HCIC Exchange (Arizona) Formulary-CustomCat/Class · Comprehensive Formulary 2016 List of covered drugs ... formulary is very comprehensive and has many brand and generic drugs that

ComprehensiveFormulary2016List of covered drugs Updated December 1, 2016

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2016 Comprehensive Formulary

Introduction

Health Choice Insurance Co. utilizes a Pharmacy and Therapeutics Committee (P & T

Committee), made up of practicing physicians, pharmacists, and nurses to help

ensure that our formulary drug list is medically sound and that it supports patient

health. This committee reviews and evaluates medications on the formulary based

on safety and efficacy to help maintain clinical integrity in all therapy categories.

Prescription medicines covered by Health Choice Insurance Co. must be prescribed for

you by your doctor and must be FDA approved products.

Formulary Drug List

The Health Choice Insurance Co formulary is closed. This means that if the drug is not

on the formulary (List of Covered Drugs) it will not be covered unless your doctor

explains why no other drugs on the formulary will work for your medical condition. The

formulary is very comprehensive and has many brand and generic drugs that treat

many medical conditions. The drugs are placed in tiers that determine your

medication cost. Drugs in higher tiers usually have higher costs.

Tier 1: Generic drugs Tier 2: Preferred brand drugsTier 3: Non‐preferred drugs Tier 4: Specialty drugs Tier 5: Oral Cancer Specialty Drugs Tier 6: Zero‐cost share, Preventive Health Drugs

Within each drug category and class, drugs are listed in alphabetical order by drug

product name. Drugs in lower case italics are generic drugs products (e.g. glipizide),

and drugs listed in upper case letters (e.g. JANUVIA) are brand drug products. Brand

drug products are listed as either preferred brand name products (Tier 2), non‐

preferred brand products (Tier 3), specialty drugs (Tier 4), and oral cancer specialty

drugs, generic and brand drug (Tier 5).

Preventive Health medications for men, women and children which are located

in Tier 6 are covered as a requirement of The Affordable Care Act of 2010.

These medications are covered at no cost, without a copayment or having to

meet the plan deductible when specific criteria are met.

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For prescriptions medicines for which a generic product exists, the generic product will be on the formulary and the brand name product will not be on the formulary. To avoid additional costs members should ask their doctor to prescribe available generic equivalent medications.

Most drugs on the formulary will have a copayment or co‐insurance. Copayment

o r c o ‐ i n s u r a n c e is a portion of the cost of a covered formulary drug that a

member must pay. For information about prescription drug copayments please

see your Health Choice Insurance Schedule of Benefits document.

Common Prescription Drug Terms

Generic Drug‐ Drugs marketed without brand names are generally less expensive than brand‐name drugs. They are chemically identical to brand‐name drugs and meet the same standards of the FDA (US Food and Drug Administration) for safety, purity and effectiveness.

Preferred Brand Drug –Drugs on the formulary that have a trade name and are protected by a patent. These drugs meet the standards of the FDA for safety, purity and effectiveness. These brand drugs are preferred over other brand drugs because of better

efficacy or lower cost. These drugs are used when there is not a generic drug available to treat your medical condition.

Non‐Preferred Brand Drug – Drugs on the formulary that have a trade name and are protected by a patent. These drugs meet the standards of the FDA for safety, purity and effectiveness. The drugs are commonly used when a “preferred brand” or “generic” drug is not available to treat your medical condition. The cost of these drugs is usually higher than “generic” or “preferred” brand drugs that can be used to treat your condition.

Specialty Drug – Drugs that are unique and/or very high‐cost drugs used to treat rare and/or complex medical conditions. Oral Cancer drugs are specialty drugs.

Preventive Health Medication‐ Drugs that are covered per the Affordable Care Act. The Affordable Care Act of 2010 requires the coverage of certain preventive medications for men, women and children. These medications are included on the formulary and are covered at no cost, without a copayment or having to meet the plan deductible when specific criteria are met. These preventive medications include products like aspirin, folic acid, iron and fluoride supplements, certain contraceptives, and vaccines.

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Medication Management

Some of the formulary drugs are subject to medication management restrictions. These restrictions promote the safe and effective use of medicines. Restrictions include age (AL), gender (GL) and/or quantity (QL) limits, step therapy (ST) and prior authorization (PA). Medication management restrictions are subject to change as medical evidence requires. Our formulary notes if a drug needs PA, ST, QL, GL, or AL. Common medication management restrictions are noted below.

Prior Authorization: This requires you or your doctor to get approval before youfill your prescription. If you don’t get approval, Health Choice may not cover thedrug.Prior authorization criteria are based on nationally recognized guidelines; FDAapproved indications and accepted standards of practice. Prior Authorizationis common for ‘specialty’ medications.

Step Therapy: This requires that you must first try certain drugs to treatyour medical condition before we will cover another drug for thatcondition. For example, if Drug Aand Drug B both treat your condition, Health Choice may not cover Drug Bunless you try Drug A first. If Drug A does not work for you, we will thencover Drug B.

Quantity Limits: This limits the amount of the drug covered per 30 day fill.

For detailed information on drugs that require prior authorization, step therapy, or have a quantity limit please visit our website, www.healthchoiceessential.com/members/rxdrugs.

Specialty Medication Management

Certain medications used for treating complex health conditions are handled through our Specialty Pharmacy, Orchard Specialty. The purpose of the Specialty Pharmacy is to assist you with monitoring your medication needs for conditions such as Multiple Sclerosis, Rheumatoid Arthritis, Cancer, Hepatitis, Psoriasis and transplant, and providing patient education. The program assists members with the use of drugs requiring complex administration methods, special storage, and handling as well as requiring close patient monitoring to make sure the drug works properly for the member.

Medications may only be obtained through Orchard Specialty pharmacy and are only dispensed in 30 day supplies. A specialty pharmacy representative may contact you to facilitate your enrollment in the specialty program. Trained specialty pharmacy staff is available 24 hours a day, 7 days a week to assist you.

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Health Choice Insurance Company2016 Formulary

Table of Contents

Table of Contents

Analgesics (Pain, Inflammation, Muscle, Joint Condition Drugs) ........................................................................................................................ 3Anesthetics (Numbing Drugs) ................................................................................................................................................................................................................................... 5Anti-Addiction/Substance Abuse Treatment Agents ............................................................................................................................................................... 5Antibacterials (Infection Fighting Drugs) ................................................................................................................................................................................................... 6Anticonvulsants (Nerve Condition Drugs) ........................................................................................................................................................................................... 11Antidementia Agents (Nerve Condition Drugs) ........................................................................................................................................................................... 14Antidepressants ......................................................................................................................................................................................................................................................................... 14Antidepressants (Nerve Condition Drugs) .......................................................................................................................................................................................... 14Antiemetics (Bowel, Instestine, And Stomach Condition Drugs) ...................................................................................................................... 17Antifungals (Infection Fighting Drugs) ....................................................................................................................................................................................................... 17Antigout Agents (Pain, Inflammation, Muscle, Joint Condition Drugs) .................................................................................................... 19Anti-Inflammatory Agents (Pain, Inflammation, Muscle, Joint Condition Drugs) ...................................................................... 19Antimigraine Agents (Nerve Condition Drugs) ............................................................................................................................................................................. 20Antimyasthenic Agents (Nerve Condition Drugs) .................................................................................................................................................................... 21Antimycobacterials (Infection Fighting Drugs) .............................................................................................................................................................................. 21Antineoplastics (Cancer Drugs) ......................................................................................................................................................................................................................... 22Antiparasitics (Infection Fighting Drugs) ............................................................................................................................................................................................... 29Antiparkinson Agents (Nerve Condition Drugs) .......................................................................................................................................................................... 29Antipsychotics (Nerve Condition Drugs) ................................................................................................................................................................................................ 30Antispasticity Agents (Muscle And Joint Drugs) ........................................................................................................................................................................ 32Antivirals (Infection Fighting Drugs) ............................................................................................................................................................................................................. 32Anxiolytics (Nerve Condition Drugs) ............................................................................................................................................................................................................ 36Bipolar Agents (Nerve Condition Drugs) ............................................................................................................................................................................................... 36Blood Glucose Regulators (Hormone And Diabetic Drugs) ..................................................................................................................................... 37Blood Products/Modifiers/ Volume Expanders (Blood Disorder Drugs) ................................................................................................. 40Cardiovascular Agents (Heart And Circulation Condition Drugs) .................................................................................................................... 41Central Nervous System Agents (Nerve Condition Drugs) ....................................................................................................................................... 48Contraceptives ............................................................................................................................................................................................................................................................................. 50Cough/Cold/Allergy ............................................................................................................................................................................................................................................................... 55Dental And Oral Agents ................................................................................................................................................................................................................................................. 55Dental And Oral Agents (Drugs For The Mouth) ...................................................................................................................................................................... 56Dermatological Agents (Drugs Affecting Skin) ............................................................................................................................................................................. 56Enzyme Replacement/ Modifiers (Hormone And Enzyme Drugs) ................................................................................................................. 62Gastrointestinal Agents (Bowel, Instestine, And Stomach Condition Drugs) ................................................................................. 63Genitourinary Agents (Bladder, Genital, And Kidney Condition Drugs) ................................................................................................. 66Hematopoietic Agents ....................................................................................................................................................................................................................................................... 68Hereditary Orotic Aciduria Treatment Agents ................................................................................................................................................................................ 68Hormonal Agents Stimulant/ Replacement/ Modifying (Adrenal) ..................................................................................................................... 69Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) ................................................................................................................... 69Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) (Hormone And Diabetic Drugs) ........................................................................................................................................................................................................................................................................... 70Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary) (Hormone And Diabetic Drugs) ............... 71Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid) (Hormone And Diabetic Drugs) ................. 72Hormonal Agents, Stimulant/Replacement/Modifying (Parathyroid) ........................................................................................................... 72Hormonal Agents, Suppressant (Parathyroid) (Hormone And Diabetic Drugs) ......................................................................... 72Hormonal Agents, Suppressant (Pituitary) (Hormone And Diabetic Drugs) .................................................................................... 73

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Table of Contents

Hormonal Agents, Suppressant (Thyroid) (Hormone And Diabetic Drugs) ...................................................................................... 73Immunological Agents (Drugs Affecting The Immune System) .......................................................................................................................... 74Inflammatory Bowel Disease Agents (Bowel, Instestine, And Stomach Condition Drugs) ........................................ 79Metabolic Bone Disease Agents (Hormone And Bone Drugs) ............................................................................................................................ 79Miscellaneous (Misc) .......................................................................................................................................................................................................................................................... 80Ophthalmic Agents (Eye Medications) ..................................................................................................................................................................................................... 81Otic Agents (Ear Drugs) ................................................................................................................................................................................................................................................. 84Respiratory Tract Agents (Allergies, Cough, Cold, And Lung Condition Drugs) ....................................................................... 85Respiratory Tract/Pulmonary Agents ......................................................................................................................................................................................................... 89Respiratory Tract/Pulmonary Agents (Allergies, Cough, Cold, And Lung Condition Drugs) .................................. 89Skeletal Muscle Relaxants (Muscle And Joint Drugs) ...................................................................................................................................................... 89Sleep Disorder Agents (Sleep Condition Drugs) ...................................................................................................................................................................... 89Therapeutic Nutrients/ Minerals/ Electrolytes (Multivitamins And Replacement Solutions) ..................................... 90

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Health Choice Insurance Company2016 Formulary

Drug Name Tier Status Requirements/Limits

Analgesics (Pain, Inflammation, Muscle, Joint Condition Drugs)

Analgesic Combinations

butalbital-acetaminophen oral tablet Tier 1

butalbital-apap-caffeine oral capsule Tier 1

butalbital-apap-caffeine oral tablet 50-325-40 mg

Tier 1

butalbital-asa-caffeine oral capsule Tier 1

Opioid Analgesics, Long-Acting (Narcotic Pain Relievers)

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

Tier 1 ST; QL (10 EA per 30 days)

methadone hcl injection solution Tier 1

methadone hcl oral concentrate Tier 1

methadone hcl oral solution Tier 1

methadone hcl oral tablet Tier 1

methadone hcl oral tablet soluble Tier 1

morphine sulfate er beads oral capsule extended release 24 hour

Tier 1

morphine sulfate er oral capsule extended release 24 hour

Tier 1

morphine sulfate er oral tablet extendedrelease*

Tier 1

morphine sulfate suppository 30 mg Tier 1

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR*

Tier 2

OPANA ER ORAL 10 MG, 20 MG, 30 MG, 40 MG, 5 MG

Tier 2

OPANA ER ORAL 15 MG, 7.5 MG Tier 2 QL (60 EA per 30 days)

oxymorphone hcl er oral tablet extended release 12 hr* 10 mg, 20 mg, 30 mg, 5 mg

Tier 1 QL (60 EA per 30 days)

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oxymorphone hcl er oral tablet extended release 12 hr* 15 mg, 7.5 mg

Tier 1

oxymorphone hcl er oral tablet extended release 12 hr* 40 mg


oxymorphone hcl oral tablet 5 mg Tier 1

Opioid Analgesics, Short-Acting (Narcotic Pain Relievers)

acetaminophen-codeine #3 oral tablet Tier 1 QL (390 EA per 30 days)

acetaminophen-codeine #4 oral tablet Tier 1 QL (390 EA per 30 days)

acetaminophen-codeine oral solution Tier 1 QL (980 ML per 30 days)

acetaminophen-codeine oral tablet 300-15 mg


butalbital-apap-caff-cod oral capsule50-325-40-30 mg


butalbital-asa-caff-codeine oral capsule Tier 1

FENTORA BUCCAL TABLET 200 MCG, 400 MCG, 600 MCG, 800 MCG

Tier 3 PA; QL (120 EA per 30 days)

hydrocodone-acetaminophen oral solution7.5-325 mg/15ml

Tier 1 QL (400 ML per 30 days)

hydrocodone-acetaminophen oral tablet10-300 mg, 5-300 mg, 7.5-300 mg

Tier 1

hydrocodone-acetaminophen oral tablet10-325 mg, 5-325 mg, 7.5-325 mg


hydrocodone-ibuprofen oral tablet Tier 1

hydromorphone hcl oral tablet Tier 1

hydromorphone hcl pf injection solution 500 mg/50ml

Tier 1

isometheptene-caffeine-apap oral tablet65-20-325 mg

Tier 1

isometheptene-dichloral-apap oral capsule Tier 1

morphine sulfate (concentrate) oral solution100 mg/5ml

Tier 1

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

Tier 1

morphine sulfate oral solution Tier 1

morphine sulfate oral tablet Tier 1

nalbuphine hcl injection solution Tier 1

NUCYNTA ORAL TABLET Tier 2

oxycodone hcl oral capsule Tier 1

oxycodone hcl oral concentrate 100 mg/5ml Tier 1

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oxycodone hcl oral solution Tier 1

oxycodone hcl oral tablet Tier 1

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


oxycodone-aspirin oral tablet 4.8355-325 mg Tier 1

oxycodone-ibuprofen oral tablet Tier 1

oxymorphone hcl oral tablet 10 mg Tier 1

pentazocine-naloxone hcl oral tablet Tier 1

REPREXAIN ORAL TABLET 2.5-200 MG Tier 3

tramadol hcl er (biphasic) oral tablet extended release 24 hr*

Tier 1

tramadol hcl er oral tablet extended release 24 hr*

Tier 1

tramadol hcl oral tablet Tier 1

tramadol-acetaminophen oral tablet Tier 1

Opioid Antagonists

BUTRANS TRANSDERMAL PATCH WEEKLY 15 MCG/HR

Tier 2

Salicylate Combinations

choline & mag trisalicylate oral tablet 1000 mg

Tier 1

choline-mag trisalicylate oral liquid† Tier 1

Anesthetics (Numbing Drugs)

Local Anesthetics - Parenteral

lidocaine hcl (pf) injection solution 0.5 %, 1 % Tier 1

lidocaine hcl injection solution 0.5 %, 1 % Tier 1

Local Anesthetics (Local Numbing Drugs)

lidocaine viscous mouth/throat solution Tier 1

Topical Anesthetic Combinations

lidocaine-prilocaine external cream Tier 1

lidocaine-prilocaine external kit Tier 1

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-Craving

disulfiram oral tablet Tier 1

naltrexone hcl oral tablet Tier 1

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Opioid Antagonists

buprenorphine hcl injection solution 0.3 mg/ml

Tier 1

buprenorphine hcl sublingual tablet sublingual

Tier 1

buprenorphine hcl-naloxone hcl sublingual tablet sublingual


SUBOXONE SUBLINGUAL FILM 12-3 MG Tier 2 QL (90 EA per 30 days)

SUBOXONE SUBLINGUAL FILM 4-1 MG Tier 2 QL (240 EA per 30 days)

ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 1.4-0.36 MG, 5.7-1.4 MG


Opioid Reversal Agents

naloxone hcl injection solution 0.4 mg/ml, 1 mg/ml

Tier 1

Smoking Cessation Agents

bupropion hcl er (smoking det) oral tablet extended release 12 hr*

Tier 6

CHANTIX CONTINUING MONTH PAK ORAL TABLET

Tier 6

CHANTIX ORAL TABLET Tier 6

CHANTIX STARTING MONTH PAK ORAL TABLET

Tier 6

nicotine mini mouth/throat lozenge Tier 6 OTC

nicotine polacrilex mouth/throat gum Tier 6 OTC

nicotine polacrilex mouth/throat lozenge Tier 6 OTC

nicotine transdermal patch 24 hr Tier 6 OTC

Antibacterials (Infection Fighting Drugs)

Aminoglycosides (Bacterial Infection Drugs (Antibiotics)

amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml

Tier 3

gentamicin sulfate injection solution Tier 1

neomycin sulfate oral tablet Tier 1

paromomycin sulfate oral capsule Tier 1

streptomycin sulfate intramuscular* solution reconstituted

Tier 1

tobramycin inhalation nebulization solution Tier 1 QL (280 ML per 30 days)

6


tobramycin sulfate injection solution 1.2 gm/30ml, 2 gm/50ml, 80 mg/2ml


tobramycin sulfate injection solution 10 mg/ml


tobramycin sulfate injection solution reconstituted


Antibacterial (Injections)

aztreonam injection solution reconstituted Tier 1

bacitracin intramuscular* solution reconstituted

Tier 1

chloramphenicol sod succinate intravenous* solution reconstituted

Tier 1

clindamycin palmitate hcl oral solution reconstituted

Tier 1

clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml, 9000 mg/60ml

Tier 1

colistimethate sodium injection solution reconstituted

Tier 4

lincomycin hcl injection solution Tier 1

linezolid intravenous* solution 600 mg/300ml Tier 3

meropenem intravenous* solution reconstituted

Tier 3

metronidazole in nacl intravenous* solution500-0.79 mg/100ml-%

Tier 1

vancomycin hcl intravenous* solution reconstituted

Tier 1

Antibacterials, Other

clindamycin hcl oral capsule Tier 1

linezolid oral suspension reconstituted Tier 3

linezolid oral tablet Tier 3

methenamine hippurate oral tablet Tier 1

methenamine mandelate oral tablet 1 gm Tier 1

metronidazole oral capsule Tier 1

metronidazole oral tablet Tier 1

MONUROL ORAL PACKET Tier 3

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

Tier 1

nitrofurantoin monohyd macro oral capsule Tier 1

tinidazole oral tablet Tier 1

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trimethoprim oral tablet Tier 1

vancomycin hcl oral capsule Tier 3

XIFAXAN ORAL TABLET 550 MG Tier 3

Anti-Infective, Other

CAYSTON INHALATION SOLUTION RECONSTITUTED

Tier 4

INVANZ INJECTION SOLUTION RECONSTITUTED

Tier 3

Cephalosporin (Injection)

cefazolin sodium injection solution reconstituted

Tier 1

cefepime hcl injection solution reconstituted Tier 1

cefoxitin sodium injection solution reconstituted

Tier 1

cefoxitin sodium intravenous* solution reconstituted

Tier 1

cefpodoxime proxetil oral tablet 200 mg Tier 1

ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm

Tier 1

ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 500 mg

Tier 1

cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 mg

Tier 1

cefuroxime sodium intravenous* solution reconstituted 1.5 gm

Tier 1

Cephalosporin Antibiotics

cefaclor er oral tablet extended release 12 hr*

Tier 1

cefaclor oral capsule Tier 1

cefadroxil oral capsule Tier 1

cefadroxil oral suspension reconstituted Tier 1

cefadroxil oral tablet Tier 1

cefdinir oral capsule Tier 1

cefdinir oral suspension reconstituted Tier 1

cefditoren pivoxil oral tablet Tier 3

cefixime oral suspension reconstituted 200 mg/5ml

Tier 1

cefpodoxime proxetil oral suspension reconstituted

Tier 1

8


cefpodoxime proxetil oral tablet 100 mg Tier 1

cefprozil oral suspension reconstituted Tier 1

cefprozil oral tablet Tier 1

cefuroxime axetil oral tablet Tier 1

cephalexin oral capsule Tier 1

cephalexin oral suspension reconstituted Tier 1

cephalexin oral tablet Tier 1

SUPRAX ORAL CAPSULE Tier 3

Cephalosporin Combinations (Injection)

AVYCAZ INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 3

Macrolides

azithromycin oral packet Tier 1

azithromycin oral suspension reconstituted Tier 1

azithromycin oral tablet 250 mg, 500 mg, 600 mg

Tier 1

clarithromycin er oral tablet extended release 24 hr*

Tier 1

clarithromycin oral suspension reconstituted Tier 1

clarithromycin oral tablet Tier 1

DIFICID ORAL TABLET Tier 4 ST

ERYTHROCIN STEARATE ORAL TABLET 250 MG

Tier 1

erythromycin ethylsuccinate oral tablet Tier 1

KETEK ORAL TABLET Tier 3

Macrolides (Injection)

azithromycin intravenous* solution reconstituted 500 mg

Tier 1

ERYTHROCIN LACTOBIONATE INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG

Tier 1

Penicillin Combination Antibiotics

amoxicillin-pot clavulanate er oral tablet extended release 12 hr*

Tier 1

amoxicillin-pot clavulanate oral suspension reconstituted

Tier 1

amoxicillin-pot clavulanate oral tablet Tier 1

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amoxicillin-pot clavulanate oral tablet chewable

Tier 1

Penicillin Combinations (Injection)

ampicillin-sulbactam sodium injection solution reconstituted 15 (10-5) gm

Tier 1

ampicillin-sulbactam sodium intravenous* solution reconstituted 15 (10-5) gm

Tier 1

piperacillin sod-tazobactam so intravenous* solution reconstituted

Tier 1

Penicillins

amoxicillin oral capsule Tier 1

amoxicillin oral suspension reconstituted Tier 1

amoxicillin oral tablet Tier 1

amoxicillin oral tablet chewable 125 mg, 250 mg

Tier 1

ampicillin oral capsule Tier 1

ampicillin oral suspension reconstituted Tier 1

dicloxacillin sodium oral capsule Tier 1

penicillin v potassium oral tablet Tier 1

Penicillins (Injection)

ampicillin sodium injection solution reconstituted

Tier 1

ampicillin sodium intravenous* solution reconstituted 2 gm

Tier 1

nafcillin sodium injection solution reconstituted

Tier 1

oxacillin sodium injection solution reconstituted 1 gm, 2 gm

Tier 1

penicillin g potassium injection solution reconstituted

Tier 1

penicillin g sodium injection solution reconstituted

Tier 1

penicillin v potassium oral solution reconstituted

Tier 1

Quinolones

ciprofloxacin hcl oral tablet Tier 1

ciprofloxacin oral suspension reconstituted Tier 1

ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hr*

Tier 1

levofloxacin oral solution Tier 1

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levofloxacin oral tablet Tier 1

ofloxacin oral tablet Tier 1

Quinolones (Injection)

ciprofloxacin intravenous* solution 200 mg/20ml, 400 mg/40ml

Tier 1

levofloxacin intravenous* solution Tier 1

Sulfonamides

sulfadiazine oral tablet Tier 1 QL (30 EA per 30 days)

sulfamethoxazole-trimethoprim intravenous* solution

Tier 1

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml

Tier 1

sulfamethoxazole-trimethoprim oral tablet Tier 1

Tetracyclines

demeclocycline hcl oral tablet Tier 1

doxycycline hyclate oral capsule Tier 1

doxycycline hyclate oral tablet 100 mg, 20 mg

Tier 1

doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 75 mg

Tier 1

doxycycline monohydrate oral capsule Tier 1

doxycycline monohydrate oral suspension reconstituted

Tier 1

doxycycline monohydrate oral tablet Tier 1

minocycline hcl er oral tablet extended release 24 hr*

Tier 1

minocycline hcl oral capsule Tier 1

minocycline hcl oral tablet Tier 1

tetracycline hcl oral capsule 250 mg Tier 1

Tetracyclines (Injection)

DOXY 100 INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 1

Anticonvulsants (Nerve Condition Drugs)

Anticonvulsants Other (Seizure Control Drugs)

levetiracetam er oral tablet extended release 24 hr*

Tier 1

levetiracetam intravenous* solution Tier 1

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levetiracetam oral solution Tier 1

levetiracetam oral tablet Tier 1

POTIGA ORAL TABLET Tier 3

tiagabine hcl oral tablet Tier 1

Barbiturates (Seizure Control Drugs)

BUTISOL SODIUM ORAL TABLET 30 MG Tier 3

phenobarbital oral solution Tier 1

phenobarbital oral tablet Tier 1

Benzodiazepines (Seizure Control Drugs)

clonazepam oral tablet Tier 1

clonazepam oral tablet dispersible Tier 1

DIASTAT PEDIATRIC GEL Tier 1 PA

diazepam gel 10 mg, 20 mg Tier 1 PA

ONFI ORAL SUSPENSION Tier 3

ONFI ORAL TABLET 10 MG, 20 MG Tier 3

Calcium Channel Modifying Agents (Seizure Control Drugs)

CELONTIN ORAL CAPSULE Tier 3

ethosuximide oral capsule Tier 1

ethosuximide oral solution Tier 1

zonisamide oral capsule Tier 1

Gamma-Aminobutyric Acid (Gaba) Augmenting Agents (Seizure Control Drugs)

divalproex sodium er oral tablet extended release 24 hr*

Tier 1

divalproex sodium oral Tier 1

divalproex sodium oral tablet delayed release Tier 1

FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG, 8 MG

Tier 3

gabapentin oral capsule Tier 1

gabapentin oral solution 250 mg/5ml Tier 1

gabapentin oral tablet Tier 1

GABITRIL ORAL TABLET 12 MG, 16 MG Tier 3

primidone oral tablet Tier 1

12


SABRIL ORAL PACKET Tier 4

SABRIL ORAL TABLET Tier 4

valproate sodium intravenous* solution 100 mg/ml

Tier 1

valproic acid oral capsule Tier 1

valproic acid oral syrup Tier 1

Glutamate Reducing Agents (Seizure Control Drugs)

felbamate oral suspension Tier 1

felbamate oral tablet Tier 1

lamotrigine er oral tablet extended release 24 hr*

Tier 1

lamotrigine oral tablet Tier 1

lamotrigine oral tablet chewable Tier 1

topiramate oral capsule sprinkle Tier 1

topiramate oral tablet Tier 1

TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR

Tier 3

Sodium Channel Agents (Seizure Control Drugs)

BANZEL ORAL SUSPENSION Tier 3

BANZEL ORAL TABLET Tier 3

carbamazepine er oral capsule extended release 12 hour

Tier 1

carbamazepine er oral tablet extended release 12 hr*

Tier 1

carbamazepine oral suspension Tier 1

carbamazepine oral tablet Tier 1

carbamazepine oral tablet chewable Tier 1

fosphenytoin sodium injection solution Tier 1

oxcarbazepine oral suspension Tier 1

oxcarbazepine oral tablet Tier 1

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3

PEGANONE ORAL TABLET Tier 3

phenytoin oral suspension 125 mg/5ml Tier 1

phenytoin oral tablet chewable Tier 1

phenytoin sodium extended oral capsule Tier 1

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phenytoin sodium injection solution Tier 1

VIMPAT INTRAVENOUS* SOLUTION Tier 3

VIMPAT ORAL SOLUTION Tier 3

VIMPAT ORAL TABLET Tier 3

Antidementia Agents (Nerve Condition Drugs)

Antidementia Agents, Other (Alzeimer's And Dementia Drugs)

ergoloid mesylates oral tablet Tier 1

Cholinesterase Inhibitors (Alzeimer's And Dementia Drugs)

donepezil hcl oral tablet Tier 1

donepezil hcl oral tablet dispersible Tier 1

galantamine hydrobromide er oral capsule extended release 24 hour

Tier 1

galantamine hydrobromide oral solution Tier 2

galantamine hydrobromide oral tablet Tier 1

rivastigmine tartrate oral capsule Tier 1

rivastigmine transdermal patch 24 hr Tier 1

N-Methyl-D-Aspartate (Nmda) Receptor Antagonist (Alzeimer's And Dementia Drugs)

NAMENDA ORAL SOLUTION Tier 3

NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR

Tier 3

NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR

Tier 3

Antidepressants

Antidepressants, Other

nefazodone hcl oral tablet Tier 1

trazodone hcl oral tablet Tier 1

VIIBRYD ORAL TABLET Tier 2

VIIBRYD STARTER PACK ORAL KIT Tier 2

Antidepressants (Nerve Condition Drugs)

APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR* 174 MG, 348 MG

Tier 3

14


BUDEPRION SR ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG

Tier 1

bupropion hcl er (sr) oral tablet extended release 12 hr*

Tier 1

bupropion hcl er (xl) oral tablet extended release 24 hr*

Tier 1

bupropion hcl oral tablet Tier 1

FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 2

maprotiline hcl oral tablet Tier 1

mirtazapine oral tablet Tier 1

mirtazapine oral tablet dispersible Tier 1

TRINTELLIX ORAL TABLET Tier 3 ST

Monoamine Oxidase Inhibitor Antidepressants

EMSAM TRANSDERMAL PATCH 24 HR Tier 3

MARPLAN ORAL TABLET Tier 3

phenelzine sulfate oral tablet Tier 1

tranylcypromine sulfate oral tablet Tier 1

Selective Serotonin Reuptake Inhibitors (Ssris)

citalopram hydrobromide oral solution Tier 1

citalopram hydrobromide oral tablet Tier 1

escitalopram oxalate oral solution Tier 1

escitalopram oxalate oral tablet Tier 1

fluoxetine hcl oral capsule Tier 1

fluoxetine hcl oral capsule delayed release Tier 1

fluoxetine hcl oral solution Tier 1

fluoxetine hcl oral tablet 10 mg, 20 mg Tier 1

fluoxetine hcl oral tablet 60 mg Tier 3

fluvoxamine maleate er oral capsule extended release 24 hour

Tier 1

fluvoxamine maleate oral tablet Tier 1

paroxetine hcl er oral tablet extended release 24 hr*

Tier 1

paroxetine hcl oral tablet Tier 1

PAXIL ORAL SUSPENSION Tier 3

PEXEVA ORAL TABLET Tier 3

15


sertraline hcl oral concentrate Tier 1

sertraline hcl oral tablet Tier 1

Serotonin/Norepinephrine Reuptake Inhibitors (Depression Drugs)

BRISDELLE ORAL CAPSULE Tier 3

fluoxetine hcl (pmdd) oral capsule Tier 1

olanzapine-fluoxetine hcl oral capsule Tier 1

TRINTELLIX ORAL TABLET Tier 3 ST

Serotonin/Norepinephrine Reuptake Inhibitors (Snris)

desvenlafaxine er oral tablet extended release 24 hr*

Tier 3

desvenlafaxine fumarate er oral tablet extended release 24 hr*

Tier 3

duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg

Tier 1

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR

Tier 2

FETZIMA TITRATION ORAL Tier 2

KHEDEZLA ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 2

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 50 MG

Tier 3

venlafaxine hcl er oral capsule extended release 24 hour

Tier 1

venlafaxine hcl er oral tablet extended release 24 hr*

Tier 1

venlafaxine hcl oral tablet Tier 1

Tricyclic Antidepressants

amitriptyline hcl oral tablet Tier 1

amoxapine oral tablet Tier 1

clomipramine hcl oral capsule Tier 1

desipramine hcl oral tablet Tier 1

doxepin hcl oral capsule Tier 1

doxepin hcl oral concentrate Tier 1

imipramine hcl oral tablet Tier 1

imipramine pamoate oral capsule Tier 1

nortriptyline hcl oral capsule Tier 1

nortriptyline hcl oral solution Tier 1

16


protriptyline hcl oral tablet Tier 1

trimipramine maleate oral capsule Tier 1

Tricyclics (Depression Drugs)

chlordiazepoxide-amitriptyline oral tablet Tier 1

Antiemetics (Bowel, Instestine, And Stomach Condition Drugs)

Antiemetics Other (Nausea And Vomiting Drugs)

meclizine hcl oral tablet Tier 1 OTC

promethazine hcl oral syrup Tier 1

promethazine hcl oral tablet Tier 1

promethazine hcl suppository 12.5 mg, 25 mg

Tier 1

trimethobenzamide hcl oral capsule Tier 1

Emetogenic Therapy Adjuncts (Nausea And Vomiting Drugs)

dronabinol oral capsule 10 mg Tier 3

dronabinol oral capsule 2.5 mg, 5 mg Tier 1

EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG

Tier 3

EMEND ORAL CAPSULE 80 & 125 MG Tier 4

granisetron hcl intravenous* solution Tier 1

granisetron hcl oral tablet Tier 1 QL (30 EA per 30 days)

ondansetron hcl injection solution 4 mg/2ml, 40 mg/20ml


ondansetron hcl oral solution Tier 1 QL (50 ML per 30 days)

ondansetron hcl oral tablet Tier 1 QL (30 EA per 30 days)

ondansetron oral tablet dispersible Tier 1 QL (30 EA per 30 days)

SANCUSO TRANSDERMAL PATCH Tier 3

VARUBI ORAL TABLET Tier 3

Antifungals (Infection Fighting Drugs)

Antifungals (Fungus Infection Drugs)

ABELCET INTRAVENOUS* SUSPENSION Tier 3 QL (60 ML per 30 days)

amphotericin b injection solution reconstituted


17


CANCIDAS INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG


CANCIDAS INTRAVENOUS* SOLUTION RECONSTITUTED 70 MG


clotrimazole mouth/throat troche Tier 1

CRESEMBA INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 3

CRESEMBA ORAL CAPSULE Tier 3

ERAXIS INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 3

fluconazole in dextrose intravenous* solution Tier 1

fluconazole in sodium chloride intravenous* solution

Tier 1

fluconazole oral suspension reconstituted 10 mg/ml


fluconazole oral suspension reconstituted 40 mg/ml


fluconazole oral tablet 100 mg Tier 1 QL (22 EA per 30 days)

fluconazole oral tablet 150 mg, 200 mg Tier 1 QL (24 EA per 30 days)

fluconazole oral tablet 50 mg Tier 1 QL (60 EA per 30 days)

flucytosine oral capsule 250 mg Tier 3 QL (60 EA per 30 days)

flucytosine oral capsule 500 mg Tier 3 QL (15 EA per 30 days)

griseofulvin microsize oral suspension Tier 1 QL (150 ML per 30 days)

griseofulvin microsize oral tablet Tier 1

griseofulvin ultramicrosize oral tablet Tier 1

itraconazole oral capsule Tier 1 QL (240 EA per 365 days)

ketoconazole oral tablet Tier 1 QL (60 EA per 30 days)

MYCAMINE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG


MYCAMINE INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG


NOXAFIL ORAL SUSPENSION Tier 3 QL (21 ML per 30 days)

NOXAFIL ORAL TABLET DELAYED RELEASE


nystatin mouth/throat suspension Tier 1

nystatin oral powder Tier 1

nystatin oral tablet Tier 1 QL (60 EA per 30 days)

terbinafine hcl oral tablet Tier 1

voriconazole oral suspension reconstituted Tier 4 QL (21 ML per 30 days)

18


voriconazole oral tablet 200 mg Tier 4 QL (21 EA per 30 days)

voriconazole oral tablet 50 mg Tier 1

Antigout Agents (Pain, Inflammation, Muscle, Joint Condition Drugs)

Antigout Agents (Gout Drugs)

allopurinol oral tablet Tier 1

COLCRYS ORAL TABLET Tier 3

probenecid oral tablet Tier 1

ULORIC ORAL TABLET Tier 2 ST

Anti-Inflammatory Agents (Pain, Inflammation, Muscle, Joint Condition Drugs)

Nonsteroidal Anti-Inflammatory Drugs (Pain, Anti-Inflammatory Drugs)

celecoxib oral capsule Tier 1

diclofenac potassium oral tablet Tier 1

diclofenac sodium er oral tablet extended release 24 hr*

Tier 1

diclofenac sodium oral tablet delayed release Tier 1

diclofenac-misoprostol oral tablet delayed release

Tier 1

etodolac er oral tablet extended release 24 hr*

Tier 1

etodolac oral capsule Tier 1

etodolac oral tablet Tier 1

fenoprofen calcium oral tablet Tier 1

flurbiprofen oral tablet Tier 1

ibuprofen childrens oral suspension Tier 1 OTC

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

Tier 1

indomethacin er oral capsule extended release*

Tier 1

indomethacin oral capsule Tier 1

ketoprofen er oral capsule extended release 24 hour

Tier 1

ketoprofen oral capsule Tier 1

ketorolac tromethamine injection solution Tier 1

19


ketorolac tromethamine intramuscular* solution 60 mg/2ml

Tier 1

ketorolac tromethamine oral tablet Tier 1 QL (20 EA per 5 days)

meclofenamate sodium oral capsule Tier 1

mefenamic acid oral capsule Tier 1

meloxicam oral tablet Tier 1

nabumetone oral tablet Tier 1

naproxen dr oral tablet delayed release Tier 1

naproxen oral suspension Tier 1

naproxen oral tablet Tier 1

naproxen sodium oral tablet 275 mg, 550 mg Tier 1

oxaprozin oral tablet Tier 1

piroxicam oral capsule Tier 1

sulindac oral tablet Tier 1

tolmetin sodium oral capsule Tier 1

tolmetin sodium oral tablet 600 mg Tier 1

Salicylates

adult aspirin low strength oral tablet dispersible

Tier 6 OTC

aspirin adult low dose oral tablet delayed release

Tier 6 OTC

aspirin ec oral tablet delayed release 325 mg Tier 6 OTC

aspirin low dose oral tablet chewable Tier 6 OTC

aspirin oral tablet 325 mg Tier 6 OTC

BAYER ASPIRIN EXTRA STRENGTH ORAL TABLET

Tier 6 OTC

diflunisal oral tablet Tier 1

tri-buffered aspirin oral tablet 325 mg Tier 6 OTC

Antimigraine Agents (Nerve Condition Drugs)

Ergot Alkaloids (Migraine Drugs)

dihydroergotamine mesylate injection solution

Tier 3

ERGOMAR SUBLINGUAL TABLET SUBLINGUAL

Tier 3

XELJANZ ORAL TABLET Tier 4 ST

20


Serotonin (5-Ht) 1B/1D Receptor Agonists (Migraine Drugs)

naratriptan hcl oral tablet Tier 1

RELPAX ORAL TABLET Tier 2 QL (9 EA per 30 days)

rizatriptan benzoate oral tablet Tier 1

rizatriptan benzoate oral tablet dispersible Tier 1

sumatriptan nasal solution Tier 1

sumatriptan succinate oral tablet Tier 1 QL (9 EA per 30 days)

sumatriptan succinate refill subcutaneous* 6 mg/0.5ml


sumatriptan succinate subcutaneous* 6 mg/0.5ml


sumatriptan succinate subcutaneous* solution 6 mg/0.5ml


zolmitriptan oral tablet Tier 1

zolmitriptan oral tablet dispersible 2.5 mg Tier 1

Antimyasthenic Agents (Nerve Condition Drugs)

Parasympathomimetics (Miscellaneous Nerve Condition Drugs)

guanidine hcl oral tablet Tier 1

MESTINON ORAL SYRUP Tier 3

pyridostigmine bromide oral tablet Tier 1

Antimycobacterials (Infection Fighting Drugs)

Antimycobacterials Other (Miscellaneous Infection Fighting Drugs)

dapsone oral tablet Tier 1

MYCOBUTIN ORAL CAPSULE Tier 3 QL (4 EA per 30 days)

rifabutin oral capsule Tier 1

Antituberculars (Tuberculosis Drugs)

CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED


cycloserine oral capsule Tier 1

ethambutol hcl oral tablet 100 mg Tier 1 QL (4 EA per 28 days)

21


ethambutol hcl oral tablet 400 mg Tier 1 QL (90 EA per 30 days)

isoniazid injection solution Tier 1 QL (60 ML per 30 days)

isoniazid oral syrup Tier 1 QL (30 ML per 30 days)

isoniazid oral tablet 100 mg Tier 1 QL (30 EA per 30 days)

isoniazid oral tablet 300 mg Tier 1 QL (13 EA per 30 days)

PASER ORAL PACKET Tier 3 QL (30 EA per 30 days)

PRIFTIN ORAL TABLET Tier 3 QL (12 EA per 30 days)

pyrazinamide oral tablet Tier 1

RIFAMATE ORAL CAPSULE Tier 1

rifampin intravenous* solution reconstituted Tier 1 QL (12 EA per 30 days)

rifampin oral capsule Tier 1 QL (11 EA per 30 days)

RIFATER ORAL TABLET Tier 2 QL (12 EA per 30 days)

SIRTURO ORAL TABLET Tier 3 QL (8 EA per 28 days)

TRECATOR ORAL TABLET Tier 3 QL (30 EA per 30 days)

Antineoplastics (Cancer Drugs)

Alkylating Agents (Chemotherapy Drugs)

BICNU INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5

BUSULFEX INTRAVENOUS* SOLUTION Tier 5

carboplatin intravenous* solution Tier 1

carboplatin intravenous* solution reconstituted 150 mg

Tier 1

cisplatin intravenous* solution Tier 1

cyclophosphamide oral tablet Tier 5

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

Tier 5

HEXALEN ORAL CAPSULE Tier 5

IFEX INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5

ifosfamide intravenous* solution reconstituted Tier 5

LEUKERAN ORAL TABLET Tier 5

melphalan hcl intravenous* solution reconstituted

Tier 5

MUSTARGEN INJECTION SOLUTION RECONSTITUTED

Tier 5

oxaliplatin intravenous* solution Tier 1

thiotepa injection solution reconstituted Tier 1

22


TREANDA INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5

Antiangiogenic Agents (Chemotherapy Drugs)

AVASTIN INTRAVENOUS* SOLUTION Tier 5

REVLIMID ORAL CAPSULE Tier 5

THALOMID ORAL CAPSULE Tier 5

Antimetabolites (Chemotherapy Drugs)

ALIMTA INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5

ARRANON INTRAVENOUS* SOLUTION Tier 5

azacitidine injection suspension reconstituted Tier 5

capecitabine oral tablet Tier 5

cladribine intravenous* solution 10 mg/10ml Tier 1

CLOLAR INTRAVENOUS* SOLUTION Tier 5

cytarabine (pf) injection solution Tier 1

cytarabine injection solution Tier 1

DACOGEN INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5

daunorubicin hcl intravenous* injectable Tier 1

decitabine intravenous* solution reconstituted Tier 1

doxorubicin hcl intravenous* solution Tier 1

doxorubicin hcl intravenous* solution reconstituted

Tier 1

ELLENCE INTRAVENOUS* SOLUTION Tier 5

epirubicin hcl intravenous* solution 200 mg/100ml, 50 mg/25ml

Tier 1

epirubicin hcl intravenous* solution reconstituted

Tier 1

ERWINAZE INJECTION SOLUTION RECONSTITUTED

Tier 5 PA

fludarabine phosphate intravenous* solution Tier 1

fludarabine phosphate intravenous* solution reconstituted

Tier 1

fluorouracil intravenous* solution Tier 1

FOLOTYN INTRAVENOUS* SOLUTION Tier 5

gemcitabine hcl intravenous* solution reconstituted

Tier 5

23


IDAMYCIN PFS INTRAVENOUS* SOLUTION 10 MG/10ML, 5 MG/5ML

Tier 5

idarubicin hcl intravenous* solution 10 mg/10ml, 5 mg/5ml

Tier 1

mercaptopurine oral tablet Tier 5

methotrexate oral tablet Tier 5

methotrexate sodium (pf) injection solution50 mg/2ml

Tier 5

methotrexate sodium injection solution 50 mg/2ml

Tier 5

methotrexate sodium injection solution reconstituted

Tier 1

mitomycin intravenous* solution reconstituted Tier 1

mitoxantrone hcl intravenous* concentrate Tier 1

TABLOID ORAL TABLET Tier 5

TREXALL ORAL TABLET Tier 5

UVADEX INJECTION SOLUTION Tier 5

Antineoplastics (Miscellaneous Chemotherapy Drugs)

ABRAXANE INTRAVENOUS* SUSPENSION RECONSTITUTED

Tier 5

ACTIMMUNE SUBCUTANEOUS* SOLUTION

Tier 5

AFINITOR DISPERZ ORAL TABLET SOLUBLE

Tier 5

AFINITOR ORAL TABLET Tier 5

ALECENSA ORAL CAPSULE Tier 5 PA

amifostine intravenous* solution reconstituted Tier 5

ARZERRA INTRAVENOUS* CONCENTRATE

Tier 5

bexarotene oral capsule Tier 5

bicalutamide oral tablet Tier 5

bleomycin sulfate injection solution reconstituted

Tier 1

BLINCYTO INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5 PA

BOSULIF ORAL TABLET Tier 5 PA

CAPRELSA ORAL TABLET Tier 5

COMETRIQ (100 MG DAILY DOSE) ORAL KIT

Tier 5

24



Tier 5


Tier 5

COSMEGEN INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5

COTELLIC ORAL TABLET Tier 5 PA

dacarbazine intravenous* solution reconstituted

Tier 1

DARZALEX INTRAVENOUS* SOLUTION Tier 5 PA

dexrazoxane intravenous* solution reconstituted

Tier 5

DOCEFREZ INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5

docetaxel intravenous* concentrate 140 mg/7ml, 160 mg/8ml, 20 mg/ml, 80 mg/4ml

Tier 5

docetaxel intravenous* solution Tier 5

ELIGARD SUBCUTANEOUS* KIT Tier 5

ELITEK INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5

EMCYT ORAL CAPSULE Tier 5

EMPLICITI INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5 PA

ERBITUX INTRAVENOUS* SOLUTION Tier 5

ERIVEDGE ORAL CAPSULE Tier 5

ETOPOPHOS INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5

etoposide intravenous* solution 1 gm/50ml, 100 mg/5ml, 500 mg/25ml

Tier 1

etoposide oral capsule Tier 5

FARESTON ORAL TABLET Tier 5

FARYDAK ORAL CAPSULE Tier 5 PA

FASLODEX INTRAMUSCULAR* SOLUTION 250 MG/5ML

Tier 5

FIRMAGON SUBCUTANEOUS* SOLUTION RECONSTITUTED

Tier 5

flutamide oral capsule Tier 5

FUSILEV INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5

GILOTRIF ORAL TABLET Tier 5 PA

25


HALAVEN INTRAVENOUS* SOLUTION Tier 5

HERCEPTIN INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5

hydroxyurea oral capsule Tier 5

IBRANCE ORAL CAPSULE Tier 5 PA

IDAMYCIN PFS INTRAVENOUS* SOLUTION 20 MG/20ML

Tier 5

idarubicin hcl intravenous* solution 20 mg/20ml

Tier 1

imatinib mesylate oral tablet Tier 5

IMBRUVICA ORAL CAPSULE Tier 5 PA

INLYTA ORAL TABLET Tier 5

INTRON A INJECTION SOLUTION Tier 5

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT

Tier 5

irinotecan hcl intravenous* solution Tier 5

ISTODAX INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5

IXEMPRA KIT INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5

JAKAFI ORAL TABLET Tier 5

JEVTANA INTRAVENOUS* SOLUTION Tier 5

KADCYLA INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5

KEPIVANCE INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5

LENVIMA 10 MG DAILY DOSE ORAL Tier 5






leucovorin calcium injection solution reconstituted

Tier 1

leucovorin calcium oral tablet Tier 5

leuprolide acetate injection kit Tier 1

LONSURF ORAL TABLET Tier 4 PA

LUPRON DEPOT INTRAMUSCULAR* KIT Tier 5

LYNPARZA ORAL CAPSULE Tier 5 PA

26


LYSODREN ORAL TABLET Tier 5

MATULANE ORAL CAPSULE Tier 5

megestrol acetate oral suspension 40 mg/ml Tier 1

megestrol acetate oral tablet Tier 1

MEKINIST ORAL TABLET Tier 5

mesna intravenous* solution Tier 1

MESNEX ORAL TABLET Tier 5

NEXAVAR ORAL TABLET Tier 5

NILANDRON ORAL TABLET Tier 5

NINLARO ORAL CAPSULE Tier 5 PA

ODOMZO ORAL CAPSULE Tier 5 PA

ONCASPAR INJECTION SOLUTION Tier 5

OPDIVO INTRAVENOUS* SOLUTION Tier 5 PA

paclitaxel intravenous* concentrate Tier 1

PERJETA INTRAVENOUS* SOLUTION Tier 5

POMALYST ORAL CAPSULE Tier 5

PORTRAZZA INTRAVENOUS* SOLUTION Tier 5 PA

PROLEUKIN INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5

RITUXAN INTRAVENOUS* SOLUTION Tier 5

SOLTAMOX ORAL SOLUTION Tier 6

SPRYCEL ORAL TABLET Tier 5

STIVARGA ORAL TABLET Tier 5 PA

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50 MG

Tier 5

SYLATRON SUBCUTANEOUS* KIT 200 MCG, 300 MCG, 600 MCG

Tier 5

SYNRIBO SUBCUTANEOUS* SOLUTION RECONSTITUTED

Tier 5

TAFINLAR ORAL CAPSULE Tier 5

TAGRISSO ORAL TABLET Tier 5 PA

TARCEVA ORAL TABLET Tier 5

TARGRETIN ORAL CAPSULE Tier 5

TASIGNA ORAL CAPSULE Tier 5

TAXOTERE INTRAVENOUS* CONCENTRATE 20 MG/ML, 80 MG/4ML

Tier 5

temozolomide oral capsule Tier 5

27


topotecan hcl intravenous* solution reconstituted

Tier 1

TORISEL INTRAVENOUS* SOLUTION Tier 5

TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED

Tier 5

tretinoin oral capsule Tier 5

TRISENOX INTRAVENOUS* SOLUTION Tier 5

TYKERB ORAL TABLET Tier 5

UNITUXIN INTRAVENOUS* SOLUTION Tier 5 PA

VECTIBIX INTRAVENOUS* SOLUTION 100 MG/5ML, 400 MG/20ML

Tier 5

VELCADE INJECTION SOLUTION RECONSTITUTED

Tier 5

vinblastine sulfate intravenous* solution Tier 1

vinblastine sulfate intravenous* solution reconstituted

Tier 1

VINCASAR PFS INTRAVENOUS* SOLUTION

Tier 1

vinorelbine tartrate intravenous* solution Tier 1

VOTRIENT ORAL TABLET Tier 5

VRAYLAR ORAL Tier 3 ST; QL (7 EA per 7 days)

VRAYLAR ORAL CAPSULE 1.5 MG Tier 3 ST; QL (60 EA per 30 days)

VRAYLAR ORAL CAPSULE 3 MG, 4.5 MG Tier 3 ST; QL (30 EA per 30 days)

VRAYLAR ORAL CAPSULE 6 MG Tier 3

XALKORI ORAL CAPSULE Tier 5 PA

XTANDI ORAL CAPSULE Tier 5 PA

YERVOY INTRAVENOUS* SOLUTION Tier 5

YONDELIS INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 5 PA

ZALTRAP INTRAVENOUS* SOLUTION Tier 5

ZELBORAF ORAL TABLET Tier 5

ZOLINZA ORAL CAPSULE Tier 5

ZYTIGA ORAL TABLET Tier 5

Aromatase Inhibitors 3Rd Generation (Hormonal Chemotherapy Drugs)

anastrozole oral tablet Tier 5

exemestane oral tablet Tier 5

letrozole oral tablet Tier 5

28


Ppaca Prev Breast Ca (Cancer Drugs)

tamoxifen citrate oral tablet Tier 6

Antiparasitics (Infection Fighting Drugs)

Anthelmintics (Miscellaneous Infection Fighting Drugs)

ALBENZA ORAL TABLET Tier 3

ivermectin oral tablet Tier 1

SKLICE EXTERNAL LOTION Tier 1

Antiprotozoals (Malaria Drugs)

ALINIA ORAL SUSPENSION RECONSTITUTED

Tier 3

ALINIA ORAL TABLET Tier 3

atovaquone oral suspension Tier 1

atovaquone-proguanil hcl oral tablet Tier 1

chloroquine phosphate oral tablet Tier 1

DARAPRIM ORAL TABLET Tier 4

hydroxychloroquine sulfate oral tablet Tier 1

mefloquine hcl oral tablet Tier 1

MEPRON ORAL SUSPENSION Tier 3

NEBUPENT INHALATION SOLUTION RECONSTITUTED

Tier 2

PENTAM INJECTION SOLUTION RECONSTITUTED

Tier 3

primaquine phosphate oral tablet Tier 3

Antiparkinson Agents (Nerve Condition Drugs)

Anticholinergics (Parkinson's Disease Drugs)

benztropine mesylate injection solution Tier 1

benztropine mesylate oral tablet Tier 1

trihexyphenidyl hcl oral elixir Tier 1

trihexyphenidyl hcl oral tablet Tier 1

Antiparkinson Agents Other (Parkinson's Disease Drugs)

amantadine hcl oral capsule Tier 1

29


amantadine hcl oral syrup Tier 1

amantadine hcl oral tablet Tier 1

entacapone oral tablet Tier 1

Dopamine Agonists (Parkinson's Disease Drugs)

APOKYN SUBCUTANEOUS* SOLUTION Tier 4

bromocriptine mesylate oral capsule Tier 1

bromocriptine mesylate oral tablet Tier 1

pramipexole dihydrochloride oral tablet Tier 1

ropinirole hcl er oral tablet extended release 24 hr*

Tier 1

ropinirole hcl oral tablet Tier 1

Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors (Parkinson's Disease Drugs)

carbidopa-levodopa er oral tablet extendedrelease* 25-100 mg, 50-200 mg

Tier 1

carbidopa-levodopa oral tablet Tier 1

carbidopa-levodopa oral tablet dispersible Tier 1

carbidopa-levodopa-entacapone oral tablet Tier 1

Monoamine Oxidase B (Mao-B) Inhibitors (Parkinson's Disease Drugs)

AZILECT ORAL TABLET Tier 3

selegiline hcl oral capsule Tier 1

selegiline hcl oral tablet Tier 1

Antipsychotics (Nerve Condition Drugs)

1St Generation/Typical (Mood Disorder Drugs)

chlorpromazine hcl injection solution Tier 1

chlorpromazine hcl oral tablet Tier 1

fluphenazine decanoate injection solution Tier 1

fluphenazine hcl injection solution Tier 1

fluphenazine hcl oral concentrate Tier 1

fluphenazine hcl oral elixir Tier 1

fluphenazine hcl oral tablet Tier 1

30


haloperidol decanoate intramuscular* solution

Tier 1

haloperidol lactate injection solution Tier 1

haloperidol lactate oral concentrate Tier 1

haloperidol oral tablet Tier 1

loxapine succinate oral capsule Tier 1

ORAP ORAL TABLET Tier 3

perphenazine oral tablet Tier 1

perphenazine-amitriptyline oral tablet Tier 1

prochlorperazine edisylate injection solution Tier 1

prochlorperazine maleate oral tablet Tier 1

prochlorperazine suppository Tier 1

thioridazine hcl oral tablet Tier 1

thiothixene oral capsule Tier 1

trifluoperazine hcl oral tablet Tier 1

2Nd Generation/Atypical (Mood Disorder Drugs)

ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 300 MG, 400 MG

Tier 3

aripiprazole oral solution Tier 1

aripiprazole oral tablet Tier 1

aripiprazole oral tablet dispersible Tier 1

ARISTADA INTRAMUSCULAR* 441 MG/1.6ML

Tier 3 ST; QL (1.8 ML per 28 days)





FANAPT ORAL TABLET Tier 3

FANAPT TITRATION PACK ORAL TABLET Tier 3

GEODON INTRAMUSCULAR* SOLUTION RECONSTITUTED

Tier 3

INVEGA ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3

INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION

Tier 3

LATUDA ORAL TABLET Tier 2

31


olanzapine intramuscular* solution reconstituted

Tier 1

olanzapine oral tablet Tier 1

olanzapine oral tablet dispersible Tier 1

quetiapine fumarate er oral tablet extended release 24 hr*

Tier 1

quetiapine fumarate oral tablet Tier 1

RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED

Tier 3

RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 3 MG, 4 MG

Tier 1

RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 2 MG

Tier 2

risperidone oral solution Tier 1

risperidone oral tablet Tier 1

risperidone oral tablet dispersible 0.25 mg Tier 1

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG

Tier 3

ziprasidone hcl oral capsule Tier 1

Treatment-Resistant (Mood Disorder Drugs)

clozapine oral tablet Tier 1

FAZACLO ORAL TABLET DISPERSIBLE 100 MG, 12.5 MG, 25 MG

Tier 3

Antispasticity Agents (Muscle And Joint Drugs)

Antispasticity Agents (Muscle And Joint Drugs)

GABLOFEN INTRATHECAL* SOLUTION 50 MCG/ML

Tier 3

Antivirals (Infection Fighting Drugs)

Anti-Cytomegalovirus (Cmv) Agents (Virus Infection Drugs)

FOSCAVIR INTRAVENOUS* SOLUTION 6000 MG/250ML

Tier 2

ganciclovir sodium intravenous* solution reconstituted

Tier 1

VALCYTE ORAL SOLUTION RECONSTITUTED

Tier 2

32


valganciclovir hcl oral tablet Tier 3

Antihepatitis Agents (Virus Infection Drugs)

adefovir dipivoxil oral tablet Tier 4

BARACLUDE ORAL SOLUTION Tier 3

entecavir oral tablet Tier 3

HARVONI ORAL TABLET Tier 4 PA

lamivudine oral tablet 100 mg Tier 1 QL (20 EA per 5 days)

PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 135 MCG/0.5ML

Tier 4

PEGASYS SUBCUTANEOUS* SOLUTION Tier 4

RIBASPHERE ORAL TABLET 400 MG Tier 1

RIBASPHERE RIBAPAK ORAL TABLET 400 & 600 MG, 400 MG

Tier 4

ribavirin oral capsule Tier 1

ribavirin oral tablet 200 mg Tier 1

SOVALDI ORAL TABLET Tier 4 PA

TYZEKA ORAL TABLET Tier 3

VICTRELIS ORAL CAPSULE Tier 4 PA

Antiherpetic Agents (Virus Infection Drugs)

acyclovir oral capsule Tier 1

acyclovir oral suspension Tier 1

acyclovir oral tablet Tier 1

acyclovir sodium intravenous* solution Tier 1

acyclovir sodium intravenous* solution reconstituted

Tier 1

famciclovir oral tablet Tier 1

valacyclovir hcl oral tablet Tier 1

Anti-Hiv Agents Other (Retrovirus Infection Drugs)

ATRIPLA ORAL TABLET Tier 3

COMPLERA ORAL TABLET Tier 3

FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED


GENVOYA ORAL TABLET Tier 4

ISENTRESS ORAL TABLET Tier 3 QL (10 EA per 30 days)

33


ISENTRESS ORAL TABLET CHEWABLE 100 MG


ISENTRESS ORAL TABLET CHEWABLE 25 MG


SELZENTRY ORAL TABLET 150 MG Tier 4 QL (30 EA per 30 days)

SELZENTRY ORAL TABLET 300 MG Tier 4 QL (10 EA per 30 days)

STRIBILD ORAL TABLET Tier 3

Anti-Hiv Agents Protease Inhibitors (Retrovirus Infection Drugs)

APTIVUS ORAL CAPSULE Tier 3 QL (360 EA per 30 days)

APTIVUS ORAL SOLUTION Tier 3 QL (360 ML per 30 days)

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG


INVIRASE ORAL CAPSULE Tier 3 QL (360 EA per 30 days)

INVIRASE ORAL TABLET Tier 3 QL (360 EA per 30 days)

KALETRA ORAL SOLUTION Tier 3

KALETRA ORAL TABLET Tier 3

LEXIVA ORAL SUSPENSION Tier 3 QL (90 ML per 30 days)

LEXIVA ORAL TABLET Tier 3 QL (90 EA per 30 days)

NORVIR ORAL CAPSULE Tier 3 QL (360 EA per 30 days)

NORVIR ORAL SOLUTION Tier 3 QL (360 ML per 30 days)

NORVIR ORAL TABLET Tier 3 QL (360 EA per 30 days)

PREZISTA ORAL SUSPENSION Tier 3 QL (120 ML per 30 days)

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG


REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG


TIVICAY ORAL TABLET 50 MG Tier 3 QL (10 EA per 30 days)

VIRACEPT ORAL TABLET 250 MG Tier 3 QL (240 EA per 30 days)

VIRACEPT ORAL TABLET 625 MG Tier 3 QL (90 EA per 30 days)

Anti-Hiv Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (Retrovirus Infection Drugs)

EDURANT ORAL TABLET Tier 3

INTELENCE ORAL TABLET Tier 3

nevirapine er oral tablet extended release 24 hr*

Tier 1

nevirapine oral suspension Tier 3

34


nevirapine oral tablet Tier 1

RESCRIPTOR ORAL TABLET Tier 2

SUSTIVA ORAL CAPSULE Tier 2

SUSTIVA ORAL TABLET Tier 2

VIRAMUNE ORAL SUSPENSION Tier 3

Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (Retrovirus Infection Drugs)

abacavir sulfate oral tablet Tier 1 QL (390 EA per 30 days)

abacavir sulfate-lamivudine oral tablet Tier 4

abacavir-lamivudine-zidovudine oral tablet Tier 1

didanosine oral capsule delayed release 125 mg


didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg


EMTRIVA ORAL CAPSULE Tier 3 QL (360 EA per 30 days)

EMTRIVA ORAL SOLUTION Tier 2 QL (400 ML per 30 days)

EPIVIR HBV ORAL SOLUTION Tier 2 QL (9 ML per 30 days)

lamivudine oral solution Tier 1

lamivudine oral tablet 150 mg, 300 mg Tier 1 QL (9 EA per 30 days)

lamivudine-zidovudine oral tablet Tier 1

RETROVIR INTRAVENOUS* SOLUTION Tier 3

stavudine oral capsule 15 mg Tier 1 QL (9 EA per 30 days)

stavudine oral capsule 20 mg, 30 mg Tier 1 QL (3 EA per 30 days)

stavudine oral capsule 40 mg Tier 1 QL (60 EA per 30 days)

stavudine oral solution reconstituted Tier 1 QL (60 ML per 30 days)

TRUVADA ORAL TABLET 200-300 MG Tier 3

VIDEX ORAL SOLUTION RECONSTITUTED


VIREAD ORAL POWDER Tier 3

VIREAD ORAL TABLET Tier 3

ZIAGEN ORAL SOLUTION Tier 3 QL (390 ML per 30 days)

zidovudine oral capsule Tier 1

zidovudine oral syrup Tier 1

zidovudine oral tablet Tier 1

35


Anti-Influenza Agents (Virus Infection Drugs)

rimantadine hcl oral tablet Tier 1

TAMIFLU ORAL CAPSULE 30 MG, 45 MG Tier 3

TAMIFLU ORAL CAPSULE 75 MG Tier 3 QL (10 EA per 5 days)

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML

Tier 3

Anxiolytics (Nerve Condition Drugs)

Anxiolytics Other (Anxiety Drugs)

buspirone hcl oral tablet Tier 1

hydroxyzine hcl intramuscular* solution Tier 1

hydroxyzine hcl oral syrup Tier 1

hydroxyzine hcl oral tablet Tier 1

hydroxyzine pamoate oral capsule Tier 1

meprobamate oral tablet Tier 1

Benzodiazepines (Anxiety Drugs)

alprazolam er oral tablet extended release 24 hr* 0.5 mg, 3 mg

Tier 1

ALPRAZOLAM INTENSOL ORAL CONCENTRATE

Tier 1

alprazolam oral tablet Tier 1

alprazolam oral tablet dispersible Tier 1

alprazolam xr oral tablet extended release 24 hr* 1 mg, 2 mg

Tier 1

chlordiazepoxide hcl oral capsule Tier 1

clorazepate dipotassium oral tablet Tier 1

diazepam oral concentrate Tier 1

diazepam oral solution 1 mg/ml Tier 1

diazepam oral tablet Tier 1

lorazepam oral concentrate Tier 1

lorazepam oral tablet Tier 1

oxazepam oral capsule Tier 1

Bipolar Agents (Nerve Condition Drugs)

Mood Stabilizers (Miscellaneous Nerve Condition Drugs)

lithium carbonate er oral tablet extendedrelease*

Tier 1

36


lithium carbonate oral capsule Tier 1

lithium carbonate oral tablet Tier 1

Blood Glucose Regulators (Hormone And Diabetic Drugs)

*Alpha-Glucosidase Inhibitors***

acarbose oral tablet Tier 1

*Diabetic Other***

GLUCAGEN DIAGNOSTIC INJECTION SOLUTION RECONSTITUTED

Tier 3

GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED

Tier 3

GLUCAGON EMERGENCY INJECTION KIT Tier 2

glucose oral tablet chewable 4-6 gm-mg Tier 1 OTC

PROGLYCEM ORAL SUSPENSION Tier 4

*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors***

NESINA ORAL TABLET Tier 3

ONGLYZA ORAL TABLET Tier 3

Antidiabetic Agents (Injectable Diabetes, Blood Sugar Drugs)

BYETTA 10 MCG PEN SUBCUTANEOUS* Tier 3

BYETTA 5 MCG PEN SUBCUTANEOUS* Tier 3

SYMLINPEN 120 SUBCUTANEOUS* Tier 3

SYMLINPEN 60 SUBCUTANEOUS* Tier 3

Antidiabetic Agents (Oral Diabetes, Blood Sugar Drugs)

glipizide-metformin hcl oral tablet Tier 1

glyburide oral tablet 2.5 mg, 5 mg Tier 1

glyburide-metformin oral tablet Tier 1

OSENI ORAL TABLET Tier 3

pioglitazone hcl-glimepiride oral tablet Tier 1

PRANDIMET ORAL TABLET Tier 3

PRANDIN ORAL TABLET Tier 3

tolazamide oral tablet Tier 1

tolbutamide oral tablet Tier 1

Antidiabetics, Other

CYCLOSET ORAL TABLET Tier 3

37


nateglinide oral tablet Tier 1

repaglinide oral tablet Tier 1

Biguanide Antidiabetics

metformin hcl er (mod) oral tablet extended release 24 hr*

Tier 1

metformin hcl er (osm) oral tablet extended release 24 hr*

Tier 1

metformin hcl er oral tablet extended release 24 hr*

Tier 1

metformin hcl oral tablet Tier 1

RIOMET ORAL SOLUTION Tier 3

Dipeptidyl Peptidase-4 (Dpp-4) Inhibitor Combinations

JANUMET ORAL TABLET Tier 2

JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 2

KAZANO ORAL TABLET Tier 3

KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 2

Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors

JANUVIA ORAL TABLET Tier 2

Insulins (Injectable Diabetes, Blood Sugar Drugs)

APIDRA INJECTION SOLUTION Tier 2

APIDRA SOLOSTAR SUBCUTANEOUS* Tier 2

LANTUS SOLOSTAR SUBCUTANEOUS* Tier 2

LANTUS SUBCUTANEOUS* SOLUTION Tier 2

LEVEMIR FLEXTOUCH SUBCUTANEOUS* Tier 2

LEVEMIR SUBCUTANEOUS* SOLUTION Tier 2

NOVOLIN 70/30 RELION SUBCUTANEOUS* SUSPENSION

Tier 2 OTC

NOVOLIN 70/30 SUBCUTANEOUS* SUSPENSION

Tier 2 OTC

NOVOLIN N RELION SUBCUTANEOUS* SUSPENSION

Tier 2 OTC

NOVOLIN N SUBCUTANEOUS* SUSPENSION

Tier 2 OTC

NOVOLIN R INJECTION SOLUTION Tier 2 OTC

38


NOVOLIN R RELION INJECTION SOLUTION

Tier 2 OTC

NOVOLOG FLEXPEN SUBCUTANEOUS* Tier 2

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS*

Tier 2

NOVOLOG MIX 70/30 SUBCUTANEOUS* SUSPENSION

Tier 2

NOVOLOG PENFILL SUBCUTANEOUS* Tier 2

NOVOLOG SUBCUTANEOUS* SOLUTION Tier 2

TOUJEO SOLOSTAR SUBCUTANEOUS* Tier 2 QL (21 ML per 30 days)

TRESIBA FLEXTOUCH SUBCUTANEOUS* Tier 3

Sodium-Glucose Co-Transport 2 (Sglt2) Inhibitors (Antidiabetic)

FARXIGA ORAL TABLET Tier 2

INVOKANA ORAL TABLET Tier 2

Sulfonylureas (Antidiabetic)

chlorpropamide oral tablet Tier 1

DIABETA ORAL TABLET Tier 1

glimepiride oral tablet Tier 1

glipizide er oral tablet extended release 24 hr*

Tier 1

glipizide oral tablet Tier 1

glipizide xl oral tablet extended release 24 hr*

Tier 1

glyburide micronized oral tablet Tier 1

glyburide oral tablet 1.25 mg Tier 1

Thiazolidinediones (Tzds)

AVANDIA ORAL TABLET Tier 3

pioglitazone hcl oral tablet Tier 1

Thiazolindinedione (Tzd) Combinations

ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 2

AVANDAMET ORAL TABLET Tier 3

pioglitazone hcl-metformin hcl oral tablet Tier 1

39


Blood Products/Modifiers/ Volume Expanders (Blood Disorder Drugs)

Anticoagulants (Blood Thinners)

ELIQUIS ORAL TABLET Tier 3

enoxaparin sodium injection solution Tier 1

enoxaparin sodium subcutaneous* solution100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 60 mg/0.6ml, 80 mg/0.8ml

Tier 4

enoxaparin sodium subcutaneous* solution30 mg/0.3ml, 40 mg/0.4ml

Tier 1

fondaparinux sodium subcutaneous* solution Tier 4

heparin (porcine) in d5w intravenous* solution

Tier 1

heparin (porcine) in nacl injection solution Tier 1

heparin lock flush intravenous* solution Tier 1

heparin sod (porcine) in d5w intravenous* solution

Tier 1

heparin sodium (porcine) injection solution1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml

Tier 1

heparin sodium (porcine) pf injection solution Tier 1

PRADAXA ORAL CAPSULE 150 MG, 75 MG Tier 3

sash kit intravenous* kit 100-0.9 unit/ml-% Tier 1

SAVAYSA ORAL TABLET Tier 3

warfarin sodium oral tablet Tier 1

XARELTO ORAL TABLET Tier 2

XARELTO STARTER PACK ORAL Tier 2

Blood Formation Modifiers (Blood Formation Drugs)

tranexamic acid intravenous* solution 1000 mg/10ml

Tier 1

Erythropoietins

PROCRIT INJECTION SOLUTION 10000 UNIT/ML

Tier 4 PA

Hematopoietic Agents, Other

PROMACTA ORAL TABLET Tier 4

40


Platelet Modifying Agents (Blood Thinners)

AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12 HOUR

Tier 3

anagrelide hcl oral capsule Tier 1

aspirin-dipyridamole er oral capsule extended release 12 hour

Tier 3

cilostazol oral tablet Tier 1

clopidogrel bisulfate oral tablet Tier 1

dipyridamole oral tablet Tier 1

EFFIENT ORAL TABLET Tier 3

ticlopidine hcl oral tablet Tier 1

Cardiovascular Agents (Heart And Circulation Condition Drugs)

Alpha-Adrenergic Blocking Agents (Blood Pressure Drugs)

clonidine hcl oral tablet Tier 1

clonidine hcl transdermal patch weekly Tier 1

doxazosin mesylate oral tablet Tier 1

guanfacine hcl oral tablet Tier 1

methyldopa oral tablet Tier 1

methyldopate hcl intravenous* solution Tier 1

prazosin hcl oral capsule Tier 1

terazosin hcl oral capsule Tier 1

Angiotensin Ii Receptor Antagonists (Blood Pressure Drugs)

ATACAND ORAL TABLET 16 MG, 32 MG Tier 1

candesartan cilexetil oral tablet Tier 1

candesartan cilexetil-hctz oral tablet Tier 1

EDARBI ORAL TABLET Tier 3 ST

eprosartan mesylate oral tablet Tier 1

irbesartan oral tablet Tier 1

losartan potassium oral tablet Tier 1

olmesartan medoxomil oral tablet Tier 1

telmisartan oral tablet Tier 1

valsartan oral tablet Tier 1

41


Angiotensin-Converting Enzyme (Ace) Inhibitors (Blood Pressure Drugs)

benazepril hcl oral tablet Tier 1

captopril oral tablet Tier 1

enalapril maleate oral tablet Tier 1

fosinopril sodium oral tablet Tier 1

lisinopril oral tablet Tier 1

moexipril hcl oral tablet Tier 1

perindopril erbumine oral tablet Tier 1

quinapril hcl oral tablet Tier 1

ramipril oral capsule Tier 1

trandolapril oral tablet Tier 1

Antiarrhythmics (Heart Regulation Drugs)

amiodarone hcl intravenous* solution Tier 1

amiodarone hcl oral tablet Tier 1

disopyramide phosphate oral capsule Tier 1

dofetilide oral capsule Tier 1

flecainide acetate oral tablet Tier 1

mexiletine hcl oral capsule Tier 1

MULTAQ ORAL TABLET Tier 3

PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG

Tier 1

procainamide hcl injection solution 100 mg/ml

Tier 1

propafenone hcl er oral capsule extended release 12 hour

Tier 1

propafenone hcl oral tablet Tier 1

quinidine gluconate er oral tablet extendedrelease*

Tier 1

quinidine sulfate er oral tablet extendedrelease*

Tier 1

quinidine sulfate oral tablet Tier 1

Antihypertensive Combinations (Blood Pressure Drugs)

amiloride-hydrochlorothiazide oral tablet Tier 1

amlodipine besy-benazepril hcl oral capsule Tier 1

42


amlodipine besylate-valsartan oral tablet Tier 1

amlodipine-atorvastatin oral tablet 10-40 mg Tier 1

amlodipine-olmesartan oral tablet Tier 1

amlodipine-valsartan-hctz oral tablet Tier 1

AMTURNIDE ORAL TABLET Tier 3

atenolol-chlorthalidone oral tablet Tier 1

benazepril-hydrochlorothiazide oral tablet Tier 1

bisoprolol-hydrochlorothiazide oral tablet Tier 1

captopril-hydrochlorothiazide oral tablet Tier 1

EDARBYCLOR ORAL TABLET Tier 3 ST

enalapril-hydrochlorothiazide oral tablet Tier 1

fosinopril sodium-hctz oral tablet Tier 1

irbesartan-hydrochlorothiazide oral tablet Tier 1

lisinopril-hydrochlorothiazide oral tablet Tier 1

losartan potassium-hctz oral tablet Tier 1

methyldopa-hydrochlorothiazide oral tablet Tier 1

metoprolol-hydrochlorothiazide oral tablet Tier 1

moexipril-hydrochlorothiazide oral tablet Tier 1

nadolol-bendroflumethiazide oral tablet Tier 1

olmesartan medoxomil-hctz oral tablet Tier 1

olmesartan-amlodipine-hctz oral tablet Tier 1

propranolol-hctz oral tablet Tier 1

quinapril-hydrochlorothiazide oral tablet Tier 1

spironolactone-hctz oral tablet Tier 1

TEKAMLO ORAL TABLET Tier 3

TEKTURNA HCT ORAL TABLET Tier 2

telmisartan-amlodipine oral tablet Tier 1

telmisartan-hctz oral tablet Tier 1

TEVETEN HCT ORAL TABLET Tier 3

trandolapril-verapamil hcl er oral tablet extendedrelease*

Tier 1

triamterene-hctz oral capsule Tier 1

triamterene-hctz oral tablet Tier 1

valsartan-hydrochlorothiazide oral tablet Tier 1

Beta-Adrenergic Blocking Agents (Blood Pressure Drugs)

acebutolol hcl oral capsule Tier 1

43


atenolol oral tablet Tier 1

betaxolol hcl oral tablet Tier 1

bisoprolol fumarate oral tablet Tier 1

carvedilol oral tablet Tier 1

INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR

Tier 3

labetalol hcl intravenous* solution Tier 1

labetalol hcl oral tablet Tier 1

metoprolol succinate er oral tablet extended release 24 hr*

Tier 1

metoprolol tartrate intravenous* solution 1 mg/ml

Tier 1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

Tier 1

nadolol oral tablet 20 mg, 40 mg, 80 mg Tier 1

pindolol oral tablet Tier 1

propranolol hcl er oral capsule extended release 24 hour

Tier 1

propranolol hcl intravenous* solution Tier 1

propranolol hcl oral solution Tier 1

propranolol hcl oral tablet Tier 1

sotalol hcl (af) oral tablet Tier 1

sotalol hcl oral tablet Tier 1

timolol maleate oral tablet Tier 1

Calcium Channel Blocking Agents (Blood Pressure Drugs)

amlodipine besylate oral tablet Tier 1

diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

Tier 1

diltiazem hcl er beads oral capsule extended release 24 hour

Tier 1

diltiazem hcl er coated beads oral capsule extended release 24 hour 300 mg, 360 mg

Tier 1

diltiazem hcl er coated beads oral tablet extended release 24 hr*

Tier 1

diltiazem hcl er oral capsule extended release 12 hour

Tier 1

diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

Tier 1

diltiazem hcl intravenous* solution Tier 1

44


diltiazem hcl oral tablet Tier 1

felodipine er oral tablet extended release 24 hr*

Tier 1

isradipine oral capsule Tier 1

nicardipine hcl oral capsule Tier 1

NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 90 MG

Tier 1

nifedipine er oral tablet extended release 24 hr* 30 mg, 60 mg

Tier 1

nifedipine er osmotic release oral tablet extended release 24 hr*

Tier 1

nifedipine oral capsule Tier 1

nimodipine oral capsule Tier 4

nisoldipine er oral tablet extended release 24 hr*

Tier 1

verapamil hcl er oral capsule extended release 24 hour

Tier 1

verapamil hcl er oral tablet extendedrelease*120 mg, 180 mg, 240 mg

Tier 1

verapamil hcl intravenous* solution Tier 1

verapamil hcl oral tablet Tier 1

Cardiovascular Agents, Other

digoxin injection solution Tier 1

digoxin oral solution Tier 1

digoxin oral tablet Tier 1 PA

epinephrine hcl pf intravenous* solution Tier 1

midodrine hcl oral tablet Tier 1

pentoxifylline er oral tablet extendedrelease* Tier 1

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR*

Tier 2

TEKTURNA ORAL TABLET Tier 2

Diuretics Carbonic Anhydrase Inhibitors [Blood Pressure Drugs (Water Pills)]

acetazolamide er oral capsule extended release 12 hour

Tier 1

acetazolamide oral tablet Tier 1

methazolamide oral tablet Tier 1

NEPTAZANE ORAL TABLET Tier 1

45


Diuretics Loop [Blood Pressure Drugs (Water Pills)]

bumetanide injection solution Tier 1

bumetanide oral tablet Tier 1

furosemide injection solution 10 mg/ml Tier 1

furosemide oral solution 10 mg/ml, 8 mg/ml Tier 1

furosemide oral tablet Tier 1

torsemide oral tablet Tier 1

Diuretics Potassium-Sparing [Blood Pressure Drugs (Water Pills)]

amiloride hcl oral tablet Tier 1

DYRENIUM ORAL CAPSULE Tier 3

eplerenone oral tablet Tier 1

spironolactone oral tablet Tier 1

Diuretics Thiazide [Blood Pressure Drugs (Water Pills)]

chlorothiazide oral tablet Tier 1

chlorthalidone oral tablet 25 mg, 50 mg Tier 1

hydrochlorothiazide oral capsule Tier 1

hydrochlorothiazide oral tablet Tier 1

indapamide oral tablet Tier 1

methyclothiazide oral tablet Tier 1

metolazone oral tablet Tier 1

Dyslipidemics Fibric Acid Derivatives (Cholesterol Drugs)

fenofibrate micronized oral capsule Tier 1

fenofibrate oral capsule Tier 1

fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg

Tier 1

fenofibric acid oral capsule delayed release Tier 1

gemfibrozil oral tablet Tier 1

LIPOFEN ORAL CAPSULE Tier 2

Dyslipidemics Hmg Coa Reductase Inhibitors (Cholesterol Drugs)

ADVICOR ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3

ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3

46


atorvastatin calcium oral tablet Tier 1

fluvastatin sodium er oral tablet extended release 24 hr*

Tier 1

fluvastatin sodium oral capsule Tier 1

LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3

LIVALO ORAL TABLET Tier 3

lovastatin oral tablet Tier 1

pravastatin sodium oral tablet Tier 1

rosuvastatin calcium oral tablet Tier 1

simvastatin oral tablet Tier 1

Dyslipidemics Other (Cholesterol Drugs)

cholestyramine light oral packet Tier 1

cholestyramine light oral powder Tier 1

cholestyramine oral packet Tier 1

cholestyramine oral powder Tier 1

colestipol hcl oral granules Tier 1

colestipol hcl oral packet Tier 1

colestipol hcl oral tablet Tier 1

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG

Tier 4

LOVAZA ORAL CAPSULE Tier 2

niacin er (antihyperlipidemic) oral tablet extendedrelease*

Tier 1

NIACOR ORAL TABLET Tier 1

omega-3-acid ethyl esters oral capsule Tier 1

VYTORIN ORAL TABLET Tier 3

WELCHOL ORAL PACKET Tier 2

WELCHOL ORAL TABLET Tier 2

ZETIA ORAL TABLET Tier 3

Vasodilators Direct-Acting Arterial (Miscellaneous Heart And Circulation Drugs)

hydralazine hcl injection solution Tier 1

hydralazine hcl oral tablet Tier 1

minoxidil oral tablet Tier 1

47


Vasodilators Direct-Acting Arterial/Venous (Chest Pain Drugs)

isosorbide dinitrate er oral tablet extendedrelease*

Tier 1

isosorbide dinitrate oral tablet Tier 1

isosorbide mononitrate er oral tablet extended release 24 hr*

Tier 1

isosorbide mononitrate oral tablet Tier 1

nitroglycerin intravenous* solution Tier 1

nitroglycerin transdermal patch 24 hr Tier 1

nitroglycerin translingual aerosol, solution Tier 3

nitroglycerin translingual solution Tier 3

NITROLINGUAL TRANSLINGUAL SOLUTION

Tier 2

NITROSTAT SUBLINGUAL TABLET SUBLINGUAL

Tier 3

Central Nervous System Agents (Nerve Condition Drugs)

Attention Deficit Hyperactivity Disorder Agents, Amphetamines (Adhd Drugs)

amphetamine-dextroamphet er oral capsule extended release 24 hour

Tier 1

amphetamine-dextroamphetamine oral tablet Tier 1

dextroamphetamine sulfate er oral capsule extended release 24 hour

Tier 1

dextroamphetamine sulfate oral tablet Tier 1

Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines (Adhd Drugs)

CONCERTA ORAL TABLET EXTENDEDRELEASE*

Tier 1

dexmethylphenidate hcl er oral capsule extended release 24 hour 15 mg, 30 mg, 40 mg

Tier 1

dexmethylphenidate hcl oral tablet Tier 1

guanfacine hcl er oral tablet extended release 24 hr*

Tier 1 PA

methylphenidate hcl er (cd) oral capsule extended release*

Tier 1

48


methylphenidate hcl er (la) oral capsule extended release 24 hour

Tier 1

methylphenidate hcl er oral tablet extendedrelease*

Tier 1

methylphenidate hcl oral solution Tier 1

methylphenidate hcl oral tablet Tier 1

methylphenidate hcl oral tablet chewable Tier 1

STRATTERA ORAL CAPSULE Tier 2

Central Nervous System, Other

NUEDEXTA ORAL CAPSULE Tier 2

riluzole oral tablet Tier 3

tetrabenazine oral tablet Tier 4

XENAZINE ORAL TABLET Tier 4

Fibromyalgia Agents

LYRICA ORAL CAPSULE Tier 3

LYRICA ORAL SOLUTION Tier 2

SAVELLA ORAL TABLET Tier 2

SAVELLA TITRATION PACK ORAL Tier 2

Multiple Sclerosis Agents (Multiple Sclerosis Drugs)

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR*

Tier 4

AUBAGIO ORAL TABLET Tier 4 ST

BETASERON SUBCUTANEOUS* KIT Tier 4

COPAXONE SUBCUTANEOUS* 20 MG/ML Tier 4

EXTAVIA SUBCUTANEOUS* KIT Tier 4

GILENYA ORAL CAPSULE Tier 4

LEMTRADA INTRAVENOUS* SOLUTION Tier 4 PA

REBIF REBIDOSE SUBCUTANEOUS* Tier 4

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS*

Tier 4

REBIF SUBCUTANEOUS* Tier 4

REBIF TITRATION PACK SUBCUTANEOUS*

Tier 4

TYSABRI INTRAVENOUS* CONCENTRATE Tier 4

49


Contraceptives

*Combination Contraceptives - Transdermal***

XULANE TRANSDERMAL PATCH WEEKLY Tier 6

*Emergency Contraceptives***

ELLA ORAL TABLET Tier 6

levonorgestrel oral tablet 1.5 mg Tier 6 OTC

Condoms, Female

FC2 FEMALE CONDOM Tier 6 OTC

Contraceptives Implant

NEXPLANON SUBCUTANEOUS* IMPLANT Tier 6

Contraceptives Injectable

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS* SUSPENSION

Tier 6

medroxyprogesterone acetate intramuscular* suspension

Tier 6

Contraceptives Intrauterine

MIRENA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE

Tier 6

PARAGARD INTRAUTERINE COPPER INTRAUTERINE INTRAUTERINE DEVICE

Tier 6

SKYLA INTRAUTERINE INTRAUTERINE DEVICE

Tier 6

Contraceptives Intravaginal

CAYA VAGINAL DIAPHRAGM Tier 6

NUVARING VAGINAL RING Tier 6

OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM

Tier 6

OPTIONS CONCEPTROL VAGINAL GEL Tier 6 OTC

OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL

Tier 6 OTC

PRENTIF FITTING SET VAGINAL Tier 6

TODAY SPONGE VAGINAL Tier 6 OTC

VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM

Tier 6 OTC

VCF VAGINAL CONTRACEPTIVE VAGINAL GEL

Tier 6 OTC

50


Contraceptives Oral

ALTAVERA ORAL TABLET Tier 6

alyacen 1/35 oral tablet Tier 6

alyacen 7/7/7 oral tablet Tier 6

AMETHIA LO ORAL TABLET Tier 6

AMETHIA ORAL TABLET Tier 6

AMETHYST ORAL TABLET Tier 6

APRI ORAL TABLET Tier 6

ARANELLE ORAL TABLET Tier 6

ASHLYNA ORAL TABLET Tier 6

AUBRA ORAL TABLET Tier 6

AVIANE ORAL TABLET Tier 6

AZURETTE ORAL TABLET Tier 6

BEKYREE ORAL TABLET Tier 6

BEYAZ ORAL TABLET Tier 6

BLISOVI 24 FE ORAL TABLET Tier 6

BLISOVI FE 1.5/30 ORAL TABLET Tier 6

BLISOVI FE 1/20 ORAL TABLET Tier 6

briellyn oral tablet Tier 6

CAMRESE LO ORAL TABLET Tier 6

CAMRESE ORAL TABLET Tier 6

CAZIANT ORAL TABLET Tier 6

CESIA ORAL TABLET Tier 6

CHATEAL ORAL TABLET Tier 6

CRYSELLE-28 ORAL TABLET Tier 6

CYCLAFEM 1/35 ORAL TABLET Tier 6

CYCLAFEM 7/7/7 ORAL TABLET Tier 6

CYRED ORAL TABLET Tier 6

DASETTA 1/35 ORAL TABLET Tier 6

DASETTA 7/7/7 ORAL TABLET Tier 6

DAYSEE ORAL TABLET Tier 6

DEBLITANE ORAL TABLET Tier 6

DELYLA ORAL TABLET Tier 6

desogestrel-ethinyl estradiol oral tablet Tier 6

drospirenone-ethinyl estradiol oral tablet Tier 6

ELINEST ORAL TABLET Tier 6

EMOQUETTE ORAL TABLET Tier 6

51


ENPRESSE-28 ORAL TABLET Tier 6

ENSKYCE ORAL TABLET Tier 6

ESTARYLLA ORAL TABLET Tier 6

estradiol-norethindrone acet oral tablet Tier 6

FALMINA ORAL TABLET Tier 6

GIANVI ORAL TABLET Tier 6

GILDAGIA ORAL TABLET Tier 6

GILDESS 1.5/30 ORAL TABLET Tier 6

GILDESS 1/20 ORAL TABLET Tier 6

GILDESS FE 1.5/30 ORAL TABLET Tier 6

GILDESS FE 1/20 ORAL TABLET Tier 6

HEATHER ORAL TABLET Tier 6

INTROVALE ORAL TABLET Tier 6

JENCYCLA ORAL TABLET Tier 6

jevantique lo oral tablet Tier 6

JINTELI ORAL TABLET Tier 6

JOLESSA ORAL TABLET Tier 6

JOLIVETTE ORAL TABLET Tier 6

JULEBER ORAL TABLET Tier 6

JUNEL 1.5/30 ORAL TABLET Tier 6

JUNEL FE 1.5/30 ORAL TABLET Tier 6

JUNEL FE 1/20 ORAL TABLET Tier 6

JUNEL FE 24 ORAL TABLET Tier 6

KAITLIB FE ORAL TABLET CHEWABLE Tier 6

KARIVA ORAL TABLET Tier 6

KELNOR 1/35 ORAL TABLET Tier 6

KIMIDESS ORAL TABLET Tier 6

KURVELO ORAL TABLET Tier 6

LARIN 1.5/30 ORAL TABLET Tier 6

LARIN 1/20 ORAL TABLET Tier 6

LARIN 24 FE ORAL TABLET Tier 6

LARIN FE 1.5/30 ORAL TABLET Tier 6

LARIN FE 1/20 ORAL TABLET Tier 6

LAYOLIS FE ORAL TABLET CHEWABLE Tier 6

LEENA ORAL TABLET Tier 6

LESSINA ORAL TABLET Tier 6

LEVONEST ORAL TABLET Tier 6

52


levonorgest-eth estrad 91-day oral tablet Tier 6

levonorgestrel-ethinyl estrad oral tablet Tier 6

levonorg-eth estrad triphasic oral tablet Tier 6

LEVORA 0.15/30 (28) ORAL TABLET Tier 6

LO LOESTRIN FE ORAL TABLET Tier 6

LOMEDIA 24 FE ORAL TABLET Tier 6

LORYNA ORAL TABLET Tier 6

LOW-OGESTREL ORAL TABLET Tier 6

LUTERA ORAL TABLET Tier 6

LYZA ORAL TABLET Tier 6

marlissa oral tablet Tier 6

MICROGESTIN 1.5/30 ORAL TABLET Tier 6

MICROGESTIN 1/20 ORAL TABLET Tier 6

MICROGESTIN 24 FE ORAL TABLET Tier 6

MICROGESTIN FE 1.5/30 ORAL TABLET Tier 6

MICROGESTIN FE 1/20 ORAL TABLET Tier 6

MINASTRIN 24 FE ORAL TABLET CHEWABLE

Tier 6

MONO-LINYAH ORAL TABLET Tier 6

MONONESSA ORAL TABLET Tier 6

MYZILRA ORAL TABLET Tier 6

NATAZIA ORAL TABLET Tier 6

NECON 0.5/35 (28) ORAL TABLET Tier 6

NECON 1/35 (28) ORAL TABLET Tier 6



NECON 7/7/7 ORAL TABLET Tier 6

NIKKI ORAL TABLET Tier 6

NORA-BE ORAL TABLET Tier 6

norethin ace-eth estrad-fe oral tablet Tier 6

norethindrone acet-ethinyl est oral tablet Tier 6

norethindrone oral tablet Tier 6

norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg

Tier 6

norethin-eth estradiol-fe oral tablet chewable0.8-25 mg-mcg

Tier 6

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg

Tier 6

53


norgestim-eth estrad triphasic oral tablet0.18/0.215/0.25 mg-35 mcg

Tier 6

NORLYROC ORAL TABLET Tier 6

NORTREL 0.5/35 (28) ORAL TABLET Tier 6

NORTREL 1/35 (21) ORAL TABLET Tier 6

NORTREL 1/35 (28) ORAL TABLET Tier 6

NORTREL 7/7/7 ORAL TABLET Tier 6

OCELLA ORAL TABLET Tier 6

OGESTREL ORAL TABLET Tier 6

ORSYTHIA ORAL TABLET Tier 6

ORTHO TRI-CYCLEN LO ORAL TABLET Tier 6

PHILITH ORAL TABLET Tier 6

PIMTREA ORAL TABLET Tier 6

PIRMELLA 1/35 ORAL TABLET Tier 6

PIRMELLA 7/7/7 ORAL TABLET Tier 6

PORTIA-28 ORAL TABLET Tier 6

PREVIFEM ORAL TABLET Tier 6

QUARTETTE ORAL TABLET Tier 6

QUASENSE ORAL TABLET Tier 6

RECLIPSEN ORAL TABLET Tier 6

SAFYRAL ORAL TABLET Tier 6

SETLAKIN ORAL TABLET Tier 6

SHAROBEL ORAL TABLET Tier 6

SOLIA ORAL TABLET Tier 6

SPRINTEC 28 ORAL TABLET Tier 6

SRONYX ORAL TABLET Tier 6

SYEDA ORAL TABLET Tier 6

TARINA FE 1/20 ORAL TABLET Tier 6

TILIA FE ORAL TABLET Tier 6

TRI-ESTARYLLA ORAL TABLET Tier 6

TRI-LEGEST FE ORAL TABLET Tier 6

TRI-LINYAH ORAL TABLET Tier 6

TRINESSA (28) ORAL TABLET Tier 6

TRI-PREVIFEM ORAL TABLET Tier 6

TRI-SPRINTEC ORAL TABLET Tier 6

TRIVORA (28) ORAL TABLET Tier 6

VELIVET ORAL TABLET Tier 6

54


VESTURA ORAL TABLET Tier 6

VIENVA ORAL TABLET Tier 6

viorele oral tablet Tier 6

VYFEMLA ORAL TABLET Tier 6

WERA ORAL TABLET Tier 6

WYMZYA FE ORAL TABLET CHEWABLE Tier 6

ZARAH ORAL TABLET Tier 6

ZENCHENT FE ORAL TABLET CHEWABLE Tier 6

ZENCHENT ORAL TABLET Tier 6

ZOVIA 1/50E (28) ORAL TABLET Tier 6

Cough/Cold/Allergy

Antitussive (Narcotic)

hydrocodone-homatropine oral syrup Tier 1

hydrocodone-homatropine oral tablet Tier 1

Antitussive Combination (Narcotic)

hydrocod polst-cpm polst er oral Tier 1

promethazine vc/codeine oral syrup Tier 1

promethazine-codeine oral syrup Tier 1

pseudoeph-chlorphen-hydrocod oral solution Tier 1

Antitussive Combination (Non-Narcotic)

DESGEN PEDIATRIC ORAL LIQUID† Tier 1 OTC

promethazine-dm oral syrup Tier 1

pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml

Tier 1 OTC

TUSSLIN PEDIATRIC ORAL LIQUID† Tier 1 OTC

Antitussives (Non-Narcotic)

benzonatate oral capsule 100 mg, 200 mg Tier 1

Decongestant-Antihistamine

cold & allergy oral elixir Tier 1 OTC

promethazine vc plain oral syrup Tier 1

Dental And Oral Agents

Fluoride

fluoritab oral tablet chewable Tier 6

FLURA-DROPS ORAL SOLUTION Tier 6

LUDENT ORAL TABLET CHEWABLE Tier 6

55


sodium fluoride oral solution Tier 6

sodium fluoride oral tablet 1.1 (0.5 f) mg Tier 6

sodium fluoride oral tablet chewable 1.1 (0.5 f) mg, 2.2 (1 f) mg

Tier 6

Fluoride Dental Products

ACT ANTICAVITY FLUORIDE RINSE MOUTH/THROAT SOLUTION

Tier 6 OTC

CAVIRINSE MOUTH/THROAT SOLUTION Tier 6

CLINPRO 5000 DENTAL PASTE Tier 6

DENTA 5000 PLUS DENTAL CREAM Tier 6

DENTAGEL DENTAL GEL Tier 6

FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE

Tier 6

Dental And Oral Agents (Drugs For The Mouth)

Dental And Oral Agents (Mouth/Throat/Dental Drugs)

chlorhexidine gluconate mouth/throat solution Tier 1

cold sore treatment external liquid† Tier 6 OTC

pilocarpine hcl oral tablet Tier 1

triamcinolone acetonide mouth/throat paste Tier 1

Dermatological Agents (Drugs Affecting Skin)

*Local Anesthetics - Topical***

lidocaine external ointment Tier 1

lidocaine external patch 5 % Tier 1

lidocaine hcl external gel 2 % Tier 1

lidocaine hcl external solution Tier 1

LIDODERM EXTERNAL PATCH Tier 3

Dermatological Agents (Drugs Affecting Skin)

8-MOP ORAL CAPSULE Tier 3

acitretin oral capsule Tier 1

acyclovir external ointment Tier 1

adapalene external cream Tier 1

adapalene external gel Tier 1

alclometasone dipropionate external cream Tier 1

56


alclometasone dipropionate external ointment

Tier 1

amcinonide external cream Tier 1

amcinonide external lotion Tier 1

amcinonide external ointment Tier 1

ammonium lactate external lotion Tier 1 OTC

benzoyl peroxide-erythromycin external gel Tier 1

betamethasone dipropionate aug external cream

Tier 1

betamethasone dipropionate aug external lotion

Tier 1

betamethasone dipropionate aug external ointment

Tier 1

betamethasone dipropionate external cream Tier 1

betamethasone dipropionate external lotion Tier 1

betamethasone dipropionate external ointment

Tier 1

betamethasone valerate external cream Tier 1

betamethasone valerate external foam Tier 1

betamethasone valerate external lotion Tier 1

betamethasone valerate external ointment Tier 1

bp wash external liquid† 2.5 %, 7 % Tier 1

calcipotriene external cream Tier 1

calcipotriene external ointment Tier 1

calcipotriene external solution Tier 1

CICLODAN CREAM EXTERNAL KIT Tier 1

CICLODAN SOLUTION EXTERNAL KIT Tier 1

ciclopirox external gel Tier 1

ciclopirox external shampoo Tier 1

ciclopirox external solution Tier 1

ciclopirox olamine external cream Tier 1

ciclopirox olamine external suspension Tier 1

ciclopirox treatment external kit Tier 1

ciclopirox-vitamin e external kit Tier 1

CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 40 MG

Tier 1

CLARAVIS ORAL CAPSULE 30 MG Tier 3

CLINDACIN PAC EXTERNAL KIT Tier 1

57


clindamycin phos-benzoyl perox external gel Tier 1

clindamycin phosphate external gel Tier 1

clindamycin phosphate external lotion Tier 1

clindamycin phosphate external solution Tier 1

clindamycin phosphate external swab Tier 1

clobetasol propionate e external cream Tier 1

clobetasol propionate emulsion external foam Tier 1

clobetasol propionate external cream Tier 1

clobetasol propionate external foam Tier 1

clobetasol propionate external gel Tier 1

clobetasol propionate external lotion Tier 1

clobetasol propionate external ointment Tier 1

clobetasol propionate external shampoo Tier 1

CLODERM PUMP EXTERNAL CREAM Tier 1

clotrimazole external cream Tier 1 OTC

clotrimazole external solution Tier 1 OTC

clotrimazole-betamethasone external cream Tier 1

clotrimazole-betamethasone external lotion Tier 1

CONDYLOX EXTERNAL GEL Tier 3

CORMAX SCALP APPLICATION EXTERNAL SOLUTION

Tier 1

DERMAZENE EXTERNAL CREAM Tier 1

desonide external cream Tier 1

desonide external lotion Tier 1

desonide external ointment Tier 1

desoximetasone external cream Tier 1

desoximetasone external gel Tier 1

desoximetasone external ointment 0.25 % Tier 1

diclofenac sodium transdermal gel 3 % Tier 1

diclofenac sodium transdermal solution Tier 1

diflorasone diacetate external cream Tier 1

diflorasone diacetate external ointment Tier 1

econazole nitrate external cream Tier 1

ELIDEL EXTERNAL CREAM Tier 3

erythromycin external gel Tier 1

erythromycin external pad Tier 1

erythromycin external solution Tier 1

58


EURAX EXTERNAL CREAM Tier 3

EXODERM EXTERNAL LOTION Tier 1

fluocinolone acetonide body external oil Tier 1

fluocinolone acetonide external cream Tier 1

fluocinolone acetonide external ointment Tier 1

fluocinolone acetonide external solution Tier 1

fluocinolone acetonide scalp external oil Tier 1

fluocinonide external cream Tier 1

fluocinonide external gel Tier 1

fluocinonide external ointment Tier 1

fluocinonide external solution Tier 1

fluocinonide-e external cream Tier 1

fluorouracil external cream 5 % Tier 1

fluorouracil external solution Tier 1

fluticasone propionate external cream Tier 1

fluticasone propionate external lotion Tier 1

fluticasone propionate external ointment Tier 1

gentamicin sulfate external cream Tier 1

gentamicin sulfate external ointment Tier 1

halobetasol propionate external cream Tier 1

halobetasol propionate external ointment Tier 1

HEMMOREX-HC SUPPOSITORY 30 MG Tier 1

hydrocortisone ace-pramoxine cream Tier 1

hydrocortisone ace-pramoxine kit Tier 1

hydrocortisone acetate external cream Tier 1 OTC

hydrocortisone acetate suppository 30 mg Tier 1

hydrocortisone butyr lipo base external cream

Tier 1

hydrocortisone butyrate external cream Tier 1

hydrocortisone butyrate external ointment Tier 1

hydrocortisone butyrate external solution Tier 1

hydrocortisone cream 2.5 % Tier 1

hydrocortisone enema Tier 1

hydrocortisone external cream 1 % Tier 1 OTC

hydrocortisone external cream 2.5 % Tier 1

hydrocortisone external lotion 1 % Tier 1 OTC

hydrocortisone external lotion 2.5 % Tier 1

59


hydrocortisone external ointment 1 % Tier 1 OTC

hydrocortisone external ointment 2.5 % Tier 1

hydrocortisone valerate external cream Tier 1

hydrocortisone valerate external ointment Tier 1

hydrocortisone-aloe external cream 1 % Tier 1 OTC

hydroquinone external cream Tier 1

hydroquinone time release external cream Tier 1

imiquimod external cream Tier 1

isopropyl alcohol wipes external Tier 1 OTC

iv prep wipes external pad 70 % Tier 1 OTC

ketoconazole external cream Tier 1

ketoconazole external foam Tier 1

ketoconazole external shampoo Tier 1

KETODAN EXTERNAL KIT Tier 1

lindane external shampoo Tier 1

LUZU EXTERNAL CREAM Tier 2

mafenide acetate external packet Tier 1

malathion external lotion Tier 1

methoxsalen rapid oral capsule Tier 1

metronidazole external cream Tier 1

metronidazole external gel Tier 1

metronidazole external lotion Tier 1

mometasone furoate external cream Tier 1

mometasone furoate external ointment Tier 1

mometasone furoate external solution Tier 1

mupirocin calcium external cream Tier 1

mupirocin external ointment Tier 1

NEUAC EXTERNAL GEL Tier 1

NEUAC EXTERNAL KIT Tier 1

nystatin external cream Tier 1

nystatin external ointment Tier 1

nystatin external powder Tier 1

nystatin-triamcinolone external cream Tier 1

nystatin-triamcinolone external ointment Tier 1

OXSORALEN ULTRA ORAL CAPSULE Tier 4

PANRETIN EXTERNAL GEL Tier 3

permethrin external cream Tier 1

60


PICATO EXTERNAL GEL Tier 2

podofilox external solution Tier 1

prednicarbate external ointment Tier 1

PROCTO-PAK CREAM Tier 1

PROCTOZONE-HC CREAM Tier 1

RECTIV OINTMENT Tier 3

REGRANEX EXTERNAL GEL Tier 3 PA

ROSADAN EXTERNAL KIT 0.75 % (CREAM)

Tier 1

ROSULA EXTERNAL PAD Tier 1

salicylic acid external cream Tier 1

salicylic acid external foam Tier 1

salicylic acid external lotion Tier 1

salicylic acid-cleanser external kit Tier 1

SANTYL EXTERNAL OINTMENT Tier 2

scalacort external lotion Tier 1

selenium sulfide external lotion Tier 1

selenium sulfide external shampoo Tier 1

silver sulfadiazine external cream Tier 1

sodium chloride irrigation solution 0.9 % Tier 1

sodium sulfacetamide external shampoo Tier 1

sodium sulfacetamide wash external liquid† Tier 1

SOLARAZE TRANSDERMAL GEL Tier 3

SORIATANE ORAL CAPSULE 10 MG, 17.5 MG

Tier 3

spinosad external suspension Tier 3

sss 10-5 external foam Tier 1

sulfacetamide sodium (acne) external lotion Tier 1

sulfacetamide sodium external gel Tier 1

sulfacetamide sodium external liquid† Tier 1

sulfacetamide sodium-sulfur external cream10-2 %, 10-5 %

Tier 1

sulfacetamide sodium-sulfur external emulsion

Tier 1

sulfacetamide sodium-sulfur external liquid†9-4.5 %

Tier 1

sulfacetamide sodium-sulfur external lotion10-5 %

Tier 1

61


sulfacetamide sodium-sulfur external pad10-4 %

Tier 1

sulfacetamide sodium-sulfur external suspension

Tier 1

sulfacetamide sod-sulfur wash external kit Tier 1

sulfacetamide-sulfur in urea external emulsion

Tier 1

sulfacetamide-sulfur-sunscreen external kit Tier 1

TARGRETIN EXTERNAL GEL Tier 3

TAZORAC EXTERNAL CREAM Tier 3

TAZORAC EXTERNAL GEL Tier 3

terbinafine hcl external cream Tier 1 OTC

tretinoin (emollient) external cream Tier 1

tretinoin external cream Tier 1

tretinoin external gel 0.01 %, 0.025 % Tier 1

tretinoin microsphere external gel Tier 1

triamcinolone acetonide external cream0.025 %, 0.5 %

Tier 1

triamcinolone acetonide external lotion Tier 1

triamcinolone acetonide external ointment Tier 1

TRIDERM EXTERNAL CREAM Tier 1

U-CORT EXTERNAL CREAM Tier 1

ULESFIA EXTERNAL LOTION Tier 3

urea external cream 40 % Tier 1

urea external lotion 40 % Tier 1

urea nail film external suspension Tier 1

WOUND WASH SALINE EXTERNAL SOLUTION

Tier 1 OTC

Enzyme Replacement/ Modifiers (Hormone And Enzyme Drugs)

Enzyme Replacement/ Modifiers (Enzyme Deficiency Drugs)

ADAGEN INTRAMUSCULAR* SOLUTION Tier 4

ALDURAZYME INTRAVENOUS* SOLUTION Tier 4

CEREZYME INTRAVENOUS* SOLUTION RECONSTITUTED 400 UNIT

Tier 4

CYSTADANE ORAL POWDER Tier 4

ELAPRASE INTRAVENOUS* SOLUTION Tier 4

62


FABRAZYME INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 4

KANUMA INTRAVENOUS* SOLUTION Tier 4 PA

KUVAN ORAL PACKET 100 MG Tier 4

KUVAN ORAL TABLET SOLUBLE Tier 4

levocarnitine intravenous* solution Tier 1

levocarnitine oral solution Tier 1 OTC

levocarnitine oral tablet Tier 1

LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 4

NAGLAZYME INTRAVENOUS* SOLUTION Tier 4

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG

Tier 3

ZAVESCA ORAL CAPSULE Tier 4

Gastrointestinal Agents (Bowel, Instestine, And Stomach Condition Drugs)

Antispasmodics Gastrointestinal (Bowel Treatment Drugs)

atropine sulfate injection solution 0.05 mg/ml, 0.1 mg/ml

Tier 1

belladonna alkaloids-opium suppository Tier 1

dicyclomine hcl oral capsule Tier 1

dicyclomine hcl oral solution Tier 1

dicyclomine hcl oral tablet Tier 1

glycopyrrolate oral tablet Tier 1

hyoscyamine sulfate er oral tablet extended release 12 hr*

Tier 1

hyoscyamine sulfate oral elixir Tier 1

hyoscyamine sulfate oral solution Tier 1

hyoscyamine sulfate oral tablet Tier 1

hyoscyamine sulfate oral tablet dispersible Tier 1

hyoscyamine sulfate sublingual tablet sublingual

Tier 1

methscopolamine bromide oral tablet 2.5 mg Tier 1

SYMAX DUOTAB ORAL TABLET EXTENDEDRELEASE*

Tier 3

SYMAX-SR ORAL TABLET EXTENDED RELEASE 12 HR*

Tier 3

63


Digestive Enzymes (Miscellaneous Digestive System Drugs)

CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 36000 UNIT

Tier 2

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000 UNIT, 15000 UNIT, 20000 UNIT, 25000 UNIT, 3000-10000 UNIT, 5000 UNIT

Tier 2

Gastrointestinal Agents Other (Miscellaneous Digestive System Drugs)

CHOLBAM ORAL CAPSULE Tier 4

diphenoxylate-atropine oral liquid† Tier 1

diphenoxylate-atropine oral tablet Tier 1

FULYZAQ ORAL TABLET DELAYED RELEASE

Tier 3 PA

loperamide hcl oral capsule Tier 1

metoclopramide hcl injection solution Tier 1

metoclopramide hcl oral solution 5 mg/5ml Tier 1

metoclopramide hcl oral tablet Tier 1

MOVANTIK ORAL TABLET Tier 3

RELISTOR SUBCUTANEOUS* SOLUTION 12 MG/0.6ML

Tier 3

ursodiol oral capsule Tier 1

ursodiol oral tablet Tier 1

Histamine2 (H2) Receptor Antagonists (Ulcer And Stomach Acid Drugs)

cimetidine 200 oral tablet Tier 1 OTC

cimetidine hcl oral solution Tier 1

cimetidine oral tablet 300 mg, 400 mg, 800 mg

Tier 1

famotidine intravenous* solution 20 mg/2ml, 200 mg/20ml, 40 mg/4ml, 500 mg/50ml

Tier 1

famotidine oral suspension reconstituted Tier 1

famotidine oral tablet 20 mg, 40 mg Tier 1

ranitidine hcl injection solution 150 mg/6ml, 50 mg/2ml

Tier 1

ranitidine hcl oral capsule Tier 1

64


ranitidine hcl oral syrup 15 mg/ml Tier 1

ranitidine hcl oral tablet 150 mg Tier 1 OTC

ranitidine hcl oral tablet 300 mg Tier 1

Irritable Bowel Syndrome Agents (Bowel Treatment Drugs)

alosetron hcl oral tablet Tier 3

AMITIZA ORAL CAPSULE Tier 2

Laxatives (Constipation Drugs)

lactulose encephalopathy oral solution Tier 1

lactulose oral solution 10 gm/15ml Tier 1

peg 3350 oral powder Tier 1 OTC

polyethylene glycol 3350 oral packet Tier 1 OTC

Ppaca Bowel Prep (Bowel Treatment Drugs)

COLYTE WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 240 GM

Tier 6 PA

GAVILYTE-C ORAL SOLUTION RECONSTITUTED

Tier 6 PA

GAVILYTE-G ORAL SOLUTION RECONSTITUTED

Tier 6 PA

GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED

Tier 6 PA

GOLYTELY ORAL SOLUTION RECONSTITUTED

Tier 6 PA

MOVIPREP ORAL SOLUTION RECONSTITUTED

Tier 6

NULYTELY WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED

Tier 6 PA

peg 3350/electrolytes oral solution reconstituted

Tier 6

peg 3350-kcl-na bicarb-nacl oral solution reconstituted

Tier 6

peg-3350/electrolytes oral solution reconstituted

Tier 6

PREPOPIK ORAL PACKET Tier 6

SUPREP BOWEL PREP ORAL SOLUTION Tier 6 PA

TRILYTE ORAL SOLUTION RECONSTITUTED

Tier 6

65


Protectants (Miscellaneous Digestive System Drugs)

CARAFATE ORAL SUSPENSION Tier 3

misoprostol oral tablet Tier 1

sucralfate oral tablet Tier 1

Proton Pump Inhibitors (Ulcer And Stomach Acid Drugs)

amoxicill-clarithro-lansopraz oral Tier 1

DEXILANT ORAL CAPSULE DELAYED RELEASE

Tier 2

esomeprazole magnesium oral capsule delayed release 40 mg

Tier 1

lansoprazole oral capsule delayed release 15 mg

Tier 1 OTC

lansoprazole oral capsule delayed release 30 mg

Tier 1

omeprazole magnesium oral capsule delayed release

Tier 1 OTC; QL (60 EA per 30 days)

omeprazole oral capsule delayed release Tier 1 QL (60 EA per 30 days)

omeprazole-sodium bicarbonate oral capsule20-1100 mg

Tier 1 OTC

omeprazole-sodium bicarbonate oral capsule40-1100 mg

Tier 1

pantoprazole sodium intravenous* solution reconstituted

Tier 1

pantoprazole sodium oral tablet delayed release

Tier 1

rabeprazole sodium oral tablet delayed release

Tier 1

Genitourinary Agents (Bladder, Genital, And Kidney Condition Drugs)

Antispasmodics Urinary (Bladder Muscle Relaxants)

bethanechol chloride oral tablet 10 mg Tier 1

darifenacin hydrobromide er oral tablet extended release 24 hr*

Tier 1 ST

HYOPHEN ORAL TABLET Tier 1

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 3 ST

66


oxybutynin chloride er oral tablet extended release 24 hr*

Tier 1

oxybutynin chloride oral syrup Tier 1

oxybutynin chloride oral tablet Tier 1

tolterodine tartrate er oral capsule extended release 24 hour

Tier 1

tolterodine tartrate oral tablet Tier 1

trospium chloride er oral capsule extended release 24 hour

Tier 1

trospium chloride oral tablet Tier 1

URECHOLINE ORAL TABLET 10 MG Tier 3

UTA ORAL CAPSULE Tier 3

UTIRA-C ORAL TABLET Tier 1

VESICARE ORAL TABLET Tier 2

Benign Prostatic Hypertrophy Agents (Prostate Drugs)

AVODART ORAL CAPSULE Tier 2

CIALIS ORAL TABLET 2.5 MG, 5 MG Tier 3 PA; QL (30 EA per 30 days)

dutasteride-tamsulosin hcl oral capsule Tier 1

finasteride oral tablet 5 mg Tier 1

RAPAFLO ORAL CAPSULE Tier 2

tamsulosin hcl oral capsule Tier 1

Genitourinary Agents Other (Miscellaneous Bladder, Genital, And Kidney Condition Drugs)

CYSTAGON ORAL CAPSULE Tier 3

ELMIRON ORAL CAPSULE Tier 2

neomycin-polymyxin b gu irrigation solution Tier 1

phenazopyridine hcl oral tablet 100 mg, 200 mg

Tier 1

potassium citrate er oral tablet extendedrelease* 10 meq (1080 mg), 5 meq (540 mg)

Tier 1

Phosphate Binders (Phosphate Removing Drugs)

calcium acetate (phos binder) oral capsule Tier 1

FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG, 750 MG

Tier 4

RENVELA ORAL PACKET Tier 4

67


RENVELA ORAL TABLET Tier 4

Vaginal Products (Hormone Replacement/Modifying Drugs)

PREMARIN VAGINAL CREAM Tier 2

Vaginal Products (Vaginal Infection Drugs)

clindamycin phosphate vaginal cream Tier 1

metronidazole vaginal gel Tier 1

miconazole 3 combo pack vaginal kit Tier 1 OTC

miconazole 3 vaginal suppository Tier 1

terconazole vaginal cream Tier 1

terconazole vaginal suppository Tier 1

Hematopoietic Agents

*Granulocyte Colony-Stimulating Factors (G-Csf)***

NEUPOGEN INJECTION Tier 4

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML

Tier 4

*Granulocyte/Macrophage Colony-Stimulating Factor

LEUKINE INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 4

Erythropoietins

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 40000 UNIT/ML

Tier 4 PA

PROCRIT INJECTION SOLUTION 2000 UNIT/ML, 4000 UNIT/ML

Tier 2 PA

Hematopoietic Agents, Other

NEUMEGA SUBCUTANEOUS* SOLUTION RECONSTITUTED

Tier 4

Hereditary Orotic Aciduria Treatment Agents

*Hereditary Orotic Aciduria Treatment - Agents**

XURIDEN ORAL PACKET Tier 3

68


Hormonal Agents Stimulant/ Replacement/ Modifying (Adrenal)

Glucocorticoids/Mineralocorticoids (Anti-Inflammatory Drugs)

budesonide oral capsule delayed release particles

Tier 3

cortisone acetate oral tablet Tier 1

dexamethasone oral solution Tier 1

dexamethasone oral tablet Tier 1

dexamethasone sodium phosphate injection solution 120 mg/30ml, 20 mg/5ml, 4 mg/ml

Tier 1

hydrocortisone oral tablet Tier 1

methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml

Tier 1

methylprednisolone oral tablet Tier 1

methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg

Tier 1

prednisolone oral solution Tier 1

prednisolone sodium phosphate oral solution15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

Tier 1

prednisone oral 10 mg (48), 5 mg (21), 5 mg (48)

Tier 1

prednisone oral tablet 10 mg Tier 1

UCERIS ORAL TABLET EXTENDED RELEASE 24 HR*

Tier 4 ST

Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)

fludrocortisone acetate oral tablet Tier 1

prednisone oral 10 mg (21) Tier 1

prednisone oral solution Tier 1

prednisone oral tablet 1 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

Tier 1

69


Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) (Hormone And Diabetic Drugs)

Anabolic Steroids (Male Hormone Drugs)

oxandrolone oral tablet 10 mg Tier 4

oxandrolone oral tablet 2.5 mg Tier 1

Androgens (Male Hormone Drugs)

ANDRODERM TRANSDERMAL PATCH 24 HR 2 MG/24HR, 4 MG/24HR

Tier 2

ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM (1%)

Tier 3

ANDROID ORAL CAPSULE Tier 4 PA

ANDROXY ORAL TABLET Tier 3

danazol oral capsule Tier 1

testosterone cypionate intramuscular* solution 100 mg/ml, 200 mg/ml

Tier 1

testosterone enanthate intramuscular* solution

Tier 1

testosterone transdermal gel 50 mg/5gm (1%)

Tier 1

Estrogens (Hormone Replacement/Modifying Drugs)

estradiol oral tablet Tier 1

estradiol transdermal patch weekly Tier 1

estropipate oral tablet Tier 1

MENEST ORAL TABLET Tier 1

PREMARIN INJECTION SOLUTION RECONSTITUTED

Tier 2

PREMARIN ORAL TABLET Tier 2

PREMPHASE ORAL TABLET Tier 2

PREMPRO ORAL TABLET Tier 2

Ppaca Oral Contraceptives (Birth Control Drugs)

norethindrone-eth estradiol oral tablet 1-5 mg-mcg

Tier 6

70


Progestins (Hormone Replacement/Modifying Drugs)

DEPO-PROVERA INTRAMUSCULAR* SUSPENSION 400 MG/ML

Tier 5

medroxyprogesterone acetate oral tablet Tier 1

MEGACE ES ORAL SUSPENSION Tier 3

megestrol acetate oral suspension 625 mg/5ml

Tier 1

norethindrone acetate oral tablet Tier 1

progesterone micronized oral capsule Tier 1

Selective Estrogen Receptor Modifying Agents

raloxifene hcl oral tablet Tier 6 PA

Hormonal Agents, Stimulant/Replacement/ Modifying (Pituitary) (Hormone And Diabetic Drugs)

*Growth Hormones***

HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG

Tier 4 PA

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS* SOLUTION

Tier 4 PA


Tier 4 PA


Tier 4 PA

NUTROPIN AQ PEN SUBCUTANEOUS* SOLUTION

Tier 4 PA

SAIZEN CLICK.EASY INJECTION SOLUTION RECONSTITUTED

Tier 4 PA

SAIZEN INJECTION SOLUTION RECONSTITUTED

Tier 4 PA

*Insulin-Like Growth Factors (Somatomedins)***

INCRELEX SUBCUTANEOUS* SOLUTION Tier 4

*Progesterone Receptor Antagonists***

KORLYM ORAL TABLET Tier 4 PA

71


Hormonal Agents, Stimulant/Replacement/ Modifying [(Pituitary) Hormone Replacement/Modifying Drugs]

chorionic gonadotropin intramuscular* solution reconstituted

Tier 1

desmopressin ace rhinal tube nasal solution Tier 1

desmopressin ace spray refrig nasal solution Tier 1

desmopressin acetate injection solution Tier 1

desmopressin acetate oral tablet Tier 1

desmopressin acetate spray nasal solution Tier 1

SIGNIFOR SUBCUTANEOUS* SOLUTION Tier 3

Hormonal Agents, Stimulant/Replacement/ Modifying (Thyroid) (Hormone And Diabetic Drugs)

Thyroid Replacement

LEVO-T ORAL TABLET 88 MCG Tier 1

LEVOTHROID ORAL TABLET 125 MCG Tier 1

levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg

Tier 1

SYNTHROID ORAL TABLET Tier 3

Hormonal Agents, Stimulant/Replacement/Modifying (Parathyroid)

Hormonal Agents, Stimulant/Replacement/ Modifying [(Parathyroid) Hormone Replacement/Modifying Drugs]

NATPARA SUBCUTANEOUS* Tier 3 PA

Hormonal Agents, Suppressant (Parathyroid) (Hormone And Diabetic Drugs)

Hormonal Agents, Suppressant [(Parathyroid) Drugs To Treat High Calcium]

SENSIPAR ORAL TABLET 30 MG Tier 2

72


SENSIPAR ORAL TABLET 60 MG, 90 MG Tier 4

Hormonal Agents, Suppressant (Pituitary) (Hormone And Diabetic Drugs)

Hormonal Agents, Suppressant [(Pituitary) Miscellaneous Hormone And Diabetic Drugs]

LUPRON DEPOT-PED INTRAMUSCULAR* KIT 11.25 MG (PED), 30 MG (PED), 7.5 MG

Tier 5

LUPRON DEPOT-PED INTRAMUSCULAR* KIT 11.25 MG, 15 MG

Tier 4

octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 500 mcg/ml

Tier 4

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

Tier 1

SANDOSTATIN LAR DEPOT INTRAMUSCULAR* KIT

Tier 4

SOMATULINE DEPOT SUBCUTANEOUS* SOLUTION

Tier 4

SOMAVERT SUBCUTANEOUS* SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG

Tier 4

SYNAREL NASAL SOLUTION Tier 4

Hormonal Agents, Suppressant (Thyroid) (Hormone And Diabetic Drugs)

*Antithyroid Agents***

methimazole oral tablet Tier 1

propylthiouracil oral tablet Tier 1

Thyroid Replacement

levothyroxine sodium oral tablet 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

Tier 1

liothyronine sodium oral tablet Tier 1

NATURE-THROID ORAL TABLET 16.25 MG Tier 1

np thyroid oral tablet 30 mg, 60 mg, 90 mg Tier 1

UNITHROID ORAL TABLET Tier 1

73


Immunological Agents (Drugs Affecting The Immune System)

*Anti-Tnf-Alpha - Monoclonoal Antibodies***

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS* 40 MG/0.8ML

Tier 4

HUMIRA PEN SUBCUTANEOUS* Tier 4

HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS*

Tier 4

HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS*

Tier 4

HUMIRA SUBCUTANEOUS* 20 MG/0.4ML, 40 MG/0.8ML

Tier 4

KINERET SUBCUTANEOUS* Tier 4 ST

SIMPONI ARIA INTRAVENOUS* SOLUTION Tier 4

SIMPONI SUBCUTANEOUS* Tier 4

*Interleukin-6 Receptor Inhibitors***

ACTEMRA INTRAVENOUS* SOLUTION Tier 4 ST

ACTEMRA SUBCUTANEOUS* Tier 4 ST

*Selective Costimulation Modulators***

ORENCIA INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 4 ST

ORENCIA SUBCUTANEOUS* Tier 4 ST

*Soluble Tumor Necrosis Factor Receptor Agents***

ENBREL SUBCUTANEOUS* Tier 4

ENBREL SURECLICK SUBCUTANEOUS* Tier 4

Angioedema (Hae) Agents (Immune System Drugs)

FIRAZYR SUBCUTANEOUS* SOLUTION Tier 4

Antipsoratics--Systemic

COSENTYX SENSOREADY PEN SUBCUTANEOUS* 150 MG/ML

Tier 4 ST

COSENTYX SUBCUTANEOUS* Tier 4

74


Immune Suppressants (Immune System Drugs)

ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR

Tier 3

AZASAN ORAL TABLET Tier 3

azathioprine oral tablet Tier 1

BENLYSTA INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 4

CELLCEPT INTRAVENOUS INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 2

cyclosporine intravenous* solution Tier 1

cyclosporine modified oral capsule Tier 1

cyclosporine modified oral solution Tier 1

ENBREL SUBCUTANEOUS* SOLUTION RECONSTITUTED

Tier 4

GENGRAF ORAL CAPSULE Tier 1

GENGRAF ORAL SOLUTION Tier 1

ILARIS SUBCUTANEOUS* SOLUTION RECONSTITUTED

Tier 3

mycophenolate mofetil oral capsule Tier 1

mycophenolate mofetil oral suspension reconstituted

Tier 3

mycophenolate mofetil oral tablet Tier 1

mycophenolic acid oral tablet delayed release

Tier 1

MYFORTIC ORAL TABLET DELAYED RELEASE

Tier 3

NULOJIX INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 4

PROGRAF INTRAVENOUS* SOLUTION Tier 3

RAPAMUNE ORAL SOLUTION Tier 2

RHEUMATREX ORAL TABLET 2.5 MG Tier 3

SANDIMMUNE ORAL CAPSULE Tier 3

SANDIMMUNE ORAL SOLUTION Tier 3

SIMPONI ARIA INTRAVENOUS* SOLUTION Tier 4

sirolimus oral tablet Tier 1

tacrolimus oral capsule 0.5 mg, 1 mg Tier 1

tacrolimus oral capsule 5 mg Tier 3

75


ZORTRESS ORAL TABLET 0.25 MG Tier 3

ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG

Tier 4

Immunizing Agents, Passive (Immune System Drugs)

ATGAM INTRAVENOUS* INJECTABLE Tier 4

CARIMUNE NF INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 4

GAMMAGARD INJECTION SOLUTION Tier 4

GAMMAGARD S/D INTRAVENOUS* SOLUTION RECONSTITUTED 2.5 GM

Tier 4

GAMMAGARD S/D LESS IGA INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 4

GAMMAPLEX INTRAVENOUS* SOLUTION Tier 4

THYMOGLOBULIN INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 4

Immunomodulators (Immune System Drugs)

ARAVA ORAL TABLET Tier 3

ARCALYST SUBCUTANEOUS* SOLUTION RECONSTITUTED

Tier 4

leflunomide oral tablet Tier 1

RIDAURA ORAL CAPSULE Tier 3

Ppaca Adult Vac (Vaccines)

ZOSTAVAX SUBCUTANEOUS* SOLUTION RECONSTITUTED

Tier 6

Ppaca Child Vac (Vaccines)

ACTHIB INTRAMUSCULAR* SOLUTION RECONSTITUTED

Tier 6

CERVARIX INTRAMUSCULAR* SUSPENSION

Tier 6

COMVAX INTRAMUSCULAR* SUSPENSION

Tier 6

ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML

Tier 6

GARDASIL INTRAMUSCULAR* SUSPENSION

Tier 6

HAVRIX INTRAMUSCULAR* SUSPENSION Tier 6

IPOL INJECTION INJECTABLE Tier 6

76


MENACTRA INTRAMUSCULAR* INJECTABLE

Tier 6

MENOMUNE SUBCUTANEOUS* INJECTABLE

Tier 6

MENVEO INTRAMUSCULAR* SOLUTION RECONSTITUTED

Tier 6

M-M-R II SUBCUTANEOUS* INJECTABLE Tier 6

PEDVAX HIB INTRAMUSCULAR* SUSPENSION

Tier 6

PROQUAD SUBCUTANEOUS* INJECTABLE

Tier 6

RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML

Tier 6

ROTARIX ORAL SUSPENSION RECONSTITUTED

Tier 6

ROTATEQ ORAL SOLUTION Tier 6

tetanus toxoid adsorbed intramuscular* solution

Tier 6

TWINRIX INTRAMUSCULAR* SUSPENSION

Tier 6

VAQTA INTRAMUSCULAR* SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML

Tier 6

VARIVAX SUBCUTANEOUS* INJECTABLE Tier 6

Tumor Necrosis Factor Alpha Blockers

CIMZIA PREFILLED SUBCUTANEOUS* KIT Tier 4 ST

CIMZIA STARTER KIT SUBCUTANEOUS* KIT

Tier 4 ST

CIMZIA SUBCUTANEOUS* KIT 2 X 200 MG Tier 4 ST

REMICADE INTRAVENOUS* SOLUTION RECONSTITUTED

Tier 4

Vaccines (Vaccines)

ADACEL INTRAMUSCULAR* SUSPENSION Tier 3

AFLURIA INTRAMUSCULAR* SUSPENSION

Tier 6

AFLURIA PRESERVATIVE FREE INTRAMUSCULAR*

Tier 6

bcg vaccine injection injectable Tier 3

BOOSTRIX INTRAMUSCULAR* SUSPENSION 5-2.5-18.5

Tier 2

77


DAPTACEL INTRAMUSCULAR* SUSPENSION

Tier 3

EZ FLU SHOT-FLUCELVAX INTRAMUSCULAR*

Tier 6

FLUARIX INTRAMUSCULAR* Tier 6

FLUARIX QUADRIVALENT INTRAMUSCULAR*

Tier 6

FLUBLOK INTRAMUSCULAR* SOLUTION Tier 6

FLUCELVAX INTRAMUSCULAR* Tier 6

FLULAVAL QUADRIVALENT INTRAMUSCULAR*

Tier 6

FLULAVAL QUADRIVALENT INTRAMUSCULAR* SUSPENSION

Tier 6

FLUMIST QUADRIVALENT NASAL SUSPENSION

Tier 6

FLUVIRIN INTRAMUSCULAR* Tier 6

FLUVIRIN INTRAMUSCULAR* SUSPENSION

Tier 6

FLUVIRIN PRESERVATIVE FREE INTRAMUSCULAR*

Tier 6

FLUZONE HIGH-DOSE INTRAMUSCULAR* Tier 6

FLUZONE PRESERVATIVE FREE INTRAMUSCULAR* SUSPENSION

Tier 6

FLUZONE QUADRIVALENT INTRADERMAL*

Tier 6

FLUZONE QUADRIVALENT INTRAMUSCULAR*

Tier 6

FLUZONE QUADRIVALENT INTRAMUSCULAR* SUSPENSION , 0.5 ML

Tier 6

IMOVAX RABIES INTRAMUSCULAR* INJECTABLE

Tier 3

INFANRIX INTRAMUSCULAR* SUSPENSION

Tier 3

IXIARO INTRAMUSCULAR* SUSPENSION Tier 3

PNEUMOVAX 23 INJECTION INJECTABLE Tier 6

PREVNAR 13 INTRAMUSCULAR* SUSPENSION

Tier 6

RABAVERT INTRAMUSCULAR* SUSPENSION RECONSTITUTED

Tier 3

tetanus-diphtheria toxoids td intramuscular* suspension

Tier 3

78


TYPHIM VI INTRAMUSCULAR* SOLUTION 25 MCG/0.5ML

Tier 3

YF-VAX SUBCUTANEOUS* INJECTABLE Tier 3

Inflammatory Bowel Disease Agents (Bowel, Instestine, And Stomach Condition Drugs)

Aminosalicylates (Bowel Treatment Drugs)

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR

Tier 3

ASACOL HD ORAL TABLET DELAYED RELEASE

Tier 3

balsalazide disodium oral capsule Tier 1

mesalamine enema Tier 1

mesalamine-cleanser kit Tier 1

ROWASA KIT Tier 3

SFROWASA ENEMA Tier 3

Sulfonamides (Bowel Treatment Drugs)

DIPENTUM ORAL CAPSULE Tier 3

sulfasalazine oral tablet Tier 1

sulfasalazine oral tablet delayed release Tier 1

Metabolic Bone Disease Agents (Hormone And Bone Drugs)

*Bisphosphonates***

alendronate sodium oral tablet 10 mg, 40 mg, 5 mg


alendronate sodium oral tablet 35 mg Tier 1 QL (8 EA per 28 days)

alendronate sodium oral tablet 70 mg Tier 1 QL (4 EA per 28 days)

FOSAMAX PLUS D ORAL TABLET Tier 2

ibandronate sodium oral tablet Tier 1

pamidronate disodium intravenous* solution Tier 1

Metabolic Bone Disease Agents (Osteoporosis Drugs)

calcitonin (salmon) nasal solution Tier 1

calcitriol intravenous* solution 1 mcg/ml Tier 1

calcitriol oral capsule Tier 1

calcitriol oral solution Tier 1

79


doxercalciferol oral capsule Tier 1

FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML

Tier 4

pamidronate disodium intravenous* solution reconstituted

Tier 1

paricalcitol intravenous* solution Tier 2

paricalcitol oral capsule Tier 1

PROLIA SUBCUTANEOUS* SOLUTION Tier 4

RECLAST INTRAVENOUS* SOLUTION Tier 4

risedronate sodium oral tablet 150 mg Tier 1

risedronate sodium oral tablet delayed release

Tier 1

XGEVA SUBCUTANEOUS* SOLUTION Tier 4

ZEMPLAR INTRAVENOUS* SOLUTION Tier 2

zoledronic acid intravenous* concentrate Tier 1

zoledronic acid intravenous* solution 5 mg/100ml

Tier 1

zoledronic acid intravenous* solution reconstituted

Tier 1

Miscellaneous (Misc)

*Applicators,Cotton Balls,Etc***

alcohol pads pad Tier 1 OTC

alcohol swabs pad 70 % Tier 1 OTC

*Needles & Syringes***

insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1" 0.3 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.5 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

Tier 1 OTC

insulin syringe/needle Tier 1 OTC

pen needles 1/2" Tier 1 OTC

pen needles 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 32g x 4 mm

Tier 1 OTC



ULTRA-THIN II PEN NEEDLES Tier 1 OTC

Antidotes

PRAXBIND INTRAVENOUS* SOLUTION Tier 3

80


Diagnostic Products

BAYER BREEZE 2 TEST IN VITRO DISK Tier 2 OTC; QL (300 EA per 30 days)

BAYER CONTOUR NEXT TEST IN VITRO STRIP


BAYER CONTOUR TEST IN VITRO STRIP Tier 2 OTC; QL (300 EA per 30 days)

EXACTECH R-S-G TEST IN VITRO STRIP Tier 2 OTC; QL (300 EA per 30 days)

EXACTECH TEST IN VITRO STRIP Tier 2 OTC; QL (300 EA per 30 days)

FREESTYLE INSULINX TEST IN VITRO STRIP


FREESTYLE LITE TEST IN VITRO STRIP Tier 2 OTC; QL (300 EA per 30 days)

FREESTYLE PRECISION NEO TEST IN VITRO STRIP


FREESTYLE TEST IN VITRO STRIP Tier 2 OTC; QL (300 EA per 30 days)

PRECISION PCX IN VITRO STRIP Tier 2 OTC; QL (300 EA per 30 days)

PRECISION PCX PLUS TEST IN VITRO STRIP


PRECISION POINT OF CARE TEST IN VITRO STRIP


PRECISION QID TEST IN VITRO STRIP Tier 2 OTC; QL (300 EA per 30 days)

PRECISION SOF-TACT TEST IN VITRO STRIP


PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP


PRECISION XTRA KETONE IN VITRO STRIP


Miscellaneous (Miscellaneous Wound Care Drugs)

lactated ringers irrigation solution Tier 1

PHYSIOSOL IRRIGATION IRRIGATION SOLUTION

Tier 1

ringers irrigation irrigation solution Tier 1

Ophthalmic Agents (Eye Medications)

Ophthalmic Agents Other (Miscellaneous Eye Medications)

atropine sulfate ophthalmic ointment Tier 1

atropine sulfate ophthalmic solution Tier 1

cyclopentolate hcl ophthalmic solution 1 %, 2 %

Tier 1

81


HOMATROPAIRE OPHTHALMIC SOLUTION

Tier 1

LACRISERT OPHTHALMIC INSERT Tier 3

naphazoline hcl ophthalmic solution Tier 1

phenylephrine hcl ophthalmic solution 10 %, 2.5 %

Tier 1

proparacaine hcl ophthalmic solution Tier 1

RESTASIS OPHTHALMIC EMULSION Tier 2

tropicamide ophthalmic solution Tier 1

Ophthalmic Anti Infectives (Infection Eye Medications)

bacitracin ophthalmic ointment Tier 1

bacitracin-polymyxin b ophthalmic ointment500-10000 unit/gm

Tier 1

BESIVANCE OPHTHALMIC SUSPENSION Tier 3

ciprofloxacin hcl ophthalmic solution Tier 1

erythromycin ophthalmic ointment Tier 1

gatifloxacin ophthalmic solution Tier 1

GENTAK OPHTHALMIC OINTMENT Tier 1

gentamicin sulfate ophthalmic ointment Tier 1

gentamicin sulfate ophthalmic solution Tier 1

levofloxacin ophthalmic solution Tier 1

MOXEZA OPHTHALMIC SOLUTION Tier 2

neomycin-bacitracin zn-polymyx ophthalmic ointment

Tier 1

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

Tier 1

ofloxacin ophthalmic solution Tier 1

POLYCIN OPHTHALMIC OINTMENT Tier 1

polymyxin b-trimethoprim ophthalmic solution Tier 1

sulfacetamide sodium ophthalmic solution Tier 1

tobramycin ophthalmic solution Tier 1

trifluridine ophthalmic solution Tier 1

VIGAMOX OPHTHALMIC SOLUTION Tier 2

ZIRGAN OPHTHALMIC GEL Tier 3

ZYMAXID OPHTHALMIC SOLUTION Tier 3

82


Ophthalmic Anti-Allergy Agents (Allergy Eye Medications)

azelastine hcl ophthalmic solution Tier 1

BEPREVE OPHTHALMIC SOLUTION Tier 3

cromolyn sodium ophthalmic solution Tier 1

ELESTAT OPHTHALMIC SOLUTION Tier 3

EMADINE OPHTHALMIC SOLUTION Tier 3

epinastine hcl ophthalmic solution Tier 1

PATADAY OPHTHALMIC SOLUTION Tier 2

PATANOL OPHTHALMIC SOLUTION Tier 3

Ophthalmic Antiglaucoma Agents (Glaucoma Medications)

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

Tier 2

apraclonidine hcl ophthalmic solution Tier 1

AZOPT OPHTHALMIC SUSPENSION Tier 2

betaxolol hcl ophthalmic solution Tier 1

brimonidine tartrate ophthalmic solution Tier 1

carteolol hcl ophthalmic solution Tier 1

COMBIGAN OPHTHALMIC SOLUTION Tier 2

dorzolamide hcl ophthalmic solution Tier 1

dorzolamide hcl-timolol mal ophthalmic solution

Tier 1

levobunolol hcl ophthalmic solution 0.5 % Tier 1

metipranolol ophthalmic solution Tier 1

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED

Tier 2

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %

Tier 1

PROLENSA OPHTHALMIC SOLUTION Tier 3

timolol maleate ophthalmic gel forming solution

Tier 1

timolol maleate ophthalmic solution Tier 1

Ophthalmic Anti-Inflammatories (Inflammation Eye Medications)

BROMDAY OPHTHALMIC SOLUTION Tier 3

bromfenac sodium (once-daily) ophthalmic solution

Tier 1

83


bromfenac sodium ophthalmic solution Tier 1

dexamethasone sodium phosphate ophthalmic solution

Tier 1

diclofenac sodium ophthalmic solution Tier 1

DUREZOL OPHTHALMIC EMULSION Tier 2

eye wash ophthalmic solution Tier 1 OTC

fluorometholone ophthalmic suspension Tier 1

flurbiprofen sodium ophthalmic solution Tier 1

ketorolac tromethamine ophthalmic solution Tier 1

neomycin-polymyxin-dexameth ophthalmic ointment

Tier 1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

Tier 1

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1

Tier 1

NEO-POLYCIN HC OPHTHALMIC OINTMENT

Tier 1

NEVANAC OPHTHALMIC SUSPENSION Tier 2

prednisolone acetate ophthalmic suspension Tier 1

prednisolone sodium phosphate ophthalmic solution

Tier 1

sulfacetamide-prednisolone ophthalmic solution

Tier 1

TOBRADEX OPHTHALMIC OINTMENT Tier 3

tobramycin-dexamethasone ophthalmic suspension

Tier 1

VEXOL OPHTHALMIC SUSPENSION Tier 3

Ophthalmic Prostaglandin And Prostamide Analogs (Glaucoma Medications)

latanoprost ophthalmic solution Tier 1

LUMIGAN OPHTHALMIC SOLUTION 0.01 %

Tier 2

TRAVATAN Z OPHTHALMIC SOLUTION Tier 2

travoprost ophthalmic solution Tier 1

Otic Agents (Ear Drugs)

Otic Agents (Ear Drugs)

acetic acid otic solution Tier 1

acetic acid-aluminum acetate otic solution Tier 1

84


antipyrine-benzocaine otic solution 54-14 mg/ml

Tier 1

CIPRODEX OTIC SUSPENSION Tier 2

CORTANE-B AQUEOUS OTIC SOLUTION Tier 1

fluocinolone acetonide otic oil Tier 1

hydrocortisone-acetic acid otic solution Tier 1

neomycin-polymyxin-hc otic solution 1 % Tier 1

neomycin-polymyxin-hc otic suspension Tier 1

ofloxacin otic solution Tier 1

otomax-hc otic solution Tier 1

PRAMOTIC OTIC LIQUID† Tier 1

Respiratory Tract Agents (Allergies, Cough, Cold, And Lung Condition Drugs)

Antihistamines (Allergies/Lung Drugs)

ARBINOXA ORAL SOLUTION Tier 1 PA

carbinoxamine maleate oral solution Tier 1

cetirizine hcl oral solution Tier 1

clemastine fumarate oral syrup Tier 1

clemastine fumarate oral tablet 2.68 mg Tier 1

cyproheptadine hcl oral syrup Tier 1

cyproheptadine hcl oral tablet Tier 1

desloratadine oral tablet Tier 1

desloratadine oral tablet dispersible Tier 1

diphenhydramine hcl injection solution Tier 1

diphenhydramine hcl oral capsule 25 mg Tier 6 OTC

diphenhydramine hcl oral capsule 50 mg Tier 1 OTC

diphenhydramine hcl oral elixir Tier 1 OTC

diphenhydramine hcl oral liquid† Tier 1 OTC

levocetirizine dihydrochloride oral solution Tier 1

levocetirizine dihydrochloride oral tablet Tier 1

WAL-DRYL ALLERGY CHILDRENS ORAL LIQUID†

Tier 1 OTC

85


Anti-Inflammatories Inhaled Corticosteroids (Asthma/Lung Drugs)

AEROSPAN INHALATION AEROSOL, SOLUTION

Tier 2

budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml

Tier 1

FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED


FLOVENT HFA INHALATION AEROSOL† 110 MCG/ACT, 220 MCG/ACT

Tier 2 QL (24 GM per 30 days)

FLOVENT HFA INHALATION AEROSOL† 44 MCG/ACT


PULMICORT FLEXHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED

Tier 2

QVAR INHALATION AEROSOL, SOLUTION 40 MCG/ACT, 80 MCG/ACT


Antileukotrienes (Asthma/Lung Drugs)

montelukast sodium oral packet Tier 1

montelukast sodium oral tablet Tier 1

montelukast sodium oral tablet chewable Tier 1

zafirlukast oral tablet Tier 1

ZYFLO CR ORAL TABLET EXTENDED RELEASE 12 HR*

Tier 3

ZYFLO ORAL TABLET Tier 3

Bronchodilators Anticholinergic (Asthma/Lung Drugs)

ATROVENT HFA INHALATION AEROSOL, SOLUTION


INCRUSE ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED

Tier 2

ipratropium bromide inhalation solution Tier 1

SPIRIVA HANDIHALER INHALATION CAPSULE


Bronchodilators Phosphodiesterase Inhibitors [Xanthines (Asthma/Lung Drugs)]

aminophylline intravenous* solution Tier 1

86


theophylline er oral tablet extended release 12 hr*

Tier 1

theophylline er oral tablet extended release 24 hr* 600 mg

Tier 1

Bronchodilators Sympathomimetic (Asthma/Lung Drugs)

ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED


ADVAIR HFA INHALATION AEROSOL† Tier 2 QL (12 GM per 30 days)

albuterol sulfate er oral tablet extended release 12 hr*

Tier 1

albuterol sulfate inhalation nebulization solution

Tier 1

albuterol sulfate oral syrup Tier 1

albuterol sulfate oral tablet Tier 1

BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 100-25 MCG/INH

Tier 2

COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION


DULERA INHALATION AEROSOL† Tier 2

epinephrine hcl injection solution 1 mg/ml Tier 1

ipratropium-albuterol inhalation solution Tier 1

levalbuterol hcl inhalation nebulization solution

Tier 1

metaproterenol sulfate oral syrup Tier 1

PROAIR HFA INHALATION AEROSOL, SOLUTION


SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED


STIOLTO RESPIMAT INHALATION AEROSOL, SOLUTION

Tier 2

SYMBICORT INHALATION AEROSOL† Tier 2 QL (11 GM per 30 days)

terbutaline sulfate injection solution Tier 1

VENTOLIN HFA INHALATION AEROSOL, SOLUTION


Mast Cell Stabilizers (Asthma/Lung Drugs)

cromolyn sodium inhalation nebulization solution

Tier 1

87


Nasal Agents (Nasal Allergy Drugs)

ASTEPRO NASAL SOLUTION 0.15 % Tier 2

azelastine hcl nasal solution Tier 1

budesonide nasal suspension Tier 1 OTC

flunisolide nasal solution 25 mcg/act (0.025%)

Tier 1

fluticasone propionate nasal suspension Tier 1 OTC

ipratropium bromide nasal solution Tier 1

olopatadine hcl nasal solution Tier 1

triamcinolone acetonide nasal aerosol† Tier 1 OTC

TYZINE NASAL SOLUTION 0.05 % Tier 3

Pulmonary Antihypertensives (Pulmonary Drugs)

LETAIRIS ORAL TABLET Tier 4

OPSUMIT ORAL TABLET Tier 4

TRACLEER ORAL TABLET Tier 4

VENTAVIS INHALATION SOLUTION Tier 3

Respiratory Tract Agents Other (Miscellaneous Respiratory Drugs)

acetylcysteine inhalation solution Tier 1

ARALAST NP INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG, 500 MG

Tier 3

cromolyn sodium oral concentrate Tier 1

DALIRESP ORAL TABLET Tier 2

ESBRIET ORAL CAPSULE Tier 4 PA

KALYDECO ORAL TABLET Tier 4 PA

NUCALA SUBCUTANEOUS* SOLUTION RECONSTITUTED

Tier 4 PA

ORKAMBI ORAL TABLET 200-125 MG Tier 4 PA

PROLASTIN-C INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG

Tier 4

PULMOZYME INHALATION SOLUTION Tier 4 QL (150 ML per 30 days)

sildenafil citrate oral tablet Tier 1 PA; QL (90 EA per 30 days)

sodium chloride inhalation nebulization solution 0.9 %

Tier 1

XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED

Tier 4

88


Respiratory Tract/Pulmonary Agents

Anapylaxis Treatment

ADRENALIN INJECTION SOLUTION 1 MG/ML

Tier 1

epinephrine injection 0.15 mg/0.15ml, 0.3 mg/0.3ml

Tier 1

EPIPEN 2-PAK INJECTION Tier 2

EPIPEN JR 2-PAK INJECTION Tier 2

Respiratory Tract/Pulmonary Agents (Allergies, Cough, Cold, And Lung Condition Drugs)

Pulmonary Antihypertensives (Pulmonary Drug)

sildenafil citrate intravenous* solution Tier 1 PA

Skeletal Muscle Relaxants (Muscle And Joint Drugs)

Skeletal Muscle Relaxants (Muscle And Joint Drugs)

baclofen oral tablet Tier 1

chlorzoxazone oral tablet 500 mg Tier 1

cyclobenzaprine hcl oral tablet Tier 1

dantrolene sodium oral capsule Tier 1

metaxalone oral tablet 800 mg Tier 1

methocarbamol oral tablet Tier 1

orphenadrine citrate er oral tablet extended release 12 hr*

Tier 1

orphenadrine citrate injection solution Tier 1

tizanidine hcl oral capsule Tier 1

tizanidine hcl oral tablet Tier 1

Sleep Disorder Agents (Sleep Condition Drugs)

Barbiturates (Sedation And Sleep Drugs)

SECONAL ORAL CAPSULE Tier 3

89


Benzodiazepines (Sedation And Sleep Drugs)

estazolam oral tablet Tier 1

flurazepam hcl oral capsule Tier 1

temazepam oral capsule Tier 1

triazolam oral tablet Tier 1

Gaba Receptor Modulators (Sedation And Sleep Drugs)

eszopiclone oral tablet Tier 1

zaleplon oral capsule Tier 1

zolpidem tartrate oral tablet Tier 1 QL (30 EA per 30 days)

Sleep Disorders Other (Sedation And Sleep Drugs)

modafinil oral tablet Tier 1 PA

NUVIGIL ORAL TABLET 250 MG, 50 MG Tier 3

sleep-aid maximum strength oral capsule Tier 1 OTC

XYREM ORAL SOLUTION Tier 4

Therapeutic Nutrients/ Minerals/ Electrolytes (Multivitamins And Replacement Solutions)

*Prenatal Mv & Min W/Fe-Fa***

prenatal low iron oral tablet 27-0.8 mg Tier 6 OTC

prenatal one daily oral tablet Tier 6 OTC

prenatal vitamin oral tablet Tier 6 OTC

RIGHT STEP PRENATAL ORAL TABLET Tier 6 OTC

Electrolyte/Mineral Modifiers (Antidotes/Protectants)

CHEMET ORAL CAPSULE Tier 3

EXJADE ORAL TABLET SOLUBLE Tier 4

KIONEX ORAL POWDER Tier 1

KIONEX ORAL SUSPENSION Tier 1

sodium polystyrene sulfonate oral powder Tier 1

sodium polystyrene sulfonate oral suspension

Tier 1

sodium polystyrene sulfonate suspension 50 gm/200ml

Tier 1

90


Electrolyte/Mineral Modifiers (Electrolytes Replacements)

SAMSCA ORAL TABLET Tier 4 PA

Electrolyte/Mineral Replacement (Electrolytes Replacements)

CARBAGLU ORAL TABLET Tier 4

chromic chloride intravenous* solution Tier 1

effervescent pot chloride oral tablet effervescent

Tier 1

gnp vitamin d-400 oral tablet Tier 6 OTC

HYPERLYTE-CR INTRAVENOUS* SOLUTION

Tier 1

kcl in dextrose-nacl intravenous* solution20-5-0.225 meq/l-%-%, 20-5-0.9 meq/l-%-%

Tier 1

k-effervescent oral tablet effervescent Tier 1

KLOR-CON 10 ORAL TABLET EXTENDEDRELEASE*

Tier 1

KLOR-CON M10 ORAL TABLET EXTENDEDRELEASE*

Tier 1


Tier 1


Tier 1

KLOR-CON ORAL PACKET Tier 1

KLOR-CON ORAL TABLET EXTENDEDRELEASE*

Tier 1

magnesium chloride injection solution Tier 1

magnesium sulfate injection solution 50 % Tier 1

nutrilyte intravenous* concentrate Tier 1

pot bicarb-pot chloride oral tablet effervescent

Tier 1

potassium acetate intravenous* solution Tier 1

potassium bicarbonate oral tablet effervescent

Tier 1

potassium chloride crys er oral tablet extendedrelease*

Tier 1

potassium chloride er oral capsule extended release*

Tier 1

potassium chloride er oral tablet extendedrelease*

Tier 1

91


potassium chloride in nacl intravenous* solution 40-0.9 meq/l-%

Tier 1

potassium chloride intravenous* solution Tier 1

potassium chloride oral packet Tier 1

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

Tier 1

sodium chloride injection solution Tier 1

sodium chloride intravenous* solution 0.9 %, 4 meq/ml

Tier 1

sodium lactate intravenous* solution 5 meq/ml

Tier 1

virt-phos 250 neutral oral tablet Tier 1

zinc sulfate oral capsule Tier 1 OTC

Electrolyte/Mineral Replacement (Fluid Replacements)

dextrose in lactated ringers intravenous* solution

Tier 1

dextrose-nacl intravenous* solution 10-0.2 %, 2.5-0.45 %, 5-0.2 %, 5-0.33 %, 5-0.45 %, 5-0.9 %

Tier 1

ISOLYTE-P IN D5W INTRAVENOUS* SOLUTION

Tier 3

ISOLYTE-S INTRAVENOUS* SOLUTION Tier 3

ISOLYTE-S PH 7.4 INTRAVENOUS* SOLUTION

Tier 3

kcl in d5w lactated ringers intravenous* solution

Tier 1

kcl in dextrose-nacl intravenous* solution10-5-0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.33 meq/l-%-%, 20-5-0.45 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%

Tier 1

kcl-lactated ringers-d5w intravenous* solution Tier 1

lactated ringers intravenous* solution Tier 1

NORMOSOL-M IN D5W INTRAVENOUS* SOLUTION

Tier 1

NORMOSOL-R IN D5W INTRAVENOUS* SOLUTION

Tier 1

NORMOSOL-R INTRAVENOUS* SOLUTION

Tier 3

NORMOSOL-R PH 7.4 INTRAVENOUS* SOLUTION

Tier 3

92


PLASMA-LYTE 148 INTRAVENOUS* SOLUTION

Tier 2

PLASMA-LYTE-56 IN D5W INTRAVENOUS* SOLUTION

Tier 2

potassium chloride in dextrose intravenous* solution 20-5 meq/l-%, 40-5 meq/l-%

Tier 1

potassium chloride in nacl intravenous* solution 20-0.45 meq/l-%, 20-0.9 meq/l-%

Tier 1

ringers intravenous* solution Tier 1

saline flush intravenous* solution Tier 1

sodium chloride bacteriostatic injection solution

Tier 1

sodium chloride flush intravenous* solution Tier 1

sodium chloride intravenous* solution 0.45 %, 3 %, 5 %

Tier 1

Nutrients (Fluid Replacements)

AMINOSYN INTRAVENOUS* SOLUTION 10 %, 8.5 %

Tier 3

AMINOSYN M INTRAVENOUS* SOLUTION Tier 3

AMINOSYN/ELECTROLYTES INTRAVENOUS* SOLUTION 8.5 %

Tier 1

AMINOSYN-PF INTRAVENOUS* SOLUTION 7 %

Tier 3

CLINIMIX E/DEXTROSE (2.75/10) INTRAVENOUS* SOLUTION

Tier 3


Tier 3


Tier 3


Tier 3

CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS* SOLUTION

Tier 3


Tier 3


Tier 3

CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS* SOLUTION

Tier 3


Tier 3

93



Tier 3


Tier 3


Tier 3

CLINIMIX/DEXTROSE (5/15) INTRAVENOUS* SOLUTION

Tier 3


Tier 3


Tier 3

dextrose intravenous* solution 10 %, 5 % Tier 1

FER-IN-SOL ORAL SOLUTION Tier 6 OTC

ferrous sulfate oral elixir Tier 6 OTC

ferrous sulfate oral liquid† Tier 6 OTC

ferrous sulfate oral solution 75 (15 fe) mg/ml Tier 1 OTC

folic acid oral tablet 1 mg Tier 1 OTC

HEPATASOL INTRAVENOUS* SOLUTION Tier 1

INTRALIPID INTRAVENOUS* EMULSION 20 %

Tier 1

iron chews pediatric oral tablet chewable Tier 1 OTC

NEPHRAMINE INTRAVENOUS* SOLUTION Tier 3

PREMASOL INTRAVENOUS* SOLUTION 6 %

Tier 1

PROCALAMINE INTRAVENOUS* SOLUTION

Tier 2

PROSOL INTRAVENOUS* SOLUTION Tier 2

Ppaca Folic (Vitamins)

calcium pnv oral capsule Tier 6

CITRANATAL B-CALM ORAL Tier 6

CONCEPT OB ORAL CAPSULE Tier 6

folcal dha oral capsule 27-1.25-300 mg Tier 6

FOLIVANE-OB ORAL CAPSULE Tier 6

FOLIVANE-PRX DHA NF ORAL CAPSULE Tier 6

GESTICARE DHA ORAL 27-1 & 250 MG Tier 6

INATAL ADVANCE ORAL TABLET Tier 6

INATAL GT ORAL TABLET Tier 6

INATAL ULTRA ORAL TABLET Tier 6

94


multi prenatal oral tablet Tier 6 OTC

MYNATAL ADVANCE ORAL TABLET Tier 6

MYNATAL ORAL TABLET Tier 6

NATELLE ONE ORAL CAPSULE 28-1-250 MG

Tier 6

pnv fe fum/docusate/folic acid oral tablet Tier 6

pnv-dha oral capsule Tier 6

pnv-dha+docusate oral capsule Tier 6

prenaissance oral capsule Tier 6

prenatal 19 oral tablet Tier 6

rulavite dha oral capsule Tier 6

se-natal 19 oral tablet Tier 6

TARON-BC ORAL Tier 6

TARON-PREX ORAL CAPSULE Tier 6

thrivite 19 oral tablet Tier 6

tl-select oral capsule Tier 6

triadvance oral tablet Tier 6

trinatal gt oral tablet Tier 6

ultra tabs oral tablet Tier 6

VEMAVITE-PRX 2 ORAL CAPSULE Tier 6

VINACAL B ORAL Tier 6

virt-advance oral tablet Tier 6

virt-pn dha oral capsule Tier 6

virt-select oral capsule Tier 6

virt-vite gt oral tablet Tier 6

VITAFOL-ONE ORAL CAPSULE Tier 6

ZATEAN-PN DHA ORAL CAPSULE Tier 6

Vitamins (Vitamins)

aqueous vitamin d oral liquid† Tier 6 OTC

bp folinatal plus b oral tablet Tier 6

multi-vit/fluoride oral solution 0.5 mg/ml Tier 1

multi-vitamin/fluoride oral solution Tier 1

multivitamin/fluoride oral tablet chewable 0.5 mg, 1 mg

Tier 1

MVC-FLUORIDE ORAL TABLET CHEWABLE 0.25 MG

Tier 1

niacin er oral tablet extendedrelease* 500 mg, 750 mg

Tier 1 OTC

95


one-daily multi vitamins oral tablet Tier 6 OTC

triple-vitamin/fluoride oral solution Tier 1

tri-vitamin/fluoride oral solution 0.5 mg/ml Tier 1

vitamin d (cholecalciferol) oral tablet 400 unit Tier 6 OTC

vitamin d oral liquid† Tier 1 OTC

96

Index

Index

8-MOP .................................................................... 56abacavir sulfate ........................................ 35abacavir sulfate-lamivudine .... 35abacavir-lamivudine-zidovudine............................................................................................ 35ABELCET .......................................................... 17ABILIFY MAINTENA ......................... 31ABRAXANE .................................................... 24acarbose ............................................................. 37acebutolol hcl ............................................... 43acetaminophen-codeine .................. 4acetaminophen-codeine #3 ........ 4acetaminophen-codeine #4 ........ 4acetazolamide ............................................ 45acetazolamide er .................................... 45acetic acid ......................................................... 84acetic acid-aluminum acetate............................................................................................ 84acetylcysteine .............................................. 88acitretin .................................................................. 56ACT ANTICAVITY FLUORIDE RINSE ..................................................................... 56ACTEMRA ........................................................ 74ACTHIB ................................................................ 76ACTIMMUNE ............................................... 24ACTOPLUS MET XR ....................... 39acyclovir ................................................... 33, 56acyclovir sodium ...................................... 33ADACEL .............................................................. 77ADAGEN ............................................................ 62adapalene ......................................................... 56adefovir dipivoxil ...................................... 33ADRENALIN .................................................. 89adult aspirin low strength ........... 20ADVAIR DISKUS ................................... 87ADVAIR HFA ................................................ 87ADVICOR .......................................................... 46AEROSPAN ................................................... 86AFINITOR ......................................................... 24AFINITOR DISPERZ ........................ 24AFLURIA ............................................................ 77AFLURIA PRESERVATIVE FREE ........................................................................ 77AGGRENOX ................................................. 41ALBENZA .......................................................... 29albuterol sulfate ........................................ 87albuterol sulfate er ................................ 87alclometasone dipropionate................................................................................ 56, 57alcohol pads .................................................. 80alcohol swabs .............................................. 80ALDURAZYME .......................................... 62ALECENSA .................................................... 24alendronate sodium ............................ 79

Index

ALIMTA ................................................................. 23ALINIA .................................................................... 29allopurinol .......................................................... 19alosetron hcl .................................................. 65ALPHAGAN P ............................................. 83alprazolam ........................................................ 36alprazolam er ............................................... 36ALPRAZOLAM INTENSOL .... 36alprazolam xr ................................................ 36ALTAVERA ..................................................... 51ALTOPREV .................................................... 46alyacen 1/35 .................................................. 51alyacen 7/7/7 ................................................ 51amantadine hcl .............................. 29, 30amcinonide ...................................................... 57AMETHIA ........................................................... 51AMETHIA LO ............................................... 51AMETHYST .................................................... 51amifostine .......................................................... 24amikacin sulfate ........................................... 6amiloride hcl .................................................. 46amiloride-hydrochlorothiazide............................................................................................ 42aminophylline ............................................... 86AMINOSYN .................................................... 93AMINOSYN M ............................................ 93AMINOSYN/ELECTROLYTES............................................................................................ 93AMINOSYN-PF ......................................... 93amiodarone hcl .......................................... 42AMITIZA .............................................................. 65amitriptyline hcl ......................................... 16amlodipine besy-benazepril hcl............................................................................................ 42amlodipine besylate ........................... 44amlodipine besylate-valsartan............................................................................................ 43amlodipine-atorvastatin ................ 43amlodipine-olmesartan .................. 43amlodipine-valsartan-hctz ......... 43ammonium lactate ................................ 57amoxapine ........................................................ 16amoxicill-clarithro-lansopraz............................................................................................ 66amoxicillin .......................................................... 10amoxicillin-pot clavulanate.................................................................................... 9, 10amoxicillin-pot clavulanate er................................................................................................ 9amphetamine-dextroamphet er............................................................................................ 48amphetamine-dextroamphetamine ................................................................................... 48amphotericin b ............................................ 17

Index

ampicillin ............................................................. 10ampicillin sodium .................................... 10ampicillin-sulbactam sodium............................................................................................ 10AMPYRA ............................................................ 49AMTURNIDE ................................................ 43anagrelide hcl .............................................. 41anastrozole ...................................................... 28ANDRODERM ............................................ 70ANDROGEL .................................................. 70ANDROID .......................................................... 70ANDROXY ....................................................... 70antipyrine-benzocaine .................... 85APIDRA ................................................................ 38APIDRA SOLOSTAR ....................... 38APLENZIN ........................................................ 14APOKYN ............................................................. 30apraclonidine hcl ..................................... 83APRI .......................................................................... 51APRISO ................................................................ 79APTIVUS ............................................................ 34aqueous vitamin d ................................ 95ARALAST NP .............................................. 88ARANELLE ..................................................... 51ARAVA .................................................................. 76ARBINOXA ...................................................... 85ARCALYST ..................................................... 76aripiprazole ...................................................... 31ARISTADA ....................................................... 31ARRANON ....................................................... 23ARZERRA ........................................................ 24ASACOL HD ................................................. 79ASHLYNA ......................................................... 51aspirin ...................................................................... 20aspirin adult low dose ...................... 20aspirin ec ............................................................ 20aspirin low dose ....................................... 20aspirin-dipyridamole er .................. 41ASTAGRAF XL ......................................... 75ASTEPRO ........................................................ 88ATACAND ........................................................ 41atenolol .................................................................. 44atenolol-chlorthalidone .................. 43ATGAM ................................................................. 76atorvastatin calcium ........................... 47atovaquone ..................................................... 29atovaquone-proguanil hcl .......... 29ATRIPLA ............................................................. 33atropine sulfate .............................. 63, 81ATROVENT HFA ................................... 86AUBAGIO .......................................................... 49AUBRA .................................................................. 51AVANDAMET .............................................. 39AVANDIA ........................................................... 39

97

Index

AVASTIN ............................................................ 23AVIANE ................................................................ 51AVODART ........................................................ 67AVYCAZ .................................................................. 9azacitidine ......................................................... 23AZASAN .............................................................. 75azathioprine .................................................... 75azelastine hcl ................................... 83, 88AZILECT ............................................................. 30azithromycin ...................................................... 9AZOPT ................................................................... 83aztreonam ............................................................. 7AZURETTE ..................................................... 51bacitracin .................................................... 7, 82bacitracin-polymyxin b .................... 82baclofen ................................................................ 89balsalazide disodium ........................ 79BANZEL ............................................................... 13BARACLUDE ............................................... 33BAYER ASPIRIN EXTRA STRENGTH ................................................... 20BAYER BREEZE 2 TEST ......... 81BAYER CONTOUR NEXT TEST ........................................................................ 81BAYER CONTOUR TEST ........ 81bcg vaccine ..................................................... 77BEKYREE ......................................................... 51belladonna alkaloids-opium .... 63benazepril hcl .............................................. 42benazepril-hydrochlorothiazide............................................................................................ 43BENLYSTA ..................................................... 75benzonatate ................................................... 55benzoyl peroxide-erythromycin............................................................................................ 57benztropine mesylate ...................... 29BEPREVE ......................................................... 83BESIVANCE .................................................. 82betamethasone dipropionate............................................................................................ 57betamethasone dipropionate aug ............................................................................... 57betamethasone valerate .............. 57BETASERON .............................................. 49betaxolol hcl ....................................... 44, 83bethanechol chloride ........................ 66bexarotene ....................................................... 24BEYAZ ................................................................... 51bicalutamide .................................................. 24BICNU .................................................................... 22bisoprolol fumarate .............................. 44bisoprolol-hydrochlorothiazide............................................................................................ 43bleomycin sulfate ................................... 24BLINCYTO ....................................................... 24

Index

BLISOVI 24 FE .......................................... 51BLISOVI FE 1.5/30 .............................. 51BLISOVI FE 1/20 .................................... 51BOOSTRIX ...................................................... 77BOSULIF ............................................................ 24bp folinatal plus b ................................... 95bp wash ................................................................ 57BREO ELLIPTA ........................................ 87briellyn .................................................................... 51brimonidine tartrate ............................. 83BRISDELLE ................................................... 16BROMDAY ...................................................... 83bromfenac sodium ................................ 84bromfenac sodium (once-daily)............................................................................................ 83bromocriptine mesylate ................ 30BUDEPRION SR .................................... 15budesonide .............................. 69, 86, 88bumetanide ..................................................... 46buprenorphine hcl ..................................... 6buprenorphine hcl-naloxone hcl................................................................................................ 6bupropion hcl ................................................ 15bupropion hcl er (smoking det)................................................................................................ 6bupropion hcl er (sr) .......................... 15bupropion hcl er (xl) ........................... 15buspirone hcl ................................................ 36BUSULFEX ..................................................... 22butalbital-acetaminophen .............. 3butalbital-apap-caff-cod .................... 4butalbital-apap-caffeine .................... 3butalbital-asa-caff-codeine .......... 4butalbital-asa-caffeine ........................ 3BUTISOL SODIUM ............................. 12BUTRANS ............................................................ 5BYETTA 10 MCG PEN ................. 37BYETTA 5 MCG PEN ..................... 37calcipotriene .................................................. 57calcitonin (salmon) ............................... 79calcitriol ................................................................. 79calcium acetate (phos binder)............................................................................................ 67calcium pnv ..................................................... 94CAMRESE ....................................................... 51CAMRESE LO ............................................ 51CANCIDAS ...................................................... 18candesartan cilexetil .......................... 41candesartan cilexetil-hctz .......... 41CAPASTAT SULFATE .................. 21capecitabine .................................................. 23CAPRELSA .................................................... 24captopril ................................................................ 42captopril-hydrochlorothiazide............................................................................................ 43

Index

CARAFATE .................................................... 66CARBAGLU ................................................... 91carbamazepine .......................................... 13carbamazepine er ................................. 13carbidopa-levodopa ............................ 30carbidopa-levodopa er ................... 30carbidopa-levodopa-entacapone ....................................................................................... 30carbinoxamine maleate ................ 85carboplatin ........................................................ 22CARIMUNE NF ......................................... 76carteolol hcl .................................................... 83carvedilol ............................................................ 44CAVIRINSE .................................................... 56CAYA ....................................................................... 50CAYSTON ............................................................ 8CAZIANT ............................................................ 51cefaclor ...................................................................... 8cefaclor er ............................................................. 8cefadroxil ................................................................ 8cefazolin sodium ......................................... 8cefdinir ........................................................................ 8cefditoren pivoxil ......................................... 8cefepime hcl ...................................................... 8cefixime .................................................................... 8cefoxitin sodium ........................................... 8cefpodoxime proxetil ..................... 8, 9cefprozil .................................................................... 9ceftazidime .......................................................... 8ceftriaxone sodium .................................. 8cefuroxime axetil ......................................... 9cefuroxime sodium .................................. 8celecoxib ............................................................. 19CELLCEPT INTRAVENOUS............................................................................................ 75CELONTIN ...................................................... 12cephalexin ............................................................ 9CEREZYME ................................................... 62CERVARIX ...................................................... 76CESIA ..................................................................... 51cetirizine hcl ................................................... 85CHANTIX ............................................................... 6CHANTIX CONTINUING MONTH PAK .................................................... 6CHANTIX STARTING MONTH PAK ................................................................................ 6CHATEAL .......................................................... 51CHEMET ............................................................ 90chloramphenicol sod succinate................................................................................................ 7chlordiazepoxide hcl .......................... 36chlordiazepoxide-amitriptyline............................................................................................ 17chlorhexidine gluconate ............... 56chloroquine phosphate .................. 29

98

Index

chlorothiazide .............................................. 46chlorpromazine hcl .............................. 30chlorpropamide ......................................... 39chlorthalidone .............................................. 46chlorzoxazone ............................................ 89CHOLBAM ....................................................... 64cholestyramine .......................................... 47cholestyramine light ........................... 47choline & mag trisalicylate ............ 5choline-mag trisalicylate .................. 5chorionic gonadotropin .................. 72chromic chloride ...................................... 91CIALIS .................................................................... 67CICLODAN CREAM .......................... 57CICLODAN SOLUTION ............... 57ciclopirox ............................................................. 57ciclopirox olamine .................................. 57ciclopirox treatment ............................ 57ciclopirox-vitamin e .............................. 57cilostazol ............................................................. 41cimetidine .......................................................... 64cimetidine 200 ............................................ 64cimetidine hcl ............................................... 64CIMZIA .................................................................. 77CIMZIA PREFILLED ......................... 77CIMZIA STARTER KIT .................. 77CIPRODEX ..................................................... 85ciprofloxacin ....................................... 10, 11ciprofloxacin hcl ............................ 10, 82ciprofloxacin-ciproflox hcl er............................................................................................ 10cisplatin ................................................................. 22citalopram hydrobromide ............ 15CITRANATAL B-CALM ................. 94cladribine ............................................................ 23CLARAVIS ....................................................... 57clarithromycin .................................................. 9clarithromycin er .......................................... 9clemastine fumarate .......................... 85CLINDACIN PAC ................................... 57clindamycin hcl .............................................. 7clindamycin palmitate hcl ............... 7clindamycin phos-benzoyl perox ......................................................................... 58clindamycin phosphate........................................................................ 7, 58, 68CLINIMIX E/DEXTROSE (2.75/10) .............................................................. 93CLINIMIX E/DEXTROSE (2.75/5) .................................................................. 93CLINIMIX E/DEXTROSE (4.25/25) .............................................................. 93CLINIMIX E/DEXTROSE (4.25/5) .................................................................. 93

Index

CLINIMIX E/DEXTROSE (5/15)............................................................................................ 93CLINIMIX E/DEXTROSE (5/20)............................................................................................ 93CLINIMIX E/DEXTROSE (5/25)............................................................................................ 93CLINIMIX/DEXTROSE (2.75/5)............................................................................................ 93CLINIMIX/DEXTROSE (4.25/10) .............................................................. 93CLINIMIX/DEXTROSE (4.25/20) .............................................................. 94CLINIMIX/DEXTROSE (4.25/25) .............................................................. 94CLINIMIX/DEXTROSE (4.25/5)............................................................................................ 94CLINIMIX/DEXTROSE (5/15)............................................................................................ 94CLINIMIX/DEXTROSE (5/20)............................................................................................ 94CLINIMIX/DEXTROSE (5/25)............................................................................................ 94CLINPRO 5000 ......................................... 56clobetasol propionate ...................... 58clobetasol propionate e ................ 58clobetasol propionate emulsion............................................................................................ 58CLODERM PUMP ................................ 58CLOLAR .............................................................. 23clomipramine hcl ..................................... 16clonazepam .................................................... 12clonidine hcl ................................................... 41clopidogrel bisulfate ........................... 41clorazepate dipotassium ............. 36clotrimazole ........................................ 18, 58clotrimazole-betamethasone............................................................................................ 58clozapine ............................................................ 32COLCRYS ........................................................ 19cold & allergy ................................................ 55cold sore treatment ............................. 56colestipol hcl .................................................. 47colistimethate sodium .......................... 7COLYTE WITH FLAVOR PACKS .................................................................. 65COMBIGAN .................................................... 83COMBIVENT RESPIMAT ......... 87COMETRIQ (100 MG DAILY DOSE) .................................................................... 24COMETRIQ (140 MG DAILY DOSE) .................................................................... 25COMETRIQ (60 MG DAILY DOSE) .................................................................... 25COMPLERA .................................................. 33COMVAX ............................................................ 76

Index

CONCEPT OB ........................................... 94CONCERTA .................................................. 48CONDYLOX .................................................. 58COPAXONE .................................................. 49CORMAX SCALP APPLICATION ........................................... 58CORTANE-B AQUEOUS .......... 85cortisone acetate .................................... 69COSENTYX ................................................... 74COSENTYX SENSOREADY PEN ............................................................................ 74COSMEGEN ................................................. 25COTELLIC ........................................................ 25CREON ................................................................. 64CRESEMBA .................................................. 18CRIXIVAN ......................................................... 34cromolyn sodium ............ 83, 87, 88CRYSELLE-28 ........................................... 51CYCLAFEM 1/35 .................................... 51CYCLAFEM 7/7/7 .................................. 51cyclobenzaprine hcl ............................ 89cyclopentolate hcl .................................. 81cyclophosphamide ............................... 22cycloserine ....................................................... 21CYCLOSET .................................................... 37cyclosporine ................................................... 75cyclosporine modified ...................... 75cyproheptadine hcl .............................. 85CYRED .................................................................. 51CYSTADANE ............................................... 62CYSTAGON .................................................. 67cytarabine .......................................................... 23cytarabine (pf) ............................................. 23dacarbazine .................................................... 25DACOGEN ...................................................... 23DALIRESP ....................................................... 88danazol .................................................................. 70dantrolene sodium ................................ 89dapsone ............................................................... 21DAPTACEL ..................................................... 78DARAPRIM ..................................................... 29darifenacin hydrobromide er............................................................................................ 66DARZALEX ..................................................... 25DASETTA 1/35 .......................................... 51DASETTA 7/7/7 ........................................ 51daunorubicin hcl ...................................... 23DAYSEE .............................................................. 51DEBLITANE ................................................... 51decitabine .......................................................... 23DELYLA ............................................................... 51demeclocycline hcl .............................. 11DENTA 5000 PLUS ............................ 56DENTAGEL .................................................... 56DEPO-PROVERA ................................. 71

99

Index

DEPO-SUBQ PROVERA 104............................................................................................ 50DERMAZENE .............................................. 58DESGEN PEDIATRIC .................... 55desipramine hcl ........................................ 16desloratadine ................................................ 85desmopressin ace rhinal tube............................................................................................ 72desmopressin ace spray refrig............................................................................................ 72desmopressin acetate .................... 72desmopressin acetate spray............................................................................................ 72desogestrel-ethinyl estradiol............................................................................................ 51desonide .............................................................. 58desoximetasone ...................................... 58desvenlafaxine er .................................. 16desvenlafaxine fumarate er .... 16dexamethasone ........................................ 69dexamethasone sodium phosphate ............................................. 69, 84DEXILANT ........................................................ 66dexmethylphenidate hcl ............... 48dexmethylphenidate hcl er ....... 48dexrazoxane .................................................. 25dextroamphetamine sulfate .... 48dextroamphetamine sulfate er............................................................................................ 48dextrose ............................................................... 94dextrose in lactated ringers .... 92dextrose-nacl ................................................ 92DIABETA ............................................................ 39DIASTAT PEDIATRIC .................... 12diazepam ................................................ 12, 36diclofenac potassium ........................ 19diclofenac sodium ......... 19, 58, 84diclofenac sodium er ......................... 19diclofenac-misoprostol ................... 19dicloxacillin sodium ............................. 10dicyclomine hcl .......................................... 63didanosine ........................................................ 35DIFICID ..................................................................... 9diflorasone diacetate ........................ 58diflunisal ............................................................... 20digoxin .................................................................... 45dihydroergotamine mesylate............................................................................................ 20diltiazem cd ..................................................... 44diltiazem hcl ....................................... 44, 45diltiazem hcl er ........................................... 44diltiazem hcl er beads ..................... 44diltiazem hcl er coated beads............................................................................................ 44DIPENTUM ..................................................... 79

Index

diphenhydramine hcl ........................ 85diphenoxylate-atropine .................. 64dipyridamole .................................................. 41disopyramide phosphate ............ 42disulfiram ................................................................ 5divalproex sodium ................................. 12divalproex sodium er ........................ 12DOCEFREZ ................................................... 25docetaxel ............................................................ 25dofetilide .............................................................. 42donepezil hcl ................................................. 14dorzolamide hcl ........................................ 83dorzolamide hcl-timolol mal .... 83doxazosin mesylate ............................ 41doxepin hcl ...................................................... 16doxercalciferol ............................................ 80doxorubicin hcl ........................................... 23DOXY 100 ........................................................ 11doxycycline hyclate ............................. 11doxycycline monohydrate .......... 11dronabinol ......................................................... 17drospirenone-ethinyl estradiol............................................................................................ 51DULERA .............................................................. 87duloxetine hcl ............................................... 16DUREZOL ........................................................ 84dutasteride-tamsulosin hcl ....... 67DYRENIUM .................................................... 46econazole nitrate .................................... 58EDARBI ................................................................ 41EDARBYCLOR ......................................... 43EDURANT ........................................................ 34effervescent pot chloride ............ 91EFFIENT ............................................................. 41ELAPRASE ..................................................... 62ELESTAT ........................................................... 83ELIDEL .................................................................. 58ELIGARD ........................................................... 25ELINEST ............................................................. 51ELIQUIS .............................................................. 40ELITEK .................................................................. 25ELLA ......................................................................... 50ELLENCE .......................................................... 23ELMIRON .......................................................... 67EMADINE .......................................................... 83EMCYT .................................................................. 25EMEND ................................................................. 17EMOQUETTE ............................................. 51EMPLICITI ........................................................ 25EMSAM ................................................................ 15EMTRIVA ........................................................... 35enalapril maleate .................................... 42enalapril-hydrochlorothiazide............................................................................................ 43ENBREL .................................................. 74, 75

Index

ENBREL SURECLICK ................... 74ENGERIX-B ................................................... 76enoxaparin sodium .............................. 40ENPRESSE-28 ......................................... 52ENSKYCE ........................................................ 52entacapone ..................................................... 30entecavir .............................................................. 33epinastine hcl ............................................... 83epinephrine ..................................................... 89epinephrine hcl .......................................... 87epinephrine hcl pf .................................. 45EPIPEN 2-PAK .......................................... 89EPIPEN JR 2-PAK ............................... 89epirubicin hcl ................................................. 23EPIVIR HBV .................................................. 35eplerenone ....................................................... 46eprosartan mesylate .......................... 41ERAXIS ................................................................ 18ERBITUX ............................................................ 25ergoloid mesylates ............................... 14ERGOMAR ...................................................... 20ERIVEDGE ...................................................... 25ERWINAZE ..................................................... 23ERYTHROCIN LACTOBIONATE ....................................... 9ERYTHROCIN STEARATE ....... 9erythromycin ...................................... 58, 82erythromycin ethylsuccinate ...... 9ESBRIET ............................................................ 88escitalopram oxalate ......................... 15esomeprazole magnesium ...... 66ESTARYLLA ................................................. 52estazolam .......................................................... 90estradiol ................................................................ 70estradiol-norethindrone acet............................................................................................ 52estropipate ....................................................... 70eszopiclone ..................................................... 90ethambutol hcl ................................ 21, 22ethosuximide ................................................ 12etodolac ................................................................ 19etodolac er ....................................................... 19ETOPOPHOS ............................................. 25etoposide ............................................................ 25EURAX .................................................................. 59EXACTECH R-S-G TEST ......... 81EXACTECH TEST ............................... 81exemestane .................................................... 28EXJADE ............................................................... 90EXODERM ...................................................... 59EXTAVIA ............................................................ 49eye wash ............................................................ 84EZ FLU SHOT-FLUCELVAX............................................................................................ 78FABRAZYME ............................................... 63

100

Index

FALMINA ............................................................ 52famciclovir ......................................................... 33famotidine .......................................................... 64FANAPT .............................................................. 31FANAPT TITRATION PACK............................................................................................ 31FARESTON .................................................... 25FARXIGA ........................................................... 39FARYDAK ......................................................... 25FASLODEX .................................................... 25FAZACLO .......................................................... 32FC2 FEMALE CONDOM ............ 50felbamate ........................................................... 13felodipine er .................................................... 45fenofibrate ......................................................... 46fenofibrate micronized .................... 46fenofibric acid .............................................. 46fenoprofen calcium .............................. 19fentanyl ...................................................................... 3FENTORA ............................................................ 4FER-IN-SOL .................................................. 94ferrous sulfate ............................................. 94FETZIMA ............................................................ 16FETZIMA TITRATION .................... 16finasteride .......................................................... 67FIRAZYR ............................................................ 74FIRMAGON .................................................... 25flecainide acetate ................................... 42FLOVENT DISKUS ............................. 86FLOVENT HFA ......................................... 86FLUARIX ............................................................ 78FLUARIX QUADRIVALENT............................................................................................ 78FLUBLOK .......................................................... 78FLUCELVAX ................................................. 78fluconazole ...................................................... 18fluconazole in dextrose ................. 18fluconazole in sodium chloride............................................................................................ 18flucytosine ......................................................... 18fludarabine phosphate .................... 23fludrocortisone acetate .................. 69FLULAVAL QUADRIVALENT............................................................................................ 78FLUMIST QUADRIVALENT............................................................................................ 78flunisolide ........................................................... 88fluocinolone acetonide ....... 59, 85fluocinolone acetonide body............................................................................................ 59fluocinolone acetonide scalp............................................................................................ 59fluocinonide .................................................... 59fluocinonide-e .............................................. 59

Index

FLUORIDEX SENSITIVITY RELIEF .................................................................. 56fluoritab ................................................................. 55fluorometholone ....................................... 84fluorouracil ............................................ 23, 59fluoxetine hcl ................................................. 15fluoxetine hcl (pmdd) ........................ 16fluphenazine decanoate .............. 30fluphenazine hcl ....................................... 30FLURA-DROPS ....................................... 55flurazepam hcl ............................................ 90flurbiprofen ....................................................... 19flurbiprofen sodium .............................. 84flutamide .............................................................. 25fluticasone propionate ........ 59, 88fluvastatin sodium ................................. 47fluvastatin sodium er ......................... 47FLUVIRIN .......................................................... 78FLUVIRIN PRESERVATIVE FREE ........................................................................ 78fluvoxamine maleate ......................... 15fluvoxamine maleate er ................ 15FLUZONE HIGH-DOSE .............. 78FLUZONE PRESERVATIVE FREE ........................................................................ 78FLUZONE QUADRIVALENT............................................................................................ 78folcal dha ............................................................ 94folic acid ............................................................... 94FOLIVANE-OB .......................................... 94FOLIVANE-PRX DHA NF ......... 94FOLOTYN ......................................................... 23fondaparinux sodium ........................ 40FORFIVO XL ................................................ 15FORTEO ............................................................. 80FOSAMAX PLUS D ............................ 79FOSCAVIR ...................................................... 32fosinopril sodium ..................................... 42fosinopril sodium-hctz ..................... 43fosphenytoin sodium ......................... 13FOSRENOL ................................................... 67FREESTYLE INSULINX TEST............................................................................................ 81FREESTYLE LITE TEST ........... 81FREESTYLE PRECISION NEO TEST ........................................................................ 81FREESTYLE TEST ............................ 81FULYZAQ .......................................................... 64furosemide ....................................................... 46FUSILEV ............................................................. 25FUZEON ............................................................. 33FYCOMPA ....................................................... 12gabapentin ....................................................... 12GABITRIL .......................................................... 12GABLOFEN .................................................... 32

Index

galantamine hydrobromide ...... 14galantamine hydrobromide er............................................................................................ 14GAMMAGARD ........................................... 76GAMMAGARD S/D ............................. 76GAMMAGARD S/D LESS IGA............................................................................................ 76GAMMAPLEX ............................................. 76ganciclovir sodium ................................ 32GARDASIL ...................................................... 76gatifloxacin ....................................................... 82GAVILYTE-C ................................................ 65GAVILYTE-G ................................................ 65GAVILYTE-N WITH FLAVOR PACK ....................................................................... 65gemcitabine hcl ......................................... 23gemfibrozil ........................................................ 46GENGRAF ....................................................... 75GENTAK ............................................................. 82gentamicin sulfate ............. 6, 59, 82GENVOYA ....................................................... 33GEODON ........................................................... 31GESTICARE DHA ................................ 94GIANVI .................................................................. 52GILDAGIA ......................................................... 52GILDESS 1.5/30 ...................................... 52GILDESS 1/20 ............................................ 52GILDESS FE 1.5/30 .......................... 52GILDESS FE 1/20 ................................ 52GILENYA ............................................................ 49GILOTRIF .......................................................... 25GLEOSTINE .................................................. 22glimepiride ........................................................ 39glipizide ................................................................. 39glipizide er ........................................................ 39glipizide xl .......................................................... 39glipizide-metformin hcl ................... 37GLUCAGEN DIAGNOSTIC .... 37GLUCAGEN HYPOKIT ................. 37GLUCAGON EMERGENCY............................................................................................ 37glucose .................................................................. 37glyburide .................................................. 37, 39glyburide micronized ......................... 39glyburide-metformin ........................... 37glycopyrrolate .............................................. 63gnp vitamin d-400 .................................. 91GOLYTELY ..................................................... 65granisetron hcl ............................................ 17griseofulvin microsize ...................... 18griseofulvin ultramicrosize ........ 18guanfacine hcl ............................................ 41guanfacine hcl er .................................... 48guanidine hcl ................................................ 21HALAVEN ......................................................... 26

101

Index

halobetasol propionate .................. 59haloperidol ........................................................ 31haloperidol decanoate .................... 31haloperidol lactate ................................ 31HARVONI .......................................................... 33HAVRIX ................................................................ 76HEATHER ........................................................ 52HEMMOREX-HC .................................... 59heparin (porcine) in d5w .............. 40heparin (porcine) in nacl .............. 40heparin lock flush ................................... 40heparin sod (porcine) in d5w............................................................................................ 40heparin sodium (porcine) ........... 40heparin sodium (porcine) pf ... 40HEPATASOL ................................................ 94HERCEPTIN ................................................. 26HEXALEN ......................................................... 22HOMATROPAIRE ................................ 82HUMATROPE ............................................. 71HUMIRA .............................................................. 74HUMIRA PEDIATRIC CROHNS START ................................................................... 74HUMIRA PEN .............................................. 74HUMIRA PEN-CROHNS STARTER ......................................................... 74HUMIRA PEN-PSORIASIS STARTER ......................................................... 74hydralazine hcl ........................................... 47hydrochlorothiazide ............................ 46hydrocod polst-cpm polst er............................................................................................ 55hydrocodone-acetaminophen................................................................................................ 4hydrocodone-homatropine ....... 55hydrocodone-ibuprofen ..................... 4hydrocortisone .................... 59, 60, 69hydrocortisone ace-pramoxine............................................................................................ 59hydrocortisone acetate .................. 59hydrocortisone butyr lipo base............................................................................................ 59hydrocortisone butyrate ................ 59hydrocortisone valerate ................ 60hydrocortisone-acetic acid ....... 85hydrocortisone-aloe ............................ 60hydromorphone hcl ................................. 4hydromorphone hcl pf ......................... 4hydroquinone ............................................... 60hydroquinone time release ...... 60hydroxychloroquine sulfate ..... 29hydroxyurea ................................................... 26hydroxyzine hcl ......................................... 36hydroxyzine pamoate ...................... 36HYOPHEN ....................................................... 66

Index

hyoscyamine sulfate .......................... 63hyoscyamine sulfate er ................. 63HYPERLYTE-CR ................................... 91ibandronate sodium ............................ 79IBRANCE ........................................................... 26ibuprofen ............................................................. 19ibuprofen childrens .............................. 19IDAMYCIN PFS ............................ 24, 26idarubicin hcl ..................................... 24, 26IFEX ........................................................................... 22ifosfamide .......................................................... 22ILARIS .................................................................... 75imatinib mesylate ................................... 26IMBRUVICA ................................................... 26imipramine hcl ............................................ 16imipramine pamoate .......................... 16imiquimod .......................................................... 60IMOVAX RABIES .................................. 78INATAL ADVANCE ............................. 94INATAL GT ...................................................... 94INATAL ULTRA ........................................ 94INCRELEX ....................................................... 71INCRUSE ELLIPTA ............................ 86indapamide ...................................................... 46indomethacin ................................................ 19indomethacin er ........................................ 19INFANRIX ......................................................... 78INLYTA .................................................................. 26INNOPRAN XL .......................................... 44insulin syringe ............................................. 80insulin syringe/needle ...................... 80INTELENCE .................................................. 34INTRALIPID ................................................... 94INTRON A ........................................................ 26INTROVALE .................................................. 52INVANZ .................................................................... 8INVEGA ................................................................ 31INVEGA SUSTENNA ...................... 31INVIRASE ......................................................... 34INVOKANA ...................................................... 39IPOL .......................................................................... 76ipratropium bromide ............... 86, 88ipratropium-albuterol ......................... 87irbesartan ........................................................... 41irbesartan-hydrochlorothiazide............................................................................................ 43irinotecan hcl ................................................ 26iron chews pediatric ........................... 94ISENTRESS ...................................... 33, 34ISOLYTE-P IN D5W .......................... 92ISOLYTE-S ..................................................... 92ISOLYTE-S PH 7.4 ............................. 92isometheptene-caffeine-apap................................................................................................ 4

Index

isometheptene-dichloral-apap................................................................................................ 4isoniazid ............................................................... 22isopropyl alcohol wipes ................. 60isosorbide dinitrate .............................. 48isosorbide dinitrate er ...................... 48isosorbide mononitrate .................. 48isosorbide mononitrate er .......... 48isradipine ............................................................ 45ISTODAX ........................................................... 26itraconazole .................................................... 18iv prep wipes ................................................. 60ivermectin .......................................................... 29IXEMPRA KIT ............................................. 26IXIARO .................................................................. 78JAKAFI .................................................................. 26JANUMET ......................................................... 38JANUMET XR ............................................. 38JANUVIA ............................................................ 38JENCYCLA ..................................................... 52jevantique lo .................................................. 52JEVTANA .......................................................... 26JINTELI ................................................................. 52JOLESSA .......................................................... 52JOLIVETTE .................................................... 52JULEBER .......................................................... 52JUNEL 1.5/30 .............................................. 52JUNEL FE 1.5/30 ................................... 52JUNEL FE 1/20 ......................................... 52JUNEL FE 24 ............................................... 52JUXTAPID ........................................................ 47KADCYLA ......................................................... 26KAITLIB FE ..................................................... 52KALETRA .......................................................... 34KALYDECO .................................................... 88KANUMA ............................................................ 63KARIVA ................................................................ 52KAZANO ............................................................. 38kcl in d5w lactated ringers ........ 92kcl in dextrose-nacl ................. 91, 92kcl-lactated ringers-d5w ............... 92k-effervescent .............................................. 91KELNOR 1/35 ............................................. 52KEPIVANCE .................................................. 26KETEK ....................................................................... 9ketoconazole .................................... 18, 60KETODAN ........................................................ 60ketoprofen ......................................................... 19ketoprofen er ................................................ 19ketorolac tromethamine.................................................................... 19, 20, 84KHEDEZLA ..................................................... 16KIMIDESS ........................................................ 52KINERET ............................................................ 74KIONEX ................................................................ 90

102

Index

KLOR-CON ..................................................... 91KLOR-CON 10 ........................................... 91KLOR-CON M10 ..................................... 91KLOR-CON M15 ..................................... 91KLOR-CON M20 ..................................... 91KOMBIGLYZE XR ................................ 38KORLYM ............................................................ 71KURVELO ........................................................ 52KUVAN .................................................................. 63labetalol hcl ..................................................... 44LACRISERT .................................................. 82lactated ringers .............................. 81, 92lactulose .............................................................. 65lactulose encephalopathy .......... 65lamivudine ............................................ 33, 35lamivudine-zidovudine .................... 35lamotrigine ........................................................ 13lamotrigine er ............................................... 13lansoprazole .................................................. 66LANTUS .............................................................. 38LANTUS SOLOSTAR ..................... 38LARIN 1.5/30 ................................................ 52LARIN 1/20 ...................................................... 52LARIN 24 FE ................................................ 52LARIN FE 1.5/30 .................................... 52LARIN FE 1/20 .......................................... 52latanoprost ....................................................... 84LATUDA .............................................................. 31LAYOLIS FE .................................................. 52LEENA ................................................................... 52leflunomide ...................................................... 76LEMTRADA .................................................... 49LENVIMA 10 MG DAILY DOSE............................................................................................ 26LENVIMA 14 MG DAILY DOSE............................................................................................ 26LENVIMA 18 MG DAILY DOSE............................................................................................ 26LENVIMA 20 MG DAILY DOSE............................................................................................ 26LENVIMA 24 MG DAILY DOSE............................................................................................ 26LENVIMA 8 MG DAILY DOSE............................................................................................ 26LESCOL XL .................................................... 47LESSINA ............................................................ 52LETAIRIS ........................................................... 88letrozole ................................................................ 28leucovorin calcium ................................ 26LEUKERAN .................................................... 22LEUKINE ............................................................ 68leuprolide acetate .................................. 26levalbuterol hcl ........................................... 87LEVEMIR ........................................................... 38LEVEMIR FLEXTOUCH .............. 38

Index

levetiracetam .................................... 11, 12levetiracetam er ........................................ 11levobunolol hcl ........................................... 83levocarnitine .................................................. 63levocetirizine dihydrochloride............................................................................................ 85levofloxacin ............................. 10, 11, 82LEVONEST .................................................... 52levonorgest-eth estrad 91-day............................................................................................ 53levonorgestrel .............................................. 50levonorgestrel-ethinyl estrad............................................................................................ 53levonorg-eth estrad triphasic............................................................................................ 53LEVORA 0.15/30 (28) ..................... 53LEVO-T ................................................................. 72LEVOTHROID ............................................ 72levothyroxine sodium ........... 72, 73LEXIVA .................................................................. 34lidocaine .............................................................. 56lidocaine hcl ........................................... 5, 56lidocaine hcl (pf) .......................................... 5lidocaine viscous ........................................ 5lidocaine-prilocaine ................................. 5LIDODERM ..................................................... 56lincomycin hcl .................................................. 7lindane .................................................................... 60linezolid ..................................................................... 7liothyronine sodium ............................. 73LIPOFEN ............................................................ 46lisinopril ................................................................. 42lisinopril-hydrochlorothiazide............................................................................................ 43lithium carbonate .................................... 37lithium carbonate er ............................ 36LIVALO .................................................................. 47LO LOESTRIN FE ................................ 53LOMEDIA 24 FE ..................................... 53LONSURF ........................................................ 26loperamide hcl ............................................ 64lorazepam ......................................................... 36LORYNA ............................................................. 53losartan potassium .............................. 41losartan potassium-hctz ............... 43lovastatin ............................................................ 47LOVAZA .............................................................. 47LOW-OGESTREL ................................. 53loxapine succinate ................................ 31LUDENT .............................................................. 55LUMIGAN .......................................................... 84LUMIZYME ...................................................... 63LUPRON DEPOT .................................. 26LUPRON DEPOT-PED ................. 73LUTERA .............................................................. 53

Index

LUZU ........................................................................ 60LYNPARZA ..................................................... 26LYRICA ................................................................. 49LYSODREN ................................................... 27LYZA ......................................................................... 53mafenide acetate .................................... 60magnesium chloride .......................... 91magnesium sulfate .............................. 91malathion ............................................................ 60maprotiline hcl ............................................ 15marlissa ................................................................ 53MARPLAN ........................................................ 15MATULANE .................................................... 27meclizine hcl .................................................. 17meclofenamate sodium ................ 20medroxyprogesterone acetate................................................................................ 50, 71mefenamic acid ........................................ 20mefloquine hcl ............................................ 29MEGACE ES ................................................ 71megestrol acetate ...................... 27, 71MEKINIST ......................................................... 27meloxicam ........................................................ 20melphalan hcl .............................................. 22MENACTRA .................................................. 77MENEST ............................................................. 70MENOMUNE ................................................ 77MENVEO ............................................................ 77meprobamate .............................................. 36MEPRON ........................................................... 29mercaptopurine ......................................... 24meropenem ........................................................ 7mesalamine .................................................... 79mesalamine-cleanser ...................... 79mesna ..................................................................... 27MESNEX ............................................................ 27MESTINON ..................................................... 21metaproterenol sulfate ................... 87metaxalone ...................................................... 89metformin hcl ................................................ 38metformin hcl er ....................................... 38metformin hcl er (mod) .................. 38metformin hcl er (osm) ................... 38methadone hcl ................................................ 3methazolamide .......................................... 45methenamine hippurate ................... 7methenamine mandelate ................ 7methimazole .................................................. 73methocarbamol ......................................... 89methotrexate ................................................. 24methotrexate sodium ........................ 24methotrexate sodium (pf) ........... 24methoxsalen rapid ................................ 60methscopolamine bromide ...... 63methyclothiazide ..................................... 46

103

Index

methyldopa ...................................................... 41methyldopa-hydrochlorothiazide............................................................................................ 43methyldopate hcl .................................... 41methylphenidate hcl ........................... 49methylphenidate hcl er .................. 49methylphenidate hcl er (cd) .... 48methylphenidate hcl er (la) ...... 49methylprednisolone ............................ 69methylprednisolone acetate ... 69methylprednisolone sodium succ ............................................................................ 69metipranolol .................................................... 83metoclopramide hcl ............................ 64metolazone ...................................................... 46metoprolol succinate er ................ 44metoprolol tartrate ................................ 44metoprolol-hydrochlorothiazide............................................................................................ 43metronidazole .......................... 7, 60, 68metronidazole in nacl ........................... 7mexiletine hcl ............................................... 42miconazole 3 ................................................ 68miconazole 3 combo pack ........ 68MICROGESTIN 1.5/30 .................. 53MICROGESTIN 1/20 ........................ 53MICROGESTIN 24 FE ................... 53MICROGESTIN FE 1.5/30 ....... 53MICROGESTIN FE 1/20 ............. 53midodrine hcl ................................................ 45MINASTRIN 24 FE .............................. 53minocycline hcl .......................................... 11minocycline hcl er .................................. 11minoxidil ............................................................... 47MIRENA (52 MG) .................................. 50mirtazapine ...................................................... 15misoprostol ...................................................... 66mitomycin .......................................................... 24mitoxantrone hcl ...................................... 24M-M-R II ............................................................... 77modafinil .............................................................. 90moexipril hcl ................................................... 42moexipril-hydrochlorothiazide............................................................................................ 43mometasone furoate ......................... 60MONO-LINYAH ........................................ 53MONONESSA ............................................ 53montelukast sodium ........................... 86MONUROL .......................................................... 7morphine sulfate .................................. 3, 4morphine sulfate (concentrate)................................................................................................ 4morphine sulfate (pf) ............................. 4morphine sulfate er ................................. 3morphine sulfate er beads ............ 3

Index

MOVANTIK ..................................................... 64MOVIPREP ..................................................... 65MOXEZA ............................................................ 82MULTAQ ............................................................. 42multi prenatal ................................................ 95multi-vit/fluoride ........................................ 95multivitamin/fluoride ........................... 95multi-vitamin/fluoride ......................... 95mupirocin ............................................................ 60mupirocin calcium ................................. 60MUSTARGEN ............................................. 22MVC-FLUORIDE .................................... 95MYCAMINE .................................................... 18MYCOBUTIN ................................................ 21mycophenolate mofetil ................... 75mycophenolic acid ................................ 75MYFORTIC ..................................................... 75MYNATAL ......................................................... 95MYNATAL ADVANCE .................... 95MYRBETRIQ ................................................ 66MYZILRA ............................................................ 53nabumetone ................................................... 20nadolol .................................................................... 44nadolol-bendroflumethiazide............................................................................................ 43nafcillin sodium .......................................... 10NAGLAZYME .............................................. 63nalbuphine hcl ................................................ 4naloxone hcl ...................................................... 6naltrexone hcl .................................................. 5NAMENDA ....................................................... 14NAMENDA XR ........................................... 14NAMENDA XR TITRATION PACK ....................................................................... 14naphazoline hcl ......................................... 82naproxen ............................................................. 20naproxen dr .................................................... 20naproxen sodium .................................... 20naratriptan hcl ............................................. 21NATAZIA ............................................................ 53nateglinide ........................................................ 38NATELLE ONE ......................................... 95NATPARA ......................................................... 72NATURE-THROID ............................... 73NEBUPENT .................................................... 29NECON 0.5/35 (28) ............................ 53NECON 1/35 (28) .................................. 53NECON 1/50 (28) .................................. 53NECON 10/11 (28) .............................. 53NECON 7/7/7 ............................................... 53nefazodone hcl .......................................... 14neomycin sulfate ......................................... 6neomycin-bacitracin zn-polymyx ...................................................... 82neomycin-polymyxin b gu .......... 67

Index

neomycin-polymyxin-dexameth............................................................................................ 84neomycin-polymyxin-gramicidin............................................................................................ 82neomycin-polymyxin-hc .... 84, 85NEO-POLYCIN HC ............................. 84NEPHRAMINE ........................................... 94NEPTAZANE ................................................ 45NESINA ................................................................ 37NEUAC .................................................................. 60NEUMEGA ...................................................... 68NEUPOGEN .................................................. 68NEVANAC ........................................................ 84nevirapine .............................................. 34, 35nevirapine er ................................................. 34NEXAVAR ........................................................ 27NEXPLANON .............................................. 50niacin er ................................................................ 95niacin er (antihyperlipidemic)............................................................................................ 47NIACOR ............................................................... 47nicardipine hcl ............................................. 45nicotine ...................................................................... 6nicotine mini ....................................................... 6nicotine polacrilex ...................................... 6NIFEDIAC CC ............................................. 45nifedipine ............................................................ 45nifedipine er .................................................... 45nifedipine er osmotic release............................................................................................ 45NIKKI ........................................................................ 53NILANDRON ................................................ 27nimodipine ........................................................ 45NINLARO ........................................................... 27nisoldipine er ................................................ 45nitrofurantoin macrocrystal .......... 7nitrofurantoin monohyd macro................................................................................................ 7nitroglycerin .................................................... 48NITROLINGUAL ...................................... 48NITROSTAT .................................................. 48NORA-BE .......................................................... 53norethin ace-eth estrad-fe ........ 53norethindrone .............................................. 53norethindrone acetate ..................... 71norethindrone acet-ethinyl est............................................................................................ 53norethindrone-eth estradiol................................................................................ 53, 70norethin-eth estradiol-fe ............... 53norgestimate-eth estradiol ........ 53norgestim-eth estrad triphasic............................................................................................ 54NORLYROC .................................................. 54NORMOSOL-M IN D5W ............. 92

104

Index

NORMOSOL-R ......................................... 92NORMOSOL-R IN D5W .............. 92NORMOSOL-R PH 7.4 ................. 92NORTREL 0.5/35 (28) .................... 54NORTREL 1/35 (21) .......................... 54NORTREL 1/35 (28) .......................... 54NORTREL 7/7/7 ...................................... 54nortriptyline hcl .......................................... 16NORVIR ............................................................... 34NOVOLIN 70/30 ...................................... 38NOVOLIN 70/30 RELION .......... 38NOVOLIN N ................................................... 38NOVOLIN N RELION ...................... 38NOVOLIN R ................................................... 38NOVOLIN R RELION ...................... 39NOVOLOG ...................................................... 39NOVOLOG FLEXPEN .................... 39NOVOLOG MIX 70/30 .................... 39NOVOLOG MIX 70/30 FLEXPEN .......................................................... 39NOVOLOG PENFILL ....................... 39NOXAFIL ............................................................ 18np thyroid ........................................................... 73NUCALA .............................................................. 88NUCYNTA ............................................................ 4NUCYNTA ER ................................................ 3NUEDEXTA .................................................... 49NULOJIX ............................................................ 75NULYTELY WITH FLAVOR PACKS .................................................................. 65nutrilyte .................................................................. 91NUTROPIN AQ NUSPIN 10............................................................................................ 71NUTROPIN AQ NUSPIN 20............................................................................................ 71NUTROPIN AQ NUSPIN 5 ...... 71NUTROPIN AQ PEN ........................ 71NUVARING ..................................................... 50NUVIGIL .............................................................. 90nystatin ...................................................... 18, 60nystatin-triamcinolone ..................... 60OCELLA .............................................................. 54octreotide acetate .................................. 73ODOMZO .......................................................... 27ofloxacin ...................................... 11, 82, 85OGESTREL .................................................... 54olanzapine ........................................................ 32olanzapine-fluoxetine hcl ............ 16olmesartan medoxomil .................. 41olmesartan medoxomil-hctz ... 43olmesartan-amlodipine-hctz............................................................................................ 43olopatadine hcl .......................................... 88omega-3-acid ethyl esters ........ 47omeprazole ..................................................... 66

Index

omeprazole magnesium .............. 66omeprazole-sodium bicarbonate ..................................................... 66OMNIFLEX DIAPHRAGM ........ 50ONCASPAR .................................................. 27ondansetron ................................................... 17ondansetron hcl ........................................ 17one-daily multi vitamins ................ 96ONFI .......................................................................... 12ONGLYZA ........................................................ 37OPANA ER .......................................................... 3OPDIVO ............................................................... 27OPSUMIT .......................................................... 88OPTIONS CONCEPTROL ...... 50OPTIONS GYNOL II CONTRACEPTIVE .............................. 50ORAP ...................................................................... 31ORENCIA .......................................................... 74ORFADIN .......................................................... 63ORKAMBI .......................................................... 88orphenadrine citrate ........................... 89orphenadrine citrate er .................. 89ORSYTHIA ...................................................... 54ORTHO TRI-CYCLEN LO ........ 54OSENI .................................................................... 37otomax-hc ......................................................... 85oxacillin sodium ........................................ 10oxaliplatin ........................................................... 22oxandrolone ................................................... 70oxaprozin ............................................................ 20oxazepam .......................................................... 36oxcarbazepine ............................................ 13OXSORALEN ULTRA .................... 60OXTELLAR XR ......................................... 13oxybutynin chloride ............................. 67oxybutynin chloride er ..................... 67oxycodone hcl ......................................... 4, 5oxycodone-acetaminophen ........ 5oxycodone-aspirin .................................... 5oxycodone-ibuprofen ............................ 5oxymorphone hcl ................................ 4, 5oxymorphone hcl er ........................ 3, 4PACERONE .................................................. 42paclitaxel ............................................................. 27pamidronate disodium ........ 79, 80PANRETIN ...................................................... 60pantoprazole sodium ........................ 66PARAGARD INTRAUTERINE COPPER ............................................................ 50paricalcitol ......................................................... 80paromomycin sulfate ............................ 6paroxetine hcl .............................................. 15paroxetine hcl er ...................................... 15PASER .................................................................. 22PATADAY ......................................................... 83

Index

PATANOL ......................................................... 83PAXIL ...................................................................... 15PEDVAX HIB ................................................ 77peg 3350 ............................................................. 65peg 3350/electrolytes ...................... 65peg 3350-kcl-na bicarb-nacl............................................................................................ 65peg-3350/electrolytes ...................... 65PEGANONE .................................................. 13PEGASYS ........................................................ 33PEGASYS PROCLICK .................. 33pen needles .................................................... 80pen needles 1/2" ..................................... 80pen needles 3/16" ................................. 80pen needles 5/16" ................................. 80penicillin g potassium ...................... 10penicillin g sodium ................................ 10penicillin v potassium ....................... 10PENTAM ............................................................. 29pentazocine-naloxone hcl ............. 5pentoxifylline er ......................................... 45perindopril erbumine ......................... 42PERJETA .......................................................... 27permethrin ........................................................ 60perphenazine ............................................... 31perphenazine-amitriptyline ...... 31PEXEVA .............................................................. 15phenazopyridine hcl ........................... 67phenelzine sulfate ................................. 15phenobarbital ............................................... 12phenylephrine hcl .................................. 82phenytoin ............................................................ 13phenytoin sodium .................................. 14phenytoin sodium extended ... 13PHILITH ............................................................... 54PHOSPHOLINE IODIDE ............ 83PHYSIOSOL IRRIGATION ..... 81PICATO ................................................................ 61pilocarpine hcl ................................. 56, 83PIMTREA ........................................................... 54pindolol .................................................................. 44pioglitazone hcl ......................................... 39pioglitazone hcl-glimepiride .... 37pioglitazone hcl-metformin hcl............................................................................................ 39piperacillin sod-tazobactam so............................................................................................ 10PIRMELLA 1/35 ....................................... 54PIRMELLA 7/7/7 ..................................... 54piroxicam ............................................................ 20PLASMA-LYTE 148 ........................... 93PLASMA-LYTE-56 IN D5W .... 93PNEUMOVAX 23 ................................... 78pnv fe fum/docusate/folic acid............................................................................................ 95

105

Index

pnv-dha ................................................................. 95pnv-dha+docusate ............................... 95podofilox .............................................................. 61POLYCIN ........................................................... 82polyethylene glycol 3350 ............ 65polymyxin b-trimethoprim .......... 82POMALYST .................................................... 27PORTIA-28 ...................................................... 54PORTRAZZA ............................................... 27pot bicarb-pot chloride .................... 91potassium acetate ................................ 91potassium bicarbonate .................. 91potassium chloride ............................... 92potassium chloride crys er ....... 91potassium chloride er ...................... 91potassium chloride in dextrose............................................................................................ 93potassium chloride in nacl................................................................................ 92, 93potassium citrate er ............................ 67POTIGA ................................................................ 12PRADAXA ........................................................ 40pramipexole dihydrochloride............................................................................................ 30PRAMOTIC ..................................................... 85PRANDIMET ................................................ 37PRANDIN .......................................................... 37pravastatin sodium .............................. 47PRAXBIND ...................................................... 80prazosin hcl .................................................... 41PRECISION PCX .................................. 81PRECISION PCX PLUS TEST............................................................................................ 81PRECISION POINT OF CARE TEST ........................................................................ 81PRECISION QID TEST ................ 81PRECISION SOF-TACT TEST............................................................................................ 81PRECISION XTRA BLOOD GLUCOSE ........................................................ 81PRECISION XTRA KETONE............................................................................................ 81prednicarbate ............................................... 61prednisolone .................................................. 69prednisolone acetate ........................ 84prednisolone sodium phosphate................................................................................ 69, 84prednisone ....................................................... 69PREMARIN ......................................... 68, 70PREMASOL ................................................... 94PREMPHASE .............................................. 70PREMPRO ...................................................... 70prenaissance ................................................ 95prenatal 19 ....................................................... 95prenatal low iron ...................................... 90

Index

prenatal one daily .................................. 90prenatal vitamin ........................................ 90PRENTIF FITTING SET .............. 50PREPOPIK ...................................................... 65PREVIFEM ...................................................... 54PREVNAR 13 .............................................. 78PREZISTA ........................................................ 34PRIFTIN ............................................................... 22primaquine phosphate .................... 29primidone ........................................................... 12PRISTIQ .............................................................. 16PROAIR HFA ............................................... 87probenecid ....................................................... 19procainamide hcl .................................... 42PROCALAMINE ...................................... 94prochlorperazine ..................................... 31prochlorperazine edisylate ....... 31prochlorperazine maleate .......... 31PROCRIT .............................................. 40, 68PROCTO-PAK ........................................... 61PROCTOZONE-HC ........................... 61progesterone micronized ............ 71PROGLYCEM ............................................. 37PROGRAF ....................................................... 75PROLASTIN-C .......................................... 88PROLENSA .................................................... 83PROLEUKIN ................................................. 27PROLIA ................................................................ 80PROMACTA .................................................. 40promethazine hcl .................................... 17promethazine vc plain ..................... 55promethazine vc/codeine ........... 55promethazine-codeine .................... 55promethazine-dm ................................... 55propafenone hcl ....................................... 42propafenone hcl er ............................... 42proparacaine hcl ...................................... 82propranolol hcl ............................................ 44propranolol hcl er ................................... 44propranolol-hctz ....................................... 43propylthiouracil .......................................... 73PROQUAD ...................................................... 77PROSOL ............................................................. 94protriptyline hcl .......................................... 17pseudoeph-bromphen-dm ........ 55pseudoeph-chlorphen-hydrocod............................................................................................ 55PULMICORT FLEXHALER .... 86PULMOZYME ............................................. 88pyrazinamide ................................................ 22pyridostigmine bromide ................ 21QUARTETTE ............................................... 54QUASENSE ................................................... 54quetiapine fumarate ........................... 32quetiapine fumarate er ................... 32

Index

quinapril hcl .................................................... 42quinapril-hydrochlorothiazide............................................................................................ 43quinidine gluconate er .................... 42quinidine sulfate ....................................... 42quinidine sulfate er .............................. 42QVAR ...................................................................... 86RABAVERT .................................................... 78rabeprazole sodium ............................ 66raloxifene hcl ................................................ 71ramipril ................................................................... 42RANEXA ............................................................. 45ranitidine hcl ...................................... 64, 65RAPAFLO ......................................................... 67RAPAMUNE .................................................. 75REBIF ...................................................................... 49REBIF REBIDOSE .............................. 49REBIF REBIDOSE TITRATION PACK ....................................................................... 49REBIF TITRATION PACK ........ 49RECLAST .......................................................... 80RECLIPSEN .................................................. 54RECOMBIVAX HB ............................... 77RECTIV ................................................................ 61REGRANEX .................................................. 61RELISTOR ....................................................... 64RELPAX .............................................................. 21REMICADE ..................................................... 77RENVELA ............................................. 67, 68repaglinide ........................................................ 38REPREXAIN ..................................................... 5RESCRIPTOR ............................................ 35RESTASIS ....................................................... 82RETROVIR ...................................................... 35REVLIMID ......................................................... 23REYATAZ .......................................................... 34RHEUMATREX ........................................ 75RIBASPHERE ............................................ 33RIBASPHERE RIBAPAK ........... 33ribavirin .................................................................. 33RIDAURA .......................................................... 76rifabutin ................................................................. 21RIFAMATE ...................................................... 22rifampin ................................................................. 22RIFATER ............................................................ 22RIGHT STEP PRENATAL ........ 90riluzole .................................................................... 49rimantadine hcl .......................................... 36ringers ..................................................................... 93ringers irrigation ....................................... 81RIOMET ............................................................... 38risedronate sodium .............................. 80RISPERDAL CONSTA .................. 32risperidone ....................................................... 32RISPERIDONE M-TAB ................. 32

106

Index

RITUXAN ........................................................... 27rivastigmine .................................................... 14rivastigmine tartrate ............................ 14rizatriptan benzoate ............................ 21ropinirole hcl .................................................. 30ropinirole hcl er .......................................... 30ROSADAN ....................................................... 61ROSULA ............................................................. 61rosuvastatin calcium .......................... 47ROTARIX ........................................................... 77ROTATEQ ........................................................ 77ROWASA ........................................................... 79rulavite dha ...................................................... 95SABRIL ................................................................. 13SAFYRAL .......................................................... 54SAIZEN ................................................................. 71SAIZEN CLICK.EASY .................... 71salicylic acid ................................................... 61salicylic acid-cleanser ..................... 61saline flush ....................................................... 93SAMSCA ............................................................ 91SANCUSO ....................................................... 17SANDIMMUNE .......................................... 75SANDOSTATIN LAR DEPOT............................................................................................ 73SANTYL ............................................................... 61SAPHRIS ........................................................... 32sash kit .................................................................. 40SAVAYSA ......................................................... 40SAVELLA ........................................................... 49SAVELLA TITRATION PACK............................................................................................ 49scalacort .............................................................. 61SECONAL ........................................................ 89selegiline hcl .................................................. 30selenium sulfide ....................................... 61SELZENTRY ................................................ 34se-natal 19 ....................................................... 95SENSIPAR .......................................... 72, 73SEREVENT DISKUS ....................... 87sertraline hcl .................................................. 16SETLAKIN ........................................................ 54SFROWASA .................................................. 79SHAROBEL .................................................... 54SIGNIFOR ........................................................ 72sildenafil citrate ............................. 88, 89silver sulfadiazine .................................. 61SIMPONI ............................................................ 74SIMPONI ARIA .............................. 74, 75simvastatin ....................................................... 47sirolimus .............................................................. 75SIRTURO .......................................................... 22SKLICE ................................................................. 29SKYLA .................................................................... 50

Index

sleep-aid maximum strength............................................................................................ 90sodium chloride .... 61, 88, 92, 93sodium chloride bacteriostatic............................................................................................ 93sodium chloride flush ....................... 93sodium fluoride .......................................... 56sodium lactate ............................................ 92sodium polystyrene sulfonate............................................................................................ 90sodium sulfacetamide ..................... 61sodium sulfacetamide wash............................................................................................ 61SOLARAZE .................................................... 61SOLIA ...................................................................... 54SOLTAMOX ................................................... 27SOMATULINE DEPOT ................. 73SOMAVERT .................................................. 73SORIATANE ................................................. 61sotalol hcl ........................................................... 44sotalol hcl (af) .............................................. 44SOVALDI ............................................................ 33spinosad .............................................................. 61SPIRIVA HANDIHALER .............. 86spironolactone ............................................ 46spironolactone-hctz ............................ 43SPRINTEC 28 ............................................ 54SPRYCEL ......................................................... 27SRONYX ............................................................ 54sss 10-5 ................................................................ 61stavudine ............................................................ 35STIOLTO RESPIMAT ..................... 87STIVARGA ...................................................... 27STRATTERA ................................................ 49streptomycin sulfate ............................... 6STRIBILD .......................................................... 34SUBOXONE ...................................................... 6sucralfate ............................................................ 66sulfacetamide sodium ......... 61, 82sulfacetamide sodium (acne)............................................................................................ 61sulfacetamide sodium-sulfur................................................................................ 61, 62sulfacetamide sod-sulfur wash............................................................................................ 62sulfacetamide-prednisolone ... 84sulfacetamide-sulfur in urea............................................................................................ 62sulfacetamide-sulfur-sunscreen............................................................................................ 62sulfadiazine ..................................................... 11sulfamethoxazole-trimethoprim............................................................................................ 11sulfasalazine ................................................. 79sulindac ................................................................ 20

Index

sumatriptan ..................................................... 21sumatriptan succinate ..................... 21sumatriptan succinate refill ...... 21SUPRAX ................................................................. 9SUPREP BOWEL PREP ............ 65SUSTIVA ............................................................ 35SUTENT .............................................................. 27SYEDA .................................................................. 54SYLATRON .................................................... 27SYMAX DUOTAB .................................. 63SYMAX-SR ..................................................... 63SYMBICORT ................................................ 87SYMLINPEN 120 ................................... 37SYMLINPEN 60 ....................................... 37SYNAREL ......................................................... 73SYNRIBO .......................................................... 27SYNTHROID ................................................ 72TABLOID ............................................................ 24tacrolimus .......................................................... 75TAFINLAR ........................................................ 27TAGRISSO ...................................................... 27TAMIFLU ............................................................ 36tamoxifen citrate ...................................... 29tamsulosin hcl ............................................. 67TARCEVA ......................................................... 27TARGRETIN ..................................... 27, 62TARINA FE 1/20 ..................................... 54TARON-BC ..................................................... 95TARON-PREX ............................................ 95TASIGNA ........................................................... 27TAXOTERE .................................................... 27TAZORAC ........................................................ 62TEKAMLO ........................................................ 43TEKTURNA .................................................... 45TEKTURNA HCT ................................... 43telmisartan ........................................................ 41telmisartan-amlodipine .................. 43telmisartan-hctz ........................................ 43temazepam ..................................................... 90temozolomide .............................................. 27terazosin hcl .................................................. 41terbinafine hcl .................................. 18, 62terbutaline sulfate .................................. 87terconazole ...................................................... 68testosterone ................................................... 70testosterone cypionate .................. 70testosterone enanthate ................. 70tetanus toxoid adsorbed .............. 77tetanus-diphtheria toxoids td............................................................................................ 78tetrabenazine ............................................... 49tetracycline hcl ........................................... 11TEVETEN HCT ......................................... 43THALOMID ...................................................... 23theophylline er ............................................ 87

107

Index

thioridazine hcl ........................................... 31thiotepa ................................................................. 22thiothixene ........................................................ 31thrivite 19 ............................................................ 95THYMOGLOBULIN ............................ 76tiagabine hcl .................................................. 12ticlopidine hcl ................................................ 41TILIA FE .............................................................. 54timolol maleate .............................. 44, 83tinidazole ................................................................ 7TIVICAY ............................................................... 34tizanidine hcl ................................................. 89tl-select .................................................................. 95TOBRADEX ................................................... 84tobramycin ................................................ 6, 82tobramycin sulfate .................................... 7tobramycin-dexamethasone............................................................................................ 84TODAY SPONGE ................................. 50tolazamide ........................................................ 37tolbutamide ...................................................... 37tolmetin sodium ........................................ 20tolterodine tartrate ................................ 67tolterodine tartrate er ........................ 67topiramate ......................................................... 13topotecan hcl ................................................ 28TORISEL ............................................................ 28torsemide ........................................................... 46TOUJEO SOLOSTAR .................... 39TRACLEER .................................................... 88tramadol hcl ........................................................ 5tramadol hcl er ............................................... 5tramadol hcl er (biphasic) .............. 5tramadol-acetaminophen ............... 5trandolapril ....................................................... 42trandolapril-verapamil hcl er............................................................................................ 43tranexamic acid ........................................ 40tranylcypromine sulfate ................. 15TRAVATAN Z .............................................. 84travoprost ........................................................... 84trazodone hcl ................................................ 14TREANDA ........................................................ 23TRECATOR ................................................... 22TRELSTAR MIXJECT .................... 28TRESIBA FLEXTOUCH .............. 39tretinoin ..................................................... 28, 62tretinoin (emollient) .............................. 62tretinoin microsphere ........................ 62TREXALL ........................................................... 24triadvance .......................................................... 95triamcinolone acetonide.................................................................... 56, 62, 88triamterene-hctz ....................................... 43triazolam .............................................................. 90

Index

tri-buffered aspirin ................................. 20TRIDERM .......................................................... 62TRI-ESTARYLLA ................................... 54trifluoperazine hcl .................................. 31trifluridine ............................................................ 82trihexyphenidyl hcl ................................ 29TRI-LEGEST FE ..................................... 54TRI-LINYAH ................................................... 54TRILYTE ............................................................. 65trimethobenzamide hcl .................. 17trimethoprim ....................................................... 8trimipramine maleate ........................ 17trinatal gt ............................................................. 95TRINESSA (28) ........................................ 54TRINTELLIX ...................................... 15, 16triple-vitamin/fluoride ........................ 96TRI-PREVIFEM ........................................ 54TRISENOX ...................................................... 28TRI-SPRINTEC ........................................ 54tri-vitamin/fluoride .................................. 96TRIVORA (28) ............................................ 54TROKENDI XR .......................................... 13tropicamide ...................................................... 82trospium chloride .................................... 67trospium chloride er ............................ 67TRUVADA ........................................................ 35TUSSLIN PEDIATRIC .................... 55TWINRIX ............................................................ 77TYKERB .............................................................. 28TYPHIM VI ....................................................... 79TYSABRI ............................................................ 49TYZEKA ............................................................... 33TYZINE ................................................................. 88UCERIS ................................................................ 69U-CORT ............................................................... 62ULESFIA ............................................................. 62ULORIC ................................................................ 19ultra tabs ............................................................. 95ULTRA-THIN II PEN NEEDLES............................................................................................ 80UNITHROID ................................................... 73UNITUXIN ......................................................... 28urea ............................................................................ 62urea nail film .................................................. 62URECHOLINE ............................................ 67ursodiol .................................................................. 64UTA ............................................................................ 67UTIRA-C .............................................................. 67UVADEX ............................................................. 24valacyclovir hcl .......................................... 33VALCYTE .......................................................... 32valganciclovir hcl .................................... 33valproate sodium .................................... 13valproic acid ................................................... 13valsartan .............................................................. 41

Index

valsartan-hydrochlorothiazide............................................................................................ 43vancomycin hcl ...................................... 7, 8VAQTA .................................................................. 77VARIVAX ............................................................ 77VARUBI ................................................................ 17VCF VAGINAL CONTRACEPTIVE .............................. 50VECTIBIX .......................................................... 28VELCADE ......................................................... 28VELIVET ............................................................. 54VEMAVITE-PRX 2 ............................... 95venlafaxine hcl ........................................... 16venlafaxine hcl er ................................... 16VENTAVIS ....................................................... 88VENTOLIN HFA ...................................... 87verapamil hcl ................................................ 45verapamil hcl er ........................................ 45VESICARE ...................................................... 67VESTURA ......................................................... 55VEXOL ................................................................... 84VICTRELIS ...................................................... 33VIDEX ..................................................................... 35VIENVA ................................................................ 55VIGAMOX ......................................................... 82VIIBRYD .............................................................. 14VIIBRYD STARTER PACK ..... 14VIMPAT ................................................................ 14VINACAL B ..................................................... 95vinblastine sulfate .................................. 28VINCASAR PFS ...................................... 28vinorelbine tartrate ............................... 28viorele ...................................................................... 55VIRACEPT ....................................................... 34VIRAMUNE ..................................................... 35VIREAD ................................................................ 35virt-advance .................................................... 95virt-phos 250 neutral ......................... 92virt-pn dha ......................................................... 95virt-select ............................................................ 95virt-vite gt ............................................................ 95VITAFOL-ONE ........................................... 95vitamin d .............................................................. 96vitamin d (cholecalciferol) .......... 96voriconazole ...................................... 18, 19VOTRIENT ...................................................... 28VRAYLAR ......................................................... 28VYFEMLA ......................................................... 55VYTORIN ........................................................... 47WAL-DRYL ALLERGY CHILDRENS ................................................. 85warfarin sodium ........................................ 40WELCHOL ....................................................... 47WERA ..................................................................... 55WOUND WASH SALINE ............ 62

108

Index

WYMZYA FE ................................................ 55XALKORI ............................................................ 28XARELTO ......................................................... 40XARELTO STARTER PACK............................................................................................ 40XELJANZ ........................................................... 20XENAZINE ....................................................... 49XGEVA .................................................................. 80XIFAXAN ................................................................ 8XOLAIR ................................................................ 88XTANDI ................................................................ 28XULANE .............................................................. 50XURIDEN .......................................................... 68XYREM ................................................................. 90YERVOY ............................................................. 28YF-VAX ................................................................. 79YONDELIS ...................................................... 28zafirlukast .......................................................... 86zaleplon ................................................................ 90ZALTRAP .......................................................... 28ZARAH .................................................................. 55ZATEAN-PN DHA ................................. 95ZAVESCA ......................................................... 63ZELBORAF ..................................................... 28ZEMPLAR ......................................................... 80ZENCHENT .................................................... 55ZENCHENT FE ........................................ 55ZENPEP .............................................................. 64ZETIA ...................................................................... 47ZIAGEN ................................................................ 35zidovudine ........................................................ 35zinc sulfate ....................................................... 92ziprasidone hcl ........................................... 32ZIRGAN ................................................................ 82zoledronic acid ........................................... 80ZOLINZA ............................................................ 28zolmitriptan ...................................................... 21zolpidem tartrate ..................................... 90zonisamide ...................................................... 12ZORTRESS .................................................... 76ZOSTAVAX .................................................... 76ZOVIA 1/50E (28) .................................. 55ZUBSOLV ............................................................. 6ZYFLO .................................................................... 86ZYFLO CR ....................................................... 86ZYMAXID ........................................................... 82ZYTIGA ................................................................. 28

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HCIC Exchange (Arizona) Formulary-CustomCat/Class · Comprehensive Formulary 2016 List of covered drugs ... formulary is very comprehensive and has many brand and generic drugs that