BCN Advantage HMO-POS and HMO - bcbsm.com · 2017. 12. 1. · 2017 Formulary (List of covered drugs) PLEASE READ: DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

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2017 Formulary(List of covered drugs)

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

This formulary was updated on 12/01/2017. For more recent information or other questions, please contact BCN Advantage Customer Service at 1‑800‑450‑3680 or, for TTY users, 711, 8 a.m. to 8 p.m. Monday through Friday, with weekend hours Oct. 1 through Feb. 14, or visit www.bcbsm.com/medicare.

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

Updated: 12/2017Formulary 17139, Version 21

BCN Advantage is an HMO‑POS plan and an HMO plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal.

bcbsm.com/medicare

BCN AdvantageSM HMO-POS and HMO

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Blue Care Network. When it refers to “plan” or “our plan,” it means BCN Advantage.

This document includes a list of the drugs (formulary) for our plan which is current as of 12/01/2017. 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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How do I use the Formulary?There are two ways to find your drug within the formulary:

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

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page Index 1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?BCN Advantage 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: BCN Advantage requiresyou or your physician to get prior authorizationfor certain drugs. This means that you will needto get approval from BCN Advantage before youfill your prescriptions. If you don’t get approval,BCN Advantage may not cover the drug.

• Quantity Limits: For certain drugs, BCNAdvantage limits the amount of the drugthat BCN Advantage will cover. For example,BCN Advantage provides thirty one tabletsper prescription for Onglyza®. This maybe in addition to a standard one‑month orthree‑month supply.

What is the BCN Advantage Formulary?A formulary is a list of covered drugs selected by BCN Advantage 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. BCN Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a BCN Advantage 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 Formulary (drug list) change?Generally, if you are taking a drug on our 2017 formulary 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 formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost‑sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary 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 formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost‑sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive up to a 60‑day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 12/01/2017. To get updated information about the drugs covered by BCN Advantage, please contact us. Our contact information appears on the front and back cover pages. In the event of a mid‑year non maintenance formulary change, we will send out an errata sheet to notify you of this change.

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• Step Therapy: In some cases, BCN Advantage 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, BCN Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, BCN Advantage will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our 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 formulary, appears on the front and back cover pages.

You can ask BCN Advantage 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 BCN Advantage’s formulary?” on page ii for information about how to request an exception.

What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.

If you learn that BCN Advantage does not cover your drug, you have two options:

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

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

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

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

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

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

Generally, BCN Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost‑sharing drug or additional 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 formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s 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.

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

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31‑day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31‑day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long‑term care facility, we will allow you to refill your prescription until we have provided you with a 91‑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 member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31‑day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Other times when we will cover a temporary 31‑day transition supply (or less, if you have a prescription for fewer days) includes:• When you enter a long‑term care facility from

hospitals or other settings.• When you leave a long‑term care facility and

return to a home.• When you are discharged from a hospital to

a home

• When you leave a skilled nursing facility covered under Medicare Part A (where all pharmacy charges are covered) and must revert to coverage under the BCN Advantage Drug list

• When you cancel hospice care to revert to standard Medicare Parts A and B benefits

• When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized

BCN Advantage will send you a letter within three business days of your filling a temporary transition supply, notifying you that this was a temporary supply and explaining your options.

Note: Our transition policy applies only to those drugs that are “Part D drugs” and that are bought at a network pharmacy. The transition policy can’t be used to buy a non‑Part D drug or a drug out‑of‑network, unless you qualify for out‑of‑network access.

In addition to any exclusions or limitations described in the BCN Advantage 2017 Formulary, or in the Evidence of Coverage, the following items and services aren’t covered under Original Medicare or by our plan:

• Replacement prescriptions resulting from loss, theft or mishandling

• Reimbursement for prescriptions that are not approved by the FDA

• Reimbursement for prescriptions that are not purchased in the United States or its territories

• Covered prescription drugs beyond 90‑day supply limit, including early refill requests

• Prescriptions written by prescribers who are subject to the plan’s Prescriber Block Policy.

Out‑of‑state prescription refills are available to you when you spend time outside of Michigan; for example, if you travel to Florida in the winter months. Please call our Customer Service number located on the front and back covers of this booklet if you need help locating an out‑of‑state participating pharmacy.

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Description of our Formulary Drug Tiers Drug Tiers Includes

Tier 1: Preferred Generic Drugs This is the lowest cost‑sharing tier.

Tier 2: Generic Drugs These are still generic drugs but not the lowest cost‑sharing tier.

Tier 3: Preferred Brand Drugs This is the lowest cost non‑generic tier.

Tier 4: Non‑Preferred Drugs These are brand and generic drugs not in a preferred tier.

Tier 5: Specialty Drugs This is the highest cost‑sharing tier.

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

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

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1‑800‑MEDICARE (1‑800‑633‑4227) 24 hours a day/7 days a week. TTY users call 1‑877‑486‑2048. Or, visit http://www.medicare.gov.

BCN Advantage FormularyThe formulary below provides coverage information about the drugs covered by BCN Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page Index 1.

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

The information in the Requirements/Limits column tells you if BCN Advantage has any special requirements for coverage of your drug.

Your costs (see cost‑share tables below)The amount you pay for a covered drug will depend on:

• Your coverage stage. BCN Advantage has different stages of coverage. In each stage, the amount you pay for a drug may change.

• The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier may have a different copay or coinsurance amount. The “Drug Tiers” chart below explains what types of drugs are included in each tier and shows how costs may change with each tier.

• The pharmacy you use. You may go to any of our network pharmacies. However, you will usually pay less for your three‑month supply of covered drugs if you use a preferred network pharmacy or network mail order pharmacy rather than a standard retail pharmacy. The Pharmacy Directory will tell you which of the pharmacies in our network are preferred network pharmacies and network mail order pharmacies.

All drugs on our Formulary are available for mail order: Our plan’s mail‑order service requires you to order at least a 31‑day supply of the drug and no more than a 90‑day supply. Tier 5 specialty drugs are limited to 31‑day supply via mail order.

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BCN Advantage Prescription Drug Tier Costs* for Initial Coverage Stage

*If you are eligible to receive a low‑income subsidy for extra help, the copay and coinsurance amounts listed in this chart are not applicable. Refer to your Evidence of Coverage for cost‑sharing details.

The BCN Advantage Classic, Prestige, MyChoice and BCN Advantage ConnectedCare plans have no deductible. You pay the amounts listed below until you reach your Initial Coverage Stage limit of $3,700. This amount includes the total drug costs paid by you (copayments and Coinsurance) and the plan.The BCN Advantage Basic1 and BCN Advantage HealthySaver2 plans have a deductible. After you (or others on your behalf) have met your deductible, the plan pays its share of the costs of your drugs and you pay your share.

Tier Drug Description

Up to a 31‑day supply Up to a 90‑day supply

At long‑term care

pharmacies**

At out‑of‑network

pharmacies

At the plan’s mail

order service

At preferred network pharmacies or the plan’s

mail order service

At standard retail network pharmacies

Tier 1Preferred Generic Drugs

Basic: $5Classic: $3

Prestige: $3MyChoice: $3

BCN Advantage ConnectedCare: $3

HealthySaver: $5

Basic: $12.50Classic: $7.50Prestige:$7.50

MyChoice: $7.50BCN Advantage

ConnectedCare: $7.50HealthySaver: $12.50


Prestige: $9MyChoice: $9

BCN Advantage ConnectedCare: $9HealthySaver: $15

Tier 2 Generic Drugs


Prestige: $10MyChoice: $15BCN Advantage

ConnectedCare: $15HealthySaver: $20


Prestige: $25MyChoice: $37.50BCN Advantage

ConnectedCare: $37.50HealthySaver: $50




Tier 3Preferred Brand Drugs




Basic: $117.50Classic: $100

Prestige: $87.50MyChoice: $117.50

BCN Advantage ConnectedCare: $117.50

HealthySaver: $117.50




Tier 4Non‑Preferred Drugs

Basic/Classic/Prestige/MyChoice/BCN Advantage

ConnectedCare/HealthySaver: 45% Coinsurance

Basic/Classic/Prestige/MyChoice/

BCN Advantage ConnectedCare/

HealthySaver: 42% Coinsurance

Basic/Classic/Prestige/MyChoice/

BCN Advantage ConnectedCare/


Tier 5 Specialty Drugs

Basic: 25% Coinsurance

A long‑term supply is not available for drugs in Tier 5


Classic/Prestige/MyChoice/BCN Advantage ConnectedCare:

33% Coinsurance1 Deductible does not apply to Tier 1 Drugs2 Deductible does not apply to Tier 1 and Tier 2 Drugs

**Brand‑name solid oral dosage drugs are limited to a 14‑day supply.

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BCN Advantage Drug Tier Costs* for Catastrophic Coverage Stage

*If you are eligible to receive a low‑income subsidy for extra help, the copay and coinsurance amounts listed in this chart are not applicable. Refer to your Evidence of Coverage for cost‑sharing details.

When your out‑of‑pocket costs have reached the $4,950 Coverage Gap Stage limit, you move on to the Catastrophic Coverage Stage. The plan will pay for most of your drug costs for the rest of the calendar year. You will pay the following at network pharmacies:

Tier Drug Description

Up to a 31‑day supply at ALL retail pharmacies

or the plan’s mail order service

Up to a 90‑day supply at preferred and standard network retail pharmacies

Tier 1Preferred Generic Drugs The greater of $3.30 or 5% of the plan’s approved amount

Tier 2 Generic Drugs

Tier 3Preferred Brand Drugs

The greater of $8.25 or 5% of the plan’s approved amount

Tier 4Non‑Preferred Drugs

Tier 5 Specialty Drugs

The greater of $3.30 (generics) $8.25 (brands) or 5% of the plan’s

approved amount

A long‑term supply is not available for drugs in Tier 5

List of AbbreviationsQL: Quantity Limit. For certain drugs, BCN Advantage limits the amount of the drug that we will cover.

ST: Step Therapy. In some cases, BCN Advantage requires you to first try a certain drug 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

PA: Prior Authorization. BCN Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, we may not cover the drug.

B/D: This drug may be covered under Medicare Part B or D depending on the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

HI: Home Infusion. This prescription drug is covered under our medical benefit. For more information, call Customer Service.

LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, call Customer Service at the numbers listed on the cover of this document.

BRAND‑NAME DRUGS ARE CAPITALIZED.

Generic drugs are lower‑case italics.

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drugs 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics.

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Drug Name Drug Tier

Requirements/Limits

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

ABELCET INTRAVENOUS SUSPENSION

5 B/D PA

AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION

5 B/D PA

amphotericin b injection recon soln

2 B/D PA

CANCIDAS INTRAVENOUS RECON SOLN

4

CASPOFUNGIN INTRAVENOUS RECON SOLN

4

clotrimazole mucous membrane troche

2

ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN

4

FLUCONAZOLE IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML

2

fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml

2 HI

Drug Name Drug Tier

Requirements/Limits

fluconazole oral suspension for reconstitution

2

fluconazole oral tablet

2

flucytosine oral capsule

2

griseofulvin microsize oral suspension

2

griseofulvin microsize oral tablet

2

griseofulvin ultramicrosize oral tablet

2

itraconazole oral capsule

4

ketoconazole oral tablet

2

NOXAFIL INTRAVENOUS SOLUTION

5

NOXAFIL ORAL SUSPENSION

5

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC)

5 QL (93 per 31 days)

nystatin oral suspension

2

nystatin oral tablet 2

SPORANOX ORAL SOLUTION

3

Drug Tier: 1-Preferred Generic 2-Generic 3-Preferred Brand 4-Non-Preferred Drugs 5-Specialty Drugs Requirements/Limits: B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability PA - Prior Authorization QL - Quantity Limit ST - Step Therapy Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. 2

Drug Name Drug Tier

Requirements/Limits

terbinafine hcl oral tablet

2

voriconazole intravenous solution

4

voriconazole oral suspension for reconstitution

4

voriconazole oral tablet

4

ANTIVIRALS

abacavir oral solution

4

abacavir oral tablet 4

abacavir-lamivudine oral tablet

5

abacavir-lamivudine-zidovudine oral tablet

5

acyclovir oral capsule

2

acyclovir oral suspension 200 mg/5 ml

2

acyclovir oral tablet 2

acyclovir sodium intravenous recon soln 500 mg

2

acyclovir sodium intravenous solution

2 B/D PA

adefovir oral tablet 5

amantadine hcl oral capsule

2

Drug Name Drug Tier

Requirements/Limits

amantadine hcl oral solution

2

amantadine hcl oral tablet

2

APTIVUS ORAL CAPSULE

5

APTIVUS ORAL SOLUTION

5

ATRIPLA ORAL TABLET

5

BARACLUDE ORAL SOLUTION

3

cidofovir intravenous solution

2

COMPLERA ORAL TABLET

5

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

3

DAKLINZA ORAL TABLET

5 PA

DESCOVY ORAL TABLET

5

didanosine oral capsule,delayed release(dr/ec)

2

EDURANT ORAL TABLET

5

EMTRIVA ORAL CAPSULE

3

EMTRIVA ORAL SOLUTION

3

entecavir oral tablet 5


3

Drug Name Drug Tier

Requirements/Limits

EPCLUSA ORAL TABLET

5 PA

EPIVIR HBV ORAL SOLUTION

3

EPZICOM ORAL TABLET

5

EVOTAZ ORAL TABLET

5

famciclovir oral tablet

2

fosamprenavir oral tablet

5

foscarnet intravenous solution

2

FUZEON SUBCUTANEOUS RECON SOLN

5

ganciclovir sodium intravenous recon soln

4 B/D PA

GENVOYA ORAL TABLET

5

HARVONI ORAL TABLET

5 PA

INTELENCE ORAL TABLET 100 MG, 200 MG

5

INTELENCE ORAL TABLET 25 MG

3

INVIRASE ORAL CAPSULE

4

INVIRASE ORAL TABLET

5

Drug Name Drug Tier

Requirements/Limits

ISENTRESS HD ORAL TABLET

5

ISENTRESS ORAL POWDER IN PACKET

3

ISENTRESS ORAL TABLET

5

ISENTRESS ORAL TABLET,CHEWABLE 100 MG

5

ISENTRESS ORAL TABLET,CHEWABLE 25 MG

3

KALETRA ORAL SOLUTION

5

KALETRA ORAL TABLET 100-25 MG

3

KALETRA ORAL TABLET 200-50 MG

5

lamivudine oral solution

2

lamivudine oral tablet

2

lamivudine-zidovudine oral tablet

2

LEXIVA ORAL SUSPENSION

4

LEXIVA ORAL TABLET

5

lopinavir-ritonavir oral solution

5


Drug Name Drug Tier

Requirements/Limits

MAVYRET ORAL TABLET

5 PA

moderiba dose pack oral tablets,dose pack 200 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7)

2

moderiba dose pack oral tablets,dose pack 400 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7)

5

moderiba oral tablet 4

nevirapine oral suspension

2

nevirapine oral tablet

2

nevirapine oral tablet extended release 24 hr

2

NORVIR ORAL CAPSULE

3

NORVIR ORAL SOLUTION

3

NORVIR ORAL TABLET

3

ODEFSEY ORAL TABLET

5

OLYSIO ORAL CAPSULE

5 PA

oseltamivir oral capsule 30 mg


oseltamivir oral capsule 45 mg, 75 mg


Drug Name Drug Tier

Requirements/Limits

PREZCOBIX ORAL TABLET

5

PREZISTA ORAL SUSPENSION

5

PREZISTA ORAL TABLET 150 MG, 75 MG

3

PREZISTA ORAL TABLET 600 MG, 800 MG

5

REBETOL ORAL SOLUTION

4

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE


RESCRIPTOR ORAL TABLET

3

RESCRIPTOR ORAL TABLET, DISPERSIBLE

3

RETROVIR INTRAVENOUS SOLUTION

4

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

5

REYATAZ ORAL POWDER IN PACKET

5

ribasphere oral capsule

2


5

Drug Name Drug Tier

Requirements/Limits

ribasphere oral tablet 200 mg, 400 mg

2

ribasphere oral tablet 600 mg

5

ribasphere ribapak oral tablets,dose pack

5

ribavirin inhalation recon soln

5 B/D PA

ribavirin oral capsule

2

ribavirin oral tablet 200 mg

2

rimantadine oral tablet

2

SELZENTRY ORAL SOLUTION

5

SELZENTRY ORAL TABLET 150 MG, 300 MG, 75 MG

5

SELZENTRY ORAL TABLET 25 MG

4

SOVALDI ORAL TABLET

5 PA

stavudine oral capsule

2

STRIBILD ORAL TABLET

5

SUSTIVA ORAL CAPSULE

3

Drug Name Drug Tier

Requirements/Limits

SUSTIVA ORAL TABLET

3

SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML

5

TAMIFLU ORAL CAPSULE 30 MG


TAMIFLU ORAL CAPSULE 45 MG, 75 MG


TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION

3 QL (360 per 180 days)

TECHNIVIE ORAL TABLET

5 PA

TIVICAY ORAL TABLET 10 MG

4

TIVICAY ORAL TABLET 25 MG, 50 MG

5

TRIUMEQ ORAL TABLET

5

TRUVADA ORAL TABLET

5

TYBOST ORAL TABLET

3

valacyclovir oral tablet

2

valganciclovir oral recon soln

5

valganciclovir oral tablet

5


Drug Name Drug Tier

Requirements/Limits

VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN

3

VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN

3

VIEKIRA PAK ORAL TABLETS,DOSE PACK

5 PA

VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR

5 PA

VIRACEPT ORAL TABLET

5

VIRAZOLE INHALATION RECON SOLN

5 B/D PA

VIREAD ORAL POWDER

5

VIREAD ORAL TABLET

3

ZEPATIER ORAL TABLET

5 PA

ZERIT ORAL RECON SOLN

5

ZIAGEN ORAL SOLUTION

3

zidovudine oral capsule

2

zidovudine oral syrup

2

zidovudine oral tablet

2

Drug Name Drug Tier

Requirements/Limits

CEPHALOSPORINS

CEDAX ORAL CAPSULE

4

cefaclor oral capsule 2

cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

2

cefaclor oral tablet extended release 12 hr

2

cefadroxil oral capsule

2

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

2

cefadroxil oral tablet 2

cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml

2

cefazolin injection recon soln

2

cefazolin intravenous recon soln

2

cefdinir oral capsule 2

cefdinir oral suspension for reconstitution

2


7

Drug Name Drug Tier

Requirements/Limits

CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 1 GRAM/50 ML

2

CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 2 GRAM/50 ML

4

cefepime in dextrose,iso-osm intravenous piggyback 1 gram/50 ml

2

cefepime injection recon soln 1 gram

2

cefixime oral suspension for reconstitution

2

cefotaxime injection recon soln

2

CEFOTETAN IN DEXTROSE, ISO-OSM INTRAVENOUS PIGGYBACK

4

cefoxitin in dextrose, iso-osm intravenous piggyback

2

cefoxitin intravenous recon soln

2

cefpodoxime oral suspension for reconstitution

2

Drug Name Drug Tier

Requirements/Limits

cefpodoxime oral tablet

2

cefprozil oral suspension for reconstitution

2

cefprozil oral tablet 2

CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK

2

ceftazidime injection recon soln

2

ceftibuten oral capsule

2

ceftibuten oral suspension for reconstitution

2

ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg

2

CEFTRIAXONE INJECTION RECON SOLN 100 GRAM

2

ceftriaxone intravenous recon soln

2 HI

cefuroxime axetil oral tablet

2

cefuroxime sodium injection recon soln 750 mg

2

cefuroxime sodium intravenous recon soln

2


Drug Name Drug Tier

Requirements/Limits

cephalexin oral capsule

1

cephalexin oral suspension for reconstitution

1

cephalexin oral tablet

1

MAXIPIME INTRAVENOUS RECON SOLN 1 GRAM

4

SUPRAX ORAL CAPSULE

4

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML

4

SUPRAX ORAL TABLET,CHEWABLE

4

TAZICEF INJECTION RECON SOLN

4

TAZICEF INTRAVENOUS RECON SOLN

4

TEFLARO INTRAVENOUS RECON SOLN

4

ZERBAXA INTRAVENOUS RECON SOLN

4

ERYTHROMYCINS / OTHER MACROLIDES

Drug Name Drug Tier

Requirements/Limits

azithromycin intravenous recon soln

2 HI

azithromycin oral packet

2

azithromycin oral suspension for reconstitution

2

azithromycin oral tablet

2

clarithromycin oral suspension for reconstitution

2

clarithromycin oral tablet

2

clarithromycin oral tablet extended release 24 hr

2

DIFICID ORAL TABLET

5

e.e.s. 400 oral tablet 2

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

4

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

4

erythrocin (as stearate) oral tablet 250 mg

2


9

Drug Name Drug Tier

Requirements/Limits

ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG

4 HI

erythromycin ethylsuccinate oral suspension for reconstitution

2

erythromycin ethylsuccinate oral tablet

2

erythromycin oral capsule,delayed release(dr/ec)

2

erythromycin oral tablet

2

PCE ORAL TABLET, PARTICLES/CRYSTALS

4

ZMAX ORAL SUSPENSION,EXTENDED REL RECON

4

MISCELLANEOUS ANTIINFECTIVES

ALBENZA ORAL TABLET

4

ALINIA ORAL SUSPENSION FOR RECONSTITUTION

3

ALINIA ORAL TABLET

3

Drug Name Drug Tier

Requirements/Limits

amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml

2

atovaquone oral suspension

5

atovaquone-proguanil oral tablet

2

AZACTAM IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML

4

AZACTAM IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2 GRAM/50 ML

4 HI

AZACTAM INJECTION RECON SOLN 1 GRAM

4

aztreonam injection recon soln

4

baciim intramuscular recon soln

2

bacitracin intramuscular recon soln

2

BETHKIS INHALATION SOLUTION FOR NEBULIZATION

5 B/D PA


Drug Name Drug Tier

Requirements/Limits

BILTRICIDE ORAL TABLET

3

CAPASTAT INJECTION RECON SOLN

4

CAYSTON INHALATION SOLUTION FOR NEBULIZATION

5 PA; QL (84 per 28 days)

chloramphenicol sod succinate intravenous recon soln

2

chloroquine phosphate oral tablet

2

clindamycin hcl oral capsule

2

clindamycin in 5 % dextrose intravenous piggyback

2 HI

clindamycin palmitate hcl oral recon soln

4

clindamycin pediatric oral recon soln

4

clindamycin phosphate injection solution

2

clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml

2

Drug Name Drug Tier

Requirements/Limits

clindamycin phosphate intravenous solution 600 mg/4 ml

2 HI

COARTEM ORAL TABLET

3

colistin (colistimethate na) injection recon soln

4

CUBICIN INTRAVENOUS RECON SOLN

4 B/D PA

CUBICIN RF INTRAVENOUS RECON SOLN

4 B/D PA

CYCLOSERINE ORAL CAPSULE

3

DALVANCE INTRAVENOUS SOLUTION

5

dapsone oral tablet 2

daptomycin intravenous recon soln

4 B/D PA

DARAPRIM ORAL TABLET

3

ethambutol oral tablet

2

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml

2 HI


11

Drug Name Drug Tier

Requirements/Limits

GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML

4

gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/50 ml, 90 mg/100 ml

2

gentamicin injection solution 40 mg/ml

2

gentamicin sulfate (pf) intravenous solution 100 mg/10 ml

2 HI

hydroxychloroquine oral tablet

2

imipenem-cilastatin intravenous recon soln

2

INVANZ INJECTION RECON SOLN

4

INVANZ INTRAVENOUS RECON SOLN

4

isoniazid injection solution

2

isoniazid oral solution

2

isoniazid oral tablet 2

ivermectin oral tablet

2

Drug Name Drug Tier

Requirements/Limits

linezolid intravenous parenteral solution

5

linezolid oral suspension for reconstitution

5

linezolid oral tablet 5

linezolid-0.9% sodium chloride intravenous parenteral solution

5

mefloquine oral tablet

2

meropenem intravenous recon soln 1 gram

2

meropenem intravenous recon soln 500 mg

4

MEROPENEM-0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 1 GRAM/50 ML

2

MEROPENEM-0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK 500 MG/50 ML

4

metronidazole in nacl (iso-os) intravenous piggyback

2 HI

metronidazole oral capsule

2


Drug Name Drug Tier

Requirements/Limits

metronidazole oral tablet

2

NEBUPENT INHALATION RECON SOLN

4 B/D PA

neomycin oral tablet 2

paromomycin oral capsule

2

PASER ORAL GRANULES DR FOR SUSP IN PACKET

4

PENTAM INJECTION RECON SOLN

4

polymyxin b sulfate injection recon soln

2

PRIFTIN ORAL TABLET

4

PRIMAQUINE ORAL TABLET

3

pyrazinamide oral tablet

2

quinine sulfate oral capsule

2

rifabutin oral capsule

4

rifampin intravenous recon soln

4

rifampin oral capsule

2

RIFATER ORAL TABLET

4

Drug Name Drug Tier

Requirements/Limits

RIMSO-50 INTRAVESICAL SOLUTION

4

SIRTURO ORAL TABLET

5 PA

SIVEXTRO ORAL TABLET

5

STREPTOMYCIN INTRAMUSCULAR RECON SOLN

4

SYNERCID INTRAVENOUS RECON SOLN

5

tinidazole oral tablet 2

TOBI PODHALER INHALATION CAPSULE

5

TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE

5

tobramycin in 0.225 % nacl inhalation solution for nebulization

5 B/D PA

tobramycin sulfate injection recon soln

2

tobramycin sulfate injection solution

2

TRECATOR ORAL TABLET

4

TYGACIL INTRAVENOUS RECON SOLN

4


13

Drug Name Drug Tier

Requirements/Limits

XIFAXAN ORAL TABLET 200 MG

4 QL (9 per 3 days)

XIFAXAN ORAL TABLET 550 MG


ZYVOX INTRAVENOUS PARENTERAL SOLUTION

5

PENICILLINS

amoxicillin oral capsule

1

amoxicillin oral suspension for reconstitution

1

amoxicillin oral tablet

1

amoxicillin oral tablet,chewable 125 mg, 250 mg

1

amoxicillin-pot clavulanate oral suspension for reconstitution

2

amoxicillin-pot clavulanate oral tablet

2

amoxicillin-pot clavulanate oral tablet extended release 12 hr

2

amoxicillin-pot clavulanate oral tablet,chewable

2

ampicillin oral capsule

1

Drug Name Drug Tier

Requirements/Limits

ampicillin sodium injection recon soln 1 gram, 125 mg, 2 gram, 250 mg, 500 mg

2

ampicillin sodium intravenous recon soln

2

ampicillin-sulbactam injection recon soln 1.5 gram

2 HI

ampicillin-sulbactam injection recon soln 15 gram, 3 gram

2

BICILLIN C-R INTRAMUSCULAR SYRINGE

4

BICILLIN L-A INTRAMUSCULAR SYRINGE

4

dicloxacillin oral capsule

2

nafcillin in dextrose iso-osm intravenous piggyback

2

nafcillin injection recon soln

2

nafcillin intravenous recon soln

2

oxacillin in dextrose(iso-osm) intravenous piggyback

2 HI

oxacillin injection recon soln

4


Drug Name Drug Tier

Requirements/Limits

oxacillin intravenous recon soln 1 gram

2

PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 1 MILLION UNIT/50 ML

4

PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 2 MILLION UNIT/50 ML, 3 MILLION UNIT/50 ML

4 HI

penicillin g potassium injection recon soln

2

penicillin g procaine intramuscular syringe 1.2 million unit/2 ml

2

penicillin g procaine intramuscular syringe 600,000 unit/ml

4

penicillin g sodium injection recon soln

2

penicillin v potassium oral recon soln

1

penicillin v potassium oral tablet

1

Drug Name Drug Tier

Requirements/Limits

pfizerpen-g injection recon soln 20 million unit

2

piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 40.5 gram

2

piperacillin-tazobactam intravenous recon soln 4.5 gram

2 HI

ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML, 3.375 GRAM/50 ML

4 HI

ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 4.5 GRAM/100 ML

4

QUINOLONES

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr


ciprofloxacin hcl oral tablet

2

ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml

2 HI


15

Drug Name Drug Tier

Requirements/Limits

ciprofloxacin lactate intravenous solution

2

ciprofloxacin oral suspension,microcapsule recon

2

levofloxacin in d5w intravenous piggyback 500 mg/100 ml

2 HI

levofloxacin intravenous solution

2

levofloxacin oral solution

2

levofloxacin oral tablet

2

moxifloxacin oral tablet

2

ofloxacin oral tablet 300 mg, 400 mg

2

SULFA'S / RELATED AGENTS

sulfadiazine oral tablet

2

sulfamethoxazole-trimethoprim intravenous solution

2

sulfamethoxazole-trimethoprim oral suspension

1

sulfamethoxazole-trimethoprim oral tablet

1

sulfatrim oral suspension

2

TETRACYCLINES

Drug Name Drug Tier

Requirements/Limits

demeclocycline oral tablet

4

doxy-100 intravenous recon soln

2

doxycycline hyclate oral capsule

2

doxycycline hyclate oral tablet

2

doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 200 mg, 50 mg, 75 mg

2

doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg

2

doxycycline monohydrate oral suspension for reconstitution

2

doxycycline monohydrate oral tablet

2

minocycline oral capsule

2

minocycline oral tablet

2

minocycline oral tablet extended release 24 hr

2

mondoxyne nl oral capsule

2


Drug Name Drug Tier

Requirements/Limits

morgidox oral capsule

2

tetracycline oral capsule

2

URINARY TRACT AGENTS

methenamine hippurate oral tablet

2

methenamine mandelate oral tablet

2

nitrofurantoin macrocrystal oral capsule

2

nitrofurantoin monohyd/m-cryst oral capsule

2

nitrofurantoin oral suspension

2

PRIMSOL ORAL SOLUTION

3

trimethoprim oral tablet

2

VANCOMYCIN

VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK

2

VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK

2

vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram

2

Drug Name Drug Tier

Requirements/Limits

vancomycin intravenous recon soln 500 mg

2 HI

VANCOMYCIN INTRAVENOUS RECON SOLN 750 MG

2

vancomycin oral capsule

4

VIBATIV INTRAVENOUS RECON SOLN 750 MG

3

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

amifostine crystalline intravenous recon soln

5

dexrazoxane hcl intravenous recon soln 250 mg

2

ELITEK INTRAVENOUS RECON SOLN

5

FUSILEV INTRAVENOUS RECON SOLN

5

KEPIVANCE INTRAVENOUS RECON SOLN

4

leucovorin calcium injection recon soln

2


17

Drug Name Drug Tier

Requirements/Limits

leucovorin calcium oral tablet

2

levoleucovorin intravenous recon soln 50 mg

4

levoleucovorin intravenous solution

4

mesna intravenous solution

2

MESNEX ORAL TABLET

4

XGEVA SUBCUTANEOUS SOLUTION

5 PA

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION

4

adriamycin intravenous solution

2

adrucil intravenous solution

2 B/D PA

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION

5 PA

AFINITOR ORAL TABLET

5 PA

ALECENSA ORAL CAPSULE

5 PA

Drug Name Drug Tier

Requirements/Limits

ALIMTA INTRAVENOUS RECON SOLN

4

ALUNBRIG ORAL TABLET

5 PA

anastrozole oral tablet

2

ARRANON INTRAVENOUS SOLUTION

4

ARZERRA INTRAVENOUS SOLUTION 1,000 MG/50 ML

4

ARZERRA INTRAVENOUS SOLUTION 100 MG/5 ML

3

ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, 1 MG

4 B/D PA

ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 5 MG

5 B/D PA

AVASTIN INTRAVENOUS SOLUTION

5

azacitidine injection recon soln

5

AZASAN ORAL TABLET

4 B/D PA


Drug Name Drug Tier

Requirements/Limits

azathioprine oral tablet

2 B/D PA

azathioprine sodium injection recon soln

2 B/D PA

BAVENCIO INTRAVENOUS SOLUTION

5 PA

BELEODAQ INTRAVENOUS RECON SOLN

5 PA

BENDEKA INTRAVENOUS SOLUTION

5 PA

bexarotene oral capsule

5 PA

bicalutamide oral tablet

2

BICNU INTRAVENOUS RECON SOLN

4

bleo 15k injection recon soln

2

bleomycin injection recon soln 15 unit

2

bleomycin injection recon soln 30 unit

2 B/D PA

BLINCYTO INTRAVENOUS KIT

5 B/D PA

BOSULIF ORAL TABLET

5 PA

busulfan intravenous solution

4

Drug Name Drug Tier

Requirements/Limits

BUSULFEX INTRAVENOUS SOLUTION

4

CABOMETYX ORAL TABLET

5 PA

CAPRELSA ORAL TABLET

5

carboplatin intravenous solution

2

CELLCEPT INTRAVENOUS RECON SOLN

4 B/D PA

cisplatin intravenous solution

2

cladribine intravenous solution

2 B/D PA

CLOFARABINE INTRAVENOUS SOLUTION

4

CLOLAR INTRAVENOUS SOLUTION

4

COMETRIQ ORAL CAPSULE

5 PA

COTELLIC ORAL TABLET

5 PA; LA

cyclophosphamide intravenous recon soln

2

CYCLOPHOSPHAMIDE ORAL CAPSULE

4 B/D PA

cyclosporine intravenous solution

2 B/D PA


19

Drug Name Drug Tier

Requirements/Limits

cyclosporine modified oral capsule

2 B/D PA

cyclosporine modified oral solution

2 B/D PA

cyclosporine oral capsule

2 B/D PA

CYRAMZA INTRAVENOUS SOLUTION

5 PA

cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml)

2

cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml), 20 mg/ml

2 B/D PA

cytarabine injection solution

2 B/D PA

dacarbazine intravenous recon soln

2

DARZALEX INTRAVENOUS SOLUTION

5 PA; LA

daunorubicin intravenous solution

2

decitabine intravenous recon soln

5

Drug Name Drug Tier

Requirements/Limits

docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)

5

DOCETAXEL INTRAVENOUS SOLUTION 20 MG/ML

5

doxorubicin intravenous recon soln

2

doxorubicin intravenous solution

2

doxorubicin, peg-liposomal intravenous suspension

2

DROXIA ORAL CAPSULE

4

ELLENCE INTRAVENOUS SOLUTION

4

EMCYT ORAL CAPSULE

3

EMPLICITI INTRAVENOUS RECON SOLN

5 PA

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR

4 B/D PA


Drug Name Drug Tier

Requirements/Limits

epirubicin intravenous solution

2

ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML

3

ERBITUX INTRAVENOUS SOLUTION 200 MG/100 ML

4

ERIVEDGE ORAL CAPSULE

5 PA

ERWINAZE INJECTION RECON SOLN

5

ETOPOPHOS INTRAVENOUS RECON SOLN

4

etoposide intravenous solution

2

EVOMELA INTRAVENOUS RECON SOLN

5 PA

exemestane oral tablet

2

FARESTON ORAL TABLET

3

FARYDAK ORAL CAPSULE


FASLODEX INTRAMUSCULAR SYRINGE

5

floxuridine injection recon soln

2

Drug Name Drug Tier

Requirements/Limits

fludarabine intravenous recon soln

2

fludarabine intravenous solution

2

fluorouracil intravenous solution 1 gram/20 ml

2

fluorouracil intravenous solution 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml

2 B/D PA

flutamide oral capsule

2

GAZYVA INTRAVENOUS SOLUTION

5 B/D PA

gemcitabine intravenous recon soln

5

gemcitabine intravenous solution

5

gengraf oral capsule 4 B/D PA

gengraf oral solution 4 B/D PA

GILOTRIF ORAL TABLET

5 PA

GLEOSTINE ORAL CAPSULE

3

HALAVEN INTRAVENOUS SOLUTION

5

HERCEPTIN INTRAVENOUS RECON SOLN

5


21

Drug Name Drug Tier

Requirements/Limits

HEXALEN ORAL CAPSULE

5

hydroxyurea oral capsule

2

IBRANCE ORAL CAPSULE

5 PA

ICLUSIG ORAL TABLET

5 PA

idarubicin intravenous solution

2

IDHIFA ORAL TABLET

5 PA

ifosfamide intravenous recon soln

2

ifosfamide intravenous solution

2

imatinib oral tablet 5

IMBRUVICA ORAL CAPSULE

5 PA

IMFINZI INTRAVENOUS SOLUTION

5 PA

INLYTA ORAL TABLET

5 PA

IRESSA ORAL TABLET

5

irinotecan intravenous solution

2

IXEMPRA INTRAVENOUS RECON SOLN

5

JAKAFI ORAL TABLET

5 PA

Drug Name Drug Tier

Requirements/Limits

JEVTANA INTRAVENOUS SOLUTION

5

KADCYLA INTRAVENOUS RECON SOLN

5 B/D PA

KEYTRUDA INTRAVENOUS RECON SOLN

5

KEYTRUDA INTRAVENOUS SOLUTION

5

KISQALI FEMARA CO-PACK ORAL TABLET

5 PA

KISQALI ORAL TABLET

5 PA

KYPROLIS INTRAVENOUS RECON SOLN

5 PA

LARTRUVO INTRAVENOUS SOLUTION

5 PA

LENVIMA ORAL CAPSULE

5 PA

letrozole oral tablet 2

LEUKERAN ORAL TABLET

3

leuprolide subcutaneous kit

2

LONSURF ORAL TABLET

5 PA


Drug Name Drug Tier

Requirements/Limits

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT

5


5


5

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT

5

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT

5

LUPRON DEPOT-PED INTRAMUSCULAR KIT

5

LYNPARZA ORAL CAPSULE

5 PA

LYNPARZA ORAL TABLET

5 PA

LYSODREN ORAL TABLET

3

MATULANE ORAL CAPSULE

5

megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml), 625 mg/5 ml

4

Drug Name Drug Tier

Requirements/Limits

megestrol oral tablet 4

MEKINIST ORAL TABLET

5 PA

melphalan hcl intravenous recon soln

2

melphalan oral tablet

4 B/D PA

mercaptopurine oral tablet

2

methotrexate sodium (pf) injection recon soln

2

methotrexate sodium (pf) injection solution

2

methotrexate sodium injection solution

2

methotrexate sodium oral tablet

2 B/D PA

mitomycin intravenous recon soln 20 mg, 5 mg

4

mitomycin intravenous recon soln 40 mg

5

mitoxantrone intravenous concentrate

2

MUSTARGEN INJECTION RECON SOLN

4


23

Drug Name Drug Tier

Requirements/Limits

mycophenolate mofetil hcl intravenous recon soln

2 B/D PA

mycophenolate mofetil oral capsule

2 B/D PA

mycophenolate mofetil oral suspension for reconstitution

5 B/D PA

mycophenolate mofetil oral tablet

2 B/D PA

mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg

2 B/D PA

MYCOPHENOLATE SODIUM ORAL TABLET,DELAYED RELEASE (DR/EC) 360 MG

4 B/D PA

NAVELBINE INTRAVENOUS SOLUTION 10 MG/ML

3

NERLYNX ORAL TABLET

5 PA

NEXAVAR ORAL TABLET

5 PA

NILANDRON ORAL TABLET

3

nilutamide oral tablet

2

NINLARO ORAL CAPSULE

5 PA

Drug Name Drug Tier

Requirements/Limits

NIPENT INTRAVENOUS RECON SOLN

4

NULOJIX INTRAVENOUS RECON SOLN

5 B/D PA

octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml

5

octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml

4

octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml)

2

octreotide acetate injection syringe 500 mcg/ml (1 ml)

5

ODOMZO ORAL CAPSULE

5 PA; LA

ONCASPAR INJECTION SOLUTION

5

OPDIVO INTRAVENOUS SOLUTION

5

oxaliplatin intravenous recon soln

5

oxaliplatin intravenous solution 100 mg/20 ml

4


Drug Name Drug Tier

Requirements/Limits

oxaliplatin intravenous solution 50 mg/10 ml (5 mg/ml)

5

paclitaxel intravenous concentrate

2

PERJETA INTRAVENOUS SOLUTION

5

POMALYST ORAL CAPSULE


PORTRAZZA INTRAVENOUS SOLUTION

5

PROGRAF INTRAVENOUS SOLUTION

4 B/D PA

PURIXAN ORAL SUSPENSION

5

RAPAMUNE ORAL SOLUTION

4 B/D PA

REVLIMID ORAL CAPSULE

5 PA; LA

RITUXAN HYCELA SUBCUTANEOUS SOLUTION

5

RITUXAN INTRAVENOUS CONCENTRATE

5

RUBRACA ORAL TABLET

5 PA

RYDAPT ORAL CAPSULE

5 PA

Drug Name Drug Tier

Requirements/Limits

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

5

SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

5

SIGNIFOR SUBCUTANEOUS SOLUTION

5

SIMULECT INTRAVENOUS RECON SOLN

5

sirolimus oral tablet 4 B/D PA

SOLTAMOX ORAL SOLUTION

3

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE

5

SPRYCEL ORAL TABLET

5 PA

STIVARGA ORAL TABLET

5

SUPPRELIN LA IMPLANT KIT

4

SUTENT ORAL CAPSULE

5 PA


25

Drug Name Drug Tier

Requirements/Limits

SYLVANT INTRAVENOUS RECON SOLN

5 PA

SYNRIBO SUBCUTANEOUS RECON SOLN

5

TABLOID ORAL TABLET

3 PA

tacrolimus oral capsule 0.5 mg, 1 mg

2 B/D PA

tacrolimus oral capsule 5 mg

4 B/D PA

TAFINLAR ORAL CAPSULE

5 PA

TAGRISSO ORAL TABLET

5 PA; LA

tamoxifen oral tablet 2

TARCEVA ORAL TABLET

5 PA

TARGRETIN TOPICAL GEL

5 PA

TASIGNA ORAL CAPSULE

5 PA

TECENTRIQ INTRAVENOUS SOLUTION

5 PA

TEMODAR INTRAVENOUS RECON SOLN

5

THALOMID ORAL CAPSULE

5 PA

thiotepa injection recon soln

2

Drug Name Drug Tier

Requirements/Limits

toposar intravenous solution

2

topotecan intravenous recon soln

2

topotecan intravenous solution

2

TORISEL INTRAVENOUS RECON SOLN

5

TREANDA INTRAVENOUS RECON SOLN

5 PA

TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

5

TRELSTAR INTRAMUSCULAR SYRINGE

5

tretinoin (chemotherapy) oral capsule

5

TREXALL ORAL TABLET

3 B/D PA

TRISENOX INTRAVENOUS SOLUTION

4

TYKERB ORAL TABLET

5

VALSTAR INTRAVESICAL SOLUTION

5


Drug Name Drug Tier

Requirements/Limits

VECTIBIX INTRAVENOUS SOLUTION

5 PA

VELCADE INJECTION RECON SOLN

4

VENCLEXTA ORAL TABLET 10 MG, 50 MG

4 PA

VENCLEXTA ORAL TABLET 100 MG

5 PA

VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK

5 PA

vinblastine intravenous solution

2 B/D PA

vincasar pfs intravenous solution

2 B/D PA

vincristine intravenous solution

2 B/D PA

vinorelbine intravenous solution

2

VOTRIENT ORAL TABLET

5 PA

VYXEOS INTRAVENOUS RECON SOLN

5

XALKORI ORAL CAPSULE


XATMEP ORAL SOLUTION

5 B/D PA

Drug Name Drug Tier

Requirements/Limits

XTANDI ORAL CAPSULE

5 PA

YERVOY INTRAVENOUS SOLUTION

5 PA

YONDELIS INTRAVENOUS RECON SOLN

5 PA

ZALTRAP INTRAVENOUS SOLUTION

5

ZANOSAR INTRAVENOUS RECON SOLN

4

ZEJULA ORAL CAPSULE

5 PA

ZELBORAF ORAL TABLET


ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG

5

ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG

4

ZOLINZA ORAL CAPSULE

5 PA

ZORTRESS ORAL TABLET 0.25 MG

3 B/D PA

ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG

5 B/D PA

ZYDELIG ORAL TABLET

5 PA

ZYKADIA ORAL CAPSULE

5 PA


27

Drug Name Drug Tier

Requirements/Limits

ZYTIGA ORAL TABLET

5 PA

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

APTIOM ORAL TABLET

4

BANZEL ORAL SUSPENSION

3

BANZEL ORAL TABLET

3

BRIVIACT INTRAVENOUS SOLUTION

4 PA

BRIVIACT ORAL SOLUTION


BRIVIACT ORAL TABLET


carbamazepine oral capsule, er multiphase 12 hr

2

carbamazepine oral suspension 100 mg/5 ml

2

carbamazepine oral tablet

2

carbamazepine oral tablet extended release 12 hr

2

carbamazepine oral tablet,chewable

2

CELONTIN ORAL CAPSULE 300 MG

3

Drug Name Drug Tier

Requirements/Limits

CEREBYX INJECTION SOLUTION 500 MG PE/10 ML

4

clonazepam oral tablet

2

clonazepam oral tablet,disintegrating

2

DIASTAT ACUDIAL RECTAL KIT

4

DIASTAT RECTAL KIT

4

diazepam rectal kit 4

DILANTIN 30 MG ORAL CAPSULE

3

divalproex oral capsule, delayed rel sprinkle

2

divalproex oral tablet extended release 24 hr

2

divalproex oral tablet,delayed release (dr/ec)

2

epitol oral tablet 2

ethosuximide oral capsule

2

ethosuximide oral solution

2

felbamate oral suspension

4

felbamate oral tablet 4


Drug Name Drug Tier

Requirements/Limits

fosphenytoin injection solution

2

FYCOMPA ORAL SUSPENSION

4

FYCOMPA ORAL TABLET

4

gabapentin oral capsule

2

gabapentin oral solution

2

gabapentin oral tablet 600 mg, 800 mg

2

GABITRIL ORAL TABLET 12 MG, 16 MG

3

LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK

3

LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK

3

LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK

3

lamotrigine oral tablet

4

Drug Name Drug Tier

Requirements/Limits

lamotrigine oral tablet disintegrating, dose pk

2

lamotrigine oral tablet extended release 24hr

4

lamotrigine oral tablet, chewable dispersible

4

lamotrigine oral tablet,disintegrating

4

lamotrigine oral tablets,dose pack

2

LEVETIRACETAM IN NACL (ISO-OS) INTRAVENOUS PIGGYBACK

4 HI

levetiracetam intravenous solution

2

levetiracetam oral solution

2

levetiracetam oral tablet

2

levetiracetam oral tablet extended release 24 hr

2

LYRICA ORAL CAPSULE

4

LYRICA ORAL SOLUTION

4

ONFI ORAL SUSPENSION

4 QL (1440 per 90 days)

ONFI ORAL TABLET 10 MG, 20 MG



29

Drug Name Drug Tier

Requirements/Limits

oxcarbazepine oral suspension

2

oxcarbazepine oral tablet

2

PEGANONE ORAL TABLET

3

phenobarbital oral elixir

2

phenobarbital oral tablet

2

phenytoin oral suspension

2

phenytoin oral tablet,chewable

2

phenytoin sodium extended oral capsule

2

phenytoin sodium intravenous solution

2

phenytoin sodium intravenous syringe

2

primidone oral tablet

2

roweepra oral tablet 2

SABRIL ORAL POWDER IN PACKET

5

SABRIL ORAL TABLET

5

SPRITAM ORAL TABLET FOR SUSPENSION

4

tiagabine oral tablet 4

Drug Name Drug Tier

Requirements/Limits

topiramate oral capsule, sprinkle

2 PA

topiramate oral tablet

2 PA

valproate sodium intravenous solution

2

valproic acid (as sodium salt) oral solution

2

valproic acid oral capsule

2

vigabatrin oral powder in packet

5

VIMPAT INTRAVENOUS SOLUTION

4

VIMPAT ORAL SOLUTION

3

VIMPAT ORAL TABLET

3

zonisamide oral capsule

2 PA

ANTIPARKINSONISM AGENTS

APOKYN SUBCUTANEOUS CARTRIDGE

5

AZILECT ORAL TABLET

3

benztropine injection solution

2

benztropine oral tablet

2

bromocriptine oral capsule

2


Drug Name Drug Tier

Requirements/Limits

bromocriptine oral tablet

2

carbidopa oral tablet

4

carbidopa-levodopa oral tablet

2

carbidopa-levodopa oral tablet extended release

2

carbidopa-levodopa oral tablet,disintegrating

2

carbidopa-levodopa-entacapone oral tablet

4

DUOPA J-TUBE INTESTINAL PUMP SUSPENSION

4 PA

entacapone oral tablet

4

NEUPRO TRANSDERMAL PATCH 24 HOUR

4

pramipexole oral tablet

2

pramipexole oral tablet extended release 24 hr

4

rasagiline oral tablet 2

ropinirole oral tablet 2

ropinirole oral tablet extended release 24 hr

2

Drug Name Drug Tier

Requirements/Limits

selegiline hcl oral capsule

2

selegiline hcl oral tablet

2

tolcapone oral tablet 2

trihexyphenidyl oral elixir

2

trihexyphenidyl oral tablet

2

ZELAPAR ORAL TABLET,DISINTEGRATING

4

MIGRAINE / CLUSTER HEADACHE THERAPY

almotriptan malate oral tablet


dihydroergotamine nasal spray,non-aerosol


eletriptan hbr oral tablet


ERGOMAR SUBLINGUAL TABLET


ergotamine-caffeine oral tablet


frovatriptan oral tablet


migergot rectal suppository

2

naratriptan oral tablet


RELPAX ORAL TABLET

4 ST; QL (18 per 90 days)


31

Drug Name Drug Tier

Requirements/Limits

rizatriptan oral tablet


rizatriptan oral tablet,disintegrating


sumatriptan nasal spray,non-aerosol

4

sumatriptan succinate oral tablet

2

sumatriptan succinate subcutaneous cartridge

4

sumatriptan succinate subcutaneous pen injector

4

sumatriptan succinate subcutaneous solution

4

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml

4

zolmitriptan oral tablet


zolmitriptan oral tablet,disintegrating


ZOMIG NASAL SPRAY,NON-AEROSOL


MISCELLANEOUS NEUROLOGICAL THERAPY

Drug Name Drug Tier

Requirements/Limits

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR

5 PA

AUBAGIO ORAL TABLET

5 PA

COPAXONE SUBCUTANEOUS SYRINGE

5 PA

donepezil oral tablet 10 mg, 5 mg


donepezil oral tablet 23 mg


donepezil oral tablet,disintegrating


galantamine oral capsule,ext rel. pellets 24 hr

2

galantamine oral solution

2

galantamine oral tablet

2

GILENYA ORAL CAPSULE

5 PA

glatopa subcutaneous syringe

5

LEMTRADA INTRAVENOUS SOLUTION

5 PA

memantine oral solution

2 QL (1080 per 90 days)

memantine oral tablet



Drug Name Drug Tier

Requirements/Limits

MEMANTINE ORAL TABLETS,DOSE PACK


NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK


NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK


NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR


NUEDEXTA ORAL CAPSULE


RADICAVA INTRAVENOUS PIGGYBACK

5 PA

rivastigmine tartrate oral capsule

2

rivastigmine transdermal patch 24 hour


TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC)

5 PA

tetrabenazine oral tablet

5 PA

TYSABRI INTRAVENOUS SOLUTION

5 LA

Drug Name Drug Tier

Requirements/Limits

MUSCLE RELAXANTS / ANTISPASMODIC THERAPY

baclofen oral tablet 2

cyclobenzaprine oral tablet

2

DANTRIUM INTRAVENOUS RECON SOLN

4

dantrolene oral capsule

2

enlon injection solution

2

ENLON-PLUS INTRAVENOUS SOLUTION

4

LIORESAL INTRATHECAL SOLUTION

4 B/D PA

MESTINON ORAL SYRUP

3

metaxall oral tablet 2

neostigmine methylsulfate intravenous solution

2

pyridostigmine bromide oral tablet

2

pyridostigmine bromide oral tablet extended release

2

regonol injection solution

2

revonto intravenous recon soln

2


33

Drug Name Drug Tier

Requirements/Limits

tizanidine oral capsule

2

tizanidine oral tablet 2

NARCOTIC ANALGESICS

ABSTRAL SUBLINGUAL TABLET


acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml

2 QL (5167 per 31 days)

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg

2 QL (1080 per 90 days)

acetaminophen-codeine oral tablet 300-60 mg


BUPRENEX INJECTION SOLUTION


buprenorphine hcl injection solution


buprenorphine hcl injection syringe


buprenorphine hcl sublingual tablet 2 mg


buprenorphine hcl sublingual tablet 8 mg


Drug Name Drug Tier

Requirements/Limits

BUPRENORPHINE TRANSDERMAL PATCH WEEKLY


butalbital-aspirin-caffeine oral tablet

2

BUTRANS TRANSDERMAL PATCH WEEKLY


codeine sulfate oral tablet


diskets oral tablet,soluble

2

duramorph (pf) injection solution 0.5 mg/ml

2 QL (4133 per 31 days)

duramorph (pf) injection solution 1 mg/ml

2 QL (6000 per 90 days)

endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

2 QL (1080 per 90 days)

fentanyl citrate (pf) injection solution

2

FENTANYL CITRATE (PF) INTRAVENOUS SYRINGE 100 MCG/2 ML (50 MCG/ML)

3

fentanyl citrate buccal lozenge on a handle



Drug Name Drug Tier

Requirements/Limits

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr


FENTORA BUCCAL TABLET, EFFERVESCENT


hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

2 QL (5735 per 31 days)

hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

2 QL (1080 per 90 days)

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg


hydromorphone (pf) injection solution

2

hydromorphone injection solution

2

HYDROMORPHONE INJECTION SYRINGE 0.5 MG/0.5 ML

2

hydromorphone injection syringe 1 mg/ml, 2 mg/ml, 4 mg/ml

2

hydromorphone oral liquid

2 QL (4500 per 90 days)

Drug Name Drug Tier

Requirements/Limits

hydromorphone oral tablet 2 mg

2 QL (1350 per 90 days)





ibuprofen-oxycodone oral tablet


INFUMORPH P/F INJECTION SOLUTION

4

KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG


LAZANDA NASAL SPRAY,NON-AEROSOL


levorphanol tartrate oral tablet


lorcet (hydrocodone) oral tablet

2 QL (1080 per 90 days)

lorcet hd oral tablet 2 QL (1080 per 90 days)

lorcet plus oral tablet 7.5-325 mg

2 QL (1080 per 90 days)

marten-tab oral tablet

2

methadone injection solution


methadone intensol oral concentrate

2

methadone oral concentrate

2


35

Drug Name Drug Tier

Requirements/Limits

methadone oral solution 10 mg/5 ml

2 QL (1800 per 90 days)

methadone oral solution 5 mg/5 ml

2 QL (3600 per 90 days)

methadone oral tablet 10 mg


methadone oral tablet 5 mg


methadone oral tablet,soluble

2

methadose oral tablet,soluble

2

morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml

2

morphine (pf) intravenous patient control.analgesia soln

2

morphine concentrate oral solution


morphine injection syringe 10 mg/ml, 5 mg/ml, 8 mg/ml

4

morphine injection syringe 2 mg/ml, 4 mg/ml

2

morphine intravenous cartridge 10 mg/ml

4

morphine intravenous cartridge 2 mg/ml, 4 mg/ml

2

Drug Name Drug Tier

Requirements/Limits

MORPHINE INTRAVENOUS CARTRIDGE 8 MG/ML

4

morphine intravenous solution 10 mg/ml

2

MORPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ML

4

MORPHINE INTRAVENOUS SYRINGE 10 MG/ML, 8 MG/ML

4

morphine intravenous syringe 2 mg/ml, 4 mg/ml

2

morphine oral capsule, er multiphase 24 hr


morphine oral capsule,extend.release pellets 10 mg, 20 mg, 30 mg


morphine oral capsule,extend.release pellets 100 mg, 50 mg, 60 mg, 80 mg


morphine oral solution

2 QL (2700 per 90 days)

morphine oral tablet 2 QL (540 per 90 days)


Drug Name Drug Tier

Requirements/Limits

morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg


morphine oral tablet extended release 200 mg


OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR


OPANA INJECTION SOLUTION

4

oxycodone oral capsule

2 QL (1080 per 90 days)

oxycodone oral concentrate


oxycodone oral solution

4 QL (3600 per 90 days)

OXYCODONE ORAL SYRINGE


oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg


oxycodone oral tablet 5 mg

2 QL (1080 per 90 days)

oxycodone-acetaminophen oral solution

2 QL (1891 per 31 days)

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

2 QL (1080 per 90 days)

Drug Name Drug Tier

Requirements/Limits

oxycodone-aspirin oral tablet

2 QL (1080 per 90 days)

oxymorphone oral tablet


oxymorphone oral tablet extended release 12 hr


SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL


xylon 10 oral tablet 2

zamicet oral solution 2 QL (5550 per 31 days)

NON-NARCOTIC ANALGESICS

buprenorphine-naloxone sublingual tablet

2

butorphanol tartrate injection solution 1 mg/ml

2 QL (2160 per 90 days)

butorphanol tartrate injection solution 2 mg/ml

2 QL (1080 per 90 days)

butorphanol tartrate nasal spray,non-aerosol


celecoxib oral capsule


clonidine (pf) epidural solution 5,000 mcg/10 ml

2

diclofenac potassium oral tablet

2


37

Drug Name Drug Tier

Requirements/Limits

diclofenac sodium oral tablet extended release 24 hr

2

diclofenac sodium oral tablet,delayed release (dr/ec)

2

diclofenac sodium topical gel 1 %

2

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic

2

diflunisal oral tablet 2

etodolac oral capsule

2

etodolac oral tablet 2

etodolac oral tablet extended release 24 hr

2

EVZIO INJECTION AUTO-INJECTOR

4

fenoprofen oral tablet

2

flurbiprofen oral tablet

2

ibuprofen oral suspension

1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

ketoprofen oral capsule

2

Drug Name Drug Tier

Requirements/Limits

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

2

meclofenamate oral capsule

4

mefenamic acid oral capsule

4

meloxicam oral tablet

1

nabumetone oral tablet

2

nalbuphine injection solution 10 mg/ml


nalbuphine injection solution 20 mg/ml


naloxone injection solution

2

naloxone injection syringe

2

naltrexone oral tablet

2

naproxen oral suspension

2

naproxen oral tablet 2

naproxen oral tablet,delayed release (dr/ec)

2

naproxen sodium oral tablet 275 mg, 550 mg

2

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

4


Drug Name Drug Tier

Requirements/Limits

NUCYNTA ORAL TABLET 100 MG



4 QL (1086 per 90 days)



oxaprozin oral tablet 2

piroxicam oral capsule

1

PRIALT INTRATHECAL SOLUTION

4

salsalate oral tablet 2

SUBOXONE SUBLINGUAL FILM

3

sulindac oral tablet 2

tolmetin oral capsule 2

tolmetin oral tablet 2

tramadol oral tablet 2 QL (720 per 90 days)

tramadol oral tablet extended release 24 hr


tramadol oral tablet, er multiphase 24 hr


tramadol-acetaminophen oral tablet

2 QL (1080 per 90 days)

Drug Name Drug Tier

Requirements/Limits

VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

5

PSYCHOTHERAPEUTIC DRUGS

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

5 ST

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING

5 ST

ADASUVE INHALATION AEROSOL POWDR BREATH ACTIVATED

4 ST

alprazolam intensol oral concentrate

2

alprazolam oral tablet

2

amitriptyline oral tablet

2 PA

amoxapine oral tablet

2

aripiprazole oral solution

4


39

Drug Name Drug Tier

Requirements/Limits

aripiprazole oral tablet

4

aripiprazole oral tablet,disintegrating

4

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING

5 ST

armodafinil oral tablet


atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg, 60 mg


atomoxetine oral capsule 100 mg, 80 mg


bupropion hcl oral tablet

1

bupropion hcl oral tablet extended release 12 hr

1

bupropion hcl oral tablet extended release 24 hr

1

buspirone oral tablet 2

chlorpromazine injection solution

4

chlorpromazine oral tablet

4

citalopram oral solution

1

Drug Name Drug Tier

Requirements/Limits

citalopram oral tablet

1

clomipramine oral capsule

4 PA

clonidine hcl oral tablet extended release 12 hr

2

clorazepate dipotassium oral tablet

2

clozapine oral tablet 2

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg

2

CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG

4

CLOZAPINE ORAL TABLET,DISINTEGRATING 200 MG

5

desipramine oral tablet

4

desvenlafaxine succinate oral tablet extended release 24 hr

4

dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg



Drug Name Drug Tier

Requirements/Limits

dexmethylphenidate oral tablet


dextroamphetamine oral capsule, extended release 10 mg, 5 mg


dextroamphetamine oral capsule, extended release 15 mg


dextroamphetamine oral solution

2

dextroamphetamine oral tablet 10 mg


dextroamphetamine oral tablet 5 mg


dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 5 mg


dextroamphetamine-amphetamine oral capsule,extended release 24hr 30 mg


dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg


dextroamphetamine-amphetamine oral tablet 30 mg


Drug Name Drug Tier

Requirements/Limits

diazepam oral solution 5 mg/5 ml (1 mg/ml)

2

diazepam oral tablet 2

doxepin oral capsule 2 PA

doxepin oral concentrate

2 PA

duloxetine oral capsule,delayed release(dr/ec)

2

EMSAM TRANSDERMAL PATCH 24 HOUR

4

ergoloid oral tablet 2

escitalopram oxalate oral solution

2

escitalopram oxalate oral tablet

2

FANAPT ORAL TABLET

4 ST

FANAPT ORAL TABLETS,DOSE PACK

4 ST

FAZACLO ORAL TABLET,DISINTEGRATING 150 MG, 200 MG

5

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK

4 ST

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR

4 ST


41

Drug Name Drug Tier

Requirements/Limits

fluoxetine oral capsule

2

fluoxetine oral capsule,delayed release(dr/ec)

2

fluoxetine oral solution

2

fluoxetine oral tablet 10 mg, 20 mg

2

fluphenazine decanoate injection solution

2

fluphenazine hcl injection solution

2

fluphenazine hcl oral concentrate

2

fluphenazine hcl oral elixir

2

fluphenazine hcl oral tablet

2

fluvoxamine oral capsule,extended release 24hr

2

fluvoxamine oral tablet

2

GEODON INTRAMUSCULAR RECON SOLN

4 ST

guanidine oral tablet 2

haloperidol decanoate intramuscular solution

2

Drug Name Drug Tier

Requirements/Limits

haloperidol lactate injection solution

2

haloperidol lactate oral concentrate

2

haloperidol oral tablet

2

HETLIOZ ORAL CAPSULE


imipramine hcl oral tablet

2 PA

imipramine pamoate oral capsule

2 PA

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML

5 ST

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML, 78 MG/0.5 ML

4 ST

INVEGA TRINZA INTRAMUSCULAR SYRINGE

5 ST

KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR

4 ST

LATUDA ORAL TABLET

4 ST

lithium carbonate oral capsule

1


Drug Name Drug Tier

Requirements/Limits

lithium carbonate oral tablet

1

lithium carbonate oral tablet extended release

1

lithium citrate oral solution 8 meq/5 ml

2

lorazepam intensol oral concentrate

2

lorazepam oral concentrate

2

lorazepam oral tablet

2

loxapine succinate oral capsule

2

maprotiline oral tablet

2

MARPLAN ORAL TABLET

4

metadate er oral tablet extended release


methamphetamine oral tablet

2 PA

methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, 20 mg, 40 mg, 60 mg


methylphenidate hcl oral capsule, er biphasic 30-70 30 mg, 50 mg


Drug Name Drug Tier

Requirements/Limits

methylphenidate hcl oral capsule,er biphasic 50-50 20 mg, 40 mg, 60 mg


methylphenidate hcl oral capsule,er biphasic 50-50 30 mg


methylphenidate hcl oral solution

2

methylphenidate hcl oral tablet


methylphenidate hcl oral tablet extended release 10 mg


methylphenidate hcl oral tablet extended release 20 mg


methylphenidate hcl oral tablet extended release 24hr


methylphenidate hcl oral tablet,chewable 10 mg


methylphenidate hcl oral tablet,chewable 2.5 mg, 5 mg


mirtazapine oral tablet

2

mirtazapine oral tablet,disintegrating

2

modafinil oral tablet 4 PA; QL (180 per 90 days)

nefazodone oral tablet

2


43

Drug Name Drug Tier

Requirements/Limits

nortriptyline oral capsule

4

nortriptyline oral solution

4

NUPLAZID ORAL TABLET

5 PA

olanzapine intramuscular recon soln

2

olanzapine oral tablet

2

olanzapine oral tablet,disintegrating

2

olanzapine-fluoxetine oral capsule

4

ORAP ORAL TABLET 2 MG

3

paliperidone oral tablet extended release 24hr

2

paroxetine hcl oral tablet

2

paroxetine hcl oral tablet extended release 24 hr

2

PAXIL ORAL SUSPENSION

4 ST

perphenazine oral tablet

2

phenelzine oral tablet

2

pimozide oral tablet 2

Drug Name Drug Tier

Requirements/Limits

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR

4 ST

protriptyline oral tablet

2

quetiapine oral tablet

2

quetiapine oral tablet extended release 24 hr

2

REXULTI ORAL TABLET

5 ST

RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML

4 ST

RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 37.5 MG/2 ML, 50 MG/2 ML

5 ST

risperidone oral solution

2

risperidone oral tablet

2

risperidone oral tablet,disintegrating

2

ROZEREM ORAL TABLET



Drug Name Drug Tier

Requirements/Limits

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET

4 ST

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR

4 ST

sertraline oral concentrate

2

sertraline oral tablet 2

STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG, 60 MG


STRATTERA ORAL CAPSULE 100 MG, 80 MG


temazepam oral capsule

2

thioridazine oral tablet

2 PA

thiothixene oral capsule

2

tranylcypromine oral tablet

4

trazodone oral tablet 1

triazolam oral tablet 2

trifluoperazine oral tablet

2

trimipramine oral capsule

2 PA

TRINTELLIX ORAL TABLET

4 ST

Drug Name Drug Tier

Requirements/Limits

venlafaxine oral capsule,extended release 24hr

2

venlafaxine oral tablet

2

VERSACLOZ ORAL SUSPENSION

5

VIIBRYD ORAL TABLET

4 ST

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)

4 ST

VRAYLAR ORAL CAPSULE

5 ST

VRAYLAR ORAL CAPSULE,DOSE PACK

4 ST

XYREM ORAL SOLUTION

5 PA; LA

zaleplon oral capsule


ziprasidone hcl oral capsule

2

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG

4 ST


45

Drug Name Drug Tier

Requirements/Limits

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG, 405 MG

5 ST

CARDIOVASCULAR, HYPERTENSION / LIPIDS

ANTIARRHYTHMIC AGENTS

adenosine intravenous solution

2

adenosine intravenous syringe

2

amiodarone intravenous solution

2

amiodarone intravenous syringe

2

amiodarone oral tablet

2

disopyramide phosphate oral capsule

2

dofetilide oral capsule

2

flecainide oral tablet 2

ibutilide fumarate intravenous solution

2

lidocaine (pf) in d7.5w intrathecal solution

2

lidocaine (pf) intravenous solution

2

Drug Name Drug Tier

Requirements/Limits

lidocaine (pf) intravenous syringe

2

mexiletine oral capsule

2

MULTAQ ORAL TABLET

3

NORPACE CR ORAL CAPSULE, EXTENDED RELEASE

4

pacerone oral tablet 100 mg, 200 mg, 400 mg

2

procainamide injection solution

2

propafenone oral capsule,extended release 12 hr

2

propafenone oral tablet

2

quinidine gluconate injection solution

2

quinidine gluconate oral tablet extended release

2

quinidine sulfate oral tablet

2

sorine oral tablet 2

sotalol af oral tablet 2

sotalol oral tablet 2

XYLOCAINE (CARDIAC) (PF) INTRAVENOUS SOLUTION

4


Drug Name Drug Tier

Requirements/Limits

ANTIHYPERTENSIVE THERAPY

acebutolol oral capsule

2

afeditab cr oral tablet extended release


amiloride oral tablet 1

amiloride-hydrochlorothiazide oral tablet

1

amlodipine oral tablet

1

amlodipine-benazepril oral capsule

1

amlodipine-olmesartan oral tablet


amlodipine-valsartan oral tablet

1

amlodipine-valsartan-hcthiazid oral tablet

1

atenolol oral tablet 1

atenolol-chlorthalidone oral tablet

1

AZOR ORAL TABLET


benazepril oral tablet

1

benazepril-hydrochlorothiazide oral tablet

1

Drug Name Drug Tier

Requirements/Limits

BENICAR HCT ORAL TABLET

3

BENICAR ORAL TABLET

3

betaxolol oral tablet 1

BIDIL ORAL TABLET

3

bisoprolol fumarate oral tablet

1

bisoprolol-hydrochlorothiazide oral tablet

1

BREVIBLOC INTRAVENOUS SOLUTION 100 MG/10 ML (10 MG/ML)

4

bumetanide injection solution

2

bumetanide oral tablet

1

candesartan oral tablet

1

candesartan-hydrochlorothiazid oral tablet

1

captopril oral tablet 1

captopril-hydrochlorothiazide oral tablet

1

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG

4


47

Drug Name Drug Tier

Requirements/Limits

CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR

4

cartia xt oral capsule,extended release 24hr

1

carvedilol oral tablet 1

chlorothiazide oral tablet

1

chlorothiazide sodium intravenous recon soln

2

chlorthalidone oral tablet 25 mg, 50 mg

1

CLEVIPREX INTRAVENOUS EMULSION

4

clonidine (pf) epidural solution 1,000 mcg/10 ml (100 mcg/ml)

2

clonidine hcl oral tablet

1

clonidine transdermal patch weekly

1

COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR


CORLOPAM INTRAVENOUS SOLUTION

4

Drug Name Drug Tier

Requirements/Limits

DEMSER ORAL CAPSULE

4

diltiazem hcl intravenous recon soln

2 HI

diltiazem hcl intravenous solution

2

diltiazem hcl oral capsule,ext.rel 24h degradable

1

diltiazem hcl oral capsule,extended release 12 hr

1

diltiazem hcl oral capsule,extended release 24 hr

1

diltiazem hcl oral capsule,extended release 24hr

1

diltiazem hcl oral tablet

1

diltiazem hcl oral tablet extended release 24 hr

1

dilt-xr oral capsule,ext.rel 24h degradable

1

doxazosin oral tablet 1

EDARBYCLOR ORAL TABLET

4

EDECRIN ORAL TABLET

3

enalapril maleate oral tablet

1


Drug Name Drug Tier

Requirements/Limits

enalaprilat intravenous solution

2

enalapril-hydrochlorothiazide oral tablet

1

eplerenone oral tablet

1

epoprostenol (glycine) intravenous recon soln

2

eprosartan oral tablet

1

esmolol intravenous solution

2

ethacrynic acid oral tablet

2

felodipine oral tablet extended release 24 hr


FLOLAN INTRAVENOUS RECON SOLN

4

fosinopril oral tablet 1

fosinopril-hydrochlorothiazide oral tablet

1

furosemide injection solution

2

furosemide injection syringe

2

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

1

Drug Name Drug Tier

Requirements/Limits

furosemide oral tablet

1

hydralazine injection solution

2

hydralazine oral tablet

1

hydrochlorothiazide oral capsule

1

hydrochlorothiazide oral tablet

1

indapamide oral tablet

1

irbesartan oral tablet

1

irbesartan-hydrochlorothiazide oral tablet

1

isradipine oral capsule

1

labetalol intravenous solution

4

labetalol oral tablet 1

lisinopril oral tablet 1

lisinopril-hydrochlorothiazide oral tablet

1

losartan oral tablet 1

losartan-hydrochlorothiazide oral tablet

1

matzim la oral tablet extended release 24 hr

1


49

Drug Name Drug Tier

Requirements/Limits

methyclothiazide oral tablet

2

methyldopa-hydrochlorothiazide oral tablet

2

methyldopate intravenous solution

2

metolazone oral tablet

1

metoprolol succinate oral tablet extended release 24 hr


metoprolol ta-hydrochlorothiaz oral tablet

1

metoprolol tartrate intravenous solution

2

metoprolol tartrate intravenous syringe

2

metoprolol tartrate oral tablet

1

minoxidil oral tablet 2

moexipril oral tablet 1

moexipril-hydrochlorothiazide oral tablet

1

nadolol oral tablet 1

nadolol-bendroflumethiazide oral tablet

1

nicardipine intravenous solution

4

nicardipine oral capsule

1

Drug Name Drug Tier

Requirements/Limits

nifedipine oral tablet extended release


nifedipine oral tablet extended release 24hr


nimodipine oral capsule

4

nisoldipine oral tablet extended release 24 hr

4

NYMALIZE ORAL SOLUTION

4

olmesartan oral tablet

1

olmesartan-hydrochlorothiazide oral tablet

1

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG

4 PA

ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG

5 PA

perindopril erbumine oral tablet

1

pindolol oral tablet 1

prazosin oral capsule

1

propranolol intravenous solution

2


Drug Name Drug Tier

Requirements/Limits

propranolol oral capsule,extended release 24 hr

1

propranolol oral solution

1

propranolol oral tablet

1

propranolol-hydrochlorothiazid oral tablet

1

quinapril oral tablet 1

quinapril-hydrochlorothiazide oral tablet

1

ramipril oral capsule

1

REMODULIN INJECTION SOLUTION

5 PA

spironolactone oral tablet

1

spironolacton-hydrochlorothiaz oral tablet

1

taztia xt oral capsule,extended release 24 hr

1

TEKTURNA HCT ORAL TABLET

4

TEKTURNA ORAL TABLET

4

telmisartan oral tablet

1

Drug Name Drug Tier

Requirements/Limits

telmisartan-amlodipine oral tablet

1

telmisartan-hydrochlorothiazid oral tablet

1

terazosin oral capsule

1

timolol maleate oral tablet

1

torsemide oral tablet 1

trandolapril oral tablet

1

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr

1

triamterene-hydrochlorothiazid oral capsule

1

triamterene-hydrochlorothiazid oral tablet

1

UPTRAVI ORAL TABLET

5 PA

UPTRAVI ORAL TABLETS,DOSE PACK

5 PA

valsartan oral tablet 1

valsartan-hydrochlorothiazide oral tablet

1

veletri intravenous recon soln

2


51

Drug Name Drug Tier

Requirements/Limits

verapamil intravenous solution

2

verapamil intravenous syringe

2

verapamil oral capsule, 24 hr er pellet ct

1

verapamil oral capsule,ext rel. pellets 24 hr

1

verapamil oral tablet 1

verapamil oral tablet extended release

1

CARDIAC GLYCOSIDES

digitek oral tablet 125 mcg


digitek oral tablet 250 mcg

2

digox oral tablet 125 mcg


digox oral tablet 250 mcg

2

digoxin injection solution

2

digoxin oral solution 50 mcg/ml

2

digoxin oral tablet 125 mcg


digoxin oral tablet 250 mcg

2

LANOXIN PEDIATRIC INJECTION SOLUTION

4

Drug Name Drug Tier

Requirements/Limits

COAGULATION THERAPY

aminocaproic acid intravenous solution

2

ARGATROBAN IN 0.9 % SOD CHLOR INTRAVENOUS PARENTERAL SOLUTION

4

ARGATROBAN INTRAVENOUS SOLUTION

4

aspirin-dipyridamole oral capsule, er multiphase 12 hr

4

BRILINTA ORAL TABLET

3

CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN

4

CEPROTIN (GREEN BAR) INTRAVENOUS RECON SOLN

4

cilostazol oral tablet 2

clopidogrel oral tablet

2

EFFIENT ORAL TABLET

3

ELIQUIS ORAL TABLET

3

enoxaparin subcutaneous solution

4


Drug Name Drug Tier

Requirements/Limits

enoxaparin subcutaneous syringe

4

fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

5

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml

4

FRAGMIN SUBCUTANEOUS SOLUTION

4

FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 7,500 ANTI-XA UNIT/0.3 ML

5

FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML

4

Drug Name Drug Tier

Requirements/Limits

heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

2

heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml

2

heparin (porcine) injection cartridge

2

heparin (porcine) injection solution

2

heparin (porcine) injection syringe 5,000 unit/ml

2

HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML

4

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml

2

heparin, porcine (pf) injection solution

2

heparin, porcine (pf) injection syringe

2

jantoven oral tablet 1


53

Drug Name Drug Tier

Requirements/Limits

NPLATE SUBCUTANEOUS RECON SOLN

5

pentoxifylline oral tablet extended release

2

PRADAXA ORAL CAPSULE

3

prasugrel oral tablet 2

PROMACTA ORAL TABLET

5 PA; LA

THROMBATE III INTRAVENOUS RECON SOLN

4

ticlopidine oral tablet

2

tranexamic acid intravenous solution

2

warfarin oral tablet 1

XARELTO ORAL TABLET

3

XARELTO ORAL TABLETS,DOSE PACK

3

LIPID/CHOLESTEROL LOWERING AGENTS

amlodipine-atorvastatin oral tablet

1

atorvastatin oral tablet

1

cholestyramine (with sugar) oral powder

2

Drug Name Drug Tier

Requirements/Limits

cholestyramine (with sugar) oral powder in packet

2

cholestyramine light oral powder

2

cholestyramine light oral powder in packet

2

colestipol oral granules

2

colestipol oral packet

2

colestipol oral tablet 2

ezetimibe oral tablet 2 QL (90 per 90 days)

ezetimibe-simvastatin oral tablet


fenofibrate micronized oral capsule

1

fenofibrate nanocrystallized oral tablet

1

fenofibrate oral tablet 160 mg, 54 mg

1

fenofibric acid (choline) oral capsule,delayed release(dr/ec)

1

fenofibric acid oral tablet

1

fluvastatin oral capsule

1


Drug Name Drug Tier

Requirements/Limits

fluvastatin oral tablet extended release 24 hr


gemfibrozil oral tablet

2

JUXTAPID ORAL CAPSULE

5 PA

KYNAMRO SUBCUTANEOUS SYRINGE

5 PA

LIPOFEN ORAL CAPSULE

4

LIVALO ORAL TABLET

4 ST

lovastatin oral tablet 1

niacin oral tablet extended release 24 hr

2

omega-3 acid ethyl esters oral capsule

2

pravastatin oral tablet 10 mg, 20 mg, 80 mg


pravastatin oral tablet 40 mg


prevalite oral powder

2

prevalite oral powder in packet

2

REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR

5 PA

Drug Name Drug Tier

Requirements/Limits

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR

5 PA

REPATHA SYRINGE SUBCUTANEOUS SYRINGE

5 PA

rosuvastatin oral tablet


simvastatin oral tablet


TRIGLIDE ORAL TABLET 160 MG

4

triklo oral capsule 2

VASCEPA ORAL CAPSULE

4

VYTORIN 10-10 ORAL TABLET








WELCHOL ORAL POWDER IN PACKET

3

WELCHOL ORAL TABLET

3

ZETIA ORAL TABLET


MISCELLANEOUS CARDIOVASCULAR AGENTS


55

Drug Name Drug Tier

Requirements/Limits

CORLANOR ORAL TABLET


dobutamine intravenous solution

2

dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/10 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/10 ml (80 mg/ml)

2

ISUPREL INJECTION SOLUTION

4

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR

4

VECAMYL ORAL TABLET

5 PA

NITRATES

isosorbide dinitrate oral tablet

1

isosorbide dinitrate oral tablet extended release

1

isosorbide mononitrate oral tablet

1

isosorbide mononitrate oral tablet extended release 24 hr

1

Drug Name Drug Tier

Requirements/Limits

nitro-bid transdermal ointment

2

nitroglycerin intravenous solution

2

nitroglycerin sublingual tablet

2

nitroglycerin transdermal patch 24 hour

2

nitroglycerin translingual aerosol,spray

4

nitroglycerin translingual spray,non-aerosol

4

NITROMIST TRANSLINGUAL AEROSOL,SPRAY

3

NITROSTAT SUBLINGUAL TABLET

4

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEIC

acitretin oral capsule

4

calcipotriene scalp solution

4

calcipotriene topical cream

4

calcipotriene topical ointment

4


Drug Name Drug Tier

Requirements/Limits

calcitrene topical ointment

2

calcitriol topical ointment

4

EPIFOAM TOPICAL FOAM

4

PRAMOSONE TOPICAL CREAM 1-1 %

4

PRAMOSONE TOPICAL LOTION

4

selenium sulfide topical lotion

2

STELARA INTRAVENOUS SOLUTION

5 PA

STELARA SUBCUTANEOUS SOLUTION

5 PA

STELARA SUBCUTANEOUS SYRINGE

5 PA

TACLONEX TOPICAL SUSPENSION

5

BURN THERAPY

silver sulfadiazine topical cream

2

ssd topical cream 2

MISCELLANEOUS DERMATOLOGICALS

ammonium lactate topical cream

2

Drug Name Drug Tier

Requirements/Limits

ammonium lactate topical lotion

2

CARAC TOPICAL CREAM

3

CONDYLOX TOPICAL GEL

3

diclofenac sodium topical gel 3 %

4

doxepin topical cream

2

ELIDEL TOPICAL CREAM

3

FLUOROURACIL TOPICAL CREAM 0.5 %

3

fluorouracil topical cream 5 %

2

fluorouracil topical solution

2

imiquimod topical cream in packet

2

methoxsalen oral capsule,liqd-filled,rapid rel

5

PANRETIN TOPICAL GEL

3

PICATO TOPICAL GEL 0.015 %


PICATO TOPICAL GEL 0.05 %


podofilox topical solution

2

tacrolimus topical ointment

4


57

Drug Name Drug Tier

Requirements/Limits

UVADEX INJECTION SOLUTION

4

VALCHLOR TOPICAL GEL

5

THERAPY FOR ACNE

adapalene topical cream

2

adapalene topical gel

2

adapalene topical gel with pump

2

adapalene-benzoyl peroxide topical gel with pump

4

amnesteem oral capsule

2

claravis oral capsule 4

clindacin etz topical swab

2

clindacin p topical swab

2

clindamycin phosphate topical gel

2

clindamycin phosphate topical lotion

2

clindamycin phosphate topical solution

2

clindamycin phosphate topical swab

2

Drug Name Drug Tier

Requirements/Limits

clindamycin-benzoyl peroxide topical gel

2

clindamycin-benzoyl peroxide topical gel with pump

2

DIFFERIN TOPICAL LOTION

3

ery pads topical swab

2

erygel topical gel 2

erythromycin with ethanol topical gel

2

erythromycin with ethanol topical solution

2

erythromycin with ethanol topical swab

2

erythromycin-benzoyl peroxide topical gel

2

FINACEA TOPICAL GEL

4

metronidazole topical cream

2

metronidazole topical gel

2

metronidazole topical gel with pump

2

metronidazole topical lotion

2

neuac topical gel 2

rosadan topical cream

2


Drug Name Drug Tier

Requirements/Limits

rosadan topical gel 2

tazarotene topical cream

4

TAZORAC TOPICAL CREAM

4

TAZORAC TOPICAL GEL

4

tretinoin topical cream

2

tretinoin topical gel 2

TRETIN-X TOPICAL CREAM 0.075 %

4

TOPICAL ANESTHETICS

carbocaine (pf) injection solution 15 mg/ml (1.5 %)

2

CARBOCAINE INJECTION SOLUTION 2 %

4

chloroprocaine (pf) injection solution

4

glydo mucous membrane jelly in applicator

2

lidocaine (pf) injection solution

2

lidocaine hcl injection solution

2

lidocaine hcl laryngotracheal solution

2

lidocaine hcl mucous membrane jelly

2

Drug Name Drug Tier

Requirements/Limits

lidocaine hcl mucous membrane jelly in applicator

2

lidocaine hcl mucous membrane solution 4 % (40 mg/ml)

2

lidocaine hcl urethral gel

2

lidocaine topical adhesive patch,medicated


lidocaine topical ointment

4

lidocaine viscous mucous membrane solution

2

LIDOCAINE-EPINEPHRINE BIT INJECTION CARTRIDGE 2 %-1:50,000

4

lidocaine-epinephrine injection solution

2

lidocaine-prilocaine topical cream

2

MEPIVACAINE (PF) INJECTION CARTRIDGE

4

NAROPIN (PF) INJECTION SOLUTION

4

NESACAINE INJECTION SOLUTION 10 MG/ML (1 %)

4


59

Drug Name Drug Tier

Requirements/Limits

relador pak plus topical kit

2

relador pak topical kit

2

ropivacaine (pf) injection solution 2 mg/ml (0.2 %)

2

ropivacaine (pf) injection solution 5 mg/ml (0.5 %)

4

xylocaine dental-epinephrine injection cartridge

2

XYLOCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 1 %-1:200,000

4

TOPICAL ANTIBACTERIALS

CENTANY TOPICAL OINTMENT

4

gentamicin topical cream

2

gentamicin topical ointment

2

mupirocin calcium topical cream

2

mupirocin topical ointment

2

sulfacetamide sodium (acne) topical suspension

2

SULFAMYLON TOPICAL CREAM

4

Drug Name Drug Tier

Requirements/Limits

TOPICAL ANTIFUNGALS

ciclodan topical cream

2

ciclodan topical solution

2

ciclopirox topical cream

2

ciclopirox topical gel

2

ciclopirox topical shampoo

2

ciclopirox topical solution

2

ciclopirox topical suspension

2

clotrimazole topical cream

2

clotrimazole topical solution

2

clotrimazole-betamethasone topical cream

2

clotrimazole-betamethasone topical lotion

2

econazole topical cream

4

ERTACZO TOPICAL CREAM

4

EXELDERM TOPICAL CREAM

4

EXELDERM TOPICAL SOLUTION

4


Drug Name Drug Tier

Requirements/Limits

ketoconazole topical cream

2

ketoconazole topical foam

2

ketoconazole topical shampoo

2

MENTAX TOPICAL CREAM

4

naftifine topical cream

2

NAFTIN TOPICAL GEL

4

nyamyc topical powder

2

nyata topical powder 2

nystatin topical cream

2

nystatin topical ointment

2

nystatin topical powder

2

nystatin-triamcinolone topical cream

2

nystatin-triamcinolone topical ointment

2

nystop topical powder

2

oxiconazole topical cream

2

OXISTAT TOPICAL LOTION

4

Drug Name Drug Tier

Requirements/Limits

TOPICAL ANTIVIRALS

acyclovir topical ointment

2

DENAVIR TOPICAL CREAM

4

ZOVIRAX TOPICAL CREAM

3

TOPICAL CORTICOSTEROIDS

alclometasone topical cream

2

alclometasone topical ointment

2

amcinonide topical cream

4

amcinonide topical lotion

4

amcinonide topical ointment

4

apexicon e topical cream

4

betamethasone dipropionate topical cream

2

betamethasone dipropionate topical lotion

2

betamethasone dipropionate topical ointment

2

betamethasone valerate topical cream

2


61

Drug Name Drug Tier

Requirements/Limits

betamethasone valerate topical lotion

2

betamethasone valerate topical ointment

2

betamethasone, augmented topical cream

2

betamethasone, augmented topical gel

2

betamethasone, augmented topical lotion

2

betamethasone, augmented topical ointment

2

CAPEX TOPICAL SHAMPOO

3

clobetasol scalp solution

4

clobetasol topical cream

4

clobetasol topical foam

4

clobetasol topical gel

4

clobetasol topical lotion

4

clobetasol topical ointment

4

clobetasol topical shampoo

4

Drug Name Drug Tier

Requirements/Limits

clobetasol topical spray,non-aerosol

4

clobetasol-emollient topical cream

4

clobetasol-emollient topical foam

4

clodan topical shampoo

4

cormax scalp solution

2

desonide topical cream

4

desonide topical lotion

4

desonide topical ointment

4

desoximetasone topical cream

4

desoximetasone topical gel

4

desoximetasone topical ointment

4

diflorasone topical cream

4

diflorasone topical ointment

4

fluocinolone and shower cap scalp oil

2

fluocinolone topical cream

2

fluocinolone topical oil

2


Drug Name Drug Tier

Requirements/Limits

fluocinolone topical ointment

2

fluocinolone topical solution

2

fluocinonide topical cream

4

fluocinonide topical gel

4

fluocinonide topical ointment

4

fluocinonide topical solution

4

fluocinonide-e topical cream

4

fluocinonide-emollient topical cream

4

flurandrenolide topical cream

4

flurandrenolide topical lotion

4

FLURANDRENOLIDE TOPICAL OINTMENT

4

fluticasone topical cream

2

fluticasone topical lotion

2

fluticasone topical ointment

2

halobetasol propionate topical cream

2

Drug Name Drug Tier

Requirements/Limits

halobetasol propionate topical ointment

2

hydrocortisone butyrate topical cream

2

hydrocortisone butyrate topical ointment

2

hydrocortisone butyrate topical solution

2

hydrocortisone butyr-emollient topical cream

2

hydrocortisone topical cream 1 %, 2.5 %

2

hydrocortisone topical lotion 2.5 %

2

hydrocortisone topical ointment 1 %, 2.5 %

2

hydrocortisone valerate topical cream

2

hydrocortisone valerate topical ointment

2

hydrocortisone-min oil-wht pet topical ointment

2

mometasone topical cream

2


63

Drug Name Drug Tier

Requirements/Limits

mometasone topical ointment

2

mometasone topical solution

2

nolix topical lotion 2

PANDEL TOPICAL CREAM

4

prednicarbate topical ointment

2

triamcinolone acetonide topical cream

2

triamcinolone acetonide topical lotion

2

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

2

trianex topical ointment

2

triderm topical cream

2

TOPICAL ENZYMES

SANTYL TOPICAL OINTMENT

3

TOPICAL SCABICIDES / PEDICULICIDES

EURAX TOPICAL CREAM

3

EURAX TOPICAL LOTION

3

lindane topical shampoo

2

Drug Name Drug Tier

Requirements/Limits

malathion topical lotion

4

permethrin topical cream

2

SKLICE TOPICAL LOTION

4

DIAGNOSTICS / MISCELLANEOUS AGENTS

ANTIDOTES

acetylcysteine intravenous solution

2

PROTOPAM CHLORIDE INJECTION RECON SOLN

4

IRRIGATING SOLUTIONS

lactated ringers irrigation solution

2

neomycin-polymyxin b gu irrigation solution

2

ringer's irrigation solution

2

SORBITOL IRRIGATION SOLUTION

4

MISCELLANEOUS AGENTS

acamprosate oral tablet,delayed release (dr/ec)

2

acetic acid irrigation solution

2


Drug Name Drug Tier

Requirements/Limits

ADAGEN INTRAMUSCULAR SOLUTION

5

alendronate oral tablet 40 mg


AMMONUL INTRAVENOUS SOLUTION

4

anagrelide oral capsule

2

ARALAST NP INTRAVENOUS RECON SOLN

5 PA

AURYXIA ORAL TABLET

5

BUPHENYL ORAL TABLET

4

caffeine citrate intravenous solution

2

caffeine citrate oral solution

2

CARBAGLU ORAL TABLET, DISPERSIBLE

5 LA

cevimeline oral capsule

2

CHEMET ORAL CAPSULE

3

d10 %-0.45 % sodium chloride intravenous parenteral solution

2

Drug Name Drug Tier

Requirements/Limits

d2.5 %-0.45 % sodium chloride intravenous parenteral solution

2

d5 % and 0.9 % sodium chloride intravenous parenteral solution

2

d5 %-0.45 % sodium chloride intravenous parenteral solution

2

deferoxamine injection recon soln

2

dextrose 10 % in water (d10w) intravenous parenteral solution

2


2

dextrose 25 % in water (d25w) intravenous syringe

2


2


2


2


65

Drug Name Drug Tier

Requirements/Limits

dextrose 5 % in water (d5w) intravenous piggyback

2

dextrose 5 %-lactated ringers intravenous parenteral solution

2

dextrose 5%-0.2 % sod chloride intravenous parenteral solution

2

dextrose 5%-0.3 % sod.chloride intravenous parenteral solution

2


2

dextrose 50 % in water (d50w) intravenous syringe

2


2

dextrose with sodium chloride intravenous parenteral solution

2

disulfiram oral tablet

2

etidronate disodium oral tablet

2

Drug Name Drug Tier

Requirements/Limits

EXJADE ORAL TABLET, DISPERSIBLE

5

FERRIPROX ORAL SOLUTION

5

FERRIPROX ORAL TABLET

5

FOSRENOL ORAL POWDER IN PACKET

4

FOSRENOL ORAL TABLET,CHEWABLE

4

GLASSIA INTRAVENOUS SOLUTION

4 PA

INCRELEX SUBCUTANEOUS SOLUTION

5 PA

JADENU ORAL TABLET

5

JADENU SPRINKLE ORAL GRANULES IN PACKET

5

kionex (with sorbitol) oral suspension

2

kionex oral powder 2

lanthanum oral tablet,chewable

4

levocarnitine (with sugar) oral solution

2 B/D PA

levocarnitine oral tablet

2 B/D PA


Drug Name Drug Tier

Requirements/Limits

md-gastroview oral solution

2

METOPIRONE ORAL CAPSULE

3

midodrine oral tablet

2

NORTHERA ORAL CAPSULE

5

ORFADIN ORAL CAPSULE

5

ORFADIN ORAL SUSPENSION

5

pilocarpine hcl oral tablet

2

PROLASTIN-C INTRAVENOUS RECON SOLN

5 PA

RAVICTI ORAL LIQUID

5 PA

RENAGEL ORAL TABLET

3

RENVELA ORAL POWDER IN PACKET

3

RENVELA ORAL TABLET

3

riluzole oral tablet 2

risedronate oral tablet 30 mg

2

sevelamer carbonate oral powder in packet

2

sevelamer carbonate oral tablet

2

Drug Name Drug Tier

Requirements/Limits

sodium benzoate-sod phenylacet intravenous solution

2

sodium chloride 0.9 % intravenous parenteral solution

2

sodium chloride 0.9 % intravenous piggyback

2

sodium chloride irrigation solution

2

sodium phenylbutyrate oral powder

2

sodium phenylbutyrate oral tablet

2

sodium polystyrene (sorb free) oral suspension

2

sodium polystyrene sulfonate oral powder

2

sodium polystyrene sulfonate oral suspension

2

sodium polystyrene sulfonate rectal enema 30 gram/120 ml

2

SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML

2


67

Drug Name Drug Tier

Requirements/Limits

SOLIRIS INTRAVENOUS SOLUTION

5

sps (with sorbitol) oral suspension

2

sps (with sorbitol) rectal enema

2

SYPRINE ORAL CAPSULE

4

VELTASSA ORAL POWDER IN PACKET

4

water for irrigation, sterile irrigation solution

2

ZEMAIRA INTRAVENOUS RECON SOLN

4 PA

zoledronic acid-mannitol-water intravenous piggyback

4

SMOKING DETERRENTS

bupropion hcl (smoking deter) oral tablet extended release 12 hr

1

CHANTIX CONTINUING MONTH BOX ORAL TABLET

3

CHANTIX ORAL TABLET

3

Drug Name Drug Tier

Requirements/Limits

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK

3

NICOTROL INHALATION CARTRIDGE

4

NICOTROL NS NASAL SPRAY,NON-AEROSOL

4

EAR, NOSE / THROAT MEDICATIONS

MISCELLANEOUS AGENTS

azelastine nasal aerosol,spray

2

azelastine nasal spray,non-aerosol

2

BACTROBAN NASAL OINTMENT

3

chlorhexidine gluconate mucous membrane mouthwash

2

CLINPRO 5000 DENTAL PASTE

4

denta 5000 plus dental cream

2

dentagel dental gel 2

ipratropium bromide nasal spray,non-aerosol

1


Drug Name Drug Tier

Requirements/Limits

olopatadine nasal spray,non-aerosol

2

oralone dental paste 2

paroex oral rinse mucous membrane mouthwash

2

periogard mucous membrane mouthwash

2

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE

4

PREVIDENT 5000 DRY MOUTH DENTAL GEL

4

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE

4

PREVIDENT 5000 SENSITIVE DENTAL PASTE

4

sf 5000 plus dental cream

2

sf dental gel 2

triamcinolone acetonide dental paste

2

MISCELLANEOUS OTIC PREPARATIONS

acetic acid otic (ear) solution

2

ciprofloxacin hcl otic (ear) dropperette

2

Drug Name Drug Tier

Requirements/Limits

floxin otic (ear) drops

2

fluocinolone acetonide oil otic (ear) drops

2

hydrocortisone-acetic acid otic (ear) drops

2

ofloxacin otic (ear) drops

2

OTIC STEROID / ANTIBIOTIC

CIPRO HC OTIC (EAR) DROPS,SUSPENSION

3

CIPRODEX OTIC (EAR) DROPS,SUSPENSION

3

COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION

4

neomycin-polymyxin-hc otic (ear) drops,suspension

2

neomycin-polymyxin-hc otic (ear) solution

2

ENDOCRINE/DIABETES

ADRENAL HORMONES

a-hydrocort injection recon soln

2


69

Drug Name Drug Tier

Requirements/Limits

ARISTOSPAN INTRA-ARTICULAR INJECTION SUSPENSION

4

betamethasone acet,sod phos injection suspension

2

cortisone oral tablet 2

deltasone oral tablet 20 mg

2

DEPO-MEDROL INJECTION SUSPENSION

4

dexamethasone intensol oral drops

2

dexamethasone oral elixir

1

dexamethasone oral solution

1

dexamethasone oral tablet

1

dexamethasone sodium phos (pf) injection solution

2

dexamethasone sodium phosphate injection solution 4 mg/ml

2

dexamethasone sodium phosphate injection syringe

2

Drug Name Drug Tier

Requirements/Limits

DEXPAK 10 DAY ORAL TABLETS,DOSE PACK

4


4


4

fludrocortisone oral tablet

1

hydrocortisone oral tablet

1

methylprednisolone acetate injection suspension

2

methylprednisolone oral tablet

1

methylprednisolone oral tablets,dose pack

1

methylprednisolone sodium succ injection recon soln 125 mg, 40 mg

2

methylprednisolone sodium succ intravenous recon soln

2

prednisolone oral solution 15 mg/5 ml

2


Drug Name Drug Tier

Requirements/Limits

prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

2

prednisolone sodium phosphate oral tablet,disintegrating 15 mg, 30 mg

2

prednisone intensol oral concentrate

1

prednisone oral solution

1

prednisone oral tablet

1

prednisone oral tablets,dose pack

1

SOLU-CORTEF (PF) INJECTION RECON SOLN

4

SOLU-CORTEF INJECTION RECON SOLN

4

SOLU-MEDROL (PF) INJECTION RECON SOLN

4

SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN 1,000 MG/8 ML

4

Drug Name Drug Tier

Requirements/Limits

SOLU-MEDROL INTRAVENOUS RECON SOLN 1,000 MG, 500 MG

4

triamcinolone acetonide injection suspension

2

ANTITHYROID AGENTS

methimazole oral tablet 10 mg, 5 mg

2

propylthiouracil oral tablet

2

DIABETES THERAPY

acarbose oral tablet 2

alcohol pads topical pads, medicated

2

APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN

3 ST

APIDRA SUBCUTANEOUS SOLUTION

3 ST

AVANDIA ORAL TABLET 2 MG, 4 MG


BD INSULIN PEN NEEDLE UF MINI NEEDLE


BD INSULIN PEN NEEDLE UF ORIG NEEDLE


BD INSULIN PEN NEEDLE UF SHORT NEEDLE



71

Drug Name Drug Tier

Requirements/Limits

BD ULTRA-FINE NANO PEN NEEDLES NEEDLE


BYDUREON SUBCUTANEOUS PEN INJECTOR


BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON


BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML

3 PA; QL (7.2 per 90 days)

BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML


CYCLOSET ORAL TABLET


FARXIGA ORAL TABLET

3 ST

GAUZE PADS 2 X 2

2

glimepiride oral tablet

1

glipizide oral tablet 1

glipizide oral tablet extended release 24hr

1

glipizide-metformin oral tablet

1

Drug Name Drug Tier

Requirements/Limits

GLUCAGEN HYPOKIT INJECTION RECON SOLN

3

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT

3

HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS INSULIN PEN, HALF-UNIT

3 ST

HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN

3 ST

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN

3 ST

HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION

3 ST

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN

3 ST

HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION

3 ST

HUMALOG SUBCUTANEOUS CARTRIDGE

3 ST


Drug Name Drug Tier

Requirements/Limits

HUMALOG SUBCUTANEOUS SOLUTION

3 ST

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN

3 ST

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION

3 ST

HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN

3 ST

HUMULIN N SUBCUTANEOUS SUSPENSION

3 ST

HUMULIN R U-100 INJECTION SOLUTION

3 ST

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN

3 ST

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION

3 ST

INSULIN PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 5/16"


Drug Name Drug Tier

Requirements/Limits

INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 ML, 1/2 ML


INVOKAMET ORAL TABLET

3 ST

INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR

3 ST

INVOKANA ORAL TABLET

3 ST

JANUMET ORAL TABLET


JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR


JANUVIA ORAL TABLET


KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG


KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG


LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN

2


73

Drug Name Drug Tier

Requirements/Limits

LANTUS SUBCUTANEOUS SOLUTION

2

LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN

2

LEVEMIR SUBCUTANEOUS SOLUTION

2

metformin oral tablet

1

metformin oral tablet extended release 24 hr

1

metformin oral tablet extended release (osm) 24 hr 500 mg

1

metformin oral tablet,er gast.retention 24 hr 500 mg

1

miglitol oral tablet 2

MONOJECT INSULIN SAFETY SYRING SYRINGE 29 GAUGE X 1/2"

2

nateglinide oral tablet

2

NEEDLES, INSULIN DISP.,SAFETY


NOVOFINE 30 NEEDLE


Drug Name Drug Tier

Requirements/Limits

NOVOFINE 32 NEEDLE


NOVOFINE PLUS NEEDLE


NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION

2

NOVOLIN N SUBCUTANEOUS SUSPENSION

2

NOVOLIN R INJECTION SOLUTION

2

NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN

2

NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN

2

NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION

2

NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE

2

NOVOLOG SUBCUTANEOUS SOLUTION

2

NOVOTWIST NEEDLE 32 GAUGE X 1/5"



Drug Name Drug Tier

Requirements/Limits

ONGLYZA ORAL TABLET


PEN NEEDLE NEEDLE 29 GAUGE X 1/2", 31 GAUGE X 1/4", 31 GAUGE X 3/16"


pioglitazone oral tablet


pioglitazone-glimepiride oral tablet


pioglitazone-metformin oral tablet


PROGLYCEM ORAL SUSPENSION

4

repaglinide oral tablet

1

repaglinide-metformin oral tablet

2

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR

4 PA

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR

4 PA

TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN

3

VGO 20 DEVICE 3

VGO 30 DEVICE 3

Drug Name Drug Tier

Requirements/Limits

VGO 40 DEVICE 3

VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR


VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR


XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR

3 ST

MISCELLANEOUS HORMONES

ALDURAZYME INTRAVENOUS SOLUTION

5

ANADROL-50 ORAL TABLET

4 PA

ANDRODERM TRANSDERMAL PATCH 24 HOUR


ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)

3 PA

ANDROGEL TRANSDERMAL GEL IN PACKET

3 PA

ANDROID ORAL CAPSULE

4

cabergoline oral tablet

2


75

Drug Name Drug Tier

Requirements/Limits

calcitonin (salmon) nasal spray,non-aerosol

2

calcitriol intravenous solution 1 mcg/ml

2 B/D PA

calcitriol oral capsule

2 B/D PA

calcitriol oral solution

2 B/D PA

CERDELGA ORAL CAPSULE

5

CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

5

chorionic gonadotropin, human intramuscular recon soln

2 PA

clomiphene citrate oral tablet

2

danazol oral capsule 2

desmopressin injection solution

4

desmopressin nasal aerosol,spray

4

desmopressin nasal solution

4

desmopressin nasal spray,non-aerosol

4

desmopressin oral tablet

2

Drug Name Drug Tier

Requirements/Limits

doxercalciferol intravenous solution

4 B/D PA

doxercalciferol oral capsule

4 B/D PA

ELAPRASE INTRAVENOUS SOLUTION

5

ELELYSO INTRAVENOUS RECON SOLN

5

FABRAZYME INTRAVENOUS RECON SOLN

5

HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML (1 ML)

4

KANUMA INTRAVENOUS SOLUTION

5 PA

KORLYM ORAL TABLET

5 PA

KUVAN ORAL POWDER IN PACKET

5 PA

KUVAN ORAL TABLET,SOLUBLE

5 PA

METHITEST ORAL TABLET

4

methyltestosterone oral capsule

2

MIACALCIN INJECTION SOLUTION

3 B/D PA


Drug Name Drug Tier

Requirements/Limits

MYALEPT SUBCUTANEOUS RECON SOLN

5 PA

NAGLAZYME INTRAVENOUS SOLUTION

5

NATPARA SUBCUTANEOUS CARTRIDGE

5 PA

novarel intramuscular recon soln 10,000 unit

2 PA

NOVAREL INTRAMUSCULAR RECON SOLN 5,000 UNIT

2 PA

oxandrolone oral tablet

2 PA

pamidronate intravenous recon soln

2

pamidronate intravenous solution

2

PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION

4

PARICALCITOL INTRAVENOUS SOLUTION

4 B/D PA

paricalcitol oral capsule

2 B/D PA

SAMSCA ORAL TABLET

5 PA

Drug Name Drug Tier

Requirements/Limits

SENSIPAR ORAL TABLET 30 MG

3

SENSIPAR ORAL TABLET 60 MG, 90 MG

5

SOMAVERT SUBCUTANEOUS RECON SOLN

5 PA

STIMATE NASAL SPRAY,NON-AEROSOL

3

STRENSIQ SUBCUTANEOUS SOLUTION

5 PA

SYNAREL NASAL SPRAY,NON-AEROSOL

3

TESTIM TRANSDERMAL GEL

4 PA

TESTOPEL IMPLANT PELLET

4

testosterone cypionate intramuscular oil

2

testosterone enanthate intramuscular oil

2

TESTOSTERONE TRANSDERMAL GEL

4 PA

TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP

4 PA


77

Drug Name Drug Tier

Requirements/Limits

testosterone transdermal gel in packet 1 % (25 mg/2.5gram)

4 PA

TESTOSTERONE TRANSDERMAL GEL IN PACKET 1 % (50 MG/5 GRAM)

4 PA

testosterone transdermal solution in metered pump w/app

4 PA

TESTRED ORAL CAPSULE

4

VPRIV INTRAVENOUS RECON SOLN

5

ZAVESCA ORAL CAPSULE

5

ZEMPLAR INTRAVENOUS SOLUTION

4 B/D PA

zoledronic acid intravenous recon soln

4

zoledronic acid intravenous solution

4

THYROID HORMONES

levothyroxine intravenous recon soln 200 mcg, 500 mcg

1

levothyroxine oral tablet

1

Drug Name Drug Tier

Requirements/Limits

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

1

liothyronine intravenous solution

2

liothyronine oral tablet

1

np thyroid oral tablet

2

thyroid (pork) oral tablet

2

unithroid oral tablet 1

GASTROENTEROLOGY

ANTIDIARRHEALS / ANTISPASMODICS

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml

2

dicyclomine intramuscular solution

2

dicyclomine oral capsule

2

dicyclomine oral solution

2

dicyclomine oral tablet

2

diphenoxylate-atropine oral liquid

2

diphenoxylate-atropine oral tablet

2


Drug Name Drug Tier

Requirements/Limits

glycopyrrolate injection solution

2

glycopyrrolate oral tablet 1 mg, 2 mg

2

loperamide oral capsule

2

methscopolamine oral tablet

2

opium tincture oral tincture

2

paregoric oral liquid 2

MISCELLANEOUS GASTROINTESTINAL AGENTS

AKYNZEO ORAL CAPSULE

4 B/D PA

alosetron oral tablet 4 QL (180 per 90 days)

ALOXI INTRAVENOUS SOLUTION

4

AMITIZA ORAL CAPSULE


ANALPRAM-HC RECTAL CREAM 1-1 %

4

ANZEMET ORAL TABLET

4 B/D PA

aprepitant oral capsule

2 B/D PA

aprepitant oral capsule,dose pack

2 B/D PA

Drug Name Drug Tier

Requirements/Limits

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR

4

ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC)

3

balsalazide oral capsule

2

budesonide oral capsule,delayed,extend.release

4

CANASA RECTAL SUPPOSITORY

3

CHOLBAM ORAL CAPSULE

5 PA

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT

5 PA

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT

5 PA

CIMZIA SUBCUTANEOUS SYRINGE KIT

5 PA

colocort rectal enema

2

compro rectal suppository

2

constulose oral solution

2


79

Drug Name Drug Tier

Requirements/Limits

CORTIFOAM RECTAL FOAM

3

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

cromolyn oral concentrate

4

CYSTADANE ORAL POWDER

4

DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS)

3

dimenhydrinate injection solution

2

DIPENTUM ORAL CAPSULE

4

dronabinol oral capsule

4 B/D PA

droperidol injection solution

2

EMEND (FOSAPREPITANT) INTRAVENOUS RECON SOLN

3

EMEND INTRAVENOUS RECON SOLN

3

EMEND ORAL CAPSULE

3 B/D PA

EMEND ORAL CAPSULE,DOSE PACK

3 B/D PA

Drug Name Drug Tier

Requirements/Limits

EMEND ORAL SUSPENSION FOR RECONSTITUTION

3 B/D PA

enulose oral solution 2

GATTEX 30-VIAL SUBCUTANEOUS KIT

5 PA

GATTEX ONE-VIAL SUBCUTANEOUS KIT

5 PA

gavilyte-c oral recon soln

2

gavilyte-g oral recon soln

2

gavilyte-n oral recon soln

2

generlac oral solution

2

GOLYTELY ORAL POWDER IN PACKET

4

granisetron (pf) intravenous solution

2

granisetron hcl intravenous solution

2

granisetron hcl oral tablet

2 B/D PA

hydrocortisone rectal enema

2

hydrocortisone topical cream with perineal applicator

2


Drug Name Drug Tier

Requirements/Limits

INFLECTRA INTRAVENOUS RECON SOLN

5 PA

lactulose oral solution

2

LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC)

4

LINZESS ORAL CAPSULE

3 PA

meclizine oral tablet 12.5 mg, 25 mg

2

mesalamine oral tablet,delayed release (dr/ec) 1.2 gram

4

mesalamine rectal enema

4

mesalamine with cleansing wipe rectal enema kit

4

metoclopramide hcl injection solution

2

metoclopramide hcl injection syringe

2

metoclopramide hcl oral solution

2

metoclopramide hcl oral tablet

2

MOVANTIK ORAL TABLET

4 PA

ondansetron hcl (pf) injection solution

2

Drug Name Drug Tier

Requirements/Limits

ondansetron hcl (pf) injection syringe

2

ondansetron hcl intravenous solution

2

ondansetron hcl oral solution

4 B/D PA

ondansetron hcl oral tablet

2 B/D PA

ondansetron oral tablet,disintegrating

2 B/D PA

PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800-56,800- 98,400 UNIT, 2,600-6,200- 10,850 UNIT, 21,000-54,700- 83,900 UNIT, 4,200-14,200- 24,600 UNIT

3

peg 3350-electrolytes oral recon soln

2

peg-electrolyte soln oral recon soln

2

PENTASA ORAL CAPSULE, EXTENDED RELEASE

3

PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC)

4


81

Drug Name Drug Tier

Requirements/Limits

polyethylene glycol 3350 oral powder

2

polyethylene glycol 3350 oral powder in packet

2

prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml)

2

prochlorperazine maleate oral tablet

2

prochlorperazine rectal suppository

2

PROCTOFOAM HC RECTAL FOAM

4

procto-med hc topical cream with perineal applicator

2

proctosol hc topical cream with perineal applicator

2

proctozone-hc topical cream with perineal applicator

2

RELISTOR ORAL TABLET

3 PA

RELISTOR SUBCUTANEOUS SOLUTION


RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML


Drug Name Drug Tier

Requirements/Limits

RELISTOR SUBCUTANEOUS SYRINGE 8 MG/0.4 ML


REMICADE INTRAVENOUS RECON SOLN

5 PA

SANCUSO TRANSDERMAL PATCH WEEKLY


scopolamine base transdermal patch 3 day

4

sulfasalazine oral tablet

1

sulfasalazine oral tablet,delayed release (dr/ec)

1

SUPREP BOWEL PREP KIT ORAL RECON SOLN

3

TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY

3

trilyte with flavor packets oral recon soln

2

ursodiol oral capsule

2

ursodiol oral tablet 2

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3


Drug Name Drug Tier

Requirements/Limits

ULCER THERAPY

esomeprazole sodium intravenous recon soln

2

famotidine (pf) intravenous solution

2

famotidine (pf)-nacl (iso-os) intravenous piggyback

2 HI

famotidine intravenous solution

2

famotidine oral suspension

2

famotidine oral tablet 20 mg, 40 mg

2

lansoprazole oral capsule,delayed release(dr/ec)

2

misoprostol oral tablet

2

nizatidine oral capsule

2

nizatidine oral solution

2

omeprazole oral capsule,delayed release(dr/ec)

2

pantoprazole intravenous recon soln

4

pantoprazole oral tablet,delayed release (dr/ec)

1

Drug Name Drug Tier

Requirements/Limits

PYLERA ORAL CAPSULE

4

ranitidine hcl injection solution

2

ranitidine hcl oral capsule

1

ranitidine hcl oral syrup

1

ranitidine hcl oral tablet 150 mg, 300 mg

1

sucralfate oral tablet 2

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

ACTIMMUNE SUBCUTANEOUS SOLUTION

5

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 300 MCG/ML

5 PA

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML, 60 MCG/ML

3 PA


83

Drug Name Drug Tier

Requirements/Limits

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML, 40 MCG/0.4 ML, 60 MCG/0.3 ML

3 PA

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML

5 PA

ARCALYST SUBCUTANEOUS RECON SOLN

5 PA

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT

5 PA

AVONEX INTRAMUSCULAR PEN INJECTOR KIT

5 PA

AVONEX INTRAMUSCULAR SYRINGE KIT

5 PA

BETASERON SUBCUTANEOUS KIT

5 PA

EGRIFTA SUBCUTANEOUS RECON SOLN

5

Drug Name Drug Tier

Requirements/Limits

EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

4 PA

EXTAVIA SUBCUTANEOUS KIT

5 PA

EXTAVIA SUBCUTANEOUS RECON SOLN

5 PA

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML

4 PA

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML

5 PA

GENOTROPIN SUBCUTANEOUS CARTRIDGE

5 PA


Drug Name Drug Tier

Requirements/Limits

GRANIX SUBCUTANEOUS SYRINGE

5

HUMATROPE INJECTION CARTRIDGE

5 PA

HUMATROPE INJECTION RECON SOLN

5 PA

ILARIS (PF) SUBCUTANEOUS RECON SOLN

5 PA

ILARIS (PF) SUBCUTANEOUS SOLUTION

5 PA

INTRON A INJECTION RECON SOLN

5

INTRON A INJECTION SOLUTION

5

LEUKINE INJECTION RECON SOLN

5

MOZOBIL SUBCUTANEOUS SOLUTION

5 PA

NEULASTA SUBCUTANEOUS SYRINGE


NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR


Drug Name Drug Tier

Requirements/Limits

NEUPOGEN INJECTION SOLUTION

5

NEUPOGEN INJECTION SYRINGE

5

NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR

5 PA

NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR

5 PA

OMNITROPE SUBCUTANEOUS CARTRIDGE

4 PA

OMNITROPE SUBCUTANEOUS RECON SOLN

5 PA

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR


PEGASYS SUBCUTANEOUS SOLUTION


PEGASYS SUBCUTANEOUS SYRINGE


PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 120 MCG/0.5 ML



85

Drug Name Drug Tier

Requirements/Limits

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML


PLEGRIDY SUBCUTANEOUS PEN INJECTOR

5 PA

PLEGRIDY SUBCUTANEOUS SYRINGE

5 PA

PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML

3 PA

PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML

5 PA

PROLEUKIN INTRAVENOUS RECON SOLN

5

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE

5 PA

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR

5 PA

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE

5 PA

Drug Name Drug Tier

Requirements/Limits

SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE

5 PA

SAIZEN SAIZENPREP SUBCUTANEOUS CARTRIDGE

5 PA

SAIZEN SUBCUTANEOUS RECON SOLN

5 PA

SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG

5 PA

SYLATRON SUBCUTANEOUS KIT

5 PA

ZARXIO INJECTION SYRINGE

5

ZORBTIVE SUBCUTANEOUS RECON SOLN

5 PA

VACCINES / MISCELLANEOUS IMMUNOLOGICALS

ACTHIB (PF) INTRAMUSCULAR RECON SOLN

3

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION

3


Drug Name Drug Tier

Requirements/Limits

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE

3

BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION

4

BEXSERO INTRAMUSCULAR SYRINGE

3

BIVIGAM INTRAVENOUS SOLUTION

5 B/D PA

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION

3

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE

3

CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM

5 B/D PA

CYTOGAM INTRAVENOUS SOLUTION 50 MG/ML

4

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION

3

Drug Name Drug Tier

Requirements/Limits

DYSPORT INTRAMUSCULAR RECON SOLN

4 PA

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION

3 B/D PA

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

3 B/D PA

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION

3 B/D PA

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

3 B/D PA

FLEBOGAMMA DIF INTRAVENOUS SOLUTION

5 B/D PA

fomepizole intravenous solution

2

GAMASTAN S/D INTRAMUSCULAR SOLUTION

3 B/D PA

GAMMAGARD LIQUID INJECTION SOLUTION

5 B/D PA

GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN

5 B/D PA


87

Drug Name Drug Tier

Requirements/Limits

GAMMAKED INJECTION SOLUTION

5 B/D PA

GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION

5 B/D PA

GAMMAPLEX INTRAVENOUS SOLUTION

5 B/D PA

GAMUNEX-C INJECTION SOLUTION

5 B/D PA

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION

3

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE

3

GRASTEK SUBLINGUAL TABLET

4

HAVRIX (PF) INTRAMUSCULAR SUSPENSION

3

HAVRIX (PF) INTRAMUSCULAR SYRINGE

3

HEPAGAM B INJECTION SOLUTION

3

HIBERIX (PF) INTRAMUSCULAR RECON SOLN

3

Drug Name Drug Tier

Requirements/Limits

HIZENTRA SUBCUTANEOUS SOLUTION

5 B/D PA

HYPERHEP B S/D INTRAMUSCULAR SOLUTION

3

HYPERHEP B S/D INTRAMUSCULAR SYRINGE

3

HYPERHEP B S-D NEONATAL INTRAMUSCULAR SYRINGE

3

HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION

3

HYPERTET S/D (PF) INTRAMUSCULAR SYRINGE

3

HYQVIA SUBCUTANEOUS SOLUTION

5 B/D PA

IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION

3

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN

3 B/D PA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

3


Drug Name Drug Tier

Requirements/Limits

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

3

IPOL INJECTION SUSPENSION

3

IXIARO (PF) INTRAMUSCULAR SYRINGE

3

KINRIX (PF) INTRAMUSCULAR SUSPENSION

3

KINRIX (PF) INTRAMUSCULAR SYRINGE

3

MENACTRA (PF) INTRAMUSCULAR SOLUTION

3

MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN

3

MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN

3

MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN

3

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT

3

M-M-R II (PF) SUBCUTANEOUS RECON SOLN

3

Drug Name Drug Tier

Requirements/Limits

NABI-HB INTRAMUSCULAR SOLUTION

3

OCTAGAM INTRAVENOUS SOLUTION

5 B/D PA

PEDIARIX (PF) INTRAMUSCULAR SYRINGE

3

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION

3

PENTACEL (PF) INTRAMUSCULAR KIT

3

PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN

3

PRIVIGEN INTRAVENOUS SOLUTION

5 B/D PA

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION

3

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

3


89

Drug Name Drug Tier

Requirements/Limits

RAGWITEK SUBLINGUAL TABLET

4

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION

3 B/D PA

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

3 B/D PA

RHOPHYLAC INJECTION SYRINGE

4

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION

3

ROTATEQ VACCINE ORAL SOLUTION

3

STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

TENIVAC (PF) INTRAMUSCULAR SUSPENSION

3

TENIVAC (PF) INTRAMUSCULAR SYRINGE

3

TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION

3

Drug Name Drug Tier

Requirements/Limits

TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION

3

THYMOGLOBULIN INTRAVENOUS RECON SOLN

5 B/D PA

TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION

4

TRUMENBA INTRAMUSCULAR SYRINGE

3

TWINRIX (PF) INTRAMUSCULAR SUSPENSION

3

TWINRIX (PF) INTRAMUSCULAR SYRINGE

3

TYPHIM VI INTRAMUSCULAR SOLUTION

3

TYPHIM VI INTRAMUSCULAR SYRINGE

3

VAQTA (PF) INTRAMUSCULAR SUSPENSION

3

VAQTA (PF) INTRAMUSCULAR SYRINGE

3


Drug Name Drug Tier

Requirements/Limits

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

VARIZIG INTRAMUSCULAR SOLUTION

3

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

allopurinol oral tablet

1

allopurinol sodium intravenous recon soln

2

COLCHICINE ORAL CAPSULE


COLCHICINE ORAL TABLET


COLCRYS ORAL TABLET


KRYSTEXXA INTRAVENOUS SOLUTION

5

Drug Name Drug Tier

Requirements/Limits

probenecid oral tablet

2

probenecid-colchicine oral tablet

2

ULORIC ORAL TABLET

3 ST

ZURAMPIC ORAL TABLET

4 PA

OSTEOPOROSIS THERAPY

alendronate oral solution

2

alendronate oral tablet 10 mg, 5 mg






BONIVA INTRAVENOUS SYRINGE

4 B/D PA

FORTEO SUBCUTANEOUS PEN INJECTOR

5 PA

FOSAMAX PLUS D ORAL TABLET


ibandronate intravenous solution

2

ibandronate intravenous syringe

2

ibandronate oral tablet



91

Drug Name Drug Tier

Requirements/Limits

PROLIA SUBCUTANEOUS SYRINGE

4 PA

raloxifene oral tablet 1 QL (90 per 90 days)



risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack)



2

TYMLOS SUBCUTANEOUS PEN INJECTOR

3

OTHER RHEUMATOLOGICALS

BENLYSTA INTRAVENOUS RECON SOLN

5

BENLYSTA SUBCUTANEOUS AUTO-INJECTOR

5

BENLYSTA SUBCUTANEOUS SYRINGE

5

DEPEN TITRATABS ORAL TABLET

4

ENBREL SUBCUTANEOUS RECON SOLN

5

ENBREL SUBCUTANEOUS SYRINGE

5

Drug Name Drug Tier

Requirements/Limits

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR

5

HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT

5

HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT

5

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT

5

HUMIRA SUBCUTANEOUS SYRINGE KIT

5

KINERET SUBCUTANEOUS SYRINGE


leflunomide oral tablet


ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR

5 PA

ORENCIA SUBCUTANEOUS SYRINGE

5 PA

OTEZLA ORAL TABLET

5 PA


Drug Name Drug Tier

Requirements/Limits

OTEZLA STARTER ORAL TABLETS,DOSE PACK

5 PA

OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 12.5 MG/0.4 ML, 17.5 MG/0.4 ML, 22.5 MG/0.4 ML

4

RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML

4

RIDAURA ORAL CAPSULE

3

SAVELLA ORAL TABLET

3

SAVELLA ORAL TABLETS,DOSE PACK

3

SIMPONI ARIA INTRAVENOUS SOLUTION

5 PA

SIMPONI SUBCUTANEOUS PEN INJECTOR

5 PA

Drug Name Drug Tier

Requirements/Limits

SIMPONI SUBCUTANEOUS SYRINGE

5 PA

XELJANZ ORAL TABLET

5 PA

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR

5 PA

OBSTETRICS / GYNECOLOGY

ESTROGENS / PROGESTINS

amabelz oral tablet 2

camila oral tablet 2

CRINONE VAGINAL GEL

3 PA

deblitane oral tablet 2

DEPO-ESTRADIOL INTRAMUSCULAR OIL

4

DEPO-PROVERA INTRAMUSCULAR SOLUTION

3

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE

4

errin oral tablet 2

ESTRACE VAGINAL CREAM

3

estradiol oral tablet 2 PA

estradiol vaginal tablet

2


93

Drug Name Drug Tier

Requirements/Limits

estradiol valerate intramuscular oil 20 mg/ml

2

ESTRING VAGINAL RING


FEMRING VAGINAL RING


heather oral tablet 2

hydroxyprogesterone caproate intramuscular oil

4

jencycla oral tablet 2

jinteli oral tablet 2

lyza oral tablet 2

MAKENA INTRAMUSCULAR OIL

5

medroxyprogesterone intramuscular suspension

2

medroxyprogesterone intramuscular syringe

2

medroxyprogesterone oral tablet

2

MENEST ORAL TABLET 1.25 MG

4 PA

norethindrone (contraceptive) oral tablet

2

norethindrone acetate oral tablet

2

Drug Name Drug Tier

Requirements/Limits

norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

2

norlyda oral tablet 2

norlyroc oral tablet 2

PREMARIN VAGINAL CREAM

3

progesterone micronized oral capsule

2

sharobel oral tablet 2

VAGIFEM VAGINAL TABLET

3

yuvafem vaginal tablet

2

MISCELLANEOUS OB/GYN

AVC VAGINAL VAGINAL CREAM

4

CLEOCIN VAGINAL SUPPOSITORY

4

clindamycin phosphate vaginal cream

2

CLINDESSE VAGINAL CREAM,EXTENDED RELEASE

4

GYNAZOLE-1 VAGINAL CREAM

4

metronidazole vaginal gel

2


Drug Name Drug Tier

Requirements/Limits

miconazole-3 vaginal suppository

2

NUVARING VAGINAL RING


terconazole vaginal cream

2

terconazole vaginal suppository

2

tranexamic acid oral tablet


vandazole vaginal gel

2

ORAL CONTRACEPTIVES / RELATED AGENTS

altavera (28) oral tablet

2

alyacen 1/35 (28) oral tablet

2

alyacen 7/7/7 (28) oral tablet

2

amethia lo oral tablets,dose pack,3 month


amethia oral tablets,dose pack,3 month


amethyst oral tablet 2

apri oral tablet 2

aranelle (28) oral tablet

2

ashlyna oral tablets,dose pack,3 month


Drug Name Drug Tier

Requirements/Limits

aubra oral tablet 2

aviane oral tablet 2

azurette (28) oral tablet

2

bekyree (28) oral tablet

2

briellyn oral tablet 2

camrese lo oral tablets,dose pack,3 month


camrese oral tablets,dose pack,3 month


caziant (28) oral tablet

2

chateal oral tablet 2

cyclafem 1/35 (28) oral tablet

2

cyclafem 7/7/7 (28) oral tablet

2

cyred oral tablet 2

dasetta 1/35 (28) oral tablet

2

dasetta 7/7/7 (28) oral tablet

2

daysee oral tablets,dose pack,3 month


delyla (28) oral tablet

2

desog-e.estradiol/e.estradiol oral tablet

2


95

Drug Name Drug Tier

Requirements/Limits

desogestrel-ethinyl estradiol oral tablet

2

drospirenone-ethinyl estradiol oral tablet

2

elinest oral tablet 2

ELLA ORAL TABLET


emoquette oral tablet

2

enpresse oral tablet 2

enskyce oral tablet 2

estarylla oral tablet 2

ethynodiol diac-eth estradiol oral tablet

2

falmina (28) oral tablet

2

fayosim oral tablets,dose pack,3 month

2

femynor oral tablet 2

gildagia oral tablet 2

introvale oral tablets,dose pack,3 month


isibloom oral tablet 2

jolessa oral tablets,dose pack,3 month


juleber oral tablet 2

junel 1.5/30 (21) oral tablet

2

junel 1/20 (21) oral tablet

2

Drug Name Drug Tier

Requirements/Limits

junel fe 1.5/30 (28) oral tablet

2

junel fe 1/20 (28) oral tablet

2

junel fe 24 oral tablet

2

kaitlib fe oral tablet,chewable

2

kariva (28) oral tablet

2

kimidess (28) oral tablet

2

kurvelo oral tablet 2

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 mcg (7)


l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg

2

larin 1.5/30 (21) oral tablet

2

larin 1/20 (21) oral tablet

2

larin 24 fe oral tablet

2

larin fe 1.5/30 (28) oral tablet

2


Drug Name Drug Tier

Requirements/Limits

larin fe 1/20 (28) oral tablet

2

larissia oral tablet 2

lessina oral tablet 2

levonest (28) oral tablet

2

levonorgestrel-ethinyl estrad oral tablet

2

levonorg-eth estrad triphasic oral tablet

2

lillow oral tablet 2

low-ogestrel (28) oral tablet

2

lutera (28) oral tablet

2

marlissa oral tablet 2

melodetta 24 fe oral tablet,chewable

2

mibelas 24 fe oral tablet,chewable

2

microgestin 1.5/30 (21) oral tablet

2

microgestin 1/20 (21) oral tablet

2

microgestin fe 1.5/30 (28) oral tablet

2

microgestin fe 1/20 (28) oral tablet

2

mono-linyah oral tablet

2

myzilra oral tablet 2

Drug Name Drug Tier

Requirements/Limits

necon 0.5/35 (28) oral tablet

2

next choice one dose oral tablet

2

nikki (28) oral tablet 2

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg

2

norethindrone-e.estradiol-iron oral tablet

2

norethindrone-e.estradiol-iron oral tablet,chewable

2

norgestimate-ethinyl estradiol oral tablet

2

nortrel 0.5/35 (28) oral tablet

2

nortrel 1/35 (21) oral tablet

2

nortrel 1/35 (28) oral tablet

2

ogestrel (28) oral tablet

2

orsythia oral tablet 2

philith oral tablet 2

pimtrea (28) oral tablet

2

pirmella oral tablet 2

previfem oral tablet 2

reclipsen (28) oral tablet

2


97

Drug Name Drug Tier

Requirements/Limits

rivelsa oral tablets,dose pack,3 month

2

sprintec (28) oral tablet

2

sronyx oral tablet 2

syeda oral tablet 2

tarina fe 1/20 (28) oral tablet

2

tilia fe oral tablet 2

tri femynor oral tablet

2

tri-estarylla oral tablet

2

tri-legest fe oral tablet

2

tri-linyah oral tablet 2

tri-lo-estarylla oral tablet

2

tri-lo-marzia oral tablet

2

tri-lo-sprintec oral tablet

2

trinessa lo oral tablet

2

tri-previfem (28) oral tablet

2

tri-sprintec (28) oral tablet

2

trivora (28) oral tablet

2

vestura (28) oral tablet

2

Drug Name Drug Tier

Requirements/Limits

vienva oral tablet 2

viorele (28) oral tablet

2

wera (28) oral tablet 2

wymzya fe oral tablet,chewable

2

zarah oral tablet 2

zovia 1/35e (28) oral tablet

2

zovia 1/50e (28) oral tablet

2

OXYTOCICS

HEMABATE INTRAMUSCULAR SOLUTION

4

methergine oral tablet

4

METHYLERGONOVINE INJECTION SOLUTION

4

OPHTHALMOLOGY

ANTIBIOTICS

AZASITE OPHTHALMIC (EYE) DROPS

4

bacitracin ophthalmic (eye) ointment

1

bacitracin-polymyxin b ophthalmic (eye) ointment

1


Drug Name Drug Tier

Requirements/Limits

BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION

4

CILOXAN OPHTHALMIC (EYE) OINTMENT

3

ciprofloxacin hcl ophthalmic (eye) drops

1

erythromycin ophthalmic (eye) ointment

2

gatifloxacin ophthalmic (eye) drops

2

gentak ophthalmic (eye) ointment

2

gentamicin ophthalmic (eye) drops

2

gentamicin ophthalmic (eye) ointment

2

levofloxacin ophthalmic (eye) drops

2

MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS

4

moxifloxacin ophthalmic (eye) drops

2

Drug Name Drug Tier

Requirements/Limits

NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION

3

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment

2

neomycin-polymyxin-gramicidin ophthalmic (eye) drops

2

neo-polycin ophthalmic (eye) ointment

2

ofloxacin ophthalmic (eye) drops

2

polycin ophthalmic (eye) ointment

1

polymyxin b sulf-trimethoprim ophthalmic (eye) drops

2

tobramycin ophthalmic (eye) drops

1

VIGAMOX OPHTHALMIC (EYE) DROPS

3

ANTIVIRALS

trifluridine ophthalmic (eye) drops

2


99

Drug Name Drug Tier

Requirements/Limits

ZIRGAN OPHTHALMIC (EYE) GEL

3

BETA-BLOCKERS

betaxolol ophthalmic (eye) drops

2

BETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSION

3

carteolol ophthalmic (eye) drops

2

levobunolol ophthalmic (eye) drops 0.5 %

2

metipranolol ophthalmic (eye) drops

2

timolol maleate ophthalmic (eye) drops

1

timolol maleate ophthalmic (eye) gel forming solution

1

CHOLINESTERASE INHIBITOR MIOTICS

PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS

3

CYCLOPLEGIC MYDRIATICS

atropine ophthalmic (eye) drops

2

Drug Name Drug Tier

Requirements/Limits

DIRECT ACTING MIOTICS

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %

2

MISCELLANEOUS OPHTHALMOLOGICS

ALOCRIL OPHTHALMIC (EYE) DROPS

3

azelastine ophthalmic (eye) drops

2

BEPREVE OPHTHALMIC (EYE) DROPS

4

cromolyn ophthalmic (eye) drops

2

CYSTARAN OPHTHALMIC (EYE) DROPS

5

EMADINE OPHTHALMIC (EYE) DROPS

4

epinastine ophthalmic (eye) drops

2

LACRISERT OPHTHALMIC (EYE) INSERT

3

olopatadine ophthalmic (eye) drops

2


Drug Name Drug Tier

Requirements/Limits

PATADAY OPHTHALMIC (EYE) DROPS

3

PAZEO OPHTHALMIC (EYE) DROPS

3

proparacaine ophthalmic (eye) drops

2

RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS

3

RESTASIS OPHTHALMIC (EYE) DROPPERETTE

3

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS

ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE

4

bromfenac ophthalmic (eye) drops

2

diclofenac sodium ophthalmic (eye) drops

2

flurbiprofen sodium ophthalmic (eye) drops

2

Drug Name Drug Tier

Requirements/Limits

ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION

4

ketorolac ophthalmic (eye) drops

2

NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION

4

ORAL DRUGS FOR GLAUCOMA

acetazolamide oral capsule, extended release

2

acetazolamide oral tablet

2

acetazolamide sodium injection recon soln

2

methazolamide oral tablet

4

OTHER GLAUCOMA DRUGS

AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION

3

bimatoprost ophthalmic (eye) drops

4

COMBIGAN OPHTHALMIC (EYE) DROPS

4


101

Drug Name Drug Tier

Requirements/Limits

dorzolamide ophthalmic (eye) drops

2

dorzolamide-timolol ophthalmic (eye) drops

2

latanoprost ophthalmic (eye) drops

2

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %

3

SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION

3

TRAVATAN Z OPHTHALMIC (EYE) DROPS

3

ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE

4

STEROID-ANTIBIOTIC COMBINATIONS

neomycin-bacitracin-poly-hc ophthalmic (eye) ointment

2

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension

2

Drug Name Drug Tier

Requirements/Limits

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment

2

neomycin-polymyxin-hc ophthalmic (eye) drops,suspension

2

neo-polycin hc ophthalmic (eye) ointment

2

PRED-G OPHTHALMIC (EYE) DROPS,SUSPENSION

4

PRED-G S.O.P. OPHTHALMIC (EYE) OINTMENT

4

TOBRADEX OPHTHALMIC (EYE) OINTMENT

3

TOBRADEX ST OPHTHALMIC (EYE) DROPS,SUSPENSION

3

tobramycin-dexamethasone ophthalmic (eye) drops,suspension

2

ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION

4

STEROIDS


Drug Name Drug Tier

Requirements/Limits

ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION

4

dexamethasone sodium phosphate ophthalmic (eye) drops

2

DUREZOL OPHTHALMIC (EYE) DROPS

3

fluorometholone ophthalmic (eye) drops,suspension

2

FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION

4

FML S.O.P. OPHTHALMIC (EYE) OINTMENT

4

OZURDEX INTRAVITREAL IMPLANT

4

PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION

3

prednisolone acetate ophthalmic (eye) drops,suspension

2

Drug Name Drug Tier

Requirements/Limits

prednisolone sodium phosphate ophthalmic (eye) drops

2

RETISERT INTRAVITREAL IMPLANT

5

STEROID-SULFONAMIDE COMBINATIONS

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT

3

sulfacetamide-prednisolone ophthalmic (eye) drops

2

SULFONAMIDES

BLEPH-10 OPHTHALMIC (EYE) DROPS

3

sulfacetamide sodium ophthalmic (eye) drops

2

sulfacetamide sodium ophthalmic (eye) ointment

2

SYMPATHOMIMETICS

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %

3

apraclonidine ophthalmic (eye) drops

1


103

Drug Name Drug Tier

Requirements/Limits

brimonidine ophthalmic (eye) drops

1

IOPIDINE OPHTHALMIC (EYE) DROPPERETTE

4

RESPIRATORY AND ALLERGY

ANTIHISTAMINE / ANTIALLERGENIC AGENTS

adrenalin injection solution

2

AUVI-Q INJECTION AUTO-INJECTOR

3

cetirizine oral solution 1 mg/ml

2

cyproheptadine oral syrup

2

cyproheptadine oral tablet

2

desloratadine oral tablet


desloratadine oral tablet,disintegrating


diphenhydramine hcl injection solution 50 mg/ml

2

diphenhydramine hcl injection syringe

2

EPINEPHRINE INJECTION AUTO-INJECTOR

3

Drug Name Drug Tier

Requirements/Limits

EPIPEN 2-PAK INJECTION AUTO-INJECTOR

4

EPIPEN INJECTION AUTO-INJECTOR

4

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR

4

EPIPEN JR INJECTION AUTO-INJECTOR

4

hydroxyzine hcl oral solution 10 mg/5 ml

2

hydroxyzine hcl oral tablet

2

hydroxyzine pamoate oral capsule 25 mg, 50 mg

2

levocetirizine oral solution

2

levocetirizine oral tablet


phenadoz rectal suppository

2 PA

phenergan rectal suppository

2 PA

promethazine injection solution

2 PA

promethazine oral syrup

2 PA

promethazine oral tablet

2 PA


Drug Name Drug Tier

Requirements/Limits

promethazine rectal suppository

2 PA

promethegan rectal suppository

2 PA

PULMONARY AGENTS

acetylcysteine solution

2 B/D PA

ADCIRCA ORAL TABLET

5 PA

ADEMPAS ORAL TABLET

5 PA

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE


ADVAIR HFA INHALATION HFA AEROSOL INHALER


albuterol sulfate inhalation solution for nebulization

1 B/D PA

albuterol sulfate oral syrup

1

albuterol sulfate oral tablet

1

albuterol sulfate oral tablet extended release 12 hr

1

ALVESCO INHALATION HFA AEROSOL INHALER


aminophylline intravenous solution

2

Drug Name Drug Tier

Requirements/Limits

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE


ASMANEX HFA INHALATION HFA AEROSOL INHALER

3

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED


ATROVENT HFA INHALATION HFA AEROSOL INHALER

3

BECONASE AQ NASAL SPRAY,NON-AEROSOL

3

BERINERT INTRAVENOUS KIT

5 PA

BROVANA INHALATION SOLUTION FOR NEBULIZATION

4 B/D PA

budesonide inhalation suspension for nebulization

4 B/D PA

budesonide nasal spray,non-aerosol

4


105

Drug Name Drug Tier

Requirements/Limits

CINRYZE INTRAVENOUS RECON SOLN

5 PA

COMBIVENT RESPIMAT INHALATION MIST

4

cromolyn inhalation solution for nebulization

2 B/D PA

DALIRESP ORAL TABLET

4 PA

DULERA INHALATION HFA AEROSOL INHALER


ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML

3

ESBRIET ORAL CAPSULE

5 PA

ESBRIET ORAL TABLET

5 PA

FIRAZYR SUBCUTANEOUS SYRINGE

5 PA

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE


Drug Name Drug Tier

Requirements/Limits

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION


FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION


flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)

2

fluticasone nasal spray,suspension

2

HAEGARDA SUBCUTANEOUS RECON SOLN

5

ipratropium bromide inhalation solution

1 B/D PA

ipratropium-albuterol inhalation solution for nebulization

1 B/D PA

KALYDECO ORAL GRANULES IN PACKET

5 PA

KALYDECO ORAL TABLET

5 PA

LETAIRIS ORAL TABLET

5 PA


Drug Name Drug Tier

Requirements/Limits

levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/3 ml

2 B/D PA

levalbuterol hcl inhalation solution for nebulization 1.25 mg/0.5 ml

2

metaproterenol oral syrup

2

metaproterenol oral tablet

2

mometasone nasal spray,non-aerosol

2

montelukast oral granules in packet


montelukast oral tablet


montelukast oral tablet,chewable


OFEV ORAL CAPSULE

5 PA

OMNARIS NASAL SPRAY,NON-AEROSOL

4 ST

OPSUMIT ORAL TABLET

5 PA

ORKAMBI ORAL TABLET

5 PA

PROAIR HFA INHALATION HFA AEROSOL INHALER


Drug Name Drug Tier

Requirements/Limits

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED


PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

3

PULMOZYME INHALATION SOLUTION

5 B/D PA

QVAR INHALATION AEROSOL

3

REVATIO ORAL SUSPENSION FOR RECONSTITUTION

5 PA

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE


sildenafil oral tablet 2 PA; QL (270 per 90 days)

SPIRIVA RESPIMAT INHALATION MIST



107

Drug Name Drug Tier

Requirements/Limits

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE


STIOLTO RESPIMAT INHALATION MIST

3

STRIVERDI RESPIMAT INHALATION MIST

3

SYMBICORT INHALATION HFA AEROSOL INHALER

3 QL (30.6 per 90 days)

terbutaline oral tablet

2

terbutaline subcutaneous solution

2

theophylline oral tablet extended release 12 hr

2

theophylline oral tablet extended release 24 hr

2

TRACLEER ORAL TABLET

5 PA; LA

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED


Drug Name Drug Tier

Requirements/Limits

TYVASO INHALATION SOLUTION FOR NEBULIZATION

5 B/D PA

TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR NEBULIZATION

5 B/D PA

TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION

5 B/D PA

TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION

5 B/D PA

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION

5 B/D PA

VENTOLIN HFA INHALATION HFA AEROSOL INHALER


XOLAIR SUBCUTANEOUS RECON SOLN

5 PA

XOPENEX HFA INHALATION HFA AEROSOL INHALER


zafirlukast oral tablet



Drug Name Drug Tier

Requirements/Limits

zileuton oral tablet, er multiphase 12 hr


ZYFLO CR ORAL TABLET, ER MULTIPHASE 12 HR


ZYFLO ORAL TABLET

4

UROLOGICALS

ANTICHOLINERGICS / ANTISPASMODICS

flavoxate oral tablet 1

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR

3

oxybutynin chloride oral syrup

2

oxybutynin chloride oral tablet

2

oxybutynin chloride oral tablet extended release 24hr


tolterodine oral capsule,extended release 24hr

2

tolterodine oral tablet

2

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR

3

Drug Name Drug Tier

Requirements/Limits

trospium oral capsule,extended release 24hr


trospium oral tablet 2

VESICARE ORAL TABLET

3

BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY

alfuzosin oral tablet extended release 24 hr

1

dutasteride oral capsule


finasteride oral tablet 5 mg

2

tamsulosin oral capsule,extended release 24hr

1

CHOLINERGIC STIMULANTS

bethanechol chloride oral tablet

2

MISCELLANEOUS UROLOGICALS

CYSTAGON ORAL CAPSULE

4

ELMIRON ORAL CAPSULE

3

K-PHOS NO 2 ORAL TABLET

4

K-PHOS ORIGINAL ORAL TABLET,SOLUBLE

4


109

Drug Name Drug Tier

Requirements/Limits

potassium citrate oral tablet extended release

2

PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE

5 PA

RENACIDIN IRRIGATION SOLUTION 6.602-3.268 GRAM/100 ML

4

VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

calcium acetate oral capsule

1

calcium acetate oral tablet 667 mg

1

calcium chloride intravenous solution

2

calcium chloride intravenous syringe

2

calcium gluconate intravenous solution

2

dextrose-kcl-nacl intravenous solution

2

effer-k oral tablet, effervescent 25 meq

2

eliphos oral tablet 1

HYPERLYTE CR INTRAVENOUS SOLUTION

4

Drug Name Drug Tier

Requirements/Limits

k-effervescent oral tablet, effervescent

2

klor-con 10 oral tablet extended release

1

klor-con 8 oral tablet extended release

1

klor-con m10 oral tablet,er particles/crystals

1


1


1

klor-con oral packet 1

klor-con sprinkle oral capsule, extended release

1

klor-con/ef oral tablet, effervescent

2

k-tab oral tablet extended release 8 meq

1

lactated ringers intravenous parenteral solution

2

magnesium sulfate in water intravenous parenteral solution

4

magnesium sulfate in water intravenous piggyback

4


Drug Name Drug Tier

Requirements/Limits

magnesium sulfate injection syringe

2

NEUT INTRAVENOUS SOLUTION

4

NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

PHOSLYRA ORAL SOLUTION

4

potassium acetate intravenous solution 2 meq/ml

2

potassium bicarb and chloride oral tablet, effervescent

2

potassium bicarb-citric acid oral tablet, effervescent

2

potassium chlorid-d5-0.45%nacl intravenous parenteral solution

2

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

2

potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l

2

Drug Name Drug Tier

Requirements/Limits

potassium chloride in lr-d5 intravenous parenteral solution

2

potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 40 meq/100 ml

2 HI

potassium chloride intravenous piggyback 30 meq/100 ml

1

potassium chloride oral capsule, extended release

1

potassium chloride oral liquid

1

potassium chloride oral packet

1

potassium chloride oral tablet extended release

1

potassium chloride oral tablet,er particles/crystals

1

potassium chloride-0.45 % nacl intravenous parenteral solution

2

potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l

2


111

Drug Name Drug Tier

Requirements/Limits

potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l

2

potassium chloride-d5-0.9%nacl intravenous parenteral solution

2

potassium phosphate m-/d-basic intravenous solution

2

ringer's intravenous parenteral solution

2

sodium acetate intravenous solution

2

sodium bicarbonate intravenous solution

2

sodium bicarbonate intravenous syringe

2

sodium chloride 0.45 % intravenous parenteral solution

2

sodium chloride 0.45 % intravenous piggyback

2

sodium chloride 3 % intravenous parenteral solution

2

sodium chloride 5 % intravenous parenteral solution

2

sodium chloride intravenous parenteral solution

2

Drug Name Drug Tier

Requirements/Limits

sodium lactate intravenous solution

2

sodium phosphate intravenous solution

2

MISCELLANEOUS NUTRITION PRODUCTS

amino acids 15 % intravenous parenteral solution

4 B/D PA

AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA


Drug Name Drug Tier

Requirements/Limits

AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

BAL IN OIL INTRAMUSCULAR SOLUTION

4

CALCIUM DISODIUM VERSENATE INJECTION SOLUTION

4

CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

cysteine (l-cysteine) intravenous solution

2

FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

freamine iii 10 % intravenous parenteral solution

2 B/D PA

intralipid intravenous emulsion 20 %

4 B/D PA

Drug Name Drug Tier

Requirements/Limits

INTRALIPID INTRAVENOUS EMULSION 30 %

4 B/D PA

ISOLYTE S PH 7.4 INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION

4

ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

KABIVEN INTRAVENOUS EMULSION

4 B/D PA

NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

NUTRILIPID INTRAVENOUS EMULSION

4 B/D PA

PERIKABIVEN INTRAVENOUS EMULSION

4 B/D PA


113

Drug Name Drug Tier

Requirements/Limits

PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

plasmanate intravenous parenteral solution

2

premasol 10 % intravenous parenteral solution

4 B/D PA

PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

SMOFLIPID INTRAVENOUS EMULSION

4 B/D PA

THAM INTRAVENOUS SOLUTION

4

travasol 10 % intravenous parenteral solution

4 B/D PA

TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION

4 B/D PA

Drug Name Drug Tier

Requirements/Limits

VITAMINS / HEMATINICS

fluor-a-day (with xylitol) oral tablet,chewable 0.25 mg f (0.55 mg)-236.79mg, 1 mg f (2.2 mg)-236.79 mg

2

fluoride (sodium) oral drops

1

fluoride (sodium) oral tablet

2

fluoride (sodium) oral tablet,chewable

2

fluoritab oral tablet,chewable

2

ludent fluoride oral tablet,chewable

2

multi-vit with fluoride-iron oral drops

2

multi-vitamin with fluoride oral drops

2

multivitamin with fluoride oral tablet,chewable

2

multivitamins with fluoride oral tablet,chewable

2

mvc-fluoride oral tablet,chewable

2

prenatal vitamin oral tablet

2

triple vitamin with fluoride oral drops

2


Drug Name Drug Tier

Requirements/Limits

tri-vit with fluoride and iron oral drops

2

tri-vitamin with fluoride oral drops

2

vitamins a,c,d and fluoride oral drops

2

Index 1

Index

A abacavir .................................. 2 abacavir-lamivudine ............... 2 abacavir-lamivudine-

zidovudine .......................... 2 ABELCET .............................. 1 ABILIFY MAINTENA ........ 38 ABRAXANE ........................ 17 ABSTRAL ............................ 33 acamprosate .......................... 63 acarbose ................................ 70 acebutolol ............................. 46 acetaminophen-codeine ........ 33 acetazolamide ..................... 100 acetazolamide sodium ........ 100 acetic acid ....................... 63, 68 acetylcysteine ............... 63, 104 acitretin ................................. 55 ACTHIB (PF) ....................... 85 ACTIMMUNE ..................... 82 ACUVAIL (PF) .................. 100 acyclovir ........................... 2, 60 acyclovir sodium .................... 2 ADACEL(TDAP

ADOLESN/ADULT)(PF)85, 86

ADAGEN ............................. 64 adapalene .............................. 57 adapalene-benzoyl peroxide . 57 ADASUVE ........................... 38 ADCIRCA .......................... 104 adefovir................................... 2 ADEMPAS ......................... 104 adenosine .............................. 45 adrenalin ............................. 103 adriamycin ............................ 17 adrucil ................................... 17 ADVAIR DISKUS ............. 104 ADVAIR HFA ................... 104 afeditab cr ............................. 46 AFINITOR ........................... 17 AFINITOR DISPERZ .......... 17 a-hydrocort ........................... 68 AKYNZEO........................... 78 ALBENZA ............................. 9 albuterol sulfate .................. 104 alclometasone ....................... 60

alcohol pads .......................... 70 ALDURAZYME .................. 74 ALECENSA ......................... 17 alendronate ..................... 64, 90 alfuzosin ............................. 108 ALIMTA .............................. 17 ALINIA .................................. 9 allopurinol ............................ 90 allopurinol sodium ................ 90 almotriptan malate ................ 30 ALOCRIL ............................. 99 alosetron ............................... 78 ALOXI.................................. 78 ALPHAGAN P ................... 102 alprazolam ............................ 38 alprazolam intensol............... 38 ALREX ............................... 102 altavera (28) .......................... 94 ALUNBRIG ......................... 17 ALVESCO.......................... 104 alyacen 1/35 (28) .................. 94 alyacen 7/7/7 (28) ................. 94 amabelz ................................. 92 amantadine hcl ........................ 2 AMBISOME .......................... 1 amcinonide ........................... 60 amethia ................................. 94 amethia lo ............................. 94 amethyst................................ 94 amifostine crystalline ........... 16 amikacin ................................. 9 amiloride ............................... 46 amiloride-hydrochlorothiazide

.......................................... 46 amino acids 15 % ............... 111 aminocaproic acid................. 51 aminophylline ..................... 104 AMINOSYN 7 % WITH

ELECTROLYTES.......... 111 AMINOSYN II 15 % ......... 111 AMINOSYN II 7 % ........... 111 AMINOSYN-HBC 7%....... 111 AMINOSYN-PF 10 % ....... 111 AMINOSYN-PF 7 %

(SULFITE-FREE) .......... 112 AMINOSYN-RF 5.2 % ...... 112 amiodarone ........................... 45

AMITIZA ............................. 78 amitriptyline ......................... 38 amlodipine ............................ 46 amlodipine-atorvastatin ........ 53 amlodipine-benazepril .......... 46 amlodipine-olmesartan ......... 46 amlodipine-valsartan ............ 46 amlodipine-valsartan-hcthiazid

.......................................... 46 ammonium lactate ................ 56 AMMONUL ......................... 64 amnesteem ............................ 57 amoxapine ............................. 38 amoxicillin ............................ 13 amoxicillin-pot clavulanate .. 13 amphotericin b ........................ 1 ampicillin .............................. 13 ampicillin sodium ................. 13 ampicillin-sulbactam ............ 13 AMPYRA ............................. 31 ANADROL-50 ..................... 74 anagrelide ............................. 64 ANALPRAM-HC ................. 78 anastrozole ............................ 17 ANDRODERM .................... 74 ANDROGEL ........................ 74 ANDROID ............................ 74 ANZEMET ........................... 78 apexicon e ............................. 60 APIDRA ............................... 70 APIDRA SOLOSTAR .......... 70 APOKYN ............................. 29 apraclonidine ...................... 102 aprepitant .............................. 78 apri ........................................ 94 APRISO ................................ 78 APTIOM ............................... 27 APTIVUS ............................... 2 ARALAST NP ...................... 64 aranelle (28) .......................... 94 ARANESP (IN

POLYSORBATE) ...... 82, 83 ARCALYST ......................... 83 ARCAPTA NEOHALER ... 104 ARGATROBAN .................. 51 ARGATROBAN IN 0.9 %

SOD CHLOR .................... 51

Index 2

aripiprazole ..................... 38, 39 ARISTADA .......................... 39 ARISTOSPAN INTRA-

ARTICULAR ................... 69 armodafinil ........................... 39 ARRANON .......................... 17 ARZERRA ........................... 17 ASACOL HD ....................... 78 ashlyna .................................. 94 ASMANEX HFA ............... 104 ASMANEX TWISTHALER

........................................ 104 aspirin-dipyridamole ............ 51 ASTAGRAF XL .................. 17 atenolol ................................. 46 atenolol-chlorthalidone......... 46 atomoxetine .......................... 39 atorvastatin ........................... 53 atovaquone ............................. 9 atovaquone-proguanil ............. 9 ATRIPLA ............................... 2 atropine ........................... 77, 99 ATROVENT HFA ............. 104 AUBAGIO ........................... 31 aubra ..................................... 94 AURYXIA ........................... 64 AUVI-Q .............................. 103 AVANDIA ........................... 70 AVASTIN ............................ 17 AVC VAGINAL .................. 93 aviane ................................... 94 AVONEX ............................. 83 AVONEX (WITH ALBUMIN)

.......................................... 83 azacitidine............................. 17 AZACTAM ............................ 9 AZACTAM IN DEXTROSE

(ISO-OSM) ......................... 9 AZASAN .............................. 17 AZASITE ............................. 97 azathioprine .......................... 18 azathioprine sodium ............. 18 azelastine ........................ 67, 99 AZILECT ............................. 29 azithromycin ........................... 8 AZOPT ............................... 100 AZOR ................................... 46 aztreonam ............................... 9 azurette (28).......................... 94

B baciim ..................................... 9 bacitracin .......................... 9, 97 bacitracin-polymyxin b......... 97 baclofen ................................ 32 BACTROBAN NASAL ....... 67 BAL IN OIL ....................... 112 balsalazide ............................ 78 BANZEL .............................. 27 BARACLUDE ....................... 2 BAVENCIO ......................... 18 BCG VACCINE, LIVE (PF) 86 BD INSULIN PEN NEEDLE

UF MINI ........................... 70 BD INSULIN PEN NEEDLE

UF ORIG .......................... 70 BD INSULIN PEN NEEDLE

UF SHORT ....................... 70 BD ULTRA-FINE NANO

PEN NEEDLES ................ 71 BECONASE AQ ................ 104 bekyree (28) .......................... 94 BELEODAQ ........................ 18 benazepril ............................. 46 benazepril-hydrochlorothiazide

.......................................... 46 BENDEKA ........................... 18 BENICAR ............................ 46 BENICAR HCT ................... 46 BENLYSTA ......................... 91 benztropine ........................... 29 BEPREVE ............................ 99 BERINERT ........................ 104 BESIVANCE........................ 98 betamethasone acet,sod phos 69 betamethasone dipropionate . 60 betamethasone valerate... 60, 61 betamethasone, augmented ... 61 BETASERON ...................... 83 betaxolol ......................... 46, 99 bethanechol chloride ........... 108 BETHKIS ............................... 9 BETOPTIC S ........................ 99 bexarotene ............................ 18 BEXSERO ............................ 86 bicalutamide ......................... 18 BICILLIN C-R ..................... 13 BICILLIN L-A ..................... 13 BICNU.................................. 18

BIDIL ................................... 46 BILTRICIDE ........................ 10 bimatoprost ......................... 100 bisoprolol fumarate ............... 46 bisoprolol-hydrochlorothiazide

.......................................... 46 BIVIGAM ............................. 86 bleo 15k ................................ 18 bleomycin ............................. 18 BLEPH-10 .......................... 102 BLEPHAMIDE S.O.P. ....... 102 BLINCYTO .......................... 18 BONIVA ............................... 90 BOOSTRIX TDAP ............... 86 BOSULIF ............................. 18 BREVIBLOC ....................... 46 briellyn .................................. 94 BRILINTA ........................... 51 brimonidine ......................... 103 BRIVIACT ........................... 27 bromfenac ........................... 100 bromocriptine ................. 29, 30 BROVANA ........................ 104 budesonide .................... 78, 104 bumetanide ........................... 46 BUPHENYL ......................... 64 BUPRENEX ......................... 33 BUPRENORPHINE ............. 33 buprenorphine hcl ................. 33 buprenorphine-naloxone ....... 36 bupropion hcl ........................ 39 bupropion hcl (smoking deter)

.......................................... 67 buspirone .............................. 39 busulfan ................................ 18 BUSULFEX ......................... 18 butalbital-aspirin-caffeine ..... 33 butorphanol tartrate .............. 36 BUTRANS ........................... 33 BYDUREON ........................ 71 BYETTA .............................. 71 C cabergoline ........................... 74 CABOMETYX ..................... 18 caffeine citrate ...................... 64 calcipotriene ......................... 55 calcitonin (salmon) ............... 75 calcitrene ............................... 56 calcitriol .......................... 56, 75

Index 3

calcium acetate ................... 109 calcium chloride ................. 109 CALCIUM DISODIUM

VERSENATE................. 112 calcium gluconate ............... 109 camila ................................... 92 camrese ................................. 94 camrese lo ............................. 94 CANASA ............................. 78 CANCIDAS ........................... 1 candesartan ........................... 46 candesartan-hydrochlorothiazid

.......................................... 46 CAPASTAT ......................... 10 CAPEX ................................. 61 CAPRELSA ......................... 18 captopril ................................ 46 captopril-hydrochlorothiazide

.......................................... 46 CARAC ................................ 56 CARBAGLU ........................ 64 carbamazepine ...................... 27 carbidopa .............................. 30 carbidopa-levodopa .............. 30 carbidopa-levodopa-

entacapone ........................ 30 CARBOCAINE .................... 58 carbocaine (pf)...................... 58 carboplatin ............................ 18 CARDIZEM LA ................... 46 CARDURA XL .................... 47 CARIMUNE NF

NANOFILTERED ........... 86 carteolol ................................ 99 cartia xt ................................. 47 carvedilol .............................. 47 CASPOFUNGIN .................... 1 CAYSTON ........................... 10 caziant (28) ........................... 94 CEDAX .................................. 6 cefaclor ................................... 6 cefadroxil ................................ 6 cefazolin ................................. 6 cefazolin in dextrose (iso-os) . 6 cefdinir ................................... 6 cefepime ................................. 7 CEFEPIME IN DEXTROSE 5

% ........................................ 7 cefepime in dextrose,iso-osm . 7

cefixime .................................. 7 cefotaxime .............................. 7 CEFOTETAN IN

DEXTROSE, ISO-OSM ..... 7 cefoxitin .................................. 7 cefoxitin in dextrose, iso-osm 7 cefpodoxime ........................... 7 cefprozil .................................. 7 ceftazidime ............................. 7 CEFTAZIDIME IN D5W ...... 7 ceftibuten ................................ 7 ceftriaxone .............................. 7 CEFTRIAXONE .................... 7 cefuroxime axetil .................... 7 cefuroxime sodium ................. 7 celecoxib ............................... 36 CELLCEPT INTRAVENOUS

.......................................... 18 CELONTIN .......................... 27 CENTANY ........................... 59 cephalexin ............................... 8 CEPROTIN (BLUE BAR) ... 51 CEPROTIN (GREEN BAR) 51 CERDELGA ......................... 75 CEREBYX ........................... 27 CEREZYME ........................ 75 cetirizine ............................. 103 cevimeline ............................ 64 CHANTIX ............................ 67 CHANTIX CONTINUING

MONTH BOX .................. 67 CHANTIX STARTING

MONTH BOX .................. 67 chateal ................................... 94 CHEMET.............................. 64 chloramphenicol sod succinate

.......................................... 10 chlorhexidine gluconate ....... 67 chloroprocaine (pf) ............... 58 chloroquine phosphate .......... 10 chlorothiazide ....................... 47 chlorothiazide sodium .......... 47 chlorpromazine ..................... 39 chlorthalidone ....................... 47 CHOLBAM .......................... 78 cholestyramine (with sugar) . 53 cholestyramine light ............. 53 chorionic gonadotropin, human

.......................................... 75

ciclodan ................................. 59 ciclopirox .............................. 59 cidofovir ................................. 2 cilostazol ............................... 51 CILOXAN ............................ 98 CIMZIA ................................ 78 CIMZIA POWDER FOR

RECONST ........................ 78 CIMZIA STARTER KIT ..... 78 CINRYZE ........................... 105 CIPRO HC ............................ 68 CIPRODEX .......................... 68 ciprofloxacin ......................... 15 ciprofloxacin (mixture) ......... 14 ciprofloxacin hcl ....... 14, 68, 98 ciprofloxacin in 5 % dextrose

.......................................... 14 ciprofloxacin lactate ............. 15 cisplatin ................................. 18 citalopram ............................. 39 cladribine .............................. 18 claravis .................................. 57 clarithromycin ......................... 8 CLEOCIN ............................. 93 CLEVIPREX ........................ 47 clindacin etz .......................... 57 clindacin p ............................ 57 clindamycin hcl .................... 10 clindamycin in 5 % dextrose 10 clindamycin palmitate hcl ..... 10 clindamycin pediatric ........... 10 clindamycin phosphate .. 10, 57,

93 clindamycin-benzoyl peroxide

.......................................... 57 CLINDESSE ......................... 93 CLINIMIX E 4.25%/D10W

SUL FREE ...................... 112 CLINPRO 5000 .................... 67 clobetasol .............................. 61 clobetasol-emollient ............. 61 clodan ................................... 61 CLOFARABINE .................. 18 CLOLAR .............................. 18 clomiphene citrate ................ 75 clomipramine ........................ 39 clonazepam ........................... 27 clonidine ............................... 47 clonidine (pf) .................. 36, 47

Index 4

clonidine hcl ................... 39, 47 clopidogrel ............................ 51 clorazepate dipotassium ....... 39 clotrimazole ...................... 1, 59 clotrimazole-betamethasone . 59 clozapine............................... 39 CLOZAPINE ........................ 39 COARTEM .......................... 10 codeine sulfate ...................... 33 COLCHICINE ...................... 90 COLCRYS ........................... 90 colestipol .............................. 53 colistin (colistimethate na) ... 10 colocort ................................. 78 COLY-MYCIN S ................. 68 COMBIGAN ...................... 100 COMBIVENT RESPIMAT 105 COMETRIQ ......................... 18 COMPLERA .......................... 2 compro .................................. 78 CONDYLOX ....................... 56 constulose ............................. 78 COPAXONE ........................ 31 COREG CR .......................... 47 CORLANOR ........................ 55 CORLOPAM ........................ 47 cormax .................................. 61 CORTIFOAM ...................... 79 cortisone ............................... 69 COTELLIC........................... 18 CREON ................................ 79 CRINONE ............................ 92 CRIXIVAN ............................ 2 cromolyn................. 79, 99, 105 CUBICIN ............................. 10 CUBICIN RF ....................... 10 cyclafem 1/35 (28) ............... 94 cyclafem 7/7/7 (28) .............. 94 cyclobenzaprine .................... 32 cyclophosphamide ................ 18 CYCLOPHOSPHAMIDE .... 18 CYCLOSERINE .................. 10 CYCLOSET ......................... 71 cyclosporine ................... 18, 19 cyclosporine modified .......... 19 cyproheptadine ................... 103 CYRAMZA .......................... 19 cyred ..................................... 94 CYSTADANE ...................... 79

CYSTAGON ...................... 108 CYSTARAN ........................ 99 cysteine (l-cysteine) ............ 112 cytarabine ............................. 19 cytarabine (pf) ...................... 19 CYTOGAM .......................... 86 D d10 %-0.45 % sodium chloride

.......................................... 64 d2.5 %-0.45 % sodium

chloride ............................. 64 d5 % and 0.9 % sodium

chloride ............................. 64 d5 %-0.45 % sodium chloride

.......................................... 64 dacarbazine ........................... 19 DAKLINZA ........................... 2 DALIRESP ......................... 105 DALVANCE ........................ 10 danazol.................................. 75 DANTRIUM ........................ 32 dantrolene ............................. 32 dapsone ................................. 10 DAPTACEL (DTAP

PEDIATRIC) (PF) ............ 86 daptomycin ........................... 10 DARAPRIM ......................... 10 DARZALEX ........................ 19 dasetta 1/35 (28) ................... 94 dasetta 7/7/7 (28) .................. 94 daunorubicin ......................... 19 daysee ................................... 94 deblitane ............................... 92 decitabine.............................. 19 deferoxamine ........................ 64 deltasone ............................... 69 delyla (28)............................. 94 DELZICOL .......................... 79 demeclocycline ..................... 15 DEMSER .............................. 47 DENAVIR ............................ 60 denta 5000 plus ..................... 67 dentagel ................................ 67 DEPEN TITRATABS .......... 91 DEPO-ESTRADIOL ............ 92 DEPO-MEDROL ................. 69 DEPO-PROVERA................ 92 DEPO-SUBQ PROVERA 104

.......................................... 92

DESCOVY ............................. 2 desipramine ........................... 39 desloratadine ....................... 103 desmopressin ........................ 75 desog-e.estradiol/e.estradiol . 94 desogestrel-ethinyl estradiol . 95 desonide ................................ 61 desoximetasone ..................... 61 desvenlafaxine succinate ...... 39 dexamethasone ..................... 69 dexamethasone intensol ........ 69 dexamethasone sodium phos

(pf) .................................... 69 dexamethasone sodium

phosphate .................. 69, 102 dexmethylphenidate ........ 39, 40 DEXPAK 10 DAY ............... 69 DEXPAK 13 DAY ............... 69 DEXPAK 6 DAY ................. 69 dexrazoxane hcl .................... 16 dextroamphetamine .............. 40 dextroamphetamine-

amphetamine ..................... 40 dextrose 10 % in water (d10w)

.......................................... 64 dextrose 20 % in water (d20w)




.......................................... 64 dextrose 5 % in water (d5w) 64,

65 dextrose 5 %-lactated ringers65 dextrose 5%-0.2 % sod

chloride ............................. 65 dextrose 5%-0.3 %

sod.chloride ...................... 65 dextrose 50 % in water (d50w)


.......................................... 65 dextrose with sodium chloride

.......................................... 65 dextrose-kcl-nacl ................ 109 DIASTAT ............................. 27 DIASTAT ACUDIAL .......... 27

Index 5

diazepam......................... 27, 40 diclofenac potassium ............ 36 diclofenac sodium .. 37, 56, 100 diclofenac-misoprostol ......... 37 dicloxacillin .......................... 13 dicyclomine .......................... 77 didanosine............................... 2 DIFFERIN ............................ 57 DIFICID ................................. 8 diflorasone ............................ 61 diflunisal ............................... 37 digitek ................................... 51 digox ..................................... 51 digoxin .................................. 51 dihydroergotamine ............... 30 DILANTIN 30 MG .............. 27 diltiazem hcl ......................... 47 dilt-xr .................................... 47 dimenhydrinate ..................... 79 DIPENTUM ......................... 79 diphenhydramine hcl .......... 103 diphenoxylate-atropine ......... 77 diskets ................................... 33 disopyramide phosphate ....... 45 disulfiram ............................. 65 divalproex ............................. 27 dobutamine ........................... 55 docetaxel............................... 19 DOCETAXEL ...................... 19 dofetilide............................... 45 donepezil .............................. 31 dopamine .............................. 55 dorzolamide ........................ 101 dorzolamide-timolol ........... 101 doxazosin .............................. 47 doxepin ........................... 40, 56 doxercalciferol ...................... 75 doxorubicin........................... 19 doxorubicin, peg-liposomal .. 19 doxy-100 .............................. 15 doxycycline hyclate .............. 15 doxycycline monohydrate .... 15 dronabinol............................. 79 droperidol ............................. 79 drospirenone-ethinyl estradiol

.......................................... 95 DROXIA .............................. 19 DULERA ............................ 105 duloxetine ............................. 40

DUOPA ................................ 30 duramorph (pf) ..................... 33 DUREZOL ......................... 102 dutasteride .......................... 108 DYSPORT ............................ 86 E e.e.s. 400 ................................. 8 econazole .............................. 59 EDARBYCLOR ................... 47 EDECRIN ............................. 47 EDURANT ............................. 2 effer-k ................................. 109 EFFIENT .............................. 51 EGRIFTA ............................. 83 ELAPRASE .......................... 75 ELELYSO ............................ 75 eletriptan hbr......................... 30 ELIDEL ................................ 56 elinest.................................... 95 eliphos ................................ 109 ELIQUIS .............................. 51 ELITEK ................................ 16 ELIXOPHYLLIN ............... 105 ELLA .................................... 95 ELLENCE ............................ 19 ELMIRON .......................... 108 EMADINE............................ 99 EMCYT ................................ 19 EMEND ................................ 79 EMEND (FOSAPREPITANT)

.......................................... 79 emoquette ............................. 95 EMPLICITI .......................... 19 EMSAM ............................... 40 EMTRIVA .............................. 2 enalapril maleate ................... 47 enalaprilat ............................. 48 enalapril-hydrochlorothiazide

.......................................... 48 ENBREL .............................. 91 ENBREL SURECLICK ....... 91 endocet.................................. 33 ENGERIX-B (PF) ................ 86 ENGERIX-B PEDIATRIC

(PF) ................................... 86 enlon ..................................... 32 ENLON-PLUS ..................... 32 enoxaparin ...................... 51, 52 enpresse ................................ 95

enskyce ................................. 95 entacapone ............................ 30 entecavir ................................. 2 enulose .................................. 79 ENVARSUS XR .................. 19 EPCLUSA .............................. 3 EPIFOAM ............................. 56 epinastine .............................. 99 EPINEPHRINE .................. 103 EPIPEN ............................... 103 EPIPEN 2-PAK .................. 103 EPIPEN JR ......................... 103 EPIPEN JR 2-PAK ............. 103 epirubicin .............................. 20 epitol ..................................... 27 EPIVIR HBV .......................... 3 eplerenone ............................. 48 EPOGEN .............................. 83 epoprostenol (glycine) .......... 48 eprosartan ............................. 48 EPZICOM ............................... 3 ERAXIS(WATER DILUENT)

............................................ 1 ERBITUX ............................. 20 ergoloid ................................. 40 ERGOMAR .......................... 30 ergotamine-caffeine .............. 30 ERIVEDGE .......................... 20 errin ....................................... 92 ERTACZO ............................ 59 ERWINAZE ......................... 20 ery pads ................................. 57 erygel .................................... 57 ery-tab ..................................... 8 ERY-TAB ............................... 8 ERYTHROCIN ...................... 9 erythrocin (as stearate) ........... 8 erythromycin ..................... 9, 98 erythromycin ethylsuccinate ... 9 erythromycin with ethanol .... 57 erythromycin-benzoyl peroxide

.......................................... 57 ESBRIET ............................ 105 escitalopram oxalate ............. 40 esmolol ................................. 48 esomeprazole sodium ........... 82 estarylla ................................. 95 ESTRACE ............................ 92 estradiol ................................ 92

Index 6

estradiol valerate .................. 93 ESTRING ............................. 93 ethacrynic acid...................... 48 ethambutol ............................ 10 ethosuximide ........................ 27 ethynodiol diac-eth estradiol 95 etidronate disodium .............. 65 etodolac ................................ 37 ETOPOPHOS ....................... 20 etoposide............................... 20 EURAX ................................ 63 EVOMELA .......................... 20 EVOTAZ ................................ 3 EVZIO .................................. 37 EXELDERM ........................ 59 exemestane ........................... 20 EXJADE ............................... 65 EXTAVIA ............................ 83 ezetimibe .............................. 53 ezetimibe-simvastatin ........... 53 F FABRAZYME ..................... 75 falmina (28) .......................... 95 famciclovir ............................. 3 famotidine............................. 82 famotidine (pf)...................... 82 famotidine (pf)-nacl (iso-os) 82 FANAPT .............................. 40 FARESTON ......................... 20 FARXIGA ............................ 71 FARYDAK .......................... 20 FASLODEX ......................... 20 fayosim ................................. 95 FAZACLO ........................... 40 felbamate .............................. 27 felodipine .............................. 48 FEMRING ............................ 93 femynor ................................ 95 fenofibrate ............................ 53 fenofibrate micronized ......... 53 fenofibrate nanocrystallized . 53 fenofibric acid ...................... 53 fenofibric acid (choline) ....... 53 fenoprofen ............................ 37 fentanyl ................................. 34 fentanyl citrate ...................... 33 fentanyl citrate (pf) ............... 33 FENTANYL CITRATE (PF)

.......................................... 33

FENTORA............................ 34 FERRIPROX ........................ 65 FETZIMA ............................. 40 FINACEA ............................. 57 finasteride ........................... 108 FIRAZYR ........................... 105 flavoxate ............................. 108 FLEBOGAMMA DIF .......... 86 flecainide .............................. 45 FLOLAN .............................. 48 FLOVENT DISKUS .......... 105 FLOVENT HFA ................. 105 floxin .................................... 68 floxuridine ............................ 20 fluconazole ............................. 1 fluconazole in nacl (iso-osm) . 1 FLUCONAZOLE IN NACL

(ISO-OSM) ......................... 1 flucytosine .............................. 1 fludarabine ............................ 20 fludrocortisone...................... 69 flunisolide ........................... 105 fluocinolone .................... 61, 62 fluocinolone acetonide oil .... 68 fluocinolone and shower cap 61 fluocinonide .......................... 62 fluocinonide-e ....................... 62 fluocinonide-emollient ......... 62 fluor-a-day (with xylitol) .... 113 fluoride (sodium) ................ 113 fluoritab .............................. 113 fluorometholone ................. 102 fluorouracil ..................... 20, 56 FLUOROURACIL ............... 56 fluoxetine .............................. 41 fluphenazine decanoate ........ 41 fluphenazine hcl ................... 41 flurandrenolide ..................... 62 FLURANDRENOLIDE ....... 62 flurbiprofen ........................... 37 flurbiprofen sodium ............ 100 flutamide ............................... 20 fluticasone .................... 62, 105 fluvastatin ....................... 53, 54 fluvoxamine .......................... 41 FML FORTE ...................... 102 FML S.O.P. ........................ 102 fomepizole ............................ 86 fondaparinux ......................... 52

FORTEO ............................... 90 FOSAMAX PLUS D ............ 90 fosamprenavir ......................... 3 foscarnet ................................. 3 fosinopril ............................... 48 fosinopril-hydrochlorothiazide

.......................................... 48 fosphenytoin ......................... 28 FOSRENOL ......................... 65 FRAGMIN ............................ 52 FREAMINE HBC 6.9 % .... 112 freamine iii 10 % ................ 112 frovatriptan ........................... 30 furosemide ............................ 48 FUSILEV .............................. 16 FUZEON ................................ 3 FYCOMPA ........................... 28 G gabapentin ............................. 28 GABITRIL ........................... 28 galantamine ........................... 31 GAMASTAN S/D ................ 86 GAMMAGARD LIQUID .... 86 GAMMAGARD S-D (IGA < 1

MCG/ML) ......................... 86 GAMMAKED ...................... 87 GAMMAPLEX .................... 87 GAMMAPLEX (WITH

SORBITOL) ..................... 87 GAMUNEX-C ...................... 87 ganciclovir sodium ................. 3 GARDASIL 9 (PF) ............... 87 gatifloxacin ........................... 98 GATTEX 30-VIAL .............. 79 GATTEX ONE-VIAL .......... 79 GAUZE PAD ........................ 71 gavilyte-c .............................. 79 gavilyte-g .............................. 79 gavilyte-n .............................. 79 GAZYVA ............................. 20 gemcitabine ........................... 20 gemfibrozil ........................... 54 generlac ................................. 79 gengraf .................................. 20 GENOTROPIN ..................... 83 GENOTROPIN MINIQUICK

.......................................... 83 gentak ................................... 98 gentamicin ................ 11, 59, 98

Index 7

gentamicin in nacl (iso-osm) .................................... 10, 11

GENTAMICIN IN NACL (ISO-OSM) ....................... 11

gentamicin sulfate (pf) ......... 11 GENVOYA ............................ 3 GEODON ............................. 41 gildagia ................................. 95 GILENYA ............................ 31 GILOTRIF ............................ 20 GLASSIA ............................. 65 glatopa .................................. 31 GLEOSTINE ........................ 20 glimepiride ........................... 71 glipizide ................................ 71 glipizide-metformin .............. 71 GLUCAGEN HYPOKIT ..... 71 GLUCAGON EMERGENCY

KIT (HUMAN) ................ 71 glycopyrrolate....................... 78 glydo ..................................... 58 GOLYTELY......................... 79 granisetron (pf) ..................... 79 granisetron hcl ...................... 79 GRANIX .............................. 84 GRASTEK ........................... 87 griseofulvin microsize ............ 1 griseofulvin ultramicrosize ..... 1 guanidine .............................. 41 GYNAZOLE-1 ..................... 93 H HAEGARDA ..................... 105 HALAVEN........................... 20 halobetasol propionate.......... 62 haloperidol ............................ 41 haloperidol decanoate ........... 41 haloperidol lactate ................ 41 HARVONI ............................. 3 HAVRIX (PF) ...................... 87 heather .................................. 93 HECTOROL......................... 75 HEMABATE ........................ 97 HEPAGAM B ...................... 87 heparin (porcine) .................. 52 heparin (porcine) in 5 % dex 52 heparin (porcine) in nacl (pf) 52 heparin(porcine) in 0.45% nacl

.......................................... 52

HEPARIN(PORCINE) IN 0.45% NACL .................... 52

heparin, porcine (pf) ............. 52 HERCEPTIN ........................ 20 HETLIOZ ............................. 41 HEXALEN ........................... 21 HIBERIX (PF) ...................... 87 HIZENTRA .......................... 87 HUMALOG.................... 71, 72 HUMALOG JUNIOR

KWIKPEN........................ 71 HUMALOG KWIKPEN ...... 71 HUMALOG MIX 50-50 ...... 71 HUMALOG MIX 50-50

KWIKPEN........................ 71 HUMALOG MIX 75-25 ...... 71 HUMALOG MIX 75-25

KWIKPEN........................ 71 HUMATROPE ..................... 84 HUMIRA .............................. 91 HUMIRA PEN ..................... 91 HUMIRA PEN CROHN'S-

UC-HS START ................ 91 HUMIRA PEN PSORIASIS-

UVEITIS .......................... 91 HUMULIN 70/30 ................. 72 HUMULIN 70/30 KWIKPEN

.......................................... 72 HUMULIN N ....................... 72 HUMULIN N KWIKPEN .... 72 HUMULIN R U-100 ............ 72 HUMULIN R U-500 (CONC)

KWIKPEN........................ 72 HUMULIN R U-500

(CONCENTRATED) ....... 72 hydralazine ........................... 48 hydrochlorothiazide .............. 48 hydrocodone-acetaminophen 34 hydrocodone-ibuprofen ........ 34 hydrocortisone .......... 62, 69, 79 hydrocortisone butyrate ........ 62 hydrocortisone butyr-emollient

.......................................... 62 hydrocortisone valerate ........ 62 hydrocortisone-acetic acid .... 68 hydrocortisone-min oil-wht pet

.......................................... 62 hydromorphone .................... 34 HYDROMORPHONE ......... 34

hydromorphone (pf) .............. 34 hydroxychloroquine .............. 11 hydroxyprogesterone caproate

.......................................... 93 hydroxyurea .......................... 21 hydroxyzine hcl .................. 103 hydroxyzine pamoate .......... 103 HYPERHEP B S/D ............... 87 HYPERHEP B S-D

NEONATAL .................... 87 HYPERLYTE CR .............. 109 HYPERRAB S/D (PF) ......... 87 HYPERTET S/D (PF) .......... 87 HYQVIA .............................. 87 I ibandronate ........................... 90 IBRANCE ............................. 21 ibuprofen ............................... 37 ibuprofen-oxycodone ............ 34 ibutilide fumarate .................. 45 ICLUSIG .............................. 21 idarubicin .............................. 21 IDHIFA ................................. 21 ifosfamide ............................. 21 ILARIS (PF) ......................... 84 ILEVRO ............................. 100 imatinib ................................. 21 IMBRUVICA ....................... 21 IMFINZI ............................... 21 imipenem-cilastatin .............. 11 imipramine hcl ...................... 41 imipramine pamoate ............. 41 imiquimod ............................. 56 IMOGAM RABIES-HT (PF)

.......................................... 87 IMOVAX RABIES VACCINE

(PF) ................................... 87 INCRELEX .......................... 65 indapamide ........................... 48 INFANRIX (DTAP) (PF) .... 87,

88 INFLECTRA ........................ 80 INFUMORPH P/F ................ 34 INLYTA ............................... 21 INSULIN PEN NEEDLE ..... 72 INSULIN SYRINGE (DISP)

U-100 ................................ 72 INTELENCE .......................... 3 intralipid ............................. 112

Index 8

INTRALIPID ..................... 112 INTRON A ........................... 84 introvale ................................ 95 INVANZ............................... 11 INVEGA SUSTENNA ......... 41 INVEGA TRINZA ............... 41 INVIRASE ............................. 3 INVOKAMET ...................... 72 INVOKAMET XR ............... 72 INVOKANA ........................ 72 IOPIDINE........................... 103 IPOL ..................................... 88 ipratropium bromide ..... 67, 105 ipratropium-albuterol ......... 105 irbesartan .............................. 48 irbesartan-hydrochlorothiazide

.......................................... 48 IRESSA ................................ 21 irinotecan .............................. 21 ISENTRESS ........................... 3 ISENTRESS HD .................... 3 isibloom ................................ 95 ISOLYTE S PH 7.4 ............ 112 ISOLYTE-P IN 5 %

DEXTROSE ................... 112 ISOLYTE-S ........................ 112 isoniazid ............................... 11 isosorbide dinitrate ............... 55 isosorbide mononitrate ......... 55 isradipine .............................. 48 ISUPREL .............................. 55 itraconazole ............................ 1 ivermectin ............................. 11 IXEMPRA ............................ 21 IXIARO (PF) ........................ 88 J JADENU .............................. 65 JADENU SPRINKLE .......... 65 JAKAFI ................................ 21 jantoven ................................ 52 JANUMET ........................... 72 JANUMET XR ..................... 72 JANUVIA ............................ 72 jencycla................................. 93 JEVTANA ............................ 21 jinteli .................................... 93 jolessa ................................... 95 juleber ................................... 95 junel 1.5/30 (21) ................... 95

junel 1/20 (21) ...................... 95 junel fe 1.5/30 (28) ............... 95 junel fe 1/20 (28) .................. 95 junel fe 24 ............................. 95 JUXTAPID ........................... 54 K KABIVEN .......................... 112 KADCYLA .......................... 21 KADIAN .............................. 34 kaitlib fe ................................ 95 KALETRA ............................. 3 KALYDECO ...................... 105 KANUMA ............................ 75 kariva (28) ............................ 95 k-effervescent ..................... 109 KEPIVANCE ....................... 16 ketoconazole ..................... 1, 60 ketoprofen ............................. 37 ketorolac ............................. 100 KEYTRUDA ........................ 21 KHEDEZLA ......................... 41 kimidess (28) ........................ 95 KINERET ............................. 91 KINRIX (PF) ........................ 88 kionex ................................... 65 kionex (with sorbitol) ........... 65 KISQALI .............................. 21 KISQALI FEMARA CO-

PACK ............................... 21 klor-con .............................. 109 klor-con 10 ......................... 109 klor-con 8 ........................... 109 klor-con m10 ...................... 109 klor-con m15 ...................... 109 klor-con m20 ...................... 109 klor-con sprinkle................. 109 klor-con/ef .......................... 109 KOMBIGLYZE XR ............. 72 KORLYM ............................. 75 K-PHOS NO 2 .................... 108 K-PHOS ORIGINAL ......... 108 KRYSTEXXA ...................... 90 k-tab .................................... 109 kurvelo .................................. 95 KUVAN................................ 75 KYNAMRO ......................... 54 KYPROLIS .......................... 21 L l norgest/e.estradiol-e.estrad . 95

labetalol ................................ 48 LACRISERT ........................ 99 lactated ringers .............. 63, 109 lactulose ................................ 80 LAMICTAL STARTER

(BLUE) KIT ..................... 28 LAMICTAL STARTER

(GREEN) KIT .................. 28 LAMICTAL STARTER

(ORANGE) KIT ............... 28 lamivudine .............................. 3 lamivudine-zidovudine ........... 3 lamotrigine ............................ 28 LANOXIN PEDIATRIC ...... 51 lansoprazole .......................... 82 lanthanum ............................. 65 LANTUS .............................. 73 LANTUS SOLOSTAR ......... 72 larin 1.5/30 (21) .................... 95 larin 1/20 (21) ....................... 95 larin 24 fe .............................. 95 larin fe 1.5/30 (28) ................ 95 larin fe 1/20 (28) ................... 96 larissia ................................... 96 LARTRUVO ........................ 21 latanoprost .......................... 101 LATUDA .............................. 41 LAZANDA ........................... 34 leflunomide ........................... 91 LEMTRADA ........................ 31 LENVIMA ............................ 21 lessina ................................... 96 LETAIRIS .......................... 105 letrozole ................................ 21 leucovorin calcium ......... 16, 17 LEUKERAN ......................... 21 LEUKINE ............................. 84 leuprolide .............................. 21 levalbuterol hcl ................... 106 LEVEMIR ............................ 73 LEVEMIR FLEXTOUCH .... 73 levetiracetam ......................... 28 LEVETIRACETAM IN NACL

(ISO-OS) ........................... 28 levobunolol ........................... 99 levocarnitine ......................... 65 levocarnitine (with sugar) ..... 65 levocetirizine ...................... 103 levofloxacin .................... 15, 98

Index 9

levofloxacin in d5w .............. 15 levoleucovorin ...................... 17 levonest (28) ......................... 96 levonorgestrel-ethinyl estrad 96 levonorg-eth estrad triphasic 96 levorphanol tartrate .............. 34 levothyroxine ........................ 77 levoxyl .................................. 77 LEXIVA ................................. 3 LIALDA ............................... 80 lidocaine ............................... 58 lidocaine (pf) in d7.5w ........ 45 lidocaine (pf) .................. 45, 58 lidocaine hcl ......................... 58 lidocaine viscous .................. 58 lidocaine-epinephrine ........... 58 LIDOCAINE-EPINEPHRINE

BIT ................................... 58 lidocaine-prilocaine .............. 58 lillow .................................... 96 lindane .................................. 63 linezolid ................................ 11 linezolid-0.9% sodium chloride

.......................................... 11 LINZESS .............................. 80 LIORESAL .......................... 32 liothyronine .......................... 77 LIPOFEN ............................. 54 lisinopril ............................... 48 lisinopril-hydrochlorothiazide

.......................................... 48 lithium carbonate ............ 41, 42 lithium citrate ....................... 42 LIVALO ............................... 54 LONSURF ............................ 21 loperamide ............................ 78 lopinavir-ritonavir .................. 3 lorazepam ............................. 42 lorazepam intensol................ 42 lorcet (hydrocodone) ............ 34 lorcet hd ................................ 34 lorcet plus ............................. 34 losartan ................................. 48 losartan-hydrochlorothiazide 48 lovastatin .............................. 54 low-ogestrel (28) .................. 96 loxapine succinate ................ 42 ludent fluoride .................... 113 LUMIGAN ......................... 101

LUPRON DEPOT ................ 22 LUPRON DEPOT (3

MONTH) .......................... 22 LUPRON DEPOT (4

MONTH) .......................... 22 LUPRON DEPOT (6

MONTH) .......................... 22 LUPRON DEPOT-PED ....... 22 LUPRON DEPOT-PED (3

MONTH) .......................... 22 lutera (28) ............................. 96 LYNPARZA ......................... 22 LYRICA ............................... 28 LYSODREN ......................... 22 lyza ....................................... 93 M magnesium sulfate .............. 110 magnesium sulfate in water 109 MAKENA ............................ 93 malathion .............................. 63 maprotiline............................ 42 marlissa ................................. 96 MARPLAN .......................... 42 marten-tab ............................. 34 MATULANE........................ 22 matzim la .............................. 48 MAVYRET ............................ 4 MAXIPIME ............................ 8 md-gastroview ...................... 66 meclizine .............................. 80 meclofenamate ...................... 37 medroxyprogesterone ........... 93 mefenamic acid ..................... 37 mefloquine ............................ 11 megestrol .............................. 22 MEKINIST ........................... 22 melodetta 24 fe ..................... 96 meloxicam ............................ 37 melphalan ............................. 22 melphalan hcl ....................... 22 memantine ............................ 31 MEMANTINE...................... 32 MENACTRA (PF) ............... 88 MENEST .............................. 93 MENHIBRIX (PF) ............... 88 MENOMUNE - A/C/Y/W-135

.......................................... 88 MENOMUNE - A/C/Y/W-135

(PF) ................................... 88

MENTAX ............................. 60 MENVEO A-C-Y-W-135-DIP

(PF) ................................... 88 MEPIVACAINE (PF) .......... 58 mercaptopurine ..................... 22 meropenem ........................... 11 MEROPENEM-0.9%

SODIUM CHLORIDE ..... 11 mesalamine ........................... 80 mesalamine with cleansing

wipe .................................. 80 mesna .................................... 17 MESNEX .............................. 17 MESTINON ......................... 32 metadate er ............................ 42 metaproterenol .................... 106 metaxall ................................ 32 metformin ............................. 73 methadone ....................... 34, 35 methadone intensol ............... 34 methadose ............................. 35 methamphetamine ................. 42 methazolamide .................... 100 methenamine hippurate ........ 16 methenamine mandelate ....... 16 methergine ............................ 97 methimazole ......................... 70 METHITEST ........................ 75 methotrexate sodium ............ 22 methotrexate sodium (pf) ..... 22 methoxsalen .......................... 56 methscopolamine .................. 78 methyclothiazide ................... 49 methyldopa-

hydrochlorothiazide .......... 49 methyldopate ........................ 49 METHYLERGONOVINE ... 97 methylphenidate hcl .............. 42 methylprednisolone .............. 69 methylprednisolone acetate .. 69 methylprednisolone sodium

succ ................................... 69 methyltestosterone ................ 75 metipranolol .......................... 99 metoclopramide hcl .............. 80 metolazone ............................ 49 METOPIRONE .................... 66 metoprolol succinate ............. 49

Index 10

metoprolol ta-hydrochlorothiaz .......................................... 49

metoprolol tartrate ................ 49 metronidazole ..... 11, 12, 57, 93 metronidazole in nacl (iso-os)

.......................................... 11 mexiletine ............................. 45 MIACALCIN ....................... 75 mibelas 24 fe ........................ 96 miconazole-3 ........................ 94 microgestin 1.5/30 (21) ........ 96 microgestin 1/20 (21) ........... 96 microgestin fe 1.5/30 (28) .... 96 microgestin fe 1/20 (28) ....... 96 midodrine ............................. 66 migergot ............................... 30 miglitol ................................. 73 minocycline .......................... 15 minoxidil .............................. 49 mirtazapine ........................... 42 misoprostol ........................... 82 mitomycin ............................ 22 mitoxantrone ........................ 22 M-M-R II (PF) ...................... 88 modafinil .............................. 42 moderiba ................................. 4 moderiba dose pack ................ 4 moexipril .............................. 49 moexipril-hydrochlorothiazide

.......................................... 49 mometasone ............ 62, 63, 106 mondoxyne nl ....................... 15 MONOJECT INSULIN

SAFETY SYRING ........... 73 mono-linyah ......................... 96 montelukast ........................ 106 morgidox .............................. 16 morphine......................... 35, 36 MORPHINE ......................... 35 morphine (pf)........................ 35 morphine concentrate ........... 35 MOVANTIK ........................ 80 MOXEZA ............................. 98 moxifloxacin................... 15, 98 MOZOBIL ............................ 84 MULTAQ ............................. 45 multi-vit with fluoride-iron 113 multivitamin with fluoride . 113 multi-vitamin with fluoride 113

multivitamins with fluoride 113 mupirocin.............................. 59 mupirocin calcium ................ 59 MUSTARGEN ..................... 22 mvc-fluoride ....................... 113 MYALEPT ........................... 76 mycophenolate mofetil ......... 23 mycophenolate mofetil hcl ... 23 mycophenolate sodium ......... 23 MYCOPHENOLATE

SODIUM .......................... 23 MYRBETRIQ .................... 108 myzilra .................................. 96 N NABI-HB ............................. 88 nabumetone .......................... 37 nadolol .................................. 49 nadolol-bendroflumethiazide 49 nafcillin ................................. 13 nafcillin in dextrose iso-osm 13 naftifine ................................ 60 NAFTIN ............................... 60 NAGLAZYME ..................... 76 nalbuphine ............................ 37 naloxone ............................... 37 naltrexone ............................. 37 NAMENDA TITRATION

PAK .................................. 32 NAMENDA XR ................... 32 naproxen ............................... 37 naproxen sodium .................. 37 naratriptan ............................. 30 NARCAN ............................. 37 NAROPIN (PF) .................... 58 NATACYN .......................... 98 nateglinide ............................ 73 NATPARA ........................... 76 NAVELBINE ....................... 23 NEBUPENT ......................... 12 necon 0.5/35 (28) .................. 96 NEEDLES, INSULIN

DISP.,SAFETY ................ 73 nefazodone............................ 42 neomycin .............................. 12 neomycin-bacitracin-poly-hc

........................................ 101 neomycin-bacitracin-

polymyxin ......................... 98 neomycin-polymyxin b gu.... 63

neomycin-polymyxin b-dexameth ......................... 101

neomycin-polymyxin-gramicidin ......................... 98

neomycin-polymyxin-hc ...... 68, 101

neo-polycin ........................... 98 neo-polycin hc .................... 101 neostigmine methylsulfate .... 32 NEPHRAMINE 5.4 % ........ 112 NERLYNX ........................... 23 NESACAINE ....................... 58 neuac ..................................... 57 NEULASTA ......................... 84 NEUPOGEN ......................... 84 NEUPRO .............................. 30 NEUT ................................. 110 NEVANAC ......................... 100 nevirapine ............................... 4 NEXAVAR ........................... 23 next choice one dose ............. 96 niacin .................................... 54 nicardipine ............................ 49 NICOTROL .......................... 67 NICOTROL NS .................... 67 nifedipine .............................. 49 nikki (28) .............................. 96 NILANDRON ...................... 23 nilutamide ............................. 23 nimodipine ............................ 49 NINLARO ............................ 23 NIPENT ................................ 23 nisoldipine ............................ 49 nitro-bid ................................ 55 nitrofurantoin ........................ 16 nitrofurantoin macrocrystal .. 16 nitrofurantoin monohyd/m-

cryst .................................. 16 nitroglycerin ......................... 55 NITROMIST ........................ 55 NITROSTAT ........................ 55 nizatidine .............................. 82 nolix ...................................... 63 NORDITROPIN FLEXPRO 84 norethindrone (contraceptive)

.......................................... 93 norethindrone acetate ............ 93 norethindrone ac-eth estradiol

.................................... 93, 96

Index 11

norethindrone-e.estradiol-iron .......................................... 96

norgestimate-ethinyl estradiol .......................................... 96

norlyda .................................. 93 norlyroc ................................ 93 NORMOSOL-R ................. 110 NORMOSOL-R PH 7.4 ..... 112 NORPACE CR ..................... 45 NORTHERA ........................ 66 nortrel 0.5/35 (28) ................ 96 nortrel 1/35 (21) ................... 96 nortrel 1/35 (28) ................... 96 nortriptyline .......................... 43 NORVIR ................................ 4 novarel .................................. 76 NOVAREL ........................... 76 NOVOFINE 30 .................... 73 NOVOFINE 32 .................... 73 NOVOFINE PLUS ............... 73 NOVOLIN 70/30 ................. 73 NOVOLIN N ........................ 73 NOVOLIN R ........................ 73 NOVOLOG .......................... 73 NOVOLOG FLEXPEN ....... 73 NOVOLOG MIX 70-30 ....... 73 NOVOLOG MIX 70-30

FLEXPEN ........................ 73 NOVOLOG PENFILL ......... 73 NOVOTWIST ...................... 73 NOXAFIL .............................. 1 np thyroid ............................. 77 NPLATE .............................. 53 NUCYNTA .......................... 38 NUEDEXTA ........................ 32 NULOJIX ............................. 23 NUPLAZID .......................... 43 NUTRILIPID ..................... 112 NUTROPIN AQ NUSPIN ... 84 NUVARING......................... 94 nyamyc ................................. 60 nyata ..................................... 60 NYMALIZE ......................... 49 nystatin ............................. 1, 60 nystatin-triamcinolone .......... 60 nystop ................................... 60 O OCTAGAM .......................... 88 octreotide acetate .................. 23

ODEFSEY .............................. 4 ODOMZO ............................ 23 OFEV.................................. 106 ofloxacin ................... 15, 68, 98 ogestrel (28) .......................... 96 olanzapine ............................. 43 olanzapine-fluoxetine ........... 43 olmesartan ............................ 49 olmesartan-

hydrochlorothiazide .......... 49 olopatadine ..................... 68, 99 OLYSIO ................................. 4 omega-3 acid ethyl esters ..... 54 omeprazole ........................... 82 OMNARIS.......................... 106 OMNITROPE ....................... 84 ONCASPAR ......................... 23 ondansetron .......................... 80 ondansetron hcl..................... 80 ondansetron hcl (pf).............. 80 ONFI ..................................... 28 ONGLYZA ........................... 74 OPANA ................................ 36 OPANA ER .......................... 36 OPDIVO ............................... 23 opium tincture....................... 78 OPSUMIT .......................... 106 oralone .................................. 68 ORAP ................................... 43 ORENCIA ............................ 91 ORENCIA CLICKJECT ...... 91 ORENITRAM ...................... 49 ORFADIN ............................ 66 ORKAMBI ......................... 106 orsythia ................................. 96 oseltamivir .............................. 4 OTEZLA .............................. 91 OTEZLA STARTER ............ 92 OTREXUP (PF) ................... 92 oxacillin .......................... 13, 14 oxacillin in dextrose(iso-osm)

.......................................... 13 oxaliplatin ....................... 23, 24 oxandrolone .......................... 76 oxaprozin .............................. 38 oxcarbazepine ....................... 29 oxiconazole ........................... 60 OXISTAT ............................. 60 oxybutynin chloride ............ 108

oxycodone ............................. 36 OXYCODONE ..................... 36 oxycodone-acetaminophen ... 36 oxycodone-aspirin ................ 36 oxymorphone ........................ 36 OZURDEX ......................... 102 P pacerone ................................ 45 paclitaxel ............................... 24 paliperidone .......................... 43 pamidronate .......................... 76 PANCREAZE ....................... 80 PANDEL .............................. 63 PANRETIN .......................... 56 pantoprazole ......................... 82 paregoric ............................... 78 paricalcitol ............................ 76 PARICALCITOL ................. 76 paroex oral rinse ................... 68 paromomycin ........................ 12 paroxetine hcl ....................... 43 PASER .................................. 12 PATADAY ......................... 100 PAXIL .................................. 43 PAZEO ............................... 100 PCE ......................................... 9 PEDIARIX (PF) ................... 88 PEDVAX HIB (PF) .............. 88 peg 3350-electrolytes ............ 80 PEGANONE ......................... 29 PEGASYS ............................ 84 PEGASYS PROCLICK ........ 84 peg-electrolyte soln .............. 80 PEGINTRON ....................... 85 PEGINTRON REDIPEN ...... 84 PEN NEEDLE ...................... 74 PENICILLIN G POT IN

DEXTROSE ..................... 14 penicillin g potassium ........... 14 penicillin g procaine ............. 14 penicillin g sodium ............... 14 penicillin v potassium ........... 14 PENTACEL (PF) .................. 88 PENTACEL ACTHIB

COMPONENT (PF) ......... 88 PENTAM .............................. 12 PENTASA ............................ 80 pentoxifylline ........................ 53 PERIKABIVEN ................. 112

Index 12

perindopril erbumine ............ 49 periogard............................... 68 PERJETA ............................. 24 permethrin ............................ 63 perphenazine......................... 43 PERTZYE ............................ 80 pfizerpen-g ........................... 14 phenadoz............................. 103 phenelzine............................. 43 phenergan ........................... 103 phenobarbital ........................ 29 phenytoin .............................. 29 phenytoin sodium ................. 29 phenytoin sodium extended .. 29 philith ................................... 96 PHOSLYRA ....................... 110 PHOSPHOLINE IODIDE .... 99 PICATO ............................... 56 pilocarpine hcl ................ 66, 99 pimozide ............................... 43 pimtrea (28) .......................... 96 pindolol ................................ 49 pioglitazone .......................... 74 pioglitazone-glimepiride ...... 74 pioglitazone-metformin ........ 74 piperacillin-tazobactam ........ 14 pirmella................................. 96 piroxicam .............................. 38 PLASMA-LYTE 148 ......... 113 PLASMA-LYTE A ............ 113 plasmanate .......................... 113 PLEGRIDY .......................... 85 podofilox .............................. 56 polycin .................................. 98 polyethylene glycol 3350 ..... 81 polymyxin b sulfate .............. 12 polymyxin b sulf-trimethoprim

.......................................... 98 POMALYST ........................ 24 PORTRAZZA ...................... 24 potassium acetate................ 110 potassium bicarb and chloride

........................................ 110 potassium bicarb-citric acid 110 potassium chlorid-d5-

0.45%nacl ....................... 110 potassium chloride.............. 110 potassium chloride in 0.9%nacl

........................................ 110

potassium chloride in 5 % dex ........................................ 110

potassium chloride in lr-d5 . 110 potassium chloride-0.45 % nacl

........................................ 110 potassium chloride-d5-

0.2%nacl ......................... 110 potassium chloride-d5-

0.3%nacl ......................... 111 potassium chloride-d5-

0.9%nacl ......................... 111 potassium citrate ................. 109 potassium phosphate m-/d-

basic ................................ 111 PRADAXA ........................... 53 pramipexole .......................... 30 PRAMOSONE ..................... 56 prasugrel ............................... 53 pravastatin ............................ 54 prazosin ................................ 49 PRED MILD....................... 102 PRED-G.............................. 101 PRED-G S.O.P. .................. 101 prednicarbate ........................ 63 prednisolone ......................... 69 prednisolone acetate ........... 102 prednisolone sodium phosphate

.................................. 70, 102 prednisone ............................ 70 prednisone intensol ............... 70 PREMARIN ......................... 93 premasol 10 % .................... 113 PREMASOL 6 % ............... 113 prenatal vitamin oral tablet . 113 prevalite ................................ 54 PREVIDENT 5000 BOOSTER

PLUS ................................ 68 PREVIDENT 5000 DRY

MOUTH ........................... 68 PREVIDENT 5000 ENAMEL

PROTECT ........................ 68 PREVIDENT 5000

SENSITIVE ...................... 68 previfem................................ 96 PREZCOBIX .......................... 4 PREZISTA ............................. 4 PRIALT ................................ 38 PRIFTIN ............................... 12 PRIMAQUINE ..................... 12

primidone .............................. 29 PRIMSOL ............................. 16 PRISTIQ ............................... 43 PRIVIGEN ........................... 88 PROAIR HFA .................... 106 PROAIR RESPICLICK ...... 106 probenecid ............................ 90 probenecid-colchicine ........... 90 procainamide ........................ 45 prochlorperazine ................... 81 prochlorperazine edisylate .... 81 prochlorperazine maleate oral

.......................................... 81 PROCRIT ............................. 85 PROCTOFOAM HC ............ 81 procto-med hc ....................... 81 proctosol hc .......................... 81 proctozone-hc ....................... 81 PROCYSBI ......................... 109 progesterone micronized ...... 93 PROGLYCEM ..................... 74 PROGRAF ............................ 24 PROLASTIN-C .................... 66 PROLEUKIN ....................... 85 PROLIA ................................ 91 PROMACTA ........................ 53 promethazine .............. 103, 104 promethegan ....................... 104 propafenone .......................... 45 proparacaine ....................... 100 propranolol ..................... 49, 50 propranolol-hydrochlorothiazid

.......................................... 50 propylthiouracil .................... 70 PROQUAD (PF) ................... 88 PROSOL 20 % ................... 113 PROTOPAM CHLORIDE ... 63 protriptyline .......................... 43 PULMICORT FLEXHALER

........................................ 106 PULMOZYME ................... 106 PURIXAN ............................ 24 PYLERA ............................... 82 pyrazinamide ........................ 12 pyridostigmine bromide ........ 32 Q QUADRACEL (PF) ............. 88 quetiapine ............................. 43 quinapril ................................ 50

Index 13

quinapril-hydrochlorothiazide .......................................... 50

quinidine gluconate .............. 45 quinidine sulfate ................... 45 quinine sulfate ...................... 12 QVAR ................................ 106 R RABAVERT (PF) ................ 88 RADICAVA ......................... 32 RAGWITEK......................... 89 raloxifene .............................. 91 ramipril ................................. 50 RANEXA ............................. 55 ranitidine hcl ......................... 82 RAPAMUNE ....................... 24 rasagiline .............................. 30 RASUVO (PF) ..................... 92 RAVICTI .............................. 66 REBETOL .............................. 4 REBIF (WITH ALBUMIN) . 85 REBIF REBIDOSE .............. 85 REBIF TITRATION PACK 85 reclipsen (28) ........................ 96 RECOMBIVAX HB (PF) .... 89 regonol .................................. 32 relador pak ............................ 59 relador pak plus .................... 59 RELENZA DISKHALER ...... 4 RELISTOR ........................... 81 RELPAX .............................. 30 REMICADE ......................... 81 REMODULIN ...................... 50 RENACIDIN ...................... 109 RENAGEL ........................... 66 RENVELA ........................... 66 repaglinide ............................ 74 repaglinide-metformin .......... 74 REPATHA PUSHTRONEX 54 REPATHA SURECLICK .... 54 REPATHA SYRINGE ......... 54 RESCRIPTOR ........................ 4 RESTASIS ......................... 100 RESTASIS MULTIDOSE . 100 RETISERT ......................... 102 RETROVIR ............................ 4 REVATIO .......................... 106 REVLIMID .......................... 24 revonto .................................. 32 REXULTI ............................. 43

REYATAZ ............................. 4 RHOPHYLAC...................... 89 ribasphere ........................... 4, 5 ribasphere ribapak .................. 5 ribavirin .................................. 5 RIDAURA ............................ 92 rifabutin ................................ 12 rifampin ................................ 12 RIFATER ............................. 12 riluzole .................................. 66 rimantadine ............................. 5 RIMSO-50 ............................ 12 ringer's .......................... 63, 111 risedronate ...................... 66, 91 RISPERDAL CONSTA ....... 43 risperidone ............................ 43 RITUXAN ............................ 24 RITUXAN HYCELA ........... 24 rivastigmine .......................... 32 rivastigmine tartrate .............. 32 rivelsa ................................... 97 rizatriptan.............................. 31 ropinirole .............................. 30 ropivacaine (pf) .................... 59 rosadan............................ 57, 58 rosuvastatin ........................... 54 ROTARIX ............................ 89 ROTATEQ VACCINE......... 89 roweepra ............................... 29 ROZEREM ........................... 43 RUBRACA ........................... 24 RYDAPT .............................. 24 S SABRIL ................................ 29 SAIZEN ................................ 85 SAIZEN CLICK.EASY ....... 85 SAIZEN SAIZENPREP ....... 85 salsalate ................................ 38 SAMSCA ............................. 76 SANCUSO ........................... 81 SANDOSTATIN LAR

DEPOT ............................. 24 SANTYL .............................. 63 SAPHRIS (BLACK

CHERRY) ........................ 44 SAVELLA ............................ 92 scopolamine base .................. 81 selegiline hcl ......................... 30 selenium sulfide .................... 56

SELZENTRY ......................... 5 SENSIPAR ........................... 76 SEREVENT DISKUS ........ 106 SEROQUEL XR ................... 44 SEROSTIM .......................... 85 sertraline ............................... 44 sevelamer carbonate ............. 66 sf 68 sf 5000 plus ........................... 68 sharobel ................................. 93 SIGNIFOR ............................ 24 SIGNIFOR LAR ................... 24 sildenafil ............................. 106 silver sulfadiazine ................. 56 SIMBRINZA ...................... 101 SIMPONI .............................. 92 SIMPONI ARIA ................... 92 SIMULECT .......................... 24 simvastatin ............................ 54 sirolimus ............................... 24 SIRTURO ............................. 12 SIVEXTRO .......................... 12 SKLICE ................................ 63 SMOFLIPID ....................... 113 sodium acetate .................... 111 sodium benzoate-sod

phenylacet ......................... 66 sodium bicarbonate ............. 111 sodium chloride ............ 66, 111 sodium chloride 0.45 % ...... 111 sodium chloride 0.9 % .......... 66 sodium chloride 3 % ........... 111 sodium chloride 5 % ........... 111 sodium lactate intravenous . 111 sodium phenylbutyrate ......... 66 sodium phosphate ............... 111 sodium polystyrene (sorb free)

.......................................... 66 sodium polystyrene sulfonate

.......................................... 66 SODIUM POLYSTYRENE

SULFONATE ................... 66 SOLIRIS ............................... 67 SOLTAMOX ........................ 24 SOLU-CORTEF ................... 70 SOLU-CORTEF (PF) ........... 70 SOLU-MEDROL ................. 70 SOLU-MEDROL (PF) ......... 70 SOMATULINE DEPOT ...... 24

Index 14

SOMAVERT ........................ 76 SORBITOL .......................... 63 sorine .................................... 45 sotalol ................................... 45 sotalol af ............................... 45 SOVALDI .............................. 5 SPIRIVA RESPIMAT ....... 106 SPIRIVA WITH

HANDIHALER .............. 107 spironolactone ...................... 50 spironolacton-hydrochlorothiaz

.......................................... 50 SPORANOX .......................... 1 sprintec (28).......................... 97 SPRITAM ............................ 29 SPRYCEL ............................ 24 sps (with sorbitol) ................. 67 sronyx ................................... 97 ssd ......................................... 56 STAMARIL (PF) ................. 89 stavudine................................. 5 STELARA ............................ 56 STIMATE ............................ 76 STIOLTO RESPIMAT ...... 107 STIVARGA .......................... 24 STRATTERA ....................... 44 STRENSIQ ........................... 76 STREPTOMYCIN ............... 12 STRIBILD .............................. 5 STRIVERDI RESPIMAT .. 107 SUBOXONE ........................ 38 SUBSYS ............................... 36 sucralfate .............................. 82 sulfacetamide sodium ......... 102 sulfacetamide sodium (acne) 59 sulfacetamide-prednisolone 102 sulfadiazine........................... 15 sulfamethoxazole-trimethoprim

.......................................... 15 SULFAMYLON .................. 59 sulfasalazine ......................... 81 sulfatrim ............................... 15 sulindac................................. 38 sumatriptan ........................... 31 sumatriptan succinate ........... 31 SUPPRELIN LA .................. 24 SUPRAX ................................ 8 SUPREP BOWEL PREP KIT

.......................................... 81

SUSTIVA ............................... 5 SUTENT ............................... 24 syeda ..................................... 97 SYLATRON ......................... 85 SYLVANT ........................... 25 SYMBICORT ..................... 107 SYMLINPEN 120 ................ 74 SYMLINPEN 60 .................. 74 SYNAGIS ............................... 5 SYNAREL............................ 76 SYNERCID .......................... 12 SYNRIBO ............................ 25 SYPRINE ............................. 67 T TABLOID ............................ 25 TACLONEX ........................ 56 tacrolimus ....................... 25, 56 TAFINLAR .......................... 25 TAGRISSO .......................... 25 TAMIFLU .............................. 5 tamoxifen .............................. 25 tamsulosin ........................... 108 TARCEVA ........................... 25 TARGRETIN ....................... 25 tarina fe 1/20 (28) ................. 97 TASIGNA ............................ 25 tazarotene.............................. 58 TAZICEF................................ 8 TAZORAC ........................... 58 taztia xt ................................. 50 TECENTRIQ ........................ 25 TECFIDERA ........................ 32 TECHNIVIE ........................... 5 TEFLARO .............................. 8 TEKTURNA ........................ 50 TEKTURNA HCT ............... 50 telmisartan ............................ 50 telmisartan-amlodipine ......... 50 telmisartan-hydrochlorothiazid

.......................................... 50 temazepam ............................ 44 TEMODAR .......................... 25 TENIVAC (PF) .................... 89 terazosin................................ 50 terbinafine hcl ......................... 2 terbutaline ........................... 107 terconazole............................ 94 TESTIM................................ 76 TESTOPEL .......................... 76

testosterone ........................... 77 TESTOSTERONE .......... 76, 77 testosterone cypionate .......... 76 testosterone enanthate ........... 76 TESTRED ............................. 77 TETANUS,DIPHTHERIA

TOX PED(PF) .................. 89 TETANUS-DIPHTHERIA

TOXOIDS-TD .................. 89 tetrabenazine ......................... 32 tetracycline ........................... 16 THALOMID ......................... 25 THAM ................................ 113 theophylline ........................ 107 thioridazine ........................... 44 thiotepa ................................. 25 thiothixene ............................ 44 THROMBATE III ................ 53 THYMOGLOBULIN ........... 89 thyroid (pork) ........................ 77 tiagabine ............................... 29 TICE BCG ............................ 89 ticlopidine ............................. 53 tilia fe .................................... 97 timolol maleate ............... 50, 99 tinidazole .............................. 12 TIVICAY ................................ 5 tizanidine .............................. 33 TOBI PODHALER .............. 12 TOBRADEX ...................... 101 TOBRADEX ST ................. 101 tobramycin ............................ 98 tobramycin in 0.225 % nacl .. 12 tobramycin sulfate ................ 12 tobramycin-dexamethasone 101 tolcapone ............................... 30 tolmetin ................................. 38 tolterodine ........................... 108 topiramate ............................. 29 toposar .................................. 25 topotecan ............................... 25 TORISEL .............................. 25 torsemide .............................. 50 TOUJEO SOLOSTAR ......... 74 TOVIAZ ............................. 108 TRACLEER ....................... 107 tramadol ................................ 38 tramadol-acetaminophen ...... 38 trandolapril ........................... 50

Index 15

trandolapril-verapamil .......... 50 tranexamic acid .............. 53, 94 TRANSDERM-SCOP .......... 81 tranylcypromine ................... 44 travasol 10 % ...................... 113 TRAVATAN Z .................. 101 trazodone .............................. 44 TREANDA ........................... 25 TRECATOR ......................... 12 TRELSTAR .......................... 25 tretinoin (chemotherapy) ...... 25 tretinoin topical .................... 58 TRETIN-X ........................... 58 TREXALL ............................ 25 tri femynor ............................ 97 triamcinolone acetonide 63, 68,

70 triamterene-hydrochlorothiazid

.......................................... 50 trianex ................................... 63 triazolam ............................... 44 triderm .................................. 63 tri-estarylla ........................... 97 trifluoperazine ...................... 44 trifluridine............................. 98 TRIGLIDE ........................... 54 trihexyphenidyl .................... 30 triklo ..................................... 54 tri-legest fe............................ 97 tri-linyah ............................... 97 tri-lo-estarylla ....................... 97 tri-lo-marzia .......................... 97 tri-lo-sprintec ........................ 97 trilyte with flavor packets ..... 81 trimethoprim ......................... 16 trimipramine ......................... 44 trinessa lo.............................. 97 TRINTELLIX....................... 44 triple vitamin with fluoride 113 tri-previfem (28) ................... 97 TRISENOX .......................... 25 tri-sprintec (28) ..................... 97 TRIUMEQ .............................. 5 tri-vit with fluoride and iron

........................................ 114 tri-vitamin with fluoride ..... 114 trivora (28)............................ 97 TROPHAMINE 10 % ........ 113 trospium .............................. 108

TRUMENBA........................ 89 TRUVADA ............................ 5 TUDORZA PRESSAIR ..... 107 TWINRIX (PF)..................... 89 TYBOST ................................ 5 TYGACIL ............................ 12 TYKERB .............................. 25 TYMLOS.............................. 91 TYPHIM VI ......................... 89 TYSABRI ............................. 32 TYVASO ............................ 107 TYVASO INSTITUTIONAL

START KIT .................... 107 TYVASO REFILL KIT...... 107 TYVASO STARTER KIT . 107 U ULORIC ............................... 90 unithroid ............................... 77 UPTRAVI ............................. 50 ursodiol ................................. 81 UVADEX ............................. 57 V VAGIFEM ............................ 93 valacyclovir ............................ 5 VALCHLOR ........................ 57 valganciclovir ......................... 5 valproate sodium .................. 29 valproic acid ......................... 29 valproic acid (as sodium salt)

.......................................... 29 valsartan................................ 50 valsartan-hydrochlorothiazide

.......................................... 50 VALSTAR............................ 25 vancomycin .......................... 16 VANCOMYCIN .................. 16 VANCOMYCIN IN 0.9%

SODIUM CL .................... 16 VANCOMYCIN IN

DEXTROSE 5 % .............. 16 vandazole .............................. 94 VAQTA (PF) ........................ 89 VARIVAX (PF) ................... 90 VARIZIG.............................. 90 VASCEPA ............................ 54 VECAMYL .......................... 55 VECTIBIX ........................... 26 VELCADE ........................... 26 veletri .................................... 50

VELTASSA .......................... 67 VENCLEXTA ...................... 26 VENCLEXTA STARTING

PACK ............................... 26 venlafaxine ........................... 44 VENTAVIS ........................ 107 VENTOLIN HFA ............... 107 verapamil .............................. 51 VERSACLOZ ....................... 44 VESICARE ......................... 108 vestura (28) ........................... 97 VGO 20 ................................ 74 VGO 30 ................................ 74 VGO 40 ................................ 74 VIBATIV .............................. 16 VICTOZA 2-PAK ................ 74 VICTOZA 3-PAK ................ 74 VIDEX 2 GRAM PEDIATRIC

............................................ 6 VIDEX 4 GRAM PEDIATRIC

............................................ 6 VIEKIRA PAK ....................... 6 VIEKIRA XR ......................... 6 vienva ................................... 97 vigabatrin .............................. 29 VIGAMOX ........................... 98 VIIBRYD ............................. 44 VIMPAT ............................... 29 vinblastine ............................. 26 vincasar pfs ........................... 26 vincristine ............................. 26 vinorelbine ............................ 26 viorele (28) ........................... 97 VIRACEPT ............................. 6 VIRAZOLE ............................ 6 VIREAD ................................. 6 vitamins a,c,d and fluoride . 114 VIVITROL ........................... 38 voriconazole ........................... 2 VOTRIENT .......................... 26 VPRIV .................................. 77 VRAYLAR ........................... 44 VYTORIN 10-10 .................. 54 VYTORIN 10-20 .................. 54 VYTORIN 10-40 .................. 54 VYTORIN 10-80 .................. 54 VYXEOS .............................. 26 W warfarin ................................. 53

Index 16

water for irrigation, sterile .... 67 WELCHOL .......................... 54 wera (28) .............................. 97 wymzya fe ............................ 97 X XALKORI ............................ 26 XARELTO ........................... 53 XATMEP ............................. 26 XELJANZ ............................ 92 XELJANZ XR ...................... 92 XGEVA ................................ 17 XIFAXAN ............................ 13 XIGDUO XR........................ 74 XOLAIR ............................. 107 XOPENEX HFA ................ 107 XTANDI............................... 26 XYLOCAINE (CARDIAC)

(PF) ................................... 45 xylocaine dental-epinephrine 59 XYLOCAINE-

MPF/EPINEPHRINE ....... 59 xylon 10 ................................ 36 XYREM ............................... 44 Y YERVOY ............................. 26 YF-VAX (PF) ....................... 90 YONDELIS .......................... 26

yuvafem ................................ 93 Z zafirlukast ........................... 107 zaleplon ................................ 44 ZALTRAP ............................ 26 zamicet.................................. 36 ZANOSAR ........................... 26 zarah ..................................... 97 ZARXIO ............................... 85 ZAVESCA............................ 77 ZEJULA ............................... 26 ZELAPAR ............................ 30 ZELBORAF ......................... 26 ZEMAIRA ............................ 67 ZEMPLAR ........................... 77 ZENPEP ............................... 81 ZEPATIER ............................. 6 ZERBAXA ............................. 8 ZERIT ..................................... 6 ZETIA .................................. 54 ZIAGEN ................................. 6 zidovudine .............................. 6 zileuton ............................... 108 ZIOPTAN (PF) ................... 101 ziprasidone hcl ...................... 44 ZIRGAN ............................... 99 ZMAX .................................... 9

ZOLADEX ........................... 26 zoledronic acid ...................... 77 zoledronic acid-mannitol-water

.......................................... 67 ZOLINZA ............................. 26 zolmitriptan ........................... 31 ZOMIG ................................. 31 zonisamide ............................ 29 ZORBTIVE .......................... 85 ZORTRESS .......................... 26 ZOSTAVAX (PF) ................ 90 ZOSYN IN DEXTROSE (ISO-

OSM) ................................ 14 zovia 1/35e (28) .................... 97 zovia 1/50e (28) .................... 97 ZOVIRAX ............................ 60 ZURAMPIC ......................... 90 ZYDELIG ............................. 26 ZYFLO ............................... 108 ZYFLO CR ......................... 108 ZYKADIA ............................ 26 ZYLET ............................... 101 ZYPREXA RELPREVV 44, 45 ZYTIGA ............................... 27 ZYVOX ................................ 13

Branch Hillsdale Monroe

Kalamazoo Calhoun Jackson WayneWashtenaw

Barry

Ionia

Montcalm Gratiot Saginaw

Shia-wassee

LapeerGenesee

SanilacTuscola

Ingham LivingstonEaton

Clinton St. Clair

OaklandMacomb

Mecosta

Osceola Clare GladwinArenac

BayMidlandIsabella

Huron

Manistee Wexford MissaukeeRoscommon Ogemaw Iosco

GrandTraverse

Kalkaska Crawford Oscoda Alcona

Antrim Otsego Mont-morency

Cheboygan PresqueIsle

Van Buren

Allegan

OttawaKent

Muskegon

NewaygoOceana

Mason Lake

Lenawee

Benzie

LeelanauAlpena

Emmet

Charlevoix

St. Joseph

St. Joseph ZIP Codes Served

490114903049052490724909349097

MackinacSchoolcraft

Luce

Branch Hillsdale Monroe

Kalamazoo Calhoun Jackson WayneWashtenaw

Barry

Ionia

Montcalm Gratiot Saginaw

Shia-wassee

LapeerGenesee

SanilacTuscola

Ingham LivingstonEaton

Clinton St. Clair

OaklandMacomb

Mecosta

Osceola Clare GladwinArenac

BayMidlandIsabella

Huron

Manistee Wexford MissaukeeRoscommon Ogemaw Iosco

GrandTraverse

Kalkaska Crawford Oscoda Alcona

Antrim Otsego Mont-morency

Cheboygan PresqueIsle

Van Buren

Allegan

OttawaKent

Muskegon

NewaygoOceana

Mason Lake

Lenawee

Benzie

LeelanauAlpena

Emmet

Charlevoix

St. Joseph

St. Joseph ZIP Codes Served

490114903049052490724909349097

MackinacSchoolcraft

Luce

BCN Advantage service area

You are always covered for emergency and urgent care anywhere in Michigan, the nation or the world.

DEEMED

MEDICARE ADVANTAGE

R075319

This formulary was updated on 12/01/2017. For more recent information or other questions, please contact BCN Advantage Customer Service at 1‑800‑450‑3680 or, for TTY users, 711, 8 a.m. to 8 p.m. Monday through Friday, with weekend hours Oct. 1 through Feb. 14, or visit www.bcbsm.com/medicare. The formulary, pharmacy network, and provider network may change at any time. You will receive notice when necessary. Medicare Customer Service: 1‑800‑MEDICARE (TTY/TDD 1‑877‑486‑2048) 24 hours a day seven days a week

Blue Care Network Corporate Offices P.O. Box 5043 Southfield, MI 48086‑5043

BCN AdvantageSM Service Area

DB 13991 DEC 17

H5883_C_2017Formulary CMS Accepted 09102016

Documents

BCN Advantage HMO-POS and HMO - bcbsm.com · 2017. 12. 1. · 2017 Formulary (List of covered drugs) PLEASE READ: DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN