c w/rose hips (tablet)* $0 (Tier 3) PA, QLGNP Vitamin C w/Rose Hips TR

gnp vitamin c w/rose hips tr (tablet extended-release)* $0 (Tier 3) PA, QLGNP Vitamin E

gnp vitamin e (capsule)* $0 (Tier 3) PAGNP Zoo Chews Gummies

gnp zoo chews gummies (tablet chewable)* $0 (Tier 3) PA, QLHard Nails

hard nails (capsule)* $0 (Tier 3) PAHoney Bears

honey bears (tablet chewable)* $0 (Tier 3) PAHoney Bears with Iron and Zinc

honey bears with iron and zinc (tablet chewable)* $0 (Tier 3) PAI-Caps Areds Formula

i-caps areds formula (tablet)* $0 (Tier 3) PA, QLI-Caps MV

i-caps mv (tablet)* $0 (Tier 3) PA, QLI-Caps Plus

i-caps plus (tablet)* $0 (Tier 3) PA, QL


page 9.




112


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useICAR-C

icar-c (tablet)* $0 (Tier 3) PAIntegra

integra (capsule)* $0 (Tier 3) PAIron 100/C

iron 100/c (tablet)* $0 (Tier 3) PAKP Adults 50+ Daily Formula

kp adults 50+ daily formula (tablet)* $0 (Tier 3) PA, QLKP Adults Daily Formula

kp adults daily formula (tablet)* $0 (Tier 3) PA, QLKP B Complex/C

kp b complex/c (tablet)* $0 (Tier 3) PAKP Mens 50+ Daily Formula

kp mens 50+ daily formula (tablet)* $0 (Tier 3) PA, QLKP Mens Daily Formula

kp mens daily formula (tablet)* $0 (Tier 3) PA, QLKP Vitamin E

kp vitamin e (capsule)* $0 (Tier 3) PAKP Womens 50+ Daily Formula

kp womens 50+ daily formula (tablet)* $0 (Tier 3) PA, QLKP Womens Daily Formula

kp womens daily formula (tablet)* $0 (Tier 3) PA, QLLife Pack Mens

life pack mens* $0 (Tier 3) PALife Pack Womens

life pack womens* $0 (Tier 3) PALysiplex Plus

lysiplex plus (liquid)* $0 (Tier 3) PAMacuvite

macuvite (tablet)* $0 (Tier 3) QLMacuvite Eye Care

macuvite eye care (tablet)* $0 (Tier 3) PA, QLMega Multiple with Chelated Minerals

mega multiple with chelated minerals (tablet)* $0 (Tier 3) PAMega Multivitamin for Men

mega multivitamin for men (tablet)* $0 (Tier 3) PA, QLMega Multivitamin for Women

mega multivitamin for women (tablet)* $0 (Tier 3) PA, QLMephyton

mephyton (tablet)* $0 (Tier 3) QLMeribin

meribin (capsule)* $0 (Tier 3) PAMG-Plus Protein

mg-plus protein (tablet)* $0 (Tier 3) PAMulti-Day Vitamins

multi-day vitamins (tablet)* $0 (Tier 3) PAMulti-Delyn

multi-delyn (liquid)* $0 (Tier 3) PA, QLMulti-Delyn/Iron

multi-delyn/iron (liquid)* $0 (Tier 3) PA, QLMultilex

multilex (tablet)* $0 (Tier 3) PA, QLMultilex T&M

multilex t&m (tablet)* $0 (Tier 3) PA, QLMultiple Vitamins

multiple vitamins (tablet)* $0 (Tier 3) PAMultiple Vitamins Plain

multiple vitamins plain (tablet)* $0 (Tier 3) PAMultiple Vitamins/Iron

multiple vitamins/iron (tablet chewable)* $0 (Tier 3) PA, QL


113


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useMulti-Vitamin

multi-vitamin (tablet)* $0 (Tier 3) PAMulti-Vitamin HP/Minerals

multi-vitamin hp/minerals (capsule)* $0 (Tier 3) PAMulti-Vitamin/Minerals

multi-vitamin/minerals (tablet)* $0 (Tier 3) PA, QLMulti-Vitamins

multi-vitamins (tablet)* $0 (Tier 3) PAMy-Vitalife

my-vitalife (capsule)* $0 (Tier 3) PANephronex

nephronex (liquid)* $0 (Tier 3) PANephro-Vite

nephro-vite (tablet)* $0 (Tier 3) PA, QLNiacin

niacin (otc only) (250mg capsule extended-release)* $0 (Tier 3) PA, QLNiacin

niacin (otc only) (500mg tablet extended-release)* $0 (Tier 3) PANiacin ER

niacin er (otc only) (250mg capsule extended-release)* $0 (Tier 3) PA, QLNiacin SR

niacin sr (capsule extended-release)* $0 (Tier 3) PA, QLNiacin TR

niacin tr (otc only) (250mg capsule extended-release)* $0 (Tier 3) PA, QLNiacin TR

niacin tr (otc only) (250mg tablet extended-release,

500mg tablet extended-release)*$0 (Tier 3) PA

No Iron Multiple Vitamin/Minerals

no iron multiple vitamin/minerals (tablet)* $0 (Tier 3) PA, QLOnce Daily

once daily (tablet)* $0 (Tier 3) PAOnce Daily/Iron

once daily/iron (tablet)* $0 (Tier 3) PA, QLOncovite

oncovite (tablet)* $0 (Tier 3) PA, QLOne Daily

one daily (tablet)* $0 (Tier 3) PAOne Daily Mens

one daily mens (tablet)* $0 (Tier 3) PA, QLOne Daily Plus Iron

one daily plus iron (tablet)* $0 (Tier 3) PA, QLOne Daily Plus Minerals

one daily plus minerals (tablet)* $0 (Tier 3) PA, QLOne-Daily Multi Vitamins

one-daily multi vitamins (tablet)* $0 (Tier 3) PAPA B-Complex with B-12

pa b-complex with b-12 (tablet)* $0 (Tier 3) PAPA Biotin

pa biotin (capsule)* $0 (Tier 3) PAPA Vitamin B-12 TR

pa vitamin b-12 tr (tablet extended-release)* $0 (Tier 3) PAPA Vitamin E

pa vitamin e (capsule)* $0 (Tier 3) PAPediavit

pediavit (liquid)* $0 (Tier 3) PA, QLPoly Vitamin

poly vitamin (tablet chewable)* $0 (Tier 3) PA, QLPoly-Vi-Sol

poly-vi-sol (oral solution)* $0 (Tier 3) QLPoly-Vi-Sol/Iron

poly-vi-sol/iron (oral solution)* $0 (Tier 3) QLPoly-Vita Drops

poly-vita drops (oral solution)* $0 (Tier 3) PA, QLPoly-Vita/Iron Drops

poly-vita/iron drops (oral solution)* $0 (Tier 3) PA, QLPolyvitamin

polyvitamin (oral solution)* $0 (Tier 3) PA, QLPolyvitamin/Iron

polyvitamin/iron (oral solution, tablet chewable)* $0 (Tier 3) PA, QLPrevent

prevent (capsule)* $0 (Tier 3) PAProSight

prosight (60mg-2mg-40mcg-5000unit-30mg-40mg

tablet)*$0 (Tier 3) PA, QL


page 9.




114


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useProtexin

protexin (syrup)* $0 (Tier 3) PA, QLPyri 500

pyri 500 (tablet)* $0 (Tier 3) PA, QLPyridoxine HCl

pyridoxine hcl (otc only) (tablet)* $0 (Tier 3) PA, QLQC Childrens Chewable Vitamins/Extra C

qc childrens chewable vitamins/extra c (tablet


QC Childrens Chewable Vitamins/Iron

qc childrens chewable vitamins/iron (tablet chewable)* $0 (Tier 3) PA, QLQC Daily Multivitamins/Iron

qc daily multivitamins/iron (tablet)* $0 (Tier 3) PA, QLQC Maximum Daily Multivitamin/Multimineral

qc maximum daily multivitamin/multimineral (tablet)* $0 (Tier 3) PA, QLQC Multi-Vite

qc multi-vite (tablet)* $0 (Tier 3) PA, QLQC Womens Daily Multivitamin

qc womens daily multivitamin (tablet)* $0 (Tier 3) PA, QLRA Balanced B-100

ra balanced b-100 (tablet)* $0 (Tier 3) PARA Balanced B-50

ra balanced b-50 (tablet)* $0 (Tier 3) PARA B-Complex

ra b-complex (tablet)* $0 (Tier 3) PARA B-Complex with B-12

ra b-complex with b-12 (tablet)* $0 (Tier 3) PARA B-Complex/Vitamin C TR

ra b-complex/vitamin c tr (tablet extended-release)* $0 (Tier 3) PARA Beta Carotene

ra beta carotene (capsule)* $0 (Tier 3) PARA Biotin

ra biotin (capsule)* $0 (Tier 3) PARA Calcium Soft Chews

ra calcium soft chews (tablet chewable)* $0 (Tier 3) PARA Central-Vite

ra central-vite (tablet)* $0 (Tier 3) PA, QLRA Central-Vite Energy

ra central-vite energy (tablet)* $0 (Tier 3) PA, QLRA Central-Vite Performance

ra central-vite performance (tablet)* $0 (Tier 3) PARA Central-Vite Select Mature

ra central-vite select mature (tablet)* $0 (Tier 3) PA, QLRA Central-Vite Senior

ra central-vite senior (tablet)* $0 (Tier 3) PA, QLRA Central-Vite Under 50 Mens

ra central-vite under 50 mens (tablet)* $0 (Tier 3) PA, QLRA Central-Vite Under 50 Womens

ra central-vite under 50 womens (tablet)* $0 (Tier 3) PA, QLRA Central-Vite Womens Mature

ra central-vite womens mature (tablet)* $0 (Tier 3) PA, QLRA Central-Vite/Antioxidants

ra central-vite/antioxidants (tablet)* $0 (Tier 3) PA, QLRA Natural Vitamin E

ra natural vitamin e (capsule)* $0 (Tier 3) PARA One Daily Energy Formula

ra one daily energy formula (tablet)* $0 (Tier 3) PA, QLRA One Daily Essential

ra one daily essential (tablet)* $0 (Tier 3) PA


115


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useRA One Daily Maximum

ra one daily maximum (tablet)* $0 (Tier 3) PA, QLRA One Daily Mens 50+ with Vitamin D-3

ra one daily mens 50+ with vitamin d-3 (tablet)* $0 (Tier 3) PA, QLRA One Daily Multi-Vitamin

ra one daily multi-vitamin (tablet)* $0 (Tier 3) PARA One Daily Multi-Vitamin Plus Iron

ra one daily multi-vitamin plus iron (tablet)* $0 (Tier 3) PA, QLRA Stress Formula Advanced

ra stress formula advanced (tablet)* $0 (Tier 3) PA, QLRA Stress Formula Energy

ra stress formula energy (tablet)* $0 (Tier 3) PA, QLRA Therapeutic M Plus Beta Carotene

ra therapeutic m plus beta carotene (tablet)* $0 (Tier 3) PA, QLRA Vitamin A

ra vitamin a (capsule)* $0 (Tier 3) PA, QLRA Vitamin B-1

ra vitamin b-1 (tablet)* $0 (Tier 3) PA, QLRA Vitamin B12

ra vitamin b12 (tablet extended-release)* $0 (Tier 3) PARA Vitamin B-12

ra vitamin b-12 (tablet)* $0 (Tier 3) PARA Vitamin B-12 TR

ra vitamin b-12 tr (tablet extended-release)* $0 (Tier 3) PARA Vitamin B-6

ra vitamin b-6 (tablet)* $0 (Tier 3) PA, QLRA Vitamin C

ra vitamin c (250mg tablet, 500mg tablet, 500mg tablet


RA Vitamin C Drops

ra vitamin c drops (lozenge)* $0 (Tier 3) PARA Vitamin C TR

ra vitamin c tr (1000mg tablet extended-release)* $0 (Tier 3) PARA Vitamin C TR

ra vitamin c tr (500mg tablet extended-release)* $0 (Tier 3) PA, QLRA Vitamin C/Acerola

ra vitamin c/acerola (tablet chewable)* $0 (Tier 3) PA, QLRA Vitamin C/Rose Hips

ra vitamin c/rose hips (tablet)* $0 (Tier 3) PA, QLRA Vitamin C/Rose Hips TR

ra vitamin c/rose hips tr (tablet extended-release)* $0 (Tier 3) PA, QLRA Vitamin E

ra vitamin e (capsule)* $0 (Tier 3) PARena-Vite

rena-vite (tablet)* $0 (Tier 3) PA, QLSentry

sentry (tablet)* $0 (Tier 3) PA, QLSentry Senior

sentry senior (tablet)* $0 (Tier 3) PASlo-Niacin

slo-niacin (otc only) (tablet extended-release)* $0 (Tier 3) PASM Balanced B-50

sm balanced b-50 (tablet)* $0 (Tier 3) PASM Calcium Soft Chews

sm calcium soft chews (tablet chewable)* $0 (Tier 3) PASM Chewable C

sm chewable c (tablet chewable)* $0 (Tier 3) PA, QLSM Complete

sm complete (tablet)* $0 (Tier 3) PA, QLSM Complete Advanced Formula

sm complete advanced formula (tablet)* $0 (Tier 3) PA, QLSM Complete Senior Formula

sm complete senior formula (tablet)* $0 (Tier 3) PA, QLSM Multiple Vitamins Essential

sm multiple vitamins essential (tablet)* $0 (Tier 3) PASM Multiple Vitamins/Iron

sm multiple vitamins/iron (tablet)* $0 (Tier 3) PA, QLSM Super B Complex-Vitamin C

sm super b complex-vitamin c (tablet)* $0 (Tier 3) PASM Vitamin B-12

sm vitamin b-12 (tablet)* $0 (Tier 3) PASM Vitamin B-6

sm vitamin b-6 (tablet)* $0 (Tier 3) PA, QL


page 9.




116


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useSM Vitamin C

sm vitamin c (1000mg tablet, 250mg tablet, 500mg

tablet chewable)*$0 (Tier 3) PA, QL

SM Vitamin C/Rose Hips

sm vitamin c/rose hips (tablet)* $0 (Tier 3) PA, QLSM Vitamin E

sm vitamin e (capsule)* $0 (Tier 3) PASM Vitamin E Blended

sm vitamin e blended (capsule)* $0 (Tier 3) PAStress Formula

stress formula (tablet)* $0 (Tier 3) PAStress Formula with Iron

stress formula with iron (tablet)* $0 (Tier 3) PA, QLStress Formula/Iron

stress formula/iron (tablet)* $0 (Tier 3) PA, QLStress Formula/Zinc

stress formula/zinc (tablet)* $0 (Tier 3) PASuper B Complex/C

super b complex/c (capsule)* $0 (Tier 3) PASuper B with C

super b with c (capsule)* $0 (Tier 3) PASuper Thera Vite M

super thera vite m (tablet)* $0 (Tier 3) PA, QLSuperplex-T

superplex-t (tablet)* $0 (Tier 3) PASuplevit

suplevit (liquid)* $0 (Tier 3) PATAB-A-VITE

tab-a-vite (tablet)* $0 (Tier 3) PATAB-A-VITE Maximum

tab-a-vite maximum (tablet)* $0 (Tier 3) PA, QLTAB-A-VITE with Beta Carotene

tab-a-vite with beta carotene (tablet)* $0 (Tier 3) PATAB-A-VITE Womens

tab-a-vite womens (tablet)* $0 (Tier 3) PATAB-A-VITE/Iron

tab-a-vite/iron (tablet)* $0 (Tier 3) PA, QLThera

thera (tablet)* $0 (Tier 3) PAThera-M

thera-m (tablet)* $0 (Tier 3) PA, QLTheramill Forte

theramill forte (capsule)* $0 (Tier 3) PATherapeutic Liquid

therapeutic liquid (oral solution)* $0 (Tier 3) PATherapeutic M

therapeutic m (tablet)* $0 (Tier 3) PA, QLThera-Tabs

thera-tabs (tablet)* $0 (Tier 3) PATheratrum Complete

theratrum complete (tablet)* $0 (Tier 3) PA, QLThiamine HCl

thiamine hcl (otc only) (tablet)* $0 (Tier 3) PA, QLTotal B/C

total b/c (tablet)* $0 (Tier 3) PATotalday Multiple

totalday multiple (tablet extended-release)* $0 (Tier 3) PATri-Vi-Sol

tri-vi-sol (oral solution)* $0 (Tier 3) PA, QL


117


will cost you

(tier level)

Necessary

actions,

restrictions, or

limits on useTri-Vita

tri-vita (oral solution)* $0 (Tier 3) PA, QLTri-Vitamin

tri-vitamin (oral solution)* $0 (Tier 3) PA, QLVita-Bee/C

vita-bee/c (tablet)* $0 (Tier 3) PAVitamin A

vitamin a (otc only) (capsule)* $0 (Tier 3) PA, QLVitamin B Complex

vitamin b complex (tablet)* $0 (Tier 3) PAVitamin B Complex-C

vitamin b complex-c (capsule)* $0 (Tier 3) PAVitamin B-1

vitamin b-1 (otc only) (tablet)* $0 (Tier 3) PA, QLVitamin B12

vitamin b12 (otc only) (1000mcg tablet extended-release,

100mcg tablet, 500mcg tablet)*$0 (Tier 3) PA

Vitamin B-12

vitamin b-12 (otc only) (1000mcg tablet, 100mcg tablet,

250mcg tablet, 500mcg tablet, 2500mcg tablet

sublingual)*

$0 (Tier 3) PA

Vitamin B-2

vitamin b-2 (otc only) (tablet)* $0 (Tier 3) PAVitamin B-6

vitamin b-6 (otc only) (tablet)* $0 (Tier 3) PA, QLVitamin C

vitamin c (500mg tablet chewable)* $0 (Tier 3) PAVitamin C

vitamin c (1000mg tablet, 250mg tablet, 500mg tablet,

250mg tablet chewable, 500mg tablet chewable,

500mg/5ml syrup)*

$0 (Tier 3) PA, QL

Vitamin C SR

vitamin c sr (capsule extended-release)* $0 (Tier 3) PAVitamin C TR

vitamin c tr (1500mg tablet extended-release, 500mg

capsule extended-release)*$0 (Tier 3) PA, QL

Vitamin C/Rose Hips

vitamin c/rose hips (tablet)* $0 (Tier 3) PA, QLVitamin D

vitamin d (capsule)* $0 (Tier 3) QLVitamin E

vitamin e (capsule)* $0 (Tier 3) PAVitamin E Water Dispersible

vitamin e water dispersible (capsule)* $0 (Tier 3) PAVitamin E Water Soluble

vitamin e water soluble (capsule)* $0 (Tier 3) PAVitamin E/D-Alpha

vitamin e/d-alpha (capsule)* $0 (Tier 3) PAVitamin K1

vitamin k1 (rx only) (injection)* $0 (Tier 3)Vitamins & Minerals

vitamins & minerals (tablet)* $0 (Tier 3) PA, QLVitamins for Hair

vitamins for hair (tablet)* $0 (Tier 3) PAWomens One Daily

womens one daily (tablet)* $0 (Tier 3) PA, QLZoo Friends

zoo friends (tablet chewable)* $0 (Tier 3) PA, QLZoo Friends Complete

zoo friends complete (tablet chewable)* $0 (Tier 3) PAZoo Friends Plus Extra C

zoo friends plus extra c (tablet chewable)* $0 (Tier 3) PA, QLZoo Friends Plus Iron

zoo friends plus iron (tablet chewable)* $0 (Tier 3) PA, QL

118


Index of Drugs

#

12 Hour Decongestant..... 90

8-MOP................................... 57

A

A-Hydrocort..........................67

Abacavir................................43

Abacavir Sulfate/

Lamivudine/Zidovudine. 43

Abelcet..................................28

Abilify Maintena...................40

Abraxane.............................. 33

Abstral................................... 14

Acamprosate Calcium DR15

Acarbose.............................. 45

Acephen............................... 10

Acerola C 500...................106

Aceta-Gesic..........................85

Acetaminophen.................. 10

Acetaminophen/Codeine.14

Acetaminophen/

Diphenhydramine............ 85

Acetazolamide.....................53

Acetazolamide ER..............53

Acetazolamide Sodium.....53

Acetic Acid...........................85

Acetylcysteine......................90

Acid Gone............................ 60

Acitretin.................................57

Actemra................................ 77

ActHIB...................................78

Actical................................. 107

Actidose/Sorbitol................60

Actimmune...........................77

Acyclovir............................... 42

Acyclovir Sodium................42

Adacel................................... 78

Adagen..................................59

Adapalene............................57

Adcirca..................................90

Added Strength Headache

Relief...................................11

Adefovir Dipivoxil................ 41

Adempas.............................. 90

Adrucil...................................33

Adult Aspirin EC Low

Strength..............................11

Advair Diskus.......................91

Advair HFA........................... 91

Afinitor...................................36

Afinitor Disperz....................36

Aggrenox..............................49

Akwa Tears.......................... 82

Ala Cort................................. 67

Ala-Hist IR.............................85

Ala-Hist PE............................85

Alahist DM............................91

Alavert................................... 85

Alavert Allergy/Sinus......... 85

Alba-Lybe NR....................107

Albenza................................. 37

Albuterol Sulfate................. 89

Alclometasone Dipropionate

..............................................67

Alcohol Prep Pads............. 81

Aldurazyme.......................... 59

Alecensa...............................33

Alendronate Sodium..........80

Alfuzosin HCl ER................ 66

Alimta.....................................33

Alinia......................................38

All Day Allergy..................... 85

All Day Allergy Childrens.. 85

All Day Allergy-D................. 85

All Day Pain Relief.............. 11

All Day Relief........................11

All-Nite Multi-Symptom

Cold/Flu Relief..................91

Aller-Chlor.............................85

Allergy................................... 85

Allergy Relief........................85

Allergy Relief Child.............85

Allergy Relief D-24..............85

Allerhist-1..............................85

Allopurinol............................ 30

Almacone............................. 60

Almacone Double Strength

..............................................60

Alora...................................... 70

Alosetron HCl...................... 63

Aloxi....................................... 28

Alphagan P.......................... 83

Alprazolam........................... 45

Aluminum Hydroxide.........60

Amantadine HCl................. 38

AmBisome............................28

Amethia.................................70

Amethyst...............................70

Amifostine............................ 33

Amikacin Sulfate.................16

Amiloride HCl...................... 53

Amiloride/

Hydrochlorothiazide........51

Aminophylline......................90

Aminosyn 7%/Electrolytes

...........................................105

119

119

Aminosyn 8.5%/Electrolytes

...........................................105

Aminosyn II........................105

Aminosyn II 8.5%/

Electrolytes......................105

Aminosyn M...................... 105

Aminosyn-HBC................. 105

Aminosyn-PF.....................105

Aminosyn-RF.....................105

Amiodarone HCl.................50

Amitiza...................................63

Amitriptyline HCl.................27

Amlodipine Besylate..........51

Amlodipine Besylate/

Atorvastatin Calcium....... 51

Amlodipine Besylate/

Benazepril HCl..................51

Ammonium Lactate........... 57

Amoxapine...........................27

Amoxicillin............................ 20

Amoxicillin/Clavulanate

Potassium..........................20

Amoxicillin/Clavulanate

Potassium ER................... 20

Amphetamine/

Dextroamphetamine....... 55

Amphotericin B................... 29

Ampicillin..............................20

Ampicillin Sodium.............. 20

Ampicillin-Sulbactam.........20

Ampyra..................................56

Anadrol-50........................... 69

Anagrelide HCl....................48

Anastrozole.......................... 35

Ancobon...............................29

Androderm...........................69

AndroGel.............................. 69

AndroGel Pump..................69

Animal Shapes..................107

Animal Shapes + Iron......107

Antacid..................................60

Antacid Extra Strength...... 60

Antacid Maximum Strength

..............................................60

Antacid Plus Anti-Gas Relief

..............................................60

Antacid/Simethicone.........60

Antacid/Simethicone

Double Strength...............60

Anti-Diarrheal....................... 60

Anti-Fungal Powder............29

Anti-Itch................................. 57

Anti-Itch Maximum Strength

..............................................57

Anti-Nausea..........................27

Antifungal............................. 29

Anu-Med............................... 57

Anzemet................................28

AP-Hist DM...........................91

Apatate Forte.................... 107

Apetex.................................107

Apetigen.............................107

Apetigen-Plus....................107

Apokyn..................................39

Apraclonidine...................... 83

Apri.........................................70

Apriso.................................... 79

Aprodine...............................91

Aptiom...................................24

Aptivus.................................. 44

Aquabase............................. 57

AquADEKs.........................107

Aqueous Vitamin D Infants

...........................................107

Aqueous Vitamin E..........107

Aralast NP.............................91

Aranelle.................................70

Aranesp Albumin Free...... 48

Arcalyst................................. 77

Argatroban........................... 48

Aripiprazole..........................40

Aripiprazole ODT................ 40

Aristada.................................40

Arnuity Ellipta.......................88

Arranon................................. 34

Artificial Tears......................82

Ascorbic Acid....................107

Ashlyna................................. 70

Aspir-Low..............................11

Aspirin................................... 11

Aspirin Adult Low Strength

..............................................11

Aspirin EC............................ 11

Aspirin EC Low Dose.........11

Aspirin Low Dose............... 11

Aspirin/Dipyridamole.........49

Atenolol.................................50

Atenolol/Chlorthalidone....51

Atgam....................................77

Atorvastatin Calcium..........53

Atovaquone..........................38

Atovaquone/Proguanil HCl

..............................................38

Atripla.................................... 43

Atropine Sulfate.................. 60

Atrovent HFA....................... 89

Aubagio................................ 56

120

120

Aubra.....................................70

Augmented Betamethasone

Dipropionate..................... 67

Avandia................................. 45

Avastin...................................37

Avelox....................................21

Aviane....................................70

Avita....................................... 57

Avonex.................................. 56

Avonex Pen..........................56

Azacitidine............................34

Azactam in Iso-Osmotic

Dextrose.............................20

Azathioprine.........................75

Azelastine HCl.......83, 85, 86

Azilect....................................39

Azithromycin........................21

AZO Tabs............................. 66

Aztreonam............................20

B

B Complex.........................107

B Complex/Folic Acid.....107

B-6....................................... 107

B-Complex.........................107

B-Complex Formula 1.....107

B-Complex Plus Vitamin C

...........................................107

B-Complex with B-12...... 107

Baby Darlings Pediatric

Electrolyte.......................... 97

BACiiM..................................17

Bacitracin..............................17

Bacitracin Zinc.................... 17

Bacitracin/Neomycin/

Polymyxin...........................17

Bacitracin/Polymyxin B.....82

Baclofen................................97

Bactocill in Dextrose.......... 20

Bactroban Nasal................. 17

Balamine DM.......................91

Balance B-100..................107

Balance B-50.................... 107

Balanced B-100............... 107

Balanced B-50..................107

Balsalazide Disodium........ 79

Balziva................................... 70

Banophen.............................86

Banzel....................................24

Baraclude............................. 41

BCG Vaccine.......................78

Bee Zee..............................107

Bekyree.................................70

Beleodaq.............................. 34

Belsomra.............................. 97

Benazepril HCl.................... 49

Benazepril HCl/


Benicar..................................49

Benicar HCT........................ 51

Benlysta................................ 77

Benzonatate.........................91

Benzoyl Peroxide................57

Benztropine Mesylate........38

Bepreve.................................83

Berinert................................. 75

Beta Carotene...................107

Betamethasone

Dipropionate..................... 67

Betamethasone Valerate.. 67

Betaseron............................. 56

Betaxolol HCl.......................83

Bethanechol Chloride........66

Bethkis.................................. 16

Bexarotene...........................37

Bexsero.................................78

Bicalutamide........................32

Bicillin C-R............................20

Bicillin L-A.............................20

BiCNU................................... 32

Biltricide................................37

Binosto..................................80

Biocal.................................. 107

Biotin...................................107

Bisac-Evac............................63

Bisacodyl EC....................... 63

Biscolax.................................63

Bismatrol...............................61

Bismatrol Maximum

Strength..............................61

BIVIGAM...............................77

Bleomycin Sulfate...............34

Blephamide..........................82

Blephamide S.O.P..............82

Blisovi 24 Fe........................ 70

Blisovi Fe 1.5/30................ 70

Blisovi Fe 1/20....................70

Boostrix.................................78

Bosulif................................... 36

Botox..................................... 81

Breo Ellipta...........................91

Briellyn...................................70

Brilinta................................... 49

Brimonidine Tartrate..........83

BRIVIACT............................. 23

Bromfed DM........................ 91

Bromocriptine Mesylate....39

121

121

Bromphen/

Pseudoephedrine HCl/

Dextromethorphan HBr..91

Brotapp................................. 86

Brotapp DM......................... 91

Brovana.................................89

Budesonide.................. 79, 88

Bumetanide......................... 53

Buphenyl.............................. 59

Buprenorphine HCl............16

Buprenorphine HCl/

Naloxone HCl....................16

Bupropion HCl.................... 26

Bupropion HCl SR...... 16, 26

Bupropion HCl XL.............. 26

Buspirone HCl.....................45

Busulfex................................ 32

Butorphanol Tartrate......... 14

Bydureon Pen..................... 46

Bydureon Vial...................... 46

Byetta.................................... 46

Bystolic..................................50

C

C 1000/Bioflavonoids/

Rosehips......................... 107

C 250..................................107

C 500/Rose Hips.............107

C Complex.........................107

C-1000/Rose Hips.......... 107

C-500..................................107

Cabergoline......................... 75

Cabometyx...........................36

Cal-Gest Antacid.................61

Calcet Petites.......................97

Calci-Chew...........................98

Calcipotriene....................... 57

Calcitonin-Salmon.............. 80

Calcitrate...............................98

Calcitriol.........................57, 80

Calcium.................................98

Calcium & Magnesium... 107

Calcium 500/D................... 98

Calcium 600........................ 98

Calcium 600+D...................98

Calcium Acetate................. 66

Calcium Antacid................. 61

Calcium Antacid Extra

Strength..............................61

Calcium Carbonate.....61, 98

Calcium Carbonate/D3.....98

Calcium Citrate Malate/

Vitamin D........................... 98

Calcium Citrate+D..............98

Calcium Citrate/Vitamin D98

Calcium Gluconate............ 98

Calcium High Potency...... 98

Calcium High Potency +

Vitamin D........................... 98

Calcium Oyster Shell......... 98

Calcium+D3.........................98

Calcium/Magnesium/Zinc

..............................................98

Calcium/Vitamin D.............98

Caldyphen............................57

Caltrate 600+D3 Soft Chews

..............................................98

Calvite P&D.......................... 98

Camila................................... 73

Canasa.................................. 79

Cancidas...............................29

Candesartan Cilexetil.........49

Candesartan Cilexetil/


Capastat Sulfate..................31

Caprelsa................................36

Captopril............................... 49

Captopril/


Carac..................................... 57

Carafate................................ 65

Carbaglu...............................98

Carbamazepine...................24

Carbamazepine ER............25

Carbidopa/Levodopa........39

Carbidopa/Levodopa ER. 39

Carbidopa/Levodopa ODT

..............................................39

Carboplatin.......................... 34

Cardene IV........................... 51

Carimune Nanofiltered......77

Carmol 10............................ 57

Carmol 20............................ 57

Carteolol HCl....................... 83

Cartia XT...............................51

Carvedilol..............................50

Cayston.................................89

Caziant.................................. 70

Cefaclor.................................19

Cefadroxil............................. 19

Cefazolin Sodium............... 19

Cefdinir..................................19

Cefepime.............................. 19

Cefepime/Dextrose............19

Cefixime................................19

Cefotaxime Sodium........... 19

Cefotetan..............................19

122

122

Cefoxitin Sodium................ 19

Cefpodoxime Proxetil........19

Cefprozil................................19

Ceftazidime.......................... 19

Ceftazidime/Dextrose........19

Ceftriaxone Sodium........... 19

Cefuroxime Axetil............... 19

Cefuroxime Sodium...........19

Cellcept.................................75

Cellcept Intravenous..........75

Celontin.................................23

Cemill SR........................... 107

Centamin............................107

Centavite A-Z Complete

Multivitamin/Minerals... 108

Centrum............................. 108

Centrum Adults................ 108

Centrum Kids Complete.108

Centrum Silver.................. 108

Centrum Silver Ultra

Womens.......................... 108

Centrum Specialist Heart

...........................................108

Centrum Ultra Mens........ 108

Centrum Ultra Womens..108

Cephalexin........................... 19

Cerezyme............................. 59

Cerovite Advanced Formula

...........................................108

Cerovite Jr..........................108

Certavite/Antioxidants.... 108

Cervarix.................................78

Cesamet................................28

Cetirizine HCl.......................86

Cetirizine HCl/

Pseudoephedrine HCl ER

..............................................86

Chantix..................................16

Chantix Continuing Month

Pak...................................... 16

Chantix Starting Month Pak

..............................................16

Chemet................................. 97

Chenodal..............................61

Cheratussin AC...................91

Cheratussin DAC................91

Chest Congestion Relief...91

Chest Congestion Relief PE

..............................................91

Chewable Antacid..............61

Chewable Vite Childrens108

Chewable Vite with Iron/

Childrens......................... 108

Childrens Aspirin................ 11

Childrens Chewable

Vitamins...........................108

Childrens Chewable

Vitamins/Iron..................108

Childrens Loratadine......... 86

Childrens Mapap Rapid

Tabs.................................... 10

Childrens Pain Reliever.....10

Childrens Silapap............... 10

Childrens Silfedrine............91

Chlo Tuss............................. 91

Chlo Tuss EX....................... 91

Chloramphenicol Sodium

Succinate...........................17

Chlordiazepoxide HCl....... 45

Chlorhexidine Gluconate

Oral Rinse..........................57

Chloroquine Phosphate....38

Chlorothiazide..................... 53

Chlorothiazide Sodium......53

Chlorpheniramine Maleate

..............................................86

Chlorpromazine HCl.......... 39

Chlorthalidone.....................53

Cholbam............................... 61

Cholestyramine Light.........54

Chorionic Gonadotropin...69

Ciclopirox............................. 29

Ciclopirox Nail Lacquer.....29

Ciclopirox Olamine.............29

Cidofovir................................41

Cilostazol.............................. 49

Cimetidine............................ 63

Cimetidine HCl....................63

Cimzia....................................76

Cinryze.................................. 75

Ciprofloxacin........................21

Ciprofloxacin ER.................21

Ciprofloxacin HCl............... 21

Ciprofloxacin I.V. in D5W..21

Cisplatin................................ 34

Citalopram HBr................... 26

Citrus Calcium+D............... 98

Cladribine............................. 33

Claravis..................................57

Clarithromycin..................... 21

Clarithromycin ER.............. 21

Climara Pro.......................... 70

Clindamycin HCl.................17

Clindamycin Palmitate HCl

..............................................17

123

123

Clindamycin Phosphate...17,

57

Clindamycin Phosphate in

D5W.................................... 17

Clindamycin/Benzoyl

Peroxide.............................57

Clinisol SF 15%................ 105

Clobetasol Propionate.......67

Clobetasol Propionate E...67

Clolar..................................... 33

Clomipramine HCl..............27

Clonazepam.........................45

Clonazepam ODT...............45

Clonidine HCl...................... 49

Clonidine HCl ER................55

Clopidogrel.......................... 49

Clorazepate Dipotassium. 45

Clotrimazole.........................29

Clotrimazole/

Betamethasone

Dipropionate..................... 57

Clozapine..............................41

Clozapine ODT....................41

Coartem................................38

Coats Aloe Vera.................. 57

Coats Aloe Vera Juice Drink

..............................................61

Coats Aloe Vera Liniment.57

Coats Aloe Vera

Moisturizing Lotion..........57

Codeine Sulfate.................. 14

Codeine/Guaifenesin........ 91

Colace................................... 63

Colchicine............................ 30

Colcrys.................................. 30

Cold/Cough DM Childrens

..............................................91

Colestipol HCl..................... 54

Colistimethate Sodium......17

Colocort................................ 79

Combigan.............................83

Combivent Respimat.........96

Combivir............................... 43

Cometriq...............................36

Compete............................ 108

Complera..............................43

Complete........................... 108

Complete Allergy Medicine

..............................................86

Complex B-100................ 108

Compro.................................27

Congestion Relief...............11

Constulose........................... 63

Copaxone.............................56

Coral Calcium......................98

Cormax Scalp Application67

Cortisone Acetate...............67

Cosmegen............................34

Cotellic.................................. 36

Cough DM............................91

Cough Syrup....................... 91

Coumadin.............................47

Creon.....................................59

Crestor...................................53

Crinone................................. 73

Crixivan................................. 44

Cromolyn Sodium...... 61, 83,

89, 91

Cryselle-28........................... 70

Cubicin..................................17

Cuprimine.............................66

Cuvposa................................60

CVS B Complex Plus C.. 108

CVS B-12........................... 108

CVS B-6..............................109

CVS Balanced B-100......109

CVS Balanced B-50........ 109

CVS Beta Carotene......... 109

CVS Biotin..........................109

CVS Biotin High Potency

...........................................109

CVS Calcium....................... 98

CVS Calcium 600 + D/

Minerals..............................99

CVS Calcium 600+D......... 99

CVS Calcium Carbonate...99

CVS Calcium Chewables

600plus.............................. 99

CVS Calcium Citrate+D.....99

CVS Calcium Citrate+D/

Magnesium........................99

CVS Calcium Soft Chews

...........................................109

CVS Calcium/Magnesium/

Zinc..................................... 99

CVS Childrens Chewable

Complete.........................109

CVS Childrens Chewable

Multivitamin/Iron............109

CVS Daily Energy.............109

CVS Daily Multiple........... 109

CVS Daily Multiple for Men

...........................................109

CVS Daily Multiple for Men

50+................................... 109

CVS Daily Multiple for

Women............................ 109

124

124

CVS Daily Multiple for

Women 50+....................109

CVS Daily Multiple Plus Iron/

Calcium/Zinc..................109

CVS E Oil........................... 109

CVS Electrolyte Solution...99

CVS Gummy Dinos..........109

CVS Hair Skin & Nails/

Antioxidants....................109

CVS Iron................................99

CVS Laxative Dietary

Supplement.......................61

CVS Magnesium..........61, 99

CVS Oyster Shell Calcium

w/ Vitamin D..................... 99

CVS Pediatric Electrolyte..99

CVS Pediatric Electrolyte

Freezer Pops.....................99

CVS Slow Release Iron..... 99

CVS Spectravite Adult 50+

...........................................109

CVS Spectravite Advanced

Formula............................109

CVS Spectravite Senior.. 109

CVS Spectravite Ultra Health

Mens.................................109

CVS Spectravite Ultra Mens

Health...............................109

CVS Spectravite Ultra

Women............................ 109


Womens Health............. 109


Womens Health Senior109

CVS Stress Formula/Zinc

...........................................109

CVS Super B Complex/C

...........................................109

CVS Vitamin A.................. 109

CVS Vitamin B-12............ 109

CVS Vitamin B-12 TR......109

CVS Vitamin B-6...............109

CVS Vitamin C.................. 109

CVS Vitamin C/Rose Hips

...........................................109

CVS Vitamin E...................109

CVS Zinc...............................99

Cyclafem...............................70

Cyclobenzaprine HCl.........97

Cyclophosphamide............32

Cycloset................................ 46

Cyclosporine........................76

Cyclosporine Modified...... 76

Cyproheptadine HCl..........86

Cyramza................................37

Cystadane............................ 59

Cystagon...............................59

Cystaran................................82

Cytarabine Aqueous.......... 33

D

Dacarbazine.........................32

Dacogen............................... 34

Daily Multiple Vitamin/Iron

...........................................110

Daily Multiple Vitamins....110

Daily Vitamins....................110

Daily Vite............................ 110

Daily Vite with Iron........... 110

Daily-Vite/Iron/Beta-

Carotene..........................110

Daklinza................................ 41

Daliresp.................................90

Dallergy................................. 86

Dalvance...............................17

Danazol................................. 69

Dantrolene Sodium............97

Dapsone............................... 31

Daptacel................................78

DARAPRIM.......................... 38

Darzalex................................ 37

Daunorubicin HCl...............34

Day Time Multi-Symptom

Cold/Flu Relief..................91

Deblitane.............................. 73

Decitabine............................ 34

Deconex DMX..................... 91

Deconex IR.......................... 91

Deep Sea Nasal Spray...... 91

Delsym.................................. 91

Delsym Childrens Night

Time Cough/Cold............91

Delsym Cough + Chest

Congestion DM................ 91

Delsym Cough + Chest

Congestion DM Childrens

..............................................91

Delsym Cough + Cold

Daytime.............................. 91

Delsym Cough + Cold

Nighttime........................... 91

Delsym Cough + Cold

Nighttime Childrens........ 91

Delsym Night Time Cough/

Cold.....................................91

Delsym Night Time Cough/

Cold Childrens..................92

Delsym Night Time Multi-

Symptom............................92

Delyla.....................................70

Demeclocycline HCl.......... 22

125

125

Demser..................................52

Depen Titratabs.................. 66

Depo-Medrol........................67

Depo-Provera.......................73

Dermabase Oil in Water....57

Descovy................................ 43

Desipramine HCl................ 27

Desmopressin Acetate......69

Desogestrel/Ethinyl Estradiol

..............................................70

Desonide.............................. 67

Desoximetasone................. 67

Dexamethasone..................67

Dexamethasone Intensol..67

Dexamethasone Sodium

Phosphate.................. 67, 84

Dexedrine............................. 55

Dexmethylphenidate HCl..55

Dexmethylphenidate HCl ER

..............................................55

Dexrazoxane........................34

Dextroamphetamine Sulfate

..............................................55

Dextromethorphan Polistirex

..............................................92

Dextrose 10% Flex

Container.........................105


...........................................105


...........................................105

Dextrose 2.5%/NaCl 0.45%

...........................................105

Dextrose 5%......................105

Dextrose 5%/Lactated

Ringers.............................105

Dextrose 5%/NaCl 0.2% 105


...........................................105


...........................................105


...........................................105

Dextrose 5%/NaCl 0.9% 105

Dextrose 5%/Potassium

Chloride 0.15%..............105

Dialyvite 800......................110

Dialyvite 800/Zinc............110

Dialyvite 800/Zinc 15..... 110

Diastat AcuDial....................23

Diastat Pediatric..................23

Diazepam...................... 23, 45

Diazepam Intensol..............45

Dibenzyline...........................49

Dibucaine............................. 58

Diclofenac Potassium........11

Diclofenac Sodium.....12, 58,

84

Diclofenac Sodium DR......12

Diclofenac Sodium ER......12

Dicloxacillin Sodium.......... 20

Dicyclomine HCl................. 60

Didanosine........................... 43

Dificid.....................................21

Diflunisal............................... 12

Digitek................................... 52

Digoxin.................................. 52

Dihydroergotamine Mesylate

..............................................31

Dilantin.................................. 25

Dilantin INFATABS.............25

Dilt-XR....................................51

Diltiazem CD........................51

Diltiazem HCl.......................51

Diltiazem HCl ER................ 51

Dimaphen Childrens..........86

Dimaphen DM Cold/Cough

Childrens............................92

Dimenhydrinate...................27

Dino-Life............................. 110

Dino-Life w/Iron & Zinc...110

Dino-Life with Extra C......110

Diocto.................................... 61

Dipentum..............................79

Diphenhist............................ 86

Diphenhydramine HCl.......86

Diphenoxylate/Atropine....61

Diphtheria/Tetanus Toxoids

Adsorbed Pediatric..........78

Disulfiram..............................15

Diuril.......................................53

Divalproex Sodium.............23

Divalproex Sodium DR......23

Divalproex Sodium ER...... 23

Doc-Q-Lace.......................... 63

Doc-Q-Lax.............................63

Docefrez............................... 34

Docetaxel..............................34

Docu...................................... 61

Docusate Sodium...............63

Docusate Sodium & Senna

Stimulant Laxative/Stool

Softener..............................63

Docusol Kids....................... 61

Docusol Mini........................61

Docusol Plus Mini-Enema 63

Dofetilide...............................50

DOK....................................... 63

DOK PLUS........................... 63

126

126

Donepezil HCl..................... 25

Donepezil HCl ODT............25

Doribax..................................20

Dorzolamide HCl................ 83

Dorzolamide HCl/Timolol

Maleate...............................84

Doxazosin Mesylate........... 49

Doxepin HCl................. 27, 58

Doxercalciferol.................... 80

Doxil.......................................34

Doxorubicin HCl................. 34

Doxorubicin HCl Liposome

..............................................34

Doxy 100.............................. 22

Doxycycline..........................22

Doxycycline Hyclate...........22

Doxycycline Monohydrate22

Dr Smiths Diaper................ 58

Dr Smiths Diaper Rash

Spray...................................58

Dr Smiths Rash + Skin...... 58

Drisdol.................................110

Dronabinol............................28

Drospirenone/Ethinyl

Estradiol............................. 70

Droxia.................................... 33

Duavee.................................. 70

Duloxetine HCl.................... 56

Duofer....................................99

Duraflu...................................92

Duramorph...........................14

Durezol..................................84

E

E-400.................................. 110

E.E.S. 400.............................21

E.E.S. Granules................... 21

Ear Drops..............................85

Ecee Plus........................... 110

Econazole Nitrate............... 29

ED A-Hist....................... 86, 92

ED A-Hist DM.......................92

ED A-Hist PSE..................... 92

ED Bron GP......................... 92

ED Chlorped........................86

ED Chlorped D....................86

ED Chlorped Jr................... 86

ED Chlortan......................... 86

ED-APAP...............................10

Edurant................................. 43

Effervescent Pain Relief.... 12

Effient.................................... 49

Egrifta.................................... 75

Elaprase................................59

Elelyso................................... 59

Elestrin.................................. 70

Elidel......................................58

Eliphos.................................. 66

Eliquis....................................47

Elitek......................................33

ElixSure Fever/Pain............10

Elmiron..................................66

Embeda................................ 13

Emcyt.....................................33

Emend...................................28

Emoquette............................70

Empliciti................................ 37

Emsam.................................. 26

Emtriva.................................. 43

Enalapril Maleate................ 49

Enalapril Maleate/


Enbrel.................................... 76

Enbrel SureClick.................76

EndaCof-C............................92

EndaCof-DM........................ 92

Endocet.................................14

Enema Ready-To-Use........63

Enemeez Mini......................61

Enemeez Plus......................63

Enfamil Enfalyte.................. 99

Engerix-B.............................. 78

Enoxaparin Sodium........... 48

Enpresse-28.........................70

Entacapone..........................39

Entecavir...............................41

Enteric Coated Aspirin...... 12

Entocort EC..........................79

Entresto.................................52

Entsol Nasal Gel................. 92

Enulose................................. 63

Epaned..................................49

Epclusa................................. 41

Epinastine HCl.....................83

EpiPen...................................89

Epirubicin HCl..................... 34

Epitol......................................25

Epivir......................................43

Epivir HBV............................ 41

Eplerenone...........................53

Eprosartan Mesylate.......... 49

Epzicom................................43

EQL One Daily Essential 110

EQL Pediatric Electrolyte..99

Equetro................................. 45

Eraxis.....................................29

Erbitux................................... 37

127

127

Ergocalciferol....................110

Erivedge................................36

Errin....................................... 73

Erwinaze............................... 34

Ery.......................................... 58

Ery-Tab..................................21

EryPed 200..........................21

EryPed 400..........................21

Erythrocin Lactobionate....21

Erythromycin................ 21, 58

Erythromycin Base............. 21

Erythromycin Ethylsuccinate

..............................................21

Erythromycin/Benzoyl

Peroxide.............................58

Esbriet................................... 92

Escitalopram Oxalate.........26

Esomeprazole Magnesium

..............................................65

Esomeprazole Sodium......65

Estradiol................................71

Estradiol Valerate................71

Estring................................... 71

Ethambutol HCl...................31

Ethosuximide.......................23

Etidronate Disodium.......... 80

Etodolac................................12

Etopophos............................35

Etoposide............................. 36

Evotaz....................................42

Exefen-IR.............................. 92

Exelon....................................25

Exemestane......................... 35

Exjade....................................97

Extra Action Cough............92

Eye Drops.............................82

EZFE 200............................. 99

F

Fabrazyme............................59

Fallback Solo.......................73

Falmina................................. 71

Famciclovir...........................42

Famotidine........................... 63

Famotidine Premixed........ 63

Fanapt................................... 40

Fanapt Titration Pack........ 40

Fareston................................33

Farxiga...................................46

Farydak................................. 34

Faslodex............................... 33

Fattibase............................... 58

Fazaclo..................................41

Fe C.....................................110

Felbamate.............................24

Felbatol................................. 24

Fenofibrate........................... 53

Fenofibrate Micronized..... 53

Fenofibric Acid....................53

Fenofibric Acid DR.............53

Fentanyl................................ 13

Fer-In-Sol...............................99

Fer-Iron..................................99

Ferate.................................... 99

Fergon...................................99

Ferosul.................................. 99

Ferretts.................................. 99

Ferretts IPS...........................99

Ferrex 150............................99

Ferrimin 150........................ 99

Ferriprox................................97

Ferrous Drops......................99

Ferrous Fumarate 324...... 99

Ferrous Gluconate..............99

Ferrous Sulfate....................99

Ferrousul............................ 100

Fetzima..................................26

Fetzima Titration Pack.......26

Fexofenadine HCl...............86

Fiber Laxative...................... 63

Fiber Tabs............................ 63

Fiber-Lax............................... 63

Finasteride............................66

Firazyr....................................75

Firmagon.............................. 75

Flebogamma DIF................77

Flecainide Acetate..............50

Flector................................... 12

Fleet Pediatric......................63

Flovent Diskus.....................88

Flovent HFA......................... 88

Fluconazole..........................29

Fluconazole in Dextrose... 29

Fluconazole in NaCl...........29

Flucytosine........................... 29

Fludarabine Phosphate.....34

Fludrocortisone Acetate....67

Flunisolide............................ 88

Fluocinolone Acetonide...67,

85

Fluocinonide........................67

Fluocinonide-E.................... 67

Fluorometholone................ 84

Fluorouracil...................33, 58

Fluoxetine DR......................26

Fluoxetine HCl.....................26

128

128

Fluphenazine Decanoate..39

Fluphenazine HCl...............39

Flurbiprofen..........................12

Flurbiprofen Sodium..........84

Flutamide..............................32

Fluticasone Propionate.... 68,

88

Fluvastatin............................ 53

Fluvoxamine Maleate.........26

Folic Acid........................... 110

Folitab 500........................ 100

Folotyn...................................33

Foltabs 800....................... 110

Fomepizole.......................... 81

Fondaparinux Sodium.......48

Formula E 400..................110

Formula EM......................... 27

Fortaz.....................................19

Forteo.................................... 80

Fosfree................................110

Fosinopril Sodium.............. 50

Fosinopril Sodium/


Fosphenytoin Sodium....... 25

Fosrenol................................66

FreAmine HBC 6.9%.......105

Freshkote..............................82

Fruity C............................... 110

Fruity Chewables

Multivitamin.....................110

Full Spectrum B/Vitamin C

...........................................110

Fungoid Tincture................ 29

Furosemide..........................53

Fusilev................................... 34

Fuzeon.................................. 44

Fycompa...............................23

G

Gabapentin.......................... 23

Gabitril...................................24

Gablofen............................... 97

Gamastan S/D.....................77

Gammagard Liquid............77

Gammaked.......................... 77

Gammaplex......................... 77

Gamunex-C..........................77

Ganciclovir........................... 41

Gardasil.................................78

Gardasil 9............................. 78

Gas Relief............................. 61

Gas Relief Extra Strength. 61

Gas Relief Maximum

Strength..............................61

Gattex.................................... 61

Gauze.................................... 81

GaviLyte-C............................ 64

GaviLyte-G............................64

GaviLyte-H............................64

GaviLyte-N/Flavor Pack.... 64

Gemcitabine HCl................ 33

Gemfibrozil...........................53

Gemzar................................. 33

Generlac............................... 64

Gengraf................................. 76

Genotropin........................... 69

Genotropin Miniquick........69

Gentak...................................17

Gentamicin Sulfate.............17

Gentamicin Sulfate/0.9%

Sodium Chloride..............17

Gentle Laxative....................64

Genvoya................................42

Geodon.................................40

Gianvi.....................................71

Giazo..................................... 79

Gildagia.................................71

Gildess 1.5/30.................... 71

Gildess 24 Fe...................... 71

Gilenya.................................. 56

Gilotrif.................................... 36

Glassia...................................92

Glatopa................................. 56

Gleostine...............................32

Glimepiride...........................46

Glipizide................................ 46

Glipizide ER......................... 46

Glipizide/Metformin HCl... 46

GlucaGen HypoKit............. 47

Glucagon Emergency Kit. 47

Glutose 15............................47

Glycopyrrolate..................... 60

GNP 12 Hour Nasal Spray

..............................................92

GNP Adult Aspirin Low

Strength..............................12

GNP All Day Allergy........... 86

GNP Allergy......................... 86

GNP Animal Shapes....... 110

GNP Animal Shapes Plus

Extra C............................. 110

GNP Animal Shapes Plus

Iron....................................110

GNP Antacid Anti-Gas.......61

GNP Arthritis Pain Relief...10

GNP Aspirin......................... 12

GNP B-50 Balanced........110

GNP Calcium.................... 100

129

129

GNP Calcium 1200.........100

GNP Calcium 500+D3... 100

GNP Calcium 500/D.......100

GNP Calcium 600+D Plus

Minerals........................... 100

GNP Calcium 600/D.......100

GNP Calcium Citrate+D

Maximum........................ 100

GNP Calcium Citrate+D3

...........................................100

GNP Calcium/Magnesium/

Zinc...................................100

GNP Calcuim/Vitamin D/

Minerals........................... 100

GNP Century.....................111

GNP Century Adults 50+

Senior...............................111

GNP Century Cardio Health

Formula............................111

GNP Century Ultimate Mens

Complete.........................111

GNP Century Ultimate

Womens Complete.......111

GNP Century Ultimate

Womens Senior Formula

...........................................111

GNP Childrens Chewables/

Extra C............................. 111

GNP Childrens Chewables/

Iron....................................111

GNP Dayhist Allergy...........86

GNP Enema.........................64

GNP Essential One Daily111

GNP Hair/Skin/Nails.......111

GNP Ibuprofen....................12

GNP Ibuprofen Junior

Strength..............................12

GNP Iron............................ 100

GNP Little Ones Childrens

...........................................111

GNP Loratadine.................. 86

GNP Magnesium..............100

GNP Masanti Maximum

Strength..............................61

GNP Masanti Regular

Strength..............................61

GNP Mega Multi for Men

...........................................111

GNP Mega Multi for Women

...........................................111

GNP Milk of Magnesia...... 64

GNP Natural Fiber.............. 64

GNP Niacin TR................. 111

GNP Omeprazole............... 65

GNP One Daily Maximum

...........................................111

GNP One Daily Mens Health

50+................................... 111

GNP One Daily Plus Iron111

GNP One Daily Womens

Health 50+...................... 111

GNP Opti-Vitamins...........111

GNP Pain Relief.................. 10

GNP Pain Relief Extra

Strength..............................10

GNP Pediatric Electrolyte

...........................................100

GNP Therapeutic-M.........111

GNP Tussin..........................92

GNP Tussin DM.................. 92

GNP Vitamin A..................111

GNP Vitamin B-12........... 111

GNP Vitamin B-12 TR.....111

GNP Vitamin B-6..............111

GNP Vitamin C................. 111

GNP Vitamin C Drops.....111

GNP Vitamin C TR...........111

GNP Vitamin C w/Rose Hips

...........................................111

GNP Vitamin C w/Rose Hips

TR......................................111

GNP Vitamin E..................111

GNP Zinc........................... 100

GNP Zoo Chews Gummies

...........................................111

Goodsense Pain & Fever

Childrens............................10

Granisetron HCl.................. 28

Granix....................................48

Griseofulvin Microsize....... 29

Griseofulvin Ultramicrosize

..............................................29

Guaiatussin AC................... 92

Guaifenesin AC...................92

Guaifenesin ER................... 92

Guaifenesin/Codeine........ 92

Guanfacine ER....................55

Guanidine HCl.....................31

H

Halaven................................. 34

Halobetasol Propionate.... 68

Haloperidol...........................39

Haloperidol Decanoate..... 39

Haloperidol Lactate............39

Hard Nails.......................... 111

Harvoni..................................41

Havrix.....................................78

Hemocyte...........................100

Hemorrhoid..........................58

Heparin Sodium..................48

Heparin Sodium/D5W.......48

130

130

HepatAmine...................... 105

Hepsera................................ 41

Herceptin..............................37

Hetlioz................................... 97

Hexalen.................................32

Hiberix................................... 78

Histex.....................................86

Histex PD..............................86

Histex-DM............................. 92

Histex-PE.............................. 92

HM Pediatric Electrolyte.100

Honey Bears......................111

Honey Bears with Iron and

Zinc...................................111

Humalog Cartridge.............47

Humalog KwikPen............. 47

Humalog Mix 50/50

KwikPen.............................47

Humalog Mix 50/50 Vial.. 47

Humalog Mix 75/25

KwikPen.............................47

Humalog Mix 75/25 Vial.. 47

Humalog Vial....................... 47

Humatrope........................... 69

Humatrope Combo Pack. 69

Humira...................................76

Humira Pediatric Crohns

Disease Starter Pack.......76

Humira Pen..........................76

Humira Pen Crohns Disease

Starter Pack.......................76

Humira Pen-Psoriasis Starter

..............................................76

Humulin 70/30 KwikPen..47

Humulin 70/30 Vial............47

Humulin N KwikPen...........47

Humulin N Vial.................... 47

Humulin R U-500 KwikPen

..............................................47

Humulin R U-500 Vial........47

Humulin R Vial.....................47

Hycamtin...............................36

Hydralazine HCl.................. 54

Hydro Skin Maximum

Strength..............................68

Hydrochlorothiazide...........53

Hydrocodone Bitartrate/

Acetaminophen................14


Chlorpheniramine

Maleate/PSE.....................92


Homatropine

Methylbromide................. 92

Hydrocodone Polistirex/

Chlorpheniramine

Polistirex.............................93

Hydrocodone/


Hydrocodone/Ibuprofen...14

Hydrocortisone............ 68, 79

Hydrocortisone Butyrate...68

Hydrocortisone Valerate... 68

Hydrocortisone/Acetic Acid

..............................................85

Hydrocream Base Water in

Oil........................................ 58

Hydromet..............................93

Hydromorphone HCl......... 14

Hydromorphone HCl ER...13

Hydroxychloroquine Sulfate

..............................................38

Hydroxyprogesterone

Caproate............................ 73

Hydroxyurea.........................33

Hydroxyzine HCl................. 45

Hydroxyzine Pamoate....... 27

I

I-Caps Areds Formula..... 111

I-Caps MV.......................... 111

I-Caps Plus.........................111

I.L.X. B-12...........................100

Ibrance.................................. 34

Ibu-Drops..............................12

Ibu-Drops Infants................ 12

Ibu-Profen Cold/Sinus.......12

Ibuprofen.............................. 12

Ibuprofen Junior Strength 12

ICAR Pediatric.................. 100

ICAR-C................................112

Iclusig.................................... 36

Idarubicin HCl......................34

Iferex 150...........................100

Ifosfamide.............................32

Ilaris........................................78

Ilevro...................................... 84

Ilotycin................................... 21

Imatinib Mesylate................36

Imbruvica..............................36

Imipenem/Cilastatin...........20

Imipramine HCl................... 27

Imipramine Pamoate......... 27

Imiquimod............................ 58

Imovax Rabies.....................78

Increlex..................................69

Indapamide..........................53

Infanrix...................................78

Infants Gas Relief................61

Infants Ibuprofen.................12

131

131

Infants Silapap.....................10

Infants Simethicone........... 61

Inlyta.......................................36

Insulin Syringes, Needles. 81

Integra.................................112

Intelence............................... 43

Intralipid..............................105

Intron A................................. 41

Intron A w/Diluent.............. 41

Introvale................................ 71

Invanz.................................... 20

Invega....................................40

Invega Sustenna................. 40

Invega Trinza....................... 40

Invirase..................................44

Ionosol-B/Dextrose 5%...105

Ionosol-MB/Dextrose 5%

...........................................105

Iophen C-NR........................93

Iophen DM-NR.................... 93

Iophen-NR............................ 93

Iosat....................................... 81

IPOL Inactivated IPV.......... 78

Ipratropium Bromide......... 89

Ipratropium Bromide/

Albuterol Sulfate...............96

Irbesartan..............................49

Irbesartan/


Iressa..................................... 36

Irinotecan..............................34

Iron...................................... 100

Iron 100/C.........................112

Iron Supplement Childrens

...........................................100

Isentress................................42

Isolyte-P/Dextrose 5%.....105

Isolyte-S.............................. 100

Isoniazid................................31

Isopto Tears......................... 82

Isosorbide Dinitrate............ 55

Isosorbide Dinitrate ER..... 55

Isosorbide Mononitrate..... 55

Isosorbide Mononitrate ER

..............................................55

Isotonic Gentamicin...........17

Istodax...................................34

Itch-X......................................58

Itraconazole..........................29

Ivermectin.............................37

Ixempra Kit........................... 34

Ixiaro...................................... 78

J

J-Max..................................... 93

J-TAN D PD..........................87

J-TAN PD..............................87

Jadenu.................................. 97

Jakafi..................................... 36

Jantoven............................... 48

Jardiance..............................46

Jentadueto........................... 46

Jentadueto XR.....................46

Jevtana..................................34

Jinteli..................................... 71

Jolivette.................................73

Jublia..................................... 29

Juleber.................................. 71

Junel 1.5/30........................ 71

Junel 1/20............................71

Junel Fe 1.5/30.................. 71

Junel Fe 1/20......................71

Junel Fe 24.......................... 71

Junior Mapap...................... 10

Juxtapid................................ 54

K

K-Tab...................................101

Kadcyla................................. 37

Kaitlib Fe...............................71

Kaletra................................... 44

Kalydeco........................89, 93

Kanuma................................ 81

Kao-Tin...........................61, 64

Kariva.....................................71

KCl 0.075%/D5W/NaCl

0.45%...............................105

KCl 0.15%/D5W/LR....... 105

KCl 0.15%/D5W/NaCl 0.2%

...........................................105

KCl 0.15%/D5W/NaCl

0.225%............................ 105

KCl 0.15%/D5W/NaCl 0.9%

...........................................105

KCl 0.3%/D5W/NaCl 0.45%

...........................................105

KCl 0.3%/D5W/NaCl 0.9%

...........................................105

Kelnor 1/35......................... 71

Kenalog-10...........................68

Kenalog-40...........................68

Kepivance.............................57

Ketoconazole.......................29

Ketoprofen........................... 12

Ketorolac Tromethamine.12,

84

Keytruda............................... 37

Kidkare Cough/Cold......... 93

Kimidess............................... 71

132

132

Kineret...................................76

Kionex................................... 97

Klor-Con 10....................... 100

Klor-Con 8..........................100

Klor-Con M15................... 100

Klor-Con M20................... 100

Klor-Con Sprinkle.............100

Kombiglyze XR....................46

Konsyl....................................64

Korlym................................... 69

KP Adults 50+ Daily Formula

...........................................112

KP Adults Daily Formula.112

KP B Complex/C............. 112

KP Calcium/Magnesium/

Zinc...................................100

KP Ferrous Gluconate.... 101

KP Ferrous Sulfate...........101

KP Mens 50+ Daily Formula

...........................................112

KP Mens Daily Formula..112

KP Vitamin E..................... 112

KP Womens 50+ Daily

Formula............................112

KP Womens Daily Formula

...........................................112

Kuvan.................................... 59

Kynamro............................... 54

L

Labetalol HCl.......................50

Lacrisert................................ 82

Lactated Ringers Irrigation

...........................................105

Lactated Ringers Viaflex.106

Lactulose.............................. 64

Lamivudine................... 41, 43

Lamivudine/Zidovudine....43

Lamotrigine..........................24

Lanoxin................................. 52

Lantus SoloStar...................47

Lantus Vial............................47

LARIN 1.5/30......................71

LARIN 1/20......................... 71

LARIN Fe 1.5/30................ 71

LARIN Fe 1/20....................71

Larissia.................................. 71

Lastacaft............................... 82

Latanoprost..........................85

Latuda................................... 40

Laxative.................................64

Laxative with Senna........... 64

Layolis Fe..............................71

Leflunomide.........................78

Lenvima................................ 36

Lessina..................................71

Letairis...................................90

Letrozole...............................35

Leucovorin Calcium...........35

Leukeran...............................32

Leukine................................. 48

Leuprolide Acetate.............75

Levalbuterol......................... 89

Levemir FlexTouch.............47

Levemir Vial..........................47

Levetiracetam......................23

Levetiracetam ER............... 23

Levobunolol HCl.................84

Levocarnitine.....................106

Levocetirizine

Dihydrochloride................87

Levofloxacin.........................21

Levofloxacin in D5W..........22

Levoleucovorin Calcium... 35

Levonest............................... 71

Levonorgestrel and Ethinyl

Estradiol............................. 71

Levonorgestrel/Ethinyl

Estradiol............................. 71

Levora 0.15/30-28.............71

Levorphanol Tartrate......... 13

Levothyroxine Sodium.......74

Levoxyl.................................. 74

Lexiva.................................... 44

Lialda.....................................79

Lidocaine..............................15

Lidocaine HCl......................15

Lidocaine Viscous.............. 15

Lidocaine/Prilocaine..........15

Life Pack Mens.................112

Life Pack Womens.......... 112

Lincocin................................ 17

Lincomycin HCl...................17

Lindane.................................38

Linezolid............................... 17

Linzess.................................. 63

Lioresal Intrathecal.............97

Liothyronine Sodium......... 74

Liquibid................................. 93

Liquid Calcium/D3.......... 101

Liquid Calcium/Vitamin D

...........................................101

Lisinopril............................... 50

Lisinopril/


Lithium.................................. 45

Lithium Carbonate..............45

Lithium Carbonate ER.......45

133

133

Lithostat................................ 66

Lodrane D............................ 87

LoHist-D................................ 87

LoHist-DM.............................93

LoHist-PEB...........................87

LoHist-PEB-DM................... 93

Lomedia 24 Fe....................71

Lonsurf..................................33

Loperamide HCl................. 61

Loratadine............................ 87

Loratadine Allergy Relief...87

Loratadine Childrens......... 87

Loratadine Hives Relief..... 87

Loratadine-D 12 Hour........87

Loratadine-D 24 Hour........87

Lorazepam........................... 45

Lorazepam Intensol........... 45

Lorcet.................................... 14

Lorcet HD............................. 14

Lorcet Plus........................... 14

Lortab.................................... 14

Lortuss DM...........................93

Lortuss EX............................ 93

Lortuss LQ............................87

Loryna................................... 71

Losartan Potassium........... 49

Losartan Potassium/


Lotemax................................84

Lovastatin............................. 53

Low-Ogestrel....................... 71

Loxapine Succinate........... 39

Lubricating Plus Eye Drops

..............................................82

Lubrifresh P.M.....................82

Lumigan................................85

Lumizyme.............................59

Lupaneta Pack....................75

Lupron Depot...................... 75

Lupron Depot-PED.............75

Lutera.................................... 71

Lynparza............................... 35

Lyrica..................................... 56

Lysiplex Plus..................... 112

Lysodren...............................74

Lyza........................................73

M

M-END DMX.........................93

M-END Max D......................93

M-END WC...........................93

M-M-R II.................................79

Macuvite.............................112

Macuvite Eye Care...........112

Mag-Delay..........................101

Mag-SR Plus Calcium..... 101

Mag-Tab SR...................... 101

Magnesium................ 61, 101

Magnesium 27................. 101

Magnesium Elemental....101

Magnesium Oxide.............. 62

Magnesium Sulfate..........101

Major-Prep Hemorrhoidal.58

Makena................................. 73

Malathion..............................38

Mapap................................... 10

Mapap Acetaminophen

Extra Strength...................11

Mapap Arthritis Pain.......... 11

Mapap Childrens................ 11

Mapap Cold Formula Multi-

Symptom............................93

Mapap PM............................87

Mapap Sinus Maximum

Strength Congestion and

Pain..................................... 93

Maprotiline HCl................... 26

Marlissa.................................72

Marplan.................................26

Matulane...............................32

Meclizine HCl...................... 27

Medi-Bismuth...................... 62

Medi-Natural........................ 64

Medi-Phedryl........................87

Medi-Profen......................... 12

Medi-Sleep........................... 87

Medi-Tabs PM Extra

Strength..............................87

Medi-Tussin DM Diabetic. 93

Medicated Body Powder..58

Medroxyprogesterone

Acetate............................... 73

Mefloquine HCl................... 38

Mega Multiple with Chelated

Minerals........................... 112

Mega Multivitamin for Men

...........................................112

Mega Multivitamin for

Women............................ 112

Megace ES...........................74

Megace Oral........................ 74

Megestrol Acetate.............. 74

Mekinist.................................36

Meloxicam............................12

Melphalan HCl.....................32

Memantine HCl................... 25

134

134

Memantine HCl Titration Pak

..............................................25

Menactra...............................78

Menest.................................. 72

MENHIBRIX......................... 78

Menomune-A/C/Y/W-135

..............................................78

Mentax.................................. 29

Menveo................................. 79

Mephyton...........................112

Mepron..................................38

Mercaptopurine.................. 33

Meribin................................112

Meropenem......................... 20

Mesalamine..........................79

Mesna....................................35

Mesnex..................................35

Mestinon...............................31

Mestinon Timespan........... 31

Metaproterenol Sulfate......89

Metformin HCl.....................46

Metformin HCl ER.............. 46

Methadone HCl...................13

Methazolamide....................84

Methenamine Hippurate...17

Methimazole........................ 75

Methotrexate........................76

Methotrexate Sodium........76

Methoxsalen........................ 58

Methscopolamine Bromide

..............................................60

Methyclothiazide.................53

Methyldopa.......................... 49

Methyldopa/


Methyldopate HCl...............49

Methylergonovine Maleate

..............................................81

Methylphenidate HCl.........55

Methylphenidate HCl ER.. 55

Methylprednisolone........... 68

Methylprednisolone Acetate

..............................................68

Methylprednisolone Dose

Pack.................................... 68

Methylprednisolone Sodium

Succinate...........................68

Metipranolol.........................84

Metoclopramide HCl......... 28

Metolazone.......................... 53

Metoprolol Succinate ER..51

Metoprolol Tartrate.............51

Metoprolol/


Metronidazole......................18

Metronidazole in NaCl

0.79%................................. 18

Metronidazole Vaginal.......18

Mexiletine HCl..................... 50

MG-Plus Protein............... 112

Mi-Acid.................................. 62

Mi-Acid Gas Relief..............62

Mi-Acid Maximum Strength

..............................................62

Miacalcin.............................. 80

Miconazole 3....................... 29

Miconazole 7....................... 29

Miconazole Nitrate............. 29

Microgestin 1.5/30............ 72

Microgestin 1/20................72

Microgestin Fe.....................72

Microgestin Fe 1.5/30.......72

Midodrine HCl..................... 49

Migergot............................... 31

Migraine Formula............... 12

Milk of Magnesia................ 64

Milk of Magnesia

Concentrate...................... 62

Millipred................................ 68

Mineral Oil............................ 64

Minitran................................. 55

Minocycline HCl..................23

Minoxidil................................54

Mintox Maximum Strength

..............................................62

Mirtazapine...........................26

Mirtazapine ODT.................26

Mirvaso..................................58

Misoprostol.......................... 65

Mitomycin.............................35

Mitoxantrone HCl................35

Mobisyl..................................13

Modafinil............................... 97

Moexipril HCl....................... 50

Moexipril/


Molindone HCl.................... 39

Mometasone Furoate. 68, 88

Monocal............................. 101

MonoNessa..........................72

Montelukast Sodium..........89

Morphine Sulfate......... 14, 15

Morphine Sulfate ER..........14

Moxeza..................................22

Moxifloxacin HCl.................22

Mozobil................................. 48

Mucaphed............................93

135

135

Mucinex................................ 93

Mucinex Chest Congestion

Childrens............................93

Mucinex Childrens Cold

Cough & Sore Throat......93

Mucinex Childrens Multi-

Symptom Cold..................93

Mucinex Childrens Multi-

Symptom Cold & Fever.. 93

Mucinex Cold for Kids.......93

Mucinex Congestion &

Cough Childrens..............93

Mucinex Cough Childrens

..............................................93

Mucinex Cough for Kids...93

Mucinex D............................ 93

Mucinex D Maximum

Strength..............................93

Mucinex DM.........................93

Mucinex DM Maximum

Strength..............................93

Mucinex Fast-Max Cold &

Sinus................................... 93

Mucinex Fast-Max Cold Flu

& Sore Throat....................94

Mucinex Fast-Max Day

Time/Night Time..............94

Mucinex Fast-Max DM Max

..............................................94

Mucinex Fast-Max Night

Time Cold & Flu................94

Mucinex Fast-Max Severe

Cold.....................................94

Mucinex Fast-Max Severe

Congestion & Cough...... 94

Mucinex for Kids.................94

Mucinex Multi-Symptom

Cold Night Time Childrens

..............................................94

Mucinex Nasal Spray Full

Force...................................94

Mucinex Stuffy Nose & Cold

Childrens............................94

Mucus ER.............................94

Mucus Relief........................94

Mucus Relief Sinus............ 94

Multaq................................... 50

Multi-Day Vitamins........... 112

Multi-Delyn......................... 112

Multi-Delyn/Iron................ 112

Multi-Vitamin......................113

Multi-Vitamin HP/Minerals

...........................................113

Multi-Vitamin/Minerals.... 113

Multi-Vitamins....................113

Multilex............................... 112

Multilex T&M..................... 112

Multiple Vitamins..............112

Multiple Vitamins Plain... 112

Multiple Vitamins/Iron.....112

Mupirocin............................. 18

Muro 128..............................82

Mustargen............................ 32

My Way................................. 74

My-Vitalife...........................113

Myalept................................. 81

Mycamine.............................29

Mycophenolate Mofetil......76

Mycophenolic Acid DR..... 76

Myferon 150......................101

Myrbetriq.............................. 66

MYTAB GAS........................62

MYTAB GAS Maximum

Strength..............................62

N

Nadolol..................................51

Nafcillin in Dextrose........... 20

Nafcillin Sodium..................20

Naglazyme........................... 59

Nalbuphine HCl.................. 15

Naloxone HCl...................... 16

Naltrexone HCl....................15

Namenda..............................25

Namenda XR....................... 25

Namenda XR Titration Pack

..............................................25

Namzaric...............................55

Naproxen..............................13

Naproxen DR.......................13

Naproxen Sodium.............. 13

Naratriptan HCl................... 31

Narcan...................................16

Nasal Decongestant.......... 94

Nasal Decongestant PE....94

Nasal Decongestant Spray

..............................................94

Nasal Spray X-Moist...........94

Nasonex................................88

Nasopen PE.........................87

Natacyn.................................29

Nateglinide...........................46

Natpara................................. 80

Natural Balance Tears.......82

Natural Fiber Therapy........64

Natures Tears...................... 82

Nebupent..............................38

Necon 0.5/35-28................72

Necon 1/35......................... 72

Necon 1/50-28................... 72

136

136

Necon 10/11-28.................72

Necon 7/7/7........................72

Nefazodone HCl................. 26

Neomycin Sulfate............... 17

Neomycin/Bacitracin/

Polymyxin...........................82

Neomycin/Polymyxin B

Sulfates...............................18

Neomycin/Polymyxin/

Bacitracin/Hydrocortisone

..............................................82

Neomycin/Polymyxin/

Dexamethasone............... 82

Neomycin/Polymyxin/

Gramicidin......................... 82

Neomycin/Polymyxin/

Hydrocortisone..........83, 85

Nephramine.......................106

Nephro-Vite........................113

Nephronex.........................113

Nesina................................... 46

Neulasta................................48

Neupogen............................ 48

Nevanac................................84

Nevirapine............................ 43

Nevirapine ER......................43

Nexavar.................................36

Nexium..................................65

Next Choice One Dose..... 74

Niacin...........................54, 113

Niacin ER....................54, 113

Niacin SR........................... 113

Niacin TR........................... 113

Niacor....................................54

Nicardipine HCl...................51

NicoDerm CQ......................16

NICOrelief.............................16

Nicorette............................... 16

Nicorette Mini...................... 16

Nicorette Starter Kit............16

Nicotine Polacrilex..............16

Nicotine Transdermal

System................................16

Nicotrol Inhaler....................16

Night Time Multi-Symptom

Cold/Flu Relief..................94

Night Time Sleep Aid.........87

Nikki.......................................72

Nilandron..............................32

Nilutamide............................ 33

Nimodipine...........................51

NinjaCof................................94

NinjaCof-A............................ 94

NinjaCof-XG......................... 94

Ninlaro...................................35

Nipent....................................33

Nitro-Bid................................55

Nitrofurantoin.......................18

Nitrofurantoin Macrocrystals

..............................................18

Nitrofurantoin Monohydrate

100mg Capsule............... 18

Nitroglycerin.........................55

Nitroglycerin Lingual..........55

Nitroglycerin Transdermal55

Nitrostat.................................55

No Iron Multiple Vitamin/

Minerals........................... 113

NoHist-DM............................94

NoHist-LQ.............................87

Nora-BE.................................74

Norditropin FlexPro............69

Norel AD............................... 94

Norel CS............................... 94

Norethindrone..................... 74

Norethindrone & Ethinyl

Estradiol Ferrous Fumarate

..............................................72

Norethindrone Acetate......74

Norethindrone Acetate/

Ethinyl Estradiol/Ferrous

Fumarate............................72

Norgestimate/Ethinyl

Estradiol............................. 72

Norlyroc................................ 74

Normosol-M in D5W........106

Normosol-R....................... 101

Normosol-R in D5W........ 106

Nortemp................................11

Nortemp Infants.................. 11

Northera................................52

Nortrel 0.5/35......................72

Nortrel 1/35......................... 72

Nortrel 7/7/7....................... 72

Nortriptyline HCl..................27

Norvir..................................... 44

NovaFerrum 125..............101

NovaFerrum 50................ 101

NovaFerrum Pediatric Drops

...........................................101

Novarel..................................69

Noxafil................................... 29

NRS Nasal Relief................ 94

Nu-Iron 150....................... 101

Nucynta ER..........................14

Nuedexta.............................. 55

Nulojix....................................76

Nuplazid................................40

137

137

NutreStore......................... 106

Nutrilipid.............................106

Nutropin AQ.........................69

NuvaRing..............................72

Nyamyc................................. 29

Nystatin................................. 30

Nystop................................... 30

O

Ocaliva.................................. 62

Ocella.................................... 72

Octagam...............................77

Octreotide Acetate............. 75

Odefsey.................................43

Odomzo................................36

Ofev........................................94

Ofloxacin...............................22

Ogestrel................................ 72

Olanzapine........................... 40

Olanzapine ODT................. 40

Olopatadine HCl................. 83

Olysio.....................................42

Omega-3-Acid Ethyl Esters

..............................................54

Omeprazole......................... 65

Omnitrope............................ 69

Oncaspar..............................35

Once Daily......................... 113

Once Daily/Iron................ 113

Oncovite............................. 113

Ondansetron HCl................28

Ondansetron ODT..............28

One Daily............................113

One Daily Mens................ 113

One Daily Plus Iron.......... 113

One Daily Plus Minerals. 113

One-Daily Multi Vitamins 113

One-Way Valved Expiratory

Mouthpiece/Disposable.81

One-Way Valved Inspiratory

Mouthpiece/Disposable.81

Onfi........................................ 24

Onglyza.................................46

ONMEL................................. 30

Opdivo...................................37

Opsumit................................ 90

Opti-Clear..............................83

Oralyte................................ 101

Oralyte Freezer Pops.......101

Orap.......................................39

Orazinc............................... 101

Orencia..................................76

Orencia Clickject................ 76

Orenitram..............................90

Orfadin.................................. 59

Organ-I NR........................... 94

Orkambi................................89

Orphenadrine Citrate.........97

Orsythia.................................72

OS-CAL...............................101

OS-CAL Calcium+D3...... 101

OS-CAL Extra D3............. 101

Osteo-Poretical................. 101

Otezla.................................... 78

Oxacillin Sodium.................20

Oxaliplatin.............................35

Oxandrolone........................69

Oxcarbazepine....................25

Oxsoralen Ultra................... 58

Oxybutynin Chloride.......... 66

Oxybutynin Chloride ER... 66

Oxycodone HCl...................15

Oxycodone/Acetaminophen

..............................................15

Oxycodone/Aspirin............15

Oxycodone/Ibuprofen.......15

Oysco 500......................... 101

Oysco 500+D....................101

Oysco D..............................101

Oyst-Cal-D 500................. 101

Oyster Calcium................. 101

Oyster Shell Calcium.......101

Oyster Shell Calcium +

Vitamin D.........................102

Oyster Shell Calcium 500+D

...........................................102

Oyster Shell Calcium Plus

Vitamin D.........................102

Oyster Shell Calcium+D. 102

Oyster Shell Calcium+D3

...........................................102

Oyster Shell Calcium/D..102

Oyster Shell/Vitamin D... 102

P

PA B-Complex with B-12

...........................................113

PA Biotin............................ 113

PA Oyster Shell Calcium 102

PA Vitamin B-12 TR........ 113

PA Vitamin E..................... 113

Pacerone.............................. 50

Paclitaxel...............................35

Pain & Fever.........................11

Pain & Fever Childrens......11

Pain & Fever Extra Strength

..............................................11

Pain Relief Childrens......... 11

138

138

Pain Relief Extra Strength.11

Pain Relief Sinus PE

Daytime.............................. 94

Pain Reliever PM Extra

Strength..............................87

Paliperidone ER..................40

Pamidronate Disodium..... 80

Panda Mask Large.............81

Panda Mask Medium........ 81

Panda Mask Small............. 81

Panretin.................................37

Pantoprazole Sodium........65

Pantothenic Acid................ 81

Paricalcitol.....................80, 81

Paromomycin Sulfate........ 17

Paroxetine HCl.................... 27

Paser......................................31

Pataday................................. 83

Patanol.................................. 83

Paxil....................................... 27

Pazeo.....................................83

Pedialyte.............................102

Pedialyte Advanced Care

...........................................102

Pedialyte Freezer Pops...102

Pedialyte Singles..............102

Pediatric Cough/Cold....... 95

Pediatric Electrolyte.........102

Pediatric Electrolyte Freeze

Pops................................. 102

Pediatric Electrolyte Freezer

Pops................................. 102

Pediatric Electrolyte/Zinc

...........................................102

Pediatric Medium Mask....81

Pediatric Mouthpiece/

Disposable.........................81

Pediatric Panda Mask....... 81

Pediatric Small Mask......... 81

Pediavit...............................113

Pedvax HIB.......................... 79

PEG-3350/Electrolytes..... 64

PEG-3350/NaCl/Na

Bicarbonate/KCl.............. 64

Peganone.............................25

Pegasys.................................42

Pegasys ProClick................42

PegIntron..............................42

PegIntron REDIPEN...........42

Penicillin G Potassium.......20

Penicillin G Procaine......... 21

Penicillin G Sodium............21

Penicillin V Potassium....... 21

Pentam 300.........................38

Pentoxifylline ER.................52

Perforomist...........................89

Perindopril Erbumine.........50

Periogard..............................57

Perjeta................................... 37

Permethrin............................38

Perphenazine...................... 28

Phenadoz............................. 87

Phenelzine Sulfate..............26

Phenergan............................87

Phenobarbital...................... 24

Phenoxybenzamine HCl... 49

Phenylephrine HCl/

Pyrilamine Maleate.......... 95

Phenylhistine DH................ 95

Phenytek...............................25

Phenytoin............................. 25

Phenytoin Sodium..............25

Phenytoin Sodium Extended

..............................................25

PhosLo..................................67

Phoslyra................................ 67

Phospholine Iodide............84

Physiolyte...........................102

Physiosol Irrigation.......... 102

PIC 200.............................. 102

Picato.................................... 58

Pilocarpine HCl............57, 84

Pimozide...............................39

Pimtrea..................................72

Pindolol.................................51

Pink Bismuth....................... 62

Pioglitazone HCl................. 46

Pioglitazone HCl/

Glimepiride........................46

Pioglitazone HCl/Metformin

HCl...................................... 46

Piperacillin/Tazobactam...21

Pirmella 1/35.......................72

Plasma-Lyte A................... 102

Plasma-Lyte-148.............. 102

Plasma-Lyte-56/D5W......106

Plenamine..........................106

Podofilox...............................58

Poly Vitamin.......................113

Poly-Hist DM........................ 95

Poly-Hist PD......................... 87

Poly-Iron 150.....................102

Poly-Vent DM.......................95

Poly-Vent IR..........................95

Poly-Vi-Sol.......................... 113

139

139

Poly-Vi-Sol/Iron................. 113

Poly-Vita Drops................. 113

Poly-Vita/Iron Drops........ 113

Polybase............................... 58

Polyethylene Glycol 3350

Powder............................... 64

Polymyxin B Sulfate........... 18

Polymyxin B Sulfate/

Trimethoprim Sulfate...... 83

Polyvitamin........................ 113

Polyvitamin/Iron............... 113

Pomalyst............................... 33

Portia-28............................... 72

Potassium Chloride......... 102

Potassium Chloride 0.15% /

NaCl 0.45% Viaflex....... 102

Potassium Chloride 0.15%

D5W/NaCl 0.33%......... 106


D5W/NaCl 0.45%......... 106

Potassium Chloride 0.15%/

NaCl 0.9%....................... 103


D5W/NaCl 0.45%......... 106


NaCl 0.9%....................... 103


D5W..................................106

Potassium Chloride ER.. 103

Potassium Citrate ER...... 103

Potiga.................................... 23

Povidone-Iodine..................18

Pradaxa.................................48

Praluent.................................54

Pramipexole

Dihydrochloride................39

Pravastatin Sodium............ 54

Prazosin HCl........................49

Prednicarbate......................68

Prednisolone Acetate........ 84

Prednisolone Sodium

Phosphate.................. 68, 85

Prednisone...........................68

Prednisone Intensol........... 68

Pregnyl w/Diluent Benzyl

Alcohol/NaCl.................... 69

Premarin............................... 72

Premasol............................ 106

Premphase...........................72

Prempro................................73

Prevalite................................ 54

Prevent............................... 113

Previfem................................73

Prezcobix..............................42

Prezista..................................44

Priftin......................................32

Prilosec OTC....................... 65

Primaquine Phosphate..... 38

Primidone.............................24

Pristiq.....................................27

Privigen................................. 77

Pro-Chlo................................95

Pro-Clear AC........................95

ProAir HFA........................... 89

ProAir RespiClick............... 89

Probenecid...........................30

Probenecid/Colchicine.....30

Procainamide HCl.............. 50

Procalamine...................... 106

Prochlorperazine................ 28

Prochlorperazine Edisylate

..............................................28

Prochlorperazine Maleate 28

Procrit....................................48

Procto-Med HC................... 80

Procto-Pak............................80

Proctosol HC....................... 80

Proctozone-HC....................80

Procysbi................................ 59

ProFe...................................103

Proferrin ES....................... 103

Proglycem............................ 47

Prograf.................................. 76

Prolastin-C............................95

Prolensa................................85

Proleukin.............................. 35

Prolia......................................81

Promacta.............................. 48

Promethazine HCl.............. 87

Promethazine VC/Codeine

..............................................95

Promethazine-DM...............95

Promethazine/Codeine.....95

Promethazine/

Dextromethorphan.......... 95

Promethegan.......................87

Propafenone HCl................50

Propafenone HCl ER......... 50

Proparacaine HCl............... 83

Propranolol HCl.................. 51

Propranolol HCl ER............51

Propranolol/


Propylene Glycol.................81

Propylthiouracil................... 75

ProQuad............................... 79

ProSight..............................113

140

140

Prosol..................................106

Protexin.............................. 114

Protriptyline HCl..................27

PRUDOXIN...........................58

Pseudoephedrine HCl.......95

Pulmicort.............................. 88

Pulmozyme.......................... 95

Puralube............................... 83

Purixan.................................. 33

Pyrazinamide.......................32

Pyri 500..............................114

Pyridostigmine Bromide... 31

Pyridoxine HCl..................114

Q

Q-Dryl.....................................87

Q-PAP....................................11

Q-PAP Childrens.................11

Q-PAP Extra Strength........ 11

Q-PAP Infants...................... 11

Q-Tussin................................95

Q-Tussin DM........................95

QC Anti-Diarrheal................62

QC Anti-Itch Extra Strength

..............................................58

QC Arthritis Pain Relief......11

QC Aspirin............................13

QC Aspirin Low Dose........13

QC Calcium Fast Dissolution

...........................................103

QC Calcium/Minerals/

Vitamin D.........................103

QC Childrens Chewable

Vitamins/Extra C............114

QC Childrens Chewable

Vitamins/Iron..................114

QC Cough/Sore Throat

Nighttime........................... 95

QC Daily Multivitamins/Iron

...........................................114

QC Daytime Multi-Symptom

Cold/Flu............................. 95

QC Ferrous Sulfate.......... 103

QC Gentle Laxative............ 64

QC Headache Relief..........13

QC Ibuprofen.......................13

QC Loratadine Allergy Relief

..............................................87

QC Loratadine-D.................87

QC Maximum Daily

Multivitamin/Multimineral

...........................................114

QC Milk of Magnesia......... 64

QC Multi-Vite..................... 114

QC Naproxen Sodium.......13

QC Nighttime Cough.........95

QC Non-Aspirin Extra

Strength..............................11

QC Non-Aspirin PM............87

QC Povidone Iodine...........18

QC Stool Softener Plus

Laxative.............................. 64

QC Suphedrine PE.............95

QC Tolnaftate...................... 30

QC Womens Daily

Multivitamin.....................114

Quadracel.............................79

Quasense............................. 73

Quetiapine Fumarate.........40

Quinapril HCl....................... 50

Quinapril/


Quinidine Gluconate..........50

Quinidine Gluconate CR...50

Quinidine Sulfate................ 50

Quinine Sulfate....................38

R

RA B-Complex.................. 114

RA B-Complex with B-12

...........................................114

RA B-Complex/Vitamin C

TR......................................114

RA Balanced B-100........ 114

RA Balanced B-50...........114

RA Beta Carotene............114

RA Biotin............................ 114

RA Calcium 600...............103

RA Calcium 600 Plus

Vitamin D-3..................... 103

RA Calcium 600/Vitamin D/

Minerals........................... 103

RA Calcium Citrate Plus

Vitamin D-3..................... 103

RA Calcium Soft Chews.114

RA Calcium/Boron.......... 103

RA Calcium/Magnesium/

Zinc/Copper...................103

RA Central-Vite................. 114

RA Central-Vite Energy... 114

RA Central-Vite Performance

...........................................114

RA Central-Vite Select

Mature..............................114

RA Central-Vite Senior.... 114

RA Central-Vite Under 50

Mens.................................114

RA Central-Vite Under 50

Womens.......................... 114

RA Central-Vite Womens

Mature..............................114

141

141

RA Central-Vite/Antioxidants

...........................................114

RA Coral Calcium............ 103

RA Hi Cal........................... 103

RA Hi-Cal Plus Vitamin D

...........................................103

RA High Potency Iron..... 103

RA Iron................................103

RA Magnesium................... 62

RA Natural Magnesium.. 103

RA Natural Vitamin E.......114

RA Niacin..............................54

RA One Daily Energy

Formula............................114

RA One Daily Essential...114

RA One Daily Maximum. 115

RA One Daily Mens 50+

with Vitamin D-3.............115

RA One Daily Multi-Vitamin

...........................................115

RA One Daily Multi-Vitamin

Plus Iron...........................115

RA Oyster Shell Calcium/

Vitamin D.........................103

RA Pediatric Electrolyte..103

RA Pediatric Electrolyte

Freezer Pops.................. 103

RA Slow Release Iron..... 103

RA Stress Formula

Advanced........................ 115

RA Stress Formula Energy

...........................................115

RA Therapeutic M Plus Beta

Carotene..........................115

RA Vitamin A.....................115

RA Vitamin B-1................. 115

RA Vitamin B-12...............115

RA Vitamin B-12 TR........ 115

RA Vitamin B-6................. 115

RA Vitamin B12................115

RA Vitamin C.....................115

RA Vitamin C Drops........ 115

RA Vitamin C TR.............. 115

RA Vitamin C/Acerola.....115

RA Vitamin C/Rose Hips115

RA Vitamin C/Rose Hips TR

...........................................115

RA Vitamin E..................... 115

RA Zinc...............................103

Rabavert............................... 79

Raloxifene HCl.................... 74

Ramipril.................................50

Ranexa.................................. 52

Ranitidine 75....................... 63

Ranitidine HCl..................... 63

Rapaflo..................................66

Rapamune............................76

RAVICTI................................ 59

Rebif...................................... 56

Rebif Rebidose................... 56

Rebif Rebidose Titration

Pack.................................... 56

Rebif Titration Pack........... 56

Reclipsen..............................73

Recombivax HB..................79

Refresh Celluvisc................83

Refresh Lacri-Lube.............83

Refresh Plus.........................83

Regranex.............................. 58

Reguloid............................... 64

Relenza Diskhaler...............44

Relistor.................................. 62

Remicade............................. 77

Remodulin............................90

Rena-Vite............................115

Renagel.................................67

Renvela................................. 67

Repaglinide..........................46

Repaglinide/Metformin HCl

..............................................46

Repatha................................ 54

Repatha Pushtronex System

..............................................54

Repatha SureClick............. 54

Rescon..................................87

Rescon DM.......................... 95

Rescon-GG.......................... 95

Rescriptor.............................43

Respaire-30..........................95

Restasis.................................83

Restfully Sleep.....................87

Retrovir IV Infusion............. 43

Revatio.................................. 90

Revlimid................................ 33

Rexulti....................................40

Reyataz................................. 44

Rezira.................................... 95

Ribasphere...........................42

Ribavirin................................42

Ridaura..................................78

Rifabutin............................... 31

Rifampin............................... 32

Rifater.................................... 32

Rilutek................................... 55

Riluzole................................. 56

Rimantadine HCl................ 45

Ringers Injection.............. 106

142

142

Ringers Irrigation..............106

Riomet...................................46

Risacal-D............................ 103

Risperdal Consta................ 40

Risperidone..........................40

Risperidone ODT................40

Rituxan.................................. 37

Rivastigmine Tartrate.........25

Rivastigmine Transdermal

System................................25

Rizatriptan Benzoate..........31

Rizatriptan Benzoate ODT31

Robafen................................ 95

Robafen CF Cough & Cold

..............................................95

Robafen DM........................ 95

Robafen DM Cough Clear95

Rocaltrol................................81

Ropinirole HCl.....................39

Rosuvastatin Calcium........54

Rotarix................................... 79

RotaTeq................................ 79

Roweepra.............................23

Rozerem............................... 97

Ru-Hist D...............................88

Ruconest.............................. 75

Rulox..................................... 62

Rymed...................................88

Rynex DM.............................95

Rynex PE.............................. 88

Rynex PSE........................... 88

S

S2........................................... 89

Sabril......................................24

Saizen....................................69

Samsca................................. 97

Sancuso................................28

Sandimmune....................... 77

Sandostatin LAR Depot.... 75

Sani-Supp Adult..................64

Sani-Supp Pediatric........... 64

Santyl.....................................58

Saphris.................................. 41

Sarna..................................... 58

Savella................................... 56

Savella Titration Pack........ 56

SB Pediatric Electrolyte.. 103

Selegiline HCl......................39

Selenium............................ 103

Selenium Sulfide.................59

Selzentry............................... 44

Senexon................................65

Senna.................................... 65

Senna Lax............................ 65

Senna Plus........................... 65

Sennalax-S........................... 65

Sennosides/Docusate

Sodium...............................65

Sensipar................................75

Sentry..................................115

Sentry Senior.....................115

Serevent Diskus.................. 89

Seroquel XR.........................41

Serostim................................62

Sertraline HCl...................... 27

Setlakin................................. 73

sfRowasa..............................79

Sharobel............................... 74

Sidestream Pediatric Face

Mask................................... 81

Sidestream Pediatric Face

Mask/Tucker the Turtle..81

Signifor..................................75

Silace.....................................62

Siladryl Allergy.....................88

Sildenafil............................... 90

Silicone Mask for

BreatheRite Chamber/

Pediatric............................. 81

Silphen DM Cough.............95

Siltussin DAS....................... 95

Siltussin DM DAS................95

Siltussin SA.......................... 95

Siltussin-DM......................... 95

Silver Sulfadiazine.............. 22

Simethicone.........................62

Simponi.................................77

Simponi Aria........................ 77

Simulect................................78

Simvastatin...........................54

Sirolimus...............................77

Sirturo....................................32

Slo-Niacin...........................115

Slow-Mag........................... 103

SM Allergy 4 Hour..............88

SM Allergy Relief................ 88

SM Antacid Anti-Gas..........62

SM Antacid Anti-Gas Extra

Strength..............................62

SM Anti-Diarrheal................62

SM Aspirin............................13

SM Aspirin EC Low Strength

..............................................13

SM Balanced B-50.......... 115

SM Calcium 500/Vitamin

D3..................................... 103

143

143

SM Calcium 600/Vitamin D

...........................................104

SM Calcium Antacid Extra

Strength..............................62

SM Calcium Citrate with

Vitamin D3...................... 104

SM Calcium Soft Chews 115

SM Calcium/Magnesium/

Zinc...................................104

SM Calcium/Vitamin D... 104

SM Chewable C............... 115

SM Childrens Aspirin.........13

SM Complete....................115

SM Complete Advanced

Formula............................115

SM Complete Senior

Formula............................115

SM Fiber............................... 65

SM Ibuprofen.......................13

SM Iron............................... 104

SM Lorata-Dine D............... 88

SM Loratadine.....................88

SM Magnesium................ 104

SM Miconazole 7................30

SM Milk of Magnesia......... 65

SM Multiple Vitamins

Essential.......................... 115

SM Multiple Vitamins/Iron

...........................................115

SM Nasal Decongestant

Maximum Strength..........95

SM Nasal Spray 12 Hour..95

SM Nasal Spray Pump Mist

..............................................96

SM Oyster Shell Calcium/

Vitamin D.........................104

SM Oyster Shell Calcium/

Vitamin D3...................... 104

SM Pain Reliever................ 11

SM Pain Reliever Childrens

..............................................11

SM Pain Reliever Extra

Strength..............................11

SM Pain Reliever PM Extra

Strength..............................88

SM Pediatric Electrolyte. 104

SM Sleep Aid.......................88

SM Slow Release Iron.....104

SM Stomach Relief............ 62

SM Stomach Relief

Maximum Strength..........62

SM Super B Complex-

Vitamin C.........................115

SM Tussin.............................96

SM Tussin DM.....................96

SM Tussin DM Cough/

Chest Congestion............96

SM Vitamin B-12.............. 115

SM Vitamin B-6.................115

SM Vitamin C.................... 116

SM Vitamin C/Rose Hips

...........................................116

SM Vitamin E.....................116

SM Vitamin E Blended....116

SM Zinc.............................. 104

Sodium Bicarbonate..........62

Sodium Chloride.......83, 104

Sodium Chloride 0.45%

Viaflex...............................104

Sodium Chloride 0.9%....104

Sodium Fluoride...............104

Sodium Lactate................ 106

Sodium Phenylbutyrate.....60

Sodium Polystyrene

Sulfonate............................97

Sodium Sulfacetamide......22

Soltamox...............................33

Solu-Cortef........................... 68

Solu-Medrol..........................68

Somatuline Depot...............75

Somavert.............................. 75

Soriatane...............................59

Sotalol HCl........................... 50

Sovaldi...................................42

Spiriva HandiHaler............. 89

Spiriva Respimat.................89

Spironolactone....................53

Spironolactone/


Sporanox.............................. 30

Sprintec 28.......................... 73

Spritam..................................23

Sprycel.................................. 36

SPS........................................ 97

Sronyx................................... 73

SSD........................................22

Stahist AD.............................96

Stavudine..............................43

Stelara................................... 77

Sterile Water Irrigation.......81

Stimulant Laxative.............. 65

Stiolto Respimat..................96

Stivarga................................. 36

Stool Softener......................65

Stool Softener Extra

Strength..............................65

Stool Softener Laxative DC

..............................................65

Strattera.................................55

144

144

Strensiq.................................60

Streptomycin Sulfate......... 17

Stress Formula..................116

Stress Formula with Iron.116

Stress Formula/Iron.........116

Stress Formula/Zinc........116

Stribild................................... 42

Suboxone............................. 16

Sucraid..................................60

Sucralfate..............................65

Sudogest.............................. 96

Sudogest 12 Hour..............96

Sudogest PE........................96

Sudogest Sinus & Allergy. 88

Sulfacetamide Sodium......22

Sulfacetamide Sodium/

Prednisolone Sodium

Phosphate......................... 83

Sulfadiazine..........................22

Sulfamethoxazole/

Trimethoprim.................... 22

Sulfamethoxazole/

Trimethoprim DS..............22

Sulfasalazine........................80

Sulindac................................13

Sumatriptan......................... 31

Sumatriptan Succinate......31


..............................................31

Sumavel DosePro...............31

Super B Complex/C........116

Super B with C..................116

Super Thera Vite M..........116

Superplex-T....................... 116

Suplevit...............................116

Suprax...................................19

Suprep Bowel Prep............65

Surmontil.............................. 27

Suspendol-S........................ 82

Sustiva...................................43

Sutent.................................... 36

Sylatron................................. 42

Sylvant...................................37

Symbicort............................. 96

SymlinPen 120....................46

SymlinPen 60...................... 47

Synagis..................................78

Synarel.................................. 75

Synercid................................18

Synjardy................................ 47

Synribo..................................35

Synthroid.............................. 74

Syprine.................................. 97

T

TAB-A-VITE........................116

TAB-A-VITE Maximum.... 116

TAB-A-VITE with Beta

Carotene..........................116

TAB-A-VITE Womens...... 116

TAB-A-VITE/Iron...............116

Tabloid.................................. 33

Tacrolimus.................... 59, 77

Tafinlar.................................. 36

Tagrisso................................ 37

Tamiflu.................................. 45

Tamoxifen Citrate............... 33

Tamsulosin HCl...................66

Tandem.............................. 104

Tarceva................................. 37

Targretin............................... 37

Tarina Fe 1/20.................... 73

Tasigna................................. 37

Taxotere................................35

Tazicef...................................19

Tazorac................................. 59

Tecentriq.............................. 37

Tecfidera...............................56

Tecfidera Starter Pack.......56

Tegretol-XR.......................... 25

Telmisartan.......................... 49

Telmisartan/Amlodipine... 52

Telmisartan/


Temazepam.........................97

Tenivac..................................79

Terazosin HCl......................66

Terbinafine HCl...................30

Terbutaline Sulfate............. 89

Terconazole......................... 30

Testosterone Cypionate....70

Testosterone Enanthate....70

Tetanus/Diphtheria Toxoids-

Adsorbed Adult................ 79

Tetrabenazine......................56

Tetracycline HCl................. 23

Thalomid...............................33

Theophylline........................ 90

Theophylline CR................. 90

Theophylline ER..................90

Thera...................................116

Thera-Gesic..........................59

Thera-M.............................. 116

Thera-Tabs.........................116

Theramill Forte..................116

Therapeutic Liquid.......... 116

Therapeutic M...................116

145

145

Theratrum Complete.......116

Thiamine HCl.................... 116

Thioridazine HCl................. 39

Thiotepa................................35

Thiothixene.......................... 39

Thymoglobulin.................... 77

Thyrolar.................................74

ThyroSafe............................. 82

ThyroShield..........................82

Tiagabine HCl......................24

Tikosyn..................................50

Timolol Maleate........... 51, 84

Timolol Maleate Ophthalmic

Gel Forming...................... 84

Tinidazole............................. 18

Tioconazole-1......................30

Tivicay............................ 42, 44

Tizanidine HCl.....................97

TOBI.......................................17

TOBI Podhaler.....................17

Tobradex.............................. 17

Tobradex ST........................ 83

Tobramycin..........................17

Tobramycin Sulfate............17

Tobramycin/

Dexamethasone............... 83

Tobrex................................... 17

Tolcapone............................ 39

Tolnaftate..............................30

Topiramate...........................24

Toposar.................................36

Topotecan HCl....................36

Torisel....................................77

Torsemide............................ 53

Total B/C............................116

Totalday Multiple..............116

Toujeo SoloStar.................. 47

TPN Electrolytes...............106

Tracleer.................................90

Tradjenta...............................47

Tramadol HCl...................... 15

Tramadol HCl/


Trandolapril..........................50

Tranexamic Acid.................48

Transderm-Scop.................28

Tranylcypromine Sulfate... 26

Travasol..............................106

Travatan Z............................ 85

Travel Sickness...................28

Travoprost............................ 85

Trazodone HCl....................27

Treanda.................................32

Trecator.................................32

Trelstar Mixject....................75

Tretinoin.........................37, 59

Tretinoin Microsphere....... 59

Trexall....................................77

Trezix..................................... 15

Tri-Legest Fe........................73

Tri-Lo-Estarylla..................... 73

Tri-Lo-Sprintec.....................73

Tri-Previfem.......................... 73

Tri-Sprintec...........................73

Tri-Vi-Sol............................. 116

Tri-Vita.................................117

Tri-Vitamin..........................117

Triamcinolone Acetonide. 69

Triamcinolone in Orabase57

Triamterene/


Triderm..................................69

Trifluoperazine HCl............ 39

Trifluridine............................ 42

Trihexyphenidyl HCl...........38

TriLyte....................................65

Trimethoprim.......................18

Trimipramine Maleate........27

Trinessa................................ 73

Trintellix.................................27

Triple Antibiotic...................18

Triple Antibiotic Plus..........18

Trisenox................................ 35

Triumeq.................................42

Trivora-28............................. 73

Trixaicin.................................59

Trixaicin HP..........................59

Trizivir.................................... 43

Trophamine.......................106

Trumenba.............................79

Truvada.................................43

Tussin....................................96

Tussin DM............................ 96

Tussin DM Clear................. 96

Tussionex Pennkinetic

Extended-Release............96

Twinrix...................................79

Tybost....................................42

Tygacil...................................18

Tykerb................................... 37

Typhim Vi..............................79

Tysabri...................................56

Tyvaso................................... 90

Tyzeka...................................41

146

146

Tyzine Pediatric Nasal Drops

..............................................96

U

Uceris.................................... 80

Uloric..................................... 30

Unithroid............................... 74

Ursodiol.................................62

Uvadex.................................. 59

V

Valacyclovir HCl..................42

Valchlor................................. 32

Valcyte...................................41

Valganciclovir...................... 41

Valproate Sodium...............24

Valproic Acid....................... 24

Valsartan...............................49

Valsartan/


VanaCof................................ 96

VanaCof DM........................ 96

VanaCof-8.............................96

Vanahist PD......................... 88

Vancocin HCl.......................18

Vancomycin HCl.................18

Vandazole.............................18

VAQTA.................................. 79

Varivax...................................79

Varizig....................................77

Vascepa................................ 54

Vectibix................................. 37

Velcade................................. 35

Velivet....................................73

Velphoro............................... 67

Venclexta..............................35

Venclexta Starting Pack....35

Venlafaxine HCl...................27

Venlafaxine HCl ER............27

Ventavis.................................90

Verapamil HCl..................... 51

Verapamil HCl ER...............51

Versacloz.............................. 41

Vesicare................................ 66

Vestura.................................. 73

Vfend..................................... 30

Vibramycin........................... 23

Vidaza....................................35

Videx Pediatric.................... 43

Vienva....................................73

Viibryd................................... 27

Viibryd Starter Pack........... 27

Vimpat................................... 25

Vinblastine Sulfate..............35

Vincasar PFS....................... 35

Vincristine Sulfate...............35

Vinorelbine Tartrate............35

Viracept.................................44

Viramune.............................. 43

Viramune XR........................43

Virazole................................. 45

Viread.................................... 44

Virtussin A/C........................96

Vita-Bee/C......................... 117

Vitamin A............................117

Vitamin A & D...................... 59

Vitamin B Complex..........117

Vitamin B Complex-C......117

Vitamin B-1........................ 117

Vitamin B-12......................117

Vitamin B-2........................ 117

Vitamin B-6........................ 117

Vitamin B12.......................117

Vitamin C............................117

Vitamin C SR.....................117

Vitamin C TR.....................117

Vitamin C/Rose Hips...... 117

Vitamin D............................117

Vitamin E............................117

Vitamin E Water Dispersible

...........................................117

Vitamin E Water Soluble.117

Vitamin E/D-Alpha........... 117

Vitamin K1......................... 117

Vitamins & Minerals.........117

Vitamins for Hair...............117

Vitekta................................... 43

Vituz....................................... 88

Vivitrol....................................15

Voltaren.................................13

Voriconazole........................30

Votrient..................................37

VP-PNV-DHA.....................106

VPRIV.................................... 60

Vraylar................................... 41

Vyfemla................................. 73

Vytorin................................... 54

W

Warfarin Sodium.................48

Wee Care........................... 104

Welchol................................. 54

White Petrolatum................59

Womens One Daily..........117

WYMZYA Fe........................ 73

X

Xalkori....................................37

Xarelto................................... 48

147

147

Xarelto Starter Pack........... 48

Xeljanz...................................77

Xeljanz XR............................ 77

Xenazine............................... 56

Xgeva.....................................81

Xifaxan...................................18

Xigduo XR............................ 47

Xolair......................................96

Xtandi.................................... 33

Xyrem.................................... 97

Y

Yervoy....................................37

YF-Vax................................... 79

Yondelis................................ 32

Z

Zafirlukast.............................89

Zaleplon................................97

Zaltrap................................... 35

Zanosar.................................32

Zarxio.....................................48

Zavesca.................................60

Zazole....................................30

Zeasorb-AF...........................30

Zelapar.................................. 39

Zelboraf.................................37

Zemaira.................................96

Zemplar.................................81

Zenchent.............................. 73

Zenchent Fe.........................73

Zenpep..................................60

Zepatier.................................42

Zerbaxa.................................20

Zetia.......................................54

Ziagen................................... 44

Zidovudine........................... 44

Zinbryta.................................77

Zinc......................................104

Zinc 15............................... 104

Zinc Chelated....................104

Zinc Gluconate................. 104

Zinc Oxide............................59

Zinc Sulfate........................104

Zinc-220.............................104

Zinc/Vitamin C..................104

Ziprasidone HCl..................41

Zirgan.................................... 41

Zmax......................................21

Zoledronic Acid...................81

Zolinza...................................35

Zolpidem Tartrate...............97

Zomacton............................. 69

Zometa..................................81

Zonatuss...............................96

Zonisamide.......................... 23

Zoo Friends....................... 117

Zoo Friends Complete....117

Zoo Friends Plus Extra C

...........................................117

Zoo Friends Plus Iron......117

Zorbtive.................................62

Zortress.................................77

Zostavax................................79

Zovia 1/35E.........................73

Zovia 1/50E.........................73

Zutripro................................. 96

Zyclara...................................59

Zyclara Pump...................... 59

Zydelig...................................35

Zyflo....................................... 89

Zyflo CR................................ 89

Zykadia..................................35

Zyprexa Relprevv................41

Zytiga.....................................33

Zyvox..................................... 18

Medicare Approved Formulary File ID 00016011, Version 20

H7833_150629_154123_FINAL10

Last Updated November 1, 2016UHTX16HM3714778_011

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