Updated 08/25/17
1
YourCare Health Plan
Essential Health Plan
September 2017
Table of Contents
ANTI - INFECTIVES ........................................................................................................................................ 3
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ....................................................................... 8
AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ....................................................................... 12
CARDIOVASCULAR, HYPERTENSION & LIPIDS ................................................................................. 20
DERMATOLOGICALS/TOPICAL THERAPY .......................................................................................... 24
DIAGNOSTICS & MISCELLANEOUS AGENTS ...................................................................................... 29
EAR, NOSE & THROAT MEDICATIONS .................................................................................................. 31
ENDOCRINE/DIABETES .............................................................................................................................. 31
GASTROENTEROLOGY .............................................................................................................................. 37
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ............................................................................. 41
MUSCULOSKELETAL & RHEUMATOLOGY ......................................................................................... 42
OBSTETRICS & GYNECOLOGY ................................................................................................................ 43
OPHTHALMOLOGY ..................................................................................................................................... 47
RESPIRATORY, ALLERGY, COUGH & COLD ....................................................................................... 49
UROLOGICALS .............................................................................................................................................. 52
VITAMINS, HEMATINICS & ELECTROLYTES ..................................................................................... 53
Index .................................................................................................................................................................. 60
2
List of Abbreviations
ACA: Affordable Care Act.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service.
OTC: Over the Counter. An OTC drug is a non-prescription drug.
PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug.
QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
List of Tiers TIER # TIER DESCRIPTION Tier 1 Generics Tier 2 Preferred brands Tier 3 Non-preferred brands* Tier 4 Specialty (generics)
Tier 5 Specialty (preferred brands)
Tier 6 ACA/Preventative drugs (no copay required) *Tier 3 products are not listed on the formulary guidebook since these are non-preferred/non-formulary.
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
3
Drug Name Drug Tier
Requirements / Limits
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
amphotericin b 1
CANCIDAS 2
clotrimazole 1
CRESEMBA 2
fluconazole in dextrose(iso-o)
1
fluconazole in nacl (iso-osm)
1
fluconazole oral suspension for reconstitution
1
fluconazole oral tablet 100 mg, 200 mg, 50 mg
1
fluconazole oral tablet 150 mg
1 QL
flucytosine 1
griseofulvin microsize
1
griseofulvin ultramicrosize
1
itraconazole 1 QL
ketoconazole 1
MYCAMINE 2
NOXAFIL 2
nystatin 1
SPORANOX 2
terbinafine hcl 1
voriconazole 1
ANTIVIRALS
Drug Name Drug Tier
Requirements / Limits
abacavir 4 LA
abacavir-lamivudine 4
abacavir-lamivudine-zidovudine
4 LA
acyclovir 1
acyclovir sodium 1
adefovir 1
amantadine hcl 1
APTIVUS 5 LA
ATRIPLA 5 LA
BARACLUDE 2
cidofovir 1
COMPLERA 5 LA
CRIXIVAN 5 LA
DAKLINZA 5 PA; LA; QL
DESCOVY 5 LA
didanosine 4 LA
EDURANT 5 LA
EMTRIVA 5 LA
entecavir 1
EPCLUSA 5 PA; LA; QL
EPIVIR HBV 2
famciclovir oral tablet 125 mg, 250 mg, 500 mg
1 QL
foscarnet 1
FUZEON 5 LA
ganciclovir sodium 1
GENVOYA 5 LA
INTELENCE 5 LA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
4
Drug Name Drug Tier
Requirements / Limits
INVIRASE 5 LA
ISENTRESS 5 LA
KALETRA 5 LA
lamivudine oral solution
4 LA
lamivudine oral tablet 100 mg
1
lamivudine oral tablet 150 mg, 300 mg
4 LA
lamivudine-zidovudine
4 LA
LEXIVA 5 LA
lopinavir-ritonavir 4 LA
nevirapine 4 LA
NORVIR 5 LA
ODEFSEY 5 LA
OLYSIO 5 PA; LA; QL
oseltamivir oral capsule 30 mg, 45 mg, 75 mg
1 QL
PREZCOBIX 5 LA
PREZISTA 5 LA
RAPIVAB 2
RELENZA DISKHALER
2 QL
RESCRIPTOR 5 LA
RETROVIR 5 LA
REYATAZ 5 LA
ribavirin 1
rimantadine 1
SELZENTRY 5 PA; LA
stavudine 4 LA
Drug Name Drug Tier
Requirements / Limits
STRIBILD 5 LA
SUSTIVA 5 LA
SYNAGIS 5 PA; LA
TAMIFLU 2 QL
TECHNIVIE 5 PA; LA; QL
TIVICAY 5 LA
TRIUMEQ 5 LA
TRUVADA 5 LA
valacyclovir 1 QL
valganciclovir 1
VEMLIDY 2
VIDEX 2 GRAM PEDIATRIC
5 LA
VIEKIRA PAK 5 PA; LA; QL
VIEKIRA XR 5 PA; LA; QL
VIRACEPT 5 LA
VIREAD 5 LA
ZEPATIER 5 PA; LA; QL
ZIAGEN 5 LA
zidovudine 4 LA
CEPHALOSPORINS
AVYCAZ 2
cefaclor 1
cefadroxil 1
cefazolin 1
cefazolin in dextrose (iso-os)
1
cefdinir 1
cefditoren pivoxil 1
cefepime 1
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
5
Drug Name Drug Tier
Requirements / Limits
cefepime in dextrose,iso-osm
1
cefixime 1
cefotaxime 1
cefotetan 1
cefoxitin 1
cefoxitin in dextrose, iso-osm
1
cefpodoxime 1
cefprozil 1
ceftazidime 1
ceftibuten 1
ceftriaxone 1
ceftriaxone in dextrose,iso-os
1
cefuroxime axetil 1
cefuroxime sodium 1
cephalexin 1
ZERBAXA 2
ERYTHROMYCINS & OTHER MACROLIDES
azithromycin 1
clarithromycin 1
DIFICID 2
e.e.s. 400 1
E.E.S. GRANULES 2
ERYPED 200 2
ERYPED 400 2
ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg
1
Drug Name Drug Tier
Requirements / Limits
ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG
2
erythrocin (as stearate)
1
erythromycin 1
erythromycin ethylsuccinate
1
MISCELLANEOUS ANTIINFECTIVES
ALBENZA 2 QL
ALINIA ORAL SUSPENSION FOR RECONSTITUTION
2 QL
ALINIA ORAL TABLET
2 QL
amikacin 1
atovaquone 1
atovaquone-proguanil
1
aztreonam 1
baciim 1
bacitracin 1
BILTRICIDE 2
CAYSTON 5 LA; QL
chloramphenicol sod succinate
1
chloroquine phosphate
1
cleocin 1
clindamycin hcl 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
6
Drug Name Drug Tier
Requirements / Limits
clindamycin in 5 % dextrose
1
clindamycin palmitate hcl
1
clindamycin pediatric
1
clindamycin phosphate
1
COARTEM 2
colistin (colistimethate na)
1
CUBICIN RF 2
CYCLOSERINE 2
DALVANCE 2
dapsone 1
daptomycin 1
DARAPRIM 5 LA
EMVERM 2 QL
ethambutol 1
gentamicin 1
gentamicin in nacl (iso-osm)
1
gentamicin sulfate (ped) (pf)
1
gentamicin sulfate (pf)
1
hydroxychloroquine 1
imipenem-cilastatin 1
IMPAVIDO 2
isoniazid 1
ivermectin 1 QL
KITABIS PAK 5 LA; QL
lincomycin 1
Drug Name Drug Tier
Requirements / Limits
linezolid intravenous 1
linezolid oral 1 PA
linezolid-0.9% sodium chloride
1
mefloquine 1
meropenem 1
MEROPENEM-0.9% SODIUM CHLORIDE
2
metro i.v. 1
metronidazole 1
metronidazole in nacl (iso-os)
1
NEBUPENT 2 QL
neomycin 1
ORBACTIV 2
paromomycin 1
PASER 2
polymyxin b sulfate 1
PRIFTIN 2
PRIMAQUINE 2
pyrazinamide 1
quinine sulfate 1
rifabutin 1
RIFAMATE 2
rifampin 1
RIFATER 2
SIRTURO 2
SIVEXTRO INTRAVENOUS
2
SIVEXTRO ORAL 2 PA
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
7
Drug Name Drug Tier
Requirements / Limits
tinidazole oral tablet 250 mg
1
tinidazole oral tablet 500 mg
1 QL
tobramycin in 0.225 % nacl
4 LA; QL
tobramycin in 0.9 % nacl
1
tobramycin sulfate 1
TRECATOR 2
TYGACIL 2
XIFAXAN ORAL TABLET 200 MG, 550 MG
2 QL
ZYVOX 2
PENICILLINS
amoxicillin 1
amoxicillin-pot clavulanate
1
ampicillin 1
ampicillin sodium 1
ampicillin-sulbactam 1
AUGMENTIN 2
dicloxacillin 1
nafcillin 1
nafcillin in dextrose iso-osm
1
oxacillin 1
oxacillin in dextrose(iso-osm)
1
penicillin g potassium
1
penicillin g procaine 1
Drug Name Drug Tier
Requirements / Limits
penicillin g sodium 1
penicillin v potassium
1
pfizerpen-g 1
piperacillin-tazobactam
1
QUINOLONES
AVELOX IN NACL (ISO-OSMOTIC)
2
ciprofloxacin 1
ciprofloxacin (mixture)
1
ciprofloxacin hcl 1
ciprofloxacin in 5 % dextrose
1
ciprofloxacin lactate 1
FACTIVE 2
levofloxacin 1
levofloxacin in d5w 1
moxifloxacin 1
MOXIFLOXACIN-SOD.ACE,SUL-WATER
2
ofloxacin 1
SULFA'S & RELATED AGENTS
sulfadiazine 1
sulfamethoxazole-trimethoprim
1
sulfatrim 1
TETRACYCLINES
avidoxy 1
demeclocycline 1
doxy-100 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
8
Drug Name Drug Tier
Requirements / Limits
doxycycline hyclate 1
doxycycline monohydrate
1
minocycline 1
mondoxyne nl 1
morgidox 1
tetracycline 1
URINARY TRACT AGENTS
methenamine hippurate
1
methenamine mandelate
1
MONUROL 2
nitrofurantoin 1
nitrofurantoin macrocrystal
1
nitrofurantoin monohyd/m-cryst
1
trimethoprim 1
VANCOMYCIN
vancomycin 1
VANCOMYCIN IN 0.9% SODIUM CL
2
VANCOMYCIN IN DEXTROSE 5 %
2
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
amifostine crystalline
1
dexrazoxane hcl 1
ELITEK 2
Drug Name Drug Tier
Requirements / Limits
KEPIVANCE 5 LA
leucovorin calcium 1
LEVOLEUCOVORIN INTRAVENOUS RECON SOLN 175 MG
2
levoleucovorin intravenous recon soln 50 mg
1
levoleucovorin intravenous solution
1
mesna 1
MESNEX 2
VISTOGARD 5 LA
XGEVA 5 LA
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS
ABRAXANE 5 LA
ADCETRIS 5 LA
adriamycin 1
adrucil 1
AFINITOR 5 PA; LA
AFINITOR DISPERZ
5 PA; LA
ALECENSA 5 PA; LA; QL
ALIMTA 2
anastrozole 1
ARRANON 5 LA
ARZERRA 5 LA
AVASTIN 5 LA
azacitidine 4 LA
AZASAN 5 LA
azathioprine 4 LA
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
9
Drug Name Drug Tier
Requirements / Limits
azathioprine sodium 4 LA
BAVENCIO 5 LA
BENDEKA 5 LA
bexarotene 4 LA
bicalutamide 1
BICNU 2
bleo 15k 1
bleomycin 1
BLINCYTO 5 LA
BOSULIF ORAL TABLET 100 MG, 500 MG
5 PA; LA; QL
busulfan 1
BUSULFEX 2
capecitabine 4 LA
CAPRELSA ORAL TABLET 100 MG, 300 MG
5 PA; LA; QL
carboplatin 1
CELLCEPT INTRAVENOUS
5 LA
cisplatin 1
cladribine 1
clofarabine 1
CLOLAR 2
COTELLIC 5 PA; LA; QL
cyclophosphamide intravenous
1
CYCLOPHOSPHAMIDE ORAL
2
cyclosporine 4 LA
cyclosporine modified
4 LA
Drug Name Drug Tier
Requirements / Limits
CYRAMZA 5 LA
cytarabine 1
cytarabine (pf) 1
dacarbazine 1
DARZALEX 5 LA
daunorubicin 1
decitabine 4 LA
docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)
1
DOCETAXEL INTRAVENOUS SOLUTION 20 MG/ML
2
doxorubicin 1
doxorubicin, peg-liposomal
1
DROXIA 2
ELIGARD 5 PA; LA
ELIGARD (3 MONTH)
5 PA; LA
ELIGARD (4 MONTH)
5 PA; LA
ELIGARD (6 MONTH)
5 PA; LA
EMCYT 2
epirubicin 1
ERBITUX 5 PA; LA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
10
Drug Name Drug Tier
Requirements / Limits
ERIVEDGE 5 PA; LA; QL
ETOPOPHOS 2
etoposide 1
exemestane 1
FARESTON 2
FASLODEX 2
floxuridine 1
fludarabine 1
fluorouracil 1
flutamide 1
FOLOTYN 5 LA
GAZYVA 5 LA
gemcitabine 1
gengraf 4 LA
GILOTRIF 5 PA; LA; QL
GLEOSTINE 2
HALAVEN 5 LA
HERCEPTIN 5 PA; LA
HEXALEN 2
HYCAMTIN 5 LA
hydroxyurea 1
IBRANCE 5 PA; LA; QL
ICLUSIG ORAL TABLET 15 MG, 45 MG
5 PA; LA; QL
idarubicin 1
ifosfamide 1
ifosfamide-mesna 1
imatinib oral tablet 100 mg, 400 mg
4 PA; LA; QL
IMBRUVICA 5 PA; LA; QL
Drug Name Drug Tier
Requirements / Limits
INLYTA ORAL TABLET 1 MG, 5 MG
5 PA; LA; QL
IRESSA 5 LA; QL
irinotecan 1
ISTODAX 5 LA
IXEMPRA 5 LA
JAKAFI 5 PA; LA; QL
KADCYLA 5 PA; LA
KEYTRUDA 5 LA
KYPROLIS 5 LA
LARTRUVO 5 LA
LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1)
5 PA; LA
LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2), 8 MG/DAY (4 MG X 2)
5 ST; LA
letrozole 1
LEUKERAN 2
leuprolide 4 LA
lipodox 1
LONSURF 5 PA; LA
LUPRON DEPOT 5 PA; LA
LUPRON DEPOT (3 MONTH)
5 PA; LA
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
11
Drug Name Drug Tier
Requirements / Limits
LUPRON DEPOT-PED
5 PA; LA
LUPRON DEPOT-PED (3 MONTH)
5 PA; LA
LYNPARZA 5 PA; LA
LYSODREN 2
MARQIBO 5 LA
MATULANE 5 LA
megestrol 1
MEKINIST ORAL TABLET 0.5 MG
5 ST; LA; QL
MEKINIST ORAL TABLET 2 MG
5 PA; LA; QL
melphalan 1
melphalan hcl 1
mercaptopurine 1
methotrexate sodium 1
methotrexate sodium (pf)
1
mitomycin 1
mitoxantrone 4 LA
MUSTARGEN 2
mycophenolate mofetil
4 LA
mycophenolate mofetil hcl
4 LA
mycophenolate sodium
4 LA
MYLERAN 2
NEXAVAR 5 PA; LA; QL
nilutamide 1
NINLARO 5 PA; LA; QL
NULOJIX 5 LA
Drug Name Drug Tier
Requirements / Limits
octreotide acetate 4 LA
ONCASPAR 2
ONIVYDE 5 LA
OPDIVO 5 LA
oxaliplatin 1
paclitaxel 1
PERJETA 5 PA; LA
PHOTOFRIN 2
PROGRAF 5 LA
PURIXAN 5 LA
RAPAMUNE 5 LA
RITUXAN 5 PA; LA
RUBRACA ORAL TABLET 200 MG, 300 MG
5 PA; LA; QL
RUBRACA ORAL TABLET 250 MG
5 PA; LA
RYDAPT 5 PA; LA
SANDIMMUNE 5 LA
SANDOSTATIN LAR DEPOT
5 LA
SIGNIFOR 5 PA; LA
SIMULECT 5 LA
sirolimus 4 LA
SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG
5 PA; LA; QL
STIVARGA 5 PA; LA; QL
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG
5 PA; LA; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
12
Drug Name Drug Tier
Requirements / Limits
SYLVANT 5 LA
TABLOID 2
tacrolimus 4 LA
TAFINLAR 5 ST; LA; QL
TAGRISSO 5 PA; LA
tamoxifen 6 ACA
TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG
5 PA; LA; QL
TARGRETIN 5 LA
TASIGNA 5 PA; LA; QL
TECENTRIQ 5 LA
TEMODAR 5 LA
temozolomide 4 PA; LA
TENIPOSIDE 2
THALOMID 5 PA; LA
thiotepa 1
toposar 1
topotecan 4 LA
TORISEL 5 LA
TREANDA 5 LA
tretinoin (chemotherapy)
1
TREXALL 2
TRISENOX 2
TYKERB 5 PA; LA; QL
UNITUXIN 5 LA
VANTAS 5 LA
VECTIBIX 5 PA; LA
VELCADE 5 LA
VENCLEXTA 5 PA; LA
Drug Name Drug Tier
Requirements / Limits
VENCLEXTA STARTING PACK
5 PA; LA; QL
vinblastine 1
vincasar pfs 1
vincristine 1
vinorelbine 1
VOTRIENT 5 PA; LA; QL
XALKORI 5 PA; LA; QL
XERMELO 5 PA; LA; QL
YERVOY 5 LA
YONDELIS 5 LA
ZANOSAR 2
ZEJULA 5 PA; LA; QL
ZELBORAF 5 PA; LA; QL
ZEVALIN (Y-90) 2
ZOLADEX 5 LA
ZOLINZA 5 LA
ZORTRESS 5 LA
ZYDELIG 5 PA; LA; QL
ZYKADIA 5 PA; LA; QL
ZYTIGA ORAL TABLET 250 MG, 500 MG
5 PA; LA; QL
AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH
ANTICONVULSANTS
APTIOM 2
BANZEL 2
carbamazepine 1
CELONTIN 2
clonazepam 1
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
13
Drug Name Drug Tier
Requirements / Limits
DILANTIN 2
DILANTIN EXTENDED
2
DILANTIN INFATABS
2
DILANTIN-125 2
divalproex 1
epitol 1
ethosuximide 1
felbamate 1
fosphenytoin 1
FYCOMPA 2
gabapentin 1
GABITRIL 2
lamotrigine 1
levetiracetam 1
levetiracetam in nacl (iso-os)
1
LYRICA 2 ST
ONFI 2
oxcarbazepine 1
PEGANONE 2
phenobarbital 1
phenytoin 1
phenytoin sodium 1
phenytoin sodium extended
1
primidone 1
roweepra 1
SABRIL 5 LA
tiagabine 1
Drug Name Drug Tier
Requirements / Limits
topiramate 1
valproate sodium 1
valproic acid 1
valproic acid (as sodium salt)
1
VIMPAT 2
zonisamide 1
ANTIPARKINSONISM AGENTS
APOKYN 5 LA
benztropine 1
bromocriptine 1
carbidopa 1
carbidopa-levodopa 1
carbidopa-levodopa-entacapone
1
entacapone 1
pramipexole 1
rasagiline 1
ropinirole 1
selegiline hcl 1
tolcapone 1
trihexyphenidyl 1
MIGRAINE & CLUSTER HEADACHE THERAPY
almotriptan malate oral tablet 12.5 mg, 6.25 mg
1 QL
dihydroergotamine injection
1
dihydroergotamine nasal
1 QL
ERGOMAR 2
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
14
Drug Name Drug Tier
Requirements / Limits
ergotamine-caffeine 1
frovatriptan 1 QL
isomethepten-caf-acetaminophen
1
migergot 1
naratriptan 1 QL
rizatriptan 1 QL
sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation
1 QL
sumatriptan succinate oral
1 QL
sumatriptan succinate subcutaneous
1 QL
zolmitriptan 1 QL
ZOMIG 2 ST; QL
MISCELLANEOUS NEUROLOGICAL THERAPY
AMPYRA 5 PA; LA; QL
donepezil oral tablet 10 mg, 5 mg
1
donepezil oral tablet 23 mg
1 ST
donepezil oral tablet,disintegrating
1
galantamine 1
memantine 1
NUEDEXTA 2 PA
RADICAVA 5 LA
rivastigmine 1
rivastigmine tartrate 1
Drug Name Drug Tier
Requirements / Limits
tetrabenazine oral tablet 12.5 mg, 25 mg
4 PA; LA; QL
TYSABRI 5 PA; LA
MUSCLE RELAXANTS & ANTISPASMODIC THERAPY
baclofen 1
carisoprodol 1
chlorzoxazone 1
cyclobenzaprine 1
dantrolene 1
meprobamate 1
MESTINON 2
metaxall 1
metaxalone 1
methocarbamol 1
orphenadrine citrate 1
pyridostigmine bromide
1
regonol 1
revonto 1
tizanidine 1
NARCOTIC ANALGESICS
acetaminophen-caff-dihydrocod
1
acetaminophen-codeine
1
ascomp with codeine 1
aspirin-caffeine-dihydrocodein
1
astramorph-pf 1
buprenorphine hcl 1
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
15
Drug Name Drug Tier
Requirements / Limits
butalbital compound w/codeine
1
butalbital-acetaminop-caf-cod
1
butalbital-acetaminophen
1
butalbital-acetaminophen-caff
1
butalbital-aspirin-caffeine
1
capacet 1
codeine sulfate 1
codeine-butalbital-asa-caff
1
diskets 1
duramorph (pf) 1
endocet 1
fentanyl 1
fentanyl citrate 1 PA; QL
fentanyl citrate (pf) 1
fentanyl citrate-0.9%nacl (pf)
1
hydrocodone-acetaminophen
1
hydrocodone-ibuprofen
1
hydromorphone (pf) 1
hydromorphone in 0.9 % nacl
1
hydromorphone injection
1
hydromorphone oral liquid
1
Drug Name Drug Tier
Requirements / Limits
hydromorphone oral tablet
1
hydromorphone oral tablet extended release 24 hr
1 QL
hydromorphone rectal
1
HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG
2 ST; QL
ibuprofen-oxycodone 1
levorphanol tartrate 1
lorcet (hydrocodone) 1
lorcet hd 1
lorcet plus 1
marten-tab 1
meperidine 1
methadone 1
methadose 1
morphine (pf) 1
morphine (pf) in 0.9 % nacl
1
morphine concentrate
1
morphine injection 1
morphine intravenous
1
morphine oral capsule, er multiphase 24 hr
1 QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
16
Drug Name Drug Tier
Requirements / Limits
morphine oral capsule,extend.release pellets
1 QL
morphine oral solution
1
morphine oral tablet 1
morphine oral tablet extended release
1 QL
morphine rectal 1
oxycodone 1
oxycodone-acetaminophen
1
oxycodone-aspirin 1
OXYCONTIN 2 ST; QL
oxymorphone oral tablet
1
oxymorphone oral tablet extended release 12 hr
1 QL
tencon 1
verdrocet 1
vicodin 1
vicodin es 1
vicodin hp 1
xylon 10 1
zamicet 1
zebutal 1
NON-NARCOTIC ANALGESICS
aspir-81 6 ACA; OTC
aspirin 6 ACA; OTC
aspirin low dose 6 ACA; OTC
aspir-low 6 ACA; OTC
aspir-trin 6 ACA; OTC
Drug Name Drug Tier
Requirements / Limits
bayer aspirin 6 ACA; OTC
buprenorphine-naloxone
1 QL
butorphanol tartrate injection
1
butorphanol tartrate nasal
1 QL
celecoxib 1 ST
children's aspirin 6 ACA; OTC
choline,magnesium salicylate
1
diclofenac potassium 1
diclofenac sodium oral
1
diclofenac sodium topical drops
1 QL
diclofenac sodium topical gel
1 QL
diclofenac-misoprostol
1
diflunisal 1
e.c. prin 6 ACA; OTC
ecotrin 6 ACA; OTC
ecotrin low strength 6 ACA; OTC
etodolac 1
EUFLEXXA 5 LA
fenoprofen 1
flurbiprofen 1
ibuprofen 1
indomethacin 1
ketoprofen 1
ketorolac injection 1
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
17
Drug Name Drug Tier
Requirements / Limits
ketorolac intramuscular
1
ketorolac oral 1 QL
lite coat aspirin 6 ACA; OTC
meclofenamate 1
mefenamic acid 1
meloxicam oral suspension
1
meloxicam oral tablet 15 mg
1
meloxicam oral tablet 7.5 mg
1 QL
nabumetone 1
nalbuphine 1
naloxone 1
naltrexone 1
naproxen 1
naproxen sodium 1
NARCAN 2 QL
NUCYNTA 2 QL
NUCYNTA ER 2 ST; QL
oxaprozin 1
piroxicam 1
salsalate 1
SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG
2 QL
sulindac 1
tolmetin 1
tramadol oral tablet 1 QL
Drug Name Drug Tier
Requirements / Limits
tramadol oral tablet extended release 24 hr
1 QL
tramadol oral tablet, er multiphase 24 hr
1
tramadol-acetaminophen
1 QL
VIVITROL 5 LA
ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG
2 QL
PSYCHOTHERAPEUTIC DRUGS
ABILIFY MAINTENA
2
alprazolam 1
alprazolam intensol 1
amitriptyline 1
amitriptyline-chlordiazepoxide
1
amoxapine 1
aripiprazole oral solution
1
aripiprazole oral tablet
1 QL
aripiprazole oral tablet,disintegrating
1 QL
ARISTADA 2
armodafinil oral tablet 150 mg, 250 mg, 50 mg
1 ST
armodafinil oral tablet 200 mg
1 PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
18
Drug Name Drug Tier
Requirements / Limits
atomoxetine 1
BELSOMRA 2 PA; QL
bupropion hcl oral tablet
1
bupropion hcl oral tablet extended release 12 hr
1 QL
bupropion hcl oral tablet extended release 24 hr
1 QL
buspirone 1
chlordiazepoxide hcl 1
chlorpromazine 1
citalopram oral solution
1
citalopram oral tablet
1 QL
clomipramine 1
clonidine hcl 1
clorazepate dipotassium
1
clozapine 1
desipramine 1
desvenlafaxine succinate
1 QL
dexedrine 1
dexmethylphenidate 1
dextroamphetamine 1
dextroamphetamine-amphetamine
1
diazepam 1
diazepam intensol 1
doxepin 1
Drug Name Drug Tier
Requirements / Limits
duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 40 mg, 60 mg
1 QL
EMSAM 2
ergoloid 1
escitalopram oxalate oral solution
1
escitalopram oxalate oral tablet
1 QL
estazolam 1 QL
eszopiclone 1 QL
FANAPT ORAL TABLET
2 QL
FANAPT ORAL TABLETS,DOSE PACK
2 QL
FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK
2 ST; QL
FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR
2 ST; QL
flumazenil 1
fluoxetine oral capsule 10 mg, 40 mg
1 QL
fluoxetine oral capsule 20 mg
1
fluoxetine oral capsule,delayed release(dr/ec)
1 QL
fluoxetine oral solution
1
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
19
Drug Name Drug Tier
Requirements / Limits
fluoxetine oral tablet 10 mg
1 QL
fluoxetine oral tablet 20 mg
1
fluphenazine decanoate
1
fluphenazine hcl 1
flurazepam 1 QL
fluvoxamine oral capsule,extended release 24hr
1 QL
fluvoxamine oral tablet 100 mg, 25 mg, 50 mg
1 QL
guanfacine 1
guanidine 1
haloperidol 1
haloperidol decanoate
1
haloperidol lactate 1
imipramine hcl 1
imipramine pamoate 1
LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG
2 QL
lithium carbonate 1
lithium citrate 1
lorazepam 1
lorazepam intensol 1
loxapine succinate 1
maprotiline 1
MARPLAN 2
metadate er 1
Drug Name Drug Tier
Requirements / Limits
methamphetamine 1
methylphenidate hcl 1
midazolam 1
mirtazapine 1
modafinil 1 PA
nefazodone 1
nortriptyline 1
olanzapine intramuscular
1
olanzapine oral 1 QL
olanzapine-fluoxetine
1
oxazepam 1
paliperidone 1 QL
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg
1 QL
paroxetine hcl oral tablet extended release 24 hr
1 QL
perphenazine 1
perphenazine-amitriptyline
1
phenelzine 1
pimozide 1
procentra 1
protriptyline 1
quazepam 1 QL
quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg
1 QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
20
Drug Name Drug Tier
Requirements / Limits
quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 300 mg, 400 mg, 50 mg
1 QL
REXULTI 2 QL
RISPERDAL CONSTA
2
risperidone oral solution
1
risperidone oral tablet
1 QL
risperidone oral tablet,disintegrating
1 QL
ROZEREM 2 ST; QL
seconal sodium 1 QL
sertraline oral concentrate
1
sertraline oral tablet 100 mg, 25 mg, 50 mg
1 QL
temazepam 1 QL
thioridazine 1
thiothixene 1
tranylcypromine 1
trazodone 1
triazolam 1 QL
trifluoperazine 1
trimipramine 1
TRINTELLIX 2 ST; QL
venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg
1 QL
Drug Name Drug Tier
Requirements / Limits
venlafaxine oral tablet
1 QL
venlafaxine oral tablet extended release 24hr
1 QL
VIIBRYD 2 ST; QL
VYVANSE 2 ST
XYREM 5 PA; LA
zaleplon 1 QL
zenzedi 1
ziprasidone hcl 1 QL
zolpidem 1 QL
CARDIOVASCULAR, HYPERTENSION & LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone 1
disopyramide phosphate
1
dofetilide 1
flecainide 1
mexiletine 1
MULTAQ 2
pacerone 1
procainamide 1
propafenone 1
quinidine gluconate 1
quinidine sulfate 1
sotalol 1
sotalol af 1
SOTYLIZE 2
ANTIHYPERTENSIVE THERAPY
acebutolol 1
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
21
Drug Name Drug Tier
Requirements / Limits
afeditab cr 1
amiloride 1
amiloride-hydrochlorothiazide
1
amlodipine 1
amlodipine-benazepril
1
amlodipine-olmesartan
1
amlodipine-valsartan
1
amlodipine-valsartan-hcthiazid
1
atenolol 1
atenolol-chlorthalidone
1
benazepril 1
benazepril-hydrochlorothiazide
1
betaxolol 1
bisoprolol fumarate 1
bisoprolol-hydrochlorothiazide
1
bumetanide 1
BYSTOLIC 2 ST
candesartan 1
candesartan-hydrochlorothiazid
1
captopril 1
captopril-hydrochlorothiazide
1
cartia xt 1
carvedilol 1
Drug Name Drug Tier
Requirements / Limits
chlorothiazide 1
chlorothiazide sodium
1
chlorthalidone 1
clonidine 1 QL
clonidine hcl 1
clorpres 1
DEMSER 2
diltiazem 1
dilt-xr 1
doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg
1 QL
DUTOPROL 2 ST
DYRENIUM 2
enalapril maleate 1
enalaprilat 1
enalapril-hydrochlorothiazide
1
eplerenone 1
epoprostenol (glycine)
4 LA
eprosartan 1
esmolol 1
ethacrynate sodium 1
ethacrynic acid 1
felodipine 1
fosinopril 1
fosinopril-hydrochlorothiazide
1
furosemide 1
guanfacine 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
22
Drug Name Drug Tier
Requirements / Limits
hydralazine 1
hydrochlorothiazide 1
indapamide 1
irbesartan 1
irbesartan-hydrochlorothiazide
1
isradipine 1
labetalol 1
LEVATOL 2 ST
lisinopril 1
lisinopril-hydrochlorothiazide
1
losartan 1
losartan-hydrochlorothiazide
1
matzim la 1
methyclothiazide 1
methyldopa 1
methyldopa-hydrochlorothiazide
1
methyldopate 1
metolazone 1
metoprolol succinate 1
metoprolol ta-hydrochlorothiaz
1
metoprolol tartrate 1
minoxidil 1
moexipril 1
moexipril-hydrochlorothiazide
1
nadolol 1
nadolol-bendroflumethiazide
1
Drug Name Drug Tier
Requirements / Limits
nicardipine 1
nifedipine 1
nimodipine 1
nisoldipine 1
olmesartan 1
olmesartan-amlodipin-hcthiazid
1
olmesartan-hydrochlorothiazide
1
papaverine 1
perindopril erbumine
1
phenoxybenzamine 1
phentolamine 1
pindolol 1
prazosin 1
propranolol 1
propranolol-hydrochlorothiazid
1
quinapril 1
quinapril-hydrochlorothiazide
1
ramipril 1
REMODULIN 5 LA
spironolactone 1
spironolacton-hydrochlorothiaz
1
taztia xt 1
telmisartan 1
telmisartan-amlodipine
1
telmisartan-hydrochlorothiazid
1
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
23
Drug Name Drug Tier
Requirements / Limits
terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg
1 QL
timolol maleate 1
torsemide 1
trandolapril 1
trandolapril-verapamil
1
triamterene-hydrochlorothiazid
1
UPTRAVI 5 LA
valsartan 1
valsartan-hydrochlorothiazide
1
veletri 4 LA
verapamil 1
CARDIAC GLYCOSIDES
digitek 1
digox 1
digoxin 1
COAGULATION THERAPY
AMICAR 2
aminocaproic acid 1
ARGATROBAN IN NACL (ISO-OS)
2
aspirin-dipyridamole 1
bivalirudin 1
BRILINTA 2
CEPROTIN (BLUE BAR)
5 LA
CEPROTIN (GREEN BAR)
5 LA
cilostazol 1
Drug Name Drug Tier
Requirements / Limits
clopidogrel 1
COAGADEX 5 LA
dipyridamole 1
EFFIENT 2
ELIQUIS 2 PA
enoxaparin 4 LA
fondaparinux 4 LA
FRAGMIN 5 LA
hep flush-10 (pf) 1
heparin (porcine) 1
heparin (porcine) in 5 % dex
1
heparin (porcine) in nacl (pf)
1
heparin flush(porcine)-0.9nacl
1
heparin lock flush 1
heparin lock flush (porcine)
1
heparin lockflush(porcine)(pf)
1
heparin(porcine) in 0.45% nacl
1
heparin, porcine (pf) 1
jantoven 1
MEPHYTON 2
NPLATE 5 PA; LA
pentoxifylline 1
PRADAXA 2 PA
PROMACTA 5 PA; LA
protamine 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
24
Drug Name Drug Tier
Requirements / Limits
RIASTAP 5 LA
ticlopidine 1
tranexamic acid 1
vitamin k 1
vitamin k1 1
warfarin 1
XARELTO 2 PA
LIPID/CHOLESTEROL LOWERING AGENTS
amlodipine-atorvastatin
1 QL
atorvastatin 1 QL
cholestyramine (with sugar)
1
cholestyramine light 1
colestipol 1
ezetimibe 1
ezetimibe-simvastatin
1 QL
fenofibrate 1
fenofibrate micronized
1
fenofibrate nanocrystallized
1
fenofibric acid 1
fenofibric acid (choline)
1
fluvastatin oral capsule 20 mg, 40 mg
1 QL
fluvastatin oral tablet extended release 24 hr
1 QL
gemfibrozil 1
Drug Name Drug Tier
Requirements / Limits
JUXTAPID 5 PA; LA
LIVALO 2 PA; QL
lovastatin oral tablet 10 mg, 20 mg, 40 mg
1 QL
niacin 1
omega-3 acid ethyl esters
1 PA
PRALUENT PEN 5 PA; LA; QL
pravastatin 1 QL
prevalite 1
REPATHA PUSHTRONEX
5 PA; LA; QL
REPATHA SURECLICK
5 PA; LA; QL
REPATHA SYRINGE
5 PA; LA; QL
rosuvastatin 1 QL
simvastatin 1 QL
VASCEPA 2 PA
MISCELLANEOUS CARDIOVASCULAR AGENTS
CORLANOR 2
ENTRESTO 2 QL
NITRATES
isosorbide dinitrate 1
isosorbide mononitrate
1
nitro-bid 1
nitroglycerin 1
nitroglycerin in 5 % dextrose
1
DERMATOLOGICALS/TOPICAL THERAPY
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
25
Drug Name Drug Tier
Requirements / Limits
ANTIPSORIATIC / ANTISEBORRHEIC
acitretin 1
calcipotriene 1
calcipotriene-betamethasone
1
calcitrene 1
calcitriol 1
COAL TAR 2
COSENTYX 5 PA; LA
COSENTYX (2 SYRINGES)
5 PA; LA
COSENTYX PEN 5 PA; LA
COSENTYX PEN (2 PENS)
5 PA; LA
drithocreme hp 1
hydrocortisone-pramoxine
1
seb-prev 1
selenium sulfide 1
STELARA 5 PA; LA
sulfacetamide sodium
1
BURN THERAPY
silver sulfadiazine 1
ssd 1
thermazene 1
KERATOLYTICS
salicylic acid 1
salicylic acid er-ceramides
1
salvax 1
Drug Name Drug Tier
Requirements / Limits
MISCELLANEOUS DERMATOLOGICALS
avo cream 1
bp-50% urea 1
celacyn 1
cem-urea 1
diclofenac sodium 1 PA; QL
doxepin 1 QL
DUPIXENT 5 PA; LA; QL
eletone 1
ELIDEL 2
emulsion sb 1
fluorouracil 1
hpr 1
hpr plus 1
hpr plus hydrogel 1
lactic acid 1
lactic acid e 1
luxamend 1
mb hydrogel 1
mb hydrogel (cyclomethicone)
1
methoxsalen 1
nivatopic plus 1
PANRETIN 2
PICATO 2
podofilox 1
pruclair 1
prudoxin 1 QL
prumyx 1
prutect 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
26
Drug Name Drug Tier
Requirements / Limits
rea lo 39 1
rea lo 40 1
REGRANEX 2 QL
silver nitrate 1
silver nitrate applicators
1
sonafine 1
sp antipruritic 1
sp scar management 1
tacrolimus 1 QL
umecta 1
urea 1
urea nail stick 1
ure-k 1
UVADEX 2
VALCHLOR 5 LA
VEREGEN 2
THERAPY FOR ACNE
adapalene 1
amnesteem 1
avar 1
avita 1 PA
AZELEX 2 ST
benzepro 1
benzoyl peroxide 1
bp 10-1 1
bpo 1
claravis 1
cleansing wash 1
clindacin p 1
Drug Name Drug Tier
Requirements / Limits
clindamycin phosphate
1
clindamycin-benzoyl peroxide
1
clindamycin-tretinoin
1
EPIDUO 2 ST
EPIDUO FORTE 2 ST
ery pads 1
erygel 1
erythromycin with ethanol
1
erythromycin-benzoyl peroxide
1
metronidazole 1
MIRVASO 2
neuac 1
rosadan 1
rosula cleansing cloths
1
SOOLANTRA 2 ST
ss 10-2 1
sss 10-5 1
sulfacetamide sodium-sulfur
1
sulfacetamide sod-sulfur-urea
1
sulfacetamide-sulfur-cleansr23
1
sulfacleanse 8-4 1
sulfact na-sul-avobnz-otn-ocsa
1
tazarotene 1 PA
TAZORAC 2 PA
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
27
Drug Name Drug Tier
Requirements / Limits
tretinoin 1 PA
tretinoin microspheres
1 PA
VELTIN 2 PA
zenatane 1
TOPICAL ANESTHETICS
cidaleaze 1
dermacinrx prizopak 1
ethyl chloride 1
glydo 1 QL
lidocaine (pf) 1
lidocaine hcl injection
1
lidocaine hcl laryngotracheal
1
lidocaine hcl mucous membrane jelly
1 QL
lidocaine hcl mucous membrane jelly in applicator
1 QL
lidocaine hcl mucous membrane solution
1
lidocaine hcl topical 1
lidocaine hcl-hydrocortison ac
1
lidocaine topical adhesive patch,medicated
1 PA
lidocaine topical ointment
1 QL
lidocaine viscous 1
lidocaine-epinephrine
1
Drug Name Drug Tier
Requirements / Limits
lidocaine-prilocaine topical cream
1 QL
lidocaine-prilocaine topical kit
1
lido-k 1
lidopin 1
lidopril 1
lta pre-attached 1
PLIAGLIS 2
relador pak 1
relador pak plus 1
TOPICAL ANTIBACTERIALS
CORTISPORIN 2
gentamicin 1
hydrocortisone-iodoquinol-aloe
1
iodoquinol-hc 1
lugols 1
mupirocin 1
mupirocin calcium 1
NEO-SYNALAR 2
sulfacetamide sodium (acne)
1
SULFAMYLON 2
TOPICAL ANTIFUNGALS
ciclodan topical cream
1 QL
ciclodan topical solution
1
ciclopirox topical cream
1 QL
ciclopirox topical gel
1 QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
28
Drug Name Drug Tier
Requirements / Limits
ciclopirox topical shampoo
1 QL
ciclopirox topical solution
1
ciclopirox topical suspension
1 QL
ciclopirox-ure-camph-menth-euc
1
clotrimazole-betamethasone topical cream
1 QL
clotrimazole-betamethasone topical lotion
1 QL
econazole 1 QL
ERTACZO 2 QL
EXELDERM 2 QL
ketoconazole topical cream
1 QL
ketoconazole topical foam
1 QL
ketoconazole topical shampoo
1 QL
LUZU 2 QL
MENTAX 2 QL
naftifine 1 QL
nyamyc 1
nyata 1
nystatin topical cream
1 QL
nystatin topical ointment
1 QL
nystatin topical powder
1
Drug Name Drug Tier
Requirements / Limits
nystatin-triamcinolone
1 QL
nystop 1
oxiconazole 1 QL
TRIACETIN 2
TOPICAL ANTIVIRALS
ABREVA 2 OTC
acyclovir 1 PA; QL
DENAVIR 2
ZOVIRAX 2 QL
TOPICAL CORTICOSTEROIDS
ala-cort 1
alclometasone 1
amcinonide 1
apexicon e 1
betamethasone dipropionate
1
betamethasone valerate
1
betamethasone, augmented
1
clobetasol scalp 1 QL
clobetasol topical cream
1 QL
clobetasol topical foam
1 QL
clobetasol topical gel
1 QL
clobetasol topical lotion
1 QL
clobetasol topical ointment
1 QL
clobetasol topical shampoo
1 QL
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
29
Drug Name Drug Tier
Requirements / Limits
clobetasol topical spray,non-aerosol
1 QL
clobetasol-emollient topical cream
1 QL
clobetasol-emollient topical foam
1 QL
clodan 1 QL
CORDRAN 2 ST
CORDRAN TAPE LARGE ROLL
2 ST
cormax 1 QL
desonide 1
desoximetasone 1
diflorasone 1
fluocinolone 1
fluocinolone and shower cap
1
fluocinonide 1 QL
fluocinonide-e 1 QL
flurandrenolide 1
fluticasone 1
halobetasol propionate
1
HALOG 2 ST
hydrocortisone 1
hydrocortisone butyrate
1
hydrocortisone butyr-emollient
1
hydrocortisone valerate
1
hydrocortisone-min oil-wht pet
1
Drug Name Drug Tier
Requirements / Limits
mometasone 1
nolix 1
prednicarbate 1
scalacort 1
triamcinolone acetonide
1
trianex 1
triderm 1
TOPICAL ENZYMES
SANTYL 2
TOPICAL SCABICIDES / PEDICULICIDES
EURAX 2
lindane 1
malathion 1
permethrin 1
spinosad 1
ULESFIA 2
DIAGNOSTICS & MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
lactated ringers 1
neomycin-polymyxin b gu
1
ringer's 1
tis-u-sol pentalyte 1
MISCELLANEOUS AGENTS
acamprosate 1
acetic acid 1
ADAGEN 5 LA
alendronate 1 QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
30
Drug Name Drug Tier
Requirements / Limits
anagrelide 1
ARALAST NP 5 PA; LA
BUPHENYL 2
caffeine citrate 1
CARBAGLU 5 LA
cevimeline 1
CHEMET 2
curity sterile water 1 OTC; QL
disulfiram 1
etidronate disodium 1
EXJADE 5 LA
FERRIPROX 5 LA
INCRELEX 5 PA; LA
JADENU 5 LA
levocarnitine 1
levocarnitine (with sugar)
1
midodrine 1
ORFADIN 5 LA
pilocarpine hcl 1
PROLASTIN-C 5 PA; LA
RAVICTI 5 LA
riluzole 1
risedronate 1 QL
sodium benzoate-sod phenylacet
1
sodium chlor 0.9% bacteriostat
1
sodium chloride 1
sodium chloride 0.9 %
1
Drug Name Drug Tier
Requirements / Limits
sodium ferric gluconat-sucrose
1
sodium phenylbutyrate
1
SOLIRIS 5 LA
water for irrigation, sterile
1 QL
XURIDEN 5 LA
ZEMAIRA 5 PA; LA
zoledronic acid-mannitol-water
4 PA; LA
SMOKING DETERRENTS
bupropion hcl (smoking deter)
6 ACA; QL
CHANTIX 6 ACA; QL
CHANTIX CONTINUING MONTH BOX
6 ACA; QL
CHANTIX STARTING MONTH BOX
6 ACA; QL
NICODERM CQ 6 ACA; OTC; QL
nicorelief 6 ACA; OTC; QL
NICORETTE BUCCAL GUM 2 MG
6 ACA; OTC; QL
nicorette buccal gum 4 mg
6 ACA; OTC; QL
NICORETTE BUCCAL LOZENGE
6 ACA; OTC; QL
NICORETTE BUCCAL MINI LOZENGE
6 ACA; OTC; QL
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
31
Drug Name Drug Tier
Requirements / Limits
nicotine 6 ACA; OTC; QL
nicotine (polacrilex) 6 ACA; OTC; QL
NICOTROL 6 ACA; QL
NICOTROL NS 6 ACA; QL
nts step 1 6 ACA; OTC; QL
quit 2 buccal gum 6 ACA; OTC; QL
QUIT 2 BUCCAL LOZENGE
6 ACA; OTC; QL
quit 4 buccal gum 6 ACA; OTC; QL
QUIT 4 BUCCAL LOZENGE
6 ACA; OTC; QL
stop smoking aid 6 ACA; OTC; QL
EAR, NOSE & THROAT MEDICATIONS
MISCELLANEOUS AGENTS
azelastine nasal aerosol,spray
1 QL
azelastine nasal spray,non-aerosol
1
BACTROBAN NASAL
2
chlorhexidine gluconate
1
DEBACTEROL 2
denta 5000 plus 1
dentagel 1
fluoride (sodium) 1
ipratropium bromide 1 QL
Drug Name Drug Tier
Requirements / Limits
olopatadine 1 QL
oralone 1
paroex oral rinse 1
periogard 1
pilocarpine hcl 1
sf 1
sf 5000 plus 1
triamcinolone acetonide
1
MISCELLANEOUS OTIC PREPARATIONS
acetic acid 1
acetic acid-aluminum acetate
1
ciprofloxacin hcl 1
floxin 1
fluocinolone acetonide oil
1
hydrocortisone-acetic acid
1
ofloxacin 1
OTIC STEROID / ANTIBIOTIC
CIPRO HC 2
CIPRODEX 2
neomycin-polymyxin-hc
1
ENDOCRINE/DIABETES
ADRENAL HORMONES
ACTHAR H.P. 5 PA; LA
betamethasone acet,sod phos
1
cortisone 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
32
Drug Name Drug Tier
Requirements / Limits
cosyntropin 1
deltasone 1
dexamethasone 1
dexamethasone intensol
1
dexamethasone sodium phos (pf)
1
dexamethasone sodium phosphate
1
fludrocortisone 1
hydrocortisone 1
methylprednisolone 1
methylprednisolone acetate
1
millipred 1
millipred dp 1
prednisolone 1
prednisolone sodium phosphate
1
prednisone 1
prednisone intensol 1
triamcinolone acetonide
1
veripred 20 1
ANTITHYROID AGENTS
methimazole 1
propylthiouracil 1
BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES
FREESTYLE INSULINX
2 OTC; QL
FREESTYLE INSULINX TEST STRIPS
2 OTC; QL
Drug Name Drug Tier
Requirements / Limits
FREESTYLE LITE STRIPS
2 OTC; QL
FREESTYLE TEST 2 OTC; QL
DIABETES, SUPPLIES, & DURABLE MEDICAL EQUIPMENT
ACE AEROSOL CLOUD ENHANCER
2 QL
AEROCHAMBER MINI
2 QL
AEROCHAMBER PLUS FLOW-VU
2 QL
AEROCHAMBER PLUS Z STAT SM MSK
2 QL
AEROTRACH PLUS
2 QL
AEROVENT PLUS 2 QL
BREATHERITE WITH MASK, SMALL
2 QL
CLEVER CHOICE CHAMBER-SM MASK
2 QL
COMPACT SPACE CHAMBER-LRG MASK
2 QL
EASIVENT HOLDING CHAMBER
2 QL
E-Z SPACER 2 QL
FLEXICHAMBER 2 QL
INSPIRACHAMBER WITH MASK-LARGE
2 QL
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
33
Drug Name Drug Tier
Requirements / Limits
INSULIN SYRINGE-NEEDLE U-100
2
LITEAIRE MDI CHAMBER
2 QL
MICROCHAMBER 2 QL
MICROSPACER 2 QL
OPTICHAMBER DIAMOND LG MASK
2 QL
POCKET CHAMBER
2 QL
PRIMEAIRE 2 QL
PROCHAMBER 2 QL
RITEFLO AEROCHAMBER
2 QL
VORTEX HOLDING CHAMBER CHILD
2 QL
VORTEX VHC FROG MASK-CHILD
2 QL
VORTEX VHC LADYBUG MASK-TODDLR
2 QL
GLUCOSE ELEVATING AGENTS
GLUCAGEN HYPOKIT
2
GLUCAGON EMERGENCY KIT (HUMAN)
2
PROGLYCEM 2
INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQU
Drug Name Drug Tier
Requirements / Limits
AUTOJECT 2 INJECTION DEVICE
2 OTC
AUTOPEN 1 TO 21 UNITS
2 OTC
CARTRIDGE STAMPED IR 1200
2 OTC
CLEO 90 INFUSION SET 24"
2 QL
COMFORT INFUSION SET 43"
2 QL
COMFORT SHORT INSULIN PUMP 23"
2 QL
CONTACT DETACH INFUS SET 23"
2 QL
FREESTYLE CONTROL
2 OTC
FREESTYLE FLASH SYSTEM
2 OTC
FREESTYLE FREEDOM
2 OTC
FREESTYLE FREEDOM LITE
2 OTC
FREESTYLE INSULINX
2 OTC
FREESTYLE LITE METER
2 OTC
FREESTYLE SIDEKICK II
2 OTC
FREESTYLE SYSTEM KIT
2 OTC
HUMAPEN LUXURA HD
2
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
34
Drug Name Drug Tier
Requirements / Limits
INSET 30 INFUSION SET 23"
2 QL
INSET INFUSION SET 23"
2 QL
LANCETS 2 OTC; QL
LANCING DEVICE 2 OTC
MINIMED INFUSION SET-MMT 390
2 QL
MIO INFUSION SET
2 QL
OMNIPOD INSULIN REFILL
2
PEN NEEDLE 2 OTC
QUICK-SET PARADIGM
2 QL
SAFE-CLIP BY MAIL
2 OTC
SNAP INSULIN PUMP-INFUSION SET
2
SURE-T PARADIGM
2 QL
T:30 INFUSION SET
2 QL
T:90 INFUSION SET 23"
2 QL
T:SLIM 2
T:SLIM G4 2
VGO 20 2
VGO 30 2
VGO 40 2
INSULIN THERAPY
APIDRA 2
Drug Name Drug Tier
Requirements / Limits
APIDRA SOLOSTAR
2
BASAGLAR KWIKPEN
2
HUMALOG 2
HUMALOG KWIKPEN
2
HUMALOG MIX 50-50
2
HUMALOG MIX 50-50 KWIKPEN
2
HUMALOG MIX 75-25
2
HUMALOG MIX 75-25 KWIKPEN
2
HUMULIN 70/30 2
HUMULIN 70/30 KWIKPEN
2
HUMULIN N 2
HUMULIN N KWIKPEN
2
HUMULIN R U-100 2
HUMULIN R U-500 (CONC) KWIKPEN
2
HUMULIN R U-500 (CONCENTRATED)
2
LANTUS 2
LANTUS SOLOSTAR
2
LEVEMIR 2
LEVEMIR FLEXTOUCH
2
NOVOLOG 2
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
35
Drug Name Drug Tier
Requirements / Limits
NOVOLOG FLEXPEN
2
NOVOLOG MIX 70-30
2
NOVOLOG MIX 70-30 FLEXPEN
2
NOVOLOG PENFILL
2
RELION NOVOLIN 70/30
2
RELION NOVOLIN N
2
RELION NOVOLIN R
2
MISCELLANEOUS HORMONES
ALDURAZYME 5 LA
ANADROL-50 2
androxy 1
BRINEURA 5 LA
cabergoline 1 QL
calcitonin (salmon) 1
calcitriol 1
CERDELGA 5 LA
danazol 1
desmopressin 1
doxercalciferol 1
ELAPRASE 5 LA
ELELYSO 5 LA
FABRAZYME 5 LA
HECTOROL 2
KANUMA 5 LA
KUVAN 5 PA; LA
Drug Name Drug Tier
Requirements / Limits
LUMIZYME 5 LA
METHITEST 2
methyltestosterone 1
MYALEPT 5 PA; LA
NAGLAZYME 5 LA
NATPARA 5 PA; LA
oxandrolone 1
pamidronate 1
paricalcitol 1
SAMSCA ORAL TABLET 15 MG, 30 MG
5 PA; LA; QL
SENSIPAR 2
SOMAVERT 5 LA
STIMATE 5 LA
STRENSIQ 5 LA
SYNAREL 2
TESTOPEL 5 PA; LA
testosterone 1 PA
testosterone cypionate
1 PA
testosterone enanthate
1 PA
VIMIZIM 5 LA
VPRIV 5 LA
ZAVESCA 5 LA
zoledronic acid 4 LA
ZOMETA 5 LA
NON-INSULIN HYPOGLYCEMIC AGENTS
acarbose 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
36
Drug Name Drug Tier
Requirements / Limits
ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 15-1,000 MG, 30-1,000 MG
2 QL
BYDUREON 2 QL
BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML
2 QL
chlorpropamide 1
FARXIGA 2 ST; QL
glimepiride 1
glipizide 1
glipizide-metformin 1
glyburide 1
glyburide micronized
1
glyburide-metformin 1
GLYXAMBI 2 ST; QL
INVOKAMET 2 QL
INVOKANA 2 QL
JANUMET 2 QL
JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, 50-500 MG
2 QL
JANUVIA ORAL TABLET 100 MG
2 QL
Drug Name Drug Tier
Requirements / Limits
JANUVIA ORAL TABLET 25 MG, 50 MG
2 ST; QL
JARDIANCE 2 ST; QL
JENTADUETO 2 QL
JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG
2 ST; QL
metformin 1
miglitol 1
nateglinide 1
pioglitazone 1 QL
pioglitazone-glimepiride
1 QL
pioglitazone-metformin
1 QL
repaglinide 1
repaglinide-metformin
1 QL
SYMLINPEN 120 2 QL
SYMLINPEN 60 2 QL
SYNJARDY 2 QL
SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 25-1,000 MG, 5-1,000 MG
2 QL
TANZEUM 2 QL
tolazamide 1
tolbutamide 1
TRADJENTA 2 QL
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
37
Drug Name Drug Tier
Requirements / Limits
VICTOZA 2-PAK 2 QL
VICTOZA 3-PAK 2 QL
XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5-1,000 MG, 5-500 MG
2 ST; QL
THYROID HORMONES
ARMOUR THYROID
2
levothyroxine 1
levoxyl 1
liothyronine 1
nature-throid 1
np thyroid 1
SYNTHROID 2
THYROLAR-1 2
THYROLAR-1/2 2
THYROLAR-1/4 2
THYROLAR-2 2
THYROLAR-3 2
unithroid 1
westhroid 1
GASTROENTEROLOGY
ANTIDIARRHEALS & ANTISPASMODICS
anaspaz 1
atropine 1
belladonna alkaloids-opium
1
belladonna-opium 1
Drug Name Drug Tier
Requirements / Limits
bismuth 1 OTC
chlordiazepoxide-clidinium
1
dicyclomine 1
diphenoxylate-atropine
1
ed-spaz 1
glycopyrrolate 1
hyoscyamine sulfate 1
hyosyne 1
loperamide 1 OTC
methscopolamine 1
MOTOFEN 2
opium tincture 1
oscimin 1
oscimin sl 1
oscimin sr 1
paregoric 1
phenohytro 1
symax fastabs 1
symax-sl 1
symax-sr 1
MISCELLANEOUS GASTROINTESTINAL AGENTS
AKYNZEO 2 QL
alophen 6 ACA; OTC
alosetron 1
ALOXI 2 QL
AMITIZA 2
aprepitant oral capsule 125 mg, 40 mg, 80 mg
1 QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
38
Drug Name Drug Tier
Requirements / Limits
aprepitant oral capsule,dose pack
1 QL
APRISO 2
balsalazide 1
bisacodyl 6 ACA; OTC
bisa-lax 6 ACA; OTC
budesonide 1
calcium acetate 1
CANASA 2
CESAMET 2 QL
CHENODAL 5 PA; LA
CHOLBAM ORAL CAPSULE 250 MG
5 LA
CHOLBAM ORAL CAPSULE 50 MG
5 LA; QL
citrate of magnesia 6 ACA; OTC
citroma 6 ACA; OTC
clearlax 6 ACA; OTC
colocort 1
compro 1
constulose 1
CORTIFOAM 2
CREON 2
cromolyn 1
CYSTADANE 5 LA
dimenhydrinate 1
DIPENTUM 2
dronabinol 1
droperidol 1
ducodyl 6 ACA; OTC
eliphos 1
Drug Name Drug Tier
Requirements / Limits
EMEND INTRAVENOUS
2 QL
EMEND ORAL CAPSULE
2 QL
EMEND ORAL SUSPENSION FOR RECONSTITUTION
2 QL
ENTYVIO 5 PA; LA
enulose 1
fleet laxative 6 ACA; OTC
FOSRENOL 2
gavilax 6 ACA; OTC
gavilyte-c 6 ACA
gavilyte-g 6 ACA
gavilyte-n 6 ACA
generlac 1
gentle laxative 6 ACA; OTC
gentlelax 6 ACA; OTC
glycolax 6 ACA; OTC
granisetron (pf) 1
granisetron hcl intravenous
1
granisetron hcl oral 1 QL
healthylax 6 ACA; OTC
hemmorex-hc 1
hydrocortisone 1
hydrocortisone acetate
1
hydrocortisone-pramoxine
1
INFLECTRA 5 PA; LA
kionex 1
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
39
Drug Name Drug Tier
Requirements / Limits
kionex (with sorbitol)
1
lactulose 1
laxaclear 6 ACA; OTC
laxative (bisacodyl) 6 ACA; OTC
laxative feminine 6 ACA; OTC
laxative peg 3350 6 ACA; OTC
lidocaine hcl-hydrocortison ac
1
lidocaine-hydrocortisone-aloe
1
LINZESS 2
MAGNEBIND 300 2 OTC
magnesium citrate 6 ACA; OTC
mesalamine 1
mesalamine with cleansing wipe
1
metoclopramide hcl 1
milk of magnesia 6 ACA; OTC
milk of magnesia concentrated
6 ACA; OTC
miralax 6 ACA; OTC
MOVANTIK 2
MOVIPREP 6 ACA
natura-lax 6 ACA; OTC
OCALIVA 5 PA; LA; QL
ondansetron 1 QL
ondansetron hcl (pf) 1
ondansetron hcl intravenous
1
ondansetron hcl oral solution
1 QL
Drug Name Drug Tier
Requirements / Limits
ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg
1 QL
oral saline laxative 6 ACA; OTC
peg 3350-electrolytes
6 ACA
peg3350 6 ACA; OTC
peg-electrolyte soln 6 ACA
peg-prep 6 ACA
PENTASA 2
phosphate laxative 6 ACA; OTC
polyethylene glycol 3350
6 ACA
powderlax 6 ACA; OTC
pramcort 1
PREPOPIK 6 ACA
prochlorperazine 1
prochlorperazine edisylate
1
prochlorperazine maleate
1
procto-med hc 1
procto-pak 1
proctosol hc 1
proctozone-hc 1
purelax 6 ACA; OTC
RECTIV 2
RELISTOR 2
REMICADE 5 PA; LA
RENVELA 2
sevelamer carbonate 1
smoothlax 6 ACA; OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
40
Drug Name Drug Tier
Requirements / Limits
sodium polystyrene sulfonate
1
sps (with sorbitol) 1
SUCRAID 5 LA
sulfasalazine 1
SUPREP BOWEL PREP KIT
6 ACA
trilyte with flavor packets
6 ACA
trimethobenzamide 1
UCERIS 2
ursodiol 1
VARUBI 2 QL
VELPHORO 2
VELTASSA 2 LA
VIBERZI 2
VIOKACE 2
woman's laxative 6 ACA; OTC
women's gentle laxative(bisac)
6 ACA; OTC
women's laxative (bisacodyl)
6 ACA; OTC
ULCER THERAPY
amoxicil-clarithromy-lansopraz
1 QL
CARAFATE 2
cimetidine 1
cimetidine hcl 1
esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg
1 QL
Drug Name Drug Tier
Requirements / Limits
esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg
1
esomeprazole sodium
1
famotidine 1
famotidine (pf) 1
famotidine (pf)-nacl (iso-os)
1
lansoprazole 1
misoprostol 1
nizatidine 1
omeprazole magnesium
1 OTC
omeprazole oral capsule,delayed release(dr/ec) 10 mg
1 QL
omeprazole oral capsule,delayed release(dr/ec) 20 mg, 40 mg
1
omeprazole oral tablet,delayed release (dr/ec)
1 OTC
omeprazole-sodium bicarbonate oral capsule
1 ST
omeprazole-sodium bicarbonate oral packet 20-1,680 mg
1 ST; QL
omeprazole-sodium bicarbonate oral packet 40-1,680 mg
1 ST
pantoprazole intravenous
1
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
41
Drug Name Drug Tier
Requirements / Limits
pantoprazole oral tablet,delayed release (dr/ec) 20 mg
1 QL
pantoprazole oral tablet,delayed release (dr/ec) 40 mg
1
rabeprazole 1
ranitidine hcl 1
sucralfate 1
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ARANESP (IN POLYSORBATE)
5 LA
GRANIX 5 LA
LEUKINE 5 LA
MOZOBIL 5 LA
NEULASTA 5 PA; LA; QL
NEUPOGEN 5 PA; LA
PROCRIT 5 LA
ZARXIO 5 LA
GROWTH HORMONES
EGRIFTA 5 PA; LA
OMNITROPE 5 PA; LA
INTERFERONS
AVONEX (WITH ALBUMIN)
5 PA; LA; QL
AVONEX INTRAMUSCULAR PEN INJECTOR KIT
5 PA; LA; QL
Drug Name Drug Tier
Requirements / Limits
AVONEX INTRAMUSCULAR SYRINGE KIT
5 PA; LA; QL
EXTAVIA 5 PA; LA; QL
GILENYA 5 PA; LA
glatopa 4 PA; LA; QL
LEMTRADA 5 LA
moderiba 4 PA; LA
moderiba dose pack 4 PA; LA
OCREVUS 5 PA; LA
PEGASYS PROCLICK
5 PA; LA; QL
PEGASYS SUBCUTANEOUS SOLUTION
5 PA; LA; QL
PEGASYS SUBCUTANEOUS SYRINGE
5 PA; LA; QL
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML
5 PA; LA; QL
PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML
5 PA; LA; QL
POMALYST 5 LA
REBIF (WITH ALBUMIN)
5 PA; LA; QL
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
42
Drug Name Drug Tier
Requirements / Limits
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6)
5 PA; LA; QL
REBIF TITRATION PACK
5 PA; LA; QL
REVLIMID 5 PA; LA
ribasphere 4 PA; LA
ribasphere ribapak 4 PA; LA
ribavirin oral capsule
4 PA; LA
ribavirin oral tablet 4 ST; LA
SYLATRON 5 LA
TECFIDERA 5 PA; LA
INTERLEUKINS
ACTIMMUNE 5 LA
ALFERON N 2
ARCALYST 5 PA; LA
ILARIS (PF) 5 PA; LA
imiquimod 1
INTRON A 5 LA
KINERET 5 PA; LA
PROLEUKIN 5 LA
VACCINES & MISCELLANEOUS IMMUNOLOGICALS
BOTOX 5 PA; LA
FLUBLOK 2017-2018 (PF)
6 ACA
FLUBLOK QUAD 2017-2018 (PF)
6 ACA
PNEUMOVAX 23 6 ACA
Drug Name Drug Tier
Requirements / Limits
PREVNAR 13 (PF) 6 ACA
PROVENGE 5 LA
ZOSTAVAX (PF) 6 ACA
MUSCULOSKELETAL & RHEUMATOLOGY
GOUT THERAPY
allopurinol 1
allopurinol sodium 1
aloprim 1
COLCRYS 2
KRYSTEXXA 5 PA; LA
MITIGARE 2
probenecid 1
probenecid-colchicine
1
ULORIC 2 ST
OSTEOPOROSIS THERAPY
alendronate oral solution
1 QL
alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg
1 QL
FORTEO 5 PA; LA; QL
FOSAMAX PLUS D
2 ST; QL
ibandronate intravenous
4 PA; LA
ibandronate oral 1 QL
raloxifene 6 ACA
risedronate oral tablet 150 mg, 35 mg, 5 mg
1 QL
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
43
Drug Name Drug Tier
Requirements / Limits
risedronate oral tablet,delayed release (dr/ec)
1 QL
TYMLOS 5 PA; LA; QL
OTHER RHEUMATOLOGICALS
ACTEMRA INTRAVENOUS
5 PA; LA
ACTEMRA SUBCUTANEOUS
5 ST; LA
BENLYSTA 5 LA
DEPEN TITRATABS
2
ENBREL SUBCUTANEOUS RECON SOLN
5 PA; LA; QL
ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML)
5 PA; LA; QL
ENBREL SURECLICK
5 ST; LA; QL
HUMIRA 5 PA; LA; QL
HUMIRA PEDIATRIC CROHN'S START
5 ST; LA; QL
HUMIRA PEN CROHN'S-UC-HS START
5 ST; LA; QL
HUMIRA PEN PSORIASIS-UVEITIS
5 ST; LA; QL
leflunomide 1 QL
ORENCIA 5 PA; LA
OTEZLA 5 PA; LA
Drug Name Drug Tier
Requirements / Limits
OTEZLA STARTER
5 PA; LA
RIDAURA 2
SAVELLA ORAL TABLET
2 ST; QL
SAVELLA ORAL TABLETS,DOSE PACK
2 ST; QL
SIMPONI 5 PA; LA
OBSTETRICS & GYNECOLOGY
DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES
CAYA CONTOURED
6 ACA
FC2 FEMALE CONDOM
6 ACA; OTC; QL
FEMCAP 6 ACA
MIRENA 6 ACA; LA
PARAGARD T 380A
6 ACA; LA
WIDE-SEAL DIAPHRAGM
6 ACA
ESTROGENS & PROGESTINS
amabelz 1
camila 6 ACA
CRINONE 2
deblitane 6 ACA
DEPO-PROVERA 2
DUAVEE 2
errin 6 ACA
ESTRACE 2
estradiol oral 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
44
Drug Name Drug Tier
Requirements / Limits
estradiol transdermal patch semiweekly
1 QL
estradiol transdermal patch weekly
1 QL
estradiol valerate 1
estradiol-norethindrone acet
1
estropipate 1
fyavolv 1
heather 6 ACA
hydroxyprogesterone caproate
1
jencycla 6 ACA
jevantique lo 1
jinteli 1
jolivette 6 ACA
lopreeza 1
lyza 6 ACA
MAKENA 5 PA; LA
medroxyprogesterone intramuscular
6 ACA; QL
medroxyprogesterone oral
1
MENEST 2
mimvey 1
mimvey lo 1
nora-be 6 ACA
norethindrone (contraceptive)
6 ACA
norethindrone acetate
1
Drug Name Drug Tier
Requirements / Limits
norethindrone ac-eth estradiol
1
norlyda 6 ACA
norlyroc 6 ACA
progesterone micronized
1
sharobel 6 ACA
yuvafem 1
MISCELLANEOUS OB/GYN
clindamycin phosphate
1
fem ph 1
GYNAZOLE-1 2
gynol ii 6 ACA; OTC
isoxsuprine 1
metronidazole 1
miconazole-3 1
NEXPLANON 6 ACA; LA
NUVARING 6 ACA
OSPHENA 2
terconazole 1
tranexamic acid 1
vaginal contraceptive foam
6 ACA; OTC
vandazole 1
xulane 6 ACA
ORAL CONTRACEPTIVES & RELATED AGENTS
altavera (28) 6 ACA
alyacen 1/35 (28) 6 ACA
alyacen 7/7/7 (28) 6 ACA
amethia 6 ACA
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
45
Drug Name Drug Tier
Requirements / Limits
amethia lo 6 ACA
amethyst 6 ACA
apri 6 ACA
aranelle (28) 6 ACA
ashlyna 6 ACA
aubra 6 ACA
aviane 6 ACA
azurette (28) 6 ACA
balziva (28) 6 ACA
bekyree (28) 6 ACA
blisovi 24 fe 6 ACA
blisovi fe 1.5/30 (28) 6 ACA
blisovi fe 1/20 (28) 6 ACA
briellyn 6 ACA
camrese 6 ACA
camrese lo 6 ACA
caziant (28) 6 ACA
chateal 6 ACA
cryselle (28) 6 ACA
cyclafem 1/35 (28) 6 ACA
cyclafem 7/7/7 (28) 6 ACA
cyred 6 ACA
dasetta 1/35 (28) 6 ACA
dasetta 7/7/7 (28) 6 ACA
daysee 6 ACA
delyla (28) 6 ACA
desog-e.estradiol/e.estradiol
6 ACA
desogestrel-ethinyl estradiol
6 ACA
Drug Name Drug Tier
Requirements / Limits
drospirenone-e.estradiol-lm.fa
6 ACA
drospirenone-ethinyl estradiol
6 ACA
econtra ez 6 ACA; OTC; QL
elinest 6 ACA
ELLA 6 ACA; QL
emoquette 6 ACA
enpresse 6 ACA
enskyce 6 ACA
estarylla 6 ACA
ethynodiol diac-eth estradiol
6 ACA
fallback solo 6 ACA; OTC; QL
falmina (28) 6 ACA
fayosim 6 ACA
femynor 6 ACA
gianvi (28) 6 ACA
gildagia 6 ACA
introvale 6 ACA
isibloom 6 ACA
jolessa 6 ACA
juleber 6 ACA
junel 1.5/30 (21) 6 ACA
junel 1/20 (21) 6 ACA
junel fe 1.5/30 (28) 6 ACA
junel fe 1/20 (28) 6 ACA
junel fe 24 6 ACA
kaitlib fe 6 ACA
kariva (28) 6 ACA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
46
Drug Name Drug Tier
Requirements / Limits
kelnor 1/35 (28) 6 ACA
kimidess (28) 6 ACA
kurvelo 6 ACA
l norgest/e.estradiol-e.estrad
6 ACA
larin 1.5/30 (21) 6 ACA
larin 1/20 (21) 6 ACA
larin 24 fe 6 ACA
larin fe 1.5/30 (28) 6 ACA
larin fe 1/20 (28) 6 ACA
larissia 6 ACA
layolis fe 6 ACA
leena 28 6 ACA
lessina 6 ACA
levonest (28) 6 ACA
levonorgestrel-ethinyl estrad
6 ACA
levonorg-eth estrad triphasic
6 ACA
levora-28 6 ACA
lomedia 24 fe 6 ACA
loryna (28) 6 ACA
low-ogestrel (28) 6 ACA
lutera (28) 6 ACA
marlissa 6 ACA
mibelas 24 fe 6 ACA
microgestin 1.5/30 (21)
6 ACA
microgestin 1/20 (21)
6 ACA
microgestin fe 1.5/30 (28)
6 ACA
Drug Name Drug Tier
Requirements / Limits
microgestin fe 1/20 (28)
6 ACA
mono-linyah 6 ACA
mononessa (28) 6 ACA
my way 6 ACA; OTC; QL
myzilra 6 ACA
necon 0.5/35 (28) 6 ACA
necon 1/50 (28) 6 ACA
necon 7/7/7 (28) 6 ACA
next choice one dose 6 ACA; OTC; QL
nikki (28) 6 ACA
noreth-ethinyl estradiol-iron
6 ACA
norethindrone ac-eth estradiol
6 ACA
norethindrone-e.estradiol-iron
6 ACA
norgestimate-ethinyl estradiol
6 ACA
nortrel 0.5/35 (28) 6 ACA
nortrel 1/35 (21) 6 ACA
nortrel 1/35 (28) 6 ACA
nortrel 7/7/7 (28) 6 ACA
ocella 6 ACA
ogestrel (28) 6 ACA
opcicon one-step 6 ACA; OTC; QL
option-2 6 ACA; OTC; QL
orsythia 6 ACA
philith 6 ACA
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
47
Drug Name Drug Tier
Requirements / Limits
pimtrea (28) 6 ACA
pirmella 6 ACA
PLAN B ONE-STEP 6 ACA; OTC; QL
portia 6 ACA
previfem 6 ACA
quasense 6 ACA
rajani 6 ACA
reclipsen (28) 6 ACA
rivelsa 6 ACA
setlakin 6 ACA
sprintec (28) 6 ACA
sronyx 6 ACA
syeda 6 ACA
tarina fe 1/20 (28) 6 ACA
tilia fe 6 ACA
tri femynor 6 ACA
tri-estarylla 6 ACA
tri-legest fe 6 ACA
tri-linyah 6 ACA
tri-lo-estarylla 6 ACA
tri-lo-marzia 6 ACA
tri-lo-sprintec 6 ACA
trinessa (28) 6 ACA
trinessa lo 6 ACA
tri-previfem (28) 6 ACA
tri-sprintec (28) 6 ACA
trivora (28) 6 ACA
velivet triphasic regimen (28)
6 ACA
vestura (28) 6 ACA
Drug Name Drug Tier
Requirements / Limits
vienva 6 ACA
viorele (28) 6 ACA
vyfemla (28) 6 ACA
wera (28) 6 ACA
wymzya fe 6 ACA
zarah 6 ACA
zenchent (28) 6 ACA
zenchent fe 6 ACA
zovia 1/35e (28) 6 ACA
zovia 1/50e (28) 6 ACA
OXYTOCICS
methergine 1
OPHTHALMOLOGY
ANTIBIOTICS
AZASITE 2
bacitracin 1
bacitracin-polymyxin b
1
BESIVANCE 2
ciprofloxacin hcl 1
erythromycin 1
gatifloxacin 1
gentak 1
gentamicin 1
levofloxacin 1
MOXEZA 2
moxifloxacin 1
NATACYN 2
neomycin-bacitracin-polymyxin
1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
48
Drug Name Drug Tier
Requirements / Limits
neomycin-polymyxin-gramicidin
1
neo-polycin 1
ofloxacin 1
polycin 1
polymyxin b sulf-trimethoprim
1
tobramycin 1
ANTIVIRALS
trifluridine 1
ZIRGAN 2
BETA-BLOCKERS
betaxolol 1
carteolol 1
levobunolol 1
metipranolol 1
timolol maleate 1
CHOLINESTERASE INHIBITOR MIOTICS
PHOSPHOLINE IODIDE
2
CYCLOPLEGIC MYDRIATICS
atropine 1
cyclopentolate 1
homatropaire 1
homatropine hbr 1
tropicamide 1
DIRECT ACTING MIOTICS
pilocarpine hcl 1
MISCELLANEOUS OPHTHALMOLOGICS
Drug Name Drug Tier
Requirements / Limits
acuicyn 1
ALOCRIL 2
ALOMIDE 2
altacaine 1
altafluor 1
azelastine 1
BEPREVE 2 ST
cromolyn 1
CYSTARAN 5 LA
EMADINE 2 ST
epinastine 1
EYLEA 5 PA; LA
flucaine 1
fluorescein-proparacaine
1
flurox 1
JETREA (PF) 5 LA
LASTACAFT 2 ST
LUCENTIS 5 PA; LA
olopatadine 1
proparacaine 1
RESTASIS 2 PA; QL
RESTASIS MULTIDOSE
2 PA; QL
tetcaine 1
tetracaine hcl 1
tetracaine hcl (pf) 1
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
bromfenac 1
diclofenac sodium 1
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
49
Drug Name Drug Tier
Requirements / Limits
flurbiprofen sodium 1
ILEVRO 2
ketorolac 1
NEVANAC 2
ORAL DRUGS FOR GLAUCOMA
acetazolamide 1
acetazolamide sodium
1
methazolamide 1
OTHER GLAUCOMA DRUGS
AZOPT 2
bimatoprost 1
COMBIGAN 2
dorzolamide 1
dorzolamide-timolol 1
latanoprost 1
miostat 1
SIMBRINZA 2
TRAVATAN Z 2 ST
ZIOPTAN (PF) 2 ST
STEROID-ANTIBIOTIC COMBINATIONS
neomycin-bacitracin-poly-hc
1
neomycin-polymyxin b-dexameth
1
neomycin-polymyxin-hc
1
neo-polycin hc 1
tobramycin-dexamethasone
1
STEROIDS
Drug Name Drug Tier
Requirements / Limits
dexamethasone sodium phosphate
1
DUREZOL 2
fluorometholone 1
LOTEMAX 2
OZURDEX 5 LA
PRED MILD 2
prednisolone acetate 1
prednisolone sodium phosphate
1
STEROID-SULFONAMIDE COMBINATIONS
sulfacetamide-prednisolone
1
SULFONAMIDES
sulfacetamide sodium
1
SYMPATHOMIMETICS
ALPHAGAN P 2
apraclonidine 1
brimonidine 1
VASOCONSTRICTOR DECONGESTANTS
phenylephrine hcl 1
RESPIRATORY, ALLERGY, COUGH & COLD
ANTIHISTAMINE & ANTIALLERGENIC AGENTS
adrenalin 1
carbinoxamine maleate
1
clemastine 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
50
Drug Name Drug Tier
Requirements / Limits
cyproheptadine 1
desloratadine oral tablet
1 QL
desloratadine oral tablet,disintegrating
1 QL
diphenhydramine hcl 1
EPINEPHRINE INJECTION AUTO-INJECTOR
2 QL
epinephrine injection solution
1
epinephrine injection syringe
1
hydroxyzine hcl 1
hydroxyzine pamoate
1
phenadoz 1
phenergan 1
promethazine 1
promethegan 1
COUGH & COLD THERAPY
benzonatate 1
brompheniramine-pseudoeph-dm
1
centergy 1
cheratussin ac 1
codeine-guaifenesin 1
g tussin ac 1
guaiatussin ac 1
guaifenesin ac 1
guaifenesin dac 1
hydrocodone-chlorpheniramine
1
Drug Name Drug Tier
Requirements / Limits
hydrocodone-cpm-pseudoephed
1
hydrocodone-homatropine
1
hydromet 1
lortuss ex 1
m-clear wc 1
promethazine vc-codeine
1
promethazine-codeine
1
promethazine-dm 1
promethazine-phenyleph-codeine
1
promethazine-phenylephrine
1
relcof c 1
rydex 1
tusnel c 1
tussigon 1
virtussin ac 1
virtussin dac 1
ZODRYL AC 40 2
ZODRYL DEC 30 2
PULMONARY AGENTS
acetylcysteine 1
ADCIRCA 5 PA; LA; QL
ADEMPAS 5 PA; LA
ADVAIR DISKUS 2 QL
ADVAIR HFA 2 QL
albuterol sulfate 1
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
51
Drug Name Drug Tier
Requirements / Limits
ALVESCO INHALATION HFA AEROSOL INHALER 160 MCG/ACTUATION, 80 MCG/ACTUATION
2 QL
ANORO ELLIPTA 2 QL
ARCAPTA NEOHALER
2 QL
ASMANEX HFA 2 QL
ASMANEX TWISTHALER
2 QL
ATROVENT HFA 2 QL
BEVESPI AEROSPHERE
2 QL
BREO ELLIPTA 2 QL
BROVANA 2 QL
budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml
1 QL
budesonide nasal 1 QL
CINRYZE 5 PA; LA
COMBIVENT RESPIMAT
2 QL
cromolyn 1
DALIRESP 2
DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION
2 QL
Drug Name Drug Tier
Requirements / Limits
ESBRIET ORAL CAPSULE
5 PA; LA; QL
ESBRIET ORAL TABLET
5 PA; LA
FIRAZYR 5 PA; LA
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION
2 QL
flunisolide 1 QL
fluticasone 1 QL
FLUTICASONE-SALMETEROL
2 QL
INCRUSE ELLIPTA
2 QL
ipratropium bromide 1
ipratropium-albuterol
1 QL
KALBITOR 5 PA; LA
KALYDECO ORAL GRANULES IN PACKET
5 PA; LA; QL
KALYDECO ORAL TABLET
5 PA; LA; QL
levalbuterol hcl 1
metaproterenol 1
mometasone 1 QL
montelukast 1
nebusal 1
NUCALA 5 PA; LA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
52
Drug Name Drug Tier
Requirements / Limits
OFEV 5 PA; LA; QL
OPSUMIT 5 PA; LA
ORKAMBI 5 PA; LA; QL
PERFOROMIST 2 QL
PROAIR HFA 2 QL
PROAIR RESPICLICK
2 QL
pulmosal 1
PULMOZYME 5 LA
QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION
2 QL
sildenafil intravenous
4 PA; LA
sildenafil oral 4 PA; LA; QL
sodium chloride 1
SPIRIVA WITH HANDIHALER
2 QL
STRIVERDI RESPIMAT
2 QL
SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION
2 QL
terbutaline 1
theochron 1
theophylline 1
TRACLEER 5 PA; LA
TUDORZA PRESSAIR
2 QL
Drug Name Drug Tier
Requirements / Limits
TYVASO 5 PA; LA
TYVASO REFILL KIT
5 PA; LA
TYVASO STARTER KIT
5 PA; LA
VENTAVIS 5 PA; LA
VENTOLIN HFA 2 QL
XOLAIR 5 PA; LA; QL
zafirlukast 1
zileuton 1
ZYFLO 2 ST
UROLOGICALS
ANTICHOLINERGICS & ANTISPASMODICS
darifenacin 1
flavoxate 1
MYRBETRIQ 2
oxybutynin chloride 1
tolterodine 1
TOVIAZ 2
trospium 1
VESICARE 2
BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY
alfuzosin 1
CIALIS ORAL TABLET 2.5 MG, 5 MG
2 QL
dutasteride 1 ST
dutasteride-tamsulosin
1 ST
finasteride 1
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
53
Drug Name Drug Tier
Requirements / Limits
RAPAFLO 2 ST
tamsulosin 1
CHOLINERGIC STIMULANTS
bethanechol chloride 1
MISCELLANEOUS UROLOGICALS
alprostadil 1
azuphen mb 1
CAVERJECT 2 PA; QL
CAVERJECT IMPULSE
2 PA; QL
CIALIS 2 QL
CYSTAGON 5 LA
cytra k crystals 1
cytra-2 1
cytra-3 1
cytra-k 1
ELMIRON 2
hyolev mb 1
hyophen 1
K-PHOS NO 2 2
K-PHOS ORIGINAL
2
methen-sod phos-meth blue-hyos
1
MUSE 2 PA; QL
phosphasal 1
pot,sodium citrate-citric acid
1
potassium citrate 1
potassium citrate-citric acid
1
RENACIDIN 2
Drug Name Drug Tier
Requirements / Limits
sodium citrate-citric acid
1
tricitrates 1
ur n-c 1
uramit mb 1
uretron d-s 1
urimar-t 1
urin ds 1
uro-458 1
urogesic-blue 1
uro-mp 1
urophen mb 1
uryl 1
ustell 1
utira-c 1
VIAGRA 2 QL
virtrate-2 1
virtrate-3 1
virtrate-k 1
URINARY ANESTHETICS
phenazopyridine 1
VITAMINS, HEMATINICS & ELECTROLYTES
ELECTROLYTES
calcium 500 + d 6 ACA; OTC
calcium 500 with d 6 ACA; OTC
calcium 600 + d(3) 6 ACA; OTC
calcium 600 with vitamin d3
6 ACA; OTC
calcium carbonate-vitamin d3
6 ACA; OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
54
Drug Name Drug Tier
Requirements / Limits
calcium citrate + d 6 ACA; OTC
calcium citrate-vitamin d3
6 ACA; OTC
citrus calcium 6 ACA; OTC
effer-k 1
hi-cal plus vit d 6 ACA; OTC
k-effervescent 1
klor-con 1
klor-con 10 1
klor-con 8 1
klor-con m10 1
klor-con m15 1
klor-con m20 1
klor-con sprinkle 1
klor-con/ef 1
k-phos-neutral 1
k-tab 1
lugols 1
oysco 500/d 6 ACA; OTC
oyster shell + d3 6 ACA; OTC
oyster shell calcium-vit d3
6 ACA; OTC
oystercal-d 6 ACA; OTC
phospha 250 neutral 1
potassium acetate 1
potassium bicarb and chloride
1
potassium bicarb-citric acid
1
potassium chlorid-d5-0.45%nacl
1
potassium chloride 1
Drug Name Drug Tier
Requirements / Limits
potassium chloride in 0.9%nacl
1
potassium chloride in 5 % dex
1
potassium chloride in lr-d5
1
potassium chloride-0.45 % nacl
1
potassium chloride-d5-0.2%nacl
1
potassium chloride-d5-0.3%nacl
1
potassium chloride-d5-0.9%nacl
1
potassium phosphate m-/d-basic
1
sodium chloride 1
sodium chloride 0.45 %
1
sodium chloride 3 % 1
sodium chloride 5 % 1
sodium phosphate 1
strong iodine 1
virt-phos 250 neutral 1
VITAMINS & HEMATINICS
AQUADEKS PEDIATRIC
2 OTC
b complex 100 1
b complex-vitamin b12
6 ACA; OTC
balanced b-100 1 OTC
balanced b-50 6 ACA; OTC
bal-care dha 1
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
55
Drug Name Drug Tier
Requirements / Limits
b-complex with vitamin c
6 ACA; OTC
calcium pnv 1
calcium-folic acid-vitamin d
1
centratex 1
child vitamin with minerals
1 OTC
children's iron 6 ACA; OTC
child's chewable vitamins/iron
1 OTC
cholecalciferol (vitamin d3)
6 ACA; OTC
ciferex 1
c-nate dha 1
complete multivitamin
1 OTC
complete natal dha 1
completenate 1
complex b-100 6 ACA; OTC
corvita 1
corvita 150 1
cyanocobalamin (vitamin b-12)
1
daily multivitamin with iron
1 OTC
delta d3 6 ACA; OTC
dialyvite 1
dothelle dha 1
d-vi-sol 6 ACA; OTC
elite-ob 1
Drug Name Drug Tier
Requirements / Limits
ergocalciferol (vitamin d2) oral capsule
1
ergocalciferol (vitamin d2) oral tablet
6 ACA; OTC
ferocon 1
ferosul 6 ACA; OTC
ferraplus 90 1
ferrex 150 forte 1
ferrex 150 forte plus 1
ferrex 150 plus 1 OTC
ferrex 28 1
ferrocite plus 1
ferrous fumarate 1 OTC
ferrous gluconate 1 OTC
ferrous sulfate oral drops
6 ACA; OTC
ferrous sulfate oral elixir
6 ACA; OTC
ferrous sulfate oral liquid
1 OTC
fluor-a-day (with xylitol) oral tablet,chewable 0.25 mg f (0.55 mg)-236.79mg
6 ACA
fluor-a-day (with xylitol) oral tablet,chewable 1 mg f (2.2 mg)-236.79 mg
1
fluoride (sodium) oral drops
6 ACA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
56
Drug Name Drug Tier
Requirements / Limits
fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)
6 ACA
fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
1
fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)
6 ACA
fluoritab oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
1
focalgin 90 dha 1
focalgin ca 1
focalgin dss 1
folbecal 1
folbee 1
folbee ar 1
folbee plus 1
folbic 1
folic acid injection 1
folic acid oral tablet 1 mg
1
folic acid oral tablet 400 mcg, 800 mcg
6 ACA; OTC
folic acid-vit b6-vit b12
1
folivane-f 1
folivane-ob 1
folivane-plus 1
Drug Name Drug Tier
Requirements / Limits
folplex 2.2 1
hematinic plus vit/minerals
1
hematinic/folic acid 1
hematogen 1
hematogen fa 1
hematogen forte 1
hemenatal ob 1
hemenatal ob + dha 1
hemetab 1
hydroxocobalamin 1
ICAPS MV 2 OTC
iferex 150 forte 1
infed 1
ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)
6 ACA
ludent fluoride oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
1
m.v.i. adult 1
multigen folic 1
multigen plus 1
multi-vit with fluoride-iron
6 ACA
multi-vitamin hp/minerals
1 OTC
multi-vitamin with fluoride oral drops
6 ACA
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
57
Drug Name Drug Tier
Requirements / Limits
multi-vitamin with fluoride oral tablet,chewable 0.25 mg, 0.5 mg
6 ACA
multi-vitamin with fluoride oral tablet,chewable 1 mg
1
multivitamins with fluoride oral tablet,chewable 0.25 mg, 0.5 mg
6 ACA
multivitamins with fluoride oral tablet,chewable 1 mg
1
mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg
6 ACA
mvc-fluoride oral tablet,chewable 1 mg
1
myferon 150 forte 1
mynatal 1
mynatal advance 1
mynatal plus 1
mynatal-z 1
mynate 90 plus 1
mynephrocaps 1
mynephron 1
nephplex rx 1
nephro-vite rx 1
newgen 1
obstetrix dha 1
one daily women's health
1 OTC
Drug Name Drug Tier
Requirements / Limits
ortho d 1
pnv 29-1 1
pnv ob+dha 1
pnv-dha 1
pnv-dha + docusate 1
pnv-ferrous fumarate-docu-fa
1
pnv-omega 1
pnv-select 1
pnv-vp-u 1
poly-iron 1 OTC
poly-iron 150 forte 1
pr natal 400 1
pr natal 400 ec 1
pr natal 430 1
pr natal 430 ec 1
prena1 chew 1
prena1 pearl 1
prena1 true 1
prenaissance 1
prenaissance plus 1
prenatabs fa 1
prenatabs rx 1
prenatal 6 ACA; OTC
prenatal formula 6 ACA; OTC
prenatal plus 1
prenatal plus (calcium carb)
1
prenatal vitamin plus low iron
1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
58
Drug Name Drug Tier
Requirements / Limits
prenatal vits96-iron fum-folic
6 ACA; OTC
prenatal-u 1
preplus 1
pretab 1
PROFERRIN-FORTE
2
prosight 1 OTC
purevit dualfe plus 1
relnate dha 1
renal caps 1
rena-vite rx 1
reno caps 1
se-natal 19 1
se-natal 19 (with docusate)
1
se-tan plus 1
stress b with zinc 1 OTC
stress formula 6 ACA; OTC
stress formula with iron
6 ACA; OTC
super b complex-vitamin c
6 ACA; OTC
super b-50 complex plus
6 ACA; OTC
super quints b-50 6 ACA; OTC
superplex-t 6 ACA; OTC
taron forte 1
taron-c dha 1
taron-prex prenatal-dha
1
thrivite-19 1
tl gard rx 1
Drug Name Drug Tier
Requirements / Limits
tl g-fol os 1
tl icon 1
tl-hem 150 1
total b/c 6 ACA; OTC
tricon 1
trigels-f forte 1
trinatal gt 1
trinatal rx 1 1
trinate 1
triphrocaps 1
tri-tabs dha 1
triveen-duo dha 1
tri-vit with fluoride and iron
6 ACA
tri-vitamin with fluoride
6 ACA
trust natal dha 1
ultimatecare one 1
ultimatecare one nf 1
ultra b-100 complex 6 ACA; OTC
v-c forte 1
vemavite-prx-2 1
VENOFER 2
vic-forte 1
vinate care 1
vinate dha 1
vinate ii 1
vinate m 1
vinate one 1
vinate ultra 1
virt-advance 1
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
59
Drug Name Drug Tier
Requirements / Limits
virt-c dha 1
virt-gard 1
virt-nate 1
virt-nate dha 1
virt-pn 1
virt-pn dha 1
virt-pn plus 1
virt-select 1
virt-vite 1
virt-vite forte 1
virt-vite gt 1
vit 3 1
VITAFOL-OB 2
vitajoy daily d 6 ACA; OTC
vitamin b complex 6 ACA; OTC
vitamin d3 6 ACA; OTC
Drug Name Drug Tier
Requirements / Limits
vitamins a,c,d and fluoride
6 ACA
vol-care rx 1
vol-nate 1
vol-plus 1
vol-tab rx 1
vp-ch plus 1
vp-ch-pnv 1
vp-ggr-b6 1
vp-heme ob 1
vp-heme one 1
vp-vite rx 1
zatean-ch 1
zatean-pn dha 1
zatean-pn plus 1
zavara 1
zingiber 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
60
Index A abacavir .................................. 3 abacavir-lamivudine ............... 3 abacavir-lamivudine-
zidovudine .......................... 3 ABILIFY MAINTENA ........ 17 ABRAXANE .......................... 8 ABREVA ............................. 28 acamprosate .......................... 29 acarbose ................................ 35 ACE AEROSOL CLOUD
ENHANCER .................... 32 acebutolol ............................. 20 acetaminophen-caff-
dihydrocod ........................ 14 acetaminophen-codeine ........ 14 acetazolamide ....................... 49 acetazolamide sodium .......... 49 acetic acid ....................... 29, 31 acetic acid-aluminum acetate 31 acetylcysteine ....................... 50 acitretin ................................. 25 ACTEMRA .......................... 43 ACTHAR H.P. ..................... 31 ACTIMMUNE ..................... 42 ACTOPLUS MET XR ......... 36 acuicyn ................................. 48 acyclovir ........................... 3, 28 acyclovir sodium .................... 3 ADAGEN ............................. 29 adapalene .............................. 26 ADCETRIS ............................ 8 ADCIRCA ............................ 50 adefovir................................... 3 ADEMPAS ........................... 50 adrenalin ............................... 49 adriamycin .............................. 8 adrucil ..................................... 8 ADVAIR DISKUS ............... 50 ADVAIR HFA ..................... 50 AEROCHAMBER MINI ..... 32 AEROCHAMBER PLUS
FLOW-VU ....................... 32 AEROCHAMBER PLUS Z
STAT SM MSK ............... 32 AEROTRACH PLUS ........... 32
AEROVENT PLUS .............. 32 afeditab cr ............................. 21 AFINITOR ............................. 8 AFINITOR DISPERZ ............ 8 AKYNZEO ........................... 37 ala-cort .................................. 28 ALBENZA ............................. 5 albuterol sulfate .................... 50 alclometasone ....................... 28 ALDURAZYME .................. 35 ALECENSA ........................... 8 alendronate ..................... 29, 42 ALFERON N ........................ 42 alfuzosin ............................... 52 ALIMTA ................................ 8 ALINIA .................................. 5 allopurinol ............................ 42 allopurinol sodium ................ 42 almotriptan malate ................ 13 ALOCRIL ............................. 48 ALOMIDE............................ 48 alophen ................................. 37 aloprim.................................. 42 alosetron ............................... 37 ALOXI.................................. 37 ALPHAGAN P ..................... 49 alprazolam ............................ 17 alprazolam intensol............... 17 alprostadil ............................. 53 altacaine ................................ 48 altafluor ................................ 48 altavera (28) .......................... 44 ALVESCO............................ 51 alyacen 1/35 (28) .................. 44 alyacen 7/7/7 (28) ................. 44 amabelz ................................. 43 amantadine hcl ........................ 3 amcinonide ........................... 28 amethia ................................. 44 amethia lo ............................. 45 amethyst................................ 45 AMICAR .............................. 23 amifostine crystalline ............. 8 amikacin ................................. 5 amiloride ............................... 21
amiloride-hydrochlorothiazide .......................................... 21
aminocaproic acid ................. 23 amiodarone ........................... 20 AMITIZA ............................. 37 amitriptyline ......................... 17 amitriptyline-chlordiazepoxide
.......................................... 17 amlodipine ............................ 21 amlodipine-atorvastatin ........ 24 amlodipine-benazepril .......... 21 amlodipine-olmesartan ......... 21 amlodipine-valsartan ............ 21 amlodipine-valsartan-hcthiazid
.......................................... 21 amnesteem ............................ 26 amoxapine ............................. 17 amoxicil-clarithromy-lansopraz
.......................................... 40 amoxicillin .............................. 7 amoxicillin-pot clavulanate .... 7 amphotericin b ........................ 3 ampicillin ................................ 7 ampicillin sodium ................... 7 ampicillin-sulbactam .............. 7 AMPYRA ............................. 14 ANADROL-50 ..................... 35 anagrelide ............................. 30 anaspaz ................................. 37 anastrozole .............................. 8 androxy ................................. 35 ANORO ELLIPTA ............... 51 apexicon e ............................. 28 APIDRA ............................... 34 APIDRA SOLOSTAR .......... 34 APOKYN ............................. 13 apraclonidine ........................ 49 aprepitant ........................ 37, 38 apri ........................................ 45 APRISO ................................ 38 APTIOM ............................... 12 APTIVUS ............................... 3 AQUADEKS PEDIATRIC .. 54 ARALAST NP ...................... 30 aranelle (28) .......................... 45
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
61
ARANESP (IN POLYSORBATE) ............ 41
ARCALYST ......................... 42 ARCAPTA NEOHALER ..... 51 ARGATROBAN IN NACL
(ISO-OS) .......................... 23 aripiprazole ........................... 17 ARISTADA .......................... 17 armodafinil ........................... 17 ARMOUR THYROID ......... 37 ARRANON ............................ 8 ARZERRA ............................. 8 ascomp with codeine ............ 14 ashlyna .................................. 45 ASMANEX HFA ................. 51 ASMANEX TWISTHALER 51 aspir-81 ................................. 16 aspirin ................................... 16 aspirin low dose .................... 16 aspirin-caffeine-dihydrocodein
.......................................... 14 aspirin-dipyridamole ............ 23 aspir-low ............................... 16 aspir-trin ............................... 16 astramorph-pf ....................... 14 atenolol ................................. 21 atenolol-chlorthalidone......... 21 atomoxetine .......................... 18 atorvastatin ........................... 24 atovaquone ............................. 5 atovaquone-proguanil ............. 5 ATRIPLA ............................... 3 atropine ........................... 37, 48 ATROVENT HFA ............... 51 aubra ..................................... 45 AUGMENTIN ........................ 7 AUTOJECT 2 INJECTION
DEVICE ........................... 33 AUTOPEN 1 TO 21 UNITS 33 avar ....................................... 26 AVASTIN .............................. 8 AVELOX IN NACL (ISO-
OSMOTIC) ........................ 7 aviane ................................... 45 avidoxy ................................... 7 avita ...................................... 26 avo cream ............................. 25
AVONEX ............................. 41 AVONEX (WITH ALBUMIN)
.......................................... 41 AVYCAZ ............................... 4 azacitidine ............................... 8 AZASAN ................................ 8 AZASITE ............................. 47 azathioprine ............................ 8 azathioprine sodium ............... 9 azelastine ........................ 31, 48 AZELEX .............................. 26 azithromycin ........................... 5 AZOPT ................................. 49 aztreonam ............................... 5 azuphen mb........................... 53 azurette (28) .......................... 45 B b complex 100 ...................... 54 b complex-vitamin b12 ......... 54 baciim ..................................... 5 bacitracin .......................... 5, 47 bacitracin-polymyxin b......... 47 baclofen ................................ 14 BACTROBAN NASAL ....... 31 balanced b-100 ..................... 54 balanced b-50 ....................... 54 bal-care dha .......................... 54 balsalazide ............................ 38 balziva (28) ........................... 45 BANZEL .............................. 12 BARACLUDE ....................... 3 BASAGLAR KWIKPEN ..... 34 BAVENCIO ........................... 9 bayer aspirin ......................... 16 b-complex with vitamin c ..... 55 bekyree (28) .......................... 45 belladonna alkaloids-opium . 37 belladonna-opium ................. 37 BELSOMRA ........................ 18 benazepril ............................. 21 benazepril-hydrochlorothiazide
.......................................... 21 BENDEKA ............................. 9 BENLYSTA ......................... 43 benzepro ............................... 26 benzonatate ........................... 50 benzoyl peroxide .................. 26
benztropine ........................... 13 BEPREVE ............................ 48 BESIVANCE ........................ 47 betamethasone acet,sod phos 31 betamethasone dipropionate . 28 betamethasone valerate ......... 28 betamethasone, augmented ... 28 betaxolol ......................... 21, 48 bethanechol chloride ............. 53 BEVESPI AEROSPHERE ... 51 bexarotene ............................... 9 bicalutamide ........................... 9 BICNU .................................... 9 BILTRICIDE .......................... 5 bimatoprost ........................... 49 bisacodyl ............................... 38 bisa-lax ................................. 38 bismuth ................................. 37 bisoprolol fumarate ............... 21 bisoprolol-hydrochlorothiazide
.......................................... 21 bivalirudin ............................. 23 bleo 15k .................................. 9 bleomycin ............................... 9 BLINCYTO ............................ 9 blisovi 24 fe .......................... 45 blisovi fe 1.5/30 (28) ............ 45 blisovi fe 1/20 (28) ............... 45 BOSULIF ............................... 9 BOTOX ................................ 42 bp 10-1 .................................. 26 bp-50% urea .......................... 25 bpo ........................................ 26 BREATHERITE WITH
MASK, SMALL ............... 32 BREO ELLIPTA .................. 51 briellyn .................................. 45 BRILINTA ........................... 23 brimonidine ........................... 49 BRINEURA .......................... 35 bromfenac ............................. 48 bromocriptine ....................... 13 brompheniramine-pseudoeph-
dm ..................................... 50 BROVANA .......................... 51 budesonide ...................... 38, 51 bumetanide ........................... 21
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
62
BUPHENYL......................... 30 buprenorphine hcl ................. 14 buprenorphine-naloxone....... 16 bupropion hcl........................ 18 bupropion hcl (smoking deter)
.......................................... 30 buspirone .............................. 18 busulfan .................................. 9 BUSULFEX ........................... 9 butalbital compound w/codeine
.......................................... 15 butalbital-acetaminop-caf-cod
.......................................... 15 butalbital-acetaminophen ..... 15 butalbital-acetaminophen-caff
.......................................... 15 butalbital-aspirin-caffeine .... 15 butorphanol tartrate .............. 16 BYDUREON ........................ 36 BYETTA .............................. 36 BYSTOLIC .......................... 21 C cabergoline ........................... 35 caffeine citrate ...................... 30 calcipotriene ......................... 25 calcipotriene-betamethasone 25 calcitonin (salmon) ............... 35 calcitrene .............................. 25 calcitriol .......................... 25, 35 calcium 500 + d .................... 53 calcium 500 with d ............... 53 calcium 600 + d(3) ............... 53 calcium 600 with vitamin d3 53 calcium acetate ..................... 38 calcium carbonate-vitamin d3
.......................................... 53 calcium citrate + d ................ 54 calcium citrate-vitamin d3 .... 54 calcium pnv .......................... 55 calcium-folic acid-vitamin d 55 camila ................................... 43 camrese ................................. 45 camrese lo ............................. 45 CANASA ............................. 38 CANCIDAS ........................... 3 candesartan ........................... 21
candesartan-hydrochlorothiazid .......................................... 21
capacet .................................. 15 capecitabine ............................ 9 CAPRELSA............................ 9 captopril ................................ 21 captopril-hydrochlorothiazide
.......................................... 21 CARAFATE ......................... 40 CARBAGLU ........................ 30 carbamazepine ...................... 12 carbidopa .............................. 13 carbidopa-levodopa .............. 13 carbidopa-levodopa-
entacapone ........................ 13 carbinoxamine maleate ......... 49 carboplatin .............................. 9 carisoprodol .......................... 14 carteolol ................................ 48 cartia xt ................................. 21 CARTRIDGE STAMPED IR
1200 .................................. 33 carvedilol .............................. 21 CAVERJECT ....................... 53 CAVERJECT IMPULSE ..... 53 CAYA CONTOURED ......... 43 CAYSTON ............................. 5 caziant (28) ........................... 45 cefaclor ................................... 4 cefadroxil ................................ 4 cefazolin ................................. 4 cefazolin in dextrose (iso-os) . 4 cefdinir.................................... 4 cefditoren pivoxil ................... 4 cefepime ................................. 4 cefepime in dextrose,iso-osm . 5 cefixime .................................. 5 cefotaxime .............................. 5 cefotetan ................................. 5 cefoxitin .................................. 5 cefoxitin in dextrose, iso-osm 5 cefpodoxime ........................... 5 cefprozil .................................. 5 ceftazidime ............................. 5 ceftibuten ................................ 5 ceftriaxone .............................. 5 ceftriaxone in dextrose,iso-os . 5
cefuroxime axetil .................... 5 cefuroxime sodium ................. 5 celacyn .................................. 25 celecoxib ............................... 16 CELLCEPT INTRAVENOUS
............................................ 9 CELONTIN .......................... 12 cem-urea ............................... 25 centergy ................................ 50 centratex ............................... 55 cephalexin ............................... 5 CEPROTIN (BLUE BAR) ... 23 CEPROTIN (GREEN BAR) 23 CERDELGA ......................... 35 CESAMET ........................... 38 cevimeline ............................. 30 CHANTIX ............................ 30 CHANTIX CONTINUING
MONTH BOX .................. 30 CHANTIX STARTING
MONTH BOX .................. 30 chateal ................................... 45 CHEMET .............................. 30 CHENODAL ........................ 38 cheratussin ac ........................ 50 child vitamin with minerals .. 55 children's aspirin ................... 16 children's iron ....................... 55 child's chewable vitamins/iron
.......................................... 55 chloramphenicol sod succinate
............................................ 5 chlordiazepoxide hcl ............. 18 chlordiazepoxide-clidinium .. 37 chlorhexidine gluconate ........ 31 chloroquine phosphate ............ 5 chlorothiazide ....................... 21 chlorothiazide sodium .......... 21 chlorpromazine ..................... 18 chlorpropamide ..................... 36 chlorthalidone ....................... 21 chlorzoxazone ....................... 14 CHOLBAM .......................... 38 cholecalciferol (vitamin d3) . 55 cholestyramine (with sugar) . 24 cholestyramine light ............. 24
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
63
choline,magnesium salicylate .......................................... 16
CIALIS ........................... 52, 53 ciclodan ................................ 27 ciclopirox ........................ 27, 28 ciclopirox-ure-camph-menth-
euc .................................... 28 cidaleaze ............................... 27 cidofovir ................................. 3 ciferex ................................... 55 cilostazol............................... 23 cimetidine ............................. 40 cimetidine hcl ....................... 40 CINRYZE ............................ 51 CIPRO HC ........................... 31 CIPRODEX .......................... 31 ciprofloxacin........................... 7 ciprofloxacin (mixture) .......... 7 ciprofloxacin hcl ......... 7, 31, 47 ciprofloxacin in 5 % dextrose. 7 ciprofloxacin lactate ............... 7 cisplatin .................................. 9 citalopram ............................. 18 citrate of magnesia ............... 38 citroma .................................. 38 citrus calcium ....................... 54 cladribine ................................ 9 claravis ................................. 26 clarithromycin ........................ 5 cleansing wash ..................... 26 clearlax ................................. 38 clemastine ............................. 49 CLEO 90 INFUSION SET 24
.......................................... 33 cleocin .................................... 5 CLEVER CHOICE
CHAMBER-SM MASK .. 32 clindacin p ............................ 26 clindamycin hcl ...................... 5 clindamycin in 5 % dextrose .. 6 clindamycin palmitate hcl ...... 6 clindamycin pediatric ............. 6 clindamycin phosphate .... 6, 26,
44 clindamycin-benzoyl peroxide
.......................................... 26 clindamycin-tretinoin ........... 26
clobetasol ........................ 28, 29 clobetasol-emollient ............. 29 clodan ................................... 29 clofarabine .............................. 9 CLOLAR ................................ 9 clomipramine ........................ 18 clonazepam ........................... 12 clonidine ............................... 21 clonidine hcl ................... 18, 21 clopidogrel ............................ 23 clorazepate dipotassium ....... 18 clorpres ................................. 21 clotrimazole ............................ 3 clotrimazole-betamethasone . 28 clozapine ............................... 18 c-nate dha ............................. 55 COAGADEX........................ 23 COAL TAR .......................... 25 COARTEM ............................ 6 codeine sulfate ...................... 15 codeine-butalbital-asa-caff ... 15 codeine-guaifenesin .............. 50 COLCRYS............................ 42 colestipol .............................. 24 colistin (colistimethate na) ..... 6 colocort ................................. 38 COMBIGAN ........................ 49 COMBIVENT RESPIMAT . 51 COMFORT INFUSION SET
43 ...................................... 33 COMFORT SHORT INSULIN
PUMP 23 .......................... 33 COMPACT SPACE
CHAMBER-LRG MASK 32 COMPLERA .......................... 3 complete multivitamin .......... 55 complete natal dha ................ 55 completenate ......................... 55 complex b-100 ...................... 55 compro .................................. 38 constulose ............................. 38 CONTACT DETACH INFUS
SET 23 .............................. 33 CORDRAN .......................... 29 CORDRAN TAPE LARGE
ROLL................................ 29 CORLANOR ........................ 24
cormax .................................. 29 CORTIFOAM ....................... 38 cortisone ............................... 31 CORTISPORIN .................... 27 corvita ................................... 55 corvita 150 ............................ 55 COSENTYX ......................... 25 COSENTYX (2 SYRINGES)
.......................................... 25 COSENTYX PEN ................ 25 COSENTYX PEN (2 PENS) 25 cosyntropin ........................... 32 COTELLIC ............................. 9 CREON ................................. 38 CRESEMBA ........................... 3 CRINONE ............................ 43 CRIXIVAN ............................. 3 cromolyn ................... 38, 48, 51 cryselle (28) .......................... 45 CUBICIN RF .......................... 6 curity sterile water ................ 30 cyanocobalamin (vitamin b-12)
.......................................... 55 cyclafem 1/35 (28) ................ 45 cyclafem 7/7/7 (28) ............... 45 cyclobenzaprine .................... 14 cyclopentolate ....................... 48 cyclophosphamide .................. 9 CYCLOPHOSPHAMIDE ...... 9 CYCLOSERINE ..................... 6 cyclosporine ............................ 9 cyclosporine modified ............ 9 cyproheptadine ..................... 50 CYRAMZA ............................ 9 cyred ..................................... 45 CYSTADANE ...................... 38 CYSTAGON ........................ 53 CYSTARAN ......................... 48 cytarabine ............................... 9 cytarabine (pf) ........................ 9 cytra k crystals ...................... 53 cytra-2 ................................... 53 cytra-3 ................................... 53 cytra-k ................................... 53 D dacarbazine ............................. 9 daily multivitamin with iron . 55
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
64
DAKLINZA ........................... 3 DALIRESP ........................... 51 DALVANCE .......................... 6 danazol ................................. 35 dantrolene ............................. 14 dapsone ................................... 6 daptomycin ............................. 6 DARAPRIM ........................... 6 darifenacin ............................ 52 DARZALEX .......................... 9 dasetta 1/35 (28) ................... 45 dasetta 7/7/7 (28) .................. 45 daunorubicin ........................... 9 daysee ................................... 45 DEBACTEROL ................... 31 deblitane ............................... 43 decitabine ............................... 9 delta d3 ................................. 55 deltasone ............................... 32 delyla (28) ............................ 45 demeclocycline ....................... 7 DEMSER .............................. 21 DENAVIR ............................ 28 denta 5000 plus..................... 31 dentagel ................................ 31 DEPEN TITRATABS .......... 43 DEPO-PROVERA ............... 43 dermacinrx prizopak ............. 27 DESCOVY ............................. 3 desipramine .......................... 18 desloratadine......................... 50 desmopressin ........................ 35 desog-e.estradiol/e.estradiol . 45 desogestrel-ethinyl estradiol . 45 desonide ................................ 29 desoximetasone .................... 29 desvenlafaxine succinate ...... 18 dexamethasone ..................... 32 dexamethasone intensol........ 32 dexamethasone sodium phos
(pf) .................................... 32 dexamethasone sodium
phosphate .................... 32, 49 dexedrine .............................. 18 dexmethylphenidate ............. 18 dexrazoxane hcl ...................... 8 dextroamphetamine .............. 18
dextroamphetamine-amphetamine .................... 18
dialyvite ................................ 55 diazepam ............................... 18 diazepam intensol ................. 18 diclofenac potassium ............ 16 diclofenac sodium..... 16, 25, 48 diclofenac-misoprostol ......... 16 dicloxacillin ............................ 7 dicyclomine .......................... 37 didanosine ............................... 3 DIFICID ................................. 5 diflorasone ............................ 29 diflunisal ............................... 16 digitek ................................... 23 digox ..................................... 23 digoxin .................................. 23 dihydroergotamine................ 13 DILANTIN ........................... 13 DILANTIN EXTENDED ..... 13 DILANTIN INFATABS ...... 13 DILANTIN-125.................... 13 diltiazem ............................... 21 dilt-xr .................................... 21 dimenhydrinate ..................... 38 DIPENTUM ......................... 38 diphenhydramine hcl ............ 50 diphenoxylate-atropine ......... 37 dipyridamole ......................... 23 diskets ................................... 15 disopyramide phosphate ....... 20 disulfiram.............................. 30 divalproex ............................. 13 docetaxel ................................. 9 DOCETAXEL ........................ 9 dofetilide ............................... 20 donepezil .............................. 14 dorzolamide .......................... 49 dorzolamide-timolol ............. 49 dothelle dha .......................... 55 doxazosin .............................. 21 doxepin ........................... 18, 25 doxercalciferol ...................... 35 doxorubicin ............................. 9 doxorubicin, peg-liposomal .... 9 doxy-100 ................................. 7 doxycycline hyclate ................ 8
doxycycline monohydrate ...... 8 drithocreme hp ...................... 25 dronabinol ............................. 38 droperidol ............................. 38 drospirenone-e.estradiol-lm.fa
.......................................... 45 drospirenone-ethinyl estradiol
.......................................... 45 DROXIA ................................. 9 DUAVEE .............................. 43 ducodyl ................................. 38 DULERA .............................. 51 duloxetine ............................. 18 DUPIXENT .......................... 25 duramorph (pf) ...................... 15 DUREZOL ........................... 49 dutasteride ............................. 52 dutasteride-tamsulosin .......... 52 DUTOPROL ......................... 21 d-vi-sol .................................. 55 DYRENIUM ......................... 21 E e.c. prin ................................. 16 e.e.s. 400 ................................. 5 E.E.S. GRANULES ................ 5 EASIVENT HOLDING
CHAMBER ...................... 32 econazole .............................. 28 econtra ez .............................. 45 ecotrin ................................... 16 ecotrin low strength .............. 16 ed-spaz .................................. 37 EDURANT ............................. 3 effer-k ................................... 54 EFFIENT .............................. 23 EGRIFTA ............................. 41 ELAPRASE .......................... 35 ELELYSO ............................ 35 eletone ................................... 25 ELIDEL ................................ 25 ELIGARD ............................... 9 ELIGARD (3 MONTH) ......... 9 ELIGARD (4 MONTH) ......... 9 ELIGARD (6 MONTH) ......... 9 elinest .................................... 45 eliphos ................................... 38 ELIQUIS ............................... 23
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
65
ELITEK .................................. 8 elite-ob .................................. 55 ELLA .................................... 45 ELMIRON ............................ 53 EMADINE ........................... 48 EMCYT .................................. 9 EMEND ................................ 38 emoquette ............................. 45 EMSAM ............................... 18 EMTRIVA .............................. 3 emulsion sb ........................... 25 EMVERM .............................. 6 enalapril maleate .................. 21 enalaprilat ............................. 21 enalapril-hydrochlorothiazide
.......................................... 21 ENBREL .............................. 43 ENBREL SURECLICK ....... 43 endocet ................................. 15 enoxaparin ............................ 23 enpresse ................................ 45 enskyce ................................. 45 entacapone ............................ 13 entecavir ................................. 3 ENTRESTO ......................... 24 ENTYVIO ............................ 38 enulose .................................. 38 EPCLUSA .............................. 3 EPIDUO ............................... 26 EPIDUO FORTE.................. 26 epinastine .............................. 48 epinephrine ........................... 50 EPINEPHRINE .................... 50 epirubicin ................................ 9 epitol ..................................... 13 EPIVIR HBV.......................... 3 eplerenone ............................ 21 epoprostenol (glycine) .......... 21 eprosartan ............................. 21 ERBITUX .............................. 9 ergocalciferol (vitamin d2) ... 55 ergoloid................................. 18 ERGOMAR .......................... 13 ergotamine-caffeine .............. 14 ERIVEDGE .......................... 10 errin ...................................... 43 ERTACZO ........................... 28
ery pads................................. 26 erygel .................................... 26 ERYPED 200 ......................... 5 ERYPED 400 ......................... 5 ery-tab ..................................... 5 ERY-TAB ............................... 5 erythrocin (as stearate) ........... 5 erythromycin .................... 5, 47 erythromycin ethylsuccinate ... 5 erythromycin with ethanol.... 26 erythromycin-benzoyl peroxide
.......................................... 26 ESBRIET .............................. 51 escitalopram oxalate ............. 18 esmolol ................................. 21 esomeprazole magnesium..... 40 esomeprazole sodium ........... 40 estarylla ................................ 45 estazolam .............................. 18 ESTRACE ............................ 43 estradiol .......................... 43, 44 estradiol valerate ................... 44 estradiol-norethindrone acet . 44 estropipate ............................ 44 eszopiclone ........................... 18 ethacrynate sodium ............... 21 ethacrynic acid ...................... 21 ethambutol .............................. 6 ethosuximide ........................ 13 ethyl chloride ........................ 27 ethynodiol diac-eth estradiol 45 etidronate disodium .............. 30 etodolac ................................ 16 ETOPOPHOS ....................... 10 etoposide ............................... 10 EUFLEXXA ......................... 16 EURAX ................................ 29 EXELDERM ........................ 28 exemestane ........................... 10 EXJADE ............................... 30 EXTAVIA ............................ 41 EYLEA ................................. 48 E-Z SPACER ........................ 32 ezetimibe .............................. 24 ezetimibe-simvastatin ........... 24 F FABRAZYME ..................... 35
FACTIVE ............................... 7 fallback solo .......................... 45 falmina (28) .......................... 45 famciclovir .............................. 3 famotidine ............................. 40 famotidine (pf) ...................... 40 famotidine (pf)-nacl (iso-os) 40 FANAPT ............................... 18 FARESTON ......................... 10 FARXIGA ............................ 36 FASLODEX ......................... 10 fayosim ................................. 45 FC2 FEMALE CONDOM ... 43 felbamate .............................. 13 felodipine .............................. 21 fem ph ................................... 44 FEMCAP .............................. 43 femynor ................................. 45 fenofibrate ............................. 24 fenofibrate micronized .......... 24 fenofibrate nanocrystallized . 24 fenofibric acid ....................... 24 fenofibric acid (choline) ....... 24 fenoprofen ............................. 16 fentanyl ................................. 15 fentanyl citrate ...................... 15 fentanyl citrate (pf) ............... 15 fentanyl citrate-0.9%nacl (pf)
.......................................... 15 ferocon .................................. 55 ferosul ................................... 55 ferraplus 90 ........................... 55 ferrex 150 forte ..................... 55 ferrex 150 forte plus ............. 55 ferrex 150 plus ...................... 55 ferrex 28 ................................ 55 FERRIPROX ........................ 30 ferrocite plus ......................... 55 ferrous fumarate .................... 55 ferrous gluconate .................. 55 ferrous sulfate ....................... 55 FETZIMA ............................. 18 finasteride ............................. 52 FIRAZYR ............................. 51 flavoxate ............................... 52 flecainide .............................. 20 fleet laxative ......................... 38
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
66
FLEXICHAMBER ............... 32 FLOVENT HFA ................... 51 floxin .................................... 31 floxuridine ............................ 10 FLUBLOK 2017-2018 (PF) . 42 FLUBLOK QUAD 2017-2018
(PF) ................................... 42 flucaine ................................. 48 fluconazole ............................. 3 fluconazole in dextrose(iso-o) 3 fluconazole in nacl (iso-osm) . 3 flucytosine .............................. 3 fludarabine ............................ 10 fludrocortisone ..................... 32 flumazenil ............................. 18 flunisolide ............................. 51 fluocinolone .......................... 29 fluocinolone acetonide oil .... 31 fluocinolone and shower cap 29 fluocinonide .......................... 29 fluocinonide-e....................... 29 fluor-a-day (with xylitol) ...... 55 fluorescein-proparacaine ...... 48 fluoride (sodium) ...... 31, 55, 56 fluoritab ................................ 56 fluorometholone ................... 49 fluorouracil ..................... 10, 25 fluoxetine ........................ 18, 19 fluphenazine decanoate ........ 19 fluphenazine hcl ................... 19 flurandrenolide ..................... 29 flurazepam ............................ 19 flurbiprofen........................... 16 flurbiprofen sodium .............. 49 flurox .................................... 48 flutamide............................... 10 fluticasone ...................... 29, 51 FLUTICASONE-
SALMETEROL ............... 51 fluvastatin ............................. 24 fluvoxamine .......................... 19 focalgin 90 dha ..................... 56 focalgin ca ............................ 56 focalgin dss ........................... 56 folbecal ................................. 56 folbee .................................... 56 folbee ar ................................ 56
folbee plus ............................ 56 folbic ..................................... 56 folic acid ............................... 56 folic acid-vit b6-vit b12 ........ 56 folivane-f .............................. 56 folivane-ob............................ 56 folivane-plus ......................... 56 FOLOTYN ........................... 10 folplex 2.2 ............................. 56 fondaparinux ......................... 23 FORTEO .............................. 42 FOSAMAX PLUS D ............ 42 foscarnet ................................. 3 fosinopril .............................. 21 fosinopril-hydrochlorothiazide
.......................................... 21 fosphenytoin ......................... 13 FOSRENOL ......................... 38 FRAGMIN............................ 23 FREESTYLE CONTROL .... 33 FREESTYLE FLASH
SYSTEM .......................... 33 FREESTYLE FREEDOM .... 33 FREESTYLE FREEDOM
LITE ................................. 33 FREESTYLE INSULINX ... 32,
33 FREESTYLE INSULINX
TEST STRIPS .................. 32 FREESTYLE LITE METER 33 FREESTYLE LITE STRIPS 32 FREESTYLE SIDEKICK II 33 FREESTYLE SYSTEM KIT 33 FREESTYLE TEST ............. 32 frovatriptan ........................... 14 furosemide ............................ 21 FUZEON ................................ 3 fyavolv .................................. 44 FYCOMPA ........................... 13 G g tussin ac ............................. 50 gabapentin ............................ 13 GABITRIL ........................... 13 galantamine .......................... 14 ganciclovir sodium ................. 3 gatifloxacin ........................... 47 gavilax .................................. 38
gavilyte-c .............................. 38 gavilyte-g .............................. 38 gavilyte-n .............................. 38 GAZYVA ............................. 10 gemcitabine ........................... 10 gemfibrozil ........................... 24 generlac ................................. 38 gengraf .................................. 10 gentak ................................... 47 gentamicin .................. 6, 27, 47 gentamicin in nacl (iso-osm) .. 6 gentamicin sulfate (ped) (pf) .. 6 gentamicin sulfate (pf) ............ 6 gentle laxative ....................... 38 gentlelax ............................... 38 GENVOYA ............................ 3 gianvi (28) ............................ 45 gildagia ................................. 45 GILENYA ............................ 41 GILOTRIF ............................ 10 glatopa .................................. 41 GLEOSTINE ........................ 10 glimepiride ............................ 36 glipizide ................................ 36 glipizide-metformin .............. 36 GLUCAGEN HYPOKIT ...... 33 GLUCAGON EMERGENCY
KIT (HUMAN) ................. 33 glyburide ............................... 36 glyburide micronized ............ 36 glyburide-metformin ............. 36 glycolax ................................ 38 glycopyrrolate ....................... 37 glydo ..................................... 27 GLYXAMBI ......................... 36 granisetron (pf) ..................... 38 granisetron hcl ...................... 38 GRANIX ............................... 41 griseofulvin microsize ............ 3 griseofulvin ultramicrosize ..... 3 guaiatussin ac ........................ 50 guaifenesin ac ....................... 50 guaifenesin dac ..................... 50 guanfacine ....................... 19, 21 guanidine .............................. 19 GYNAZOLE-1 ..................... 44 gynol ii .................................. 44
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
67
H HALAVEN........................... 10 halobetasol propionate.......... 29 HALOG ................................ 29 haloperidol ............................ 19 haloperidol decanoate ........... 19 haloperidol lactate ................ 19 healthylax ............................. 38 heather .................................. 44 HECTOROL......................... 35 hematinic plus vit/minerals .. 56 hematinic/folic acid .............. 56 hematogen ............................ 56 hematogen fa ........................ 56 hematogen forte .................... 56 hemenatal ob ........................ 56 hemenatal ob + dha .............. 56 hemetab ................................ 56 hemmorex-hc ........................ 38 hep flush-10 (pf) ................... 23 heparin (porcine) .................. 23 heparin (porcine) in 5 % dex 23 heparin (porcine) in nacl (pf) 23 heparin flush(porcine)-0.9nacl
.......................................... 23 heparin lock flush ................. 23 heparin lock flush (porcine) . 23 heparin lockflush(porcine)(pf)
.......................................... 23 heparin(porcine) in 0.45% nacl
.......................................... 23 heparin, porcine (pf) ............. 23 HERCEPTIN ........................ 10 HEXALEN ........................... 10 hi-cal plus vit d ..................... 54 homatropaire......................... 48 homatropine hbr ................... 48 hpr ........................................ 25 hpr plus ................................. 25 hpr plus hydrogel .................. 25 HUMALOG ......................... 34 HUMALOG KWIKPEN ...... 34 HUMALOG MIX 50-50 ...... 34 HUMALOG MIX 50-50
KWIKPEN ....................... 34 HUMALOG MIX 75-25 ...... 34
HUMALOG MIX 75-25 KWIKPEN........................ 34
HUMAPEN LUXURA HD .. 33 HUMIRA .............................. 43 HUMIRA PEDIATRIC
CROHN'S START ........... 43 HUMIRA PEN CROHN'S-
UC-HS START ................ 43 HUMIRA PEN PSORIASIS-
UVEITIS .......................... 43 HUMULIN 70/30 ................. 34 HUMULIN 70/30 KWIKPEN
.......................................... 34 HUMULIN N ....................... 34 HUMULIN N KWIKPEN .... 34 HUMULIN R U-100 ............ 34 HUMULIN R U-500 (CONC)
KWIKPEN........................ 34 HUMULIN R U-500
(CONCENTRATED) ....... 34 HYCAMTIN ........................ 10 hydralazine ........................... 22 hydrochlorothiazide .............. 22 hydrocodone-acetaminophen 15 hydrocodone-chlorpheniramine
.......................................... 50 hydrocodone-cpm-
pseudoephed ..................... 50 hydrocodone-homatropine .... 50 hydrocodone-ibuprofen ........ 15 hydrocortisone .......... 29, 32, 38 hydrocortisone acetate .......... 38 hydrocortisone butyrate ........ 29 hydrocortisone butyr-emollient
.......................................... 29 hydrocortisone valerate ........ 29 hydrocortisone-acetic acid .... 31 hydrocortisone-iodoquinol-aloe
.......................................... 27 hydrocortisone-min oil-wht pet
.......................................... 29 hydrocortisone-pramoxine... 25,
38 hydromet ............................... 50 hydromorphone .................... 15 hydromorphone (pf) ............. 15
hydromorphone in 0.9 % nacl .......................................... 15
hydroxocobalamin ................ 56 hydroxychloroquine ................ 6 hydroxyprogesterone caproate
.......................................... 44 hydroxyurea .......................... 10 hydroxyzine hcl .................... 50 hydroxyzine pamoate ............ 50 hyolev mb ............................. 53 hyophen ................................ 53 hyoscyamine sulfate ............. 37 hyosyne ................................. 37 HYSINGLA ER .................... 15 I ibandronate ........................... 42 IBRANCE ............................. 10 ibuprofen ............................... 16 ibuprofen-oxycodone ............ 15 ICAPS MV ........................... 56 ICLUSIG .............................. 10 idarubicin .............................. 10 iferex 150 forte ..................... 56 ifosfamide ............................. 10 ifosfamide-mesna ................. 10 ILARIS (PF) ......................... 42 ILEVRO ............................... 49 imatinib ................................. 10 IMBRUVICA ....................... 10 imipenem-cilastatin ................ 6 imipramine hcl ...................... 19 imipramine pamoate ............. 19 imiquimod ............................. 42 IMPAVIDO ............................ 6 INCRELEX .......................... 30 INCRUSE ELLIPTA ............ 51 indapamide ........................... 22 indomethacin ........................ 16 infed ...................................... 56 INFLECTRA ........................ 38 INLYTA ............................... 10 INSET 30 INFUSION SET 23
.......................................... 34 INSET INFUSION SET 23 .. 34 INSPIRACHAMBER WITH
MASK-LARGE ................ 32
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
68
INSULIN SYRINGE-NEEDLE U-100 ............... 33
INTELENCE .......................... 3 INTRON A ........................... 42 introvale ................................ 45 INVIRASE ............................. 4 INVOKAMET ...................... 36 INVOKANA ........................ 36 iodoquinol-hc ....................... 27 ipratropium bromide ....... 31, 51 ipratropium-albuterol ........... 51 irbesartan .............................. 22 irbesartan-hydrochlorothiazide
.......................................... 22 IRESSA ................................ 10 irinotecan .............................. 10 ISENTRESS ........................... 4 isibloom ................................ 45 isomethepten-caf-
acetaminophen .................. 14 isoniazid ................................. 6 isosorbide dinitrate ............... 24 isosorbide mononitrate ......... 24 isoxsuprine ........................... 44 isradipine .............................. 22 ISTODAX ............................ 10 itraconazole ............................ 3 ivermectin ............................... 6 IXEMPRA ............................ 10 J JADENU .............................. 30 JAKAFI ................................ 10 jantoven ................................ 23 JANUMET ........................... 36 JANUMET XR ..................... 36 JANUVIA ............................ 36 JARDIANCE ........................ 36 jencycla................................. 44 JENTADUETO .................... 36 JENTADUETO XR.............. 36 JETREA (PF) ....................... 48 jevantique lo ......................... 44 jinteli .................................... 44 jolessa ................................... 45 jolivette ................................. 44 juleber ................................... 45 junel 1.5/30 (21) ................... 45
junel 1/20 (21) ...................... 45 junel fe 1.5/30 (28) ............... 45 junel fe 1/20 (28) .................. 45 junel fe 24 ............................. 45 JUXTAPID ........................... 24 K KADCYLA .......................... 10 kaitlib fe ................................ 45 KALBITOR .......................... 51 KALETRA ............................. 4 KALYDECO ........................ 51 KANUMA ............................ 35 kariva (28) ............................ 45 k-effervescent ....................... 54 kelnor 1/35 (28) .................... 46 KEPIVANCE ......................... 8 ketoconazole ..................... 3, 28 ketoprofen ............................. 16 ketorolac ................... 16, 17, 49 KEYTRUDA ........................ 10 kimidess (28) ........................ 46 KINERET ............................. 42 kionex ................................... 38 kionex (with sorbitol) ........... 39 KITABIS PAK ....................... 6 klor-con ................................ 54 klor-con 10 ........................... 54 klor-con 8 ............................. 54 klor-con m10 ........................ 54 klor-con m15 ........................ 54 klor-con m20 ........................ 54 klor-con sprinkle................... 54 klor-con/ef ............................ 54 K-PHOS NO 2 ...................... 53 K-PHOS ORIGINAL ........... 53 k-phos-neutral ....................... 54 KRYSTEXXA ...................... 42 k-tab ...................................... 54 kurvelo .................................. 46 KUVAN................................ 35 KYPROLIS .......................... 10 L l norgest/e.estradiol-e.estrad . 46 labetalol ................................ 22 lactated ringers ..................... 29 lactic acid .............................. 25 lactic acid e ........................... 25
lactulose ................................ 39 lamivudine .............................. 4 lamivudine-zidovudine ........... 4 lamotrigine ............................ 13 LANCETS ............................ 34 LANCING DEVICE ............ 34 lansoprazole .......................... 40 LANTUS .............................. 34 LANTUS SOLOSTAR ......... 34 larin 1.5/30 (21) .................... 46 larin 1/20 (21) ....................... 46 larin 24 fe .............................. 46 larin fe 1.5/30 (28) ................ 46 larin fe 1/20 (28) ................... 46 larissia ................................... 46 LARTRUVO ........................ 10 LASTACAFT ....................... 48 latanoprost ............................ 49 LATUDA .............................. 19 laxaclear ................................ 39 laxative (bisacodyl) .............. 39 laxative feminine .................. 39 laxative peg 3350 .................. 39 layolis fe ............................... 46 leena 28 ................................. 46 leflunomide ........................... 43 LEMTRADA ........................ 41 LENVIMA ............................ 10 lessina ................................... 46 letrozole ................................ 10 leucovorin calcium ................. 8 LEUKERAN ......................... 10 LEUKINE ............................. 41 leuprolide .............................. 10 levalbuterol hcl ..................... 51 LEVATOL ............................ 22 LEVEMIR ............................ 34 LEVEMIR FLEXTOUCH .... 34 levetiracetam ......................... 13 levetiracetam in nacl (iso-os) 13 levobunolol ........................... 48 levocarnitine ......................... 30 levocarnitine (with sugar) ..... 30 levofloxacin ...................... 7, 47 levofloxacin in d5w ................ 7 levoleucovorin ........................ 8 LEVOLEUCOVORIN ........... 8
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
69
levonest (28) ......................... 46 levonorgestrel-ethinyl estrad 46 levonorg-eth estrad triphasic 46 levora-28............................... 46 levorphanol tartrate .............. 15 levothyroxine ........................ 37 levoxyl .................................. 37 LEXIVA ................................. 4 lidocaine ............................... 27 lidocaine (pf) ........................ 27 lidocaine hcl ......................... 27 lidocaine hcl-hydrocortison ac
.................................... 27, 39 lidocaine viscous .................. 27 lidocaine-epinephrine ........... 27 lidocaine-hydrocortisone-aloe
.......................................... 39 lidocaine-prilocaine .............. 27 lido-k .................................... 27 lidopin .................................. 27 lidopril .................................. 27 lincomycin .............................. 6 lindane .................................. 29 linezolid .................................. 6 linezolid-0.9% sodium chloride
............................................ 6 LINZESS .............................. 39 liothyronine .......................... 37 lipodox .................................. 10 lisinopril ............................... 22 lisinopril-hydrochlorothiazide
.......................................... 22 lite coat aspirin ..................... 17 LITEAIRE MDI CHAMBER
.......................................... 33 lithium carbonate .................. 19 lithium citrate ....................... 19 LIVALO ............................... 24 lomedia 24 fe ........................ 46 LONSURF ............................ 10 loperamide ............................ 37 lopinavir-ritonavir .................. 4 lopreeza ................................ 44 lorazepam ............................. 19 lorazepam intensol................ 19 lorcet (hydrocodone) ............ 15 lorcet hd ................................ 15
lorcet plus ............................. 15 lortuss ex............................... 50 loryna (28) ............................ 46 losartan ................................. 22 losartan-hydrochlorothiazide 22 LOTEMAX .......................... 49 lovastatin .............................. 24 low-ogestrel (28) .................. 46 loxapine succinate ................ 19 lta pre-attached ..................... 27 LUCENTIS ........................... 48 ludent fluoride ...................... 56 lugols .............................. 27, 54 LUMIZYME ........................ 35 LUPRON DEPOT ................ 10 LUPRON DEPOT (3
MONTH) .......................... 10 LUPRON DEPOT-PED ....... 11 LUPRON DEPOT-PED (3
MONTH) .......................... 11 lutera (28) ............................. 46 luxamend .............................. 25 LUZU ................................... 28 LYNPARZA ......................... 11 LYRICA ............................... 13 LYSODREN ......................... 11 lyza ....................................... 44 M m.v.i. adult ............................ 56 MAGNEBIND 300............... 39 magnesium citrate................. 39 MAKENA ............................ 44 malathion .............................. 29 maprotiline............................ 19 marlissa ................................. 46 MARPLAN .......................... 19 MARQIBO ........................... 11 marten-tab ............................. 15 MATULANE........................ 11 matzim la .............................. 22 mb hydrogel .......................... 25 mb hydrogel (cyclomethicone)
.......................................... 25 m-clear wc ............................ 50 meclofenamate ...................... 17 medroxyprogesterone ........... 44 mefenamic acid ..................... 17
mefloquine .............................. 6 megestrol .............................. 11 MEKINIST ........................... 11 meloxicam ............................ 17 melphalan ............................. 11 melphalan hcl ........................ 11 memantine ............................ 14 MENEST .............................. 44 MENTAX ............................. 28 meperidine ............................ 15 MEPHYTON ........................ 23 meprobamate ........................ 14 mercaptopurine ..................... 11 meropenem ............................. 6 MEROPENEM-0.9%
SODIUM CHLORIDE ....... 6 mesalamine ........................... 39 mesalamine with cleansing
wipe .................................. 39 mesna ...................................... 8 MESNEX ................................ 8 MESTINON ......................... 14 metadate er ............................ 19 metaproterenol ...................... 51 metaxall ................................ 14 metaxalone ............................ 14 metformin ............................. 36 methadone ............................. 15 methadose ............................. 15 methamphetamine ................. 19 methazolamide ...................... 49 methenamine hippurate .......... 8 methenamine mandelate ......... 8 methen-sod phos-meth blue-
hyos ................................... 53 methergine ............................ 47 methimazole ......................... 32 METHITEST ........................ 35 methocarbamol ..................... 14 methotrexate sodium ............ 11 methotrexate sodium (pf) ..... 11 methoxsalen .......................... 25 methscopolamine .................. 37 methyclothiazide ................... 22 methyldopa ........................... 22 methyldopa-
hydrochlorothiazide .......... 22
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
70
methyldopate ........................ 22 methylphenidate hcl ............. 19 methylprednisolone .............. 32 methylprednisolone acetate .. 32 methyltestosterone ................ 35 metipranolol ......................... 48 metoclopramide hcl .............. 39 metolazone ........................... 22 metoprolol succinate ............ 22 metoprolol ta-hydrochlorothiaz
.......................................... 22 metoprolol tartrate ................ 22 metro i.v. ................................ 6 metronidazole ............. 6, 26, 44 metronidazole in nacl (iso-os) 6 mexiletine ............................. 20 mibelas 24 fe ........................ 46 miconazole-3 ........................ 44 MICROCHAMBER ............. 33 microgestin 1.5/30 (21) ........ 46 microgestin 1/20 (21) ........... 46 microgestin fe 1.5/30 (28) .... 46 microgestin fe 1/20 (28) ....... 46 MICROSPACER .................. 33 midazolam ............................ 19 midodrine ............................. 30 migergot ............................... 14 miglitol ................................. 36 milk of magnesia .................. 39 milk of magnesia concentrated
.......................................... 39 millipred ............................... 32 millipred dp .......................... 32 mimvey ................................. 44 mimvey lo ............................. 44 MINIMED INFUSION SET-
MMT 390 ......................... 34 minocycline ............................ 8 minoxidil .............................. 22 MIO INFUSION SET .......... 34 miostat .................................. 49 miralax .................................. 39 MIRENA .............................. 43 mirtazapine ........................... 19 MIRVASO ........................... 26 misoprostol ........................... 40 MITIGARE .......................... 42
mitomycin ............................. 11 mitoxantrone ......................... 11 modafinil .............................. 19 moderiba ............................... 41 moderiba dose pack .............. 41 moexipril .............................. 22 moexipril-hydrochlorothiazide
.......................................... 22 mometasone .................... 29, 51 mondoxyne nl ......................... 8 mono-linyah.......................... 46 mononessa (28)..................... 46 montelukast .......................... 51 MONUROL ............................ 8 morgidox ................................ 8 morphine ......................... 15, 16 morphine (pf) ........................ 15 morphine (pf) in 0.9 % nacl .. 15 morphine concentrate ........... 15 MOTOFEN ........................... 37 MOVANTIK ........................ 39 MOVIPREP .......................... 39 MOXEZA ............................. 47 moxifloxacin ..................... 7, 47 MOXIFLOXACIN-
SOD.ACE,SUL-WATER ... 7 MOZOBIL ............................ 41 MULTAQ ............................. 20 multigen folic ....................... 56 multigen plus ........................ 56 multi-vit with fluoride-iron .. 56 multi-vitamin hp/minerals .... 56 multi-vitamin with fluoride . 56,
57 multivitamins with fluoride .. 57 mupirocin.............................. 27 mupirocin calcium ................ 27 MUSE ................................... 53 MUSTARGEN ..................... 11 mvc-fluoride ......................... 57 my way ................................. 46 MYALEPT ........................... 35 MYCAMINE .......................... 3 mycophenolate mofetil ......... 11 mycophenolate mofetil hcl ... 11 mycophenolate sodium ......... 11 myferon 150 forte ................. 57
MYLERAN .......................... 11 mynatal ................................. 57 mynatal advance ................... 57 mynatal plus .......................... 57 mynatal-z .............................. 57 mynate 90 plus ...................... 57 mynephrocaps ....................... 57 mynephron ............................ 57 MYRBETRIQ ....................... 52 myzilra .................................. 46 N nabumetone ........................... 17 nadolol .................................. 22 nadolol-bendroflumethiazide 22 nafcillin ................................... 7 nafcillin in dextrose iso-osm .. 7 naftifine ................................. 28 NAGLAZYME ..................... 35 nalbuphine ............................ 17 naloxone ............................... 17 naltrexone ............................. 17 naproxen ............................... 17 naproxen sodium .................. 17 naratriptan ............................. 14 NARCAN ............................. 17 NATACYN ........................... 47 nateglinide ............................ 36 NATPARA ........................... 35 natura-lax .............................. 39 nature-throid ......................... 37 NEBUPENT ........................... 6 nebusal .................................. 51 necon 0.5/35 (28) .................. 46 necon 1/50 (28) ..................... 46 necon 7/7/7 (28) .................... 46 nefazodone ............................ 19 neomycin ................................ 6 neomycin-bacitracin-poly-hc 49 neomycin-bacitracin-
polymyxin ......................... 47 neomycin-polymyxin b gu .... 29 neomycin-polymyxin b-
dexameth ........................... 49 neomycin-polymyxin-
gramicidin ......................... 48 neomycin-polymyxin-hc . 31, 49 neo-polycin ........................... 48
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
71
neo-polycin hc ...................... 49 NEO-SYNALAR ................. 27 nephplex rx ........................... 57 nephro-vite rx ....................... 57 neuac..................................... 26 NEULASTA ......................... 41 NEUPOGEN ........................ 41 NEVANAC .......................... 49 nevirapine ............................... 4 newgen ................................. 57 NEXAVAR .......................... 11 NEXPLANON ..................... 44 next choice one dose ............ 46 niacin .................................... 24 nicardipine ............................ 22 NICODERM CQ .................. 30 nicorelief............................... 30 nicorette ................................ 30 NICORETTE ........................ 30 nicotine ................................. 31 nicotine (polacrilex) ............. 31 NICOTROL .......................... 31 NICOTROL NS ................... 31 nifedipine .............................. 22 nikki (28) .............................. 46 nilutamide ............................. 11 nimodipine ............................ 22 NINLARO ............................ 11 nisoldipine ............................ 22 nitro-bid ................................ 24 nitrofurantoin .......................... 8 nitrofurantoin macrocrystal .... 8 nitrofurantoin monohyd/m-
cryst .................................... 8 nitroglycerin ......................... 24 nitroglycerin in 5 % dextrose 24 nivatopic plus ....................... 25 nizatidine .............................. 40 nolix ...................................... 29 nora-be .................................. 44 noreth-ethinyl estradiol-iron . 46 norethindrone (contraceptive)
.......................................... 44 norethindrone acetate ........... 44 norethindrone ac-eth estradiol
.................................... 44, 46
norethindrone-e.estradiol-iron .......................................... 46
norgestimate-ethinyl estradiol .......................................... 46
norlyda .................................. 44 norlyroc ................................ 44 nortrel 0.5/35 (28)................. 46 nortrel 1/35 (21).................... 46 nortrel 1/35 (28).................... 46 nortrel 7/7/7 (28) .................. 46 nortriptyline .......................... 19 NORVIR ................................. 4 NOVOLOG .......................... 34 NOVOLOG FLEXPEN ........ 35 NOVOLOG MIX 70-30 ....... 35 NOVOLOG MIX 70-30
FLEXPEN ........................ 35 NOVOLOG PENFILL ......... 35 NOXAFIL .............................. 3 np thyroid ............................. 37 NPLATE ............................... 23 nts step 1 ............................... 31 NUCALA ............................. 51 NUCYNTA .......................... 17 NUCYNTA ER .................... 17 NUEDEXTA ........................ 14 NULOJIX ............................. 11 NUVARING ......................... 44 nyamyc ................................. 28 nyata ..................................... 28 nystatin ............................. 3, 28 nystatin-triamcinolone .......... 28 nystop ................................... 28 O obstetrix dha ......................... 57 OCALIVA ............................ 39 ocella .................................... 46 OCREVUS ........................... 41 octreotide acetate .................. 11 ODEFSEY .............................. 4 OFEV.................................... 52 ofloxacin ..................... 7, 31, 48 ogestrel (28) .......................... 46 olanzapine ............................. 19 olanzapine-fluoxetine ........... 19 olmesartan ............................ 22
olmesartan-amlodipin-hcthiazid ........................... 22
olmesartan-hydrochlorothiazide .......... 22
olopatadine ..................... 31, 48 OLYSIO ................................. 4 omega-3 acid ethyl esters ..... 24 omeprazole ........................... 40 omeprazole magnesium ........ 40 omeprazole-sodium
bicarbonate ....................... 40 OMNIPOD INSULIN REFILL
.......................................... 34 OMNITROPE ....................... 41 ONCASPAR ......................... 11 ondansetron ........................... 39 ondansetron hcl ..................... 39 ondansetron hcl (pf) .............. 39 one daily women's health ..... 57 ONFI ..................................... 13 ONIVYDE ............................ 11 opcicon one-step ................... 46 OPDIVO ............................... 11 opium tincture ....................... 37 OPSUMIT ............................. 52 OPTICHAMBER DIAMOND
LG MASK ........................ 33 option-2 ................................. 46 oral saline laxative ................ 39 oralone .................................. 31 ORBACTIV ............................ 6 ORENCIA ............................ 43 ORFADIN ............................ 30 ORKAMBI ........................... 52 orphenadrine citrate .............. 14 orsythia ................................. 46 ortho d ................................... 57 oscimin ................................. 37 oscimin sl .............................. 37 oscimin sr .............................. 37 oseltamivir .............................. 4 OSPHENA ............................ 44 OTEZLA ............................... 43 OTEZLA STARTER ............ 43 oxacillin .................................. 7 oxacillin in dextrose(iso-osm) 7 oxaliplatin ............................. 11
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
72
oxandrolone .......................... 35 oxaprozin .............................. 17 oxazepam .............................. 19 oxcarbazepine ....................... 13 oxiconazole........................... 28 oxybutynin chloride.............. 52 oxycodone ............................ 16 oxycodone-acetaminophen ... 16 oxycodone-aspirin ................ 16 OXYCONTIN ...................... 16 oxymorphone ........................ 16 oysco 500/d .......................... 54 oyster shell + d3 ................... 54 oyster shell calcium-vit d3 ... 54 oystercal-d ............................ 54 OZURDEX ........................... 49 P pacerone ............................... 20 paclitaxel .............................. 11 paliperidone .......................... 19 pamidronate .......................... 35 PANRETIN .......................... 25 pantoprazole ................... 40, 41 papaverine ............................ 22 PARAGARD T 380A .......... 43 paregoric ............................... 37 paricalcitol ............................ 35 paroex oral rinse ................... 31 paromomycin .......................... 6 paroxetine hcl ....................... 19 PASER ................................... 6 peg 3350-electrolytes ........... 39 peg3350 ................................ 39 PEGANONE ........................ 13 PEGASYS ............................ 41 PEGASYS PROCLICK ....... 41 peg-electrolyte soln .............. 39 peg-prep ................................ 39 PEN NEEDLE ...................... 34 penicillin g potassium............. 7 penicillin g procaine ............... 7 penicillin g sodium ................. 7 penicillin v potassium............. 7 PENTASA ............................ 39 pentoxifylline ....................... 23 PERFOROMIST .................. 52 perindopril erbumine ............ 22
periogard ............................... 31 PERJETA ............................. 11 permethrin ............................ 29 perphenazine ......................... 19 perphenazine-amitriptyline ... 19 pfizerpen-g.............................. 7 phenadoz ............................... 50 phenazopyridine ................... 53 phenelzine ............................. 19 phenergan ............................. 50 phenobarbital ........................ 13 phenohytro ............................ 37 phenoxybenzamine ............... 22 phentolamine ........................ 22 phenylephrine hcl ................. 49 phenytoin .............................. 13 phenytoin sodium ................. 13 phenytoin sodium extended .. 13 philith.................................... 46 phospha 250 neutral.............. 54 phosphasal ............................ 53 phosphate laxative ................ 39 PHOSPHOLINE IODIDE .... 48 PHOTOFRIN........................ 11 PICATO................................ 25 pilocarpine hcl .......... 30, 31, 48 pimozide ............................... 19 pimtrea (28) .......................... 47 pindolol ................................. 22 pioglitazone .......................... 36 pioglitazone-glimepiride ...... 36 pioglitazone-metformin ........ 36 piperacillin-tazobactam .......... 7 pirmella ................................. 47 piroxicam .............................. 17 PLAN B ONE-STEP ............ 47 PLEGRIDY .......................... 41 PLIAGLIS ............................ 27 PNEUMOVAX 23 ............... 42 pnv 29-1 ................................ 57 pnv ob+dha ........................... 57 pnv-dha ................................. 57 pnv-dha + docusate ............... 57 pnv-ferrous fumarate-docu-fa
.......................................... 57 pnv-omega ............................ 57 pnv-select.............................. 57
pnv-vp-u ............................... 57 POCKET CHAMBER .......... 33 podofilox ............................... 25 polycin .................................. 48 polyethylene glycol 3350 ..... 39 poly-iron ............................... 57 poly-iron 150 forte ................ 57 polymyxin b sulfate ................ 6 polymyxin b sulf-trimethoprim
.......................................... 48 POMALYST ......................... 41 portia ..................................... 47 pot,sodium citrate-citric acid 53 potassium acetate .................. 54 potassium bicarb and chloride
.......................................... 54 potassium bicarb-citric acid .. 54 potassium chlorid-d5-
0.45%nacl ......................... 54 potassium chloride ................ 54 potassium chloride in 0.9%nacl
.......................................... 54 potassium chloride in 5 % dex
.......................................... 54 potassium chloride in lr-d5 ... 54 potassium chloride-0.45 % nacl
.......................................... 54 potassium chloride-d5-
0.2%nacl ........................... 54 potassium chloride-d5-
0.3%nacl ........................... 54 potassium chloride-d5-
0.9%nacl ........................... 54 potassium citrate ................... 53 potassium citrate-citric acid .. 53 potassium phosphate m-/d-
basic .................................. 54 powderlax ............................. 39 pr natal 400 ........................... 57 pr natal 400 ec ...................... 57 pr natal 430 ........................... 57 pr natal 430 ec ...................... 57 PRADAXA ........................... 23 PRALUENT PEN ................. 24 pramcort ................................ 39 pramipexole .......................... 13 pravastatin ............................. 24
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
73
prazosin ................................ 22 PRED MILD ........................ 49 prednicarbate ........................ 29 prednisolone ......................... 32 prednisolone acetate ............. 49 prednisolone sodium phosphate
.................................... 32, 49 prednisone ............................ 32 prednisone intensol ............... 32 prena1 chew.......................... 57 prena1 pearl .......................... 57 prena1 true ............................ 57 prenaissance ......................... 57 prenaissance plus .................. 57 prenatabs fa .......................... 57 prenatabs rx .......................... 57 prenatal ................................. 57 prenatal formula ................... 57 prenatal plus ......................... 57 prenatal plus (calcium carb) . 57 prenatal vitamin plus low iron
.......................................... 57 prenatal vits96-iron fum-folic
.......................................... 58 prenatal-u .............................. 58 preplus .................................. 58 PREPOPIK ........................... 39 pretab .................................... 58 prevalite ................................ 24 previfem ............................... 47 PREVNAR 13 (PF) .............. 42 PREZCOBIX .......................... 4 PREZISTA ............................. 4 PRIFTIN ................................. 6 PRIMAQUINE ....................... 6 PRIMEAIRE ........................ 33 primidone ............................. 13 PROAIR HFA ...................... 52 PROAIR RESPICLICK ....... 52 probenecid ............................ 42 probenecid-colchicine .......... 42 procainamide ........................ 20 procentra ............................... 19 PROCHAMBER .................. 33 prochlorperazine ................... 39 prochlorperazine edisylate.... 39 prochlorperazine maleate ..... 39
PROCRIT ............................. 41 procto-med hc ....................... 39 procto-pak ............................. 39 proctosol hc .......................... 39 proctozone-hc ....................... 39 PROFERRIN-FORTE .......... 58 progesterone micronized ...... 44 PROGLYCEM ..................... 33 PROGRAF ........................... 11 PROLASTIN-C .................... 30 PROLEUKIN ....................... 42 PROMACTA ........................ 23 promethazine ........................ 50 promethazine vc-codeine ...... 50 promethazine-codeine .......... 50 promethazine-dm .................. 50 promethazine-phenyleph-
codeine.............................. 50 promethazine-phenylephrine 50 promethegan ......................... 50 propafenone .......................... 20 proparacaine ......................... 48 propranolol ........................... 22 propranolol-hydrochlorothiazid
.......................................... 22 propylthiouracil .................... 32 prosight ................................. 58 protamine .............................. 23 protriptyline .......................... 19 PROVENGE ......................... 42 pruclair.................................. 25 prudoxin................................ 25 prumyx.................................. 25 prutect ................................... 25 pulmosal ............................... 52 PULMOZYME ..................... 52 purelax .................................. 39 purevit dualfe plus ................ 58 PURIXAN ............................ 11 pyrazinamide .......................... 6 pyridostigmine bromide ....... 14 Q quasense................................ 47 quazepam .............................. 19 quetiapine ....................... 19, 20 QUICK-SET PARADIGM... 34 quinapril................................ 22
quinapril-hydrochlorothiazide .......................................... 22
quinidine gluconate .............. 20 quinidine sulfate ................... 20 quinine sulfate ........................ 6 quit 2 ..................................... 31 QUIT 2 .................................. 31 quit 4 ..................................... 31 QUIT 4 .................................. 31 QVAR ................................... 52 R rabeprazole ........................... 41 RADICAVA ......................... 14 rajani ..................................... 47 raloxifene .............................. 42 ramipril ................................. 22 ranitidine hcl ......................... 41 RAPAFLO ............................ 53 RAPAMUNE ........................ 11 RAPIVAB ............................... 4 rasagiline ............................... 13 RAVICTI .............................. 30 rea lo 39 ................................ 26 rea lo 40 ................................ 26 REBIF (WITH ALBUMIN) . 41 REBIF REBIDOSE .............. 42 REBIF TITRATION PACK . 42 reclipsen (28) ........................ 47 RECTIV ................................ 39 regonol .................................. 14 REGRANEX ........................ 26 relador pak ............................ 27 relador pak plus .................... 27 relcof c .................................. 50 RELENZA DISKHALER ...... 4 RELION NOVOLIN 70/30 .. 35 RELION NOVOLIN N ........ 35 RELION NOVOLIN R ......... 35 RELISTOR ........................... 39 relnate dha ............................ 58 REMICADE ......................... 39 REMODULIN ...................... 22 RENACIDIN ........................ 53 renal caps .............................. 58 rena-vite rx ............................ 58 reno caps ............................... 58 RENVELA ........................... 39
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
74
repaglinide ............................ 36 repaglinide-metformin .......... 36 REPATHA PUSHTRONEX 24 REPATHA SURECLICK .... 24 REPATHA SYRINGE ......... 24 RESCRIPTOR ........................ 4 RESTASIS ........................... 48 RESTASIS MULTIDOSE ... 48 RETROVIR ............................ 4 REVLIMID .......................... 42 revonto .................................. 14 REXULTI ............................. 20 REYATAZ ............................. 4 RIASTAP ............................. 24 ribasphere ............................. 42 ribasphere ribapak ................ 42 ribavirin ............................ 4, 42 RIDAURA ............................ 43 rifabutin .................................. 6 RIFAMATE ........................... 6 rifampin .................................. 6 RIFATER ............................... 6 riluzole .................................. 30 rimantadine ............................. 4 ringer's .................................. 29 risedronate ................ 30, 42, 43 RISPERDAL CONSTA ....... 20 risperidone ............................ 20 RITEFLO AEROCHAMBER
.......................................... 33 RITUXAN ............................ 11 rivastigmine .......................... 14 rivastigmine tartrate.............. 14 rivelsa ................................... 47 rizatriptan ............................. 14 ropinirole .............................. 13 rosadan ................................. 26 rosula cleansing cloths ......... 26 rosuvastatin........................... 24 roweepra ............................... 13 ROZEREM ........................... 20 RUBRACA .......................... 11 RYDAPT .............................. 11 rydex ..................................... 50 S SABRIL ................................ 13 SAFE-CLIP BY MAIL ........ 34
salicylic acid ......................... 25 salicylic acid er-ceramides ... 25 salsalate ................................ 17 salvax .................................... 25 SAMSCA ............................. 35 SANDIMMUNE .................. 11 SANDOSTATIN LAR
DEPOT ............................. 11 SANTYL .............................. 29 SAVELLA ............................ 43 scalacort ................................ 29 seb-prev ................................ 25 seconal sodium ..................... 20 selegiline hcl ......................... 13 selenium sulfide .................... 25 SELZENTRY ......................... 4 se-natal 19............................. 58 se-natal 19 (with docusate) ... 58 SENSIPAR ........................... 35 sertraline ............................... 20 se-tan plus ............................. 58 setlakin.................................. 47 sevelamer carbonate ............. 39 sf 31 sf 5000 plus .......................... 31 sharobel ................................ 44 SIGNIFOR............................ 11 sildenafil ............................... 52 silver nitrate .......................... 26 silver nitrate applicators ....... 26 silver sulfadiazine ................. 25 SIMBRINZA ........................ 49 SIMPONI.............................. 43 SIMULECT .......................... 11 simvastatin ............................ 24 sirolimus ............................... 11 SIRTURO ............................... 6 SIVEXTRO ............................ 6 smoothlax ............................. 39 SNAP INSULIN PUMP-
INFUSION SET ............... 34 sodium benzoate-sod
phenylacet ......................... 30 sodium chlor 0.9% bacteriostat
.......................................... 30 sodium chloride ........ 30, 52, 54 sodium chloride 0.45 % ........ 54
sodium chloride 0.9 % .......... 30 sodium chloride 3 % ............. 54 sodium chloride 5 % ............. 54 sodium citrate-citric acid ...... 53 sodium ferric gluconat-sucrose
.......................................... 30 sodium phenylbutyrate ......... 30 sodium phosphate ................. 54 sodium polystyrene sulfonate
.......................................... 40 SOLIRIS ............................... 30 SOMAVERT ........................ 35 sonafine ................................. 26 SOOLANTRA ...................... 26 sotalol ................................... 20 sotalol af ............................... 20 SOTYLIZE ........................... 20 sp antipruritic ........................ 26 sp scar management .............. 26 spinosad ................................ 29 SPIRIVA WITH
HANDIHALER ................ 52 spironolactone ....................... 22 spironolacton-hydrochlorothiaz
.......................................... 22 SPORANOX ........................... 3 sprintec (28) .......................... 47 SPRYCEL ............................. 11 sps (with sorbitol) ................. 40 sronyx ................................... 47 ss 10-2 ................................... 26 ssd ......................................... 25 sss 10-5 ................................. 26 stavudine ................................. 4 STELARA ............................ 25 STIMATE ............................. 35 STIVARGA .......................... 11 stop smoking aid ................... 31 STRENSIQ ........................... 35 stress b with zinc .................. 58 stress formula ........................ 58 stress formula with iron ........ 58 STRIBILD .............................. 4 STRIVERDI RESPIMAT .... 52 strong iodine ......................... 54 SUBOXONE ........................ 17 SUCRAID ............................. 40
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
75
sucralfate .............................. 41 sulfacetamide sodium ..... 25, 49 sulfacetamide sodium (acne) 27 sulfacetamide sodium-sulfur 26 sulfacetamide sod-sulfur-urea
.......................................... 26 sulfacetamide-prednisolone .. 49 sulfacetamide-sulfur-cleansr23
.......................................... 26 sulfacleanse 8-4 .................... 26 sulfact na-sul-avobnz-otn-ocsa
.......................................... 26 sulfadiazine............................. 7 sulfamethoxazole-trimethoprim
............................................ 7 SULFAMYLON .................. 27 sulfasalazine ......................... 40 sulfatrim ................................. 7 sulindac................................. 17 sumatriptan ........................... 14 sumatriptan succinate ........... 14 super b complex-vitamin c ... 58 super b-50 complex plus ...... 58 super quints b-50 .................. 58 superplex-t ............................ 58 SUPREP BOWEL PREP KIT
.......................................... 40 SURE-T PARADIGM ......... 34 SUSTIVA ............................... 4 SUTENT .............................. 11 syeda ..................................... 47 SYLATRON......................... 42 SYLVANT ........................... 12 symax fastabs ....................... 37 symax-sl ............................... 37 symax-sr ............................... 37 SYMBICORT ...................... 52 SYMLINPEN 120 ................ 36 SYMLINPEN 60 .................. 36 SYNAGIS .............................. 4 SYNAREL ........................... 35 SYNJARDY ......................... 36 SYNJARDY XR .................. 36 SYNTHROID ....................... 37 T T
30 INFUSION SET .......... 34
90 INFUSION SET 23 ..... 34 SLIM ................................ 34 SLIM G4........................... 34
TABLOID ............................ 12 tacrolimus ....................... 12, 26 TAFINLAR .......................... 12 TAGRISSO .......................... 12 TAMIFLU .............................. 4 tamoxifen .............................. 12 tamsulosin ............................. 53 TANZEUM .......................... 36 TARCEVA ........................... 12 TARGRETIN ....................... 12 tarina fe 1/20 (28) ................. 47 taron forte ............................. 58 taron-c dha ............................ 58 taron-prex prenatal-dha ........ 58 TASIGNA ............................ 12 tazarotene.............................. 26 TAZORAC ........................... 26 taztia xt ................................. 22 TECENTRIQ ........................ 12 TECFIDERA ........................ 42 TECHNIVIE ........................... 4 telmisartan ............................ 22 telmisartan-amlodipine ......... 22 telmisartan-hydrochlorothiazid
.......................................... 22 temazepam ............................ 20 TEMODAR .......................... 12 temozolomide ....................... 12 tencon ................................... 16 TENIPOSIDE ....................... 12 terazosin................................ 23 terbinafine hcl ......................... 3 terbutaline ............................. 52 terconazole............................ 44 TESTOPEL .......................... 35 testosterone ........................... 35 testosterone cypionate .......... 35 testosterone enanthate ........... 35 tetcaine.................................. 48 tetrabenazine ......................... 14 tetracaine hcl......................... 48 tetracaine hcl (pf) .................. 48 tetracycline ............................. 8 THALOMID ......................... 12
theochron .............................. 52 theophylline .......................... 52 thermazene ............................ 25 thioridazine ........................... 20 thiotepa ................................. 12 thiothixene ............................ 20 thrivite-19 ............................. 58 THYROLAR-1 ..................... 37 THYROLAR-1/2 .................. 37 THYROLAR-1/4 .................. 37 THYROLAR-2 ..................... 37 THYROLAR-3 ..................... 37 tiagabine ............................... 13 ticlopidine ............................. 24 tilia fe .................................... 47 timolol maleate ............... 23, 48 tinidazole ................................ 7 tis-u-sol pentalyte ................. 29 TIVICAY ................................ 4 tizanidine .............................. 14 tl gard rx ............................... 58 tl g-fol os ............................... 58 tl icon .................................... 58 tl-hem 150 ............................. 58 tobramycin ............................ 48 tobramycin in 0.225 % nacl .... 7 tobramycin in 0.9 % nacl ........ 7 tobramycin sulfate .................. 7 tobramycin-dexamethasone .. 49 tolazamide ............................. 36 tolbutamide ........................... 36 tolcapone ............................... 13 tolmetin ................................. 17 tolterodine ............................. 52 topiramate ............................. 13 toposar .................................. 12 topotecan ............................... 12 TORISEL .............................. 12 torsemide .............................. 23 total b/c ................................. 58 TOVIAZ ............................... 52 TRACLEER ......................... 52 TRADJENTA ....................... 36 tramadol ................................ 17 tramadol-acetaminophen ...... 17 trandolapril ........................... 23 trandolapril-verapamil .......... 23
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
76
tranexamic acid .............. 24, 44 tranylcypromine ................... 20 TRAVATAN Z .................... 49 trazodone .............................. 20 TREANDA ........................... 12 TRECATOR ........................... 7 tretinoin ................................ 27 tretinoin (chemotherapy) ...... 12 tretinoin microspheres .......... 27 TREXALL ............................ 12 tri femynor ............................ 47 TRIACETIN ......................... 28 triamcinolone acetonide 29, 31,
32 triamterene-hydrochlorothiazid
.......................................... 23 trianex ................................... 29 triazolam ............................... 20 tricitrates ............................... 53 tricon..................................... 58 triderm .................................. 29 tri-estarylla ........................... 47 trifluoperazine ...................... 20 trifluridine............................. 48 trigels-f forte ......................... 58 trihexyphenidyl .................... 13 tri-legest fe............................ 47 tri-linyah ............................... 47 tri-lo-estarylla ....................... 47 tri-lo-marzia .......................... 47 tri-lo-sprintec ........................ 47 trilyte with flavor packets ..... 40 trimethobenzamide ............... 40 trimethoprim ........................... 8 trimipramine ......................... 20 trinatal gt .............................. 58 trinatal rx 1 ........................... 58 trinate .................................... 58 trinessa (28) .......................... 47 trinessa lo.............................. 47 TRINTELLIX....................... 20 triphrocaps ............................ 58 tri-previfem (28) ................... 47 TRISENOX .......................... 12 tri-sprintec (28) ..................... 47 tri-tabs dha ............................ 58 TRIUMEQ .............................. 4
triveen-duo dha ..................... 58 tri-vit with fluoride and iron . 58 tri-vitamin with fluoride ....... 58 trivora (28) ............................ 47 tropicamide ........................... 48 trospium ................................ 52 trust natal dha ....................... 58 TRUVADA ............................ 4 TUDORZA PRESSAIR ....... 52 tusnel c .................................. 50 tussigon ................................. 50 TYGACIL .............................. 7 TYKERB .............................. 12 TYMLOS.............................. 43 TYSABRI ............................. 14 TYVASO .............................. 52 TYVASO REFILL KIT........ 52 TYVASO STARTER KIT ... 52 U UCERIS ................................ 40 ULESFIA.............................. 29 ULORIC ............................... 42 ultimatecare one ................... 58 ultimatecare one nf ............... 58 ultra b-100 complex.............. 58 umecta .................................. 26 unithroid ............................... 37 UNITUXIN .......................... 12 UPTRAVI ............................. 23 ur n-c..................................... 53 uramit mb ............................. 53 urea ....................................... 26 urea nail stick........................ 26 ure-k...................................... 26 uretron d-s............................. 53 urimar-t ................................. 53 urin ds ................................... 53 uro-458 ................................. 53 urogesic-blue ........................ 53 uro-mp .................................. 53 urophen mb ........................... 53 ursodiol ................................. 40 uryl........................................ 53 ustell ..................................... 53 utira-c.................................... 53 UVADEX ............................. 26
V vaginal contraceptive foam ... 44 valacyclovir ............................ 4 VALCHLOR ........................ 26 valganciclovir ......................... 4 valproate sodium .................. 13 valproic acid ......................... 13 valproic acid (as sodium salt)
.......................................... 13 valsartan ................................ 23 valsartan-hydrochlorothiazide
.......................................... 23 vancomycin ............................. 8 VANCOMYCIN IN 0.9%
SODIUM CL ...................... 8 VANCOMYCIN IN
DEXTROSE 5 % ................ 8 vandazole .............................. 44 VANTAS .............................. 12 VARUBI ............................... 40 VASCEPA ............................ 24 v-c forte ................................ 58 VECTIBIX ........................... 12 VELCADE ........................... 12 veletri .................................... 23 velivet triphasic regimen (28)
.......................................... 47 VELPHORO ......................... 40 VELTASSA .......................... 40 VELTIN ................................ 27 vemavite-prx-2 ..................... 58 VEMLIDY .............................. 4 VENCLEXTA ...................... 12 VENCLEXTA STARTING
PACK ............................... 12 venlafaxine ........................... 20 VENOFER ............................ 58 VENTAVIS .......................... 52 VENTOLIN HFA ................. 52 verapamil .............................. 23 verdrocet ............................... 16 VEREGEN ........................... 26 veripred 20 ............................ 32 VESICARE ........................... 52 vestura (28) ........................... 47 VGO 20 ................................ 34 VGO 30 ................................ 34
Updated 08/25/17
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
77
VGO 40 ................................ 34 VIAGRA .............................. 53 VIBERZI .............................. 40 vic-forte ................................ 58 vicodin .................................. 16 vicodin es.............................. 16 vicodin hp ............................. 16 VICTOZA 2-PAK ................ 37 VICTOZA 3-PAK ................ 37 VIDEX 2 GRAM PEDIATRIC
............................................ 4 VIEKIRA PAK ...................... 4 VIEKIRA XR ......................... 4 vienva ................................... 47 VIIBRYD ............................. 20 VIMIZIM ............................. 35 VIMPAT .............................. 13 vinate care ............................ 58 vinate dha ............................. 58 vinate ii ................................. 58 vinate m ................................ 58 vinate one ............................. 58 vinate ultra ............................ 58 vinblastine ............................ 12 vincasar pfs ........................... 12 vincristine ............................. 12 vinorelbine ............................ 12 VIOKACE ............................ 40 viorele (28) ........................... 47 VIRACEPT ............................ 4 VIREAD ................................. 4 virt-advance .......................... 58 virt-c dha .............................. 59 virt-gard ................................ 59 virt-nate ................................ 59 virt-nate dha.......................... 59 virt-phos 250 neutral ............ 54 virt-pn ................................... 59 virt-pn dha ............................ 59 virt-pn plus ........................... 59 virtrate-2 ............................... 53 virtrate-3 ............................... 53 virtrate-k ............................... 53 virt-select .............................. 59 virtussin ac............................ 50 virtussin dac.......................... 50 virt-vite ................................. 59
virt-vite forte......................... 59 virt-vite gt ............................. 59 VISTOGARD ......................... 8 vit 3 ....................................... 59 VITAFOL-OB ...................... 59 vitajoy daily d ....................... 59 vitamin b complex ................ 59 vitamin d3 ............................. 59 vitamin k ............................... 24 vitamin k1 ............................. 24 vitamins a,c,d and fluoride ... 59 VIVITROL ........................... 17 vol-care rx............................. 59 vol-nate ................................. 59 vol-plus ................................. 59 vol-tab rx .............................. 59 voriconazole ........................... 3 VORTEX HOLDING
CHAMBER CHILD ......... 33 VORTEX VHC FROG
MASK-CHILD ................. 33 VORTEX VHC LADYBUG
MASK-TODDLR ............. 33 VOTRIENT .......................... 12 vp-ch plus ............................. 59 vp-ch-pnv.............................. 59 vp-ggr-b6 .............................. 59 vp-heme ob ........................... 59 vp-heme one ......................... 59 VPRIV .................................. 35 vp-vite rx .............................. 59 vyfemla (28) ......................... 47 VYVANSE ........................... 20 W warfarin ................................ 24 water for irrigation, sterile .... 30 wera (28)............................... 47 westhroid .............................. 37 WIDE-SEAL DIAPHRAGM
.......................................... 43 woman's laxative .................. 40 women's gentle laxative(bisac)
.......................................... 40 women's laxative (bisacodyl)40 wymzya fe ............................ 47 X XALKORI ............................ 12
XARELTO ........................... 24 XERMELO ........................... 12 XGEVA .................................. 8 XIFAXAN .............................. 7 XIGDUO XR ........................ 37 XOLAIR ............................... 52 xulane ................................... 44 XURIDEN ............................ 30 xylon 10 ................................ 16 XYREM ................................ 20 Y YERVOY ............................. 12 YONDELIS .......................... 12 yuvafem ................................ 44 Z zafirlukast ............................. 52 zaleplon ................................. 20 zamicet .................................. 16 ZANOSAR ........................... 12 zarah ..................................... 47 ZARXIO ............................... 41 zatean-ch ............................... 59 zatean-pn dha ........................ 59 zatean-pn plus ....................... 59 zavara .................................... 59 ZAVESCA ............................ 35 zebutal ................................... 16 ZEJULA ............................... 12 ZELBORAF ......................... 12 ZEMAIRA ............................ 30 zenatane ................................ 27 zenchent (28) ........................ 47 zenchent fe ............................ 47 zenzedi .................................. 20 ZEPATIER ............................. 4 ZERBAXA ............................. 5 ZEVALIN (Y-90) ................. 12 ZIAGEN ................................. 4 zidovudine .............................. 4 zileuton ................................. 52 zingiber ................................. 59 ZIOPTAN (PF) ..................... 49 ziprasidone hcl ...................... 20 ZIRGAN ............................... 48 ZODRYL AC 40 .................. 50 ZODRYL DEC 30 ................ 50 ZOLADEX ........................... 12
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.
78
zoledronic acid ..................... 35 zoledronic acid-mannitol-water
.......................................... 30 ZOLINZA............................. 12 zolmitriptan .......................... 14 zolpidem ............................... 20 ZOMETA ............................. 35
ZOMIG ................................. 14 zonisamide ............................ 13 ZORTRESS .......................... 12 ZOSTAVAX (PF) ................ 42 zovia 1/35e (28) .................... 47 zovia 1/50e (28) .................... 47 ZOVIRAX ............................ 28
ZUBSOLV ............................ 17 ZYDELIG ............................. 12 ZYFLO ................................. 52 ZYKADIA ............................ 12 ZYTIGA ............................... 12 ZYVOX .................................. 7