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San Francisco Health Plan Medi-Cal Formulary AS OF August 2020
SAN FRANCISCO HEALTH PLAN
Medi-Cal Formulary As of August 2020
San Francisco Health Plan Medi-Cal Formulary AS OF August 2020
San Francisco Health Plan Medi-Cal Formulary The San Francisco Health Plan (SFHP), with the direction from the Pharmacy and Therapeutics Committee (P&T), has developed a formulary to be used by members, clinicians, and pharmacists. The P&T Committee is composed of the SFHP Chief Medical Officer, the SFHP Pharmacy Director, physicians from various medical specialties and clinics, and community clinical pharmacists. The P&T meets quarterly to review formulary changes based on quality of care considerations and sound pharmacoeconomic principles. The formulary is a list of drug products designed to reflect the most appropriate, high quality and cost-effective drug therapies. The formulary is updated regularly and is subject to change without notice. The formulary requires the continuous support of all our providers and pharmacists. Please contact us at (415) 547-7818 x 7085 option 3 or [email protected] if you have any questions regarding the formulary. The SFHP formulary can be easily accessed online at http://www.sfhp.org/providers/formulary/sfhp-formulary/.
Request for Addition or Deletion of a Drug to the Formulary SFHP providers may request evaluation of drugs for addition to or deletion from the formulary by submitting the Formulary Modification Request Form available on our website at http://www.sfhp.org/providers/formulary/prior-authorization-requests/.
Request for Non-Preferred Medications Non-preferred or non-formulary medications may be authorized when there is clinical justification for doing so. Providers can submit a prior authorization (PA) request in one of three different ways:
1. Online: Submit using the Online Pharmacy Prior Authorization Request Form. 2. Fax: Download a Prior Authorization Request Form and fax to 1(855) 811-9331 for both standard
and urgent requests. Urgent requests should be clearly labeled “URGENT” at the top of the prior authorization request form.
3. Phone: Pharmacy Benefits Manager (PBM) PerformRx at (888) 989-0091 to submit a verbal request.
The Prior Authorization Request Form and the Online Pharmacy Prior Authorization Request Form can be accessed from our website at http://www.sfhp.org/providers/formulary/prior-authorization-requests/.
San Francisco Health Plan Medi-Cal Formulary AS OF August 2020
Brand Medication Policy SFHP has a mandatory generic policy and requires generic substitution when an equivalent AB-rated generic product is available. Dispensing of brand name medications when generic equivalent is available is allowed only in certain cases:
• Pharmacy bills brand medication as DAW 5 (i.e. billed as a generic product). • Pharmacy bills brand medication as DAW 8 (i.e. generic formulation is not currently available). • Pharmacy is dispensing one (1) of the following narrow therapeutic index drugs/classes: Dilantin
(phenytoin), thyroid hormones, coumarin type anticoagulants. • For all other brand name medication requests, prior authorization with documentation that two
(2) generic medications from different manufacturers were tried and did not meet the medical needs of the member.
All brand name medication prior authorization requests are reviewed by an SFHP pharmacist or Medical Director. In all other cases, a prior authorization (PA) request should be submitted using the instructions above. Detailed PA criteria for brand name medication requests can be found at http://www.sfhp.org/files/providers/formulary/Prior_Auth_Criteria.pdf under “Brand Medication Requests” section.
Medi-Cal Formulary Exclusions The following drugs classes are excluded from the SFHP Medi-Cal formulary and are covered by fee-for-service (FFS) Medi-Cal. TAR may need to be submitted to FFS Medi-Cal for certain medications. For more information, refer to the “Capitiated/Noncapitated Drugs” section in the “MCP: Two-Plan Model” document available at Medi-Cal’s website (www.medi-cal.ca.gov).
• Anti-psychotics • AIDs/HIV drugs (except didanosine, zidovudine covered on SFHP Medi-Cal formulary)
o Note: If a medication is carved out, it is carved out regardless of indications. For example, Viread® (tenofovir) and Epivir® (lamivudine) are carved out whether they are used for treatment of HIV or Hepatitis B.
• Alcohol, heroin detoxification and dependency treatment drugs
Medications in the following categories are excluded from the SFHP Medi-Cal formulary: • Erectile dysfunction drugs • Fertility medications • Medications for cosmetic uses (e.g. hydroquinone for hyperpigmentation of the skin)
Day Supply Policy SFHP standard day supply policy is 30 day supply for most brand medications and 90 day supply for generic medications with some exceptions. Refills are allowed when 75% of the medication has been used, except for opiate pain medications where refills are allowed when 90% of the medication has been used.
San Francisco Health Plan Medi-Cal Formulary AS OF August 2020
Exceptions to the 30 day supply policy for brand medications are as follows:
• Up to 100 day supply is allowed for test strips, lancets, insulin syringes and urine ketone testing strips
• Up to 90 day supply is allowed for select medications used for treatment of chronic conditions. Examples include but are not limited to antidiabetic medications including insulin, anticonvulsants, anticoagulants, antidepressants, antihyperlipidemics, antihypertensives, inhaled steroids and contraceptives.
Exceptions to the 90 day supply policy for generic medications are as follows: • 30 day supply only is allowed for all opiate medications except tramadol
Formulary Restrictions Standard formulary restrictions applicable to SFHP formulary are medication quantity and age limitations. All formulary restrictions are based on FDA approved indications, standards of practice and safety and abuse potential considerations.
Step Therapy (ST) Step Therapy (ST) medications will process at point of sale at the pharmacy if there are paid prescription claims for preferred medications. If there are no paid prescription claims, a prior authorization (PA) request must be submitted for consideration of coverage. Visit our website at http://www.sfhp.org/providers/formulary/sfhp-formulary/ for detailed information on all active step therapy rules.
Therapeutic Interchange Policy Per American College of Clinical Pharmacy (AACP), therapeutic interchange is defined as the dispensing of a drug that is therapeutically equivalent to but chemically different from the drug originally prescribed by a physician or other authorized prescriber. SFHP follows ACCP’s definition of therapeutic interchange and will only employ therapeutic interchange with prescriber’s approval. Criteria for consideration in therapeutic interchange include availability of agents within a therapeutic class, therapeutic equivalence, safety data, and costs.
Diabetic Supplies The following diabetic supplies are covered on SFHP formulary as a pharmacy benefit:
• Glucometers: ACCU-CHEK Nano SmartView, ACCU-CHEK Aviva Plus, Accu-Chek Designer Care Kit, 1 glucometer per 365 days
• Test strips: ACCU-CHEK SmartView (for Nano) and ACCU-CHEK Aviva Plus test strips with the following quantity limits:
o 400 per 100 days for all members o 800 per 100 days for members with gestational diabetes
• Lancets: ACCU-CHEK FastClix, Multiclix, SoftClix lancets, 100 day supply
San Francisco Health Plan Medi-Cal Formulary AS OF August 2020
Respiratory Supplies The following respiratory supplies are covered as a pharmacy benefit for a quantity of 2 per 365 days:
• Inhalers and inhaler assist devices • Nebulizers • Peak flow meters
Home Blood Pressure Monitors Omron Series 3, 5, and 10 home blood pressure monitors are covered as a pharmacy benefit for a quantity of 1 monitor per member every 5 years.
Vaccines Certain vaccines are covered as a pharmacy benefit for Medi-Cal members over the age of 18. Please visit SFHP website at http://www.sfhp.org/providers/formulary/sfhp-formulary/ for a detailed list of covered vaccines. Children 18 years of age or younger are eligible for vaccinations through the California Vaccines for Children (VFC) Program. Please contact VFC at 1-877-243-8832 for more information.
Formulary Document Details The SFHP formulary document is listed by drug class and includes the following information: drug name, dosage form, drug tier, quantity and age limit and prior authorization or step therapy requirements. Brand products are listed in all uppercase letters and generic products are listed in all lowercase letters. Tier 1 drugs are formulary preferred and will pay at point of sale if quantity and age limits are met (see “Formulary Restrictions” above). Tier 2 drugs require a Prior Authorization (see “Request for Non-Preferred Medications” above) or Step Therapy (see “Step Therapy (ST)” above). **Some medications may be listed as both Tier 1 and Tier 2 due to a particular strength being formulary and another strength of the same medication requiring a prior authorization. If you are hearing impaired, please call the TDD/TYY line at 1(415) 547-7830, toll-free at 1(888) 883-7347 or through the California Relay Service at 711. You may request this document in alternative formats like Braille, large size print, and audio. To request other formats, or for help with reading this document and other SFHP materials, please call Customer Service at 1(415) 547-7800 or toll-free at 1(800) 288-5555.
1
Drug Generic drugs = lowercase italics Brand name drugs = UPPERCASE
Tier T1= Formulary, Generic T2= Formulary, Brand T3= Formulary, Prior Authorization or Step Therapy T4= Specialty Pharmacy, Prior Authorization T5= Non-Formulary, Carve Out, or Obtain through the Medical Benefit
Notes AL= Age Limit CO= Carve-Out. Bill to Fee-for-Service (FFS) Medi-Cal PA= Prior Authorization QL= Quantity Limit ST= Step Therapy
Drug Tier Notes
Antihistamine Drugs
Ethanolamine Derivatives
ALLERGY (DIPHENHYDRAMINE) ORAL LIQUID
T1
CHILDREN'S BENADRYL ALLERGY ORAL TABLET,CHEWABLE
T1
dimenhydrinate oral T1
diphenhydramine hcl injection solution 50 mg/ml T5
diphenhydramine hcl injection syringe T5
diphenhydramine hcl oral capsule T1
diphenhydramine hcl oral tablet 25 mg T1
SLEEP AID (DOXYLAMINE) T1
Ethylenediamine Derivatives
pyrilamine-phenylephrine oral tablet T5
First Gen. Antihist. Derivatives, Misc.
cyproheptadine T1
First Generation Antihistamines
ALLERGY (DIPHENHYDRAMINE) ORAL LIQUID
T1
CHILDREN'S BENADRYL ALLERGY ORAL TABLET,CHEWABLE
T1
chlorpheniramine maleate oral tablet T1
chlorpheniramine maleate oral tablet extended release
T1
2
Drug Tier Notes
cyproheptadine T1
dimenhydrinate oral T1
diphenhydramine hcl injection solution 50 mg/ml T5
diphenhydramine hcl injection syringe T5
diphenhydramine hcl oral capsule T1
diphenhydramine hcl oral tablet 25 mg T1
SLEEP AID (DOXYLAMINE) T1
Phenothiazine Derivatives
PHENADOZ RECTAL SUPPOSITORY 12.5 MG T1 AL (Min 2 Years)
promethazine injection solution T5
promethazine oral T1 AL (Min 2 Years)
promethazine rectal suppository 25 mg T1 AL (Min 2 Years)
PROMETHAZINE VC T1 AL (Min 2 Years)
promethazine-dm T1 AL (Min 2 Years)
Piperazine Derivatives
hydroxyzine hcl oral solution 10 mg/5 ml T1
hydroxyzine hcl oral tablet T1
hydroxyzine pamoate T1
meclizine oral tablet 12.5 mg, 25 mg T1
meclizine oral tablet,chewable T1
Propylamine Derivatives
APRODINE T1 AL (Min 6 Years)
chlorpheniramine maleate oral tablet T1
chlorpheniramine maleate oral tablet extended release
T1
PEDIA RELIEF COUGH-COLD T1 AL (Min 6 Years)
Second Generation Antihistamines
ALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING
T1
cetirizine oral solution 1 mg/ml T1
cetirizine oral tablet T1
cetirizine oral tablet,chewable T1
CHILDREN'S ALLEGRA ALLERGY ORAL TABLET,DISINTEGRATING
T1
3
Drug Tier Notes
desloratadine oral tablet T1
fexofenadine oral suspension T1
fexofenadine oral tablet 180 mg, 60 mg T1
levocetirizine oral tablet T1
loratadine oral solution T1
loratadine oral tablet T1
LORATADINE-D T1 AL (Min 12 Years)
Anti-Infective Agents
1St Generation Cephalosporin Antibiotics
cefadroxil oral capsule T1
cephalexin oral capsule 250 mg, 500 mg T1
cephalexin oral suspension for reconstitution T1 AL (Max 12 Years)
2Nd Generation Cephalosporin Antibiotics
cefaclor oral capsule T1
cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
T1 AL (Max 12 Years)
cefprozil oral suspension for reconstitution T1 AL (Max 12 Years)
cefprozil oral tablet T1
CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 250 MG/5 ML
T2 AL (Max 12 Years)
cefuroxime axetil oral suspension for reconstitution 125 mg/5 ml
T1 AL (Max 12 Years)
cefuroxime axetil oral tablet T1
3Rd Generation Cephalosporin Antibiotics
cefdinir oral capsule T1
cefdinir oral suspension for reconstitution T1 AL (Max 12 Years)
cefixime oral capsule T1
cefixime oral suspension for reconstitution T1 AL (Max 12 Years)
cefpodoxime oral suspension for reconstitution T1 AL (Max 12 Years)
cefpodoxime oral tablet T1
4Th Generation Cephalosporin Antibiotics
cefepime injection recon soln 1 gram T5
5Th Generation Cephalosporin Antibiotics
4
Drug Tier Notes
TEFLARO INTRAVENOUS RECON SOLN 400 MG
T5
Adamantane Antivirals
amantadine hcl T5 CO
GOCOVRI T5 CO
OSMOLEX ER T5 CO
Allylamine Antifungals
terbinafine hcl oral T1 QL (180 EA per 365 days)
Amebicides
metronidazole oral tablet T1
Aminoglycoside Antibiotics
BETHKIS T5
neomycin T1
paromomycin T1
TOBI PODHALER T5
tobramycin in 0.225 % nacl T4 PA
tobramycin with nebulizer T5
Aminomethylcyclines
NUZYRA ORAL T5
Aminopenicillin Antibiotics
amoxicillin oral capsule T1
amoxicillin oral suspension for reconstitution T1 AL (Max 12 Years)
amoxicillin oral tablet T1
amoxicillin oral tablet,chewable 125 mg, 250 mg T1 AL (Max 12 Years)
amoxicillin-pot clavulanate oral suspension for reconstitution
T1 AL (Max 12 Years)
amoxicillin-pot clavulanate oral tablet T1
amoxicillin-pot clavulanate oral tablet extended release 12 hr
T1 AL (Max 12 Years)
amoxicillin-pot clavulanate oral tablet,chewable T1 AL (Max 12 Years)
ampicillin oral capsule T1
AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML
T2 AL (Max 12 Years)
Anthelmintics
5
Drug Tier Notes
albendazole T1 QL (6 EA per 365 days)
ivermectin oral T1 QL (30 EA per 365 days)
PIN-X ORAL SUSPENSION T1
praziquantel T1 QL (15 EA per 365 days)
Antifungals, Miscellaneous
griseofulvin microsize T1
griseofulvin ultramicrosize T1
Antimalarials
atovaquone-proguanil T1 QL (180 EA per 365 days)
chloroquine phosphate T1
DARAPRIM T4 PA
hydroxychloroquine T1
mefloquine T1
primaquine T1
quinidine gluconate injection T5
quinidine gluconate oral T1
Antimycobacterials, Miscellaneous
dapsone oral T1
Antiprotozoals, Miscellaneous
ALINIA T2 QL (30 ML per 365 days)
atovaquone T1
dapsone oral T1
metronidazole oral tablet T1
NEBUPENT T3 PA
PENTAM T5
tinidazole T1 QL (30 EA per 365 days)
Antituberculosis Agents
ciprofloxacin T1 AL (Max 12 Years)
ciprofloxacin (mixture) T5
ciprofloxacin hcl oral T1
clarithromycin oral suspension for reconstitution T1
clarithromycin oral tablet T1
cycloserine T1
6
Drug Tier Notes
ethambutol T1
isoniazid oral solution T1 AL (Max 12 Years)
isoniazid oral tablet T1
levofloxacin oral solution T1 AL (Max 12 Years)
levofloxacin oral tablet T1
moxifloxacin oral T3 PA
PASER T2
pretomanid T3 PA
PRIFTIN T2
pyrazinamide T1
rifabutin T1
rifampin oral T1
RIFATER T2
SIRTURO T3 PA
TRECATOR T2
Antivirals, Miscellaneous
FOSCAVIR T5
XOFLUZA T2 QL (2 tabs per 180 days)
Azole Antifungals
CRESEMBA T5
fluconazole T1
fluconazole in dextrose(iso-o) T5
fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml
T5
itraconazole oral capsule T3 PA
itraconazole oral solution T5
ketoconazole oral T1
NOXAFIL ORAL SUSPENSION T5
ONMEL T3 PA
posaconazole oral tablet,delayed release (dr/ec) T5
SPORANOX ORAL SOLUTION T5
voriconazole oral T3 PA
Bacitracin Antibiotics
bacitracin intramuscular T5
7
Drug Tier Notes
Carbapenem Antibiotics
meropenem intravenous recon soln 500 mg T5
Chloramphenicol Antibiotics
chloramphenicol sod succinate T5
Cyclic Lipopeptide Antibiotics
daptomycin intravenous recon soln 500 mg T5
Echinocandin Antifungals
caspofungin intravenous recon soln 50 mg T5
Erythromycin Antibiotics
ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG
T1
erythromycin ethylsuccinate oral suspension for reconstitution
T1 AL (Max 12 Years)
erythromycin ethylsuccinate oral tablet T1
erythromycin oral T1
PCE T2
Fluorocyclines
XERAVA T5
Glycopeptide Antibiotics
FIRVANQ ORAL RECON SOLN 25 MG/ML T2 QL (400 ML per 10 days); AL (Max 12 Years)
vancomycin oral capsule T1
vancomycin oral recon soln T1 AL (Max 12 Years)
Glycylcycline Antibiotics
tigecycline T5
Hcv Polymerase Inhibitor Antivirals
HARVONI ORAL PELLETS IN PACKET T4 PA
HARVONI ORAL TABLET 45-200 MG T4 PA
ledipasvir-sofosbuvir T4 PA
sofosbuvir-velpatasvir T4 PA
SOVALDI ORAL PELLETS IN PACKET T4 PA
SOVALDI ORAL TABLET 200 MG T4 PA
SOVALDI ORAL TABLET 400 MG T5
VIEKIRA PAK T5
8
Drug Tier Notes
VOSEVI T4 PA
Hcv Protease Inhibitor Antivirals
MAVYRET T4 PA
TECHNIVIE T5
VIEKIRA PAK T5
ZEPATIER T5
Hcv Replication Complex Inhibitors
DAKLINZA ORAL TABLET 30 MG, 60 MG T5
HARVONI ORAL PELLETS IN PACKET T4 PA
HARVONI ORAL TABLET 45-200 MG T4 PA
ledipasvir-sofosbuvir T4 PA
MAVYRET T4 PA
sofosbuvir-velpatasvir T4 PA
TECHNIVIE T5
VIEKIRA PAK T5
VOSEVI T4 PA
ZEPATIER T5
Hiv Entry And Fusion Inhibitors
FUZEON SUBCUTANEOUS RECON SOLN T5 CO
RUKOBIA T5 CO
SELZENTRY ORAL TABLET T5 CO
TROGARZO T5 CO
Hiv Integrase Inhibitor Antiretrovirals
DOVATO T5 CO
GENVOYA T5 CO
ISENTRESS T5 CO
STRIBILD T5 CO
TIVICAY T5 CO
TIVICAY PD T5 CO
TRIUMEQ T5 CO
Hiv Nonnucleoside Rev.Transcrip. Inhib.
ATRIPLA T5 CO
COMPLERA T5 CO
9
Drug Tier Notes
DELSTRIGO T5 CO
EDURANT T5 CO
efavirenz oral capsule T5 CO
efavirenz oral tablet T5
INTELENCE T5 CO
nevirapine T5 CO
ODEFSEY T5 CO
RESCRIPTOR T5 CO
SYMFI T5 CO
SYMFI LO T5 CO
Hiv Nucleoside, Nucleotide Rt Inhibitors
abacavir T5 CO
abacavir-lamivudine-zidovudine T5 CO
ATRIPLA T5 CO
COMPLERA T5 CO
DELSTRIGO T5 CO
DESCOVY T5 CO
didanosine oral capsule,delayed release(dr/ec) 250 mg, 400 mg
T1
DOVATO T5 CO
EMTRIVA T5 CO
EPIVIR HBV ORAL SOLUTION T5 CO
EPIVIR ORAL SOLUTION T5 CO
EPZICOM T5 CO
GENVOYA T5 CO
lamivudine oral tablet T5 CO
lamivudine-zidovudine T5 CO
ODEFSEY T5 CO
RETROVIR INTRAVENOUS T5 CO
stavudine oral capsule T5 CO
STRIBILD T5 CO
SYMFI T5 CO
SYMFI LO T5 CO
SYMTUZA T5 CO
10
Drug Tier Notes
tenofovir disoproxil fumarate T5 CO
TRIUMEQ T5 CO
TRUVADA T5 CO
VIDEX 2 GRAM PEDIATRIC T2
VIDEX 4 GRAM PEDIATRIC T1
VIREAD ORAL POWDER T5 CO
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG
T5 CO
zidovudine T1
Hiv Protease Inhibitor Antiretrovirals
APTIVUS T5 CO
APTIVUS (WITH VITAMIN E) T5 CO
atazanavir T5 CO
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG T5 CO
EVOTAZ T5 CO
fosamprenavir T5 CO
INVIRASE ORAL TABLET T5 CO
KALETRA T5 CO
LEXIVA ORAL SUSPENSION T5 CO
NORVIR ORAL POWDER IN PACKET T5 CO
NORVIR ORAL SOLUTION T5 CO
PREZCOBIX T5 CO
PREZISTA ORAL SUSPENSION T5 CO
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG
T5 CO
REYATAZ ORAL POWDER IN PACKET T5 CO
ritonavir T5 CO
SYMTUZA T5 CO
TECHNIVIE T5
VIEKIRA PAK T5
VIRACEPT ORAL TABLET T5 CO
Interferon Antivirals
PEGASYS SUBCUTANEOUS SYRINGE T5
Lincomycin Antibiotics
11
Drug Tier Notes
CLEOCIN INTRAVENOUS SOLUTION 300 MG/2 ML
T5
clindamycin hcl oral capsule 150 mg, 300 mg T1
clindamycin palmitate hcl T1 AL (Max 12 Years)
clindamycin phosphate intravenous solution 300 mg/2 ml
T5
Macrolide Antibiotics
ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG
T1
erythromycin ethylsuccinate oral suspension for reconstitution
T1 AL (Max 12 Years)
erythromycin ethylsuccinate oral tablet T1
erythromycin oral T1
PCE T2
Monobactam Antibiotics
CAYSTON T4 PA
Monoclonal Antibody Antivirals
SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML
T5
Natural Penicillin Antibiotics
penicillin g sodium T5
penicillin v potassium oral recon soln T1 AL (Max 12 Years)
penicillin v potassium oral tablet T1
Neuraminidase Inhibitor Antivirals
oseltamivir oral capsule 30 mg, 75 mg T1
oseltamivir oral capsule 45 mg T1 AL (Max 12 Years)
oseltamivir oral suspension for reconstitution T1 AL (Max 12 Years)
RELENZA DISKHALER T2 QL (20 QY per 30 DYs)
Nucleoside And Nucleotide Antivirals
acyclovir oral capsule T1 QL (150 QY per 30 DYs)
acyclovir oral suspension 200 mg/5 ml T1 AL (Max 12 Years)
acyclovir oral tablet T1 QL (150 QY per 30 DYs)
adefovir T5
BARACLUDE ORAL SOLUTION T2 AL (Max 12 Years)
cidofovir T5
12
Drug Tier Notes
entecavir T1 QL (30 EA per 30 days)
famciclovir oral tablet 125 mg T1 QL (60 EA per 30 days)
famciclovir oral tablet 250 mg T1 QL (90 EA per 30 days)
famciclovir oral tablet 500 mg T1 QL (120 EA per 30 days)
ganciclovir sodium intravenous recon soln T5
ribavirin oral capsule T1
ribavirin oral tablet 200 mg T1
SYMTUZA T5 CO
valacyclovir oral tablet 1 gram T1 QL (120 EA per 30 days)
valacyclovir oral tablet 500 mg T1 QL (90 QY per 30 DYs)
valganciclovir T3 PA
VEMLIDY T5 CO
Other Macrolide Antibiotics
azithromycin oral packet T1
azithromycin oral suspension for reconstitution T1 AL (Max 12 Years)
azithromycin oral tablet T1
clarithromycin oral suspension for reconstitution T1
clarithromycin oral tablet T1
DIFICID T4 PA
Oxazolidinone Antibiotics
linezolid oral suspension for reconstitution T1 AL (Max 12 Years)
linezolid oral tablet T1
Penicillinase-Resistant Penicillins
dicloxacillin T1
Pleuromutilins
XENLETA ORAL T5
Polyene Antifungals
amphotericin b T5
nystatin oral suspension T1
nystatin oral tablet T1
Polymyxin Antibiotics
polymyxin b sulfate T5
Quinolone Antibiotics
13
Drug Tier Notes
BAXDELA ORAL T5
ciprofloxacin T1 AL (Max 12 Years)
ciprofloxacin (mixture) T5
ciprofloxacin hcl oral T1
FACTIVE T5
levofloxacin oral solution T1 AL (Max 12 Years)
levofloxacin oral tablet T1
moxifloxacin oral T3 PA
ofloxacin oral tablet 300 mg, 400 mg T5
Rifamycin Antibiotics
PRIFTIN T2
rifabutin T1
RIFAMATE T2
rifampin oral T1
RIFATER T2
XIFAXAN ORAL TABLET 200 MG T3 ST; QL (90 QY per 30 DYs)
XIFAXAN ORAL TABLET 550 MG T3 ST; QL (60 QY per 30 DYs)
Streptogramin Antibiotics
SYNERCID T5
Sulfonamide Antibiotics (Systemic)
sulfadiazine T1
sulfamethoxazole-trimethoprim intravenous T5
sulfamethoxazole-trimethoprim oral suspension T1 AL (Max 12 Years)
sulfamethoxazole-trimethoprim oral tablet T1
sulfasalazine T1
Tetracycline Antibiotics
doxycycline hyclate oral capsule T1 QL (60 EA per 30 days)
doxycycline hyclate oral tablet 100 mg T1 QL (60 EA per 30 days)
doxycycline monohydrate oral capsule 100 mg, 50 mg
T1 QL (60 EA per 30 days)
doxycycline monohydrate oral tablet 100 mg T1 QL (60 EA per 30 days)
minocycline oral capsule T1 QL (60 EA per 30 days)
tetracycline T1 QL (120 QY per 30 DYs)
Urinary Anti-Infectives
14
Drug Tier Notes
methenamine hippurate T1
nitrofurantoin T1 AL (Max 12 Years)
nitrofurantoin macrocrystal T1
nitrofurantoin monohyd/m-cryst T1
trimethoprim T1
Antineoplastic Agents
Antineoplastic Agents
abiraterone T4 PA
ADRIAMYCIN INTRAVENOUS SOLUTION 10 MG/5 ML, 2 MG/ML, 50 MG/25 ML
T5
AFINITOR DISPERZ T4 PA
AFINITOR ORAL TABLET 10 MG T4 PA
ALECENSA T3 PA
ALIMTA T5
ALKERAN T4 PA
ALUNBRIG T3 PA
anastrozole T1 QL (30 QY per 30 DYs)
ARRANON T5
ARZERRA T5
AVASTIN T5
AYVAKIT T4 PA
BALVERSA T4 PA
BENDEKA T5
bexarotene T4 PA
bicalutamide T1
BICNU T5
BOSULIF T4 PA
BRAFTOVI T4 PA
BRUKINSA T4 PA
BUSULFEX T5
CABOMETYX T4 PA
CALQUENCE T4 PA
CAMPTOSAR INTRAVENOUS SOLUTION 300 MG/15 ML
T5
15
Drug Tier Notes
capecitabine T4 PA
CAPRELSA T3 PA
carboplatin T5
cisplatin intravenous solution T5
cladribine T5
COMETRIQ T4 PA
COPIKTRA T4 PA
COTELLIC T3 PA
cyclophosphamide intravenous T5
cyclophosphamide oral capsule T3 PA
CYRAMZA T5 PA
dacarbazine T5
DARZALEX T5
daunorubicin T5
DAURISMO T4 PA
decitabine T5
diclofenac sodium topical gel 3 % T5
docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/8 ml (10 mg/ml)
T5
doxorubicin T5
DROXIA T5
ELIGARD T4 PA
ELIGARD (3 MONTH) T4 PA
ELIGARD (4 MONTH) T4 PA
ELIGARD (6 MONTH) T4 PA
EMCYT T4 PA
EMPLICITI T5
epirubicin intravenous solution T5
ERBITUX T5
ERIVEDGE T4 PA
ERLEADA T4 PA
erlotinib T4 PA
ETOPOPHOS T5
etoposide intravenous T5
16
Drug Tier Notes
etoposide oral T4 PA
everolimus (antineoplastic) T4 PA
exemestane T3 PA
FARESTON T4 PA
FARYDAK T4 PA
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG
T4 PA
floxuridine T5
fludarabine intravenous recon soln T5
fluorouracil intravenous T5
fluorouracil topical cream 5 % T1 QL (1 FL per 365 DYs)
fluorouracil topical solution T5
flutamide T1
fulvestrant T5
GAZYVA T5
gemcitabine intravenous recon soln 1 gram, 200 mg
T5
GILOTRIF T4 PA
GLEOSTINE T3 PA
HALAVEN T5
HERCEPTIN INTRAVENOUS RECON SOLN 440 MG
T5
HEXALEN T4 PA
HYCAMTIN ORAL T3 PA
hydroxyurea T1
IBRANCE T4 PA
ICLUSIG T3 PA
IDHIFA T4 PA
ifosfamide intravenous recon soln T5
ifosfamide-mesna T5
imatinib T4 PA
IMBRUVICA T4 PA
INLYTA T4 PA
INREBIC T4 PA
IRESSA T4 PA
17
Drug Tier Notes
irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml, 500 mg/25 ml
T5
IXEMPRA T5
JAKAFI T4 PA
JEVTANA T5
KADCYLA T5
KEYTRUDA INTRAVENOUS SOLUTION T3 PA
KISQALI T3 PA
KOSELUGO T4 PA
LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2)
T4 PA
letrozole T1
LEUKERAN T3 PA
leuprolide T3 PA
LONSURF T4 PA
LORBRENA T4 PA
LUPANETA PACK (1 MONTH) T5
LUPANETA PACK (3 MONTH) T5
LUPRON DEPOT T4 PA
LUPRON DEPOT (3 MONTH) T4 PA
LUPRON DEPOT (4 MONTH) T4 PA
LUPRON DEPOT-PED T4 PA
LUPRON DEPOT-PED (3 MONTH) T4 PA
LYNPARZA T4 PA
LYSODREN T4 PA
MATULANE T4 PA
megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml)
T1
megestrol oral tablet T1
MEKINIST T3 PA
MEKTOVI T4 PA
mercaptopurine T1
methotrexate sodium (pf) injection solution T1 QL (16 ML per 28 days)
18
Drug Tier Notes
methotrexate sodium injection T1 QL (16 ML per 28 days)
methotrexate sodium oral T1
mitomycin intravenous T5
mitoxantrone T5
MYLERAN T3 PA
NERLYNX T3 PA
NEXAVAR T4 PA
NINLARO T3 PA
NIPENT T5
NUBEQA T4 PA
ODOMZO T3 PA
ONCASPAR T5
OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 40 MG/4 ML
T5
oxaliplatin intravenous solution T5
paclitaxel T5
PANRETIN T5
PEMAZYRE T4 PA
PERJETA T5
PHOTOFRIN T5
PIQRAY T4 PA
POMALYST T4 PA
PORTRAZZA T5
PROLEUKIN T5
PURIXAN T3 PA
QINLOCK T4 PA
RETEVMO T4 PA
REVLIMID T4 PA
RITUXAN T5
ROZLYTREK T4 PA
RUBRACA T4 PA
RYDAPT T3 PA
SOLTAMOX T3 PA
SPRYCEL T4 PA
19
Drug Tier Notes
STIVARGA T4 PA
SUTENT T4 PA
SYNRIBO T4 PA
TABLOID T3 PA
TABRECTA T4 PA
TAFINLAR T3 PA
TAGRISSO T4 PA
TALZENNA T4 PA
tamoxifen T1
TASIGNA T4 PA
TAZVERIK T4 PA
TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML)
T5
TEMODAR INTRAVENOUS T5
temozolomide T3 PA
teniposide T5
thiotepa injection recon soln 15 mg T5
TIBSOVO T4 PA
topotecan intravenous recon soln T5
TREANDA INTRAVENOUS RECON SOLN T5
TRELSTAR INTRAMUSCULAR SYRINGE T5
tretinoin (antineoplastic) T3 PA
TREXALL T3 PA
TUKYSA T4 PA
TURALIO T4 PA
TYKERB T4 PA
VALCHLOR T5
VECTIBIX T5
VELCADE T5
VENCLEXTA T4 PA
VENCLEXTA STARTING PACK T4 PA
VERZENIO T4 PA
vinblastine intravenous solution T5
20
Drug Tier Notes
VINCASAR PFS INTRAVENOUS SOLUTION 2 MG/2 ML
T5
vincristine T5
vinorelbine T5
VITRAKVI T4 PA
VIZIMPRO T3 PA
VOTRIENT T4 PA
XALKORI T4 PA
XOSPATA T4 PA
XPOVIO T4 PA
XTANDI T4 PA
YERVOY T5
YONDELIS T5
YONSA T4 PA
ZALTRAP T5
ZANOSAR T5
ZEJULA T3 PA
ZELBORAF T4 PA
ZOLADEX T5
ZOLINZA T4 PA
ZYDELIG T4 PA
ZYKADIA T4 PA
Antitoxins,Immune Glob,Toxoids,Vaccines
Allergenic Extracts (Therapeutic)
GRASTEK T5
ODACTRA T5
ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY
T5
RAGWITEK T5
Antitoxins And Immune Globulins
HEPAGAM B T2 AL (Min 19 Years)
HYPERHEP B S/D T2 AL (Min 19 Years)
HYPERHEP B S-D NEONATAL T2 AL (Min 19 Years)
NABI-HB T2 AL (Min 19 Years)
21
Drug Tier Notes
VARIZIG INTRAMUSCULAR SOLUTION T5
Toxoids
ADACEL(TDAP ADOLESN/ADULT)(PF) T2 QL (0.5 ML per 1 fill); AL (Min 19 Years)
BOOSTRIX TDAP T2 QL (0.5 ML per 1 fill); AL (Min 19 Years)
TENIVAC (PF) T2 QL (0.5 ML per 1 fill); AL (Min 19 Years)
tetanus-diphtheria toxoids-td T5
Vaccines
ACTHIB (PF) T2 QL (1 EA per 1 fill); AL (Min 19 Years)
AFLURIA QD 2020-21(3YR UP)(PF) T2 QL (1 Rx per 270 days); AL (Min 19 Years)
AFLURIA QD 2020-21(6-35MO)(PF) T2 QL (1 Rx per 270 days); AL (Min 19 Years)
AFLURIA QUAD 2020-2021(6MO UP) T2 QL (1 Rx per 270 days); AL (Min 19 Years)
BEXSERO T2 QL (0.5 ML per 1 fill); AL (Min 19 Years)
ENGERIX-B (PF) T2 AL (Min 19 Years)
ENGERIX-B PEDIATRIC (PF) T2 AL (Min 19 Years)
FLUAD QUAD 2020-21(65Y UP)(PF) T2 QL (1 Rx per 270 days); AL (Min 19 Years)
FLUARIX QUAD 2020-2021 (PF) T2 QL (1 Rx per 270 days); AL (Min 19 Years)
FLUBLOK QUAD 2020-2021 (PF) T2 QL (1 Rx per 270 days); AL (Min 19 Years)
FLUCELVAX QUAD 2020-2021 T2 QL (1 Rx per 270 days); AL (Min 19 Years)
FLUCELVAX QUAD 2020-2021 (PF) T2 QL (1 Rx per 270 days); AL (Min 19 Years)
FLULAVAL QUAD 2020-2021 (PF) T2 QL (1 Rx per 270 days); AL (Max 19 Years)
FLUMIST QUAD 2020-2021 T2 QL (1 Rx per 270 days); AL (Max 19 Years)
FLUZONE HIGHDOSE QUAD 20-21 PF T2 QL (1 Rx per 270 days); AL (Min 19 Years)
22
Drug Tier Notes
FLUZONE QUAD 2020-2021 T2 QL (1 Rx per 270 days); AL (Min 19 Years)
FLUZONE QUAD 2020-2021 (PF) T2 QL (1 Rx per 270 days); AL (Min 19 Years)
GARDASIL (PF) T2 AL (Min 19 Years)
GARDASIL 9 (PF) T2 AL (Min 19 Years)
HAVRIX (PF) T2 AL (Min 19 Years)
HEPLISAV-B (PF) T2 AL (Min 19 Years)
IMOVAX RABIES VACCINE (PF) T2 AL (Min 19 Years)
MENACTRA (PF) INTRAMUSCULAR SOLUTION
T2 QL (0.5 ML per 1 fill); AL (Min 19 Years)
MENOMUNE - A/C/Y/W-135 T2 QL (1 EA per 1 fill); AL (Min 19 Years)
MENOMUNE - A/C/Y/W-135 (PF) T2 QL (1 EA per 1 fill); AL (Min 19 Years)
MENVEO A-C-Y-W-135-DIP (PF) T2 QL (1 EA per 1 fill); AL (Min 19 Years)
M-M-R II (PF) T2 QL (1 EA per 1 fill); AL (Min 19 Years)
PENTACEL (PF) INTRAMUSCULAR KIT 15LF-48MCG-62DU -10 MCG/0.5ML
T2 AL (Min 19 Years)
PENTACEL ACTHIB COMPONENT (PF) T2 AL (Min 19 Years)
PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 62 DU/0.5 ML
T2 AL (Min 19 Years)
PNEUMOVAX-23 T2 QL (1 ML per 1 fill); AL (Min 19 Years)
PREVNAR 13 (PF) T2 QL (0.5 ML per 1 fill); AL (Min 19 Years)
RABAVERT (PF) T2 AL (Min 19 Years)
RECOMBIVAX HB (PF) T2 AL (Min 19 Years)
SHINGRIX (PF) T2 QL (1 EA per 1 Fill)
TRUMENBA T2 QL (0.5 ML per 1 fill); AL (Min 19 Years)
TWINRIX (PF) T2 AL (Min 19 Years)
VAQTA (PF) T2 AL (Min 19 Years)
VARIVAX (PF) T2 QL (1 EA per 1 fill); AL (Min 19 Years)
23
Drug Tier Notes
VIVOTIF BERNA VACCINE T2 QL (4 EA per 1 fill)
ZOSTAVAX (PF) T2 QL (1 EA per 1 fill); AL (Min 50 Years)
Autonomic Drugs
Alpha- And Beta-Adrenergic Agonists
ADRENACLICK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML
T5
ADRENALIN INJECTION SOLUTION 1 MG/ML (1 ML)
T5
APRODINE T1 AL (Min 6 Years)
AUVI-Q INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML, 0.3 MG/0.3 ML
T5
CHILDREN'S SILFEDRINE T1 AL (Min 4 Years)
epinephrine injection auto-injector T1 QL (6 EA per 365 days)
EPIPEN 2-PAK T5
EPIPEN JR 2-PAK T5
LORATADINE-D T1 AL (Min 12 Years)
PEDIA RELIEF COUGH-COLD T1 AL (Min 6 Years)
pseudoephedrine hcl oral liquid T1 AL (Min 4 Years)
pseudoephedrine hcl oral tablet 30 mg T1 AL (Min 4 Years)
pseudoephedrine-guaifenesin oral tablet extended release 12 hr 60-600 mg
T1 AL (Min 6 Years)
SUDAFED 24 HOUR T1
SUDOGEST 12-HOUR T1 AL (Min 4 Years)
SUDOGEST ORAL TABLET 60 MG T1 AL (Min 4 Years)
Alpha-Adrenergic Agonists
clonidine hcl T1
clonidine transdermal patch weekly 0.1 mg/24 hr T1 QL (4 EA per 28 days)
clonidine transdermal patch weekly 0.2 mg/24 hr, 0.3 mg/24 hr
T1 QL (8 EA per 28 days)
methyldopa T1
midodrine T1
PROMETHAZINE VC T1 AL (Min 2 Years)
pyrilamine-phenylephrine oral tablet T5
Antimuscarinics/Antispasmodics
24
Drug Tier Notes
ANORO ELLIPTA T3 ST
ATROVENT HFA T2 QL (25.8 QY per 30 DYs)
BEVESPI AEROSPHERE T3 ST
COMBIVENT RESPIMAT T2 QL (4 QY per 20 DYs)
dicyclomine oral capsule T1
dicyclomine oral tablet T1
diphenoxylate-atropine oral tablet T1
glycopyrrolate oral tablet 1 mg, 2 mg T1
hyoscyamine sulfate oral tablet T1
hyoscyamine sulfate oral tablet extended release 12 hr
T1
hyoscyamine sulfate sublingual T1
INCRUSE ELLIPTA T2 QL (30 EA per 30 days)
ipratropium bromide inhalation T1 QL (312.5 QY per 30 DYs)
ipratropium-albuterol T1 QL (570 QY per 30 DYs)
phenobarb-hyoscy-atropine-scop oral elixir 16.2-0.1037 -0.0194 mg/5 ml
T5
phenobarb-hyoscy-atropine-scop oral tablet T5
PHENOHYTRO T5
SPIRIVA RESPIMAT T2 QL (4 GM per 30 days)
STIOLTO RESPIMAT T2 QL (4 GM per 30 days)
TRELEGY ELLIPTA T3 ST
Antiparkinsonian Agents
benztropine T5 CO
trihexyphenidyl T5 CO
Autonomic Drugs, Miscellaneous
CHANTIX T2 QL (60 EA per 30 days)
CHANTIX STARTING MONTH BOX T2 QL (159 EA per 365 days)
nicotine (polacrilex) buccal gum T1 QL (360 QY per 30 DYs)
nicotine (polacrilex) buccal lozenge T1 QL (600 EA per 30 days)
nicotine (polacrilex) buccal mini lozenge T1 QL (600 EA per 30 days)
nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr
T1 QL (30 QY per 30 DYs)
NICOTROL T3 PA
NICOTROL NS T3 PA
25
Drug Tier Notes
Centrally Acting Skeletal Muscle Relaxnt
cyclobenzaprine oral tablet 10 mg, 5 mg T1 QL (90 QY per 30 DYs)
methocarbamol oral T1 QL (120 EA per 30 days)
tizanidine oral tablet T1 QL (90 QY per 30 DYs)
Direct-Acting Skeletal Muscle Relaxants
dantrolene oral capsule 100 mg T5
Gaba-Derivative Skeletal Muscle Relaxant
baclofen oral T1
Neuromuscular Blocking Agents
vecuronium bromide intravenous recon soln 10 mg T5
Non-Sel. Beta-Adrenergic Blocking Agents
carvedilol T1
carvedilol phosphate T5
labetalol oral T1
nadolol T1
propranolol intravenous T5
propranolol oral T1
sotalol oral T1
Non-Sel.Alpha-1-Adrenergic Blocking Agts
doxazosin T1
prazosin T1
terazosin T1
Non-Sel.Alpha-Adrenergic Blocking Agents
CAFERGOT T5
phenoxybenzamine T3 PA
Non-Selective Beta-Adrenergic Agonists
ISUPREL T5
Parasympathomimetic (Cholinergic Agents)
bethanechol chloride T1
donepezil T1
galantamine T1
NAMZARIC T2
pilocarpine hcl oral tablet 5 mg T1 QL (180 QY per 30 DYs)
26
Drug Tier Notes
pilocarpine hcl oral tablet 7.5 mg T1 QL (120 EA per 30 days)
pyridostigmine bromide oral syrup T1
pyridostigmine bromide oral tablet 60 mg T1
pyridostigmine bromide oral tablet extended release
T1
rivastigmine T1
rivastigmine tartrate T1
Selective Alpha-1-Adrenergic Block.Agent
alfuzosin T1
carvedilol T1
carvedilol phosphate T5
labetalol oral T1
tamsulosin T1
Selective Beta-1-Adrenergic Agonists
dobutamine intravenous solution 250 mg/20 ml (12.5 mg/ml)
T5
Selective Beta-2-Adrenergic Agonists
ADVAIR HFA T3 PA
albuterol sulfate inhalation hfa aerosol inhaler T1 QL (2 INH per 30 days)
albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg/0.5 ml
T1
albuterol sulfate inhalation solution for nebulization 2.5 mg /3 ml (0.083 %)
T1 QL (525 QY per 30 DYs)
albuterol sulfate inhalation solution for nebulization 5 mg/ml
T1 QL (100 QY per 30 DYs)
albuterol sulfate oral syrup T1 QL (120 QY per 30 DYs); AL (Max 5 Years)
albuterol sulfate oral tablet T1 QL (120 QY per 30 DYs)
ANORO ELLIPTA T3 ST
ARCAPTA NEOHALER T2 QL (30 EA per 30 days)
BEVESPI AEROSPHERE T3 ST
BREO ELLIPTA T3 PA
BROVANA T3 PA
budesonide-formoterol T1 QL (20.4 QY per 30 days)
COMBIVENT RESPIMAT T2 QL (4 QY per 20 DYs)
27
Drug Tier Notes
DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION
T2 QL (13 QY per 30 DYs)
DULERA INHALATION HFA AEROSOL INHALER 50-5 MCG/ACTUATION
T2 QL (13 GM per 30 days)
fluticasone propion-salmeterol inhalation aerosol powdr breath activated
T1 QL (1 EA per 30 days)
fluticasone propion-salmeterol inhalation blister with device
T1 QL (60 EA per 30 days)
ipratropium-albuterol T1 QL (570 QY per 30 DYs)
levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml
T3 ST; QL (240 QY per 30 DYs)
levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml
T3 ST; QL (360 QY per 30 DYs)
levalbuterol hcl inhalation solution for nebulization 1.25 mg/0.5 ml
T3 ST; QL (150 QY per 30 DYs)
levalbuterol tartrate T3 ST; QL (30 GM per 30 days)
PERFOROMIST T5
PROAIR RESPICLICK T2 QL (2 EA per 30 days)
SEREVENT DISKUS T3 PA
STIOLTO RESPIMAT T2 QL (4 GM per 30 days)
STRIVERDI RESPIMAT T2 QL (4 GM per 30 days)
terbutaline oral T1
terbutaline subcutaneous T5
TRELEGY ELLIPTA T3 ST
WIXELA INHUB T1 QL (60 EA per 30 days)
Selective Beta-Adrenergic Blocking Agent
atenolol T1
atenolol-chlorthalidone T1
bisoprolol fumarate T1
bisoprolol-hydrochlorothiazide T1
metoprolol succinate T1
metoprolol tartrate intravenous T5
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
T1
Blood Derivatives
28
Drug Tier Notes
Blood Derivatives
albumin, human 25 % T5
Blood Formation, Coagulation, Thrombosis
Anticoagulants, Miscellaneous
CEPROTIN (BLUE BAR) T5
Antihemorrhagic Agents, Miscellaneous
PRAXBIND T5
Antiheparin Agents
protamine T5
Antithrombotic Agents, Miscellaneous
DEFITELIO T5
Blood Form.,Coag,Thrombosis Agents Misc.
OXBRYTA T3 PA
TAVALISSE T5
Coumarin Derivatives
warfarin T1
Direct Factor Xa Inhibitors
ELIQUIS T2 QL (60 EA per 30 days)
ELIQUIS DVT-PE TREAT 30D START T2 QL (74 EA per 30 days)
SAVAYSA T2 QL (30 EA per 30 days)
XARELTO ORAL TABLET 10 MG, 20 MG T2 QL (30 EA per 30 days)
XARELTO ORAL TABLET 15 MG, 2.5 MG T2 QL (60 EA per 30 days)
XARELTO ORAL TABLETS,DOSE PACK T2 QL (51 EA per 30 days)
Direct Thrombin Inhibitors
PRADAXA T3 PA
Hematopoietic Agents
ARANESP (IN POLYSORBATE) T3 PA
DOPTELET (10 TAB PACK) T5
DOPTELET (15 TAB PACK) T5
EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML
T3 PA
FULPHILA T5
29
Drug Tier Notes
GRANIX T5
MIRCERA T5
MOZOBIL T4 PA
MULPLETA T5
NEULASTA T5
NEUPOGEN T5
NIVESTYM T3 PA
NPLATE T5
PROCRIT INJECTION SOLUTION 4,000 UNIT/ML, 40,000 UNIT/ML
T3 PA
PROMACTA ORAL POWDER IN PACKET T5
PROMACTA ORAL TABLET T3 PA
RETACRIT T3 PA
UDENYCA T5
ZARXIO T5
ZIEXTENZO T3 PA
Hemorrheologic Agents
pentoxifylline T1
Hemostatics
ADVATE T5 CO
ADYNOVATE INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT
T5 CO
ALPHANATE T5 CO
ALPHANINE SD T5 CO
ALPROLIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 3,000 UNIT, 500 UNIT
T5 CO
BEBULIN T5 CO
BENEFIX T5 CO
COAGADEX T5 CO
CORIFACT T5 CO
DDAVP NASAL SOLUTION T5
desmopressin nasal spray,non-aerosol T1
desmopressin oral T1
30
Drug Tier Notes
ELOCTATE INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT, 750 UNIT
T5 CO
ESPEROCT T5 CO
FEIBA NF INTRAVENOUS RECON SOLN 1,750-3,250 UNIT, 400-650 UNIT, 651-1,200 UNIT
T5 CO
HELIXATE FS T5 CO
HEMLIBRA T5 CO
HEMOFIL M HIGH T5 CO
HEMOFIL M LOW T5 CO
HEMOFIL M MID T5 CO
HEMOFIL M SUPER HIGH T5 CO
HUMATE-P T5 CO
IDELVION INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT
T5 CO
IXINITY INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 500 UNIT
T5 CO
JIVI INTRAVENOUS RECON SOLN 3,000 (+/-) UNIT
T5 CO
KOATE INTRAVENOUS RECON SOLN 250 (+/-) UNIT, 500 (+/-) UNIT
T5 CO
KOGENATE FS T5 CO
MONOCLATE-P INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT
T5 CO
NOVOEIGHT T5 CO
NOVOSEVEN RT T5 CO
OBIZUR T5 CO
PROFILNINE T5 CO
REBINYN T5 CO
RECOMBINATE T5 CO
RIXUBIS T5 CO
STIMATE T3 PA
tranexamic acid oral T1
TRETTEN T5 CO
31
Drug Tier Notes
WILATE INTRAVENOUS RECON SOLN 450-450 UNIT, 900-900 UNIT
T5 CO
XYNTHA T5 CO
XYNTHA SOLOFUSE T5 CO
Heparins
enoxaparin subcutaneous solution T1 QL (18 ML per 30 days)
enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml
T1 QL (60 ML per 30 days)
enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml
T1 QL (48 ML per 30 days)
enoxaparin subcutaneous syringe 30 mg/0.3 ml T1 QL (18 ML per 30 days)
enoxaparin subcutaneous syringe 40 mg/0.4 ml T1 QL (24 ML per 30 days)
enoxaparin subcutaneous syringe 60 mg/0.6 ml T1 QL (36 ML per 30 days)
heparin (porcine) injection solution 10,000 unit/ml, 20,000 unit/ml
T1
Iron Preparations
ATABEX EC T2 QL (30 QY per 30 DYs)
BIOTECT PLUS T1
CENTRUM COMPLETE T1
CLASSIC PRENATAL T2
ELITE-OB 400 T1 QL (30 QY per 30 DYs)
ferrous gluconate oral tablet 324 mg (38 mg iron) T1
ferrous sulfate oral drops T1
ferrous sulfate oral elixir T1
ferrous sulfate oral solution T1
ferrous sulfate oral tablet 325 mg (65 mg iron) T1
ferrous sulfate oral tablet extended release T1
ferrous sulfate oral tablet,delayed release (dr/ec) T1
FLINTSTONES COMPLETE (IRON) ORAL TABLET,CHEWABLE 18 MG IRON
T2 AL (Max 12 Years)
FOLIVANE-OB T1 QL (30 QY per 30 DYs)
INFED T5
KPN ORAL TABLET 9 MG IRON- 267 MCG T2 QL (30 QY per 30 DYs)
NATACHEW (FE BIS-GLYCINATE) T2 QL (30 QY per 30 DYs)
NEWGEN T1 QL (30 EA per 30 days)
32
Drug Tier Notes
OB COMPLETE PREMIER T2 QL (30 QY per 30 DYs)
O-CAL FA T2 QL (30 QY per 30 DYs)
ONE DAILY MULTI-VIT W-MINERAL ORAL TABLET
T1
POLYVITAMIN WITH IRON T1 AL (Max 12 Years)
PRENATA T2 QL (30 QY per 30 DYs)
PRENATAL PLUS T1 QL (30 QY per 30 DYs)
PRENATAL PLUS (CALCIUM CARB) T1
PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 0.8 MG
T1
PRENATAL VITAMIN WITH MINERALS T1 QL (30 QY per 30 DYs)
prenatal vits96-iron fum-folic T1 QL (30 QY per 30 DYs)
PRETAB T1 QL (30 EA per 30 days)
PUREFE OB PLUS T2 QL (30 QY per 30 DYs)
SELECT-OB (FOLIC ACID) T2 QL (30 QY per 30 DYs)
STROVITE FORTE T2
THERA-M ORAL TABLET , 9 MG IRON-400 MCG
T1
THEREMS-M T2
TRIADVANCE T1
TRINATAL GT T1 QL (30 QY per 30 DYs)
TRIVEEN-ONE T1 QL (30 QY per 30 DYs)
TRIVEEN-PRX RNF T1 QL (30 QY per 30 DYs)
TRI-VI-SOL WITH IRON T2 AL (Max 12 Years)
ULTIMATECARE ONE NF T1 QL (30 QY per 30 DYs)
VINACAL B T1
VINATE M T1 QL (30 QY per 30 DYs)
VINATE ONE T1 QL (30 QY per 30 DYs)
VINATE ULTRA T1 QL (30 EA per 30 days)
VIRT-SELECT T1 QL (30 QY per 30 DYs)
VITAFOL GUMMIES T2
VITAMED MD ONE RX T2 QL (30 EA per 30 days)
VOL-NATE T1 QL (30 EA per 30 days)
VP-CH PLUS T1 QL (30 EA per 30 days)
ZATEAN-CH T1
33
Drug Tier Notes
Platelet-Aggregation Inhibitors
aspirin oral tablet T1
aspirin oral tablet,chewable T1
aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg
T1
aspirin-dipyridamole T1 QL (60 EA per 30 days)
BRILINTA T2 QL (60 EA per 30 days)
BUFFERED ASPIRIN T5
BUFFERIN T5
butalbital-aspirin-caffeine oral tablet T3 PA
cilostazol T1 QL (60 QY per 30 DYs)
clopidogrel oral tablet 75 mg T1
dipyridamole oral T1
MIGRAINE FORMULA T1
prasugrel T1 ST; QL (30 EA per 30 days)
TRI-BUFFERED ASPIRIN T5
Platelet-Reducing Agents
anagrelide T1
Thrombolytic Agents
aspirin oral tablet T1
aspirin oral tablet,chewable T1
aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg
T1
BUFFERED ASPIRIN T5
BUFFERIN T5
butalbital-aspirin-caffeine oral tablet T3 PA
MIGRAINE FORMULA T1
TRI-BUFFERED ASPIRIN T5
Cardiovascular Drugs
Alpha-Adrenergic Blocking Agents
carvedilol T1
carvedilol phosphate T5
doxazosin T1
labetalol oral T1
34
Drug Tier Notes
prazosin T1
terazosin T1
Alpha-Adrenergic Blocking Agt.(Hypoten)
doxazosin T1
labetalol oral T1
prazosin T1
terazosin T1
Angiotensin Ii Receptor Antagon.(Hypotn)
amlodipine-valsartan T1
irbesartan T1
irbesartan-hydrochlorothiazide T1
losartan T1
losartan-hydrochlorothiazide T1
olmesartan T1
telmisartan T1
valsartan T1
valsartan-hydrochlorothiazide T1
Angiotensin Ii Receptor Antagonists
amlodipine-valsartan T1
ENTRESTO T3 ST
irbesartan T1
irbesartan-hydrochlorothiazide T1
losartan T1
losartan-hydrochlorothiazide T1
olmesartan T1
telmisartan T1
valsartan T1
valsartan-hydrochlorothiazide T1
Angiotensin-Convert.Enzyme Inhib(Hypotn)
amlodipine-benazepril T1
benazepril T1
benazepril-hydrochlorothiazide T1
captopril T1
35
Drug Tier Notes
enalapril maleate T1
enalapril-hydrochlorothiazide T1
fosinopril T1
lisinopril T1
lisinopril-hydrochlorothiazide T1
quinapril T1
ramipril T1
Angiotensin-Converting Enzyme Inhibitors
amlodipine-benazepril T1
benazepril T1
benazepril-hydrochlorothiazide T1
captopril T1
enalapril maleate T1
enalapril-hydrochlorothiazide T1
fosinopril T1
lisinopril T1
lisinopril-hydrochlorothiazide T1
quinapril T1
ramipril T1
Antiarrhythmics, Miscellaneous
digoxin injection solution T5
digoxin oral solution 50 mcg/ml (0.05 mg/ml) T1
digoxin oral tablet T1
Antilipemic Agents, Miscellaneous
FISH OIL ORAL CAPSULE 340-1,000 MG T1
niacin oral capsule, extended release 250 mg, 500 mg
T1
niacin oral tablet 100 mg, 500 mg T1
niacin oral tablet extended release 24 hr 1,000 mg, 750 mg
T5
niacin oral tablet extended release 500 mg T1
NIACOR T1
omega-3 acid ethyl esters T5
36
Drug Tier Notes
omega-3 fatty acids-fish oil oral capsule 300-1,000 mg
T1
VASCEPA T5
Beta-Adrenergic Blocking Agents
atenolol T1
atenolol-chlorthalidone T1
bisoprolol fumarate T1
bisoprolol-hydrochlorothiazide T1
carvedilol T1
carvedilol phosphate T5
labetalol oral T1
LEVATOL T5
metoprolol succinate T1
metoprolol tartrate intravenous T5
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
T1
nadolol T1
propranolol intravenous T5
propranolol oral T1
sotalol oral T1
Beta-Adrenergic Blocking Agt.(Hypoten)
atenolol T1
atenolol-chlorthalidone T1
bisoprolol fumarate T1
bisoprolol-hydrochlorothiazide T1
labetalol oral T1
metoprolol succinate T1
metoprolol tartrate intravenous T5
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
T1
nadolol T1
propranolol intravenous T5
propranolol oral T1
sotalol oral T1
37
Drug Tier Notes
Bile Acid Sequestrants
cholestyramine (with sugar) T1
CHOLESTYRAMINE LIGHT T1
colesevelam oral tablet T3 PA
colestipol oral granules T3 PA
colestipol oral packet T3 PA
colestipol oral tablet T1
WELCHOL ORAL POWDER IN PACKET T3 PA
Calcium-Channel Block.Agt,Misc(Hypoten)
diltiazem hcl oral capsule,ext.rel 24h degradable T1
diltiazem hcl oral capsule,extended release 12 hr T1
diltiazem hcl oral capsule,extended release 24 hr 180 mg, 300 mg, 360 mg, 420 mg
T1
diltiazem hcl oral capsule,extended release 24hr T1
diltiazem hcl oral tablet T1
TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 240 MG
T1
verapamil intravenous T5
verapamil oral capsule,ext rel. pellets 24 hr T1
verapamil oral tablet T1
verapamil oral tablet extended release T1
Calcium-Channel Blocking Agents
amlodipine T1
amlodipine-benazepril T1
amlodipine-valsartan T1
diltiazem hcl oral capsule,ext.rel 24h degradable T1
diltiazem hcl oral capsule,extended release 12 hr T1
diltiazem hcl oral capsule,extended release 24 hr 180 mg, 300 mg, 360 mg, 420 mg
T1
diltiazem hcl oral capsule,extended release 24hr T1
diltiazem hcl oral tablet T1
felodipine T1
nifedipine oral tablet extended release T1
nifedipine oral tablet extended release 24hr T1
38
Drug Tier Notes
TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 240 MG
T1
verapamil intravenous T5
verapamil oral capsule,ext rel. pellets 24 hr T1
verapamil oral tablet T1
verapamil oral tablet extended release T1
Calcium-Channel Blocking Agents(Hypoten)
diltiazem hcl oral capsule,ext.rel 24h degradable T1
diltiazem hcl oral capsule,extended release 12 hr T1
diltiazem hcl oral capsule,extended release 24 hr 180 mg, 300 mg, 360 mg, 420 mg
T1
diltiazem hcl oral capsule,extended release 24hr T1
diltiazem hcl oral tablet T1
TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 240 MG
T1
verapamil intravenous T5
verapamil oral capsule,ext rel. pellets 24 hr T1
verapamil oral tablet T1
verapamil oral tablet extended release T1
Calcium-Channel Blocking Agents, Misc.
diltiazem hcl oral capsule,ext.rel 24h degradable T1
diltiazem hcl oral capsule,extended release 12 hr T1
diltiazem hcl oral capsule,extended release 24 hr 180 mg, 300 mg, 360 mg, 420 mg
T1
diltiazem hcl oral capsule,extended release 24hr T1
diltiazem hcl oral tablet T1
TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 240 MG
T1
verapamil intravenous T5
verapamil oral capsule,ext rel. pellets 24 hr T1
verapamil oral tablet T1
verapamil oral tablet extended release T1
Carbonic Anhydrase Inhibitors(Hypoten)
acetazolamide T1
Cardiac Drugs, Miscellaneous
39
Drug Tier Notes
ranolazine T3 ST
Cardiotonic Agents
digoxin injection solution T5
digoxin oral solution 50 mcg/ml (0.05 mg/ml) T1
digoxin oral tablet T1
dobutamine intravenous solution 250 mg/20 ml (12.5 mg/ml)
T5
Central Alpha-Agonists
clonidine hcl T1
clonidine transdermal patch weekly 0.1 mg/24 hr T1 QL (4 EA per 28 days)
clonidine transdermal patch weekly 0.2 mg/24 hr, 0.3 mg/24 hr
T1 QL (8 EA per 28 days)
guanfacine T1
methyldopa T1
Cholesterol Absorption Inhibitors
ezetimibe T1
Class Ia Antiarrhythmics
disopyramide phosphate oral capsule T1
NORPACE CR T2
procainamide injection solution 100 mg/ml T5
quinidine gluconate injection T5
quinidine gluconate oral T1
Class Ib Antiarrhythmics
DILANTIN T2
mexiletine T1
phenytoin oral suspension 125 mg/5 ml T1 AL (Max 16 Years)
phenytoin oral tablet,chewable T1 AL (Max 16 Years)
phenytoin sodium extended T1
Class Ic Antiarrhythmics
flecainide T1
propafenone oral tablet T1
Class Ii Antiarrhythmics
atenolol T1
atenolol-chlorthalidone T1
40
Drug Tier Notes
bisoprolol fumarate T1
bisoprolol-hydrochlorothiazide T1
carvedilol T1
carvedilol phosphate T5
labetalol oral T1
metoprolol succinate T1
metoprolol tartrate intravenous T5
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
T1
nadolol T1
propranolol intravenous T5
propranolol oral T1
sotalol oral T1
Class Iii Antiarrhythmics
amiodarone oral T1
dofetilide T1
sotalol oral T1
Class Iv Antiarrhythmics
diltiazem hcl oral capsule,ext.rel 24h degradable T1
diltiazem hcl oral capsule,extended release 12 hr T1
diltiazem hcl oral capsule,extended release 24 hr 180 mg, 300 mg, 360 mg, 420 mg
T1
diltiazem hcl oral capsule,extended release 24hr T1
diltiazem hcl oral tablet T1
TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 240 MG
T1
verapamil intravenous T5
verapamil oral capsule,ext rel. pellets 24 hr T1
verapamil oral tablet T1
verapamil oral tablet extended release T1
Dihydropyridines
amlodipine T1
amlodipine-benazepril T1
amlodipine-valsartan T1
41
Drug Tier Notes
felodipine T1
nifedipine oral tablet extended release T1
nifedipine oral tablet extended release 24hr T1
Dihydropyridines (Antihypertensive)
amlodipine T1
amlodipine-benazepril T1
amlodipine-valsartan T1
felodipine T1
nifedipine oral tablet extended release T1
nifedipine oral tablet extended release 24hr T1
Direct Vasodilators
BIDIL T5
hydralazine injection T5
hydralazine oral T1
minoxidil oral T1
Diuretics, Miscellaneous (Hypotensive)
theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg
T1
theophylline oral tablet extended release 24 hr T1
Fibric Acid Derivatives
ANTARA ORAL CAPSULE 30 MG, 90 MG T5
fenofibrate micronized T1
fenofibrate nanocrystallized oral tablet 145 mg, 48 mg
T1
fenofibrate oral tablet 160 mg, 54 mg T1
fenofibric acid (choline) T1
gemfibrozil T1
Hmg-Coa Reductase Inhibitors
atorvastatin T1
fluvastatin oral tablet extended release 24 hr T5
lovastatin T1
pravastatin T1
rosuvastatin T1
simvastatin oral tablet T1
42
Drug Tier Notes
Hypotensive Agents, Miscellaneous
amlodipine T1
amlodipine-benazepril T1
amlodipine-valsartan T1
carvedilol T1
carvedilol phosphate T5
doxazosin T1
felodipine T1
nifedipine oral tablet extended release T1
nifedipine oral tablet extended release 24hr T1
phenoxybenzamine T3 PA
propranolol intravenous T5
propranolol oral T1
sotalol oral T1
terazosin T1
Loop Diuretics (Hypotensive Agents)
bumetanide oral T1
furosemide injection syringe T5
furosemide oral T1
torsemide oral T1
Mineralocorticoid (Aldosterone) Antagnts
eplerenone T3 ST
spironolactone T1
spironolacton-hydrochlorothiaz T1
Mineralocorticoid(Aldoster.)Antag(Hypot)
eplerenone T3 ST
spironolactone T1
spironolacton-hydrochlorothiaz T1
Nitrates And Nitrites
BIDIL T5
DILATRATE-SR T2
isosorbide dinitrate oral T1
isosorbide mononitrate T1
43
Drug Tier Notes
NITRO-BID T2
nitroglycerin sublingual T1
Osmotic Diuretics (Hypotensive Agents)
mannitol 20 % T5
Pcsk9 Inhibitors
PRALUENT PEN T3 PA
REPATHA PUSHTRONEX T4 PA
REPATHA SURECLICK T4 PA
REPATHA SYRINGE T4 PA
Phosphodiesterase Type 5 Inhibitors
cilostazol T1 QL (60 QY per 30 DYs)
sildenafil (pulm.hypertension) intravenous T5
sildenafil (pulm.hypertension) oral suspension for reconstitution
T5
sildenafil (pulm.hypertension) oral tablet T3 PA
tadalafil (pulm. hypertension) T3 PA
Potassium-Sparing Diuretics (Hypoten)
amiloride T1
eplerenone T3 ST
spironolactone T1
spironolacton-hydrochlorothiaz T1
triamterene-hydrochlorothiazid oral capsule 37.5-25 mg
T1
triamterene-hydrochlorothiazid oral capsule 50-25 mg
T5
triamterene-hydrochlorothiazid oral tablet T1
Renin Inhibitors
aliskiren T5
TEKTURNA HCT T5
Renin-Angioten.-Aldost. Sys. Inhib, Misc
ENTRESTO T3 ST
Sclerosing Agents
VARITHENA T5
Thiazide Diuretics(Hypotensive Agents)
44
Drug Tier Notes
benazepril-hydrochlorothiazide T1
bisoprolol-hydrochlorothiazide T1
chlorothiazide T1
DIURIL T2 AL (Max 12 Years)
enalapril-hydrochlorothiazide T1
hydrochlorothiazide T1
irbesartan-hydrochlorothiazide T1
lisinopril-hydrochlorothiazide T1
losartan-hydrochlorothiazide T1
spironolacton-hydrochlorothiaz T1
TEKTURNA HCT T5
triamterene-hydrochlorothiazid oral capsule 37.5-25 mg
T1
triamterene-hydrochlorothiazid oral capsule 50-25 mg
T5
triamterene-hydrochlorothiazid oral tablet T1
valsartan-hydrochlorothiazide T1
Thiazide-Like Diuretics(Hypotensive Agt)
atenolol-chlorthalidone T1
chlorthalidone oral tablet 25 mg, 50 mg T1
indapamide T1
metolazone T1
Vasodilating Agents, Miscellaneous
ADEMPAS T4 PA
ambrisentan T4 PA
amlodipine T1
amlodipine-benazepril T1
amlodipine-valsartan T1
aspirin-dipyridamole T1 QL (60 EA per 30 days)
bosentan T5
diltiazem hcl oral capsule,ext.rel 24h degradable T1
diltiazem hcl oral capsule,extended release 12 hr T1
diltiazem hcl oral capsule,extended release 24 hr 180 mg, 300 mg, 360 mg, 420 mg
T1
diltiazem hcl oral capsule,extended release 24hr T1
45
Drug Tier Notes
diltiazem hcl oral tablet T1
dipyridamole oral T1
felodipine T1
nifedipine oral tablet extended release T1
nifedipine oral tablet extended release 24hr T1
OPSUMIT T5
ORENITRAM T5
TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 240 MG
T1
treprostinil sodium T4 PA
TYVASO T4 PA
TYVASO INSTITUTIONAL START KIT T4 PA
TYVASO REFILL KIT T4 PA
TYVASO STARTER KIT T4 PA
UPTRAVI T4 PA
VENTAVIS T4 PA
verapamil intravenous T5
verapamil oral capsule,ext rel. pellets 24 hr T1
verapamil oral tablet T1
verapamil oral tablet extended release T1
Cellular And Gene Therapy
Cellular And Gene Therapy
PROVENGE T5
Cellular Therapy
PROVENGE T5
Central Nervous System Agents
Adamantanes (Cns)
amantadine hcl T5 CO
GOCOVRI T5 CO
OSMOLEX ER T5 CO
Amphetamine Derivatives
diethylpropion oral tablet T5
LOMAIRA T5
46
Drug Tier Notes
phendimetrazine tartrate oral tablet T5
phentermine T3 PA
QSYMIA T5
Amphetamines
ADZENYS XR-ODT T5
amphetamine T5
amphetamine sulfate T5
benzphetamine T5
dextroamphetamine oral capsule, extended release T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years)
dextroamphetamine oral solution T5
dextroamphetamine oral tablet 10 mg T1 QL (120 QY per 30 DYs); AL (Min 5 Years and Max 18 Years)
dextroamphetamine oral tablet 5 mg T1 QL (60 QY per 30 DYs); AL (Min 5 Years and Max 18 Years)
dextroamphetamine-amphetamine T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years)
DYANAVEL XR T5
EVEKEO ODT T5
methamphetamine T5
MYDAYIS T5
PROCENTRA T5
VYVANSE T5
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG
T5
Analgesics And Antipyretics, Misc.
acetaminophen oral elixir T1
acetaminophen oral tablet T1
acetaminophen oral tablet extended release T1
acetaminophen rectal suppository 120 mg T1
acetaminophen-codeine oral solution 120-12 mg/5 ml
T1 AL (Min 12 Years)
acetaminophen-codeine oral tablet T1 QL (120 QY per 30 DYs); AL (Min 12 Years)
butalbital-acetaminophen-caff oral capsule T5
47
Drug Tier Notes
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
T3 PA
CHILDREN'S PAIN RELIEF ORAL SUSPENSION
T1
FEVERALL RECTAL SUPPOSITORY 325 MG, 80 MG
T1
FIORICET ORAL CAPSULE T5
gabapentin oral capsule T1
gabapentin oral solution 250 mg/5 ml T1 AL (Max 16 Years)
gabapentin oral tablet 600 mg, 800 mg T1
hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml
T5
hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg
T5
hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg
T1 QL (120 QY per 30 DYs)
hydrocodone-acetaminophen oral tablet 2.5-325 mg
T1 QL (120 EA per 30 days)
INFANT'S NON-ASPIRIN ORAL DROPS T1
INFANT'S PAIN RELIEF ORAL DROPS,SUSPENSION 80 MG/0.8 ML
T1
MAPAP (ACETAMINOPHEN) ORAL LIQUID 160 MG/5 ML
T1
MIGRAINE FORMULA T1
NORTEMP ORAL DROPS T1
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 7.5-325 mg
T1 QL (120 EA per 30 days)
oxycodone-acetaminophen oral tablet 5-325 mg T1 QL (120 QY per 30 DYs)
PHRENILIN FORTE(WITH CAFFEINE) T5
pregabalin oral capsule T1 QL (2 EA per 1 day)
PRIMLEV T5
TENSION HEADACHE T1
tramadol-acetaminophen T1 QL (120 EA per 30 DYs); AL (Min 18 Years)
VICODIN ES T5
VICODIN HP T5
Anorexigenic Agents, Miscellaneous
48
Drug Tier Notes
CONTRAVE T3 PA
Anticholinergic Agents (Cns)
benztropine T5 CO
trihexyphenidyl T5 CO
Anticonvulsants, Miscellaneous
APTIOM T2
BANZEL ORAL TABLET T2
carbamazepine oral capsule, er multiphase 12 hr T1
carbamazepine oral suspension 100 mg/5 ml T1 AL (Max 16 Years)
carbamazepine oral tablet T1
carbamazepine oral tablet extended release 12 hr T1
carbamazepine oral tablet,chewable T1 AL (Max 16 Years)
divalproex T1
EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG, 300 MG
T5
gabapentin oral capsule T1
gabapentin oral solution 250 mg/5 ml T1 AL (Max 16 Years)
gabapentin oral tablet 600 mg, 800 mg T1
lamotrigine oral tablet T1
lamotrigine oral tablet, chewable dispersible T1 AL (Max 16 Years)
levetiracetam oral solution 100 mg/ml T1 AL (Max 16 Years)
levetiracetam oral tablet T1
oxcarbazepine oral suspension T1 AL (Max 16 Years)
oxcarbazepine oral tablet T1
POTIGA T2
pregabalin oral capsule T1 QL (2 EA per 1 day)
QSYMIA T5
topiramate oral capsule, sprinkle T1
topiramate oral tablet T1
valproic acid T1
valproic acid (as sodium salt) oral solution 250 mg/5 ml
T1 AL (Max 16 Years)
VIMPAT ORAL SOLUTION T2 AL (Max 16 Years)
VIMPAT ORAL TABLET T2
49
Drug Tier Notes
zonisamide T1
Antidepressants, Miscellaneous
bupropion hcl (smoking deter) T1
bupropion hcl oral tablet T1
bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg
T1
bupropion hcl oral tablet sustained-release 12 hr T1
mirtazapine T1
Antimanic Agents
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON
T5 CO
aripiprazole T5 CO
ARISTADA INITIO T5 CO
ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML
T5 CO
carbamazepine oral capsule, er multiphase 12 hr T1
carbamazepine oral suspension 100 mg/5 ml T1 AL (Max 16 Years)
carbamazepine oral tablet T1
carbamazepine oral tablet extended release 12 hr T1
carbamazepine oral tablet,chewable T1 AL (Max 16 Years)
divalproex T1
EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG, 300 MG
T5
GEODON INTRAMUSCULAR T5 CO
lamotrigine oral tablet T1
lamotrigine oral tablet, chewable dispersible T1 AL (Max 16 Years)
lithium carbonate T5 CO
lithium citrate oral solution 8 meq/5 ml T5 CO
olanzapine T5 CO
quetiapine oral tablet T5 CO
RISPERDAL CONSTA T5 CO
risperidone oral solution T5 CO
risperidone oral tablet T5 CO
risperidone oral tablet,disintegrating T5 CO
50
Drug Tier Notes
SAPHRIS (BLACK CHERRY) T5 CO
SECUADO T5 CO
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR
T5 CO
valproic acid T1
valproic acid (as sodium salt) oral solution 250 mg/5 ml
T1 AL (Max 16 Years)
ziprasidone hcl T5 CO
ZYPREXA RELPREVV T5 CO
Antimigraine Agents, Miscellaneous
AIMOVIG AUTOINJECTOR T5
AIMOVIG AUTOINJECTOR (2 PACK) T5
AJOVY SYRINGE T5
aspirin oral tablet T1
aspirin oral tablet,chewable T1
aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg
T1
BUFFERED ASPIRIN T5
BUFFERIN T5
butalbital-acetaminophen-caff oral capsule T5
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
T3 PA
butalbital-aspirin-caffeine oral tablet T3 PA
CAFERGOT T5
divalproex T1
EMGALITY PEN T3 PA
EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MG/ML
T3 PA
FIORICET ORAL CAPSULE T5
MIGRAINE FORMULA T1
PHRENILIN FORTE(WITH CAFFEINE) T5
propranolol intravenous T5
propranolol oral T1
tramadol-acetaminophen T1 QL (120 EA per 30 DYs); AL (Min 18 Years)
TRI-BUFFERED ASPIRIN T5
51
Drug Tier Notes
valproic acid T1
valproic acid (as sodium salt) oral solution 250 mg/5 ml
T1 AL (Max 16 Years)
Antipsychotics, Miscellaneous
loxapine succinate T5 CO
pimozide T5 CO
Anxiolytics,Sedatives,And Hypnotics,Misc
BELSOMRA T5
buspirone T1
EDLUAR T5
eszopiclone oral tablet 1 mg T1 QL (30 EA per 30 days); AL (Min 16 Years)
eszopiclone oral tablet 2 mg, 3 mg T3 ST; QL (30 EA per 30 days); AL (Min 16 Years)
HETLIOZ T5
hydroxyzine hcl oral solution 10 mg/5 ml T1
hydroxyzine hcl oral tablet T1
hydroxyzine pamoate T1
PHENADOZ RECTAL SUPPOSITORY 12.5 MG T1 AL (Min 2 Years)
promethazine injection solution T5
promethazine oral T1 AL (Min 2 Years)
promethazine rectal suppository 25 mg T1 AL (Min 2 Years)
propofol intravenous emulsion T5
ramelteon T3 PA
SLEEP AID (DOXYLAMINE) T1
zaleplon T1 QL (30 EA per 30 days); AL (Min 16 Years)
zolpidem oral tablet T1 QL (30 QY per 30 DYs); AL (Min 16 Years)
zolpidem oral tablet,ext release multiphase T3 PA
zolpidem sublingual T5
ZOLPIMIST T5
Atypical Antipsychotics
ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON
T5 CO
52
Drug Tier Notes
aripiprazole T5 CO
ARISTADA INITIO T5 CO
ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML
T5 CO
CAPLYTA T5 CO
clozapine T5 CO
FANAPT T5 CO
GEODON INTRAMUSCULAR T5 CO
INVEGA T5 CO
INVEGA SUSTENNA T5 CO
INVEGA TRINZA T5 CO
LATUDA T5 CO
NUPLAZID ORAL TABLET 17 MG T5 CO
olanzapine T5 CO
olanzapine-fluoxetine T5 CO
quetiapine oral tablet T5 CO
REXULTI T5 CO
RISPERDAL CONSTA T5 CO
risperidone oral solution T5 CO
risperidone oral tablet T5 CO
risperidone oral tablet,disintegrating T5 CO
SAPHRIS (BLACK CHERRY) T5 CO
SECUADO T5 CO
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR
T5 CO
VRAYLAR T5 CO
ziprasidone hcl T5 CO
ZYPREXA RELPREVV T5 CO
Barbiturates (Anticonvulsants)
BREVITAL INJECTION RECON SOLN 500 MG T5
phenobarb-hyoscy-atropine-scop oral elixir 16.2-0.1037 -0.0194 mg/5 ml
T5
phenobarb-hyoscy-atropine-scop oral tablet T5
phenobarbital oral elixir T1 AL (Max 16 Years)
53
Drug Tier Notes
phenobarbital oral tablet T1
PHENOHYTRO T5
primidone T1
Barbiturates (Anxiolytic, Sedative/Hyp)
butalbital-acetaminophen-caff oral capsule T5
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
T3 PA
butalbital-aspirin-caffeine oral tablet T3 PA
FIORICET ORAL CAPSULE T5
phenobarb-hyoscy-atropine-scop oral elixir 16.2-0.1037 -0.0194 mg/5 ml
T5
phenobarb-hyoscy-atropine-scop oral tablet T5
phenobarbital oral elixir T1 AL (Max 16 Years)
phenobarbital oral tablet T1
PHENOHYTRO T5
PHRENILIN FORTE(WITH CAFFEINE) T5
Barbiturates (General Anesthetics)
BREVITAL INJECTION RECON SOLN 500 MG T5
Benzodiazepines (Anticonvulsants)
clobazam oral suspension T1 AL (Max 16 Years)
clobazam oral tablet T1
clonazepam oral tablet T1 QL (60 QY per 30 DYs)
clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 2 mg
T1 QL (90 EA per 30 days); AL (Max 12 Years)
diazepam oral tablet T1 QL (120 QY per 30 DYs)
diazepam rectal kit 12.5-15-17.5-20 mg, 5-7.5-10 mg
T1 QL (3 EA per 365 days)
diazepam rectal kit 2.5 mg T1 QL (3 FL per 365 DYs)
lorazepam oral tablet 0.5 mg, 1 mg T1 QL (90 QY per 30 DYs)
lorazepam oral tablet 2 mg T1 QL (150 QY per 30 DYs)
NAYZILAM T2 QL (3 fills per 365 days)
VALTOCO T2 QL (3 fills per 365 days)
Benzodiazepines (Anxiolytic,Sedativ/Hyp)
chlordiazepoxide hcl T1 QL (120 QY per 30 DYs)
clobazam oral suspension T1 AL (Max 16 Years)
54
Drug Tier Notes
clobazam oral tablet T1
clonazepam oral tablet T1 QL (60 QY per 30 DYs)
clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg
T1 QL (90 EA per 30 days); AL (Max 12 Years)
diazepam oral tablet T1 QL (120 QY per 30 DYs)
diazepam rectal kit 12.5-15-17.5-20 mg, 5-7.5-10 mg
T1 QL (3 EA per 365 days)
diazepam rectal kit 2.5 mg T1 QL (3 FL per 365 DYs)
estazolam T5
flurazepam T5
lorazepam oral tablet 0.5 mg, 1 mg T1 QL (90 QY per 30 DYs)
lorazepam oral tablet 2 mg T1 QL (150 QY per 30 DYs)
midazolam injection solution 5 mg/ml T1 QL (5 ML per 1 fill)
NAYZILAM T2 QL (3 fills per 365 days)
ONFI ORAL SUSPENSION T2 AL (Max 16 Years)
quazepam T5
temazepam T1 QL (30 QY per 30 DYs); AL (Min 16 Years)
triazolam T5
VALTOCO T2 QL (3 fills per 365 days)
Butyrophenones
haloperidol T5 CO
haloperidol decanoate T5 CO
haloperidol lactate injection T5 CO
haloperidol lactate oral T5 CO
Calcitonin Gene-Related Peptide Antag.
AIMOVIG AUTOINJECTOR T5
AIMOVIG AUTOINJECTOR (2 PACK) T5
AJOVY AUTOINJECTOR T5
AJOVY SYRINGE T5
EMGALITY PEN T3 PA
EMGALITY SYRINGE T3 PA
NURTEC ODT T5
UBRELVY T5
55
Drug Tier Notes
Catechol-O-Methyltransferase(Comt)Inhib.
carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg
T5
carbidopa-levodopa-entacapone oral tablet 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg
T1
entacapone T1
tolcapone T3 PA
Central Nervous System Agents, Misc.
acamprosate T5 CO
atomoxetine T1 QL (60 EA per 30 days)
AUSTEDO T4 PA
carbidopa T1
guanfacine T1
INGREZZA T4 PA
memantine T1
NAMZARIC T2
NUEDEXTA T3 PA
riluzole T1
tetrabenazine T4 PA
XYREM T5
Cyclooxygenase-2 (Cox-2) Inhibitors
celecoxib T1
Dopamine Precursors
carbidopa-levodopa oral tablet T1
carbidopa-levodopa oral tablet extended release T1
carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg
T5
carbidopa-levodopa-entacapone oral tablet 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg
T1
Ergot-Deriv. Dopamine Receptor Agonists
bromocriptine T1
cabergoline T1
Fibromyalgia Agents
56
Drug Tier Notes
duloxetine T1
pregabalin oral capsule T1 QL (2 EA per 1 day)
SAVELLA T5
General Anesthetics, Miscellaneous
propofol intravenous emulsion T5
Hydantoins
DILANTIN T2
phenytoin oral suspension 125 mg/5 ml T1 AL (Max 16 Years)
phenytoin oral tablet,chewable T1 AL (Max 16 Years)
phenytoin sodium extended T1
Inhalation Anesthetics
sevoflurane T5
Monoamine Oxidase B Inhibitors
EMSAM T5 CO
selegiline hcl T1
Monoamine Oxidase Inhibitors
EMSAM T5 CO
phenelzine T5 CO
selegiline hcl T1
tranylcypromine T5 CO
Nonergot-Deriv.Dopamine Receptor Agonist
pramipexole oral tablet T1
pramipexole oral tablet extended release 24 hr 0.375 mg, 0.75 mg, 1.5 mg, 3 mg, 4.5 mg
T5
ropinirole oral tablet T1
Opiate Agonists
acetaminophen-codeine oral solution 120-12 mg/5 ml
T1 AL (Min 12 Years)
acetaminophen-codeine oral tablet T1 QL (120 QY per 30 DYs); AL (Min 12 Years)
ARYMO ER T5
codeine sulfate oral tablet T1 QL (120 QY per 30 DYs); AL (Min 12 Years)
codeine-guaifenesin T1 AL (Min 18 Years)
57
Drug Tier Notes
DEMEROL (PF) INJECTION SOLUTION 100 MG/2 ML, 100 MG/ML, 25 MG/0.5 ML, 75 MG/1.5 ML
T5
DEMEROL INJECTION T5
fentanyl T3 PA
hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml
T5
hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg
T5
hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg
T1 QL (120 QY per 30 DYs)
hydrocodone-acetaminophen oral tablet 2.5-325 mg
T1 QL (120 EA per 30 days)
hydromorphone oral tablet T1 QL (120 QY per 30 DYs)
hydromorphone oral tablet extended release 24 hr 12 mg, 32 mg, 8 mg
T5
hydromorphone rectal T5
levorphanol tartrate T5
meperidine (pf) injection solution 100 mg/ml, 25 mg/ml, 50 mg/ml
T5
meperidine oral solution T5
methadone oral concentrate T5
methadone oral solution T5
methadone oral tablet T5
methadone oral tablet,soluble T5
MORPHABOND ER T5
morphine concentrate oral solution T1 QL (360 ML per 30 days)
morphine oral capsule, er multiphase 24 hr T5
morphine oral capsule,extend.release pellets T3 PA
morphine oral solution T1 QL (360 ML per 30 days)
morphine oral tablet T1 QL (120 QY per 30 DYs)
morphine oral tablet extended release T1 QL (90 EA per 30 days)
NUCYNTA ER T5
oxycodone oral concentrate T1 QL (360 ML per 30 days)
oxycodone oral solution T1 QL (360 ML per 30 days)
oxycodone oral tablet T1 QL (120 QY per 30 DYs)
58
Drug Tier Notes
oxycodone oral tablet,oral only,ext.rel.12 hr T3 PA
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 7.5-325 mg
T1 QL (120 EA per 30 days)
oxycodone-acetaminophen oral tablet 5-325 mg T1 QL (120 QY per 30 DYs)
OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 20 MG, 40 MG, 80 MG
T3 PA
oxymorphone oral tablet extended release 12 hr T5
PRIMLEV T5
tramadol oral tablet 100 mg T5
tramadol oral tablet 50 mg T1 QL (240 QY per 30 DYs); AL (Min 18 Years)
tramadol-acetaminophen T1 QL (120 EA per 30 DYs); AL (Min 18 Years)
VICODIN ES T5
VICODIN HP T5
XTAMPZA ER T5
Opiate Antagonists
EVZIO INJECTION AUTO-INJECTOR 0.4 MG/0.4 ML
T5 CO
naloxone injection solution T5 CO
naloxone injection syringe T5 CO
naltrexone T5 CO
NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION
T5 CO
VIVITROL T5 CO
Opiate Partial Agonists
BUNAVAIL T5 CO
buprenorphine hcl injection solution T5 CO
buprenorphine hcl sublingual T5 CO
buprenorphine-naloxone sublingual tablet T5 CO
BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR
T5 CO
SUBOXONE T5 CO
ZUBSOLV T5 CO
Other Nonsteroidal Anti-Inflam. Agents
59
Drug Tier Notes
DICLO GEL T5
diclofenac potassium T1
diclofenac sodium oral T1
diclofenac sodium topical drops T5
diclofenac sodium topical gel 1 % T1 QL (300 GM per 30 days)
diclofenac-misoprostol T1
etodolac T1
FLECTOR T5
flurbiprofen T1
IBUPROFEN JR STRENGTH T1
ibuprofen oral suspension T1
ibuprofen oral tablet 200 mg, 400 mg, 600 mg, 800 mg
T1
INDOCIN ORAL T2 AL (Max 12 Years)
INDOCIN RECTAL T2
indomethacin oral T1
INFANT'S IBUPROFEN T1
ketorolac oral T1 QL (20 EA per 30 days)
meloxicam oral tablet T1
nabumetone T1
naproxen oral suspension T1 AL (Max 12 Years)
naproxen oral tablet T1
naproxen oral tablet,delayed release (dr/ec) T1
naproxen sodium oral tablet T1
PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP
T5
piroxicam T1
sulindac T1
sumatriptan-naproxen T5
Phenothiazines
chlorpromazine T5 CO
fluphenazine decanoate T5 CO
fluphenazine hcl T5 CO
perphenazine T5 CO
60
Drug Tier Notes
prochlorperazine T1
prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml)
T5
prochlorperazine maleate T1
thioridazine T5 CO
trifluoperazine T5 CO
Respiratory And Cns Stimulants
ADHANSIA XR T5
APTENSIO XR T5
butalbital-acetaminophen-caff oral capsule T5
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
T3 PA
butalbital-aspirin-caffeine oral tablet T3 PA
COTEMPLA XR-ODT T5
DAYTRANA T5
dexmethylphenidate oral capsule,er biphasic 50-50
T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years)
dexmethylphenidate oral tablet 10 mg T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years)
dexmethylphenidate oral tablet 2.5 mg, 5 mg T1 QL (60 QY per 30 DYs); AL (Min 5 Years and Max 18 Years)
FIORICET ORAL CAPSULE T5
JORNAY PM T5
methylphenidate hcl oral capsule, er biphasic 30-70
T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years)
methylphenidate hcl oral capsule,er biphasic 50-50
T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years)
methylphenidate hcl oral solution 10 mg/5 ml T1 QL (900 QY per 30 DYs); AL (Min 5 Years and Max 12 Years)
methylphenidate hcl oral solution 5 mg/5 ml T1 QL (300 QY per 30 DYs); AL (Min 5 Years and Max 12 Years)
methylphenidate hcl oral tablet T1 QL (90 QY per 30 DYs); AL (Min 5 Years and Max 18 Years)
methylphenidate hcl oral tablet extended release 10 mg
T1 QL (60 QY per 30 DYs); AL (Min 5 Years and Max 18 Years)
methylphenidate hcl oral tablet extended release 20 mg
T1 QL (90 QY per 30 DYs); AL (Min 5 Years and Max 18 Years)
61
Drug Tier Notes
methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg
T1 QL (60 EA per 30 days); AL (Min 5 Years and Max 18 Years)
methylphenidate hcl oral tablet extended release 24hr 72 mg
T5
methylphenidate hcl oral tablet,chewable T5
MIGRAINE FORMULA T1
PHRENILIN FORTE(WITH CAFFEINE) T5
QUILLICHEW ER T5
QUILLIVANT XR T5
TENSION HEADACHE T1
Salicylates
aspirin oral tablet T1
aspirin oral tablet,chewable T1
aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg
T1
aspirin-dipyridamole T1 QL (60 EA per 30 days)
BUFFERED ASPIRIN T5
BUFFERIN T5
butalbital-aspirin-caffeine oral tablet T3 PA
choline,magnesium salicylate T1
MIGRAINE FORMULA T1
MUSCLE RUB (WITH CAMPHOR) T1
PAIN RELIEVING(CAM-M.SAL-MENT) TOPICAL ADHESIVE PATCH,MEDICATED
T1 QL (40 EA per 30 days); AL (Min 18 Years)
salsalate T1
TRI-BUFFERED ASPIRIN T5
Sel.Serotonin,Norepi Reuptake Inhibitor
desvenlafaxine T5
desvenlafaxine fumarate T5
desvenlafaxine succinate T5
duloxetine T1
SAVELLA T5
venlafaxine oral capsule,extended release 24hr T1
venlafaxine oral tablet T1
venlafaxine oral tablet extended release 24hr T5
62
Drug Tier Notes
Selective Serotonin Agonists
almotriptan malate T5
eletriptan T5
frovatriptan T5
naratriptan T3 ST; QL (36 EA per 30 days)
ONZETRA XSAIL T5
REYVOW T5
rizatriptan T1 QL (36 EA per 30 days); AL (Min 6 Years)
sumatriptan T3 PA
sumatriptan succinate oral T1 QL (36 EA per 30 days); AL (Min 12 Years)
sumatriptan succinate subcutaneous cartridge T5
sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml
T5
sumatriptan succinate subcutaneous solution T5
sumatriptan-naproxen T5
SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML
T5
TOSYMRA T5
ZEMBRACE SYMTOUCH T5
zolmitriptan T5
ZOMIG NASAL T5
Selective Serotonin Receptor Agonists
BELVIQ XR T3 PA
Selective-Serotonin Reuptake Inhibitors
citalopram oral solution T1 AL (Max 12 Years)
citalopram oral tablet T1
escitalopram oxalate oral solution T1 AL (Max 12 Years)
escitalopram oxalate oral tablet T1
fluoxetine oral capsule T1
fluoxetine oral capsule,delayed release(dr/ec) T5
fluoxetine oral solution T1 AL (Max 12 Years)
fluoxetine oral tablet T5
fluvoxamine oral tablet T1
63
Drug Tier Notes
olanzapine-fluoxetine T5 CO
paroxetine hcl oral tablet T1
sertraline oral concentrate T1 AL (Max 12 Years)
sertraline oral tablet T1
Serotonin Modulators
trazodone T1
TRINTELLIX T5
VIIBRYD ORAL TABLET T5
VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)
T5
Succinimides
ethosuximide oral capsule T1
ethosuximide oral solution T1 AL (Max 16 Years)
Thioxanthenes
thiothixene T5 CO
Tricyclics, Other Norepi-Ru Inhibitors
amitriptyline T1
desipramine T1
doxepin oral capsule T1
doxepin oral concentrate T1
doxepin oral tablet T5
imipramine hcl T1
nortriptyline oral capsule T1
Vesicular Monoamine Transport2 Inhibitor
AUSTEDO T4 PA
INGREZZA T4 PA
INGREZZA INITIATION PACK T4 PA
tetrabenazine T4 PA
Wakefulness-Promoting Agents
armodafinil T3 PA
modafinil T3 PA
SUNOSI T5
WAKIX T5
64
Drug Tier Notes
Devices
Devices
ACCU-CHEK AVIVA CONTROL SOLN T1
ACCU-CHEK FASTCLIX LANCET DRUM T1
ACCU-CHEK FASTCLIX LANCING DEV T1
ACCU-CHEK GUIDE GLUCOSE METER T1 QL (1 EA per 365 days)
ACCU-CHEK GUIDE L1-L2 CTRL SOL T1
ACCU-CHEK GUIDE ME GLUCOSE MTR T1 QL (1 EA per 365 days)
ACCU-CHEK SMARTVIEW CONTRL SOL T1
ACCU-CHEK SOFT DEV LANCETS T1
ACCU-CHEK SOFTCLIX LANCET DEV T1
ACCU-CHEK SOFTCLIX LANCETS T1
AEROCHAMBER PLUS FLOW-VU,S MSK T1 QL (2 FL per 365 DYs)
AEROECLIPSE II NEBULIZER T1 QL (2 FL per 365 days)
BIONECT TOPICAL CREAM T5
BIOTENE DRY MOUTH ORAL RINSE T2
BLOOD PRESSURE KIT T1 QL (1 EA per 5 yrs)
blood pressure kit med and lrg T1 QL (1 EA per 5 yrs)
blood pressure monitor T1 QL (1 EA per 5 yrs)
COMPACT COMPRESSOR NEBULIZER T1 QL (2 FL per 365 days)
FREESTYLE LIBRE 10 DAY READER T3 PA
FREESTYLE LIBRE 10 DAY SENSOR T3 PA
FREESTYLE LIBRE 14 DAY READER T3 PA
FREESTYLE LIBRE 14 DAY SENSOR T3 PA
SILICONE MASK - INFANT T1 QL (2 FL per 365 days)
sodium chloride inhalation solution for nebulization 0.9 %, 3 %, 7 %
T1
SOFT TOUCH LANCETS T1
TRUZONE PEAK FLOW METER T1 QL (2 FL per 365 days)
Diagnostic Agents
Adrenocortical Insufficiency
ACTHAR H.P. T4 PA
ACTHREL T5
Cardiac Function
65
Drug Tier Notes
thallous chloride tl-201 intravenous solution 74 mbq/ml (2 mci/ml)
T5
Diabetes Mellitus
ACCU-CHEK AVIVA PLUS TEST STRP T1 QL (120 EA per 30 days)
ACCU-CHEK GUIDE TEST STRIPS T1 QL (120 EA per 30 days)
ACCU-CHEK SMARTVIEW TEST STRIP T1 QL (120 EA per 30 days)
Diagnostic Agents
GLUCAGEN DIAGNOSTIC KIT T5
Drug Hypersensitivity
PRE-PEN T2
Ketones
KETOSTIX T2 QL (100 QY per 100 DYs)
Kidney Function
mannitol 20 % T5
Ocular Disorders
ALTAFLUOR T1
Pituitary Function
ACTHREL T5
Thyroid Function
THYROGEN T5
Urine And Feces Contents
KETO-DIASTIX T5
Electrolytic, Caloric, And Water Balance
Alkalinizing Agents
CYTRA K CRYSTALS T1 QL (120 EA per 30 days)
potassium citrate T1 QL (120 QY per 30 DYs)
sodium bicarbonate intravenous syringe 8.4 % (1 meq/ml)
T1
sodium citrate-citric acid T1 QL (120 ML per 1 day)
Ammonia Detoxicants
ENULOSE T1
lactulose oral solution 10 gram/15 ml T1
Caloric Agents
66
Drug Tier Notes
AMINOSYN 10 % T5
AMINOSYN 8.5 % T5
AMINOSYN 8.5 %-ELECTROLYTES T5
AMINOSYN II 10 % T5
AMINOSYN II 15 % T5
AMINOSYN II 8.5 % T5
AMINOSYN II 8.5 %-ELECTROLYTES T5
AMINOSYN M 3.5 % T5
AMINOSYN-HBC 7% T5
AMINOSYN-PF 10 % T5
AMINOSYN-PF 7 % (SULFITE-FREE) T5
AMINOSYN-RF 5.2 % T5
BOOST CALORIE SMART ORAL LIQUID T3 PA
CLINIMIX 5%/D15W SULFITE FREE T5
CLINIMIX 5%/D25W SULFITE-FREE T5
CLINIMIX 2.75%/D5W SULFIT FREE T5
CLINIMIX 4.25%/D5W SULFIT FREE T5
CLINIMIX 4.25%-D20W SULF-FREE T5
CLINIMIX 4.25%-D25W SULF-FREE T5
CLINIMIX 5%-D20W(SULFITE-FREE) T5
CLINIMIX E 2.75%/D5W SULF FREE T5
CLINIMIX E 4.25%/D10W SUL FREE T5
CLINIMIX E 4.25%/D25W SUL FREE T5
CLINIMIX E 4.25%/D5W SULF FREE T5
CLINIMIX E 5%/D15W SULFIT FREE T5
CLINIMIX E 5%/D20W SULFIT FREE T5
CLINIMIX E 5%/D25W SULFIT FREE T5
CLINISOL SF 15 % T5
d10 %-0.45 % sodium chloride T5
d2.5 %-0.45 % sodium chloride T5
dextrose 10 % and 0.2 % nacl T5
dextrose 10 % in water (d10w) T5
dextrose 20 % in water (d20w) T5
dextrose 30 % in water (d30w) T5
67
Drug Tier Notes
dextrose 40 % in water (d40w) T5
dextrose 5 % in water (d5w) intravenous piggyback
T5
dextrose 5%-0.2 % sod chloride T5
dextrose 5%-0.3 % sod.chloride T5
dextrose 50 % in water (d50w) intravenous parenteral solution
T5
dextrose 70 % in water (d70w) T5
ENSURE ORIGINAL ORAL LIQUID 0.04-1.05 GRAM-KCAL/ML
T3 PA
ENSURE PLUS T3 PA
FREAMINE HBC 6.9 % T5
FREAMINE III 10 % T5
glucose oral tablet,chewable 4 gram T1
HEPATAMINE 8% T5
INTRALIPID INTRAVENOUS EMULSION 20 %, 30 %
T5
KABIVEN T5
NEPHRAMINE 5.4 % T5
NEPRO CARB STEADY T3 PA
NUTRAMIGEN WITH ENFLORA LGG T3 PA
NUTRILIPID T5
PEDIASURE ORAL LIQUID 0.03-1 GRAM-KCAL/ML
T3 PA
PERIKABIVEN T5
PKU 2 T3 PA
PKU TRIO T3 PA
PREMASOL 10 % T5
PREMASOL 6 % T5
PROCALAMINE 3% T5
SIMILAC ALIMENTUM T3 PA
SIMILAC EXPERT CARE NEOSURE T3 PA
SIMILAC NEOSURE T3 PA
TROPHAMINE 10 % T5
TROPHAMINE 6% T5
68
Drug Tier Notes
Carbonic Anhydrase Inhibitors
acetazolamide T1
Diuretics, Miscellaneous
theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg
T1
theophylline oral tablet extended release 24 hr T1
Electrolytic,Caloric,Water Balance Misc,
CRYSVITA SUBCUTANEOUS SOLUTION 10 MG/ML
T5
Irrigating Solutions
acetic acid irrigation T5
lactated ringers irrigation T5
sodium chloride irrigation T1
Loop Diuretics
bumetanide oral T1
furosemide injection syringe T5
furosemide oral T1
torsemide oral T1
Osmotic Diuretics
mannitol 20 % T5
Other Ion-Removing Agents
RADIOGARDASE T5
Phosphate-Removing Agents
AURYXIA T3 PA
calcium acetate(phosphat bind) T1
lanthanum T3 PA
PHOSLYRA T2 AL (Max 12 Years)
sevelamer carbonate oral powder in packet T3 PA
sevelamer carbonate oral tablet T1
sevelamer hcl T5
VELPHORO T3 PA
Potassium-Removing Agents
KIONEX (WITH SORBITOL) T1
69
Drug Tier Notes
LOKELMA T2 QL (35 EA per 30 DYs)
SODIUM POLYSTYRENE (SORB FREE) T1
sodium polystyrene sulfonate oral powder T1
SPS (WITH SORBITOL) ORAL T2
VELTASSA T3 ST
Potassium-Sparing Diuretics
amiloride T1
spironolactone T1
spironolacton-hydrochlorothiaz T1
triamterene-hydrochlorothiazid oral capsule 37.5-25 mg
T1
triamterene-hydrochlorothiazid oral capsule 50-25 mg
T5
triamterene-hydrochlorothiazid oral tablet T1
Replacement Preparations
ANTACID (CALCIUM CARBONATE) ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG)
T1
ATABEX EC T2 QL (30 QY per 30 DYs)
CALCIUM 500 WITH D T1
CALCIUM 600 + D(3) ORAL TABLET 600 MG(1,500MG) -400 UNIT
T1
CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG)
T1
calcium carbonate oral tablet 260 mg calcium (648 mg), 500 mg calcium (1,250 mg), 600 mg calcium (1,500 mg)
T1
calcium carbonate-vitamin d3 oral tablet 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -200 unit
T1
calcium citrate-vitamin d3 oral tablet 200-125 mg-unit
T1
calcium gluconate oral tablet 45 mg (500 mg) T1
dextrose 5 %-lactated ringers T5
electrolyte-48 in d5w T5
IONOSOL-B IN D5W T5
IONOSOL-MB IN D5W T5
ISOLYTE S PH 7.4 T5
70
Drug Tier Notes
ISOLYTE-P IN 5 % DEXTROSE T5
ISOLYTE-S T5
KLOR-CON M15 T2
lactated ringers intravenous T5
magnesium gluconate oral tablet 27 mg magnesium (500 mg)
T1
magnesium oral tablet 200 mg T1
NEWGEN T1 QL (30 EA per 30 days)
NORMOSOL-M IN 5 % DEXTROSE T5
NORMOSOL-R T5
NORMOSOL-R PH 7.4 T5
OB COMPLETE PREMIER T2 QL (30 QY per 30 DYs)
O-CAL FA T2 QL (30 QY per 30 DYs)
ORALYTE T1
OS-CAL 500 + D3 ORAL TABLET 500 MG(1,250MG) -200 UNIT
T1
OYSTER SHELL + D3 T1
PEDIATRIC ELECTROLYTE ORAL SOLUTION
T1
PHOS-NAK T2
PLASMA-LYTE 148 T5
PLASMA-LYTE A T5
potassium chlorid-d5-0.45%nacl T5
potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l
T5
potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l
T5
potassium chloride in lr-d5 T5
potassium chloride in water intravenous piggyback 10 meq/100 ml, 10 meq/50 ml, 20 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml
T5
potassium chloride intravenous T5
potassium chloride oral capsule, extended release T1
potassium chloride oral liquid T1 AL (Max 12 Years)
potassium chloride oral tablet extended release T1
potassium chloride oral tablet,er particles/crystals T1
71
Drug Tier Notes
potassium chloride-0.45 % nacl T5
potassium chloride-d5-0.2%nacl T5
potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l
T5
potassium chloride-d5-0.9%nacl T5
PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 0.8 MG
T1
PRETAB T1 QL (30 EA per 30 days)
ringer's intravenous T5
RISACAL-D T1
sodium chloride 0.45 % intravenous T5
sodium chloride 0.9 % intravenous piggyback T5
sodium chloride 3 % T5
sodium chloride 5 % T5
sodium chloride inhalation solution for nebulization 0.9 %, 3 %, 7 %
T1
sodium chloride oral T1
THERA-M ORAL TABLET 9 MG IRON-400 MCG
T1
TRIADVANCE T1
TRIVEEN-ONE T1 QL (30 QY per 30 DYs)
TRIVEEN-PRX RNF T1 QL (30 QY per 30 DYs)
ULTIMATECARE ONE NF T1 QL (30 QY per 30 DYs)
VINATE ONE T1 QL (30 QY per 30 DYs)
VINATE ULTRA T1 QL (30 EA per 30 days)
VIRT-SELECT T1 QL (30 QY per 30 DYs)
VITAFOL GUMMIES T2
VOL-NATE T1 QL (30 EA per 30 days)
ZATEAN-CH T1
zinc sulfate oral capsule T1
ZINGIBER T1 QL (60 QY per 30 DYs)
Thiazide Diuretics
benazepril-hydrochlorothiazide T1
bisoprolol-hydrochlorothiazide T1
chlorothiazide T1
72
Drug Tier Notes
DIURIL T2 AL (Max 12 Years)
enalapril-hydrochlorothiazide T1
hydrochlorothiazide T1
irbesartan-hydrochlorothiazide T1
lisinopril-hydrochlorothiazide T1
losartan-hydrochlorothiazide T1
spironolacton-hydrochlorothiaz T1
TEKTURNA HCT T5
triamterene-hydrochlorothiazid oral capsule 37.5-25 mg
T1
triamterene-hydrochlorothiazid oral capsule 50-25 mg
T5
triamterene-hydrochlorothiazid oral tablet T1
valsartan-hydrochlorothiazide T1
Thiazide-Like Diuretics
atenolol-chlorthalidone T1
chlorthalidone oral tablet 25 mg, 50 mg T1
indapamide T1
metolazone T1
Uricosuric Agents
probenecid T1
Vasopressin Antagonists
tolvaptan T5
Enzymes
Enzymes
PULMOZYME T4 PA
Eye, Ear, Nose And Throat (Eent) Preps.
Alpha-Adrenergic Agonists (Eent)
ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %
T2
brimonidine T1
COMBIGAN T2
Antiallergic Agents
azelastine nasal aerosol,spray T1 QL (30 QY per 30 DYs)
73
Drug Tier Notes
azelastine nasal spray,non-aerosol T5
azelastine ophthalmic (eye) T1
BEPREVE T5
cromolyn nasal T1 AL (Min 2 Years)
cromolyn ophthalmic (eye) T1
epinastine T3 ST
ketotifen fumarate T1
LASTACAFT T5
olopatadine ophthalmic (eye) T3 ST
PAZEO T5
Antibacterials (Eent)
bacitracin ophthalmic (eye) T1
bacitracin-polymyxin b ophthalmic (eye) T1
BLEPHAMIDE T3 ST
BLEPHAMIDE S.O.P. T3 ST
CIPRO HC T5
CIPRODEX T2 QL (7.5 QY per 30 DYs)
ciprofloxacin hcl ophthalmic (eye) T1
doxycycline hyclate oral tablet 20 mg T1 QL (60 EA per 30 days)
erythromycin ophthalmic (eye) T1
gentamicin ophthalmic (eye) T1
neomycin-bacitracin-poly-hc T1
neomycin-polymyxin b-dexameth T1
neomycin-polymyxin-gramicidin T1
neomycin-polymyxin-hc T1
NEO-POLYCIN T1
ofloxacin ophthalmic (eye) T1
ofloxacin otic (ear) T1
polymyxin b sulf-trimethoprim T1
sulfacetamide sodium ophthalmic (eye) T1
sulfacetamide-prednisolone T1
TOBRADEX OPHTHALMIC (EYE) OINTMENT
T2
tobramycin T1
74
Drug Tier Notes
tobramycin-dexamethasone T1
Antifungals (Eent)
NATACYN T2
Antiglaucoma Agents, Miscellaneous
RHOPRESSA T5
Antivirals (Eent)
trifluridine T1
ZIRGAN T2
Beta-Adrenergic Blocking Agents (Eent)
betaxolol ophthalmic (eye) T1
COMBIGAN T2
dorzolamide-timolol T1
levobunolol ophthalmic (eye) drops 0.5 % T1
timolol maleate ophthalmic (eye) drops T1
Carbonic Anhydrase Inhibitors (Eent)
acetazolamide T1
dorzolamide T1
dorzolamide-timolol T1
Corticosteroids (Eent)
budesonide nasal T1 QL (8.6 GM per 30 days)
CIPRO HC T5
CIPRODEX T2 QL (7.5 QY per 30 DYs)
dexamethasone sodium phosphate ophthalmic (eye)
T1
DUREZOL T3 ST; QL (5 QY per 30 DYs)
fluocinolone acetonide oil T1
fluorometholone T1
fluticasone propionate nasal T1 QL (16 QY per 30 DYs)
hydrocortisone-acetic acid T1
NASAL ALLERGY T1 QL (16.9 ML per 30 days)
neomycin-bacitracin-poly-hc T1
neomycin-polymyxin b-dexameth T1
neomycin-polymyxin-hc ophthalmic (eye) T1
75
Drug Tier Notes
PRED MILD T3 ST
prednisolone acetate T1
prednisolone sodium phosphate ophthalmic (eye) T1
RHINOCORT ALLERGY T2 QL (8.43 ML per 30 days)
TOBRADEX OPHTHALMIC (EYE) OINTMENT
T2
tobramycin-dexamethasone T1
triamcinolone acetonide nasal T1
Eent Anti-Infectives, Miscellaneous
acetic acid otic (ear) T1
chlorhexidine gluconate mucous membrane T1
EAR DROPS (CARBAMIDE PEROXIDE) T1
hydrocortisone-acetic acid T1
Eent Anti-Inflammatory Agents, Misc.
CEQUA T5
RESTASIS T3 PA
RESTASIS MULTIDOSE T3 PA
XIIDRA T3 PA
Eent Drugs, Miscellaneous
ARTIFICIAL TEARS (PETRO/MIN) T1
ARTIFICIAL TEARS (PF) OPHTHALMIC (EYE) DROPPERETTE 0.1-0.3 %
T1
ARTIFICIAL TEARS (POLYVIN ALC) T1
ARTIFICIAL TEARS(DEXT70-HYPRO) T1
BABY AYR SALINE T2
DEEP SEA NASAL T1 QL (90 QY per 30 DYs)
ENUCLENE T2
HYPOTEARS T1
ipratropium bromide nasal spray,non-aerosol 0.03 %
T1 QL (30 QY per 30 DYs)
ipratropium bromide nasal spray,non-aerosol 42 mcg (0.06 %)
T1 QL (15 QY per 30 DYs)
MURO 128 OPHTHALMIC (EYE) DROPS 2 % T1
sodium chloride ophthalmic (eye) T1
76
Drug Tier Notes
THERATEARS OPHTHALMIC (EYE) DROPPERETTE,GEL
T1
ULTRA FRESH T1
Eent Nonsteroidal Anti-Inflam. Agents
ACUVAIL (PF) T5
bromfenac T5
BROMSITE T5
diclofenac sodium ophthalmic (eye) T1
flurbiprofen sodium T1
ILEVRO T5
ketorolac ophthalmic (eye) T1
NEVANAC T5
PROLENSA T5
Local Anesthetics (Eent)
ALTAFLUOR T1
lidocaine hcl mucous membrane jelly T1
LIDOCAINE VISCOUS T1
proparacaine T1
Miotics
pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %
T1
Mydriatics
atropine ophthalmic (eye) drops T1
atropine ophthalmic (eye) ointment T1
cyclopentolate T1
tropicamide ophthalmic (eye) drops 1 % T1
Prostaglandin Analogs
bimatoprost ophthalmic (eye) T1
latanoprost T1
LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %
T5
travoprost T5
VYZULTA T5
XELPROS T5
77
Drug Tier Notes
ZIOPTAN (PF) T5
Rho Kinase Inhibitors
RHOPRESSA T5
Vasoconstrictors
EYE ALLERGY RELIEF T1
phenylephrine hcl ophthalmic (eye) T5
Gastrointestinal Drugs
5-Ht3 Receptor Antagonists
AKYNZEO (NETUPITANT) T3 PA
ALOXI T5
granisetron hcl intravenous solution 1 mg/ml (1 ml)
T5
granisetron hcl oral T3 PA
ondansetron hcl (pf) T5
ondansetron hcl intravenous T5
ondansetron hcl oral solution T3 PA
ondansetron hcl oral tablet 4 mg T1 QL (180 EA per 30 days)
ondansetron hcl oral tablet 8 mg T1 QL (90 EA per 30 days)
ondansetron oral tablet,disintegrating 4 mg T1 QL (180 EA per 30 days)
ondansetron oral tablet,disintegrating 8 mg T1 QL (90 EA per 30 days)
Antacids And Adsorbents
alum-mag hydroxide-simeth oral suspension 200-200-20 mg/5 ml
T1
ANTACID (CALCIUM CARBONATE) ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG)
T1
CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG)
T1
calcium carbonate oral tablet 260 mg calcium (648 mg)
T1
MAALOX MAXIMUM STRENGTH T1
magnesium oxide oral tablet 250 mg magnesium, 400 mg (241.3 mg magnesium)
T1
PEPTIC RELIEF ORAL TABLET,CHEWABLE T1
PINK BISMUTH ORAL SUSPENSION 262 MG/15 ML
T1
78
Drug Tier Notes
PINK BISMUTH ORAL TABLET T1
sodium bicarbonate oral T1
Antidiarrhea Agents
ANTI-DIARRHEAL (LOPERAMIDE) ORAL TABLET
T1 QL (30 EA per 30 days)
diphenoxylate-atropine oral tablet T1
loperamide oral capsule T1 QL (30 EA per 30 days)
loperamide oral liquid 1 mg/5 ml T1 QL (150 ML per 30 days)
PEPTIC RELIEF ORAL TABLET,CHEWABLE T1
PINK BISMUTH ORAL SUSPENSION 262 MG/15 ML
T1
PINK BISMUTH ORAL TABLET T1
Antiemetics, Miscellaneous
BONJESTA T5
DICLEGIS T5
dronabinol T3 PA
scopolamine base T3 PA
Antiflatulents
alum-mag hydroxide-simeth oral suspension 200-200-20 mg/5 ml
T1
GAS RELIEF (SIMETHICONE) ORAL TABLET,CHEWABLE 80 MG
T1
MAALOX MAXIMUM STRENGTH T1
simethicone oral capsule 180 mg T1
simethicone oral drops,suspension T1
simethicone oral tablet,chewable 125 mg T1
Antihistamines (Gi Drugs)
BONJESTA T5
DICLEGIS T5
dimenhydrinate oral T1
meclizine oral tablet 12.5 mg, 25 mg T1
meclizine oral tablet,chewable T1
prochlorperazine T1
prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml)
T5
79
Drug Tier Notes
prochlorperazine maleate T1
Anti-Inflammatory Agents (Gi Drugs)
alosetron T3 PA
balsalazide T1
mesalamine oral tablet,delayed release (dr/ec) 1.2 gram
T1
mesalamine oral tablet,delayed release (dr/ec) 800 mg
T3 ST
mesalamine rectal T1
sulfasalazine T1
Cathartics And Laxatives
AMITIZA T3 PA
ATABEX EC T2 QL (30 QY per 30 DYs)
bisacodyl T1
CVS DAILY FIBER 0.52 GRAM CAP T1
DAILY FIBER (PSYLLIUM-SUCROSE) ORAL POWDER 3.4 GRAM/12 GRAM
T1
docusate calcium T1
docusate sodium oral capsule T1
docusate sodium oral liquid T1
ENEMA DISPOSABLE T1
glycerin (adult) T1
magnesium citrate oral solution T1
METAMUCIL (SUGAR) T1
MILK OF MAGNESIA T1
MINERAL OIL LAXATIVE T1
MOVIPREP T2
NATURAL FIBER LAXATIVE (SUGAR) ORAL POWDER 3.4 GRAM/7 GRAM
T1
peg 3350-electrolytes T1
PEG-3350 WITH FLAVOR PACKS T1
polyethylene glycol 3350 T1
PREPOPIK T2
SENNA ORAL SYRUP 176 MG/5 ML T2
SENNA ORAL SYRUP 8.8 MG/5 ML T1
80
Drug Tier Notes
SENNA ORAL TABLET T1
SENNA WITH DOCUSATE SODIUM T1
SILACE ORAL SYRUP T1
STOOL SOFTENER ORAL CAPSULE 50 MG T1
SUPREP BOWEL PREP KIT T2
TRIVEEN-PRX RNF T1 QL (30 QY per 30 DYs)
VINATE ULTRA T1 QL (30 EA per 30 days)
VIRT-SELECT T1 QL (30 QY per 30 DYs)
VP-CH PLUS T1 QL (30 EA per 30 days)
ZATEAN-CH T1
Cholelitholytic Agents
ursodiol T1
Digestants
CREON T2
lactase T1
ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 10,000-34,000 -55,000 UNIT, 15,000-47,000 -63,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,000-10,000 -14,000-UNIT, 3,000-10,000- 16,000 UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000 -27,000 UNIT, 5,000-17,000- 24,000 UNIT
T2
Gi Drugs, Miscellaneous
ALLI T2
CIMZIA T4 PA
CIMZIA POWDER FOR RECONST T4 PA
CULTURELLE KIDS PROBIOTICS ORAL POWDER IN PACKET
T2
CULTURELLE ORAL CAPSULE, SPRINKLE T2
ENDARI T4 PA
HUMIRA PEN T4 PA
HUMIRA PEN PSOR-UVEITS-ADOL HS T4 PA
HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML, 40 MG/0.8 ML
T4 PA
81
Drug Tier Notes
HUMIRA(CF) T4 PA
HUMIRA(CF) PEDI CROHNS STARTER T4 PA
HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML
T4 PA
LINZESS T2
MOVANTIK T3 PA
OCALIVA T4 PA
PROBIOTIC (S.BOULARDII) T1
RELISTOR ORAL T5
RELISTOR SUBCUTANEOUS SOLUTION T5
RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML
T5
SIMPONI T4 PA
SYMPROIC T3 PA
VSL#3 ORAL CAPSULE T3 PA
XENICAL T5
Histamine H2-Antagonists
cimetidine T1
famotidine oral suspension T1 AL (Max 12 Years)
famotidine oral tablet T1
ranitidine hcl oral syrup T1 AL (Max 12 Years)
ranitidine hcl oral tablet T1
Lipotropic Agents
FISH OIL ORAL CAPSULE 120-180 MG T5
Neurokinin-1 Receptor Antagonists
AKYNZEO (NETUPITANT) T3 PA
aprepitant oral capsule T3 PA
EMEND ORAL CAPSULE,DOSE PACK T3 PA
EMEND ORAL SUSPENSION FOR RECONSTITUTION
T3 PA
Prokinetic Agents
metoclopramide hcl injection T5
metoclopramide hcl oral solution T1
metoclopramide hcl oral tablet T1
82
Drug Tier Notes
Prostaglandins
diclofenac-misoprostol T1
misoprostol T1
Protectants
sucralfate oral suspension T1 AL (Max 12 Years)
sucralfate oral tablet T1
Proton-Pump Inhibitors
ACIPHEX SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 5 MG
T5
DEXILANT T5
esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg
T1
esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg
T5
lansoprazole oral capsule,delayed release(dr/ec) T1
lansoprazole oral tablet,disintegrat, delay rel T1 AL (Max 12 Years)
NEXIUM PACKET T5
OMEPPI T5
omeprazole magnesium oral capsule,delayed release(dr/ec)
T5
omeprazole oral capsule,delayed release(dr/ec) T1
omeprazole oral tablet,delayed release (dr/ec) T5
omeprazole oral tablet,disintegrat, delay rel T5
omeprazole-sodium bicarbonate T5
pantoprazole oral T1
PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON
T5
PRILOSEC OTC T5
PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET
T5
rabeprazole oral capsule, delayed rel sprinkle T5
rabeprazole oral tablet,delayed release (dr/ec) T1
Gold Compounds
Gold Compounds
RIDAURA T2
83
Drug Tier Notes
Heavy Metal Antagonists
Heavy Metal Antagonists
CHEMET T3 PA
deferasirox oral tablet 180 mg, 360 mg T4 PA
deferasirox oral tablet, dispersible T4 PA
JADENU ORAL TABLET 90 MG T4 PA
JADENU SPRINKLE T4 PA
Hormones And Synthetic Substitutes
Adrenals
ADVAIR HFA T3 PA
ARNUITY ELLIPTA T2 QL (60 EA per 30 days)
ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION
T2 QL (26 GM per 30 days)
ASMANEX TWISTHALER T2 QL (2 QY per 30 DYs)
BREO ELLIPTA T3 PA
budesonide inhalation suspension for nebulization 0.25 mg/2 ml
T1 QL (120 QY per 30 DYs)
budesonide inhalation suspension for nebulization 0.5 mg/2 ml
T1 QL (240 QY per 30 DYs)
budesonide oral capsule,delayed,extend.release T1
budesonide-formoterol T1 QL (20.4 QY per 30 days)
DEXAMETHASONE INTENSOL T1
dexamethasone oral elixir T1
dexamethasone oral solution T1
dexamethasone oral tablet T1
dexamethasone sodium phosphate injection solution 4 mg/ml
T5
DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION
T2 QL (13 QY per 30 DYs)
DULERA INHALATION HFA AEROSOL INHALER 50-5 MCG/ACTUATION
T2 QL (13 GM per 30 days)
EMFLAZA T3 PA
FLOVENT DISKUS T2 QL (120 QY per 30 DYs)
84
Drug Tier Notes
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION
T2 QL (24 QY per 30 DYs)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION
T2 QL (21.2 QY per 30 DYs)
fludrocortisone T1
fluticasone propion-salmeterol inhalation aerosol powdr breath activated
T1 QL (1 EA per 30 days)
fluticasone propion-salmeterol inhalation blister with device
T1 QL (60 EA per 30 days)
hydrocortisone oral T1
MEDROL ORAL TABLET 2 MG T2
methylprednisolone T1
prednisolone oral solution 15 mg/5 ml T1
prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)
T1
prednisolone sodium phosphate oral tablet,disintegrating
T5
prednisone T1
PREDNISONE INTENSOL T1
PULMICORT FLEXHALER T2 QL (2 EA per 30 days)
PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/2 ML
T2 QL (120 QY per 30 DYs)
QVAR REDIHALER T2 QL (21.2 GM per 30 days)
TRELEGY ELLIPTA T3 ST
triamcinolone acetonide injection T5
WIXELA INHUB T1 QL (60 EA per 30 days)
Alpha-Glucosidase Inhibitors
acarbose T1
Amylinomimetics
SYMLINPEN 120 T5
SYMLINPEN 60 T5
Androgens
ANDRODERM T5 PA
ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (50 MG/5 GRAM)
T3 PA
85
Drug Tier Notes
danazol T1
JATENZO T5
NATESTO T5
oxandrolone T3 PA
testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml
T1 QL (5 QY per 30 DYs)
testosterone enanthate T1 QL (5 ML per 30 days)
testosterone transdermal gel T3 PA
testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation
T5 PA
testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %), 20.25 mg/1.25 gram (1.62 %)
T3 PA
testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1.62 % (20.25 mg/1.25 gram), 1.62 % (40.5 mg/2.5 gram)
T3 PA
testosterone transdermal solution in metered pump w/app
T5
Antidiabetic Agents, Miscellaneous
colesevelam oral tablet T3 PA
KORLYM T5
WELCHOL ORAL POWDER IN PACKET T3 PA
Antiestrogens
anastrozole T1 QL (30 QY per 30 DYs)
exemestane T3 PA
letrozole T1
Antigonadtropins
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG
T4 PA
ORILISSA T3 PA
Antihypoglycemic Agents, Miscellaneous
GLUCOSE POWDER T5
Antiparathyroid Agents
calcitonin (salmon) T1
cinacalcet T3 PA
MIACALCIN INJECTION T5
86
Drug Tier Notes
Antithyroid Agents
methimazole oral tablet 10 mg, 5 mg T1
propylthiouracil T1
Biguanides
alogliptin-metformin T3 ST
glipizide-metformin T1
glyburide-metformin T1
INVOKAMET T3 ST
INVOKAMET XR T3 ST
JANUMET T5
JANUMET XR T5
JENTADUETO T5
JENTADUETO XR T5
KOMBIGLYZE XR T5
metformin oral tablet T1
metformin oral tablet extended release 24 hr T1
metformin oral tablet extended release 24hr 1,000 mg
T5
SEGLUROMET T5
SYNJARDY T3 ST
SYNJARDY XR T3 ST
TRIJARDY XR T5
XIGDUO XR T5
Contraceptives
AMETHIA T1
ANNOVERA T2
BALCOLTRA T2
CAMRESE LO T1
CHATEAL (28) T1
CRYSELLE (28) T1
CYCLAFEM 1/35 (28) T1
drospirenone-e.estradiol-lm.fa T1
ELLA T2
etonogestrel-ethinyl estradiol T1
87
Drug Tier Notes
FALMINA (28) T1
GIANVI (28) T1
JOLESSA T1
JUNEL FE 1.5/30 (28) T1
JUNEL FE 1/20 (28) T1
JUNEL FE 24 T1
KELNOR 1/35 (28) T1
LEENA 28 T1
levonorgestrel-ethinyl estrad oral tablet 90-20 mcg (28)
T1
LO LOESTRIN FE T2
MIBELAS 24 FE T1
MICROGESTIN 1.5/30 (21) T1
MICROGESTIN 1/20 (21) T1
MONONESSA (28) T1
MY WAY T1
MYZILRA T1
NATAZIA T2
NORA-BE T1
noreth-ethinyl estradiol-iron T1
norethindrone-e.estradiol-iron oral tablet,chewable
T1
norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg
T1
NORTREL 0.5/35 (28) T1
NORTREL 7/7/7 (28) T1
OGESTREL (28) T1
PHILITH T1
QUARTETTE T2
RAJANI T1
RECLIPSEN (28) T1
SLYND T2
SYEDA T1
TAYTULLA T2
TRI-LEGEST FE T1
88
Drug Tier Notes
TRI-SPRINTEC (28) T1
TWIRLA T2
VELIVET TRIPHASIC REGIMEN (28) T1
VIORELE (28) T1
XULANE T1
ZOVIA 1/50E (28) T1
Dipeptidyl Peptidase-4(Dpp-4) Inhibitors
alogliptin T3 ST
alogliptin-metformin T3 ST
alogliptin-pioglitazone T3 ST
GLYXAMBI T5
JANUMET T5
JANUMET XR T5
JANUVIA T5
JENTADUETO T5
JENTADUETO XR T5
KOMBIGLYZE XR T5
ONGLYZA T5
QTERN T5
STEGLUJAN T5
TRADJENTA T5
TRIJARDY XR T5
Estrogen Agonist-Antagonists
FARESTON T4 PA
raloxifene T1
SOLTAMOX T3 PA
tamoxifen T1
Estrogens
CLIMARA PRO T2 QL (4 QY per 28 DYs)
COMBIPATCH T2 QL (8 QY per 28 DYs)
DEPO-ESTRADIOL T1 QL (10 QY per 90 DYs)
ESTRACE VAGINAL T2
estradiol oral T1
estradiol transdermal patch semiweekly T1 QL (24 EA per 84 days)
89
Drug Tier Notes
estradiol transdermal patch weekly T1 QL (4 QY per 28 DYs)
estradiol vaginal tablet T1
estradiol valerate T1 QL (10 QY per 90 DYs)
ESTRING T2 QL (1 EA per 30 days)
ESTROGEL T2 QL (50 GM per 30 days)
MENOSTAR T2 QL (4 QY per 28 DYs)
norethindrone ac-eth estradiol oral tablet 1-5 mg-mcg
T1
PREMARIN ORAL T2
PREMARIN VAGINAL T2
PREMPHASE T2
PREMPRO T2
Glycogenolytic Agents
BAQSIMI T2
GLUCAGEN DIAGNOSTIC KIT T5
GLUCAGEN HYPOKIT T5
GLUCAGON EMERGENCY KIT (HUMAN) T2
GVOKE PFS 1-PACK SYRINGE T2
GVOKE PFS 2-PACK SYRINGE T2
Gonadotropins
ELIGARD T4 PA
ELIGARD (3 MONTH) T4 PA
ELIGARD (4 MONTH) T4 PA
ELIGARD (6 MONTH) T4 PA
leuprolide T3 PA
LUPANETA PACK (1 MONTH) T5
LUPANETA PACK (3 MONTH) T5
LUPRON DEPOT T4 PA
LUPRON DEPOT (3 MONTH) T4 PA
LUPRON DEPOT (4 MONTH) T4 PA
LUPRON DEPOT-PED T4 PA
LUPRON DEPOT-PED (3 MONTH) T4 PA
SYNAREL T5
TRELSTAR INTRAMUSCULAR SYRINGE T5
90
Drug Tier Notes
ZOLADEX T5
Gonadotropins And Antigonadotropins
ELIGARD T4 PA
ELIGARD (3 MONTH) T4 PA
ELIGARD (4 MONTH) T4 PA
ELIGARD (6 MONTH) T4 PA
leuprolide T3 PA
LUPANETA PACK (1 MONTH) T5
LUPANETA PACK (3 MONTH) T5
LUPRON DEPOT T4 PA
LUPRON DEPOT (3 MONTH) T4 PA
LUPRON DEPOT (4 MONTH) T4 PA
LUPRON DEPOT-PED T4 PA
LUPRON DEPOT-PED (3 MONTH) T4 PA
SYNAREL T5
ZOLADEX T5
Incretin Mimetics
BYDUREON T5
BYDUREON BCISE T5
BYETTA T5
OZEMPIC T3 ST; QL (9 ML per 84 days)
RYBELSUS ORAL TABLET 14 MG, 7 MG T3 ST
RYBELSUS ORAL TABLET 3 MG T3
SAXENDA T5
TRULICITY T5
VICTOZA 2-PAK T3 ST; QL (27 ML per 90 days)
VICTOZA 3-PAK T3 ST; QL (27 ML per 90 days)
Insulins
ADMELOG SOLOSTAR U-100 INSULIN T2
ADMELOG U-100 INSULIN LISPRO T2
BASAGLAR KWIKPEN U-100 INSULIN T2
HUMALOG MIX 50-50 INSULN U-100 T2
HUMALOG MIX 50-50 KWIKPEN T2
HUMALOG MIX 75-25(U-100)INSULN T2
91
Drug Tier Notes
HUMULIN 70/30 U-100 INSULIN T2
HUMULIN 70/30 U-100 KWIKPEN T2
HUMULIN N NPH INSULIN KWIKPEN T2
HUMULIN N NPH U-100 INSULIN T2
HUMULIN R REGULAR U-100 INSULN T2
HUMULIN R U-500 (CONC) INSULIN T2
HUMULIN R U-500 (CONC) KWIKPEN T2
insulin aspart protamine-insulin aspart 70-30 flexpen outer,suv,latex-free
T1
insulin aspart protamine-insulin aspart 70-30 vial T1
insulin lispro jr 100 unit/ml kwikpen suv, outer T1
insulin lispro mix 75-25 kwkpn suv, outer T1
insulin lispro subcutaneous insulin pen T1
insulin lispro subcutaneous solution T1
LANTUS SOLOSTAR U-100 INSULIN T5
LANTUS U-100 INSULIN T5
LEVEMIR FLEXTOUCH U-100 INSULN T3 ST
LEVEMIR U-100 INSULIN T3 ST
NOVOLIN N NPH U-100 INSULIN T2
NOVOLIN R REGULAR U-100 INSULN T2
TOUJEO MAX U-300 SOLOSTAR T5
TOUJEO SOLOSTAR U-300 INSULIN T5
TRESIBA FLEXTOUCH U-100 T3 ST
TRESIBA FLEXTOUCH U-200 T3 ST
TRESIBA U-100 INSULIN T3 ST
Intermediate-Acting Insulins
HUMALOG MIX 50-50 INSULN U-100 T2
HUMALOG MIX 50-50 KWIKPEN T2
HUMALOG MIX 75-25(U-100)INSULN T2
HUMULIN 70/30 U-100 INSULIN T2
HUMULIN 70/30 U-100 KWIKPEN T2
HUMULIN N NPH INSULIN KWIKPEN T2
HUMULIN N NPH U-100 INSULIN T2
92
Drug Tier Notes
insulin aspart protamine-insulin aspart 70-30 flexpen outer,suv,latex-free
T1
insulin aspart protamine-insulin aspart 70-30 vial T1
insulin lispro mix 75-25 kwkpn suv, outer T1
NOVOLIN N NPH U-100 INSULIN T2
Leptins
MYALEPT T5
Long-Acting Insulins
BASAGLAR KWIKPEN U-100 INSULIN T2
LANTUS SOLOSTAR U-100 INSULIN T5
LANTUS U-100 INSULIN T5
LEVEMIR FLEXTOUCH U-100 INSULN T3 ST
LEVEMIR U-100 INSULIN T3 ST
TOUJEO MAX U-300 SOLOSTAR T5
TOUJEO SOLOSTAR U-300 INSULIN T5
TRESIBA FLEXTOUCH U-100 T3 ST
TRESIBA FLEXTOUCH U-200 T3 ST
TRESIBA U-100 INSULIN T3 ST
Meglitinides
nateglinide T1
repaglinide T1
Parathyroid Agents
FORTEO T3 PA
teriparatide T3 PA
TYMLOS T3 PA
Parathyroid And Antiparathyroid Agents
calcitonin (salmon) T1
FORTEO T3 PA
MIACALCIN INJECTION T5
TYMLOS T3 PA
Pituitary
ACTHAR H.P. T4 PA
DDAVP NASAL SOLUTION T5
93
Drug Tier Notes
desmopressin nasal spray,non-aerosol T1
desmopressin oral T1
GENOTROPIN T5
GENOTROPIN MINIQUICK T5
HUMATROPE T5
NORDITROPIN FLEXPRO T4 PA
NUTROPIN AQ NUSPIN T4 PA
OMNITROPE T5
SAIZEN SUBCUTANEOUS RECON SOLN 8.8 MG
T5
SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 6 MG
T5
STIMATE T3 PA
ZOMACTON T4 PA
Progestins
COMBIPATCH T2 QL (8 QY per 28 DYs)
CRINONE T2
DEPO-SUBQ PROVERA 104 T2
ENDOMETRIN T3 PA
hydroxyprogest(pf)(preg presv) T4 PA
hydroxyprogesterone cap(ppres) T4 PA
LUPANETA PACK (1 MONTH) T5
LUPANETA PACK (3 MONTH) T5
MAKENA (PF) T4 PA
medroxyprogesterone T1
megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml)
T1
megestrol oral tablet T1
norethindrone acetate T1
norethindrone ac-eth estradiol oral tablet 1-5 mg-mcg
T1
progesterone micronized T1 QL (30 QY per 30 DYs)
SLYND T2
Rapid-Acting Insulins
ADMELOG SOLOSTAR U-100 INSULIN T2
94
Drug Tier Notes
ADMELOG U-100 INSULIN LISPRO T2
HUMALOG MIX 50-50 INSULN U-100 T2
HUMALOG MIX 50-50 KWIKPEN T2
HUMALOG MIX 75-25(U-100)INSULN T2
insulin aspart protamine-insulin aspart 70-30 flexpen outer,suv,latex-free
T1
insulin aspart protamine-insulin aspart 70-30 vial T1
insulin lispro jr 100 unit/ml kwikpen suv, outer T1
insulin lispro mix 75-25 kwkpn suv, outer T1
insulin lispro subcutaneous insulin pen T1
insulin lispro subcutaneous solution T1
Short-Acting Insulins
HUMULIN 70/30 U-100 INSULIN T2
HUMULIN 70/30 U-100 KWIKPEN T2
HUMULIN R REGULAR U-100 INSULN T2
HUMULIN R U-500 (CONC) INSULIN T2
HUMULIN R U-500 (CONC) KWIKPEN T2
NOVOLIN R REGULAR U-100 INSULN T2
Sodium-Gluc Cotransport 2 (Sglt2) Inhib
FARXIGA T5
GLYXAMBI T5
INVOKAMET T3 ST
INVOKANA T3 ST
JARDIANCE T3 ST
QTERN T5
SEGLUROMET T5
STEGLATRO T5
STEGLUJAN T5
SYNJARDY T3 ST
SYNJARDY XR T3 ST
TRIJARDY XR T5
XIGDUO XR T5
Somatostatin Agonists
95
Drug Tier Notes
octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml
T4 PA
octreotide acetate injection syringe T3 PA
SANDOSTATIN INJECTION SOLUTION 50 MCG/ML, 500 MCG/ML
T4 PA
Somatotropin Agonists
EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG
T5
EGRIFTA SV 2 MG VIAL T5
Somatotropin Antagonists
SOMAVERT T4 PA
Sulfonylureas
chlorpropamide T5
glimepiride T1
glipizide T1
glipizide-metformin T1
glyburide T1
glyburide-metformin T1
tolazamide T5
Thiazolidinediones
alogliptin-pioglitazone T3 ST
pioglitazone T1
Thyroid Agents
ARMOUR THYROID ORAL TABLET 180 MG, 240 MG, 300 MG
T2
levothyroxine oral T1
liothyronine oral T1
NATURE-THROID T2
NP THYROID ORAL TABLET 15 MG, 30 MG, 60 MG, 90 MG
T1
thyroid (pork) oral tablet 120 mg T1
TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG
T5
Local Anesthetics (Parenteral)
96
Drug Tier Notes
Local Anesthetics (Parenteral)
lidocaine (pf) injection solution 10 mg/ml (1 %) T5
lidocaine hcl injection solution 10 mg/ml (1 %) T5
Miscellaneous Therapeutic Agents
5-Alpha-Reductase Inhibitors
dutasteride T1
finasteride oral tablet 5 mg T1
Alcohol Deterrents
disulfiram T1
naltrexone T5 CO
VIVITROL T5 CO
Antidotes
acetylcysteine intravenous T5
BAQSIMI T2
CHEMET T3 PA
EVZIO INJECTION AUTO-INJECTOR 0.4 MG/0.4 ML
T5 CO
GLUCAGEN HYPOKIT T5
GLUCAGON EMERGENCY KIT (HUMAN) T2
GVOKE PFS 1-PACK SYRINGE T2
GVOKE PFS 2-PACK SYRINGE T2
KIONEX (WITH SORBITOL) T1
lanthanum T3 PA
leucovorin calcium injection recon soln 100 mg, 50 mg
T5
leucovorin calcium oral T1
naloxone injection solution T5 CO
naloxone injection syringe T5 CO
NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION
T5 CO
phytonadione (vitamin k1) oral tablet 5 mg T1
protamine T5
RADIOGARDASE T5
sevelamer carbonate oral powder in packet T3 PA
97
Drug Tier Notes
sevelamer carbonate oral tablet T1
sevelamer hcl T5
SODIUM POLYSTYRENE (SORB FREE) T1
sodium polystyrene sulfonate oral powder T1
SPS (WITH SORBITOL) ORAL T2
VITAMIN K1 INJECTION T5
Antigout Agents
allopurinol T1
colchicine T1 QL (60 EA per 30 days)
febuxostat T3 PA
INDOCIN ORAL T2 AL (Max 12 Years)
INDOCIN RECTAL T2
indomethacin oral T1
naproxen oral suspension T1 AL (Max 12 Years)
naproxen oral tablet T1
naproxen oral tablet,delayed release (dr/ec) T1
naproxen sodium oral tablet T1
probenecid T1
Antisense Oligonucleotides
TEGSEDI T5
Bone Anabolic Agents
EVENITY SUBCUTANEOUS SYRINGE 105 MG/1.17 ML
T5
FORTEO T3 PA
teriparatide T3 PA
TYMLOS T3 PA
Bone Resorption Inhibitors
alendronate oral solution T5
alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg T1
alendronate oral tablet 40 mg T5
BINOSTO T5
calcitonin (salmon) T1
etidronate disodium T5
FOSAMAX PLUS D T5
98
Drug Tier Notes
ibandronate oral T1
MIACALCIN INJECTION T5
pamidronate intravenous recon soln T5
raloxifene T1
risedronate T5
Carbonic Anhydrase Inhibitors (Misc.)
KEVEYIS T5
Cariostatic Agents
DENTA 5000 PLUS T1
FLUOR-A-DAY T1
fluoride (sodium) dental paste T1
fluoride (sodium) oral drops T1
fluoride (sodium) oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid), 1 mg (2.2 mg sod. fluoride)
T1
FLUORIDEX DAILY DEFENSE DENTAL PASTE
T1
FLURA-DROPS T1
LUDENT FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG(0.55 MG SOD. FLUORIDE), 0.5 MG (1.1 MG SODIUM FLUORID)
T1
MULTIVITAMIN WITH FLUORIDE T1
MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 1 MG
T1 AL (Max 12 Years)
PREVIDENT DENTAL GEL T1
PREVIDENT DENTAL SOLUTION T2
TRI-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC 0.25 MG/ML FLUORIDE
T5
TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML
T1 AL (Max 12 Years)
Complement Inhibitors
HAEGARDA T5
icatibant T4 PA
KALBITOR T5
TAKHZYRO T3 PA
Disease-Modifying Antirheumatic Agents
99
Drug Tier Notes
ACTEMRA ACTPEN T4 PA
ACTEMRA SUBCUTANEOUS T4 PA
azathioprine T1
CIMZIA T4 PA
CIMZIA POWDER FOR RECONST T4 PA
cyclosporine modified oral capsule T1
cyclosporine modified oral solution T1 AL (Max 12 Years)
ENBREL T4 PA
ENBREL MINI T4 PA
ENBREL SURECLICK T4 PA
HUMIRA PEN T4 PA
HUMIRA PEN PSOR-UVEITS-ADOL HS T4 PA
HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML, 40 MG/0.8 ML
T4 PA
HUMIRA(CF) T4 PA
HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML
T4 PA
HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML
T4 PA
hydroxychloroquine T1
KEVZARA T5
KINERET T4 PA
leflunomide T1
methotrexate sodium (pf) injection solution T1 QL (16 ML per 28 days)
methotrexate sodium injection T1 QL (16 ML per 28 days)
methotrexate sodium oral T1
OLUMIANT T4 PA
ORENCIA T4 PA
ORENCIA CLICKJECT T4 PA
OTEZLA T4 PA
OTEZLA STARTER T4 PA
RIDAURA T2
RINVOQ T5
SANDIMMUNE ORAL SOLUTION T5
100
Drug Tier Notes
SIMPONI T4 PA
STELARA SUBCUTANEOUS T4 PA
sulfasalazine T1
TREXALL T3 PA
XELJANZ T4 PA
XELJANZ XR T4 PA
Gonadotropin-Releasing Hormone Antagnts
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG
T4 PA
Immunomodulatory Agents
ACTEMRA ACTPEN T4 PA
ACTEMRA SUBCUTANEOUS T4 PA
AUBAGIO T5
AVONEX (WITH ALBUMIN) T4 PA
AVONEX INTRAMUSCULAR PEN INJECTOR KIT
T4 PA
AVONEX INTRAMUSCULAR SYRINGE KIT T4 PA
azathioprine T1
BETASERON SUBCUTANEOUS KIT T4 PA
CIMZIA T4 PA
CIMZIA POWDER FOR RECONST T4 PA
cyclosporine modified oral capsule T1
cyclosporine modified oral solution T1 AL (Max 12 Years)
ENBREL T4 PA
ENBREL MINI T4 PA
ENBREL SURECLICK T4 PA
EXTAVIA T4 PA
GILENYA ORAL CAPSULE 0.5 MG T4 PA
glatiramer T4 PA
GLATOPA SUBCUTANEOUS SYRINGE 20 MG/ML
T4 PA
HUMIRA PEN T4 PA
HUMIRA PEN PSOR-UVEITS-ADOL HS T4 PA
HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML, 40 MG/0.8 ML
T4 PA
101
Drug Tier Notes
HUMIRA(CF) T4 PA
HUMIRA(CF) PEDI CROHNS STARTER T4 PA
HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML
T4 PA
hydroxychloroquine T1
KEVZARA T5
KINERET T4 PA
leflunomide T1
MAYZENT T5
methotrexate sodium (pf) injection solution T1 QL (16 ML per 28 days)
methotrexate sodium injection T1 QL (16 ML per 28 days)
methotrexate sodium oral T1
OLUMIANT T4 PA
ORENCIA T4 PA
ORENCIA CLICKJECT T4 PA
OTEZLA T4 PA
OTEZLA STARTER T4 PA
PLEGRIDY T5
POMALYST T4 PA
PROLEUKIN T5
REBIF (WITH ALBUMIN) T4 PA
REBIF REBIDOSE T4 PA
REBIF TITRATION PACK T4 PA
REVLIMID T4 PA
RIDAURA T2
RINVOQ T5
SANDIMMUNE ORAL SOLUTION T5
SIMPONI T4 PA
STELARA SUBCUTANEOUS T4 PA
sulfasalazine T1
TECFIDERA T4 PA
TREXALL T3 PA
XELJANZ T4 PA
XELJANZ XR T4 PA
102
Drug Tier Notes
Immunosuppressive Agents
azathioprine T1
CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION
T2 AL (Max 12 Years)
cyclophosphamide intravenous T5
cyclophosphamide oral capsule T3 PA
cyclosporine modified oral capsule T1
cyclosporine modified oral solution T1 AL (Max 12 Years)
everolimus (immunosuppressive) T1
MAVENCLAD (10 TABLET PACK) T4 PA
mercaptopurine T1
methotrexate sodium (pf) injection solution T1 QL (16 ML per 28 days)
methotrexate sodium injection T1 QL (16 ML per 28 days)
methotrexate sodium oral T1
mycophenolate mofetil oral capsule T1
mycophenolate mofetil oral tablet T1
mycophenolate sodium T1
pimecrolimus T5
PURIXAN T3 PA
SANDIMMUNE ORAL SOLUTION T5
sirolimus oral solution T1 AL (Max 12 Years)
sirolimus oral tablet 0.5 mg, 1 mg T1
sirolimus oral tablet 2 mg T1 AL (Min 2 Years)
tacrolimus oral T1
TREXALL T3 PA
ZORTRESS ORAL TABLET 1 MG T2
Other Miscellaneous Therapeutic Agents
acetylcysteine solution 100 mg/ml (10 %) T1 QL (300 ML per 30 days)
acetylcysteine solution 200 mg/ml (20 %) T1
CERDELGA T4 PA
cinacalcet T3 PA
dalfampridine T4 PA
ENDARI T4 PA
GRASTEK T5
103
Drug Tier Notes
levocarnitine (with sugar) T1
levocarnitine oral solution 100 mg/ml T1
levocarnitine oral tablet T5
melatonin oral liquid 5 mg/15 ml T1
melatonin oral tablet 1 mg, 3 mg, 5 mg T1
melatonin oral tablet,disintegrating 3 mg, 5 mg T1
miglustat T4 PA
nitisinone T5
NITYR T4 PA
octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml
T4 PA
octreotide acetate injection syringe T3 PA
OCUVITE LUTEIN AND ZEAXANTHIN T2
ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY
T5
ORFADIN ORAL CAPSULE 20 MG T5
ORFADIN ORAL SUSPENSION T5
RAGWITEK T5
SANDOSTATIN INJECTION SOLUTION 50 MCG/ML
T4 PA
SYMTUZA T5 CO
TYBOST T5 CO
Protective Agents
ELMIRON T2
Nonhormonal Contraceptives
Nonhormonal Contraceptives
CONCEPTROL T1
GYNOL II T1
PHEXXI T2
TODAY CONTRACEPTIVE SPONGE T2
VAGINAL CONTRACEPTIVE FILM T2
VAGINAL CONTRACEPTIVE FOAM T1
VCF CONTRACEPTIVE GEL T1
WIDE-SEAL DIAPHRAGM 60 T1
104
Drug Tier Notes
Oxytocics
Oxytocics
methylergonovine oral T1 QL (30 EA per 30 days)
Pharmaceutical Aids
Pharmaceutical Aids
water for inject, bacteriostat T5
water for injection, sterile intravenous T5
Radioactive Agents
Radioactive Agents
AMYVID T5
Respiratory Tract Agents
Alpha And Beta Adrenergic Agonist(Respr)
ADRENACLICK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML
T5
ADRENALIN INJECTION SOLUTION 1 MG/ML (1 ML)
T5
APRODINE T1 AL (Min 6 Years)
AUVI-Q INJECTION AUTO-INJECTOR 0.15 MG/0.15 ML, 0.3 MG/0.3 ML
T5
CHILDREN'S SILFEDRINE T1 AL (Min 4 Years)
epinephrine injection auto-injector T1 QL (6 EA per 365 days)
EPIPEN 2-PAK T5
EPIPEN JR 2-PAK T5
LORATADINE-D T1 AL (Min 12 Years)
PEDIA RELIEF COUGH-COLD T1 AL (Min 6 Years)
pseudoephedrine hcl oral liquid T1 AL (Min 4 Years)
pseudoephedrine hcl oral tablet 30 mg T1 AL (Min 4 Years)
pseudoephedrine-guaifenesin oral tablet extended release 12 hr 60-600 mg
T1 AL (Min 6 Years)
SUDAFED 24 HOUR T1
SUDOGEST 12-HOUR T1 AL (Min 4 Years)
SUDOGEST ORAL TABLET 60 MG T1 AL (Min 4 Years)
Anticholinergic Agents (Respir.Tract)
ANORO ELLIPTA T3 ST
105
Drug Tier Notes
ATROVENT HFA T2 QL (25.8 QY per 30 DYs)
COMBIVENT RESPIMAT T2 QL (4 QY per 20 DYs)
diphenoxylate-atropine oral tablet T1
INCRUSE ELLIPTA T2 QL (30 EA per 30 days)
ipratropium bromide inhalation T1 QL (312.5 QY per 30 DYs)
ipratropium-albuterol T1 QL (570 QY per 30 DYs)
SPIRIVA RESPIMAT T2 QL (4 GM per 30 days)
TRELEGY ELLIPTA T3 ST
Antifibrotic Agents
ESBRIET T4 PA
OFEV T5
Anti-Inflammatory Agents (Respiratory)
NUCALA SUBCUTANEOUS RECON SOLN T5
Antitussives
ADULT TUSSIN COUGH CONGEST DM T1 AL (Min 2 Years)
benzonatate oral capsule 100 mg, 200 mg T1
codeine sulfate oral tablet T1 QL (120 QY per 30 DYs); AL (Min 12 Years)
codeine-guaifenesin T1 AL (Min 18 Years)
dextromethorphan polistirex T1 AL (Min 4 Years)
dextromethorphan-guaifenesin oral syrup T1 AL (Min 2 Years)
DIABETIC TUSSIN DM ORAL LIQUID 10-200 MG/5 ML
T1 AL (Min 2 Years)
NUEDEXTA T3 PA
PEDIA RELIEF COUGH-COLD T1 AL (Min 6 Years)
promethazine-dm T1 AL (Min 2 Years)
Cystic Fibrosis (Cftr) Correctors
ORKAMBI T4 PA
SYMDEKO T4 PA
TRIKAFTA T4 PA
Cystic Fibrosis (Cftr) Potentiators
KALYDECO T4 PA
ORKAMBI T4 PA
SYMDEKO T4 PA
106
Drug Tier Notes
TRIKAFTA T4 PA
Expectorants
ADULT TUSSIN COUGH CONGEST DM T1 AL (Min 2 Years)
codeine-guaifenesin T1 AL (Min 18 Years)
dextromethorphan-guaifenesin oral syrup T1 AL (Min 2 Years)
DIABETIC TUSSIN DM ORAL LIQUID 10-200 MG/5 ML
T1 AL (Min 2 Years)
guaifenesin oral tablet 200 mg T1 AL (Min 2 Years)
guaifenesin oral tablet extended release 12hr T1 AL (Min 2 Years)
pseudoephedrine-guaifenesin oral tablet extended release 12 hr 60-600 mg
T1 AL (Min 6 Years)
TUSSIN ORAL LIQUID T1 AL (Min 2 Years)
First Generation Antihist.(Respir Tract)
ALLERGY (DIPHENHYDRAMINE) ORAL LIQUID
T1
APRODINE T1 AL (Min 6 Years)
BONJESTA T5
CHILDREN'S BENADRYL ALLERGY ORAL TABLET,CHEWABLE
T1
chlorpheniramine maleate oral tablet T1
chlorpheniramine maleate oral tablet extended release
T1
cyproheptadine T1
DICLEGIS T5
dimenhydrinate oral T1
diphenhydramine hcl injection solution 50 mg/ml T5
diphenhydramine hcl injection syringe T5
diphenhydramine hcl oral capsule T1
diphenhydramine hcl oral tablet 25 mg T1
PEDIA RELIEF COUGH-COLD T1 AL (Min 6 Years)
promethazine injection solution T5
promethazine oral T1 AL (Min 2 Years)
PROMETHAZINE VC T1 AL (Min 2 Years)
promethazine-dm T1 AL (Min 2 Years)
pyrilamine-phenylephrine oral tablet T5
107
Drug Tier Notes
SLEEP AID (DOXYLAMINE) T1
Interleukin Antagonists
CINQAIR T5
DUPIXENT PEN T4 PA
DUPIXENT SYRINGE T4 PA
FASENRA T5
FASENRA PEN T5
NUCALA T5
Leukotriene Modifiers
montelukast oral granules in packet T1 AL (Max 2 Years)
montelukast oral tablet T1
montelukast oral tablet,chewable T1
Mast-Cell Stabilizers
cromolyn inhalation T1
cromolyn nasal T1 AL (Min 2 Years)
cromolyn ophthalmic (eye) T1
cromolyn oral T1
Mucolytic Agents
acetylcysteine solution 100 mg/ml (10 %) T1 QL (300 ML per 30 days)
acetylcysteine solution 200 mg/ml (20 %) T1
PULMOZYME T4 PA
Nasal Preparations (Steroids)
budesonide nasal T1 QL (8.6 GM per 30 days)
fluticasone propionate nasal T1 QL (16 QY per 30 DYs)
NASAL ALLERGY T1 QL (16.9 ML per 30 days)
RHINOCORT ALLERGY T2 QL (8.43 ML per 30 days)
triamcinolone acetonide nasal T1
Non-Select.Beta-Adrenergic Agont(Respir)
ISUPREL T5
Orally Inhaled Preparations (Steroids)
ADVAIR HFA T3 PA
ARNUITY ELLIPTA T2 QL (60 EA per 30 days)
108
Drug Tier Notes
ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION
T2 QL (26 GM per 30 days)
ASMANEX TWISTHALER T2 QL (2 QY per 30 DYs)
BREO ELLIPTA T3 PA
budesonide inhalation suspension for nebulization 0.25 mg/2 ml
T1 QL (120 QY per 30 DYs)
budesonide inhalation suspension for nebulization 0.5 mg/2 ml
T1 QL (240 QY per 30 DYs)
budesonide-formoterol T1 QL (20.4 QY per 30 days)
DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION
T2 QL (13 QY per 30 DYs)
DULERA INHALATION HFA AEROSOL INHALER 50-5 MCG/ACTUATION
T2 QL (13 GM per 30 days)
FLOVENT DISKUS T2 QL (120 QY per 30 DYs)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION
T2 QL (24 QY per 30 DYs)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION
T2 QL (21.2 QY per 30 DYs)
fluticasone propion-salmeterol inhalation aerosol powdr breath activated
T1 QL (1 EA per 30 days)
fluticasone propion-salmeterol inhalation blister with device
T1 QL (60 EA per 30 days)
PULMICORT FLEXHALER T2 QL (2 EA per 30 days)
PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/2 ML
T2 QL (120 QY per 30 DYs)
QVAR REDIHALER T2 QL (21.2 GM per 30 days)
TRELEGY ELLIPTA T3 ST
WIXELA INHUB T1 QL (60 EA per 30 days)
Phosphodiesterase Type 4 Inhibitors
DALIRESP T3 PA
Pulmonary Surfactants
SURVANTA T5
Respiratory Tract Agents, Miscellaneous
XOLAIR SUBCUTANEOUS RECON SOLN T5
109
Drug Tier Notes
Second Generation Antihist(Respir Tract)
ALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING
T1
cetirizine oral solution 1 mg/ml T1
cetirizine oral tablet T1
cetirizine oral tablet,chewable T1
CHILDREN'S ALLEGRA ALLERGY ORAL TABLET,DISINTEGRATING
T1
desloratadine oral tablet T1
fexofenadine oral suspension T1
fexofenadine oral tablet 180 mg, 60 mg T1
loratadine oral solution T1
loratadine oral tablet T1
LORATADINE-D T1 AL (Min 12 Years)
Select.Beta-2-Adrenergic Agonist(Respir)
ADVAIR HFA T3 PA
albuterol sulfate inhalation hfa aerosol inhaler T1 QL (2 INH per 30 days)
albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg/0.5 ml
T1
albuterol sulfate inhalation solution for nebulization 2.5 mg /3 ml (0.083 %)
T1 QL (525 QY per 30 DYs)
albuterol sulfate inhalation solution for nebulization 5 mg/ml
T1 QL (100 QY per 30 DYs)
albuterol sulfate oral syrup T1 QL (120 QY per 30 DYs); AL (Max 5 Years)
albuterol sulfate oral tablet T1 QL (120 QY per 30 DYs)
ANORO ELLIPTA T3 ST
ARCAPTA NEOHALER T2 QL (30 EA per 30 days)
BEVESPI AEROSPHERE T3 ST
BREO ELLIPTA T3 PA
BROVANA T3 PA
budesonide-formoterol T1 QL (20.4 QY per 30 days)
COMBIVENT RESPIMAT T2 QL (4 QY per 20 DYs)
110
Drug Tier Notes
DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION
T2 QL (13 QY per 30 DYs)
DULERA INHALATION HFA AEROSOL INHALER 50-5 MCG/ACTUATION
T2 QL (13 GM per 30 days)
fluticasone propion-salmeterol inhalation aerosol powdr breath activated
T1 QL (1 EA per 30 days)
fluticasone propion-salmeterol inhalation blister with device
T1 QL (60 EA per 30 days)
ipratropium-albuterol T1 QL (570 QY per 30 DYs)
levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml
T3 ST; QL (240 QY per 30 DYs)
levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml
T3 ST; QL (360 QY per 30 DYs)
levalbuterol hcl inhalation solution for nebulization 1.25 mg/0.5 ml
T3 ST; QL (150 QY per 30 DYs)
levalbuterol tartrate T3 ST; QL (30 GM per 30 days)
PERFOROMIST T5
PROAIR RESPICLICK T2 QL (2 EA per 30 days)
SEREVENT DISKUS T3 PA
STRIVERDI RESPIMAT T2 QL (4 GM per 30 days)
terbutaline oral T1
terbutaline subcutaneous T5
TRELEGY ELLIPTA T3 ST
WIXELA INHUB T1 QL (60 EA per 30 days)
Vasodilating Agents (Respiratory Tract)
ADEMPAS T4 PA
ambrisentan T4 PA
bosentan T5
OPSUMIT T5
ORENITRAM T5
sildenafil (pulm.hypertension) intravenous T5
sildenafil (pulm.hypertension) oral suspension for reconstitution
T5
sildenafil (pulm.hypertension) oral tablet T3 PA
tadalafil (pulm. hypertension) T3 PA
treprostinil sodium T4 PA
111
Drug Tier Notes
TYVASO T4 PA
TYVASO INSTITUTIONAL START KIT T4 PA
TYVASO REFILL KIT T4 PA
TYVASO STARTER KIT T4 PA
UPTRAVI T4 PA
VENTAVIS T4 PA
Xanthine Derivatives
theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg
T1
theophylline oral tablet extended release 24 hr T1
Skin And Mucous Membrane Agents
Allylamines (Skin And Mucous Membrane)
terbinafine hcl topical T1 QL (120 QY per 30 DYs)
Antibacterials (Skin, Mucous Membrane)
AKTIPAK T5
bacitracin topical ointment T1
bacitracin zinc topical ointment T1
bacitracin-polymyxin b topical ointment T1
clindamycin phosphate topical gel T1
clindamycin phosphate topical lotion T1
clindamycin phosphate topical solution T1
clindamycin phosphate topical swab T1
clindamycin phosphate vaginal T1
clindamycin-benzoyl peroxide T5
clindamycin-tretinoin T5
erythromycin with ethanol topical gel T1
erythromycin with ethanol topical solution T1
erythromycin-benzoyl peroxide T5
metronidazole topical cream T1 QL (45 QY per 30 DYs)
metronidazole topical gel 0.75 % T1 QL (45 QY per 30 DYs)
metronidazole topical gel 1 % T3 ST; QL (60 QY per 30 DYs)
metronidazole topical gel with pump T3 ST; QL (60 QY per 30 DYs)
metronidazole topical lotion T1 QL (59 QY per 30 DYs)
metronidazole vaginal T1
112
Drug Tier Notes
mupirocin T1
mupirocin calcium T5
neomycin-polymyxin b gu T5
NEUAC T5
NEUAC KIT T5
ONEXTON TOPICAL GEL WITH PUMP T5
TRIPLE ANTIBIOTIC TOPICAL OINTMENT T1
Anti-Inflammatory Agents (Skin, Mucous)
alclometasone T5
amcinonide T5
ANTI-ITCH (HC) TOPICAL LOTION T5
ANUSOL-HC RECTAL CREAM WITH APPLICATOR
T1
APEXICON E T5
betamethasone dipropionate topical cream T1 QL (240 GM per 30 DYs)
betamethasone dipropionate topical lotion T1 QL (240 QY per 30 DYs)
betamethasone dipropionate topical ointment T1 QL (120 QY per 30 DYs)
betamethasone valerate topical cream T1 QL (240 QY per 30 DYs)
betamethasone valerate topical foam T5
betamethasone valerate topical lotion T1 QL (240 QY per 30 DYs)
betamethasone valerate topical ointment T1 QL (240 GM per 30 DYs)
betamethasone, augmented T1 QL (120 QY per 30 DYs)
CAPEX T5
clobetasol scalp T1 QL (100 ML per 30 days)
clobetasol topical cream T1 QL (120 GM per 30 days)
clobetasol topical foam T5
clobetasol topical gel T1 QL (120 GM per 30 days)
clobetasol topical lotion T5
clobetasol topical ointment T1 QL (120 GM per 30 days)
clobetasol topical shampoo T1 QL (118 ML per 30 days)
clobetasol topical spray,non-aerosol T5
clobetasol-emollient T5
clocortolone pivalate T5
clotrimazole-betamethasone topical cream T1 QL (180 QY per 30 DYs)
113
Drug Tier Notes
CORDRAN TAPE LARGE ROLL T5
CORDRAN TOPICAL CREAM 0.025 % T5
CORTISONE COOLING T5
desonide T5
desoximetasone topical cream 0.05 % T5
desoximetasone topical cream 0.25 % T1 QL (120 QY per 30 DYs)
desoximetasone topical gel T5
desoximetasone topical ointment T5
desoximetasone topical spray,non-aerosol T5
diflorasone T5
EUCRISA T5
fluocinolone and shower cap T1 QL (119 ML per 30 DYs)
fluocinolone topical cream 0.01 % T5
fluocinolone topical cream 0.025 % T1 QL (240 QY per 30 DYs)
fluocinolone topical oil T1 QL (119 ML per 30 DYs)
fluocinolone topical ointment T5
fluocinolone topical solution T1 QL (180 ML per 30 DYs)
fluocinonide topical cream 0.05 % T1 QL (240 GM per 30 DYs)
fluocinonide topical cream 0.1 % T5
fluocinonide topical gel T1 QL (240 QY per 30 DYs)
fluocinonide topical ointment T1 QL (240 QY per 30 DYs)
fluocinonide topical solution T1 QL (240 QY per 30 DYs)
FLUOCINONIDE-E T5
fluocinonide-emollient T5
flurandrenolide T5
fluticasone propionate topical cream T1 QL (240 QY per 30 DYs)
fluticasone propionate topical lotion T5
fluticasone propionate topical ointment T5
halobetasol propionate topical cream T1 QL (120 GM per 30 days)
halobetasol propionate topical ointment T1 QL (120 QY per 30 DYs)
HALOG TOPICAL CREAM T5
HALOG TOPICAL OINTMENT T5
hydrocortisone acetate rectal suppository 25 mg T1
hydrocortisone acetate topical cream 1 % T1 QL (240 GM per 30 DYs)
114
Drug Tier Notes
hydrocortisone butyrate T5
hydrocortisone butyr-emollient T5
hydrocortisone rectal T1
hydrocortisone topical cream T1 QL (240 QY per 30 DYs)
hydrocortisone topical cream in packet T5
hydrocortisone topical cream with perineal applicator 1 %
T5
hydrocortisone topical lotion 1 % T1 QL (240 GM per 30 DYs)
hydrocortisone topical lotion 2.5 % T1 QL (240 QY per 30 DYs)
hydrocortisone topical ointment T1 QL (240 QY per 30 DYs)
hydrocortisone valerate T5
hydrocortisone-aloe vera topical cream 1 % T1 QL (240 QY per 30 DYs)
IMPOYZ T5
MICORT-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %
T5
mometasone topical cream T1 QL (60 QY per 30 DYs)
mometasone topical ointment T1 QL (240 QY per 30 DYs)
mometasone topical solution T1 QL (240 QY per 30 DYs)
NOLIX TOPICAL LOTION T5
NUCORT T5
PANDEL T5
prednicarbate T5
PROCTOFOAM HC T2
PROCTO-PAK T5
PROCTOZONE-HC T1 QL (60 GM per 30 DYs)
PSORCON T5
SCALACORT T5
SCALP RELIEF TOPICAL SOLUTION T5
SERNIVO T5
TEXACORT T5
TOPICORT TOPICAL GEL T5
triamcinolone acetonide dental T1
triamcinolone acetonide topical aerosol T5
triamcinolone acetonide topical cream 0.025 %, 0.5 %
T1 QL (240 QY per 30 DYs)
115
Drug Tier Notes
triamcinolone acetonide topical cream 0.1 % T1 QL (454 QY per 30 DYs)
triamcinolone acetonide topical lotion T1 QL (240 QY per 30 DYs)
triamcinolone acetonide topical ointment 0.025 %, 0.5 %
T1 QL (240 QY per 30 DYs)
triamcinolone acetonide topical ointment 0.1 % T1 QL (454 GM per 30 days)
TRIANEX T5
ULTRAVATE TOPICAL LOTION T5
VERDESO T5
Anti-Inflammatory Agents, Misc (Skin)
EUCRISA T5
Antipruritics And Local Anesthetics
ANTI-ITCH (BENZ-RESOR) T1
ANTI-ITCH (DIPHENHYDRAMINE) TOPICAL GEL
T1
ANTI-ITCH (PRAMOXINE) T1
LIDOCAINE PAIN RELIEF TOPICAL ADHESIVE PATCH,MEDICATED
T1
lidocaine topical adhesive patch,medicated 5 % T1
lidocaine topical cream 4 % T1 QL (60 GM per 30 days)
lidocaine topical cream 5 % T1
lidocaine topical ointment T1 QL (60 QY per 30 DYs)
lidocaine-prilocaine topical cream T1
phenazopyridine oral tablet 100 mg, 200 mg T1
PROCTOFOAM HC T2
VAGICAINE (WITH VIT A,D) T1
Antivirals (Skin And Mucous Membrane)
ABREVA T2 QL (2 QY per 30 DYs)
acyclovir topical T3 PA
DENAVIR T3 PA
Astringents
aluminum chloride T1 QL (75 ML per 30 days)
HEMORRHOIDAL (WITCH HAZEL) T1
Azoles (Skin And Mucous Membrane)
AZOLEN TINCTURE T1
116
Drug Tier Notes
clotrimazole mucous membrane T1
clotrimazole topical cream T1 QL (180 QY per 30 DYs)
clotrimazole topical solution T1
clotrimazole vaginal cream T1
clotrimazole-betamethasone topical cream T1 QL (180 QY per 30 DYs)
econazole T1 QL (340 QY per 30 DYs)
GYNE-LOTRIMIN T1
JUBLIA T5
ketoconazole topical cream T1
ketoconazole topical shampoo T1
LOTRIMIN AF POWDER T1
LOTRIMIN AF TOPICAL POWDER T1
MICONAZOLE 7 T1
miconazole nitrate topical cream T1
MICONAZOLE-3 VAGINAL SUPPOSITORY T1
terconazole vaginal cream T1
Basic Lotions And Liniments
ammonium lactate topical lotion T1
calamine T5
calamine-zinc oxide topical lotion 8-8 % T1
LAC-HYDRIN FIVE T2
Basic Ointments And Protectants
ammonium lactate topical cream T1
Benzylamines (Skin And Mucous Membrane)
LOTRIMIN ULTRA T5
Cell Stimulants And Proliferants
ALTRENO T5
clindamycin-tretinoin T5
RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.06 %, 0.08 %
T5
tretinoin microspheres T5
tretinoin topical cream T1 QL (20 QY per 30 DYs); AL (Max 30 Years)
117
Drug Tier Notes
tretinoin topical gel 0.01 %, 0.025 % T1 QL (15 QY per 30 DYs); AL (Max 30 Years)
Corticosteroids (Skin, Mucous Membrane)
alclometasone T5
amcinonide T5
ANTI-ITCH (HC) TOPICAL LOTION T5
ANUSOL-HC RECTAL CREAM WITH APPLICATOR
T1
APEXICON E T5
betamethasone dipropionate topical cream T1 QL (240 GM per 30 DYs)
betamethasone dipropionate topical lotion T1 QL (240 QY per 30 DYs)
betamethasone dipropionate topical ointment T1 QL (120 QY per 30 DYs)
betamethasone valerate topical cream T1 QL (240 QY per 30 DYs)
betamethasone valerate topical foam T5
betamethasone valerate topical lotion T1 QL (240 QY per 30 DYs)
betamethasone valerate topical ointment T1 QL (240 GM per 30 DYs)
betamethasone, augmented T1 QL (120 QY per 30 DYs)
BRYHALI T5
CAPEX T5
clobetasol scalp T1 QL (100 ML per 30 days)
clobetasol topical cream T1 QL (120 GM per 30 days)
clobetasol topical foam T5
clobetasol topical gel T1 QL (120 GM per 30 days)
clobetasol topical lotion T5
clobetasol topical ointment T1 QL (120 GM per 30 days)
clobetasol topical shampoo T1 QL (118 ML per 30 days)
clobetasol topical spray,non-aerosol T5
clobetasol-emollient T5
clocortolone pivalate T5
clotrimazole-betamethasone topical cream T1 QL (180 QY per 30 DYs)
CORDRAN TAPE LARGE ROLL T5
CORDRAN TOPICAL CREAM 0.025 % T5
CORTISONE COOLING T5
DESONATE T5
118
Drug Tier Notes
desonide T5
desoximetasone topical cream 0.05 % T5
desoximetasone topical cream 0.25 % T1 QL (120 QY per 30 DYs)
desoximetasone topical gel T5
desoximetasone topical ointment T5
desoximetasone topical spray,non-aerosol T5
diflorasone T5
fluocinolone and shower cap T1 QL (119 ML per 30 DYs)
fluocinolone topical cream 0.01 % T5
fluocinolone topical cream 0.025 % T1 QL (240 QY per 30 DYs)
fluocinolone topical oil T1 QL (119 ML per 30 DYs)
fluocinolone topical ointment T5
fluocinolone topical solution T1 QL (180 ML per 30 DYs)
fluocinonide topical cream 0.05 % T1 QL (240 GM per 30 DYs)
fluocinonide topical cream 0.1 % T5
fluocinonide topical gel T1 QL (240 QY per 30 DYs)
fluocinonide topical ointment T1 QL (240 QY per 30 DYs)
fluocinonide topical solution T1 QL (240 QY per 30 DYs)
FLUOCINONIDE-E T5
fluocinonide-emollient T5
flurandrenolide T5
fluticasone propionate topical cream T1 QL (240 QY per 30 DYs)
fluticasone propionate topical lotion T5
fluticasone propionate topical ointment T5
halobetasol propionate topical cream T1 QL (120 GM per 30 days)
halobetasol propionate topical foam T5
halobetasol propionate topical ointment T1 QL (120 QY per 30 DYs)
HALOG TOPICAL CREAM T5
HALOG TOPICAL OINTMENT T5
hydrocortisone acetate rectal suppository 25 mg T1
hydrocortisone acetate topical cream 1 % T1 QL (240 GM per 30 DYs)
hydrocortisone butyrate T5
hydrocortisone butyr-emollient T5
hydrocortisone rectal T1
119
Drug Tier Notes
hydrocortisone topical cream T1 QL (240 QY per 30 DYs)
hydrocortisone topical cream in packet T5
hydrocortisone topical cream with perineal applicator 1 %
T5
hydrocortisone topical lotion 1 % T1 QL (240 GM per 30 DYs)
hydrocortisone topical lotion 2.5 % T1 QL (240 QY per 30 DYs)
hydrocortisone topical ointment T1 QL (240 QY per 30 DYs)
hydrocortisone valerate T5
hydrocortisone-aloe vera topical cream 1 % T1 QL (240 QY per 30 DYs)
IMPOYZ T5
LEXETTE T5
MICORT-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %
T5
mometasone topical cream T1 QL (60 QY per 30 DYs)
mometasone topical ointment T1 QL (240 QY per 30 DYs)
mometasone topical solution T1 QL (240 QY per 30 DYs)
NOLIX TOPICAL LOTION T5
NUCORT T5
PANDEL T5
prednicarbate T5
PROCTOFOAM HC T2
PROCTO-PAK T5
PROCTOZONE-HC T1 QL (60 GM per 30 DYs)
PSORCON T5
SCALACORT T5
SCALP RELIEF TOPICAL SOLUTION T5
SERNIVO T5
TEXACORT T5
TOPICORT TOPICAL GEL T5
triamcinolone acetonide dental T1
triamcinolone acetonide topical aerosol T5
triamcinolone acetonide topical cream 0.025 %, 0.5 %
T1 QL (240 QY per 30 DYs)
triamcinolone acetonide topical cream 0.1 % T1 QL (454 QY per 30 DYs)
triamcinolone acetonide topical lotion T1 QL (240 QY per 30 DYs)
120
Drug Tier Notes
triamcinolone acetonide topical ointment 0.025 %, 0.5 %
T1 QL (240 QY per 30 DYs)
triamcinolone acetonide topical ointment 0.1 % T1 QL (454 GM per 30 days)
TRIANEX T5
ULTRAVATE TOPICAL LOTION T5
VERDESO T5
Detergents
PERIFRESH T2
Hydroxypyridones (Skin, Mucous Membrane)
ciclopirox topical cream T1 QL (90 QY per 30 DYs)
ciclopirox topical solution T1 QL (6.6 ML per 30 days)
Keratolytic Agents
ACNE MEDICATION TOPICAL LOTION 10 % T1
ACNE MEDICATION TOPICAL LOTION 5 % T2
benzoyl peroxide topical cleanser 10 %, 4 %, 6 % T1
benzoyl peroxide topical gel 10 %, 2.5 % T1 QL (60 QY per 30 DYs)
benzoyl peroxide topical gel 5 % T1
BP WASH TOPICAL CLEANSER 5 % T1
clindamycin-benzoyl peroxide T5
LIQUID CORN AND CALLUS REMOVER TOPICAL LIQUID 17 %
T1 QL (15 ML per 30 days)
NEUAC T5
NEUAC KIT T5
ONEXTON TOPICAL GEL WITH PUMP T5
SELSUN BLUE (SALICYLIC ACID) T1
sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w)
T1 QL (170 GM per 30 days)
urea topical cream 20 % T1 QL (85 QY per 30 DYs)
urea topical cream 40 % T1 QL (198.4 GM per 30 days)
Keratoplastic Agents
coal tar (bulk) T1
Local Anti-Infectives, Miscellaneous
ALCOHOL PREP PADS T2
ANTI-DANDRUFF T1
121
Drug Tier Notes
ANTI-DANDRUFF WITH MENTHOL T1
ANTISEPTIC WOUND-SKIN T1
DANDRUFF SHAMPOO (SELEN-ALOE) T1
selenium sulfide topical lotion T1
silver sulfadiazine T1
sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w)
T1 QL (170 GM per 30 days)
ULESFIA T5
Nonsteroidal Anti-Inflammat.Agents(Skin)
DICLO GEL T5
diclofenac sodium topical drops T5
diclofenac sodium topical gel 1 % T1 QL (300 GM per 30 days)
diclofenac sodium topical gel 3 % T5
FLECTOR T5
PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP
T5
Oxaboroles
KERYDIN T5
Pigmenting Agents
methoxsalen T1 QL (12 EA per 28 days)
Polyenes (Skin And Mucous Membrane)
nystatin topical cream T1 QL (120 QY per 30 DYs)
nystatin topical ointment T1 QL (120 QY per 30 DYs)
nystatin topical powder T1 QL (1280 QY per 30 DYs)
nystatin-triamcinolone T1 QL (480 QY per 30 DYs)
Scabicides And Pediculicides
CROTAN T5
EURAX T5
LICE KILLING T1
LICE KILLING (PERMETHRIN) T1
malathion T3 PA
permethrin topical cream T1
SKLICE T5
spinosad T3 PA
122
Drug Tier Notes
ULESFIA T5
Skin And Mucous Membrane Agents, Misc.
ABSORICA T5
ABSORICA LD T5
acitretin T3 PA
adapalene topical cream T3 ST; QL (45 GM per 30 days); AL (Max 30 Years)
adapalene topical gel 0.3 % T3 ST; QL (45 GM per 30 days); AL (Max 30 Years)
adapalene topical gel with pump T3 ST; QL (45 GM per 30 days); AL (Max 30 Years)
adapalene topical lotion T5
adapalene topical solution T5
adapalene topical swab T5
adapalene-benzoyl peroxide T5
ARTHRITIS PAIN RELIEF(CAPSAIC) TOPICAL CREAM 0.075 %
T1
AVAGE T5
azelaic acid T3 PA
AZELEX T3 PA
calcipotriene scalp T1 QL (60 ML per 30 days)
calcipotriene topical cream T1 QL (60 QY per 30 DYs)
calcipotriene topical ointment T1 QL (60 QY per 30 DYs)
capsaicin topical cream 0.025 % T1
COSENTYX T4 PA
COSENTYX (2 SYRINGES) T4 PA
COSENTYX PEN T4 PA
COSENTYX PEN (2 PENS) T4 PA
DICLO GEL T5
diclofenac sodium topical drops T5
diclofenac sodium topical gel 1 % T1 QL (300 GM per 30 days)
diclofenac sodium topical gel 3 % T5
DIFFERIN TOPICAL GEL 0.1 % T2 QL (45 GM per 30 days); AL (Max 30 Years)
DUPIXENT PEN T4 PA
123
Drug Tier Notes
DUPIXENT SYRINGE T4 PA
ENBREL T4 PA
ENBREL MINI T4 PA
ENBREL SURECLICK T4 PA
EPIDUO FORTE T5
FABIOR T5
FINACEA TOPICAL FOAM T3 PA
FLECTOR T5
fluorouracil topical cream 5 % T1 QL (1 FL per 365 DYs)
fluorouracil topical solution T5
HIGH POTENCY CAPSAICIN T1 QL (42.5 QY per 30 DYs)
HUMIRA PEN T4 PA
HUMIRA PEN PSOR-UVEITS-ADOL HS T4 PA
HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML, 40 MG/0.8 ML
T4 PA
HUMIRA(CF) T4 PA
HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML
T4 PA
HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML
T4 PA
ILUMYA T5
imiquimod topical cream in packet T1 AL (Min 12 Years)
isotretinoin T3 PA
K-Y LUBRICATING T1
ORAL RELIEF DRY MOUTH T2
OTEZLA T4 PA
OTEZLA STARTER T4 PA
PANRETIN T5
PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP
T5
pimecrolimus T5
podofilox T1
PROSHIELD FOAM/SPRAY CLEANSER T2
RECTIV T3 PA
124
Drug Tier Notes
SANTYL T2 QL (30 GM per 30 days)
SILIQ T5
SKYRIZI SUBCUTANEOUS SYRINGE KIT T5
STELARA SUBCUTANEOUS T4 PA
tacrolimus topical ointment 0.03 % T3 ST; QL (30 GM per 30 days)
tacrolimus topical ointment 0.1 % T3 ST; QL (30 GM per 30 days); AL (Min 2 Years)
TALTZ AUTOINJECTOR T4 PA
TALTZ AUTOINJECTOR (2 PACK) T4 PA
TALTZ AUTOINJECTOR (3 PACK) T4 PA
TALTZ SYRINGE T4 PA
tazarotene T5
TAZORAC TOPICAL CREAM 0.05 % T5
TAZORAC TOPICAL GEL T5
TREMFYA T5
VALCHLOR T5
XYLIMELTS T5
Thiocarbamates(Skin And Mucous Membrane)
LAMISIL AF TOPICAL POWDER T1
tolnaftate topical cream T1 QL (120 QY per 30 DYs)
Smooth Muscle Relaxants
Antimuscarinics
darifenacin T5
flavoxate T5
GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 100 MG/GRAM (10 %)
T5
GELNIQUE TRANSDERMAL GEL IN PACKET T5
oxybutynin chloride T1
OXYTROL T5
OXYTROL FOR WOMEN T3 ST; QL (8 EA per 28 days)
solifenacin T3 ST; QL (90 EA per 90 days)
tolterodine oral capsule,extended release 24hr T3 ST; QL (30 EA per 30 days)
tolterodine oral tablet T3 ST; QL (60 EA per 30 days)
125
Drug Tier Notes
TOVIAZ T5
trospium oral capsule,extended release 24hr T3 ST; QL (30 EA per 30 days)
trospium oral tablet T3 ST; QL (60 EA per 30 days)
Respiratory Smooth Muscle Relaxants
theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg
T1
theophylline oral tablet extended release 24 hr T1
Selective Beta-3-Adrenergic Agonists
MYRBETRIQ T5
Vitamins
Multivitamin Preparations
ATABEX EC T2 QL (30 QY per 30 DYs)
BIOTECT PLUS T1
CENTRAL-VITE SELECT T1
CENTRUM COMPLETE T1
CENTRUM SILVER ORAL TABLET T1
CHEWABLE-VITE T2
CHILDREN'S CHEWABLE VITAMIN T1 AL (Max 12 Years)
CHILD'S CHEWABLE VITAMINS/IRON ORAL TABLET,CHEWABLE
T1 AL (Max 12 Years)
CLASSIC PRENATAL T2
COMPLETENATE T1 QL (30 QY per 30 DYs)
DAILY MULTI-VITAMIN T1
ELITE-OB 400 T1 QL (30 QY per 30 DYs)
FLINTSTONES COMPLETE (IRON) ORAL TABLET,CHEWABLE 18 MG IRON
T2 AL (Max 12 Years)
FOLIVANE-OB T1 QL (30 QY per 30 DYs)
KPN ORAL TABLET 9 MG IRON- 267 MCG T2 QL (30 QY per 30 DYs)
MULTI-DELYN T1
MULTIVITAMIN WITH FLUORIDE T1 AL (Max 12 Years)
MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 1 MG
T1 AL (Max 12 Years)
mv-min-folic acid-lutein T1
NATACHEW (FE BIS-GLYCINATE) T2 QL (30 QY per 30 DYs)
NEWGEN T1 QL (30 EA per 30 days)
126
Drug Tier Notes
OB COMPLETE PREMIER T2 QL (30 QY per 30 DYs)
O-CAL FA T2 QL (30 QY per 30 DYs)
OCUVITE WITH LUTEIN T1
ONE DAILY FOR MEN 50+ ADVANCED T1
ONE DAILY MULTI-VIT W-MINERAL ORAL TABLET
T1
POLYVITAMIN WITH IRON T1 AL (Max 12 Years)
PRENATA T2 QL (30 QY per 30 DYs)
PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 0.8 MG
T1
PRETAB T1 QL (30 EA per 30 days)
PUREFE OB PLUS T2 QL (30 QY per 30 DYs)
SELECT-OB (FOLIC ACID) T2 QL (30 QY per 30 DYs)
STROVITE FORTE T2
THERA ORAL TABLET T1
THERA-M ORAL TABLET , 9 MG IRON-400 MCG
T1
THERATRUM COMPLETE 50 PLUS/LUT T1
THEREMS-M T2
TRIADVANCE T1
TRIVEEN-ONE T1 QL (30 QY per 30 DYs)
TRIVEEN-PRX RNF T1 QL (30 QY per 30 DYs)
TRI-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC 0.25 MG/ML FLUORIDE
T5
TRI-VI-SOL WITH IRON T2 AL (Max 12 Years)
TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML
T1 AL (Max 12 Years)
ULTIMATECARE ONE NF T1 QL (30 QY per 30 DYs)
VIC-FORTE T1
VINACAL B T1
VINATE II T1
VINATE M T1 QL (30 QY per 30 DYs)
VINATE ONE T1 QL (30 QY per 30 DYs)
VINATE PN CARE T1 QL (30 QY per 30 DYs)
VINATE ULTRA T1 QL (30 EA per 30 days)
127
Drug Tier Notes
VIRT-SELECT T1 QL (30 QY per 30 DYs)
VITAFOL GUMMIES T2
VITAMED MD ONE RX T2 QL (30 EA per 30 days)
VOL-NATE T1 QL (30 EA per 30 days)
VP-CH PLUS T1 QL (30 EA per 30 days)
ZATEAN-CH T1
ZINGIBER T1 QL (60 QY per 30 DYs)
Vitamin A
TRI-VI-SOL WITH IRON T2 AL (Max 12 Years)
TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML
T1 AL (Max 12 Years)
vitamin a oral capsule 10,000 unit T1
Vitamin B Complex
ATABEX EC T2 QL (30 QY per 30 DYs)
b-complex with vitamin c oral tablet T1
biotin oral capsule 5 mg T1
BONJESTA T5
CENTRUM COMPLETE T1
CENTRUM SILVER ORAL TABLET T1
CLASSIC PRENATAL T2
cyanocobalamin (vitamin b-12) injection T1 QL (1 QY per 30 DYs)
cyanocobalamin (vitamin b-12) oral tablet 500 mcg
T1
cyanocobalamin (vitamin b-12) oral tablet extended release 1,000 mcg
T1
DIALYVITE 800 ORAL TABLET T1
DIALYVITE 800-ULTRA D T2
DIALYVITE ORAL TABLET 100-1 MG T2
DICLEGIS T5
ELITE-OB 400 T1 QL (30 QY per 30 DYs)
folic acid oral tablet T1
FOLIVANE-OB T1 QL (30 QY per 30 DYs)
KPN ORAL TABLET 9 MG IRON- 267 MCG T2 QL (30 QY per 30 DYs)
levomefolate calcium T1 QL (30 EA per 30 days)
mv-min-folic acid-lutein T1
128
Drug Tier Notes
MYNEPHROCAPS T1
NATACHEW (FE BIS-GLYCINATE) T2 QL (30 QY per 30 DYs)
NEWGEN T1 QL (30 EA per 30 days)
OB COMPLETE PREMIER T2 QL (30 QY per 30 DYs)
O-CAL FA T2 QL (30 QY per 30 DYs)
ONE DAILY FOR MEN 50+ ADVANCED T1
PRENATA T2 QL (30 QY per 30 DYs)
PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 0.8 MG
T1
PRETAB T1 QL (30 EA per 30 days)
PUREFE OB PLUS T2 QL (30 QY per 30 DYs)
pyridoxine (vitamin b6) injection T5
pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg, 50 mg
T1
RENA-VITE RX T1
SELECT-OB (FOLIC ACID) T2 QL (30 QY per 30 DYs)
STROVITE FORTE T2
THERA-M ORAL TABLET 9 MG IRON-400 MCG
T1
thiamine hcl (vitamin b1) oral tablet 50 mg T1
thiamine mononitrate (vit b1) T1
TRIADVANCE T1
TRIVEEN-ONE T1 QL (30 QY per 30 DYs)
TRIVEEN-PRX RNF T1 QL (30 QY per 30 DYs)
ULTIMATECARE ONE NF T1 QL (30 QY per 30 DYs)
VIC-FORTE T1
VINACAL B T1
VINATE M T1 QL (30 QY per 30 DYs)
VINATE ONE T1 QL (30 QY per 30 DYs)
VINATE ULTRA T1 QL (30 EA per 30 days)
VIRT-SELECT T1 QL (30 QY per 30 DYs)
VITAFOL GUMMIES T2
VITAMED MD ONE RX T2 QL (30 EA per 30 days)
VITAMIN B-1 ORAL TABLET 100 MG T1
VITAMIN B-12 ORAL TABLET 1,000 MCG T1
129
Drug Tier Notes
VITAMIN B-12 ORAL TABLET 100 MCG T1 QL (100 QY per 30 DYs)
VOL-NATE T1 QL (30 EA per 30 days)
VP-CH PLUS T1 QL (30 EA per 30 days)
ZATEAN-CH T1
ZINGIBER T1 QL (60 QY per 30 DYs)
Vitamin C
ascorbic acid (vitamin c) oral tablet 250 mg, 500 mg
T1
b-complex with vitamin c oral tablet T1
DIALYVITE 800 ORAL TABLET T1
DIALYVITE 800-ULTRA D T2
DIALYVITE ORAL TABLET 100-1 MG T2
MYNEPHROCAPS T1
TRI-VI-SOL WITH IRON T2 AL (Max 12 Years)
TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML
T1 AL (Max 12 Years)
VITAMIN C ORAL TABLET 1,000 MG T1
VITAMIN C ORAL TABLET,CHEWABLE 500 MG
T1
Vitamin D
calcitriol oral capsule T1
calcitriol oral solution T1 AL (Max 12 Years)
CALCIUM 500 WITH D T1
CALCIUM 600 + D(3) ORAL TABLET 600 MG(1,500MG) -400 UNIT
T1
calcium carbonate-vitamin d3 oral tablet 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -200 unit
T1
calcium citrate-vitamin d3 oral tablet 200-125 mg-unit
T1
cholecalciferol (vitamin d3) oral capsule 1,250 mcg (50,000 unit), 125 mcg (5,000 unit)
T1
cholecalciferol (vitamin d3) oral drops 10 mcg/ml (400 unit/ml)
T1
cholecalciferol (vitamin d3) oral tablet 125 mcg (5,000 unit), 25 mcg (1,000 unit), 50 mcg (2,000 unit)
T1
DIALYVITE 800-ULTRA D T2
130
Drug Tier Notes
ergocalciferol (vitamin d2) oral drops T1 AL (Max 12 Years)
FOSAMAX PLUS D T5
OS-CAL 500 + D3 ORAL TABLET 500 MG(1,250MG) -200 UNIT
T1
OYSTER SHELL + D3 T1
RISACAL-D T1
TRI-VI-SOL WITH IRON T2 AL (Max 12 Years)
TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML
T1 AL (Max 12 Years)
VITAMIN D2 T1
VITAMIN D3 ORAL CAPSULE 10 MCG (400 UNIT), 25 MCG (1,000 UNIT), 50 MCG (2,000 UNIT)
T1
VITAMIN D3 ORAL TABLET 10 MCG (400 UNIT), 25 MCG (1,000 UNIT)
T1
VITAMIN D3 ORAL TABLET,CHEWABLE 10 MCG (400 UNIT)
T1
Vitamin E
vitamin e (dl, acetate) oral capsule 100 unit, 400 unit
T1
vitamin e (dl, acetate) oral drops 100 unit/0.25 ml T1
Vitamin K Activity
phytonadione (vitamin k1) oral tablet 5 mg T1
VITAMIN K1 INJECTION T5
131
Index
A abacavir .................................. 9 abacavir-lamivudine-
zidovudine .......................... 9 ABILIFY MAINTENA .. 48, 51 abiraterone ............................ 13 ABREVA ........................... 115 ABSORICA ........................ 121 ABSORICA LD ................. 121 acamprosate .......................... 54 acarbose ................................ 84 ACCU-CHEK AVIVA
CONTROL SOLN............ 63 ACCU-CHEK AVIVA PLUS
TEST STRP ...................... 64 ACCU-CHEK FASTCLIX
LANCET DRUM ............. 63 ACCU-CHEK FASTCLIX
LANCING DEV ............... 63 ACCU-CHEK GUIDE
GLUCOSE METER ......... 63 ACCU-CHEK GUIDE L1-L2
CTRL SOL ....................... 63 ACCU-CHEK GUIDE ME
GLUCOSE MTR .............. 63 ACCU-CHEK GUIDE TEST
STRIPS ............................. 64 ACCU-CHEK SMARTVIEW
CONTRL SOL ................. 63 ACCU-CHEK SMARTVIEW
TEST STRIP .................... 64 ACCU-CHEK SOFT DEV
LANCETS ........................ 63 ACCU-CHEK SOFTCLIX
LANCET DEV ................. 63 ACCU-CHEK SOFTCLIX
LANCETS ........................ 63 acetaminophen ...................... 46 acetaminophen-codeine .. 46, 56 acetazolamide ........... 38, 67, 74 acetic acid ....................... 67, 74 acetylcysteine ....... 95, 102, 107 ACIPHEX SPRINKLE ........ 81 acitretin ............................... 121 ACNE MEDICATION ....... 119 ACTEMRA .................... 98, 99 ACTEMRA ACTPEN .... 98, 99 ACTHAR H.P. ............... 64, 92 ACTHIB (PF) ....................... 21
ACTHREL...................... 64, 65 ACUVAIL (PF) .................... 75 acyclovir ....................... 11, 115 ADACEL(TDAP
ADOLESN/ADULT)(PF) 20 adapalene ............................ 121 adapalene-benzoyl peroxide
........................................ 121 adefovir ................................. 11 ADEMPAS ................... 44, 110 ADHANSIA XR................... 59 ADMELOG SOLOSTAR U-
100 INSULIN ............. 90, 93 ADMELOG U-100 INSULIN
LISPRO ...................... 90, 93 ADRENACLICK ......... 22, 104 ADRENALIN ............... 22, 104 ADRIAMYCIN .................... 13 ADULT TUSSIN COUGH
CONGEST DM .............. 105 ADVAIR HFA 26, 82, 107, 109 ADVATE.............................. 29 ADYNOVATE ..................... 29 ADZENYS XR-ODT ........... 45 AEROCHAMBER PLUS
FLOW-VU,S MSK ........... 63 AEROECLIPSE II
NEBULIZER .................... 63 AFINITOR ........................... 14 AFINITOR DISPERZ .......... 14 AFLURIA QD 2020-21(3YR
UP)(PF) ............................ 21 AFLURIA QD 2020-21(6-
35MO)(PF) ....................... 21 AFLURIA QUAD 2020-
2021(6MO UP) ................. 21 AIMOVIG AUTOINJECTOR
.................................... 49, 54 AIMOVIG AUTOINJECTOR
(2 PACK) .................... 49, 54 AJOVY AUTOINJECTOR .. 54 AJOVY SYRINGE......... 49, 54 AKTIPAK .......................... 110 AKYNZEO (NETUPITANT)
.................................... 76, 81 albendazole ............................. 4 albumin, human 25 % ........... 27 albuterol sulfate ............ 26, 109 alclometasone ............. 111, 116
ALCOHOL PREP PADS ... 120 ALECENSA ......................... 14 alendronate ........................... 97 alfuzosin ............................... 26 ALIMTA ............................... 14 ALINIA .................................. 5 aliskiren ................................ 43 ALKERAN ........................... 14 ALLERGY
(DIPHENHYDRAMINE) . 1, 106
ALLERGY RELIEF (LORATADINE) ........ 2, 108
ALLI ..................................... 80 allopurinol ............................. 96 almotriptan malate ................ 61 alogliptin ............................... 87 alogliptin-metformin ....... 85, 87 alogliptin-pioglitazone .... 87, 95 alosetron ............................... 78 ALOXI .................................. 76 ALPHAGAN P ..................... 72 ALPHANATE ...................... 29 ALPHANINE SD ................. 29 ALPROLIX .......................... 29 ALTAFLUOR ................ 65, 75 ALTRENO ......................... 116 aluminum chloride .............. 115 alum-mag hydroxide-simeth 77,
78 ALUNBRIG ......................... 14 amantadine hcl .................. 3, 45 ambrisentan ................... 44, 110 amcinonide ................. 111, 116 AMETHIA ............................ 86 amiloride ......................... 43, 68 AMINOSYN 10 % ............... 65 AMINOSYN 8.5 % .............. 65 AMINOSYN 8.5 %-
ELECTROLYTES ............ 65 AMINOSYN II 10 % ............ 65 AMINOSYN II 15 % ............ 65 AMINOSYN II 8.5 % ........... 65 AMINOSYN II 8.5 %-
ELECTROLYTES ............ 65 AMINOSYN M 3.5 % .......... 65 AMINOSYN-HBC 7% ......... 65 AMINOSYN-PF 10 % ......... 65
132
AMINOSYN-PF 7 % (SULFITE-FREE) ............ 65
AMINOSYN-RF 5.2 % ........ 65 amiodarone ........................... 40 AMITIZA ............................. 78 amitriptyline ......................... 63 amlodipine .......... 37, 40, 41, 44 amlodipine-benazepril ... 34, 37,
40, 41, 44 amlodipine-valsartan33, 34, 37,
40, 41, 44 ammonium lactate .............. 116 amoxicillin .............................. 4 amoxicillin-pot clavulanate .... 4 amphetamine ........................ 45 amphetamine sulfate ............. 45 amphotericin b ...................... 12 ampicillin ................................ 4 AMYVID ........................... 103 anagrelide ............................. 33 anastrozole ...................... 14, 85 ANDRODERM .................... 84 ANDROGEL ........................ 84 ANNOVERA ....................... 86 ANORO ELLIPTA 23, 26, 104,
109 ANTACID (CALCIUM
CARBONATE) .......... 69, 77 ANTARA ............................. 41 ANTI-DANDRUFF ........... 120 ANTI-DANDRUFF WITH
MENTHOL .................... 120 ANTI-DIARRHEAL
(LOPERAMIDE) ............. 77 ANTI-ITCH (BENZ-RESOR)
........................................ 114 ANTI-ITCH
(DIPHENHYDRAMINE) ........................................ 114
ANTI-ITCH (HC) ...... 111, 116 ANTI-ITCH (PRAMOXINE)
........................................ 114 ANTISEPTIC WOUND-SKIN
........................................ 120 ANUSOL-HC ............. 111, 116 APEXICON E ............ 111, 116 aprepitant .............................. 81 APRODINE ...... 2, 22, 104, 106 APTENSIO XR .................... 59 APTIOM............................... 47 APTIVUS ............................. 10
APTIVUS (WITH VITAMIN E) ...................................... 10
ARANESP (IN POLYSORBATE) ............ 28
ARCAPTA NEOHALER .... 26, 109
aripiprazole ..................... 48, 51 ARISTADA .................... 49, 51 ARISTADA INITIO....... 48, 51 armodafinil ........................... 63 ARMOUR THYROID ......... 95 ARNUITY ELLIPTA ... 82, 107 ARRANON .......................... 14 ARTHRITIS PAIN
RELIEF(CAPSAIC) ....... 121 ARTIFICIAL TEARS
(PETRO/MIN) .................. 75 ARTIFICIAL TEARS (PF) .. 75 ARTIFICIAL TEARS
(POLYVIN ALC) ............. 75 ARTIFICIAL
TEARS(DEXT70-HYPRO) .......................................... 75
ARYMO ER ......................... 56 ARZERRA ........................... 14 ascorbic acid (vitamin c) .... 128 ASMANEX HFA ......... 82, 107 ASMANEX TWISTHALER
.................................. 82, 107 aspirin ................. 32, 33, 50, 60 aspirin-dipyridamole 32, 44, 60 ATABEX EC ... 31, 69, 78, 124,
126 atazanavir.............................. 10 atenolol ............... 27, 35, 36, 39 atenolol-chlorthalidone .. 27, 35,
36, 39, 44, 72 atomoxetine .......................... 54 atorvastatin ........................... 41 atovaquone.............................. 5 atovaquone-proguanil ............. 4 ATRIPLA ........................... 8, 9 atropine ................................. 76 ATROVENT HFA ....... 23, 104 AUBAGIO............................ 99 AUGMENTIN ........................ 4 AURYXIA............................ 68 AUSTEDO ..................... 54, 63 AUVI-Q ........................ 23, 104 AVAGE .............................. 121 AVASTIN ............................ 14
AVONEX ........................... 100 AVONEX (WITH ALBUMIN)
.......................................... 99 AYVAKIT ............................ 14 azathioprine .......... 98, 100, 101 azelaic acid ......................... 122 azelastine .............................. 72 AZELEX ............................. 122 azithromycin ......................... 12 AZOLEN TINCTURE ....... 115 B BABY AYR SALINE .......... 75 bacitracin .................. 6, 72, 111 bacitracin zinc ..................... 111 bacitracin-polymyxin b . 72, 111 baclofen ................................ 24 BALCOLTRA ...................... 86 balsalazide ............................ 78 BALVERSA ......................... 14 BANZEL .............................. 47 BAQSIMI ....................... 88, 95 BARACLUDE ...................... 11 BASAGLAR KWIKPEN U-
100 INSULIN ............. 90, 91 BAXDELA ........................... 12 b-complex with vitamin c .. 126,
128 BEBULIN ............................. 29 BELSOMRA ........................ 50 BELVIQ XR ......................... 62 benazepril ............................. 34 benazepril-hydrochlorothiazide
........................ 34, 35, 43, 71 BENDEKA ........................... 14 BENEFIX ............................. 29 benzonatate ......................... 105 benzoyl peroxide ........ 119, 120 benzphetamine ...................... 45 benztropine ..................... 24, 47 BEPREVE ............................ 72 betamethasone dipropionate
........................ 111, 112, 116 betamethasone valerate ...... 112,
116 betamethasone, augmented 112,
116 BETASERON ..................... 100 betaxolol ............................... 73 bethanechol chloride ............. 25 BETHKIS ............................... 4
133
BEVESPI AEROSPHERE .. 23, 26, 109
bexarotene ............................ 14 BEXSERO ............................ 21 bicalutamide ......................... 14 BICNU ................................. 14 BIDIL ............................. 40, 42 bimatoprost ........................... 76 BINOSTO............................. 97 BIONECT............................. 63 BIOTECT PLUS .......... 31, 124 BIOTENE DRY MOUTH
ORAL RINSE .................. 64 biotin................................... 126 bisacodyl............................... 78 bisoprolol fumarate . 27, 35, 36,
39 bisoprolol-hydrochlorothiazide
............ 27, 35, 36, 39, 43, 71 BLEPHAMIDE .................... 73 BLEPHAMIDE S.O.P. ......... 73 BLOOD PRESSURE KIT .... 64 blood pressure kit med and lrg
.......................................... 64 blood pressure monitor ......... 64 BONJESTA .... 77, 78, 106, 126 BOOST CALORIE SMART 65 BOOSTRIX TDAP .............. 20 bosentan ........................ 44, 110 BOSULIF ............................. 14 BP WASH .......................... 120 BRAFTOVI .......................... 14 BREO ELLIPTA ... 26, 83, 107,
109 BREVITAL .................... 52, 53 BRILINTA ........................... 32 brimonidine .......................... 72 bromfenac ............................. 75 bromocriptine ....................... 55 BROMSITE .......................... 75 BROVANA .................. 26, 109 BRUKINSA ......................... 14 BRYHALI .......................... 117 budesonide .............. 74, 83, 107 budesonide-formoterol .. 26, 83,
107, 109 BUFFERED ASPIRIN .. 32, 33,
50, 61 BUFFERIN......... 32, 33, 50, 61 bumetanide ..................... 42, 67 BUNAVAIL ......................... 58
buprenorphine hcl ................. 58 buprenorphine-naloxone ....... 58 bupropion hcl ........................ 48 bupropion hcl (smoking deter)
.......................................... 48 buspirone .............................. 50 BUSULFEX ......................... 14 butalbital-acetaminophen-caff
........................ 46, 50, 52, 59 butalbital-aspirin-caffeine ... 32,
33, 50, 52, 59, 61 BUTRANS ........................... 58 BYDUREON ........................ 90 BYDUREON BCISE ........... 90 BYETTA .............................. 90 C cabergoline ........................... 55 CABOMETYX ..................... 14 CAFERGOT ................... 25, 50 calamine.............................. 116 calamine-zinc oxide ............ 116 calcipotriene ....................... 122 calcitonin (salmon) ... 85, 92, 97 calcitriol .............................. 129 CALCIUM 500 WITH D .... 69,
129 CALCIUM 600 + D(3) . 69, 129 calcium acetate(phosphat bind)
.......................................... 68 CALCIUM ANTACID... 69, 77 calcium carbonate ........... 69, 77 calcium carbonate-vitamin d3
.................................. 69, 129 calcium citrate-vitamin d3 ... 69,
129 calcium gluconate ................. 69 CALQUENCE ...................... 14 CAMPTOSAR...................... 14 CAMRESE LO ..................... 86 capecitabine .......................... 14 CAPEX ....................... 112, 117 CAPLYTA............................ 51 CAPRELSA.......................... 14 capsaicin ............................. 122 captopril .......................... 34, 35 carbamazepine ................ 47, 49 carbidopa .............................. 54 carbidopa-levodopa .............. 55 carbidopa-levodopa-
entacapone .................. 54, 55 carboplatin ............................ 14
carvedilol 25, 26, 33, 35, 39, 41 carvedilol phosphate 25, 26, 33,
35, 39, 41 caspofungin ............................. 6 CAYSTON ........................... 11 cefaclor ................................... 3 cefadroxil ................................ 3 cefdinir .................................... 3 cefepime ................................. 3 cefixime .................................. 3 cefpodoxime ........................... 3 cefprozil .................................. 3 CEFTIN .................................. 3 cefuroxime axetil .................... 3 celecoxib ............................... 55 CELLCEPT ........................ 101 CENTRAL-VITE SELECT 124 CENTRUM COMPLETE ... 31,
124, 127 CENTRUM SILVER .. 124, 127 cephalexin ............................... 3 CEPROTIN (BLUE BAR) ... 27 CEQUA ................................ 75 CERDELGA ....................... 102 cetirizine ......................... 2, 108 CHANTIX ............................ 24 CHANTIX STARTING
MONTH BOX .................. 24 CHATEAL (28) .................... 86 CHEMET ........................ 82, 95 CHEWABLE-VITE ........... 125 CHILDREN'S ALLEGRA
ALLERGY ................. 2, 108 CHILDREN'S BENADRYL
ALLERGY ................. 1, 106 CHILDREN'S CHEWABLE
VITAMIN ....................... 125 CHILDREN'S PAIN RELIEF
.......................................... 46 CHILDREN'S SILFEDRINE
.................................. 23, 104 CHILD'S CHEWABLE
VITAMINS/IRON .......... 125 chloramphenicol sod succinate
............................................ 6 chlordiazepoxide hcl ............. 53 chlorhexidine gluconate ........ 74 chloroquine phosphate ............ 5 chlorothiazide ................. 43, 71 chlorpheniramine maleate . 1, 2,
106
134
chlorpromazine ..................... 59 chlorpropamide..................... 94 chlorthalidone ................. 44, 72 cholecalciferol (vitamin d3) 129 cholestyramine (with sugar) . 36 CHOLESTYRAMINE LIGHT
.......................................... 36 choline,magnesium salicylate
.......................................... 61 ciclopirox ............................ 119 cidofovir ............................... 11 cilostazol......................... 33, 42 cimetidine ............................. 81 CIMZIA .................. 80, 98, 100 CIMZIA POWDER FOR
RECONST .......... 80, 98, 100 cinacalcet ...................... 85, 102 CINQAIR ........................... 106 CIPRO HC...................... 73, 74 CIPRODEX .................... 73, 74 ciprofloxacin..................... 5, 12 ciprofloxacin (mixture) .... 5, 12 ciprofloxacin hcl ......... 5, 12, 73 cisplatin ................................ 14 citalopram ............................. 62 cladribine .............................. 14 clarithromycin .................. 5, 12 CLASSIC PRENATAL ...... 31,
125, 127 CLEOCIN............................. 10 CLIMARA PRO ................... 88 clindamycin hcl .................... 10 clindamycin palmitate hcl .... 10 clindamycin phosphate . 10, 111 clindamycin-benzoyl peroxide
................................ 111, 120 clindamycin-tretinoin . 111, 116 CLINIMIX 5%/D15W
SULFITE FREE ............... 65 CLINIMIX 5%/D25W
SULFITE-FREE ............... 66 CLINIMIX 2.75%/D5W
SULFIT FREE.................. 66 CLINIMIX 4.25%/D5W
SULFIT FREE.................. 66 CLINIMIX 4.25%-D20W
SULF-FREE ..................... 66 CLINIMIX 4.25%-D25W
SULF-FREE ..................... 66 CLINIMIX 5%-
D20W(SULFITE-FREE) . 66
CLINIMIX E 2.75%/D5W SULF FREE ..................... 66
CLINIMIX E 4.25%/D10W SUL FREE ........................ 66
CLINIMIX E 4.25%/D25W SUL FREE ........................ 66
CLINIMIX E 4.25%/D5W SULF FREE ..................... 66
CLINIMIX E 5%/D15W SULFIT FREE .................. 66
CLINIMIX E 5%/D20W SULFIT FREE .................. 66
CLINIMIX E 5%/D25W SULFIT FREE .................. 66
CLINISOL SF 15 % ............. 66 clobazam ............................... 53 clobetasol .................... 112, 117 clobetasol-emollient ... 112, 117 clocortolone pivalate .. 112, 117 clonazepam ........................... 53 clonidine ......................... 23, 38 clonidine hcl ................... 23, 38 clopidogrel ............................ 33 clotrimazole ........................ 115 clotrimazole-betamethasone
........................ 112, 115, 117 clozapine ............................... 51 COAGADEX........................ 29 coal tar (bulk) ..................... 120 codeine sulfate .............. 56, 105 codeine-guaifenesin ...... 56, 105 colchicine.............................. 96 colesevelam .................... 36, 85 colestipol .............................. 36 COMBIGAN .................. 72, 73 COMBIPATCH .............. 88, 92 COMBIVENT RESPIMAT 23,
26, 104, 109 COMETRIQ ......................... 14 COMPACT COMPRESSOR
NEBULIZER .................... 64 COMPLERA ...................... 8, 9 COMPLETENATE ............ 125 CONCEPTROL .................. 103 CONTRAVE ........................ 47 COPIKTRA .......................... 14 CORDRAN ................ 112, 117 CORDRAN TAPE LARGE
ROLL...................... 112, 117 CORIFACT .......................... 29
CORTISONE COOLING .. 112, 117
COSENTYX ....................... 122 COSENTYX (2 SYRINGES)
........................................ 122 COSENTYX PEN .............. 122 COSENTYX PEN (2 PENS)
........................................ 122 COTELLIC ........................... 14 COTEMPLA XR-ODT ........ 59 CREON ................................. 79 CRESEMBA ........................... 6 CRINONE ............................ 93 CRIXIVAN ........................... 10 cromolyn ....................... 72, 107 CROTAN ............................ 121 CRYSELLE (28) .................. 86 CRYSVITA .......................... 67 CULTURELLE .................... 80 CULTURELLE KIDS
PROBIOTICS ................... 80 cyanocobalamin (vitamin b-12)
........................................ 127 CYCLAFEM 1/35 (28) ......... 86 cyclobenzaprine .................... 24 cyclopentolate ....................... 76 cyclophosphamide ........ 14, 101 cycloserine .............................. 5 cyclosporine modified . 98, 100,
101 cyproheptadine ............... 1, 106 CYRAMZA .......................... 15 CYTRA K CRYSTALS ....... 65 D d10 %-0.45 % sodium chloride
.......................................... 66 d2.5 %-0.45 % sodium
chloride ............................. 66 dacarbazine ........................... 15 DAILY FIBER ..................... 78 DAILY FIBER (PSYLLIUM-
SUCROSE) ....................... 79 DAILY MULTI-VITAMIN125 DAKLINZA ........................... 7 dalfampridine ...................... 102 DALIRESP ......................... 108 danazol .................................. 84 DANDRUFF SHAMPOO
(SELEN-ALOE) ............. 120 dantrolene ............................. 24 dapsone ................................... 5
135
daptomycin ............................. 6 DARAPRIM ........................... 5 darifenacin .......................... 124 DARZALEX ........................ 15 daunorubicin ......................... 15 DAURISMO......................... 15 DAYTRANA ....................... 59 DDAVP .......................... 29, 92 decitabine ............................. 15 DEEP SEA NASAL ............. 75 deferasirox ............................ 82 DEFITELIO ......................... 28 DELSTRIGO ...................... 8, 9 DEMEROL........................... 56 DEMEROL (PF) .................. 56 DENAVIR .......................... 115 DENTA 5000 PLUS............. 97 DEPO-ESTRADIOL ............ 88 DEPO-SUBQ PROVERA 104
.......................................... 93 DESCOVY ............................. 9 desipramine .......................... 63 desloratadine................... 2, 108 desmopressin .................. 29, 92 DESONATE ....................... 117 desonide ...................... 112, 117 desoximetasone .......... 112, 117 desvenlafaxine ...................... 61 desvenlafaxine fumarate ....... 61 desvenlafaxine succinate ...... 61 dexamethasone ..................... 83 DEXAMETHASONE
INTENSOL ...................... 83 dexamethasone sodium
phosphate .................... 74, 83 DEXILANT .......................... 81 dexmethylphenidate ............. 60 dextroamphetamine ........ 45, 46 dextroamphetamine-
amphetamine .................... 46 dextromethorphan polistirex
........................................ 105 dextromethorphan-guaifenesin
........................................ 105 dextrose 10 % and 0.2 % nacl
.......................................... 66 dextrose 10 % in water (d10w)
.......................................... 66 dextrose 20 % in water (d20w)
.......................................... 66
dextrose 30 % in water (d30w) .......................................... 66
dextrose 40 % in water (d40w) .......................................... 66
dextrose 5 % in water (d5w). 66 dextrose 5 %-lactated ringers69 dextrose 5%-0.2 % sod
chloride ............................. 66 dextrose 5%-0.3 %
sod.chloride ...................... 66 dextrose 50 % in water (d50w)
.......................................... 66 dextrose 70 % in water (d70w)
.......................................... 66 DIABETIC TUSSIN DM ... 105 DIALYVITE .............. 127, 128 DIALYVITE 800 ....... 127, 128 DIALYVITE 800-ULTRA D
........................ 127, 128, 129 diazepam ............................... 53 DICLEGIS ...... 77, 78, 106, 127 DICLO GEL ......... 58, 120, 122 diclofenac potassium ............ 58 diclofenac sodium.... 15, 58, 75,
120, 122 diclofenac-misoprostol ... 58, 81 dicloxacillin .......................... 12 dicyclomine .......................... 23 didanosine ............................... 9 diethylpropion ...................... 45 DIFFERIN .......................... 122 DIFICID ............................... 12 diflorasone .................. 112, 117 digoxin ............................ 35, 38 DILANTIN ..................... 39, 55 DILATRATE-SR ................. 42 diltiazem hcl . 36, 37, 38, 40, 44 dimenhydrinate ......... 1, 78, 106 diphenhydramine hcl ...... 1, 106 diphenoxylate-atropine .. 23, 77,
104 dipyridamole ................... 33, 44 disopyramide phosphate ....... 39 disulfiram.............................. 95 DIURIL .......................... 43, 71 divalproex ................. 48, 49, 50 dobutamine ..................... 26, 38 docetaxel ............................... 15 docusate calcium .................. 79 docusate sodium ................... 79 dofetilide ............................... 40
donepezil ............................... 25 DOPTELET (10 TAB PACK)
.......................................... 28 DOPTELET (15 TAB PACK)
.......................................... 28 dorzolamide .......................... 74 dorzolamide-timolol ....... 73, 74 DOVATO ........................... 8, 9 doxazosin .................. 25, 33, 41 doxepin ................................. 63 doxorubicin ........................... 15 doxycycline hyclate ........ 13, 73 doxycycline monohydrate .... 13 dronabinol ............................. 78 drospirenone-e.estradiol-lm.fa
.......................................... 86 DROXIA ............................... 15 DULERA ........ 26, 83, 107, 109 duloxetine ....................... 55, 61 DUPIXENT PEN ........ 106, 122 DUPIXENT SYRINGE ..... 106,
122 DUREZOL ........................... 74 dutasteride ............................. 95 DYANAVEL XR ................. 46 E EAR DROPS (CARBAMIDE
PEROXIDE) ..................... 74 econazole ............................ 115 EDLUAR .............................. 50 EDURANT ............................. 8 efavirenz ................................. 8 EGRIFTA ............................. 94 EGRIFTA SV ....................... 94 electrolyte-48 in d5w ............ 69 eletriptan ............................... 61 ELIGARD ....................... 15, 89 ELIGARD (3 MONTH) . 15, 89 ELIGARD (4 MONTH) . 15, 89 ELIGARD (6 MONTH) . 15, 89 ELIQUIS ............................... 28 ELIQUIS DVT-PE TREAT
30D START ...................... 28 ELITE-OB 400 ..... 31, 125, 127 ELLA .................................... 86 ELMIRON .......................... 103 ELOCTATE ......................... 29 EMCYT ................................ 15 EMEND ................................ 81 EMFLAZA ........................... 83 EMGALITY PEN ........... 50, 54
136
EMGALITY SYRINGE . 50, 54 EMPLICITI .......................... 15 EMSAM ............................... 56 EMTRIVA .............................. 9 enalapril maleate ............ 34, 35 enalapril-hydrochlorothiazide
........................ 34, 35, 43, 71 ENBREL .............. 98, 100, 122 ENBREL MINI .... 98, 100, 122 ENBREL SURECLICK ...... 98,
100, 122 ENDARI ....................... 80, 102 ENDOMETRIN ................... 93 ENEMA DISPOSABLE ...... 79 ENGERIX-B (PF) ................ 21 ENGERIX-B PEDIATRIC
(PF) ................................... 21 enoxaparin ...................... 30, 31 ENSURE ORIGINAL .......... 66 ENSURE PLUS.................... 66 entacapone ............................ 54 entecavir ............................... 11 ENTRESTO ................... 34, 43 ENUCLENE ......................... 75 ENULOSE ............................ 65 EPIDUO FORTE................ 122 epinastine .............................. 72 epinephrine ................... 23, 104 EPIPEN 2-PAK ............ 23, 104 EPIPEN JR 2-PAK ....... 23, 104 epirubicin .............................. 15 EPIVIR ................................... 9 EPIVIR HBV.......................... 9 eplerenone ...................... 42, 43 EPOGEN .............................. 28 EPZICOM .............................. 9 EQUETRO ..................... 48, 49 ERBITUX............................. 15 ergocalciferol (vitamin d2) . 129 ERIVEDGE .......................... 15 ERLEADA ........................... 15 erlotinib ................................ 15 ERYTHROCIN (AS
STEARATE) ................ 7, 10 erythromycin .............. 7, 11, 73 erythromycin ethylsuccinate . 7,
10, 11 erythromycin with ethanol . 111 erythromycin-benzoyl peroxide
........................................ 111 ESBRIET ............................ 104
escitalopram oxalate ............. 62 esomeprazole magnesium..... 81 ESPEROCT .......................... 29 estazolam .............................. 53 ESTRACE ............................ 88 estradiol ................................ 88 estradiol valerate................... 88 ESTRING ............................. 88 ESTROGEL.......................... 88 eszopiclone ..................... 50, 51 ethambutol .............................. 5 ethosuximide ........................ 62 etidronate disodium .............. 97 etodolac ................................ 58 etonogestrel-ethinyl estradiol86 ETOPOPHOS ....................... 15 etoposide ............................... 15 EUCRISA ................... 112, 114 EURAX .............................. 121 EVEKEO ODT ..................... 46 EVENITY ............................. 97 everolimus (antineoplastic) .. 15 everolimus
(immunosuppressive) ..... 101 EVOTAZ .............................. 10 EVZIO ............................ 58, 95 exemestane ..................... 15, 85 EXTAVIA .......................... 100 EYE ALLERGY RELIEF .... 76 ezetimibe .............................. 39 F FABIOR ............................. 122 FACTIVE ............................. 12 FALMINA (28) .................... 86 famciclovir............................ 11 famotidine ............................. 81 FANAPT .............................. 51 FARESTON ................... 15, 88 FARXIGA ............................ 94 FARYDAK ........................... 15 FASENRA .......................... 106 FASENRA PEN ................. 106 febuxostat ............................. 96 FEIBA NF ............................ 29 felodipine ............ 37, 40, 41, 44 fenofibrate ............................ 41 fenofibrate micronized ......... 41 fenofibrate nanocrystallized . 41 fenofibric acid (choline) ....... 41 fentanyl ................................. 56 ferrous gluconate .................. 31
ferrous sulfate ....................... 31 FEVERALL .......................... 46 fexofenadine ................... 2, 108 FINACEA ........................... 122 finasteride ............................. 95 FIORICET .......... 46, 50, 52, 60 FIRMAGON KIT W
DILUENT SYRINGE 15, 85, 99
FIRVANQ .............................. 7 FISH OIL ........................ 35, 81 flavoxate ............................. 124 flecainide .............................. 39 FLECTOR ............ 58, 120, 122 FLINTSTONES COMPLETE
(IRON) ...................... 31, 125 FLOVENT DISKUS .... 83, 108 FLOVENT HFA ........... 83, 108 floxuridine ............................ 15 FLUAD QUAD 2020-21(65Y
UP)(PF) ............................. 21 FLUARIX QUAD 2020-2021
(PF) ................................... 21 FLUBLOK QUAD 2020-2021
(PF) ................................... 21 FLUCELVAX QUAD 2020-
2021 .................................. 21 FLUCELVAX QUAD 2020-
2021 (PF) .......................... 21 fluconazole ............................. 6 fluconazole in dextrose(iso-o) 6 fluconazole in nacl (iso-osm) . 6 fludarabine ............................ 15 fludrocortisone ...................... 83 FLULAVAL QUAD 2020-
2021 (PF) .......................... 21 FLUMIST QUAD 2020-2021
.......................................... 21 fluocinolone ........ 112, 113, 117 fluocinolone acetonide oil .... 74 fluocinolone and shower cap
................................ 112, 117 fluocinonide ........ 113, 117, 118 FLUOCINONIDE-E ... 113, 118 fluocinonide-emollient 113, 118 FLUOR-A-DAY ................... 97 fluoride (sodium) .................. 97 FLUORIDEX DAILY
DEFENSE ......................... 97 fluorometholone ................... 74 fluorouracil ............. 15, 16, 122
137
fluoxetine .............................. 62 fluphenazine decanoate ........ 59 fluphenazine hcl ................... 59 FLURA-DROPS .................. 97 flurandrenolide ........... 113, 118 flurazepam ............................ 53 flurbiprofen........................... 58 flurbiprofen sodium .............. 75 flutamide............................... 16 fluticasone propionate . 74, 107,
113, 118 fluticasone propion-salmeterol
.................... 26, 83, 108, 109 fluvastatin ............................. 41 fluvoxamine .......................... 62 FLUZONE HIGHDOSE
QUAD 20-21 PF............... 21 FLUZONE QUAD 2020-2021
.......................................... 21 FLUZONE QUAD 2020-2021
(PF) ................................... 21 folic acid ............................. 127 FOLIVANE-OB ... 31, 125, 127 FORTEO ........................ 92, 97 FOSAMAX PLUS D .... 97, 129 fosamprenavir ....................... 10 FOSCAVIR ............................ 6 fosinopril ........................ 34, 35 FREAMINE HBC 6.9 % ...... 66 FREAMINE III 10 % ........... 66 FREESTYLE LIBRE 10 DAY
READER .......................... 64 FREESTYLE LIBRE 10 DAY
SENSOR........................... 64 FREESTYLE LIBRE 14 DAY
READER .......................... 64 FREESTYLE LIBRE 14 DAY
SENSOR........................... 64 frovatriptan ........................... 61 FULPHILA........................... 28 fulvestrant ............................. 16 furosemide ...................... 42, 68 FUZEON ................................ 8 G gabapentin ...................... 46, 48 galantamine .......................... 25 ganciclovir sodium ............... 11 GARDASIL (PF).................. 21 GARDASIL 9 (PF)............... 21 GAS RELIEF
(SIMETHICONE) ............ 78
GAZYVA ............................. 16 GELNIQUE ........................ 124 gemcitabine .......................... 16 gemfibrozil ........................... 41 GENOTROPIN .................... 92 GENOTROPIN MINIQUICK
.......................................... 92 gentamicin ............................ 73 GENVOYA ........................ 8, 9 GEODON ....................... 49, 51 GIANVI (28) ........................ 86 GILENYA .......................... 100 GILOTRIF ............................ 16 glatiramer............................ 100 GLATOPA ......................... 100 GLEOSTINE ........................ 16 glimepiride............................ 94 glipizide ................................ 94 glipizide-metformin ........ 85, 94 GLUCAGEN DIAGNOSTIC
KIT ............................. 64, 89 GLUCAGEN HYPOKIT 89, 96 GLUCAGON EMERGENCY
KIT (HUMAN)........... 89, 96 glucose .................................. 66 GLUCOSE POWDER .......... 85 glyburide ............................... 94 glyburide-metformin ...... 85, 95 glycerin (adult) ..................... 79 glycopyrrolate ....................... 23 GLYXAMBI .................. 87, 94 GOCOVRI ........................ 3, 45 granisetron hcl ...................... 76 GRANIX .............................. 28 GRASTEK.................... 20, 102 griseofulvin microsize ............ 4 griseofulvin ultramicrosize ..... 4 guaifenesin.......................... 105 guanfacine ...................... 39, 54 GVOKE PFS 1-PACK
SYRINGE ................... 89, 96 GVOKE PFS 2-PACK
SYRINGE ................... 89, 96 GYNE-LOTRIMIN ............ 115 GYNOL II .......................... 103 H HAEGARDA........................ 98 HALAVEN ........................... 16 halobetasol propionate 113, 118 HALOG ...................... 113, 118 haloperidol ............................ 54
haloperidol decanoate ........... 54 haloperidol lactate ................ 54 HARVONI .......................... 7, 8 HAVRIX (PF) ...................... 21 HELIXATE FS ..................... 29 HEMLIBRA ......................... 29 HEMOFIL M HIGH ............. 29 HEMOFIL M LOW .............. 30 HEMOFIL M MID ............... 30 HEMOFIL M SUPER HIGH30 HEMORRHOIDAL (WITCH
HAZEL) .......................... 115 HEPAGAM B ....................... 20 heparin (porcine) .................. 31 HEPATAMINE 8% .............. 66 HEPLISAV-B (PF) ............... 21 HERCEPTIN ........................ 16 HETLIOZ ............................. 51 HEXALEN ........................... 16 HIGH POTENCY
CAPSAICIN ................... 122 HUMALOG MIX 50-50
INSULN U-100 .... 90, 91, 93 HUMALOG MIX 50-50
KWIKPEN ............ 90, 91, 93 HUMALOG MIX 75-25(U-
100)INSULN ........ 90, 91, 93 HUMATE-P ......................... 30 HUMATROPE ..................... 92 HUMIRA ........ 80, 98, 100, 122 HUMIRA PEN80, 98, 100, 122 HUMIRA PEN PSOR-
UVEITS-ADOL HS .. 80, 98, 100, 122
HUMIRA(CF) 80, 98, 100, 122 HUMIRA(CF) PEDI
CROHNS STARTER 80, 99, 100, 123
HUMIRA(CF) PEN ....... 80, 99, 100, 123
HUMULIN 70/30 U-100 INSULIN .............. 90, 91, 93
HUMULIN 70/30 U-100 KWIKPEN ............ 90, 91, 93
HUMULIN N NPH INSULIN KWIKPEN .................. 90, 91
HUMULIN N NPH U-100 INSULIN .................... 90, 91
HUMULIN R REGULAR U-100 INSULN .............. 90, 93
138
HUMULIN R U-500 (CONC) INSULIN .................... 90, 93
HUMULIN R U-500 (CONC) KWIKPEN ................. 90, 94
HYCAMTIN ........................ 16 hydralazine ........................... 41 hydrochlorothiazide ........ 43, 71 hydrocodone-acetaminophen
.............................. 46, 47, 56 hydrocortisone ...... 83, 113, 118 hydrocortisone acetate 113, 118 hydrocortisone butyrate ..... 113,
118 hydrocortisone butyr-emollient
................................ 113, 118 hydrocortisone valerate ..... 113,
118 hydrocortisone-acetic acid.... 74 hydrocortisone-aloe vera ... 113,
118 hydromorphone .............. 56, 57 hydroxychloroquine . 5, 99, 100 hydroxyprogest(pf)(preg presv)
.......................................... 93 hydroxyprogesterone
cap(ppres) ......................... 93 hydroxyurea .......................... 16 hydroxyzine hcl ................ 2, 51 hydroxyzine pamoate ....... 2, 51 hyoscyamine sulfate ....... 23, 24 HYPERHEP B S/D .............. 20 HYPERHEP B S-D
NEONATAL .................... 20 HYPOTEARS ...................... 75 I ibandronate ........................... 97 IBRANCE ............................ 16 ibuprofen .............................. 58 IBUPROFEN JR STRENGTH
.......................................... 58 icatibant ................................ 98 ICLUSIG .............................. 16 IDELVION ........................... 30 IDHIFA ................................ 16 ifosfamide ............................. 16 ifosfamide-mesna ................. 16 ILEVRO ............................... 75 ILUMYA ............................ 123 imatinib................................. 16 IMBRUVICA ....................... 16 imipramine hcl...................... 63
imiquimod .......................... 123 IMOVAX RABIES VACCINE
(PF) ................................... 21 IMPOYZ ..................... 113, 118 INCRUSE ELLIPTA .... 24, 104 indapamide ..................... 44, 72 INDOCIN ....................... 58, 96 indomethacin .................. 59, 96 INFANT'S IBUPROFEN ..... 59 INFANT'S NON-ASPIRIN .. 47 INFANT'S PAIN RELIEF ... 47 INFED .................................. 31 INGREZZA .................... 55, 63 INGREZZA INITIATION
PACK ............................... 63 INLYTA ............................... 16 INREBIC .............................. 16 insulin asp prt-insulin aspart 90,
91, 93 insulin lispro ................... 90, 93 insulin lispro protamin-lispro
.............................. 90, 91, 93 INTELENCE .......................... 8 INTRALIPID........................ 67 INVEGA ............................... 51 INVEGA SUSTENNA ......... 51 INVEGA TRINZA ............... 51 INVIRASE ........................... 10 INVOKAMET ................ 85, 94 INVOKAMET XR ............... 85 INVOKANA ........................ 94 IONOSOL-B IN D5W.......... 69 IONOSOL-MB IN D5W ...... 69 ipratropium bromide ...... 24, 75,
104 ipratropium-albuterol..... 24, 27,
104, 109 irbesartan .............................. 34 irbesartan-hydrochlorothiazide
.............................. 34, 43, 71 IRESSA ................................ 16 irinotecan .............................. 16 ISENTRESS ........................... 8 ISOLYTE S PH 7.4 .............. 69 ISOLYTE-P IN 5 %
DEXTROSE ..................... 69 ISOLYTE-S .......................... 69 isoniazid.................................. 5 isosorbide dinitrate ............... 42 isosorbide mononitrate ......... 42 isotretinoin .......................... 123
ISUPREL ...................... 25, 107 itraconazole ............................. 6 ivermectin ............................... 4 IXEMPRA ............................ 16 IXINITY ............................... 30 J JADENU ............................... 82 JADENU SPRINKLE .......... 82 JAKAFI ................................ 16 JANUMET ..................... 85, 87 JANUMET XR ............... 85, 87 JANUVIA ............................. 87 JARDIANCE ........................ 94 JATENZO ............................. 84 JENTADUETO .............. 85, 88 JENTADUETO XR ........ 85, 88 JEVTANA ............................ 16 JIVI ....................................... 30 JOLESSA ............................. 86 JORNAY PM ........................ 60 JUBLIA .............................. 115 JUNEL FE 1.5/30 (28) ......... 86 JUNEL FE 1/20 (28) ............ 86 JUNEL FE 24 ....................... 86 K KABIVEN ............................ 67 KADCYLA ........................... 16 KALBITOR .......................... 98 KALETRA ........................... 10 KALYDECO ...................... 105 KELNOR 1/35 (28) .............. 86 KERYDIN .......................... 121 ketoconazole ................... 6, 115 KETO-DIASTIX .................. 65 ketorolac ......................... 59, 75 KETOSTIX ........................... 64 ketotifen fumarate ................. 72 KEVEYIS ............................. 97 KEVZARA ................... 99, 100 KEYTRUDA ........................ 16 KINERET ..................... 99, 100 KIONEX (WITH SORBITOL)
.................................... 68, 96 KISQALI .............................. 16 KLOR-CON M15 ................. 69 KOATE ................................. 30 KOGENATE FS ................... 30 KOMBIGLYZE XR ....... 85, 88 KORLYM ............................. 85 KOSELUGO ......................... 16 KPN ...................... 31, 125, 127
139
K-Y LUBRICATING ......... 123 L labetalol .. 25, 26, 33, 35, 36, 39 LAC-HYDRIN FIVE ......... 116 lactase ................................... 80 lactated ringers ............... 67, 69 lactulose ................................ 65 LAMISIL AF...................... 124 lamivudine .............................. 9 lamivudine-zidovudine ........... 9 lamotrigine ..................... 48, 49 lansoprazole .................... 81, 82 lanthanum ....................... 68, 96 LANTUS SOLOSTAR U-100
INSULIN .......................... 91 LANTUS U-100 INSULIN .. 91 LASTACAFT ....................... 72 latanoprost ............................ 76 LATUDA ............................. 51 ledipasvir-sofosbuvir .......... 7, 8 LEENA 28 ............................ 86 leflunomide................... 99, 100 LENVIMA ........................... 17 letrozole .......................... 17, 85 leucovorin calcium ............... 96 LEUKERAN ........................ 17 leuprolide ........................ 17, 89 levalbuterol hcl ............. 27, 109 levalbuterol tartrate ...... 27, 109 LEVATOL ........................... 36 LEVEMIR FLEXTOUCH U-
100 INSULN .................... 91 LEVEMIR U-100 INSULIN 91 levetiracetam ........................ 48 levobunolol ........................... 73 levocarnitine ....................... 102 levocarnitine (with sugar)... 102 levocetirizine .......................... 2 levofloxacin ...................... 5, 12 levomefolate calcium ......... 127 levonorgestrel-ethinyl estrad 86 levorphanol tartrate .............. 57 levothyroxine ........................ 95 LEXETTE .......................... 118 LEXIVA ............................... 10 LICE KILLING .................. 121 LICE KILLING
(PERMETHRIN) ............ 121 lidocaine ............................. 115 lidocaine (pf) ........................ 95 lidocaine hcl ................... 76, 95
LIDOCAINE PAIN RELIEF ........................................ 115
LIDOCAINE VISCOUS ...... 76 lidocaine-prilocaine ............ 115 linezolid ................................ 12 LINZESS .............................. 80 liothyronine .......................... 95 LIQUID CORN AND
CALLUS REMOVER .... 120 lisinopril.......................... 34, 35 lisinopril-hydrochlorothiazide
........................ 34, 35, 43, 71 lithium carbonate .................. 49 lithium citrate ....................... 49 LO LOESTRIN FE ............... 86 LOKELMA .......................... 68 LOMAIRA ........................... 45 LONSURF ............................ 17 loperamide ............................ 77 loratadine ........................ 2, 108 LORATADINE-D ... 2, 23, 104,
108 lorazepam ............................. 53 LORBRENA ........................ 17 losartan ................................. 34 losartan-hydrochlorothiazide
.............................. 34, 43, 71 LOTRIMIN AF .................. 115 LOTRIMIN AF POWDER 115 LOTRIMIN ULTRA .......... 116 lovastatin .............................. 41 loxapine succinate ................ 50 LUDENT FLUORIDE ......... 98 LUMIGAN ........................... 76 LUPANETA PACK (1
MONTH) .............. 17, 89, 93 LUPANETA PACK (3
MONTH) .............. 17, 89, 93 LUPRON DEPOT .......... 17, 89 LUPRON DEPOT (3
MONTH) .................... 17, 89 LUPRON DEPOT (4
MONTH) .................... 17, 89 LUPRON DEPOT-PED . 17, 89 LUPRON DEPOT-PED (3
MONTH) .................... 17, 89 LYNPARZA ......................... 17 LYSODREN ......................... 17 M MAALOX MAXIMUM
STRENGTH ............... 77, 78
magnesium ............................ 69 magnesium citrate ................. 79 magnesium gluconate ........... 69 magnesium oxide .................. 77 MAKENA (PF) .................... 93 malathion ............................ 121 mannitol 20 % ........... 42, 64, 68 MAPAP
(ACETAMINOPHEN) ..... 47 MATULANE ........................ 17 MAVENCLAD (10 TABLET
PACK) ............................ 101 MAVYRET ........................ 7, 8 MAYZENT ......................... 100 meclizine ........................... 2, 78 MEDROL ............................. 83 medroxyprogesterone ........... 93 mefloquine .............................. 5 megestrol ........................ 17, 93 MEKINIST ........................... 17 MEKTOVI ............................ 17 melatonin ............................ 102 meloxicam ............................ 59 memantine ............................ 55 MENACTRA (PF) ................ 21 MENOMUNE - A/C/Y/W-135
.......................................... 22 MENOMUNE - A/C/Y/W-135
(PF) ................................... 22 MENOSTAR ........................ 88 MENVEO A-C-Y-W-135-DIP
(PF) ................................... 22 meperidine ............................ 57 meperidine (pf) ..................... 57 mercaptopurine ............. 17, 101 meropenem ............................. 6 mesalamine ........................... 78 METAMUCIL (SUGAR) ..... 79 metformin ....................... 85, 86 methadone ............................. 57 methamphetamine ................. 46 methenamine hippurate ........ 13 methimazole ......................... 85 methocarbamol ..................... 24 methotrexate sodium ..... 17, 99,
100, 101 methotrexate sodium (pf) .... 17,
99, 100, 101 methoxsalen ........................ 121 methyldopa ..................... 23, 39 methylergonovine ............... 103
140
methylphenidate hcl ............. 60 methylprednisolone .............. 83 metoclopramide hcl .............. 81 metolazone ..................... 44, 72 metoprolol succinate 27, 36, 39 metoprolol tartrate .... 27, 36, 39 metronidazole ............. 4, 5, 111 mexiletine ............................. 39 MIACALCIN ........... 85, 92, 97 MIBELAS 24 FE .................. 86 MICONAZOLE 7 .............. 115 miconazole nitrate .............. 115 MICONAZOLE-3 .............. 115 MICORT-HC ............. 113, 118 MICROGESTIN 1.5/30 (21) 86 MICROGESTIN 1/20 (21) ... 86 midazolam ............................ 53 midodrine ............................. 23 miglustat ............................. 102 MIGRAINE FORMULA .... 33,
47, 50, 60, 61 MILK OF MAGNESIA ....... 79 MINERAL OIL LAXATIVE
.......................................... 79 minocycline .......................... 13 minoxidil .............................. 41 MIRCERA ............................ 28 mirtazapine ........................... 48 misoprostol ........................... 81 mitomycin............................. 17 mitoxantrone......................... 17 M-M-R II (PF) ...................... 22 modafinil .............................. 63 mometasone ................ 114, 118 MONOCLATE-P ................. 30 MONONESSA (28) ............. 86 montelukast ........................ 106 MORPHABOND ER ........... 57 morphine............................... 57 morphine concentrate ........... 57 MOVANTIK ........................ 80 MOVIPREP .......................... 79 moxifloxacin..................... 5, 12 MOZOBIL ............................ 28 MULPLETA......................... 28 MULTI-DELYN ................ 125 MULTIVITAMIN WITH
FLUORIDE .............. 98, 125 MULTI-VITAMIN WITH
FLUORIDE ...................... 98
MULTI-VITAMIN WITH FLUORIDE .................... 125
mupirocin............................ 111 mupirocin calcium .............. 111 MURO 128 ........................... 75 MUSCLE RUB (WITH
CAMPHOR) ..................... 61 mv-min-folic acid-lutein.... 125,
127 MY WAY ............................. 87 MYALEPT ........................... 91 mycophenolate mofetil ....... 102 mycophenolate sodium ....... 102 MYDAYIS ........................... 46 MYLERAN .......................... 17 MYNEPHROCAPS.... 127, 128 MYRBETRIQ .................... 124 MYZILRA ............................ 87 N NABI-HB ............................. 20 nabumetone .......................... 59 nadolol ...................... 25, 36, 39 naloxone ......................... 58, 96 naltrexone ....................... 58, 95 NAMZARIC ................... 25, 55 naproxen ......................... 59, 96 naproxen sodium ............ 59, 96 naratriptan ............................. 61 NARCAN ....................... 58, 96 NASAL ALLERGY ..... 74, 107 NATACHEW (FE BIS-
GLYCINATE) .. 31, 125, 127 NATACYN .......................... 73 NATAZIA ............................ 87 nateglinide ............................ 92 NATESTO ............................ 84 NATURAL FIBER
LAXATIVE (SUGAR)..... 79 NATURE-THROID ............. 95 NAYZILAM ................... 53, 54 NEBUPENT ........................... 5 neomycin ................................ 4 neomycin-bacitracin-poly-hc
.................................... 73, 74 neomycin-polymyxin b gu.. 111 neomycin-polymyxin b-
dexameth .................... 73, 74 neomycin-polymyxin-
gramicidin ......................... 73 neomycin-polymyxin-hc 73, 74 NEO-POLYCIN ................... 73
NEPHRAMINE 5.4 % .......... 67 NEPRO CARB STEADY .... 67 NERLYNX ........................... 17 NEUAC ...................... 111, 120 NEUAC KIT ............... 111, 120 NEULASTA ......................... 28 NEUPOGEN ......................... 28 NEVANAC ........................... 75 nevirapine ............................... 8 NEWGEN ....... 31, 69, 125, 127 NEXAVAR ........................... 17 NEXIUM PACKET .............. 82 niacin .................................... 35 NIACOR ............................... 35 nicotine ................................. 24 nicotine (polacrilex) .............. 24 NICOTROL .......................... 24 NICOTROL NS .................... 24 nifedipine ............ 37, 40, 41, 44 NINLARO ............................ 17 NIPENT ................................ 18 nitisinone ............................ 102 NITRO-BID .......................... 42 nitrofurantoin ........................ 13 nitrofurantoin macrocrystal .. 13 nitrofurantoin monohyd/m-
cryst .................................. 13 nitroglycerin ......................... 42 NITYR ................................ 102 NIVESTYM ......................... 28 NOLIX ........................ 114, 118 NORA-BE ............................ 87 NORDITROPIN FLEXPRO 92 noreth-ethinyl estradiol-iron . 87 norethindrone acetate ............ 93 norethindrone ac-eth estradiol
.................................... 88, 93 norethindrone-e.estradiol-iron
.......................................... 87 norgestimate-ethinyl estradiol
.......................................... 87 NORMOSOL-M IN 5 %
DEXTROSE ..................... 69 NORMOSOL-R .................... 69 NORMOSOL-R PH 7.4 ........ 69 NORPACE CR ..................... 39 NORTEMP ........................... 47 NORTREL 0.5/35 (28) ......... 87 NORTREL 7/7/7 (28) ........... 87 nortriptyline .......................... 63 NORVIR ............................... 10
141
NOVOEIGHT ...................... 30 NOVOLIN N NPH U-100
INSULIN .......................... 91 NOVOLIN R REGULAR U-
100 INSULN .............. 91, 94 NOVOSEVEN RT ............... 30 NOXAFIL .............................. 6 NP THYROID ...................... 95 NPLATE............................... 28 NUBEQA ............................. 18 NUCALA ................... 104, 106 NUCORT ................... 114, 119 NUCYNTA ER .................... 57 NUEDEXTA ................ 55, 105 NUPLAZID .......................... 52 NURTEC ODT ..................... 54 NUTRAMIGEN WITH
ENFLORA LGG .............. 67 NUTRILIPID ....................... 67 NUTROPIN AQ NUSPIN ... 92 NUZYRA ............................... 4 nystatin ......................... 12, 121 nystatin-triamcinolone ........ 121 O OB COMPLETE PREMIER
.................... 31, 69, 125, 127 OBIZUR ............................... 30 O-CAL FA...... 31, 69, 125, 127 OCALIVA ............................ 80 octreotide acetate .......... 94, 102 OCUVITE LUTEIN AND
ZEAXANTHIN .............. 102 OCUVITE WITH LUTEIN 125 ODACTRA........................... 20 ODEFSEY .......................... 8, 9 ODOMZO ............................ 18 OFEV ................................. 104 ofloxacin ......................... 12, 73 OGESTREL (28) .................. 87 olanzapine....................... 49, 52 olanzapine-fluoxetine ..... 52, 62 olmesartan ............................ 34 olopatadine ........................... 72 OLUMIANT................. 99, 100 omega-3 acid ethyl esters ..... 35 omega-3 fatty acids-fish oil .. 35 OMEPPI ............................... 82 omeprazole ........................... 82 omeprazole magnesium ........ 82 omeprazole-sodium
bicarbonate ....................... 82
OMNITROPE ....................... 92 ONCASPAR ......................... 18 ondansetron .......................... 77 ondansetron hcl............... 76, 77 ondansetron hcl (pf).............. 76 ONE DAILY FOR MEN 50+
ADVANCED.......... 125, 127 ONE DAILY MULTI-VIT W-
MINERAL ................ 31, 125 ONEXTON ................. 111, 120 ONFI ..................................... 54 ONGLYZA ........................... 88 ONMEL .................................. 6 ONZETRA XSAIL............... 61 OPDIVO ............................... 18 OPSUMIT .................... 44, 110 ORAL RELIEF DRY MOUTH
........................................ 123 ORALAIR .................... 20, 103 ORALYTE ........................... 69 ORENCIA .................... 99, 100 ORENCIA CLICKJECT ..... 99,
101 ORENITRAM .............. 44, 110 ORFADIN .......................... 103 ORILISSA ............................ 85 ORKAMBI ......................... 105 OS-CAL 500 + D3 ....... 70, 129 oseltamivir ............................ 11 OSMOLEX ER................. 3, 45 OTEZLA .............. 99, 101, 123 OTEZLA STARTER ... 99, 101,
123 oxaliplatin ............................. 18 oxandrolone .......................... 84 OXBRYTA ........................... 28 oxcarbazepine ....................... 48 oxybutynin chloride ............ 124 oxycodone ............................ 57 oxycodone-acetaminophen .. 47,
57 OXYCONTIN ...................... 57 oxymorphone ........................ 57 OXYTROL ......................... 124 OXYTROL FOR WOMEN 124 OYSTER SHELL + D3 70, 129 OZEMPIC ............................ 90 P paclitaxel .............................. 18 PAIN RELIEVING(CAM-
M.SAL-MENT) ................ 61
pamidronate .......................... 97 PANDEL .................... 114, 119 PANRETIN .................. 18, 123 pantoprazole ......................... 82 paromomycin .......................... 4 paroxetine hcl ....................... 62 PASER .................................... 5 PAZEO ................................. 72 PCE ................................... 7, 11 PEDIA RELIEF COUGH-
COLD ... 2, 23, 104, 105, 106 PEDIASURE ........................ 67 PEDIATRIC ELECTROLYTE
.......................................... 70 peg 3350-electrolytes ............ 79 PEG-3350 WITH FLAVOR
PACKS ............................. 79 PEGASYS ............................ 10 PEMAZYRE ......................... 18 penicillin g sodium ............... 11 penicillin v potassium ........... 11 PENNSAID .......... 59, 120, 123 PENTACEL (PF) .................. 22 PENTACEL ACTHIB
COMPONENT (PF) ......... 22 PENTACEL DTAP-IPV
COMPNT (PF) ................. 22 PENTAM ................................ 5 pentoxifylline ........................ 29 PEPTIC RELIEF .................. 77 PERFOROMIST ........... 27, 109 PERIFRESH ....................... 119 PERIKABIVEN ................... 67 PERJETA ............................. 18 permethrin ........................... 121 perphenazine ......................... 59 PHENADOZ ..................... 2, 51 phenazopyridine ................. 115 phendimetrazine tartrate ....... 45 phenelzine ............................. 56 phenobarb-hyoscy-atropine-
scop ............................. 24, 52 phenobarbital .................. 52, 53 PHENOHYTRO ....... 24, 52, 53 phenoxybenzamine ......... 25, 41 phentermine .......................... 45 phenylephrine hcl ................. 76 phenytoin ........................ 39, 55 phenytoin sodium extended . 39,
55 PHEXXI ............................. 103
142
PHILITH .............................. 87 PHOSLYRA ......................... 68 PHOS-NAK .......................... 70 PHOTOFRIN ....................... 18 PHRENILIN FORTE(WITH
CAFFEINE) ... 47, 50, 53, 60 phytonadione (vitamin k1) .. 96,
130 pilocarpine hcl ................ 25, 76 pimecrolimus .............. 102, 123 pimozide ............................... 50 PINK BISMUTH.................. 77 PIN-X ..................................... 4 pioglitazone .......................... 95 PIQRAY ............................... 18 piroxicam .............................. 59 PKU 2 ................................... 67 PKU TRIO............................ 67 PLASMA-LYTE 148 ........... 70 PLASMA-LYTE A .............. 70 PLEGRIDY ........................ 101 PNEUMOVAX-23 ............... 22 podofilox ............................ 123 polyethylene glycol 3350 ..... 79 polymyxin b sulfate .............. 12 polymyxin b sulf-trimethoprim
.......................................... 73 POLYVITAMIN WITH IRON
.................................. 31, 125 POMALYST ................ 18, 101 PORTRAZZA ...................... 18 posaconazole .......................... 6 potassium chlorid-d5-
0.45%nacl ......................... 70 potassium chloride................ 70 potassium chloride in 0.9%nacl
.......................................... 70 potassium chloride in 5 % dex
.......................................... 70 potassium chloride in lr-d5 ... 70 potassium chloride in water.. 70 potassium chloride-0.45 % nacl
.......................................... 70 potassium chloride-d5-
0.2%nacl ........................... 70 potassium chloride-d5-
0.3%nacl ........................... 70 potassium chloride-d5-
0.9%nacl ........................... 70 potassium citrate ................... 65 POTIGA ............................... 48
PRADAXA ........................... 28 PRALUENT PEN................. 42 pramipexole .......................... 56 prasugrel ............................... 33 pravastatin ............................ 41 PRAXBIND.......................... 27 praziquantel ............................ 4 prazosin .......................... 25, 33 PRED MILD......................... 74 prednicarbate .............. 114, 119 prednisolone ......................... 83 prednisolone acetate ............. 74 prednisolone sodium phosphate
.................................... 74, 83 prednisone ............................ 84 PREDNISONE INTENSOL. 84 pregabalin ................. 47, 48, 55 PREMARIN ......................... 88 PREMASOL 10 % ............... 67 PREMASOL 6 % ................. 67 PREMPHASE ...................... 88 PREMPRO ........................... 88 PRENATA............ 31, 125, 127 PRENATAL PLUS .............. 31 PRENATAL PLUS
(CALCIUM CARB) ......... 31 PRENATAL VITAMIN 31, 70,
125, 127 PRENATAL VITAMIN WITH
MINERALS...................... 31 prenatal vits96-iron fum-folic
.......................................... 32 PRE-PEN .............................. 64 PREPOPIK ........................... 79 PRETAB ......... 32, 70, 125, 127 pretomanid .............................. 5 PREVIDENT ........................ 98 PREVNAR 13 (PF) .............. 22 PREZCOBIX ........................ 10 PREZISTA ........................... 10 PRIFTIN ........................... 5, 13 PRILOSEC ........................... 82 PRILOSEC OTC .................. 82 primaquine .............................. 5 primidone.............................. 52 PRIMLEV ...................... 47, 57 PROAIR RESPICLICK 27, 110 probenecid ...................... 72, 97 PROBIOTIC (S.BOULARDII)
.......................................... 80 procainamide ........................ 39
PROCALAMINE 3% ........... 67 PROCENTRA ...................... 46 prochlorperazine ............. 59, 78 prochlorperazine edisylate ... 59,
78 prochlorperazine maleate 59, 78 PROCRIT ............................. 29 PROCTOFOAM HC . 114, 115,
119 PROCTO-PAK ........... 114, 119 PROCTOZONE-HC ... 114, 119 PROFILNINE ....................... 30 progesterone micronized ...... 93 PROLENSA ......................... 75 PROLEUKIN ............... 18, 101 PROMACTA ........................ 29 promethazine ............ 2, 51, 106 PROMETHAZINE VC ... 2, 23,
106 promethazine-dm .... 2, 105, 106 propafenone .......................... 39 proparacaine ......................... 76 propofol .......................... 51, 55 propranolol .. 25, 36, 39, 41, 42,
50 propylthiouracil .................... 85 PROSHIELD FOAM/SPRAY
CLEANSER ................... 123 protamine ........................ 28, 96 PROTONIX .......................... 82 PROVENGE ......................... 45 pseudoephedrine hcl ..... 23, 104 pseudoephedrine-guaifenesin
.......................... 23, 104, 105 PSORCON .................. 114, 119 PULMICORT ............... 84, 108 PULMICORT FLEXHALER
.................................. 84, 108 PULMOZYME ............. 72, 107 PUREFE OB PLUS ..... 32, 125,
127 PURIXAN .................... 18, 102 pyrazinamide .......................... 5 pyridostigmine bromide ........ 25 pyridoxine (vitamin b6) ...... 127 pyrilamine-phenylephrine 1, 23,
106 Q QINLOCK ............................ 18 QSYMIA ........................ 45, 48 QTERN ........................... 88, 94
143
QUARTETTE ...................... 87 quazepam .............................. 54 quetiapine ....................... 49, 52 QUILLICHEW ER ............... 60 QUILLIVANT XR ............... 60 quinapril ......................... 34, 35 quinidine gluconate .......... 5, 39 QVAR REDIHALER ... 84, 108 R RABAVERT (PF) ................ 22 rabeprazole ........................... 82 RADIOGARDASE ........ 68, 96 RAGWITEK................. 20, 103 RAJANI ................................ 87 raloxifene ........................ 88, 97 ramelteon .............................. 51 ramipril ........................... 34, 35 ranitidine hcl ......................... 81 ranolazine ............................. 38 REBIF (WITH ALBUMIN)
........................................ 101 REBIF REBIDOSE ............ 101 REBIF TITRATION PACK
........................................ 101 REBINYN ............................ 30 RECLIPSEN (28) ................. 87 RECOMBINATE ................. 30 RECOMBIVAX HB (PF) .... 22 RECTIV ............................. 123 RELENZA DISKHALER .... 11 RELISTOR ........................... 80 RENA-VITE RX ................ 127 repaglinide ............................ 92 REPATHA PUSHTRONEX 42 REPATHA SURECLICK .... 42 REPATHA SYRINGE ......... 42 RESCRIPTOR ........................ 8 RESTASIS ........................... 75 RESTASIS MULTIDOSE ... 75 RETACRIT .......................... 29 RETEVMO........................... 18 RETIN-A MICRO PUMP .. 116 RETROVIR ............................ 9 REVLIMID .................. 18, 101 REXULTI ............................. 52 REYATAZ ........................... 10 REYVOW ............................ 61 RHINOCORT ALLERGY .. 74,
107 RHOPRESSA ................. 73, 76 ribavirin ................................ 11
RIDAURA .............. 82, 99, 101 rifabutin ............................ 6, 13 RIFAMATE.......................... 13 rifampin ............................ 6, 13 RIFATER ......................... 6, 13 riluzole .................................. 55 ringer's .................................. 70 RINVOQ ...................... 99, 101 RISACAL-D ................. 70, 129 risedronate ............................ 97 RISPERDAL CONSTA . 49, 52 risperidone ...................... 49, 52 ritonavir ................................ 10 RITUXAN ............................ 18 rivastigmine .......................... 25 rivastigmine tartrate .............. 25 RIXUBIS .............................. 30 rizatriptan.............................. 61 ropinirole .............................. 56 rosuvastatin ........................... 41 ROZLYTREK ...................... 18 RUBRACA ........................... 18 RUKOBIA .............................. 8 RYBELSUS.......................... 90 RYDAPT .............................. 18 S SAIZEN ................................ 92 salsalate ................................ 61 SANDIMMUNE .. 99, 101, 102 SANDOSTATIN .......... 94, 103 SANTYL ............................ 123 SAPHRIS (BLACK
CHERRY) .................. 49, 52 SAVAYSA ........................... 28 SAVELLA ...................... 55, 61 SAXENDA ........................... 90 SCALACORT ............ 114, 119 SCALP RELIEF ......... 114, 119 scopolamine base .................. 78 SECUADO ..................... 49, 52 SEGLUROMET ............. 86, 94 SELECT-OB (FOLIC ACID)
.......................... 32, 125, 127 selegiline hcl ......................... 56 selenium sulfide .................. 120 SELSUN BLUE (SALICYLIC
ACID) ............................. 120 SELZENTRY ......................... 8 SENNA ................................. 79 SENNA WITH DOCUSATE
SODIUM .......................... 79
SEREVENT DISKUS .. 27, 110 SERNIVO ................... 114, 119 SEROQUEL XR ............. 49, 52 SEROSTIM .......................... 92 sertraline ............................... 62 sevelamer carbonate ....... 68, 96 sevelamer hcl .................. 68, 96 sevoflurane ........................... 55 SHINGRIX (PF) ................... 22 SILACE ................................ 79 sildenafil (pulm.hypertension)
............................ 42, 43, 110 SILICONE MASK - INFANT
.......................................... 64 SILIQ .................................. 123 silver sulfadiazine ............... 120 simethicone ........................... 78 SIMILAC ALIMENTUM .... 67 SIMILAC EXPERT CARE
NEOSURE ........................ 67 SIMILAC NEOSURE .......... 67 SIMPONI ................ 80, 99, 101 simvastatin ............................ 41 sirolimus ............................. 102 SIRTURO ............................... 6 SKLICE .............................. 121 SKYRIZI ............................ 123 SLEEP AID (DOXYLAMINE)
.............................. 1, 51, 106 SLYND ........................... 87, 93 sodium bicarbonate ......... 65, 77 sodium chloride .. 64, 67, 71, 75 sodium chloride 0.45 % ........ 70 sodium chloride 0.9 % .......... 70 sodium chloride 3 % ............. 70 sodium chloride 5 % ............. 70 sodium citrate-citric acid ...... 65 SODIUM POLYSTYRENE
(SORB FREE) ............ 68, 96 sodium polystyrene sulfonate
.................................... 68, 96 sofosbuvir-velpatasvir ........ 7, 8 SOFT TOUCH LANCETS ... 64 solifenacin ........................... 124 SOLTAMOX .................. 18, 88 SOMAVERT ........................ 94 sotalol ................. 25, 36, 40, 42 SOVALDI ............................... 7 spinosad .............................. 121 SPIRIVA RESPIMAT .. 24, 104 spironolactone ........... 42, 43, 68
144
spironolacton-hydrochlorothiaz ........................ 42, 43, 68, 71
SPORANOX .......................... 6 SPRYCEL ............................ 18 SPS (WITH SORBITOL).... 68,
96 stavudine................................. 9 STEGLATRO....................... 94 STEGLUJAN ................. 88, 94 STELARA ............ 99, 101, 123 STIMATE....................... 30, 92 STIOLTO RESPIMAT .. 24, 27 STIVARGA .......................... 18 STOOL SOFTENER ............ 79 STRIBILD .......................... 8, 9 STRIVERDI RESPIMAT ... 27,
110 STROVITE FORTE .... 32, 125,
127 SUBOXONE ........................ 58 sucralfate .............................. 81 SUDAFED 24 HOUR .. 23, 104 SUDOGEST ................. 23, 104 SUDOGEST 12-HOUR 23, 104 sulfacetamide sodium ........... 73 sulfacetamide sodium-sulfur
........................................ 120 sulfacetamide-prednisolone .. 73 sulfadiazine........................... 13 sulfamethoxazole-trimethoprim
.......................................... 13 sulfasalazine ..... 13, 78, 99, 101 sulindac................................. 59 sumatriptan ........................... 61 sumatriptan succinate ........... 61 sumatriptan-naproxen ..... 59, 62 SUMAVEL DOSEPRO ....... 62 SUNOSI ............................... 63 SUPREP BOWEL PREP KIT
.......................................... 79 SURVANTA ...................... 108 SUTENT............................... 18 SYEDA................................. 87 SYMDEKO ........................ 105 SYMFI ................................ 8, 9 SYMFI LO ......................... 8, 9 SYMLINPEN 120 ................ 84 SYMLINPEN 60 .................. 84 SYMPROIC ......................... 80 SYMTUZA......... 9, 10, 11, 103 SYNAGIS............................. 11
SYNAREL...................... 89, 90 SYNERCID .......................... 13 SYNJARDY ................... 86, 94 SYNJARDY XR............. 86, 94 SYNRIBO ............................ 18 T TABLOID ............................ 18 TABRECTA ......................... 18 tacrolimus ................... 102, 123 tadalafil (pulm. hypertension)
.................................. 43, 110 TAFINLAR .......................... 18 TAGRISSO .......................... 18 TAKHZYRO ........................ 98 TALTZ AUTOINJECTOR 123 TALTZ AUTOINJECTOR (2
PACK) ............................ 123 TALTZ AUTOINJECTOR (3
PACK) ............................ 123 TALTZ SYRINGE ............. 123 TALZENNA ......................... 18 tamoxifen ........................ 19, 88 tamsulosin ............................. 26 TASIGNA ............................ 19 TAVALISSE ........................ 28 TAYTULLA ......................... 87 tazarotene............................ 123 TAZORAC ......................... 123 TAZTIA XT ....... 37, 38, 40, 44 TAZVERIK .......................... 19 TECENTRIQ ........................ 19 TECFIDERA ...................... 101 TECHNIVIE ................. 7, 8, 10 TEFLARO .............................. 3 TEGSEDI ............................. 97 TEKTURNA HCT ......... 43, 71 telmisartan ............................ 34 temazepam ............................ 54 TEMODAR .......................... 19 temozolomide ....................... 19 teniposide.............................. 19 TENIVAC (PF) .................... 20 tenofovir disoproxil fumarate . 9 TENSION HEADACHE 47, 60 terazosin.................... 25, 33, 42 terbinafine hcl ................. 3, 110 terbutaline ..................... 27, 110 terconazole.......................... 116 teriparatide ...................... 92, 97 testosterone ........................... 84 testosterone cypionate .......... 84
testosterone enanthate ........... 84 tetanus-diphtheria toxoids-td 20 tetrabenazine ................... 55, 63 tetracycline ........................... 13 TEXACORT ............... 114, 119 thallous chloride tl-201 ......... 64 theophylline .... 41, 67, 110, 124 THERA ............................... 125 THERA-M ...... 32, 71, 125, 128 THERATEARS .................... 75 THERATRUM COMPLETE
50 PLUS/LUT ................ 126 THEREMS-M ............... 32, 126 thiamine hcl (vitamin b1) ... 128 thiamine mononitrate (vit b1)
........................................ 128 thioridazine ........................... 59 thiotepa ................................. 19 thiothixene ............................ 62 THYROGEN ........................ 65 thyroid (pork) ........................ 95 TIBSOVO ............................. 19 tigecycline ............................... 7 timolol maleate ..................... 74 tinidazole ................................ 5 TIROSINT ............................ 95 TIVICAY ................................ 8 TIVICAY PD .......................... 8 tizanidine .............................. 24 TOBI PODHALER ................ 4 TOBRADEX .................. 73, 74 tobramycin ............................ 73 tobramycin in 0.225 % nacl .... 4 tobramycin with nebulizer ...... 4 tobramycin-dexamethasone . 73,
74 TODAY CONTRACEPTIVE
SPONGE ......................... 103 tolazamide ............................. 95 tolcapone ............................... 54 tolnaftate ............................. 124 tolterodine ........................... 124 tolvaptan ............................... 72 TOPICORT ................. 114, 119 topiramate ............................. 48 topotecan ............................... 19 torsemide ........................ 42, 68 TOSYMRA ........................... 62 TOUJEO MAX U-300
SOLOSTAR ..................... 91
145
TOUJEO SOLOSTAR U-300 INSULIN .......................... 91
TOVIAZ ............................. 124 TRADJENTA ....................... 88 tramadol ................................ 57 tramadol-acetaminophen47, 50,
57 tranexamic acid .................... 30 tranylcypromine ................... 56 travoprost .............................. 76 trazodone .............................. 62 TREANDA ........................... 19 TRECATOR ........................... 6 TRELEGY ELLIPTA ... 24, 27,
84, 104, 108, 110 TRELSTAR .................... 19, 89 TREMFYA ......................... 123 treprostinil sodium........ 44, 110 TRESIBA FLEXTOUCH U-
100 .............................. 91, 92 TRESIBA FLEXTOUCH U-
200 .............................. 91, 92 TRESIBA U-100 INSULIN 91,
92 tretinoin .............................. 116 tretinoin (antineoplastic) ...... 19 tretinoin microspheres ........ 116 TRETTEN ............................ 30 TREXALL ...... 19, 99, 101, 102 TRIADVANCE ..... 32, 71, 126,
128 triamcinolone acetonide 74, 84,
107, 114, 119 triamterene-hydrochlorothiazid
........................ 43, 44, 68, 71 TRIANEX .................. 114, 119 triazolam ............................... 54 TRI-BUFFERED ASPIRIN 33,
50, 61 trifluoperazine ...................... 59 trifluridine............................. 73 trihexyphenidyl............... 24, 47 TRIJARDY XR ........ 86, 88, 94 TRIKAFTA ........................ 105 TRI-LEGEST FE.................. 87 trimethoprim ......................... 13 TRINATAL GT.................... 32 TRINTELLIX....................... 62 TRIPLE ANTIBIOTIC ...... 111 TRI-SPRINTEC (28)............ 87 TRIUMEQ .......................... 8, 9
TRIVEEN-ONE .... 32, 71, 126, 128
TRIVEEN-PRX RNF .... 32, 71, 79, 126, 128
TRI-VI-FLOR .............. 98, 126 TRI-VI-SOL WITH IRON .. 32,
126, 128, 129 TRI-VITAMIN WITH
FLUORIDE ..... 98, 126, 128, 129
TROGARZO .......................... 8 TROPHAMINE 10 % .......... 67 TROPHAMINE 6% ............. 67 tropicamide ........................... 76 trospium .............................. 124 TRULICITY ......................... 90 TRUMENBA........................ 22 TRUVADA ............................ 9 TRUZONE PEAK FLOW
METER ............................ 64 TUKYSA .............................. 19 TURALIO ............................ 19 TUSSIN .............................. 105 TWINRIX (PF)..................... 22 TWIRLA .............................. 87 TYBOST ............................ 103 TYKERB .............................. 19 TYMLOS........................ 92, 97 TYVASO ...................... 44, 110 TYVASO INSTITUTIONAL
START KIT .............. 44, 110 TYVASO REFILL KIT 44, 110 TYVASO STARTER KIT .. 45,
110 U UBRELVY ........................... 54 UDENYCA .......................... 29 ULESFIA.................... 120, 121 ULTIMATECARE ONE NF
.................... 32, 71, 126, 128 ULTRA FRESH ................... 75 ULTRAVATE ............ 114, 119 UPTRAVI ..................... 45, 110 urea ..................................... 120 ursodiol ................................. 79 V VAGICAINE (WITH VIT
A,D) ................................ 115 VAGINAL
CONTRACEPTIVE FILM ........................................ 103
VAGINAL CONTRACEPTIVE FOAM ........................................ 103
valacyclovir .......................... 11 VALCHLOR ................ 19, 123 valganciclovir ....................... 12 valproic acid ............. 48, 49, 50 valproic acid (as sodium salt)
.............................. 48, 49, 50 valsartan ................................ 34 valsartan-hydrochlorothiazide
.............................. 34, 44, 71 VALTOCO ..................... 53, 54 vancomycin ............................. 7 VAQTA (PF) ........................ 22 VARITHENA ....................... 43 VARIVAX (PF) .................... 22 VARIZIG .............................. 20 VASCEPA ............................ 35 VCF CONTRACEPTIVE GEL
........................................ 103 VECTIBIX ........................... 19 vecuronium bromide ............. 25 VELCADE ........................... 19 VELIVET TRIPHASIC
REGIMEN (28) ................ 87 VELPHORO ......................... 68 VELTASSA .......................... 68 VEMLIDY ............................ 12 VENCLEXTA ...................... 19 VENCLEXTA STARTING
PACK ............................... 19 venlafaxine ........................... 61 VENTAVIS .................. 45, 110 verapamil ............ 37, 38, 40, 45 VERDESO .................. 114, 119 VERZENIO .......................... 19 VIC-FORTE ............... 126, 128 VICODIN ES .................. 47, 57 VICODIN HP ................. 47, 57 VICTOZA 2-PAK ................ 90 VICTOZA 3-PAK ................ 90 VIDEX 2 GRAM PEDIATRIC
............................................ 9 VIDEX 4 GRAM PEDIATRIC
............................................ 9 VIEKIRA PAK ............. 7, 8, 10 VIIBRYD ............................. 62 VIMPAT ............................... 48 VINACAL B ........ 32, 126, 128 VINATE II .......................... 126
146
VINATE M .......... 32, 126, 128 VINATE ONE 32, 71, 126, 128 VINATE PN CARE ........... 126 VINATE ULTRA .... 32, 71, 79,
126, 128 vinblastine ............................ 19 VINCASAR PFS .................. 19 vincristine ............................. 19 vinorelbine ............................ 19 VIORELE (28) ..................... 87 VIRACEPT .......................... 10 VIREAD ................................. 9 VIRT-SELECT 32, 71, 79, 126,
128 VITAFOL GUMMIES .. 32, 71,
126, 128 VITAMED MD ONE RX ... 32,
126, 128 vitamin a ............................. 126 VITAMIN B-1.................... 128 VITAMIN B-12.................. 128 VITAMIN C ............... 128, 129 VITAMIN D2 ..................... 129 VITAMIN D3 ..................... 129 vitamin e (dl, acetate) ......... 130 VITAMIN K1 ............... 96, 130 VITRAKVI........................... 19 VIVITROL ..................... 58, 95 VIVOTIF BERNA VACCINE
.......................................... 22 VIZIMPRO........................... 19 VOL-NATE .... 32, 71, 126, 128 voriconazole ........................... 6 VOSEVI ............................. 7, 8 VOTRIENT .......................... 19 VP-CH PLUS . 32, 79, 126, 128 VRAYLAR........................... 52 VSL#3 .................................. 80 VYVANSE ........................... 46
VYZULTA ........................... 76 W WAKIX ................................ 63 warfarin ................................ 28 water for inject, bacteriostat
........................................ 103 water for injection, sterile ... 103 WELCHOL .................... 36, 85 WIDE-SEAL DIAPHRAGM
60 .................................... 103 WILATE ............................... 30 WIXELA INHUB.. 27, 84, 108,
110 X XALKORI ............................ 19 XARELTO ........................... 28 XELJANZ .................... 99, 101 XELJANZ XR .............. 99, 101 XELPROS ............................ 76 XENICAL ............................ 81 XENLETA............................ 12 XERAVA ............................... 7 XIFAXAN ............................ 13 XIGDUO XR .................. 86, 94 XIIDRA ................................ 75 XOFLUZA ............................. 6 XOLAIR ............................. 108 XOSPATA............................ 19 XPOVIO ............................... 20 XTAMPZA ER..................... 58 XTANDI ............................... 20 XULANE.............................. 87 XYLIMELTS ..................... 124 XYNTHA ............................. 30 XYNTHA SOLOFUSE ........ 30 XYREM................................ 55 Y YERVOY ............................. 20 YONDELIS .......................... 20
YONSA ................................ 20 Z zaleplon ................................. 51 ZALTRAP ............................ 20 ZANOSAR ........................... 20 ZARXIO ............................... 29 ZATEAN-CH .. 32, 71, 79, 126,
128 ZEJULA ............................... 20 ZELBORAF ......................... 20 ZEMBRACE SYMTOUCH . 62 ZENPEP ............................... 80 ZENZEDI ............................. 46 ZEPATIER ......................... 7, 8 zidovudine .............................. 9 ZIEXTENZO ........................ 29 zinc sulfate ............................ 71 ZINGIBER ........... 71, 126, 128 ZIOPTAN (PF) ..................... 76 ziprasidone hcl ................ 49, 52 ZIRGAN ............................... 73 ZOLADEX ............... 20, 89, 90 ZOLINZA ............................. 20 zolmitriptan ........................... 62 zolpidem ............................... 51 ZOLPIMIST ......................... 51 ZOMACTON ....................... 92 ZOMIG ................................. 62 zonisamide ............................ 48 ZORTRESS ........................ 102 ZOSTAVAX (PF) ................ 22 ZOVIA 1/50E (28) ............... 87 ZUBSOLV ............................ 58 ZYDELIG ............................. 20 ZYKADIA ............................ 20 ZYPREXA RELPREVV 49, 52