drug formulary - pharmacy - amerihealth caritas · pdf fileuppercase= brand name drugs tier...

Drug Formulary

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www.keystonefirstpa.com

100KF-162188

KEY Generics must be used when they are available (denoted in lower case).These symbols are used in the

list to represent the following:PA= Prior Authorization Required ST =Step Therapy Required QL= Quantity

Limit, F= for females, M= for males. If you have any questions, please call Member Services (1-800-521-

6860),Provider Services (1-888-521-6007) or visit http://www.keystonefirstpa.com.

1

lowercase italics= Generic drugs

UPPERCASE= Brand name

drugs

Tier Alt= Alt

Benefit Exclusion= Benefit

Exclusion

Non-formulary= Non-formulary

Not covered= Not covered

T1= Formulary

T2= Non-Preferred Brand,

Generic Available

T3= Non-Formulary

T4= Specialty

Notes AL= Age limit applies

PA= PA Applies

QL= Quantity Limit

ST= ST applies

Drug Tier Notes

Antihistamine Drugs

Ethanolamine Derivatives

clemastine T1

DIPHENHIST T1

diphenhydramine hcl injection T1 QL (20 ML per 25 days)

diphenhydramine hcl oral T1

SLEEP AID (DOXYLAMINE) T1

First Gen. Antihist. Derivatives, Misc.

cyproheptadine T1

First Generation Antihistamines

ALLER-CHLOR T1

chlorpheniramine maleate T1

clemastine T1

cyproheptadine T1

DIPHENHIST T1




Phenothiazine Derivatives





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Drug Tier Notes

PHENERGAN T2

promethazine injection solution T1 QL (20 ML per 25 days)

promethazine injection syringe T1

promethazine oral T1

promethazine rectal T1

PROMETHAZINE VC T1

PROMETHAZINE VC-CODEINE T1

Piperazine Derivatives

ANTIVERT T2

hydroxyzine hcl T1

hydroxyzine pamoate T1

meclizine T1

VISTARIL T2

Propylamine Derivatives

ALLER-CHLOR T1


M-END DMX T1

Second Generation Antihistamines

ALAVERT T2

ALAVERT D-12 ALLERGY-SINUS T2

ALLEGRA ALLERGY T2 ST

cetirizine T1

cetirizine-pseudoephedrine T1

CHILDREN'S CLARITIN T2

CLARINEX T3 PA

CLARITIN T2

CLARITIN REDITABS T2

CLARITIN-D 12 HOUR T2


desloratadine T3 PA





3

Drug Tier Notes

fexofenadine oral suspension T1 ST; QL (10 ML per 1 day)

fexofenadine oral tablet T1 ST

levocetirizine oral solution T3 PA

levocetirizine oral tablet T1 ST

loratadine T1

loratadine-pseudoephedrine T1

XYZAL ORAL SOLUTION T3 PA

XYZAL ORAL TABLET T2 ST

ZYRTEC T2

ZYRTEC-D T2

Anti-Infective Agents

Adamantanes

amantadine hcl T1

Allylamines

LAMISIL T2 QL (90 DS per 365 DYs)

terbinafine hcl T1 QL (90 DS per 365 DYs)

Amebicides

FLAGYL T2

metronidazole T1

paromomycin T1 PA; QL (10 DS per 30 DYs)

YODOXIN T1

Aminoglycosides

BETHKIS T4 PA

paromomycin T1 PA; QL (10 DS per 30 DYs)

TOBI T4 PA

TOBI PODHALER T4 PA

Aminopenicillins

amoxicillin T1

amoxicillin-pot clavulanate T1

ampicillin T1





4

Drug Tier Notes

AUGMENTIN T2

Anthelmintics

ALBENZA T1

BILTRICIDE T1

ivermectin T1

STROMECTOL T2

Antifungals, Miscellaneous

griseofulvin microsize T1

griseofulvin ultramicrosize T1

GRIS-PEG (ULTRAMICROSIZE) ORAL

TABLET 125 MG

T1

GRIS-PEG (ULTRAMICROSIZE) ORAL

TABLET 250 MG

T2

SSKI T1

Antimalarials

ARALEN T2

chloroquine phosphate T1

DARAPRIM T4 PA

hydroxychloroquine T1

mefloquine T1

PLAQUENIL T2

primaquine T1

quinidine sulfate T1

Antimycobacterials, Miscellaneous

dapsone T1

Antiprotozoals, Miscellaneous

dapsone T1

FLAGYL T2

MEPRON T1 PA

metronidazole T1





5

Drug Tier Notes

NEBUPENT T4 PA

Antituberculosis Agents

AVELOX T2 QL (10 QY per 30 DYs)

AVELOX ABC PACK T2 QL (1 FL per 30 DYs)

BIAXIN T2 QL (1 FL per 30 DYs)

BIAXIN XL T2 QL (1 FL per 30 DYs)

CIPRO ORAL SUSPENSION,MICROCAPSULE

RECON

T2

CIPRO ORAL TABLET T2 QL (68 QY per 34 DYs)

ciprofloxacin T1

ciprofloxacin hcl oral tablet 250 mg T1 QL (68 EA per 34 DYs)

ciprofloxacin hcl oral tablet 500 mg T1 QL (68 QY per 34 DYs)


clarithromycin T1 QL (1 FL per 30 DYs)

ethambutol T1

isoniazid T1

LEVAQUIN ORAL SOLUTION T2 QL (1 FL per 30 DYs)

LEVAQUIN ORAL TABLET T2 QL (14 QY per 30 DYs)

levofloxacin oral solution T1 QL (1 FL per 30 DYs)

levofloxacin oral tablet T1 QL (14 QY per 30 DYs)

moxifloxacin T1 QL (10 QY per 30 DYs)

pyrazinamide T1

rifabutin T1

RIFADIN INTRAVENOUS T4 PA

RIFADIN ORAL T2

rifampin T1

Azoles

DIFLUCAN ORAL SUSPENSION FOR

RECONSTITUTION

T2

DIFLUCAN ORAL TABLET 100 MG, 200 MG,

50 MG

T2





6

Drug Tier Notes

DIFLUCAN ORAL TABLET 150 MG T2 QL (2 QY per 30 DYs)

fluconazole oral suspension for reconstitution T1

fluconazole oral tablet 100 mg, 200 mg, 50 mg T1

fluconazole oral tablet 150 mg T1 QL (2 QY per 30 DYs)

ketoconazole T1

Carbapenems

INVANZ T4 PA

Chloramphenicol

chloramphenicol sod succinate T1

Cyclic Lipopeptides

CUBICIN T4 PA

Erythromycins

ERY-TAB T1

ERYTHROCIN (AS STEARATE) T1

erythromycin T2

erythromycin ethylsuccinate T1

erythromycin-sulfisoxazole T1

Fifth Generation Cephalosporins

TEFLARO T4 PA

First Generation Cephalosporins

cefadroxil T1

cephalexin T1

KEFLEX T2

Glycopeptides

DALVANCE T4 PA

vancomycin T1 PA

Glycylcyclines

TYGACIL T4 PA

Hcv Polymerase Inhibitors





7

Drug Tier Notes

EPCLUSA T4 PA

HARVONI T4 PA

SOVALDI T4 PA

VIEKIRA PAK T4 PA

VIEKIRA XR T4 PA

Hcv Protease Inhibitors

OLYSIO T4 PA

VIEKIRA PAK T4 PA

VIEKIRA XR T4 PA

ZEPATIER T4 PA

Hcv Replication Complex Inhibitors

EPCLUSA T4 PA

HARVONI T4 PA

VIEKIRA PAK T4 PA

VIEKIRA XR T4 PA

ZEPATIER T4 PA

Hiv Entry And Fusion Inhibitors

FUZEON T4 PA

SELZENTRY ORAL TABLET 150 MG T1 QL (2 EA per 1 day)

SELZENTRY ORAL TABLET 25 MG, 300 MG,

75 MG

T1

Hiv Integrase Inhibitors

GENVOYA T1

ISENTRESS T1

STRIBILD T1

TIVICAY T1

TRIUMEQ T1

Hiv Nonnucleoside Rev.Transcrip. Inhib.

EDURANT T1

INTELENCE ORAL TABLET 100 MG T1 QL (2 EA per 1 day)





8

Drug Tier Notes

INTELENCE ORAL TABLET 200 MG T1

nevirapine oral suspension T1

nevirapine oral tablet T1

nevirapine oral tablet extended release 24 hr 100

mg

T1 QL (4 EA per 1 day)

nevirapine oral tablet extended release 24 hr 400

mg

T1

ODEFSEY T1

RESCRIPTOR T1

SUSTIVA ORAL CAPSULE 200 MG T1

SUSTIVA ORAL CAPSULE 50 MG T1 QL (3 EA per 1 day)

SUSTIVA ORAL TABLET T1

Hiv Nucleoside, Nucleotide Rt Inhibitors

abacavir T1

abacavir-lamivudine-zidovudine T1

COMBIVIR T2

DESCOVY T1

didanosine T1

EMTRIVA T1

EPIVIR T2

EPIVIR HBV ORAL SOLUTION T1

EPIVIR HBV ORAL TABLET T2

EPZICOM T1

GENVOYA T1

lamivudine T1

lamivudine-zidovudine T1

ODEFSEY T1

RETROVIR T2

stavudine oral capsule 15 mg, 20 mg T1 QL (2 EA per 1 day)

stavudine oral capsule 30 mg, 40 mg T1

stavudine oral recon soln T1





9

Drug Tier Notes

STRIBILD T1

TRIZIVIR T2

TRUVADA T1

VIDEX 2 GRAM PEDIATRIC T1

VIDEX EC T2

VIREAD T1

ZERIT T2

ZIAGEN T1

zidovudine T1

Hiv Protease Inhibitors

APTIVUS T1

CRIXIVAN T1

INVIRASE T1

KALETRA T1

LEXIVA T1

NORVIR T1

PREZCOBIX T1

PREZISTA ORAL SUSPENSION T1

PREZISTA ORAL TABLET 150 MG T1 QL (6 EA per 1 day)

PREZISTA ORAL TABLET 600 MG, 800 MG T1

PREZISTA ORAL TABLET 75 MG T1 QL (4 EA per 1 day)

REYATAZ T1

VIEKIRA PAK T4 PA

VIEKIRA XR T4 PA

VIRACEPT T1

Interferons

ALFERON N T4 PA

INTRON A T4 PA

PEGASYS T4 PA

PEGASYS PROCLICK T4 PA





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Drug Tier Notes

PEGINTRON T4 PA

PEGINTRON REDIPEN T4 PA

SYLATRON T4 PA

Lincomycins

CLEOCIN HCL T2

CLEOCIN PEDIATRIC T2

clindamycin hcl T1

clindamycin palmitate hcl T1

Macrolides

ERY-TAB T1

ERYTHROCIN (AS STEARATE) T1

erythromycin T2

erythromycin ethylsuccinate T1

Monobactams

CAYSTON T4 PA

Monoclonal Antibodies

SYNAGIS T4 PA

Natural Penicillins

penicillin v potassium T1

Neuraminidase Inhibitors

RELENZA DISKHALER T1 QL (1 FL per 180 DYs)

TAMIFLU T1 QL (1 FL per 180 DYs)

Nucleosides And Nucleotides

acyclovir T1

adefovir T4 PA

BARACLUDE T4 PA

cidofovir T4 PA

COPEGUS T4 PA

CYTOVENE T4 PA

entecavir T1





11

Drug Tier Notes

HEPSERA T3 PA

MODERIBA DOSE PACK T4 PA

REBETOL T4 PA

RIBASPHERE T4 PA

RIBASPHERE RIBAPAK T4 PA

RIBATAB DOSE PACK T4 PA

valacyclovir oral tablet 1 gram T1

valacyclovir oral tablet 500 mg T1 QL (3 EA per 1 day)

VALCYTE T4 PA

valganciclovir T4 PA

VALTREX T2

VIRAZOLE T4 PA

ZOVIRAX T2

Other Macrolides

azithromycin oral packet T1 QL (1 FL per 30 DYs)

azithromycin oral suspension for reconstitution T1 QL (1 FL per 30 DYs)

azithromycin oral tablet 250 mg T1 QL (6 QY per 30 DYs)

azithromycin oral tablet 500 mg T1 QL (1 FL per 30 DYs)

azithromycin oral tablet 600 mg T1 QL (8 QY per 24 DYs)

BIAXIN T2 QL (1 FL per 30 DYs)

BIAXIN XL T2 QL (1 FL per 30 DYs)

clarithromycin T1 QL (1 FL per 30 DYs)

ZITHROMAX T2 QL (1 FL per 30 DYs)

ZITHROMAX TRI-PAK T2 QL (1 FL per 30 DYs)

ZMAX T1 QL (1 QY per 30 DYs)

Oxazolidinones

linezolid T3 PA

SIVEXTRO T4 PA

ZYVOX T3 PA

Penicillinase-Resistant Penicillins





12

Drug Tier Notes

dicloxacillin T1

Polyenes

nystatin T1

Polymyxins

colistin (colistimethate na) T4 PA

Quinolones

AVELOX T2 QL (10 QY per 30 DYs)

CIPRO ORAL SUSPENSION,MICROCAPSULE

RECON

T2

CIPRO ORAL TABLET T2 QL (68 QY per 34 DYs)

ciprofloxacin T1

ciprofloxacin hcl oral tablet 250 mg T1 QL (68 EA per 34 DYs)



LEVAQUIN T2 QL (14 QY per 30 DYs)

levofloxacin oral solution T1 QL (1 FL per 30 DYs)

levofloxacin oral tablet T1 QL (14 QY per 30 DYs)

moxifloxacin T1 QL (10 QY per 30 DYs)

Rifamycins

rifabutin T1

RIFADIN INTRAVENOUS T4 PA

RIFADIN ORAL T2

rifampin T1

Second Generation Cephalosporins

cefaclor T1

cefprozil T1

CEFTIN ORAL SUSPENSION FOR

RECONSTITUTION

T1 QL (100 QY per 1 day)

CEFTIN ORAL TABLET T2

cefuroxime axetil oral suspension for

reconstitution

T1 QL (100 QY per 1 day)





13

Drug Tier Notes

cefuroxime axetil oral tablet 250 mg T1 QL (2 EA per 1 day)

cefuroxime axetil oral tablet 500 mg T1

Sulfonamides (Systemic)

AZULFIDINE T2

AZULFIDINE EN-TABS T2

BACTRIM T2

BACTRIM DS T2

erythromycin-sulfisoxazole T1

sulfadiazine T1

sulfamethoxazole-trimethoprim T1

sulfasalazine T1

Tetracyclines

doxycycline monohydrate T1

minocycline T1

tetracycline T1

Third Generation Cephalosporins

cefdinir T1

cefpodoxime T1

ceftriaxone T1

Urinary Anti-Infectives

MACROBID T2

MACRODANTIN T2

nitrofurantoin T1

nitrofurantoin macrocrystal T1

nitrofurantoin monohyd/m-cryst T1

trimethoprim T1

Antineoplastic Agents

Antineoplastic Agents

ABRAXANE T4 PA

ADCETRIS T4 PA





14

Drug Tier Notes

ADRUCIL T4 PA

AFINITOR T4 PA

AFINITOR DISPERZ T4 PA

ALFERON N T4 PA

ALIMTA T4 PA

ALKERAN T4 PA

anastrozole T1

ARIMIDEX T2

AROMASIN T4 PA

ARZERRA T4 PA

AVASTIN T4 PA

azacitidine T4 PA

BELEODAQ T4 PA

bicalutamide T1

BICNU T4 PA

bleomycin T4 PA

BOSULIF T4 PA

BUSULFEX T4 PA

CAMPTOSAR T4 PA

CAPRELSA T4 PA

carboplatin T4 PA

CASODEX T2

CEENU T1

cisplatin T4 PA

COMETRIQ T4 PA

COSMEGEN T4 PA

cyclophosphamide intravenous T4 PA

cyclophosphamide oral T1

CYRAMZA T4 PA

cytarabine T4 PA





15

Drug Tier Notes

cytarabine (pf) T4 PA

dacarbazine T4 PA

daunorubicin T4 PA

decitabine T4 PA

DOCEFREZ T4 PA

docetaxel T4 PA

doxorubicin T4 PA

doxorubicin, peg-liposomal T4 PA

DROXIA T1

ELIGARD T4 PA

ELIGARD (3 MONTH) T4 PA



ELLENCE T4 PA

ELOXATIN T4 PA

EMCYT T1

epirubicin T4 PA

ERBITUX T4 PA

ERIVEDGE T4 PA

ERWINAZE T4 PA

ETOPOPHOS T4 PA

etoposide T4 PA

FARESTON T1 ST

FASLODEX T4 PA

FEMARA T2 QL (1 QY per 1 DY)

FIRMAGON T4 PA

floxuridine T4 PA

fludarabine T4 PA

fluorouracil T4 PA

flutamide T1





16

Drug Tier Notes

FOLOTYN T4 PA

GAZYVA T4 PA

gemcitabine T4 PA

GEMZAR T4 PA

GILOTRIF T4 PA

GLEEVEC T4 PA

GLEOSTINE T4 PA

HALAVEN T4 PA

HERCEPTIN T4 PA

HEXALEN T4 PA

HYCAMTIN T4 PA

HYDREA T2

hydroxyurea T1

ICLUSIG T4 PA

IDAMYCIN PFS T4 PA

IFEX T4 PA

ifosfamide T4 PA

ifosfamide-mesna T4 PA

imatinib T4 PA

IMBRUVICA T4 PA

INLYTA T4 PA

INTRON A T4 PA

irinotecan T4 PA

ISTODAX T4 PA

IXEMPRA T4 PA

JAKAFI T4 PA

JEVTANA T4 PA

KADCYLA T4 PA

KEYTRUDA T4 PA

KYPROLIS T4 PA





17

Drug Tier Notes

letrozole T1 QL (1 QY per 1 DY)

LEUKERAN T4 PA

leuprolide T4 PA

lomustine T4 PA

LUPANETA PACK (1 MONTH) T4 PA


LUPRON DEPOT T4 PA

LUPRON DEPOT (3 MONTH) T4 PA



LUPRON DEPOT-PED T4 PA

LUPRON DEPOT-PED (3 MONTH) T4 PA

LYSODREN T4 PA

MARQIBO T4 PA

MATULANE T4

MEGACE T2

MEGACE ES T2 QL (150 QY per 30 DYs)

megestrol oral suspension 400 mg/10 ml (40

mg/ml)

T1

megestrol oral suspension 625 mg/5 ml T1 QL (150 ML per 30 DYs)

megestrol oral tablet T1

MEKINIST T4 PA

mercaptopurine T1

methotrexate sodium (pf) T4 PA

methotrexate sodium injection T4 PA

methotrexate sodium oral T1

mitomycin T4 PA

mitoxantrone T4 PA

MUSTARGEN T4 PA

MYLERAN T1

NEXAVAR T4 PA





18

Drug Tier Notes

nilutamide T4 PA

NIPENT T4 PA

ONCASPAR T4 PA

OTREXUP (PF) T4 PA

oxaliplatin T4 PA

PERJETA T4 PA

PHOTOFRIN T4 PA

POMALYST T4 PA

PROLEUKIN T4 PA

REVLIMID T4 PA

RHEUMATREX T2

RITUXAN T4 PA

RITUXAN HYCELA T4 PA

SPRYCEL T4 PA

STIVARGA T4 PA

SUTENT T4 PA

SYLATRON T4 PA

SYLVANT T4 PA

SYNRIBO T4 PA

TABLOID T4 PA

TAFINLAR T4 PA

tamoxifen T1

TARCEVA T4 PA

TARGRETIN T4 PA

TASIGNA T4 PA

TAXOTERE T4 PA

TEMODAR T4 PA

teniposide T4 PA

THERACYS T4 PA

TICE BCG T4 PA





19

Drug Tier Notes

TOPOSAR T4 PA

topotecan T4 PA

TREANDA T4 PA

TRELSTAR T4 PA

TRELSTAR DEPOT T4 PA

TRELSTAR LA T4 PA

tretinoin (chemotherapy) T4 PA

TREXALL ORAL TABLET 10 MG, 5 MG T4 PA

TREXALL ORAL TABLET 7.5 MG T1

TRISENOX T4 PA

TYKERB T4 PA

VALSTAR T4 PA

VANTAS T4 PA

VECTIBIX T4 PA

VELCADE T4 PA

vinblastine T4 PA

VINCASAR PFS T4 PA

vinorelbine T4 PA

VOTRIENT T4 PA

XALKORI T4 PA

XELODA T4 PA

XTANDI T4 PA

YERVOY T4 PA

ZALTRAP T4 PA

ZELBORAF T4 PA

ZEVALIN (Y-90) T4 PA

ZOLADEX T4 PA

ZOLINZA T4 PA

ZYDELIG T4 PA

ZYKADIA T4 PA





20

Drug Tier Notes

ZYTIGA T4 PA

Antitoxins,Immune Glob,Toxoids,Vaccines

Antitoxins And Immune Globulins

CARIMUNE NF NANOFILTERED T4 PA

CYTOGAM T4 PA

FLEBOGAMMA DIF T4 PA

GAMASTAN S/D T4 PA

GAMMAGARD LIQUID T4 PA

GAMMAGARD S/D T4 PA

GAMUNEX-C T4 PA

HEPAGAM B T4 PA

HIZENTRA T4 PA

HYPERHEP B S/D T4 PA

HYPERHEP B S-D NEONATAL T4 PA

HYPERRAB S/D (PF) T4 PA

HYPERTET S/D (PF) T4 PA

HYQVIA T4 PA

NABI-HB T4 PA

OCTAGAM T4 PA

RHOGAM ULTRA-FILTERED PLUS T4 PA

RHOPHYLAC T4 PA

VARIZIG T4 PA

WINRHO SDF T4 PA

Toxoids

ADACEL(TDAP ADOLESN/ADULT)(PF) T1 AL

BOOSTRIX TDAP T1 AL

Vaccines

AFLURIA 2016-2017 T1 QL (0.5 ML per 180 days); AL

AFLURIA 2016-2017 (PF) T1 QL (0.5 ML per 180 days); AL

AFLURIA 2017-2018 T1 QL (0.5 ML per 180 days); AL





21

Drug Tier Notes

AFLURIA 2017-2018 (PF) T1 QL (0.5 ML per 180 days); AL

AFLURIA QUAD 2017-2018 T1 QL (0.5 ML per 180 days); AL

AFLURIA QUAD 2017-2018 (PF) T1 QL (0.5 ML per 180 days); AL

ENGERIX-B (PF) T1 AL

FLUARIX QUAD 2017-2018 (PF) T1 QL (0.5 ML per 180 days); AL

FLUCELVAX QUAD 2017-2018 T1 QL (0.5 ML per 180 days); AL

FLUCELVAX QUAD 2017-2018 (PF) T1 QL (0.5 ML per 180 days); AL

FLULAVAL QUAD 2017-2018 T1 QL (0.5 ML per 180 days); AL

FLULAVAL QUAD 2017-2018 (PF) T1 QL (0.5 ML per 180 days); AL

FLUVIRIN 2017-2018 T1 QL (0.5 ML per 180 days); AL

FLUVIRIN 2017-2018 (PF) T1 QL (0.5 ML per 180 days); AL

FLUZONE HIGH-DOSE 2017-18 (PF) T1 QL (0.5 ML per 180 days); AL

FLUZONE INTRADERM QUAD 2017-18 T1 QL (0.1 ML per 180 days); AL

FLUZONE QUAD 2017-2018 T1 QL (0.5 ML per 180 days); AL

FLUZONE QUAD 2017-2018 (PF)

INTRAMUSCULAR SUSPENSION

T1 QL (0.5 ML per 180 days); AL

FLUZONE QUAD 2017-2018 (PF)

INTRAMUSCULAR SYRINGE

T1 QL (0.5 ML per 180 days)

HAVRIX (PF) T1 AL

PNEUMOVAX 23 INJECTION SOLUTION T1 AL

PNEUMOVAX 23 INJECTION SYRINGE T1

PREVNAR 13 (PF) T1 AL

RECOMBIVAX HB (PF) T1 AL

THERACYS T4 PA

TICE BCG T4 PA

TWINRIX (PF) T1 AL

VAQTA (PF) T1 AL

ZOSTAVAX (PF) T1 QL (1 QY per 365 DYs)

Autonomic Drugs

Alpha- And Beta-Adrenergic Agonists






22

Drug Tier Notes

BROMFED DM T1


CHERATUSSIN DAC T1



epinephrine T1 QL (2 EA per 30 DYs)


M-END DMX T1

MUCINEX D T1

pseudoephedrine hcl T1

ZYRTEC-D T2

Alpha-Adrenergic Agonists

CATAPRES T2

CATAPRES-TTS-1 T2

CATAPRES-TTS-2 T2

CATAPRES-TTS-3 T2

clonidine T1

clonidine hcl T1

CLORPRES T1

ED BRON GP T1

methyldopa T1

methyldopa-hydrochlorothiazide T1

phenylephrine-chlophedianol-gg T1

PROMETHAZINE VC T1


ROBAFEN CF (PHENYLEPHRINE) T1

Antimuscarinics/Antispasmodics

ANORO ELLIPTA T1

ATROVENT HFA T1

BENTYL T2





23

Drug Tier Notes

COMBIVENT RESPIMAT T1

dicyclomine T1

diphenoxylate-atropine T1

glycopyrrolate T1

hydrocodone-homatropine T1

hyoscyamine sulfate T1

ipratropium bromide T1

LEVBID T2

LOMOTIL T2

propantheline T1

ROBINUL T2

ROBINUL FORTE T2

SPIRIVA RESPIMAT T1 AL

TUSSIGON T1

Antiparkinsonian Agents

benztropine T1

trihexyphenidyl T1

Autonomic Drugs, Miscellaneous

CHANTIX T1 QL (360 QY per 365 DYs); AL

CHANTIX CONTINUING MONTH BOX T1 QL (360 EA per 365 DYs)

CHANTIX CONTINUING MONTH PAK T1 QL (360 EA per 365 DYs)

CHANTIX STARTING MONTH BOX T1 QL (360 QY per 365 DYs); AL

NICODERM CQ T2

NICORETTE T2

nicotine T1

nicotine (polacrilex) buccal gum T1

nicotine (polacrilex) buccal lozenge T1 QL (20 EA per 1 day)

nicotine (polacrilex) buccal mini lozenge T1 QL (20 EA per 1 day)

Centrally Acting Skeletal Muscle Relaxnt

carisoprodol T1





24

Drug Tier Notes

chlorzoxazone T1

cyclobenzaprine T1

methocarbamol T1

ROBAXIN T2

ROBAXIN-750 T2

SOMA T2

tizanidine T1

ZANAFLEX T2

Gaba-Derivative Skeletal Muscle Relaxant

baclofen T1

GABLOFEN T4 PA

LIORESAL T4 PA

Non-Sel. Beta-Adrenergic Blocking Agents

BETAPACE T2

BETAPACE AF T2

carvedilol T1

COREG T2

CORGARD T2

CORZIDE T2

INDERAL LA T2

labetalol T1

nadolol T1

nadolol-bendroflumethiazide T1

pindolol T1

propranolol T1

propranolol-hydrochlorothiazid T1

sotalol T1

SOTALOL AF T1

timolol maleate T1

TRANDATE T2





25

Drug Tier Notes

Non-Sel.Alpha-1-Adrenergic Blocking Agts

CARDURA T2

doxazosin T1

MINIPRESS T2

prazosin T1

terazosin T1

Non-Sel.Alpha-Adrenergic Blocking Agents

CAFERGOT T2

D.H.E.45 T2

DIBENZYLINE T2

dihydroergotamine injection T1 QL (12 ML per 30 days)

dihydroergotamine nasal T1 QL (1 QY per 30 DYs)

ERGOMAR T1 QL (20 EA per 30 days)

MIGRANAL T2 QL (1 QY per 30 DYs)

phenoxybenzamine T1 PA

Parasympathomimetic (Cholinergic Agents)

ARICEPT T2 AL

ARICEPT ODT T2 AL

bethanechol chloride T1

donepezil oral tablet 10 mg T1 AL

donepezil oral tablet 5 mg T1 QL (1 EA per 1 DY); AL

donepezil oral tablet,disintegrating T1 AL

EXELON ORAL T2 AL

EXELON TRANSDERMAL PATCH 24 HOUR

4.6 MG/24 HR

T1 QL (1 EA per 1 day); AL

EXELON TRANSDERMAL PATCH 24 HOUR

9.5 MG/24 HR

T1 AL

MESTINON ORAL SYRUP T1

MESTINON ORAL TABLET T2

MESTINON TIMESPAN T2

PROSTIGMIN T1 AL





26

Drug Tier Notes

pyridostigmine bromide T1 AL

rivastigmine T1 AL

rivastigmine tartrate oral capsule 1.5 mg, 3 mg T1 QL (2 EA per 1 day); AL

rivastigmine tartrate oral capsule 4.5 mg, 6 mg T1 AL

URECHOLINE T2

Selective Alpha-1-Adrenergic Block.Agent

alfuzosin T1

carvedilol T1

COREG T2

labetalol T1

tamsulosin T1

TRANDATE T2

Selective Beta-2-Adrenergic Agonists

albuterol sulfate T1

ANORO ELLIPTA T1

BREO ELLIPTA T1


DULERA T1 QL (13 QY per 30 DYs); AL

SEREVENT DISKUS T1

terbutaline T1

VENTOLIN HFA T1 QL (1 QY per 30 DYs)

XOPENEX HFA T1 ST

Selective Beta-Adrenergic Blocking Agent

atenolol T1

bisoprolol fumarate T1

bisoprolol-hydrochlorothiazide T1

LOPRESSOR T2

LOPRESSOR HCT T2

metoprolol succinate T1

metoprolol ta-hydrochlorothiaz T1





27

Drug Tier Notes

metoprolol tartrate T1

TENORMIN T2

TOPROL XL T2

ZEBETA T2

ZIAC T2

Skeletal Muscle Relaxants, Miscellaneous

BOTOX T4 PA

BOTOX COSMETIC T4 PA

DYSPORT T4 PA

MYOBLOC T4 PA

XEOMIN T4 PA

Blood Formation, Coagulation, Thrombosis

Coumarin Derivatives

COUMADIN T2

warfarin T1

Direct Factor Xa Inhibitors

ARIXTRA T4 PA

ELIQUIS T1

XARELTO T1

Direct Thrombin Inhibitors

PRADAXA ORAL CAPSULE 110 MG, 150 MG T1

PRADAXA ORAL CAPSULE 75 MG T1 QL (2 EA per 1 day)

Hematopoietic Agents

ARANESP (IN ALBUMIN) T4 PA

ARANESP (IN POLYSORBATE) T4 PA

EPOGEN T4 PA

GRANIX T4 PA

LEUKINE T4 PA

MOZOBIL T4 PA

NEULASTA T4 PA





28

Drug Tier Notes

NEUMEGA T4 PA

NEUPOGEN T4 PA

NPLATE T4 PA

PROCRIT T4 PA

PROMACTA T4 PA

ZARXIO T4 PA

Hemorrheologic Agents

pentoxifylline T1

Hemostatics

ADVATE T4 PA

ALPHANATE T4 PA

ALPHANINE SD T4 PA

ALPROLIX T4 PA

AMICAR T1

BEBULIN T4 PA

BENEFIX T4 PA

CORIFACT T4 PA

DDAVP NASAL T2 PA

DDAVP ORAL T2 PA; AL

desmopressin nasal T1 PA

desmopressin oral T1 PA; AL

ELOCTATE T4 PA

FEIBA NF T4 PA

HEMOFIL M HIGH T4 PA

HEMOFIL M LOW T4 PA

HEMOFIL M MID T4 PA

HEMOFIL M SUPER HIGH T4 PA

HUMATE-P T4 PA

KOATE-DVI T4 PA

KOGENATE FS T4 PA





29

Drug Tier Notes

MONOCLATE-P T4 PA

NOVOSEVEN RT T4 PA

PROFILNINE T4 PA

RECOMBINATE T4 PA

RIASTAP T4 PA

RIXUBIS T4 PA

STIMATE T1 PA

WILATE T4 PA

XYNTHA T4 PA

XYNTHA SOLOFUSE T4 PA

Heparins

enoxaparin T4 PA

FRAGMIN T4 PA

heparin (porcine) T1

LOVENOX T4 PA

Iron Preparations

CADEAU DHA T1

CENTRUM COMPLETE T2 AL

CERTAVITE-ANTIOXID (IRON GLUC) T2

DAILY PRENATAL T1

DAILY VITES/IRON T1 AL

FERAHEME T4 PA

FERRETTS T1

FERRLECIT T4 PA

ferrous fumarate T1

ferrous gluconate T1

ferrous sulfate T1

INFED T4 PA

INJECTAFER T4 PA

iron oral tablet T1





30

Drug Tier Notes

IRON ORAL TABLET EXTENDED RELEASE T1

MULTIGEN T1

MULTIGEN FOLIC T1

MULTIGEN PLUS T1

MULTI-VIT WITH FLUORIDE-IRON T1 AL

MULTIVITAMIN WITH MINERALS T1

OBSTETRIX DHA T1

OBTREX DHA T1

ONE DAILY PRENATAL T1

ONE-A-DAY WOMENS FORMULA T1

ONE-A-DAY WOMEN'S PRENATAL 1 T1

POLY-VITAMIN WITH IRON T1 AL

PR NATAL 400 T1

PR NATAL 400 EC T1

PR NATAL 430 T1

PRENATA T1

PRENATAL + DHA T1

PRENATAL 19 T1

PRENATAL MULTI-DHA T1

PRENATAL MULTI-DHA (ALGAL OIL) T1

PRENATAL VITAMIN T1

PRENATAL VITAMIN PLUS LOW IRON T1

prenatal vit-iron fum-folic ac T1

PRORENAL QD T1

TRINATAL GT T1

TRIVEEN-DUO DHA T1

TRI-VI-SOL WITH IRON T1 AL

TRI-VIT WITH FLUORIDE AND IRON T1 AL

VENOFER T4 PA

WOMEN'S PRENATAL + DHA T1





31

Drug Tier Notes

Platelet-Aggregation Inhibitors

aspirin T1

aspirin-caffeine-dihydrocodein T3

aspirin-dipyridamole T1

butalbital-aspirin-caffeine T1

cilostazol T1

clopidogrel T1

dipyridamole T1

EFFIENT ORAL TABLET 10 MG T1

EFFIENT ORAL TABLET 5 MG T1 QL (1 EA per 1 day)

PERSANTINE T2

PLAVIX T2

PLETAL T2

SYNALGOS-DC T3

ticlopidine T1

Thrombolytic Agents

ACTIVASE T4 PA

aspirin T1



CATHFLO ACTIVASE T4 PA

SYNALGOS-DC T3

Cardiovascular Drugs

Alpha-Adrenergic Blocking Agents

CARDURA T2

carvedilol T1

COREG T2

doxazosin T1

labetalol T1

MINIPRESS T2





32

Drug Tier Notes

prazosin T1

terazosin T1

TRANDATE T2

Alpha-Adrenergic Blocking Agt.(Hypoten)

CARDURA T2

doxazosin T1

labetalol T1

MINIPRESS T2

prazosin T1

terazosin T1

TRANDATE T2

Angiotensin Ii Receptor Antagon.(Hypotn)

AVALIDE T2 ST

AVAPRO T2 ST

COZAAR T2

HYZAAR T2

irbesartan T1 ST

irbesartan-hydrochlorothiazide T1 ST

losartan T1

losartan-hydrochlorothiazide T1

valsartan T1 ST

valsartan-hydrochlorothiazide T1 ST

Angiotensin Ii Receptor Antagonists

AVALIDE T2 ST

AVAPRO T2 ST

COZAAR T2

HYZAAR T2

irbesartan T1 ST


losartan T1





33

Drug Tier Notes


valsartan T1 ST


Angiotensin-Convert.Enzyme Inhib(Hypotn)

ACCUPRIL T2

ACCURETIC T2

ACEON T2

benazepril oral tablet 10 mg, 20 mg, 5 mg T1 QL (2 EA per 1 day)

benazepril oral tablet 40 mg T1

benazepril-hydrochlorothiazide oral tablet 10-12.5

mg, 20-12.5 mg, 5-6.25 mg


benazepril-hydrochlorothiazide oral tablet 20-25

mg

T1

captopril T1

captopril-hydrochlorothiazide T1

enalapril maleate T1

enalapril-hydrochlorothiazide T1

fosinopril T1

lisinopril T1

lisinopril-hydrochlorothiazide T1

LOTENSIN T2

LOTENSIN HCT T2

MAVIK T2

moexipril T1

moexipril-hydrochlorothiazide T1

perindopril erbumine T1

PRINIVIL T2

quinapril T1

quinapril-hydrochlorothiazide T1

trandolapril T1

UNIRETIC T2





34

Drug Tier Notes

UNIVASC T2

VASERETIC T2

VASOTEC T2

ZESTORETIC T2

ZESTRIL T2

Angiotensin-Converting Enzyme Inhibitors

ACCUPRIL T2

ACCURETIC T2

ACEON T2

benazepril oral tablet 10 mg, 20 mg, 5 mg T1 QL (2 EA per 1 day)

benazepril oral tablet 40 mg T1


mg, 20-12.5 mg, 5-6.25 mg



mg

T1

captopril T1


enalapril maleate T1


fosinopril T1

lisinopril T1


LOTENSIN T2

LOTENSIN HCT T2

MAVIK T2

moexipril T1


perindopril erbumine T1

PRINIVIL T2

quinapril T1






35

Drug Tier Notes

trandolapril T1

UNIRETIC T2

UNIVASC T2

VASERETIC T2

VASOTEC T2

ZESTORETIC T2

ZESTRIL T2

Antiarrhythmics, Miscellaneous

digoxin T1

LANOXIN T2

Antilipemic Agents, Miscellaneous

JUXTAPID T4 PA

KYNAMRO T4 PA

niacin oral capsule, extended release T1

niacin oral tablet T1

niacin oral tablet extended release 1,000 mg, 500

mg, 750 mg

T1 ST

niacin oral tablet extended release 24 hr T1 ST

niacin oral tablet extended release 250 mg T1

NIACOR T1

Beta-Adrenergic Blocking Agents

atenolol T1

BETAPACE T2

BETAPACE AF T2



carvedilol T1

COREG T2

CORGARD T2

CORZIDE T2





36

Drug Tier Notes

INDERAL LA T2

labetalol T1

LOPRESSOR T2

LOPRESSOR HCT T2




nadolol T1


pindolol T1

propranolol T1


sotalol T1

SOTALOL AF T1

TENORMIN T2

timolol maleate T1

TOPROL XL T2

TRANDATE T2

ZEBETA T2

ZIAC T2

Beta-Adrenergic Blocking Agt.(Hypoten)

atenolol T1

BETAPACE T2

BETAPACE AF T2



CORGARD T2

CORZIDE T2

INDERAL LA T2

labetalol T1





37

Drug Tier Notes

LOPRESSOR T2

LOPRESSOR HCT T2




nadolol T1


pindolol T1

propranolol T1


sotalol T1

SOTALOL AF T1

TENORMIN T2

timolol maleate T1

TOPROL XL T2

TRANDATE T2

ZEBETA T2

ZIAC T2

Bile Acid Sequestrants

cholestyramine (with sugar) T1

CHOLESTYRAMINE LIGHT T1

COLESTID T2

colestipol T1

PREVALITE T1

QUESTRAN T2

QUESTRAN LIGHT T2

WELCHOL T1

Calcium-Channel Block.Agt,Misc(Hypoten)

CALAN T2

CALAN SR T2





38

Drug Tier Notes

CARDIZEM T2

CARDIZEM CD T2

diltiazem hcl T1

DILT-XR T2

ISOPTIN SR T2

TAZTIA XT ORAL CAPSULE,EXTENDED

RELEASE 24 HR 120 MG, 180 MG, 240 MG

T1


RELEASE 24 HR 300 MG, 360 MG

T2

TIAZAC T2

verapamil T1

VERELAN T2

Calcium-Channel Blocking Agents

ADALAT CC T2

amlodipine oral tablet 10 mg T1

amlodipine oral tablet 2.5 mg, 5 mg T1 QL (1 EA per 1 DY)

AMTURNIDE T2 ST

CALAN T2

CALAN SR T2

CARDIZEM T2

CARDIZEM CD T2

diltiazem hcl T1

DILT-XR T2

ISOPTIN SR T2

NIFEDICAL XL ORAL TABLET EXTENDED

RELEASE 24HR 30 MG

T1


RELEASE 24HR 60 MG

T2

nifedipine oral capsule T1

nifedipine oral tablet extended release 24hr T1

nifedipine oral tablet extended release 30 mg T1 QL (1 EA per 1 day)





39

Drug Tier Notes

nifedipine oral tablet extended release 90 mg T1

nisoldipine oral tablet extended release 24 hr 17

mg, 8.5 mg



mg, 30 mg, 34 mg, 40 mg

T1

NORVASC T2

PROCARDIA T2

PROCARDIA XL T2

SULAR T2



T1



T2

TEKAMLO T2 ST

TIAZAC T2

verapamil T1

VERELAN T2

Calcium-Channel Blocking Agents, Misc.

CALAN T2

CALAN SR T2

CARDIZEM T2

CARDIZEM CD T2

diltiazem hcl T1

DILT-XR T2

ISOPTIN SR T2



T1



T2

TIAZAC T2

verapamil T1

VERELAN T2





40

Drug Tier Notes

Carbonic Anhydrase Inhibitors(Hypoten)

acetazolamide T1

DIAMOX SEQUELS T2 PA

Cardiotonic Agents

digoxin T1

LANOXIN T2

milrinone T4 PA

Central Alpha-Agonists

CATAPRES T2

CATAPRES-TTS-1 T2

CATAPRES-TTS-2 T2

CATAPRES-TTS-3 T2

clonidine T1

clonidine hcl T1

CLORPRES T1

guanfacine oral tablet T1

guanfacine oral tablet extended release 24 hr T1 AL

methyldopa T1


TENEX T2

Cholesterol Absorption Inhibitors

ezetimibe T1

Class Ia Antiarrhythmics

disopyramide phosphate T1

NORPACE T2

NORPACE CR T2

quinidine gluconate T1

quinidine sulfate T1

Class Ib Antiarrhythmics

DILANTIN T2





41

Drug Tier Notes

DILANTIN EXTENDED T2

DILANTIN INFATABS T2

DILANTIN-125 T2

mexiletine T1

phenytoin T1

phenytoin sodium extended T1

Class Ic Antiarrhythmics

flecainide T1

propafenone T1

RYTHMOL T2

Class Ii Antiarrhythmics

atenolol T1

BETAPACE T2

BETAPACE AF T2



carvedilol T1

COREG T2

CORGARD T2

CORZIDE T2

INDERAL LA T2

labetalol T1

LOPRESSOR T2

LOPRESSOR HCT T2




nadolol T1


pindolol T1





42

Drug Tier Notes

propranolol T1


sotalol T1

SOTALOL AF T1

TENORMIN T2

timolol maleate T1

TOPROL XL T2

TRANDATE T2

ZEBETA T2

ZIAC T2

Class Iii Antiarrhythmics

amiodarone T1

BETAPACE T2

BETAPACE AF T2

CORDARONE T2

MULTAQ T3 PA

sotalol T1

SOTALOL AF T1

Class Iv Antiarrhythmics

CALAN T2

CALAN SR T2

CARDIZEM T2

CARDIZEM CD T2

diltiazem hcl T1

DILT-XR T2

ISOPTIN SR T2



T1



T2

TIAZAC T2





43

Drug Tier Notes

verapamil T1

VERELAN T2

Dihydropyridines

ADALAT CC T2



AMTURNIDE T2 ST


RELEASE 24HR 30 MG

T1


RELEASE 24HR 60 MG

T2






mg, 8.5 mg



mg, 30 mg, 34 mg, 40 mg

T1

NORVASC T2

PROCARDIA T2

PROCARDIA XL T2

SULAR T2

TEKAMLO T2 ST

Dihydropyridines (Hypotensive Agents)

ADALAT CC T2




RELEASE 24HR 30 MG

T1


RELEASE 24HR 60 MG

T2





44

Drug Tier Notes






mg, 8.5 mg



mg, 30 mg, 34 mg, 40 mg

T1

NORVASC T2

PROCARDIA T2

PROCARDIA XL T2

SULAR T2

TEKAMLO T2 ST

Direct Vasodilators

hydralazine T1

minoxidil T1

Diuretics, Miscellaneous (Hypotensive)

THEO-24 T1

theophylline T1

Fibric Acid Derivatives

fenofibrate T1

fenofibrate micronized T1

fenofibrate nanocrystallized T1

gemfibrozil T1

LOFIBRA T2

LOPID T2

TRICOR T2

Hmg-Coa Reductase Inhibitors

atorvastatin oral tablet 10 mg T1 QL (1 EA per 1 DY)

atorvastatin oral tablet 20 mg, 40 mg, 80 mg T1





45

Drug Tier Notes

fluvastatin T1 ST

LESCOL T2 ST

LESCOL XL T1 ST

LIPITOR T2

lovastatin oral tablet 10 mg, 20 mg T1 QL (3 EA per 1 day)

lovastatin oral tablet 40 mg T1

MEVACOR T2

PRAVACHOL T2 ST

pravastatin oral tablet 10 mg, 20 mg T1 ST; QL (1 EA per 1 day)

pravastatin oral tablet 40 mg T1 ST; QL (2 EA per 1 day)

pravastatin oral tablet 80 mg T1 ST

rosuvastatin T1

simvastatin T1

ZOCOR T2

Hypotensive Agents, Miscellaneous

BETAPACE T2

BETAPACE AF T2

CARDURA T2

carvedilol T1

COREG T2

DIBENZYLINE T2

doxazosin T1

INDERAL LA T2

phenoxybenzamine T1 PA

pindolol T1

propranolol T1

sotalol T1

SOTALOL AF T1

terazosin T1

timolol maleate T1





46

Drug Tier Notes

Loop Diuretics (Hypotensive Agents)

bumetanide T1

DEMADEX T2

furosemide T1

LASIX T2

torsemide T1

Mineralocorticoid (Aldosterone) Antagnts

ALDACTAZIDE T2

ALDACTONE T2

spironolactone T1

spironolacton-hydrochlorothiaz T1

Mineralocorticoid(Aldoster.)Antag(Hypot)

ALDACTAZIDE T2

ALDACTONE T2

spironolactone T1


Nitrates And Nitrites

ISORDIL T2

isosorbide dinitrate T1

isosorbide mononitrate T1

NITRO-BID T2

NITRO-DUR TRANSDERMAL PATCH 24

HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6

MG/HR

T2

NITRO-DUR TRANSDERMAL PATCH 24

HOUR 0.3 MG/HR, 0.8 MG/HR

T1

nitroglycerin T1

NITROSTAT T1

NITRO-TIME T2

Peripheral Adrenergic Inhibitors

reserpine T1





47

Drug Tier Notes

Phosphodiesterase Type 5 Inhibitors

ADCIRCA T4 PA

cilostazol T1

PLETAL T2

REVATIO T4 PA

sildenafil T1 PA

Potassium-Sparing Diuretics (Hypoten)

ALDACTAZIDE T2

ALDACTONE T2

amiloride T1

amiloride-hydrochlorothiazide T1

DYAZIDE T2

DYRENIUM T1

MAXZIDE T2

MAXZIDE-25MG T2

spironolactone T1


triamterene-hydrochlorothiazid T1

Renin Inhibitors

AMTURNIDE T2 ST

TEKAMLO T2 ST

Thiazide Diuretics(Hypotensive Agents)

ACCURETIC T2

ALDACTAZIDE T2


AMTURNIDE T2 ST

AVALIDE T2 ST


mg, 20-12.5 mg, 5-6.25 mg






48

Drug Tier Notes


mg

T1



chlorothiazide T1

CORZIDE T2

DIURIL T1

DYAZIDE T2


hydrochlorothiazide T1

HYZAAR T2



LOPRESSOR HCT T2


LOTENSIN HCT T2

MAXZIDE T2

MAXZIDE-25MG T2

methyclothiazide T1









UNIRETIC T2


VASERETIC T2

ZESTORETIC T2





49

Drug Tier Notes

ZIAC T2

Thiazide-Like Diuretics(Hypotensive Agt)

chlorthalidone T1

CLORPRES T1

indapamide T1

metolazone T1

ZAROXOLYN T2

Vasodilating Agents, Miscellaneous

ADALAT CC T2



AMTURNIDE T2 ST


CALAN T2

CALAN SR T2

CARDIZEM T2

CARDIZEM CD T2

diltiazem hcl T1

DILT-XR T2

dipyridamole T1

epoprostenol (glycine) T4 PA

FLOLAN T4 PA

ISOPTIN SR T2

LETAIRIS T4 PA


RELEASE 24HR 30 MG

T1


RELEASE 24HR 60 MG

T2








50

Drug Tier Notes


NORVASC T2

OPSUMIT T4 PA

ORENITRAM T4 PA

PERSANTINE T2

PROCARDIA T2

PROCARDIA XL T2

REMODULIN T4 PA



T1



T2

TEKAMLO T2 ST

TIAZAC T2

TRACLEER T4 PA

TYVASO T4 PA

TYVASO REFILL KIT T4 PA

TYVASO STARTER KIT T4 PA

UPTRAVI T4 PA

VELETRI T4 PA

VENTAVIS T4 PA

verapamil T1

VERELAN T2

Cellular Therapy

Cellular Therapy

PROVENGE T4 PA

Central Nervous System Agents

Adamantanes (Cns)

amantadine hcl T1

Amphetamines





51

Drug Tier Notes

ADDERALL T2

ADDERALL XR T2

DEXEDRINE SPANSULE T2

dextroamphetamine T1 PA; AL

dextroamphetamine-amphetamine T1 PA; AL

VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30

MG, 40 MG, 50 MG, 60 MG, 70 MG

T1 PA; AL

VYVANSE ORAL TABLET,CHEWABLE T1

Analgesics And Antipyretics, Misc.

acetaminophen T1

acetaminophen-caff-dihydrocod T3

acetaminophen-codeine T1

butalbital-acetaminop-caf-cod oral capsule 50-

300-40-30 mg

T3


325-40-30 mg

T1

butalbital-acetaminophen T1

butalbital-acetaminophen-caff T1

CAPITAL WITH CODEINE T3

ED-APAP T1

ENDOCET ORAL TABLET 10-325 MG, 2.5-325

MG, 7.5-325 MG

T3

ENDOCET ORAL TABLET 5-325 MG T1

ESGIC T2

FIORICET WITH CODEINE T3

gabapentin T1

HORIZANT T4 PA

HYCET T3

hydrocodone-acetaminophen oral solution T1

hydrocodone-acetaminophen oral tablet 10-300

mg, 2.5-325 mg, 5-300 mg, 7.5-300 mg

T3





52

Drug Tier Notes


mg, 5-325 mg, 5-500 mg, 7.5-325 mg, 7.5-500 mg,

7.5-750 mg

T1


mg

T2

LORTAB T2

LORTAB ELIXIR ORAL SOLUTION 10-300

MG/15 ML

T1

LORTAB ELIXIR ORAL SOLUTION 7.5-500

MG/15 ML

T2

MARTEN-TAB T2

NEURONTIN T2

oxycodone-acetaminophen oral capsule T1

oxycodone-acetaminophen oral solution T3

oxycodone-acetaminophen oral tablet 10-325 mg,

2.5-325 mg, 7.5-325 mg

T3

oxycodone-acetaminophen oral tablet 5-325 mg T1

PAIN RELIEF T2

PERCOCET ORAL TABLET 10-325 MG, 2.5-

325 MG, 7.5-325 MG

T3

PERCOCET ORAL TABLET 5-325 MG T2

PRIALT T4 PA

PRIMLEV T3

Q-PAP T1

tramadol-acetaminophen T3

TREZIX T3

TYLENOL-CODEINE #4 T2

ULTRACET T3

VERDROCET T3

VICODIN T3

VICODIN ES T3

VICODIN HP T3

XODOL 10/300 T3





53

Drug Tier Notes

XODOL 5/300 T3

XODOL 7.5/300 T3

ZAMICET T1

Anticholinergic Agents (Cns)

benztropine T1

trihexyphenidyl T1

Anticonvulsants, Miscellaneous

BANZEL T3 PA

carbamazepine T1

DEPAKENE T2

DEPAKOTE T2

DEPAKOTE ER T2

DEPAKOTE SPRINKLES T2

divalproex oral capsule, delayed rel sprinkle T1

divalproex oral tablet extended release 24 hr 250

mg



mg

T1

divalproex oral tablet,delayed release (dr/ec) T1

gabapentin T1

HORIZANT T4 PA

KEPPRA T2

LAMICTAL T2

LAMICTAL STARTER (BLUE) KIT T1

LAMICTAL STARTER (GREEN) KIT T1

LAMICTAL STARTER (ORANGE) KIT T1

lamotrigine oral tablet 100 mg T1 QL (5 EA per 1 day)

lamotrigine oral tablet 150 mg, 200 mg T1

lamotrigine oral tablet 25 mg T1 QL (3 EA per 1 day)

lamotrigine oral tablet, chewable dispersible 25

mg






54

Drug Tier Notes

lamotrigine oral tablet, chewable dispersible 5 mg T1 QL (2 EA per 1 day)

levetiracetam T1

NEURONTIN T2

oxcarbazepine T1

SABRIL T4 PA

TEGRETOL T2

TEGRETOL XR T2

TOPAMAX T2

topiramate oral capsule, sprinkle T1

topiramate oral tablet 100 mg, 200 mg, 25 mg T1

topiramate oral tablet 50 mg T1 QL (6 EA per 1 day)

TRILEPTAL T2

valproic acid T1

valproic acid (as sodium salt) T1

Antidepressants, Miscellaneous

bupropion hcl T1

mirtazapine oral tablet T1 QL (1 EA per 1 day)

mirtazapine oral tablet,disintegrating T1

REMERON T2

REMERON SOLTAB T2

WELLBUTRIN T2

WELLBUTRIN SR T2

WELLBUTRIN XL T2

ZYBAN T2

Antimanic Agents

DEPAKENE T2

DEPAKOTE T2

DEPAKOTE ER T2







55

Drug Tier Notes


mg



mg

T1


lithium carbonate T1

lithium citrate T1

LITHOBID T2

valproic acid T1


Antimigraine Agents, Miscellaneous

ASCOMP WITH CODEINE T3

aspirin T1


BUTALBITAL COMPOUND W/CODEINE T1

BUTALBITAL COMPOUND-CODEINE T3


300-40-30 mg

T3


325-40-30 mg

T1



CAFERGOT T2

codeine-butalbital-asa-caff T3

D.H.E.45 T2

DEPAKENE T2

DEPAKOTE T2

DEPAKOTE ER T2


dihydroergotamine injection T1 QL (12 ML per 30 days)

dihydroergotamine nasal T1 QL (1 QY per 30 DYs)





56

Drug Tier Notes



mg



mg

T1


ERGOMAR T1 QL (20 EA per 30 days)

ESGIC T2


FIORINAL-CODEINE #3 T2

INDERAL LA T2

MIGRANAL T2 QL (1 QY per 30 DYs)

propranolol T1

SYNALGOS-DC T3

timolol maleate T1


ULTRACET T3

valproic acid T1


Antipsychotics, Miscellaneous

loxapine succinate T1 AL

pimozide T1 AL

Anxiolytics,Sedatives,And Hypnotics,Misc

AMBIEN T2

AMBIEN CR T3 PA

buspirone T1

droperidol T1

EDLUAR T3 PA

eszopiclone T1 ST

HETLIOZ T4 PA

hydroxyzine hcl T1





57

Drug Tier Notes

hydroxyzine pamoate T1

LUNESTA T3 PA

meprobamate T1

PHENERGAN T2




promethazine rectal T1


SONATA T2

VISTARIL T2

zaleplon oral capsule 10 mg T1 QL (14 EA per 25 days)

zaleplon oral capsule 5 mg T1 QL (1 EA per 1 day)

zolpidem T1

Atypical Antipsychotics

ABILIFY T2 AL

ABILIFY MAINTENA T4 PA

aripiprazole oral solution T1 AL

aripiprazole oral tablet 10 mg, 15 mg T1 QL (1 EA per 1 DY); AL

aripiprazole oral tablet 2 mg, 20 mg, 30 mg, 5 mg T1 AL

aripiprazole oral tablet,disintegrating 10 mg T1 QL (2 EA per 1 day); AL

aripiprazole oral tablet,disintegrating 15 mg T1 AL

ARISTADA T4 PA

clozapine oral tablet 100 mg, 200 mg, 50 mg T1 AL

clozapine oral tablet 25 mg T1 QL (3 EA per 1 day); AL

CLOZARIL T2 AL

GEODON T2 AL

INVEGA SUSTENNA T4 PA

INVEGA TRINZA T4 PA

LATUDA T1 AL





58

Drug Tier Notes

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 5 mg,

7.5 mg


olanzapine oral tablet 20 mg T1 AL

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50

mg


quetiapine oral tablet 300 mg, 400 mg T1 AL

quetiapine oral tablet extended release 24 hr T1 AL

RISPERDAL T2 AL

RISPERDAL CONSTA T4 PA

risperidone oral solution T1 AL

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2

mg


risperidone oral tablet 3 mg, 4 mg T1 AL

SAPHRIS T1 AL

SAPHRIS (BLACK CHERRY) T1 QL (2 EA per 1 day); AL

SEROQUEL T2 AL

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg T1 QL (2 EA per 1 day); AL

ziprasidone hcl oral capsule 80 mg T1 AL

ZYPREXA INTRAMUSCULAR T4 PA

ZYPREXA ORAL T2 AL

ZYPREXA RELPREVV T4 PA

Barbiturates (Anticonvulsants)

MYSOLINE T2

phenobarbital T1

primidone T1

Barbiturates (Anxiolytic, Sedative/Hyp)





300-40-30 mg

T3





59

Drug Tier Notes


325-40-30 mg

T1

butalbital-acetaminophen T1




ESGIC T2



MARTEN-TAB T2

phenobarbital T1

Benzodiazepines (Anticonvulsants)

ATIVAN T2

clonazepam T1

clorazepate dipotassium T1

DIASTAT T1 QL (2 QY per 30 DYs)

DIASTAT ACUDIAL T1 QL (2 QY per 30 DYs)

diazepam T1

KLONOPIN T2

lorazepam T1

TRANXENE T-TAB T2

Benzodiazepines (Anxiolytic,Sedativ/Hyp)

alprazolam T1 QL (4 EA per 1 day)

amitriptyline-chlordiazepoxide T1

ATIVAN T2

chlordiazepoxide hcl T1

clonazepam T1

clorazepate dipotassium T1

DIASTAT T1 QL (2 QY per 30 DYs)

DIASTAT ACUDIAL T1 QL (2 QY per 30 DYs)





60

Drug Tier Notes

diazepam T1

estazolam T1

HALCION T2

KLONOPIN T2

lorazepam T1

oxazepam T1

RESTORIL T2

temazepam T1

TRANXENE T-TAB T2

triazolam T1

XANAX T2

Butyrophenones

haloperidol T1 AL

haloperidol decanoate T1

haloperidol lactate injection T1

haloperidol lactate oral T1 AL

Central Nervous System Agents, Misc.

atomoxetine T1 AL

guanfacine oral tablet T1

guanfacine oral tablet extended release 24 hr T1 AL

memantine T1 AL

NAMENDA T2 AL

NAMENDA TITRATION PAK T2 AL

riluzole T4 PA

TENEX T2

XENAZINE T4 PA

XYREM T4 PA

Cyclooxygenase-2 (Cox-2) Inhibitors

celecoxib oral capsule 100 mg, 200 mg, 50 mg T1 QL (2 EA per 1 day)

celecoxib oral capsule 400 mg T1





61

Drug Tier Notes

Dopamine Precursors

carbidopa-levodopa T1

SINEMET T2

SINEMET CR T2

Ergot-Deriv. Dopamine Receptor Agonists

bromocriptine T1

cabergoline T1 PA

PARLODEL T2

Fibromyalgia Agents

CYMBALTA T2

duloxetine oral capsule,delayed release(dr/ec) 20

mg



mg



mg


SAVELLA ORAL TABLET 100 MG T1

SAVELLA ORAL TABLET 12.5 MG, 25 MG, 50

MG


SAVELLA ORAL TABLETS,DOSE PACK T1

Hydantoins

DILANTIN T2

DILANTIN EXTENDED T2

DILANTIN INFATABS T2

DILANTIN-125 T2

phenytoin T1

phenytoin sodium extended T1

Monoamine Oxidase B Inhibitors

ELDEPRYL T2

selegiline hcl T1

Monoamine Oxidase Inhibitors





62

Drug Tier Notes

ELDEPRYL T2

NARDIL T2

PARNATE T2

phenelzine T1

selegiline hcl T1

tranylcypromine T1

Nonergot-Deriv.Dopamine Receptor Agonist

APOKYN T4 PA

MIRAPEX T2

pramipexole T1

REQUIP T2

ropinirole T1

Opiate Agonists

ABSTRAL T3


acetaminophen-codeine T1

ACTIQ T3



belladonna alkaloids-opium T3

BELLADONNA-OPIUM T3




300-40-30 mg

T3


325-40-30 mg

T1

CAPITAL WITH CODEINE T3

codeine sulfate T3


DEMEROL T2





63

Drug Tier Notes

DILAUDID T2

DOLOPHINE T2

DURAGESIC T2 QL (10 QY per 30 DYs)

ENDOCET ORAL TABLET 10-325 MG, 2.5-325

MG, 7.5-325 MG

T3

ENDOCET ORAL TABLET 5-325 MG T1

ENDODAN T2

fentanyl T1 QL (10 QY per 30 DYs)

fentanyl citrate T3

FENTORA T3



HYCET T3

hydrocodone-acetaminophen oral solution T1


mg, 2.5-325 mg, 5-300 mg, 7.5-300 mg

T3


mg, 5-325 mg, 5-500 mg, 7.5-325 mg, 7.5-500 mg,

7.5-750 mg

T1


mg

T2

hydrocodone-ibuprofen T3

hydromorphone T1

IBUDONE T3

ibuprofen-oxycodone T3

KADIAN ORAL CAPSULE,EXTEND.RELEASE

PELLETS 10 MG, 100 MG, 20 MG, 30 MG, 50

MG, 60 MG, 80 MG

T2

KADIAN ORAL CAPSULE,EXTEND.RELEASE

PELLETS 200 MG

T1

LAZANDA T3

levorphanol tartrate T3

LORTAB T2





64

Drug Tier Notes

LORTAB ELIXIR ORAL SOLUTION 10-300

MG/15 ML

T1

LORTAB ELIXIR ORAL SOLUTION 7.5-500

MG/15 ML

T2

meperidine T1

methadone T1

morphine concentrate T1

morphine intramuscular T3

morphine oral capsule, er multiphase 24 hr T3 PA

morphine oral capsule,extend.release pellets 10

mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg

T1

morphine oral capsule,extend.release pellets 80

mg


morphine oral solution T1

morphine oral tablet T1

morphine oral tablet extended release T1

morphine rectal T1

MS CONTIN T2

NUCYNTA T3

OPANA T3

OXAYDO T3

oxycodone oral capsule T1 QL (12 EA per 1 day)

oxycodone oral concentrate T2

oxycodone oral solution T3

oxycodone oral tablet 10 mg T1 QL (9 EA per 1 day)


oxycodone oral tablet 20 mg, 30 mg T1


oxycodone-acetaminophen oral capsule T1

oxycodone-acetaminophen oral solution T3

oxycodone-acetaminophen oral tablet 10-325 mg,

2.5-325 mg, 7.5-325 mg

T3





65

Drug Tier Notes

oxycodone-acetaminophen oral tablet 5-325 mg T1

oxycodone-aspirin T1

oxymorphone T3

PERCOCET ORAL TABLET 10-325 MG, 2.5-

325 MG, 7.5-325 MG

T3

PERCOCET ORAL TABLET 5-325 MG T2

PRIMLEV T3


REPREXAIN T3

ROXICODONE ORAL TABLET 15 MG, 30 MG T2

ROXICODONE ORAL TABLET 5 MG T3

SUBSYS T3

SYNALGOS-DC T3

tramadol T1


TREZIX T3

TYLENOL-CODEINE #4 T2

ULTRACET T3

ULTRAM T2

VERDROCET T3

VICODIN T3

VICODIN ES T3

VICODIN HP T3

VICOPROFEN T3

XODOL 10/300 T3

XODOL 5/300 T3

XODOL 7.5/300 T3

XYLON 10 T3

ZAMICET T1

Opiate Antagonists

naloxone T1





66

Drug Tier Notes

naltrexone T1

NARCAN T1

REVIA T2

VIVITROL T1 QL (1 EA per 30 days)

Opiate Partial Agonists

buprenorphine hcl T3 PA

buprenorphine-naloxone T1 PA

butorphanol tartrate T1 PA

nalbuphine T1

ZUBSOLV T3 PA

Other Nonsteroidal Anti-Inflam. Agents

ANAPROX T2

ANAPROX DS T2

CATAFLAM T2

CHILDREN'S IBUPROFEN T2

DAYPRO T2

diclofenac potassium T1

diclofenac sodium oral T1

diclofenac sodium topical T1 ST

EC-NAPROSYN T2

FELDENE T2

fenoprofen T1

hydrocodone-ibuprofen T3

IBUDONE T3

ibuprofen T1

ibuprofen-oxycodone T3

INDOCIN T1

indomethacin T1

INFANT'S IBUPROFEN T2

ketoprofen T1





67

Drug Tier Notes

meclofenamate T1

meloxicam oral tablet 15 mg T1

meloxicam oral tablet 7.5 mg T1 QL (1 EA per 1 DY)

MOBIC T2

NAPROSYN T2

naproxen T1

naproxen sodium T1

oxaprozin T1

piroxicam T1

REPREXAIN T3

VICOPROFEN T3

XYLON 10 T3

Phenothiazines

chlorpromazine T1 AL

fluphenazine decanoate T1

fluphenazine hcl injection T1

fluphenazine hcl oral T1 AL

perphenazine T1 AL

perphenazine-amitriptyline T1 AL

prochlorperazine T1

prochlorperazine edisylate T1 QL (20 ML per 30 days)

prochlorperazine maleate T1 AL

thioridazine T1 AL

trifluoperazine T1 AL

Respiratory And Cns Stimulants










68

Drug Tier Notes


300-40-30 mg

T3


325-40-30 mg

T1



CAFCIT T2

caffeine citrate T1


CONCERTA T2 PA; AL

dexmethylphenidate oral capsule,er biphasic 50-

50 10 mg, 15 mg, 5 mg

T1 PA; QL (1 EA per 1 day); AL


50 20 mg



50 30 mg, 40 mg

T1 PA; AL

dexmethylphenidate oral tablet 10 mg T1 PA; AL

dexmethylphenidate oral tablet 2.5 mg, 5 mg T1 QL (4 EA per 1 day); AL

ESGIC T2



FOCALIN XR ORAL CAPSULE,ER BIPHASIC

50-50 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5

MG

T2 PA; AL

FOCALIN XR ORAL CAPSULE,ER BIPHASIC

50-50 25 MG, 35 MG

T1 PA; AL

methylphenidate hcl oral solution T1 AL

methylphenidate hcl oral tablet T1 PA; AL

methylphenidate hcl oral tablet extended release T1 PA; AL

methylphenidate hcl oral tablet extended release

24hr 18 mg, 27 mg, 54 mg


methylphenidate hcl oral tablet extended release

24hr 36 mg






69

Drug Tier Notes

methylphenidate hcl oral tablet,chewable T1 AL

RITALIN T2 PA; AL

RITALIN SR T2 PA; AL

SYNALGOS-DC T3

TREZIX T3

Salicylates


aspirin T1






choline,magnesium salicylate T1


ENDODAN T2


oxycodone-aspirin T1

salsalate T1

SYNALGOS-DC T3

Sel.Serotonin,Norepi Reuptake Inhibitor

CYMBALTA T2


mg



mg



mg


EFFEXOR XR T2

SAVELLA ORAL TABLET 100 MG T1





70

Drug Tier Notes

SAVELLA ORAL TABLET 12.5 MG, 25 MG, 50

MG


SAVELLA ORAL TABLETS,DOSE PACK T1

venlafaxine oral capsule,extended release 24hr

150 mg

T1

venlafaxine oral capsule,extended release 24hr

37.5 mg, 75 mg


venlafaxine oral tablet 100 mg T1

venlafaxine oral tablet 25 mg, 37.5 mg, 50 mg, 75

mg


venlafaxine oral tablet extended release 24hr 150

mg, 225 mg

T1

venlafaxine oral tablet extended release 24hr 37.5

mg, 75 mg


Selective Serotonin Agonists

AMERGE T3 PA; QL (12 QY per 30 DYs)

eletriptan hbr T3 PA; QL (12 EA per 30 days)

FROVA T3 PA; QL (12 QY per 30 DYs)

IMITREX ORAL T2 QL (12 QY per 30 DYs)

IMITREX STATDOSE KIT REFILL T2 QL (2 QY per 30 DYs)

IMITREX STATDOSE PEN T2 QL (2 QY per 30 DYs)

IMITREX SUBCUTANEOUS T2 QL (4 QY per 30 DYs)

MAXALT T2 QL (12 QY per 30 DYs)

MAXALT-MLT T2 QL (12 QY per 30 DYs)

rizatriptan T1 QL (12 QY per 30 DYs)

sumatriptan T1 QL (6 QY per 30 DYs)

sumatriptan succinate oral T1 QL (12 QY per 30 DYs)

sumatriptan succinate subcutaneous cartridge T1 QL (2 QY per 30 DYs)

sumatriptan succinate subcutaneous pen injector T1 QL (2 QY per 30 DYs)

sumatriptan succinate subcutaneous solution T1 QL (4 QY per 30 DYs)

ZOMIG T3 PA; QL (1 QY per 30 DYs)

Selective-Serotonin Reuptake Inhibitors





71

Drug Tier Notes

CELEXA T2

citalopram T1

escitalopram oxalate T1

fluoxetine T1

fluvoxamine T1

LEXAPRO T2

paroxetine hcl oral tablet 10 mg, 30 mg, 40 mg T1

paroxetine hcl oral tablet 20 mg T1 QL (1 EA per 1 day)

PAXIL T2

PROZAC T2

sertraline oral concentrate T1

sertraline oral tablet 100 mg T1

sertraline oral tablet 25 mg, 50 mg T1 QL (1 EA per 1 day)

ZOLOFT T2

Serotonin Modulators

nefazodone T1

trazodone T1

Succinimides

ethosuximide T1

ZARONTIN T2

Thioxanthenes

thiothixene T1 AL

Tricyclics, Other Norepi-Ru Inhibitors

amitriptyline T1

amitriptyline-chlordiazepoxide T1

amoxapine T1

ANAFRANIL T2

clomipramine T1

desipramine T1

doxepin T1





72

Drug Tier Notes

imipramine hcl T1

maprotiline T1

NORPRAMIN T2

nortriptyline T1

PAMELOR T2

perphenazine-amitriptyline T1

TOFRANIL T2

Devices

Devices

1ST TIER UNIFINE PENTIPS T1 QL (100 EA per 20 days)

1ST TIER UNIFINE PENTIPS PLUS T1 QL (100 EA per 20 days)

ACCU-CHEK AVIVA CONTROL SOLN T1

ACCU-CHEK AVIVA PLUS METER T1

ACCU-CHEK FASTCLIX T1

ACCU-CHEK GUIDE GLUCOSE METER T1

ACCU-CHEK GUIDE L1-L2 CTRL SOL T1

ACCU-CHEK MULTICLIX LANCET T1

ACCU-CHEK NANO T1

ACCU-CHEK SMARTVIEW CONTRL SOL T1

ACCU-CHEK SOFT DEV LANCETS T1

ACCU-CHEK SOFTCLIX LANCET DEV T1

ACCU-CHEK SOFTCLIX LANCETS T1

EUFLEXXA T4 PA

GEL-ONE T4 PA

HYALGAN T4 PA

MEDI-JECTOR NEEDLE-FREE SYR A T1 QL (1 EA per 365 days)

MEDI-JECTOR NEEDLE-FREE SYR B T1 QL (1 EA per 365 days)

MEDI-JECTOR NEEDLE-FREE SYR C T1 QL (1 EA per 365 days)

MONOVISC T4 PA

NEEDLE FREE SYRINGE KIT A T1 QL (100 EA per 20 days)





73

Drug Tier Notes

NEEDLE FREE SYRINGE KIT B T1 QL (100 EA per 20 days)

NEUROPEN T1 QL (1 EA per 365 days)

NEUROTIPS T1 QL (1 EA per 365 days)

ORTHOVISC T4 PA

PEN NEEDLE T1 QL (100 EA per 20 days)

pen needle, diabetic T1 QL (100 EA per 20 days)

PENTIPS T1 QL (100 EA per 20 days)

SOFT TOUCH LANCETS T1

SOLESTA T4 PA

SYNVISC T4 PA

SYNVISC-ONE T4 PA

UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2",

30 GAUGE X 5/16", 31 GAUGE X 1/4", 31

GAUGE X 5/16"

T1 QL (100 EA per 20 days)

UNIFINE PENTIPS NEEDLE 29 GAUGE X

5/16"

T1 QL (1 EA per 365 days)

UNIFINE PENTIPS PLUS T1 QL (100 EA per 20 days)

Diagnostic Agents

Adrenocortical Insufficiency

ACTHREL T4 PA

Diabetes Mellitus

ACCU-CHEK AVIVA PLUS TEST STRP T1

ACCU-CHEK GUIDE T1

ACCU-CHEK SMARTVIEW TEST STRIP T1

Pituitary Function

ACTHREL T4 PA

Protein

ALBUSTIX REAGENT T1

Thyroid Function

THYROGEN T4 PA





74

Drug Tier Notes

Electrolytic, Caloric, And Water Balance

Alkalinizing Agents

potassium citrate T1

sodium citrate-citric acid T1

UROCIT-K 10 T2

UROCIT-K 5 T2

Ammonia Detoxicants

CARBAGLU T4 PA

lactulose T1

Caloric Agents

glucose T1

Carbonic Anhydrase Inhibitors

acetazolamide T1


Diuretics, Miscellaneous

THEO-24 T1

theophylline T1

Loop Diuretics

bumetanide T1

DEMADEX T2

furosemide T1

LASIX T2

torsemide T1

Phosphate-Removing Agents

calcium acetate T1

FOSRENOL T1

PHOSLO T2

sevelamer carbonate T1

Potassium-Removing Agents





75

Drug Tier Notes

SPS (WITH SORBITOL) T1

Potassium-Sparing Diuretics

ALDACTAZIDE T2

ALDACTONE T2

amiloride T1


DYAZIDE T2

DYRENIUM T1

MAXZIDE T2

MAXZIDE-25MG T2

spironolactone T1



Replacement Preparations

ANTACID EXTRA-STRENGTH T1

CALCITRATE T2

CALCIUM 600 T1

CALCIUM 600 + D(3) T2

CALCIUM ANTACID T1

calcium carbonate T1

calcium carbonate-vitamin d2 T1


calcium citrate T1

calcium citrate-vitamin d3 T1

CITRACAL + D3 (CALCIUM PHOS) T1

CITRUS CALCIUM T2

DAILY PRENATAL T1

KLOR-CON T1

KLOR-CON M10 T2

KLOR-CON M20 T2





76

Drug Tier Notes

LIQUID CALCIUM WITH VITAMIN D T1




OYSTER SHELL CALCIUM 500 T2

OYSTER SHELL CALCIUM-VIT D2 T1

OYSTER SHELL CALCIUM-VIT D3 ORAL

TABLET 250-125 MG-UNIT

T1

OYSTER SHELL CALCIUM-VIT D3 ORAL

TABLET 500 MG(1,250MG) -400 UNIT

T2

PEDIATRIC ELECTROLYTE T1

potassium chloride T1

PR NATAL 400 T1

PR NATAL 400 EC T1

PR NATAL 430 T1

PRENATAL VITAMIN T1



TRIVEEN-DUO DHA T1

TUMS T2

TUMS ULTRA T2

Thiazide Diuretics

ACCURETIC T2

ALDACTAZIDE T2


AMTURNIDE T2 ST

AVALIDE T2 ST


mg, 20-12.5 mg, 5-6.25 mg



mg

T1





77

Drug Tier Notes



chlorothiazide T1

CORZIDE T2

DIURIL T1

DYAZIDE T2


hydrochlorothiazide T1

HYZAAR T2



LOPRESSOR HCT T2


LOTENSIN HCT T2

MAXZIDE T2

MAXZIDE-25MG T2

methyclothiazide T1









UNIRETIC T2


VASERETIC T2

ZESTORETIC T2

ZIAC T2





78

Drug Tier Notes

Thiazide-Like Diuretics

chlorthalidone T1

CLORPRES T1

indapamide T1

metolazone T1

ZAROXOLYN T2

Uricosuric Agents

probenecid T1

probenecid-colchicine T1

Vasopressin Antagonists

SAMSCA T4 PA

Enzymes

Enzymes

ACTIVASE T4 PA

ADAGEN T4 PA

ALDURAZYME T4 PA

CATHFLO ACTIVASE T4 PA

CEREZYME T4 PA

ELAPRASE T4 PA

ELELYSO T4 PA

ELITEK T4 PA

FABRAZYME T4 PA

MYOZYME T4 PA

NAGLAZYME T4 PA

PULMOZYME T4 PA

SUCRAID T4 PA

VIMIZIM T4 PA

VORAXAZE T4 PA

VPRIV T4 PA

XIAFLEX T4 PA





79

Drug Tier Notes

Eye, Ear, Nose And Throat (Eent) Preps.

Alpha-Adrenergic Agonists (Eent)

ALPHAGAN P T2

brimonidine T1

Antiallergic Agents

ALAWAY T2 QL (1 QY per 30 DYs)

ASTELIN T2

ASTEPRO T2

azelastine T1

cromolyn T1

ketotifen fumarate T1 QL (1 QY per 30 DYs)

PATADAY T1 ST; QL (1 QY per 30 DYs)

ZADITOR T2 QL (1 QY per 30 DYs)

Antibacterials (Eent)

bacitracin-polymyxin b T1

BLEPH-10 T2

CILOXAN T2

CIPRODEX T3 PA; ST

ciprofloxacin hcl T1 QL (10 ML per 25 days)

CORTISPORIN T2

erythromycin T1 QL (3.5 GM per 25 days)

GENTAK T1 QL (4 GM per 30 days)

gentamicin T1

MAXITROL T2

MOXEZA T1

moxifloxacin T1 QL (3 ML per 30 days)

neomycin-bacitracin-poly-hc T1 QL (3.5 GM per 25 days)

neomycin-bacitracin-polymyxin T1 QL (4 GM per 30 days)

neomycin-polymyxin b-dexameth ophthalmic

drops,suspension

T1 QL (5 ML per 30 days)





80

Drug Tier Notes


ointment

T1 QL (4 GM per 30 days)

neomycin-polymyxin-gramicidin T1 QL (10 ML per 25 days)

neomycin-polymyxin-hc T1

NEOSPORIN (NEO-POLYM-GRAMICID) T2

OCUFLOX T2

ofloxacin ophthalmic T1 QL (10 ML per 25 days)

ofloxacin otic T1

polymyxin b sulf-trimethoprim T1 QL (10 ML per 30 days)

POLYTRIM T2

sulfacetamide sodium T1

sulfacetamide-prednisolone T1

TOBRADEX T2

tobramycin T1 QL (5 ML per 25 days)

tobramycin-dexamethasone T1

TOBREX OPHTHALMIC DROPS T2

TOBREX OPHTHALMIC OINTMENT T1 QL (4 GM per 30 days)

Antivirals (Eent)

trifluridine T1 QL (8 ML per 25 days)

VIROPTIC T2

Beta-Adrenergic Blocking Agents (Eent)

BETAGAN T2

carteolol T1

COSOPT T2

dorzolamide-timolol T1

levobunolol T1

timolol maleate T1

TIMOPTIC T2

TIMOPTIC OCUDOSE (PF) T1

TIMOPTIC-XE T2





81

Drug Tier Notes

Carbonic Anhydrase Inhibitors (Eent)

acetazolamide T1

COSOPT T2


dorzolamide T1

dorzolamide-timolol T1

TRUSOPT T2

Corticosteroids (Eent)

ACETASOL HC T2

CIPRODEX T3 PA; ST

dexamethasone sodium phosphate T1

fluorometholone T1

fluticasone T1

FML FORTE T1

FML LIQUIFILM T2

FML S.O.P. T1

hydrocortisone-acetic acid T1

MAXIDEX T1

MAXITROL T2

neomycin-bacitracin-poly-hc T1 QL (3.5 GM per 25 days)


drops,suspension

T1 QL (5 ML per 30 days)


ointment

T1 QL (4 GM per 30 days)

neomycin-polymyxin-hc T1

OMNARIS T3 PA

OZURDEX T4 PA

PRED FORTE T2

PRED MILD T1

prednisolone acetate T1

prednisolone sodium phosphate T1 QL (10 ML per 30 days)





82

Drug Tier Notes

RETISERT T4 PA

TOBRADEX T2

tobramycin-dexamethasone T1

triamcinolone acetonide T1 ST

Eent Anti-Infectives, Miscellaneous

ACETASOL HC T2

acetic acid T1

acetic acid-aluminum acetate T1

chlorhexidine gluconate T1

hydrocortisone-acetic acid T1

PERIOGARD T2

Eent Anti-Inflammatory Agents, Misc.

RESTASIS T1 PA

Eent Drugs, Miscellaneous

apraclonidine T1

ARTIFICIAL TEARS (POLYVIN ALC) T2

ATROVENT T2

CYSTARAN T4 PA

EYLEA T4 PA

IOPIDINE OPHTHALMIC DROPPERETTE T1

IOPIDINE OPHTHALMIC DROPS T2


JETREA (PF) T4 PA

LUCENTIS T4 PA

MACUGEN T4 PA

polyvinyl alcohol T1

TEARS NATURALE FREE (PF) T1

TEARS NATURALE II T1

VISUDYNE T4 PA

Eent Nonsteroidal Anti-Inflam. Agents





83

Drug Tier Notes

ACULAR T2

ACULAR LS T2

flurbiprofen sodium T1 QL (2.5 ML per 30 days)

ketorolac ophthalmic drops 0.4 % T1 QL (5 ML per 30 days)

ketorolac ophthalmic drops 0.5 % T1 QL (20 ML per 25 days)

OCUFEN T2

Local Anesthetics (Eent)

lidocaine hcl T1

LIDOCAINE VISCOUS T1

XYLOCAINE T2

Miotics

ISOPTO CARBACHOL T2

PHOSPHOLINE IODIDE T1

pilocarpine hcl T1

PILOPINE HS T1

Mydriatics

atropine T1

cyclopentolate T1

Prostaglandin Analogs

latanoprost T1 QL (6 ML per 30 days)

travoprost (benzalkonium) T1 ST; QL (5 ML per 30 days)

XALATAN T2

Vasoconstrictors

ADRENALIN T1

MYDFRIN T2

naphazoline T1

NEO-SYNEPHRINE (PHENYLEPHRINE) T2

phenylephrine hcl T1

Gastrointestinal Drugs

5-Ht3 Receptor Antagonists





84

Drug Tier Notes

ALOXI T4 PA

granisetron hcl T1 ST

ondansetron T1

ondansetron hcl T1

ZOFRAN (AS HYDROCHLORIDE) T2

ZOFRAN ODT T2

Antacids And Adsorbents

aluminum hydroxide gel T1

ANTACID EXTRA-STRENGTH T1

ANTACID PLUS ANTI-GAS T1

bismuth subsalicylate T1

CALCIUM ANTACID T1

magnesium oxide T1

PEPTO-BISMOL T2

PINK BISMUTH T1

sodium bicarbonate T1

TUMS T2

TUMS ULTRA T2

URO-MAG T1

Antidiarrhea Agents

bismuth subsalicylate T1


LOMOTIL T2

loperamide T1

PEPTO-BISMOL T2

PINK BISMUTH T1

Antiemetics, Miscellaneous

DICLEGIS T1 PA

scopolamine base T3 PA

Antiflatulents





85

Drug Tier Notes

ANTACID PLUS ANTI-GAS T1

Antihistamines (Gi Drugs)

ANTIVERT T2

DICLEGIS T1 PA

meclizine T1

prochlorperazine T1

prochlorperazine edisylate T1 QL (20 ML per 30 days)

prochlorperazine maleate T1

TIGAN T2

trimethobenzamide T1

Anti-Inflammatory Agents (Gi Drugs)

AZULFIDINE T2


balsalazide T1

CANASA T1

COLAZAL T2

DELZICOL T1

mesalamine T1

PENTASA ORAL CAPSULE, EXTENDED

RELEASE 250 MG


PENTASA ORAL CAPSULE, EXTENDED

RELEASE 500 MG

T1

sulfasalazine T1

Cathartics And Laxatives

AMITIZA ORAL CAPSULE 24 MCG T1

AMITIZA ORAL CAPSULE 8 MCG T1 QL (2 EA per 1 day)

bisacodyl T1

COL-RITE T1

COLYTE WITH FLAVOR PACKS T2

docusate calcium T1

docusate sodium T1





86

Drug Tier Notes

FLEET LAXATIVE T1

GAVILYTE-G T1

GOLYTELY T2

MILK OF MAGNESIA T1

MINERAL OIL HEAVY T1

MIRALAX T2

NATURAL FIBER LAXATIVE (SUGAR) T1

NATURAL FIBER LAXATIVE THERAPY T1

NULYTELY WITH FLAVOR PACKS T2

peg 3350-electrolytes T1

peg-electrolyte soln T1

polyethylene glycol 3350 T1

SENNA T1

SENNA-S T2

sennosides-docusate sodium T1

SILACE T2

TRILYTE WITH FLAVOR PACKETS T2

Cholelitholytic Agents

ACTIGALL T2

URSO 250 T2

URSO FORTE T2

ursodiol T1

Digestants

CREON T1

ZENPEP T1

Gi Drugs, Miscellaneous

CIMZIA T4 PA

CIMZIA POWDER FOR RECONST T4 PA

ENTYVIO T4 PA

GATTEX 30-VIAL T4 PA





87

Drug Tier Notes

HUMIRA T4 PA

HUMIRA PEN T4 PA

LINZESS ORAL CAPSULE 145 MCG, 290 MCG T1 AL

LINZESS ORAL CAPSULE 72 MCG T1

REMICADE T4 PA

Histamine H2-Antagonists

cimetidine T1

cimetidine hcl T1

famotidine T1

nizatidine oral capsule 150 mg T1 QL (2 EA per 1 day)

nizatidine oral capsule 300 mg T1

PEPCID T2

ranitidine hcl T1

ZANTAC T2

Neurokinin-1 Receptor Antagonists

EMEND INTRAVENOUS T4 PA

EMEND ORAL CAPSULE 125 MG, 80 MG T1

EMEND ORAL CAPSULE 40 MG T1 QL (1 QY per 30 DYs)

EMEND ORAL CAPSULE,DOSE PACK T1

Prokinetic Agents

metoclopramide hcl T1

REGLAN T2

Prostaglandins

CYTOTEC T2

misoprostol T1

Protectants

CARAFATE T2

sucralfate T1

Proton-Pump Inhibitors

ACIPHEX T3 PA





88

Drug Tier Notes

esomeprazole magnesium T3 PA

lansoprazole T1 ST; QL (1 EA per 1 day)

NEXIUM 24HR T1 ST; QL (1 EA per 1 day)

NEXIUM PACKET T3 PA

omeprazole T1 QL (1 EA per 1 day)

omeprazole-sodium bicarbonate T1 ST

pantoprazole T1 QL (1 EA per 1 day)

PREVACID 24HR T1 ST; QL (1 EA per 1 day)

PRILOSEC T1 QL (1 EA per 1 day); AL

PRILOSEC OTC T3 PA

PROTONIX ORAL GRANULES DR FOR SUSP

IN PACKET

T3 PA

PROTONIX ORAL TABLET,DELAYED

RELEASE (DR/EC)

T2

rabeprazole T3 PA

ZEGERID T3 PA

ZEGERID OTC T2 ST

Heavy Metal Antagonists

Heavy Metal Antagonists

CHEMET T1

CUPRIMINE T4 PA

deferoxamine T4 PA

DEPEN TITRATABS T4 PA

EXJADE T4 PA

FERRIPROX T4 PA

GALZIN T4 PA

JADENU T4 PA

JADENU SPRINKLE T4 PA

SYPRINE T4 PA

Hormones And Synthetic Substitutes





89

Drug Tier Notes

Adrenals

ARNUITY ELLIPTA T1

ASMANEX HFA T1

ASMANEX TWISTHALER INHALATION

AEROSOL POWDR BREATH ACTIVATED 110

MCG (30 DOSES), 220 MCG (120 DOSES), 220

MCG (30 DOSES), 220 MCG (60 DOSES)

T1 QL (1 QY per 30 DYs)



MCG (7 DOSES)




MCG (14 DOSES)


BREO ELLIPTA T1

budesonide inhalation suspension for nebulization

0.25 mg/2 ml

T1 QL (60 QY per 30 DYs); AL


0.5 mg/2 ml



1 mg/2 ml

T1 QL (60 ML per 30 DYs); AL

CORTEF T2

cortisone T1

dexamethasone T1

DEXAMETHASONE INTENSOL T1

dexamethasone sodium phos (pf) T1

dexamethasone sodium phosphate T1


EMFLAZA T4 PA

ENTOCORT EC T3 PA

FLOVENT DISKUS INHALATION BLISTER

WITH DEVICE 100 MCG/ACTUATION









90

Drug Tier Notes




FLOVENT HFA INHALATION HFA AEROSOL

INHALER 110 MCG/ACTUATION







T1 QL (10.6 QY per 30 DYs)

fludrocortisone T1

hydrocortisone T1

MEDROL T2

MEDROL (PAK) T2

methylprednisolone T1

ORAPRED T2

prednisolone T1

prednisolone sodium phosphate T1

prednisone T1

PREDNISONE INTENSOL T1

PRELONE T2

PULMICORT INHALATION SUSPENSION

FOR NEBULIZATION 0.25 MG/2 ML, 1 MG/2

ML



FOR NEBULIZATION 0.5 MG/2 ML


QVAR INHALATION AEROSOL 40

MCG/ACTUATION



MCG/ACTUATION


Androgens

AVEED T4 PA

danazol T1 PA

fluoxymesterone T1 PA

TESTIM T3 PA





91

Drug Tier Notes

TESTOPEL T4 PA

testosterone T1 PA

testosterone cypionate T1 PA

testosterone enanthate T1 PA; QL (1 QY per 30 DYs)

Antidiabetic Agents, Miscellaneous

WELCHOL T1

Antithyroid Agents

methimazole T1

propylthiouracil T1

SSKI T1

TAPAZOLE T2

Biguanides

glipizide-metformin oral tablet 2.5-250 mg T1 QL (3 EA per 1 day)

glipizide-metformin oral tablet 2.5-500 mg, 5-500

mg

T1

GLUCOPHAGE T2

GLUCOPHAGE XR T2

GLUCOVANCE T2

glyburide-metformin oral tablet 1.25-250 mg T1 QL (3 EA per 1 day)

glyburide-metformin oral tablet 2.5-500 mg, 5-500

mg

T1

JANUMET T1 ST

JANUMET XR T1 ST

metformin oral tablet T1

metformin oral tablet extended release 24 hr 500

mg

T1

metformin oral tablet extended release 24 hr 750

mg


Contraceptives

APRI T2

ARANELLE (28) T1





92

Drug Tier Notes

AVIANE T2

BALZIVA (28) T1

CAMILA T2

CAMRESE T1

CRYSELLE (28) T1

CYCLESSA (28) T2

desog-e.estradiol/e.estradiol T1

DESOGEN T2

desogestrel-ethinyl estradiol T2

drospirenone-ethinyl estradiol T1

ELLA T1

ENPRESSE T1

ERRIN T2

ESTROSTEP FE-28 T2

FEMCON FE T2

INTROVALE T2

JOLESSA T2

JOLIVETTE T2

JUNEL 1.5/30 (21) T1

JUNEL 1/20 (21) T2

JUNEL FE 1.5/30 (28) T2

JUNEL FE 1/20 (28) T2

KARIVA (28) T2

KELNOR 1/35 (28) T1

KURVELO T2

LEENA 28 T1

LESSINA T2

levonorgestrel-ethinyl estrad T1

LEVORA-28 T2

LOESTRIN 1.5/30 (21) T2





93

Drug Tier Notes

LOESTRIN 1/20 (21) T2

LOESTRIN 24 FE T1

LOESTRIN FE 1.5/30 (28-DAY) T1

LOESTRIN FE 1/20 (28-DAY) T2

LOW-OGESTREL (28) T1

LUTERA (28) T2

MICROGESTIN 1.5/30 (21) T1

MICROGESTIN 1/20 (21) T2

MICROGESTIN FE 1.5/30 (28) T1

MICROGESTIN FE 1/20 (28) T2

MIRCETTE (28) T2

MODICON (28) T2

MONONESSA (28) T2

NECON 1/35 (28) T1

NECON 1/50 (28) T1

NECON 7/7/7 (28) T1

NEXT CHOICE ONE DOSE T1

NORA-BE T2

norethindrone (contraceptive) T1

norethindrone ac-eth estradiol T1

norethindrone-e.estradiol-iron T1

norgestimate-ethinyl estradiol T1

NORINYL 1/35 (28) T2

NORTREL 0.5/35 (28) T1

NORTREL 1/35 (21) T1

NORTREL 1/35 (28) T1

NORTREL 7/7/7 (28) T1

NUVARING T1 QL (1 EA per 28 DYs)

OCELLA T2

OGESTREL (28) T2





94

Drug Tier Notes

ORTHO TRI-CYCLEN (28) T2

ORTHO TRI-CYCLEN LO (28) T2

ORTHO-NOVUM 1/35 (28) T2

OVCON-35 (28) T2

PLAN B T2

PLAN B ONE-STEP T1

PORTIA T2

QUASENSE T2

RECLIPSEN (28) T1

SEASONIQUE T2

SPRINTEC (28) T2

SRONYX T2

TILIA FE T1

TRINESSA (28) T1

TRI-NORINYL (28) T2

TRI-SPRINTEC (28) T2

TRIVORA (28) T1

VELIVET TRIPHASIC REGIMEN (28) T1

XULANE T1 QL (3 EA per 28 days)

YASMIN (28) T2

ZENCHENT FE T1

ZOVIA 1/35E (28) T1

ZOVIA 1/50E (28) T1

Dipeptidyl Peptidase-4(Dpp-4) Inhibitors

JANUMET T1 ST

JANUMET XR T1 ST

JANUVIA T1 ST

Estrogen Agonist-Antagonists

raloxifene T1

Estrogens





95

Drug Tier Notes

CLIMARA T2

ESTRACE ORAL T2

ESTRACE VAGINAL T1

estradiol T1

estropipate T1

FEMHRT LOW DOSE T2

JINTELI T2

MENEST T1


PREMARIN T1

PREMPHASE T1

PREMPRO T1

Glycogenolytic Agents

GLUCAGEN HYPOKIT T1 QL (2 QY per 30 DYs)

GLUCAGON EMERGENCY KIT (HUMAN) T1 QL (2 QY per 30 DYs)

Gonadotropins

ELIGARD T4 PA




leuprolide T4 PA



LUPRON DEPOT T4 PA




LUPRON DEPOT-PED T4 PA

LUPRON DEPOT-PED (3 MONTH) T4 PA

VANTAS T4 PA





96

Drug Tier Notes

ZOLADEX T4 PA

Incretin Mimetics

TRULICITY T1 ST

VICTOZA 2-PAK T1 ST

VICTOZA 3-PAK T1 ST

Insulins

APIDRA T1 QL (3 QY per 30 DYs)

APIDRA SOLOSTAR T1 QL (2 QY per 30 DYs)

BASAGLAR KWIKPEN T1 QL (30 ML per 30 DYs)

HUMALOG KWIKPEN T1 QL (2 QY per 30 DYs)

HUMALOG MIX 50-50 T1 QL (3 QY per 30 DYs)

HUMALOG MIX 50-50 KWIKPEN T1 QL (2 QY per 30 DYs)

HUMALOG MIX 75-25 T1 QL (3 QY per 30 DYs)

HUMALOG MIX 75-25 KWIKPEN T1 QL (2 QY per 30 DYs)

HUMALOG SUBCUTANEOUS CARTRIDGE T1 QL (2 QY per 30 DYs)

HUMALOG SUBCUTANEOUS SOLUTION T1 QL (3 QY per 30 DYs)

HUMULIN 70/30 T1 QL (3 QY per 30 DYs)

HUMULIN N T1 QL (3 QY per 30 DYs)

HUMULIN R U-100 T1 QL (3 QY per 30 DYs)

HUMULIN R U-500 (CONCENTRATED) T1

Parathyroid

calcitonin (salmon) T1

FORTEO T4 PA

MIACALCIN INJECTION T4 PA

MIACALCIN NASAL T2

TYMLOS T4 PA

Pituitary

DDAVP NASAL T2 PA

DDAVP ORAL T2 PA; AL

desmopressin nasal T1 PA





97

Drug Tier Notes

desmopressin oral T1 PA; AL

GENOTROPIN T4 PA

GENOTROPIN MINIQUICK T4 PA

HUMATROPE T4 PA

NORDITROPIN FLEXPRO T4 PA

NORDITROPIN NORDIFLEX T4 PA

NUTROPIN AQ T4 PA

NUTROPIN AQ NUSPIN T4 PA

OMNITROPE T4 PA

SAIZEN T4 PA

SAIZEN CLICK.EASY T4 PA

SEROSTIM T4 PA

STIMATE T1 PA

Progestins

AYGESTIN T2

DEPO-PROVERA INTRAMUSCULAR

SOLUTION

T1

DEPO-PROVERA INTRAMUSCULAR

SUSPENSION

T2

FEMHRT LOW DOSE T2

JINTELI T2



MAKENA T4 PA

medroxyprogesterone intramuscular T1 QL (1 ML per 30 days)

medroxyprogesterone oral T1

norethindrone acetate T1


PROVERA T2

Somatostatin Agonists

octreotide acetate T4 PA





98

Drug Tier Notes

SANDOSTATIN T4 PA

SANDOSTATIN LAR DEPOT T4 PA

SIGNIFOR T4 PA

SOMATULINE DEPOT T4 PA

Somatotropin Agonists

EGRIFTA T4 PA

INCRELEX T4 PA

Somatotropin Antagonists

SOMAVERT T4 PA

Sulfonylureas

AMARYL T2

DIABETA T2

glimepiride oral tablet 1 mg, 2 mg T1 QL (3 EA per 1 day)

glimepiride oral tablet 4 mg T1

glipizide oral tablet 10 mg T1

glipizide oral tablet 5 mg T1 QL (5 EA per 1 day)

glipizide oral tablet extended release 24hr 10 mg T1

glipizide oral tablet extended release 24hr 2.5 mg,

5 mg


glipizide-metformin oral tablet 2.5-250 mg T1 QL (3 EA per 1 day)

glipizide-metformin oral tablet 2.5-500 mg, 5-500

mg

T1

GLUCOTROL T2

GLUCOTROL XL T2

GLUCOVANCE T2

glyburide micronized oral tablet 1.5 mg, 3 mg T1 QL (3 EA per 1 day)

glyburide micronized oral tablet 6 mg T1

glyburide oral tablet 1.25 mg, 2.5 mg T1 QL (3 EA per 1 day)

glyburide oral tablet 5 mg T1

glyburide-metformin oral tablet 1.25-250 mg T1 QL (3 EA per 1 day)





99

Drug Tier Notes

glyburide-metformin oral tablet 2.5-500 mg, 5-500

mg

T1

GLYNASE T2

Thyroid Agents

ARMOUR THYROID T1

CYTOMEL T2

levothyroxine T1

liothyronine T1

NATURE-THROID T1

SYNTHROID T2

THYROLAR-1 T1

THYROLAR-1/2 T1

THYROLAR-1/4 T1

THYROLAR-2 T1

THYROLAR-3 T1

UNITHROID T2

Miscellaneous Therapeutic Agents

5-Alpha-Reductase Inhibitors

dutasteride T1

finasteride T1

PROSCAR T2

Alcohol Deterrents

ANTABUSE T2

disulfiram T1

naltrexone T1

REVIA T2

VIVITROL T1 QL (1 EA per 30 days)

Antidotes

CHEMET T1

deferoxamine T4 PA





100

Drug Tier Notes

FOSRENOL T1

FUSILEV T4 PA

GLUCAGEN HYPOKIT T1 QL (2 QY per 30 DYs)

GLUCAGON EMERGENCY KIT (HUMAN) T1 QL (2 QY per 30 DYs)

leucovorin calcium T4 PA

MEPHYTON T1

naloxone T1

NARCAN T1

sevelamer carbonate T1

SPS (WITH SORBITOL) T1

SSKI T1

VORAXAZE T4 PA

Antigout Agents

allopurinol oral tablet 100 mg T1

allopurinol oral tablet 300 mg T1 QL (2 EA per 1 day)

ANAPROX T2

ANAPROX DS T2

EC-NAPROSYN T2

INDOCIN T1

indomethacin T1

KRYSTEXXA T4 PA

NAPROSYN T2

naproxen T1

naproxen sodium T1

probenecid T1

probenecid-colchicine T1

ZYLOPRIM T2

Bone Resorption Inhibitors

alendronate T1

BONIVA T4 PA





101

Drug Tier Notes

calcitonin (salmon) T1

DIDRONEL T2

etidronate disodium T1

FOSAMAX T2

MIACALCIN INJECTION T4 PA

MIACALCIN NASAL T2

pamidronate T4 PA

PROLIA T4 PA

raloxifene T1

RECLAST T4 PA

XGEVA T4 PA

zoledronic acid T4 PA

zoledronic ac-mannitol-0.9nacl T4 PA

ZOMETA T4 PA

Cariostatic Agents

CLINPRO 5000 T1 AL

fluoride (sodium) T1 AL

FLUORITAB T1 AL


MULTI-VITAMIN WITH FLUORIDE T1 AL

MULTIVITAMINS WITH FLUORIDE T1 AL

PHOS-FLUR T1 AL

PREVIDENT T2 AL

PREVIDENT 5000 PLUS T2 AL

SF T1 AL

SF 5000 PLUS T1 AL


TRI-VITAMIN WITH FLUORIDE T1 AL

Complement Inhibitors

BERINERT T4 PA





102

Drug Tier Notes

CINRYZE T4 PA

FIRAZYR T4 PA

KALBITOR T4 PA

RUCONEST T4 PA

SOLIRIS T4 PA

Disease-Modifying Antirheumatic Agents

ACTEMRA T4 PA

ARAVA T2

azathioprine T1

AZULFIDINE T2


CIMZIA T4 PA


CUPRIMINE T4 PA

cyclosporine T1

cyclosporine modified T1

DEPEN TITRATABS T4 PA

ENBREL T4 PA

ENBREL SURECLICK T4 PA

GENGRAF T2

HUMIRA T4 PA

HUMIRA PEN T4 PA


IMURAN T2

KINERET T4 PA

leflunomide T1




NEORAL T2





103

Drug Tier Notes

ORENCIA T4 PA

ORENCIA (WITH MALTOSE) T4 PA

ORENCIA CLICKJECT T4 PA

OTEZLA T4 PA

OTEZLA STARTER T4 PA

OTREXUP (PF) T4 PA

PLAQUENIL T2

REMICADE T4 PA

RHEUMATREX T2

SANDIMMUNE T2

SIMPONI T4 PA

SIMPONI ARIA T4 PA

STELARA T4 PA

sulfasalazine T1



XELJANZ T4 PA

XELJANZ XR T4 PA

Gonadotropin-Releasing Hormone Antagnts

FIRMAGON T4 PA

Immunomodulatory Agents

ACTEMRA T4 PA

ACTIMMUNE T4 PA

ARAVA T2

AUBAGIO T4 PA

AVONEX T4 PA

AVONEX (WITH ALBUMIN) T4 PA

azathioprine T1

AZULFIDINE T2






104

Drug Tier Notes

CIMZIA T4 PA


COPAXONE T4 PA

cyclosporine T1


ENBREL T4 PA

ENBREL SURECLICK T4 PA

ENTYVIO T4 PA

EXTAVIA T4 PA

GENGRAF T2

GILENYA T4 PA

GLATOPA T4 PA

HUMIRA T4 PA

HUMIRA PEN T4 PA


IMURAN T2

INTRON A T4 PA

KINERET T4 PA

leflunomide T1

LEMTRADA T4 PA




NEORAL T2

ORENCIA T4 PA

ORENCIA (WITH MALTOSE) T4 PA

ORENCIA CLICKJECT T4 PA

OTREXUP (PF) T4 PA

PLAQUENIL T2

PLEGRIDY T4 PA





105

Drug Tier Notes

POMALYST T4 PA

PROLEUKIN T4 PA

REBIF (WITH ALBUMIN) T4 PA

REBIF REBIDOSE T4 PA

REBIF TITRATION PACK T4 PA

REVLIMID T4 PA

RHEUMATREX T2

SANDIMMUNE T2

SIMPONI T4 PA

SIMPONI ARIA T4 PA

STELARA T4 PA

sulfasalazine T1

TECFIDERA T4 PA

THALOMID T4 PA



TYSABRI T4 PA

XELJANZ T4 PA

XELJANZ XR T4 PA

Immunosuppressive Agents

ASTAGRAF XL T4 PA

ATGAM T4 PA

azathioprine T1

BENLYSTA T4 PA

CELLCEPT T2

CELLCEPT INTRAVENOUS T4 PA

cyclophosphamide intravenous T4 PA

cyclophosphamide oral T1

cyclosporine T1






106

Drug Tier Notes

ELIDEL T1 PA

GENGRAF T2

IMURAN T2

mercaptopurine T1




mycophenolate mofetil T1

NEORAL T2

NULOJIX T4 PA

OTREXUP (PF) T4 PA

PROGRAF INTRAVENOUS T4 PA

PROGRAF ORAL T2

RAPAMUNE T4 PA

RHEUMATREX T2

SANDIMMUNE T2

SIMULECT T4 PA

tacrolimus T1

THYMOGLOBULIN T4 PA



ZORTRESS T4 PA

Other Miscellaneous Therapeutic Agents

acetylcysteine T1

AMPYRA T4 PA

ARCALYST T4 PA

BOTOX T4 PA

BOTOX COSMETIC T4 PA

CARNITOR T2

CARNITOR (SUGAR-FREE) T4 PA





107

Drug Tier Notes

CERDELGA T4 PA

CYSTADANE T4 PA

DEMSER T4 PA

DYSPORT T4 PA

ILARIS (PF) T4 PA

KUVAN T4 PA

levocarnitine T1

MYOBLOC T4 PA

octreotide acetate T4 PA

ORFADIN T4 PA

PANHEMATIN T4 PA

PREZCOBIX T1

PROCYSBI T4 PA

REMICADE T4 PA

SANDOSTATIN T4 PA

SANDOSTATIN LAR DEPOT T4 PA

THIOLA T4 PA

XEOMIN T4 PA

ZAVESCA T4 PA

Protective Agents

amifostine crystalline T4 PA

MESNEX T4 PA

Oxytocics

Oxytocics

METHERGINE T1 QL (28 EA per 7 days)

Pharmaceutical Aids

Pharmaceutical Aids

DILUENT FOR EPOPROSTENOL/FLOLA T4 PA

Radioactive Agents

Radioactive Agents





108

Drug Tier Notes

XOFIGO T4 PA

Respiratory Tract Agents

Alpha And Beta Adrenergic Agonist(Respr)


BROMFED DM T1


CHERATUSSIN DAC T1



epinephrine T1 QL (2 EA per 30 DYs)


M-END DMX T1

MUCINEX D T1

pseudoephedrine hcl T1

ZYRTEC-D T2

Anticholinergic Agents (Respir.Tract)

ANORO ELLIPTA T1

ATROVENT HFA T1




LOMOTIL T2

SPIRIVA RESPIMAT T1 AL

Antifibrotic Agents

ESBRIET T4 PA

OFEV T4 PA

Antitussives


benzonatate T1

BROMFED DM T1





109

Drug Tier Notes

CHERATUSSIN AC T2

CHERATUSSIN DAC T1

codeine sulfate T3

codeine-guaifenesin T1 AL

hydrocodone-homatropine T1

M-END DMX T1



promethazine-codeine T1

promethazine-dm T1


ROBAFEN DM T1

SYNALGOS-DC T3

TESSALON PERLES T2

TUSSIGON T1

Cystic Fibrosis (Cftr) Potentiators

KALYDECO T4 PA

Expectorants

CHERATUSSIN AC T2

CHERATUSSIN DAC T1

codeine-guaifenesin T1 AL

ED BRON GP T1

guaifenesin T1

MUCINEX T2

MUCINEX D T1



ROBAFEN DM T1

SSKI T1

First Generation Antihist.(Respir Tract)





110

Drug Tier Notes

ALLER-CHLOR T1

BROMFED DM T1


clemastine T1

cyproheptadine T1

DICLEGIS T1 PA

DIPHENHIST T1



M-END DMX T1

PHENERGAN T2




PROMETHAZINE VC T1


promethazine-codeine T1

promethazine-dm T1


Leukotriene Modifiers

montelukast oral granules in packet T1 QL (1 EA per 1 day); AL

montelukast oral tablet T1 QL (1 EA per 1 day)

montelukast oral tablet,chewable T1 QL (1 EA per 1 day)

SINGULAIR ORAL GRANULES IN PACKET T2 AL

SINGULAIR ORAL TABLET T2

SINGULAIR ORAL TABLET,CHEWABLE T2

Mast-Cell Stabilizers

cromolyn T1

Mucolytic Agents

acetylcysteine T1





111

Drug Tier Notes

PULMOZYME T4 PA

Nasal Preparations (Steroids)

fluticasone T1

OMNARIS T3 PA

triamcinolone acetonide T1 ST

Orally Inhaled Preparations (Steroids)

ARNUITY ELLIPTA T1

ASMANEX HFA T1



MCG (30 DOSES), 220 MCG (120 DOSES), 220

MCG (30 DOSES), 220 MCG (60 DOSES)




MCG (7 DOSES)




MCG (14 DOSES)


BREO ELLIPTA T1


0.25 mg/2 ml



0.5 mg/2 ml



1 mg/2 ml

T1 QL (60 ML per 30 DYs); AL


















112

Drug Tier Notes








FOR NEBULIZATION 0.25 MG/2 ML, 1 MG/2

ML



FOR NEBULIZATION 0.5 MG/2 ML



MCG/ACTUATION



MCG/ACTUATION


Phosphodiesterase Type 4 Inhibitors

DALIRESP T1 ST

Respiratory Tract Agents, Miscellaneous

ARALAST NP T4 PA

GLASSIA T4 PA

XOLAIR T4 PA

ZEMAIRA T4 PA

Second Generation Antihist(Respir Tract)

ALAVERT T2


ALLEGRA ALLERGY T2 ST

cetirizine T1


CHILDREN'S CLARITIN T2

CLARINEX T3 PA

CLARITIN T2

CLARITIN REDITABS T2







113

Drug Tier Notes

desloratadine T3 PA

fexofenadine oral suspension T1 ST; QL (10 ML per 1 day)

fexofenadine oral tablet T1 ST

levocetirizine oral solution T3 PA

levocetirizine oral tablet T1 ST

loratadine T1


XYZAL ORAL SOLUTION T3 PA

XYZAL ORAL TABLET T2 ST

ZYRTEC T2

ZYRTEC-D T2

Select.Beta-2-Adrenergic Agonist(Respir)

albuterol sulfate T1

ANORO ELLIPTA T1

BREO ELLIPTA T1



SEREVENT DISKUS T1

terbutaline T1

VENTOLIN HFA T1 QL (1 QY per 30 DYs)

XOPENEX HFA T1 ST

Vasodilating Agents (Respiratory Tract)

ADCIRCA T4 PA

epoprostenol (glycine) T4 PA

FLOLAN T4 PA

LETAIRIS T4 PA

OPSUMIT T4 PA

ORENITRAM T4 PA

REMODULIN T4 PA

REVATIO T4 PA





114

Drug Tier Notes

sildenafil T1 PA

TRACLEER T4 PA

TYVASO T4 PA

TYVASO REFILL KIT T4 PA

TYVASO STARTER KIT T4 PA

UPTRAVI T4 PA

VELETRI T4 PA

VENTAVIS T4 PA

Xanthine Derivatives

THEO-24 T1

theophylline T1

Skin And Mucous Membrane Agents

Antibacterials (Skin, Mucous Membrane)

bacitracin-polymyxin b T1

BACTROBAN T2

BENZAMYCIN T2

CLEOCIN T T2

clindamycin phosphate T1

ERY PADS T1

erythromycin with ethanol T1

erythromycin-benzoyl peroxide T1

gentamicin T1

METROGEL T2

METROGEL VAGINAL T2

metronidazole T1

mupirocin T1

POLYSPORIN T2

Anti-Inflammatory Agents (Skin, Mucous)

amcinonide T1 QL (15 GM per 30 days)

betamethasone dipropionate T1





115

Drug Tier Notes

betamethasone valerate T1

betamethasone, augmented T1

clobetasol T1

clobetasol-emollient T1

clotrimazole-betamethasone T1 QL (15 QY per 34 DYs)

desonide T1

desoximetasone T1

diflorasone topical cream T1 QL (15 GM per 25 days)

diflorasone topical ointment T1 QL (15 GM per 30 days)

DIPROLENE T2

DIPROLENE AF T2

ELOCON TOPICAL CREAM T2 QL (45 QY per 30 DYs)

ELOCON TOPICAL OINTMENT T2 QL (45 QY per 30 DYs)

ELOCON TOPICAL SOLUTION T2

fluocinolone T1

fluocinonide T1

FLUOCINONIDE-E T1

hydrocortisone T1

hydrocortisone acetate T1

hydrocortisone valerate T1

hydrocortisone-min oil-wht pet T1

LOTRISONE T2 QL (15 QY per 34 DYs)

mometasone topical cream T1 QL (45 QY per 30 DYs)

mometasone topical ointment T1 QL (45 QY per 30 DYs)

mometasone topical solution T1

PROCTOFOAM HC T1

TEMOVATE T2

TEMOVATE E T2

TOPICORT T2

triamcinolone acetonide T1





116

Drug Tier Notes

WESTCORT T2

Antipruritics And Local Anesthetics

dibucaine T1

lidocaine T3 PA

lidocaine hcl T1

lidocaine-prilocaine T1 QL (30 QY per 30 DYs)

LIDODERM T3 PA

NUPERCAINAL T1

phenazopyridine T1

PROCTOFOAM HC T1

PYRIDIUM T2

Antivirals (Skin And Mucous Membrane)

ZOVIRAX T3 PA

Astringents

DRYSOL DAB-O-MATIC T2

Azoles (Skin And Mucous Membrane)

clotrimazole T1

clotrimazole-betamethasone T1 QL (15 QY per 34 DYs)

ketoconazole topical cream T1

ketoconazole topical shampoo T1 ST

LOTRIMIN AF T2

LOTRISONE T2 QL (15 QY per 34 DYs)

miconazole nitrate T1

MICONAZOLE-3 T1

NIZORAL T2 ST

NIZORAL A-D T1

Basic Lotions And Liniments

AMLACTIN T2

ammonium lactate T1

Basic Ointments And Protectants





117

Drug Tier Notes

ammonium lactate T1

LAC-HYDRIN T2

Benzylamines (Skin And Mucous Membrane)

LOTRIMIN ULTRA T1

MENTAX T2

Cell Stimulants And Proliferants

KEPIVANCE T4 PA

tretinoin T1 AL

tretinoin microspheres T1 AL

Keratolytic Agents

benzoyl peroxide T1

DESQUAM-X T1

NEUTROGENA ON THE SPOT T1

NEUTROGENA T-GEL CONDITNER(SA) T1

sulfacetamide sodium-sulfur T1

urea T1

Keratoplastic Agents

DRITHOCREME HP T1

Local Anti-Infectives, Miscellaneous

KLARON T2

selenium sulfide T1

SILVADENE T2

silver sulfadiazine T1

sulfacetamide sodium (acne) T1

sulfacetamide sodium-sulfur T1

Pigmenting Agents

8-MOP T4 PA

OXSORALEN ULTRA T4 PA

Polyenes (Skin And Mucous Membrane)

nystatin T1





118

Drug Tier Notes

nystatin-triamcinolone T1

Scabicides And Pediculicides

CUTTER BACKWOODS T1 QL (170 GM per 6 days)

CUTTER SKINSATIONS T1 QL (177 ML per 6 days)

LICE BEDDING SPRAY T1 QL (142 GM per 5 days)

LICE KILLING T1 QL (120 QY per 30 DYs)

OFF ACTIVE T1 QL (170 GM per 6 days)

OFF DEEP WOODS T1 QL (170 GM per 6 days)

OFF DEEP WOODS DRY T1 QL (113 GM per 4 days)

OFF FAMILYCARE (WITH DEET) T1 QL (71 GM per 2 days)

permethrin topical cream T1 QL (60 QY per 1 PD)

permethrin topical liquid T1 QL (118 QY per 30 DYs)

REPEL SPORTSMEN T1 QL (184 GM per 6 days)

REPEL SPORTSMEN MAX T1 QL (184 GM per 6 days)

RID COMPLETE LICE ELIM KIT T1 QL (141.8 GM per 5 days)

spinosad T1

STOP LICE T1 QL (142 GM per 5 days)

Skin And Mucous Membrane Agents, Misc.

ABSORICA T3 PA

ALDARA T2 QL (24 QY per 30 DYs)

ARTHRITIS PAIN RELIEF(CAPSAIC) T1

capsaicin T1

CAPZASIN-HP T1

CLARAVIS T1 PA; QL (1 EA per 1 day)

CONDYLOX T2

COSENTYX T4 PA

COSENTYX (2 SYRINGES) T4 PA

COSENTYX PEN T4 PA

COSENTYX PEN (2 PENS) T4 PA

CUTTER BACKWOODS T1 QL (170 GM per 6 days)





119

Drug Tier Notes

CUTTER SKINSATIONS T1 QL (177 ML per 6 days)

diclofenac sodium T1 ST

ELIDEL T1 PA

HIGH POTENCY CAPSAICIN T1

imiquimod T1 QL (24 QY per 30 DYs)

INSECT REPELLENT (PICARIDIN) T1 QL (118 GM per 4 days)

MYORISAN T1 PA; QL (1 EA per 1 day)

NATRAPEL T1 QL (177 ML per 6 days)

OFF ACTIVE T1 QL (170 GM per 6 days)

OFF DEEP WOODS T1 QL (170 GM per 6 days)

OFF DEEP WOODS DRY T1 QL (113 GM per 4 days)

OFF FAMILYCARE (WITH DEET) T1 QL (71 GM per 2 days)

podofilox T1

PROTOPIC TOPICAL OINTMENT 0.03 % T2 PA

PROTOPIC TOPICAL OINTMENT 0.1 % T1 PA

REPEL SPORTSMEN T1 QL (184 GM per 6 days)

REPEL SPORTSMEN MAX T1 QL (184 GM per 6 days)

SANTYL T1

STELARA T4 PA

tacrolimus T1 PA

TALTZ AUTOINJECTOR T4 PA

TALTZ SYRINGE T4 PA

TARGRETIN T4 PA

TRIXAICIN HP T1

ZENATANE T1 PA; QL (1 EA per 1 day)

ZOSTRIX-HP FOOT T1

ZOSTRIX-HP TOPICAL CREAM 0.075 % T2

ZOSTRIX-HP TOPICAL CREAM 0.1 % T1

Thiocarbamates(Skin And Mucous Membrane)

tolnaftate T1





120

Drug Tier Notes

Smooth Muscle Relaxants

Antimuscarinics

DETROL T2

DETROL LA ORAL CAPSULE,EXTENDED

RELEASE 24HR 2 MG

T2

DETROL LA ORAL CAPSULE,EXTENDED

RELEASE 24HR 4 MG

T1

flavoxate T1

oxybutynin chloride T1

tolterodine oral capsule,extended release 24hr 2

mg


tolterodine oral capsule,extended release 24hr 4

mg

T1

tolterodine oral tablet 1 mg T1 QL (2 EA per 1 day)

tolterodine oral tablet 2 mg T1

trospium T1

Respiratory Smooth Muscle Relaxants

THEO-24 T1

theophylline T1

Vitamins

Multivitamin Preparations

CADEAU DHA T1


CERTAVITE-ANTIOXID (IRON GLUC) T2

CHILDREN'S CHEWABLE VITAMIN T1 AL

CHILD'S VITAMIN WITH IRON T1 AL

CHILDS/IRON T1 AL

COMPLETE NATAL DHA T1

COMPLETENATE T2

DAILY PRENATAL T1

DAILY VITES/IRON T1 AL





121

Drug Tier Notes

GERAVIM T1 AL


multivitamin T1 AL

MULTI-VITAMIN WITH FLUORIDE T1 AL

MULTIVITAMIN WITH MINERALS T1

MULTIVITAMINS WITH FLUORIDE T1 AL

MY-VITALIFE T1 AL

OBSTETRIX DHA T1

OBTREX DHA T1

ONE DAILY PLUS MINERALS T1 AL




PEDIAVIT T1 AL

POLY-VI-SOL T2 AL

POLY-VI-SOL WITH IRON T2 AL

POLY-VITAMIN T1 AL

POLY-VITAMIN WITH IRON T1 AL

POLYVITAMIN/IRON T1 AL

PR NATAL 400 T1

PR NATAL 400 EC T1

PR NATAL 430 T1

PRENA1 CHEW (QUATREFOLIC) T1

PRENATA T1

PRENATAL + DHA T1

PRENATAL 19 T1

PRENATAL GUMMY T1



PRENATAL VITAMIN T1





122

Drug Tier Notes



PRORENAL QD T1

TAB-A-VITE-MINERALS T1 AL

THERATRUM COMPLETE 50 PLUS T1 AL

TRINATAL GT T1

TRIVEEN-DUO DHA T1



TRI-VITAMIN T1 AL


TRUST NATAL DHA T1

VITRUM SENIOR T1 AL


Vitamin A

beta carotene T1 AL


TRI-VITAMIN T1 AL


vitamin a T1 AL

Vitamin B Complex

B COMPLEX-VITAMIN B12 T1 AL

b complex-vitamin c-folic acid T1 AL

B-COMPLEX WITH VITAMIN C T1 AL

biotin T1 AL

CADEAU DHA T1


cyanocobalamin (vitamin b-12) injection T1

cyanocobalamin (vitamin b-12) oral tablet T2 AL





123

Drug Tier Notes

cyanocobalamin (vitamin b-12) oral tablet

extended release

T1 AL

cyanocobalamin (vitamin b-12) sublingual T1 AL

DAILY PRENATAL T1

DICLEGIS T1 PA

folic acid T1

MULTIGEN FOLIC T1

MULTIGEN PLUS T1

niacinamide T1

NICOMIDE T1

OBSTETRIX DHA T1

OBTREX DHA T1



pantothenic acid (vit b5) T1 AL

PR NATAL 400 T1

PR NATAL 400 EC T1

PR NATAL 430 T1

PRENA1 CHEW (QUATREFOLIC) T1

PRENATA T1

PRENATAL + DHA T1

PRENATAL 19 T1

PRENATAL GUMMY T1



PRENATAL VITAMIN T1



PRORENAL QD T1

PYRI 500 T1 AL

pyridoxine (vitamin b6) T1





124

Drug Tier Notes

riboflavin (vitamin b2) T1 AL

STRESS B-COMPLEX T1

thiamine hcl (vitamin b1) oral tablet 100 mg T1 AL

thiamine hcl (vitamin b1) oral tablet 250 mg T1

TRINATAL GT T1

TRIVEEN-DUO DHA T1

vit b complex-folic acid T1 AL

VITAMIN B-1 ORAL TABLET 100 MG T2 AL

VITAMIN B-1 ORAL TABLET 250 MG T2


VITAMIN B-12 ORAL T1 AL

VITAMIN B-12 SUBLINGUAL T2 AL

VITAMIN B-2 ORAL TABLET 100 MG, 25 MG T1 AL


VITAMIN B-6 ORAL TABLET 100 MG, 25 MG T1


VITAMIN B-6 ORAL TABLET 50 MG T2

VITAMIN B-6 ORAL TABLET EXTENDED

RELEASE

T1 AL

VITAMINS B COMPLEX T1 AL


Vitamin C

ascorbic acid (vitamin c) oral tablet T1 AL

ascorbic acid (vitamin c) oral tablet extended

release 1,500 mg

T1

ascorbic acid (vitamin c) oral tablet extended

release 500 mg

T1 AL

b complex-vitamin c-folic acid T1 AL

B-COMPLEX WITH VITAMIN C T1 AL

MULTIGEN FOLIC T1

MULTIGEN PLUS T1





125

Drug Tier Notes

STRESS B-COMPLEX T1


TRI-VITAMIN T1 AL


VITAMIN C ORAL SYRUP T1 AL

VITAMIN C ORAL TABLET 1,000 MG, 500

MG

T1 AL

VITAMIN C ORAL TABLET 250 MG T2 AL

VITAMIN C ORAL TABLET EXTENDED

RELEASE

T2 AL

VITAMIN C ORAL TABLET,CHEWABLE T1 AL

Vitamin D

calcitriol T1

CALCIUM 600 + D(3) T2



calcium citrate-vitamin d3 T1

cholecalciferol (vitamin d3) T1

CITRACAL + D3 (CALCIUM PHOS) T1

CITRUS CALCIUM T2

DRISDOL T2

ergocalciferol (vitamin d2) T1

JUST D T2

LIQUID CALCIUM WITH VITAMIN D T1




PRORENAL QD T1

ROCALTROL T2


TRI-VITAMIN T1 AL





126

Drug Tier Notes


VITAMIN D3 ORAL CAPSULE 1,000 UNIT,

2,000 UNIT

T2

VITAMIN D3 ORAL CAPSULE 400 UNIT T1

VITAMIN D3 ORAL TABLET 1,000 UNIT,

2,000 UNIT

T2

VITAMIN D3 ORAL TABLET 400 UNIT T1

VITAMIN D3 ORAL TABLET,CHEWABLE T2

Vitamin E

vitamin e T1 AL

vitamin e (dl, acetate) T1 AL

vitamin e mixed T1 AL

Vitamin K Activity

MEPHYTON T1





127

Index

INDEX \e " " \c "3" \h "A" \z "1033"

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