Printable Preferred Drug List | Select Health of South ... · mg/5 mL, 500 mg/5 mL cefadroxil oral tablet cefazolin injection recon soln 1 gram, 10 gram, 500 mg Specialty PA ... 500

Preferred Drug ListSelect Health PerformRx Pharmacy Services

Phone 1.866.610.2773 | Fax 1.866.610.2775Member ServicesPhone 1.888.276.2020Providers may request the addition or deletion of a medication

to this list. Requests must include the drug name, rationale for

inclusion on the list, role in therapy and medications that may

be replaced by the addition. Please direct such requests to:

Pharmacy and Therapeutics Committee at Select Health

PO Box 40849Charleston, SC 29423Members may request changes to the list by calling Member

Services.

For the most current Preferred Drug List (PDL), please use the

searchable PDL on our website, www.selecthealthofsc.com.

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AL = Age Limit

GL = Gender Limit

PA = Prior Authorization

QL = Quantity Limit

ST = Step therapy

1

Drug Name Tier Requirements/Limits

Antihistamine Drugs

Ethanolamine Derivatives

dimenhydrinate oral

diphenhydramine HCl injection solution 50

mg/mL

diphenhydramine HCl injection syringe

diphenhydramine HCl oral capsule

diphenhydramine HCl oral liquid

diphenhydramine HCl oral syrup

diphenhydramine HCl oral tablet 25 mg

Sleep Aid (doxylamine)

First Gen. Antihist. Derivatives, Misc.

cyproheptadine

First Generation Antihistamines

chlorpheniramine maleate oral tablet

cyproheptadine

dimenhydrinate oral


mg/mL







Phenothiazine Derivatives

promethazine oral

promethazine rectal

Promethazine VC

Promethazine VC-Codeine QL; AL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

2


promethazine-DM

Piperazine Derivatives

hydroxyzine HCl oral solution 10 mg/5 mL

hydroxyzine HCl oral tablet

hydroxyzine pamoate

meclizine oral tablet 12.5 mg, 25 mg

meclizine oral tablet,chewable

Propylamine Derivatives

Carbaphen CH

Centergy


Conex oral solution

Dimetapp Cold-Allergy (PE)

Ed Chlorped D

Lodrane D

LoHist - D

M-End DMX

NoHist-DM

Rynex PSE

Trexbrom

Second Generation Antihistamines

Allergy Relief (cetirizine) oral capsule ST

cetirizine oral solution 1 mg/mL

cetirizine oral tablet

cetirizine-pseudoephedrine ST

Children's Zyrtec Allergy oral tablet,disintegrating ST

fexofenadine oral suspension ST

fexofenadine oral tablet 180 mg ST

levocetirizine oral tablet

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

3


loratadine oral capsule ST

loratadine oral solution ST

loratadine oral tablet

loratadine oral tablet,disintegrating ST

Anti-Infective Agents

1St Generation Cephalosporin Antibiotics

cefadroxil oral capsule

cefadroxil oral suspension for reconstitution 250

mg/5 mL, 500 mg/5 mL

cefadroxil oral tablet

cefazolin injection recon soln 1 gram, 10 gram,

500 mg

Specialty PA

cephalexin oral capsule 250 mg, 500 mg

cephalexin oral suspension for reconstitution

2Nd Generation Cephalosporin Antibiotics

cefotetan Specialty PA

cefotetan in dextrose, iso-osm Specialty PA

cefprozil

cefuroxime axetil oral tablet

cefuroxime sodium intravenous recon soln 7.5

gram

Specialty PA

3Rd Generation Cephalosporin Antibiotics

cefdinir QL

cefotaxime Specialty PA

ceftazidime Specialty PA

ceftriaxone in dextrose,iso-os Specialty PA

ceftriaxone injection recon soln 1 gram, 10 gram, 2

gram, 250 mg, 500 mg

Specialty PA

ceftriaxone intravenous Specialty PA

Claforan intravenous recon soln Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

4


Suprax oral capsule QL

Suprax oral suspension for reconstitution 100 mg/5

mL, 200 mg/5 mL

TAZICEF intravenous Specialty PA

4Th Generation Cephalosporin Antibiotics

cefepime in dextrose 5 % Specialty PA

cefepime in dextrose,iso-osm Specialty PA

cefepime injection Specialty PA

Adamantane Antivirals

amantadine HCl oral capsule

amantadine HCl oral solution

rimantadine

Allylamine Antifungals

terbinafine HCl oral

Amebicides

metronidazole in NaCl (iso-os) Specialty PA

metronidazole oral tablet

Aminoglycoside Antibiotics

amikacin injection solution 1,000 mg/4 mL, 500

mg/2 mL

Specialty PA

gentamicin in NaCl (iso-osm) intravenous

piggyback 100 mg/100 mL, 100 mg/50 mL, 80

mg/100 mL, 80 mg/50 mL

Specialty PA

gentamicin injection Specialty PA

gentamicin sulfate (PF) intravenous solution 100

mg/10 mL, 60 mg/6 mL

Specialty PA

Tobi Podhaler Specialty PA

tobramycin in 0.225 % NaCl Specialty PA

tobramycin sulfate Specialty PA

Aminopenicillin Antibiotics

amoxicillin oral capsule

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

5


amoxicillin oral suspension for reconstitution

amoxicillin oral tablet

amoxicillin oral tablet,chewable 125 mg, 250 mg

amoxicillin-pot clavulanate oral suspension for

reconstitution

amoxicillin-pot clavulanate oral tablet

amoxicillin-pot clavulanate oral tablet,chewable

ampicillin oral capsule

ampicillin sodium Specialty PA

ampicillin-sulbactam Specialty PA

Augmentin oral suspension for reconstitution 125-

31.25 mg/5 mL

Anthelmintics

Biltricide

Antifungals, Miscellaneous

griseofulvin microsize

griseofulvin ultramicrosize

SSKI

Antimalarials

atovaquone-proguanil

chloroquine phosphate

Daraprim Specialty PA

hydroxychloroquine

mefloquine

primaquine

quinidine gluconate oral

quinidine sulfate oral tablet

Antimycobacterials, Miscellaneous

dapsone oral

Antiprotozoals, Miscellaneous

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

6


atovaquone PA

dapsone oral

metronidazole in NaCl (iso-os) Specialty PA

metronidazole oral tablet

Nebupent Specialty PA

Pentam Specialty PA

Antituberculosis Agents

amikacin injection solution 1,000 mg/4 mL, 500

mg/2 mL

Specialty PA

ciprofloxacin

ciprofloxacin (mixture)

ciprofloxacin HCl oral tablet 250 mg, 500 mg QL

ciprofloxacin HCl oral tablet 750 mg

ciprofloxacin in 5 % dextrose intravenous

piggyback 400 mg/200 mL

Specialty PA

clarithromycin QL

ethambutol

isoniazid oral

levofloxacin oral QL

moxifloxacin oral QL

Mycobutin

pyrazinamide

rifampin intravenous Specialty PA

rifampin oral

Antivirals, Miscellaneous

foscarnet Specialty PA

Azole Antifungals

fluconazole in dextrose(iso-o) intravenous


Specialty PA

fluconazole in NaCl (iso-osm) intravenous

piggyback 200 mg/100 mL, 400 mg/200 mL

Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

7


fluconazole oral suspension for reconstitution

fluconazole oral tablet 100 mg, 200 mg, 50 mg

fluconazole oral tablet 150 mg QL

itraconazole oral capsule PA

ketoconazole oral

Sporanox oral solution PA

Vfend IV Specialty PA

Carbapenem Antibiotics

Invanz Specialty PA

meropenem Specialty PA

Cephamycin Antibiotics

cefotetan Specialty PA

cefotetan in dextrose, iso-osm Specialty PA

Cyclic Lipopeptide Antibiotics

daptomycin intravenous recon soln 500 mg Specialty PA

Echinocandin Antifungals

caspofungin Specialty PA

Eraxis(Water Diluent) Specialty PA

Mycamine Specialty PA

Erythromycin Antibiotics

Ery-Tab

Erythrocin (as stearate) oral tablet 250 mg

erythromycin ethylsuccinate oral suspension for

reconstitution

erythromycin ethylsuccinate oral tablet

erythromycin oral capsule,delayed release(DR/EC)

erythromycin oral tablet

Extended-Spectrum Penicillins

piperacillin-tazobactam intravenous recon soln

2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

8


Zosyn in dextrose (iso-osm) Specialty PA

Glycopeptide Antibiotics

Firvanq

vancomycin in dextrose 5 % intravenous

piggyback 1 gram/200 mL, 750 mg/150 mL

Specialty PA

vancomycin intravenous recon soln 1,000 mg, 10

gram, 5 gram, 500 mg, 750 mg

Specialty PA

vancomycin oral capsule

Vibativ intravenous recon soln 750 mg Specialty PA

Glycylcycline Antibiotics

tigecycline Specialty PA

Hiv Entry And Fusion Inhibitors

Fuzeon subcutaneous recon soln PA

Selzentry oral tablet

Hiv Integrase Inhibitor Antiretrovirals

Genvoya

Isentress HD

Isentress oral tablet

Isentress oral tablet,chewable

Juluca

Stribild

Hiv Nonnucleoside Rev.Transcrip. Inhib.

Edurant

efavirenz

Intelence oral tablet 100 mg, 200 mg

nevirapine oral suspension

nevirapine oral tablet

nevirapine oral tablet extended release 24 hr 400

mg

Odefsey

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

9


Rescriptor

Symfi

Symfi Lo

Viramune XR oral tablet extended release 24 hr

100 mg

Hiv Nucleoside, Nucleotide Rt Inhibitors

abacavir

abacavir-lamivudine

Cimduo

Descovy

didanosine

Emtriva

Epivir HBV

Genvoya

lamivudine oral solution

lamivudine oral tablet 150 mg, 300 mg

lamivudine-zidovudine

Odefsey

stavudine oral capsule

Stribild

Symfi

Symfi Lo

tenofovir disoproxil fumarate

Trizivir

Truvada

Videx 2 gram Pediatric

Viread oral tablet 150 mg, 200 mg, 250 mg

Zerit oral recon soln

zidovudine

Hiv Protease Inhibitor Antiretrovirals

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

10


Aptivus

atazanavir

Crixivan oral capsule 200 mg, 400 mg

fosamprenavir

Invirase

Kaletra oral tablet

Lexiva oral suspension

lopinavir-ritonavir

Norvir oral capsule

Norvir oral solution

Prezcobix

Prezista oral suspension

Prezista oral tablet 150 mg, 600 mg, 75 mg, 800

mg

ritonavir

Viracept oral tablet

Interferon Antivirals

Alferon N Specialty PA

Intron A injection Specialty PA

Sylatron Specialty PA

Lincomycin Antibiotics

clindamycin HCl oral capsule 150 mg, 300 mg

clindamycin in 5 % dextrose Specialty PA

clindamycin palmitate HCl

clindamycin phosphate injection Specialty PA

clindamycin phosphate intravenous solution 900

mg/6 mL

Specialty PA

Lincocin Specialty PA

Macrolide Antibiotics

Ery-Tab

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

11


Erythrocin (as stearate) oral tablet 250 mg

erythromycin ethylsuccinate oral suspension for

reconstitution

erythromycin ethylsuccinate oral tablet

erythromycin oral capsule,delayed release(DR/EC)

erythromycin oral tablet

Monobactam Antibiotics

Azactam in dextrose (iso-osm) Specialty PA

aztreonam Specialty PA

Cayston Specialty PA

Monoclonal Antibody Antivirals

Synagis PA

Natural Penicillin Antibiotics

Bicillin L-A

penicillin G potassium Specialty PA

penicillin V potassium

Neuraminidase Inhibitor Antivirals

oseltamivir QL

Relenza Diskhaler QL

Nucleoside And Nucleotide Antivirals

acyclovir oral capsule

acyclovir oral suspension 200 mg/5 mL

acyclovir oral tablet

adefovir Specialty PA

cidofovir Specialty PA

Cytovene Specialty PA

entecavir

Rebetol oral solution Specialty PA

valacyclovir QL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

12


Other Macrolide Antibiotics

azithromycin oral QL

clarithromycin QL

Dificid PA

Zmax QL

Oxazolidinone Antibiotics

Zyvox intravenous Specialty PA

Penicillinase-Resistant Penicillins

dicloxacillin

nafcillin in dextrose iso-osm intravenous

piggyback 2 gram/100 mL

Specialty PA

nafcillin injection Specialty PA

oxacillin injection Specialty PA

Polyene Antifungals

Abelcet Specialty PA

AmBisome Specialty PA

nystatin oral powder 150 million unit, 500 million

unit

nystatin oral suspension

nystatin oral tablet

Polymyxin Antibiotics

colistin (colistimethate Na) Specialty PA

Quinolone Antibiotics

ciprofloxacin

ciprofloxacin (mixture)

ciprofloxacin HCl oral tablet 250 mg, 500 mg QL

ciprofloxacin HCl oral tablet 750 mg

ciprofloxacin in 5 % dextrose intravenous


Specialty PA

levofloxacin oral QL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

13


moxifloxacin oral QL

ofloxacin oral tablet 400 mg

Rifamycin Antibiotics

Mycobutin

rifampin intravenous Specialty PA

rifampin oral

Streptogramin Antibiotics

Synercid Specialty PA

Sulfonamide Antibiotics (Systemic)

sulfadiazine

sulfamethoxazole-trimethoprim intravenous Specialty PA

sulfamethoxazole-trimethoprim oral

sulfasalazine

Tetracycline Antibiotics

Doxy-100 Specialty PA

doxycycline hyclate oral capsule

doxycycline hyclate oral tablet 100 mg

doxycycline hyclate oral tablet,delayed release

(DR/EC) 75 mg

doxycycline monohydrate oral capsule 100 mg, 50

mg

doxycycline monohydrate oral tablet

minocycline oral capsule

minocycline oral tablet

tetracycline

Urinary Anti-Infectives

nitrofurantoin

nitrofurantoin macrocrystal oral capsule 100 mg,

50 mg

nitrofurantoin monohyd/m-cryst

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

14


trimethoprim

Urin DS

Antineoplastic Agents

Antineoplastic Agents

Abraxane Specialty PA

Adcetris Specialty PA

Afinitor Specialty PA

Afinitor Disperz Specialty PA

Alferon N Specialty PA

Alimta Specialty PA

anastrozole

Arranon Specialty PA

Arzerra intravenous solution 100 mg/5 mL Specialty PA

Avastin Specialty PA

bexarotene Specialty PA

bicalutamide

BiCNU Specialty PA

bleomycin Specialty PA

Bosulif Specialty PA

busulfan Specialty PA

Camptosar intravenous solution 300 mg/15 mL Specialty PA

capecitabine Specialty PA

Caprelsa Specialty PA

carboplatin Specialty PA

cisplatin Specialty PA

cladribine Specialty PA

clofarabine Specialty PA

Cometriq Specialty PA

cyclophosphamide intravenous Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

15


cytarabine Specialty PA

cytarabine (PF) injection solution Specialty PA

dacarbazine Specialty PA

Dacogen Specialty PA

dactinomycin Specialty PA

daunorubicin intravenous solution Specialty PA

Docefrez Specialty PA

docetaxel intravenous solution 160 mg/16 mL (10

mg/mL), 160 mg/8 mL (20 mg/mL), 20 mg/2 mL

(10 mg/mL), 20 mg/mL (1 mL), 80 mg/4 mL (20

mg/mL), 80 mg/8 mL (10 mg/mL)

Specialty PA

Doxil Specialty PA

doxorubicin intravenous solution Specialty PA

Droxia

Eligard Specialty PA

Eligard (3 month) Specialty PA



Emcyt

epirubicin intravenous recon soln 50 mg Specialty PA

epirubicin intravenous solution Specialty PA

Erbitux Specialty PA

Erivedge Specialty PA

Erwinaze Specialty PA

Etopophos Specialty PA

etoposide Specialty PA

exemestane

Fareston Specialty PA

Faslodex Specialty PA

Firmagon kit w diluent syringe Specialty PA

Firmagon subcutaneous recon soln 120 mg Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

16


floxuridine Specialty PA

fludarabine Specialty PA

fluorouracil intravenous Specialty PA

flutamide

Folotyn Specialty PA

gemcitabine intravenous recon soln Specialty PA

gemcitabine intravenous solution 1 gram/26.3 mL

(38 mg/mL), 2 gram/52.6 mL (38 mg/mL), 200

mg/5.26 mL (38 mg/mL)

Specialty PA

Gliadel Wafer Specialty PA

Halaven Specialty PA

Herceptin intravenous recon soln 440 mg Specialty PA

Hexalen

Hycamtin oral Specialty PA

hydroxyurea

Ibrance Specialty PA

Iclusig Specialty PA

idarubicin Specialty PA

ifosfamide Specialty PA

ifosfamide-mesna intravenous kit 1-1 gram Specialty PA

imatinib Specialty PA

Inlyta Specialty PA


irinotecan Specialty PA

Ixempra Specialty PA

Jakafi Specialty PA

Jevtana Specialty PA

Kadcyla Specialty PA

Kyprolis intravenous recon soln 60 mg Specialty PA

letrozole QL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

17


Leukeran

leuprolide subcutaneous kit Specialty PA

Lupron Depot Specialty PA

Lupron Depot (3 month) Specialty PA


Lupron Depot (6 Month) Specialty PA

Lupron Depot-Ped Specialty PA

Lupron Depot-Ped (3 month) Specialty PA

Lysodren

Matulane

megestrol oral suspension 400 mg/10 mL (40

mg/mL)

megestrol oral suspension 625 mg/5 mL QL

megestrol oral tablet

melphalan

melphalan HCl Specialty PA

mercaptopurine

methotrexate sodium

methotrexate sodium (PF)

mitomycin intravenous Specialty PA

mitoxantrone Specialty PA

Mustargen Specialty PA

Myleran

Nexavar Specialty PA

nilutamide Specialty PA

Oncaspar Specialty PA

oxaliplatin Specialty PA

paclitaxel Specialty PA

Perjeta Specialty PA

Photofrin Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

18


Pomalyst Specialty PA

Proleukin Specialty PA

Revlimid oral capsule 10 mg, 15 mg, 2.5 mg, 25

mg, 5 mg

Specialty PA

Rituxan Specialty PA

Rituxan Hycela Specialty PA

romidepsin Specialty PA

Sprycel Specialty PA

Stivarga Specialty PA

Supprelin LA Specialty PA

Sutent Specialty PA

Sylatron Specialty PA

Synribo Specialty PA

Tabloid

tamoxifen

Tarceva Specialty PA

Targretin topical Specialty PA

Tasigna Specialty PA

Temodar intravenous Specialty PA

temozolomide Specialty PA

teniposide Specialty PA

thiotepa Specialty PA

Tice BCG Specialty PA

topotecan Specialty PA

Torisel Specialty PA

Treanda intravenous recon soln Specialty PA

Trelstar Specialty PA

tretinoin (chemotherapy) Specialty PA

Tykerb Specialty PA

Valstar Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

19


Vectibix Specialty PA

Velcade Specialty PA

Vidaza Specialty PA

vinblastine intravenous solution Specialty PA

vincristine Specialty PA

vinorelbine Specialty PA

Votrient Specialty PA

Xalkori Specialty PA

Xtandi Specialty PA

Yervoy Specialty PA

Zaltrap Specialty PA

Zanosar Specialty PA

Zelboraf Specialty PA

Zevalin (Y-90) Specialty PA

Zoladex Specialty PA

Zolinza Specialty PA

Zytiga oral tablet 250 mg Specialty PA

Antitoxins,Immune Glob,Toxoids,Vaccines

Antitoxins And Immune Globulins

Carimune NF Nanofiltered intravenous recon soln

12 gram, 6 gram

Specialty PA

CytoGam intravenous solution 50 mg/mL Specialty PA

Flebogamma DIF intravenous solution 5 % Specialty PA

GamaSTAN S/D Specialty PA

Gamunex-C injection solution 1 gram/10 mL (10

%), 10 gram/100 mL (10 %), 2.5 gram/25 mL (10

%), 20 gram/200 mL (10 %), 5 gram/50 mL (10

%)

Specialty PA

Hizentra subcutaneous solution 1 gram/5 mL (20

%), 2 gram/10 mL (20 %), 4 gram/20 mL (20 %)

Specialty PA

MICRhoGAM Ultra-Filtered PLUS Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

20


Privigen Specialty PA

RhoGAM Ultra-Filtered PLUS Specialty PA

Rhophylac Specialty PA

WinRho SDF Specialty PA

Toxoids

Adacel(Tdap Adolesn/Adult)(PF)

Boostrix Tdap

Vaccines

Afluria 2017-2018 QL; AL

Afluria 2017-2018 (PF) QL; AL

Afluria Quad 2017-2018 QL; AL

Afluria Quad 2017-2018 (PF) QL; AL

Fluarix Quad 2017-2018 (PF) QL; AL

Flucelvax Quad 2017-2018 QL; AL

Flucelvax Quad 2017-2018 (PF) QL; AL

Flulaval Quad 2017-2018 (PF) QL; AL

Fluvirin 2017-2018 QL; AL

Fluvirin 2017-2018 (PF) QL; AL

Fluzone High-Dose 2017-18 (PF) QL; AL

Fluzone Intraderm Quad 2017-18 QL; AL

Fluzone Quad 2017-2018 QL; AL

Fluzone Quad 2017-2018 (PF) QL; AL

Fluzone Quad Pedi 2017-18 (PF) QL; AL

Tice BCG Specialty PA

Autonomic Drugs

Alpha- And Beta-Adrenergic Agonists

Bromfed DM


Children's Silfedrine

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

21


Conex oral solution

epinephrine injection auto-injector 0.15 mg/0.3

mL, 0.3 mg/0.3 mL

QL

epinephrine injection solution

epinephrine injection syringe 0.1 mg/mL

Lodrane D

LoHist - D

Lortuss EX oral syrup AL

M-End DMX

Nasal Decongestant (pseudoeph) oral tablet

pseudoephedrine HCl oral tablet 60 mg

pseudoephedrine-guaifenesin

Rynex PSE

Alpha-Adrenergic Agonists

Carbaphen CH

Centergy

clonidine

clonidine HCl oral tablet


ED Bron GP

Ed Chlorped D

methyldopa

methyldopa-hydrochlorothiazide

midodrine

NoHist-DM

Promethazine VC


Trexbrom

Tussin CF (PE-DM-guaif)

Antimuscarinics/Antispasmodics

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

22


Anoro Ellipta

Atrovent HFA

chlordiazepoxide-clidinium

Combivent Respimat

dicyclomine oral capsule

dicyclomine oral solution

dicyclomine oral tablet

diphenoxylate-atropine

glycopyrrolate oral tablet 1 mg, 2 mg

hydrocodone-homatropine oral syrup 5-1.5 mg/5

mL

AL

hydrocodone-homatropine oral tablet AL

hyoscyamine sulfate

ipratropium bromide inhalation

ipratropium-albuterol

methscopolamine

propantheline

Spiriva Respimat AL

Stiolto Respimat

Antiparkinsonian Agents

benztropine oral

trihexyphenidyl

Autonomic Drugs, Miscellaneous

Chantix QL

Chantix Starting Month Box QL

nicotine (polacrilex) buccal gum QL

nicotine (polacrilex) buccal lozenge QL

nicotine transdermal patch 24 hour 14 mg/24 hr,

21 mg/24 hr, 7 mg/24 hr

QL

Nicotrol QL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

23


Nicotrol NS QL

Centrally Acting Skeletal Muscle Relaxnt

carisoprodol oral tablet 350 mg ST; QL

carisoprodol-ASA-codeine

carisoprodol-aspirin

chlorzoxazone oral tablet 500 mg

cyclobenzaprine oral tablet 10 mg, 5 mg

methocarbamol oral

tizanidine oral tablet

Gaba-Derivative Skeletal Muscle Relaxant

baclofen oral tablet 10 mg, 20 mg

Lioresal Specialty PA

Non-Sel. Beta-Adrenergic Blocking Agents

carvedilol

labetalol oral

nadolol

nadolol-bendroflumethiazide

pindolol

propranolol oral

propranolol-hydrochlorothiazid

sotalol oral

timolol maleate oral

Non-Sel.Alpha-1-Adrenergic Blocking Agts

doxazosin

prazosin

terazosin

Non-Sel.Alpha-Adrenergic Blocking Agents

dihydroergotamine injection

dihydroergotamine nasal QL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

24


Ergomar

phenoxybenzamine

Parasympathomimetic (Cholinergic Agents)

bethanechol chloride

donepezil oral tablet 10 mg, 5 mg QL; AL

donepezil oral tablet 23 mg ST; QL

donepezil oral tablet,disintegrating QL; AL

Mestinon oral syrup

pyridostigmine bromide

rivastigmine tartrate AL

Selective Alpha-1-Adrenergic Block.Agent

alfuzosin

carvedilol

labetalol oral

tamsulosin

Selective Beta-2-Adrenergic Agonists

albuterol sulfate inhalation solution for

nebulization

albuterol sulfate oral syrup

albuterol sulfate oral tablet

albuterol sulfate oral tablet extended release 12 hr

8 mg

Anoro Ellipta

Breo Ellipta

Combivent Respimat

fluticasone-salmeterol


levalbuterol tartrate ST

Serevent Diskus

Stiolto Respimat

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

25


terbutaline oral

Ventolin HFA QL

Selective Beta-Adrenergic Blocking Agent

atenolol

atenolol-chlorthalidone

bisoprolol fumarate

bisoprolol-hydrochlorothiazide

metoprolol succinate

metoprolol ta-hydrochlorothiaz

metoprolol tartrate oral tablet 100 mg, 25 mg, 50

mg

Skeletal Muscle Relaxants, Miscellaneous

Botox Specialty PA

Dysport Specialty PA

Myobloc Specialty PA

orphenadrine citrate oral

Xeomin Specialty PA

Blood Formation, Coagulation, Thrombosis

Coumarin Derivatives

warfarin

Direct Factor Xa Inhibitors

Eliquis

Xarelto oral tablet 10 mg, 15 mg, 20 mg

Xarelto oral tablets,dose pack

Direct Thrombin Inhibitors

Pradaxa

Hematopoietic Agents

Aranesp (in polysorbate) Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

26


Epogen injection solution 10,000 unit/mL, 2,000

unit/mL, 20,000 unit/2 mL, 20,000 unit/mL, 3,000

unit/mL, 4,000 unit/mL

Specialty PA

Fulphila Specialty PA

Granix subcutaneous syringe Specialty PA

Leukine injection recon soln Specialty PA

Mozobil Specialty PA

Neulasta Specialty PA

Neupogen Specialty PA

Nplate Specialty PA

Procrit Specialty PA

Promacta Specialty PA

RETACRIT 10,000 UNIT/ML VIAL L/F, P/F,

INNER, SDV

Specialty PA


INNER, SDV

Specialty PA


INNER, SDV

Specialty PA


INNER, SDV

Specialty PA


INNER, SDV

Specialty PA

Zarxio Specialty PA

Hemorrheologic Agents

pentoxifylline

Hemostatics

Amicar

DDAVP nasal solution PA

desmopressin nasal spray,non-aerosol PA

desmopressin oral PA

Heparins

enoxaparin subcutaneous solution

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

27


enoxaparin subcutaneous syringe QL

heparin (porcine) in 5 % dex Specialty PA

heparin (porcine) in NaCl (PF) Specialty PA

heparin (porcine) injection solution 1,000 unit/mL,

5,000 unit/mL

heparin, porcine (PF) injection syringe

Iron Preparations

Atabex EC AL

Bio-35, Gluten Free

Cadeau DHA AL

Centrum Specialist Prenatal AL

Classic Prenatal AL

Daily Prenatal AL

Expecta Prenatal AL

FE C AL

FE C Plus AL

Feraheme Specialty PA

Ferocon

Ferrex 28

Ferrlecit Specialty PA

ferrous gluconate oral tablet 324 mg (37.5 mg

iron), 324 mg (38 mg iron)

ferrous sulfate oral drops

ferrous sulfate oral elixir

ferrous sulfate oral solution

ferrous sulfate oral tablet 325 mg (65 mg iron)

ferrous sulfate oral tablet,delayed release (DR/EC)

Infed

Injectafer

Iron Chews

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

28


KPN oral tablet 9 mg iron- 267 mcg AL

Mini Prenatal AL

Multigen

Multigen Folic

Multigen Plus

Multi-Vit with Fluoride-Iron

Mynatal oral capsule AL

Mynatal Plus AL

Mynatal-Z AL

Obstetrix DHA AL

Obstetrix EC AL

O-Cal FA AL

O-Cal Prenatal AL

One A Day Women's Prenatal DHA AL

One-A-Day Womens Formula oral tablet 18 mg

iron-400 mcg-500 mg Ca

One-A-Day Women's Prenatal 1 AL

Perry Prenatal AL

PNV cmb#95-ferrous fumarate-FA AL

Poly-Vi-Flor with Iron

Prenatabs Rx AL

Prenatal + DHA oral combo pack 28 mg iron-800

mcg-200 mg

AL

Prenatal 19 AL

Prenatal Formula oral tablet 9 mg iron- 267 mcg AL

Prenatal Low Iron

Prenatal Multi-DHA (algal oil) AL

Prenatal Multi-DHA oral capsule 27 mg iron-800

mcg-228 mg

AL

Prenatal oral tablet 28 mg iron- 800 mcg AL

Prenatal Plus AL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

29


Prenatal Plus (calcium carb) AL

Prenatal Plus DHA oral combo pack

Prenatal Vitamin Plus Low Iron AL

prenatal vit-iron fum-folic ac AL

prenatal vits96-iron fum-folic AL

ProRenal QD

Protect Iron

Right Step Prenatal Vitamins AL

Similac Prenatal AL

Slow Release Iron oral tablet extended release 143

mg (45 mg iron), 160 mg (50 mg iron)

TriAdvance AL

Trinatal GT AL

Trinatal Rx 1 AL

Trinate AL

Triveen-Duo DHA AL

Tri-Vit with Fluoride and Iron

Venofer

Vinate GT AL

Vinate M AL

Vinate One AL

Vinate Ultra AL

Vol-Nate AL

Vol-Tab Rx AL

Wee Care

Women's Daily Caplet

Women's Prenatal + DHA AL

Platelet-Aggregation Inhibitors

aspirin oral tablet

aspirin oral tablet,chewable

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

30


aspirin oral tablet,delayed release (DR/EC) 325

mg, 81 mg

aspirin rectal

aspirin-dipyridamole

butalbital-aspirin-caffeine oral capsule

cilostazol

clopidogrel

dipyridamole oral

prasugrel

Thrombolytic Agents

Activase intravenous recon soln 50 mg Specialty PA

aspirin oral tablet



mg, 81 mg

aspirin rectal


Cathflo Activase Specialty PA

Cardiovascular Drugs

Alpha-Adrenergic Blocking Agents

carvedilol

doxazosin

labetalol oral

prazosin

terazosin

Alpha-Adrenergic Blocking Agt.(Hypoten)

doxazosin

labetalol oral

prazosin

terazosin

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

31


Angiotensin Ii Receptor Antagon.(Hypotn)

amlodipine-valsartan ST

irbesartan ST

irbesartan-hydrochlorothiazide ST

losartan

losartan-hydrochlorothiazide

olmesartan ST

olmesartan-hydrochlorothiazide ST

telmisartan ST

valsartan oral tablet 160 mg, 40 mg, 80 mg ST

valsartan oral tablet 320 mg

valsartan-hydrochlorothiazide ST

Angiotensin Ii Receptor Antagonists


Entresto

irbesartan ST


losartan


olmesartan ST


telmisartan ST

valsartan ST


Angiotensin-Convert.Enzyme Inhib(Hypotn)

amlodipine-benazepril

benazepril

benazepril-hydrochlorothiazide

captopril

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

32


captopril-hydrochlorothiazide

enalapril maleate

enalapril-hydrochlorothiazide

fosinopril

fosinopril-hydrochlorothiazide

lisinopril

lisinopril-hydrochlorothiazide

moexipril

moexipril-hydrochlorothiazide

perindopril erbumine

quinapril

quinapril-hydrochlorothiazide

ramipril

trandolapril

Angiotensin-Converting Enzyme Inhibitors


benazepril


captopril


enalapril maleate


fosinopril


lisinopril


moexipril


perindopril erbumine

quinapril

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

33



ramipril

trandolapril

Antiarrhythmics, Miscellaneous

Digox

digoxin oral solution 50 mcg/mL

magnesium sulfate injection Specialty PA

Antilipemic Agents, Miscellaneous

Juxtapid Specialty PA

Kynamro Specialty PA

Niacin Flush Free oral capsule 750 mg

niacin oral capsule, extended release 250 mg, 500

mg

niacin oral tablet extended release 24 hr

Beta-Adrenergic Blocking Agents

atenolol


bisoprolol fumarate


carvedilol

labetalol oral




mg

nadolol


pindolol

propranolol oral


AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

34


sotalol oral


Beta-Adrenergic Blocking Agt.(Hypoten)

atenolol


bisoprolol fumarate


labetalol oral




mg

nadolol


pindolol

propranolol oral


sotalol oral


Bile Acid Sequestrants

cholestyramine (with sugar)

Cholestyramine Light oral powder in packet

colestipol

Prevalite oral powder

WelChol

Calcium-Channel Block.Agt,Misc(Hypoten)

diltiazem HCl oral capsule,ext.rel 24h degradable

diltiazem HCl oral capsule,extended release 12 hr


diltiazem HCl oral capsule,extended release 24hr

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

35


diltiazem HCl oral tablet

verapamil oral tablet

verapamil oral tablet extended release

Calcium-Channel Blocking Agents

amlodipine








felodipine

nifedipine oral capsule

nifedipine oral tablet extended release 24hr

nifedipine oral tablet extended release 30 mg, 90

mg



Calcium-Channel Blocking Agents(Hypoten)








Calcium-Channel Blocking Agents, Misc.



AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

36







Carbonic Anhydrase Inhibitors(Hypoten)

acetazolamide

Cardiotonic Agents

Digox

digoxin oral solution 50 mcg/mL

Central Alpha-Agonists

clonidine

clonidine HCl oral tablet

guanfacine oral tablet

guanfacine oral tablet extended release 24 hr AL

methyldopa


Class Ia Antiarrhythmics

disopyramide phosphate oral capsule

quinidine gluconate oral

quinidine sulfate oral tablet

Class Ib Antiarrhythmics

Dilantin

mexiletine

phenytoin oral suspension

phenytoin oral tablet,chewable

phenytoin sodium extended oral capsule 100 mg

Class Ic Antiarrhythmics

flecainide

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

37


propafenone oral tablet

Class Ii Antiarrhythmics

atenolol


bisoprolol fumarate


carvedilol

labetalol oral




mg

nadolol


pindolol

propranolol oral


sotalol oral


Class Iii Antiarrhythmics

amiodarone oral tablet 200 mg, 400 mg

Pacerone oral tablet 100 mg

sotalol oral

Class Iv Antiarrhythmics







AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

38



Dihydropyridines

amlodipine



felodipine




mg

Dihydropyridines (Antihypertensive)

amlodipine



felodipine




mg

Direct Vasodilators

BiDil

hydralazine oral

minoxidil oral

Diuretics, Miscellaneous (Hypotensive)

Theo-24

theophylline oral tablet extended release 12 hr


Fibric Acid Derivatives

fenofibrate micronized oral capsule 134 mg, 200

mg, 67 mg

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

39


fenofibrate nanocrystallized oral tablet 145 mg, 48

mg

fenofibrate oral tablet 160 mg, 54 mg

gemfibrozil

Hmg-Coa Reductase Inhibitors

atorvastatin

lovastatin

pravastatin

rosuvastatin

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg

Hypotensive Agents, Miscellaneous

amlodipine



carvedilol

doxazosin

felodipine




mg

phenoxybenzamine

pindolol

propranolol oral

sotalol oral

terazosin


Loop Diuretics (Hypotensive Agents)

bumetanide oral

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

40


furosemide oral solution 10 mg/mL, 40 mg/5 mL

(8 mg/mL)

furosemide oral tablet

torsemide oral

Mineralocorticoid (Aldosterone) Antagnts

Aldactazide oral tablet 50-50 mg

spironolactone

spironolacton-hydrochlorothiaz

Mineralocorticoid(Aldoster.)Antag(Hypot)


spironolactone


Nitrates And Nitrites

BiDil

isosorbide dinitrate oral

isosorbide mononitrate

Nitro-Bid

Nitro-Dur transdermal patch 24 hour 0.3 mg/hr,

0.8 mg/hr

nitroglycerin oral

nitroglycerin transdermal patch 24 hour

Pcsk9 Inhibitors

Praluent Pen Specialty PA

Repatha Pushtronex Specialty PA

Repatha SureClick Specialty PA

Repatha Syringe Specialty PA

Phosphodiesterase Type 5 Inhibitors

Adcirca Specialty PA

cilostazol

Revatio intravenous Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

41


Revatio oral suspension for reconstitution Specialty PA

sildenafil (antihypertensive) oral PA

Potassium-Sparing Diuretics (Hypoten)


amiloride

amiloride-hydrochlorothiazide

spironolactone


triamterene-hydrochlorothiazid oral capsule 37.5-

25 mg

triamterene-hydrochlorothiazid oral tablet

Renin-Angioten.-Aldost. Sys. Inhib, Misc

Entresto

Thiazide Diuretics(Hypotensive Agents)






chlorothiazide

Diuril



hydrochlorothiazide




methyclothiazide



AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

42









25 mg



Thiazide-Like Diuretics(Hypotensive Agt)


chlorthalidone oral tablet 25 mg, 50 mg

indapamide

metolazone

Vasodilating Agents, Miscellaneous

amlodipine









dipyridamole oral

epoprostenol (glycine) Specialty PA

felodipine

Letairis Specialty PA


AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

43




mg

Orenitram Specialty PA

Remodulin Specialty PA

Tracleer Specialty PA

Tyvaso Specialty PA

Tyvaso Refill Kit Specialty PA

Tyvaso Starter Kit Specialty PA

Veletri Specialty PA

Ventavis Specialty PA



Cellular And Gene Therapy

Cellular And Gene Therapy

Provenge Specialty PA

Cellular Therapy

Provenge Specialty PA

Central Nervous System Agents

Adamantanes (Cns)

amantadine HCl oral capsule

amantadine HCl oral solution

Amphetamines

dextroamphetamine oral tablet PA; AL

dextroamphetamine-amphetamine oral

capsule,extended release 24hr

AL

dextroamphetamine-amphetamine oral tablet 10

mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

AL

Vyvanse AL

Analgesics And Antipyretics, Misc.

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

44


acetaminophen oral elixir

acetaminophen oral liquid 160 mg/5 mL, 500 mg/5

mL

acetaminophen oral suspension 160 mg/5 mL

acetaminophen oral tablet

acetaminophen oral tablet,chewable

acetaminophen rectal

acetaminophen-codeine oral solution 120-12 mg/5

mL

AL

acetaminophen-codeine oral tablet AL

butalbital-acetaminop-caf-cod oral capsule 50-

325-40-30 mg

butalbital-acetaminophen oral tablet 50-325 mg

butalbital-acetaminophen-caff oral tablet 50-325-

40 mg

Feverall rectal suppository 325 mg, 80 mg

gabapentin oral capsule

gabapentin oral solution 250 mg/5 mL

gabapentin oral tablet 600 mg QL

gabapentin oral tablet 800 mg

hydrocodone-acetaminophen oral solution 7.5-325

mg/15 mL

hydrocodone-acetaminophen oral tablet 10-325

mg, 5-325 mg, 7.5-325 mg

isometh-dichloral-acetaminophn

Mapap (acetaminophen) oral capsule

Nortemp oral drops

oxycodone-acetaminophen oral tablet 10-325 mg,

5-325 mg, 7.5-325 mg

QL

Pain Relief oral tablet extended release

Prialt Specialty PA

tramadol-acetaminophen AL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

45


Anticholinergic Agents (Cns)

benztropine oral

trihexyphenidyl

Anticonvulsants, Miscellaneous

Banzel ST; AL

carbamazepine oral suspension 100 mg/5 mL

carbamazepine oral tablet

carbamazepine oral tablet extended release 12 hr

carbamazepine oral tablet,chewable

divalproex

gabapentin oral capsule

gabapentin oral solution 250 mg/5 mL

gabapentin oral tablet 600 mg QL

gabapentin oral tablet 800 mg

lamotrigine oral tablet

lamotrigine oral tablet, chewable dispersible

lamotrigine oral tablets,dose pack

levetiracetam intravenous Specialty PA

levetiracetam oral solution 100 mg/mL

levetiracetam oral tablet


oxcarbazepine oral tablet

Sabril oral tablet Specialty PA

topiramate oral capsule, sprinkle

topiramate oral tablet

valproic acid

valproic acid (as sodium salt) oral solution 250

mg/5 mL

vigabatrin Specialty PA

zonisamide

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

46


Antidepressants, Miscellaneous

bupropion HCl (smoking deter) QL

bupropion HCl oral tablet

bupropion HCl oral tablet extended release 24 hr

150 mg, 300 mg

bupropion HCl oral tablet sustained-release 12 hr

mirtazapine

Antimanic Agents

divalproex

lithium carbonate

lithium citrate oral solution 8 mEq/5 mL

valproic acid


mg/5 mL

Antimigraine Agents, Miscellaneous

Aimovig Autoinjector Specialty PA

Aimovig Autoinjector (2 Pack) Specialty PA

aspirin oral tablet



mg, 81 mg

aspirin rectal

Butalbital Compound W/Codeine


325-40-30 mg


40 mg


dihydroergotamine injection

dihydroergotamine nasal QL

divalproex

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

47


Ergomar

propranolol oral



valproic acid


mg/5 mL

Antipsychotics, Miscellaneous

loxapine succinate AL

pimozide AL

Anxiolytics,Sedatives,And Hypnotics,Misc

buspirone

droperidol injection solution

eszopiclone ST

hydroxyzine HCl oral solution 10 mg/5 mL

hydroxyzine HCl oral tablet

hydroxyzine pamoate

promethazine oral

promethazine rectal


zaleplon

zolpidem oral tablet

Atypical Antipsychotics

Abilify Maintena Specialty PA

aripiprazole oral solution AL

aripiprazole oral tablet QL; AL

Aristada Specialty PA

clozapine QL; AL

Geodon intramuscular PA

Invega Sustenna Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

48


Invega Trinza Specialty PA

Latuda QL; AL

olanzapine intramuscular PA; AL

olanzapine oral QL; AL

olanzapine-fluoxetine QL; AL

paliperidone QL; AL

quetiapine QL; AL

Risperdal Consta Specialty PA

risperidone oral solution QL; AL

risperidone oral tablet QL; AL

risperidone oral tablet,disintegrating QL; AL

ziprasidone HCl QL; AL

Zyprexa Relprevv Specialty PA

Barbiturates (Anticonvulsants)

phenobarbital

primidone

Barbiturates (Anxiolytic, Sedative/Hyp)



325-40-30 mg

butalbital-acetaminophen oral tablet 50-325 mg


40 mg


phenobarbital

Benzodiazepines (Anticonvulsants)

clonazepam

clorazepate dipotassium

Diazepam Intensol

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

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

49


diazepam oral tablet

diazepam rectal QL

Lorazepam Intensol

lorazepam oral tablet

Benzodiazepines (Anxiolytic,Sedativ/Hyp)

alprazolam oral tablet

amitriptyline-chlordiazepoxide

chlordiazepoxide HCl

chlordiazepoxide-clidinium

clonazepam

clorazepate dipotassium

Diazepam Intensol

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

diazepam oral tablet

diazepam rectal QL

estazolam

Lorazepam Intensol

lorazepam oral tablet

midazolam oral syrup 2 mg/mL

oxazepam

temazepam oral capsule 15 mg, 30 mg

triazolam

Butyrophenones

haloperidol AL

haloperidol decanoate AL

haloperidol lactate injection AL

haloperidol lactate oral AL

Central Nervous System Agents, Misc.

atomoxetine AL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

50


Austedo Specialty PA

guanfacine oral tablet

guanfacine oral tablet extended release 24 hr AL

Ingrezza Specialty PA

memantine oral tablet AL

memantine oral tablets,dose pack

Radicava Specialty PA

riluzole

Xenazine Specialty PA

Cyclooxygenase-2 (Cox-2) Inhibitors

celecoxib oral capsule 100 mg, 200 mg QL

celecoxib oral capsule 400 mg, 50 mg

Dopamine Precursors

carbidopa-levodopa oral tablet

carbidopa-levodopa oral tablet extended release

Ergot-Deriv. Dopamine Receptor Agonists

bromocriptine

cabergoline ST

Fibromyalgia Agents

duloxetine oral capsule,delayed release(DR/EC)

20 mg, 30 mg


60 mg

QL

Savella

Hydantoins

Dilantin

phenytoin oral suspension

phenytoin oral tablet,chewable

phenytoin sodium extended oral capsule 100 mg

Monoamine Oxidase B Inhibitors

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

51


selegiline HCl

Monoamine Oxidase Inhibitors

phenelzine

selegiline HCl

tranylcypromine

Nonergot-Deriv.Dopamine Receptor Agonist

APOKYN Specialty PA

pramipexole oral tablet

ropinirole oral tablet

Opiate Agonists

acetaminophen-codeine oral solution 120-12 mg/5

mL

AL

acetaminophen-codeine oral tablet AL



325-40-30 mg


codeine sulfate oral tablet AL

codeine-guaifenesin QL; AL

fentanyl transdermal patch 72 hour 100 mcg/hr, 12

mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

QL

Guaifenesin AC AL

hydrocodone-acetaminophen oral solution 7.5-325

mg/15 mL

hydrocodone-acetaminophen oral tablet 10-325

mg, 5-325 mg, 7.5-325 mg


mL

AL


hydromorphone oral liquid

hydromorphone oral tablet

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

52


hydromorphone rectal


meperidine oral

morphine concentrate oral solution

morphine oral solution

morphine oral tablet

morphine oral tablet extended release

oxycodone oral concentrate

oxycodone oral solution

oxycodone oral tablet 10 mg, 15 mg, 20 mg, 5 mg QL

oxycodone oral tablet 30 mg

oxycodone-acetaminophen oral tablet 10-325 mg,

5-325 mg, 7.5-325 mg

QL


promethazine-codeine QL; AL

tramadol oral tablet AL


Opiate Antagonists

Evzio PA

naltrexone

Narcan nasal spray,non-aerosol 4 mg/actuation QL

Vivitrol QL

Opiate Partial Agonists

buprenorphine HCl sublingual QL; AL

buprenorphine-naloxone sublingual tablet QL; AL

butorphanol tartrate nasal PA; QL

nalbuphine

Other Nonsteroidal Anti-Inflam. Agents

diclofenac potassium

diclofenac sodium oral

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

53


diclofenac sodium topical gel 1 % ST

diflunisal

etodolac oral tablet

flurbiprofen oral tablet 50 mg

ibuprofen oral suspension

ibuprofen oral tablet

ibuprofen oral tablet,chewable

indomethacin oral capsule

Infant's Ibuprofen

ketoprofen oral capsule 50 mg, 75 mg

ketorolac oral

meclofenamate

meloxicam oral tablet

nabumetone

naproxen

naproxen sodium oral capsule

naproxen sodium oral tablet

piroxicam

sulindac

Phenothiazines

chlorpromazine AL

fluphenazine decanoate AL

fluphenazine HCl injection AL

fluphenazine HCl oral tablet AL

perphenazine AL

perphenazine-amitriptyline

prochlorperazine AL

prochlorperazine Edisylate injection solution 10

mg/2 mL (5 mg/mL)

AL

prochlorperazine maleate AL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

54


thioridazine

trifluoperazine AL

Respiratory And Cns Stimulants



325-40-30 mg


40 mg


caffeine citrate oral

dexmethylphenidate AL

methylphenidate HCl oral capsule, ER biphasic

30-70

AL

methylphenidate HCl oral solution 10 mg/5 mL AL

methylphenidate HCl oral tablet AL

methylphenidate HCl oral tablet extended release

20 mg

AL

methylphenidate HCl oral tablet extended release

24hr 18 mg, 27 mg, 36 mg, 54 mg

AL

Salicylates

aspirin oral tablet



mg, 81 mg

aspirin rectal





carisoprodol-aspirin

salsalate

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

55


Sel.Serotonin,Norepi Reuptake Inhibitor


20 mg, 30 mg


60 mg

QL

Savella

venlafaxine oral capsule,extended release 24hr

venlafaxine oral tablet

Selective Serotonin Agonists

rizatriptan QL

sumatriptan QL

sumatriptan succinate oral QL

sumatriptan succinate subcutaneous cartridge QL

sumatriptan succinate subcutaneous pen injector QL

sumatriptan succinate subcutaneous solution QL

Selective-Serotonin Reuptake Inhibitors

citalopram oral tablet

escitalopram oxalate oral tablet

fluoxetine oral capsule

fluoxetine oral solution

fluoxetine oral tablet 10 mg, 20 mg

fluvoxamine oral tablet

olanzapine-fluoxetine QL; AL

paroxetine HCl oral tablet

sertraline oral concentrate

sertraline oral tablet QL

Serotonin Modulators

nefazodone

trazodone

Succinimides

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

56


ethosuximide

Thioxanthenes

thiothixene AL

Tricyclics, Other Norepi-Ru Inhibitors

amitriptyline


amoxapine

clomipramine

desipramine

doxepin oral

imipramine HCl

maprotiline

nortriptyline oral capsule

perphenazine-amitriptyline

Vesicular Monoamine Transport2 Inhibitor

Austedo Specialty PA

Ingrezza Specialty PA

Xenazine Specialty PA

Wakefulness-Promoting Agents

modafinil PA

Devices

Devices

Accu-Chek Aviva Control Soln

Accu-Chek Guide Glucose Meter

Accu-Chek Guide L1-L2 Ctrl Sol

Accu-Chek Multiclix Lancet

Accu-Chek SmartView Contrl Sol

Accu-Chek Soft Dev Lancets

Accu-Chek Softclix Lancet Dev

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

57


Accu-Chek Softclix Lancets

Aerochamber MV

Euflexxa Specialty PA

Gelclair

Gel-One Specialty PA

Gelsyn-3 Specialty PA

GenVisc 850 Specialty PA

heparin (porcine) in NaCl (PF) Specialty PA

Hyalgan Specialty PA

Hyper-Sal inhalation solution for nebulization 7 % PA

Insulin Syringe syringe 0.5 mL 29 gauge x 1/2"

Lancets,Ultra Thin 26 gauge

Monovisc Specialty PA

ORTHOVISC Specialty PA

pen needle, diabetic needle 29 gauge x 1/2"

sodium chloride inhalation solution for

nebulization 0.9 %

QL

Soft Touch Lancets

Solesta Specialty PA

Supartz FX Specialty PA

Synvisc Specialty PA

Synvisc-One Specialty PA

Vortex Holding Chamber

Diagnostic Agents

Adrenocortical Insufficiency

Acthar H.P. PA

cosyntropin injection Specialty PA

Diabetes Mellitus

Accu-Chek Aviva Plus test strp QL

Accu-Chek Guide QL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

58


Accu-Chek SmartView Test Strip QL

Thyroid Function

Thyrogen Specialty PA

Electrolytic, Caloric, And Water Balance

Alkalinizing Agents

Cytra-2

Oracit

potassium citrate oral tablet extended release 10

mEq (1,080 mg), 5 mEq (540 mg)

Ammonia Detoxicants

Carbaglu Specialty PA

Enulose

lactulose oral solution 10 gram/15 mL

Caloric Agents

Clinisol SF 15 % Specialty PA

D5 %-0.45 % sodium chloride Specialty PA

dextrose 70 % in water (D70W) Specialty PA

Intralipid intravenous emulsion 20 % Specialty PA

Liposyn III intravenous emulsion 10 %, 30 % Specialty PA

Prosol 20 % Specialty PA

Travasol 10 % Specialty PA

TrophAmine 10 % Specialty PA

Carbonic Anhydrase Inhibitors

acetazolamide

Diuretics, Miscellaneous

Theo-24



Irrigating Solutions

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

59


sodium chloride irrigation

water for irrigation, sterile

Loop Diuretics

bumetanide oral

furosemide oral solution 10 mg/mL, 40 mg/5 mL

(8 mg/mL)

furosemide oral tablet

torsemide oral

Phosphate-Removing Agents

calcium acetate oral capsule

sevelamer carbonate oral tablet

Potassium-Removing Agents

Kionex (with sorbitol)

SPS (with sorbitol) rectal

Potassium-Sparing Diuretics


amiloride


spironolactone



25 mg


Replacement Preparations

Atabex EC AL

Bio-35, Gluten Free

Ca-D3-mag-zinc-cop-mang-bor

CALCIUM 250-VIT D3 125 TABLET

Calcium 500 + D oral tablet 500 mg(1,250mg) -

400 unit

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

60


CALCIUM 500 + VIT D CAPLET P/F, CAPLET

CALCIUM 500-VIT D3 200 TABLET P/F,NA/F


Calcium 600 + D(3) oral tablet 600 mg(1,500mg) -

200 unit

CALCIUM 600 + VIT D TABLET

CALCIUM 600 MG TABLET

CALCIUM 600-VIT D3 800 CAPLET S/F, P/F,

CAPLET

calcium carbonate-vitamin D3 oral tablet 1,000

mg(2,500 mg)-800 unit, 600 mg(1,500mg) -400

unit

calcium citrate-vitamin D3 oral tablet 315-250 mg-

unit

Citrus Calcium oral tablet 315-250 mg-unit

Daily Prenatal AL

Hyper-Sal inhalation solution for nebulization 7 % PA

Klor-Con

Klor-Con/EF


Mynatal Plus AL

Mynatal-Z AL

O-Cal FA AL

O-Cal Prenatal AL





Oralyte

Oyster Shell Calcium-Vit D3 oral tablet 500

mg(1,250mg) -200 unit, 500 mg(1,250mg) -400

unit

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

61


Perry Prenatal AL

potassium chloride oral capsule, extended release

10 mEq

potassium chloride oral liquid

potassium chloride oral tablet extended release 10

mEq, 8 mEq

potassium chloride oral tablet,ER particles/crystals

Prenatabs Rx AL


Prenatal Low Iron

Prenatal Plus AL





Prosteon


selenium oral tablet,delayed release (DR/EC)

SM CALCIUM 500 MG TABLET

sodium chloride inhalation solution for

nebulization 0.9 %

QL

TheraCal D4000

TPN Electrolytes Specialty PA

TPN Electrolytes II Specialty PA

TriAdvance AL

Trinatal Rx 1 AL

Trinate AL

Triveen-Duo DHA AL

Upcal D

Vinate One AL

Vinate Ultra AL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

62


VP-GGR-B6


Thiazide Diuretics






chlorothiazide

Diuril



hydrochlorothiazide




methyclothiazide










25 mg



Thiazide-Like Diuretics

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

63



chlorthalidone oral tablet 25 mg, 50 mg

indapamide

metolazone

Uricosuric Agents

probenecid

probenecid-colchicine

Vasopressin Antagonists

Jynarque oral tablets, sequential 45 mg (AM)/ 15

mg (PM), 90 mg (AM)/ 30 mg (PM)

Specialty PA

Jynarque oral tablets, sequential 60 mg (AM)/ 30

mg (PM)

Specialty

Samsca Specialty PA

Enzymes

Enzymes

Activase intravenous recon soln 50 mg Specialty PA

Adagen Specialty PA

Aldurazyme Specialty PA

Cathflo Activase Specialty PA

Cerezyme intravenous recon soln 400 unit Specialty PA

Elaprase Specialty PA

Elelyso Specialty PA

Elitek Specialty PA

Fabrazyme Specialty PA

Naglazyme Specialty PA

Pulmozyme Specialty PA

Sucraid Specialty PA

Voraxaze Specialty PA

VPRIV Specialty PA

Xiaflex Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

64


Eye, Ear, Nose And Throat (Eent) Preps.

Alpha-Adrenergic Agonists (Eent)

brimonidine

Antiallergic Agents

azelastine nasal

azelastine ophthalmic (eye) ST; QL

cromolyn nasal

cromolyn ophthalmic (eye)

ketotifen fumarate QL

olopatadine ophthalmic (eye) drops 0.1 % ST; QL

Antibacterials (Eent)

bacitracin-polymyxin B ophthalmic (eye)

Ciprodex

ciprofloxacin HCl ophthalmic (eye)

doxycycline hyclate oral tablet 20 mg

erythromycin ophthalmic (eye)

Gentak ophthalmic (eye) ointment

Moxeza

moxifloxacin ophthalmic (eye)

neomycin-bacitracin-poly-HC

neomycin-bacitracin-polymyxin

neomycin-polymyxin B-dexameth

neomycin-polymyxin-gramicidin

neomycin-polymyxin-HC

ofloxacin ophthalmic (eye)

ofloxacin otic (ear)

polymyxin B sulf-trimethoprim

sulfacetamide sodium ophthalmic (eye) drops

sulfacetamide-prednisolone

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

65


tobramycin

tobramycin-dexamethasone

Tobrex ophthalmic (eye) ointment

Antivirals (Eent)

trifluridine

Beta-Adrenergic Blocking Agents (Eent)

carteolol

dorzolamide-timolol

levobunolol ophthalmic (eye) drops 0.5 %

metipranolol

timolol maleate ophthalmic (eye) drops

timolol maleate ophthalmic (eye) gel forming

solution

Carbonic Anhydrase Inhibitors (Eent)

acetazolamide

Azopt

dorzolamide

dorzolamide-timolol

Corticosteroids (Eent)

Ciprodex

dexamethasone sodium phosphate ophthalmic

(eye)

Flarex

fluorometholone

fluticasone nasal

FML Forte

FML S.O.P.

Maxidex

Nasal Allergy ST


AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

66


neomycin-polymyxin B-dexameth

neomycin-polymyxin-HC ophthalmic (eye)

Ozurdex Specialty PA

Pred Mild

prednisolone acetate

prednisolone sodium phosphate ophthalmic (eye)

Retisert Specialty PA

tobramycin-dexamethasone

Eent Anti-Infectives, Miscellaneous

acetic acid otic (ear)

chlorhexidine gluconate mucous membrane

Ear Wax Treatment

Eent Anti-Inflammatory Agents, Misc.

Restasis ST

Restasis MultiDose ST

Xiidra ST

Eent Drugs, Miscellaneous

apraclonidine

Artificial Tears (petro/min)

Artificial Tears (polyvin alc)

Artificial Tears(glycerin-peg)

Ayr Sinus Rinse Refill

Baby Ayr Saline

Eylea Specialty PA

Hypotears

Iopidine ophthalmic (eye) dropperette

ipratropium bromide nasal

Lucentis intravitreal solution 0.3 mg/0.05 mL Specialty PA

Lucentis intravitreal syringe Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

67


Macugen Specialty PA

Muro 128 ophthalmic (eye) drops 2 %

Saline Mist

sodium chloride ophthalmic (eye)

Visudyne Specialty PA

Eent Nonsteroidal Anti-Inflam. Agents

diclofenac sodium ophthalmic (eye)

flurbiprofen sodium

ketorolac ophthalmic (eye)

Local Anesthetics (Eent)

lidocaine HCl mucous membrane jelly in

applicator

lidocaine HCl mucous membrane solution 4 % (40

mg/mL)

Lidocaine Viscous

proparacaine

tetracaine HCl

tetracaine HCl (PF) ophthalmic (eye)

Tetravisc ophthalmic (eye) drops, viscous

Miotics

Phospholine Iodide

pilocarpine HCl ophthalmic (eye) drops 1 %, 2 %,

4 %

Mydriatics

atropine ophthalmic (eye)

cyclopentolate ophthalmic (eye) drops 1 %, 2 %

Homatropaire

tropicamide

Prostaglandin Analogs

latanoprost

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

68


Vasoconstrictors

Neo-Synephrine (phenylephrine) nasal spray,non-

aerosol 0.25 %

phenylephrine HCl ophthalmic (eye)

Visine-A

Gastrointestinal Drugs

5-Ht3 Receptor Antagonists

Akynzeo (fosnetupitant) Specialty PA

Akynzeo (netupitant) PA

granisetron (PF) Specialty PA

granisetron HCl intravenous Specialty PA

granisetron HCl oral ST

ondansetron QL

ondansetron HCl (PF) injection solution Specialty PA

ondansetron HCl intravenous Specialty PA

ondansetron HCl oral solution QL

ondansetron HCl oral tablet 4 mg, 8 mg QL

palonosetron intravenous solution Specialty PA

Sustol Specialty PA

Antacids And Adsorbents

aluminum hydroxide gel oral suspension 320 mg/5

mL

Antacid Plus Anti-Gas oral suspension 400-400-40

mg/5 mL

Maalox Advanced oral tablet,chewable

magnesium oxide oral tablet 250 mg, 400 mg

(241.3 mg magnesium), 420 mg

Pink Bismuth oral suspension 262 mg/15 mL

sodium bicarbonate oral

Antidiarrhea Agents

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

69



loperamide oral capsule

loperamide oral liquid 1 mg/5 mL

loperamide oral tablet

Pink Bismuth oral suspension 262 mg/15 mL

Antiemetics, Miscellaneous

Diclegis PA

Formula EM

Antiflatulents

Antacid Plus Anti-Gas oral suspension 400-400-40

mg/5 mL

Maalox Advanced oral tablet,chewable

Antihistamines (Gi Drugs)

Diclegis PA

dimenhydrinate oral

meclizine oral tablet 12.5 mg, 25 mg

meclizine oral tablet,chewable

prochlorperazine AL

prochlorperazine Edisylate injection solution 10

mg/2 mL (5 mg/mL)

AL

prochlorperazine maleate AL

trimethobenzamide oral

Anti-Inflammatory Agents (Gi Drugs)

balsalazide

Canasa

Delzicol oral capsule (with del rel tablets)

Dipentum

mesalamine oral tablet,delayed release (DR/EC)

1.2 gram

mesalamine rectal

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

70


Pentasa

sulfasalazine

Cathartics And Laxatives

Amitiza

Atabex EC AL

docusate sodium oral capsule

docusate sodium oral syrup

Obstetrix EC AL

peg 3350-electrolytes

Perdiem Overnight Relief

polyethylene glycol 3350 oral powder

senna oral syrup 8.8 mg/5 mL

senna oral tablet

TriLyte With Flavor Packets

Vinate Ultra AL

Cholelitholytic Agents

ursodiol

Digestants

Creon

Zenpep oral capsule,delayed release(DR/EC)

10,000-32,000 -42,000 unit, 15,000-47,000 -

63,000 unit, 20,000-63,000- 84,000 unit, 25,000-

79,000- 105,000 unit, 3,000-10,000 -14,000-unit,

40,000-126,000- 168,000 unit, 5,000-17,000-

24,000 unit

Emetics

ipecac

Gi Drugs, Miscellaneous

Cimzia Specialty PA

Cimzia Powder for Reconst Specialty PA

Endari Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

71


Entyvio Specialty PA

Gattex 30-Vial Specialty PA

Humira Specialty PA

Humira Pediatric Crohn's Start subcutaneous

syringe kit 80 mg/0.8 mL, 80 mg/0.8 mL-40

mg/0.4 mL

Specialty PA

Humira Pen Specialty PA

Humira Pen Crohn's-UC-HS Start subcutaneous

pen injector kit 80 mg/0.8 mL

Specialty PA

Humira Pen Psoriasis-Uveitis subcutaneous pen

injector kit 80 mg/0.8 mL-40 mg/0.4 mL

Specialty PA

Inflectra Specialty PA

Linzess oral capsule 145 mcg, 290 mcg AL

Ocaliva Specialty PA

Remicade Specialty PA

Renflexis Specialty PA

Simponi Specialty PA

Simponi ARIA Specialty PA

Histamine H2-Antagonists

cimetidine

cimetidine HCl oral

famotidine oral

nizatidine

ranitidine HCl injection solution 50 mg/2 mL (25

mg/mL)

Specialty PA

ranitidine HCl oral syrup

ranitidine HCl oral tablet

Neurokinin-1 Receptor Antagonists

Akynzeo (fosnetupitant) Specialty PA

Akynzeo (netupitant) PA

aprepitant oral capsule 80 mg

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

72


aprepitant oral capsule,dose pack

Emend oral capsule 125 mg

Emend oral capsule 40 mg QL

Prokinetic Agents

metoclopramide HCl oral solution

metoclopramide HCl oral tablet

Prostaglandins

misoprostol

Protectants

sucralfate oral tablet

Proton-Pump Inhibitors

esomeprazole magnesium ST; QL

lansoprazole oral capsule,delayed release(DR/EC) ST; QL

Nexium 24HR oral tablet,delayed release (DR/EC) ST; QL

omeprazole oral capsule,delayed release(DR/EC) QL

omeprazole-sodium bicarbonate oral capsule 20-

1.1 mg-gram

ST; QL

pantoprazole oral QL

Prilosec oral susp,delayed release for recon QL; AL

Gold Compounds

Gold Compounds

Ridaura

Heavy Metal Antagonists

Heavy Metal Antagonists

Chemet

Cuprimine Specialty PA

deferoxamine Specialty PA

Depen Titratabs Specialty PA

Exjade Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

73


Ferriprox oral tablet Specialty PA

Galzin Specialty PA

Jadenu Specialty PA

Jadenu Sprinkle Specialty PA

trientine Specialty PA

Hormones And Synthetic Substitutes

Adrenals

ArmonAir RespiClick

Arnuity Ellipta inhalation blister with device 100

mcg/actuation, 200 mcg/actuation

QL


mcg/actuation

Asmanex HFA

Asmanex Twisthaler QL

Breo Ellipta

budesonide inhalation QL; AL

cortisone

Dexamethasone Intensol

dexamethasone oral elixir

dexamethasone oral solution

dexamethasone oral tablet

dexamethasone sodium phos (PF)

dexamethasone sodium phosphate injection

solution

Emflaza Specialty PA

Flovent Diskus QL

Flovent HFA QL

fludrocortisone


hydrocortisone oral

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

74


Intrarosa

methylprednisolone

methylprednisolone sodium succ intravenous Specialty PA

prednisolone oral solution 15 mg/5 mL

prednisolone sodium phosphate oral solution 15

mg/5 mL (3 mg/mL), 5 mg base/5 mL (6.7 mg/5

mL)

prednisone

Prednisone Intensol

Qvar QL

Qvar RediHaler QL

Solu-Cortef (PF) injection recon soln 100 mg/2

mL

Androgens

danazol PA

estrogens-methyltestosterone

testosterone cypionate QL

testosterone enanthate QL

testosterone transdermal gel PA

testosterone transdermal gel in metered-dose pump

10 mg/0.5 gram /actuation, 12.5 mg/ 1.25 gram (1

%)

PA

testosterone transdermal gel in packet 1 % (25

mg/2.5gram), 1 % (50 mg/5 gram)

PA

testosterone transdermal solution in metered pump

w/app

PA

Antidiabetic Agents, Miscellaneous

WelChol

Antiestrogens

anastrozole

exemestane

letrozole QL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

75


Antigonadtropins



Antiparathyroid Agents

calcitonin (salmon)

Antithyroid Agents

methimazole oral tablet 10 mg, 5 mg

propylthiouracil

SSKI

Biguanides

alogliptin-metformin ST

glipizide-metformin

glyburide-metformin

Janumet ST

Janumet XR ST

metformin oral tablet

metformin oral tablet extended release 24 hr

pioglitazone-metformin ST

Segluromet ST

Contraceptives

Aranelle (28)

Balziva (28)

desogestrel-ethinyl estradiol

Ella

ethynodiol diac-eth estradiol oral tablet 1-50 mg-

mcg

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-

mcg, 0.15-0.03 mg

levonorgestrel-ethinyl estrad oral tablets,dose

pack,3 month

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

76


levonorg-eth estrad triphasic

Low-Ogestrel (28)

Microgestin 1.5/30 (21)

Microgestin Fe 1.5/30 (28)

Microgestin FE 1/20 (28)

norethindrone (contraceptive)

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

mcg

norgestimate-ethinyl estradiol oral tablet

0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg

Nortrel 0.5/35 (28)

Nortrel 1/35 (21)

Nortrel 1/35 (28)

Nortrel 7/7/7 (28)

NuvaRing

Velivet Triphasic Regimen (28)

Xulane

Zovia 1/35E (28)

Dipeptidyl Peptidase-4(Dpp-4) Inhibitors

alogliptin ST

alogliptin-metformin ST

alogliptin-pioglitazone ST

Janumet ST

Janumet XR ST

Januvia ST

Estrogen Agonist-Antagonists

Fareston Specialty PA

raloxifene

tamoxifen

Estrogens

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

77


estradiol oral

estradiol transdermal

estradiol vaginal cream


estropipate oral tablet 0.75 mg, 1.5 mg

Femhrt Low Dose

Jinteli

Menest oral tablet 0.3 mg, 0.625 mg, 1.25 mg

Premarin oral

Premarin vaginal

Premphase

Prempro

Yuvafem QL

Glycogenolytic Agents

Glucagon Emergency Kit (human) QL

Gonadotropins













Trelstar Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

78



Gonadotropins And Antigonadotropins














Incretin Mimetics

Ozempic ST

Trulicity ST

Victoza 2-Pak ST

Victoza 3-Pak ST

Insulins

Admelog SoloStar U-100 Insulin QL

Admelog U-100 Insulin lispro QL

Basaglar KwikPen U-100 Insulin QL

Humalog Junior KwikPen U-100 QL

Humalog Mix 50-50 Insuln U-100 QL

Humalog Mix 50-50 KwikPen QL


Humalog Mix 75-25(U-100)Insuln QL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

79


Humulin 70/30 U-100 Insulin QL

Humulin N NPH Insulin KwikPen QL

Humulin N NPH U-100 Insulin QL

Humulin R Regular U-100 Insuln QL

Novolin 70/30 U-100 Insulin QL

Novolin N NPH U-100 Insulin QL

Novolin R Regular U-100 Insuln QL

Novolog Mix 70-30 U-100 Insuln QL

Novolog Mix 70-30FlexPen U-100 QL

Intermediate-Acting Insulins


Humulin N NPH Insulin KwikPen QL

Humulin N NPH U-100 Insulin QL


Novolin N NPH U-100 Insulin QL

Long-Acting Insulins

Basaglar KwikPen U-100 Insulin QL

Parathyroid Agents

Forteo Specialty PA

Tymlos Specialty PA

Parathyroid And Antiparathyroid Agents

calcitonin (salmon)

Forteo Specialty PA

Tymlos Specialty PA

Pituitary

Acthar H.P. PA

DDAVP nasal solution PA

desmopressin nasal spray,non-aerosol PA

desmopressin oral PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

80


Humatrope Specialty PA

Nutropin AQ Nuspin subcutaneous pen injector 5

mg/2 mL (2.5 mg/mL)

Specialty PA

Omnitrope Specialty PA

Saizen click.easy Specialty PA

Saizen subcutaneous recon soln 8.8 mg Specialty PA

Serostim subcutaneous recon soln 4 mg, 5 mg, 6

mg

Specialty PA

Progestins

Depo-Provera intramuscular suspension 400

mg/mL

Femhrt Low Dose

Jinteli

Makena Specialty PA

Makena (PF) Specialty PA

medroxyprogesterone

megestrol oral suspension 400 mg/10 mL (40

mg/mL)

megestrol oral suspension 625 mg/5 mL QL

megestrol oral tablet

norethindrone acetate

progesterone micronized

Rapid-Acting Insulins

Admelog SoloStar U-100 Insulin QL

Admelog U-100 Insulin lispro QL

Humalog Junior KwikPen U-100 QL

Humalog Mix 50-50 Insuln U-100 QL



Humalog Mix 75-25(U-100)Insuln QL

Novolog Mix 70-30 U-100 Insuln QL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

81


Novolog Mix 70-30FlexPen U-100 QL

Short-Acting Insulins


Humulin R Regular U-100 Insuln QL


Novolin R Regular U-100 Insuln QL

Sodium-Gluc Cotransport 2 (Sglt2) Inhib

Segluromet ST

Steglatro ST

Somatostatin Agonists

octreotide acetate Specialty PA

Signifor Specialty PA

Somatuline Depot Specialty PA

Somatotropin Agonists

Increlex Specialty PA

Somatotropin Antagonists

Somavert subcutaneous recon soln 15 mg, 20 mg Specialty PA

Sulfonylureas

chlorpropamide

glimepiride

glipizide

glipizide-metformin

glyburide

glyburide micronized

glyburide-metformin

tolazamide

tolbutamide

Thiazolidinediones

alogliptin-pioglitazone ST

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

82


pioglitazone ST

pioglitazone-metformin ST

Thyroid Agents

Armour Thyroid oral tablet 180 mg, 240 mg, 300

mg

levothyroxine oral

Levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg,

137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50

mcg, 75 mcg, 88 mcg

liothyronine oral

Nature-Throid oral tablet 130 mg, 16.25 mg, 195

mg, 32.5 mg, 65 mg

NP Thyroid oral tablet 15 mg, 30 mg, 60 mg, 90

mg

thyroid (pork) oral tablet 120 mg

Thyrolar-1

Thyrolar-1/2

Thyrolar-1/4

Thyrolar-2

Thyrolar-3

Unithroid oral tablet 100 mcg, 112 mcg, 125 mcg,

150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50

mcg, 75 mcg, 88 mcg

Miscellaneous Therapeutic Agents

5-Alpha-Reductase Inhibitors

dutasteride

finasteride oral tablet 5 mg

Alcohol Deterrents

disulfiram

naltrexone

Vivitrol QL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

83


Antidotes

Chemet

deferoxamine Specialty PA

Evzio PA

Glucagon Emergency Kit (human) QL

Kionex (with sorbitol)

leucovorin calcium injection recon soln Specialty PA

leucovorin calcium oral

levoleucovorin calcium intravenous recon soln 50

mg

Specialty PA


Narcan nasal spray,non-aerosol 4 mg/actuation QL

sevelamer carbonate oral tablet

SPS (with sorbitol) rectal

SSKI

Voraxaze Specialty PA

Antigout Agents

allopurinol

colchicine oral tablet ST; QL

indomethacin oral capsule

Krystexxa Specialty PA

naproxen

naproxen sodium oral capsule

naproxen sodium oral tablet

probenecid

probenecid-colchicine

Antisense Oligonucleotides

Kynamro Specialty PA

Spinraza (PF) Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

84


Bone Resorption Inhibitors

alendronate oral tablet

calcitonin (salmon)

etidronate disodium

ibandronate intravenous syringe Specialty PA

pamidronate intravenous recon soln 30 mg Specialty PA

pamidronate intravenous solution Specialty PA

Prolia Specialty PA

raloxifene

Xgeva Specialty PA

zoledronic acid intravenous solution Specialty PA

zoledronic acid-mannitol-water intravenous


Specialty PA

Zometa intravenous piggyback Specialty PA

Cariostatic Agents

fluoride (sodium) oral drops AL

fluoride (sodium) oral tablet,chewable AL

Gel-Kam AL


Multivitamin With Fluoride

Multi-Vitamin With Fluoride oral drops

Multivitamins With Fluoride oral tablet,chewable

0.25 mg, 1 mg

Poly-Vi-Flor


PreviDent 5000 Dry Mouth

PreviDent dental solution

SF AL

SF 5000 Plus AL


AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

85


Tri-Vitamin With Fluoride

Complement Inhibitors

Berinert intravenous kit Specialty PA

Cinryze PA

Firazyr Specialty PA

Haegarda Specialty PA

Kalbitor Specialty PA

Soliris Specialty PA

Disease-Modifying Antirheumatic Agents

Actemra Specialty PA

azathioprine

Cimzia Specialty PA


Cuprimine Specialty PA

cyclosporine intravenous Specialty PA

cyclosporine modified

cyclosporine oral capsule

Depen Titratabs Specialty PA

Enbrel Specialty PA

Enbrel Mini Specialty PA

Enbrel SureClick Specialty PA

Humira Specialty PA


syringe kit 80 mg/0.8 mL

Specialty PA




Specialty PA



Specialty PA

hydroxychloroquine

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

86



Kevzara subcutaneous syringe Specialty PA

Kineret Specialty PA

leflunomide

methotrexate sodium


Orencia Specialty PA

Orencia (with maltose) Specialty PA

Orencia ClickJect Specialty PA

Otezla Specialty PA

Otezla Starter Specialty PA



Ridaura

Sandimmune intravenous Specialty PA



Stelara intravenous Specialty PA

Stelara subcutaneous syringe Specialty PA

sulfasalazine

Xeljanz oral tablet 5 mg Specialty PA

Xeljanz XR Specialty PA

Gonadotropin-Releasing Hormone Antagnts



Immunomodulatory Agents

Actemra Specialty PA

Actimmune Specialty PA

Aubagio Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

87


Avonex (with albumin) Specialty PA

Avonex intramuscular pen injector kit Specialty PA

Avonex intramuscular syringe kit Specialty PA

azathioprine

Betaseron Specialty PA

Cimzia Specialty PA


Copaxone subcutaneous syringe Specialty PA




Enbrel Specialty PA



Entyvio Specialty PA

Extavia Specialty PA

Gilenya oral capsule 0.5 mg Specialty PA

glatiramer Specialty PA

Glatopa subcutaneous syringe 20 mg/mL Specialty PA

Humira Specialty PA


syringe kit 80 mg/0.8 mL, 80 mg/0.8 mL-40

mg/0.4 mL

Specialty PA




Specialty PA



Specialty PA

hydroxychloroquine



AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

88


Kevzara subcutaneous syringe Specialty PA

Kineret Specialty PA

leflunomide

Lemtrada Specialty PA

methotrexate sodium


Ocrevus Specialty PA

Orencia Specialty PA

Orencia (with maltose) Specialty PA

Orencia ClickJect Specialty PA

Otezla Specialty PA


Plegridy Specialty PA

Pomalyst Specialty PA

Proleukin Specialty PA

Rebif (with albumin) Specialty PA

Rebif Rebidose Specialty PA

Rebif Titration Pack Specialty PA



Revlimid oral capsule 10 mg, 15 mg, 2.5 mg, 25

mg, 5 mg

Specialty PA

Ridaura






sulfasalazine

Tecfidera Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

89


Thalomid Specialty PA

Tysabri Specialty PA

Xeljanz oral tablet 5 mg Specialty PA

Xeljanz XR Specialty PA

Immunosuppressive Agents

Atgam Specialty PA

azathioprine

Benlysta intravenous Specialty PA

CellCept oral suspension for reconstitution

cyclophosphamide intravenous Specialty PA




Elidel PA

mercaptopurine

methotrexate sodium


mycophenolate mofetil

mycophenolate mofetil HCl Specialty PA

mycophenolate sodium PA

Prograf intravenous Specialty PA

Rapamune oral solution PA


Simulect Specialty PA

sirolimus PA

tacrolimus oral

Thymoglobulin Specialty PA

Zortress oral tablet 0.25 mg, 0.5 mg, 0.75 mg Specialty PA

Other Miscellaneous Therapeutic Agents

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

90


acetylcysteine

Ampyra Specialty PA

Arcalyst Specialty PA

Botox Specialty PA

Cerdelga Specialty PA

Demser Specialty PA

Dysport Specialty PA

Endari Specialty PA

Ilaris (PF) subcutaneous solution Specialty PA

Kuvan oral tablet,soluble Specialty PA

levocarnitine (with sugar) Specialty PA

levocarnitine oral tablet

miglustat Specialty PA

Myobloc PA

octreotide acetate Specialty PA

Orfadin Specialty PA

Prezcobix


Spinraza (PF) Specialty PA

Xeomin Specialty PA

Protective Agents

amifostine crystalline Specialty PA

dexrazoxane HCl Specialty PA

Elmiron QL

mesna Specialty PA

Oxytocics

Oxytocics

Methergine QL

Respiratory Tract Agents

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

91


Alpha And Beta Adrenergic Agonist(Respr)

Bromfed DM


Children's Silfedrine

Conex oral solution

epinephrine injection auto-injector 0.15 mg/0.3

mL, 0.3 mg/0.3 mL

QL

epinephrine injection solution

epinephrine injection syringe 0.1 mg/mL

Lodrane D

LoHist - D


M-End DMX

Nasal Decongestant (pseudoeph) oral tablet

pseudoephedrine HCl oral tablet 60 mg


Rynex PSE

Anticholinergic Agents (Respir.Tract)

Anoro Ellipta

Atrovent HFA

Combivent Respimat


ipratropium bromide inhalation


Spiriva Respimat AL

Antifibrotic Agents

Esbriet Specialty PA

Anti-Inflammatory Agents (Respiratory)

Nucala Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

92


Antitussives

Adult Robitussin Peak Cold DM

benzonatate oral capsule 100 mg, 200 mg

Bromfed DM

Carbaphen CH

codeine sulfate oral tablet AL


Cough DM ER

Guaifenesin AC AL


mL

AL



M-End DMX

Mucinex DM oral tablet extended release 12 hr 30-

600 mg

NoHist-DM



promethazine-DM

Trexbrom


Cystic Fibrosis (Cftr) Correctors

Orkambi oral tablet Specialty PA

Symdeko Specialty PA

Cystic Fibrosis (Cftr) Potentiators

Kalydeco oral tablet Specialty PA

Orkambi oral tablet Specialty PA

Symdeko Specialty PA

Expectorants

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

93


Adult Robitussin Peak Cold DM


ED Bron GP

Guaifenesin AC AL

guaifenesin oral liquid

guaifenesin oral tablet extended release 12hr 1,200

mg


Mucinex DM oral tablet extended release 12 hr 30-

600 mg


SSKI


First Generation Antihist.(Respir Tract)

Bromfed DM

Carbaphen CH

Centergy


Conex oral solution

cyproheptadine

Diclegis PA

dimenhydrinate oral



mg/mL






AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

94


Ed Chlorped D

Lodrane D

LoHist - D

M-End DMX

NoHist-DM

promethazine oral

Promethazine VC



promethazine-DM

Rynex PSE


Trexbrom

Interleukin Antagonists

Cinqair Specialty PA

Dupixent subcutaneous syringe 300 mg/2 mL Specialty PA

Fasenra Specialty PA

Leukotriene Modifiers

montelukast oral granules in packet QL; AL

montelukast oral tablet QL

montelukast oral tablet,chewable QL

Mast-Cell Stabilizers

cromolyn inhalation

cromolyn nasal

cromolyn ophthalmic (eye)

Mucolytic Agents

acetylcysteine

Pulmozyme Specialty PA

Nasal Preparations (Steroids)

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

95


fluticasone nasal

Nasal Allergy ST

Orally Inhaled Preparations (Steroids)

ArmonAir RespiClick


mcg/actuation, 200 mcg/actuation

QL


mcg/actuation

Asmanex HFA

Asmanex Twisthaler QL

Breo Ellipta

budesonide inhalation QL; AL

Flovent Diskus QL

Flovent HFA QL


Qvar QL

Qvar RediHaler QL

Phosphodiesterase Type 4 Inhibitors

Daliresp ST

Respiratory Tract Agents, Miscellaneous

Aralast NP intravenous recon soln 500 mg PA

Glassia Specialty PA

Prolastin-C intravenous recon soln Specialty PA

Xolair subcutaneous recon soln PA

Second Generation Antihist(Respir Tract)

Allergy Relief (cetirizine) oral capsule ST

cetirizine oral solution 1 mg/mL

cetirizine oral tablet


Children's Zyrtec Allergy oral tablet,disintegrating ST

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

96


fexofenadine oral suspension ST

fexofenadine oral tablet 180 mg ST

levocetirizine oral tablet

loratadine oral capsule ST

loratadine oral solution ST

loratadine oral tablet

loratadine oral tablet,disintegrating ST

Select.Beta-2-Adrenergic Agonist(Respir)

albuterol sulfate inhalation solution for

nebulization

albuterol sulfate oral syrup

albuterol sulfate oral tablet

albuterol sulfate oral tablet extended release 12 hr

8 mg

Anoro Ellipta

Breo Ellipta

Combivent Respimat



levalbuterol tartrate ST

Serevent Diskus

terbutaline oral

Ventolin HFA QL

Vasodilating Agents (Respiratory Tract)

Adcirca Specialty PA

epoprostenol (glycine) Specialty PA

Letairis Specialty PA

Orenitram Specialty PA

Remodulin Specialty PA

Revatio intravenous Specialty PA

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

97


Revatio oral suspension for reconstitution Specialty PA

sildenafil (antihypertensive) oral PA

Tracleer Specialty PA

Tyvaso Specialty PA

Tyvaso Refill Kit Specialty PA

Tyvaso Starter Kit Specialty PA

Veletri Specialty PA

Ventavis Specialty PA

Xanthine Derivatives

Theo-24



Skin And Mucous Membrane Agents

Allylamines (Skin And Mucous Membrane)

terbinafine HCl topical

Antibacterials (Skin, Mucous Membrane)

bacitracin zinc topical ointment

Cleocin vaginal suppository

clindamycin phosphate topical gel

clindamycin phosphate topical lotion

clindamycin phosphate topical solution

clindamycin phosphate topical swab

clindamycin phosphate vaginal

Ery Pads

erythromycin with ethanol topical gel

erythromycin with ethanol topical solution

erythromycin-benzoyl peroxide

gentamicin topical

metronidazole topical cream

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

98


metronidazole topical gel

metronidazole vaginal

mupirocin

Triple Antibiotic topical ointment

Anti-Inflammatory Agents (Skin, Mucous)

ApexiCon E

betamethasone dipropionate

betamethasone valerate topical cream

betamethasone valerate topical lotion

betamethasone valerate topical ointment

betamethasone, augmented

clobetasol scalp

clobetasol topical cream

clobetasol topical gel

clobetasol topical ointment

clobetasol-emollient topical cream

clotrimazole-betamethasone

Colocort

desonide

desoximetasone topical cream

desoximetasone topical gel

desoximetasone topical ointment 0.25 %

diflorasone

fluocinolone

fluocinolone and shower cap

fluocinonide topical cream 0.05 %

fluocinonide topical gel

fluocinonide topical ointment

fluocinonide topical solution

Fluocinonide-E

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

99


fluticasone topical cream

fluticasone topical ointment

hydrocortisone acetate rectal suppository 25 mg

hydrocortisone butyrate topical cream

hydrocortisone butyrate topical ointment

hydrocortisone butyrate topical solution

hydrocortisone topical cream

hydrocortisone topical lotion

hydrocortisone topical ointment

hydrocortisone valerate

hydrocortisone-min oil-wht pet

hydrocortisone-pramoxine rectal cream 1-1 %

mometasone topical cream QL

mometasone topical ointment QL

mometasone topical solution

triamcinolone acetonide dental

triamcinolone acetonide topical cream

triamcinolone acetonide topical lotion

triamcinolone acetonide topical ointment 0.025 %,

0.1 %, 0.5 %

Antipruritics And Local Anesthetics

dibucaine


lidocaine HCl topical cream 3 %

lidocaine topical cream 4 %

lidocaine-prilocaine topical cream QL

phenazopyridine oral tablet 100 mg, 200 mg

pramoxine

Antivirals (Skin And Mucous Membrane)

Abreva

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

100


acyclovir topical PA

Zovirax topical cream PA

Astringents

aluminum chloride

Azoles (Skin And Mucous Membrane)

clotrimazole mucous membrane

clotrimazole topical

clotrimazole vaginal cream


econazole

Fungi Cure

Gyne-Lotrimin

ketoconazole topical cream

ketoconazole topical shampoo

Lotrimin AF

Lotrimin AF Powder

Miconazole 7 vaginal cream

miconazole nitrate topical cream

miconazole nitrate vaginal suppository

Miconazole-3 vaginal suppository

terconazole

Basic Lotions And Liniments

ammonium lactate topical lotion

CeraVe topical lotion

Hydrocerin

Lac-Hydrin Five

Lubriderm Daily Moisture

Lubriderm Sensitive Skin

Basic Ointments And Protectants

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

101


ammonium lactate topical cream

Aquaphor Healing

CeraVe topical cream

GRx Vitamin E topical cream

Minerin Creme

Benzylamines (Skin And Mucous Membrane)

Lotrimin Ultra

Cell Stimulants And Proliferants

Kepivance Specialty PA

tretinoin topical cream AL

tretinoin topical gel 0.01 %, 0.025 % AL

Corticosteroids (Skin, Mucous Membrane)

ApexiCon E

betamethasone dipropionate

betamethasone valerate topical cream

betamethasone valerate topical lotion

betamethasone valerate topical ointment

betamethasone, augmented

clobetasol scalp

clobetasol topical cream

clobetasol topical gel

clobetasol topical ointment

clobetasol-emollient topical cream


Colocort

desonide

desoximetasone topical cream

desoximetasone topical gel

desoximetasone topical ointment 0.25 %

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

102


diflorasone

fluocinolone


fluocinonide topical cream 0.05 %

fluocinonide topical gel

fluocinonide topical ointment

fluocinonide topical solution

Fluocinonide-E

fluticasone topical cream

fluticasone topical ointment

hydrocortisone acetate rectal suppository 25 mg

hydrocortisone butyrate topical cream

hydrocortisone butyrate topical ointment

hydrocortisone butyrate topical solution

hydrocortisone topical cream

hydrocortisone topical lotion

hydrocortisone topical ointment

hydrocortisone valerate



mometasone topical cream QL

mometasone topical ointment QL

mometasone topical solution

triamcinolone acetonide dental

triamcinolone acetonide topical cream

triamcinolone acetonide topical lotion

triamcinolone acetonide topical ointment 0.025 %,

0.1 %, 0.5 %

Hydroxypyridones (Skin, Mucous Membrane)

ciclopirox topical suspension

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

103


Keratolytic Agents

benzoyl peroxide topical cleanser 10 %

benzoyl peroxide topical gel 10 %, 5 %

Neutrogena On The Spot

sulfacetamide sodium-sulfur topical cleanser 10-5

% (w/w)

sulfacetamide sodium-sulfur topical lotion 10-5 %

(w/v)

urea topical lotion 40 %

Keratoplastic Agents

Drithocreme HP

Local Anti-Infectives, Miscellaneous

chlorhexidine gluconate topical liquid 4 %

Neosporin Wound Cleanser Kids

silver sulfadiazine

sulfacetamide sodium (acne)

sulfacetamide sodium-sulfur topical cleanser 10-5

% (w/w)

sulfacetamide sodium-sulfur topical lotion 10-5 %

(w/v)

Nonsteroidal Anti-Inflammat.Agents(Skin)


Pigmenting Agents

Oxsoralen Ultra Specialty PA

Polyenes (Skin And Mucous Membrane)

nystatin topical

nystatin-triamcinolone

Scabicides And Pediculicides

Complete Lice Treatment

Cutter Backwoods topical aerosol,spray QL; AL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

104


Lice Killing

Off Deep Woods Dry QL; AL

Off Deep Woods topical aerosol,spray QL; AL

permethrin topical cream QL

Repel Sportsmen QL; AL

Repel Sportsmen Max topical aerosol,spray QL; AL

Sklice ST

SPINOSAD 0.9% TOPICAL SUSP ST

Skin And Mucous Membrane Agents, Misc.

Cosentyx Specialty PA

Cosentyx Pen Specialty PA

Cutter Backwoods topical aerosol,spray QL; AL


Dupixent subcutaneous syringe 300 mg/2 mL Specialty PA

Elidel PA

Enbrel Specialty PA



Humira Specialty PA


syringe kit 80 mg/0.8 mL

Specialty PA




Specialty PA



Specialty PA

imiquimod topical cream in packet QL


Insect Repellent (picaridin) QL; AL

Natrapel QL; AL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

105


Off Deep Woods Dry QL; AL

Off Deep Woods topical aerosol,spray QL; AL

Otezla Specialty PA


podofilox



Repel Sportsmen QL; AL

Repel Sportsmen Max topical aerosol,spray QL; AL

Santyl

Siliq Specialty PA



tacrolimus topical PA

Taltz Autoinjector Specialty PA

Taltz Syringe Specialty PA

Targretin topical Specialty PA

Tremfya Specialty PA

Smooth Muscle Relaxants

Antimuscarinics

flavoxate

oxybutynin chloride

Oxytrol For Women

tolterodine

trospium oral tablet

Respiratory Smooth Muscle Relaxants

Theo-24



AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

106


Vitamins

Multivitamin Preparations

AquADEKs oral tablet,chewable

AquADEKs Pediatric

Atabex EC AL

Bio-35, Gluten Free

Cadeau DHA AL


Child Multivitamins

Classic Prenatal AL

Complete Natal DHA AL

Daily Prenatal AL

Expecta Prenatal AL

Flintstones Multi-Vit Gummies oral

tablet,chewable 200 mcg

KPN AL

Mini Prenatal AL


Multivitamin With Fluoride

Multi-Vitamin With Fluoride oral drops

Multivitamins With Fluoride oral tablet,chewable

0.25 mg, 1 mg

Mynatal AL

Mynatal Plus AL

Mynatal-Z AL

Mynate 90 Plus AL

Obstetrix DHA AL

Obstetrix EC AL

O-Cal FA AL

O-Cal Prenatal AL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

107






Perry Prenatal AL


Poly-Vi-Flor


Poly-Vitamins

Prenatabs Rx AL


mcg-200 mg

AL

Prenatal 19 AL


Prenatal Gummy AL

Prenatal Low Iron



mcg-228 mg

AL


Prenatal Plus AL



Prenatal Vitamin oral tablet AL




Prenatal-U AL

ProRenal QD

Protect Iron


AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

108


Similac Prenatal AL

TriAdvance AL

Trinatal GT AL

Trinatal Rx 1 AL

Trinate AL

Triveen-Duo DHA AL



Vinate GT AL

Vinate II AL

Vinate M AL

Vinate One AL

Vinate Ultra AL

Vol-Nate AL

Vol-Tab Rx AL

VP-GGR-B6



Vitamin A

Child Multivitamins


Vitamin B Complex

AquADEKs oral tablet,chewable

Atabex EC AL

Bio-35, Gluten Free

Cadeau DHA AL


Child Multivitamins

Classic Prenatal AL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

109


cyanocobalamin (vitamin B-12) injection

Daily Prenatal AL

Diclegis PA

Expecta Prenatal AL

FE C Plus AL

Flintstones Multi-Vit Gummies oral

tablet,chewable 200 mcg

folic acid oral tablet 1 mg

KPN oral tablet 9 mg iron- 267 mcg AL

Mini Prenatal AL

Multigen Folic

Multigen Plus


Mynatal Plus AL

Mynatal-Z AL

Nicomide

Obstetrix DHA AL

Obstetrix EC AL

O-Cal FA AL

O-Cal Prenatal AL




Perry Prenatal AL


Prenatabs Rx AL


mcg-200 mg

AL

Prenatal 19 AL


Prenatal Gummy AL

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

110


Prenatal Low Iron



mcg-228 mg

AL


Prenatal Plus AL






ProRenal QD

Protect Iron

pyridoxine (vitamin B6) oral tablet 25 mg

Rena-Vite

Rena-Vite Rx


Similac Prenatal AL

TriAdvance AL

Trinatal GT AL

Trinatal Rx 1 AL

Trinate AL

Triveen-Duo DHA AL

Vinate GT AL

Vinate M AL

Vinate One AL

Vinate Ultra AL

Vol-Nate AL

Vol-Tab Rx AL

VP-GGR-B6

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

111




Vitamin C

FE C AL

FE C Plus AL

Multigen Folic

Multigen Plus

Rena-Vite

Rena-Vite Rx


Vitamin D

Ca-D3-mag-zinc-cop-mang-bor

calcitriol intravenous solution 1 mcg/mL

calcitriol oral


Calcium 500 + D oral tablet 500 mg(1,250mg) -

400 unit

CALCIUM 500 + VIT D CAPLET P/F, CAPLET

CALCIUM 500-VIT D3 200 TABLET P/F,NA/F

Calcium 600 + D(3) oral tablet 600 mg(1,500mg) -

200 unit

CALCIUM 600 + VIT D TABLET

CALCIUM 600-VIT D3 800 CAPLET S/F, P/F,

CAPLET

calcium carbonate-vitamin D3 oral tablet 1,000

mg(2,500 mg)-800 unit, 600 mg(1,500mg) -400

unit

calcium citrate-vitamin D3 oral tablet 315-250 mg-

unit

Child Multivitamins

cholecalciferol (vitamin D3) oral capsule 1,000

unit

AL = Age Limit

GL = Gender Limit


QL = Quantity Limit

ST = Step therapy

112


cholecalciferol (vitamin D3) oral capsule 2,000

unit, 50,000 unit

cholecalciferol (vitamin D3) oral drops 400

unit/mL, 5,000 unit/mL

Citrus Calcium oral tablet 315-250 mg-unit

ergocalciferol (vitamin D2) oral capsule

ergocalciferol (vitamin D2) oral drops

HM VITAMIN D3 4,000 UNIT SFTGL

SOFTGEL

Kids Vitamin D3


Oyster Shell Calcium-Vit D3 oral tablet 500

mg(1,250mg) -200 unit, 500 mg(1,250mg) -400

unit

ProRenal QD


Upcal D

VITAMIN D 400 UNIT TABLET P/F,NA/F,S/F

VITAMIN D2 2,000 UNIT TABLET

VITAMIN D3 10,000 UNIT SOFTGEL

SOFTGEL

VITAMIN D3 2,000 UNIT SOFTGEL SOFTGEL

VITAMIN D3 5,000 UNIT CAPSULE S/F, P/F

Vitamin D3 oral capsule 1,000 unit, 400 unit

Vitamin D3 oral tablet 1,000 unit, 400 unit

Vitamin E

Child Multivitamins

Vitamin K Activity

AquADEKs Pediatric

phytonadione (vitamin K1) oral tablet 5 mg

113

Index

A abacavir .................................. 9

abacavir-lamivudine ............... 9

Abelcet ................................. 12

Abilify Maintena .................. 47

Abraxane .............................. 14

Abreva .................................. 99

Accu-Chek Aviva Control Soln

.......................................... 56

Accu-Chek Aviva Plus test strp

.......................................... 57

Accu-Chek Guide ................. 57

Accu-Chek Guide Glucose

Meter ................................ 56

Accu-Chek Guide L1-L2 Ctrl

Sol..................................... 56

Accu-Chek Multiclix Lancet 56

Accu-Chek SmartView Contrl

Sol..................................... 56

Accu-Chek SmartView Test

Strip .................................. 58

Accu-Chek Soft Dev Lancets

.......................................... 56

Accu-Chek Softclix Lancet

Dev ................................... 56

Accu-Chek Softclix Lancets. 57

acetaminophen ...................... 44

acetaminophen-codeine .. 44, 51

acetazolamide ........... 36, 58, 65

acetic acid ............................. 66

acetylcysteine ................. 90, 94

Actemra .......................... 85, 86

Acthar H.P. ..................... 57, 79

Actimmune ........................... 86

Activase .......................... 30, 63

acyclovir ....................... 11, 100

Adacel(Tdap

Adolesn/Adult)(PF) .......... 20

Adagen ................................. 63

Adcetris ................................ 14

Adcirca ........................... 40, 96

adefovir................................. 11

Admelog SoloStar U-100

Insulin ......................... 78, 80

Admelog U-100 Insulin lispro

.................................... 78, 80

Adult Robitussin Peak Cold

DM.............................. 92, 93

Aerochamber MV ................. 57

Afinitor ................................. 14

Afinitor Disperz .................... 14

Afluria 2017-2018 ................ 20

Afluria 2017-2018 (PF) ........ 20

Afluria Quad 2017-2018 ...... 20

Afluria Quad 2017-2018 (PF)

.......................................... 20

Aimovig Autoinjector........... 46

Aimovig Autoinjector (2 Pack)

.......................................... 46

Akynzeo (fosnetupitant) . 68, 71

Akynzeo (netupitant) ...... 68, 71

albuterol sulfate .............. 24, 96

Aldactazide ......... 40, 41, 59, 62

Aldurazyme .......................... 63

alendronate ........................... 84

Alferon N ........................ 10, 14

alfuzosin ............................... 24

Alimta ................................... 14

Allergy Relief (cetirizine) 2, 95

allopurinol ............................ 83

alogliptin ............................... 76

alogliptin-metformin ...... 75, 76

alogliptin-pioglitazone.... 76, 81

alprazolam ............................ 49

aluminum chloride .............. 100

aluminum hydroxide gel ....... 68

amantadine HCl ................ 4, 43

AmBisome ............................ 12

Amicar .................................. 26

amifostine crystalline ........... 90

amikacin ............................. 4, 6

amiloride ......................... 41, 59


.............................. 41, 59, 62

amiodarone ........................... 37

Amitiza ................................. 70

amitriptyline ......................... 56


.................................... 49, 56

amlodipine .......... 35, 38, 39, 42

amlodipine-benazepril ... 31, 32,

35, 38, 39, 42

amlodipine-valsartan31, 35, 38,

39, 42

ammonium lactate ...... 100, 101

amoxapine ............................. 56

amoxicillin .......................... 4, 5

amoxicillin-pot clavulanate .... 5

ampicillin ................................ 5

ampicillin sodium ................... 5

ampicillin-sulbactam .............. 5

Ampyra ................................. 90

anastrozole ...................... 14, 74

Anoro Ellipta ...... 22, 24, 91, 96

Antacid Plus Anti-Gas .... 68, 69

ApexiCon E .................. 98, 101

APOKYN ............................. 51

apraclonidine ........................ 66

aprepitant ........................ 71, 72

Aptivus ................................. 10

AquADEKs ................. 106, 108

AquADEKs Pediatric . 106, 112

Aquaphor Healing .............. 101

Aralast NP ............................ 95

Aranelle (28) ......................... 75

Aranesp (in polysorbate) ...... 25

Arcalyst ................................. 90

aripiprazole ........................... 47

Aristada ................................. 47

ArmonAir RespiClick ..... 73, 95

Armour Thyroid .................... 82

Arnuity Ellipta ................ 73, 95

Arranon ................................. 14

Artificial Tears (petro/min) .. 66

Artificial Tears (polyvin alc) 66

Artificial Tears(glycerin-peg)

.......................................... 66

Arzerra .................................. 14

Asmanex HFA ................ 73, 95

Asmanex Twisthaler ....... 73, 95

aspirin ................. 29, 30, 46, 54

aspirin-dipyridamole . 30, 42, 54

Atabex EC 27, 59, 70, 106, 108

atazanavir .............................. 10

atenolol ............... 25, 33, 34, 37

atenolol-chlorthalidone .. 25, 33,

34, 37, 42, 63

Atgam ................................... 89

atomoxetine .......................... 49

114

atorvastatin ........................... 39

atovaquone ............................. 6

atovaquone-proguanil ............. 5

atropine ................................. 67

Atrovent HFA ................. 22, 91

Aubagio ................................ 86

Augmentin .............................. 5

Austedo........................... 50, 56

Avastin ................................. 14

Avonex ................................. 87

Avonex (with albumin) ........ 87

Ayr Sinus Rinse Refill.......... 66

Azactam in dextrose (iso-osm)

.......................................... 11

azathioprine .............. 85, 87, 89

azelastine .............................. 64

azithromycin ......................... 12

Azopt .................................... 65

aztreonam ............................. 11

B Baby Ayr Saline ................... 66

bacitracin zinc ...................... 97

bacitracin-polymyxin B ........ 64

baclofen ................................ 23

balsalazide ............................ 69

Balziva (28) .......................... 75

Banzel ................................... 45

Basaglar KwikPen U-100

Insulin ......................... 78, 79

benazepril ....................... 31, 32


........................ 31, 32, 41, 62

Benlysta ................................ 89

benzonatate ........................... 92

benzoyl peroxide ................ 103

benztropine ..................... 22, 45

Berinert ................................. 85

betamethasone dipropionate 98,

101

betamethasone valerate 98, 101

betamethasone, augmented.. 98,

101

Betaseron .............................. 87

bethanechol chloride ............ 24

bexarotene ............................ 14

bicalutamide ......................... 14

Bicillin L-A .......................... 11

BiCNU .................................. 14

BiDil ............................... 38, 40

Biltricide ................................. 5

Bio-35, Gluten Free ....... 27, 59,

106, 108

bisoprolol fumarate.. 25, 33, 34,

37


............ 25, 33, 34, 37, 41, 62

bleomycin ............................. 14

Boostrix Tdap ....................... 20

Bosulif .................................. 14

Botox .............................. 25, 90

Breo Ellipta......... 24, 73, 95, 96

brimonidine .......................... 64

Bromfed DM ...... 20, 91, 92, 93

bromocriptine ....................... 50

budesonide ...................... 73, 95

bumetanide ..................... 39, 59

buprenorphine HCl ............... 52

buprenorphine-naloxone ....... 52

bupropion HCl ...................... 46

bupropion HCl (smoking deter)

.......................................... 46

buspirone .............................. 47

busulfan ................................ 14

Butalbital Compound

W/Codeine ...... 46, 48, 51, 54

butalbital-acetaminop-caf-cod

.................. 44, 46, 48, 51, 54

butalbital-acetaminophen 44, 48

butalbital-acetaminophen-caff

........................ 44, 46, 48, 54

butalbital-aspirin-caffeine ... 30,

46, 48, 54

butorphanol tartrate .............. 52

C cabergoline ........................... 50

Ca-D3-mag-zinc-cop-mang-

bor ............................. 59, 111

Cadeau DHA ........ 27, 106, 108

caffeine citrate ...................... 54

calcitonin (salmon) ... 75, 79, 84

calcitriol .............................. 111

Calcium 500 ......................... 61

Calcium 500 + D .... 59, 60, 111

Calcium 500 + D (D3) .. 60, 111

Calcium 600 ......................... 60

Calcium 600 + D(3) ...... 60, 111

calcium acetate ..................... 59

calcium carbonate-vitamin D3

............................ 59, 60, 111

calcium citrate-vitamin D3 .. 60,

111

Camptosar ............................. 14

Canasa ................................... 69

capecitabine .......................... 14

Caprelsa ................................ 14

captopril .......................... 31, 32


.............................. 32, 41, 62

Carbaglu ............................... 58

carbamazepine ...................... 45

Carbaphen CH ...... 2, 21, 92, 93

carbidopa-levodopa .............. 50

carboplatin ............................ 14

Carimune NF Nanofiltered ... 19

carisoprodol .......................... 23

carisoprodol-ASA-codeine .. 23,

51, 54

carisoprodol-aspirin ........ 23, 54

carteolol ................................ 65

carvedilol 23, 24, 30, 33, 37, 39

caspofungin ............................. 7

Cathflo Activase ............. 30, 63

Cayston ................................. 11

cefadroxil ................................ 3

cefazolin ................................. 3

cefdinir .................................... 3

cefepime ................................. 4

cefepime in dextrose 5 % ....... 4

cefepime in dextrose,iso-osm . 4

cefotaxime .............................. 3

cefotetan ............................. 3, 7

cefotetan in dextrose, iso-osm

........................................ 3, 7

cefprozil .................................. 3

ceftazidime ............................. 3

ceftriaxone .............................. 3

ceftriaxone in dextrose,iso-os . 3

cefuroxime axetil .................... 3

cefuroxime sodium ................. 3

celecoxib ............................... 50

CellCept ................................ 89

Centergy ..................... 2, 21, 93

Centrum Specialist Prenatal 27,

106, 108

cephalexin ............................... 3

CeraVe ........................ 100, 101

Cerdelga ................................ 90

Cerezyme .............................. 63

cetirizine ........................... 2, 95

115

cetirizine-pseudoephedrine.... 2,

20, 91, 95

Chantix ................................. 22

Chantix Starting Month Box 22

Chemet ........................... 72, 83

Child Multivitamins .. 106, 108,

111, 112

Children's Silfedrine ....... 20, 91

Children's Zyrtec Allergy . 2, 95

chlordiazepoxide HCl ........... 49

chlordiazepoxide-clidinium . 22,

49

chlorhexidine gluconate 66, 103

chloroquine phosphate............ 5

chlorothiazide ................. 41, 62

chlorpheniramine maleate . 1, 2,

93

chlorpromazine ..................... 53

chlorpropamide..................... 81

chlorthalidone ................. 42, 63

chlorzoxazone....................... 23

cholecalciferol (vitamin D3)

................................ 111, 112

cholestyramine (with sugar) . 34

Cholestyramine Light ........... 34

ciclopirox ............................ 102

cidofovir ............................... 11

cilostazol......................... 30, 40

Cimduo ................................... 9

cimetidine ............................. 71

cimetidine HCl ..................... 71

Cimzia ...................... 70, 85, 87

Cimzia Powder for Reconst. 70,

85, 87

Cinqair .................................. 94

Cinryze ................................. 85

Ciprodex ......................... 64, 65

ciprofloxacin..................... 6, 12

ciprofloxacin (mixture) .... 6, 12

ciprofloxacin HCl ....... 6, 12, 64

ciprofloxacin in 5 % dextrose 6,

12

cisplatin ................................ 14

citalopram ............................. 55

Citrus Calcium.............. 60, 112

cladribine .............................. 14

Claforan .................................. 3

clarithromycin .................. 6, 12

Classic Prenatal .... 27, 106, 108

Cleocin ................................. 97

clindamycin HCl................... 10

clindamycin in 5 % dextrose 10

clindamycin palmitate HCl ... 10

clindamycin phosphate ... 10, 97

Clinisol SF 15 %................... 58

clobetasol ...................... 98, 101

clobetasol-emollient ..... 98, 101

clofarabine ............................ 14

clomipramine ........................ 56

clonazepam ..................... 48, 49

clonidine ......................... 21, 36

clonidine HCl ................. 21, 36

clopidogrel ............................ 30

clorazepate dipotassium . 48, 49

clotrimazole ........................ 100

clotrimazole-betamethasone 98,

100, 101

clozapine ............................... 47

codeine sulfate ................ 51, 92

codeine-guaifenesin .. 51, 92, 93

colchicine.............................. 83

colestipol .............................. 34

colistin (colistimethate Na) .. 12

Colocort ........................ 98, 101

Combivent Respimat ..... 22, 24,

91, 96

Cometriq ............................... 14

Complete Lice Treatment ... 103

Complete Natal DHA ......... 106

Conex.................... 2, 21, 91, 93

Copaxone .............................. 87

cortisone ............................... 73

Cosentyx ............................. 104

Cosentyx Pen ...................... 104

cosyntropin ........................... 57

Cough DM ER ...................... 92

Creon .................................... 70

Crixivan ................................ 10

cromolyn ......................... 64, 94

Cuprimine ....................... 72, 85

Cutter Backwoods ...... 103, 104

cyanocobalamin (vitamin B-

12) ................................... 109

cyclobenzaprine .................... 23

cyclopentolate ....................... 67

cyclophosphamide .......... 14, 89

cyclosporine.............. 85, 87, 89

cyclosporine modified ... 85, 87,

89

cyproheptadine ................. 1, 93

cytarabine ............................. 15

cytarabine (PF) ..................... 15

CytoGam ............................... 19

Cytovene ............................... 11

Cytra-2 .................................. 58

D D5 %-0.45 % sodium chloride

.......................................... 58

dacarbazine ........................... 15

Dacogen ................................ 15

dactinomycin ........................ 15

Daily Prenatal . 27, 60, 106, 109

Daliresp ................................. 95

danazol .................................. 74

dapsone ............................... 5, 6

daptomycin ............................. 7

Daraprim ................................. 5

daunorubicin ......................... 15

DDAVP .......................... 26, 79

deferoxamine .................. 72, 83

Delzicol ................................. 69

Demser .................................. 90

Depen Titratabs .............. 72, 85

Depo-Provera ........................ 80

Descovy .................................. 9

desipramine ........................... 56

desmopressin .................. 26, 79

desogestrel-ethinyl estradiol . 75

desonide ........................ 98, 101

desoximetasone ............. 98, 101

dexamethasone ..................... 73

Dexamethasone Intensol ....... 73

dexamethasone sodium phos

(PF) ................................... 73

dexamethasone sodium

phosphate .................... 65, 73

dexmethylphenidate .............. 54

dexrazoxane HCl .................. 90

dextroamphetamine .............. 43

dextroamphetamine-

amphetamine ..................... 43

dextrose 70 % in water

(D70W) ............................. 58

diazepam ......................... 48, 49

Diazepam Intensol .......... 48, 49

dibucaine ............................... 99

Diclegis ................... 69, 93, 109

diclofenac potassium ............ 52

diclofenac sodium .... 52, 53, 67,

103, 104

116

dicloxacillin .......................... 12

dicyclomine .......................... 22

didanosine............................... 9

Dificid................................... 12

diflorasone .................... 98, 102

diflunisal ............................... 53

Digox .............................. 33, 36

digoxin ............................ 33, 36

dihydroergotamine ......... 23, 46

Dilantin ........................... 36, 50

diltiazem HCl 34, 35, 36, 37, 42

dimenhydrinate ........... 1, 69, 93

Dimetapp Cold-Allergy (PE) 2,

21, 93

Dipentum .............................. 69

diphenhydramine HCl ...... 1, 93

diphenoxylate-atropine .. 22, 69,

91

dipyridamole................... 30, 42

disopyramide phosphate ....... 36

disulfiram ............................. 82

Diuril .............................. 41, 62

divalproex ....................... 45, 46

Docefrez ............................... 15

docetaxel............................... 15

docusate sodium ................... 70

donepezil .............................. 24

dorzolamide .......................... 65

dorzolamide-timolol ............. 65

doxazosin .................. 23, 30, 39

doxepin ................................. 56

Doxil ..................................... 15

doxorubicin........................... 15

Doxy-100 .............................. 13

doxycycline hyclate ........ 13, 64

doxycycline monohydrate .... 13

Drithocreme HP.................. 103

droperidol ............................. 47

Droxia ................................... 15

duloxetine ....................... 50, 55

Dupixent ....................... 94, 104

dutasteride ............................ 82

Dysport ........................... 25, 90

E Ear Wax Treatment .............. 66

econazole ............................ 100

ED Bron GP ................... 21, 93

Ed Chlorped D ............ 2, 21, 94

Edurant ................................... 8

efavirenz ................................. 8

Elaprase ................................ 63

Elelyso .................................. 63

Elidel ............................ 89, 104

Eligard ...................... 15, 77, 78

Eligard (3 month) ..... 15, 77, 78

Eligard (4 month) ..... 15, 77, 78

Eligard (6 month) ..... 15, 77, 78

Eliquis ................................... 25

Elitek .................................... 63

Ella........................................ 75

Elmiron ................................. 90

Emcyt.................................... 15

Emend ................................... 72

Emflaza ................................. 73

Emtriva ................................... 9

enalapril maleate................... 32


.............................. 32, 41, 62

Enbrel ..................... 85, 87, 104

Enbrel Mini............. 85, 87, 104

Enbrel SureClick .... 85, 87, 104

Endari ............................. 70, 90

enoxaparin ...................... 26, 27

entecavir ............................... 11

Entresto ........................... 31, 41

Entyvio ........................... 71, 87

Enulose ................................. 58

epinephrine ..................... 21, 91

epirubicin .............................. 15

Epivir HBV............................. 9

Epogen .................................. 26

epoprostenol (glycine) .... 42, 96

Eraxis(Water Diluent) ............ 7

Erbitux .................................. 15

ergocalciferol (vitamin D2) 112

Ergomar .......................... 24, 47

Erivedge................................ 15

Erwinaze ............................... 15

Ery Pads ................................ 97

Ery-Tab ............................. 7, 10

Erythrocin (as stearate) ..... 7, 11

erythromycin .............. 7, 11, 64

erythromycin ethylsuccinate.. 7,

11

erythromycin with ethanol.... 97

erythromycin-benzoyl peroxide

.......................................... 97

Esbriet ................................... 91

escitalopram oxalate ............. 55

esomeprazole magnesium..... 72

estazolam .............................. 49

estradiol ................................ 77


.................................... 74, 77

estropipate ............................. 77

eszopiclone ........................... 47

ethambutol .............................. 6

ethosuximide ......................... 56

ethynodiol diac-eth estradiol 75

etidronate disodium .............. 84

etodolac ................................. 53

Etopophos ............................. 15

etoposide ............................... 15

Euflexxa ................................ 57

Evzio ............................... 52, 83

exemestane ..................... 15, 74

Exjade ................................... 72

Expecta Prenatal ... 27, 106, 109

Extavia .................................. 87

Eylea ..................................... 66

F Fabrazyme ............................ 63

famotidine ............................. 71

Fareston .......................... 15, 76

Fasenra .................................. 94

Faslodex ................................ 15

FE C .............................. 27, 111

FE C Plus .............. 27, 109, 111

felodipine ............ 35, 38, 39, 42

Femhrt Low Dose ........... 77, 80

fenofibrate ............................. 39

fenofibrate micronized .......... 38

fenofibrate nanocrystallized . 39

fentanyl ................................. 51

Feraheme .............................. 27

Ferocon ................................. 27

Ferrex 28 ............................... 27

Ferriprox ............................... 73

Ferrlecit ................................. 27

ferrous gluconate .................. 27

ferrous sulfate ....................... 27

Feverall ................................. 44

fexofenadine ..................... 2, 96

finasteride ............................. 82

Firazyr ................................... 85

Firmagon ................... 15, 75, 86

Firmagon kit w diluent syringe

.............................. 15, 75, 86

Firvanq .................................... 8

Flarex .................................... 65

117

flavoxate ............................. 105

Flebogamma DIF.................. 19

flecainide .............................. 36

Flintstones Multi-Vit Gummies

................................ 106, 109

Flovent Diskus................ 73, 95

Flovent HFA ................... 73, 95

floxuridine ............................ 16

Fluarix Quad 2017-2018 (PF)

.......................................... 20

Flucelvax Quad 2017-2018 .. 20

Flucelvax Quad 2017-2018

(PF) ................................... 20

fluconazole ............................. 7

fluconazole in dextrose(iso-o) 6

fluconazole in NaCl (iso-osm) 6

fludarabine ............................ 16

fludrocortisone ..................... 73

Flulaval Quad 2017-2018 (PF)

.......................................... 20

fluocinolone .................. 98, 102


.................................. 98, 102

fluocinonide .................. 98, 102

Fluocinonide-E ............. 98, 102

fluoride (sodium) .................. 84

fluorometholone ................... 65

fluorouracil ........................... 16

fluoxetine .............................. 55

fluphenazine decanoate ........ 53

fluphenazine HCl.................. 53

flurbiprofen........................... 53

flurbiprofen sodium .............. 67

flutamide............................... 16

fluticasone ........ 65, 95, 99, 102

fluticasone-salmeterol ... 24, 73,

95, 96

Fluvirin 2017-2018 ............... 20

Fluvirin 2017-2018 (PF)....... 20

fluvoxamine .......................... 55

Fluzone High-Dose 2017-18

(PF) ................................... 20

Fluzone Intraderm Quad 2017-

18 ...................................... 20

Fluzone Quad 2017-2018 ..... 20

Fluzone Quad 2017-2018 (PF)

.......................................... 20

Fluzone Quad Pedi 2017-18

(PF) ................................... 20

FML Forte ............................ 65

FML S.O.P. .......................... 65

folic acid ............................. 109

Folotyn.................................. 16

Formula EM ......................... 69

Forteo.................................... 79

fosamprenavir ....................... 10

foscarnet ................................. 6

fosinopril .............................. 32


.............................. 32, 41, 62

Fulphila ................................. 26

Fungi Cure .......................... 100

furosemide ...................... 40, 59

Fuzeon .................................... 8

G gabapentin ...................... 44, 45

Galzin ................................... 73

GamaSTAN S/D ................... 19

Gamunex-C .......................... 19

Gattex 30-Vial ...................... 71

Gelclair ................................. 57

Gel-Kam ............................... 84

Gel-One ................................ 57

Gelsyn-3 ............................... 57

gemcitabine .......................... 16

gemfibrozil ........................... 39

Gentak .................................. 64

gentamicin ........................ 4, 97

gentamicin in NaCl (iso-osm) 4

gentamicin sulfate (PF) .......... 4

GenVisc 850 ......................... 57

Genvoya.............................. 8, 9

Geodon ................................. 47

Gilenya ................................. 87

Glassia .................................. 95

glatiramer.............................. 87

Glatopa ................................. 87

Gliadel Wafer ....................... 16

glimepiride............................ 81

glipizide ................................ 81

glipizide-metformin ........ 75, 81

Glucagon Emergency Kit

(human) ...................... 77, 83

glyburide ............................... 81

glyburide micronized ............ 81

glyburide-metformin ...... 75, 81

glycopyrrolate ....................... 22

granisetron (PF) .................... 68

granisetron HCl .................... 68

Granix ................................... 26

griseofulvin microsize ............ 5

griseofulvin ultramicrosize ..... 5

GRx Vitamin E ................... 101

guaifenesin ............................ 93

Guaifenesin AC ........ 51, 92, 93

guanfacine ....................... 36, 50

Gyne-Lotrimin .................... 100

H Haegarda ............................... 85

Halaven ................................. 16

haloperidol ............................ 49

haloperidol decanoate ........... 49

haloperidol lactate ................ 49

heparin (porcine) .................. 27

heparin (porcine) in 5 % dex 27

heparin (porcine) in NaCl (PF)

.................................... 27, 57

heparin, porcine (PF) ............ 27

Herceptin .............................. 16

Hexalen ................................. 16

Hizentra ................................ 19

Homatropaire ........................ 67

Humalog Junior KwikPen U-

100 .............................. 78, 80

Humalog Mix 50-50 Insuln U-

100 .............................. 78, 80

Humalog Mix 50-50 KwikPen

.................................... 78, 80

Humalog Mix 75-25 KwikPen

.................................... 78, 80

Humalog Mix 75-25(U-

100)Insuln ................... 78, 80

Humatrope ............................ 80

Humira .............. 71, 85, 87, 104

Humira Pediatric Crohn's Start

...................... 71, 85, 87, 104

Humira Pen ....... 71, 85, 87, 104

Humira Pen Crohn's-UC-HS

Start ............... 71, 85, 87, 104

Humira Pen Psoriasis-Uveitis

...................... 71, 85, 87, 104

Humulin 70/30 U-100 Insulin

.................................... 79, 81

Humulin N NPH Insulin

KwikPen ........................... 79

Humulin N NPH U-100 Insulin

.......................................... 79

Humulin R Regular U-100

Insuln .......................... 79, 81

Hyalgan ................................. 57

118

Hycamtin .............................. 16

hydralazine ........................... 38

Hydrocerin .......................... 100

hydrochlorothiazide ........ 41, 62

hydrocodone-acetaminophen

.................................... 44, 51

hydrocodone-homatropine .. 22,

51, 92

hydrocortisone ........ 73, 99, 102

hydrocortisone acetate .. 99, 102

hydrocortisone butyrate 99, 102

hydrocortisone valerate 99, 102


.................................. 99, 102

hydrocortisone-pramoxine .. 99,

102

hydromorphone .............. 51, 52

hydroxychloroquine ... 5, 85, 87

hydroxyurea .......................... 16

hydroxyzine HCl .............. 2, 47

hydroxyzine pamoate ....... 2, 47

hyoscyamine sulfate ............. 22

Hyper-Sal ....................... 57, 60

Hypotears ............................. 66

I ibandronate ........................... 84

Ibrance .................................. 16

ibuprofen .............................. 53

Iclusig ................................... 16

idarubicin .............................. 16

ifosfamide ............................. 16

ifosfamide-mesna ................. 16

Ilaris (PF).............................. 90

imatinib................................. 16

imipramine HCl .................... 56

imiquimod .......................... 104

Increlex ................................. 81

indapamide ..................... 42, 63

indomethacin .................. 53, 83

Infant's Ibuprofen ................. 53

Infed ..................................... 27

Inflectra ............ 71, 86, 87, 104

Ingrezza .......................... 50, 56

Injectafer............................... 27

Inlyta..................................... 16

Insect Repellent (picaridin) 104

Insulin Syringe ..................... 57

Intelence ................................. 8

Intralipid ............................... 58

Intrarosa ................................ 74

Intron A .................... 10, 16, 87

Invanz ..................................... 7

Invega Sustenna .................... 47

Invega Trinza ........................ 48

Invirase ................................. 10

Iopidine ................................. 66

ipecac .................................... 70

ipratropium bromide . 22, 66, 91

ipratropium-albuterol..... 22, 24,

91, 96

irbesartan .............................. 31

irbesartan-hydrochlorothiazide

.............................. 31, 41, 62

irinotecan .............................. 16

Iron Chews ........................... 27

Isentress .................................. 8

Isentress HD ........................... 8

isometh-dichloral-

acetaminophn.................... 44

isoniazid.................................. 6

isosorbide dinitrate ............... 40

isosorbide mononitrate ......... 40

itraconazole ............................ 7

Ixempra ................................. 16

J Jadenu ................................... 73

Jadenu Sprinkle .................... 73

Jakafi .................................... 16

Janumet ........................... 75, 76

Janumet XR .................... 75, 76

Januvia .................................. 76

Jevtana .................................. 16

Jinteli .............................. 77, 80

Juluca ...................................... 8

Juxtapid ................................ 33

Jynarque................................ 63

K Kadcyla ................................. 16

Kalbitor ................................. 85

Kaletra .................................. 10

Kalydeco ............................... 92

Kepivance ........................... 101

ketoconazole ................... 7, 100

ketoprofen ............................. 53

ketorolac ......................... 53, 67

ketotifen fumarate................. 64

Kevzara ........................... 86, 88

Kids Vitamin D3 ................ 112

Kineret ............................ 86, 88

Kionex (with sorbitol) .... 59, 83

Klor-Con ............................... 60

Klor-Con/EF ......................... 60

KPN ...................... 28, 106, 109

Krystexxa .............................. 83

Kuvan ................................... 90

Kynamro ......................... 33, 83

Kyprolis ................................ 16

L labetalol .. 23, 24, 30, 33, 34, 37

Lac-Hydrin Five ................. 100

lactulose ................................ 58

lamivudine .............................. 9

lamivudine-zidovudine ........... 9

lamotrigine ............................ 45

Lancets,Ultra Thin ................ 57

lansoprazole .......................... 72

latanoprost ............................ 67

Latuda ................................... 48

leflunomide ..................... 86, 88

Lemtrada ............................... 88

Letairis ............................ 42, 96

letrozole .......................... 16, 74

leucovorin calcium ............... 83

Leukeran ............................... 17

Leukine ................................. 26

leuprolide .................. 17, 77, 78

levalbuterol tartrate ......... 24, 96

levetiracetam ......................... 45

levobunolol ........................... 65

levocarnitine ......................... 90

levocarnitine (with sugar) ..... 90

levocetirizine .................... 2, 96

levofloxacin ...................... 6, 12

levoleucovorin calcium ........ 83

levonorgestrel-ethinyl estrad 75

levonorg-eth estrad triphasic 76

levothyroxine ........................ 82

Levoxyl ................................. 82

Lexiva ................................... 10

Lice Killing ......................... 104

lidocaine ............................... 99

lidocaine HCl .................. 67, 99

Lidocaine Viscous ................ 67

lidocaine-prilocaine .............. 99

Lincocin ................................ 10

Linzess .................................. 71

Lioresal ................................. 23

liothyronine ........................... 82

Liposyn III ............................ 58

lisinopril ................................ 32

119


.............................. 32, 41, 62

lithium carbonate .................. 46

lithium citrate ....................... 46

Lodrane D ............. 2, 21, 91, 94

LoHist - D............. 2, 21, 91, 94

loperamide ............................ 69

lopinavir-ritonavir ................ 10

loratadine .......................... 3, 96

lorazepam ............................. 49

Lorazepam Intensol .............. 49

Lortuss EX.... 21, 52, 91, 92, 93

losartan ................................. 31


.............................. 31, 41, 62

Lotrimin AF........................ 100

Lotrimin AF Powder .......... 100

Lotrimin Ultra .................... 101

lovastatin .............................. 39

Low-Ogestrel (28) ................ 76

loxapine succinate ................ 47

Lubriderm Daily Moisture . 100

Lubriderm Sensitive Skin ... 100

Lucentis ................................ 66

Lupron Depot ........... 17, 77, 78

Lupron Depot (3 month) 17, 77,

78

Lupron Depot (4 month) 17, 77,

78

Lupron Depot (6 Month) ..... 17,

77, 78

Lupron Depot-Ped .... 17, 77, 78

Lupron Depot-Ped (3 month)

.............................. 17, 77, 78

Lysodren ............................... 17

M Maalox Advanced .......... 68, 69

Macugen ............................... 67

magnesium oxide.................. 68

magnesium sulfate .... 33, 45, 83

Makena ................................. 80

Makena (PF) ......................... 80

Mapap (acetaminophen) ....... 44

maprotiline ........................... 56

Matulane ............................... 17

Maxidex ................................ 65

meclizine .......................... 2, 69

meclofenamate ..................... 53

medroxyprogesterone ........... 80

mefloquine .............................. 5

megestrol ........................ 17, 80

meloxicam ............................ 53

melphalan ............................. 17

melphalan HCl ...................... 17

memantine ............................ 50

M-End DMX .. 2, 21, 91, 92, 94

Menest .................................. 77

meperidine ............................ 52

mercaptopurine ............... 17, 89

meropenem ............................. 7

mesalamine ........................... 69

mesna .................................... 90

Mestinon ............................... 24

metformin ............................. 75

Methergine............................ 90

methimazole ......................... 75

methocarbamol ..................... 23

methotrexate sodium 17, 86, 88,

89

methotrexate sodium (PF) ... 17,

86, 88, 89

methscopolamine .................. 22

methyclothiazide ............ 41, 62

methyldopa ..................... 21, 36

methyldopa-

hydrochlorothiazide ... 21, 36,

41, 62

methylphenidate HCl ............ 54

methylprednisolone .............. 74

methylprednisolone sodium

succ ................................... 74

metipranolol.......................... 65

metoclopramide HCl ............ 72

metolazone...................... 42, 63

metoprolol succinate 25, 33, 34,

37


............ 25, 33, 34, 37, 41, 62

metoprolol tartrate ... 25, 33, 34,

37

metronidazole ......... 4, 6, 97, 98

metronidazole in NaCl (iso-os)

........................................ 4, 6

mexiletine ............................. 36

Miconazole 7 ...................... 100

miconazole nitrate .............. 100

Miconazole-3 ...................... 100

MICRhoGAM Ultra-Filtered

PLUS ................................ 19

Microgestin 1.5/30 (21) ........ 76

Microgestin Fe 1.5/30 (28) ... 76

Microgestin FE 1/20 (28) ..... 76

midazolam ............................ 49

midodrine .............................. 21

miglustat ............................... 90

Minerin Creme .................... 101

Mini Prenatal ........ 28, 106, 109

minocycline .......................... 13

minoxidil ............................... 38

mirtazapine ........................... 46

misoprostol ........................... 72

mitomycin ............................. 17

mitoxantrone ......................... 17

modafinil ............................... 56

moexipril ............................... 32


.............................. 32, 42, 62

mometasone .................. 99, 102

Monovisc .............................. 57

montelukast ........................... 94

morphine ............................... 52

morphine concentrate ........... 52

Moxeza ................................. 64

moxifloxacin ............... 6, 13, 64

Mozobil ................................. 26

Mucinex DM .................. 92, 93

Multigen ............................... 28

Multigen Folic ...... 28, 109, 111

Multigen Plus ........ 28, 109, 111


............................ 28, 84, 106

Multivitamin With Fluoride 84,

106

Multi-Vitamin With Fluoride

.................................. 84, 106

Multivitamins With Fluoride

.................................. 84, 106

mupirocin .............................. 98

Muro 128 .............................. 67

Mustargen ............................. 17

Mycamine ............................... 7

Mycobutin ......................... 6, 13

mycophenolate mofetil ......... 89

mycophenolate mofetil HCl . 89

mycophenolate sodium ......... 89

Myleran ................................. 17

Mynatal ........... 28, 60, 106, 109

Mynatal Plus ... 28, 60, 106, 109

Mynatal-Z ....... 28, 60, 106, 109

Mynate 90 Plus ................... 106

120

Myobloc ......................... 25, 90

N nabumetone .......................... 53

nadolol ................ 23, 33, 34, 37


............ 23, 33, 34, 37, 42, 62

nafcillin................................. 12

nafcillin in dextrose iso-osm 12

Naglazyme ............................ 63

nalbuphine ............................ 52

naltrexone ....................... 52, 82

naproxen ......................... 53, 83

naproxen sodium ............ 53, 83

Narcan ............................ 52, 83

Nasal Allergy.................. 65, 95

Nasal Decongestant

(pseudoeph) ................ 21, 91

Natrapel .............................. 104

Nature-Throid ....................... 82

Nebupent ................................ 6

nefazodone ........................... 55


.................................... 64, 65

neomycin-bacitracin-

polymyxin......................... 64

neomycin-polymyxin B-

dexameth .................... 64, 66

neomycin-polymyxin-

gramicidin......................... 64

neomycin-polymyxin-HC ... 64,

66

Neosporin Wound Cleanser

Kids ................................ 103

Neo-Synephrine

(phenylephrine) ................ 68

Neulasta ................................ 26

Neupogen ............................. 26

Neutrogena On The Spot .... 103

nevirapine ............................... 8

Nexavar ................................ 17

Nexium 24HR ...................... 72

niacin .................................... 33

Niacin Flush Free ................. 33

Nicomide ............................ 109

nicotine ................................. 22

nicotine (polacrilex) ............. 22

Nicotrol................................. 22

Nicotrol NS .......................... 23

nifedipine ...... 35, 38, 39, 42, 43

nilutamide ............................. 17

Nitro-Bid .............................. 40

Nitro-Dur .............................. 40

nitrofurantoin ........................ 13

nitrofurantoin macrocrystal .. 13

nitrofurantoin monohyd/m-

cryst .................................. 13

nitroglycerin ......................... 40

nizatidine .............................. 71

NoHist-DM ........... 2, 21, 92, 94

norethindrone (contraceptive)

.......................................... 76

norethindrone acetate ........... 80

norethindrone ac-eth estradiol

.......................................... 76

norgestimate-ethinyl estradiol

.......................................... 76

Nortemp ................................ 44

Nortrel 0.5/35 (28) ................ 76

Nortrel 1/35 (21) ................... 76

Nortrel 1/35 (28) ................... 76

Nortrel 7/7/7 (28).................. 76

nortriptyline .......................... 56

Norvir ................................... 10

Novolin 70/30 U-100 Insulin

.................................... 79, 81

Novolin N NPH U-100 Insulin

.......................................... 79

Novolin R Regular U-100

Insuln .......................... 79, 81

Novolog Mix 70-30 U-100

Insuln .......................... 79, 80

Novolog Mix 70-30FlexPen U-

100 .............................. 79, 81

NP Thyroid ........................... 82

Nplate ................................... 26

Nucala ................................... 91

Nutropin AQ Nuspin ............ 80

NuvaRing.............................. 76

nystatin ......................... 12, 103

nystatin-triamcinolone ........ 103

O Obstetrix DHA ..... 28, 106, 109

Obstetrix EC ... 28, 70, 106, 109

O-Cal FA ........ 28, 60, 106, 109

O-Cal Prenatal 28, 60, 106, 109

Ocaliva.................................. 71

Ocrevus ................................. 88

octreotide acetate ............ 81, 90

Odefsey ............................... 8, 9

Off Deep Woods ......... 104, 105

Off Deep Woods Dry .. 104, 105

ofloxacin ......................... 13, 64

olanzapine ............................. 48

olanzapine-fluoxetine ..... 48, 55

olmesartan ............................. 31

olmesartan-

hydrochlorothiazide ... 31, 42,

62

olopatadine ........................... 64

omeprazole ........................... 72

omeprazole-sodium

bicarbonate ....................... 72

Omnitrope ............................. 80

Oncaspar ............................... 17

ondansetron ........................... 68

ondansetron HCl ................... 68

ondansetron HCl (PF) ........... 68

One A Day Women's Prenatal

DHA ........... 28, 60, 107, 109

One-A-Day Womens Formula

.................... 28, 60, 107, 109

One-A-Day Women's Prenatal

1 .................. 28, 60, 107, 112

Oracit .................................... 58

Oralyte .................................. 60

Orencia ........................... 86, 88

Orencia (with maltose) ... 86, 88

Orencia ClickJect ............ 86, 88

Orenitram ........................ 43, 96

Orfadin .................................. 90

Orkambi ................................ 92

orphenadrine citrate .............. 25

ORTHOVISC ....................... 57

oseltamivir ............................ 11

Otezla ...................... 86, 88, 105

Otezla Starter .......... 86, 88, 105

oxacillin ................................ 12

oxaliplatin ............................. 17

oxazepam .............................. 49

oxcarbazepine ....................... 45

Oxsoralen Ultra .................. 103

oxybutynin chloride ............ 105

oxycodone ............................. 52

oxycodone-acetaminophen .. 44,

52

Oxytrol For Women ........... 105

Oyster Shell Calcium-Vit D3

.................................. 60, 112

Ozempic ................................ 78

Ozurdex ................................ 66

121

P Pacerone ............................... 37

paclitaxel .............................. 17

Pain Relief ............................ 44

paliperidone .......................... 48

palonosetron ......................... 68

pamidronate .......................... 84

pantoprazole ......................... 72

paroxetine HCl ..................... 55

peg 3350-electrolytes ........... 70

pen needle, diabetic .............. 57

penicillin G potassium .......... 11

penicillin V potassium .......... 11

Pentam .................................... 6

Pentasa .................................. 70

pentoxifylline ....................... 26

Perdiem Overnight Relief..... 70

perindopril erbumine ............ 32

Perjeta ................................... 17

permethrin .......................... 104

perphenazine......................... 53

perphenazine-amitriptyline.. 53,

56

Perry Prenatal . 28, 61, 107, 109

phenazopyridine ................... 99

phenelzine............................. 51

phenobarbital ........................ 48

phenoxybenzamine ......... 24, 39

phenylephrine HCl ............... 68

phenytoin ........................ 36, 50

phenytoin sodium extended . 36,

50

Phospholine Iodide ............... 67

Photofrin ............................... 17

phytonadione (vitamin K1) 112

pilocarpine HCl .................... 67

pimozide ............................... 47

pindolol......... 23, 33, 34, 37, 39

Pink Bismuth .................. 68, 69

pioglitazone .......................... 82

pioglitazone-metformin .. 75, 82

piperacillin-tazobactam .......... 7

piroxicam .............................. 53

Plegridy ................................ 88

PNV cmb#95-ferrous

fumarate-FA ..... 28, 107, 109

podofilox ............................ 105

polyethylene glycol 3350 ..... 70

polymyxin B sulf-trimethoprim

.......................................... 64

Poly-Vi-Flor ................. 84, 107

Poly-Vi-Flor with Iron... 28, 84,

107

Poly-Vitamins ..................... 107

Pomalyst ......................... 18, 88

potassium chloride ................ 61

potassium citrate ................... 58

Pradaxa ................................. 25

Praluent Pen .......................... 40

pramipexole .......................... 51

pramoxine ............................. 99

prasugrel ............................... 30

pravastatin ............................ 39

prazosin .......................... 23, 30

Pred Mild .............................. 66

prednisolone ......................... 74

prednisolone acetate ............. 66

prednisolone sodium phosphate

.................................... 66, 74

prednisone ............................ 74

Prednisone Intensol .............. 74

Premarin ............................... 77

Premphase ............................ 77

Prempro ................................ 77

Prenatabs Rx ... 28, 61, 107, 109

Prenatal ................. 28, 107, 110

Prenatal + DHA .... 28, 107, 109

Prenatal 19 ............ 28, 107, 109

Prenatal Formula ... 28, 61, 107,

109

Prenatal Gummy ......... 107, 109

Prenatal Low Iron .. 28, 61, 107,

110

Prenatal Multi-DHA .... 28, 107,

110

Prenatal Multi-DHA (algal oil)

.......................... 28, 107, 110

Prenatal Plus ... 28, 61, 107, 110

Prenatal Plus (calcium carb) 29,

61, 107, 110

Prenatal Plus DHA 29, 107, 110

Prenatal Vitamin ................. 107

Prenatal Vitamin Plus Low

Iron ............. 29, 61, 107, 110

prenatal vit-iron fum-folic ac

.................... 29, 61, 107, 110

prenatal vits96-iron fum-folic

.................... 29, 61, 107, 110

Prenatal-U ........................... 107

Prevalite ................................ 34

PreviDent .............................. 84

PreviDent 5000 Dry Mouth .. 84

Prezcobix ........................ 10, 90

Prezista ................................. 10

Prialt ..................................... 44

Prilosec ................................. 72

primaquine .............................. 5

primidone .............................. 48

Privigen ................................. 20

probenecid ...................... 63, 83

probenecid-colchicine ..... 63, 83

prochlorperazine ............. 53, 69

prochlorperazine Edisylate .. 53,

69

prochlorperazine maleate 53, 69

Procrit ................................... 26

progesterone micronized ...... 80

Prograf .................................. 89

Prolastin-C ............................ 95

Proleukin ......................... 18, 88

Prolia ..................................... 84

Promacta ............................... 26

promethazine .............. 1, 47, 94

Promethazine VC ........ 1, 21, 94

Promethazine VC-Codeine .... 1,

21, 52, 92, 94

promethazine-codeine .... 52, 92,

94

promethazine-DM ....... 2, 92, 94

propafenone .......................... 37

propantheline ........................ 22

proparacaine ......................... 67

propranolol .. 23, 33, 34, 37, 39,

47


............ 23, 33, 34, 37, 42, 62

propylthiouracil .................... 75

ProRenal QD 29, 107, 110, 112

Prosol 20 % ........................... 58

Prosteon ................................ 61

Protect Iron ........... 29, 107, 110

Provenge ............................... 43

pseudoephedrine HCl ..... 21, 91


.............................. 21, 91, 93

Pulmozyme ..................... 63, 94

pyrazinamide .......................... 6

pyridostigmine bromide ........ 24

pyridoxine (vitamin B6) ..... 110

122

Q quetiapine ............................. 48

quinapril ............................... 32


........................ 32, 33, 42, 62

quinidine gluconate .......... 5, 36

quinidine sulfate ............... 5, 36

Qvar ................................ 74, 95

Qvar RediHaler .............. 74, 95

R Radicava ............................... 50

raloxifene ........................ 76, 84

ramipril ........................... 32, 33

ranitidine HCl ....................... 71

Rapamune ............................. 89

Rebetol ................................. 11

Rebif (with albumin) ............ 88

Rebif Rebidose ..................... 88

Rebif Titration Pack ............. 88

Relenza Diskhaler ................ 11

Remicade .... 71, 86, 88, 90, 105

Remodulin ...................... 43, 96

Rena-Vite ................... 110, 111

Rena-Vite Rx .............. 110, 111

Renflexis........... 71, 86, 88, 105

Repatha Pushtronex .............. 40

Repatha SureClick ................ 40

Repatha Syringe ................... 40

Repel Sportsmen ........ 104, 105

Repel Sportsmen Max 104, 105

Rescriptor ............................... 9

Restasis ................................. 66

Restasis MultiDose ............... 66

Retacrit ................................. 26

Retisert ................................. 66

Revatio ............... 40, 41, 96, 97

Revlimid ......................... 18, 88

RhoGAM Ultra-Filtered PLUS

.......................................... 20

Rhophylac............................. 20

Ridaura ..................... 72, 86, 88

rifampin ............................ 6, 13

Right Step Prenatal Vitamins

.................... 29, 61, 107, 110

riluzole .................................. 50

rimantadine ............................. 4

Risperdal Consta .................. 48

risperidone ............................ 48

ritonavir ................................ 10

Rituxan ................................. 18

Rituxan Hycela ..................... 18

rivastigmine tartrate .............. 24

rizatriptan.............................. 55

romidepsin ............................ 18

ropinirole .............................. 51

rosuvastatin ........................... 39

Rynex PSE ............ 2, 21, 91, 94

S Sabril .................................... 45

Saizen ................................... 80

Saizen click.easy .................. 80

Saline Mist ............................ 67

salsalate ................................ 54

Samsca .................................. 63

Sandimmune ............. 86, 88, 89

Santyl .................................. 105

Savella ............................ 50, 55

Segluromet...................... 75, 81

selegiline HCl ....................... 51

selenium................................ 61

Selzentry ................................. 8

senna ..................................... 70

Serevent Diskus .............. 24, 96

Serostim ................................ 80

sertraline ............................... 55

sevelamer carbonate ....... 59, 83

SF.......................................... 84

SF 5000 Plus ......................... 84

Signifor ................................. 81

sildenafil (antihypertensive) 41,

97

Siliq .................................... 105

silver sulfadiazine ............... 103

Similac Prenatal .... 29, 108, 110

Simponi .................... 71, 86, 88

Simponi ARIA .......... 71, 86, 88

Simulect ................................ 89

simvastatin ............................ 39

sirolimus ............................... 89

Sklice .................................. 104

Sleep Aid (doxylamine)... 1, 47,

94

Slow Release Iron ................. 29

sodium bicarbonate............... 68

sodium chloride .. 57, 59, 61, 67

Soft Touch Lancets ............... 57

Solesta .................................. 57

Soliris.................................... 85

Solu-Cortef (PF) ................... 74

Somatuline Depot ................. 81

Somavert ............................... 81

sotalol ................. 23, 34, 37, 39

spinosad .............................. 104

Spinraza (PF) .................. 83, 90

Spiriva Respimat ............ 22, 91

spironolactone ........... 40, 41, 59


.................. 40, 41, 42, 59, 62

Sporanox ................................. 7

Sprycel .................................. 18

SPS (with sorbitol) ......... 59, 83

SSKI ..................... 5, 75, 83, 93

stavudine ................................. 9

Steglatro ................................ 81

Stelara ..................... 86, 88, 105

Stiolto Respimat ............. 22, 24

Stivarga ................................. 18

Stribild ................................ 8, 9

Sucraid .................................. 63

sucralfate ............................... 72

sulfacetamide sodium ........... 64

sulfacetamide sodium (acne)

........................................ 103

sulfacetamide sodium-sulfur

........................................ 103

sulfacetamide-prednisolone .. 64

sulfadiazine ........................... 13

sulfamethoxazole-trimethoprim

.......................................... 13

sulfasalazine ....... 13, 70, 86, 88

sulindac ................................. 53

sumatriptan ........................... 55

sumatriptan succinate ........... 55

Supartz FX ............................ 57

Supprelin LA ............ 18, 77, 78

Suprax ..................................... 4

Sustol .................................... 68

Sutent .................................... 18

Sylatron ........................... 10, 18

Symdeko ............................... 92

Symfi ...................................... 9

Symfi Lo ................................. 9

Synagis ................................. 11

Synercid ................................ 13

Synribo ................................. 18

Synvisc ................................. 57

Synvisc-One ......................... 57

T Tabloid .................................. 18

tacrolimus ..................... 89, 105

123

Taltz Autoinjector .............. 105

Taltz Syringe ...................... 105

tamoxifen ........................ 18, 76

tamsulosin............................. 24

Tarceva ................................. 18

Targretin ....................... 18, 105

Tasigna ................................. 18

TAZICEF ............................... 4

Tecfidera............................... 88

telmisartan ............................ 31

temazepam ............................ 49

Temodar ............................... 18

temozolomide ....................... 18

teniposide ............................. 18

tenofovir disoproxil fumarate . 9

terazosin ................... 23, 30, 39

terbinafine HCl ................. 4, 97

terbutaline ....................... 25, 96

terconazole ......................... 100

testosterone ........................... 74

testosterone cypionate .......... 74

testosterone enanthate .......... 74

tetracaine HCl ....................... 67

tetracaine HCl (PF)............... 67

tetracycline ........................... 13

Tetravisc ............................... 67

Thalomid .............................. 89

Theo-24 ............ 38, 58, 97, 105

theophylline ...... 38, 58, 97, 105

TheraCal D4000 ................... 61

thioridazine ........................... 54

thiotepa ................................. 18

thiothixene ............................ 56

Thymoglobulin ..................... 89

Thyrogen .............................. 58

thyroid (pork) ....................... 82

Thyrolar-1............................. 82

Thyrolar-1/2 ......................... 82

Thyrolar-1/4 ......................... 82

Thyrolar-2............................. 82

Thyrolar-3............................. 82

Tice BCG........................ 18, 20

tigecycline .............................. 8

timolol maleate .. 23, 34, 37, 39,

47, 65

tizanidine .............................. 23

Tobi Podhaler ......................... 4

tobramycin ............................ 65

tobramycin in 0.225 % NaCl .. 4

tobramycin sulfate .................. 4

tobramycin-dexamethasone . 65,

66

Tobrex .................................. 65

tolazamide ............................ 81

tolbutamide ........................... 81

tolterodine ........................... 105

topiramate ............................. 45

topotecan .............................. 18

Torisel ................................... 18

torsemide ........................ 40, 59

TPN Electrolytes .................. 61

TPN Electrolytes II ............... 61

Tracleer ........................... 43, 97

tramadol ................................ 52

tramadol-acetaminophen44, 47,

52

trandolapril ..................... 32, 33

tranylcypromine.................... 51

Travasol 10 % ....................... 58

trazodone .............................. 55

Treanda ................................. 18

Trelstar............................ 18, 77

Tremfya .............................. 105

tretinoin .............................. 101

tretinoin (chemotherapy) ...... 18

Trexbrom .............. 2, 21, 92, 94

TriAdvance ..... 29, 61, 108, 110

triamcinolone acetonide 99, 102

triamterene-hydrochlorothiazid

........................ 41, 42, 59, 62

triazolam ............................... 49

trientine ................................. 73

trifluoperazine ...................... 54

trifluridine ............................. 65

trihexyphenidyl ............... 22, 45

TriLyte With Flavor Packets 70

trimethobenzamide ............... 69

trimethoprim ......................... 14

Trinatal GT ........... 29, 108, 110

Trinatal Rx 1 ... 29, 61, 108, 110

Trinate ............ 29, 61, 108, 110

Triple Antibiotic ................... 98

Triveen-Duo DHA . 29, 61, 108,

110


............................ 29, 84, 108

Tri-Vitamin With Fluoride .. 85,

108, 111, 112

Trizivir .................................... 9

TrophAmine 10 % ................ 58

tropicamide ........................... 67

trospium .............................. 105

Trulicity ................................ 78

Truvada ................................... 9

Tussin CF (PE-DM-guaif) ... 21,

92, 93

Tykerb ................................... 18

Tymlos .................................. 79

Tysabri .................................. 89

Tyvaso ............................ 43, 97

Tyvaso Refill Kit ............ 43, 97

Tyvaso Starter Kit ........... 43, 97

U Unithroid ............................... 82

Upcal D ......................... 61, 112

urea ..................................... 103

Urin DS ................................. 14

ursodiol ................................. 70

V valacyclovir .......................... 11

valproic acid ............. 45, 46, 47

valproic acid (as sodium salt)

.............................. 45, 46, 47

valsartan ................................ 31

valsartan-hydrochlorothiazide

.............................. 31, 42, 62

Valstar ................................... 18

vancomycin ............................. 8

vancomycin in dextrose 5 % ... 8

Vectibix ................................ 19

Velcade ................................. 19

Veletri ............................. 43, 97

Velivet Triphasic Regimen

(28) ................................... 76

venlafaxine ........................... 55

Venofer ................................. 29

Ventavis .......................... 43, 97

Ventolin HFA ................. 25, 96

verapamil ...... 35, 36, 37, 38, 43

Vfend IV ................................. 7

Vibativ .................................... 8

Victoza 2-Pak ....................... 78

Victoza 3-Pak ....................... 78

Vidaza ................................... 19

Videx 2 gram Pediatric ........... 9

vigabatrin .............................. 45

Vinate GT ............. 29, 108, 110

Vinate II .............................. 108

Vinate M ............... 29, 108, 110

Vinate One ...... 29, 61, 108, 110

124

Vinate Ultra ..... 29, 61, 70, 108,

110

vinblastine ............................ 19

vincristine ............................. 19

vinorelbine ............................ 19

Viracept ................................ 10

Viramune XR ......................... 9

Viread ..................................... 9

Visine-A ............................... 68

Visudyne............................... 67

Vitamin D3 ......................... 112

Vivitrol ........................... 52, 82

Vol-Nate ............... 29, 108, 110

Vol-Tab Rx ........... 29, 108, 110

Voraxaze......................... 63, 83

Vortex Holding Chamber ..... 57

Votrient................................. 19

VP-GGR-B6 ......... 62, 108, 110

VPRIV .................................. 63

Vyvanse ................................ 43

W warfarin ................................ 25

water for irrigation, sterile .... 59

Wee Care .............................. 29

WelChol ......................... 34, 74

WinRho SDF ........................ 20

Women's Daily Caplet ... 29, 62,

108, 111

Women's Prenatal + DHA ... 29,

108, 111

X Xalkori .................................. 19

Xarelto .................................. 25

Xeljanz............................ 86, 89

Xeljanz XR ..................... 86, 89

Xenazine ......................... 50, 56

Xeomin ........................... 25, 90

Xgeva.................................... 84

Xiaflex .................................. 63

Xiidra .................................... 66

Xolair .................................... 95

Xtandi ................................... 19

Xulane .................................. 76

Y Yervoy .................................. 19

Yuvafem ............................... 77

Z zaleplon ................................ 47

Zaltrap .................................. 19

Zanosar ................................. 19

Zarxio ................................... 26

Zelboraf ................................ 19

Zenpep .................................. 70

Zerit ........................................ 9

Zevalin (Y-90) ...................... 19

zidovudine .............................. 9

ziprasidone HCl .................... 48

Zmax ..................................... 12

Zoladex ........................... 19, 78

zoledronic acid ...................... 84

zoledronic acid-mannitol-water

.......................................... 84

Zolinza .................................. 19

zolpidem ............................... 47

Zometa .................................. 84

zonisamide ............................ 45

Zortress ................................. 89

Zosyn in dextrose (iso-osm) ... 8

Zovia 1/35E (28) ................... 76

Zovirax ............................... 100

Zyprexa Relprevv ................. 48

Zytiga .................................... 19

Zyvox .................................... 12

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Printable Preferred Drug List | Select Health of South ... · mg/5 mL, 500 mg/5 mL cefadroxil oral tablet cefazolin injection recon soln 1 gram, 10 gram, 500 mg Specialty PA ... 500