2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
1
Drug Name Drug Tier
Requirements/Limits
ANALGESICS GOUT allopurinol (generic of ZYLOPRIM) TABS
1
colchicine w/ probenecid 1
COLCRYS QL (120 tabs / 30 days)
2 QL
febuxostat (generic of ULORIC)
1 PA
KRYSTEXXA 3 NDS NM LA PA
MITIGARE QL (60 caps / 30 days)
3 QL
probenecid 1
NSAIDS celecoxib (generic of CELEBREX) CAPS 50mg
QL (240 caps / 30 days)
1 QL
celecoxib (generic of CELEBREX) CAPS 100mg
QL (120 caps / 30 days)
1 QL
celecoxib (generic of CELEBREX) CAPS 200mg
QL (60 caps / 30 days)
1 QL
celecoxib (generic of CELEBREX) CAPS 400mg
QL (30 caps / 30 days)
1 QL
diclofenac potassium QL (120 tabs / 30 days)
1 QL
diclofenac sodium TB24; TBEC
1
diclofenac w/ misoprostol (generic of ARTHROTEC 50)
1
diclofenac w/ misoprostol (generic of ARTHROTEC 75)
1
diflunisal TABS 1
ec-naproxen (generic of EC-NAPROSYN) 375mg
1
ec-naproxen 500mg 1
etodolac CAPS 1
etodolac (generic of LODINE) TABS 400mg
1
etodolac TABS 500mg 1
etodolac TB24 1
flurbiprofen TABS 100mg 1
ibu tab 600mg 1
Drug Name Drug Tier
Requirements/Limits
ibu tab 800mg 1
ibuprofen SUSP 1
ibuprofen TABS 400mg, 600mg, 800mg
1
ketoprofen CAPS; CP24 1
meclofenamate sodium CAPS
1
meloxicam (generic of MOBIC) TABS
1
nabumetone TABS 1
naproxen (generic of NAPROSYN) TABS 250mg
1
naproxen TABS 375mg, 500mg
1
naproxen dr (generic of EC-NAPROSYN) 375mg
1
naproxen dr 500mg 1
naproxen sodium TABS 275mg
1
naproxen sodium (generic of ANAPROX DS) TABS 550mg
1
oxaprozin (generic of DAYPRO)
1
piroxicam (generic of FELDENE) CAPS
1
QMIIZ ODT 3
sulindac TABS 1
tolmetin sodium 1
OPIOID ANALGESICS acetaminophen w/ codeine 300-15mg
QL (400 tabs / 30 days)
1 QL
acetaminophen w/ codeine 300-30mg
QL (360 tabs / 30 days)
1 QL
acetaminophen w/ codeine 300-60mg
QL (180 tabs / 30 days)
1 QL
acetaminophen w/ codeine soln
QL (2700 mL / 30 days)
1 QL
acetaminophen-caff-dihydrocod CAPS
QL (300 caps / 30 days)
1 QL
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
2
Drug Name Drug Tier
Requirements/Limits
acetaminophen-caff-dihydrocod TABS
QL (300 tabs / 30 days)
1 QL
BELBUCA 75mcg, 150mcg, 300mcg, 450mcg, 600mcg
QL (60 buccal films / 30 days)
2 QL PA
BELBUCA 750mcg, 900mcg QL (60 buccal films / 30 days)
3 NDS QL PA
buprenorphine patch (generic of BUTRANS)
QL (4 patches / 28 days)
1 QL PA
butorphanol nasal spray QL (10 mL / 30 days)
1 QL
butorphanol tartrate SOLN 1
dvorah QL (300 tabs / 30 days)
1 QL
nalbuphine hcl SOLN 1
tramadol hcl CP24 QL (30 caps / 30 days)
1 QL PA
tramadol hcl TB24 QL (30 tabs / 30 days)
1 QL PA
tramadol hcl er (biphasic) 100mg
QL (30 tabs / 30 days)
1 QL PA
tramadol hcl er (biphasic) 200mg
QL (30 tabs / 30 days)
1 QL PA
tramadol hcl er (biphasic) 300mg
QL (30 tabs / 30 days)
1 QL PA
tramadol hcl tab 50 mg (generic of ULTRAM)
QL (240 tabs / 30 days)
1 QL
tramadol hcl tab 100 mg QL (120 tabs / 30 days)
1 QL
tramadol-acetaminophen (generic of ULTRACET)
QL (240 tabs / 30 days)
1 QL
trezix QL (300 caps / 30 days)
1 QL
OPIOID ANALGESICS, CII ARYMO ER 15mg, 30mg
QL (90 tabs / 30 days) 3 QL PA
ARYMO ER 60mg QL (90 tabs / 30 days)
3 NDS QL PA
Drug Name Drug Tier
Requirements/Limits
CODEINE SULFATE 15mg, 60mg
QL (180 tabs / 30 days)
3 QL
codeine sulfate 30mg QL (180 tabs / 30 days)
1 QL
endocet 2.5-325mg (generic of PERCOCET)
QL (360 tabs / 30 days)
1 QL
endocet 5-325mg (generic of PERCOCET)
QL (360 tabs / 30 days)
1 QL
endocet 7.5-325mg (generic of PERCOCET)
QL (240 tabs / 30 days)
1 QL
endocet 10-325mg (generic of PERCOCET)
QL (180 tabs / 30 days)
1 QL
fentanyl 37.5mcg/hr QL (10 patches / 30 days)
1 QL PA
fentanyl 62.5mcg/hr, 87.5mcg/hr
QL (10 patches / 30 days)
3 NDS QL PA
fentanyl citrate (generic of ACTIQ) LPOP
QL (120 lozenges / 30 days)
3 NDS QL PA
fentanyl citrate TABS QL (120 tabs / 30 days)
3 NDS QL PA
fentanyl patch 12 mcg/hr (generic of DURAGESIC)
QL (10 patches / 30 days)
1 QL PA
fentanyl patch 25 mcg/hr (generic of DURAGESIC)
QL (10 patches / 30 days)
1 QL PA
fentanyl patch 50 mcg/hr (generic of DURAGESIC)
QL (10 patches / 30 days)
1 QL PA
fentanyl patch 75 mcg/hr (generic of DURAGESIC)
QL (10 patches / 30 days)
1 QL PA
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
3
Drug Name Drug Tier
Requirements/Limits
fentanyl patch 100 mcg/hr (generic of DURAGESIC)
QL (10 patches / 30 days)
1 QL PA
hydrocodone bitartrate (generic of ZOHYDRO ER) C12A
QL (60 caps / 30 days)
1 QL PA
hydrocodone-acetaminophen 5-300mg (generic of XODOL)
QL (240 tabs / 30 days)
1 QL
hydrocodone-acetaminophen 5-325mg (generic of NORCO)
QL (240 tabs / 30 days)
1 QL
hydrocodone-acetaminophen 7.5-300mg
QL (180 tabs / 30 days)
1 QL
hydrocodone-acetaminophen 7.5-325 mg/15ml
QL (2700 mL / 30 days)
1 QL
hydrocodone-acetaminophen 7.5-325mg (generic of NORCO)
QL (180 tabs / 30 days)
1 QL
hydrocodone-acetaminophen 10-300mg
QL (180 tabs / 30 days)
1 QL
hydrocodone-acetaminophen 10-325mg (generic of NORCO)
QL (180 tabs / 30 days)
1 QL
hydrocodone-ibuprofen QL (150 tabs / 30 days)
1 QL
hydromorphone hcl (generic of DILAUDID) LIQD
QL (600 mL / 30 days)
1 QL
hydromorphone hcl (generic of DILAUDID) SOLN 1mg/ml, 2mg/ml
1 B/D
hydromorphone hcl SOLN 4mg/ml, 10mg/ml, 50mg/5ml, 500mg/50ml
1 B/D
hydromorphone hcl T24A 12mg, 16mg
QL (30 tabs / 30 days)
1 QL PA
hydromorphone hcl T24A 32mg
QL (30 tabs / 30 days)
3 NDS QL PA
Drug Name Drug Tier
Requirements/Limits
hydromorphone hcl (generic of DILAUDID) TABS
QL (180 tabs / 30 days)
1 QL
hydromorphone hcl t24a 8mg QL (30 tabs / 30 days)
1 QL PA
HYDROMORPHONE HYDROCHLORI SOLN 1mg/ml, 2mg/ml, 4mg/ml
3 B/D
HYSINGLA ER QL (30 tabs / 30 days)
2 QL PA
KADIAN 200mg QL (60 caps / 30 days)
3 NDS QL PA
lorcet hd tab 10-325mg (generic of NORCO)
QL (180 tabs / 30 days)
1 QL
lorcet plus tab 7.5-325 (generic of NORCO)
QL (180 tabs / 30 days)
1 QL
lorcet tab 5-325mg (generic of NORCO)
QL (240 tabs / 30 days)
1 QL
methadone hcl SOLN 5mg/5ml, 10mg/5ml
QL (450 mL / 30 days)
1 QL PA
methadone hcl (generic of METHADONE HCL) SOLN 10mg/ml
1
methadone hcl intensol (generic of METHADOSE)
QL (90 mL / 30 days)
1 QL PA
methadone tab 5mg (generic of DOLOPHINE)
QL (90 tabs / 30 days)
1 QL PA
methadone tab 10mg (generic of DOLOPHINE)
QL (90 tabs / 30 days)
1 QL PA
MORPHABOND ER 15mg QL (90 tabs / 30 days)
3 QL PA
MORPHABOND ER 30mg, 60mg, 100mg
QL (90 tabs / 30 days)
3 NDS QL PA
morphine sul inj 1mg/ml 1 B/D
morphine sulfate (generic of KADIAN) CP24 10mg, 20mg, 30mg, 40mg, 50mg, 60mg, 80mg
QL (60 caps / 30 days)
1 QL PA
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
4
Drug Name Drug Tier
Requirements/Limits
morphine sulfate (generic of KADIAN) CP24 100mg
QL (60 caps / 30 days)
3 NDS QL PA
MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml
3 B/D
morphine sulfate (generic of MORPHINE SULFATE) SOLN 4mg/ml, 8mg/ml, 10mg/ml
1 B/D
morphine sulfate TABS QL (180 tabs / 30 days)
1 QL
morphine sulfate beads QL (30 caps / 30 days)
1 QL PA
morphine sulfate ext-rel tab (generic of MS CONTIN)
QL (90 tabs / 30 days)
1 QL PA
morphine sulfate oral soln 10mg/5ml
QL (900 mL / 30 days)
1 QL
morphine sulfate oral soln 20mg/5ml
QL (900 mL / 30 days)
1 QL
morphine sulfate oral soln 100mg/5ml
QL (180 mL / 30 days)
1 QL
NUCYNTA 50mg, 75mg QL (180 tabs / 30 days)
2 QL
NUCYNTA 100mg QL (180 tabs / 30 days)
3 NDS QL
NUCYNTA ER QL (60 tabs / 30 days)
2 QL PA
OXAYDO 5mg QL (540 tabs / 30 days)
3 QL
OXAYDO 7.5mg QL (360 tabs / 30 days)
3 NDS QL
oxycodone hcl CAPS QL (180 caps / 30 days)
1 QL
oxycodone hcl CONC QL (180 mL / 30 days)
1 QL
oxycodone hcl SOLN QL (900 mL / 30 days)
1 QL
oxycodone hcl (generic of ROXICODONE) TABS 5mg, 15mg, 30mg
QL (180 tabs / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
oxycodone hcl TABS 10mg, 20mg
QL (180 tabs / 30 days)
1 QL
oxycodone w/ acetaminophen 2.5-325mg (generic of PERCOCET)
QL (360 tabs / 30 days)
1 QL
oxycodone w/ acetaminophen 5-325mg (generic of PERCOCET)
QL (360 tabs / 30 days)
1 QL
oxycodone w/ acetaminophen 7.5-325mg (generic of PERCOCET)
QL (240 tabs / 30 days)
1 QL
oxycodone w/ acetaminophen 10-325mg (generic of PERCOCET)
QL (180 tabs / 30 days)
1 QL
oxycodone-aspirin QL (360 tabs / 30 days)
1 QL
oxycodone-ibuprofen QL (120 tabs / 30 days)
1 QL
OXYCONTIN QL (60 tabs / 30 days)
2 QL PA
oxymorphone tabs 5mg QL (180 tabs / 30 days)
1 QL
oxymorphone tabs (generic of OPANA) 10mg
QL (180 tabs / 30 days)
1 QL
SUBSYS SPRAY 100MCG QL (120 spray units / 30 days)
3 NDS QL PA
SUBSYS SPRAY 200MCG QL (120 spray units / 30 days)
3 NDS QL PA
SUBSYS SPRAY 400MCG QL (120 spray units / 30 days)
3 NDS QL PA
SUBSYS SPRAY 600MCG QL (120 sprays / 30 days)
3 NDS QL PA
SUBSYS SPRAY 800MCG QL (120 sprays / 30 days)
3 NDS QL PA
SUBSYS SPRAY 1200MCG QL (240 sprays / 30 days)
3 NDS QL PA
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
5
Drug Name Drug Tier
Requirements/Limits
SUBSYS SPRAY 1600MCG QL (240 sprays / 30 days)
3 NDS QL PA
XTAMPZA ER 9mg, 13.5mg, 18mg, 27mg
QL (60 caps / 30 days)
3 QL PA
XTAMPZA ER 36mg QL (240 caps / 30 days)
3 NDS QL PA
ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) (generic of XYLOCAINE) 2%
1 B/D
lidocaine hcl (local anesth.) (generic of XYLOCAINE-MPF) .5%, 1%
1 B/D
lidocaine inj 0.5% (generic of XYLOCAINE)
1 B/D
lidocaine inj 1% (generic of XYLOCAINE)
1 B/D
lidocaine inj 1.5% preservative free (pf) (generic of XYLOCAINE-MPF)
1 B/D
lidocaine inj 2% preservative free (pf) (generic of XYLOCAINE-MPF)
1 B/D
lidocaine inj 4% preservative free (pf)
1
ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 1
ARIKAYCE 3 NDS NM LA PA
BETHKIS 3 NDS NM PA
gentamicin in saline 1
gentamicin sulfate SOLN 1
neomycin sulfate TABS 1
paromomycin sulfate CAPS 1
streptomycin sulfate SOLR 3 NDS
SULFADIAZINE TABS 3
TOBI PODHALER 3 NDS NM LA PA
tobramycin (generic of KITABIS PAK) NEBU
3 NDS NM PA
tobramycin inj 1.2 gm/30ml 1
tobramycin inj 1.2gm 3 NDS
tobramycin inj 10mg/ml 1
Drug Name Drug Tier
Requirements/Limits
tobramycin inj 80mg/2ml 1
tobramycin sulfate SOLN 1
ZEMDRI 3 NDS
ANTI-INFECTIVES - MISCELLANEOUS AEMCOLO
QL (12 tabs / 30 days) 3 QL
albendazole (generic of ALBENZA) TABS
3 NDS
ALINIA 3 NDS
atovaquone (generic of MEPRON) SUSP
3 NDS
aztreonam (generic of AZACTAM)
1
CAYSTON 3 NDS NM LA PA
clindamycin hcl (generic of CLEOCIN) CAPS
1
clindamycin phosphate in d5w 1
CLINDAMYCIN PHOSPHATE IN NACL
3
clindamycin phosphate inj (generic of CLEOCIN PHOSPHATE)
1
clindamycin soln 75mg/5ml (generic of CLEOCIN PEDIATRIC GRANULE)
1
colistimethate sodium (generic of COLY-MYCIN M) SOLR
1
DALVANCE 3 NDS
dapsone TABS 1
daptomycin (generic of DAPTOMYCIN) 350mg
3 NDS
daptomycin (generic of CUBICIN) 500mg
3 NDS
EMVERM QL (12 tabs / 365 days)
3 NDS QL
ertapenem sodium (generic of INVANZ)
1
FIRVANQ 3
imipenem-cilastatin 1
imipenem-cilastatin (generic of PRIMAXIN IV)
1
ivermectin (generic of STROMECTOL) TABS
1
linezolid in sodium chloride 1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
6
Drug Name Drug Tier
Requirements/Limits
linezolid inj (generic of ZYVOX)
1
linezolid susp (generic of ZYVOX)
3 NDS
linezolid tab 600mg (generic of ZYVOX)
1
meropenem (generic of MERREM)
1
MEROPENEM/SODIUM CHLORIDE
3
methenamine hippurate (generic of HIPREX)
1
metronidazole (generic of FLAGYL) CAPS; TABS
1
METRONIDAZOLE SOLN 3
metronidazole in nacl 1
metronidazole in nacl (generic of METRONIDAZOLE)
1
nitrofurantoin SUSP 3
nitrofurantoin macrocrystal (generic of MACRODANTIN)
2
nitrofurantoin monohyd macro (generic of MACROBID)
2
ORBACTIV 3 NDS
pentamidine isethionate inh (generic of NEBUPENT)
1 B/D
pentamidine isethionate inj (generic of PENTAM 300)
1
polymyxin b sulfate SOLR 1
praziquantel (generic of BILTRICIDE) TABS
1
pyrimethamine TABS 3 NDS PA
RECARBRIO 3 NDS
SIVEXTRO 3 NDS
SOLOSEC 3
sulfamethoxazole-trimethop ds (generic of BACTRIM DS)
1
sulfamethoxazole-trimethoprim inj
1
sulfamethoxazole-trimethoprim susp
1
sulfamethoxazole-trimethoprim tab 400-80mg (generic of BACTRIM)
1
SYNERCID 3 NDS
TIGECYCLINE 50mg 3 NDS
Drug Name Drug Tier
Requirements/Limits
tigecycline (generic of TYGACIL) 50mg
3 NDS
tinidazole TABS 1
trimethoprim TABS 1
VABOMERE 3 NDS
vancomycin hcl (generic of VANCOCIN HCL) CAPS 125mg
QL (120 caps / 30 days)
1 QL
vancomycin hcl (generic of VANCOCIN) CAPS 250mg
QL (240 caps / 30 days)
3 NDS QL
vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg
1
VANCOMYCIN HYDROCHLORIDE SOLN 500mg/100ml, 1000mg/200ml, 1500mg/300ml, 2000mg/400ml
3
VANCOMYCIN HYDROCHLORIDE SOLR
3
VANCOMYCIN IN NACL 3
VANCOMYCIN INJ 250MG 3
VIBATIV 3 NDS
XENLETA 3 NDS NM
XIFAXAN TAB 200MG QL (9 tabs / 30 days)
3 NDS QL
ZYVOX SOLN 200mg/100ml 3 NDS
ANTIFUNGALS ABELCET 3 NDS B/D
AMBISOME 3 NDS B/D
amphotericin b SOLR 1 B/D
CASPOFUNGIN ACETATE 50mg, 70mg
3 NDS
caspofungin acetate (generic of CANCIDAS) 50mg, 70mg
3 NDS
CRESEMBA 3 NDS
ERAXIS 50mg 3
ERAXIS 100mg 3 NDS
fluconazole (generic of DIFLUCAN) SUSR; TABS
1
fluconazole inj nacl 200 1
fluconazole inj nacl 400 1
flucytosine (generic of ANCOBON) CAPS
3 NDS
griseofulvin microsize 1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
7
Drug Name Drug Tier
Requirements/Limits
griseofulvin ultramicrosize 1
itraconazole (generic of SPORANOX) CAPS
1 PA
itraconazole (generic of SPORANOX) SOLN
3 NDS
ketoconazole TABS 1 PA
micafungin sodium (generic of MYCAMINE)
3 NDS
MYCAMINE 3 NDS
NOXAFIL SOLN 3 NDS
NOXAFIL SUSP QL (630 mL / 30 days)
3 NDS QL
nystatin TABS 1
posaconazole (generic of NOXAFIL)
QL (93 tabs / 30 days)
3 NDS QL
terbinafine hcl (generic of LAMISIL) TABS
QL (90 tabs / year)
1 QL
TOLSURA 3 NDS PA
voriconazole (generic of VFEND) SUSR
3 NDS PA
voriconazole (generic of VFEND) TABS 50mg
1
voriconazole (generic of VFEND) TABS 200mg
3 NDS
voriconazole inj 200mg (generic of VFEND IV)
3 NDS PA
ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg (generic of MALARONE)
1
atovaquone-proguanil hcl tab 250-100 mg (generic of MALARONE)
1
chloroquine phosphate TABS
1
COARTEM 3
KRINTAFEL 3
mefloquine hcl 1
PRIMAQUINE PHOSPHATE 26.3mg
3
primaquine phosphate (generic of PRIMAQUINE PHOSPHATE) 26.3mg
1
Drug Name Drug Tier
Requirements/Limits
quinine sulfate (generic of QUALAQUIN) CAPS
1 PA
ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN)
1 NM
APTIVUS 3 NDS NM
atazanavir sulfate (generic of REYATAZ)
1 NM
CRIXIVAN 3 NM
didanosine 1 NM
EDURANT 3 NDS NM
efavirenz (generic of SUSTIVA) CAPS 50mg
1 NM
efavirenz (generic of SUSTIVA) CAPS 200mg
3 NDS NM
efavirenz (generic of SUSTIVA) TABS
3 NDS NM
EMTRIVA 2 NM
fosamprenavir tab 700 mg (generic of LEXIVA)
3 NDS NM
FUZEON 3 NDS NM
INTELENCE 25mg 2 NM
INTELENCE 100mg, 200mg 3 NDS NM
INVIRASE 3 NDS NM
ISENTRESS CHEW 25mg 2 NM
ISENTRESS CHEW 100mg 3 NDS NM
ISENTRESS PACK 2 NM
ISENTRESS TABS 3 NDS NM
ISENTRESS HD 3 NDS NM
lamivudine (generic of EPIVIR)
1 NM
LEXIVA SUSP 3 NM
nevirapine susp 50 mg/5ml (generic of VIRAMUNE)
1 NM
nevirapine tab 100mg er 1 NM
nevirapine tab 200mg (generic of VIRAMUNE)
1 NM
nevirapine tab 400mg er (generic of VIRAMUNE XR)
1 NM
NORVIR PACK 2 NM
NORVIR SOLN 2 NM
PIFELTRO 3 NDS NM
PREZISTA SUSP QL (400 mL / 30 days)
3 NDS QL NM
PREZISTA TABS 75mg QL (480 tabs / 30 days)
2 QL NM
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
8
Drug Name Drug Tier
Requirements/Limits
PREZISTA TABS 150mg QL (240 tabs / 30 days)
3 NDS QL NM
PREZISTA TABS 600mg QL (60 tabs / 30 days)
3 NDS QL NM
PREZISTA TABS 800mg QL (30 tabs / 30 days)
3 NDS QL NM
REYATAZ PACK 3 NDS NM
ritonavir (generic of NORVIR) 1 NM
SELZENTRY SOLN 3 NDS NM
SELZENTRY TABS 25mg 3 NM
SELZENTRY TABS 75mg, 150mg, 300mg
3 NDS NM
stavudine 15mg, 20mg 1 NM
stavudine (generic of ZERIT) 30mg, 40mg
1 NM
tenofovir disoproxil fumarate (generic of VIREAD)
1 NM
TIVICAY 10mg 2 NM
TIVICAY 25mg, 50mg 3 NDS NM
TIVICAY PD 2 NM
TROGARZO 3 NDS NM LA
TYBOST 3 NM
VIRACEPT 3 NDS NM
VIREAD POWD 3 NDS NM
VIREAD TABS 150mg, 200mg, 250mg
3 NDS NM
zidovudine cap 100mg (generic of RETROVIR)
1 NM
zidovudine syp 50mg/5ml (generic of RETROVIR)
1 NM
zidovudine tab 300mg 1 NM
ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine (generic of EPZICOM)
1 NM
abacavir sulfate-lamivudine-zidovudine (generic of TRIZIVIR)
3 NDS NM
ATRIPLA 3 NDS NM
BIKTARVY 3 NDS NM
CIMDUO 3 NDS NM
COMPLERA 3 NDS NM
DELSTRIGO 3 NDS NM
DESCOVY 3 NDS NM
DOVATO 3 NDS NM
EVOTAZ 3 NDS NM
Drug Name Drug Tier
Requirements/Limits
GENVOYA 3 NDS NM
JULUCA 3 NDS NM
KALETRA TAB 100-25MG 2 NM
KALETRA TAB 200-50MG 3 NDS NM
lamivudine-zidovudine (generic of COMBIVIR)
1 NM
lopinavir-ritonavir (generic of KALETRA)
1 NM
ODEFSEY 3 NDS NM
PREZCOBIX 3 NDS NM
STRIBILD 3 NDS NM
SYMFI 3 NDS NM
SYMFI LO 3 NDS NM
SYMTUZA 3 NDS NM
TEMIXYS 3 NDS NM
TRIUMEQ 3 NDS NM
TRUVADA TAB 100-150 QL (30 tabs / 30 days)
3 NDS QL NM
TRUVADA TAB 133-200 QL (30 tabs / 30 days)
3 NDS QL NM
TRUVADA TAB 167-250 QL (30 tabs / 30 days)
3 NDS QL NM
TRUVADA TAB 200-300 QL (30 tabs / 30 days)
3 NDS QL NM
ANTITUBERCULAR AGENTS cycloserine CAPS 3 NDS
ethambutol hcl TABS 100mg 1
ethambutol hcl (generic of MYAMBUTOL) TABS 400mg
1
isoniazid SYRP 1
isoniazid tabs 1
PASER D/R 3
PRETOMANID 3
PRIFTIN 3
pyrazinamide TABS 1
rifabutin (generic of MYCOBUTIN)
1
rifampin (generic of RIFADIN) CAPS; SOLR
1
SIRTURO 100mg 3 NDS LA PA
TRECATOR 3
ANTIVIRALS acyclovir CAPS 1
acyclovir (generic of ZOVIRAX) SUSP; TABS
1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
9
Drug Name Drug Tier
Requirements/Limits
acyclovir sodium 1 B/D
adefovir dipivoxil (generic of HEPSERA)
3 NDS NM
BARACLUDE SOLN 3 NDS NM
cidofovir 3 NDS
entecavir (generic of BARACLUDE)
1 NM
EPCLUSA 3 NDS NM PA
EPIVIR HBV SOLN 3 NM
famciclovir TABS 1
GANCICLOVIR INJ 500MG/10ML
3 B/D
ganciclovir sodium (generic of CYTOVENE)
1 B/D
HARVONI 3 NDS NM PA
lamivudine (hbv) (generic of EPIVIR HBV)
1 NM
MAVYRET 3 NDS NM PA
oseltamivir phosphate (generic of TAMIFLU) CAPS; SUSR
1
PEGASYS 3 NDS NM PA
PEGASYS PROCLICK 3 NDS NM PA
PREVYMIS INJ 3 NDS
PREVYMIS TABS QL (28 tabs / 28 days)
3 NDS QL
RELENZA DISKHALER 2
ribavirin 200mg 1 NM
rimantadine hydrochloride 1
SITAVIG QL (2 tabs / 30 days)
3 NDS QL PA
valacyclovir hcl (generic of VALTREX) TABS
1
valganciclovir hcl (generic of VALCYTE)
3 NDS
VEMLIDY 3 NDS NM
VOSEVI 3 NDS NM PA
XOFLUZA 3
CEPHALOSPORINS AVYCAZ 3 NDS
cefaclor 1
CEFACLOR ER TAB 500MG 3
cefadroxil 1
CEFAZOLIN IN DEXTROSE 2GM/100ML-4%
3
cefazolin inj 1
Drug Name Drug Tier
Requirements/Limits
cefazolin sodium SOLR 1gm 1
CEFAZOLIN SODIUM 1 GM/50ML
3
cefdinir 1
CEFEPIME 1GM SOLN 3
CEFEPIME 2GM SOLN 3
cefepime inj 1gm 1
cefepime inj 2gm 1
CEFEPIME/DEXTROSE 3
cefixime (generic of SUPRAX) 1
cefotetan disodium (generic of CEFOTAN)
1
CEFOXITIN SODIUM 3
cefoxitin sodium 1gm, 2gm, 10gm
1
cefpodoxime proxetil 1
cefprozil 1
ceftazidime SOLR 1
CEFTAZIDIME/DEXTROSE 3
ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg
1
cefuroxime axetil 1
cefuroxime sodium 1
cephalexin (generic of KEFLEX) CAPS
1
cephalexin SUSR; TABS 1
FETROJA 3 NDS
SUPRAX CHEW 2
SUPRAX SUSR 500mg/5ml 2
tazicef SOLR 1
TEFLARO 3 NDS
ZERBAXA 3 NDS
ERYTHROMYCINS/MACROLIDES azithromycin PACK 1
azithromycin (generic of ZITHROMAX) SOLR
1
azithromycin (generic of ZITHROMAX) SUSR
1
azithromycin (generic of ZITHROMAX) TABS 250mg, 500mg
1
azithromycin TABS 600mg 1
clarithromycin SUSR; TABS 1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
10
Drug Name Drug Tier
Requirements/Limits
clarithromycin (generic of BIAXIN XL) TB24
1
DIFICID 3 NDS
ery-tab 1
ERYTHROCIN LACTOBIONATE
3
erythrocin stearate 1
erythromycin base 1
erythromycin cap 250mg ec 1
erythromycin ethylsuccinate (generic of E.E.S. GRANULES) SUSR 200mg/5ml
1
erythromycin ethylsuccinate (generic of ERYPED 400) SUSR 400mg/5ml
3 NDS
erythromycin ethylsuccinate TABS
1
erythromycin tab ec 1
FLUOROQUINOLONES BAXDELA 3 NDS
CIPRO SUSR 3
CIPRO SUSP 3
ciprofloxacin hcl TABS 100mg, 750mg
1
ciprofloxacin hcl (generic of CIPRO) TABS 250mg, 500mg
1
ciprofloxacin in d5w 1
levofloxacin SOLN 1
levofloxacin (generic of LEVAQUIN) TABS
1
levofloxacin in d5w 1
moxifloxacin hcl TABS 1
moxifloxacin hcl in sodium chloride
1
MOXIFLOXACIN HYDROCHLORID SOLN 400mg/250ml
3
PENICILLINS amoxicillin 1
amoxicillin & pot clavulanate 200-28.5 chw tabs
1
amoxicillin & pot clavulanate 200/5ml susr
1
Drug Name Drug Tier
Requirements/Limits
amoxicillin & pot clavulanate 250-125 tabs
1
amoxicillin & pot clavulanate 250/5ml susr (generic of AUGMENTIN)
1
amoxicillin & pot clavulanate 400-57 chw tabs
1
amoxicillin & pot clavulanate 400/5ml susr
1
amoxicillin & pot clavulanate 500-125 tabs (generic of AUGMENTIN)
1
amoxicillin & pot clavulanate 600/5ml susr
1
amoxicillin & pot clavulanate 875-125 tabs
1
amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs
1
ampicillin & sulbactam sodium (generic of UNASYN)
1
ampicillin & sulbactam sodium (generic of UNASYN BULK PACK)
1
ampicillin cap 500mg 1
ampicillin inj 1
ampicillin sodium 1
BACTOCILL INJ DEX 1GM 3
BACTOCILL INJ DEX 2GM 3
BICILLIN C-R 3
BICILLIN L-A 3
dicloxacillin sodium 1
NAFCILLIN IN DEXTROSE 3
nafcillin sodium 1gm, 2gm 1
nafcillin sodium 10gm 3 NDS
NAFCILLIN SODIUM FOR INJ 10GM
3
oxacillin sodium 1gm, 2gm 1
oxacillin sodium 10gm 3 NDS
PENICILLIN G POT IN DEXTROSE 1MU
3
PENICILLIN G POT IN DEXTROSE 2MU
3
PENICILLIN G POT IN DEXTROSE 3MU
3
PENICILLIN G PROCAINE 3
penicillin g sodium 1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
11
Drug Name Drug Tier
Requirements/Limits
penicillin v potassium 1
penicilln gk inj 5mu 1
penicilln gk inj 20mu 1
pfizerpen-g inj 5mu 1
pfizerpen-g inj 20mu 1
piper/tazoba inj 2-0.25gm 1
piper/tazoba inj 3-0.375gm 1
piper/tazoba inj 4-0.5gm 1
piper/tazoba inj 12-1.5gm 1
piper/tazoba inj 36-4.5gm 1
ZOSYN 3
TETRACYCLINES demeclocycline hcl 1
doxy 100 1
doxycycline (monohydrate) CAPS; TABS
1
doxycycline (monohydrate) (generic of VIBRAMYCIN) SUSR
1
doxycycline hyclate CAPS 50mg
1
doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg
1
doxycycline hyclate SOLR 1
doxycycline hyclate TABS 20mg, 50mg, 100mg
1
doxycycline hyclate (generic of ACTICLATE) TABS 75mg, 150mg
1
doxycycline hyclate (generic of DORYX) TBEC
1
doxycycline hyclate tab 75 mg dr
1
doxycycline hyclate tab 100 mg dr
1
doxycycline hyclate tab 150 mg dr
1
minocycline hcl CAPS 50mg, 75mg
1
minocycline hcl (generic of MINOCIN) CAPS 100mg
1
minocycline hcl TABS 1
minocycline tab 45mg er 1 PA
Drug Name Drug Tier
Requirements/Limits
minocycline tab 55mg er (generic of SOLODYN)
3 NDS PA
minocycline tab 65mg er (generic of SOLODYN)
3 NDS PA
minocycline tab 80mg er (generic of SOLODYN)
3 NDS PA
minocycline tab 90mg er 1 PA
minocycline tab 105mg er (generic of SOLODYN)
3 NDS PA
minocycline tab 115mg er (generic of SOLODYN)
3 NDS PA
minocycline tab 135mg er 1 PA
MINOLIRA 3 PA
mondoxyne nl cap 75mg 1
mondoxyne nl cap 100mg 1
tetracycline hcl CAPS 1
VIBRAMYCIN SYRP 2
XIMINO 3 NDS PA
ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA 3 NDS B/D NM
cyclophosphamide CAPS 1 B/D
cyclophosphamide SOLR 3 NDS B/D
dacarbazine 100mg 1 B/D
EMCYT 2
GLEOSTINE 10mg 3
GLEOSTINE 40mg, 100mg 3 NDS
IFEX INJ 3GM 3 B/D
ifosfamide SOLN 1 B/D
IFOSFAMIDE INJ 3GM 3 B/D
LEUKERAN 3 NDS
TREANDA 3 NDS B/D NM
ANTHRACYCLINES adriamycin SOLN 1 B/D
doxorubicin hcl 1 B/D
doxorubicin hcl liposomal (generic of DOXIL)
3 NDS B/D
epirubicin hcl 50mg/25ml 1 B/D
epirubicin hcl (generic of ELLENCE) 200mg/100ml
1 B/D
ANTIBIOTICS bleomycin sulfate 1 B/D
mitomycin SOLR 5mg 1 B/D
mitomycin SOLR 20mg, 40mg
3 NDS B/D
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
12
Drug Name Drug Tier
Requirements/Limits
valrubicin (generic of VALSTAR)
3 NDS NM
ANTIMETABOLITES adrucil inj 1 B/D
ALIMTA 3 NDS B/D
azacitidine (generic of VIDAZA)
3 NDS B/D NM
cytarabine 1 B/D
decitabine (generic of DACOGEN)
3 NDS B/D NM
fludarabine phosphate SOLN 3 NDS B/D
fludarabine phosphate SOLR 1 B/D
fluorouracil SOLN 1 B/D
FOLOTYN 3 NDS NM PA
gemcitabine inj soln 1gm/10ml, 2gm/20ml, 200mg/2ml
1 B/D
gemcitabine inj soln (generic of GEMCITABINE) 1gm/26.3ml, 2gm/52.6ml, 200mg/5.26ml
1 B/D
gemcitabine inj solr 1 B/D
INFUGEM 3 NDS B/D
mercaptopurine TABS 1
methotrexate sodium inj soln 1 B/D
methotrexate sodium inj solr 1 B/D
NIPENT 3 NDS B/D
PURIXAN 3 NDS NM
TABLOID 3 NDS
ANTIMITOTIC, TAXOIDS ABRAXANE 3 NDS B/D
docetaxel CONC 20mg/ml 3 NDS B/D
docetaxel (generic of TAXOTERE) CONC 80mg/4ml
3 NDS B/D
DOCETAXEL CONC 80mg/4ml, 160mg/8ml, 200mg/10ml
3 NDS B/D
docetaxel (generic of DOCETAXEL) CONC 160mg/8ml
3 NDS B/D
DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml
3 NDS B/D
Drug Name Drug Tier
Requirements/Limits
docetaxel (generic of DOCETAXEL) SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml
3 NDS B/D
JEVTANA 3 NDS NM PA
paclitaxel 1 B/D
TAXOTERE 3 NDS B/D
ANTIMITOTIC, VINCA ALKALOIDS MARQIBO 3 NDS B/D NM
vinblastine sulfate 1 B/D
vincristine sulfate 1 B/D
vinorelbine tartrate 1 B/D
BIOLOGIC RESPONSE MODIFIERS ADAKVEO 3 NDS NM PA
ARZERRA 3 NDS B/D NM
AVASTIN 3 NDS NM LA PA
BAVENCIO 3 NDS NM LA PA
BELEODAQ 3 NDS NM PA
BESPONSA 3 NDS NM LA PA
BORTEZOMIB 3 NDS NM PA
CYRAMZA 3 NDS NM LA PA
DARZALEX 3 NDS NM LA PA
DARZALEX FASPRO 3 NDS NM PA
DAURISMO 3 NDS NM LA PA
EMPLICITI 3 NDS NM LA PA
ENHERTU 3 NDS NM LA PA
ERBITUX 3 NDS B/D NM
ERIVEDGE 3 NDS NM LA PA
FARYDAK 3 NDS NM LA PA
GAZYVA 3 NDS NM LA PA
HERCEPTIN 3 NDS NM PA
HERCEPTIN HYLECTA 3 NDS NM PA
HERZUMA 3 NDS NM PA
IBRANCE CAPS QL (21 caps / 28 days)
3 NDS QL NM LA PA
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
13
Drug Name Drug Tier
Requirements/Limits
IBRANCE TABS QL (21 tabs / 28 days)
3 NDS QL NM LA PA
IDHIFA QL (30 tabs / 30 days)
3 NDS QL NM LA PA
IMFINZI 3 NDS NM LA PA
KADCYLA 3 NDS B/D NM
KANJINTI 3 NDS NM PA
KEYTRUDA 3 NDS NM PA
KISQALI 3 NDS NM PA
KISQALI FEMARA 200 DOSE 3 NDS NM PA
KISQALI FEMARA 400 DOSE 3 NDS NM PA
KISQALI FEMARA 600 DOSE 3 NDS NM PA
KYPROLIS 3 NDS NM LA PA
LARTRUVO 3 NDS NM LA PA
LIBTAYO 3 NDS NM LA PA
LUMOXITI 3 NDS NM LA PA
LYNPARZA 3 NDS NM LA PA
MVASI 3 NDS NM LA PA
MYLOTARG 3 NDS NM LA PA
NINLARO 3 NDS NM PA
ODOMZO 3 NDS NM LA PA
OGIVRI 3 NDS NM PA
ONTRUZANT 3 NDS NM PA
OPDIVO 3 NDS NM LA PA
PADCEV 3 NDS NM LA PA
PERJETA 3 NDS NM PA
POLIVY 3 NDS NM PA
PORTRAZZA 3 NDS NM LA PA
POTELIGEO 3 NDS NM LA PA
RITUXAN 3 NDS NM LA PA
RITUXAN HYCELA 3 NDS NM LA PA
Drug Name Drug Tier
Requirements/Limits
RUBRACA 3 NDS NM LA PA
RUXIENCE 3 NDS NM PA
SARCLISA 3 NDS NM LA PA
TALZENNA 3 NDS NM LA PA
TECENTRIQ 3 NDS NM LA PA
temsirolimus (generic of TORISEL)
3 NDS B/D NM
TIBSOVO 3 NDS NM LA PA
TRAZIMERA 3 NDS NM PA
TRODELVY 3 NDS NM LA PA
TRUXIMA 3 NDS NM PA
VECTIBIX 3 NDS B/D NM
VELCADE 3 NDS NM PA
VENCLEXTA 10mg 3 NM LA PA
VENCLEXTA 50mg, 100mg 3 NDS NM LA PA
VENCLEXTA STARTING PACK
3 NDS NM LA PA
VERZENIO 3 NDS NM LA PA
YERVOY 3 NDS NM PA
ZALTRAP 3 NDS NM LA PA
ZEJULA 3 NDS NM LA PA
ZIRABEV 3 NDS NM PA
ZOLINZA 3 NDS NM PA
HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate (generic of ZYTIGA)
3 NDS NM PA
anastrozole (generic of ARIMIDEX) TABS
1
bicalutamide (generic of CASODEX)
1
DEPO-PROVERA INJ 400/ML 3 B/D
ELIGARD INJ 7.5MG 2 B/D NM
ELIGARD INJ 22.5MG 2 B/D NM
ELIGARD INJ 30MG 2 B/D NM
ELIGARD INJ 45MG 2 B/D NM
ERLEADA 3 NDS NM LA PA
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
14
Drug Name Drug Tier
Requirements/Limits
exemestane (generic of AROMASIN)
1
FIRMAGON 80mg 3 B/D NM
FIRMAGON 120mg/vial 3 NDS B/D NM
flutamide 1
fulvestrant (generic of FASLODEX)
3 NDS B/D
hydroxyprogesterone caproate (antineoplastic)
3 NDS B/D
letrozole (generic of FEMARA) TABS
1
leuprolide inj 1mg/0.2 1 NM PA
LUPRON DEPOT (1-MONTH) 3 NDS NM PA
LUPRON DEPOT (6-MONTH) 3 NDS NM PA
LUPRON DEPOT INJ 11.25MG (3-MONTH)
3 NDS NM PA
LUPRON DEPOT INJ 22.5MG (3-MONTH)
3 NDS NM PA
LUPRON DEPOT INJ 30MG (4-MONTH)
3 NDS NM PA
LYSODREN 2
megestrol ac sus 40mg/ml 2
megestrol ac tab 20mg 2
megestrol ac tab 40mg 2
megestrol sus 625mg/5ml 3 PA
nilutamide (generic of NILANDRON)
3 NDS
NUBEQA 3 NDS NM LA PA
SOLTAMOX 3 NDS
tamoxifen citrate TABS 1
toremifene citrate (generic of FARESTON)
3 NDS
TRELSTAR MIXJECT 3 NDS NM PA
VANTAS 3 NM PA
XTANDI 3 NDS NM LA PA
ZOLADEX 3 NM PA
ZYTIGA 500mg 3 NDS NM LA PA
IMMUNOMODULATORS POMALYST 1mg, 2mg
QL (21 caps / 21 days) 3 NDS QL NM
LA PA
POMALYST 3mg, 4mg QL (21 caps / 28 days)
3 NDS QL NM LA PA
Drug Name Drug Tier
Requirements/Limits
REVLIMID 3 NDS NM LA PA
THALOMID 3 NDS NM PA
KINASE INHIBITORS AFINITOR 10mg
QL (30 tabs / 30 days) 3 NDS QL NM
PA
AFINITOR DISPERZ 2mg QL (150 tabs / 30 days)
3 NDS QL NM PA
AFINITOR DISPERZ 3mg QL (90 tabs / 30 days)
3 NDS QL NM PA
AFINITOR DISPERZ 5mg QL (60 tabs / 30 days)
3 NDS QL NM PA
ALECENSA 3 NDS NM LA PA
ALIQOPA 3 NDS NM LA PA
ALUNBRIG 3 NDS NM LA PA
AYVAKIT QL (30 tabs / 30 days)
3 NDS QL NM LA PA
BALVERSA 3 NDS NM LA PA
BOSULIF 3 NDS NM PA
BRAFTOVI 3 NDS NM LA PA
BRUKINSA 3 NDS NM LA PA
CABOMETYX QL (30 tabs / 30 days)
3 NDS QL NM LA PA
CALQUENCE 3 NDS NM LA PA
CAPRELSA 3 NDS NM LA PA
COMETRIQ 3 NDS NM LA PA
COPIKTRA 3 NDS NM LA PA
COTELLIC 3 NDS NM LA PA
erlotinib hcl (generic of TARCEVA) 25mg
QL (90 tabs / 30 days)
3 NDS QL NM PA
erlotinib hcl (generic of TARCEVA) 100mg, 150mg
QL (30 tabs / 30 days)
3 NDS QL NM PA
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
15
Drug Name Drug Tier
Requirements/Limits
everolimus (generic of AFINITOR)
QL (30 tabs / 30 days)
3 NDS QL NM PA
GILOTRIF TAB 20MG 3 NDS NM LA PA
GILOTRIF TAB 30MG 3 NDS NM LA PA
GILOTRIF TAB 40MG 3 NDS NM LA PA
ICLUSIG 3 NDS NM LA PA
imatinib mesylate (generic of GLEEVEC) 100mg
QL (90 tabs / 30 days)
3 NDS QL NM PA
imatinib mesylate (generic of GLEEVEC) 400mg
QL (60 tabs / 30 days)
3 NDS QL NM PA
IMBRUVICA 3 NDS NM LA PA
INLYTA 1mg QL (180 tabs / 30 days)
3 NDS QL NM LA PA
INLYTA 5mg QL (120 tabs / 30 days)
3 NDS QL NM LA PA
INREBIC 3 NDS NM LA PA
IRESSA 3 NDS NM LA PA
JAKAFI QL (60 tabs / 30 days)
3 NDS QL NM LA PA
KOSELUGO 3 NDS NM LA PA
LENVIMA 4 MG DAILY DOSE 3 NDS NM LA PA
LENVIMA 8 MG DAILY DOSE 3 NDS NM LA PA
LENVIMA 10 MG DAILY DOSE
3 NDS NM LA PA
LENVIMA 12MG DAILY DOSE
3 NDS NM LA PA
LENVIMA 14 MG DAILY DOSE
3 NDS NM LA PA
LENVIMA 18 MG DAILY DOSE
3 NDS NM LA PA
LENVIMA 20 MG DAILY DOSE
3 NDS NM LA PA
LENVIMA 24 MG DAILY DOSE
3 NDS NM LA PA
Drug Name Drug Tier
Requirements/Limits
LORBRENA 3 NDS NM LA PA
MEKINIST 3 NDS NM LA PA
MEKTOVI 3 NDS NM LA PA
NERLYNX 3 NDS NM LA PA
NEXAVAR 3 NDS NM LA PA
PEMAZYRE 3 NDS NM LA PA
PIQRAY 200MG DAILY DOSE
3 NDS NM PA
PIQRAY 250MG DAILY DOSE
3 NDS NM PA
PIQRAY 300MG DAILY DOSE
3 NDS NM PA
QINLOCK 3 NDS NM LA PA
RETEVMO 3 NDS NM LA PA
ROZLYTREK 3 NDS NM LA PA
RYDAPT 3 NDS NM PA
SPRYCEL 3 NDS NM PA
STIVARGA 3 NDS NM LA PA
SUTENT QL (30 caps / 30 days)
3 NDS QL NM PA
TABRECTA 3 NDS NM PA
TAFINLAR 3 NDS NM LA PA
TAGRISSO QL (30 tabs / 30 days)
3 NDS QL NM LA PA
TASIGNA 3 NDS NM PA
TUKYSA 3 NDS NM LA PA
TURALIO 3 NDS NM LA PA
TYKERB 3 NDS NM LA PA
VITRAKVI 3 NDS NM LA PA
VIZIMPRO 3 NDS NM LA PA
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
16
Drug Name Drug Tier
Requirements/Limits
VOTRIENT 3 NDS NM LA PA
XALKORI 3 NDS NM LA PA
XOSPATA 3 NDS NM LA PA
ZELBORAF 3 NDS NM LA PA
ZYDELIG 3 NDS NM LA PA
ZYKADIA 3 NDS NM LA PA
MISCELLANEOUS bexarotene (generic of TARGRETIN)
3 NDS NM PA
ERWINAZE 3 NDS NM LA PA
HALAVEN 3 NDS B/D NM
hydroxyurea (generic of HYDREA) CAPS
1
IXEMPRA KIT 3 NDS B/D NM
LONSURF 3 NDS NM PA
MATULANE 3 NDS LA
mitoxantrone hcl 1 B/D NM
SIKLOS 100mg 3
SIKLOS 1000mg 3 NDS
SYLATRON 3 NDS NM PA
SYLVANT 3 NDS NM LA PA
SYNRIBO 3 NDS NM PA
TAZVERIK 3 NDS NM LA PA
tretinoin CAPS 3 NDS
XPOVIO 40 MG ONCE WEEKLY
3 NDS NM LA PA
XPOVIO 40 MG TWICE WEEKLY
3 NDS NM LA PA
XPOVIO 60 MG ONCE WEEKLY
3 NDS NM LA PA
XPOVIO 60 MG TWICE WEEKLY
3 NDS NM LA PA
XPOVIO 80 MG ONCE WEEKLY
3 NDS NM LA PA
XPOVIO 80 MG TWICE WEEKLY
3 NDS NM LA PA
XPOVIO 100 MG ONCE WEEKLY
3 NDS NM LA PA
Drug Name Drug Tier
Requirements/Limits
PLATINUM-BASED AGENTS carboplatin 1 B/D
cisplatin SOLN 1 B/D
oxaliplatin inj 50mg 3 NDS B/D
oxaliplatin inj 50mg/10ml 1 B/D
oxaliplatin inj 100mg 3 NDS B/D
oxaliplatin inj 100mg/20ml 1 B/D
PROTECTIVE AGENTS dexrazoxane hcl 3 NDS B/D
ELITEK 3 NDS B/D
KHAPZORY 3 NDS B/D NM
leucovorin calcium SOLN 500mg/50ml
1 B/D
leucovorin calcium SOLR 1 B/D
leucovorin calcium TABS 1
levoleucovorin calcium 175mg/17.5ml
3 NDS B/D NM
levoleucovorin calcium 250mg/25ml
1 B/D NM
levoleucovorin calcium 50mg 3 NDS B/D NM
MESNEX TABS 3 NDS
TOTECT 3 NDS B/D
ZINECARD 3 NDS B/D
TOPOISOMERASE INHIBITORS ETOPOPHOS 3 B/D
etoposide SOLN 1 B/D
irinotecan hcl (generic of CAMPTOSAR) 40mg/2ml, 100mg/5ml
1 B/D
irinotecan hcl 300mg/15ml, 500mg/25ml
1 B/D
ONIVYDE 3 NDS B/D NM
toposar 1 B/D
topotecan hcl (generic of TOPOTECAN HCL) SOLN
3 NDS B/D
topotecan hcl (generic of HYCAMTIN) SOLR
3 NDS B/D
CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl
1
amlodipine besylate-benazepril hcl (generic of LOTREL)
1
benazepril & hydrochlorothiazide
1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
17
Drug Name Drug Tier
Requirements/Limits
benazepril & hydrochlorothiazide (generic of LOTENSIN HCT)
1
captopril & hydrochlorothiazide
1
enalapril maleate & hydrochlorothiazide
1
enalapril maleate & hydrochlorothiazide (generic of VASERETIC)
1
fosinopril-hydrochlorothiazide tab 10/12.5mg
1
fosinopril-hydrochlorothiazide tab 20/12.5mg
1
lisinopril & hydrochlorothiazide (generic of ZESTORETIC)
1
quinapril-hydrochlorothiazide (generic of ACCURETIC)
1
trandolapril-verapamil hcl 1
trandolapril-verapamil hcl (generic of TARKA)
1
ACE INHIBITORS benazepril hcl TABS 5mg 1
benazepril hcl (generic of LOTENSIN) TABS 10mg, 20mg, 40mg
1
captopril TABS 1
enalapril maleate (generic of VASOTEC) TABS
1
EPANED 3 NDS
fosinopril sodium 1
lisinopril (generic of ZESTRIL) TABS 2.5mg, 5mg, 30mg, 40mg
1
lisinopril (generic of PRINIVIL) TABS 10mg, 20mg
1
moexipril hcl 1
perindopril erbumine 1
QBRELIS 3 NDS
quinapril hcl (generic of ACCUPRIL)
1
ramipril (generic of ALTACE) 1
trandolapril 1mg, 2mg 1
trandolapril (generic of MAVIK) 4mg
1
Drug Name Drug Tier
Requirements/Limits
ALDOSTERONE RECEPTOR ANTAGONISTS CAROSPIR 3
eplerenone (generic of INSPRA)
1
spironolactone (generic of ALDACTONE) TABS
1
ALPHA BLOCKERS doxazosin mesylate (generic of CARDURA) TABS
1
prazosin hcl (generic of MINIPRESS)
1
terazosin hcl 1
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil (generic of AZOR)
1
amlodipine besylate-valsartan (generic of EXFORGE)
1
amlodipine-valsartan-hydrochlorothiazide (generic of EXFORGE HCT)
1
candesartan cilexetil-hydrochlorothiazide (generic of ATACAND HCT)
1
EDARBYCLOR 3
ENTRESTO 2
irbesartan-hydrochlorothiazide (generic of AVALIDE)
1
losartan-hydrochlorothiazide tab 100-12.5mg (generic of HYZAAR)
1
losartan-hydrochlorothiazide tab 100-25mg (generic of HYZAAR)
1
losartan-hydrochlorothiazidetab 50-12.5mg (generic of HYZAAR)
1
olmesartan medoxomil-amlodipine-hydrochlorothiazide (generic of TRIBENZOR)
1
olmesartan medoxomil-hydrochlorothiazide (generic of BENICAR HCT)
1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
18
Drug Name Drug Tier
Requirements/Limits
telmisartan-amlodipine (generic of TWYNSTA)
1
telmisartan-hydrochlorothiazide (generic of MICARDIS HCT)
1
valsartan-hydrochlorothiazide (generic of DIOVAN HCT)
1
ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil (generic of ATACAND)
1
EDARBI 3
irbesartan (generic of AVAPRO)
1
losartan potassium (generic of COZAAR) TABS
1
olmesartan medoxomil (generic of BENICAR) TABS
1
telmisartan (generic of MICARDIS)
1
valsartan (generic of DIOVAN) 1
ANTIARRHYTHMICS amiodarone hcl soln 1
amiodarone tab 100mg 1
amiodarone tab 200mg 1
amiodarone tab 400mg 1
disopyramide phosphate (generic of NORPACE)
3
dofetilide (generic of TIKOSYN)
1 NM
flecainide acetate 1
MULTAQ 2
NORPACE CR 3
pacerone 1
propafenone hcl (generic of RYTHMOL SR) CP12
1
propafenone hcl TABS 1
quinidine sulfate 1
sorine (generic of BETAPACE) 80mg, 120mg, 160mg
1
sorine 240mg 1
sotalol hcl (generic of BETAPACE) 80mg, 120mg, 160mg
1
sotalol hcl 240mg 1
Drug Name Drug Tier
Requirements/Limits
sotalol hcl (afib/afl) (generic of BETAPACE AF)
1
SOTYLIZE 3
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 3 NDS
atorvastatin calcium (generic of LIPITOR) TABS
1
EZALLOR SPRINKLE 3
FLOLIPID 3
fluvastatin sodium CAPS 1
fluvastatin sodium (generic of LESCOL XL) TB24
1
LIVALO 3
lovastatin 1
pravastatin sodium 10mg, 80mg
1
pravastatin sodium (generic of PRAVACHOL) 20mg, 40mg
1
rosuvastatin calcium (generic of CRESTOR)
1
simvastatin (generic of ZOCOR) TABS 5mg, 10mg, 20mg, 40mg
1
simvastatin (generic of ZOCOR) TABS 80mg
QL (30 tabs / 30 days)
1 QL
ZYPITAMAG 3
ANTILIPEMICS, MISCELLANEOUS ANTARA 3
cholestyramine (generic of QUESTRAN)
1
cholestyramine light pack 1
cholestyramine light powd (generic of QUESTRAN LIGHT)
1
choline fenofibrate (generic of TRILIPIX)
1
colesevelam hcl (generic of WELCHOL)
1
colestipol hcl gran (generic of COLESTID)
1
colestipol hcl pack (generic of COLESTID)
1
colestipol hcl tabs (generic of COLESTID)
1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
19
Drug Name Drug Tier
Requirements/Limits
ezetimibe (generic of ZETIA) 1
ezetimibe-simvastatin (generic of VYTORIN)
1
fenofibrate CAPS 1
fenofibrate (generic of TRICOR) TABS 48mg, 145mg
1
fenofibrate TABS 54mg, 160mg
1
fenofibrate micronized 1
gemfibrozil (generic of LOPID) TABS
1
JUXTAPID 3 NDS NM LA PA
NEXLETOL QL (30 tabs / 30 days)
3 QL PA
NEXLIZET QL (30 tabs / 30 days)
3 QL PA
niacin (antihyperlipidemic) 1
niacin er (antihyperlipidemic) (generic of NIASPAN)
1
niacor 1
omega-3-acid ethyl esters (generic of LOVAZA)
1 PA
PRALUENT 2 NM PA
prevalite PACK 1
prevalite (generic of QUESTRAN LIGHT) POWD
1
TRIGLIDE 3
VASCEPA 2
BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone (generic of TENORETIC 50)
1
atenolol & chlorthalidone (generic of TENORETIC 100)
1
bisoprolol & hydrochlorothiazide (generic of ZIAC)
1
metoprolol & hydrochlorothiazide
1
metoprolol & hydrochlorothiazide (generic of LOPRESSOR HCT)
1
propranolol & hydrochlorothiazide
1
Drug Name Drug Tier
Requirements/Limits
BETA-BLOCKERS acebutolol hcl CAPS 1
atenolol (generic of TENORMIN) TABS
1
betaxolol hcl 1
bisoprolol fumarate 1
BYSTOLIC 2
carvedilol (generic of COREG) 1
carvedilol er (generic of COREG CR)
1
KAPSPARGO SPRINKLE 3
labetalol hcl SOLN; TABS 1
metoprolol succinate (generic of TOPROL XL)
1
metoprolol tartrate SOCT 1
metoprolol tartrate SOLN 1
metoprolol tartrate TABS 25mg, 37.5mg, 75mg
1
metoprolol tartrate (generic of LOPRESSOR) TABS 50mg, 100mg
1
nadolol (generic of CORGARD) TABS
1
pindolol 1
propranolol cap er (generic of INDERAL LA)
1
propranolol inj 1mg/ml 1
propranolol oral sol 1
propranolol tab 1
timolol maleate TABS 1
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate-atorvastatin calcium
1
amlodipine besylate-atorvastatin calcium (generic of CADUET)
1
CALCIUM CHANNEL BLOCKERS amlodipine besylate (generic of NORVASC) TABS
1
CARDIZEM LA 120mg 3
cartia xt (generic of CARDIZEM CD)
1
dilt-xr 1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
20
Drug Name Drug Tier
Requirements/Limits
diltiazem cd (generic of CARDIZEM CD)
1
diltiazem er tab 180mg (generic of CARDIZEM LA)
1
diltiazem er tab 240mg (generic of CARDIZEM LA)
1
diltiazem er tab 300mg (generic of CARDIZEM LA)
1
diltiazem er tab 360mg (generic of CARDIZEM LA)
1
diltiazem er tab 420mg (generic of CARDIZEM LA)
1
diltiazem hcl (generic of CARDIZEM) TABS 30mg, 60mg, 120mg
1
diltiazem hcl TABS 90mg 1
diltiazem hcl cap er/12hr 1
diltiazem hcl coated beads (generic of CARDIZEM CD)
1
diltiazem hcl coated beads cap sr 24hr (generic of CARDIZEM CD) 120mg
1
diltiazem hcl coated beads cap sr 24hr (generic of TIAZAC) 120mg
1
diltiazem hcl extended release beads cap sr (generic of TIAZAC) 180mg, 240mg, 300mg, 360mg, 420mg
1
diltiazem hcl extended release beads cap sr (generic of CARDIZEM CD) 180mg, 300mg
1
diltiazem inj 1
felodipine 1
isradipine 1
KATERZIA 3
matzim la (generic of CARDIZEM LA)
1
nicardipine hcl CAPS 1
NICARDIPINE HYDROCHLORIDE SOLN
3
nifedipine TB24 30mg, 60mg, 90mg
1
Drug Name Drug Tier
Requirements/Limits
nifedipine (generic of PROCARDIA XL) TB24 30mg, 60mg, 90mg
1
nimodipine CAPS 3 NDS
nisoldipine (generic of SULAR) 8.5mg, 17mg, 34mg
1
nisoldipine 20mg, 25.5mg, 30mg, 40mg
1
NYMALIZE 3 NDS
taztia xt (generic of TIAZAC) 1
tiadylt er (generic of TIAZAC) 1
verapamil hcl (generic of VERELAN PM) CP24 100mg, 200mg
1
verapamil hcl (generic of VERELAN) CP24 120mg, 180mg, 240mg
1
verapamil hcl CP24 300mg, 360mg
1
verapamil hcl SOLN 1
verapamil hcl TABS 1
verapamil hcl (generic of CALAN SR) TBCR 120mg, 240mg
1
verapamil hcl TBCR 180mg 1
DIGITALIS GLYCOSIDES digitek (generic of LANOXIN) .25mg
PA if 70 years and older
1 PA
digitek (generic of LANOXIN) .125mg
QL (30 tabs / 30 days)
1 QL
digox (generic of LANOXIN) 125mcg
QL (30 tabs / 30 days)
1 QL
digox (generic of LANOXIN) 250mcg
PA if 70 years and older
1 PA
digoxin (generic of LANOXIN) TABS 125mcg
QL (30 tabs / 30 days)
1 QL
digoxin (generic of LANOXIN) TABS 250mcg
PA if 70 years and older
1 PA
digoxin inj (generic of LANOXIN)
1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
21
Drug Name Drug Tier
Requirements/Limits
digoxin sol 50mcg/ml PA if 70 years and older
1 PA
LANOXIN PEDIATRIC INJ 3
LANOXIN TABS 62.5MCG QL (60 tabs / 30 days)
2 QL
DIURETICS acetazolamide CP12; TABS 1
ALDACTAZIDE 3
amiloride & hydrochlorothiazide
1
amiloride hcl TABS 1
bumetanide SOLN 1
bumetanide (generic of BUMEX) TABS
1
chlorothiazide TABS 1
chlorthalidone 1
DIURIL 3
ethacrynic acid (generic of EDECRIN)
3 NDS
furosemide SOLN 1
furosemide (generic of LASIX) TABS
1
furosemide oral soln 8 mg/ml 1
furosemide oral soln 10 mg/ml 1
hydrochlorothiazide CAPS; TABS
1
indapamide 1
KEVEYIS 3 NDS NM PA
methazolamide TABS 1
metolazone 1
spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE)
1
torsemide 1
triamterene & hydrochlorothiazide cap 37.5-25mg (generic of DYAZIDE)
1
triamterene & hydrochlorothiazide tab 37.5-25mg (generic of MAXZIDE-25)
1
Drug Name Drug Tier
Requirements/Limits
triamterene & hydrochlorothiazide tab 75-50mg (generic of MAXZIDE)
1
MISCELLANEOUS aliskiren fumarate (generic of TEKTURNA)
1
BIDIL 2
clonidine hcl (generic of CATAPRES) TABS
1
clonidine hcl ptwk (generic of CATAPRES-TTS-1) .1mg/24hr
1
clonidine hcl ptwk (generic of CATAPRES-TTS-2) .2mg/24hr
1
clonidine hcl ptwk (generic of CATAPRES-TTS-3) .3mg/24hr
1
CORLANOR SOL 5MG/5ML 3
CORLANOR TAB 5MG 2
CORLANOR TAB 7.5MG 2
DEMSER 3 NDS PA
hydralazine hcl SOLN; TABS 1
midodrine hcl 1
minoxidil TABS 1
NORTHERA 100mg QL (90 caps / 30 days)
3 NDS QL NM LA PA
NORTHERA 200mg, 300mg QL (180 caps / 30 days)
3 NDS QL NM LA PA
phenoxybenzamine hcl (generic of DIBENZYLINE) CAPS
3 NDS PA
ranolazine (generic of RANEXA)
1
TEKTURNA HCT 2
VYNDAMAX QL (30 caps / 30 days)
3 NDS QL NM LA PA
VYNDAQEL 3 NDS NM LA PA
NITRATES DILATRATE SR 3
isosorbide dinitrate (generic of ISORDIL TITRADOSE) 5mg
1
isosorbide dinitrate 10mg, 20mg, 30mg
1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
22
Drug Name Drug Tier
Requirements/Limits
isosorbide dinitrate (generic of ISORDIL TITRADOSE) 40mg
3 NDS
isosorbide mononitrate 1
isosorbide mononitrate er 1
minitran (generic of NITRO-DUR)
1
NITRO-BID 2
NITRO-DUR .3mg/hr, .8mg/hr
2
nitroglycerin (generic of NITROLINGUAL PUMPSPRAY) SOLN .4mg/spray
1
nitroglycerin (generic of NITROSTAT) SUBL
1
nitroglycerin td patch 1
PULMONARY ARTERIAL HYPERTENSION ADEMPAS 3 NDS NM LA
PA
alyq (generic of ADCIRCA) 3 NDS NM PA
ambrisentan (generic of LETAIRIS)
3 NDS NM LA PA
bosentan (generic of TRACLEER)
3 NDS NM LA PA
epoprostenol sodium (generic of FLOLAN)
3 NDS B/D NM LA
FLOLAN 3 NDS B/D NM LA
OPSUMIT 3 NDS NM LA PA
ORENITRAM .25mg, 1mg, 2.5mg, 5mg
3 NDS NM LA PA
ORENITRAM .125mg 2 NM LA PA
sildenafil citrate (pulmonary hypertension) (generic of REVATIO)
3 NDS NM PA
sildenafil citrate tab 20 mg (pulmonary hypertension) (generic of REVATIO)
1 NM PA
tadalafil (pulmonary hypertension) (generic of ADCIRCA)
3 NDS NM PA
TRACLEER TBSO 3 NDS NM LA PA
treprostinil 3 NDS NM LA PA
Drug Name Drug Tier
Requirements/Limits
TYVASO 3 NDS NM PA
UPTRAVI 3 NDS NM LA PA
VELETRI 3 NDS B/D NM LA
VENTAVIS 3 NDS NM PA
CENTRAL NERVOUS SYSTEM ANTIANXIETY ALPRAZOLAM INTENSOL
QL (300 mL / 30 days) 3 QL
alprazolam tab 0.5mg (generic of XANAX)
QL (150 tabs / 30 days)
1 QL
alprazolam tab 0.25mg (generic of XANAX)
QL (150 tabs / 30 days)
1 QL
alprazolam tab 1mg (generic of XANAX)
QL (150 tabs / 30 days)
1 QL
alprazolam tab 2mg (generic of XANAX)
QL (150 tabs / 30 days)
1 QL
buspirone hcl TABS 1
fluvoxamine cap er 100mg QL (90 caps / 30 days)
1 QL
fluvoxamine cap er 150mg QL (60 caps / 30 days)
1 QL
fluvoxamine tab 25mg 1
fluvoxamine tab 50mg 1
fluvoxamine tab 100mg 1
lorazepam (generic of ATIVAN) SOLN
1
lorazepam (generic of ATIVAN) TABS
QL (150 tabs / 30 days)
1 QL
lorazepam intensol QL (150 mL / 30 days)
1 QL
ANTICONVULSANTS APTIOM 3 NDS
BANZEL 3 NDS PA
BRIVIACT INJ 50MG/5ML 3 PA
BRIVIACT SOL 10MG/ML 3 NDS PA
BRIVIACT TAB 10MG 3 NDS PA
BRIVIACT TAB 25MG 3 NDS PA
BRIVIACT TAB 50MG 3 NDS PA
BRIVIACT TAB 75MG 3 NDS PA
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
23
Drug Name Drug Tier
Requirements/Limits
BRIVIACT TAB 100MG 3 NDS PA
carbamazepine CHEW 1
carbamazepine (generic of CARBATROL) CP12
1
carbamazepine (generic of TEGRETOL) SUSP; TABS
1
carbamazepine (generic of TEGRETOL-XR) TB12
1
CELONTIN 3
clobazam (generic of ONFI) 1 PA
clonazepam (generic of KLONOPIN) TABS 2mg
QL (300 tabs / 30 days)
1 QL
clonazepam (generic of KLONOPIN) TABS .5mg, 1mg
QL (90 tabs / 30 days)
1 QL
clonazepam TBDP 2mg QL (300 tabs / 30 days)
1 QL
clonazepam TBDP .125mg, .25mg, .5mg, 1mg
QL (90 tabs / 30 days)
1 QL
clorazepate dipotassium QL (180 tabs / 30 days)
PA if 65 years and older
1 QL PA
DIASTAT ACUDIAL 3
DIASTAT PEDIATRIC 3
diazepam (generic of VALIUM) TABS
QL (120 tabs / 30 days) PA if 65 years and older
1 QL PA
diazepam gel 1
diazepam inj 1
diazepam intensol 5mg/ml QL (240 mL / 30 days)
PA if 65 years and older
1 QL PA
diazepam oral soln 1 mg/ml QL (1200 mL / 30 days)
PA if 65 years and older
1 QL PA
DILANTIN CAP 30MG 3
DILANTIN CAP 100MG 3
DILANTIN CHEW TAB 50MG 3
DILANTIN-125 SUSP 3
divalproex sodium (generic of DEPAKOTE SPRINKLES) CSDR
1
Drug Name Drug Tier
Requirements/Limits
divalproex sodium (generic of DEPAKOTE ER) TB24
1
divalproex sodium (generic of DEPAKOTE) TBEC
1
EPIDIOLEX QL (600 mL / 30 days)
3 NDS QL NM LA PA
epitol (generic of TEGRETOL) 1
ethosuximide (generic of ZARONTIN) CAPS; SOLN
1
felbamate (generic of FELBATOL) SUSP
3 NDS
felbamate (generic of FELBATOL) TABS
1
FYCOMPA SUSP 3 NDS PA
FYCOMPA TABS 2mg 2 PA
FYCOMPA TABS 4mg, 6mg, 8mg, 10mg, 12mg
3 NDS PA
gabapentin (generic of NEURONTIN) CAPS 100mg
QL (1080 caps / 30 days)
1 QL
gabapentin (generic of NEURONTIN) CAPS 300mg
QL (360 caps / 30 days)
1 QL
gabapentin (generic of NEURONTIN) CAPS 400mg
QL (270 caps / 30 days)
1 QL
gabapentin (generic of NEURONTIN) SOLN
QL (2160 mL / 30 days)
1 QL
gabapentin (generic of NEURONTIN) TABS 600mg
QL (180 tabs / 30 days)
1 QL
gabapentin (generic of NEURONTIN) TABS 800mg
QL (120 tabs / 30 days)
1 QL
LAMICTAL ODT KIT 3
LAMICTAL XR KIT 3
lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW
1
lamotrigine (generic of LAMICTAL STARTER/NOT TAKI) KIT
1
lamotrigine (generic of LAMICTAL STARTER/TAKING C) KIT
1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
24
Drug Name Drug Tier
Requirements/Limits
lamotrigine (generic of LAMICTAL STARTER/TAKING V) KIT 25mg
1
lamotrigine (generic of LAMICTAL) TABS
1
lamotrigine (generic of LAMICTAL XR) TB24
1
lamotrigine (generic of LAMICTAL ODT) TBDP
1
levetiracetam (generic of KEPPRA) SOLN; TABS
1
levetiracetam (generic of KEPPRA XR) TB24
1
levetiracetam in sodium chloride (generic of LEVETIRACETAM)
1
levetiracetam oral soln 100 mg/ml (generic of KEPPRA)
1
NAYZILAM 3
oxcarbazepine (generic of TRILEPTAL)
1
OXTELLAR XR 150mg, 300mg
2
OXTELLAR XR 600mg 3 NDS
PEGANONE 3
phenobarbital ELIX PA if 70 years and older
3 PA
phenobarbital TABS PA if 70 years and older
2 PA
phenobarbital sodium SOLN PA if 70 years and older
3 PA
PHENYTEK 3
phenytoin (generic of DILANTIN INFATABS) CHEW
1
phenytoin (generic of DILANTIN-125) SUSP
1
phenytoin sodium extended (generic of DILANTIN) 100mg
1
phenytoin sodium extended (generic of PHENYTEK) 200mg, 300mg
1
phenytoin sodium inj 50mg/ml 1
Drug Name Drug Tier
Requirements/Limits
pregabalin (generic of LYRICA) CAPS 25mg, 50mg, 75mg, 100mg, 150mg
QL (120 caps / 30 days)
1 QL PA
pregabalin (generic of LYRICA) CAPS 200mg
QL (90 caps / 30 days)
1 QL PA
pregabalin (generic of LYRICA) CAPS 225mg, 300mg
QL (60 caps / 30 days)
1 QL PA
pregabalin (generic of LYRICA) SOLN
QL (900 mL / 30 days)
1 QL PA
primidone (generic of MYSOLINE) TABS
1
roweepra (generic of KEPPRA)
1
roweepra xr (generic of KEPPRA XR)
1
SPRITAM 3
subvenite starter kit (generic of LAMICTAL STARTER/NOT TAKI)
1
subvenite starter kit (generic of LAMICTAL STARTER/TAKING C)
1
subvenite starter kit (generic of LAMICTAL STARTER/TAKING V) 25mg
1
subvenite tab (generic of LAMICTAL)
1
SYMPAZAN 5mg 3 PA
SYMPAZAN 10mg, 20mg 3 NDS PA
tiagabine hcl (generic of GABITRIL)
1
topiramate (generic of TOPAMAX SPRINKLE) CPSP
1
topiramate CS24 25mg, 50mg, 100mg, 150mg
1
topiramate CS24 200mg 3 NDS
topiramate (generic of TOPAMAX) TABS
1
TROKENDI XR 25mg, 50mg 2
TROKENDI XR 100mg, 200mg
3 NDS
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
25
Drug Name Drug Tier
Requirements/Limits
valproate sodium SOLN 1
valproic acid CAPS 1
VALTOCO 3
vigabatrin powd pack 500mg (generic of SABRIL)
QL (180 packets / 30 days)
3 NDS QL NM LA PA
vigabatrin tab 500mg (generic of SABRIL)
QL (180 tabs / 30 days)
3 NDS QL NM LA PA
vigadrone (generic of SABRIL)
QL (180 packets / 30 days)
3 NDS QL NM LA PA
VIMPAT 50mg 2
VIMPAT 100mg, 150mg, 200mg
3 NDS
VIMPAT INJ 200MG/20ML 3 NDS
VIMPAT SOL 10MG/ML 3 NDS
XCOPRI MAINTENANCE PAK 150-200MG
3 NDS
XCOPRI PAK 12.5-25MG 3
XCOPRI PAK 50-100MG 3 NDS
XCOPRI PAK 50-200MG 3 NDS
XCOPRI TABS 3 NDS
XCOPRI TITRATION PAK 150-200MG
3 NDS
zonisamide (generic of ZONEGRAN) CAPS 25mg, 100mg
1
zonisamide CAPS 50mg 1
ANTIDEMENTIA donepezil 5mg odt 1
donepezil 10mg odt 1
donepezil hydrochloride (generic of ARICEPT)
1
galantamine hydrobromide SOLN
1
galantamine hydrobromide (generic of RAZADYNE) TABS 4mg
1
galantamine hydrobromide TABS 8mg, 12mg
1
galantamine hydrobromide er (generic of RAZADYNE ER)
1
Drug Name Drug Tier
Requirements/Limits
memantine hcl cp24 (generic of NAMENDA XR)
PA if < 30 yrs
1 PA
memantine soln PA if < 30 yrs
1 PA
memantine tabs (generic of NAMENDA)
PA if < 30 yrs
1 PA
memantine titration pak (generic of NAMENDA TITRATION PAK)
PA if < 30 yrs
1 PA
NAMENDA XR TITRATION PACK
PA if < 30 yrs
3 PA
NAMZARIC 2
rivastigmine tartrate 1
rivastigmine td patch 24hr 4.6mg/24hr (generic of EXELON)
1
rivastigmine td patch 24hr 9.5mg/24hr (generic of EXELON)
1
rivastigmine td patch 24hr 13.3mg/24hr (generic of EXELON)
1
ANTIDEPRESSANTS amitriptyline hcl TABS 2
amoxapine 2
bupropion hcl TABS 1
bupropion hcl (generic of WELLBUTRIN SR) TB12
1
bupropion hcl (generic of WELLBUTRIN XL) TB24 150mg, 300mg
1
bupropion hcl TB24 450mg QL (30 tabs / 30 days)
1 QL
citalopram hydrobromide SOLN
1
citalopram hydrobromide (generic of CELEXA) TABS
1
clomipramine hcl (generic of ANAFRANIL) CAPS
3 PA
desipramine hcl (generic of NORPRAMIN) TABS 10mg, 25mg
3
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
26
Drug Name Drug Tier
Requirements/Limits
desipramine hcl TABS 50mg, 75mg, 100mg, 150mg
3
DESVENLAFAXINE ER 3
desvenlafaxine succinate (generic of PRISTIQ)
1 PA
doxepin hcl CAPS; CONC 2
DRIZALMA SPRINKLE 20mg, 30mg, 60mg
QL (60 caps / 30 days)
3 QL PA
DRIZALMA SPRINKLE 40mg
QL (90 caps / 30 days)
3 QL PA
duloxetine cap 20mg (generic of CYMBALTA)
QL (60 caps / 30 days)
1 QL
duloxetine cap 30mg (generic of CYMBALTA)
QL (60 caps / 30 days)
1 QL
duloxetine cap 40mg QL (90 caps / 30 days)
1 QL
duloxetine cap 60mg (generic of CYMBALTA)
QL (60 caps / 30 days)
1 QL
EMSAM 3 NDS PA
escitalopram oxalate SOLN 1
escitalopram oxalate (generic of LEXAPRO) TABS
1
FETZIMA 2 PA
FETZIMA TITRATION PACK 2 PA
fluoxetine hcl (generic of PROZAC) CAPS
1
fluoxetine hcl CPDR 1
fluoxetine hcl SOLN 1
fluoxetine hcl TABS 10mg, 20mg
1
fluoxetine hcl (generic of FLUOXETINE HYDROCHLORIDE) TABS 60mg
1
imipramine hcl TABS 1
imipramine pamoate 3
maprotiline hcl 1
MARPLAN TAB 10MG 3
mirtazapine tab 15mg odt (generic of REMERON SOLTAB)
1
Drug Name Drug Tier
Requirements/Limits
mirtazapine tab 30mg odt (generic of REMERON SOLTAB)
1
mirtazapine tab 45mg odt (generic of REMERON SOLTAB)
1
mirtazapine tabs 7.5mg, 45mg
1
mirtazapine tabs (generic of REMERON) 15mg, 30mg
1
nefazodone hcl 1
nortriptyline hcl (generic of PAMELOR) CAPS
1
nortriptyline hcl SOLN 3
paroxetine er tab (generic of PAXIL CR)
QL (60 tabs / 30 days)
3 QL
paroxetine hcl tabs (generic of PAXIL)
1
PAXIL SUSP 3
PEXEVA 10mg, 30mg QL (60 tabs / 30 days)
3 QL
PEXEVA 20mg, 40mg QL (30 tabs / 30 days)
3 QL
phenelzine sulfate (generic of NARDIL) TABS
1
protriptyline hcl 3
sertraline hcl (generic of ZOLOFT) CONC; TABS
1
tranylcypromine sulfate (generic of PARNATE)
1
trazodone hcl TABS 1
trimipramine maleate CAPS 3
TRINTELLIX 2
venlafaxine cap er (generic of EFFEXOR XR)
1
venlafaxine tab 1
venlafaxine tab 225mg er 1
VIIBRYD STARTER PACK 2
VIIBRYD TAB 2
ANTIPARKINSONIAN AGENTS amantadine hcl CAPS
QL (120 caps / 30 days) 1 QL
amantadine hcl SYRP; TABS
1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
27
Drug Name Drug Tier
Requirements/Limits
APOKYN QL (20 cartridges / 30 days)
3 NDS QL NM LA PA
benztropine mesylate inj (generic of COGENTIN)
1
benztropine mesylate tab 0.5mg
PA if 70 years and older
2 PA
benztropine mesylate tab 1mg PA if 70 years and older
2 PA
benztropine mesylate tab 2mg PA if 70 years and older
2 PA
bromocriptine mesylate (generic of PARLODEL) CAPS; TABS
1
carbidopa (generic of LODOSYN) TABS
3 NDS
carbidopa-levodopa (generic of SINEMET) TABS
1
carbidopa-levodopa TBCR; TBDP
1
carbidopa-levodopa-entacapone
1
carbidopa-levodopa-entacapone (generic of STALEVO 100)
1
carbidopa-levodopa-entacapone (generic of STALEVO 150)
1
DUOPA 3 NDS B/D NM
entacapone (generic of COMTAN)
1
GOCOVRI QL (60 caps / 30 days)
3 NDS QL NM LA PA
INBRIJA 3 NDS NM LA PA
NEUPRO 2
NOURIANZ QL (30 tabs / 30 days)
3 NDS QL NM
OSMOLEX ER T4PK QL (60 tabs / 30 days)
3 QL NM PA
OSMOLEX ER TB24 QL (30 tabs / 30 days)
3 QL NM PA
pramipexole er (generic of MIRAPEX ER)
1
pramipexole tab 0.5mg (generic of MIRAPEX)
1
pramipexole tab 0.25mg 1
Drug Name Drug Tier
Requirements/Limits
pramipexole tab 0.75mg (generic of MIRAPEX)
1
pramipexole tab 0.125mg (generic of MIRAPEX)
1
pramipexole tab 1.5mg 1
pramipexole tab 1mg (generic of MIRAPEX)
1
rasagiline mesylate (generic of AZILECT) TABS
1
ropinirole er 2mg, 4mg, 8mg 1
ropinirole er (generic of REQUIP XL) 6mg, 12mg
1
ropinirole tab 0.5mg 1
ropinirole tab 0.25mg 1
ropinirole tab 1mg 1
ropinirole tab 2mg 1
ropinirole tab 3mg 1
ropinirole tab 4mg 1
ropinirole tab 5mg 1
RYTARY 3
selegiline hcl CAPS; TABS 1
trihexyphenidyl hcl PA if 70 years and older
2 PA
XADAGO 3 NDS
ZELAPAR 3 NDS
ANTIPSYCHOTICS ABILIFY MAINTENA
QL (1 injection / 28 days)
3 NDS QL
ABILIFY MYCITE QL (30 tabs / 30 days)
3 NDS QL PA
aripiprazole odt QL (60 tabs / 30 days)
3 NDS QL
aripiprazole oral solution 1 mg/ml
QL (900 mL / 30 days)
3 NDS QL
aripiprazole tabs (generic of ABILIFY)
QL (30 tabs / 30 days)
1 QL
ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml
QL (1 injection / 28 days)
3 NDS QL
ARISTADA 1064mg/3.9ml QL (1 injection / 56 days)
3 NDS QL
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
28
Drug Name Drug Tier
Requirements/Limits
ARISTADA INITIO 3 NDS
CAPLYTA QL (30 caps / 30 days)
2 QL
chlorpromazine hcl TABS 1
CHLORPROMAZINE INJ 3
clozapine odt 12.5mg, 25mg 1 PA
clozapine odt 100mg QL (270 tabs / 30 days)
1 QL PA
clozapine odt 150mg QL (180 tabs / 30 days)
1 QL PA
clozapine odt 200mg QL (135 tabs / 30 days)
1 QL PA
clozapine tab 25mg (generic of CLOZARIL)
1
clozapine tab 50mg (generic of CLOZARIL)
1
clozapine tab 100mg (generic of CLOZARIL)
QL (270 tabs / 30 days)
1 QL
clozapine tab 200mg (generic of CLOZARIL)
QL (135 tabs / 30 days)
1 QL
FANAPT QL (60 tabs / 30 days)
3 QL PA
FANAPT TITRATION PACK 3 PA
fluphenazine decanoate SOLN
1
fluphenazine hcl 1
GEODON INJ QL (6 mL / 3 days)
3 QL
haloperidol TABS 1
haloperidol conc 2mg/ml 1
haloperidol decanoate (generic of HALDOL DECANOATE 50) SOLN 50mg/ml
1
haloperidol decanoate (generic of HALDOL DECANOATE 100) SOLN 100mg/ml
1
haloperidol lactate inj 5mg/ml (generic of HALDOL)
1
INVEGA SUSTENNA 39mg/0.25ml
QL (1 injection / 28 days)
3 QL
Drug Name Drug Tier
Requirements/Limits
INVEGA SUSTENNA 78mg/0.5ml, 117mg/0.75ml, 156mg/ml, 234mg/1.5ml
QL (1 injection / 28 days)
3 NDS QL
INVEGA TRINZA QL (1 injection / 90 days)
3 NDS QL
LATUDA 20mg, 40mg, 60mg, 120mg
QL (30 tabs / 30 days)
2 QL
LATUDA 80mg QL (60 tabs / 30 days)
2 QL
loxapine succinate 1
molindone hcl 1
NUPLAZID CAPS QL (30 caps / 30 days)
3 NDS QL NM LA PA
NUPLAZID TABS 10MG QL (30 tabs / 30 days)
3 NDS QL NM LA PA
olanzapine (generic of ZYPREXA) SOLR
QL (3 vials / 1 day)
1 QL
olanzapine (generic of ZYPREXA) TABS 2.5mg, 5mg, 10mg
QL (60 tabs / 30 days)
1 QL
olanzapine (generic of ZYPREXA) TABS 7.5mg, 15mg, 20mg
QL (30 tabs / 30 days)
1 QL
olanzapine odt (generic of ZYPREXA ZYDIS) 5mg, 15mg, 20mg
QL (30 tabs / 30 days)
1 QL
olanzapine odt (generic of ZYPREXA ZYDIS) 10mg
QL (60 tabs / 30 days)
1 QL
paliperidone (generic of INVEGA) 1.5mg, 3mg, 9mg
QL (30 tabs / 30 days)
1 QL
paliperidone (generic of INVEGA) 6mg
QL (60 tabs / 30 days)
1 QL
perphenazine TABS 1
PERSERIS QL (1 injection / 30 days)
3 NDS QL
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
29
Drug Name Drug Tier
Requirements/Limits
pimozide 1
quetiapine fumarate (generic of SEROQUEL) TABS
1
quetiapine fumarate (generic of SEROQUEL XR) TB24 50mg, 300mg, 400mg
QL (60 tabs / 30 days)
1 QL PA
quetiapine fumarate (generic of SEROQUEL XR) TB24 150mg, 200mg
QL (30 tabs / 30 days)
1 QL PA
REXULTI 3mg, 4mg QL (30 tabs / 30 days)
3 NDS QL
REXULTI .25mg, .5mg, 1mg, 2mg
QL (60 tabs / 30 days)
3 NDS QL
RISPERDAL INJ 12.5MG QL (2 injections / 28 days)
2 QL
RISPERDAL INJ 25MG QL (2 injections / 28 days)
2 QL
RISPERDAL INJ 37.5MG QL (2 injections / 28 days)
3 NDS QL
RISPERDAL INJ 50MG QL (2 injections / 28 days)
3 NDS QL
risperidone (generic of RISPERDAL) SOLN
QL (240 mL / 30 days)
1 QL
risperidone (generic of RISPERDAL) TABS .5mg, 1mg, 2mg, 3mg, 4mg
1
risperidone TABS .25mg 1
risperidone odt 1mg, 2mg, 3mg, 4mg
QL (60 tabs / 30 days)
1 QL
risperidone odt .25mg, .5mg QL (90 tabs / 30 days)
1 QL
SAPHRIS QL (60 tabs / 30 days)
3 QL
SECUADO QL (30 patches / 30 days)
2 QL
thioridazine hcl TABS 1
thiothixene 1
Drug Name Drug Tier
Requirements/Limits
trifluoperazine hcl 1
VERSACLOZ QL (600 mL / 30 days)
3 NDS QL PA
VRAYLAR 1.5mg QL (60 caps / 30 days)
3 NDS QL PA
VRAYLAR 3mg, 4.5mg, 6mg QL (30 caps / 30 days)
3 NDS QL PA
VRAYLAR THERAPY PACK 2 PA
ziprasidone hcl (generic of GEODON)
QL (60 caps / 30 days)
1 QL
ziprasidone mesylate (generic of GEODON)
QL (6 injections / 3 days)
1 QL
ZYPREXA RELPREVV 300mg
QL (2 vials / 28 days)
3 NDS QL PA
ZYPREXA RELPREVV 405mg
QL (1 vial / 28 days)
3 NDS QL PA
ZYPREXA RELPREVV INJ 210MG
QL (2 vials / 28 days)
3 QL PA
ATTENTION DEFICIT HYPERACTIVITY DISORDER ADZENYS ER SUS 1.25MG
QL (450 ml / 30 days) 3 QL
ADZENYS XR-ODT 3.1mg, 6.3mg, 9.4mg
QL (60 tabs / 30 days)
3 QL
ADZENYS XR-ODT 12.5mg, 15.7mg, 18.8mg
QL (30 tabs / 30 days)
3 QL
amphetamine er sus 1.25mg/ml
QL (450 mL / 30 days)
1 QL
amphetamine-dextroamphetamine cap sr 24hr 5 mg (generic of ADDERALL XR)
QL (90 caps / 30 days)
1 QL
amphetamine-dextroamphetamine cap sr 24hr 10 mg (generic of ADDERALL XR)
QL (90 caps / 30 days)
1 QL
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
30
Drug Name Drug Tier
Requirements/Limits
amphetamine-dextroamphetamine cap sr 24hr 15 mg (generic of ADDERALL XR)
QL (30 caps / 30 days)
1 QL
amphetamine-dextroamphetamine cap sr 24hr 20 mg (generic of ADDERALL XR)
QL (30 caps / 30 days)
1 QL
amphetamine-dextroamphetamine cap sr 24hr 25 mg (generic of ADDERALL XR)
QL (30 caps / 30 days)
1 QL
amphetamine-dextroamphetamine cap sr 24hr 30 mg (generic of ADDERALL XR)
QL (30 caps / 30 days)
1 QL
amphetamine-dextroamphetamine tab 5 mg (generic of ADDERALL)
QL (120 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 7.5 mg (generic of ADDERALL)
QL (120 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 10 mg (generic of ADDERALL)
QL (120 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 12.5 mg (generic of ADDERALL)
QL (120 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 15 mg (generic of ADDERALL)
QL (90 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 20 mg (generic of ADDERALL)
QL (90 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 30 mg (generic of ADDERALL)
QL (60 tabs / 30 days)
1 QL
APTENSIO XR 10mg, 15mg, 20mg, 30mg
QL (60 caps / 30 days)
3 QL
Drug Name Drug Tier
Requirements/Limits
APTENSIO XR 40mg, 50mg, 60mg
QL (30 caps / 30 days)
3 QL
atomoxetine hcl (generic of STRATTERA) 10mg, 18mg, 25mg
QL (120 caps / 30 days)
1 QL
atomoxetine hcl (generic of STRATTERA) 40mg
QL (60 caps / 30 days)
1 QL
atomoxetine hcl (generic of STRATTERA) 60mg, 80mg, 100mg
QL (30 caps / 30 days)
1 QL
COTEMPLA XR-ODT QL (60 tabs / 30 days)
3 QL
DAYTRANA QL (30 patches / 30 days)
3 QL
dexmethylphenidate hcl (generic of FOCALIN XR) CP24 5mg, 10mg, 15mg, 20mg
QL (60 caps / 30 days)
1 QL
dexmethylphenidate hcl (generic of FOCALIN XR) CP24 25mg, 30mg, 35mg, 40mg
QL (30 caps / 30 days)
1 QL
dexmethylphenidate hcl (generic of FOCALIN) TABS 2.5mg, 5mg
QL (120 tabs / 30 days)
1 QL
dexmethylphenidate hcl (generic of FOCALIN) TABS 10mg
QL (60 tabs / 30 days)
1 QL
dextroamphetamine sulfate (generic of DEXEDRINE) CP24 5mg, 10mg
QL (150 caps / 30 days)
1 QL
dextroamphetamine sulfate (generic of DEXEDRINE) CP24 15mg
QL (120 caps / 30 days)
1 QL
dextroamphetamine sulfate TABS
QL (180 tabs / 30 days)
1 QL
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
31
Drug Name Drug Tier
Requirements/Limits
DYANAVEL XR QL (240 ml / 30 days)
3 QL
guanfacine er (adhd) (generic of INTUNIV)
PA if 70 years and older
2 PA
JORNAY PM 20mg, 40mg QL (60 caps / 30 days)
3 QL
JORNAY PM 60mg, 80mg, 100mg
QL (30 caps / 30 days)
3 QL
metadate er tab 20mg QL (90 tabs / 30 days)
1 QL
methylphenidate hcl CHEW QL (180 tabs / 30 days)
1 QL
methylphenidate hcl CP24 10mg, 15mg, 20mg, 30mg
QL (60 caps / 30 days)
1 QL
methylphenidate hcl (generic of RITALIN LA) CP24 10mg, 20mg, 30mg
QL (60 caps / 30 days)
1 QL
methylphenidate hcl (generic of RITALIN LA) CP24 40mg
QL (30 caps / 30 days)
1 QL
methylphenidate hcl CP24 40mg, 50mg, 60mg
QL (30 caps / 30 days)
1 QL
methylphenidate hcl CPCR 10mg, 20mg, 30mg
QL (60 caps / 30 days)
1 QL
methylphenidate hcl CPCR 40mg, 50mg, 60mg
QL (30 caps / 30 days)
1 QL
methylphenidate hcl (generic of METHYLIN) SOLN 5mg/5ml
QL (1800 mL / 30 days)
1 QL
methylphenidate hcl (generic of METHYLIN) SOLN 10mg/5ml
QL (900 mL / 30 days)
1 QL
methylphenidate hcl (generic of RITALIN) TABS 5mg, 10mg
QL (180 tabs / 30 days)
1 QL
methylphenidate hcl (generic of RITALIN) TABS 20mg
QL (90 tabs / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
methylphenidate hcl TB24 18mg, 27mg, 36mg
QL (60 tabs / 30 days)
1 QL
methylphenidate hcl TB24 54mg
QL (30 tabs / 30 days)
1 QL
methylphenidate hcl (generic of CONCERTA) TBCR 18mg, 27mg, 36mg
QL (60 tabs / 30 days)
1 QL
methylphenidate hcl (generic of CONCERTA) TBCR 54mg
QL (30 tabs / 30 days)
1 QL
methylphenidate hcl tbcr 10 mg
QL (90 tabs / 30 days)
1 QL
methylphenidate hcl tbcr 20mg
QL (90 tabs / 30 days)
1 QL
METHYLPHENIDATE HCL TBCR 72MG
QL (30 tabs / 30 days)
1 QL
MYDAYIS CAP 12.5MG QL (60 caps / 30 days)
2 QL
MYDAYIS CAP 25MG QL (60 caps / 30 days)
2 QL
MYDAYIS CAP 37.5MG QL (30 caps / 30 days)
2 QL
MYDAYIS CAP 50MG QL (30 caps / 30 days)
2 QL
QUILLICHEW ER 20mg, 30mg
QL (60 tabs / 30 days)
3 QL
QUILLICHEW ER 40mg QL (30 tabs / 30 days)
3 QL
QUILLIVANT XR QL (360 mL / 30 days)
3 QL
RELEXXII QL (30 tabs / 30 days)
1 QL
VYVANSE CAPS 10mg, 20mg, 30mg
QL (60 caps / 30 days)
2 QL
VYVANSE CAPS 40mg, 50mg, 60mg, 70mg
QL (30 caps / 30 days)
2 QL
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
32
Drug Name Drug Tier
Requirements/Limits
VYVANSE CHEW 10mg, 20mg, 30mg
QL (60 tabs / 30 days)
2 QL
VYVANSE CHEW 40mg, 50mg, 60mg
QL (30 tabs / 30 days)
2 QL
zenzedi 2.5mg, 5mg, 7.5mg, 10mg
QL (180 tabs / 30 days)
1 QL
zenzedi 15mg QL (120 tabs / 30 days)
1 QL
zenzedi 20mg QL (90 tabs / 30 days)
1 QL
zenzedi 30mg QL (60 tabs / 30 days)
1 QL
HYPNOTICS BELSOMRA
QL (30 tabs / 30 days) 2 QL
DAYVIGO QL (30 tabs / 30 days)
3 QL
doxepin hcl (sleep) (generic of SILENOR)
QL (30 tabs / 30 days)
1 QL
HETLIOZ 3 NDS NM LA PA
ramelteon (generic of ROZEREM)
QL (30 tabs / 30 days)
1 QL
temazepam (generic of RESTORIL) 7.5mg
QL (30 caps / 30 days) PA applies if 65 years and older after a 90 day supply in a calendar year
1 QL PA
temazepam (generic of RESTORIL) 15mg
QL (60 caps / 30 days) PA applies if 65 years and older after a 90 day supply in a calendar year
1 QL PA
zolpidem tartrate (generic of AMBIEN) TABS
QL (30 tabs / 30 days) PA applies if 70 years and older after a 90 day supply in a calendar year
1 QL PA
MIGRAINE
Drug Name Drug Tier
Requirements/Limits
AIMOVIG QL (1 pen / 30 days)
2 QL NM PA
almotriptan malate QL (12 tabs / 30 days)
1 QL
dihydroergotamine mesylate inj 1 mg/ml (generic of D.H.E. 45)
3 NDS
dihydroergotamine mesylate nasal spr 4 mg/ml (generic of MIGRANAL)
QL (8 mL / 30 days)
3 NDS QL PA
eletriptan hydrobromide (generic of RELPAX)
QL (12 tabs / 30 days)
1 QL
EMGALITY SOAJ QL (2 pens / 30 days)
2 QL NM PA
EMGALITY SOSY 120mg/ml QL (2 syringes / 30 days)
2 QL NM PA
ergotamine w/ caffeine (generic of CAFERGOT)
1
frovatriptan succinate (generic of FROVA)
QL (18 tabs / 30 days)
1 QL
migergot 3 NDS
naratriptan hcl (generic of AMERGE)
QL (12 tabs / 30 days)
1 QL
ONZETRA XSAIL QL (16 nosepieces / 30 days)
3 NDS QL
rizatriptan benzoate 5mg QL (18 tabs / 30 days)
1 QL
rizatriptan benzoate (generic of MAXALT) 10mg
QL (18 tabs / 30 days)
1 QL
rizatriptan benzoate odt 5mg QL (18 tabs / 30 days)
1 QL
rizatriptan benzoate odt (generic of MAXALT-MLT) 10mg
QL (18 tabs / 30 days)
1 QL
sumatriptan (generic of IMITREX) SOLN 5mg/act
QL (24 inhalers / 30 days)
1 QL
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
33
Drug Name Drug Tier
Requirements/Limits
sumatriptan (generic of IMITREX) SOLN 20mg/act
QL (12 inhalers / 30 days)
1 QL
sumatriptan inj 4mg/0.5ml (generic of IMITREX STATDOSE SYSTEM) SOAJ
QL (18 injections / 30 days)
1 QL
sumatriptan inj 4mg/0.5ml (generic of IMITREX STATDOSE REFILL) SOCT
QL (18 injections / 30 days)
1 QL
sumatriptan inj 6mg/0.5ml (generic of IMITREX STATDOSE SYSTEM) SOAJ
QL (12 injections / 30 days)
1 QL
sumatriptan inj 6mg/0.5ml (generic of IMITREX STATDOSE REFILL) SOCT
QL (12 injections / 30 days)
1 QL
sumatriptan inj 6mg/0.5ml (generic of IMITREX) SOLN
QL (12 injections / 30 days)
1 QL
sumatriptan inj 6mg/0.5ml SOSY
QL (12 injections / 30 days)
1 QL
sumatriptan succinate (generic of IMITREX) TABS
QL (12 tabs / 30 days)
1 QL
sumatriptan-naproxen sodium (generic of TREXIMET)
QL (9 tabs / 30 days)
1 QL
TOSYMRA QL (18 nasal units / 30 days)
3 QL
ZEMBRACE SYMTOUCH QL (24 pens / 30 days)
3 NDS QL
zolmitriptan (generic of ZOMIG) TABS
QL (12 tabs / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
zolmitriptan (generic of ZOMIG ZMT) TBDP
QL (12 tabs / 30 days)
1 QL
ZOMIG NASAL SPRAY QL (12 inhalers / 30 days)
2 QL
MISCELLANEOUS AUSTEDO 6mg
QL (60 tabs / 30 days) 3 NDS QL NM
PA
AUSTEDO 9mg, 12mg QL (120 tabs / 30 days)
3 NDS QL NM PA
EQUETRO 3
FIRDAPSE 3 NDS NM LA PA
GRALISE 300mg QL (180 tabs / 30 days)
2 QL PA
GRALISE 600mg QL (90 tabs / 30 days)
2 QL PA
GRALISE STARTER 2 PA
HORIZANT 3 PA
INGREZZA CAPS QL (30 caps / 30 days)
3 NDS QL NM PA
INGREZZA CPPK QL (28 caps / 28 days)
3 NDS QL NM PA
lithium carb tab 300mg 1
lithium carbonate CAPS 1
lithium carbonate (generic of LITHOBID) TBCR 300mg
1
lithium carbonate TBCR 450mg
1
LITHIUM SOLN 8MEQ/5ML 3
LYRICA CR QL (60 tabs / 30 days)
2 QL PA
NUEDEXTA QL (60 caps / 30 days)
2 QL PA
paroxetine mesylate (vasomotor) (generic of BRISDELLE)
QL (30 caps / 30 days)
3 QL
pyridostigmine bromide (generic of MESTINON) SOLN
3 NDS
pyridostigmine bromide (generic of MESTINON TIMESPAN) TBCR
1
pyridostigmine bromide tab 30 mg
1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
34
Drug Name Drug Tier
Requirements/Limits
pyridostigmine tab 60mg (generic of MESTINON)
1
RADICAVA 3 NDS NM LA PA
riluzole (generic of RILUTEK) 1
RUZURGI 3 NDS NM LA PA
SAVELLA QL (60 tabs / 30 days)
2 QL
SAVELLA TITRATION PACK 2
TEGSEDI QL (4 syringes / 28 days)
3 NDS QL NM LA PA
tetrabenazine (generic of XENAZINE) 12.5mg
QL (240 tabs / 30 days)
3 NDS QL NM PA
tetrabenazine (generic of XENAZINE) 25mg
QL (120 tabs / 30 days)
3 NDS QL NM PA
TIGLUTIK QL (600 mL / 30 days)
3 NDS QL PA
MULTIPLE SCLEROSIS AGENTS AUBAGIO
QL (30 tabs / 30 days) 3 NDS QL NM
LA PA
AVONEX QL (4 injections / 28 days)
3 NDS QL NM PA
AVONEX PEN QL (4 injections / 28 days)
3 NDS QL NM PA
BETASERON QL (14 syringes / 28 days)
3 NDS QL NM PA
dalfampridine (generic of AMPYRA) TB12
3 NDS NM PA
GILENYA CAP 0.5MG QL (28 caps / 28 days)
3 NDS QL NM PA
glatiramer acetate 20mg/ml (generic of COPAXONE)
QL (30 syringes / 30 days)
3 NDS QL NM PA
glatiramer acetate 40mg/ml (generic of COPAXONE)
QL (12 syringes / 28 days)
3 NDS QL NM PA
Drug Name Drug Tier
Requirements/Limits
glatopa (generic of COPAXONE) 20mg/ml
QL (30 syringes / 30 days)
3 NDS QL NM PA
glatopa (generic of COPAXONE) 40mg/ml
QL (12 syringes / 28 days)
3 NDS QL NM PA
LEMTRADA 3 NDS NM LA PA
MAVENCLAD PAK 10MG(4) QL (16 tabs in lifetime)
3 NDS QL NM LA PA
MAVENCLAD PAK 10MG(5) QL (20 tabs in lifetime)
3 NDS QL NM LA PA
MAVENCLAD PAK 10MG(6) QL (24 tabs in lifetime)
3 NDS QL NM LA PA
MAVENCLAD PAK 10MG(7) QL (28 tabs in lifetime)
3 NDS QL NM LA PA
MAVENCLAD PAK 10MG(8) QL (32 tabs in lifetime)
3 NDS QL NM LA PA
MAVENCLAD PAK 10MG(9) QL (36 tabs in lifetime)
3 NDS QL NM LA PA
MAVENCLAD PAK 10MG(10) QL (40 tabs in lifetime)
3 NDS QL NM LA PA
MAYZENT 2mg QL (30 tabs / 30 days)
3 NDS QL NM LA PA
MAYZENT .25mg QL (112 tabs / 28 days)
3 NDS QL NM LA PA
OCREVUS 3 NDS NM LA PA
PLEGRIDY SOPN QL (2 pens / 28 days)
3 NDS QL NM PA
PLEGRIDY SOSY QL (2 syringes / 28 days)
3 NDS QL NM PA
PLEGRIDY STARTER PACK SOPN
QL (2 pens / 28 days)
3 NDS QL NM PA
PLEGRIDY STARTER PACK SOSY
QL (2 syringes / 28 days)
3 NDS QL NM PA
REBIF QL (12 injections / 28 days)
3 NDS QL NM PA
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
35
Drug Name Drug Tier
Requirements/Limits
REBIF REBIDOSE QL (12 injections / 28 days)
3 NDS QL NM PA
REBIF REBIDOSE TITRATION
QL (12 injections / 28 days)
3 NDS QL NM PA
REBIF TITRATION PACK QL (12 injections / 28 days)
3 NDS QL NM PA
TECFIDERA 120mg QL (14 caps / 7 days)
3 NDS QL NM LA PA
TECFIDERA 240mg QL (60 caps / 30 days)
3 NDS QL NM LA PA
TECFIDERA STARTER PACK
3 NDS NM LA PA
TYSABRI 3 NDS NM LA PA
VUMERITY QL (120 caps / 30 days)
3 NDS QL NM LA PA
VUMERITY STARTER 3 NDS NM LA PA
MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 1
BOTOX 3 NDS NM PA
cyclobenzaprine hcl TABS 5mg, 10mg
PA if 70 years and older
2 PA
dantrolene sodium (generic of DANTRIUM) CAPS 25mg, 50mg
1
dantrolene sodium CAPS 100mg
1
DYSPORT 3 NM PA
MYOBLOC 3 NM PA
tizanidine hcl (generic of ZANAFLEX) CAPS
1
tizanidine tabs 2mg 1
tizanidine tabs (generic of ZANAFLEX) 4mg
1
XEOMIN INJ 50 UNITS 3 NM PA
XEOMIN INJ 100 UNITS 3 NDS NM PA
XEOMIN INJ 200 UNITS 3 NDS NM PA
NARCOLEPSY/CATAPLEXY armodafinil (generic of NUVIGIL) 50mg
QL (90 tabs / 30 days)
1 QL PA
Drug Name Drug Tier
Requirements/Limits
armodafinil (generic of NUVIGIL) 150mg, 200mg, 250mg
QL (30 tabs / 30 days)
1 QL PA
modafinil (generic of PROVIGIL) 100mg
QL (30 tabs / 30 days)
1 QL PA
modafinil (generic of PROVIGIL) 200mg
QL (60 tabs / 30 days)
1 QL PA
SUNOSI QL (30 tabs / 30 days)
2 QL PA
WAKIX 4.45mg QL (14 tabs / 7 days)
3 NDS QL NM LA PA
WAKIX 17.8mg QL (60 tabs / 30 days)
3 NDS QL NM LA PA
XYREM QL (540 mL / 30 days)
3 NDS QL NM LA PA
PSYCHOTHERAPEUTIC-MISC acamprosate calcium 1
BUNAVAIL MIS 2.1-0.3MG QL (90 films / 30 days)
2 QL
BUNAVAIL MIS 4.2-0.7MG QL (90 films / 30 days)
2 QL
BUNAVAIL MIS 6.3-1MG QL (60 films / 30 days)
2 QL
buprenorphine hcl SUBL QL (90 tabs / 30 days)
1 QL PA
buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg (generic of SUBOXONE)
QL (90 films / 30 days)
1 QL
buprenorphine hcl-naloxone hcl dihydrate 4-1mg (generic of SUBOXONE)
QL (90 films / 30 days)
1 QL
buprenorphine hcl-naloxone hcl dihydrate 8-2mg (generic of SUBOXONE)
QL (90 films / 30 days)
1 QL
buprenorphine hcl-naloxone hcl dihydrate 12-3mg (generic of SUBOXONE)
QL (60 films / 30 days)
1 QL
buprenorphine hcl-naloxone hcl sl
QL (90 tabs / 30 days)
1 QL
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
36
Drug Name Drug Tier
Requirements/Limits
bupropion hcl (smoking deterrent)
1
CHANTIX CONTINUING MONTH
2 PA
CHANTIX STARTER PACK 2 PA
CHANTIX TABS 2 PA
disulfiram (generic of ANTABUSE) TABS
1
fluoxetine hcl (pmdd) (generic of SARAFEM)
(generic of SARAFEM)
1
LUCEMYRA QL (228 tabs / 14 days)
3 NDS QL PA
naloxone inj 0.4mg/ml 1
naloxone inj 1mg/ml 1
naltrexone hcl TABS 1
NARCAN 2
NICOTROL INHALER 3
NICOTROL NS 3
SUBLOCADE 3 NDS NM
VIVITROL 3 NDS NM
ZUBSOLV SUB 0.7-0.18MG QL (90 tabs / 30 days)
2 QL
ZUBSOLV SUB 1.4-0.36MG QL (90 tabs / 30 days)
2 QL
ZUBSOLV SUB 2.9-0.71MG QL (90 tabs / 30 days)
2 QL
ZUBSOLV SUB 5.7-1.4MG QL (90 tabs / 30 days)
2 QL
ZUBSOLV SUB 8.6-2.1MG QL (60 tabs / 30 days)
2 QL
ZUBSOLV SUB 11.4-2.9MG QL (30 tabs / 30 days)
2 QL
ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 3 NDS PA
ANDRODERM QL (30 patches / 30 days)
2 QL PA
AVEED 3 NM LA PA
oxandrolone TABS 1 PA
testosterone GEL 1% QL (300 grams / 30 days)
1 QL PA
Drug Name Drug Tier
Requirements/Limits
testosterone (generic of ANDROGEL PUMP) GEL 1.62%
QL (150 grams / 30 days)
1 QL PA
testosterone (generic of FORTESTA) GEL 10mg/act
QL (120 grams / 30 days)
1 QL PA
testosterone (generic of ANDROGEL) GEL 20.25mg/1.25gm, 40.5mg/2.5gm
QL (150 grams / 30 days)
1 QL PA
testosterone (generic of ANDROGEL) GEL 25mg/2.5gm, 50mg/5gm
QL (300 grams / 30 days)
1 QL PA
testosterone cypionate (generic of DEPO-TESTOSTERONE) SOLN
1 PA
testosterone enanthate SOLN
1 PA
testosterone td soln 30 mg/act QL (180 mL / 30 days)
1 QL PA
XYOSTED 3 PA
ANTIDIABETICS, INJECTABLE BASAGLAR KWIKPEN 2
BD ALCOHOL SWABS 2
BD ULTRAFINE INSULIN SYRINGE
2
BD ULTRAFINE/NANO PEN NEEDLES
2
BYDUREON BCISE QL (4 pens / 28 days)
2 QL
BYDUREON PEN QL (4 pens / 28 days)
2 QL
BYETTA QL (1 pen / 30 days)
3 QL
FIASP 2
FIASP FLEXTOUCH 2
FIASP PENFILL 2
GAUZE PADS 2X2 2
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
37
Drug Name Drug Tier
Requirements/Limits
HUMULIN R U-500 (CONCENTRATE)
3 NDS B/D
HUMULIN R U-500 KWIKPEN 3 NDS
INSULIN PEN NEEDLES 2
INSULIN SAFETY NEEDLES 2
INSULIN SYRINGES 2
LEVEMIR 2
LEVEMIR FLEXTOUCH 2
NOVOLIN 70/30 (brand RELION not covered)
2
NOVOLIN 70/30 FLEXPEN (brand RELION not covered)
2
NOVOLIN N (brand RELION not covered)
2
NOVOLIN N FLEXPEN (brand RELION not covered)
2
NOVOLIN R (brand RELION not covered)
2
NOVOLIN R FLEXPEN (brand RELION not covered)
2
NOVOLOG 2
NOVOLOG 70/30 FLEXPEN 2
NOVOLOG FLEXPEN 2
NOVOLOG MIX 70/30 2
NOVOLOG PENFILL 2
OZEMPIC INJ 0.25 OR 0.5MG/DOSE
QL (1 pen / 28 days)
2 QL
OZEMPIC INJ 1MG/DOSE QL (2 pens / 28 days)
2 QL
SOLIQUA 100/33 QL (10 pens / 30 days)
2 QL
SYMLINPEN 60 3 NDS PA
SYMLINPEN 120 3 NDS PA
TRESIBA FLEXTOUCH 2
TRESIBA INJ 2
TRULICITY QL (4 pens / 28 days)
2 QL
VICTOZA QL (3 pens / 30 days)
2 QL
Drug Name Drug Tier
Requirements/Limits
XULTOPHY 100/3.6 QL (5 pens / 30 days)
2 QL
ANTIDIABETICS, ORAL acarbose (generic of PRECOSE) TABS
1
FARXIGA QL (30 tabs / 30 days)
2 QL
glimepiride (generic of AMARYL) 1mg, 2mg
QL (90 tabs / 30 days)
1 QL
glimepiride (generic of AMARYL) 4mg
QL (60 tabs / 30 days)
1 QL
glipizide (generic of GLUCOTROL) TABS 5mg
QL (240 tabs / 30 days)
1 QL
glipizide (generic of GLUCOTROL) TABS 10mg
QL (120 tabs / 30 days)
1 QL
glipizide er (generic of GLUCOTROL XL) 2.5mg, 5mg
QL (90 tabs / 30 days)
1 QL
glipizide er (generic of GLUCOTROL XL) 10mg
QL (60 tabs / 30 days)
1 QL
glipizide xl (generic of GLUCOTROL XL) 2.5mg, 5mg
QL (90 tabs / 30 days)
1 QL
glipizide xl (generic of GLUCOTROL XL) 10mg
QL (60 tabs / 30 days)
1 QL
glipizide-metformin 2.5-250 mg
QL (240 tabs / 30 days)
1 QL
glipizide-metformin 2.5-500 mg
QL (120 tabs / 30 days)
1 QL
glipizide-metformin 5-500mg QL (120 tabs / 30 days)
1 QL
GLYXAMBI QL (30 tabs / 30 days)
2 QL
JANUMET QL (60 tabs / 30 days)
2 QL
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
38
Drug Name Drug Tier
Requirements/Limits
JANUMET XR TAB 50-500MG
QL (60 tabs / 30 days)
2 QL
JANUMET XR TAB 50-1000 QL (60 tabs / 30 days)
2 QL
JANUMET XR TAB 100-1000 QL (30 tabs / 30 days)
2 QL
JANUVIA QL (30 tabs / 30 days)
2 QL
JARDIANCE 10mg QL (60 tabs / 30 days)
2 QL
JARDIANCE 25mg QL (30 tabs / 30 days)
2 QL
JENTADUETO QL (60 tabs / 30 days)
2 QL
JENTADUETO TAB XR 2.5-1000 MG
QL (60 tabs / 30 days)
2 QL
JENTADUETO TAB XR 5-1000 MG
QL (30 tabs / 30 days)
2 QL
metformin er 500mg QL (120 tabs / 30 days)
(generic of GLUCOPHAGE XR)
1 QL
metformin er 750mg QL (60 tabs / 30 days)
(generic of GLUCOPHAGE XR)
1 QL
metformin hcl (generic of RIOMET) SOLN
QL (780 mL / 30 days)
1 QL
metformin hcl TABS 500mg QL (150 tabs / 30 days)
1 QL
metformin hcl TABS 850mg QL (90 tabs / 30 days)
1 QL
metformin hcl TABS 1000mg QL (75 tabs / 30 days)
1 QL
miglitol (generic of GLYSET) 1
nateglinide QL (90 tabs / 30 days)
1 QL
pioglitazone hcl (generic of ACTOS)
QL (30 tabs / 30 days)
1 QL
pioglitazone hcl-glimepiride (generic of DUETACT)
QL (30 tabs / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
pioglitazone hcl-metformin hcl (generic of ACTOPLUS MET)
QL (90 tabs / 30 days)
1 QL
repaglinide 2mg QL (240 tabs / 30 days)
1 QL
repaglinide .5mg, 1mg QL (120 tabs / 30 days)
1 QL
RIOMET QL (780 mL / 30 days)
3 QL
RIOMET ER QL (600 mL / 30 days)
3 QL
RYBELSUS QL (30 tabs / 30 days)
2 QL
SYNJARDY TAB 5-500MG QL (120 tabs / 30 days)
2 QL
SYNJARDY TAB 5-1000MG QL (60 tabs / 30 days)
2 QL
SYNJARDY TAB 12.5-500MG QL (60 tabs / 30 days)
2 QL
SYNJARDY TAB 12.5-1000MG
QL (60 tabs / 30 days)
2 QL
SYNJARDY XR TAB 5-1000MG
QL (60 tabs / 30 days)
2 QL
SYNJARDY XR TAB 10-1000MG
QL (60 tabs / 30 days)
2 QL
SYNJARDY XR TAB 12.5-1000MG
QL (60 tabs / 30 days)
2 QL
SYNJARDY XR TAB 25-1000MG
QL (30 tabs / 30 days)
2 QL
TRADJENTA QL (30 tabs / 30 days)
2 QL
TRIJARDY XR TAB ER 24HR 5-2.5-1000MG
QL (60 tabs / 30 days)
2 QL
TRIJARDY XR TAB ER 24HR 10-5-1000 MG
QL (30 tabs / 30 days)
2 QL
TRIJARDY XR TAB ER 24HR 12.5-2.5-1000MG
QL (60 tabs / 30 days)
2 QL
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
39
Drug Name Drug Tier
Requirements/Limits
TRIJARDY XR TAB ER 24HR 25-5-1000 MG
QL (30 tabs / 30 days)
2 QL
XIGDUO XR TAB 2.5-1000MG
QL (60 tabs / 30 days)
2 QL
XIGDUO XR TAB 5-500MG QL (60 tabs / 30 days)
2 QL
XIGDUO XR TAB 5-1000MG QL (60 tabs / 30 days)
2 QL
XIGDUO XR TAB 10-500MG QL (30 tabs / 30 days)
2 QL
XIGDUO XR TAB 10-1000MG QL (30 tabs / 30 days)
2 QL
BISPHOSPHONATES alendronate sodium SOLN 1
alendronate sodium TABS 5mg, 10mg, 35mg, 40mg
1
alendronate sodium (generic of FOSAMAX) TABS 70mg
1
BINOSTO 3
FOSAMAX PLUS D 3
ibandronate sodium inj (generic of BONIVA)
QL (1 injection / 90 days)
1 B/D QL
ibandronate sodium tabs (generic of BONIVA)
1 B/D
PAMIDRONATE DISODIUM 6mg/ml
3 B/D
pamidronate disodium 30mg/10ml, 90mg/10ml
1 B/D
pamidronate inj 30mg 1 B/D
pamidronate inj 90mg 1 B/D
risedronate sodium (generic of ACTONEL) TABS
1
risedronate sodium (generic of ATELVIA) TBEC
1
zoledronic acid inj 4mg/100ml 1 B/D NM
zoledronic acid inj 5mg/100ml (generic of RECLAST)
1 B/D NM
zoledronic inj 4mg/5ml 1 B/D NM
ZOLEDRONIC INJ 4MG/100ML
3 B/D NM
CHELATING AGENTS CHEMET 3
Drug Name Drug Tier
Requirements/Limits
clovique (generic of SYPRINE)
3 NDS PA
deferasirox tab (generic of JADENU)
3 NDS NM PA
deferasirox tab for oral susp (generic of EXJADE)
3 NDS NM PA
deferoxamine mesylate 2gm 1 NM PA
deferoxamine mesylate (generic of DESFERAL) 500mg
1 NM PA
FERRIPROX 3 NDS NM LA PA
JADENU 180mg 3 NDS NM LA PA
JADENU SPRINKLE 3 NDS NM LA PA
kionex sus 15gm/60ml 1
LOKELMA 2
penicillamine (generic of DEPEN TITRATABS) TABS
3 NDS
sodium polystyrene sulfonate powder
1
sodium polystyrene sulfonate susp
1
sps 1
trientine hcl (generic of SYPRINE)
3 NDS PA
VELTASSA 3 NDS LA
CONTRACEPTIVES altavera tab 1
alyacen 1/35 1
amethia (generic of SEASONIQUE)
1
amethia lo (generic of LOSEASONIQUE)
1
ANNOVERA 3
apri 1
aranelle 1
ashlyna (generic of SEASONIQUE)
1
aubra 1
aviane 1
BALCOLTRA 3
balziva 1
bekyree (generic of MIRCETTE)
1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
40
Drug Name Drug Tier
Requirements/Limits
blisovi 24 fe 1
blisovi fe 1.5/30 (generic of LOESTRIN FE 1.5/30)
1
briellyn 1
camila 1
camrese lo tab (generic of LOSEASONIQUE)
1
caziant pak 1
cryselle-28 1
cyclafem 1/35 1
cyclafem 7/7/7 1
cyred tab 1
dasetta 1/35 1
dasetta 7/7/7 1
deblitane 1
DEPO-SUBQ PROVERA 104 2
desogestrel & ethinyl estradiol 1
desogestrel-ethinyl estradiol (biphasic) (generic of MIRCETTE)
1
drospirenone-ethinyl estradiol (generic of YASMIN 28)
1
drospirenone-ethinyl estradiol (generic of YAZ)
1
drospirenone-ethinyl estradiol-levomefolate calcium (generic of BEYAZ)
1
drospirenone-ethinyl estradiol-levomefolate calcium (generic of SAFYRAL)
1
ELLA 3
eluryng (generic of NUVARING)
1
emoquette 1
enpresse-28 1
enskyce 1
errin 1
estarylla tab 0.25-35 1
ethynodiol diacet & eth estrad 1
ethynodiol tab 1-50 1
etonogestrel-ethinyl estradiol (generic of NUVARING)
1
falmina 1
fayosim (generic of QUARTETTE)
1
Drug Name Drug Tier
Requirements/Limits
femynor 1
gianvi tab 3-0.02mg (generic of YAZ)
1
hailey 24 fe 1
heather 1
incassia 1
introvale 1
isibloom 1
jasmiel (generic of YAZ) 1
jolessa tab 0.15-0.03 mg 1
jolivette 1
juleber 1
junel 1.5/30 (generic of LOESTRIN 1.5/30-21)
1
junel 1/20 (generic of LOESTRIN 1/20-21)
1
junel fe 1.5/30 (generic of LOESTRIN FE 1.5/30)
1
junel fe 1/20 (generic of LOESTRIN FE 1/20)
1
junel fe 24 1
kaitlib fe (generic of GENERESS FE)
1
kariva (generic of MIRCETTE) 1
kelnor 1/35 1
kelnor 1/50 1
kurvelo 1
larin 1.5/30 (generic of LOESTRIN 1.5/30-21)
1
larin 1/20 (generic of LOESTRIN 1/20-21)
1
larin fe 1.5/30 (generic of LOESTRIN FE 1.5/30)
1
larin fe 1/20 (generic of LOESTRIN FE 1/20)
1
larissia tab 1
layolis fe chw (generic of GENERESS FE)
1
leena tab 1
lessina 1
levonest 1
levonor/ethi tab 1
levonorgestrel & eth estradiol 1
levonorgestrel-ethinyl estradiol (91-day)
1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
41
Drug Name Drug Tier
Requirements/Limits
levonorgestrel-ethinyl estradiol (91-day) (generic of LOSEASONIQUE)
1
levonorgestrel-ethinyl estradiol (91-day) (generic of QUARTETTE)
1
levonorgestrel-ethinyl estradiol (91-day) (generic of SEASONIQUE)
1
levonorgestrel-ethinyl estradiol (continuous)
1
levora 0.15/30-28 1
LO LOESTRIN FE 2
loryna (generic of YAZ) 1
low-ogestrel 1
lutera 1
lyza 1
marlissa 1
medroxyprogesterone acetate (contraceptive) (generic of DEPO-PROVERA CONTRACEPTIV)
1
melodetta 24 fe (generic of MINASTRIN 24 FE)
1
mibelas 24 fe (generic of MINASTRIN 24 FE)
1
microgestin 1.5/30 (generic of LOESTRIN 1.5/30-21)
1
microgestin 1/20 (generic of LOESTRIN 1/20-21)
1
microgestin fe 1.5/30 (generic of LOESTRIN FE 1.5/30)
1
microgestin fe 1/20 (generic of LOESTRIN FE 1/20)
1
mili 1
mono-linyah tab 0.25-35 1
NATAZIA 2
necon 0.5/35-28 1
nikki (generic of YAZ) 1
nora-be tab 1
nore/eth/fer chw 0.4mg-35 1
noreth/ethin chw fe (generic of GENERESS FE)
1
norethin acet & estrad-fe (generic of MINASTRIN 24 FE)
1
Drug Name Drug Tier
Requirements/Limits
norethindrone (contraceptive) 1
norethindrone acet & eth estra (generic of LOESTRIN 1/20-21)
1
norgest/ethi tab 0.25/35 1
norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg (generic of ORTHO TRI-CYCLEN LO)
1
norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg
1
nortrel 0.5/35 (28) 1
nortrel 1/35 1
nortrel 7/7/7 1
ocella tab 3-0.03mg (generic of YASMIN 28)
1
orsythia 1
philith 1
pimtrea (generic of MIRCETTE)
1
pirmella 1/35 1
portia-28 1
previfem 1
reclipsen 1
rivelsa (generic of QUARTETTE)
1
setlakin tab 1
sharobel 1
SLYND 3
sprintec 28 1
sronyx 1
syeda (generic of YASMIN 28) 1
tarina 24 fe 1
tarina fe 1/20 (generic of LOESTRIN FE 1/20)
1
TAYTULLA 2
tilia fe (generic of ESTROSTEP FE)
1
tri-estarylla 1
tri-legest fe (generic of ESTROSTEP FE)
1
tri-linyah 1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
42
Drug Name Drug Tier
Requirements/Limits
tri-lo- tab marzia (generic of ORTHO TRI-CYCLEN LO)
1
tri-lo-estarylla (generic of ORTHO TRI-CYCLEN LO)
1
tri-lo-sprintec (generic of ORTHO TRI-CYCLEN LO)
1
tri-mili 1
tri-previfem 1
tri-sprintec 1
tri-vylibra 1
tri-vylibra lo (generic of ORTHO TRI-CYCLEN LO)
1
trivora-28 1
tulana 1
tydemy (generic of SAFYRAL) 1
velivet 1
vienva 1
viorele (generic of MIRCETTE)
1
vyfemla 1
vylibra 1
wymzya fe 1
xulane dis 150-35 1
zarah (generic of YASMIN 28) 1
zovia 1/35e 1
ENDOMETRIOSIS danazol CAPS 1
LUPANETA PACK 3 NDS NM PA
ORILISSA 3 NDS PA
SYNAREL 3 NDS
ENZYME REPLACEMENTS ALDURAZYME 3 NDS NM LA
PA
CARBAGLU 3 NDS NM LA PA
CARNITOR SOLN 200mg/ml 3 B/D
CERDELGA 3 NDS NM PA
CEREZYME 3 NDS NM LA PA
CYSTADANE 3 NDS NM LA
CYSTAGON 3 NM LA PA
ELAPRASE 3 NDS NM LA PA
ELELYSO 3 NDS NM PA
Drug Name Drug Tier
Requirements/Limits
FABRAZYME 3 NDS NM LA PA
GALAFOLD 3 NDS NM LA PA
KANUMA 3 NDS NM LA PA
KUVAN 3 NDS NM LA PA
levocarnitine (metabolic modifiers) (generic of CARNITOR)
1 B/D
LUMIZYME 3 NDS NM LA PA
miglustat (generic of ZAVESCA)
3 NDS NM PA
NAGLAZYME 3 NDS NM LA PA
nitisinone (generic of ORFADIN)
3 NDS NM PA
NITYR 3 NDS NM LA PA
ORFADIN 3 NDS NM LA PA
PALYNZIQ 3 NDS NM LA PA
PROCYSBI 3 NDS NM LA PA
RAVICTI 3 NDS NM LA PA
REVCOVI 3 NDS NM LA PA
sodium phenylbutyrate (generic of BUPHENYL)
3 NDS NM PA
STRENSIQ 3 NDS NM LA PA
VIMIZIM 3 NDS NM PA
VPRIV 3 NDS NM PA
ESTROGENS ALORA 3
DELESTROGEN 10mg/ml 3
DEPO-ESTRADIOL 3
dotti (generic of VIVELLE-DOT)
2
estradiol (generic of VIVELLE-DOT) PTTW
2
estradiol (generic of CLIMARA) PTWK
2
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
43
Drug Name Drug Tier
Requirements/Limits
estradiol (generic of ESTRACE) TABS
1
estradiol vaginal cream (generic of ESTRACE)
1
estradiol vaginal tab (generic of VAGIFEM)
1
estradiol valerate (generic of DELESTROGEN) OIL
1
ESTRING 2
FEMRING 3
fyavolv 2
fyavolv (generic of FEMHRT LOW DOSE)
2
IMVEXXY MAINTENANCE PACK
3 PA
IMVEXXY STARTER PACK 3 PA
jinteli 2
MENEST 3
MENOSTAR 3
norethindrone acetate-ethinyl estradiol
2
norethindrone acetate-ethinyl estradiol (generic of FEMHRT LOW DOSE)
2
PREMARIN CREAM 2
PREMARIN INJ 3
PREMARIN TABS 2
PREMPHASE 2
PREMPRO 2
yuvafem vaginal tablet 10 mcg (generic of VAGIFEM)
1
GLUCOCORTICOIDS cortisone acetate TABS 1
DEPO-MEDROL 20mg/ml 3 B/D
DEXAMETHASONE CONC 3
dexamethasone ELIX; SOLN; TABS
1
dexamethasone sodium phosphate 4mg/ml, 10mg/ml, 20mg/5ml, 100mg/10ml, 120mg/30ml
1
dexamethasone sodium phosphate (generic of DEXAMETHASONE SODIUM PHOS) 10mg/ml
1
Drug Name Drug Tier
Requirements/Limits
fludrocortisone acetate TABS
1
hydrocortisone (generic of CORTEF) TABS
1
KENALOG-10 3 B/D
KENALOG-80 3 B/D
MEDROL TAB 2MG 3 B/D
methylpr ss inj (generic of SOLU-MEDROL)
1 B/D
methylpred pak 4mg (generic of MEDROL DOSEPAK)
1
methylpred tab 4mg (generic of MEDROL)
1 B/D
methylpred tab 8mg (generic of MEDROL)
1 B/D
methylpred tab 16mg (generic of MEDROL)
1 B/D
methylpred tab 32mg (generic of MEDROL)
1 B/D
methylprednisolone acetate (generic of DEPO-MEDROL)
1 B/D
pred sod pho sol 5mg/5ml (generic of PEDIAPRED)
1 B/D
prednisolone sodium phosphate SOLN
1 B/D
prednisolone sodium phosphate (generic of ORAPRED ODT) TBDP
1 B/D
prednisolone sol 15mg/5ml 1 B/D
prednisolone sol 25mg/5ml 1 B/D
PREDNISONE CON 5MG/ML 3 B/D
prednisone pak 5mg 1
prednisone pak 10mg 1
prednisone sol 5mg/5ml 1 B/D
prednisone tab 1mg 1 B/D
prednisone tab 2.5mg 1 B/D
prednisone tab 5mg 1 B/D
prednisone tab 10mg 1 B/D
prednisone tab 20mg 1 B/D
prednisone tab 50mg 1 B/D
SOLU-CORTEF 100MG 3
SOLU-CORTEF 250MG 3
SOLU-CORTEF 500MG 3
SOLU-CORTEF 1000MG 3
SOLU-MEDROL 2gm 3 B/D
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
44
Drug Name Drug Tier
Requirements/Limits
triamcinolone acetonide (generic of KENALOG-40) SUSP 40mg/ml
1 B/D
GLUCOSE ELEVATING AGENTS diazoxide (generic of PROGLYCEM) SUSP
1
GLUCAGEN HYPOKIT 2
GLUCAGON EMERGENCY KIT
2
GVOKE HYPOPEN 2-PACK 2
GVOKE PFS 2
PROGLYCEM SUS 50MG/ML 3
MISCELLANEOUS BYNFEZIA PEN 3 NDS NM PA
cabergoline 1
calcitonin (salmon) nasal spray (generic of MIACALCIN)
1 B/D
CHORIONIC GONADOTROPIN SOLR
3 NM PA
cinacalcet hcl (generic of SENSIPAR)
3 NDS B/D NM
CRYSVITA 3 NDS NM LA PA
EGRIFTA 3 NDS NM LA PA
EVENITY 3 NDS NM PA
FORTEO 3 NDS NM PA
GENOTROPIN 3 NDS NM PA
GENOTROPIN MINIQUICK .2mg
3 NM PA
GENOTROPIN MINIQUICK .4mg, .6mg, .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg
3 NDS NM PA
HUMATROPE 3 NDS NM PA
HUMATROPE COMBO PACK 3 NDS NM PA
INCRELEX 3 NDS NM LA PA
ISTURISA 3 NDS NM LA PA
JYNARQUE PAK 30-15MG 3 NDS NM LA PA
JYNARQUE PAK 45-15MG 3 NDS NM LA PA
JYNARQUE PAK 60-30MG 3 NDS NM LA PA
Drug Name Drug Tier
Requirements/Limits
JYNARQUE PAK 90-30MG 3 NDS NM LA PA
JYNARQUE TABS 3 NDS NM LA PA
KORLYM 3 NDS NM LA PA
LUPRON DEP-PED INJ 7.5MG
3 NDS NM PA
LUPRON DEP-PED INJ 11.25MG (3-MONTH)
3 NDS NM PA
LUPRON DEPOT-PED (1-MONTH
3 NDS NM PA
LUPRON DEPOT-PED (3-MONTH
3 NDS NM PA
MYALEPT 3 NDS NM LA PA
NATPARA 3 NDS NM PA
NORDITROPIN FLEXPRO 3 NDS NM PA
NOVAREL 5000unit 3 NM PA
NUTROPIN AQ NUSPIN 5 3 NDS NM LA PA
NUTROPIN AQ NUSPIN 10 3 NDS NM LA PA
NUTROPIN AQ NUSPIN 20 3 NDS NM LA PA
octreotide acetate (generic of SANDOSTATIN) 50mcg/ml
1 NM PA
octreotide acetate 200mcg/ml
1 NM PA
octreotide acetate (generic of SANDOSTATIN) 500mcg/ml
3 NDS NM PA
octreotide acetate 1000mcg/ml
3 NDS NM PA
octreotide inj 100mcg/ml (generic of SANDOSTATIN)
1 NM PA
OMNITROPE 5.8MG 3 NDS NM LA PA
OMNITROPE 5MG 3 NDS NM LA PA
OMNITROPE 10MG 3 NDS NM LA PA
OSPHENA 2 PA
PREGNYL W/DILUENT BENZYL
3 NM PA
PROLIA QL (1 injection / 180 days)
2 QL NM
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
45
Drug Name Drug Tier
Requirements/Limits
raloxifene hcl (generic of EVISTA)
1
SAIZEN 3 NDS NM LA PA
SAIZENPREP RECONSTITUTION
3 NDS NM LA PA
SAMSCA 3 NDS NM LA PA
SANDOSTATIN LAR DEPOT 3 NDS NM PA
SEROSTIM 3 NDS NM LA PA
SIGNIFOR 3 NDS NM LA PA
SIGNIFOR LAR 3 NDS NM LA PA
SOMATULINE DEPOT 3 NDS NM PA
SOMAVERT 3 NDS NM LA PA
TEPEZZA 3 NDS NM LA PA
tolvaptan (generic of SAMSCA)
3 NDS NM PA
TYMLOS 3 NDS NM PA
XGEVA 3 NDS NM PA
ZOMACTON 5mg 3 NM PA
ZOMACTON 10mg 3 NDS NM PA
ZORBTIVE 3 NDS NM PA
PHOSPHATE BINDER AGENTS AURYXIA 3 NDS PA
calcium acetate (phosphate binder) (generic of PHOSLO) CAPS
1
calcium acetate (phosphate binder) TABS
1
FOSRENOL PACK 3 NDS
lanthanum chew tab (generic of FOSRENOL)
3 NDS
PHOSLYRA 2
sevelamer carbonate (generic of RENVELA) PACK
3 NDS
sevelamer carbonate (generic of RENVELA) TABS
1
sevelamer tab 400mg 1
sevelamer tab 800mg (generic of RENAGEL)
1
VELPHORO 3 NDS
Drug Name Drug Tier
Requirements/Limits
PROGESTINS CRINONE 2 PA
medroxyprogesterone acetate (generic of PROVERA)
1
norethindrone acetate (generic of AYGESTIN) TABS
1
progesterone micronized (generic of PROMETRIUM) CAPS
1
THYROID AGENTS euthyrox (generic of SYNTHROID)
1
levo-t (generic of SYNTHROID)
1
levothyroxine sodium (generic of SYNTHROID) TABS
1
levoxyl (generic of SYNTHROID)
1
liothyronine sodium (generic of CYTOMEL) TABS
1
methimazole (generic of TAPAZOLE) TABS
1
propylthiouracil TABS 1
SYNTHROID 2
TIROSINT 3
TIROSINT-SOL 3
unithroid (generic of SYNTHROID)
1
VASOPRESSINS DDAVP SPRAY (REFRIGERATED)
2
desmopressin acetate (generic of DDAVP) TABS
1
desmopressin acetate spray (generic of DDAVP)
1
desmopressin acetate spray refrigerated
1
desmopressin inj 4mcg/ml (generic of DDAVP)
1
STIMATE 3 NDS NM
GASTROINTESTINAL ANTIEMETICS AKYNZEO CAPS 3 B/D
AKYNZEO SOLN; SOLR 3
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
46
Drug Name Drug Tier
Requirements/Limits
aprepitant (generic of EMEND) 40mg, 80mg
1 B/D
aprepitant 125mg 1 B/D
aprepitant pak 80mg & 125mg 1 B/D
BONJESTA 3
CINVANTI 3
compro 1
doxylamine-pyridoxine (generic of DICLEGIS)
1
dronabinol (generic of MARINOL)
QL (60 caps / 30 days)
1 B/D QL
EMEND SUSR 3 B/D
fosaprepitant dimeglumine (generic of EMEND)
1
granisetron hcl SOLN 1
granisetron hcl TABS 1 B/D
meclizine hcl TABS 1
metoclopramide hcl SOLN 1
metoclopramide hcl (generic of REGLAN) TABS
1
metoclopramide hcl inj 1
metoclopramide odt 5mg 1
METOCLOPRAMIDE ODT 10MG
3
ondansetron hcl (generic of ZOFRAN) TABS 4mg, 8mg
1 B/D
ondansetron hcl TABS 24mg 1 B/D
ondansetron hcl inj 1
ondansetron hcl oral soln 1 B/D
ondansetron odt 1 B/D
palonosetron hcl (generic of ALOXI) SOLN
1
palonosetron hcl SOSY 1
PALONOSETRON HYDROCHLORID 0.25MG/2ML
3
phenadoz PA if 70 years and older
3 PA
prochlorperazine inj 1
prochlorperazine maleate TABS
1
prochlorperazine supp 1
promethazine hcl SUPP PA if 70 years and older
3 PA
Drug Name Drug Tier
Requirements/Limits
promethazine hcl SYRP; TABS
PA if 70 years and older
1 PA
promethazine hcl inj (generic of PHENERGAN)
PA if 70 years and older
3 PA
promethegan PA if 70 years and older
3 PA
SANCUSO QL (4 patches / 28 days)
3 NDS QL
scopolamine (generic of TRANSDERM SCOP)
QL (10 patches / 30 days)
PA if 70 years and older
3 QL PA
SUSTOL 3
SYNDROS QL (120 mL / 30 days)
3 NDS B/D QL
VARUBI TAB 90MG 2 B/D
ZUPLENZ 3 NDS B/D
ANTISPASMODICS atropine sulfate SOSY .25mg/5ml, 1mg/10ml
3
CUVPOSA 3
dicyclomine hcl cap 10mg 2
dicyclomine hcl inj (generic of BENTYL)
3
dicyclomine hcl soln 10mg/5ml
3
dicyclomine hcl tab 20mg 2
GLYCATE 3
glycopyrrolate SOLN 1
GLYCOPYRROLATE SOSY .2mg/ml, .4mg/2ml
3
glycopyrrolate tab 1mg 1
glycopyrrolate tab 2mg 1
methscopolamine bromide TABS
PA if 70 years and older
1 PA
propantheline bromide TABS 1
H2-RECEPTOR ANTAGONISTS cimetidine TABS 1
cimetidine oral soln 1
famotidine SUSR 1
famotidine (generic of PEPCID) TABS 20mg, 40mg
1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
47
Drug Name Drug Tier
Requirements/Limits
famotidine in nacl 1
famotidine inj 1
nizatidine 1
INFLAMMATORY BOWEL DISEASE balsalazide disodium (generic of COLAZAL)
1
budesonide (generic of ENTOCORT EC) CPEP
1
budesonide (generic of UCERIS) TB24
3 NDS
colocort (generic of CORTENEMA)
1
DIPENTUM 3 NDS
ENTYVIO 3 NDS NM PA
hydrocortisone (enema) (generic of CORTENEMA)
1
mesalamine (generic of APRISO) CP24
1
mesalamine (generic of DELZICOL) CPDR
1
mesalamine (generic of CANASA) SUPP
3 NDS
mesalamine (generic of LIALDA) TBEC 1.2gm
1
mesalamine (generic of ASACOL HD) TBEC 800mg
1
mesalamine enema 1
mesalamine w/ cleanser (generic of ROWASA)
1
PENTASA 3 NDS
SFROWASA 3 NDS
sulfasalazine dr (generic of AZULFIDINE EN-TABS)
1
sulfasalazine ir (generic of AZULFIDINE)
1
UCERIS FOAM 3
LAXATIVES CLENPIQ 3
constulose 1
enulose 1
gavilyte-c 1
gavilyte-g (generic of GOLYTELY)
1
gavilyte-n/flavor pack (generic of NULYTELY)
1
generlac 1
Drug Name Drug Tier
Requirements/Limits
GOLYTELY 3
KRISTALOSE 3
lactulose SOLN 1
lactulose (encephalopathy) 1
MOVIPREP 3
NULYTELY/FLAVOR PACKS 3
OSMOPREP 3
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
1
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate (generic of GOLYTELY)
1
peg 3350-potassium chloride-sod bicarbonate-sod chloride (generic of NULYTELY)
1
PLENVU 3
SUPREP BOWEL PREP KIT 2
trilyte (generic of NULYTELY) 1
MISCELLANEOUS alosetron hcl (generic of LOTRONEX)
3 NDS PA
AMITIZA CAP 8MCG 2
AMITIZA CAP 24MCG 2
amoxicillin-clarithromycin w/ lansoprazole
1
CHOLBAM 3 NDS NM LA PA
cromolyn sodium (mastocytosis) (generic of GASTROCROM)
3 NDS
diphenoxylate w/ atropine LIQD
3
diphenoxylate w/ atropine (generic of LOMOTIL) TABS
2
GATTEX 3 NDS NM LA PA
LINZESS 3
loperamide hcl CAPS 1
LOPERAMIDE HYDROCHLORIDE SOLN
3
misoprostol (generic of CYTOTEC) TABS
1
MOTEGRITY 3
MOVANTIK 2
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
48
Drug Name Drug Tier
Requirements/Limits
OCALIVA 3 NDS NM LA PA
OMECLAMOX-PAK 3
RELISTOR 3 NDS PA
SUCRAID 3 NDS LA
sucralfate (generic of CARAFATE) SUSP; TABS
1
SYMPROIC 3
TALICIA 3
TRULANCE 3
ursodiol (generic of ACTIGALL) CAPS
1
ursodiol (generic of URSO 250) TABS 250mg
1
ursodiol (generic of URSO FORTE) TABS 500mg
1
VIBERZI 3 NDS PA
XERMELO 3 NDS NM LA PA
XIFAXAN TAB 550MG 3 NDS PA
ZELNORM QL (60 tabs / 30 days)
3 QL PA
PANCREATIC ENZYMES CREON 2
PANCREAZE 3
PERTZYE 3
VIOKACE 10 2
VIOKACE 20 3 NDS
ZENPEP 2
PROTON PUMP INHIBITORS DEXILANT
QL (30 caps / 30 days) 2 QL
esomeprazole magnesium (generic of NEXIUM) CPDR
QL (30 caps / 30 days)
1 QL ST
esomeprazole magnesium (generic of NEXIUM) PACK
QL (30 packets / 30 days)
1 QL
esomeprazole sodium inj (generic of NEXIUM I.V.)
1
lansoprazole (generic of PREVACID) CPDR
QL (30 caps / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
lansoprazole (generic of PREVACID SOLUTAB) TBDD
QL (30 tabs / 30 days)
1 QL
NEXIUM GRA 2.5MG DR 3
NEXIUM GRA 5MG DR 3
NEXIUM GRA 10MG DR QL (30 packets / 30 days)
3 QL
NEXIUM GRA 20MG DR QL (30 packets / 30 days)
3 QL
NEXIUM GRA 40MG DR QL (30 packets / 30 days)
3 QL
omeprazole cap 10mg 1
omeprazole cap 20mg 1
omeprazole cap 40mg 1
pantoprazole sodium (generic of PROTONIX) SOLR; TBEC
1
PRILOSEC 3
PROTONIX PACK QL (30 packets / 30 days)
3 QL
rabeprazole sodium (generic of ACIPHEX)
QL (30 tabs / 30 days)
1 QL
GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of UROXATRAL)
1
CARDURA XL 3
dutasteride (generic of AVODART) CAPS
1
dutasteride-tamsulosin hcl (generic of JALYN)
1
finasteride (generic of PROSCAR) TABS 5mg
1
silodosin (generic of RAPAFLO)
1
tamsulosin hcl (generic of FLOMAX)
1
MISCELLANEOUS bethanechol chloride TABS 1
ELMIRON 3 NDS
INTRAROSA 3 PA
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
49
Drug Name Drug Tier
Requirements/Limits
potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 15) 15meq
1
potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 5) 540mg
1
potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 10) 1080mg
1
THIOLA 3 NDS
THIOLA EC 3 NDS
URINARY ANTISPASMODICS darifenacin hydrobromide (generic of ENABLEX)
1
GELNIQUE 3
MYRBETRIQ 2
oxybutynin chloride SYRP 1
oxybutynin chloride TABS 1
oxybutynin chloride (generic of DITROPAN XL) TB24 5mg, 10mg
1
oxybutynin chloride TB24 15mg
1
OXYTROL 3
solifenacin succinate (generic of VESICARE)
1
tolterodine er (generic of DETROL LA)
1
tolterodine tartrate (generic of DETROL)
1
TOVIAZ 2
trospium chloride 1
VAGINAL ANTI-INFECTIVES CLEOCIN SUPP 3
clindamycin cre 2% vag (generic of CLEOCIN)
1
CLINDESSE 3
GYNAZOLE-1 3
metronidazole vaginal 1
miconazole 3 SUPP 1
terconazole vaginal 1
vandazole 1
HEMATOLOGIC ANTICOAGULANTS COUMADIN 3
Drug Name Drug Tier
Requirements/Limits
ELIQUIS 2.5mg QL (60 tabs / 30 days)
2 QL
ELIQUIS 5mg QL (74 tabs / 30 days)
2 QL
ELIQUIS STARTER PACK QL (74 tabs / 30 days)
2 QL
enoxaparin sodium (generic of LOVENOX)
1
fondaparinux sodium (generic of ARIXTRA) 2.5mg/0.5ml
1
fondaparinux sodium (generic of ARIXTRA) 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml
3 NDS
FRAGMIN 2500unit/0.2ml, 5000unit/0.2ml
2
FRAGMIN 7500unit/0.3ml, 10000unit/ml, 12500unit/0.5ml, 15000unit/0.6ml, 18000unt/0.72ml, 95000unit/3.8ml
3 NDS
heparin sod (porcine) in d5w 1
heparin sod inj 5000u/0.5ml 1 B/D
heparin sodium (porcine) 1000 u/ml
1 B/D
heparin sodium (porcine) 5000 u/ml
1 B/D
heparin sodium (porcine) 10000 u/ml
1 B/D
heparin sodium (porcine) 20000 u/ml
1 B/D
HEPARIN SODIUM INJ 5000U/0.5ML
3 B/D
HEPARIN SODIUM INJ 5000U/ML
3 B/D
HEPARIN SODIUM/NACL 0.45%
3
jantoven 1
PRADAXA QL (60 caps / 30 days)
3 QL
warfarin sodium 1
XARELTO 2.5mg QL (60 tabs / 30 days)
2 QL
XARELTO 10mg, 15mg, 20mg
QL (30 tabs / 30 days)
2 QL
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
50
Drug Name Drug Tier
Requirements/Limits
XARELTO STARTER PACK QL (51 tabs / 30 days)
2 QL
HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE SOLN 25mcg/ml, 40mcg/ml
2 NM PA
ARANESP ALBUMIN FREE SOLN 60mcg/ml, 100mcg/ml, 200mcg/ml, 300mcg/ml
3 NDS NM PA
ARANESP ALBUMIN FREE SOSY 10mcg/0.4ml, 25mcg/0.42ml, 40mcg/0.4ml
2 NM PA
ARANESP ALBUMIN FREE SOSY 60mcg/0.3ml, 100mcg/0.5ml, 150mcg/0.3ml, 200mcg/0.4ml, 300mcg/0.6ml, 500mcg/ml
3 NDS NM PA
LEUKINE 3 NDS NM PA
MOZOBIL 3 NDS NM PA
NPLATE 3 NDS NM PA
PROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml
2 NM PA
PROCRIT 20000unit/ml, 40000unit/ml
3 NDS NM PA
ZARXIO 3 NDS NM PA
MISCELLANEOUS anagrelide hcl 1mg 1
anagrelide hcl (generic of AGRYLIN) .5mg
1
BERINERT QL (24 boxes / 30 days)
3 NDS QL NM LA PA
CABLIVI 3 NDS NM LA PA
cilostazol 1
CINRYZE QL (20 vials / 30 days)
3 NDS QL NM LA PA
DOPTELET 3 NDS NM LA PA
DROXIA CAP 200MG 3
DROXIA CAP 300MG 3
DROXIA CAP 400MG 3
ENDARI 3 NDS NM LA PA
GIVLAARI 3 NDS NM LA PA
Drug Name Drug Tier
Requirements/Limits
HAEGARDA 2000unit QL (30 vials / 30 days)
3 NDS QL NM LA PA
HAEGARDA 3000unit QL (20 vials / 30 days)
3 NDS QL NM LA PA
icatibant acetate (generic of FIRAZYR)
QL (9 syringes / 30 days)
3 NDS QL NM PA
KALBITOR QL (18 mL / 30 days)
3 NDS QL NM LA PA
MULPLETA 3 NDS NM PA
OXBRYTA 3 NDS NM LA PA
pentoxifylline TBCR 1
PROMACTA PACK 12.5mg QL (360 packets / 30 days)
3 NDS QL NM LA PA
PROMACTA PACK 25mg QL (180 packets / 30 days)
3 NDS QL NM LA PA
PROMACTA TABS 12.5mg, 25mg
QL (30 tabs / 30 days)
3 NDS QL NM LA PA
PROMACTA TABS 50mg, 75mg
QL (60 tabs / 30 days)
3 NDS QL NM LA PA
REBLOZYL 3 NDS NM LA PA
RUCONEST QL (12 vials / 30 days)
3 NDS QL NM PA
SOLIRIS 3 NDS NM LA PA
TAKHZYRO QL (2 vials / 28 days)
3 NDS QL NM LA PA
TAVALISSE QL (60 tabs / 30 days)
3 NDS QL NM LA PA
tranexamic acid (generic of CYKLOKAPRON) SOLN
1
tranexamic acid (generic of LYSTEDA) TABS
1
ULTOMIRIS 3 NDS NM LA PA
PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole (generic of AGGRENOX)
1
BRILINTA 2
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
51
Drug Name Drug Tier
Requirements/Limits
clopidogrel bisulfate (generic of PLAVIX) TABS 75mg
1
clopidogrel bisulfate TABS 300mg
1
prasugrel hcl (generic of EFFIENT)
1
ZONTIVITY 3
IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) AVSOLA 3 NDS NM PA
ENBREL SOLR QL (16 vials / 28 days)
3 NDS QL NM PA
ENBREL SOSY 25mg/0.5ml QL (16 syringes / 28 days)
3 NDS QL NM PA
ENBREL SOSY 50mg/ml QL (8 syringes / 28 days)
3 NDS QL NM PA
ENBREL MINI QL (8 injections / 28 days)
3 NDS QL NM PA
ENBREL SURECLICK QL (8 injections / 28 days)
3 NDS QL NM PA
HUMIRA 10mg/0.1ml, 20mg/0.2ml
QL (2 injections / 28 days)
3 NDS QL NM PA
HUMIRA 40mg/0.4ml QL (6 injections / 28 days)
3 NDS QL NM PA
HUMIRA INJ 10MG/0.2ML QL (2 syringes / 28 days)
3 NDS QL NM PA
HUMIRA KIT 20MG/0.4ML QL (2 syringes / 28 days)
3 NDS QL NM PA
HUMIRA KIT 40MG/0.8ML QL (6 syringes / 28 days)
3 NDS QL NM PA
HUMIRA PEDIATRIC CROHNS DISEASE
3 NDS NM PA
HUMIRA PEN QL (6 pens / 28 days)
3 NDS QL NM PA
HUMIRA PEN CD/UC/HS STARTER
3 NDS NM PA
Drug Name Drug Tier
Requirements/Limits
HUMIRA PEN INJ CD/UC/HS STARTER
3 NDS NM PA
HUMIRA PEN INJ PS/UV STARTER
3 NDS NM PA
HUMIRA PEN-PS/UV STARTER
3 NDS NM PA
hydroxychloroquine sulfate (generic of PLAQUENIL)
1
leflunomide (generic of ARAVA) TABS
QL (30 tabs / 30 days)
1 QL
methotrexate sodium tabs 1
RENFLEXIS 3 NDS NM LA PA
RINVOQ QL (30 tabs / 30 days)
3 NDS QL NM PA
SKYRIZI QL (7 kits / year)
3 NDS QL NM PA
STELARA SOLN 45mg/0.5ml
QL (1 vial / 28 days)
3 NDS QL NM LA PA
STELARA SOSY QL (1 syringe / 28 days)
3 NDS QL NM PA
TREXALL 2 B/D
XATMEP 3 B/D
XELJANZ QL (60 tabs / 30 days)
3 NDS QL NM PA
XELJANZ XR QL (30 tabs / 30 days)
3 NDS QL NM PA
IMMUNOGLOBULINS BIVIGAM 3 NDS NM PA
CUTAQUIG 3 NDS NM LA PA
CUVITRU 3 NDS NM LA PA
CYTOGAM 3 NDS NM
GAMASTAN 2 B/D NM
GAMMAGARD LIQUID 3 NDS NM PA
GAMMAGARD S/D 3 NDS NM PA
GAMMAKED 3 NDS NM PA
GAMMAPLEX 3 NDS NM PA
GAMMAPLEX 10GM/100ML 3 NDS NM PA
GAMUNEX-C 3 NDS NM PA
HIZENTRA 3 NDS NM LA PA
HYQVIA 3 NDS NM PA
OCTAGAM 3 NDS NM PA
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
52
Drug Name Drug Tier
Requirements/Limits
PANZYGA 3 NDS NM PA
PRIVIGEN 3 NDS NM PA
XEMBIFY 3 NDS NM LA PA
IMMUNOMODULATORS ACTIMMUNE 3 NDS NM LA
PA
ARCALYST 3 NDS NM PA
GRASTEK 3 PA
ILARIS 3 NDS NM LA PA
INTRON-A INJ 10MU 3 NDS B/D NM
INTRON-A INJ 18MU 3 NDS B/D NM
INTRON-A INJ 25MU 3 NDS B/D NM
INTRON-A INJ 50MU 3 NDS B/D NM
ODACTRA 3 PA
ORALAIR 2 NM PA
RAGWITEK 3 PA
IMMUNOSUPPRESSANTS ASTAGRAF XL 5mg 3 NDS B/D NM
ASTAGRAF XL .5mg, 1mg 3 B/D NM
ATGAM 3 NDS B/D
AZASAN 2 B/D
azathioprine (generic of IMURAN) TABS
1 B/D
BENLYSTA 3 NDS NM PA
cyclosporine (generic of SANDIMMUNE) CAPS; SOLN
1 B/D NM
cyclosporine modified (for microemulsion) (generic of NEORAL) CAPS 25mg, 100mg
1 B/D NM
cyclosporine modified (for microemulsion) CAPS 50mg
1 B/D NM
cyclosporine modified (for microemulsion) (generic of NEORAL) SOLN
1 B/D NM
ENVARSUS XR 3 B/D NM
everolimus (immunosuppressant) (generic of ZORTRESS) .5mg, .75mg
3 NDS B/D NM
everolimus (immunosuppressant) (generic of ZORTRESS) .25mg
1 B/D NM
Drug Name Drug Tier
Requirements/Limits
gengraf (generic of NEORAL) 1 B/D NM
mycophenolate mofetil (generic of CELLCEPT) CAPS; TABS
1 B/D NM
mycophenolate mofetil (generic of CELLCEPT) SUSR
3 NDS B/D NM
mycophenolate sodium tbec (generic of MYFORTIC)
1 B/D NM
NULOJIX 3 NDS B/D NM
PROGRAF PACK 3 B/D NM
SANDIMMUNE SOLN 100MG/ML
3 B/D NM
sirolimus (generic of RAPAMUNE) SOLN
3 NDS B/D NM
sirolimus (generic of RAPAMUNE) TABS 2mg
3 NDS B/D NM
sirolimus (generic of RAPAMUNE) TABS .5mg, 1mg
1 B/D NM
tacrolimus (generic of PROGRAF) CAPS
1 B/D NM
ZORTRESS TAB 0.5MG 3 NDS B/D NM
ZORTRESS TAB 0.25MG 3 NDS B/D NM
ZORTRESS TAB 0.75MG 3 NDS B/D NM
ZORTRESS TAB 1MG 3 NDS B/D NM
VACCINES ACTHIB 3
ADACEL 3
BCG VACCINE 3
BEXSERO 3
BOOSTRIX 3
DAPTACEL 3
DIPHTHERIA/TETANUS TOXOID
3 B/D
ENGERIX-B SUSP 3 B/D
GARDASIL 9 3
HAVRIX 3
HIBERIX 3
IMOVAX RABIES (H.D.C.V.) 3 B/D
INFANRIX 3
IPOL INACTIVATED IPV 2
IXIARO 3
KINRIX 3
M-M-R II 3
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
53
Drug Name Drug Tier
Requirements/Limits
MENACTRA 3
MENVEO 3
PEDIARIX 3
PEDVAX HIB 3
PENTACEL 3
PROQUAD 3
QUADRACEL 3
RABAVERT 3 B/D
RECOMBIVAX HB 3 B/D
ROTARIX 2
ROTATEQ 3
SHINGRIX QL (2 vials per lifetime)
3 QL
TDVAX 3 B/D
TENIVAC 3 B/D
TRUMENBA 3
TWINRIX INJ 3
TYPHIM VI 3
VAQTA 3
VARIVAX 3
YF-VAX 3
ZOSTAVAX QL (1 vial per lifetime)
3 QL
NUTRITIONAL/SUPPLEMENTS ELECTROLYTES klor-con 8 1
klor-con 10 1
klor-con m10 1
klor-con m15 1
klor-con m20 1
klor-con pak 20meq 1
klor-con spr cap 8meq 1
klor-con spr cap 10meq 1
MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml
3
magnesium sulfate (generic of MAGNESIUM SULFATE) SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml
1
magnesium sulfate SOLN 50%
1
Drug Name Drug Tier
Requirements/Limits
MAGNESIUM SULFATE IN D5W
3
magnesium sulfate in dextrose (generic of MAGNESIUM SULFATE IN D5W)
1
magnesium sulfate inj 50% 1
potassium chloride CPCR 1
potassium chloride PACK 1
potassium chloride SOLN 10%, 20%
1
potassium chloride TBCR 8meq, 10meq
1
potassium chloride (generic of K-TAB) TBCR 20meq
1
potassium chloride microencapsulated crystals er
1
sodium chloride SOLN 2.5meq/ml
1
sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln
1
TPN ELECTROLYTES 3 B/D
IV NUTRITION AMINOSYN II INJ 10% 3 B/D
AMINOSYN-PF 7% 3 B/D
CLINIMIX 4.25%/DEXTROSE 5
3 B/D
CLINIMIX 5%/DEXTROSE 15%
3 B/D
CLINIMIX 5%/DEXTROSE 20%
3 B/D
CLINIMIX E 2.75%/DEXTROSE
3 B/D
CLINIMIX E 4.25%/DEXTROSE
3 B/D
CLINIMIX E 5%/DEXTROSE 15
3 B/D
CLINIMIX E 5%/DEXTROSE 20
3 B/D
CLINIMIX INJ 4.25/D10 3 B/D
clinisol sf 15% 1 B/D
CLINOLIPID 3 B/D
FREAMINE HBC 6.9% 3 B/D
FREAMINE III 3 B/D
hepatamine 1 B/D
INTRALIPID 30% 3 B/D
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
54
Drug Name Drug Tier
Requirements/Limits
INTRALIPID INJ 20% 3 B/D
NEPHRAMINE 3 B/D
NUTRILIPID INJ 20% 3 B/D
plenamine 1 B/D
PREMASOL 10% 3 B/D
PROCALAMINE 3 B/D
PROSOL 3 B/D
SMOFLIPID 3 B/D
TRAVASOL 3 B/D
TROPHAMINE INJ 6% 3 B/D
TROPHAMINE INJ 10% 3 B/D
IV REPLACEMENT SOLUTIONS dextrose SOLN 50%, 70% 1
dextrose 5% 1
DEXTROSE 5% /ELECTROLYTE
3
DEXTROSE 5%/NACL 0.3% 3
dextrose 10% 1
DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%
3
dextrose in lactated ringers 1
dextrose w/ sodium chloride 1
ISOLYTE-P/DEXTROSE 5% 3
ISOLYTE-S 3
kcl0.15%/d5w/nacl0.2% 1
KCL 0.3%/D5W/NACL 0.9% 3
KCL 0.15%/D5W/NACL 0.225%
3
kcl/d5w/nacl inj 0.22%/0.45% 1
kcl/nacl inj 0.15%-0.9% 1
lactated ringer's 1
NORMOSOL-M IN D5W 3
NORMOSOL-R 3
NORMOSOL-R IN D5W 3
PLASMA-LYTE A 3
PLASMA-LYTE-148 3
potassium chloride SOLN 2meq/ml
1
POTASSIUM CHLORIDE SOLN .4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml
1
potassium chloride 0.15% in nacl 0.45%
1
Drug Name Drug Tier
Requirements/Limits
potassium chloride in dextrose 1
potassium chloride in dextrose & sodium chloride
1
potassium chloride in nacl 1
POTASSIUM CHLORIDE/DEXTRO
3
sodium chloride SOLN .9%, 3%, 5%
1
sodium chloride 0.45% 1
VITAMINS calcitriol (generic of ROCALTROL) CAPS; SOLN
1 B/D
calcitriol inj 1 B/D
doxercalciferol CAPS 1 B/D
M-NATAL PLUS 2
ONE VITE WOMENS PRENATAL
2
paricalcitol (generic of ZEMPLAR) CAPS 1mcg, 2mcg
1 B/D
paricalcitol CAPS 4mcg 1 B/D
PNV FOLIC ACID + IRON MUL
2
PRENATAL 2
PRENATAL PLUS 2
PRENATAL PLUS LOW IRON 2
RAYALDEE 3 NDS
TRICARE 2
OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 1
BLEPHAMIDE 3
BLEPHAMIDE S.O.P. 3
neomycin-polymy-dexameth (generic of MAXITROL)
1
neomycin-polymyxin-hc (ophth)
1
PRED-G 3
PRED-G S.O.P. 3
sulfacetamide sod-prednisolone
1
TOBRADEX OINT 2
TOBRADEX ST 2
tobramycin-dexamethasone (generic of TOBRADEX)
1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
55
Drug Name Drug Tier
Requirements/Limits
ZYLET 2
ANTI-INFECTIVES AZASITE 3
bacitracin (ophthalmic) 1
bacitracin-polymyxin b (ophth) 1
BESIVANCE 2
CILOXAN OINT 2
ciprofloxacin hcl (ophth) (generic of CILOXAN)
1
erythromycin (ophth) 1
gatifloxacin (ophth) (generic of ZYMAXID)
1
gentak 1
gentamicin sulfate soln (ophth)
1
levofloxacin (ophth) 1
MOXEZA 2
moxifloxacin hcl (ophth) (generic of MOXEZA) .5%
1
moxifloxacin hcl (ophth) (generic of VIGAMOX) .5%
1
NATACYN 3
neomycin-bacitracin zn-polymyxin
1
neomycin-polymyxin-gramicidin
1
ofloxacin (ophth) (generic of OCUFLOX)
1
polymyxin b-trimethoprim (generic of POLYTRIM)
1
sulfacetamide sodium (ophth) OINT
1
sulfacetamide sodium (ophth) (generic of BLEPH-10) SOLN
1
tobramycin (ophth) (generic of TOBREX)
1
TOBREX OINT 3
trifluridine 1
ZIRGAN 3
ANTI-INFLAMMATORIES ACUVAIL 2
ALREX 3
bromfenac sodium (ophth) 1
BROMSITE 3
Drug Name Drug Tier
Requirements/Limits
dexamethasone sodium phosphate (ophth)
1
diclofenac sodium (ophth) 1
DUREZOL 2
FLAREX 2
fluorometholone (ophth) 1
flurbiprofen sodium 1
FML 2
FML FORTE 2
ILEVRO 2
INVELTYS 3
ketorolac tromethamine (ophth) (generic of ACULAR LS) .4%
1
ketorolac tromethamine (ophth) (generic of ACULAR) .5%
1
LOTEMAX GEL; OINT 3
LOTEMAX SM 3
loteprednol etabonate (generic of LOTEMAX)
1
MAXIDEX 2
NEVANAC 2
PRED MILD 2
prednisolone acetate (ophth) (generic of PRED FORTE)
1
PREDNISOLONE SODIUM PHOSPHATE (OPHTH)
3
PROLENSA 3
ANTIALLERGICS ALOCRIL 3
ALOMIDE 3
azelastine hcl (ophth) 1
BEPREVE 3
cromolyn sodium (ophth) 1
epinastine hcl (ophth) 1
LASTACAFT 2
olopatadine hcl 0.1% 1
olopatadine hcl 0.2% 1
PAZEO 2
ZERVIATE 3
ANTIGLAUCOMA ALPHAGAN P .1% 2
AZOPT 2
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
56
Drug Name Drug Tier
Requirements/Limits
betaxolol hcl (ophth) 1
BETIMOL 2
BETOPTIC-S 2
brimonidine sol 0.2% 1
brimonidine sol 0.15% (generic of ALPHAGAN P)
1
carteolol hcl (ophth) 1
COMBIGAN 2
dorzol/timol sol 22.3-6.8 pf (generic of COSOPT PF)
1
dorzolamide hcl (generic of TRUSOPT)
1
dorzolamide hcl-timolol maleate (generic of COSOPT)
1
latanoprost (generic of XALATAN) SOLN
1
levobunolol hcl 1
LUMIGAN 2
PHOSPHOLINE IODIDE 3
pilocarpine hcl (generic of ISOPTO CARPINE) SOLN
1
RHOPRESSA 3
SIMBRINZA 2
timolol maleate (ophth) soln (generic of TIMOPTIC)
1
timolol maleate gel (generic of TIMOPTIC-XE)
1
timolol maleate ophth soln 0.5% (once-daily) (generic of ISTALOL)
1
TIMOPTIC OCUDOSE 3
travoprost (generic of TRAVATAN Z)
1
MISCELLANEOUS ATROPINE SULFATE SOLN 1%
2
BEOVU 3 NDS NM LA PA
CYSTARAN 3 NDS NM LA PA
EYLEA 3 NDS NM LA PA
LACRISERT 3
LUCENTIS SOLN 3 NDS NM LA PA
Drug Name Drug Tier
Requirements/Limits
LUCENTIS SOSY .3mg/0.05ml
3 NDS NM LA PA
OXERVATE 3 NDS NM LA PA
proparacaine hcl (generic of ALCAINE) SOLN
1
RESTASIS 2
RESTASIS MULTIDOSE 2
RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA
QL (60 blisters / 30 days)
2 QL
BEVESPI AEROSPHERE QL (1 inhaler / 30 days)
2 QL
COMBIVENT RESPIMAT QL (2 inhalers / 30 days)
2 QL
ipratropium-albuterol 1 B/D
TRELEGY ELLIPTA QL (60 blisters / 30 days)
2 QL
ANTICHOLINERGICS ATROVENT HFA
QL (2 inhalers / 30 days) 3 QL
INCRUSE ELLIPTA QL (30 blisters / 30 days)
2 QL
ipratropium bromide (nasal) 1
ipratropium sol inhal 1 B/D
SPIRIVA HANDIHALER QL (30 caps / 30 days)
2 QL
SPIRIVA RESPIMAT 1.25MCG/ACT
QL (1 inhaler / 30 days)
2 QL
SPIRIVA RESPIMAT 2.5MCG/ACT
QL (1 inhaler / 30 days)
2 QL
SPIRIVA RESPIMAT 2.5MCG/ACT (INSTITUTIONAL PACK)
QL (2 inhalers / 28 days)
2 QL
ANTIHISTAMINE COMBINATIONS
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
57
Drug Name Drug Tier
Requirements/Limits
azelastine hcl-fluticasone propionate (generic of DYMISTA)
QL (1 bottle / 30 days)
1 QL
CLARINEX-D 12 HOUR 3
DYMISTA QL (1 bottle / 30 days)
2 QL
SEMPREX-D 3
ANTIHISTAMINES azelastine hcl SOLN 1
cetirizine hcl SOLN 1
cyproheptadine hcl SYRP; TABS
PA if 70 years and older
2 PA
desloratadine (generic of CLARINEX) TABS
1
desloratadine TBDP 1
diphenhydramine hcl inj 50mg/ml
1
hydroxyzine hcl SYRP PA if 70 years and older
2 PA
hydroxyzine hcl TABS PA if 70 years and older
1 PA
hydroxyzine hcl inj PA if 70 years and older
3 PA
hydroxyzine pamoate (generic of VISTARIL) CAPS 25mg, 50mg
PA if 70 years and older
1 PA
hydroxyzine pamoate CAPS 100mg
PA if 70 years and older
1 PA
levocetirizine oral soln 1
levocetirizine tab 5 mg 1
olopatadine hcl (nasal) (generic of PATANASE)
1
QUZYTTIR 3
BETA AGONISTS albuterol sulfate AERS 108mcg/act
QL (2 inhalers / 30 days) (generic of Ventolin HFA)
1 QL
Drug Name Drug Tier
Requirements/Limits
albuterol sulfate (generic of PROAIR HFA) AERS 108mcg/act
QL (2 inhalers / 30 days) (generic of Proair HFA)
1 QL
albuterol sulfate (generic of PROVENTIL HFA) AERS 108mcg/act
QL (2 inhalers / 30 days) (generic of Proventil HFA)
1 QL
albuterol sulfate NEBU .083%, .63mg/3ml, 1.25mg/3ml, 2.5mg/0.5ml
1 B/D
albuterol sulfate SYRP 1
albuterol sulfate TABS 1
albuterol sulfate TB12 1
ARCAPTA NEOHALER QL (30 caps / 30 days)
3 QL
BROVANA 3 NDS B/D
levalbuterol hcl (generic of XOPENEX) NEBU
1 B/D
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (generic of XOPENEX CONCENTRATE)
1 B/D
levalbuterol tartrate hfa QL (2 inhalers / 30 days)
1 QL
PERFOROMIST 3 NDS B/D
PROAIR DIGIHALER QL (2 inhalers / 30 days)
3 QL
PROAIR RESPICLICK QL (2 inhalers / 30 days)
2 QL
SEREVENT DISKUS QL (60 inhalations / 30 days)
2 QL
STRIVERDI RESPIMAT QL (1 inhaler / 30 days)
2 QL
terbutaline sulfate SOLN 3 NDS
terbutaline sulfate TABS 1
VENTOLIN HFA QL (2 inhalers / 30 days)
2 QL
LEUKOTRIENE MODULATORS montelukast sodium (generic of SINGULAIR) CHEW; PACK; TABS
1
zafirlukast (generic of ACCOLATE)
1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
58
Drug Name Drug Tier
Requirements/Limits
MAST CELL STABILIZERS cromolyn sod neb 20mg/2ml 1 B/D
MISCELLANEOUS acetylcysteine SOLN 10%, 20%
1 B/D
ARALAST NP 3 NDS NM LA PA
CINQAIR 3 NDS NM LA PA
DALIRESP 2
ELIXOPHYLLIN 3
epinephrine (anaphylaxis) (generic of EPIPEN 2-PAK) .3mg/0.3ml
(generic of EpiPen)
1
epinephrine (anaphylaxis) (generic of EPIPEN-JR 2-PAK) .15mg/0.3ml
(generic of EpiPen)
1
epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml
(generic of Adrenaclick)
1
ESBRIET 3 NDS NM PA
FASENRA 3 NDS NM LA PA
FASENRA PEN 3 NDS NM LA PA
GLASSIA 3 NDS NM LA PA
KALYDECO 3 NDS NM PA
NUCALA 3 NDS NM LA PA
OFEV 3 NDS NM PA
ORKAMBI 3 NDS NM PA
PROLASTIN-C 3 NDS NM LA PA
PULMOZYME 3 NDS NM PA
SYMDEKO 3 NDS NM LA PA
SYMJEPI 2
THEO-24 3
theophylline 1
theophylline tab er 12hr 300 mg
1
theophylline tab er 12hr 450 mg
1
Drug Name Drug Tier
Requirements/Limits
theophylline tab sr 24hr 1
TRIKAFTA 3 NDS NM LA PA
XOLAIR 3 NDS NM LA PA
ZEMAIRA 3 NDS NM LA PA
NASAL STEROIDS BECONASE AQ
QL (2 inhalers / 30 days) 3 QL
flunisolide (nasal) QL (3 bottles / 30 days)
1 QL
fluticasone propionate (nasal) QL (1 bottle / 30 days)
1 QL
mometasone furoate (nasal) (generic of NASONEX)
QL (2 inhalers / 30 days)
1 QL
OMNARIS QL (1 inhaler / 30 days)
3 QL
QNASL QL (1 inhaler / 30 days)
3 QL
QNASL CHILDRENS QL (1 inhaler / 30 days)
3 QL
XHANCE QL (2 bottles / 30 days)
3 QL
ZETONNA QL (1 inhaler / 30 days)
3 QL
STEROID INHALANTS ARNUITY ELLIPTA
QL (30 inhalations / 30 days)
2 QL
budesonide (inhalation) (generic of PULMICORT)
1 B/D
FLOVENT DISKUS 50mcg/blist, 100mcg/blist
QL (120 inhalations / 30 days)
2 QL
FLOVENT DISKUS 250mcg/blist
QL (240 inhalations / 30 days)
2 QL
FLOVENT HFA QL (2 inhalers / 30 days)
2 QL
PULMICORT FLEXHALER QL (2 inhalers / 30 days)
2 QL
STEROID/BETA-AGONIST COMBINATIONS
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
59
Drug Name Drug Tier
Requirements/Limits
ADVAIR DISKUS QL (60 inhalations / 30 days)
2 QL
ADVAIR HFA QL (1 inhaler / 30 days)
2 QL
BREO ELLIPTA QL (60 blisters / 30 days)
2 QL
SYMBICORT QL (1 inhaler / 30 days)
2 QL
TOPICAL DERMATOLOGY, ACNE ABSORICA 3 NDS PA
ABSORICA LD 3 NDS PA
adapalene (generic of DIFFERIN) CREA
1
adapalene GEL .1% 1
adapalene (generic of DIFFERIN) GEL .3%
1
ADAPALENE SOLN 3
adapalene-benzoyl peroxide gel 0.1-2.5% (generic of EPIDUO)
1
AKLIEF QL (45 grams / 30 days)
3 QL PA
ALTRENO QL (45 grams / 30 days)
3 QL PA
amnesteem 1 PA
AMZEEQ QL (30 grams / 30 days)
3 QL
ARAZLO QL (45 grams / 30 days)
3 QL PA
avita (generic of RETIN-A) CREA
QL (45 grams / 30 days)
1 QL PA
avita GEL QL (45 grams / 30 days)
1 QL PA
AZELEX 3
benzoyl peroxide-erythromycin (generic of BENZAMYCIN)
1
claravis 1 PA
clindacin-p 1
clindam/benz gel 1.2-2.5% (generic of ACANYA)
QL (50 grams / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
clindamy/ben gel 1-5% (generic of BENZACLIN)
1
clindamycin phosphate (topical) (generic of EVOCLIN) FOAM
1
clindamycin phosphate (topical) (generic of CLEOCIN-T) GEL
QL (75 grams / 30 days)
1 QL
clindamycin phosphate (topical) (generic of CLEOCIN-T) LOTN
1
clindamycin phosphate (topical) SOLN
QL (60 mL / 30 days)
1 QL
clindamycin phosphate (topical) SWAB
1
clindamycin phosphate-benzoyl peroxide (refrigerate)
1
clindamycin phosphate-tretinoin (generic of ZIANA)
1
dapsone gel 5% (generic of ACZONE)
QL (90 grams / 30 days)
1 QL
dapsone gel 7.5% (generic of ACZONE)
QL (90 grams / 30 days)
1 QL
DIFFERIN LOTN 3
EPIDUO FORTE 2
ery pad 2% 1
erythromycin (acne aid) (generic of ERYGEL) GEL
1
erythromycin (acne aid) SOLN
1
FABIOR QL (100 grams / 30 days)
3 QL PA
isotretinoin CAPS 1 PA
myorisan 1 PA
neuac gel 1.2-5% 1
ONEXTON 2
RETIN-A MICRO .06% QL (50 grams / 30 days)
3 NDS QL PA
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
60
Drug Name Drug Tier
Requirements/Limits
RETIN-A MICRO PUMP .08%
QL (50 grams / 30 days)
3 NDS QL PA
sulfacetamide sodium (acne) (generic of KLARON)
1
tretinoin (generic of RETIN-A) CREA
QL (45 grams / 30 days)
1 QL PA
tretinoin (generic of RETIN-A) GEL .01%, .025%
QL (45 grams / 30 days)
1 QL PA
tretinoin (generic of ATRALIN) GEL .05%
QL (45 grams / 30 days)
1 QL PA
tretinoin microsphere (generic of RETIN-A MICRO)
QL (50 grams / 30 days)
1 QL PA
VELTIN 2
zenatane 1 PA
DERMATOLOGY, ANTIBIOTICS ALTABAX
QL (30 grams / 30 days) 3 QL
CENTANY QL (220 grams / 30 days)
3 QL
CORTISPORIN 3
gentamicin sulfate (topical) 1
mafenide acetate (generic of SULFAMYLON) PACK
1
mupirocin OINT QL (220 grams / 30 days)
1 QL
silver sulfadiazine (generic of SILVADENE) CREA
1
ssd (generic of SILVADENE) 1
SULFAMYLON CREA 3
XEPI 3
DERMATOLOGY, ANTIFUNGALS ciclopirox olamine (generic of LOPROX) CREA
QL (90 grams / 30 days)
1 QL
ciclopirox olamine (generic of LOPROX) SUSP
QL (60 mL / 30 days)
1 QL
clotrimazole (topical) CREA 1
Drug Name Drug Tier
Requirements/Limits
clotrimazole (topical) SOLN QL (30 mL / 30 days)
1 QL
clotrimazole w/ betamethasone CREA
1
clotrimazole w/ betamethasone LOTN
QL (30 mL / 30 days)
1 QL
econazole nitrate CREA QL (85 grams / 30 days)
1 QL
ERTACZO QL (60 grams / 30 days)
3 NDS QL
JUBLIA QL (8 mL / 30 days)
3 NDS QL
ketoconazole cream QL (60 grams / 30 days)
1 QL
ketoconazole foam (generic of EXTINA)
QL (100 grams / 30 days)
1 QL
ketodan (generic of EXTINA) QL (100 grams / 30 days)
1 QL
luliconazole QL (60 grams / 30 days)
1 QL
MENTAX 3
miconazole-zinc oxide-white petrolatum
1 PA
naftifine hcl CREA 1% QL (90 grams / 30 days)
1 QL
naftifine hcl (generic of NAFTIN) CREA 2%
QL (60 grams / 30 days)
1 QL
naftifine hcl (generic of NAFTIN) GEL
QL (90 grams / 30 days)
1 QL
NAFTIN GEL 1% QL (90 grams / 30 days)
2 QL
NAFTIN GEL 2% QL (60 grams / 30 days)
2 QL
nyamyc QL (60 grams / 30 days)
1 QL
nystatin (topical) 1
nystatin pow 100000 QL (60 grams / 30 days)
1 QL
nystop QL (60 grams / 30 days)
1 QL
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
61
Drug Name Drug Tier
Requirements/Limits
OXISTAT LOTN QL (60 mL / 30 days)
3 QL PA
DERMATOLOGY, ANTIPSORIATICS acitretin (generic of SORIATANE) 10mg, 25mg
1 PA
acitretin 17.5mg 1 PA
calcipotriene OINT QL (120 grams / 30 days)
1 QL PA
calcipotriene SOLN QL (120 mL / 30 days)
1 QL PA
calcitrene QL (120 grams / 30 days)
1 QL PA
methoxsalen rapid (generic of OXSORALEN ULTRA)
3 NDS
SORILUX QL (120 grams / 30 days)
3 NDS QL PA
tazarotene (generic of TAZORAC) CREA
QL (60 grams / 30 days)
1 QL PA
TAZORAC CREAM 0.05% QL (60 grams / 30 days)
2 QL PA
TAZORAC GEL 0.1% QL (100 grams / 30 days)
2 QL PA
TAZORAC GEL 0.05% QL (100 grams / 30 days)
2 QL PA
DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 1
selenium sulfide LOTN 1
XOLEGEL QL (45 grams / 30 days)
3 NDS QL
DERMATOLOGY, CORTICOSTEROIDS ALA SCALP 3
ala-cort 1
alclometasone dipropionate 1
amcinonide CREA; LOTN 1
AMCINONIDE OINT 3
APEXICON E QL (60 grams / 30 days)
3 NDS QL
beser (generic of CUTIVATE) LOTN
QL (120 mL / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
betamethasone dipropionate (topical)
1
betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA
1
betamethasone dipropionate augmented GEL; LOTN
1
betamethasone dipropionate augmented (generic of DIPROLENE) OINT
1
betamethasone valerate CREA; LOTN; OINT
1
betamethasone valerate (generic of LUXIQ) FOAM
1
BRYHALI QL (100 grams / 30 days)
2 QL
calcipotriene-betamethasone dipropionate (generic of TACLONEX) OINT
QL (400 grams / 28 days)
1 QL PA
calcipotriene-betamethasone dipropionate (generic of TACLONEX) SUSP
QL (400 grams / 28 days)
3 NDS QL PA
CAPEX 2
clobetasol propionate (generic of TEMOVATE) CREA; OINT
QL (60 grams / 30 days)
1 QL
clobetasol propionate (generic of OLUX) FOAM
QL (100 grams / 30 days)
1 QL
clobetasol propionate GEL QL (60 grams / 30 days)
1 QL
clobetasol propionate (generic of CLOBEX) LIQD
QL (125 mL / 30 days)
1 QL
clobetasol propionate (generic of CLOBEX) LOTN; SHAM
QL (118 mL / 30 days)
1 QL
clobetasol propionate SOLN QL (50 mL / 30 days)
1 QL
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
62
Drug Name Drug Tier
Requirements/Limits
clobetasol propionate emo QL (60 grams / 30 days)
1 QL
clobetasol propionate emulsion (generic of OLUX-E)
QL (100 grams / 30 days)
1 QL
clocortolone pivalate (generic of CLODERM)
1
clodan (generic of CLOBEX) QL (118 mL / 30 days)
1 QL
CORDRAN TAPE 3
DESONATE QL (60 grams / 30 days)
3 QL
desonide (generic of DESOWEN) CREA
QL (60 grams / 30 days)
1 QL
desonide (generic of DESONATE) GEL
QL (60 grams / 30 days)
1 QL
desonide LOTN QL (118 mL / 30 days)
1 QL
desonide OINT QL (60 grams / 30 days)
1 QL
desoximetasone (generic of TOPICORT) LIQD
QL (100 mL / 30 days)
1 QL
DUOBRII QL (100 grams / 30 days)
3 NDS QL PA
ENSTILAR QL (120 grams / 30 days)
2 QL PA
fluocinolone acetonide CREA .01%
1
fluocinolone acetonide (generic of SYNALAR) CREA .025%
1
fluocinolone acetonide (generic of DERMA-SMOOTHE/FS BODY) OIL
1
fluocinolone acetonide (generic of SYNALAR) OINT
1
fluocinolone acetonide (generic of SYNALAR) SOLN
QL (90 mL / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
fluocinolone acetonide oil body (generic of DERMA-SMOOTHE/FS SCALP)
1
fluocinonide CREA .05% QL (120 grams / 30 days)
1 QL
fluocinonide GEL QL (60 grams / 30 days)
1 QL
fluocinonide OINT QL (60 grams / 30 days)
1 QL
fluocinonide SOLN QL (60 mL / 30 days)
1 QL
fluocinonide emulsified base QL (120 grams / 30 days)
1 QL
flurandrenolide (generic of CORDRAN) CREA
QL (120 grams / 30 days)
1 QL
flurandrenolide (generic of CORDRAN) LOTN
1
fluticasone propionate CREA; OINT
1
fluticasone propionate (generic of CUTIVATE) LOTN
QL (120 mL / 30 days)
1 QL
halcinonide (generic of HALOG)
QL (240 grams / 30 days)
1 QL
halobetasol propionate CREA; OINT
QL (50 grams / 30 days)
1 QL
HALOBETASOL PROPIONATE FOAM
3 NDS
HALOG OINT QL (240 grams / 30 days)
3 NDS QL
hydrocortisone (topical) cream 1%
1
hydrocortisone (topical) cream 2.5%
1
hydrocortisone (topical) lotion 2.5%
1
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
63
Drug Name Drug Tier
Requirements/Limits
hydrocortisone (topical) oint 1%
QL (30 grams / 30 days)
1 QL
hydrocortisone (topical) oint 2.5%
1
hydrocortisone butyrate cream 0.1%
QL (45 grams / 30 days)
1 QL
hydrocortisone butyrate cream 0.1% lipo base (generic of LOCOID LIPOCREAM)
1
hydrocortisone butyrate lotion 0.1% (generic of LOCOID)
1
hydrocortisone butyrate oint 0.1%
QL (45 grams / 30 days)
1 QL
hydrocortisone butyrate soln 0.1%
QL (60 mL / 30 days)
1 QL
IMPOYZ QL (60 grams / 30 days)
3 QL
LEXETTE 3 NDS
mometasone furoate CREA; OINT; SOLN
1
nolix (generic of CORDRAN) CREA
QL (120 grams / 30 days)
1 QL
nolix (generic of CORDRAN) LOTN
1
PANDEL QL (80 grams / 30 days)
3 NDS QL
prednicarbate 1
SERNIVO 3 NDS
TEXACORT 2
tovet (generic of OLUX-E) QL (100 grams / 30 days)
1 QL
triamcinolone acetonide (topical) (generic of KENALOG) AERS
1
triamcinolone acetonide (topical) CREA .1%
QL (454 grams / 30 days)
1 QL
triamcinolone acetonide (topical) CREA .025%, .5%
1
Drug Name Drug Tier
Requirements/Limits
triamcinolone acetonide (topical) LOTN
1
triamcinolone acetonide (topical) OINT .025%, .1%, .5%
1
triderm QL (454 grams / 30 days)
1 QL
ULTRAVATE LOTN QL (120 mL / 30 days)
3 NDS QL
VERDESO QL (100 grams / 30 days)
3 NDS QL
DERMATOLOGY, LOCAL ANESTHETICS glydo
QL (30 mL / 30 days) 1 QL PA
lidocaine OINT QL (50 grams / 30 days)
1 QL PA
lidocaine (generic of LIDODERM) PTCH 5%
QL (3 patches / 1 day)
1 QL PA
lidocaine hcl GEL QL (30 mL / 30 days)
1 QL PA
lidocaine hcl SOLN 4% QL (50 mL / 30 days)
1 QL PA
lidocaine-prilocaine QL (30 grams / 30 days)
1 QL PA
ZTLIDO QL (3 patches / 1 day)
3 QL PA
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir topical (generic of ZOVIRAX) CREA
QL (5 grams / 30 days)
3 NDS QL
acyclovir topical (generic of ZOVIRAX) OINT
QL (30 grams / 30 days)
1 QL
azelaic acid (generic of FINACEA) GEL
QL (50 grams / 30 days)
1 QL
CONDYLOX 2
CORTIFOAM 2
DENAVIR QL (5 grams / 30 days)
3 NDS QL
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
64
Drug Name Drug Tier
Requirements/Limits
diclofenac sodium (topical) 1% gel (generic of VOLTAREN)
QL (1000 grams / 30 days)
1 QL PA
diclofenac sodium (topical) 1.5% soln
QL (450 mL / 30 days)
1 QL PA
diclofenac sodium (topical) 3% gel
QL (100 grams / 30 days)
3 NDS QL PA
doxycycline (rosacea) 1
FINACEA AER 15% 2
FLUOROPLEX QL (30 grams / 30 days)
3 NDS QL
fluorouracil (topical) cream 5% (generic of EFUDEX)
QL (40 grams / 30 days)
1 QL
fluorouracil (topical) soln QL (10 mL / 30 days)
1 QL
imiquimod (generic of ALDARA) CREA 5%
QL (24 packets / 30 days)
1 QL
IVERMECTIN CREA QL (45 grams / 30 days)
1 QL
lactic acid (ammonium lactate) 1
metronidazole (topical) (generic of METROCREAM) CREA
1
metronidazole (topical) (generic of METROLOTION) LOTN
1
metronidazole gel 0.75% 1
MIRVASO QL (30 grams / 30 days)
3 QL
NORITATE QL (60 grams / 30 days)
3 NDS QL
PANRETIN QL (60 grams / 30 days)
3 NDS QL
PENNSAID QL (224 grams / 28 days)
3 NDS QL PA
PICATO .05% QL (2 tubes / 30 days)
3 QL
Drug Name Drug Tier
Requirements/Limits
PICATO .015% QL (3 tubes / 30 days)
3 QL
pimecrolimus (generic of ELIDEL)
QL (100 grams / 30 days)
1 QL PA
podofilox SOLN 1
procto-med hc (generic of ANUSOL-HC)
1
procto-pak (generic of PROCTOCORT)
1
proctosol hc cre 2.5% (generic of ANUSOL-HC)
1
proctozone-hc (generic of ANUSOL-HC)
1
QBREXZA 3 PA
RECTIV 3
rosadan cre 0.75% (generic of METROCREAM)
1
tacrolimus (topical) (generic of PROTOPIC)
QL (100 grams / 30 days)
1 QL
TARGRETIN GEL QL (60 grams / 30 days)
3 NDS QL NM PA
VALCHLOR QL (60 grams / 30 days)
3 NDS QL NM LA PA
XERESE QL (5 grams / 30 days)
3 NDS QL
DERMATOLOGY, SCABICIDES AND PEDICULIDES crotan
QL (454 grams / 30 days)
1 QL
malathion 1
NATROBA 3
permethrin cre 5% (generic of ELIMITE)
1
SKLICE 3
DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 1
neomycin/polymyxin b gu 1
REGRANEX QL (30 grams / 30 days)
3 NDS QL PA
SANTYL 3
2020 632 3T Platinum eff 09/01/2020
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access NDS - Non-Extended Days Supply
65
Drug Name Drug Tier
Requirements/Limits
sodium chloride 0.9% irrigation
1
water for irrigation, sterile 1
MOUTH/THROAT/DENTAL AGENTS cevimeline hcl (generic of EVOXAC)
1
chlorhexidine gluconate (mouth-throat) (generic of PERIDEX)
1
clotrimazole TROC 1
lidocaine hcl (mouth-throat) 1
nystatin (mouth-throat) 1
ORAVIG 3 NDS
paroex sol 0.12% (generic of PERIDEX)
1
periogard (generic of PERIDEX)
1
pilocarpine hcl (oral) (generic of SALAGEN)
1
triamcinolone acetonide (mouth)
1
OTIC acetic acid (otic) 1
CIPRO HC 3
CIPRODEX 2
ciprofloxacin hcl (otic) 1
ciprofloxacin-fluocinolone acetonide
1
CORTISPORIN-TC 3
flac (generic of DERMOTIC) 1
fluocinolone acetonide (otic) (generic of DERMOTIC)
1
hydrocortisone w/acetic acid 1
neomycin-polymyxin-hc (otic) 1
ofloxacin (otic) 1
OTOVEL 3
2020 632 3T Platinum eff 09/01/2020
66
Index A abacavir sulfate ...................7 abacavir sulfate-lamivudine.8 abacavir sulfate-lamivudine-zidovudine ..........................................8 ABELCET............................6 ABILIFY
see aripiprazole tabs ..... 27 ABILIFY MAINTENA ......... 27 ABILIFY MYCITE .............. 27 abiraterone acetate ........... 13 ABRAXANE ...................... 12 ABSORICA ....................... 59 ABSORICA LD .................. 59 acamprosate calcium ........ 35 ACANYA
see clindam/benz gel 1.2-2.5% ........................ 59
acarbose ........................... 37 ACCOLATE
see zafirlukast ............... 57 ACCUPRIL
see quinapril hcl ............ 17 ACCURETIC
see quinapril-hydrochlorothiazide .................................. 17
acebutolol hcl .................... 19 acetaminophen w/ codeine 300-15mg ............................1 acetaminophen w/ codeine 300-30mg ............................1 acetaminophen w/ codeine 300-60mg ............................1 acetaminophen w/ codeine soln .....................................1 acetaminophen-caff-dihydrocod .................................... 1, 2 acetazolamide ................... 21 acetic acid ......................... 64 acetic acid (otic) ................ 65 acetylcysteine ................... 58 ACIPHEX
see rabeprazole sodium 48 acitretin ............................. 61 ACTHIB ............................. 52
ACTICLATE see doxycycline hyclate . 11
ACTIGALL see ursodiol ................... 48
ACTIMMUNE .................... 52 ACTIQ
see fentanyl citrate .......... 2 ACTONEL
see risedronate sodium . 39 ACTOPLUS MET
see pioglitazone hcl-metformin hcl ........... 38
ACTOS see pioglitazone hcl ....... 38
ACULAR see ketorolac tromethamine (ophth) .... 55
ACULAR LS see ketorolac tromethamine (ophth) .... 55
ACUVAIL .......................... 55 acyclovir .............................. 8 acyclovir sodium ................. 9 acyclovir topical ................ 63 ACZONE
see dapsone gel 5% ...... 59 see dapsone gel 7.5% ... 59
ADACEL ........................... 52 ADAKVEO ........................ 12 adapalene ......................... 59 ADAPALENE .................... 59 adapalene-benzoyl peroxide gel 0.1-2.5% ...................... 59 ADCIRCA
see alyq ......................... 22 see tadalafil (pulmonary hypertension) ................ 22
ADDERALL see amphetamine-dextroamphetamine tab 10 mg......... 30 see amphetamine-dextroamphetamine tab 12.5 mg...... 30 see amphetamine-dextroamphetamine tab 15 mg......... 30
see amphetamine-dextroamphetamine tab 20 mg ........ 30 see amphetamine-dextroamphetamine tab 30 mg ........ 30 see amphetamine-dextroamphetamine tab 5 mg .......... 30 see amphetamine-dextroamphetamine tab 7.5 mg ....... 30
ADDERALL XR see amphetamine-dextroamphetamine cap sr 24hr 10 mg ...................................... 29 see amphetamine-dextroamphetamine cap sr 24hr 15 mg ...................................... 30 see amphetamine-dextroamphetamine cap sr 24hr 20 mg ...................................... 30 see amphetamine-dextroamphetamine cap sr 24hr 25 mg ...................................... 30 see amphetamine-dextroamphetamine cap sr 24hr 30 mg ...................................... 30 see amphetamine-dextroamphetamine cap sr 24hr 5 mg ...................................... 29
adefovir dipivoxil ................. 9 ADEMPAS ........................ 22 adriamycin ........................ 11 adrucil inj .......................... 12 ADVAIR DISKUS .............. 59 ADVAIR HFA .................... 59 ADZENYS ER SUS 1.25MG.......................................... 29 ADZENYS XR-ODT .......... 29 AEMCOLO .......................... 5
2020 632 3T Platinum eff 09/01/2020
67
AFINITOR ......................... 14 see everolimus .............. 15
AFINITOR DISPERZ ......... 14 AGGRENOX
see aspirin-dipyridamole 50 AGRYLIN
see anagrelide hcl ......... 50 AIMOVIG........................... 32 AKLIEF ............................. 59 AKYNZEO ......................... 45 ALA SCALP ...................... 61 ala-cort .............................. 61 albendazole .........................5 ALBENZA
see albendazole ..............5 albuterol sulfate ................. 57 ALCAINE
see proparacaine hcl ..... 56 alclometasone dipropionate .......................................... 61 ALDACTAZIDE ................. 21
see spironolactone & hydrochlorothiazide ....... 21
ALDACTONE see spironolactone ........ 17
ALDARA see imiquimod ............... 64
ALDURAZYME ................. 42 ALECENSA ....................... 14 alendronate sodium .......... 39 alfuzosin hcl ...................... 48 ALIMTA ............................. 12 ALINIA ................................5 ALIQOPA .......................... 14 aliskiren fumarate .............. 21 allopurinol............................1 almotriptan malate ............ 32 ALOCRIL........................... 55 ALOMIDE .......................... 55 ALORA .............................. 42 alosetron hcl ...................... 47 ALOXI
see palonosetron hcl ..... 46 ALPHAGAN P ................... 55
see brimonidine sol 0.15% ...................................... 56
ALPRAZOLAM INTENSOL .......................................... 22
alprazolam tab 0.25mg ..... 22 alprazolam tab 0.5mg ....... 22 alprazolam tab 1mg .......... 22 alprazolam tab 2mg .......... 22 ALREX .............................. 55 ALTABAX .......................... 60 ALTACE
see ramipril .................... 17 altavera tab ....................... 39 ALTOPREV ....................... 18 ALTRENO ......................... 59 ALUNBRIG ....................... 14 alyacen 1/35 ..................... 39 alyq ................................... 22 amantadine hcl ................. 26 AMARYL
see glimepiride .............. 37 AMBIEN
see zolpidem tartrate ..... 32 AMBISOME ........................ 6 ambrisentan ...................... 22 amcinonide ....................... 61 AMCINONIDE ................... 61 AMERGE
see naratriptan hcl ......... 32 amethia ............................. 39 amethia lo ......................... 39 amikacin sulfate .................. 5 amiloride & hydrochlorothiazide ........... 21 amiloride hcl ...................... 21 AMINOSYN II INJ 10% ..... 53 AMINOSYN-PF 7% ........... 53 amiodarone hcl soln .......... 18 amiodarone tab 100mg ..... 18 amiodarone tab 200mg ..... 18 amiodarone tab 400mg ..... 18 AMITIZA CAP 24MCG ...... 47 AMITIZA CAP 8MCG ........ 47 amitriptyline hcl ................. 25 amlodipine besylate .......... 19 amlodipine besylate-atorvastatin calcium .......................................... 19 amlodipine besylate-benazepril hcl ..... 16 amlodipine besylate-olmesartan
medoxomil ........................ 17 amlodipine besylate-valsartan............. 17 amlodipine-valsartan-hydrochlorothiazide ..................... 17 amnesteem ....................... 59 amoxapine ........................ 25 amoxicillin ......................... 10 amoxicillin & pot clavulanate 200/5ml susr ..................... 10 amoxicillin & pot clavulanate 200-28.5 chw tabs ............ 10 amoxicillin & pot clavulanate 250/5ml susr ..................... 10 amoxicillin & pot clavulanate 250-125 tabs ..................... 10 amoxicillin & pot clavulanate 400/5ml susr ..................... 10 amoxicillin & pot clavulanate 400-57 chw tabs ............... 10 amoxicillin & pot clavulanate 500-125 tabs ..................... 10 amoxicillin & pot clavulanate 600/5ml susr ..................... 10 amoxicillin & pot clavulanate 875-125 tabs ..................... 10 amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs ..... 10 amoxicillin-clarithromycin w/ lansoprazole ..................... 47 amphetamine er sus 1.25mg/ml ......................... 29 amphetamine-dextroamphetamine cap sr 24hr 10 mg .. 29 amphetamine-dextroamphetamine cap sr 24hr 15 mg .. 30 amphetamine-dextroamphetamine cap sr 24hr 20 mg .. 30 amphetamine-dextroamphetamine cap sr 24hr 25 mg .. 30 amphetamine-dextroamphetamine cap sr 24hr 30 mg .. 30 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 29 amphetamine-dextroamphetamine tab 10 mg ............... 30 amphetamine-dextroamphetamine tab 12.5 mg ............ 30
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amphetamine-dextroamphetamine tab 15 mg ............... 30 amphetamine-dextroamphetamine tab 20 mg ............... 30 amphetamine-dextroamphetamine tab 30 mg ............... 30 amphetamine-dextroamphetamine tab 5 mg ................. 30 amphetamine-dextroamphetamine tab 7.5 mg .............. 30 amphotericin b ....................6 ampicillin & sulbactam sodium .............................. 10 ampicillin cap 500mg ........ 10 ampicillin inj ....................... 10 ampicillin sodium ............... 10 AMPYRA
see dalfampridine .......... 34 AMZEEQ ........................... 59 ANADROL-50 ................... 36 ANAFRANIL
see clomipramine hcl ..... 25 anagrelide hcl .................... 50 ANAPROX DS
see naproxen sodium ......1 anastrozole ....................... 13 ANCOBON
see flucytosine .................6 ANDRODERM .................. 36 ANDROGEL
see testosterone ............ 36 ANDROGEL PUMP
see testosterone ............ 36 ANNOVERA ...................... 39 ANORO ELLIPTA ............. 56 ANTABUSE
see disulfiram ................ 36 ANTARA ........................... 18 ANUSOL-HC
see procto-med hc ......... 64 see proctosol hc cre 2.5% ...................................... 64 see proctozone-hc ......... 64
APEXICON E .................... 61 APOKYN ........................... 27 aprepitant .......................... 46 aprepitant pak 80mg & 125mg ............................... 46
apri .................................... 39 APRISO
see mesalamine ............ 47 APTENSIO XR .................. 30 APTIOM ............................ 22 APTIVUS ............................ 7 ARALAST NP ................... 58 aranelle ............................. 39 ARANESP ALBUMIN FREE .......................................... 50 ARAVA
see leflunomide ............. 51 ARAZLO ........................... 59 ARCALYST ....................... 52 ARCAPTA NEOHALER .... 57 ARICEPT
see donepezil hydrochloride ................. 25
ARIKAYCE .......................... 5 ARIMIDEX
see anastrozole ............. 13 aripiprazole odt ................. 27 aripiprazole oral solution 1 mg/ml ................................ 27 aripiprazole tabs ............... 27 ARISTADA ........................ 27 ARISTADA INITIO ............ 28 ARIXTRA
see fondaparinux sodium ...................................... 49
armodafinil ........................ 35 ARNUITY ELLIPTA ........... 58 AROMASIN
see exemestane ............ 14 ARTHROTEC 50
see diclofenac w/ misoprostol ...................... 1
ARTHROTEC 75 see diclofenac w/ misoprostol ...................... 1
ARYMO ER ......................... 2 ARZERRA ......................... 12 ASACOL HD
see mesalamine ............ 47 ashlyna ............................. 39 aspirin-dipyridamole .......... 50 ASTAGRAF XL ................. 52 ATACAND
see candesartan cilexetil ...................................... 18
ATACAND HCT see candesartan cilexetil-hydrochlorothiazide .................................... 17
atazanavir sulfate................ 7 ATELVIA
see risedronate sodium . 39 atenolol ............................. 19 atenolol & chlorthalidone .. 19 ATGAM ............................. 52 ATIVAN
see lorazepam............... 22 atomoxetine hcl................. 30 atorvastatin calcium .......... 18 atovaquone ......................... 5 atovaquone-proguanil hcl tab 250-100 mg ........................ 7 atovaquone-proguanil hcl tab 62.5-25 mg ......................... 7 ATRALIN
see tretinoin .................. 60 ATRIPLA ............................. 8 atropine sulfate ................. 46 ATROPINE SULFATE ...... 56 ATROVENT HFA .............. 56 AUBAGIO ......................... 34 aubra ................................ 39 AUGMENTIN
see amoxicillin & pot clavulanate 250/5ml susr ...................................... 10 see amoxicillin & pot clavulanate 500-125 tabs ...................................... 10
AURYXIA .......................... 45 AUSTEDO ........................ 33 AVALIDE
see irbesartan-hydrochlorothiazide ............................... 17
AVAPRO see irbesartan ............... 18
AVASTIN .......................... 12 AVEED ............................. 36 aviane ............................... 39 avita .................................. 59
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AVODART see dutasteride .............. 48
AVONEX ........................... 34 AVONEX PEN ................... 34 AVSOLA............................ 51 AVYCAZ..............................9 AYGESTIN
see norethindrone acetate ...................................... 45
AYVAKIT ........................... 14 azacitidine ......................... 12 AZACTAM
see aztreonam .................5 AZASAN............................ 52 AZASITE ........................... 55 azathioprine ...................... 52 azelaic acid ....................... 63 azelastine hcl .................... 57 azelastine hcl (ophth) ........ 55 azelastine hcl-fluticasone propionate ......................... 57 AZELEX ............................ 59 AZILECT
see rasagiline mesylate . 27 azithromycin ........................9 AZOPT .............................. 55 AZOR
see amlodipine besylate-olmesartan medoxomil ..................... 17
aztreonam ...........................5 AZULFIDINE
see sulfasalazine ir ........ 47 AZULFIDINE EN-TABS
see sulfasalazine dr ....... 47 B bacitracin (ophthalmic) ...... 55 bacitracin-polymyxin b (ophth) .............................. 55 bacitracin-poly-neomycin-hc .......................................... 54 baclofen ............................ 35 BACTOCILL INJ DEX 1GM .......................................... 10 BACTOCILL INJ DEX 2GM .......................................... 10 BACTRIM
see
sulfamethoxazole-trimethoprim tab 400-80mg .......... 6
BACTRIM DS see sulfamethoxazole-trimethop ds ................................. 6
BALCOLTRA .................... 39 balsalazide disodium......... 47 BALVERSA ....................... 14 balziva ............................... 39 BANZEL ............................ 22 BARACLUDE ...................... 9
see entecavir ................... 9 BASAGLAR KWIKPEN ..... 36 BAVENCIO ....................... 12 BAXDELA ......................... 10 BCG VACCINE ................. 52 BD ALCOHOL SWABS ..... 36 BD ULTRAFINE INSULIN SYRINGE .......................... 36 BD ULTRAFINE/NANO PEN NEEDLES ......................... 36 BECONASE AQ ................ 58 bekyree ............................. 39 BELBUCA ........................... 2 BELEODAQ ...................... 12 BELSOMRA ...................... 32 benazepril & hydrochlorothiazide ..... 16, 17 benazepril hcl .................... 17 BENDEKA ......................... 11 BENICAR
see olmesartan medoxomil ...................................... 18
BENICAR HCT see olmesartan medoxomil-hydrochlorothiazide .............................. 17
BENLYSTA ....................... 52 BENTYL
see dicyclomine hcl inj ... 46 BENZACLIN
see clindamy/ben gel 1-5% .............................. 59
BENZAMYCIN see benzoyl peroxide-erythromycin ... 59
benzoyl
peroxide-erythromycin ...... 59 benztropine mesylate inj ... 27 benztropine mesylate tab 0.5mg ................................ 27 benztropine mesylate tab 1mg ................................... 27 benztropine mesylate tab 2mg ................................... 27 BEOVU ............................. 56 BEPREVE ......................... 55 BERINERT ....................... 50 beser ................................. 61 BESIVANCE ..................... 55 BESPONSA ...................... 12 betamethasone dipropionate (topical) ............................. 61 betamethasone dipropionate augmented ........................ 61 betamethasone valerate ... 61 BETAPACE
see sorine ..................... 18 see sotalol hcl ............... 18
BETAPACE AF see sotalol hcl (afib/afl) . 18
BETASERON ................... 34 betaxolol hcl ...................... 19 betaxolol hcl (ophth) ......... 56 bethanechol chloride ......... 48 BETHKIS ............................ 5 BETIMOL .......................... 56 BETOPTIC-S .................... 56 BEVESPI AEROSPHERE 56 bexarotene ........................ 16 BEXSERO ........................ 52 BEYAZ
see drospirenone-ethinyl estradiol-levomefolate calcium .......................... 40
BIAXIN XL see clarithromycin ......... 10
bicalutamide ..................... 13 BICILLIN C-R .................... 10 BICILLIN L-A .................... 10 BIDIL ................................. 21 BIKTARVY .......................... 8 BILTRICIDE
see praziquantel .............. 6 BINOSTO ......................... 39
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bisoprolol & hydrochlorothiazide ........... 19 bisoprolol fumarate ........... 19 BIVIGAM ........................... 51 bleomycin sulfate .............. 11 BLEPH-10
see sulfacetamide sodium (ophth) ........................... 55
BLEPHAMIDE ................... 54 BLEPHAMIDE S.O.P. ....... 54 blisovi 24 fe ....................... 40 blisovi fe 1.5/30 ................. 40 BONIVA
see ibandronate sodium inj ...................................... 39 see ibandronate sodium tabs ............................... 39
BONJESTA ....................... 46 BOOSTRIX ....................... 52 BORTEZOMIB .................. 12 bosentan ........................... 22 BOSULIF........................... 14 BOTOX ............................. 35 BRAFTOVI ........................ 14 BREO ELLIPTA ................ 59 briellyn .............................. 40 BRILINTA .......................... 50 brimonidine sol 0.15% ....... 56 brimonidine sol 0.2% ......... 56 BRISDELLE
see paroxetine mesylate (vasomotor) ................... 33
BRIVIACT INJ 50MG/5ML 22 BRIVIACT SOL 10MG/ML. 22 BRIVIACT TAB 100MG ..... 23 BRIVIACT TAB 10MG ....... 22 BRIVIACT TAB 25MG ....... 22 BRIVIACT TAB 50MG ....... 22 BRIVIACT TAB 75MG ....... 22 bromfenac sodium (ophth) 55 bromocriptine mesylate ..... 27 BROMSITE ....................... 55 BROVANA ........................ 57 BRUKINSA ........................ 14 BRYHALI........................... 61 budesonide ....................... 47 budesonide (inhalation) ..... 58 bumetanide ....................... 21
BUMEX see bumetanide ............. 21
BUNAVAIL MIS 2.1-0.3MG .......................................... 35 BUNAVAIL MIS 4.2-0.7MG .......................................... 35 BUNAVAIL MIS 6.3-1MG .. 35 BUPHENYL
see sodium phenylbutyrate ...................................... 42
buprenorphine hcl ............. 35 buprenorphine hcl-naloxone hcl dihydrate 12-3mg ........ 35 buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg ....... 35 buprenorphine hcl-naloxone hcl dihydrate 4-1mg .......... 35 buprenorphine hcl-naloxone hcl dihydrate 8-2mg .......... 35 buprenorphine hcl-naloxone hcl sl.................................. 35 buprenorphine patch ........... 2 bupropion hcl .................... 25 bupropion hcl (smoking deterrent) .......................... 36 buspirone hcl .................... 22 butorphanol nasal spray ...... 2 butorphanol tartrate ............ 2 BUTRANS
see buprenorphine patch . 2 BYDUREON BCISE .......... 36 BYDUREON PEN ............. 36 BYETTA ............................ 36 BYNFEZIA PEN ................ 44 BYSTOLIC ........................ 19 C cabergoline ....................... 44 CABLIVI ............................ 50 CABOMETYX ................... 14 CADUET
see amlodipine besylate-atorvastatin calcium .......................... 19
CAFERGOT see ergotamine w/ caffeine ...................................... 32
CALAN SR see verapamil hcl .......... 20
calcipotriene ..................... 61 calcipotriene-betamethasone dipropionate ...................... 61 calcitonin (salmon) nasal spray ................................. 44 calcitrene .......................... 61 calcitriol ............................. 54 calcitriol inj ........................ 54 calcium acetate (phosphate binder) .............................. 45 CALQUENCE ................... 14 camila ............................... 40 CAMPTOSAR
see irinotecan hcl .......... 16 camrese lo tab .................. 40 CANASA
see mesalamine ............ 47 CANCIDAS
see caspofungin acetate . 6 candesartan cilexetil ......... 18 candesartan cilexetil-hydrochlorothiazide.......................................... 17 CAPEX ............................. 61 CAPLYTA ......................... 28 CAPRELSA ...................... 14 captopril ............................ 17 captopril & hydrochlorothiazide ........... 17 CARAFATE
see sucralfate ................ 48 CARBAGLU ...................... 42 carbamazepine ................. 23 CARBATROL
see carbamazepine ....... 23 carbidopa .......................... 27 carbidopa-levodopa .......... 27 carbidopa-levodopa-entacapone .................................... 27 carboplatin ........................ 16 CARDIZEM
see diltiazem hcl ............ 20 CARDIZEM CD
see cartia xt ................... 19 see diltiazem cd ............ 20 see diltiazem hcl coated beads ............................ 20 see diltiazem hcl coated
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beads cap sr 24hr .......... 20 see diltiazem hcl extended release beads cap sr ..... 20
CARDIZEM LA .................. 19 see diltiazem er tab 180mg ........................... 20 see diltiazem er tab 240mg ........................... 20 see diltiazem er tab 300mg ........................... 20 see diltiazem er tab 360mg ........................... 20 see diltiazem er tab 420mg ........................... 20 see matzim la ................ 20
CARDURA see doxazosin mesylate 17
CARDURA XL ................... 48 CARNITOR ....................... 42
see levocarnitine (metabolic modifiers) ..... 42
CAROSPIR ....................... 17 carteolol hcl (ophth) .......... 56 cartia xt ............................. 19 carvedilol ........................... 19 carvedilol er ....................... 19 CASODEX
see bicalutamide ........... 13 caspofungin acetate ............6 CASPOFUNGIN ACETATE 6 CATAPRES
see clonidine hcl ............ 21 CATAPRES-TTS-1
see clonidine hcl ptwk ... 21 CATAPRES-TTS-2
see clonidine hcl ptwk ... 21 CATAPRES-TTS-3
see clonidine hcl ptwk ... 21 CAYSTON ...........................5 caziant pak ........................ 40 cefaclor ...............................9 CEFACLOR ER TAB 500MG ............................................9 cefadroxil.............................9 CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ..................9 cefazolin inj .........................9 cefazolin sodium .................9
CEFAZOLIN SODIUM 1 GM/50ML ............................ 9 cefdinir ................................ 9 CEFEPIME 1GM SOLN ...... 9 CEFEPIME 2GM SOLN ...... 9 cefepime inj 1gm ................. 9 cefepime inj 2gm ................. 9 CEFEPIME/DEXTROSE ..... 9 cefixime ............................... 9 CEFOTAN
see cefotetan disodium ... 9 cefotetan disodium .............. 9 cefoxitin sodium .................. 9 CEFOXITIN SODIUM ......... 9 cefpodoxime proxetil ........... 9 cefprozil .............................. 9 ceftazidime .......................... 9 CEFTAZIDIME/DEXTROSE ............................................ 9 ceftriaxone sodium .............. 9 cefuroxime axetil ................. 9 cefuroxime sodium .............. 9 CELEBREX
see celecoxib .................. 1 celecoxib ............................. 1 CELEXA
see citalopram hydrobromide ................ 25
CELLCEPT see mycophenolate mofetil ...................................... 52
CELONTIN ........................ 23 CENTANY ......................... 60 cephalexin ........................... 9 CERDELGA ...................... 42 CEREZYME ...................... 42 cetirizine hcl ...................... 57 cevimeline hcl ................... 65 CHANTIX CONTINUING MONTH ............................. 36 CHANTIX STARTER PACK .......................................... 36 CHANTIX TABS ................ 36 CHEMET ........................... 39 chlorhexidine gluconate (mouth-throat) ................... 65 chloroquine phosphate........ 7 chlorothiazide .................... 21
chlorpromazine hcl ............ 28 CHLORPROMAZINE INJ . 28 chlorthalidone ................... 21 CHOLBAM ........................ 47 cholestyramine ................. 18 cholestyramine light pack . 18 cholestyramine light powd 18 choline fenofibrate ............ 18 CHORIONIC GONADOTROPIN ............ 44 ciclopirox olamine ............. 60 cidofovir .............................. 9 cilostazol ........................... 50 CILOXAN .......................... 55
see ciprofloxacin hcl (ophth) ........................... 55
CIMDUO ............................. 8 cimetidine ......................... 46 cimetidine oral soln ........... 46 cinacalcet hcl .................... 44 CINQAIR ........................... 58 CINRYZE .......................... 50 CINVANTI ......................... 46 CIPRO .............................. 10
see ciprofloxacin hcl ...... 10 CIPRO HC ........................ 65 CIPRO SUSP ................... 10 CIPRODEX ....................... 65 ciprofloxacin hcl ................ 10 ciprofloxacin hcl (ophth) .... 55 ciprofloxacin hcl (otic) ....... 65 ciprofloxacin in d5w .......... 10 ciprofloxacin-fluocinolone acetonide .......................... 65 cisplatin ............................. 16 citalopram hydrobromide .. 25 claravis ............................. 59 CLARINEX
see desloratadine .......... 57 CLARINEX-D 12 HOUR ... 57 clarithromycin ............... 9, 10 CLENPIQ .......................... 47 CLEOCIN .......................... 49
see clindamycin cre 2% vag ................................ 49 see clindamycin hcl ......... 5
CLEOCIN PEDIATRIC GRANULE
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see clindamycin soln 75mg/5ml .........................5
CLEOCIN PHOSPHATE see clindamycin phosphate inj ...................5
CLEOCIN-T see clindamycin phosphate (topical) ........ 59
CLIMARA see estradiol .................. 42
clindacin-p ......................... 59 clindam/benz gel 1.2-2.5% 59 clindamy/ben gel 1-5% ...... 59 clindamycin cre 2% vag .... 49 clindamycin hcl ....................5 clindamycin phosphate (topical) ............................. 59 clindamycin phosphate in d5w .....................................5 CLINDAMYCIN PHOSPHATE IN NACL .......5 clindamycin phosphate inj ...5 clindamycin phosphate-benzoyl peroxide (refrigerate) ....................... 59 clindamycin phosphate-tretinoin ........... 59 clindamycin soln 75mg/5ml .5 CLINDESSE ...................... 49 CLINIMIX 4.25%/DEXTROSE 5 ........ 53 CLINIMIX 5%/DEXTROSE 15% ................................... 53 CLINIMIX 5%/DEXTROSE 20% ................................... 53 CLINIMIX E 2.75%/DEXTROSE ........... 53 CLINIMIX E 4.25%/DEXTROSE ........... 53 CLINIMIX E 5%/DEXTROSE 15 ...................................... 53 CLINIMIX E 5%/DEXTROSE 20 ...................................... 53 CLINIMIX INJ 4.25/D10 .... 53 clinisol sf 15% ................... 53 CLINOLIPID ...................... 53 clobazam........................... 23 clobetasol propionate ........ 61
clobetasol propionate emo 62 clobetasol propionate emulsion ........................... 62 CLOBEX
see clobetasol propionate ...................................... 61 see clodan ..................... 62
clocortolone pivalate ......... 62 clodan ............................... 62 CLODERM
see clocortolone pivalate ...................................... 62
clomipramine hcl ............... 25 clonazepam ...................... 23 clonidine hcl ...................... 21 clonidine hcl ptwk .............. 21 clopidogrel bisulfate .......... 51 clorazepate dipotassium ... 23 clotrimazole ....................... 65 clotrimazole (topical) ......... 60 clotrimazole w/ betamethasone ................. 60 clovique ............................. 39 clozapine odt ..................... 28 clozapine tab 100mg ......... 28 clozapine tab 200mg ......... 28 clozapine tab 25mg ........... 28 clozapine tab 50mg ........... 28 CLOZARIL
see clozapine tab 100mg ...................................... 28 see clozapine tab 200mg ...................................... 28 see clozapine tab 25mg 28 see clozapine tab 50mg 28
COARTEM .......................... 7 codeine sulfate .................... 2 CODEINE SULFATE .......... 2 COGENTIN
see benztropine mesylate inj................................... 27
COLAZAL see balsalazide disodium ...................................... 47
colchicine w/ probenecid ..... 1 COLCRYS .......................... 1 colesevelam hcl ................ 18 COLESTID
see colestipol hcl gran ... 18 see colestipol hcl pack .. 18 see colestipol hcl tabs ... 18
colestipol hcl gran ............. 18 colestipol hcl pack............. 18 colestipol hcl tabs ............. 18 colistimethate sodium ......... 5 colocort ............................. 47 COLY-MYCIN M
see colistimethate sodium ........................................ 5
COMBIGAN ...................... 56 COMBIVENT RESPIMAT . 56 COMBIVIR
see lamivudine-zidovudine ........................................ 8
COMETRIQ ...................... 14 COMPLERA ....................... 8 compro .............................. 46 COMTAN
see entacapone............. 27 CONCERTA
see methylphenidate hcl 31 CONDYLOX ..................... 63 constulose ........................ 47 COPAXONE
see glatiramer acetate 20mg/ml ........................ 34 see glatiramer acetate 40mg/ml ........................ 34 see glatopa ................... 34
COPIKTRA ....................... 14 CORDRAN ....................... 62
see flurandrenolide ........ 62 see nolix ........................ 63
COREG see carvedilol ................ 19
COREG CR see carvedilol er ............ 19
CORGARD see nadolol .................... 19
CORLANOR SOL 5MG/5ML.......................................... 21 CORLANOR TAB 5MG ..... 21 CORLANOR TAB 7.5MG .. 21 CORTEF
see hydrocortisone ........ 43 CORTENEMA
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see colocort ................... 47 see hydrocortisone (enema) ......................... 47
CORTIFOAM .................... 63 cortisone acetate ............... 43 CORTISPORIN ................. 60 CORTISPORIN-TC ........... 65 COSOPT
see dorzolamide hcl-timolol maleate ........ 56
COSOPT PF see dorzol/timol sol 22.3-6.8 pf ..................... 56
COTELLIC ........................ 14 COTEMPLA XR-ODT ....... 30 COUMADIN ...................... 49 COZAAR
see losartan potassium.. 18 CREON ............................. 48 CRESEMBA ........................6 CRESTOR
see rosuvastatin calcium ...................................... 18
CRINONE ......................... 45 CRIXIVAN ...........................7 cromolyn sod neb 20mg/2ml .......................................... 58 cromolyn sodium (mastocytosis) ................... 47 cromolyn sodium (ophth) .. 55 crotan ................................ 64 cryselle-28......................... 40 CRYSVITA ........................ 44 CUBICIN
see daptomycin ...............5 CUTAQUIG ....................... 51 CUTIVATE
see beser ....................... 61 see fluticasone propionate ...................................... 62
CUVITRU .......................... 51 CUVPOSA ........................ 46 cyclafem 1/35 .................... 40 cyclafem 7/7/7 ................... 40 cyclobenzaprine hcl .......... 35 cyclophosphamide ............ 11 cycloserine ..........................8 cyclosporine ...................... 52
cyclosporine modified (for microemulsion) ................. 52 CYKLOKAPRON
see tranexamic acid ...... 50 CYMBALTA
see duloxetine cap 20mg ...................................... 26 see duloxetine cap 30mg ...................................... 26 see duloxetine cap 60mg ...................................... 26
cyproheptadine hcl ............ 57 CYRAMZA ........................ 12 cyred tab ........................... 40 CYSTADANE .................... 42 CYSTAGON ...................... 42 CYSTARAN ...................... 56 cytarabine ......................... 12 CYTOGAM ........................ 51 CYTOMEL
see liothyronine sodium . 45 CYTOTEC
see misoprostol ............. 47 CYTOVENE
see ganciclovir sodium .... 9 D D.H.E. 45
see dihydroergotamine mesylate inj 1 mg/ml ...... 32
dacarbazine ...................... 11 DACOGEN
see decitabine ............... 12 dalfampridine .................... 34 DALIRESP ........................ 58 DALVANCE ........................ 5 danazol ............................. 42 DANTRIUM
see dantrolene sodium .. 35 dantrolene sodium ............ 35 dapsone .............................. 5 dapsone gel 5% ................ 59 dapsone gel 7.5% ............. 59 DAPTACEL ....................... 52 daptomycin ......................... 5 DAPTOMYCIN
see daptomycin ............... 5 darifenacin hydrobromide . 49 DARZALEX ....................... 12
DARZALEX FASPRO ....... 12 dasetta 1/35 ...................... 40 dasetta 7/7/7 ..................... 40 DAURISMO ...................... 12 DAYPRO
see oxaprozin .................. 1 DAYTRANA ...................... 30 DAYVIGO ......................... 32 DDAVP
see desmopressin acetate ...................................... 45 see desmopressin acetate spray ............................. 45 see desmopressin inj 4mcg/ml ........................ 45
DDAVP SPRAY (REFRIGERATED) ........... 45 deblitane ........................... 40 decitabine ......................... 12 deferasirox tab .................. 39 deferasirox tab for oral susp.......................................... 39 deferoxamine mesylate ..... 39 DELESTROGEN............... 42
see estradiol valerate .... 43 DELSTRIGO ....................... 8 DELZICOL
see mesalamine ............ 47 demeclocycline hcl ............ 11 DEMSER .......................... 21 DENAVIR .......................... 63 DEPAKOTE
see divalproex sodium .. 23 DEPAKOTE ER
see divalproex sodium .. 23 DEPAKOTE SPRINKLES
see divalproex sodium .. 23 DEPEN TITRATABS
see penicillamine ........... 39 DEPO-ESTRADIOL .......... 42 DEPO-MEDROL ............... 43
see methylprednisolone acetate .......................... 43
DEPO-PROVERA CONTRACEPTIV
see medroxyprogesterone acetate (contraceptive) .. 41
DEPO-PROVERA INJ
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400/ML .............................. 13 DEPO-SUBQ PROVERA 104 .................................... 40 DEPO-TESTOSTERONE
see testosterone cypionate ...................................... 36
DERMA-SMOOTHE/FS BODY
see fluocinolone acetonide ...................................... 62
DERMA-SMOOTHE/FS SCALP
see fluocinolone acetonide oil body .......................... 62
DERMOTIC see flac .......................... 65 see fluocinolone acetonide (otic) .............................. 65
DESCOVY ..........................8 DESFERAL
see deferoxamine mesylate ........................ 39
desipramine hcl ........... 25, 26 desloratadine .................... 57 desmopressin acetate ....... 45 desmopressin acetate spray .......................................... 45 desmopressin acetate spray refrigerated ........................ 45 desmopressin inj 4mcg/ml. 45 desogestrel & ethinyl estradiol ............................ 40 desogestrel-ethinyl estradiol (biphasic) .......................... 40 DESONATE ...................... 62
see desonide ................. 62 desonide ........................... 62 DESOWEN
see desonide ................. 62 desoximetasone ................ 62 DESVENLAFAXINE ER .... 26 desvenlafaxine succinate .. 26 DETROL
see tolterodine tartrate .. 49 DETROL LA
see tolterodine er ........... 49 dexamethasone ................ 43 DEXAMETHASONE ......... 43
DEXAMETHASONE SODIUM PHOS
see dexamethasone sodium phosphate ......... 43
dexamethasone sodium phosphate ......................... 43 dexamethasone sodium phosphate (ophth) ............. 55 DEXEDRINE
see dextroamphetamine sulfate ............................ 30
DEXILANT ........................ 48 dexmethylphenidate hcl .... 30 dexrazoxane hcl ................ 16 dextroamphetamine sulfate .......................................... 30 dextrose ............................ 54 dextrose 10% .................... 54 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% .......................................... 54 dextrose 5% ...................... 54 DEXTROSE 5% /ELECTROLYTE ............... 54 DEXTROSE 5%/NACL 0.3% .......................................... 54 dextrose in lactated ringers .......................................... 54 dextrose w/ sodium chloride .......................................... 54 DIASTAT ACUDIAL .......... 23 DIASTAT PEDIATRIC....... 23 diazepam .......................... 23 diazepam gel .................... 23 diazepam inj ...................... 23 diazepam intensol 5mg/ml 23 diazepam oral soln 1 mg/ml .......................................... 23 diazoxide ........................... 44 DIBENZYLINE
see phenoxybenzamine hcl.................................. 21
DICLEGIS see doxylamine-pyridoxine ...................................... 46
diclofenac potassium .......... 1 diclofenac sodium ............... 1 diclofenac sodium (ophth) . 55
diclofenac sodium (topical) 1% gel ............................... 64 diclofenac sodium (topical) 1.5% soln .......................... 64 diclofenac sodium (topical) 3% gel ............................... 64 diclofenac w/ misoprostol .... 1 dicloxacillin sodium ........... 10 dicyclomine hcl cap 10mg . 46 dicyclomine hcl inj ............. 46 dicyclomine hcl soln 10mg/5ml .......................... 46 dicyclomine hcl tab 20mg . 46 didanosine .......................... 7 DIFFERIN ......................... 59
see adapalene............... 59 DIFICID ............................. 10 DIFLUCAN
see fluconazole ............... 6 diflunisal .............................. 1 digitek ............................... 20 digox ................................. 20 digoxin .............................. 20 digoxin inj .......................... 20 digoxin sol 50mcg/ml ........ 21 dihydroergotamine mesylate inj 1 mg/ml ........................ 32 dihydroergotamine mesylate nasal spr 4 mg/ml ............. 32 DILANTIN
see phenytoin sodium extended ....................... 24
DILANTIN CAP 100MG .... 23 DILANTIN CAP 30MG ...... 23 DILANTIN CHEW TAB 50MG ................................ 23 DILANTIN INFATABS
see phenytoin ................ 24 DILANTIN-125
see phenytoin ................ 24 DILANTIN-125 SUSP ....... 23 DILATRATE SR ................ 21 DILAUDID
see hydromorphone hcl ... 3 diltiazem cd ....................... 20 diltiazem er tab 180mg ..... 20 diltiazem er tab 240mg ..... 20 diltiazem er tab 300mg ..... 20
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diltiazem er tab 360mg ...... 20 diltiazem er tab 420mg ...... 20 diltiazem hcl ...................... 20 diltiazem hcl cap er/12hr ... 20 diltiazem hcl coated beads 20 diltiazem hcl coated beads cap sr 24hr ........................ 20 diltiazem hcl extended release beads cap sr ......... 20 diltiazem inj ....................... 20 dilt-xr ................................. 19 DIOVAN
see valsartan ................. 18 DIOVAN HCT
see valsartan-hydrochlorothiazide .................................. 18
DIPENTUM ....................... 47 diphenhydramine hcl inj 50mg/ml ............................ 57 diphenoxylate w/ atropine . 47 DIPHTHERIA/TETANUS TOXOID ............................ 52 DIPROLENE
see betamethasone dipropionate augmented 61
DIPROLENE AF see betamethasone dipropionate augmented 61
disopyramide phosphate ... 18 disulfiram........................... 36 DITROPAN XL
see oxybutynin chloride . 49 DIURIL .............................. 21 divalproex sodium ............. 23 docetaxel........................... 12 DOCETAXEL .................... 12
see docetaxel ................ 12 dofetilide............................ 18 DOLOPHINE
see methadone tab 10mg 3 see methadone tab 5mg ..3
donepezil 10mg odt ........... 25 donepezil 5mg odt ............. 25 donepezil hydrochloride .... 25 DOPTELET ....................... 50 DORYX
see doxycycline hyclate . 11
dorzol/timol sol 22.3-6.8 pf 56 dorzolamide hcl ................. 56 dorzolamide hcl-timolol maleate ............................. 56 dotti ................................... 42 DOVATO ............................. 8 doxazosin mesylate .......... 17 doxepin hcl ........................ 26 doxepin hcl (sleep) ............ 32 doxercalciferol ................... 54 DOXIL
see doxorubicin hcl liposomal ....................... 11
doxorubicin hcl .................. 11 doxorubicin hcl liposomal .. 11 doxy 100 ........................... 11 doxycycline (monohydrate) .......................................... 11 doxycycline (rosacea) ....... 64 doxycycline hyclate ........... 11 doxycycline hyclate tab 100 mg dr................................. 11 doxycycline hyclate tab 150 mg dr................................. 11 doxycycline hyclate tab 75 mg dr................................. 11 doxylamine-pyridoxine ...... 46 DRIZALMA SPRINKLE ..... 26 dronabinol ......................... 46 drospirenone-ethinyl estradiol ............................ 40 drospirenone-ethinyl estradiol-levomefolate calcium .............................. 40 DROXIA CAP 200MG ....... 50 DROXIA CAP 300MG ....... 50 DROXIA CAP 400MG ....... 50 DUETACT
see pioglitazone hcl-glimepiride ............... 38
duloxetine cap 20mg ......... 26 duloxetine cap 30mg ......... 26 duloxetine cap 40mg ......... 26 duloxetine cap 60mg ......... 26 DUOBRII ........................... 62 DUOPA ............................. 27 DURAGESIC
see fentanyl patch 100
mcg/hr ............................. 3 see fentanyl patch 12 mcg/hr ............................. 2 see fentanyl patch 25 mcg/hr ............................. 2 see fentanyl patch 50 mcg/hr ............................. 2 see fentanyl patch 75 mcg/hr ............................. 2
DUREZOL ........................ 55 dutasteride ........................ 48 dutasteride-tamsulosin hcl 48 dvorah ................................. 2 DYANAVEL XR................. 31 DYAZIDE
see triamterene & hydrochlorothiazide cap 37.5-25mg ..................... 21
DYMISTA .......................... 57 see azelastine hcl-fluticasone propionate ...................................... 57
DYSPORT ........................ 35 E E.E.S. GRANULES
see erythromycin ethylsuccinate ............... 10
EC-NAPROSYN see ec-naproxen ............. 1 see naproxen dr .............. 1
ec-naproxen ........................ 1 econazole nitrate .............. 60 EDARBI ............................ 18 EDARBYCLOR ................. 17 EDECRIN
see ethacrynic acid ....... 21 EDURANT .......................... 7 efavirenz ............................. 7 EFFEXOR XR
see venlafaxine cap er .. 26 EFFIENT
see prasugrel hcl ........... 51 EFUDEX
see fluorouracil (topical) cream 5% ...................... 64
EGRIFTA .......................... 44 ELAPRASE ....................... 42 ELELYSO ......................... 42
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eletriptan hydrobromide .... 32 ELIDEL
see pimecrolimus .......... 64 ELIGARD INJ 22.5MG ...... 13 ELIGARD INJ 30MG ......... 13 ELIGARD INJ 45MG ......... 13 ELIGARD INJ 7.5MG ........ 13 ELIMITE
see permethrin cre 5% .. 64 ELIQUIS ............................ 49 ELIQUIS STARTER PACK .......................................... 49 ELITEK ............................. 16 ELIXOPHYLLIN ................ 58 ELLA ................................. 40 ELLENCE
see epirubicin hcl ........... 11 ELMIRON.......................... 48 eluryng .............................. 40 EMCYT ............................. 11 EMEND ............................. 46
see aprepitant ................ 46 see fosaprepitant dimeglumine .................. 46
EMGALITY ........................ 32 emoquette ......................... 40 EMPLICITI ........................ 12 EMSAM ............................. 26 EMTRIVA ............................7 EMVERM ............................5 ENABLEX
see darifenacin hydrobromide ................ 49
enalapril maleate ............... 17 enalapril maleate & hydrochlorothiazide ........... 17 ENBREL............................ 51 ENBREL MINI ................... 51 ENBREL SURECLICK ...... 51 ENDARI ............................ 50 endocet 10-325mg ..............2 endocet 2.5-325mg .............2 endocet 5-325mg ................2 endocet 7.5-325mg .............2 ENGERIX-B ...................... 52 ENHERTU ......................... 12 enoxaparin sodium ............ 49 enpresse-28 ...................... 40
enskyce ............................. 40 ENSTILAR ........................ 62 entacapone ....................... 27 entecavir ............................. 9 ENTOCORT EC
see budesonide ............. 47 ENTRESTO ...................... 17 ENTYVIO .......................... 47 enulose ............................. 47 ENVARSUS XR ................ 52 EPANED ........................... 17 EPCLUSA ........................... 9 EPIDIOLEX ....................... 23 EPIDUO
see adapalene-benzoyl peroxide gel 0.1-2.5% ... 59
EPIDUO FORTE ............... 59 epinastine hcl (ophth)........ 55 epinephrine (anaphylaxis) . 58 EPIPEN 2-PAK
see epinephrine (anaphylaxis) ................. 58
EPIPEN-JR 2-PAK see epinephrine (anaphylaxis) ................. 58
epirubicin hcl ..................... 11 epitol ................................. 23 EPIVIR
see lamivudine ................ 7 EPIVIR HBV ........................ 9
see lamivudine (hbv) ....... 9 eplerenone ........................ 17 epoprostenol sodium......... 22 EPZICOM
see abacavir sulfate-lamivudine ........... 8
EQUETRO ........................ 33 ERAXIS ............................... 6 ERBITUX .......................... 12 ergotamine w/ caffeine ...... 32 ERIVEDGE ....................... 12 ERLEADA ......................... 13 erlotinib hcl ........................ 14 errin................................... 40 ERTACZO ......................... 60 ertapenem sodium .............. 5 ERWINAZE ....................... 16 ery pad 2% ........................ 59
ERYGEL see erythromycin (acne aid) ................................ 59
ERYPED 400 see erythromycin ethylsuccinate ............... 10
ery-tab .............................. 10 ERYTHROCIN LACTOBIONATE .............. 10 erythrocin stearate ............ 10 erythromycin (acne aid) .... 59 erythromycin (ophth) ......... 55 erythromycin base ............ 10 erythromycin cap 250mg ec.......................................... 10 erythromycin ethylsuccinate.......................................... 10 erythromycin tab ec .......... 10 ESBRIET .......................... 58 escitalopram oxalate ......... 26 esomeprazole magnesium 48 esomeprazole sodium inj .. 48 estarylla tab 0.25-35 ......... 40 ESTRACE
see estradiol .................. 43 see estradiol vaginal cream ............................ 43
estradiol ...................... 42, 43 estradiol vaginal cream ..... 43 estradiol vaginal tab .......... 43 estradiol valerate .............. 43 ESTRING .......................... 43 ESTROSTEP FE
see tilia fe ...................... 41 see tri-legest fe.............. 41
ethacrynic acid .................. 21 ethambutol hcl .................... 8 ethosuximide .................... 23 ethynodiol diacet & eth estrad ................................ 40 ethynodiol tab 1-50 ........... 40 etodolac .............................. 1 etonogestrel-ethinyl estradiol.......................................... 40 ETOPOPHOS ................... 16 etoposide .......................... 16 euthyrox ............................ 45 EVENITY .......................... 44
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everolimus......................... 15 everolimus (immunosuppressant) ....... 52 EVISTA
see raloxifene hcl .......... 45 EVOCLIN
see clindamycin phosphate (topical) ........ 59
EVOTAZ..............................8 EVOXAC
see cevimeline hcl ......... 65 EXELON
see rivastigmine td patch 24hr 13.3mg/24hr .......... 25 see rivastigmine td patch 24hr 4.6mg/24hr ............ 25 see rivastigmine td patch 24hr 9.5mg/24hr ............ 25
exemestane ...................... 14 EXFORGE
see amlodipine besylate-valsartan ......... 17
EXFORGE HCT see amlodipine-valsartan-hydrochlorothiazide .............. 17
EXJADE see deferasirox tab for oral susp ............................... 39
EXTINA see ketoconazole foam.. 60 see ketodan ................... 60
EYLEA .............................. 56 EZALLOR SPRINKLE ....... 18 ezetimibe........................... 19 ezetimibe-simvastatin ....... 19 F FABIOR............................. 59 FABRAZYME .................... 42 falmina .............................. 40 famciclovir ...........................9 famotidine ......................... 46 famotidine in nacl .............. 47 famotidine inj ..................... 47 FANAPT ............................ 28 FANAPT TITRATION PACK .......................................... 28 FARESTON
see toremifene citrate .... 14 FARXIGA .......................... 37 FARYDAK ......................... 12 FASENRA ......................... 58 FASENRA PEN ................ 58 FASLODEX
see fulvestrant ............... 14 fayosim ............................. 40 febuxostat ........................... 1 felbamate .......................... 23 FELBATOL
see felbamate ................ 23 FELDENE
see piroxicam .................. 1 felodipine .......................... 20 FEMARA
see letrozole .................. 14 FEMHRT LOW DOSE
see fyavolv .................... 43 see norethindrone acetate-ethinyl estradiol 43
FEMRING ......................... 43 femynor ............................. 40 fenofibrate ......................... 19 fenofibrate micronized....... 19 fentanyl ............................... 2 fentanyl citrate .................... 2 fentanyl patch 100 mcg/hr ... 3 fentanyl patch 12 mcg/hr ..... 2 fentanyl patch 25 mcg/hr ..... 2 fentanyl patch 50 mcg/hr ..... 2 fentanyl patch 75 mcg/hr ..... 2 FERRIPROX ..................... 39 FETROJA ........................... 9 FETZIMA .......................... 26 FETZIMA TITRATION PACK .......................................... 26 FIASP ............................... 36 FIASP FLEXTOUCH ......... 36 FIASP PENFILL ................ 36 FINACEA
see azelaic acid ............. 63 FINACEA AER 15% .......... 64 finasteride ......................... 48 FIRAZYR
see icatibant acetate ..... 50 FIRDAPSE ........................ 33 FIRMAGON ...................... 14
FIRVANQ ............................ 5 flac .................................... 65 FLAGYL
see metronidazole ........... 6 FLAREX ............................ 55 flecainide acetate .............. 18 FLOLAN ............................ 22
see epoprostenol sodium ...................................... 22
FLOLIPID .......................... 18 FLOMAX
see tamsulosin hcl ......... 48 FLOVENT DISKUS ........... 58 FLOVENT HFA ................. 58 fluconazole ......................... 6 fluconazole inj nacl 200 ...... 6 fluconazole inj nacl 400 ...... 6 flucytosine ........................... 6 fludarabine phosphate ...... 12 fludrocortisone acetate ..... 43 flunisolide (nasal) .............. 58 fluocinolone acetonide ...... 62 fluocinolone acetonide (otic).......................................... 65 fluocinolone acetonide oil body .................................. 62 fluocinonide ...................... 62 fluocinonide emulsified base.......................................... 62 fluorometholone (ophth) .... 55 FLUOROPLEX.................. 64 fluorouracil ........................ 12 fluorouracil (topical) cream 5% .................................... 64 fluorouracil (topical) soln ... 64 fluoxetine hcl ..................... 26 fluoxetine hcl (pmdd) ........ 36 FLUOXETINE HYDROCHLORIDE
see fluoxetine hcl .......... 26 fluphenazine decanoate .... 28 fluphenazine hcl ................ 28 flurandrenolide .................. 62 flurbiprofen .......................... 1 flurbiprofen sodium ........... 55 flutamide ........................... 14 fluticasone propionate ....... 62 fluticasone propionate
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(nasal) ............................... 58 fluvastatin sodium ............. 18 fluvoxamine cap er ............ 22 fluvoxamine tab 100mg ..... 22 fluvoxamine tab 25mg ....... 22 fluvoxamine tab 50mg ....... 22 FML ................................... 55 FML FORTE ...................... 55 FOCALIN
see dexmethylphenidate hcl .................................. 30
FOCALIN XR see dexmethylphenidate hcl .................................. 30
FOLOTYN ......................... 12 fondaparinux sodium ......... 49 FORTEO ........................... 44 FORTESTA
see testosterone ............ 36 FOSAMAX
see alendronate sodium 39 FOSAMAX PLUS D .......... 39 fosamprenavir tab 700 mg ..7 fosaprepitant dimeglumine 46 fosinopril sodium ............... 17 fosinopril-hydrochlorothiazide tab 10/12.5mg ................ 17 fosinopril-hydrochlorothiazide tab 20/12.5mg ................ 17 FOSRENOL ...................... 45
see lanthanum chew tab 45 FRAGMIN ......................... 49 FREAMINE HBC 6.9% ...... 53 FREAMINE III ................... 53 FROVA
see frovatriptan succinate ...................................... 32
frovatriptan succinate ........ 32 fulvestrant ......................... 14 furosemide ........................ 21 furosemide oral soln 10 mg/ml ................................ 21 furosemide oral soln 8 mg/ml .......................................... 21 FUZEON .............................7 fyavolv ............................... 43 FYCOMPA ........................ 23
G gabapentin ........................ 23 GABITRIL
see tiagabine hcl ........... 24 GALAFOLD ....................... 42 galantamine hydrobromide 25 galantamine hydrobromide er ...................................... 25 GAMASTAN ...................... 51 GAMMAGARD LIQUID ..... 51 GAMMAGARD S/D ........... 51 GAMMAKED ..................... 51 GAMMAPLEX ................... 51 GAMMAPLEX 10GM/100ML .......................................... 51 GAMUNEX-C .................... 51 GANCICLOVIR INJ 500MG/10ML ...................... 9 ganciclovir sodium .............. 9 GARDASIL 9 ..................... 52 GASTROCROM
see cromolyn sodium (mastocytosis) ............... 47
gatifloxacin (ophth) ........... 55 GATTEX ........................... 47 GAUZE PADS 2X2 ........... 36 gavilyte-c ........................... 47 gavilyte-g .......................... 47 gavilyte-n/flavor pack ........ 47 GAZYVA ........................... 12 GELNIQUE ....................... 49 GEMCITABINE
see gemcitabine inj soln 12 gemcitabine inj soln .......... 12 gemcitabine inj solr ........... 12 gemfibrozil ........................ 19 GENERESS FE
see kaitlib fe .................. 40 see layolis fe chw .......... 40 see noreth/ethin chw fe . 41
generlac ............................ 47 gengraf .............................. 52 GENOTROPIN .................. 44 GENOTROPIN MINIQUICK .......................................... 44 gentak ............................... 55 gentamicin in saline ............ 5 gentamicin sulfate ............... 5
gentamicin sulfate (topical).......................................... 60 gentamicin sulfate soln (ophth) .............................. 55 GENVOYA .......................... 8 GEODON
see ziprasidone hcl ....... 29 see ziprasidone mesylate ...................................... 29
GEODON INJ ................... 28 gianvi tab 3-0.02mg .......... 40 GILENYA CAP 0.5MG ...... 34 GILOTRIF TAB 20MG ...... 15 GILOTRIF TAB 30MG ...... 15 GILOTRIF TAB 40MG ...... 15 GIVLAARI ......................... 50 GLASSIA .......................... 58 glatiramer acetate 20mg/ml.......................................... 34 glatiramer acetate 40mg/ml.......................................... 34 glatopa .............................. 34 GLEEVEC
see imatinib mesylate .... 15 GLEOSTINE ..................... 11 glimepiride ........................ 37 glipizide ............................. 37 glipizide er ........................ 37 glipizide xl ......................... 37 glipizide-metformin 2.5-250 mg ..................................... 37 glipizide-metformin 2.5-500 mg ..................................... 37 glipizide-metformin 5-500mg.......................................... 37 GLUCAGEN HYPOKIT ..... 44 GLUCAGON EMERGENCY KIT .................................... 44 GLUCOTROL
see glipizide .................. 37 GLUCOTROL XL
see glipizide er .............. 37 see glipizide xl ............... 37
GLYCATE ......................... 46 glycopyrrolate ................... 46 GLYCOPYRROLATE ....... 46 glycopyrrolate tab 1mg ..... 46 glycopyrrolate tab 2mg ..... 46
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glydo ................................. 63 GLYSET
see miglitol .................... 38 GLYXAMBI ........................ 37 GOCOVRI ......................... 27 GOLYTELY ....................... 47
see gavilyte-g ................ 47 see peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ............................ 47
GRALISE .......................... 33 GRALISE STARTER ......... 33 granisetron hcl .................. 46 GRASTEK ......................... 52 griseofulvin microsize ..........6 griseofulvin ultramicrosize ...7 guanfacine er (adhd) ......... 31 GVOKE HYPOPEN 2-PACK .......................................... 44 GVOKE PFS ..................... 44 GYNAZOLE-1 ................... 49 H HAEGARDA ...................... 50 hailey 24 fe........................ 40 HALAVEN ......................... 16 halcinonide ........................ 62 HALDOL
see haloperidol lactate inj 5mg/ml........................... 28
HALDOL DECANOATE 100 see haloperidol decanoate ...................................... 28
HALDOL DECANOATE 50 see haloperidol decanoate ...................................... 28
halobetasol propionate ...... 62 HALOBETASOL PROPIONATE .................. 62 HALOG ............................. 62
see halcinonide ............. 62 haloperidol ........................ 28 haloperidol conc 2mg/ml ... 28 haloperidol decanoate ....... 28 haloperidol lactate inj 5mg/ml .......................................... 28 HARVONI............................9 HAVRIX............................. 52 heather .............................. 40
heparin sod (porcine) in d5w .......................................... 49 heparin sod inj 5000u/0.5ml .......................................... 49 heparin sodium (porcine) 1000 u/ml .......................... 49 heparin sodium (porcine) 10000 u/ml ........................ 49 heparin sodium (porcine) 20000 u/ml ........................ 49 heparin sodium (porcine) 5000 u/ml .......................... 49 HEPARIN SODIUM INJ 5000U/0.5ML .................... 49 HEPARIN SODIUM INJ 5000U/ML ......................... 49 HEPARIN SODIUM/NACL 0.45%................................ 49 hepatamine ....................... 53 HEPSERA
see adefovir dipivoxil ....... 9 HERCEPTIN ..................... 12 HERCEPTIN HYLECTA .... 12 HERZUMA ........................ 12 HETLIOZ ........................... 32 HIBERIX ........................... 52 HIPREX
see methenamine hippurate ......................... 6
HIZENTRA ........................ 51 HORIZANT ....................... 33 HUMATROPE ................... 44 HUMATROPE COMBO PACK ................................ 44 HUMIRA ............................ 51 HUMIRA INJ 10MG/0.2ML 51 HUMIRA KIT 20MG/0.4ML 51 HUMIRA KIT 40MG/0.8ML 51 HUMIRA PEDIATRIC CROHNS DISEASE .......... 51 HUMIRA PEN ................... 51 HUMIRA PEN CD/UC/HS STARTER ......................... 51 HUMIRA PEN INJ CD/UC/HS STARTER ....... 51 HUMIRA PEN INJ PS/UV STARTER ......................... 51 HUMIRA PEN-PS/UV
STARTER ......................... 51 HUMULIN R U-500 (CONCENTRATE) ............ 37 HUMULIN R U-500 KWIKPEN ......................... 37 HYCAMTIN
see topotecan hcl .......... 16 hydralazine hcl .................. 21 HYDREA
see hydroxyurea ............ 16 hydrochlorothiazide ........... 21 hydrocodone bitartrate ........ 3 hydrocodone-acetaminophen 10-300mg ........................... 3 hydrocodone-acetaminophen 10-325mg ........................... 3 hydrocodone-acetaminophen 5-300mg ............................. 3 hydrocodone-acetaminophen 5-325mg ............................. 3 hydrocodone-acetaminophen 7.5-300mg .......................... 3 hydrocodone-acetaminophen 7.5-325 mg/15ml ................. 3 hydrocodone-acetaminophen 7.5-325mg .......................... 3 hydrocodone-ibuprofen ....... 3 hydrocortisone .................. 43 hydrocortisone (enema) .... 47 hydrocortisone (topical) cream 1% ......................... 62 hydrocortisone (topical) cream 2.5% ...................... 62 hydrocortisone (topical) lotion 2.5% ........................ 62 hydrocortisone (topical) oint 1% .................................... 63 hydrocortisone (topical) oint 2.5% ................................. 63 hydrocortisone butyrate cream 0.1% ...................... 63 hydrocortisone butyrate cream 0.1% lipo base ....... 63 hydrocortisone butyrate lotion 0.1% ........................ 63 hydrocortisone butyrate oint 0.1% ................................. 63 hydrocortisone butyrate soln
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0.1% .................................. 63 hydrocortisone w/acetic acid .......................................... 65 hydromorphone hcl .............3 hydromorphone hcl t24a 8mg .....................................3 HYDROMORPHONE HYDROCHLORI .................3 hydroxychloroquine sulfate .......................................... 51 hydroxyprogesterone caproate (antineoplastic) ... 14 hydroxyurea ...................... 16 hydroxyzine hcl ................. 57 hydroxyzine hcl inj ............. 57 hydroxyzine pamoate ........ 57 HYQVIA ............................ 51 HYSINGLA ER ....................3 HYZAAR
see losartan-hydrochlorothiazide tab 100-12.5mg ........ 17 see losartan-hydrochlorothiazide tab 100-25mg ........... 17 see losartan-hydrochlorothiazidetab 50-12.5mg ........... 17
I ibandronate sodium inj ...... 39 ibandronate sodium tabs ... 39 IBRANCE .................... 12, 13 ibu tab 600mg .....................1 ibu tab 800mg .....................1 ibuprofen .............................1 icatibant acetate ................ 50 ICLUSIG............................ 15 IDHIFA .............................. 13 IFEX INJ 3GM ................... 11 ifosfamide.......................... 11 IFOSFAMIDE INJ 3GM ..... 11 ILARIS .............................. 52 ILEVRO ............................. 55 imatinib mesylate .............. 15 IMBRUVICA ...................... 15 IMFINZI ............................. 13 imipenem-cilastatin .............5 imipramine hcl ................... 26
imipramine pamoate ......... 26 imiquimod ......................... 64 IMITREX
see sumatriptan ....... 32, 33 see sumatriptan inj 6mg/0.5ml ..................... 33 see sumatriptan succinate ...................................... 33
IMITREX STATDOSE REFILL
see sumatriptan inj 4mg/0.5ml ..................... 33 see sumatriptan inj 6mg/0.5ml ..................... 33
IMITREX STATDOSE SYSTEM
see sumatriptan inj 4mg/0.5ml ..................... 33 see sumatriptan inj 6mg/0.5ml ..................... 33
IMOVAX RABIES (H.D.C.V.) .......................................... 52 IMPOYZ ............................ 63 IMURAN
see azathioprine ............ 52 IMVEXXY MAINTENANCE PACK ................................ 43 IMVEXXY STARTER PACK .......................................... 43 INBRIJA ............................ 27 incassia ............................. 40 INCRELEX ........................ 44 INCRUSE ELLIPTA .......... 56 indapamide ....................... 21 INDERAL LA
see propranolol cap er ... 19 INFANRIX ......................... 52 INFUGEM ......................... 12 INGREZZA ........................ 33 INLYTA ............................. 15 INREBIC ........................... 15 INSPRA
see eplerenone ............. 17 INSULIN PEN NEEDLES .. 37 INSULIN SAFETY NEEDLES ......................... 37 INSULIN SYRINGES ........ 37 INTELENCE ........................ 7
INTRALIPID 30% .............. 53 INTRALIPID INJ 20% ....... 54 INTRAROSA ..................... 48 INTRON-A INJ 10MU ....... 52 INTRON-A INJ 18MU ....... 52 INTRON-A INJ 25MU ....... 52 INTRON-A INJ 50MU ....... 52 introvale ............................ 40 INTUNIV
see guanfacine er (adhd) ...................................... 31
INVANZ see ertapenem sodium .... 5
INVEGA see paliperidone ............ 28
INVEGA SUSTENNA ........ 28 INVEGA TRINZA .............. 28 INVELTYS ........................ 55 INVIRASE ........................... 7 IPOL INACTIVATED IPV .. 52 ipratropium bromide (nasal).......................................... 56 ipratropium sol inhal .......... 56 ipratropium-albuterol ......... 56 irbesartan .......................... 18 irbesartan-hydrochlorothiazide........................................ 17 IRESSA ............................ 15 irinotecan hcl .................... 16 ISENTRESS ....................... 7 ISENTRESS HD ................. 7 isibloom ............................ 40 ISOLYTE-P/DEXTROSE 5%.......................................... 54 ISOLYTE-S ....................... 54 isoniazid .............................. 8 isoniazid tabs ...................... 8 ISOPTO CARPINE
see pilocarpine hcl ........ 56 ISORDIL TITRADOSE
see isosorbide dinitrate 21, 22
isosorbide dinitrate ...... 21, 22 isosorbide mononitrate ..... 22 isosorbide mononitrate er . 22 isotretinoin ........................ 59 isradipine .......................... 20 ISTALOL
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see timolol maleate ophth soln 0.5% (once-daily) ... 56
ISTURISA ......................... 44 itraconazole .........................7 ivermectin............................5 IVERMECTIN .................... 64 IXEMPRA KIT ................... 16 IXIARO .............................. 52 J JADENU............................ 39
see deferasirox tab ........ 39 JADENU SPRINKLE ......... 39 JAKAFI .............................. 15 JALYN
see dutasteride-tamsulosin hcl .................................. 48
jantoven ............................ 49 JANUMET ......................... 37 JANUMET XR TAB 100-1000 ........................... 38 JANUMET XR TAB 50-1000 .......................................... 38 JANUMET XR TAB 50-500MG ......................... 38 JANUVIA ........................... 38 JARDIANCE ...................... 38 jasmiel ............................... 40 JENTADUETO .................. 38 JENTADUETO TAB XR 2.5-1000 MG ..................... 38 JENTADUETO TAB XR 5-1000 MG ........................ 38 JEVTANA .......................... 12 jinteli .................................. 43 jolessa tab 0.15-0.03 mg ... 40 jolivette .............................. 40 JORNAY PM ..................... 31 JUBLIA .............................. 60 juleber ............................... 40 JULUCA ..............................8 junel 1.5/30 ....................... 40 junel 1/20 .......................... 40 junel fe 1.5/30 ................... 40 junel fe 1/20 ...................... 40 junel fe 24 ......................... 40 JUXTAPID ......................... 19 JYNARQUE PAK 30-15MG .......................................... 44
JYNARQUE PAK 45-15MG .......................................... 44 JYNARQUE PAK 60-30MG .......................................... 44 JYNARQUE PAK 90-30MG .......................................... 44 JYNARQUE TABS ............ 44 K KADCYLA ......................... 13 KADIAN .............................. 3
see morphine sulfate ... 3, 4 kaitlib fe ............................. 40 KALBITOR ........................ 50 KALETRA
see lopinavir-ritonavir ...... 8 KALETRA TAB 100-25MG .. 8 KALETRA TAB 200-50MG .. 8 KALYDECO ...................... 58 KANJINTI .......................... 13 KANUMA .......................... 42 KAPSPARGO SPRINKLE . 19 kariva ................................ 40 KATERZIA ........................ 20 KCL 0.15%/D5W/NACL 0.225% .............................. 54 KCL 0.3%/D5W/NACL 0.9% .......................................... 54 kcl/d5w/nacl inj 0.22%/0.45% .......................................... 54 kcl/nacl inj 0.15%-0.9% ..... 54 kcl0.15%/d5w/nacl0.2% .... 54 KEFLEX
see cephalexin ................ 9 kelnor 1/35 ........................ 40 kelnor 1/50 ........................ 40 KENALOG
see triamcinolone acetonide (topical) ......... 63
KENALOG-10 ................... 43 KENALOG-40
see triamcinolone acetonide ....................... 44
KENALOG-80 ................... 43 KEPPRA
see levetiracetam .......... 24 see levetiracetam oral soln 100 mg/ml ..................... 24 see roweepra ................ 24
KEPPRA XR see levetiracetam .......... 24 see roweepra xr ............ 24
ketoconazole ...................... 7 ketoconazole cream .......... 60 ketoconazole foam ............ 60 ketoconazole shampoo ..... 61 ketodan ............................. 60 ketoprofen ........................... 1 ketorolac tromethamine (ophth) .............................. 55 KEVEYIS .......................... 21 KEYTRUDA ...................... 13 KHAPZORY ...................... 16 KINRIX .............................. 52 kionex sus 15gm/60ml ...... 39 KISQALI ............................ 13 KISQALI FEMARA 200 DOSE ............................... 13 KISQALI FEMARA 400 DOSE ............................... 13 KISQALI FEMARA 600 DOSE ............................... 13 KITABIS PAK
see tobramycin ................ 5 KLARON
see sulfacetamide sodium (acne) ............................ 60
KLONOPIN see clonazepam ............ 23
klor-con 10 ........................ 53 klor-con 8 .......................... 53 klor-con m10 ..................... 53 klor-con m15 ..................... 53 klor-con m20 ..................... 53 klor-con pak 20meq .......... 53 klor-con spr cap 10meq .... 53 klor-con spr cap 8meq ...... 53 KORLYM .......................... 44 KOSELUGO ..................... 15 KRINTAFEL ........................ 7 KRISTALOSE ................... 47 KRYSTEXXA ...................... 1 K-TAB
see potassium chloride . 53 kurvelo .............................. 40 KUVAN ............................. 42 KYPROLIS ........................ 13
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L labetalol hcl ....................... 19 LACRISERT ...................... 56 lactated ringer's ................. 54 lactic acid (ammonium lactate) .............................. 64 lactulose ............................ 47 lactulose (encephalopathy) .......................................... 47 LAMICTAL
see lamotrigine .............. 24 see subvenite tab .......... 24
LAMICTAL CHEWABLE DISPERS
see lamotrigine .............. 23 LAMICTAL ODT ................ 23
see lamotrigine .............. 24 LAMICTAL STARTER/NOT TAKI
see lamotrigine .............. 23 see subvenite starter kit. 24
LAMICTAL STARTER/TAKING C
see lamotrigine .............. 23 see subvenite starter kit. 24
LAMICTAL STARTER/TAKING V
see lamotrigine .............. 24 see subvenite starter kit. 24
LAMICTAL XR .................. 23 see lamotrigine .............. 24
LAMISIL see terbinafine hcl ...........7
lamivudine ...........................7 lamivudine (hbv) ..................9 lamivudine-zidovudine ........8 lamotrigine .................. 23, 24 LANOXIN
see digitek ..................... 20 see digox ....................... 20 see digoxin .................... 20 see digoxin inj ................ 20
LANOXIN PEDIATRIC INJ 21 LANOXIN TABS 62.5MCG 21 lansoprazole ...................... 48 lanthanum chew tab .......... 45 larin 1.5/30 ........................ 40 larin 1/20 ........................... 40
larin fe 1.5/30 .................... 40 larin fe 1/20 ....................... 40 larissia tab ......................... 40 LARTRUVO ...................... 13 LASIX
see furosemide .............. 21 LASTACAFT ..................... 55 latanoprost ........................ 56 LATUDA ............................ 28 layolis fe chw .................... 40 leena tab ........................... 40 leflunomide ....................... 51 LEMTRADA ...................... 34 LENVIMA 10 MG DAILY DOSE ................................ 15 LENVIMA 12MG DAILY DOSE ................................ 15 LENVIMA 14 MG DAILY DOSE ................................ 15 LENVIMA 18 MG DAILY DOSE ................................ 15 LENVIMA 20 MG DAILY DOSE ................................ 15 LENVIMA 24 MG DAILY DOSE ................................ 15 LENVIMA 4 MG DAILY DOSE ................................ 15 LENVIMA 8 MG DAILY DOSE ................................ 15 LESCOL XL
see fluvastatin sodium ... 18 lessina ............................... 40 LETAIRIS
see ambrisentan ............ 22 letrozole ............................ 14 leucovorin calcium ............ 16 LEUKERAN ...................... 11 LEUKINE .......................... 50 leuprolide inj 1mg/0.2 ........ 14 levalbuterol hcl .................. 57 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml .......... 57 levalbuterol tartrate hfa ..... 57 LEVAQUIN
see levofloxacin ............. 10 LEVEMIR .......................... 37 LEVEMIR FLEXTOUCH ... 37 levetiracetam .................... 24
LEVETIRACETAM see levetiracetam in sodium chloride ............. 24
levetiracetam in sodium chloride ............................. 24 levetiracetam oral soln 100 mg/ml ................................ 24 levobunolol hcl .................. 56 levocarnitine (metabolic modifiers) .......................... 42 levocetirizine oral soln ...... 57 levocetirizine tab 5 mg ...... 57 levofloxacin ....................... 10 levofloxacin (ophth) ........... 55 levofloxacin in d5w ............ 10 levoleucovorin calcium ...... 16 levoleucovorin calcium 50mg.......................................... 16 levonest ............................ 40 levonor/ethi tab ................. 40 levonorgestrel & eth estradiol.......................................... 40 levonorgestrel-ethinyl estradiol (91-day) ........ 40, 41 levonorgestrel-ethinyl estradiol (continuous) ....... 41 levora 0.15/30-28 .............. 41 levo-t ................................. 45 levothyroxine sodium ........ 45 levoxyl ............................... 45 LEXAPRO
see escitalopram oxalate ...................................... 26
LEXETTE .......................... 63 LEXIVA ............................... 7
see fosamprenavir tab 700 mg ................................... 7
LIALDA see mesalamine ............ 47
LIBTAYO .......................... 13 lidocaine ........................... 63 lidocaine hcl ...................... 63 lidocaine hcl (local anesth.) 5 lidocaine hcl (mouth-throat).......................................... 65 lidocaine inj 0.5% ................ 5 lidocaine inj 1% ................... 5 lidocaine inj 1.5%
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preservative free (pf) ...........5 lidocaine inj 2% preservative free (pf) ...............................5 lidocaine inj 4% preservative free (pf) ...............................5 lidocaine-prilocaine ........... 63 LIDODERM
see lidocaine ................. 63 linezolid in sodium chloride .5 linezolid inj ..........................6 linezolid susp ......................6 linezolid tab 600mg .............6 LINZESS ........................... 47 liothyronine sodium ........... 45 LIPITOR
see atorvastatin calcium 18 lisinopril ............................. 17 lisinopril & hydrochlorothiazide ........... 17 lithium carb tab 300mg ...... 33 lithium carbonate ............... 33 LITHIUM SOLN 8MEQ/5ML .......................................... 33 LITHOBID
see lithium carbonate .... 33 LIVALO ............................. 18 LO LOESTRIN FE ............. 41 LOCOID
see hydrocortisone butyrate lotion 0.1% ....... 63
LOCOID LIPOCREAM see hydrocortisone butyrate cream 0.1% lipo base .............................. 63
LODINE see etodolac ....................1
LODOSYN see carbidopa ................ 27
LOESTRIN 1.5/30-21 see junel 1.5/30 ............. 40 see larin 1.5/30 .............. 40 see microgestin 1.5/30 .. 41
LOESTRIN 1/20-21 see junel 1/20 ................ 40 see larin 1/20 ................. 40 see microgestin 1/20 ..... 41 see norethindrone acet & eth estra ........................ 41
LOESTRIN FE 1.5/30 see blisovi fe 1.5/30....... 40 see junel fe 1.5/30 ......... 40 see larin fe 1.5/30 .......... 40 see microgestin fe 1.5/30 ...................................... 41
LOESTRIN FE 1/20 see junel fe 1/20 ............ 40 see larin fe 1/20 ............. 40 see microgestin fe 1/20 . 41 see tarina fe 1/20 .......... 41
LOKELMA ......................... 39 LOMOTIL
see diphenoxylate w/ atropine ......................... 47
LONSURF ......................... 16 loperamide hcl .................. 47 LOPERAMIDE HYDROCHLORIDE .......... 47 LOPID
see gemfibrozil .............. 19 lopinavir-ritonavir ................ 8 LOPRESSOR
see metoprolol tartrate .. 19 LOPRESSOR HCT
see metoprolol & hydrochlorothiazide ....... 19
LOPROX see ciclopirox olamine ... 60
lorazepam ......................... 22 lorazepam intensol ............ 22 LORBRENA ...................... 15 lorcet hd tab 10-325mg ....... 3 lorcet plus tab 7.5-325 ........ 3 lorcet tab 5-325mg .............. 3 loryna ................................ 41 losartan potassium ............ 18 losartan-hydrochlorothiazide tab 100-12.5mg ................. 17 losartan-hydrochlorothiazide tab 100-25mg .................... 17 losartan-hydrochlorothiazidetab 50-12.5mg .................... 17 LOSEASONIQUE
see amethia lo ............... 39 see camrese lo tab ........ 40 see levonorgestrel-ethinyl estradiol (91-day) .......... 41
LOTEMAX ........................ 55 see loteprednol etabonate ...................................... 55
LOTEMAX SM .................. 55 LOTENSIN
see benazepril hcl ......... 17 LOTENSIN HCT
see benazepril & hydrochlorothiazide ....... 17
loteprednol etabonate ....... 55 LOTREL
see amlodipine besylate-benazepril hcl . 16
LOTRONEX see alosetron hcl ........... 47
lovastatin .......................... 18 LOVAZA
see omega-3-acid ethyl esters ............................ 19
LOVENOX see enoxaparin sodium . 49
low-ogestrel ...................... 41 loxapine succinate ............ 28 LUCEMYRA ...................... 36 LUCENTIS ........................ 56 luliconazole ....................... 60 LUMIGAN ......................... 56 LUMIZYME ....................... 42 LUMOXITI ......................... 13 LUPANETA PACK ............ 42 LUPRON DEPOT (1-MONTH) ....................... 14 LUPRON DEPOT (6-MONTH) ....................... 14 LUPRON DEPOT INJ 11.25MG (3-MONTH) ....... 14 LUPRON DEPOT INJ 22.5MG (3-MONTH) ......... 14 LUPRON DEPOT INJ 30MG (4-MONTH) ....................... 14 LUPRON DEPOT-PED (1-MONTH ........................ 44 LUPRON DEPOT-PED (3-MONTH ........................ 44 LUPRON DEP-PED INJ 11.25MG (3-MONTH) ....... 44 LUPRON DEP-PED INJ 7.5MG ............................... 44
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lutera ................................. 41 LUXIQ
see betamethasone valerate.......................... 61
LYNPARZA ....................... 13 LYRICA
see pregabalin ............... 24 LYRICA CR ....................... 33 LYSODREN ...................... 14 LYSTEDA
see tranexamic acid ...... 50 lyza ................................... 41 M MACROBID
see nitrofurantoin monohyd macro ...............6
MACRODANTIN see nitrofurantoin macrocrystal ....................6
mafenide acetate .............. 60 magnesium sulfate ............ 53 MAGNESIUM SULFATE ... 53
see magnesium sulfate . 53 MAGNESIUM SULFATE IN D5W .................................. 53
see magnesium sulfate in dextrose......................... 53
magnesium sulfate in dextrose ............................ 53 magnesium sulfate inj 50% .......................................... 53 MALARONE
see atovaquone-proguanil hcl tab 250-100 mg ..........7 see atovaquone-proguanil hcl tab 62.5-25 mg ...........7
malathion .......................... 64 maprotiline hcl ................... 26 MARINOL
see dronabinol ............... 46 marlissa............................. 41 MARPLAN TAB 10MG ...... 26 MARQIBO ......................... 12 MATULANE ...................... 16 matzim la........................... 20 MAVENCLAD PAK 10MG(10) .......................... 34 MAVENCLAD PAK 10MG(4)
.......................................... 34 MAVENCLAD PAK 10MG(5) .......................................... 34 MAVENCLAD PAK 10MG(6) .......................................... 34 MAVENCLAD PAK 10MG(7) .......................................... 34 MAVENCLAD PAK 10MG(8) .......................................... 34 MAVENCLAD PAK 10MG(9) .......................................... 34 MAVIK
see trandolapril .............. 17 MAVYRET .......................... 9 MAXALT
see rizatriptan benzoate 32 MAXALT-MLT
see rizatriptan benzoate odt ................................. 32
MAXIDEX .......................... 55 MAXITROL
see neomycin-polymy-dexameth .................................... 54
MAXZIDE see triamterene & hydrochlorothiazide tab 75-50mg ........................ 21
MAXZIDE-25 see triamterene & hydrochlorothiazide tab 37.5-25mg ..................... 21
MAYZENT ......................... 34 meclizine hcl ..................... 46 meclofenamate sodium ....... 1 MEDROL
see methylpred tab 16mg ...................................... 43 see methylpred tab 32mg ...................................... 43 see methylpred tab 4mg 43 see methylpred tab 8mg 43
MEDROL DOSEPAK see methylpred pak 4mg ...................................... 43
MEDROL TAB 2MG .......... 43 medroxyprogesterone acetate .............................. 45
medroxyprogesterone acetate (contraceptive) ..... 41 mefloquine hcl .................... 7 megestrol ac sus 40mg/ml 14 megestrol ac tab 20mg ..... 14 megestrol ac tab 40mg ..... 14 megestrol sus 625mg/5ml . 14 MEKINIST ......................... 15 MEKTOVI ......................... 15 melodetta 24 fe ................. 41 meloxicam .......................... 1 memantine hcl cp24 .......... 25 memantine soln ................ 25 memantine tabs ................ 25 memantine titration pak .... 25 MENACTRA ..................... 53 MENEST ........................... 43 MENOSTAR ..................... 43 MENTAX ........................... 60 MENVEO .......................... 53 MEPRON
see atovaquone............... 5 mercaptopurine ................. 12 meropenem ........................ 6 MEROPENEM/SODIUM CHLORIDE ......................... 6 MERREM
see meropenem .............. 6 mesalamine ...................... 47 mesalamine enema .......... 47 mesalamine w/ cleanser ... 47 MESNEX .......................... 16 MESTINON
see pyridostigmine bromide ......................... 33 see pyridostigmine tab 60mg ............................. 34
MESTINON TIMESPAN see pyridostigmine bromide ......................... 33
metadate er tab 20mg ....... 31 metformin er ..................... 38 metformin hcl .................... 38 methadone hcl .................... 3 METHADONE HCL
see methadone hcl .......... 3 methadone hcl intensol ....... 3 methadone tab 10mg .......... 3
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methadone tab 5mg ............3 METHADOSE
see methadone hcl intensol ............................3
methazolamide .................. 21 methenamine hippurate ......6 methimazole ...................... 45 methotrexate sodium inj soln .......................................... 12 methotrexate sodium inj solr .......................................... 12 methotrexate sodium tabs . 51 methoxsalen rapid ............. 61 methscopolamine bromide 46 METHYLIN
see methylphenidate hcl 31 methylphenidate hcl .......... 31 methylphenidate hcl tbcr 10 mg ..................................... 31 methylphenidate hcl tbcr 20mg ................................. 31 METHYLPHENIDATE HCL TBCR 72MG ..................... 31 methylpr ss inj ................... 43 methylpred pak 4mg ......... 43 methylpred tab 16mg ........ 43 methylpred tab 32mg ........ 43 methylpred tab 4mg .......... 43 methylpred tab 8mg .......... 43 methylprednisolone acetate .......................................... 43 metoclopramide hcl ........... 46 metoclopramide hcl inj ...... 46 METOCLOPRAMIDE ODT 10MG ................................ 46 metoclopramide odt 5mg .. 46 metolazone ....................... 21 metoprolol & hydrochlorothiazide ........... 19 metoprolol succinate ......... 19 metoprolol tartrate ............. 19 METROCREAM
see metronidazole (topical).......................... 64 see rosadan cre 0.75% . 64
METROLOTION see metronidazole (topical).......................... 64
metronidazole ..................... 6 METRONIDAZOLE ............. 6
see metronidazole in nacl 6 metronidazole (topical)...... 64 metronidazole gel 0.75% .. 64 metronidazole in nacl .......... 6 metronidazole vaginal ....... 49 MIACALCIN
see calcitonin (salmon) nasal spray .................... 44
mibelas 24 fe .................... 41 micafungin sodium .............. 7 MICARDIS
see telmisartan .............. 18 MICARDIS HCT
see telmisartan-hydrochlorothiazide .............................. 18
miconazole 3 ..................... 49 miconazole-zinc oxide-white petrolatum ......................... 60 microgestin 1.5/30 ............ 41 microgestin 1/20 ............... 41 microgestin fe 1.5/30......... 41 microgestin fe 1/20 ........... 41 midodrine hcl .................... 21 migergot ............................ 32 miglitol ............................... 38 miglustat ........................... 42 MIGRANAL
see dihydroergotamine mesylate nasal spr 4 mg/ml ............................ 32
mili .................................... 41 MINASTRIN 24 FE
see melodetta 24 fe ....... 41 see mibelas 24 fe .......... 41 see norethin acet & estrad-fe ........................ 41
MINIPRESS see prazosin hcl ............ 17
minitran ............................. 22 MINOCIN
see minocycline hcl ....... 11 minocycline hcl ................. 11 minocycline tab 105mg er . 11 minocycline tab 115mg er . 11 minocycline tab 135mg er . 11
minocycline tab 45mg er ... 11 minocycline tab 55mg er ... 11 minocycline tab 65mg er ... 11 minocycline tab 80mg er ... 11 minocycline tab 90mg er ... 11 MINOLIRA ........................ 11 minoxidil ............................ 21 MIRAPEX
see pramipexole tab 0.125mg ........................ 27 see pramipexole tab 0.5mg ............................ 27 see pramipexole tab 0.75mg .......................... 27 see pramipexole tab 1mg ...................................... 27
MIRAPEX ER see pramipexole er ........ 27
MIRCETTE see bekyree .................. 39 see desogestrel-ethinyl estradiol (biphasic) ........ 40 see kariva ...................... 40 see pimtrea ................... 41 see viorele ..................... 42
mirtazapine tab 15mg odt . 26 mirtazapine tab 30mg odt . 26 mirtazapine tab 45mg odt . 26 mirtazapine tabs ............... 26 MIRVASO ......................... 64 misoprostol ....................... 47 MITIGARE .......................... 1 mitomycin ......................... 11 mitoxantrone hcl ............... 16 M-M-R II ............................ 52 M-NATAL PLUS................ 54 MOBIC
see meloxicam ................ 1 modafinil ........................... 35 moexipril hcl ...................... 17 molindone hcl ................... 28 mometasone furoate ......... 63 mometasone furoate (nasal).......................................... 58 mondoxyne nl cap 100mg . 11 mondoxyne nl cap 75mg ... 11 mono-linyah tab 0.25-35 ... 41 montelukast sodium .......... 57
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MORPHABOND ER ............3 morphine sul inj 1mg/ml ......3 morphine sulfate ............. 3, 4 MORPHINE SULFATE .......4
see morphine sulfate .......4 morphine sulfate beads .......4 morphine sulfate ext-rel tab.4 morphine sulfate oral soln 100mg/5ml ..........................4 morphine sulfate oral soln 10mg/5ml ............................4 morphine sulfate oral soln 20mg/5ml ............................4 MOTEGRITY ..................... 47 MOVANTIK ....................... 47 MOVIPREP ....................... 47 MOXEZA ........................... 55
see moxifloxacin hcl (ophth) ........................... 55
moxifloxacin hcl ................. 10 moxifloxacin hcl (ophth) .... 55 moxifloxacin hcl in sodium chloride ............................. 10 MOXIFLOXACIN HYDROCHLORID ............. 10 MOZOBIL .......................... 50 MS CONTIN
see morphine sulfate ext-rel tab ........................4
MULPLETA ....................... 50 MULTAQ ........................... 18 mupirocin .......................... 60 MVASI ............................... 13 MYALEPT ......................... 44 MYAMBUTOL
see ethambutol hcl ..........8 MYCAMINE .........................7
see micafungin sodium ....7 MYCOBUTIN
see rifabutin .....................8 mycophenolate mofetil ...... 52 mycophenolate sodium tbec .......................................... 52 MYDAYIS CAP 12.5MG .... 31 MYDAYIS CAP 25MG ....... 31 MYDAYIS CAP 37.5MG .... 31 MYDAYIS CAP 50MG ....... 31 MYFORTIC
see mycophenolate sodium tbec ................... 52
MYLOTARG ...................... 13 MYOBLOC ........................ 35 myorisan ........................... 59 MYRBETRIQ .................... 49 MYSOLINE
see primidone ................ 24 N nabumetone ........................ 1 nadolol .............................. 19 NAFCILLIN IN DEXTROSE .......................................... 10 nafcillin sodium ................. 10 NAFCILLIN SODIUM FOR INJ 10GM .......................... 10 naftifine hcl ........................ 60 NAFTIN ............................. 60
see naftifine hcl ............. 60 NAGLAZYME .................... 42 nalbuphine hcl ..................... 2 naloxone inj 0.4mg/ml ....... 36 naloxone inj 1mg/ml .......... 36 naltrexone hcl ................... 36 NAMENDA
see memantine tabs ...... 25 NAMENDA TITRATION PAK
see memantine titration pak ................................ 25
NAMENDA XR see memantine hcl cp24 25
NAMENDA XR TITRATION PACK ................................ 25 NAMZARIC ....................... 25 NAPROSYN
see naproxen .................. 1 naproxen ............................. 1 naproxen dr ......................... 1 naproxen sodium ................ 1 naratriptan hcl ................... 32 NARCAN ........................... 36 NARDIL
see phenelzine sulfate ... 26 NASONEX
see mometasone furoate (nasal) ........................... 58
NATACYN ......................... 55 NATAZIA ........................... 41
nateglinide ........................ 38 NATPARA ......................... 44 NATROBA ........................ 64 NAYZILAM ........................ 24 NEBUPENT
see pentamidine isethionate inh ................. 6
necon 0.5/35-28 ................ 41 nefazodone hcl ................. 26 neomycin sulfate ................. 5 neomycin/polymyxin b gu . 64 neomycin-bacitracin zn-polymyxin ..................... 55 neomycin-polymy-dexameth.......................................... 54 neomycin-polymyxin-gramicidin ..................................... 55 neomycin-polymyxin-hc (ophth) .............................. 54 neomycin-polymyxin-hc (otic).......................................... 65 NEORAL
see cyclosporine modified (for microemulsion) ....... 52 see gengraf ................... 52
NEPHRAMINE .................. 54 NERLYNX ......................... 15 neuac gel 1.2-5% .............. 59 NEUPRO .......................... 27 NEURONTIN
see gabapentin.............. 23 NEVANAC ........................ 55 nevirapine susp 50 mg/5ml . 7 nevirapine tab 100mg er ..... 7 nevirapine tab 200mg ......... 7 nevirapine tab 400mg er ..... 7 NEXAVAR ........................ 15 NEXIUM
see esomeprazole magnesium ................... 48
NEXIUM GRA 10MG DR .. 48 NEXIUM GRA 2.5MG DR . 48 NEXIUM GRA 20MG DR .. 48 NEXIUM GRA 40MG DR .. 48 NEXIUM GRA 5MG DR .... 48 NEXIUM I.V.
see esomeprazole sodium inj .................................. 48
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NEXLETOL ....................... 19 NEXLIZET ......................... 19 niacin (antihyperlipidemic). 19 niacin er (antihyperlipidemic) .......................................... 19 niacor ................................ 19 NIASPAN
see niacin er (antihyperlipidemic) ....... 19
nicardipine hcl ................... 20 NICARDIPINE HYDROCHLORIDE .......... 20 NICOTROL INHALER ....... 36 NICOTROL NS ................. 36 nifedipine........................... 20 nikki ................................... 41 NILANDRON
see nilutamide ............... 14 nilutamide.......................... 14 nimodipine......................... 20 NINLARO .......................... 13 NIPENT ............................. 12 nisoldipine ......................... 20 nitisinone ........................... 42 NITRO-BID ........................ 22 NITRO-DUR ...................... 22
see minitran ................... 22 nitrofurantoin .......................6 nitrofurantoin macrocrystal ..6 nitrofurantoin monohyd macro ..................................6 nitroglycerin ....................... 22 nitroglycerin td patch ......... 22 NITROLINGUAL PUMPSPRAY
see nitroglycerin ............ 22 NITROSTAT
see nitroglycerin ............ 22 NITYR ............................... 42 nizatidine ........................... 47 nolix .................................. 63 nora-be tab........................ 41 NORCO
see hydrocodone-acetaminophen 10-325mg ...................3 see hydrocodone-acetaminoph
en 5-325mg ..................... 3 see hydrocodone-acetaminophen 7.5-325mg .................. 3 see lorcet hd tab 10-325mg ........................ 3 see lorcet plus tab 7.5-325 ........................................ 3 see lorcet tab 5-325mg .... 3
NORDITROPIN FLEXPRO .......................................... 44 nore/eth/fer chw 0.4mg-35 41 noreth/ethin chw fe ........... 41 norethin acet & estrad-fe ... 41 norethindrone (contraceptive) .................. 41 norethindrone acet & eth estra .................................. 41 norethindrone acetate ....... 45 norethindrone acetate-ethinyl estradiol ............................ 43 norgest/ethi tab 0.25/35 .... 41 norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ............................. 41 norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg ............................. 41 NORITATE ........................ 64 NORMOSOL-M IN D5W ... 54 NORMOSOL-R ................. 54 NORMOSOL-R IN D5W .... 54 NORPACE
see disopyramide phosphate ..................... 18
NORPACE CR .................. 18 NORPRAMIN
see desipramine hcl ...... 25 NORTHERA ...................... 21 nortrel 0.5/35 (28) ............. 41 nortrel 1/35 ........................ 41 nortrel 7/7/7 ....................... 41 nortriptyline hcl .................. 26 NORVASC
see amlodipine besylate 19 NORVIR
see ritonavir .................... 8 NORVIR PACK ................... 7 NORVIR SOLN ................... 7 NOURIANZ ....................... 27 NOVAREL ........................ 44 NOVOLIN 70/30................ 37 NOVOLIN 70/30 FLEXPEN.......................................... 37 NOVOLIN N ...................... 37 NOVOLIN N FLEXPEN ..... 37 NOVOLIN R ...................... 37 NOVOLIN R FLEXPEN ..... 37 NOVOLOG ....................... 37 NOVOLOG 70/30 FLEXPEN.......................................... 37 NOVOLOG FLEXPEN ...... 37 NOVOLOG MIX 70/30 ...... 37 NOVOLOG PENFILL ........ 37 NOXAFIL ............................ 7
see posaconazole ........... 7 NPLATE ............................ 50 NUBEQA .......................... 14 NUCALA ........................... 58 NUCYNTA .......................... 4 NUCYNTA ER .................... 4 NUEDEXTA ...................... 33 NULOJIX .......................... 52 NULYTELY
see gavilyte-n/flavor pack ...................................... 47 see peg 3350-potassium chloride-sod bicarbonate-sod chloride ...................................... 47 see trilyte ....................... 47
NULYTELY/FLAVOR PACKS ............................. 47 NUPLAZID CAPS ............. 28 NUPLAZID TABS 10MG ... 28 NUTRILIPID INJ 20% ....... 54 NUTROPIN AQ NUSPIN 10.......................................... 44 NUTROPIN AQ NUSPIN 20.......................................... 44 NUTROPIN AQ NUSPIN 5 44 NUVARING
see eluryng ................... 40 see etonogestrel-ethinyl
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estradiol ......................... 40 NUVIGIL
see armodafinil .............. 35 nyamyc ............................. 60 NYMALIZE ........................ 20 nystatin ...............................7 nystatin (mouth-throat) ...... 65 nystatin (topical) ................ 60 nystatin pow 100000 ......... 60 nystop ............................... 60 O OCALIVA .......................... 48 ocella tab 3-0.03mg .......... 41 OCREVUS ........................ 34 OCTAGAM ........................ 51 octreotide acetate ............. 44 octreotide inj 100mcg/ml ... 44 OCUFLOX
see ofloxacin (ophth) ..... 55 ODACTRA ........................ 52 ODEFSEY ...........................8 ODOMZO .......................... 13 OFEV ................................ 58 ofloxacin (ophth) ............... 55 ofloxacin (otic) ................... 65 OGIVRI ............................. 13 olanzapine......................... 28 olanzapine odt ................... 28 olmesartan medoxomil ...... 18 olmesartan medoxomil-amlodipine-hydrochlorothiazide .................... 17 olmesartan medoxomil-hydrochlorothiazide ...................................... 17 olopatadine hcl (nasal) ...... 57 olopatadine hcl 0.1% ......... 55 olopatadine hcl 0.2% ......... 55 OLUX
see clobetasol propionate ...................................... 61
OLUX-E see clobetasol propionate emulsion ........................ 62 see tovet ........................ 63
OMECLAMOX-PAK .......... 48 omega-3-acid ethyl esters . 19 omeprazole cap 10mg ...... 48
omeprazole cap 20mg ...... 48 omeprazole cap 40mg ...... 48 OMNARIS ......................... 58 OMNITROPE 10MG ......... 44 OMNITROPE 5.8MG ........ 44 OMNITROPE 5MG ........... 44 ondansetron hcl ................ 46 ondansetron hcl inj ............ 46 ondansetron hcl oral soln .. 46 ondansetron odt ................ 46 ONE VITE WOMENS PRENATAL ....................... 54 ONEXTON ........................ 59 ONFI
see clobazam ................ 23 ONIVYDE .......................... 16 ONTRUZANT .................... 13 ONZETRA XSAIL ............. 32 OPANA
see oxymorphone tabs .... 4 OPDIVO ............................ 13 OPSUMIT ......................... 22 ORALAIR .......................... 52 ORAPRED ODT
see prednisolone sodium phosphate ..................... 43
ORAVIG ............................ 65 ORBACTIV ......................... 6 ORENITRAM .................... 22 ORFADIN .......................... 42
see nitisinone ................ 42 ORILISSA ......................... 42 ORKAMBI ......................... 58 orsythia ............................. 41 ORTHO TRI-CYCLEN LO
see norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ......................... 41 see tri-lo- tab marzia ...... 42 see tri-lo-estarylla .......... 42 see tri-lo-sprintec ........... 42 see tri-vylibra lo ............. 42
oseltamivir phosphate ......... 9 OSMOLEX ER .................. 27 OSMOPREP ..................... 47 OSPHENA ........................ 44 OTOVEL ........................... 65
oxacillin sodium ................ 10 oxaliplatin inj 100mg ......... 16 oxaliplatin inj 100mg/20ml 16 oxaliplatin inj 50mg ........... 16 oxaliplatin inj 50mg/10ml .. 16 oxandrolone ...................... 36 oxaprozin ............................ 1 OXAYDO ............................ 4 OXBRYTA ........................ 50 oxcarbazepine .................. 24 OXERVATE ...................... 56 OXISTAT .......................... 61 OXSORALEN ULTRA
see methoxsalen rapid .. 61 OXTELLAR XR ................. 24 oxybutynin chloride ........... 49 oxycodone hcl ..................... 4 oxycodone w/ acetaminophen 10-325mg .. 4 oxycodone w/ acetaminophen 2.5-325mg . 4 oxycodone w/ acetaminophen 5-325mg .... 4 oxycodone w/ acetaminophen 7.5-325mg . 4 oxycodone-aspirin............... 4 oxycodone-ibuprofen .......... 4 OXYCONTIN ...................... 4 oxymorphone tabs .............. 4 OXYTROL ........................ 49 OZEMPIC INJ 0.25 OR 0.5MG/DOSE .................... 37 OZEMPIC INJ 1MG/DOSE.......................................... 37 P pacerone ........................... 18 paclitaxel ........................... 12 PADCEV ........................... 13 paliperidone ...................... 28 palonosetron hcl ............... 46 PALONOSETRON HYDROCHLORID 0.25MG/2ML ..................... 46 PALYNZIQ ........................ 42 PAMELOR
see nortriptyline hcl ....... 26 pamidronate disodium ...... 39 PAMIDRONATE DISODIUM
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.......................................... 39 pamidronate inj 30mg ....... 39 pamidronate inj 90mg ....... 39 PANCREAZE .................... 48 PANDEL............................ 63 PANRETIN ........................ 64 pantoprazole sodium ......... 48 PANZYGA ......................... 52 paricalcitol ......................... 54 PARLODEL
see bromocriptine mesylate ........................ 27
PARNATE see tranylcypromine sulfate ............................ 26
paroex sol 0.12% .............. 65 paromomycin sulfate ...........5 paroxetine er tab ............... 26 paroxetine hcl tabs ............ 26 paroxetine mesylate (vasomotor) ....................... 33 PASER D/R .........................8 PATANASE
see olopatadine hcl (nasal) ...................................... 57
PAXIL ................................ 26 see paroxetine hcl tabs.. 26
PAXIL CR see paroxetine er tab ..... 26
PAZEO .............................. 55 PEDIAPRED
see pred sod pho sol 5mg/5ml ......................... 43
PEDIARIX ......................... 53 PEDVAX HIB .................... 53 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........... 47 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 47 PEGANONE ...................... 24 PEGASYS ...........................9 PEGASYS PROCLICK .......9 PEMAZYRE ...................... 15 penicillamine ..................... 39 PENICILLIN G POT IN DEXTROSE 1MU .............. 10 PENICILLIN G POT IN
DEXTROSE 2MU ............. 10 PENICILLIN G POT IN DEXTROSE 3MU ............. 10 PENICILLIN G PROCAINE .......................................... 10 penicillin g sodium ............ 10 penicillin v potassium ........ 11 penicilln gk inj 20mu ......... 11 penicilln gk inj 5mu ........... 11 PENNSAID ....................... 64 PENTACEL ....................... 53 PENTAM 300
see pentamidine isethionate inj .................. 6
pentamidine isethionate inh 6 pentamidine isethionate inj . 6 PENTASA ......................... 47 pentoxifylline ..................... 50 PEPCID
see famotidine ............... 46 PERCOCET
see endocet 10-325mg .... 2 see endocet 2.5-325mg ... 2 see endocet 5-325mg ...... 2 see endocet 7.5-325mg ... 2 see oxycodone w/ acetaminophen 10-325mg ........................................ 4 see oxycodone w/ acetaminophen 2.5-325mg ........................................ 4 see oxycodone w/ acetaminophen 5-325mg . 4 see oxycodone w/ acetaminophen 7.5-325mg ........................................ 4
PERFOROMIST ............... 57 PERIDEX
see chlorhexidine gluconate (mouth-throat) ...................................... 65 see paroex sol 0.12% .... 65 see periogard ................ 65
perindopril erbumine ......... 17 periogard ........................... 65 PERJETA .......................... 13 permethrin cre 5% ............ 64 perphenazine .................... 28
PERSERIS ....................... 28 PERTZYE ......................... 48 PEXEVA ........................... 26 pfizerpen-g inj 20mu ......... 11 pfizerpen-g inj 5mu ........... 11 phenadoz .......................... 46 phenelzine sulfate ............. 26 PHENERGAN
see promethazine hcl inj 46 phenobarbital .................... 24 phenobarbital sodium ....... 24 phenoxybenzamine hcl ..... 21 PHENYTEK ...................... 24
see phenytoin sodium extended ....................... 24
phenytoin .......................... 24 phenytoin sodium extended.......................................... 24 phenytoin sodium inj 50mg/ml ............................ 24 philith ................................ 41 PHOSLO
see calcium acetate (phosphate binder) ........ 45
PHOSLYRA ...................... 45 PHOSPHOLINE IODIDE .. 56 PICATO ............................ 64 PIFELTRO .......................... 7 pilocarpine hcl ................... 56 pilocarpine hcl (oral) ......... 65 pimecrolimus .................... 64 pimozide ........................... 29 pimtrea .............................. 41 pindolol ............................. 19 pioglitazone hcl ................. 38 pioglitazone hcl-glimepiride.......................................... 38 pioglitazone hcl-metformin hcl ..................................... 38 piper/tazoba inj 12-1.5gm . 11 piper/tazoba inj 2-0.25gm . 11 piper/tazoba inj 3-0.375gm11 piper/tazoba inj 36-4.5gm . 11 piper/tazoba inj 4-0.5gm ... 11 PIQRAY 200MG DAILY DOSE ............................... 15 PIQRAY 250MG DAILY DOSE ............................... 15
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PIQRAY 300MG DAILY DOSE ................................ 15 pirmella 1/35 ..................... 41 piroxicam.............................1 PLAQUENIL
see hydroxychloroquine sulfate ............................ 51
PLASMA-LYTE A .............. 54 PLASMA-LYTE-148 .......... 54 PLAVIX
see clopidogrel bisulfate 51 PLEGRIDY ........................ 34 PLEGRIDY STARTER PACK ................................ 34 plenamine ......................... 54 PLENVU............................ 47 PNV FOLIC ACID + IRON MUL .................................. 54 podofilox............................ 64 POLIVY ............................. 13 polymyxin b sulfate .............6 polymyxin b-trimethoprim .. 55 POLYTRIM
see polymyxin b-trimethoprim ............... 55
POMALYST ...................... 14 portia-28 ............................ 41 PORTRAZZA .................... 13 posaconazole ......................7 potassium chloride ...... 53, 54 POTASSIUM CHLORIDE . 54 potassium chloride 0.15% in nacl 0.45% ........................ 54 potassium chloride in dextrose ............................ 54 potassium chloride in dextrose & sodium chloride .......................................... 54 potassium chloride in nacl . 54 potassium chloride microencapsulated crystals er ....................................... 53 POTASSIUM CHLORIDE/DEXTRO ....... 54 potassium citrate (alkalinizer) er tabs ............................... 49 POTELIGEO ..................... 13 PRADAXA ......................... 49
PRALUENT ....................... 19 pramipexole er .................. 27 pramipexole tab 0.125mg . 27 pramipexole tab 0.25mg ... 27 pramipexole tab 0.5mg ..... 27 pramipexole tab 0.75mg ... 27 pramipexole tab 1.5mg ..... 27 pramipexole tab 1mg ........ 27 prasugrel hcl ..................... 51 PRAVACHOL
see pravastatin sodium . 18 pravastatin sodium ............ 18 praziquantel ........................ 6 prazosin hcl ....................... 17 PRECOSE
see acarbose ................. 37 PRED FORTE
see prednisolone acetate (ophth) ........................... 55
PRED MILD ...................... 55 pred sod pho sol 5mg/5ml . 43 PRED-G ............................ 54 PRED-G S.O.P. ................ 54 prednicarbate .................... 63 prednisolone acetate (ophth) .......................................... 55 prednisolone sodium phosphate ......................... 43 PREDNISOLONE SODIUM PHOSPHATE (OPHTH) .... 55 prednisolone sol 15mg/5ml .......................................... 43 prednisolone sol 25mg/5ml .......................................... 43 PREDNISONE CON 5MG/ML ............................ 43 prednisone pak 10mg ....... 43 prednisone pak 5mg ......... 43 prednisone sol 5mg/5ml .... 43 prednisone tab 10mg ........ 43 prednisone tab 1mg .......... 43 prednisone tab 2.5mg ....... 43 prednisone tab 20mg ........ 43 prednisone tab 50mg ........ 43 prednisone tab 5mg .......... 43 pregabalin ......................... 24 PREGNYL W/DILUENT BENZYL ............................ 44
PREMARIN CREAM ......... 43 PREMARIN INJ ................ 43 PREMARIN TABS ............ 43 PREMASOL 10%.............. 54 PREMPHASE ................... 43 PREMPRO ....................... 43 PRENATAL ....................... 54 PRENATAL PLUS ............ 54 PRENATAL PLUS LOW IRON ................................. 54 PRETOMANID .................... 8 PREVACID
see lansoprazole ........... 48 PREVACID SOLUTAB
see lansoprazole ........... 48 prevalite ............................ 19 previfem ............................ 41 PREVYMIS INJ ................... 9 PREVYMIS TABS ............... 9 PREZCOBIX ....................... 8 PREZISTA ...................... 7, 8 PRIFTIN .............................. 8 PRILOSEC ....................... 48 primaquine phosphate ........ 7 PRIMAQUINE PHOSPHATE............................................ 7
see primaquine phosphate ........................................ 7
PRIMAXIN IV see imipenem-cilastatin ... 5
primidone .......................... 24 PRINIVIL
see lisinopril .................. 17 PRISTIQ
see desvenlafaxine succinate ....................... 26
PRIVIGEN ........................ 52 PROAIR DIGIHALER ........ 57 PROAIR HFA
see albuterol sulfate ...... 57 PROAIR RESPICLICK ...... 57 probenecid .......................... 1 PROCALAMINE................ 54 PROCARDIA XL
see nifedipine ................ 20 prochlorperazine inj .......... 46 prochlorperazine maleate . 46 prochlorperazine supp ...... 46
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PROCRIT .......................... 50 PROCTOCORT
see procto-pak ............... 64 procto-med hc ................... 64 procto-pak ......................... 64 proctosol hc cre 2.5% ....... 64 proctozone-hc ................... 64 PROCYSBI ....................... 42 progesterone micronized... 45 PROGLYCEM
see diazoxide ................ 44 PROGLYCEM SUS 50MG/ML .......................... 44 PROGRAF ........................ 52
see tacrolimus ............... 52 PROLASTIN-C .................. 58 PROLENSA ...................... 55 PROLIA ............................. 44 PROMACTA ...................... 50 promethazine hcl ............... 46 promethazine hcl inj .......... 46 promethegan ..................... 46 PROMETRIUM
see progesterone micronized ..................... 45
propafenone hcl ................ 18 propantheline bromide ...... 46 proparacaine hcl ............... 56 propranolol & hydrochlorothiazide ........... 19 propranolol cap er ............. 19 propranolol inj 1mg/ml ....... 19 propranolol oral sol ........... 19 propranolol tab .................. 19 propylthiouracil .................. 45 PROQUAD ........................ 53 PROSCAR
see finasteride ............... 48 PROSOL ........................... 54 PROTONIX ....................... 48
see pantoprazole sodium ...................................... 48
PROTOPIC see tacrolimus (topical).. 64
protriptyline hcl .................. 26 PROVENTIL HFA
see albuterol sulfate ...... 57 PROVERA
see medroxyprogesterone acetate .......................... 45
PROVIGIL see modafinil ................. 35
PROZAC see fluoxetine hcl .......... 26
PULMICORT see budesonide (inhalation) .................... 58
PULMICORT FLEXHALER .......................................... 58 PULMOZYME ................... 58 PURIXAN .......................... 12 pyrazinamide ...................... 8 pyridostigmine bromide ..... 33 pyridostigmine bromide tab 30 mg ................................ 33 pyridostigmine tab 60mg ... 34 pyrimethamine .................... 6 Q QBRELIS .......................... 17 QBREXZA ......................... 64 QINLOCK .......................... 15 QMIIZ ODT ......................... 1 QNASL .............................. 58 QNASL CHILDRENS ........ 58 QUADRACEL ................... 53 QUALAQUIN
see quinine sulfate .......... 7 QUARTETTE
see fayosim ................... 40 see levonorgestrel-ethinyl estradiol (91-day) .......... 41 see rivelsa ..................... 41
QUESTRAN see cholestyramine ....... 18
QUESTRAN LIGHT see cholestyramine light powd .............................. 18 see prevalite .................. 19
quetiapine fumarate .......... 29 QUILLICHEW ER ............. 31 QUILLIVANT XR ............... 31 quinapril hcl ....................... 17 quinapril-hydrochlorothiazide .......................................... 17 quinidine sulfate ................ 18 quinine sulfate ..................... 7
QUZYTTIR ........................ 57 R RABAVERT ...................... 53 rabeprazole sodium .......... 48 RADICAVA ....................... 34 RAGWITEK ...................... 52 raloxifene hcl .................... 45 ramelteon .......................... 32 ramipril .............................. 17 RANEXA
see ranolazine ............... 21 ranolazine ......................... 21 RAPAFLO
see silodosin ................. 48 RAPAMUNE
see sirolimus ................. 52 rasagiline mesylate ........... 27 RAVICTI ........................... 42 RAYALDEE ...................... 54 RAZADYNE
see galantamine hydrobromide ................ 25
RAZADYNE ER see galantamine hydrobromide er ............ 25
REBIF ............................... 34 REBIF REBIDOSE ............ 35 REBIF REBIDOSE TITRATION ....................... 35 REBIF TITRATION PACK 35 REBLOZYL ....................... 50 RECARBRIO ...................... 6 RECLAST
see zoledronic acid inj 5mg/100ml .................... 39
reclipsen ........................... 41 RECOMBIVAX HB ............ 53 RECTIV ............................ 64 REGLAN
see metoclopramide hcl 46 REGRANEX ..................... 64 RELENZA DISKHALER ...... 9 RELEXXII ......................... 31 RELISTOR ........................ 48 RELPAX
see eletriptan hydrobromide ................ 32
REMERON
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see mirtazapine tabs ..... 26 REMERON SOLTAB
see mirtazapine tab 15mg odt ................................. 26 see mirtazapine tab 30mg odt ................................. 26 see mirtazapine tab 45mg odt ................................. 26
RENAGEL see sevelamer tab 800mg ...................................... 45
RENFLEXIS ...................... 51 RENVELA
see sevelamer carbonate ...................................... 45
repaglinide ........................ 38 REQUIP XL
see ropinirole er ............. 27 RESTASIS ........................ 56 RESTASIS MULTIDOSE .. 56 RESTORIL
see temazepam ............. 32 RETEVMO ........................ 15 RETIN-A
see avita ........................ 59 see tretinoin ................... 60
RETIN-A MICRO ............... 59 see tretinoin microsphere ...................................... 60
RETIN-A MICRO PUMP ... 60 RETROVIR
see zidovudine cap 100mg ........................................8 see zidovudine syp 50mg/5ml .........................8
REVATIO see sildenafil citrate (pulmonary hypertension) ...................................... 22 see sildenafil citrate tab 20 mg (pulmonary hypertension) ................. 22
REVCOVI .......................... 42 REVLIMID ......................... 14 REXULTI ........................... 29 REYATAZ ...........................8
see atazanavir sulfate .....7 RHOPRESSA ................... 56
ribavirin 200mg ................... 9 rifabutin ............................... 8 RIFADIN
see rifampin ..................... 8 rifampin ............................... 8 RILUTEK
see riluzole .................... 34 riluzole .............................. 34 rimantadine hydrochloride ... 9 RINVOQ ............................ 51 RIOMET ............................ 38
see metformin hcl .......... 38 RIOMET ER ...................... 38 risedronate sodium ........... 39 RISPERDAL
see risperidone .............. 29 RISPERDAL INJ 12.5MG . 29 RISPERDAL INJ 25MG .... 29 RISPERDAL INJ 37.5MG . 29 RISPERDAL INJ 50MG .... 29 risperidone ........................ 29 risperidone odt .................. 29 RITALIN
see methylphenidate hcl 31 RITALIN LA
see methylphenidate hcl 31 ritonavir ............................... 8 RITUXAN .......................... 13 RITUXAN HYCELA ........... 13 rivastigmine tartrate .......... 25 rivastigmine td patch 24hr 13.3mg/24hr ...................... 25 rivastigmine td patch 24hr 4.6mg/24hr ........................ 25 rivastigmine td patch 24hr 9.5mg/24hr ........................ 25 rivelsa ............................... 41 rizatriptan benzoate .......... 32 rizatriptan benzoate odt .... 32 ROCALTROL
see calcitriol .................. 54 ropinirole er ....................... 27 ropinirole tab 0.25mg ........ 27 ropinirole tab 0.5mg .......... 27 ropinirole tab 1mg ............. 27 ropinirole tab 2mg ............. 27 ropinirole tab 3mg ............. 27 ropinirole tab 4mg ............. 27
ropinirole tab 5mg ............. 27 rosadan cre 0.75% ............ 64 rosuvastatin calcium ......... 18 ROTARIX .......................... 53 ROTATEQ ........................ 53 ROWASA
see mesalamine w/ cleanser ........................ 47
roweepra ........................... 24 roweepra xr ....................... 24 ROXICODONE
see oxycodone hcl .......... 4 ROZEREM
see ramelteon ............... 32 ROZLYTREK .................... 15 RUBRACA ........................ 13 RUCONEST ..................... 50 RUXIENCE ....................... 13 RUZURGI ......................... 34 RYBELSUS ...................... 38 RYDAPT ........................... 15 RYTARY ........................... 27 RYTHMOL SR
see propafenone hcl ...... 18 S SABRIL
see vigabatrin powd pack 500mg ........................... 25 see vigabatrin tab 500mg ...................................... 25 see vigadrone................ 25
SAFYRAL see drospirenone-ethinyl estradiol-levomefolate calcium .......................... 40 see tydemy .................... 42
SAIZEN ............................. 45 SAIZENPREP RECONSTITUTION .......... 45 SALAGEN
see pilocarpine hcl (oral) ...................................... 65
SAMSCA .......................... 45 see tolvaptan ................. 45
SANCUSO ........................ 46 SANDIMMUNE
see cyclosporine ........... 52 SANDIMMUNE SOLN
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100MG/ML ........................ 52 SANDOSTATIN
see octreotide acetate ... 44 see octreotide inj 100mcg/ml ..................... 44
SANDOSTATIN LAR DEPOT ............................. 45 SANTYL ............................ 64 SAPHRIS .......................... 29 SARAFEM
see fluoxetine hcl (pmdd) ...................................... 36
SARCLISA ........................ 13 SAVELLA .......................... 34 SAVELLA TITRATION PACK ................................ 34 scopolamine ...................... 46 SEASONIQUE
see amethia ................... 39 see ashlyna ................... 39 see levonorgestrel-ethinyl estradiol (91-day) .......... 41
SECUADO ........................ 29 selegiline hcl ..................... 27 selenium sulfide ................ 61 SELZENTRY .......................8 SEMPREX-D ..................... 57 SENSIPAR
see cinacalcet hcl .......... 44 SEREVENT DISKUS ........ 57 SERNIVO .......................... 63 SEROQUEL
see quetiapine fumarate 29 SEROQUEL XR
see quetiapine fumarate 29 SEROSTIM ....................... 45 sertraline hcl ...................... 26 setlakin tab ........................ 41 sevelamer carbonate ........ 45 sevelamer tab 400mg ....... 45 sevelamer tab 800mg ....... 45 SFROWASA ..................... 47 sharobel ............................ 41 SHINGRIX ......................... 53 SIGNIFOR ......................... 45 SIGNIFOR LAR ................. 45 SIKLOS ............................. 16 sildenafil citrate (pulmonary
hypertension) .................... 22 sildenafil citrate tab 20 mg (pulmonary hypertension) . 22 SILENOR
see doxepin hcl (sleep) . 32 silodosin ............................ 48 SILVADENE
see silver sulfadiazine ... 60 see ssd .......................... 60
silver sulfadiazine ............. 60 SIMBRINZA ...................... 56 simvastatin ........................ 18 SINEMET
see carbidopa-levodopa 27 SINGULAIR
see montelukast sodium 57 sirolimus ............................ 52 SIRTURO ............................ 8 SITAVIG .............................. 9 SIVEXTRO .......................... 6 SKLICE ............................. 64 SKYRIZI ............................ 51 SLYND .............................. 41 SMOFLIPID ...................... 54 sodium chloride ........... 53, 54 sodium chloride 0.45%...... 54 sodium chloride 0.9% irrigation ............................ 65 sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln ........ 53 sodium phenylbutyrate ...... 42 sodium polystyrene sulfonate powder .............................. 39 sodium polystyrene sulfonate susp .................................. 39 solifenacin succinate ......... 49 SOLIQUA 100/33 .............. 37 SOLIRIS ............................ 50 SOLODYN
see minocycline tab 105mg er ....................... 11 see minocycline tab 115mg er ....................... 11 see minocycline tab 55mg er ................................... 11 see minocycline tab 65mg er ................................... 11 see minocycline tab 80mg
er ................................... 11 SOLOSEC .......................... 6 SOLTAMOX ...................... 14 SOLU-CORTEF 1000MG . 43 SOLU-CORTEF 100MG ... 43 SOLU-CORTEF 250MG ... 43 SOLU-CORTEF 500MG ... 43 SOLU-MEDROL ............... 43
see methylpr ss inj ........ 43 SOMATULINE DEPOT ..... 45 SOMAVERT ..................... 45 SORIATANE
see acitretin ................... 61 SORILUX .......................... 61 sorine ................................ 18 sotalol hcl .......................... 18 sotalol hcl (afib/afl) ............ 18 SOTYLIZE ........................ 18 SPIRIVA HANDIHALER ... 56 SPIRIVA RESPIMAT 1.25MCG/ACT .................. 56 SPIRIVA RESPIMAT 2.5MCG/ACT .................... 56 SPIRIVA RESPIMAT 2.5MCG/ACT (INSTITUTIONAL PACK) .. 56 spironolactone .................. 17 spironolactone & hydrochlorothiazide ........... 21 SPORANOX
see itraconazole .............. 7 sprintec 28 ........................ 41 SPRITAM .......................... 24 SPRYCEL ......................... 15 sps .................................... 39 sronyx ............................... 41 ssd .................................... 60 STALEVO 100
see carbidopa-levodopa-entacapone ............................ 27
STALEVO 150 see carbidopa-levodopa-entacapone ............................ 27
stavudine ............................ 8 STELARA ......................... 51 STIMATE .......................... 45
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STIVARGA ........................ 15 STRATTERA
see atomoxetine hcl ...... 30 STRENSIQ ........................ 42 streptomycin sulfate ............5 STRIBILD ............................8 STRIVERDI RESPIMAT.... 57 STROMECTOL
see ivermectin .................5 SUBLOCADE .................... 36 SUBOXONE
see buprenorphine hcl-naloxone hcl dihydrate 12-3mg .......................... 35 see buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg ......................... 35 see buprenorphine hcl-naloxone hcl dihydrate 4-1mg ............................ 35 see buprenorphine hcl-naloxone hcl dihydrate 8-2mg ............................ 35
SUBSYS SPRAY 100MCG .4 SUBSYS SPRAY 1200MCG ............................................4 SUBSYS SPRAY 1600MCG ............................................5 SUBSYS SPRAY 200MCG .4 SUBSYS SPRAY 400MCG .4 SUBSYS SPRAY 600MCG .4 SUBSYS SPRAY 800MCG .4 subvenite starter kit ........... 24 subvenite tab ..................... 24 SUCRAID .......................... 48 sucralfate .......................... 48 SULAR
see nisoldipine ............... 20 sulfacetamide sodium (acne) .......................................... 60 sulfacetamide sodium (ophth) .............................. 55 sulfacetamide sod-prednisolone .............. 54 SULFADIAZINE ..................5 sulfamethoxazole-trimethop ds ........................................6 sulfamethoxazole-trimethopri
m inj .................................... 6 sulfamethoxazole-trimethoprim susp ................................ 6 sulfamethoxazole-trimethoprim tab 400-80mg .................. 6 SULFAMYLON ................. 60
see mafenide acetate .... 60 sulfasalazine dr ................. 47 sulfasalazine ir .................. 47 sulindac ............................... 1 sumatriptan ................. 32, 33 sumatriptan inj 4mg/0.5ml . 33 sumatriptan inj 6mg/0.5ml . 33 sumatriptan succinate ....... 33 sumatriptan-naproxen sodium .............................. 33 SUNOSI ............................ 35 SUPRAX ............................. 9
see cefixime .................... 9 SUPREP BOWEL PREP KIT .......................................... 47 SUSTIVA
see efavirenz ................... 7 SUSTOL ........................... 46 SUTENT ........................... 15 syeda ................................ 41 SYLATRON ...................... 16 SYLVANT ......................... 16 SYMBICORT .................... 59 SYMDEKO ........................ 58 SYMFI ................................. 8 SYMFI LO ........................... 8 SYMJEPI .......................... 58 SYMLINPEN 120 .............. 37 SYMLINPEN 60 ................ 37 SYMPAZAN ...................... 24 SYMPROIC ....................... 48 SYMTUZA ........................... 8 SYNALAR
see fluocinolone acetonide ...................................... 62
SYNAREL ......................... 42 SYNDROS ........................ 46 SYNERCID ......................... 6 SYNJARDY TAB 12.5-1000MG .................... 38 SYNJARDY TAB 12.5-500MG ...................... 38
SYNJARDY TAB 5-1000MG.......................................... 38 SYNJARDY TAB 5-500MG.......................................... 38 SYNJARDY XR TAB 10-1000MG ....................... 38 SYNJARDY XR TAB 12.5-1000MG .................... 38 SYNJARDY XR TAB 25-1000MG ....................... 38 SYNJARDY XR TAB 5-1000MG ......................... 38 SYNRIBO ......................... 16 SYNTHROID .................... 45
see euthyrox ................. 45 see levo-t ...................... 45 see levothyroxine sodium ...................................... 45 see levoxyl .................... 45 see unithroid ................. 45
SYPRINE see clovique .................. 39 see trientine hcl ............. 39
T TABLOID .......................... 12 TABRECTA ...................... 15 TACLONEX
see calcipotriene-betamethasone dipropionate ............. 61
tacrolimus ......................... 52 tacrolimus (topical) ............ 64 tadalafil (pulmonary hypertension) .................... 22 TAFINLAR ........................ 15 TAGRISSO ....................... 15 TAKHZYRO ...................... 50 TALICIA ............................ 48 TALZENNA ....................... 13 TAMIFLU
see oseltamivir phosphate ........................................ 9
tamoxifen citrate ............... 14 tamsulosin hcl ................... 48 TAPAZOLE
see methimazole ........... 45 TARCEVA
see erlotinib hcl ............. 14
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TARGRETIN ..................... 64 see bexarotene .............. 16
tarina 24 fe ........................ 41 tarina fe 1/20 ..................... 41 TARKA
see trandolapril-verapamil hcl .................................. 17
TASIGNA .......................... 15 TAVALISSE ...................... 50 TAXOTERE ....................... 12
see docetaxel ................ 12 TAYTULLA ........................ 41 tazarotene ......................... 61 tazicef .................................9 TAZORAC
see tazarotene ............... 61 TAZORAC CREAM 0.05% 61 TAZORAC GEL 0.05% ..... 61 TAZORAC GEL 0.1% ....... 61 taztia xt ............................. 20 TAZVERIK ........................ 16 TDVAX .............................. 53 TECENTRIQ ..................... 13 TECFIDERA ...................... 35 TECFIDERA STARTER PACK ................................ 35 TEFLARO ...........................9 TEGRETOL
see carbamazepine ....... 23 see epitol ....................... 23
TEGRETOL-XR see carbamazepine ....... 23
TEGSEDI .......................... 34 TEKTURNA
see aliskiren fumarate ... 21 TEKTURNA HCT .............. 21 telmisartan ........................ 18 telmisartan-amlodipine ...... 18 telmisartan-hydrochlorothiazide ...................................... 18 temazepam ....................... 32 TEMIXYS ............................8 TEMOVATE
see clobetasol propionate ...................................... 61
temsirolimus ...................... 13 TENIVAC .......................... 53 tenofovir disoproxil fumarate
............................................ 8 TENORETIC 100
see atenolol & chlorthalidone ................ 19
TENORETIC 50 see atenolol & chlorthalidone ................ 19
TENORMIN see atenolol ................... 19
TEPEZZA .......................... 45 terazosin hcl ...................... 17 terbinafine hcl ..................... 7 terbutaline sulfate ............. 57 terconazole vaginal ........... 49 testosterone ...................... 36 testosterone cypionate ...... 36 testosterone enanthate ..... 36 testosterone td soln 30 mg/act ............................... 36 tetrabenazine .................... 34 tetracycline hcl .................. 11 TEXACORT ...................... 63 THALOMID ....................... 14 THEO-24 ........................... 58 theophylline ....................... 58 theophylline tab er 12hr 300 mg ..................................... 58 theophylline tab er 12hr 450 mg ..................................... 58 theophylline tab sr 24hr ..... 58 THIOLA ............................. 49 THIOLA EC ....................... 49 thioridazine hcl .................. 29 thiothixene ........................ 29 tiadylt er ............................ 20 tiagabine hcl ...................... 24 TIAZAC
see diltiazem hcl coated beads cap sr 24hr ......... 20 see diltiazem hcl extended release beads cap sr ..... 20 see taztia xt ................... 20 see tiadylt er .................. 20
TIBSOVO .......................... 13 tigecycline ........................... 6 TIGECYCLINE .................... 6 TIGLUTIK .......................... 34 TIKOSYN
see dofetilide ................. 18 tilia fe ................................ 41 timolol maleate ................. 19 timolol maleate (ophth) soln.......................................... 56 timolol maleate gel ............ 56 timolol maleate ophth soln 0.5% (once-daily) .............. 56 TIMOPTIC
see timolol maleate (ophth) soln ................... 56
TIMOPTIC OCUDOSE ..... 56 TIMOPTIC-XE
see timolol maleate gel . 56 tinidazole ............................ 6 TIROSINT ......................... 45 TIROSINT-SOL................. 45 TIVICAY .............................. 8 TIVICAY PD ........................ 8 tizanidine hcl ..................... 35 tizanidine tabs ................... 35 TOBI PODHALER ............... 5 TOBRADEX ...................... 54
see tobramycin-dexamethasone .................................... 54
TOBRADEX ST ................ 54 tobramycin .......................... 5 tobramycin (ophth) ............ 55 tobramycin inj 1.2 gm/30ml . 5 tobramycin inj 1.2gm ........... 5 tobramycin inj 10mg/ml ....... 5 tobramycin inj 80mg/2ml ..... 5 tobramycin sulfate............... 5 tobramycin-dexamethasone.......................................... 54 TOBREX ........................... 55
see tobramycin (ophth) . 55 tolmetin sodium................... 1 TOLSURA ........................... 7 tolterodine er ..................... 49 tolterodine tartrate............. 49 tolvaptan ........................... 45 TOPAMAX
see topiramate .............. 24 TOPAMAX SPRINKLE
see topiramate .............. 24 TOPICORT
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see desoximetasone ..... 62 topiramate ......................... 24 toposar .............................. 16 topotecan hcl ..................... 16 TOPOTECAN HCL
see topotecan hcl .......... 16 TOPROL XL
see metoprolol succinate ...................................... 19
toremifene citrate .............. 14 TORISEL
see temsirolimus ........... 13 torsemide .......................... 21 TOSYMRA ........................ 33 TOTECT............................ 16 tovet .................................. 63 TOVIAZ ............................. 49 TPN ELECTROLYTES ..... 53 TRACLEER ....................... 22
see bosentan ................. 22 TRADJENTA ..................... 38 tramadol hcl ........................2 tramadol hcl er (biphasic) 100mg .................................2 tramadol hcl er (biphasic) 200mg .................................2 tramadol hcl er (biphasic) 300mg .................................2 tramadol hcl tab 100 mg .....2 tramadol hcl tab 50 mg .......2 tramadol-acetaminophen ....2 trandolapril ........................ 17 trandolapril-verapamil hcl .. 17 tranexamic acid ................. 50 TRANSDERM SCOP
see scopolamine ........... 46 tranylcypromine sulfate ..... 26 TRAVASOL ....................... 54 TRAVATAN Z
see travoprost ................ 56 travoprost .......................... 56 TRAZIMERA ..................... 13 trazodone hcl .................... 26 TREANDA ......................... 11 TRECATOR ........................8 TRELEGY ELLIPTA .......... 56 TRELSTAR MIXJECT ....... 14 treprostinil ......................... 22
TRESIBA FLEXTOUCH .... 37 TRESIBA INJ .................... 37 tretinoin ....................... 16, 60 tretinoin microsphere ........ 60 TREXALL .......................... 51 TREXIMET
see sumatriptan-naproxen sodium ........................... 33
trezix ................................... 2 triamcinolone acetonide .... 44 triamcinolone acetonide (mouth) ............................. 65 triamcinolone acetonide (topical) ............................. 63 triamterene & hydrochlorothiazide cap 37.5-25mg ......................... 21 triamterene & hydrochlorothiazide tab 37.5-25mg ......................... 21 triamterene & hydrochlorothiazide tab 75-50mg ............................ 21 TRIBENZOR
see olmesartan medoxomil-amlodipine-hydrochlorothiazide ............. 17
TRICARE .......................... 54 TRICOR
see fenofibrate .............. 19 triderm ............................... 63 trientine hcl ....................... 39 tri-estarylla ........................ 41 trifluoperazine hcl .............. 29 trifluridine .......................... 55 TRIGLIDE ......................... 19 trihexyphenidyl hcl ............ 27 TRIJARDY XR TAB ER 24HR 10-5-1000 MG......... 38 TRIJARDY XR TAB ER 24HR 12.5-2.5-1000MG.... 38 TRIJARDY XR TAB ER 24HR 25-5-1000 MG......... 39 TRIJARDY XR TAB ER 24HR 5-2.5-1000MG......... 38 TRIKAFTA ........................ 58 tri-legest fe ........................ 41 TRILEPTAL
see oxcarbazepine ........ 24 tri-linyah ............................ 41 TRILIPIX
see choline fenofibrate .. 18 tri-lo- tab marzia ................ 42 tri-lo-estarylla .................... 42 tri-lo-sprintec ..................... 42 trilyte ................................. 47 trimethoprim ........................ 6 tri-mili ................................ 42 trimipramine maleate ........ 26 TRINTELLIX ..................... 26 tri-previfem ........................ 42 tri-sprintec ......................... 42 TRIUMEQ ........................... 8 trivora-28 .......................... 42 tri-vylibra ........................... 42 tri-vylibra lo ....................... 42 TRIZIVIR
see abacavir sulfate-lamivudine-zidovudine ................................... 8
TRODELVY ...................... 13 TROGARZO ....................... 8 TROKENDI XR ................. 24 TROPHAMINE INJ 10% ... 54 TROPHAMINE INJ 6% ..... 54 trospium chloride .............. 49 TRULANCE ...................... 48 TRULICITY ....................... 37 TRUMENBA ..................... 53 TRUSOPT
see dorzolamide hcl ...... 56 TRUVADA TAB 100-150 .... 8 TRUVADA TAB 133-200 .... 8 TRUVADA TAB 167-250 .... 8 TRUVADA TAB 200-300 .... 8 TRUXIMA ......................... 13 TUKYSA ........................... 15 tulana ................................ 42 TURALIO .......................... 15 TWINRIX INJ .................... 53 TWYNSTA
see telmisartan-amlodipine ...................................... 18
TYBOST ............................. 8 tydemy .............................. 42 TYGACIL
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see tigecycline .................6 TYKERB............................ 15 TYMLOS ........................... 45 TYPHIM VI ........................ 53 TYSABRI........................... 35 TYVASO ........................... 22 U UCERIS
see budesonide ............. 47 UCERIS FOAM ................. 47 ULORIC
see febuxostat .................1 ULTOMIRIS ...................... 50 ULTRACET
see tramadol-acetaminophen .2
ULTRAM see tramadol hcl tab 50 mg ...................................2
ULTRAVATE LOTN .......... 63 UNASYN
see ampicillin & sulbactam sodium ........................... 10
UNASYN BULK PACK see ampicillin & sulbactam sodium ........................... 10
unithroid ............................ 45 UPTRAVI .......................... 22 UROCIT-K 10
see potassium citrate (alkalinizer) er tabs ........ 49
UROCIT-K 15 see potassium citrate (alkalinizer) er tabs ........ 49
UROCIT-K 5 see potassium citrate (alkalinizer) er tabs ........ 49
UROXATRAL see alfuzosin hcl ............ 48
URSO 250 see ursodiol ................... 48
URSO FORTE see ursodiol ................... 48
ursodiol ............................. 48 V VABOMERE ........................6 VAGIFEM
see estradiol vaginal tab 43
see yuvafem vaginal tablet 10 mcg .......................... 43
valacyclovir hcl .................... 9 VALCHLOR ...................... 64 VALCYTE
see valganciclovir hcl ...... 9 valganciclovir hcl ................. 9 VALIUM
see diazepam ................ 23 valproate sodium .............. 25 valproic acid ...................... 25 valrubicin ........................... 12 valsartan ........................... 18 valsartan-hydrochlorothiazide ........................................ 18 VALSTAR
see valrubicin ................ 12 VALTOCO ......................... 25 VALTREX
see valacyclovir hcl ......... 9 VANCOCIN
see vancomycin hcl ......... 6 VANCOCIN HCL
see vancomycin hcl ......... 6 vancomycin hcl ................... 6 VANCOMYCIN HYDROCHLORIDE ............ 6 VANCOMYCIN IN NACL .... 6 VANCOMYCIN INJ 250MG 6 vandazole ......................... 49 VANTAS ........................... 14 VAQTA .............................. 53 VARIVAX .......................... 53 VARUBI TAB 90MG .......... 46 VASCEPA ......................... 19 VASERETIC
see enalapril maleate & hydrochlorothiazide ....... 17
VASOTEC see enalapril maleate .... 17
VECTIBIX ......................... 13 VELCADE ......................... 13 VELETRI ........................... 22 velivet ................................ 42 VELPHORO ...................... 45 VELTASSA ....................... 39 VELTIN ............................. 60 VEMLIDY ............................ 9
VENCLEXTA .................... 13 VENCLEXTA STARTING PACK ................................ 13 venlafaxine cap er............. 26 venlafaxine tab ................. 26 venlafaxine tab 225mg er . 26 VENTAVIS ........................ 22 VENTOLIN HFA................ 57 verapamil hcl .................... 20 VERDESO ........................ 63 VERELAN
see verapamil hcl .......... 20 VERELAN PM
see verapamil hcl .......... 20 VERSACLOZ .................... 29 VERZENIO ....................... 13 VESICARE
see solifenacin succinate ...................................... 49
VFEND see voriconazole ............. 7
VFEND IV see voriconazole inj 200mg ............................. 7
VIBATIV .............................. 6 VIBERZI ............................ 48 VIBRAMYCIN ................... 11
see doxycycline (monohydrate) ............... 11 see doxycycline hyclate 11
VICTOZA .......................... 37 VIDAZA
see azacitidine .............. 12 vienva ............................... 42 vigabatrin powd pack 500mg.......................................... 25 vigabatrin tab 500mg ........ 25 vigadrone .......................... 25 VIGAMOX
see moxifloxacin hcl (ophth) ........................... 55
VIIBRYD STARTER PACK.......................................... 26 VIIBRYD TAB ................... 26 VIMIZIM ............................ 42 VIMPAT ............................ 25 VIMPAT INJ 200MG/20ML 25 VIMPAT SOL 10MG/ML ... 25
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vinblastine sulfate ............. 12 vincristine sulfate .............. 12 vinorelbine tartrate ............ 12 VIOKACE 10 ..................... 48 VIOKACE 20 ..................... 48 viorele ............................... 42 VIRACEPT ..........................8 VIRAMUNE
see nevirapine susp 50 mg/5ml.............................7 see nevirapine tab 200mg ........................................7
VIRAMUNE XR see nevirapine tab 400mg er .....................................7
VIREAD...............................8 see tenofovir disoproxil fumarate ..........................8
VISTARIL see hydroxyzine pamoate ...................................... 57
VITRAKVI.......................... 15 VIVELLE-DOT
see dotti ......................... 42 see estradiol .................. 42
VIVITROL.......................... 36 VIZIMPRO ......................... 15 VOLTAREN
see diclofenac sodium (topical) 1% gel .............. 64
voriconazole ........................7 voriconazole inj 200mg .......7 VOSEVI...............................9 VOTRIENT ........................ 16 VPRIV ............................... 42 VRAYLAR ......................... 29 VRAYLAR THERAPY PACK .......................................... 29 VUMERITY ....................... 35 VUMERITY STARTER ...... 35 vyfemla ............................. 42 vylibra ............................... 42 VYNDAMAX ...................... 21 VYNDAQEL ...................... 21 VYTORIN
see ezetimibe-simvastatin ...................................... 19
VYVANSE ................... 31, 32
W WAKIX .............................. 35 warfarin sodium ................ 49 water for irrigation, sterile 65 WELCHOL
see colesevelam hcl ...... 18 WELLBUTRIN SR
see bupropion hcl .......... 25 WELLBUTRIN XL
see bupropion hcl .......... 25 wymzya fe ......................... 42 X XADAGO .......................... 27 XALATAN
see latanoprost .............. 56 XALKORI .......................... 16 XANAX
see alprazolam tab 0.25mg .......................... 22 see alprazolam tab 0.5mg ...................................... 22 see alprazolam tab 1mg 22 see alprazolam tab 2mg 22
XARELTO ......................... 49 XARELTO STARTER PACK .......................................... 50 XATMEP ........................... 51 XCOPRI MAINTENANCE PAK 150-200MG ............... 25 XCOPRI PAK 12.5-25MG . 25 XCOPRI PAK 50-100MG .. 25 XCOPRI PAK 50-200MG .. 25 XCOPRI TABS .................. 25 XCOPRI TITRATION PAK 150-200MG ....................... 25 XELJANZ .......................... 51 XELJANZ XR .................... 51 XEMBIFY .......................... 52 XENAZINE
see tetrabenazine .......... 34 XENLETA ........................... 6 XEOMIN INJ 100 UNITS ... 35 XEOMIN INJ 200 UNITS ... 35 XEOMIN INJ 50 UNITS ..... 35 XEPI.................................. 60 XERESE ........................... 64 XERMELO ........................ 48 XGEVA ............................. 45
XHANCE ........................... 58 XIFAXAN TAB 200MG ........ 6 XIFAXAN TAB 550MG ...... 48 XIGDUO XR TAB 10-1000MG ....................... 39 XIGDUO XR TAB 10-500MG.......................................... 39 XIGDUO XR TAB 2.5-1000MG ...................... 39 XIGDUO XR TAB 5-1000MG.......................................... 39 XIGDUO XR TAB 5-500MG.......................................... 39 XIMINO ............................. 11 XODOL
see hydrocodone-acetaminophen 5-300mg ..................... 3
XOFLUZA ........................... 9 XOLAIR ............................ 58 XOLEGEL ......................... 61 XOPENEX
see levalbuterol hcl ....... 57 XOPENEX CONCENTRATE
see levalbuterol hcl soln nebu conc 1.25 mg/0.5ml ...................................... 57
XOSPATA ......................... 16 XPOVIO 100 MG ONCE WEEKLY ........................... 16 XPOVIO 40 MG ONCE WEEKLY ........................... 16 XPOVIO 40 MG TWICE WEEKLY ........................... 16 XPOVIO 60 MG ONCE WEEKLY ........................... 16 XPOVIO 60 MG TWICE WEEKLY ........................... 16 XPOVIO 80 MG ONCE WEEKLY ........................... 16 XPOVIO 80 MG TWICE WEEKLY ........................... 16 XTAMPZA ER ..................... 5 XTANDI ............................ 14 xulane dis 150-35 ............. 42 XULTOPHY 100/3.6 ......... 37 XYLOCAINE
see lidocaine hcl (local
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anesth.) ...........................5 see lidocaine inj 0.5% ......5 see lidocaine inj 1% .........5
XYLOCAINE-MPF see lidocaine hcl (local anesth.) ...........................5 see lidocaine inj 1.5% preservative free (pf) .......5 see lidocaine inj 2% preservative free (pf) .......5
XYOSTED ......................... 36 XYREM ............................. 35 Y YASMIN 28
see drospirenone-ethinyl estradiol ......................... 40 see ocella tab 3-0.03mg 41 see syeda ...................... 41 see zarah ....................... 42
YAZ see drospirenone-ethinyl estradiol ......................... 40 see gianvi tab 3-0.02mg 40 see jasmiel .................... 40 see loryna ...................... 41 see nikki ........................ 41
YERVOY ........................... 13 YF-VAX ............................. 53 yuvafem vaginal tablet 10 mcg ................................... 43 Z zafirlukast .......................... 57 ZALTRAP .......................... 13 ZANAFLEX
see tizanidine hcl ........... 35 see tizanidine tabs ......... 35
zarah ................................. 42 ZARONTIN
see ethosuximide .......... 23 ZARXIO............................. 50 ZAVESCA
see miglustat ................. 42 ZEJULA............................. 13 ZELAPAR.......................... 27 ZELBORAF ....................... 16 ZELNORM ........................ 48 ZEMAIRA .......................... 58 ZEMBRACE SYMTOUCH . 33
ZEMDRI .............................. 5 ZEMPLAR
see paricalcitol .............. 54 zenatane ........................... 60 ZENPEP ........................... 48 zenzedi ............................. 32 ZERBAXA ........................... 9 ZERIT
see stavudine .................. 8 ZERVIATE ........................ 55 ZESTORETIC
see lisinopril & hydrochlorothiazide ....... 17
ZESTRIL see lisinopril .................. 17
ZETIA see ezetimibe ................ 19
ZETONNA ......................... 58 ZIAC
see bisoprolol & hydrochlorothiazide ....... 19
ZIAGEN see abacavir sulfate ........ 7
ZIANA see clindamycin phosphate-tretinoin........ 59
zidovudine cap 100mg ........ 8 zidovudine syp 50mg/5ml ... 8 zidovudine tab 300mg ......... 8 ZINECARD ....................... 16 ziprasidone hcl .................. 29 ziprasidone mesylate ........ 29 ZIRABEV .......................... 13 ZIRGAN ............................ 55 ZITHROMAX
see azithromycin ............. 9 ZOCOR
see simvastatin ............. 18 ZOFRAN
see ondansetron hcl ...... 46 ZOHYDRO ER
see hydrocodone bitartrate ........................................ 3
ZOLADEX ......................... 14 zoledronic acid inj 4mg/100ml ........................ 39 zoledronic acid inj 5mg/100ml ........................ 39
ZOLEDRONIC INJ 4MG/100ML ...................... 39 zoledronic inj 4mg/5ml ...... 39 ZOLINZA .......................... 13 zolmitriptan ....................... 33 ZOLOFT
see sertraline hcl ........... 26 zolpidem tartrate ............... 32 ZOMACTON ..................... 45 ZOMIG
see zolmitriptan ............. 33 ZOMIG NASAL SPRAY .... 33 ZOMIG ZMT
see zolmitriptan ............. 33 ZONEGRAN
see zonisamide ............. 25 zonisamide ....................... 25 ZONTIVITY ....................... 51 ZORBTIVE ........................ 45 ZORTRESS
see everolimus (immunosuppressant) ... 52
ZORTRESS TAB 0.25MG 52 ZORTRESS TAB 0.5MG .. 52 ZORTRESS TAB 0.75MG 52 ZORTRESS TAB 1MG ..... 52 ZOSTAVAX ...................... 53 ZOSYN ............................. 11 zovia 1/35e ....................... 42 ZOVIRAX
see acyclovir ................... 8 see acyclovir topical ...... 63
ZTLIDO ............................. 63 ZUBSOLV SUB 0.7-0.18MG.......................................... 36 ZUBSOLV SUB 1.4-0.36MG.......................................... 36 ZUBSOLV SUB 11.4-2.9MG.......................................... 36 ZUBSOLV SUB 2.9-0.71MG.......................................... 36 ZUBSOLV SUB 5.7-1.4MG.......................................... 36 ZUBSOLV SUB 8.6-2.1MG.......................................... 36 ZUPLENZ ......................... 46 ZYDELIG .......................... 16 ZYKADIA .......................... 16
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ZYLET ............................... 55 ZYLOPRIM
see allopurinol .................1 ZYMAXID
see gatifloxacin (ophth) . 55 ZYPITAMAG ..................... 18 ZYPREXA
see olanzapine .............. 28 ZYPREXA RELPREVV ..... 29 ZYPREXA RELPREVV INJ 210MG .............................. 29 ZYPREXA ZYDIS
see olanzapine odt ........ 28 ZYTIGA ............................. 14
see abiraterone acetate 13 ZYVOX ............................... 6
see linezolid inj ................ 6 see linezolid susp ............ 6 see linezolid tab 600mg .. 6