reader’s digest value rx (pdp)
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Page 1 of 79 Effective: January 1, 2013
P.O. Box 4169
Scranton, PA 18505
Reader’s Digest Value Rx (PDP)
2013 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE
COVER IN THIS PLAN
Note to existing members: This formulary has changed since last year. Please review this document to
make sure that it still contains the drugs you take.
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits,
formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1,
2014.
Reader's Digest Value Rx (PDP) is a stand-alone prescription drug plan with a Medicare contract.
This information is available for free in other languages. Please contact our Customer Care number at
1-888-630-9137 for additional information. TTY users should call 711. Hours are 8 a.m. - 8 p.m.,
Monday through Friday. Customer Care also has free language interpreter services available for non-
English speakers.
S0128_H095 CMS Accepted 08072012
Formulary ID 13466, Version 9
Page 2 of 79 Effective: January 1, 2013
What is the Reader’s Digest Value Rx Formulary?
A formulary is a list of covered drugs selected by Reader’s Digest Value Rx in consultation with a team
of health care providers, which represents the prescription therapies believed to be a necessary part of a
quality treatment program. Reader’s Digest Value Rx will generally cover the drugs listed in our
formulary as long as the drug is medically necessary, the prescription is filled at a Reader’s Digest Value
Rx network pharmacy, and other plan rules are followed. For more information on how to fill your
prescriptions, please review your Evidence of Coverage.
Can the Formulary change?
Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year,
we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a
new, less expensive generic drug becomes available or when new adverse information about the safety
or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from
our formulary, will not affect members who are currently taking the drug. It will remain available at the
same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is
important that you have continued access for the remainder of the coverage year to the formulary drugs
that were available when you chose our plan, except for cases in which you can save additional money
or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of
the change at least 60 days before the change becomes effective, or at the time the member requests a
refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and
Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes
the drug from the market, we will immediately remove the drug from our formulary and provide notice
to members who take the drug. The enclosed formulary is current as of January 1, 2013. To get updated
information about the drugs covered by Reader’s Digest Value Rx, please visit our Web site at
www.hmic-medicare.com/formulary or call Customer Care at 1-888-630-9137, 8 a.m. - 8 p.m., Monday
through Friday. TTY users should call 711. If we have a mid-year non-maintenance formulary change
(i.e. remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy
restrictions on a drug, or move a drug to a higher cost-sharing tier), we will update our formulary and
post in on our website. You will also be notified in your Explanation of Benefits if you are affected by
the change. The updated formulary may be obtained from our Web site at www.hmic-
medicare.com/formulary or by calling Customer Care at 1-888-630-9137, 8 a.m. - 8 p.m., Monday
through Friday. TTY users should call 711. We will notify beneficiaries in writing prior to making this
type of change.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 6. The drugs in this formulary are grouped into categories depending on
the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category, cardiovascular drugs. If you know what your drug is used for,
look for the category name in the list that begins on page number 6. Then look under the category name
for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins
on page 63. The Index provides an alphabetical list of all of the drugs included in this document. Both
brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next
Page 3 of 79 Effective: January 1, 2013
to your drug, you will see the page number where you can find coverage information. Turn to the page
listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
Reader’s Digest Value Rx covers both brand name drugs and generic drugs. A generic drug is approved
by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost
less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and
limits may include:
Prior Authorization: Reader’s Digest Value Rx requires you [or your physician] to get prior
authorization for certain drugs. This means that you will need to get approval from Reader’s
Digest Value Rx before you fill your prescriptions. If you don’t get approval, Reader’s Digest
Value Rx may not cover the drug.
Quantity Limits: For certain drugs, Reader’s Digest Value Rx limits the amount of the drug that
Reader’s Digest Value Rx will cover. For example, Reader’s Digest Value Rx provides 30
tablets per prescription for Crestor. This may be in addition to a standard one month or three
month supply.
Step Therapy: In some cases, Reader’s Digest Value Rx requires you to first try certain drugs to
treat your medical condition before we will cover another drug for that condition. For example,
if Drug A and Drug B both treat your medical condition, Reader’s Digest Value Rx may not
cover Drug B unless you try Drug A first. If Drug A does not work for you, Reader’s Digest
Value Rx will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 6. You can also get more information about the restrictions applied to specific covered
drugs by visiting our Web site at www.hmic-medicare.com/formulary.
You can ask Reader’s Digest Value Rx to make an exception to these restrictions or limits. See the
section, “How do I request an exception to the Reader’s Digest Value Rx formulary?” on page 3 for
information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact Customer Care and confirm that
your drug is not covered. If you learn that Reader’s Digest Value Rx does not cover your drug, you
have two options:
You can ask Customer Care for a list of similar drugs that are covered by Reader’s Digest Value Rx.
When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is
covered by Reader’s Digest Value Rx.
You can ask Reader’s Digest Value Rx to make an exception and cover your drug. See below for
information about how to request an exception.
How do I request an exception to the Reader’s Digest Value Rx Formulary? You can ask Reader’s Digest Value Rx to make an exception to our coverage rules. There are several
types of exceptions that you can ask us to make.
You can ask us to cover your drug even if it is not on our formulary.
Page 4 of 79 Effective: January 1, 2013
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
Reader’s Digest Value Rx limit the amount of the drug that we will cover. If your drug has a quantity
limit, you can ask us to waive the limit and cover more.
You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our
non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the
preferred tier instead. This would lower the amount you must pay for your drug. Please note, if we grant
your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of
coverage for the drug.
Generally, Reader’s Digest Value Rx will only approve your request for an exception if the alternative
drugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would
not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you are requesting a formulary, tiering or utilization restriction
exception you should submit a statement from your physician supporting your request. Generally,
we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s
supporting statement. You can request an expedited (fast) exception if you or your doctor believe that
your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to
expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or
prescribing physician’s supporting statement.
What do I do before I can talk to my doctor about changing my drugs or requesting
an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or,
you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you
may need a prior authorization from us before you can fill your prescription. You should talk to your
doctor to decide if you should switch to an appropriate drug that we cover or request a formulary
exception so that we will cover the drug you take. While you talk to your doctor to determine the right
course of action for you, we may cover your drug in certain cases during the first 90 days you are a
member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will
cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to
a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have
been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we
have provided you with a 91-day transition supply, consistent with the dispensing increment, (unless
you have a prescription written for fewer days). We will cover more than one refill of these drugs for the
first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your
ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will
cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you
pursue a formulary exception.
If you are a current enrollee with a level of care change and you need a drug that is not on our formulary
or if your ability to get your drugs is limited, we will cover a temporary 31-day transition supply (unless
you have a prescription written for fewer days), while you seek to obtain a formulary exception from
Reader’s Digest Value Rx. If you are in the process of seeking an exception, we will consider allowing
continued coverage until a decision is made.
For more information
For more detailed information about your Reader’s Digest Value Rx prescription drug coverage, please
review your Evidence of Coverage and other plan materials. If you have questions about Reader’s
Digest Value Rx, please call Customer Care at 1-888-630-9137, 8 a.m. - 8 p.m., Monday through Friday.
Page 5 of 79 Effective: January 1, 2013
TTY users should call 711.) Or visit www.hmic-medicare.com/formulary.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-
MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-
2048. Or, visit www.medicare.gov.
Reader’s Digest Value Rx Formulary
The formulary below provides coverage information about some of the drugs covered by Reader’s
Digest Value Rx. If you have trouble finding your drug in the list, turn to the Index that begins on page
63.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g. CRESTOR) and
generic drugs are listed in lower-case italics (e.g., atorvastatin calcium).
The information in the Requirements/Limits column tells you if Reader’s Digest Value Rx has any
special requirements for coverage of your drug.
B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. This
drug may be covered under Medicare Part B or D depending upon the circumstances. Information may
need to be submitted describing the use and setting of the drug to make the determination.
CB: This prescription drug has a capped benefit limit.
ED: This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount
you pay when you fill a prescription for this drug does not count towards your total drug costs (that is,
the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are
receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.
FF: Free First Fill. This prescription drug will be provided at reduced cost-sharing the first time you fill
it.
GC: Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap.
Please refer to our Evidence of Coverage for more information about this coverage.
HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more
information, call Customer Care at 1-888-630-9137, 8 a.m. - 8 p.m., Monday through Friday. TTY users
should call 711.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more
information consult your Pharmacy Directory or call Customer Care at 1-888-630-9137, 8 a.m. - 8 p.m.,
Monday through Friday. TTY users should call 711.
MO: Mail Order Drug. This prescription drug is available through a mail-order service.
MW: Medicaid Wrap for Dual Demonstration Plan. This prescription drug is covered under the
Medicaid Wrap benefit for Dual Demonstration plan members.
PA: Prior Authorization. Reader’s Digest Value Rx requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from Reader’s Digest
Value Rx before you fill your prescriptions. If you don't get approval, Reader’s Digest Value Rx may
not cover the drug.
QL: Quantity Limit. For certain drugs, Reader’s Digest Value Rx limits the amount of the drug that
Reader’s Digest Value Rx will cover. For example, Reader’s Digest Value Rx provides 30 tablets per
prescription for Crestor. This may be in addition to a standard one month or three month supply.
ST: Step Therapy. In some cases, Reader’s Digest Value Rx requires you to first try certain drugs to
treat your medical condition before we will cover another drug for that condition. For example, if Drug
A and Drug B both treat your medical condition, Reader’s Digest Value Rx may not cover drug B unless
you try Drug A first. If Drug A does not work for you, Reader’s Digest Value Rx will then cover Drug
Page 6 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
ANTI-INFECTIVE AGENTS
ADAMANTANES
amantadine hcl 2 MO
rimantadine hcl 2 MO
ALLYLAMINES
terbinafine hcl 2 QL (90 EA per 365 days)
MO
AMEBICIDES
METRO IV 4 MO
metronidazole 1 MO
AMINOGLYCOSIDES
amikacin sulfate 3 MO
gentamicin sulfate/0.9% sodium chloride 3 MO
gentamicin sulfate/sodium chloride 3 MO
gentamicin sulfate inj 40mg/ml 2 MO
gentamicin sulfate inj 10mg/ml 3 MO
isotonic gentamicin 3 MO
kanamycin sulfate 1 MO
neomycin sulfate 2 MO
paromomycin sulfate 3 MO
streptomycin sulfate 3 MO
TOBI 4 QL (280 ML per 28 days)
PA MO
tobramycin sulfate 1 MO
tobramycin sulfate/sodium chloride 2 MO
ANTHELMINTICS
ALBENZA 4 MO
BILTRICIDE 4 MO
STROMECTOL 3 MO
ANTIBACTERIALS, MISCELLANEOUS
bacitracin 2 MO
CLEOCIN GALAXY 4 MO
CLEOCIN IN D5W 4 MO
clindamycin hcl 2 MO
clindamycin palmitate hcl 3 MO
clindamycin phosphate 2 MO
clindamycin phosphate add-vantage 2 MO
clindamycin phosphate pharmacy bulk package 2 MO
colistimethate sodium 4 MO
COLY-MYCIN M 4 MO
CUBICIN 4 B/D MO
isonarif 2 MO
MYCOBUTIN 4 MO
polymyxin b sulfate 2 MO
PRIFTIN 4 MO
RIFAMATE 4 MO
rifampin 3 MO
SYNERCID 4 MO
VANCOCIN HCL 4 MO
vancomycin hcl inj 3 B/D MO
vancomycin hcl caps 4 MO
Page 7 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
VIBATIV 4 B/D MO
XIFAXAN TABS 550MG 4 QL (60 EA per 30 days)
PA MO
XIFAXAN TABS 200MG 4 QL (9 EA per 30 days) PA
MO
ZYVOX 4 MO
ANTIFUNGALS, MISCELLANEOUS
GRIS-PEG 4 MO
griseofulvin microsize 3 MO
ANTIMALARIALS
atovaquone/proguanil hcl 4 MO
chloroquine phosphate 2 MO
COARTEM 4 QL (24 EA per 30 days)
MO
DARAPRIM 4 MO
hydroxychloroquine sulfate 2 MO
MALARONE 4 MO
mefloquine hcl 2 MO
QUALAQUIN 4 QL (42 EA per 7 days) PA
MO
quinidine gluconate 2 MO
quinidine gluconate cr 3 MO
quinidine gluconate er 3 MO
quinidine sulfate 2 MO
quinidine sulfate er 2 MO
ANTIMYCOBACTERIALS, MISCELLANEOUS
dapsone 2 MO
ANTIPROTOZOALS, MISCELLANEOUS
ALINIA SUSR 4 QL (150 ML per 30 days)
MO
ALINIA TABS 4 QL (40 EA per 30 days)
MO
MEPRON 4 MO
ANTIRETROVIRALS
APTIVUS CAPS 4 QL (120 EA per 30 days)
MO
APTIVUS SOLN 4 QL (285 ML per 28 days)
MO
ATRIPLA 4 QL (30 EA per 30 days)
MO
COMPLERA 4 QL (30 EA per 30 days)
MO
CRIXIVAN CAPS 400MG 4 QL (180 EA per 30 days)
MO
CRIXIVAN CAPS 200MG 4 QL (360 EA per 30 days)
MO
didanosine cpdr 250mg, 400mg 3 QL (30 EA per 30 days)
MO
didanosine cpdr 200mg 3 QL (60 EA per 30 days)
MO
didanosine cpdr 125mg 3 QL (90 EA per 30 days)
Page 8 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
MO
EDURANT 4 QL (30 EA per 30 days)
MO
EMTRIVA CAPS 4 QL (30 EA per 30 days)
MO
EMTRIVA SOLN 4 QL (680 ML per 28 days)
MO
EPIVIR HBV SOLN 4 QL (1680 ML per 28 days)
MO
EPIVIR HBV TABS 4 QL (90 EA per 30 days)
MO
EPIVIR SOLN 4 QL (960 ML per 30 days)
MO
EPIVIR TABS 300MG 4 QL (30 EA per 30 days)
MO
EPIVIR TABS 150MG 4 QL (60 EA per 30 days)
MO
EPZICOM 4 QL (30 EA per 30 days)
MO
FUZEON 3 QL (60 EA per 30 days)
MO
INTELENCE TABS 100MG 4 QL (120 EA per 30 days)
MO
INTELENCE TABS 200MG 4 QL (60 EA per 30 days)
MO
INVIRASE TABS 4 QL (120 EA per 30 days)
MO
INVIRASE CAPS 4 QL (300 EA per 30 days)
MO
ISENTRESS 4 QL (120 EA per 30 days)
MO
KALETRA SOLN 4 MO
KALETRA TABS 200MG; 50MG 4 QL (150 EA per 30 days)
MO
KALETRA TABS 100MG; 25MG 4 QL (300 EA per 30 days)
MO
lamivudine/zidovudine 4 QL (60 EA per 30 days)
MO
lamivudine tabs 300mg 4 QL (30 EA per 30 days)
MO
lamivudine tabs 150mg 4 QL (60 EA per 30 days)
MO
LEXIVA SUSP 3 QL (1575 ML per 28 days)
MO
LEXIVA TABS 4 QL (120 EA per 30 days)
MO
nevirapine 3 QL (60 EA per 30 days)
MO
NORVIR CAPS, TABS 4 QL (360 EA per 30 days)
MO
NORVIR SOLN 4 QL (480 ML per 30 days)
Page 9 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
MO
PREZISTA TABS 150MG 4 QL (240 EA per 30 days)
MO
PREZISTA TABS 75MG 4 QL (480 EA per 30 days)
MO
PREZISTA TABS 600MG 4 QL (60 EA per 30 days)
MO
PREZISTA TABS 400MG 4 QL (90 EA per 30 days)
MO
RESCRIPTOR TABS 200MG 4 QL (180 EA per 30 days)
MO
RESCRIPTOR TABS 100MG 4 QL (360 EA per 30 days)
MO
RETROVIR IV INFUSION 4 MO
RETROVIR SYRP 4 QL (1680 ML per 28 days)
MO
RETROVIR CAPS 4 QL (180 EA per 30 days)
MO
RETROVIR TABS 4 QL (60 EA per 30 days)
MO
REYATAZ CAPS 100MG 4 QL (120 EA per 30 days)
MO
REYATAZ CAPS 300MG 4 QL (30 EA per 30 days)
MO
REYATAZ CAPS 150MG, 200MG 4 QL (60 EA per 30 days)
MO
SELZENTRY TABS 300MG 4 QL (120 EA per 30 days)
MO
SELZENTRY TABS 150MG 4 QL (240 EA per 30 days)
MO
stavudine caps 15mg, 20mg 2 QL (120 EA per 30 days)
MO
stavudine caps 30mg 2 QL (30 EA per 30 days)
MO
stavudine caps 40mg 2 QL (60 EA per 30 days)
MO
SUSTIVA TABS 4 QL (30 EA per 30 days)
MO
SUSTIVA CAPS 200MG 4 QL (120 EA per 30 days)
MO
SUSTIVA CAPS 50MG 4 QL (480 EA per 30 days)
MO
TRIZIVIR 3 QL (60 EA per 30 days)
MO
TRUVADA 4 QL (30 EA per 30 days)
MO
VIDEX PEDIATRIC SOLR 2GM 4 QL (1200 ML per 30 days)
VIDEX PEDIATRIC SOLR 4GM 4 QL (1200 ML per 30 days)
MO
VIRACEPT TABS 625MG 4 QL (120 EA per 30 days)
MO
Page 10 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
VIRACEPT TABS 250MG 4 QL (300 EA per 30 days)
MO
VIRAMUNE XR 4 QL (30 EA per 30 days)
MO
VIRAMUNE SUSP 3 QL (1200 ML per 30 days)
MO
VIRAMUNE TABS 3 QL (60 EA per 30 days)
MO
VIREAD POWD 4 QL (240 GM per 30 days)
MO
VIREAD TABS 4 QL (30 EA per 30 days)
MO
ZERIT SOLR 4 QL (2400 ML per 30 days)
MO
ZERIT CAPS 15MG 4 QL (120 EA per 30 days)
MO
ZERIT CAPS 30MG 4 QL (30 EA per 30 days)
MO
ZIAGEN TABS 4 QL (60 EA per 30 days)
MO
ZIAGEN SOLN 4 QL (960 ML per 30 days)
MO
zidovudine syrp 3 QL (1680 ML per 28 days)
MO
zidovudine caps 3 QL (180 EA per 30 days)
MO
zidovudine tabs 3 QL (60 EA per 30 days)
MO
ANTITUBERCULOSIS AGENTS
CAPASTAT SULFATE 4 MO
ethambutol hcl 3 MO
isoniazid 1 MO
PASER 2 MO
pyrazinamide 3 MO
SEROMYCIN 4 MO
TRECATOR 4 MO
AZOLES
fluconazole in dextrose 1 MO
fluconazole in nacl 2 MO
fluconazole susr 1 MO
fluconazole tabs 100mg, 200mg, 50mg 2 MO
fluconazole tabs 150mg 2 QL (4 EA per 28 days)
MO
itraconazole 3 QL (120 EA per 30 days)
MO
ketoconazole 2 MO
NOXAFIL 4 QL (840 ML per 28 days)
PA MO
VFEND 4 QL (400 ML per 30 days)
PA MO
VFEND IV 4 MO
Page 11 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
voriconazole 3 QL (120 EA per 30 days)
PA MO
CEPHALOSPORINS
cefaclor 2 MO
cefaclor er 3 MO
cefadroxil 2 MO
cefazolin sodium 3 MO
cefazolin sodium/dextrose 3 MO
cefdinir 3 MO
cefditoren pivoxil 1 MO
cefepime 3 MO
cefotaxime sodium 1 MO
cefotetan 3 MO
cefoxitin sodium inj 1gm; 4%, 2gm; 2.2% 1 MO
cefoxitin sodium inj 10gm, 1gm, 2gm 3 MO
cefpodoxime proxetil 3 MO
cefprozil 3 MO
ceftazidime 2 MO
ceftazidime/dextrose 2 MO
ceftriaxone sodium 3 MO
cefuroxime axetil 2 MO
cefuroxime sodium 3 MO
cephalexin 2 MO
KEFLEX 4 MO
ROCEPHIN 4 MO
SUPRAX 4 MO
tazicef 3 MO
TEFLARO 4 MO
CHLORAMPHENICOL
chloramphenicol sodium succinate 2 MO
ECHINOCANDINS
CANCIDAS 4 B/D MO
ERAXIS 4 B/D MO
HCV PROTEASE INHIBITORS
INCIVEK 4 QL (168 EA per 28 days)
PA MO
VICTRELIS 4 QL (336 EA per 28 days)
PA MO
INTERFERONS
INFERGEN 4 QL (30 ML per 30 days)
PA MO
INTRON-A 4 PA MO
INTRON-A W/DILUENT 4 PA MO
PEG-INTRON 4 QL (4 EA per 28 days) PA
PEG-INTRON REDIPEN 4 QL (4 EA per 28 days) PA
PEG-INTRON REDIPEN PAK 4 INJ 120MCG/0.5ML,
150MCG/0.5ML, 80MCG/0.5ML
4 QL (4 EA per 28 days) PA
PEG-INTRON REDIPEN PAK 4 INJ 50MCG/0.5ML 4 QL (4 EA per 28 days) PA
MO
PEGASYS INJ 180MCG/0.5ML 4 QL (4 EA per 28 days) PA
MO
Page 12 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
PEGASYS INJ 180MCG/ML 4 QL (4 ML per 28 days) PA
MO
SYLATRON 4 QL (4 EA per 28 days) PA
MO
MACROLIDES
azithromycin 2 MO
clarithromycin 2 MO
clarithromycin er 3 MO
DIFICID 4 QL (20 EA per 10 days)
MO
E.E.S. 400 4 MO
E.E.S. GRANULES 4 MO
e.s.p. 2 MO
ERY-TAB 4 MO
ERYPED 200 4 MO
ERYPED 400 4 MO
ERYTHROCIN LACTOBIONATE 1 MO
ERYTHROCIN STEARATE 2 MO
erythromycin base 2 MO
erythromycin ethylsuccinate 2 MO
erythromycin/sulfisoxazole 2 MO
KETEK 4 MO
PCE 4 MO
MISCELLANEOUS B-LACTAM ANTIBIOTICS
aztreonam inj 1gm 2 MO
aztreonam inj 2gm 4 MO
CAYSTON 4 QL (84 ML per 28 days)
PA MO
DORIBAX 4 MO
imipenem/cilastatin 3 MO
meropenem 3 MO
MERREM 4 MO
PRIMAXIN IV 3 MO
PRIMAXIN IV ADD-VANTAGE 3 MO
NEURAMINIDASE INHIBITORS
RELENZA DISKHALER 4 QL (60 EA per 180 days)
MO
TAMIFLU SUSR 4 QL (720 ML per 365 days)
MO
TAMIFLU CAPS 30MG 4 QL (112 EA per 365 days)
MO
TAMIFLU CAPS 45MG, 75MG 4 QL (56 EA per 365 days)
MO
NUCLEOSIDES AND NUCLEOTIDES
acyclovir 2 MO
acyclovir sodium 2 MO
BARACLUDE TABS 4 QL (30 EA per 30 days)
MO
BARACLUDE SOLN 4 QL (630 ML per 30 days)
MO
CYTOVENE 4 MO
Page 13 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
famciclovir 3 QL (60 EA per 30 days)
MO
ganciclovir 3 MO
HEPSERA 4 MO
REBETOL 4 QL (1000 ML per 30 days)
PA MO
ribavirin 3 QL (168 EA per 28 days)
PA MO
TYZEKA 4 QL (30 EA per 30 days)
MO
valacyclovir hcl tabs 500mg 3 QL (60 EA per 30 days)
MO
valacyclovir hcl tabs 1000mg 3 QL (90 EA per 30 days)
MO
VALCYTE SOLR 4 QL (1056 ML per 30 days)
MO
VALCYTE TABS 4 QL (120 EA per 30 days)
MO
PENICILLINS
amoxicillin 1 MO
amoxicillin/clavulanate potassium er 3 MO
amoxicillin/clavulanate potassium chew 2 MO
amoxicillin/clavulanate potassium susr 200mg/5ml;
28.5mg/5ml, 250mg/5ml; 62.5mg/5ml, 400mg/5ml;
57mg/5ml
2 MO
amoxicillin/clavulanate potassium susr 600mg/5ml;
42.9mg/5ml
3 MO
amoxicillin/clavulanate potassium tabs 500mg; 125mg,
875mg; 125mg
2 MO
amoxicillin/clavulanate potassium tabs 250mg; 125mg 3 MO
amoxicillin/potassium clavulanate 2 MO
ampicillin 2 MO
ampicillin sodium 3 MO
ampicillin-sulbactam 3 MO
bactocill in dextrose 3 MO
dicloxacillin sodium 2 MO
nafcillin sodium 3 MO
nallpen/dextrose 4 MO
oxacillin sodium 3 MO
penicillin g potassium 2 MO
penicillin g potassium in iso-osmotic dextrose 2 MO
penicillin g procaine 3 MO
penicillin g sodium 2 MO
penicillin v potassium 2 MO
pfizerpen-g 2 MO
piperacillin sodium/tazobactam sodium 2 MO
piperacillin/tazobactam 2 MO
TIMENTIN 4 MO
POLYENES
AMPHOTEC 4 MO
amphotericin b 3 MO
Page 14 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
nystatin 2 MO
PYRIMIDINES
ANCOBON 4 MO
flucytosine 3 MO
QUINOLONES
AVELOX 4 MO
ciprofloxacin 2 MO
ciprofloxacin hcl 1 MO
ciprofloxacin i.v.-in d5w 2 MO
FACTIVE 4 MO
levofloxacin in d5w 4 MO
levofloxacin oral soln, tabs 2 MO
levofloxacin inj 4 MO
ofloxacin 2 MO
SULFONAMIDES (SYSTEMIC)
sulfadiazine 3 MO
sulfamethoxazole/trimethoprim 1 MO
sulfamethoxazole/trimethoprim ds 1 MO
sulfasalazine 2 MO
sulfazine 2 MO
TETRACYCLINES
demeclocycline hcl 3 MO
doxycycline 3 QL (30 EA per 30 days)
MO
doxycycline hyclate cpep, inj 1 MO
doxycycline hyclate caps, tabs 2 MO
doxycycline hyclate tbec 3 MO
doxycycline monohydrate tabs 2 MO
doxycycline monohydrate caps 2 QL (60 EA per 30 days)
MO
minocycline hcl 2 MO
morgidox 1x100mg 1 MO
morgidox 2x100mg 1 MO
tetracycline hcl 1 MO
TYGACIL 4 MO
VIBRAMYCIN 4 MO
URINARY ANTI-INFECTIVES
methenamine hippurate 3 MO
nitrofurantoin 4 PA MO
nitrofurantoin macrocrystal 3 PA MO
nitrofurantoin macrocrystalline 3 PA MO
nitrofurantoin monohydrate 3 PA MO
nitrofurantoin monohydrate/macrocrystals 3 PA MO
PRIMSOL 2 MO
trimethoprim 2 MO
UREX 2 MO
ANTIHISTAMINE DRUGS
FIRST GENERATION ANTIHISTAMINES
arbinoxa 2 MO
carbinoxamine maleate 2 MO
clemastine fumarate syrp 2 MO
Page 15 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
clemastine fumarate tabs 2.68mg 2 MO
palgic 2 MO
PHENOTHIAZINE DERIVATIVES
phenadoz 2 PA MO
promethegan supp 50mg 3 MO
promethegan supp 12.5mg, 25mg 3 PA MO
PIPERAZINE DERIVATIVES
hydroxyzine hcl 2 PA MO
meclizine hcl 2 MO
SECOND GENERATION ANTIHISTAMINES
cetirizine hcl syrp 2 QL (300 ML per 30 days)
MO
levocetirizine dihydrochloride tabs 2 QL (30 EA per 30 days)
MO
SEMPREX-D 4 MO
ANTINEOPLASTIC AGENTS
ANTINEOPLASTIC AGENTS
ABRAXANE 4 QL (700 EA per 21 days)
PA MO
adriamycin inj 2mg/ml 3 B/D
AFINITOR 4 QL (30 EA per 30 days)
PA MO
ALIMTA INJ 500MG 4 QL (60 EA per 21 days)
PA MO
ALKERAN INJ 4 B/D MO
anastrozole 1 QL (30 EA per 30 days)
MO
ARRANON 4 PA MO
ARZERRA 4 QL (400 ML per 28 days)
PA MO
AVASTIN INJ 100MG/4ML 4 PA
AVASTIN INJ 400MG/16ML 4 PA MO
bicalutamide 2 QL (30 EA per 30 days)
MO
BICNU 4 B/D MO
bleomycin sulfate inj 30unit 3 B/D MO
BUSULFEX 4 B/D MO
CAMPATH 4 QL (12 ML per 28 days)
PA MO
CAPRELSA TABS 300MG 4 QL (30 EA per 30 days)
PA MO
CAPRELSA TABS 100MG 4 QL (60 EA per 30 days)
PA MO
carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml,
600mg/60ml
3 B/D MO
CEENU 4 MO
CERUBIDINE 4 B/D MO
cisplatin inj 100mg/100ml 3 B/D
cisplatin inj 200mg/200ml, 50mg/50ml 3 B/D MO
cladribine 1 B/D MO
CLOLAR 4 B/D MO
Page 16 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
COSMEGEN 4 B/D MO
cyclophosphamide tabs 3 B/D MO
cytarabine aqueous 1 B/D MO
cytarabine inj 100mg/ml, 500mg 1 B/D MO
dacarbazine inj 200mg 1 B/D MO
DACOGEN 4 PA MO
dactinomycin 3 B/D MO
daunorubicin hcl inj 20mg 1 B/D MO
DOCEFREZ 4 B/D MO
docetaxel inj 80mg/2ml, 80mg/4ml, 80mg/8ml 4 B/D MO
DROXIA 4 MO
ELOXATIN INJ 100MG/20ML 4 PA MO
EMCYT 4 MO
epirubicin hcl inj 50mg/25ml 3 PA MO
epirubicin hcl inj 200mg/100ml 3 PA MO
ERBITUX INJ 100MG/50ML 4 PA MO
ERIVEDGE 4 QL (28 EA per 28 days)
PA MO
ETOPOPHOS 4 B/D MO
etoposide inj 3 MO
exemestane 3 QL (60 EA per 30 days)
MO
FARESTON 4 QL (30 EA per 30 days)
MO
FASLODEX 4 QL (30 ML per 30 days)
B/D MO
FIRMAGON INJ 80MG 4 QL (4 EA per 28 days) PA
MO
FIRMAGON INJ 120MG 4 QL (6 EA per 365 days)
PA MO
fludarabine phosphate inj 50mg 2 B/D MO
fluorouracil inj 500mg/10ml 3 B/D MO
flutamide 3 MO
FOLOTYN INJ 40MG/2ML 4 PA MO
gemcitabine hcl inj 1gm 4 B/D MO
gemcitabine inj 1gm/26.3ml 4 B/D MO
GEMZAR INJ 1GM 4 PA MO
GLEEVEC TABS 100MG 4 QL (180 EA per 30 days)
PA MO
GLEEVEC TABS 400MG 4 QL (60 EA per 30 days)
PA MO
HALAVEN 4 QL (10 ML per 21 days)
PA MO
HERCEPTIN 4 PA MO
HEXALEN 4 MO
HYCAMTIN INJ 4 B/D MO
hydroxyurea 2 MO
IDAMYCIN PFS 4 B/D MO
idarubicin hcl 4 B/D MO
Page 17 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
IFEX 4 B/D MO
ifosfamide inj 1gm, 3gm 3 B/D MO
INLYTA TABS 1MG 4 QL (180 EA per 30 days)
PA MO
INLYTA TABS 5MG 4 QL (60 EA per 30 days)
PA MO
IRESSA 3 QL (30 EA per 30 days)
MO
irinotecan inj 100mg/5ml 3 B/D MO
ISTODAX 4 PA MO
IXEMPRA KIT INJ 45MG 4 QL (45 EA per 21 days)
PA MO
JAKAFI 4 QL (60 EA per 30 days)
PA MO
JEVTANA 4 QL (4 ML per 21 days) PA
MO
letrozole 2 QL (30 EA per 30 days)
MO
LEUKERAN 3 MO
leuprolide acetate 3 QL (2.8 EA per 14 days)
PA MO
LUPRON DEPOT-PED INJ 11.25MG, 15MG 4 QL (1 EA per 28 days) PA
MO
LUPRON DEPOT INJ 30MG 4 QL (1 EA per 120 days)
PA MO
LUPRON DEPOT INJ 45MG 4 QL (1 EA per 180 days)
PA MO
LUPRON DEPOT INJ 3.75MG, 7.5MG 4 QL (1 EA per 30 days) PA
MO
LUPRON DEPOT INJ 11.25MG, 22.5MG 4 QL (1 EA per 90 days) PA
MO
LYSODREN 3 MO
MATULANE 4 MO
megestrol acetate susp 3 MO
megestrol acetate tabs 20mg 2 MO
megestrol acetate tabs 40mg 3 MO
melphalan hydrochloride 1 B/D MO
mercaptopurine 3 MO
methotrexate 2 B/D MO
methotrexate sodium 2 MO
mitomycin inj 20mg 4 B/D MO
mitoxantrone hcl inj 2mg/ml 3 B/D
mitoxantrone hcl inj 2mg/ml 3 B/D MO
MUSTARGEN 4 B/D MO
NAVELBINE INJ 50MG/5ML 4 MO
NEXAVAR 4 QL (120 EA per 30 days)
PA MO
NILANDRON 4 QL (60 EA per 30 days)
MO
NIPENT 4 B/D MO
ONTAK 4 QL (108 ML per 21 days)
Page 18 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
PA MO
oxaliplatin inj 100mg/20ml 2 PA MO
paclitaxel inj 300mg/50ml 3 B/D
paclitaxel inj 100mg/16.7ml, 150mg/25ml, 30mg/5ml 3 B/D MO
pentostatin 1 B/D MO
PROLEUKIN 4 MO
REVLIMID CAPS 10MG, 15MG, 25MG, 5MG 4 QL (28 EA per 28 days)
PA MO
RHEUMATREX 4 B/D MO
RITUXAN 3 PA MO
SPRYCEL TABS 140MG 4 QL (30 EA per 30 days)
PA MO
SPRYCEL TABS 100MG, 50MG, 70MG, 80MG 4 QL (60 EA per 30 days)
PA MO
SPRYCEL TABS 20MG 4 QL (90 EA per 30 days)
PA MO
SUTENT 4 QL (28 EA per 28 days)
PA MO
TABLOID 4 MO
tamoxifen citrate 2 MO
TARCEVA TABS 100MG, 150MG 4 QL (30 EA per 30 days)
PA MO
TARCEVA TABS 25MG 4 QL (90 EA per 30 days)
PA MO
TARGRETIN 4 QL (300 EA per 30 days)
PA MO
TASIGNA 4 QL (120 EA per 30 days)
PA MO
TAXOTERE INJ 80MG/2ML, 80MG/4ML 4 B/D MO
thiotepa 1 B/D MO
toposar 4 B/D MO
topotecan hcl inj 4mg 4 B/D MO
TORISEL 4 QL (100 ML per 28 days)
PA MO
TREANDA INJ 100MG 4 QL (600 EA per 21 days)
PA MO
TRELSTAR DEPOT MIXJECT 4 PA
TRELSTAR LA MIXJECT 4 PA
TRELSTAR MIXJECT 4 PA
tretinoin 3 MO
TREXALL 4 B/D MO
TRISENOX 4 B/D MO
TYKERB 3 QL (150 EA per 30 days)
PA MO
VANDETANIB TABS 300MG 4 QL (30 EA per 30 days)
PA MO
VANDETANIB TABS 100MG 4 QL (60 EA per 30 days)
PA MO
VECTIBIX INJ 100MG/5ML 4 PA MO
VELCADE 4 PA MO
VIDAZA 4 PA MO
Page 19 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
vinblastine sulfate inj 10mg 1 B/D MO
vincasar pfs 1 B/D
vincristine sulfate 1 B/D
vinorelbine tartrate inj 50mg/5ml 3 MO
VOTRIENT 4 QL (120 EA per 30 days)
PA MO
XALKORI 4 QL (60 EA per 30 days)
PA MO
YERVOY INJ 50MG/10ML 4 QL (70 ML per 21 days)
PA MO
ZANOSAR 4 B/D MO
ZELBORAF 4 QL (240 EA per 30 days)
PA MO
ZOLINZA 4 QL (120 EA per 30 days)
PA MO
ZYTIGA 4 QL (120 EA per 30 days)
PA MO
AUTONOMIC DRUGS
ALPHA- AND BETA-ADRENERGIC AGONISTS
epinephrine 3 MO
epinephrine hcl 1 MO
TWINJECT INJ 0.15MG/0.15ML 4
TWINJECT INJ 0.3MG/0.3ML 4 MO
ALPHA-ADRENERGIC AGONISTS
methyldopa 2 MO
methyldopa/hydrochlorothiazide 2 MO
methyldopate hcl 1 MO
midodrine hcl 3 MO
ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)
alfuzosin hcl er 3 QL (30 EA per 30 days)
MO
carvedilol 1 MO
dihydroergotamine mesylate 4 MO
doxazosin mesylate 2 MO
ergoloid mesylates 2 PA MO
ergotamine tartrate/caffeine 2 MO
labetalol hcl 2 MO
migergot 4 MO
prazosin hcl 2 MO
tamsulosin hcl 2 QL (60 EA per 30 days)
MO
terazosin hcl 2 MO
ANTIMUSCARINICS/ANTISPASMODICS
atropine sulfate 2 MO
ATROVENT HFA 4 QL (30 GM per 30 days)
MO
dicyclomine hcl 2 PA MO
diphenoxylate/atropine 2 PA MO
DUONEB 4 B/D MO
glycopyrrolate 2 MO
ipratropium bromide 2 B/D MO
Page 20 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
ipratropium bromide/albuterol sulfate 3 B/D MO
methscopolamine bromide 3 MO
propantheline bromide 2 PA MO
SPIRIVA HANDIHALER 3 QL (30 EA per 30 days)
MO
ANTIPARKINSONIAN AGENTS
benztropine mesylate inj 1 MO
benztropine mesylate tabs 2 MO
trihexyphenidyl hcl 2 MO
AUTONOMIC DRUGS, MISCELLANEOUS
CHANTIX 4 QL (56 EA per 28 days)
MO
CHANTIX CONTINUING MONTH PAK 4 QL (56 EA per 28 days)
MO
CHANTIX STARTING MONTH PAK 4 QL (56 EA per 28 days)
MO
NICOTROL NS 4 MO
BETA-ADRENERGIC AGONISTS
albuterol sulfate er 3 MO
albuterol sulfate nebu 2 B/D MO
albuterol sulfate syrp, tabs 2 MO
BROVANA 4 QL (124 ML per 30 days)
PA MO
FORADIL AEROLIZER 4 QL (60 EA per 30 days)
MO
levalbuterol 2 B/D MO
metaproterenol sulfate tabs 2 MO
metaproterenol sulfate syrp 3 MO
PERFOROMIST 4 QL (120 ML per 30 days)
PA MO
PROAIR HFA 3 QL (36 GM per 30 days)
MO
SEREVENT DISKUS 4 QL (60 EA per 30 days)
MO
SYMBICORT 3 QL (11 GM per 30 days)
MO
terbutaline sulfate tabs 3 MO
terbutaline sulfate inj 4
BETA-ADRENERGIC BLOCKING AGENTS(SYMPATH)
acebutolol hcl 2 MO
atenolol 1 MO
atenolol/chlorthalidone 2 MO
betaxolol hcl 2 MO
bisoprolol fumarate 2 MO
bisoprolol fumarate/hydrochlorothiazide 2 MO
metoprolol succinate er 2 QL (60 EA per 30 days)
MO
metoprolol tartrate 1 MO
metoprolol/hydrochlorothiazide 3 MO
nadolol 2 MO
nadolol/bendroflumethiazide 3 MO
Page 21 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
pindolol 2 MO
propranolol hcl er 3 MO
propranolol hcl inj, oral soln 1 MO
propranolol hcl tabs 2 MO
propranolol/hydrochlorothiazide 2 MO
sorine 1 MO
sotalol hcl 2 MO
sotalol hcl (af) 2 MO
timolol maleate 2 MO
CENTRALLY ACTING SKELETAL MUSCLE RELAXNT
carisoprodol 2 PA MO
carisoprodol/aspirin 3 PA MO
carisoprodol/aspirin/codeine 3 QL (360 EA per 30 days)
PA MO
metaxalone 3 QL (120 EA per 30 days)
PA MO
methocarbamol 2 PA MO
tizanidine hcl 2 MO
DIRECT-ACTING SKELETAL MUSCLE RELAXANTS
dantrolene sodium 3 MO
GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT
baclofen 2 MO
ed baclofen 2 MO
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
bethanechol chloride 3 MO
donepezil hcl tbdp 1 QL (30 EA per 30 days)
MO
donepezil hcl tabs 5mg 1 QL (30 EA per 30 days)
MO
donepezil hcl tabs 10mg 1 QL (60 EA per 30 days)
MO
EXELON SOLN 4 QL (240 ML per 30 days)
MO
EXELON PT24 4 QL (30 EA per 30 days)
MO
galantamine 3 QL (60 EA per 30 days)
MO
galantamine hydrobromide soln 2 QL (200 ML per 30 days)
MO
galantamine hydrobromide cp24 2 QL (30 EA per 30 days)
MO
galantamine hydrobromide tabs 3 QL (60 EA per 30 days)
MO
MESTINON TIMESPAN 4 MO
MESTINON SYRP 4 MO
MESTINON TABS 4 PA MO
pilocarpine hcl 3 MO
pilocarpine hydrochloride 3 MO
pyridostigmine bromide 2 MO
rivastigmine tartrate caps 4.5mg, 6mg 2 QL (60 EA per 30 days)
MO
Page 22 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
rivastigmine tartrate caps 1.5mg, 3mg 2 QL (90 EA per 30 days)
MO
SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS
orphenadrine citrate 3 MO
orphenadrine citrate er 3 PA MO
BLOOD FORMATION, COAGULATION, AND
THROMBOSIS
ANTICOAGULANTS
argatroban 1 B/D MO
COUMADIN 4 MO
enoxaparin sodium 3 QL (28 ML per 30 days)
MO
fondaparinux sodium 4 QL (14 ML per 30 days)
MO
FRAGMIN INJ 10000UNIT/ML, 12500UNIT/0.5ML,
15000UNIT/0.6ML, 18000UNT/0.72ML,
2500UNIT/0.2ML, 5000UNIT/0.2ML, 7500UNIT/0.3ML
4 QL (14 ML per 30 days)
MO
FRAGMIN INJ 25000UNIT/ML 4 QL (2 ML per 30 days)
MO
heparin sodium dcu 3 MO
heparin sodium/d5w 1 MO
heparin sodium/nacl 0.45% 1 MO
heparin sodium/sodium chloride 0.9% 1 MO
heparin sodium/sodium chloride 0.9% premix 1 MO
heparin sodium inj 1000unit/ml 3 B/D MO
heparin sodium inj 10000unit/ml, 20000unit/ml,
2000unit/ml, 5000unit/ml
3 MO
jantoven 2 MO
PRADAXA 4 QL (60 EA per 30 days)
MO
warfarin sodium 1 MO
XARELTO TABS 15MG, 20MG 4 QL (30 EA per 30 days)
MO
XARELTO TABS 10MG 4 QL (35 EA per 60 days)
MO
HEMATOPOIETIC AGENTS
EPOGEN INJ 2000UNIT/ML, 3000UNIT/ML,
4000UNIT/ML
3 QL (14 ML per 30 days)
PA
EPOGEN INJ 10000UNIT/ML, 20000UNIT/ML 4 QL (14 ML per 30 days)
PA
LEUKINE 4 PA MO
MOZOBIL 4 QL (8 ML per 30 days) PA
MO
NEULASTA 4 QL (2 ML per 28 days) PA
MO
NEUMEGA 4 QL (42 EA per 30 days)
MO
NEUPOGEN 4 QL (14 ML per 30 days)
PA MO
PROCRIT INJ 10000UNIT/ML, 20000UNIT/ML 4 QL (14 ML per 30 days)
PA
Page 23 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
PROCRIT INJ 40000UNIT/ML 4 QL (4 ML per 30 days) PA
procrit inj 2000unit/ml, 3000unit/ml, 4000unit/ml 3 QL (14 ML per 30 days)
PA
PROMACTA 4 QL (30 EA per 30 days)
PA MO
HEMORRHEOLOGIC AGENTS
pentoxifylline er 2 MO
HEMOSTATICS
CYKLOKAPRON 3 QL (400 ML per 30 days)
PA MO
desmopressin acetate 3 MO
STIMATE 4 MO
tranexamic acid 3 MO
PLATELET-AGGREGATION INHIBITORS
AGGRENOX 4 MO
cilostazol 2 MO
clopidogrel tabs 300mg 2 QL (1 EA per 30 days)
MO
clopidogrel tabs 75mg 2 QL (30 EA per 30 days)
MO
EFFIENT 4 QL (30 EA per 30 days)
MO
ticlopidine hcl 3 MO
PLATELET-REDUCING AGENTS
anagrelide hydrochloride 2 MO
CARDIOVASCULAR DRUGS
ANGIOTENSIN II RECEPTOR ANTAGONISTS
irbesartan 3 QL (30 EA per 30 days)
MO
irbesartan/hydrochlorothiazide 3 QL (30 EA per 30 days)
MO
ANTIARRHYTHMIC AGENTS
amiodarone hcl 2 MO
cartia xt cp24 300mg 1 QL (30 EA per 30 days)
MO
cartia xt cp24 120mg, 180mg, 240mg 1 QL (60 EA per 30 days)
MO
COVERA-HS TB24 240MG 4 QL (60 EA per 30 days)
MO
COVERA-HS TB24 180MG 4 QL (90 EA per 30 days)
MO
digoxin 1 MO
DILANTIN 4 MO
dilantin infatabs 4 MO
dilt-cd cp24 300mg 2 QL (30 EA per 30 days)
MO
dilt-cd cp24 180mg, 240mg 2 QL (60 EA per 30 days)
MO
dilt-cd cp24 120mg 3 QL (60 EA per 30 days)
MO
dilt-xr 3 QL (60 EA per 30 days)
Page 24 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
MO
diltiazem cd cp24 120mg, 180mg 2 QL (60 EA per 30 days)
MO
diltiazem cd cp24 300mg 3 QL (30 EA per 30 days)
MO
diltiazem cd cp24 240mg 3 QL (60 EA per 30 days)
MO
diltiazem hcl er cp24 300mg, 360mg 2 QL (30 EA per 30 days)
MO
diltiazem hcl er cp24 120mg, 180mg, 240mg 2 QL (60 EA per 30 days)
MO
diltiazem hcl er cp24 300mg, 420mg 3 QL (30 EA per 30 days)
MO
diltiazem hcl er cp24 180mg, 240mg 3 QL (60 EA per 30 days)
MO
diltiazem hcl er cp12 3 MO
diltiazem hcl cp24 300mg, 360mg 2 QL (30 EA per 30 days)
MO
diltiazem hcl cp24 120mg, 240mg 2 QL (60 EA per 30 days)
MO
diltiazem hcl cp24 180mg 3 QL (60 EA per 30 days)
MO
diltiazem hcl tabs 2 MO
diltiazem hcl inj 4 MO
diltzac cp24 300mg, 360mg 3 QL (30 EA per 30 days)
MO
diltzac cp24 120mg, 180mg, 240mg 3 QL (60 EA per 30 days)
MO
disopyramide phosphate 2 MO
flecainide acetate 3 MO
LANOXIN 4 MO
magnesium sulfate 2 MO
magnesium sulfate in d5w 2 MO
mexiletine hcl 2 MO
MULTAQ 3 QL (60 EA per 30 days)
MO
NORPACE CR 4 MO
PACERONE TABS 100MG, 400MG 4 MO
pacerone tabs 200mg 4 MO
PHENYTEK 3 MO
phenytoin 2 MO
phenytoin sodium 3 MO
phenytoin sodium extended 2 MO
procainamide hcl 1 MO
propafenone hcl 3 MO
propafenone hcl er 3 MO
sotalol hydrochloride 2 MO
taztia xt cp24 300mg, 360mg 3 QL (30 EA per 30 days)
MO
taztia xt cp24 120mg, 180mg, 240mg 3 QL (60 EA per 30 days)
MO
Page 25 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
TIKOSYN CAPS 250MCG 4 QL (120 EA per 30 days)
MO
TIKOSYN CAPS 125MCG 4 QL (240 EA per 30 days)
MO
TIKOSYN CAPS 500MCG 4 QL (60 EA per 30 days)
MO
verapamil hcl 2 MO
verapamil hcl er cp24 100mg, 300mg 2 QL (30 EA per 30 days)
MO
verapamil hcl er cp24 120mg, 180mg, 200mg, 240mg 2 QL (60 EA per 30 days)
MO
verapamil hcl er tbcr 2 MO
verapamil hcl sr tbcr 2 MO
verapamil hcl sr cp24 2 QL (60 EA per 30 days)
MO
ANTILIPEMIC AGENTS, MISCELLANEOUS
lovaza 3 QL (120 EA per 30 days)
MO
niacor 2 MO
NIASPAN 3 MO
BETA-ADRENERGIC BLOCKING AGENTS
carvedilol 1 MO
propranolol/hydrochlorothiazide 2 MO
TENORMIN 4 PA MO
BILE ACID SEQUESTRANTS
cholestyramine 3 MO
cholestyramine light 3 MO
colestipol hcl 3 MO
micronized colestipol hcl 3 MO
prevalite 3 MO
WELCHOL 3 MO
CALCIUM-CHANNEL BLOCKING AGENTS(HYPOTEN)
afeditab cr 3 QL (60 EA per 30 days)
MO
amlodipine besylate 1 MO
amlodipine besylate/benazepril hcl 3 QL (30 EA per 30 days)
MO
amlodipine besylate/benazepril hydrochloride 3 QL (60 EA per 30 days)
MO
felodipine er 3 QL (30 EA per 30 days)
MO
isradipine 3 MO
nicardipine hcl 2 MO
nifediac cc 3 QL (60 EA per 30 days)
MO
nifedical xl 3 QL (60 EA per 30 days)
MO
nifedipine er 3 QL (60 EA per 30 days)
MO
nimodipine 4 MO
nisoldipine er 3 QL (60 EA per 30 days)
Page 26 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
MO
nisoldipine tb24 17mg, 20mg, 34mg, 40mg, 8.5mg 3 QL (30 EA per 30 days)
MO
nisoldipine tb24 30mg 3 QL (60 EA per 30 days)
MO
CARDIAC DRUGS, MISCELLANEOUS
RANEXA 3 QL (120 EA per 30 days)
ST MO
CENTRAL ALPHA-AGONISTS
clonidine hcl ptwk 3 QL (4 EA per 28 days)
MO
clonidine hcl tabs 0.1mg, 0.2mg 2 MO
clonidine hcl tabs 0.3mg 3 MO
clorpres 4 MO
guanfacine hcl 2 MO
KAPVAY 4 QL (120 EA per 30 days)
ST MO
CHOLESTEROL ABSORPTION INHIBITORS
ZETIA 3 QL (30 EA per 30 days)
MO
DIHYDROPYRIDINES
amlodipine besylate/atorvastatin calcium 2 QL (30 EA per 30 days)
MO
DIRECT VASODILATORS
BIDIL 3 QL (180 EA per 30 days)
MO
hydralazine hcl inj 3 MO
hydralazine hcl tabs 10mg, 25mg 2 MO
hydralazine hcl tabs 100mg, 50mg 3 MO
minoxidil 2 MO
PROGLYCEM 4 MO
DIURETICS (HYPOTENSIVE AGENTS)
acetazolamide 2 MO
acetazolamide er 2 MO
acetazolamide sodium 2 MO
amiloride hcl 2 MO
amiloride/hydrochlorothiazide 2 MO
benazepril hcl/hydrochlorothiazide 2 MO
bumetanide 2 MO
captopril/hydrochlorothiazide 2 MO
chlorothiazide 2 MO
chlorothiazide sodium 2 MO
chlorthalidone 2 MO
DIURIL 3 MO
DYRENIUM 4 MO
ELIXOPHYLLIN 2 MO
enalapril maleate/hydrochlorothiazide 2 MO
eplerenone 3 MO
fosinopril sodium/hydrochlorothiazide 3 MO
furosemide 1 MO
hydrochlorothiazide 1 MO
Page 27 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
indapamide 1 MO
lisinopril/hydrochlorothiazide 1 MO
losartan potassium/hydrochlorothiazide 1 QL (60 EA per 30 days)
MO
methyclothiazide 2 MO
metolazone 2 MO
moexipril/hydrochlorothiazide 2 MO
quinapril/hydrochlorothiazide 3 MO
SODIUM EDECRIN 3 MO
spironolactone 2 MO
spironolactone/hydrochlorothiazide 2 MO
theophylline cr 2 MO
theophylline er 2 MO
torsemide 2 MO
triamterene/hydrochlorothiazide caps 25mg; 50mg 1 MO
triamterene/hydrochlorothiazide caps 25mg; 37.5mg 2 MO
triamterene/hydrochlorothiazide tabs 2 MO
FIBRIC ACID DERIVATIVES
fenofibrate micronized caps 134mg, 200mg 3 QL (30 EA per 30 days)
MO
fenofibrate micronized caps 67mg 3 QL (60 EA per 30 days)
MO
fenofibrate tabs 160mg 3 QL (30 EA per 30 days)
MO
fenofibrate tabs 54mg 3 QL (60 EA per 30 days)
MO
gemfibrozil 2 QL (60 EA per 30 days)
MO
TRICOR TABS 145MG 3 QL (30 EA per 30 days)
MO
TRICOR TABS 48MG 3 QL (60 EA per 30 days)
MO
HMG-COA REDUCTASE INHIBITORS
amlodipine besylate/atorvastatin calcium 2 QL (30 EA per 30 days)
MO
atorvastatin calcium 2 QL (30 EA per 30 days)
MO
CRESTOR 3 QL (30 EA per 30 days)
MO
JUVISYNC 3 QL (30 EA per 30 days)
ST MO
lovastatin 2 QL (60 EA per 30 days)
MO
pravastatin sodium tabs 10mg, 20mg, 80mg 2 QL (30 EA per 30 days)
MO
pravastatin sodium tabs 40mg 2 QL (60 EA per 30 days)
MO
simvastatin 1 QL (30 EA per 30 days)
MO
NITRATES AND NITRITES
DILATRATE SR 4 MO
Page 28 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
isoditrate er 3 MO
ISORDIL TITRADOSE 4 MO
isosorbide dinitrate er 3 MO
isosorbide dinitrate tabs 2 MO
isosorbide dinitrate subl 2.5mg 1 MO
isosorbide dinitrate subl 5mg 2 MO
isosorbide mononitrate 2 MO
isosorbide mononitrate er 2 MO
minitran pt24 0.1mg/hr, 0.2mg/hr, 0.6mg/hr 3 QL (30 EA per 30 days)
MO
minitran pt24 0.4mg/hr 3 QL (60 EA per 30 days)
MO
nitroglycerin lingual 3 MO
nitroglycerin transdermal pt24 0.1mg/hr, 0.2mg/hr,
0.6mg/hr
2 QL (30 EA per 30 days)
MO
nitroglycerin transdermal pt24 0.4mg/hr 2 QL (60 EA per 30 days)
MO
nitroglycerin inj 2 MO
nitroglycerin pt24 0.2mg/hr, 0.6mg/hr 2 QL (30 EA per 30 days)
MO
nitroglycerin pt24 0.4mg/hr 2 QL (60 EA per 30 days)
MO
NITROLINGUAL PUMPSPRAY 4 MO
NITROSTAT 3 MO
PERIPHERAL ADRENERGIC INHIBITORS
reserpine 2 MO
PHOSPHODIESTERASE TYPE 5 INHIBITORS
ADCIRCA 4 QL (60 EA per 30 days)
PA MO
REVATIO 3 QL (90 EA per 30 days)
PA MO
RENIN INHIBITORS
TEKTURNA 4 QL (30 EA per 30 days)
MO
RENIN-ANGIOTENSIN-ALDOSTERINHIB(HYPOTN)
benazepril hcl 1 MO
captopril 1 MO
enalapril maleate 1 MO
fosinopril sodium 2 MO
lisinopril 1 MO
losartan potassium 1 QL (60 EA per 30 days)
MO
moexipril hcl 2 MO
perindopril erbumine 3 MO
quinapril hcl 2 MO
ramipril 2 MO
trandolapril 2 MO
VASODILATING AGENTS, MISCELLANEOUS
LETAIRIS 4 QL (30 EA per 30 days)
PA MO
REMODULIN 4 PA MO
Page 29 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
TRACLEER 4 QL (60 EA per 30 days)
PA MO
Central Nervous System Agents
"BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)"
DIAZEPAM 4 MO
ANTICONVULSANTS, MISCELLANEOUS
TRILEPTAL 4 MO
ANTIPSYCHOTIC AGENTS
GEODON 4 MO
ZYPREXA 4 QL (60 EA per 30 days)
MO
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
phenobarbital tabs 30mg 3 QL (210 EA per 30 days)
PA MO
phenobarbital tabs 16.2mg, 32.4mg, 64.8mg, 97.2mg 3 QL (90 EA per 30 days)
PA MO
BENZODIAZEPINES (ANTICONVULSANTS)
clonazepam 3 MO
CLONAZEPAM ODT 4 MO
ONFI 4 QL (60 EA per 30 days)
PA MO
BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)
CLORAZEPATE DIPOTASSIUM 4 MO
DIAZEPAM INTENSOL 4 QL (1200 ML per 30 days)
MO
DIAZEPAM GEL 4 MO
DIAZEPAM SOLN 4 QL (1200 ML per 30 days)
MO
DIAZEPAM TABS 10MG 4 QL (120 EA per 30 days)
MO
DIAZEPAM TABS 2MG, 5MG 4 QL (90 EA per 30 days)
MO
CENTRAL NERVOUS SYSTEMS AGENTS
AMPHETAMINES
dextroamphetamine sulfate 3 PA MO
dextroamphetamine sulfate er 3 PA MO
methamphetamine hcl 3 MO
ANOREX,RESPIR,CEREBRAL STIMULANTS,MISC
dexmethylphenidate hcl 2 PA MO
methylphenidate hcl 2 PA MO
ANTICONVULSANTS, MISCELLANEOUS
BANZEL SUSP 4 QL (2760 ML per 30 days)
PA MO
BANZEL TABS 400MG 4 QL (240 EA per 30 days)
PA MO
BANZEL TABS 200MG 4 QL (480 EA per 30 days)
PA MO
carbamazepine 2 MO
carbamazepine er cp12 300mg 4 QL (150 EA per 30 days)
MO
carbamazepine er cp12 200mg 4 QL (240 EA per 30 days)
Page 30 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
MO
carbamazepine er cp12 100mg 4 QL (60 EA per 30 days)
MO
carbamazepine er tb12 2 MO
CARBATROL CP12 300MG 4 QL (150 EA per 30 days)
MO
CARBATROL CP12 200MG 4 QL (240 EA per 30 days)
MO
CARBATROL CP12 100MG 4 QL (60 EA per 30 days)
MO
divalproex sodium 3 MO
divalproex sodium dr 3 MO
divalproex sodium er 2 MO
epitol 2 MO
EQUETRO 4 MO
felbamate 4 MO
FELBATOL 4 MO
gabapentin tabs 2 QL (180 EA per 30 days)
MO
gabapentin caps 2 QL (270 EA per 30 days)
MO
gabapentin soln 3 MO
GABITRIL TABS 4MG 4 MO
GABITRIL TABS 12MG 4 QL (120 EA per 30 days)
MO
GABITRIL TABS 16MG, 2MG 4 QL (90 EA per 30 days)
MO
LAMICTAL CHEWABLE DISPERSIBLE 4 MO
LAMICTAL ODT TBDP 100MG, 25MG 4 QL (120 EA per 30 days)
MO
LAMICTAL ODT TBDP 200MG, 50MG 4 QL (90 EA per 30 days)
MO
LAMICTAL STARTER/NOT TAKING
CARBAMAZEPINE
4 MO
LAMICTAL STARTER/TAKING
CARBAMAZEPINE/NOT TAKING VALPROATE
4 MO
LAMICTAL STARTER/TAKING VALPROATE 4 MO
LAMICTAL XR KIT 4 MO
LAMICTAL XR TB24 100MG 4 QL (120 EA per 30 days)
MO
LAMICTAL XR TB24 250MG 4 QL (60 EA per 30 days)
MO
LAMICTAL XR TB24 200MG, 25MG, 50MG 4 QL (90 EA per 30 days)
MO
LAMICTAL TABS 25MG 4 QL (120 EA per 30 days)
MO
LAMICTAL TABS 100MG 4 QL (150 EA per 30 days)
MO
LAMICTAL TABS 150MG, 200MG 4 QL (90 EA per 30 days)
MO
lamotrigine chew 2 MO
Page 31 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
lamotrigine tabs 25mg 2 QL (120 EA per 30 days)
MO
lamotrigine tabs 100mg 2 QL (150 EA per 30 days)
MO
lamotrigine tabs 150mg, 200mg 2 QL (90 EA per 30 days)
MO
levetiracetam er tb24 750mg 2 QL (120 EA per 30 days)
MO
levetiracetam er tb24 500mg 2 QL (180 EA per 30 days)
MO
levetiracetam inj, oral soln 2 MO
levetiracetam tabs 2 QL (120 EA per 30 days)
MO
LYRICA CAPS 225MG, 300MG 4 QL (60 EA per 30 days)
ST MO
LYRICA CAPS 100MG, 150MG, 200MG, 25MG,
50MG, 75MG
4 QL (90 EA per 30 days)
ST MO
NEURONTIN 4 MO
oxcarbazepine 3 MO
POTIGA TABS 50MG 4 QL (270 EA per 30 days)
PA MO
POTIGA TABS 200MG, 300MG, 400MG 4 QL (90 EA per 30 days)
PA MO
SABRIL 4 QL (180 EA per 30 days)
PA MO
TEGRETOL-XR 4 MO
topiragen tabs 100mg, 200mg, 50mg 2 QL (120 EA per 30 days)
MO
topiragen tabs 25mg 2 QL (90 EA per 30 days)
MO
topiramate cpsp 2 MO
topiramate tabs 100mg, 200mg, 50mg 2 QL (120 EA per 30 days)
MO
topiramate tabs 25mg 2 QL (90 EA per 30 days)
MO
valproate sodium 2 MO
valproic acid 2 MO
VIMPAT INJ 4 MO
VIMPAT ORAL SOLN 4 QL (1395 ML per 30 days)
MO
VIMPAT TABS 200MG 4 QL (60 EA per 30 days)
MO
VIMPAT TABS 100MG, 150MG, 50MG 4 QL (90 EA per 30 days)
MO
zonisamide 2 MO
ANTIDEPRESSANTS
amitriptyline hcl 1 MO
amoxapine 2 MO
budeprion sr tb12 100mg 3 QL (120 EA per 30 days)
MO
budeprion sr tb12 150mg 3 QL (90 EA per 30 days)
Page 32 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
MO
budeprion xl 3 QL (90 EA per 30 days)
MO
buproban 3 QL (90 EA per 30 days)
MO
bupropion hcl er tb12 150mg 2 QL (90 EA per 30 days)
MO
bupropion hcl er tb12 100mg 3 QL (120 EA per 30 days)
MO
bupropion hcl er tb12 200mg 3 QL (60 EA per 30 days)
MO
bupropion hcl sr tb12 150mg 2 QL (90 EA per 30 days)
MO
bupropion hcl sr tb12 100mg 3 QL (120 EA per 30 days)
MO
bupropion hcl sr tb12 200mg 3 QL (60 EA per 30 days)
MO
bupropion hcl xl 3 QL (90 EA per 30 days)
MO
bupropion hcl tabs 75mg 3 MO
bupropion hcl tabs 100mg 3 QL (180 EA per 30 days)
MO
citalopram hydrobromide soln 1 MO
citalopram hydrobromide tabs 1 QL (30 EA per 30 days)
MO
clomipramine hcl 2 MO
CYMBALTA 4 QL (60 EA per 30 days)
MO
desipramine hcl 3 MO
doxepin hcl 2 MO
EMSAM 4 QL (30 EA per 30 days)
MO
escitalopram oxalate tabs 3 QL (30 EA per 30 days)
MO
escitalopram oxalate soln 3 QL (600 ML per 30 days)
MO
fluoxetine dr 3 QL (4 EA per 28 days)
MO
fluoxetine hcl caps 20mg 1 QL (120 EA per 30 days)
MO
fluoxetine hcl caps 10mg 1 QL (60 EA per 30 days)
MO
fluoxetine hcl caps 40mg 2 QL (60 EA per 30 days)
MO
fluoxetine hcl soln, tabs 2 MO
fluoxetine caps 20mg 1 QL (120 EA per 30 days)
MO
fluoxetine caps 10mg 1 QL (60 EA per 30 days)
MO
fluvoxamine maleate 3 QL (90 EA per 30 days)
MO
Page 33 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
imipramine hcl 2 MO
imipramine pamoate 3 MO
LUVOX CR 4 QL (60 EA per 30 days)
MO
maprotiline hcl 2 MO
MARPLAN 4 MO
mirtazapine odt tbdp 15mg 2 QL (30 EA per 30 days)
MO
mirtazapine odt tbdp 30mg, 45mg 3 QL (30 EA per 30 days)
MO
mirtazapine tbdp 2 QL (30 EA per 30 days)
MO
mirtazapine tabs 7.5mg 2 MO
mirtazapine tabs 15mg, 30mg, 45mg 2 QL (30 EA per 30 days)
MO
NARDIL 4 MO
nefazodone hcl 2 MO
nortriptyline hcl 2 MO
paroxetine hcl er tb24 12.5mg, 37.5mg 3 QL (60 EA per 30 days)
MO
paroxetine hcl er tb24 25mg 3 QL (90 EA per 30 days)
MO
paroxetine hcl tabs 10mg, 20mg 2 QL (30 EA per 30 days)
MO
paroxetine hcl tabs 30mg, 40mg 2 QL (60 EA per 30 days)
MO
PAXIL 4 MO
perphenazine/amitriptyline 2 MO
phenelzine sulfate 3 MO
PRISTIQ 4 QL (30 EA per 30 days)
MO
protriptyline hcl 2 MO
selegiline hcl 3 MO
sertraline hcl conc 1 MO
sertraline hcl tabs 1 QL (60 EA per 30 days)
MO
SURMONTIL 4 MO
tranylcypromine sulfate 3 MO
trazodone hcl 2 MO
trimipramine maleate 4 MO
venlafaxine hcl 3 MO
venlafaxine hcl er cp24 37.5mg 2 QL (30 EA per 30 days)
MO
venlafaxine hcl er cp24 150mg 2 QL (60 EA per 30 days)
MO
venlafaxine hcl er cp24 75mg 2 QL (90 EA per 30 days)
MO
VENLAFAXINE HCL ER TB24 225MG 4 QL (30 EA per 30 days)
MO
venlafaxine hcl er tb24 150mg, 37.5mg 4 QL (30 EA per 30 days)
MO
Page 34 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
venlafaxine hcl er tb24 75mg 4 QL (60 EA per 30 days)
MO
VIIBRYD 4 QL (30 EA per 30 days)
MO
ZYBAN 3 QL (90 EA per 30 days)
MO
ANTIMANIC AGENTS
lithium carbonate 2 MO
lithium carbonate er 2 MO
lithium citrate 2 MO
ANTIPSYCHOTIC AGENTS
ABILIFY DISCMELT 4 QL (60 EA per 30 days)
MO
ABILIFY INJ 4 QL (120 ML per 30 days)
MO
ABILIFY TABS 4 QL (30 EA per 30 days)
MO
ABILIFY ORAL SOLN 4 QL (750 ML per 30 days)
MO
chlorpromazine hcl inj 2 MO
chlorpromazine hcl tabs 10mg, 25mg 2 B/D MO
chlorpromazine hcl tabs 100mg, 200mg, 50mg 2 MO
clozapine 3 MO
compro 2 MO
FANAPT 4 QL (60 EA per 30 days)
PA MO
FANAPT TITRATION PACK 4 QL (60 EA per 30 days)
PA MO
FAZACLO 4 ST MO
fluphenazine decanoate 2 MO
fluphenazine hcl 2 MO
HALDOL 4 MO
haloperidol 2 MO
haloperidol decanoate 3 MO
haloperidol lactate 2 MO
INVEGA SUSTENNA 4 QL (1 ML per 30 days)
MO
INVEGA TB24 1.5MG, 3MG, 9MG 4 QL (30 EA per 30 days)
ST MO
INVEGA TB24 6MG 4 QL (60 EA per 30 days)
ST MO
LATUDA TABS 20MG, 40MG 4 QL (30 EA per 30 days)
PA MO
LATUDA TABS 80MG 4 QL (60 EA per 30 days)
PA MO
loxapine 3 MO
loxapine succinate 3 MO
olanzapine odt tbdp 10mg, 5mg 3 QL (30 EA per 30 days)
MO
olanzapine odt tbdp 15mg, 20mg 3 QL (60 EA per 30 days)
MO
Page 35 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
olanzapine inj 3 QL (60 EA per 30 days)
MO
olanzapine tabs 10mg, 2.5mg, 5mg, 7.5mg 3 QL (30 EA per 30 days)
MO
olanzapine tabs 15mg, 20mg 3 QL (60 EA per 30 days)
MO
ORAP 4 MO
perphenazine 2 MO
prochlorperazine 2 MO
prochlorperazine edisylate 2 MO
prochlorperazine maleate 1 B/D MO
quetiapine fumarate tabs 200mg, 25mg, 50mg 3 QL (120 EA per 30 days)
MO
quetiapine fumarate tabs 100mg, 300mg, 400mg 3 QL (90 EA per 30 days)
MO
RISPERDAL CONSTA INJ 12.5MG, 25MG 4 QL (2 EA per 28 days)
MO
RISPERDAL CONSTA INJ 37.5MG, 50MG 4 QL (4 EA per 28 days)
MO
risperidone m-tab tbdp 0.5mg 3 QL (120 EA per 30 days)
MO
risperidone m-tab tbdp 1mg, 2mg, 3mg, 4mg 3 QL (60 EA per 30 days)
MO
risperidone odt tbdp 0.5mg 3 QL (120 EA per 30 days)
MO
risperidone odt tbdp 0.25mg, 1mg, 2mg, 3mg, 4mg 3 QL (60 EA per 30 days)
MO
risperidone soln 3 MO
risperidone tabs 0.5mg 2 QL (120 EA per 30 days)
MO
risperidone tabs 0.25mg, 1mg, 2mg, 3mg, 4mg 2 QL (60 EA per 30 days)
MO
SAPHRIS 4 QL (60 EA per 30 days)
PA MO
SEROQUEL XR TB24 50MG 3 QL (120 EA per 30 days)
MO
SEROQUEL XR TB24 200MG 3 QL (30 EA per 30 days)
MO
SEROQUEL XR TB24 300MG, 400MG 3 QL (60 EA per 30 days)
MO
SEROQUEL XR TB24 150MG 3 QL (90 EA per 30 days)
MO
thioridazine hcl 2 PA MO
thiothixene 2 MO
trifluoperazine hcl 2 MO
ziprasidone hcl 3 QL (60 EA per 30 days)
MO
ANXIOLYTICS, SEDATIVES - HYPNOTICS,MISC
buspirone hcl 2 MO
zaleplon caps 5mg 2 QL (30 EA per 30 days)
MO
Page 36 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
zaleplon caps 10mg 2 QL (60 EA per 30 days)
MO
zolpidem tartrate 1 QL (30 EA per 30 days)
MO
BARBITURATES (ANTICONVULSANTS)
primidone 3 MO
CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB
COMTAN 3 QL (300 EA per 30 days)
MO
TASMAR 4 PA MO
CENTRAL NERVOUS SYSTEM AGENTS, MISC
NAMENDA TITRATION PAK 3 QL (98 EA per 30 days)
MO
NAMENDA SOLN 3 QL (360 ML per 30 days)
MO
NAMENDA TABS 3 QL (60 EA per 30 days)
MO
NUEDEXTA 4 QL (60 EA per 30 days)
MO
RILUTEK 3 MO
STRATTERA CAPS 100MG, 80MG 4 QL (30 EA per 30 days)
MO
STRATTERA CAPS 10MG, 18MG, 25MG, 40MG,
60MG
4 QL (60 EA per 30 days)
MO
XENAZINE TABS 25MG 4 QL (120 EA per 30 days)
PA MO
XENAZINE TABS 12.5MG 4 QL (240 EA per 30 days)
PA MO
XYREM 4 MO
DOPAMINE PRECURSORS
carbidopa/levodopa 3 MO
carbidopa/levodopa cr 2 MO
carbidopa/levodopa er 2 MO
carbidopa/levodopa odt 3 MO
carbidopa/levodopa sr 2 MO
DOPAMINE RECEPTOR AGONISTS
APOKYN 4 QL (60 ML per 30 days)
MO
bromocriptine mesylate 3 MO
cabergoline 2 QL (16 EA per 28 days)
MO
pramipexole dihydrochloride 2 MO
ropinirole hcl 2 MO
FIBROMYALGIA AGENTS
SAVELLA 3 QL (60 EA per 30 days)
MO
SAVELLA TITRATION PACK 3 QL (60 EA per 30 days)
MO
HYDANTOINS
fosphenytoin sodium 1 MO
PEGANONE 4 MO
Page 37 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
MONOAMINE OXIDASE B INHIBITORS
AZILECT 3 QL (30 EA per 30 days)
MO
ELDEPRYL 4 PA MO
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
ascomp/codeine 3 QL (360 EA per 30 days)
MO
butalbital/aspirn/caffeine/codeine 3 QL (360 EA per 30 days)
MO
diclofenac potassium 2 MO
diclofenac sodium dr 2 MO
diclofenac sodium er 2 MO
diclofenac sodium xr 2 MO
diflunisal 3 MO
etodolac 2 MO
etodolac er 3 MO
fenoprofen calcium 3 MO
flurbiprofen 2 MO
hydrocodone/ibuprofen 3 QL (150 EA per 30 days)
MO
ibuprofen 1 MO
INDOCIN 4 MO
indomethacin 2 MO
indomethacin er 2 MO
ketoprofen 2 MO
ketoprofen er 3 MO
meclofenamate sodium 2 MO
meloxicam susp 1 QL (300 ML per 30 days)
MO
meloxicam tabs 15mg 1 QL (30 EA per 30 days)
MO
meloxicam tabs 7.5mg 1 QL (60 EA per 30 days)
MO
nabumetone 3 MO
NALFON 4 MO
naproxen 2 MO
naproxen dr 2 MO
naproxen sodium 2 MO
oxaprozin 2 MO
oxycodone/aspirin 3 MO
oxycodone/ibuprofen 3 QL (240 EA per 30 days)
MO
piroxicam 2 MO
sulindac 2 MO
tolmetin sodium 3 MO
voltaren 3 MO
OPIATE AGONISTS
acetaminophen/caffeine/dihydrocodeine bitartrate 4 QL (180 EA per 30 days)
MO
acetaminophen/codeine #2 3 QL (390 EA per 30 days)
MO
Page 38 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
acetaminophen/codeine #3 3 QL (390 EA per 30 days)
MO
acetaminophen/codeine #4 3 QL (390 EA per 30 days)
MO
acetaminophen/codeine phosphate 3 QL (390 EA per 30 days)
MO
acetaminophen/codeine tabs 3 QL (390 EA per 30 days)
MO
acetaminophen/codeine soln 3 QL (5010 ML per 30 days)
MO
ASTRAMORPH 3 MO
butalbital/acetaminophen/caffeine/codeine 3 QL (360 EA per 30 days)
MO
CAPITAL/CODEINE 3 QL (5010 ML per 30 days)
MO
codeine sulfate tabs 60mg 3 QL (180 EA per 30 days)
MO
codeine sulfate tabs 15mg, 30mg 3 QL (360 EA per 30 days)
MO
DURAMORPH 4 MO
endocet tabs 650mg; 10mg 3 QL (180 EA per 30 days)
MO
endocet tabs 500mg; 7.5mg 3 QL (240 EA per 30 days)
MO
endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg 3 QL (360 EA per 30 days)
MO
fentanyl 3 QL (20 EA per 30 days)
MO
fentanyl citrate 3 MO
fentanyl citrate oral transmucosal 4 QL (120 EA per 30 days)
PA MO
hydrocodone bitartrate/acetaminophen soln 3 QL (5520 ML per 30 days)
MO
hydrocodone bitartrate/acetaminophen tabs 750mg; 10mg 3 QL (150 EA per 30 days)
MO
hydrocodone bitartrate/acetaminophen tabs 300mg;
10mg, 300mg; 5mg, 300mg; 7.5mg
3 QL (360 EA per 30 days)
MO
hydrocodone/acetaminophen tabs 750mg; 7.5mg 3 QL (150 EA per 30 days)
MO
hydrocodone/acetaminophen tabs 650mg; 10mg, 650mg;
7.5mg, 660mg; 10mg
3 QL (180 EA per 30 days)
MO
hydrocodone/acetaminophen tabs 500mg; 10mg, 500mg;
2.5mg, 500mg; 5mg, 500mg; 7.5mg
3 QL (240 EA per 30 days)
MO
hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg;
5mg, 325mg; 7.5mg
3 QL (360 EA per 30 days)
MO
hydromorphone hcl inj 3 MO
hydromorphone hcl tabs 8mg 3 QL (240 EA per 30 days)
MO
hydromorphone hcl tabs 2mg, 4mg 3 QL (360 EA per 30 days)
MO
INFUMORPH 200 4 MO
Page 39 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
INFUMORPH 500 4 MO
levorphanol tartrate 3 MO
methadone hcl 3 MO
methadone hcl intensol 3 MO
METHADOSE SUGAR-FREE 3 MO
METHADOSE CONC 3 MO
methadose tabs 3 MO
morphine sulfate 3 MO
morphine sulfate er 3 MO
oxycodone hcl 3 MO
oxycodone/acetaminophen caps 3 QL (240 EA per 30 days)
MO
oxycodone/acetaminophen tabs 650mg; 10mg 3 QL (180 EA per 30 days)
MO
oxycodone/acetaminophen tabs 500mg; 7.5mg 3 QL (240 EA per 30 days)
MO
oxycodone/acetaminophen tabs 325mg; 10mg, 325mg;
2.5mg, 325mg; 5mg, 325mg; 7.5mg
3 QL (360 EA per 30 days)
MO
ROXICET TABS 500MG; 5MG 3 QL (240 EA per 30 days)
MO
roxicet tabs 325mg; 5mg 3 QL (360 EA per 30 days)
MO
tramadol hcl 2 QL (240 EA per 30 days)
MO
tramadol hydrochloride/acetaminophen 3 QL (240 EA per 30 days)
MO
OPIATE ANTAGONISTS
naloxone hcl 2 MO
naltrexone hcl 2 MO
OPIATE PARTIAL AGONISTS
buprenorphine hcl subl 3 QL (90 EA per 30 days)
PA MO
buprenorphine hcl inj 4 QL (240 ML per 30 days)
PA MO
butorphanol tartrate nasal soln 3 QL (5 ML per 28 days)
MO
butorphanol tartrate inj 2mg/ml 3 QL (480 ML per 30 days)
MO
butorphanol tartrate inj 1mg/ml 3 QL (960 ML per 30 days)
MO
nalbuphine hcl 3 MO
SELECTIVE SEROTONIN AGONISTS
ALSUMA 4 QL (6 ML per 30 days)
MO
naratriptan hcl 3 QL (9 EA per 30 days)
MO
sumatriptan 3 QL (12 EA per 30 days)
MO
sumatriptan succinate refill 3 QL (6 ML per 30 days)
MO
sumatriptan succinate tabs 2 QL (9 EA per 30 days)
Page 40 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
MO
sumatriptan succinate inj 3 QL (6 ML per 30 days)
MO
SUCCINIMIDES
CELONTIN 4 MO
ethosuximide 3 MO
Devices
Devices
bd insulin syringe safetyglide/1ml/29g x 1/2" 1 MO
bd insulin syringe ultrafine/0.3ml/31g x 5/16" 1 MO
bd insulin syringe ultrafine/0.5ml/30g x 1/2" 1 MO
bd insulin syringe ultrafine/1ml/31g x 5/16" 1 MO
ELECTROLYTIC, CALORIC, AND WATER BALANCE
ACIDIFYING AGENTS
ammonium chloride 1 MO
ALKALINIZING AGENTS
potassium citrate 3 MO
sodium bicarbonate inj 7.5%, 8.4% 2 MO
sodium lactate 1 MO
UROCIT-K 10 4 MO
UROCIT-K 5 4 MO
AMMONIA DETOXICANTS
BUPHENYL 4 MO
CARBAGLU 4 PA MO
enulose 2 MO
generlac 2 MO
lactulose 2 MO
CALORIC AGENTS
AMINOSYN 4 B/D MO
AMINOSYN 8.5%/ELECTROLYTES 4 B/D MO
AMINOSYN II 4 B/D MO
AMINOSYN II 8.5%/ELECTROLYTES 4 B/D MO
AMINOSYN M 4 B/D MO
AMINOSYN-HBC 4 B/D MO
AMINOSYN-PF 4 B/D MO
AMINOSYN-PF 7% 4 B/D MO
CLINIMIX 2.75%/DEXTROSE 5% 4 B/D MO
CLINIMIX 4.25%/DEXTROSE 10% 4 B/D MO
CLINIMIX 4.25%/DEXTROSE 20% 4 B/D MO
CLINIMIX 4.25%/DEXTROSE 25% 4 B/D MO
CLINIMIX 4.25%/DEXTROSE 5% 4 B/D MO
CLINIMIX 5%/DEXTROSE 15% 4 B/D MO
CLINIMIX 5%/DEXTROSE 20% 4 B/D MO
CLINIMIX 5%/DEXTROSE 25% 4 B/D MO
CLINIMIX E 2.75%/DEXTROSE 10% 4 B/D MO
CLINIMIX E 2.75%/DEXTROSE 5% 4 B/D MO
CLINIMIX E 4.25%/DEXTROSE 25% 4 B/D MO
CLINIMIX E 4.25%/DEXTROSE 5% 4 B/D MO
CLINIMIX E 5%/DEXTROSE 15% 4 B/D MO
CLINIMIX E 5%/DEXTROSE 20% 4 B/D MO
CLINIMIX E 5%/DEXTROSE 25% 4 B/D MO
Page 41 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
dextrose 10%/nacl 0.45% 1 MO
dextrose 10% 2 MO
dextrose 10% flex container 2 MO
dextrose 10%/nacl 0.2% 2 MO
dextrose 10%/nacl 0.225% 2 MO
dextrose 2.5%/nacl 0.45% 2 MO
dextrose 2.5%/sodium chloride 0.45% 2 MO
dextrose 5% 2 MO
dextrose 5% viaflex 2 MO
dextrose 5%/nacl 0.2% 2 MO
dextrose 5%/nacl 0.225% 2 MO
dextrose 5%/nacl 0.3% 2 MO
dextrose 5%/nacl 0.33% 2 MO
dextrose 5%/nacl 0.45% 2 MO
dextrose 5%/nacl 0.9% 2 MO
dextrose 5%/sodium chloride 0.2% 2 MO
dextrose 5%/sodium chloride 0.33% 2 MO
dextrose 5%/sodium chloride 0.45% 2 MO
dextrose 5%/sodium chloride 0.9% 2 MO
dextrose thermoject system 2 MO
FREAMINE III 3% 4 B/D MO
FREAMINE III INJ 72MEQ/L; 600MG/100ML;
810MG/100ML; 3MEQ/L; 14MG/100ML;
1190MG/100ML; 240MG/100ML; 590MG/100ML;
770MG/100ML; 620MG/100ML; 450MG/100ML;
480MG/100ML; 10MMOLE/L; 115MG/100ML;
950MG/100ML; 500MG/100ML; 10MEQ/L;
340MG/100ML; 130MG/100ML; 560MG/100ML
4 B/D MO
HEPATAMINE 4 B/D MO
HEPATASOL 4 B/D MO
INTRALIPID 4 B/D MO
LIPOSYN II 4 B/D MO
LIPOSYN III 4 B/D MO
NEPHRAMINE 4 B/D MO
PREMASOL 1 B/D MO
PROCALAMINE 4 B/D MO
TRAVASOL 4 B/D MO
TROPHAMINE 4 B/D MO
IRRIGATING SOLUTIONS
lactated ringers irrigation 2 MO
PHYSIOLYTE 1 MO
PHYSIOSOL IRRIGATION 1 MO
PHYSIOSOL IRRIGATION PH 7.4 1 MO
ringers irrigation 1 MO
sodium chloride 2 MO
sodium chloride 0.9% 2 MO
sodium chloride 0.9% 2 MO
sterile water irrigation 2 MO
sterile water irrigation plastic bottle 2 MO
sterile water irrigation w/hanger 2 MO
PHOSPHATE-REMOVING AGENTS
Page 42 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
calcium acetate 3 MO
eliphos 2 MO
PHOSLYRA 4 MO
RENVELA TABS 3 QL (540 EA per 30 days)
MO
RENVELA PACK 2.4GM 3 QL (180 EA per 30 days)
MO
RENVELA PACK 0.8GM 3 QL (540 EA per 30 days)
MO
POTASSIUM-REMOVING AGENTS
kalexate 4 MO
kionex 3 MO
sodium polystyrene sulfonate 3 MO
REPLACEMENT PREPARATIONS
dextrose 5% /electrolyte #48 viaflex 2 MO
dextrose 5%/potassium chloride 0.15% 2 MO
IONOSOL-B/DEXTROSE 5% 4 MO
IONOSOL-MB/DEXTROSE 5% 4 MO
ISOLYTE-H/DEXTROSE 5% 4 MO
ISOLYTE-M/DEXTROSE 5% 4 MO
ISOLYTE-P/DEXTROSE 5% 4 MO
ISOLYTE-S 4 MO
ISOLYTE-S/DEXTROSE 5% 4 MO
kcl 0.075%/d5w/nacl 0.2% 2 MO
kcl 0.075%/d5w/nacl 0.45% 2 MO
kcl 0.15%/d5w/ nacl 0.3% 2 MO
kcl 0.15%/d5w/lr 2 MO
kcl 0.15%/d5w/nacl 0.2% 2 MO
kcl 0.15%/d5w/nacl 0.225% 2 MO
kcl 0.15%/d5w/nacl 0.45% 2 MO
kcl 0.15%/d5w/nacl 0.9% 2 MO
kcl 0.3%/d5w/lr 2 MO
kcl 0.3%/d5w/lr iv lac ring 2 MO
kcl 0.3%/d5w/nacl 0.2% 2 MO
kcl 0.3%/d5w/nacl 0.45% 2 MO
kcl 0.3%/d5w/nacl 0.9% 2 MO
KLOR-CON 10 2 MO
KLOR-CON 8 2 MO
klor-con m10 2 MO
klor-con m15 2 MO
klor-con m20 2 MO
lactated ringers 2 MO
lactated ringers viaflex 2 MO
MICRO-K 4 MO
NORMOSOL -R 4 MO
NORMOSOL-M IN D5W 4 MO
NORMOSOL-R 4 MO
NORMOSOL-R IN D5W 4 MO
nutrilyte ii 4 MO
PLASMA-LYTE A 4 MO
PLASMA-LYTE-148 4 MO
Page 43 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
PLASMA-LYTE-56/D5W 4 MO
potassium chloride 0.075%/d5w/nacl 0.225% 2 MO
potassium chloride 0.15% /nacl 0.45% viaflex 2 MO
potassium chloride 0.15% d5w/nacl 0.33% 2 MO
potassium chloride 0.15% d5w/nacl 0.45% 2 MO
potassium chloride 0.15% d5w/nacl 0.45% viaflex 2 MO
potassium chloride 0.15% nacl 0.9% 2 MO
potassium chloride 0.15% w/nacl 0.9% viaflex 2 MO
potassium chloride 0.15%/d5w 2 MO
potassium chloride 0.15%/nacl 0.9% 2 MO
potassium chloride 0.22% d5w/nacl 0.45% 2 MO
potassium chloride 0.224%/d5w 2 MO
potassium chloride 0.224%/d5w/nacl 0.45% 2 MO
potassium chloride 0.224%/dextrose 5% viaflex 2 MO
potassium chloride 0.224%d5w/nacl 0.45% viaflex 2 MO
potassium chloride 0.3%/ nacl 0.9% 2 MO
potassium chloride 0.3%/d5w 2 MO
potassium chloride 0.3%/d5w/viaflex 2 MO
potassium chloride 0.3%/nacl 0.9%/viaflex 2 MO
potassium chloride cr 2 MO
potassium chloride er 2 MO
potassium chloride sr 2 MO
potassium chloride inj 0.4meq/ml, 10meq/100ml,
10meq/50ml, 2meq/ml, 30meq/100ml
1 MO
ringers injection 1 MO
sodium chloride 0.45% 2 MO
sodium chloride 0.45% viaflex 2
sodium chloride pab 2 MO
sodium chloride inj 0.9%, 2.5meq/ml 2
sodium chloride inj 3%, 5% 2 MO
TPN ELECTROLYTES 4 MO
URICOSURIC AGENTS
probenecid 2 MO
probenecid/colchicine 2 MO
VASOPRESSIN ANTAGONISTS
SAMSCA 4 QL (60 EA per 30 days)
MO
ENZYMES
ENZYMES
ADAGEN 4 MO
ALDURAZYME 4 QL (480 ML per 28 days)
PA MO
CEREDASE 4 PA MO
CEREZYME INJ 200UNIT 4 PA MO
ELAPRASE 4 PA MO
ELITEK INJ 1.5MG 4 PA MO
FABRAZYME INJ 35MG 4 PA MO
LUMIZYME 4 PA MO
MYOZYME 4 PA MO
NAGLAZYME 4 QL (480 ML per 28 days)
PA MO
Page 44 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
PULMOZYME 4 QL (150 ML per 30 days)
B/D MO
SUCRAID 4 MO
VPRIV 4 PA MO
EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS
ALPHA-ADRENERGIC AGONISTS (EENT)
brimonidine tartrate 3 MO
ANTIALLERGIC AGENTS
azelastine hcl 3 MO
ELESTAT 4 MO
epinastine hcl 3 MO
PATADAY 3 MO
ANTIBACTERIALS (EENT)
ak-poly-bac 2 MO
AZASITE 3 MO
bacitracin 2 MO
bacitracin/polymyxin b 2 MO
BESIVANCE 3 MO
BLEPHAMIDE 4 MO
BLEPHAMIDE S.O.P. 4 MO
ciprofloxacin hcl 1 MO
doxycycline hyclate 2 MO
erythromycin 2 MO
GARAMYCIN 3 MO
gentak 3 MO
gentamicin sulfate 2 MO
ILOTYCIN 3 MO
levofloxacin 2 MO
MAXITROL 3 MO
MOXEZA 4 MO
neo-polycin 2 MO
neomycin/bacitracin/polymyxin 2 MO
neomycin/polymyxin/bacitracin zinc 2 MO
neomycin/polymyxin/bacitracin/hydrocortisone 2 MO
neomycin/polymyxin/dexamethasone 2 MO
neomycin/polymyxin/gramicidin 2 MO
neomycin/polymyxin/hc 2 MO
neomycin/polymyxin/hydrocortisone 2 MO
neosporin 2 MO
ofloxacin 2 MO
poly-dex 1 MO
polymyxin b sulfate/trimethoprim sulfate 2 MO
POLYTRIM 2 MO
PRED-G 4 MO
PRED-G S.O.P. 4 MO
romycin 1 MO
sodium sulfacetamide 2 MO
sulfacetamide sodium/prednisolone sodium phosphate 2 MO
sulfacetamide sodium soln 2 MO
sulfacetamide sodium oint 3 MO
TOBRADEX 4 MO
Page 45 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
TOBRADEX ST 4 MO
tobramycin sulfate 2 MO
tobramycin/dexamethasone 3 MO
TOBREX 4 MO
trimethoprim sulfate/polymyxin b sulfate 2 MO
VIGAMOX 4 MO
ZYMAXID 4 QL (2.5 ML per 25 days)
MO
ANTIFUNGALS (EENT)
NATACYN 4 MO
ANTIVIRALS (EENT)
trifluridine 3 MO
ZIRGAN 4 QL (5 GM per 30 days)
MO
BETA-ADRENERGIC BLOCKING AGENTS (EENT)
betaxolol hcl 3 MO
BETIMOL 4 MO
dorzolamide hcl/timolol maleate 3 QL (10 ML per 30 days)
MO
levobunolol hcl 2 MO
metipranolol 2 MO
timolol maleate 2 MO
timolol maleate ophthalmic gel forming 3 MO
TIMOPTIC OCUDOSE 4 MO
CARBONIC ANHYDRASE INHIBITORS (EENT)
AZOPT 3 MO
dorzolamide hcl 3 QL (10 ML per 30 days)
MO
methazolamide 3 MO
CORTICOSTEROIDS (EENT)
dexamethasone sodium phosphate 2 MO
DUREZOL 3 MO
fluorometholone 2 MO
FML 4 MO
FML FORTE 4 MO
PRED MILD 4 MO
prednisolone acetate 2 MO
prednisolone sodium phosphate 2 MO
EENT ANTI-INFECTIVES, MISCELLANEOUS
acetasol hc 3 MO
acetic acid 2 MO
chlorhexadine gluconate oral rinse 1 MO
chlorhexidine gluconate 1 MO
chlorhexidine gluconate oral rinse 1 MO
hydrocortisone/acetic acid 3 MO
PERIDEX 4 MO
periogard 1 MO
EENT ANTI-INFLAMMATORY AGENTS, MISC
RESTASIS 3 QL (60 EA per 30 days)
MO
EENT DRUGS, MISCELLANEOUS
Page 46 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
apraclonidine 3 MO
carteolol hcl 2 MO
ipratropium bromide nasal soln 0.03% 2 QL (30 ML per 30 days)
MO
ipratropium bromide nasal soln 0.06% 2 QL (45 ML per 30 days)
MO
LACRISERT 4 MO
EENT NONSTEROIDAL ANTI-INFLAM AGENTS
diclofenac sodium 2 MO
flurbiprofen sodium 2 MO
ketorolac tromethamine 2 MO
LOCAL ANESTHETICS (EENT)
lidocaine hcl 2 MO
lidocaine hcl jelly 1 MO
lidocaine viscous 2 MO
proparacaine hcl 1 MO
MIOTICS
PHOSPHOLINE IODIDE 4 MO
pilocarpine hcl soln 1%, 2% 2 MO
pilocarpine hcl soln 4% 3 MO
PILOPINE HS 4 MO
MYDRIATICS
mydral 1 MO
tropicamide 1 MO
PROSTAGLANDIN ANALOGS
latanoprost 2 QL (3 ML per 25 days)
MO
LUMIGAN 3 QL (3 ML per 25 days)
MO
TRAVATAN Z 3 QL (3 ML per 25 days)
MO
VASOCONSTRICTORS
ak-con 1 MO
TYZINE 3 MO
TYZINE PEDIATRIC NASAL DROPS 3 MO
GASTROINTESTINAL DRUGS
5-HT3 RECEPTOR ANTAGONISTS
granisetron hcl tabs 3 QL (28 EA per 28 days)
B/D MO
granisetron hcl inj 0.1mg/ml 3 MO
granisetron hcl inj 1mg/ml 3 QL (4 ML per 28 days)
ondansetron hcl oral soln 3 QL (450 ML per 30 days)
B/D MO
ondansetron hcl inj 4mg/2ml 3
ondansetron hcl inj 40mg/20ml 3 MO
ondansetron hcl tabs 24mg 3 QL (30 EA per 30 days)
B/D MO
ondansetron hcl tabs 4mg, 8mg 3 QL (90 EA per 30 days)
B/D MO
ondansetron odt 2 QL (90 EA per 30 days)
B/D MO
Page 47 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
SANCUSO 4 QL (4 EA per 30 days)
MO
ANTI-INFLAMMATORY AGENTS (GI DRUGS)
APRISO 3 QL (120 EA per 30 days)
MO
balsalazide disodium 3 MO
CANASA 3 QL (30 EA per 30 days)
MO
LIALDA 4 QL (120 EA per 30 days)
MO
LOTRONEX 4 QL (60 EA per 30 days)
MO
mesalamine enem 2 QL (1800 ML per 30 days)
MO
mesalamine kit 3 QL (1800 EA per 30 days)
MO
Antidiarrhea Agents
LOMOTIL 4 PA MO
loperamide hcl caps 2 MO
ANTIEMETICS, MISCELLANEOUS
dronabinol caps 2.5mg, 5mg 3 QL (120 EA per 30 days)
B/D MO
dronabinol caps 10mg 4 QL (120 EA per 30 days)
B/D MO
EMEND CAPS 125MG, 40MG 4 QL (2 EA per 28 days)
B/D MO
EMEND CAPS 80MG 4 QL (4 EA per 28 days)
B/D MO
EMEND CAPS 0 4 QL (6 EA per 28 days)
B/D MO
ANTIHISTAMINES (GI DRUGS)
ANTIVERT 4 PA MO
trimethobenzamide hcl 3 B/D MO
CATHARTICS AND LAXATIVES
AMITIZA 3 MO
gavilyte-c 2 MO
gavilyte-g 2 MO
gavilyte-n/flavor pack 2 MO
GOLYTELY 3 MO
HALFLYTELY BOWEL PREP/FLAVOR PACKS 3 MO
MOVIPREP 4 MO
NULYTELY/FLAVOR PACKS 3 MO
OSMOPREP 4 MO
peg 3350/electrolytes 2 MO
peg-3350/electrolytes 2 MO
peg-3350/nacl/na bicarbonate/kcl 2 MO
polyethylene glycol 3350 powd 2 MO
SUPREP BOWEL PREP 3 MO
trilyte 2 MO
CHOLELITHOLYTIC AGENTS
ursodiol 3 MO
Page 48 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
DIGESTANTS
CREON 3 MO
PANCREAZE 4 MO
ZENPEP 3 MO
GI DRUGS, MISCELLANEOUS
CIMZIA INJ 200MG/ML 4 QL (6 EA per 30 days) PA
CIMZIA INJ 200MG 4 QL (6 EA per 30 days) PA
MO
RELISTOR INJ 12MG/0.6ML 4 QL (28 EA per 28 days)
PA MO
HISTAMINE H2-ANTAGONISTS
cimetidine 2 MO
cimetidine hcl 2 MO
famotidine 2 MO
famotidine premixed 2 MO
nizatidine 2 MO
ranitidine hcl caps 300mg 2 MO
ranitidine hcl caps 150mg 3 MO
ranitidine hcl inj 1 MO
ranitidine hcl syrp, tabs 2 MO
PROKINETIC AGENTS
metoclopramide hcl 2 MO
PROSTAGLANDINS
misoprostol 2 MO
PROTECTANTS
sucralfate 2 MO
PROTON-PUMP INHIBITORS
lansoprazole 3 QL (30 EA per 30 days)
MO
omeprazole cpdr 10mg, 40mg 2 QL (30 EA per 30 days)
MO
omeprazole cpdr 20mg 2 QL (60 EA per 30 days)
MO
pantoprazole sodium 1 QL (30 EA per 30 days)
MO
PROTONIX 3 MO
GOLD COMPOUNDS
GOLD COMPOUNDS
RIDAURA 4 MO
HEAVY METAL ANTAGONISTS
HEAVY METAL ANTAGONISTS
CHEMET 4 MO
CUPRIMINE 4 MO
EXJADE 3 PA MO
SYPRINE 4 MO
HORMONES AND SYNTHETIC SUBSTITUTES
ADRENALS
a-hydrocort 1 MO
a-methapred 2 MO
baycadron 1 MO
Page 49 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
BUDESONIDE 4 MO
cortisone acetate 2 MO
dexamethasone intensol 3 MO
dexamethasone sodium phosphate inj 4mg/ml 2 MO
dexamethasone elix 2 MO
dexamethasone tabs 6mg 1 MO
dexamethasone tabs 0.5mg, 0.75mg, 1.5mg, 1mg, 2mg,
4mg
2 MO
ENTOCORT EC 4 MO
fludrocortisone acetate 2 MO
hydrocortisone 2 MO
methylprednisolone 2 MO
methylprednisolone acetate 1 MO
methylprednisolone dose pack 2 MO
methylprednisolone sodiumsuccinate inj 1gm 2 MO
ORAPRED ODT TBDP 15MG, 30MG 4 MO
prednisolone sodium phosphate 2 MO
prednisone 1 MO
prednisone intensol 3 MO
SOLU-CORTEF INJ 100MG, 250MG 4 MO
SOLU-MEDROL 4 MO
VERIPRED 20 4 MO
ALPHA-GLUCOSIDASE INHIBITORS
acarbose 3 MO
GLYSET 4 MO
AMYLINOMIMETICS
SYMLINPEN 120 4 QL (11 ML per 30 days)
PA MO
SYMLINPEN 60 4 QL (11 ML per 30 days)
PA MO
ANDROGENS
ANADROL-50 4 MO
ANDROGEL PUMP GEL 1.62% 3 QL (176 GM per 30 days)
MO
ANDROGEL GEL 50MG/5GM 3 QL (300 GM per 30 days)
MO
androxy 4 MO
danazol 3 MO
oxandrolone tabs 2.5mg 3 QL (120 EA per 30 days)
MO
oxandrolone tabs 10mg 4 QL (60 EA per 30 days)
MO
testosterone cypionate inj 100mg/ml 2 MO
testosterone cypionate inj 200mg/ml 3 MO
testosterone enanthate 3 MO
ANTITHYROID AGENTS
methimazole 2 MO
propylthiouracil 2 MO
BIGUANIDES
glipizide/metformin hcl 3 MO
glyburide/metformin hcl 2 MO
Page 50 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
JANUMET 3 QL (60 EA per 30 days)
MO
metformin hcl 1 MO
metformin hcl er tb24 500mg 1 QL (120 EA per 30 days)
MO
metformin hcl er tb24 1000mg, 750mg 1 QL (60 EA per 30 days)
MO
CONTRACEPTIVES
altavera 4 MO
amethia lo 4 QL (91 EA per 90 days)
MO
apri 4 MO
aranelle 4 MO
aviane 4 MO
azurette 4 MO
camila 4 MO
camrese lo 4 QL (91 EA per 90 days)
MO
caziant 4 MO
cryselle-28 4 MO
cyclafem 1/35 4 MO
cyclafem 7/7/7 4 MO
emoquette 4 MO
enpresse-28 4 MO
errin 4 MO
FEMCON FE 4 MO
gianvi 4 MO
gildess fe 1.5/30 4 MO
gildess fe 1/20 4 MO
heather 4 MO
introvale 4 QL (91 EA per 90 days)
MO
junel 1.5/30 4 MO
junel 1/20 4 MO
junel fe 1.5/30 4 MO
junel fe 1/20 4 MO
kariva 4 MO
kelnor 1/35 4 MO
lessina-28 4 MO
levonorgestrel 3 MO
levonorgestrel and ethinyl estradiol 4 QL (91 EA per 90 days)
MO
levora 0.15/30-28 4 MO
loryna 4 MO
LOSEASONIQUE 4 QL (91 EA per 90 days)
MO
low-ogestrel 4 MO
lutera 4 MO
MARLISSA 4 MO
microgestin 1.5/30 4 MO
microgestin 1/20 4 MO
Page 51 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
microgestin fe 4 MO
microgestin fe 1.5/30 4 MO
necon 0.5/35-28 4 MO
necon 1/35-28 4 MO
necon 10/11-28 4 MO
next choice 3 MO
norethindrone 4 MO
norgestimate/ethinyl estradiol tabs 0; 0 4 MO
norgestrel/ethinyl estradiol 4 MO
nortrel 0.5/35 (28) 4 MO
nortrel 1/35 (21) 4 MO
nortrel 1/35 (28) 4 MO
nortrel 7/7/7 4 MO
ogestrel 4 MO
orsythia 4 MO
PLAN B 4 MO
portia-28 4 MO
previfem 4 MO
quasense 4 QL (91 EA per 90 days)
MO
reclipsen 4 MO
sprintec 28 2 MO
sronyx 4 MO
syeda 4 MO
tilia fe 4 MO
tri-legest fe 4 MO
tri-previfem 4 MO
tri-sprintec 3 MO
trinessa 4 MO
trivora-28 4 MO
velivet 4 MO
vestura 2 MO
wymzya fe 4 MO
zarah 4 MO
zenchent fe 4 MO
zeosa 4 MO
zovia 1/35e 4 MO
zovia 1/50e 4 MO
DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS
JANUMET XR TB24 1000MG; 100MG 3 QL (30 EA per 30 days)
ST MO
JANUMET XR TB24 1000MG; 50MG, 500MG; 50MG 3 QL (60 EA per 30 days)
ST MO
JANUVIA 3 QL (30 EA per 30 days)
MO
onglyza 3 QL (30 EA per 30 days)
ST MO
ESTROGEN AGONIST-ANTAGONISTS
EVISTA 3 QL (30 EA per 30 days)
MO
ESTROGENS
Page 52 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
DEPO-ESTRADIOL 2 MO
estradiol valerate 3 MO
estradiol/norethindrone acetate 3 MO
estradiol tabs 2 MO
estradiol ptwk 2 QL (4 EA per 28 days)
MO
EVAMIST 4 MO
jevantique 3 MO
jinteli 3 MO
mimvey 2 MO
PREMARIN 3 MO
GLYCOGENOLYTIC AGENTS
GLUCAGEN HYPOKIT 3 MO
GLUCAGON EMERGENCY KIT 4 MO
GONADOTROPINS
chorionic gonadotropin 4 MO
SYNAREL 4 MO
INCRETIN MIMETICS
BYETTA 4 QL (3 ML per 30 days) PA
MO
victoza 3 QL (9 ML per 30 days) PA
MO
INSULINS
HUMALOG 3 QL (240 ML per 30 days)
MO
HUMALOG KWIKPEN 3 MO
HUMALOG MIX 50/50 3 MO
HUMALOG MIX 50/50 KWIKPEN 3 MO
HUMALOG MIX 75/25 3 MO
HUMALOG MIX 75/25 KWIKPEN 3 MO
HUMULIN 70/30 3 MO
HUMULIN 70/30 PEN 3 MO
HUMULIN N 3 MO
HUMULIN N U-100 PEN 3 MO
HUMULIN R 3 MO
HUMULIN R U-500 (CONCENTRATED) 3 MO
LANTUS 3 MO
LANTUS SOLOSTAR 3 MO
LEVEMIR 3 MO
LEVEMIR FLEXPEN 3 MO
NOVOLIN 70/30 3 MO
NOVOLIN N 3 MO
NOVOLIN R 3 MO
NOVOLOG 3 MO
NOVOLOG FLEXPEN 3 MO
NOVOLOG MIX 70/30 3 MO
NOVOLOG MIX 70/30 PREFILLED FLEXPEN 3 MO
MEGLITINIDES
nateglinide 3 MO
PRANDIN 4 MO
PARATHYROID
Page 53 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
calcitonin-salmon 3 QL (4 ML per 28 days)
B/D MO
FORTEO 4 QL (2.4 ML per 28 days)
ST MO
FORTICAL 4 QL (4 ML per 28 days)
B/D MO
Pituitary
DDAVP 4 PA MO
desmopressin acetate 3 MO
OMNITROPE INJ 10MG/1.5ML, 5MG/1.5ML 4 PA
OMNITROPE INJ 5.8MG 4 PA MO
SAIZEN CLICK.EASY 4 PA
SAIZEN INJ 5MG 4 PA
SAIZEN INJ 8.8MG 4 PA MO
SEROSTIM INJ 5MG 4 PA
SEROSTIM INJ 4MG, 6MG 4 PA MO
PROGESTINS
CRINONE GEL 8% 4 MO
ENDOMETRIN 4 MO
medroxyprogesterone acetate tabs 2 MO
medroxyprogesterone acetate inj 2 QL (1 ML per 90 days)
MO
norethindrone acetate 3 MO
progesterone caps 3 MO
SOMATOTROPIN AGONISTS
EGRIFTA 4 QL (60 EA per 30 days)
PA MO
INCRELEX 4 PA MO
SOMATOTROPIN ANTAGONISTS
SOMAVERT 4 QL (60 EA per 30 days)
PA MO
SULFONYLUREAS
glimepiride 1 MO
glipizide 1 MO
glipizide er 2 MO
glipizide xl 2 MO
glyburide 2 MO
glyburide micronized 2 MO
tolazamide 3 MO
tolbutamide 3 MO
THIAZOLIDINEDIONES
ACTOS 4 QL (30 EA per 30 days)
MO
THYROID AGENTS
CYTOMEL 4 MO
LEVOTHROID 1 MO
levothyroxine sodium 1 MO
LEVOXYL 3 MO
liothyronine sodium tabs 2 MO
liothyronine sodium inj 3 MO
SYNTHROID 3 MO
Page 54 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
UNITHROID 2 MO
LOCAL ANESTHETICS
LOCAL ANESTHETICS (PARENTERAL)
lidocaine hcl 1 MO
Miscellaneous Therapeutic Agents
5-alpha-Reductase Inhibitors
avodart 3 QL (30 EA per 30 days)
MO
finasteride 3 QL (30 EA per 30 days)
MO
ANTIDOTES
ANTIZOL 4 MO
fomepizole 1 MO
FUSILEV 4 PA MO
leucovorin calcium tabs 2 MO
leucovorin calcium inj 100mg, 350mg 2 B/D MO
ANTIGOUT AGENTS
allopurinol 1 MO
allopurinol sodium 1 MO
COLCRYS 3 QL (120 EA per 30 days)
MO
BIOLOGIC RESPONSE MODIFIERS
ACTIMMUNE 4 PA MO
AVONEX INJ 30MCG/0.5ML 4 QL (4 EA per 28 days) PA
AVONEX INJ 30MCG/VIAL 4 QL (4 EA per 28 days) PA
MO
BETASERON 4 QL (15 EA per 30 days)
PA
COPAXONE 4 QL (30 EA per 30 days)
PA MO
REBIF 4 QL (12 ML per 30 days)
PA MO
REBIF TITRATION PACK 4 QL (12 ML per 30 days)
PA MO
THALOMID CAPS 100MG, 50MG 3 QL (30 EA per 30 days)
PA MO
THALOMID CAPS 200MG 4 QL (30 EA per 30 days)
PA MO
THALOMID CAPS 150MG 4 QL (60 EA per 30 days)
PA MO
BONE RESORPTION INHIBITORS
ACTONEL TABS 150MG 4 QL (2 EA per 30 days)
MO
ACTONEL TABS 30MG, 5MG 4 QL (30 EA per 30 days)
MO
ACTONEL TABS 35MG 4 QL (4 EA per 28 days)
MO
alendronate sodium tabs 10mg, 40mg, 5mg 1 QL (30 EA per 30 days)
MO
alendronate sodium tabs 35mg, 70mg 1 QL (4 EA per 28 days)
MO
Page 55 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
ATELVIA 4 QL (4 EA per 28 days)
MO
etidronate disodium 3 MO
ibandronate sodium 4 QL (1 EA per 28 days)
MO
pamidronate disodium inj 30mg/10ml, 6mg/ml,
90mg/10ml
3 B/D MO
pamidronate disodium inj 90mg 3 B/D MO
pamidronate disodium inj 30mg 3 B/D MO
PROLIA 4 QL (60 ML per 180 days)
PA MO
RECLAST 4 QL (100 ML per 365 days)
PA MO
XGEVA 4 QL (1.7 ML per 28 days)
PA MO
ZOMETA INJ 4MG/5ML 4 QL (15 ML per 21 days)
PA MO
COMPLEMENT INHIBITORS
FIRAZYR 4 QL (9 ML per 30 days) PA
MO
DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
ENBREL INJ 25MG 4 QL (8 EA per 28 days) PA
MO
ENBREL INJ 50MG/ML 4 QL (8 ML per 28 days) PA
ENBREL INJ 25MG/0.5ML 4 QL (8 ML per 28 days) PA
MO
HUMIRA PEN 4 QL (6 EA per 28 days) PA
MO
HUMIRA PEN-CROHNS DISEASESTARTER 4 QL (6 EA per 28 days) PA
HUMIRA PEN-PSORIASIS STARTER 4 QL (6 EA per 28 days) PA
MO
HUMIRA INJ 40MG/0.8ML 4 QL (6 EA per 28 days) PA
HUMIRA INJ 20MG/0.4ML 4 QL (6 EA per 28 days) PA
MO
leflunomide 2 QL (30 EA per 30 days)
MO
REMICADE 4 PA MO
IMMUNOSUPPRESSIVE AGENTS
azathioprine 2 B/D MO
azathioprine sodium 1 B/D MO
BENLYSTA INJ 120MG 4 QL (30 EA per 28 days)
PA MO
CELLCEPT 4 B/D MO
CELLCEPT INTRAVENOUS 4 B/D MO
cyclosporine 3 B/D MO
cyclosporine modified caps 100mg 2 B/D MO
cyclosporine modified caps 25mg 3 B/D MO
gengraf 3 B/D
mycophenolate mofetil 2 B/D MO
MYFORTIC 3 B/D MO
NULOJIX 4 QL (20 EA per 30 days)
Page 56 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
PA MO
PROGRAF INJ 4 B/D MO
RAPAMUNE 4 B/D MO
SIMULECT INJ 20MG 4 B/D MO
tacrolimus 2 B/D MO
THYMOGLOBULIN 3 B/D MO
ZORTRESS 4 QL (60 EA per 30 days)
B/D MO
OTHER MISCELLANEOUS THERAPEUTIC AGENTS
AMPYRA 4 QL (60 EA per 30 days)
PA MO
ARCALYST 4 PA MO
CARNITOR INJ 3 B/D MO
CYSTADANE 4 MO
CYSTAGON 4 MO
DEMSER 4 MO
KUVAN 4 PA MO
levocarnitine 3 B/D MO
octreotide acetate inj 500mcg/ml, 50mcg/ml 3 PA
octreotide acetate inj 100mcg/ml 4 PA
octreotide acetate inj 1000mcg/ml, 200mcg/ml 4 PA MO
ORFADIN 4 MO
SANDOSTATIN LAR DEPOT 4 PA MO
SANDOSTATIN INJ 100MCG/ML, 500MCG/ML,
50MCG/ML
4 PA
SANDOSTATIN INJ 1000MCG/ML, 200MCG/ML 4 PA MO
SENSIPAR TABS 30MG 3 QL (60 EA per 30 days)
MO
SENSIPAR TABS 90MG 4 QL (120 EA per 30 days)
MO
SENSIPAR TABS 60MG 4 QL (60 EA per 30 days)
MO
SOMATULINE DEPOT 4 QL (1 ML per 28 days) PA
MO
ZAVESCA 4 QL (90 EA per 30 days)
MO
PROTECTIVE AGENTS
amifostine 3 B/D MO
dexrazoxane inj 500mg 3 B/D
dexrazoxane inj 250mg 3 B/D MO
ETHYOL 4 B/D MO
mesna 4 B/D MO
MESNEX INJ 4 B/D MO
MESNEX TABS 4 MO
TOTECT 4 MO
OXYTOCICS
OXYTOCICS
METHERGINE 4 MO
methylergonovine maleate tabs 3 MO
Pharmaceutical Aids
Pharmaceutical Aids
Page 57 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
curity gauze pads 2"x2" 1 MO
RESPIRATORY TRACT AGENTS
CORTICOSTEROIDS (RESPIRATORY TRACT)
ASMANEX 120 METERED DOSES 3 QL (0.24 EA per 28 days)
MO
ASMANEX 14 METERED DOSES 3 QL (0.24 EA per 28 days)
MO
ASMANEX 30 METERED DOSES AEPB
110MCG/INH
3 QL (0.13 EA per 28 days)
MO
ASMANEX 30 METERED DOSES AEPB
220MCG/INH
3 QL (0.24 EA per 28 days)
MO
ASMANEX 60 METERED DOSES 3 QL (0.24 EA per 28 days)
MO
budesonide susp 0.25mg/2ml 2 B/D MO
budesonide susp 0.5mg/2ml 3 B/D MO
DULERA 3 QL (13 GM per 30 days)
MO
flunisolide 3 QL (50 ML per 30 days)
MO
fluticasone propionate 2 QL (16 GM per 30 days)
MO
NASONEX 3 QL (34 GM per 30 days)
MO
QVAR AERS 80MCG/ACT 3 QL (22 GM per 30 days)
MO
QVAR AERS 40MCG/ACT 3 QL (37 GM per 30 days)
MO
VERAMYST 4 QL (10 GM per 30 days)
MO
LEUKOTRIENE MODIFIERS
SINGULAIR 4 QL (30 EA per 30 days)
MO
zafirlukast 3 QL (60 EA per 30 days)
MO
MAST-CELL STABILIZERS
cromolyn sodium nebu 2 B/D MO
cromolyn sodium conc, soln 2 MO
MUCOLYTIC AGENTS
acetylcysteine 2 B/D MO
RESPIRATORY TRACT AGENTS, MISCELLANEOUS
ARALAST NP INJ 400MG 4 PA
ARALAST NP INJ 1000MG, 500MG, 800MG 4 PA MO
GLASSIA 4 PA MO
KALYDECO 4 QL (60 EA per 30 days)
PA MO
PROLASTIN-C 4 PA
PROLASTIN INJ 500MG 4 PA
PROLASTIN INJ 1000MG 4 PA MO
XOLAIR 4 QL (900 EA per 28 days)
PA MO
ZEMAIRA 4 PA
Page 58 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
XANTHINE DERIVATIVES
aminophylline 2 MO
LUFYLLIN 4 MO
SERUMS, TOXOIDS, AND VACCINES
SERUMS
carimune nanofiltered 4 PA MO
flebogamma 4 PA MO
FLEBOGAMMA DIF INJ 10% 4 PA MO
flebogamma dif inj 0.5gm/10ml, 20gm/400ml, 5% 4 PA MO
GAMMAGARD LIQUID INJ 0 4 PA MO
gammagard liquid inj 0 4 PA
gammagard liquid inj 0 4 PA MO
gammaplex inj 10gm/200ml 4 PA
gammaplex inj 2.5gm/50ml, 5gm/100ml 4 PA MO
GAMUNEX INJ 10% 4 PA
GAMUNEX INJ 10% 4 PA MO
HIZENTRA 4 PA MO
privigen inj 20gm/200ml 4 PA
privigen inj 10gm/100ml, 5gm/50ml 4 PA MO
TOXOIDS
ADACEL 4
BOOSTRIX 4
DAPTACEL 4 MO
DECAVAC 4
diphtheria/tetanus toxoid pediatric 4 MO
INFANRIX 4
TENIVAC 4 MO
tetanus/diphtheria toxoids-adsorbed adult 4 MO
TRIPEDIA 4 MO
VACCINES
ACTHIB 4
CERVARIX 4 MO
COMVAX 4 MO
ENGERIX-B 4 B/D
GARDASIL 4 QL (3 ML per 365 days)
HAVRIX 4
HIBERIX 4 MO
IPOL INACTIVATED IPV 4
IXIARO 4 MO
JE-VAX 4 MO
M-M-R II W/DILUENT 10 DOSE 4 MO
MENACTRA 4
MENOMUNE-A/C/Y/W-135 4
MENVEO 4 MO
PEDVAX HIB 4 MO
PROQUAD 4 MO
RABAVERT 3 B/D MO
RECOMBIVAX HB INJ 10MCG/ML 4 B/D
RECOMBIVAX HB INJ 40MCG/ML 4 B/D MO
ROTATEQ 4 MO
TWINRIX 4
Page 59 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
TYPHIM VI 4
VAQTA 4 MO
VARIVAX 3 MO
YF-VAX 4 MO
ZOSTAVAX 4 QL (1 EA per 365 days)
MO
SKIN AND MUCOUS MEMBRANE AGENTS
ANTI-INFLAMMATORY AGENTS (SKIN - MUCOUS)
ALA SCALP 3 MO
alclometasone dipropionate 2 MO
amcinonide 2 MO
apexicon 3 MO
augmented betamethasone dipropionate 2 MO
betamethasone dipropionate 3 MO
betamethasone valerate 2 MO
clobetasol propionate 2 MO
clobetasol propionate e 2 MO
clobetasol propionate emollient 2 MO
colocort 3 MO
cormax 4 MO
CORTIFOAM 4 MO
desonide 2 MO
desoximetasone 3 MO
diflorasone diacetate 3 MO
fluocinolone acetonide 2 MO
fluocinonide 2 MO
fluocinonide emollient base 2 MO
fluocinonide-e 2 MO
fluticasone propionate 2 MO
halobetasol propionate 3 MO
HALOG 4 MO
hydrocortisone butyrate 2 MO
hydrocortisone valerate 2 MO
hydrocortisone enem 1 MO
hydrocortisone crea, lotn, oint 2 MO
KENALOG 4 MO
lokara 2 MO
mometasone furoate 2 MO
oralone 1 MO
prednicarbate 2 MO
proctocream hc 2 MO
proctosol hc 2 MO
scalacort 1 MO
triamcinolone acetonide 2 MO
triamcinolone in orabase 2 MO
triderm 1 MO
u-cort 2 MO
ANTIBACTERIALS (SKIN - MUCOUS MEMBRANE)
ALTABAX 4 MO
BACTROBAN 4 MO
clindacin-p 2 MO
Page 60 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
clindamax 1 MO
clindamycin phosphate 2 MO
clindamycin/benzoyl peroxide 2 MO
ery 2 MO
erythromycin 2 MO
erythromycin/benzoyl peroxide 3 MO
gentamicin sulfate 2 MO
metronidazole 1 MO
metronidazole vaginal 2 MO
mupirocin 3 MO
neomycin/polymyxin b sulfates 3 MO
vitazol 4 MO
ANTIFUNGALS (SKIN - MUCOUS MEMBRANE)
ciclodan 3 MO
ciclopirox 3 MO
ciclopirox nail lacquer 3 MO
ciclopirox olamine 3 MO
clotrimazole 2 MO
clotrimazole/betamethasone dipropionate 2 MO
econazole nitrate 2 MO
ketoconazole 2 MO
MENTAX 4 MO
miconazole 3 2 MO
nyamyc 2 MO
nystatin 2 MO
nystatin/triamcinolone 2 MO
nystop 2 MO
pedi-dri 2 MO
terconazole 2 MO
ANTIPRURITICS AND LOCAL ANESTHETICS
lidocaine 2 B/D MO
lidocaine/prilocaine 2 B/D MO
LIDODERM 4 QL (90 EA per 30 days)
PA MO
SYNERA 4 B/D MO
ANTIVIRALS (SKIN - MUCOUS MEMBRANE)
DENAVIR 4 MO
ZOVIRAX OINT 4 PA MO
ZOVIRAX CREA 4 ST MO
BASIC LOTIONS AND LINIMENTS
ammonium lactate 2 MO
laclotion 4 MO
BASIC OINTMENTS AND PROTECTANTS
ammonium lactate 2 MO
CELL STIMULANTS AND PROLIFERANTS
KEPIVANCE 4 PA MO
tretinoin 3 PA MO
LOCAL ANTI-INFECTIVES, MISCELLANEOUS
ALCOHOL PREPS 1 MO
selenium sulfide 2 MO
silver sulfadiazine 2 MO
Page 61 of 79 Effective: January 1, 2013
Drug Name Drug Tier Requirements/Limits
sodium sulfacetamide 2 MO
sulfacetamide sodium 2 MO
thermazene 2 MO
PIGMENTING AGENTS
8-MOP 4 MO
OXSORALEN 4 MO
OXSORALEN ULTRA 4 MO
UVADEX 4 B/D MO
SCABICIDES AND PEDICULICIDES
acticin 2 MO
EURAX 4 MO
lindane 3 MO
malathion 2 MO
permethrin 2 MO
SKIN AND MUCOUS MEMBRANE AGENTS, MISC
ACZONE 4 MO
adapalene 3 MO
calcipotriene oint 3 MO
calcipotriene soln 3 QL (60 ML per 30 days)
MO
calcitrene 3 MO
CARAC 4 MO
ELIDEL 4 MO
EPIDUO 4 MO
FLUOROPLEX 4 MO
fluorouracil 3 MO
imiquimod 3 QL (12 EA per 30 days)
MO
PANRETIN 4 MO
podofilox 3 MO
REGRANEX 4 MO
SANTYL 4 MO
SORIATANE 4 MO
STELARA INJ 45MG/0.5ML 4 QL (3 ML per 84 days) PA
STELARA INJ 90MG/ML 4 QL (3 ML per 84 days) PA
MO
TARGRETIN 4 PA MO
TAZORAC 4 MO
VEREGEN 4 MO
SMOOTH MUSCLE RELAXANTS
GENITOURINARY SMOOTH MUSCLE RELAXANTS
flavoxate hcl 3 MO
oxybutynin chloride 2 MO
oxybutynin chloride er 3 QL (60 EA per 30 days)
MO
trospium chloride 3 MO
VITAMINS
VITAMIN D
calcitriol 3 B/D MO
HECTOROL 3 B/D MO
ZEMPLAR 3 B/D MO
Page 62 of 79 Effective: January 1, 2013
OTC products
Drug Name
Drug
Tier Requirements/Limits
SKIN AND MUCOUS MEMBRANE AGENTS
LOCAL ANTI-INFECTIVES, MISCELLANEOUS
ALCOHOL PREP PADS 1 MO
ALCOHOL SWABS 1 MO
BD SWABS SINGLE USE 1 MO
CURITY ALCOHOL PREPS 1 MO
CURITY ALCOHOL PREPS/MEDIUM/2 PLY 1 MO
FIFTY50 ALCOHOL PREP PADS 1 MO
GLOBAL ALCOHOL PREP EASE PADS 1 MO
IV PREP WIPES 1 MO
PHARMACIST CHOICE ALCOHOLPREP PADS 1 MO
SURE-PREP ALCOHOL PREP PADS 1 MO
ULTILET ALCOHOL SWAB 1 MO
ULTILET ALCOHOL SWABS 1 MO
WEBCOL ALCOHOL PREP LARGE 1 PLY 1 MO
WEBCOL ALCOHOL PREP LARGE 2 PLY 1 MO
WEBCOL ALCOHOL PREP MEDIUM 2 PLY 1 MO
Page 63 of 79
Index Drug Name Page #
8-MOP 61
ABILIFY 34
ABILIFY DISCMELT 34
ABRAXANE 15
acarbose 49
acebutolol hcl 20
acetaminophen/caffeine/dihydrocodeine
bitartrate
37
acetaminophen/codeine 38
acetaminophen/codeine #2 37
acetaminophen/codeine #3 38
acetaminophen/codeine #4 38
acetaminophen/codeine phosphate 38
acetasol hc 45
acetazolamide 26
acetazolamide er 26
acetazolamide sodium 26
acetic acid 45
acetylcysteine 57
ACTHIB 58
acticin 61
ACTIMMUNE 54
ACTONEL 54
ACTOS 53
acyclovir 12
acyclovir sodium 12
ACZONE 61
ADACEL 58
ADAGEN 43
adapalene 61
ADCIRCA 28
adriamycin 15
afeditab cr 25
AFINITOR 15
AGGRENOX 23
a-hydrocort 48
ak-con 46
ak-poly-bac 44
ALA SCALP 59
ALBENZA 6
albuterol sulfate 20
albuterol sulfate er 20
alclometasone dipropionate 59
ALCOHOL PREP PADS 62
ALCOHOL PREPS 60
ALCOHOL SWABS 62
ALDURAZYME 43
Drug Name Page #
alendronate sodium 54
alfuzosin hcl er 19
ALIMTA 15
ALINIA 7
ALKERAN 15
allopurinol 54
allopurinol sodium 54
ALSUMA 39
ALTABAX 59
altavera 50
amantadine hcl 6
amcinonide 59
a-methapred 48
amethia lo 50
amifostine 56
amikacin sulfate 6
amiloride hcl 26
amiloride/hydrochlorothiazide 26
aminophylline 58
AMINOSYN 40
AMINOSYN 8.5%/ELECTROLYTES 40
AMINOSYN II 40
AMINOSYN II 8.5%/ELECTROLYTES 40
AMINOSYN M 40
AMINOSYN-HBC 40
AMINOSYN-PF 40
AMINOSYN-PF 7% 40
amiodarone hcl 23
AMITIZA 47
amitriptyline hcl 31
amlodipine besylate 25
amlodipine besylate/atorvastatin calcium 26
amlodipine besylate/atorvastatin calcium 27
amlodipine besylate/benazepril hcl 25
amlodipine besylate/benazepril
hydrochloride
25
ammonium chloride 40
ammonium lactate 60
ammonium lactate 60
amoxapine 31
amoxicillin 13
amoxicillin/clavulanate potassium 13
amoxicillin/clavulanate potassium er 13
amoxicillin/potassium clavulanate 13
AMPHOTEC 13
amphotericin b 13
ampicillin 13
ampicillin sodium 13
ampicillin-sulbactam 13
AMPYRA 56
ANADROL-50 49
Page 64 of 79
Drug Name Page #
anagrelide hydrochloride 23
anastrozole 15
ANCOBON 14
ANDROGEL 49
ANDROGEL PUMP 49
androxy 49
ANTIVERT 47
ANTIZOL 54
apexicon 59
APOKYN 36
apraclonidine 46
apri 50
APRISO 47
APTIVUS 7
ARALAST NP 57
aranelle 50
arbinoxa 14
ARCALYST 56
argatroban 22
ARRANON 15
ARZERRA 15
ascomp/codeine 37
ASMANEX 120 METERED DOSES 57
ASMANEX 14 METERED DOSES 57
ASMANEX 30 METERED DOSES 57
ASMANEX 60 METERED DOSES 57
ASTRAMORPH 38
ATELVIA 55
atenolol 20
atenolol/chlorthalidone 20
atorvastatin calcium 27
atovaquone/proguanil hcl 7
ATRIPLA 7
atropine sulfate 19
ATROVENT HFA 19
augmented betamethasone dipropionate 59
AVASTIN 15
AVELOX 14
aviane 50
avodart 54
AVONEX 54
AZASITE 44
azathioprine 55
azathioprine sodium 55
azelastine hcl 44
AZILECT 37
azithromycin 12
AZOPT 45
aztreonam 12
azurette 50
bacitracin 6
Drug Name Page #
bacitracin 44
bacitracin/polymyxin b 44
baclofen 21
bactocill in dextrose 13
BACTROBAN 59
balsalazide disodium 47
BANZEL 29
BARACLUDE 12
baycadron 48
bd insulin syringe safetyglide/1ml/29g x
1/2"
40
bd insulin syringe ultrafine/0.3ml/31g x
5/16"
40
bd insulin syringe ultrafine/0.5ml/30g x 1/2" 40
bd insulin syringe ultrafine/1ml/31g x 5/16" 40
BD SWABS SINGLE USE 62
benazepril hcl 28
benazepril hcl/hydrochlorothiazide 26
BENLYSTA 55
benztropine mesylate 20
BESIVANCE 44
betamethasone dipropionate 59
betamethasone valerate 59
BETASERON 54
betaxolol hcl 20
betaxolol hcl 45
bethanechol chloride 21
BETIMOL 45
bicalutamide 15
BICNU 15
BIDIL 26
BILTRICIDE 6
bisoprolol fumarate 20
bisoprolol fumarate/hydrochlorothiazide 20
bleomycin sulfate 15
BLEPHAMIDE 44
BLEPHAMIDE S.O.P. 44
BOOSTRIX 58
brimonidine tartrate 44
bromocriptine mesylate 36
BROVANA 20
budeprion sr 31
budeprion xl 32
BUDESONIDE 49
budesonide 57
bumetanide 26
BUPHENYL 40
buprenorphine hcl 39
buproban 32
bupropion hcl 32
bupropion hcl er 32
Page 65 of 79
Drug Name Page #
bupropion hcl sr 32
bupropion hcl xl 32
buspirone hcl 35
BUSULFEX 15
butalbital/acetaminophen/caffeine/codeine 38
butalbital/aspirn/caffeine/codeine 37
butorphanol tartrate 39
BYETTA 52
cabergoline 36
calcipotriene 61
calcitonin-salmon 53
calcitrene 61
calcitriol 61
calcium acetate 42
camila 50
CAMPATH 15
camrese lo 50
CANASA 47
CANCIDAS 11
CAPASTAT SULFATE 10
CAPITAL/CODEINE 38
CAPRELSA 15
captopril 28
captopril/hydrochlorothiazide 26
CARAC 61
CARBAGLU 40
carbamazepine 29
carbamazepine er 29
CARBATROL 30
carbidopa/levodopa 36
carbidopa/levodopa cr 36
carbidopa/levodopa er 36
carbidopa/levodopa odt 36
carbidopa/levodopa sr 36
carbinoxamine maleate 14
carboplatin 15
carimune nanofiltered 58
carisoprodol 21
carisoprodol/aspirin 21
carisoprodol/aspirin/codeine 21
CARNITOR 56
carteolol hcl 46
cartia xt 23
carvedilol 19
carvedilol 25
CAYSTON 12
caziant 50
CEENU 15
cefaclor 11
cefaclor er 11
cefadroxil 11
Drug Name Page #
cefazolin sodium 11
cefazolin sodium/dextrose 11
cefdinir 11
cefditoren pivoxil 11
cefepime 11
cefotaxime sodium 11
cefotetan 11
cefoxitin sodium 11
cefpodoxime proxetil 11
cefprozil 11
ceftazidime 11
ceftazidime/dextrose 11
ceftriaxone sodium 11
cefuroxime axetil 11
cefuroxime sodium 11
CELLCEPT 55
CELLCEPT INTRAVENOUS 55
CELONTIN 40
cephalexin 11
CEREDASE 43
CEREZYME 43
CERUBIDINE 15
CERVARIX 58
cetirizine hcl 15
CHANTIX 20
CHANTIX CONTINUING MONTH PAK 20
CHANTIX STARTING MONTH PAK 20
CHEMET 48
chloramphenicol sodium succinate 11
chlorhexadine gluconate oral rinse 45
chlorhexidine gluconate 45
chlorhexidine gluconate oral rinse 45
chloroquine phosphate 7
chlorothiazide 26
chlorothiazide sodium 26
chlorpromazine hcl 34
chlorthalidone 26
cholestyramine 25
cholestyramine light 25
chorionic gonadotropin 52
ciclodan 60
ciclopirox 60
ciclopirox nail lacquer 60
ciclopirox olamine 60
cilostazol 23
cimetidine 48
cimetidine hcl 48
CIMZIA 48
ciprofloxacin 14
ciprofloxacin hcl 14
ciprofloxacin hcl 44
Page 66 of 79
Drug Name Page #
ciprofloxacin i.v.-in d5w 14
cisplatin 15
citalopram hydrobromide 32
cladribine 15
clarithromycin 12
clarithromycin er 12
clemastine fumarate 14
CLEOCIN GALAXY 6
CLEOCIN IN D5W 6
clindacin-p 59
clindamax 60
clindamycin hcl 6
clindamycin palmitate hcl 6
clindamycin phosphate 6
clindamycin phosphate 60
clindamycin phosphate add-vantage 6
clindamycin phosphate pharmacy bulk
package
6
clindamycin/benzoyl peroxide 60
CLINIMIX 2.75%/DEXTROSE 5% 40
CLINIMIX 4.25%/DEXTROSE 10% 40
CLINIMIX 4.25%/DEXTROSE 20% 40
CLINIMIX 4.25%/DEXTROSE 25% 40
CLINIMIX 4.25%/DEXTROSE 5% 40
CLINIMIX 5%/DEXTROSE 15% 40
CLINIMIX 5%/DEXTROSE 20% 40
CLINIMIX 5%/DEXTROSE 25% 40
CLINIMIX E 2.75%/DEXTROSE 10% 40
CLINIMIX E 2.75%/DEXTROSE 5% 40
CLINIMIX E 4.25%/DEXTROSE 25% 40
CLINIMIX E 4.25%/DEXTROSE 5% 40
CLINIMIX E 5%/DEXTROSE 15% 40
CLINIMIX E 5%/DEXTROSE 20% 40
CLINIMIX E 5%/DEXTROSE 25% 40
clobetasol propionate 59
clobetasol propionate e 59
clobetasol propionate emollient 59
CLOLAR 15
clomipramine hcl 32
clonazepam 29
CLONAZEPAM ODT 29
clonidine hcl 26
clopidogrel 23
CLORAZEPATE DIPOTASSIUM 29
clorpres 26
clotrimazole 60
clotrimazole/betamethasone dipropionate 60
clozapine 34
COARTEM 7
codeine sulfate 38
COLCRYS 54
Drug Name Page #
colestipol hcl 25
colistimethate sodium 6
colocort 59
COLY-MYCIN M 6
COMPLERA 7
compro 34
COMTAN 36
COMVAX 58
COPAXONE 54
cormax 59
CORTIFOAM 59
cortisone acetate 49
COSMEGEN 16
COUMADIN 22
COVERA-HS 23
CREON 48
CRESTOR 27
CRINONE 53
CRIXIVAN 7
cromolyn sodium 57
cryselle-28 50
CUBICIN 6
CUPRIMINE 48
CURITY ALCOHOL PREPS 62
CURITY ALCOHOL PREPS/MEDIUM/2
PLY
62
curity gauze pads 2"x2" 57
cyclafem 1/35 50
cyclafem 7/7/7 50
cyclophosphamide 16
cyclosporine 55
cyclosporine modified 55
CYKLOKAPRON 23
CYMBALTA 32
CYSTADANE 56
CYSTAGON 56
cytarabine 16
cytarabine aqueous 16
CYTOMEL 53
CYTOVENE 12
dacarbazine 16
DACOGEN 16
dactinomycin 16
danazol 49
dantrolene sodium 21
dapsone 7
DAPTACEL 58
DARAPRIM 7
DAUNORUBICIN HCL DisplayText cannot span more than one line! DDAVP 53
Page 67 of 79
Drug Name Page #
DECAVAC 58
demeclocycline hcl 14
DEMSER 56
DENAVIR 60
DEPO-ESTRADIOL 52
desipramine hcl 32
desmopressin acetate 23
desmopressin acetate 53
desonide 59
desoximetasone 59
dexamethasone 49
dexamethasone intensol 49
dexamethasone sodium phosphate 45
dexamethasone sodium phosphate 49
dexmethylphenidate hcl 29
dexrazoxane 56
dextroamphetamine sulfate 29
dextroamphetamine sulfate er 29
dextrose 10%/nacl 0.45% 41
dextrose 5% /electrolyte #48 viaflex 42
dextrose 10% 41
dextrose 10% flex container 41
dextrose 10%/nacl 0.2% 41
dextrose 10%/nacl 0.225% 41
dextrose 2.5%/nacl 0.45% 41
dextrose 2.5%/sodium chloride 0.45% 41
dextrose 5% 41
dextrose 5% viaflex 41
dextrose 5%/nacl 0.2% 41
dextrose 5%/nacl 0.225% 41
dextrose 5%/nacl 0.3% 41
dextrose 5%/nacl 0.33% 41
dextrose 5%/nacl 0.45% 41
dextrose 5%/nacl 0.9% 41
dextrose 5%/potassium chloride 0.15% 42
dextrose 5%/sodium chloride 0.2% 41
dextrose 5%/sodium chloride 0.33% 41
dextrose 5%/sodium chloride 0.45% 41
dextrose 5%/sodium chloride 0.9% 41
dextrose thermoject system 41
DIAZEPAM 29
DIAZEPAM 29
DIAZEPAM INTENSOL 29
diclofenac potassium 37
diclofenac sodium 46
diclofenac sodium dr 37
diclofenac sodium er 37
diclofenac sodium xr 37
dicloxacillin sodium 13
dicyclomine hcl 19
didanosine 7
Drug Name Page #
DIFICID 12
diflorasone diacetate 59
diflunisal 37
digoxin 23
dihydroergotamine mesylate 19
DILANTIN 23
dilantin infatabs 23
DILATRATE SR 27
dilt-cd 23
diltiazem cd 24
diltiazem hcl 24
diltiazem hcl er 24
dilt-xr 23
diltzac 24
diphenoxylate/atropine 19
diphtheria/tetanus toxoid pediatric 58
disopyramide phosphate 24
DIURIL 26
divalproex sodium 30
divalproex sodium dr 30
divalproex sodium er 30
DOCEFREZ 16
docetaxel 16
donepezil hcl 21
DORIBAX 12
dorzolamide hcl 45
dorzolamide hcl/timolol maleate 45
doxazosin mesylate 19
doxepin hcl 32
doxycycline 14
doxycycline hyclate 14
doxycycline hyclate 44
doxycycline monohydrate 14
dronabinol 47
DROXIA 16
DULERA 57
DUONEB 19
DURAMORPH 38
DUREZOL 45
DYRENIUM 26
E.E.S. 400 12
E.E.S. GRANULES 12
e.s.p. 12
econazole nitrate 60
ed baclofen 21
EDURANT 8
EFFIENT 23
EGRIFTA 53
ELAPRASE 43
ELDEPRYL 37
ELESTAT 44
Page 68 of 79
Drug Name Page #
ELIDEL 61
eliphos 42
ELITEK 43
ELIXOPHYLLIN 26
ELOXATIN 16
EMCYT 16
EMEND 47
emoquette 50
EMSAM 32
EMTRIVA 8
enalapril maleate 28
enalapril maleate/hydrochlorothiazide 26
ENBREL 55
endocet 38
ENDOMETRIN 53
ENGERIX-B 58
enoxaparin sodium 22
enpresse-28 50
ENTOCORT EC 49
enulose 40
EPIDUO 61
epinastine hcl 44
epinephrine 19
epinephrine hcl 19
epirubicin hcl 16
epitol 30
EPIVIR 8
EPIVIR HBV 8
eplerenone 26
EPOGEN 22
EPZICOM 8
EQUETRO 30
ERAXIS 11
ERBITUX 16
ergoloid mesylates 19
ergotamine tartrate/caffeine 19
ERIVEDGE 16
errin 50
ery 60
ERYPED 200 12
ERYPED 400 12
ERY-TAB 12
ERYTHROCIN LACTOBIONATE 12
ERYTHROCIN STEARATE 12
erythromycin 44
erythromycin 60
erythromycin base 12
erythromycin ethylsuccinate 12
erythromycin/benzoyl peroxide 60
erythromycin/sulfisoxazole 12
escitalopram oxalate 32
Drug Name Page #
estradiol 52
estradiol valerate 52
estradiol/norethindrone acetate 52
ethambutol hcl 10
ethosuximide 40
ETHYOL 56
etidronate disodium 55
etodolac 37
etodolac er 37
ETOPOPHOS 16
etoposide 16
EURAX 61
EVAMIST 52
EVISTA 51
EXELON 21
exemestane 16
EXJADE 48
FABRAZYME 43
FACTIVE 14
famciclovir 13
famotidine 48
famotidine premixed 48
FANAPT 34
FANAPT TITRATION PACK 34
FARESTON 16
FASLODEX 16
FAZACLO 34
felbamate 30
FELBATOL 30
felodipine er 25
FEMCON FE 50
fenofibrate 27
fenofibrate micronized 27
fenoprofen calcium 37
fentanyl 38
fentanyl citrate 38
fentanyl citrate oral transmucosal 38
FIFTY50 ALCOHOL PREP PADS 62
finasteride 54
FIRAZYR 55
FIRMAGON 16
flavoxate hcl 61
flebogamma 58
FLEBOGAMMA DIF 58
flecainide acetate 24
fluconazole 10
fluconazole in dextrose 10
fluconazole in nacl 10
flucytosine 14
fludarabine phosphate 16
fludrocortisone acetate 49
Page 69 of 79
Drug Name Page #
flunisolide 57
fluocinolone acetonide 59
fluocinonide 59
fluocinonide emollient base 59
fluocinonide-e 59
fluorometholone 45
FLUOROPLEX 61
fluorouracil 16
fluorouracil 61
fluoxetine 32
fluoxetine dr 32
fluoxetine hcl 32
fluphenazine decanoate 34
fluphenazine hcl 34
flurbiprofen 37
flurbiprofen sodium 46
flutamide 16
fluticasone propionate 57
fluticasone propionate 59
fluvoxamine maleate 32
FML 45
FML FORTE 45
FOLOTYN 16
fomepizole 54
fondaparinux sodium 22
FORADIL AEROLIZER 20
FORTEO 53
FORTICAL 53
fosinopril sodium 28
fosinopril sodium/hydrochlorothiazide 26
fosphenytoin sodium 36
FRAGMIN 22
FREAMINE III 41
FREAMINE III 3% 41
furosemide 26
FUSILEV 54
FUZEON 8
gabapentin 30
GABITRIL 30
galantamine 21
galantamine hydrobromide 21
GAMMAGARD LIQUID 58
gammaplex 58
GAMUNEX 58
ganciclovir 13
GARAMYCIN 44
GARDASIL 58
gavilyte-c 47
gavilyte-g 47
gavilyte-n/flavor pack 47
gemcitabine 16
Drug Name Page #
gemcitabine hcl 16
gemfibrozil 27
GEMZAR 16
generlac 40
gengraf 55
gentak 44
gentamicin sulfate 6
gentamicin sulfate 44
gentamicin sulfate 60
gentamicin sulfate/0.9% sodium chloride 6
gentamicin sulfate/sodium chloride 6
GEODON 29
gianvi 50
gildess fe 1.5/30 50
gildess fe 1/20 50
GLASSIA 57
GLEEVEC 16
glimepiride 53
glipizide 53
glipizide er 53
glipizide xl 53
glipizide/metformin hcl 49
GLOBAL ALCOHOL PREP EASE PADS 62
GLUCAGEN HYPOKIT 52
GLUCAGON EMERGENCY KIT 52
glyburide 53
glyburide micronized 53
glyburide/metformin hcl 49
glycopyrrolate 19
GLYSET 49
GOLYTELY 47
granisetron hcl 46
griseofulvin microsize 7
GRIS-PEG 7
guanfacine hcl 26
HALAVEN 16
HALDOL 34
HALFLYTELY BOWEL PREP/FLAVOR
PACKS
47
halobetasol propionate 59
HALOG 59
haloperidol 34
haloperidol decanoate 34
haloperidol lactate 34
HAVRIX 58
heather 50
HECTOROL 61
heparin sodium 22
heparin sodium dcu 22
heparin sodium/d5w 22
heparin sodium/nacl 0.45% 22
Page 70 of 79
Drug Name Page #
heparin sodium/sodium chloride 0.9% 22
heparin sodium/sodium chloride 0.9%
premix
22
HEPATAMINE 41
HEPATASOL 41
HEPSERA 13
HERCEPTIN 16
HEXALEN 16
HIBERIX 58
HIZENTRA 58
HUMALOG 52
HUMALOG KWIKPEN 52
HUMALOG MIX 50/50 52
HUMALOG MIX 50/50 KWIKPEN 52
HUMALOG MIX 75/25 52
HUMALOG MIX 75/25 KWIKPEN 52
HUMIRA 55
HUMIRA PEN 55
HUMIRA PEN-CROHNS
DISEASESTARTER
55
HUMIRA PEN-PSORIASIS STARTER 55
HUMULIN 70/30 52
HUMULIN 70/30 PEN 52
HUMULIN N 52
HUMULIN N U-100 PEN 52
HUMULIN R 52
HUMULIN R U-500 (CONCENTRATED) 52
HYCAMTIN 16
hydralazine hcl 26
hydrochlorothiazide 26
hydrocodone bitartrate/acetaminophen 38
hydrocodone/acetaminophen 38
hydrocodone/ibuprofen 37
hydrocortisone 49
hydrocortisone 59
hydrocortisone butyrate 59
hydrocortisone valerate 59
hydrocortisone/acetic acid 45
hydromorphone hcl 38
hydroxychloroquine sulfate 7
hydroxyurea 16
hydroxyzine hcl 15
ibandronate sodium 55
ibuprofen 37
IDAMYCIN PFS 16
idarubicin hcl 16
IFEX 17
ifosfamide 17
ILOTYCIN 44
imipenem/cilastatin 12
imipramine hcl 33
Drug Name Page #
imipramine pamoate 33
imiquimod 61
INCIVEK 11
INCRELEX 53
indapamide 27
INDOCIN 37
indomethacin 37
indomethacin er 37
INFANRIX 58
INFERGEN 11
INFUMORPH 200 38
INFUMORPH 500 39
INLYTA 17
INTELENCE 8
INTRALIPID 41
INTRON-A 11
INTRON-A W/DILUENT 11
introvale 50
INVEGA 34
INVEGA SUSTENNA 34
INVIRASE 8
IONOSOL-B/DEXTROSE 5% 42
IONOSOL-MB/DEXTROSE 5% 42
IPOL INACTIVATED IPV 58
ipratropium bromide 19
ipratropium bromide 46
ipratropium bromide/albuterol sulfate 20
irbesartan 23
irbesartan/hydrochlorothiazide 23
IRESSA 17
irinotecan 17
ISENTRESS 8
isoditrate er 28
ISOLYTE-H/DEXTROSE 5% 42
ISOLYTE-M/DEXTROSE 5% 42
ISOLYTE-P/DEXTROSE 5% 42
ISOLYTE-S 42
ISOLYTE-S/DEXTROSE 5% 42
isonarif 6
isoniazid 10
ISORDIL TITRADOSE 28
isosorbide dinitrate 28
isosorbide dinitrate er 28
isosorbide mononitrate 28
isosorbide mononitrate er 28
isotonic gentamicin 6
isradipine 25
ISTODAX 17
itraconazole 10
IV PREP WIPES 62
IXEMPRA KIT 17
Page 71 of 79
Drug Name Page #
IXIARO 58
JAKAFI 17
jantoven 22
JANUMET 50
JANUMET XR 51
JANUVIA 51
jevantique 52
JE-VAX 58
JEVTANA 17
jinteli 52
junel 1.5/30 50
junel 1/20 50
junel fe 1.5/30 50
junel fe 1/20 50
JUVISYNC 27
KALETRA 8
kalexate 42
KALYDECO 57
kanamycin sulfate 6
KAPVAY 26
kariva 50
kcl 0.075%/d5w/nacl 0.2% 42
kcl 0.075%/d5w/nacl 0.45% 42
kcl 0.15%/d5w/ nacl 0.3% 42
kcl 0.15%/d5w/lr 42
kcl 0.15%/d5w/nacl 0.2% 42
kcl 0.15%/d5w/nacl 0.225% 42
kcl 0.15%/d5w/nacl 0.45% 42
kcl 0.15%/d5w/nacl 0.9% 42
kcl 0.3%/d5w/lr 42
kcl 0.3%/d5w/lr iv lac ring 42
kcl 0.3%/d5w/nacl 0.2% 42
kcl 0.3%/d5w/nacl 0.45% 42
kcl 0.3%/d5w/nacl 0.9% 42
KEFLEX 11
kelnor 1/35 50
KENALOG 59
KEPIVANCE 60
KETEK 12
ketoconazole 10
ketoconazole 60
ketoprofen 37
ketoprofen er 37
ketorolac tromethamine 46
kionex 42
KLOR-CON 10 42
KLOR-CON 8 42
klor-con m10 42
klor-con m15 42
klor-con m20 42
KUVAN 56
Drug Name Page #
labetalol hcl 19
laclotion 60
LACRISERT 46
lactated ringers 42
lactated ringers irrigation 41
lactated ringers viaflex 42
lactulose 40
LAMICTAL 30
LAMICTAL CHEWABLE DISPERSIBLE 30
LAMICTAL ODT 30
LAMICTAL STARTER/NOT TAKING
CARBAMAZEPINE
30
LAMICTAL STARTER/TAKING
CARBAMAZEPINE/NOT TAKING
VALPROATE
30
LAMICTAL STARTER/TAKING
VALPROATE
30
LAMICTAL XR 30
lamivudine 8
lamivudine/zidovudine 8
lamotrigine 30
LANOXIN 24
lansoprazole 48
LANTUS 52
LANTUS SOLOSTAR 52
latanoprost 46
LATUDA 34
leflunomide 55
lessina-28 50
LETAIRIS 28
letrozole 17
leucovorin calcium 54
LEUKERAN 17
LEUKINE 22
leuprolide acetate 17
levalbuterol 20
LEVEMIR 52
LEVEMIR FLEXPEN 52
levetiracetam 31
levetiracetam er 31
levobunolol hcl 45
levocarnitine 56
levocetirizine dihydrochloride 15
levofloxacin 14
levofloxacin 44
levofloxacin in d5w 14
levonorgestrel 50
levonorgestrel and ethinyl estradiol 50
levora 0.15/30-28 50
levorphanol tartrate 39
LEVOTHROID 53
Page 72 of 79
Drug Name Page #
levothyroxine sodium 53
LEVOXYL 53
LEXIVA 8
LIALDA 47
lidocaine 60
lidocaine hcl 46
lidocaine hcl 54
lidocaine hcl jelly 46
lidocaine viscous 46
lidocaine/prilocaine 60
LIDODERM 60
lindane 61
liothyronine sodium 53
LIPOSYN II 41
LIPOSYN III 41
lisinopril 28
lisinopril/hydrochlorothiazide 27
lithium carbonate 34
lithium carbonate er 34
lithium citrate 34
lokara 59
LOMOTIL 47
loperamide hcl 47
loryna 50
losartan potassium 28
losartan potassium/hydrochlorothiazide 27
LOSEASONIQUE 50
LOTRONEX 47
lovastatin 27
lovaza 25
low-ogestrel 50
loxapine 34
loxapine succinate 34
LUFYLLIN 58
LUMIGAN 46
LUMIZYME 43
LUPRON DEPOT 17
LUPRON DEPOT-PED 17
lutera 50
LUVOX CR 33
LYRICA 31
LYSODREN 17
magnesium sulfate 24
magnesium sulfate in d5w 24
MALARONE 7
malathion 61
maprotiline hcl 33
MARLISSA 50
MARPLAN 33
MATULANE 17
MAXITROL 44
Drug Name Page #
meclizine hcl 15
meclofenamate sodium 37
medroxyprogesterone acetate 53
mefloquine hcl 7
megestrol acetate 17
meloxicam 37
melphalan hydrochloride 17
MENACTRA 58
MENOMUNE-A/C/Y/W-135 58
MENTAX 60
MENVEO 58
MEPRON 7
mercaptopurine 17
meropenem 12
MERREM 12
mesalamine 47
mesna 56
MESNEX 56
MESTINON 21
MESTINON TIMESPAN 21
metaproterenol sulfate 20
metaxalone 21
metformin hcl 50
metformin hcl er 50
methadone hcl 39
methadone hcl intensol 39
METHADOSE 39
METHADOSE SUGAR-FREE 39
methamphetamine hcl 29
methazolamide 45
methenamine hippurate 14
METHERGINE 56
methimazole 49
methocarbamol 21
methotrexate 17
methotrexate sodium 17
methscopolamine bromide 20
methyclothiazide 27
methyldopa 19
methyldopa/hydrochlorothiazide 19
methyldopate hcl 19
methylergonovine maleate 56
methylphenidate hcl 29
methylprednisolone 49
methylprednisolone acetate 49
methylprednisolone dose pack 49
methylprednisolone sodiumsuccinate 49
metipranolol 45
metoclopramide hcl 48
metolazone 27
metoprolol succinate er 20
Page 73 of 79
Drug Name Page #
metoprolol tartrate 20
metoprolol/hydrochlorothiazide 20
METRO IV 6
metronidazole 6
metronidazole 60
metronidazole vaginal 60
mexiletine hcl 24
miconazole 3 60
microgestin 1.5/30 50
microgestin 1/20 50
microgestin fe 51
microgestin fe 1.5/30 51
MICRO-K 42
micronized colestipol hcl 25
midodrine hcl 19
migergot 19
mimvey 52
minitran 28
minocycline hcl 14
minoxidil 26
mirtazapine 33
mirtazapine odt 33
misoprostol 48
mitomycin 17
mitoxantrone hcl 17
M-M-R II W/DILUENT 10 DOSE 58
moexipril hcl 28
moexipril/hydrochlorothiazide 27
mometasone furoate 59
morgidox 1x100mg 14
morgidox 2x100mg 14
morphine sulfate 39
morphine sulfate er 39
MOVIPREP 47
MOXEZA 44
MOZOBIL 22
MULTAQ 24
mupirocin 60
MUSTARGEN 17
MYCOBUTIN 6
mycophenolate mofetil 55
mydral 46
MYFORTIC 55
MYOZYME 43
nabumetone 37
nadolol 20
nadolol/bendroflumethiazide 20
nafcillin sodium 13
NAGLAZYME 43
nalbuphine hcl 39
NALFON 37
Drug Name Page #
nallpen/dextrose 13
naloxone hcl 39
naltrexone hcl 39
NAMENDA 36
NAMENDA TITRATION PAK 36
naproxen 37
naproxen dr 37
naproxen sodium 37
naratriptan hcl 39
NARDIL 33
NASONEX 57
NATACYN 45
nateglinide 52
NAVELBINE 17
necon 0.5/35-28 51
necon 1/35-28 51
necon 10/11-28 51
nefazodone hcl 33
neomycin sulfate 6
neomycin/bacitracin/polymyxin 44
neomycin/polymyxin b sulfates 60
neomycin/polymyxin/bacitracin zinc 44
neomycin/polymyxin/bacitracin/hydrocortis
one
44
neomycin/polymyxin/dexamethasone 44
neomycin/polymyxin/gramicidin 44
neomycin/polymyxin/hc 44
neomycin/polymyxin/hydrocortisone 44
neo-polycin 44
neosporin 44
NEPHRAMINE 41
NEULASTA 22
NEUMEGA 22
NEUPOGEN 22
NEURONTIN 31
nevirapine 8
NEXAVAR 17
next choice 51
niacor 25
NIASPAN 25
nicardipine hcl 25
NICOTROL NS 20
nifediac cc 25
nifedical xl 25
nifedipine er 25
NILANDRON 17
nimodipine 25
NIPENT 17
nisoldipine 26
nisoldipine er 25
nitrofurantoin 14
Page 74 of 79
Drug Name Page #
nitrofurantoin macrocrystal 14
nitrofurantoin macrocrystalline 14
nitrofurantoin monohydrate 14
nitrofurantoin monohydrate/macrocrystals 14
nitroglycerin 28
nitroglycerin lingual 28
nitroglycerin transdermal 28
NITROLINGUAL PUMPSPRAY 28
NITROSTAT 28
nizatidine 48
norethindrone 51
norethindrone acetate 53
norgestimate/ethinyl estradiol 51
norgestrel/ethinyl estradiol 51
NORMOSOL -R 42
NORMOSOL-M IN D5W 42
NORMOSOL-R 42
NORMOSOL-R IN D5W 42
NORPACE CR 24
nortrel 0.5/35 (28) 51
nortrel 1/35 (21) 51
nortrel 1/35 (28) 51
nortrel 7/7/7 51
nortriptyline hcl 33
NORVIR 8
NOVOLIN 70/30 52
NOVOLIN N 52
NOVOLIN R 52
NOVOLOG 52
NOVOLOG FLEXPEN 52
NOVOLOG MIX 70/30 52
NOVOLOG MIX 70/30 PREFILLED
FLEXPEN
52
NOXAFIL 10
NUEDEXTA 36
NULOJIX 55
NULYTELY/FLAVOR PACKS 47
nutrilyte ii 42
nyamyc 60
nystatin 14
nystatin 60
nystatin/triamcinolone 60
nystop 60
octreotide acetate 56
ofloxacin 14
ofloxacin 44
ogestrel 51
olanzapine 35
olanzapine odt 34
omeprazole 48
OMNITROPE 53
Drug Name Page #
ondansetron hcl 46
ondansetron odt 46
ONFI 29
onglyza 51
ONTAK 17
oralone 59
ORAP 35
ORAPRED ODT 49
ORFADIN 56
orphenadrine citrate 22
orphenadrine citrate er 22
orsythia 51
OSMOPREP 47
oxacillin sodium 13
oxaliplatin 18
oxandrolone 49
oxaprozin 37
oxcarbazepine 31
OXSORALEN 61
OXSORALEN ULTRA 61
oxybutynin chloride 61
oxybutynin chloride er 61
oxycodone hcl 39
oxycodone/acetaminophen 39
oxycodone/aspirin 37
oxycodone/ibuprofen 37
PACERONE 24
paclitaxel 18
palgic 15
pamidronate disodium 55
PANCREAZE 48
PANRETIN 61
pantoprazole sodium 48
paromomycin sulfate 6
paroxetine hcl 33
paroxetine hcl er 33
PASER 10
PATADAY 44
PAXIL 33
PCE 12
pedi-dri 60
PEDVAX HIB 58
peg 3350/electrolytes 47
peg-3350/electrolytes 47
peg-3350/nacl/na bicarbonate/kcl 47
PEGANONE 36
PEGASYS 11
PEG-INTRON 11
PEG-INTRON REDIPEN 11
PEG-INTRON REDIPEN PAK 4 11
penicillin g potassium 13
Page 75 of 79
Drug Name Page #
penicillin g potassium in iso-osmotic
dextrose
13
penicillin g procaine 13
penicillin g sodium 13
penicillin v potassium 13
pentostatin 18
pentoxifylline er 23
PERFOROMIST 20
PERIDEX 45
perindopril erbumine 28
periogard 45
permethrin 61
perphenazine 35
perphenazine/amitriptyline 33
pfizerpen-g 13
PHARMACIST CHOICE ALCOHOLPREP
PADS
62
phenadoz 15
phenelzine sulfate 33
phenobarbital 29
PHENYTEK 24
phenytoin 24
phenytoin sodium 24
phenytoin sodium extended 24
PHOSLYRA 42
PHOSPHOLINE IODIDE 46
PHYSIOLYTE 41
PHYSIOSOL IRRIGATION 41
PHYSIOSOL IRRIGATION PH 7.4 41
pilocarpine hcl 21
pilocarpine hcl 46
pilocarpine hydrochloride 21
PILOPINE HS 46
pindolol 21
piperacillin sodium/tazobactam sodium 13
piperacillin/tazobactam 13
piroxicam 37
PLAN B 51
PLASMA-LYTE A 42
PLASMA-LYTE-148 42
PLASMA-LYTE-56/D5W 43
podofilox 61
poly-dex 44
polyethylene glycol 3350 47
polymyxin b sulfate 6
polymyxin b sulfate/trimethoprim sulfate 44
POLYTRIM 44
portia-28 51
potassium chloride 43
potassium chloride 0.075%/d5w/nacl
0.225%
43
Drug Name Page #
potassium chloride 0.15% /nacl 0.45%
viaflex
43
potassium chloride 0.15% d5w/nacl 0.33% 43
potassium chloride 0.15% d5w/nacl 0.45% 43
potassium chloride 0.15% d5w/nacl 0.45%
viaflex
43
potassium chloride 0.15% nacl 0.9% 43
potassium chloride 0.15% w/nacl 0.9%
viaflex
43
potassium chloride 0.15%/d5w 43
potassium chloride 0.15%/nacl 0.9% 43
potassium chloride 0.22% d5w/nacl 0.45% 43
potassium chloride 0.224%/d5w 43
potassium chloride 0.224%/d5w/nacl 0.45% 43
potassium chloride 0.224%/dextrose 5%
viaflex
43
potassium chloride 0.224%d5w/nacl 0.45%
viaflex
43
potassium chloride 0.3%/ nacl 0.9% 43
potassium chloride 0.3%/d5w 43
potassium chloride 0.3%/d5w/viaflex 43
potassium chloride 0.3%/nacl 0.9%/viaflex 43
potassium chloride cr 43
potassium chloride er 43
potassium chloride sr 43
potassium citrate 40
POTIGA 31
PRADAXA 22
pramipexole dihydrochloride 36
PRANDIN 52
pravastatin sodium 27
prazosin hcl 19
PRED MILD 45
PRED-G 44
PRED-G S.O.P. 44
prednicarbate 59
prednisolone acetate 45
prednisolone sodium phosphate 45
prednisolone sodium phosphate 49
prednisone 49
prednisone intensol 49
PREMARIN 52
PREMASOL 41
prevalite 25
previfem 51
PREZISTA 9
PRIFTIN 6
PRIMAXIN IV 12
PRIMAXIN IV ADD-VANTAGE 12
primidone 36
PRIMSOL 14
Page 76 of 79
Drug Name Page #
PRISTIQ 33
privigen 58
PROAIR HFA 20
probenecid 43
probenecid/colchicine 43
procainamide hcl 24
PROCALAMINE 41
prochlorperazine 35
prochlorperazine edisylate 35
prochlorperazine maleate 35
PROCRIT 22
proctocream hc 59
proctosol hc 59
progesterone 53
PROGLYCEM 26
PROGRAF 56
PROLASTIN 57
PROLASTIN-C 57
PROLEUKIN 18
PROLIA 55
PROMACTA 23
promethegan 15
propafenone hcl 24
propafenone hcl er 24
propantheline bromide 20
proparacaine hcl 46
propranolol hcl 21
propranolol hcl er 21
propranolol/hydrochlorothiazide 21
propranolol/hydrochlorothiazide 25
propylthiouracil 49
PROQUAD 58
PROTONIX 48
protriptyline hcl 33
PULMOZYME 44
pyrazinamide 10
pyridostigmine bromide 21
QUALAQUIN 7
quasense 51
quetiapine fumarate 35
quinapril hcl 28
quinapril/hydrochlorothiazide 27
quinidine gluconate 7
quinidine gluconate cr 7
quinidine gluconate er 7
quinidine sulfate 7
quinidine sulfate er 7
QVAR 57
RABAVERT 58
ramipril 28
RANEXA 26
Drug Name Page #
ranitidine hcl 48
RAPAMUNE 56
REBETOL 13
REBIF 54
REBIF TITRATION PACK 54
RECLAST 55
reclipsen 51
RECOMBIVAX HB 58
REGRANEX 61
RELENZA DISKHALER 12
RELISTOR 48
REMICADE 55
REMODULIN 28
RENVELA 42
RESCRIPTOR 9
reserpine 28
RESTASIS 45
RETROVIR 9
RETROVIR IV INFUSION 9
REVATIO 28
REVLIMID 18
REYATAZ 9
RHEUMATREX 18
ribavirin 13
RIDAURA 48
RIFAMATE 6
rifampin 6
RILUTEK 36
rimantadine hcl 6
ringers injection 43
ringers irrigation 41
RISPERDAL CONSTA 35
risperidone 35
risperidone m-tab 35
risperidone odt 35
RITUXAN 18
rivastigmine tartrate 21
ROCEPHIN 11
romycin 44
ropinirole hcl 36
ROTATEQ 58
ROXICET 39
SABRIL 31
SAIZEN 53
SAIZEN CLICK.EASY 53
SAMSCA 43
SANCUSO 47
SANDOSTATIN 56
SANDOSTATIN LAR DEPOT 56
SANTYL 61
SAPHRIS 35
Page 77 of 79
Drug Name Page #
SAVELLA 36
SAVELLA TITRATION PACK 36
scalacort 59
selegiline hcl 33
selenium sulfide 60
SELZENTRY 9
SEMPREX-D 15
SENSIPAR 56
SEREVENT DISKUS 20
SEROMYCIN 10
SEROQUEL XR 35
SEROSTIM 53
sertraline hcl 33
silver sulfadiazine 60
SIMULECT 56
simvastatin 27
SINGULAIR 57
sodium bicarbonate 40
sodium chloride 41
sodium chloride 43
sodium chloride 0.9% 41
sodium chloride 0.45% 43
sodium chloride 0.45% viaflex 43
sodium chloride 0.9% 41
sodium chloride pab 43
SODIUM EDECRIN 27
sodium lactate 40
sodium polystyrene sulfonate 42
sodium sulfacetamide 44
sodium sulfacetamide 61
SOLU-CORTEF 49
SOLU-MEDROL 49
SOMATULINE DEPOT 56
SOMAVERT 53
SORIATANE 61
sorine 21
sotalol hcl 21
sotalol hcl (af) 21
sotalol hydrochloride 24
SPIRIVA HANDIHALER 20
spironolactone 27
spironolactone/hydrochlorothiazide 27
sprintec 28 51
SPRYCEL 18
sronyx 51
stavudine 9
STELARA 61
sterile water irrigation 41
sterile water irrigation plastic bottle 41
sterile water irrigation w/hanger 41
STIMATE 23
Drug Name Page #
STRATTERA 36
streptomycin sulfate 6
STROMECTOL 6
SUCRAID 44
sucralfate 48
sulfacetamide sodium 44
sulfacetamide sodium 61
sulfacetamide sodium/prednisolone sodium
phosphate
44
sulfadiazine 14
sulfamethoxazole/trimethoprim 14
sulfamethoxazole/trimethoprim ds 14
sulfasalazine 14
sulfazine 14
sulindac 37
sumatriptan 39
sumatriptan succinate 39
sumatriptan succinate refill 39
SUPRAX 11
SUPREP BOWEL PREP 47
SURE-PREP ALCOHOL PREP PADS 62
SURMONTIL 33
SUSTIVA 9
SUTENT 18
syeda 51
SYLATRON 12
SYMBICORT 20
SYMLINPEN 120 49
SYMLINPEN 60 49
SYNAREL 52
SYNERA 60
SYNERCID 6
SYNTHROID 53
SYPRINE 48
TABLOID 18
tacrolimus 56
TAMIFLU 12
tamoxifen citrate 18
tamsulosin hcl 19
TARCEVA 18
TARGRETIN 18
TARGRETIN 61
TASIGNA 18
TASMAR 36
TAXOTERE 18
tazicef 11
TAZORAC 61
taztia xt 24
TEFLARO 11
TEGRETOL-XR 31
TEKTURNA 28
Page 78 of 79
Drug Name Page #
TENIVAC 58
TENORMIN 25
terazosin hcl 19
terbinafine hcl 6
terbutaline sulfate 20
terconazole 60
testosterone cypionate 49
testosterone enanthate 49
tetanus/diphtheria toxoids-adsorbed adult 58
tetracycline hcl 14
THALOMID 54
theophylline cr 27
theophylline er 27
thermazene 61
thioridazine hcl 35
thiotepa 18
thiothixene 35
THYMOGLOBULIN 56
ticlopidine hcl 23
TIKOSYN 25
tilia fe 51
TIMENTIN 13
timolol maleate 21
timolol maleate 45
timolol maleate ophthalmic gel forming 45
TIMOPTIC OCUDOSE 45
tizanidine hcl 21
TOBI 6
TOBRADEX 44
TOBRADEX ST 45
tobramycin sulfate 6
tobramycin sulfate 45
tobramycin sulfate/sodium chloride 6
tobramycin/dexamethasone 45
TOBREX 45
tolazamide 53
tolbutamide 53
tolmetin sodium 37
topiragen 31
topiramate 31
toposar 18
topotecan hcl 18
TORISEL 18
torsemide 27
TOTECT 56
TPN ELECTROLYTES 43
TRACLEER 29
tramadol hcl 39
tramadol hydrochloride/acetaminophen 39
trandolapril 28
tranexamic acid 23
Drug Name Page #
tranylcypromine sulfate 33
TRAVASOL 41
TRAVATAN Z 46
trazodone hcl 33
TREANDA 18
TRECATOR 10
TRELSTAR DEPOT MIXJECT 18
TRELSTAR LA MIXJECT 18
TRELSTAR MIXJECT 18
tretinoin 18
tretinoin 60
TREXALL 18
triamcinolone acetonide 59
triamcinolone in orabase 59
triamterene/hydrochlorothiazide 27
TRICOR 27
triderm 59
trifluoperazine hcl 35
trifluridine 45
trihexyphenidyl hcl 20
tri-legest fe 51
TRILEPTAL 29
trilyte 47
trimethobenzamide hcl 47
trimethoprim 14
trimethoprim sulfate/polymyxin b sulfate 45
trimipramine maleate 33
trinessa 51
TRIPEDIA 58
tri-previfem 51
TRISENOX 18
tri-sprintec 51
trivora-28 51
TRIZIVIR 9
TROPHAMINE 41
tropicamide 46
trospium chloride 61
TRUVADA 9
TWINJECT 19
TWINRIX 58
TYGACIL 14
TYKERB 18
TYPHIM VI 59
TYZEKA 13
TYZINE 46
TYZINE PEDIATRIC NASAL DROPS 46
u-cort 59
ULTILET ALCOHOL SWAB 62
ULTILET ALCOHOL SWABS 62
UNITHROID 54
UREX 14
Page 79 of 79
Drug Name Page #
UROCIT-K 10 40
UROCIT-K 5 40
ursodiol 47
UVADEX 61
valacyclovir hcl 13
VALCYTE 13
valproate sodium 31
valproic acid 31
VANCOCIN HCL 6
vancomycin hcl 6
VANDETANIB 18
VAQTA 59
VARIVAX 59
VECTIBIX 18
VELCADE 18
velivet 51
venlafaxine hcl 33
venlafaxine hcl er 33
VERAMYST 57
verapamil hcl 25
verapamil hcl er 25
verapamil hcl sr 25
VEREGEN 61
VERIPRED 20 49
vestura 51
VFEND 10
VFEND IV 10
VIBATIV 7
VIBRAMYCIN 14
victoza 52
VICTRELIS 11
VIDAZA 18
VIDEX PEDIATRIC 9
VIGAMOX 45
VIIBRYD 34
VIMPAT 31
vinblastine sulfate 19
vincasar pfs 19
vincristine sulfate 19
vinorelbine tartrate 19
VIRACEPT 9
VIRAMUNE 10
VIRAMUNE XR 10
VIREAD 10
vitazol 60
voltaren 37
voriconazole 11
VOTRIENT 19
VPRIV 44
warfarin sodium 22
WEBCOL ALCOHOL PREP LARGE 1 62
Drug Name Page #
PLY
WEBCOL ALCOHOL PREP LARGE 2
PLY
62
WEBCOL ALCOHOL PREP MEDIUM 2
PLY
62
WELCHOL 25
wymzya fe 51
XALKORI 19
XARELTO 22
XENAZINE 36
XGEVA 55
XIFAXAN 7
XOLAIR 57
XYREM 36
YERVOY 19
YF-VAX 59
zafirlukast 57
zaleplon 35
ZANOSAR 19
zarah 51
ZAVESCA 56
ZELBORAF 19
ZEMAIRA 57
ZEMPLAR 61
zenchent fe 51
ZENPEP 48
zeosa 51
ZERIT 10
ZETIA 26
ZIAGEN 10
zidovudine 10
ziprasidone hcl 35
ZIRGAN 45
ZOLINZA 19
zolpidem tartrate 36
ZOMETA 55
zonisamide 31
ZORTRESS 56
ZOSTAVAX 59
zovia 1/35e 51
zovia 1/50e 51
ZOVIRAX 60
ZYBAN 34
ZYMAXID 45
ZYPREXA 29
ZYTIGA 19
ZYVOX 7
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