2018 formulary drug list - home | globalhealth...labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg...
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MSTDF18 Lists Updated 11/2017
2018 Formulary Drug List
For State, Education, and Local Government Employees
GlobalHealth, Inc.701 NE 10th Street, Suite 300
Oklahoma City, OK 73104-5403 www.GlobalHealth.com/state
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HELPFUL NUMBERS Plan Issuer: GlobalHealth, Inc. PO Box 2393 Oklahoma City, OK 73101-2393
GlobalHealth Customer Care, Language Assistance, and Disease Management: [email protected] 405.280.5600 (local) 1.877.280.5600 (toll-free) 711 (TTY) Monday – Friday, 9 a.m. – 5 p.m. Central www.GlobalHealth.com/state
Behavioral Health and Substance Use: [email protected] 405.280.5600 (local) 1.877.280.5600 (toll-free) 711 (TTY) Monday – Friday, 9 a.m. – 5 p.m. Central www.GlobalHealth.com/state
Pharmacy Benefits Manager: Magellan Rx Management, LLC Customer Service 1.800.424.1789 (toll-free) 711 (TTY)
Medication Prior Authorizations: [email protected] 918.878.7361
Mail Claims to: Magellan Rx Management, LLC PO Box 85042 Richmond, VA 23261-5042
Mail Order Pharmacy: Magellan Rx Management, LLC 1.800.424.1789 (toll-free) 711 (TTY) P.O. Box 620968 Orlando, FL 32862
24/7 Nurse Help Line: Information Line 1.877.280.2993 (toll-free)
GlobalHealth Compliance Officer: 1.877.280.5852 (toll-free) 405.280.5852 [email protected]
GlobalHealth Privacy Officer: 405.280.5524 [email protected]
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IMPORTANT INFORMATION This formulary applies to Members who enrolled through the State, Education, and Local Government employees Plan.
Member Materials Your comprehensive Member handbook has three booklets. Each one has a different purpose. These documents are important legal documents. Keep them in a safe place.
Booklet Purpose
Member Handbook for State, Education, and Local Government Employees (“Member
Handbook”)
Tells you about your benefits.o What benefits are covered and how much you will pay.o How they are covered (including limitations and exclusions).o How to use them.
Physicians and Health Providers Directory (“Provider Directory”)
Lists our Network of doctors, Facilities, and pharmacies.
Tells you if a Facility is preferred or not.
Formulary Drug List for State, Education, and Local Government Employees (“Drug Formulary” or “Formulary”)
Lists drugs we cover.
Tells you what Tier a drug is in.
Tells you if there are any rules to getting a drug.
Member materials are available on our website. Contact Customer Care for printed copies at no charge. But, be aware that the most current Drug Formulary and Provider Directory lists are on the website.
This is an important legal document. Please keep it in a safe place.
When this document says “we”, “us”, or “our”, it means GlobalHealth, Inc. Words or phrases that start with a capital letter are defined in the Member Handbook glossary.
For specific questions about your coverage, please call the phone number printed on your Member ID card.
Preferred Drugs Preferred drugs are listed in this Drug Formulary. Drugs on the list are selected based on quality (effectiveness and safety) as well as cost-effectiveness. Doctors and pharmacists have worked together to develop the Formulary, which includes generics and brand name drugs that are approved by the U. S. Food and Drug Administration (“FDA”).
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For the Member: Generic drugs contain the same active ingredients in the same amounts as brand name products. However, they may be a different color, shape, or size.
For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you.
THIS DOCUMENT LIST IS EFFECTIVE AS OF THE DATE ON THE COVER. THIS LIST IS SUBJECT TO CHANGE. You may find the most current list, including any
Utilization Management requirements, on our website. Contact Customer Care for printed copies.
TIER DESCRIPTION
0 Health Care Reform
1 Generics
2 Preferred Brands
3 Non-Preferred Brands
4 Specialty Drug
TYPE DESCRIPTION
QL Quantity LimitThere is a limit on the amount of this drug that is covered perprescription, or within a specific time frame.
PA Prior AuthorizationYour provider is required to get prior authorization before you fillyour prescription, which ensures appropriate use of the selecteddrug. Without prior approval, we may not cover this drug.
ST Step TherapyIn some cases, you may be required to first try certain drugs to treatyour medical condition before you move up a “step” to other drugoptions.
GL Gender Limit This prescription drug is restricted for a single gender. .
AL Age LimitThis prescription drug may only be covered if you meet theminimum or maximum age limit.
C Custom This drug has unique restrictions.
S Specialty DrugSpecialty drugs are high-cost drugs used to treat complex or rareconditions. Some examples of the diseases include; multiplesclerosis, rheumatoid arthritis, hepatitis C, and hemophilia.
MED Medical DrugThis medication is not on our drug list. Click on the THERAPEUTICCLASS or sub class to find covered alternative medications. If youhave questions, please contact member services.
HCR Health Care Reform ProductsThe Affordable Care Act (ACA) requires certain preventive genericproducts to be covered at zero dollar copay. This does not includeplans that are grandfathered.
PAGE 1 LAST UPDATED 11/2017
PS Preferred Specialty Preferred Specialty.
HCG High Cost Generic High Cost Generic.
LCG Low Cost Generic
Generic drugs available at the lowest cost. Please note the specificstrengths and dosage forms; other strengths and/or dosage formsof these products would be subject to the standard generic Cost-share.
PAGE 2 LAST UPDATED 11/2017
LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ADRENERGIC AGENTS
ALPHA AND BETA ADRENERGIC AGONIST(RESPR)
epinephrine (0.1 mg/ml syringe, 1 mg/ml vial, 1 mg/ml(1)ampul) 1
epinephrine (0.15/0.15 auto injct, 0.15mg/0.3 auto injct,0.3mg/0.3 auto injct) 1 QL 2 / fill
epinephrine hcl/pf 1
epinephrine/pf 1
SELECT.BETA-2-ADRENERGIC AGONIST(RESPIR)
ADVAIR DISKUS 2 QL 2 / day
ADVAIR HFA 2 QL 0.4 / day
albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2mg/5 ml syrup, 4 mg tab er 12h, 8 mg tab er 12h) 1
albuterol sulfate (2 mg tablet, 2.5 mg/0.5 vial-neb, 2.5 mg/3mlvial-neb, 4 mg tablet, 5 mg/ml solution) 1 LCG
ANORO ELLIPTA 2 QL 2 / day
BREO ELLIPTA 2 QL 2 / day
COMBIVENT RESPIMAT 2 QL 0.267 / day
fluticasone propionate/salmeterol xinafoate 1QL 0.04 / day
AL At least 12 yrs old
ipratropium bromide/albuterol sulfate 1
levalbuterol hcl (0.31mg/3ml vial-neb, 0.63mg/3ml vial-neb,1.25mg/0.5 vial-neb, 1.25mg/3ml vial-neb) 3 HCG
metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mgtablet) 1
PROAIR HFA 2 QL .8 / day
PROAIR RESPICLICK 2QL 0.07 / day
AL At least 12 yrs old
PAGE 3 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SEREVENT DISKUS 2 QL 2 / day
STRIVERDI RESPIMAT 2QL .144 / day
ST
SYMBICORT 2 QL 0.4 / day
terbutaline sulfate (2.5 mg tablet, 5 mg tablet) 1 LCG
terbutaline sulfate 1 mg/ml vial 1
VENTOLIN HFA 2 QL 1.5 / day
ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)
NON-SEL.ALPHA-1-ADRENERGIC BLOCKING AGTS
doxazosin mesylate (1 mg tablet, 2 mg tablet, 4 mg tablet, 8 mgtablet) 1
prazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule) 1
terazosin hcl 1
NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS
dihydroergotamine mesylate (1 mg/ml ampul, 1 mg/ml vial) 1
dihydroergotamine mesylate 0.5mg/spry spray/pump 3QL 8 / 30 days
HCG
ergoloid mesylates 1 mg tablet 1
ergotamine tartrate/caffeine 1
phenoxybenzamine hcl 10 mg capsule 1
phentolamine mesylate 5 mg vial 1
phentolamine mesylate/alprostadil in bacteriostatic water 1
SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENT
alfuzosin hcl 1QL 1 / day
GL Male
carvedilol 1
PAGE 4 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
dutasteride/tamsulosin hcl 1QL 1 / day
GL Male
labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) 1
RAPAFLO 2QL 1 / day
GL Male
tamsulosin hcl 1 QL 2 / day
ANALGESICS AND ANTIPYRETICS
ANALGESICS AND ANTIPYRETICS, MISC.
acetaminophen with codeine phosphate (120-12mg/5 solution,300mg/12.5 solution) 1
QL 139 / day
AL At least 18 yrs old
acetaminophen with codeine 300mg-15mg tablet 1QL 22 / day
AL At least 18 yrs old
acetaminophen with codeine 300mg-30mg tablet 1QL 12 / day
AL At least 12 yrs old
acetaminophen with codeine 300mg-60mg tablet 1QL 6 / day
AL At least 12 yrs old
acetaminophen/caff/dihydrocod 320.5-30mg capsule 1QL 10 / day
AL At least 18 yrs old
acetaminophen/caff/dihydrocod 325-30-16 tablet 1 QL 10 / day
butalbital/acetaminophen/caffeine(butalb/acetaminophen/caffeine 50-300-40 capsule,butalb/acetaminophen/caffeine 50-325-40 capsule,butalb/acetaminophen/caffeine 50-325-40 tablet)
1 QL 6 / day
butalbital/acetaminophen/caffeine/codeine phosphate 1 QL 6 / day
CAPACET 1 QL 6 / day
ENDOCET 1QL 12 / day
AL At least 18 yrs old
PAGE 5 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ESGIC CAPSULE 1 QL 6 / day
gabapentin (100 mg capsule, 300 mg capsule, 400 mg capsule) 1 QL 9 / day
gabapentin (250 mg/5ml solution, 300 mg/6ml solution) 1 QL 72 / day
gabapentin 600 mg tablet 1 QL 6 / day
gabapentin 800 mg tablet 1 QL 5 / day
hydrocodone bitartrate/acetaminophen(hydrocodone/acetaminophen 2.5-108/5 solution,hydrocodone/acetaminophen 5-217mg/10 solution,hydrocodone/acetaminophen 7.5-325/15 solution)
1QL 140 / day
AL At least 2 yrs old
hydrocodone/acetaminophen 2.5-167/5 solution 1QL 100 / day
AL At least 2 yrs old
hydrocodone bitartrate/acetaminophen(hydrocodone/acetaminophen 5 mg-300mg tablet,hydrocodone/acetaminophen 7.5-300 mg tablet,hydrocodone/acetaminophen 10mg-300mg tablet)
1QL 13 / day
AL At least 18 yrs old
hydrocodone bitartrate/acetaminophen(hydrocodone/acetaminophen 5 mg-325mg tablet,hydrocodone/acetaminophen 10mg-325mg tablet)
1QL 12 / day
AL At least 18 yrs old
hydrocodone/acetaminophen 2.5-325 mg tablet 1QL 20 / day
AL At least 18 yrs old
hydrocodone/acetaminophen 7.5-325 mg tablet 1QL 8 / day
AL At least 18 yrs old
isometheptene mucate/caffeine/acetaminophen 1
isometheptene mucate/dichloralphenazone/acetaminophen 1
LORCET 1QL 12 / day
AL At least 18 yrs old
LORCET HD 1QL 12 / day
AL At least 18 yrs old
LORCET PLUS 1QL 6 / day
AL At least 18 yrs old
PAGE 6 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LORTAB (5-325 MG TABLET, 7.5-325 MG TABLET, 10-325 MGTABLET) 1
QL 8 / day
AL At least 18 yrs old
MARGESIC 1 QL 6 / day
MARTEN-TAB 1 QL 6 / day
NODOLOR 1
NORCO 5-325 TABLET 1QL 12 / day
AL At least 18 yrs old
oxycodone hcl/acetaminophen 5-325/5 ml solution 1QL 62 / day
AL At least 18 yrs old
oxycodone hcl/acetaminophen (hcl/acetaminophen 2.5-325 mgtablet, hcl/acetaminophen 5 mg-325mg tablet,hcl/acetaminophen 7.5-325 mg tablet, hcl/acetaminophen10mg-325mg tablet)
1QL 12 / day
AL At least 18 yrs old
oxycodone hcl/acetaminophen 10mg-300mg tablet 1QL 3 / day
AL At least 18 yrs old
oxycodone hcl/acetaminophen 5 mg-300mg tablet 1QL 7 / day
AL At least 18 yrs old
oxycodone hcl/acetaminophen 7.5-300 mg tablet 1QL 4 / day
AL At least 18 yrs old
TENCON 1 QL 6 / day
tramadol hcl/acetaminophen 1QL 8 / day
AL At least 18 yrs old
VERDROCET 1QL 20 / day
AL At least 18 yrs old
VICODIN 1QL 8 / day
AL At least 18 yrs old
VICODIN ES 1QL 13 / day
AL At least 18 yrs old
PAGE 7 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VICODIN HP 1QL 13 / day
AL At least 18 yrs old
ZEBUTAL 1 QL 6 / day
OPIATE AGONISTS
alfentanil hcl 1
ASCOMP WITH CODEINE 1QL 6 / day
AL At least 18 yrs old
ASTRAMORPH-PF (1 MG/ML AMPUL, 10 MG/10 ML VIAL) 1 QL 50 / day
ASTRAMORPH-PF (1 MG/2 ML AMPULE, 5 MG/10 ML VIAL) 1 QL 100 / day
carisoprodol/aspirin/codeine 200-325-16 tablet 1 QL 21 / day
codeine/butalbital/asa/caffein 30-50-325 capsule 1QL 6 / day
AL At least 18 yrs old
codeine sulfate 1QL 6 / day
AL At least 18 yrs old
DURAMORPH 10 MG/10 ML AMPUL 1 QL 5 / day
DURAMORPH 5 MG/10 ML AMPUL 1 QL 10 / day
EMBEDA 2QL 2 / day
PA
fentanyl (12 mcg/hr patch td72, 25 mcg/hr patch td72,37.5mcg/hr patch td72, 50mcg/hr patch td72, 62.5mcg/hrpatch td72, 75mcg/hr patch td72, 87.5mcg/hr patch td72, 100mcg/hr patch td72)
1QL 0.5 / day
PA
fentanyl citrate (200 mcg lozenge hd, 400 mcg lozenge hd, 600mcg lozenge hd, 800 mcg lozenge hd, 1200 mcg lozenge hd,1600 mcg lozenge hd)
3
QL 4 / day
PA
AL At least 18 yrs old
HCG
fentanyl citrate-0.9 % nacl/pf 600mcg/30 pca vial 1 QL 19 / day
PAGE 8 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fentanyl/bupivacaine/ns/pf 2-1250mcg plast. bag 1 QL 192 / day
fentanyl/bupivacaine/ns/pf 4mcg/ml-.1 plast. bag 1 QL 96 / day
fentanyl/bupivacaine/ns/pf 2-625mcg/1 pump resvr 1 QL 192 / day
fentanyl citrate/pf 50 mcg/ml ampul 1 MED Medical Drug
fentanyl citrate/pf 50 mcg/ml vial 1 MED Medical Drug
fentanyl citrate/ropivacaine hcl/sodium chloride 0.9%/pf(fentanyl/ropivacaine/ns/pf 2-1500mcg pump resvr,fentanyl/ropivacaine/ns/pf 2mcg/ml-.1 pump resvr)
1 QL 192 / day
hydrocodone bitart/chlorpheniraminemaleate/pseudoephedrine 1
QL 20 / day
AL At least 18 yrs old
hydrocodone/ibuprofen (hydrocodone/ibuprofen 2.5-200mgtablet, hydrocodone/ibuprofen 7.5-200 mg tablet,hydrocodone/ibuprofen 10mg-200mg tablet)
1QL 5 / day
AL At least 16 yrs old
hydrocodone/ibuprofen 5mg-200mg tablet 1QL 6 / day
AL At least 16 yrs old
hydromorphone hcl 1 mg/ml ampul 1 QL 13 / day
hydromorphone hcl 1 mg/ml liquid 1QL 13 / day
AL At least 18 yrs old
hydromorphone hcl 3 mg supp.rect 1 QL 4 / day
hydromorphone hcl 0.5mg/.5ml syringe 1QL 50 / day
AL At least 18 yrs old
hydromorphone hcl 1 mg/ml syringe 1QL 13 / day
AL At least 18 yrs old
hydromorphone hcl 2 mg/ml syringe 1
QL 6 / day
AL At least 18 yrs old
MED Medical Drug
hydromorphone hcl 4 mg/ml syringe 1QL 3 / day
AL At least 18 yrs old
PAGE 9 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hydromorphone hcl (8 mg tab er 24h, 12 mg tab er 24h, 16 mgtab er 24h, 32 mg tab er 24h) 3
QL 2 / day
PA
HCG
hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mg tablet) 1QL 6 / day
AL At least 18 yrs old
hydromorphone hcl (2 mg/ml ampul, 2 mg/ml vial) 1 QL 6 / day
hydromorphone hcl/pf 10 mg/ml ampul 1QL 1 / day
AL At least 18 yrs old
hydromorphone hcl/pf 10 mg/ml vial 1 QL 1 / day
IBUDONE 5-200 MG TABLET 1QL 6 / day
AL At least 16 yrs old
ibuprofen/oxycodone hcl 1QL 4 / day
AL At least 18 yrs old
levorphanol tartrate 2 mg tablet 1QL 4 / day
AL At least 18 yrs old
meperidine hcl 10 mg/ml cartridge 1QL 50 / day
AL At least 18 yrs old
meperidine hcl 50 mg/5 ml solution 1QL 50 / day
AL At least 18 yrs old
meperidine hcl 100 mg tablet 1QL 5 / day
AL At least 18 yrs old
meperidine hcl 50 mg tablet 1QL 10 / day
AL At least 18 yrs old
meperidine hcl/pf 100 mg/ml vial 1QL 5 / day
AL At least 18 yrs old
meperidine hcl/pf 25 mg/ml vial 1QL 20 / day
AL At least 18 yrs old
PAGE 10 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
meperidine hcl/pf 50 mg/ml vial 1QL 10 / day
AL At least 18 yrs old
methadone hcl 10 mg/5 ml solution 1QL 8 / day
PA
methadone hcl 5 mg/5 ml solution 1QL 18 / day
PA
methadone hcl (10 mg tablet, 10 mg/ml oral conc) 1QL 2 / day
PA
methadone hcl 5 mg tablet 1QL 3 / day
PA
methadone hcl 10 mg/ml vial 1 QL 2 / day
METHADONE INTENSOL 1QL 2 / day
PA
morphine sulfate (10 mg cap er pel, 20 mg cap er pel, 50 mg caper pel, 100 mg cap er pel) 1
QL 2 / day
PA
morphine sulfate (30 mg cap er pel, 30 mg cpmp 24hr, 45 mgcpmp 24hr, 60 mg cap er pel, 60 mg cpmp 24hr, 75 mg cpmp24hr, 80 mg cap er pel, 90 mg cpmp 24hr, 120 mg cpmp 24hr)
1QL 1 / day
PA
morphine sulfate (10mg/0.7ml pen injctr, 15 mg/ml vial) 1QL 3 / day
PA
morphine sulfate (20 mg supp.rect, 100 mg/5ml solution) 1 QL 3 / day
morphine sulfate 10 mg/5 ml solution 1 QL 25 / day
morphine sulfate 20 mg/5 ml solution 1 QL 13 / day
morphine sulfate 10 mg supp.rect 1 QL 5 / day
morphine sulfate 30 mg supp.rect 1 QL 2 / day
morphine sulfate 5 mg supp.rect 1 QL 10 / day
PAGE 11 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
morphine sulfate 5 mg/ml syringe 1QL 10 / day
PA
morphine sulfate 15 mg tablet 1QL 3 / day
AL At least 18 yrs old
morphine sulfate 30 mg tablet 1QL 2 / day
AL At least 18 yrs old
morphine sulfate (15 mg tablet er, 30 mg tablet er, 60 mg tableter, 100 mg tablet er, 200 mg tablet er) 1
QL 3 / day
PA
morphine sulfate 8 mg/ml vial 1
QL 6 / day
PA
MED Medical Drug
morphine sulfate/pf 0.5 mg/ml vial 1QL 100 / day
PA
morphine sulfate/pf 1 mg/ml vial 1QL 50 / day
PA
opium/belladonna alkaloids 30-16.2 mg supp.rect 1 QL 2 / day
opium/belladonna alkaloids 60-16.2 mg supp.rect 1 QL 1 / day
oxycodone hcl 20 mg/ml oral conc 1 QL 2 / day
oxycodone hcl 5 mg/5 ml solution 1 QL 33 / day
oxycodone hcl 10mg/0.5ml syringe 1 QL 4 / day
oxycodone hcl (10 mg tab er 12h, 15 mg tab er 12h, 20 mg taber 12h, 30 mg tab er 12h, 40 mg tab er 12h, 60 mg tab er 12h,80 mg tab er 12h)
1QL 3 / day
PA
oxycodone hcl (5 mg capsule, 5 mg tablet, 15 mg tablet, 20 mgtablet, 30 mg tablet) 1
QL 8 / day
AL At least 18 yrs old
oxycodone hcl 10 mg tablet 1 QL 8 / day
PAGE 12 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
oxycodone hcl/aspirin 1QL 7 / day
AL At least 18 yrs old
oxymorphone hcl (5 mg tab er 12h, 7.5 mg tab er 12h, 10 mgtab er 12h, 15 mg tab er 12h, 20 mg tab er 12h, 30 mg tab er12h, 40 mg tab er 12h)
3
QL 2 / day
PA
AL At least 18 yrs old
HCG
oxymorphone hcl (5 mg tablet, 10 mg tablet) 3
QL 12 / day
AL At least 18 yrs old
HCG
promethazine/phenyleph/codeine 6.25-5-10 syrup 1QL 30 / day
AL At least 6 yrs old
REPREXAIN 10-200 MG TABLET 1QL 5 / day
AL At least 16 yrs old
tramadol hcl (100 mg cpbp 25-75, 150 mg cpbp 25-75, 200 mgcpbp 25-75, 300 mg cpbp 17-83) 1
QL 1 / day
PA
AL At least 18 yrs old
tramadol hcl (100 mg tab er 24h, 100 mg tbmp 24hr, 200 mgtab er 24h, 200 mg tbmp 24hr, 300 mg tab er 24h, 300 mgtbmp 24hr)
3
QL 1 / day
PA
AL At least 18 yrs old
HCG
tramadol hcl 50 mg tablet 1QL 8 / day
AL At least 18 yrs old
XYLON 10 1
OPIATE PARTIAL AGONISTS
buprenorphine hcl (0.3 mg/ml syringe, 0.3 mg/ml vial) 1 QL 17 / day
buprenorphine hcl (2 mg tab subl, 8 mg tab subl) 1QL 3 / day
PA
PAGE 13 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
buprenorphine hcl/naloxone hcl 3
QL 3 / day
PA
HCG
butorphanol tartrate 10 mg/ml spray 1QL 0.3 / day
AL At least 18 yrs old
butorphanol tartrate 1 mg/ml vial 1QL 7 / day
AL At least 18 yrs old
butorphanol tartrate 2 mg/ml vial 1QL 4 / day
AL At least 18 yrs old
nalbuphine hcl (10 mg/ml ampul, 10 mg/ml vial) 1 QL 5 / day
nalbuphine hcl (20 mg/ml ampul, 20 mg/ml vial) 1 QL 3 / day
pentazocine hcl/naloxone hcl 1QL 12 / day
AL At least 12 yrs old
SUBOXONE (2 MG-0.5 MG FILM, 8 MG-2 MG FILM) 2QL 3 / day
PA
SUBOXONE (4 MG-1 MG FILM, 12 MG-3 MG FILM) 2QL 2 / day
PA
ANOREXIGENIC AGENTS
AMPHETAMINE DERIVATIVES
diethylpropion hcl 25 mg tablet 1
QL 3 / day
PA
AL At least 16 yrs old
diethylpropion hcl 75 mg tablet er 1QL 1 / day
PA
LOMAIRA 1
QL 3 / day
PA
AL At least 17 yrs old
PAGE 14 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
phendimetrazine tartrate 105 mg capsule er 1QL 1 / day
PA
phendimetrazine tartrate 35 mg tablet 1QL 3 / day
PA
phentermine hcl (15 mg capsule, 30 mg capsule) 1QL 1 / day
PA
phentermine hcl (37.5 mg capsule, 37.5 mg tablet) 1
QL 2 / day
PA
AL At least 17 yrs old
ANOREXIGENICS;RESPIRATORY,CNS STIMULANTS
AMPHETAMINES
benzphetamine hcl 25 mg tablet 1
QL 3 / day
PA
AL At least 12 yrs old
benzphetamine hcl 50 mg tablet 1QL 3 / day
PA
DEXEDRINE 10 MG TABLET 1 QL 6 / day
DEXEDRINE 5 MG TABLET 1 QL 2 / day
PAGE 15 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate (dextroamphetamine/amphetamine 5 mg cap er 24h,dextroamphetamine/amphetamine 5 mg tablet,dextroamphetamine/amphetamine 7.5 mg tablet,dextroamphetamine/amphetamine 10 mg cap er 24h,dextroamphetamine/amphetamine 10 mg tablet,dextroamphetamine/amphetamine 12.5 mg tablet,dextroamphetamine/amphetamine 15 mg cap er 24h,dextroamphetamine/amphetamine 15 mg tablet,dextroamphetamine/amphetamine 20 mg cap er 24h,dextroamphetamine/amphetamine 20 mg tablet,dextroamphetamine/amphetamine 25 mg cap er 24h,dextroamphetamine/amphetamine 30 mg cap er 24h,dextroamphetamine/amphetamine 30 mg tablet)
1 QL 2 / day
dextroamphetamine sulfate 10 mg capsule er 3QL 5 / day
HCG
dextroamphetamine sulfate 15 mg capsule er 3QL 4 / day
HCG
dextroamphetamine sulfate 5 mg/5 ml solution 3QL 60 / day
HCG
dextroamphetamine sulfate (5 mg capsule er, 5 mg tablet) 3QL 2 / day
HCG
dextroamphetamine sulfate 10 mg tablet 3QL 6 / day
HCG
methamphetamine hcl 1 QL 5 / day
VYVANSE (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE,40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE, 70 MGCAPSULE)
2 QL 1 / day
VYVANSE (10 MG TABLET, 20 MG TABLET, 30 MG TABLET, 40MG TABLET, 50 MG TABLET, 60 MG TABLET) 2 QL 1 / day
ZENZEDI 10 MG TABLET 1 QL 6 / day
ZENZEDI 5 MG TABLET 1 QL 2 / day
PAGE 16 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RESPIRATORY AND CNS STIMULANTS
caffeine citrate 60 mg/3 ml solution 1
caffeine/sodium benzoate 1
dexmethylphenidate hcl (5 mg cpbp 50-50, 10 mg cpbp 50-50,15 mg cpbp 50-50, 25 mg cpbp 50-50, 30 mg cpbp 50-50, 35mg cpbp 50-50, 40 mg cpbp 50-50)
3QL 1 / day
HCG
dexmethylphenidate hcl 20 mg cpbp 50-50 3QL 2 / day
HCG
dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet) 1 QL 3 / day
dexmethylphenidate hcl 10 mg tablet 1 QL 2 / day
METADATE ER 1QL 3 / day
LCG
methylphenidate hcl (10 mg cpbp 30-70, 20 mg cpbp 30-70, 20mg cpbp 50-50, 40 mg cpbp 30-70, 40 mg cpbp 50-50, 50 mgcpbp 30-70, 60 mg cpbp 30-70)
3QL 1 / day
HCG
methylphenidate hcl (30 mg cpbp 30-70, 30 mg cpbp 50-50) 3QL 2 / day
HCG
methylphenidate hcl (54 mg tab er 24, 60 mg cpbp 50-50) 1 QL 1 / day
methylphenidate hcl 10 mg/5 ml solution 1 QL 30 / day
methylphenidate hcl 5 mg/5 ml solution 1 QL 60 / day
methylphenidate hcl 2.5 mg tab chew 1
methylphenidate hcl (18 mg tab er 24, 27 mg tab er 24, 36 mgtab er 24) 1 QL 2 / day
methylphenidate hcl (5 mg tab chew, 10 mg tab chew, 20 mgtablet, 20 mg tablet er) 1 QL 3 / day
methylphenidate hcl 10 mg tablet 1QL 5 / day
LCG
methylphenidate hcl 5 mg tablet 1QL 3 / day
LCG
PAGE 17 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
methylphenidate hcl 10 mg tablet er 1 QL 5 / day
WAKEFULNESS-PROMOTING AGENTS
armodafinil 3
QL 1 / day
PA
HCG
modafinil 1QL 1 / day
PA
ANTI-INFECTIVE AGENTS
ANTHELMINTICS
ivermectin 3 mg tablet 1 PA
URINARY ANTI-INFECTIVES
AZUPHEN MB 1
HYOPHEN 1
INDIOMIN MB 1
methenamine hippurate 1
methenamine mandelate (1 g tablet, 500 mg tablet) 1
methenamine/sod phosph,monobasic/methyleneblue/hyoscyamine 1
nitrofurantoin 25 mg/5 ml oral susp 1
nitrofurantoin macrocrystal (25 mg capsule, 50 mg capsule,100 mg capsule) 1
nitrofurantoin monohydrate/macrocrystals 1
PHOSPHASAL 1
trimethoprim 100 mg tablet 1
UR N-C 1
URELLE 1
URETRON D-S 1
PAGE 18 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
URIBEL 1 QL 4 / day
URIMAR-T 1
URIN D.S. 1
URO-458 1
URO-BLUE 1
URO-L 1
UROPHEN MB 1
URYL 1
USTELL 1
UTA 1
UTIRA-C 1
ANTI-INFECTIVES (EENT)
ANTIBACTERIALS (EENT)
AK-POLY-BAC 1 QL 0.434 / day
bacitracin 500 unit/g oint. (g) 1 QL 0.434 / day
bacitracin/polymyxin b sulfate 1 QL 0.434 / day
BACTROBAN NASAL 2
CIPRODEX 2 QL 0.257 / day
ciprofloxacin hcl 0.2 % droperette 1 QL 0.567 / day
ciprofloxacin hcl 0.3 % drops 1 QL 0.767 / day
doxycycline hyclate 20 mg tablet 1
erythromycin base 5 mg/gram oint. (g) 1 QL 0.54 / day
gatifloxacin 0.5 % drops 1 QL 0.36/day
GENTAK 1 QL 0.54 / day
gentamicin sulfate 0.3 % drops 1 QL 2.143 / day
PAGE 19 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
gentamicin sulfate 0.3 % oint. (g) 1 QL 0.54 / day
ILOTYCIN 1 QL 0.54 / day
levofloxacin 0.5 % drops 1 QL 0.767 / day
MOXEZA 2 QL 0.434 / day
moxifloxacin hcl 0.5 % drops 1 QL 0.434 / day
NEO-POLYCIN 1 QL 0.124 / day
NEO-POLYCIN HC 1 QL 4 / fill
neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone 1 QL 4 / fill
neomycin sulfate/bacitracin/polymyxin b 1 QL 0.124 / day
neomycin sulfate/polymyxin b sulfate/gramicidin d 1 QL 1.47 / day
neomycin sulfate/polymyxin b sulfate/hydrocortisone(neomycin/polymyxin b/hydrocort 3.5-10k-1 drops susp,neomycin/polymyxin b/hydrocort 3.5-10k-1 solution)
1 QL 10 / fill
neomycin/polymyxin b/hydrocort 3.5-10k-10 drops susp 1 QL 10/ fill
neomycin/polymyxin b/dexametha 0.1 % drops susp 1 QL 5 / fill
neomycin/polymyxin b/dexametha 3.5-10k-.1 oint. (g) 1 QL 4 / fill
ofloxacin 0.3 % drops 1 QL 1.47 / day
POLYCIN 1 QL 0.434 / day
polymyxin b sulfate/trimethoprim 1 QL 1.47 / day
sulfacetamide sodium 10 % drops 1 QL 5 / fill
sulfacetamide sodium 10 % oint. (g) 1 QL 4 / fill
sulfacetamide sodium/prednisolone sodium phosphate 1 QL 5 / fill
tobramycin 0.3 % drops 1 QL 2.143 / day
tobramycin/dexamethasone 1 QL 5 / fill
PAGE 20 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VIGAMOX 2 QL 0.434 / day
ANTIVIRALS (EENT)
trifluridine 1 % drops 1
EENT ANTI-INFECTIVES, MISCELLANEOUS
ACETASOL HC 1
acetic acid 2 % solution 1
acetic acid/aluminum acetate 1
chlorhexidine gluconate 0.12 % mouthwash 1
hydrocortisone/acetic acid 1
PAROEX 1
PERIOGARD 1
povidone-iodine 5 % solution 1
ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)
ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)
CLEOCIN 100 MG VAGINAL OVULE 2
CLINDACIN ETZ 1% PLEDGET 1
CLINDACIN P 1
clindamycin phosphate 1 % foam 1 QL 1.667 / day
clindamycin phosphate 1 % gel (gram) 1 QL 75 / 30 days
clindamycin phosphate (1 % lotion, 1 % med. swab, 1 %solution, 2 % cream/appl) 1
clindamycin phos/benzoyl perox 1.2(1)%-5% gel (gram) 3QL 1.5 / day
HCG
clindamycin phosphate/benzoyl peroxide (phos/benzoyl 1 % gel(gram), phos/benzoyl 1 % gel w/pump) 3
QL 1.667 / day
HCG
clindamycin phosphate/tretinoin 3QL 2 / day
HCG
PAGE 21 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ERY 1
erythromycin base/benzoyl peroxide 3QL 1.60 / day
HCG
erythromycin base/ethanol 2 % gel (gram) 1 QL 1 / day
erythromycin base/ethyl alcohol (base/ethanol 2 % med. swab,base/ethanol 2 % solution) 1
gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g)) 1
metronidazole (0.75 % cream (g), 0.75 % gel (gram), 0.75 %lotion, 1 % gel (gram)) 3 HCG
metronidazole (0.75 % gel w/appl, 1 % gel w/pump) 1
mupirocin 2 % oint. (g) 1
mupirocin calcium 1
NEUAC GEL 1 QL 1.5 / day
ROSADAN (CREAM, GEL) 1
VANDAZOLE 1
ANTIVIRALS (SKIN AND MUCOUS MEMBRANE)
acyclovir 5 % oint. (g) 3 HCG
ZOVIRAX 5% CREAM 2
QL 0.167 / day
PA
AL At least 12 yrs old
LOCAL ANTI-INFECTIVES, MISCELLANEOUS
AVAR CLEANSER 1
AVAR-E 1
AVAR-E GREEN 1
BP 10-1 1
CLEANSING WASH 1
DERMAZENE 1
PAGE 22 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
guaiacol 1
hydrocortisone acetate/iodoquinol/aloe vera 1
hydrocortisone/iodoquinol 1
LUGOL'S STRONG IODINE SOLUTION 1
phenol liquid 1
ROSANIL 1
SEB-PREV 3QL 12 / day
HCG
selenium sulfide (2.25 % shampoo, 2.5 % lotion) 1
silver nitrate (0.5 % solution, 10 % oint. (g), 25 % solution, 50% solution) 1
silver sulfadiazine 1 % cream (g) 1
SSD 1
SSS 10-5 (10-5 CREAM, 10-5 FOAM) 1
sulfacetamide sodium (10 % cleanser, 10 % clnsr gel) 3QL 12 / day
HCG
sulfacetamide sodium 10 % shampoo 1 QL 8 / day
sulfacetamide sodium 10 % suspension 1 QL 4 / day
PAGE 23 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
sulfacetamide sodium/sulfur (sodium/sulfur 8 %-4 %suspension, sodium/sulfur 9 %-4 % cleanser, sodium/sulfur 9%-4.5 % cleanser, sodium/sulfur 9.8%-4.8% cleanser,sodium/sulfur 10 %-2 % cleanser, sodium/sulfur 10 %-2 %cream (g), sodium/sulfur 10 %-4 % med. pad, sodium/sulfur 10%-5 % foam, sodium/sulfur 10-5%(w/v) lotion, sodium/sulfur10-5%(w/w) cream (g), sodium/sulfur 10-5%(w/w) lotion,sodium/sulfur 10-5%(w/w) suspension)
1
sulfacetamide sodium/sulfur 10-5%(w/w) cleanser 1
sulfacetamide sodium/sulfur/skin cleanser comb no.23 1
sulfacetamide sodium/sulfur/urea 1
SULFACLEANSE 8-4 3 HCG
THERMAZENE 1
ZENCIA 1
SCABICIDES AND PEDICULICIDES
lindane (1 % lotion, 1 % shampoo) 1
malathion 3 HCG
permethrin 5 % cream (g) 1
spinosad 3 HCG
ANTI-INFLAMMATORY AGENTS (EENT)
CORTICOSTEROIDS (EENT)
budesonide 32mcg spray/pump 1 QL 0.574 / day
dexamethasone sod phosphate 0.1 % drops 1 QL 10 / fill
flunisolide 25 mcg spray 1 QL .834 / day
fluocinolone acetonide oil 3 HCG
fluorometholone 1 QL 10 / fill
fluticasone propionate 50 mcg spray susp 1 QL 0.6 / day
mometasone furoate 50 mcg spray/pump 1 QL 0.567 / day
PAGE 24 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
prednisolone acetate 1 QL 21 / fill
prednisolone sod phosphate 1 % drops 1
triamcinolone acetonide 55 mcg spray 1 QL 0.55 / day
EENT ANTI-INFLAMMATORY AGENTS, MISC.
RESTASIS 2 PA
RESTASIS MULTIDOSE 2 PA
EENT NONSTEROIDAL ANTI-INFLAM. AGENTS
ACUVAIL 2 QL 1 / day
bromfenac sodium 0.09% drops 1 QL 8 / rx
diclofenac sodium 0.1 % drops 1 QL 5 / fill
flurbiprofen sodium 1 QL 3/ fill
ketorolac tromethamine 0.4 % drops 1 QL 5 / fill
ketorolac tromethamine 0.5 % drops 1 QL 15 / 30 days
ANTI-INFLAMMATORY AGENTS (RESPIRATORY)
LEUKOTRIENE MODIFIERS
montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tabchew, 10 mg tablet) 1 QL 1 / day
zafirlukast 1 QL 2 / day
MAST-CELL STABILIZERS
cromolyn sodium 20 mg/2 ml ampul-neb 1
cromolyn sodium 4 % drops 1 QL 10 / fill
cromolyn sodium 20 mg/ml oral conc 1
PAGE 25 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIANEMIA DRUGS
IRON PREPARATIONS
FEROCON 1
FEROTRINSIC 1
FERROCITE PLUS 1
HEMATINIC PLUS 1
HEMATINIC WITH FOLIC ACID 1
HEMAX 1
HEMOCYTE-F 1
INFED 4 S
OBSTETRIX ONE 1 GL Female
pediatric multivitamin no.45/sodium fluoride/ferrous sulfate 1
POLYSACCHARIDE IRON FORTE 1
TRIFERIC 272 MG POWDER PACKET 4 S
VYNATAL-FA 1 GL Female
ANTIARRHYTHMIC AGENTS
ANTIARRHYTHMICS, MISCELLANEOUS
DIGITEK 1
DIGOX 1
digoxin (250 mcg/ml ampul, 250 mcg/ml syringe) 1
digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg tablet) 1
LANOXIN 500 MCG/2 ML AMPULE 2
LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, 187.5 MCGTABLET, 250 MCG TABLET) 2
LANOXIN PEDIATRIC 2
magnesium sulfate (4 meq/ml syringe, 4 meq/ml vial) 1
PAGE 26 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CLASS IA ANTIARRHYTHMICS
disopyramide phosphate 1
NORPACE CR 100 MG CAPSULE 2
procainamide hcl 500 mg/ml vial 1
quinidine gluconate 324 mg tablet er 1
quinidine gluconate 80 mg/ml vial 1
quinidine sulfate (200 mg tablet, 300 mg tablet, 300 mg tableter) 1
CLASS IB ANTIARRHYTHMICS
DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MG CAPSULE) 2
DILANTIN-125 2
lidocaine hcl (20 mg/ml vial, 30 mg/3 ml syringe, 100mg/10mlsyringe) 1
lidocaine hcl/pf (hcl/pf 20 mg/ml ampul, hcl/pf 20 mg/ml vial) 1 MED Medical Drug
lidocaine hcl/pf 100mg/10ml syringe 1
mexiletine hcl (150 mg capsule, 200 mg capsule, 250 mgcapsule) 1
PHENYTEK 2
phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5mloral susp) 1
phenytoin sodium extended 1
CLASS IC ANTIARRHYTHMICS
flecainide acetate 1
propafenone hcl (225 mg cap er 12h, 325 mg cap er 12h, 425mg cap er 12h) 3 HCG
propafenone hcl (150 mg tablet, 225 mg tablet, 300 mg tablet) 1
CLASS II ANTIARRHYTHMICS
acebutolol hcl (200 mg capsule, 400 mg capsule) 1
atenolol (25 mg tablet, 50 mg tablet) 1 LCG
PAGE 27 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
atenolol 100 mg tablet 1
atenolol/chlorthalidone 1
betaxolol hcl (10 mg tablet, 20 mg tablet) 1
bisoprolol fumarate 1
bisoprolol fumarate/hydrochlorothiazide 1 LCG
HEMANGEOL 4 S
metoprolol succinate 1
metoprolol tartrate (25 mg tablet, 50 mg tablet) 1 LCG
metoprolol tartrate (37.5 mg tablet, 75 mg tablet) 1
metoprolol tartrate 100 mg tablet 1
metoprolol tartrate/hydrochlorothiazide 1
nadolol (20 mg tablet, 40 mg tablet, 80 mg tablet) 1
nadolol/bendroflumethiazide 1
pindolol 1
propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 mlsolution, 40 mg tablet, 40mg/5ml solution, 60 mg cap sa 24h,60 mg tablet, 80 mg cap sa 24h, 80 mg tablet, 120 mg cap sa24h, 160 mg cap sa 24h)
1
propranolol hcl/hydrochlorothiazide 1
SORINE 1
sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mgtablet) 1
timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1
CLASS III ANTIARRHYTHMICS
amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet) 1
CORDARONE 2
dofetilide 4 S
PACERONE 1
PAGE 28 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TIKOSYN 4 S
CLASS IV ANTIARRHYTHMICS
CARTIA XT 1 QL 1 / day
DILT XR 120 MG CAPSULE 1 QL 1 / day
DILT-XR (180 MG CAPSULE, 240 MG CAPSULE) 1
diltiazem hcl (60 mg cap er 12h, 90 mg cap er 12h, 90 mgtablet, 120 mg cap er 12h, 240 mg cap er 24h, 240 mg cap erdeg, 240 mg cap sa 24h, 300 mg cap er 24h, 300 mg cap sa24h, 360 mg cap er 24h, 360 mg cap sa 24h, 420 mg cap sa24h)
1
diltiazem hcl 180 mg cap er 24h 1 QL 1 / day
diltiazem hcl (120 mg cap er 24h, 120 mg cap er deg, 120 mgcap sa 24h, 180 mg cap er deg, 180 mg cap sa 24h, 300 mg taber 24h, 360 mg tab er 24h, 420 mg tab er 24h)
1 QL 1 / day
diltiazem hcl 180 mg tab er 24h 1 QL 3 / day
diltiazem hcl 240 mg tab er 24h 1 QL 2 / day
diltiazem hcl (30 mg tablet, 60 mg tablet, 120 mg tablet) 1 QL 4 / day
MATZIM LA (300 MG TABLET, 360 MG TABLET, 420 MG TABLET) 1 QL 1 / day
MATZIM LA 180 MG TABLET 1 QL 3 / day
MATZIM LA 240 MG TABLET 1 QL 2 / day
TAZTIA XT (120 MG CAPSULE, 180 MG CAPSULE) 1 QL 1 / day
TAZTIA XT (240 MG CAPSULE, 300 MG CAPSULE, 360 MGCAPSULE) 1
verapamil hcl (100 mg cap24h pct, 120 mg cap24h pel, 120 mgtablet er, 180 mg cap24h pel, 180 mg tablet er, 200 mg cap24hpct, 240 mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct,360 mg cap24h pel)
1 QL 1 / day
verapamil hcl (80 mg tablet, 120 mg tablet) 1 QL 3 / day
verapamil hcl 40 mg tablet 1
PAGE 29 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIBACTERIALS
AMINOGLYCOSIDES
amikacin sulfate 1
BETHKIS 4
PA
S
PS
gentamicin sulfate (20 mg/2 ml vial, 40 mg/ml vial) 1
gentamicin sulfate/pf 20 mg/2 ml vial 1
KITABIS PAK 4PA
S
neomycin sulfate 500 mg tablet 1
paromomycin sulfate 250 mg capsule 1
streptomycin sulfate 1 g vial 1
TOBI 4PA
S
TOBI PODHALER 4PA
S
tobramycin in 0.225 % sodium chloride 4PA
S
tobramycin sulfate (1.2 g vial, 10 mg/ml vial, 40 mg/ml vial) 1
tobramycin/nebulizer 4PA
S
MACROLIDES
ERYPED 200 2
erythromycin base 250 mg capsule dr 1
erythromycin base (250 mg tablet, 500 mg tablet) 3 HCG
PAGE 30 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
erythromycin ethylsuccinate 200 mg/5ml susp recon 1
erythromycin ethylsuccinate 400 mg tablet 3 HCG
QUINOLONES
ciprofloxacin 250 mg/5ml sus mc rec 1 QL 7 / day
ciprofloxacin 500 mg/5ml sus mc rec 1 QL 10 / day
ciprofloxacin hcl (100 mg tablet, 250 mg tablet, 750 mg tablet) 1 QL 2 / day
ciprofloxacin hcl 500 mg tablet 1QL 2 / day
LCG
ciprofloxacin/ciprofloxa hcl 1000 mg tbmp 24hr 1 QL 14 / 1 rx
ciprofloxacin/ciprofloxa hcl 500 mg tbmp 24hr 1 QL 28 / fill
levofloxacin (250mg/10ml solution, 500mg/20ml solution) 1
levofloxacin (250 mg tablet, 500 mg tablet, 750 mg tablet) 1 QL 30 / fill
moxifloxacin hcl 400 mg tablet 1 QL 21 / fill
ofloxacin (300 mg tablet, 400 mg tablet) 1 QL 56 / fill
SULFONAMIDES (SYSTEMIC)
sulfadiazine 500 mg tablet 1
sulfamethoxazole/trimethoprim(sulfamethoxazole/trimethoprim 200-40mg/5 oral susp,sulfamethoxazole/trimethoprim 400mg-80mg tablet,sulfamethoxazole/trimethoprim 800-160/20 oral susp)
1
sulfamethoxazole/trimethoprim 800-160 mg tablet 1 LCG
sulfasalazine (500 mg tablet, 500 mg tablet dr) 1
SULFATRIM 1
TETRACYCLINES
AVIDOXY 1
demeclocycline hcl 1
PAGE 31 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
doxycycline hyclate (50 mg capsule, 100 mg capsule, 100 mgtablet) 1
doxycycline hyclate (50 mg tablet dr, 75 mg tablet dr, 100 mgtablet dr, 150 mg tablet dr) 3 HCG
doxycycline hyclate 200 mg tablet dr 3QL 7/ rx
HCG
doxycycline monohydrate 40 mg cap ir dr 1 QL 1 / day
doxycycline monohydrate 150 mg capsule 1 QL 30 / fill
doxycycline monohydrate (25 mg/5 ml susp recon, 50 mgcapsule, 50 mg tablet, 75 mg capsule, 75 mg tablet, 100 mgcapsule, 100 mg tablet, 150 mg tablet)
1
minocycline hcl (90 mg tab er 24h, 135 mg tab er 24h) 3QL 1 / day
HCG
minocycline hcl 45 mg tab er 24h 3QL 3 / day
HCG
minocycline hcl (50 mg capsule, 50 mg tablet, 75 mg capsule,75 mg tablet, 100 mg capsule, 100 mg tablet) 1
MONDOXYNE NL 1
MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 1
PYLERA 2 QL 120 / 365 days
tetracycline hcl (250 mg capsule, 500 mg capsule) 3 HCG
ANTIBACTERIALS, MISCELLANEOUS
BACITRACINS
BACIIM 1
bacitracin 50000 unit vial 1
GLYCOPEPTIDES
vancomycin hcl (125 mg capsule, 250 mg capsule) 3 HCG
vancomycin hcl 125mg/2.5 syringe 1
PAGE 32 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LINCOMYCINS
clindamycin hcl (75 mg capsule, 150 mg capsule, 300 mgcapsule) 1 QL 4 / day
clindamycin palmitate hcl 75 mg/5 ml soln recon 1 QL 70/ day
clindamycin phosphate 150 mg/ml vial 1
lincomycin hcl 1 QL 10 / day
OXAZOLIDINONES
linezolid 100 mg/5ml susp recon 1 QL 900 / rx
linezolid 600 mg tablet 1 QL 2 / day
POLYMYXINS
colistin (colistimethate na) 150 mg vial 1
polymyxin b sulfate 1
RIFAMYCINS
rifabutin 1
rifampin (150 mg capsule, 300 mg capsule) 1
ANTICHOLINERGIC AGENTS
ANTIMUSCARINICS/ANTISPASMODICS
atropine sulfate (0.05 mg/ml syringe, 0.1 mg/ml disp syrin, 0.1mg/ml syringe, 0.4 mg/ml vial, 1 mg/ml vial) 1
B-DONNA 1
chlordiazepoxide/clidinium bromide 1
dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20 mgtablet) 1 LCG
dicyclomine hcl 10 mg/ml vial 1
diphenoxylate hcl/atropine sulfate (hcl/atropine 2.5-.025/5liquid, hcl/atropine 2.5-.025mg tablet) 1
ED-SPAZ 1
PAGE 33 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
glycopyrrolate (1 mg tablet, 2 mg tablet) 1
hydrocodone bit/homatrop me-br 5-1.5 mg/5 syrup 1QL 30 / day
AL At least 2 yrs old
hydrocodone bit/homatrop me-br 5 mg-1.5mg tablet 1QL 6 / day
AL At least 6 yrs old
HYDROMET 1QL 30 / day
AL At least 2 yrs old
hyoscyamine sulfate (0.125 mg tab rapdis, 0.125 mg tab subl,0.125 mg tablet, 0.125mg/ml drops, 0.375 mg tab er 12h,125mcg/5ml elixir)
1
HYOSYNE (0.125 MG/ML DROP, 125 MCG/5 ML ELIXIR) 1
INCRUSE ELLIPTA 2 QL 1 / day
ipratropium bromide 0.2 mg/ml solution 1 QL 12.5 / day
methscopolamine bromide (2.5 mg tablet, 5 mg tablet) 1
NULEV 1
OSCIMIN (0.125 MG ODT, 0.125 MG TABLET) 1
OSCIMIN SL 1
OSCIMIN SR 1
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb 1
PHENOHYTRO 1
propantheline bromide 15 mg tablet 1
scopolamine hydrobromide 0.4 mg/ml vial 1
SPIRIVA 2 QL 1 / day
SPIRIVA RESPIMAT 2 QL 1 / day
STIOLTO RESPIMAT 2 QL 0.134 / day
SYMAX 1
SYMAX-SL 1
PAGE 34 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SYMAX-SR 1
TUSSIGON 1QL 6 / day
AL At least 6 yrs old
ANTIPARKINSONIAN AGENTS
benztropine mesylate (2 mg/2 ml ampul, 2 mg/2 ml vial) 1
benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1
trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elixir, 5 mg tablet) 1
ANTICOAGULANTS
ANTICOAGULANTS, MISCELLANEOUS
sodium citrate 4 % (3 ml) syringe 1
COUMARIN DERIVATIVES
COUMADIN 2
JANTOVEN (1 MG TABLET, 2.5 MG TABLET, 3 MG TABLET, 4 MGTABLET, 5 MG TABLET) 1 LCG
JANTOVEN (2 MG TABLET, 6 MG TABLET, 7.5 MG TABLET, 10 MGTABLET) 1
warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mgtablet, 4 mg tablet, 5 mg tablet) 1 LCG
warfarin sodium (6 mg tablet, 7.5 mg tablet, 10 mg tablet) 1
DIRECT FACTOR XA INHIBITORS
ARIXTRA (2.5 MG/0.5 ML SYRINGE, 5 MG/0.4 ML SYRINGE) 4 S
ARIXTRA (7.5 MG/0.6 ML SYRINGE, 10 MG/0.8 ML SYRINGE) 4 S
fondaparinux sodium (2.5 mg/0.5 syringe, 7.5mg/0.6 syringe,10mg/0.8ml syringe) 4 S
fondaparinux sodium 5mg/0.4ml syringe 4 S
XARELTO STARTER PACK 2
XARELTO (10 MG TABLET, 20 MG TABLET) 2 QL 1 / day
PAGE 35 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
XARELTO 15 MG TABLET 2 QL 2 / day
DIRECT THROMBIN INHIBITORS
IPRIVASK 4 S
PRADAXA 2 QL 2 / day
HEPARINS
enoxaparin sodium (30mg/0.3ml syringe, 40mg/0.4ml syringe,60mg/0.6ml syringe, 80mg/0.8ml syringe, 100 mg/ml syringe,120mg/.8ml syringe, 150 mg/ml syringe, 300mg/3ml vial)
4 S
FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR,7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML SYRING, 12,500UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML,95,000 UNITS/3.8 ML VL)
4 S
heparin sodium,porcine (5000/ml(1) cartridge, 20000/ml vial) 1
heparin sodium,porcine 10000/ml vial 1 MED Medical Drug
heparin sodium,porcine/pf (sodium,porcine/pf 5000/0.5mlsyringe, sodium,porcine/pf 5000/0.5ml vial) 1
heparin sodium,porcine/pf 1000/ml vial 1
LOVENOX (30 MG/0.3 ML SYRINGE, 40 MG/0.4 ML SYRINGE, 60MG/0.6 ML SYRINGE, 80 MG/0.8 ML SYRINGE, 100 MG/MLSYRINGE, 120 MG/0.8 ML SYRINGE, 150 MG/ML SYRINGE, 300MG/3 ML VIAL)
4 S
ANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100mg/5ml oral susp, 200 mg cpmp 12hr, 200 mg tablet, 300 mgcpmp 12hr)
1
carbamazepine (100 mg tab er 12h, 200 mg tab er 12h, 400 mgtab er 12h) 3 HCG
CARBATROL 2
DEPAKOTE ER 2
DEPAKOTE SPRINKLE 2
PAGE 36 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
divalproex sodium (125 mg cap dr spr, 125 mg tablet dr, 250mg tab er 24h, 250 mg tablet dr, 500 mg tab er 24h, 500 mgtablet dr)
1
EPITOL 1
felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oralsusp) 1
GABITRIL (12 MG TABLET, 16 MG TABLET) 2
lamotrigine (25 mg tab er 24, 50 mg tab er 24, 100 mg tab er24, 200 mg tab er 24, 250 mg tab er 24, 300 mg tab er 24) 3 HCG
lamotrigine (5 mg tb chw dsp, 25 mg tab rapdis, 25 mg tablet,25 mg tb chw dsp, 25(21)-50 tb rd dspk, 25(42)-100 tab ds pk,25(84)-100 tab ds pk, 25-50-100 tb rd dspk, 25mg (35) tab dspk, 50 mg tab rapdis, 50(42)-100 tb rd dspk, 100 mg tab rapdis,100 mg tablet, 150 mg tablet, 200 mg tab rapdis, 200 mgtablet)
1
levetiracetam 500 mg/5ml solution 1 QL 946 / 30 days
levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg taber 24h, 500 mg tablet, 750 mg tab er 24h, 750 mg tablet, 1000mg tablet)
1
magnesium chloride 200 mg/ml vial 1
oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oralsusp, 600 mg tablet) 1
ROWEEPRA 1
SABRIL (500 MG POWDER PACKET, 500 MG TABLET) 4
QL 6 / day
PA
S
TEGRETOL XR 2
tiagabine hcl 1
TOPAMAX (15 MG SPRINKLE CAP, 25 MG SPRINKLE CAP, 25 MGTABLET, 50 MG TABLET, 100 MG TABLET, 200 MG TABLET) 2
topiramate (25 mg cap spr 24, 50 mg cap spr 24, 100 mg capspr 24, 150 mg cap spr 24, 200 mg cap spr 24) 3 HCG
topiramate 15 mg cap sprink 1 LCG
PAGE 37 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
topiramate (25 mg cap sprink, 25 mg tablet, 50 mg tablet, 100mg tablet, 200 mg tablet) 1
valproic acid 250 mg capsule 1
valproic acid (as sodium salt) (valproate sodium) (250 mg/5mlsolution, 500mg/10ml solution) 1
vigabatrin 4
QL 6 / day
PA
S
ZONEGRAN 2
zonisamide (25 mg capsule, 100 mg capsule) 1
zonisamide 50 mg capsule 1 LCG
BARBITURATES (ANTICONVULSANTS)
phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir,30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet,97.2mg tablet, 100 mg tablet)
1
phenobarbital sodium 1
primidone (50 mg tablet, 250 mg tablet) 1
BENZODIAZEPINES (ANTICONVULSANTS)
ATIVAN 4 MG/ML VIAL 1
clonazepam (2 mg tab rapdis, 2 mg tablet) 1 QL 10 / day
clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mgtab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet) 1 QL 3 / day
clorazepate dipotassium 15 mg tablet 1 QL 6 / day
clorazepate dipotassium 3.75 mg tablet 1 QL 24 / day
clorazepate dipotassium 7.5 mg tablet 1 QL 12 / day
diazepam (2.5 mg kit, 5-7.5-10mg kit, 12.5-15-20 kit) 1 QL 0.07 / day
diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5mg/ml oral conc, 5 mg/ml syringe, 5 mg/ml vial, 10 mg tablet) 1
PAGE 38 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
lorazepam (2 mg tablet, 2 mg/ml oral conc) 1 QL 5 / day
lorazepam (0.5 mg tablet, 1 mg tablet) 1 QL 3 / day
lorazepam (2 mg/ml syringe, 2 mg/ml vial, 4 mg/ml syringe, 4mg/ml vial) 1
LORAZEPAM INTENSOL 1 QL 5 / day
ONFI (2.5 MG/ML SUSPENSION, 10 MG TABLET, 20 MG TABLET) 4PA
S
SUCCINIMIDES
ethosuximide (250 mg capsule, 250 mg/5ml solution) 1
ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 2
ANTIDEPRESSANTS
ANTIDEPRESSANTS, MISCELLANEOUS
BUPROBAN 0QL 2 / day
HCR
bupropion hcl (200 mg tab er 12h, 200 mg tablet er) 1 QL 2 / day
bupropion hcl 150 mg tab er 24h 1 QL 3 / day
bupropion hcl 300 mg tab er 24h 1 QL 1 / day
bupropion hcl 100 mg tablet 1 QL 5 / day
bupropion hcl 75 mg tablet 1 QL 6 / day
bupropion hcl (100 mg tab er 12h, 100 mg tablet er) 1 QL 4 / day
bupropion hcl (150 mg tab er 12h, 150 mg tablet er) 1QL 2 / day
HCR
mirtazapine (15 mg tab rapdis, 15 mg tablet, 30 mg tab rapdis,30 mg tablet, 45 mg tab rapdis, 45 mg tablet) 1 QL 1 / day
mirtazapine 7.5 mg tablet 1 QL 2 / day
PAGE 39 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MONOAMINE OXIDASE INHIBITORS
phenelzine sulfate 15 mg tablet 1 QL 6 / day
rasagiline mesylate (0.5 mg tablet, 1 mg tablet) 1
selegiline hcl (5 mg capsule, 5 mg tablet) 1
tranylcypromine sulfate 1 QL 6 / day
SEL.SEROTONIN,NOREPI REUPTAKE INHIBITOR
desvenlafaxine (50 mg tab er 24, 50 mg tab er 24h, 100 mg taber 24, 100 mg tab er 24h) 3
QL 1 / day
HCG
desvenlafaxine fumarate 3QL 1 / day
HCG
desvenlafaxine succinate 3QL 1 / day
HCG
duloxetine hcl (20 mg capsule dr, 30 mg capsule dr) 1 QL 1 / day
duloxetine hcl (40 mg capsule dr, 60 mg capsule dr) 1 QL 2 / day
venlafaxine hcl 75 mg cap er 24h 1 QL 3 / day
venlafaxine hcl (37.5 mg cap er 24h, 37.5 mg tab er 24, 75 mgtab er 24, 150 mg cap er 24h, 150 mg tab er 24, 225 mg tab er24)
1 QL 1 / day
venlafaxine hcl (37.5 mg tablet, 50 mg tablet, 75 mg tablet, 100mg tablet) 1
venlafaxine hcl 25 mg tablet 1 LCG
SELECTIVE-SEROTONIN REUPTAKE INHIBITORS
citalopram hydrobromide 10 mg/5 ml solution 1 QL 20 / day
citalopram hydrobromide (10 mg tablet, 20 mg tablet, 40 mgtablet) 1
QL 1 / day
LCG
escitalopram oxalate 5 mg/5 ml solution 1 QL 20 / day
PAGE 40 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
escitalopram oxalate (5 mg tablet, 10 mg tablet) 1 QL 1.5 / day
escitalopram oxalate 20 mg tablet 1 QL 1 / day
fluoxetine hcl 10 mg capsule 1QL 1 / day
LCG
fluoxetine hcl 20 mg capsule 1QL 4 / day
LCG
fluoxetine hcl 40 mg capsule 1 QL 2 / day
fluoxetine hcl 90 mg capsule dr 1 QL 0.142 / day
fluoxetine hcl 20 mg/5 ml solution 1 QL 20 / day
fluoxetine hcl 10 mg tablet 1QL 1.5 / day
LCG
fluoxetine hcl 20 mg tablet 1 QL 4 / day
fluoxetine hcl 60 mg tablet 1 QL 1.5 / day
fluvoxamine maleate (100 mg cap er 24h, 150 mg cap er 24h) 3QL 2 / day
HCG
fluvoxamine maleate (25 mg tablet, 50 mg tablet) 1 QL 1 / day
fluvoxamine maleate 100 mg tablet 1 QL 3 / day
olanzapine/fluoxetine hcl 3
QL 1 / day
AL At least 10 yrs old
HCG
paroxetine hcl (25 mg tab er 24h, 30 mg tablet, 37.5 mg tab er24h) 1 QL 2 / day
paroxetine hcl (12.5 mg tab er 24h, 40 mg tablet) 1 QL 1 / day
paroxetine hcl 10 mg tablet 1QL 1.5 / day
LCG
PAGE 41 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
paroxetine hcl 20 mg tablet 1QL 1 / day
LCG
paroxetine mesylate 1 QL 1 / day
sertraline hcl 20 mg/ml oral conc 1 QL 10 / day
sertraline hcl (25 mg tablet, 50 mg tablet) 1QL 1.5 / day
LCG
sertraline hcl 100 mg tablet 1QL 2 / day
LCG
SEROTONIN MODULATORS
nefazodone hcl 100 mg tablet 1 QL 6 / day
nefazodone hcl 150 mg tablet 1 QL 4 / day
nefazodone hcl 200 mg tablet 1 QL 3 / day
nefazodone hcl 250 mg tablet 1 QL 2.5 / day
nefazodone hcl 50 mg tablet 1 QL 12 / day
trazodone hcl 100 mg tablet 1QL 4 / day
LCG
trazodone hcl 150 mg tablet 1QL 2 / day
LCG
trazodone hcl 300 mg tablet 1 QL 1 / day
trazodone hcl 50 mg tablet 1QL 3 / day
LCG
TRICYCLICS, OTHER NOREPI-RU INHIBITORS
amitriptyline hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75mg tablet, 100 mg tablet, 150 mg tablet) 1 LCG
amitriptyline hcl/chlordiazepoxide 1
PAGE 42 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
amoxapine 1
clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mgcapsule) 3 HCG
desipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75mg tablet, 100 mg tablet, 150 mg tablet) 3 HCG
doxepin hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 100mg capsule) 1 LCG
doxepin hcl (10 mg/ml oral conc, 75 mg capsule, 150 mgcapsule) 1
imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) 1 LCG
imipramine pamoate 3 HCG
maprotiline hcl 1
nortriptyline hcl (10 mg capsule, 10 mg/5 ml solution, 25 mgcapsule, 50 mg capsule, 75 mg capsule) 1
perphenazine/amitriptyline hcl 1
protriptyline hcl 1
trimipramine maleate 1
ANTIDIABETIC AGENTS
ALPHA-GLUCOSIDASE INHIBITORS
acarbose 100 mg tablet 1 QL 3 / day
acarbose 25 mg tablet 1 QL 12 / day
acarbose 50 mg tablet 1 QL 6 / day
miglitol 1 QL 3 / day
AMYLINOMIMETICS
SYMLINPEN 120 2 QL 0.4 / day
SYMLINPEN 60 2 QL 0.2 / day
PAGE 43 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIDIABETIC AGENTS, MISCELLANEOUS
KORLYM 4PA
S
WELCHOL 3.75G PACKET 2 QL 1 / day
WELCHOL 625 MG TABLET 2 QL 6 / day
BIGUANIDES
ACTOPLUS MET XR 15-1,000 MG TB 2QL 3 / day
ST
ACTOPLUS MET XR 30-1,000 MG TB 2QL 1 / day
ST
AVANDAMET 2QL 2 / day
PA
glipizide/metformin hcl (glipizide/metformin 2.5-500 mg tablet,glipizide/metformin 5 mg-500mg tablet) 1 QL 4 / day
glipizide/metformin hcl 2.5-250 mg tablet 1 QL 8 / day
glyburide/metformin hcl (glyburide/metformin 2.5-500 mgtablet, glyburide/metformin 5 mg-500mg tablet) 1 QL 4 / day
glyburide/metformin hcl 1.25-250mg tablet 1QL 8 / day
LCG
INVOKAMET 2QL 2 / day
ST
INVOKAMET XR 2QL 2 / day
ST
JANUMET 2QL 2 / day
ST
JANUMET XR (50-1,000 MG TABLET, 50-500 MG TABLET) 2QL 2 / day
ST
PAGE 44 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
JANUMET XR 100-1,000 MG TABLET 2QL 1 / day
ST
JENTADUETO 2QL 2 / day
ST
JENTADUETO XR 2QL 1 / day
ST
metformin hcl 500 mg tab er 24h 1
QL 5 / day
C Only Glucophage ERgeneric covered
LCG
metformin hcl 750 mg tab er 24h 1QL 3 / day
C Only Glucophage ERgeneric covered
metformin hcl 1000 mg tablet 1QL 2.5 / day
LCG
metformin hcl 500 mg tablet 1QL 5 / day
LCG
metformin hcl 850 mg tablet 1QL 3 / day
LCG
pioglitazone hcl/metformin hcl 3QL 3 / day
HCG
repaglinide/metformin hcl 1 QL 5 / day
SYNJARDY 2QL 2 / day
ST
SYNJARDY XR (5-1,000 MG TABLET, 10-1,000 MG TABLET, 12.5-1,000 MG TAB) 2
QL 2 / day
ST
SYNJARDY XR 25-1,000 MG TABLET 2QL 1 / day
ST
PAGE 45 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS
JANUVIA 2QL 1 / day
ST
TRADJENTA 2QL 1 / day
ST
INCRETIN MIMETICS
BYDUREON 2QL 0.15 / day
ST
BYDUREON PEN 2QL .15 / day
ST
BYETTA 10 MCG DOSE PEN INJ 2QL 0.8 / day
ST
BYETTA 5 MCG DOSE PEN INJ 2QL 0.04 / day
ST
SOLIQUA 100-33 2QL 0.6 / day
PA
TRULICITY 2QL 0.08 / day
ST
VICTOZA 2-PAK 2QL 0.3 / day
ST
VICTOZA 3-PAK 2QL 0.3 / day
ST
INSULINS
HUMALOG (100 UNITS/ML CARTRIDGE, 100 UNITS/ML VIAL) 2
HUMALOG KWIKPEN U-100 2
HUMALOG KWIKPEN U-200 2
PAGE 46 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HUMALOG MIX 50-50 2
HUMALOG MIX 50-50 KWIKPEN 2
HUMALOG MIX 75-25 2
HUMALOG MIX 75-25 KWIKPEN 2
HUMULIN R U-500 2
HUMULIN R U-500 KWIKPEN 2
LANTUS 2
LANTUS SOLOSTAR 2
TOUJEO SOLOSTAR 2
MEGLITINIDES
nateglinide 1 QL 3 / day
repaglinide (0.5 mg tablet, 1 mg tablet) 1 QL 4 / day
repaglinide 2 mg tablet 1 QL 8 / day
SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB
INVOKANA 2QL 1 / day
ST
JARDIANCE 2QL 1 / day
ST
SULFONYLUREAS
chlorpropamide 100 mg tablet 1
chlorpropamide 250 mg tablet 1 QL 3 / day
glimepiride 1 LCG
glipizide (2.5 mg tab er 24, 5 mg tab er 24, 10 mg tab er 24) 1 LCG
glipizide (5 mg tablet, 10 mg tablet) 1 LCG
glyburide (1.25 mg tablet, 2.5 mg tablet, 5 mg tablet) 1 LCG
PAGE 47 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
glyburide,micronized 1 LCG
pioglitazone hcl/glimepiride 1 QL 1 / day
tolazamide 250 mg tablet 1 QL 4 / day
tolazamide 500 mg tablet 1 QL 2 / day
tolbutamide 1 QL 6 / day
THIAZOLIDINEDIONES
AVANDIA 2 MG TABLET 2QL 3 / day
PA
AVANDIA 4 MG TABLET 2QL 2 / day
PA
AVANDIA 8 MG TABLET 2QL 1 / day
PA
pioglitazone hcl 1 QL 1 / day
ANTIEMETICS
5-HT3 RECEPTOR ANTAGONISTS
AKYNZEO 4
QL 0.15 / day
PA
S
granisetron hcl 1 mg tablet 1 QL 6 / 30 days
ondansetron 1
QL 24 / 30 days
CMax allowable- 3/daywith max of 24 / 30days
ondansetron hcl 4 mg/5 ml solution 1 QL 20 / day
ondansetron hcl (4 mg tablet, 8 mg tablet) 1
QL 24 / 30 days
CMax allowable- 3/daywith max of 24 / 30days
PAGE 48 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ondansetron hcl 24 mg tablet 1 QL 3 days
ondansetron hcl/pf (hcl/pf 4 mg/2 ml ampul, hcl/pf 4 mg/2 mlvial) 4 S
ondansetron hcl/pf 4 mg/2 ml syringe 4 S
SANCUSO 4QL 0.144 / day
S
ANTIEMETICS, MISCELLANEOUS
aprepitant 125mg-80mg cap ds pk 1 QL 3/ fill
aprepitant (40 mg capsule, 125 mg capsule) 1 QL 0.08 / day
aprepitant 80 mg capsule 1 QL 0.15 / day
CESAMET 4
QL 0.67 / day
PA
S
dronabinol 3QL 5 / day
HCG
scopolamine 1
TRANSDERM-SCOP 2
VARUBI 90 MG TABLET 4
QL 0.15 / day
PA
S
ANTIHISTAMINES (GI DRUGS)
COMPAZINE 25 MG SUPPOSITORY 1
COMPRO 1
dimenhydrinate 50 mg/ml vial 1
meclizine hcl (12.5 mg tablet, 25 mg tablet) 1
prochlorperazine 1
PAGE 49 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
prochlorperazine edisylate (5 mg/ml vial, 10 mg/2 ml vial) 1
prochlorperazine maleate (5 mg tablet, 10 mg tablet) 1
trimethobenzamide hcl 300 mg capsule 1
ANTIFUNGAL (SYSTEMIC)
ALLYLAMINES
terbinafine hcl 250 mg tablet 1
ANTIFUNGALS, MISCELLANEOUS
griseofulvin ultramicrosize 1
griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet) 3 HCG
LUGOL'S SOLUTION 1
potassium iodide/iodine 1
triacetin 1
AZOLES
fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mgtablet, 100 mg tablet, 200 mg tablet) 1
fluconazole 150 mg tablet 1QL 0.4 / day
LCG
itraconazole 100 mg capsule 1
ketoconazole 200 mg tablet 1
voriconazole 200 mg/5ml susp recon 3QL 20 / day
HCG
voriconazole (50 mg tablet, 200 mg tablet) 3QL 4 / day
HCG
POLYENES
amphotericin b 50 mg vial 1
nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500kunit tablet, 500mm unit powder(ea), 100000/ml oral susp) 1
PAGE 50 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PYRIMIDINES
flucytosine (250 mg capsule, 500 mg capsule) 1
ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)
ALLYLAMINES (SKIN AND MUCOUS MEMBRANE)
naftifine hcl 1
ANTIFULGALS (SKIN, MUCOUS MEMBRANE),MISC
EXODERM 1
AZOLES (SKIN AND MUCOUS MEMBRANE)
clotrimazole (1 % cream (g), 1 % solution, 10 mg troche) 1
clotrimazole/betamethasone dipropionate(clotrimazole/betamethasone 1 % cream (g),clotrimazole/betamethasone 1 % lotion)
1
econazole nitrate 1 % cream (g) 3 HCG
ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo) 1
oxiconazole nitrate 3 HCG
terconazole 1QL 1.5 / day
GL Female
HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)
CICLODAN 0.77% CREAM 1
CICLODAN 8% SOLUTION 1 QL 0.22 / day
ciclopirox (0.77 % gel (gram), 1 % shampoo) 1
ciclopirox 8 % solution 1 QL 0.22 / day
ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) 1
POLYENES (SKIN AND MUCOUS MEMBRANE)
NYAMYC 1
NYATA 100,000 UNIT/GM POWDER 1
PAGE 51 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
nystatin (100000/g cream (g), 100000/g oint. (g), 100000/gpowder) 1
nystatin/triamcinolone acetonide (nystatin/triamcin 100000-0.1 cream (g), nystatin/triamcin 100000-0.1 oint. (g)) 3 HCG
NYSTOP 1
ANTIGLAUCOMA AGENTS
ALPHA-ADRENERGIC AGONISTS (EENT)
ALPHAGAN P 0.1% DROPS 2 QL 0.4 / day
brimonidine tartrate (0.15 % drops, 0.2 % drops) 1 QL 0.4 / day
COMBIGAN 2 QL 0.334 / day
BETA-ADRENERGIC BLOCKING AGENTS (EENT)
betaxolol hcl 0.5 % drops 1 QL 0.54 / day
carteolol hcl 1 QL 0.334 / day
dorzolamide hcl/timolol maleate 1 QL 0.334 / day
levobunolol hcl 1 QL 0.4 / day
metipranolol 1 QL 0.334 / day
timolol maleate 0.5 % drops 1 QL 0.334 / day
timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % sol-gel) 1 QL 0.286 / day
CARBONIC ANHYDRASE INHIBITORS (EENT)
acetazolamide 500 mg capsule er 3 HCG
acetazolamide (125 mg tablet, 250 mg tablet) 1
acetazolamide sodium 1
AZOPT 2 QL 0.334 / day
dorzolamide hcl 1 QL 0.4 / day
methazolamide (25 mg tablet, 50 mg tablet) 1
PAGE 52 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MIOTICS
pilocarpine hcl (1 % drops, 2 % drops, 4 % drops) 1 QL 0.54 / day
PROSTAGLANDIN ANALOGS
bimatoprost 0.03 % drops 1 QL 0.13 / day
bimatoprost 0.03 % drop w/app 1
latanoprost 0.005 % drops 1 QL 0.13 / day
LUMIGAN 2 QL 0.13 / day
TRAVATAN Z 2 QL 0.167 / day
travoprost (benzalkonium) 1 QL 0.167 / day
ANTIHEMORRHAGIC AGENTS
HEMOSTATICS
desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2mg tablet, 10/spray spray/pump) 1
desmopressin acetate (4 mcg/ml ampul, 4 mcg/ml vial) 1
RECOTHROM (5,000 UNIT VIAL, 20,000 UNIT VIAL) 4 S
STIMATE 4 S
tranexamic acid 650 mg tablet 1QL 6 / day
GL Female
ANTIHISTAMINE DRUGS
FIRST GENERATION ANTIHISTAMINES
ARBINOXA (4 MG TABLET, 4 MG/5 ML LIQUID) 1 AL At least 2 yrs old
carbinoxamine maleate (4 mg tablet, 4 mg/5 ml liquid) 1 AL At least 2 yrs old
clemastine fumarate 2.68 mg tablet 1 AL At least 2 yrs old
cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet, 4 mg/10 mlsyrup) 1 AL At least 2 yrs old
PAGE 53 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
diphenhydramine hcl 12.5mg/5ml elixir 1
diphenhydramine hcl (50 mg/ml syringe, 50 mg/ml vial) 1
SECOND GENERATION ANTIHISTAMINES
cetirizine hcl 1 mg/ml solution 1 QL 10 / day
desloratadine (2.5 mg tab rapdis, 5 mg tab rapdis, 5 mg tablet) 1 QL 1 / day
fexofenadine hcl 180 mg tablet 1 QL 1 / day
fexofenadine hcl 30 mg tablet 1
fexofenadine hcl 60 mg tablet 1 QL 2 / day
levocetirizine dihydrochloride 2.5 mg/5ml solution 1 QL 30 / day
levocetirizine dihydrochloride 5 mg tablet 1 QL 1 / day
ANTIHISTAMINES (RESPIRATORY TRACT AGNTS)
FIRST GENERATION ANTIHIST.(RESPIR TRACT)
BROMFED DM 1 AL At least 2 yrs old
brompheniramine maleate/pseudoephedrinehcl/dextromethorphan 1 AL At least 2 yrs old
CENTERGY 1
CENTERGY DM 1
hydrocodone polistirex/chlorpheniramine polistirex 1QL 10 / day
AL At least 6 yrs old
phenylephrine hcl/prometh hcl 5-6.25mg/5 syrup 1
promethazine hcl (25 mg/ml ampul, 25 mg/ml syringe, 25mg/ml vial, 50 mg/ml ampul, 50 mg/ml vial) 1 AL At least 2 yrs old
promethazine hcl (6.25mg/5ml syrup, 12.5 mg tablet, 50 mgtablet) 1 AL At least 2 yrs old
promethazine hcl 25 mg tablet 1AL At least 2 yrs old
LCG
promethazine hcl/codeine 1
PAGE 54 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
promethazine/dextromethorphan 6.25-15/5 syrup 1AL At least 2 yrs old
LCG
SECOND GENERATION ANTIHIST(RESPIR TRACT)
DYMISTA 2 QL 0.8 / day
ANTIHYPOGLYCEMIC AGENTS
GLYCOGENOLYTIC AGENTS
GLUCAGEN 2
GLUCAGON EMERGENCY KIT 2
glucagon hcl 1
ANTILIPEMIC AGENTS
ANTILIPEMIC AGENTS, MISCELLANEOUS
JUXTAPID (20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE,60 MG CAPSULE) 4
QL 1 / day
PA
S
JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE) 4
QL 2 / day
PA
S
KYNAMRO 4
QL 0.15 / day
PA
S
niacin (750 mg tab er 24h, 1000 mg tab er 24h) 1 QL 2 / day
niacin 500 mg tab er 24h 1 QL 3 / day
omega-3 acid ethyl esters 3QL 4 / day
HCG
TRIKLO 3QL 4 / day
HCG
PAGE 55 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BILE ACID SEQUESTRANTS
cholestyramine (with sugar) 4 g powder 1 QL 24 / day
cholestyramine (with sugar) 4 g powd pack 1 QL 4 / day
cholestyramine/aspartame 4 g powder 3QL 24 / day
HCG
cholestyramine/aspartame 4 g powd pack 3QL 4 / day
HCG
colestipol hcl (5 g granules, 5 g packet) 1 QL 6 / day
colestipol hcl 1 g tablet 1 QL 4 / day
PREVALITE POWDER 3QL 24 / day
HCG
PREVALITE PACKET 3QL 4 / day
HCG
CHOLESTEROL ABSORPTION INHIBITORS
ezetimibe 1 QL 1 / day
ezetimibe/simvastatin 1 QL 1 / day
FIBRIC ACID DERIVATIVES
fenofibrate (40 mg tablet, 50 mg capsule) 1 QL 2 / day
fenofibrate (150 mg capsule, 160 mg tablet) 1 QL 1 / day
fenofibrate 120 mg tablet 1 QL 1 / day
fenofibrate 54 mg tablet 1 QL 2 / day
fenofibrate nanocrystallized 145mg tablet 1 QL 1 / day
fenofibrate nanocrystallized 48 mg tablet 1 QL 2 / day
fenofibrate,micronized (67 mg capsule, 130 mg capsule, 134mg capsule, 200 mg capsule) 1 QL 1 / day
PAGE 56 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fenofibrate,micronized 43 mg capsule 1 QL 2 / day
fenofibric acid 105 mg tablet 1 QL 1 / day
fenofibric acid 35 mg tablet 1 QL 2 / day
fenofibric acid (choline) 135 mg capsule dr 1 QL 1 / day
fenofibric acid (choline) 45 mg capsule dr 1 QL 2 / day
gemfibrozil 600 mg tablet 1 QL 2 / day
HMG-COA REDUCTASE INHIBITORS
amlodipine besylate/atorvastatin calcium 3QL 1 / day
HCG
atorvastatin calcium 1 QL 1 / day
fluvastatin sodium 40 mg capsule 1 QL 2 / day
fluvastatin sodium (20 mg capsule, 80 mg tab er 24h) 1 QL 1 / day
lovastatin (10 mg tablet, 20 mg tablet) 1 QL 1 / day
lovastatin 40 mg tablet 1 QL 2 / day
pravastatin sodium (10 mg tablet, 20 mg tablet, 40 mg tablet) 1QL 1 / day
LCG
pravastatin sodium 80 mg tablet 1
rosuvastatin calcium 1 QL 1 / day
simvastatin (10 mg tablet, 20 mg tablet, 40 mg tablet) 1QL 1.5 / day
LCG
simvastatin 5 mg tablet 1QL 1 / day
LCG
simvastatin 80 mg tablet 1QL 1 / day
PA
PAGE 57 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PCSK9 INHIBITORS
PRALUENT PEN 4
QL 0.08 / day
PA
S
PS
PRALUENT SYRINGE 4
QL 0.08 / day
PA
S
PS
REPATHA PUSHTRONEX 4
QL 0.13 / day
PA
S
PS
REPATHA SURECLICK 4
QL 0.08 / day
PA
S
PS
REPATHA SYRINGE 4
QL 0.08 / day
PA
S
PS
ANTIMIGRAINE AGENTS
SELECTIVE SEROTONIN AGONISTS
almotriptan malate 3QL 0.4 / day
HCG
eletriptan hbr 3QL 0.4 / day
HCG
PAGE 58 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
frovatriptan succinate 3QL 0.6 / day
HCG
naratriptan hcl (1 mg tablet, 2.5 mg tablet) 1 QL 0.6 / day
rizatriptan benzoate (5 mg tab rapdis, 5 mg tablet, 10 mg tabrapdis, 10 mg tablet) 1 QL 0.6 / day
sumatriptan (5 mg spray, 20 mg spray) 3QL 6 / 30 days
HCG
sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5ml peninjctr, 6 mg/0.5ml cartridge, 6 mg/0.5ml pen injctr, 6 mg/0.5mlvial)
3QL 0.167 / day
HCG
sumatriptan succinate 6 mg/0.5ml syringe 1 QL 0.167 / day
sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mgtablet) 1 QL 0.3 / day
zolmitriptan (2.5 mg tablet, 5 mg tablet) 1 QL 0.2 / day
zolmitriptan (2.5 mg tab rapdis, 5 mg tab rapdis) 3QL 0.2 / day
HCG
ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 2 QL 0.2 / day
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, MISCELLANEOUS
dapsone (25 mg tablet, 100 mg tablet) 1
ANTITUBERCULOSIS AGENTS
clarithromycin (125 mg/5ml susp recon, 250 mg tablet, 250mg/5ml susp recon, 500 mg tab er 24h, 500 mg tablet) 1
cycloserine 250 mg capsule 1
ethambutol hcl 1
isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet) 1
isoniazid 100 mg/ml vial 1
pyrazinamide 500 mg tablet 1
PAGE 59 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIPARKINSONIAN AGENTS (CNS)
ADAMANTANES (CNS)
amantadine hcl (50 mg/5 ml solution, 100 mg capsule, 100 mgtablet) 1
CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.
carbidopa/levodopa/entacapone 1
entacapone 1
tolcapone 1
DOPAMINE PRECURSORS
carbidopa/levodopa (carbidopa/levodopa 10mg-100mg tabrapdis, carbidopa/levodopa 10mg-100mg tablet,carbidopa/levodopa 25mg-100mg tab rapdis,carbidopa/levodopa 25mg-100mg tablet, carbidopa/levodopa25mg-100mg tablet er, carbidopa/levodopa 25mg-250mg tabrapdis, carbidopa/levodopa 25mg-250mg tablet,carbidopa/levodopa 50mg-200mg tablet er)
1
DUOPA 4
QL 1 / day
PA
S
ANTIPROTOZOALS
AMEBICIDES
metronidazole (250 mg tablet, 375 mg capsule, 500 mg tablet) 1
ANTIMALARIALS
atovaquone/proguanil hcl 1 PA
chloroquine phosphate (250 mg tablet, 500 mg tablet) 1
hydroxychloroquine sulfate 200 mg tablet 1
mefloquine hcl 1
primaquine phosphate 1
quinine sulfate 324 mg capsule 1QL 42 / 365 days
PA
PAGE 60 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIPROTOZOALS, MISCELLANEOUS
atovaquone 1 PA
IMPAVIDO 4 S
tinidazole (250 mg tablet, 500 mg tablet) 1
ANTIPSYCHOTIC AGENTS
ANTIPSYCHOTICS, MISCELLANEOUS
loxapine succinate 1 AL At least 18 yrs old
molindone hcl 1
pimozide 1
ATYPICAL ANTIPSYCHOTICS
aripiprazole 1 mg/ml solution 1QL 30 / day
AL At least 6 yrs old
aripiprazole (2 mg tablet, 5 mg tablet, 10 mg tab rapdis, 10 mgtablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 30 mgtablet)
1QL 1 / day
AL At least 6 yrs old
clozapine 200 mg tablet 1QL 4 / day
AL At least 18 yrs old
clozapine 25 mg tablet 1QL 18 / day
AL At least 18 yrs old
clozapine (100 mg tab rapdis, 100 mg tablet) 1QL 9 / day
AL At least 18 yrs old
clozapine (12.5 mg tab rapdis, 25 mg tab rapdis, 50 mg tablet) 1QL 3 / day
AL At least 18 yrs old
clozapine (150 mg tab rapdis, 200 mg tab rapdis) 1 AL At least 18 yrs old
NUPLAZID 4
QL 2 / day
PA
S
PAGE 61 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
olanzapine (2.5 mg tablet, 5 mg tablet) 1 QL 6 / day
olanzapine 10 mg tablet 1 QL 3 / day
olanzapine 15 mg tablet 1 QL 2 / day
olanzapine 20 mg tablet 1 QL 1 / day
olanzapine 7.5 mg tablet 1 QL 4 / day
olanzapine 10 mg tab rapdis 3QL 3 / day
HCG
olanzapine 15 mg tab rapdis 3QL 2 / day
HCG
olanzapine 20 mg tab rapdis 3QL 1 / day
HCG
olanzapine 5 mg tab rapdis 3QL 6 / day
HCG
olanzapine 10 mg vial 1
paliperidone 3AL At least 12 yrs old
HCG
quetiapine fumarate (300 mg tab er 24h, 400 mg tab er 24h) 3
QL 2 / day
AL At least 10 yrs old
HCG
quetiapine fumarate 150 mg tab er 24h 3
QL 5 / day
AL At least 10 yrs old
HCG
quetiapine fumarate 200 mg tab er 24h 3
QL 4 / day
AL At least 10 yrs old
HCG
quetiapine fumarate 50 mg tab er 24h 3
QL 6 / day
AL At least 10 yrs old
HCG
PAGE 62 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
quetiapine fumarate (25 mg tablet, 50 mg tablet) 1QL 6 / day
AL At least 10 yrs old
quetiapine fumarate 100 mg tablet 1QL 3 / day
AL At least 10 yrs old
quetiapine fumarate 200 mg tablet 1QL 1.5 / day
AL At least 10 yrs old
quetiapine fumarate 300 mg tablet 1QL 1 / day
AL At least 10 yrs old
quetiapine fumarate 400 mg tablet 1QL 2 / day
AL At least 10 yrs old
risperidone 1 mg/ml solution 1QL 16/day
AL At least 5 yrs old
risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mgtablet) 1
QL 8 / day
AL At least 5 yrs old
risperidone 3 mg tablet 1QL 5 / day
AL At least 5 yrs old
risperidone 4 mg tablet 1QL 4 / day
AL At least 5 yrs old
risperidone (0.25 mg tab rapdis, 0.5 mg tab rapdis, 1 mg tabrapdis, 2 mg tab rapdis) 3
QL 8 / day
AL At least 5 yrs old
HCG
risperidone 3 mg tab rapdis 3
QL 5 / day
AL At least 5 yrs old
HCG
risperidone 4 mg tab rapdis 3
QL 4 / day
AL At least 5 yrs old
HCG
PAGE 63 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SEROQUEL XR SAMPLE KIT 2 AL At least 10 yrs old
SEROQUEL XR (300 MG TABLET, 400 MG TABLET) 2QL 2 / day
AL At least 10 yrs old
SEROQUEL XR 150 MG TABLET 2QL 5 / day
AL At least 10 yrs old
SEROQUEL XR 200 MG TABLET 2QL 4 / day
AL At least 10 yrs old
SEROQUEL XR 50 MG TABLET 2QL 6 / day
AL At least 10 yrs old
ziprasidone hcl 1QL 2 / day
AL At least 18 yrs old
BUTYROPHENONES
haloperidol (0.5 mg tablet, 2 mg tablet, 5 mg tablet, 10 mgtablet, 20 mg tablet) 1
haloperidol 1 mg tablet 1 LCG
haloperidol decanoate 50 mg/ml ampul 1
haloperidol decanoate (50 mg/ml vial, 100 mg/ml ampul, 100mg/ml vial) 1
haloperidol lactate 5 mg/ml ampul 1
haloperidol lactate 2 mg/ml oral conc 1
haloperidol lactate 5 mg/ml vial 1
PHENOTHIAZINES
chlorpromazine hcl 25 mg/ml ampul 1
chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet,100 mg tablet, 200 mg tablet) 3 HCG
fluphenazine decanoate 25 mg/ml vial 1
fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5ml elixir,5 mg tablet, 5 mg/ml oral conc, 10 mg tablet) 1
PAGE 64 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fluphenazine hcl 2.5 mg/ml vial 1
perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet, 16 mgtablet) 1 AL At least 18 yrs old
thioridazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100mg tablet) 1
trifluoperazine hcl 1
THIOXANTHENES
thiothixene 1
ANTIRETROVIRALS
HIV ENTRY AND FUSION INHIBITORS
FUZEON 4QL 2 / day
S
SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 75 MGTABLET, 150 MG TABLET, 300 MG TABLET) 4
S
PS
HIV INTEGRASE INHIBITORS
GENVOYA 4 S
ISENTRESS 100 MG POWDER PACKET 4S
PS
ISENTRESS (25 MG TABLET CHEW, 100 MG TABLET CHEW, 400MG TABLET) 4
S
PS
ISENTRESS HD 4S
PS
STRIBILD 4 S
TIVICAY 4 S
TRIUMEQ 4 S
PAGE 65 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.
ATRIPLA 4S
PS
COMPLERA 4S
PS
EDURANT 4S
PS
INTELENCE 4S
PS
nevirapine (50 mg/5 ml oral susp, 100 mg tab er 24h, 200 mgtablet, 400 mg tab er 24h) 4 S
ODEFSEY 4 S
RESCRIPTOR (100 MG TABLET, 200 MG TABLET) 4 S
SUSTIVA (50 MG CAPSULE, 200 MG CAPSULE, 600 MG TABLET) 4 S
VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) 4 S
VIRAMUNE XR 4 S
HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORS
abacavir sulfate (20 mg/ml solution, 300 mg tablet) 4 S
abacavir sulfate/lamivudine 4 S
abacavir sulfate/lamivudine/zidovudine 4 S
COMBIVIR 4 S
DESCOVY 4QL 1 / day
S
didanosine 4 S
EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 4S
PS
PAGE 66 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MGTABLET) 4 S
EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET) 4 S
EPZICOM 4 S
lamivudine 10 mg/ml solution 4 S
lamivudine (150 mg tablet, 300 mg tablet) 4 S
lamivudine 100 mg tablet 4 S
lamivudine/zidovudine 4 S
RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE) 4 S
stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule,30 mg capsule, 40 mg capsule) 4 S
TRIZIVIR 4 S
TRUVADA 4S
PS
VIDEX 4S
PS
VIDEX EC 4 S
VIREAD POWDER 4 S
VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300MG TABLET) 4
S
PS
ZERIT (1 MG/ML SOLUTION, 15 MG CAPSULE, 20 MG CAPSULE,30 MG CAPSULE, 40 MG CAPSULE) 4 S
ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) 4 S
zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet) 4 S
PAGE 67 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HIV PROTEASE INHIBITORS
APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 4S
PS
CRIXIVAN 4S
PS
EVOTAZ 4 S
fosamprenavir calcium 4 S
INVIRASE (200 MG CAPSULE, 500 MG TABLET) 4S
PS
KALETRA (80 MG-20 MG/ML SOLN, 100-25 MG TABLET, 200-50MG TABLET) 4 S
LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 4 S
lopinavir/ritonavir 4S
PS
NORVIR (80 MG/ML SOLUTION, 100 MG SOFTGEL CAP, 100 MGTABLET) 4 S
PREZCOBIX 4 S
PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MGTABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET) 4
S
PS
REYATAZ (150 MG CAPSULE, 200 MG CAPSULE, 300 MGCAPSULE) 4
S
PS
REYATAZ 50 MG POWDER PACKET 4S
PS
TECHNIVIE 4
QL 2 / day
PA
S
VIEKIRA PAK 4
QL 4 / day
PA
S
PAGE 68 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VIEKIRA XR 4
QL 3 / day
PA
S
VIRACEPT 4S
PS
ANTITHROMBOTIC AGENTS
PLATELET-AGGREGATION INHIBITORS
aspirin/caffeine/dihydrocodeine bitartrate 1QL 10 / day
AL At least 18 yrs old
aspirin/dipyridamole 3QL 2 / day
HCG
BRILINTA 2 QL 2 / day
butalbital/aspirin/caffeine 50-325-40 capsule 1 QL 6 / day
cilostazol 1 QL 2 / day
clopidogrel bisulfate (75 mg tablet, 300 mg tablet) 1 QL 1 / day
dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1 QL 4 / day
prasugrel hcl 1 QL 1 / day
ticlopidine hcl 1 QL 2 / day
PLATELET-REDUCING AGENTS
anagrelide hcl 1 QL 4 / day
THROMBOLYTIC AGENTS
CATHFLO ACTIVASE 4 S
PAGE 69 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES
ANTITOXINS AND IMMUNE GLOBULINS
antivenin,latrodectus mactans 1
antivenin,micrurus fulvius 1
CUVITRU 4PA
S
GAMMAGARD LIQUID 4PA
S
GAMMAKED 4PA
S
GAMUNEX-C 4PA
S
HIZENTRA 4PA
S
HYPERHEP B S-D (NEONATAL SYRIN., SYRINGE, VIAL) 4 S
HYPERRAB S-D 4 S
HYPERTET S-D 4 S
HYQVIA 4PA
S
HYQVIA IG COMPONENT 4PA
S
IMOGAM RABIES-HT 4 S
NABI-HB 4 S
VARIZIG (125 UNIT VIAL, 125 UNIT/1.2 ML VIAL) 4 S
PAGE 70 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TOXOIDS
ADACEL TDAP (SYRINGE, VIAL) 0 HCR
BOOSTRIX TDAP (SYRINGE, VIAL) 0 HCR
DAPTACEL DTAP 0 HCR
INFANRIX DTAP (SYRINGE, VIAL) 2
PEDIARIX 2
TENIVAC (SYRINGE, VIAL) 0 HCR
tetanus and diphtheria toxoids, adult 0 HCR
tetanus,diphtheria toxoid ped/pf 1
VACCINES
ACTHIB VACCINE WITH DILUENT 2
AFLURIA 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 0 HCR
AFLURIA QUAD 2016-2017 (2016-2017 SYRINGE, 2016-2017VIAL) 0 HCR
BEXSERO 2
BIOTHRAX 2
CERVARIX 0 HCR
ENGERIX-B ADULT (20 MCG/ML SYRN, 20 MCG/ML VIAL) 0 HCR
ENGERIX-B PEDIATRIC-ADOLESCENT (10 MCG/0.5 ML PED VL,PEDI 10 MCG/0.5 SYRN) 0 HCR
EZ FLU 16-17 (FLUZON QUAD PED) 0 HCR
EZ FLU 2016-2017 (AFLURIA) 0 HCR
EZ FLU 2016-2017 (FLUVIRIN) 0 HCR
FLUAD 2016-2017 0 HCR
FLUARIX QUAD 2016-2017 0 HCR
PAGE 71 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FLUBLOK 2016-2017 0 HCR
FLUCELVAX QUAD 2016-2017 0 HCR
FLULAVAL QUAD 2016-2017 (2016-2017 SYR, 2016-2017VIAL) 0 HCR
FLUVIRIN 2016-2017 (2016-2017 SYRINGE, 2016-2017 VIAL) 0 HCR
FLUZONE HIGH-DOSE 2016-2017 0 HCR
FLUZONE INTRADERM QUAD 2016-17 0 HCR
FLUZONE QUAD 2016-2017 (2016-2017 SYRINGE, 2016-2017VIAL) 0 HCR
FLUZONE QUAD PEDI 2016-2017 0 HCR
GARDASIL (SYRINGE, VIAL) 0 HCR
GARDASIL 9 (9 SYRINGE, 9 VIAL) 0 HCR
HAVRIX (720 UNIT/0.5 ML SYRINGE, 720 UNITS/0.5 ML VIAL,1,440 UNITS/ML SYRINGE, 1,440 UNITS/ML VIAL) 0 HCR
HIBERIX VACCINE WITH DILUENT 2
IMOVAX RABIES VACCINE 2
IPOL VIAL 2
IXIARO 2
KINRIX (TIP-LOK SYRINGE, VIAL) 2
M-M-R II VACCINE 0 HCR
MENACTRA 0 HCR
MENHIBRIX 2
MENOMUNE-A-C-Y-W-135 0 HCR
MENVEO A-C-Y-W-135-DIP 0 HCR
MENVEO MENA COMPONENT 2
MENVEO MENCYW-135 COMPONENT 2
PAGE 72 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PEDVAXHIB 2
PENTACEL 2
PENTACEL DTAP-IPV COMPONENT 2
PNEUMOVAX 23 (23 SYRINGE, 23 VIAL) 0 HCR
PREVNAR 13 0 HCR
PROQUAD 2
QUADRACEL DTAP-IPV 2
RABAVERT 2
RECOMBIVAX HB (5 MCG/0.5 ML SYR, 5 MCG/0.5 ML VL, 10MCG/ML SYR, 10 MCG/ML VIAL, 40 MCG/ML VIAL) 0 HCR
ROTARIX 2
ROTATEQ 2
STAMARIL 2
THERACYS 4 S
TWINRIX (SYRINGE, VIAL) 0 HCR
TYPHIM VI (25 MCG/0.5 ML AL, 25 MCG/0.5 ML SYRNG) 2
VAQTA (25 UNITS/0.5 ML SYRINGE, 25 UNITS/0.5 ML VIAL, 50UNITS/ML SYRINGE, 50 UNITS/ML VIAL) 0 HCR
VARIVAX VACCINE 0 HCR
VAXCHORA ACTIVE COMPONENT 2
VAXCHORA VACCINE 2
VIVOTIF 2
VIVOTIF BERNA 2
YF-VAX 2
ZOSTAVAX 0 HCR
PAGE 73 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIULCER AGENTS AND ACID SUPPRESSANTS
HISTAMINE H2-ANTAGONISTS
cimetidine (200 mg tablet, 300 mg tablet, 400 mg tablet, 800mg tablet) 1
cimetidine hcl 1
famotidine (20 mg tablet, 40 mg tablet, 40mg/5ml oral susp) 1
nizatidine 150 mg capsule 1 QL 2 / day
nizatidine (150mg/10ml solution, 300 mg capsule) 1
ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 mg tablet,300 mg capsule, 300 mg tablet) 1
ranitidine hcl (25 mg/ml vial, 50 mg/2 ml vial) 1
PROSTAGLANDINS
diclofenac sodium/misoprostol (sodium/misoprostol 50 tab irdr, sodium/misoprostol 75 tab ir dr) 1
misoprostol (100 mcg tablet, 200 mcg tablet) 1
PROTECTANTS
CARAFATE 1 GM/10 ML SUSP 2
sucralfate 1 g tablet 1
PROTON-PUMP INHIBITORS
esomeprazole magnesium 20 mg capsule dr 1 QL 1 / day
esomeprazole magnesium 40 mg capsule dr 3QL 1 / day
HCG
esomeprazole strontium 1 QL 1 / day
lansoprazole 15 mg capsule dr 1
lansoprazole 30 mg capsule dr 1 QL 1 / day
lansoprazole/amoxicillin trihydrate/clarithromycin 3QL 112 / 365 days
HCG
PAGE 74 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
omeprazole (10 mg capsule dr, 20 mg capsule dr, 40 mg capsuledr) 1 QL 1 / day
omeprazole/sodium bicarbonate 40mg-1.1g capsule 3 HCG
omeprazole/sodium bicarbonate (omeprazole/sodium 20-1680mg packet, omeprazole/sodium 20mg-1.1g capsule,omeprazole/sodium 40-1680mg packet)
1
pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr) 1QL 1 / day
LCG
rabeprazole sodium 1 QL 2 / day
ANTIVIRALS (SYSTEMIC)
ADAMANTANES
rimantadine hcl 1
INTERFERONS
INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 18MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50 MILLION UNITSVIL)
4PA
S
PEGASYS (180 MCG/0.5 ML SYRINGE, 180 MCG/ML VIAL) 4PA
S
PEGASYS PROCLICK 4PA
S
PEGINTRON 4
PA
S
PS
PEGINTRON REDIPEN 4
PA
S
PS
SYLATRON 4PA
S
PAGE 75 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NEURAMINIDASE INHIBITORS
oseltamivir phosphate (30 mg capsule, 45 mg capsule, 75 mgcapsule) 1 QL 20 / 365 days
NUCLEOSIDES AND NUCLEOTIDES
acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mgtablet, 800 mg tablet) 1
adefovir dipivoxil 4 S
BARACLUDE 0.05 MG/ML SOLUTION 4
QL 20 / day
PA
S
BARACLUDE (0.5 MG TABLET, 1 MG TABLET) 4
QL 1 / day
PA
S
COPEGUS 4
QL 6 / day
PA
S
entecavir 4QL 1 / day
S
famciclovir 1
HEPSERA 4
QL 1 / day
PA
S
MODERIBA (200-400 MG DOSEPACK, 400-400 MG DOSEPACK,600-400 MG DOSEPACK, 600-600 MG DOSEPACK) 4
QL 2 / day
PA
S
MODERIBA 200 MG TABLET 4
QL 6 / day
PA
S
PAGE 76 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
REBETOL 200 MG CAPSULE 4
QL 6 / day
PA
S
REBETOL 40 MG/ML SOLUTION 4
QL 30 / day
PA
S
RIBASPHERE (200 MG CAPSULE, 200 MG TABLET) 4
QL 6 / day
PA
S
RIBASPHERE 400 MG TABLET 4
QL 3 / day
PA
S
RIBASPHERE 600 MG TABLET 4
QL 2 / day
PA
S
RIBASPHERE RIBAPAK 4
QL 2 / day
PA
S
RIBATAB 4
QL 2 / day
PA
S
ribavirin (200 mg capsule, 200 mg tablet) 4
QL 6 / day
PA
S
ribavirin 6 g vial-neb 1
TYZEKA 4
QL 1 / day
PA
S
PAGE 77 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
valacyclovir hcl (500 mg tablet, 1000 mg tablet) 3 HCG
valganciclovir hcl 50 mg/ml soln recon 1
valganciclovir hcl 450 mg tablet 1 QL 4 / day
VEMLIDY 4
QL 1 / day
PA
AL At least 18 yrs old
S
ANXIOLYTICS, SEDATIVES AND HYPNOTICS
ANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC
buspirone hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mgtablet, 30 mg tablet) 1
droperidol (2.5 mg/ml ampul, 2.5 mg/ml vial) 1
eszopiclone (1 mg tablet, 2 mg tablet) 1 QL 1 / day
eszopiclone 3 mg tablet 1QL 1 / day
AL Up to 65 yrs old
HETLIOZ 4
QL 1 / day
PA
S
hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mgtablet, 50 mg tablet, 50 mg/25ml solution) 1 AL At least 2 yrs old
hydroxyzine hcl (25 mg/ml vial, 50 mg/ml vial) 1 AL At least 2 yrs old
hydroxyzine pamoate (25 mg capsule, 50 mg capsule) 1 AL At least 2 yrs old
hydroxyzine pamoate 100 mg capsule 1
meprobamate 1
PHENADOZ 1 AL At least 2 yrs old
PHENERGAN (12.5 MG, 25 MG, 50 MG) 1 AL At least 2 yrs old
promethazine hcl (12.5 mg supp.rect, 25 mg supp.rect, 50 mgsupp.rect) 1 AL At least 2 yrs old
PAGE 78 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PROMETHEGAN 1 AL At least 2 yrs old
zaleplon 1 QL 1 / day
zolpidem tartrate (1.75 mg tab subl, 3.5 mg tab subl, 5 mgtablet, 6.25 mg tab mphase, 10 mg tablet, 12.5 mg tab mphase) 1 QL 1 / day
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
pentobarbital sodium 50 mg/ml vial 1
BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)
alprazolam (0.5 mg tab er 24h, 1 mg tab er 24h) 1 QL 1 / day
alprazolam (2 mg tab er 24h, 2 mg tab rapdis, 2 mg tablet) 1 QL 5 / day
alprazolam 3 mg tab er 24h 1 QL 3 / day
alprazolam (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tabrapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet) 1 QL 4 / day
chlordiazepoxide hcl 10 mg capsule 1 QL 30 / day
chlordiazepoxide hcl 25 mg capsule 1 QL 12 / day
chlordiazepoxide hcl 5 mg capsule 1 QL 4 / day
estazolam 1 QL 1 / day
flurazepam hcl 1 QL 1 / day
midazolam hcl 2 mg/ml syrup 1
midazolam hcl (2 mg/2 ml vial, 5 mg/5 ml vial, 5 mg/ml vial, 5mg/ml(1) vial, 10 mg/10ml vial, 10 mg/2 ml vial) 1
midazolam hcl/pf (hcl/pf 2 mg/2 ml vial, hcl/pf 5 mg/5 ml vial,hcl/pf 5 mg/ml syringe, hcl/pf 5 mg/ml(1) vial, hcl/pf 10 mg/2ml vial)
1
oxazepam 1 QL 4 / day
quazepam 1 QL 1 / day
temazepam 1 QL 1 / day
triazolam 0.125 mg tablet 1 QL 1 / day
PAGE 79 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
triazolam 0.25 mg tablet 1 QL 2 / day
AUTONOMIC DRUGS
AUTONOMIC DRUGS, MISCELLANEOUS
CHANTIX STARTING MONTH BOX 0 HCR
CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 MGTABLET) 0
QL 2 / day
HCR
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
bethanechol chloride (5 mg tablet, 10 mg tablet, 25 mg tablet,50 mg tablet) 1
cevimeline hcl 3 HCG
donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tab rapdis,10 mg tablet, 23 mg tablet) 1 AL At least 40 yrs old
galantamine hbr (8 mg cap24h pel, 16 mg cap24h pel, 24 mgcap24h pel) 3 HCG
galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg tablet, 12mg tablet) 1
guanidine hcl 1
MESTINON 60 MG/5 ML SYRUP 2
physostigmine salicylate 1
pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1
pyridostigmine bromide (60 mg tablet, 180 mg tablet er) 1
rivastigmine 1 AL At least 40 yrs old
rivastigmine tartrate 1 AL At least 40 yrs old
BETA-3-ADRENERGIC AGONISTS
SELECTIVE BETA-3-ADRENERGIC AGONISTS
MYRBETRIQ 2 QL 1 / day
PAGE 80 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BETA-ADRENERGIC BLOCKING AGENTS(SYMPATH)
NON-SEL. BETA-ADRENERGIC BLOCKING AGENTS
BYSTOLIC (5 MG TABLET, 10 MG TABLET) 2 QL 3 / day
BYSTOLIC 2.5 MG TABLET 2 QL 1 / day
BYSTOLIC 20 MG TABLET 2 QL 2 / day
BYVALSON 2 QL 1 / day
BLOOD FORMATION, COAGULATION, THROMBOSIS
HEMATOPOIETIC AGENTS
ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42 ML SYRING,25 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 40 MCG/ML VIAL,60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, 100 MCG/0.5 MLSYRINGE, 100 MCG/ML VIAL, 150 MCG/0.3 ML SYRINGE, 150MCG/0.75 ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/MLVIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 500MCG/1 ML SYRINGE)
4
PA
S
PS
EPOGEN 4PA
S
GRANIX 4PA
S
LEUKINE 4PA
S
MIRCERA 4PA
S
MOZOBIL 4PA
S
NEULASTA (6 MG/0.6 ML SYRINGE, ONPRO 6 MG/0.6 ML KIT) 4
PA
S
PS
PAGE 81 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL, 480MCG/0.8 ML SYR, 480 MCG/1.6 ML VIAL) 4
PA
S
PS
PROCRIT 4
PA
S
PS
PROMACTA 4PA
S
ZARXIO 4
QL 90 / 30 days
PA
S
HEMORRHEOLOGIC AGENTS
pentoxifylline 400 mg tablet er 1
BRONCHODILATORS
XANTHINE DERIVATIVES
THEOCHRON 1
theophylline anhydrous (80 mg/15ml elixir, 80 mg/15mlsolution, 100 mg tab er 12h, 200 mg tab er 12h, 300 mg tab er12h, 400 mg tab er 24h, 450 mg tab er 12h, 600 mg tab er 24h)
1
CALCIUM-CHANNEL BLOCKING AGENTS
DIHYDROPYRIDINES
felodipine 1 QL 1 / day
isradipine 1 QL 2 / day
nisoldipine 3QL 1 / day
HCG
PAGE 82 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CALCIUM-CHANNEL BLOCKING AGENTS(HYPOTEN)
CALCIUM-CHANNEL BLOCK.AGT,MISC(HYPOTEN)
trandolapril/verapamil hcl 1
DIHYDROPYRIDINES (HYPOTENSIVE AGENTS)
AFEDITAB CR 30 MG TABLET 1 QL 1 / day
AFEDITAB CR 60 MG TABLET 1 QL 2 / day
amlodipine besylate (2.5 mg tablet, 5 mg tablet, 10 mg tablet) 1 QL 1 / day
amlodipine besylate/benazepril hcl 1 QL 1 / day
amlodipine besylate/olmesartan medoxomil 3QL 1 / day
HCG
amlodipine besylate/valsartan (besylate/valsartan 5 mg-320mgtablet, besylate/valsartan 10mg-160mg tablet,besylate/valsartan 10mg-320mg tablet)
1 QL 1 / day
amlodipine besylate/valsartan 5 mg-160mg tablet 1 QL 2 / day
amlodipine besylate/valsartan/hydrochlorothiazide 3QL 1 / day
HCG
nicardipine hcl (20 mg capsule, 30 mg capsule) 3 HCG
NIFEDICAL XL 1 QL 1 / day
nifedipine (10 mg capsule, 20 mg capsule) 1 QL 4 / day
nifedipine (30 mg tab er 24, 30 mg tablet er, 90 mg tab er 24,90 mg tablet er) 1 QL 1 / day
nifedipine (60 mg tab er 24, 60 mg tablet er) 1 QL 2 / day
nimodipine 30 mg capsule 1
PAGE 83 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CARDIAC DRUGS
CARDIAC DRUGS, MISCELLANEOUS
CORLANOR 2QL 2 / day
ST
RANEXA 2 QL 2 / day
CARDIOVASCULAR DRUGS
CALCIUM-CHANNEL BLOCKING AGENTS
telmisartan/amlodipine besylate 1 QL 1 / day
CENTRAL NERVOUS SYSTEM AGENTS
ANTIMANIC AGENTS
lithium carbonate (150 mg capsule, 300 mg capsule, 300 mgtablet, 300 mg tablet er, 450 mg tablet er, 600 mg capsule) 1
lithium citrate 1
CENTRAL NERVOUS SYSTEM AGENTS, MISC.
acamprosate calcium 3 HCG
atomoxetine hcl 1QL 2 / day
AL At least 6 yrs old
AUSTEDO 4
QL 4 / day
PA
AL At least 18 yrs old
S
carbidopa 25 mg tablet 1
guanfacine hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 mg tab er24h, 4 mg tab er 24h) 1
guanfacine hcl (1 mg tablet, 2 mg tablet) 1
INGREZZA 40 MG CAPSULE 4
QL 2 / day
PA
AL At least 18 yrs old
S
PAGE 84 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
memantine hcl 2 mg/ml solution 1QL 360 / 30 days
AL At least 40 yrs old
memantine hcl 5 mg-10 mg tab ds pk 1 AL At least 40 yrs old
memantine hcl 10 mg tablet 1QL 2 / day
AL At least 40 yrs old
memantine hcl 5 mg tablet 1QL 3 / day
AL At least 40 yrs old
NUEDEXTA 2 PA
riluzole 1
tetrabenazine 4PA
S
XENAZINE 4PA
S
XYREM 4
QL 18 / day
PA
S
OPIATE ANTAGONISTS
DEPADE 1
naloxone hcl (0.4 mg/ml syringe, 0.4 mg/ml vial, 1 mg/mlsyringe) 1
naltrexone hcl 50 mg tablet 1
VIVITROL 380 MG VIAL 4PA
S
CEPHALOSPORINS
FIRST GENERATION CEPHALOSPORINS
cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule,500 mg/5ml susp recon) 1
PAGE 85 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
cefazolin sodium (10 g vial, 20 g vial, 100 g bulkbaginj, 300gbulkbaginj, 500 mg vial) 1
cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mgtablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg tablet,750 mg capsule)
1
FOURTH GENERATION CEPHALOSPORINS
cefepime hcl 1
SECOND GENERATION CEPHALOSPORINS
cefaclor (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5mlsusp recon, 375 mg/5ml susp recon, 500 mg capsule) 1
cefaclor 500 mg tab er 12h 1 QL 20 / 30 days
cefotetan disodium (1 g vial, 2 g vial) 1
cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5mlsusp recon, 500 mg tablet) 1
CEFTIN (125 MG/5 ML ORAL SUSP, 250 MG/5 ML ORAL SUSP) 2
cefuroxime axetil 1
cefuroxime sodium 750 mg vial 1
THIRD GENERATION CEPHALOSPORINS
cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300mg capsule) 1
cefditoren pivoxil 1
cefixime 3QL 1200 / 90 days
HCG
cefotaxime sodium 1
cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet,100 mg/5ml susp recon, 200 mg tablet) 1
ceftazidime (1 g vial, 2 g vial, 6 g vial) 1
ceftibuten (180 mg/5ml susp recon, 400 mg capsule) 3 HCG
ceftriaxone sodium (1 g vial, 2 g vial, 10 g vial, 100 gbulkbaginj, 250 mg vial, 500 mg vial) 1
PAGE 86 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TAZICEF (1 VIAL, 2 VIAL, 6 VIAL) 1
CORTICOSTEROIDS (RESPIRATORY TRACT)
ORALLY INHALED PREPARATIONS (STEROIDS)
AEROSPAN 2 QL 0.334 / day
ARNUITY ELLIPTA 100 MCG INH 2 QL 2 / day
ARNUITY ELLIPTA 200 MCG INH 2 QL 1 / day
budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1mg/2 ml ampul-neb) 1
FLOVENT 250 MCG DISKUS 2 QL 8 / day
FLOVENT DISKUS (50 MCG, 100 MCG) 2 QL 4 / day
FLOVENT HFA (HFA 110 MCG INHALER, HFA 220 MCG INHALER) 2 QL 0.8 / day
FLOVENT HFA 44 MCG INHALER 2 QL 0.767 / day
PULMICORT FLEXHALER 2 QL 0.07 / day
CYSTIC FIBROSIS (CFTR) MODULATORS
CYSTIC FIBROSIS (CFTR) CORRECTORS
ORKAMBI 4
QL 4 / day
PA
S
CYSTIC FIBROSIS (CFTR) POTENTIATORS
KALYDECO (50 MG GRANULES PACKET, 75 MG GRANULESPACKET, 150 MG TABLET) 4
QL 2 / day
PA
S
PAGE 87 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DEPIGMENTING AND PIGMENTING AGENTS
DEPIGMENTING AGENTS
ALPHAQUIN HP 1
BLANCHE 1
hydroquinone 4 % cream (g) 1
hydroquinone microspheres 1
MELPAQUE HP 1
PIGMENTING AGENTS
methoxsalen 10 mg cap lq rap 1
UVADEX 4 S
DIAGNOSTIC AGENTS
ADRENOCORTICAL INSUFFICIENCY
cosyntropin 0.25 mg vial 1
H.P. ACTHAR 4PA
S
CARDIAC FUNCTION
indocyanine green 1
KIDNEY FUNCTION
INDIGO CARMINE 1
indigotindisulfonate sodium in water for injection,sterile 1
OCULAR DISORDERS
BIOGLO 1
FLUCAINE 1
FLUOR-I-STRIP AT 1
FUL-GLO 1 MG OPTH STRIPS 1
proparacaine hcl/fluorescein sodium 1
PAGE 88 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ROENTGENOGRAPHY
MD-GASTROVIEW 1
DIURETICS
LOOP DIURETICS
bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1
bumetanide 0.25 mg/ml vial 1
ethacrynic acid 1
furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet,40mg/5ml solution, 80 mg tablet) 1
furosemide (10 mg/ml syringe, 10 mg/ml vial) 1
torsemide 1
OSMOTIC DIURETICS
mannitol/sorbitol solution 1
POTASSIUM-SPARING DIURETICS
amiloride hcl 1
amiloride hcl/hydrochlorothiazide 1
triamterene/hydrochlorothiazide(triamterene/hydrochlorothiazid 37.5-25 mg capsule,triamterene/hydrochlorothiazid 37.5-25 mg tablet,triamterene/hydrochlorothiazid 50 mg-25mg capsule,triamterene/hydrochlorothiazid 75 mg-50mg tablet)
1
THIAZIDE DIURETICS
chlorothiazide 1
hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet, 50 mgtablet) 1
hydrochlorothiazide 25 mg tablet 1 LCG
methyclothiazide 1
PAGE 89 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
THIAZIDE-LIKE DIURETICS
chlorthalidone 1
indapamide 1
metolazone 1
VASOPRESSIN ANTAGONISTS
SAMSCA 15 MG TABLET 4
QL 1 / day
PA
S
SAMSCA 30 MG TABLET 4
QL 2 / day
PA
S
DIURETICS (HYPOTENSIVE AGENTS)
POTASSIUM-SPARING DIURETICS (HYPOTEN)
eplerenone 3 HCG
spironolactone (25 mg tablet, 50 mg tablet, 100 mg tablet) 1
spironolactone/hydrochlorothiazide 1
THIAZIDE DIURETICS(HYPOTENSIVE AGENTS)
benazepril hcl/hydrochlorothiazide 1 QL 1 / day
candesartan cilexetil/hydrochlorothiazide(candesartan/hydrochlorothiazid 32-12.5mg tablet,candesartan/hydrochlorothiazid 32mg-25mg tablet)
1 QL 1 / day
candesartan/hydrochlorothiazid 16-12.5mg tablet 1 QL 2 / day
captopril/hydrochlorothiazide 1 QL 2 / day
enalapril/hydrochlorothiazide 10 mg-25mg tablet 1 QL 2 / day
enalapril/hydrochlorothiazide 5mg-12.5mg tablet 1
fosinopril sodium/hydrochlorothiazide 1 QL 2 / day
PAGE 90 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
irbesartan/hydrochlorothiazide 150-12.5mg tablet 1 QL 2 / day
irbesartan/hydrochlorothiazide 300-12.5mg tablet 1 QL 1 / day
lisinopril/hydrochlorothiazide (lisinopril/hydrochlorothiazide10-12.5mg tablet, lisinopril/hydrochlorothiazide 20-12.5 mgtablet)
1 QL 2 / day
lisinopril/hydrochlorothiazide (lisinopril/hydrochlorothiazide20 mg-25mg tablet, lisinopril/hydrochlorothiazide 20-25mgtablet)
1QL 2 / day
LCG
losartan potassium/hydrochlorothiazide(losartan/hydrochlorothiazide 100-12.5mg tablet,losartan/hydrochlorothiazide 100mg-25mg tablet)
1 QL 1 / day
losartan/hydrochlorothiazide 50-12.5 mg tablet 1 QL 2 / day
methyldopa/hydrochlorothiazide 1
moexipril hcl/hydrochlorothiazide 1 QL 2 / day
olmesartan medoxomil/amlodipinebesylate/hydrochlorothiazide 3
QL 1 / day
HCG
olmesartan medoxomil/hydrochlorothiazide 1 QL 1 / day
quinapril hcl/hydrochlorothiazide(quinapril/hydrochlorothiazide 10-12.5mg tablet,quinapril/hydrochlorothiazide 20-12.5 mg tablet)
1 QL 2 / day
quinapril/hydrochlorothiazide 20 mg-25mg tablet 1 QL 1 / day
telmisartan/hydrochlorothiazid 80-12.5mg tablet 3QL 2 / day
HCG
telmisartan/hydrochlorothiazide(telmisartan/hydrochlorothiazid 40-12.5 mg tablet,telmisartan/hydrochlorothiazid 80 mg-25mg tablet)
3QL 1 / day
HCG
valsartan/hydrochlorothiazide (valsartan/hydrochlorothiazide320-12.5mg tablet, valsartan/hydrochlorothiazide 320mg-25mg tablet)
1 QL 1 / day
PAGE 91 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
valsartan/hydrochlorothiazide (valsartan/hydrochlorothiazide80-12.5mg tablet, valsartan/hydrochlorothiazide 160-12.5mgtablet, valsartan/hydrochlorothiazide 160-25mg tablet)
1 QL 2 / day
DOPAMINE RECEPTOR AGONISTS
ERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS
bromocriptine mesylate (2.5 mg tablet, 5 mg capsule) 1
cabergoline 1
NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST
APOKYN 4PA
S
pramipexole di-hcl (0.375 mg tab er 24h, 0.75 mg tab er 24h,1.5 mg tab er 24h, 2.25 mg tab er 24h, 3 mg tab er 24h, 3.75 mgtab er 24h, 4.5 mg tab er 24h)
3 HCG
pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 mgtablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet) 1
ropinirole hcl (2 mg tab er 24h, 4 mg tab er 24h, 6 mg tab er24h, 8 mg tab er 24h, 12 mg tab er 24h) 1 QL 1 / day
ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mgtablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) 1
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ACIDIFYING AGENTS
PHOSPHA 250 NEUTRAL 1
VIRT-PHOS 250 NEUTRAL 1
ALKALINIZING AGENTS
citric acid/sodium citrate 1
CYTRA-2 1
CYTRA-K (CRYSTALS PACKET, ORAL SOLUTION) 1
potassium citrate 1
potassium citrate/citric acid 1100-334/5 solution 1
PAGE 92 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
sodium/potassium/potassium citrate/sodium citrate/cit ac 1
TARON-CRYSTALS 1
TRICITRATES 1
VIRTRATE-2 1
VIRTRATE-3 1
VIRTRATE-K 1
AMMONIA DETOXICANTS
BUPHENYL (500 MG TABLET, POWDER) 4 S
CARBAGLU 4 S
CONSTULOSE 1
ENULOSE 1
GENERLAC 1
KRISTALOSE 1
lactulose 1
RAVICTI 4
QL 20 / day
PA
S
sodium phenylbutyrate (0.94 g/g powder, 500 mg tablet) 4 S
CALORIC AGENTS
ACD 1
LYSIPLEX PLUS 1
REPLACEMENT PREPARATIONS
0.9 % sodium chloride 0.9 % syringe 1
0.9 % sodium chloride 0.9 % vial 1
bacteriostatic sodium chloride 1
cardioplegic solution no.1 1
PAGE 93 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EFFER-K 25 MEQ TABLET EFF 1
K EFFERVESCENT 1
K-SOL 1
KLOR-CON 20 MEQ PACKET 1
KLOR-CON 10 1
KLOR-CON 8 1
KLOR-CON M10 1
KLOR-CON M15 1
KLOR-CON M20 1
KLOR-CON SPRINKLE 1
KLOR-CON-EF 1
MONOJECT 0.9% SODIUM CHLORIDE 1
MONOJECT PREFILL 0.9% FLUSH 1
MONOJECT PREFILL ADVANCED 1
NEBUSAL 3% VIAL 1
potassium bicarbonate/citric acid 1
potassium chloride (8 meq capsule er, 8 meq tablet er, 10 meqcapsule er, 10 meq tab er prt, 10 meq tablet er, 20 meq packet,20 meq tab er prt, 20 meq tablet er, 20meq/15ml liquid,40meq/15ml liquid)
1
potassium chloride/potassium bicarbonate/citric acid 1
PULMOSAL 1
sodium chloride for inhalation 1
SYREX 1
SALT AND SUGAR SUBSTITUTES
saccharin 1
URICOSURIC AGENTS
probenecid 1 QL 4 / day
PAGE 94 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
probenecid/colchicine 1 QL 2 / day
EMOLLIENTS, DEMULCENTS, AND PROTECTANTS
BASIC LOTIONS AND LINIMENTS
ammonium lactate 12 % lotion 1
lactic acid 10 % lotion 1
BASIC OILS AND OTHER SOLVENTS
LUXAMEND 1
BASIC OINTMENTS AND PROTECTANTS
ammonium lactate 12 % cream (g) 1
lactic acid 10 % cream (g) 1
ESTROGENS AND ANTIESTROGENS
ESTROGEN AGONIST-ANTAGONISTS
clomiphene citrate 50 mg tablet 1 GL Female
DUAVEE 2
raloxifene hcl 0 HCR
SEROPHENE 1 GL Female
ESTROGENS
AMABELZ 1QL 1 / day
GL Female
CLIMARA PRO 2QL 0.15 / day
GL Female
COVARYX 1 GL Female
COVARYX H.S. 1 GL Female
DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 1 MG GELPACKET) 2 GL Female
PAGE 95 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EEMT 1 GL Female
EEMT H.S. 1 GL Female
ENJUVIA 2QL 1 / day
GL Female
ESTRACE 0.01% CREAM 2 GL Female
estradiol (.025mg/24h patch tdsw, .0375mg/24 patch tdsw,0.05mg/24h patch tdsw, .075mg/24h patch tdsw, 0.1mg/24hrpatch tdsw)
1QL 0.29 / day
GL Female
estradiol (.025mg/24h patch tdwk, 0.05mg/24h patch tdwk,0.1mg/24hr patch tdwk) 1
QL 0.15 / day
GL Female
estradiol (.0375mg/24 patch tdwk, 0.06mg/24h patch tdwk,.075mg/24h patch tdwk) 1
QL 0.15 / day
GL Female
estradiol (0.5 mg tablet, 1 mg tablet) 1
QL 1 / day
GL Female
LCG
estradiol 10 mcg tablet 1 GL Female
estradiol 2 mg tablet 1QL 1 / day
GL Female
estradiol valerate (20 mg/ml vial, 40 mg/ml vial) 1 GL Female
estradiol/norethindrone acetate 1QL 1 / day
GL Female
ESTRING 2QL 90 days
GL Female
estrogens,esterified/methyltestosterone 1 GL Female
estropipate 1
QL 1 / day
GL Female
LCG
PAGE 96 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FYAVOLV 1 GL Female
JINTELI 0
QL 1 / day
GL Female
HCR
LOPREEZA 1QL 1 / day
GL Female
MENEST 0.3 MG TABLET 2QL 1 / day
GL Female
MIMVEY 1QL 1 / day
GL Female
MIMVEY LO 1
norethindrone acetate-ethinyl estradiol (0.5mg-2.5 tablet, 1mg-5mcg tablet) 0 HCR
PREMARIN VAGINAL CREAM-APPL 2 GL Female
PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET,0.9 MG TABLET, 1.25 MG TABLET) 2
QL 1 / day
GL Female
PREMARIN 25 MG VIAL 2
PREMPHASE 2QL 1 / day
GL Female
PREMPRO 2QL 1 / day
GL Female
YUVAFEM 1 GL Female
EYE, EAR, NOSE AND THROAT (EENT) PREPS.
ANTIALLERGIC AGENTS
azelastine hcl 0.05 % drops 1 QL 0.267 / day
azelastine hcl (137 mcg spray/pump, 205.5 mcg spray/pump) 1 QL 2 / day
PAGE 97 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
epinastine hcl 1 QL 0.286 / day
olopatadine hcl (0.1 % drops, 0.2 % drops) 1 QL 0.286 / day
olopatadine hcl 0.6 % spray/pump 3QL 31 / 30 days
HCG
EENT DRUGS, MISCELLANEOUS
acetylcysteine in sterile water/pf 1 QL 10 / 30 days
apraclonidine hcl 1 QL 0.8 / day
balanced salt irrig soln no.2 1
BSS 1
CYSTARAN 4PA
S
ipratropium bromide (21 mcg spray, 42 mcg spray) 1 QL 2 / day
LUCENTIS (0.3 MG/0.05 ML VIAL, 0.5 MG/0.05 ML SYRING, 0.5MG/0.05 ML VIAL) 4
QL 0.04 / day
PA
S
OCUCOAT 1
LOCAL ANESTHETICS (EENT)
ALTACAINE 1
ALTAFLUOR 1
benoxinate hcl/fluorescein sodium 1
cocaine hcl 4 % solution 1
cyclopentolate hcl/lidocaine hcl/phenylephrine/tropicamide 1
FLUROX 1
GLYDO 1
lidocaine hcl (2 % jel/pf app, 2 % jelly(ml), 2 % solution, 40mg/ml solution) 1
PAGE 98 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
proparacaine hcl 0.5 % drops 1
TETCAINE 1
tetracaine hcl 0.5 % drops 1
tetracaine hcl/pf 0.5 % drops 1
TETRAVISC 1
TETRAVISC FORTE 1
MYDRIATICS
atropine sulfate (1 % drops, 1 % oint. (g)) 1
cyclopentolate hcl (0.5 % drops, 1 % drops, 2 % drops) 1
cyclopentolate hcl/tropicamide/phenylephrine hcl in water 1
HOMATROPAIRE 1
homatropine hbr 1
tropicamide (0.5 % drops, 1 % drops) 1
VASOCONSTRICTORS
naphazoline hcl 1
phenylephrine hcl (2.5 % drops, 10 % drops) 1
GASTROINTESTINAL DRUGS
ANTI-INFLAMMATORY AGENTS (GI DRUGS)
alosetron hcl 1GL Female
AL At least 18 yrs old
APRISO 2
balsalazide disodium 1
CANASA 2
LIALDA 2
mesalamine 4 g/60 ml enema 1
mesalamine 1.2 g tablet dr 3 HCG
mesalamine with cleansing wipes 1
PAGE 99 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIDIARRHEA AGENTS
FULYZAQ 4 S
loperamide hcl 2 mg capsule 1
MYTESI 4 S
opium tincture 1 QL 5 / day
paregoric 1
XERMELO 4
PA
AL At least 18 yrs old
S
CATHARTICS AND LAXATIVES
AMITIZA 2QL 2 / day
AL At least 18 yrs old
GAVILYTE-C 0 HCR
GAVILYTE-G 0 HCR
GAVILYTE-N 0 HCR
GOLYTELY PACKET 0 HCR
MOVIPREP 0 HCR
peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride 0 HCR
PEG-PREP 1
polyethylene glycol 3350 (3350 17g powd pack, 335017g/dose powder) 0 HCR
sodium chloride/nahco3/kcl/peg 420g soln recon 0 HCR
sorbitol solution 70 % solution 1
TRILYTE WITH FLAVOR PACKETS 0 HCR
PAGE 100 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CHOLELITHOLYTIC AGENTS
CHENODAL 4 S
ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 1
DIGESTANTS
CREON 2
ZENPEP 2
GI DRUGS, MISCELLANEOUS
CHOLBAM 250 MG CAPSULE 4
QL 7 / day
PA
S
CHOLBAM 50 MG CAPSULE 4
QL 4 / day
PA
S
CIMZIA (200 MG VIAL KIT, 200 MG/ML SYRINGE KIT) 4
QL 0.08 / day
PA
S
CIMZIA 200 MG/ML STARTER KIT 4
QL 3/ fill
PA
S
GATTEX 4PA
S
HUMIRA (20 MG/0.4 ML SYRINGE, 40 MG/0.8 ML SYRINGE) 4
QL 0.22 / day
PA
S
PS
HUMIRA 10 MG/0.2 ML SYRINGE 4
QL 0.15 / day
PA
S
PS
PAGE 101 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HUMIRA PEDIATRIC CROHN'S 4
QL 0.22 / day
PA
S
PS
HUMIRA PEN 4
QL 0.22 / day
PA
S
PS
HUMIRA PEN CROHN-UC-HS STARTER 4
QL 0.22 / day
PA
S
PS
HUMIRA PEN PSORIASIS-UVEITIS 4
QL 0.22 / day
PA
S
PS
LINZESS 2QL 1 / day
ST
OCALIVA 4
QL 1 / day
PA
S
VIBERZI 2QL 2 / day
PA
PROKINETIC AGENTS
metoclopramide hcl 10 mg/2 ml syringe 1
metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mgtablet, 10 mg/10ml solution) 1 LCG
metoclopramide hcl (5 mg tab rapdis, 10 mg tab rapdis) 1
PAGE 102 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
metoclopramide hcl 5 mg/ml vial 1 LCG
GENERAL ANESTHETICS
GENERAL ANESTHETICS, MISCELLANEOUS
ketamine hcl (10 mg/ml vial, 50 mg/ml vial, 100 mg/ml vial) 1
INHALATION ANESTHETICS
COMPOUND 347 1
isoflurane 1
sevoflurane 1
SOJOURN 1
TERRELL 1
GENITOURINARY SMOOTH MUSCLE RELAXANTS
ANTIMUSCARINICS
darifenacin hydrobromide 3QL 1 / day
HCG
flavoxate hcl 1
oxybutynin chloride 5 mg/5 ml syrup 1 QL 20 / day
oxybutynin chloride (10 mg tab er 24, 15 mg tab er 24) 1 QL 2 / day
oxybutynin chloride 5 mg tab er 24 1 QL 1 / day
oxybutynin chloride 5 mg tablet 1 QL 4 / day
tolterodine tartrate (2 mg cap er 24h, 4 mg cap er 24h) 3QL 1 / day
HCG
tolterodine tartrate (1 mg tablet, 2 mg tablet) 1 QL 2 / day
trospium chloride 60 mg cap er 24h 3QL 1 / day
HCG
trospium chloride 20 mg tablet 3QL 2 / day
HCG
PAGE 103 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VESICARE 2 QL 1 / day
HCV ANTIVIRALS
HCV POLYMERASE INHIBITORS
EPCLUSA 4
QL 1 / day
PA
S
PS
HARVONI 4
QL 1 / day
PA
S
PS
SOVALDI 4
QL 1 / day
PA
S
PS
HCV PROTEASE INHIBITORS
OLYSIO 4
QL 1 / day
PA
S
ZEPATIER 4
QL 1 / day
PA
S
HCV REPLICATION COMPLEX INHIBITORS
DAKLINZA 4
QL 1 / day
PA
S
PAGE 104 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
A-METHAPRED 1
betamethasone acetate/betamethasone sodium phosphate 1
budesonide 3 mg capdr - er 3 HCG
cortisone acetate 25 mg tablet 1
DELTASONE 1
dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5mlsolution, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet,4 mg tablet, 6 mg tablet)
1
DEXAMETHASONE INTENSOL 2
EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/ML ORALSUSP, 30 MG TABLET, 36 MG TABLET) 4
PA
AL At least 5 yrs old
S
fludrocortisone acetate 0.1 mg tablet 1
hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) 1
MEDROL 2 MG TABLET 2
methylprednisolone (4 mg tab ds pk, 4 mg tablet, 8 mg tablet,16 mg tablet, 32 mg tablet) 1
methylprednisolone acetate 1
methylprednisolone sodium succinate (40 mg vial, 125 mg vial) 1
prednisolone 1
prednisolone sod phosphate (5 mg/5 ml solution, 10 mg tabrapdis, 10 mg/5 ml solution, 15 mg tab rapdis, 15 mg/5 mlsolution, 20 mg/5 ml solution, 25 mg/5 ml solution, 30 mg tabrapdis)
1
prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab ds pk, 5 mgtablet, 5 mg/5 ml solution, 10 mg tab ds pk, 10 mg tablet, 20mg tablet, 50 mg tablet)
1
PREDNISONE INTENSOL 2
PAGE 105 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
triamcinolone acetonide (10 mg/ml vial, 40 mg/ml vial) 1
ANDROGENS
ANDRODERM 2
QL 1 / day
PA
GL Male
ANDROGEL (1.62% GEL PUMP, 1.62%(1.25G) GEL PCKT,1.62%(2.5G) GEL PCKT) 2
QL 5 / day
PA
GL Male
danazol (50 mg capsule, 100 mg capsule, 200 mg capsule) 1
methyltestosterone 10 mg capsule 1
oxandrolone (2.5 mg tablet, 10 mg tablet) 1PA
GL Male
testosterone cypionate (100 mg/ml vial, 200 mg/ml vial) 1 GL Male
testosterone enanthate 1PA
GL Male
CONTRACEPTIVES
ALTAVERA 0
QL 1 / day
GL Female
HCR
ALYACEN 0GL Female
HCR
AMETHIA 0
QL 91 days
GL Female
HCR
AMETHIA LO 0
QL 91 days
GL Female
HCR
PAGE 106 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AMETHYST 0
QL 1 / day
GL Female
HCR
APRI 0GL Female
HCR
ARANELLE 0GL Female
HCR
ASHLYNA 0GL Female
HCR
AUBRA 0
QL 1 / day
GL Female
HCR
AVIANE 0
QL 1 / day
GL Female
HCR
AZURETTE 0GL Female
HCR
BALZIVA 0GL Female
HCR
BEKYREE 0GL Female
HCR
BLISOVI 24 FE 0GL Female
HCR
BLISOVI FE 0GL Female
HCR
BRIELLYN 0GL Female
HCR
PAGE 107 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CAMILA 0GL Female
HCR
CAMRESE 0
QL 91 days
GL Female
HCR
CAMRESE LO 0
QL 91 days
GL Female
HCR
CAZIANT 0GL Female
HCR
CHATEAL 0
QL 1 / day
GL Female
HCR
CRYSELLE 0GL Female
HCR
CYCLAFEM 0GL Female
HCR
CYRED 0GL Female
HCR
DASETTA 0GL Female
HCR
DAYSEE 0
QL 91 days
GL Female
HCR
DEBLITANE 0GL Female
HCR
DELYLA 0
QL 1 / day
GL Female
HCR
PAGE 108 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
desogestrel-ethinyl estradiol 0.15-0.03 tablet 0GL Female
HCR
desogestrel-ethinyl estradiol/ethinyl estradiol 0GL Female
HCR
drospirenone/ethinyl estradiol/levomefolate calcium 0GL Female
HCR
ELINEST 0GL Female
HCR
ELLA 0
QL 1 / day
GL Female
HCR
EMOQUETTE 0GL Female
HCR
ENPRESSE 0GL Female
HCR
ENSKYCE 0GL Female
HCR
ERRIN 0GL Female
HCR
ESTARYLLA 0GL Female
HCR
ethinyl estradiol/drospirenone 0GL Female
HCR
ethynodiol diacetate-ethinyl estradiol 0GL Female
HCR
FALMINA 0
QL 1 / day
GL Female
HCR
PAGE 109 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FAYOSIM 0
QL 91 days
GL Female
HCR
FEMYNOR 0GL Female
HCR
GIANVI 0GL Female
HCR
GILDAGIA 0GL Female
HCR
GILDESS 0GL Female
HCR
GILDESS 24 FE 0GL Female
HCR
GILDESS FE 0GL Female
HCR
HEATHER 0GL Female
HCR
INTROVALE 0
QL 91 days
GL Female
HCR
ISIBLOOM 0GL Female
HCR
JENCYCLA 0GL Female
HCR
JOLESSA 0
QL 91 days
GL Female
HCR
PAGE 110 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
JOLIVETTE 0GL Female
HCR
JULEBER 0GL Female
HCR
JUNEL 0GL Female
HCR
JUNEL FE 0GL Female
HCR
JUNEL FE 24 0GL Female
HCR
KAITLIB FE 0GL Female
HCR
KARIVA 0GL Female
HCR
KELNOR 1-35 0GL Female
HCR
KIMIDESS 0GL Female
HCR
KURVELO 0
QL 1 / day
GL Female
HCR
LARIN 0GL Female
HCR
LARIN 24 FE 0GL Female
HCR
LARIN FE 0GL Female
HCR
PAGE 111 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LARISSIA 0
QL 1 / day
GL Female
HCR
LAYOLIS FE 0GL Female
HCR
LEENA 0GL Female
HCR
LESSINA 0
QL 1 / day
GL Female
HCR
LEVONEST 0GL Female
HCR
levonorgestrel 0
QL 0.07 / day
GL Female
HCR
levonorgestrel-ethin estradiol 0.15-0.03 tablet 0
QL 91 days
GL Female
HCR
levonorgestrel-ethin estradiol 6-5-10 tablet 0GL Female
HCR
levonorgestrel-ethinyl estradiol (0.1-0.02 tablet, 90-20 mcgtablet) 0
QL 1 / day
GL Female
HCR
levonorgestrel-ethin estradiol 0.15-0.03 tbdspk 3mo 0
QL 91 days
GL Female
HCR
l-norgest/e.estradiol-e.estrad 150-30(84) tbdspk 3mo 0GL Female
HCR
PAGE 112 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
levonorgestrel/ethinyl estradiol and ethinyl estradiol (l-norgest/e.estradiol-e.estrad 0.15mg(84) tbdspk 3mo, l-norgest/e.estradiol-e.estrad 100-20(84) tbdspk 3mo)
0
QL 91 days
GL Female
HCR
LEVORA-28 0
QL 1 / day
GL Female
HCR
LILLOW 0
QL 1 / day
GL Female
HCR
LO LOESTRIN FE 0GL Female
HCR
LOESTRIN FE 1.5-30 TABLET 0GL Female
HCR
LOMEDIA 24 FE 0GL Female
HCR
LORYNA 0GL Female
HCR
LOW-OGESTREL 0GL Female
HCR
LUTERA 0
QL 1 / day
GL Female
HCR
LYZA 0GL Female
HCR
MARLISSA 0
QL 1 / day
GL Female
HCR
PAGE 113 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MELODETTA 24 FE 0GL Female
HCR
MIBELAS 24 FE 0GL Female
HCR
MICROGESTIN 0GL Female
HCR
MICROGESTIN 24 FE 0GL Female
HCR
MICROGESTIN FE 0GL Female
HCR
MONO-LINYAH 0GL Female
HCR
MONONESSA 0GL Female
HCR
MYZILRA 0GL Female
HCR
NATAZIA 2 GL Female
NECON (0.5-35-28 TABLET, 1-35-28 TABLET, 1-50-28 TABLET,10-11-28 TABLET) 0
GL Female
HCR
NECON 7-7-7-28 TABLET 1
QL 1 / day
GL Female
HCR
NIKKI 0GL Female
HCR
NORA-BE 0GL Female
HCR
PAGE 114 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
norethindrone 0.35 mg tablet 0GL Female
HCR
norethindrone ac-eth estradiol 1mg-20mcg tablet 0GL Female
HCR
norethindrone acetate-ethinyl estradiol/ferrous fumarate (1mg-20(21) tablet, 1mg-20(24) tab chew, 1mg-20(24) tablet) 0
GL Female
HCR
norethindrone-ethinyl estradiol/ferrous fumarate 0GL Female
HCR
norgestimate-ethinyl estradiol 0GL Female
HCR
NORINYL 1+50 0GL Female
HCR
NORLYDA 0GL Female
HCR
NORLYROC 0GL Female
HCR
NORTREL 0GL Female
HCR
NUVARING 0GL Female
HCR
OCELLA 0GL Female
HCR
OGESTREL 0
QL 1 / day
GL Female
HCR
ORSYTHIA 0
QL 1 / day
GL Female
HCR
PAGE 115 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PHILITH 0GL Female
HCR
PIMTREA 0GL Female
HCR
PIRMELLA 0GL Female
HCR
PORTIA 0
QL 1 / day
GL Female
HCR
PREVIFEM 0GL Female
HCR
QUASENSE 0
QL 91 days
GL Female
HCR
RAJANI 0GL Female
HCR
RECLIPSEN 0GL Female
HCR
RIVELSA 0
QL 91 days
GL Female
HCR
SETLAKIN 0
QL 91 days
GL Female
HCR
SHAROBEL 0GL Female
HCR
SPRINTEC 0GL Female
HCR
PAGE 116 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SRONYX 0
QL 1 / day
GL Female
HCR
SYEDA 0GL Female
HCR
TARINA FE 0GL Female
HCR
TAYTULLA 0GL Female
HCR
TILIA FE 0GL Female
HCR
TRI FEMYNOR 0GL Female
HCR
TRI-ESTARYLLA 0GL Female
HCR
TRI-LEGEST FE 0GL Female
HCR
TRI-LINYAH 0GL Female
HCR
TRI-LO-ESTARYLLA 0GL Female
HCR
TRI-LO-MARZIA 0GL Female
HCR
TRI-LO-SPRINTEC 0GL Female
HCR
TRI-PREVIFEM 0GL Female
HCR
PAGE 117 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRI-SPRINTEC 0GL Female
HCR
TRINESSA 0GL Female
HCR
TRINESSA LO 0GL Female
HCR
TRIVORA-28 0GL Female
HCR
VELIVET 0GL Female
HCR
VESTURA 0GL Female
HCR
VIENVA 0
QL 1 / day
GL Female
HCR
VIORELE 0GL Female
HCR
VYFEMLA 0GL Female
HCR
WERA 0GL Female
HCR
WYMZYA FE 0GL Female
HCR
XULANE 0
QL 0.12 / day
GL Female
HCR
PAGE 118 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZARAH 0GL Female
HCR
ZENCHENT 0GL Female
HCR
ZENCHENT FE 0GL Female
HCR
ZEOSA 0GL Female
HCR
ZOVIA 1-35E 0GL Female
HCR
ZOVIA 1-50E 0GL Female
HCR
GONADOTROPINS
BRAVELLE 4
PA
GL Female
S
PS
chorionic gonadotropin, human (1mm unit powder(ea), 2mmunit powder(ea), 5mm unit powder(ea), 10mm unit powder(ea),10000 unit vial)
4 S
ELIGARD 4PA
S
FOLLISTIM AQ (75 UNIT VIAL, 300 UNIT CARTRIDG, 600 UNITCARTRIDG, 900 UNIT CARTRIDG) 4
PA
S
GONAL-F 4
PA
S
PS
PAGE 119 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GONAL-F RFF 4
PA
GL Female
S
PS
GONAL-F RFF REDI-JECT 4
PA
GL Female
S
PS
leuprolide acetate (1 mg/0.2ml kit, 1 mg/0.2ml vial) 4PA
S
LUPANETA PACK 4 S
LUPRON DEPOT (DEPOT-4 MONTH KIT, DEPOT 7.5 MG KIT,DEPOT 11.25 MG 3MO KIT, DEPOT 22.5 MG 3MO KIT, DEPOT 45MG 6MO KIT)
4PA
S
LUPRON DEPOT 3.75 MG KIT 4PA
S
LUPRON DEPO 11.25MG (LUPANETA) 4PA
S
LUPRON DEPOT 3.75MG (LUPANETA) 4PA
S
LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG 3MO, 11.25 MGKIT, 15 MG KIT, 30 MG 3MO KIT) 4
PA
S
MENOPUR 4
PA
GL Female
S
PS
NOVAREL 10,000 UNITS VIAL 4PA
S
PAGE 120 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
OVIDREL 4
PA
S
PS
PREGNYL 4PA
S
SYNAREL 4PA
S
LEPTINS
MYALEPT 4PA
S
PARATHYROID
calcitonin,salmon,synthetic 1 QL 0.13 / day
FORTEO 4PA
S
MIACALCIN 400 UNIT/2 ML VIAL 4 S
NATPARA 4PA
S
TYMLOS 4
QL 1.60 / day
PA
AL At least 18 yrs old
S
PITUITARY
desmopressin acetate (non-refrigerated) 1
PAGE 121 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG,MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, MINIQUICK 1 MG,MINIQUICK 1.2 MG, MINIQUICK 1.4 MG, MINIQUICK 1.6 MG,MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MG CARTRIDGE, 12 MGCARTRIDGE)
4PA
S
HUMATROPE (5 MG VIAL, 6 MG CARTRIDGE, 12 MG CARTRIDGE,24 MG CARTRIDGE) 4
PA
S
NORDITROPIN FLEXPRO 4
PA
S
PS
NUTROPIN AQ 4PA
S
NUTROPIN AQ NUSPIN 4PA
S
OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 MLCRTG) 4
PA
S
SAIZEN (5 MG VIAL, 8.8 MG CLICK.EASY CARTG, 8.8 MG VIAL) 4PA
S
SAIZEN-SAIZENPREP 4PA
S
SEROSTIM 4
QL 1 / day
PA
S
vasopressin 1
ZOMACTON 4PA
S
ZORBTIVE 4
QL 1 / day
PA
S
PAGE 122 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PROGESTINS
DEPO-SUBQ PROVERA 104 0
QL 90 days
GL Female
HCR
ENDOMETRIN 4
GL Female
S
PS
hydroxyprogesterone caproate 250 mg/ml vial 4
PA
GL Female
S
MAKENA (250 MG/ML VIAL, 1,250 MG/5 ML VIAL) 4
PA
GL Female
S
PS
medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 10mg tablet) 1
GL Female
LCG
medroxyprogesterone acetate (150 mg/ml syringe, 150 mg/mlvial) 0
QL 0.04 / day
GL Female
HCR
norethindrone acetate 1 GL Female
progesterone 50 mg/ml vial 1 GL Female
progesterone, micronized (100 mg capsule, 200 mg capsule) 1 GL Female
HYPOTENSIVE AGENTS
CENTRAL ALPHA-AGONISTS
clonidine (0.2mg/24hr patch tdwk, 0.3mg/24hr patch tdwk) 3QL 0.29 / day
HCG
PAGE 123 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
clonidine 0.1mg/24hr patch tdwk 3QL 0.15 / day
HCG
clonidine hcl 0.1 mg tab er 12h 3QL 4 / day
HCG
clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1 LCG
methyldopa 1
DIRECT VASODILATORS
hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100mg tablet) 1
hydralazine hcl 20 mg/ml vial 1
minoxidil (2.5 mg tablet, 10 mg tablet) 1
HYPOTENSIVE AGENTS, MISCELLANEOUS
VECAMYL 4PA
S
PERIPHERAL ADRENERGIC INHIBITORS
reserpine (0.1 mg tablet, 0.25 mg tablet) 1
ION-REMOVING AGENTS
PHOSPHATE-REMOVING AGENTS
calcium acetate 1
FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW,1,000 MG TABLET CHEW) 2
lanthanum carbonate 1
RENVELA 800 MG TABLET 2
sevelamer carbonate (0.8 g powd pack, 2.4 g powd pack, 800mg tablet) 3 HCG
POTASSIUM-REMOVING AGENTS
KIONEX (15 GM/60 ML SUSPENSION, POWDER) 1
PAGE 124 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
sodium polystyrene sulfonate (15 g/60 ml oral susp, 30g/120ml enema, 50 g/200ml enema, powder) 1
SPS (15 GM/60 ML SUSPENSION, 30 GM/120 ML ENEMA) 1
MACROLIDES
OTHER MACROLIDES
azithromycin (1 g packet, 100 mg/5ml susp recon, 200 mg/5mlsusp recon, 500 mg tablet, 600 mg tablet) 1
azithromycin 250 mg tablet 1 QL 6 / 5 days
ZMAX 2 QL 60 / fill
MISCELLANEOUS B-LACTAM ANTIBIOTICS
MONOBACTAMS
aztreonam 1
CAYSTON 4PA
S
MISCELLANEOUS THERAPEUTIC AGENTS
5-ALPHA-REDUCTASE INHIBITORS
dutasteride 3
QL 1 / day
GL Male
HCG
finasteride 5 mg tablet 1QL 1 / day
GL Male
ALCOHOL DETERRENTS
disulfiram (250 mg tablet, 500 mg tablet) 1
ANTIDOTES
amyl nitrite 1
deferoxamine mesylate 1
PAGE 125 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
edetate calcium disodium 200 mg/ml ampul 1
leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25mg tablet) 1
leucovorin calcium (50 mg vial, 100 mg vial, 200 mg vial, 350mg vial, 500 mg vial) 4 S
MEPHYTON 2
phytonadione (vit k1) (1mg/0.5ml ampul, 1mg/0.5ml syringe,10 mg/ml ampul) 1
pralidoxime chloride 600 mg/2ml pen injctr 1
VISTOGARD 4 S
ANTIGOUT AGENTS
allopurinol 100 mg tablet 1QL 3 / day
LCG
allopurinol 300 mg tablet 1QL 2 / day
LCG
colchicine 0.6 mg capsule 1 QL 2 / day
colchicine 0.6 mg tablet 1 QL 4 / day
COLCRYS 2 QL 4 / day
indomethacin (50 mg capsule, 75 mg capsule er) 1
indomethacin 25 mg capsule 1 LCG
naproxen (125 mg/5ml oral susp, 375 mg tablet, 500 mg tablet) 1 LCG
naproxen (250 mg tablet, 375 mg tablet dr, 500 mg tablet dr) 1
naproxen sodium (275 mg tablet, 550 mg tablet) 1
naproxen sodium (375 mg tbmp 24hr, 500 mg tbmp 24hr) 3 HCG
ULORIC 2QL 1 / day
ST
PAGE 126 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BONE RESORPTION INHIBITORS
alendronate sodium (35 mg tablet, 40 mg tablet, 70 mg tablet,70 mg/75ml solution) 1 QL .15 / day
alendronate sodium (5 mg tablet, 10 mg tablet) 1 QL 1 / day
etidronate disodium 1
ibandronate sodium 150 mg tablet 1 QL 0.04 / day
risedronate sodium 150 mg tablet 3QL 0.04 / day
HCG
risedronate sodium 30 mg tablet 3 HCG
risedronate sodium 35 mg tablet 3QL 0.15 / day
HCG
risedronate sodium 5 mg tablet 3QL 1 / day
HCG
risedronate sodium 35 mg tablet dr 1
CARIOSTATIC AGENTS
CLINPRO 5000 1
DENTA 5000 PLUS 1
DENTAGEL 1
FLUOR-A-DAY 2.5 MG/ML DROPS 0 HCR
fluoride (sodium) 0.2 % solution 1
fluoride (sodium) (0.25(0.55) tab chew, 0.5 mg/ml drops,0.5(1.1)mg tab chew, 1mg(2.2mg) tab chew) 0 HCR
FLUORIDEX 1
FLUORIDEX DAILY DEFENSE 1
FLUORIDEX SENSITIVITY RELIEF 1
FLUORITAB (0.125 MG/DRP DROPS, 0.5 MG TABLET CHEW, 1MG TABLET CHEW) 0 HCR
PAGE 127 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FLURA-DROPS 0 HCR
LUDENT FLUORIDE 0 HCR
pediatric multivitamin no.150 with sodium fluoride 1
pediatric multivitamin no.2/sodium fluoride 1
SF 1
SF 5000 PLUS 1
COMPLEMENT INHIBITORS
FIRAZYR 4PA
S
DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
ACTEMRA 162 MG/0.9 ML SYRINGE 4
QL 0.15 / day
PA
S
azathioprine 50 mg tablet 1
azathioprine sodium 1
cyclosporine (25 mg capsule, 100 mg capsule) 4 S
cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mgcapsule, 100 mg/ml solution) 4 S
DEPEN 2
ENBREL 50 MG/ML SURECLICK SYR 4
QL 0.15 / day
PA
S
PS
ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/MLSYRINGE) 4
QL 0.29 / day
PA
S
PS
PAGE 128 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE,100 MG/ML SOLUTION) 4 S
KEVZARA 4
QL 0.1 / day
PA
AL At least 18 yrs old
S
leflunomide 1
methotrexate sodium (2.5 mg tablet, 25 mg/ml vial) 1
methotrexate sodium/pf (sodium/pf 1 g vial, sodium/pf 25mg/ml vial) 1
NEORAL (25 MG GELATIN CAPSULE, 100 MG GELATIN CAPSULE,100 MG/ML SOLUTION) 4 S
ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 ML SYRINGE,125 MG/ML SYRINGE) 4
QL 0.15 / day
PA
S
ORENCIA CLICKJECT 4
QL 0.15 / day
PA
S
OTEZLA (28 DAY STARTER PACK, 30 MG TABLET, STARTERPACK) 4
QL 2 / day
PA
S
RIDAURA 2
SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE) 4 S
SANDIMMUNE 100 MG/ML SOLN 4S
PS
SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 ML SYRINGE,100 MG/ML PEN INJECTOR, 100 MG/ML SYRINGE) 4
QL 0.04 / day
PA
S
PAGE 129 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
STELARA (45 MG/0.5 ML SYRINGE, 45 MG/0.5 ML VIAL, 90MG/ML SYRINGE) 4
QL 0.08 / day
PA
S
TREXALL 2
XELJANZ 4
QL 2 / day
PA
S
XELJANZ XR 4
QL 1 / day
PA
S
GONADOTROPIN-RELEASING HORMONE ANTAGNTS
CETROTIDE 4
PA
GL Female
S
PS
FIRMAGON 120 MG VIAL 4PA
S
ganirelix acetate 4GL Female
S
IMMUNOMODULATORY AGENTS
ACTIMMUNE 4 S
AUBAGIO 4
QL 1 / day
PA
S
PS
AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG, PREFILLEDSYR 30 MCG KT) 4
QL 0.15 / day
PA
S
PS
PAGE 130 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AVONEX PEN (PEN 30 MCG/0.5 ML, PEN 30 MCG/0.5 ML KIT) 4
QL 0.15 / day
PA
S
PS
BETASERON (0.3 MG KIT, 0.3 MG VIAL) 4
QL 0.5 / day
PA
S
COPAXONE 4
QL 1 / day
PA
S
PS
EXTAVIA (0.3 MG KIT, 0.3 MG VIAL) 4
QL 0.5 / day
PA
S
GILENYA 4
QL 1 / day
PA
S
PS
GLATOPA 4
QL 1 / day
PA
S
PLEGRIDY 125 MCG/0.5 ML SYRING 4
QL 0.04 / day
PA
S
PS
PLEGRIDY SYRINGE STARTER PACK 4
QL 1 / lifetime
PA
S
PS
PAGE 131 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PLEGRIDY 125 MCG/0.5 ML PEN 4
QL 0.04 / day
PA
S
PS
PLEGRIDY PEN INJ STARTER PACK 4
QL 1 / lifetime
PA
S
PS
POMALYST 4
QL 1 / day
PA
S
REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML SYRINGE) 4
QL 0.22 / day
PA
S
REBIF TITRATION PACK 4
QL 4.2 / 365 days
PA
S
REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) 4
QL 0.22 / day
PA
S
REBIF REBIDOSE TITRATION PACK 4
QL 4.2 / 365 days
PA
S
REVLIMID 4
QL 1 / day
PA
S
TECFIDERA 4
QL 2 / day
PA
S
PS
PAGE 132 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
THALOMID (150 MG CAPSULE, 200 MG CAPSULE) 4
QL 2 / day
PA
S
THALOMID (50 MG CAPSULE, 100 MG CAPSULE) 4
QL 1 / day
PA
S
ZINBRYTA 4
QL 1 / day
PA
S
IMMUNOSUPPRESSIVE AGENTS
ASTAGRAF XL 0.5 MG CAPSULE 4
QL 15 / day
PA
S
ASTAGRAF XL 1 MG CAPSULE 4
QL 30 / day
PA
S
ASTAGRAF XL 5 MG CAPSULE 4
QL 6 / day
PA
S
CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500 MGTABLET) 4 S
cyclophosphamide (25 mg capsule, 50 mg capsule) 1 PA
ELIDEL 2
QL 2.5 / day
ST
AL At least 2 yrs old
ENVARSUS XR 4
QL 1 / day
PA
S
PAGE 133 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
mercaptopurine 50 mg tablet 1
mycophenolate mofetil 200 mg/ml susp recon 4 S
mycophenolate mofetil (250 mg capsule, 500 mg tablet) 4 S
mycophenolate sodium 4 S
MYFORTIC 4 S
PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 4 S
PURIXAN 4PA
S
RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/ML ORALSOLN, 2 MG TABLET) 4 S
sirolimus (1 mg tablet, 2 mg tablet) 4 S
sirolimus 0.5 mg tablet 4 S
tacrolimus 0.5 mg capsule 4QL 2 / day
S
tacrolimus 1 mg capsule 4QL 8 / day
S
tacrolimus 5 mg capsule 4QL 4 / day
S
ZORTRESS 4PA
S
OTHER MISCELLANEOUS THERAPEUTIC AGENTS
acetylcysteine (100 mg/ml vial, 200 mg/ml vial) 1
AMPYRA 4
QL 2 / day
PA
S
PS
PAGE 134 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ARCALYST 4PA
S
BOTOX COSMETIC 4PA
S
CERDELGA 4
QL 2 / day
PA
S
CYSTADANE 4 S
CYSTAGON 4 S
ethyl alcohol (98 % ampul, 98 % vial) 1
ILARIS 150 MG/ML VIAL 4
QL 0.04 / day
PA
S
KEVEYIS 4
QL 4 / day
PA
S
KUVAN (100 MG POWDER PACKET, 100 MG TABLET, 500 MGPOWDER PACKET) 4
PA
S
levocarnitine 330 mg tablet 1
levocarnitine (with sugar) 1
ORALAIR (100-300 IR CHILD SAMPL, 300 IR ADULT SAMPLE KT,300 IR STARTER PACK, 300 IR SUBLINGUAL TAB) 4
PA
S
ORALAIR 100 IR STARTER PACK 4 S
ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MGCAPSULE, 10 MG CAPSULE, 20 MG CAPSULE) 4
PA
S
PROCYSBI 4 S
PAGE 135 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SENSIPAR (30 MG TABLET, 60 MG TABLET) 4
QL 2 / day
PA
S
SENSIPAR 90 MG TABLET 4
QL 4 / day
PA
S
TYBOST 4S
PS
XURIDEN 4 S
ZAVESCA 4PA
S
PROTECTIVE AGENTS
MESNEX 400 MG TABLET 4 S
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
CYCLOOXYGENASE-2 (COX-2) INHIBITORS
celecoxib (50 mg capsule, 200 mg capsule) 1 QL 2 / day
celecoxib 100 mg capsule 1 QL 3 / day
celecoxib 400 mg capsule 1 QL 1 / day
OTHER NONSTEROIDAL ANTI-INFLAM. AGENTS
diclofenac potassium 1
diclofenac sodium 1.5 % drops 3 HCG
diclofenac sodium 1 % gel (gram) 3QL 1000/ 30 days
HCG
diclofenac sodium (25 mg tablet dr, 50 mg tablet dr, 75 mgtablet dr, 100 mg tab er 24h) 1
diflunisal 1
PAGE 136 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h,400 mg tablet, 500 mg tab er 24h, 500 mg tablet, 600 mg tab er24h)
1
fenoprofen calcium (200 mg capsule, 400 mg capsule, 600 mgtablet) 1
flurbiprofen (50 mg tablet, 100 mg tablet) 1
ibuprofen 100 mg/5ml oral susp 1
ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) 1 LCG
ketoprofen 200 mg cap24h pel 3 HCG
ketoprofen 50 mg capsule 1 LCG
ketoprofen 75 mg capsule 1
ketorolac tromethamine 30 mg/ml cartridge 1QL 20 / 30 days
LCG
ketorolac tromethamine 30 mg/ml syringe 1 QL 20 / 23 days
ketorolac tromethamine 10 mg tablet 1QL 21 / fill
LCG
ketorolac tromethamine (15 mg/ml cartridge, 15 mg/ml vial) 1 QL 40 / 23 days
ketorolac tromethamine (30 mg/ml vial, 60 mg/2 ml syringe) 1 QL 20 / 30 days
ketorolac tromethamine (60 mg/2 ml cartridge, 60 mg/2 mlvial) 1
QL 20 / 30 days
LCG
ketorolac tromethamine 30mg/ml(1) vial 1QL 20 / 23 days
LCG
KLOFENSAID II 3 HCG
meclofenamate sodium (50 mg capsule, 100 mg capsule) 1
mefenamic acid 250 mg capsule 3QL 5 / day
HCG
meloxicam 7.5 mg/5ml oral susp 1 QL 10 / day
PAGE 137 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
meloxicam (7.5 mg tablet, 15 mg tablet) 1QL 1 / day
LCG
nabumetone (500 mg tablet, 750 mg tablet) 1
oxaprozin 600 mg tablet 3 HCG
piroxicam (10 mg capsule, 20 mg capsule) 1 AL Up to 75 yrs old
sulindac (150 mg tablet, 200 mg tablet) 1
tolmetin sodium (200 mg tablet, 400 mg capsule, 600 mgtablet) 1
SALICYLATES
carisoprodol/aspirin 200-325 mg tablet 1
choline salicyl/mag salicylate 500 mg/5ml liquid 1
salsalate (500 mg tablet, 750 mg tablet) 1
PENICILLINS
AMINOPENICILLINS
amoxicillin (125 mg/5ml susp recon, 200 mg/5ml susp recon,250 mg capsule, 400 mg/5ml susp recon, 875 mg tablet) 1 LCG
amoxicillin (125 mg tab chew, 250 mg tab chew, 250 mg/5mlsusp recon, 500 mg capsule, 500 mg tablet, 775 mg tbmp 24hr) 1
amoxicillin/potassium clav 1000-62.5 tab er 12h 3 HCG
PAGE 138 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
amoxicillin/potassium clavulanate (amoxicillin/potassium 200-28.5/5 susp recon, amoxicillin/potassium 200-28.5mg tabchew, amoxicillin/potassium 250-125 mg tablet,amoxicillin/potassium 250-62.5/5 susp recon,amoxicillin/potassium 400-57mg tab chew,amoxicillin/potassium 400-57mg/5 susp recon,amoxicillin/potassium 500-125 mg tablet,amoxicillin/potassium 600-42.9/5 susp recon,amoxicillin/potassium 875-125 mg tablet)
1
ampicillin sodium (1 g vial, 2 g vial, 10 g vial, 125 mg vial, 250mg vial, 500 mg vial) 1
ampicillin sodium/sulbactam sodium (sodium/sulbactam 1.5 gvial, sodium/sulbactam 3 g vial, sodium/sulbactam 15 g vial) 1
ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule,250 mg/5ml susp recon, 500 mg capsule) 1
AUGMENTIN 125-31.25 MG/5 ML 2
NATURAL PENICILLINS
penicillin g potassium 1
penicillin g procaine 1
penicillin g sodium 1
penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet,250 mg/5ml soln recon, 500 mg tablet) 1 LCG
PENICILLINASE-RESISTANT PENICILLINS
dicloxacillin sodium 250 mg capsule 1
dicloxacillin sodium 500 mg capsule 1 LCG
nafcillin sodium (1 g vial, 2 g vial, 10 g vial) 1
oxacillin sodium (1 g vial, 2 g vial, 10 g vial) 1
RENIN-ANGIOTENSIN-ALDOSTER.INHIB(HYPOTN)
ANGIOTENSIN II RECEPTOR ANTAGON.(HYPOTN)
candesartan cilexetil 1 QL 1 / day
eprosartan mesylate 1 QL 1 / day
PAGE 139 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
irbesartan 1 QL 1 / day
losartan potassium (25 mg tablet, 50 mg tablet) 1QL 2 / day
LCG
losartan potassium 100 mg tablet 1QL 1 / day
LCG
olmesartan medoxomil 1 QL 3 / day
telmisartan 1 QL 1 / day
valsartan (40 mg tablet, 80 mg tablet, 160 mg tablet) 1 QL 2 / day
valsartan 320 mg tablet 1 QL 1 / day
ANGIOTENSIN-CONVERT.ENZYME INHIB(HYPOTN)
benazepril hcl (10 mg tablet, 40 mg tablet) 1 QL 2 / day
benazepril hcl 20 mg tablet 1 QL 4 / day
benazepril hcl 5 mg tablet 1 QL 3 / day
captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet, 100 mgtablet) 1 QL 4 / day
enalapril maleate (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20mg tablet) 1 QL 2 / day
fosinopril sodium 1 QL 2 / day
lisinopril (2.5 mg tablet, 10 mg tablet, 20 mg tablet) 1QL 1 / day
LCG
lisinopril (5 mg tablet, 30 mg tablet) 1 QL 1 / day
lisinopril 40 mg tablet 1 QL 2 / day
moexipril hcl 1 QL 1 / day
perindopril erbumine 1 QL 1 / day
quinapril hcl 1 QL 2 / day
PAGE 140 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ramipril 1 QL 2 / day
trandolapril 1 QL 2 / day
RESPIRATORY TRACT AGENTS
ANTIFIBROTIC AGENTS
ESBRIET (267 MG CAPSULE, 267 MG TABLET) 4
QL 9 / day
PA
S
ESBRIET 801 MG TABLET 4
QL 3 / day
PA
S
OFEV 4
QL 2 / day
PA
S
ANTITUSSIVES
benzonatate 1 AL At least 11 yrs old
MUCOLYTIC AGENTS
PULMOZYME 4
QL 5 / day
PA
S
VASODILATING AGENTS (RESPIRATORY TRACT)
ADCIRCA 4
QL 2 / day
PA
S
ADEMPAS 4
QL 3 / day
PA
S
PAGE 141 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LETAIRIS 4
QL 1 / day
PA
S
PS
OPSUMIT 4
QL 1 / day
PA
S
ORENITRAM ER 4
QL 3 / day
PA
S
REMODULIN 4PA
S
REVATIO 10 MG/ML ORAL SUSP 4
QL 6 / day
PA
AL At least 18 yrs old
S
REVATIO 20 MG TABLET 4
QL 3 / day
PA
AL At least 18 yrs old
S
sildenafil citrate 20 mg tablet 4
QL 3 / day
PA
S
TRACLEER 4
QL 2 / day
PA
S
PS
TYVASO 4
QL 1 / day
PA
S
PAGE 142 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TYVASO INSTITUTIONAL START KIT 4
QL 1 / day
PA
S
TYVASO REFILL KIT 4
QL 1 / day
PA
S
TYVASO STARTER KIT 4
QL 1 / day
PA
S
UPTRAVI 200-800 TITRATION PACK 4
PA
AL At least 18 yrs old
S
UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600 MCGTABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCGTABLET, 1,400 MCG TABLET, 1,600 MCG TABLET)
4
QL 2 / day
PA
AL At least 18 yrs old
S
SKELETAL MUSCLE RELAXANTS
CENTRALLY ACTING SKELETAL MUSCLE RELAXNT
carisoprodol (250 mg tablet, 350 mg tablet) 1
chlorzoxazone 500 mg tablet 1
cyclobenzaprine hcl (5 mg tablet, 7.5 mg tablet) 1
cyclobenzaprine hcl 10 mg tablet 1 LCG
LORZONE 750 MG TABLET 1
METAXALL 1
metaxalone 3 HCG
methocarbamol (500 mg tablet, 750 mg tablet) 1
methocarbamol 100 mg/ml vial 1
PAGE 143 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
tizanidine hcl (2 mg capsule, 2 mg tablet, 4 mg capsule, 4 mgtablet, 6 mg capsule) 1
DIRECT-ACTING SKELETAL MUSCLE RELAXANTS
dantrolene sodium (25 mg capsule, 50 mg capsule, 100 mgcapsule) 1
GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT
baclofen (10 mg tablet, 20 mg tablet) 1
SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS
orphenadrine citrate 100 mg tablet er 1
orphenadrine citrate (30 mg/ml ampul, 30 mg/ml vial) 1
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)
ALA-CORT 1
alclometasone dipropionate (0.05 % cream (g), 0.05 % oint.(g)) 1
amcinonide (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g)) 1
ANUCORT-HC 1
ANUSOL-HC 25 MG SUPPOSITORY 1
betamethasone dipropionate (0.05 % cream (g), 0.05 % gel(gram), 0.05 % lotion, 0.05 % oint. (g)) 1
betamethasone dipropionate/propylene glycol(betamethasone/propylene 0.05 % cream (g),betamethasone/propylene 0.05 % lotion,betamethasone/propylene 0.05 % oint. (g))
1
betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 %oint. (g), 0.12 % foam) 1
calcipotriene/betamethasone dipropionate 1 QL 3 / day
clobetasol propionate (0.05 % cream (g), 0.05 % foam, 0.05 %gel (gram), 0.05 % lotion, 0.05 % oint. (g), 0.05 % shampoo,0.05 % solution, 0.05 % spray)
1
PAGE 144 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
clobetasol propionate/emollient base (propionate/emoll 0.05 %cream (g), propionate/emoll 0.05 % foam) 1
clocortolone pivalate 0.1 % cream (g) 1
CLODAN 0.05% SHAMPOO 1
COLOCORT 1
CORMAX 1
desonide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) 3 HCG
desoximetasone (0.05 % cream (g), 0.05 % gel (gram), 0.05 %oint. (g), 0.25 % cream (g), 0.25 % oint. (g)) 3 HCG
diflorasone diacetate (0.05 % cream (g), 0.05 % oint. (g)) 1
EUCRISA 2
QL 2.143 / day
ST
AL At least 2 yrs old
fluocinolone acetonide (0.01 % cream (g), 0.01 % oil, 0.025 %cream (g), 0.025 % oint. (g)) 3 HCG
fluocinolone acetonide 0.01 % solution 1
fluocinolone acetonide/shower cap 3 HCG
fluocinonide (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint.(g), 0.05 % solution, 0.1 % cream (g)) 1
fluocinonide/emollient base 1
fluticasone propionate (0.005 % oint. (g), 0.05 % cream (g),0.05 % lotion) 1
halobetasol propionate (0.05 % cream (g), 0.05 % oint. (g)) 3 HCG
HEMMOREX-HC 1
hydrocortisone (1 % cream (g), 1 % crm/pe app, 1 % oint. (g),2.5 % cream (g), 2.5 % crm/pe app, 2.5 % lotion, 2.5 % oint.(g), 100mg/60ml enema)
1
hydrocortisone acetate (25 mg supp.rect, 30 mg supp.rect) 1
hydrocortisone/lidocaine/aloe 0.55%-2.8% gel w/appl 1
PAGE 145 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hydrocortisone acetate/pramoxine hcl(hydrocortisone/pramoxine 1 %-1 % cream/appl,hydrocortisone/pramoxine 2.5 %-1 % cream (g),hydrocortisone/pramoxine 2.5 %-1 % cream/appl,hydrocortisone/pramoxine 2.5-1%(4g) cream/appl)
1
hydrocortisone butyrate (0.1 % cream (g), 0.1 % oint. (g), 0.1 %solution) 1
hydrocortisone butyrate/emoll 0.1 % cream (g) 1
hydrocortisone valerate (0.2 % cream (g), 0.2 % oint. (g)) 1
hydrocortisone/mineral oil/petrolatum,white 1
lidocaine/hydrocortisone ac 3 %-0.5 % cream (g) 3 HCG
lidocaine hcl/hydrocortisone acetate (lidocaine/hydrocortisone3 %-0.5 % cream/appl, lidocaine/hydrocortisone 3-2.5%(7g)gel w/appl)
1
mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 %solution) 1
ORALONE 1
PRAMCORT 1
prednicarbate (0.1 % cream (g), 0.1 % oint. (g)) 1
PROCTO-MED HC 1
PROCTO-PAK 1
PROCTOFOAM-HC 2
PROCTOSOL-HC 1
PROCTOZONE-HC 1
SANADERMRX 1
SCALACORT 1
triamcinolone acetonide (0.025 % cream (g), 0.025 % lotion,0.025 % oint. (g), 0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g),0.1 % paste (g), 0.147mg/g aerosol, 0.5 % cream (g), 0.5 %oint. (g))
1
TRIANEX 1
TRIDERM 1
PAGE 146 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIPRURITICS AND LOCAL ANESTHETICS
CIDALEAZE 1
doxepin hcl 5 % cream (g) 1
ethyl chloride 1
lidocaine 5 % adh. patch 3QL 3 / day
HCG
lidocaine 5 % oint. (g) 1
lidocaine hcl (3 % cream (g), 3 % lotion, 4 % solution) 1
lidocaine/prilocaine (lidocaine/prilocaine 2.5 cream (g),lidocaine/prilocaine 2.5 kit) 1
lidocaine/tetracaine 1
LIDOPIN 3% CREAM 1
LIDOPRIL 1
LIDORX 2QL 1 / day
PA
LP LITE PAK 1
phenazopyridine hcl (100 mg tablet, 200 mg tablet) 1
CELL STIMULANTS AND PROLIFERANTS
AVITA (CREAM, GEL) 1
tretinoin (0.01 % gel (gram), 0.025 % cream (g), 0.025 % gel(gram), 0.05 % cream (g), 0.05 % gel (gram), 0.1 % cream (g)) 1
tretinoin microspheres (0.04 % gel (gram), 0.04 % gel w/pump,0.1 % gel (gram), 0.1 % gel w/pump) 3
QL 1.667 / day
HCG
tretinoin/emollient base 1
KERATOLYTIC AGENTS
BENZEPRO (6% FOAMING CLOTHS, 7% CREAMY WASH) 1
benzoyl peroxide 7 % cleanser 1
PAGE 147 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BP-50% UREA 1
BPO 6% FOAMING CLOTHS 1 QL 2 / day
LATRIX 1
PACNEX 1
potassium hydroxide 5 % solution 1
PR BENZOYL PEROXIDE 1
REA LO 40 (40 CM, 40 TION) 1
REMEVEN 1
SALACYN (CREAM, LOTION) 1
salicylic acid (6 % cream (g), 6 % crm er (g), 6 % foam, 6 % gel(gram), 6 % lotion, 6 % lotion er, 6 % shampoo, 26 % liquid,27.5 % liq-film, 28.5 % sol-filmer)
1
salicylic acid/ammonium lactate/aloe vera 1
silver nitrate 10 % solution 1
silver nitrate/potassium nitrate 1
UMECTA 40% MOUSSE 1
URE-K 1
urea (35 % foam, 39 % cream (g), 40 % cream (g), 40 % gel(ml), 40 % lotion, 40 % nl fm susp, 45 % cream (g), 45 % gel(ml), 45 % lotion, 47 % cream (g), 50 % cream (g))
1
KERATOPLASTIC AGENTS
coal tar 20 % solution 1
SKIN AND MUCOUS MEMBRANE AGENTS, MISC.
acitretin (17.5 mg capsule, 25 mg capsule) 3QL 2 / day
HCG
acitretin 10 mg capsule 3QL 4 / day
HCG
adapalene (0.1 % cream (g), 0.3 % gel (gram), 0.3 % gelw/pump) 3
QL 1.5 / day
HCG
PAGE 148 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
adapalene 0.1 % gel (gram) 1 QL 1.5 / day
adapalene 0.1 % lotion 1 QL 2 / day
AMNESTEEM 3PA
HCG
calcipotriene (0.005 % cream (g), 0.005 % oint. (g)) 3QL 2 / day
HCG
calcipotriene 0.005 % solution 1 QL 2 / day
CALCITRENE 1 QL 2 / day
calcitriol 3 mcg/g oint. (g) 1 QL 3.334 / day
CARAC 2
CLARAVIS 3PA
HCG
COSENTYX (2 SYRINGES) 4
QL 0.357 / day
PA
S
COSENTYX PEN 4
QL 0.357 / day
PA
S
COSENTYX PEN (2 PENS) 4
QL 0.357 / day
PA
S
COSENTYX SYRINGE 4
QL 0.357 / day
PA
S
dapsone 5 % gel (gram) 1 QL 3 / day
diclofenac sodium 3 % gel (gram) 1 QL 100 / 30 days
PAGE 149 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DUPIXENT 4
QL 0.15 / day
PA
AL At least 18 yrs old
S
finasteride 1 mg tablet 1
FLUOROPLEX 2
fluorouracil (0.5 % cream (g), 2 % solution, 5 % cream (g), 5 %solution) 1
FORMADON 1
formaldehyde 1
imiquimod 5 % cream pack 1QL 0.434 / day
AL At least 12 yrs old
MIRVASO (GEL, GEL PUMP) 2 QL 1 / day
MYORISAN 3PA
HCG
podofilox 0.5 % solution 1
PYROGALLIC ACID 1
SOOLANTRA 2 QL 1.5 / day
tacrolimus (0.03 % oint. (g), 0.1 % oint. (g)) 3
QL 100 / 30 days
ST
HCG
TALTZ AUTOINJECTOR 4
QL 0.15 / day
PA
S
TALTZ AUTOINJECTOR (2 PACK) 4
QL 0.15 / day
PA
S
PAGE 150 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TALTZ AUTOINJECTOR (3 PACK) 4
QL 0.15 / day
PA
S
TALTZ SYRINGE 4
QL 0.15 / day
PA
S
TALTZ SYRINGE (2 PACK) 4
QL 0.15 / day
PA
S
TALTZ SYRINGE (3 PACK) 4
QL 0.15 / day
PA
S
TARGRETIN 1% GEL 4PA
S
tazarotene 0.1 % cream (g) 3QL 1.47 / day
HCG
trichloroacetic acid (25 % soln recon, 75 % soln recon) 1
VALCHLOR 4
QL 3 / day
PA
S
ZENATANE 3PA
HCG
PAGE 151 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SOMATOSTATIN AGONISTS AND ANTAGONISTS
SOMATOSTATIN AGONISTS
octreotide acetate (50 mcg/ml ampul, 50 mcg/ml syringe, 100mcg/ml ampul, 100 mcg/ml syringe, 100 mcg/ml vial, 500mcg/ml ampul, 500 mcg/ml syringe, 500 mcg/ml vial)
4PA
S
octreotide acetate (50 mcg/ml vial, 200 mcg/ml vial,1000mcg/ml vial) 4
PA
S
SANDOSTATIN 0.05 MG/ML AMPUL 4
QL 30 / day
PA
S
SANDOSTATIN 0.1 MG/ML AMPUL 4
QL 15 / day
PA
S
SANDOSTATIN 0.5 MG/ML AMPUL 4
QL 3 / day
PA
S
SANDOSTATIN 0.2 MG/ML VIAL 4
QL 8 / day
PA
S
SANDOSTATIN 1 MG/ML VIAL 4
QL 1.5 / day
PA
S
SANDOSTATIN LAR DEPOT (10 MG KT, 10 MG VL, 30 MG KT, 30MG VL) 4
QL 0.04 / day
PA
S
SANDOSTATIN LAR DEPOT (20 MG KT, 20 MG VL) 4
QL 0.07 / day
PA
S
PAGE 152 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SIGNIFOR 4PA
S
SIGNIFOR LAR (20 MG KIT, 20 MG VIAL) 4
QL 0.1 / day
PA
S
SIGNIFOR LAR (40 MG KIT, 40 MG VIAL) 4
QL 0.067 / day
PA
S
SIGNIFOR LAR (60 MG KIT, 60 MG VIAL) 4
QL 0.04 / day
PA
S
SOMATOTROPIN AGONISTS AND ANTAGONISTS
SOMATOTROPIN AGONISTS
EGRIFTA 4
QL 2 / day
PA
S
INCRELEX 4PA
S
SOMATOTROPIN ANTAGONISTS
SOMAVERT 4 S
SYMPATHOMIMETIC (ADRENERGIC) AGENTS
ALPHA- AND BETA-ADRENERGIC AGONISTS
bupivacaine hcl/epinephrine 1
bupivacaine hcl/epinephrine bitartrate 1
bupivacaine hcl/epinephrine/pf 1
PAGE 153 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
lidocaine hcl/epinephrine (hcl/epinephrine 0.5-1:200k vial,hcl/epinephrine 1%-1:100k vial, hcl/epinephrine 1.5-1:200kampul, hcl/epinephrine 1.5-1:200k vial, hcl/epinephrine 2 %-1:100k vial, hcl/epinephrine 2%-1:200k vial)
1
lidocaine hcl/epinephrine bitartrate 1
NORTHERA 4
QL 84 / 14 days
PA
S
SENSORCAINE-EPINEPHRINE 1
SENSORCAINE-MPF EPINEPHRINE (SENSORC MPF 0.25%-EPI,SENSORCN-MPF 0.5%-EPI) 1
XYLOCAINE DENTAL-EPINEPHRINE 1
ALPHA-ADRENERGIC AGONISTS
midodrine hcl 1
phenylephrine hcl 10 mg/ml vial 1
THYROID AND ANTITHYROID AGENTS
ANTITHYROID AGENTS
methimazole (5 mg tablet, 10 mg tablet) 1
propylthiouracil 50 mg tablet 1
THYROID AGENTS
LEVO-T 1
levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 100 mcgtablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150mcg tablet, 175mcg tablet)
1 LCG
levothyroxine sodium (75 mcg tablet, 88 mcg tablet, 200 mcgtablet, 300 mcg tablet) 1
LEVOXYL (25 MCG TABLET, 50 MCG TABLET, 100 MCG TABLET) 1 LCG
LEVOXYL (75 MCG TABLET, 88 MCG TABLET, 112 MCG TABLET,125 MCG TABLET, 137 MCG TABLET, 150 MCG TABLET, 175MCG TABLET, 200 MCG TABLET)
1
PAGE 154 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcgtablet) 1
NP THYROID 1
SYNTHROID 2
UNITHROID (25 MCG TABLET, 50 MCG TABLET, 100 MCGTABLET, 112 MCG TABLET) 1 LCG
UNITHROID (75 MCG TABLET, 88 MCG TABLET, 125 MCGTABLET, 137 MCG TABLET, 150 MCG TABLET, 175 MCG TABLET,200 MCG TABLET, 300 MCG TABLET)
1
Uncategorized
Unclassified
0.9 % sodium chloride 0.9 % syringe cp 1
AFINITOR (5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) 4
QL 2 / day
PA
S
AFINITOR 2.5 MG TABLET 4
QL 1 / day
PA
S
AFINITOR DISPERZ 4PA
S
AFLURIA 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 0 HCR
AFLURIA QUAD 2017-2018 (2017-2018 SYRINGE, 2017-2018VIAL) 0 HCR
ALECENSA 4
QL 8 / day
PA
AL At least 18 yrs old
S
ALUNBRIG 4
QL 6 / day
PA
AL At least 18 yrs old
S
PAGE 155 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
anastrozole 1 mg tablet 1
azacitidine 4 S
B-PLEX PLUS 1
BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/ML SYRINGE) 4PA
S
bexarotene 4PA
S
bicalutamide 1
bismuth tribromoph/petrolatum 5"x9" bandage 1
BLEO 15K 4 S
bleomycin sulfate 4 S
BOSULIF 100 MG TABLET 4
QL 4 / day
PA
S
PS
BOSULIF 500 MG TABLET 4
QL 1 / day
PA
S
PS
bupivacaine hcl/dex-water/pf 0.75 % ampul 1
bupivacaine hcl/pf (hcl/pf 2.5 mg/ml ampul, hcl/pf 5 mg/mlampul, hcl/pf 7.5 mg/ml ampul) 1
butalbital/aspirin/caffeine 50-325-40 tablet 1 QL 6 / day
CABOMETYX 20 MG TABLET 4
QL 4 / day
PA
S
CABOMETYX 40 MG TABLET 4
QL 2 / day
PA
S
PAGE 156 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CABOMETYX 60 MG TABLET 4
QL 1.5 / day
PA
S
capecitabine 4 S
CAPRELSA 100 MG TABLET 4
QL 2 / day
PA
S
CAPRELSA 300 MG TABLET 4
QL 1 / day
PA
S
catheter (12fr-16" each, 14 fr-16 " each, 16fr-16" each) 1
catheter 14 fr each 1
CERAMAX 1
cervical cap 22mm each 0 HCR
chloroprocaine hcl/pf 1
chlorzoxazone 250 mg tablet 1
COMETRIQ 100 MG DAILY-DOSE PK 4
QL 2 / day
PA
S
COMETRIQ 140 MG DAILY-DOSE PK 4
QL 4 / day
PA
S
COMETRIQ 60 MG DAILY-DOSE PACK 4
QL 3 / day
PA
S
compressor, for nebulizer 1
conception assistance supplies combination no.1 1
PAGE 157 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
COTELLIC 4
QL 2.5 / day
PA
AL At least 18 yrs old
S
cytarabine 4 S
cytarabine/pf (cytarabine/pf 2 g/20 ml vial, cytarabine/pf 100mg/5ml vial) 4 S
cytarabine/pf 20 mg/ml vial 4 S
dexchlorpheniramine maleate 1
diaphragms, wide seal 0 HCR
EMCYT 4 S
ERIVEDGE 4
QL 1 / day
PA
S
ERWINAZE 4 S
ethyl acetate 1
exemestane 1
EXJADE 4PA
S
FARESTON 2
FARYDAK 4PA
S
FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET) 4PA
S
fexofenadine hcl/pseudoephedrine hcl 1 QL 1 / day
floxuridine 500 mg vial 4 S
PAGE 158 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FLUAD 2017-2018 0AL At least 65 yrs old
HCR
FLUARIX QUAD 2017-2018 0 HCR
FLUBLOK 2017-2018 0 HCR
FLUBLOK QUAD 2017-2018 0 HCR
FLUCELVAX QUAD 2017-2018 (2017-2018 SYR, 2017-2018VIAL) 0 HCR
FLULAVAL QUAD 2017-2018 (2017-2018 SYR, 2017-2018VIAL) 0 HCR
flutamide 1
FLUVIRIN 2017-2018 (2017-2018 SYRINGE, 2017-2018 VIAL) 0 HCR
FLUZONE HIGH-DOSE 2017-2018 0AL At least 65 yrs old
HCR
FLUZONE INTRADERM QUAD 2017-18 0 HCR
FLUZONE QUAD 2017-2018 (2017-2018 SYRINGE, 2017-2018VIAL) 0 HCR
FLUZONE QUAD PEDI 2017-2018 0 HCR
foam bandage 1
gel dressing 1
GILOTRIF 4
QL 1 / day
PA
S
GLEEVEC 100 MG TABLET 4
QL 8 / day
PA
S
PS
GLEEVEC 400 MG TABLET 4
QL 2 / day
PA
S
PS
PAGE 159 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
glutaraldehyde 1
glycopyrrolate 1.5 mg tablet 1
HEXALEN 4PA
S
HUMALOG JUNIOR KWIKPEN 2
HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 4PA
S
hydrocolloid dressing (4" 4" bandage, 6" 6" bandage, 8" 8"bandage) 1
hydroxyurea 500 mg capsule 1
HYQVIA HY COMPONENT 4PA
S
IBRANCE 100 MG CAPSULE 4
QL 1.25 / day
PA
S
IBRANCE 125 MG CAPSULE 4
QL 1 / day
PA
S
IBRANCE 75 MG CAPSULE 4
QL 1.667 / day
PA
S
ICLUSIG 15 MG TABLET 4
QL 2 / day
PA
S
ICLUSIG 45 MG TABLET 4
QL 1 / day
PA
S
IMBRUVICA 4
QL 4 / day
PA
S
PAGE 160 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
INGREZZA 80 MG CAPSULE 4
QL 1 / day
PA
AL At least 18 yrs old
S
inhaler, assist devices spacer 2
inhaler,assist device,accesory each 1
INLYTA 4
QL 4 / day
PA
S
PS
IPOL SINGLE DOSE SYRINGE 2
IRESSA 4
QL 1 / day
PA
S
isoproterenol hcl 1
JADENU 4PA
S
JADENU SPRINKLE 4PA
S
JAKAFI 4
QL 2 / day
PA
S
KISQALI 200 MG DAILY DOSE 4
QL 3 / day
PA
AL At least 18 yrs old
S
KISQALI 400 MG DAILY DOSE 4
QL 1.5 / day
PA
AL At least 18 yrs old
S
PAGE 161 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
KISQALI 600 MG DAILY DOSE 4
QL 1 / day
PA
AL At least 18 yrs old
S
KISQALI FEMARA 200 MG CO-PACK 4
QL 3 / day
PA
AL At least 18 yrs old
S
KISQALI FEMARA 400 MG CO-PACK 4
QL 1.5 / day
PA
AL At least 18 yrs old
S
KISQALI FEMARA 600 MG CO-PACK 4
QL 1 / day
PA
AL At least 18 yrs old
S
lancing device/lancets 2
LENVIMA 4
QL 3 / day
PA
S
letrozole 2.5 mg tablet 1
lidocaine hcl (5 mg/ml vial, 10 mg/ml syringe, 10 mg/ml vial, 50mg/5 ml syringe) 1
lidocaine hcl/pf 10 mg/ml ampul 1 MED Medical Drug
lidocaine hcl/pf (hcl/pf 10 mg/ml syringe, hcl/pf 10 mg/ml vial,hcl/pf 15 mg/ml ampul, hcl/pf 200mg/10ml syringe) 1
lomustine 1
LONSURF 15 MG-6.14 MG TABLET 4
QL 2.15 / day
PA
S
PAGE 162 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LONSURF 20 MG-8.19 MG TABLET 4
QL 3 / day
PA
S
LYNPARZA (50 MG CAPSULE, 100 MG TABLET, 150 MG TABLET) 4PA
S
LYSODREN 4 S
MATULANE 4 S
MAVYRET 4
QL 3 / day
PA
AL At least 18 yrs old
S
PS
megestrol acetate (400mg/10ml oral susp, 625mg/5ml oralsusp) 1
megestrol acetate (20 mg tablet, 40 mg tablet) 1
MEKINIST 0.5 MG TABLET 4
QL 4 / day
PA
S
MEKINIST 2 MG TABLET 4
QL 1 / day
PA
S
melphalan 1
mepivacaine hcl/pf 1
methadone hcl 5 mg/0.5ml syringe 1QL 2 / day
PA
METHERGINE 1
methylene blue/gentian violet/foam bandage 1
PAGE 163 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
methylergonovine maleate 0.2 mg tablet 1
methylergonovine maleate (.2mg/ml(1) ampul, .2mg/ml(1) vial) 1
middle ear inflation device 1
MUSTARGEN 4 S
MYLERAN 4 S
nebulizer 1
nebulizer accessories (each, kit) 1
NEXAVAR 4
QL 4 / day
PA
S
NILANDRON 4 S
nilutamide 4PA
S
NINLARO 4
QL 0.124 / day
PA
AL At least 18 yrs old
S
NOVAREL 5,000 UNIT VIAL 4PA
S
ODOMZO 4
QL 1 / day
PA
S
ONCASPAR 4 S
ORAFATE 4 S
oxytocin 10 unit/ml vial 1
pen needle, diabetic 2
PAGE 164 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
POLOCAINE (1% VIAL, 2% VIAL, 3% CARTRIDGE) 1
POLOCAINE-MPF 1
PROTHELIAL 4 S
ropivacaine hcl in 0.9 % sodium chloride/pf (ropivacae chl/pf0.1% 400ml els pmp hr, ropivacae chl/pf 0.2% 550ml els pmphr)
1
ropivacaine hcl/pf (hcl/pf 2 mg/ml vial, hcl/pf 5 mg/ml vial,hcl/pf 7.5 mg/ml vial, hcl/pf 10 mg/ml vial) 1
RUBRACA (200 MG TABLET, 250 MG TABLET) 4
QL 2 / day
PA
AL At least 18 yrs old
S
RUBRACA 300 MG TABLET 4
QL 2 / day
PA
AL At least 18 yrs old
S
RYDAPT 4
QL 2 / day
PA
AL At least 18 yrs old
S
SENSORCAINE 1
SENSORCAINE WITH DEXTROSE 1
SENSORCAINE-MPF (0.25% AMPUL, 0.25% VIAL, 0.5% AMPUL,0.5% VIAL, 0.75% AMPUL, 0.75% VIAL) 1
silver (4" x 8" bandage, 4"x48" bandage, 8"x16" bandage,16"x16" bandage) 1
silver sulfadiazine/foam bandage (sulfadiaz/foam bandage 5%-2"x 2" bandage, sulfadiaz/foam bandage 5 %-4"x 4"bandage, sulfadiaz/foam bandage 5 %-6"x 6" bandage,sulfadiaz/foam bandage 5 %-8"x 8" bandage)
1
silver/foam bandage 1
PAGE 165 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
sodium succinate 1
SPRYCEL (100 MG TABLET, 140 MG TABLET) 4
QL 1 / day
PA
S
SPRYCEL (70 MG TABLET, 80 MG TABLET) 4
QL 2 / day
PA
S
SPRYCEL 20 MG TABLET 4
QL 9 / day
PA
S
SPRYCEL 50 MG TABLET 4
QL 3 / day
PA
S
STIVARGA 4
QL 4 / day
PA
S
STRENSIQ 4
PA
AL Up to 18 yrs old
S
PS
SUCRAID 4 S
SUTENT (37.5 MG CAPSULE, 50 MG CAPSULE) 4
QL 1 / day
PA
S
PS
SUTENT 12.5 MG CAPSULE 4
QL 7 / day
PA
S
PS
PAGE 166 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SUTENT 25 MG CAPSULE 4
QL 3 / day
PA
S
PS
SWABFLUSH 1
SYNRIBO 4PA
S
SYPRINE 4PA
S
syringe with needle, insulin, safety, 0.3 ml 2
syringe with needle, insulin, safety, 0.5 ml 2
syringe with needle, insulin, safety, 1 ml 2
syringe with needle,disposable,insulin 1 ml (syringe disp syrin,syringe 28gx1/2" disp syrin, syringe 29 g x1/2" disp syrin,syringe 30g x5/16" disp syrin, syringe 30gx1/2" disp syrin)
2
syringe with needle,insulin,0.3 ml 2
syringe with needle,insulin,0.5 ml (ml 28 gauge disp syrin, ml29 g x1/2" disp syrin, ml 30g x5/16" disp syrin, ml 30gx1/2"disp syrin)
2
syringe, disposable irrigation, 70 ml 1
syringe, insulin u-500 with needle, disposable, 0.5 ml 2
TAFINLAR 50 MG CAPSULE 4
QL 6 / day
PA
S
TAFINLAR 75 MG CAPSULE 4
QL 4 / day
PA
S
TAGRISSO 4
QL 1 / day
PA
AL At least 18 yrs old
S
PS
PAGE 167 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
tamoxifen citrate (10 mg tablet, 20 mg tablet) 0 HCR
TARCEVA (100 MG TABLET, 150 MG TABLET) 4
QL 1 / day
PA
S
TARCEVA 25 MG TABLET 4
QL 6 / day
PA
S
TARGRETIN 75 MG CAPSULE 4PA
S
TASIGNA 4
QL 4 / day
PA
S
PS
TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MG CAPSULE,140 MG CAPSULE, 180 MG CAPSULE, 250 MG CAPSULE) 4
PA
S
temozolomide 4PA
S
tetracaine hcl/pf 10 mg/ml ampul 1
thiotepa 15 mg vial 4 S
tretinoin 10 mg capsule 4QL 90 / 365 days
S
TYKERB 4
QL 6 / day
PA
S
PS
VALSTAR 4 S
VAXCHORA BUFFER COMPONENT 2
PAGE 168 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VENCLEXTA 4
QL 4 / day
PA
S
VENCLEXTA STARTING PACK 4
QL 1.5 / day
PA
S
VOSEVI 4
QL 1 / day
PA
AL At least 18 yrs old
S
PS
VOTRIENT 4
QL 4 / day
PA
S
water for inj.,bacteriostatic 1
water for inj.,bacteriostatic/methylparaben/propylparaben 1
water for injection,sterile (ampul, vial) 1
XALKORI 4
QL 2 / day
PA
S
XELODA 4
QL 4 / day
PA
S
XTANDI 4
QL 4 / day
PA
S
yohimbine hcl 5.4 mg tablet 1
ZEJULA 4
QL 3 / day
PA
AL At least 18 yrs old
S
PAGE 169 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZELBORAF 4
QL 8 / day
PA
S
ZOLINZA 4
QL 4 / day
PA
S
ZYDELIG 4
QL 2 / day
PA
S
ZYKADIA 4
QL 8 / day
PA
AL At least 18 yrs old
S
ZYTIGA 250 MG TABLET 4
QL 4 / day
PA
S
PS
ZYTIGA 500 MG TABLET 4
QL 2 / day
PA
S
PS
VASODILATING AGENTS
NITRATES AND NITRITES
ISOCHRON 1 QL 4 / day
isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg tablet, 30mg tablet) 1 QL 12 / day
isosorbide dinitrate 40 mg tablet er 1 QL 4 / day
PAGE 170 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
isosorbide mononitrate (10 mg tablet, 20 mg tablet, 30 mg taber 24h, 60 mg tab er 24h, 120 mg tab er 24h) 1 QL 2 / day
MINITRAN 1 QL 1 / day
NITRO-BID 2 QL 4 / day
NITRO-TIME 1 QL 4 / day
nitroglycerin (2.5 mg capsule er, 6.5 mg capsule er, 9 mgcapsule er) 1 QL 4 / day
nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24,0.4mg/hr patch td24, 0.6mg/hr patch td24) 1 QL 1 / day
nitroglycerin 400mcg/spr spray 3QL 0.8 / day
HCG
nitroglycerin (0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl) 1 QL 6 / day
PHOSPHODIESTERASE TYPE 5 INHIBITORS
CIALIS (10 MG TABLET, 20 MG TABLET) 2QL 0.2 / day
GL Male
CIALIS (2.5 MG TABLET, 5 MG TABLET) 2QL 1 / day
GL Male
VIAGRA 2
QL 0.2 / day
GL Male
AL At least 18 yrs old
VASODILATING AGENTS, MISCELLANEOUS
alprostadil 500 mcg/ml vial 1
isoxsuprine hcl (10 mg tablet, 20 mg tablet) 1
papaverine hcl 30 mg/ml vial 1
papaverine hcl/alprostadil in bacteriostatic water 1
PAGE 171 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VITAMINS
MULTIVITAMIN PREPARATIONS
ELDERCAPS 1
MATERNITY 1 GL Female
multivitamin-minerals no.44/cholecalciferol (vit d3)/vit k1 1
pedi multivit 65/cholecalciferol(vit d3)/phytonadione(vit k) 1
pediatric multivit no.22/cholecalciferol(d3)/phytonadione(k) 1
THERAPEUTIC VITAMIN W-MINERALS 1
V-C FORTE 1
VIC-FORTE 1
VITAMIN A
ped mvit a,c,d3 no.21/fluoride 0.25 mg/ml drops 1
VITAMIN B COMPLEX
B-12 KIT 1
cyanocobalamin (vitamin b-12) 1000mcg/ml vial 1
cyanocobalamin/folic acid/pyridoxine 1
FOLBEE 1
FOLBEE PLUS CZ 1
folic acid 1 mg tablet 1
folic acid 5 mg/ml vial 1
FOLPLEX 2.2 1
hydroxocobalamin 1000mcg/ml vial 1
pyridoxine hcl (vitamin b6) 100 mg/ml vial 1
RENA-VITE RX 1
thiamine hcl 100 mg/ml vial 1
thiamine hcl/riboflavin/niacinamide/dexpanthenol/pyridoxine 1
VIRT-CAPS SOFTGEL 1
PAGE 172 LAST UPDATED 11/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VIRT-GARD 1
VIRT-VITE 1
VIRT-VITE PLUS 1
VP-VITE RX 1
ZOLATE 1
VITAMIN C
ascorbic acid 500 mg/ml vial 1
VITAMIN D
calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/mlsolution) 1
doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcgcapsule) 4 S
ergocalciferol (vitamin d2) 50000 unit capsule 1
HECTOROL (0.5 MCG CAPSULE, 1 MCG CAPSULE, 2.5 MCGCAPSULE) 4 S
paricalcitol (1 mcg capsule, 2 mcg capsule, 4mcg capsule) 4 S
RAYALDEE 4 S
ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 4PA
S
PAGE 173 LAST UPDATED 11/2017
Index of Covered Drugs
00.9 % sodium chloride 93,155
AA-METHAPRED 105
abacavir sulfate 66
abacavir sulfate/lamivudine 66
abacavir sulfate/lamivudine/zidovudine 66
acamprosate calcium 84
acarbose 43
ACD 93
acebutolol hcl 27
acetaminophen with codeine phosphate 5
acetaminophen/caffeine/dihydrocodeine bitartrate 5
ACETASOL HC 21
acetazolamide 52
acetazolamide sodium 52
acetic acid 21
acetic acid/aluminum acetate 21
acetylcysteine 134
acetylcysteine in sterile water/pf 98
acitretin 148
ACTEMRA 128
ACTHIB 71
ACTIMMUNE 130
ACTOPLUS MET XR 44
ACUVAIL 25
acyclovir 22,76
ADACEL TDAP 71
adapalene 148,149
ADCIRCA 141
adefovir dipivoxil 76
ADEMPAS 141
ADVAIR DISKUS 3
ADVAIR HFA 3
AEROSPAN 87
AFEDITAB CR 83
AFINITOR 155
AFINITOR DISPERZ 155
AFLURIA 2016-2017 71
AFLURIA 2017-2018 155
AFLURIA QUAD 2016-2017 71
AFLURIA QUAD 2017-2018 155
AK-POLY-BAC 19
AKYNZEO 48
ALA-CORT 144
albuterol sulfate 3
alclometasone dipropionate 144
ALECENSA 155
alendronate sodium 127
alfentanil hcl 8
alfuzosin hcl 4
allopurinol 126
almotriptan malate 58
alosetron hcl 99
ALPHAGAN P 52
ALPHAQUIN HP 88
alprazolam 79
alprostadil 171
ALTACAINE 98
ALTAFLUOR 98
ALTAVERA 106
ALUNBRIG 155
ALYACEN 106
AMABELZ 95
amantadine hcl 60
amcinonide 144
AMETHIA 106
AMETHIA LO 106
AMETHYST 107
amikacin sulfate 30
amiloride hcl 89
amiloride hcl/hydrochlorothiazide 89
amiodarone hcl 28
AMITIZA 100
amitriptyline hcl 42
amitriptyline hcl/chlordiazepoxide 42
amlodipine besylate 83
amlodipine besylate/atorvastatin calcium 57
amlodipine besylate/benazepril hcl 83
amlodipine besylate/olmesartan medoxomil 83
amlodipine besylate/valsartan 83
amlodipine besylate/valsartan/hydrochlorothiazide 83
ammonium lactate 95
AMNESTEEM 149
amoxapine 43
amoxicillin 138
amoxicillin/potassium clavulanate 138,139
amphotericin b 50
ampicillin sodium 139
ampicillin sodium/sulbactam sodium 139
ampicillin trihydrate 139
AMPYRA 134
amyl nitrite 125
anagrelide hcl 69
anastrozole 156
ANDRODERM 106
ANDROGEL 106
ANORO ELLIPTA 3
antivenin,latrodectus mactans 70
antivenin,micrurus fulvius 70
ANUCORT-HC 144
ANUSOL-HC 144
APOKYN 92
apraclonidine hcl 98
aprepitant 49
APRI 107
APRISO 99
APTIVUS 68
ARANELLE 107
ARANESP 81
ARBINOXA 53
ARCALYST 135
aripiprazole 61
ARIXTRA 35
armodafinil 18
ARNUITY ELLIPTA 87
ASCOMP WITH CODEINE 8
ascorbic acid 173
ASHLYNA 107
aspirin/caffeine/dihydrocodeine bitartrate 69
aspirin/dipyridamole 69
ASTAGRAF XL 133
ASTRAMORPH-PF 8
atenolol 27,28
atenolol/chlorthalidone 28
ATIVAN 38
atomoxetine hcl 84
atorvastatin calcium 57
atovaquone 61
atovaquone/proguanil hcl 60
ATRIPLA 66
atropine sulfate 33,99
AUBAGIO 130
AUBRA 107
AUGMENTIN 139
AUSTEDO 84
AVANDAMET 44
AVANDIA 48
AVAR 22
AVAR-E 22
AVAR-E GREEN 22
AVIANE 107
AVIDOXY 31
AVITA 147
AVONEX 130
AVONEX PEN 131
azacitidine 156
azathioprine 128
azathioprine sodium 128
azelastine hcl 97
azithromycin 125
AZOPT 52
aztreonam 125
AZUPHEN MB 18
AZURETTE 107
BB-12 KIT 172
B-DONNA 33
B-PLEX PLUS 156
BACIIM 32
bacitracin 19,32
bacitracin/polymyxin b sulfate 19
baclofen 144
bacteriostatic sodium chloride 93
BACTROBAN NASAL 19
balanced salt irrig soln no.2 98
balsalazide disodium 99
BALZIVA 107
BARACLUDE 76
BEKYREE 107
benazepril hcl 140
benazepril hcl/hydrochlorothiazide 90
BENLYSTA 156
benoxinate hcl/fluorescein sodium 98
BENZEPRO 147
benzonatate 141
benzoyl peroxide 147
benzphetamine hcl 15
benztropine mesylate 35
betamethasone acetate/betamethasone sodium
phosphate 105
betamethasone dipropionate 144
betamethasone dipropionate/propylene glycol 144
betamethasone valerate 144
BETASERON 131
betaxolol hcl 28,52
bethanechol chloride 80
BETHKIS 30
bexarotene 156
BEXSERO 71
bicalutamide 156
bimatoprost 53
BIOGLO 88
BIOTHRAX 71
bismuth tribromophenate/petrolatum,white 156
bisoprolol fumarate 28
bisoprolol fumarate/hydrochlorothiazide 28
BLANCHE 88
BLEO 15K 156
bleomycin sulfate 156
BLISOVI 24 FE 107
BLISOVI FE 107
BOOSTRIX TDAP 71
BOSULIF 156
BOTOX COSMETIC 135
BP 10-1 22
BP-50% UREA 148
BPO 148
BRAVELLE 119
BREO ELLIPTA 3
BRIELLYN 107
BRILINTA 69
brimonidine tartrate 52
BROMFED DM 54
bromfenac sodium 25
bromocriptine mesylate 92
brompheniramine maleate/pseudoephedrine
hcl/dextromethorphan 54
BSS 98
budesonide 24,87,105
bumetanide 89
BUPHENYL 93
bupivacaine hcl/dextrose-water/pf 156
bupivacaine hcl/epinephrine 153
bupivacaine hcl/epinephrine bitartrate 153
bupivacaine hcl/epinephrine/pf 153
bupivacaine hcl/pf 156
buprenorphine hcl 13
buprenorphine hcl/naloxone hcl 14
BUPROBAN 39
bupropion hcl 39
buspirone hcl 78
butalbital/acetaminophen/caffeine 5
butalbital/acetaminophen/caffeine/codeine phosphate 5
butalbital/aspirin/caffeine 69,156
butorphanol tartrate 14
BYDUREON 46
BYDUREON PEN 46
BYETTA 46
BYSTOLIC 81
BYVALSON 81
Ccabergoline 92
CABOMETYX 156,157
caffeine citrate 17
caffeine/sodium benzoate 17
calcipotriene 149
calcipotriene/betamethasone dipropionate 144
calcitonin,salmon,synthetic 121
CALCITRENE 149
calcitriol 149,173
calcium acetate 124
CAMILA 108
CAMRESE 108
CAMRESE LO 108
CANASA 99
candesartan cilexetil 139
candesartan cilexetil/hydrochlorothiazide 90
CAPACET 5
capecitabine 157
CAPRELSA 157
captopril 140
captopril/hydrochlorothiazide 90
CARAC 149
CARAFATE 74
CARBAGLU 93
carbamazepine 36
CARBATROL 36
carbidopa 84
carbidopa/levodopa 60
carbidopa/levodopa/entacapone 60
carbinoxamine maleate 53
cardioplegic solution no.1 93
carisoprodol 143
carisoprodol/aspirin 138
carisoprodol/aspirin/codeine phosphate 8
carteolol hcl 52
CARTIA XT 29
carvedilol 4
catheter 157
CATHFLO ACTIVASE 69
CAYSTON 125
CAZIANT 108
cefaclor 86
cefadroxil 85
cefazolin sodium 86
cefdinir 86
cefditoren pivoxil 86
cefepime hcl 86
cefixime 86
cefotaxime sodium 86
cefotetan disodium 86
cefpodoxime proxetil 86
cefprozil 86
ceftazidime 86
ceftibuten 86
CEFTIN 86
ceftriaxone sodium 86
cefuroxime axetil 86
cefuroxime sodium 86
celecoxib 136
CELLCEPT 133
CENTERGY 54
CENTERGY DM 54
cephalexin 86
CERAMAX 157
CERDELGA 135
CERVARIX 71
cervical cap 157
CESAMET 49
cetirizine hcl 54
CETROTIDE 130
cevimeline hcl 80
CHANTIX 80
CHATEAL 108
CHENODAL 101
chlordiazepoxide hcl 79
chlordiazepoxide/clidinium bromide 33
chlorhexidine gluconate 21
chloroprocaine hcl/pf 157
chloroquine phosphate 60
chlorothiazide 89
chlorpromazine hcl 64
chlorpropamide 47
chlorthalidone 90
chlorzoxazone 143,157
CHOLBAM 101
cholestyramine (with sugar) 56
cholestyramine/aspartame 56
choline salicylate/magnesium salicylate 138
chorionic gonadotropin, human 119
CIALIS 171
CICLODAN 51
ciclopirox 51
ciclopirox olamine 51
CIDALEAZE 147
cilostazol 69
cimetidine 74
cimetidine hcl 74
CIMZIA 101
CIPRODEX 19
ciprofloxacin 31
ciprofloxacin hcl 19,31
ciprofloxacin/ciprofloxacin hcl 31
citalopram hydrobromide 40
citric acid/sodium citrate 92
CLARAVIS 149
clarithromycin 59
CLEANSING WASH 22
clemastine fumarate 53
CLEOCIN 21
CLIMARA PRO 95
CLINDACIN ETZ 21
CLINDACIN P 21
clindamycin hcl 33
clindamycin palmitate hcl 33
clindamycin phosphate 21,33
clindamycin phosphate/benzoyl peroxide 21
clindamycin phosphate/tretinoin 21
CLINPRO 5000 127
clobetasol propionate 144
clobetasol propionate/emollient base 145
clocortolone pivalate 145
CLODAN 145
clomiphene citrate 95
clomipramine hcl 43
clonazepam 38
clonidine 123,124
clonidine hcl 124
clopidogrel bisulfate 69
clorazepate dipotassium 38
clotrimazole 51
clotrimazole/betamethasone dipropionate 51
clozapine 61
coal tar 148
cocaine hcl 98
codeine phosphate/butalbital/aspirin/caffeine 8
codeine sulfate 8
colchicine 126
COLCRYS 126
colestipol hcl 56
colistin (as colistimethate sodium) 33
COLOCORT 145
COMBIGAN 52
COMBIVENT RESPIMAT 3
COMBIVIR 66
COMETRIQ 157
COMPAZINE 49
COMPLERA 66
COMPOUND 347 103
compressor, for nebulizer 157
COMPRO 49
conception assistance supplies combination no.1 157
CONSTULOSE 93
COPAXONE 131
COPEGUS 76
CORDARONE 28
CORLANOR 84
CORMAX 145
cortisone acetate 105
COSENTYX (2 SYRINGES) 149
COSENTYX PEN 149
COSENTYX PEN (2 PENS) 149
COSENTYX SYRINGE 149
cosyntropin 88
COTELLIC 158
COUMADIN 35
COVARYX 95
COVARYX H.S. 95
CREON 101
CRIXIVAN 68
cromolyn sodium 25
CRYSELLE 108
CUVITRU 70
cyanocobalamin (vitamin b-12) 172
cyanocobalamin/folic acid/pyridoxine 172
CYCLAFEM 108
cyclobenzaprine hcl 143
cyclopentolate hcl 99
cyclopentolate hcl/lidocaine
hcl/phenylephrine/tropicamide 98
cyclopentolate hcl/tropicamide/phenylephrine hcl in
water 99
cyclophosphamide 133
cycloserine 59
cyclosporine 128
cyclosporine, modified 128
cyproheptadine hcl 53
CYRED 108
CYSTADANE 135
CYSTAGON 135
CYSTARAN 98
cytarabine 158
cytarabine/pf 158
CYTRA-2 92
CYTRA-K 92
DDAKLINZA 104
danazol 106
dantrolene sodium 144
dapsone 59,149
DAPTACEL DTAP 71
darifenacin hydrobromide 103
DASETTA 108
DAYSEE 108
DEBLITANE 108
deferoxamine mesylate 125
DELTASONE 105
DELYLA 108
demeclocycline hcl 31
DENTA 5000 PLUS 127
DENTAGEL 127
DEPADE 85
DEPAKOTE ER 36
DEPAKOTE SPRINKLE 36
DEPEN 128
DEPO-SUBQ PROVERA 104 123
DERMAZENE 22
DESCOVY 66
desipramine hcl 43
desloratadine 54
desmopressin acetate 53
desmopressin acetate (non-refrigerated) 121
desogestrel-ethinyl estradiol 109
desogestrel-ethinyl estradiol/ethinyl estradiol 109
desonide 145
desoximetasone 145
desvenlafaxine 40
desvenlafaxine fumarate 40
desvenlafaxine succinate 40
dexamethasone 105
DEXAMETHASONE INTENSOL 105
dexamethasone sod phosphate 24
dexchlorpheniramine maleate 158
DEXEDRINE 15
dexmethylphenidate hcl 17
dextroamphetamine sulf-saccharate/amphetamine sulf-
aspartate 16
dextroamphetamine sulfate 16
diaphragms, wide seal 158
diazepam 38
diclofenac potassium 136
diclofenac sodium 25,136,149
diclofenac sodium/misoprostol 74
dicloxacillin sodium 139
dicyclomine hcl 33
didanosine 66
diethylpropion hcl 14
diflorasone diacetate 145
diflunisal 136
DIGITEK 26
DIGOX 26
digoxin 26
dihydroergotamine mesylate 4
DILANTIN 27
DILANTIN-125 27
DILT-XR 29
diltiazem hcl 29
dimenhydrinate 49
diphenhydramine hcl 54
diphenoxylate hcl/atropine sulfate 33
dipyridamole 69
disopyramide phosphate 27
disulfiram 125
divalproex sodium 37
DIVIGEL 95
dofetilide 28
donepezil hcl 80
dorzolamide hcl 52
dorzolamide hcl/timolol maleate 52
doxazosin mesylate 4
doxepin hcl 43,147
doxercalciferol 173
doxycycline hyclate 19,32
doxycycline monohydrate 32
dronabinol 49
droperidol 78
drospirenone/ethinyl estradiol/levomefolate calcium 109
DUAVEE 95
duloxetine hcl 40
DUOPA 60
DUPIXENT 150
DURAMORPH 8
dutasteride 125
dutasteride/tamsulosin hcl 5
DYMISTA 55
Eeconazole nitrate 51
ED-SPAZ 33
edetate calcium disodium 126
EDURANT 66
EEMT 96
EEMT H.S. 96
EFFER-K 94
EGRIFTA 153
ELDERCAPS 172
eletriptan hbr 58
ELIDEL 133
ELIGARD 119
ELINEST 109
ELLA 109
EMBEDA 8
EMCYT 158
EMFLAZA 105
EMOQUETTE 109
EMTRIVA 66
enalapril maleate 140
enalapril maleate/hydrochlorothiazide 90
ENBREL 128
ENDOCET 5
ENDOMETRIN 123
ENGERIX-B ADULT 71
ENGERIX-B PEDIATRIC-ADOLESCENT 71
ENJUVIA 96
enoxaparin sodium 36
ENPRESSE 109
ENSKYCE 109
entacapone 60
entecavir 76
ENULOSE 93
ENVARSUS XR 133
EPCLUSA 104
epinastine hcl 98
epinephrine 3
epinephrine hcl/pf 3
epinephrine/pf 3
EPITOL 37
EPIVIR 67
EPIVIR HBV 67
eplerenone 90
EPOGEN 81
eprosartan mesylate 139
EPZICOM 67
ergocalciferol (vitamin d2) 173
ergoloid mesylates 4
ergotamine tartrate/caffeine 4
ERIVEDGE 158
ERRIN 109
ERWINAZE 158
ERY 22
ERYPED 200 30
erythromycin base 19,30
erythromycin base/benzoyl peroxide 22
erythromycin base/ethyl alcohol 22
erythromycin ethylsuccinate 31
ESBRIET 141
escitalopram oxalate 40,41
ESGIC 6
esomeprazole magnesium 74
esomeprazole strontium 74
ESTARYLLA 109
estazolam 79
ESTRACE 96
estradiol 96
estradiol valerate 96
estradiol/norethindrone acetate 96
ESTRING 96
estrogens,esterified/methyltestosterone 96
estropipate 96
eszopiclone 78
ethacrynic acid 89
ethambutol hcl 59
ethinyl estradiol/drospirenone 109
ethosuximide 39
ethyl acetate 158
ethyl alcohol 135
ethyl chloride 147
ethynodiol diacetate-ethinyl estradiol 109
etidronate disodium 127
etodolac 137
EUCRISA 145
EVOTAZ 68
exemestane 158
EXJADE 158
EXODERM 51
EXTAVIA 131
EZ FLU 16-17 (FLUZON QUAD PED) 71
EZ FLU 2016-2017 (AFLURIA) 71
EZ FLU 2016-2017 (FLUVIRIN) 71
ezetimibe 56
ezetimibe/simvastatin 56
FFALMINA 109
famciclovir 76
famotidine 74
FARESTON 158
FARYDAK 158
FAYOSIM 110
felbamate 37
felodipine 82
FEMYNOR 110
fenofibrate 56
fenofibrate nanocrystallized 56
fenofibrate,micronized 56,57
fenofibric acid 57
fenofibric acid (choline) 57
fenoprofen calcium 137
fentanyl 8
fentanyl citrate 8
fentanyl citrate in 0.9 % sodium chloride/pf 8
fentanyl citrate/bupivacaine hcl in 0.9 % sodium
chloride/pf 9
fentanyl citrate/pf 9
fentanyl citrate/ropivacaine hcl/sodium chloride 0.9%/pf 9
FEROCON 26
FEROTRINSIC 26
FERRIPROX 158
FERROCITE PLUS 26
fexofenadine hcl 54
fexofenadine hcl/pseudoephedrine hcl 158
finasteride 125,150
FIRAZYR 128
FIRMAGON 130
flavoxate hcl 103
flecainide acetate 27
FLOVENT DISKUS 87
FLOVENT HFA 87
floxuridine 158
FLUAD 2016-2017 71
FLUAD 2017-2018 159
FLUARIX QUAD 2016-2017 71
FLUARIX QUAD 2017-2018 159
FLUBLOK 2016-2017 72
FLUBLOK 2017-2018 159
FLUBLOK QUAD 2017-2018 159
FLUCAINE 88
FLUCELVAX QUAD 2016-2017 72
FLUCELVAX QUAD 2017-2018 159
fluconazole 50
flucytosine 51
fludrocortisone acetate 105
FLULAVAL QUAD 2016-2017 72
FLULAVAL QUAD 2017-2018 159
flunisolide 24
fluocinolone acetonide 145
fluocinolone acetonide oil 24
fluocinolone acetonide/shower cap 145
fluocinonide 145
fluocinonide/emollient base 145
FLUOR-A-DAY 127
FLUOR-I-STRIP AT 88
fluoride (sodium) 127
FLUORIDEX 127
FLUORIDEX DAILY DEFENSE 127
FLUORIDEX SENSITIVITY RELIEF 127
FLUORITAB 127
fluorometholone 24
FLUOROPLEX 150
fluorouracil 150
fluoxetine hcl 41
fluphenazine decanoate 64
fluphenazine hcl 64,65
FLURA-DROPS 128
flurazepam hcl 79
flurbiprofen 137
flurbiprofen sodium 25
FLUROX 98
flutamide 159
fluticasone propionate 24,145
fluticasone propionate/salmeterol xinafoate 3
fluvastatin sodium 57
FLUVIRIN 2016-2017 72
FLUVIRIN 2017-2018 159
fluvoxamine maleate 41
FLUZONE HIGH-DOSE 2016-2017 72
FLUZONE HIGH-DOSE 2017-2018 159
FLUZONE INTRADERM QUAD 2016-17 72
FLUZONE INTRADERM QUAD 2017-18 159
FLUZONE QUAD 2016-2017 72
FLUZONE QUAD 2017-2018 159
FLUZONE QUAD PEDI 2016-2017 72
FLUZONE QUAD PEDI 2017-2018 159
foam bandage 159
FOLBEE 172
FOLBEE PLUS CZ 172
folic acid 172
FOLLISTIM AQ 119
FOLPLEX 2.2 172
fondaparinux sodium 35
FORMADON 150
formaldehyde 150
FORTEO 121
fosamprenavir calcium 68
fosinopril sodium 140
fosinopril sodium/hydrochlorothiazide 90
FOSRENOL 124
FRAGMIN 36
frovatriptan succinate 59
FUL-GLO 88
FULYZAQ 100
furosemide 89
FUZEON 65
FYAVOLV 97
Ggabapentin 6
GABITRIL 37
galantamine hbr 80
GAMMAGARD LIQUID 70
GAMMAKED 70
GAMUNEX-C 70
ganirelix acetate 130
GARDASIL 72
GARDASIL 9 72
gatifloxacin 19
GATTEX 101
GAVILYTE-C 100
GAVILYTE-G 100
GAVILYTE-N 100
gel dressing 159
gemfibrozil 57
GENERLAC 93
GENGRAF 129
GENOTROPIN 122
GENTAK 19
gentamicin sulfate 19,20,22,30
gentamicin sulfate/pf 30
GENVOYA 65
GIANVI 110
GILDAGIA 110
GILDESS 110
GILDESS 24 FE 110
GILDESS FE 110
GILENYA 131
GILOTRIF 159
GLATOPA 131
GLEEVEC 159
glimepiride 47
glipizide 47
glipizide/metformin hcl 44
GLUCAGEN 55
GLUCAGON EMERGENCY KIT 55
glucagon hcl 55
glutaraldehyde 160
glyburide 47
glyburide,micronized 48
glyburide/metformin hcl 44
glycopyrrolate 34,160
GLYDO 98
GOLYTELY 100
GONAL-F 119
GONAL-F RFF 120
GONAL-F RFF REDI-JECT 120
granisetron hcl 48
GRANIX 81
griseofulvin ultramicrosize 50
griseofulvin, microsize 50
guaiacol 23
guanfacine hcl 84
guanidine hcl 80
HH.P. ACTHAR 88
halobetasol propionate 145
haloperidol 64
haloperidol decanoate 64
haloperidol lactate 64
HARVONI 104
HAVRIX 72
HEATHER 110
HECTOROL 173
HEMANGEOL 28
HEMATINIC PLUS 26
HEMATINIC WITH FOLIC ACID 26
HEMAX 26
HEMMOREX-HC 145
HEMOCYTE-F 26
heparin sodium,porcine 36
heparin sodium,porcine/pf 36
HEPSERA 76
HETLIOZ 78
HEXALEN 160
HIBERIX 72
HIZENTRA 70
HOMATROPAIRE 99
homatropine hbr 99
HUMALOG 46
HUMALOG JUNIOR KWIKPEN 160
HUMALOG KWIKPEN U-100 46
HUMALOG KWIKPEN U-200 46
HUMALOG MIX 50-50 47
HUMALOG MIX 50-50 KWIKPEN 47
HUMALOG MIX 75-25 47
HUMALOG MIX 75-25 KWIKPEN 47
HUMATROPE 122
HUMIRA 101
HUMIRA PEDIATRIC CROHN'S 102
HUMIRA PEN 102
HUMIRA PEN CROHN-UC-HS STARTER 102
HUMIRA PEN PSORIASIS-UVEITIS 102
HUMULIN R U-500 47
HUMULIN R U-500 KWIKPEN 47
HYCAMTIN 160
hydralazine hcl 124
hydrochlorothiazide 89
hydrocodone bitart/chlorpheniramine
maleate/pseudoephedrine 9
hydrocodone bitartrate/acetaminophen 6
hydrocodone bitartrate/homatropine methylbromide 34
hydrocodone polistirex/chlorpheniramine polistirex 54
hydrocodone/ibuprofen 9
hydrocolloid dressing 160
hydrocortisone 105,145
hydrocortisone acetate 145
hydrocortisone acetate/iodoquinol/aloe vera 23
hydrocortisone acetate/lidocaine hcl/aloe vera 145
hydrocortisone acetate/pramoxine hcl 146
hydrocortisone butyrate 146
hydrocortisone butyrate/emollient base 146
hydrocortisone valerate 146
hydrocortisone/acetic acid 21
hydrocortisone/iodoquinol 23
hydrocortisone/mineral oil/petrolatum,white 146
HYDROMET 34
hydromorphone hcl 9,10
hydromorphone hcl/pf 10
hydroquinone 88
hydroquinone microspheres 88
hydroxocobalamin 172
hydroxychloroquine sulfate 60
hydroxyprogesterone caproate 123
hydroxyurea 160
hydroxyzine hcl 78
hydroxyzine pamoate 78
HYOPHEN 18
hyoscyamine sulfate 34
HYOSYNE 34
HYPERHEP B S-D 70
HYPERRAB S-D 70
HYPERTET S-D 70
HYQVIA 70
HYQVIA HY COMPONENT 160
HYQVIA IG COMPONENT 70
Iibandronate sodium 127
IBRANCE 160
IBUDONE 10
ibuprofen 137
ibuprofen/oxycodone hcl 10
ICLUSIG 160
ILARIS 135
ILOTYCIN 20
IMBRUVICA 160
imipramine hcl 43
imipramine pamoate 43
imiquimod 150
IMOGAM RABIES-HT 70
IMOVAX RABIES VACCINE 72
IMPAVIDO 61
INCRELEX 153
INCRUSE ELLIPTA 34
indapamide 90
INDIGO CARMINE 88
indigotindisulfonate sodium in water for injection,sterile 88
INDIOMIN MB 18
indocyanine green 88
indomethacin 126
INFANRIX DTAP 71
INFED 26
INGREZZA 84,161
inhaler, assist devices 161
inhaler, assist devices, accessories 161
INLYTA 161
INTELENCE 66
INTRON A 75
INTROVALE 110
INVIRASE 68
INVOKAMET 44
INVOKAMET XR 44
INVOKANA 47
IPOL 72,161
ipratropium bromide 34,98
ipratropium bromide/albuterol sulfate 3
IPRIVASK 36
irbesartan 140
irbesartan/hydrochlorothiazide 91
IRESSA 161
ISENTRESS 65
ISENTRESS HD 65
ISIBLOOM 110
ISOCHRON 170
isoflurane 103
isometheptene mucate/caffeine/acetaminophen 6
isometheptene
mucate/dichloralphenazone/acetaminophen 6
isoniazid 59
isoproterenol hcl 161
isosorbide dinitrate 170
isosorbide mononitrate 171
isoxsuprine hcl 171
isradipine 82
itraconazole 50
ivermectin 18
IXIARO 72
JJADENU 161
JADENU SPRINKLE 161
JAKAFI 161
JANTOVEN 35
JANUMET 44
JANUMET XR 44,45
JANUVIA 46
JARDIANCE 47
JENCYCLA 110
JENTADUETO 45
JENTADUETO XR 45
JINTELI 97
JOLESSA 110
JOLIVETTE 111
JULEBER 111
JUNEL 111
JUNEL FE 111
JUNEL FE 24 111
JUXTAPID 55
KK EFFERVESCENT 94
K-SOL 94
KAITLIB FE 111
KALETRA 68
KALYDECO 87
KARIVA 111
KELNOR 1-35 111
ketamine hcl 103
ketoconazole 50,51
ketoprofen 137
ketorolac tromethamine 25,137
KEVEYIS 135
KEVZARA 129
KIMIDESS 111
KINRIX 72
KIONEX 124
KISQALI 161,162
KISQALI FEMARA CO-PACK 162
KITABIS PAK 30
KLOFENSAID II 137
KLOR-CON 94
KLOR-CON 10 94
KLOR-CON 8 94
KLOR-CON M10 94
KLOR-CON M15 94
KLOR-CON M20 94
KLOR-CON SPRINKLE 94
KLOR-CON-EF 94
KORLYM 44
KRISTALOSE 93
KURVELO 111
KUVAN 135
KYNAMRO 55
Llabetalol hcl 5
lactic acid 95
lactulose 93
lamivudine 67
lamivudine/zidovudine 67
lamotrigine 37
lancing device/lancets 162
LANOXIN 26
LANOXIN PEDIATRIC 26
lansoprazole 74
lansoprazole/amoxicillin trihydrate/clarithromycin 74
lanthanum carbonate 124
LANTUS 47
LANTUS SOLOSTAR 47
LARIN 111
LARIN 24 FE 111
LARIN FE 111
LARISSIA 112
latanoprost 53
LATRIX 148
LAYOLIS FE 112
LEENA 112
leflunomide 129
LENVIMA 162
LESSINA 112
LETAIRIS 142
letrozole 162
leucovorin calcium 126
LEUKINE 81
leuprolide acetate 120
levalbuterol hcl 3
levetiracetam 37
LEVO-T 154
levobunolol hcl 52
levocarnitine 135
levocarnitine (with sugar) 135
levocetirizine dihydrochloride 54
levofloxacin 20,31
LEVONEST 112
levonorgestrel 112
levonorgestrel-ethinyl estradiol 112
levonorgestrel/ethinyl estradiol and ethinyl
estradiol 112,113
LEVORA-28 113
levorphanol tartrate 10
levothyroxine sodium 154
LEVOXYL 154
LEXIVA 68
LIALDA 99
lidocaine 147
lidocaine hcl 27,98,147,162
lidocaine hcl/epinephrine 154
lidocaine hcl/epinephrine bitartrate 154
lidocaine hcl/hydrocortisone acetate 146
lidocaine hcl/pf 27,162
lidocaine/prilocaine 147
lidocaine/tetracaine 147
LIDOPIN 147
LIDOPRIL 147
LIDORX 147
LILLOW 113
lincomycin hcl 33
lindane 24
linezolid 33
LINZESS 102
liothyronine sodium 155
lisinopril 140
lisinopril/hydrochlorothiazide 91
lithium carbonate 84
lithium citrate 84
LO LOESTRIN FE 113
LOESTRIN FE 113
LOMAIRA 14
LOMEDIA 24 FE 113
lomustine 162
LONSURF 162,163
loperamide hcl 100
lopinavir/ritonavir 68
LOPREEZA 97
lorazepam 39
LORAZEPAM INTENSOL 39
LORCET 6
LORCET HD 6
LORCET PLUS 6
LORTAB 7
LORYNA 113
LORZONE 143
losartan potassium 140
losartan potassium/hydrochlorothiazide 91
lovastatin 57
LOVENOX 36
LOW-OGESTREL 113
loxapine succinate 61
LP LITE PAK 147
LUCENTIS 98
LUDENT FLUORIDE 128
LUGOL'S 23,50
LUMIGAN 53
LUPANETA PACK 120
LUPRON DEPOT 120
LUPRON DEPOT (LUPANETA) 120
LUPRON DEPOT-PED 120
LUTERA 113
LUXAMEND 95
LYNPARZA 163
LYSIPLEX PLUS 93
LYSODREN 163
LYZA 113
MM-M-R II VACCINE 72
magnesium chloride 37
magnesium sulfate 26
MAKENA 123
malathion 24
mannitol/sorbitol solution 89
maprotiline hcl 43
MARGESIC 7
MARLISSA 113
MARTEN-TAB 7
MATERNITY 172
MATULANE 163
MATZIM LA 29
MAVYRET 163
MD-GASTROVIEW 89
meclizine hcl 49
meclofenamate sodium 137
MEDROL 105
medroxyprogesterone acetate 123
mefenamic acid 137
mefloquine hcl 60
megestrol acetate 163
MEKINIST 163
MELODETTA 24 FE 114
meloxicam 137,138
MELPAQUE HP 88
melphalan 163
memantine hcl 85
MENACTRA 72
MENEST 97
MENHIBRIX 72
MENOMUNE-A-C-Y-W-135 72
MENOPUR 120
MENVEO A-C-Y-W-135-DIP 72
MENVEO MENA COMPONENT 72
MENVEO MENCYW-135 COMPONENT 72
meperidine hcl 10
meperidine hcl/pf 10,11
MEPHYTON 126
mepivacaine hcl/pf 163
meprobamate 78
mercaptopurine 134
mesalamine 99
mesalamine with cleansing wipes 99
MESNEX 136
MESTINON 80
METADATE ER 17
metaproterenol sulfate 3
METAXALL 143
metaxalone 143
metformin hcl 45
methadone hcl 11,163
METHADONE INTENSOL 11
methamphetamine hcl 16
methazolamide 52
methenamine hippurate 18
methenamine mandelate 18
methenamine/sod phosph,monobasic/methylene
blue/hyoscyamine 18
METHERGINE 163
methimazole 154
methocarbamol 143
methotrexate sodium 129
methotrexate sodium/pf 129
methoxsalen 88
methscopolamine bromide 34
methyclothiazide 89
methyldopa 124
methyldopa/hydrochlorothiazide 91
methylene blue/gentian violet/foam bandage 163
methylergonovine maleate 164
methylphenidate hcl 17,18
methylprednisolone 105
methylprednisolone acetate 105
methylprednisolone sodium succinate 105
methyltestosterone 106
metipranolol 52
metoclopramide hcl 102,103
metolazone 90
metoprolol succinate 28
metoprolol tartrate 28
metoprolol tartrate/hydrochlorothiazide 28
metronidazole 22,60
mexiletine hcl 27
MIACALCIN 121
MIBELAS 24 FE 114
MICROGESTIN 114
MICROGESTIN 24 FE 114
MICROGESTIN FE 114
midazolam hcl 79
midazolam hcl/pf 79
middle ear inflation device 164
midodrine hcl 154
miglitol 43
MIMVEY 97
MIMVEY LO 97
MINITRAN 171
minocycline hcl 32
minoxidil 124
MIRCERA 81
mirtazapine 39
MIRVASO 150
misoprostol 74
modafinil 18
MODERIBA 76
moexipril hcl 140
moexipril hcl/hydrochlorothiazide 91
molindone hcl 61
mometasone furoate 24,146
MONDOXYNE NL 32
MONO-LINYAH 114
MONOJECT 0.9% SODIUM CHLORIDE 94
MONOJECT PREFILL 94
MONOJECT PREFILL ADVANCED 94
MONONESSA 114
montelukast sodium 25
MORGIDOX 32
morphine sulfate 11,12
morphine sulfate/pf 12
MOVIPREP 100
MOXEZA 20
moxifloxacin hcl 20,31
MOZOBIL 81
multivitamin-minerals no.44/cholecalciferol (vit d3)/vit
k1 172
mupirocin 22
mupirocin calcium 22
MUSTARGEN 164
MYALEPT 121
mycophenolate mofetil 134
mycophenolate sodium 134
MYFORTIC 134
MYLERAN 164
MYORISAN 150
MYRBETRIQ 80
MYTESI 100
MYZILRA 114
NNABI-HB 70
nabumetone 138
nadolol 28
nadolol/bendroflumethiazide 28
nafcillin sodium 139
naftifine hcl 51
nalbuphine hcl 14
naloxone hcl 85
naltrexone hcl 85
naphazoline hcl 99
naproxen 126
naproxen sodium 126
naratriptan hcl 59
NATAZIA 114
nateglinide 47
NATPARA 121
nebulizer 164
nebulizer accessories 164
NEBUSAL 94
NECON 114
nefazodone hcl 42
NEO-POLYCIN 20
NEO-POLYCIN HC 20
neomycin sulfate 30
neomycin sulfate/bacitracin zinc/polymyxin
b/hydrocortisone 20
neomycin sulfate/bacitracin/polymyxin b 20
neomycin sulfate/polymyxin b sulfate/gramicidin d 20
neomycin sulfate/polymyxin b sulfate/hydrocortisone 20
neomycin/polymyxin b sulfate/dexamethasone 20
NEORAL 129
NEUAC 22
NEULASTA 81
NEUPOGEN 82
nevirapine 66
NEXAVAR 164
niacin 55
nicardipine hcl 83
NIFEDICAL XL 83
nifedipine 83
NIKKI 114
NILANDRON 164
nilutamide 164
nimodipine 83
NINLARO 164
nisoldipine 82
NITRO-BID 171
NITRO-TIME 171
nitrofurantoin 18
nitrofurantoin macrocrystal 18
nitrofurantoin monohydrate/macrocrystals 18
nitroglycerin 171
nizatidine 74
NODOLOR 7
NORA-BE 114
NORCO 7
NORDITROPIN FLEXPRO 122
norethindrone 115
norethindrone acetate 123
norethindrone acetate-ethinyl estradiol 97,115
norethindrone acetate-ethinyl estradiol/ferrous
fumarate 115
norethindrone-ethinyl estradiol/ferrous fumarate 115
norgestimate-ethinyl estradiol 115
NORINYL 1+50 115
NORLYDA 115
NORLYROC 115
NORPACE CR 27
NORTHERA 154
NORTREL 115
nortriptyline hcl 43
NORVIR 68
NOVAREL 120,164
NP THYROID 155
NUEDEXTA 85
NULEV 34
NUPLAZID 61
NUTROPIN AQ 122
NUTROPIN AQ NUSPIN 122
NUVARING 115
NYAMYC 51
NYATA 51
nystatin 50,52
nystatin/triamcinolone acetonide 52
NYSTOP 52
OOBSTETRIX ONE 26
OCALIVA 102
OCELLA 115
octreotide acetate 152
OCUCOAT 98
ODEFSEY 66
ODOMZO 164
OFEV 141
ofloxacin 20,31
OGESTREL 115
olanzapine 62
olanzapine/fluoxetine hcl 41
olmesartan medoxomil 140
olmesartan medoxomil/amlodipine
besylate/hydrochlorothiazide 91
olmesartan medoxomil/hydrochlorothiazide 91
olopatadine hcl 98
OLYSIO 104
omega-3 acid ethyl esters 55
omeprazole 75
omeprazole/sodium bicarbonate 75
OMNITROPE 122
ONCASPAR 164
ondansetron 48
ondansetron hcl 48,49
ondansetron hcl/pf 49
ONFI 39
opium tincture 100
opium/belladonna alkaloids 12
OPSUMIT 142
ORAFATE 164
ORALAIR 135
ORALONE 146
ORENCIA 129
ORENCIA CLICKJECT 129
ORENITRAM ER 142
ORFADIN 135
ORKAMBI 87
orphenadrine citrate 144
ORSYTHIA 115
OSCIMIN 34
OSCIMIN SL 34
OSCIMIN SR 34
oseltamivir phosphate 76
OTEZLA 129
OVIDREL 121
oxacillin sodium 139
oxandrolone 106
oxaprozin 138
oxazepam 79
oxcarbazepine 37
oxiconazole nitrate 51
oxybutynin chloride 103
oxycodone hcl 12
oxycodone hcl/acetaminophen 7
oxycodone hcl/aspirin 13
oxymorphone hcl 13
oxytocin 164
PPACERONE 28
PACNEX 148
paliperidone 62
pantoprazole sodium 75
papaverine hcl 171
papaverine hcl/alprostadil in bacteriostatic water 171
paregoric 100
paricalcitol 173
PAROEX 21
paromomycin sulfate 30
paroxetine hcl 41,42
paroxetine mesylate 42
pedi multivit 65/cholecalciferol(vit d3)/phytonadione(vit
k) 172
PEDIARIX 71
pediatric multivit
no.22/cholecalciferol(d3)/phytonadione(k) 172
pediatric multivit with a,c,d3 no.21/sodium fluoride 172
pediatric multivitamin no.150 with sodium fluoride 128
pediatric multivitamin no.2/sodium fluoride 128
pediatric multivitamin no.45/sodium fluoride/ferrous
sulfate 26
PEDVAXHIB 73
peg 3350/sod sulf/sod bicarb/sod chloride/potassium
chloride 100
PEG-PREP 100
PEGASYS 75
PEGASYS PROCLICK 75
PEGINTRON 75
PEGINTRON REDIPEN 75
pen needle, diabetic 164
penicillin g potassium 139
penicillin g procaine 139
penicillin g sodium 139
penicillin v potassium 139
PENTACEL 73
PENTACEL DTAP-IPV COMPONENT 73
pentazocine hcl/naloxone hcl 14
pentobarbital sodium 79
pentoxifylline 82
perindopril erbumine 140
PERIOGARD 21
permethrin 24
perphenazine 65
perphenazine/amitriptyline hcl 43
PHENADOZ 78
phenazopyridine hcl 147
phendimetrazine tartrate 15
phenelzine sulfate 40
PHENERGAN 78
phenobarbital 38
phenobarbital sodium 38
phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine
hb 34
PHENOHYTRO 34
phenol 23
phenoxybenzamine hcl 4
phentermine hcl 15
phentolamine mesylate 4
phentolamine mesylate/alprostadil in bacteriostatic water 4
phenylephrine hcl 99,154
phenylephrine hcl/promethazine hcl 54
PHENYTEK 27
phenytoin 27
phenytoin sodium extended 27
PHILITH 116
PHOSPHA 250 NEUTRAL 92
PHOSPHASAL 18
physostigmine salicylate 80
phytonadione (vit k1) 126
pilocarpine hcl 53,80
pimozide 61
PIMTREA 116
pindolol 28
pioglitazone hcl 48
pioglitazone hcl/glimepiride 48
pioglitazone hcl/metformin hcl 45
PIRMELLA 116
piroxicam 138
PLEGRIDY 131
PLEGRIDY PEN 132
PNEUMOVAX 23 73
podofilox 150
POLOCAINE 165
POLOCAINE-MPF 165
POLYCIN 20
polyethylene glycol 3350 100
polymyxin b sulfate 33
polymyxin b sulfate/trimethoprim 20
POLYSACCHARIDE IRON FORTE 26
POMALYST 132
PORTIA 116
potassium bicarbonate/citric acid 94
potassium chloride 94
potassium chloride/potassium bicarbonate/citric acid 94
potassium citrate 92
potassium citrate/citric acid 92
potassium hydroxide 148
potassium iodide/iodine 50
povidone-iodine 21
PR BENZOYL PEROXIDE 148
PRADAXA 36
pralidoxime chloride 126
PRALUENT PEN 58
PRALUENT SYRINGE 58
PRAMCORT 146
pramipexole di-hcl 92
prasugrel hcl 69
pravastatin sodium 57
prazosin hcl 4
prednicarbate 146
prednisolone 105
prednisolone acetate 25
prednisolone sod phosphate 25,105
prednisone 105
PREDNISONE INTENSOL 105
PREGNYL 121
PREMARIN 97
PREMPHASE 97
PREMPRO 97
PREVALITE 56
PREVIFEM 116
PREVNAR 13 73
PREZCOBIX 68
PREZISTA 68
primaquine phosphate 60
primidone 38
PROAIR HFA 3
PROAIR RESPICLICK 3
probenecid 94
probenecid/colchicine 95
procainamide hcl 27
prochlorperazine 49
prochlorperazine edisylate 50
prochlorperazine maleate 50
PROCRIT 82
PROCTO-MED HC 146
PROCTO-PAK 146
PROCTOFOAM-HC 146
PROCTOSOL-HC 146
PROCTOZONE-HC 146
PROCYSBI 135
progesterone 123
progesterone, micronized 123
PROGRAF 134
PROMACTA 82
promethazine hcl 54,78
promethazine hcl/codeine 54
promethazine hcl/dextromethorphan hbr 55
promethazine/phenylephrine hcl/codeine 13
PROMETHEGAN 79
propafenone hcl 27
propantheline bromide 34
proparacaine hcl 99
proparacaine hcl/fluorescein sodium 88
propranolol hcl 28
propranolol hcl/hydrochlorothiazide 28
propylthiouracil 154
PROQUAD 73
PROTHELIAL 165
protriptyline hcl 43
PULMICORT FLEXHALER 87
PULMOSAL 94
PULMOZYME 141
PURIXAN 134
PYLERA 32
pyrazinamide 59
pyridostigmine bromide 80
pyridoxine hcl (vitamin b6) 172
PYROGALLIC ACID 150
QQUADRACEL DTAP-IPV 73
QUASENSE 116
quazepam 79
quetiapine fumarate 62,63
quinapril hcl 140
quinapril hcl/hydrochlorothiazide 91
quinidine gluconate 27
quinidine sulfate 27
quinine sulfate 60
RRABAVERT 73
rabeprazole sodium 75
RAJANI 116
raloxifene hcl 95
ramipril 141
RANEXA 84
ranitidine hcl 74
RAPAFLO 5
RAPAMUNE 134
rasagiline mesylate 40
RAVICTI 93
RAYALDEE 173
REA LO 40 148
REBETOL 77
REBIF 132
REBIF REBIDOSE 132
RECLIPSEN 116
RECOMBIVAX HB 73
RECOTHROM 53
REMEVEN 148
REMODULIN 142
RENA-VITE RX 172
RENVELA 124
repaglinide 47
repaglinide/metformin hcl 45
REPATHA PUSHTRONEX 58
REPATHA SURECLICK 58
REPATHA SYRINGE 58
REPREXAIN 13
RESCRIPTOR 66
reserpine 124
RESTASIS 25
RESTASIS MULTIDOSE 25
RETROVIR 67
REVATIO 142
REVLIMID 132
REYATAZ 68
RIBASPHERE 77
RIBASPHERE RIBAPAK 77
RIBATAB 77
ribavirin 77
RIDAURA 129
rifabutin 33
rifampin 33
riluzole 85
rimantadine hcl 75
risedronate sodium 127
risperidone 63
rivastigmine 80
rivastigmine tartrate 80
RIVELSA 116
rizatriptan benzoate 59
ropinirole hcl 92
ropivacaine hcl in 0.9 % sodium chloride/pf 165
ropivacaine hcl/pf 165
ROSADAN 22
ROSANIL 23
rosuvastatin calcium 57
ROTARIX 73
ROTATEQ 73
ROWEEPRA 37
RUBRACA 165
RYDAPT 165
SSABRIL 37
saccharin 94
SAIZEN 122
SAIZEN-SAIZENPREP 122
SALACYN 148
salicylic acid 148
salicylic acid/ammonium lactate/aloe vera 148
salsalate 138
SAMSCA 90
SANADERMRX 146
SANCUSO 49
SANDIMMUNE 129
SANDOSTATIN 152
SANDOSTATIN LAR DEPOT 152
SCALACORT 146
scopolamine 49
scopolamine hydrobromide 34
SEB-PREV 23
selegiline hcl 40
selenium sulfide 23
SELZENTRY 65
SENSIPAR 136
SENSORCAINE 165
SENSORCAINE WITH DEXTROSE 165
SENSORCAINE-EPINEPHRINE 154
SENSORCAINE-MPF 165
SENSORCAINE-MPF EPINEPHRINE 154
SEREVENT DISKUS 4
SEROPHENE 95
SEROQUEL XR 64
SEROSTIM 122
sertraline hcl 42
SETLAKIN 116
sevelamer carbonate 124
sevoflurane 103
SF 128
SF 5000 PLUS 128
SHAROBEL 116
SIGNIFOR 153
SIGNIFOR LAR 153
sildenafil citrate 142
silver 165
silver nitrate 23,148
silver nitrate/potassium nitrate 148
silver sulfadiazine 23
silver sulfadiazine/foam bandage 165
silver/foam bandage 165
SIMPONI 129
simvastatin 57
sirolimus 134
sodium chloride for inhalation 94
sodium chloride/sodium bicarbonate/potassium
chloride/peg 100
sodium citrate 35
sodium phenylbutyrate 93
sodium polystyrene sulfonate 125
sodium succinate 166
sodium/potassium/potassium citrate/sodium citrate/cit
ac 93
SOJOURN 103
SOLIQUA 100-33 46
SOMAVERT 153
SOOLANTRA 150
sorbitol solution 100
SORINE 28
sotalol hcl 28
SOVALDI 104
spinosad 24
SPIRIVA 34
SPIRIVA RESPIMAT 34
spironolactone 90
spironolactone/hydrochlorothiazide 90
SPRINTEC 116
SPRYCEL 166
SPS 125
SRONYX 117
SSD 23
SSS 10-5 23
STAMARIL 73
stavudine 67
STELARA 130
STIMATE 53
STIOLTO RESPIMAT 34
STIVARGA 166
STRENSIQ 166
streptomycin sulfate 30
STRIBILD 65
STRIVERDI RESPIMAT 4
SUBOXONE 14
SUCRAID 166
sucralfate 74
sulfacetamide sodium 20,23
sulfacetamide sodium/prednisolone sodium phosphate 20
sulfacetamide sodium/sulfur 24
sulfacetamide sodium/sulfur/skin cleanser comb no.23 24
sulfacetamide sodium/sulfur/urea 24
SULFACLEANSE 8-4 24
sulfadiazine 31
sulfamethoxazole/trimethoprim 31
sulfasalazine 31
SULFATRIM 31
sulindac 138
sumatriptan 59
sumatriptan succinate 59
SUSTIVA 66
SUTENT 166,167
SWABFLUSH 167
SYEDA 117
SYLATRON 75
SYMAX 34
SYMAX-SL 34
SYMAX-SR 35
SYMBICORT 4
SYMLINPEN 120 43
SYMLINPEN 60 43
SYNAREL 121
SYNJARDY 45
SYNJARDY XR 45
SYNRIBO 167
SYNTHROID 155
SYPRINE 167
SYREX 94
syringe with needle, insulin, safety, 0.3 ml 167
syringe with needle, insulin, safety, 0.5 ml 167
syringe with needle, insulin, safety, 1 ml 167
syringe with needle,disposable,insulin 1 ml 167
syringe with needle,insulin,0.3 ml 167
syringe with needle,insulin,0.5 ml 167
syringe, disposable irrigation, 70 ml 167
syringe, insulin u-500 with needle, disposable, 0.5 ml 167
Ttacrolimus 134,150
TAFINLAR 167
TAGRISSO 167
TALTZ AUTOINJECTOR 150
TALTZ AUTOINJECTOR (2 PACK) 150
TALTZ AUTOINJECTOR (3 PACK) 151
TALTZ SYRINGE 151
TALTZ SYRINGE (2 PACK) 151
TALTZ SYRINGE (3 PACK) 151
tamoxifen citrate 168
tamsulosin hcl 5
TARCEVA 168
TARGRETIN 151,168
TARINA FE 117
TARON-CRYSTALS 93
TASIGNA 168
TAYTULLA 117
tazarotene 151
TAZICEF 87
TAZTIA XT 29
TECFIDERA 132
TECHNIVIE 68
TEGRETOL XR 37
telmisartan 140
telmisartan/amlodipine besylate 84
telmisartan/hydrochlorothiazide 91
temazepam 79
TEMODAR 168
temozolomide 168
TENCON 7
TENIVAC 71
terazosin hcl 4
terbinafine hcl 50
terbutaline sulfate 4
terconazole 51
TERRELL 103
testosterone cypionate 106
testosterone enanthate 106
tetanus and diphtheria toxoids, adult 71
tetanus,diphtheria toxoid ped/pf 71
TETCAINE 99
tetrabenazine 85
tetracaine hcl 99
tetracaine hcl/pf 99,168
tetracycline hcl 32
TETRAVISC 99
TETRAVISC FORTE 99
THALOMID 133
THEOCHRON 82
theophylline anhydrous 82
THERACYS 73
THERAPEUTIC VITAMIN W-MINERALS 172
THERMAZENE 24
thiamine hcl 172
thiamine
hcl/riboflavin/niacinamide/dexpanthenol/pyridoxine 172
thioridazine hcl 65
thiotepa 168
thiothixene 65
tiagabine hcl 37
ticlopidine hcl 69
TIKOSYN 29
TILIA FE 117
timolol maleate 28,52
tinidazole 61
TIVICAY 65
tizanidine hcl 144
TOBI 30
TOBI PODHALER 30
tobramycin 20
tobramycin in 0.225 % sodium chloride 30
tobramycin sulfate 30
tobramycin/dexamethasone 20
tobramycin/nebulizer 30
tolazamide 48
tolbutamide 48
tolcapone 60
tolmetin sodium 138
tolterodine tartrate 103
TOPAMAX 37
topiramate 37,38
torsemide 89
TOUJEO SOLOSTAR 47
TRACLEER 142
TRADJENTA 46
tramadol hcl 13
tramadol hcl/acetaminophen 7
trandolapril 141
trandolapril/verapamil hcl 83
tranexamic acid 53
TRANSDERM-SCOP 49
tranylcypromine sulfate 40
TRAVATAN Z 53
travoprost (benzalkonium) 53
trazodone hcl 42
tretinoin 147,168
tretinoin microspheres 147
tretinoin/emollient base 147
TREXALL 130
TRI FEMYNOR 117
TRI-ESTARYLLA 117
TRI-LEGEST FE 117
TRI-LINYAH 117
TRI-LO-ESTARYLLA 117
TRI-LO-MARZIA 117
TRI-LO-SPRINTEC 117
TRI-PREVIFEM 117
TRI-SPRINTEC 118
triacetin 50
triamcinolone acetonide 25,106,146
triamterene/hydrochlorothiazide 89
TRIANEX 146
triazolam 79,80
trichloroacetic acid 151
TRICITRATES 93
TRIDERM 146
TRIFERIC 26
trifluoperazine hcl 65
trifluridine 21
trihexyphenidyl hcl 35
TRIKLO 55
TRILYTE WITH FLAVOR PACKETS 100
trimethobenzamide hcl 50
trimethoprim 18
trimipramine maleate 43
TRINESSA 118
TRINESSA LO 118
TRIUMEQ 65
TRIVORA-28 118
TRIZIVIR 67
tropicamide 99
trospium chloride 103
TRULICITY 46
TRUVADA 67
TUSSIGON 35
TWINRIX 73
TYBOST 136
TYKERB 168
TYMLOS 121
TYPHIM VI 73
TYVASO 142
TYVASO INSTITUTIONAL START KIT 143
TYVASO REFILL KIT 143
TYVASO STARTER KIT 143
TYZEKA 77
UULORIC 126
UMECTA 148
UNITHROID 155
UPTRAVI 143
UR N-C 18
URE-K 148
urea 148
URELLE 18
URETRON D-S 18
URIBEL 19
URIMAR-T 19
URIN D.S. 19
URO-458 19
URO-BLUE 19
URO-L 19
UROPHEN MB 19
ursodiol 101
URYL 19
USTELL 19
UTA 19
UTIRA-C 19
UVADEX 88
VV-C FORTE 172
valacyclovir hcl 78
VALCHLOR 151
valganciclovir hcl 78
valproic acid 38
valproic acid (as sodium salt) (valproate sodium) 38
valsartan 140
valsartan/hydrochlorothiazide 91,92
VALSTAR 168
vancomycin hcl 32
VANDAZOLE 22
VAQTA 73
VARIVAX VACCINE 73
VARIZIG 70
VARUBI 49
vasopressin 122
VAXCHORA ACTIVE COMPONENT 73
VAXCHORA BUFFER COMPONENT 168
VAXCHORA VACCINE 73
VECAMYL 124
VELIVET 118
VEMLIDY 78
VENCLEXTA 169
VENCLEXTA STARTING PACK 169
venlafaxine hcl 40
VENTOLIN HFA 4
verapamil hcl 29
VERDROCET 7
VESICARE 104
VESTURA 118
VIAGRA 171
VIBERZI 102
VIC-FORTE 172
VICODIN 7
VICODIN ES 7
VICODIN HP 8
VICTOZA 2-PAK 46
VICTOZA 3-PAK 46
VIDEX 67
VIDEX EC 67
VIEKIRA PAK 68
VIEKIRA XR 69
VIENVA 118
vigabatrin 38
VIGAMOX 21
VIORELE 118
VIRACEPT 69
VIRAMUNE 66
VIRAMUNE XR 66
VIREAD 67
VIRT-CAPS 172
VIRT-GARD 173
VIRT-PHOS 250 NEUTRAL 92
VIRT-VITE 173
VIRT-VITE PLUS 173
VIRTRATE-2 93
VIRTRATE-3 93
VIRTRATE-K 93
VISTOGARD 126
VIVITROL 85
VIVOTIF 73
VIVOTIF BERNA 73
voriconazole 50
VOSEVI 169
VOTRIENT 169
VP-VITE RX 173
VYFEMLA 118
VYNATAL-FA 26
VYVANSE 16
Wwarfarin sodium 35
water for inj.,bacteriostatic 169
water for
inj.,bacteriostatic/methylparaben/propylparaben 169
water for injection,sterile 169
WELCHOL 44
WERA 118
WYMZYA FE 118
XXALKORI 169
XARELTO 35,36
XELJANZ 130
XELJANZ XR 130
XELODA 169
XENAZINE 85
XERMELO 100
XTANDI 169
XULANE 118
XURIDEN 136
XYLOCAINE DENTAL-EPINEPHRINE 154
XYLON 10 13
XYREM 85
YYF-VAX 73
yohimbine hcl 169
YUVAFEM 97
Zzafirlukast 25
zaleplon 79
ZARAH 119
ZARONTIN 39
ZARXIO 82
ZAVESCA 136
ZEBUTAL 8
ZEJULA 169
ZELBORAF 170
ZEMPLAR 173
ZENATANE 151
ZENCHENT 119
ZENCHENT FE 119
ZENCIA 24
ZENPEP 101
ZENZEDI 16
ZEOSA 119
ZEPATIER 104
ZERIT 67
ZIAGEN 67
zidovudine 67
ZINBRYTA 133
ziprasidone hcl 64
ZMAX 125
ZOLATE 173
ZOLINZA 170
zolmitriptan 59
zolpidem tartrate 79
ZOMACTON 122
ZOMIG 59
ZONEGRAN 38
zonisamide 38
ZORBTIVE 122
ZORTRESS 134
ZOSTAVAX 73
ZOVIA 1-35E 119
ZOVIA 1-50E 119
ZOVIRAX 22
ZYDELIG 170
ZYKADIA 170
ZYTIGA 170
NOTICE ABOUT NON-DISCRIMINATION
GlobalHealth, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. GlobalHealth does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
GlobalHealth:
Provides free aids and services to people with disabilities to communicate effectively with us, suchas:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats,other formats)
Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact the Director of Compliance and Legal Services.
If you believe that GlobalHealth has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: ATTN: Director of Compliance and Legal Services, 701 NE 10th St, Ste. 300, Oklahoma City, OK 73104-5403, Fax: (405) 280-5894, or E-mail: [email protected]. You can file a grievance in person or by mail, fax, or e-mail. If you need help filing a grievance, the Compliance Attorney is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Language Translation
Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-280-5600 (TTY: 711).
Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-280-5600 (TTY: 711).
Chinese 注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-877-280-
5600 (TTY: 711).
Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
1-877-280-5600 OR (TTY: 711)번으로 전화해 주십시오.
German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche
Language Translation
Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-280-5600 (TTY: 711).
Arabic 4692-082-778-1 117) .اتصل .إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان :ملحوظة (ھاتف الصم والبكم برقم
Burmese သတိျပဳရန ္- အကယ္၍ သင္သည္ ျမန္မာစကား ကို ေျပာပါက၊ ဘာသာစကား အကူအညီ၊ အခမ့ဲ၊
သင့္အတြက ္စီစဥ္ေဆာင္ရြက္ေပးပါမည္။ ဖုန္းနံပါတ္ 1-877-280-5600 (TTY: 711) သု႔ိ ေခၚဆိုပါ။
Hmong LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-877-280-5600 (TTY: 711).
Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-280-5600 (TTY: 711).
French ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-877-280-5600 (ATS: 711).
Laotian ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບ່ໍເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້
ທ່ານ. ໂທຣ 1-877-280-5600 (TTY: 711).
Thai เรยีน: ถา้คณุพดูภาษาไทยคณุสามารถใชบ้รกิารชว่ยเหลอืทางภาษาไดฟ้ร ีโทร 1-877-280-5600 (TTY: 711).
Urdu 280-877-1 کریں کال ۔ ہیں دستیاب میں مفت خدمات کی مدد کی زبان کو آپ تو ہیں، بولتے اردو آپ اگر :خبردار-5600 (TTY: 711).
Cherokee Hagsesda: iyuhno hyiwoniha [tsalagi gawonihisdi]. Call 1-877-280-5600 (TTY: 711).
Persian می کنید، تسھیالت زبانی بصورت رایگان برای شمااگر بھ زبان فارسی گفتگو :توجھ
1-877-280-5600 (TTY: 711) با تماس بگیرید .فراھم می باشد.
MSTDF18
GlobalHealth, Inc.
PO Box 2393Oklahoma City, OK 73101-2393
www.GlobalHealth.com/state Effective: 2018 Lists Updated 11/2017