2017 Cigna-HealthSpring COMPREHENSIVE DRUG LIST (Formulary) · 2 see the page number where you can find coverage information. Turn to the page listed in the Covered Drug Index and

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

2017 Cigna-HealthSpring COMPREHENSIVE DRUG LIST (Formulary)

This drug list was updated on November 1, 2017. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. For more recent information or other questions, please contact Cigna-HealthSpring Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. - 8 p.m., or visit www.CignaHealthSpring.com. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal.HPMS Approved Formulary File Submission ID 17132, Version Number 16 Y0036_17_42746_Final_1i Populated Template 08052016

Plans coveredCigna-HealthSpring Preferred (HMO)Cigna-HealthSpring Preferred (PPO)Cigna-HealthSpring Preferred AR (HMO)Cigna-HealthSpring Preferred KNX (HMO)Cigna-HealthSpring Preferred NGA (HMO)Cigna-HealthSpring Preferred SMS (HMO)Cigna-HealthSpring Preferred Plus (HMO)Cigna-HealthSpring Premier (HMO-POS)Cigna-HealthSpring Premier Plus (HMO-POS)Cigna-HealthSpring PreventiveCare (HMO)

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What is the Cigna-HealthSpring Comprehensive Drug List?A drug list is a list of covered drugs selected by Cigna-HealthSpring in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Cigna-HealthSpring will generally cover the drugs listed in our drug list as long as the drug is medically necessary, the prescription is filled at a Cigna-HealthSpring network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Drug List (formulary) change?Generally, if you are taking a drug on our 2017 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2017 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of drug list changes, such as removing a drug from our drug list, will not affect customers who are currently taking the drug. It will remain available at the same cost-sharing for those customers taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our drug list, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected customers of the change at least 60 days before the change becomes effective, or at the time the customer requests

a refill of the drug, at which time the customer will receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) deems a drug on our drug list to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug. The enclosed drug list is current as of November 2017. To get updated information about the drugs covered by Cigna-HealthSpring, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website are reviewed and updated on a monthly basis.

How do I use the Drug List? There are two ways to find your drug within the drug list:Medical ConditionThe drug list begins on page 16. The drugs in this drug list are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “CARDIOVASCULAR AGENTS”. If you know what your drug is used for, look for the category name in the list that begins on page 16. Then look under the category name for your drug. Covered Drug IndexIf you are not sure what category to look under, you should look for your drug in the Covered Drugs Index section that begins on page 59. The Covered Drugs Index provides a list of all of the drugs included in this document. Both brand name drugs and generic drugs are in the Drug List. Next to your drug, you will

Note to existing customers: This drug list has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna-HealthSpring. When it refers to “plan” or “our plan,” it means Cigna-HealthSpring Preferred (HMO), Cigna-HealthSpring Preferred (PPO), Cigna-HealthSpring Preferred AR (HMO), Cigna-HealthSpring Preferred KNX (HMO), Cigna-HealthSpring Preferred NGA (HMO), Cigna-HealthSpring Preferred SMS (HMO), Cigna-HealthSpring Preferred Plus (HMO), Cigna-HealthSpring Premier (HMO-POS), Cigna-HealthSpring Premier Plus (HMO-POS) and Cigna-HealthSpring PreventiveCare (HMO).

This document includes a list of the drugs (formulary) for our plans, which is current as of November 2017. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2018, and from time to time during the year.

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see the page number where you can find coverage information. Turn to the page listed in the Covered Drug Index and find the name of your drug in the drug name column of the list.

What are generic drugs?Cigna-HealthSpring covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

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

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

• Quantity Limits: For certain drugs, Cigna-HealthSpring limits the amount of the drug that Cigna-HealthSpring will cover. For example, Cigna-HealthSpring allows for 1 tablet per day for VESICARE. This applies to standard one-month supply (for total quantity of 30 per 30 days) or three-month supply (for total quantity of 90 per 90 days).

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

You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 16. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.You can ask Cigna-HealthSpring to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Cigna-HealthSpring drug list?” on page 3 for information about how to request an exception.

Options for Maintenance MedicationsTaking the medications prescribed by your doctor (or other prescriber) is important to your health. We are committed to helping you achieve control of chronic conditions by making it easy for you to receive your maintenance medications. As part of our commitment to coordinating your healthcare needs, we have set a goal of helping you take your medications at least 80% of the time. There are several ways we can work together to accomplish this goal:• Talk with your doctor about whether a 90-day supply of your

ongoing, stable medications may be appropriate. Taking these medications every day as prescribed is important for your overall health, and getting 90-day prescriptions of these medications can ensure that you don’t miss a dose.

• You can receive a 90-day supply at most retail pharmacies or through one of our mail-order pharmacies.

• Talk to your pharmacist if you are experiencing any new challenges with your maintenance medications.

How can I use my prescription drug coverage to save money on my medications?There may be opportunities for you to save money on your medications using your Cigna-HealthSpring coverage.• Ask your doctor (or other prescriber) if there are any lower-

cost generic alternatives available for any of your current medications.

• Explore whether the ‘CMS Extra Help’ program may offer additional financial support for your medications.

• If your medication is not covered on the Cigna-HealthSpring drug list, talk with your doctor about alternative medications which are covered in the drug list.

• What if my drug is not in the Drug List?If your drug is not included in this drug list, you should first contact Customer Service and ask if your drug is covered. If you learn that Cigna-HealthSpring does not cover your drug, you have two options:• You can ask Customer Service for a list of similar drugs that

are covered by Cigna-HealthSpring. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Cigna-HealthSpring.

• You can ask Cigna-HealthSpring to make an exception and cover your drug. See below for information about how to request an exception.

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How do I request an exception to the Cigna-HealthSpring’s Drug List?You can ask Cigna-HealthSpring to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.• You can ask us to cover a drug even if it is not in our drug

list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Cigna-HealthSpring limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

• You can ask us to provide a tiering exception for a higher cost-sharing drug to be covered at a lower cost-sharing tier. If your drug is contained in the Non-Preferred Drugs tier, you can ask us to cover it at the Preferred Brand Drugs tier, and if your drug is contained in the Generic Drugs tier, you can ask us to cover it at the Preferred Generic Drugs tier. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.

Generally, Cigna-HealthSpring will only approve your request for an exception if the alternative drugs included on the plan’s drug list, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a drug list, tiering or utilization restriction exception. When you request a drug list, tiering or utilization restriction exception you should submit a statement from your prescriber or doctor supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing customer in our plan you may be taking drugs that are not in our drug list. Or, you may be taking a drug

that is on our drug list but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a customer of our plan.For each of your drugs that is not on our drug list or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a customer of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91- to 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a customer of our plan. If you need a drug that is not in our drug list or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a drug list exception. In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna-HealthSpring will allow a one-time 31-day supply (unless the prescription is written for fewer days). Cigna-HealthSpring’s Drug ListThe comprehensive drug list provides coverage information about all of the drugs covered by Cigna-HealthSpring. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 59. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., VESICARE) and generic drugs are listed in lower-case italics (e.g., simvastatin).The information in the Requirements/Limits column tells you if Cigna-HealthSpring has any special requirements for coverage of your drug. Some Cigna-HealthSpring plans offer additional prescription drug coverage in the coverage gap. Please refer to your Evidence of Coverage to see if your plan has this coverage and for more information.

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We provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 16 along with the amount dispensed per the days supplied. (For example: VESICARE QL 30/30; this means the drug VESICARE is limited to 30 tablets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 tablets per 90 days).

What is a preferred network pharmacy?If your plan has preferred network pharmacies, you will typically save money by using these pharmacies. Your prescription drug costs (like a copay or coinsurance) will typically be less at a preferred network pharmacy because it has a preferred agreement with your plan. You will receive a Pharmacy Directory in your Welcome Kit after you enroll, or you can visit www.CignaHealthSpring.com for the most current Pharmacy Directory.

For more information

For more detailed information about your Cigna-HealthSpring prescription drug coverage, please review your Evidence of Coverage and other plan materials.If you have questions about Cigna-HealthSpring, please contact us. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Key:B/D – This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on circumstances.

PA – This drug requires prior authorization

QL – This drug has quantity limits

ST – This drug has step therapy requirements

Generally all medications in the drug list are available through mail order, except when special circumstances or situations prohibit mailing a particular medication to your home.

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Drug Tier and Cost-Share TableThe following table represents the plan name, plan service area, the drug tier number as it appears in the drug list, and the cost-share amount for that tier number. Tier 1 is for Preferred Generic drugs. Tier 2 is for Generic drugs. Tier 3 is for Preferred Brand drugs. Tier 4 is for Non-Preferred drugs. Tier 5 is for Specialty tier drugs. You may also refer to your Evidence of Coverage document for additional details.

Note for customers receiving Extra Help: Your Low Income Subsidy (LIS) copay level will be based on how the Food and Drug Administration (FDA) classifies certain drugs. Due to this, a generic drug may receive a preferred brand copay, or a preferred brand drug may receive a generic drug copay. Please see your LIS Rider for additional information on these copay levels. Or call Customer Service for further clarification regarding a specific drug.

To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantage plan in which you are currently enrolled or would like to enroll.Cigna-HealthSpring has pharmacies with preferred cost-shares. See your Pharmacy Directory or visit www.CignaHealthSpring.com for information on which stores with preferred cost-shares are near you.

Service Area: Alabama H0150-024-001, H0150-024-002Cigna-HealthSpring Preferred (HMO) Autauga, Baldwin, Bibb, Blount, Cherokee, Chilton, Colbert, Cullman, Dallas, DeKalb, Elmore, Etowah, Jackson, Jefferson, Lauderdale, Lawrence, Limestone, Lowndes, Madison, Marshall, Mobile, Montgomery, Morgan, Shelby, St. Clair, Talladega, Tuscaloosa and Walker, Alabama

Preferred Retail Cost-Sharing

Standard Retail Cost-Sharing

Standard Mail Order Cost-Sharing

30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days

Tier 1: Preferred Generic Drugs $1 / $2 / $1 $6 / $12 / $6 $6 / $6

Tier 2: Generic Drugs $7 / $14 / $7 $12 / $24 / $12 $12 / $12

Tier 3: Preferred Brand Drugs $40 / $80 / $120 $45 / $90 / $135 $45 / $135

Tier 4: Non-Preferred Drugs $90 / $180 / $270 $95 / $190 / $285 $95 / $285

Tier 5: Specialty Tier 31% (30-day supply only)

31% (30-day supply only)


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Service Area: Alabama H0150-025Cigna-HealthSpring Premier (HMO-POS) Autauga, Baldwin, Bibb, Blount, Cherokee, Chilton, Colbert, Cullman, Dallas, DeKalb, Elmore, Etowah, Jackson, Jefferson, Lauderdale, Lawrence, Limestone, Lowndes, Madison, Marshall, Mobile, Montgomery, Morgan, Shelby, St. Clair, Talladega, Tuscaloosa and Walker, Alabama




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








Service Area: Arkansas H4454-033Cigna-HealthSpring Preferred AR (HMO) Craighead, Crittenden, Greene, Lawrence, Mississippi and Poinsett, Arkansas




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days

Tier 1: Preferred Generic Drugs $3 / $6 / $7.50 $8 / $16 / $20 $8 / $20

Tier 2: Generic Drugs $15 / $30 / $37.50 $20 / $40 / $50 $20 / $50






Service Area: Arkansas H6972-001Cigna-HealthSpring Preferred (HMO) Conway, Crawford, Franklin, Johnson, Logan, Pope, Scott, Sebastian and Yell, Arkansas




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








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Service Area: Florida H5410-018Cigna-HealthSpring Premier (HMO-POS)Bay, Escambia, Okaloosa, Santa Rosa and Walton, Florida




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








Service Area: GeorgiaH0439-003-001, H0439-003-002Cigna-HealthSpring Preferred (HMO) Baldwin, Banks, Barrow, Bartow, Butts, Chattooga, Cherokee, Clarke, Clayton, Cobb, Coweta, Dawson, DeKalb, Douglas, Elbert, Fayette, Floyd, Forsyth, Franklin, Fulton, Gordon, Greene, Gwinnett, Habersham, Hall, Hart, Henry, Jackson, Jasper, Lamar, Lumpkin, Madison, Morgan, Newton, Oconee, Oglethorpe, Paulding, Pickens, Pike, Polk, Putnam, Rabun, Rockdale, Spalding, Stephens, Walton, White, and Wilkes, Georgia




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








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Service Area: Illinois H1415-021Cigna-HealthSpring Premier (HMO-POS)Cook, DuPage, Kane and Will, Illinois




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days




Tier 4: Non-Preferred Drugs $95 / $190 / $237.50 $100 / $200 / $300 $100 / $300




Service Area: Indiana H3945-003Cigna-HealthSpring Premier (HMO-POS)Lake, Indiana




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days




Tier 4: Non-Preferred Drugs $95 / $190 / $237.50 $100 / $200 / $300 $100 / $300




Service Area: Kansas CityH9460-001Cigna-HealthSpring Preferred (HMO)Clay, Jackson, Platte and Ray, Missouri; Johnson and Wyandotte, Kansas




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








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Service Area: Maryland H2108-022Cigna-HealthSpring Preferred (HMO) H2108-033Cigna-HealthSpring PreventiveCare (HMO) Anne Arundel, Baltimore, Baltimore City, Caroline, Dorchester, Harford, Howard, Kent, Queen Anne’s and Talbot, Maryland




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








Service Area: Mid-Atlantic H2108-028Cigna-HealthSpring Preferred (HMO) H2108-032Cigna-HealthSpring PreventiveCare (HMO) District of Columbia; Kent, New Castle and Sussex, Delaware; Montgomery and Prince George’s, Maryland




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








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Service Area: MississippiH4407-025-001, H4407-025-002Cigna-HealthSpring Preferred SMS (HMO)Attala, Covington, Forrest, George, Hancock, Harrison, Hinds, Jackson, Jones, Lamar, Leake, Madison, Marion, Pearl River, Perry, Rankin and Stone, Mississippi




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








Service Area: North Carolina, South CarolinaH9725-001, H7020-003-001, H7020-003-002Cigna-HealthSpring Preferred (HMO) Alexander, Cabarrus, Catawba, Cleveland, Davidson, Davie, Forsyth, Gaston, Guilford, Iredell, Lincoln, Polk, Rowan, Stokes, Union and Yadkin, North Carolina; Cherokee, Chester, Greenville, Lancaster, Spartanburg, Union and York, South Carolina




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








Service Area: North GeorgiaH2165-005Cigna-HealthSpring Preferred NGA (HMO) Catoosa, Dade and Walker, Georgia




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








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Service Area: Pennsylvania H3949-030Cigna-HealthSpring Preferred (HMO) H3949-028Cigna-HealthSpring PreventiveCare (HMO)Berks, Bucks, Chester, Cumberland, Delaware, Lancaster, Lehigh, Montgomery, Northampton, Philadelphia and York, Pennsylvania




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days

Tier 1: Preferred Generic Drugs $4 / $8 / $10 $9 / $18 / $22.50 $9 / $22.50

Tier 2: Generic Drugs $10 / $20 / $25 $15 / $30 / $37.50 $15 / $37.50






Service Area: Pennsylvania H3949-013Cigna-HealthSpring Preferred Plus (HMO)Berks, Bucks, Chester, Cumberland, Delaware, Lancaster, Lehigh, Montgomery, Northampton, Philadelphia and York, Pennsylvania




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








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Service Area: Tennessee H4454-036Cigna-HealthSpring Premier Plus (HMO-POS)Bedford, Benton, Bledsoe, Bradley, Cannon, Carroll, Cheatham, Chester, Clay, Coffee, Crockett, Cumberland, Davidson, Decatur, DeKalb, Dickson, Fayette, Fentress, Gibson, Giles, Grundy, Hamilton, Hardeman, Hardin, Haywood, Henderson, Hickman, Houston, Humphreys, Jackson, Lauderdale, Lawrence, Lewis, Lincoln, Macon, Madison, Marion, Marshall, Maury, McMinn, McNairy, Meigs, Monroe, Montgomery, Moore, Overton, Perry, Pickett, Polk, Putnam, Rhea, Robertson, Rutherford, Sequatchie, Shelby, Smith, Stewart, Sumner, Tipton, Trousdale, Van Buren, Warren, Wayne, White, Williamson and Wilson, Tennessee




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days



Tier 3: Preferred Brand Drugs $42 / $84 / $105 $47 / $94 / $117.50 $47 / $117.50





Service Area: Tennessee H4454-037-001, H4454-037-002Cigna-HealthSpring Preferred (HMO)Bedford, Benton, Bledsoe, Bradley, Cannon, Carroll, Cheatham, Chester, Clay, Coffee, Crockett, Cumberland, Davidson, Decatur, DeKalb, Dickson, Fayette, Fentress, Gibson, Giles, Grundy, Hamilton, Hardeman, Hardin, Haywood, Henderson, Hickman, Houston, Humphreys, Jackson, Lauderdale, Lawrence, Lewis, Lincoln, Macon, Madison, Marion, Marshall, Maury, McMinn, McNairy, Meigs, Monroe, Montgomery, Moore, Overton, Perry, Pickett, Polk, Putnam, Rhea, Robertson, Rutherford, Sequatchie, Shelby, Smith, Stewart, Sumner, Tipton, Trousdale, Van Buren, Warren, Wayne, White, Williamson and Wilson, Tennessee




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








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Service Area: TennesseeH4454-030Cigna-HealthSpring Premier (HMO-POS)Bedford, Benton, Bledsoe, Bradley, Cannon, Carroll, Cheatham, Chester, Clay, Coffee, Crockett, Cumberland, Davidson, Decatur, DeKalb, Dickson, Fayette, Fentress, Gibson, Giles, Grundy, Hamilton, Hardeman, Hardin, Haywood, Henderson, Hickman, Houston, Humphreys, Jackson, Lauderdale, Lawrence, Lewis, Lincoln, Macon, Madison, Marion, Marshall, Maury, McMinn, McNairy, Meigs, Monroe, Montgomery, Moore, Overton, Perry, Pickett, Polk, Putnam, Rhea, Robertson, Rutherford, Sequatchie, Shelby, Smith, Stewart, Sumner, Tipton, Trousdale, Van Buren, Warren, Wayne, White, Williamson and Wilson, Tennessee




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








Service Area: TennesseeH4454-031Cigna-HealthSpring Preferred KNX (HMO)Anderson, Blount, Campbell, Cocke, Grainger, Hamblen, Hancock, Jefferson, Knox, Loudon, Morgan, Roane, Scott, Sevier and Union, Tennessee




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








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Service Area: TexasH4513-025Cigna-HealthSpring Preferred (HMO)Angelina, Brazoria, Cameron, Chambers, El Paso, Fort Bend, Galveston (77510, 77511, 77517, 77518, 77539, 77546, 77549, 77563. 77565, 77568, 77573, 77574, 77590, 77591, and 77592), Hardin, Harris, Hidalgo, Jasper, Jefferson, Liberty, Montgomery, Nacogdoches, Newton, Orange, Polk, San Jacinto, Tyler, Walker, Waller, Webb and Willacy, Texas




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








Service Area: Texas H2165-018, H4528-001Cigna-HealthSpring Preferred (HMO) Bexar, Collin, Dallas, Denton, El Paso, Henderson, Hood, Johnson, Lubbock, Parker, Rusk, Smith, Tarrant, Upshur, Van Zandt and Wise, Texas




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








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My MedicationsIn this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at 1-800-668-3813, 7 days a week, 8 a.m. - 8 p.m. TTY users can call 711.

My Medications Page Number in the Drug List

Cost-Share through Cigna-HealthSpring

Generic Available?

Generic Cost-Share

Service Area: TexasH7787-001Cigna-HealthSpring Preferred (PPO)Cherokee, Collin, Dallas, Denton, Henderson, Johnson, Lubbock, Rusk, Tarrant, Upshur, Van Zandt and Wood, Texas




30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 90 Days








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Covered Drugs By Category

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Analgesics

Analgesicsbutalbital/acetaminophen/caffeine caps

3 PA QL(180/30)

butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg

3 PA QL(180/30)

butalbital/aspirin/caffeine caps 3 PA QL(180/30)capacet 3 PA QL(180/30)esgic caps 3 PA QL(180/30)zebutal caps 325mg; 50mg; 40mg

3 PA QL(180/30)

NonsteroidalAnti-inflammatoryDrugscelecoxib caps 400mg 2 QL(30/30)celecoxib caps 100mg, 200mg, 50mg

2 QL(60/30)

diclofenac potassium 2diclofenac sodium dr tbec 25mg, 50mg

2

diclofenac sodium dr tbec 75mg 1diclofenac sodium er 2diflunisal 2etodolac 2etodolac er 2fenoprofen calcium caps 400mg

2

fenoprofen calcium tabs 2flurbiprofen 2ibuprofen susp 1ibuprofen tabs 400mg, 600mg, 800mg

1

ketoprofen 2ketoprofen er 2 QL(30/30)meclofenamate sodium 2meloxicam 1 QL(30/30)nabumetone 2naproxen dr 2naproxen sodium tabs 275mg, 550mg

2

naproxen susp 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

naproxen tabs 250mg 2naproxen tabs 375mg, 500mg 1oxaprozin 2piroxicam 2salsalate 2sulindac 2tolmetin sodium 2Opioid Analgesics, Long-actingbuprenorphine hcl inj 4 QL(150/30)DURAMORPH 4 QL(180/30)fentanyl 4 QL(10/30)INFUMORPH 200 4 QL(200/30)INFUMORPH 500 4 QL(200/30)levorphanol tartrate 2 QL(120/30)methadone hcl conc 2 QL(500/30)methadone hcl inj 4 QL(150/30)methadone hcl intensol 2 QL(500/30)methadone hcl oral soln 10mg/5ml

2 QL(450/30)

methadone hcl oral soln 5mg/5ml

2 QL(600/30)

methadone hcl tabs 10mg 2 QL(120/30)methadone hcl tabs 5mg 2 QL(180/30)morphine sulfate er tbcr 3 QL(90/30)morphine sulfate inj 0.5mg/ml, 1mg/ml

4 QL(180/30)

Opioid Analgesics, Short-actingacetaminophen/caffeine/dihydrocodeine

2 QL(300/30)

acetaminophen/codeine oral soln

2 QL(2700/30)

acetaminophen/codeine tabs 300mg; 60mg

2 QL(180/30)

acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg

2 QL(360/30)

ascomp/codeine 3 PA QL(180/30)butalbital/acetaminophen/caffeine/codeine

3 PA QL(180/30)

butalbital/aspirin/caffeine/codeine

3 PA QL(180/30)

butorphanol tartrate inj 2mg/ml 4 QL(240/30)

17


CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drugQL = Quantity Limits listed as (qty/days) ST = Step Therapy rules applyPA = Prior Authorization may be required B/D = Drugs covered under Medicare Part B or Part DYou can find more information on the symbols by going to page 4.

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lorcet plus tabs 325mg; 7.5mg 3 QL(180/30)MORPHINE SULFATE INJ 150MG/30ML, 15MG/ML, 50MG/ML

4

morphine sulfate inj 5mg/ml 4MORPHINE SULFATE INJ 1MG/ML

4 QL(180/30)

MORPHINE SULFATE INJ 10MG/ML

4 QL(200/30)

morphine sulfate inj 10mg/ml 4 QL(200/30)MORPHINE SULFATE INJ 2MG/ML, 4MG/ML

4 QL(240/30)

MORPHINE SULFATE INJ 8MG/ML

4 QL(250/30)

morphine sulfate inj 8mg/ml 4 QL(250/30)morphine sulfate oral soln 100mg/5ml

2 QL(180/30)

morphine sulfate oral soln 20mg/5ml

2 QL(300/30)

morphine sulfate oral soln 10mg/5ml

2 QL(700/30)

MORPHINE SULFATE TABS 3 QL(120/30)nalbuphine hcl inj 20mg/ml 4 QL(90/30)nalbuphine hcl inj 10mg/ml 4 QL(180/30)oxycodone hcl caps 3 QL(120/30)oxycodone hcl conc 3 QL(120/30)oxycodone hcl oral soln 3 QL(1200/30)oxycodone hcl tabs 30mg 3 QL(90/30)oxycodone hcl tabs 10mg, 15mg, 20mg, 5mg

3 QL(120/30)

oxycodone/acetaminophen tabs 325mg; 10mg

3 QL(180/30)

oxycodone/acetaminophen tabs 325mg; 7.5mg

3 QL(240/30)

oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg

3 QL(360/30)

oxycodone/aspirin 3 QL(180/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

butorphanol tartrate inj 1mg/ml 4 QL(480/30)butorphanol tartrate nasal soln 2 QL(5/30)endocet tabs 325mg; 10mg 3 QL(180/30)endocet tabs 325mg; 7.5mg 3 QL(240/30)endocet tabs 325mg; 2.5mg, 325mg; 5mg

3 QL(360/30)

fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 2500mcg/50ml, 250mcg/5ml

4 B/D PA

fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg

4 PA QL(120/30)

fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg

5 PA QL(120/30)

hydrocodone bitartrate/acetaminophen oral soln

3 QL(2700/30)

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

3 QL(180/30)

hydrocodone bitartrate/acetaminophen tabs 300mg; 5mg, 325mg; 2.5mg

3 QL(360/30)

hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg

3 QL(180/30)

hydrocodone/acetaminophen tabs 325mg; 5mg

3 QL(360/30)

hydrocodone/ibuprofen 3 QL(150/30)hydromorphone hcl dosette 4hydromorphone hcl inj 4hydromorphone hcl liqd 3 QL(1200/30)hydromorphone hcl tabs 8mg 3 QL(120/30)hydromorphone hcl tabs 2mg, 4mg

3 QL(180/30)

ibudone tabs 5mg; 200mg 3 QL(150/30)lorcet 3 QL(360/30)lorcet hd 3 QL(180/30)

18


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG

3 PA QL(90/30)

Opioid Reversal Agentsnaloxone hcl 2NARCAN 3 QL(4/30)Smoking Cessation Agentsbupropion hcl sr 3 QL(60/30)CHANTIX 3 QL(336/365)CHANTIX CONTINUING MONTH PAK

3 QL(336/365)

CHANTIX STARTING MONTH PAK

3 QL(336/365)

NICOTROL INHALER 3 QL(1008/90)NICOTROL NS 3 QL(30/30)

Antibacterials

Aminoglycosidesamikacin sulfate 4gentak 2gentamicin sulfate crea 2gentamicin sulfate inj 4gentamicin sulfate oint 2gentamicin sulfate ophthalmic soln

4

gentamicin sulfate pediatric 4gentamicin sulfate/0.9% sodium chloride

4

isotonic gentamicin 4neomycin sulfate 2neomycin/polymyxin b sulfates 4paromomycin sulfate 4streptomycin sulfate 4tobramycin ophthalmic soln 2tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml

4

tobramycin sulfate ophthalmic soln

2

TOBREX OINT 3ZYLET 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

oxycodone/ibuprofen 3 QL(28/30)TALWIN 4tramadol hcl 2 QL(240/30)tramadol hydrochloride/acetaminophen

2 QL(240/30)

trezix caps 320.5mg; 30mg; 16mg

2 QL(300/30)

vicodin es tabs 300mg; 7.5mg 3 QL(180/30)vicodin hp tabs 300mg; 10mg 3 QL(180/30)vicodin tabs 300mg; 5mg 3 QL(360/30)xylon 3 QL(150/30)

Anesthetics

Local Anestheticsglydo 2lidocaine hcl external soln 2lidocaine hcl gel 2lidocaine hcl inj 4lidocaine hcl jelly 2lidocaine hcl mouth/throat soln 1lidocaine hcl viscous 1lidocaine oint 2 QL(120/30)lidocaine ptch 4 PA QL(90/30)lidocaine viscous 1lidocaine/prilocaine crea 2

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-cravingacamprosate calcium dr 2 PAdisulfiram 2Opioid Dependence Treatmentsbuprenorphine hcl inj 4 QL(150/30)buprenorphine hcl subl 4 PA QL(90/30)buprenorphine hcl/naloxone hcl 4 PA QL(90/30)naltrexone hcl 2SUBOXONE 3 PA QL(90/30)ZUBSOLV SUBL 0.7MG; 0.18MG

3 PA QL(30/30)

19



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

metronidazole gel 2metronidazole in nacl 0.79% 4metronidazole inj 4metronidazole lotn 2metronidazole tabs 1metronidazole vaginal 2mupirocin 2neo-polycin 2neo-polycin hc 2neomycin/bacitracin/polymyxin 2neomycin/polymyxin/bacitracin/hydrocortisone

2

neomycin/polymyxin/gramicidin 2neomycin/polymyxin/hydrocortisone

2

nitrofurantoin 4nitrofurantoin macrocrystals 2nitrofurantoin monohydrate 2nitrofurantoin monohydrate/macrocrystals

2

polycin 2polymyxin b sulfate 4polymyxin b sulfate/trimethoprim sulfate

2

PRIMSOL 3rosadan 2silver sulfadiazine 3SSD 3SYNERCID 5tigecycline 5trimethoprim 2trimethoprim sulfate/polymyxin b sulfate

2

TYGACIL 5vancomycin 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antibacterials, Otheralcohol prep pads 1baciim 4bacitracin inj 4bacitracin ophthalmic oint 2bacitracin/polymyxin b 2BACTROBAN NASAL 3chloramphenicol sodium succinate

1

clindacin etz pledgets 2clindacin-p 2clindamycin 4clindamycin hcl 2clindamycin phosphate crea 2clindamycin phosphate external soln

2

clindamycin phosphate gel 2clindamycin phosphate in d5w 4clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml

4

clindamycin phosphate lotn 2clindamycin phosphate pharmacy bulk package

4

clindamycin phosphate swab 2clindamycin/sodium chloride 4colistimethate sodium 4CUBICIN 5 B/D PAdaptomycin 5 B/D PAlincomycin hcl 4linezolid inj 4linezolid susr 5 QL(1800/30)linezolid tabs 5 QL(60/30)methenamine hippurate 2metronidazole crea 2

20


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Beta-lactam, OtherAZACTAM IN ISO-OSMOTIC DEXTROSE

4

aztreonam inj 1gm 4AZTREONAM INJ 2GM 5cefotetan 4imipenem/cilastatin inj 500mg; 500mg

4

imipenem/cilastatin inj 250mg; 250mg

2

INVANZ 4meropenem 4meropenem/sodium chloride 4Beta-lactam, Penicillinsamoxicillin caps 1amoxicillin chew 2amoxicillin susr 1amoxicillin tabs 2amoxicillin/clavulanate potassium

2

amoxicillin/clavulanate potassium er

2

ampicillin 2ampicillin sodium 4ampicillin-sulbactam 4AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML

3

BICILLIN L-A 4dicloxacillin sodium 2nafcillin sodium inj 10gm, 1gm, 2gm

4

nafcillin sodium inj 2gm 5oxacillin sodium inj 10gm 4penicillin g potassium inj 20000000unit, 5000000unit

4

penicillin v potassium oral soln 1penicillin v potassium tabs 250mg

1

penicillin v potassium tabs 500mg

2

PFIZERPEN-G INJ 20MU 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

vancomycin hcl caps 125mg 4 QL(40/10)vancomycin hcl caps 250mg 4 QL(80/10)vancomycin hcl in dextrose 4vancomycin hcl inj 4vandazole 2XIFAXAN TABS 200MG 4 PA QL(9/30)XIFAXAN TABS 550MG 5 PA QL(90/30)Beta-lactam, Cephalosporinscefaclor 2cefaclor er 2cefadroxil 2CEFAZOLIN 4cefazolin sodium inj 10gm, 1gm, 1gm; 5%, 500mg

4

cefazolin sodium/dextrose inj 2gm; 3%

4

cefdinir 2cefepime 4cefepime/dextrose 4cefixime 2cefotaxime sodium inj 1gm, 2gm, 500mg

4

cefoxitin sodium inj 10gm, 1gm, 2gm

4

cefpodoxime proxetil 2cefprozil 2ceftazidime 4ceftazidime/dextrose 4ceftriaxone in iso-osmotic dextrose

4

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

4

cefuroxime axetil 2cefuroxime sodium 4cephalexin caps 250mg, 500mg 1cephalexin susr 2cephalexin tabs 2SUPRAX SUSR 500MG/5ML 3tazicef inj 1gm, 2gm, 6gm 4TEFLARO 5

21



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

erythromycin oint 2erythromycin pads 2ZMAX 3 QL(60/30)QuinolonesAVELOX INJ 4BESIVANCE 4CILOXAN OINT 3CIPRO HC 3CIPRODEX 3ciprofloxacin er tb24 500mg; 0 2 QL(3/3)ciprofloxacin er tb24 1000mg; 0 2 QL(14/14)ciprofloxacin hcl ophthalmic soln

2

ciprofloxacin hcl tabs 100mg, 750mg

2

ciprofloxacin hcl tabs 250mg, 500mg

1

ciprofloxacin i.v.-in d5w 4ciprofloxacin inj 4ciprofloxacin susr 2levofloxacin in d5w 4levofloxacin inj 4levofloxacin oral soln 2levofloxacin tabs 2 QL(30/30)moxifloxacin hcl inj 4moxifloxacin hcl ophthalmic soln

3

moxifloxacin hcl tabs 2 QL(30/30)ofloxacin 2VIGAMOX 3SulfonamidesBLEPHAMIDE 3BLEPHAMIDE S.O.P. 3sodium sulfacetamide ophthalmic soln

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

pfizerpen-g inj 5000000unit 4piperacillin sodium/tazobactam sodium

4

piperacillin/tazobactam 4ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML

4

MacrolidesAZASITE 3azithromycin inj 4azithromycin pack 3azithromycin susr 200mg/5ml 2 QL(75/30)azithromycin susr 100mg/5ml 2 QL(150/30)azithromycin tabs 250mg, 500mg

2 QL(12/28)

azithromycin tabs 600mg 2 QL(60/30)clarithromycin er 2 QL(60/30)clarithromycin susr 2clarithromycin tabs 2 QL(42/14)e.e.s. 400 2E.E.S. GRANULES 3ery 2ERY-TAB 3ERYPED 200 3ERYPED 400 3ERYTHROCIN LACTOBIONATE

4

erythrocin stearate 2erythromycin base 2erythromycin ethylsuccinate susr

3

erythromycin ethylsuccinate tabs

2

erythromycin external soln 2erythromycin gel 2

22


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

BRIVIACT INJ 5 QL(600/30)BRIVIACT ORAL SOLN 5 QL(1200/30)BRIVIACT TABS 10MG, 25MG, 50MG, 75MG

5 QL(60/30)

BRIVIACT TABS 100MG 5 QL(120/30)FYCOMPA SUSP 4 QL(720/30)FYCOMPA TABS 4 QL(30/30)levetiracetam er tb24 750mg 2 QL(120/30)levetiracetam er tb24 500mg 2 QL(180/30)levetiracetam inj 4levetiracetam oral soln 2levetiracetam tabs 2magnesium sulfate in d5w inj 5%; 1gm/100ml

4 B/D PA

roweepra 2SPRITAM TB3D 1000MG, 250MG, 500MG

4 QL(60/30)

SPRITAM TB3D 750MG 4 QL(120/30)Calcium Channel Modifying AgentsCELONTIN 3ethosuximide 2LYRICA CAPS 225MG, 300MG 3 QL(60/30)LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG

3 QL(90/30)

LYRICA ORAL SOLN 3 QL(900/30)zonisamide 2Gamma-aminobutyric Acid (GABA) Augmenting Agentsclonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg

2 QL(90/30)

clonazepam odt tbdp 2mg 2 QL(300/30)clonazepam tabs 0.5mg, 1mg 2 QL(90/30)clonazepam tabs 2mg 2 QL(300/30)DIASTAT ACUDIAL GEL 10MG 4 QL(20/30)DIASTAT ACUDIAL GEL 20MG 4 QL(40/30)DIASTAT PEDIATRIC 4 QL(5/30)diazepam rectal gel gel 2.5mg 3 QL(5/30)diazepam rectal gel gel 10mg 3 QL(20/30)divalproex sodium 2divalproex sodium dr 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sulfacetamide sodium ophthalmic soln

2

sulfacetamide sodium susp 2sulfacetamide sodium/prednisolone sodium phosphate

2

sulfadiazine 2sulfamethoxazole/trimethoprim ds

1

sulfamethoxazole/trimethoprim inj

4

sulfamethoxazole/trimethoprim susp

1

sulfamethoxazole/trimethoprim tabs

1

sulfatrim pediatric 1Tetracyclinesdemeclocycline hcl 2doxy 100 4doxycycline hyclate caps 1doxycycline hyclate inj 4doxycycline hyclate tabs 100mg 1doxycycline hyclate tabs 20mg 2doxycycline monohydrate caps 100mg, 50mg, 75mg

2 QL(60/30)

doxycycline monohydrate tabs 2doxycycline susr 2minocycline hcl 2mondoxyne nl 2 QL(60/30)morgidox 1x100mg caps 1morgidox 1x50mg 1morgidox 2x100mg caps 1tetracycline hcl 1tetracycline hydrochloride caps 500mg

1

Anticonvulsants

Anticonvulsants, OtherAPTIOM TABS 200MG 4 QL(30/30)APTIOM TABS 400MG, 800MG 5 QL(30/30)APTIOM TABS 600MG 5 QL(60/30)

23



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TROKENDI XR CP24 200MG 5 QL(60/30)Sodium Channel AgentsBANZEL SUSP 5 PA QL(2400/30)BANZEL TABS 200MG 5 PA QL(60/30)BANZEL TABS 400MG 5 PA QL(240/30)carbamazepine 2carbamazepine er 2DILANTIN CAPS 30MG 3epitol 2fosphenytoin sodium 4oxcarbazepine 2PEGANONE 3phenytoin 2phenytoin infatabs 2phenytoin sodium 4phenytoin sodium extended 2VIMPAT INJ 4 QL(1200/30)VIMPAT ORAL SOLN 4 QL(1200/30)VIMPAT TABS 4 QL(60/30)

Antidementia Agents

Antidementia Agents, Otherergoloid mesylates 2 PANAMZARIC C4PK 3 QL(56/365)NAMZARIC CP24 3 QL(30/30)Cholinesterase Inhibitorsdonepezil hcl tabs 23mg, 5mg 2 QL(30/30)donepezil hcl tabs 10mg 2 QL(60/30)donepezil hcl tbdp 5mg 2 QL(30/30)donepezil hcl tbdp 10mg 2 QL(60/30)galantamine hydrobromide er 2 QL(30/30)galantamine hydrobromide oral soln

2 QL(200/30)

galantamine hydrobromide tabs 2 QL(60/30)rivastigmine tartrate 2 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

divalproex sodium er 2gabapentin caps 100mg 2 QL(180/30)gabapentin caps 300mg, 400mg

2 QL(270/30)

gabapentin oral soln 2 QL(2160/30)gabapentin tabs 800mg 2 QL(90/30)gabapentin tabs 600mg 2 QL(180/30)GABITRIL TABS 16MG 4 QL(90/30)GABITRIL TABS 12MG 4 QL(120/30)ONFI SUSP 5 QL(480/30)ONFI TABS 20MG 5 QL(60/30)ONFI TABS 10MG 3 QL(30/30)phenobarbital elix 2 QL(1500/30)phenobarbital tabs 2 QL(90/30)primidone 2SABRIL PACK 5 PA QL(200/30)SABRIL TABS 5 PA QL(180/30)tiagabine hydrochloride tabs 4mg

2

tiagabine hydrochloride tabs 2mg

2 QL(240/30)

valproate sodium 4valproic acid 2vigabatrin 5 PA QL(200/30)Glutamate Reducing Agentsfelbamate 4lamotrigine 2lamotrigine er 2lamotrigine odt 2topiramate cpsp 2topiramate tabs 200mg 2 QL(60/30)topiramate tabs 100mg, 25mg, 50mg

2 QL(90/30)

TROKENDI XR CP24 100MG, 25MG, 50MG

4 QL(30/30)

24


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

escitalopram oxalate oral soln 2 QL(600/30)escitalopram oxalate tabs 2 QL(30/30)FETZIMA 4 QL(30/30) STFETZIMA TITRATION PACK 4 QL(56/365) STfluoxetine caps 10mg 2 QL(30/30)fluoxetine caps 20mg 2 QL(120/30)fluoxetine dr 2 QL(4/28)fluoxetine hcl caps 10mg 2 QL(30/30)fluoxetine hcl caps 40mg 2 QL(60/30)fluoxetine hcl caps 20mg 2 QL(120/30)fluoxetine hcl oral soln 2 QL(600/30)fluoxetine hcl tabs 10mg 2 QL(30/30)fluoxetine hcl tabs 20mg 2 QL(120/30)fluvoxamine maleate er 2 QL(60/30)fluvoxamine maleate tabs 25mg, 50mg

2 QL(30/30)

fluvoxamine maleate tabs 100mg

2 QL(90/30)

olanzapine/fluoxetine 2 QL(30/30)paroxetine hcl er tb24 12.5mg 2 QL(30/30)paroxetine hcl er tb24 25mg, 37.5mg

2 QL(60/30)

paroxetine hcl tabs 40mg 2 QL(30/30)paroxetine hcl tabs 30mg 2 QL(60/30)paroxetine hcl tabs 10mg, 20mg

1 QL(30/30)

PAXIL SUSP 3 QL(900/30) STPRISTIQ 4 QL(30/30)sertraline hcl conc 2 QL(300/30)sertraline hcl tabs 25mg, 50mg 2 QL(30/30)sertraline hcl tabs 100mg 2 QL(60/30)venlafaxine hcl 2 QL(90/30)venlafaxine hcl er cp24 37.5mg, 75mg

2 QL(30/30)

venlafaxine hcl er cp24 150mg 2 QL(60/30)venlafaxine hcl er tb24 37.5mg, 75mg

2 QL(30/30)

venlafaxine hcl er tb24 150mg 2 QL(60/30)VIIBRYD 4 QL(30/30) STVIIBRYD STARTER PACK 4 ST

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

rivastigmine transdermal system

2 QL(30/30)

N-methyl-D-aspartate (NMDA) Receptor Antagonistmemantine hcl tabs 10mg 2 PA QL(60/30)memantine hcl tabs 5mg 2 PA QL(90/30)memantine hcl titration pak 2 PA QL(49/28)memantine hydrochloride 2 PA QL(300/30)NAMENDA XR 3 PA QL(30/30)NAMENDA XR TITRATION PACK

3 PA QL(56/365)

Antidepressants

Antidepressants, Otherbupropion hcl er tb12 100mg, 200mg

3 QL(60/30)

bupropion hcl sr 3 QL(60/30)bupropion hcl tabs 75mg 3 QL(60/30)bupropion hcl tabs 100mg 3 QL(120/30)bupropion hcl xl 3 QL(30/30)maprotiline hcl 2 QL(90/30)mirtazapine 2 QL(30/30)mirtazapine odt 2 QL(30/30)nefazodone hcl 2 QL(60/30)trazodone hcl tabs 300mg 2trazodone hcl tabs 100mg, 150mg, 50mg

1

TRINTELLIX 4 QL(30/30) STMonoamine Oxidase InhibitorsEMSAM 5 QL(30/30)MARPLAN 4 QL(180/30)phenelzine sulfate 2tranylcypromine sulfate 2SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitorcitalopram hydrobromide oral soln

1 QL(600/30)

citalopram hydrobromide tabs 1 QL(30/30)desvenlafaxine er 4 QL(30/30)duloxetine hcl cpep 20mg, 60mg

2 QL(60/30)

duloxetine hcl cpep 30mg 2 QL(90/30)

25



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

EMEND SUSR 3 B/D PA QL(6/28)EMEND TRIPACK 3 B/D PA QL(6/28)granisetron hcl inj 4mg/4ml 4 B/D PAgranisetron hcl inj 0.1mg/ml, 1mg/ml

4 B/D PA QL(60/30)

granisetron hcl tabs 2 B/D PA QL(30/30)ondansetron hcl inj 40mg/20ml, 4mg/2ml

4

ondansetron hcl oral soln 2 B/D PA QL(450/30)ondansetron hcl tabs 24mg 1 B/D PA QL(15/30)ondansetron hcl tabs 4mg, 8mg 1 B/D PA QL(90/30)ondansetron odt 1 B/D PA QL(90/30)

Antifungals

AntifungalsABELCET 5 PAAMBISOME 5 PAamphotericin b 4 PACANCIDAS 5 PAcaspofungin acetate 5 PAciclodan 2ciclopirox nail lacquer 2ciclopirox olamine 2ciclopirox sham 2ciclopirox susp 2clotrimazole external crea 2clotrimazole external soln 2clotrimazole troc 2clotrimazole/betamethasone dipropionate

2

econazole nitrate 2fluconazole in dextrose inj 56mg/ml; 400mg/200ml

4

fluconazole in nacl 4fluconazole susr 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Tricyclicsamitriptyline hcl 3 PAamoxapine 2clomipramine hcl 3 PAdesipramine hcl 2doxepin hcl 3 PAimipramine hcl 3 PAimipramine pamoate 3 PAnortriptyline hcl 2perphenazine/amitriptyline 2 PAprotriptyline hcl 2trimipramine maleate 3 PA

Antiemetics

Antiemetics, Othermeclizine hcl tabs 2phenadoz 2phenergan supp 2promethazine hcl plain 2 PApromethazine hcl supp 2promethazine hcl syrp 2 PApromethazine hcl tabs 2 PApromethegan 2scopolamine 4 QL(10/30)TRANSDERM-SCOP 4 QL(10/30)Emetogenic Therapy AdjunctsALOXI 5 B/D PAaprepitant caps 40mg 3 B/D PA QL(1/30)aprepitant caps 125mg 3 B/D PA QL(2/28)aprepitant caps 80mg 3 B/D PA QL(4/28)aprepitant caps 3 B/D PA QL(6/28)dronabinol 4 PA QL(60/30)EMEND CAPS 40MG 3 B/D PA QL(1/30)EMEND CAPS 125MG 3 B/D PA QL(2/28)EMEND CAPS 80MG 3 B/D PA QL(4/28)

26


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antimigraine Agents

Ergot Alkaloidscafergot 2 QL(40/28)dihydroergotamine mesylate inj 4 QL(30/28)ergotamine tartrate/caffeine 2 QL(40/28)migergot 5 QL(20/28)Serotonin (5-HT) 1b/1d Receptor Agonistsnaratriptan hcl 2 QL(9/30)rizatriptan benzoate 2 QL(12/30)rizatriptan benzoate odt 2 QL(12/30)sumatriptan 3 QL(12/30)sumatriptan succinate inj 6mg/0.5ml

2 QL(4/30)

sumatriptan succinate inj 4mg/0.5ml

2 QL(8/30)

sumatriptan succinate refill inj 6mg/0.5ml

2 QL(4/30)

sumatriptan succinate refill inj 4mg/0.5ml

2 QL(8/30)

sumatriptan succinate tabs 2 QL(9/30)

Antimyasthenic Agents

ParasympathomimeticsGUANIDINE HCL 3pyridostigmine bromide 2pyridostigmine bromide er 2REGONOL 4

Antimycobacterials

Antimycobacterials, Otherdapsone 2rifabutin 2AntitubercularsCAPASTAT SULFATE 4cycloserine 2ethambutol hcl 2isoniazid inj 4isoniazid syrp 2isoniazid tabs 100mg 2isoniazid tabs 300mg 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluconazole tabs 100mg, 200mg, 50mg

2

fluconazole tabs 150mg 1flucytosine 5griseofulvin microsize 2griseofulvin ultramicrosize 2itraconazole 4 PA QL(120/30)ketoconazole crea 2ketoconazole sham 2ketoconazole tabs 2naftifine hcl 2naftifine hydrochloride 2NAFTIN CREA 4NAFTIN GEL 3NATACYN 3NOXAFIL SUSP 5 PA QL(600/30)NOXAFIL TBEC 5 PA QL(93/30)nyamyc 2nystatin 2nystatin/triamcinolone 2nystop 2SPORANOX ORAL SOLN 4 PAterbinafine hcl tabs 1 QL(90/365)terconazole 2voriconazole inj 4 PAvoriconazole susr 5 PA QL(300/30)voriconazole tabs 4 PA QL(90/30)

Antigout Agents

Antigout Agentsallopurinol 1allopurinol sodium 4ALOPRIM 4colchicine caps 2 QL(60/30)colchicine tabs 2 QL(120/30)MITIGARE 3 QL(60/30)probenecid 2probenecid/colchicine 2ULORIC 3 QL(30/30) ST

27



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

YONDELIS 5 PAZANOSAR 4 B/D PAAntiandrogensbicalutamide 2 QL(30/30)flutamide 2NILANDRON 5 QL(60/30)nilutamide 5 QL(60/30)XTANDI 5 PA QL(120/30)ZYTIGA TABS 500MG 5 PA QL(60/30)ZYTIGA TABS 250MG 5 PA QL(120/30)Antiangiogenic AgentsPOMALYST 5 PA QL(21/28)REVLIMID CAPS 15MG, 20MG, 25MG

5 PA QL(21/28)

REVLIMID CAPS 10MG, 2.5MG, 5MG

5 PA QL(28/28)

THALOMID CAPS 100MG, 150MG, 50MG

5 PA QL(30/30)

THALOMID CAPS 200MG 5 PA QL(60/30)Antiestrogens/ModifiersEMCYT 3FARESTON 5 QL(30/30)FASLODEX 5 B/D PA QL(30/30)SOLTAMOX 5tamoxifen citrate 2Antimetabolitesadrucil 4 B/D PAALIMTA 5 B/D PAARRANON 4cladribine 4 B/D PAclofarabine 4 B/D PACLOLAR 4 B/D PAcytarabine 4 B/D PAcytarabine aqueous 4 B/D PADROXIA 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PASER 3PRIFTIN 4pyrazinamide 2rifampin caps 2rifampin inj 4RIFATER 3SIRTURO 4 PA QL(188/365)TRECATOR 3

Antineoplastics

Alkylating AgentsBENDEKA 5 B/D PA QL(8/21)BICNU 4 B/D PAbusulfan 5 B/D PABUSULFEX 5 B/D PAcyclophosphamide caps 3 B/D PAcyclophosphamide inj 2gm 5 B/D PAcyclophosphamide inj 1gm, 500mg

4 B/D PA

dacarbazine 4 B/D PAEVOMELA 5 PAGLEOSTINE 3HEXALEN 5ifosfamide 4 B/D PAKISQALI FEMARA 200 DOSE 5 PA QL(49/28)KISQALI FEMARA 400 DOSE 5 PA QL(70/28)KISQALI FEMARA 600 DOSE 5 PA QL(91/28)LEUKERAN 3MATULANE 5melphalan hydrochloride 5 B/D PAMUSTARGEN 4 B/D PATEPADINA 4 PAthiotepa 4 PATREANDA 5 B/D PA QL(8/21)VALCHLOR 5 PA QL(60/30)

28


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HALAVEN 5 PAidarubicin hcl inj 10mg/10ml 5 B/D PAirinotecan 4 B/D PAirinotecan hcl 4 B/D PAISTODAX (OVERFILL) 5 PAIXEMPRA KIT 5 B/D PAJEVTANA 5 B/D PAKISQALI 5 PA QL(63/21)LARTRUVO 5 PAleucovorin calcium inj 100mg, 350mg, 500mg, 50mg

4

leucovorin calcium tabs 2levoleucovorin calcium 5levoleucovorin inj 175mg/17.5ml, 250mg/25ml, 50mg

5

LYNPARZA TABS 5 PA QL(120/30)mesna 2 B/D PAMESNEX TABS 5mitomycin inj 40mg 5 B/D PAmitomycin inj 20mg, 5mg 4 B/D PAmitoxantrone hcl 2 B/D PANERLYNX 5 PA QL(180/30)NINLARO 5 PA QL(3/28)ODOMZO 5 PA QL(30/30)oxaliplatin inj 100mg 5 B/D PAoxaliplatin inj 100mg/20ml, 50mg/10ml

4 B/D PA

paclitaxel 4 B/D PAPORTRAZZA 5 PA QL(100/21)PROLEUKIN 5 B/D PARUBRACA 5 PA QL(120/30)RYDAPT 5 PA QL(224/28)SYLATRON 5 PA QL(4/28)SYNRIBO 5 PA QL(28/28)TRISENOX 4 B/D PAVELCADE 5 B/D PA QL(14/21)VENCLEXTA STARTING PACK 5 PA QL(84/365)VENCLEXTA TABS 100MG 5 PA QL(120/30)VENCLEXTA TABS 50MG 4 PA QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ELITEK 5 B/D PAfluorouracil inj 4 B/D PAFOLOTYN 5 B/D PAgemcitabine 4 B/D PAgemcitabine hcl inj 200mg, 2gm 4 B/D PAgemcitabine hcl inj 1gm 5 B/D PAhydroxyurea 2LONSURF TABS 8.19MG; 20MG

5 PA QL(80/28)

LONSURF TABS 6.14MG; 15MG

5 PA QL(100/28)

mercaptopurine 2NIPENT 5 B/D PAPURIXAN 5 PA QL(300/30)TABLOID 3VYXEOS 5 B/D PAAntineoplasticsdocetaxel inj 200mg/10ml 5 B/D PAAntineoplastics, OtherABRAXANE 5 B/D PAazacitidine 5 B/D PABELEODAQ 5 PAbleomycin sulfate 4 B/D PAcarboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml

4 B/D PA

cisplatin 4 B/D PACOSMEGEN 5 B/D PAdaunorubicin hcl 4 B/D PAdecitabine 5dexrazoxane 4 B/D PAdocetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml

5 B/D PA

doxorubicin hcl 2 B/D PAdoxorubicin hcl liposome 5 B/D PAepirubicin hcl inj 200mg/100ml 5 B/D PAERWINAZE 5 B/D PA QL(60/28)ETHYOL 5 B/D PAfludarabine phosphate 4 B/D PAFUSILEV 5

29



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

COMETRIQ KIT 20MG 5 PA QL(84/28)COMETRIQ KIT 5 PA QL(112/28)COTELLIC 5 PA QL(63/28)ERIVEDGE 5 PA QL(30/30)FARYDAK 5 PA QL(6/21)GILOTRIF 5 PA QL(30/30)IBRANCE 5 PA QL(21/28)ICLUSIG TABS 45MG 5 PA QL(30/30)ICLUSIG TABS 15MG 5 PA QL(60/30)IDHIFA 5 PA QL(30/30)imatinib mesylate 5 PA QL(60/30)IMBRUVICA 5 PA QL(120/30)INLYTA 5 PA QL(120/30)IRESSA 5 PA QL(30/30)JAKAFI 5 PA QL(60/30)KISQALI 5 PA QL(63/21)LENVIMA 10 MG DAILY DOSE 5 PA QL(30/30)LENVIMA 14 MG DAILY DOSE 5 PA QL(60/30)LENVIMA 18 MG DAILY DOSE 5 PA QL(90/30)LENVIMA 20 MG DAILY DOSE 5 PA QL(60/30)LENVIMA 24 MG DAILY DOSE 5 PA QL(90/30)LENVIMA 8 MG DAILY DOSE 5 PA QL(60/30)LYNPARZA CAPS 5 PA QL(480/30)MEKINIST TABS 2MG 5 PA QL(30/30)MEKINIST TABS 0.5MG 5 PA QL(90/30)NEXAVAR 5 PA QL(120/30)SPRYCEL 5 PA QL(30/30)STIVARGA 5 PA QL(84/28)SUTENT 5 PA QL(28/28)TAFINLAR 5 PA QL(120/30)TAGRISSO 5 PA QL(30/30)TARCEVA TABS 100MG, 150MG

5 PA QL(30/30)

TARCEVA TABS 25MG 5 PA QL(60/30)TASIGNA 5 PA QL(120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VENCLEXTA TABS 10MG 4 PA QL(60/30)vinblastine sulfate 4 B/D PAvincasar pfs 4 B/D PAvincristine sulfate 4 B/D PAvinorelbine tartrate 4 B/D PAZEJULA 5 PA QL(90/30)ZOLINZA 5 QL(120/30)Aromatase Inhibitors, 3rd Generationanastrozole 2 QL(30/30)exemestane 2 QL(60/30)letrozole 2 QL(30/30)Enzyme Inhibitorsetoposide inj 3 B/D PAKYPROLIS 5 B/D PAtoposar 3 B/D PAtopotecan hcl inj 4mg 5Molecular Target InhibitorsAFINITOR DISPERZ TBSO 2MG, 3MG

5 PA QL(60/30)

AFINITOR DISPERZ TBSO 5MG

5 PA QL(120/30)

AFINITOR TABS 2.5MG, 5MG, 7.5MG

5 PA QL(30/30)

AFINITOR TABS 10MG 5 PA QL(60/30)ALECENSA 5 PA QL(240/30)ALIQOPA 5 PA QL(3/28)ALUNBRIG 5 PA QL(180/30)BOSULIF TABS 500MG 5 PA QL(30/30)BOSULIF TABS 100MG 5 PA QL(120/30)CABOMETYX TABS 20MG, 60MG

5 PA QL(30/30)

CABOMETYX TABS 40MG 5 PA QL(60/30)CAPRELSA TABS 300MG 5 PA QL(30/30)CAPRELSA TABS 100MG 5 PA QL(60/30)COMETRIQ KIT 5 PA QL(56/28)

30


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ivermectin 2AntiprotozoalsALINIA SUSR 3 QL(150/30)ALINIA TABS 3 QL(20/30)atovaquone 4atovaquone/proguanil hcl 2chloroquine phosphate 2COARTEM 3 QL(24/30)DARAPRIM 5 QL(90/30)hydroxychloroquine sulfate 2mefloquine hcl 2NEBUPENT 3 B/D PA QL(6/28)PENTAM 300 3PRIMAQUINE PHOSPHATE 3 QL(90/30)quinine sulfate 1 QL(42/7)Pediculicides/Scabicideslindane 2malathion 4permethrin 2

Antiparkinson Agents

Anticholinergicsbenztropine mesylate inj 4benztropine mesylate tabs 2 PAtrihexyphenidyl hcl 2 PAAntiparkinson Agents, Otherentacapone 4 QL(240/30)tolcapone 5Dopamine AgonistsAPOKYN 5 PA QL(60/30)bromocriptine mesylate 2NEUPRO 4 QL(30/30)pramipexole dihydrochloride 2 QL(90/30)pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg

2 QL(30/30)

pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg

2 QL(90/30)

ropinirole hcl 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

TYKERB 5 PA QL(180/30)VOTRIENT 5 PA QL(120/30)XALKORI 5 PA QL(60/30)ZALTRAP 5 PA QL(40/28)ZELBORAF 5 PA QL(240/30)ZYDELIG 5 PA QL(60/30)ZYKADIA 5 PA QL(150/30)Monoclonal AntibodiesAVASTIN 5 B/D PABAVENCIO 5 PABESPONSA 5 PACYRAMZA 5 PADARZALEX 5 PAEMPLICITI 5 PAERBITUX 5 B/D PAGAZYVA 5 PAHERCEPTIN 5 B/D PAIMFINZI 5 PAKADCYLA 5 PAKEYTRUDA 5 PAMYLOTARG 5 PAOPDIVO 5 PA QL(80/28)PERJETA 5 PARITUXAN 5 PARITUXAN HYCELA 5 PATECENTRIQ 5 PA QL(20/21)UNITUXIN 5 PAVECTIBIX 5 B/D PAYERVOY INJ 200MG/40ML 5 B/D PA QL(80/21)YERVOY INJ 50MG/10ML 5 B/D PA QL(300/21)Retinoidsbexarotene 5PANRETIN 5TARGRETIN GEL 5 QL(60/30)tretinoin caps 5

Antiparasitics

AnthelminticsALBENZA 4BILTRICIDE 4

31



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

loxapine succinate caps 10mg, 5mg

2 QL(120/30)

perphenazine 2pimozide 2prochlorperazine 2prochlorperazine edisylate 4prochlorperazine maleate tabs 10mg

1

prochlorperazine maleate tabs 5mg

2

thioridazine hcl 2thiothixene caps 10mg, 1mg, 5mg

2

thiothixene caps 2mg 1trifluoperazine hcl 22nd Generation/AtypicalABILIFY MAINTENA 5 PA QL(1/30)aripiprazole odt 5 QL(60/30) STaripiprazole oral soln 2 QL(900/30) STaripiprazole tabs 2 QL(30/30) STARISTADA INJ 441MG/1.6ML 5 QL(1.6/30)ARISTADA INJ 662MG/2.4ML 5 QL(2.4/30)ARISTADA INJ 882MG/3.2ML 5 QL(3.2/30)ARISTADA INJ 1064MG/3.9ML 5 QL(3.9/60)FANAPT TABS 10MG, 12MG, 6MG, 8MG

5 QL(60/30) ST

FANAPT TABS 1MG, 2MG, 4MG

4 QL(60/30) ST

FANAPT TITRATION PACK 4 QL(16/365) STGEODON INJ 4 QL(6/30)INVEGA SUSTENNA INJ 39MG/0.25ML

4 QL(0.25/28)

INVEGA SUSTENNA INJ 78MG/0.5ML

5 QL(0.5/28)


5 QL(0.75/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitorscarbidopa 2carbidopa/levodopa 2carbidopa/levodopa er 2carbidopa/levodopa odt 2carbidopa/levodopa/entacapone

3

RYTARY 4 STMonoamine Oxidase B (MAO-B) InhibitorsAZILECT 3 QL(30/30)rasagiline mesylate 3 QL(30/30)selegiline hcl 2

Antipsychotics

1st Generation/Typicalchlorpromazine hcl inj 4chlorpromazine hcl tabs 2compro 2fluphenazine decanoate 4fluphenazine hcl conc 2fluphenazine hcl elix 2fluphenazine hcl inj 4fluphenazine hcl tabs 1mg 1fluphenazine hcl tabs 10mg, 2.5mg, 5mg

2

haloperidol conc 2haloperidol decanoate 4haloperidol lactate 4haloperidol tabs 0.5mg, 1mg, 2mg, 5mg

1

haloperidol tabs 10mg, 20mg 2loxapine caps 25mg, 50mg 2loxapine caps 10mg, 5mg 2 QL(120/30)loxapine succinate caps 25mg, 50mg

2

32


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

risperidone tabs 4mg 2 QL(120/30)SAPHRIS 4 QL(60/30) STVRAYLAR CAPS 5 QL(30/30) STVRAYLAR CPPK 4 QL(14/365) STziprasidone hcl 2 QL(60/30)ZYPREXA RELPREVV INJ 210MG

4 QL(2/28)

ZYPREXA RELPREVV INJ 405MG

5 QL(1/28)

ZYPREXA RELPREVV INJ 300MG

5 QL(2/28)

Treatment-Resistantclozapine odt tbdp 12.5mg, 25mg

3

clozapine odt tbdp 150mg 3 QL(180/30)clozapine odt tbdp 100mg 3 QL(270/30)clozapine odt tbdp 200mg 5 QL(120/30)clozapine tabs 25mg, 50mg 3clozapine tabs 200mg 3 QL(120/30)clozapine tabs 100mg 3 QL(270/30)VERSACLOZ 4 QL(540/30)

Antispasticity Agents

Antispasticity Agentsbaclofen tabs 10mg 1baclofen tabs 20mg 2dantrolene sodium 2tizanidine hcl 2

Antivirals

Anti-cytomegalovirus (CMV) Agentscidofovir 5FOSCAVIR 4ganciclovir inj 500mg 4 B/D PAVALCYTE ORAL SOLN 5valganciclovir 5valganciclovir hydrochlorde 5ZIRGAN 3 STAnti-hepatitis B (HBV) Agentsadefovir dipivoxil 5 QL(30/30)BARACLUDE ORAL SOLN 3 QL(630/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

INVEGA SUSTENNA INJ 156MG/ML

5 QL(1/28)


5 QL(1.5/28)

INVEGA TRINZA INJ 273MG/0.875ML

5 QL(0.88/90)


5 QL(1.32/90)


5 QL(1.75/90)


5 QL(2.63/90)

LATUDA TABS 120MG, 20MG, 40MG, 60MG

5 QL(30/30) ST

LATUDA TABS 80MG 5 QL(60/30) STNUPLAZID 5 PA QL(60/30)olanzapine inj 4 QL(30/30)olanzapine odt 2 QL(30/30)olanzapine tabs 2 QL(30/30)paliperidone er tb24 1.5mg, 3mg

2 QL(30/30) ST

paliperidone er tb24 6mg 2 QL(60/30) STpaliperidone er tb24 9mg 5 QL(30/30) STquetiapine fumarate 2 QL(60/30)quetiapine fumarate er tb24 150mg, 200mg

3 QL(30/30)

quetiapine fumarate er tb24 300mg, 400mg, 50mg

3 QL(60/30)

REXULTI 5 QL(30/30) STRISPERDAL CONSTA INJ 50MG

5 QL(2/28)

RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG

4 QL(2/28)

risperidone m-tab tbdp 0.5mg, 1mg, 2mg, 3mg

2 QL(60/30)

risperidone m-tab tbdp 4mg 2 QL(120/30)risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg

2 QL(60/30)

risperidone odt tbdp 4mg 2 QL(120/30)risperidone oral soln 2 QL(240/30)risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg

2 QL(60/30)

33



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nevirapine er tb24 400mg 2 QL(30/30)nevirapine er tb24 100mg 2 QL(90/30)nevirapine susp 3 QL(1200/30)nevirapine tabs 2 QL(60/30)ODEFSEY 5 QL(30/30)RESCRIPTOR TABS 200MG 3 QL(180/30)RESCRIPTOR TABS 100MG 3 QL(270/30)STRIBILD 5 QL(30/30)SUSTIVA CAPS 200MG 5 QL(60/30)SUSTIVA CAPS 50MG 3 QL(90/30)SUSTIVA TABS 5 QL(30/30)VIRAMUNE SUSP 4 QL(1200/30)Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)abacavir sulfate/lamivudine/zidovudine

5 QL(60/30)

abacavir tabs 4 QL(60/30)abacavir/lamivudine 5 QL(30/30)DESCOVY 5 QL(30/30)didanosine 2 QL(30/30)EMTRIVA CAPS 3 QL(30/30)EMTRIVA ORAL SOLN 3 QL(680/28)EPZICOM 5 QL(30/30)lamivudine oral soln 2 QL(900/30)lamivudine tabs 300mg 2 QL(30/30)lamivudine tabs 150mg 2 QL(60/30)lamivudine/zidovudine 4 QL(60/30)RETROVIR IV INFUSION 4stavudine 2 QL(60/30)TRIUMEQ 5 QL(30/30)TRUVADA 5 QL(30/30)VIDEX PEDIATRIC ORAL SOLN 2GM

3 QL(900/30)

VIDEX PEDIATRIC ORAL SOLN 4GM

3 QL(1200/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

entecavir 4 QL(30/30)EPIVIR HBV ORAL SOLN 3INTRON A INJ 6000000UNIT/ML

4

INTRON A INJ 10MU, 10MU/ML, 18MU, 50MU

5

INTRON A W/DILUENT 5lamivudine tabs 100mg 2Anti-hepatitis C (HCV) AgentsEPCLUSA 5 PA QL(28/28)HARVONI 5 PA QL(28/28)PEG-INTRON REDIPEN 5 PA QL(4/28)PEGASYS INJ 180MCG/0.5ML 5 PA QL(2/28)PEGASYS INJ 180MCG/ML 5 PA QL(4/28)PEGASYS PROCLICK 5 PA QL(2/28)PEGINTRON 5 PA QL(4/28)ribavirin caps 3 QL(168/28)ribavirin tabs 3 QL(168/28)SOVALDI 5 PA QL(28/28)Anti-HIV Agents, Integrase Inhibitors (INSTI)GENVOYA 5 QL(30/30)ISENTRESS CHEW 100MG 5 QL(180/30)ISENTRESS CHEW 25MG 3 QL(180/30)ISENTRESS HD 5 QL(60/30)ISENTRESS PACK 5 QL(180/30)ISENTRESS TABS 5 QL(60/30)TIVICAY TABS 50MG 5 QL(60/30)TIVICAY TABS 10MG, 25MG 4 QL(60/30)Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)COMPLERA 5 QL(30/30)EDURANT 5 QL(30/30)INTELENCE TABS 100MG, 200MG

5 QL(60/30)

INTELENCE TABS 25MG 4 QL(120/30)

34


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PREZISTA TABS 150MG 4 QL(180/30)PREZISTA TABS 75MG 4 QL(210/30)REYATAZ CAPS 150MG, 300MG

5 QL(30/30)

REYATAZ CAPS 200MG 5 QL(60/30)REYATAZ PACK 5 QL(180/30)VIRACEPT TABS 625MG 5 QL(120/30)VIRACEPT TABS 250MG 5 QL(270/30)Anti-influenzaAgentsamantadine hcl 2oseltamivir phosphate caps 45mg, 75mg

3 QL(56/365)

oseltamivir phosphate caps 30mg

3 QL(112/365)

rimantadine hcl 2TAMIFLU CAPS 45MG, 75MG 3 QL(56/365)TAMIFLU CAPS 30MG 3 QL(112/365)TAMIFLU SUSR 3 QL(700/365)Antiherpetic Agentsacyclovir caps 2acyclovir oint 2 QL(30/30)acyclovir sodium inj 50mg/ml 4 B/D PAacyclovir susp 2acyclovir tabs 2DENAVIR 5 QL(5/30)famciclovir 2 QL(60/30)trifluridine 2valacyclovir hcl 2 QL(30/30)ZOVIRAX CREA 4 QL(5/30)

Anxiolytics

Anxiolytics, Otherbuspirone hcl tabs 10mg, 5mg 1buspirone hcl tabs 15mg, 30mg, 7.5mg

2

Benzodiazepinesalprazolam odt tbdp 0.25mg, 0.5mg, 1mg

2 QL(90/30)

alprazolam odt tbdp 2mg 2 QL(150/30)alprazolam tabs 0.25mg, 0.5mg, 1mg

2 QL(90/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VIREAD POWD 5 QL(240/30)VIREAD TABS 5 QL(30/30)ZERIT ORAL SOLN 3 QL(2400/30)ZIAGEN ORAL SOLN 3 QL(960/30)zidovudine caps 2 QL(180/30)zidovudine syrp 2 QL(1680/28)zidovudine tabs 2 QL(60/30)Anti-HIV Agents, OtherATRIPLA 5 QL(30/30)FUZEON 5 QL(60/30)SELZENTRY ORAL SOLN 5 QL(1610/26)SELZENTRY TABS 150MG, 75MG

5 QL(60/30)

SELZENTRY TABS 300MG 5 QL(120/30)SELZENTRY TABS 25MG 4 QL(240/30)TYBOST 3 QL(30/30)Anti-HIV Agents, Protease InhibitorsAPTIVUS CAPS 5 QL(120/30)APTIVUS ORAL SOLN 5 QL(285/28)CRIXIVAN CAPS 400MG 3 QL(180/30)CRIXIVAN CAPS 200MG 3 QL(270/30)EVOTAZ 5 QL(30/30)fosamprenavir calcium 5 QL(120/30)INVIRASE CAPS 5 QL(300/30)INVIRASE TABS 5 QL(120/30)KALETRA ORAL SOLN 4 QL(480/30)KALETRA TABS 100MG; 25MG

4 QL(300/30)

KALETRA TABS 200MG; 50MG

5 QL(120/30)

LEXIVA SUSP 4 QL(1575/28)LEXIVA TABS 5 QL(120/30)lopinavir/ritonavir 4 QL(480/30)NORVIR CAPS 3 QL(360/30)NORVIR ORAL SOLN 3 QL(480/30)NORVIR TABS 3 QL(360/30)PREZCOBIX 5 QL(30/30)PREZISTA SUSP 5 QL(400/30)PREZISTA TABS 800MG 5 QL(30/30)PREZISTA TABS 600MG 5 QL(60/30)

35



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

glipizide tabs 10mg 1 QL(120/30)glipizide xl tb24 2.5mg, 5mg 1 QL(30/30)glipizide xl tb24 10mg 1 QL(60/30)glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg

1 QL(120/30)

glipizide/metformin hcl tabs 2.5mg; 250mg

1 QL(240/30)

GLYXAMBI 4 QL(30/30)INVOKAMET 3 QL(60/30)INVOKAMET XR 3 QL(60/30)INVOKANA 3 QL(30/30)JANUMET 3 QL(60/30)JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG

3 QL(30/30)

JANUMET XR TB24 1000MG; 50MG

3 QL(60/30)

JANUVIA 3 QL(30/30)JARDIANCE 4 QL(30/30)JENTADUETO 3 QL(60/30)JENTADUETO XR TB24 5MG; 1000MG

3 QL(30/30)

JENTADUETO XR TB24 2.5MG; 1000MG

3 QL(60/30)

Metformin hcl er tb24 500mg, 1000mg (generic for Fortamet)

1 QL(60/30)

Metformin hcl er tb24 750mg (generic for Glucophage XR)

1 QL(60/30)

Metformin hcl er tb24 500mg (generic for Glucophage XR)

1 QL(120/30)

metformin hcl tabs 1000mg 1 QL(60/30)metformin hcl tabs 850mg 1 QL(90/30)metformin hcl tabs 500mg 1 QL(150/30)miglitol 2 QL(90/30)nateglinide 2 QL(90/30)pioglitazone hcl 2 QL(30/30)pioglitazone hcl-glimepiride 2 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

alprazolam tabs 2mg 2 QL(150/30)clorazepate dipotassium tabs 3.75mg, 7.5mg

2 QL(90/30)

clorazepate dipotassium tabs 15mg

2 QL(180/30)

diazepam inj 5mg/ml 2diazepam oral soln 2 QL(1200/30)diazepam tabs 2 QL(120/30)lorazepam conc 2 QL(150/30)lorazepam inj 2mg/ml, 4mg/ml 4lorazepam intensol 2 QL(150/30)lorazepam tabs 0.5mg, 1mg 2 QL(90/30)lorazepam tabs 2mg 2 QL(150/30)oxazepam 2 QL(120/30)

Bipolar Agents

Mood Stabilizerslithium carbonate caps 300mg 1lithium carbonate caps 150mg, 600mg

2

lithium carbonate er 2lithium carbonate tabs 2

Blood Glucose Regulators

Antidiabetic Agentsacarbose 2 QL(90/30)BYDUREON 3 QL(4/28)BYDUREON PEN 3 QL(4/28)BYETTA INJ 5MCG/0.02ML 3 QL(1.2/30)BYETTA INJ 10MCG/0.04ML 3 QL(2.4/30)CYCLOSET 4 QL(180/30)FARXIGA 3 QL(30/30)glimepiride 1 QL(60/30)glipizide er tb24 2.5mg, 5mg 1 QL(30/30)glipizide er tb24 10mg 1 QL(60/30)glipizide tabs 5mg 1 QL(60/30)

36


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LANTUS 3LANTUS SOLOSTAR 3LEVEMIR 3LEVEMIR FLEXTOUCH 3SOLIQUA 100/33 3 QL(18/30) STTOUJEO SOLOSTAR 3 QL(9/30)TRESIBA FLEXTOUCH 3XULTOPHY 100/3.6 3 QL(15/30) ST

BloodProducts/Modifiers/VolumeExpanders

AnticoagulantsCOUMADIN 4enoxaparin sodium inj 30mg/0.3ml

4 QL(9/90)

enoxaparin sodium inj 40mg/0.4ml

4 QL(12/90)

enoxaparin sodium inj 60mg/0.6ml

4 QL(18/90)

enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml

4 QL(24/90)

enoxaparin sodium inj 100mg/ml, 150mg/ml, 300mg/3ml

4 QL(30/90)

fondaparinux sodium inj 2.5mg/0.5ml

4 QL(15/90)

fondaparinux sodium inj 5mg/0.4ml

5 QL(12/90)

fondaparinux sodium inj 7.5mg/0.6ml

5 QL(18/90)

fondaparinux sodium inj 10mg/0.8ml

5 QL(24/90)

heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml

4

heparin sodium/d5w 4heparin sodium/nacl 0.45% inj 50unit/ml; 0.45%

4

heparin sodium/nacl 0.9% 4heparin sodium/sodium chloride 0.9%

4

heparin sodium/sodium chloride 0.9% premix

4

jantoven 1PRADAXA 3 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

pioglitazone hcl/metformin hcl 2 QL(90/30)repaglinide tabs 0.5mg, 1mg 2 QL(120/30)repaglinide tabs 2mg 2 QL(240/30)RIOMET 3 QL(750/30)SYMLINPEN 120 5 PA QL(10.8/28)SYMLINPEN 60 3 PA QL(6/30)SYNJARDY 4 QL(60/30)SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG

4 QL(30/30)

SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG

4 QL(60/30)

TRADJENTA 3 QL(30/30)TRULICITY 3 QL(2/28)VICTOZA 3 QL(9/30)XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 5MG; 500MG

3 QL(30/30)

XIGDUO XR TB24 5MG; 1000MG

3 QL(60/30)

Glycemic AgentsGLUCAGEN HYPOKIT 3 QL(4/30)GLUCAGON EMERGENCY KIT

3 QL(4/30)

PROGLYCEM 4InsulinsHUMALOG 3HUMALOG KWIKPEN 3HUMALOG MIX 50/50 3HUMALOG MIX 50/50 KWIKPEN

3

HUMALOG MIX 75/25 3HUMALOG MIX 75/25 KWIKPEN

3

HUMULIN 70/30 3HUMULIN 70/30 KWIKPEN 3HUMULIN N 3HUMULIN N KWIKPEN 3HUMULIN R 3HUMULIN R U-500 (CONCENTRATED)

3

HUMULIN R U-500 KWIKPEN 3

37



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NEUPOGEN INJ 300MCG/ML 5 PA QL(14/28)NEUPOGEN INJ 480MCG/1.6ML

5 PA QL(22.4/30)

PROCRIT INJ 40000UNIT/ML 5 PA QL(6/28)PROCRIT INJ 20000UNIT/ML 5 PA QL(12/28)PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

4 PA QL(12/28)

PROMACTA 5 PA QL(30/30)Coagulantstranexamic acid inj 2 PAtranexamic acid tabs 2 QL(30/28)Platelet Modifying Agentsaspirin/dipyridamole 2 QL(60/30)BRILINTA 3 QL(60/30)cilostazol 2clopidogrel tabs 300mg 2 QL(2/365)clopidogrel tabs 75mg 2 QL(30/30)EFFIENT 4 QL(30/30)prasugrel 4 QL(30/30)

Cardiovascular Agents

Alpha-adrenergic Agonistsclonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr

2 QL(4/28)

clonidine hcl ptwk 0.3mg/24hr 2 QL(8/28)clonidine hcl tabs 0.3mg 2clonidine hcl tabs 0.1mg, 0.2mg 1midodrine hcl 2Alpha-adrenergic Blocking Agentsphenoxybenzamine hydrochloride

5

prazosin hcl 2Angiotensin II Receptor AntagonistsBENICAR 4 QL(30/30) STBENICAR HCT 4 QL(30/30) ST

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SAVAYSA 4 QL(30/30)warfarin sodium 1XARELTO STARTER PACK 3 QL(102/365)XARELTO TABS 20MG 3 QL(30/30)XARELTO TABS 10MG 3 QL(35/90)XARELTO TABS 15MG 3 QL(60/30)BloodFormationModifiersanagrelide hydrochloride 2ARANESP ALBUMIN FREE INJ 60MCG/0.3ML

4 PA QL(1.2/28)

ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML

4 PA QL(1.6/28)

ARANESP ALBUMIN FREE INJ 25MCG/0.42ML

4 PA QL(1.68/28)

ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML

4 PA QL(4/28)

ARANESP ALBUMIN FREE INJ 500MCG/ML

5 PA QL(1/21)


5 PA QL(1.2/28)


5 PA QL(1.6/28)


5 PA QL(2/28)


5 PA QL(2.4/28)

ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML

5 PA QL(4/28)

LEUKINE INJ 250MCG 5 PAMOZOBIL 5 QL(9.6/30)NEULASTA 5 PA QL(1.2/28)NEULASTA ONPRO KIT 5 PA QL(1.2/28)NEUPOGEN INJ 300MCG/0.5ML

5 PA QL(7/28)

NEUPOGEN INJ 480MCG/0.8ML

5 PA QL(11.2/28)

38


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lisinopril 1 QL(60/30)lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg

1 QL(30/30)

lisinopril/hydrochlorothiazide tabs 25mg; 20mg

1 QL(60/30)

lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg

1 QL(120/30)

moexipril hcl 2moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg

2 QL(30/30)

moexipril/hydrochlorothiazide tabs 12.5mg; 15mg, 25mg; 15mg

2 QL(60/30)

perindopril erbumine tabs 2mg, 4mg

1 QL(30/30)

perindopril erbumine tabs 8mg 1 QL(60/30)quinapril hcl 1 QL(60/30)quinapril/hydrochlorothiazide tabs 12.5mg; 10mg

2 QL(30/30)

quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg

2 QL(60/30)

ramipril 1 QL(60/30)trandolapril tabs 1mg, 2mg 2 QL(30/30)trandolapril tabs 4mg 2 QL(60/30)Antiarrhythmicsamiodarone hcl inj 4amiodarone hcl tabs 2dofetilide 3 QL(60/30)flecainide acetate 2lidocaine hcl inj 4mexiletine hcl 2MULTAQ 3 QL(60/30)pacerone 2propafenone hcl 2propafenone hcl er 2quinidine sulfate 2sorine 2sotalol hcl 2sotalol hcl (af) 2TIKOSYN 4 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

candesartan cilexetil 2 QL(30/30)candesartan cilexetil/hydrochlorothiazide

2 QL(30/30)

ENTRESTO 3 QL(60/30)irbesartan 1 QL(30/30)irbesartan/hydrochlorothiazide 1 QL(30/30)losartan potassium tabs 100mg, 25mg

1 QL(30/30)

losartan potassium tabs 50mg 1 QL(60/30)losartan potassium/hydrochlorothiazide

1 QL(30/30)

olmesartan medoxomil 4 QL(30/30)olmesartan medoxomil/hydrochlorothiazide

4 QL(30/30)

telmisartan 2 QL(30/30)telmisartan/amlodipine 2 QL(30/30)telmisartan/hydrochlorothiazide 2 QL(30/30)valsartan 2 QL(30/30)valsartan/hydrochlorothiazide 2 QL(30/30)Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl tabs 10mg, 20mg, 5mg

1 QL(30/30)

benazepril hcl tabs 40mg 1 QL(60/30)benazepril hcl/hydrochlorothiazide

2 QL(30/30)

captopril tabs 12.5mg, 25mg 1 QL(90/30)captopril tabs 100mg 1 QL(120/30)captopril tabs 50mg 1 QL(270/30)captopril/hydrochlorothiazide tabs 25mg; 25mg, 50mg; 25mg

2 QL(60/30)

captopril/hydrochlorothiazide tabs 25mg; 15mg, 50mg; 15mg

2 QL(90/30)

enalapril maleate 1 QL(60/30)enalapril maleate/hydrochlorothiazide tabs 5mg; 12.5mg

1 QL(30/30)

enalapril maleate/hydrochlorothiazide tabs 10mg; 25mg

1 QL(60/30)

fosinopril sodium 2 QL(60/30)fosinopril sodium/hydrochlorothiazide

2 QL(120/30)

39



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Calcium Channel Blocking Agentsafeditab cr tb24 30mg 2 QL(30/30)afeditab cr tb24 60mg 2 QL(60/30)amlodipine besylate tabs 10mg, 2.5mg

1 QL(30/30)

amlodipine besylate tabs 5mg 1 QL(45/30)amlodipine besylate/benazepril hydrochloride

2 QL(30/30)

amlodipine besylate/valsartan 2 QL(30/30)amlodipine/olmesartan medoxomil

4 QL(30/30)

amlodipine/valsartan/hctz 2 QL(30/30)AZOR 4 QL(30/30) STcartia xt cp24 120mg, 300mg 2 QL(30/30)cartia xt cp24 180mg, 240mg 2 QL(60/30)dilt-xr cp24 120mg 2 QL(30/30)dilt-xr cp24 180mg, 240mg 2 QL(60/30)diltiazem cd cp24 240mg 2 QL(60/30)diltiazem hcl cd 2 QL(30/30)diltiazem hcl er cp12 2diltiazem hcl er cp24 120mg, 300mg, 360mg, 420mg

2 QL(30/30)

diltiazem hcl er cp24 180mg, 240mg

2 QL(60/30)

diltiazem hcl er tb24 300mg, 360mg, 420mg

2 QL(30/30)

diltiazem hcl er tb24 180mg, 240mg

2 QL(60/30)

diltiazem hcl inj 4diltiazem hcl tabs 2felodipine er 2 QL(30/30)isradipine 2matzim la tb24 300mg, 360mg, 420mg

2 QL(30/30)

matzim la tb24 180mg, 240mg 2 QL(60/30)nicardipine hcl caps 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Beta-adrenergic Blocking Agentsacebutolol hcl 2atenolol 1atenolol/chlorthalidone 1betaxolol hcl 2bisoprolol fumarate 2bisoprolol fumarate/hydrochlorothiazide

1

BYSTOLIC TABS 10MG, 2.5MG, 5MG

3 QL(30/30)

BYSTOLIC TABS 20MG 3 QL(60/30)BYVALSON 3 QL(30/30)carvedilol 1COREG CR 3 QL(30/30)labetalol hcl inj 4labetalol hcl tabs 2metoprolol succinate er 2 QL(60/30)metoprolol tartrate inj 4metoprolol tartrate tabs 1metoprolol/hydrochlorothiazide 2nadolol 2nadolol/bendroflumethiazide tabs 5mg; 80mg

2

nadolol/bendroflumethiazide tabs 5mg; 40mg

2 QL(30/30)

pindolol 1propranolol hcl er 2propranolol hcl inj 4propranolol hcl oral soln 2propranolol hcl tabs 60mg 2propranolol hcl tabs 10mg, 20mg, 40mg, 80mg

1

propranolol/hydrochlorothiazide 2timolol maleate tabs 2

40


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Diuretics, Loopbumetanide inj 4bumetanide tabs 0.5mg, 1mg 1bumetanide tabs 2mg 2ethacrynate sodium 4furosemide inj 2furosemide oral soln 2furosemide tabs 1torsemide 2Diuretics, Potassium-sparingamiloride hcl 2amiloride/hydrochlorothiazide 1spironolactone tabs 25mg 1spironolactone tabs 100mg, 50mg

2

spironolactone/hydrochlorothiazide

2

triamterene/hydrochlorothiazide caps 25mg; 50mg

2

triamterene/hydrochlorothiazide caps 25mg; 37.5mg

1

triamterene/hydrochlorothiazide tabs

1

Diuretics, Thiazidechlorothiazide 2chlorothiazide sodium 4chlorthalidone 1hydrochlorothiazide caps 1hydrochlorothiazide tabs 25mg, 50mg

1

hydrochlorothiazide tabs 12.5mg

2

indapamide 1metolazone 2Dyslipidemics, Fibric Acid Derivativesfenofibrate caps 130mg, 150mg 2 QL(30/30)fenofibrate caps 43mg, 50mg 2 QL(60/30)fenofibrate micronized caps 134mg, 200mg

2 QL(30/30)

fenofibrate micronized caps 67mg

2 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nicardipine hcl inj 4nifedipine er tb24 30mg, 90mg 2 QL(30/30)nifedipine er tb24 60mg 2 QL(60/30)nimodipine 4nisoldipine er tb24 20mg, 30mg, 40mg

2

nisoldipine er tb24 17mg, 25.5mg, 34mg, 8.5mg

2 QL(30/30)

taztia xt cp24 120mg, 300mg, 360mg

2 QL(30/30)

taztia xt cp24 180mg, 240mg 2 QL(60/30)verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg

2 QL(30/30)

verapamil hcl er cp24 200mg 2 QL(60/30)verapamil hcl er tbcr 2verapamil hcl inj 4verapamil hcl sr cp24 360mg 2 QL(30/30)verapamil hcl tabs 40mg 2verapamil hcl tabs 120mg, 80mg

1

Cardiovascular Agents, OtherDEMSER 5digitek tabs 0.125mg 2 QL(30/30)digitek tabs 0.25mg 2 PAdigox tabs 125mcg 2 QL(30/30)digox tabs 250mcg 2 PAdigoxin inj 4 PAdigoxin tabs 125mcg 2 QL(30/30)digoxin tabs 250mcg 2 PALANOXIN PEDIATRIC 4 PANORTHERA CAPS 100MG 5 PA QL(90/30)NORTHERA CAPS 200MG, 300MG

5 PA QL(180/30)

pentoxifylline er 2RANEXA 3 QL(60/30)TEKTURNA 3 QL(30/30) STTEKTURNA HCT 3 QL(30/30) STDiuretics, Carbonic Anhydrase Inhibitorsacetazolamide 2acetazolamide sodium 4

41



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ZETIA 4 QL(30/30)Vasodilators, Direct-acting Arterialhydralazine hcl inj 4hydralazine hcl tabs 2minoxidil 2Vasodilators, Direct-acting Arterial/VenousBIDIL 3 QL(180/30)isosorbide dinitrate er 2isosorbide dinitrate tabs 2isosorbide mononitrate 2isosorbide mononitrate er 2minitran 2 QL(30/30)nitroglycerin inj 4nitroglycerin lingual translingual soln

2

nitroglycerin subl 2nitroglycerin transdermal 2 QL(30/30)NITROSTAT 3

Central Nervous System Agents

AttentionDeficitHyperactivityDisorderAgents,Amphetaminesamphetamine/dextroamphetamine cp24

2 QL(30/30)

amphetamine/dextroamphetamine tabs

2 QL(60/30)

dextroamphetamine sulfate er cp24 5mg

2 QL(60/30)


2 QL(90/30)


2 QL(120/30)

dextroamphetamine sulfate oral soln

2 QL(1800/30)

dextroamphetamine sulfate tabs 5mg

2 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fenofibrate tabs 145mg, 160mg 2 QL(30/30)fenofibrate tabs 48mg, 54mg 2 QL(60/30)fenofibric acid dr cpdr 135mg 2 QL(30/30)fenofibric acid dr cpdr 45mg 2 QL(60/30)gemfibrozil 2 QL(60/30)Dyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium 1 QL(30/30)CRESTOR 4 QL(30/30) STLIVALO 3 QL(30/30) STlovastatin tabs 40mg 2 QL(60/30)lovastatin tabs 10mg, 20mg 1 QL(30/30)pravastatin sodium 1 QL(30/30)rosuvastatin calcium 2 QL(30/30)simvastatin 1 QL(30/30)Dyslipidemics, Othercholestyramine 2cholestyramine light 2colestipol hcl gran 2colestipol hcl tabs 2ezetimibe 3 QL(30/30)ezetimibe/simvastatin 4 QL(30/30)KYNAMRO 5 PA QL(4/28)niacin er tbcr 500mg 2 QL(30/30)niacin er tbcr 1000mg, 750mg 2 QL(60/30)niacor 2omega-3-acid ethyl esters 2 QL(120/30)prevalite 2REPATHA 5 PA QL(3/30)REPATHA PUSHTRONEX SYSTEM

5 PA QL(3.5/30)

REPATHA SURECLICK 5 PA QL(3/30)VASCEPA CAPS 1GM 4 QL(120/30)VASCEPA CAPS 0.5GM 4 QL(240/30)VYTORIN 4 QL(30/30)WELCHOL 3

42


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

REBIF REBIDOSE 5 PA QL(6/28)REBIF REBIDOSE TITRATION PACK

5 PA QL(4.2/28)

REBIF TITRATION PACK 5 PA QL(4.2/28)TECFIDERA CPDR 120MG 5 PA QL(14/30)TECFIDERA CPDR 240MG 5 PA QL(60/30)TECFIDERA STARTER PACK 5 PA QL(120/365)TYSABRI 5 PA QL(15/28)

Dental and Oral Agents

Dental and Oral Agentschlorhexidine gluconate mouth/throat soln

1

oralone dental paste 2paroex 1periogard 1pilocarpine hcl tabs 2pilocarpine hydrochloride 2triamcinolone acetonide dental paste

2

Dermatological Agents

Dermatological Agentsacitretin 4 PAammonium lactate 2amnesteem 2calcipotriene crea 4 QL(120/30)calcipotriene external soln 4calcipotriene oint 4 QL(120/30)calcitrene 4 QL(120/30)calcitriol oint 3 QL(800/30)CARAC 5claravis 2curity gauze pads 2”x2” 2diclofenac sodium transdermal soln

2 QL(1050/30)

doxepin hydrochloride 2ELIDEL 3 QL(100/90)erythromycin/benzoyl peroxide 2fluorouracil crea 5% 2fluorouracil crea 0.5% 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dextroamphetamine sulfate tabs 10mg

2 QL(180/30)

AttentionDeficitHyperactivityDisorderAgents, Non-amphetaminesatomoxetine caps 100mg, 60mg, 80mg

3 QL(30/30)

atomoxetine caps 10mg, 18mg, 25mg, 40mg

3 QL(60/30)

clonidine hcl er 2 QL(120/30)dexmethylphenidate hcl 2 QL(60/30)metadate er 2 QL(90/30)methylphenidate hcl er tbcr 10mg, 27mg, 54mg

2 QL(30/30)

methylphenidate hcl er tbcr 36mg

2 QL(60/30)


2 QL(90/30)


2 QL(120/30)

methylphenidate hcl tabs 10mg, 5mg

2 QL(60/30)

methylphenidate hcl tabs 20mg 2 QL(90/30)STRATTERA CAPS 100MG, 60MG, 80MG

3 QL(30/30)

STRATTERA CAPS 10MG, 18MG, 25MG, 40MG

3 QL(60/30)

Central Nervous System, OtherHETLIOZ 5 PA QL(30/30)NUEDEXTA 3 QL(60/30)riluzole 4tetrabenazine tabs 12.5mg 5 PA QL(90/30)tetrabenazine tabs 25mg 5 PA QL(120/30)Multiple Sclerosis AgentsAMPYRA 5 PA QL(60/30)AVONEX 5 PA QL(4/28)AVONEX PEN 5 PA QL(4/28)BETASERON 5 PA QL(14/28)COPAXONE INJ 40MG/ML 5 PA QL(12/28)COPAXONE INJ 20MG/ML 5 PA QL(30/30)GILENYA 5 PA QL(30/30)REBIF 5 PA QL(6/28)

43



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

FABRAZYME 5 B/D PAKUVAN PACK 500MG 5 PA QL(150/30)KUVAN PACK 100MG 5 PA QL(750/30)KUVAN TBSO 5 PA QL(750/30)LUMIZYME 5 PANAGLAZYME 5 PAORFADIN 5sodium phenylbutyrate 5VPRIV 5 PAZAVESCA 5 QL(90/30)ZENPEP 3

Gastrointestinal Agents

Antispasmodics, Gastrointestinalanaspaz 2atropine sulfate inj 0.25mg/5ml, 1mg/10ml, 1mg/ml, 8mg/20ml

4

dicyclomine hcl caps 1dicyclomine hcl oral soln 2dicyclomine hcl tabs 1ed-spaz 2glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml

4

glycopyrrolate tabs 2hyoscyamine sulfate elix 2hyoscyamine sulfate odt 2hyoscyamine sulfate subl 2hyoscyamine sulfate tabs 2hyoscyamine sulfate tbdp 2methscopolamine bromide 2nulev 2oscimin 2propantheline bromide 2Gastrointestinal AgentsTRULANCE 4 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluorouracil external soln 2imiquimod 2 QL(12/30)methoxsalen 5myorisan 2PICATO GEL 0.05% 4 QL(2/56) STPICATO GEL 0.015% 4 QL(3/56) STpodofilox 2REGRANEX 5 PA QL(15/30)SANTYL 3selenium sulfide lotn 1tacrolimus oint 2 QL(100/90)tazarotene 4 QL(120/30)TAZORAC CREA 4 QL(120/30)TAZORAC GEL 4 QL(100/30)tretinoin crea 2 PA QL(45/30)tretinoin gel 2 PA QL(45/30)tretinoin microsphere 2 PAtretinoin microsphere pump gel 0.1%

2 PA

UVADEX 4 B/D PAVOLTAREN GEL 3 QL(1000/30)zenatane 2ZYCLARA 5 QL(56/30)ZYCLARA PUMP CREA 2.5% 5 QL(15/30)

EnzymeReplacement/Modifiers

EnzymeReplacement/ModifiersADAGEN 5 PAALDURAZYME 5 PABUPHENYL TABS 5CEREZYME 5 B/D PACREON 3CYSTADANE 5CYSTAGON 3ELAPRASE 5 PA

44


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MOVIPREP 3peg 3350/electrolytes 2peg-3350/electrolytes 2peg-3350/nacl/na bicarbonate/kcl

2

polyethylene glycol 3350 powd 2SUPREP BOWEL PREP KIT 3trilyte 2ProtectantsCARAFATE SUSP 4misoprostol 3sucralfate 2Proton Pump InhibitorsDEXILANT 4 QL(60/30) STesomeprazole magnesium 2 QL(60/30)esomeprazole sodium 4omeprazole cpdr 2 QL(60/30)pantoprazole sodium tbec 2 QL(60/30)

Genitourinary Agents

Antispasmodics, Urinarydarifenacin hydrobromide er 2 QL(30/30)ENABLEX 4 QL(30/30) STflavoxate hcl 2MYRBETRIQ 3 QL(30/30)oxybutynin chloride er tb24 10mg, 5mg

2 QL(30/30)

oxybutynin chloride er tb24 15mg

2 QL(60/30)

oxybutynin chloride syrp 1 QL(600/30)oxybutynin chloride tabs 1 QL(120/30)tolterodine tartrate 2 QL(60/30)tolterodine tartrate er 3 QL(30/30)VESICARE 3 QL(30/30)Benign Prostatic Hypertrophy Agentsalfuzosin hcl er 2 QL(30/30)doxazosin 2 QL(30/30)doxazosin mesylate tabs 1mg, 2mg

2 QL(30/30)

doxazosin mesylate tabs 8mg 2 QL(60/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Gastrointestinal Agents, Othercromolyn sodium conc 2diphenoxylate/atropine 2GATTEX 5 PA QL(30/30)loperamide hcl caps 2metoclopramide hcl inj 4metoclopramide hcl oral soln 2metoclopramide hcl tabs 2OSMOPREP 3RELISTOR INJ 8MG/0.4ML 5 PA QL(12/30)RELISTOR INJ 12MG/0.6ML 5 PA QL(18/30)ursodiol 3Histamine2 (H2) Receptor Antagonistscimetidine 2cimetidine hcl 2famotidine inj 4famotidine premixed 4famotidine tabs 20mg, 40mg 2nizatidine caps 2ranitidine hcl caps 2ranitidine hcl inj 4ranitidine hcl syrp 2ranitidine hcl tabs 1Irritable Bowel Syndrome Agentsalosetron hydrochloride tabs 0.5mg

4 PA QL(60/30)

alosetron hydrochloride tabs 1mg

5 PA QL(60/30)

AMITIZA 3 QL(60/30)LINZESS 4 QL(30/30)VIBERZI 4 PA QL(60/30)Laxativesconstulose 1enulose 1gavilyte-c 2gavilyte-g 2gavilyte-n/flavor pack 2generlac 1lactulose 2

45



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clobetasol propionate emollient 2clobetasol propionate external soln

2

clobetasol propionate foam 2clobetasol propionate gel 2clobetasol propionate oint 2clobetasol propionate sham 2clodan 2cormax scalp application 2cortisone acetate 2DEPO-MEDROL INJ 20MG/ML 4desonide lotn 2desonide oint 2desoximetasone 2dexamethasone elix 2dexamethasone intensol 2dexamethasone oral soln 2dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml

4

dexamethasone tabs 1.5mg, 1mg, 2mg, 6mg

2

dexamethasone tabs 0.5mg, 0.75mg, 4mg

1

diflorasone diacetate 2fludrocortisone acetate 2fluocinolone acetonide body 2fluocinolone acetonide crea 2fluocinolone acetonide external soln

1

fluocinolone acetonide oint 2fluocinolone acetonide scalp 2fluocinonide 2fluocinonide emulsified base 2fluticasone propionate crea 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dutasteride 2 QL(30/30)dutasteride/tamsulosin hydrochloride

2 QL(30/30)

finasteride tabs 5mg 2 QL(30/30)tamsulosin hcl 2 QL(60/30)terazosin hcl caps 1mg, 2mg, 5mg

1 QL(30/30)

terazosin hcl caps 10mg 1 QL(60/30)Genitourinary Agents, Otherbethanechol chloride 2ELMIRON 4phenazopyridine hcl 2Phosphate BindersAURYXIA 4 QL(360/30)calcium acetate caps 2calcium acetate tabs 667mg 2PHOSLYRA 4RENVELA PACK 3 QL(180/30)RENVELA TABS 3 QL(540/30)VELPHORO 4 QL(180/30)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)a-methapred 4ALA SCALP 3ala-cort crea 1% 1alclometasone dipropionate 2amcinonide 2augmented betamethasone dipropionate

2

betamethasone dipropionate 3betamethasone valerate 2clobetasol propionate crea 2clobetasol propionate e 2

46


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

triamcinolone acetonide crea 0.1%

1

triamcinolone acetonide lotn 2triamcinolone acetonide oint 2trianex 2triderm crea 0.1% 1

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)chorionic gonadotropin 4 PAdesmopressin acetate inj 4desmopressin acetate nasal soln

2 QL(15/30)

desmopressin acetate tabs 2INCRELEX 4 PANOVAREL 4 PAPREGNYL W/DILUENT BENZYL ALCOHOL/NACL

4 PA

SAIZEN 5 PASAIZEN CLICK.EASY 5 PASTIMATE 3

Hormonal Agents, Stimulant/Replacement/Modifying (SexHormones/Modifiers)

Anabolic SteroidsANADROL-50 5 PAOXANDROLONE TABS 10MG 5 PA QL(60/30)OXANDROLONE TABS 2.5MG 3 PA QL(120/30)Androgensdanazol 2testosterone cypionate 4 PAtestosterone enanthate 4 PA QL(5/30)testosterone gel 25mg/2.5gm, 50mg/5gm

4 PA QL(300/30)

testosterone pump 4 PA QL(300/30)EstrogensALORA 3 PA QL(8/28)altavera 2alyacen 1/35 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluticasone propionate oint 2halobetasol propionate 2hydrocortisone butyrate 2hydrocortisone butyrate (lipid) 2hydrocortisone butyrate (lipophilic)

2

hydrocortisone external crea 1hydrocortisone lotn 2.5% 2hydrocortisone oint 1%, 2.5% 2hydrocortisone rectal crea 2hydrocortisone tabs 2hydrocortisone valerate 2MEDROL TABS 2MG 3methylprednisolone 2methylprednisolone acetate 4methylprednisolone dose pack 2methylprednisolone sodiumsuccinate

4

mometasone furoate crea 2mometasone furoate external soln

2

mometasone furoate oint 2prednicarbate oint 2prednisolone oral soln 2prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml

2

prednisone intensol 2prednisone oral soln 2prednisone tabs 50mg 2prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg

1

prednisone tbpk 1procto-med hc 2procto-pak 2proctosol hc 2proctozone-hc 2SOLU-CORTEF 4TEXACORT 3triamcinolone acetonide crea 0.025%, 0.5%

2

47



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

estradiol ptwk 2 PA QL(4/28)estradiol tabs 0.5mg, 1mg, 2mg 2 PAestradiol tabs 10mcg 4 QL(18/28)estradiol valerate 4ESTRING 3 QL(1/90)ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg

2

falmina 2FEMRING 3 QL(1/90)femynor 2fyavolv tabs 2.5mcg; 0.5mg 3 PAgildagia 2introvale 2 QL(91/91)isibloom 2jevantique lo 3 PAjolessa 2 QL(91/91)juleber 2junel 1.5/30 2junel 1/20 2junel fe 1.5/30 2junel fe 1/20 2kariva 2kelnor 1/35 2kimidess 2kurvelo 2larin 1.5/30 2larin 1/20 2larin fe 1.5/30 2larin fe 1/20 2larissia 2lessina 2levonest 2levonorgestrel and ethinyl estradiol tabs 0; 0

2 QL(91/91)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

alyacen 7/7/7 2amethia 2 QL(91/91)amethia lo 2 QL(91/91)apri 2aranelle 2ashlyna 2 QL(91/91)aubra 2aviane 2balziva 2bekyree 2blisovi fe 1.5/30 2blisovi fe 1/20 2briellyn 2camrese 2 QL(91/91)camrese lo 2 QL(91/91)caziant 2chateal 2cryselle-28 2cyclafem 1/35 2cyclafem 7/7/7 2cyred 2dasetta 1/35 2dasetta 7/7/7 2daysee 2 QL(91/91)DELESTROGEN INJ 10MG/ML 4delyla 2DEPO-ESTRADIOL 4desogestrel/ethinyl estradiol 2elinest 2emoquette 2enpresse-28 2enskyce 2estarylla 2estradiol pttw 2 PA QL(8/28)

48


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PREMARIN TABS 3 PA QL(30/30)previfem 2quasense 2 QL(91/91)reclipsen 2setlakin 2 QL(91/91)sprintec 28 2sronyx 2tarina fe 1/20 2tilia fe 2tri-estarylla 2tri-legest fe 2tri-linyah 2tri-previfem 2tri-sprintec 2trivora-28 2VAGIFEM 4 QL(18/28)velivet 2vienva 2viorele 2vyfemla 2wera 2yuvafem 4 QL(18/28)zenchent 2zovia 1/35e 2zovia 1/50e 2Progesterone Agonists/AntagonistsELLA 3Progestinscamila 2deblitane 2DEPO-PROVERA 4 QL(10/28)errin 2heather 2hydroxyprogesterone caproate 5 PAjencycla 2jolivette 2lyza 2MAKENA 5 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

2

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0

2 QL(91/91)

levora 0.15/30-28 2low-ogestrel 2lutera 2marlissa 2MENEST 3 PAMENOSTAR 3 PA QL(4/28)microgestin 1.5/30 2microgestin 1/20 2microgestin fe 2microgestin fe 1.5/30 2MINIVELLE 3 PA QL(8/28)mono-linyah 2myzilra 2necon 0.5/35-28 2necon 1/50-28 2necon 7/7/7 2norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg

2

norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg

3 PA

norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs

2

norgestimate/ethinyl estradiol 2nortrel 0.5/35 (28) 2nortrel 1/35 2nortrel 7/7/7 2ogestrel 2orsythia 2philith 2pimtrea 2pirmella 1/35 2pirmella 7/7/7 2portia-28 2PREMARIN CREA 3PREMARIN INJ 4

49



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Hormonal Agents, Suppressant (Parathyroid)

Hormonal Agents, Suppressant (Parathyroid)SENSIPAR TABS 30MG 3 QL(60/30)SENSIPAR TABS 60MG 5 QL(60/30)SENSIPAR TABS 90MG 5 QL(120/30)

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)cabergoline 2 QL(16/30)ELIGARD INJ 30MG 4 PA QL(1/120)ELIGARD INJ 45MG 4 PA QL(1/180)ELIGARD INJ 7.5MG 4 PA QL(1/30)ELIGARD INJ 22.5MG 4 PA QL(1/90)FIRMAGON INJ 80MG 4 B/D PA QL(1/28)FIRMAGON INJ 120MG 5 B/D PA QL(4/365)leuprolide acetate 4 PALUPRON DEPOT (1-MONTH) 5 PA QL(1/30)LUPRON DEPOT (3-MONTH) INJ 22.5MG

5 PA QL(1/84)

LUPRON DEPOT (3-MONTH) INJ 11.25MG

5 PA QL(1/90)

LUPRON DEPOT (4-MONTH) 5 PA QL(1/112)LUPRON DEPOT (6-MONTH) 5 PA QL(1/168)LUPRON DEPOT-PED (1-MONTH)

5 PA QL(1/30)

LUPRON DEPOT-PED (3-MONTH)

5 PA QL(1/30)

octreotide acetate inj 500mcg/ml

5 PA

octreotide acetate inj 1000mcg/ml, 100mcg/ml, 200mcg/ml, 50mcg/ml

4 PA

SANDOSTATIN LAR DEPOT 5 PASIGNIFOR 5 PA QL(60/30)SOMATULINE DEPOT INJ 60MG/0.2ML

5 PA QL(0.2/28)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

medroxyprogesterone acetate inj

4 QL(1/90)

medroxyprogesterone acetate tabs

1

megestrol acetate susp 40mg/ml

3 PA

megestrol acetate tabs 3 PAnora-be 2norethindrone 2norethindrone acetate 2norlyroc 2progesterone caps 2sharobel 2Selective Estrogen Receptor Modifying Agentsraloxifene hydrochloride 2 QL(30/30)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tabs 1LEVOXYL 3liothyronine sodium inj 4liothyronine sodium tabs 2SYNTHROID 3THYROLAR-1 3THYROLAR-1/2 3THYROLAR-1/4 3THYROLAR-2 3THYROLAR-3 3UNITHROID 3

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)LYSODREN 5

50


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMIRA INJ 40MG/0.8ML 5 PA QL(4/28)HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK

5 PA QL(6/365)

HUMIRA PEN 5 PA QL(4/28)HUMIRA PEN-CROHNS DISEASE STARTER

5 PA QL(12/365)

HUMIRA PEN-PSORIASIS STARTER

5 PA QL(8/365)

KINERET 5 PA QL(20.1/30)methotrexate 2methotrexate sodium 4mycophenolate mofetil caps 2 PAmycophenolate mofetil inj 4 PAmycophenolate mofetil susr 5 PAmycophenolate mofetil tabs 2 PAmycophenolic acid dr 2 PANULOJIX 5 PA QL(150/30)PROGRAF INJ 4 PARAPAMUNE ORAL SOLN 5 PAREMICADE 5 PASANDIMMUNE ORAL SOLN 5 PAsirolimus 2 PAtacrolimus caps 2 PATORISEL 5 B/D PA QL(4/28)XATMEP 4 PAZORTRESS TABS 0.25MG, 0.75MG

5 PA QL(60/30)

ZORTRESS TABS 0.5MG 5 PA QL(120/30)Immunizing Agents, PassiveATGAM 4 PAGAMMAKED INJ 1GM/10ML 4 B/D PAGAMMAKED INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 5GM/50ML

5 B/D PA

GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML

5 B/D PA

GAMUNEX-C INJ 1GM/10ML 4 B/D PATHYMOGLOBULIN 3 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SOMATULINE DEPOT INJ 90MG/0.3ML

5 PA QL(0.3/28)

SOMATULINE DEPOT INJ 120MG/0.5ML

5 PA QL(0.5/28)

SOMAVERT 5 PA QL(30/30)SYNAREL 5 PATRELSTAR MIXJECT INJ 22.5MG

5 PA QL(1/168)

TRELSTAR MIXJECT INJ 3.75MG

5 PA QL(1/28)

TRELSTAR MIXJECT INJ 11.25MG

5 PA QL(1/84)

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agentsmethimazole 2propylthiouracil 2

Immunological Agents

Angioedema (HAE) AgentsCINRYZE 5 PA QL(100/30)FIRAZYR 5 PA QL(18/30)Immune SuppressantsASTAGRAF XL CP24 0.5MG, 1MG

4 PA

ASTAGRAF XL CP24 5MG 5 PAAZASAN 3 PAazathioprine inj 4 PAazathioprine tabs 2 PACELLCEPT INTRAVENOUS 4 PAcyclosporine caps 2 PAcyclosporine inj 4 PAcyclosporine modified 2 PAENBREL INJ 25MG/0.5ML 5 PA QL(4.08/28)ENBREL INJ 25MG, 50MG/ML 5 PA QL(8/28)ENBREL SURECLICK 5 PA QL(8/28)ENVARSUS XR 4 PAgengraf 2 PAHUMIRA INJ 10MG/0.2ML, 20MG/0.4ML

5 PA QL(2/28)

51



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MENVEO 4PEDIARIX 4PEDVAX HIB 4PROQUAD 4 QL(2/365)QUADRACEL 4RABAVERT 4RECOMBIVAX HB 4 B/D PA QL(3/365)ROTARIX 3ROTATEQ 3STAMARIL 4 QL(1/999)TENIVAC 4 QL(0.5/28)TETANUS/DIPHTHERIA TOXOIDS-ADSORBED

4

TRUMENBA 4TWINRIX 4TYPHIM VI 4VAQTA 4VARIVAX 4 QL(1/365)VARIZIG 4 QL(12/30)VAXCHORA 4YF-VAX 4ZOSTAVAX 4 QL(1/999)

InflammatoryBowelDiseaseAgents

AminosalicylatesAPRISO 3 QL(120/30)balsalazide disodium 2mesalamine kit 4Glucocorticoidsbudesonide cpep 2colocort 2hydrocortisone enem 2Sulfonamidessulfasalazine 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ImmunomodulatorsACTEMRA INJ 162MG/0.9ML 5 PA QL(3.6/28)ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML

5 PA QL(40/28)

ACTIMMUNE 5 PAARCALYST 5 PABENLYSTA INJ 400MG 5 PA QL(9/28)BENLYSTA INJ 120MG 5 PA QL(30/28)ILARIS 5 PA QL(2/28)leflunomide 2 QL(30/30)RIDAURA 4SIMULECT 5 B/D PASYNAGIS 5 PAVaccinesACTHIB 4ADACEL 4 QL(0.5/365)BEXSERO 4BOOSTRIX 4 QL(0.5/365)DAPTACEL 4DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC

4

ENGERIX-B INJ 10MCG/0.5ML 4 B/D PA QL(3/365)ENGERIX-B INJ 20MCG/ML 4 B/D PA QL(8/365)GARDASIL 4 QL(1.5/365)GARDASIL 9 4 QL(1.5/365)HAVRIX 4HIBERIX 4IMOVAX RABIES (H.D.C.V.) 4INFANRIX 4IPOL INACTIVATED IPV 4IXIARO 4KINRIX 4M-M-R II 4 QL(2/365)MENACTRA 4

52


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

bd insulin syringe ultrafine/1ml/31g x 5/16”

2 QL(200/30)

bd pen needle/mini/ultrafine/31g x 3/16”

2 QL(200/30)

bd pen needle/nano/ultra fine/32g x 4mm

2 QL(200/30)

bd pen needle/ultrafine/29g x 12.7mm

2 QL(200/30)

bd safetyglide 27g x 5/8” 2 QL(200/30)CARNITOR INJ 4 B/D PAFERRIPROX 5 PAfomepizole 5INTRALIPID 4 B/D PAKORLYM 5 PA QL(120/30)LACTATED RINGERS IRRIGATION

4

levocarnitine 2LIPOSYN III 4 B/D PANATPARA 5 PA QL(2/28)novofine 30gx8mm 2 QL(200/30)novofine 31 2 QL(200/30)novofine 32gx6mm 2 QL(200/30)novofine autocover 30gx8mm 2 QL(200/30)novotwist 32gx5mm 2 QL(200/30)NUTRILIPID 4 B/D PAPHYSIOLYTE 4PHYSIOSOL IRRIGATION 4RINGERS IRRIGATION 4sodium chloride 0.9% 4sterile water irrigation 4techlite pen needles/31g x 6 mm

2 QL(200/30)

techlite pen needles/31g x 8mm 2 QL(200/30)techlite pen needles/32g x 4mm 2 QL(200/30)techlite pen needles/32g x 6mm 2 QL(200/30)techlite pen needles/32g x 8mm 2 QL(200/30)TIS-U-SOL 4

Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogsbimatoprost ophthalmic soln 2 QL(5/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Metabolic Bone Disease Agents

Metabolic Bone Disease Agentsalendronate sodium tabs 35mg, 70mg

1 QL(4/28)

alendronate sodium tabs 10mg, 40mg, 5mg

1 QL(30/30)

calcitonin-salmon 2 QL(3.7/30)calcitriol caps 2calcitriol inj 4calcitriol oral soln 2doxercalciferol caps 0.5mcg 2 QL(90/30)doxercalciferol caps 2.5mcg 2 QL(120/30)doxercalciferol caps 1mcg 2 QL(240/30)doxercalciferol inj 4etidronate disodium 2FORTEO 5 PA QL(2.4/28)ibandronate sodium tabs 3 QL(1/28)MIACALCIN 5pamidronate disodium 4 B/D PAparicalcitol caps 4mcg 4 QL(60/30)paricalcitol caps 1mcg, 2mcg 2 QL(90/30)PROLIA 4 QL(1/180) STrisedronate sodium tabs 150mg 3 QL(1/30)risedronate sodium tabs 35mg 3 QL(4/28)risedronate sodium tabs 30mg, 5mg

3 QL(30/30)

XGEVA 5 PA QL(1.7/28)zoledronic acid inj 4mg/5ml 4 B/D PA QL(15/21)zoledronic acid inj 5mg/100ml 4 B/D PA QL(100/365)

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agentsbd eclipse syringe/1ml/30gx1/2” 2 QL(200/30)bd insulin syringe safetyglide/1ml/29g x 1/2”

2 QL(200/30)

bd insulin syringe ultrafine/0.3ml/31g x 5/16”

2 QL(200/30)

bd insulin syringe ultrafine/0.5ml/30g x 1/2”

2 QL(200/30)

53



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PRED MILD 3PRED-G 3PRED-G S.O.P. 3prednisolone acetate 3prednisolone sodium phosphate ophthalmic soln

1

PROLENSA 4TOBRADEX OINT 3tobramycin/dexamethasone 2Ophthalmic Antiglaucoma Agentsacetazolamide er 2apraclonidine 2AZOPT 3betaxolol hcl 2brimonidine tartrate ophthalmic soln 0.2%

2

brimonidine tartrate ophthalmic soln 0.15%

3

carteolol hcl 2dorzolamide hcl 2 QL(10/30)dorzolamide hcl/timolol maleate 2 QL(10/30)levobunolol hcl 1methazolamide 2metipranolol 2PHOSPHOLINE IODIDE 4pilocarpine hcl ophthalmic soln 3SIMBRINZA 4timolol maleate ophthalmic soln 1

Otic Agents

Otic Agentsacetasol hc 2acetic acid 2COLY-MYCIN S 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

COMBIGAN 3latanoprost 2 QL(5/30)LUMIGAN 4 QL(5/30) STTRAVATAN Z 3 QL(5/30)ZIOPTAN 4 QL(30/30)Ophthalmic Agents, Otheratropine sulfate ophthalmic soln 2CYSTARAN 5 PA QL(60/30)LACRISERT 3proparacaine hcl 2RESTASIS 3 QL(60/30)tropicamide 2Ophthalmic Anti-allergy AgentsALOCRIL 3azelastine hcl ophthalmic soln 2cromolyn sodium ophthalmic soln

2

epinastine hcl 2olopatadine hcl ophthalmic soln 2 QL(5/30)PATADAY 3 QL(2.5/30)PAZEO 3 QL(2.5/30)OphthalmicAnti-inflammatoriesbromfenac 4dexamethasone sodium phosphate ophthalmic soln

2

diclofenac sodium ophthalmic soln

2

DUREZOL 3fluorometholone 3flurbiprofen sodium 2ILEVRO 3ketorolac tromethamine ophthalmic soln

2

LOTEMAX 4neomycin/polymyxin/dexamethasone

2

54


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Bronchodilators, AnticholinergicATROVENT HFA 3 QL(25.8/30)COMBIVENT RESPIMAT 3 QL(8/30)INCRUSE ELLIPTA 3 QL(30/30)ipratropium bromide inhalation soln

2 B/D PA QL(300/30)

ipratropium bromide nasal soln 2 QL(30/30)ipratropium bromide/albuterol sulfate

2 B/D PA QL(540/30)

Bronchodilators, Sympathomimeticalbuterol sulfate er 2albuterol sulfate nebu 0.5% 2 B/D PA QL(180/30)albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml

2 B/D PA QL(360/30)

albuterol sulfate syrp 1albuterol sulfate tabs 1ANORO ELLIPTA 3 QL(60/30)epinephrine hcl inj 1mg/10ml, 1mg/ml

4

epinephrine inj 0.15mg/0.3ml, 0.3mg/0.3ml

2 QL(2/30)

EPIPEN 2-PAK 3 QL(2/30)EPIPEN-JR 2-PAK 3 QL(2/30)metaproterenol sulfate 2PERFOROMIST 3 B/D PA QL(120/30)PROAIR HFA 3 QL(17/30)PROAIR RESPICLICK 3 QL(2/30)SEREVENT DISKUS 3 QL(60/30)terbutaline sulfate inj 4terbutaline sulfate tabs 2VENTOLIN HFA 4 QL(36/30)Cystic Fibrosis AgentsCAYSTON 5 PA QL(84/56)KALYDECO 5 PA QL(60/30)ORKAMBI 5 PA QL(120/30)PULMOZYME 5 B/D PA QL(150/30)TOBI PODHALER 5 QL(1568/365)tobramycin nebu 5 B/D PA QL(280/56)Mast Cell Stabilizerscromolyn sodium nebu 2 B/D PA QL(240/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fluocinolone acetonide ear drops

4

fluocinolone acetonide oil 4hydrocortisone/acetic acid 2neomycin/polymyxin/hc 2neomycin/polymyxin/hydrocortisone

2

Respiratory Tract/Pulmonary Agents

Anti-inflammatories,InhaledCorticosteroidsADVAIR DISKUS 3 QL(60/30)ADVAIR HFA 3 QL(12/30)ARNUITY ELLIPTA 3 QL(30/30)BREO ELLIPTA 3 QL(60/30)budesonide nasal spray 2 QL(17.2/30)budesonide susp 4 B/D PA QL(120/30)FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST

3 QL(60/30)

FLOVENT DISKUS AEPB 250MCG/BLIST

3 QL(240/30)

FLOVENT HFA AERO 44MCG/ACT

3 QL(10.6/30)


3 QL(12/30)


3 QL(24/30)

flunisolide 1 QL(50/30)fluticasone propionate susp 2 QL(16/30)mometasone furoate susp 2 QL(34/30)NASONEX 4 QL(34/30) STAntihistaminesazelastine hcl nasal soln 2 QL(30/25)desloratadine 2 QL(30/30)desloratadine odt 2 QL(30/30)diphenhydramine hcl inj 4levocetirizine dihydrochloride oral soln

2 QL(300/30)

levocetirizine dihydrochloride tabs

2 QL(30/30)

Antileukotrienesmontelukast sodium 2 QL(30/30)zafirlukast 2 QL(60/30)

55



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Sleep Disorder Agents

GABA Receptor Modulatorstemazepam 2 QL(60/365)zaleplon 2 QL(90/365)zolpidem tartrate tabs 3 PA QL(30/30)Sleep Disorders, Otherarmodafinil 4 PA QL(30/30)modafinil 4 PA QL(30/30)NUVIGIL 4 PA QL(30/30)ROZEREM 3 QL(30/30)SILENOR 3 QL(30/30)XYREM 5 PA QL(540/30)

Therapeutic Nutrients/Minerals/Electrolytes

Electrolyte/MineralModifiersCHEMET 5CUPRIMINE 5DEPEN TITRATABS 5EXJADE 5JADENU 5JADENU SPRINKLE 5kionex 3SAMSCA TABS 15MG 5 PA QL(30/30)SAMSCA TABS 30MG 5 PA QL(60/30)sodium bicarbonate inj 4sodium bicarbonate partial fill 4SODIUM LACTATE INJ 5MEQ/ML

4 B/D PA

sodium polystyrene sulfonate powd

3

sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml

3

sps 3SYPRINE 5VELTASSA 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Phosphodiesterase Inhibitors, Airways Diseaseaminophylline 4DALIRESP 4 PA QL(30/30)THEO-24 3theophylline cr 2theophylline er tb12 300mg, 450mg

2

theophylline er tb24 2Pulmonary AntihypertensivesADEMPAS 5 PA QL(90/30)LETAIRIS 5 PA QL(30/30)OPSUMIT 5 PA QL(30/30)REMODULIN 5 B/D PAsildenafil tabs 3 PA QL(90/30)TRACLEER 5 PA QL(60/30)VENTAVIS 5 PA QL(270/30)Respiratory Tract Agents, Otheracetylcysteine inhalation soln 2 B/D PAARALAST NP INJ 500MG 4 B/D PAESBRIET CAPS 5 PA QL(270/30)ESBRIET TABS 801MG 5 PA QL(90/30)ESBRIET TABS 267MG 5 PA QL(270/30)OFEV 5 PA QL(60/30)PROLASTIN-C 5 B/D PAribavirin inhalation soln 5 B/D PAVIRAZOLE 5 B/D PAXOLAIR 5 PA QL(6/28)ZEMAIRA 5 B/D PA

Skeletal Muscle Relaxants

Skeletal Muscle Relaxantscyclobenzaprine hcl tabs 10mg, 5mg

3 PA QL(90/30)

orphenadrine citrate er 2 PA QL(60/30)

56


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dextrose 10%/nacl 0.2% 4 B/D PAdextrose 2.5%/nacl 0.45% 4 B/D PADEXTROSE 20% 4 B/D PADEXTROSE 25% 4 B/D PADEXTROSE 30% 4 B/D PADEXTROSE 40% 4 B/D PADEXTROSE 5% 4DEXTROSE 5%/LACTATED RINGERS

4 B/D PA

dextrose 5%/nacl 0.2% 4dextrose 5%/nacl 0.225% 4DEXTROSE 5%/NACL 0.3% 4dextrose 5%/nacl 0.33% 4dextrose 5%/nacl 0.45% 4dextrose 5%/nacl 0.9% 4DEXTROSE 50% 4 B/D PADEXTROSE 70% 4fluoride chew 0.25mg 1fluoritab chew 0.5mg, 1mg 1FREAMINE HBC 6.9% 4 B/D PAFREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML

4 B/D PA

HEPATAMINE 4 B/D PAKABIVEN 4 B/D PAkcl 0.075%/d5w/nacl 0.45% 4 B/D PAkcl 0.15%/d5w/nacl 0.2% 4 B/D PAkcl 0.15%/d5w/nacl 0.225% 4 B/D PAkcl 0.15%/d5w/nacl 0.45% 4 B/D PAkcl 0.15%/d5w/nacl 0.9% 4 B/D PAkcl 0.3%/d5w/nacl 0.45% 4 B/D PAkcl 0.3%/d5w/nacl 0.9% 4 B/D PAklor-con 10 1

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Electrolyte/Mineral ReplacementAMINOSYN 4 B/D PAAMINOSYN 7%/ELECTROLYTES

4 B/D PA

AMINOSYN 8.5%/ELECTROLYTES

4 B/D PA

AMINOSYN II 4 B/D PAAMINOSYN II 8.5%/ELECTROLYTES

4 B/D PA

AMINOSYN M 4 B/D PAAMINOSYN-HBC 4 B/D PAAMINOSYN-PF 4 B/D PAAMINOSYN-PF 7% 4 B/D PAAMINOSYN-RF 4 B/D PAav-phos 250 neutral 2CARBAGLU 5CLINIMIX 2.75%/DEXTROSE 5%

4 B/D PA

CLINIMIX 4.25%/DEXTROSE 10%

4 B/D PA


4 B/D PA


4 B/D PA


4 B/D PA

CLINIMIX 5%/DEXTROSE 15% 4 B/D PACLINIMIX 5%/DEXTROSE 20% 4 B/D PACLINIMIX 5%/DEXTROSE 25% 4 B/D PACLINIMIX E 2.75%/DEXTROSE 10%

4 B/D PA

CLINIMIX E 4.25%/DEXTROSE 10%

4 B/D PA

CLINIMIX E 4.25%/DEXTROSE 25%

4 B/D PA

CLINIMIX E 5%/DEXTROSE 25%

4 B/D PA

CLINISOL SF 15% 4 B/D PAdextrose10%/nacl 0.45% 4 B/D PAdextrose5% /electrolyte #48 viaflex

4 B/D PA

DEXTROSE 10% 4 B/D PA

57



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

potassium chloride 0.22% d5w/nacl 0.45%

4 B/D PA

potassium chloride cr 1potassium chloride er cpcr 2potassium chloride er tbcr 1potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml

4 B/D PA

potassium chloride oral soln 2potassium chloride sr 1potassium chloride/dextrose 4 B/D PAPOTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS INJ 3MEQ/L; 149MEQ/L; 5%; 28MEQ/L; 44MEQ/L; 130MEQ/L

4 B/D PA

potassium chloride/dextrose/lactated ringers inj 3meq/l; 149meq/l; 5%; 28meq/l; 24meq/l; 130meq/l

4 B/D PA

potassium chloride/dextrose/sodium chloride

4 B/D PA

potassium chloride/sodium chloride inj 20meq/l; 0.45%, 20meq/l; 0.9%, 40meq/l; 0.9%

4 B/D PA

potassium citrate er 2PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML

4 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

klor-con 8 1klor-con m10 1klor-con m20 1klor-con sprinkle 2LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L

4 B/D PA

LACTATED RINGERS VIAFLEX

4 B/D PA

ludent 1MAGNESIUM SULFATE INJ 20GM/500ML, 2GM/50ML, 40GM/1000ML, 4GM/100ML, 4GM/50ML

4 B/D PA

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

4 B/D PA

NEPHRAMINE 4 B/D PANORMOSOL -R 4 B/D PANORMOSOL-M IN D5W 4 B/D PANORMOSOL-R 4 B/D PANORMOSOL-R IN D5W 4 B/D PANUTRILYTE INJ 2.03MEQ/ML; 0.25MEQ/ML; 1.68MEQ/ML; 0.25MEQ/ML; 0.4MEQ/ML; 2.03MEQ/ML; 1.25MEQ

4 B/D PA

PERIKABIVEN 4 B/D PAphospha 250 neutral 2PLENAMINE 4 B/D PAPOTASSIUM CHLORIDE /SODIUM CHLORIDE

4 B/D PA

potassium chloride 0.15% d5w/nacl 0.45%

4 B/D PA

potassium chloride 0.15% d5w/nacl 0.45%viaflex

4 B/D PA

58


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

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

4 B/D PA

PROCALAMINE 4 B/D PAPROSOL 4 B/D PARINGERS INJECTION 4 B/D PAsodium chloride 0.45% 4sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5%

4

sodium fluoride chew 0.5mg, 1mg

1

TPN ELECTROLYTES 4 B/D PATRAVASOL 4 B/D PATROPHAMINE 4 B/D PAvirt-phos 250 neutral 2Therapeutic Nutrients/Minerals/ElectrolytesLIPOSYN III 4 B/D PAVitaminsmultivitamin with fluoride chew 2VP-PNV-DHA 3

59

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

Aabacavir/lamivudine . . . . . . . . . . . . . . . 33abacavir sulfate/ lamivudine/zidovudine . . . . . . . . . . . . . 33abacavir tabs . . . . . . . . . . . . . . . . . . . . . 33ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . 25ABILIFY MAINTENA . . . . . . . . . . . . . . . 31ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 28acamprosate calcium dr . . . . . . . . . . . . 18acarbose . . . . . . . . . . . . . . . . . . . . . . . . . . 35acebutolol hcl . . . . . . . . . . . . . . . . . . . . . 39acetaminophen/caffeine/ dihydrocodeine . . . . . . . . . . . . . . . . . . . . 16acetaminophen/codeine oral soln . . . 16acetaminophen/codeine tabs 300mg; 15mg, 300mg; 30mg . . . . . . . 16acetaminophen/codeine tabs 300mg; 60mg . . . . . . . . . . . . . . . . . . . . . 16acetasol hc . . . . . . . . . . . . . . . . . . . . . . . . 53acetazolamide . . . . . . . . . . . . . . . . . . . . . 40acetazolamide er . . . . . . . . . . . . . . . . . . 53acetazolamide sodium . . . . . . . . . . . . . 40acetic acid . . . . . . . . . . . . . . . . . . . . . . . . 53acetylcysteine inhalation soln . . . . . . . 55acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 42ACTEMRA INJ 162MG/0.9ML . . . . . . 51ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/4ML . . . . . . . . . . 51ACTHIB . . . . . . . . . . . . . . . . . . . . . . . . . . . 51ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 51acyclovir caps . . . . . . . . . . . . . . . . . . . . 34acyclovir oint . . . . . . . . . . . . . . . . . . . . . 34acyclovir sodium inj 50mg/ml . . . . . . . 34acyclovir susp . . . . . . . . . . . . . . . . . . . . 34acyclovir tabs . . . . . . . . . . . . . . . . . . . . . 34ADACEL . . . . . . . . . . . . . . . . . . . . . . . . . . 51ADAGEN . . . . . . . . . . . . . . . . . . . . . . . . . 43adefovir dipivoxil . . . . . . . . . . . . . . . . . . . 32ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 55adrucil . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

ADVAIR DISKUS . . . . . . . . . . . . . . . . . . 54ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 54afeditab cr tb24 30mg . . . . . . . . . . . . . . 39afeditab cr tb24 60mg . . . . . . . . . . . . . . 39AFINITOR DISPERZ TBSO 2MG, 3MG . . . . . . . . . . . . . . . . . . . . . . . . 29AFINITOR DISPERZ TBSO 5MG . . . 29AFINITOR TABS 2.5MG, 5MG, 7.5MG . . . . . . . . . . . . . . 29AFINITOR TABS 10MG . . . . . . . . . . . . 29ala-cort crea 1% . . . . . . . . . . . . . . . . . . . 45ALA SCALP . . . . . . . . . . . . . . . . . . . . . . . 45ALBENZA . . . . . . . . . . . . . . . . . . . . . . . . . 30albuterol sulfate er . . . . . . . . . . . . . . . . . 54albuterol sulfate nebu 0.5% . . . . . . . . 54albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml . . . . . . . . . . . 54albuterol sulfate syrp . . . . . . . . . . . . . . 54albuterol sulfate tabs . . . . . . . . . . . . . . 54alclometasone dipropionate . . . . . . . . 45alcohol prep pads . . . . . . . . . . . . . . . . . 19ALDURAZYME . . . . . . . . . . . . . . . . . . . . 43ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 29alendronate sodium tabs 10mg, 40mg, 5mg . . . . . . . . . . . . . . . . . 52alendronate sodium tabs 35mg, 70mg . . . . . . . . . . . . . . . . . . . . . . . 52alfuzosin hcl er . . . . . . . . . . . . . . . . . . . . 44ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 27ALINIA SUSR . . . . . . . . . . . . . . . . . . . . . 30ALINIA TABS . . . . . . . . . . . . . . . . . . . . . 30ALIQOPA . . . . . . . . . . . . . . . . . . . . . . . . . 29allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 26allopurinol sodium . . . . . . . . . . . . . . . . . 26ALOCRIL . . . . . . . . . . . . . . . . . . . . . . . . . 53ALOPRIM . . . . . . . . . . . . . . . . . . . . . . . . . 26ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . . 46alosetron hydrochloride tabs 0.5mg . . . . . . . . . . . . . . . . . . . . . . . . 44alosetron hydrochloride tabs 1mg . . . 44ALOXI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

alprazolam odt tbdp 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 34alprazolam odt tbdp 2mg . . . . . . . . . . . 34alprazolam tabs 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 34alprazolam tabs 2mg . . . . . . . . . . . . . . 35altavera . . . . . . . . . . . . . . . . . . . . . . . . . . . 46ALUNBRIG . . . . . . . . . . . . . . . . . . . . . . . 29alyacen 1/35 . . . . . . . . . . . . . . . . . . . . . . 46alyacen 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 47amantadine hcl . . . . . . . . . . . . . . . . . . . . 34AMBISOME . . . . . . . . . . . . . . . . . . . . . . . 25amcinonide . . . . . . . . . . . . . . . . . . . . . . . 45a-methapred . . . . . . . . . . . . . . . . . . . . . . 45amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 47amethia lo . . . . . . . . . . . . . . . . . . . . . . . . . 47amikacin sulfate . . . . . . . . . . . . . . . . . . . 18amiloride hcl . . . . . . . . . . . . . . . . . . . . . . 40amiloride/hydrochlorothiazide . . . . . . 40aminophylline . . . . . . . . . . . . . . . . . . . . . 55AMINOSYN . . . . . . . . . . . . . . . . . . . . . . . 56AMINOSYN 7%/ELECTROLYTES . . 56AMINOSYN 8.5%/ ELECTROLYTES . . . . . . . . . . . . . . . . . . 56AMINOSYN-HBC . . . . . . . . . . . . . . . . . . 56AMINOSYN II . . . . . . . . . . . . . . . . . . . . . 56AMINOSYN II 8.5%/ ELECTROLYTES . . . . . . . . . . . . . . . . . . 56AMINOSYN M . . . . . . . . . . . . . . . . . . . . . 56AMINOSYN-PF . . . . . . . . . . . . . . . . . . . . 56AMINOSYN-PF 7% . . . . . . . . . . . . . . . . 56AMINOSYN-RF . . . . . . . . . . . . . . . . . . . 56amiodarone hcl inj . . . . . . . . . . . . . . . . 38amiodarone hcl tabs . . . . . . . . . . . . . . 38AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . . 44amitriptyline hcl . . . . . . . . . . . . . . . . . . . . 25amlodipine besylate/ benazepril hydrochloride . . . . . . . . . . . 39amlodipine besylate tabs 5mg . . . . . . 39amlodipine besylate tabs 10mg, 2.5mg . . . . . . . . . . . . . . . . . . . . . . 39

60


Covered Drugs Index

ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 50atomoxetine caps 10mg, 18mg, 25mg, 40mg . . . . . . . . . 42atomoxetine caps 100mg, 60mg, 80mg . . . . . . . . . . . . . . . 42atorvastatin calcium . . . . . . . . . . . . . . . 41atovaquone . . . . . . . . . . . . . . . . . . . . . . . 30atovaquone/proguanil hcl . . . . . . . . . . 30ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . 34atropine sulfate inj 0.25mg/5ml, 1mg/10ml, 1mg/ml, 8mg/20ml . . . . . . 43atropine sulfate ophthalmic soln . . . . 53ATROVENT HFA . . . . . . . . . . . . . . . . . . 54aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47augmented betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . 45AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML . . . . . . . . 20AURYXIA . . . . . . . . . . . . . . . . . . . . . . . . . 45AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 30AVELOX INJ . . . . . . . . . . . . . . . . . . . . . . 21aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47AVONEX . . . . . . . . . . . . . . . . . . . . . . . . . . 42AVONEX PEN . . . . . . . . . . . . . . . . . . . . . 42av-phos 250 neutral . . . . . . . . . . . . . . . 56azacitidine . . . . . . . . . . . . . . . . . . . . . . . . 28AZACTAM IN ISO-OSMOTIC DEXTROSE . . . . . . . . . . . . . . . . . . . . . . . 20AZASAN . . . . . . . . . . . . . . . . . . . . . . . . . . 50AZASITE . . . . . . . . . . . . . . . . . . . . . . . . . . 21azathioprine inj . . . . . . . . . . . . . . . . . . . 50azathioprine tabs . . . . . . . . . . . . . . . . . 50azelastine hcl nasal soln . . . . . . . . . . . 54azelastine hcl ophthalmic soln . . . . . . 53AZILECT . . . . . . . . . . . . . . . . . . . . . . . . . . 31azithromycin inj . . . . . . . . . . . . . . . . . . . 21azithromycin pack . . . . . . . . . . . . . . . . . 21azithromycin susr 100mg/5ml . . . . . . 21azithromycin susr 200mg/5ml . . . . . . 21azithromycin tabs 250mg, 500mg . . . 21azithromycin tabs 600mg . . . . . . . . . . . 21

ARALAST NP INJ 500MG . . . . . . . . . . 55aranelle . . . . . . . . . . . . . . . . . . . . . . . . . . . 47ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 40MCG/0.4ML . . . . . 37ARANESP ALBUMIN FREE INJ 25MCG/0.42ML . . . . . . . . . . . . . . . . . . . 37ARANESP ALBUMIN FREE INJ 25MCG/ML, 40MCG/ML . . . . . . . . . . . 37ARANESP ALBUMIN FREE INJ 60MCG/0.3ML . . . . . . . . . . . . . . . . . . . . 37ARANESP ALBUMIN FREE INJ 100MCG/0.5ML . . . . . . . . . . . . . . . . . . . 37ARANESP ALBUMIN FREE INJ 100MCG/ML, 200MCG/ML, 300MCG/ML, 60MCG/ML . . . . . . . . . . 37ARANESP ALBUMIN FREE INJ 150MCG/0.3ML . . . . . . . . . . . . . . . . . . . 37ARANESP ALBUMIN FREE INJ 200MCG/0.4ML . . . . . . . . . . . . . . . . . . . 37ARANESP ALBUMIN FREE INJ 300MCG/0.6ML . . . . . . . . . . . . . . . . . . . 37ARANESP ALBUMIN FREE INJ 500MCG/ML . . . . . . . . . . . . . . . . . . . . . . 37ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 51aripiprazole odt . . . . . . . . . . . . . . . . . . . . 31aripiprazole oral soln . . . . . . . . . . . . . . 31aripiprazole tabs . . . . . . . . . . . . . . . . . . 31ARISTADA INJ 441MG/1.6ML . . . . . . 31ARISTADA INJ 662MG/2.4ML . . . . . . 31ARISTADA INJ 882MG/3.2ML . . . . . . 31ARISTADA INJ 1064MG/3.9ML . . . . . 31armodafinil . . . . . . . . . . . . . . . . . . . . . . . . 55ARNUITY ELLIPTA . . . . . . . . . . . . . . . . 54ARRANON . . . . . . . . . . . . . . . . . . . . . . . . 27ascomp/codeine . . . . . . . . . . . . . . . . . . . 16ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 47aspirin/dipyridamole . . . . . . . . . . . . . . . 37ASTAGRAF XL CP24 0.5MG, 1MG . . . . . . . . . . . . . . . . . . . . . . 50ASTAGRAF XL CP24 5MG . . . . . . . . . 50atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 39atenolol/chlorthalidone . . . . . . . . . . . . . 39

amlodipine besylate/valsartan . . . . . . 39amlodipine/olmesartan medoxomil . . . 39amlodipine/valsartan/hctz . . . . . . . . . . 39ammonium lactate . . . . . . . . . . . . . . . . . 42amnesteem . . . . . . . . . . . . . . . . . . . . . . . 42amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 25amoxicillin caps . . . . . . . . . . . . . . . . . . . 20amoxicillin chew . . . . . . . . . . . . . . . . . . 20amoxicillin/clavulanate potassium . . . 20amoxicillin/clavulanate potassium er . . . . . . . . . . . . . . . . . . . . . . 20amoxicillin susr . . . . . . . . . . . . . . . . . . . 20amoxicillin tabs . . . . . . . . . . . . . . . . . . . 20amphetamine/ dextroamphetamine cp24 . . . . . . . . . . 41amphetamine/ dextroamphetamine tabs . . . . . . . . . . 41amphotericin b . . . . . . . . . . . . . . . . . . . . 25ampicillin . . . . . . . . . . . . . . . . . . . . . . . . . . 20ampicillin sodium . . . . . . . . . . . . . . . . . . 20ampicillin-sulbactam . . . . . . . . . . . . . . . 20AMPYRA . . . . . . . . . . . . . . . . . . . . . . . . . 42ANADROL-50 . . . . . . . . . . . . . . . . . . . . . 46anagrelide hydrochloride . . . . . . . . . . . 37anaspaz . . . . . . . . . . . . . . . . . . . . . . . . . . 43anastrozole . . . . . . . . . . . . . . . . . . . . . . . 29ANORO ELLIPTA . . . . . . . . . . . . . . . . . . 54APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 30apraclonidine . . . . . . . . . . . . . . . . . . . . . . 53aprepitant caps . . . . . . . . . . . . . . . . . . . 25aprepitant caps 40mg . . . . . . . . . . . . . . 25aprepitant caps 80mg . . . . . . . . . . . . . . 25aprepitant caps 125mg . . . . . . . . . . . . . 25apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . 51APTIOM TABS 200MG . . . . . . . . . . . . . 22APTIOM TABS 400MG, 800MG . . . . 22APTIOM TABS 600MG . . . . . . . . . . . . . 22APTIVUS CAPS . . . . . . . . . . . . . . . . . . 34APTIVUS ORAL SOLN . . . . . . . . . . . . 34

61


Covered Drugs Index

brimonidine tartrate ophthalmic soln 0.15% . . . . . . . . . . . . . 53BRIVIACT INJ . . . . . . . . . . . . . . . . . . . . 22BRIVIACT ORAL SOLN . . . . . . . . . . . 22BRIVIACT TABS 10MG, 25MG, 50MG, 75MG . . . . . . . 22BRIVIACT TABS 100MG . . . . . . . . . . . 22bromfenac . . . . . . . . . . . . . . . . . . . . . . . . 53bromocriptine mesylate . . . . . . . . . . . . 30budesonide cpep . . . . . . . . . . . . . . . . . 51budesonide nasal spray . . . . . . . . . . . . 54budesonide susp . . . . . . . . . . . . . . . . . . 54bumetanide inj . . . . . . . . . . . . . . . . . . . . 40bumetanide tabs 0.5mg, 1mg . . . . . . . 40bumetanide tabs 2mg . . . . . . . . . . . . . . 40BUPHENYL TABS . . . . . . . . . . . . . . . . 43buprenorphine hcl inj . . . . . . . . . . . . . . 16buprenorphine hcl inj . . . . . . . . . . . . . . 18buprenorphine hcl/naloxone hcl . . . . . 18buprenorphine hcl subl . . . . . . . . . . . . 18bupropion hcl er tb12 100mg, 200mg . . . . . . . . . . . . . . . . . . . . 24bupropion hcl sr . . . . . . . . . . . . . . . . . . . 18bupropion hcl sr . . . . . . . . . . . . . . . . . . . 24bupropion hcl tabs 75mg . . . . . . . . . . . 24bupropion hcl tabs 100mg . . . . . . . . . . 24bupropion hcl xl . . . . . . . . . . . . . . . . . . . 24buspirone hcl tabs 10mg, 5mg . . . . . . 34buspirone hcl tabs 15mg, 30mg, 7.5mg . . . . . . . . . . . . . . . 34busulfan . . . . . . . . . . . . . . . . . . . . . . . . . . 27BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . 27butalbital/acetaminophen/ caffeine caps . . . . . . . . . . . . . . . . . . . . . 16butalbital/acetaminophen/ caffeine/codeine . . . . . . . . . . . . . . . . . . . 16butalbital/acetaminophen/ caffeine tabs 325mg; 50mg; 40mg . . . 16butalbital/aspirin/caffeine caps . . . . . 16butalbital/aspirin/caffeine/codeine . . . 16butorphanol tartrate inj 1mg/ml . . . . . 17

benazepril hcl tabs 40mg . . . . . . . . . . . 38BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 27BENICAR . . . . . . . . . . . . . . . . . . . . . . . . . 37BENICAR HCT . . . . . . . . . . . . . . . . . . . . 37BENLYSTA INJ 120MG . . . . . . . . . . . . 51BENLYSTA INJ 400MG . . . . . . . . . . . . 51benztropine mesylate inj . . . . . . . . . . . 30benztropine mesylate tabs . . . . . . . . . 30BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 21BESPONSA . . . . . . . . . . . . . . . . . . . . . . . 30betamethasone dipropionate . . . . . . . 45betamethasone valerate . . . . . . . . . . . 45BETASERON . . . . . . . . . . . . . . . . . . . . . 42betaxolol hcl . . . . . . . . . . . . . . . . . . . . . . . 39betaxolol hcl . . . . . . . . . . . . . . . . . . . . . . . 53bethanechol chloride . . . . . . . . . . . . . . . 45bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 30BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 51bicalutamide . . . . . . . . . . . . . . . . . . . . . . 27BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 20BICNU . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41BILTRICIDE . . . . . . . . . . . . . . . . . . . . . . . 30bimatoprost ophthalmic soln . . . . . . . . 52bisoprolol fumarate . . . . . . . . . . . . . . . . 39bisoprolol fumarate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 39bleomycin sulfate . . . . . . . . . . . . . . . . . . 28BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 21BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 21blisovi fe 1.5/30 . . . . . . . . . . . . . . . . . . . . 47blisovi fe 1/20 . . . . . . . . . . . . . . . . . . . . . 47BOOSTRIX . . . . . . . . . . . . . . . . . . . . . . . 51BOSULIF TABS 100MG . . . . . . . . . . . . 29BOSULIF TABS 500MG . . . . . . . . . . . . 29BREO ELLIPTA . . . . . . . . . . . . . . . . . . . 54briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 37brimonidine tartrate ophthalmic soln 0.2% . . . . . . . . . . . . . . 53

AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 53AZOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39aztreonam inj 1gm . . . . . . . . . . . . . . . . . 20AZTREONAM INJ 2GM . . . . . . . . . . . . 20

Bbaciim . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19bacitracin inj . . . . . . . . . . . . . . . . . . . . . . 19bacitracin ophthalmic oint . . . . . . . . . . 19bacitracin/polymyxin b . . . . . . . . . . . . . 19baclofen tabs 10mg . . . . . . . . . . . . . . . . 32baclofen tabs 20mg . . . . . . . . . . . . . . . . 32BACTROBAN NASAL . . . . . . . . . . . . . 19balsalazide disodium . . . . . . . . . . . . . . 51balziva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47BANZEL SUSP . . . . . . . . . . . . . . . . . . . 23BANZEL TABS 200MG . . . . . . . . . . . . 23BANZEL TABS 400MG . . . . . . . . . . . . 23BARACLUDE ORAL SOLN . . . . . . . . 32BAVENCIO . . . . . . . . . . . . . . . . . . . . . . . . 30bd eclipse syringe/1ml/30gx1/2” . . . . 52bd insulin syringe safetyglide/ 1ml/29g x 1/2” . . . . . . . . . . . . . . . . . . . . . 52bd insulin syringe ultrafine/ 0.3ml/31g x 5/16” . . . . . . . . . . . . . . . . . . 52bd insulin syringe ultrafine/ 0.5ml/30g x 1/2” . . . . . . . . . . . . . . . . . . . 52bd insulin syringe ultrafine/ 1ml/31g x 5/16” . . . . . . . . . . . . . . . . . . . . 52bd pen needle/mini/ultrafine/ 31g x 3/16” . . . . . . . . . . . . . . . . . . . . . . . . 52bd pen needle/nano/ultra fine/ 32g x 4mm . . . . . . . . . . . . . . . . . . . . . . . . 52bd pen needle/ultrafine/ 29g x 12.7mm . . . . . . . . . . . . . . . . . . . . . 52bd safetyglide 27g x 5/8” . . . . . . . . . . . 52bekyree . . . . . . . . . . . . . . . . . . . . . . . . . . . 47BELEODAQ . . . . . . . . . . . . . . . . . . . . . . . 28benazepril hcl/hydrochlorothiazide . . . 38benazepril hcl tabs 10mg, 20mg, 5mg . . . . . . . . . . . . . . . . . 38

62


Covered Drugs Index

cefoxitin sodium inj 10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 20cefpodoxime proxetil . . . . . . . . . . . . . . . 20cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 20ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . 20ceftazidime/dextrose . . . . . . . . . . . . . . . 20ceftriaxone in iso-osmotic dextrose . . . . . . . . . . . . . . . . . . . . . . . . . . 20ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg . . . 20cefuroxime axetil . . . . . . . . . . . . . . . . . . 20cefuroxime sodium . . . . . . . . . . . . . . . . 20celecoxib caps 100mg, 200mg, 50mg . . . . . . . . . . . . . . 16celecoxib caps 400mg . . . . . . . . . . . . . 16CELLCEPT INTRAVENOUS . . . . . . . 50CELONTIN . . . . . . . . . . . . . . . . . . . . . . . . 22cephalexin caps 250mg, 500mg . . . . 20cephalexin susr . . . . . . . . . . . . . . . . . . . 20cephalexin tabs . . . . . . . . . . . . . . . . . . . 20CEREZYME . . . . . . . . . . . . . . . . . . . . . . . 43CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . 18CHANTIX CONTINUING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . 18CHANTIX STARTING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . 18chateal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . 55chloramphenicol sodium succinate . . 19chlorhexidine gluconate mouth/throat soln . . . . . . . . . . . . . . . . . 42chloroquine phosphate . . . . . . . . . . . . . 30chlorothiazide . . . . . . . . . . . . . . . . . . . . . 40chlorothiazide sodium . . . . . . . . . . . . . . 40chlorpromazine hcl inj . . . . . . . . . . . . . 31chlorpromazine hcl tabs . . . . . . . . . . . 31chlorthalidone . . . . . . . . . . . . . . . . . . . . . 40cholestyramine . . . . . . . . . . . . . . . . . . . . 41cholestyramine light . . . . . . . . . . . . . . . 41chorionic gonadotropin . . . . . . . . . . . . . 46ciclodan . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

captopril/hydrochlorothiazide tabs 25mg; 25mg, 50mg; 25mg . . . . . 38captopril tabs 12.5mg, 25mg . . . . . . . 38captopril tabs 50mg . . . . . . . . . . . . . . . . 38captopril tabs 100mg . . . . . . . . . . . . . . 38CARAC . . . . . . . . . . . . . . . . . . . . . . . . . . . 42CARAFATE SUSP . . . . . . . . . . . . . . . . 44CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 56carbamazepine . . . . . . . . . . . . . . . . . . . . 23carbamazepine er . . . . . . . . . . . . . . . . . 23carbidopa . . . . . . . . . . . . . . . . . . . . . . . . . 31carbidopa/levodopa . . . . . . . . . . . . . . . . 31carbidopa/levodopa/entacapone . . . . 31carbidopa/levodopa er . . . . . . . . . . . . . 31carbidopa/levodopa odt . . . . . . . . . . . . 31carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml . . . . . . . . . . . . 28CARNITOR INJ . . . . . . . . . . . . . . . . . . . 52carteolol hcl . . . . . . . . . . . . . . . . . . . . . . . 53cartia xt cp24 120mg, 300mg . . . . . . . 39cartia xt cp24 180mg, 240mg . . . . . . . 39carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 39caspofungin acetate . . . . . . . . . . . . . . . 25CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 54caziant . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47cefaclor . . . . . . . . . . . . . . . . . . . . . . . . . . . 20cefaclor er . . . . . . . . . . . . . . . . . . . . . . . . 20cefadroxil . . . . . . . . . . . . . . . . . . . . . . . . . 20CEFAZOLIN . . . . . . . . . . . . . . . . . . . . . . . 20cefazolin sodium/dextrose inj 2gm; 3% . . . . . . . . . . . . . . . . . . . . . . . . . . 20cefazolin sodium inj 10gm, 1gm, 1gm; 5%, 500mg . . . . . . 20cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20cefepime . . . . . . . . . . . . . . . . . . . . . . . . . . 20cefepime/dextrose . . . . . . . . . . . . . . . . . 20cefixime . . . . . . . . . . . . . . . . . . . . . . . . . . . 20cefotaxime sodium inj 1gm, 2gm, 500mg . . . . . . . . . . . . . . . . . 20cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . 20

butorphanol tartrate inj 2mg/ml . . . . . 16butorphanol tartrate nasal soln . . . . . 17BYDUREON . . . . . . . . . . . . . . . . . . . . . . 35BYDUREON PEN . . . . . . . . . . . . . . . . . 35BYETTA INJ 5MCG/0.02ML . . . . . . . . 35BYETTA INJ 10MCG/0.04ML . . . . . . . 35BYSTOLIC TABS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 39BYSTOLIC TABS 20MG . . . . . . . . . . . 39BYVALSON . . . . . . . . . . . . . . . . . . . . . . . 39

Ccabergoline . . . . . . . . . . . . . . . . . . . . . . . 49CABOMETYX TABS 20MG, 60MG . . . 29CABOMETYX TABS 40MG . . . . . . . . 29cafergot . . . . . . . . . . . . . . . . . . . . . . . . . . . 26calcipotriene crea . . . . . . . . . . . . . . . . . 42calcipotriene external soln . . . . . . . . . 42calcipotriene oint . . . . . . . . . . . . . . . . . . 42calcitonin-salmon . . . . . . . . . . . . . . . . . . 52calcitrene . . . . . . . . . . . . . . . . . . . . . . . . . 42calcitriol caps . . . . . . . . . . . . . . . . . . . . . 52calcitriol inj . . . . . . . . . . . . . . . . . . . . . . . 52calcitriol oint . . . . . . . . . . . . . . . . . . . . . . 42calcitriol oral soln . . . . . . . . . . . . . . . . . 52calcium acetate caps . . . . . . . . . . . . . . 45calcium acetate tabs 667mg . . . . . . . . 45camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 47camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 47CANCIDAS . . . . . . . . . . . . . . . . . . . . . . . 25candesartan cilexetil . . . . . . . . . . . . . . . 38candesartan cilexetil/ hydrochlorothiazide . . . . . . . . . . . . . . . . 38capacet . . . . . . . . . . . . . . . . . . . . . . . . . . . 16CAPASTAT SULFATE . . . . . . . . . . . . . . 26CAPRELSA TABS 100MG . . . . . . . . . 29CAPRELSA TABS 300MG . . . . . . . . . 29captopril/hydrochlorothiazide tabs 25mg; 15mg, 50mg; 15mg . . . . . 38

63


Covered Drugs Index

clonazepam tabs 2mg . . . . . . . . . . . . . 22clonidine hcl er . . . . . . . . . . . . . . . . . . . . 42clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr . . . . . . . . . . . . 37clonidine hcl ptwk 0.3mg/24hr . . . . . . 37clonidine hcl tabs 0.1mg, 0.2mg . . . . 37clonidine hcl tabs 0.3mg . . . . . . . . . . . 37clopidogrel tabs 75mg . . . . . . . . . . . . . 37clopidogrel tabs 300mg . . . . . . . . . . . . 37clorazepate dipotassium tabs 3.75mg, 7.5mg . . . . . . . . . . . . . . . 35clorazepate dipotassium tabs 15mg . . . . . . . . . . . . . . . . . . . . . . . . 35clotrimazole/betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . 25clotrimazole external crea . . . . . . . . . 25clotrimazole external soln . . . . . . . . . . 25clotrimazole troc . . . . . . . . . . . . . . . . . . 25clozapine odt tbdp 12.5mg, 25mg . . . 32clozapine odt tbdp 100mg . . . . . . . . . . 32clozapine odt tbdp 150mg . . . . . . . . . . 32clozapine odt tbdp 200mg . . . . . . . . . . 32clozapine tabs 25mg, 50mg . . . . . . . . 32clozapine tabs 100mg . . . . . . . . . . . . . . 32clozapine tabs 200mg . . . . . . . . . . . . . . 32COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 30colchicine caps . . . . . . . . . . . . . . . . . . . 26colchicine tabs . . . . . . . . . . . . . . . . . . . . 26colestipol hcl gran . . . . . . . . . . . . . . . . . 41colestipol hcl tabs . . . . . . . . . . . . . . . . . 41colistimethate sodium . . . . . . . . . . . . . . 19colocort . . . . . . . . . . . . . . . . . . . . . . . . . . . 51COLY-MYCIN S . . . . . . . . . . . . . . . . . . . 53COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 53COMBIVENT RESPIMAT . . . . . . . . . . 54COMETRIQ KIT . . . . . . . . . . . . . . . . . . 29COMETRIQ KIT . . . . . . . . . . . . . . . . . . 29COMETRIQ KIT 20MG . . . . . . . . . . . . 29COMPLERA . . . . . . . . . . . . . . . . . . . . . . 33compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml . . . . . . . . . . . . 19clindamycin phosphate lotn . . . . . . . . 19clindamycin phosphate pharmacy bulk package . . . . . . . . . . . . 19clindamycin phosphate swab . . . . . . 19clindamycin/sodium chloride . . . . . . . . 19CLINIMIX 2.75%/DEXTROSE 5% . . . 56CLINIMIX 4.25%/DEXTROSE 5% . . . 56CLINIMIX 4.25%/DEXTROSE 10% . . 56CLINIMIX 4.25%/DEXTROSE 20% . . 56CLINIMIX 4.25%/DEXTROSE 25% . . 56CLINIMIX 5%/DEXTROSE 15% . . . . 56CLINIMIX 5%/DEXTROSE 20% . . . . 56CLINIMIX 5%/DEXTROSE 25% . . . . 56CLINIMIX E 2.75%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 56CLINIMIX E 4.25%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 56CLINIMIX E 4.25%/ DEXTROSE 25% . . . . . . . . . . . . . . . . . . 56CLINIMIX E 5%/DEXTROSE 25% . . . 56CLINISOL SF 15% . . . . . . . . . . . . . . . . 56clobetasol propionate crea . . . . . . . . . 45clobetasol propionate e . . . . . . . . . . . . 45clobetasol propionate emollient . . . . . 45clobetasol propionate external soln . . . . . . . . . . . . . . . . . . . . . . 45clobetasol propionate foam . . . . . . . . 45clobetasol propionate gel . . . . . . . . . . 45clobetasol propionate oint . . . . . . . . . 45clobetasol propionate sham . . . . . . . . 45clodan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45clofarabine . . . . . . . . . . . . . . . . . . . . . . . . 27CLOLAR . . . . . . . . . . . . . . . . . . . . . . . . . . 27clomipramine hcl . . . . . . . . . . . . . . . . . . 25clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg . . . . . 22clonazepam odt tbdp 2mg . . . . . . . . . . 22clonazepam tabs 0.5mg, 1mg . . . . . . 22

ciclopirox nail lacquer . . . . . . . . . . . . . . 25ciclopirox olamine . . . . . . . . . . . . . . . . . 25ciclopirox sham . . . . . . . . . . . . . . . . . . . 25ciclopirox susp . . . . . . . . . . . . . . . . . . . . 25cidofovir . . . . . . . . . . . . . . . . . . . . . . . . . . 32cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . 37CILOXAN OINT . . . . . . . . . . . . . . . . . . . 21cimetidine . . . . . . . . . . . . . . . . . . . . . . . . . 44cimetidine hcl . . . . . . . . . . . . . . . . . . . . . 44CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . . 50CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 21ciprofloxacin er tb24 500mg; 0 . . . . . . 21ciprofloxacin er tb24 1000mg; 0 . . . . 21ciprofloxacin hcl ophthalmic soln . . . . 21ciprofloxacin hcl tabs 100mg, 750mg . . . . . . . . . . . . . . . . . . . . 21ciprofloxacin hcl tabs 250mg, 500mg . . . . . . . . . . . . . . . . . . . . 21ciprofloxacin inj . . . . . . . . . . . . . . . . . . . 21ciprofloxacin i.v.-in d5w . . . . . . . . . . . . 21ciprofloxacin susr . . . . . . . . . . . . . . . . . 21CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . . 21cisplatin . . . . . . . . . . . . . . . . . . . . . . . . . . . 28citalopram hydrobromide oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 24citalopram hydrobromide tabs . . . . . 24cladribine . . . . . . . . . . . . . . . . . . . . . . . . . 27claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 42clarithromycin er . . . . . . . . . . . . . . . . . . . 21clarithromycin susr . . . . . . . . . . . . . . . . 21clarithromycin tabs . . . . . . . . . . . . . . . . 21clindacin etz pledgets . . . . . . . . . . . . . . 19clindacin-p . . . . . . . . . . . . . . . . . . . . . . . . 19clindamycin . . . . . . . . . . . . . . . . . . . . . . . 19clindamycin hcl . . . . . . . . . . . . . . . . . . . . 19clindamycin phosphate crea . . . . . . . 19clindamycin phosphate external soln . . . . . . . . . . . . . . . . . . . . . . 19clindamycin phosphate gel . . . . . . . . 19clindamycin phosphate in d5w . . . . . . 19

64


Covered Drugs Index

dexamethasone intensol . . . . . . . . . . . 45dexamethasone oral soln . . . . . . . . . . 45dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml, 20mg/5ml, 4mg/ml . . . . 45dexamethasone sodium phosphate ophthalmic soln . . . . . . . . 53dexamethasone tabs 0.5mg, 0.75mg, 4mg . . . . . . . . . . . . . . . 45dexamethasone tabs 1.5mg, 1mg, 2mg, 6mg . . . . . . . . . . . . 45DEXILANT . . . . . . . . . . . . . . . . . . . . . . . . 44dexmethylphenidate hcl . . . . . . . . . . . . 42dexrazoxane . . . . . . . . . . . . . . . . . . . . . . 28dextroamphetamine sulfate er cp24 5mg . . . . . . . . . . . . . . . . . . . . . . . . . 41dextroamphetamine sulfate er cp24 10mg . . . . . . . . . . . . . . . . . . . . . . . . 41dextroamphetamine sulfate er cp24 15mg . . . . . . . . . . . . . . . . . . . . . . . . 41dextroamphetamine sulfate oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 41dextroamphetamine sulfate tabs 5mg . . . . . . . . . . . . . . . . . . . . . . . . . . 41dextroamphetamine sulfate tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 42dextrose 2.5%/nacl 0.45% . . . . . . . . . 56DEXTROSE 5% . . . . . . . . . . . . . . . . . . . 56dextrose5% / electrolyte #48 viaflex . . . . . . . . . . . . . . 56DEXTROSE 5%/ LACTATED RINGERS . . . . . . . . . . . . . 56dextrose 5%/nacl 0.2% . . . . . . . . . . . . 56DEXTROSE 5%/NACL 0.3% . . . . . . . 56dextrose 5%/nacl 0.9% . . . . . . . . . . . . 56dextrose 5%/nacl 0.33% . . . . . . . . . . . 56dextrose 5%/nacl 0.45% . . . . . . . . . . . 56dextrose 5%/nacl 0.225% . . . . . . . . . . 56DEXTROSE 10% . . . . . . . . . . . . . . . . . . 56dextrose 10%/nacl 0.2% . . . . . . . . . . . 56dextrose10%/nacl 0.45% . . . . . . . . . . . 56DEXTROSE 20% . . . . . . . . . . . . . . . . . . 56

Ddacarbazine . . . . . . . . . . . . . . . . . . . . . . . 27DALIRESP . . . . . . . . . . . . . . . . . . . . . . . . 55danazol . . . . . . . . . . . . . . . . . . . . . . . . . . . 46dantrolene sodium . . . . . . . . . . . . . . . . . 32dapsone . . . . . . . . . . . . . . . . . . . . . . . . . . 26DAPTACEL . . . . . . . . . . . . . . . . . . . . . . . 51daptomycin . . . . . . . . . . . . . . . . . . . . . . . 19DARAPRIM . . . . . . . . . . . . . . . . . . . . . . . 30darifenacin hydrobromide er . . . . . . . . 44DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 30dasetta 1/35 . . . . . . . . . . . . . . . . . . . . . . . 47dasetta 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 47daunorubicin hcl . . . . . . . . . . . . . . . . . . . 28daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 48decitabine . . . . . . . . . . . . . . . . . . . . . . . . . 28DELESTROGEN INJ 10MG/ML . . . . 47delyla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47demeclocycline hcl . . . . . . . . . . . . . . . . 22DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 40DENAVIR . . . . . . . . . . . . . . . . . . . . . . . . . 34DEPEN TITRATABS . . . . . . . . . . . . . . . 55DEPO-ESTRADIOL . . . . . . . . . . . . . . . 47DEPO-MEDROL INJ 20MG/ML . . . . . 45DEPO-PROVERA . . . . . . . . . . . . . . . . . 48DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . 33desipramine hcl . . . . . . . . . . . . . . . . . . . 25desloratadine . . . . . . . . . . . . . . . . . . . . . . 54desloratadine odt . . . . . . . . . . . . . . . . . . 54desmopressin acetate inj . . . . . . . . . . 46desmopressin acetate nasal soln . . . 46desmopressin acetate tabs . . . . . . . . 46desogestrel/ethinyl estradiol . . . . . . . . 47desonide lotn . . . . . . . . . . . . . . . . . . . . . 45desonide oint . . . . . . . . . . . . . . . . . . . . . 45desoximetasone . . . . . . . . . . . . . . . . . . . 45desvenlafaxine er . . . . . . . . . . . . . . . . . . 24dexamethasone elix . . . . . . . . . . . . . . . 45

constulose . . . . . . . . . . . . . . . . . . . . . . . . 44COPAXONE INJ 20MG/ML . . . . . . . . . 42COPAXONE INJ 40MG/ML . . . . . . . . . 42COREG CR . . . . . . . . . . . . . . . . . . . . . . . 39cormax scalp application . . . . . . . . . . . 45cortisone acetate . . . . . . . . . . . . . . . . . . 45COSMEGEN . . . . . . . . . . . . . . . . . . . . . . 28COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 29COUMADIN . . . . . . . . . . . . . . . . . . . . . . . 36CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 43CRESTOR . . . . . . . . . . . . . . . . . . . . . . . . 41CRIXIVAN CAPS 200MG . . . . . . . . . . 34CRIXIVAN CAPS 400MG . . . . . . . . . . 34cromolyn sodium conc . . . . . . . . . . . . 44cromolyn sodium nebu . . . . . . . . . . . . 54cromolyn sodium ophthalmic soln . . . 53cryselle-28 . . . . . . . . . . . . . . . . . . . . . . . . 47CUBICIN . . . . . . . . . . . . . . . . . . . . . . . . . . 19CUPRIMINE . . . . . . . . . . . . . . . . . . . . . . 55curity gauze pads 2”x2” . . . . . . . . . . . . 42cyclafem 1/35 . . . . . . . . . . . . . . . . . . . . . 47cyclafem 7/7/7 . . . . . . . . . . . . . . . . . . . . . 47cyclobenzaprine hcl tabs 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 55cyclophosphamide caps . . . . . . . . . . . 27cyclophosphamide inj 1gm, 500mg . . . . . . . . . . . . . . . . . . . . . . . 27cyclophosphamide inj 2gm . . . . . . . . . 27cycloserine . . . . . . . . . . . . . . . . . . . . . . . . 26CYCLOSET . . . . . . . . . . . . . . . . . . . . . . . 35cyclosporine caps . . . . . . . . . . . . . . . . . 50cyclosporine inj . . . . . . . . . . . . . . . . . . . 50cyclosporine modified . . . . . . . . . . . . . . 50CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 30cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47CYSTADANE . . . . . . . . . . . . . . . . . . . . . 43CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 43CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 53cytarabine . . . . . . . . . . . . . . . . . . . . . . . . . 27cytarabine aqueous . . . . . . . . . . . . . . . . 27

65


Covered Drugs Index

doxercalciferol inj . . . . . . . . . . . . . . . . . 52doxorubicin hcl . . . . . . . . . . . . . . . . . . . . 28doxorubicin hcl liposome . . . . . . . . . . . 28doxy 100 . . . . . . . . . . . . . . . . . . . . . . . . . . 22doxycycline hyclate caps . . . . . . . . . . 22doxycycline hyclate inj . . . . . . . . . . . . . 22doxycycline hyclate tabs 20mg . . . . . 22doxycycline hyclate tabs 100mg . . . . 22doxycycline monohydrate caps 100mg, 50mg, 75mg . . . . . . . . . . . . . . . 22doxycycline monohydrate tabs . . . . . 22doxycycline susr . . . . . . . . . . . . . . . . . . 22dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 25DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 27duloxetine hcl cpep 20mg, 60mg . . . 24duloxetine hcl cpep 30mg . . . . . . . . . . 24DURAMORPH . . . . . . . . . . . . . . . . . . . . 16DUREZOL . . . . . . . . . . . . . . . . . . . . . . . . 53dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 45dutasteride/tamsulosin hydrochloride . . . . . . . . . . . . . . . . . . . . . . 45

Eeconazole nitrate . . . . . . . . . . . . . . . . . . 25ed-spaz . . . . . . . . . . . . . . . . . . . . . . . . . . . 43EDURANT . . . . . . . . . . . . . . . . . . . . . . . . 33e.e.s. 400 . . . . . . . . . . . . . . . . . . . . . . . . . 21E.E.S. GRANULES . . . . . . . . . . . . . . . . 21EFFIENT . . . . . . . . . . . . . . . . . . . . . . . . . . 37ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 43ELIDEL . . . . . . . . . . . . . . . . . . . . . . . . . . . 42ELIGARD INJ 7.5MG . . . . . . . . . . . . . . 49ELIGARD INJ 22.5MG . . . . . . . . . . . . . 49ELIGARD INJ 30MG . . . . . . . . . . . . . . . 49ELIGARD INJ 45MG . . . . . . . . . . . . . . . 49elinest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47ELITEK . . . . . . . . . . . . . . . . . . . . . . . . . . . 28ELLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 45EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

diltiazem hcl er cp12 . . . . . . . . . . . . . . 39diltiazem hcl er cp24 120mg, 300mg, 360mg, 420mg . . . . . 39diltiazem hcl er cp24 180mg, 240mg . . . . . . . . . . . . . . . . . . . . 39diltiazem hcl er tb24 180mg, 240mg . . . . . . . . . . . . . . . . . . . . 39diltiazem hcl er tb24 300mg, 360mg, 420mg . . . . . . . . . . . . 39diltiazem hcl inj . . . . . . . . . . . . . . . . . . . 39diltiazem hcl tabs . . . . . . . . . . . . . . . . . 39dilt-xr cp24 120mg . . . . . . . . . . . . . . . . . 39dilt-xr cp24 180mg, 240mg . . . . . . . . . 39diphenhydramine hcl inj . . . . . . . . . . . 54diphenoxylate/atropine . . . . . . . . . . . . . 44DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC . . . . . . . . . . 51disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . 18divalproex sodium . . . . . . . . . . . . . . . . . 22divalproex sodium dr . . . . . . . . . . . . . . . 22divalproex sodium er . . . . . . . . . . . . . . . 23docetaxel inj 160mg/16ml, 160mg/8ml, 20mg/2ml, 20mg/ml, 80mg/4ml, 80mg/8ml . . . . . . . . . . . . . . 28docetaxel inj 200mg/10ml . . . . . . . . . . 28dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 38donepezil hcl tabs 10mg . . . . . . . . . . . 23donepezil hcl tabs 23mg, 5mg . . . . . . 23donepezil hcl tbdp 5mg . . . . . . . . . . . . 23donepezil hcl tbdp 10mg . . . . . . . . . . . 23dorzolamide hcl . . . . . . . . . . . . . . . . . . . 53dorzolamide hcl/timolol maleate . . . . 53doxazosin . . . . . . . . . . . . . . . . . . . . . . . . . 44doxazosin mesylate tabs 1mg, 2mg . . . . . . . . . . . . . . . . . . . . . . . . . 44doxazosin mesylate tabs 8mg . . . . . . 44doxepin hcl . . . . . . . . . . . . . . . . . . . . . . . . 25doxepin hydrochloride . . . . . . . . . . . . . 42doxercalciferol caps 0.5mcg . . . . . . . . 52doxercalciferol caps 1mcg . . . . . . . . . . 52doxercalciferol caps 2.5mcg . . . . . . . . 52

DEXTROSE 25% . . . . . . . . . . . . . . . . . . 56DEXTROSE 30% . . . . . . . . . . . . . . . . . . 56DEXTROSE 40% . . . . . . . . . . . . . . . . . . 56DEXTROSE 50% . . . . . . . . . . . . . . . . . . 56DEXTROSE 70% . . . . . . . . . . . . . . . . . . 56DIASTAT ACUDIAL GEL 10MG . . . . . 22DIASTAT ACUDIAL GEL 20MG . . . . . 22DIASTAT PEDIATRIC . . . . . . . . . . . . . . 22diazepam inj 5mg/ml . . . . . . . . . . . . . . . 35diazepam oral soln . . . . . . . . . . . . . . . . 35diazepam rectal gel gel 2.5mg . . . . . . 22diazepam rectal gel gel 10mg . . . . . . 22diazepam tabs . . . . . . . . . . . . . . . . . . . . 35diclofenac potassium . . . . . . . . . . . . . . 16diclofenac sodium dr tbec 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 16diclofenac sodium dr tbec 75mg . . . . 16diclofenac sodium er . . . . . . . . . . . . . . . 16diclofenac sodium ophthalmic soln . . . . . . . . . . . . . . . . . . . 53diclofenac sodium transdermal soln . . . . . . . . . . . . . . . . . . 42dicloxacillin sodium . . . . . . . . . . . . . . . . 20dicyclomine hcl caps . . . . . . . . . . . . . . 43dicyclomine hcl oral soln . . . . . . . . . . . 43dicyclomine hcl tabs . . . . . . . . . . . . . . . 43didanosine . . . . . . . . . . . . . . . . . . . . . . . . 33diflorasone diacetate . . . . . . . . . . . . . . . 45diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . 16digitek tabs 0.25mg . . . . . . . . . . . . . . . . 40digitek tabs 0.125mg . . . . . . . . . . . . . . . 40digoxin inj . . . . . . . . . . . . . . . . . . . . . . . . 40digoxin tabs 125mcg . . . . . . . . . . . . . . . 40digoxin tabs 250mcg . . . . . . . . . . . . . . . 40digox tabs 125mcg . . . . . . . . . . . . . . . . 40digox tabs 250mcg . . . . . . . . . . . . . . . . 40dihydroergotamine mesylate inj . . . . . 26DILANTIN CAPS 30MG . . . . . . . . . . . . 23diltiazem cd cp24 240mg . . . . . . . . . . . 39diltiazem hcl cd . . . . . . . . . . . . . . . . . . . . 39

66


Covered Drugs Index

estarylla . . . . . . . . . . . . . . . . . . . . . . . . . . 47estradiol pttw . . . . . . . . . . . . . . . . . . . . . 47estradiol ptwk . . . . . . . . . . . . . . . . . . . . . 47estradiol tabs 0.5mg, 1mg, 2mg . . . . 47estradiol tabs 10mcg . . . . . . . . . . . . . . . 47estradiol valerate . . . . . . . . . . . . . . . . . . 47ESTRING . . . . . . . . . . . . . . . . . . . . . . . . . 47ethacrynate sodium . . . . . . . . . . . . . . . . 40ethambutol hcl . . . . . . . . . . . . . . . . . . . . 26ethosuximide . . . . . . . . . . . . . . . . . . . . . . 22ethynodiol diacetate/ethinyl estradiol tabs 50mcg; 1mg . . . . . . . . . 47ETHYOL . . . . . . . . . . . . . . . . . . . . . . . . . . 28etidronate disodium . . . . . . . . . . . . . . . . 52etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . 16etodolac er . . . . . . . . . . . . . . . . . . . . . . . . 16etoposide inj . . . . . . . . . . . . . . . . . . . . . . 29EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 27EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . 34exemestane . . . . . . . . . . . . . . . . . . . . . . . 29EXJADE . . . . . . . . . . . . . . . . . . . . . . . . . . 55ezetimibe . . . . . . . . . . . . . . . . . . . . . . . . . 41ezetimibe/simvastatin . . . . . . . . . . . . . . 41

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 43falmina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47famciclovir . . . . . . . . . . . . . . . . . . . . . . . . 34famotidine inj . . . . . . . . . . . . . . . . . . . . . 44famotidine premixed . . . . . . . . . . . . . . . 44famotidine tabs 20mg, 40mg . . . . . . . 44FANAPT TABS 1MG, 2MG, 4MG . . . 31FANAPT TABS 10MG, 12MG, 6MG, 8MG . . . . . . . . . . 31FANAPT TITRATION PACK . . . . . . . . 31FARESTON . . . . . . . . . . . . . . . . . . . . . . . 27FARXIGA . . . . . . . . . . . . . . . . . . . . . . . . . 35FARYDAK . . . . . . . . . . . . . . . . . . . . . . . . 29FASLODEX . . . . . . . . . . . . . . . . . . . . . . . 27felbamate . . . . . . . . . . . . . . . . . . . . . . . . . 23

EPCLUSA . . . . . . . . . . . . . . . . . . . . . . . . 33epinastine hcl . . . . . . . . . . . . . . . . . . . . . 53epinephrine hcl inj 1mg/10ml, 1mg/ml . . . . . . . . . . . . . . . . . 54epinephrine inj 0.15mg/0.3ml, 0.3mg/0.3ml . . . . . . . . 54EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . . 54EPIPEN-JR 2-PAK . . . . . . . . . . . . . . . . . 54epirubicin hcl inj 200mg/100ml . . . . . 28epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23EPIVIR HBV ORAL SOLN . . . . . . . . . 33EPZICOM . . . . . . . . . . . . . . . . . . . . . . . . . 33ERBITUX . . . . . . . . . . . . . . . . . . . . . . . . . 30ergoloid mesylates . . . . . . . . . . . . . . . . . 23ergotamine tartrate/caffeine . . . . . . . . 26ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 29errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48ERWINAZE . . . . . . . . . . . . . . . . . . . . . . . 28ery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21ERYPED 200 . . . . . . . . . . . . . . . . . . . . . 21ERYPED 400 . . . . . . . . . . . . . . . . . . . . . 21ERY-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . 21ERYTHROCIN LACTOBIONATE . . . 21erythrocin stearate . . . . . . . . . . . . . . . . . 21erythromycin base . . . . . . . . . . . . . . . . . 21erythromycin/benzoyl peroxide . . . . . 42erythromycin ethylsuccinate susr . . . 21erythromycin ethylsuccinate tabs . . . 21erythromycin external soln . . . . . . . . . 21erythromycin gel . . . . . . . . . . . . . . . . . . 21erythromycin oint . . . . . . . . . . . . . . . . . 21erythromycin pads . . . . . . . . . . . . . . . . 21ESBRIET CAPS . . . . . . . . . . . . . . . . . . 55ESBRIET TABS 267MG . . . . . . . . . . . . 55ESBRIET TABS 801MG . . . . . . . . . . . . 55escitalopram oxalate oral soln . . . . . . 24escitalopram oxalate tabs . . . . . . . . . 24esgic caps . . . . . . . . . . . . . . . . . . . . . . . . 16esomeprazole magnesium . . . . . . . . . 44esomeprazole sodium . . . . . . . . . . . . . 44

EMEND CAPS 40MG . . . . . . . . . . . . . . 25EMEND CAPS 80MG . . . . . . . . . . . . . . 25EMEND CAPS 125MG . . . . . . . . . . . . . 25EMEND SUSR . . . . . . . . . . . . . . . . . . . . 25EMEND TRIPACK . . . . . . . . . . . . . . . . . 25emoquette . . . . . . . . . . . . . . . . . . . . . . . . 47EMPLICITI . . . . . . . . . . . . . . . . . . . . . . . . 30EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 24EMTRIVA CAPS . . . . . . . . . . . . . . . . . . 33EMTRIVA ORAL SOLN . . . . . . . . . . . . 33ENABLEX . . . . . . . . . . . . . . . . . . . . . . . . . 44enalapril maleate . . . . . . . . . . . . . . . . . . 38enalapril maleate/ hydrochlorothiazide tabs 5mg; 12.5mg . . . . . . . . . . . . . . . . . . . . . . 38enalapril maleate/ hydrochlorothiazide tabs 10mg; 25mg . . . . . . . . . . . . . . . . . . . . . . . 38ENBREL INJ 25MG/0.5ML . . . . . . . . . 50ENBREL INJ 25MG, 50MG/ML . . . . . 50ENBREL SURECLICK . . . . . . . . . . . . . 50endocet tabs 325mg; 2.5mg, 325mg; 5mg . . . . . . . . 17endocet tabs 325mg; 7.5mg . . . . . . . . 17endocet tabs 325mg; 10mg . . . . . . . . 17ENGERIX-B INJ 10MCG/0.5ML . . . . 51ENGERIX-B INJ 20MCG/ML . . . . . . . 51enoxaparin sodium inj 30mg/0.3ml . . 36enoxaparin sodium inj 40mg/0.4ml . . 36enoxaparin sodium inj 60mg/0.6ml . . 36enoxaparin sodium inj 100mg/ml, 150mg/ml, 300mg/3ml . . . 36enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml . . . . . . . . . . 36enpresse-28 . . . . . . . . . . . . . . . . . . . . . . . 47enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 47entacapone . . . . . . . . . . . . . . . . . . . . . . . 30entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . 33ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 38enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 44ENVARSUS XR . . . . . . . . . . . . . . . . . . . 50

67


Covered Drugs Index

fluphenazine hcl inj . . . . . . . . . . . . . . . . 31fluphenazine hcl tabs 1mg . . . . . . . . . 31fluphenazine hcl tabs 10mg, 2.5mg, 5mg . . . . . . . . . . . . . . . . . 31flurbiprofen . . . . . . . . . . . . . . . . . . . . . . . . 16flurbiprofen sodium . . . . . . . . . . . . . . . . 53flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 27fluticasone propionate crea . . . . . . . . 45fluticasone propionate oint . . . . . . . . . 46fluticasone propionate susp . . . . . . . . 54fluvoxamine maleate er . . . . . . . . . . . . 24fluvoxamine maleate tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 24fluvoxamine maleate tabs 100mg . . . 24FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 28fomepizole . . . . . . . . . . . . . . . . . . . . . . . . 52fondaparinux sodium inj 2.5mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . 36fondaparinux sodium inj 5mg/0.4ml . . . . . . . . . . . . . . . . . . . . . . . . 36fondaparinux sodium inj 7.5mg/0.6ml . . . . . . . . . . . . . . . . . . . . . . . 36fondaparinux sodium inj 10mg/0.8ml . . . . . . . . . . . . . . . . . . . . . . . 36FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . 52fosamprenavir calcium . . . . . . . . . . . . . 34FOSCAVIR . . . . . . . . . . . . . . . . . . . . . . . . 32fosinopril sodium . . . . . . . . . . . . . . . . . . 38fosinopril sodium/ hydrochlorothiazide . . . . . . . . . . . . . . . . 38fosphenytoin sodium . . . . . . . . . . . . . . . 23FREAMINE HBC 6.9% . . . . . . . . . . . . . 56FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML . . . . . 56

fluconazole in dextrose inj 56mg/ml; 400mg/200ml . . . . . . . . . . . . 25fluconazole in nacl . . . . . . . . . . . . . . . . . 25fluconazole susr . . . . . . . . . . . . . . . . . . 25fluconazole tabs 100mg, 200mg, 50mg . . . . . . . . . . . . . . 26fluconazole tabs 150mg . . . . . . . . . . . . 26flucytosine . . . . . . . . . . . . . . . . . . . . . . . . 26fludarabine phosphate . . . . . . . . . . . . . 28fludrocortisone acetate . . . . . . . . . . . . . 45flunisolide . . . . . . . . . . . . . . . . . . . . . . . . . 54fluocinolone acetonide body . . . . . . . . 45fluocinolone acetonide crea . . . . . . . . 45fluocinolone acetonide ear drops . . . 54fluocinolone acetonide external soln . . . . . . . . . . . . . . . . . . . . . . 45fluocinolone acetonide oil . . . . . . . . . . 54fluocinolone acetonide oint . . . . . . . . 45fluocinolone acetonide scalp . . . . . . . 45fluocinonide . . . . . . . . . . . . . . . . . . . . . . . 45fluocinonide emulsified base . . . . . . . 45fluoride chew 0.25mg . . . . . . . . . . . . . . 56fluoritab chew 0.5mg, 1mg . . . . . . . . . 56fluorometholone . . . . . . . . . . . . . . . . . . . 53fluorouracil crea 0.5% . . . . . . . . . . . . . . 42fluorouracil crea 5% . . . . . . . . . . . . . . . 42fluorouracil external soln . . . . . . . . . . . 43fluorouracil inj . . . . . . . . . . . . . . . . . . . . . 28fluoxetine caps 10mg . . . . . . . . . . . . . . 24fluoxetine caps 20mg . . . . . . . . . . . . . . 24fluoxetine dr . . . . . . . . . . . . . . . . . . . . . . . 24fluoxetine hcl caps 10mg . . . . . . . . . . . 24fluoxetine hcl caps 20mg . . . . . . . . . . . 24fluoxetine hcl caps 40mg . . . . . . . . . . . 24fluoxetine hcl oral soln . . . . . . . . . . . . . 24fluoxetine hcl tabs 10mg . . . . . . . . . . . 24fluoxetine hcl tabs 20mg . . . . . . . . . . . 24fluphenazine decanoate . . . . . . . . . . . . 31fluphenazine hcl conc . . . . . . . . . . . . . 31fluphenazine hcl elix . . . . . . . . . . . . . . 31

felodipine er . . . . . . . . . . . . . . . . . . . . . . . 39FEMRING . . . . . . . . . . . . . . . . . . . . . . . . . 47femynor . . . . . . . . . . . . . . . . . . . . . . . . . . . 47fenofibrate caps 43mg, 50mg . . . . . . . 40fenofibrate caps 130mg, 150mg . . . . 40fenofibrate micronized caps 67mg . . 40fenofibrate micronized caps 134mg, 200mg . . . . . . . . . . . . . . . . . . . . 40fenofibrate tabs 48mg, 54mg . . . . . . . 41fenofibrate tabs 145mg, 160mg . . . . . 41fenofibric acid dr cpdr 45mg . . . . . . . . 41fenofibric acid dr cpdr 135mg . . . . . . . 41fenoprofen calcium caps 400mg . . . . 16fenoprofen calcium tabs . . . . . . . . . . . 16fentanyl . . . . . . . . . . . . . . . . . . . . . . . . . . . 16fentanyl citrate inj 1000mcg/20ml, 100mcg/2ml, 2500mcg/50ml, 250mcg/5ml . . . . . . . 17fentanyl citrate oral transmucosal lpop 200mcg, 400mcg, 600mcg . . . . 17fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 800mcg . . 17FERRIPROX . . . . . . . . . . . . . . . . . . . . . . 52FETZIMA . . . . . . . . . . . . . . . . . . . . . . . . . 24FETZIMA TITRATION PACK . . . . . . . 24finasteride tabs 5mg . . . . . . . . . . . . . . . 45FIRAZYR . . . . . . . . . . . . . . . . . . . . . . . . . 50FIRMAGON INJ 80MG . . . . . . . . . . . . . 49FIRMAGON INJ 120MG . . . . . . . . . . . 49flavoxate hcl . . . . . . . . . . . . . . . . . . . . . . . 44flecainide acetate . . . . . . . . . . . . . . . . . . 38FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST . . . . 54FLOVENT DISKUS AEPB 250MCG/BLIST . . . . . . . . . . . . . . . . . . . 54FLOVENT HFA AERO 44MCG/ACT . . . . . . . . . . . . . . . . . . . . . . 54FLOVENT HFA AERO 110MCG/ACT . . . . . . . . . . . . . . . . . . . . . 54FLOVENT HFA AERO 220MCG/ACT . . . . . . . . . . . . . . . . . . . . . 54

68


Covered Drugs Index

griseofulvin ultramicrosize . . . . . . . . . . 26GUANIDINE HCL . . . . . . . . . . . . . . . . . . 26

HHALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 28halobetasol propionate . . . . . . . . . . . . . 46haloperidol conc . . . . . . . . . . . . . . . . . . 31haloperidol decanoate . . . . . . . . . . . . . 31haloperidol lactate . . . . . . . . . . . . . . . . . 31haloperidol tabs 0.5mg, 1mg, 2mg, 5mg . . . . . . . . . . . . 31haloperidol tabs 10mg, 20mg . . . . . . . 31HARVONI . . . . . . . . . . . . . . . . . . . . . . . . . 33HAVRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 51heather . . . . . . . . . . . . . . . . . . . . . . . . . . . 48heparin sodium/d5w . . . . . . . . . . . . . . . 36heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/0.5ml, 5000unit/ml . . . . . . . . 36heparin sodium/nacl 0.9% . . . . . . . . . . 36heparin sodium/nacl 0.45% inj 50unit/ml; 0.45% . . . . . . . . . . . . . . . . . . 36heparin sodium/ sodium chloride 0.9% . . . . . . . . . . . . . . 36heparin sodium/ sodium chloride 0.9% premix . . . . . . . 36HEPATAMINE . . . . . . . . . . . . . . . . . . . . . 56HERCEPTIN . . . . . . . . . . . . . . . . . . . . . . 30HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 42HEXALEN . . . . . . . . . . . . . . . . . . . . . . . . 27HIBERIX . . . . . . . . . . . . . . . . . . . . . . . . . . 51HUMALOG . . . . . . . . . . . . . . . . . . . . . . . . 36HUMALOG KWIKPEN . . . . . . . . . . . . . 36HUMALOG MIX 50/50 . . . . . . . . . . . . . 36HUMALOG MIX 50/50 KWIKPEN . . . 36HUMALOG MIX 75/25 . . . . . . . . . . . . . 36HUMALOG MIX 75/25 KWIKPEN . . . 36HUMIRA INJ 10MG/0.2ML, 20MG/0.4ML . . . . . . . . 50HUMIRA INJ 40MG/0.8ML . . . . . . . . . 50

gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 41generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 44gengraf . . . . . . . . . . . . . . . . . . . . . . . . . . . 50gentak . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18gentamicin sulfate/ 0.9% sodium chloride . . . . . . . . . . . . . . 18gentamicin sulfate crea . . . . . . . . . . . . 18gentamicin sulfate inj . . . . . . . . . . . . . . 18gentamicin sulfate oint . . . . . . . . . . . . 18gentamicin sulfate ophthalmic soln . . . . . . . . . . . . . . . . . . . 18gentamicin sulfate pediatric . . . . . . . . 18GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . 33GEODON INJ . . . . . . . . . . . . . . . . . . . . 31gildagia . . . . . . . . . . . . . . . . . . . . . . . . . . . 47GILENYA . . . . . . . . . . . . . . . . . . . . . . . . . 42GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 29GLEOSTINE . . . . . . . . . . . . . . . . . . . . . . 27glimepiride . . . . . . . . . . . . . . . . . . . . . . . . 35glipizide er tb24 2.5mg, 5mg . . . . . . . 35glipizide er tb24 10mg . . . . . . . . . . . . . 35glipizide/metformin hcl tabs 2.5mg; 250mg . . . . . . . . . . . . . . . . . . . . . 35glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg . . . . . . . . 35glipizide tabs 5mg . . . . . . . . . . . . . . . . . 35glipizide tabs 10mg . . . . . . . . . . . . . . . . 35glipizide xl tb24 2.5mg, 5mg . . . . . . . . 35glipizide xl tb24 10mg . . . . . . . . . . . . . . 35GLUCAGEN HYPOKIT . . . . . . . . . . . . 36GLUCAGON EMERGENCY KIT . . . . 36glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml . . . . 43glycopyrrolate tabs . . . . . . . . . . . . . . . . 43glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18GLYXAMBI . . . . . . . . . . . . . . . . . . . . . . . . 35granisetron hcl inj 0.1mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . 25granisetron hcl inj 4mg/4ml . . . . . . . . . 25granisetron hcl tabs . . . . . . . . . . . . . . . 25griseofulvin microsize . . . . . . . . . . . . . . 26

furosemide inj . . . . . . . . . . . . . . . . . . . . 40furosemide oral soln . . . . . . . . . . . . . . 40furosemide tabs . . . . . . . . . . . . . . . . . . . 40FUSILEV . . . . . . . . . . . . . . . . . . . . . . . . . . 28FUZEON . . . . . . . . . . . . . . . . . . . . . . . . . . 34fyavolv tabs 2.5mcg; 0.5mg . . . . . . . . 47FYCOMPA SUSP . . . . . . . . . . . . . . . . . 22FYCOMPA TABS . . . . . . . . . . . . . . . . . 22

Ggabapentin caps 100mg . . . . . . . . . . . 23gabapentin caps 300mg, 400mg . . . . 23gabapentin oral soln . . . . . . . . . . . . . . 23gabapentin tabs 600mg . . . . . . . . . . . . 23gabapentin tabs 800mg . . . . . . . . . . . . 23GABITRIL TABS 12MG . . . . . . . . . . . . 23GABITRIL TABS 16MG . . . . . . . . . . . . 23galantamine hydrobromide er . . . . . . 23galantamine hydrobromide oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 23galantamine hydrobromide tabs . . . . 23GAMMAKED INJ 1GM/10ML . . . . . . . 50GAMMAKED INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 5GM/50ML . . . . . . . . . . 50GAMUNEX-C INJ 1GM/10ML . . . . . . 50GAMUNEX-C INJ 10GM/100ML, 2.5GM/25ML, 20GM/200ML, 40GM/400ML, 5GM/50ML . . . . . . . . . . 50ganciclovir inj 500mg . . . . . . . . . . . . . . 32GARDASIL . . . . . . . . . . . . . . . . . . . . . . . . 51GARDASIL 9 . . . . . . . . . . . . . . . . . . . . . . 51GATTEX . . . . . . . . . . . . . . . . . . . . . . . . . . 44gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 44gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . . 44gavilyte-n/flavor pack . . . . . . . . . . . . . . 44GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 30gemcitabine . . . . . . . . . . . . . . . . . . . . . . . 28gemcitabine hcl inj 1gm . . . . . . . . . . . . 28gemcitabine hcl inj 200mg, 2gm . . . . 28

69


Covered Drugs Index

imipramine pamoate . . . . . . . . . . . . . . . 25imiquimod . . . . . . . . . . . . . . . . . . . . . . . . . 43IMOVAX RABIES (H.D.C.V.) . . . . . . . 51INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . 46INCRUSE ELLIPTA . . . . . . . . . . . . . . . . 54indapamide . . . . . . . . . . . . . . . . . . . . . . . 40INFANRIX . . . . . . . . . . . . . . . . . . . . . . . . . 51INFUMORPH 200 . . . . . . . . . . . . . . . . . 16INFUMORPH 500 . . . . . . . . . . . . . . . . . 16INLYTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 29INTELENCE TABS 25MG . . . . . . . . . . 33INTELENCE TABS 100MG, 200MG . . . . . . . . . . . . . . . . . . . 33INTRALIPID . . . . . . . . . . . . . . . . . . . . . . . 52INTRON A INJ 10MU, 10MU/ML, 18MU, 50MU . . . . 33INTRON A INJ 6000000UNIT/ML . . . 33INTRON A W/DILUENT . . . . . . . . . . . . 33introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 47INVANZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 20INVEGA SUSTENNA INJ 39MG/0.25ML . . . . . . . . . . . . . . . . . . . . . 31INVEGA SUSTENNA INJ 78MG/0.5ML . . . . . . . . . . . . . . . . . . . . . . 31INVEGA SUSTENNA INJ 117MG/0.75ML . . . . . . . . . . . . . . . . . . . . 31INVEGA SUSTENNA INJ 156MG/ML . . . . . . . . . . . . . . . . . . . . . . . . 32INVEGA SUSTENNA INJ 234MG/1.5ML . . . . . . . . . . . . . . . . . . . . . 32INVEGA TRINZA INJ 273MG/0.875ML . . . . . . . . . . . . . . . . . . 32INVEGA TRINZA INJ 410MG/1.315ML . . . . . . . . . . . . . . . . . . 32INVEGA TRINZA INJ 546MG/1.75ML . . . . . . . . . . . . . . . . . . . . 32INVEGA TRINZA INJ 819MG/2.625ML . . . . . . . . . . . . . . . . . . 32INVIRASE CAPS . . . . . . . . . . . . . . . . . 34INVIRASE TABS . . . . . . . . . . . . . . . . . . 34INVOKAMET . . . . . . . . . . . . . . . . . . . . . . 35INVOKAMET XR . . . . . . . . . . . . . . . . . . 35

hydrocortisone rectal crea . . . . . . . . . 46hydrocortisone tabs . . . . . . . . . . . . . . . 46hydrocortisone valerate . . . . . . . . . . . . 46hydromorphone hcl dosette . . . . . . . . 17hydromorphone hcl inj . . . . . . . . . . . . . 17hydromorphone hcl liqd . . . . . . . . . . . 17hydromorphone hcl tabs 2mg, 4mg . . . . . . . . . . . . . . . . . . . . . . . . . 17hydromorphone hcl tabs 8mg . . . . . . . 17hydroxychloroquine sulfate . . . . . . . . . 30hydroxyprogesterone caproate . . . . . 48hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 28hyoscyamine sulfate elix . . . . . . . . . . . 43hyoscyamine sulfate odt . . . . . . . . . . . 43hyoscyamine sulfate subl . . . . . . . . . . 43hyoscyamine sulfate tabs . . . . . . . . . . 43hyoscyamine sulfate tbdp . . . . . . . . . . 43

Iibandronate sodium tabs . . . . . . . . . . 52IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . . 29ibudone tabs 5mg; 200mg . . . . . . . . . . 17ibuprofen susp . . . . . . . . . . . . . . . . . . . . 16ibuprofen tabs 400mg, 600mg, 800mg . . . . . . . . . . . . 16ICLUSIG TABS 15MG . . . . . . . . . . . . . 29ICLUSIG TABS 45MG . . . . . . . . . . . . . 29idarubicin hcl inj 10mg/10ml . . . . . . . . 28IDHIFA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29ifosfamide . . . . . . . . . . . . . . . . . . . . . . . . . 27ILARIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51ILEVRO . . . . . . . . . . . . . . . . . . . . . . . . . . . 53imatinib mesylate . . . . . . . . . . . . . . . . . . 29IMBRUVICA . . . . . . . . . . . . . . . . . . . . . . . 29IMFINZI . . . . . . . . . . . . . . . . . . . . . . . . . . . 30imipenem/cilastatin inj 250mg; 250mg . . . . . . . . . . . . . . . . . . . . 20imipenem/cilastatin inj 500mg; 500mg . . . . . . . . . . . . . . . . . . . . 20imipramine hcl . . . . . . . . . . . . . . . . . . . . . 25

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK . . . . . . . . 50HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 50HUMIRA PEN-CROHNS DISEASE STARTER . . . . . . . . . . . . . . . 50HUMIRA PEN-PSORIASIS STARTER . . . . . . . . . . . . . . . . . . . . . . . . . 50HUMULIN 70/30 . . . . . . . . . . . . . . . . . . . 36HUMULIN 70/30 KWIKPEN . . . . . . . . 36HUMULIN N . . . . . . . . . . . . . . . . . . . . . . . 36HUMULIN N KWIKPEN . . . . . . . . . . . . 36HUMULIN R . . . . . . . . . . . . . . . . . . . . . . . 36HUMULIN R U-500 (CONCENTRATED) . . . . . . . . . . . . . . . 36HUMULIN R U-500 KWIKPEN. . . . . . 36hydralazine hcl inj . . . . . . . . . . . . . . . . . 41hydralazine hcl tabs . . . . . . . . . . . . . . . 41hydrochlorothiazide caps . . . . . . . . . . 40hydrochlorothiazide tabs 12.5mg . . . 40hydrochlorothiazide tabs 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 40hydrocodone/acetaminophen tabs 325mg; 5mg . . . . . . . . . . . . . . . . . . 17hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 7.5mg . . 17hydrocodone bitartrate/ acetaminophen oral soln . . . . . . . . . . 17hydrocodone bitartrate/ acetaminophen tabs 300mg; 5mg, 325mg; 2.5mg . . . . . . . . 17hydrocodone bitartrate/ acetaminophen tabs 300mg; 10mg, 300mg; 7.5mg . . . . . . 17hydrocodone/ibuprofen . . . . . . . . . . . . 17hydrocortisone/acetic acid . . . . . . . . . . 54hydrocortisone butyrate . . . . . . . . . . . . 46hydrocortisone butyrate (lipid) . . . . . . 46hydrocortisone butyrate (lipophilic) . . . 46hydrocortisone enem . . . . . . . . . . . . . . 51hydrocortisone external crea . . . . . . . 46hydrocortisone lotn 2.5% . . . . . . . . . . . 46hydrocortisone oint 1%, 2.5% . . . . . . 46

70


Covered Drugs Index

ketoconazole tabs . . . . . . . . . . . . . . . . . 26ketoprofen . . . . . . . . . . . . . . . . . . . . . . . . 16ketoprofen er . . . . . . . . . . . . . . . . . . . . . . 16ketorolac tromethamine ophthalmic soln . . . . . . . . . . . . . . . . . . . 53KEYTRUDA . . . . . . . . . . . . . . . . . . . . . . . 30kimidess . . . . . . . . . . . . . . . . . . . . . . . . . . 47KINERET . . . . . . . . . . . . . . . . . . . . . . . . . 50KINRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 51kionex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55KISQALI . . . . . . . . . . . . . . . . . . . . . . . . . . 28KISQALI . . . . . . . . . . . . . . . . . . . . . . . . . . 29KISQALI FEMARA 200 DOSE . . . . . . 27KISQALI FEMARA 400 DOSE . . . . . . 27KISQALI FEMARA 600 DOSE . . . . . . 27klor-con 8 . . . . . . . . . . . . . . . . . . . . . . . . . 57klor-con 10 . . . . . . . . . . . . . . . . . . . . . . . . 56klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 57klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 57klor-con sprinkle . . . . . . . . . . . . . . . . . . . 57KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 52kurvelo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47KUVAN PACK 100MG . . . . . . . . . . . . . 43KUVAN PACK 500MG . . . . . . . . . . . . . 43KUVAN TBSO . . . . . . . . . . . . . . . . . . . . 43KYNAMRO . . . . . . . . . . . . . . . . . . . . . . . . 41KYPROLIS . . . . . . . . . . . . . . . . . . . . . . . . 29

Llabetalol hcl inj . . . . . . . . . . . . . . . . . . . . 39labetalol hcl tabs . . . . . . . . . . . . . . . . . . 39LACRISERT . . . . . . . . . . . . . . . . . . . . . . 53LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L; 28MEQ/L; 4MEQ/L; 130MEQ/L . . . . . . . . . . . . . . . 57LACTATED RINGERS IRRIGATION . . . . . . . . . . . . . . . . . . . . . . 52LACTATED RINGERS VIAFLEX . . . . 57lactulose . . . . . . . . . . . . . . . . . . . . . . . . . . 44lamivudine oral soln . . . . . . . . . . . . . . . 33

JANUMET XR TB24 1000MG; 50MG . . . . . . . . . . . . . . . . . . . 35JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG . . . 35JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . 35JARDIANCE . . . . . . . . . . . . . . . . . . . . . . 35jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . . 48JENTADUETO . . . . . . . . . . . . . . . . . . . . 35JENTADUETO XR TB24 2.5MG; 1000MG . . . . . . . . . . . . . . . . . . . 35JENTADUETO XR TB24 5MG; 1000MG . . . . . . . . . . . . . . . . . . . . 35jevantique lo . . . . . . . . . . . . . . . . . . . . . . 47JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . . 28jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47jolivette . . . . . . . . . . . . . . . . . . . . . . . . . . . 48juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47junel 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . 47junel 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . 47junel fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 47junel fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 47

KKABIVEN . . . . . . . . . . . . . . . . . . . . . . . . . 56KADCYLA . . . . . . . . . . . . . . . . . . . . . . . . 30KALETRA ORAL SOLN . . . . . . . . . . . 34KALETRA TABS 100MG; 25MG . . . . 34KALETRA TABS 200MG; 50MG . . . . 34KALYDECO . . . . . . . . . . . . . . . . . . . . . . . 54kariva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47kcl 0.3%/d5w/nacl 0.9% . . . . . . . . . . . . 56kcl 0.3%/d5w/nacl 0.45% . . . . . . . . . . . 56kcl 0.15%/d5w/nacl 0.2% . . . . . . . . . . . 56kcl 0.15%/d5w/nacl 0.9% . . . . . . . . . . . 56kcl 0.15%/d5w/nacl 0.45% . . . . . . . . . 56kcl 0.15%/d5w/nacl 0.225% . . . . . . . . 56kcl 0.075%/d5w/nacl 0.45% . . . . . . . . 56kelnor 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 47ketoconazole crea . . . . . . . . . . . . . . . . 26ketoconazole sham . . . . . . . . . . . . . . . 26

INVOKANA . . . . . . . . . . . . . . . . . . . . . . . 35IPOL INACTIVATED IPV . . . . . . . . . . . 51ipratropium bromide/ albuterol sulfate . . . . . . . . . . . . . . . . . . . 54ipratropium bromide inhalation soln . . . . . . . . . . . . . . . . . . . . 54ipratropium bromide nasal soln . . . . 54irbesartan . . . . . . . . . . . . . . . . . . . . . . . . . 38irbesartan/hydrochlorothiazide . . . . . . 38IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 29irinotecan . . . . . . . . . . . . . . . . . . . . . . . . . 28irinotecan hcl . . . . . . . . . . . . . . . . . . . . . . 28ISENTRESS CHEW 25MG . . . . . . . . . 33ISENTRESS CHEW 100MG . . . . . . . 33ISENTRESS HD . . . . . . . . . . . . . . . . . . . 33ISENTRESS PACK . . . . . . . . . . . . . . . 33ISENTRESS TABS . . . . . . . . . . . . . . . . 33isibloom . . . . . . . . . . . . . . . . . . . . . . . . . . . 47isoniazid inj . . . . . . . . . . . . . . . . . . . . . . . 26isoniazid syrp . . . . . . . . . . . . . . . . . . . . . 26isoniazid tabs 100mg . . . . . . . . . . . . . . 26isoniazid tabs 300mg . . . . . . . . . . . . . . 26isosorbide dinitrate er . . . . . . . . . . . . . . 41isosorbide dinitrate tabs . . . . . . . . . . . 41isosorbide mononitrate . . . . . . . . . . . . . 41isosorbide mononitrate er . . . . . . . . . . 41isotonic gentamicin . . . . . . . . . . . . . . . . 18isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 39ISTODAX (OVERFILL) . . . . . . . . . . . . . 28itraconazole . . . . . . . . . . . . . . . . . . . . . . . 26ivermectin . . . . . . . . . . . . . . . . . . . . . . . . . 30IXEMPRA KIT . . . . . . . . . . . . . . . . . . . . . 28IXIARO . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

JJADENU . . . . . . . . . . . . . . . . . . . . . . . . . . 55JADENU SPRINKLE . . . . . . . . . . . . . . . 55JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 29jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 36JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 35

71


Covered Drugs Index

lindane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30linezolid inj . . . . . . . . . . . . . . . . . . . . . . . 19linezolid susr . . . . . . . . . . . . . . . . . . . . . 19linezolid tabs . . . . . . . . . . . . . . . . . . . . . 19LINZESS . . . . . . . . . . . . . . . . . . . . . . . . . . 44liothyronine sodium inj . . . . . . . . . . . . . 49liothyronine sodium tabs . . . . . . . . . . . 49LIPOSYN III . . . . . . . . . . . . . . . . . . . . . . . 52LIPOSYN III . . . . . . . . . . . . . . . . . . . . . . . 58lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 38lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg . . . . . . . . . . . . . . . . 38lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg . . . . . . . . . . . . . . . . 38lisinopril/hydrochlorothiazide tabs 25mg; 20mg . . . . . . . . . . . . . . . . . . 38lithium carbonate caps 150mg, 600mg . . . . . . . . . . . . . . . . . . . . 35lithium carbonate caps 300mg . . . . . . 35lithium carbonate er . . . . . . . . . . . . . . . . 35lithium carbonate tabs . . . . . . . . . . . . . 35LIVALO . . . . . . . . . . . . . . . . . . . . . . . . . . . 41LONSURF TABS 6.14MG; 15MG . . . 28LONSURF TABS 8.19MG; 20MG . . . 28loperamide hcl caps . . . . . . . . . . . . . . . 44lopinavir/ritonavir . . . . . . . . . . . . . . . . . . 34lorazepam conc . . . . . . . . . . . . . . . . . . . 35lorazepam inj 2mg/ml, 4mg/ml . . . . . . 35lorazepam intensol . . . . . . . . . . . . . . . . 35lorazepam tabs 0.5mg, 1mg . . . . . . . . 35lorazepam tabs 2mg . . . . . . . . . . . . . . . 35lorcet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . . 17lorcet plus tabs 325mg; 7.5mg . . . . . . 17losartan potassium/ hydrochlorothiazide . . . . . . . . . . . . . . . . 38losartan potassium tabs 50mg . . . . . . 38losartan potassium tabs 100mg, 25mg . . . . . . . . . . . . . . . . . . . . . 38LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . 53lovastatin tabs 10mg, 20mg . . . . . . . . 41

levetiracetam inj . . . . . . . . . . . . . . . . . . 22levetiracetam oral soln . . . . . . . . . . . . 22levetiracetam tabs . . . . . . . . . . . . . . . . 22levobunolol hcl . . . . . . . . . . . . . . . . . . . . 53levocarnitine . . . . . . . . . . . . . . . . . . . . . . 52levocetirizine dihydrochloride oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 54levocetirizine dihydrochloride tabs . . . 54levofloxacin in d5w . . . . . . . . . . . . . . . . 21levofloxacin inj . . . . . . . . . . . . . . . . . . . . 21levofloxacin oral soln . . . . . . . . . . . . . . 21levofloxacin tabs . . . . . . . . . . . . . . . . . . 21levoleucovorin calcium . . . . . . . . . . . . . 28levoleucovorin inj 175mg/17.5ml, 250mg/25ml, 50mg . . 28levonest . . . . . . . . . . . . . . . . . . . . . . . . . . 47levonorgestrel and ethinyl estradiol tabs 0; 0 . . . . . . . . . . . . . . . . . 47levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0 . . . . . . . . . 48levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 0; 0, 20mcg; 0.1mg . . . . . . . . . . . . . . . . . . 48levora 0.15/30-28 . . . . . . . . . . . . . . . . . . 48levorphanol tartrate . . . . . . . . . . . . . . . . 16levothyroxine sodium tabs . . . . . . . . . 49LEVOXYL . . . . . . . . . . . . . . . . . . . . . . . . . 49LEXIVA SUSP . . . . . . . . . . . . . . . . . . . . 34LEXIVA TABS . . . . . . . . . . . . . . . . . . . . . 34lidocaine hcl external soln . . . . . . . . . 18lidocaine hcl gel . . . . . . . . . . . . . . . . . . . 18lidocaine hcl inj . . . . . . . . . . . . . . . . . . . 18lidocaine hcl inj . . . . . . . . . . . . . . . . . . . 38lidocaine hcl jelly . . . . . . . . . . . . . . . . . . 18lidocaine hcl mouth/throat soln . . . . . 18lidocaine hcl viscous . . . . . . . . . . . . . . . 18lidocaine oint . . . . . . . . . . . . . . . . . . . . . 18lidocaine/prilocaine crea . . . . . . . . . . . 18lidocaine ptch . . . . . . . . . . . . . . . . . . . . . 18lidocaine viscous . . . . . . . . . . . . . . . . . . 18lincomycin hcl . . . . . . . . . . . . . . . . . . . . . 19

lamivudine tabs 100mg . . . . . . . . . . . . 33lamivudine tabs 150mg . . . . . . . . . . . . 33lamivudine tabs 300mg . . . . . . . . . . . . 33lamivudine/zidovudine . . . . . . . . . . . . . 33lamotrigine . . . . . . . . . . . . . . . . . . . . . . . . 23lamotrigine er . . . . . . . . . . . . . . . . . . . . . 23lamotrigine odt . . . . . . . . . . . . . . . . . . . . 23LANOXIN PEDIATRIC . . . . . . . . . . . . . 40LANTUS . . . . . . . . . . . . . . . . . . . . . . . . . . 36LANTUS SOLOSTAR . . . . . . . . . . . . . . 36larin 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . . 47larin 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . . 47larin fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 47larin fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 47larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47LARTRUVO . . . . . . . . . . . . . . . . . . . . . . . 28latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 53LATUDA TABS 80MG . . . . . . . . . . . . . . 32LATUDA TABS 120MG, 20MG, 40MG, 60MG . . . . . . 32leflunomide . . . . . . . . . . . . . . . . . . . . . . . 51LENVIMA 8 MG DAILY DOSE . . . . . . 29LENVIMA 10 MG DAILY DOSE . . . . . 29LENVIMA 14 MG DAILY DOSE . . . . . 29LENVIMA 18 MG DAILY DOSE . . . . . 29LENVIMA 20 MG DAILY DOSE . . . . . 29LENVIMA 24 MG DAILY DOSE . . . . . 29lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . . 55letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 29leucovorin calcium inj 100mg, 350mg, 500mg, 50mg . . . . . . 28leucovorin calcium tabs . . . . . . . . . . . 28LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 27LEUKINE INJ 250MCG . . . . . . . . . . . . 37leuprolide acetate . . . . . . . . . . . . . . . . . 49LEVEMIR . . . . . . . . . . . . . . . . . . . . . . . . . 36LEVEMIR FLEXTOUCH . . . . . . . . . . . 36levetiracetam er tb24 500mg . . . . . . . 22levetiracetam er tb24 750mg . . . . . . . 22

72


Covered Drugs Index

metaproterenol sulfate . . . . . . . . . . . . . 54Metformin hcl er tb24 500mg, 1000mg (generic for Fortamet) . . . . . 35Metformin hcl er tb24 500mg (generic for Glucophage XR) . . . . . . . 35Metformin hcl er tb24 750mg (generic for Glucophage XR) . . . . . . . 35metformin hcl tabs 500mg . . . . . . . . . . 35metformin hcl tabs 850mg . . . . . . . . . . 35metformin hcl tabs 1000mg . . . . . . . . 35methadone hcl conc . . . . . . . . . . . . . . . 16methadone hcl inj . . . . . . . . . . . . . . . . . 16methadone hcl intensol . . . . . . . . . . . . 16methadone hcl oral soln 5mg/5ml . . . 16methadone hcl oral soln 10mg/5ml . . 16methadone hcl tabs 5mg . . . . . . . . . . . 16methadone hcl tabs 10mg . . . . . . . . . . 16methazolamide . . . . . . . . . . . . . . . . . . . . 53methenamine hippurate . . . . . . . . . . . . 19methimazole . . . . . . . . . . . . . . . . . . . . . . 50methotrexate . . . . . . . . . . . . . . . . . . . . . . 50methotrexate sodium . . . . . . . . . . . . . . 50methoxsalen . . . . . . . . . . . . . . . . . . . . . . 43methscopolamine bromide . . . . . . . . . 43methylphenidate hcl er tbcr 10mg, 27mg, 54mg . . . . . . . . . . . . . . . . 42methylphenidate hcl er tbcr 18mg . . . 42methylphenidate hcl er tbcr 20mg . . . 42methylphenidate hcl er tbcr 36mg . . . 42methylphenidate hcl tabs 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 42methylphenidate hcl tabs 20mg . . . . . 42methylprednisolone . . . . . . . . . . . . . . . . 46methylprednisolone acetate . . . . . . . . 46methylprednisolone dose pack . . . . . 46methylprednisolone sodiumsuccinate . . . . . . . . . . . . . . . . . . 46metipranolol . . . . . . . . . . . . . . . . . . . . . . . 53metoclopramide hcl inj . . . . . . . . . . . . 44metoclopramide hcl oral soln . . . . . . 44metoclopramide hcl tabs . . . . . . . . . . . 44

magnesium sulfate inj 20gm/500ml, 2gm/50ml, 40gm/1000ml, 4gm/100ml, 4gm/50ml, 50% . . . . . . . . . . . . . . . . . . . . 57MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 48malathion . . . . . . . . . . . . . . . . . . . . . . . . . 30maprotiline hcl . . . . . . . . . . . . . . . . . . . . . 24marlissa . . . . . . . . . . . . . . . . . . . . . . . . . . 48MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 24MATULANE . . . . . . . . . . . . . . . . . . . . . . . 27matzim la tb24 180mg, 240mg . . . . . 39matzim la tb24 300mg, 360mg, 420mg . . . . . . . . . . . . 39meclizine hcl tabs . . . . . . . . . . . . . . . . . 25meclofenamate sodium . . . . . . . . . . . . 16MEDROL TABS 2MG . . . . . . . . . . . . . . 46medroxyprogesterone acetate inj . . . 49medroxyprogesterone acetate tabs . . . . . . . . . . . . . . . . . . . . . . 49mefloquine hcl . . . . . . . . . . . . . . . . . . . . . 30megestrol acetate susp 40mg/ml . . . 49megestrol acetate tabs . . . . . . . . . . . . 49MEKINIST TABS 0.5MG . . . . . . . . . . . 29MEKINIST TABS 2MG . . . . . . . . . . . . . 29meloxicam . . . . . . . . . . . . . . . . . . . . . . . . 16melphalan hydrochloride . . . . . . . . . . . 27memantine hcl tabs 5mg . . . . . . . . . . . 24memantine hcl tabs 10mg . . . . . . . . . . 24memantine hcl titration pak . . . . . . . . . 24memantine hydrochloride . . . . . . . . . . 24MENACTRA . . . . . . . . . . . . . . . . . . . . . . 51MENEST . . . . . . . . . . . . . . . . . . . . . . . . . . 48MENOSTAR . . . . . . . . . . . . . . . . . . . . . . 48MENVEO . . . . . . . . . . . . . . . . . . . . . . . . . 51mercaptopurine . . . . . . . . . . . . . . . . . . . . 28meropenem . . . . . . . . . . . . . . . . . . . . . . . 20meropenem/sodium chloride . . . . . . . 20mesalamine kit . . . . . . . . . . . . . . . . . . . . 51mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28MESNEX TABS . . . . . . . . . . . . . . . . . . . 28metadate er . . . . . . . . . . . . . . . . . . . . . . . 42

lovastatin tabs 40mg . . . . . . . . . . . . . . . 41low-ogestrel . . . . . . . . . . . . . . . . . . . . . . . 48loxapine caps 10mg, 5mg . . . . . . . . . . 31loxapine caps 25mg, 50mg . . . . . . . . . 31loxapine succinate caps 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 31loxapine succinate caps 25mg, 50mg . . . . . . . . . . . . . . . . . . . . . . . 31ludent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57LUMIGAN . . . . . . . . . . . . . . . . . . . . . . . . . 53LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 43LUPRON DEPOT (1-MONTH) . . . . . . 49LUPRON DEPOT (3-MONTH) INJ 11.25MG . . . . . . . . . . . . . . . . . . . . . . 49LUPRON DEPOT (3-MONTH) INJ 22.5MG . . . . . . . . . . . . . . . . . . . . . . . 49LUPRON DEPOT (4-MONTH) . . . . . . 49LUPRON DEPOT (6-MONTH) . . . . . . 49LUPRON DEPOT-PED (1-MONTH) . . . . . . . . . . . . . . . . . . . . . . . 49LUPRON DEPOT-PED (3-MONTH) . . . . . . . . . . . . . . . . . . . . . . . 49lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48LYNPARZA CAPS . . . . . . . . . . . . . . . . 29LYNPARZA TABS . . . . . . . . . . . . . . . . . 28LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG . . . . . . . . . . . . . . 22LYRICA CAPS 225MG, 300MG . . . . . 22LYRICA ORAL SOLN . . . . . . . . . . . . . . 22LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 49lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Mmagnesium sulfate in d5w inj 5%; 1gm/100ml . . . . . . . . . . . . . . . . . . . . 22MAGNESIUM SULFATE INJ 20GM/500ML, 2GM/50ML, 40GM/1000ML, 4GM/100ML, 4GM/50ML . . . . . . . . . . . . . . . . . . . . . . . . 57

73


Covered Drugs Index

MUSTARGEN . . . . . . . . . . . . . . . . . . . . . 27mycophenolate mofetil caps . . . . . . . 50mycophenolate mofetil inj . . . . . . . . . . 50mycophenolate mofetil susr . . . . . . . . 50mycophenolate mofetil tabs . . . . . . . . 50mycophenolic acid dr . . . . . . . . . . . . . . 50MYLOTARG . . . . . . . . . . . . . . . . . . . . . . . 30myorisan . . . . . . . . . . . . . . . . . . . . . . . . . . 43MYRBETRIQ . . . . . . . . . . . . . . . . . . . . . . 44myzilra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . 16nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39nadolol/bendroflumethiazide tabs 5mg; 40mg . . . . . . . . . . . . . . . . . . . 39nadolol/bendroflumethiazide tabs 5mg; 80mg . . . . . . . . . . . . . . . . . . . 39nafcillin sodium inj 2gm . . . . . . . . . . . . 20nafcillin sodium inj 10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 20naftifine hcl . . . . . . . . . . . . . . . . . . . . . . . . 26naftifine hydrochloride . . . . . . . . . . . . . 26NAFTIN CREA . . . . . . . . . . . . . . . . . . . . 26NAFTIN GEL . . . . . . . . . . . . . . . . . . . . . 26NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 43nalbuphine hcl inj 10mg/ml . . . . . . . . . 17nalbuphine hcl inj 20mg/ml . . . . . . . . . 17naloxone hcl . . . . . . . . . . . . . . . . . . . . . . 18naltrexone hcl . . . . . . . . . . . . . . . . . . . . . 18NAMENDA XR . . . . . . . . . . . . . . . . . . . . 24NAMENDA XR TITRATION PACK . . . 24NAMZARIC C4PK . . . . . . . . . . . . . . . . 23NAMZARIC CP24 . . . . . . . . . . . . . . . . . 23naproxen dr . . . . . . . . . . . . . . . . . . . . . . . 16naproxen sodium tabs 275mg, 550mg . . . . . . . . . . . . . . . . . . . . 16naproxen susp . . . . . . . . . . . . . . . . . . . . 16naproxen tabs 250mg . . . . . . . . . . . . . . 16naproxen tabs 375mg, 500mg . . . . . . 16

mometasone furoate external soln . . . . . . . . . . . . . . . . . . . . . . 46mometasone furoate oint . . . . . . . . . . 46mometasone furoate susp . . . . . . . . . 54mondoxyne nl . . . . . . . . . . . . . . . . . . . . . 22mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 48montelukast sodium . . . . . . . . . . . . . . . 54morgidox 1x50mg . . . . . . . . . . . . . . . . . 22morgidox 1x100mg caps . . . . . . . . . . 22morgidox 2x100mg caps . . . . . . . . . . 22morphine sulfate er tbcr . . . . . . . . . . . 16morphine sulfate inj 0.5mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . 16MORPHINE SULFATE INJ 1MG/ML . . . . . . . . . . . . . . . . . . . . . . . . . . 17MORPHINE SULFATE INJ 2MG/ML, 4MG/ML . . . . . . . . . . . . . . . . . 17morphine sulfate inj 5mg/ml . . . . . . . . 17MORPHINE SULFATE INJ 8MG/ML . . . . . . . . . . . . . . . . . . . . . . . . . . 17morphine sulfate inj 8mg/ml . . . . . . . . 17MORPHINE SULFATE INJ 10MG/ML . . . . . . . . . . . . . . . . . . . . . . . . . 17morphine sulfate inj 10mg/ml . . . . . . . 17MORPHINE SULFATE INJ 150MG/30ML, 15MG/ML, 50MG/ML . . . . . . . . . . . . . . . . . . . . . . . . . 17morphine sulfate oral soln 10mg/5ml . . . . . . . . . . . . . . . . 17morphine sulfate oral soln 20mg/5ml . . . . . . . . . . . . . . . . 17morphine sulfate oral soln 100mg/5ml . . . . . . . . . . . . . . . 17MORPHINE SULFATE TABS . . . . . . 17MOVIPREP . . . . . . . . . . . . . . . . . . . . . . . 44moxifloxacin hcl inj . . . . . . . . . . . . . . . . 21moxifloxacin hcl ophthalmic soln . . . . 21moxifloxacin hcl tabs . . . . . . . . . . . . . . 21MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 37MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . . 38multivitamin with fluoride chew . . . . . 58mupirocin . . . . . . . . . . . . . . . . . . . . . . . . . 19

metolazone . . . . . . . . . . . . . . . . . . . . . . . 40metoprolol/hydrochlorothiazide . . . . . 39metoprolol succinate er . . . . . . . . . . . . 39metoprolol tartrate inj . . . . . . . . . . . . . . 39metoprolol tartrate tabs . . . . . . . . . . . . 39metronidazole crea . . . . . . . . . . . . . . . . 19metronidazole gel . . . . . . . . . . . . . . . . . 19metronidazole inj . . . . . . . . . . . . . . . . . . 19metronidazole in nacl 0.79% . . . . . . . 19metronidazole lotn . . . . . . . . . . . . . . . . 19metronidazole tabs . . . . . . . . . . . . . . . . 19metronidazole vaginal . . . . . . . . . . . . . . 19mexiletine hcl . . . . . . . . . . . . . . . . . . . . . 38MIACALCIN . . . . . . . . . . . . . . . . . . . . . . . 52microgestin 1.5/30 . . . . . . . . . . . . . . . . . 48microgestin 1/20 . . . . . . . . . . . . . . . . . . . 48microgestin fe . . . . . . . . . . . . . . . . . . . . . 48microgestin fe 1.5/30 . . . . . . . . . . . . . . 48midodrine hcl . . . . . . . . . . . . . . . . . . . . . . 37migergot . . . . . . . . . . . . . . . . . . . . . . . . . . 26miglitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 41MINIVELLE . . . . . . . . . . . . . . . . . . . . . . . 48minocycline hcl . . . . . . . . . . . . . . . . . . . . 22minoxidil . . . . . . . . . . . . . . . . . . . . . . . . . . 41mirtazapine . . . . . . . . . . . . . . . . . . . . . . . 24mirtazapine odt . . . . . . . . . . . . . . . . . . . . 24misoprostol . . . . . . . . . . . . . . . . . . . . . . . 44MITIGARE . . . . . . . . . . . . . . . . . . . . . . . . 26mitomycin inj 20mg, 5mg . . . . . . . . . . . 28mitomycin inj 40mg . . . . . . . . . . . . . . . . 28mitoxantrone hcl . . . . . . . . . . . . . . . . . . . 28M-M-R II . . . . . . . . . . . . . . . . . . . . . . . . . . 51modafinil . . . . . . . . . . . . . . . . . . . . . . . . . . 55moexipril hcl . . . . . . . . . . . . . . . . . . . . . . . 38moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg . . . . . . . . . . . . . . . 38moexipril/hydrochlorothiazide tabs 12.5mg; 15mg, 25mg; 15mg . . . 38mometasone furoate crea . . . . . . . . . 46

74


Covered Drugs Index

NORMOSOL-M IN D5W . . . . . . . . . . . 57NORMOSOL -R . . . . . . . . . . . . . . . . . . . 57NORMOSOL-R . . . . . . . . . . . . . . . . . . . . 57NORMOSOL-R IN D5W. . . . . . . . . . . . 57NORTHERA CAPS 100MG . . . . . . . . 40NORTHERA CAPS 200MG, 300MG . . . . . . . . . . . . . . . . . . . 40nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . 48nortrel 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 48nortrel 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 48nortriptyline hcl . . . . . . . . . . . . . . . . . . . . 25NORVIR CAPS . . . . . . . . . . . . . . . . . . . 34NORVIR ORAL SOLN . . . . . . . . . . . . . 34NORVIR TABS . . . . . . . . . . . . . . . . . . . . 34NOVAREL . . . . . . . . . . . . . . . . . . . . . . . . 46novofine 30gx8mm . . . . . . . . . . . . . . . . 52novofine 31 . . . . . . . . . . . . . . . . . . . . . . . 52novofine 32gx6mm . . . . . . . . . . . . . . . . 52novofine autocover 30gx8mm . . . . . . 52novotwist 32gx5mm . . . . . . . . . . . . . . . 52NOXAFIL SUSP . . . . . . . . . . . . . . . . . . 26NOXAFIL TBEC . . . . . . . . . . . . . . . . . . 26NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 42nulev . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 50NUPLAZID . . . . . . . . . . . . . . . . . . . . . . . . 32NUTRILIPID . . . . . . . . . . . . . . . . . . . . . . . 52NUTRILYTE INJ 2.03MEQ/ML; 0.25MEQ/ML; 1.68MEQ/ML; 0.25MEQ/ML; 0.4MEQ/ML; 2.03MEQ/ML; 1.25MEQ . . . . . . . . . . . . . . . . . . . . . . . . . 57NUVIGIL . . . . . . . . . . . . . . . . . . . . . . . . . . 55nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 26nystatin . . . . . . . . . . . . . . . . . . . . . . . . . . . 26nystatin/triamcinolone . . . . . . . . . . . . . . 26nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Ooctreotide acetate inj 500mcg/ml . . . 49

niacin er tbcr 500mg . . . . . . . . . . . . . . . 41niacin er tbcr 1000mg, 750mg . . . . . . 41niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41nicardipine hcl caps . . . . . . . . . . . . . . . 39nicardipine hcl inj . . . . . . . . . . . . . . . . . 40NICOTROL INHALER. . . . . . . . . . . . . . 18NICOTROL NS . . . . . . . . . . . . . . . . . . . . 18nifedipine er tb24 30mg, 90mg . . . . . 40nifedipine er tb24 60mg . . . . . . . . . . . . 40NILANDRON . . . . . . . . . . . . . . . . . . . . . . 27nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 27nimodipine . . . . . . . . . . . . . . . . . . . . . . . . 40NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 28NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . . . 28nisoldipine er tb24 17mg, 25.5mg, 34mg, 8.5mg . . . . . . . 40nisoldipine er tb24 20mg, 30mg, 40mg . . . . . . . . . . . . . . . . 40nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 19nitrofurantoin macrocrystals . . . . . . . . 19nitrofurantoin monohydrate . . . . . . . . . 19nitrofurantoin monohydrate/macrocrystals . . . . . . . . . . . . . . . . . . . . . 19nitroglycerin inj . . . . . . . . . . . . . . . . . . . . 41nitroglycerin lingual translingual soln . . . . . . . . . . . . . . . . . . 41nitroglycerin subl . . . . . . . . . . . . . . . . . . 41nitroglycerin transdermal . . . . . . . . . . . 41NITROSTAT . . . . . . . . . . . . . . . . . . . . . . . 41nizatidine caps . . . . . . . . . . . . . . . . . . . . 44nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . 49norethindrone . . . . . . . . . . . . . . . . . . . . . 49norethindrone acetate . . . . . . . . . . . . . . 49norethindrone acetate/ethinyl estradiol/ferrous fumarate tabs . . . . . 48norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg . . . . . . . 48norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg . . . . . . . . . 48norgestimate/ethinyl estradiol . . . . . . 48norlyroc . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

naratriptan hcl . . . . . . . . . . . . . . . . . . . . . 26NARCAN . . . . . . . . . . . . . . . . . . . . . . . . . 18NASONEX . . . . . . . . . . . . . . . . . . . . . . . . 54NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 26nateglinide . . . . . . . . . . . . . . . . . . . . . . . . 35NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 52NEBUPENT . . . . . . . . . . . . . . . . . . . . . . . 30necon 0.5/35-28 . . . . . . . . . . . . . . . . . . . 48necon 1/50-28 . . . . . . . . . . . . . . . . . . . . . 48necon 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 48nefazodone hcl . . . . . . . . . . . . . . . . . . . . 24neomycin/bacitracin/polymyxin . . . . . 19neomycin/polymyxin/ bacitracin/hydrocortisone . . . . . . . . . . . 19neomycin/polymyxin b sulfates . . . . . 18neomycin/polymyxin/ dexamethasone . . . . . . . . . . . . . . . . . . . 53neomycin/polymyxin/gramicidin . . . . . 19neomycin/polymyxin/hc . . . . . . . . . . . . 54neomycin/polymyxin/ hydrocortisone . . . . . . . . . . . . . . . . . . . . 19neomycin/polymyxin/ hydrocortisone . . . . . . . . . . . . . . . . . . . . 54neomycin sulfate . . . . . . . . . . . . . . . . . . 18neo-polycin . . . . . . . . . . . . . . . . . . . . . . . 19neo-polycin hc . . . . . . . . . . . . . . . . . . . . . 19NEPHRAMINE . . . . . . . . . . . . . . . . . . . . 57NERLYNX . . . . . . . . . . . . . . . . . . . . . . . . 28NEULASTA . . . . . . . . . . . . . . . . . . . . . . . 37NEULASTA ONPRO KIT . . . . . . . . . . . 37NEUPOGEN INJ 300MCG/0.5ML . . . 37NEUPOGEN INJ 300MCG/ML. . . . . . 37NEUPOGEN INJ 480MCG/0.8ML . . . 37NEUPOGEN INJ 480MCG/1.6ML . . . 37NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 30nevirapine er tb24 100mg . . . . . . . . . . 33nevirapine er tb24 400mg . . . . . . . . . . 33nevirapine susp . . . . . . . . . . . . . . . . . . . 33nevirapine tabs . . . . . . . . . . . . . . . . . . . 33NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 29

75


Covered Drugs Index

paroxetine hcl er tb24 25mg, 37.5mg . . . . . . . . . . . . . . . . . . . . . 24paroxetine hcl tabs 10mg, 20mg . . . . 24paroxetine hcl tabs 30mg . . . . . . . . . . 24paroxetine hcl tabs 40mg . . . . . . . . . . 24PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 27PATADAY . . . . . . . . . . . . . . . . . . . . . . . . . 53PAXIL SUSP . . . . . . . . . . . . . . . . . . . . . . 24PAZEO . . . . . . . . . . . . . . . . . . . . . . . . . . . 53PEDIARIX . . . . . . . . . . . . . . . . . . . . . . . . 51PEDVAX HIB . . . . . . . . . . . . . . . . . . . . . . 51peg 3350/electrolytes . . . . . . . . . . . . . . 44peg-3350/electrolytes . . . . . . . . . . . . . . 44peg-3350/nacl/na bicarbonate/kcl . . . 44PEGANONE . . . . . . . . . . . . . . . . . . . . . . 23PEGASYS INJ 180MCG/0.5ML . . . . . 33PEGASYS INJ 180MCG/ML . . . . . . . . 33PEGASYS PROCLICK . . . . . . . . . . . . . 33PEGINTRON . . . . . . . . . . . . . . . . . . . . . . 33PEG-INTRON REDIPEN . . . . . . . . . . . 33penicillin g potassium inj 20000000unit, 5000000unit . . . . . . . . 20penicillin v potassium oral soln . . . . . 20penicillin v potassium tabs 250mg . . . 20penicillin v potassium tabs 500mg . . . 20PENTAM 300 . . . . . . . . . . . . . . . . . . . . . 30pentoxifylline er . . . . . . . . . . . . . . . . . . . . 40PERFOROMIST . . . . . . . . . . . . . . . . . . . 54PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 57perindopril erbumine tabs 2mg, 4mg . . . . . . . . . . . . . . . . . . . . . . . . . 38perindopril erbumine tabs 8mg . . . . . 38periogard . . . . . . . . . . . . . . . . . . . . . . . . . 42PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 30permethrin . . . . . . . . . . . . . . . . . . . . . . . . 30perphenazine . . . . . . . . . . . . . . . . . . . . . 31perphenazine/amitriptyline . . . . . . . . . 25PFIZERPEN-G INJ 20MU . . . . . . . . . . 20pfizerpen-g inj 5000000unit . . . . . . . . 21phenadoz . . . . . . . . . . . . . . . . . . . . . . . . . 25

oxaliplatin inj 100mg/20ml, 50mg/10ml . . . . . . . . . . . 28OXANDROLONE TABS 2.5MG . . . . . 46OXANDROLONE TABS 10MG . . . . . 46oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . 16oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 35oxcarbazepine . . . . . . . . . . . . . . . . . . . . 23oxybutynin chloride er tb24 10mg, 5mg . . . . . . . . . . . . . . . . . . . 44oxybutynin chloride er tb24 15mg . . . 44oxybutynin chloride syrp . . . . . . . . . . . 44oxybutynin chloride tabs . . . . . . . . . . . 44oxycodone/acetaminophen tabs 325mg; 2.5mg, 325mg; 5mg . . . 17oxycodone/acetaminophen tabs 325mg; 7.5mg . . . . . . . . . . . . . . . . 17oxycodone/acetaminophen tabs 325mg; 10mg . . . . . . . . . . . . . . . . . 17oxycodone/aspirin . . . . . . . . . . . . . . . . . 17oxycodone hcl caps . . . . . . . . . . . . . . . 17oxycodone hcl conc . . . . . . . . . . . . . . . 17oxycodone hcl oral soln . . . . . . . . . . . 17oxycodone hcl tabs 10mg, 15mg, 20mg, 5mg . . . . . . . . . . . 17oxycodone hcl tabs 30mg . . . . . . . . . . 17oxycodone/ibuprofen . . . . . . . . . . . . . . 18

Ppacerone . . . . . . . . . . . . . . . . . . . . . . . . . . 38paclitaxel . . . . . . . . . . . . . . . . . . . . . . . . . . 28paliperidone er tb24 1.5mg, 3mg . . . 32paliperidone er tb24 6mg . . . . . . . . . . . 32paliperidone er tb24 9mg . . . . . . . . . . . 32pamidronate disodium . . . . . . . . . . . . . 52PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 30pantoprazole sodium tbec . . . . . . . . . 44paricalcitol caps 1mcg, 2mcg . . . . . . . 52paricalcitol caps 4mcg . . . . . . . . . . . . . 52paroex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42paromomycin sulfate . . . . . . . . . . . . . . . 18paroxetine hcl er tb24 12.5mg . . . . . . 24

octreotide acetate inj 1000mcg/ml, 100mcg/ml, 200mcg/ml, 50mcg/ml . . . . . . . . . . . . . 49ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . 33ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 28OFEV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55ofloxacin . . . . . . . . . . . . . . . . . . . . . . . . . . 21ogestrel . . . . . . . . . . . . . . . . . . . . . . . . . . . 48olanzapine/fluoxetine . . . . . . . . . . . . . . 24olanzapine inj . . . . . . . . . . . . . . . . . . . . . 32olanzapine odt . . . . . . . . . . . . . . . . . . . . 32olanzapine tabs . . . . . . . . . . . . . . . . . . . 32olmesartan medoxomil . . . . . . . . . . . . . 38olmesartan medoxomil/hydrochlorothiazide . . . . . . . . . . . . . . . . 38olopatadine hcl ophthalmic soln . . . . 53omega-3-acid ethyl esters . . . . . . . . . . 41omeprazole cpdr . . . . . . . . . . . . . . . . . . 44ondansetron hcl inj 40mg/20ml, 4mg/2ml . . . . . . . . . . . . . . 25ondansetron hcl oral soln . . . . . . . . . . 25ondansetron hcl tabs 4mg, 8mg . . . . 25ondansetron hcl tabs 24mg . . . . . . . . 25ondansetron odt . . . . . . . . . . . . . . . . . . . 25ONFI SUSP . . . . . . . . . . . . . . . . . . . . . . 23ONFI TABS 10MG . . . . . . . . . . . . . . . . . 23ONFI TABS 20MG . . . . . . . . . . . . . . . . . 23OPDIVO . . . . . . . . . . . . . . . . . . . . . . . . . . 30OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . . 55oralone dental paste . . . . . . . . . . . . . . . 42ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 43ORKAMBI . . . . . . . . . . . . . . . . . . . . . . . . . 54orphenadrine citrate er . . . . . . . . . . . . . 55orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 48oscimin . . . . . . . . . . . . . . . . . . . . . . . . . . . 43oseltamivir phosphate caps 30mg . . 34oseltamivir phosphate caps 45mg, 75mg . . . . . . . . . . . . . . . . . . . . . . . 34OSMOPREP . . . . . . . . . . . . . . . . . . . . . . 44oxacillin sodium inj 10gm . . . . . . . . . . . 20oxaliplatin inj 100mg . . . . . . . . . . . . . . . 28

76


Covered Drugs Index

PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . . 53PRED-G S.O.P. . . . . . . . . . . . . . . . . . . . 53PRED MILD . . . . . . . . . . . . . . . . . . . . . . . 53prednicarbate oint . . . . . . . . . . . . . . . . . 46prednisolone acetate . . . . . . . . . . . . . . 53prednisolone oral soln . . . . . . . . . . . . . 46prednisolone sodium phosphate ophthalmic soln . . . . . . . . . . . . . . . . . . . 53prednisolone sodium phosphate oral soln 15mg/5ml, 25mg/5ml, 5mg/5ml . . . . . . . . . . . . . . . . 46prednisone intensol . . . . . . . . . . . . . . . . 46prednisone oral soln . . . . . . . . . . . . . . 46prednisone tabs 10mg, 1mg, 2.5mg, 20mg, 5mg . . . . . 46prednisone tabs 50mg . . . . . . . . . . . . . 46prednisone tbpk . . . . . . . . . . . . . . . . . . . 46PREGNYL W/DILUENT BENZYL ALCOHOL/NACL . . . . . . . . . 46PREMARIN CREA . . . . . . . . . . . . . . . . 48PREMARIN INJ . . . . . . . . . . . . . . . . . . . 48PREMARIN TABS . . . . . . . . . . . . . . . . 48PREMASOL INJ 52MEQ/L; 1760MG/100ML; 880MG/100ML; 34MEQ/L; 1760MG/100ML; 372MG/100ML; 406MG/100ML; 526MG/100ML; 492MG/100ML; 492MG/100ML; 526MG/100ML; 356MG/100ML; 356MG/100ML; 390MG/100ML; 34MG/100ML; 152MG/100ML . . . . . . 57premasol inj 56meq/l; 320mg/100ml; 730mg/100ml; 190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml; 220mg/100ml; 290mg/100ml; 490mg/100ml; 840mg/100ml; 490mg/100ml; 200mg/100ml; 290mg/100ml; 410mg/100ml; 230mg/100ml; 5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml; 140mg/100ml; 470mg/100ml . . . . . . . 58prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 41previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 48PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . 34

POMALYST . . . . . . . . . . . . . . . . . . . . . . . 27portia-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 48PORTRAZZA . . . . . . . . . . . . . . . . . . . . . 28potassium chloride 0.15% d5w/ nacl 0.45% . . . . . . . . . . . . . . . . . . . . . . . . 57potassium chloride 0.15% d5w/ nacl 0.45%viaflex . . . . . . . . . . . . . . . . . . 57potassium chloride 0.22% d5w/ nacl 0.45% . . . . . . . . . . . . . . . . . . . . . . . . 57potassium chloride cr . . . . . . . . . . . . . . 57potassium chloride/dextrose . . . . . . . . 57potassium chloride/dextrose/ lactated ringers inj 3meq/l; 149meq/l; 5%; 28meq/l; 24meq/l; 130meq/l . . . . . . . . . . . . . . . . . 57POTASSIUM CHLORIDE/ DEXTROSE/LACTATED RINGERS INJ 3MEQ/L; 149MEQ/L; 5%; 28MEQ/L; 44MEQ/L; 130MEQ/L . . . . 57potassium chloride/ dextrose/sodium chloride . . . . . . . . . . . 57potassium chloride er cpcr . . . . . . . . . 57potassium chloride er tbcr . . . . . . . . . 57potassium chloride inj 10meq/100ml, 20meq/100ml, 2meq/ml, 40meq/100ml . . . . . . . . . . . . 57potassium chloride oral soln . . . . . . . 57POTASSIUM CHLORIDE / SODIUM CHLORIDE . . . . . . . . . . . . . . 57potassium chloride/sodium chloride inj 20meq/l; 0.45%, 20meq/l; 0.9%, 40meq/l; 0.9% . . . . . . 57potassium chloride sr . . . . . . . . . . . . . . 57potassium citrate er . . . . . . . . . . . . . . . . 57PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . 36pramipexole dihydrochloride . . . . . . . . 30pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg . . . . . . 30pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 3mg, 4.5mg . . 30prasugrel . . . . . . . . . . . . . . . . . . . . . . . . . . 37pravastatin sodium . . . . . . . . . . . . . . . . 41prazosin hcl . . . . . . . . . . . . . . . . . . . . . . . 37

phenazopyridine hcl . . . . . . . . . . . . . . . 45phenelzine sulfate . . . . . . . . . . . . . . . . . 24phenergan supp . . . . . . . . . . . . . . . . . . 25phenobarbital elix . . . . . . . . . . . . . . . . . 23phenobarbital tabs . . . . . . . . . . . . . . . . 23phenoxybenzamine hydrochloride . . 37phenytoin . . . . . . . . . . . . . . . . . . . . . . . . . 23phenytoin infatabs . . . . . . . . . . . . . . . . . 23phenytoin sodium . . . . . . . . . . . . . . . . . . 23phenytoin sodium extended . . . . . . . . 23philith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . . 45phospha 250 neutral . . . . . . . . . . . . . . . 57PHOSPHOLINE IODIDE . . . . . . . . . . . 53PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . 52PHYSIOSOL IRRIGATION . . . . . . . . . 52PICATO GEL 0.05% . . . . . . . . . . . . . . . 43PICATO GEL 0.015% . . . . . . . . . . . . . . 43pilocarpine hcl ophthalmic soln . . . . . 53pilocarpine hcl tabs . . . . . . . . . . . . . . . 42pilocarpine hydrochloride . . . . . . . . . . . 42pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 31pimtrea . . . . . . . . . . . . . . . . . . . . . . . . . . . 48pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 39pioglitazone hcl . . . . . . . . . . . . . . . . . . . . 35pioglitazone hcl-glimepiride . . . . . . . . 35pioglitazone hcl/metformin hcl . . . . . . 36piperacillin sodium/ tazobactam sodium . . . . . . . . . . . . . . . . 21piperacillin/tazobactam . . . . . . . . . . . . . 21pirmella 1/35 . . . . . . . . . . . . . . . . . . . . . . 48pirmella 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 48piroxicam . . . . . . . . . . . . . . . . . . . . . . . . . 16PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 57podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 43polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19polyethylene glycol 3350 powd . . . . . 44polymyxin b sulfate . . . . . . . . . . . . . . . . 19polymyxin b sulfate/ trimethoprim sulfate . . . . . . . . . . . . . . . . 19

77


Covered Drugs Index

RRABAVERT . . . . . . . . . . . . . . . . . . . . . . . 51raloxifene hydrochloride . . . . . . . . . . . . 49ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 38RANEXA . . . . . . . . . . . . . . . . . . . . . . . . . . 40ranitidine hcl caps . . . . . . . . . . . . . . . . . 44ranitidine hcl inj . . . . . . . . . . . . . . . . . . . 44ranitidine hcl syrp . . . . . . . . . . . . . . . . . 44ranitidine hcl tabs . . . . . . . . . . . . . . . . . 44RAPAMUNE ORAL SOLN . . . . . . . . . 50rasagiline mesylate . . . . . . . . . . . . . . . . 31REBIF . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42REBIF REBIDOSE . . . . . . . . . . . . . . . . 42REBIF REBIDOSE TITRATION PACK . . . . . . . . . . . . . . . . . 42REBIF TITRATION PACK . . . . . . . . . . 42reclipsen . . . . . . . . . . . . . . . . . . . . . . . . . . 48RECOMBIVAX HB . . . . . . . . . . . . . . . . . 51REGONOL . . . . . . . . . . . . . . . . . . . . . . . . 26REGRANEX . . . . . . . . . . . . . . . . . . . . . . 43RELISTOR INJ 8MG/0.4ML . . . . . . . . 44RELISTOR INJ 12MG/0.6ML . . . . . . . 44REMICADE . . . . . . . . . . . . . . . . . . . . . . . 50REMODULIN . . . . . . . . . . . . . . . . . . . . . . 55RENVELA PACK . . . . . . . . . . . . . . . . . . 45RENVELA TABS . . . . . . . . . . . . . . . . . . 45repaglinide tabs 0.5mg, 1mg . . . . . . . 36repaglinide tabs 2mg . . . . . . . . . . . . . . 36REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 41REPATHA PUSHTRONEX SYSTEM . . . . . . . . . . 41REPATHA SURECLICK . . . . . . . . . . . . 41RESCRIPTOR TABS 100MG . . . . . . . 33RESCRIPTOR TABS 200MG . . . . . . . 33RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 53RETROVIR IV INFUSION . . . . . . . . . . 33REVLIMID CAPS 10MG, 2.5MG, 5MG . . . . . . . . . . . . . . . 27REVLIMID CAPS 15MG, 20MG, 25MG . . . . . . . . . . . . . . 27

promethazine hcl syrp . . . . . . . . . . . . . 25promethazine hcl tabs . . . . . . . . . . . . . 25promethegan . . . . . . . . . . . . . . . . . . . . . . 25propafenone hcl . . . . . . . . . . . . . . . . . . . 38propafenone hcl er . . . . . . . . . . . . . . . . . 38propantheline bromide . . . . . . . . . . . . . 43proparacaine hcl . . . . . . . . . . . . . . . . . . . 53propranolol hcl er . . . . . . . . . . . . . . . . . . 39propranolol hcl inj . . . . . . . . . . . . . . . . . 39propranolol hcl oral soln . . . . . . . . . . . 39propranolol hcl tabs 10mg, 20mg, 40mg, 80mg . . . . . . . . . 39propranolol hcl tabs 60mg . . . . . . . . . . 39propranolol/hydrochlorothiazide . . . . 39propylthiouracil . . . . . . . . . . . . . . . . . . . . 50PROQUAD . . . . . . . . . . . . . . . . . . . . . . . . 51PROSOL . . . . . . . . . . . . . . . . . . . . . . . . . . 58protriptyline hcl . . . . . . . . . . . . . . . . . . . . 25PULMOZYME . . . . . . . . . . . . . . . . . . . . . 54PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 28pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 27pyridostigmine bromide . . . . . . . . . . . . 26pyridostigmine bromide er . . . . . . . . . . 26

QQUADRACEL . . . . . . . . . . . . . . . . . . . . . 51quasense . . . . . . . . . . . . . . . . . . . . . . . . . 48quetiapine fumarate . . . . . . . . . . . . . . . 32quetiapine fumarate er tb24 150mg, 200mg . . . . . . . . . . . . . . . 32quetiapine fumarate er tb24 300mg, 400mg, 50mg . . . . . . . . . 32quinapril hcl . . . . . . . . . . . . . . . . . . . . . . . 38quinapril/hydrochlorothiazide tabs 12.5mg; 10mg . . . . . . . . . . . . . . . . 38quinapril/hydrochlorothiazide tabs 12.5mg; 20mg, 25mg; 20mg . . . 38quinidine sulfate . . . . . . . . . . . . . . . . . . . 38quinine sulfate . . . . . . . . . . . . . . . . . . . . . 30

PREZISTA SUSP . . . . . . . . . . . . . . . . . 34PREZISTA TABS 75MG . . . . . . . . . . . . 34PREZISTA TABS 150MG . . . . . . . . . . . 34PREZISTA TABS 600MG . . . . . . . . . . . 34PREZISTA TABS 800MG . . . . . . . . . . . 34PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 27PRIMAQUINE PHOSPHATE . . . . . . . 30primidone . . . . . . . . . . . . . . . . . . . . . . . . . 23PRIMSOL . . . . . . . . . . . . . . . . . . . . . . . . . 19PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . . . . 24PROAIR HFA . . . . . . . . . . . . . . . . . . . . . 54PROAIR RESPICLICK . . . . . . . . . . . . . 54probenecid . . . . . . . . . . . . . . . . . . . . . . . . 26probenecid/colchicine . . . . . . . . . . . . . . 26PROCALAMINE . . . . . . . . . . . . . . . . . . . 58prochlorperazine . . . . . . . . . . . . . . . . . . 31prochlorperazine edisylate . . . . . . . . . 31prochlorperazine maleate tabs 5mg . . . . . . . . . . . . . . . . . . . . . . . . . . 31prochlorperazine maleate tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 31PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML . . . . . . 37PROCRIT INJ 20000UNIT/ML . . . . . . 37PROCRIT INJ 40000UNIT/ML . . . . . . 37procto-med hc . . . . . . . . . . . . . . . . . . . . . 46procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 46proctosol hc . . . . . . . . . . . . . . . . . . . . . . . 46proctozone-hc . . . . . . . . . . . . . . . . . . . . . 46progesterone caps . . . . . . . . . . . . . . . . 49PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 36PROGRAF INJ . . . . . . . . . . . . . . . . . . . 50PROLASTIN-C . . . . . . . . . . . . . . . . . . . . 55PROLENSA . . . . . . . . . . . . . . . . . . . . . . . 53PROLEUKIN . . . . . . . . . . . . . . . . . . . . . . 28PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 52PROMACTA . . . . . . . . . . . . . . . . . . . . . . 37promethazine hcl plain . . . . . . . . . . . . . 25promethazine hcl supp . . . . . . . . . . . . 25

78


Covered Drugs Index

SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 49sildenafil tabs . . . . . . . . . . . . . . . . . . . . . 55SILENOR . . . . . . . . . . . . . . . . . . . . . . . . . 55silver sulfadiazine . . . . . . . . . . . . . . . . . 19SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . . 53SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 51simvastatin . . . . . . . . . . . . . . . . . . . . . . . . 41sirolimus . . . . . . . . . . . . . . . . . . . . . . . . . . 50SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 27sodium bicarbonate inj . . . . . . . . . . . . 55sodium bicarbonate partial fill . . . . . . . 55sodium chloride 0.9% . . . . . . . . . . . . . . 52sodium chloride 0.45% . . . . . . . . . . . . . 58sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5% . . . . . . . . . . 58sodium fluoride chew 0.5mg, 1mg . . . 58SODIUM LACTATE INJ 5MEQ/ML . . 55sodium phenylbutyrate . . . . . . . . . . . . . 43sodium polystyrene sulfonate powd . . . . . . . . . . . . . . . . . . . 55sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml . . . . . . 55sodium sulfacetamide ophthalmic soln . . . . . . . . . . . . . . . . . . . 21SOLIQUA 100/33 . . . . . . . . . . . . . . . . . . 36SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 27SOLU-CORTEF . . . . . . . . . . . . . . . . . . . 46SOMATULINE DEPOT INJ 60MG/0.2ML . . . . . . . . . . . . . . . . . . . . . . 49SOMATULINE DEPOT INJ 90MG/0.3ML . . . . . . . . . . . . . . . . . . . . . . 50SOMATULINE DEPOT INJ 120MG/0.5ML . . . . . . . . . . . . . . . . . . . . . 50SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 50sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38sotalol hcl . . . . . . . . . . . . . . . . . . . . . . . . . 38sotalol hcl (af) . . . . . . . . . . . . . . . . . . . . . 38SOVALDI . . . . . . . . . . . . . . . . . . . . . . . . . 33spironolactone/ hydrochlorothiazide . . . . . . . . . . . . . . . . 40spironolactone tabs 25mg . . . . . . . . . . 40

rosadan . . . . . . . . . . . . . . . . . . . . . . . . . . . 19rosuvastatin calcium . . . . . . . . . . . . . . . 41ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 51ROTATEQ . . . . . . . . . . . . . . . . . . . . . . . . 51roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 22ROZEREM . . . . . . . . . . . . . . . . . . . . . . . . 55RUBRACA . . . . . . . . . . . . . . . . . . . . . . . . 28RYDAPT . . . . . . . . . . . . . . . . . . . . . . . . . . 28RYTARY . . . . . . . . . . . . . . . . . . . . . . . . . . 31

SSABRIL PACK . . . . . . . . . . . . . . . . . . . . 23SABRIL TABS . . . . . . . . . . . . . . . . . . . . 23SAIZEN . . . . . . . . . . . . . . . . . . . . . . . . . . . 46SAIZEN CLICK.EASY . . . . . . . . . . . . . 46salsalate . . . . . . . . . . . . . . . . . . . . . . . . . . 16SAMSCA TABS 15MG . . . . . . . . . . . . . 55SAMSCA TABS 30MG . . . . . . . . . . . . . 55SANDIMMUNE ORAL SOLN . . . . . . 50SANDOSTATIN LAR DEPOT . . . . . . . 49SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 43SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 32SAVAYSA . . . . . . . . . . . . . . . . . . . . . . . . . 37scopolamine . . . . . . . . . . . . . . . . . . . . . . 25selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 31selenium sulfide lotn . . . . . . . . . . . . . . 43SELZENTRY ORAL SOLN . . . . . . . . 34SELZENTRY TABS 25MG . . . . . . . . . 34SELZENTRY TABS 150MG, 75MG . . 34SELZENTRY TABS 300MG . . . . . . . . 34SENSIPAR TABS 30MG . . . . . . . . . . . 49SENSIPAR TABS 60MG . . . . . . . . . . . 49SENSIPAR TABS 90MG . . . . . . . . . . . 49SEREVENT DISKUS . . . . . . . . . . . . . . 54sertraline hcl conc . . . . . . . . . . . . . . . . . 24sertraline hcl tabs 25mg, 50mg . . . . . 24sertraline hcl tabs 100mg . . . . . . . . . . 24setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 48sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 49

REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 32REYATAZ CAPS 150MG, 300MG . . . 34REYATAZ CAPS 200MG . . . . . . . . . . . 34REYATAZ PACK . . . . . . . . . . . . . . . . . . 34ribavirin caps . . . . . . . . . . . . . . . . . . . . . 33ribavirin inhalation soln . . . . . . . . . . . . 55ribavirin tabs . . . . . . . . . . . . . . . . . . . . . . 33RIDAURA . . . . . . . . . . . . . . . . . . . . . . . . . 51rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 26rifampin caps . . . . . . . . . . . . . . . . . . . . . 27rifampin inj . . . . . . . . . . . . . . . . . . . . . . . 27RIFATER . . . . . . . . . . . . . . . . . . . . . . . . . . 27riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42rimantadine hcl . . . . . . . . . . . . . . . . . . . . 34RINGERS INJECTION . . . . . . . . . . . . . 58RINGERS IRRIGATION . . . . . . . . . . . . 52RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . 36risedronate sodium tabs 30mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 52risedronate sodium tabs 35mg . . . . . 52risedronate sodium tabs 150mg . . . . 52RISPERDAL CONSTA INJ 12.5MG, 25MG, 37.5MG . . . . . . . . . . . 32RISPERDAL CONSTA INJ 50MG . . . 32risperidone m-tab tbdp 0.5mg, 1mg, 2mg, 3mg . . . . . . . . . . . . 32risperidone m-tab tbdp 4mg . . . . . . . . 32risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 32risperidone odt tbdp 4mg . . . . . . . . . . . 32risperidone oral soln . . . . . . . . . . . . . . 32risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 32risperidone tabs 4mg . . . . . . . . . . . . . . 32RITUXAN . . . . . . . . . . . . . . . . . . . . . . . . . 30RITUXAN HYCELA . . . . . . . . . . . . . . . . 30rivastigmine tartrate . . . . . . . . . . . . . . . . 23rivastigmine transdermal system . . . . 24rizatriptan benzoate . . . . . . . . . . . . . . . . 26rizatriptan benzoate odt . . . . . . . . . . . . 26ropinirole hcl . . . . . . . . . . . . . . . . . . . . . . 30

79


Covered Drugs Index

TARCEVA TABS 25MG . . . . . . . . . . . . 29TARCEVA TABS 100MG, 150MG . . . 29TARGRETIN GEL . . . . . . . . . . . . . . . . . 30tarina fe 1/20 . . . . . . . . . . . . . . . . . . . . . . 48TASIGNA . . . . . . . . . . . . . . . . . . . . . . . . . 29tazarotene . . . . . . . . . . . . . . . . . . . . . . . . 43tazicef inj 1gm, 2gm, 6gm . . . . . . . . . . 20TAZORAC CREA . . . . . . . . . . . . . . . . . 43TAZORAC GEL . . . . . . . . . . . . . . . . . . . 43taztia xt cp24 120mg, 300mg, 360mg . . . . . . . . . . . . 40taztia xt cp24 180mg, 240mg . . . . . . . 40TECENTRIQ . . . . . . . . . . . . . . . . . . . . . . 30TECFIDERA CPDR 120MG . . . . . . . . 42TECFIDERA CPDR 240MG . . . . . . . . 42TECFIDERA STARTER PACK . . . . . . 42techlite pen needles/31g x 6 mm . . . 52techlite pen needles/31g x 8mm . . . . 52techlite pen needles/32g x 4mm . . . . 52techlite pen needles/32g x 6mm . . . . 52techlite pen needles/32g x 8mm . . . . 52TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 20TEKTURNA . . . . . . . . . . . . . . . . . . . . . . . 40TEKTURNA HCT . . . . . . . . . . . . . . . . . . 40telmisartan . . . . . . . . . . . . . . . . . . . . . . . . 38telmisartan/amlodipine . . . . . . . . . . . . . 38telmisartan/hydrochlorothiazide . . . . . 38temazepam . . . . . . . . . . . . . . . . . . . . . . . 55TENIVAC . . . . . . . . . . . . . . . . . . . . . . . . . 51TEPADINA . . . . . . . . . . . . . . . . . . . . . . . . 27terazosin hcl caps 1mg, 2mg, 5mg . . 45terazosin hcl caps 10mg . . . . . . . . . . . 45terbinafine hcl tabs . . . . . . . . . . . . . . . . 26terbutaline sulfate inj . . . . . . . . . . . . . . 54terbutaline sulfate tabs . . . . . . . . . . . . 54terconazole . . . . . . . . . . . . . . . . . . . . . . . 26testosterone cypionate . . . . . . . . . . . . . 46testosterone enanthate . . . . . . . . . . . . 46testosterone gel 25mg/2.5gm, 50mg/5gm . . . . . . . . . . . 46

sumatriptan succinate inj 6mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . . 26sumatriptan succinate refill inj 4mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . . 26sumatriptan succinate refill inj 6mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . . 26sumatriptan succinate tabs . . . . . . . . 26SUPRAX SUSR 500MG/5ML . . . . . . . 20SUPREP BOWEL PREP KIT . . . . . . . 44SUSTIVA CAPS 50MG . . . . . . . . . . . . . 33SUSTIVA CAPS 200MG . . . . . . . . . . . 33SUSTIVA TABS . . . . . . . . . . . . . . . . . . . 33SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 29SYLATRON . . . . . . . . . . . . . . . . . . . . . . . 28SYMLINPEN 60 . . . . . . . . . . . . . . . . . . . 36SYMLINPEN 120 . . . . . . . . . . . . . . . . . . 36SYNAGIS . . . . . . . . . . . . . . . . . . . . . . . . . 51SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 50SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 19SYNJARDY . . . . . . . . . . . . . . . . . . . . . . . 36SYNJARDY XR TB24 10MG; 1000MG, 25MG; 1000MG . . . 36SYNJARDY XR TB24 12.5MG; 1000MG, 5MG; 1000MG . . 36SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 28SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 49SYPRINE . . . . . . . . . . . . . . . . . . . . . . . . . 55

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 28tacrolimus caps . . . . . . . . . . . . . . . . . . . 50tacrolimus oint . . . . . . . . . . . . . . . . . . . . 43TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 29TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 29TALWIN . . . . . . . . . . . . . . . . . . . . . . . . . . . 18TAMIFLU CAPS 30MG . . . . . . . . . . . . 34TAMIFLU CAPS 45MG, 75MG . . . . . 34TAMIFLU SUSR . . . . . . . . . . . . . . . . . . 34tamoxifen citrate . . . . . . . . . . . . . . . . . . . 27tamsulosin hcl . . . . . . . . . . . . . . . . . . . . . 45

spironolactone tabs 100mg, 50mg . . . 40SPORANOX ORAL SOLN . . . . . . . . . 26sprintec 28 . . . . . . . . . . . . . . . . . . . . . . . . 48SPRITAM TB3D 750MG . . . . . . . . . . . 22SPRITAM TB3D 1000MG, 250MG, 500MG . . . . . . . . . . 22SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . 29sps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48SSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19STAMARIL . . . . . . . . . . . . . . . . . . . . . . . . 51stavudine . . . . . . . . . . . . . . . . . . . . . . . . . 33sterile water irrigation . . . . . . . . . . . . . . 52STIMATE . . . . . . . . . . . . . . . . . . . . . . . . . 46STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 29STRATTERA CAPS 10MG, 18MG, 25MG, 40MG . . . . . . . 42STRATTERA CAPS 100MG, 60MG, 80MG . . . . . . . . . . . . . 42streptomycin sulfate . . . . . . . . . . . . . . . 18STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . 33SUBOXONE . . . . . . . . . . . . . . . . . . . . . . 18sucralfate . . . . . . . . . . . . . . . . . . . . . . . . . 44sulfacetamide sodium ophthalmic soln . . . . . . . . . . . . . . . . . . . 22sulfacetamide sodium/ prednisolone sodium phosphate . . . . 22sulfacetamide sodium susp . . . . . . . . 22sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 22sulfamethoxazole/trimethoprim ds . . . 22sulfamethoxazole/trimethoprim inj . . . 22sulfamethoxazole/ trimethoprim susp . . . . . . . . . . . . . . . . . 22sulfamethoxazole/ trimethoprim tabs . . . . . . . . . . . . . . . . . 22sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 51sulfatrim pediatric . . . . . . . . . . . . . . . . . . 22sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . 16sumatriptan . . . . . . . . . . . . . . . . . . . . . . . 26sumatriptan succinate inj 4mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . . 26

80


Covered Drugs Index

TRELSTAR MIXJECT INJ 11.25MG . . 50TRELSTAR MIXJECT INJ 22.5MG . . 50TRESIBA FLEXTOUCH . . . . . . . . . . . . 36tretinoin caps . . . . . . . . . . . . . . . . . . . . . 30tretinoin crea . . . . . . . . . . . . . . . . . . . . . 43tretinoin gel . . . . . . . . . . . . . . . . . . . . . . . 43tretinoin microsphere . . . . . . . . . . . . . . 43tretinoin microsphere pump gel 0.1% . . . . . . . . . . . . . . . . . . . . 43trezix caps 320.5mg; 30mg; 16mg . . . 18triamcinolone acetonide crea 0.1% . . 46triamcinolone acetonide crea 0.025%, 0.5% . . . . . . . . . . . . . . . . 46triamcinolone acetonide dental paste . . . . . . . . . . . . . . . . . . . . . . . 42triamcinolone acetonide lotn . . . . . . . . 46triamcinolone acetonide oint . . . . . . . . 46triamterene/hydrochlorothiazide caps 25mg; 37.5mg . . . . . . . . . . . . . . . . 40triamterene/hydrochlorothiazide caps 25mg; 50mg . . . . . . . . . . . . . . . . . 40triamterene/ hydrochlorothiazide tabs . . . . . . . . . . . 40trianex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46triderm crea 0.1% . . . . . . . . . . . . . . . . . 46tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 48trifluoperazine hcl . . . . . . . . . . . . . . . . . . 31trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 34trihexyphenidyl hcl . . . . . . . . . . . . . . . . . 30tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 48tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 48trilyte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 19trimethoprim sulfate/ polymyxin b sulfate . . . . . . . . . . . . . . . . 19trimipramine maleate . . . . . . . . . . . . . . 25TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 24tri-previfem . . . . . . . . . . . . . . . . . . . . . . . . 48TRISENOX . . . . . . . . . . . . . . . . . . . . . . . 28tri-sprintec . . . . . . . . . . . . . . . . . . . . . . . . 48TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . 33

tobramycin/dexamethasone . . . . . . . . 53tobramycin nebu . . . . . . . . . . . . . . . . . . 54tobramycin ophthalmic soln . . . . . . . . 18tobramycin sulfate inj 1.2gm, 10mg/ml, 80mg/2ml . . . . . . . . 18tobramycin sulfate ophthalmic soln . . . . . . . . . . . . . . . . . . . 18TOBREX OINT . . . . . . . . . . . . . . . . . . . 18tolcapone . . . . . . . . . . . . . . . . . . . . . . . . . 30tolmetin sodium . . . . . . . . . . . . . . . . . . . 16tolterodine tartrate . . . . . . . . . . . . . . . . . 44tolterodine tartrate er . . . . . . . . . . . . . . 44topiramate cpsp . . . . . . . . . . . . . . . . . . . 23topiramate tabs 100mg, 25mg, 50mg . . . . . . . . . . . . . . . 23topiramate tabs 200mg . . . . . . . . . . . . 23toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 29topotecan hcl inj 4mg . . . . . . . . . . . . . . 29TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . 50torsemide . . . . . . . . . . . . . . . . . . . . . . . . . 40TOUJEO SOLOSTAR . . . . . . . . . . . . . . 36TPN ELECTROLYTES . . . . . . . . . . . . . 58TRACLEER . . . . . . . . . . . . . . . . . . . . . . . 55TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 36tramadol hcl . . . . . . . . . . . . . . . . . . . . . . . 18tramadol hydrochloride/ acetaminophen . . . . . . . . . . . . . . . . . . . . 18trandolapril tabs 1mg, 2mg . . . . . . . . . 38trandolapril tabs 4mg . . . . . . . . . . . . . . 38tranexamic acid inj . . . . . . . . . . . . . . . . 37tranexamic acid tabs . . . . . . . . . . . . . . 37TRANSDERM-SCOP . . . . . . . . . . . . . . 25tranylcypromine sulfate . . . . . . . . . . . . 24TRAVASOL . . . . . . . . . . . . . . . . . . . . . . . 58TRAVATAN Z . . . . . . . . . . . . . . . . . . . . . . 53trazodone hcl tabs 100mg, 150mg, 50mg . . . . . . . . . . . . . . 24trazodone hcl tabs 300mg . . . . . . . . . . 24TREANDA . . . . . . . . . . . . . . . . . . . . . . . . 27TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 27TRELSTAR MIXJECT INJ 3.75MG . . 50

testosterone pump . . . . . . . . . . . . . . . . . 46TETANUS/DIPHTHERIA TOXOIDS-ADSORBED . . . . . . . . . . . . 51tetrabenazine tabs 12.5mg . . . . . . . . . 42tetrabenazine tabs 25mg . . . . . . . . . . . 42tetracycline hcl . . . . . . . . . . . . . . . . . . . . 22tetracycline hydrochloride caps 500mg . . . . . . . . . . . . . . . . . . . . . . . 22TEXACORT . . . . . . . . . . . . . . . . . . . . . . . 46THALOMID CAPS 100MG, 150MG, 50MG . . . . . . . . . . . . 27THALOMID CAPS 200MG . . . . . . . . . 27THEO-24 . . . . . . . . . . . . . . . . . . . . . . . . . 55theophylline cr . . . . . . . . . . . . . . . . . . . . . 55theophylline er tb12 300mg, 450mg . . . . . . . . . . . . . . . . . . . . 55theophylline er tb24 . . . . . . . . . . . . . . . 55thioridazine hcl . . . . . . . . . . . . . . . . . . . . 31thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . 27thiothixene caps 2mg . . . . . . . . . . . . . . 31thiothixene caps 10mg, 1mg, 5mg . . . 31THYMOGLOBULIN . . . . . . . . . . . . . . . . 50THYROLAR-1 . . . . . . . . . . . . . . . . . . . . . 49THYROLAR-1/2 . . . . . . . . . . . . . . . . . . . 49THYROLAR-1/4 . . . . . . . . . . . . . . . . . . . 49THYROLAR-2 . . . . . . . . . . . . . . . . . . . . . 49THYROLAR-3 . . . . . . . . . . . . . . . . . . . . . 49tiagabine hydrochloride tabs 2mg . . . 23tiagabine hydrochloride tabs 4mg . . . 23tigecycline . . . . . . . . . . . . . . . . . . . . . . . . 19TIKOSYN . . . . . . . . . . . . . . . . . . . . . . . . . 38tilia fe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48timolol maleate ophthalmic soln . . . . 53timolol maleate tabs . . . . . . . . . . . . . . . 39TIS-U-SOL . . . . . . . . . . . . . . . . . . . . . . . . 52TIVICAY TABS 10MG, 25MG . . . . . . . 33TIVICAY TABS 50MG . . . . . . . . . . . . . . 33tizanidine hcl . . . . . . . . . . . . . . . . . . . . . . 32TOBI PODHALER . . . . . . . . . . . . . . . . . 54TOBRADEX OINT . . . . . . . . . . . . . . . . 53

81


Covered Drugs Index

vicodin tabs 300mg; 5mg . . . . . . . . . . . 18VICTOZA . . . . . . . . . . . . . . . . . . . . . . . . . 36VIDEX PEDIATRIC ORAL SOLN 2GM . . . . . . . . . . . . . . . . . 33VIDEX PEDIATRIC ORAL SOLN 4GM . . . . . . . . . . . . . . . . . 33vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48vigabatrin . . . . . . . . . . . . . . . . . . . . . . . . . 23VIGAMOX . . . . . . . . . . . . . . . . . . . . . . . . 21VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . . . . 24VIIBRYD STARTER PACK . . . . . . . . . 24VIMPAT INJ . . . . . . . . . . . . . . . . . . . . . . 23VIMPAT ORAL SOLN . . . . . . . . . . . . . 23VIMPAT TABS . . . . . . . . . . . . . . . . . . . . 23vinblastine sulfate . . . . . . . . . . . . . . . . . 29vincasar pfs . . . . . . . . . . . . . . . . . . . . . . . 29vincristine sulfate . . . . . . . . . . . . . . . . . . 29vinorelbine tartrate . . . . . . . . . . . . . . . . . 29viorele . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48VIRACEPT TABS 250MG . . . . . . . . . . 34VIRACEPT TABS 625MG . . . . . . . . . . 34VIRAMUNE SUSP . . . . . . . . . . . . . . . . 33VIRAZOLE . . . . . . . . . . . . . . . . . . . . . . . . 55VIREAD POWD . . . . . . . . . . . . . . . . . . . 34VIREAD TABS . . . . . . . . . . . . . . . . . . . . 34virt-phos 250 neutral . . . . . . . . . . . . . . . 58VOLTAREN GEL . . . . . . . . . . . . . . . . . . 43voriconazole inj . . . . . . . . . . . . . . . . . . . 26voriconazole susr . . . . . . . . . . . . . . . . . 26voriconazole tabs . . . . . . . . . . . . . . . . . 26VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 30VP-PNV-DHA . . . . . . . . . . . . . . . . . . . . . 58VPRIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43VRAYLAR CAPS . . . . . . . . . . . . . . . . . . 32VRAYLAR CPPK . . . . . . . . . . . . . . . . . . 32vyfemla . . . . . . . . . . . . . . . . . . . . . . . . . . . 48VYTORIN . . . . . . . . . . . . . . . . . . . . . . . . . 41VYXEOS . . . . . . . . . . . . . . . . . . . . . . . . . . 28

vancomycin hcl inj . . . . . . . . . . . . . . . . 20vandazole . . . . . . . . . . . . . . . . . . . . . . . . . 20VAQTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51VARIVAX . . . . . . . . . . . . . . . . . . . . . . . . . 51VARIZIG . . . . . . . . . . . . . . . . . . . . . . . . . . 51VASCEPA CAPS 0.5GM . . . . . . . . . . . 41VASCEPA CAPS 1GM . . . . . . . . . . . . . 41VAXCHORA . . . . . . . . . . . . . . . . . . . . . . . 51VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 30VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 28velivet . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48VELPHORO . . . . . . . . . . . . . . . . . . . . . . . 45VELTASSA . . . . . . . . . . . . . . . . . . . . . . . . 55VENCLEXTA STARTING PACK . . . . 28VENCLEXTA TABS 10MG . . . . . . . . . 29VENCLEXTA TABS 50MG . . . . . . . . . 28VENCLEXTA TABS 100MG . . . . . . . . 28venlafaxine hcl . . . . . . . . . . . . . . . . . . . . 24venlafaxine hcl er cp24 37.5mg, 75mg . . . . . . . . . . . . . . . . . . . . . 24venlafaxine hcl er cp24 150mg . . . . . 24venlafaxine hcl er tb24 37.5mg, 75mg . . . . . . . . . . . . . . . . . . . . . 24venlafaxine hcl er tb24 150mg . . . . . . 24VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 55VENTOLIN HFA . . . . . . . . . . . . . . . . . . . 54verapamil hcl er cp24 100mg, 120mg, 180mg, 240mg, 300mg . . . . . . . . . . . . . . . . . . . . 40verapamil hcl er cp24 200mg . . . . . . . 40verapamil hcl er tbcr . . . . . . . . . . . . . . 40verapamil hcl inj . . . . . . . . . . . . . . . . . . 40verapamil hcl sr cp24 360mg . . . . . . . 40verapamil hcl tabs 40mg . . . . . . . . . . . 40verapamil hcl tabs 120mg, 80mg . . . 40VERSACLOZ . . . . . . . . . . . . . . . . . . . . . 32VESICARE . . . . . . . . . . . . . . . . . . . . . . . . 44VIBERZI . . . . . . . . . . . . . . . . . . . . . . . . . . 44vicodin es tabs 300mg; 7.5mg . . . . . . 18vicodin hp tabs 300mg; 10mg . . . . . . 18

trivora-28 . . . . . . . . . . . . . . . . . . . . . . . . . 48TROKENDI XR CP24 100MG, 25MG, 50MG . . . . . . . . . . . . . 23TROKENDI XR CP24 200MG . . . . . . 23TROPHAMINE . . . . . . . . . . . . . . . . . . . . 58tropicamide . . . . . . . . . . . . . . . . . . . . . . . 53TRULANCE . . . . . . . . . . . . . . . . . . . . . . . 43TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 36TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 51TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . 33TWINRIX . . . . . . . . . . . . . . . . . . . . . . . . . 51TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . . 34TYGACIL . . . . . . . . . . . . . . . . . . . . . . . . . 19TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 30TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 51TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 42

UULORIC . . . . . . . . . . . . . . . . . . . . . . . . . . 26UNITHROID . . . . . . . . . . . . . . . . . . . . . . . 49UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . . 30ursodiol . . . . . . . . . . . . . . . . . . . . . . . . . . . 44UVADEX . . . . . . . . . . . . . . . . . . . . . . . . . . 43

VVAGIFEM . . . . . . . . . . . . . . . . . . . . . . . . . 48valacyclovir hcl . . . . . . . . . . . . . . . . . . . . 34VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 27VALCYTE ORAL SOLN . . . . . . . . . . . 32valganciclovir . . . . . . . . . . . . . . . . . . . . . . 32valganciclovir hydrochlorde . . . . . . . . 32valproate sodium . . . . . . . . . . . . . . . . . . 23valproic acid . . . . . . . . . . . . . . . . . . . . . . . 23valsartan . . . . . . . . . . . . . . . . . . . . . . . . . . 38valsartan/hydrochlorothiazide . . . . . . 38vancomycin . . . . . . . . . . . . . . . . . . . . . . . 19vancomycin hcl caps 125mg . . . . . . . 20vancomycin hcl caps 250mg . . . . . . . 20vancomycin hcl in dextrose . . . . . . . . . 20

82


Covered Drugs Index

ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . . 30ZYLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ZYPREXA RELPREVV INJ 210MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 32ZYPREXA RELPREVV INJ 300MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 32ZYPREXA RELPREVV INJ 405MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 32ZYTIGA TABS 250MG . . . . . . . . . . . . . 27ZYTIGA TABS 500MG . . . . . . . . . . . . . 27

zebutal caps 325mg; 50mg; 40mg . . . 16ZEJULA . . . . . . . . . . . . . . . . . . . . . . . . . . 29ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 30ZEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . . 55zenatane . . . . . . . . . . . . . . . . . . . . . . . . . . 43zenchent . . . . . . . . . . . . . . . . . . . . . . . . . . 48ZENPEP . . . . . . . . . . . . . . . . . . . . . . . . . . 43ZERIT ORAL SOLN . . . . . . . . . . . . . . . 34ZETIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41ZIAGEN ORAL SOLN . . . . . . . . . . . . . 34zidovudine caps . . . . . . . . . . . . . . . . . . 34zidovudine syrp . . . . . . . . . . . . . . . . . . . 34zidovudine tabs . . . . . . . . . . . . . . . . . . . 34ZIOPTAN . . . . . . . . . . . . . . . . . . . . . . . . . 53ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 32ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 32ZMAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21zoledronic acid inj 4mg/5ml . . . . . . . . 52zoledronic acid inj 5mg/100ml . . . . . . 52ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 29zolpidem tartrate tabs . . . . . . . . . . . . . 55zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 22ZORTRESS TABS 0.5MG . . . . . . . . . . 50ZORTRESS TABS 0.25MG, 0.75MG . . . . . . . . . . . . . . . . . . 50ZOSTAVAX . . . . . . . . . . . . . . . . . . . . . . . 51ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML; 0.5GM/100ML . . . 21zovia 1/35e . . . . . . . . . . . . . . . . . . . . . . . 48zovia 1/50e . . . . . . . . . . . . . . . . . . . . . . . 48ZOVIRAX CREA . . . . . . . . . . . . . . . . . . 34ZUBSOLV SUBL 0.7MG; 0.18MG . . 18ZUBSOLV SUBL 1.4MG; 0.36MG, 11.4MG; 2.9MG, 2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG . . . . . 18ZYCLARA . . . . . . . . . . . . . . . . . . . . . . . . . 43ZYCLARA PUMP CREA 2.5% . . . . . . 43ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 30

Wwarfarin sodium . . . . . . . . . . . . . . . . . . . 37WELCHOL . . . . . . . . . . . . . . . . . . . . . . . . 41wera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 30XARELTO STARTER PACK . . . . . . . . 37XARELTO TABS 10MG . . . . . . . . . . . . 37XARELTO TABS 15MG . . . . . . . . . . . . 37XARELTO TABS 20MG . . . . . . . . . . . . 37XATMEP . . . . . . . . . . . . . . . . . . . . . . . . . . 50XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 52XIFAXAN TABS 200MG . . . . . . . . . . . . 20XIFAXAN TABS 550MG . . . . . . . . . . . . 20XIGDUO XR TB24 5MG; 1000MG . . 36XIGDUO XR TB24 10MG; 1000MG, 10MG; 500MG, 5MG; 500MG . . . . . . . . . . . . . 36XOLAIR . . . . . . . . . . . . . . . . . . . . . . . . . . . 55XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . . 27XULTOPHY 100/3.6 . . . . . . . . . . . . . . . 36xylon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

YYERVOY INJ 50MG/10ML . . . . . . . . . 30YERVOY INJ 200MG/40ML . . . . . . . . 30YF-VAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 51YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 27yuvafem . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 54zaleplon . . . . . . . . . . . . . . . . . . . . . . . . . . 55ZALTRAP . . . . . . . . . . . . . . . . . . . . . . . . . 30ZANOSAR . . . . . . . . . . . . . . . . . . . . . . . . 27ZAVESCA . . . . . . . . . . . . . . . . . . . . . . . . . 43

1-800-668-3813 (TTY 711) October 1 – February 14, 8 a.m. – 8 p.m. local time, 7 days a week. From February 15 – September 30, Monday – Friday, 8 a.m. – 8 p.m. local time, Saturday, 8 a.m. – 6 p.m. local time. Messaging service used weekends, after hours, and on federal holidays.

CignaHealthSpring.com

This drug list was updated on November 1, 2017. For more recent information or other questions, please contact Cigna-HealthSpring Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. - 8 p.m., or visit www.CignaHealthSpring.com. This information is available for free in other languages. Please call our customer service number at 1-800-668-3813 (TTY 711), 7 days a week, 8 a.m. - 8 p.m.. Esta información está disponible de forma gratuita en otros idiomas. Por favor, llame a nuestro servicio al cliente al 1-800-668-3813 (TTY 711), 7 dias de la semana, 8 a.m. - 8 p.m. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Tennessee, Inc., HealthSpring of Alabama, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2017 Cigna

Documents

2017 Cigna-HealthSpring COMPREHENSIVE DRUG LIST (Formulary) · 2 see the page number where you can find coverage information. Turn to the page listed in the Covered Drug Index and