Kaiser Permanente Point-of-Service Drug Formulary with ... POS... · POS Formulary with Specialty Tier – Last revised 12/22/2015, 1 Kaiser Permanente Point-of-Service Drug Formulary

POS Formulary with Specialty Tier – Last revised 12/22/2015, 1

Kaiser Permanente Point-of-Service Drug Formulary with Specialty Drug Tier

For California Point-of-Service (POS) Plans*

Effective January 1, 2016

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION REGARDING THE DRUGS THAT ARE COVERED WHEN YOU PARTICIPATE IN OUR POS HEALTH INSURANCE PLAN(S) AND USE A MEDIMPACT PHARMACY. IF YOU BELONG TO OUR POS PLAN AND YOU INTEND TO FILL YOUR PRESCRIPTIONS AT A KAISER PERMANENTE PHARMACY, PLEASE VISIT KP.ORG/FORMULARY FOR DETAILS ON THE DRUGS COVERED THROUGH YOUR TIER 1 BENEFIT.

This formulary was updated on December 22, 2015, and is effective on January 1, 2016. For more recent information or other questions, please call MedImpact 24 hours a day, 7 days a week (closed holidays), at 1-800-788-2949. You can also view the Kaiser Permanente Point-of-Service (POS) Formulary with Specialty Drug Tier on our website at kp.org/kpic.

What is the Kaiser Permanente Point-of-Service (POS) Formulary with Specialty Drug Tier?

The Kaiser Permanente POS Formulary with Specialty Drug Tier is an open formulary of unrestricted drugs that are covered under your POS health insurance plan’s Tier 2 benefit. The formulary consists of generic, brand, and specialty drugs when you use a MedImpact pharmacy. Unless specifically excluded under your plan, all FDA-approved drugs are part of your plan’s open formulary.

What drugs are covered?

Kaiser Permanente will generally cover prescribed generic, brand-name, and specialty drugs listed on the Kaiser Permanente POS Formulary with Specialty Drug Tier as long as the drug is medically necessary, the prescription is filled at a MedImpact pharmacy, and other coverage rules are followed.


Additionally, your plan covers certain preventive drugs at no cost share when prescribed by a physician. Contraceptives for women, tobacco-cessation drugs, and certain over-the-counter drugs (such as aspirin, iron supplements, folic acid supplements, vitamin D, and oral fluoride supplements) are covered at no cost share regardless of the drug tier indicated on the Kaiser Permanente POS Formulary with Specialty Drug Tier. For more information about coverage of preventive drugs, please refer to the “Preventive Care under the General Benefits” section of your Certificate of Insurance.

What drugs are not covered?

Drugs not listed on the Kaiser Permanente POS Formulary with Specialty Drug Tier are not covered.

Are there any restrictions on the drugs covered on the Kaiser Permanente POS Formulary with Specialty Drug Tier?

There are no step therapy or prior authorization requirements for any drugs covered under your plan. However, for certain drugs, Kaiser Permanente may limit the amount of the drug dispensed to a certain days’ supply. Generic and brand drugs are limited to 100 days of supply and specialty drugs are limited to 30 days of supply.

What is a generic drug?

A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Under your POS Plan, you will pay different amounts for preferred generic drugs and non-preferred generic drugs. Preferred drugs cost you less than non-preferred drugs.

What is a brand-name drug?

Brand-name drugs are usually manufactured and sold by the drug company that originally researched and developed the drug. When the patent on a brand-name drug expires, other drug companies may manufacture and sell an FDA-approved generic version of the drug with the same active ingredient(s) at lower prices.

Under your POS Plan, you will pay different amounts for preferred brand drugs and non-preferred brand drugs. Preferred drugs cost you less than non-preferred drugs.

If you request a brand-name drug when a generic drug is prescribed, you may be responsible for paying the brand-name copay plus the difference in cost between the generic drug and the brand-name drug. Please see your Certificate of Insurance for details.


What is a specialty drug?

Specialty drugs are high-cost prescription medications that are used to treat complex and chronic conditions, such as multiple sclerosis, rheumatoid arthritis, and hepatitis C. Specialty drugs often require special handling, administration, or monitoring. Under your POS Plan, you will pay different amounts for preferred specialty drugs and non-preferred specialty drugs. Preferred drugs cost you less than non-preferred drugs.

What drugs are eligible to be mailed from the mail-order pharmacy?

This drug formulary only applies to drugs obtained at a MedImpact retail pharmacy. There is no mail-order pharmacy coverage available through MedImpact pharmacies. Mail-order pharmacy coverage is provided by the Kaiser Permanente mail-order pharmacy. Please refer to your Evidence of Coverage or visit kp.org/formulary for details of this benefit.

Kaiser Permanente POS Formulary with Specialty Drug Tier

The most current drug formulary list begins on page 4. It provides information about the drugs covered by Kaiser Permanente. All dosage forms and strengths for a particular drug may not appear on the formulary. Some drugs have multiple dosage forms. In such cases, some dosages may be listed on the formulary and others may not. In cases where a particular drug has multiple dosage forms and/or strengths, the drug may be associated with multiple drug tiers. You can call MedImpact at 1-800-788-2949 to confirm which cost-sharing tier applies for the specific dosage form and strength you want.

Kaiser Permanente may add or remove drugs from the Kaiser Permanente POS Formulary with Specialty Drug Tier during the year. These changes to the formulary are based on new information or new drugs that become available.

Tier designations

The table below identifies drugs based on their drug category – preferred generic (Tier 1), preferred brand (Tier 2), non-preferred generic or brand (Tier 3), preferred specialty (Tier 4), or non-preferred specialty (Tier 5). Typically, you will pay a copay for generic and brand drugs and a coinsurance for specialty drugs as shown in your Schedule of Coverage. Certain preventive drugs, however, are covered at no cost to you. Those drugs are indicated with a “+” (for example, 1+ or 2+).

*Kaiser Foundation Health Plan, Inc. (KFHP), underwrites the HMO portion of the Kaiser Permanente POS Plan and Kaiser Permanente Insurance Company (KPIC), a subsidiary of KFHP, underwrites the PPO and Out-of-Network portions of the Kaiser Permanente POS Plan.


DRUG CATEGORY & NAME DRUG TIER ALLERGY

2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS CLARINEX-D 12 HOUR 2 SEMPREX-D 2

ALLERGENIC EXTRACTS, THERAPEUTICS ASPERGILLUS FUMIGATUS 2 GRASTEK 2 ORALAIR 2 RAGWITEK 2

ANTIHISTAMINES - 1ST GENERATION CARBINOXAMINE MALEATE 1 CLEMASTINE FUMARATE 1, 2 CYPROHEPTADINE HCL 1 DIPHENHYDRAMINE HCL 1 HYDROXYZINE HCL 1 HYDROXYZINE PAMOATE 1, 2 KARBINAL ER 2 PROMETHAZINE HCL 1, 2 VISTARIL 2

ANTIHISTAMINES - 2ND GENERATION CETIRIZINE HCL 1 CLARINEX 2 DESLORATADINE 1 FEXOFENADINE HCL 1 LEVOCETIRIZINE DIHYDROCHLORIDE 1 XYZAL 2 ZYRTEC 2

NASAL ANTIHISTAMINE ASTEPRO 2 AZELASTINE HCL 1 OLOPATADINE HCL 1 PATANASE 2

NASAL ANTIHISTAMINE & ANTI-INFLAM. STEROID COMB. DYMISTA 2

NASAL ANTI-INFLAMMATORY STEROIDS BECONASE AQ 2 BUDESONIDE 1 FLUNISOLIDE 1 FLUTICASONE PROPIONATE 1 NASONEX 2 OMNARIS 2 QNASL 2 QNASL CHILDREN 2 RHINOCORT AQUA 2 TRIAMCINOLONE ACETONIDE 1 VERAMYST 2 ZETONNA 2


DRUG CATEGORY & NAME DRUG TIER ANTIEMESIS/ANTIVERTIGO

ANTIEMETIC/ANTIVERTIGO AGENTS AKYNZEO 2 ANTIVERT 2 ANZEMET 2 CESAMET 2 COMPAZINE 2 DEXTROSE/FRUCTOSE/SODIUM CIT 1 DICLEGIS 2 DRONABINOL 1 EMEND 2 GRANISETRON HCL 1 MARINOL 2 MECLIZINE HCL 1 ONDANSETRON 1 ONDANSETRON HCL 1 PROCHLORPERAZINE 1 PROCHLORPERAZINE MALEATE 1 PROMETHAZINE HCL 1 SANCUSO 2 TIGAN 2 TRANSDERM-SCOP 2 TRIMETHOBENZAMIDE HCL 1 ZOFRAN 2 ZOFRAN ODT 2 ZUPLENZ 2

ASTHMA AND COPD 5-LIPOXYGENASE INHIBITORS

ZILEUTON 4 ZYFLO 4 ZYFLO CR 4

ADRENERGIC AGENTS,CATECHOLAMINES EPINEPHRINE 1

BETA-ADRENERGIC AGENTS ALBUTEROL SULFATE 1 ARCAPTA NEOHALER 2 BROVANA 2 FORADIL 2 LEVALBUTEROL HCL 1 METAPROTERENOL SULFATE 2 PERFOROMIST 2 PROAIR HFA 2 PROAIR RESPICLICK 2 PROVENTIL HFA 2 SEREVENT DISKUS 2 STRIVERDI RESPIMAT 2 TERBUTALINE SULFATE 1


DRUG CATEGORY & NAME DRUG TIER VENTOLIN HFA 2 VOSPIRE ER 2 XOPENEX 2 XOPENEX CONCENTRATE 2 XOPENEX HFA 2

BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONS ANORO ELLIPTA 2 COMBIVENT RESPIMAT 2 IPRATROPIUM/ALBUTEROL SULFATE 1 STIOLTO RESPIMAT 2

BETA-ADRENERGIC AND GLUCOCORTICOID COMBINATIONS ADVAIR DISKUS 2 ADVAIR HFA 2 BREO ELLIPTA 2 DULERA 2 SYMBICORT 2

GENERAL BRONCHODILATOR AGENTS ATROVENT HFA 2 INCRUSE ELLIPTA 2 IPRATROPIUM BROMIDE 1 SPIRIVA 2 SPIRIVA RESPIMAT 2 TUDORZA PRESSAIR 2

GLUCOCORTICOIDS, ORALLY INHALED AEROSPAN 2 ALVESCO 2 ARNUITY ELLIPTA 2 ASMANEX 2 ASMANEX HFA 2 BUDESONIDE 1 FLOVENT DISKUS 2 FLOVENT HFA 2 PULMICORT 2 PULMICORT FLEXHALER 2 QVAR 2

LEUKOTRIENE RECEPTOR ANTAGONISTS ACCOLATE 2 MONTELUKAST SODIUM 1 SINGULAIR 2 ZAFIRLUKAST 1

MAST CELL STABILIZERS CROMOLYN SODIUM 1, 2, 4 GASTROCROM 4

MONOCLONAL ANTIBODIES TO IMMUNOGLOBULIN E(IGE) OMALIZUMAB 4 XOLAIR 4

PHOSPHODIESTERASE-4 (PDE4) INHIBITORS


DRUG CATEGORY & NAME DRUG TIER DALIRESP 2

RESPIRATORY AIDS,DEVICES,EQUIPMENT ACE AEROSOL CLOUD ENHANCER 2 AEROBIKA 2 AEROCHAMBER MINI 2 AEROCHAMBER MV 2 AEROCHAMBER PLUS FLOW-VU 2 AEROCHAMBER PLUS Z STAT 2 AEROCHAMBER WITH FLOWSIGNAL 2 AEROCHAMBER Z-STAT PLUS 2 AEROECLIPSE 2 AEROECLIPSE II 2 AEROGEAR ASTHMA ACTION KIT 2 AERONEB GO NEBULISER 2 AEROTRACH PLUS 2 ALTERA NEBULIZER 2 ASTHMAPACK CHILDREN'S 2 BABY NEBULIZER 2 BREATHERITE 2 BREATHRITE 2 COMPACT SPACE CHAMBER PLUS 2 COMP-AIR ELITE COMPRESSOR SYST 2 COMP-AIR NEBULIZER COMPRESSOR 2 DEVILBISS PULMO-AIDE 2 DEVILBISS PULMONEB LT COMP-NEB 2 DEVILBISS TRAVELER 2 EASIVENT 2 ERAPID NEBULIZER 2 E-Z SPACER 2 FLEXICHAMBER 2 FLUTTER 2 INNOSPIRE DELUXE 2 INNOSPIRE ELEGANCE 2 INNOSPIRE ESSENCE 2 INNOSPIRE MINI 2 INSPIRACHAMBER 2 INSPIRATION 2 INSPIRATION ELITE 2 LC D NEBULIZER SET 2 LC PLUS 2 LC SPRINT NEBULIZER 2 LC STAR 2 LITEAIRE 2 LITETOUCH 2 MICRO ELITE 2 MICRO PLUS 2 MICROCHAMBER 2


DRUG CATEGORY & NAME DRUG TIER MICROSPACER 2 MINI PLUS NEBULIZER 2 MINIELITE 2 MINI-WRIGHT PEAK FLOW METER 2 MONAGHAN Z STAT 2 NASONEB NASAL NEBULIZER 2 OPTICHAMBER 2 OPTICHAMBER DIAMOND 2 PARI LC SPRINT SINUS 2 PARI SINUS AEROSOL SYSTEM 2 PFLEX TRAINER 2 POCKET CHAMBER 2 PRIMEAIRE 2 PROCHAMBER 2 PRODIGY MINI-MIST 2 PRONEB ULTRA II 2 PROVENT 2 PULMO-AIDE 2 QUAKE 2 RITEFLO 2 SAMI THE SEAL 2 SIDESTREAM 2 SIDESTREAM NEBULIZER 2 SIDESTREAM PLUS 2 SILICONE MASK 2 SINUSTAR 2 SPACE CHAMBER PLUS 2 SUNRISE COMPRESSOR-NEBULIZER 2 THRESHOLD IMT 2 THRESHOLD PEP 2 TREK S COMBO PACK 2 TREK S COMPACT COMPRESSOR 2 TRUZONE PEAK FLOW METER 2 VIOS AEROSOL DELIVERY SYSTEM 2 VORTEX 2 VORTEX VHC FROG MASK 2 VORTEX VHC LADYBUG MASK 2

XANTHINES CAFFEINE CITRATED 1 ELIXOPHYLLIN 2 THEO-24 2 THEOPHYLLINE 2 THEOPHYLLINE ANHYDROUS 1

AUTONOMIC NERVOUS SYSTEM DISORDERS ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS

MEMANTINE HCL 1 NAMENDA 2


DRUG CATEGORY & NAME DRUG TIER NAMENDA XR 2

ALZHEIMER'S THX,NMDA RECEPT ANTAG & CHOLINES INHIB NAMZARIC 2

CHOLINESTERASE INHIBITORS ARICEPT 2 DONEPEZIL HCL 1 EXELON 2 GALANTAMINE HBR 1 GALANTAMINE HYDROBROMIDE 2 MESTINON 2 PYRIDOSTIGMINE BROMIDE 1 RAZADYNE 2 RAZADYNE ER 2 RIVASTIGMINE TARTRATE 1

BEHAVIORAL HEALTH - ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS

MIRTAZAPINE 1 REMERON 2

MAOIS - NON-SELECTIVE & IRREVERSIBLE MARPLAN 2 NARDIL 2 PARNATE 2 PHENELZINE SULFATE 1 TRANYLCYPROMINE SULFATE 1

NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) APLENZIN 2 BUPROPION HCL 1 FORFIVO XL 2 WELLBUTRIN 2 WELLBUTRIN SR 2 WELLBUTRIN XL 2

SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) BRISDELLE 2 CELEXA 2 CITALOPRAM HYDROBROMIDE 1 ESCITALOPRAM OXALATE 1 FLUOXETINE HCL 1, 2 FLUVOXAMINE MALEATE 1 LEXAPRO 2 PAROXETINE HCL 1 PAXIL 2 PAXIL CR 2 PEXEVA 2 PROZAC 2 PROZAC WEEKLY 2 SARAFEM 2 SERTRALINE HCL 1


DRUG CATEGORY & NAME DRUG TIER ZOLOFT 2

SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) NEFAZODONE HCL 1, 2 OLEPTRO ER 2 TRAZODONE HCL 1

SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) CYMBALTA 2 DESVENLAFAXINE ER 2 DESVENLAFAXINE FUMARATE ER 2 DULOXETINE HCL 1, 2 EFFEXOR XR 2 FETZIMA 2 IRENKA 2 KHEDEZLA 2 PRISTIQ ER 2 VENLAFAXINE HCL 1 VENLAFAXINE HCL ER 2

SSRI & 5HT1A PARTIAL AGONIST ANTIDEPRESSANT VIIBRYD 2

SSRI & SEROTONIN RECEPTOR MODULATOR ANTIDEPRESSANT BRINTELLIX 2

TRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNS CHLORDIAZEPOXIDE-AMITRIPTYLINE 2

TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINE COMBINATNS PERPHENAZINE-AMITRIPTYLINE 2

TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB AMITRIPTYLINE HCL 1 AMOXAPINE 2 ANAFRANIL 2 CLOMIPRAMINE HCL 1 DESIPRAMINE HCL 1 DOXEPIN HCL 1, 2 IMIPRAMINE HCL 1 IMIPRAMINE PAMOATE 1 MAPROTILINE HCL 2 NORPRAMIN 2 NORTRIPTYLINE HCL 1, 2 PAMELOR 2 PROTRIPTYLINE HCL 1 SURMONTIL 2 TOFRANIL 2 TOFRANIL-PM 2

BEHAVIORAL HEALTH - OTHER ADRENERGICS, AROMATIC, NON-CATECHOLAMINE

ADDERALL 2 ADDERALL XR 2 DESOXYN 2


DRUG CATEGORY & NAME DRUG TIER DEXEDRINE 2 DEXTROAMPHETAMINE SULFATE 1 DEXTROAMPHETAMINE/AMPHETAMINE 1 EVEKEO 2 METHAMPHETAMINE HCL 1 PROCENTRA 2 VYVANSE 2 ZENZEDI 2

ANTI-ALCOHOLIC PREPARATIONS ACAMPROSATE CALCIUM 1 ANTABUSE 2 DISULFIRAM 1

ANTI-ANXIETY DRUGS ALPRAZOLAM 1 ALPRAZOLAM INTENSOL 2 ATIVAN 2 BUSPIRONE HCL 1 CHLORDIAZEPOXIDE HCL 1 CLORAZEPATE DIPOTASSIUM 1 DIAZEPAM 1, 2 LORAZEPAM 1 LORAZEPAM INTENSOL 2 MEPROBAMATE 1 OXAZEPAM 1 TRANXENE T-TAB 2 VALIUM 2 XANAX 2 XANAX XR 2

ANTI-MANIA DRUGS EQUETRO 2 LITHIUM 2 LITHIUM CARBONATE 1, 2 LITHOBID 2

ANTI-NARCOLEPSY & ANTI-CATAPLEXY,SEDATIVE-TYPE AGT SODIUM OXYBATE 4 XYREM 4

ANTIPSYCH,DOPAMINE ANTAG.,DIPHENYLBUTYLPIPERIDINES ORAP 2

ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED ABILIFY 2 ARIPIPRAZOLE 1 REXULTI 2

ANTIPSYCHOTICS, DOPAMINE & SEROTONIN ANTAGONISTS ADASUVE 2 LOXAPINE SUCCINATE 1

ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG CLOZAPINE 1


DRUG CATEGORY & NAME DRUG TIER CLOZAPINE ODT 2 CLOZARIL 2 FANAPT 2 FAZACLO 2 GEODON 2 INVEGA 2 LATUDA 2 OLANZAPINE 1 QUETIAPINE FUMARATE 1 RISPERDAL 2 RISPERDAL M-TAB 2 RISPERIDONE 1 SAPHRIS 2 SEROQUEL 2 SEROQUEL XR 2 VERSACLOZ 2 ZIPRASIDONE HCL 1 ZYPREXA 2 ZYPREXA ZYDIS 2

ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS, THIOXANTHENES THIOTHIXENE 1

ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES HALOPERIDOL 1 HALOPERIDOL LACTATE 1

ANTI-PSYCHOTICS,PHENOTHIAZINES CHLORPROMAZINE HCL 1 FLUPHENAZINE HCL 1, 2 PERPHENAZINE 1 THIORIDAZINE HCL 1 TRIFLUOPERAZINE HCL 1

BARBITURATES BUTISOL SODIUM 2 PHENOBARBITAL 1, 2 SECONAL SODIUM 2

HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTS HETLIOZ 4 ROZEREM 2 TASIMELTEON 4

MONOAMINE OXIDASE(MAO) INHIBITORS EMSAM 2

NARCOLEPSY AND SLEEP DISORDER THERAPY AGENTS MODAFINIL 1 NUVIGIL 2 PROVIGIL 2

NARCOTIC ANTAGONISTS NALTREXONE HCL 1 REVIA 2


DRUG CATEGORY & NAME DRUG TIER SEDATIVE-HYPNOTICS,NON-BARBITURATE

AMBIEN 2 AMBIEN CR 2 BELSOMRA 2 EDLUAR 2 ESTAZOLAM 1 ESZOPICLONE 1 FLURAZEPAM HCL 2 HALCION 2 INTERMEZZO 2 LUNESTA 2 MIDAZOLAM HCL 1 RESTORIL 2 SILENOR 2 SONATA 2 TEMAZEPAM 1 TRIAZOLAM 1 ZALEPLON 1 ZOLPIDEM TARTRATE 1 ZOLPIMIST 2

SSRI &ANTIPSYCH,ATYP,DOPAMINE&SEROTONIN ANTAG COMB OLANZAPINE/FLUOXETINE HCL 1 SYMBYAX 2

TX FOR ADHD - SELECTIVE ALPHA-2A RECEPTOR AGONIST CLONIDINE HCL 1 GUANFACINE HCL 1 INTUNIV 2 KAPVAY 2

TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY APTENSIO XR 2 CONCERTA 2 DAYTRANA 2 DEXMETHYLPHENIDATE HCL 1 FOCALIN 2 FOCALIN XR 2 METADATE CD 2 METHYLIN 2 METHYLPHENIDATE ER 2 METHYLPHENIDATE HCL 1 QUILLIVANT XR 2 RITALIN 2 RITALIN LA 2

TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE STRATTERA 2

CARDIOVASCULAR DISEASE - ARRHYTHMIA ANTIARRHYTHMICS

AMIODARONE HCL 1


DRUG CATEGORY & NAME DRUG TIER CORDARONE 2 DISOPYRAMIDE PHOSPHATE 1 FLECAINIDE ACETATE 1 MEXILETINE HCL 1 MULTAQ 2 NORPACE 2 NORPACE CR 2 PROPAFENONE HCL 1 QUINIDINE GLUCONATE 1 QUINIDINE SULFATE 1, 2 RYTHMOL 2 RYTHMOL SR 2 TIKOSYN 2

CARDIOVASCULAR DISEASE - CARDIAC STIMULANT DIGITALIS GLYCOSIDES

DIGOXIN 1, 2 LANOXIN 2

CARDIOVASCULAR DISEASE - HYPERTENSION ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION

AMLODIPINE BESYLATE/BENAZEPRIL 1 LOTREL 2 PRESTALIA 2 TARKA 2 TRANDOLAPRIL/VERAPAMIL HCL 1

ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC ACCURETIC 2 BENAZEPRIL/HYDROCHLOROTHIAZIDE 1 CAPTOPRIL-HYDROCHLOROTHIAZIDE 2 ENALAPRIL/HYDROCHLOROTHIAZIDE 1 FOSINOPRIL/HYDROCHLOROTHIAZIDE 1 LISINOPRIL/HYDROCHLOROTHIAZIDE 1 LOTENSIN HCT 2 MOEXIPRIL/HYDROCHLOROTHIAZIDE 1 QUINAPRIL/HYDROCHLOROTHIAZIDE 1 VASERETIC 2 ZESTORETIC 2

ALPHA/BETA-ADRENERGIC BLOCKING AGENTS CARVEDILOL 1 COREG 2 COREG CR 2 LABETALOL HCL 1 TRANDATE 2

ALPHA-ADRENERGIC BLOCKING AGENTS CARDURA 2 CARDURA XL 2 DIBENZYLINE 2 DOXAZOSIN MESYLATE 1


DRUG CATEGORY & NAME DRUG TIER MINIPRESS 2 PHENOXYBENZAMINE HCL 1 PRAZOSIN HCL 1 TERAZOSIN HCL 1

ANGIOTEN.RECEPTR ANTAG./CAL.CHANL BLKR/THIAZIDE CB AMLODIPINE/VALSARTAN/HCTHIAZID 1 EXFORGE HCT 2 TRIBENZOR 2

ANGIOTENSIN RECEPTOR ANTAG./THIAZIDE DIURETIC COMB ATACAND HCT 2 AVALIDE 2 BENICAR HCT 2 CANDESARTAN/HYDROCHLOROTHIAZID 1 DIOVAN HCT 2 EDARBYCLOR 2 HYZAAR 2 IRBESARTAN/HYDROCHLOROTHIAZIDE 1 LOSARTAN/HYDROCHLOROTHIAZIDE 1 MICARDIS HCT 2 TELMISARTAN/HYDROCHLOROTHIAZID 1 TEVETEN HCT 2 VALSARTAN/HYDROCHLOROTHIAZIDE 1

ANGIOTENSIN RECEPTOR ANTGNST & CALC.CHANNEL BLOCKR AMLODIPINE/VALSARTAN 1 AZOR 2 EXFORGE 2 TELMISARTAN/AMLODIPINE 1 TWYNSTA 2

ANTIHYPERTENSIVES, ACE INHIBITORS ACCUPRIL 2 ACEON 2 ALTACE 2 BENAZEPRIL HCL 1 CAPTOPRIL 1 ENALAPRIL MALEATE 1 EPANED 2 FOSINOPRIL SODIUM 1 LISINOPRIL 1 LOTENSIN 2 MAVIK 2 MOEXIPRIL HCL 1 PERINDOPRIL ERBUMINE 1 PRINIVIL 2 QUINAPRIL HCL 1 RAMIPRIL 1 TRANDOLAPRIL 1 VASOTEC 2


DRUG CATEGORY & NAME DRUG TIER ZESTRIL 2

ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST ATACAND 2 AVAPRO 2 BENICAR 2 CANDESARTAN CILEXETIL 1 COZAAR 2 DIOVAN 2 EDARBI 2 EPROSARTAN MESYLATE 2 IRBESARTAN 1 LOSARTAN POTASSIUM 1 MICARDIS 2 TELMISARTAN 1 VALSARTAN 1

ANTIHYPERTENSIVES, GANGLIONIC BLOCKERS MECAMYLAMINE HCL 4 VECAMYL 4

ANTIHYPERTENSIVES, MISCELLANEOUS DEMSER 2

ANTIHYPERTENSIVES, SYMPATHOLYTIC CATAPRES 2 CATAPRES-TTS 1 2 CATAPRES-TTS 2 2 CATAPRES-TTS 3 2 CLONIDINE 1 CLONIDINE HCL 1 CLORPRES 2 GUANFACINE HCL 1 METHYLDOPA 1 METHYLDOPA-HYDROCHLOROTHIAZIDE 2 RESERPINE 2 TENEX 2

ANTIHYPERTENSIVES, VASODILATORS HYDRALAZINE HCL 1 MINOXIDIL 1

BETA-ADRENERGIC BLOCKING AGENTS ACEBUTOLOL HCL 1 ATENOLOL 1 BETAPACE 2 BETAPACE AF 2 BETAXOLOL HCL 1 BISOPROLOL FUMARATE 1 BYSTOLIC 2 CORGARD 2 HEMANGEOL 2 INDERAL LA 2


DRUG CATEGORY & NAME DRUG TIER INDERAL XL 2 INNOPRAN XL 2 LEVATOL 2 LOPRESSOR 2 METOPROLOL SUCCINATE 1 METOPROLOL TARTRATE 1 NADOLOL 1 PINDOLOL 1 PROPRANOLOL HCL 1, 2 SECTRAL 2 SOTALOL HCL 1 SOTYLIZE 2 TENORMIN 2 TIMOLOL MALEATE 2 TOPROL XL 2 ZEBETA 2

BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & RELATED ATENOLOL/CHLORTHALIDONE 1 BISOPROLOL FUMARATE/HCTZ 1 CORZIDE 2 DUTOPROL 2 LOPRESSOR HCT 2 METOPROLOL/HYDROCHLOROTHIAZIDE 1 NADOLOL/BENDROFLUMETHIAZIDE 1 PROPRANOLOL-HYDROCHLOROTHIAZID 2 TENORETIC 100 2 TENORETIC 50 2 ZIAC 2

CALCIUM CHANNEL BLOCKING AGENTS ADALAT CC 2 AMLODIPINE BESYLATE 1 CALAN 2 CALAN SR 2 CARDENE SR 2 CARDIZEM 2 CARDIZEM CD 2 CARDIZEM LA 2 DILTIAZEM HCL 1 FELODIPINE 1 FELODIPINE ER 2 ISRADIPINE 1 NICARDIPINE HCL 1 NIFEDIPINE 1 NIMODIPINE 1 NISOLDIPINE 1, 2 NORVASC 2 NYMALIZE 2


DRUG CATEGORY & NAME DRUG TIER PROCARDIA 2 PROCARDIA XL 2 SULAR 2 TIAZAC 2 VERAPAMIL HCL 1, 2 VERELAN 2 VERELAN PM 2

LOOP DIURETICS BUMETANIDE 1 DEMADEX 2 EDECRIN 2 FUROSEMIDE 1, 2 LASIX 2 TORSEMIDE 1

OSMOTIC DIURETICS RESECTISOL 2

POTASSIUM SPARING DIURETICS ALDACTONE 2 AMILORIDE HCL 1 DYRENIUM 2 EPLERENONE 1 INSPRA 2 SPIRONOLACTONE 1

POTASSIUM SPARING DIURETICS IN COMBINATION ALDACTAZIDE 2 AMILORIDE/HYDROCHLOROTHIAZIDE 1 DYAZIDE 2 MAXZIDE 2 MAXZIDE-25 MG 2 SPIRONOLACT/HYDROCHLOROTHIAZID 1 TRIAMTERENE/HYDROCHLOROTHIAZID 1 TRIAMTERENE-HYDROCHLOROTHIAZID 2

PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR ADEMPAS 4 RIOCIGUAT 4

PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASE T5 INHIB ADCIRCA 4 REVATIO 2, 4 SILDENAFIL CITRATE 1, 4 TADALAFIL 4

PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST AMBRISENTAN 4 BOSENTAN 4 LETAIRIS 4 MACITENTAN 4 OPSUMIT 4 TRACLEER 4


DRUG CATEGORY & NAME DRUG TIER PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE

ILOPROST TROMETHAMINE 4 ORENITRAM ER 4 TREPROSTINIL DIOLAMINE 4 TYVASO 2 VENTAVIS 4

RENIN INHIBITOR, DIRECT TEKTURNA 2

RENIN INHIBITOR, DIRECT & CALCIUM CHANNEL BLOCKER TEKAMLO 2

RENIN INHIBITOR, DIRECT/THIAZIDE DIURETIC COMB TEKTURNA HCT 2

THIAZIDE AND RELATED DIURETICS CHLOROTHIAZIDE 1, 2 CHLORTHALIDONE 2 DIURIL 2 HYDROCHLOROTHIAZIDE 1 INDAPAMIDE 1 METHYCLOTHIAZIDE 2 METOLAZONE 1 MICROZIDE 2

VASODILATORS, COMBINATION BIDIL 2

CARDIOVASCULAR DISEASE - LIPID IRREGULARITY ANTIHYPERLIP.HMG COA REDUCT INHIB&CHOLEST.AB.INHIB

LIPTRUZET 2 VYTORIN 2

ANTIHYPERLIPIDEMIC - APO B-100 SYNTHESIS INHIBITOR KYNAMRO 4 MIPOMERSEN SODIUM 4

ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS ALTOPREV 2 ATORVASTATIN CALCIUM 1 CRESTOR 2 FLUVASTATIN SODIUM 1 LESCOL 2 LESCOL XL 2 LIPITOR 2 LIVALO 2 LOVASTATIN 1 PRAVACHOL 2 PRAVASTATIN SODIUM 1 SIMVASTATIN 1 ZOCOR 2

ANTIHYPERLIPIDEMIC - MTP INHIBITOR JUXTAPID 2, 4 LOMITAPIDE MESYLATE 4


DRUG CATEGORY & NAME DRUG TIER ANTIHYPERLIPIDEMIC - PCSK9 INHIBITORS

PRALUENT PEN 2 PRALUENT SYRINGE 2

ANTIHYPERLIPIDEMIC-HMG COA REDUCTASE INHIB.&NIACIN ADVICOR 2 SIMCOR 2

BILE SALT SEQUESTRANTS CHOLESTYRAMINE (WITH SUGAR) 1 CHOLESTYRAMINE/ASPARTAME 1 COLESTID 2 COLESTIPOL HCL 1 QUESTRAN 2 QUESTRAN LIGHT 2 WELCHOL 2

LIPOTROPICS ANTARA 2 FENOFIBRATE 1, 2 FENOFIBRATE NANOCRYSTALLIZED 1 FENOFIBRATE,MICRONIZED 1 FENOFIBRIC ACID 2 FENOFIBRIC ACID (CHOLINE) 1 FENOGLIDE 2 FIBRICOR 2 GEMFIBROZIL 1 LIPOCHOL PLUS 2 LIPOFEN 2 LOFIBRA 2 LOPID 2 LOVAZA 2 NIACIN 1 NIACOR 2 NIASPAN 2 OMEGA-3 ACID ETHYL ESTERS 1 TRICOR 2 TRIGLIDE 2 TRILIPIX 2 VASCAZEN 2 VASCEPA 2 VAYAROL 2 ZETIA 2

CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS ADRENERGIC VASOPRESSOR AGENTS

DROXIDOPA 4 MIDODRINE HCL 1 NORTHERA 4

ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITOR COMB(ARNI) ENTRESTO 2


DRUG CATEGORY & NAME DRUG TIER ANTIANGINAL & ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMIC

RANEXA 2 ANTIANGINAL, HEART RATE REDUCING, I(F) INHIBITOR

CORLANOR 2 ANTIHYPERLIP - HMG-COA&CALCIUM CHANNEL BLOCKER CB

AMLODIPINE/ATORVASTATIN 1 CADUET 2

CARDIOVASCULAR DISEASE - VASODILATION VASODILATORS,CORONARY

DILATRATE-SR 2 ISORDIL 2 ISORDIL TITRADOSE 2 ISOSORBIDE DINITRATE 1, 2 ISOSORBIDE MONONITRATE 1 NITRO-BID 2 NITRO-DUR 2 NITROGLYCERIN 1, 2 NITROLINGUAL 2 NITROMIST 2 NITROSTAT 2

VASODILATORS,PERIPHERAL ERGOLOID MESYLATES 2 ISOXSUPRINE HCL 1, 2

CONTRACEPTION/OXYTOCICS CONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC

NUVARING 2+ CONTRACEPTIVES,IMPLANTABLE

NEXPLANON 2+ CONTRACEPTIVES,INTRAVAGINAL

CONCEPTROL 2+ GYNOL II 2+ TODAY CONTRACEPTIVE SPONGE 2+ VCF 2+

CONTRACEPTIVES,ORAL BEYAZ 2+ BREVICON 2+ CYCLESSA 2+ DESOG-E.ESTRADIOL/E.ESTRADIOL 1+ DESOGEN 2+ DESOGESTREL-ETHINYL ESTRADIOL 1+ ELLA 2+ ESTROSTEP FE 2+ ETHINYL ESTRADIOL/DROSPIRENONE 1+ ETHYNODIOL D-ETHINYL ESTRADIOL 1+ FEMCON FE 2+ GENERESS FE 2+ LEVONORGESTREL 1+


DRUG CATEGORY & NAME DRUG TIER LEVONORGESTREL-ETHIN ESTRADIOL 1+ L-NORGEST/E.ESTRADION-E.ESTRAD 1+ LO LOESTRIN FE 2+ LOESTRIN 2+ LOESTRIN FE 2+ LOSEASONIQUE 2+ MINASTRIN 24 FE 2+ MIRCETTE 2+ MODICON 2+ NATAZIA 2+ NECON 2+ NORETH-ETHINYL ESTRADIOL/IRON 1+ NORETHINDRONE 1+ NORETHINDRONE AC-ETH ESTRADIOL 1+ NORETHINDRONE-E.ESTRADIOL-IRON 1+ NORETHINDRONE-ETHINYL ESTRAD 1+ NORGESTIMATE-ETHINYL ESTRADIOL 1+ NORGESTREL-ETHINYL ESTRADIOL 1+ NORINYL 1+35 2+ NORINYL 1+50 2+ NOR-Q-D 2+ OGESTREL 2+ ORTHO MICRONOR 2+ ORTHO TRI-CYCLEN 2+ ORTHO TRI-CYCLEN LO 2+ ORTHO-CEPT 2+ ORTHO-CYCLEN 2+ ORTHO-NOVUM 2+ OVCON-35 2+ PLAN B ONE-STEP 2+ QUARTETTE 2+ SAFYRAL 2+ SEASONIQUE 2+ TRI-NORINYL 2+ YASMIN 28 2+ YAZ 2+ ZOVIA 1-50E 2+

CONTRACEPTIVES,TRANSDERMAL ORTHO EVRA 2+ XULANE 2+

DIAPHRAGMS/CERVICAL CAP CAYA CONTOURED 2+ FEMCAP 2+ WIDE SEAL DIAPHRAGM 2+

OXYTOCICS CERVIDIL 2 METHYLERGONOVINE MALEATE 1


DRUG CATEGORY & NAME DRUG TIER PREPIDIL 2 PROSTIN E2 VAGINAL SUPPOSITORY 2

COUGH AND COLD 1ST GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS

PHENYLEPHRINE HCL/PROMETH HCL 1 PHENYLEPHRINE/CHLORPHENIRAMINE 1

1ST GEN ANTIHIST-DECONGEST-ANTICHOLINERGIC COMB RESPA A.R. 2

ANTITUSSIVES,NON-NARCOTIC BENZONATATE 1 TESSALON PERLE 2 ZONATUSS 2

NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST PROMETHAZINE VC-CODEINE 2 PROMETHAZINE/PHENYLEPH/CODEINE 1 PSEUDOEPHED/HYDROCODONE/CPM 1 ZUTRIPRO 2

NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT COMB HYCOFENIX 2

NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE HYDROCODONE/CHLORPHEN P-STIREX 1 PROMETHAZINE HCL/CODEINE 1 TUSSICAPS 2 TUSSIONEX 2 TUZISTRA XR 2 VITUZ 2

NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMB. HYDROCODONE BIT/HOMATROP ME-BR 1

NARCOTIC ANTITUSSIVE-DECONGESTANT COMBINATIONS REZIRA 2

NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION FLOWTUSS 2 OBREDON 2

NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST DM/PHENYLEPH/CHLORPHENIRAMINE 1 D-METHORPHAN HB/P-EPD HCL/BPM 1

NON-NARC ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB. PROMETHAZINE/DEXTROMETHORPHAN 1

NON-NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT CMB TUSNEL PEDIATRIC 2

NOSE PREPARATIONS, VASOCONSTRICTORS (RX) ADRENALIN CHLORIDE 2 TYZINE 2

DERMATOLOGY - ACNE ACNE AGENTS,SYSTEMIC

ABSORICA 2 ISOTRETINOIN 1


DRUG CATEGORY & NAME DRUG TIER ACNE AGENTS,TOPICAL

ACANYA 2 ACZONE 2 AZELEX 2 BENZACLIN 2 CLINDAMYCIN PHOS/BENZOYL PEROX 1 DUAC 2 EPIDUO 2 EPIDUO FORTE 2 KLARON 2 NEUAC 2 ONEXTON 2 SULFACETAMIDE SODIUM 1 VELTIN 2 ZIANA 2

ANTICORROSIVE AGENTS BUTYLATED HYDROXYTOLUENE(BHT) 2

KERATOLYTIC-GLUCOCORTICOID COMBINATIONS VANOXIDE-HC 2

ROSACEA AGENTS, TOPICAL FINACEA 2 METROCREAM 2 METROGEL 2 METROLOTION 2 METRONIDAZOLE 1 MIRVASO 2 NORITATE 2 ROSADAN 2 SOOLANTRA 2

TOPICAL PREPARATIONS,ANTIBACTERIALS ALA-QUIN 2 ALCORTIN A 2 ALOQUIN 2 DERMASORB AF 2 HYDROCORTISONE/IODOQUINOL 1 HYDROCORTISONE/IODOQUINOL/ALOE 1 IODINE/POTASSIUM IODIDE 1 IODOFLEX 2 IODOSORB 2 NORMLGEL AG 2 SILVER NITRATE 2 SILVRSTAT 2 VYTONE 2

VITAMIN A DERIVATIVES ADAPALENE 1, 2 ATRALIN 2 DIFFERIN 2


DRUG CATEGORY & NAME DRUG TIER RETIN-A 2 RETIN-A MICRO 2 RETIN-A MICRO PUMP 2 TRETINOIN 1 TRETINOIN MICROSPHERES 1 TRETIN-X 2

VITAMIN A DERIVATIVES, TOPICAL ACNE AGENTS FABIOR 2

VITAMIN A DERIVATIVES, TOPICAL COSMETIC AGENTS AVAGE 2 REFISSA 2 RENOVA 2 RENOVA PUMP 2 TRETINOIN 2

DERMATOLOGY - ANTIINFECTIVE ANTIPARASITICS

ALINIA 2 TOPICAL ANTIBIOTICS

BACTROBAN 2 BENZAMYCIN 2 BENZAMYCINPAK 2 CENTANY 2 CENTANY AT 2 CLEOCIN T 2 CLINDACIN ETZ 2 CLINDACIN PAC 2 CLINDAGEL 2 CLINDAMYCIN PHOSPHATE 1 ERYGEL 2 ERYTHROMYCIN BASE/ETHANOL 1 ERYTHROMYCIN/BENZOYL PEROXIDE 1 EVOCLIN 2 GENTAMICIN SULFATE 2 MUPIROCIN 1 MUPIROCIN CALCIUM 1

TOPICAL ANTIFUNGAL/ANTIINFLAMMATORY,STERIOD AGENT CLOTRIMAZOLE/BETAMETHASONE DIP 1 LOTRISONE 2

TOPICAL ANTIFUNGALS CICLODAN 2 CICLOPIROX 1 CICLOPIROX OLAMINE 1 CICLOPIROX/URE/CAMPH/MENTH/EUC 1 CLOTRIMAZOLE 1 CNL 8 2 ECONAZOLE NITRATE 1 ECOZA 2


DRUG CATEGORY & NAME DRUG TIER ERTACZO 2 EXELDERM 2 EXODERM 2 EXTINA 2 JUBLIA 2 KERYDIN 2 KETOCONAZOLE 1 LOPROX 2 LUZU 2 MENTAX 2 NAFTIFINE HCL 1 NAFTIN 2 NIZORAL 2 NYSTATIN 1 NYSTATIN/TRIAMCIN 1 OXISTAT 2 PEDIADERM AF 2 PENLAC 2 TRIPLE DYE 2 VUSION 2 XOLEGEL 2

TOPICAL ANTIPARASITICS ELIMITE 2 EURAX 2 LINDANE 1 LYCELLE 2 MALATHION 1 NATROBA 2 OVIDE 2 PERMETHRIN 1 SKLICE 2 SPINOSAD 2 ULESFIA 2

TOPICAL ANTIVIRALS ACYCLOVIR 1 DENAVIR 2 ZOVIRAX 2

TOPICAL ANTIVIRALS/ANTIINFLAMMATORY, STEROID AGENT XERESE 2

TOPICAL GENITAL WART-HPV TREATMENT AGENTS VEREGEN 2

TOPICAL PLEUROMUTILIN DERIVATIVES ALTABAX 2

TOPICAL SULFONAMIDES AVAR 2 AVAR LS 2 AVAR-E LS 2


DRUG CATEGORY & NAME DRUG TIER CLARIFOAM EF 2 CLEANSING WASH 2 PLEXION 2 ROSULA 2 SILVADENE 2 SILVER SULFADIAZINE 1 SODIUM SULFACETAMIDE-SULFUR 2 SULFACETAMIDE SODIUM/SULFUR 1 SULFACETAMIDE/SULFUR/CLEANSR23 1 SULFACT SOD/SULUR/AVOB/OTN/OCT 1 SULFAMYLON 2 SUMADAN 2 SUMADAN XLT 2 SUMAXIN 2 SUMAXIN CP 2 SUMAXIN TS 2

DERMATOLOGY - ANTIINFLAMMATORY TOPICAL ANTIBIOTICS/ANTIINFLAMMATORY,STEROIDAL

CORTISPORIN 2 NEO-SYNALAR 2

TOPICAL ANTI-INFLAMMATORY STEROIDAL ADV ALLERGY COLLECTION KIT 2 ALA-SCALP 2 ALCLOMETASONE DIPROPIONATE 1 AMCINONIDE 1, 2 APEXICON E 2 AQUA GLYCOLIC HC 2 BETAMETHASONE DIPROPIONATE 1 BETAMETHASONE VALERATE 1 BETAMETHASONE/PROPYLENE GLYC 1 CAPEX SHAMPOO 2 CLOBETASOL PROPIONATE 1 CLOBETASOL PROPIONATE/EMOLL 1 CLOBEX 2 CLOCORTOLONE PIVALATE 2 CLODAN 2 CLODERM 2 CORDRAN 2 CUTIVATE 2 DERMACINRX SILAPAK 2 DERMASILKRX SDS 2 DERMA-SMOOTHE-FS 2 DERMASORB HC 2 DERMASORB TA 2 DERMATOP 2 DESONATE 2 DESONIDE 1


DRUG CATEGORY & NAME DRUG TIER DESOWEN 2 DESOXIMETASONE 1, 2 DIFLORASONE DIACETATE 2 DIPROLENE 2 DIPROLENE AF 2 ELOCON 2 FLUOCINOLONE ACETONIDE 1 FLUOCINOLONE/SHOWER CAP 1 FLUOCINONIDE 1 FLUOCINONIDE/EMOLLIENT BASE 1 FLUTICASONE PROPIONATE 1 HALOBETASOL PROPIONATE 1 HALOG 2 HC/MINERAL OIL/PETROLAT,WHT 1 HYDROCORTISONE 1 HYDROCORTISONE ACETATE/ALOE V 1 HYDROCORTISONE BUTYRATE 1 HYDROCORTISONE BUTYRATE/EMOLL 1 HYDROCORTISONE VALERATE 1 KENALOG 2 LOCOID 2 LOCOID LIPOCREAM 2 LUXIQ 2 MOMETASONE FUROATE 1 OLUX 2 OLUX-E 2 PANDEL 2 PEDIADERM HC 2 PEDIADERM TA 2 PREDNICARBATE 1 PSORCON 2 SCALACORT DK 2 SYNALAR 2 SYNALAR TS 2 TEMOVATE 2 TEMOVATE EMOLLIENT 2 TEXACORT 2 TOPICORT 2 TRIAMCINOLONE ACETONIDE 1, 2 TRIANEX 2 U-CORT 2 ULTRAVATE 2 ULTRAVATE X 2 VANOS 2 VERDESO 2

TOPICAL ANTI-INFLAMMATORY, NSAIDS DICLOFENAC SODIUM 1


DRUG CATEGORY & NAME DRUG TIER FLECTOR 2 PENNSAID 2 VOLTAREN 2

DERMATOLOGY - ANTIPRURITIC DRUGS ANTIPRURITICS,TOPICAL

ALEVICYN 2 PRUDOXIN 2 ZONALON 2

DERMATOLOGY - MISCELLANEOUS ANTIPERSPIRANTS

DRYSOL 2 ANTISEBORRHEIC AGENTS

LOUTREX 2 OVACE 2 OVACE PLUS 2 OVACE PLUS WASH 2 PROMISEB 2 PROMISEB COMPLETE 2 SELENIUM SULFIDE 1 SELRX 2 SODIUM SULFACETAMIDE 2 SULFACETAMIDE SODIUM 1 TERSI FOAM 2

ANTISEPTICS,MISCELLANEOUS GUAIACOL 2

EMOLLIENTS ALEVICYN ANTIPRURITIC SG 2 AMMONIUM LACTATE 1 ATOPICLAIR 2 ATRAPRO CP 2 ATRAPRO HYDROGEL 2 AURSTAT 2 AVO CREAM 2 BIAFINE 2 ELETONE 2 EMOLLIENT COMBINATION NO.60 1 EMULSION SB 2 EPICERAM 2 HPR 2 HPR PLUS 2 HPR PLUS HYDROGEL 2 HPR PLUS-MB HYDROGEL 2 HYLATOPIC 2 HYLATOPIC PLUS 2 LACTIC ACID 1 MB HYDROGEL 2 NEOSALUS 2


DRUG CATEGORY & NAME DRUG TIER NEOSALUS CP 2 NIVATOPIC PLUS 2 PRESERA 2 PRUCLAIR 2 PRUMYX 2 PRUTECT 2 SONAFINE 2 TL-CERMIDE 2 TROPAZONE 2 XCLAIR 2

HYPERTRICHOTIC AGENTS, SYSTEMIC/INCL. COMBINATIONS FINASTERIDE 1 PROPECIA 2

IRRIGANTS ACETIC ACID 1 NEOMYCIN SU/POLYMYX B SULF 1 NEOSPORIN G.U. IRRIGANT 2 PHYSIOLOGICAL IRRIG SOL CMB #1 1 PHYSIOSOL 2 RINGERS SOLUTION 1 RINGERS SOLUTION,LACTATED 1 SODIUM CHLOR/HYPOCHLOROUS ACID 1 SODIUM CHLORIDE IRRIG SOLUTION 1 SORBITOL 2 SORBITOL-MANNITOL 2 WATER FOR IRRIGATION,STERILE 1

IRRITANTS/COUNTER-IRRITANTS CAPTRACIN 2 MAC 2 NEUVAXIN 2 PAIN RELIEF 2 QROXIN 2 QUTENZA 2 RELYYT 2 RENOVO 2 SINELEE 2 SOLAICE 2

KERATOLYTICS ALUVEA 2 BENSAL HP 2 BENZEFOAM 2 BENZEFOAM ULTRA 2 BENZOYL PEROXIDE 1 BENZOYL PEROXIDE MICROSPHERES 1 BPO 2 CEM-UREA 2 CONDYLOX 2


DRUG CATEGORY & NAME DRUG TIER DERMASORB XM 2 GORDO-UREA 2 HYDRO 35 2 HYDRO 40 2 INOVA 2 INOVA 4-1 2 INOVA 8-2 2 KERAFOAM 2 KERALAC 2 KERALYT 2 KERALYT SCALP 2 NUOX 2 PACNEX HP 2 PACNEX LP 2 PACNEX MX 2 PODOCON-25 2 PODOFILOX 1 POTASSIUM HYDROXIDE 2 SALEX 2 SALICYLIC ACID 1, 2 SALICYLIC ACID/CERAMIDE CMB #1 1 SALKERA 2 SALVAX 2 SALVAX DUO PLUS 2 SILVER NITRATE 2 SILVER NITRATE APPLICATOR 1, 2 ULTRASAL-ER 2 UMECTA 2 UMECTA PD 2 URAMAXIN 2 URAMAXIN GT 2 UREA 1, 2 UREA/LACTIC AC/ZN UNDECYLENATE 1 UREA/LACTIC ACID/SALICYLIC AC 1 UREVAZ 2 UTOPIC 2 VIRASAL 2

OXIDIZING AGENTS ALEVICYN 2 ATRAPRO DERMAL SPRAY 2

PROTECTIVES BEAU RX 2 BIONECT 2 GENADUR 2 NUVAIL 2 PR CREAM 2 RADIAPLEXRX 2


DRUG CATEGORY & NAME DRUG TIER RECEDO 2 TETRIX 2 VASELINE WHITE PETROLEUM 2

TOPICAL ANTI-INFLAMMATORY STEROID-LOCAL ANESTHETIC EPIFOAM 2 HYDROCORTISONE/PRAMOXINE 1 LIDOCAINE/HYDROCORTISONE AC 1 NOVACORT 2 PRAMOSONE 2 PRAMOSONE E 2

TOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGNTS ALITRETINOIN 4 BEXAROTENE 4 CARAC 2 DICLOFENAC SODIUM 1 EFUDEX 2 FLUOROPLEX 2 FLUOROURACIL 1, 2 MECHLORETHAMINE HCL 4 PANRETIN 4 PICATO 2 SOLARAZE 2 TARGRETIN 4 VALCHLOR 4

TOPICAL LOCAL ANESTHETICS ADAZIN 2 ANACAINE 2 CETACAINE 2 CETACAINE ANESTHETIC 2 COCAINE HCL 2 EMLA 2 ETHYL CHLORIDE 2 LIDOCAINE 1 LIDOCAINE HCL 1, 2 LIDOCAINE HCL/MENTHOL 1 LIDOCAINE/MENTHOL 1 LIDOCAINE/PRILOCAINE 1 LIDOCAINE-TETRACAINE 2 LIDODERM 2 LIDOPIN 2 LIDORX 2 LIDOVEX 2 PAIN EASE 2 PAIN RELIEF 2 PLIAGLIS 2 PONTOCAINE 2 PRE-ATTACHED LTA KIT 2


DRUG CATEGORY & NAME DRUG TIER REGENECARE 2 RELYYKS 2 SCAR 2 SILVERA 2 SPRAY AND STRETCH 2 SYNERA 2 SYNVEXIA TC 2 VELMA 2 VEXA 2

TOPICAL PREPARATIONS,MISCELLANEOUS BETADINE 2

TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMES GRANULEX 2 SANTYL 2

DERMATOLOGY - PIGMENTATION DISORDERS HYPOPIGMENTATION AGENTS

ACLARO 2 C-CLARIFYING SERUM 2 C-THERAPY NIGHT CREAM 2 ELASTIDERM 2 HYDROQUINONE 1 HYDROQUINONE MICROSPHERES 1 HYDROQUINONE/FERRIC OXIDE 1 LUSTRA 2 LUSTRA-AF 2 LUSTRA-ULTRA 2 MELQUIN-3 2 NU-DERM SUNFADER 2 OXYBENZONE/OCTINOX/H-QUINONE 1 TRI-LUMA 2

TOPICAL HYPERPIGMENTATION AGENTS OXSORALEN 2

DERMATOLOGY - PSORIASIS/ECZEMA ANTIPSORIATIC AGENTS,SYSTEMIC

8-MOP 2 ACITRETIN 1, 4 COSENTYX (2 SYRINGES) 4 COSENTYX PEN 4 COSENTYX PEN (2 PENS) 4 COSENTYX SYRINGE 4 METHOXSALEN, RAPID 1 OXSORALEN-ULTRA 2 SECUKINUMAB 4 SORIATANE 4

ANTIPSORIATICS AGENTS CALCIPOTRIENE 1 CALCITRIOL 2


DRUG CATEGORY & NAME DRUG TIER DOVONEX 2 DRITHOCREME HP 2 SORILUX 2 TAZORAC 2 VECTICAL 2 ZITHRANOL 2 ZITHRANOL-RR 2

HAIR GROWTH REDUCTION AGENTS VANIQA 2

TOPICAL AGENTS,MISCELLANEOUS GORDO-UREA 2 PYROGALLIC ACID 2 UREA 1

TOPICAL IMMUNOSUPPRESSIVE AGENTS ELIDEL 2 PROTOPIC 2 TACROLIMUS 1

TOPICAL VIT D ANALOG/ANTIINFLAMMATORY, STEROIDAL CALCIPOTRIENE/BETAMETHASONE 1, 4 TACLONEX 2, 4

DIABETES ANTIHYPERGLY, (DPP-4) INHIBITOR & BIGUANIDE COMB.

JANUMET 2 JANUMET XR 2 JENTADUETO 2 KAZANO 2 KOMBIGLYZE XR 2

ANTIHYPERGLY,DPP-4 ENZYME INHIB &THIAZOLIDINEDIONE OSENI 2

ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST) BYDUREON 2 BYDUREON PEN 2 BYETTA 2 TANZEUM 2 TRULICITY 2 VICTOZA 2-PAK 2 VICTOZA 3-PAK 2

ANTIHYPERGLYCEMC-SOD/GLUC COTRANSPORT2(SGLT2)INHIB FARXIGA 2 INVOKANA 2 JARDIANCE 2

ANTIHYPERGLYCEMIC - DOPAMINE RECEPTOR AGONISTS CYCLOSET 2

ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIB (N-S) ACARBOSE 1 GLYSET 2 PRECOSE 2


DRUG CATEGORY & NAME DRUG TIER ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPE

SYMLINPEN 120 2 SYMLINPEN 60 2

ANTIHYPERGLYCEMIC, DPP-4 INHIBITORS JANUVIA 2 NESINA 2 ONGLYZA 2 TRADJENTA 2

ANTIHYPERGLYCEMIC, INSULIN-RELEASE STIMULANT TYPE AMARYL 2 CHLORPROPAMIDE 2 DIABETA 2 GLIMEPIRIDE 1 GLIPIZIDE 1 GLUCOTROL 2 GLUCOTROL XL 2 GLYBURIDE 1, 2 GLYBURIDE,MICRONIZED 1 GLYNASE 2 NATEGLINIDE 1 PRANDIN 2 REPAGLINIDE 1 STARLIX 2 TOLAZAMIDE 1, 2 TOLBUTAMIDE 2

ANTIHYPERGLYCEMIC, INSULIN-RESPONSE ENHANCER (N-S) ACTOS 2 AVANDIA 2 PIOGLITAZONE HCL 1

ANTIHYPERGLYCEMIC, SGLT-2 & DPP-4 INHIBITOR COMB. GLYXAMBI 2

ANTIHYPERGLYCEMIC,BIGUANIDE TYPE(NON-SULFONYLUREA) FORTAMET 2 GLUCOPHAGE 2 GLUCOPHAGE XR 2 GLUMETZA 2 METFORMIN HCL 1 RIOMET 2

ANTIHYPERGLYCEMIC,INSULIN-REL STIM.& BIGUANIDE CMB GLIPIZIDE/METFORMIN HCL 1 GLUCOVANCE 2 GLYBURIDE/METFORMIN HCL 1 PRANDIMET 2

ANTIHYPERGLYCEMIC,INSULIN-RESPONSE & RELEASE COMB. DUETACT 2 PIOGLITAZONE HCL/GLIMEPIRIDE 1

ANTIHYPERGLYCEMIC-GLUCOCORTICOID RECEPTOR BLOCKER


DRUG CATEGORY & NAME DRUG TIER KORLYM 4 MIFEPRISTONE 4

ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR & BIGUANIDE COMB INVOKAMET 2 XIGDUO XR 2

ANTIHYPERGLYCM,INSUL-RESP.ENHANCER & BIGUANIDE CMB ACTOPLUS MET 2 ACTOPLUS MET XR 2 AVANDAMET 2 PIOGLITAZONE HCL/METFORMIN HCL 1

DIABETIC SUPPLIES AUTOJECT 2 2 AUTOPEN 2 HUMAPEN LUXURA HD 2 NOVOPEN ECHO 2 OMNIPOD 2 T:SLIM 2

DIABETIC ULCER PREPARATIONS,TOPICAL BECAPLERMIN 4 REGRANEX 4

HYPERGLYCEMICS DIAZOXIDE 4 PROGLYCEM 4

INSULINS AFREZZA 2 APIDRA 2 APIDRA SOLOSTAR 2 HUMALOG 2 HUMALOG KWIKPEN 2 HUMALOG MIX 50-50 2 HUMALOG MIX 50-50 KWIKPEN 2 HUMALOG MIX 75-25 2 HUMALOG MIX 75-25 KWIKPEN 2 HUMULIN 70/30 KWIKPEN 2 HUMULIN 70-30 2 HUMULIN N 2 HUMULIN N KWIKPEN 2 HUMULIN R 2 HUMULIN R U-500 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXTOUCH 2 NOVOLIN 70-30 2 NOVOLIN N 2 NOVOLIN R 2 NOVOLOG 2


DRUG CATEGORY & NAME DRUG TIER NOVOLOG FLEXPEN 2 NOVOLOG MIX 70-30 2 NOVOLOG MIX 70-30 FLEXPEN 2 TOUJEO SOLOSTAR 2

URINE GLUCOSE TEST AIDS CLINITEST REAGENT 2 DIASTIX REAGENT 2 NO-STICK GLUCOSE 2

URINE GLUCOSE/ACETONE TEST AIDS,STRIPS CHEMSTRIP UGK 2 KETO-DIASTIX REAGENT 2

EAR - GENERAL DISORDERS EAR PREPARATIONS ANTI-INFLAMMATORY

DERMOTIC 2 FLUOCINOLONE ACETONIDE OIL 1

EAR PREPARATIONS, MISC. ANTI-INFECTIVES ACETIC ACID 1 ACETIC ACID/HYDROCORTISONE 1 ACETIC ACID-ALUMINUM 2 CORTANE-B 2

EAR PREPARATIONS,ANTIBIOTICS CETRAXAL 2 CIPROFLOXACIN HCL 2 COLY-MYCIN S 2 CORTISPORIN-TC 2 NEOMYCIN/POLYMYXIN B SULF/HC 1 OFLOXACIN 1

OTIC PREPARATIONS,ANTI-INFLAMMATORY-ANTIBIOTICS CIPRO HC 2 CIPRODEX 2

ELECTROLYTE REGULATION ARGININE VASOPRESSIN (AVP) RECEPTOR ANTAGONISTS

SAMSCA 4 TOLVAPTAN 4

ELECTROLYTE DEPLETERS AURYXIA 2 CALCIUM ACETATE 1 ELIPHOS 2 FOSRENOL 2, 4 KAYEXALATE 2 LANTHANUM CARBONATE 4 MAGNEBIND 400 RX 2 PHOSLO 2 PHOSLYRA 2 RENAGEL 2 RENVELA 2 SODIUM POLYSTYRENE SULFONATE 1


DRUG CATEGORY & NAME DRUG TIER VELPHORO 2

POTASSIUM REPLACEMENT EFFER-K 2 KLOR-CON 2 KLOR-CON M15 2 K-TAB ER 2 POT CHLORIDE/POT BICARB/CIT AC 1 POTASSIUM BICARBONATE/CIT AC 1 POTASSIUM CHLORIDE 1, 2

ENDOCRINE DISORDER - FERTILITY FERTILITY STIMULATING PREPARATIONS,NON-FSH

CLOMIPHENE CITRATE 1 FOLLICLE STIM./LUTEINIZING HORMONES

MENOPUR 2 FOLLICLE-STIMULATING HORMONE (FSH)

BRAVELLE 2 FOLLISTIM AQ 2 GONAL-F 2 GONAL-F RFF 2 GONAL-F RFF REDI-JECT 2

HUMAN CHORIONIC GONADOTROPIN (HCG) OVIDREL 2

PREGNANCY FACILITATING/MAINTAINING AGENT,HORMONAL CRINONE 2 ENDOMETRIN 2

ENDOCRINE DISORDER - OTHER ANTIDIURETIC AND VASOPRESSOR HORMONES

DDAVP 2 DESMOPRESSIN (NONREFRIGERATED) 1 DESMOPRESSIN ACETATE 1, 4 STIMATE 4

ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. ELIGARD 2 LEUPROLIDE ACETATE 1 ZOLADEX 2

BONE FORMATION STIM. AGENTS - PARATHYROID HORMONE FORTEO 4 TERIPARATIDE 4

BONE RESORPTION INHIBITOR & VITAMIN D COMBINATIONS FOSAMAX PLUS D 2

BONE RESORPTION INHIBITORS ACTONEL 2 ALENDRONATE SODIUM 1, 2 ATELVIA 2 BINOSTO 2 BONIVA 2 CALCITONIN,SALMON,SYNTHETIC 1


DRUG CATEGORY & NAME DRUG TIER DENOSUMAB 4 ETIDRONATE DISODIUM 2 EVISTA 2 FORTICAL 2 FOSAMAX 2 IBANDRONATE SODIUM 1 MIACALCIN 2 PROLIA 2 RALOXIFENE HCL 1 RISEDRONATE SODIUM 1 XGEVA 4

CALCIMIMETIC,PARATHYROID CALCIUM ENHANCER CINACALCET HCL 4 SENSIPAR 4

GROWTH HORMONE RECEPTOR ANTAGONISTS PEGVISOMANT 4 SOMAVERT 2, 4

GROWTH HORMONE RELEASING HORMONE (GHRH) & ANALOGS EGRIFTA 4 TESAMORELIN ACETATE 4

GROWTH HORMONES GENOTROPIN 4 HUMATROPE 4 NORDITROPIN FLEXPRO 4 NUTROPIN AQ 4 NUTROPIN AQ NUSPIN 4 OMNITROPE 2 SAIZEN 4 SEROSTIM 4 SOMATROPIN 4 ZOMACTON 4 ZORBTIVE 4

HYPERPARATHYROID TX AGENTS - VITAMIN D ANALOG-TYPE DOXERCALCIFEROL 1 HECTOROL 2 PARICALCITOL 1 ZEMPLAR 2

INSULIN-LIKE GROWTH FACTOR-1 (IGF-1) HORMONES INCRELEX 4 MECASERMIN 4

LEPTIN HORMONE ANALOGS MYALEPT 2

LHRH(GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS NAFARELIN ACETATE 4 SYNAREL 4

LHRH(GNRH) ANTAGONIST,PITUITARY SUPPRESSANT AGENTS GANIRELIX ACETATE 2


DRUG CATEGORY & NAME DRUG TIER MENOPAUSAL SYMPT SUPP-SEL ESTROGEN RECEP MODULATOR

OSPHENA 2 PARATHYROID HORMONES

NATPARA 2 PITUITARY SUPPRESSIVE AGENTS

CABERGOLINE 1 DANAZOL 1

ENDOCRINE DISORDER - THYROID ANTITHYROID PREPARATIONS

METHIMAZOLE 1 PROPYLTHIOURACIL 1 TAPAZOLE 2

IODINE CONTAINING AGENTS SSKI 2 STRONG IODINE 2

THYROID HORMONES ARMOUR THYROID 2 CYTOMEL 2 LEVOTHYROXINE SODIUM 1 LIOTHYRONINE SODIUM 1 NATURE-THROID 2 SYNTHROID 2 THYROID,PORK 1 THYROLAR-1 2 THYROLAR-1/2 2 THYROLAR-1/4 2 THYROLAR-2 2 THYROLAR-3 2 TIROSINT 2 WESTHROID 2 WP THYROID 2

EYE - GENERAL DISORDERS EYE ANTIBIOTIC-CORTICOID COMBINATIONS

MAXITROL 2 NEO/POLYMYX B SULF/DEXAMETH 1 NEOMYCIN SU/BACI ZN/POLY/HC 1 NEOMYCIN-POLYMYXIN-HC 2 PRED-G 2 TOBRADEX 2 TOBRADEX ST 2 TOBRAMYCIN/DEXAMETHASONE 1 ZYLET 2

EYE ANTIHISTAMINES AZELASTINE HCL 1 BEPREVE 2 ELESTAT 2 EMADINE 2


DRUG CATEGORY & NAME DRUG TIER EPINASTINE HCL 1 LASTACAFT 2 PATADAY 2 PATANOL 2 PAZEO 2

EYE ANTIINFLAMMATORY AGENTS ACULAR 2 ACULAR LS 2 ACUVAIL 2 ALREX 2 BROMFENAC SODIUM 1 DEXAMETHASONE SOD PHOSPHATE 1 DICLOFENAC SODIUM 1 DUREZOL 2 FLAREX 2 FLUOROMETHOLONE 1 FLURBIPROFEN SODIUM 1 FML 2 FML FORTE 2 FML S.O.P. 2 ILEVRO 2 KETOROLAC TROMETHAMINE 1 LOTEMAX 2 MAXIDEX 2 NEVANAC 2 OCUFEN 2 OMNIPRED 2 PRED FORTE 2 PRED MILD 2 PREDNISOLONE ACETATE 1 PREDNISOLONE SODIUM PHOSPHATE 2 PROLENSA 2 VEXOL 2

EYE ANTIVIRALS TRIFLURIDINE 1 VIROPTIC 2 ZIRGAN 2

EYE LOCAL ANESTHETICS AKTEN 2 ALCAINE 2 BENOXINATE HCL/FLUORESCEIN NA 1 PROPARACAINE HCL 1 PROPARACAINE/FLUORESCEIN SOD 1 TETRACAINE HCL 1 TETRACAINE HCL/PF 1

EYE SULFONAMIDES BLEPH-10 2


DRUG CATEGORY & NAME DRUG TIER BLEPHAMIDE 2 BLEPHAMIDE S.O.P. 2 SULFACETAMIDE SODIUM 1, 2 SULFACETAMIDE/PREDNISOLONE SP 1

EYE VASOCONSTRICTORS (RX ONLY) NAPHAZOLINE HCL 2 PHENYLEPHRINE HCL 1

OPHTHALMIC ANTIBIOTICS AZASITE 2 BACITRACIN 2 BACITRACIN/POLYMYXIN B SULFATE 1 BESIVANCE 2 CILOXAN 2 CIPROFLOXACIN HCL 1 ERYTHROMYCIN BASE 1 GARAMYCIN 2 GATIFLOXACIN 1 GENTAMICIN SULFATE 1 LEVOFLOXACIN 1 MOXEZA 2 NATACYN 2 NEOMYCIN SU/BACITRA/POLYMYXIN 1 NEOMYCIN/POLYMYXN B/GRAMICIDIN 1 NEOSPORIN 2 OCUFLOX 2 OFLOXACIN 1 POLYMYXIN B SULF/TRIMETHOPRIM 1 POLYTRIM 2 TOBRAMYCIN 1 TOBREX 2 VIGAMOX 2 ZYMAXID 2

OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPE RESTASIS 2

OPHTHALMIC MAST CELL STABILIZERS ALOCRIL 2 ALOMIDE 2 CROMOLYN SODIUM 1

OPHTHALMIC PREPARATIONS, MISCELLANEOUS ACUICYN 2 AVENOVA 2

EYE - GLAUCOMA CARBONIC ANHYDRASE INHIBITORS

ACETAZOLAMIDE 1, 2 DIAMOX SEQUELS 2 METHAZOLAMIDE 1 NEPTAZANE 2


DRUG CATEGORY & NAME DRUG TIER MIOTICS/OTHER INTRAOC. PRESSURE REDUCERS

ALPHAGAN P 2 APRACLONIDINE HCL 1 AZOPT 2 BETAGAN 2 BETAXOLOL HCL 1 BETIMOL 2 BETOPTIC S 2 BIMATOPROST 2 BRIMONIDINE TARTRATE 1 CARTEOLOL HCL 1 COMBIGAN 2 COSOPT 2 COSOPT PF 2 DORZOLAMIDE HCL 1 DORZOLAMIDE HCL/TIMOLOL MALEAT 1 IOPIDINE 2 ISOPTO CARPINE 2 ISTALOL 2 LATANOPROST 1 LEVOBUNOLOL HCL 1 LUMIGAN 2 METIPRANOLOL 2 PHOSPHOLINE IODIDE 2 PILOCARPINE HCL 1 RESCULA 2 SIMBRINZA 2 TIMOLOL MALEATE 1 TIMOPTIC 2 TIMOPTIC OCUDOSE 2 TIMOPTIC-XE 2 TRAVATAN Z 2 TRAVOPROST 2 TRUSOPT 2 XALATAN 2 ZIOPTAN 2

MYDRIATICS ATROPINE SULFATE 1, 2 CYCLOGYL 2 CYCLOMYDRIL 2 CYCLOPENTOLATE HCL 1 HOMATROPINE HBR 1 ISOPTO ATROPINE 2 MYDRIACYL 2 PAREMYD 2 TROPICAMIDE 1

OPHTHALMIC ANTIFIBROTIC AGENTS


DRUG CATEGORY & NAME DRUG TIER MITOSOL 2

EYE - MISCELLANEOUS ARTIFICIAL TEARS

LACRISERT 2 EYE DIAGNOSTIC AGENTS

FLUORESCEIN SODIUM 1 FUL-GLO 2

EYE PREPARATIONS, MISCELLANEOUS (OTC) GELFILM 2

OPHTHALMIC CYSTINE DEPLETING AGENTS CYSTARAN 2

TOPICAL HYPERTRICHOTIC AGENTS, EYELASHES LATISSE 2

GOUT AND RELATED DISEASES COLCHICINE

COLCHICINE 2 COLCHICINE/PROBENECID 1 COLCRYS 2 MITIGARE 2

HYPERURICEMIA TX - PURINE INHIBITORS ALLOPURINOL 1 ULORIC 2 ZYLOPRIM 2

URICOSURIC AGENTS PROBENECID 1

HEMATOLOGICAL DISORDERS ANTICOAGULANTS,COUMARIN TYPE

COUMADIN 2 WARFARIN SODIUM 1

ANTIFIBRINOLYTIC AGENTS AMICAR 2 LYSTEDA 2 TRANEXAMIC ACID 1

CITRATES AS ANTICOAGULANTS ACD 2 ACD-A 2 CITRATE PHOSPHATE DEXTROSE 2 SODIUM CITRATE 1, 2

DIRECT FACTOR XA INHIBITORS ELIQUIS 2 SAVAYSA 2 XARELTO 2

HEMORRHEOLOGIC AGENTS PENTOXIFYLLINE 1

HEPARIN AND RELATED PREPARATIONS ARIXTRA 2 ENOXAPARIN SODIUM 1


DRUG CATEGORY & NAME DRUG TIER FONDAPARINUX SODIUM 1 FRAGMIN 2 HEPARIN SODIUM,PORCINE/PF 1 LOVENOX 2

LEUKOCYTE (WBC) STIMULANTS FILGRASTIM 4 GRANIX 4 NEULASTA 2, 4 NEUPOGEN 4 PEGFILGRASTIM 4 TBO-FILGRASTIM 4

PLATELET AGGREGATION INHIBITORS AGGRENOX 2 ASPIRIN-DIPYRIDAMOLE ER 2 BRILINTA 2 CILOSTAZOL 1 CLOPIDOGREL BISULFATE 1 DIPYRIDAMOLE 1 EFFIENT 2 PERSANTINE 2 PLAVIX 2 PLETAL 2 TICLOPIDINE HCL 1 ZONTIVITY 2

PLATELET PROLIFERATION STIMULANTS NEUMEGA 4 OPRELVEKIN 4

PLATELET REDUCING AGENTS AGRYLIN 2 ANAGRELIDE HCL 1

SICKLE CELL ANEMIA AGENTS DROXIA 2

THROMBIN INHIBITORS,SELECTIVE,DIRECT, & REVERSIBLE PRADAXA 2

THROMBOPOIETIN RECEPTOR AGONISTS ELTROMBOPAG OLAMINE 4 NPLATE 2 PROMACTA 4

TOPICAL HEMOSTATICS ASTRINGYN 2 AVITENE 2 ENDO-AVITENE 2 GELFOAM 2 GELFOAM COMPRESSED 2 MONSEL'S 2 OXYCEL 2 RECOTHROM 2


DRUG CATEGORY & NAME DRUG TIER SYRINGE AVITENE 2 TACHOSIL 2 THROMBI-GEL 2 THROMBIN-JMI 2 THROMBI-PAD 2 TISSEEL VHSD 2 ULTRAFOAM 2

VITAMIN K PREPARATIONS MEPHYTON 2

HORMONAL DEFICIENCY ANDROGENIC AGENTS

ANADROL-50 2 ANDRODERM 2 ANDROGEL 2 ANDROID 2 ANDROXY 2 AXIRON 2 FORTESTA 2 METHITEST 2 NATESTO 2 OXANDRIN 2 OXANDROLONE 1 STRIANT 2 TESTIM 2 TESTOSTERONE 2 TESTRED 2 VOGELXO 2

ESTROGEN & PROGESTIN WITH ANTIMINERALOCORTICOID CB ANGELIQ 2

ESTROGEN & SELECTIVE ESTROGEN RECEPT MOD(SERM)COMB DUAVEE 2

ESTROGEN/ANDROGEN COMBINATIONS ESTROGEN,ESTER/ME-TESTOSTERONE 1

ESTROGENIC AGENTS ACTIVELLA 2 ALORA 2 CLIMARA 2 CLIMARA PRO 2 COMBIPATCH 2 DIVIGEL 2 ELESTRIN 2 ENJUVIA 2 ESTRACE 2 ESTRADIOL 1 ESTRADIOL/NORETHINDRONE ACET 1 ESTROGEL 2 ESTROPIPATE 1, 2


DRUG CATEGORY & NAME DRUG TIER EVAMIST 2 FEMHRT 2 MENEST 2 MENOSTAR 2 MINIVELLE 2 NORETHINDRONE AC-ETH ESTRADIOL 1 PREFEST 2 PREMARIN 2 PREMPHASE 2 PREMPRO 2 VIVELLE-DOT 2

LHRH (GNRH) AGONIST ANALOG AND PROGESTIN COMB LUPANETA PACK 2

PROGESTATIONAL AGENTS AYGESTIN 2 CRINONE 2 MEDROXYPROGESTERONE ACETATE 1 NORETHINDRONE ACETATE 1 PROGESTERONE,MICRONIZED 1 PROMETRIUM 2 PROVERA 2

IMMUNIZATION ANTISERA

HYQVIA 2 ENTERIC VIRUS VACCINES

ROTARIX 2 ROTATEQ 2

GRAM (-) BACILLI (NON-ENTERIC) VACCINES VIVOTIF BERNA 2

GRAM NEGATIVE COCCI VACCINES MENOMUNE-A-C-Y-W-135 2

INFLUENZA VIRUS VACCINES FLUMIST QUAD 2015-2016 2

NEUROTOXIC VIRUS VACCINES YF-VAX 2

VACCINE/TOXOID PREPARATIONS,COMBINATIONS M-M-R II VACCINE 2 PROQUAD 2

VIRAL/TUMORIGENIC VACCINES ADENOVIRUS TYPE 4 2 ADENOVIRUS TYPE 4 AND TYPE 7 2 ADENOVIRUS TYPE 7 2 VARIVAX VACCINE 2 ZOSTAVAX 2

IMMUNOSUPPRESSION/MODULATION IMMUNOMODULATORS

ACTIMMUNE 4


DRUG CATEGORY & NAME DRUG TIER ALDARA 2 IMIQUIMOD 1 INTERFERON GAMMA-1B,RECOMB. 4 ZYCLARA 2

IMMUNOSUPPRESSIVES ASTAGRAF XL 2, 4 AZASAN 2 AZATHIOPRINE 1 CELLCEPT 2 CYCLOSPORINE 1 CYCLOSPORINE MODIFIED 2 CYCLOSPORINE, MODIFIED 1 EVEROLIMUS 4 IMURAN 2 MYCOPHENOLATE MOFETIL 1 MYCOPHENOLATE SODIUM 1 MYFORTIC 2 NEORAL 2 PROGRAF 2 RAPAMUNE 2 SANDIMMUNE 2 SIROLIMUS 1 TACROLIMUS 1, 4 ZORTRESS 4

INFECTIOUS DISEASE - BACTERIAL ABSORBABLE SULFONAMIDES

BACTRIM 2 BACTRIM DS 2 SULFAMETHOXAZOLE/TRIMETHOPRIM 1

BETALACTAMS AZTREONAM LYSINE 4 CAYSTON 4

CEPHALOSPORINS - 1ST GENERATION CEFADROXIL 1 CEPHALEXIN 1, 2 KEFLEX 2

CEPHALOSPORINS - 2ND GENERATION CEFACLOR 1, 2 CEFACLOR ER 2 CEFPROZIL 1 CEFTIN 2 CEFUROXIME AXETIL 1

CEPHALOSPORINS - 3RD GENERATION CEDAX 2 CEFDINIR 1 CEFDITOREN PIVOXIL 2 CEFIXIME 1


DRUG CATEGORY & NAME DRUG TIER CEFPODOXIME PROXETIL 1 CEFTIBUTEN 2 SPECTRACEF 2 SUPRAX 2

CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC. HIPREX 2 METHEN/M-BLUE/SAL/NA PHOS/HYOS 1 METHEN/SOD PHOS/METH BLUE/HYOS 1 METHENAM/ME BLUE/BA/SALICY/HYO 1 METHENAMINE HIPPURATE 1 METHENAMINE MANDELATE 1, 2 MONUROL 2 MTH/ME BLUE/SOD PHOS/PHEN/HYOS 1 PRIMSOL 2 PROSED-DS 2 TRIMETHOPRIM 1 URIMAR-T 2 UROGESIC-BLUE 2

KETOLIDES KETEK 2

MACROLIDES AZITHROMYCIN 1, 2 BIAXIN 2 CLARITHROMYCIN 1 DIFICID 4 E.E.S. 200 2 E.E.S. 400 2 ERYPED 200 2 ERYPED 400 2 ERY-TAB 2 ERYTHROCIN STEARATE 2 ERYTHROMYCIN 2 ERYTHROMYCIN BASE 1 ERYTHROMYCIN ETHYLSUCCINATE 1, 2 FIDAXOMICIN 4 PCE 2 ZITHROMAX 2 ZITHROMAX TRI-PAK 2 ZMAX 2

NITROFURAN DERIVATIVES FURADANTIN 2 MACROBID 2 MACRODANTIN 2 NITROFURANTOIN 1 NITROFURANTOIN MACROCRYSTAL 1 NITROFURANTOIN MONOHYD/M-CRYST 1

OXAZOLIDINONES


DRUG CATEGORY & NAME DRUG TIER LINEZOLID 1, 4 SIVEXTRO 4 TEDIZOLID PHOSPHATE 4 ZYVOX 4

PENICILLINS AMOXICILLIN 1, 2 AMOXICILLIN ER 2 AMOXICILLIN/POTASSIUM CLAV 1 AMPICILLIN TRIHYDRATE 1, 2 AUGMENTIN 2 AUGMENTIN ES-600 2 AUGMENTIN XR 2 DICLOXACILLIN SODIUM 1 MOXATAG 2 PENICILLIN V POTASSIUM 1

QUINOLONES AVELOX 2 AVELOX ABC PACK 2 CIPRO 2 CIPRO XR 2 CIPROFLOXACIN 1 CIPROFLOXACIN HCL 1, 2 CIPROFLOXACIN/CIPROFLOXA HCL 1 FACTIVE 2 LEVAQUIN 2 LEVOFLOXACIN 1 MOXIFLOXACIN HCL 1 OFLOXACIN 2

TETRACYCLINES ACTICLATE 2 ADOXA 2 AVIDOXY DK 2 BENOXYLDOXY 30 2 BENOXYLDOXY 60 2 DEMECLOCYCLINE HCL 1 DORYX 2 DOXYCYCLINE HYCLATE 1 DOXYCYCLINE IR-DR 2 DOXYCYCLINE MONOHYDRATE 1 MINOCIN 2 MINOCYCLINE HCL 1 MONODOX 2 MORGIDOX 2 ORACEA 2 SOLODYN 2 TETRACYCLINE HCL 1, 2 VIBRAMYCIN 2


DRUG CATEGORY & NAME DRUG TIER INFECTIOUS DISEASE - FUNGAL

ANTIFUNGAL AGENTS ANCOBON 4 CLOTRIMAZOLE 1 CRESEMBA 2 DIFLUCAN 2 FLUCONAZOLE 1 FLUCYTOSINE 1, 4 ITRACONAZOLE 1 KETOCONAZOLE 1 LAMISIL 2 NOXAFIL 4 ONMEL 2 ORAVIG 2 POSACONAZOLE 4 SPORANOX 2 TERBINAFINE HCL 1 VFEND 4 VORICONAZOLE 1, 4

ANTIFUNGAL ANTIBIOTICS GRIFULVIN V 2 GRISEOFULVIN ULTRAMICROSIZE 1 GRISEOFULVIN, MICROSIZE 1 GRIS-PEG 2 NYSTATIN 1

INFECTIOUS DISEASE - MISCELLANEOUS AMINOGLYCOSIDES

BETHKIS 4 GENTAMICIN IN NACL, ISO-OSM 1 GENTAMICIN SULFATE IN NS 2 GENTAMICIN SULFATE/PF 1 KITABIS PAK 4 NEOMYCIN SULFATE 1 TOBI 4 TOBI PODHALER 4 TOBRAMYCIN 4 TOBRAMYCIN IN 0.225% NACL 1, 4 TOBRAMYCIN SULFATE IN NS 2 TOBRAMYCIN/NEBULIZER 4

ANTIBACTERIAL AGENTS,MISCELLANEOUS GLYCINE UROLOGIC SOLUTION 1

ANTILEPROTICS DAPSONE 2 THALIDOMIDE 4 THALOMID 4

ANTI-MYCOBACTERIUM AGENTS ETHAMBUTOL HCL 1


DRUG CATEGORY & NAME DRUG TIER ISONIAZID 1, 2 MYAMBUTOL 2 MYCOBUTIN 4 PASER 2 PYRAZINAMIDE 1 RIFABUTIN 1, 4 TRECATOR 2

ANTITUBERCULAR ANTIBIOTICS BEDAQUILINE FUMARATE 4 CYCLOSERINE 2 PRIFTIN 2 RIFADIN 2 RIFAMATE 2 RIFAMPIN 1 RIFATER 2 SIRTURO 4

LINCOSAMIDES CLEOCIN HCL 2 CLEOCIN PALMITATE 2 CLINDAMYCIN HCL 1 CLINDAMYCIN PALMITATE HCL 1

RIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICS XIFAXAN 2

VANCOMYCIN AND DERIVATIVES VANCOCIN HCL 4 VANCOMYCIN HCL 1, 4

INFECTIOUS DISEASE - PARASITIC 2ND GEN. ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL

TINDAMAX 2 TINIDAZOLE 1

AMEBACIDES PAROMOMYCIN SULFATE 1

ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTS FLAGYL 2 FLAGYL ER 2 METRO IV 2 METRONIDAZOLE 1 METRONIDAZOLE/SODIUM CHLORIDE 1

ANTHELMINTICS ALBENZA 2 BILTRICIDE 2 IVERMECTIN 1 STROMECTOL 2

ANTIMALARIAL DRUGS ATOVAQUONE/PROGUANIL HCL 1 CHLOROQUINE PHOSPHATE 1 COARTEM 2


DRUG CATEGORY & NAME DRUG TIER DARAPRIM 2 HYDROXYCHLOROQUINE SULFATE 1 MALARONE 2 MEFLOQUINE HCL 1 PLAQUENIL 2 PRIMAQUINE 2 QUALAQUIN 2 QUININE SULFATE 1

ANTIPROTOZOAL DRUGS,MISCELLANEOUS ATOVAQUONE 1, 4 MEPRON 4 NEBUPENT 2

INFECTIOUS DISEASE - VIRAL ANTIVIRALS, GENERAL

ACYCLOVIR 1 FAMCICLOVIR 1 FAMVIR 2 FLUMADINE 2 RELENZA 2 RIBAVIRIN 4 RIMANTADINE HCL 1 SITAVIG 2 TAMIFLU 2 VALACYCLOVIR HCL 1 VALCYTE 4 VALGANCICLOVIR HCL 1, 4 VALTREX 2 VIRAZOLE 4 ZOVIRAX 2

ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB APTIVUS 2 PREZCOBIX 2 PREZISTA 2

ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG TRUVADA 2

ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMB ABACAVIR/LAMIVUDINE/ZIDOVUDINE 1 COMBIVIR 2 EPZICOM 2 LAMIVUDINE/ZIDOVUDINE 1 TRIZIVIR 2

ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAG. SELZENTRY 2

ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORS FUZEON 2

ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI EDURANT 2


DRUG CATEGORY & NAME DRUG TIER INTELENCE 2 NEVIRAPINE 1, 2 RESCRIPTOR 2 SUSTIVA 2 VIRAMUNE 2 VIRAMUNE XR 2

ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI ABACAVIR SULFATE 1 DIDANOSINE 1 EMTRIVA 2 EPIVIR 2 LAMIVUDINE 1 RETROVIR 2 STAVUDINE 1 VIDEX 2 VIDEX EC 2 ZERIT 2 ZIAGEN 2 ZIDOVUDINE 1

ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI VIREAD 2

ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMB KALETRA 2

ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS CRIXIVAN 2 EVOTAZ 2 INVIRASE 2 LEXIVA 2 NORVIR 2 REYATAZ 2 VIRACEPT 2

ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR ISENTRESS 2 TIVICAY 2 VITEKTA 2

ARTV CMB NUCLEOSIDE,NUCLEOTIDE,&NON-NUCLEOSIDE RTI ATRIPLA 2 COMPLERA 2

ARV CMB-NRTI,N(T)RTI, INTEGRASE INHIBITOR STRIBILD 2

ARV COMB-NRTIS & INTEGRASE INHIBITOR TRIUMEQ 2

CYTOCHROME P450 INHIBITORS TYBOST 2

HEP C VIRUS - NS5A & NS5B POLYMERASE INHIB. COMBO. HARVONI 4 LEDIPASVIR/SOFOSBUVIR 4


DRUG CATEGORY & NAME DRUG TIER HEP C VIRUS,NUCLEOTIDE ANALOG NS5B POLYMERASE INH

SOFOSBUVIR 4 SOVALDI 4

HEPATITIS B TREATMENT AGENTS ADEFOVIR DIPIVOXIL 1, 4 BARACLUDE 4 ENTECAVIR 1, 4 EPIVIR HBV 2 HEPSERA 4 LAMIVUDINE 1 TELBIVUDINE 4 TYZEKA 4

HEPATITIS C TREATMENT AGENTS COPEGUS 2 MODERIBA 2 PEGASYS 4 PEGASYS PROCLICK 4 PEGINTERFERON ALFA-2A 4 PEGINTERFERON ALFA-2B 4 PEGINTRON 4 PEGINTRON REDIPEN 4 REBETOL 2 RIBASPHERE 2 RIBASPHERE RIBAPAK 2 RIBATAB 2 RIBAVIRIN 1

HEPATITIS C VIRUS - NS5A REPLICATION COMPLEX INHIB DAKLINZA 2

HEPATITIS C VIRUS - NS5A, NS3/4A, NS5B INHIB CMB. OMBITA/PARITAP/RITON/DASABUVIR 4 VIEKIRA PAK 4

HEPATITIS C VIRUS NS3/4A SERINE PROTEASE INHIB. OLYSIO 4 SIMEPREVIR SODIUM 4

HEPATITIS C VIRUS- NS5A AND NS3/4A INHIBITOR COMB TECHNIVIE 2

INFLAMMATORY DISEASE ANTI-ARTHRITIC AND CHELATING AGENTS

CUPRIMINE 2 DEPEN 2

ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS OTREXUP 2 RASUVO 2 RHEUMATREX 2

ANTI-FLAM. INTERLEUKIN-1 RECEPTOR ANTAGONIST ANAKINRA 4 KINERET 4


DRUG CATEGORY & NAME DRUG TIER ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR

ADALIMUMAB 4 ENBREL 4 ETANERCEPT 4 GOLIMUMAB 4 HUMIRA 2, 4 HUMIRA CROHN'S 4 HUMIRA PEDIATRIC CROHN'S 4 HUMIRA PSORIASIS 4 SIMPONI 4

ANTI-INFLAMMATORY, INTERLEUKIN-1 BETA BLOCKERS CANAKINUMAB/PF 4 ILARIS 4

ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR ARAVA 4 LEFLUNOMIDE 1, 4

ANTI-INFLAMMATORY,PHOSPHODIESTERASE-4(PDE4) INHIB. APREMILAST 4 OTEZLA 4

ANTI-INFLAMMATORY/ANTIARTHRITICS AGENTS, MISC. TREPADONE 2

ANTINFLAMMATORY, SEL.COSTIM.MOD.,T-CELL INHIBITOR ABATACEPT 4 ORENCIA 4

GLUCOCORTICOIDS BUDESONIDE 1, 4 CORTEF 2 CORTISONE ACETATE 2 DEXAMETHASONE 1, 2 DEXAMETHASONE INTENSOL 2 DEXPAK 2 ENTOCORT EC 4 FLO-PRED 2 HYDROCORTISONE 1 MEDROL 2 METHYLPREDNISOLONE 1 MILLIPRED 2 MILLIPRED DP 2 ORAPRED ODT 2 PEDIAPRED 2 PREDNISOLONE 1 PREDNISOLONE SOD PHOSPHATE 1 PREDNISOLONE SODIUM PHOSPHATE 2 PREDNISONE 1, 2 PREDNISONE INTENSOL 2 RAYOS 2 SOLU-CORTEF 2


DRUG CATEGORY & NAME DRUG TIER UCERIS 4 VERIPRED 20 2

GOLD SALTS RIDAURA 2

JANUS KINASE (JAK) INHIBITORS TOFACITINIB CITRATE 4 XELJANZ 4

MINERALOCORTICOIDS FLUDROCORTISONE ACETATE 1

MONOCLONAL ANTIBODY-HUMAN INTERLEUKIN 12/23 INHIB STELARA 4 USTEKINUMAB 4

NASAL NSAIDS, COX NON-SELECTIVE,SYSTEMIC ANALGESIC SPRIX 2

NSAID & HISTAMINE H2 RECEPTOR ANTAGONIST COMB. DUEXIS 2

NSAID, COX INHIBITOR-TYPE & PROTON PUMP INHIB COMB VIMOVO 2

NSAIDS (COX NON-SPECIFIC INHIB)& PROSTAGLANDIN CMB ARTHROTEC 50 2 ARTHROTEC 75 2 DICLOFENAC SODIUM/MISOPROSTOL 1

NSAIDS, CYCLOOXYGENASE 2 INHIBITOR - TYPE CELEBREX 2 CELECOXIB 1

NSAIDS, CYCLOOXYGENASE INHIBITOR-TYPE ANAPROX 2 ANAPROX DS 2 CELEBREX 2 CELECOXIB 1 DAYPRO 2 DICLOFENAC POTASSIUM 1 DICLOFENAC SODIUM 1 EC-NAPROSYN 2 ETODOLAC 1 FELDENE 2 FENOPROFEN CALCIUM 2 FLURBIPROFEN 1 IBUPROFEN 1 INDOCIN 2 INDOMETHACIN 1 KETOPROFEN 1, 2 KETOROLAC TROMETHAMINE 1 MECLOFENAMATE SODIUM 2 MEFENAMIC ACID 1 MELOXICAM 1, 2 MOBIC 2


DRUG CATEGORY & NAME DRUG TIER NABUMETONE 1 NALFON 2 NAPRELAN 2 NAPROSYN 2 NAPROXEN 1, 2 NAPROXEN SODIUM 1 OXAPROZIN 1 PIROXICAM 1 PONSTEL 2 SULINDAC 1 TIVORBEX 2 TOLMETIN SODIUM 1, 2 VOLTAREN-XR 2 ZIPSOR 2 ZORVOLEX 2

PLASMA KALLIKREIN INHIBITORS KALBITOR 2

UNKNOWN COMFORT PAC-IBUPROFEN 2 COMFORT PAC-MELOXICAM 2 COMFORT PAC-NAPROXEN 2

LOCAL ANESTHESIA LOCAL ANESTHETICS

ADVANCED DNA MEDICATED COLLECT 2 BUCALSEP 2 DYNAMIC 2 LIDOCAINE HCL 1 PRO DNA COLLECTION 2 XYLOCAINE 2

LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT ABSORBABLE SULFONAMIDES

SULFAMETHOXAZOLE/TRIMETHOPRIM 1 BOWEL ANTIINFLAMATORY AGENTS

SULFADIAZINE 2 CHRONIC INFLAM. COLON DX, 5-A-SALICYLAT,RECTAL TX

CANASA 2 MESALAMINE 1 MESALAMINE W/CLEANSING WIPES 1 ROWASA 2 SFROWASA 2

DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLAT APRISO 2 ASACOL HD 2 AZULFIDINE 2 BALSALAZIDE DISODIUM 1 COLAZAL 2 DELZICOL 2


DRUG CATEGORY & NAME DRUG TIER DIPENTUM 4 GIAZO 2 LIALDA 2 OLSALAZINE SODIUM 4 PENTASA 2 SULFASALAZINE 1

DRUGS TO TX CHRONIC INFLAMM. DISEASE OF COLON CERTOLIZUMAB PEGOL 4 CIMZIA 4

HEMORRHOIDAL PREP, ANTI-INFAM STEROID/LOCAL ANESTH ANALPRAM E 2 ANALPRAM HC 2 HYDROCORT/PRAMOXIN/EMOL/PRAM#1 1 HYDROCORTISONE/LIDOCAINE/ALOE 1 HYDROCORTISONE/PRAMOXINE 1 LIDOCAINE/HYDROCORTISONE AC 1 LIDOCAINE-HYDROCORTISONE 2 PROCORT 2 PROCTOFOAM-HC 2 ZYPRAM 2

HEMORRHOIDAL PREPARATIONS ANALPRAM ADVANCED 2

IRRITABLE BOWEL AGENTS,GUANYLATE CYLASE-C AGONIST LINZESS 2

LOCAL ANORECTAL NITRATE PREPARATIONS RECTIV 2

RECTAL PREPARATIONS ANUSOL-HC 2 HYDROCORTISONE 1 HYDROCORTISONE ACETATE 1 PROCTOCORT 2

RECTAL/LOWER BOWEL PREP.,GLUCOCORT. (NON-HEMORR) CORTENEMA 2 CORTIFOAM 2 HYDROCORTISONE 1 UCERIS 2

LOWER GASTROINTESTINAL DISORDERS - OTHER AMMONIA INHIBITORS

AMMONUL 2 BUPHENYL 4 CARBAGLU 2 GLYCEROL PHENYLBUTYRATE 4 LACTULOSE 1 LITHOSTAT 2 RAVICTI 4 SODIUM PHENYLBUTYRATE 1, 4

ANTIDIARRHEAL - G.I. CHLORIDE CHANNEL INHIBITORS


DRUG CATEGORY & NAME DRUG TIER FULYZAQ 2

ANTIDIARRHEALS DIPHENOXYLATE HCL/ATROPINE 1 DIPHENOXYLATE-ATROPINE 2 LOMOTIL 2 LOPERAMIDE HCL 1 MOTOFEN 2 OPIUM TINCTURE 1 PAREGORIC 2

BILE SALTS ACTIGALL 2 CHENODAL 2 CHOLBAM 2 URSO 2 URSO FORTE 2 URSODIOL 1

IRRITABLE BOWEL SYND. AGENT,5HT-3 ANTAGONIST-TYPE ALOSETRON HCL 1, 4 LOTRONEX 4

LAXATIVES AND CATHARTICS AMITIZA 2 BISAC/NACL/NAHCO3/KCL/PEG 3350 1 COLYTE WITH FLAVOR PACKETS 2 COLYTE WITH FLAVOR PACKS 2 GOLYTELY 2 KRISTALOSE 2 LACTULOSE 1 MOVIPREP 2 NULYTELY WITH FLAVOR PACKS 2 OSMOPREP 2 PEG 3350/NA SULF,BICARB,CL/KCL 1 POLYETHYLENE GLYCOL 3350 1, 2 PREPOPIK 2 SODIUM CHLORIDE/NAHCO3/KCL/PEG 1 SUPREP 2

NARCOTIC ANTAGONISTS, PERIPHERALLY-ACTING ENTEREG 2 MOVANTIK 2 RELISTOR 2

MEDICAL SUPPLIES BANDAGES AND RELATED SUPPLIES

ACTICOAT 2 ACTICOAT 7 2 ACTICOAT FLEX 3 2 ACTICOAT FLEX 7 2 ACTICOAT SURGICAL 2 ALLEVYN 2


DRUG CATEGORY & NAME DRUG TIER ALLEVYN ADHESIVE 2 ALLEVYN AG 2 ALLEVYN AG ADHESIVE 2 ALLEVYN AG GENTLE 2 ALLEVYN HEEL 2 ALLEVYN LIFE 2 BIOSTEP 2 BIOSTEP AG 2 CARRASYN HYDROGEL WOUND 2 CURAFIL 2 CURITY AMD 2 CURITY IODOFORM 2 HYDROFERA BLUE 2 HYDROFERA BLUE READY 2 KERLIX AMD 2 KERLIX AMD BANDAGE 2 OASIS ULTRA 2 REPLICARE 2 REPLICARE THIN 2 REPLICARE ULTRA 2 REPLICARE ULTRA SACRUM 2 RESTORE 2 RESTORE CALCIUM ALGINATE 2 RESTORE CONTACT LAYER SILVER 2 SILVERSEAL HYDROGEL 2 SPECTRAGEL 2 VASCUDERM HYDROGEL WOUND 2 WOUND MATRIX 2 XEROFORM 2 XEROFORM PETROLATUM DRESSING 2

BLOOD ADMINISTRATION SETS HEMA ACCESS PORT 2

CATHETERS AND RELATED DEVICES ADVANCE PLUS INTERMITTENT 2 APOGEE HC INTERMITTENT 2 CATHETER 2 CURITY 2 DOVER ADVANTAGE 2 DOVER ADVANTAGE DRAINAGE 2 DOVER COATED LATEX FOLEY 2 DOVER LATEX FOLEY CATHETER 2 DOVER PREMIUM 2 DOVER RED RUBBER ROBIBSON CATH 2 DOVER UNIVERSAL 2 FEMALE SELF CATHETER 2 KENGUARD 2 MONO-FLO 2


DRUG CATEGORY & NAME DRUG TIER ROBINSON CLEAR VINYL CATHETER 2 TOUCH-TROL 2

DURABLE MEDICAL EQUIPMENT,MISC AERONEB GO 2 AIR FILTER 2 ALL FLOW 1000 2 ALL FLOW 2000 2 ALL FLOW 3000 KIT 2 ALL FLOW 3000 PFT 2 ALL FLOW 4000 2 ALL FLOW 5000 2 ALL FLOW 6000 2 ALL FLOW 7000 2 AMIELLE VAGINAL TRAINER 2 ARGYLE 2 BABY CONVERSION KIT 2 BABY CONVERSION PACK 1 2 BABY CONVERSION PACK 2 2 ERAPID NEBULIZER HANDSET 2 E-Z SPACER PEDSPAK 2 FILTER PAD 2 FILTER, VALVE SET FOR LL & LC 2 INNOSPIRE REPLACEMENT FILTER 2 INSPIRATION ELITE FILTER 2 JETCO-SPRAY CANNULA 2 MASK SET WITH Y-PIECE 2 MICRO ELITE 2 MINIELITE 2 MOUTHPIECE 2 NOSE CLIP 2 PARI LC PLUS NEBULIZER 2 PILLOW MASK FOR CHILDREN 2 PRO-CEPTION FERTILITY PAK 2 RECONSTITUBE 2 REUSABLE NEBULIZER KIT 2 RUBBER MOUTHPIECE 2 SAMI THE SEAL MASK 2 SIDESTREAM MASK 2 SILICONE MASK 2 SMARTMASK KIDS 2 STERILE EMPTY VIAL 2 T.E.D. SEQUNT COMPRESS DEVICE 2 TENS 502 2 TENS 504 2 TREK S PORTABLE PWR KIT 2

DURABLE MEDICAL EQUIPMENT,MISC(GROUP 2) RELIEFBAND 2


DRUG CATEGORY & NAME DRUG TIER FEEDING DEVICES

ARGYLE 2 KANGAROO 924 SAFETY SCREW 2 KANGAROO EPUMP SET 2 KANGAROO GRAVITY SET 2

INCONTINENCE SUPPLIES FLEXI-SEAL SIGNAL FMS 2

MEDICAL SUPPLIES,MISCELLANEOUS VARITHENA ADMINISTRATION PACK 2

MEDICAL SUPPLIES,MISCELLANEOUS(GROUP 2) EAR POPPER 2 FREEDOM PRECISION AIRLESS 2 PCCA ACCUPEN-15 2 ZYMOGENETICS SPRAY APPLICATOR 2

MEDICAL SUPPLIES,MISCELLANEOUS(GROUP 3) CONT EPIDURAL W-BUPIV-EPI 2 CONT EPIDURAL W-LIDOCAINE-EPI 2 MYELOGRAM TRAY 2 SPINAL ANESTHESIA TRAY 2 SPINAL-22 W-BUPIV-EPI-EPHED 2

OSTOMY SUPPLIES ASSURA 2 NUTRIPORT BALLOON 2 SENSURA CLICK OSTOMY POUCH 2 SENSURA FLEX OSTOMY BASE PLATE 2 SENSURA FLEX OSTOMY POUCH 2 SENSURA OSTOMY BASE PLATE 2

SYRINGES AND ACCESSORIES ADVOCATE SYRINGES 2 ALLERGIST SYRINGE 2 ALLERGIST SYRINGE TRAY 2 ALLERGIST SYRINGE WITH NEEDLE 2 ALLERGIST TRAY 2 ALLERGIST TRAY SYR-DETACH NDL 2 ALLERGIST TRAY SYR-PERM NEEDLE 2 ALLERGY SYRINGE 2 ASEPTO BULB SYRINGE GLASS TIP 2 ASSURE ID INSULIN SAFETY 2 BULK SYRINGE 2 CANNULA 2 COMFORT EZ 2 CORNWALL METAL PIPETING HOLDER 2 CORNWALL SYRINGE TIP CONNECTOR 2 CORNWALL SYRINGES LUER-LOK TIP 2 DAVOL IRRIGATION SYRINGE 2 EASY COMFORT INSULIN SYRINGE 2 EASY TOUCH 2


DRUG CATEGORY & NAME DRUG TIER EASY TOUCH FLURINGE 2 EASY TOUCH FLURINGE FLU TRAY 2 EASY TOUCH INSULIN SAFETY 2 EASY TOUCH INSULIN SYRINGE 2 EASY TOUCH SYR ALLERGY TRAY 2 EASY-TOUCH INSULIN SYRINGE 2 ECLIPSE LUER-LOK SYRINGE 2 ECLIPSE SYRINGE 2 ECLIPSE SYRINGE-NEEDLE 2 EXEL ALLERGY SYRINGE 2 EXEL SYRINGE 2 EXEL TB WITH NEEDLE 2 EXEL TUBERCULIN SYRINGE 2 FIFTY50 RESERVOIR 2 FILTER, MILLEX-OR SYRINGE 2 FINGER GRIP EXTENDER 2 FREESTYLE PRECISION 2 GLASPAK 2 INJECT-EASE 2 INPERSOL PERITONEAL CATH. 11FR 2 INSULIN SYRINGE 2 INTEGRA SYRINGE 2 INTERLINK SYRINGE 2 INTERLINK SYRINGE W-CANNULA 2 IRRIGATION SYRINGE 2 KENDALL DISINFECTANT CAP 2 LEVER LOCK CANNULA 2 LIFESHIELD BLUNT CANNULA 2 LITE TOUCH 2 LUER LOCK SYRINGE 2 LUER SLIP TIP CAP 2 LUER SLIP TIP SYRINGE TRAY 2 LUER-LOCK SYRINGE 2 LUER-LOK SYRINGE 2 LUER-LOK SYRINGE-NEEDLE 2 LUER-LOK TIP SYRINGE 2 LUERSLIP SYRINGE 2 MAGELLAN INSULIN SAFETY SYRNG 2 MAGELLAN INSULIN SYRINGE 2 MAGELLAN TUBERCULIN SYRINGE 2 MAXI-COMFORT 2 MEDSAVER 2 MINIMED RESERVOIR 2 MONOJECT 2 MONOJECT ALLERGY TRAY-NEEDLE 2 MONOJECT CONTROL SYRINGE 2 MONOJECT INSULIN SAFETY SYRNG 2


DRUG CATEGORY & NAME DRUG TIER MONOJECT INSULIN SYRINGE 2 MONOJECT LUER LOCK TB SYRINGE 2 MONOJECT MAGELLAN 2 MONOJECT MEGELLAN TB SYRINGE 2 MONOJECT PHARMACY TRAY 2 MONOJECT SAFETY SYR TIP CAP 2 MONOJECT SAFETY SYRINGE 2 MONOJECT SMARTIP CANNULA 2 MONOJECT SYRINGE 2 MONOJECT SYRINGE PHARMACY TRAY 2 MONOJECT TB 2 MONOJECT TB SYRINGE 2 MONOJECT TUBERCULIN SAFETY SYR 2 MONOJECT TUBERCULIN SYRINGE 2 NORM-JECT 2 NUTRIMIX 2 PARADIGM 2 PRECISIONGLIDE 2 PRODIGY COUNT-A-DOSE 2 PRODIGY INSULIN SYRINGE 2 SAFE-CLIP 2 SAFESNAP ALLERGY SYRINGE 2 SAFESNAP INSULIN SYRINGE 2 SAFESNAP SYRINGE 2 SAFESNAP TUBERCULIN SYRINGE 2 SAFETY SYRINGE WITH SHIELD 2 SAFETY SYRINGE-NEEDLE 2 SAFETYGLIDE ALLERGY 2 SAFETYGLIDE ALLERGY SYRINGE 2 SAFETYGLIDE INSULIN SYRINGE 2 SAFETYGLIDE SYRINGE 2 SAFETYGLIDE TB SYRINGE 2 SAFETY-LOK SAFETY SYRINGE 2 SAFETY-LOK SAFETY SYRINGES 2 SAFETY-LOK SYRINGES 2 SLIP-TIP SYRINGE 2 SUPOR 2 SURE COMFORT 2 SURE-JECT INSULIN SYRINGE 2 SYRINGE 2 SYRINGE BULK 2 SYRINGE CATHETER TIP 2 SYRINGE FILTER, MILLEX-GP 2 SYRINGE FILTER, MILLEX-GS 2 SYRINGE STORAGE BIN 2 SYRINGE TIP CAP 2 SYRINGE WITH NEEDLE DISP 2


DRUG CATEGORY & NAME DRUG TIER SYRINGE WITHOUT NEEDLE 2 SYRINGE, DISPOSABLE, 20 ML 1 SYRINGE, DISPOSABLE, 30 ML 1 SYRINGE-LUER TIP CAP 2 SYRINGE-NEEDLE 2 SYRINGE-PRECISIONGLIDE NEEDLE 2 TB SYRINGE 2 TERUMO ALLERGY SYRINGE 2 TERUMO HYPODERMIC NEEDLE-SYRIN 2 TERUMO INSULIN SYRINGE 2 TERUMO SURGUARD2 2 TERUMO SYRINGE 2 THINPRO INSULIN SYRINGE 2 THINSET 2 TOOMEY SYRINGE 2 TOPCARE ULTRA COMFORT 2 TRUEPLUS INSULIN SYRINGE 2 TUBERCULIN SYRINGE 2 TUBERCULIN SYRINGE-NEEDLE 2 TWINPAK DUAL CANNULA 2 ULTICARE 2 ULTICARE SYRINGE 2 ULTILET INSULIN SYRINGE 2 ULTRA COMFORT 2 ULTRA-THIN II 2 UNIVERSAL SYRINGE TIP ADAPTOR 2 VANISHPOINT 2 YALE GLASS TB SYRINGE 2 YALE SYRINGE 2

MISCELLANEOUS AGENTS PARASYMPATHETIC AGENTS

BETHANECHOL CHLORIDE 1 CEVIMELINE HCL 1 EVOXAC 2 GUANIDINE HCL 2 PILOCARPINE HCL 1 SALAGEN 2 URECHOLINE 2

NEOPLASTIC DISEASE ALKYLATING AGENTS

ALKERAN 2 ALTRETAMINE 4 BENDAMUSTINE HCL 4 BICNU 2 BUSULFAN 4 BUSULFEX 4 CARBOPLATIN 1, 2


DRUG CATEGORY & NAME DRUG TIER CISPLATIN 1, 2 CYCLOPHOSPHAMIDE 1, 2 ELOXATIN 4 GLEOSTINE 2 GLIADEL 2 HEXALEN 4 HYDREA 2 HYDROXYUREA 1 IFEX 2 IFOSFAMIDE 1, 2 IFOSFAMIDE-MESNA 2 LEUKERAN 2 LOMUSTINE 2 MELPHALAN HCL 1 MYLERAN 2 OXALIPLATIN 1, 4 TEMODAR 4 TEMOZOLOMIDE 1, 4 TREANDA 2, 4

ANTIANDROGENIC AGENTS ABIRATERONE ACETATE 4 BICALUTAMIDE 1 CASODEX 2 ENZALUTAMIDE 4 FLUTAMIDE 1 NILANDRON 2 XTANDI 4 ZYTIGA 4

ANTIMETABOLITES CAPECITABINE 1 MERCAPTOPURINE 1 METHOTREXATE SODIUM 1 METHOTREXATE SODIUM/PF 1 PURIXAN 2 TABLOID 2 TREXALL 2 XELODA 2

ANTINEOPLASTIC AROMATASE INHIBITORS ANASTROZOLE 1 ARIMIDEX 2 AROMASIN 2 EXEMESTANE 1 FEMARA 2 LETROZOLE 1

ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITOR ERIVEDGE 4 VISMODEGIB 4


DRUG CATEGORY & NAME DRUG TIER ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS

JAKAFI 4 RUXOLITINIB PHOSPHATE 4

ANTINEOPLASTIC - MTOR KINASE INHIBITORS AFINITOR 4 AFINITOR DISPERZ 4 EVEROLIMUS 4

ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS HYCAMTIN 4 TOPOTECAN HCL 4

ANTINEOPLASTIC IMMUNOMODULATOR AGENTS LENALIDOMIDE 4 PEGINTERFERON ALFA-2B 4 POMALIDOMIDE 4 POMALYST 4 REVLIMID 4 SYLATRON 4

ANTINEOPLASTIC LHRH(GNRH) ANTAGONIST,PITUIT.SUPPRS FIRMAGON 2

ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS AFATINIB DIMALEATE 4 AXITINIB 4 BOSULIF 4 BOSUTINIB 4 CABOZANTINIB S-MALATE 4 CAPRELSA 4 CERITINIB 4 COMETRIQ 4 CRIZOTINIB 4 DABRAFENIB MESYLATE 4 DASATINIB 4 ERLOTINIB HCL 4 GEFITINIB 4 GILOTRIF 4 GLEEVEC 4 IBRANCE 4 IBRUTINIB 4 ICLUSIG 4 IDELALISIB 4 IMATINIB MESYLATE 4 IMBRUVICA 4 INLYTA 4 IRESSA 4 LAPATINIB DITOSYLATE 4 LENVATINIB MESYLATE 4 LENVIMA 4 LYNPARZA 4


DRUG CATEGORY & NAME DRUG TIER MEKINIST 4 NEXAVAR 4 NILOTINIB HCL 4 OLAPARIB 4 PALBOCICLIB 4 PAZOPANIB HCL 4 PONATINIB HCL 4 REGORAFENIB 4 SORAFENIB TOSYLATE 4 SPRYCEL 4 STIVARGA 4 SUNITINIB MALATE 4 SUTENT 4 TAFINLAR 4 TARCEVA 4 TASIGNA 4 TRAMETINIB DIMETHYL SULFOXIDE 4 TYKERB 4 VANDETANIB 4 VEMURAFENIB 4 VOTRIENT 4 XALKORI 4 ZELBORAF 4 ZYDELIG 4 ZYKADIA 4

ANTINEOPLASTIC,HISTONE DEACETYLASE INHIBITORS,HDIS FARYDAK 4 PANOBINOSTAT LACTATE 4 VORINOSTAT 4 ZOLINZA 4

ANTINEOPLASTICS,MISCELLANEOUS ETOPOSIDE 2 LYSODREN 2 MATULANE 4 OMACETAXINE MEPESUCCINATE 4 PROCARBAZINE HCL 4 SYNRIBO 4 TRETINOIN 1

CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS LEUCOVORIN CALCIUM 1, 2 MESNEX 2

PHOTOACTIVATED, ANTINEOPLS. & PREMALIGNANT LESIONS LEVULAN 2

SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM) FARESTON 4 SOLTAMOX 2 TAMOXIFEN CITRATE 1


DRUG CATEGORY & NAME DRUG TIER TOREMIFENE CITRATE 4

SELECTIVE RETINOID X RECEPTOR AGONISTS (RXR) BEXAROTENE 1, 4 TARGRETIN 4

STEROID ANTINEOPLASTICS EMCYT 4 ESTRAMUSTINE PHOSPHATE SODIUM 4 MEGESTROL ACETATE 1

NEUROLOGICAL DISEASE - MISCELLANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS

AUBAGIO 4 AVONEX 2, 4 AVONEX ADMINISTRATION PACK 4 AVONEX PEN 4 BETASERON 2 COPAXONE 4 DIMETHYL FUMARATE 4 EXTAVIA 2 FINGOLIMOD HCL 4 GILENYA 4 GLATIRAMER ACETATE 1, 4 INTERFERON BETA-1A 4 INTERFERON BETA-1A/ALBUMIN 4 PEGINTERFERON BETA-1A 4 PLEGRIDY 4 PLEGRIDY PEN 4 REBIF 2 REBIF REBIDOSE 2 TECFIDERA 4 TERIFLUNOMIDE 4

AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKR AMPYRA 4 DALFAMPRIDINE 4

AMYOTROPHIC LATERAL SCLEROSIS AGENTS RILUTEK 4 RILUZOLE 1, 4

FIBROMYALGIA AGENTS,SEROTONIN-NOREPINEPH RU INHIB SAVELLA 2

MOVEMENT DISORDERS(DRUG THERAPY) HORIZANT 2 TETRABENAZINE 1, 4 XENAZINE 4

POSTHERPETIC NEURALGIA AGENTS GRALISE 2

PSEUDOBULBAR AFFECT (PBA) AGENTS, NMDA ANTAGONISTS NUEDEXTA 2

ORAL/PHARYNGEAL DISORDERS


DRUG CATEGORY & NAME DRUG TIER DENTAL AIDS AND PREPARATIONS

CHLORHEXIDINE GLUCONATE 1 PERIDEX 2 Q-CARE RX 2 TRIAMCINOLONE ACETONIDE 1

NOSE PREPARATIONS ANTIBIOTICS BACTROBAN NASAL 2

NOSE PREPARATIONS, MISCELLANEOUS (RX) ATROVENT 2 IPRATROPIUM BROMIDE 1

PERIODONTAL COLLAGENASE INHIBITORS DOXYCYCLINE HYCLATE 1

PERIODONTAL TETRACYCLINE ANTIINFECTIVE, LOCAL ARESTIN 2

OTHER DRUGS ABORTIFACIENT,PROGESTERONE RECEPTOR ANTAGONIST-TYP

MIFEPREX 2 AGENTS FOR STOMATOLOGICAL USE

DEBACTEROL 2 ORAFATE 2 PROTHELIAL 2

ANTIDIARRHEAL MICROORGANISMS AGENTS RESTORA RX 2 VSL#3 DS 2

APPETITE STIM. FOR ANOREXIA,CACHEXIA,WASTING SYND. MEGACE 2 MEGACE ES 2 MEGESTROL ACETATE 1

BULK CHEMICALS DIMETHYL SULFOXIDE 2 HYDROCHLORIC ACID 2 HYDROGEN PEROXIDE 2 HYDROXYETHYL METHACRYLATE 2 LACTIC ACID 2 TRI-CHLOR 2 TRICHLOROACETIC ACID 2 VITAMIN E ACETATE 2

CARBOHYDRATES GLUTOL 2

CHELATING AGENTS GLUTATHIONE 2 GLUTATHIONE-L 2

CONCEPTION ASSISTANCE SUPPLIES CONCEPTION 2

CXCR4 CHEMOKINE RECEPTOR ANTAGONIST MOZOBIL 4 PLERIXAFOR 4


DRUG CATEGORY & NAME DRUG TIER DIAGNOSTIC PREPARATIONS,MISC.

ISOSULFAN BLUE 2 LYMPHAZURIN 2 PROVOCHOLINE 2 TC99M SULFUR COLLOID PREP 2 TOXICOLOGY SALIVA COLLECTION 2

DIETARY SUPPLEMENT, MISCELLANEOUS APPTRIM 2 APPTRIM-D 2 B3/AZEL/QUER/TUR/FA/B6/ZN/COPP 1 CARDIOVID PLUS 2 CITICOLINE SODIUM 1 DERMANIC 2 ENTERAGAM 2 FOSTEUM 2 FOSTEUM PLUS 2 GABADONE 2 HYPERTENSA 2 LIMBREL 2 LIMBREL250 2 LIMBREL500 2 LISTER-V 2 MEDI-10 2 NICADAN 2 NICAZEL 2 NICAZEL FORTE 2 PERCURA 2 RHEUMATE 2 SENTRA AM 2 SENTRA PM 2 THERAMINE 2 THERAMINE PLUS 2 TL-ICARE 2 TOZAL 2 VAYACOG 2 VAYARIN 2 VP-GSTN 2 VP-ZEL 2

DILUENT SOLUTIONS DILUENT FOR MENOMUNE 2 DILUENT FOR ROTARIX 2 DILUENT FOR YF-VAX 2 DILUENT-MERCK LIVE VIRUS VACC 2

DRUGS TO TREAT HEREDITARY TYROSINEMIA NITISINONE 4 ORFADIN 4

DRUGS TO TX GAUCHER DX-TYPE 1, SUBSTRATE REDUCING


DRUG CATEGORY & NAME DRUG TIER CERDELGA 4 ELIGLUSTAT TARTRATE 4 MIGLUSTAT 4 ZAVESCA 4

FLAVORING AGENTS ETHYL ACETATE 2

GASTROINTESTINAL RADIOPAQUE DIAGNOSTICS ENTERO VU 2 E-Z DISK 2 E-Z-CAT 2 E-Z-HD 2 E-Z-PAQUE 2 E-Z-PASTE 2 GASTROMARK 2 LIQUID E-Z PAQUE 2 LIQUID POLIBAR PLUS 2 POLIBAR ACB 2 READI-CAT 2 2 SITZMARKS 2 TAGITOL 2 VARIBAR HONEY 2 VARIBAR NECTAR 2 VARIBAR PUDDING 2 VARIBAR THIN HONEY 2 VARIBAR THIN LIQUID 2 VOLUMEN 2

GENERAL ANESTHETICS,INHALANT ENFLURANE 1 FORANE 2 ISOFLURANE 1 SEVOFLURANE 1 SUPRANE 2 ULTANE 2

GENERAL INHALATION AGENTS HYPER-SAL 2 NEBUSAL 2 SODIUM CHLORIDE FOR INHALATION 1

HERBAL DRUGS FLAXSEED/EVENING PRIM/BILBERRY 1

HOMEOPATHIC DRUGS AURUMHEEL 2 CANTHARIS COMPOSITUM 2 CRALONIN 2 EYE 2 HOMEOPATHIC DRUGS 1 LAMIOFLUR 2 PLANTAGO-HOMACCORD 2


DRUG CATEGORY & NAME DRUG TIER POPULUS COMPOSITUM 2 PSORINOHEEL 2 RENEEL 2 SABAL-HOMACCORD 2 SYZYGIUM COMPOSITUM 2 VERTIGOHEEL 2

INTRA-UTERINE DEVICES (IUD'S) LILETTA 2 MIRENA 2 PARAGARD T 380-A 2 SKYLA 2

METABOLIC DEFICIENCY AGENTS BETAINE 4 CARNITOR 2 CARNITOR SF 2 CYSTADANE 4 LEVOCARNITINE 1 LEVOCARNITINE (WITH SUGAR) 1 SULFZIX 2

METABOLIC FUNCTION DIAGNOSTICS METOPIRONE 2

METALLIC POISON,AGENTS TO TREAT CHEMET 4 DEFERASIROX 4 DEFERIPRONE 4 EXJADE 4 FERRIPROX 4 GALZIN 2 JADENU 2 RADIOGARDASE 2 SUCCIMER 4 SYPRINE 2

NUTRITIONAL THERAPY, MED COND SPECIAL FORMULATION BOOST GLUCOSE CONTROL 2 DIABETISOURCE AC 2 GLUCERNA 2 GLUCERNA 1 CAL 2 GLUCERNA 1.2 CAL 2 GLUCERNA 1.5 CAL 2 GLUCERNA ADVANCE 2 GLUCERNA CRISPY DELIGHTS 2 GLUCERNA HUNGER SMART 2 GLUCERNA MINI SNACKS 2 GLUCO BURST 2 GLYTROL 2 GLYTROL WITH PREBIO1 2 NUTRESTORE 2


DRUG CATEGORY & NAME DRUG TIER OINTMENT/CREAM BASES

RADIAGEL 2 ORAL MUCOSITIS/STOMATITIS AGENTS

GELCLAIR 2 GELX 2 MUGARD 2 ORAMAGICRX 2

ORAL MUCOSITIS/STOMATITIS ANTI-INFLAMMATORY AGENT EPISIL 2 MUCOTROL 2

PHARMACEUTICAL ADJUVANTS, TABLETING MICROCRYSTALLINE CELLULOSE 2

PKU TX AGENT-COFACTOR OF PHENYLALANINE HYDROXYLASE KUVAN 2

PRESERVATIVES FORMA-RAY 2

PROTEIN REPLACEMENT LYSINE/VIT E/FA/VIT BCOMP&C/ZN 1

RADIOPHARMACEUTICALS ELEMENTS INDICLOR 2

RUBBER SYRINGES CHILD EAR SYRINGE 2 EAR SYRINGE 2 ENEMA SYRINGE 2 FEMININE BULB SYRINGE 2 FEMININE COMBINATION SYRINGE 2 FEMININE COMPACT TRAVEL SYRNGE 2 FEMININE FOLDING SYRINGE 2 INFANT EAR SYRINGE 2 NASAL ASPIRATOR 2 RECTAL SYRINGE 2

SALIVA STIMULANT AGENTS NUMOISYN 2

SALIVA SUBSTITUTE AGENTS AQUORAL 2 CAPHOSOL 2 NEUTRASAL 2 NUMOISYN 2

SEXUAL DYSFUNCTION DEVICES RAPPORT VACUUM THERAPY 2

SKIN TISSUE REPLACEMENT APLIGRAF 2 DERMAGRAFT 2 ENDOFORM 2 EPIFIX AMNIOTIC MEMBRANE 2 GRAFIX CORE 2 GRAFIX PRIME 2


DRUG CATEGORY & NAME DRUG TIER MATRISTEM 2 MATRISTEM MICROMATRIX 2

SOLVENTS MURI-LUBE MINERAL OIL 2 PROPYLENE GLYCOL 2 SODIUM SUCCINATE 2

SOMATOSTATIC AGENTS LANREOTIDE ACETATE 4 SOMATULINE DEPOT 4

SUPPORT HOSIERY T.E.D. ANTI-EMBOLISM STOCKING 2

SUSPENDING AGENTS GELFILM 2

SWEETENERS SACCHARIN 2

TISSUE/WOUND ADHESIVES ARTISS 2

TOPICAL ANTISEPTIC DRYING AGENTS FORMALDEHYDE 1

UNKNOWN CRYOSERV 2

URINARY TRACT RADIOPAQUE DIAGNOSTICS CYSTO-CONRAY II 2 CYSTOGRAFIN 2 CYSTOGRAFIN-DILUTE 2 DIATRIZOATE MEGLU/DIATRIZO SOD 1 GASTROGRAFIN 2

URINE ACETONE TEST AIDS ACETEST REAGENT 2 CHEMSTRIP K 2 KETONE 2 KETONE CARE 2 KETOSTIX REAGENT 2

URINE TEST AIDS,MISCELLANEOUS ALBUSTIX REAGENT 2 CHEMSTRIP MICRAL 2 ICTOTEST 2 MICRO-BUMINTEST 2

VEHICLES CITRIC ACID 2 SORBITOL 2

WOUND HEALING AGENTS, LOCAL DERMACINRX SURGICAL PHARMAPAK 2 RADIGEL 2 VENELEX 2

OTHER RESPIRATORY DISORDERS ANTIFIBROTIC THERAPY - PYRIDONE ANALOGS


DRUG CATEGORY & NAME DRUG TIER ESBRIET 4 PIRFENIDONE 4

CYSTIC FIB.TRANSMEMB CONDUCT.REG.(CFTR)POTENTIATOR IVACAFTOR 4 KALYDECO 2, 4

CYSTIC FIBROSIS-CFTR POTENTIATOR & CORRECTOR COMB. ORKAMBI 2

LUNG SURFACTANTS CUROSURF 2 INFASURF 2 SURFAXIN 2 SURVANTA 2

MUCOLYTICS ACETYLCYSTEINE 1 DORNASE ALFA 4 PULMOZYME 4

PULMONARY FIBROSIS - SYSTEMIC ENZYME INHIBITORS NINTEDANIB ESYLATE 4 OFEV 4

PAIN MANAGEMENT - ANALGESICS ANALGESIC, NON-SALICYLATE & BARBITURATE COMB.

BUPAP 2 BUTALBITAL/ACETAMINOPHEN 1

ANALGESIC, SALICYLATE, BARBITURATE,& XANTHINE CMB BUTALBITAL/ASPIRIN/CAFFEINE 1 FIORINAL 2

ANALGESIC,NON-SALICYLATE,BARBITURATE,&XANTHINE CMB BUTALB/ACETAMINOPHEN/CAFFEINE 1 ESGIC 2 FIORICET 2 VANATOL LQ 2

ANALGESIC/ANTIPYRETICS, SALICYLATES ASPIRIN 1 ASPIRIN EC 2 CHOLINE SAL/MAG SALICYLATE 1 DIFLUNISAL 1 DISALCID 2 ECOTRIN 2 LEVACET 2 SALSALATE 1

ANALGESIC/ANTIPYRETICS,NON-SALICYLATE OFIRMEV 2

ANALGESICS NARCOTIC, ANESTHETIC ADJUNCT AGENTS FENTANYL CITRATE/PF 1 SUFENTA 2 SUFENTANIL CITRATE 1 ULTIVA 2


DRUG CATEGORY & NAME DRUG TIER ANALGESICS, NARCOTIC AGONIST AND NSAID COMBINATION

HYDROCODONE/IBUPROFEN 1 IBUDONE 2 IBUPROFEN/OXYCODONE HCL 1 REPREXAIN 2 VICOPROFEN 2

ANALGESICS,NARCOTICS ABSTRAL 2 ACTIQ 2 ASPIRIN-CAFFEINE-DIHYDROCODEIN 2 BELLADONNA-OPIUM 2 BUTORPHANOL TARTRATE 1 BUTRANS 2 CODEINE SULFATE 1, 2 CODEINE/CARISOPRODOL/ASPIRIN 1 CONZIP 2 DEMEROL 2 DHCODEINE BT/ACETAMINOPHN/CAFF 1 DILAUDID 2 DOLOPHINE HCL 2 DURAGESIC 2 EMBEDA 2 EXALGO 2 FENTANYL 1, 2 FENTANYL CITRATE 1 FENTORA 2 HYCET 2 HYDROCODONE/ACETAMINOPHEN 1 HYDROCODONE-ACETAMINOPHEN 2 HYDROMORPHONE ER 2 HYDROMORPHONE HCL 1, 2 HYSINGLA ER 2 IONSYS 2 KADIAN 2 LAZANDA 2 LEVORPHANOL TARTRATE 2 LORTAB 2 MEPERIDINE HCL 1, 2 METHADONE HCL 1, 2 METHADOSE 2 MORPHINE SULFATE 1, 2 MORPHINE SULFATE ER 2 MS CONTIN 2 NORCO 2 NUCYNTA 2 NUCYNTA ER 2 OPANA 2


DRUG CATEGORY & NAME DRUG TIER OPANA ER 2 OXECTA 2 OXYCODONE HCL 1, 2 OXYCODONE HCL ER 2 OXYCODONE HCL/ACETAMINOPHEN 1 OXYCODONE HCL/ASPIRIN 1 OXYCONTIN 2 OXYMORPHONE HCL 1 PENTAZOCINE HCL/NALOXONE HCL 1 PERCOCET 2 PRIMLEV 2 ROXICODONE 2 SUBSYS 2 SYNALGOS-DC 2 TRAMADOL HCL 1 TRAMADOL HCL ER 2 TRAMADOL HCL/ACETAMINOPHEN 1 TREZIX 2 ULTRACET 2 ULTRAM 2 ULTRAM ER 2 XARTEMIS XR 2 XODOL 10-300 2 XODOL 5-300 2 XODOL 7.5-300 2 ZAMICET 2 ZOHYDRO ER 2

ANTIMIGRAINE PREPARATIONS ALMOTRIPTAN MALATE 1 ALSUMA 2 AMERGE 2 AXERT 2 CAFERGOT 2 CAMBIA 2 D.H.E.45 2 DIHYDROERGOTAMINE MESYLATE 1, 2 ERGOMAR 2 FROVA 2 IMITREX 2 ISOMETHEPT/DICHLPHN/ACETAMINOP 1 ISOMETHEPTEN/CAF/ACETAMINOPHEN 1 MAXALT 2 MAXALT MLT 2 MIGERGOT 2 MIGRANAL 2 NARATRIPTAN HCL 1 PRODRIN 2


DRUG CATEGORY & NAME DRUG TIER RELPAX 2 RIZATRIPTAN BENZOATE 1 SUMATRIPTAN 2 SUMATRIPTAN SUCCINATE 1, 2 SUMAVEL DOSEPRO 2 TREXIMET 2 ZOLMITRIPTAN 1 ZOMIG 2 ZOMIG ZMT 2

NARC.& NON-SAL.ANALGESIC,BARBITURATE &XANTHINE CMB BUTALBIT/ACETAMIN/CAFF/CODEINE 1 FIORICET WITH CODEINE 2

NARCOTIC & SALICYLATE ANALGESICS, BARB.& XANTHINE CODEINE/BUTALBITAL/ASA/CAFFEIN 1 FIORINAL WITH CODEINE #3 2

NARCOTIC ANALGESIC & NON-SALICYLATE ANALGESIC COMB ACETAMINOPHEN WITH CODEINE 1 CAPITAL W-CODEINE 2 TYLENOL-CODEINE NO.3 2 TYLENOL-CODEINE NO.4 2

NARCOTIC WITHDRAWAL THERAPY AGENTS BUNAVAIL 2 BUPRENORPHINE HCL 1 BUPRENORPHINE HCL/NALOXONE HCL 1 SUBOXONE 2 ZUBSOLV 2

PARKINSONS DISEASE ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC

BENZTROPINE MESYLATE 1 TRIHEXYPHENIDYL HCL 1

ANTIPARKINSONISM DRUGS,OTHER AMANTADINE 2 AMANTADINE HCL 1 APOKYN 4 APOMORPHINE HCL 4 AZILECT 2 BROMOCRIPTINE MESYLATE 1 CARBIDOPA/LEVODOPA 1 CARBIDOPA-LEVODOPA-ENTACAPONE 2 COMTAN 2 DUOPA 2 ELDEPRYL 2 ENTACAPONE 1 MIRAPEX 2 MIRAPEX ER 2 NEUPRO 2 PARLODEL 2


DRUG CATEGORY & NAME DRUG TIER PRAMIPEXOLE DI-HCL 1 REQUIP 2 REQUIP XL 2 ROPINIROLE HCL 1 RYTARY 2 SELEGILINE HCL 1 SINEMET 10-100 2 SINEMET 25-100 2 SINEMET 25-250 2 SINEMET CR 2 STALEVO 100 2 STALEVO 125 2 STALEVO 150 2 STALEVO 200 2 STALEVO 50 2 STALEVO 75 2 TASMAR 4 TOLCAPONE 1, 4 ZELAPAR 2

DECARBOXYLASE INHIBITORS CARBIDOPA 1 LODOSYN 2

SEIZURE DISORDER ANTICONVULSANTS

APTIOM 4 BANZEL 4 CARBAMAZEPINE 1 CARBATROL 2 CELONTIN 2 CLONAZEPAM 1 DEPAKENE 2 DEPAKOTE 2 DEPAKOTE ER 2 DEPAKOTE SPRINKLE 2 DIASTAT 2 DIASTAT ACUDIAL 2 DIAZEPAM 2 DILANTIN 2 DILANTIN-125 2 DIVALPROEX SODIUM 1 ESLICARBAZEPINE ACETATE 4 ETHOSUXIMIDE 1 FELBAMATE 1, 4 FELBATOL 4 FYCOMPA 2 GABAPENTIN 1 GABITRIL 2


DRUG CATEGORY & NAME DRUG TIER KEPPRA 2 KEPPRA XR 2 KLONOPIN 2 LAMICTAL 2 LAMICTAL (BLUE) 2 LAMICTAL (GREEN) 2 LAMICTAL (ORANGE) 2 LAMICTAL ODT 2 LAMICTAL ODT (BLUE) 2 LAMICTAL ODT (GREEN) 2 LAMICTAL ODT (ORANGE) 2 LAMICTAL XR 2 LAMICTAL XR (BLUE) 2 LAMICTAL XR (GREEN) 2 LAMICTAL XR (ORANGE) 2 LAMOTRIGINE 1 LEVETIRACETAM 1 LYRICA 2 MYSOLINE 2 NEURONTIN 2 ONFI 2 OXCARBAZEPINE 1 OXTELLAR XR 2 PEGANONE 2 PHENYTEK 2 PHENYTOIN 1 PHENYTOIN SODIUM EXTENDED 1 POTIGA 2 PRIMIDONE 1 QUDEXY XR 2 RUFINAMIDE 4 SABRIL 4 TEGRETOL 2 TEGRETOL XR 2 TIAGABINE HCL 1 TOPAMAX 2 TOPIRAMATE 1 TOPIRAMATE ER 2 TRILEPTAL 2 TROKENDI XR 2 VALPROIC ACID 1 VALPROIC ACID (AS SODIUM SALT) 1 VIGABATRIN 4 VIMPAT 2 ZARONTIN 2 ZONEGRAN 2 ZONISAMIDE 1


DRUG CATEGORY & NAME DRUG TIER SKELETAL MUSCLE DISORDER

SKELETAL MUSCLE RELAXANTS AMRIX 2 BACLOFEN 1 CARISOPRODOL 1, 2 CARISOPRODOL/ASPIRIN 1 CHLORZOXAZONE 1 CYCLOBENZAPRINE HCL 1 DANTRIUM 2 DANTROLENE SODIUM 1, 2 FEXMID 2 LORZONE 2 METAXALONE 1, 2 METHOCARBAMOL 1 ORPHENADRINE CITRATE 1 PARAFON FORTE DSC 2 ROBAXIN 2 ROBAXIN-750 2 SKELAXIN 2 SOMA 2 TIZANIDINE HCL 1 ZANAFLEX 2

UNKNOWN COMFORT PAC-CYCLOBENZAPRINE 2 COMFORT PAC-TIZANIDINE 2

SMOKING CESSATION SMOKING DETERRENT AGENTS (GANGLIONIC STIM,OTHERS)

NICODERM CQ 2+ NICORETTE 2+ NICOTINE 1+ NICOTINE LOZENGE 2+ NICOTINE PATCH 2+ NICOTINE POLACRILEX 1+ NICOTROL 2+ NICOTROL NS 2+

SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONIST CHANTIX 2+

SMOKING DETERRENTS, OTHER BUPROPION HCL 1+ ZYBAN 2+

UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE GASTRIC ENZYMES

SUCRAID 2 PANCREATIC ENZYMES

CREON 2 PANCREAZE 2 PANCRELIPASE 5,000 2


DRUG CATEGORY & NAME DRUG TIER PERTZYE 2 ULTRESA 2 VIOKACE 2 ZENPEP 2

UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE ANTICHOLINERGICS/ANTISPASMODICS

BENTYL 2 DICYCLOMINE HCL 1

BELLADONNA ALKALOIDS ANASPAZ 2 DONNATAL 2 HYOSCYAMINE SULFATE 1 LEVBID 2 LEVSIN 2 LEVSIN-SL 2 METHSCOPOLAMINE BROMIDE 1 PHENOBARB/HYOSCY/ATROPINE/SCOP 1 SYMAX DUOTAB 2

UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE ANTICHOLINERGICS,QUATERNARY AMMONIUM

CANTIL 2 CHLORDIAZEPOXIDE/CLIDINIUM BR 1 CUVPOSA 2 GLYCOPYRROLATE 1 LIBRAX 2 PROPANTHELINE BROMIDE 2 ROBINUL 2 ROBINUL FORTE 2

ANTI-ULCER PREPARATIONS CARAFATE 2 CYTOTEC 2 MISOPROSTOL 1 SUCRALFATE 1, 2

ANTI-ULCER-H.PYLORI AGENTS LANSOPRAZOLE/AMOXICILN/CLARITH 1 OMECLAMOX-PAK 2 PREVPAC 2 PYLERA 2

HISTAMINE H2-RECEPTOR INHIBITORS CIMETIDINE 1 CIMETIDINE HCL 1 FAMOTIDINE 1 NIZATIDINE 1 PEPCID 2 RANITIDINE HCL 1 ZANTAC 2

INTESTINAL MOTILITY STIMULANTS


DRUG CATEGORY & NAME DRUG TIER METOCLOPRAMIDE HCL 1 METOZOLV ODT 2 REGLAN 2

PROTON-PUMP INHIBITORS ACIPHEX 2 ACIPHEX SPRINKLE 2 DEXILANT 2 ESOMEPRAZOLE MAGNESIUM 1 LANSOPRAZOLE 1 NEXIUM 2 OMEPRAZOLE 1 OMEPRAZOLE/SODIUM BICARBONATE 1 PANTOPRAZOLE SODIUM 1 PREVACID 2 PRILOSEC 2 PROTONIX 2 RABEPRAZOLE SODIUM 1 ZEGERID 2

URINARY TRACT - FUNCTIONAL DISORDERS BENIGN PROSTATIC HYPERTROPHY/MICTURITION AGENTS

ALFUZOSIN HCL 1 AVODART 2 FINASTERIDE 1 FLOMAX 2 PROSCAR 2 RAPAFLO 2 TAMSULOSIN HCL 1 UROXATRAL 2

BPH AGENTS,5-ALPHA-RED INH & ALPHA-1-ADR ANTG CMB JALYN 2

KIDNEY STONE AGENTS CYSTAGON 2 CYSTEAMINE BITARTRATE 4 PROCYSBI 4 THIOLA 2

OVERACTIVE BLADDER AGENTS, BETA-3 ADRENERGIC RECEP MYRBETRIQ 2

URINARY PH MODIFIERS CITRIC ACID/SODIUM CITRATE 1 CYTRA-3 2 K-PHOS NEUTRAL 2 K-PHOS NO.2 2 K-PHOS ORIGINAL 2 ORACIT 2 PHOSPHORUS #1 1 POTASSIUM CITRATE 1 POTASSIUM CITRATE/CITRIC ACID 1


DRUG CATEGORY & NAME DRUG TIER RENACIDIN 2 SHOHL'S MODIFIED 2 SOD/POT/K CIT/SOD CIT/CIT ACID 1 UROCIT-K 2 UROQID-ACID NO.2 2

URINARY TRACT ANALGESIC AGENTS ELMIRON 2

URINARY TRACT ANESTHETIC/ANALGESIC AGNT (AZO-DYE) PHENAZOPYRIDINE HCL 1 PYRIDIUM 2

URINARY TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG. ENABLEX 2 VESICARE 2

URINARY TRACT ANTISPASMODIC/ANTIINCONTINENCE AGENT DETROL 2 DETROL LA 2 DITROPAN XL 2 FLAVOXATE HCL 1 GELNIQUE 2 OXYBUTYNIN CHLORIDE 1 OXYTROL 2 TOLTERODINE TARTRATE 1 TOVIAZ 2 TROSPIUM CHLORIDE 1

VAGINAL DISORDERS VAGINAL ANTIBIOTICS

CLEOCIN 2 CLINDAMYCIN PHOSPHATE 1 CLINDESSE 2 METROGEL-VAGINAL 2 METRONIDAZOLE 1 NUVESSA 2

VAGINAL ANTIFUNGALS GYNAZOLE 1 2 MICONAZOLE 3 2 TERAZOL 3 2 TERAZOL 7 2 TERCONAZOLE 1

VAGINAL ANTISEPTICS FEM PH 2 RELAGARD 2

VAGINAL ESTROGEN PREPARATIONS ESTRACE 2 ESTRING 2 FEMRING 2 PREMARIN 2 VAGIFEM 2


DRUG CATEGORY & NAME DRUG TIER VAGINAL SULFONAMIDES

AVC 2 VITAMIN AND/OR MINERAL DEFICIENCY

ANTIOXIDANT MULTIVITAMIN COMBINATIONS MACUVEX 2 MACUZIN 2 OCUVEL 2

BIOFLAVONOIDS VASCULERA 2

CALCIUM REPLACEMENT CALCIUM-FOLIC ACID PLUS D 2 FOLGARD OS 2 TL G-FOL OS 2

FLUORIDE PREPARATIONS FLORIVA 2 FLUORABON 2 FLUOR-A-DAY 2 FLURA-DROPS 2 GEL-KAM 2 PHOS-FLUR 2 PREVIDENT 2 PREVIDENT 5000 2 PREVIDENT 5000 ENAMEL PROTECT 2 PREVIDENT 5000 PLUS 2 PREVIDENT 5000 SENSITIVE 2 SODIUM FLUORIDE 1 SODIUM FLUORIDE/POTASSIUM NIT 1 STANNOUS FLUORIDE 1

FOLIC ACID PREPARATIONS DEPLIN-ALGAL OIL 2 ENLYTE 2 FA/MULTIVIT-MIN/YHBK/GIN/DAM 1 FA-8 2 FOLIC ACID 1, 2 LEVOMEFOLATE CALCIUM-ALGAL 2 L-METHYLFOLATE 2 L-METHYLFOLATE CALCIUM 2 L-METHYLFOLATE FORMULA 2 L-METHYLFOLATE FORTE 2 MULTIVIT-MIN/FA/LYCOPENE/LUT 1 PURALOR CI 2

GERIATRIC VITAMIN PREPARATIONS REQ49+ 2

IRON REPLACEMENT ACTIVE FE 2 APETIGEN PLUS 2 APETIGEN-PLUS 2


DRUG CATEGORY & NAME DRUG TIER BIFERA RX 2 CENTRATEX 2 CHEWABLE IRON 2 CHOLECALCIFEROL (VITAMIN D3) 1 CORVITE 150 2 CORVITE FE 2 DUOFER 2 FE FUMARATE/LIVER EXT/BCOMP&C 1 FE FUMARATE/VIT C/B12/STOMC 1 FE FUMARATE/VIT C/B12-IF/FA 1 FEOSOL 2 FERGON 2 FER-IN-SOL 2 FERIVA 2 FERIVA 21-7 2 FERIVA FA 2 FERRACTIV IRON 2 FERRALET 90 2 FERRAPLUS 90 2 FERRETTS 2 FERRETTS IPS 2 FERREX 150 FORTE PLUS 2 FERREX 150 PLUS 2 FERREX 28 2 FERRIC AMCIT/LYS/VIT B COMP/FA 1 FERRIMIN 150 2 FERROUS FUMARATE 1, 2 FERROUS FUMARATE/DOCUSATE NA 1 FERROUS FUMARATE/FOLIC ACID 1 FERROUS GLUCONATE 1, 2 FERROUS SULFATE 1, 2 FERROUS SULFATE, DRIED 1 FOCALGIN DSS 2 FOLITAB 500 2 FOLIVANE-F 2 FOLIVANE-PLUS 2 FUSION 2 FUSION PLUS 2 HEMATOGEN FA 2 HEMATRON-AF 2 HEMETAB 2 HEMOCYTE 2 HEMOCYTE PLUS 2 I.L.X. B-12 2 ICAR 2 ICAR-C 2 INTEGRA 2


DRUG CATEGORY & NAME DRUG TIER INTEGRA F 2 INTEGRA PLUS 2 IRON 2 IRON 21/7 2 IRON CHEWS 2 IRON FUM&POLYSAC#1/FA/MV NO.18 1 IRON FUMARATE/VIT C/VIT B12/FA 1 IRON POLYSACCHARIDE COMPLEX 1 IRON PS CMPLX/VIT B12/FA 1 IRON, CARBONYL/FA/C/B-6/B12/ZN 1 IRON,CARB/DSS/B12IF/FA/MV-MN 1 IRON,CARBONYL 1 IRON,CARBONYL/ASCORBIC ACID 1 IRON,CARBONYL/VIT C/VIT B12/FA 1 IRON/FA/C/E/B12/BIO/COPPER/DSS 1 IRON/FA/VIT B CMPLX #16/MAG/ZN 1 IRON/FA/VITAMIN B COMP W-C/MIN 1 IRON/MULTIVITS,STRESS FORMULA 1 IRONUP 2 IRO-PLEX 2 IROSPAN 2 LYDIA PINKHAM HERBAL 2 MAXARON FORTE 2 MAXFE 2 MULTIGEN 2 MULTIGEN FOLIC 2 MULTIGEN PLUS 2 MYKIDZ IRON 10 2 NEPHRON FA 2 NOVAFERRUM 2 NOVAFERRUM 125 2 NOVAFERRUM 50 2 PERFECT IRON 2 PRO FE 2 PROFERRIN 2 PROFERRIN-FORTE 2 SIDEROL 2 SLOW RELEASE IRON 2 TANDEM DUAL ACTION 2 TANDEM PLUS 2 TARON FORTE 2 VIT B COMP/C/FA/IRON SULF/VITE 1 VIT B COMP/C/FA/IRON/VIT E 1 VITAFOL 2 VITRON-C 2

MULTIVITAMIN PREPARATIONS ADVANCED AM/PM 2


DRUG CATEGORY & NAME DRUG TIER ANIMI-3 2 BACMIN 2 BP VIT 3 PLUS 2 CORVITE 2 DIALYVITE 800 WITH IRON 2 FA/MU-VITS-MIN TH/LYCOPENE/LUT 1 FORTAVIT 2 MULTICHEW 2 MULTIVITAMIN NO.44/VIT D3/K 1 MULTIVITAMINS WITH MIN NO.5/FA 1 MULTIVITAMINS WITH MIN NO.7/FA 1 MULTIVITS,THERAP W-FE,HEMATIN 1 MV, MIN CMB #6/FA/LUT/LYCO/Q10 1 NICOMIDE 2 NUTRICAP 2 PARVLEX 2 PROTECT IRON 2 STROVITE FORTE 2 STROVITE ONE 2 SUPERVITE EC 2 UDAMIN SP 2 VIT 3 2

PEDIATRIC VITAMIN PREPARATIONS COMPLETE FORMULATION D3000 2 COMPLETE FORMULATION PEDIATRIC 2 ESCAVITE 2 ESCAVITE D 2 ESCAVITE LQ 2 FLORIVA 2 MYKIDZ IRON FL 2 PED MV A,C,D3 #21 W-FLUORIDE 1 PEDI M.VIT NO.17 WITH FLUORIDE 1 PEDI MULTIVIT #22/VIT D3/VIT K 1 PEDI MULTIVIT #65/VIT D3/VIT K 1 PEDI MULTIVIT NO.2 W-FLUORIDE 1 PEDI MV #45/FLUORIDE/IRON 1 PEDI MV #75/FLUORIDE/IRON 1 PEDI MVI NO.12/SODIUM FLUORIDE 1 PEDI MVI NO.16 WITH FLUORIDE 1 PEDI MVI NO.82 WITH FLUORIDE 1 POLY-VI-FLOR 2 POLY-VI-FLOR FS 2 POLY-VI-FLOR WITH IRON 2 QUFLORA 2 TEXAVITE LQ 2 TRI-VI-FLOR 2 TRI-VIT WITH FLUORIDE-IRON 2


DRUG CATEGORY & NAME DRUG TIER PRENATAL VITAMIN PREPARATIONS

ACTIVE OB 2 ATABEX EC 2 BAL-CARE DHA 2 BAL-CARE DHA ESSENTIAL 2 CALCIUM PNV 2 CITRANATAL 90 DHA 2 CITRANATAL ASSURE 2 CITRANATAL B-CALM 2 CITRANATAL DHA 2 CITRANATAL HARMONY 2 CITRANATAL RX 2 C-NATE DHA 2 COMPLETE NATAL DHA 2 COMPLETENATE 2 CONCEPT DHA 2 CONCEPT OB 2 DOTHELLE DHA 2 DUET DHA 400 2 DUET DHA BALANCED 2 ELITE OB DHA 2 ELITE-OB 2 ELITE-OB 400 2 ENBRACE HR 2 EXTRA-VIRT PLUS DHA 2 FOCALGIN 90 DHA 2 FOCALGIN CA 2 FOLET DHA 2 FOLET ONE 2 FOLIVANE-OB 2 HEMENATAL OB 2 HEMENATAL OB + DHA 2 ICAR-C PLUS 2 INATAL ADVANCE 2 INATAL ULTRA 2 INFANATE BALANCE 2 IRON,CARBONYL/VIT C/VIT B12/FA 1 LEVOMEFOLATE DHA 2 MACNATAL CN DHA 2 MARNATAL-F 2 MAXINATE 2 M-VIT 2 MYNATAL 2 MYNATAL ADVANCE 2 MYNATAL PLUS 2 MYNATAL-Z 2 MYNATE 90 PLUS 2


DRUG CATEGORY & NAME DRUG TIER NATACHEW 2 NATALVIT 2 NATELLE ONE 2 NEEVODHA 2 NESTABS 2 NESTABS ABC 2 NESTABS DHA 2 NEWGEN 2 NEXA PLUS 2 NIVA-PLUS 2 OB COMPLETE 2 OB COMPLETE ONE 2 OB COMPLETE PETITE 2 OB COMPLETE PREMIER 2 OB COMPLETE WITH DHA 2 OBSTETRIX DHA 2 OBSTETRIX EC 2 OBTREX DHA 2 O-CAL FA 2 O-CAL PRENATAL 2 PAIRE OB PLUS DHA 2 PNV 29-1 2 PNV NO12/IRON,CARB/FA/DSS/OM-3 1 PNV OB+DHA 2 PNV W-CA8/IRON/FA/LMEFOLATE CA 1 PNV,CA42/IRON/FA/LMEFOL CA/DHA 1 PNV-DHA 2 PNV-DHA + DOCUSATE 2 PNV-FERROUS FUMARATE-DOCU-FA 2 PNV-OMEGA 2 PNV-SELECT 2 PNV-TOTAL 2 PNV-VP-U 2 PR NATAL 400 2 PR NATAL 400 EC 2 PR NATAL 430 2 PR NATAL 430 EC 2 PREFERA OB 2 PREFERA-OB ONE 2 PREFERA-OB PLUS DHA 2 PRENA1 CHEW 2 PRENA1 PEARL 2 PRENAISSANCE 2 PRENAISSANCE BALANCE 2 PRENAISSANCE PLUS 2 PRENATA 2 PRENATABS FA 2


DRUG CATEGORY & NAME DRUG TIER PRENATABS RX 2 PRENATAL 19 2 PRENATAL LOW IRON 2 PRENATAL PLUS 2 PRENATAL VIT #83/IRON/FA#6/DHA 1 PRENATAL VITAMINS LOW IRON 2 PRENATAL-U 2 PRENATE AM 2 PRENATE CHEWABLE 2 PRENATE DHA 2 PRENATE ELITE 2 PRENATE ENHANCE 2 PRENATE ESSENTIAL 2 PRENATE MINI 2 PRENATE PIXIE 2 PRENATE RESTORE 2 PRENATE STAR 2 PREPLUS 2 PREQUE 10 2 PRETAB 2 PROVIDA DHA 2 PROVIDA OB 2 PUREFE OB PLUS 2 PUREFE PLUS 2 RELNATE DHA 2 R-NATAL OB 2 RULAVITE DHA 2 SELECT-OB 2 SELECT-OB + DHA 2 SE-NATAL 19 2 SE-TAN DHA 2 TARON-BC 2 TARON-C DHA 2 TARON-PREX PRENATAL 2 THRIVITE 19 2 TL FOLATE 2 TL-SELECT 2 TRIADVANCE 2 TRICARE 2 TRICARE PRENATAL DHA ONE 2 TRINATAL GT 2 TRINATAL RX 1 2 TRINATE 2 TRISTART DHA 2 TRI-TABS DHA 2 TRIVEEN-DUO DHA 2 TRIVEEN-ONE 2


DRUG CATEGORY & NAME DRUG TIER TRIVEEN-PRX RNF 2 TRIVEEN-U 2 TRUST NATAL DHA 2 ULTIMATECARE ONE 2 ULTIMATECARE ONE NF 2 VEMAVITE-PRX 2 2 VENA-BAL DHA 2 VENATAL COMPLETE DHA 2 VINACAL 2 VINATE CARE 2 VINATE DHA 2 VINATE DHA RF 2 VINATE GT 2 VINATE II 2 VINATE ONE 2 VINATE PN CARE 2 VINATE ULTRA 2 VINATE-M 2 VIRT NATE 2 VIRT-ADVANCE 2 VIRT-C DHA 2 VIRT-CARE ONE 2 VIRT-PN 2 VIRT-PN DHA 2 VIRT-PN PLUS 2 VIRTPREX 2 VIRT-SELECT 2 VIRT-VITE GT 2 VITAFOL NANO 2 VITAFOL ULTRA 2 VITAFOL-OB 2 VITAFOL-OB+DHA 2 VITAFOL-ONE 2 VITAMEDMD ONE RX 2 VITAMEDMD PLUS RX 2 VITAMEDMD REDICHEW RX 2 VITAPEARL 2 VITASPIRE 2 VIVA DHA 2 VOL-NATE 2 VOL-PLUS 2 VOL-TAB RX 2 VP-CH PLUS 2 VP-CH-PNV 2 VP-HEME OB 2 VP-HEME OB + DHA 2 VP-HEME ONE 2


DRUG CATEGORY & NAME DRUG TIER VP-PNV-DHA 2 ZATEAN-CH 2 ZATEAN-PN DHA 2 ZATEAN-PN PLUS 2

PRENATAL VITAMINS WITHOUT IRON FOLBECAL 2 FOLINATAL PLUS B 2 PRENAISSANCE NEXT 2 PRENAISSANCE NEXT-B 2 VP-GGR-B6 2 ZINGIBER 2

VITAMIN A & D PREPARATIONS VIT A & D3 IN COD LIVER OIL 1

VITAMIN B PREPARATIONS B COMPLEX & C NO.20/FOLIC ACID 1 CARDIOTEK-RX 2 CEREFOLIN 2 CEREFOLIN NAC 2 CYANOCOBALAMIN/FA/PYRIDOXINE 1 DIALYVITE 3000 2 DIALYVITE 5000 2 DIALYVITE SUPREME D 2 DIALYVITE ZINC 2 FOLBIC RF 2 FOLGARD RX 2 FOLIC ACID/B COMPLEX & C NO.17 1 FOLIC ACID/VIT BCOMP&C/CU/ZNOX 1 FOLIC ACID/VITAMIN B COMP W-C 1 FOLTANX 2 FOLTANX RF 2 FOLTX 2 LEVOMEFOLATE-NAC-MECOBAL-ALGAL 2 LEVOMEFOL-PYRIDOXAL-MEC-ALGAL 2 L-METHYL-B6-B12 2 L-METHYLFOLATE CA P-5-P ME-CBL 2 L-METHYLFOLATE-MECOBALAMIN-NAC 2 L-METHYL-MC 2 L-METHYL-MC NAC 2 LMTHF-PYRIDOXINE-CYANOCOBAL 2 METAFOLBIC 2 METAFOLBIC PLUS 2 METAFOLBIC PLUS RF 2 METANX 2 NEPHPLEX RX 2 NEPHROCAPS 2 NEPHROCAPS QT 2 NEPHRO-VITE RX 2


DRUG CATEGORY & NAME DRUG TIER PODIAPN 2 POTABA 2 SUPERVITE 2 VIT B CMPLX 3/FA/VIT C/BIOTIN 1 VITAL-D RX 2 VITA-RESPA 2

VITAMIN B12 PREPARATIONS ELIGEN B12 2 FOLTRATE 2 NASCOBAL 2 NEURIN-SL 2

VITAMIN D PREPARATIONS CALCITRIOL 1 CHILDREN'S REPLESTA 2 CHOLECALCIFEROL (VITAMIN D3) 1 CIFEREX 2 COD LIVER OIL 1, 2 D3 + K2 DOTS 2 DECARA 2 DIALYVITE VITAMIN D3 MAX 2 DRISDOL 2 DURACHOL 2 D-VI-SOL 2 ERGOCALCIFEROL (VITAMIN D2) 1 FISH OIL/DHA/EPA 1 ISO D3 2 K2 PLUS D3 2 ORTHO D 2 REPLESTA 2 REPLESTA NX 2 REVESTA 2 ROCALTROL 2 SUPER DAILY D3 2 THERA-D 2 VITAMIN D 2 VITAMIN D2 2 VITAMIN D3 2

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Kaiser Permanente Point-of-Service Drug Formulary with ... POS... · POS Formulary with Specialty Tier – Last revised 12/22/2015, 1 Kaiser Permanente Point-of-Service Drug Formulary