2016 formulary (list of covered drugs) - blue · 2016 formulary (list of covered drugs) ii ......

2016 Formulary (List of Covered Drugs)Blue Cross MedicareRx Value (PDP)SM

Y0096_MRK_IL_PDPFRMV16b Accepted 07162016

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

HPMS Approved Formulary File ID: 00016056, Version 20

This formulary was updated on 11/16/2016. For more recent information or other questions, please contact Blue Cross MedicareRxSM Customer Service, at 1-888-285-2249 or, for TTY/TDD users, 711, 8 a.m. - 8 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays, or visit www.getblueil.com/pdp/druglist.

Note to existing members: This formulary has changed since last year. Please review this document to make sure it still contains the drugs you take.

850969.1216 Value

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This information is available for free in other languages. Please call our Customer Service number at 1-888-285-2249. (TTY/TDD users should call 711). We are open between 8 a.m.- 8 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on the weekends and holidays.

Esta información está disponible en otros idiomas de forma gratuita. Comuníquese a nuestro número de Servicio al cliente al 1-888-285-2249 (los usuarios de TTY/TDD deben llamar al 711). Nuestro horario es de 8 a.m. a 8 p.m., hora local, los 7 días de la semana. Si usted llama del 15 de febrero al 30 de septiembre, durante los fines de semana y feriados, se usarán tecnologías alternas (por ejemplo, correo de voz).

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Note to existing members: This formulary has changed since last year. Please review this document to make sure it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Blue Cross and Blue Shield of Illinois. When it refers to “plan” or “our plan,” it means Blue Cross MedicareRx.

This document includes a list of the drugs (formulary) for our plan which is current as of November 2016. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. The benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year.

Blue Cross MedicareRx (PDP)

2016 Formulary (List of Covered Drugs)

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What is the Blue Cross MedicareRx Formulary?A formulary is a list of covered drugs selected by Blue Cross MedicareRx in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Blue Cross MedicareRx will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Blue Cross MedicareRx network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of November 16, 2016. To get updated information about the drugs covered by Blue Cross MedicareRx, please contact us. Our contact information appears on the front and back cover pages.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical ConditionThe formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 104. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

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What are generic drugs?Blue Cross MedicareRx covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

Prior Authorization: Blue Cross MedicareRx requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Blue Cross MedicareRx before you fill your prescriptions. If you don’t get approval, Blue Cross MedicareRx may not cover the drug.

Quantity Limits: For certain drugs, Blue Cross MedicareRx limits the amount of the drug that Blue Cross MedicareRx will cover. For example, Blue Cross MedicareRx provides 30 tablets per prescription for alfuzosin ER. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, Blue Cross MedicareRx 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, Blue Cross MedicareRx may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Blue Cross MedicareRx will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Blue Cross MedicareRx to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Blue Cross MedicareRx’s formulary?” on page iv for information about how to request an exception.

What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.

If you learn that Blue Cross MedicareRx does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by Blue Cross MedicareRx. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Blue Cross MedicareRx.

• You can ask Blue Cross MedicareRx to make an exception and cover your drug. See below for information about how to request an exception.

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How do I request an exception to the Blue Cross MedicareRx’s Formulary?You can ask Blue Cross MedicareRx to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Blue Cross MedicareRx limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Blue Cross MedicareRx will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

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What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan or during the first 90 days of the new year.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network retail pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a maximum 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

You may have changes that take you from one level of care setting to another. During this level of care change, drugs may be prescribed that are not covered by your plan. If this happens, you and your doctor must use your plan’s coverage determination request process. To prevent a gap in care when you are discharged, you may get a full outpatient supply that will allow therapy to continue once the limited discharge supply is gone. When you are admitted to, or discharged from, an LTC setting, you may not have access to the drugs you were previously given. However, you may get a refill upon admission or discharge.

For more informationFor more detailed information about your Blue Cross MedicareRx prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Blue Cross MedicareRx, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Blue Cross MedicareRx’s FormularyThe formulary that begins on page 1 provides coverage information about the drugs covered by Blue Cross MedicareRx. If you have trouble finding your drug in the list, turn to the Index that begins on page 104.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LANTUS) and generic drugs are listed in lower-case italics (e.g., metformin).

The information in the Requirements/Limits column tells you if Blue Cross MedicareRx has any special requirements for coverage of your drug.

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KEYUppercase = BRAND-NAME

Lower case italics = generics

Tier 1 = Preferred Generic Drugs

Tier 2 = Generic Drugs

Tier 3 = Preferred Brand Drugs

Tier 4 = Non-Preferred Brand Drugs

Tier 5 = Specialty Drugs

BD = Drugs that may be covered under Medicare Part B or Part D depending on the circumstance. These drugs require prior authorization to determine coverage under Part B or Part D. Information may need to be provided that describes the use or the place where the drug is received to determine coverage.

PA = Prior Authorization

QL = Quantity Limits

ST = Step Therapy

* = Limited Distribution Drug. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-888-285-2249, 8 a.m. - 8 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays. TTY users should call 711.

# = High Risk Medication (HRM). Medicine that may be unsafe in patients greater than 65 years of age. Our formulary does include coverage for some of these drugs, but alternatives may be found in lower co-pay tiers. Please discuss with your doctor if there are alternatives to these medications that would be appropriate for you to use.

^ = We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.

The last three columns, Prior Authorization, Quantity Limit and Step Therapy, indicate if Blue Cross MedicareRx has any special requirements for coverage of that drug.

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Copayment and Coinsurance Amounts:

Tier 1 - Preferred Generic Drugs: $0/$5

Tier 2 - Generic Drugs: $10/$15

Tier 3 - Preferred Brand Drugs: $42/$47

Tier 4 - Non-Preferred Brand Drugs: $95/$100

Tier 5 - Specialty Drugs: 25%

You must continue to pay your Medicare Part B premium.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Below is the key for abbreviations used within the drug list.

KEY

act actuation la long acting

ad adsorbed mcg microgram

aer, aero aerosol meq milliequivalent

ba breath activated mg milligram

bau bioequivalent allergy units ml milliliter

cap capsules mu million units

chew tab chewable tablets nebu nebules

conc concentrate NF non-formulary

conj conjugate odt orally disintegrating tablets

cr controlled-release oin, oint ointment

crys crystals op, ophth ophthalmic

dr delayed-release pow, powd powder

deter deterrent pf preservative-free

ec enteric coated pfu plaque forming units

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KEY Continued

elenzyme-linked immunosorbent assay

pref prefilled

er, extended, extended rel, xl, xr

extended-release recmb, recomb recombinant

g, gm gram sl sublingual

gu genitourinary soln solution

hr hour suppos suppositories

ir immediate-release susp suspension

inh, inhal inhalation sr sustained-release

inj injection syr syringe

im intramuscular tab tablets

iv intravenous td transdermal

l liter tl translingual

lf flocculation units unt unit

liqd liquid vac vaccine

2016

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

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Drug Name Drug Tier Requirements/LimitsAnalgesicsABSTRAL - fentanyl citrate sl tab 100 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 200 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 300 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 400 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 600 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 800 mcg 5 PA, QL (120 tablets/30 days)acetaminophen w/ codeine soln 120-12 mg/5ml 2 QL (2700 mls/30 days)acetaminophen w/ codeine tab 300-15 mg 2 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-30 mg 2 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-60 mg 2 QL (180 tablets/30 days)butorphanol tartrate inj 1 mg/ml 4butorphanol tartrate inj 2 mg/ml 4butorphanol tartrate nasal soln 10 mg/ml 4celecoxib cap 50 mg 2 QL (60 capsules/30 days)celecoxib cap 100 mg 2 QL (60 capsules/30 days)celecoxib cap 200 mg 2 QL (60 capsules/30 days)celecoxib cap 400 mg 2 QL (30 capsules/30 days)codeine sulfate tab 15 mg 2 QL (180 tablets/30 days)codeine sulfate tab 30 mg 2 QL (180 tablets/30 days)codeine sulfate tab 60 mg 2 QL (180 tablets/30 days)diclofenac potassium tab 50 mg 2diclofenac sodium gel 1% 2 STdiclofenac sodium tab delayed release 25 mg 2diclofenac sodium tab delayed release 50 mg 2diclofenac sodium tab delayed release 75 mg 2diclofenac sodium tab sr 24hr 100 mg 2diclofenac w/ misoprostol tab delayed release 50-0.2 mg 2diclofenac w/ misoprostol tab delayed release 75-0.2 mg 2etodolac cap 200 mg 2etodolac cap 300 mg 2etodolac tab sr 24hr 400 mg 2etodolac tab sr 24hr 500 mg 2etodolac tab sr 24hr 600 mg 2etodolac tab 400 mg 2etodolac tab 500 mg 2fentanyl citrate lozenge on a handle 200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 400 mcg 5 PA, QL (120 lozenges/30 days)

2016

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.2

Drug Name Drug Tier Requirements/Limitsfentanyl citrate lozenge on a handle 600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 800 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl td patch 72hr 12 mcg/hr 4 QL (15 patches/30 days)fentanyl td patch 72hr 25 mcg/hr 4 QL (15 patches/30 days)fentanyl td patch 72hr 50 mcg/hr 4 QL (15 patches/30 days)fentanyl td patch 72hr 75 mcg/hr 4 QL (15 patches/30 days)fentanyl td patch 72hr 100 mcg/hr 4 QL (15 patches/30 days)flurbiprofen tab 50 mg 2flurbiprofen tab 100 mg 2hydrocodone-acetaminophen soln 7.5-325 mg/15ml 4 QL (3600 mls/30 days)hydrocodone-acetaminophen tab 10-325 mg 4 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-300 mg 4 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-300 mg 4 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-325 mg 4 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-325 mg 4 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 10-300 mg 4 QL (180 tablets/30 days)hydrocodone-ibuprofen tab 5-200 mg 4 QL (150 tablets/30 days)hydrocodone-ibuprofen tab 7.5-200 mg 4 QL (150 tablets/30 days)hydrocodone-ibuprofen tab 10-200 mg 4 QL (150 tablets/30 days)hydromorphone hcl liqd 1 mg/ml 2 QL (1440 mls/30 days)hydromorphone hcl preservative free inj 10 mg/ml 4 BDhydromorphone hcl tab 2 mg 4 QL (180 tablets/30 days)hydromorphone hcl tab 4 mg 4 QL (180 tablets/30 days)hydromorphone hcl tab 8 mg 4 QL (180 tablets/30 days)ibuprofen susp 100 mg/5ml 2ibuprofen tab 400 mg 2ibuprofen tab 600 mg 2ibuprofen tab 800 mg 2ketoprofen cap 50 mg 2ketoprofen cap 75 mg 2LAZANDA - fentanyl citrate nasal spray 100 mcg/act 5 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 300 mcg/act 5 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 400 mcg/act 5 PA, QL (30 bottles/30 days)LEVORPHANOL TARTRATE - levorphanol tartrate tab 2 mg 4 QL (120 tablets/30 days)meloxicam tab 7.5 mg 2meloxicam tab 15 mg 2

2016


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Drug Name Drug Tier Requirements/Limitsmethadone hcl tab 5 mg 2 QL (180 tablets/30 days)methadone hcl tab 10 mg 2 QL (360 tablets/30 days)MORPHINE SULFATE - morphine sulfate tab 15 mg 4 QL (240 tablets/30 days)MORPHINE SULFATE - morphine sulfate tab 30 mg 4 QL (180 tablets/30 days)morphine sulfate beads cap sr 24hr 120 mg 4 QL (30 capsules/30 days)morphine sulfate beads cap sr 24hr 30 mg 4 QL (30 capsules/30 days)morphine sulfate beads cap sr 24hr 45 mg 4 QL (30 capsules/30 days)morphine sulfate beads cap sr 24hr 60 mg 4 QL (30 capsules/30 days)morphine sulfate beads cap sr 24hr 75 mg 4 QL (30 capsules/30 days)morphine sulfate beads cap sr 24hr 90 mg 4 QL (30 capsules/30 days)morphine sulfate inj pf 0.5 mg/ml 4 BDmorphine sulfate inj pf 1 mg/ml 4 BDmorphine sulfate oral soln 10 mg/5ml 4 QL (2700 mls/30 days)morphine sulfate oral soln 20 mg/5ml 4 QL (1350 mls/30 days)morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 4 QL (270 mls/30 days)morphine sulfate tab cr 15 mg 4 QL (90 tablets/30 days)morphine sulfate tab cr 30 mg 4 QL (90 tablets/30 days)morphine sulfate tab cr 60 mg 4 QL (90 tablets/30 days)morphine sulfate tab cr 100 mg 4 QL (90 tablets/30 days)morphine sulfate tab cr 200 mg 4 QL (90 tablets/30 days)nabumetone tab 500 mg 2nabumetone tab 750 mg 2naproxen sodium tab 275 mg 2naproxen sodium tab 550 mg 2naproxen susp 125 mg/5ml 2naproxen tab ec 375 mg 2naproxen tab ec 500 mg 2naproxen tab 250 mg 2naproxen tab 375 mg 2naproxen tab 500 mg 2NUCYNTA ER - tapentadol hcl tab sr 12hr 50 mg 3 QL (60 tablets/30 days)NUCYNTA ER - tapentadol hcl tab sr 12hr 100 mg 3 QL (60 tablets/30 days)NUCYNTA ER - tapentadol hcl tab sr 12hr 150 mg 3 QL (60 tablets/30 days)NUCYNTA ER - tapentadol hcl tab sr 12hr 200 mg 3 QL (60 tablets/30 days)NUCYNTA ER - tapentadol hcl tab sr 12hr 250 mg 3 QL (60 tablets/30 days)oxaprozin tab 600 mg 2oxycodone hcl tab 5 mg 4 QL (360 tablets/30 days)oxycodone hcl tab 10 mg 4 QL (180 tablets/30 days)

2016


Drug Name Drug Tier Requirements/Limitsoxycodone hcl tab 15 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 20 mg 4 QL (180 tablets/30 days)oxycodone hcl tab 30 mg 4 QL (180 tablets/30 days)oxycodone w/ acetaminophen tab 2.5-325 mg 4 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 5-325 mg 4 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 7.5-325 mg 4 QL (240 tablets/30 days)oxycodone w/ acetaminophen tab 10-325 mg 4 QL (180 tablets/30 days)oxycodone-aspirin tab 4.8355-325 mg 4 QL (360 tablets/30 days)piroxicam cap 10 mg 2piroxicam cap 20 mg 2sulindac tab 150 mg 2sulindac tab 200 mg 2tolmetin sodium cap 400 mg 2tramadol hcl tab sr 24hr 100 mg 2 QL (30 tablets/30 days)tramadol hcl tab sr 24hr 200 mg 2 QL (30 tablets/30 days)tramadol hcl tab sr 24hr 300 mg 2 QL (30 tablets/30 days)tramadol hcl tab 50 mg 2 QL (240 tablets/30 days)tramadol-acetaminophen tab 37.5-325 mg 2 QL (240 tablets/30 days)VOLTAREN - diclofenac sodium gel 1% 4 STZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abuse-

deterrent 10 mg4 PA, QL (60 capsules/30 days)

ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abuse-deterrent 15 mg

4 PA, QL (60 capsules/30 days)









ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr 10 mg 4 PA, QL (60 capsules/30 days)ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr 15 mg 4 PA, QL (60 capsules/30 days)ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr 20 mg 4 PA, QL (60 capsules/30 days)ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr 30 mg 4 PA, QL (60 capsules/30 days)ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr 40 mg 4 PA, QL (60 capsules/30 days)ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr 50 mg 4 PA, QL (60 capsules/30 days)Anestheticslidocaine hcl gel 2% 2lidocaine hcl local inj 1% 2

2016


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Drug Name Drug Tier Requirements/Limitslidocaine hcl local preservative free inj 1% 2lidocaine hcl soln 4% 2lidocaine hcl viscous soln 2% 2lidocaine oint 5% 2lidocaine patch 5% 2 PA, QL (90 patches/30 days)lidocaine-prilocaine cream 2.5-2.5% 2Anti-Addiction/Substance Abuse Treatment Agentsacamprosate calcium tab delayed release 333 mg 2buprenorphine hcl sl tab 2 mg 2 PAbuprenorphine hcl sl tab 8 mg 2 PAbuprenorphine hcl-naloxone hcl sl tab 2-0.5 mg 2 PAbuprenorphine hcl-naloxone hcl sl tab 8-2 mg 2 PAbupropion hcl (smoking deterrent) tab sr 12hr 150 mg 2BUTRANS - buprenorphine td patch weekly 5 mcg/hr 3 QL (4 patches/28 days)BUTRANS - buprenorphine td patch weekly 7.5 mcg/hr 3 QL (4 patches/28 days)BUTRANS - buprenorphine td patch weekly 10 mcg/hr 3 QL (4 patches/28 days)BUTRANS - buprenorphine td patch weekly 15 mcg/hr 3 QL (4 patches/28 days)BUTRANS - buprenorphine td patch weekly 20 mcg/hr 3 QL (4 patches/28 days)CHANTIX - varenicline tartrate tab 0.5 mg 3CHANTIX - varenicline tartrate tab 1 mg 3CHANTIX CONTINUING MONTH - varenicline tartrate tab 1 mg 3CHANTIX STARTING MONTH PACK - varenicline tartrate tab

0.5 mg x 11 & tab 1 mg x 42 pack3

disulfiram tab 250 mg 2disulfiram tab 500 mg 2NALOXONE HCL - naloxone hcl soln cartridge 0.4 mg/ml 2NALOXONE HCL - naloxone hcl soln prefilled syringe 2 mg/2ml 3naloxone hcl inj 0.4 mg/ml 2naloxone hcl inj 4 mg/10ml 2naltrexone hcl tab 50 mg 2NARCAN - naloxone hcl nasal spray 4 mg/0.1ml 4NICOTROL INHALER - nicotine inhaler system 10 mg (4 mg

delivered)4

NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray) 4SUBOXONE - buprenorphine hcl-naloxone hcl sl film 2-0.5 mg 4 PASUBOXONE - buprenorphine hcl-naloxone hcl sl film 4-1 mg 4 PASUBOXONE - buprenorphine hcl-naloxone hcl sl film 8-2 mg 4 PASUBOXONE - buprenorphine hcl-naloxone hcl sl film 12-3 mg 4 PAVIVITROL - naltrexone for im extended release susp 380 mg 5

2016


Drug Name Drug Tier Requirements/LimitsAntibacterialsamikacin sulfate inj 500 mg/2ml (250 mg/ml) 2amikacin sulfate inj 1 gm/4ml (250 mg/ml) 2amoxicillin (trihydrate) cap 250 mg 2amoxicillin (trihydrate) cap 500 mg 2amoxicillin (trihydrate) for susp 125 mg/5ml 2amoxicillin (trihydrate) for susp 200 mg/5ml 2amoxicillin (trihydrate) for susp 250 mg/5ml 2amoxicillin (trihydrate) for susp 400 mg/5ml 2amoxicillin (trihydrate) tab 500 mg 2amoxicillin (trihydrate) tab 875 mg 2amoxicillin & k clavulanate chew tab 200-28.5 mg 2amoxicillin & k clavulanate chew tab 400-57 mg 2amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 2amoxicillin & k clavulanate for susp 400-57 mg/5ml 2amoxicillin & k clavulanate for susp 600-42.9 mg/5ml 2amoxicillin & k clavulanate tab 250-125 mg 2amoxicillin & k clavulanate tab 500-125 mg 2amoxicillin & k clavulanate tab 875-125 mg 2AMPICILLIN - ampicillin for susp 125 mg/5ml 4AMPICILLIN - ampicillin for susp 250 mg/5ml 4ampicillin & sulbactam sodium for inj 3 (2-1) gm 2ampicillin cap 250 mg 2ampicillin cap 500 mg 2AMPICILLIN SODIUM - ampicillin sodium for iv soln 1 gm 4ampicillin sodium for inj 250 mg 2ampicillin sodium for inj 500 mg 2ampicillin sodium for inj 1 gm 2ampicillin sodium for inj 2 gm 2ampicillin sodium for iv soln 2 gm 2ampicillin sodium for iv soln 10 gm 2AVELOX - moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8%

inj3

AZACTAM - aztreonam in dextrose inj 1 gm/50 ml 4AZACTAM - aztreonam in dextrose inj 2 gm/50 ml 4AZITHROMYCIN - azithromycin powd pack for susp 1 gm 4azithromycin for susp 100 mg/5ml 2azithromycin for susp 200 mg/5ml 2azithromycin iv for soln 500 mg 2

2016


7

Drug Name Drug Tier Requirements/Limitsazithromycin tab 250 mg 2azithromycin tab 500 mg 2azithromycin tab 600 mg 2aztreonam for inj 1 gm 2aztreonam for inj 2 gm 2BICILLIN L-A - penicillin g benzathine intramuscular susp 600000

unit/ml4

BICILLIN L-A - penicillin g benzathine intramuscular susp 1200000unit/2ml

4

BICILLIN L-A - penicillin g benzathine intramuscular susp 2400000unit/4ml

4

cefaclor cap 250 mg 2cefaclor cap 500 mg 2cefadroxil cap 500 mg 2cefadroxil for susp 250 mg/5ml 2cefadroxil for susp 500 mg/5ml 2cefadroxil tab 1 gm 2cefazolin sodium for inj 500 mg 2cefazolin sodium for inj 1 gm 2cefazolin sodium for inj 10 gm 2cefazolin sodium for inj 20 gm 2cefdinir cap 300 mg 2cefdinir for susp 125 mg/5ml 2cefdinir for susp 250 mg/5ml 2cefepime hcl for inj 1 gm 2cefepime hcl for inj 2 gm 2cefotaxime sodium for inj 1 gm 2cefotaxime sodium for inj 500 mg 2cefotaxime sodium for inj 2 gm 2cefotaxime sodium for inj 10 gm 2cefoxitin sodium for inj 10 gm 2cefoxitin sodium for iv soln 1 gm 2cefoxitin sodium for iv soln 2 gm 2cefpodoxime proxetil for susp 50 mg/5ml 2cefpodoxime proxetil for susp 100 mg/5ml 2cefpodoxime proxetil tab 100 mg 2cefpodoxime proxetil tab 200 mg 2cefprozil for susp 125 mg/5ml 2cefprozil for susp 250 mg/5ml 2

2016


Drug Name Drug Tier Requirements/Limitscefprozil tab 250 mg 2cefprozil tab 500 mg 2ceftazidime for inj 1 gm 2ceftazidime for inj 2 gm 2ceftazidime for inj 6 gm 2ceftazidime for iv soln 1 gm 2ceftazidime for iv soln 2 gm 2CEFTRIAXONE IN ISO-OSMOTIC - ceftriaxone sodium in dextrose

inj 20 mg/ml4

CEFTRIAXONE IN ISO-OSMOTIC - ceftriaxone sodium in dextroseinj 40 mg/ml

4

ceftriaxone sodium for inj 250 mg 2ceftriaxone sodium for inj 500 mg 2ceftriaxone sodium for inj 1 gm 2ceftriaxone sodium for inj 2 gm 2ceftriaxone sodium for inj 10 gm 2ceftriaxone sodium for iv soln 1 gm 2ceftriaxone sodium for iv soln 2 gm 2CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 1 gm

and dextrose 3.74%4

CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 2 gmand dextrose 2.22%

4

cefuroxime axetil tab 250 mg 2cefuroxime axetil tab 500 mg 2cefuroxime sodium for inj 750 mg 2cefuroxime sodium for inj 1.5 gm 2cefuroxime sodium for inj 7.5 gm 2cefuroxime sodium for iv soln 1.5 gm 2cephalexin cap 250 mg 2cephalexin cap 500 mg 2cephalexin cap 750 mg 2cephalexin for susp 125 mg/5ml 2cephalexin for susp 250 mg/5ml 2CHLORAMPHENICOL SODIUM SUCCINATE - chloramphenicol

sodium succinate for iv inj 1 gm4

ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) 2ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) 2CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg 4ciprofloxacin hcl tab sr 24hr 500 mg 2ciprofloxacin hcl tab sr 24hr 1000 mg 2

2016


9

Drug Name Drug Tier Requirements/Limitsciprofloxacin hcl tab 250 mg 2ciprofloxacin hcl tab 500 mg 2ciprofloxacin hcl tab 750 mg 2ciprofloxacin iv soln 200 mg/20ml (1%) 2ciprofloxacin iv soln 400 mg/40ml (1%) 2ciprofloxacin 200 mg/100ml in d5w 2ciprofloxacin 400 mg/200ml in d5w 2CLAFORAN/D5W - cefotaxime sodium in d5w iv soln 1 gm/50ml 4CLAFORAN/D5W - cefotaxime sodium in d5w iv soln 2 gm/50ml 4clarithromycin for susp 125 mg/5ml 2clarithromycin for susp 250 mg/5ml 2clarithromycin tab sr 24hr 500 mg 2clarithromycin tab 250 mg 2clarithromycin tab 500 mg 2clindamycin hcl cap 75 mg 2clindamycin hcl cap 150 mg 2clindamycin hcl cap 300 mg 2clindamycin phosphate in d5w iv soln 300 mg/50ml 2clindamycin phosphate in d5w iv soln 600 mg/50ml 2clindamycin phosphate in d5w iv soln 900 mg/50ml 2clindamycin phosphate inj 300 mg/2ml 2clindamycin phosphate inj 600 mg/4ml 2clindamycin phosphate inj 900 mg/6ml 2clindamycin phosphate inj 9 gm/60ml 2clindamycin phosphate iv soln 300 mg/2ml 2clindamycin phosphate iv soln 600 mg/4ml 2clindamycin phosphate iv soln 900 mg/6ml 2clindamycin phosphate vaginal cream 2% 2colistimethate sodium for inj 150 mg 2CUBICIN - daptomycin for iv soln 500 mg 5CUBICIN RF - daptomycin for iv soln 500 mg 5DALVANCE - dalbavancin hcl for iv soln 500 mg 5daptomycin for iv soln 500 mg 5demeclocycline hcl tab 150 mg 2demeclocycline hcl tab 300 mg 2dicloxacillin sodium cap 250 mg 2dicloxacillin sodium cap 500 mg 2DIFICID - fidaxomicin tab 200 mg 5

2016


Drug Name Drug Tier Requirements/Limitsdoxycycline hyclate cap 50 mg 2doxycycline hyclate cap 100 mg 2doxycycline hyclate for inj 100 mg 2doxycycline hyclate tab 20 mg 2doxycycline hyclate tab 100 mg 2doxycycline monohydrate cap 50 mg 2doxycycline monohydrate cap 75 mg 2doxycycline monohydrate cap 100 mg 2doxycycline monohydrate cap 150 mg 2doxycycline monohydrate tab 50 mg 2doxycycline monohydrate tab 75 mg 2doxycycline monohydrate tab 100 mg 2doxycycline monohydrate tab 150 mg 2E.E.S. GRANULES - erythromycin ethylsuccinate for susp

200 mg/5ml4

ERY-TAB - erythromycin tab delayed release 250 mg 4ERY-TAB - erythromycin tab delayed release 333 mg 4ERY-TAB - erythromycin tab delayed release 500 mg 4ERYPED 200 - erythromycin ethylsuccinate for susp 200 mg/5ml 4ERYPED 400 - erythromycin ethylsuccinate for susp 400 mg/5ml 4ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for inj

500 mg4

ERYTHROCIN STEARATE - erythromycin stearate tab 250 mg 4ERYTHROMYCIN BASE - erythromycin tab 250 mg 4ERYTHROMYCIN BASE - erythromycin tab 500 mg 4erythromycin ethylsuccinate for susp 200 mg/5ml 2FORTAZ - ceftazidime for inj 500 mg 4FORTAZ - ceftazidime sodium in d5w inj 1 gm/50ml 4FORTAZ - ceftazidime sodium in d5w inj 2 gm/50ml 4gentamicin in saline inj 0.8 mg/ml 2gentamicin in saline inj 1 mg/ml 2gentamicin in saline inj 1.2 mg/ml 2gentamicin in saline inj 1.6 mg/ml 2gentamicin sulfate inj 10 mg/ml 2gentamicin sulfate inj 40 mg/ml 2gentamicin sulfate iv soln 10 mg/ml 2GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE - gentamicin in

saline inj 0.9 mg/ml4

2016


11

Drug Name Drug Tier Requirements/LimitsGENTAMICIN SULFATE/0.9% SODIUM CHLORIDE - gentamicin in

saline inj 1.4 mg/ml4

imipenem-cilastatin intravenous for soln 250 mg 2imipenem-cilastatin intravenous for soln 500 mg 2INVANZ - ertapenem sodium for inj 1 gm 4INVANZ - ertapenem sodium for iv inj 1 gm 4levofloxacin in d5w iv soln 250 mg/50ml 2levofloxacin in d5w iv soln 500 mg/100ml 2levofloxacin in d5w iv soln 750 mg/150ml 2levofloxacin iv soln 25 mg/ml 2levofloxacin oral soln 25 mg/ml 2levofloxacin tab 250 mg 2levofloxacin tab 500 mg 2levofloxacin tab 750 mg 2linezolid for susp 100 mg/5ml 5 PAlinezolid in sodium chloride iv soln 600 mg/300ml-0.9% 5linezolid iv soln 600 mg/300ml (2 mg/ml) 5linezolid tab 600 mg 5 PAmeropenem iv for soln 500 mg 2meropenem iv for soln 1 gm 2methenamine hippurate tab 1 gm 2METRO IV - metronidazole in nacl 0.74% iv soln 500 mg/100ml 4metronidazole cap 375 mg 2metronidazole in nacl 0.79% iv soln 500 mg/100ml 2metronidazole tab 250 mg 2metronidazole tab 500 mg 2metronidazole vaginal gel 0.75% 2minocycline hcl cap 50 mg 2minocycline hcl cap 75 mg 2minocycline hcl cap 100 mg 2minocycline hcl tab 50 mg 2minocycline hcl tab 75 mg 2minocycline hcl tab 100 mg 2moxifloxacin hcl tab 400 mg 2NAFCILLIN SODIUM - nafcillin sodium for iv soln 1 gm 4NAFCILLIN SODIUM - nafcillin sodium for iv soln 2 gm 4nafcillin sodium for inj 1 gm 2nafcillin sodium for inj 2 gm 2nafcillin sodium for inj 10 gm 2

2016


Drug Name Drug Tier Requirements/Limitsneomycin sulfate tab 500 mg 2neomycin-polymyxin b gu irrigation soln 2nitrofurantoin macrocrystalline cap 50 mg# 4 PAnitrofurantoin macrocrystalline cap 100 mg# 4 PAnitrofurantoin monohydrate macrocrystalline cap 100 mg# 4 PAnitrofurantoin susp 25 mg/5ml# 4 PAOFLOXACIN - ofloxacin tab 400 mg 4paromomycin sulfate cap 250 mg 2penicillin g potassium for inj 5000000 unit 2penicillin g potassium for inj 20000000 unit 2PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g

potassium inj 20000 unit/ml in dextrose4

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 40000 unit/ml in dextrose

4

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 60000 unit/ml in dextrose

4

PENICILLIN G SODIUM - penicillin g sodium for inj 5000000 unit 4penicillin v potassium for soln 125 mg/5ml 2penicillin v potassium for soln 250 mg/5ml 2penicillin v potassium tab 250 mg 2penicillin v potassium tab 500 mg 2piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) 2piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) 2piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) 2SIVEXTRO - tedizolid phosphate for iv soln 200 mg 5SIVEXTRO - tedizolid phosphate tab 200 mg 5 PASTREPTOMYCIN SULFATE - streptomycin sulfate for inj 1 gm 4SULFADIAZINE - sulfadiazine tab 500 mg 4sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 2sulfamethoxazole-trimethoprim tab 400-80 mg 2sulfamethoxazole-trimethoprim tab 800-160 mg 2SULFAMETHOXAZOLE/TRIMETHOPRIM - sulfamethoxazole-

trimethoprim iv soln 400-80 mg/5ml4

SUPRAX - cefixime cap 400 mg 4SUPRAX - cefixime chew tab 100 mg 4SUPRAX - cefixime chew tab 200 mg 4SYNERCID - quinupristin-dalfopristin for inj 500 mg (150-350 mg) 5TEFLARO - ceftaroline fosamil for iv soln 400 mg 4TEFLARO - ceftaroline fosamil for iv soln 600 mg 4

2016


13

Drug Name Drug Tier Requirements/Limitstetracycline hcl cap 250 mg 2tetracycline hcl cap 500 mg 2tobramycin sulfate for inj 1.2 gm 2tobramycin sulfate inj 10 mg/ml 2tobramycin sulfate inj 80 mg/2ml (40 mg/ml) 2tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) 2tobramycin sulfate inj 2 gm/50ml (40 mg/ml) 2trimethoprim tab 100 mg 2TYGACIL - tigecycline for iv soln 50 mg 4vancomycin hcl cap 125 mg 5vancomycin hcl cap 250 mg 5vancomycin hcl for inj 500 mg 2vancomycin hcl for inj 750 mg 2vancomycin hcl for inj 1000 mg 2vancomycin hcl for inj 5000 mg 2vancomycin hcl for inj 10 gm 2VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl in dextrose

inj 500 mg/100ml4

VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl in dextroseinj 750 mg/150ml

4

VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl in dextroseinj 1 gm/200ml

4

XIFAXAN - rifaximin tab 550 mg 5ZINACEF - cefuroxime in sterile water inj 1.5 gm/50ml 4ZOSYN - piperacillin sod-tazobactam sod in dex iv soln

2-0.25gm/50ml4

ZOSYN - piperacillin sod-tazobactam sod in dex iv soln4-0.5gm/100ml

4

ZOSYN - piperacillin sod-tazobactam sod in dex iv sol3-0.375gm/50ml

4

ZYVOX - linezolid for susp 100 mg/5ml 5 PAAnticonvulsantsAPTIOM - eslicarbazepine acetate tab 200 mg 4APTIOM - eslicarbazepine acetate tab 400 mg 4APTIOM - eslicarbazepine acetate tab 600 mg 4APTIOM - eslicarbazepine acetate tab 800 mg 4BANZEL - rufinamide susp 40 mg/ml 5BANZEL - rufinamide tab 200 mg 4BANZEL - rufinamide tab 400 mg 5BRIVIACT - brivaracetam iv soln 50 mg/5ml 4

2016


Drug Name Drug Tier Requirements/LimitsBRIVIACT - brivaracetam oral soln 10 mg/ml 5BRIVIACT - brivaracetam tab 10 mg 5BRIVIACT - brivaracetam tab 25 mg 5BRIVIACT - brivaracetam tab 50 mg 5BRIVIACT - brivaracetam tab 75 mg 5BRIVIACT - brivaracetam tab 100 mg 5carbamazepine cap sr 12hr 100 mg 2carbamazepine cap sr 12hr 200 mg 2carbamazepine cap sr 12hr 300 mg 2carbamazepine chew tab 100 mg 2carbamazepine susp 100 mg/5ml 2carbamazepine tab sr 12hr 100 mg 2carbamazepine tab sr 12hr 200 mg 2carbamazepine tab sr 12hr 400 mg 2carbamazepine tab 200 mg 2CELONTIN - methsuximide cap 300 mg 4clonazepam orally disintegrating tab 0.125 mg 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.5 mg 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 1 mg 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg 2 PA, QL (300 tablets/30 days)clonazepam tab 0.5 mg 2 PA, QL (90 tablets/30 days)clonazepam tab 1 mg 2 PA, QL (90 tablets/30 days)clonazepam tab 2 mg 2 PA, QL (300 tablets/30 days)clorazepate dipotassium tab 3.75 mg 2 PA, QL (90 tablets/30 days)clorazepate dipotassium tab 7.5 mg 2 PA, QL (90 tablets/30 days)clorazepate dipotassium tab 15 mg 2 PA, QL (180 tablets/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 10 mg 4 QL (5 twin pack(s)/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 20 mg 4 QL (5 twin pack(s)/30 days)DIASTAT PEDIATRIC - diazepam rectal gel delivery system 2.5 mg 4 QL (5 twin pack(s)/30 days)DIAZEPAM - diazepam oral soln 1 mg/ml 4 PA, QL (1200 mls/30 days)DIAZEPAM - diazepam rectal gel delivery system 2.5 mg 4 QL (5 twin pack(s)/30 days)DIAZEPAM - diazepam rectal gel delivery system 10 mg 4 QL (5 twin pack(s)/30 days)DIAZEPAM - diazepam rectal gel delivery system 20 mg 4 QL (5 twin pack(s)/30 days)diazepam conc 5 mg/ml 2 PA, QL (240 mls/30 days)diazepam tab 2 mg 2 PA, QL (120 tablets/30 days)diazepam tab 5 mg 2 PA, QL (120 tablets/30 days)diazepam tab 10 mg 2 PA, QL (120 tablets/30 days)

2016


15

Drug Name Drug Tier Requirements/LimitsDILANTIN - phenytoin sodium extended cap 30 mg 4divalproex sodium cap delayed release sprinkle 125 mg 2divalproex sodium tab delayed release 125 mg 2divalproex sodium tab delayed release 250 mg 2divalproex sodium tab delayed release 500 mg 2divalproex sodium tab sr 24 hr 250 mg 2divalproex sodium tab sr 24 hr 500 mg 2ethosuximide cap 250 mg 2ethosuximide soln 250 mg/5ml 2felbamate susp 600 mg/5ml 2felbamate tab 400 mg 2felbamate tab 600 mg 2fosphenytoin sodium inj 100 mg/2ml 2fosphenytoin sodium inj 500 mg/10ml 2FYCOMPA - perampanel susp 0.5 mg/ml 4FYCOMPA - perampanel tab 2 mg 4FYCOMPA - perampanel tab 4 mg 4FYCOMPA - perampanel tab 6 mg 4FYCOMPA - perampanel tab 8 mg 4FYCOMPA - perampanel tab 10 mg 4FYCOMPA - perampanel tab 12 mg 4gabapentin cap 100 mg 2gabapentin cap 300 mg 2gabapentin cap 400 mg 2gabapentin oral soln 250 mg/5ml 2gabapentin tab 600 mg 2gabapentin tab 800 mg 2GABITRIL - tiagabine hcl tab 12 mg 4GABITRIL - tiagabine hcl tab 16 mg 4lamotrigine orally disintegrating tab 25 mg 2lamotrigine orally disintegrating tab 50 mg 2lamotrigine orally disintegrating tab 100 mg 2lamotrigine orally disintegrating tab 200 mg 2lamotrigine tab chewable dispersible 5 mg 2lamotrigine tab chewable dispersible 25 mg 2lamotrigine tab 25 mg 2lamotrigine tab 100 mg 2lamotrigine tab 150 mg 2

2016


Drug Name Drug Tier Requirements/Limitslamotrigine tab 200 mg 2LEVETIRACETAM - levetiracetam in sodium chloride iv soln

500 mg/100ml4

LEVETIRACETAM - levetiracetam in sodium chloride iv soln1000 mg/100ml

4

LEVETIRACETAM - levetiracetam in sodium chloride iv soln1500 mg/100ml

4

levetiracetam inj 500 mg/5ml (100 mg/ml) 2levetiracetam oral soln 100 mg/ml 2levetiracetam tab 250 mg 2levetiracetam tab 500 mg 2levetiracetam tab 750 mg 2levetiracetam tab 1000 mg 2LYRICA - pregabalin cap 25 mg 3LYRICA - pregabalin cap 50 mg 3LYRICA - pregabalin cap 75 mg 3LYRICA - pregabalin cap 100 mg 3LYRICA - pregabalin cap 150 mg 3LYRICA - pregabalin cap 200 mg 3LYRICA - pregabalin cap 225 mg 3LYRICA - pregabalin cap 300 mg 3LYRICA - pregabalin soln 20 mg/ml 3ONFI - clobazam suspension 2.5 mg/ml 4 PA, QL (480 mls/30 days)ONFI - clobazam tab 5 mg 4 PA, QL (60 tablets/30 days)ONFI - clobazam tab 10 mg 4 PA, QL (60 tablets/30 days)ONFI - clobazam tab 20 mg 4 PA, QL (60 tablets/30 days)oxcarbazepine susp 300 mg/5ml (60 mg/ml) 2oxcarbazepine tab 150 mg 2oxcarbazepine tab 300 mg 2oxcarbazepine tab 600 mg 2PEGANONE - ethotoin tab 250 mg 4PHENOBARBITAL - phenobarbital tab 15 mg# 4 PAPHENOBARBITAL - phenobarbital tab 30 mg# 4 PAPHENOBARBITAL - phenobarbital tab 60 mg# 4 PAPHENOBARBITAL - phenobarbital tab 100 mg# 4 PAphenobarbital elixir 20 mg/5ml# 4 PAPHENOBARBITAL SODIUM - phenobarbital sodium inj 65 mg/ml# 4 PAPHENOBARBITAL SODIUM - phenobarbital sodium inj 130 mg/ml# 4 PAphenobarbital tab 16.2 mg# 4 PA

2016


17

Drug Name Drug Tier Requirements/Limitsphenobarbital tab 32.4 mg# 4 PAphenobarbital tab 64.8 mg# 4 PAphenobarbital tab 97.2 mg# 4 PAphenytoin chew tab 50 mg 2phenytoin sodium extended cap 100 mg 2phenytoin sodium extended cap 200 mg 2phenytoin sodium extended cap 300 mg 2phenytoin susp 125 mg/5ml 2POTIGA - ezogabine tab 50 mg 4POTIGA - ezogabine tab 200 mg 4POTIGA - ezogabine tab 300 mg 4POTIGA - ezogabine tab 400 mg 4primidone tab 50 mg 2primidone tab 250 mg 2SABRIL - vigabatrin powd pack 500 mg* 4SABRIL - vigabatrin tab 500 mg* 5SPRITAM - levetiracetam tab disintegrating soluble 250 mg 4SPRITAM - levetiracetam tab disintegrating soluble 500 mg 4SPRITAM - levetiracetam tab disintegrating soluble 750 mg 4SPRITAM - levetiracetam tab disintegrating soluble 1000 mg 4TEGRETOL-XR - carbamazepine tab sr 12hr 100 mg 4tiagabine hcl tab 2 mg 2tiagabine hcl tab 4 mg 2topiramate sprinkle cap 15 mg 2topiramate sprinkle cap 25 mg 2topiramate tab 25 mg 2topiramate tab 50 mg 2topiramate tab 100 mg 2topiramate tab 200 mg 2valproate sodium inj 100 mg/ml 2valproate sodium syrup 250 mg/5ml 2valproic acid cap 250 mg 2VIMPAT - lacosamide iv inj 200 mg/20ml (10 mg/ml) 3VIMPAT - lacosamide oral solution 10 mg/ml 3VIMPAT - lacosamide tab 50 mg 3VIMPAT - lacosamide tab 100 mg 3VIMPAT - lacosamide tab 150 mg 3VIMPAT - lacosamide tab 200 mg 3

2016


Drug Name Drug Tier Requirements/Limitszonisamide cap 25 mg 2zonisamide cap 50 mg 2zonisamide cap 100 mg 2Antidementia Agentsdonepezil hydrochloride orally disintegrating tab 5 mg 2donepezil hydrochloride orally disintegrating tab 10 mg 2donepezil hydrochloride tab 5 mg 2donepezil hydrochloride tab 10 mg 2donepezil hydrochloride tab 23 mg 2ergoloid mesylates tab 1 mg# 3 PAEXELON - rivastigmine td patch 24hr 4.6 mg/24hr 3EXELON - rivastigmine td patch 24hr 9.5 mg/24hr 3EXELON - rivastigmine td patch 24hr 13.3 mg/24hr 3GALANTAMINE HYDROBROMIDE - galantamine hydrobromide

oral soln 4 mg/ml4

galantamine hydrobromide cap sr 24hr 8 mg 2galantamine hydrobromide cap sr 24hr 16 mg 2galantamine hydrobromide cap sr 24hr 24 mg 2galantamine hydrobromide tab 4 mg 2galantamine hydrobromide tab 8 mg 2galantamine hydrobromide tab 12 mg 2memantine hcl oral solution 2 mg/ml 2 PAmemantine hcl tab 5 mg 2 PAmemantine hcl tab 10 mg 2 PAmemantine hcl tab 5 mg (28) & 10 mg (21) titration pak 2 PANAMENDA - memantine hcl oral solution 2 mg/ml 3 PANAMENDA - memantine hcl tab 5 mg 3 PANAMENDA - memantine hcl tab 10 mg 3 PANAMENDA TITRATION PAK - memantine hcl tab 5 mg (28) &

10 mg (21) titration pak3 PA

NAMENDA XR - memantine hcl cap sr 24hr 7 mg 3 PANAMENDA XR - memantine hcl cap sr 24hr 14 mg 3 PANAMENDA XR - memantine hcl cap sr 24hr 21 mg 3 PANAMENDA XR - memantine hcl cap sr 24hr 28 mg 3 PANAMENDA XR TITRATION PACK - memantine hcl cap sr 24hr

7 mg & 14 mg & 21 mg & 28 mg pack3 PA

rivastigmine tartrate cap 1.5 mg 2rivastigmine tartrate cap 3 mg 2rivastigmine tartrate cap 4.5 mg 2

2016


19

Drug Name Drug Tier Requirements/Limitsrivastigmine tartrate cap 6 mg 2rivastigmine td patch 24hr 4.6 mg/24hr 2rivastigmine td patch 24hr 9.5 mg/24hr 2rivastigmine td patch 24hr 13.3 mg/24hr 2AntidepressantsABILIFY MAINTENA - aripiprazole im for extended release susp

300 mg5 PA, QL (1 syringe

or vial/30 days)ABILIFY MAINTENA - aripiprazole im for extended release susp


or vial/30 days)amitriptyline hcl tab 10 mg# 4 PAamitriptyline hcl tab 25 mg# 4 PAamitriptyline hcl tab 50 mg# 4 PAamitriptyline hcl tab 75 mg# 4 PAamitriptyline hcl tab 100 mg# 4 PAamitriptyline hcl tab 150 mg# 4 PAAMOXAPINE - amoxapine tab 25 mg 4AMOXAPINE - amoxapine tab 50 mg 4AMOXAPINE - amoxapine tab 100 mg 4AMOXAPINE - amoxapine tab 150 mg 4aripiprazole oral solution 1 mg/ml 5 PA, QL (750 mls/30 days)aripiprazole orally disintegrating tab 10 mg 5 PA, QL (60 tablets/30 days)aripiprazole orally disintegrating tab 15 mg 5 PA, QL (60 tablets/30 days)aripiprazole tab 2 mg 5 PA, QL (30 tablets/30 days)aripiprazole tab 5 mg 5 PA, QL (30 tablets/30 days)aripiprazole tab 10 mg 5 PA, QL (30 tablets/30 days)aripiprazole tab 15 mg 5 PA, QL (30 tablets/30 days)aripiprazole tab 20 mg 5 PA, QL (30 tablets/30 days)aripiprazole tab 30 mg 5 PA, QL (30 tablets/30 days)bupropion hcl tab sr 12hr 100 mg 2 QL (60 tablets/30 days)bupropion hcl tab sr 12hr 150 mg 2 QL (60 tablets/30 days)bupropion hcl tab sr 12hr 200 mg 2 QL (60 tablets/30 days)bupropion hcl tab sr 24hr 150 mg 2 QL (30 tablets/30 days)bupropion hcl tab sr 24hr 300 mg 2 QL (30 tablets/30 days)bupropion hcl tab 75 mg 2 QL (60 tablets/30 days)bupropion hcl tab 100 mg 2 QL (120 tablets/30 days)citalopram hydrobromide oral soln 10 mg/5ml 2 QL (600 mls/30 days)citalopram hydrobromide tab 10 mg 1 QL (30 tablets/30 days)citalopram hydrobromide tab 20 mg 1 QL (30 tablets/30 days)citalopram hydrobromide tab 40 mg 1 QL (30 tablets/30 days)

2016


Drug Name Drug Tier Requirements/Limitsclomipramine hcl cap 25 mg# 4 PAclomipramine hcl cap 50 mg# 4 PAclomipramine hcl cap 75 mg# 4 PAdesipramine hcl tab 10 mg 2desipramine hcl tab 25 mg 2desipramine hcl tab 50 mg 2desipramine hcl tab 75 mg 2desipramine hcl tab 100 mg 2desipramine hcl tab 150 mg 2DOXEPIN HCL - doxepin hcl cap 75 mg# 4 PAdoxepin hcl cap 10 mg# 4 PAdoxepin hcl cap 25 mg# 4 PAdoxepin hcl cap 50 mg# 4 PAdoxepin hcl cap 100 mg# 4 PAdoxepin hcl cap 150 mg# 4 PAdoxepin hcl conc 10 mg/ml# 4 PAduloxetine hcl enteric coated pellets cap 20 mg 2 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg 2 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 60 mg 2 QL (60 capsules/30 days)EMSAM - selegiline td patch 24hr 6 mg/24hr 5EMSAM - selegiline td patch 24hr 9 mg/24hr 5EMSAM - selegiline td patch 24hr 12 mg/24hr 5escitalopram oxalate soln 5 mg/5ml 2 QL (600 mls/30 days)escitalopram oxalate tab 5 mg 1 QL (30 tablets/30 days)escitalopram oxalate tab 10 mg 1 QL (30 tablets/30 days)escitalopram oxalate tab 20 mg 1 QL (30 tablets/30 days)FETZIMA - levomilnacipran hcl cap sr 24hr 20 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap sr 24hr 40 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap sr 24hr 80 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap sr 24hr 120 mg 4 QL (30 capsules/30 days)FETZIMA TITRATION PACK - levomilnacipran hcl cap sr 24hr 20 &

40 mg therapy pack4 QL (28 capsules/28 days)

fluoxetine hcl cap delayed release 90 mg 2 QL (4 capsules/28 days)fluoxetine hcl cap 10 mg 2 QL (30 capsules/30 days)fluoxetine hcl cap 20 mg 2 QL (120 capsules/30 days)fluoxetine hcl cap 40 mg 2 QL (60 capsules/30 days)fluoxetine hcl solution 20 mg/5ml 2 QL (600 mls/30 days)fluoxetine hcl tab 10 mg 2 QL (30 tablets/30 days)fluoxetine hcl tab 20 mg 2 QL (120 tablets/30 days)

2016


21

Drug Name Drug Tier Requirements/Limitsfluvoxamine maleate tab 25 mg 2 QL (30 tablets/30 days)fluvoxamine maleate tab 50 mg 2 QL (30 tablets/30 days)fluvoxamine maleate tab 100 mg 2 QL (90 tablets/30 days)imipramine hcl tab 10 mg# 4 PAimipramine hcl tab 25 mg# 4 PAimipramine hcl tab 50 mg# 4 PAMAPROTILINE HCL - maprotiline hcl tab 25 mg 4 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 50 mg 4 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 75 mg 4 QL (90 tablets/30 days)MARPLAN - isocarboxazid tab 10 mg 4mirtazapine orally disintegrating tab 15 mg 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 30 mg 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 45 mg 2 QL (30 tablets/30 days)mirtazapine tab 7.5 mg 1 QL (30 tablets/30 days)mirtazapine tab 15 mg 1 QL (30 tablets/30 days)mirtazapine tab 30 mg 1 QL (30 tablets/30 days)mirtazapine tab 45 mg 1 QL (30 tablets/30 days)NEFAZODONE HCL - nefazodone hcl tab 100 mg 4NEFAZODONE HCL - nefazodone hcl tab 150 mg 4NEFAZODONE HCL - nefazodone hcl tab 200 mg 4nefazodone hcl tab 50 mg 2nefazodone hcl tab 250 mg 2NORTRIPTYLINE HCL - nortriptyline hcl soln 10 mg/5ml 4nortriptyline hcl cap 10 mg 2nortriptyline hcl cap 25 mg 2nortriptyline hcl cap 50 mg 2nortriptyline hcl cap 75 mg 2paroxetine hcl tab sr 24hr 12.5 mg 2 QL (30 tablets/30 days)paroxetine hcl tab sr 24hr 25 mg 2 QL (60 tablets/30 days)paroxetine hcl tab sr 24hr 37.5 mg 2 QL (60 tablets/30 days)paroxetine hcl tab 10 mg 2 QL (30 tablets/30 days)paroxetine hcl tab 20 mg 2 QL (30 tablets/30 days)paroxetine hcl tab 30 mg 2 QL (60 tablets/30 days)paroxetine hcl tab 40 mg 2 QL (30 tablets/30 days)PAXIL - paroxetine hcl oral susp 10 mg/5ml 4 QL (900 mls/30 days)phenelzine sulfate tab 15 mg 2PRISTIQ - desvenlafaxine succinate tab sr 24hr 25 mg 4 QL (30 tablets/30 days)PRISTIQ - desvenlafaxine succinate tab sr 24hr 50 mg 4 QL (30 tablets/30 days)

2016


Drug Name Drug Tier Requirements/LimitsPRISTIQ - desvenlafaxine succinate tab sr 24hr 100 mg 4 QL (30 tablets/30 days)protriptyline hcl tab 5 mg 2protriptyline hcl tab 10 mg 2quetiapine fumarate tab 25 mg 2 PA, QL (90 tablets/30 days)quetiapine fumarate tab 50 mg 2 PA, QL (90 tablets/30 days)quetiapine fumarate tab 100 mg 2 PA, QL (90 tablets/30 days)quetiapine fumarate tab 200 mg 2 PA, QL (90 tablets/30 days)quetiapine fumarate tab 300 mg 2 PA, QL (60 tablets/30 days)quetiapine fumarate tab 400 mg 2 PA, QL (60 tablets/30 days)REXULTI - brexpiprazole tab 0.25 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 0.5 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 1 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 2 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 3 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 4 mg 5 PA, QL (30 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab sr 24hr 50 mg 3 PA, QL (60 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab sr 24hr 150 mg 3 PA, QL (30 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab sr 24hr 200 mg 3 PA, QL (30 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab sr 24hr 300 mg 3 PA, QL (60 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab sr 24hr 400 mg 3 PA, QL (60 tablets/30 days)sertraline hcl oral conc 20 mg/ml 2 QL (300 mls/30 days)sertraline hcl tab 25 mg 1 QL (30 tablets/30 days)sertraline hcl tab 50 mg 1 QL (30 tablets/30 days)sertraline hcl tab 100 mg 1 QL (60 tablets/30 days)SURMONTIL - trimipramine maleate cap 25 mg# 4 PASURMONTIL - trimipramine maleate cap 50 mg# 4 PASURMONTIL - trimipramine maleate cap 100 mg# 4 PAtranylcypromine sulfate tab 10 mg 2trazodone hcl tab 50 mg 2trazodone hcl tab 100 mg 2trazodone hcl tab 150 mg 2trazodone hcl tab 300 mg 2trimipramine maleate cap 25 mg# 4 PAtrimipramine maleate cap 50 mg# 4 PAtrimipramine maleate cap 100 mg# 4 PATRINTELLIX - vortioxetine hbr tab 5 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 10 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 20 mg 4 QL (30 tablets/30 days)

2016


23

Drug Name Drug Tier Requirements/Limitsvenlafaxine hcl cap sr 24hr 37.5 mg 2 QL (30 capsules/30 days)venlafaxine hcl cap sr 24hr 75 mg 2 QL (90 capsules/30 days)venlafaxine hcl cap sr 24hr 150 mg 2 QL (30 capsules/30 days)venlafaxine hcl tab sr 24hr 37.5 mg 2 QL (30 tablets/30 days)venlafaxine hcl tab sr 24hr 75 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab sr 24hr 150 mg 2 QL (30 tablets/30 days)venlafaxine hcl tab 25 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 37.5 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 50 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 75 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 100 mg 2 QL (90 tablets/30 days)VIIBRYD - vilazodone hcl tab 10 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 20 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 40 mg 4 QL (30 tablets/30 days)VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10 (7) &

20 (23) mg4 QL (1 kit/30 days)

AntiemeticsALOXI - palonosetron hcl iv soln 0.25 mg/5ml 4CHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/ml 4 PACHLORPROMAZINE HCL - chlorpromazine hcl inj 50 mg/2ml 4 PAchlorpromazine hcl tab 10 mg 2 PAchlorpromazine hcl tab 25 mg 2 PAchlorpromazine hcl tab 50 mg 2 PAchlorpromazine hcl tab 100 mg 2 PAchlorpromazine hcl tab 200 mg 2 PAdiphenhydramine hcl inj 50 mg/ml 2dronabinol cap 2.5 mg 2 BDdronabinol cap 5 mg 2 BDdronabinol cap 10 mg 2 BDEMEND - aprepitant capsule therapy pack 80 & 125 mg 4 BDEMEND - aprepitant capsule 40 mg 4 BDEMEND - aprepitant capsule 80 mg 4 BDEMEND - aprepitant capsule 125 mg 4 BDEMEND - fosaprepitant dimeglumine for iv infusion 150 mg 4granisetron hcl tab 1 mg 2 BDhydroxyzine hcl syrup 10 mg/5ml# 4 PAhydroxyzine hcl tab 10 mg# 4 PAhydroxyzine hcl tab 25 mg# 4 PAhydroxyzine hcl tab 50 mg# 4 PA

2016


Drug Name Drug Tier Requirements/Limitsmeclizine hcl tab 12.5 mg 2meclizine hcl tab 25 mg 2metoclopramide hcl inj 5 mg/ml 2metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 2metoclopramide hcl tab 5 mg 2metoclopramide hcl tab 10 mg 2ondansetron hcl inj 4 mg/2ml (2 mg/ml) 2ondansetron hcl inj 40 mg/20ml (2 mg/ml) 2ondansetron hcl oral soln 4 mg/5ml 2 BDondansetron hcl tab 4 mg 2 BDondansetron hcl tab 8 mg 2 BDondansetron hcl tab 24 mg 2 BDondansetron orally disintegrating tab 4 mg 2 BDondansetron orally disintegrating tab 8 mg 2 BDperphenazine tab 2 mg 2 PAperphenazine tab 4 mg 2 PAperphenazine tab 8 mg 2 PAperphenazine tab 16 mg 2 PAprochlorperazine edisylate inj 5 mg/ml 2prochlorperazine maleate tab 5 mg 2prochlorperazine maleate tab 10 mg 2prochlorperazine suppos 25 mg 2promethazine hcl suppos 12.5 mg# 4 PApromethazine hcl suppos 25 mg# 4 PApromethazine hcl syrup 6.25 mg/5ml# 4 PApromethazine hcl tab 12.5 mg# 4 PApromethazine hcl tab 25 mg# 4 PApromethazine hcl tab 50 mg# 4 PAAntifungalsAMBISOME - amphotericin b liposome iv for susp 50 mg 5 BDAMPHOTERICIN B - amphotericin b for inj 50 mg 4 BDCANCIDAS - caspofungin acetate for iv soln 50 mg 5CANCIDAS - caspofungin acetate for iv soln 70 mg 5clotrimazole troche 10 mg 2CRESEMBA - isavuconazonium sulfate cap 186 mg 5 PACRESEMBA - isavuconazonium sulfate for iv soln 372 mg 5 PAfluconazole for susp 10 mg/ml 2fluconazole for susp 40 mg/ml 2

2016


25

Drug Name Drug Tier Requirements/Limitsfluconazole in dextrose inj 200 mg/100ml 2fluconazole in dextrose inj 400 mg/200ml 2fluconazole in nacl 0.9% inj 200 mg/100ml 2fluconazole in nacl 0.9% inj 400 mg/200ml 2fluconazole tab 50 mg 2fluconazole tab 100 mg 2fluconazole tab 150 mg 2fluconazole tab 200 mg 2flucytosine cap 250 mg 5flucytosine cap 500 mg 5griseofulvin microsize susp 125 mg/5ml 2griseofulvin ultramicrosize tab 125 mg 2griseofulvin ultramicrosize tab 250 mg 2itraconazole cap 100 mg 2ketoconazole tab 200 mg 2MYCAMINE - micafungin sodium for iv soln 50 mg 5MYCAMINE - micafungin sodium for iv soln 100 mg 5NOXAFIL - posaconazole iv soln 300 mg/16.7ml (18 mg/ml) 4 PANOXAFIL - posaconazole susp 40 mg/ml 5 PANOXAFIL - posaconazole tab delayed release 100 mg 5 PAnystatin susp 100000 unit/ml 2nystatin tab 500000 unit 2terbinafine hcl tab 250 mg 2terconazole vaginal cream 0.4% 2terconazole vaginal cream 0.8% 2terconazole vaginal suppos 80 mg 2voriconazole for inj 200 mg 2 PAvoriconazole for susp 40 mg/ml 5 PAvoriconazole tab 50 mg 5 PAvoriconazole tab 200 mg 5 PAAntigout Agentsallopurinol tab 100 mg 1allopurinol tab 300 mg 1ALOPRIM - allopurinol sodium for inj 500 mg 4colchicine w/ probenecid tab 0.5-500 mg 2COLCRYS - colchicine tab 0.6 mg 3probenecid tab 500 mg 2ULORIC - febuxostat tab 40 mg 3

2016


Drug Name Drug Tier Requirements/LimitsULORIC - febuxostat tab 80 mg 3Anti-Inflammatory Agentscelecoxib cap 50 mg 2 QL (60 capsules/30 days)celecoxib cap 100 mg 2 QL (60 capsules/30 days)celecoxib cap 200 mg 2 QL (60 capsules/30 days)celecoxib cap 400 mg 2 QL (30 capsules/30 days)diclofenac potassium tab 50 mg 2diclofenac sodium gel 1% 2 STdiclofenac sodium tab delayed release 25 mg 2diclofenac sodium tab delayed release 50 mg 2diclofenac sodium tab delayed release 75 mg 2diclofenac sodium tab sr 24hr 100 mg 2diclofenac w/ misoprostol tab delayed release 50-0.2 mg 2diclofenac w/ misoprostol tab delayed release 75-0.2 mg 2etodolac cap 200 mg 2etodolac cap 300 mg 2etodolac tab sr 24hr 400 mg 2etodolac tab sr 24hr 500 mg 2etodolac tab sr 24hr 600 mg 2etodolac tab 400 mg 2etodolac tab 500 mg 2flurbiprofen tab 50 mg 2flurbiprofen tab 100 mg 2ibuprofen susp 100 mg/5ml 2ibuprofen tab 400 mg 2ibuprofen tab 600 mg 2ibuprofen tab 800 mg 2ketoprofen cap 50 mg 2ketoprofen cap 75 mg 2meloxicam tab 7.5 mg 2meloxicam tab 15 mg 2nabumetone tab 500 mg 2nabumetone tab 750 mg 2naproxen sodium tab 275 mg 2naproxen sodium tab 550 mg 2naproxen susp 125 mg/5ml 2naproxen tab ec 375 mg 2naproxen tab ec 500 mg 2

2016


27

Drug Name Drug Tier Requirements/Limitsnaproxen tab 250 mg 2naproxen tab 375 mg 2naproxen tab 500 mg 2oxaprozin tab 600 mg 2piroxicam cap 10 mg 2piroxicam cap 20 mg 2sulindac tab 150 mg 2sulindac tab 200 mg 2tolmetin sodium cap 400 mg 2VOLTAREN - diclofenac sodium gel 1% 4 STAntimigraine Agentsbutalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg# 4 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg# 4 PA, QL (180 capsules/30 days)butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg# 4 PA, QL (180 capsules/30 days)divalproex sodium cap delayed release sprinkle 125 mg 2divalproex sodium tab delayed release 125 mg 2divalproex sodium tab delayed release 250 mg 2divalproex sodium tab delayed release 500 mg 2divalproex sodium tab sr 24 hr 250 mg 2divalproex sodium tab sr 24 hr 500 mg 2MIGERGOT - ergotamine w/ caffeine suppos 2-100 mg 4MIGRANAL - dihydroergotamine mesylate nasal spray 4 mg/ml 3naratriptan hcl tab 1 mg 2 QL (18 tablets/30 days)naratriptan hcl tab 2.5 mg 2 QL (18 tablets/30 days)propranolol hcl cap sr 24hr 60 mg 2propranolol hcl cap sr 24hr 80 mg 2propranolol hcl cap sr 24hr 120 mg 2propranolol hcl cap sr 24hr 160 mg 2propranolol hcl inj 1 mg/ml 2propranolol hcl tab 10 mg 1propranolol hcl tab 20 mg 1propranolol hcl tab 40 mg 1propranolol hcl tab 60 mg 2propranolol hcl tab 80 mg 1rizatriptan benzoate orally disintegrating tab 5 mg 2 QL (18 tablets/30 days)rizatriptan benzoate orally disintegrating tab 10 mg 2 QL (18 tablets/30 days)rizatriptan benzoate tab 5 mg 2 QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg 2 QL (18 tablets/30 days)

2016


Drug Name Drug Tier Requirements/Limitssumatriptan nasal spray 5 mg/act 2 QL (12 units (2

packages)/30 days)sumatriptan nasal spray 20 mg/act 2 QL (12 units (2

packages)/30 days)SUMATRIPTAN SUCCINATE - sumatriptan succinate solution

prefilled syringe 6 mg/0.5ml2

sumatriptan succinate inj 6 mg/0.5ml 2sumatriptan succinate solution auto-injector 4 mg/0.5ml 2sumatriptan succinate solution auto-injector 6 mg/0.5ml 2sumatriptan succinate solution cartridge 4 mg/0.5ml 2sumatriptan succinate solution cartridge 6 mg/0.5ml 2sumatriptan succinate tab 25 mg 2 QL (18 tablets/30 days)sumatriptan succinate tab 50 mg 2 QL (18 tablets/30 days)sumatriptan succinate tab 100 mg 2 QL (18 tablets/30 days)TIMOLOL MALEATE - timolol maleate tab 5 mg 4TIMOLOL MALEATE - timolol maleate tab 10 mg 4TIMOLOL MALEATE - timolol maleate tab 20 mg 4topiramate sprinkle cap 15 mg 2topiramate sprinkle cap 25 mg 2topiramate tab 25 mg 2topiramate tab 50 mg 2topiramate tab 100 mg 2topiramate tab 200 mg 2Antimyasthenic AgentsGUANIDINE HCL - guanidine hcl tab 125 mg 4MESTINON - pyridostigmine bromide syrup 60 mg/5ml 4MESTINON TIMESPAN - pyridostigmine bromide tab cr 180 mg 3pyridostigmine bromide tab cr 180 mg 2pyridostigmine bromide tab 60 mg 2AntimycobacterialsCAPASTAT SULFATE - capreomycin sulfate for inj 1 gm 4CYCLOSERINE - cycloserine cap 250 mg 4dapsone tab 25 mg 2dapsone tab 100 mg 2ethambutol hcl tab 100 mg 2ethambutol hcl tab 400 mg 2ISONIAZID - isoniazid inj 100 mg/ml 4isoniazid tab 100 mg 2isoniazid tab 300 mg 2

2016


29

Drug Name Drug Tier Requirements/LimitsPASER - aminosalicylic acid cr granules packet 4 gm 4PRIFTIN - rifapentine tab 150 mg 4pyrazinamide tab 500 mg 2rifabutin cap 150 mg 2rifampin cap 150 mg 2rifampin cap 300 mg 2rifampin for inj 600 mg 2SIRTURO - bedaquiline fumarate tab 100 mg 5TRECATOR - ethionamide tab 250 mg 4AntineoplasticsABRAXANE - paclitaxel protein-bound particles for iv susp 100 mg 5AFINITOR - everolimus tab 2.5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 7.5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 10 mg 5 PA, QL (30 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 2 mg 5 PA, QL (60 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 3 mg 5 PA, QL (90 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 5 mg 5 PA, QL (60 tablets/30 days)ALECENSA - alectinib hcl cap 150 mg 5 PA, QL (240 capsules/30 days)ALIMTA - pemetrexed disodium for iv soln 100 mg 5ALIMTA - pemetrexed disodium for iv soln 500 mg 5amifostine crystalline for inj 500 mg 5anastrozole tab 1 mg 2ARRANON - nelarabine iv soln 5 mg/ml 5ARZERRA - ofatumumab conc for iv infusion 100 mg/5ml* 5ARZERRA - ofatumumab conc for iv infusion 1000 mg/50ml* 5AVASTIN - bevacizumab iv soln 100 mg/4ml (for infusion)* 5AVASTIN - bevacizumab iv soln 400 mg/16ml (for infusion)* 5azacitidine for inj 100 mg 5BELEODAQ - belinostat for iv inj 500 mg* 5BENDEKA - bendamustine hcl iv soln 100 mg/4ml (25 mg/ml) 5bexarotene cap 75 mg 5 PAbicalutamide tab 50 mg 2BICNU - carmustine for inj 100 mg 4BLEO 15K - bleomycin sulf for inj 15 usp unit(15000 international

unit)4 BD

bleomycin sulfate for inj 15 unit 2 BDbleomycin sulfate for inj 30 unit 2 BDBLINCYTO - blinatumomab for iv infusion 35 mcg* 5

2016


Drug Name Drug Tier Requirements/LimitsBOSULIF - bosutinib tab 100 mg 5 PA, QL (120 tablets/30 days)BOSULIF - bosutinib tab 500 mg 5 PA, QL (30 tablets/30 days)BUSULFEX - busulfan inj 6 mg/ml 5CABOMETYX - cabozantinib s-malate tab 20 mg 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 40 mg 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 60 mg 5 PA, QL (30 tablets/30 days)CAPRELSA - vandetanib tab 100 mg* 5 PA, QL (60 tablets/30 days)CAPRELSA - vandetanib tab 300 mg* 5 PA, QL (30 tablets/30 days)carboplatin iv soln 50 mg/5ml 2carboplatin iv soln 150 mg/15ml 2carboplatin iv soln 450 mg/45ml 2carboplatin iv soln 600 mg/60ml 2CISPLATIN - cisplatin inj 200 mg/200ml (1 mg/ml) 2cisplatin inj 50 mg/50ml (1 mg/ml) 2cisplatin inj 100 mg/100ml (1 mg/ml) 2cladribine iv soln 10 mg/10ml (1 mg/ml) 5 BDCLOLAR - clofarabine iv soln 1 mg/ml 5COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100

dose) kit*5 PA, QL (56 capsules/28 days)

COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140dose) kit*


COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg dose)kit*


COSMEGEN - dactinomycin for inj 0.5 mg 5COTELLIC - cobimetinib fumarate tab 20 mg* 5 PA, QL (63 tablets/28 days)CYCLOPHOSPHAMIDE - cyclophosphamide cap 25 mg 4 BDCYCLOPHOSPHAMIDE - cyclophosphamide cap 50 mg 4 BDcyclophosphamide for inj 500 mg 2cyclophosphamide for inj 1 gm 2cyclophosphamide for inj 2 gm 2CYRAMZA - ramucirumab iv soln 100 mg/10ml (for infusion)* 5CYRAMZA - ramucirumab iv soln 500 mg/50ml (for infusion)* 5cytarabine inj pf 20 mg/ml 2 BDcytarabine inj pf 100 mg/ml 2 BDcytarabine inj 20 mg/ml 2 BDDACARBAZINE - dacarbazine for inj 100 mg 4dacarbazine for inj 200 mg 2DARZALEX - daratumumab iv soln 100 mg/5ml* 5DARZALEX - daratumumab iv soln 400 mg/20ml* 5

2016


31

Drug Name Drug Tier Requirements/Limitsdaunorubicin hcl inj 5 mg/ml 2DAUNOXOME - daunorubicin citrate liposome inj 2 mg/ml 5decitabine for inj 50 mg 5dexrazoxane for inj 250 mg 5dexrazoxane for inj 500 mg 5DOCEFREZ - docetaxel for inj 20 mg 5DOCETAXEL - docetaxel for inj conc 20 mg/ml 5DOCETAXEL - docetaxel for inj conc 80 mg/4ml (20 mg/ml) 5DOCETAXEL - docetaxel for inj conc 140 mg/7ml (20 mg/ml) 5DOCETAXEL - docetaxel for inj conc 160 mg/8ml (20 mg/ml) 5DOCETAXEL - docetaxel soln for iv infusion 20 mg/2ml 5DOCETAXEL - docetaxel soln for iv infusion 80 mg/8ml 5DOCETAXEL - docetaxel soln for iv infusion 160 mg/16ml 5DOCETAXEL - docetaxel soln for iv infusion 200 mg/20ml 5docetaxel for inj conc 20 mg/ml 5docetaxel for inj conc 80 mg/4ml (20 mg/ml) 5doxorubicin hcl for inj 10 mg 2 BDdoxorubicin hcl for inj 50 mg 2 BDdoxorubicin hcl inj 2 mg/ml 2 BDdoxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml 2 BDELITEK - rasburicase for iv soln 1.5 mg 5ELITEK - rasburicase for iv soln 7.5 mg 5EMCYT - estramustine phosphate sodium cap 140 mg 4EMPLICITI - elotuzumab for iv soln 300 mg 5EMPLICITI - elotuzumab for iv soln 400 mg 5epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) 2epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) 2ERBITUX - cetuximab iv soln 100 mg/50ml (2 mg/ml) 5ERBITUX - cetuximab iv soln 200 mg/100ml (2 mg/ml) 5ERIVEDGE - vismodegib cap 150 mg* 5 PA, QL (30 capsules/30 days)ERWINAZE - asparaginase erwinia chrysanthemi for inj 10000 unit 5ETOPOPHOS - etoposide phosphate iv for inj 100 mg 4etoposide inj 100 mg/5ml (20 mg/ml) 2etoposide inj 500 mg/25ml (20 mg/ml) 2etoposide inj 1 gm/50ml (20 mg/ml) 2EVOMELA - melphalan hcl for inj 50 mg 5exemestane tab 25 mg 2FARESTON - toremifene citrate tab 60 mg 5

2016


Drug Name Drug Tier Requirements/LimitsFARYDAK - panobinostat lactate cap 10 mg 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 15 mg 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 20 mg 5 PA, QL (6 capsules/21 days)FASLODEX - fulvestrant inj 250 mg/5ml 5fludarabine phosphate for inj 50 mg 2fludarabine phosphate inj 25 mg/ml 2fluorouracil inj 500 mg/10ml (50 mg/ml) 2 BDfluorouracil inj 1 gm/20ml (50 mg/ml) 2 BDfluorouracil inj 2.5 gm/50ml (50 mg/ml) 2 BDfluorouracil inj 5 gm/100ml (50 mg/ml) 2 BDflutamide cap 125 mg 2FOLOTYN - pralatrexate iv inj 20 mg/ml 5FOLOTYN - pralatrexate iv inj 40 mg/2ml 5GAZYVA - obinutuzumab soln for iv infusion 1000 mg/40ml (25 mg/

ml)5

gemcitabine hcl for inj 200 mg 2gemcitabine hcl for inj 1 gm 2gemcitabine hcl for inj 2 gm 2gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) 2gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) 2gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) 2GILOTRIF - afatinib dimaleate tab 20 mg 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 30 mg 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 40 mg 5 PA, QL (30 tablets/30 days)GLEEVEC - imatinib mesylate tab 100 mg 5 PA, QL (90 tablets/30 days)GLEEVEC - imatinib mesylate tab 400 mg 5 PA, QL (60 tablets/30 days)GLEOSTINE - lomustine cap 5 mg 4GLEOSTINE - lomustine cap 10 mg 4GLEOSTINE - lomustine cap 40 mg 4GLEOSTINE - lomustine cap 100 mg 4HALAVEN - eribulin mesylate inj 1 mg/2ml (0.5 mg/ml) 5HERCEPTIN - trastuzumab for iv soln 440 mg* 5HEXALEN - altretamine cap 50 mg 5 PAHYDROXYPROGESTERONE CAPROATE - hydroxyprogesterone

caproate im in oil 1.25 gm/5ml5

hydroxyurea cap 500 mg 2IBRANCE - palbociclib cap 75 mg 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 100 mg 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 125 mg 5 PA, QL (21 capsules/28 days)

2016


33

Drug Name Drug Tier Requirements/LimitsICLUSIG - ponatinib hcl tab 15 mg 5 PA, QL (60 tablets/30 days)ICLUSIG - ponatinib hcl tab 45 mg 5 PA, QL (30 tablets/30 days)idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 5idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 5idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 5IFEX - ifosfamide for inj 3 gm 4IFOSFAMIDE - ifosfamide for inj 3 gm 4ifosfamide for inj 1 gm 2ifosfamide iv inj 1 gm/20ml (50 mg/ml) 2ifosfamide iv inj 3 gm/60ml (50 mg/ml) 2imatinib mesylate tab 100 mg 5 PA, QL (90 tablets/30 days)imatinib mesylate tab 400 mg 5 PA, QL (60 tablets/30 days)IMBRUVICA - ibrutinib cap 140 mg 5 PA, QL (120 capsules/30 days)IMLYGIC - talimogene laherparepvec intralesional inj 1000000 unit/

ml4

IMLYGIC - talimogene laherparepvec intralesional inj 100000000unit/ml

5

INLYTA - axitinib tab 1 mg* 5 PA, QL (180 tablets/30 days)INLYTA - axitinib tab 5 mg* 5 PA, QL (120 tablets/30 days)IRESSA - gefitinib tab 250 mg 5 PA, QL (30 tablets/30 days)IRINOTECAN - irinotecan hcl inj 500 mg/25ml (20 mg/ml) 2irinotecan hcl inj 40 mg/2ml (20 mg/ml) 2irinotecan hcl inj 100 mg/5ml (20 mg/ml) 2ISTODAX - romidepsin for iv inj 10 mg 5ISTODAX (OVERFILL) - romidepsin for iv inj 10 mg 5IXEMPRA KIT - ixabepilone for iv infusion 15 mg 5IXEMPRA KIT - ixabepilone for iv infusion 45 mg 5JAKAFI - ruxolitinib phosphate tab 5 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 10 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 15 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 20 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 25 mg* 5 PA, QL (60 tablets/30 days)JEVTANA - cabazitaxel inj 60 mg/1.5ml (for iv infusion) 5KADCYLA - ado-trastuzumab emtansine for iv soln 100 mg 5KADCYLA - ado-trastuzumab emtansine for iv soln 160 mg 5KEYTRUDA - pembrolizumab for iv soln 50 mg* 5KEYTRUDA - pembrolizumab iv soln 100 mg/4ml (25 mg/ml)* 5LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack 10 mg 5 PA, QL (30 capsules/30 days)

2016


Drug Name Drug Tier Requirements/LimitsLENVIMA 14 MG DAILY DOSE - lenvatinib cap therapy pack 10 &

4 mg5 PA, QL (60 capsules/30 days)

LENVIMA 18 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 (2) mg


LENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 10(2) mg


LENVIMA 24 MG DAILY DOSE - lenvatinib cap therapy pack 10 (2)& 4 mg


LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 4(2) mg


letrozole tab 2.5 mg 2LEUCOVORIN CALCIUM - leucovorin calcium for inj 50 mg 4LEUCOVORIN CALCIUM - leucovorin calcium for inj 500 mg 4LEUCOVORIN CALCIUM - leucovorin calcium tab 10 mg 4LEUCOVORIN CALCIUM - leucovorin calcium tab 15 mg 4leucovorin calcium for inj 100 mg 2leucovorin calcium for inj 200 mg 2leucovorin calcium for inj 350 mg 2leucovorin calcium tab 5 mg 2leucovorin calcium tab 25 mg 2LEUKERAN - chlorambucil tab 2 mg 3LONSURF - trifluridine-tipiracil tab 15-6.14 mg 5 PA, QL (100 tablets/28 days)LONSURF - trifluridine-tipiracil tab 20-8.19 mg 5 PA, QL (80 tablets/28 days)LYNPARZA - olaparib cap 50 mg 5 PA, QL (480 capsules/30 days)MARQIBO - vincristine sulfate liposome iv susp 5 mg/31ml

(0.16 mg/ml)5

MATULANE - procarbazine hcl cap 50 mg* 5 PAMEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg 5 PA, QL (90 tablets/30 days)MEKINIST - trametinib dimethyl sulfoxide tab 2 mg 5 PA, QL (30 tablets/30 days)melphalan hcl for inj 50 mg 5mercaptopurine tab 50 mg 2mesna inj 100 mg/ml 2MESNEX - mesna tab 400 mg 5methotrexate sodium for inj 1 gm 2methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) 2methotrexate sodium inj pf 100 mg/4ml (25 mg/ml) 2methotrexate sodium inj pf 200 mg/8ml (25 mg/ml) 2methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) 2methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) 2methotrexate sodium inj 250 mg/10ml (25 mg/ml) 2

2016


35

Drug Name Drug Tier Requirements/Limitsmethotrexate sodium inj 50 mg/2ml (25 mg/ml) 2methotrexate sodium tab 2.5 mg 2MITOMYCIN - mitomycin for iv soln 5 mg 4mitomycin for iv soln 20 mg 2mitomycin for iv soln 40 mg 2mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) 2mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) 2mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) 2MUSTARGEN - mechlorethamine hcl for inj 10 mg 4NEXAVAR - sorafenib tosylate tab 200 mg* 5 PA, QL (120 tablets/30 days)NILANDRON - nilutamide tab 150 mg 5nilutamide tab 150 mg 5NINLARO - ixazomib citrate cap 2.3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 4 mg 5 PA, QL (3 capsules/28 days)NIPENT - pentostatin for inj 10 mg 5ODOMZO - sonidegib phosphate cap 200 mg* 5 PA, QL (30 capsules/30 days)ONCASPAR - pegaspargase inj 750 unit/ml 5OPDIVO - nivolumab iv soln 40 mg/4ml 5OPDIVO - nivolumab iv soln 100 mg/10ml 5oxaliplatin for iv inj 50 mg 5oxaliplatin for iv inj 100 mg 5oxaliplatin iv soln 50 mg/10ml 2oxaliplatin iv soln 100 mg/20ml 2paclitaxel iv conc 30 mg/5ml (6 mg/ml) 2paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) 2paclitaxel iv conc 300 mg/50ml (6 mg/ml) 2PANRETIN - alitretinoin gel 0.1% 5PERJETA - pertuzumab soln for iv infusion 420 mg/14ml (30 mg/

ml)*5

POMALYST - pomalidomide cap 1 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 2 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 3 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 4 mg* 5 PA, QL (21 capsules/28 days)PORTRAZZA - necitumumab iv soln 800 mg/50ml (16 mg/ml) 5PROLEUKIN - aldesleukin for iv soln 22000000 unit 5PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml)* 5REVLIMID - lenalidomide caps 2.5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 5 mg* 5 PA, QL (30 capsules/30 days)

2016


Drug Name Drug Tier Requirements/LimitsREVLIMID - lenalidomide cap 10 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 15 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 20 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 25 mg* 5 PA, QL (21 capsules/28 days)RITUXAN - rituximab iv soln 100 mg/10ml* 5 PARITUXAN - rituximab iv soln 500 mg/50ml* 5 PASOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml 4SPRYCEL - dasatinib tab 20 mg 5 PA, QL (60 tablets/30 days)SPRYCEL - dasatinib tab 50 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 70 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 80 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 100 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 140 mg 5 PA, QL (30 tablets/30 days)STIVARGA - regorafenib tab 40 mg* 5 PA, QL (84 tablets/28 days)SUTENT - sunitinib malate cap 12.5 mg 5 PA, QL (90 capsules/30 days)SUTENT - sunitinib malate cap 25 mg 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 37.5 mg 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 50 mg 5 PA, QL (30 capsules/30 days)SYLATRON - peginterferon alfa-2b for inj kit 200 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 300 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 600 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 4 x 200 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 4 x 300 mcg 5 PASYLVANT - siltuximab for iv infusion 100 mg 5SYLVANT - siltuximab for iv infusion 400 mg 5SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg 5TABLOID - thioguanine tab 40 mg 4TAFINLAR - dabrafenib mesylate cap 50 mg 5 PA, QL (120 capsules/30 days)TAFINLAR - dabrafenib mesylate cap 75 mg 5 PA, QL (120 capsules/30 days)TAGRISSO - osimertinib mesylate tab 40 mg* 5 PA, QL (30 tablets/30 days)TAGRISSO - osimertinib mesylate tab 80 mg* 5 PA, QL (30 tablets/30 days)tamoxifen citrate tab 10 mg 2tamoxifen citrate tab 20 mg 2TARCEVA - erlotinib hcl tab 25 mg 5 PA, QL (60 tablets/30 days)TARCEVA - erlotinib hcl tab 100 mg 5 PA, QL (30 tablets/30 days)TARCEVA - erlotinib hcl tab 150 mg 5 PA, QL (30 tablets/30 days)TARGRETIN - bexarotene cap 75 mg 5 PATARGRETIN - bexarotene gel 1% 5

2016


37

Drug Name Drug Tier Requirements/LimitsTASIGNA - nilotinib hcl cap 150 mg 5 PA, QL (120 capsules/30 days)TASIGNA - nilotinib hcl cap 200 mg 5 PA, QL (120 capsules/30 days)TAXOTERE - docetaxel for inj conc 20 mg/ml 5TAXOTERE - docetaxel for inj conc 80 mg/4ml (20 mg/ml) 5TECENTRIQ - atezolizumab iv soln 1200 mg/20ml 5TEMODAR - temozolomide for iv soln 100 mg 5THALOMID - thalidomide cap 50 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 100 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 150 mg 5 PA, QL (60 capsules/30 days)THALOMID - thalidomide cap 200 mg 5 PA, QL (60 capsules/30 days)THIOTEPA - thiotepa for inj 15 mg 5TOPOTECAN HCL - topotecan hcl inj 4 mg/4ml (for infusion) 5topotecan hcl for inj 4 mg 5TORISEL - temsirolimus soln for iv infusion 25 mg/ml 5TREANDA - bendamustine hcl for iv soln 25 mg 5TREANDA - bendamustine hcl for iv soln 100 mg 5TREANDA - bendamustine hcl iv soln 180 mg/2ml (90 mg/ml) 5tretinoin cap 10 mg 5 PATRISENOX - arsenic trioxide inj 10 mg/10ml (1 mg/ml) 4TYKERB - lapatinib ditosylate tab 250 mg* 5 PA, QL (180 tablets/30 days)UNITUXIN - dinutuximab iv soln 17.5 mg/5ml (3.5 mg/ml) 5UVADEX - methoxsalen soln 20 mcg/ml 4VECTIBIX - panitumumab iv soln 100 mg/5ml 5VECTIBIX - panitumumab iv soln 400 mg/20ml 5VELCADE - bortezomib for inj 3.5 mg 5VENCLEXTA - venetoclax tab 10 mg 4 PA, QL (60 tablets/30 days)VENCLEXTA - venetoclax tab 50 mg 4 PA, QL (30 tablets/30 days)VENCLEXTA - venetoclax tab 100 mg 5 PA, QL (120 tablets/30 days)VENCLEXTA STARTING PACK - venetoclax tab therapy starter

pack 10 & 50 & 100 mg5 PA, QL (1 pack (42

tablets)/28 days)VINBLASTINE SULFATE - vinblastine sulfate inj 1 mg/ml 4 BDvincristine sulfate iv soln 1 mg/ml 2vinorelbine tartrate inj 10 mg/ml 2vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) 2VOTRIENT - pazopanib hcl tab 200 mg* 5 PA, QL (120 tablets/30 days)XALKORI - crizotinib cap 200 mg* 5 PA, QL (60 capsules/30 days)XALKORI - crizotinib cap 250 mg* 5 PA, QL (60 capsules/30 days)XTANDI - enzalutamide cap 40 mg* 5 PA, QL (120 capsules/30 days)YERVOY - ipilimumab soln for iv infusion 50 mg/10ml (5 mg/ml)* 5

2016


Drug Name Drug Tier Requirements/LimitsYERVOY - ipilimumab soln for iv infusion 200 mg/40ml (5 mg/ml)* 5YONDELIS - trabectedin for inj 1 mg 5ZALTRAP - ziv-aflibercept iv soln 100 mg/4ml (for infusion) 5ZALTRAP - ziv-aflibercept iv soln 200 mg/8ml (for infusion) 5ZANOSAR - streptozocin for inj 1 gm 4ZELBORAF - vemurafenib tab 240 mg* 5 PA, QL (240 tablets/30 days)ZOLINZA - vorinostat cap 100 mg 5 PA, QL (120 capsules/30 days)ZYDELIG - idelalisib tab 100 mg* 5 PA, QL (60 tablets/30 days)ZYDELIG - idelalisib tab 150 mg* 5 PA, QL (60 tablets/30 days)ZYKADIA - ceritinib cap 150 mg* 5 PA, QL (150 capsules/30 days)ZYTIGA - abiraterone acetate tab 250 mg* 5 PA, QL (120 tablets/30 days)AntiparasiticsALBENZA - albendazole tab 200 mg 4ALINIA - nitazoxanide for susp 100 mg/5ml 4ALINIA - nitazoxanide tab 500 mg 4atovaquone susp 750 mg/5ml 5atovaquone-proguanil hcl tab 62.5-25 mg 2atovaquone-proguanil hcl tab 250-100 mg 2BILTRICIDE - praziquantel tab 600 mg 4chloroquine phosphate tab 250 mg 2chloroquine phosphate tab 500 mg 2COARTEM - artemether-lumefantrine tab 20-120 mg 4DARAPRIM - pyrimethamine tab 25 mg 4hydroxychloroquine sulfate tab 200 mg 2ivermectin tab 3 mg 2lindane shampoo 1% 2malathion lotion 0.5% 2mefloquine hcl tab 250 mg 2NEBUPENT - pentamidine isethionate for nebulization soln 300 mg 4 BDPENTAM 300 - pentamidine isethionate for soln 300 mg 4 BDpermethrin cream 5% 2PRIMAQUINE PHOSPHATE - primaquine phosphate tab 26.3 mg 4Antiparkinson AgentsAMANTADINE HCL - amantadine hcl tab 100 mg 4amantadine hcl cap 100 mg 2amantadine hcl syrup 50 mg/5ml 2APOKYN - apomorphine hydrochloride inj 10 mg/ml* 5AZILECT - rasagiline mesylate tab 0.5 mg 3AZILECT - rasagiline mesylate tab 1 mg 3

2016


39

Drug Name Drug Tier Requirements/Limitsbenztropine mesylate tab 0.5 mg# 3 PAbenztropine mesylate tab 1 mg# 3 PAbenztropine mesylate tab 2 mg# 3 PAbromocriptine mesylate cap 5 mg 2bromocriptine mesylate tab 2.5 mg 2carbidopa & levodopa orally disintegrating tab 10-100 mg 2carbidopa & levodopa orally disintegrating tab 25-100 mg 2carbidopa & levodopa orally disintegrating tab 25-250 mg 2carbidopa & levodopa tab cr 25-100 mg 2carbidopa & levodopa tab cr 50-200 mg 2carbidopa & levodopa tab 10-100 mg 2carbidopa & levodopa tab 25-100 mg 2carbidopa & levodopa tab 25-250 mg 2carbidopa tab 25 mg 5CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-

entacapone tabs 12.5-50-200 mg2

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 18.75-75-200 mg

2

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 25-100-200 mg

2


2


2

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 50-200-200 mg

2

diphenhydramine hcl inj 50 mg/ml 2entacapone tab 200 mg 2NEUPRO - rotigotine td patch 24hr 1 mg/24hr 3NEUPRO - rotigotine td patch 24hr 2 mg/24hr 3NEUPRO - rotigotine td patch 24hr 3 mg/24hr 3NEUPRO - rotigotine td patch 24hr 4 mg/24hr 3NEUPRO - rotigotine td patch 24hr 6 mg/24hr 3NEUPRO - rotigotine td patch 24hr 8 mg/24hr 3NUPLAZID - pimavanserin tartrate tab 17 mg 5 PA, QL (60 tablets/30 days)pramipexole dihydrochloride tab 0.125 mg 2pramipexole dihydrochloride tab 0.25 mg 2pramipexole dihydrochloride tab 0.5 mg 2pramipexole dihydrochloride tab 0.75 mg 2pramipexole dihydrochloride tab 1 mg 2

2016


Drug Name Drug Tier Requirements/Limitspramipexole dihydrochloride tab 1.5 mg 2ropinirole hydrochloride tab 0.25 mg 2ropinirole hydrochloride tab 0.5 mg 2ropinirole hydrochloride tab 1 mg 2ropinirole hydrochloride tab 2 mg 2ropinirole hydrochloride tab 3 mg 2ropinirole hydrochloride tab 4 mg 2ropinirole hydrochloride tab 5 mg 2selegiline hcl cap 5 mg 2selegiline hcl tab 5 mg 2tolcapone tab 100 mg 5AntipsychoticsABILIFY MAINTENA - aripiprazole im for extended release susp




or vial/30 days)ADASUVE - loxapine aerosol powder breath activated 10 mg 4 PAaripiprazole oral solution 1 mg/ml 5 PA, QL (750 mls/30 days)aripiprazole orally disintegrating tab 10 mg 5 PA, QL (60 tablets/30 days)aripiprazole orally disintegrating tab 15 mg 5 PA, QL (60 tablets/30 days)aripiprazole tab 2 mg 5 PA, QL (30 tablets/30 days)aripiprazole tab 5 mg 5 PA, QL (30 tablets/30 days)aripiprazole tab 10 mg 5 PA, QL (30 tablets/30 days)aripiprazole tab 15 mg 5 PA, QL (30 tablets/30 days)aripiprazole tab 20 mg 5 PA, QL (30 tablets/30 days)aripiprazole tab 30 mg 5 PA, QL (30 tablets/30 days)CHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/ml 4 PACHLORPROMAZINE HCL - chlorpromazine hcl inj 50 mg/2ml 4 PAchlorpromazine hcl tab 10 mg 2 PAchlorpromazine hcl tab 25 mg 2 PAchlorpromazine hcl tab 50 mg 2 PAchlorpromazine hcl tab 100 mg 2 PAchlorpromazine hcl tab 200 mg 2 PAclozapine orally disintegrating tab 25 mg 2 PA, QL (270 tablets/30 days)clozapine orally disintegrating tab 100 mg 2 PA, QL (90 tablets/30 days)clozapine tab 25 mg 2 PA, QL (90 tablets/30 days)clozapine tab 50 mg 2 PA, QL (90 tablets/30 days)clozapine tab 100 mg 2 PA, QL (270 tablets/30 days)clozapine tab 200 mg 2 PA, QL (120 tablets/30 days)

2016


41

Drug Name Drug Tier Requirements/LimitsFANAPT - iloperidone tab 1 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 2 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 4 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 6 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 8 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 10 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 12 mg 4 PA, QL (60 tablets/30 days)FANAPT TITRATION PACK - iloperidone tab 1 mg & 2 mg & 4 mg

& 6 mg titration pak4 PA, QL (7 packs (56

tablets)/28 days)FAZACLO - clozapine orally disintegrating tab 12.5 mg 4 PA, QL (90 tablets/30 days)FAZACLO - clozapine orally disintegrating tab 25 mg 4 PA, QL (270 tablets/30 days)FAZACLO - clozapine orally disintegrating tab 100 mg 4 PA, QL (90 tablets/30 days)FAZACLO - clozapine orally disintegrating tab 150 mg 4 PA, QL (180 tablets/30 days)FAZACLO - clozapine orally disintegrating tab 200 mg 4 PA, QL (120 tablets/30 days)fluphenazine decanoate inj 25 mg/ml 2 PAFLUPHENAZINE HCL - fluphenazine hcl elixir 2.5 mg/5ml 4 PAFLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml 4 PAFLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml 4 PAfluphenazine hcl tab 1 mg 2 PAfluphenazine hcl tab 2.5 mg 2 PAfluphenazine hcl tab 5 mg 2 PAfluphenazine hcl tab 10 mg 2 PAGEODON - ziprasidone mesylate for inj 20 mg 4 PA, QL (60 vials/30 days)haloperidol decanoate im soln 50 mg/ml 2 PAhaloperidol decanoate im soln 100 mg/ml 2 PAhaloperidol lactate inj 5 mg/ml 2 PAhaloperidol lactate oral conc 2 mg/ml 2 PAhaloperidol tab 0.5 mg 2 PAhaloperidol tab 1 mg 2 PAhaloperidol tab 2 mg 2 PAhaloperidol tab 5 mg 2 PAhaloperidol tab 10 mg 2 PAhaloperidol tab 20 mg 2 PAINVEGA - paliperidone tab sr 24hr 1.5 mg 5 PA, QL (30 tablets/30 days)INVEGA - paliperidone tab sr 24hr 3 mg 5 PA, QL (30 tablets/30 days)INVEGA - paliperidone tab sr 24hr 6 mg 5 PA, QL (60 tablets/30 days)INVEGA - paliperidone tab sr 24hr 9 mg 5 PA, QL (30 tablets/30 days)INVEGA SUSTENNA - paliperidone palmitate im extend-release

susp 117 mg/0.75ml5 PA, QL (1 kit/30 days)

2016


Drug Name Drug Tier Requirements/LimitsINVEGA SUSTENNA - paliperidone palmitate im extended-release

susp 39 mg/0.25ml4 PA, QL (1 kit/30 days)

INVEGA SUSTENNA - paliperidone palmitate im extended-releasesusp 78 mg/0.5ml

5 PA, QL (1 kit/30 days)

INVEGA SUSTENNA - paliperidone palmitate im extended-releasesusp 156 mg/ml


INVEGA SUSTENNA - paliperidone palmitate im extended-releasesusp 234 mg/1.5ml


INVEGA TRINZA - paliperidone palmitate im extend-release susp273 mg/0.875ml








LATUDA - lurasidone hcl tab 20 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 40 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 60 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 80 mg 5 PA, QL (60 tablets/30 days)LATUDA - lurasidone hcl tab 120 mg 5 PA, QL (30 tablets/30 days)loxapine succinate cap 5 mg 2 PAloxapine succinate cap 10 mg 2 PAloxapine succinate cap 25 mg 2 PAloxapine succinate cap 50 mg 2 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 5 mg 4 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 10 mg 4 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 25 mg 4 PANUPLAZID - pimavanserin tartrate tab 17 mg 5 PA, QL (60 tablets/30 days)olanzapine for im inj 10 mg 2 PA, QL (90 vials/30 days)olanzapine orally disintegrating tab 5 mg 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 10 mg 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 15 mg 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 20 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 2.5 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 5 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 7.5 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 10 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 15 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 20 mg 2 PA, QL (30 tablets/30 days)ORAP - pimozide tab 1 mg 4

2016


43

Drug Name Drug Tier Requirements/LimitsORAP - pimozide tab 2 mg 4paliperidone tab sr 24hr 1.5 mg 5 PA, QL (30 tablets/30 days)paliperidone tab sr 24hr 3 mg 5 PA, QL (30 tablets/30 days)paliperidone tab sr 24hr 6 mg 5 PA, QL (60 tablets/30 days)paliperidone tab sr 24hr 9 mg 5 PA, QL (30 tablets/30 days)perphenazine tab 2 mg 2 PAperphenazine tab 4 mg 2 PAperphenazine tab 8 mg 2 PAperphenazine tab 16 mg 2 PApimozide tab 1 mg 2pimozide tab 2 mg 2prochlorperazine edisylate inj 5 mg/ml 2prochlorperazine maleate tab 5 mg 2prochlorperazine maleate tab 10 mg 2prochlorperazine suppos 25 mg 2quetiapine fumarate tab 25 mg 2 PA, QL (90 tablets/30 days)quetiapine fumarate tab 50 mg 2 PA, QL (90 tablets/30 days)quetiapine fumarate tab 100 mg 2 PA, QL (90 tablets/30 days)quetiapine fumarate tab 200 mg 2 PA, QL (90 tablets/30 days)quetiapine fumarate tab 300 mg 2 PA, QL (60 tablets/30 days)quetiapine fumarate tab 400 mg 2 PA, QL (60 tablets/30 days)REXULTI - brexpiprazole tab 0.25 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 0.5 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 1 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 2 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 3 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 4 mg 5 PA, QL (30 tablets/30 days)RISPERDAL CONSTA - risperidone microspheres for inj 12.5 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 25 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 37.5 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 50 mg 5 PA, QL (2 vials/28 days)risperidone orally disintegrating tab 0.25 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 0.5 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 1 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 2 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 3 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 4 mg 2 PA, QL (120 tablets/30 days)risperidone soln 1 mg/ml 2 PA, QL (480 mls/30 days)

2016


Drug Name Drug Tier Requirements/Limitsrisperidone tab 0.25 mg 2 PA, QL (60 tablets/30 days)risperidone tab 0.5 mg 2 PA, QL (60 tablets/30 days)risperidone tab 1 mg 2 PA, QL (60 tablets/30 days)risperidone tab 2 mg 2 PA, QL (60 tablets/30 days)risperidone tab 3 mg 2 PA, QL (60 tablets/30 days)risperidone tab 4 mg 2 PA, QL (120 tablets/30 days)SAPHRIS - asenapine maleate sl tab 2.5 mg 4 PA, QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 5 mg 4 PA, QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 10 mg 4 PA, QL (60 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab sr 24hr 50 mg 3 PA, QL (60 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab sr 24hr 150 mg 3 PA, QL (30 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab sr 24hr 200 mg 3 PA, QL (30 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab sr 24hr 300 mg 3 PA, QL (60 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab sr 24hr 400 mg 3 PA, QL (60 tablets/30 days)thioridazine hcl tab 10 mg# 4 PAthioridazine hcl tab 25 mg# 4 PAthioridazine hcl tab 50 mg# 4 PAthioridazine hcl tab 100 mg# 4 PAthiothixene cap 1 mg 2 PAthiothixene cap 2 mg 2 PAthiothixene cap 5 mg 2 PAthiothixene cap 10 mg 2 PAtrifluoperazine hcl tab 1 mg 2 PAtrifluoperazine hcl tab 2 mg 2 PAtrifluoperazine hcl tab 5 mg 2 PAtrifluoperazine hcl tab 10 mg 2 PAVERSACLOZ - clozapine susp 50 mg/ml 5 PA, QL (540 mls/30 days)VRAYLAR - cariprazine hcl cap therapy pack 1.5 mg (1) & 3 mg (6) 4 PA, QL (28 capsules/28 days)VRAYLAR - cariprazine hcl cap 1.5 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 3 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 4.5 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 6 mg 5 PA, QL (30 capsules/30 days)ziprasidone hcl cap 20 mg 2 PA, QL (60 capsules/30 days)ziprasidone hcl cap 40 mg 2 PA, QL (60 capsules/30 days)ziprasidone hcl cap 60 mg 2 PA, QL (60 capsules/30 days)ziprasidone hcl cap 80 mg 2 PA, QL (60 capsules/30 days)ZYPREXA RELPREVV - olanzapine pamoate for extended rel im

susp 210 mg5 PA, QL (2 vials/28 days)

2016


45

Drug Name Drug Tier Requirements/LimitsZYPREXA RELPREVV - olanzapine pamoate for extended rel im

susp 300 mg5 PA, QL (2 vials/28 days)

ZYPREXA RELPREVV - olanzapine pamoate for extended rel imsusp 405 mg

5 PA, QL (1 vial/28 days)

Antispasticity Agentsbaclofen tab 10 mg 1baclofen tab 20 mg 1dantrolene sodium cap 25 mg 2dantrolene sodium cap 50 mg 2dantrolene sodium cap 100 mg 2tizanidine hcl cap 2 mg 2tizanidine hcl cap 4 mg 2tizanidine hcl cap 6 mg 2tizanidine hcl tab 2 mg 1tizanidine hcl tab 4 mg 1Antiviralsabacavir sulfate tab 300 mg 2 QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg 5 QL (30 tablets/30 days)abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg 5 QL (60 tablets/30 days)acyclovir cap 200 mg 2acyclovir sodium for inj 500 mg 2 BDacyclovir sodium iv soln 50 mg/ml 2 BDacyclovir susp 200 mg/5ml 2acyclovir tab 400 mg 2acyclovir tab 800 mg 2adefovir dipivoxil tab 10 mg 5AMANTADINE HCL - amantadine hcl tab 100 mg 4amantadine hcl cap 100 mg 2amantadine hcl syrup 50 mg/5ml 2APTIVUS - tipranavir cap 250 mg 5 QL (120 capsules/30 days)APTIVUS - tipranavir oral soln 100 mg/ml 5 QL (380 mls/30 days)ATRIPLA - efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg 5 QL (30 tablets/30 days)BARACLUDE - entecavir oral soln 0.05 mg/ml 5cidofovir iv inj 75 mg/ml 2COMPLERA - emtricitabine-rilpivirine-tenofovir df tab

200-25-300 mg5 QL (30 tablets/30 days)

CRIXIVAN - indinavir sulfate cap 200 mg 3 QL (270 capsules/30 days)CRIXIVAN - indinavir sulfate cap 400 mg 3 QL (180 capsules/30 days)DAKLINZA - daclatasvir dihydrochloride tab 30 mg 5 PADAKLINZA - daclatasvir dihydrochloride tab 60 mg 5 PA

2016


Drug Name Drug Tier Requirements/LimitsDAKLINZA - daclatasvir dihydrochloride tab 90 mg 5 PADESCOVY - emtricitabine-tenofovir alafenamide fumarate tab

200-25 mg5 QL (30 tablets/30 days)

didanosine delayed release capsule 125 mg 2 QL (30 capsules/30 days)didanosine delayed release capsule 200 mg 2 QL (30 capsules/30 days)didanosine delayed release capsule 250 mg 2 QL (30 capsules/30 days)didanosine delayed release capsule 400 mg 2 QL (30 capsules/30 days)EDURANT - rilpivirine hcl tab 25 mg 5 QL (30 tablets/30 days)EMTRIVA - emtricitabine caps 200 mg 4 QL (30 capsules/30 days)EMTRIVA - emtricitabine soln 10 mg/ml 4 QL (850 mls/30 days)entecavir tab 0.5 mg 5entecavir tab 1 mg 5EPCLUSA - sofosbuvir-velpatasvir tab 400-100 mg 5 PAEPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv) 3EPZICOM - abacavir sulfate-lamivudine tab 600-300 mg 5 QL (30 tablets/30 days)EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg 5 QL (30 tablets/30 days)famciclovir tab 125 mg 2famciclovir tab 250 mg 2famciclovir tab 500 mg 2FUZEON - enfuvirtide for inj 90 mg 5 QL (60 vials/30 days)ganciclovir sodium for inj 500 mg 2 BDGENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg5 QL (30 tablets/30 days)

HARVONI - ledipasvir-sofosbuvir tab 90-400 mg 5 PAINTELENCE - etravirine tab 25 mg 4 QL (120 tablets/30 days)INTELENCE - etravirine tab 100 mg 5 QL (60 tablets/30 days)INTELENCE - etravirine tab 200 mg 5 QL (60 tablets/30 days)INTRON A - interferon alfa-2b inj 6000000 unit/ml 5INTRON A - interferon alfa-2b inj 10000000 unit/ml 5INTRON A - interferon alfa-2b for inj 10000000 unit 5INTRON A - interferon alfa-2b for inj 18000000 unit 5INTRON A - interferon alfa-2b for inj 50000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 10000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 18000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 50000000 unit 5INVIRASE - saquinavir mesylate cap 200 mg 5 QL (300 capsules/30 days)INVIRASE - saquinavir mesylate tab 500 mg 5 QL (120 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 25 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 100 mg 3 QL (180 tablets/30 days)

2016


47

Drug Name Drug Tier Requirements/LimitsISENTRESS - raltegravir potassium packet for susp 100 mg 4 QL (60 packets/30 days)ISENTRESS - raltegravir potassium tab 400 mg 5 QL (60 tablets/30 days)KALETRA - lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 5 QL (320 mls/30 days)KALETRA - lopinavir-ritonavir tab 100-25 mg 4 QL (300 tablets/30 days)KALETRA - lopinavir-ritonavir tab 200-50 mg 5 QL (120 tablets/30 days)lamivudine oral soln 10 mg/ml 2 QL (960 mls/30 days)lamivudine tab 100 mg (hbv) 2lamivudine tab 150 mg 2 QL (60 tablets/30 days)lamivudine tab 300 mg 2 QL (30 tablets/30 days)lamivudine-zidovudine tab 150-300 mg 5 QL (60 tablets/30 days)LEXIVA - fosamprenavir calcium susp 50 mg/ml 4 QL (1800 mls/30 days)LEXIVA - fosamprenavir calcium tab 700 mg 5 QL (120 tablets/30 days)NEVIRAPINE - nevirapine susp 50 mg/5ml 4 QL (1200 mls/30 days)nevirapine tab sr 24hr 100 mg 2 QL (120 tablets/30 days)nevirapine tab sr 24hr 400 mg 2 QL (30 tablets/30 days)nevirapine tab 200 mg 2 QL (60 tablets/30 days)NORVIR - ritonavir cap 100 mg 4 QL (360 capsules/30 days)NORVIR - ritonavir oral soln 80 mg/ml 4 QL (480 mls/30 days)NORVIR - ritonavir tab 100 mg 4 QL (360 tablets/30 days)ODEFSEY - emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg 5 QL (30 tablets/30 days)OLYSIO - simeprevir sodium cap 150 mg 5 PAPEG-INTRON - peginterferon alfa-2b for inj kit 50 mcg/0.5ml 5 PAPEG-INTRON - peginterferon alfa-2b for inj kit 80 mcg/0.5ml 5 PAPEG-INTRON - peginterferon alfa-2b for inj kit 120 mcg/0.5ml 5 PAPEG-INTRON - peginterferon alfa-2b for inj kit 150 mcg/0.5ml 5 PAPEG-INTRON REDIPEN - peginterferon alfa-2b for inj kit

50 mcg/0.5ml5 PA

PEG-INTRON REDIPEN - peginterferon alfa-2b for inj kit80 mcg/0.5ml

5 PA


5 PA


5 PA

PEG-INTRON REDIPEN PAK 4 - peginterferon alfa-2b for inj kit50 mcg/0.5ml

5 PA


5 PA


5 PA


5 PA

2016


Drug Name Drug Tier Requirements/LimitsPEGASYS - peginterferon alfa-2a inj 180 mcg/ml 5 PAPEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPEGASYS PROCLICK - peginterferon alfa-2a inj 135 mcg/0.5ml 5 PAPEGASYS PROCLICK - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPREZCOBIX - darunavir-cobicistat tab 800-150 mg 5 QL (30 tablets/30 days)PREZISTA - darunavir ethanolate susp 100 mg/ml 5 QL (400 mls/30 days)PREZISTA - darunavir ethanolate tab 75 mg 4 QL (300 tablets/30 days)PREZISTA - darunavir ethanolate tab 150 mg 4 QL (180 tablets/30 days)PREZISTA - darunavir ethanolate tab 600 mg 5 QL (60 tablets/30 days)PREZISTA - darunavir ethanolate tab 800 mg 5 QL (30 tablets/30 days)REBETOL - ribavirin soln 40 mg/ml 4RESCRIPTOR - delavirdine mesylate tab 100 mg 4 QL (360 tablets/30 days)RESCRIPTOR - delavirdine mesylate tab 200 mg 4 QL (180 tablets/30 days)RETROVIR IV INFUSION - zidovudine iv soln 10 mg/ml 4REYATAZ - atazanavir sulfate cap 150 mg 5 QL (30 capsules/30 days)REYATAZ - atazanavir sulfate cap 200 mg 5 QL (60 capsules/30 days)REYATAZ - atazanavir sulfate cap 300 mg 5 QL (30 capsules/30 days)REYATAZ - atazanavir sulfate oral powder packet 50 mg 5 QL (150 packets/30 days)RIBASPHERE - ribavirin tab 400 mg 4RIBASPHERE - ribavirin tab 600 mg 5RIBASPHERE RIBAPAK - ribavirin tab 400 mg 5RIBASPHERE RIBAPAK - ribavirin tab 600 mg 5ribavirin cap 200 mg 2ribavirin tab 200 mg 2rimantadine hydrochloride tab 100 mg 2SELZENTRY - maraviroc tab 150 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 300 mg 5 QL (120 tablets/30 days)SOVALDI - sofosbuvir tab 400 mg 5 PAstavudine cap 15 mg 2 QL (60 capsules/30 days)stavudine cap 20 mg 2 QL (60 capsules/30 days)stavudine cap 30 mg 2 QL (60 capsules/30 days)stavudine cap 40 mg 2 QL (60 capsules/30 days)stavudine for oral soln 1 mg/ml 2 QL (2400 mls/30 days)STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab

150-150-200-300 mg5 QL (30 tablets/30 days)

SUSTIVA - efavirenz cap 50 mg 4 QL (90 capsules/30 days)SUSTIVA - efavirenz cap 200 mg 5 QL (60 capsules/30 days)SUSTIVA - efavirenz tab 600 mg 5 QL (30 tablets/30 days)SYLATRON - peginterferon alfa-2b for inj kit 200 mcg 5 PA

2016


49

Drug Name Drug Tier Requirements/LimitsSYLATRON - peginterferon alfa-2b for inj kit 300 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 600 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 4 x 200 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 4 x 300 mcg 5 PATAMIFLU - oseltamivir phosphate cap 30 mg 4TAMIFLU - oseltamivir phosphate cap 45 mg 4TAMIFLU - oseltamivir phosphate cap 75 mg 4TAMIFLU - oseltamivir phosphate for susp 6 mg/ml 4TECHNIVIE - ombitasvir-paritaprevir-ritonavir tab 12.5-75-50 mg 5 PATIVICAY - dolutegravir sodium tab 10 mg 4 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 25 mg 5 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 50 mg 5 QL (60 tablets/30 days)TRIUMEQ - abacavir-dolutegravir-lamivudine tab 600-50-300 mg 5 QL (30 tablets/30 days)TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab


TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab133-200 mg

5 QL (30 tablets/30 days)





TYBOST - cobicistat tab 150 mg 3 QL (30 tablets/30 days)TYZEKA - telbivudine tab 600 mg 4valacyclovir hcl tab 500 mg 2valacyclovir hcl tab 1 gm 2VALCYTE - valganciclovir hcl for soln 50 mg/ml 5valganciclovir hcl for soln 50 mg/ml 5valganciclovir hcl tab 450 mg 5VIDEX - didanosine for soln 2 gm 4 QL (1200 mls/30 days)VIDEX - didanosine for soln 4 gm 4 QL (1200 mls/30 days)VIEKIRA PAK - ombitas-paritapre-riton & dasab tab pak 12.5-75-50

& 250 mg5 PA

VIEKIRA XR - dasab-ombit-paritap-riton tab sr 24hr200-8.33-50-33.33 mg

5 PA

VIRACEPT - nelfinavir mesylate tab 250 mg 5 QL (270 tablets/30 days)VIRACEPT - nelfinavir mesylate tab 625 mg 5 QL (120 tablets/30 days)VIRAMUNE - nevirapine susp 50 mg/5ml 4 QL (1200 mls/30 days)VIRAMUNE XR - nevirapine tab sr 24hr 100 mg 4 QL (120 tablets/30 days)VIRAZOLE - ribavirin for inhal soln 6 gm 5VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm 5 QL (240 grams/30 days)

2016


Drug Name Drug Tier Requirements/LimitsVIREAD - tenofovir disoproxil fumarate tab 150 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 200 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 250 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 300 mg 5 QL (30 tablets/30 days)VITEKTA - elvitegravir tab 85 mg 5 QL (30 tablets/30 days)VITEKTA - elvitegravir tab 150 mg 5 QL (30 tablets/30 days)ZEPATIER - elbasvir-grazoprevir tab 50-100 mg 5 PAZIAGEN - abacavir sulfate soln 20 mg/ml 4 QL (960 mls/30 days)zidovudine cap 100 mg 2 QL (180 capsules/30 days)zidovudine syrup 10 mg/ml 2 QL (1920 mls/30 days)zidovudine tab 300 mg 2 QL (60 tablets/30 days)Anxiolyticsbuspirone hcl tab 5 mg 2buspirone hcl tab 7.5 mg 2buspirone hcl tab 10 mg 2buspirone hcl tab 15 mg 2buspirone hcl tab 30 mg 2clonazepam orally disintegrating tab 0.125 mg 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.5 mg 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 1 mg 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg 2 PA, QL (300 tablets/30 days)clonazepam tab 0.5 mg 2 PA, QL (90 tablets/30 days)clonazepam tab 1 mg 2 PA, QL (90 tablets/30 days)clonazepam tab 2 mg 2 PA, QL (300 tablets/30 days)clorazepate dipotassium tab 3.75 mg 2 PA, QL (90 tablets/30 days)clorazepate dipotassium tab 7.5 mg 2 PA, QL (90 tablets/30 days)clorazepate dipotassium tab 15 mg 2 PA, QL (180 tablets/30 days)DIAZEPAM - diazepam oral soln 1 mg/ml 4 PA, QL (1200 mls/30 days)diazepam conc 5 mg/ml 2 PA, QL (240 mls/30 days)diazepam tab 2 mg 2 PA, QL (120 tablets/30 days)diazepam tab 5 mg 2 PA, QL (120 tablets/30 days)diazepam tab 10 mg 2 PA, QL (120 tablets/30 days)DOXEPIN HCL - doxepin hcl cap 75 mg# 4 PAdoxepin hcl cap 10 mg# 4 PAdoxepin hcl cap 25 mg# 4 PAdoxepin hcl cap 50 mg# 4 PAdoxepin hcl cap 100 mg# 4 PA

2016


51

Drug Name Drug Tier Requirements/Limitsdoxepin hcl cap 150 mg# 4 PAdoxepin hcl conc 10 mg/ml# 4 PAduloxetine hcl enteric coated pellets cap 20 mg 2 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg 2 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 60 mg 2 QL (60 capsules/30 days)escitalopram oxalate soln 5 mg/5ml 2 QL (600 mls/30 days)escitalopram oxalate tab 5 mg 1 QL (30 tablets/30 days)escitalopram oxalate tab 10 mg 1 QL (30 tablets/30 days)escitalopram oxalate tab 20 mg 1 QL (30 tablets/30 days)hydroxyzine hcl syrup 10 mg/5ml# 4 PAhydroxyzine hcl tab 10 mg# 4 PAhydroxyzine hcl tab 25 mg# 4 PAhydroxyzine hcl tab 50 mg# 4 PAlorazepam tab 0.5 mg 2 PA, QL (90 tablets/30 days)lorazepam tab 1 mg 2 PA, QL (90 tablets/30 days)lorazepam tab 2 mg 2 PA, QL (150 tablets/30 days)paroxetine hcl tab sr 24hr 12.5 mg 2 QL (30 tablets/30 days)paroxetine hcl tab sr 24hr 25 mg 2 QL (60 tablets/30 days)paroxetine hcl tab sr 24hr 37.5 mg 2 QL (60 tablets/30 days)paroxetine hcl tab 10 mg 2 QL (30 tablets/30 days)paroxetine hcl tab 20 mg 2 QL (30 tablets/30 days)paroxetine hcl tab 30 mg 2 QL (60 tablets/30 days)paroxetine hcl tab 40 mg 2 QL (30 tablets/30 days)PAXIL - paroxetine hcl oral susp 10 mg/5ml 4 QL (900 mls/30 days)sertraline hcl oral conc 20 mg/ml 2 QL (300 mls/30 days)sertraline hcl tab 25 mg 1 QL (30 tablets/30 days)sertraline hcl tab 50 mg 1 QL (30 tablets/30 days)sertraline hcl tab 100 mg 1 QL (60 tablets/30 days)venlafaxine hcl cap sr 24hr 37.5 mg 2 QL (30 capsules/30 days)venlafaxine hcl cap sr 24hr 75 mg 2 QL (90 capsules/30 days)venlafaxine hcl cap sr 24hr 150 mg 2 QL (30 capsules/30 days)venlafaxine hcl tab sr 24hr 37.5 mg 2 QL (30 tablets/30 days)venlafaxine hcl tab sr 24hr 75 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab sr 24hr 150 mg 2 QL (30 tablets/30 days)venlafaxine hcl tab 25 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 37.5 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 50 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 75 mg 2 QL (90 tablets/30 days)

2016


Drug Name Drug Tier Requirements/Limitsvenlafaxine hcl tab 100 mg 2 QL (90 tablets/30 days)Bipolar AgentsABILIFY MAINTENA - aripiprazole im for extended release susp




or vial/30 days)aripiprazole oral solution 1 mg/ml 5 PA, QL (750 mls/30 days)aripiprazole orally disintegrating tab 10 mg 5 PA, QL (60 tablets/30 days)aripiprazole orally disintegrating tab 15 mg 5 PA, QL (60 tablets/30 days)aripiprazole tab 2 mg 5 PA, QL (30 tablets/30 days)aripiprazole tab 5 mg 5 PA, QL (30 tablets/30 days)aripiprazole tab 10 mg 5 PA, QL (30 tablets/30 days)aripiprazole tab 15 mg 5 PA, QL (30 tablets/30 days)aripiprazole tab 20 mg 5 PA, QL (30 tablets/30 days)aripiprazole tab 30 mg 5 PA, QL (30 tablets/30 days)divalproex sodium cap delayed release sprinkle 125 mg 2divalproex sodium tab delayed release 125 mg 2divalproex sodium tab delayed release 250 mg 2divalproex sodium tab delayed release 500 mg 2divalproex sodium tab sr 24 hr 250 mg 2divalproex sodium tab sr 24 hr 500 mg 2EQUETRO - carbamazepine cap sr 12hr 100 mg 4EQUETRO - carbamazepine cap sr 12hr 200 mg 4EQUETRO - carbamazepine cap sr 12hr 300 mg 4lamotrigine orally disintegrating tab 25 mg 2lamotrigine orally disintegrating tab 50 mg 2lamotrigine orally disintegrating tab 100 mg 2lamotrigine orally disintegrating tab 200 mg 2lamotrigine tab chewable dispersible 5 mg 2lamotrigine tab chewable dispersible 25 mg 2lamotrigine tab 25 mg 2lamotrigine tab 100 mg 2lamotrigine tab 150 mg 2lamotrigine tab 200 mg 2LITHIUM - lithium oral solution 8 meq/5ml 4lithium carbonate cap 150 mg 2lithium carbonate cap 300 mg 2lithium carbonate cap 600 mg 2lithium carbonate tab cr 300 mg 2

2016


53

Drug Name Drug Tier Requirements/Limitslithium carbonate tab cr 450 mg 2lithium carbonate tab 300 mg 2olanzapine for im inj 10 mg 2 PA, QL (90 vials/30 days)olanzapine orally disintegrating tab 5 mg 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 10 mg 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 15 mg 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 20 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 2.5 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 5 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 7.5 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 10 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 15 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 20 mg 2 PA, QL (30 tablets/30 days)quetiapine fumarate tab 25 mg 2 PA, QL (90 tablets/30 days)quetiapine fumarate tab 50 mg 2 PA, QL (90 tablets/30 days)quetiapine fumarate tab 100 mg 2 PA, QL (90 tablets/30 days)quetiapine fumarate tab 200 mg 2 PA, QL (90 tablets/30 days)quetiapine fumarate tab 300 mg 2 PA, QL (60 tablets/30 days)quetiapine fumarate tab 400 mg 2 PA, QL (60 tablets/30 days)RISPERDAL CONSTA - risperidone microspheres for inj 12.5 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 25 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 37.5 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 50 mg 5 PA, QL (2 vials/28 days)risperidone orally disintegrating tab 0.25 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 0.5 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 1 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 2 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 3 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 4 mg 2 PA, QL (120 tablets/30 days)risperidone soln 1 mg/ml 2 PA, QL (480 mls/30 days)risperidone tab 0.25 mg 2 PA, QL (60 tablets/30 days)risperidone tab 0.5 mg 2 PA, QL (60 tablets/30 days)risperidone tab 1 mg 2 PA, QL (60 tablets/30 days)risperidone tab 2 mg 2 PA, QL (60 tablets/30 days)risperidone tab 3 mg 2 PA, QL (60 tablets/30 days)risperidone tab 4 mg 2 PA, QL (120 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab sr 24hr 50 mg 3 PA, QL (60 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab sr 24hr 150 mg 3 PA, QL (30 tablets/30 days)

2016


Drug Name Drug Tier Requirements/LimitsSEROQUEL XR - quetiapine fumarate tab sr 24hr 200 mg 3 PA, QL (30 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab sr 24hr 300 mg 3 PA, QL (60 tablets/30 days)SEROQUEL XR - quetiapine fumarate tab sr 24hr 400 mg 3 PA, QL (60 tablets/30 days)valproic acid cap 250 mg 2VRAYLAR - cariprazine hcl cap therapy pack 1.5 mg (1) & 3 mg (6) 4 PA, QL (28 capsules/28 days)VRAYLAR - cariprazine hcl cap 1.5 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 3 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 4.5 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 6 mg 5 PA, QL (30 capsules/30 days)ziprasidone hcl cap 20 mg 2 PA, QL (60 capsules/30 days)ziprasidone hcl cap 40 mg 2 PA, QL (60 capsules/30 days)ziprasidone hcl cap 60 mg 2 PA, QL (60 capsules/30 days)ziprasidone hcl cap 80 mg 2 PA, QL (60 capsules/30 days)Blood Glucose Regulatorsacarbose tab 25 mg 2 QL (360 tablets/30 days)acarbose tab 50 mg 2 QL (180 tablets/30 days)acarbose tab 100 mg 2 QL (90 tablets/30 days)ALCOHOL SWABS 3BYDUREON - exenatide for inj extended release susp 2 mg 3 QL (4 vials/28 days)BYDUREON PEN - exenatide extended release for susp pen-

injector 2 mg3 QL (4 vials/28 days)

CYCLOSET - bromocriptine mesylate tab 0.8 mg 4 QL (180 tablets/30 days)GAUZE PADS 2" X 2" 3glimepiride tab 1 mg 1 QL (240 tablets/30 days)glimepiride tab 2 mg 1 QL (120 tablets/30 days)glimepiride tab 4 mg 1 QL (60 tablets/30 days)glipizide tab sr 24hr 2.5 mg 1 QL (240 tablets/30 days)glipizide tab sr 24hr 5 mg 1 QL (120 tablets/30 days)glipizide tab sr 24hr 10 mg 1 QL (60 tablets/30 days)glipizide tab 5 mg 1 QL (240 tablets/30 days)glipizide tab 10 mg 1 QL (120 tablets/30 days)glipizide-metformin hcl tab 2.5-250 mg 2 QL (240 tablets/30 days)glipizide-metformin hcl tab 2.5-500 mg 2 QL (120 tablets/30 days)glipizide-metformin hcl tab 5-500 mg 2 QL (120 tablets/30 days)GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg 3GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit 1 mg 3HUMALOG - insulin lispro inj 100 unit/ml 2HUMALOG - insulin lispro soln cartridge 100 unit/ml 2HUMALOG KWIKPEN - insulin lispro soln pen-injector 100 unit/ml 2

2016


55

Drug Name Drug Tier Requirements/LimitsHUMALOG KWIKPEN - insulin lispro soln pen-injector 200 unit/ml 2HUMALOG MIX 50/50 - insulin lispro protamine & lispro inj 100

unit/ml (50-50)2

HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot & lispro suspen-inj 100 unit/ml (50-50)

2

HUMALOG MIX 75/25 - insulin lispro prot & lispro inj 100 unit/ml(75-25)

2

HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot & lispro suspen-inj 100 unit/ml (75-25)

2

HUMULIN N - insulin nph (human) (isophane) inj 100 unit/ml 2HUMULIN N KWIKPEN - insulin nph (human) (isophane) susp pen-

injector 100 unit/ml2

HUMULIN R - insulin regular (human) inj 100 unit/ml 2HUMULIN R U-500 (CONCENTRATE) - insulin regular (human) inj

500 unit/ml2

HUMULIN R U-500 KWIKPEN - insulin regular (human) soln pen-injector 500 unit/ml

2

HUMULIN 70/30 - insulin nph isophane & regular human inj 100unit/ml (70-30)

2

HUMULIN 70/30 KWIKPEN - insulin nph & regular susp pen-inj 100unit/ml (70-30)

2

INSULIN INJECTION DEVICE 3INSULIN SYRINGE/NEEDLE 3INVOKAMET - canagliflozin-metformin hcl tab 50-500 mg 3 QL (120 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-500 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-1000 mg 3 QL (60 tablets/30 days)INVOKANA - canagliflozin tab 100 mg 3 QL (90 tablets/30 days)INVOKANA - canagliflozin tab 300 mg 3 QL (30 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-500 mg 3 QL (60 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab sr 24hr 50-500 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab sr 24hr 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab sr 24hr 100-1000 mg 3 QL (30 tablets/30 days)JANUVIA - sitagliptin phosphate tab 25 mg 3 QL (120 tablets/30 days)JANUVIA - sitagliptin phosphate tab 50 mg 3 QL (60 tablets/30 days)JANUVIA - sitagliptin phosphate tab 100 mg 3 QL (30 tablets/30 days)JARDIANCE - empagliflozin tab 10 mg 4 QL (60 tablets/30 days)JARDIANCE - empagliflozin tab 25 mg 4 QL (30 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-500 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-850 mg 4 QL (60 tablets/30 days)

2016


Drug Name Drug Tier Requirements/LimitsJENTADUETO - linagliptin-metformin hcl tab 2.5-1000 mg 4 QL (60 tablets/30 days)JENTADUETO XR - linagliptin-metformin hcl tab sr 24hr

2.5-1000 mg4 QL (60 tablets/30 days)

JENTADUETO XR - linagliptin-metformin hcl tab sr 24hr 5-1000 mg 4 QL (30 tablets/30 days)KOMBIGLYZE XR - saxagliptin-metformin hcl tab sr 24hr

2.5-1000 mg3 QL (60 tablets/30 days)

KOMBIGLYZE XR - saxagliptin-metformin hcl tab sr 24hr 5-500 mg 3 QL (30 tablets/30 days)KOMBIGLYZE XR - saxagliptin-metformin hcl tab sr 24hr


LANTUS - insulin glargine inj 100 unit/ml 2LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/ml 2LEVEMIR - insulin detemir inj 100 unit/ml 2LEVEMIR FLEXPEN - insulin detemir soln pen-injector 100 unit/ml 2LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector 100 unit/

ml2

metformin hcl tab sr 24hr 500 mg 1 QL (120 tablets/30 days)metformin hcl tab sr 24hr 750 mg 1 QL (60 tablets/30 days)metformin hcl tab 500 mg 1 QL (150 tablets/30 days)metformin hcl tab 850 mg 1 QL (90 tablets/30 days)metformin hcl tab 1000 mg 1 QL (75 tablets/30 days)nateglinide tab 60 mg 2 QL (180 tablets/30 days)nateglinide tab 120 mg 2 QL (90 tablets/30 days)ONGLYZA - saxagliptin hcl tab 2.5 mg 3 QL (60 tablets/30 days)ONGLYZA - saxagliptin hcl tab 5 mg 3 QL (30 tablets/30 days)pioglitazone hcl tab 15 mg 1 QL (90 tablets/30 days)pioglitazone hcl tab 30 mg 1 QL (30 tablets/30 days)pioglitazone hcl tab 45 mg 1 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-2 mg 2 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-4 mg 2 QL (30 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-500 mg 2 QL (90 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-850 mg 2 QL (90 tablets/30 days)PROGLYCEM - diazoxide susp 50 mg/ml 4repaglinide tab 0.5 mg 2 QL (960 tablets/30 days)repaglinide tab 1 mg 2 QL (480 tablets/30 days)repaglinide tab 2 mg 2 QL (240 tablets/30 days)SYMLINPEN 120 - pramlintide acetate pen-inj 2700 mcg/2.7ml

(1000 mcg/ml)3

SYMLINPEN 60 - pramlintide acetate pen-inj 1500 mcg/1.5ml(1000 mcg/ml)

3

SYNJARDY - empagliflozin-metformin hcl tab 5-500 mg 4 QL (120 tablets/30 days)

2016


57

Drug Name Drug Tier Requirements/LimitsSYNJARDY - empagliflozin-metformin hcl tab 5-1000 mg 4 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-500 mg 4 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-1000 mg 4 QL (60 tablets/30 days)TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/

ml2

TRADJENTA - linagliptin tab 5 mg 4 QL (30 tablets/30 days)VICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 3 QL (1 package/30 days)WELCHOL - colesevelam hcl packet for susp 3.75 gm 4WELCHOL - colesevelam hcl tab 625 mg 4Blood Products/Modifiers/Volume ExpandersAGGRENOX - aspirin-dipyridamole cap sr 12hr 25-200 mg 4anagrelide hcl cap 0.5 mg 2anagrelide hcl cap 1 mg 2ARANESP ALBUMIN FREE - darbepoetin alfa soln inj 25 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 40 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 60 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 100 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 200 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 300 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe

10 mcg/0.4ml4 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe25 mcg/0.42ml

4 PA


4 PA


4 PA


5 PA


5 PA


5 PA


5 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe500 mcg/ml

5 PA

BRILINTA - ticagrelor tab 60 mg 3BRILINTA - ticagrelor tab 90 mg 3cilostazol tab 50 mg 1cilostazol tab 100 mg 1

2016


Drug Name Drug Tier Requirements/Limitsclopidogrel bisulfate tab 75 mg 2COUMADIN - warfarin sodium tab 1 mg 4COUMADIN - warfarin sodium tab 2 mg 4COUMADIN - warfarin sodium tab 2.5 mg 4COUMADIN - warfarin sodium tab 3 mg 4COUMADIN - warfarin sodium tab 4 mg 4COUMADIN - warfarin sodium tab 5 mg 4COUMADIN - warfarin sodium tab 6 mg 4COUMADIN - warfarin sodium tab 7.5 mg 4COUMADIN - warfarin sodium tab 10 mg 4dipyridamole tab 25 mg# 4dipyridamole tab 50 mg# 4dipyridamole tab 75 mg# 4EFFIENT - prasugrel hcl tab 5 mg 3EFFIENT - prasugrel hcl tab 10 mg 3ELIQUIS - apixaban tab 2.5 mg 3 QL (60 tablets/30 days)ELIQUIS - apixaban tab 5 mg 3 QL (120 tablets/30 days)enoxaparin sodium inj 30 mg/0.3ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 40 mg/0.4ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 60 mg/0.6ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 80 mg/0.8ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 100 mg/ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 120 mg/0.8ml 5 QL (30 syringes/90 days)enoxaparin sodium inj 150 mg/ml 5 QL (30 syringes/90 days)enoxaparin sodium inj 300 mg/3ml 2 QL (10 vials/90 days)EPOGEN - epoetin alfa inj 2000 unit/ml 4 PAEPOGEN - epoetin alfa inj 3000 unit/ml 4 PAEPOGEN - epoetin alfa inj 4000 unit/ml 4 PAEPOGEN - epoetin alfa inj 10000 unit/ml 4 PAEPOGEN - epoetin alfa inj 20000 unit/ml 4 PAfondaparinux sodium subcutaneous inj 2.5 mg/0.5ml 2 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 5 mg/0.4ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 10 mg/0.8ml 5 QL (30 syringes/90 days)GRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml 5GRANIX - tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml 5heparin sodium (porcine) inj 1000 unit/ml 2heparin sodium (porcine) inj 5000 unit/ml 2

2016


59

Drug Name Drug Tier Requirements/Limitsheparin sodium (porcine) inj 10000 unit/ml 2heparin sodium (porcine) inj 20000 unit/ml 2heparin sodium (porcine) pf inj 5000 unit/0.5ml 2heparin sodium (porcine) 40 unit/ml in d5w 2LEUKINE - sargramostim lyophilized for inj 250 mcg 5MOZOBIL - plerixafor subcutaneous inj 24 mg/1.2ml (20 mg/ml) 5NEULASTA - pegfilgrastim soln prefilled syringe 6 mg/0.6ml 5NEULASTA ONPRO KIT - pegfilgrastim soln prefilled syringe kit

6 mg/0.6ml5

PRADAXA - dabigatran etexilate mesylate cap 75 mg 4 QL (60 capsules/30 days)PRADAXA - dabigatran etexilate mesylate cap 110 mg 4 QL (71 capsules/90 days)PRADAXA - dabigatran etexilate mesylate cap 150 mg 4 QL (60 capsules/30 days)PROCRIT - epoetin alfa inj 2000 unit/ml 4 PAPROCRIT - epoetin alfa inj 3000 unit/ml 4 PAPROCRIT - epoetin alfa inj 4000 unit/ml 4 PAPROCRIT - epoetin alfa inj 10000 unit/ml 4 PAPROCRIT - epoetin alfa inj 20000 unit/ml 5 PAPROCRIT - epoetin alfa inj 40000 unit/ml 5 PAPROMACTA - eltrombopag olamine tab 12.5 mg* 5 PAPROMACTA - eltrombopag olamine tab 25 mg* 5 PAPROMACTA - eltrombopag olamine tab 50 mg* 5 PAPROMACTA - eltrombopag olamine tab 75 mg* 5 PAtranexamic acid iv soln 1000 mg/10ml (100 mg/ml) 2tranexamic acid tab 650 mg 2warfarin sodium tab 1 mg 2warfarin sodium tab 2 mg 2warfarin sodium tab 2.5 mg 2warfarin sodium tab 3 mg 2warfarin sodium tab 4 mg 2warfarin sodium tab 5 mg 2warfarin sodium tab 6 mg 2warfarin sodium tab 7.5 mg 2warfarin sodium tab 10 mg 2XARELTO - rivaroxaban tab 10 mg 3 QL (35 tablets/90 days)XARELTO - rivaroxaban tab 15 mg 3 QL (60 tablets/30 days)XARELTO - rivaroxaban tab 20 mg 3 QL (30 tablets/30 days)XARELTO STARTER PACK - rivaroxaban tab starter therapy pack

15 mg & 20 mg3 QL (51 tablets/30 days)

ZONTIVITY - vorapaxar sulfate tab 2.08 mg 4

2016


Drug Name Drug Tier Requirements/LimitsCardiovascular Agentsacebutolol hcl cap 200 mg 2acebutolol hcl cap 400 mg 2ACETAZOLAMIDE - acetazolamide tab 125 mg 4acetazolamide cap sr 12hr 500 mg 2acetazolamide tab 250 mg 2amiloride & hydrochlorothiazide tab 5-50 mg 2amiloride hcl tab 5 mg 2amiodarone hcl tab 200 mg 2amiodarone hcl tab 400 mg 2amlodipine besylate tab 2.5 mg 1amlodipine besylate tab 5 mg 1amlodipine besylate tab 10 mg 1amlodipine besylate-atorvastatin calcium tab 2.5-10 mg 2amlodipine besylate-atorvastatin calcium tab 2.5-20 mg 2amlodipine besylate-atorvastatin calcium tab 2.5-40 mg 2amlodipine besylate-atorvastatin calcium tab 5-10 mg 2amlodipine besylate-atorvastatin calcium tab 5-20 mg 2amlodipine besylate-atorvastatin calcium tab 5-40 mg 2amlodipine besylate-atorvastatin calcium tab 5-80 mg 2amlodipine besylate-atorvastatin calcium tab 10-10 mg 2amlodipine besylate-atorvastatin calcium tab 10-20 mg 2amlodipine besylate-atorvastatin calcium tab 10-40 mg 2amlodipine besylate-atorvastatin calcium tab 10-80 mg 2amlodipine besylate-benazepril hcl cap 2.5-10 mg 2amlodipine besylate-benazepril hcl cap 5-10 mg 2amlodipine besylate-benazepril hcl cap 5-20 mg 2amlodipine besylate-benazepril hcl cap 5-40 mg 2amlodipine besylate-benazepril hcl cap 10-20 mg 2amlodipine besylate-benazepril hcl cap 10-40 mg 2amlodipine besylate-valsartan tab 5-160 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 5-320 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-160 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-320 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg 2 QL (30 tablets/30 days)

2016


61

Drug Name Drug Tier Requirements/Limitsamlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg 2 QL (30 tablets/30 days)atenolol & chlorthalidone tab 50-25 mg 2atenolol & chlorthalidone tab 100-25 mg 2atenolol tab 25 mg 1atenolol tab 50 mg 1atenolol tab 100 mg 1atorvastatin calcium tab 10 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 20 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 40 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 80 mg 1 QL (30 tablets/30 days)benazepril & hydrochlorothiazide tab 5-6.25 mg 2benazepril & hydrochlorothiazide tab 10-12.5 mg 2benazepril & hydrochlorothiazide tab 20-12.5 mg 2benazepril & hydrochlorothiazide tab 20-25 mg 2benazepril hcl tab 5 mg 1benazepril hcl tab 10 mg 1benazepril hcl tab 20 mg 1benazepril hcl tab 40 mg 1betaxolol hcl tab 10 mg 2betaxolol hcl tab 20 mg 2bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg 2bisoprolol & hydrochlorothiazide tab 5-6.25 mg 2bisoprolol & hydrochlorothiazide tab 10-6.25 mg 2bisoprolol fumarate tab 5 mg 2bisoprolol fumarate tab 10 mg 2bumetanide inj 0.25 mg/ml 2bumetanide tab 0.5 mg 2bumetanide tab 1 mg 2bumetanide tab 2 mg 2candesartan cilexetil tab 4 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 8 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 16 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 32 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-25 mg 2 QL (30 tablets/30 days)captopril tab 12.5 mg 2captopril tab 25 mg 2

2016


Drug Name Drug Tier Requirements/Limitscaptopril tab 50 mg 2captopril tab 100 mg 2carvedilol tab 3.125 mg 1carvedilol tab 6.25 mg 1carvedilol tab 12.5 mg 1carvedilol tab 25 mg 1CHLOROTHIAZIDE - chlorothiazide tab 250 mg 4chlorothiazide tab 500 mg 2CHLORTHALIDONE - chlorthalidone tab 50 mg 4chlorthalidone tab 25 mg 2cholestyramine light powder packets 4 gm 2cholestyramine light powder 4 gm/dose 2cholestyramine powder packets 4 gm 2cholestyramine powder 4 gm/dose 2choline fenofibrate cap dr 45 mg 2 QL (60 capsules/30 days)choline fenofibrate cap dr 135 mg 2 QL (30 capsules/30 days)clonidine hcl tab 0.1 mg 2clonidine hcl tab 0.2 mg 2clonidine hcl tab 0.3 mg 2clonidine hcl td patch weekly 0.1 mg/24hr 2clonidine hcl td patch weekly 0.2 mg/24hr 2clonidine hcl td patch weekly 0.3 mg/24hr 2colestipol hcl granule packets 5 gm 2colestipol hcl granules 5 gm 2colestipol hcl tab 1 gm 2CORLANOR - ivabradine hcl tab 5 mg 3 PA, QL (60 tablets/30 days)CORLANOR - ivabradine hcl tab 7.5 mg 3 PA, QL (60 tablets/30 days)CRESTOR - rosuvastatin calcium tab 5 mg 3 QL (45 tablets/30 days)CRESTOR - rosuvastatin calcium tab 10 mg 3 QL (45 tablets/30 days)CRESTOR - rosuvastatin calcium tab 20 mg 3 QL (45 tablets/30 days)CRESTOR - rosuvastatin calcium tab 40 mg 3 QL (30 tablets/30 days)DEMSER - metyrosine cap 250 mg 5DIGOXIN - digoxin oral soln 0.05 mg/ml# 4 QL (150 mls/30 days)digoxin tab 125 mcg (0.125 mg)# 2 QL (30 tablets/30 days)digoxin tab 250 mcg (0.25 mg)# 4 PA, QL (30 tablets/30 days)diltiazem hcl cap sr 12hr 60 mg 2diltiazem hcl cap sr 12hr 90 mg 2diltiazem hcl cap sr 12hr 120 mg 2

2016


63

Drug Name Drug Tier Requirements/Limitsdiltiazem hcl cap sr 24hr 120 mg 2diltiazem hcl cap sr 24hr 180 mg 2diltiazem hcl cap sr 24hr 240 mg 2diltiazem hcl coated beads cap sr 24hr 120 mg 2diltiazem hcl coated beads cap sr 24hr 180 mg 2diltiazem hcl coated beads cap sr 24hr 240 mg 2diltiazem hcl coated beads cap sr 24hr 300 mg 2diltiazem hcl coated beads cap sr 24hr 360 mg 2diltiazem hcl coated beads tab sr 24hr 180 mg 2diltiazem hcl coated beads tab sr 24hr 240 mg 2diltiazem hcl coated beads tab sr 24hr 300 mg 2diltiazem hcl coated beads tab sr 24hr 360 mg 2diltiazem hcl coated beads tab sr 24hr 420 mg 2diltiazem hcl extended release beads cap sr 24hr 120 mg 2diltiazem hcl extended release beads cap sr 24hr 180 mg 2diltiazem hcl extended release beads cap sr 24hr 240 mg 2diltiazem hcl extended release beads cap sr 24hr 300 mg 2diltiazem hcl extended release beads cap sr 24hr 360 mg 2diltiazem hcl extended release beads cap sr 24hr 420 mg 2diltiazem hcl tab 30 mg 2diltiazem hcl tab 60 mg 2diltiazem hcl tab 90 mg 2diltiazem hcl tab 120 mg 2dofetilide cap 125 mcg (0.125 mg) 2dofetilide cap 250 mcg (0.25 mg) 2dofetilide cap 500 mcg (0.5 mg) 2doxazosin mesylate tab 1 mg 2 QL (30 tablets/30 days)doxazosin mesylate tab 2 mg 2 QL (30 tablets/30 days)doxazosin mesylate tab 4 mg 2 QL (30 tablets/30 days)doxazosin mesylate tab 8 mg 2 QL (60 tablets/30 days)enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1enalapril maleate & hydrochlorothiazide tab 10-25 mg 1enalapril maleate tab 2.5 mg 1enalapril maleate tab 5 mg 1enalapril maleate tab 10 mg 1enalapril maleate tab 20 mg 1eplerenone tab 25 mg 2eplerenone tab 50 mg 2

2016


Drug Name Drug Tier Requirements/Limitseprosartan mesylate tab 600 mg 2 QL (30 tablets/30 days)felodipine tab sr 24hr 2.5 mg 2felodipine tab sr 24hr 5 mg 2felodipine tab sr 24hr 10 mg 2fenofibrate micronized cap 67 mg 2 QL (30 capsules/30 days)fenofibrate micronized cap 134 mg 2 QL (30 capsules/30 days)fenofibrate micronized cap 200 mg 2 QL (30 capsules/30 days)fenofibrate tab 48 mg 2 QL (60 tablets/30 days)fenofibrate tab 54 mg 2 QL (60 tablets/30 days)fenofibrate tab 145 mg 2 QL (30 tablets/30 days)fenofibrate tab 160 mg 2 QL (30 tablets/30 days)flecainide acetate tab 50 mg 2flecainide acetate tab 100 mg 2flecainide acetate tab 150 mg 2fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg 2fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg 2fosinopril sodium tab 10 mg 1fosinopril sodium tab 20 mg 1fosinopril sodium tab 40 mg 1furosemide inj 10 mg/ml 2furosemide oral soln 10 mg/ml 2furosemide tab 20 mg 2furosemide tab 40 mg 2furosemide tab 80 mg 2gemfibrozil tab 600 mg 2 QL (60 tablets/30 days)hydralazine hcl tab 10 mg 2hydralazine hcl tab 25 mg 2hydralazine hcl tab 50 mg 2hydralazine hcl tab 100 mg 2hydrochlorothiazide cap 12.5 mg 2hydrochlorothiazide tab 12.5 mg 2hydrochlorothiazide tab 25 mg 2hydrochlorothiazide tab 50 mg 2indapamide tab 1.25 mg 2indapamide tab 2.5 mg 2irbesartan tab 75 mg 1 QL (30 tablets/30 days)irbesartan tab 150 mg 1 QL (30 tablets/30 days)irbesartan tab 300 mg 1 QL (30 tablets/30 days)

2016


65

Drug Name Drug Tier Requirements/Limitsirbesartan-hydrochlorothiazide tab 150-12.5 mg 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 300-12.5 mg 1 QL (30 tablets/30 days)isosorbide dinitrate tab cr 40 mg 2isosorbide dinitrate tab 5 mg 2isosorbide dinitrate tab 10 mg 2isosorbide dinitrate tab 20 mg 2isosorbide dinitrate tab 30 mg 2isosorbide mononitrate tab sr 24hr 30 mg 2isosorbide mononitrate tab sr 24hr 60 mg 2isosorbide mononitrate tab sr 24hr 120 mg 2isosorbide mononitrate tab 10 mg 2isosorbide mononitrate tab 20 mg 2isradipine cap 2.5 mg 2isradipine cap 5 mg 2JUXTAPID - lomitapide mesylate cap 5 mg* 5 PAJUXTAPID - lomitapide mesylate cap 10 mg* 5 PAJUXTAPID - lomitapide mesylate cap 20 mg* 5 PAJUXTAPID - lomitapide mesylate cap 30 mg* 5 PAJUXTAPID - lomitapide mesylate cap 40 mg* 5 PAJUXTAPID - lomitapide mesylate cap 60 mg* 5 PAKYNAMRO - mipomersen sodium soln prefilled syringe 200 mg/ml* 5 PAlabetalol hcl tab 100 mg 2labetalol hcl tab 200 mg 2labetalol hcl tab 300 mg 2LIDOCAINE HCL - lidocaine hcl iv inj 10 mg/ml 4lisinopril & hydrochlorothiazide tab 10-12.5 mg 1lisinopril & hydrochlorothiazide tab 20-12.5 mg 1lisinopril & hydrochlorothiazide tab 20-25 mg 1lisinopril tab 2.5 mg 1lisinopril tab 5 mg 1lisinopril tab 10 mg 1lisinopril tab 20 mg 1lisinopril tab 30 mg 1lisinopril tab 40 mg 1LIVALO - pitavastatin calcium tab 1 mg 4 QL (45 tablets/30 days)LIVALO - pitavastatin calcium tab 2 mg 4 QL (45 tablets/30 days)LIVALO - pitavastatin calcium tab 4 mg 4 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 50-12.5 mg 1 QL (30 tablets/30 days)

2016


Drug Name Drug Tier Requirements/Limitslosartan potassium & hydrochlorothiazide tab 100-12.5 mg 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-25 mg 1 QL (30 tablets/30 days)losartan potassium tab 25 mg 1 QL (60 tablets/30 days)losartan potassium tab 50 mg 1 QL (60 tablets/30 days)losartan potassium tab 100 mg 1 QL (30 tablets/30 days)lovastatin tab 10 mg 1 QL (60 tablets/30 days)lovastatin tab 20 mg 1 QL (60 tablets/30 days)lovastatin tab 40 mg 1 QL (60 tablets/30 days)methazolamide tab 25 mg 2methazolamide tab 50 mg 2metolazone tab 2.5 mg 2metolazone tab 5 mg 2metolazone tab 10 mg 2metoprolol & hydrochlorothiazide tab 50-25 mg 2metoprolol & hydrochlorothiazide tab 100-25 mg 2metoprolol succinate tab sr 24hr 25 mg 2metoprolol succinate tab sr 24hr 50 mg 2metoprolol succinate tab sr 24hr 100 mg 2metoprolol succinate tab sr 24hr 200 mg 2metoprolol tartrate tab 25 mg 1metoprolol tartrate tab 50 mg 1metoprolol tartrate tab 100 mg 1mexiletine hcl cap 150 mg 2mexiletine hcl cap 200 mg 2mexiletine hcl cap 250 mg 2midodrine hcl tab 2.5 mg 2midodrine hcl tab 5 mg 2midodrine hcl tab 10 mg 2minoxidil tab 2.5 mg 2minoxidil tab 10 mg 2moexipril hcl tab 7.5 mg 2moexipril hcl tab 15 mg 2moexipril-hydrochlorothiazide tab 7.5-12.5 mg 2moexipril-hydrochlorothiazide tab 15-12.5 mg 2moexipril-hydrochlorothiazide tab 15-25 mg 2MULTAQ - dronedarone hcl tab 400 mg 3nadolol tab 20 mg 2nadolol tab 40 mg 2

2016


67

Drug Name Drug Tier Requirements/Limitsnadolol tab 80 mg 2niacin tab cr 500 mg 2 QL (30 tablets/30 days)niacin tab cr 750 mg 2 QL (60 tablets/30 days)niacin tab cr 1000 mg 2 QL (60 tablets/30 days)nicardipine hcl cap 20 mg 2nicardipine hcl cap 30 mg 2nifedipine tab sr 24hr 30 mg 2nifedipine tab sr 24hr 60 mg 2nifedipine tab sr 24hr 90 mg 2nifedipine tab sr 24hr osmotic release 30 mg 2nifedipine tab sr 24hr osmotic release 60 mg 2nifedipine tab sr 24hr osmotic release 90 mg 2NISOLDIPINE ER - nisoldipine tab sr 24hr 25.5 mg 4nisoldipine tab sr 24hr 8.5 mg 2nisoldipine tab sr 24hr 17 mg 2nisoldipine tab sr 24hr 34 mg 2NITRO-BID - nitroglycerin oint 2% 4nitroglycerin sl tab 0.3 mg 2nitroglycerin sl tab 0.4 mg 2nitroglycerin sl tab 0.6 mg 2nitroglycerin td patch 24hr 0.1 mg/hr 2nitroglycerin td patch 24hr 0.2 mg/hr 2nitroglycerin td patch 24hr 0.4 mg/hr 2nitroglycerin td patch 24hr 0.6 mg/hr 2nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) 2NITROSTAT - nitroglycerin sl tab 0.3 mg 3NITROSTAT - nitroglycerin sl tab 0.4 mg 3NITROSTAT - nitroglycerin sl tab 0.6 mg 3NORTHERA - droxidopa cap 100 mg 5 PANORTHERA - droxidopa cap 200 mg 5 PANORTHERA - droxidopa cap 300 mg 5 PAomega-3-acid ethyl esters cap 1 gm 2pentoxifylline tab cr 400 mg 2perindopril erbumine tab 2 mg 2perindopril erbumine tab 4 mg 2perindopril erbumine tab 8 mg 2phenoxybenzamine hcl cap 10 mg 2pindolol tab 5 mg 2

2016


Drug Name Drug Tier Requirements/Limitspindolol tab 10 mg 2PRALUENT - alirocumab subcutaneous soln pen-injector 75 mg/ml 5 PA, QL (2 pens/28 days)PRALUENT - alirocumab subcutaneous soln pen-injector 150 mg/

ml5 PA, QL (2 pens/28 days)

PRALUENT - alirocumab subcutaneous soln prefilled syringe75 mg/ml

5 PA, QL (2 syringes/28 days)

PRALUENT - alirocumab subcutaneous soln prefilled syringe150 mg/ml


pravastatin sodium tab 10 mg 1 QL (45 tablets/30 days)pravastatin sodium tab 20 mg 1 QL (45 tablets/30 days)pravastatin sodium tab 40 mg 1 QL (45 tablets/30 days)pravastatin sodium tab 80 mg 1 QL (30 tablets/30 days)prazosin hcl cap 1 mg 2prazosin hcl cap 2 mg 2prazosin hcl cap 5 mg 2propafenone hcl cap sr 12hr 225 mg 2propafenone hcl cap sr 12hr 325 mg 2propafenone hcl cap sr 12hr 425 mg 2propafenone hcl tab 150 mg 2propafenone hcl tab 225 mg 2propafenone hcl tab 300 mg 2propranolol hcl cap sr 24hr 60 mg 2propranolol hcl cap sr 24hr 80 mg 2propranolol hcl cap sr 24hr 120 mg 2propranolol hcl cap sr 24hr 160 mg 2propranolol hcl inj 1 mg/ml 2propranolol hcl tab 10 mg 1propranolol hcl tab 20 mg 1propranolol hcl tab 40 mg 1propranolol hcl tab 60 mg 2propranolol hcl tab 80 mg 1quinapril hcl tab 5 mg 1quinapril hcl tab 10 mg 1quinapril hcl tab 20 mg 1quinapril hcl tab 40 mg 1quinapril-hydrochlorothiazide tab 10-12.5 mg 2quinapril-hydrochlorothiazide tab 20-12.5 mg 2quinapril-hydrochlorothiazide tab 20-25 mg 2quinidine gluconate tab cr 324 mg 2

2016


69

Drug Name Drug Tier Requirements/LimitsQUINIDINE SULFATE - quinidine sulfate tab 200 mg 4quinidine sulfate tab 300 mg 2ramipril cap 1.25 mg 1ramipril cap 2.5 mg 1ramipril cap 5 mg 1ramipril cap 10 mg 1RANEXA - ranolazine tab sr 12hr 500 mg 3RANEXA - ranolazine tab sr 12hr 1000 mg 3REPATHA - evolocumab subcutaneous soln prefilled syringe

140 mg/ml5 PA, QL (3 syringes/30 days)

REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneoussoln cartridge/infusor 420 mg/3.5ml

5 PA, QL (1 system/30 days)

REPATHA SURECLICK - evolocumab subcutaneous soln auto-injector 140 mg/ml

5 PA, QL (3 pens/30 days)

rosuvastatin calcium tab 5 mg 2 QL (45 tablets/30 days)rosuvastatin calcium tab 10 mg 2 QL (45 tablets/30 days)rosuvastatin calcium tab 20 mg 2 QL (45 tablets/30 days)rosuvastatin calcium tab 40 mg 2 QL (30 tablets/30 days)simvastatin tab 5 mg 1 QL (45 tablets/30 days)simvastatin tab 10 mg 1 QL (45 tablets/30 days)simvastatin tab 20 mg 1 QL (60 tablets/30 days)simvastatin tab 40 mg 1 QL (45 tablets/30 days)simvastatin tab 80 mg 1 QL (30 tablets/30 days)sotalol hcl (afib/afl) tab 80 mg 2sotalol hcl (afib/afl) tab 120 mg 2sotalol hcl (afib/afl) tab 160 mg 2sotalol hcl tab 80 mg 2sotalol hcl tab 120 mg 2sotalol hcl tab 160 mg 2sotalol hcl tab 240 mg 2spironolactone & hydrochlorothiazide tab 25-25 mg 2spironolactone tab 25 mg 2spironolactone tab 50 mg 2spironolactone tab 100 mg 2TEKTURNA - aliskiren fumarate tab 150 mg 3 QL (30 tablets/30 days)TEKTURNA - aliskiren fumarate tab 300 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-25 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-12.5 mg 3 QL (30 tablets/30 days)

2016


Drug Name Drug Tier Requirements/LimitsTEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-25 mg 3 QL (30 tablets/30 days)telmisartan tab 20 mg 2 QL (30 tablets/30 days)telmisartan tab 40 mg 2 QL (30 tablets/30 days)telmisartan tab 80 mg 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 40-12.5 mg 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-12.5 mg 2 QL (60 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-25 mg 2 QL (30 tablets/30 days)terazosin hcl cap 1 mg 2 QL (30 capsules/30 days)terazosin hcl cap 2 mg 2 QL (30 capsules/30 days)terazosin hcl cap 5 mg 2 QL (30 capsules/30 days)terazosin hcl cap 10 mg 2 QL (60 capsules/30 days)TIKOSYN - dofetilide cap 125 mcg (0.125 mg) 4TIKOSYN - dofetilide cap 250 mcg (0.25 mg) 4TIKOSYN - dofetilide cap 500 mcg (0.5 mg) 4TIMOLOL MALEATE - timolol maleate tab 5 mg 4TIMOLOL MALEATE - timolol maleate tab 10 mg 4TIMOLOL MALEATE - timolol maleate tab 20 mg 4torsemide tab 5 mg 2torsemide tab 10 mg 2torsemide tab 20 mg 2torsemide tab 100 mg 2trandolapril tab 1 mg 1trandolapril tab 2 mg 1trandolapril tab 4 mg 1triamterene & hydrochlorothiazide cap 37.5-25 mg 2triamterene & hydrochlorothiazide tab 37.5-25 mg 2triamterene & hydrochlorothiazide tab 75-50 mg 2valsartan tab 40 mg 2 QL (60 tablets/30 days)valsartan tab 80 mg 2 QL (60 tablets/30 days)valsartan tab 160 mg 2 QL (60 tablets/30 days)valsartan tab 320 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 80-12.5 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-12.5 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-25 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-12.5 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-25 mg 2 QL (30 tablets/30 days)VASCEPA - icosapent ethyl cap 0.5 gm 3VASCEPA - icosapent ethyl cap 1 gm 3

2016


71

Drug Name Drug Tier Requirements/Limitsverapamil hcl cap sr 24hr 100 mg 2verapamil hcl cap sr 24hr 120 mg 2verapamil hcl cap sr 24hr 180 mg 2verapamil hcl cap sr 24hr 200 mg 2verapamil hcl cap sr 24hr 240 mg 2verapamil hcl cap sr 24hr 300 mg 2verapamil hcl cap sr 24hr 360 mg 2verapamil hcl tab cr 120 mg 2verapamil hcl tab cr 180 mg 2verapamil hcl tab cr 240 mg 2verapamil hcl tab 40 mg 2verapamil hcl tab 80 mg 2verapamil hcl tab 120 mg 2VYTORIN - ezetimibe-simvastatin tab 10-10 mg 3 QL (30 tablets/30 days)VYTORIN - ezetimibe-simvastatin tab 10-20 mg 3 QL (30 tablets/30 days)VYTORIN - ezetimibe-simvastatin tab 10-40 mg 3 QL (30 tablets/30 days)VYTORIN - ezetimibe-simvastatin tab 10-80 mg 3 QL (30 tablets/30 days)WELCHOL - colesevelam hcl packet for susp 3.75 gm 4WELCHOL - colesevelam hcl tab 625 mg 4ZETIA - ezetimibe tab 10 mg 3 QL (30 tablets/30 days)Central Nervous System Agentsamphetamine-dextroamphetamine cap sr 24hr 5 mg 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap sr 24hr 10 mg 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap sr 24hr 15 mg 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap sr 24hr 20 mg 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap sr 24hr 25 mg 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap sr 24hr 30 mg 2 QL (30 capsules/30 days)AMPYRA - dalfampridine tab sr 12hr 10 mg* 5 PAAVONEX - interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/

vial)5 PA, QL (1 kit/28 days)

AVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)AVONEX PEN - interferon beta-1a im auto-injector kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)BETASERON - interferon beta-1b for inj kit 0.3 mg 5 PA, QL (15 vials/

syringes/30 days)clonidine hcl tab sr 12hr 0.1 mg 2 QL (120 tablets/30 days)COPAXONE - glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)COPAXONE - glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)dexmethylphenidate hcl tab 2.5 mg 2 QL (60 tablets/30 days)dexmethylphenidate hcl tab 5 mg 2 QL (60 tablets/30 days)

2016


Drug Name Drug Tier Requirements/Limitsdexmethylphenidate hcl tab 10 mg 2 QL (60 tablets/30 days)dextroamphetamine sulfate cap sr 24hr 5 mg 2 QL (90 capsules/30 days)dextroamphetamine sulfate cap sr 24hr 10 mg 2 QL (120 capsules/30 days)dextroamphetamine sulfate cap sr 24hr 15 mg 2 QL (120 capsules/30 days)dextroamphetamine sulfate tab 5 mg 2 QL (90 tablets/30 days)dextroamphetamine sulfate tab 10 mg 2 QL (180 tablets/30 days)duloxetine hcl enteric coated pellets cap 20 mg 2 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg 2 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 60 mg 2 QL (60 capsules/30 days)Glatopa - glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)LYRICA - pregabalin cap 25 mg 3LYRICA - pregabalin cap 50 mg 3LYRICA - pregabalin cap 75 mg 3LYRICA - pregabalin cap 100 mg 3LYRICA - pregabalin cap 150 mg 3LYRICA - pregabalin cap 200 mg 3LYRICA - pregabalin cap 225 mg 3LYRICA - pregabalin cap 300 mg 3LYRICA - pregabalin soln 20 mg/ml 3methylphenidate hcl tab cr 20 mg 2 QL (90 tablets/30 days)methylphenidate hcl tab 5 mg 2 QL (90 tablets/30 days)methylphenidate hcl tab 10 mg 2 QL (90 tablets/30 days)methylphenidate hcl tab 20 mg 2 QL (90 tablets/30 days)mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) 2mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) 2mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) 2NUEDEXTA - dextromethorphan hbr-quinidine sulfate cap

20-10 mg3

PLEGRIDY - peginterferon beta-1a soln pen-injector 125 mcg/0.5ml 5 PA, QL (2 syringes/28 days)PLEGRIDY - peginterferon beta-1a soln prefilled syringe

125 mcg/0.5ml5 PA, QL (2 syringes/28 days)

PLEGRIDY STARTER PACK - peginterferon beta-1a soln pen-inj63 & 94 mcg/0.5ml pack


PLEGRIDY STARTER PACK - peginterferon beta-1a soln pref syr63 & 94 mcg/0.5ml pack


riluzole tab 50 mg 2STRATTERA - atomoxetine hcl cap 10 mg 4 QL (60 capsules/30 days)STRATTERA - atomoxetine hcl cap 18 mg 4 QL (60 capsules/30 days)STRATTERA - atomoxetine hcl cap 25 mg 4 QL (60 capsules/30 days)

2016


73

Drug Name Drug Tier Requirements/LimitsSTRATTERA - atomoxetine hcl cap 40 mg 4 QL (60 capsules/30 days)STRATTERA - atomoxetine hcl cap 60 mg 4 QL (30 capsules/30 days)STRATTERA - atomoxetine hcl cap 80 mg 4 QL (30 capsules/30 days)STRATTERA - atomoxetine hcl cap 100 mg 4 QL (30 capsules/30 days)TECFIDERA - dimethyl fumarate capsule delayed release 120 mg 5 PA, QL (60 capsules/30 days)TECFIDERA - dimethyl fumarate capsule delayed release 240 mg 5 PA, QL (60 capsules/30 days)TECFIDERA STARTER PACK - dimethyl fumarate capsule dr

starter pack 120 mg & 240 mg5 PA, QL (60 capsules/30 days)

tetrabenazine tab 12.5 mg 5 PA, QL (240 tablets/30 days)tetrabenazine tab 25 mg 5 PA, QL (120 tablets/30 days)TYSABRI - natalizumab for iv inj conc 300 mg/15ml* 5 PAXENAZINE - tetrabenazine tab 12.5 mg* 5 PA, QL (240 tablets/30 days)XENAZINE - tetrabenazine tab 25 mg* 5 PA, QL (120 tablets/30 days)Dental and Oral Agentschlorhexidine gluconate soln 0.12% 2doxycycline hyclate cap 50 mg 2doxycycline hyclate cap 100 mg 2doxycycline hyclate for inj 100 mg 2doxycycline hyclate tab 20 mg 2doxycycline hyclate tab 100 mg 2KEPIVANCE - palifermin for iv inj 6.25 mg 5pilocarpine hcl tab 5 mg 2pilocarpine hcl tab 7.5 mg 2triamcinolone acetonide dental paste 0.1% 2Dermatological Agentsacitretin cap 10 mg 5acitretin cap 17.5 mg 5acitretin cap 25 mg 5acyclovir oint 5% 2alclometasone dipropionate cream 0.05% 2alclometasone dipropionate oint 0.05% 2AZELEX - azelaic acid cream 20% 4benzoyl peroxide-erythromycin gel 5-3% 2betamethasone dipropionate augmented cream 0.05% 2betamethasone dipropionate augmented gel 0.05% 2betamethasone dipropionate augmented lotion 0.05% 2betamethasone dipropionate augmented oint 0.05% 2betamethasone dipropionate cream 0.05% 2betamethasone dipropionate lotion 0.05% 2

2016


Drug Name Drug Tier Requirements/Limitsbetamethasone dipropionate oint 0.05% 2betamethasone valerate cream 0.1% 2betamethasone valerate lotion 0.1% 2betamethasone valerate oint 0.1% 2calcipotriene cream 0.005% 2calcipotriene oint 0.005% 2calcipotriene soln 0.005% (50 mcg/ml) 2CARAC - fluorouracil cream 0.5% 5ciclopirox gel 0.77% 2ciclopirox olamine cream 0.77% 2ciclopirox olamine susp 0.77% 2ciclopirox shampoo 1% 2ciclopirox solution 8% 2clindamycin phosphate gel 1% 2clindamycin phosphate lotion 1% 2clindamycin phosphate soln 1% 2clindamycin phosphate swab 1% 2clindamycin phosphate-benzoyl peroxide gel 1-5% 2clobetasol propionate cream 0.05% 2clobetasol propionate emollient base cream 0.05% 2clobetasol propionate gel 0.05% 2clobetasol propionate oint 0.05% 2clobetasol propionate soln 0.05% 2clotrimazole cream 1% 2clotrimazole w/ betamethasone cream 1-0.05% 2clotrimazole w/ betamethasone lotion 1-0.05% 2DENAVIR - penciclovir cream 1% 4desonide cream 0.05% 2desonide lotion 0.05% 2desonide oint 0.05% 2DESOXIMETASONE - desoximetasone cream 0.05% 4desoximetasone cream 0.25% 2desoximetasone gel 0.05% 2desoximetasone oint 0.25% 2diclofenac sodium gel 1% 2 STdiclofenac sodium gel 3% 5DIFLORASONE DIACETATE - diflorasone diacetate oint 0.05% 4econazole nitrate cream 1% 2

2016


75

Drug Name Drug Tier Requirements/LimitsELIDEL - pimecrolimus cream 1% 4 STerythromycin pads 2% 2erythromycin soln 2% 2FINACEA - azelaic acid foam 15% 4FINACEA - azelaic acid gel 15% 4fluocinolone acetonide cream 0.01% 2fluocinonide cream 0.05% 2fluocinonide emulsified base cream 0.05% 2fluocinonide gel 0.05% 2fluocinonide oint 0.05% 2fluocinonide soln 0.05% 2fluorouracil cream 5% 2fluorouracil soln 2% 2fluorouracil soln 5% 2fluticasone propionate cream 0.05% 2fluticasone propionate oint 0.005% 2GENTAMICIN SULFATE - gentamicin sulfate cream 0.1% 4GENTAMICIN SULFATE - gentamicin sulfate oint 0.1% 4halobetasol propionate cream 0.05% 2halobetasol propionate oint 0.05% 2hydrocortisone butyrate cream 0.1% 2hydrocortisone butyrate oint 0.1% 2hydrocortisone butyrate soln 0.1% 2hydrocortisone cream 1% 2hydrocortisone cream 2.5% 2hydrocortisone lotion 2.5% 2hydrocortisone oint 1% 2hydrocortisone oint 2.5% 2hydrocortisone valerate cream 0.2% 2hydrocortisone valerate oint 0.2% 2imiquimod cream 5% 2 PAisotretinoin cap 10 mg 2isotretinoin cap 20 mg 2isotretinoin cap 30 mg 2isotretinoin cap 40 mg 2ketoconazole cream 2% 2ketoconazole shampoo 2% 2lactic acid (ammonium lactate) cream 12% 2

2016


Drug Name Drug Tier Requirements/Limitslactic acid (ammonium lactate) lotion 12% 2methoxsalen rapid cap 10 mg 5metronidazole cream 0.75% 2metronidazole gel 0.75% 2metronidazole gel 1% 2metronidazole lotion 0.75% 2mometasone furoate cream 0.1% 2mometasone furoate oint 0.1% 2mometasone furoate solution 0.1% (lotion) 2mupirocin oint 2% 2nystatin cream 100000 unit/gm 2nystatin oint 100000 unit/gm 2nystatin topical powder 2nystatin-triamcinolone cream 100000-0.1 unit/gm-% 2nystatin-triamcinolone oint 100000-0.1 unit/gm-% 2ORACEA - doxycycline cap delayed release 40 mg 4PICATO - ingenol mebutate gel 0.015% 3 QL (3 tubes/30 days)PICATO - ingenol mebutate gel 0.05% 3 QL (2 tubes/30 days)podofilox soln 0.5% 2prednicarbate cream 0.1% 2prednicarbate oint 0.1% 2SANTYL - collagenase oint 250 unit/gm 3selenium sulfide lotion 2.5% 2silver sulfadiazine cream 1% 2STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml 5 PASTELARA - ustekinumab soln prefilled syringe 90 mg/ml 5 PAsulfacetamide sodium lotion 10% 2tacrolimus oint 0.03% 2 STtacrolimus oint 0.1% 2 STTAZORAC - tazarotene cream 0.05% 4TAZORAC - tazarotene cream 0.1% 4TAZORAC - tazarotene gel 0.05% 4TAZORAC - tazarotene gel 0.1% 4tretinoin cream 0.025% 2tretinoin cream 0.05% 2tretinoin cream 0.1% 2tretinoin gel 0.01% 2tretinoin gel 0.025% 2

2016


77

Drug Name Drug Tier Requirements/Limitstriamcinolone acetonide cream 0.025% 2triamcinolone acetonide cream 0.1% 2triamcinolone acetonide cream 0.5% 2triamcinolone acetonide lotion 0.025% 2triamcinolone acetonide lotion 0.1% 2triamcinolone acetonide oint 0.025% 2triamcinolone acetonide oint 0.1% 2triamcinolone acetonide oint 0.5% 2UVADEX - methoxsalen soln 20 mcg/ml 4VALCHLOR - mechlorethamine hcl gel 0.016%* 5VOLTAREN - diclofenac sodium gel 1% 4 STEnzyme Replacements/ModifiersADAGEN - pegademase bovine inj 250 unit/ml* 5ALDURAZYME - laronidase soln for iv infusion 2.9 mg/5ml (500

unit/5ml)*5

BUPHENYL - sodium phenylbutyrate tab 500 mg 5CEREZYME - imiglucerase for inj 400 unit* 5CREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit 3CREON - pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000

unit3

CREON - pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit

3

CYSTADANE - betaine powder for oral solution 5CYSTAGON - cysteamine bitartrate cap 50 mg* 4CYSTAGON - cysteamine bitartrate cap 150 mg* 4ELAPRASE - idursulfase soln for iv infusion 6 mg/3ml (2 mg/ml)* 5ELELYSO - taliglucerase alfa for inj 200 unit* 5FABRAZYME - agalsidase beta for iv soln 5 mg* 5FABRAZYME - agalsidase beta for iv soln 35 mg* 5KUVAN - sapropterin dihydrochloride powder packet 100 mg* 5 PAKUVAN - sapropterin dihydrochloride powder packet 500 mg* 5 PAKUVAN - sapropterin dihydrochloride soluble tab 100 mg* 5 PANAGLAZYME - galsulfase soln for iv infusion 1 mg/ml* 5ORFADIN - nitisinone cap 2 mg* 5ORFADIN - nitisinone cap 5 mg* 5ORFADIN - nitisinone cap 10 mg* 5

2016


Drug Name Drug Tier Requirements/LimitsORFADIN - nitisinone cap 20 mg* 5ORFADIN - nitisinone susp 4 mg/ml* 5sodium phenylbutyrate oral powder 3 gm/teaspoonful 5STRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml* 5STRENSIQ - asfotase alfa subcutaneous inj 28 mg/0.7ml* 5STRENSIQ - asfotase alfa subcutaneous inj 40 mg/ml* 5STRENSIQ - asfotase alfa subcutaneous inj 80 mg/0.8ml* 5VIOKACE - pancrelipase (lip-prot-amyl) tab 10440-39150-39150

unit4

VIOKACE - pancrelipase (lip-prot-amyl) tab 20880-78300-78300unit

4

VPRIV - velaglucerase alfa for inj 400 unit 5ZAVESCA - miglustat cap 100 mg* 5ZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000

unit3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000unit

3


3


3


3


3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap40000-136000-218000 unit

3

Gastrointestinal Agentsalosetron hcl tab 0.5 mg 5alosetron hcl tab 1 mg 5AMITIZA - lubiprostone cap 8 mcg 3 PAAMITIZA - lubiprostone cap 24 mcg 3 PACHENODAL - chenodiol tab 250 mg* 5cimetidine hcl soln 300 mg/5ml 2cimetidine tab 200 mg 2cimetidine tab 300 mg 2cimetidine tab 400 mg 2cimetidine tab 800 mg 2cromolyn sodium oral conc 100 mg/5ml 2DEXILANT - dexlansoprazole cap delayed release 30 mg 4 QL (30 capsules/30 days)DEXILANT - dexlansoprazole cap delayed release 60 mg 4 QL (30 capsules/30 days)

2016


79

Drug Name Drug Tier Requirements/Limitsdicyclomine hcl tab 20 mg 2esomeprazole magnesium cap delayed release 20 mg 2 QL (30 capsules/30 days)esomeprazole magnesium cap delayed release 40 mg 2 QL (30 capsules/30 days)ESOMEPRAZOLE SODIUM - esomeprazole sodium for

intravenous soln 20 mg4

esomeprazole sodium for intravenous soln 40 mg 2famotidine for susp 40 mg/5ml 2famotidine inj 20 mg/2ml 2famotidine inj 40 mg/4ml 2famotidine inj 200 mg/20ml 2famotidine tab 20 mg 2famotidine tab 40 mg 2GATTEX - teduglutide (rdna) for inj kit 5 mg* 5 PAglycopyrrolate tab 1 mg 2glycopyrrolate tab 2 mg 2lactulose (encephalopathy) solution 10 gm/15ml 2lactulose solution 10 gm/15ml 2lansoprazole cap delayed release 15 mg 2 QL (30 capsules/30 days)lansoprazole cap delayed release 30 mg 2 QL (30 capsules/30 days)LINZESS - linaclotide cap 145 mcg 3 PALINZESS - linaclotide cap 290 mcg 3 PAloperamide hcl cap 2 mg 2methscopolamine bromide tab 2.5 mg 2methscopolamine bromide tab 5 mg 2metoclopramide hcl inj 5 mg/ml 2metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 2metoclopramide hcl tab 5 mg 2metoclopramide hcl tab 10 mg 2misoprostol tab 100 mcg 2misoprostol tab 200 mcg 2MOVIPREP - peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln

100 gm4

NEXIUM - esomeprazole magnesium for delayed release susppacket 5 mg

4 QL (30 packets/30 days)







2016


Drug Name Drug Tier Requirements/LimitsNEXIUM - esomeprazole magnesium for delayed release susp

packet 2.5 mg4 QL (30 packets/30 days)

nizatidine cap 150 mg 2nizatidine cap 300 mg 2OCALIVA - obeticholic acid tab 5 mg 5 PA, QL (30 tablets/30 days)OCALIVA - obeticholic acid tab 10 mg 5 PA, QL (30 tablets/30 days)omeprazole cap delayed release 10 mg 2 QL (30 capsules/30 days)omeprazole cap delayed release 20 mg 2 QL (60 capsules/30 days)omeprazole cap delayed release 40 mg 2 QL (60 capsules/30 days)pantoprazole sodium ec tab 20 mg 2 QL (30 tablets/30 days)pantoprazole sodium ec tab 40 mg 2 QL (60 tablets/30 days)pantoprazole sodium for iv soln 40 mg 2peg 3350-kcl-sod bicarb-nacl for soln 420 gm 2peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm 2peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm 2polyethylene glycol 3350 oral packet 2polyethylene glycol 3350 oral powder 2PYLERA - bismuth subcit-metronidazole-tetracycline cap

140-125-125 mg3

rabeprazole sodium ec tab 20 mg 2 QL (30 tablets/30 days)ranitidine hcl cap 150 mg 2ranitidine hcl cap 300 mg 2ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 2ranitidine hcl tab 150 mg 2ranitidine hcl tab 300 mg 2RELISTOR - methylnaltrexone bromide inj kit 12 mg/0.6ml 4 PARELISTOR - methylnaltrexone bromide inj 8 mg/0.4ml (20 mg/ml) 4 PARELISTOR - methylnaltrexone bromide inj 12 mg/0.6ml (20 mg/ml) 4 PAsucralfate tab 1 gm 2SUPREP BOWEL PREP - sodium sulfate-potassium sulfate-

magnesium sulfate oral soln4

ursodiol cap 300 mg 2ursodiol tab 250 mg 2ursodiol tab 500 mg 2XIFAXAN - rifaximin tab 550 mg 5Genitourinary Agentsalfuzosin hcl tab sr 24hr 10 mg 2 QL (30 tablets/30 days)bethanechol chloride tab 5 mg 2bethanechol chloride tab 10 mg 2

2016


81

Drug Name Drug Tier Requirements/Limitsbethanechol chloride tab 25 mg 2bethanechol chloride tab 50 mg 2calcium acetate cap 667 mg 2calcium acetate tab 667 mg 2CUPRIMINE - penicillamine cap 250 mg 5DEPEN TITRATABS - penicillamine tab 250 mg 5doxazosin mesylate tab 1 mg 2 QL (30 tablets/30 days)doxazosin mesylate tab 2 mg 2 QL (30 tablets/30 days)doxazosin mesylate tab 4 mg 2 QL (30 tablets/30 days)doxazosin mesylate tab 8 mg 2 QL (60 tablets/30 days)dutasteride cap 0.5 mg 2 QL (30 capsules/30 days)dutasteride-tamsulosin hcl cap 0.5-0.4 mg 2 QL (30 capsules/30 days)finasteride tab 5 mg 2 QL (30 tablets/30 days)FOSRENOL - lanthanum carbonate chew tab 500 mg 3FOSRENOL - lanthanum carbonate chew tab 750 mg 3FOSRENOL - lanthanum carbonate chew tab 1000 mg 3FOSRENOL - lanthanum carbonate oral powder pack 750 mg 3FOSRENOL - lanthanum carbonate oral powder pack 1000 mg 3methylergonovine maleate tab 0.2 mg 2MYRBETRIQ - mirabegron tab sr 24 hr 25 mg 3 QL (30 tablets/30 days)MYRBETRIQ - mirabegron tab sr 24 hr 50 mg 3 QL (30 tablets/30 days)neomycin-polymyxin b gu irrigation soln 2oxybutynin chloride syrup 5 mg/5ml 2 QL (600 mls/30 days)oxybutynin chloride tab sr 24hr 5 mg 2 QL (30 tablets/30 days)oxybutynin chloride tab sr 24hr 10 mg 2 QL (60 tablets/30 days)oxybutynin chloride tab sr 24hr 15 mg 2 QL (60 tablets/30 days)oxybutynin chloride tab 5 mg 2 QL (120 tablets/30 days)PHOSLYRA - calcium acetate oral soln 667 mg/5ml 3prazosin hcl cap 1 mg 2prazosin hcl cap 2 mg 2prazosin hcl cap 5 mg 2RAPAFLO - silodosin cap 4 mg 3 QL (30 capsules/30 days)RAPAFLO - silodosin cap 8 mg 3 QL (30 capsules/30 days)RENVELA - sevelamer carbonate packet 0.8 gm 5RENVELA - sevelamer carbonate packet 2.4 gm 5RENVELA - sevelamer carbonate tab 800 mg 5tamsulosin hcl cap 0.4 mg 2 QL (60 capsules/30 days)terazosin hcl cap 1 mg 2 QL (30 capsules/30 days)

2016


Drug Name Drug Tier Requirements/Limitsterazosin hcl cap 2 mg 2 QL (30 capsules/30 days)terazosin hcl cap 5 mg 2 QL (30 capsules/30 days)terazosin hcl cap 10 mg 2 QL (60 capsules/30 days)tolterodine tartrate cap sr 24hr 2 mg 2 QL (30 capsules/30 days)tolterodine tartrate cap sr 24hr 4 mg 2 QL (30 capsules/30 days)tolterodine tartrate tab 1 mg 2 QL (60 tablets/30 days)tolterodine tartrate tab 2 mg 2 QL (60 tablets/30 days)TOVIAZ - fesoterodine fumarate tab sr 24hr 4 mg 3 QL (30 tablets/30 days)TOVIAZ - fesoterodine fumarate tab sr 24hr 8 mg 3 QL (30 tablets/30 days)trospium chloride cap sr 24hr 60 mg 2 QL (30 capsules/30 days)trospium chloride tab 20 mg 2 QL (60 tablets/30 days)VESICARE - solifenacin succinate tab 5 mg 3 QL (30 tablets/30 days)VESICARE - solifenacin succinate tab 10 mg 3 QL (30 tablets/30 days)Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)CORTISONE ACETATE - cortisone acetate tab 25 mg 4DEXAMETHASONE - dexamethasone tab 1 mg 4DEXAMETHASONE - dexamethasone tab 2 mg 4dexamethasone elixir 0.5 mg/5ml 2dexamethasone sodium phosphate inj 4 mg/ml 2dexamethasone sodium phosphate inj 20 mg/5ml 2dexamethasone sodium phosphate inj 120 mg/30ml 2dexamethasone tab 0.5 mg 2dexamethasone tab 0.75 mg 2dexamethasone tab 1.5 mg 2dexamethasone tab 4 mg 2dexamethasone tab 6 mg 2fludrocortisone acetate tab 0.1 mg 2H.P. ACTHAR - corticotropin inj gel 80 unit/ml* 5 PAhydrocortisone tab 5 mg 2hydrocortisone tab 10 mg 2hydrocortisone tab 20 mg 2methylprednisolone sodium succinate for inj 40 mg 2methylprednisolone sodium succinate for inj 125 mg 2methylprednisolone sodium succinate for inj 1000 mg 2methylprednisolone tab therapy pack 4 mg (21) 2methylprednisolone tab 4 mg 2 BDmethylprednisolone tab 8 mg 2 BDmethylprednisolone tab 16 mg 2 BD

2016


83

Drug Name Drug Tier Requirements/Limitsmethylprednisolone tab 32 mg 2 BDMYALEPT - metreleptin for subcutaneous inj 11.3 mg* 5 PAprednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) 2 BDprednisolone sod phosphate oral soln 15 mg/5ml 2 BDprednisolone syrup 15 mg/5ml 2 BDPREDNISONE - prednisone oral soln 5 mg/5ml 4 BDPREDNISONE - prednisone tab therapy pack 5 mg (21) 2PREDNISONE - prednisone tab therapy pack 5 mg (48) 2PREDNISONE - prednisone tab therapy pack 10 mg (21) 2PREDNISONE - prednisone tab therapy pack 10 mg (48) 2PREDNISONE - prednisone tab 50 mg 4 BDprednisone tab 1 mg 2 BDprednisone tab 2.5 mg 2 BDprednisone tab 5 mg 2 BDprednisone tab 10 mg 2 BDprednisone tab 20 mg 2 BDHormonal Agents, Stimulant/Replacement/Modifying (Pituitary)chorionic gonadotropin for inj 10000 unit 2desmopressin acetate inj 4 mcg/ml 2desmopressin acetate nasal soln 0.01% (refrigerated) 2desmopressin acetate nasal spray soln 0.01% 2desmopressin acetate nasal spray soln 0.01% (refrigerated) 2desmopressin acetate tab 0.1 mg 2desmopressin acetate tab 0.2 mg 2EGRIFTA - tesamorelin acetate for inj 1 mg* 5 PAEGRIFTA - tesamorelin acetate for inj 2 mg* 5 PAINCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)* 5OMNITROPE - somatropin for inj 5.8 mg* 3 PAOMNITROPE - somatropin inj 5 mg/1.5ml* 5 PAOMNITROPE - somatropin inj 10 mg/1.5ml* 5 PASTIMATE - desmopressin acetate nasal soln 1.5 mg/ml 5Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)ANADROL-50 - oxymetholone tab 50 mg 5 PAANDRODERM - testosterone td patch 24hr 2 mg/24hr 3 PA, QL (30 patches/30 days)ANDRODERM - testosterone td patch 24hr 4 mg/24hr 3 PA, QL (30 patches/30 days)ANDROGEL - testosterone td gel 25 mg/2.5gm (1%) 3 PA, QL (90 packets/30 days)ANDROGEL - testosterone td gel 50 mg/5gm (1%) 3 PA, QL (60 packets/30 days)ANDROGEL - testosterone td gel 20.25 mg/1.25gm (1.62%) 3 PA, QL (30 packets/30 days)ANDROGEL - testosterone td gel 40.5 mg/2.5gm (1.62%) 3 PA, QL (60 packets/30 days)

2016


Drug Name Drug Tier Requirements/LimitsANDROGEL PUMP - testosterone td gel 20.25 mg/act (1.62%) 3 PA, QL (2 pump bottles/30 days)ANDROID - methyltestosterone cap 10 mg 4 PAANDROXY - fluoxymesterone tab 10 mg 4 PAAXIRON - testosterone td soln 30 mg/act 4 PA, QL (2 pump bottles/30 days)danazol cap 50 mg 2 PAdanazol cap 100 mg 2 PAdanazol cap 200 mg 2 PADEPO-PROVERA - medroxyprogesterone acetate im susp 400 mg/

ml4

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) 2desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg 2desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 2DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%)# 4 PADIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)# 4 PADIVIGEL - estradiol td gel 1 mg/gm (0.1%)# 4 PAdrospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg 2drospirenone-ethinyl estradiol tab 3-0.02 mg 2drospirenone-ethinyl estradiol tab 3-0.03 mg 2ELLA - ulipristal acetate tab 30 mg 3ESTRACE - estradiol vaginal cream 0.1 mg/gm 4estradiol & norethindrone acetate tab 0.5-0.1 mg# 4 PAestradiol & norethindrone acetate tab 1-0.5 mg# 4 PAestradiol tab 0.5 mg# 4 PAestradiol tab 1 mg# 4 PAestradiol tab 2 mg# 4 PAestradiol td patch weekly 0.025 mg/24hr# 4 PAestradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)# 4 PAestradiol td patch weekly 0.05 mg/24hr# 4 PAestradiol td patch weekly 0.06 mg/24hr# 4 PAestradiol td patch weekly 0.075 mg/24hr# 4 PAestradiol td patch weekly 0.1 mg/24hr# 4 PAestradiol vaginal tab 10 mcg 2ESTROPIPATE - estropipate tab 3 mg# 4 PAestropipate tab 0.75 mg# 4 PAestropipate tab 1.5 mg# 4 PAethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg 2levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) 2levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) 2levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg 2

2016


85

Drug Name Drug Tier Requirements/Limitslevonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 2levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 2levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg 2levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg 2medroxyprogesterone acetate im susp prefilled syr 150 mg/ml 2medroxyprogesterone acetate im susp 150 mg/ml 2medroxyprogesterone acetate tab 2.5 mg 2medroxyprogesterone acetate tab 5 mg 2medroxyprogesterone acetate tab 10 mg 2megestrol acetate susp 40 mg/ml# 4 PAmegestrol acetate tab 20 mg# 4 PAmegestrol acetate tab 40 mg# 4 PAMENEST - esterified estrogens tab 0.3 mg# 4 PAMENEST - esterified estrogens tab 0.625 mg# 4 PAMENEST - esterified estrogens tab 1.25 mg# 4 PAMENEST - esterified estrogens tab 2.5 mg# 4 PAmethyltestosterone cap 10 mg 2 PAnorethindrone & ethinyl estradiol tab 0.4 mg-35 mcg 2norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg 2norethindrone & ethinyl estradiol tab 1 mg-35 mcg 2norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg 2norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg 2norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg 2norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg 2norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg 2norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg 2norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg 2norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) 2norethindrone acetate tab 5 mg 2norethindrone tab 0.35 mg 2norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg 2norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg 2norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg 2norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg 2norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg 2norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 2oxandrolone tab 2.5 mg 2 PAoxandrolone tab 10 mg 5 PA

2016


Drug Name Drug Tier Requirements/LimitsPREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm 3PREMARIN - estrogens, conjugated tab 0.3 mg# 4 PAPREMARIN - estrogens, conjugated tab 0.45 mg# 4 PAPREMARIN - estrogens, conjugated tab 0.625 mg# 4 PAPREMARIN - estrogens, conjugated tab 0.9 mg# 4 PAPREMARIN - estrogens, conjugated tab 1.25 mg# 4 PAPREMPHASE - conj est 0.625(14)/conj est-medroxypro ac tab

0.625-5mg(14)#4 PA

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.3-1.5 mg#

4 PA


4 PA


4 PA

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.625-5 mg#

4 PA

raloxifene hcl tab 60 mg 2testosterone cypionate im inj in oil 100 mg/ml 2 PAtestosterone cypionate im inj in oil 200 mg/ml 2 PAtestosterone enanthate im inj in oil 200 mg/ml 2 PAtestosterone td gel 25 mg/2.5gm (1%) (generic for AndroGel 1%) 2 PA, QL (90 packets/30 days)testosterone td gel 50 mg/5gm (1%) (generic for AndroGel 1%) 2 PA, QL (60 packets/30 days)testosterone td gel 12.5 mg/act (1%) (generic for AndroGel Pump

1%)2 PA, QL (4 pump bottles/30 days)

VAGIFEM - estradiol vaginal tab 10 mcg 3Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tab 25 mcg 2levothyroxine sodium tab 50 mcg 2levothyroxine sodium tab 75 mcg 2levothyroxine sodium tab 88 mcg 2levothyroxine sodium tab 100 mcg 2levothyroxine sodium tab 112 mcg 2levothyroxine sodium tab 125 mcg 2levothyroxine sodium tab 137 mcg 2levothyroxine sodium tab 150 mcg 2levothyroxine sodium tab 175 mcg 2levothyroxine sodium tab 200 mcg 2levothyroxine sodium tab 300 mcg 2liothyronine sodium tab 5 mcg 2liothyronine sodium tab 25 mcg 2

2016


87

Drug Name Drug Tier Requirements/Limitsliothyronine sodium tab 50 mcg 2NATPARA - parathyroid hormone (recombinant) for inj cartridge

25 mcg*5 PA, QL (2 cartridges/28 days)

NATPARA - parathyroid hormone (recombinant) for inj cartridge50 mcg*

5 PA, QL (2 cartridges/28 days)





SYNTHROID - levothyroxine sodium tab 25 mcg 4SYNTHROID - levothyroxine sodium tab 50 mcg 4SYNTHROID - levothyroxine sodium tab 75 mcg 4SYNTHROID - levothyroxine sodium tab 88 mcg 4SYNTHROID - levothyroxine sodium tab 100 mcg 4SYNTHROID - levothyroxine sodium tab 112 mcg 4SYNTHROID - levothyroxine sodium tab 125 mcg 4SYNTHROID - levothyroxine sodium tab 137 mcg 4SYNTHROID - levothyroxine sodium tab 150 mcg 4SYNTHROID - levothyroxine sodium tab 175 mcg 4SYNTHROID - levothyroxine sodium tab 200 mcg 4SYNTHROID - levothyroxine sodium tab 300 mcg 4Hormonal Agents, Suppressant (Adrenal)KORLYM - mifepristone tab 300 mg 5 PA, QL (120 tablets/30 days)LYSODREN - mitotane tab 500 mg 3Hormonal Agents, Suppressant (Parathyroid)SENSIPAR - cinacalcet hcl tab 30 mg 3 PASENSIPAR - cinacalcet hcl tab 60 mg 3 PASENSIPAR - cinacalcet hcl tab 90 mg 3 PAHormonal Agents, Suppressant (Pituitary)bromocriptine mesylate cap 5 mg 2bromocriptine mesylate tab 2.5 mg 2cabergoline tab 0.5 mg 2ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit

22.5mg4

ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit30 mg

4

ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit45 mg

4

ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg 4FIRMAGON - degarelix acetate for inj 80 mg 4FIRMAGON - degarelix acetate for inj 120 mg 5

2016


Drug Name Drug Tier Requirements/Limitsleuprolide acetate inj kit 5 mg/ml 2LUPRON DEPOT - leuprolide acetate (3 month) for inj kit 11.25 mg 5LUPRON DEPOT - leuprolide acetate (3 month) for inj kit 22.5 mg 5LUPRON DEPOT - leuprolide acetate (4 month) for inj kit 30 mg 5LUPRON DEPOT - leuprolide acetate (6 month) for inj kit 45 mg 5LUPRON DEPOT - leuprolide acetate for inj kit 3.75 mg 5LUPRON DEPOT - leuprolide acetate for inj kit 7.5 mg 5LUPRON DEPOT-PED - leuprolide acetate (3 month) for inj

pediatric kit 11.25 mg5

LUPRON DEPOT-PED - leuprolide acetate (3 month) for injpediatric kit 30 mg

5

LUPRON DEPOT-PED - leuprolide acetate for inj pediatric kit7.5 mg

5

LUPRON DEPOT-PED - leuprolide acetate for inj pediatric kit11.25 mg

5

LUPRON DEPOT-PED - leuprolide acetate for inj pediatric kit15 mg

5

octreotide acetate inj 50 mcg/ml (0.05 mg/ml) 2 PAoctreotide acetate inj 100 mcg/ml (0.1 mg/ml) 2 PAoctreotide acetate inj 200 mcg/ml (0.2 mg/ml) 2 PAoctreotide acetate inj 500 mcg/ml (0.5 mg/ml) 5 PAoctreotide acetate inj 1000 mcg/ml (1 mg/ml) 5 PASIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.6 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.9 mg/ml* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 20 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 40 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 60 mg* 5 PASOMATULINE DEPOT - lanreotide acetate extended release inj

60 mg/0.2ml5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj90 mg/0.3ml

5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj120 mg/0.5ml

5 PA

SOMAVERT - pegvisomant for inj 10 mg* 5 PASOMAVERT - pegvisomant for inj 15 mg* 5 PASOMAVERT - pegvisomant for inj 20 mg* 5 PASOMAVERT - pegvisomant for inj 25 mg* 5 PASOMAVERT - pegvisomant for inj 30 mg* 5 PASYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) 5TRELSTAR - triptorelin pamoate for im susp 3.75 mg 5

2016


89

Drug Name Drug Tier Requirements/LimitsTRELSTAR - triptorelin pamoate for im susp 11.25 mg 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 3.75 mg 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 11.25 mg 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 22.5 mg 5Hormonal Agents, Suppressant (Thyroid)methimazole tab 5 mg 2methimazole tab 10 mg 2propylthiouracil tab 50 mg 2Immunological AgentsACTHIB - haemophilus b polysaccharide conjugate vaccine for inj 4ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000

unit/0.5ml)*5

ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml 4ARCALYST - rilonacept for inj 220 mg* 5 PAATGAM - lymphocyte immune globulin anti-thymocyte g inj 50 mg/

ml(eq)5 BD

AZASAN - azathioprine tab 75 mg 4 BDAZASAN - azathioprine tab 100 mg 4 BDAZATHIOPRINE - azathioprine sodium for inj 100 mg 4 BDazathioprine tab 50 mg 2 BDBCG VACCINE - bcg vaccine inj 4BENLYSTA - belimumab for iv soln 120 mg 5 PABENLYSTA - belimumab for iv soln 400 mg 5 PABEXSERO - meningococcal vac b (recomb omv adjuv) inj prefilled

syringe4

BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml

4

CELLCEPT INTRAVENOUS - mycophenolate mofetil hcl for iv soln500 mg

4 BD

CERVARIX - human papillomavirus (hpv) bival (type 16, 18) recmbvac inj

4

CINRYZE - c1 esterase inhibitor (human) for iv inj 500 unit* 5 PA, QL (20 vials/30 days)CUPRIMINE - penicillamine cap 250 mg 5cyclosporine cap 25 mg 2 BDcyclosporine cap 100 mg 2 BDcyclosporine iv soln 50 mg/ml 2 BDcyclosporine modified cap 25 mg 2 BDcyclosporine modified cap 50 mg 2 BDcyclosporine modified cap 100 mg 2 BDcyclosporine modified oral soln 100 mg/ml 2 BD

2016


Drug Name Drug Tier Requirements/LimitsDAPTACEL - diph, acellular pert & tet tox inj 15 lf-10 mcg-5 lf/0.5ml 4DEPEN TITRATABS - penicillamine tab 250 mg 5DIPHTHERIA/TETANUS TOXOID - diphtheria-tetanus tox adsorbed

(dt) im inj 25-5 unit/0.5ml4

ELIDEL - pimecrolimus cream 1% 4 STENBREL - etanercept for subcutaneous inj 25 mg 5 PAENBREL - etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml5 PA

ENBREL - etanercept subcutaneous soln prefilled syringe 50 mg/ml 5 PAENBREL SURECLICK - etanercept subcutaneous solution auto-

injector 50 mg/ml5 PA

ENGERIX-B - hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml 4 BDENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml 4 BDFIRAZYR - icatibant acetate inj 30 mg/3ml* 5 PA, QL (6 syringes/30 days)GAMMAPLEX - immune globulin (human) iv soln 2.5 gm/50ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 5 gm/100ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 10 gm/200ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 20 gm/400ml 5 BD, PAGAMUNEX-C - immune globulin (human) iv or subcutaneous soln

1 gm/10ml3 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln2.5 gm/25ml

3 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln5 gm/50ml

3 BD, PA


3 BD, PA


3 BD, PA


3 BD, PA

GARDASIL - human papillomavirus (hpv) quadrivalent recombinantvac inj

4

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac imsusp

4

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vacsusp pref syr

4

HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml 4HAVRIX - hepatitis a vaccine inj susp 1440 el unit/ml 4HIBERIX - haemophilus b polysaccharide conjugate vac for inj

10 mcg4

HUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml 5 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.4ml 5 PA

2016


91

Drug Name Drug Tier Requirements/LimitsHUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml 5 PAHUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -

adalimumab prefilled syringe kit 40 mg/0.8ml5 PA

HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml 5 PAHUMIRA PEN-CROHNS DISEASE STARTER - adalimumab pen-

injector kit 40 mg/0.8ml5 PA

HUMIRA PEN-PSORIASIS STARTER - adalimumab pen-injector kit40 mg/0.8ml

5 PA

ILARIS - canakinumab for inj 180 mg* 5 PAIMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj 3 BDINFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml 4IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection 4IXIARO - japanese encephalitis vaccine inactivated adsorbed inj 4KINERET - anakinra subcutaneous soln prefilled syringe

100 mg/0.67ml5 PA

KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj 4leflunomide tab 10 mg 2leflunomide tab 20 mg 2M-M-R II - measles, mumps & rubella virus vaccines for inj 4MENACTRA - meningococcal (a, c, y, and w-135) conjugate

vaccine inj4

MENHIBRIX - meningococcal (c & y)-haemophilus b tet tox conjvac for inj

4

MENOMUNE-A/C/Y/W-135 - meningococcal vaccine a, c, y, andw-135 inj

4

MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac for inj 4methotrexate sodium for inj 1 gm 2methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) 2methotrexate sodium inj pf 100 mg/4ml (25 mg/ml) 2methotrexate sodium inj pf 200 mg/8ml (25 mg/ml) 2methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) 2methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) 2methotrexate sodium inj 250 mg/10ml (25 mg/ml) 2methotrexate sodium inj 50 mg/2ml (25 mg/ml) 2methotrexate sodium tab 2.5 mg 2mycophenolate mofetil cap 250 mg 2 BDmycophenolate mofetil for oral susp 200 mg/ml 5 BDmycophenolate mofetil tab 500 mg 2 BDmycophenolate sodium tab dr 180 mg 2 BDmycophenolate sodium tab dr 360 mg 2 BD

2016


Drug Name Drug Tier Requirements/LimitsNULOJIX - belatacept for iv infusion 250 mg 5 BDPEDVAX HIB - haemophilus b polysaccharide conj vac im susp

7.5 mcg/0.5 ml4

PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac forim susp

4

PROGRAF - tacrolimus inj 5 mg/ml 4 BDPROQUAD - measles-mumps-rubella-varicella virus vaccines for inj 4QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vac

inj4

RABAVERT - rabies vaccine, pcec for inj 4 BDRAPAMUNE - sirolimus oral soln 1 mg/ml 5 BDRECOMBIVAX HB - hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml4 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp10 mcg/ml

4 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp40 mcg/ml

4 BD

REMICADE - infliximab for iv inj 100 mg 5 PARIDAURA - auranofin cap 3 mg 4ROTARIX - rotavirus vaccine, live for oral susp 4ROTATEQ - rotavirus vaccine, live oral pentavalent soln 4SANDIMMUNE - cyclosporine oral soln 100 mg/ml 4 BDSIMULECT - basiliximab for iv soln 10 mg 5 BDSIMULECT - basiliximab for iv soln 20 mg 5 BDsirolimus tab 0.5 mg 2 BDsirolimus tab 1 mg 2 BDsirolimus tab 2 mg 5 BDSTELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml 5 PASTELARA - ustekinumab soln prefilled syringe 90 mg/ml 5 PASYNAGIS - palivizumab im soln 50 mg/0.5ml* 5SYNAGIS - palivizumab im soln 100 mg/ml* 5tacrolimus cap 0.5 mg 2 BDtacrolimus cap 1 mg 2 BDtacrolimus cap 5 mg 2 BDTENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu 3TETANUS/DIPHTHERIA TOXOID - tetanus-diphtheria toxoids (td)

inj 2-2 lf/0.5ml3

THALOMID - thalidomide cap 50 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 100 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 150 mg 5 PA, QL (60 capsules/30 days)

2016


93

Drug Name Drug Tier Requirements/LimitsTHALOMID - thalidomide cap 200 mg 5 PA, QL (60 capsules/30 days)THYMOGLOBULIN - anti-thymocyte globulin for iv soln 25 mg

(lymphocyte ig)5 BD

TRUMENBA - meningococcal group b vac (recomb) im suspprefilled syr

4

TWINRIX - hepatitis a (inact)-hep b (recomb) vac inj 720-20 elu-mcg/ml

4

TYPHIM VI - typhoid vi polysaccharide intramuscular vac inj25 mcg/0.5ml

4

TYSABRI - natalizumab for iv inj conc 300 mg/15ml* 5 PAVAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml 4VAQTA - hepatitis a vaccine inj susp 50 unit/ml 4VARIVAX - varicella virus vac live for subcutaneous inj 1350

pfu/0.5ml4

YF-VAX - yellow fever vaccine subcutaneous inj 4ZORTRESS - everolimus tab 0.25 mg 4 BDZORTRESS - everolimus tab 0.5 mg 5 BDZORTRESS - everolimus tab 0.75 mg 5 BDZOSTAVAX - zoster vaccine live for inj 19400 unit/0.65ml 4 QL (1 vaccine/lifetime)Inflammatory Bowel Disease AgentsAPRISO - mesalamine cap sr 24hr 0.375 gm 4ASACOL HD - mesalamine tab delayed release 800 mg 3balsalazide disodium cap 750 mg 2budesonide delayed release particles cap 3 mg 5CANASA - mesalamine suppos 1000 mg 3DELZICOL - mesalamine cap dr 400 mg 3DIPENTUM - olsalazine sodium cap 250 mg 5hydrocortisone enema 100 mg/60ml 2hydrocortisone rectal cream 1% 2hydrocortisone rectal cream 2.5% 2LIALDA - mesalamine tab delayed release 1.2 gm 4mesalamine enema 4 gm 2PENTASA - mesalamine cap cr 250 mg 4PENTASA - mesalamine cap cr 500 mg 4sulfasalazine tab delayed release 500 mg 2sulfasalazine tab 500 mg 2Metabolic Bone Disease Agentsalendronate sodium tab 5 mg 1 QL (30 tablets/30 days)alendronate sodium tab 10 mg 1 QL (120 tablets/30 days)alendronate sodium tab 35 mg 1 QL (4 tablets/28 days)

2016


Drug Name Drug Tier Requirements/Limitsalendronate sodium tab 70 mg 1 QL (4 tablets/28 days)calcitonin (salmon) nasal soln 200 unit/act 2calcitriol cap 0.25 mcg 2calcitriol cap 0.5 mcg 2calcitriol inj 1 mcg/ml 2calcitriol oral soln 1 mcg/ml 2ETIDRONATE DISODIUM - etidronate disodium tab 200 mg 4ETIDRONATE DISODIUM - etidronate disodium tab 400 mg 4FORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml 5 PAFORTICAL - calcitonin (salmon) nasal soln 200 unit/act 4ibandronate sodium iv soln 3 mg/3ml 2ibandronate sodium tab 150 mg 2 QL (1 tablet/28 days)MIACALCIN - calcitonin (salmon) inj 200 unit/ml 4paricalcitol cap 1 mcg 2paricalcitol cap 2 mcg 2paricalcitol cap 4 mcg 2paricalcitol iv soln 2 mcg/ml 2paricalcitol iv soln 5 mcg/ml 2PROLIA - denosumab inj 60 mg/ml 4 PArisedronate sodium tab delayed release 35 mg 2 QL (4 tablets/28 days)risedronate sodium tab 5 mg 2 QL (30 tablets/30 days)risedronate sodium tab 30 mg 2 QL (30 tablets/30 days)risedronate sodium tab 35 mg 2 QL (4 tablets/28 days)risedronate sodium tab 150 mg 2 QL (1 tablet/28 days)XGEVA - denosumab inj 120 mg/1.7ml 5ZEMPLAR - paricalcitol iv soln 2 mcg/ml 3ZEMPLAR - paricalcitol iv soln 5 mcg/ml 3zoledronic acid inj conc for iv infusion 4 mg/5ml 2zoledronic acid iv soln 5 mg/100ml 2ZOMETA - zoledronic acid iv soln 4 mg/100ml 5Ophthalmic AgentsALPHAGAN P - brimonidine tartrate ophth soln 0.1% 4azelastine hcl ophth soln 0.05% 2AZOPT - brinzolamide ophth susp 1% 4BACITRACIN - bacitracin ophth oint 500 unit/gm 4bacitracin-polymyxin b ophth oint 2bacitracin-polymyxin-neomycin-hc ophth oint 1% 2BESIVANCE - besifloxacin hcl ophth susp 0.6% 4

2016


95

Drug Name Drug Tier Requirements/Limitsbetaxolol hcl ophth soln 0.5% 2BETOPTIC-S - betaxolol hcl ophth susp 0.25% 4brimonidine tartrate ophth soln 0.15% 2brimonidine tartrate ophth soln 0.2% 2bromfenac sodium ophth soln 0.09% (once-daily) 2carteolol hcl ophth soln 1% 2ciprofloxacin hcl ophth soln 0.3% 2COMBIGAN - brimonidine tartrate-timolol maleate ophth soln

0.2-0.5%3

cromolyn sodium ophth soln 4% 2dexamethasone sodium phosphate ophth soln 0.1% 2diclofenac sodium ophth soln 0.1% 2dorzolamide hcl ophth soln 2% 2dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml 2DUREZOL - difluprednate ophth emulsion 0.05% 3epinastine hcl ophth soln 0.05% 2erythromycin ophth oint 5 mg/gm 2fluorometholone ophth susp 0.1% 2flurbiprofen sodium ophth soln 0.03% 2gentamicin sulfate ophth oint 0.3% 2gentamicin sulfate ophth soln 0.3% 2ILEVRO - nepafenac ophth susp 0.3% 3ISTALOL - timolol maleate ophth soln 0.5% (once-daily) 4ketorolac tromethamine ophth soln 0.4% 2ketorolac tromethamine ophth soln 0.5% 2LACRISERT - artificial tear ophth insert 4latanoprost ophth soln 0.005% 2levobunolol hcl ophth soln 0.5% 2LOTEMAX - loteprednol etabonate ophth gel 0.5% 3LOTEMAX - loteprednol etabonate ophth oint 0.5% 3LOTEMAX - loteprednol etabonate ophth susp 0.5% 3LUMIGAN - bimatoprost ophth soln 0.01% 3MOXEZA - moxifloxacin hcl ophth soln 0.5% (2 times daily) 4NATACYN - natamycin ophth susp 5% 4neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 2neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml 2neomycin-polymyxin-dexamethasone ophth oint 0.1% 2neomycin-polymyxin-dexamethasone ophth susp 0.1% 2NEVANAC - nepafenac ophth susp 0.1% 3

2016


Drug Name Drug Tier Requirements/Limitsofloxacin ophth soln 0.3% 2olopatadine hcl ophth soln 0.1% 2PATADAY - olopatadine hcl ophth soln 0.2% 3PATANOL - olopatadine hcl ophth soln 0.1% 4PAZEO - olopatadine hcl ophth soln 0.7% 3PHOSPHOLINE IODIDE - echothiophate iodide ophth for soln

0.125%4

pilocarpine hcl ophth soln 1% 2pilocarpine hcl ophth soln 2% 2pilocarpine hcl ophth soln 4% 2polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% 2prednisolone acetate ophth susp 1% 2PROLENSA - bromfenac sodium ophth soln 0.07% 4RESTASIS - cyclosporine (ophth) emulsion 0.05% 3 PASIMBRINZA - brinzolamide-brimonidine tartrate ophth susp 1-0.2% 3sulfacetamide sodium ophth soln 10% 2sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% 2timolol maleate ophth gel forming soln 0.25% 2timolol maleate ophth gel forming soln 0.5% 2timolol maleate ophth soln 0.25% 2timolol maleate ophth soln 0.5% 2TOBRADEX - tobramycin-dexamethasone ophth oint 0.3-0.1% 4tobramycin ophth soln 0.3% 2tobramycin-dexamethasone ophth susp 0.3-0.1% 2TRAVATAN Z - travoprost ophth soln 0.004% 3trifluridine ophth soln 1% 2VIGAMOX - moxifloxacin hcl ophth soln 0.5% 3Otic Agentsacetic acid otic soln 2% 2ACETIC ACID/ALUMINUM ACETATE - acetic acid 2% in aluminum

acetate otic soln4

CIPRODEX - ciprofloxacin-dexamethasone otic susp 0.3-0.1% 4fluocinolone acetonide (otic) oil 0.01% 2hydrocortisone w/ acetic acid otic soln 1-2% 2neomycin-polymyxin-hc otic soln 1% 2neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% 2ofloxacin otic soln 0.3% 2Respiratory Tract/Pulmonary Agentsacetylcysteine inhal soln 10% 2 BD

2016


97

Drug Name Drug Tier Requirements/Limitsacetylcysteine inhal soln 20% 2 BDADCIRCA - tadalafil tab 20 mg 5 PA, QL (60 tablets/30 days)ADEMPAS - riociguat tab 0.5 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1.5 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2.5 mg 5 PA, QL (90 tablets/30 days)ADVAIR DISKUS - fluticasone-salmeterol aer powder ba

100-50 mcg/dose3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba250-50 mcg/dose

3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba500-50 mcg/dose


ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 230-21 mcg/act 3 QL (1 canister/30 days)albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 2 BDalbuterol sulfate soln nebu 0.5% (5 mg/ml) 2 BDalbuterol sulfate soln nebu 0.63 mg/3ml 2 BDalbuterol sulfate soln nebu 1.25 mg/3ml 2 BDalbuterol sulfate syrup 2 mg/5ml 2albuterol sulfate tab sr 12hr 4 mg 2albuterol sulfate tab sr 12hr 8 mg 2albuterol sulfate tab 2 mg 2albuterol sulfate tab 4 mg 2ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba

62.5-25 mcg/inh3 QL (1 package/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breathactiv 100 mcg/act

3 QL (30 blisters/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breathactiv 200 mcg/act

3 QL (30 blisters/30 days)

ASMANEX HFA - mometasone furoate inhal aerosol suspension100 mcg/act

3 QL (1 canister/30 days)

ASMANEX HFA - mometasone furoate inhal aerosol suspension200 mcg/act


ASMANEX TWISTHALER 120 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh






2016


Drug Name Drug Tier Requirements/LimitsASMANEX TWISTHALER 30 METERED DOSES - mometasone

furoate inhal powd 220 mcg/inh3 QL (1 canister/30 days)





ATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/act

4 QL (2 canisters/30 days)

azelastine hcl nasal spray 0.1% (137 mcg/spray) 2 QL (2 bottles/30 days)azelastine hcl nasal spray 0.15% (205.5 mcg/spray) 2 QL (2 bottles/30 days)BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba

100-25 mcg/inh3 QL (1 package/30 days)

BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba200-25 mcg/inh

3 QL (1 package/30 days)

caffeine citrate oral soln 60 mg/3ml 2clemastine fumarate tab 2.68 mg# 4 PACOMBIVENT RESPIMAT - ipratropium-albuterol inhal aerosol soln

20-100 mcg/act4 QL (2 canisters/30 days)

CROMOLYN SODIUM - cromolyn sodium soln nebu 20 mg/2ml 3 BDDALIRESP - roflumilast tab 500 mcg 4DULERA - mometasone furoate-formoterol fumarate aerosol

100-5 mcg/act4 QL (1 canister/30 days)

DULERA - mometasone furoate-formoterol fumarate aerosol200-5 mcg/act


EPIPEN 2-PAK - epinephrine solution auto-injector 0.3 mg/0.3ml(1:1000)

3

EPIPEN-JR 2-PAK - epinephrine solution auto-injector0.15 mg/0.3ml (1:2000)

3

ESBRIET - pirfenidone cap 267 mg 5 PA, QL (270 capsules/30 days)FLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/

blister3 QL (1 inhaler/30 days)

FLOVENT DISKUS - fluticasone propionate aer pow ba 100 mcg/blister


FLOVENT DISKUS - fluticasone propionate aer pow ba 250 mcg/blister

3 QL (4 inhalers/30 days)

FLOVENT HFA - fluticasone propionate hfa inhal aero 44 mcg/act(50/valve)


FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act(125/valve)


FLOVENT HFA - fluticasone propionate hfa inhal aer 220 mcg/act(250/valve)

3 QL (2 canisters/30 days)

fluticasone propionate nasal susp 50 mcg/act 2 QL (1 bottle/30 days)GRASTEK - timothy grass pollen allergen ext tab sl 2800 bau 4 PA, QL (30 tablets/30 days)

2016


99

Drug Name Drug Tier Requirements/Limitshydroxyzine hcl syrup 10 mg/5ml# 4 PAhydroxyzine hcl tab 10 mg# 4 PAhydroxyzine hcl tab 25 mg# 4 PAhydroxyzine hcl tab 50 mg# 4 PAINCRUSE ELLIPTA - umeclidinium br aero powd breath act

62.5 mcg/inh3 QL (30 blisters/30 days)

ipratropium bromide nasal soln 0.03% (21 mcg/spray) 2 QL (2 bottles/30 days)ipratropium bromide nasal soln 0.06% (42 mcg/spray) 2 QL (3 bottles/30 days)KALYDECO - ivacaftor packet 50 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor packet 75 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor tab 150 mg 5 PA, QL (60 tablets/30 days)LETAIRIS - ambrisentan tab 5 mg* 5 PA, QL (30 tablets/30 days)LETAIRIS - ambrisentan tab 10 mg* 5 PA, QL (30 tablets/30 days)levocetirizine dihydrochloride tab 5 mg 2montelukast sodium chew tab 4 mg 2montelukast sodium chew tab 5 mg 2montelukast sodium oral granules packet 4 mg 2montelukast sodium tab 10 mg 2NASONEX - mometasone furoate nasal susp 50 mcg/act 2 QL (2 bottles/30 days)OFEV - nintedanib esylate cap 100 mg 5 PA, QL (60 capsules/30 days)OFEV - nintedanib esylate cap 150 mg 5 PA, QL (60 capsules/30 days)olopatadine hcl nasal soln 0.6% 2 QL (1 bottle/30 days)OPSUMIT - macitentan tab 10 mg* 5 PA, QL (30 tablets/30 days)ORALAIR - grass mixed pollen ext tab sl 300 ir 4 PA, QL (30 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 200-125 mg 5 PA, QL (120 tablets/30 days)PROAIR HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (2 canisters/30 days)PROAIR RESPICLICK - albuterol sulfate aer pow ba 108 mcg/act 3 QL (2 canisters/30 days)PROLASTIN-C - alpha1-proteinase inhibitor (human) for iv soln

1000 mg*5

promethazine hcl suppos 12.5 mg# 4 PApromethazine hcl suppos 25 mg# 4 PApromethazine hcl syrup 6.25 mg/5ml# 4 PApromethazine hcl tab 12.5 mg# 4 PApromethazine hcl tab 25 mg# 4 PApromethazine hcl tab 50 mg# 4 PAPULMOZYME - dornase alfa inhal soln 1 mg/ml 5 BDQVAR - beclomethasone diprop inhal aero soln 40 mcg/act (50/

valve)3 QL (1 canister/30 days)

2016


Drug Name Drug Tier Requirements/LimitsQVAR - beclomethasone diprop inhal aero soln 80 mcg/act (100/

valve)3 QL (2 canisters/30 days)

RAGWITEK - short ragweed pollen allergen extract tab sl 12 amb a1-u

4 PA, QL (30 tablets/30 days)

REMODULIN - treprostinil sodium inj 1 mg/ml* 5 BDREMODULIN - treprostinil sodium inj 2.5 mg/ml* 5 BDREMODULIN - treprostinil sodium inj 5 mg/ml* 5 BDREMODULIN - treprostinil sodium inj 10 mg/ml* 5 BDSEREVENT DISKUS - salmeterol xinafoate aer pow ba 50 mcg/

dose3 QL (1 inhaler/30 days)

sildenafil citrate tab 20 mg 2 PA, QL (90 tablets/30 days)SPIRIVA HANDIHALER - tiotropium bromide monohydrate inhal

cap 18 mcg3 QL (30 capsules/30 days)

SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 1.25 mcg/act


SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 2.5 mcg/act


STIOLTO RESPIMAT - tiotropium br-olodaterol inhal aero soln2.5-2.5 mcg/act


SYMBICORT - budesonide-formoterol fumarate dihyd aerosol80-4.5 mcg/act


SYMBICORT - budesonide-formoterol fumarate dihyd aerosol160-4.5 mcg/act


terbutaline sulfate tab 2.5 mg 2terbutaline sulfate tab 5 mg 2theophylline tab sr 12hr 100 mg 2theophylline tab sr 12hr 200 mg 2theophylline tab sr 12hr 300 mg 2theophylline tab sr 12hr 450 mg 2theophylline tab sr 24hr 400 mg 2theophylline tab sr 24hr 600 mg 2tobramycin nebu soln 300 mg/5ml 5 BDTRACLEER - bosentan tab 62.5 mg* 5 PA, QL (60 tablets/30 days)TRACLEER - bosentan tab 125 mg* 5 PA, QL (60 tablets/30 days)triamcinolone acetonide nasal aerosol suspension 55 mcg/act 2 QL (1 bottle/30 days)TYZINE PEDIATRIC NASAL DROPS - tetrahydrozoline hcl nasal

soln 0.05%4

UPTRAVI - selexipag tab therapy pack 200 mcg (140) & 800 mcg(60)*

5 PA, QL (1 pack (200tablets)/28 days)

UPTRAVI - selexipag tab 200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 400 mcg* 5 PA, QL (60 tablets/30 days)

2016


101

Drug Name Drug Tier Requirements/LimitsUPTRAVI - selexipag tab 600 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 800 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1000 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1600 mcg* 5 PA, QL (60 tablets/30 days)VENTAVIS - iloprost inhalation solution 10 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTAVIS - iloprost inhalation solution 20 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (2 canisters/30 days)XOLAIR - omalizumab for inj 150 mg* 5 PAXOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/act 4 QL (2 canisters/30 days)zafirlukast tab 10 mg 2zafirlukast tab 20 mg 2Skeletal Muscle Relaxantscyclobenzaprine hcl tab 5 mg# 4 PAcyclobenzaprine hcl tab 7.5 mg# 4 PAcyclobenzaprine hcl tab 10 mg# 4 PAmethocarbamol tab 500 mg# 4methocarbamol tab 750 mg# 4Sleep Disorder Agentsarmodafinil tab 50 mg 2 PA, QL (30 tablets/30 days)armodafinil tab 150 mg 2 PA, QL (30 tablets/30 days)armodafinil tab 250 mg 2 PA, QL (30 tablets/30 days)HETLIOZ - tasimelteon capsule 20 mg* 5 PA, QL (30 capsules/30 days)modafinil tab 100 mg 2 PA, QL (30 tablets/30 days)modafinil tab 200 mg 5 PA, QL (30 tablets/30 days)NUVIGIL - armodafinil tab 50 mg 4 PA, QL (30 tablets/30 days)NUVIGIL - armodafinil tab 150 mg 4 PA, QL (30 tablets/30 days)NUVIGIL - armodafinil tab 200 mg 4 PA, QL (30 tablets/30 days)NUVIGIL - armodafinil tab 250 mg 4 PA, QL (30 tablets/30 days)SILENOR - doxepin hcl tab 3 mg 3 QL (30 tablets/30 days)SILENOR - doxepin hcl tab 6 mg 3 QL (30 tablets/30 days)XYREM - sodium oxybate oral solution 500 mg/ml* 5 PA, QL (540 mls/30 days)zaleplon cap 5 mg# 3 PAzaleplon cap 10 mg# 3 PAzolpidem tartrate tab 5 mg# 4 PAzolpidem tartrate tab 10 mg# 4 PATherapeutic Nutrients/Minerals/Electrolytesamino acid infusion 6% 2 BD

2016


Drug Name Drug Tier Requirements/Limitsamino acid infusion 8% 2 BDamino acid infusion 15% 2 BDCARBAGLU - carglumic acid tab 200 mg 5CHEMET - succimer cap 100 mg 4CUPRIMINE - penicillamine cap 250 mg 5DEPEN TITRATABS - penicillamine tab 250 mg 5dextrose inj 5% 2dextrose inj 10% 2dextrose 5% in lactated ringers 2dextrose 2.5% w/ sodium chloride 0.45% 2dextrose 5% w/ sodium chloride 0.2% 2dextrose 5% w/ sodium chloride 0.33% 2dextrose 5% w/ sodium chloride 0.45% 2dextrose 5% w/ sodium chloride 0.9% 2electrolyte-m in d5w soln 2EXJADE - deferasirox tab for oral susp 125 mg* 5EXJADE - deferasirox tab for oral susp 250 mg* 5EXJADE - deferasirox tab for oral susp 500 mg* 5fat emulsion iv soln 20% 2 BDfomepizole inj 1 gm/ml (for iv infusion) 5JADENU - deferasirox tab 90 mg 5JADENU - deferasirox tab 180 mg 5JADENU - deferasirox tab 360 mg 5KCL 0.15%/D5W/LR - potassium chloride 20 meq/l (0.15%) in d5w

lactated ringers4

KCL 0.3%/D5W/LR IV LACTATED RINGERS - potassium chloride40 meq/l (0.3%) in d5w lactated ringers

4

kcl 20 meq/l (0.15%) in nacl 0.45% inj 2kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj 2kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj 2kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj 2kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj 2kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj 2kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj 2lactated ringer's solution 2levocarnitine oral soln 1 gm/10ml (10%) 2levocarnitine tab 330 mg 2magnesium sulfate inj 50% 2potassium chloride cap cr 8 meq 2

2016


103

Drug Name Drug Tier Requirements/Limitspotassium chloride cap cr 10 meq 2potassium chloride inj 2 meq/ml 2potassium chloride microencapsulated crys cr tab 10 meq 2potassium chloride microencapsulated crys cr tab 20 meq 2potassium chloride tab cr 8 meq (600 mg) 2potassium chloride tab cr 10 meq 2potassium chloride 20 meq/l (0.15%) in dextrose 5% inj 2potassium chloride 40 meq/l (0.3%) in dextrose 5% inj 2potassium citrate tab cr 5 meq (540 mg) 2potassium citrate tab cr 10 meq (1080 mg) 2potassium citrate tab cr 15 meq (1620 mg) 2SAMSCA - tolvaptan tab 15 mg 5 PASAMSCA - tolvaptan tab 30 mg 5 PAsodium chloride inj 0.45% 2sodium chloride irrigation soln 0.9% 2sodium chloride iv soln 0.9% 2sodium polystyrene sulfonate oral susp 15 gm/60ml 2sodium polystyrene sulfonate powder 2sodium polystyrene sulfonate rectal susp 30 gm/120ml 2SYPRINE - trientine hcl cap 250 mg 5water for irrigation, sterile irrigation soln 2

2016

104

INDEX

Aabacavir sulfate-lamivudine tab 600-300

mg................................................................................45abacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg........................................................45abacavir sulfate tab 300 mg.......................................45ABILIFY MAINTENA....................................................19ABILIFY MAINTENA....................................................19ABILIFY MAINTENA....................................................40ABILIFY MAINTENA....................................................40ABILIFY MAINTENA....................................................52ABILIFY MAINTENA....................................................52ABRAXANE...................................................................29ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1acamprosate calcium tab delayed release 333

mg..................................................................................5acarbose tab 100 mg.................................................. 54acarbose tab 25 mg.................................................... 54acarbose tab 50 mg.................................................... 54acebutolol hcl cap 200 mg..........................................60acebutolol hcl cap 400 mg..........................................60acetaminophen w/ codeine soln 120-12

mg/5ml.......................................................................... 1acetaminophen w/ codeine tab 300-15

mg..................................................................................1acetaminophen w/ codeine tab 300-30

mg..................................................................................1acetaminophen w/ codeine tab 300-60

mg..................................................................................1ACETAZOLAMIDE....................................................... 60acetazolamide cap sr 12hr 500 mg........................... 60acetazolamide tab 250 mg......................................... 60ACETIC ACID/ALUMINUM ACETATE...................... 96acetic acid otic soln 2%.............................................. 96acetylcysteine inhal soln 10%.................................... 96acetylcysteine inhal soln 20%.................................... 97acitretin cap 10 mg......................................................73acitretin cap 17.5 mg...................................................73acitretin cap 25 mg......................................................73ACTHIB..........................................................................89ACTIMMUNE................................................................ 89acyclovir cap 200 mg.................................................. 45acyclovir oint 5%..........................................................73acyclovir sodium for inj 500 mg................................. 45

acyclovir sodium iv soln 50 mg/ml.............................45acyclovir susp 200 mg/5ml......................................... 45acyclovir tab 400 mg................................................... 45acyclovir tab 800 mg................................................... 45ADACEL........................................................................ 89ADAGEN........................................................................77ADASUVE..................................................................... 40ADCIRCA...................................................................... 97adefovir dipivoxil tab 10 mg........................................45ADEMPAS..................................................................... 97ADEMPAS..................................................................... 97ADEMPAS..................................................................... 97ADEMPAS..................................................................... 97ADEMPAS..................................................................... 97ADVAIR DISKUS..........................................................97ADVAIR DISKUS..........................................................97ADVAIR DISKUS..........................................................97ADVAIR HFA.................................................................97ADVAIR HFA.................................................................97ADVAIR HFA.................................................................97AFINITOR......................................................................29AFINITOR......................................................................29AFINITOR......................................................................29AFINITOR......................................................................29AFINITOR DISPERZ................................................... 29AFINITOR DISPERZ................................................... 29AFINITOR DISPERZ................................................... 29AGGRENOX................................................................. 57ALBENZA...................................................................... 38albuterol sulfate soln nebu 0.083% (2.5

mg/3ml).......................................................................97albuterol sulfate soln nebu 0.5% (5 mg/

ml)................................................................................97albuterol sulfate soln nebu 0.63

mg/3ml........................................................................ 97albuterol sulfate soln nebu 1.25

mg/3ml........................................................................ 97albuterol sulfate syrup 2 mg/5ml................................97albuterol sulfate tab 2 mg...........................................97albuterol sulfate tab 4 mg...........................................97albuterol sulfate tab sr 12hr 4 mg..............................97albuterol sulfate tab sr 12hr 8 mg..............................97alclometasone dipropionate cream

0.05%..........................................................................73alclometasone dipropionate oint

0.05%..........................................................................73ALCOHOL SWABS......................................................54ALDURAZYME............................................................. 77ALECENSA................................................................... 29alendronate sodium tab 10 mg.................................. 93alendronate sodium tab 35 mg.................................. 93alendronate sodium tab 5 mg.................................... 93

2016

105

alendronate sodium tab 70 mg.................................. 94alfuzosin hcl tab sr 24hr 10 mg..................................80ALIMTA.......................................................................... 29ALIMTA.......................................................................... 29ALINIA............................................................................38ALINIA............................................................................38allopurinol tab 100 mg.................................................25allopurinol tab 300 mg.................................................25ALOPRIM...................................................................... 25alosetron hcl tab 0.5 mg............................................. 78alosetron hcl tab 1 mg................................................ 78ALOXI.............................................................................23ALPHAGAN P...............................................................94AMANTADINE HCL..................................................... 38AMANTADINE HCL..................................................... 45amantadine hcl cap 100 mg.......................................38amantadine hcl cap 100 mg.......................................45amantadine hcl syrup 50 mg/5ml...............................38amantadine hcl syrup 50 mg/5ml...............................45AMBISOME...................................................................24amifostine crystalline for inj 500 mg.......................... 29amikacin sulfate inj 1 gm/4ml (250 mg/

ml)..................................................................................6amikacin sulfate inj 500 mg/2ml (250 mg/

ml)..................................................................................6amiloride & hydrochlorothiazide tab 5-50

mg................................................................................60amiloride hcl tab 5 mg.................................................60amino acid infusion 15%...........................................102amino acid infusion 6%.............................................101amino acid infusion 8%.............................................102amiodarone hcl tab 200 mg........................................60amiodarone hcl tab 400 mg........................................60AMITIZA.........................................................................78AMITIZA.........................................................................78amitriptyline hcl tab 100 mg....................................... 19amitriptyline hcl tab 10 mg..........................................19amitriptyline hcl tab 150 mg....................................... 19amitriptyline hcl tab 25 mg..........................................19amitriptyline hcl tab 50 mg..........................................19amitriptyline hcl tab 75 mg..........................................19amlodipine besylate-atorvastatin calcium tab 10-10

mg................................................................................60amlodipine besylate-atorvastatin calcium tab 10-20



mg................................................................................60amlodipine besylate-atorvastatin calcium tab 2.5-10

mg................................................................................60

amlodipine besylate-atorvastatin calcium tab 2.5-20mg................................................................................60

amlodipine besylate-atorvastatin calcium tab 2.5-40mg................................................................................60

amlodipine besylate-atorvastatin calcium tab 5-10mg................................................................................60




amlodipine besylate-benazepril hcl cap 10-20mg................................................................................60


amlodipine besylate-benazepril hcl cap 2.5-10mg................................................................................60




amlodipine besylate tab 10 mg..................................60amlodipine besylate tab 2.5 mg.................................60amlodipine besylate tab 5 mg.................................... 60amlodipine besylate-valsartan tab 10-160

mg................................................................................60amlodipine besylate-valsartan tab 10-320



mg................................................................................60amlodipine-valsartan-hydrochlorothiazide tab

10-160-12.5 mg.........................................................60amlodipine-valsartan-hydrochlorothiazide tab

10-160-25 mg............................................................60amlodipine-valsartan-hydrochlorothiazide tab

10-320-25 mg............................................................61amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg...........................................................60amlodipine-valsartan-hydrochlorothiazide tab

5-160-25 mg.............................................................. 60AMOXAPINE.................................................................19AMOXAPINE.................................................................19AMOXAPINE.................................................................19AMOXAPINE.................................................................19amoxicillin (trihydrate) cap 250 mg..............................6amoxicillin (trihydrate) cap 500 mg..............................6

2016

106

amoxicillin (trihydrate) for susp 125mg/5ml.......................................................................... 6




amoxicillin (trihydrate) tab 500 mg...............................6amoxicillin (trihydrate) tab 875 mg...............................6amoxicillin & k clavulanate chew tab 200-28.5

mg..................................................................................6amoxicillin & k clavulanate chew tab 400-57

mg..................................................................................6amoxicillin & k clavulanate for susp 200-28.5

mg/5ml.......................................................................... 6amoxicillin & k clavulanate for susp 400-57

mg/5ml.......................................................................... 6amoxicillin & k clavulanate for susp 600-42.9

mg/5ml.......................................................................... 6amoxicillin & k clavulanate tab 250-125

mg..................................................................................6amoxicillin & k clavulanate tab 500-125

mg..................................................................................6amoxicillin & k clavulanate tab 875-125

mg..................................................................................6amphetamine-dextroamphetamine cap sr 24hr 10

mg................................................................................71amphetamine-dextroamphetamine cap sr 24hr 15





mg................................................................................71AMPHOTERICIN B......................................................24AMPICILLIN.................................................................... 6AMPICILLIN.................................................................... 6ampicillin & sulbactam sodium for inj 3 (2-1)

gm..................................................................................6ampicillin cap 250 mg....................................................6ampicillin cap 500 mg....................................................6AMPICILLIN SODIUM................................................... 6ampicillin sodium for inj 1 gm.......................................6ampicillin sodium for inj 250 mg...................................6ampicillin sodium for inj 2 gm.......................................6ampicillin sodium for inj 500 mg...................................6ampicillin sodium for iv soln 10 gm..............................6ampicillin sodium for iv soln 2 gm................................6

AMPYRA........................................................................71ANADROL-50............................................................... 83anagrelide hcl cap 0.5 mg.......................................... 57anagrelide hcl cap 1 mg............................................. 57anastrozole tab 1 mg...................................................29ANDRODERM.............................................................. 83ANDRODERM.............................................................. 83ANDROGEL.................................................................. 83ANDROGEL.................................................................. 83ANDROGEL.................................................................. 83ANDROGEL.................................................................. 83ANDROGEL PUMP..................................................... 84ANDROID......................................................................84ANDROXY.....................................................................84ANORO ELLIPTA.........................................................97APOKYN........................................................................38APRISO......................................................................... 93APTIOM......................................................................... 13APTIOM......................................................................... 13APTIOM......................................................................... 13APTIOM......................................................................... 13APTIVUS....................................................................... 45APTIVUS....................................................................... 45ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARANESP ALBUMIN FREE.......................................57ARCALYST....................................................................89aripiprazole orally disintegrating tab 10

mg................................................................................19aripiprazole orally disintegrating tab 10





mg................................................................................52aripiprazole oral solution 1 mg/ml..............................19

2016

107

aripiprazole oral solution 1 mg/ml..............................40aripiprazole oral solution 1 mg/ml..............................52aripiprazole tab 10 mg................................................ 19aripiprazole tab 10 mg................................................ 40aripiprazole tab 10 mg................................................ 52aripiprazole tab 15 mg................................................ 19aripiprazole tab 15 mg................................................ 40aripiprazole tab 15 mg................................................ 52aripiprazole tab 20 mg................................................ 19aripiprazole tab 20 mg................................................ 40aripiprazole tab 20 mg................................................ 52aripiprazole tab 2 mg...................................................19aripiprazole tab 2 mg...................................................40aripiprazole tab 2 mg...................................................52aripiprazole tab 30 mg................................................ 19aripiprazole tab 30 mg................................................ 40aripiprazole tab 30 mg................................................ 52aripiprazole tab 5 mg...................................................19aripiprazole tab 5 mg...................................................40aripiprazole tab 5 mg...................................................52armodafinil tab 150 mg............................................. 101armodafinil tab 250 mg............................................. 101armodafinil tab 50 mg............................................... 101ARNUITY ELLIPTA......................................................97ARNUITY ELLIPTA......................................................97ARRANON.................................................................... 29ARZERRA..................................................................... 29ARZERRA..................................................................... 29ASACOL HD.................................................................93ASMANEX HFA............................................................97ASMANEX HFA............................................................97ASMANEX TWISTHALER 120 METERED

DOSES....................................................................... 97ASMANEX TWISTHALER 14 METERED





DOSES....................................................................... 98atenolol & chlorthalidone tab 100-25

mg................................................................................61atenolol & chlorthalidone tab 50-25 mg.................... 61atenolol tab 100 mg.....................................................61atenolol tab 25 mg.......................................................61atenolol tab 50 mg.......................................................61ATGAM.......................................................................... 89atorvastatin calcium tab 10 mg.................................. 61atorvastatin calcium tab 20 mg.................................. 61

atorvastatin calcium tab 40 mg.................................. 61atorvastatin calcium tab 80 mg.................................. 61atovaquone-proguanil hcl tab 250-100

mg................................................................................38atovaquone-proguanil hcl tab 62.5-25

mg................................................................................38atovaquone susp 750 mg/5ml....................................38ATRIPLA........................................................................ 45ATROVENT HFA..........................................................98AVASTIN........................................................................29AVASTIN........................................................................29AVELOX...........................................................................6AVONEX........................................................................ 71AVONEX........................................................................ 71AVONEX PEN.............................................................. 71AXIRON......................................................................... 84azacitidine for inj 100 mg............................................29AZACTAM........................................................................6AZACTAM........................................................................6AZASAN........................................................................ 89AZASAN........................................................................ 89AZATHIOPRINE........................................................... 89azathioprine tab 50 mg............................................... 89azelastine hcl nasal spray 0.1% (137 mcg/

spray)..........................................................................98azelastine hcl nasal spray 0.15% (205.5 mcg/

spray)..........................................................................98azelastine hcl ophth soln 0.05%................................ 94AZELEX......................................................................... 73AZILECT........................................................................38AZILECT........................................................................38AZITHROMYCIN............................................................ 6azithromycin for susp 100 mg/5ml...............................6azithromycin for susp 200 mg/5ml...............................6azithromycin iv for soln 500 mg................................... 6azithromycin tab 250 mg...............................................7azithromycin tab 500 mg...............................................7azithromycin tab 600 mg...............................................7AZOPT........................................................................... 94aztreonam for inj 1 gm.................................................. 7aztreonam for inj 2 gm.................................................. 7BBACITRACIN................................................................ 94bacitracin-polymyxin b ophth oint.............................. 94bacitracin-polymyxin-neomycin-hc ophth oint

1%............................................................................... 94baclofen tab 10 mg......................................................45baclofen tab 20 mg......................................................45balsalazide disodium cap 750 mg............................. 93BANZEL.........................................................................13BANZEL.........................................................................13

2016

108

BANZEL.........................................................................13BARACLUDE................................................................ 45BCG VACCINE.............................................................89BELEODAQ.................................................................. 29benazepril & hydrochlorothiazide tab 10-12.5

mg................................................................................61benazepril & hydrochlorothiazide tab 20-12.5

mg................................................................................61benazepril & hydrochlorothiazide tab 20-25

mg................................................................................61benazepril & hydrochlorothiazide tab 5-6.25

mg................................................................................61benazepril hcl tab 10 mg............................................ 61benazepril hcl tab 20 mg............................................ 61benazepril hcl tab 40 mg............................................ 61benazepril hcl tab 5 mg.............................................. 61BENDEKA..................................................................... 29BENLYSTA.................................................................... 89BENLYSTA.................................................................... 89benzoyl peroxide-erythromycin gel

5-3%............................................................................73benztropine mesylate tab 0.5 mg.............................. 39benztropine mesylate tab 1 mg..................................39benztropine mesylate tab 2 mg..................................39BESIVANCE..................................................................94betamethasone dipropionate augmented cream

0.05%..........................................................................73betamethasone dipropionate augmented gel

0.05%..........................................................................73betamethasone dipropionate augmented lotion

0.05%..........................................................................73betamethasone dipropionate augmented oint

0.05%..........................................................................73betamethasone dipropionate cream

0.05%..........................................................................73betamethasone dipropionate lotion

0.05%..........................................................................73betamethasone dipropionate oint

0.05%..........................................................................74betamethasone valerate cream 0.1%....................... 74betamethasone valerate lotion 0.1%.........................74betamethasone valerate oint 0.1%............................74BETASERON................................................................ 71betaxolol hcl ophth soln 0.5%.................................... 95betaxolol hcl tab 10 mg...............................................61betaxolol hcl tab 20 mg...............................................61bethanechol chloride tab 10 mg.................................80bethanechol chloride tab 25 mg.................................81bethanechol chloride tab 50 mg.................................81bethanechol chloride tab 5 mg...................................80BETOPTIC-S.................................................................95bexarotene cap 75 mg................................................ 29

BEXSERO..................................................................... 89bicalutamide tab 50 mg...............................................29BICILLIN L-A...................................................................7BICILLIN L-A...................................................................7BICILLIN L-A...................................................................7BICNU............................................................................29BILTRICIDE...................................................................38bisoprolol & hydrochlorothiazide tab 10-6.25

mg................................................................................61bisoprolol & hydrochlorothiazide tab 2.5-6.25

mg................................................................................61bisoprolol & hydrochlorothiazide tab 5-6.25

mg................................................................................61bisoprolol fumarate tab 10 mg................................... 61bisoprolol fumarate tab 5 mg..................................... 61BLEO 15K..................................................................... 29bleomycin sulfate for inj 15 unit................................. 29bleomycin sulfate for inj 30 unit................................. 29BLINCYTO.....................................................................29BOOSTRIX....................................................................89BOSULIF....................................................................... 30BOSULIF....................................................................... 30BREO ELLIPTA............................................................ 98BREO ELLIPTA............................................................ 98BRILINTA.......................................................................57BRILINTA.......................................................................57brimonidine tartrate ophth soln 0.15%...................... 95brimonidine tartrate ophth soln 0.2%........................ 95BRIVIACT......................................................................13BRIVIACT......................................................................14BRIVIACT......................................................................14BRIVIACT......................................................................14BRIVIACT......................................................................14BRIVIACT......................................................................14BRIVIACT......................................................................14bromfenac sodium ophth soln 0.09% (once-

daily)............................................................................95bromocriptine mesylate cap 5 mg..............................39bromocriptine mesylate cap 5 mg..............................87bromocriptine mesylate tab 2.5 mg........................... 39bromocriptine mesylate tab 2.5 mg........................... 87budesonide delayed release particles cap 3

mg................................................................................93bumetanide inj 0.25 mg/ml......................................... 61bumetanide tab 0.5 mg............................................... 61bumetanide tab 1 mg.................................................. 61bumetanide tab 2 mg.................................................. 61BUPHENYL...................................................................77buprenorphine hcl-naloxone hcl sl tab 2-0.5

mg..................................................................................5buprenorphine hcl-naloxone hcl sl tab 8-2

mg..................................................................................5

2016

109

buprenorphine hcl sl tab 2 mg......................................5buprenorphine hcl sl tab 8 mg......................................5bupropion hcl (smoking deterrent) tab sr 12hr 150

mg..................................................................................5bupropion hcl tab 100 mg...........................................19bupropion hcl tab 75 mg.............................................19bupropion hcl tab sr 12hr 100 mg..............................19bupropion hcl tab sr 12hr 150 mg..............................19bupropion hcl tab sr 12hr 200 mg..............................19bupropion hcl tab sr 24hr 150 mg..............................19bupropion hcl tab sr 24hr 300 mg..............................19buspirone hcl tab 10 mg............................................. 50buspirone hcl tab 15 mg............................................. 50buspirone hcl tab 30 mg............................................. 50buspirone hcl tab 5 mg............................................... 50buspirone hcl tab 7.5 mg............................................ 50BUSULFEX................................................................... 30butalbital-acetaminophen-caff w/ cod cap

50-300-40-30 mg...................................................... 27butalbital-acetaminophen-caff w/ cod cap

50-325-40-30 mg...................................................... 27butalbital-aspirin-caff w/ codeine cap 50-325-40-30

mg................................................................................27butorphanol tartrate inj 1 mg/ml................................... 1butorphanol tartrate inj 2 mg/ml................................... 1butorphanol tartrate nasal soln 10 mg/

ml................................................................................... 1BUTRANS........................................................................5BUTRANS........................................................................5BUTRANS........................................................................5BUTRANS........................................................................5BUTRANS........................................................................5BYDUREON..................................................................54BYDUREON PEN........................................................ 54Ccabergoline tab 0.5 mg............................................... 87CABOMETYX............................................................... 30CABOMETYX............................................................... 30CABOMETYX............................................................... 30caffeine citrate oral soln 60 mg/3ml...........................98calcipotriene cream 0.005%.......................................74calcipotriene oint 0.005%............................................74calcipotriene soln 0.005% (50 mcg/ml).....................74calcitonin (salmon) nasal soln 200 unit/

act................................................................................94calcitriol cap 0.25 mcg................................................ 94calcitriol cap 0.5 mcg...................................................94calcitriol inj 1 mcg/ml...................................................94calcitriol oral soln 1 mcg/ml........................................94calcium acetate cap 667 mg...................................... 81calcium acetate tab 667 mg....................................... 81

CANASA........................................................................93CANCIDAS....................................................................24CANCIDAS....................................................................24candesartan cilexetil-hydrochlorothiazide tab 16-12.5

mg................................................................................61candesartan cilexetil-hydrochlorothiazide tab 32-12.5

mg................................................................................61candesartan cilexetil-hydrochlorothiazide tab 32-25

mg................................................................................61candesartan cilexetil tab 16 mg................................. 61candesartan cilexetil tab 32 mg................................. 61candesartan cilexetil tab 4 mg................................... 61candesartan cilexetil tab 8 mg................................... 61CAPASTAT SULFATE..................................................28CAPRELSA................................................................... 30CAPRELSA................................................................... 30captopril tab 100 mg....................................................62captopril tab 12.5 mg...................................................61captopril tab 25 mg......................................................61captopril tab 50 mg......................................................62CARAC.......................................................................... 74CARBAGLU................................................................ 102carbamazepine cap sr 12hr 100 mg..........................14carbamazepine cap sr 12hr 200 mg..........................14carbamazepine cap sr 12hr 300 mg..........................14carbamazepine chew tab 100 mg..............................14carbamazepine susp 100 mg/5ml..............................14carbamazepine tab 200 mg........................................14carbamazepine tab sr 12hr 100 mg.......................... 14carbamazepine tab sr 12hr 200 mg.......................... 14carbamazepine tab sr 12hr 400 mg.......................... 14CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................39CARBIDOPA/LEVODOPA/





ENTACAPONE..........................................................39carbidopa & levodopa orally disintegrating tab

10-100 mg..................................................................39carbidopa & levodopa orally disintegrating tab

25-100 mg..................................................................39carbidopa & levodopa orally disintegrating tab

25-250 mg..................................................................39carbidopa & levodopa tab 10-100 mg....................... 39carbidopa & levodopa tab 25-100 mg....................... 39carbidopa & levodopa tab 25-250 mg....................... 39

2016

110

carbidopa & levodopa tab cr 25-100mg................................................................................39

carbidopa & levodopa tab cr 50-200mg................................................................................39

carbidopa tab 25 mg................................................... 39carboplatin iv soln 150 mg/15ml................................ 30carboplatin iv soln 450 mg/45ml................................ 30carboplatin iv soln 50 mg/5ml.................................... 30carboplatin iv soln 600 mg/60ml................................ 30carteolol hcl ophth soln 1%........................................ 95carvedilol tab 12.5 mg.................................................62carvedilol tab 25 mg....................................................62carvedilol tab 3.125 mg...............................................62carvedilol tab 6.25 mg.................................................62cefaclor cap 250 mg......................................................7cefaclor cap 500 mg......................................................7cefadroxil cap 500 mg...................................................7cefadroxil for susp 250 mg/5ml....................................7cefadroxil for susp 500 mg/5ml....................................7cefadroxil tab 1 gm........................................................ 7cefazolin sodium for inj 10 gm..................................... 7cefazolin sodium for inj 1 gm....................................... 7cefazolin sodium for inj 20 gm..................................... 7cefazolin sodium for inj 500 mg................................... 7cefdinir cap 300 mg....................................................... 7cefdinir for susp 125 mg/5ml........................................7cefdinir for susp 250 mg/5ml........................................7cefepime hcl for inj 1 gm.............................................. 7cefepime hcl for inj 2 gm.............................................. 7cefotaxime sodium for inj 10 gm..................................7cefotaxime sodium for inj 1 gm.................................... 7cefotaxime sodium for inj 2 gm.................................... 7cefotaxime sodium for inj 500 mg................................7cefoxitin sodium for inj 10 gm...................................... 7cefoxitin sodium for iv soln 1 gm................................. 7cefoxitin sodium for iv soln 2 gm................................. 7cefpodoxime proxetil for susp 100

mg/5ml.......................................................................... 7cefpodoxime proxetil for susp 50

mg/5ml.......................................................................... 7cefpodoxime proxetil tab 100 mg.................................7cefpodoxime proxetil tab 200 mg.................................7cefprozil for susp 125 mg/5ml...................................... 7cefprozil for susp 250 mg/5ml...................................... 7cefprozil tab 250 mg......................................................8cefprozil tab 500 mg......................................................8ceftazidime for inj 1 gm.................................................8ceftazidime for inj 2 gm.................................................8ceftazidime for inj 6 gm.................................................8ceftazidime for iv soln 1 gm..........................................8ceftazidime for iv soln 2 gm..........................................8CEFTRIAXONE/DEXTROSE....................................... 8

CEFTRIAXONE/DEXTROSE....................................... 8CEFTRIAXONE IN ISO-OSMOTIC............................. 8CEFTRIAXONE IN ISO-OSMOTIC............................. 8ceftriaxone sodium for inj 10 gm..................................8ceftriaxone sodium for inj 1 gm....................................8ceftriaxone sodium for inj 250 mg................................8ceftriaxone sodium for inj 2 gm....................................8ceftriaxone sodium for inj 500 mg................................8ceftriaxone sodium for iv soln 1 gm.............................8ceftriaxone sodium for iv soln 2 gm.............................8cefuroxime axetil tab 250 mg....................................... 8cefuroxime axetil tab 500 mg....................................... 8cefuroxime sodium for inj 1.5 gm.................................8cefuroxime sodium for inj 7.5 gm.................................8cefuroxime sodium for inj 750 mg................................8cefuroxime sodium for iv soln 1.5 gm..........................8celecoxib cap 100 mg................................................... 1celecoxib cap 100 mg................................................. 26celecoxib cap 200 mg................................................... 1celecoxib cap 200 mg................................................. 26celecoxib cap 400 mg................................................... 1celecoxib cap 400 mg................................................. 26celecoxib cap 50 mg......................................................1celecoxib cap 50 mg................................................... 26CELLCEPT INTRAVENOUS...................................... 89CELONTIN.................................................................... 14cephalexin cap 250 mg.................................................8cephalexin cap 500 mg.................................................8cephalexin cap 750 mg.................................................8cephalexin for susp 125 mg/5ml..................................8cephalexin for susp 250 mg/5ml..................................8CEREZYME.................................................................. 77CERVARIX.................................................................... 89CHANTIX......................................................................... 5CHANTIX......................................................................... 5CHANTIX CONTINUING MONTH............................... 5CHANTIX STARTING MONTH PACK.........................5CHEMET..................................................................... 102CHENODAL.................................................................. 78CHLORAMPHENICOL SODIUM

SUCCINATE.................................................................8chlorhexidine gluconate soln 0.12%..........................73chloroquine phosphate tab 250 mg...........................38chloroquine phosphate tab 500 mg...........................38CHLOROTHIAZIDE..................................................... 62chlorothiazide tab 500 mg.......................................... 62CHLORPROMAZINE HCL..........................................23CHLORPROMAZINE HCL..........................................23CHLORPROMAZINE HCL..........................................40CHLORPROMAZINE HCL..........................................40chlorpromazine hcl tab 100 mg..................................23chlorpromazine hcl tab 100 mg..................................40

2016

111

chlorpromazine hcl tab 10 mg....................................23chlorpromazine hcl tab 10 mg....................................40chlorpromazine hcl tab 200 mg..................................23chlorpromazine hcl tab 200 mg..................................40chlorpromazine hcl tab 25 mg....................................23chlorpromazine hcl tab 25 mg....................................40chlorpromazine hcl tab 50 mg....................................23chlorpromazine hcl tab 50 mg....................................40CHLORTHALIDONE....................................................62chlorthalidone tab 25 mg............................................ 62cholestyramine light powder 4 gm/

dose............................................................................ 62cholestyramine light powder packets 4

gm................................................................................62cholestyramine powder 4 gm/dose............................62cholestyramine powder packets 4 gm.......................62choline fenofibrate cap dr 135 mg............................. 62choline fenofibrate cap dr 45 mg............................... 62chorionic gonadotropin for inj 10000

unit...............................................................................83ciclopirox gel 0.77%.................................................... 74ciclopirox olamine cream 0.77%................................74ciclopirox olamine susp 0.77%...................................74ciclopirox shampoo 1%............................................... 74ciclopirox solution 8%..................................................74cidofovir iv inj 75 mg/ml.............................................. 45cilostazol tab 100 mg.................................................. 57cilostazol tab 50 mg.................................................... 57cimetidine hcl soln 300 mg/5ml..................................78cimetidine tab 200 mg.................................................78cimetidine tab 300 mg.................................................78cimetidine tab 400 mg.................................................78cimetidine tab 800 mg.................................................78CINRYZE.......................................................................89CIPRODEX....................................................................96ciprofloxacin 200 mg/100ml in d5w............................. 9ciprofloxacin 400 mg/200ml in d5w............................. 9ciprofloxacin for oral susp 250 mg/5ml (5%) (5

gm/100ml).....................................................................8ciprofloxacin for oral susp 500 mg/5ml (10%) (10

gm/100ml).....................................................................8CIPROFLOXACIN HCL.................................................8ciprofloxacin hcl ophth soln 0.3%.............................. 95ciprofloxacin hcl tab 250 mg.........................................9ciprofloxacin hcl tab 500 mg.........................................9ciprofloxacin hcl tab 750 mg.........................................9ciprofloxacin hcl tab sr 24hr 1000 mg......................... 8ciprofloxacin hcl tab sr 24hr 500 mg........................... 8ciprofloxacin iv soln 200 mg/20ml (1%)...................... 9ciprofloxacin iv soln 400 mg/40ml (1%)...................... 9CISPLATIN.................................................................... 30cisplatin inj 100 mg/100ml (1 mg/ml).........................30

cisplatin inj 50 mg/50ml (1 mg/ml).............................30citalopram hydrobromide oral soln 10

mg/5ml........................................................................ 19citalopram hydrobromide tab 10 mg..........................19citalopram hydrobromide tab 20 mg..........................19citalopram hydrobromide tab 40 mg..........................19cladribine iv soln 10 mg/10ml (1 mg/

ml)................................................................................30CLAFORAN/D5W...........................................................9CLAFORAN/D5W...........................................................9clarithromycin for susp 125 mg/5ml.............................9clarithromycin for susp 250 mg/5ml.............................9clarithromycin tab 250 mg............................................ 9clarithromycin tab 500 mg............................................ 9clarithromycin tab sr 24hr 500 mg............................... 9clemastine fumarate tab 2.68 mg.............................. 98clindamycin hcl cap 150 mg......................................... 9clindamycin hcl cap 300 mg......................................... 9clindamycin hcl cap 75 mg........................................... 9clindamycin phosphate-benzoyl peroxide gel

1-5%............................................................................74clindamycin phosphate gel 1%.................................. 74clindamycin phosphate in d5w iv soln 300

mg/50ml........................................................................ 9clindamycin phosphate in d5w iv soln 600

mg/50ml........................................................................ 9clindamycin phosphate in d5w iv soln 900

mg/50ml........................................................................ 9clindamycin phosphate inj 300 mg/2ml....................... 9clindamycin phosphate inj 600 mg/4ml....................... 9clindamycin phosphate inj 900 mg/6ml....................... 9clindamycin phosphate inj 9 gm/60ml......................... 9clindamycin phosphate iv soln 300

mg/2ml.......................................................................... 9clindamycin phosphate iv soln 600

mg/4ml.......................................................................... 9clindamycin phosphate iv soln 900

mg/6ml.......................................................................... 9clindamycin phosphate lotion 1%.............................. 74clindamycin phosphate soln 1%................................ 74clindamycin phosphate swab 1%.............................. 74clindamycin phosphate vaginal cream

2%..................................................................................9clobetasol propionate cream 0.05%..........................74clobetasol propionate emollient base cream

0.05%..........................................................................74clobetasol propionate gel 0.05%................................74clobetasol propionate oint 0.05%.............................. 74clobetasol propionate soln 0.05%..............................74CLOLAR........................................................................ 30clomipramine hcl cap 25 mg...................................... 20clomipramine hcl cap 50 mg...................................... 20

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112

clomipramine hcl cap 75 mg...................................... 20clonazepam orally disintegrating tab 0.125

mg................................................................................14clonazepam orally disintegrating tab 0.125





mg................................................................................50clonazepam orally disintegrating tab 1




mg................................................................................50clonazepam tab 0.5 mg.............................................. 14clonazepam tab 0.5 mg.............................................. 50clonazepam tab 1 mg..................................................14clonazepam tab 1 mg..................................................50clonazepam tab 2 mg..................................................14clonazepam tab 2 mg..................................................50clonidine hcl tab 0.1 mg..............................................62clonidine hcl tab 0.2 mg..............................................62clonidine hcl tab 0.3 mg..............................................62clonidine hcl tab sr 12hr 0.1 mg.................................71clonidine hcl td patch weekly 0.1

mg/24hr...................................................................... 62clonidine hcl td patch weekly 0.2

mg/24hr...................................................................... 62clonidine hcl td patch weekly 0.3

mg/24hr...................................................................... 62clopidogrel bisulfate tab 75 mg..................................58clorazepate dipotassium tab 15 mg...........................14clorazepate dipotassium tab 15 mg...........................50clorazepate dipotassium tab 3.75 mg....................... 14clorazepate dipotassium tab 3.75 mg....................... 50clorazepate dipotassium tab 7.5 mg......................... 14clorazepate dipotassium tab 7.5 mg......................... 50clotrimazole cream 1%................................................74clotrimazole troche 10 mg.......................................... 24clotrimazole w/ betamethasone cream

1-0.05%...................................................................... 74clotrimazole w/ betamethasone lotion

1-0.05%...................................................................... 74clozapine orally disintegrating tab 100

mg................................................................................40

clozapine orally disintegrating tab 25mg................................................................................40

clozapine tab 100 mg..................................................40clozapine tab 200 mg..................................................40clozapine tab 25 mg....................................................40clozapine tab 50 mg....................................................40COARTEM.....................................................................38codeine sulfate tab 15 mg............................................ 1codeine sulfate tab 30 mg............................................ 1codeine sulfate tab 60 mg............................................ 1colchicine w/ probenecid tab 0.5-500

mg................................................................................25COLCRYS..................................................................... 25colestipol hcl granule packets 5 gm.......................... 62colestipol hcl granules 5 gm.......................................62colestipol hcl tab 1 gm................................................ 62colistimethate sodium for inj 150 mg...........................9COMBIGAN...................................................................95COMBIVENT RESPIMAT........................................... 98COMETRIQ...................................................................30COMETRIQ...................................................................30COMETRIQ...................................................................30COMPLERA.................................................................. 45COPAXONE.................................................................. 71COPAXONE.................................................................. 71CORLANOR..................................................................62CORLANOR..................................................................62CORTISONE ACETATE..............................................82COSMEGEN................................................................. 30COTELLIC.....................................................................30COUMADIN...................................................................58COUMADIN...................................................................58COUMADIN...................................................................58COUMADIN...................................................................58COUMADIN...................................................................58COUMADIN...................................................................58COUMADIN...................................................................58COUMADIN...................................................................58COUMADIN...................................................................58CREON..........................................................................77CREON..........................................................................77CREON..........................................................................77CREON..........................................................................77CREON..........................................................................77CRESEMBA.................................................................. 24CRESEMBA.................................................................. 24CRESTOR.....................................................................62CRESTOR.....................................................................62CRESTOR.....................................................................62CRESTOR.....................................................................62CRIXIVAN......................................................................45CRIXIVAN......................................................................45

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CROMOLYN SODIUM................................................ 98cromolyn sodium ophth soln 4%................................95cromolyn sodium oral conc 100

mg/5ml........................................................................ 78CUBICIN.......................................................................... 9CUBICIN RF................................................................... 9CUPRIMINE.................................................................. 81CUPRIMINE.................................................................. 89CUPRIMINE................................................................102cyclobenzaprine hcl tab 10 mg................................ 101cyclobenzaprine hcl tab 5 mg.................................. 101cyclobenzaprine hcl tab 7.5 mg...............................101CYCLOPHOSPHAMIDE............................................. 30CYCLOPHOSPHAMIDE............................................. 30cyclophosphamide for inj 1 gm.................................. 30cyclophosphamide for inj 2 gm.................................. 30cyclophosphamide for inj 500 mg..............................30CYCLOSERINE............................................................28CYCLOSET...................................................................54cyclosporine cap 100 mg............................................89cyclosporine cap 25 mg..............................................89cyclosporine iv soln 50 mg/ml....................................89cyclosporine modified cap 100 mg............................ 89cyclosporine modified cap 25 mg.............................. 89cyclosporine modified cap 50 mg.............................. 89cyclosporine modified oral soln 100 mg/

ml.................................................................................89CYRAMZA.....................................................................30CYRAMZA.....................................................................30CYSTADANE................................................................ 77CYSTAGON.................................................................. 77CYSTAGON.................................................................. 77cytarabine inj 20 mg/ml...............................................30cytarabine inj pf 100 mg/ml........................................ 30cytarabine inj pf 20 mg/ml.......................................... 30DDACARBAZINE............................................................ 30dacarbazine for inj 200 mg.........................................30DAKLINZA.....................................................................45DAKLINZA.....................................................................45DAKLINZA.....................................................................46DALIRESP.....................................................................98DALVANCE......................................................................9danazol cap 100 mg....................................................84danazol cap 200 mg....................................................84danazol cap 50 mg......................................................84dantrolene sodium cap 100 mg................................. 45dantrolene sodium cap 25 mg....................................45dantrolene sodium cap 50 mg....................................45dapsone tab 100 mg................................................... 28dapsone tab 25 mg......................................................28

DAPTACEL....................................................................90daptomycin for iv soln 500 mg..................................... 9DARAPRIM................................................................... 38DARZALEX................................................................... 30DARZALEX................................................................... 30daunorubicin hcl inj 5 mg/ml.......................................31DAUNOXOME.............................................................. 31decitabine for inj 50 mg.............................................. 31DELZICOL.....................................................................93demeclocycline hcl tab 150 mg....................................9demeclocycline hcl tab 300 mg....................................9DEMSER....................................................................... 62DENAVIR.......................................................................74DEPEN TITRATABS.................................................... 81DEPEN TITRATABS.................................................... 90DEPEN TITRATABS..................................................102DEPO-PROVERA........................................................ 84DESCOVY.....................................................................46desipramine hcl tab 100 mg.......................................20desipramine hcl tab 10 mg......................................... 20desipramine hcl tab 150 mg.......................................20desipramine hcl tab 25 mg......................................... 20desipramine hcl tab 50 mg......................................... 20desipramine hcl tab 75 mg......................................... 20desmopressin acetate inj 4 mcg/ml...........................83desmopressin acetate nasal soln 0.01%

(refrigerated).............................................................. 83desmopressin acetate nasal spray soln

0.01%..........................................................................83desmopressin acetate nasal spray soln 0.01%

(refrigerated).............................................................. 83desmopressin acetate tab 0.1 mg............................. 83desmopressin acetate tab 0.2 mg............................. 83desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5)..................................................................... 84desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg................................................................................84

desogestrel & ethinyl estradiol tab 0.15 mg-30mcg..............................................................................84

desonide cream 0.05%............................................... 74desonide lotion 0.05%.................................................74desonide oint 0.05%....................................................74DESOXIMETASONE................................................... 74desoximetasone cream 0.25%...................................74desoximetasone gel 0.05%........................................ 74desoximetasone oint 0.25%....................................... 74DEXAMETHASONE.................................................... 82DEXAMETHASONE.................................................... 82dexamethasone elixir 0.5 mg/5ml..............................82dexamethasone sodium phosphate inj 120

mg/30ml......................................................................82

2016

114

dexamethasone sodium phosphate inj 20mg/5ml........................................................................ 82

dexamethasone sodium phosphate inj 4 mg/ml.................................................................................82

dexamethasone sodium phosphate ophth soln0.1%............................................................................95

dexamethasone tab 0.5 mg........................................82dexamethasone tab 0.75 mg......................................82dexamethasone tab 1.5 mg........................................82dexamethasone tab 4 mg...........................................82dexamethasone tab 6 mg...........................................82DEXILANT.....................................................................78DEXILANT.....................................................................78dexmethylphenidate hcl tab 10 mg............................72dexmethylphenidate hcl tab 2.5 mg...........................71dexmethylphenidate hcl tab 5 mg..............................71dexrazoxane for inj 250 mg........................................31dexrazoxane for inj 500 mg........................................31dextroamphetamine sulfate cap sr 24hr 10

mg................................................................................72dextroamphetamine sulfate cap sr 24hr 15

mg................................................................................72dextroamphetamine sulfate cap sr 24hr 5

mg................................................................................72dextroamphetamine sulfate tab 10 mg......................72dextroamphetamine sulfate tab 5 mg........................72dextrose 2.5% w/ sodium chloride

0.45%........................................................................102dextrose 5% in lactated ringers............................... 102dextrose 5% w/ sodium chloride

0.2%..........................................................................102dextrose 5% w/ sodium chloride

0.33%........................................................................102dextrose 5% w/ sodium chloride

0.45%........................................................................102dextrose 5% w/ sodium chloride

0.9%..........................................................................102dextrose inj 10%........................................................ 102dextrose inj 5%.......................................................... 102DIASTAT ACUDIAL......................................................14DIASTAT ACUDIAL......................................................14DIASTAT PEDIATRIC..................................................14DIAZEPAM.................................................................... 14DIAZEPAM.................................................................... 14DIAZEPAM.................................................................... 14DIAZEPAM.................................................................... 14DIAZEPAM.................................................................... 50diazepam conc 5 mg/ml..............................................14diazepam conc 5 mg/ml..............................................50diazepam tab 10 mg....................................................14diazepam tab 10 mg....................................................50diazepam tab 2 mg......................................................14

diazepam tab 2 mg......................................................50diazepam tab 5 mg......................................................14diazepam tab 5 mg......................................................50diclofenac potassium tab 50 mg.................................. 1diclofenac potassium tab 50 mg................................ 26diclofenac sodium gel 1%.............................................1diclofenac sodium gel 1%...........................................26diclofenac sodium gel 1%...........................................74diclofenac sodium gel 3%...........................................74diclofenac sodium ophth soln 0.1%...........................95diclofenac sodium tab delayed release 25

mg..................................................................................1diclofenac sodium tab delayed release 25

mg................................................................................26diclofenac sodium tab delayed release 50


mg................................................................................26diclofenac sodium tab delayed release 75


mg................................................................................26diclofenac sodium tab sr 24hr 100 mg........................ 1diclofenac sodium tab sr 24hr 100 mg......................26diclofenac w/ misoprostol tab delayed release 50-0.2

mg..................................................................................1diclofenac w/ misoprostol tab delayed release 50-0.2

mg................................................................................26diclofenac w/ misoprostol tab delayed release 75-0.2

mg..................................................................................1diclofenac w/ misoprostol tab delayed release 75-0.2

mg................................................................................26dicloxacillin sodium cap 250 mg.................................. 9dicloxacillin sodium cap 500 mg.................................. 9dicyclomine hcl tab 20 mg..........................................79didanosine delayed release capsule 125

mg................................................................................46didanosine delayed release capsule 200



mg................................................................................46DIFICID............................................................................ 9DIFLORASONE DIACETATE.....................................74DIGOXIN........................................................................62digoxin tab 125 mcg (0.125 mg)................................62digoxin tab 250 mcg (0.25 mg).................................. 62DILANTIN...................................................................... 15diltiazem hcl cap sr 12hr 120 mg...............................62diltiazem hcl cap sr 12hr 60 mg.................................62diltiazem hcl cap sr 12hr 90 mg.................................62

2016

115

diltiazem hcl cap sr 24hr 120 mg...............................63diltiazem hcl cap sr 24hr 180 mg...............................63diltiazem hcl cap sr 24hr 240 mg...............................63diltiazem hcl coated beads cap sr 24hr 120

mg................................................................................63diltiazem hcl coated beads cap sr 24hr 180




mg................................................................................63diltiazem hcl coated beads tab sr 24hr 180





mg................................................................................63diltiazem hcl extended release beads cap sr 24hr

120 mg....................................................................... 63diltiazem hcl extended release beads cap sr 24hr





420 mg....................................................................... 63diltiazem hcl tab 120 mg.............................................63diltiazem hcl tab 30 mg...............................................63diltiazem hcl tab 60 mg...............................................63diltiazem hcl tab 90 mg...............................................63DIPENTUM....................................................................93diphenhydramine hcl inj 50 mg/ml.............................23diphenhydramine hcl inj 50 mg/ml.............................39DIPHTHERIA/TETANUS TOXOID.............................90dipyridamole tab 25 mg.............................................. 58dipyridamole tab 50 mg.............................................. 58dipyridamole tab 75 mg.............................................. 58disulfiram tab 250 mg....................................................5disulfiram tab 500 mg....................................................5divalproex sodium cap delayed release sprinkle 125

mg................................................................................15divalproex sodium cap delayed release sprinkle 125

mg................................................................................27

divalproex sodium cap delayed release sprinkle 125mg................................................................................52

divalproex sodium tab delayed release 125mg................................................................................15









divalproex sodium tab sr 24 hr 250 mg.....................15divalproex sodium tab sr 24 hr 250 mg.....................27divalproex sodium tab sr 24 hr 250 mg.....................52divalproex sodium tab sr 24 hr 500 mg.....................15divalproex sodium tab sr 24 hr 500 mg.....................27divalproex sodium tab sr 24 hr 500 mg.....................52DIVIGEL.........................................................................84DIVIGEL.........................................................................84DIVIGEL.........................................................................84DOCEFREZ.................................................................. 31DOCETAXEL.................................................................31DOCETAXEL.................................................................31DOCETAXEL.................................................................31DOCETAXEL.................................................................31DOCETAXEL.................................................................31DOCETAXEL.................................................................31DOCETAXEL.................................................................31DOCETAXEL.................................................................31docetaxel for inj conc 20 mg/ml................................. 31docetaxel for inj conc 80 mg/4ml (20 mg/

ml)................................................................................31dofetilide cap 125 mcg (0.125 mg)............................63dofetilide cap 250 mcg (0.25 mg).............................. 63dofetilide cap 500 mcg (0.5 mg)................................ 63donepezil hydrochloride orally disintegrating tab 10

mg................................................................................18donepezil hydrochloride orally disintegrating tab 5

mg................................................................................18donepezil hydrochloride tab 10 mg........................... 18donepezil hydrochloride tab 23 mg........................... 18donepezil hydrochloride tab 5 mg..............................18dorzolamide hcl ophth soln 2%..................................95

2016

116

dorzolamide hcl-timolol maleate ophth soln 22.3-6.8mg/ml.......................................................................... 95

doxazosin mesylate tab 1 mg.................................... 63doxazosin mesylate tab 1 mg.................................... 81doxazosin mesylate tab 2 mg.................................... 63doxazosin mesylate tab 2 mg.................................... 81doxazosin mesylate tab 4 mg.................................... 63doxazosin mesylate tab 4 mg.................................... 81doxazosin mesylate tab 8 mg.................................... 63doxazosin mesylate tab 8 mg.................................... 81DOXEPIN HCL............................................................. 20DOXEPIN HCL............................................................. 50doxepin hcl cap 100 mg..............................................20doxepin hcl cap 100 mg..............................................50doxepin hcl cap 10 mg................................................20doxepin hcl cap 10 mg................................................50doxepin hcl cap 150 mg..............................................20doxepin hcl cap 150 mg..............................................51doxepin hcl cap 25 mg................................................20doxepin hcl cap 25 mg................................................50doxepin hcl cap 50 mg................................................20doxepin hcl cap 50 mg................................................50doxepin hcl conc 10 mg/ml.........................................20doxepin hcl conc 10 mg/ml.........................................51doxorubicin hcl for inj 10 mg...................................... 31doxorubicin hcl for inj 50 mg...................................... 31doxorubicin hcl inj 2 mg/ml.........................................31doxorubicin hcl liposomal inj (for iv infusion) 2 mg/

ml.................................................................................31doxycycline hyclate cap 100 mg................................10doxycycline hyclate cap 100 mg................................73doxycycline hyclate cap 50 mg..................................10doxycycline hyclate cap 50 mg..................................73doxycycline hyclate for inj 100 mg.............................10doxycycline hyclate for inj 100 mg.............................73doxycycline hyclate tab 100 mg.................................10doxycycline hyclate tab 100 mg.................................73doxycycline hyclate tab 20 mg...................................10doxycycline hyclate tab 20 mg...................................73doxycycline monohydrate cap 100 mg......................10doxycycline monohydrate cap 150 mg......................10doxycycline monohydrate cap 50 mg........................10doxycycline monohydrate cap 75 mg........................10doxycycline monohydrate tab 100 mg...................... 10doxycycline monohydrate tab 150 mg...................... 10doxycycline monohydrate tab 50 mg.........................10doxycycline monohydrate tab 75 mg.........................10dronabinol cap 10 mg................................................. 23dronabinol cap 2.5 mg................................................ 23dronabinol cap 5 mg....................................................23drospirenone-ethinyl estradiol tab 3-0.02

mg................................................................................84

drospirenone-ethinyl estradiol tab 3-0.03mg................................................................................84

drospirenone-ethinyl estrad-levomefolate tab3-0.02-0.451 mg........................................................84

DULERA........................................................................ 98DULERA........................................................................ 98duloxetine hcl enteric coated pellets cap 20

mg................................................................................20duloxetine hcl enteric coated pellets cap 20








mg................................................................................72DUREZOL..................................................................... 95dutasteride cap 0.5 mg............................................... 81dutasteride-tamsulosin hcl cap 0.5-0.4

mg................................................................................81EE.E.S. GRANULES......................................................10econazole nitrate cream 1%.......................................74EDURANT..................................................................... 46EFFIENT........................................................................58EFFIENT........................................................................58EGRIFTA....................................................................... 83EGRIFTA....................................................................... 83ELAPRASE................................................................... 77electrolyte-m in d5w soln..........................................102ELELYSO.......................................................................77ELIDEL...........................................................................75ELIDEL...........................................................................90ELIGARD.......................................................................87ELIGARD.......................................................................87ELIGARD.......................................................................87ELIGARD.......................................................................87ELIQUIS.........................................................................58ELIQUIS.........................................................................58ELITEK...........................................................................31ELITEK...........................................................................31ELLA...............................................................................84EMCYT.......................................................................... 31EMEND..........................................................................23

2016

117

EMEND..........................................................................23EMEND..........................................................................23EMEND..........................................................................23EMEND..........................................................................23EMPLICITI.....................................................................31EMPLICITI.....................................................................31EMSAM..........................................................................20EMSAM..........................................................................20EMSAM..........................................................................20EMTRIVA.......................................................................46EMTRIVA.......................................................................46enalapril maleate & hydrochlorothiazide tab 10-25

mg................................................................................63enalapril maleate & hydrochlorothiazide tab 5-12.5

mg................................................................................63enalapril maleate tab 10 mg.......................................63enalapril maleate tab 2.5 mg......................................63enalapril maleate tab 20 mg.......................................63enalapril maleate tab 5 mg.........................................63ENBREL........................................................................ 90ENBREL........................................................................ 90ENBREL........................................................................ 90ENBREL SURECLICK................................................ 90ENGERIX-B.................................................................. 90ENGERIX-B.................................................................. 90enoxaparin sodium inj 100 mg/ml..............................58enoxaparin sodium inj 120 mg/0.8ml........................ 58enoxaparin sodium inj 150 mg/ml..............................58enoxaparin sodium inj 300 mg/3ml............................58enoxaparin sodium inj 30 mg/0.3ml...........................58enoxaparin sodium inj 40 mg/0.4ml...........................58enoxaparin sodium inj 60 mg/0.6ml...........................58enoxaparin sodium inj 80 mg/0.8ml...........................58entacapone tab 200 mg..............................................39entecavir tab 0.5 mg....................................................46entecavir tab 1 mg.......................................................46EPCLUSA......................................................................46epinastine hcl ophth soln 0.05%................................95EPIPEN 2-PAK............................................................. 98EPIPEN-JR 2-PAK....................................................... 98epirubicin hcl iv soln 200 mg/100ml (2 mg/

ml)................................................................................31epirubicin hcl iv soln 50 mg/25ml (2 mg/

ml)................................................................................31EPIVIR HBV..................................................................46eplerenone tab 25 mg.................................................63eplerenone tab 50 mg.................................................63EPOGEN....................................................................... 58EPOGEN....................................................................... 58EPOGEN....................................................................... 58EPOGEN....................................................................... 58EPOGEN....................................................................... 58

eprosartan mesylate tab 600 mg............................... 64EPZICOM...................................................................... 46EQUETRO.....................................................................52EQUETRO.....................................................................52EQUETRO.....................................................................52ERBITUX....................................................................... 31ERBITUX....................................................................... 31ergoloid mesylates tab 1 mg...................................... 18ERIVEDGE....................................................................31ERWINAZE................................................................... 31ERYPED 200................................................................10ERYPED 400................................................................10ERY-TAB....................................................................... 10ERY-TAB....................................................................... 10ERY-TAB....................................................................... 10ERYTHROCIN LACTOBIONATE...............................10ERYTHROCIN STEARATE........................................ 10ERYTHROMYCIN BASE............................................ 10ERYTHROMYCIN BASE............................................ 10erythromycin ethylsuccinate for susp 200

mg/5ml........................................................................ 10erythromycin ophth oint 5 mg/gm.............................. 95erythromycin pads 2%.................................................75erythromycin soln 2%..................................................75ESBRIET....................................................................... 98escitalopram oxalate soln 5 mg/5ml..........................20escitalopram oxalate soln 5 mg/5ml..........................51escitalopram oxalate tab 10 mg.................................20escitalopram oxalate tab 10 mg.................................51escitalopram oxalate tab 20 mg.................................20escitalopram oxalate tab 20 mg.................................51escitalopram oxalate tab 5 mg...................................20escitalopram oxalate tab 5 mg...................................51esomeprazole magnesium cap delayed release 20

mg................................................................................79esomeprazole magnesium cap delayed release 40

mg................................................................................79ESOMEPRAZOLE SODIUM...................................... 79esomeprazole sodium for intravenous soln 40

mg................................................................................79ESTRACE......................................................................84estradiol & norethindrone acetate tab 0.5-0.1

mg................................................................................84estradiol & norethindrone acetate tab 1-0.5

mg................................................................................84estradiol tab 0.5 mg.....................................................84estradiol tab 1 mg........................................................84estradiol tab 2 mg........................................................84estradiol td patch weekly 0.025

mg/24hr...................................................................... 84estradiol td patch weekly 0.0375 mg/24hr (37.5

mcg/24hr)................................................................... 84

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estradiol td patch weekly 0.05 mg/24hr.................... 84estradiol td patch weekly 0.06 mg/24hr.................... 84estradiol td patch weekly 0.075

mg/24hr...................................................................... 84estradiol td patch weekly 0.1 mg/24hr...................... 84estradiol vaginal tab 10 mcg...................................... 84ESTROPIPATE............................................................. 84estropipate tab 0.75 mg..............................................84estropipate tab 1.5 mg................................................ 84ethambutol hcl tab 100 mg.........................................28ethambutol hcl tab 400 mg.........................................28ethosuximide cap 250 mg...........................................15ethosuximide soln 250 mg/5ml.................................. 15ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg..............................................................................84ETIDRONATE DISODIUM..........................................94ETIDRONATE DISODIUM..........................................94etodolac cap 200 mg.....................................................1etodolac cap 200 mg...................................................26etodolac cap 300 mg.....................................................1etodolac cap 300 mg...................................................26etodolac tab 400 mg......................................................1etodolac tab 400 mg....................................................26etodolac tab 500 mg......................................................1etodolac tab 500 mg....................................................26etodolac tab sr 24hr 400 mg........................................ 1etodolac tab sr 24hr 400 mg...................................... 26etodolac tab sr 24hr 500 mg........................................ 1etodolac tab sr 24hr 500 mg...................................... 26etodolac tab sr 24hr 600 mg........................................ 1etodolac tab sr 24hr 600 mg...................................... 26ETOPOPHOS............................................................... 31etoposide inj 100 mg/5ml (20 mg/ml)........................31etoposide inj 1 gm/50ml (20 mg/ml).......................... 31etoposide inj 500 mg/25ml (20 mg/ml)......................31EVOMELA..................................................................... 31EVOTAZ.........................................................................46EXELON........................................................................ 18EXELON........................................................................ 18EXELON........................................................................ 18exemestane tab 25 mg............................................... 31EXJADE.......................................................................102EXJADE.......................................................................102EXJADE.......................................................................102FFABRAZYME................................................................ 77FABRAZYME................................................................ 77famciclovir tab 125 mg................................................46famciclovir tab 250 mg................................................46famciclovir tab 500 mg................................................46famotidine for susp 40 mg/5ml...................................79

famotidine inj 200 mg/20ml........................................ 79famotidine inj 20 mg/2ml.............................................79famotidine inj 40 mg/4ml.............................................79famotidine tab 20 mg...................................................79famotidine tab 40 mg...................................................79FANAPT.........................................................................41FANAPT.........................................................................41FANAPT.........................................................................41FANAPT.........................................................................41FANAPT.........................................................................41FANAPT.........................................................................41FANAPT.........................................................................41FANAPT TITRATION PACK....................................... 41FARESTON...................................................................31FARYDAK......................................................................32FARYDAK......................................................................32FARYDAK......................................................................32FASLODEX................................................................... 32fat emulsion iv soln 20%...........................................102FAZACLO...................................................................... 41FAZACLO...................................................................... 41FAZACLO...................................................................... 41FAZACLO...................................................................... 41FAZACLO...................................................................... 41felbamate susp 600 mg/5ml....................................... 15felbamate tab 400 mg................................................. 15felbamate tab 600 mg................................................. 15felodipine tab sr 24hr 10 mg...................................... 64felodipine tab sr 24hr 2.5 mg..................................... 64felodipine tab sr 24hr 5 mg........................................ 64fenofibrate micronized cap 134 mg........................... 64fenofibrate micronized cap 200 mg........................... 64fenofibrate micronized cap 67 mg............................. 64fenofibrate tab 145 mg................................................64fenofibrate tab 160 mg................................................64fenofibrate tab 48 mg.................................................. 64fenofibrate tab 54 mg.................................................. 64fentanyl citrate lozenge on a handle 1200

mcg................................................................................2fentanyl citrate lozenge on a handle 1600





mcg................................................................................2fentanyl td patch 72hr 100 mcg/hr...............................2fentanyl td patch 72hr 12 mcg/hr................................. 2fentanyl td patch 72hr 25 mcg/hr................................. 2

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119

fentanyl td patch 72hr 50 mcg/hr................................. 2fentanyl td patch 72hr 75 mcg/hr................................. 2FETZIMA....................................................................... 20FETZIMA....................................................................... 20FETZIMA....................................................................... 20FETZIMA....................................................................... 20FETZIMA TITRATION PACK......................................20FINACEA....................................................................... 75FINACEA....................................................................... 75finasteride tab 5 mg.....................................................81FIRAZYR....................................................................... 90FIRMAGON...................................................................87FIRMAGON...................................................................87flecainide acetate tab 100 mg....................................64flecainide acetate tab 150 mg....................................64flecainide acetate tab 50 mg...................................... 64FLOVENT DISKUS......................................................98FLOVENT DISKUS......................................................98FLOVENT DISKUS......................................................98FLOVENT HFA.............................................................98FLOVENT HFA.............................................................98FLOVENT HFA.............................................................98fluconazole for susp 10 mg/ml................................... 24fluconazole for susp 40 mg/ml................................... 24fluconazole in dextrose inj 200

mg/100ml....................................................................25fluconazole in dextrose inj 400

mg/200ml....................................................................25fluconazole in nacl 0.9% inj 200

mg/100ml....................................................................25fluconazole in nacl 0.9% inj 400

mg/200ml....................................................................25fluconazole tab 100 mg...............................................25fluconazole tab 150 mg...............................................25fluconazole tab 200 mg...............................................25fluconazole tab 50 mg.................................................25flucytosine cap 250 mg............................................... 25flucytosine cap 500 mg............................................... 25fludarabine phosphate for inj 50 mg..........................32fludarabine phosphate inj 25 mg/ml.......................... 32fludrocortisone acetate tab 0.1 mg............................ 82fluocinolone acetonide (otic) oil 0.01%..................... 96fluocinolone acetonide cream 0.01%........................ 75fluocinonide cream 0.05%.......................................... 75fluocinonide emulsified base cream

0.05%..........................................................................75fluocinonide gel 0.05%................................................75fluocinonide oint 0.05%...............................................75fluocinonide soln 0.05%..............................................75fluorometholone ophth susp 0.1%.............................95fluorouracil cream 5%................................................. 75fluorouracil inj 1 gm/20ml (50 mg/ml)........................32

fluorouracil inj 2.5 gm/50ml (50 mg/ml).....................32fluorouracil inj 500 mg/10ml (50 mg/

ml)................................................................................32fluorouracil inj 5 gm/100ml (50 mg/ml)......................32fluorouracil soln 2%..................................................... 75fluorouracil soln 5%..................................................... 75fluoxetine hcl cap 10 mg.............................................20fluoxetine hcl cap 20 mg.............................................20fluoxetine hcl cap 40 mg.............................................20fluoxetine hcl cap delayed release 90

mg................................................................................20fluoxetine hcl solution 20 mg/5ml.............................. 20fluoxetine hcl tab 10 mg..............................................20fluoxetine hcl tab 20 mg..............................................20fluphenazine decanoate inj 25 mg/ml........................41FLUPHENAZINE HCL.................................................41FLUPHENAZINE HCL.................................................41FLUPHENAZINE HCL.................................................41fluphenazine hcl tab 10 mg........................................ 41fluphenazine hcl tab 1 mg.......................................... 41fluphenazine hcl tab 2.5 mg....................................... 41fluphenazine hcl tab 5 mg.......................................... 41flurbiprofen sodium ophth soln 0.03%.......................95flurbiprofen tab 100 mg.................................................2flurbiprofen tab 100 mg...............................................26flurbiprofen tab 50 mg................................................... 2flurbiprofen tab 50 mg.................................................26flutamide cap 125 mg..................................................32fluticasone propionate cream 0.05%.........................75fluticasone propionate nasal susp 50 mcg/

act................................................................................98fluticasone propionate oint 0.005%........................... 75fluvoxamine maleate tab 100 mg...............................21fluvoxamine maleate tab 25 mg.................................21fluvoxamine maleate tab 50 mg.................................21FOLOTYN......................................................................32FOLOTYN......................................................................32fomepizole inj 1 gm/ml (for iv

infusion)....................................................................102fondaparinux sodium subcutaneous inj 10

mg/0.8ml.....................................................................58fondaparinux sodium subcutaneous inj 2.5

mg/0.5ml.....................................................................58fondaparinux sodium subcutaneous inj 5

mg/0.4ml.....................................................................58fondaparinux sodium subcutaneous inj 7.5

mg/0.6ml.....................................................................58FORTAZ.........................................................................10FORTAZ.........................................................................10FORTAZ.........................................................................10FORTEO........................................................................94FORTICAL.....................................................................94

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120

fosinopril sodium & hydrochlorothiazide tab 10-12.5mg................................................................................64

fosinopril sodium & hydrochlorothiazide tab 20-12.5mg................................................................................64

fosinopril sodium tab 10 mg....................................... 64fosinopril sodium tab 20 mg....................................... 64fosinopril sodium tab 40 mg....................................... 64fosphenytoin sodium inj 100 mg/2ml.........................15fosphenytoin sodium inj 500 mg/10ml.......................15FOSRENOL.................................................................. 81FOSRENOL.................................................................. 81FOSRENOL.................................................................. 81FOSRENOL.................................................................. 81FOSRENOL.................................................................. 81furosemide inj 10 mg/ml..............................................64furosemide oral soln 10 mg/ml...................................64furosemide tab 20 mg................................................. 64furosemide tab 40 mg................................................. 64furosemide tab 80 mg................................................. 64FUZEON........................................................................46FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15Ggabapentin cap 100 mg.............................................. 15gabapentin cap 300 mg.............................................. 15gabapentin cap 400 mg.............................................. 15gabapentin oral soln 250 mg/5ml.............................. 15gabapentin tab 600 mg............................................... 15gabapentin tab 800 mg............................................... 15GABITRIL...................................................................... 15GABITRIL...................................................................... 15GALANTAMINE HYDROBROMIDE.......................... 18galantamine hydrobromide cap sr 24hr 16

mg................................................................................18galantamine hydrobromide cap sr 24hr 24

mg................................................................................18galantamine hydrobromide cap sr 24hr 8

mg................................................................................18galantamine hydrobromide tab 12 mg...................... 18galantamine hydrobromide tab 4 mg.........................18galantamine hydrobromide tab 8 mg.........................18GAMMAPLEX............................................................... 90GAMMAPLEX............................................................... 90GAMMAPLEX............................................................... 90GAMMAPLEX............................................................... 90GAMUNEX-C................................................................ 90

GAMUNEX-C................................................................ 90GAMUNEX-C................................................................ 90GAMUNEX-C................................................................ 90GAMUNEX-C................................................................ 90GAMUNEX-C................................................................ 90ganciclovir sodium for inj 500 mg.............................. 46GARDASIL.................................................................... 90GARDASIL 9.................................................................90GARDASIL 9.................................................................90GATTEX.........................................................................79GAUZE PADS 2" X 2".................................................54GAZYVA.........................................................................32gemcitabine hcl for inj 1 gm....................................... 32gemcitabine hcl for inj 200 mg...................................32gemcitabine hcl for inj 2 gm....................................... 32gemcitabine hcl inj 1 gm/26.3ml (38 mg/

ml)................................................................................32gemcitabine hcl inj 200 mg/5.26ml (38 mg/

ml)................................................................................32gemcitabine hcl inj 2 gm/52.6ml (38 mg/

ml)................................................................................32gemfibrozil tab 600 mg............................................... 64gentamicin in saline inj 0.8 mg/ml............................. 10gentamicin in saline inj 1.2 mg/ml............................. 10gentamicin in saline inj 1.6 mg/ml............................. 10gentamicin in saline inj 1 mg/ml.................................10GENTAMICIN SULFATE............................................. 75GENTAMICIN SULFATE............................................. 75GENTAMICIN SULFATE/0.9% SODIUM

CHLORIDE.................................................................10GENTAMICIN SULFATE/0.9% SODIUM

CHLORIDE.................................................................11gentamicin sulfate inj 10 mg/ml................................. 10gentamicin sulfate inj 40 mg/ml................................. 10gentamicin sulfate iv soln 10 mg/ml.......................... 10gentamicin sulfate ophth oint 0.3%........................... 95gentamicin sulfate ophth soln 0.3%...........................95GENVOYA.....................................................................46GEODON.......................................................................41GILOTRIF......................................................................32GILOTRIF......................................................................32GILOTRIF......................................................................32Glatopa - glatiramer acetate soln prefilled syringe 20

mg/ml.......................................................................... 72GLEEVEC......................................................................32GLEEVEC......................................................................32GLEOSTINE..................................................................32GLEOSTINE..................................................................32GLEOSTINE..................................................................32GLEOSTINE..................................................................32glimepiride tab 1 mg....................................................54glimepiride tab 2 mg....................................................54

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glimepiride tab 4 mg....................................................54glipizide-metformin hcl tab 2.5-250 mg.....................54glipizide-metformin hcl tab 2.5-500 mg.....................54glipizide-metformin hcl tab 5-500 mg........................ 54glipizide tab 10 mg...................................................... 54glipizide tab 5 mg.........................................................54glipizide tab sr 24hr 10 mg.........................................54glipizide tab sr 24hr 2.5 mg........................................54glipizide tab sr 24hr 5 mg........................................... 54GLUCAGEN HYPOKIT............................................... 54GLUCAGON EMERGENCY KIT............................... 54glycopyrrolate tab 1 mg.............................................. 79glycopyrrolate tab 2 mg.............................................. 79granisetron hcl tab 1 mg.............................................23GRANIX......................................................................... 58GRANIX......................................................................... 58GRASTEK..................................................................... 98griseofulvin microsize susp 125

mg/5ml........................................................................ 25griseofulvin ultramicrosize tab 125 mg......................25griseofulvin ultramicrosize tab 250 mg......................25GUANIDINE HCL.........................................................28HH.P. ACTHAR............................................................... 82HALAVEN...................................................................... 32halobetasol propionate cream 0.05%........................75halobetasol propionate oint 0.05%............................ 75haloperidol decanoate im soln 100 mg/

ml.................................................................................41haloperidol decanoate im soln 50 mg/

ml.................................................................................41haloperidol lactate inj 5 mg/ml................................... 41haloperidol lactate oral conc 2 mg/ml........................41haloperidol tab 0.5 mg................................................ 41haloperidol tab 10 mg................................................. 41haloperidol tab 1 mg....................................................41haloperidol tab 20 mg................................................. 41haloperidol tab 2 mg....................................................41haloperidol tab 5 mg....................................................41HARVONI...................................................................... 46HAVRIX..........................................................................90HAVRIX..........................................................................90heparin sodium (porcine) 40 unit/ml in

d5w..............................................................................59heparin sodium (porcine) inj 10000 unit/

ml.................................................................................59heparin sodium (porcine) inj 1000 unit/

ml.................................................................................58heparin sodium (porcine) inj 20000 unit/

ml.................................................................................59

heparin sodium (porcine) inj 5000 unit/ml.................................................................................58

heparin sodium (porcine) pf inj 5000unit/0.5ml....................................................................59

HERCEPTIN................................................................. 32HETLIOZ..................................................................... 101HEXALEN......................................................................32HIBERIX........................................................................ 90HUMALOG.................................................................... 54HUMALOG.................................................................... 54HUMALOG KWIKPEN.................................................54HUMALOG KWIKPEN.................................................55HUMALOG MIX 50/50.................................................55HUMALOG MIX 50/50 KWIKPEN............................. 55HUMALOG MIX 75/25.................................................55HUMALOG MIX 75/25 KWIKPEN............................. 55HUMIRA.........................................................................90HUMIRA.........................................................................90HUMIRA.........................................................................91HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.......................................................91HUMIRA PEN............................................................... 91HUMIRA PEN-CROHNS DISEASE

STARTER...................................................................91HUMIRA PEN-PSORIASIS STARTER..................... 91HUMULIN 70/30...........................................................55HUMULIN 70/30 KWIKPEN....................................... 55HUMULIN N..................................................................55HUMULIN N KWIKPEN.............................................. 55HUMULIN R..................................................................55HUMULIN R U-500 (CONCENTRATE).....................55HUMULIN R U-500 KWIKPEN...................................55hydralazine hcl tab 100 mg........................................ 64hydralazine hcl tab 10 mg.......................................... 64hydralazine hcl tab 25 mg.......................................... 64hydralazine hcl tab 50 mg.......................................... 64hydrochlorothiazide cap 12.5 mg...............................64hydrochlorothiazide tab 12.5 mg................................64hydrochlorothiazide tab 25 mg...................................64hydrochlorothiazide tab 50 mg...................................64hydrocodone-acetaminophen soln 7.5-325

mg/15ml........................................................................ 2hydrocodone-acetaminophen tab 10-300

mg..................................................................................2hydrocodone-acetaminophen tab 10-325



mg..................................................................................2hydrocodone-acetaminophen tab 7.5-300

mg..................................................................................2

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122

hydrocodone-acetaminophen tab 7.5-325mg..................................................................................2

hydrocodone-ibuprofen tab 10-200 mg.......................2hydrocodone-ibuprofen tab 5-200 mg......................... 2hydrocodone-ibuprofen tab 7.5-200 mg......................2hydrocortisone butyrate cream 0.1%........................ 75hydrocortisone butyrate oint 0.1%.............................75hydrocortisone butyrate soln 0.1%............................ 75hydrocortisone cream 1%...........................................75hydrocortisone cream 2.5%........................................75hydrocortisone enema 100 mg/60ml.........................93hydrocortisone lotion 2.5%......................................... 75hydrocortisone oint 1%............................................... 75hydrocortisone oint 2.5%............................................ 75hydrocortisone rectal cream 1%................................ 93hydrocortisone rectal cream 2.5%.............................93hydrocortisone tab 10 mg...........................................82hydrocortisone tab 20 mg...........................................82hydrocortisone tab 5 mg............................................. 82hydrocortisone valerate cream 0.2%.........................75hydrocortisone valerate oint 0.2%............................. 75hydrocortisone w/ acetic acid otic soln

1-2%............................................................................96hydromorphone hcl liqd 1 mg/ml..................................2hydromorphone hcl preservative free inj 10 mg/

ml................................................................................... 2hydromorphone hcl tab 2 mg....................................... 2hydromorphone hcl tab 4 mg....................................... 2hydromorphone hcl tab 8 mg....................................... 2hydroxychloroquine sulfate tab 200 mg.................... 38HYDROXYPROGESTERONE

CAPROATE................................................................32hydroxyurea cap 500 mg............................................ 32hydroxyzine hcl syrup 10 mg/5ml.............................. 23hydroxyzine hcl syrup 10 mg/5ml.............................. 51hydroxyzine hcl syrup 10 mg/5ml.............................. 99hydroxyzine hcl tab 10 mg..........................................23hydroxyzine hcl tab 10 mg..........................................51hydroxyzine hcl tab 10 mg..........................................99hydroxyzine hcl tab 25 mg..........................................23hydroxyzine hcl tab 25 mg..........................................51hydroxyzine hcl tab 25 mg..........................................99hydroxyzine hcl tab 50 mg..........................................23hydroxyzine hcl tab 50 mg..........................................51hydroxyzine hcl tab 50 mg..........................................99Iibandronate sodium iv soln 3 mg/3ml........................94ibandronate sodium tab 150 mg................................ 94IBRANCE.......................................................................32IBRANCE.......................................................................32IBRANCE.......................................................................32

ibuprofen susp 100 mg/5ml.......................................... 2ibuprofen susp 100 mg/5ml........................................26ibuprofen tab 400 mg.................................................... 2ibuprofen tab 400 mg.................................................. 26ibuprofen tab 600 mg.................................................... 2ibuprofen tab 600 mg.................................................. 26ibuprofen tab 800 mg.................................................... 2ibuprofen tab 800 mg.................................................. 26ICLUSIG........................................................................ 33ICLUSIG........................................................................ 33idarubicin hcl iv inj 10 mg/10ml (1 mg/

ml)................................................................................33idarubicin hcl iv inj 20 mg/20ml (1 mg/

ml)................................................................................33idarubicin hcl iv inj 5 mg/5ml (1 mg/ml).....................33IFEX............................................................................... 33IFOSFAMIDE................................................................ 33ifosfamide for inj 1 gm.................................................33ifosfamide iv inj 1 gm/20ml (50 mg/ml)..................... 33ifosfamide iv inj 3 gm/60ml (50 mg/ml)..................... 33ILARIS............................................................................91ILEVRO..........................................................................95imatinib mesylate tab 100 mg.................................... 33imatinib mesylate tab 400 mg.................................... 33IMBRUVICA.................................................................. 33imipenem-cilastatin intravenous for soln 250

mg................................................................................11imipenem-cilastatin intravenous for soln 500

mg................................................................................11imipramine hcl tab 10 mg........................................... 21imipramine hcl tab 25 mg........................................... 21imipramine hcl tab 50 mg........................................... 21imiquimod cream 5%...................................................75IMLYGIC........................................................................ 33IMLYGIC........................................................................ 33IMOVAX RABIES (H.D.C.V.)...................................... 91INCRELEX.................................................................... 83INCRUSE ELLIPTA..................................................... 99indapamide tab 1.25 mg............................................. 64indapamide tab 2.5 mg............................................... 64INFANRIX......................................................................91INLYTA...........................................................................33INLYTA...........................................................................33INSULIN INJECTION DEVICE...................................55INSULIN SYRINGE/NEEDLE.....................................55INTELENCE.................................................................. 46INTELENCE.................................................................. 46INTELENCE.................................................................. 46INTRON A.....................................................................46INTRON A.....................................................................46INTRON A.....................................................................46INTRON A.....................................................................46

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INTRON A.....................................................................46INTRON A W/DILUENT..............................................46INTRON A W/DILUENT..............................................46INTRON A W/DILUENT..............................................46INVANZ.......................................................................... 11INVANZ.......................................................................... 11INVEGA......................................................................... 41INVEGA......................................................................... 41INVEGA......................................................................... 41INVEGA......................................................................... 41INVEGA SUSTENNA.................................................. 41INVEGA SUSTENNA.................................................. 42INVEGA SUSTENNA.................................................. 42INVEGA SUSTENNA.................................................. 42INVEGA SUSTENNA.................................................. 42INVEGA TRINZA..........................................................42INVEGA TRINZA..........................................................42INVEGA TRINZA..........................................................42INVEGA TRINZA..........................................................42INVIRASE......................................................................46INVIRASE......................................................................46INVOKAMET.................................................................55INVOKAMET.................................................................55INVOKAMET.................................................................55INVOKAMET.................................................................55INVOKANA....................................................................55INVOKANA....................................................................55IPOL INACTIVATED IPV.............................................91ipratropium bromide nasal soln 0.03% (21 mcg/

spray)..........................................................................99ipratropium bromide nasal soln 0.06% (42 mcg/

spray)..........................................................................99irbesartan-hydrochlorothiazide tab 150-12.5

mg................................................................................65irbesartan-hydrochlorothiazide tab 300-12.5

mg................................................................................65irbesartan tab 150 mg.................................................64irbesartan tab 300 mg.................................................64irbesartan tab 75 mg................................................... 64IRESSA..........................................................................33IRINOTECAN................................................................33irinotecan hcl inj 100 mg/5ml (20 mg/

ml)................................................................................33irinotecan hcl inj 40 mg/2ml (20 mg/ml).................... 33ISENTRESS..................................................................46ISENTRESS..................................................................46ISENTRESS..................................................................47ISENTRESS..................................................................47ISONIAZID.................................................................... 28isoniazid tab 100 mg................................................... 28isoniazid tab 300 mg................................................... 28isosorbide dinitrate tab 10 mg....................................65

isosorbide dinitrate tab 20 mg....................................65isosorbide dinitrate tab 30 mg....................................65isosorbide dinitrate tab 5 mg......................................65isosorbide dinitrate tab cr 40 mg............................... 65isosorbide mononitrate tab 10 mg............................. 65isosorbide mononitrate tab 20 mg............................. 65isosorbide mononitrate tab sr 24hr 120

mg................................................................................65isosorbide mononitrate tab sr 24hr 30

mg................................................................................65isosorbide mononitrate tab sr 24hr 60

mg................................................................................65isotretinoin cap 10 mg.................................................75isotretinoin cap 20 mg.................................................75isotretinoin cap 30 mg.................................................75isotretinoin cap 40 mg.................................................75isradipine cap 2.5 mg..................................................65isradipine cap 5 mg..................................................... 65ISTALOL........................................................................ 95ISTODAX.......................................................................33ISTODAX (OVERFILL)................................................33itraconazole cap 100 mg............................................ 25ivermectin tab 3 mg.....................................................38IXEMPRA KIT...............................................................33IXEMPRA KIT...............................................................33IXIARO...........................................................................91JJADENU...................................................................... 102JADENU...................................................................... 102JADENU...................................................................... 102JAKAFI...........................................................................33JAKAFI...........................................................................33JAKAFI...........................................................................33JAKAFI...........................................................................33JAKAFI...........................................................................33JANUMET......................................................................55JANUMET......................................................................55JANUMET XR...............................................................55JANUMET XR...............................................................55JANUMET XR...............................................................55JANUVIA........................................................................55JANUVIA........................................................................55JANUVIA........................................................................55JARDIANCE..................................................................55JARDIANCE..................................................................55JENTADUETO.............................................................. 55JENTADUETO.............................................................. 55JENTADUETO.............................................................. 56JENTADUETO XR....................................................... 56JENTADUETO XR....................................................... 56JEVTANA.......................................................................33

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JUXTAPID..................................................................... 65JUXTAPID..................................................................... 65JUXTAPID..................................................................... 65JUXTAPID..................................................................... 65JUXTAPID..................................................................... 65JUXTAPID..................................................................... 65KKADCYLA......................................................................33KADCYLA......................................................................33KALETRA...................................................................... 47KALETRA...................................................................... 47KALETRA...................................................................... 47KALYDECO...................................................................99KALYDECO...................................................................99KALYDECO...................................................................99KCL 0.15%/D5W/LR..................................................102KCL 0.3%/D5W/LR IV LACTATED

RINGERS.................................................................102kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45%

inj...............................................................................102kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2%



inj...............................................................................102kcl 20 meq/l (0.15%) in nacl 0.45%



inj...............................................................................102KEPIVANCE..................................................................73ketoconazole cream 2%..............................................75ketoconazole shampoo 2%........................................ 75ketoconazole tab 200 mg........................................... 25ketoprofen cap 50 mg................................................... 2ketoprofen cap 50 mg................................................. 26ketoprofen cap 75 mg................................................... 2ketoprofen cap 75 mg................................................. 26ketorolac tromethamine ophth soln

0.4%............................................................................95ketorolac tromethamine ophth soln

0.5%............................................................................95KEYTRUDA...................................................................33KEYTRUDA...................................................................33KINERET....................................................................... 91KINRIX........................................................................... 91KOMBIGLYZE XR........................................................56KOMBIGLYZE XR........................................................56KOMBIGLYZE XR........................................................56KORLYM........................................................................87

KUVAN...........................................................................77KUVAN...........................................................................77KUVAN...........................................................................77KYNAMRO.................................................................... 65Llabetalol hcl tab 100 mg..............................................65labetalol hcl tab 200 mg..............................................65labetalol hcl tab 300 mg..............................................65LACRISERT.................................................................. 95lactated ringer's solution........................................... 102lactic acid (ammonium lactate) cream

12%............................................................................. 75lactic acid (ammonium lactate) lotion

12%............................................................................. 76lactulose (encephalopathy) solution 10

gm/15ml......................................................................79lactulose solution 10 gm/15ml....................................79lamivudine oral soln 10 mg/ml................................... 47lamivudine tab 100 mg (hbv)......................................47lamivudine tab 150 mg................................................47lamivudine tab 300 mg................................................47lamivudine-zidovudine tab 150-300 mg.................... 47lamotrigine orally disintegrating tab 100

mg................................................................................15lamotrigine orally disintegrating tab 100







mg................................................................................52lamotrigine tab 100 mg............................................... 15lamotrigine tab 100 mg............................................... 52lamotrigine tab 150 mg............................................... 15lamotrigine tab 150 mg............................................... 52lamotrigine tab 200 mg............................................... 16lamotrigine tab 200 mg............................................... 52lamotrigine tab 25 mg................................................. 15lamotrigine tab 25 mg................................................. 52lamotrigine tab chewable dispersible 25

mg................................................................................15lamotrigine tab chewable dispersible 25

mg................................................................................52

2016

125

lamotrigine tab chewable dispersible 5mg................................................................................15

lamotrigine tab chewable dispersible 5mg................................................................................52

lansoprazole cap delayed release 15mg................................................................................79

lansoprazole cap delayed release 30mg................................................................................79

LANTUS.........................................................................56LANTUS SOLOSTAR..................................................56latanoprost ophth soln 0.005%.................................. 95LATUDA.........................................................................42LATUDA.........................................................................42LATUDA.........................................................................42LATUDA.........................................................................42LATUDA.........................................................................42LAZANDA........................................................................ 2LAZANDA........................................................................ 2LAZANDA........................................................................ 2leflunomide tab 10 mg.................................................91leflunomide tab 20 mg.................................................91LENVIMA 10 MG DAILY DOSE.................................33LENVIMA 14 MG DAILY DOSE.................................34LENVIMA 18 MG DAILY DOSE.................................34LENVIMA 20 MG DAILY DOSE.................................34LENVIMA 24 MG DAILY DOSE.................................34LENVIMA 8 MG DAILY DOSE...................................34LETAIRIS.......................................................................99LETAIRIS.......................................................................99letrozole tab 2.5 mg.....................................................34LEUCOVORIN CALCIUM...........................................34LEUCOVORIN CALCIUM...........................................34LEUCOVORIN CALCIUM...........................................34LEUCOVORIN CALCIUM...........................................34leucovorin calcium for inj 100 mg.............................. 34leucovorin calcium for inj 200 mg.............................. 34leucovorin calcium for inj 350 mg.............................. 34leucovorin calcium tab 25 mg.................................... 34leucovorin calcium tab 5 mg.......................................34LEUKERAN...................................................................34LEUKINE....................................................................... 59leuprolide acetate inj kit 5 mg/ml............................... 88LEVEMIR.......................................................................56LEVEMIR FLEXPEN................................................... 56LEVEMIR FLEXTOUCH..............................................56LEVETIRACETAM........................................................16LEVETIRACETAM........................................................16LEVETIRACETAM........................................................16levetiracetam inj 500 mg/5ml (100 mg/

ml)................................................................................16levetiracetam oral soln 100 mg/ml.............................16levetiracetam tab 1000 mg......................................... 16

levetiracetam tab 250 mg........................................... 16levetiracetam tab 500 mg........................................... 16levetiracetam tab 750 mg........................................... 16levobunolol hcl ophth soln 0.5%................................ 95levocarnitine oral soln 1 gm/10ml

(10%)........................................................................ 102levocarnitine tab 330 mg.......................................... 102levocetirizine dihydrochloride tab 5 mg.....................99levofloxacin in d5w iv soln 250

mg/50ml......................................................................11levofloxacin in d5w iv soln 500

mg/100ml....................................................................11levofloxacin in d5w iv soln 750

mg/150ml....................................................................11levofloxacin iv soln 25 mg/ml..................................... 11levofloxacin oral soln 25 mg/ml..................................11levofloxacin tab 250 mg..............................................11levofloxacin tab 500 mg..............................................11levofloxacin tab 750 mg..............................................11levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg............................................................. 84levonorgestrel & ethinyl estradiol tab 0.15 mg-30

mcg..............................................................................85levonorgestrel & ethinyl estradiol tab 0.1 mg-20

mcg..............................................................................85levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg........................85levonorgestrel-ethinyl estradiol (continuous) tab

90-20 mcg..................................................................85levonorg-eth est tab 0.1-0.02mg(84) & eth est tab

0.01mg(7)...................................................................84levonorg-eth est tab 0.15-0.03mg(84) & eth est tab

0.01mg(7)...................................................................84LEVORPHANOL TARTRATE....................................... 2levothyroxine sodium tab 100 mcg............................86levothyroxine sodium tab 112 mcg............................ 86levothyroxine sodium tab 125 mcg............................86levothyroxine sodium tab 137 mcg............................86levothyroxine sodium tab 150 mcg............................86levothyroxine sodium tab 175 mcg............................86levothyroxine sodium tab 200 mcg............................86levothyroxine sodium tab 25 mcg..............................86levothyroxine sodium tab 300 mcg............................86levothyroxine sodium tab 50 mcg..............................86levothyroxine sodium tab 75 mcg..............................86levothyroxine sodium tab 88 mcg..............................86LEXIVA...........................................................................47LEXIVA...........................................................................47LIALDA...........................................................................93LIDOCAINE HCL..........................................................65lidocaine hcl gel 2%.......................................................4lidocaine hcl local inj 1%...............................................4

2016

126

lidocaine hcl local preservative free inj1%..................................................................................5

lidocaine hcl soln 4%.....................................................5lidocaine hcl viscous soln 2%.......................................5lidocaine oint 5%............................................................5lidocaine patch 5%.........................................................5lidocaine-prilocaine cream 2.5-2.5%........................... 5lindane shampoo 1%...................................................38linezolid for susp 100 mg/5ml.................................... 11linezolid in sodium chloride iv soln 600

mg/300ml-0.9%......................................................... 11linezolid iv soln 600 mg/300ml (2 mg/

ml)................................................................................11linezolid tab 600 mg.................................................... 11LINZESS........................................................................79LINZESS........................................................................79liothyronine sodium tab 25 mcg.................................86liothyronine sodium tab 50 mcg.................................87liothyronine sodium tab 5 mcg................................... 86lisinopril & hydrochlorothiazide tab 10-12.5

mg................................................................................65lisinopril & hydrochlorothiazide tab 20-12.5

mg................................................................................65lisinopril & hydrochlorothiazide tab 20-25

mg................................................................................65lisinopril tab 10 mg...................................................... 65lisinopril tab 2.5 mg..................................................... 65lisinopril tab 20 mg...................................................... 65lisinopril tab 30 mg...................................................... 65lisinopril tab 40 mg...................................................... 65lisinopril tab 5 mg.........................................................65LITHIUM........................................................................ 52lithium carbonate cap 150 mg....................................52lithium carbonate cap 300 mg....................................52lithium carbonate cap 600 mg....................................52lithium carbonate tab 300 mg.....................................53lithium carbonate tab cr 300 mg................................ 52lithium carbonate tab cr 450 mg................................ 53LIVALO...........................................................................65LIVALO...........................................................................65LIVALO...........................................................................65LONSURF..................................................................... 34LONSURF..................................................................... 34loperamide hcl cap 2 mg............................................ 79lorazepam tab 0.5 mg................................................. 51lorazepam tab 1 mg.................................................... 51lorazepam tab 2 mg.................................................... 51losartan potassium & hydrochlorothiazide tab

100-12.5 mg.............................................................. 66losartan potassium & hydrochlorothiazide tab 100-25

mg................................................................................66

losartan potassium & hydrochlorothiazide tab50-12.5 mg.................................................................65

losartan potassium tab 100 mg..................................66losartan potassium tab 25 mg....................................66losartan potassium tab 50 mg....................................66LOTEMAX..................................................................... 95LOTEMAX..................................................................... 95LOTEMAX..................................................................... 95lovastatin tab 10 mg....................................................66lovastatin tab 20 mg....................................................66lovastatin tab 40 mg....................................................66loxapine succinate cap 10 mg....................................42loxapine succinate cap 25 mg....................................42loxapine succinate cap 50 mg....................................42loxapine succinate cap 5 mg......................................42LUMIGAN...................................................................... 95LUPRON DEPOT.........................................................88LUPRON DEPOT.........................................................88LUPRON DEPOT.........................................................88LUPRON DEPOT.........................................................88LUPRON DEPOT.........................................................88LUPRON DEPOT.........................................................88LUPRON DEPOT-PED............................................... 88LUPRON DEPOT-PED............................................... 88LUPRON DEPOT-PED............................................... 88LUPRON DEPOT-PED............................................... 88LUPRON DEPOT-PED............................................... 88LYNPARZA....................................................................34LYRICA.......................................................................... 16LYRICA.......................................................................... 16LYRICA.......................................................................... 16LYRICA.......................................................................... 16LYRICA.......................................................................... 16LYRICA.......................................................................... 16LYRICA.......................................................................... 16LYRICA.......................................................................... 16LYRICA.......................................................................... 16LYRICA.......................................................................... 72LYRICA.......................................................................... 72LYRICA.......................................................................... 72LYRICA.......................................................................... 72LYRICA.......................................................................... 72LYRICA.......................................................................... 72LYRICA.......................................................................... 72LYRICA.......................................................................... 72LYRICA.......................................................................... 72LYSODREN...................................................................87Mmagnesium sulfate inj 50%...................................... 102malathion lotion 0.5%..................................................38MAPROTILINE HCL.................................................... 21MAPROTILINE HCL.................................................... 21

2016

127

MAPROTILINE HCL.................................................... 21MARPLAN..................................................................... 21MARQIBO......................................................................34MATULANE...................................................................34meclizine hcl tab 12.5 mg...........................................24meclizine hcl tab 25 mg..............................................24medroxyprogesterone acetate im susp 150 mg/

ml.................................................................................85medroxyprogesterone acetate im susp prefilled syr

150 mg/ml.................................................................. 85medroxyprogesterone acetate tab 10

mg................................................................................85medroxyprogesterone acetate tab 2.5

mg................................................................................85medroxyprogesterone acetate tab 5

mg................................................................................85mefloquine hcl tab 250 mg......................................... 38megestrol acetate susp 40 mg/ml..............................85megestrol acetate tab 20 mg..................................... 85megestrol acetate tab 40 mg..................................... 85MEKINIST......................................................................34MEKINIST......................................................................34meloxicam tab 15 mg....................................................2meloxicam tab 15 mg..................................................26meloxicam tab 7.5 mg...................................................2meloxicam tab 7.5 mg.................................................26melphalan hcl for inj 50 mg........................................ 34memantine hcl oral solution 2 mg/ml.........................18memantine hcl tab 10 mg...........................................18memantine hcl tab 5 mg............................................. 18memantine hcl tab 5 mg (28) & 10 mg (21) titration

pak...............................................................................18MENACTRA.................................................................. 91MENEST........................................................................85MENEST........................................................................85MENEST........................................................................85MENEST........................................................................85MENHIBRIX.................................................................. 91MENOMUNE-A/C/Y/W-135........................................ 91MENVEO....................................................................... 91mercaptopurine tab 50 mg......................................... 34meropenem iv for soln 1 gm...................................... 11meropenem iv for soln 500 mg.................................. 11mesalamine enema 4 gm........................................... 93mesna inj 100 mg/ml...................................................34MESNEX........................................................................34MESTINON................................................................... 28MESTINON TIMESPAN.............................................. 28metformin hcl tab 1000 mg.........................................56metformin hcl tab 500 mg...........................................56metformin hcl tab 850 mg...........................................56metformin hcl tab sr 24hr 500 mg..............................56

metformin hcl tab sr 24hr 750 mg..............................56methadone hcl tab 10 mg.............................................3methadone hcl tab 5 mg............................................... 3methazolamide tab 25 mg.......................................... 66methazolamide tab 50 mg.......................................... 66methenamine hippurate tab 1 gm..............................11methimazole tab 10 mg.............................................. 89methimazole tab 5 mg.................................................89methocarbamol tab 500 mg..................................... 101methocarbamol tab 750 mg..................................... 101methotrexate sodium for inj 1 gm.............................. 34methotrexate sodium for inj 1 gm.............................. 91methotrexate sodium inj 250 mg/10ml (25 mg/

ml)................................................................................34methotrexate sodium inj 250 mg/10ml (25 mg/



ml)................................................................................91methotrexate sodium inj pf 1000 mg/40ml (25 mg/










ml)................................................................................91methotrexate sodium tab 2.5 mg............................... 35methotrexate sodium tab 2.5 mg............................... 91methoxsalen rapid cap 10 mg....................................76methscopolamine bromide tab 2.5 mg......................79methscopolamine bromide tab 5 mg......................... 79methylergonovine maleate tab 0.2 mg......................81methylphenidate hcl tab 10 mg..................................72methylphenidate hcl tab 20 mg..................................72methylphenidate hcl tab 5 mg....................................72methylphenidate hcl tab cr 20 mg............................. 72methylprednisolone sodium succinate for inj 1000

mg................................................................................82

2016

128

methylprednisolone sodium succinate for inj 125mg................................................................................82

methylprednisolone sodium succinate for inj 40mg................................................................................82

methylprednisolone tab 16 mg...................................82methylprednisolone tab 32 mg...................................83methylprednisolone tab 4 mg.....................................82methylprednisolone tab 8 mg.....................................82methylprednisolone tab therapy pack 4 mg

(21)..............................................................................82methyltestosterone cap 10 mg...................................85metoclopramide hcl inj 5 mg/ml................................. 24metoclopramide hcl inj 5 mg/ml................................. 79metoclopramide hcl soln 5 mg/5ml (10

mg/10ml).....................................................................24metoclopramide hcl soln 5 mg/5ml (10

mg/10ml).....................................................................79metoclopramide hcl tab 10 mg...................................24metoclopramide hcl tab 10 mg...................................79metoclopramide hcl tab 5 mg.....................................24metoclopramide hcl tab 5 mg.....................................79metolazone tab 10 mg................................................ 66metolazone tab 2.5 mg............................................... 66metolazone tab 5 mg...................................................66metoprolol & hydrochlorothiazide tab 100-25

mg................................................................................66metoprolol & hydrochlorothiazide tab 50-25

mg................................................................................66metoprolol succinate tab sr 24hr 100




mg................................................................................66metoprolol tartrate tab 100 mg...................................66metoprolol tartrate tab 25 mg.....................................66metoprolol tartrate tab 50 mg.....................................66METRO IV.....................................................................11metronidazole cap 375 mg.........................................11metronidazole cream 0.75%.......................................76metronidazole gel 0.75%............................................ 76metronidazole gel 1%..................................................76metronidazole in nacl 0.79% iv soln 500

mg/100ml....................................................................11metronidazole lotion 0.75%........................................ 76metronidazole tab 250 mg..........................................11metronidazole tab 500 mg..........................................11metronidazole vaginal gel 0.75%...............................11mexiletine hcl cap 150 mg..........................................66mexiletine hcl cap 200 mg..........................................66

mexiletine hcl cap 250 mg..........................................66MIACALCIN...................................................................94midodrine hcl tab 10 mg............................................. 66midodrine hcl tab 2.5 mg............................................ 66midodrine hcl tab 5 mg............................................... 66MIGERGOT...................................................................27MIGRANAL....................................................................27minocycline hcl cap 100 mg.......................................11minocycline hcl cap 50 mg......................................... 11minocycline hcl cap 75 mg......................................... 11minocycline hcl tab 100 mg........................................11minocycline hcl tab 50 mg..........................................11minocycline hcl tab 75 mg..........................................11minoxidil tab 10 mg..................................................... 66minoxidil tab 2.5 mg.................................................... 66mirtazapine orally disintegrating tab 15

mg................................................................................21mirtazapine orally disintegrating tab 30

mg................................................................................21mirtazapine orally disintegrating tab 45

mg................................................................................21mirtazapine tab 15 mg................................................ 21mirtazapine tab 30 mg................................................ 21mirtazapine tab 45 mg................................................ 21mirtazapine tab 7.5 mg............................................... 21misoprostol tab 100 mcg............................................ 79misoprostol tab 200 mcg............................................ 79MITOMYCIN..................................................................35mitomycin for iv soln 20 mg....................................... 35mitomycin for iv soln 40 mg....................................... 35mitoxantrone hcl inj conc 20 mg/10ml (2 mg/

ml)................................................................................35mitoxantrone hcl inj conc 20 mg/10ml (2 mg/

ml)................................................................................72mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/

ml)................................................................................35mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/



ml)................................................................................72M-M-R II........................................................................ 91modafinil tab 100 mg.................................................101modafinil tab 200 mg.................................................101moexipril hcl tab 15 mg...............................................66moexipril hcl tab 7.5 mg..............................................66moexipril-hydrochlorothiazide tab 15-12.5

mg................................................................................66moexipril-hydrochlorothiazide tab 15-25

mg................................................................................66

2016

129

moexipril-hydrochlorothiazide tab 7.5-12.5mg................................................................................66

MOLINDONE HYDROCHLORIDE............................ 42MOLINDONE HYDROCHLORIDE............................ 42MOLINDONE HYDROCHLORIDE............................ 42mometasone furoate cream 0.1%............................. 76mometasone furoate oint 0.1%..................................76mometasone furoate solution 0.1%

(lotion).........................................................................76montelukast sodium chew tab 4 mg..........................99montelukast sodium chew tab 5 mg..........................99montelukast sodium oral granules packet 4

mg................................................................................99montelukast sodium tab 10 mg..................................99MORPHINE SULFATE.................................................. 3MORPHINE SULFATE.................................................. 3morphine sulfate beads cap sr 24hr 120

mg..................................................................................3morphine sulfate beads cap sr 24hr 30





mg..................................................................................3morphine sulfate inj pf 0.5 mg/ml.................................3morphine sulfate inj pf 1 mg/ml....................................3morphine sulfate oral soln 100 mg/5ml (20 mg/

ml)..................................................................................3morphine sulfate oral soln 10 mg/5ml......................... 3morphine sulfate oral soln 20 mg/5ml......................... 3morphine sulfate tab cr 100 mg................................... 3morphine sulfate tab cr 15 mg..................................... 3morphine sulfate tab cr 200 mg................................... 3morphine sulfate tab cr 30 mg..................................... 3morphine sulfate tab cr 60 mg..................................... 3MOVIPREP................................................................... 79MOXEZA........................................................................95moxifloxacin hcl tab 400 mg.......................................11MOZOBIL...................................................................... 59MULTAQ........................................................................ 66mupirocin oint 2%........................................................ 76MUSTARGEN............................................................... 35MYALEPT...................................................................... 83MYCAMINE...................................................................25MYCAMINE...................................................................25mycophenolate mofetil cap 250 mg...........................91mycophenolate mofetil for oral susp 200 mg/

ml.................................................................................91

mycophenolate mofetil tab 500 mg........................... 91mycophenolate sodium tab dr 180 mg......................91mycophenolate sodium tab dr 360 mg......................91MYRBETRIQ.................................................................81MYRBETRIQ.................................................................81Nnabumetone tab 500 mg...............................................3nabumetone tab 500 mg.............................................26nabumetone tab 750 mg...............................................3nabumetone tab 750 mg.............................................26nadolol tab 20 mg........................................................66nadolol tab 40 mg........................................................66nadolol tab 80 mg........................................................67NAFCILLIN SODIUM...................................................11NAFCILLIN SODIUM...................................................11nafcillin sodium for inj 10 gm......................................11nafcillin sodium for inj 1 gm........................................11nafcillin sodium for inj 2 gm........................................11NAGLAZYME................................................................77NALOXONE HCL........................................................... 5NALOXONE HCL........................................................... 5naloxone hcl inj 0.4 mg/ml............................................5naloxone hcl inj 4 mg/10ml...........................................5naltrexone hcl tab 50 mg.............................................. 5NAMENDA.................................................................... 18NAMENDA.................................................................... 18NAMENDA.................................................................... 18NAMENDA TITRATION PAK......................................18NAMENDA XR..............................................................18NAMENDA XR..............................................................18NAMENDA XR..............................................................18NAMENDA XR..............................................................18NAMENDA XR TITRATION PACK............................ 18naproxen sodium tab 275 mg.......................................3naproxen sodium tab 275 mg.................................... 26naproxen sodium tab 550 mg.......................................3naproxen sodium tab 550 mg.................................... 26naproxen susp 125 mg/5ml.......................................... 3naproxen susp 125 mg/5ml........................................26naproxen tab 250 mg.................................................... 3naproxen tab 250 mg.................................................. 27naproxen tab 375 mg.................................................... 3naproxen tab 375 mg.................................................. 27naproxen tab 500 mg.................................................... 3naproxen tab 500 mg.................................................. 27naproxen tab ec 375 mg...............................................3naproxen tab ec 375 mg.............................................26naproxen tab ec 500 mg...............................................3naproxen tab ec 500 mg.............................................26naratriptan hcl tab 1 mg..............................................27naratriptan hcl tab 2.5 mg...........................................27

2016

130

NARCAN..........................................................................5NASONEX.....................................................................99NATACYN......................................................................95nateglinide tab 120 mg............................................... 56nateglinide tab 60 mg..................................................56NATPARA...................................................................... 87NATPARA...................................................................... 87NATPARA...................................................................... 87NATPARA...................................................................... 87NEBUPENT...................................................................38NEFAZODONE HCL....................................................21NEFAZODONE HCL....................................................21NEFAZODONE HCL....................................................21nefazodone hcl tab 250 mg........................................21nefazodone hcl tab 50 mg..........................................21neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oin..........................95neomycin-polymy-gramicid op sol

1.75-10000-0.025mg-unt-mg/ml............................. 95neomycin-polymyxin b gu irrigation

soln..............................................................................12neomycin-polymyxin b gu irrigation

soln..............................................................................81neomycin-polymyxin-dexamethasone ophth oint

0.1%............................................................................95neomycin-polymyxin-dexamethasone ophth susp

0.1%............................................................................95neomycin-polymyxin-hc otic soln 1%........................ 96neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000

unit/ml-1%.................................................................. 96neomycin sulfate tab 500 mg.....................................12NEULASTA....................................................................59NEULASTA ONPRO KIT............................................ 59NEUPRO....................................................................... 39NEUPRO....................................................................... 39NEUPRO....................................................................... 39NEUPRO....................................................................... 39NEUPRO....................................................................... 39NEUPRO....................................................................... 39NEVANAC..................................................................... 95NEVIRAPINE................................................................ 47nevirapine tab 200 mg................................................ 47nevirapine tab sr 24hr 100 mg...................................47nevirapine tab sr 24hr 400 mg...................................47NEXAVAR......................................................................35NEXIUM.........................................................................79NEXIUM.........................................................................79NEXIUM.........................................................................79NEXIUM.........................................................................79NEXIUM.........................................................................80niacin tab cr 1000 mg................................................. 67niacin tab cr 500 mg....................................................67

niacin tab cr 750 mg....................................................67nicardipine hcl cap 20 mg...........................................67nicardipine hcl cap 30 mg...........................................67NICOTROL INHALER................................................... 5NICOTROL NS............................................................... 5nifedipine tab sr 24hr 30 mg...................................... 67nifedipine tab sr 24hr 60 mg...................................... 67nifedipine tab sr 24hr 90 mg...................................... 67nifedipine tab sr 24hr osmotic release 30

mg................................................................................67nifedipine tab sr 24hr osmotic release 60

mg................................................................................67nifedipine tab sr 24hr osmotic release 90

mg................................................................................67NILANDRON.................................................................35nilutamide tab 150 mg.................................................35NINLARO.......................................................................35NINLARO.......................................................................35NINLARO.......................................................................35NIPENT..........................................................................35NISOLDIPINE ER........................................................ 67nisoldipine tab sr 24hr 17 mg.....................................67nisoldipine tab sr 24hr 34 mg.....................................67nisoldipine tab sr 24hr 8.5 mg....................................67NITRO-BID....................................................................67nitrofurantoin macrocrystalline cap 100

mg................................................................................12nitrofurantoin macrocrystalline cap 50

mg................................................................................12nitrofurantoin monohydrate macrocrystalline cap 100

mg................................................................................12nitrofurantoin susp 25 mg/5ml....................................12nitroglycerin sl tab 0.3 mg.......................................... 67nitroglycerin sl tab 0.4 mg.......................................... 67nitroglycerin sl tab 0.6 mg.......................................... 67nitroglycerin td patch 24hr 0.1 mg/hr.........................67nitroglycerin td patch 24hr 0.2 mg/hr.........................67nitroglycerin td patch 24hr 0.4 mg/hr.........................67nitroglycerin td patch 24hr 0.6 mg/hr.........................67nitroglycerin tl soln 0.4 mg/spray (400 mcg/

spray)..........................................................................67NITROSTAT.................................................................. 67NITROSTAT.................................................................. 67NITROSTAT.................................................................. 67nizatidine cap 150 mg.................................................80nizatidine cap 300 mg.................................................80norethindrone & ethinyl estradiol-fe chew tab 0.4

mg-35 mcg.................................................................85norethindrone & ethinyl estradiol-fe chew tab 0.8

mg-25 mcg.................................................................85norethindrone & ethinyl estradiol tab 0.4 mg-35

mcg..............................................................................85

2016

131

norethindrone & ethinyl estradiol tab 0.5 mg-35mcg..............................................................................85

norethindrone & ethinyl estradiol tab 1 mg-35mcg..............................................................................85

norethindrone ace & ethinyl estradiol-fe tab 1.5mg-30 mcg.................................................................85

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20mcg..............................................................................85

norethindrone ace & ethinyl estradiol tab 1.5 mg-30mcg..............................................................................85

norethindrone ace & ethinyl estradiol tab 1 mg-20mcg..............................................................................85

norethindrone ace-ethinyl estradiol-fe tab 1 mg-20mcg (24).....................................................................85

norethindrone acetate tab 5 mg.................................85norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35

mg-mcg.......................................................................85norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35

mg-mcg.......................................................................85norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35

mg-mcg.......................................................................85norethindrone tab 0.35 mg......................................... 85norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg..............................................................................85norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg.........................85norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg.........................85norgestrel & ethinyl estradiol tab 0.3 mg-30

mcg..............................................................................85NORTHERA.................................................................. 67NORTHERA.................................................................. 67NORTHERA.................................................................. 67NORTRIPTYLINE HCL............................................... 21nortriptyline hcl cap 10 mg......................................... 21nortriptyline hcl cap 25 mg......................................... 21nortriptyline hcl cap 50 mg......................................... 21nortriptyline hcl cap 75 mg......................................... 21NORVIR.........................................................................47NORVIR.........................................................................47NORVIR.........................................................................47NOXAFIL....................................................................... 25NOXAFIL....................................................................... 25NOXAFIL....................................................................... 25NUCYNTA ER.................................................................3NUCYNTA ER.................................................................3NUCYNTA ER.................................................................3NUCYNTA ER.................................................................3NUCYNTA ER.................................................................3NUEDEXTA...................................................................72NULOJIX........................................................................92NUPLAZID.....................................................................39

NUPLAZID.....................................................................42NUVIGIL...................................................................... 101NUVIGIL...................................................................... 101NUVIGIL...................................................................... 101NUVIGIL...................................................................... 101nystatin cream 100000 unit/gm..................................76nystatin oint 100000 unit/gm...................................... 76nystatin susp 100000 unit/ml......................................25nystatin tab 500000 unit..............................................25nystatin topical powder............................................... 76nystatin-triamcinolone cream 100000-0.1 unit/gm-

%..................................................................................76nystatin-triamcinolone oint 100000-0.1 unit/gm-

%..................................................................................76OOCALIVA....................................................................... 80OCALIVA....................................................................... 80octreotide acetate inj 1000 mcg/ml (1 mg/

ml)................................................................................88octreotide acetate inj 100 mcg/ml (0.1 mg/




ml)................................................................................88ODEFSEY..................................................................... 47ODOMZO...................................................................... 35OFEV............................................................................. 99OFEV............................................................................. 99OFLOXACIN................................................................. 12ofloxacin ophth soln 0.3%...........................................96ofloxacin otic soln 0.3%.............................................. 96olanzapine for im inj 10 mg........................................ 42olanzapine for im inj 10 mg........................................ 53olanzapine orally disintegrating tab 10

mg................................................................................42olanzapine orally disintegrating tab 10






mg................................................................................42

2016

132

olanzapine orally disintegrating tab 5mg................................................................................53

olanzapine tab 10 mg..................................................42olanzapine tab 10 mg..................................................53olanzapine tab 15 mg..................................................42olanzapine tab 15 mg..................................................53olanzapine tab 2.5 mg.................................................42olanzapine tab 2.5 mg.................................................53olanzapine tab 20 mg..................................................42olanzapine tab 20 mg..................................................53olanzapine tab 5 mg....................................................42olanzapine tab 5 mg....................................................53olanzapine tab 7.5 mg.................................................42olanzapine tab 7.5 mg.................................................53olopatadine hcl nasal soln 0.6%................................ 99olopatadine hcl ophth soln 0.1%................................96OLYSIO..........................................................................47omega-3-acid ethyl esters cap 1 gm.........................67omeprazole cap delayed release 10

mg................................................................................80omeprazole cap delayed release 20

mg................................................................................80omeprazole cap delayed release 40

mg................................................................................80OMNITROPE................................................................ 83OMNITROPE................................................................ 83OMNITROPE................................................................ 83ONCASPAR.................................................................. 35ondansetron hcl inj 40 mg/20ml (2 mg/

ml)................................................................................24ondansetron hcl inj 4 mg/2ml (2 mg/

ml)................................................................................24ondansetron hcl oral soln 4 mg/5ml.......................... 24ondansetron hcl tab 24 mg.........................................24ondansetron hcl tab 4 mg...........................................24ondansetron hcl tab 8 mg...........................................24ondansetron orally disintegrating tab 4

mg................................................................................24ondansetron orally disintegrating tab 8

mg................................................................................24ONFI...............................................................................16ONFI...............................................................................16ONFI...............................................................................16ONFI...............................................................................16ONGLYZA......................................................................56ONGLYZA......................................................................56OPDIVO.........................................................................35OPDIVO.........................................................................35OPSUMIT...................................................................... 99ORACEA........................................................................76ORALAIR.......................................................................99ORAP............................................................................. 42

ORAP............................................................................. 43ORFADIN.......................................................................77ORFADIN.......................................................................77ORFADIN.......................................................................77ORFADIN.......................................................................78ORFADIN.......................................................................78ORKAMBI......................................................................99oxaliplatin for iv inj 100 mg.........................................35oxaliplatin for iv inj 50 mg...........................................35oxaliplatin iv soln 100 mg/20ml..................................35oxaliplatin iv soln 50 mg/10ml....................................35oxandrolone tab 10 mg............................................... 85oxandrolone tab 2.5 mg..............................................85oxaprozin tab 600 mg....................................................3oxaprozin tab 600 mg................................................. 27oxcarbazepine susp 300 mg/5ml (60 mg/

ml)................................................................................16oxcarbazepine tab 150 mg.........................................16oxcarbazepine tab 300 mg.........................................16oxcarbazepine tab 600 mg.........................................16oxybutynin chloride syrup 5 mg/5ml..........................81oxybutynin chloride tab 5 mg..................................... 81oxybutynin chloride tab sr 24hr 10 mg......................81oxybutynin chloride tab sr 24hr 15 mg......................81oxybutynin chloride tab sr 24hr 5 mg........................ 81oxycodone-aspirin tab 4.8355-325 mg........................4oxycodone hcl tab 10 mg..............................................3oxycodone hcl tab 15 mg..............................................4oxycodone hcl tab 20 mg..............................................4oxycodone hcl tab 30 mg..............................................4oxycodone hcl tab 5 mg................................................3oxycodone w/ acetaminophen tab 10-325

mg..................................................................................4oxycodone w/ acetaminophen tab 2.5-325

mg..................................................................................4oxycodone w/ acetaminophen tab 5-325

mg..................................................................................4oxycodone w/ acetaminophen tab 7.5-325

mg..................................................................................4Ppaclitaxel iv conc 100 mg/16.7ml (6 mg/

ml)................................................................................35paclitaxel iv conc 300 mg/50ml (6 mg/

ml)................................................................................35paclitaxel iv conc 30 mg/5ml (6 mg/ml).....................35paliperidone tab sr 24hr 1.5 mg.................................43paliperidone tab sr 24hr 3 mg.................................... 43paliperidone tab sr 24hr 6 mg.................................... 43paliperidone tab sr 24hr 9 mg.................................... 43PANRETIN.....................................................................35pantoprazole sodium ec tab 20 mg........................... 80

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pantoprazole sodium ec tab 40 mg........................... 80pantoprazole sodium for iv soln 40 mg..................... 80paricalcitol cap 1 mcg................................................. 94paricalcitol cap 2 mcg................................................. 94paricalcitol cap 4 mcg................................................. 94paricalcitol iv soln 2 mcg/ml....................................... 94paricalcitol iv soln 5 mcg/ml....................................... 94paromomycin sulfate cap 250 mg..............................12paroxetine hcl tab 10 mg............................................ 21paroxetine hcl tab 10 mg............................................ 51paroxetine hcl tab 20 mg............................................ 21paroxetine hcl tab 20 mg............................................ 51paroxetine hcl tab 30 mg............................................ 21paroxetine hcl tab 30 mg............................................ 51paroxetine hcl tab 40 mg............................................ 21paroxetine hcl tab 40 mg............................................ 51paroxetine hcl tab sr 24hr 12.5 mg............................21paroxetine hcl tab sr 24hr 12.5 mg............................51paroxetine hcl tab sr 24hr 25 mg...............................21paroxetine hcl tab sr 24hr 25 mg...............................51paroxetine hcl tab sr 24hr 37.5 mg............................21paroxetine hcl tab sr 24hr 37.5 mg............................51PASER........................................................................... 29PATADAY.......................................................................96PATANOL.......................................................................96PAXIL............................................................................. 21PAXIL............................................................................. 51PAZEO........................................................................... 96PEDVAX HIB................................................................ 92peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236

gm................................................................................80peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240

gm................................................................................80peg 3350-kcl-sod bicarb-nacl for soln 420

gm................................................................................80PEGANONE..................................................................16PEGASYS..................................................................... 48PEGASYS..................................................................... 48PEGASYS PROCLICK................................................48PEGASYS PROCLICK................................................48PEG-INTRON............................................................... 47PEG-INTRON............................................................... 47PEG-INTRON............................................................... 47PEG-INTRON............................................................... 47PEG-INTRON REDIPEN............................................ 47PEG-INTRON REDIPEN............................................ 47PEG-INTRON REDIPEN............................................ 47PEG-INTRON REDIPEN............................................ 47PEG-INTRON REDIPEN PAK 4................................ 47PEG-INTRON REDIPEN PAK 4................................ 47PEG-INTRON REDIPEN PAK 4................................ 47PEG-INTRON REDIPEN PAK 4................................ 47

penicillin g potassium for inj 20000000unit...............................................................................12

penicillin g potassium for inj 5000000unit...............................................................................12

PENICILLIN G POTASSIUM INDEXTROSE............................................................... 12



PENICILLIN G SODIUM............................................. 12penicillin v potassium for soln 125

mg/5ml........................................................................ 12penicillin v potassium for soln 250

mg/5ml........................................................................ 12penicillin v potassium tab 250 mg............................. 12penicillin v potassium tab 500 mg............................. 12PENTACEL....................................................................92PENTAM 300................................................................38PENTASA...................................................................... 93PENTASA...................................................................... 93pentoxifylline tab cr 400 mg....................................... 67perindopril erbumine tab 2 mg................................... 67perindopril erbumine tab 4 mg................................... 67perindopril erbumine tab 8 mg................................... 67PERJETA.......................................................................35permethrin cream 5%..................................................38perphenazine tab 16 mg.............................................24perphenazine tab 16 mg.............................................43perphenazine tab 2 mg............................................... 24perphenazine tab 2 mg............................................... 43perphenazine tab 4 mg............................................... 24perphenazine tab 4 mg............................................... 43perphenazine tab 8 mg............................................... 24perphenazine tab 8 mg............................................... 43phenelzine sulfate tab 15 mg.....................................21PHENOBARBITAL....................................................... 16PHENOBARBITAL....................................................... 16PHENOBARBITAL....................................................... 16PHENOBARBITAL....................................................... 16phenobarbital elixir 20 mg/5ml...................................16PHENOBARBITAL SODIUM...................................... 16PHENOBARBITAL SODIUM...................................... 16phenobarbital tab 16.2 mg..........................................16phenobarbital tab 32.4 mg..........................................17phenobarbital tab 64.8 mg..........................................17phenobarbital tab 97.2 mg..........................................17phenoxybenzamine hcl cap 10 mg............................67phenytoin chew tab 50 mg......................................... 17phenytoin sodium extended cap 100

mg................................................................................17

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phenytoin sodium extended cap 200mg................................................................................17

phenytoin sodium extended cap 300mg................................................................................17

phenytoin susp 125 mg/5ml....................................... 17PHOSLYRA...................................................................81PHOSPHOLINE IODIDE.............................................96PICATO..........................................................................76PICATO..........................................................................76pilocarpine hcl ophth soln 1%.................................... 96pilocarpine hcl ophth soln 2%.................................... 96pilocarpine hcl ophth soln 4%.................................... 96pilocarpine hcl tab 5 mg..............................................73pilocarpine hcl tab 7.5 mg.......................................... 73pimozide tab 1 mg....................................................... 43pimozide tab 2 mg....................................................... 43pindolol tab 10 mg....................................................... 68pindolol tab 5 mg......................................................... 67pioglitazone hcl-glimepiride tab 30-2

mg................................................................................56pioglitazone hcl-glimepiride tab 30-4

mg................................................................................56pioglitazone hcl-metformin hcl tab 15-500

mg................................................................................56pioglitazone hcl-metformin hcl tab 15-850

mg................................................................................56pioglitazone hcl tab 15 mg..........................................56pioglitazone hcl tab 30 mg..........................................56pioglitazone hcl tab 45 mg..........................................56piperacillin sod-tazobactam na for inj 3.375 gm

(3-0.375 gm)..............................................................12piperacillin sod-tazobactam sod for inj 2.25 gm

(2-0.25 gm)................................................................ 12piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5

gm).............................................................................. 12piroxicam cap 10 mg..................................................... 4piroxicam cap 10 mg...................................................27piroxicam cap 20 mg..................................................... 4piroxicam cap 20 mg...................................................27PLEGRIDY.................................................................... 72PLEGRIDY.................................................................... 72PLEGRIDY STARTER PACK..................................... 72PLEGRIDY STARTER PACK..................................... 72podofilox soln 0.5%..................................................... 76polyethylene glycol 3350 oral packet........................ 80polyethylene glycol 3350 oral powder.......................80polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%...................................................................... 96POMALYST...................................................................35POMALYST...................................................................35POMALYST...................................................................35POMALYST...................................................................35

PORTRAZZA................................................................ 35potassium chloride 20 meq/l (0.15%) in dextrose 5%

inj...............................................................................103potassium chloride 40 meq/l (0.3%) in dextrose 5%

inj...............................................................................103potassium chloride cap cr 10 meq.......................... 103potassium chloride cap cr 8 meq.............................102potassium chloride inj 2 meq/ml.............................. 103potassium chloride microencapsulated crys cr tab 10

meq........................................................................... 103potassium chloride microencapsulated crys cr tab 20

meq........................................................................... 103potassium chloride tab cr 10 meq........................... 103potassium chloride tab cr 8 meq (600

mg)............................................................................103potassium citrate tab cr 10 meq (1080



mg)............................................................................103POTIGA......................................................................... 17POTIGA......................................................................... 17POTIGA......................................................................... 17POTIGA......................................................................... 17PRADAXA..................................................................... 59PRADAXA..................................................................... 59PRADAXA..................................................................... 59PRALUENT................................................................... 68PRALUENT................................................................... 68PRALUENT................................................................... 68PRALUENT................................................................... 68pramipexole dihydrochloride tab 0.125

mg................................................................................39pramipexole dihydrochloride tab 0.25




mg................................................................................40pramipexole dihydrochloride tab 1 mg...................... 39pravastatin sodium tab 10 mg....................................68pravastatin sodium tab 20 mg....................................68pravastatin sodium tab 40 mg....................................68pravastatin sodium tab 80 mg....................................68prazosin hcl cap 1 mg.................................................68prazosin hcl cap 1 mg.................................................81prazosin hcl cap 2 mg.................................................68prazosin hcl cap 2 mg.................................................81prazosin hcl cap 5 mg.................................................68

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prazosin hcl cap 5 mg.................................................81prednicarbate cream 0.1%......................................... 76prednicarbate oint 0.1%..............................................76prednisolone acetate ophth susp 1%........................96prednisolone sod phosphate oral soln 15

mg/5ml........................................................................ 83prednisolone sod phosph oral soln 6.7 mg/5ml (5

mg/5ml base).............................................................83prednisolone syrup 15 mg/5ml...................................83PREDNISONE.............................................................. 83PREDNISONE.............................................................. 83PREDNISONE.............................................................. 83PREDNISONE.............................................................. 83PREDNISONE.............................................................. 83PREDNISONE.............................................................. 83prednisone tab 10 mg................................................. 83prednisone tab 1 mg................................................... 83prednisone tab 2.5 mg................................................ 83prednisone tab 20 mg................................................. 83prednisone tab 5 mg................................................... 83PREMARIN................................................................... 86PREMARIN................................................................... 86PREMARIN................................................................... 86PREMARIN................................................................... 86PREMARIN................................................................... 86PREMARIN................................................................... 86PREMPHASE............................................................... 86PREMPRO.................................................................... 86PREMPRO.................................................................... 86PREMPRO.................................................................... 86PREMPRO.................................................................... 86PREZCOBIX................................................................. 48PREZISTA..................................................................... 48PREZISTA..................................................................... 48PREZISTA..................................................................... 48PREZISTA..................................................................... 48PREZISTA..................................................................... 48PRIFTIN.........................................................................29PRIMAQUINE PHOSPHATE......................................38primidone tab 250 mg................................................. 17primidone tab 50 mg................................................... 17PRISTIQ........................................................................ 21PRISTIQ........................................................................ 21PRISTIQ........................................................................ 22PROAIR HFA................................................................99PROAIR RESPICLICK................................................ 99probenecid tab 500 mg............................................... 25prochlorperazine edisylate inj 5 mg/ml......................24prochlorperazine edisylate inj 5 mg/ml......................43prochlorperazine maleate tab 10 mg.........................24prochlorperazine maleate tab 10 mg.........................43prochlorperazine maleate tab 5 mg...........................24

prochlorperazine maleate tab 5 mg...........................43prochlorperazine suppos 25 mg................................ 24prochlorperazine suppos 25 mg................................ 43PROCRIT...................................................................... 59PROCRIT...................................................................... 59PROCRIT...................................................................... 59PROCRIT...................................................................... 59PROCRIT...................................................................... 59PROCRIT...................................................................... 59PROGLYCEM............................................................... 56PROGRAF.....................................................................92PROLASTIN-C..............................................................99PROLENSA...................................................................96PROLEUKIN................................................................. 35PROLIA..........................................................................94PROMACTA.................................................................. 59PROMACTA.................................................................. 59PROMACTA.................................................................. 59PROMACTA.................................................................. 59promethazine hcl suppos 12.5 mg............................ 24promethazine hcl suppos 12.5 mg............................ 99promethazine hcl suppos 25 mg................................24promethazine hcl suppos 25 mg................................99promethazine hcl syrup 6.25 mg/5ml........................ 24promethazine hcl syrup 6.25 mg/5ml........................ 99promethazine hcl tab 12.5 mg....................................24promethazine hcl tab 12.5 mg....................................99promethazine hcl tab 25 mg.......................................24promethazine hcl tab 25 mg.......................................99promethazine hcl tab 50 mg.......................................24promethazine hcl tab 50 mg.......................................99propafenone hcl cap sr 12hr 225 mg........................ 68propafenone hcl cap sr 12hr 325 mg........................ 68propafenone hcl cap sr 12hr 425 mg........................ 68propafenone hcl tab 150 mg...................................... 68propafenone hcl tab 225 mg...................................... 68propafenone hcl tab 300 mg...................................... 68propranolol hcl cap sr 24hr 120 mg...........................27propranolol hcl cap sr 24hr 120 mg...........................68propranolol hcl cap sr 24hr 160 mg...........................27propranolol hcl cap sr 24hr 160 mg...........................68propranolol hcl cap sr 24hr 60 mg.............................27propranolol hcl cap sr 24hr 60 mg.............................68propranolol hcl cap sr 24hr 80 mg.............................27propranolol hcl cap sr 24hr 80 mg.............................68propranolol hcl inj 1 mg/ml......................................... 27propranolol hcl inj 1 mg/ml......................................... 68propranolol hcl tab 10 mg...........................................27propranolol hcl tab 10 mg...........................................68propranolol hcl tab 20 mg...........................................27propranolol hcl tab 20 mg...........................................68propranolol hcl tab 40 mg...........................................27

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propranolol hcl tab 40 mg...........................................68propranolol hcl tab 60 mg...........................................27propranolol hcl tab 60 mg...........................................68propranolol hcl tab 80 mg...........................................27propranolol hcl tab 80 mg...........................................68propylthiouracil tab 50 mg.......................................... 89PROQUAD.................................................................... 92protriptyline hcl tab 10 mg.......................................... 22protriptyline hcl tab 5 mg............................................ 22PULMOZYME............................................................... 99PURIXAN.......................................................................35PYLERA.........................................................................80pyrazinamide tab 500 mg........................................... 29pyridostigmine bromide tab 60 mg............................ 28pyridostigmine bromide tab cr 180 mg......................28QQUADRACEL................................................................92quetiapine fumarate tab 100 mg................................22quetiapine fumarate tab 100 mg................................43quetiapine fumarate tab 100 mg................................53quetiapine fumarate tab 200 mg................................22quetiapine fumarate tab 200 mg................................43quetiapine fumarate tab 200 mg................................53quetiapine fumarate tab 25 mg..................................22quetiapine fumarate tab 25 mg..................................43quetiapine fumarate tab 25 mg..................................53quetiapine fumarate tab 300 mg................................22quetiapine fumarate tab 300 mg................................43quetiapine fumarate tab 300 mg................................53quetiapine fumarate tab 400 mg................................22quetiapine fumarate tab 400 mg................................43quetiapine fumarate tab 400 mg................................53quetiapine fumarate tab 50 mg..................................22quetiapine fumarate tab 50 mg..................................43quetiapine fumarate tab 50 mg..................................53quinapril hcl tab 10 mg............................................... 68quinapril hcl tab 20 mg............................................... 68quinapril hcl tab 40 mg............................................... 68quinapril hcl tab 5 mg..................................................68quinapril-hydrochlorothiazide tab 10-12.5

mg................................................................................68quinapril-hydrochlorothiazide tab 20-12.5

mg................................................................................68quinapril-hydrochlorothiazide tab 20-25

mg................................................................................68quinidine gluconate tab cr 324 mg............................ 68QUINIDINE SULFATE................................................. 69quinidine sulfate tab 300 mg...................................... 69QVAR............................................................................. 99QVAR........................................................................... 100

RRABAVERT................................................................... 92rabeprazole sodium ec tab 20 mg............................. 80RAGWITEK.................................................................100raloxifene hcl tab 60 mg............................................. 86ramipril cap 1.25 mg....................................................69ramipril cap 10 mg.......................................................69ramipril cap 2.5 mg......................................................69ramipril cap 5 mg.........................................................69RANEXA........................................................................69RANEXA........................................................................69ranitidine hcl cap 150 mg........................................... 80ranitidine hcl cap 300 mg........................................... 80ranitidine hcl syrup 15 mg/ml (75

mg/5ml).......................................................................80ranitidine hcl tab 150 mg............................................ 80ranitidine hcl tab 300 mg............................................ 80RAPAFLO...................................................................... 81RAPAFLO...................................................................... 81RAPAMUNE.................................................................. 92REBETOL......................................................................48RECOMBIVAX HB....................................................... 92RECOMBIVAX HB....................................................... 92RECOMBIVAX HB....................................................... 92RELISTOR.....................................................................80RELISTOR.....................................................................80RELISTOR.....................................................................80REMICADE................................................................... 92REMODULIN.............................................................. 100REMODULIN.............................................................. 100REMODULIN.............................................................. 100REMODULIN.............................................................. 100RENVELA......................................................................81RENVELA......................................................................81RENVELA......................................................................81repaglinide tab 0.5 mg................................................ 56repaglinide tab 1 mg....................................................56repaglinide tab 2 mg....................................................56REPATHA...................................................................... 69REPATHA PUSHTRONEX SYSTEM........................69REPATHA SURECLICK.............................................. 69RESCRIPTOR.............................................................. 48RESCRIPTOR.............................................................. 48RESTASIS.....................................................................96RETROVIR IV INFUSION...........................................48REVLIMID......................................................................35REVLIMID......................................................................35REVLIMID......................................................................36REVLIMID......................................................................36REVLIMID......................................................................36REVLIMID......................................................................36REXULTI........................................................................22

2016

137

REXULTI........................................................................22REXULTI........................................................................22REXULTI........................................................................22REXULTI........................................................................22REXULTI........................................................................22REXULTI........................................................................43REXULTI........................................................................43REXULTI........................................................................43REXULTI........................................................................43REXULTI........................................................................43REXULTI........................................................................43REYATAZ.......................................................................48REYATAZ.......................................................................48REYATAZ.......................................................................48REYATAZ.......................................................................48RIBASPHERE...............................................................48RIBASPHERE...............................................................48RIBASPHERE RIBAPAK.............................................48RIBASPHERE RIBAPAK.............................................48ribavirin cap 200 mg....................................................48ribavirin tab 200 mg.....................................................48RIDAURA...................................................................... 92rifabutin cap 150 mg....................................................29rifampin cap 150 mg....................................................29rifampin cap 300 mg....................................................29rifampin for inj 600 mg................................................ 29riluzole tab 50 mg........................................................ 72rimantadine hydrochloride tab 100 mg......................48risedronate sodium tab 150 mg................................. 94risedronate sodium tab 30 mg................................... 94risedronate sodium tab 35 mg................................... 94risedronate sodium tab 5 mg..................................... 94risedronate sodium tab delayed release 35

mg................................................................................94RISPERDAL CONSTA................................................ 43RISPERDAL CONSTA................................................ 43RISPERDAL CONSTA................................................ 43RISPERDAL CONSTA................................................ 43RISPERDAL CONSTA................................................ 53RISPERDAL CONSTA................................................ 53RISPERDAL CONSTA................................................ 53RISPERDAL CONSTA................................................ 53risperidone orally disintegrating tab 0.25

mg................................................................................43risperidone orally disintegrating tab 0.25



mg................................................................................53risperidone orally disintegrating tab 1

mg................................................................................43

risperidone orally disintegrating tab 1mg................................................................................53







risperidone soln 1 mg/ml............................................ 43risperidone soln 1 mg/ml............................................ 53risperidone tab 0.25 mg..............................................44risperidone tab 0.25 mg..............................................53risperidone tab 0.5 mg................................................ 44risperidone tab 0.5 mg................................................ 53risperidone tab 1 mg................................................... 44risperidone tab 1 mg................................................... 53risperidone tab 2 mg................................................... 44risperidone tab 2 mg................................................... 53risperidone tab 3 mg................................................... 44risperidone tab 3 mg................................................... 53risperidone tab 4 mg................................................... 44risperidone tab 4 mg................................................... 53RITUXAN.......................................................................36RITUXAN.......................................................................36rivastigmine tartrate cap 1.5 mg................................ 18rivastigmine tartrate cap 3 mg....................................18rivastigmine tartrate cap 4.5 mg................................ 18rivastigmine tartrate cap 6 mg....................................19rivastigmine td patch 24hr 13.3

mg/24hr...................................................................... 19rivastigmine td patch 24hr 4.6 mg/24hr.....................19rivastigmine td patch 24hr 9.5 mg/24hr.....................19rizatriptan benzoate orally disintegrating tab 10

mg................................................................................27rizatriptan benzoate orally disintegrating tab 5

mg................................................................................27rizatriptan benzoate tab 10 mg.................................. 27rizatriptan benzoate tab 5 mg.................................... 27ropinirole hydrochloride tab 0.25 mg.........................40ropinirole hydrochloride tab 0.5 mg...........................40ropinirole hydrochloride tab 1 mg.............................. 40ropinirole hydrochloride tab 2 mg.............................. 40ropinirole hydrochloride tab 3 mg.............................. 40ropinirole hydrochloride tab 4 mg.............................. 40ropinirole hydrochloride tab 5 mg.............................. 40rosuvastatin calcium tab 10 mg................................. 69

2016

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rosuvastatin calcium tab 20 mg................................. 69rosuvastatin calcium tab 40 mg................................. 69rosuvastatin calcium tab 5 mg................................... 69ROTARIX.......................................................................92ROTATEQ......................................................................92SSABRIL.......................................................................... 17SABRIL.......................................................................... 17SAMSCA..................................................................... 103SAMSCA..................................................................... 103SANDIMMUNE............................................................. 92SANTYL.........................................................................76SAPHRIS.......................................................................44SAPHRIS.......................................................................44SAPHRIS.......................................................................44selegiline hcl cap 5 mg............................................... 40selegiline hcl tab 5 mg................................................ 40selenium sulfide lotion 2.5%.......................................76SELZENTRY.................................................................48SELZENTRY.................................................................48SENSIPAR.....................................................................87SENSIPAR.....................................................................87SENSIPAR.....................................................................87SEREVENT DISKUS.................................................100SEROQUEL XR........................................................... 22SEROQUEL XR........................................................... 22SEROQUEL XR........................................................... 22SEROQUEL XR........................................................... 22SEROQUEL XR........................................................... 22SEROQUEL XR........................................................... 44SEROQUEL XR........................................................... 44SEROQUEL XR........................................................... 44SEROQUEL XR........................................................... 44SEROQUEL XR........................................................... 44SEROQUEL XR........................................................... 53SEROQUEL XR........................................................... 53SEROQUEL XR........................................................... 54SEROQUEL XR........................................................... 54SEROQUEL XR........................................................... 54sertraline hcl oral conc 20 mg/ml...............................22sertraline hcl oral conc 20 mg/ml...............................51sertraline hcl tab 100 mg............................................ 22sertraline hcl tab 100 mg............................................ 51sertraline hcl tab 25 mg.............................................. 22sertraline hcl tab 25 mg.............................................. 51sertraline hcl tab 50 mg.............................................. 22sertraline hcl tab 50 mg.............................................. 51SIGNIFOR..................................................................... 88SIGNIFOR..................................................................... 88SIGNIFOR..................................................................... 88SIGNIFOR LAR............................................................88SIGNIFOR LAR............................................................88

SIGNIFOR LAR............................................................88sildenafil citrate tab 20 mg....................................... 100SILENOR.....................................................................101SILENOR.....................................................................101silver sulfadiazine cream 1%......................................76SIMBRINZA...................................................................96SIMULECT.................................................................... 92SIMULECT.................................................................... 92simvastatin tab 10 mg.................................................69simvastatin tab 20 mg.................................................69simvastatin tab 40 mg.................................................69simvastatin tab 5 mg................................................... 69simvastatin tab 80 mg.................................................69sirolimus tab 0.5 mg.................................................... 92sirolimus tab 1 mg....................................................... 92sirolimus tab 2 mg....................................................... 92SIRTURO.......................................................................29SIVEXTRO.................................................................... 12SIVEXTRO.................................................................... 12sodium chloride inj 0.45%........................................ 103sodium chloride irrigation soln 0.9%....................... 103sodium chloride iv soln 0.9%................................... 103sodium phenylbutyrate oral powder 3 gm/

teaspoonful.................................................................78sodium polystyrene sulfonate oral susp 15

gm/60ml....................................................................103sodium polystyrene sulfonate powder.....................103sodium polystyrene sulfonate rectal susp 30

gm/120ml................................................................. 103SOLTAMOX...................................................................36SOMATULINE DEPOT................................................88SOMATULINE DEPOT................................................88SOMATULINE DEPOT................................................88SOMAVERT.................................................................. 88SOMAVERT.................................................................. 88SOMAVERT.................................................................. 88SOMAVERT.................................................................. 88SOMAVERT.................................................................. 88sotalol hcl (afib/afl) tab 120 mg..................................69sotalol hcl (afib/afl) tab 160 mg..................................69sotalol hcl (afib/afl) tab 80 mg....................................69sotalol hcl tab 120 mg.................................................69sotalol hcl tab 160 mg.................................................69sotalol hcl tab 240 mg.................................................69sotalol hcl tab 80 mg...................................................69SOVALDI....................................................................... 48SPIRIVA HANDIHALER............................................100SPIRIVA RESPIMAT................................................. 100SPIRIVA RESPIMAT................................................. 100spironolactone & hydrochlorothiazide tab 25-25

mg................................................................................69spironolactone tab 100 mg.........................................69

2016

139

spironolactone tab 25 mg........................................... 69spironolactone tab 50 mg........................................... 69SPRITAM.......................................................................17SPRITAM.......................................................................17SPRITAM.......................................................................17SPRITAM.......................................................................17SPRYCEL......................................................................36SPRYCEL......................................................................36SPRYCEL......................................................................36SPRYCEL......................................................................36SPRYCEL......................................................................36SPRYCEL......................................................................36stavudine cap 15 mg...................................................48stavudine cap 20 mg...................................................48stavudine cap 30 mg...................................................48stavudine cap 40 mg...................................................48stavudine for oral soln 1 mg/ml..................................48STELARA...................................................................... 76STELARA...................................................................... 76STELARA...................................................................... 92STELARA...................................................................... 92STIMATE....................................................................... 83STIOLTO RESPIMAT................................................ 100STIVARGA.....................................................................36STRATTERA.................................................................72STRATTERA.................................................................72STRATTERA.................................................................72STRATTERA.................................................................73STRATTERA.................................................................73STRATTERA.................................................................73STRATTERA.................................................................73STRENSIQ....................................................................78STRENSIQ....................................................................78STRENSIQ....................................................................78STRENSIQ....................................................................78STREPTOMYCIN SULFATE...................................... 12STRIBILD...................................................................... 48SUBOXONE....................................................................5SUBOXONE....................................................................5SUBOXONE....................................................................5SUBOXONE....................................................................5sucralfate tab 1 gm......................................................80sulfacetamide sodium lotion 10%.............................. 76sulfacetamide sodium ophth soln 10%..................... 96sulfacetamide sodium-prednisolone ophth soln

10-0.23(0.25)%..........................................................96SULFADIAZINE............................................................ 12SULFAMETHOXAZOLE/

TRIMETHOPRIM...................................................... 12sulfamethoxazole-trimethoprim susp 200-40

mg/5ml........................................................................ 12

sulfamethoxazole-trimethoprim tab 400-80mg................................................................................12

sulfamethoxazole-trimethoprim tab 800-160mg................................................................................12

sulfasalazine tab 500 mg............................................93sulfasalazine tab delayed release 500

mg................................................................................93sulindac tab 150 mg...................................................... 4sulindac tab 150 mg....................................................27sulindac tab 200 mg...................................................... 4sulindac tab 200 mg....................................................27sumatriptan nasal spray 20 mg/act........................... 28sumatriptan nasal spray 5 mg/act..............................28SUMATRIPTAN SUCCINATE.....................................28sumatriptan succinate inj 6 mg/0.5ml........................28sumatriptan succinate solution auto-injector 4

mg/0.5ml.....................................................................28sumatriptan succinate solution auto-injector 6

mg/0.5ml.....................................................................28sumatriptan succinate solution cartridge 4

mg/0.5ml.....................................................................28sumatriptan succinate solution cartridge 6

mg/0.5ml.....................................................................28sumatriptan succinate tab 100 mg............................ 28sumatriptan succinate tab 25 mg...............................28sumatriptan succinate tab 50 mg...............................28SUPRAX........................................................................12SUPRAX........................................................................12SUPRAX........................................................................12SUPREP BOWEL PREP............................................ 80SURMONTIL.................................................................22SURMONTIL.................................................................22SURMONTIL.................................................................22SUSTIVA........................................................................48SUSTIVA........................................................................48SUSTIVA........................................................................48SUTENT........................................................................ 36SUTENT........................................................................ 36SUTENT........................................................................ 36SUTENT........................................................................ 36SYLATRON................................................................... 36SYLATRON................................................................... 36SYLATRON................................................................... 36SYLATRON................................................................... 36SYLATRON................................................................... 36SYLATRON................................................................... 48SYLATRON................................................................... 49SYLATRON................................................................... 49SYLATRON................................................................... 49SYLATRON................................................................... 49SYLVANT.......................................................................36SYLVANT.......................................................................36

2016

140

SYMBICORT...............................................................100SYMBICORT...............................................................100SYMLINPEN 120......................................................... 56SYMLINPEN 60............................................................56SYNAGIS.......................................................................92SYNAGIS.......................................................................92SYNAREL......................................................................88SYNERCID....................................................................12SYNJARDY................................................................... 56SYNJARDY................................................................... 57SYNJARDY................................................................... 57SYNJARDY................................................................... 57SYNRIBO...................................................................... 36SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYNTHROID.................................................................87SYPRINE.....................................................................103TTABLOID........................................................................36tacrolimus cap 0.5 mg.................................................92tacrolimus cap 1 mg....................................................92tacrolimus cap 5 mg....................................................92tacrolimus oint 0.03%..................................................76tacrolimus oint 0.1%.................................................... 76TAFINLAR..................................................................... 36TAFINLAR..................................................................... 36TAGRISSO.................................................................... 36TAGRISSO.................................................................... 36TAMIFLU........................................................................49TAMIFLU........................................................................49TAMIFLU........................................................................49TAMIFLU........................................................................49tamoxifen citrate tab 10 mg........................................36tamoxifen citrate tab 20 mg........................................36tamsulosin hcl cap 0.4 mg..........................................81TARCEVA...................................................................... 36TARCEVA...................................................................... 36TARCEVA...................................................................... 36TARGRETIN..................................................................36TARGRETIN..................................................................36TASIGNA....................................................................... 37TASIGNA....................................................................... 37TAXOTERE................................................................... 37

TAXOTERE................................................................... 37TAZORAC......................................................................76TAZORAC......................................................................76TAZORAC......................................................................76TAZORAC......................................................................76TECENTRIQ................................................................. 37TECFIDERA..................................................................73TECFIDERA..................................................................73TECFIDERA STARTER PACK...................................73TECHNIVIE................................................................... 49TEFLARO......................................................................12TEFLARO......................................................................12TEGRETOL-XR............................................................ 17TEKTURNA...................................................................69TEKTURNA...................................................................69TEKTURNA HCT......................................................... 69TEKTURNA HCT......................................................... 69TEKTURNA HCT......................................................... 69TEKTURNA HCT......................................................... 70telmisartan-hydrochlorothiazide tab 40-12.5

mg................................................................................70telmisartan-hydrochlorothiazide tab 80-12.5

mg................................................................................70telmisartan-hydrochlorothiazide tab 80-25

mg................................................................................70telmisartan tab 20 mg................................................. 70telmisartan tab 40 mg................................................. 70telmisartan tab 80 mg................................................. 70TEMODAR.................................................................... 37TENIVAC....................................................................... 92terazosin hcl cap 10 mg..............................................70terazosin hcl cap 10 mg..............................................82terazosin hcl cap 1 mg................................................70terazosin hcl cap 1 mg................................................81terazosin hcl cap 2 mg................................................70terazosin hcl cap 2 mg................................................82terazosin hcl cap 5 mg................................................70terazosin hcl cap 5 mg................................................82terbinafine hcl tab 250 mg..........................................25terbutaline sulfate tab 2.5 mg.................................. 100terbutaline sulfate tab 5 mg......................................100terconazole vaginal cream 0.4%................................25terconazole vaginal cream 0.8%................................25terconazole vaginal suppos 80 mg............................25testosterone cypionate im inj in oil 100 mg/

ml.................................................................................86testosterone cypionate im inj in oil 200 mg/

ml.................................................................................86testosterone enanthate im inj in oil 200 mg/

ml.................................................................................86testosterone td gel 12.5 mg/act (1%) (generic for

AndroGel Pump 1%)................................................ 86

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141

testosterone td gel 25 mg/2.5gm (1%) (generic forAndroGel 1%)............................................................86

testosterone td gel 50 mg/5gm (1%) (generic forAndroGel 1%)............................................................86

TETANUS/DIPHTHERIA TOXOID.............................92tetrabenazine tab 12.5 mg..........................................73tetrabenazine tab 25 mg.............................................73tetracycline hcl cap 250 mg........................................13tetracycline hcl cap 500 mg........................................13THALOMID....................................................................37THALOMID....................................................................37THALOMID....................................................................37THALOMID....................................................................37THALOMID....................................................................92THALOMID....................................................................92THALOMID....................................................................92THALOMID....................................................................93theophylline tab sr 12hr 100 mg.............................. 100theophylline tab sr 12hr 200 mg.............................. 100theophylline tab sr 12hr 300 mg.............................. 100theophylline tab sr 12hr 450 mg.............................. 100theophylline tab sr 24hr 400 mg.............................. 100theophylline tab sr 24hr 600 mg.............................. 100thioridazine hcl tab 100 mg........................................ 44thioridazine hcl tab 10 mg.......................................... 44thioridazine hcl tab 25 mg.......................................... 44thioridazine hcl tab 50 mg.......................................... 44THIOTEPA.....................................................................37thiothixene cap 10 mg.................................................44thiothixene cap 1 mg...................................................44thiothixene cap 2 mg...................................................44thiothixene cap 5 mg...................................................44THYMOGLOBULIN......................................................93tiagabine hcl tab 2 mg.................................................17tiagabine hcl tab 4 mg.................................................17TIKOSYN.......................................................................70TIKOSYN.......................................................................70TIKOSYN.......................................................................70TIMOLOL MALEATE................................................... 28TIMOLOL MALEATE................................................... 28TIMOLOL MALEATE................................................... 28TIMOLOL MALEATE................................................... 70TIMOLOL MALEATE................................................... 70TIMOLOL MALEATE................................................... 70timolol maleate ophth gel forming soln

0.25%..........................................................................96timolol maleate ophth gel forming soln

0.5%............................................................................96timolol maleate ophth soln 0.25%..............................96timolol maleate ophth soln 0.5%................................96TIVICAY......................................................................... 49TIVICAY......................................................................... 49

TIVICAY......................................................................... 49tizanidine hcl cap 2 mg............................................... 45tizanidine hcl cap 4 mg............................................... 45tizanidine hcl cap 6 mg............................................... 45tizanidine hcl tab 2 mg................................................45tizanidine hcl tab 4 mg................................................45TOBRADEX...................................................................96tobramycin-dexamethasone ophth susp

0.3-0.1%..................................................................... 96tobramycin nebu soln 300 mg/5ml.......................... 100tobramycin ophth soln 0.3%.......................................96tobramycin sulfate for inj 1.2 gm................................13tobramycin sulfate inj 1.2 gm/30ml (40 mg/

ml)................................................................................13tobramycin sulfate inj 10 mg/ml................................. 13tobramycin sulfate inj 2 gm/50ml (40 mg/

ml)................................................................................13tobramycin sulfate inj 80 mg/2ml (40 mg/

ml)................................................................................13tolcapone tab 100 mg................................................. 40tolmetin sodium cap 400 mg........................................ 4tolmetin sodium cap 400 mg...................................... 27tolterodine tartrate cap sr 24hr 2 mg.........................82tolterodine tartrate cap sr 24hr 4 mg.........................82tolterodine tartrate tab 1 mg.......................................82tolterodine tartrate tab 2 mg.......................................82topiramate sprinkle cap 15 mg...................................17topiramate sprinkle cap 15 mg...................................28topiramate sprinkle cap 25 mg...................................17topiramate sprinkle cap 25 mg...................................28topiramate tab 100 mg................................................17topiramate tab 100 mg................................................28topiramate tab 200 mg................................................17topiramate tab 200 mg................................................28topiramate tab 25 mg.................................................. 17topiramate tab 25 mg.................................................. 28topiramate tab 50 mg.................................................. 17topiramate tab 50 mg.................................................. 28TOPOTECAN HCL...................................................... 37topotecan hcl for inj 4 mg........................................... 37TORISEL....................................................................... 37torsemide tab 100 mg................................................. 70torsemide tab 10 mg................................................... 70torsemide tab 20 mg................................................... 70torsemide tab 5 mg......................................................70TOUJEO SOLOSTAR..................................................57TOVIAZ.......................................................................... 82TOVIAZ.......................................................................... 82TRACLEER.................................................................100TRACLEER.................................................................100TRADJENTA................................................................. 57

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tramadol-acetaminophen tab 37.5-325mg..................................................................................4

tramadol hcl tab 50 mg................................................. 4tramadol hcl tab sr 24hr 100 mg..................................4tramadol hcl tab sr 24hr 200 mg..................................4tramadol hcl tab sr 24hr 300 mg..................................4trandolapril tab 1 mg................................................... 70trandolapril tab 2 mg................................................... 70trandolapril tab 4 mg................................................... 70tranexamic acid iv soln 1000 mg/10ml (100 mg/

ml)................................................................................59tranexamic acid tab 650 mg.......................................59tranylcypromine sulfate tab 10 mg............................ 22TRAVATAN Z................................................................ 96trazodone hcl tab 100 mg...........................................22trazodone hcl tab 150 mg...........................................22trazodone hcl tab 300 mg...........................................22trazodone hcl tab 50 mg.............................................22TREANDA..................................................................... 37TREANDA..................................................................... 37TREANDA..................................................................... 37TRECATOR...................................................................29TRELSTAR....................................................................88TRELSTAR....................................................................89TRELSTAR MIXJECT..................................................89TRELSTAR MIXJECT..................................................89TRELSTAR MIXJECT..................................................89tretinoin cap 10 mg......................................................37tretinoin cream 0.025%............................................... 76tretinoin cream 0.05%................................................. 76tretinoin cream 0.1%................................................... 76tretinoin gel 0.01%.......................................................76tretinoin gel 0.025%.....................................................76triamcinolone acetonide cream

0.025%........................................................................77triamcinolone acetonide cream 0.1%........................77triamcinolone acetonide cream 0.5%........................77triamcinolone acetonide dental paste

0.1%............................................................................73triamcinolone acetonide lotion 0.025%..................... 77triamcinolone acetonide lotion 0.1%..........................77triamcinolone acetonide nasal aerosol suspension

55 mcg/act............................................................... 100triamcinolone acetonide oint 0.025%........................ 77triamcinolone acetonide oint 0.1%.............................77triamcinolone acetonide oint 0.5%.............................77triamterene & hydrochlorothiazide cap 37.5-25

mg................................................................................70triamterene & hydrochlorothiazide tab 37.5-25

mg................................................................................70triamterene & hydrochlorothiazide tab 75-50

mg................................................................................70

trifluoperazine hcl tab 10 mg......................................44trifluoperazine hcl tab 1 mg........................................44trifluoperazine hcl tab 2 mg........................................44trifluoperazine hcl tab 5 mg........................................44trifluridine ophth soln 1%............................................ 96trimethoprim tab 100 mg.............................................13trimipramine maleate cap 100 mg............................. 22trimipramine maleate cap 25 mg............................... 22trimipramine maleate cap 50 mg............................... 22TRINTELLIX..................................................................22TRINTELLIX..................................................................22TRINTELLIX..................................................................22TRISENOX....................................................................37TRIUMEQ......................................................................49trospium chloride cap sr 24hr 60 mg.........................82trospium chloride tab 20 mg.......................................82TRUMENBA.................................................................. 93TRUVADA......................................................................49TRUVADA......................................................................49TRUVADA......................................................................49TRUVADA......................................................................49TWINRIX........................................................................93TYBOST........................................................................ 49TYGACIL....................................................................... 13TYKERB........................................................................ 37TYPHIM VI.................................................................... 93TYSABRI....................................................................... 73TYSABRI....................................................................... 93TYZEKA.........................................................................49TYZINE PEDIATRIC NASAL DROPS.....................100UULORIC......................................................................... 25ULORIC......................................................................... 26UNITUXIN......................................................................37UPTRAVI..................................................................... 100UPTRAVI..................................................................... 100UPTRAVI..................................................................... 100UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101UPTRAVI..................................................................... 101ursodiol cap 300 mg....................................................80ursodiol tab 250 mg.....................................................80ursodiol tab 500 mg.....................................................80UVADEX........................................................................ 37UVADEX........................................................................ 77VVAGIFEM.......................................................................86valacyclovir hcl tab 1 gm............................................ 49

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valacyclovir hcl tab 500 mg........................................49VALCHLOR................................................................... 77VALCYTE.......................................................................49valganciclovir hcl for soln 50 mg/ml.......................... 49valganciclovir hcl tab 450 mg.....................................49valproate sodium inj 100 mg/ml.................................17valproate sodium syrup 250 mg/5ml......................... 17valproic acid cap 250 mg............................................17valproic acid cap 250 mg............................................54valsartan-hydrochlorothiazide tab 160-12.5

mg................................................................................70valsartan-hydrochlorothiazide tab 160-25

mg................................................................................70valsartan-hydrochlorothiazide tab 320-12.5

mg................................................................................70valsartan-hydrochlorothiazide tab 320-25

mg................................................................................70valsartan-hydrochlorothiazide tab 80-12.5

mg................................................................................70valsartan tab 160 mg...................................................70valsartan tab 320 mg...................................................70valsartan tab 40 mg.....................................................70valsartan tab 80 mg.....................................................70vancomycin hcl cap 125 mg.......................................13vancomycin hcl cap 250 mg.......................................13vancomycin hcl for inj 1000 mg................................. 13vancomycin hcl for inj 10 gm......................................13vancomycin hcl for inj 5000 mg................................. 13vancomycin hcl for inj 500 mg................................... 13vancomycin hcl for inj 750 mg................................... 13VANCOMYCIN HCL IN DEXTROSE.........................13VANCOMYCIN HCL IN DEXTROSE.........................13VANCOMYCIN HCL IN DEXTROSE.........................13VAQTA........................................................................... 93VAQTA........................................................................... 93VARIVAX........................................................................93VASCEPA...................................................................... 70VASCEPA...................................................................... 70VECTIBIX...................................................................... 37VECTIBIX...................................................................... 37VELCADE......................................................................37VENCLEXTA.................................................................37VENCLEXTA.................................................................37VENCLEXTA.................................................................37VENCLEXTA STARTING PACK................................ 37venlafaxine hcl cap sr 24hr 150 mg.......................... 23venlafaxine hcl cap sr 24hr 150 mg.......................... 51venlafaxine hcl cap sr 24hr 37.5 mg......................... 23venlafaxine hcl cap sr 24hr 37.5 mg......................... 51venlafaxine hcl cap sr 24hr 75 mg.............................23venlafaxine hcl cap sr 24hr 75 mg.............................51venlafaxine hcl tab 100 mg........................................ 23

venlafaxine hcl tab 100 mg........................................ 52venlafaxine hcl tab 25 mg...........................................23venlafaxine hcl tab 25 mg...........................................51venlafaxine hcl tab 37.5 mg....................................... 23venlafaxine hcl tab 37.5 mg....................................... 51venlafaxine hcl tab 50 mg...........................................23venlafaxine hcl tab 50 mg...........................................51venlafaxine hcl tab 75 mg...........................................23venlafaxine hcl tab 75 mg...........................................51venlafaxine hcl tab sr 24hr 150 mg........................... 23venlafaxine hcl tab sr 24hr 150 mg........................... 51venlafaxine hcl tab sr 24hr 37.5 mg.......................... 23venlafaxine hcl tab sr 24hr 37.5 mg.......................... 51venlafaxine hcl tab sr 24hr 75 mg............................. 23venlafaxine hcl tab sr 24hr 75 mg............................. 51VENTAVIS................................................................... 101VENTAVIS................................................................... 101VENTOLIN HFA......................................................... 101verapamil hcl cap sr 24hr 100 mg............................. 71verapamil hcl cap sr 24hr 120 mg............................. 71verapamil hcl cap sr 24hr 180 mg............................. 71verapamil hcl cap sr 24hr 200 mg............................. 71verapamil hcl cap sr 24hr 240 mg............................. 71verapamil hcl cap sr 24hr 300 mg............................. 71verapamil hcl cap sr 24hr 360 mg............................. 71verapamil hcl tab 120 mg........................................... 71verapamil hcl tab 40 mg............................................. 71verapamil hcl tab 80 mg............................................. 71verapamil hcl tab cr 120 mg.......................................71verapamil hcl tab cr 180 mg.......................................71verapamil hcl tab cr 240 mg.......................................71VERSACLOZ................................................................ 44VESICARE.................................................................... 82VESICARE.................................................................... 82VICTOZA....................................................................... 57VIDEX............................................................................ 49VIDEX............................................................................ 49VIEKIRA PAK................................................................49VIEKIRA XR..................................................................49VIGAMOX......................................................................96VIIBRYD.........................................................................23VIIBRYD.........................................................................23VIIBRYD.........................................................................23VIIBRYD STARTER PACK......................................... 23VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VINBLASTINE SULFATE............................................37vincristine sulfate iv soln 1 mg/ml..............................37

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vinorelbine tartrate inj 10 mg/ml.................................37vinorelbine tartrate inj 50 mg/5ml (10 mg/

ml)................................................................................37VIOKACE.......................................................................78VIOKACE.......................................................................78VIRACEPT.................................................................... 49VIRACEPT.................................................................... 49VIRAMUNE................................................................... 49VIRAMUNE XR............................................................ 49VIRAZOLE.....................................................................49VIREAD..........................................................................49VIREAD..........................................................................50VIREAD..........................................................................50VIREAD..........................................................................50VIREAD..........................................................................50VITEKTA........................................................................ 50VITEKTA........................................................................ 50VIVITROL........................................................................ 5VOLTAREN......................................................................4VOLTAREN....................................................................27VOLTAREN....................................................................77voriconazole for inj 200 mg........................................ 25voriconazole for susp 40 mg/ml.................................25voriconazole tab 200 mg............................................ 25voriconazole tab 50 mg...............................................25VOTRIENT.................................................................... 37VPRIV............................................................................ 78VRAYLAR...................................................................... 44VRAYLAR...................................................................... 44VRAYLAR...................................................................... 44VRAYLAR...................................................................... 44VRAYLAR...................................................................... 44VRAYLAR...................................................................... 54VRAYLAR...................................................................... 54VRAYLAR...................................................................... 54VRAYLAR...................................................................... 54VRAYLAR...................................................................... 54VYTORIN.......................................................................71VYTORIN.......................................................................71VYTORIN.......................................................................71VYTORIN.......................................................................71Wwarfarin sodium tab 10 mg.........................................59warfarin sodium tab 1 mg...........................................59warfarin sodium tab 2.5 mg........................................59warfarin sodium tab 2 mg...........................................59warfarin sodium tab 3 mg...........................................59warfarin sodium tab 4 mg...........................................59warfarin sodium tab 5 mg...........................................59warfarin sodium tab 6 mg...........................................59warfarin sodium tab 7.5 mg........................................59

water for irrigation, sterile irrigationsoln............................................................................103

WELCHOL.....................................................................57WELCHOL.....................................................................57WELCHOL.....................................................................71WELCHOL.....................................................................71XXALKORI....................................................................... 37XALKORI....................................................................... 37XARELTO...................................................................... 59XARELTO...................................................................... 59XARELTO...................................................................... 59XARELTO STARTER PACK.......................................59XENAZINE.................................................................... 73XENAZINE.................................................................... 73XGEVA...........................................................................94XIFAXAN........................................................................13XIFAXAN........................................................................80XOLAIR........................................................................101XOPENEX HFA..........................................................101XTANDI.......................................................................... 37XYREM........................................................................101YYERVOY........................................................................37YERVOY........................................................................38YF-VAX.......................................................................... 93YONDELIS.................................................................... 38Zzafirlukast tab 10 mg.................................................101zafirlukast tab 20 mg.................................................101zaleplon cap 10 mg...................................................101zaleplon cap 5 mg..................................................... 101ZALTRAP.......................................................................38ZALTRAP.......................................................................38ZANOSAR..................................................................... 38ZAVESCA...................................................................... 78ZELBORAF................................................................... 38ZEMPLAR......................................................................94ZEMPLAR......................................................................94ZENPEP........................................................................ 78ZENPEP........................................................................ 78ZENPEP........................................................................ 78ZENPEP........................................................................ 78ZENPEP........................................................................ 78ZENPEP........................................................................ 78ZENPEP........................................................................ 78ZEPATIER..................................................................... 50ZETIA............................................................................. 71ZIAGEN..........................................................................50zidovudine cap 100 mg...............................................50

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zidovudine syrup 10 mg/ml.........................................50zidovudine tab 300 mg................................................50ZINACEF....................................................................... 13ziprasidone hcl cap 20 mg..........................................44ziprasidone hcl cap 20 mg..........................................54ziprasidone hcl cap 40 mg..........................................44ziprasidone hcl cap 40 mg..........................................54ziprasidone hcl cap 60 mg..........................................44ziprasidone hcl cap 60 mg..........................................54ziprasidone hcl cap 80 mg..........................................44ziprasidone hcl cap 80 mg..........................................54ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4zoledronic acid inj conc for iv infusion 4

mg/5ml........................................................................ 94zoledronic acid iv soln 5 mg/100ml........................... 94ZOLINZA........................................................................38zolpidem tartrate tab 10 mg..................................... 101zolpidem tartrate tab 5 mg....................................... 101ZOMETA........................................................................ 94zonisamide cap 100 mg..............................................18zonisamide cap 25 mg................................................18zonisamide cap 50 mg................................................18ZONTIVITY....................................................................59ZORTRESS...................................................................93ZORTRESS...................................................................93ZORTRESS...................................................................93ZOSTAVAX....................................................................93ZOSYN...........................................................................13ZOSYN...........................................................................13ZOSYN...........................................................................13ZYDELIG....................................................................... 38ZYDELIG....................................................................... 38ZYKADIA....................................................................... 38ZYPREXA RELPREVV............................................... 44ZYPREXA RELPREVV............................................... 45ZYPREXA RELPREVV............................................... 45ZYTIGA..........................................................................38ZYVOX...........................................................................13

Blue Cross MedicareRx is a prescription drug plan provided by HCSC Insurance Services Company (HISC), an Independent Licensee of the Blue Cross and Blue Shield Association. A Medicare-approved Part D sponsor. Enrollment in HISC’s plan depends on contract renewal.

This formulary was updated on 11/16/2016. For more recent information or other questions, please contact Blue Cross MedicareRxSM Customer Service, at 1-888-285-2249 or, for TTY/TDD users, 711, 8 a.m. - 8 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays, or visit www.getblueil.com/pdp/druglist.

2016 formulary (list of covered drugs) - blue · 2016 formulary (list of covered drugs) ii ......

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