formulary - blue cross and blue shield of alabama

Local Government Health Insurance Plan (LGHIP)Prescription Drug Coverage for Medicare Members

2013 Comprehensive FormularyList of Covered Drugs

S1030_FDL_LGHIP_13

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BlueRx (PDP)

2013 Formulary

(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Beneficiaries must use network pharmacies to access their prescription drug benefits. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2014. BlueRx (PDP) is a Medicare-approved Part D sponsor. To receive this material in large print, contact Member Services at 1-855-314-4990 (TTY 711), 7 a.m. to 5:30 p.m., Monday through Friday.

S1030_FDL_LGHIP_13 Last Updated: 10222013

Approved Formulary ID: 00013156-V17

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What is the BlueRx (PDP) Formulary?

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

Can the Formulary change? Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of October 22, 2013. To get updated information about the drugs covered by BlueRx (PDP), please visit our Web site at www.alseib.org or call Member Services at 1-855-314-4990 (TTY 711), 7 a.m. to 5:30 p.m., Monday through Friday. In the event BlueRx (PDP) makes a non-maintenance change to the formulary, such as removing a drug from our formulary, or adding prior authorizations, quantity limits and/or step therapy restrictions to a drug, or changing a tiered cost-sharing status, our plan will mail a written notice at least 60 days prior to the change becoming effective. Please keep the notice with your formulary.

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

Medical Condition

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

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Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 42. The Index provides an alphabetical list of all of the drugs, excluding those in the supplemental drug lists, included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

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

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

• Prior Authorization: BlueRx (PDP) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from BlueRx (PDP) before you fill your prescriptions. If you do not get approval, BlueRx (PDP) may not cover the drug.

• Quantity Limits: For certain drugs, BlueRx (PDP) limits the amount of the drug that BlueRx (PDP) will cover. For example, BlueRx (PDP) provides 30 tablets per prescription for JANUVIA. This may be in addition to a standard one month or three month supply.

• Step Therapy: In some cases, BlueRx (PDP) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, BlueRx (PDP) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, BlueRx (PDP) will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site at www.alseib.org.

You can ask BlueRx (PDP) to make an exception to these restrictions or limits. See the section, “How do I request an exception to the BlueRx (PDP)’s formulary?” on page iv for information about how to request an exception.

What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact Member Services and confirm that your drug is not covered. If you learn that BlueRx (PDP) does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by BlueRx (PDP). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by BlueRx (PDP).

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• You can ask BlueRx (PDP) to make an exception and cover your drug. See below for information about how to request an exception.

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

• You can ask us to cover your drug even if it is not on our formulary.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, BlueRx (PDP) limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

• You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug.

Generally, BlueRx (PDP) will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restriction, would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

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

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

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

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If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93-day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Circumstances exist in which unplanned transitions for members could arise and in which prescribed drug regimens may not be on the formulary. These circumstances usually involve level of care changes in which a member is changing from one treatment setting to another. For these unplanned transitions, you must use our exceptions and appeals process. Coverage determinations and redeterminations will be processed as expeditiously as your health condition requires.

In order to prevent a temporary gap in care when a member is discharged to home, members are permitted to have a full outpatient supply available to continue therapy once their limited supply provided at discharge is exhausted. This outpatient supply is available in advance of discharge for a Part A stay.

When a member is admitted to, or discharged from, a long term care facility, he or she does not have access to the remainder of the previously dispensed prescription. We will ensure you have a refill upon admission or discharge. A one-time override of the “refill too soon” edits are provided for each medication which would be impacted due to a member being admitted to, or discharged from, a long term care facility. Early refill edits are not used to limit appropriate and necessary access to a member’s Part D benefit, and such members are allowed to access a refill upon admission or discharge.

For more information

For more detailed information about your BlueRx (PDP) prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about BlueRx (PDP), please call Member Services at 1-855-314-4990 (TTY 711), 7 a.m. to 5:30 p.m., Monday through Friday, or visit www.alseib.org.

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

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BlueRx (PDP)’s Formulary

The formulary that begins on page 1 provides coverage information about some of the drugs covered by BlueRx (PDP). If you have trouble finding your drug in the list, turn to the Index that begins on page 42.

The supplemental lists of drugs for your plan begin on page 57.

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

The information in the Requirements/Limits column tells you if BlueRx (PDP) has any special requirements for coverage of your drug.

Requirements/ Limits

Drug Name

Dru

g Ti

er

B or

D

Prio

r A

utho

rizat

ion

Qua

ntity

Lim

its†

Step

The

rapy

Column 1

Col

umn

2

Col

umn

3

Col

umn

4

Col

umn

5

Col

umn

6

Column 1, the Drug Name column, provides information such as drug name and if the drug is BRAND or generic. Column 2, the Drug Tier column, provides information on which of the 4 tiers the drug has been assigned. Member cost-sharing is based on drug tier assignment, day supply, and pharmacy selected. Column 3, the B or D column, identifies drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance (B or D).

X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance. Medicare covered Part B drugs will be coordinated through your medical benefits, not BlueRx (PDP). Not all Part D Network pharmacies can provide these drugs.

Columns 4, 5, and 6, the Requirements/Limits columns, indicates if a drug has any additional requirements or limits under Utilization Management including Prior Authorization, Quantity Limits, and Step Therapy.

• = Utilization Management

† = Quantity limit restrictions for these drugs are listed beginning on page 29.

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You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in our network. Drugs identified as Limited Distribution Drugs will be marked with an asterisk after the drug name in the formulary. These prescriptions may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Member Services at 1-855-314-4990 (TTY 711), 7 a.m. to 5:30 p.m., Monday through Friday. * = Limited Distribution Drugs The table below describes your share of the cost when you get a covered Part D prescription drug.

Drug Tiers

In-Network In-Network Out of Network*

Retail Preferred Pharmacy

Retail Non-Preferred Pharmacy

Non-Participating

Pharmacy

Tier 1 30 day $5 co-pay $5 co-pay $5 co-pay

Generic 60 day $10 co-pay $10 co-pay

90 day $10 co-pay $15 co-pay

Tier 2 Preferred Brand

20% coinsurance 20% coinsurance 20% coinsurance

Tier 3 Non- Preferred Brand


Tier 4 Specialty


*Note: For Out-of-Network Non-Participating Pharmacies, the member is responsible for submitting Non-Participating Pharmacy paper claims. Member will not be reimbursed for the difference between the Out-of-Network pharmacy charge and the plan’s In-Network allowable amount. Member is responsible for the full cost of the drug minus the copays/coinsurance.

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An Abbreviation Key for prescription drug dosages is provided below as a quick reference for our list of formulary drugs beginning on page 1.

Prescription Drug Dosage Restrictions Abbreviation Key

Key

caps capsules chew tabs chewable tablets conc concentrate crm cream DR delayed-release ER extended-release g gram hr hour IM intramuscular inhal inhalation inj injection IR immediate-release IV intravenous liq liquid lotn lotion mcg microgram mEq milliequivalent mg milligram mL milliliter NF non-formulary ODT orally disintegrating tablets oint ointment SL sublingual soln solution supp suppositories susp suspension tabs tablets

2013

1 = Generic Drugs 2 = Preferred Brand Drugs 3 = Non-Preferred Brand Drugs4 = Specialty Tier Drugs • = Utilization Management (UM) * = Limited Distribution DrugX = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance† = Quantity limit restrictions for these drugs are listed beginning on page 29

1

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

Analgesicsacetaminophen/codeine 1 •AVINZA 2 •butorphanol 1CELEBREX 2 •CODEINE SULFATE tabs 3etodolac 1fentanyl transdermal 1 •fentanyl citrate oral lozenges 4 • •hydrocodone/acetaminophen

caps; oral soln,7.5-325 mg/15 mL,7.5-500 mg/15 mL

1 •

hydrocodone/acetaminophentabs, 2.5-500 mg, 5-300 mg,5-325 mg, 5-500 mg,7.5-300 mg, 7.5-325 mg,7.5-500 mg, 7.5-650 mg,7.5-750 mg, 10-300 mg,10-325 mg, 10-500 mg,10-650 mg, 10-660 mg,10-750 mg

1 •

hydrocodone/ibuprofen 1 •hydromorphone inj, 10 mg/mL 1 Xhydromorphone liq, tabs 1ibuprofen 1ketoprofen 1ketorolac tabs 1 •LEVORPHANOL 3methadone tabs, 5 mg, 10 mg 1morphine sulfate inj, 0.5 mg/mL,

1 mg/mL1 X

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

morphine sulfate oral soln 1MORPHINE SULFATE tabs 3morphine sulfate ER tabs 1 •naproxen 1naproxen sodium 1NUCYNTA ER 2 •oxycodone tabs, 5 mg, 10 mg,

15 mg, 20 mg, 30 mg1

oxycodone/acetaminophen 1 •oxycodone/aspirin 1 •OXYCONTIN 2 •PENNSAID 2 • •tramadol 1 •tramadol ER (Generic for Ultram

ER)1 •

tramadol/acetaminophen 1 •VOLTAREN gel 2 • •Anestheticslidocaine local inj, 0.5%, 1%;

topical soln, 4%1

lidocaine patch 1lidocaine viscous 1lidocaine/prilocaine 1LIDODERM 2Anti-Addiction/Substance Abuse Treatment Agentsbuprenorphine SL tabs 1 •buprenorphine/naloxone 1 •bupropion hcl ER, 12 hr (smoking

deterrent)1

CHANTIX 2 •

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Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

disulfiram 1NALOXONE inj, 0.4 mg/mL 3naloxone inj, 1 mg/mL 1naltrexone 1NICOTROL INHALER 3NICOTROL NS nasal spray 3SUBOXONE 3 •VIVITROL 4AntibacterialsAMIKACIN inj, 100 mg/2 mL 3amikacin inj, 500 mg/2 mL,

1 g/4 mL1

amoxicillin caps; chew tabs,250 mg; for susp; tabs

1

AMOXICILLIN chew tabs, 125 mg 3amoxicillin/clarithromycin/

lansoprazole1

amoxicillin/potassium clavulanatechew tabs; for susp,200 mg/5 mL, 400 mg/5 mL,600 mg/5 mL; tabs

1

ampicillin caps 1AMPICILLIN for susp 3ampicillin sodium for inj, 125 mg,

250 mg, 500 mg, 1 g, 2 g; forIV, 10 g

1

AMPICILLIN SODIUM for IV, 1 g,2 g

3

AVELOX 2AZACTAM inj in dextrose 3azithromycin for IV, for susp, tabs 1

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

AZITHROMYCIN powder pack forsusp

2

aztreonam for inj 1cefaclor caps 1cefadroxil 1cefazolin for inj, 500 mg, 1 g,

10 g, 20 g1

cefdinir 1cefepime for inj 1cefotaxime for inj, 500 mg, 1 g,

2 g, 10 g1

cefoxitin for inj 1cefpodoxime 1cefprozil 1ceftazidime for inj, 500 mg, 1 g,

2 g, 6 g; for IV, 1 g, 2 g1

ceftriaxone for inj, for IV 1CEFTRIAXONE for IV in

dextrose, inj in dextrose3

cefuroxime axetil 1cefuroxime sodium for inj,

750 mg, 1.5 g, 7.5 g; for IV,1.5 g

1

cephalexin caps, for susp 1CHLORAMPHENICOL 3CIPRO for susp 3ciprofloxacin for IV, 200 mg,

400 mg; for IV in dextrose; tabs1

ciprofloxacin ER 1CLAFORAN IV in dextrose 3clarithromycin 1

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Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

clarithromycin ER 1CLEOCIN IV in dextrose 3clindamycin caps; inj; IV in

dextrose; IV soln, 600 mg/4 mL,900 mg/6 mL; vaginal crm

1

colistimethate sodium 1CUBICIN 4 Xdemeclocycline 1dicloxacillin 1DIFICID 4doxycycline hyclate caps, for inj,

tabs1

doxycycline monohydrate 1E.E.S. GRANULES 3ERY-TAB 3ERYPED 3ERYTHROCIN 3FORTAZ for inj, 500 mg; inj in

dextrose3

GENTAMICIN inj in saline,0.9 mg/mL, 1.4 mg/mL

3

gentamicin inj; inj in saline,0.8 mg/mL, 1 mg/mL, 1.2 mg/mL, 1.6 mg/mL; IV soln

1

imipenem/cilastatin 1INVANZ 3KANAMYCIN 3levofloxacin 1MEFOXIN 3meropenem 1methenamine hippurate 1

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

METRO IV 3metronidazole caps, IV soln, tabs,

vaginal gel1

minocycline 1nafcillin for inj 1NAFCILLIN for IV 3neomycin sulfate tabs 1nitrofurantoin susp 1nitrofurantoin macrocrystalline

caps1

nitrofurantoin monohydrate/macrocrystalline caps

1

ofloxacin 1penicillin g potassium for inj 1PENICILLIN G POTASSIUM inj in

dextrose3

PENICILLIN G SODIUM for inj 3penicillin v potassium 1piperacillin/tazobactam for inj,

2-0.25 g, 3-0.375 g, 4-0.5 g1

PREVPAC 2STREPTOMYCIN 3SULFADIAZINE 3SULFAMETHOXAZOLE/

TRIMETHOPRIM inj3

sulfamethoxazole/trimethoprimsusp, tabs

1

SUPRAX caps, chew tabs, tabs 3SYNERCID 4TEFLARO 3TETRACYCLINE caps, 250 mg 3

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Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

tetracycline caps, 500 mg 1TIMENTIN 3TOBI 4 Xtobramycin for inj, inj 1TOBRAMYCIN inj in saline 3trimethoprim tabs 1TYGACIL 3VANCOCIN caps 4vancomycin caps 4vancomycin for inj, 500 mg, 1 g,

5 g1 X

VANCOMYCIN inj in dextrose 3 XXIFAXAN tabs, 550 mg 2ZINACEF inj in dextrose, inj in

sterile water3

ZOSYN IV in dextrose 3ZYVOX 4AnticonvulsantsBANZEL susp; tabs, 400 mg 4BANZEL tabs, 200 mg 3carbamazepine 1carbamazepine ER caps; ER

tabs, 200 mg, 400 mg1

CELONTIN 3clonazepam ODT, tabs 1 • •clorazepate 1 • •DIASTAT 3 •DIAZEPAM oral conc, oral soln 3 • •DIAZEPAM rectal gel 3 •diazepam tabs 1 • •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

DILANTIN caps, 30 mg; chewtabs

3

divalproex sprinkle caps 1divalproex DR tabs 1divalproex ER 1ethosuximide caps, oral soln 1felbamate 1fosphenytoin 1gabapentin 1GABITRIL 3LAMICTAL ODT 3 •lamotrigine chew tabs, 5 mg,

25 mg; tabs1

levetiracetam inj, oral soln, tabs 1LEVETIRACETAM IV in saline 3LYRICA 2ONFI 3 • •oxcarbazepine 1PEGANONE 3phenobarbital 1phenytoin chew tabs, susp 1phenytoin sodium ER caps,

100 mg, 200 mg, 300 mg1

POTIGA 3 •primidone 1SABRIL 3TEGRETOL-XR 100 mg 3tiagabine 1topiramate sprinkle caps 1topiramate tabs 1

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Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

TRILEPTAL susp 3 •valproate inj 1valproic acid 1VIMPAT 3 •zonisamide 1Antidementia Agentsdonepezil 1 •EXELON oral soln, transdermal 2 •galantamine 1 •galantamine ER 1 •NAMENDA 2 •rivastigmine caps 1 •AntidepressantsABILIFY 2 •ABILIFY DISCMELT 2 •ABILIFY MAINTENA 4 •amitriptyline 1AMOXAPINE 3bupropion hcl 1 •bupropion hcl ER, 12 hr 1 •bupropion hcl ER, 24 hr 1 •citalopram oral soln, tabs 1 •clomipramine 1CYMBALTA 2 • •desipramine 1doxepin 1EMSAM 3escitalopram 1 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

fluoxetine caps; oral soln; tabs,10 mg, 20 mg

1 •

fluoxetine DR 1 •fluvoxamine 1 •imipramine hcl 1imipramine pamoate 1MAPROTILINE 3 • •MARPLAN 3mirtazapine tabs 1 •mirtazapine ODT 1 •nefazodone tabs, 250 mg 1NEFAZODONE tabs, 50 mg,

100 mg, 150 mg, 200 mg3

nortriptyline caps 1NORTRIPTYLINE oral soln 3OLEPTRO 3 • •paroxetine hcl tabs 1 •paroxetine hcl ER 1 •PAXIL susp 3 • •phenelzine 1PRISTIQ 3 • •protriptyline 1quetiapine 1 •SEROQUEL 3 •SEROQUEL XR 2 •sertraline 1 •SURMONTIL 3tranylcypromine 1trazodone 1

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Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

trimipramine 1venlafaxine 1 •venlafaxine ER caps; ER tabs,

37.5 mg, 75 mg, 150 mg1 •

VIIBRYD 3 • •AntiemeticsALOXI 3CHLORPROMAZINE inj 3chlorpromazine tabs 1diphenhydramine 1dronabinol 1 XEMEND caps 2 XEMEND for IV 3granisetron tabs 1 Xhydroxyzine hcl syrup, tabs 1meclizine tabs, 12.5 mg, 25 mg 1metoclopramide oral soln, tabs 1ondansetron inj 1ondansetron ODT, oral soln, tabs 1 Xperphenazine 1PROCHLORPERAZINE inj 3prochlorperazine supp, tabs 1promethazine supp, syrup, tabs 1SANCUSO 3 •AntifungalsAMPHOTERICIN B 3 XCANCIDAS 4clotrimazole troche 1fluconazole for susp, inj in

dextrose, tabs1

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

FLUCONAZOLE inj in normalsaline, 100 mg/50 mL

3

fluconazole inj in normalsaline, 200 mg/100 mL,400 mg/200 mL

1

flucytosine 1GRIS-PEG 2griseofulvin 1itraconazole caps 1ketoconazole tabs 1MYCAMINE 4NOXAFIL 4 •nystatin susp, tabs 1terbinafine 1terconazole 1VFEND susp 4 •VFEND IV 3 •voriconazole for inj 1 •voriconazole tabs 4 •Antigout Agentsallopurinol 1COLCRYS 2probenecid 1probenecid/colchicine 1ULORIC 2Anti-Inflammatory AgentsCELEBREX 2 •diclofenac potassium 1diclofenac sodium DR 1diclofenac sodium ER 1

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Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

diclofenac/misoprostol 1etodolac 1etodolac ER 1flurbiprofen 1ibuprofen 1indomethacin caps 1indomethacin ER 1ketoprofen 1meloxicam tabs 1nabumetone 1naproxen 1naproxen DR 1naproxen sodium 1oxaprozin 1PENNSAID 2 • •piroxicam 1sulindac 1tolmetin sodium caps, 400 mg 1VIMOVO 2 •VOLTAREN gel 2 • •Antimigraine Agentsdivalproex sprinkle caps 1divalproex DR tabs 1divalproex ER 1MIGERGOT 3MIGRANAL 2naratriptan 1 •propranolol tabs 1propranolol ER caps 1

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

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ntity

Lim

its †

Ste

p Th

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y

rizatriptan 1 •sumatriptan inj 1SUMATRIPTAN nasal spray 3 •sumatriptan tabs 1 •TIMOLOL tabs 3topiramate sprinkle caps 1topiramate tabs 1Antimyasthenic AgentsMESTINON syrup 3pyridostigmine 1AntimycobacterialsCAPASTAT 3CYCLOSERINE 3DAPSONE 2ethambutol 1ISONIAZID inj 3isoniazid tabs 1isoniazid/rifampin 1MYCOBUTIN 3PASER 3PRIFTIN 3pyrazinamide 1rifampin 1SEROMYCIN 3TRECATOR 3AntineoplasticsABRAXANE 4ADRIAMYCIN for inj, 20 mg 3 XAFINITOR 4 • •

2013


8

Requirements/Limits

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horiz

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Lim

its †

Ste

p Th

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y

AFINITOR DISPERZ 4 • •ALIMTA 4amifostine 4anastrozole 1ARRANON 4ARZERRA 4AVASTIN* 4BICNU 3bleomycin 1 XBOSULIF 4 • •BUSULFEX 4CAMPATH 4CAPRELSA* 4 • •carboplatin IV soln 1CEENU 3cisplatin inj 1cladribine 4 XCLOLAR 4COMETRIQ 4 • •COSMEGEN 4CYCLOPHOSPHAMIDE for inj 3CYCLOPHOSPHAMIDE tabs 3 XCYTARABINE for inj, 100 mg 3 Xcytarabine for inj, 500 mg, 1 g,

2 g; inj1 X

DACARBAZINE for inj, 100 mg 3dacarbazine for inj, 200 mg 1DACOGEN 4daunorubicin 1

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

decitabine 4dexrazoxane 4DOCEFREZ 4DOCETAXEL for inj, 20 mg/mL,

80 mg/4 mL, 140 mg/7 mL; forIV

4

DOXIL 3 Xdoxorubicin 1 XELITEK 4ELSPAR 3EMCYT 3epirubicin inj 1ERBITUX 4ERIVEDGE 4 • •ETOPOPHOS 3etoposide inj 1exemestane 1FARESTON 3FASLODEX 4fludarabine 1fluorouracil inj 1 Xgemcitabine for inj 4GEMCITABINE inj 4GILOTRIF 4 • •GLEEVEC 4 • •HALAVEN 4HERCEPTIN 4HEXALEN 4 •hydroxyurea 1

2013


9

Requirements/Limits

Drug Name Dru

g Ti

er

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Prio

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

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y

ICLUSIG 4 • •idarubicin 4IFEX for inj, 3 g 3ifosfamide for inj, 1 g; IV 1IFOSFAMIDE for inj, 3 g 3IFOSFAMIDE/MESNA 3INLYTA 4 • •INTRON-A 10 million units, 25

million units3

INTRON-A 18 million units, 50million units

4

IRESSA* 4irinotecan 1ISTODAX 4IXEMPRA 4JAKAFI 4 • •JEVTANA 4KADCYLA 4letrozole 1leucovorin calcium for inj, 50 mg,

100 mg, 200 mg, 350 mg; tabs,5 mg, 25 mg

1

LEUCOVORIN CALCIUM for inj,500 mg; inj, 10 mg/mL; tabs,10 mg, 15 mg

3

LEUKERAN 2LOMUSTINE caps, 10 mg, 40 mg 3MATULANE 4 •MEKINIST 4 • •melphalan 4

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

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horiz

atio

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ntity

Lim

its †

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y

mercaptopurine 1mesna 1MESNEX tabs 3methotrexate for inj, inj 1methotrexate tabs 1 Xmitomycin 1mitoxantrone 1MUSTARGEN 3NEXAVAR* 4 • •ONCASPAR 4ONTAK 4oxaliplatin 4paclitaxel IV, 30 mg/5 mL,

100 mg/16.7 mL, 300 mg/50 mL1

PANRETIN 4pentostatin 4PERJETA 4POMALYST 4 • •PROLEUKIN 4REVLIMID* 4 • •RITUXAN* 4 •SOLTAMOX 3SPRYCEL 4 • •STIVARGA 4 • •SUTENT 4 • •SYLATRON 4 •SYNRIBO 4TABLOID 3TAFINLAR 4 • •

2013


10

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

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horiz

atio

n

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ntity

Lim

its †

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p Th

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y

tamoxifen 1TARCEVA 4 • •TARGRETIN caps 4 •TARGRETIN gel 4TASIGNA 4 • •TAXOTERE 4TEMODAR for IV 4THALOMID 4 • •THIOTEPA 3topotecan for inj 4TOPOTECAN inj 4TORISEL 4TREANDA 4tretinoin caps 4 •TRISENOX 3TYKERB* 4 • •UVADEX 3VANDETANIB* 4 • •VECTIBIX 4VELCADE 4VIDAZA 4VINBLASTINE 3 Xvincristine 1vinorelbine 1VOTRIENT 4 • •XALKORI 4 • •YERVOY 4ZALTRAP 4ZANOSAR 4

Requirements/Limits

Drug Name Dru

g Ti

er

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horiz

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n

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its †

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p Th

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y

ZELBORAF 4 • •ZOLINZA 4 • •ZYTIGA 4 • •AntiparasiticsALBENZA 3ALINIA 3atovaquone/proguanil tabs,

250-100 mg1

BILTRICIDE 3chloroquine phosphate 1COARTEM 3DARAPRIM 3hydroxychloroquine 1lindane lotn, shampoo 1MALARONE tabs, 62.5-25 mg 3malathion 1mefloquine 1MEPRON 4paromomycin 1PENTAM 300 3 Xpermethrin 1PRIMAQUINE 3STROMECTOL 2ULESFIA 3Antiparkinson Agentsamantadine caps, syrup 1AMANTADINE tabs 3APOKYN* 4AZILECT 2

2013


11

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

benztropine tabs 1bromocriptine 1carbidopa/levodopa 1carbidopa/levodopa ER 1COMTAN 3diphenhydramine 1entacapone 1NEUPRO 2pramipexole 1ropinirole 1selegiline 1STALEVO 2TASMAR 4trihexyphenidyl 1AntipsychoticsABILIFY 2 •ABILIFY DISCMELT 2 •ABILIFY MAINTENA 4 •CHLORPROMAZINE inj 3chlorpromazine tabs 1clozapine 1 •FANAPT 3 •FAZACLO 3 •FLUPHENAZINE DECANOATE 3FLUPHENAZINE HCL elixir, inj,

oral conc3

fluphenazine hcl tabs 1GEODON 3 •haloperidol inj, oral conc, tabs 1

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

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horiz

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n

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ntity

Lim

its †

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p Th

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y

haloperidol decanoate 1INVEGA tabs, 1.5 mg, 3 mg, 6 mg 3 •INVEGA tabs, 9 mg 4 •INVEGA SUSTENNA inj, 117 mg,

156 mg, 234 mg4 •

INVEGA SUSTENNA inj, 39 mg,78 mg

3 •

LATUDA 3 •loxapine 1olanzapine 1 •ORAP 3perphenazine 1PROCHLORPERAZINE inj 3prochlorperazine supp, tabs 1quetiapine 1 •RISPERDAL CONSTA 3 •risperidone 1 •SAPHRIS 3 •SEROQUEL 3 •SEROQUEL XR 2 •thioridazine 1thiothixene 1trifluoperazine 1ziprasidone 1 •ZYPREXA for inj 3 •ZYPREXA RELPREVV* 4 •Antispasticity Agentsbaclofen tabs 1dantrolene caps 1

2013


12

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

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y

tizanidine 1Antiviralsabacavir 1 •acyclovir 1ACYCLOVIR SODIUM for inj,

1000 mg; IV soln3 X

acyclovir sodium for inj, 500 mg 1 Xadefovir 4amantadine caps, syrup 1AMANTADINE tabs 3APTIVUS 3 •ATRIPLA 3 •BARACLUDE oral soln 3BARACLUDE tabs 4cidofovir 1COMPLERA 3 •CRIXIVAN 3 •didanosine DR 1 •EDURANT 3 •EMTRIVA 3 •EPIVIR oral soln 2 •EPIVIR-HBV 2EPZICOM 2 •famciclovir 1FOSCARNET 3 XFUZEON 4 •ganciclovir for inj 1 XHEPSERA 4INCIVEK 4 •

Requirements/Limits

Drug Name Dru

g Ti

er

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Prio

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horiz

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its †

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INTELENCE 3 •INTRON-A 10 million units, 25

million units3

INTRON-A 18 million units, 50million units

4

INVIRASE 3 •ISENTRESS 2 •KALETRA 3 •lamivudine 1 •lamivudine/zidovudine 1 •LEXIVA 2 •nevirapine tabs 1 •NORVIR 3 •PREZISTA 3 •REBETOL oral soln 3RESCRIPTOR 3 •RETROVIR IV 3REYATAZ 2 •RIBAPAK 800, 1200 4RIBASPHERE tabs, 400 mg 3RIBASPHERE tabs, 600 mg 4ribavirin caps; tabs, 200 mg 1rimantadine 1SELZENTRY 3 •stavudine 1 •STRIBILD 3 •SUSTIVA 2 •TAMIFLU 3TIVICAY 4 •

2013


13

Requirements/Limits

Drug Name Dru

g Ti

er

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horiz

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its †

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p Th

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y

TRIZIVIR 2 •TRUVADA 3 •TYZEKA 3valacyclovir 1VALCYTE 4VICTRELIS 4 •VIDEX 3 •VIRACEPT 3 •VIRAMUNE 3 •VIRAMUNE XR 3 •VIREAD 3 •VISTIDE 3ZERIT oral soln 3 •ZIAGEN 2 •zidovudine 1 •Anxiolyticsbuspirone 1clorazepate 1 • •CYMBALTA 2 • •DIAZEPAM oral conc, oral soln 3 • •diazepam tabs 1 • •doxepin 1escitalopram 1 •hydroxyzine hcl syrup, tabs 1paroxetine hcl tabs 1 •paroxetine hcl ER 1 •PAXIL susp 3 • •sertraline 1 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

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horiz

atio

n

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ntity

Lim

its †

Ste

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y

venlafaxine ER caps; ER tabs,37.5 mg, 75 mg, 150 mg

1 •

Bipolar AgentsABILIFY 2 •ABILIFY DISCMELT 2 •ABILIFY MAINTENA 4 •divalproex sprinkle caps 1divalproex DR tabs 1divalproex ER 1EQUETRO 3GEODON 3 •LAMICTAL ODT 3 •lamotrigine chew tabs, 5 mg,

25 mg; tabs1

lithium carbonate caps, tabs 1lithium carbonate ER 1LITHIUM CITRATE 3olanzapine 1 •quetiapine 1 •RISPERDAL CONSTA 3 •risperidone 1 •SEROQUEL 3 •SEROQUEL XR 2 •valproic acid 1ziprasidone 1 •ZYPREXA for inj 3 •Blood Glucose Regulatorsacarbose 1 •ACTOS 3 • •ALCOHOL SWABS 2

2013


14

Requirements/Limits

Drug Name Dru

g Ti

er

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

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y

GAUZE PADS 2" X 2" 2glimepiride 1 •glipizide 1 •glipizide ER 1 •glipizide/metformin 1 •GLUCAGEN KIT 2GLUCAGON EMERGENCY KIT 2glyburide 1 •GLYBURIDE (distributor of

Diabeta)2 •

glyburide micronized 1 •glyburide/metformin 1 •HUMALOG 2 XHUMALOG MIX 2HUMULIN N 2HUMULIN R 2HUMULIN 70/30 2INSULIN INJECTION DEVICE 2INSULIN INJECTION DEVICE/

NOVOLIN2

INSULIN SYRINGE/NEEDLE 2JANUMET 2 • •JANUMET XR 2 • •JANUVIA 2 • •JENTADUETO 3 • •JUVISYNC 2 • •KOMBIGLYZE XR 2 • •LANTUS 2LEVEMIR 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

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ntity

Lim

its †

Ste

p Th

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y

metformin 1 •metformin ER (Generic for

Glucophage XR)1 •

nateglinide 1 •NOVOLIN N 2NOVOLIN R 2NOVOLIN 70/30 2NOVOLOG 2 XNOVOLOG MIX 2ONGLYZA 2 • •pioglitazone 1 •PRANDIN 3 •PROGLYCEM 3repaglinide 1 •SYMLINPEN 3TRADJENTA 3 • •VICTOZA 2 • •WELCHOL 2Blood Products/Modifiers/Volume ExpandersAGGRENOX 3anagrelide 1ARANESP inj, 100 mcg, 150 mcg,

200 mcg, 300 mcg, 500 mcg4 X •

ARANESP inj, 25 mcg, 40 mcg,60 mcg

2 X •

BRILINTA 2cilostazol 1clopidogrel tabs, 75 mg 1dipyridamole tabs 1EFFIENT 2

2013


15

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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r Aut

horiz

atio

n

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ntity

Lim

its †

Ste

p Th

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y

enoxaparin 1 •EPOGEN 3 X •fondaparinux 1 •heparin inj in dextrose, 20,000

units/500 mL1 X

heparin inj, 1,000 units/mL, 5,000units/mL, 10,000 units/mL,20,000 units/mL

1 X

LEUKINE 4LOVENOX 300 mg/3 mL 3 •NEULASTA 4NEUMEGA 4NEUPOGEN 4pentoxifylline ER tabs 1PLAVIX tabs, 75 mg 3PRADAXA 2 •PROCRIT inj, 2,000 units/mL,

3,000 units/mL, 4,000 units/mL,10,000 units/mL

3 X •

PROCRIT inj, 20,000 units/mL,40,000 units/mL

4 X •

PROMACTA* 4 •tranexamic acid inj 1warfarin tabs 1XARELTO 2 •Cardiovascular Agentsacebutolol 1acetazolamide tabs 1acetazolamide ER caps 1ADCIRCA 4 • •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

amiloride 1amiloride/hydrochlorothiazide 1amiodarone tabs, 200 mg,

400 mg1

amlodipine 1amlodipine/benazepril 1atenolol 1atenolol/chlorthalidone 1atorvastatin 1 •AZOR 2 • •benazepril 1benazepril/hydrochlorothiazide 1BENICAR 2 • •BENICAR HCT 2 • •betaxolol tabs 1bisoprolol 1bisoprolol/hydrochlorothiazide 1bumetanide 1BYSTOLIC 2candesartan 1 •candesartan/hydrochlorothiazide 1 •captopril 1carvedilol 1chlorothiazide tabs 1chlorthalidone tabs, 25 mg, 50 mg 1cholestyramine 1cholestyramine light 1clonidine tabs 1clonidine transdermal 1

2013


16

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

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y

colestipol 1CRESTOR 2 •DIBENZYLINE 3DIGOXIN oral soln 3digoxin tabs 1diltiazem tabs 1diltiazem ER 1DIOVAN 3 • •DIOVAN HCT 3 • •disopyramide 1doxazosin 1 •DYNACIRC CR 3enalapril tabs 1enalapril/hydrochlorothiazide 1eplerenone 1eprosartan 1 •EXFORGE 2 • •EXFORGE HCT 2 • •felodipine ER 1fenofibrate tabs 1 •fenofibrate micronized caps,

67 mg, 134 mg, 200 mg1 •

fenofibric acid DR 1 •FIRAZYR 4 •flecainide 1fosinopril 1fosinopril/hydrochlorothiazide 1furosemide inj; oral soln, 10 mg/

mL; tabs1

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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r Aut

horiz

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n

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ntity

Lim

its †

Ste

p Th

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y

gemfibrozil 1 •hydralazine tabs 1hydrochlorothiazide 1indapamide 1irbesartan 1 •irbesartan/hydrochlorothiazide 1 •ISOSORBIDE DINITRATE SL

tabs3

isosorbide dinitrate tabs 1isosorbide dinitrate ER tabs 1isosorbide mononitrate 1isosorbide mononitrate ER tabs 1ISRADIPINE 3labetalol tabs 1LETAIRIS* 4 • •LIDOCAINE IV, 10 mg/mL 3LIPOFEN 3 •lisinopril 1lisinopril/hydrochlorothiazide 1losartan 1 •losartan/hydrochlorothiazide 1 •lovastatin 1 •LOVAZA 2methazolamide 1methyldopa 1metolazone 1metoprolol succinate ER 1metoprolol tartrate tabs 1

2013


17

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

metoprolol/hydrochlorothiazidetabs, 50-25 mg, 100-25 mg

1

mexiletine 1MICARDIS 3 • •MICARDIS HCT 3 • •midodrine 1minoxidil 1moexipril 1moexipril/hydrochlorothiazide 1MULTAQ 2nadolol 1NIASPAN 2 •nicardipine caps 1nifedipine ER tabs 1NISOLDIPINE ER tabs, 25.5 mg 3nisoldipine ER tabs, 8.5 mg,

17 mg, 34 mg1

NITRO-BID 3nitroglycerin transdermal, 0.1 mg/

hr, 0.2 mg/hr, 0.4 mg/hr,0.6 mg/hr

1

NITROMIST 3NITROSTAT 2NORPACE CR 100 mg 3perindopril 1PINDOLOL 3pravastatin 1 •prazosin 1propafenone 1propafenone ER 1

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

propranolol tabs 1propranolol ER caps 1quinapril 1quinapril/hydrochlorothiazide 1quinidine gluconate ER 1quinidine sulfate 1ramipril 1RANEXA 2REMODULIN* 4 Xsildenafil (Generic for Revatio) 4 • •simvastatin 1 •sotalol tabs 1sotalol AF tabs 1spironolactone 1spironolactone/

hydrochlorothiazide1

TEKTURNA 2 • •TEKTURNA HCT 2 • •terazosin 1 •TIKOSYN 3TIMOLOL tabs 3torsemide tabs 1TRACLEER* 4 • •trandolapril 1triamterene/hydrochlorothiazide 1TRILIPIX 2 •valsartan/hydrochlorothiazide 1 •verapamil tabs 1verapamil ER 1

2013


18

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

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y

VYTORIN 2 •WELCHOL 2ZETIA 2 •Central Nervous System AgentsADDERALL XR 3 •amphetamine/

dextroamphetamine ER caps1 •

AMPYRA 4 •AVONEX 4 • •BETASERON 4 • •caffeine citrate oral soln 1COPAXONE 4 • •CYMBALTA 2 • •dexmethylphenidate tabs 1 •dextroamphetamine tabs 1 •dextroamphetamine ER caps 1 •INTUNIV 2 •LYRICA 2methylphenidate tabs, 5 mg,

10 mg, 20 mg1 •

methylphenidate ER tabs, 20 mg 1 •mitoxantrone 1NUEDEXTA 3RILUTEK 4riluzole 4TYSABRI* 4 • •XENAZINE* 2 • •Dental and Oral Agentschlorhexidine gluconate oral

rinse, 0.12%1

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

doxycycline hyclate tabs, 20 mg 1KEPIVANCE 4pilocarpine tabs 1triamcinolone acetonide paste 1Dermatological Agentsacitretin 4acyclovir oint 1alclometasone 1amcinonide crm 1ammonium lactate crm; lotn, 12% 1AZELEX crm 3betamethasone dipropionate crm,

lotn, oint1

betamethasone dipropionate,augmented; crm, gel, lotn, oint

1

betamethasone valerate crm, lotn,oint

1

calcipotriene crm, oint, soln 1CARAC crm 3ciclopirox crm, gel, shampoo, soln

(nail lacquer), susp1

clindamycin gel, lotn, soln, swabs 1clindamycin/benzoyl peroxide gel 1clobetasol crm, crm

(emollient), gel, oint, soln1

clotrimazole crm 1clotrimazole/betamethasone crm,

lotn1

CORTIFOAM rectal foam 3DENAVIR crm 3desonide crm, lotn, oint 1

2013


19

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

desoximetasone crm, gel, oint 1diflorasone oint 1DOVONEX crm 3econazole crm 1erythromycin pads, soln 1erythromycin/benzoyl

peroxide gel1

FINACEA gel 3fluocinolone crm, 0.01% 1fluocinonide crm, crm

(emollient), gel, oint, soln1

FLUOROPLEX crm 3fluorouracil crm, soln 1fluticasone crm, oint 1GENTAMICIN crm, oint 3halobetasol crm, oint 1hydrocortisone crm; lotn, 2.5%;

oint; rectal crm1

hydrocortisone butyrate crm, oint,soln

1

hydrocortisone valerate crm, oint 1isotretinoin caps 1ketoconazole crm, shampoo 1lactic acid crm; lotn, 12% 1lidocaine gel, 2%; oint, 5% 1METROGEL 1% 3metronidazole crm, gel, lotn 1mometasone crm, lotn, oint 1mupirocin oint 1nystatin crm, oint, topical powder 1

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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horiz

atio

n

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ntity

Lim

its †

Ste

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y

nystatin/triamcinolone crm 1NYSTATIN/TRIAMCINOLONE

oint3

ORACEA caps 3OXSORALEN ULTRA caps 4PANRETIN 4PENNSAID 2 • •PICATO 2podofilox soln 1prednicarbate 1PROTOPIC 2 •SANTYL 2selenium sulfide lotn, shampoo 1silver sulfadiazine crm 1sodium chloride irrigation, 0.9% 1SOLARAZE gel 2SORIATANE caps 4sulfacetamide sodium lotn 1TARGRETIN gel 4TAZORAC crm, gel 3tretinoin crm, gel 1triamcinolone crm; lotn; oint,

0.025%, 0.1%1

TRIAMCINOLONE oint, 0.5% 3urea/hydrocortisone acetate crm 1VECTICAL oint 2VOLTAREN gel 2 • •water for irrigation 1ZOVIRAX oint 3

2013


20

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

Enzyme Replacements/ModifiersADAGEN* 4ALDURAZYME* 4BUPHENYL 4CEREZYME* 4CREON 2CYSTADANE 4CYSTAGON* 3ELAPRASE 4ELELYSO 4FABRAZYME* 4KUVAN* 4 •MYOZYME 4NAGLAZYME* 4ORFADIN* 4sodium phenylbutyrate oral

powder4

VIOKACE 3VPRIV 4ZAVESCA* 4ZENPEP 2Gastrointestinal AgentsAMITIZA 2 •CHENODAL 4cimetidine inj, oral soln, tabs 1cromolyn sodium oral conc 1famotidine for susp, inj, tabs 1glycopyrrolate tabs 1lactulose 1

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

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y

lansoprazole DR 1 •loperamide 1LOTRONEX 4methscopolamine 1metoclopramide oral soln, tabs 1misoprostol 1MOVIPREP 2NEXIUM 2 •NEXIUM I.V. 2nizatidine caps 1omeprazole DR caps 1 •pantoprazole DR tabs 1 •peg 3350/kcl/sod bicarb/nacl for

soln1

peg 3350/kcl/sod bicarb/nacl/sodsulf for soln

1

polyethylene glycol 3350 oralpowder

1

PREVACID SOLUTAB 3 •PREVPAC 2PYLERA 2ranitidine caps, syrup, tabs 1RELISTOR 3 •sucralfate tabs 1SUPREP 3ursodiol caps 1Genitourinary Agentsalfuzosin ER tabs 1 •AVODART 2 •bethanechol 1

2013


21

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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r Aut

horiz

atio

n

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ntity

Lim

its †

Ste

p Th

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y

calcium acetate 1CUPRIMINE 2DEPEN TITRATABS 3DETROL 3 •DETROL LA 2 •doxazosin 1 •finasteride 1 •FOSRENOL 2methylergonovine tabs 1neomycin/polymyxin B GU

irrigation soln1

oxybutynin 1 •oxybutynin ER 1 •PHOSLYRA 2potassium citrate ER 1prazosin 1RAPAFLO 2 •RENVELA 2SANCTURA XR 3 •tamsulosin 1 •terazosin 1 •tolterodine 1 •TOVIAZ 2 •trospium 1 •trospium ER 1 •VESICARE 2 •Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)ACTHAR HP 4 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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n

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Lim

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y

CORTISONE 3dexamethasone elixir; tabs,

0.5 mg, 0.75 mg, 1.5 mg, 4 mg,6 mg

1

DEXAMETHASONE tabs, 1 mg,2 mg

3

dexamethasone sodiumphosphate inj, 4 mg/mL

1

fludrocortisone 1hydrocortisone tabs 1methylprednisolone tabs, 4 mg,

8 mg, 16 mg, 32 mg1 X

methylprednisolone sodiumsuccinate for inj

1

prednisolone syrup 1 Xprednisolone sodium phosphate

oral soln, 5 mg/ 5 mL,15 mg/5 mL

1 X

prednisone dose-pack, 5 mg,10 mg

1

PREDNISONE oral soln,5 mg/5 mL; tabs, 50 mg

3 X

prednisone tabs, 1 mg, 2.5 mg,5 mg, 10 mg, 20 mg

1 X

SOLU-MEDROL for inj 3Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)chorionic gonadotropin 1desmopressin nasal soln, nasal

spray, tabs1

INCRELEX* 4OMNITROPE 3 •

2013


22

Requirements/Limits

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STIMATE 3Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)ANADROL-50 4 •ANDRODERM 2 • •ANDROGEL 2 • •ANDROXY 3 •COMBIPATCH 2danazol 1 •DEPO-PROVERA 400 mg/mL 3DIVIGEL 2ELLA 3ESTRACE vaginal crm 3estradiol tabs, transdermal 1estradiol/norethindrone acetate 1estropipate 1EVISTA 2FORTESTA 3 • •medroxyprogesterone inj,

150 mg/mL; tabs1

megestrol 1MENEST 3norethindrone acetate 1oral contraceptives – all generics 1oxandrolone tabs, 10 mg 4 •oxandrolone tabs, 2.5 mg 1 •PREMARIN tabs 2PREMARIN vaginal crm 2PREMPHASE 2

Requirements/Limits

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PREMPRO 2testosterone cypionate 1 •testosterone enanthate 1 •VAGIFEM vaginal tabs, 10 mcg 2VIVELLE-DOT 2Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine tabs 1Levoxyl 1liothyronine tabs 1Hormonal Agents, Suppressant (Adrenal)LYSODREN 2Hormonal Agents, Suppressant (Parathyroid)SENSIPAR 2 •Hormonal Agents, Suppressant (Pituitary)bromocriptine 1cabergoline 1ELIGARD 45 mg 4ELIGARD 7.5 mg, 22.5 mg,

30 mg3

FIRMAGON 120 mg 4FIRMAGON 80 mg 3leuprolide acetate 1LUPRON DEPOT 4LUPRON DEPOT-PED 4octreotide inj, 50 mcg/mL,

100 mcg/mL, 200 mcg/mL1 •

octreotide inj, 500 mcg/mL,1000 mcg/mL

4 •

SOMATULINE DEPOT 4 •

2013


23

Requirements/Limits

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SOMAVERT* 4 •SYNAREL 4TRELSTAR DEPOT 3TRELSTAR DEPOT MIXJECT 3TRELSTAR LA 4TRELSTAR LA MIXJECT 4TRELSTAR MIXJECT 4Hormonal Agents, Suppressant (Sex Hormones/Modifiers)AVODART 2 •bicalutamide 1finasteride 1 •flutamide 1NILANDRON 3XTANDI 4 • •ZYTIGA 4 • •Hormonal Agents, Suppressant (Thyroid)methimazole 1propylthiouracil 1Immunological AgentsACTHIB 3ACTIMMUNE* 4ADACEL 3ARCALYST* 4 •ATGAM 4 XAVONEX 4 • •AZASAN 3 XAZATHIOPRINE for inj 3 Xazathioprine tabs, 50 mg 1 X

Requirements/Limits

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BETASERON 4 • •BOOSTRIX 3CELLCEPT for IV 3 XCELLCEPT for susp 4 XCERVARIX 3COMVAX 3CUPRIMINE 2cyclosporine 1 Xcyclosporine modified caps,

25 mg, 100 mg; oral soln1 X

CYCLOSPORINE modified caps,50 mg

3 X

DAPTACEL 3DECAVAC 2DEPEN TITRATABS 3DIPHTHERIA/TETANUS

ADSORBED pediatric3

ENBREL 4 •ENGERIX-B 3 XGAMMAGARD 4 X •GAMMAGARD S/D 4 X •GARDASIL 3HAVRIX 3HIBERIX 3HUMIRA 4 •imiquimod 1 •INFANRIX 3INFERGEN 4IPOL 3IXIARO 3

2013


24

Requirements/Limits

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g Ti

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KINRIX 3leflunomide 1M-M-R II W/DILUENT 3MENACTRA 3MENOMUNE 3MENVEO 3methotrexate for inj, inj 1methotrexate tabs 1 Xmycophenolate mofetil 1 XMYFORTIC 3 XNULOJIX 4 XORTHOCLONE OKT3 4 XPEDVAX HIB 3PEG-INTRON 4 •PEGASYS 4 •PENTACEL 3PROGRAF inj 3 XPROQUAD 3PROTOPIC 2 •RABAVERT 3 XRAPAMUNE 2 XRECOMBIVAX HB 3 XREMICADE 4 •RIDAURA 3ROTARIX 3ROTATEQ 3SANDIMMUNE oral soln 3 XSIMULECT 4 XSYNAGIS 4

Requirements/Limits

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g Ti

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tacrolimus 1 XTENIVAC 2TETANUS/DIPHTHERIA

ADSORBED adult2

THALOMID 4 • •THYMOGLOBULIN 4 XTWINRIX 3TYPHIM VI 3TYSABRI* 4 • •VAQTA 3VARIVAX 3XOLAIR 4 •YF-VAX 3ZORTRESS tabs, 0.25 mg 3 XZORTRESS tabs, 0.5 mg,

0.75 mg4 X

ZOSTAVAX 3 •Inflammatory Bowel Disease AgentsAPRISO 2ASACOL 2ASACOL HD 2balsalazide 1budesonide ER 1CANASA 2DELZICOL 2DIPENTUM 3hydrocortisone enema 1LIALDA 2mesalamine enema 1

2013


25

Requirements/Limits

Drug Name Dru

g Ti

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B o

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PENTASA 2sulfasalazine 1sulfasalazine DR 1Metabolic Bone Disease AgentsACTONEL 3 • •alendronate tabs 1 •ATELVIA 2 • •BONIVA inj 3 X •calcitonin nasal spray 1calcitriol caps 1 Xcalcitriol inj, oral soln 1 XETIDRONATE tabs, 200 mg 3etidronate tabs, 400 mg 1FORTEO 4 •FORTICAL 3ibandronate tabs 1 X •PROLIA 3 •ZEMPLAR 2 Xzoledronic acid conc for IV,

4 mg/5 mL4

ZOMETA 4Ophthalmic AgentsALPHAGAN P soln, 0.1% 3azelastine 1AZOPT 3BACITRACIN oint 3bacitracin/polymyxin B 1BESIVANCE 3betaxolol soln, 0.5% 1

Requirements/Limits

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BETOPTIC-S 3brimonidine 1BROMFENAC 3carteolol 1ciprofloxacin 1COMBIGAN 2cromolyn sodium 1dexamethasone sodium

phosphate1

diclofenac sodium 1dorzolamide 1dorzolamide/timolol 1DUREZOL 2epinastine 1erythromycin 1fluorometholone 1flurbiprofen soln 1gentamicin oint, soln 1ILEVRO 3ISTALOL 3ketorolac 1LACRISERT 3latanoprost 1LEVOBUNOLOL soln, 0.25% 3levobunolol soln, 0.5% 1LOTEMAX 2LUMIGAN 2metipranolol 1MOXEZA 3

2013


26

Requirements/Limits

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g Ti

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NAPHAZOLINE 3NATACYN 3neomycin/polymyxin B/bacitracin

oint1

neomycin/polymyxin B/bacitracin/hydrocortisone oint

1

neomycin/polymyxin B/dexamethasone oint, susp

1

neomycin/polymyxin B/gramicidinsoln

1

NEVANAC 3ofloxacin 1PATADAY 2PATANOL 3PHOSPHOLINE IODIDE 3pilocarpine 1PILOPINE HS 3polymyxin B/trimethoprim 1prednisolone acetate 1RESTASIS 3sulfacetamide sodium soln 1sulfacetamide sodium/

prednisolone soln1

timolol maleate gel-forming soln 1timolol maleate soln 1TOBRADEX oint 2tobramycin 1tobramycin/dexamethasone 1TRAVATAN Z 2trifluridine 1

Requirements/Limits

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y

VIGAMOX 2Otic Agentsacetic acid soln 1acetic acid/aluminum acetate soln 1CIPRODEX 3fluocinolone acetonide oil 1hydrocortisone/acetic acid soln 1neomycin/polymyxin B/

hydrocortisone soln, susp1

ofloxacin soln 1Respiratory Tract Agentsacetylcysteine inhal soln 1 XADVAIR DISKUS 2 •ADVAIR HFA 2 •albuterol sulfate inhal soln 1 Xalbuterol sulfate syrup, tabs 1albuterol sulfate ER 1ASMANEX 2 •ASTEPRO 2 •ATROVENT HFA 3 •azelastine nasal spray, 137 mcg/

spray1 •

caffeine citrate oral soln 1COMBIVENT 3 •COMBIVENT RESPIMAT 3 •cromolyn sodium inhal soln 1 Xdiphenhydramine 1EPIPEN 2EPIPEN-JR 2FLOVENT DISKUS 2 •

2013


27

Requirements/Limits

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FLOVENT HFA 2 •fluticasone nasal spray 1 •FORADIL AEROLIZER 2 •hydroxyzine hcl syrup, tabs 1ipratropium nasal soln 1 •KALYDECO 4 • •levocetirizine tabs 1LUFYLLIN 3montelukast 1NASONEX 2 •PATANASE 3 •PROAIR HFA 2 •PROLASTIN-C* 4promethazine supp, syrup, tabs 1PULMOZYME 4 XQVAR 2 •SEREVENT DISKUS 2 •SINGULAIR 3 •SPIRIVA HANDIHALER 2 •SYMBICORT 2 •terbutaline tabs 1theophylline ER tabs 1triamcinolone nasal spray 1 •TYZINE 3TYZINE PEDIATRIC 3VENTOLIN HFA 2 •zafirlukast 1 •Sleep Disorder Agentsdoxepin 1

Requirements/Limits

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LUNESTA 3 • •modafinil 1 • •NUVIGIL 3 • •PROVIGIL 3 • •XYREM* 4 • •zaleplon 1 •zolpidem 1 •Skeletal Muscle Relaxantscyclobenzaprine 1methocarbamol 1Therapeutic Nutrients/Minerals/Electrolytesamino acid IV 1 XCHEMET 3CUPRIMINE 2DEPEN TITRATABS 3EXJADE* tabs for oral susp,

125 mg3

EXJADE* tabs for oral susp,250 mg, 500 mg

4

fat emulsion IV, 20%, 30% 1 Xfomepizole 4iv fluids - generics 1IV FLUIDS - KCL/D5W/

LACTATED RINGERS inj3

levocarnitine oral soln, tabs 1 Xpotassium chloride ER caps 1potassium chloride ER tabs, 8

mEq, 10 mEq, 20 mEq1

potassium citrate ER 1sodium polystyrene sulfonate 1

2013


28

Requirements/Limits

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SYPRINE 4

2013

29

The following drugs have quantity limit restrictions. For information on requesting an exception,see page iv.

Drug NameMonthly Limit(unless otherwise noted)

abacavir 300 mg 60 tabletsABILIFY DISCMELT all strengths 60 tabletsABILIFY injection 90 vialsABILIFY MAINTENA 1 vialABILIFY oral solution 750 mLABILIFY tablets all strengths 30 tabletsacarbose 100 mg 90 tabletsacarbose 25 mg 360 tabletsacarbose 50 mg 180 tabletsacetaminophen w/codeine solution 120 mg/12 mg/5 mL 2700 mLacetaminophen w/codeine 300-15 mg, 300-30 mg 360 tabletsacetaminophen w/codeine 300-60 mg 180 tabletsACTONEL 150 mg 1 tabletACTONEL 35 mg 4 tablets per 28 daysACTONEL 5 mg, 30 mg 30 tabletsACTOS 15 mg 90 tabletsACTOS 30 mg, 45 mg 30 tabletsADCIRCA 20 mg 60 tabletsADDERALL XR 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg 30 capsulesADVAIR DISKUS 1 package of 60ADVAIR HFA 1 canisterAFINITOR DISPERZ 2 mg, 5 mg 60 tabletsAFINITOR DISPERZ 3 mg 90 tabletsAFINITOR 2.5 mg, 5 mg, 7.5 mg, 10 mg 30 tabletsalendronate 35 mg, 70 mg 4 tablets per 28 daysALENDRONATE 40 mg 30 tabletsalendronate 5 mg, 10 mg 30 tabletsalfuzosin ER 10 mg 30 tabletsamphetamine/dextroamphetamine ER 5 mg, 10 mg, 15 mg, 20 mg, 25 mg,

30 mg30 capsules

ANDRODERM 24 hr patch 2 mg, 4 mg, 5 mg 30 patchesANDRODERM 24 hr patch 2.5 mg 90 patchesANDROGEL PUMP 1% 4 pumpsANDROGEL 1.62% 2 pumpsANDROGEL 1% 25 mg/2.5 gm, 50 mg/5 gm 60 packetsAPTIVUS 100 mg/mL 4 bottlesAPTIVUS 250 mg 120 capsulesASMANEX 1 canister

2013

30


ASTEPRO 2 bottlesATELVIA 35 mg 4 tablets per 28 daysatorvastatin 10 mg, 20 mg, 40 mg 45 tabletsatorvastatin 80 mg 30 tabletsATRIPLA 600-200-300 mg 30 tabletsATROVENT HFA INHALER 2 canistersAVINZA SR 30 mg, 45 mg, 60 mg, 75 mg, 90 mg, 120 mg 30 capsulesAVODART 0.5 mg 30 capsulesAVONEX PEN 4 pens per 28 daysAVONEX 30 mcg, 30 mcg/0.5 mL 4 syringes (1 box/kit) per 28 daysazelastine hcl 0.1% 2 bottlesAZOR 5-20 mg, 5-40 mg, 10-20 mg, 10-40 mg 30 tabletsBENICAR HCT 20-12.5 mg, 40-12.5 mg, 40-25 mg 30 tabletsBENICAR 20 mg, 40 mg 30 tabletsBENICAR 5 mg 60 tabletsBETASERON 0.3 mg 15 vials/syringesBOSULIF 100 mg 120 tabletsBOSULIF 500 mg 30 tabletsbudeprion SR (12 hr) 100 mg, 150 mg 60 tabletsbudeprion XL (24 hr) 150 mg, 300 mg 30 tabletsbuprenorphine hcl 2 mg, 8 mg 15 tablets per 90 daysbuprenorphine hcl/naloxone 2-0.5 mg, 8-2 mg 90 tabletsbupropion hcl ER (12 hr) 100 mg, 150 mg, 200 mg 60 tabletsbupropion hcl XL (24 hr) 150 mg, 300 mg 30 tabletsbupropion hcl 100 mg 120 tabletsbupropion hcl 75 mg 60 tabletscandesartan 32 mg 30 tabletscandesartan 4 mg, 8 mg, 16 mg 60 tabletscandesartan/hydrochlorothiazide 16-12.5 mg, 32-12.5 mg, 32-25 mg 30 tabletsCAPRELSA 100 mg 60 tabletsCAPRELSA 300 mg 30 tabletsCELEBREX 400 mg 30 capsulesCELEBREX 50 mg, 100 mg, 200 mg 60 capsulesCHANTIX 168 days of therapycitalopram 10 mg/5 mL 600 mLcitalopram 10 mg, 20 mg, 40 mg 30 tabletsclonazepam ODT 0.125 mg, 0.25 mg 90 tabletsclonazepam/clonazepam ODT 0.5 mg, 1 mg 90 tablets

2013

31


clonazepam/clonazepam ODT 2 mg 300 tabletsclorazepate 15 mg 180 tabletsclorazepate 3.75 mg, 7.5 mg 90 tabletsclozapine 100 mg 270 tabletsclozapine 200 mg 120 tabletsclozapine 25 mg, 50 mg 90 tabletsco-gesic 5-500 mg 240 tabletsCOMBIVENT 2 canistersCOMBIVENT RESPIMAT 2 canistersCOMETRIQ 100 mg 56 capsules per 28 daysCOMETRIQ 140 mg 112 capsules per 28 daysCOMETRIQ 60 mg 84 capsules per 28 daysCOMPLERA 200-25-300 mg 30 tabletsCOPAXONE 20 mg/mL 30 syringesCRESTOR 40 mg 30 tabletsCRESTOR 5 mg, 10 mg, 20 mg 45 tabletsCRIXIVAN 100 mg 90 capsulesCRIXIVAN 200 mg 270 capsulesCRIXIVAN 400 mg 180 capsulesCYMBALTA 20 mg, 30 mg, 60 mg 60 capsulesDETROL all strengths 60 tabletsDETROL LA all strengths 30 capsulesdexmethylphenidate 2.5 mg, 5 mg, 10 mg 60 tabletsdextroamphetamine ER 10 mg, 15 mg 120 capsulesdextroamphetamine ER 5 mg 90 capsulesdextroamphetamine 10 mg 180 tabletsdextroamphetamine 5 mg 60 tabletsDIASTAT ACUDIAL gel 10 mg, 20 mg 5 twin packsDIASTAT PEDIATRIC gel 2.5 mg 5 twin packsDIAZEPAM gel 2.5 mg, 10 mg, 20 mg 5 twin packsDIAZEPAM 1 mg/mL 1200 mLdiazepam 2 mg, 5 mg, 10 mg 60 tabletsDIAZEPAM 5 mg/mL 240 mLdidanosine 125 mg, 200 mg, 250 mg, 400 mg 30 capsulesDIOVAN HCT 80-12.5 mg, 160-12.5 mg, 160-25 mg, 320-12.5 mg,

320-25 mg30 tablets

DIOVAN 320 mg 30 tabletsDIOVAN 40 mg, 80 mg, 160 mg 60 tabletsdonepezil 23 mg 30 tabletsdonepezil/donepezil ODT 5 mg, 10 mg 30 tablets

2013

32


doxazosin 1 mg, 2 mg, 4 mg 30 tabletsdoxazosin 8 mg 60 tabletsEDURANT 25 mg 30 tabletsEMTRIVA 10 mg/mL 5 bottlesEMTRIVA 200 mg 30 capsulesendocet 10-325 mg, 10-650 mg 180 tabletsendocet 5-325 mg 360 tabletsendocet 7.5-325 mg, 7.5-500 mg 240 tabletsendodan 4.88-325 mg 360 tabletsenoxaparin syringes 30 syringes per 90 daysenoxaparin 300 mg/3 mL vials 10 vials per 90 daysEPIVIR 10 mg/mL 960 mLeprosartan 600 mg 30 tabletsEPZICOM 600-300 mg 30 tabletsERIVEDGE 150 mg 30 capsulesescitalopram 5 mg/5 mL 600 mLescitalopram 5 mg, 10 mg, 20 mg 30 tabletsEXELON 4.6 mg/24 hr, 9.5 mg/24 hr, 13.3 mg/24 hr 30 patchesEXELON 2 mg/mL 240 mLEXFORGE HCT 5-160-12.5 mg, 5-160-25 mg, 10-160-12.5 mg,

10-160-25 mg, 10-320-25 mg30 tablets

EXFORGE 5-160 mg, 5-320 mg, 10-160 mg, 10-320 mg 30 tabletsFANAPT TITRATION PAK 1 kit/4 daysFANAPT 1 mg, 2 mg, 4 mg, 6 mg, 8 mg, 10 mg, 12 mg 60 tabletsFAZACLO 12.5 mg, 100 mg 90 tabletsFAZACLO 150 mg 180 tabletsFAZACLO 200 mg 120 tabletsFAZACLO 25 mg 270 tabletsfenofibrate micronized 67 mg, 134 mg, 200 mg 30 capsulesfenofibrate 145 mg, 160 mg 30 tabletsfenofibrate 48 mg, 54 mg 60 tabletsfenofibric acid DR 135 mg 30 capsulesfenofibric acid DR 45 mg 60 capsulesfentanyl citrate oral lozenges 200 mcg, 400 mcg, 600 mcg, 800 mcg,

1200 mcg, 1600 mcg120 lozenges

fentanyl transdermal all strengths 15 patchesfinasteride 5 mg 30 tabletsFIRAZYR 3 syringesFLOVENT DISKUS 250 mcg 4 cartons of 60

2013

33


FLOVENT DISKUS 50 mcg, 100 mcg 1 carton of 60FLOVENT HFA 220 mcg 2 canistersFLOVENT HFA 44 mcg, 110 mcg 1 canisterfluoxetine weekly DR 90 mg 4 capsules per 28 daysfluoxetine 10 mg 30 capsules or tabletsfluoxetine 20 mg 120 capsules or tabletsfluoxetine 20 mg/5 mL 600 mLfluoxetine 40 mg 60 capsulesfluticasone nasal 1 bottlefluvoxamine 100 mg 90 tabletsfluvoxamine 25 mg, 50 mg 30 tabletsfondaparinux solution 2.5 mg/0.5 mL, 5.0 mg/0.4 mL, 7.5 mg/0.6 mL,

10 mg/0.8 mL30 syringes per 90 days

FORADIL 1 package of 60FORTESTA 10 mg/act 2 bottlesFUZEON 90 mg 1 kitgalantamine ER 8 mg, 16 mg, 24 mg 30 capsulesgalantamine oral solution 4 mg/mL 200 mLgalantamine 4 mg, 8 mg, 12 mg 60 tabletsgemfibrozil 600 mg 60 tabletsGEODON capsules - all strengths 60 capsulesGEODON injection 60 vialsGILOTRIF 20 mg, 30 mg, 40 mg 30 tabletsGLEEVEC 100 mg 90 tabletsGLEEVEC 400 mg 60 tabletsglimepiride 1 mg 240 tabletsglimepiride 2 mg 120 tabletsglimepiride 4 mg 60 tabletsglipizide ER 10 mg 60 tabletsglipizide ER 2.5 mg 240 tabletsglipizide ER 5 mg 120 tabletsglipizide XL 10 mg 60 tabletsglipizide XL 2.5 mg 240 tabletsglipizide XL 5 mg 120 tabletsglipizide 10 mg 120 tabletsglipizide 5 mg 240 tabletsglipizide/metformin 2.5-250 mg 240 tabletsglipizide/metformin 2.5-500 mg, 5-500 mg 120 tabletsglyburide micronized 1.5 mg 240 tabletsglyburide micronized 3 mg 120 tablets

2013

34


glyburide micronized 6 mg 60 tabletsglyburide 1.25 mg 480 tabletsGLYBURIDE 1.25 mg 480 tabletsglyburide 2.5 mg 240 tabletsGLYBURIDE 2.5 mg 240 tabletsglyburide 5 mg 120 tabletsGLYBURIDE 5 mg 120 tabletsglyburide/metformin 1.25-250 mg 240 tabletsglyburide/metformin 2.5-500 mg, 5-500 mg 120 tabletshydrocodone/acetaminophen 10-660 mg 180 tabletshydrocodone/acetaminophen 2.5-500 mg, 5-500 mg 240 tabletshydrocodone/acetaminophen 5-300 mg, 5-325 mg 360 tabletshydrocodone/acetaminophen 7.5 mg/500 mg/15 mL 2700 mLhydrocodone/acetaminophen 7.5-300 mg, 7.5-325 mg, 7.5-500 mg,

7.5-650 mg, 10-300 mg, 10-325 mg, 10-500 mg, 10-650 mg180 tablets

hydrocodone/acetaminophen 7.5-325 mg/15 mL 3600 mLhydrocodone/acetaminophen 7.5-750 mg, 10-750 mg 150 tabletshydrocodone/ibuprofen all strengths 150 tabletshydrogesic 5-500 mg 240 capsulesibandronate 150 mg 1 tabletibudone 5-200 mg 150 tabletsICLUSIG 15 mg 60 tabletsICLUSIG 45 mg 30 tabletsINLYTA 1 mg 180 tabletsINLYTA 5 mg 120 tabletsINTELENCE 100 mg, 200 mg 60 tabletsINTELENCE 25 mg 120 tabletsINTUNIV 1 mg, 2 mg, 3 mg, 4 mg 30 tabletsINVEGA SUSTENNA 1 kitINVEGA 1.5 mg, 3 mg, 9 mg 30 tabletsINVEGA 6 mg 60 tabletsINVIRASE 200 mg 300 capsulesINVIRASE 500 mg 120 tabletsipratropium nasal 0.03% 2 bottlesipratropium nasal 0.06% 3 bottlesirbesartan 75 mg, 150 mg, 300 mg 30 tabletsirbesartan/hydrochlorothiazide 150-12.5 mg, 300-12.5 mg 30 tabletsISENTRESS 25 mg, 100 mg 180 tabletsISENTRESS 400 mg 60 tablets

2013

35


JAKAFI all strengths 60 tabletsJANUMET all strengths 60 tabletsJANUMET XR 100-1000 mg 30 tabletsJANUMET XR 50-500 mg, 50-1000 mg 60 tabletsJANUVIA 100 mg 30 tabletsJANUVIA 25 mg 120 tabletsJANUVIA 50 mg 60 tabletsJENTADUETO 2.5-500 mg, 2.5-850 mg, 2.5-1000 mg 60 tabletsJUVISYNC 50 mg/10 mg, 50 mg/20 mg 60 tabletsJUVISYNC 50 mg/40 mg, 100 mg/10 mg, 100 mg/20 mg, 100 mg/40 mg 30 tabletsKALETRA 100-25 mg 300 tabletsKALETRA 200-50 mg 120 tabletsKALETRA 400-100mg/5mL 2 bottlesKALYDECO 150 mg 60 tabletsketorolac 10 mg 21 tabletsKOMBIGLYZE XR 2.5-1000 mg 60 tabletsKOMBIGLYZE XR 5-500 mg, 5-1000 mg 30 tabletslamivudine 150 mg 60 tabletslamivudine 300 mg 30 tabletslamivudine/zidovudine 150-300 mg 60 tabletslansoprazole/lansoprazole ODT 15 mg, 30 mg 30 capsules or tabletsLATUDA 20 mg, 40 mg, 60 mg, 120 mg 30 tabletsLATUDA 80 mg 60 tabletsLETAIRIS 5 mg, 10 mg 30 tabletsLEXIVA 50 mg/mL 1800 mLLEXIVA 700 mg 120 tabletsLIPOFEN 150 mg 30 capsulesLIPOFEN 50 mg 60 capsuleslosartan 100 mg 30 tabletslosartan 25 mg, 50 mg 60 tabletslosartan/hydrochlorothiazide 50-12.5 mg, 100-12.5 mg, 100-25 mg 30 tabletslovastatin all strengths 60 tabletsLOVENOX 300 mg/3 mL 10 vials per 90 daysLUNESTA 1 mg, 2 mg, 3 mg 30 tabletsMAPROTILINE 25 mg, 50 mg, 75 mg 90 tabletsMEKINIST 0.5 mg 90 tabletsMEKINIST 2 mg 30 tabletsmetadate ER 20 mg 90 tabletsmetformin ER 500 mg 120 tabletsmetformin ER 750 mg 60 tablets

2013

36


metformin 1000 mg 60 tabletsmetformin 500 mg 150 tabletsmetformin 850 mg 90 tabletsmethylin ER 10 mg, 20 mg 90 tabletsmethylin 5 mg, 10 mg, 20 mg 90 tabletsmethylphenidate ER 20 mg 90 tabletsmethylphenidate 5 mg, 10 mg, 20 mg 90 tabletsMICARDIS HCT 40-12.5 mg, 80-25 mg 30 tabletsMICARDIS HCT 80-12.5 mg 60 tabletsMICARDIS 20 mg, 40 mg, 80 mg 30 tabletsmirtazapine 7.5 mg 30 tabletsmirtazapine/mirtazapine ODT 15 mg, 30 mg, 45 mg 30 tabletsmodafinil all strengths 30 tabletsmorphine sulfate SR 15 mg, 30 mg, 60 mg, 100 mg, 200 mg 90 tabletsNAMENDA TITRATION PACK 49 tablets per 28 daysNAMENDA 10 mg/5 mL 360 mLNAMENDA 5 mg, 10 mg 60 tabletsnaratriptan all strengths 18 tabletsNASONEX 2 bottlesnateglinide 120 mg 90 tabletsnateglinide 60 mg 180 tabletsnevirapine 200 mg 60 tabletsNEXAVAR 200 mg 120 tabletsNEXIUM all strengths 30 capsules or packetsNIASPAN ER 500 mg 30 tabletsNIASPAN ER 750 mg, 1000 mg 60 tabletsNORVIR 100 mg 360 capsules or tabletsNORVIR 80 mg/mL 2 bottlesNUCYNTA ER 50 mg, 100 mg, 150 mg, 200 mg, 250 mg 60 tabletsNUVIGIL all strengths 30 tabletsolanzapine IM injection, 10 mg 90 vialsolanzapine ODT 5 mg, 10 mg, 15 mg, 20 mg 30 tabletsolanzapine 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg 30 tabletsOLEPTRO 150 mg 45 tabletsOLEPTRO 300 mg 30 tabletsomeprazole 10 mg, 20 mg, 40 mg 30 capsulesONFI 2.5 mg/mL 480 mLONFI 5 mg, 10 mg, 20 mg 60 tablets

2013

37


ONGLYZA 2.5 mg 60 tabletsONGLYZA 5 mg 30 tabletsoxybutynin ER 10 mg, 15 mg 60 tabletsoxybutynin ER 5 mg 30 tabletsoxybutynin syrup 5 mg/5 mL 600 mLoxybutynin 5 mg 120 tabletsoxycodone w/acetaminophen 10-325 mg, 10-650 mg 180 tabletsoxycodone w/acetaminophen 2.5-325 mg, 5-325 mg 360 tabletsoxycodone w/acetaminophen 5-500 mg 240 capsulesoxycodone w/acetaminophen 7.5-325 mg, 7.5-500 mg 240 tabletsoxycodone/aspirin 4.8355-325 mg 360 tabletsOXYCONTIN 10 mg, 15 mg, 20 mg, 30 mg, 40 mg 60 tabletsOXYCONTIN 60 mg, 80 mg 120 tabletspantoprazole tablets - all strengths 30 tabletsparoxetine hcl ER 12.5 mg 30 tabletsparoxetine hcl ER 25 mg, 37.5 mg 60 tabletsparoxetine hcl 10 mg/5 mL 900 mLparoxetine hcl 10 mg, 20 mg, 40 mg 30 tabletsparoxetine hcl 30 mg 60 tabletsPATANASE 1 bottlePAXIL 10 mg/5 mL 900 mLPENNSAID 1.5% 300 mLpioglitazone 15 mg 90 tabletspioglitazone 30 mg, 45 mg 30 tabletspolygesic 5-500 mg 240 capsulesPOMALYST 1 mg, 2 mg, 3 mg, 4 mg 21 capsules per 28 daysPRADAXA all strengths 60 capsulesPRANDIN 0.5 mg 960 tabletsPRANDIN 1 mg 480 tabletsPRANDIN 2 mg 240 tabletspravastatin 10 mg, 20 mg, 40 mg 45 tabletspravastatin 80 mg 30 tabletsPREVACID SOLUTAB 15 mg, 30 mg 30 tabletsPREZISTA 100 mg/mL 400 mLPREZISTA 150 mg 180 tabletsPREZISTA 400 mg, 600 mg 60 tabletsPREZISTA 75 mg 300 tabletsPREZISTA 800 mg 30 tabletsPRISTIQ all strengths 30 tabletsPROAIR HFA 2 canisters

2013

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PROVIGIL all strengths 30 tabletsquetiapine 25 mg, 50 mg, 100 mg, 200 mg 90 tabletsquetiapine 300 mg, 400 mg 60 tabletsQVAR 40 mcg 1 canisterQVAR 80 mcg 2 canistersRAPAFLO 4 mg, 8 mg 30 capsulesrepaglinide 0.5 mg 960 tabletsrepaglinide 1 mg 480 tabletsrepaglinide 2 mg 240 tabletsreprexain 10-200 mg 150 tabletsRESCRIPTOR 100 mg 360 tabletsRESCRIPTOR 200 mg 180 tabletsREVLIMID 15 mg, 20 mg, 25 mg 21 capsules per 28 daysREVLIMID 2.5 mg, 5 mg, 10 mg 30 capsulesREYATAZ 100 mg, 150 mg, 300 mg 30 capsulesREYATAZ 200 mg 60 capsulesRISPERDAL CONSTA injection 2 vials per 28 daysrisperidone ODT 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg 60 tabletsrisperidone ODT 4 mg 120 tabletsrisperidone oral solution 480 mLrisperidone 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg 60 tabletsrisperidone 4 mg 120 tabletsrivastigmine 1.5 mg, 3 mg, 4.5 mg, 6 mg 60 capsulesrizatriptan ODT 5 mg, 10 mg 18 tabletsrizatriptan 5 mg, 10 mg 18 tabletsroxicet 5-325 mg 360 tabletsSANCTURA XR 60 mg 30 capsulesSANCUSO 3.1 mg 4 patches per 28 daysSAPHRIS 5 mg, 10 mg 60 tabletsSELZENTRY 150 mg 60 tabletsSELZENTRY 300 mg 120 tabletsSEREVENT DISKUS 1 package of 60SEROQUEL XR 150 mg, 200 mg 30 tabletsSEROQUEL XR 50 mg, 300 mg, 400 mg 60 tabletsSEROQUEL 25 mg, 50 mg, 100 mg, 200 mg 90 tabletsSEROQUEL 300 mg, 400 mg 60 tabletssertraline 100 mg 60 tabletssertraline 20 mg/mL 300 mL

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sertraline 25 mg, 50 mg 30 tabletssildenafil 20 mg 90 tabletssimvastatin 20 mg 60 tabletssimvastatin 5 mg, 10 mg, 40 mg 45 tabletssimvastatin 80 mg 30 tabletsSPIRIVA 30 capsulesSPRYCEL 20 mg 60 tabletsSPRYCEL 50 mg, 70 mg, 80 mg, 100 mg, 140 mg 30 tabletsstagesic 5-500 mg 240 capsulesstavudine 1 mg/mL 2400 mLstavudine 15 mg, 20 mg, 30 mg, 40 mg 60 capsulesSTIVARGA 84 tablets per 28 daysSTRIBILD 30 tabletsSUBOXONE MIS 12-3 mg 60 filmsSUBOXONE MIS 2-0.5 mg, 8-2 mg 90 filmsSUBOXONE MIS 4-1 mg 30 filmsSUBOXONE SUB 2-0.5 mg, 8-2 mg 90 tabletsSUMATRIPTAN NASAL 12 units/2 packagessumatriptan tablets - all strengths 18 tabletsSUSTIVA 200 mg 60 capsulesSUSTIVA 50 mg 90 capsulesSUSTIVA 600 mg 30 tabletsSUTENT 12.5 mg 90 capsulesSUTENT 25 mg, 50 mg 30 capsulesSYMBICORT 1 canisterTAFINLAR 50 mg, 75 mg 120 capsulestamsulosin 0.4 mg 60 capsulesTARCEVA 100 mg, 150 mg 30 tabletsTARCEVA 25 mg 60 tabletsTASIGNA 150 mg, 200 mg 120 capsulesTEKTURNA HCT 150-12.5 mg, 150-25 mg, 300-12.5 mg, 300-25 mg 30 tabletsTEKTURNA 150 mg, 300 mg 30 tabletsterazosin 1 mg, 2 mg, 5 mg 30 capsulesterazosin 10 mg 60 capsulesTHALOMID 150 mg, 200 mg 60 capsulesTHALOMID 50 mg, 100 mg 30 capsulesTIVICAY 50 mg 60 tabletstolterodine all strengths 60 tabletsTOVIAZ all strengths 30 tabletsTRACLEER 62.5 mg, 125 mg 60 tablets

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TRADJENTA 30 tabletstramadol hcl ER 100 mg, 200 mg, 300 mg 30 tabletstramadol hcl 50 mg 240 tabletstramadol/acetaminophen 37.5-325 mg 240 tabletstriamcinolone nasal inhaler 1 bottleTRILIPIX 135 mg 30 capsulesTRILIPIX 45 mg 60 capsulesTRIZIVIR 300-150-300 mg 60 tabletstrospium 60 tabletstrospium ER 30 capsulesTRUVADA 200-300 mg 30 tabletsTYKERB 250 mg 180 tabletsTYSABRI 300 mg/15 mL 1 vial per 28 daysvalsartan/hydrochlorothiazide 80-12.5 mg, 160-12.5 mg, 160-25 mg,

320-12.5 mg, 320-25 mg30 tablets

VANDETANIB 100 mg 60 tabletsVANDETANIB 300 mg 30 tabletsvenlafaxine ER capsules 37.5 mg, 150 mg 30 capsulesvenlafaxine ER capsules 75 mg 90 capsulesvenlafaxine ER tablets 37.5 mg, 150 mg 30 tabletsvenlafaxine ER tablets 75 mg 90 tabletsvenlafaxine 25 mg, 37.5 mg, 50 mg, 75 mg, 100 mg 90 tabletsVENTOLIN HFA 2 canistersVESICARE all strengths 30 tabletsvicodin ES 7.5-300 mg 180 tabletsvicodin HP 10-300 mg, 10-660 mg 180 tabletsvicodin 5-300 mg 360 tabletsVICTOZA 18 mg/3 mL 2 Pen Package 1 package of 2 pensVICTOZA 18 mg/3 mL 3 Pen Package 1 package of 3 pensVIDEX 2 gm, 4 gm 1200 mLVIIBRYD 30 tabletsVIIBRYD starter kit 1 kit per 28 daysVIMOVO 375-20 mg, 500-20 mg 60 tabletsVIRACEPT 250 mg 270 tabletsVIRACEPT 625 mg 120 tabletsVIRAMUNE XR 100 mg 90 tabletsVIRAMUNE XR 400 mg 30 tabletsVIRAMUNE 200 mg 60 tabletsVIRAMUNE 50 mg/5 mL 1200 mL

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VIREAD 150 mg, 200 mg, 250 mg, 300 mg 30 tabletsVIREAD 40 mg/gm 240 gmVOLTAREN gel 1% 10 tubesVOTRIENT 200 mg 120 tabletsVYTORIN 10-10 mg, 10-20 mg, 10-40 mg 45 tabletsVYTORIN 10-80 mg 30 tabletsXALKORI 60 capsulesXARELTO 10 mg 35 tablets per 90 daysXARELTO 15 mg 60 tabletsXARELTO 20 mg 30 tabletsXENAZINE 12.5 mg 240 tabletsXENAZINE 25 mg 120 tabletsXTANDI 120 capsulesXYREM 500 mg/mL 540 mLzaleplon 5 mg, 10 mg 30 capsulesZELBORAF 240 tabletszenzedi 10 mg 180 tabletszenzedi 5 mg 60 tabletsZERIT 1 mg/mL 2400 mLZETIA 10 mg 30 tabletsZIAGEN 20 mg/mL 960 mLZIAGEN 300 mg 60 tabletszidovudine syrup 10 mg/mL 1920 mLzidovudine 100 mg 180 capsuleszidovudine 300 mg 60 tabletsziprasidone capsules - all strengths 60 capsulesZOLINZA 100 mg 120 capsuleszolpidem 5 mg, 10 mg 30 tabletsZOSTAVAX 1 vaccine per lifetimeZYPREXA injection 90 vialsZYPREXA RELPREVV 210 mg, 300 mg 2 vials per 28 daysZYPREXA RELPREVV 405 mg 1 vial per 28 daysZYTIGA 120 tablets

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INDEX

Aabacavir............................................................................12ABILIFY.............................................................................. 5ABILIFY............................................................................ 11ABILIFY............................................................................ 13ABILIFY DISCMELT.........................................................5ABILIFY DISCMELT.......................................................11ABILIFY DISCMELT.......................................................13ABILIFY MAINTENA........................................................ 5ABILIFY MAINTENA...................................................... 11ABILIFY MAINTENA...................................................... 13ABRAXANE....................................................................... 7acarbose.......................................................................... 13acebutolol.........................................................................15acetaminophen/codeine...................................................1acetazolamide ER caps.................................................15acetazolamide tabs........................................................ 15acetic acid/aluminum acetate ear soln........................ 26acetic acid ear soln........................................................26acetylcysteine inhal soln................................................26acitretin.............................................................................18ACTHAR HP....................................................................21ACTHIB............................................................................ 23ACTIMMUNE*................................................................. 23ACTONEL........................................................................ 25ACTOS............................................................................. 13acyclovir........................................................................... 12acyclovir oint................................................................... 18acyclovir sodium for inj..................................................12ACYCLOVIR SODIUM for inj, IV soln......................... 12ADACEL...........................................................................23ADAGEN*.........................................................................20ADCIRCA.........................................................................15ADDERALL XR...............................................................18adefovir.............................................................................12ADRIAMYCIN for inj.........................................................7ADVAIR DISKUS............................................................26ADVAIR HFA...................................................................26AFINITOR.......................................................................... 7AFINITOR DISPERZ........................................................8AGGRENOX....................................................................14ALBENZA.........................................................................10albuterol sulfate ER........................................................26albuterol sulfate inhal soln............................................ 26albuterol sulfate syrup, tabs..........................................26alclometasone................................................................. 18

ALCOHOL SWABS........................................................ 13ALDURAZYME*.............................................................. 20alendronate tabs.............................................................25alfuzosin ER tabs........................................................... 20ALIMTA...............................................................................8ALINIA.............................................................................. 10allopurinol...........................................................................6ALOXI................................................................................. 6ALPHAGAN P eye soln.................................................25amantadine caps, syrup................................................ 10amantadine caps, syrup................................................ 12AMANTADINE tabs........................................................10AMANTADINE tabs........................................................12amcinonide crm.............................................................. 18amifostine...........................................................................8amikacin inj........................................................................2AMIKACIN inj.................................................................... 2amiloride...........................................................................15amiloride/hydrochlorothiazide....................................... 15amino acid IV..................................................................27amiodarone tabs.............................................................15AMITIZA........................................................................... 20amitriptyline........................................................................5amlodipine........................................................................15amlodipine/benazepril.................................................... 15ammonium lactate crm, lotn......................................... 18AMOXAPINE..................................................................... 5amoxicillin/clarithromycin/lansoprazole..........................2amoxicillin/potassium clavulanate chew tabs, for susp,

tabs.................................................................................. 2amoxicillin caps, chew tabs, for susp, tabs...................2AMOXICILLIN chew tabs................................................ 2amphetamine/dextroamphetamine ER caps...............18AMPHOTERICIN B...........................................................6ampicillin caps...................................................................2AMPICILLIN for susp....................................................... 2ampicillin sodium for inj, for IV....................................... 2AMPICILLIN SODIUM for IV...........................................2AMPYRA.......................................................................... 18ANADROL-50..................................................................22anagrelide........................................................................ 14anastrozole.........................................................................8ANDRODERM.................................................................22ANDROGEL.....................................................................22ANDROXY....................................................................... 22APOKYN*.........................................................................10APRISO............................................................................24APTIVUS..........................................................................12ARANESP inj.................................................................. 14ARANESP inj.................................................................. 14

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ARCALYST*.................................................................... 23ARRANON......................................................................... 8ARZERRA.......................................................................... 8ASACOL...........................................................................24ASACOL HD................................................................... 24ASMANEX....................................................................... 26ASTEPRO........................................................................26ATELVIA.......................................................................... 25atenolol.............................................................................15atenolol/chlorthalidone................................................... 15ATGAM.............................................................................23atorvastatin...................................................................... 15atovaquone/proguanil tabs............................................10ATRIPLA.......................................................................... 12ATROVENT HFA............................................................26AVASTIN*.......................................................................... 8AVELOX............................................................................. 2AVINZA...............................................................................1AVODART........................................................................20AVODART........................................................................23AVONEX.......................................................................... 18AVONEX.......................................................................... 23AZACTAM inj in dextrose................................................2AZASAN...........................................................................23AZATHIOPRINE for inj.................................................. 23azathioprine tabs............................................................ 23azelastine eye soln........................................................ 25azelastine nasal spray................................................... 26AZELEX crm................................................................... 18AZILECT.......................................................................... 10azithromycin for IV, for susp, tabs................................. 2AZITHROMYCIN powder pack for susp........................2AZOPT eye susp............................................................25AZOR................................................................................15aztreonam for inj...............................................................2Bbacitracin/polymyxin B eye oint....................................25BACITRACIN eye oint................................................... 25baclofen tabs...................................................................11balsalazide.......................................................................24BANZEL susp, tabs..........................................................4BANZEL tabs.....................................................................4BARACLUDE oral soln..................................................12BARACLUDE tabs..........................................................12benazepril.........................................................................15benazepril/hydrochlorothiazide..................................... 15BENICAR......................................................................... 15BENICAR HCT................................................................15benztropine tabs............................................................. 11

BESIVANCE eye susp...................................................25betamethasone dipropionate, augmented; crm, gel,

lotn, oint........................................................................ 18betamethasone dipropionate crm, lotn, oint............... 18betamethasone valerate crm, lotn, oint.......................18BETASERON.................................................................. 18BETASERON.................................................................. 23betaxolol eye soln.......................................................... 25betaxolol tabs..................................................................15bethanechol..................................................................... 20BETOPTIC-S eye susp..................................................25bicalutamide.....................................................................23BICNU.................................................................................8BILTRICIDE.....................................................................10bisoprolol..........................................................................15bisoprolol/hydrochlorothiazide...................................... 15bleomycin........................................................................... 8BONIVA inj...................................................................... 25BOOSTRIX...................................................................... 23BOSULIF............................................................................ 8BRILINTA.........................................................................14brimonidine eye soln......................................................25BROMFENAC eye soln................................................. 25bromocriptine...................................................................11bromocriptine...................................................................22budesonide ER............................................................... 24bumetanide...................................................................... 15BUPHENYL..................................................................... 20buprenorphine/naloxone.................................................. 1buprenorphine SL tabs.................................................... 1bupropion hcl.....................................................................5bupropion hcl ER, 12 hr.................................................. 5bupropion hcl ER, 12 hr (smoking deterrent)................1bupropion hcl ER, 24 hr.................................................. 5buspirone......................................................................... 13BUSULFEX........................................................................ 8butorphanol........................................................................ 1BYSTOLIC....................................................................... 15Ccabergoline...................................................................... 22caffeine citrate oral soln................................................ 18caffeine citrate oral soln................................................ 26calcipotriene crm, oint, soln.......................................... 18calcitonin nasal spray.................................................... 25calcitriol caps...................................................................25calcitriol inj, oral soln..................................................... 25calcium acetate...............................................................21CAMPATH..........................................................................8CANASA.......................................................................... 24

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CANCIDAS.........................................................................6candesartan.....................................................................15candesartan/hydrochlorothiazide..................................15CAPASTAT........................................................................ 7CAPRELSA*...................................................................... 8captopril............................................................................15CARAC crm.....................................................................18carbamazepine..................................................................4carbamazepine ER caps, ER tabs.................................4carbidopa/levodopa........................................................ 11carbidopa/levodopa ER................................................. 11carboplatin IV soln............................................................8carteolol eye soln........................................................... 25carvedilol.......................................................................... 15CEENU............................................................................... 8cefaclor caps..................................................................... 2cefadroxil............................................................................ 2cefazolin for inj..................................................................2cefdinir................................................................................ 2cefepime for inj................................................................. 2cefotaxime for inj.............................................................. 2cefoxitin for inj...................................................................2cefpodoxime.......................................................................2cefprozil.............................................................................. 2ceftazidime for inj, for IV................................................. 2ceftriaxone for inj, for IV..................................................2CEFTRIAXONE for IV in dextrose, inj in dextrose....... 2cefuroxime axetil...............................................................2cefuroxime sodium for inj, for IV.................................... 2CELEBREX........................................................................1CELEBREX........................................................................6CELLCEPT for IV........................................................... 23CELLCEPT for susp.......................................................23CELONTIN.........................................................................4cephalexin caps, for susp............................................... 2CEREZYME*................................................................... 20CERVARIX.......................................................................23CHANTIX............................................................................1CHEMET.......................................................................... 27CHENODAL.....................................................................20CHLORAMPHENICOL.....................................................2chlorhexidine gluconate oral rinse............................... 18chloroquine phosphate.................................................. 10chlorothiazide tabs......................................................... 15CHLORPROMAZINE inj.................................................. 6CHLORPROMAZINE inj................................................ 11chlorpromazine tabs.........................................................6chlorpromazine tabs.......................................................11chlorthalidone tabs......................................................... 15cholestyramine................................................................ 15

cholestyramine light....................................................... 15chorionic gonadotropin.................................................. 21ciclopirox crm, gel, shampoo, soln (nail lacquer),

susp............................................................................... 18cidofovir............................................................................ 12cilostazol.......................................................................... 14cimetidine inj, oral soln, tabs........................................ 20CIPRODEX ear susp..................................................... 26ciprofloxacin ER................................................................2ciprofloxacin eye soln.................................................... 25ciprofloxacin for IV, for IV in dextrose, tabs..................2CIPRO for susp................................................................ 2cisplatin inj......................................................................... 8citalopram oral soln, tabs................................................ 5cladribine............................................................................ 8CLAFORAN IV in dextrose............................................. 2clarithromycin.....................................................................2clarithromycin ER..............................................................3CLEOCIN IV in dextrose................................................. 3clindamycin/benzoyl peroxide gel................................ 18clindamycin caps, inj, IV in dextrose, IV soln, vaginal

crm................................................................................... 3clindamycin gel, lotn, soln, swabs................................18clobetasol crm, crm (emollient), gel, oint, soln........... 18CLOLAR............................................................................. 8clomipramine..................................................................... 5clonazepam ODT, tabs....................................................4clonidine tabs.................................................................. 15clonidine transdermal.....................................................15clopidogrel tabs...............................................................14clorazepate.........................................................................4clorazepate...................................................................... 13clotrimazole/betamethasone crm, lotn.........................18clotrimazole crm..............................................................18clotrimazole troche........................................................... 6clozapine.......................................................................... 11COARTEM.......................................................................10CODEINE SULFATE tabs...............................................1COLCRYS..........................................................................6colestipol.......................................................................... 16colistimethate sodium.......................................................3COMBIGAN eye soln.....................................................25COMBIPATCH................................................................ 22COMBIVENT................................................................... 26COMBIVENT RESPIMAT..............................................26COMETRIQ........................................................................8COMPLERA.....................................................................12COMTAN..........................................................................11COMVAX..........................................................................23COPAXONE.................................................................... 18

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CORTIFOAM rectal foam..............................................18CORTISONE................................................................... 21COSMEGEN......................................................................8CREON............................................................................ 20CRESTOR....................................................................... 16CRIXIVAN........................................................................ 12cromolyn sodium eye soln............................................ 25cromolyn sodium inhal soln.......................................... 26cromolyn sodium oral conc...........................................20CUBICIN.............................................................................3CUPRIMINE.....................................................................21CUPRIMINE.....................................................................23CUPRIMINE.....................................................................27cyclobenzaprine.............................................................. 27CYCLOPHOSPHAMIDE for inj.......................................8CYCLOPHOSPHAMIDE tabs......................................... 8CYCLOSERINE.................................................................7cyclosporine.....................................................................23CYCLOSPORINE modified caps................................. 23cyclosporine modified caps, oral soln..........................23CYMBALTA........................................................................5CYMBALTA..................................................................... 13CYMBALTA..................................................................... 18CYSTADANE...................................................................20CYSTAGON*...................................................................20CYTARABINE for inj........................................................ 8cytarabine for inj, inj.........................................................8Ddacarbazine for inj............................................................8DACARBAZINE for inj..................................................... 8DACOGEN.........................................................................8danazol.............................................................................22dantrolene caps.............................................................. 11DAPSONE..........................................................................7DAPTACEL......................................................................23DARAPRIM......................................................................10daunorubicin...................................................................... 8DECAVAC........................................................................23decitabine...........................................................................8DELZICOL....................................................................... 24demeclocycline..................................................................3DENAVIR crm................................................................. 18DEPEN TITRATABS......................................................21DEPEN TITRATABS......................................................23DEPEN TITRATABS......................................................27DEPO-PROVERA...........................................................22desipramine....................................................................... 5desmopressin nasal soln, nasal spray, tabs...............21desonide crm, lotn, oint.................................................18

desoximetasone crm, gel, oint......................................19DETROL...........................................................................21DETROL LA.................................................................... 21dexamethasone elixir, tabs........................................... 21dexamethasone sodium phosphate eye soln............. 25dexamethasone sodium phosphate inj........................21DEXAMETHASONE tabs.............................................. 21dexmethylphenidate tabs...............................................18dexrazoxane...................................................................... 8dextroamphetamine ER caps....................................... 18dextroamphetamine tabs...............................................18DIASTAT............................................................................ 4DIAZEPAM oral conc, oral soln......................................4DIAZEPAM oral conc, oral soln................................... 13DIAZEPAM rectal gel.......................................................4diazepam tabs...................................................................4diazepam tabs.................................................................13DIBENZYLINE.................................................................16diclofenac/misoprostol......................................................7diclofenac potassium........................................................6diclofenac sodium DR......................................................6diclofenac sodium ER...................................................... 6diclofenac sodium eye soln...........................................25dicloxacillin.........................................................................3didanosine DR................................................................ 12DIFICID...............................................................................3diflorasone oint................................................................19DIGOXIN oral soln......................................................... 16digoxin tabs..................................................................... 16DILANTIN caps, chew tabs.............................................4diltiazem ER.................................................................... 16diltiazem tabs.................................................................. 16DIOVAN............................................................................16DIOVAN HCT..................................................................16DIPENTUM...................................................................... 24diphenhydramine...............................................................6diphenhydramine............................................................ 11diphenhydramine............................................................ 26DIPHTHERIA/TETANUS ADSORBED pediatric........23dipyridamole tabs........................................................... 14disopyramide................................................................... 16disulfiram............................................................................ 2divalproex DR tabs...........................................................4divalproex DR tabs...........................................................7divalproex DR tabs.........................................................13divalproex ER....................................................................4divalproex ER....................................................................7divalproex ER..................................................................13divalproex sprinkle caps.................................................. 4divalproex sprinkle caps.................................................. 7

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divalproex sprinkle caps................................................13DIVIGEL........................................................................... 22DOCEFREZ....................................................................... 8DOCETAXEL for inj, for IV..............................................8donepezil............................................................................ 5dorzolamide/timolol maleate eye soln......................... 25dorzolamide eye soln.....................................................25DOVONEX crm...............................................................19doxazosin.........................................................................16doxazosin.........................................................................21doxepin............................................................................... 5doxepin.............................................................................13doxepin.............................................................................27DOXIL................................................................................. 8doxorubicin.........................................................................8doxycycline hyclate caps, for inj, tabs........................... 3doxycycline hyclate tabs................................................18doxycycline monohydrate................................................ 3dronabinol.......................................................................... 6DUREZOL........................................................................25DYNACIRC CR...............................................................16EE.E.S. GRANULES...........................................................3econazole crm.................................................................19EDURANT........................................................................12EFFIENT.......................................................................... 14ELAPRASE......................................................................20ELELYSO.........................................................................20ELIGARD......................................................................... 22ELIGARD......................................................................... 22ELITEK............................................................................... 8ELLA................................................................................. 22ELSPAR............................................................................. 8EMCYT............................................................................... 8EMEND caps.....................................................................6EMEND for IV................................................................... 6EMSAM.............................................................................. 5EMTRIVA......................................................................... 12enalapril/hydrochlorothiazide........................................ 16enalapril tabs...................................................................16ENBREL...........................................................................23ENGERIX-B.....................................................................23enoxaparin....................................................................... 15entacapone...................................................................... 11epinastine eye soln........................................................ 25EPIPEN............................................................................ 26EPIPEN-JR...................................................................... 26epirubicin inj.......................................................................8EPIVIR-HBV.................................................................... 12

EPIVIR oral soln.............................................................12eplerenone.......................................................................16EPOGEN..........................................................................15eprosartan........................................................................16EPZICOM.........................................................................12EQUETRO....................................................................... 13ERBITUX............................................................................8ERIVEDGE.........................................................................8ERYPED.............................................................................3ERY-TAB............................................................................3ERYTHROCIN...................................................................3erythromycin/benzoyl peroxide gel.............................. 19erythromycin eye oint.....................................................25erythromycin pads, soln................................................ 19escitalopram.......................................................................5escitalopram.................................................................... 13ESTRACE vaginal crm.................................................. 22estradiol/norethindrone acetate....................................22estradiol tabs, transdermal............................................22estropipate....................................................................... 22ethambutol......................................................................... 7ethosuximide caps, oral soln.......................................... 4etidronate tabs................................................................ 25ETIDRONATE tabs........................................................ 25etodolac..............................................................................1etodolac..............................................................................7etodolac ER.......................................................................7ETOPOPHOS....................................................................8etoposide inj...................................................................... 8EVISTA.............................................................................22EXELON oral soln, transdermal..................................... 5exemestane....................................................................... 8EXFORGE....................................................................... 16EXFORGE HCT..............................................................16EXJADE* tabs for oral susp......................................... 27EXJADE* tabs for oral susp......................................... 27FFABRAZYME*................................................................. 20famciclovir........................................................................ 12famotidine for susp, inj, tabs.........................................20FANAPT........................................................................... 11FARESTON....................................................................... 8FASLODEX........................................................................8fat emulsion IV................................................................27FAZACLO.........................................................................11felbamate............................................................................4felodipine ER...................................................................16fenofibrate micronized caps..........................................16fenofibrate tabs............................................................... 16

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fenofibric acid DR...........................................................16fentanyl citrate oral lozenges..........................................1fentanyl transdermal.........................................................1FINACEA gel...................................................................19finasteride.........................................................................21finasteride.........................................................................23FIRAZYR..........................................................................16FIRMAGON..................................................................... 22FIRMAGON..................................................................... 22flecainide.......................................................................... 16FLOVENT DISKUS........................................................ 26FLOVENT HFA............................................................... 27fluconazole for susp, inj in dextrose, tabs.....................6fluconazole inj in normal saline...................................... 6FLUCONAZOLE inj in normal saline............................. 6flucytosine.......................................................................... 6fludarabine......................................................................... 8fludrocortisone.................................................................21fluocinolone acetonide ear oil.......................................26fluocinolone crm..............................................................19fluocinonide crm, crm (emollient), gel, oint, soln........19fluorometholone eye susp.............................................25FLUOROPLEX crm........................................................ 19fluorouracil crm, soln......................................................19fluorouracil inj.................................................................... 8fluoxetine caps, oral soln, tabs.......................................5fluoxetine DR.....................................................................5FLUPHENAZINE DECANOATE...................................11FLUPHENAZINE HCL elixir, inj, oral conc..................11fluphenazine hcl tabs.....................................................11flurbiprofen......................................................................... 7flurbiprofen eye soln.......................................................25flutamide...........................................................................23fluticasone crm, oint.......................................................19fluticasone nasal spray..................................................27fluvoxamine........................................................................5fomepizole........................................................................27fondaparinux....................................................................15FORADIL AEROLIZER..................................................27FORTAZ for inj, inj in dextrose.......................................3FORTEO.......................................................................... 25FORTESTA......................................................................22FORTICAL....................................................................... 25FOSCARNET.................................................................. 12fosinopril...........................................................................16fosinopril/hydrochlorothiazide........................................16fosphenytoin.......................................................................4FOSRENOL.....................................................................21furosemide inj, oral soln, tabs...................................... 16FUZEON.......................................................................... 12

Ggabapentin......................................................................... 4GABITRIL...........................................................................4galantamine....................................................................... 5galantamine ER................................................................ 5GAMMAGARD................................................................ 23GAMMAGARD S/D........................................................ 23ganciclovir for inj.............................................................12GARDASIL.......................................................................23GAUZE PADS 2" X 2"...................................................14gemcitabine for inj............................................................ 8GEMCITABINE inj............................................................ 8gemfibrozil........................................................................16GENTAMICIN crm, oint................................................. 19gentamicin eye oint, soln.............................................. 25gentamicin inj, inj in saline, IV soln................................3GENTAMICIN inj in saline...............................................3GEODON......................................................................... 11GEODON......................................................................... 13GILOTRIF...........................................................................8GLEEVEC.......................................................................... 8glimepiride........................................................................14glipizide............................................................................ 14glipizide/metformin..........................................................14glipizide ER..................................................................... 14GLUCAGEN KIT.............................................................14GLUCAGON EMERGENCY KIT..................................14glyburide...........................................................................14glyburide/metformin........................................................14GLYBURIDE (distributor of Diabeta)........................... 14glyburide micronized...................................................... 14glycopyrrolate tabs......................................................... 20granisetron tabs................................................................ 6griseofulvin.........................................................................6GRIS-PEG..........................................................................6HHALAVEN.......................................................................... 8halobetasol crm, oint......................................................19haloperidol decanoate....................................................11haloperidol inj, oral conc, tabs......................................11HAVRIX............................................................................ 23heparin inj........................................................................ 15heparin inj in dextrose................................................... 15HEPSERA........................................................................12HERCEPTIN...................................................................... 8HEXALEN.......................................................................... 8HIBERIX...........................................................................23HUMALOG.......................................................................14

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HUMALOG MIX.............................................................. 14HUMIRA........................................................................... 23HUMULIN 70/30............................................................. 14HUMULIN N.................................................................... 14HUMULIN R.................................................................... 14hydralazine tabs..............................................................16hydrochlorothiazide........................................................ 16hydrocodone/acetaminophen caps, oral soln............... 1hydrocodone/acetaminophen tabs................................. 1hydrocodone/ibuprofen.................................................... 1hydrocortisone/acetic acid ear soln............................. 26hydrocortisone butyrate crm, oint, soln....................... 19hydrocortisone crm, lotn, oint, rectal crm....................19hydrocortisone enema................................................... 24hydrocortisone tabs........................................................21hydrocortisone valerate crm, oint.................................19hydromorphone inj............................................................1hydromorphone liq, tabs..................................................1hydroxychloroquine........................................................ 10hydroxyurea....................................................................... 8hydroxyzine hcl syrup, tabs............................................ 6hydroxyzine hcl syrup, tabs.......................................... 13hydroxyzine hcl syrup, tabs.......................................... 27Iibandronate tabs.............................................................25ibuprofen............................................................................ 1ibuprofen............................................................................ 7ICLUSIG............................................................................. 9idarubicin............................................................................ 9IFEX for inj.........................................................................9IFOSFAMIDE/MESNA......................................................9IFOSFAMIDE for inj......................................................... 9ifosfamide for inj, IV......................................................... 9ILEVRO............................................................................ 25imipenem/cilastatin........................................................... 3imipramine hcl................................................................... 5imipramine pamoate.........................................................5imiquimod.........................................................................23INCIVEK...........................................................................12INCRELEX*..................................................................... 21indapamide...................................................................... 16indomethacin caps............................................................7indomethacin ER.............................................................. 7INFANRIX........................................................................ 23INFERGEN...................................................................... 23INLYTA............................................................................... 9INSULIN INJECTION DEVICE.....................................14INSULIN INJECTION DEVICE/NOVOLIN.................. 14INSULIN SYRINGE/NEEDLE....................................... 14

INTELENCE.....................................................................12INTRON-A..........................................................................9INTRON-A..........................................................................9INTRON-A........................................................................12INTRON-A........................................................................12INTUNIV...........................................................................18INVANZ.............................................................................. 3INVEGA SUSTENNA inj................................................11INVEGA SUSTENNA inj................................................11INVEGA tabs...................................................................11INVEGA tabs...................................................................11INVIRASE........................................................................ 12IPOL..................................................................................23ipratropium nasal soln................................................... 27irbesartan......................................................................... 16irbesartan/hydrochlorothiazide......................................16IRESSA*.............................................................................9irinotecan............................................................................9ISENTRESS.................................................................... 12isoniazid/rifampin.............................................................. 7ISONIAZID inj....................................................................7isoniazid tabs.....................................................................7isosorbide dinitrate ER tabs..........................................16ISOSORBIDE DINITRATE SL tabs............................. 16isosorbide dinitrate tabs................................................ 16isosorbide mononitrate.................................................. 16isosorbide mononitrate ER tabs...................................16isotretinoin caps..............................................................19ISRADIPINE.................................................................... 16ISTALOL eye soln..........................................................25ISTODAX............................................................................9itraconazole caps..............................................................6iv fluids - generics.......................................................... 27IV FLUIDS - KCL/D5W/LACTATED RINGERS inj.....27IXEMPRA........................................................................... 9IXIARO............................................................................. 23JJAKAFI................................................................................9JANUMET........................................................................ 14JANUMET XR................................................................. 14JANUVIA.......................................................................... 14JENTADUETO................................................................ 14JEVTANA........................................................................... 9JUVISYNC....................................................................... 14KKADCYLA.......................................................................... 9KALETRA.........................................................................12KALYDECO..................................................................... 27

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KANAMYCIN..................................................................... 3KEPIVANCE.................................................................... 18ketoconazole crm, shampoo.........................................19ketoconazole tabs.............................................................6ketoprofen.......................................................................... 1ketoprofen.......................................................................... 7ketorolac eye soln.......................................................... 25ketorolac tabs....................................................................1KINRIX..............................................................................24KOMBIGLYZE XR.......................................................... 14KUVAN*............................................................................20Llabetalol tabs................................................................... 16LACRISERT eye insert..................................................25lactic acid crm, lotn........................................................ 19lactulose........................................................................... 20LAMICTAL ODT................................................................4LAMICTAL ODT..............................................................13lamivudine........................................................................12lamivudine/zidovudine....................................................12lamotrigine chew tabs, tabs............................................ 4lamotrigine chew tabs, tabs.......................................... 13lansoprazole DR............................................................. 20LANTUS........................................................................... 14latanoprost eye soln.......................................................25LATUDA........................................................................... 11leflunomide.......................................................................24LETAIRIS*........................................................................16letrozole..............................................................................9LEUCOVORIN CALCIUM for inj, inj, tabs.....................9leucovorin calcium for inj, tabs....................................... 9LEUKERAN........................................................................9LEUKINE..........................................................................15leuprolide acetate........................................................... 22LEVEMIR......................................................................... 14levetiracetam inj, oral soln, tabs.....................................4LEVETIRACETAM IV in saline.......................................4levobunolol eye soln...................................................... 25LEVOBUNOLOL eye soln.............................................25levocarnitine oral soln, tabs.......................................... 27levocetirizine tabs...........................................................27levofloxacin........................................................................ 3LEVORPHANOL............................................................... 1levothyroxine tabs...........................................................22Levoxyl............................................................................. 22LEXIVA.............................................................................12LIALDA............................................................................. 24lidocaine/prilocaine........................................................... 1lidocaine gel, oint........................................................... 19

LIDOCAINE IV................................................................ 16lidocaine local inj, topical soln........................................ 1lidocaine patch.................................................................. 1lidocaine viscous...............................................................1LIDODERM........................................................................ 1lindane lotn, shampoo................................................... 10liothyronine tabs..............................................................22LIPOFEN..........................................................................16lisinopril............................................................................ 16lisinopril/hydrochlorothiazide......................................... 16lithium carbonate caps, tabs.........................................13lithium carbonate ER..................................................... 13LITHIUM CITRATE.........................................................13LOMUSTINE caps............................................................ 9loperamide....................................................................... 20losartan.............................................................................16losartan/hydrochlorothiazide......................................... 16LOTEMAX eye susp...................................................... 25LOTRONEX.....................................................................20lovastatin.......................................................................... 16LOVAZA........................................................................... 16LOVENOX........................................................................15loxapine............................................................................ 11LUFYLLIN........................................................................ 27LUMIGAN eye soln........................................................ 25LUNESTA.........................................................................27LUPRON DEPOT........................................................... 22LUPRON DEPOT-PED..................................................22LYRICA...............................................................................4LYRICA............................................................................ 18LYSODREN.....................................................................22MMALARONE tabs............................................................10malathion..........................................................................10MAPROTILINE.................................................................. 5MARPLAN..........................................................................5MATULANE....................................................................... 9meclizine tabs................................................................... 6medroxyprogesterone inj, tabs..................................... 22mefloquine....................................................................... 10MEFOXIN...........................................................................3megestrol......................................................................... 22MEKINIST.......................................................................... 9meloxicam tabs................................................................. 7melphalan...........................................................................9MENACTRA.....................................................................24MENEST.......................................................................... 22MENOMUNE................................................................... 24MENVEO..........................................................................24

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MEPRON......................................................................... 10mercaptopurine................................................................. 9meropenem........................................................................3mesalamine enema........................................................24mesna................................................................................. 9MESNEX tabs................................................................... 9MESTINON syrup.............................................................7metformin......................................................................... 14metformin ER.................................................................. 14methadone tabs................................................................ 1methazolamide................................................................16methenamine hippurate................................................... 3methimazole.................................................................... 23methocarbamol............................................................... 27methotrexate for inj, inj.................................................... 9methotrexate for inj, inj..................................................24methotrexate tabs.............................................................9methotrexate tabs...........................................................24methscopolamine............................................................20methyldopa...................................................................... 16methylergonovine tabs...................................................21methylphenidate ER tabs.............................................. 18methylphenidate tabs.....................................................18methylprednisolone sodium succinate for inj..............21methylprednisolone tabs................................................21metipranolol eye soln.....................................................25metoclopramide oral soln, tabs...................................... 6metoclopramide oral soln, tabs.................................... 20metolazone...................................................................... 16metoprolol/hydrochlorothiazide tabs............................ 17metoprolol succinate ER............................................... 16metoprolol tartrate tabs..................................................16METROGEL.....................................................................19METRO IV......................................................................... 3metronidazole caps, IV soln, tabs, vaginal gel............. 3metronidazole crm, gel, lotn......................................... 19mexiletine.........................................................................17MICARDIS....................................................................... 17MICARDIS HCT..............................................................17midodrine......................................................................... 17MIGERGOT....................................................................... 7MIGRANAL........................................................................ 7minocycline........................................................................ 3minoxidil........................................................................... 17mirtazapine ODT...............................................................5mirtazapine tabs................................................................5misoprostol.......................................................................20mitomycin........................................................................... 9mitoxantrone...................................................................... 9mitoxantrone....................................................................18

M-M-R II W/DILUENT....................................................24modafinil...........................................................................27moexipril...........................................................................17moexipril/hydrochlorothiazide........................................17mometasone crm, lotn, oint.......................................... 19montelukast..................................................................... 27morphine sulfate ER tabs................................................1morphine sulfate inj..........................................................1morphine sulfate oral soln...............................................1MORPHINE SULFATE tabs............................................1MOVIPREP......................................................................20MOXEZA eye soln..........................................................25MULTAQ.......................................................................... 17mupirocin oint..................................................................19MUSTARGEN....................................................................9MYCAMINE........................................................................6MYCOBUTIN..................................................................... 7mycophenolate mofetil...................................................24MYFORTIC...................................................................... 24MYOZYME.......................................................................20Nnabumetone.......................................................................7nadolol..............................................................................17nafcillin for inj.................................................................... 3NAFCILLIN for IV............................................................. 3NAGLAZYME*.................................................................20naloxone inj....................................................................... 2NALOXONE inj..................................................................2naltrexone.......................................................................... 2NAMENDA......................................................................... 5NAPHAZOLINE eye soln.............................................. 26naproxen............................................................................ 1naproxen............................................................................ 7naproxen DR..................................................................... 7naproxen sodium.............................................................. 1naproxen sodium.............................................................. 7naratriptan.......................................................................... 7NASONEX....................................................................... 27NATACYN eye susp...................................................... 26nateglinide........................................................................14nefazodone tabs............................................................... 5NEFAZODONE tabs.........................................................5neomycin/polymyxin B/bacitracin/hydrocortisone eye

oint................................................................................. 26neomycin/polymyxin B/bacitracin eye oint.................. 26neomycin/polymyxin B/dexamethasone eye oint,

susp............................................................................... 26neomycin/polymyxin B/gramicidin eye soln................ 26

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neomycin/polymyxin B/hydrocortisone ear soln,susp............................................................................... 26

neomycin/polymyxin B GU irrigation soln................... 21neomycin sulfate tabs...................................................... 3NEULASTA......................................................................15NEUMEGA.......................................................................15NEUPOGEN.................................................................... 15NEUPRO..........................................................................11NEVANAC eye susp...................................................... 26nevirapine tabs................................................................12NEXAVAR*.........................................................................9NEXIUM........................................................................... 20NEXIUM I.V.....................................................................20NIASPAN......................................................................... 17nicardipine caps..............................................................17NICOTROL INHALER......................................................2NICOTROL NS nasal spray............................................2nifedipine ER tabs..........................................................17NILANDRON................................................................... 23nisoldipine ER tabs........................................................ 17NISOLDIPINE ER tabs..................................................17NITRO-BID.......................................................................17nitrofurantoin macrocrystalline caps.............................. 3nitrofurantoin monohydrate/macrocrystalline caps.......3nitrofurantoin susp............................................................ 3nitroglycerin transdermal............................................... 17NITROMIST.....................................................................17NITROSTAT.................................................................... 17nizatidine caps................................................................ 20norethindrone acetate....................................................22NORPACE CR................................................................17nortriptyline caps...............................................................5NORTRIPTYLINE oral soln.............................................5NORVIR........................................................................... 12NOVOLIN 70/30..............................................................14NOVOLIN N.....................................................................14NOVOLIN R.....................................................................14NOVOLOG.......................................................................14NOVOLOG MIX.............................................................. 14NOXAFIL............................................................................ 6NUCYNTA ER...................................................................1NUEDEXTA..................................................................... 18NULOJIX.......................................................................... 24NUVIGIL...........................................................................27nystatin/triamcinolone crm.............................................19NYSTATIN/TRIAMCINOLONE oint............................. 19nystatin crm, oint, topical powder................................ 19nystatin susp, tabs........................................................... 6

Ooctreotide inj....................................................................22octreotide inj....................................................................22ofloxacin............................................................................. 3ofloxacin ear soln........................................................... 26ofloxacin eye soln...........................................................26olanzapine........................................................................11olanzapine........................................................................13OLEPTRO.......................................................................... 5omeprazole DR caps..................................................... 20OMNITROPE...................................................................21ONCASPAR.......................................................................9ondansetron inj..................................................................6ondansetron ODT, oral soln, tabs..................................6ONFI....................................................................................4ONGLYZA........................................................................14ONTAK............................................................................... 9ORACEA caps................................................................ 19oral contraceptives – all generics................................ 22ORAP................................................................................11ORFADIN*....................................................................... 20ORTHOCLONE OKT3................................................... 24oxaliplatin........................................................................... 9oxandrolone tabs............................................................ 22oxandrolone tabs............................................................ 22oxaprozin............................................................................7oxcarbazepine................................................................... 4OXSORALEN ULTRA caps.......................................... 19oxybutynin........................................................................21oxybutynin ER.................................................................21oxycodone/acetaminophen..............................................1oxycodone/aspirin............................................................. 1oxycodone tabs.................................................................1OXYCONTIN..................................................................... 1Ppaclitaxel IV....................................................................... 9PANRETIN.........................................................................9PANRETIN.......................................................................19pantoprazole DR tabs....................................................20paromomycin...................................................................10paroxetine hcl ER.............................................................5paroxetine hcl ER...........................................................13paroxetine hcl tabs........................................................... 5paroxetine hcl tabs.........................................................13PASER................................................................................7PATADAY eye soln........................................................26PATANASE......................................................................27PATANOL eye soln........................................................26

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52

PAXIL susp........................................................................5PAXIL susp......................................................................13PEDVAX HIB...................................................................24peg 3350/kcl/sod bicarb/nacl/sod sulf for soln............20peg 3350/kcl/sod bicarb/nacl for soln..........................20PEGANONE.......................................................................4PEGASYS........................................................................24PEG-INTRON..................................................................24penicillin g potassium for inj............................................3PENICILLIN G POTASSIUM inj in dextrose.................3PENICILLIN G SODIUM for inj.......................................3penicillin v potassium.......................................................3PENNSAID.........................................................................1PENNSAID.........................................................................7PENNSAID.......................................................................19PENTACEL......................................................................24PENTAM 300.................................................................. 10PENTASA........................................................................ 25pentostatin..........................................................................9pentoxifylline ER tabs.................................................... 15perindopril........................................................................ 17PERJETA........................................................................... 9permethrin........................................................................10perphenazine.....................................................................6perphenazine...................................................................11phenelzine..........................................................................5phenobarbital.....................................................................4phenytoin chew tabs, susp..............................................4phenytoin sodium ER caps............................................. 4PHOSLYRA..................................................................... 21PHOSPHOLINE IODIDE eye soln............................... 26PICATO............................................................................ 19pilocarpine eye soln....................................................... 26pilocarpine tabs...............................................................18PILOPINE HS eye gel................................................... 26PINDOLOL.......................................................................17pioglitazone......................................................................14piperacillin/tazobactam for inj......................................... 3piroxicam............................................................................ 7PLAVIX tabs....................................................................15podofilox soln.................................................................. 19polyethylene glycol 3350 oral powder......................... 20polymyxin B/trimethoprim eye soln..............................26POMALYST....................................................................... 9potassium chloride ER caps......................................... 27potassium chloride ER tabs..........................................27potassium citrate ER......................................................21potassium citrate ER......................................................27POTIGA..............................................................................4PRADAXA........................................................................15

pramipexole..................................................................... 11PRANDIN.........................................................................14pravastatin....................................................................... 17prazosin............................................................................17prazosin............................................................................21prednicarbate...................................................................19prednisolone acetate eye susp.................................... 26prednisolone sodium phosphate oral soln.................. 21prednisolone syrup.........................................................21prednisone dose-pack....................................................21PREDNISONE oral soln, tabs...................................... 21prednisone tabs.............................................................. 21PREMARIN tabs.............................................................22PREMARIN vaginal crm................................................22PREMPHASE..................................................................22PREMPRO.......................................................................22PREVACID SOLUTAB...................................................20PREVPAC.......................................................................... 3PREVPAC........................................................................20PREZISTA....................................................................... 12PRIFTIN..............................................................................7PRIMAQUINE..................................................................10primidone............................................................................4PRISTIQ............................................................................. 5PROAIR HFA.................................................................. 27probenecid......................................................................... 6probenecid/colchicine.......................................................6PROCHLORPERAZINE inj............................................. 6PROCHLORPERAZINE inj........................................... 11prochlorperazine supp, tabs............................................6prochlorperazine supp, tabs......................................... 11PROCRIT inj....................................................................15PROCRIT inj....................................................................15PROGLYCEM................................................................. 14PROGRAF inj..................................................................24PROLASTIN-C*...............................................................27PROLEUKIN...................................................................... 9PROLIA............................................................................ 25PROMACTA*...................................................................15promethazine supp, syrup, tabs..................................... 6promethazine supp, syrup, tabs...................................27propafenone.....................................................................17propafenone ER..............................................................17propranolol ER caps........................................................ 7propranolol ER caps...................................................... 17propranolol tabs................................................................ 7propranolol tabs.............................................................. 17propylthiouracil................................................................ 23PROQUAD.......................................................................24PROTOPIC...................................................................... 19

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PROTOPIC...................................................................... 24protriptyline.........................................................................5PROVIGIL........................................................................ 27PULMOZYME..................................................................27PYLERA........................................................................... 20pyrazinamide..................................................................... 7pyridostigmine................................................................... 7Qquetiapine...........................................................................5quetiapine.........................................................................11quetiapine.........................................................................13quinapril............................................................................17quinapril/hydrochlorothiazide........................................ 17quinidine gluconate ER..................................................17quinidine sulfate..............................................................17QVAR................................................................................27RRABAVERT..................................................................... 24ramipril..............................................................................17RANEXA.......................................................................... 17ranitidine caps, syrup, tabs...........................................20RAPAFLO........................................................................ 21RAPAMUNE.................................................................... 24REBETOL oral soln........................................................12RECOMBIVAX HB......................................................... 24RELISTOR.......................................................................20REMICADE......................................................................24REMODULIN*................................................................. 17RENVELA........................................................................ 21repaglinide....................................................................... 14RESCRIPTOR.................................................................12RESTASIS eye emulsion.............................................. 26RETROVIR IV................................................................. 12REVLIMID*.........................................................................9REYATAZ.........................................................................12RIBAPAK..........................................................................12RIBASPHERE tabs........................................................ 12RIBASPHERE tabs........................................................ 12ribavirin caps, tabs......................................................... 12RIDAURA.........................................................................24rifampin...............................................................................7RILUTEK.......................................................................... 18riluzole.............................................................................. 18rimantadine...................................................................... 12RISPERDAL CONSTA.................................................. 11RISPERDAL CONSTA.................................................. 13risperidone....................................................................... 11risperidone....................................................................... 13

RITUXAN*.......................................................................... 9rivastigmine caps.............................................................. 5rizatriptan............................................................................7ropinirole.......................................................................... 11ROTARIX......................................................................... 24ROTATEQ........................................................................24SSABRIL...............................................................................4SANCTURA XR.............................................................. 21SANCUSO......................................................................... 6SANDIMMUNE oral soln............................................... 24SANTYL........................................................................... 19SAPHRIS......................................................................... 11selegiline.......................................................................... 11selenium sulfide lotn, shampoo....................................19SELZENTRY................................................................... 12SENSIPAR.......................................................................22SEREVENT DISKUS..................................................... 27SEROMYCIN.....................................................................7SEROQUEL.......................................................................5SEROQUEL.....................................................................11SEROQUEL.....................................................................13SEROQUEL XR................................................................5SEROQUEL XR..............................................................11SEROQUEL XR..............................................................13sertraline.............................................................................5sertraline.......................................................................... 13sildenafil........................................................................... 17silver sulfadiazine crm................................................... 19SIMULECT.......................................................................24simvastatin.......................................................................17SINGULAIR..................................................................... 27sodium chloride irrigation.............................................. 19sodium phenylbutyrate oral powder.............................20sodium polystyrene sulfonate....................................... 27SOLARAZE gel...............................................................19SOLTAMOX.......................................................................9SOLU-MEDROL for inj.................................................. 21SOMATULINE DEPOT..................................................22SOMAVERT*...................................................................23SORIATANE caps.......................................................... 19sotalol AF tabs................................................................17sotalol tabs...................................................................... 17SPIRIVA HANDIHALER................................................ 27spironolactone................................................................. 17spironolactone/hydrochlorothiazide..............................17SPRYCEL.......................................................................... 9STALEVO.........................................................................11stavudine..........................................................................12

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STIMATE..........................................................................22STIVARGA.........................................................................9STREPTOMYCIN..............................................................3STRIBILD.........................................................................12STROMECTOL............................................................... 10SUBOXONE.......................................................................2sucralfate tabs.................................................................20sulfacetamide sodium/prednisolone eye soln.............26sulfacetamide sodium eye soln.................................... 26sulfacetamide sodium lotn.............................................19SULFADIAZINE.................................................................3SULFAMETHOXAZOLE/TRIMETHOPRIM inj..............3sulfamethoxazole/trimethoprim susp, tabs....................3sulfasalazine....................................................................25sulfasalazine DR.............................................................25sulindac.............................................................................. 7sumatriptan inj...................................................................7SUMATRIPTAN nasal spray...........................................7sumatriptan tabs............................................................... 7SUPRAX caps, chew tabs, tabs.....................................3SUPREP.......................................................................... 20SURMONTIL......................................................................5SUSTIVA..........................................................................12SUTENT............................................................................. 9SYLATRON........................................................................9SYMBICORT................................................................... 27SYMLINPEN....................................................................14SYNAGIS......................................................................... 24SYNAREL........................................................................ 23SYNERCID.........................................................................3SYNRIBO........................................................................... 9SYPRINE......................................................................... 28TTABLOID............................................................................ 9tacrolimus.........................................................................24TAFINLAR..........................................................................9TAMIFLU..........................................................................12tamoxifen..........................................................................10tamsulosin........................................................................21TARCEVA........................................................................ 10TARGRETIN caps.......................................................... 10TARGRETIN gel............................................................. 10TARGRETIN gel............................................................. 19TASIGNA......................................................................... 10TASMAR.......................................................................... 11TAXOTERE..................................................................... 10TAZORAC crm, gel........................................................ 19TEFLARO...........................................................................3TEGRETOL-XR.................................................................4

TEKTURNA..................................................................... 17TEKTURNA HCT............................................................17TEMODAR for IV............................................................10TENIVAC..........................................................................24terazosin...........................................................................17terazosin...........................................................................21terbinafine.......................................................................... 6terbutaline tabs............................................................... 27terconazole.........................................................................6testosterone cypionate...................................................22testosterone enanthate..................................................22TETANUS/DIPHTHERIA ADSORBED adult.............. 24tetracycline caps............................................................... 4TETRACYCLINE caps..................................................... 3THALOMID...................................................................... 10THALOMID...................................................................... 24theophylline ER tabs......................................................27thioridazine.......................................................................11THIOTEPA.......................................................................10thiothixene........................................................................11THYMOGLOBULIN........................................................ 24tiagabine.............................................................................4TIKOSYN......................................................................... 17TIMENTIN.......................................................................... 4timolol maleate eye soln................................................26timolol maleate gel-forming eye soln...........................26TIMOLOL tabs...................................................................7TIMOLOL tabs................................................................ 17TIVICAY........................................................................... 12tizanidine.......................................................................... 12TOBI....................................................................................4TOBRADEX eye oint..................................................... 26tobramycin/dexamethasone eye susp.........................26tobramycin eye soln.......................................................26tobramycin for inj, inj........................................................4TOBRAMYCIN inj in saline............................................. 4tolmetin sodium caps....................................................... 7tolterodine........................................................................ 21topiramate sprinkle caps..................................................4topiramate sprinkle caps..................................................7topiramate tabs................................................................. 4topiramate tabs................................................................. 7topotecan for inj..............................................................10TOPOTECAN inj.............................................................10TORISEL..........................................................................10torsemide tabs................................................................ 17TOVIAZ............................................................................ 21TRACLEER*.................................................................... 17TRADJENTA................................................................... 14tramadol..............................................................................1

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tramadol/acetaminophen................................................. 1tramadol ER.......................................................................1trandolapril....................................................................... 17tranexamic acid inj......................................................... 15tranylcypromine................................................................. 5TRAVATAN Z eye soln................................................. 26trazodone........................................................................... 5TREANDA........................................................................10TRECATOR....................................................................... 7TRELSTAR DEPOT....................................................... 23TRELSTAR DEPOT MIXJECT.....................................23TRELSTAR LA................................................................23TRELSTAR LA MIXJECT..............................................23TRELSTAR MIXJECT....................................................23tretinoin caps...................................................................10tretinoin crm, gel.............................................................19triamcinolone acetonide paste......................................18triamcinolone crm, lotn, oint..........................................19triamcinolone nasal spray............................................. 27TRIAMCINOLONE oint..................................................19triamterene/hydrochlorothiazide................................... 17trifluoperazine..................................................................11trifluridine eye soln......................................................... 26trihexyphenidyl................................................................ 11TRILEPTAL susp.............................................................. 5TRILIPIX...........................................................................17trimethoprim tabs.............................................................. 4trimipramine....................................................................... 6TRISENOX.......................................................................10TRIZIVIR.......................................................................... 13trospium............................................................................21trospium ER.....................................................................21TRUVADA........................................................................13TWINRIX.......................................................................... 24TYGACIL............................................................................ 4TYKERB*......................................................................... 10TYPHIM VI.......................................................................24TYSABRI*........................................................................ 18TYSABRI*........................................................................ 24TYZEKA........................................................................... 13TYZINE.............................................................................27TYZINE PEDIATRIC...................................................... 27UULESFIA.......................................................................... 10ULORIC..............................................................................6urea/hydrocortisone acetate crm..................................19ursodiol caps................................................................... 20UVADEX.......................................................................... 10

VVAGIFEM vaginal tabs.................................................. 22valacyclovir...................................................................... 13VALCYTE.........................................................................13valproate inj....................................................................... 5valproic acid.......................................................................5valproic acid.................................................................... 13valsartan/hydrochlorothiazide....................................... 17VANCOCIN caps.............................................................. 4vancomycin caps.............................................................. 4vancomycin for inj.............................................................4VANCOMYCIN inj in dextrose........................................4VANDETANIB*................................................................10VAQTA............................................................................. 24VARIVAX..........................................................................24VECTIBIX.........................................................................10VECTICAL oint................................................................19VELCADE........................................................................ 10venlafaxine.........................................................................6venlafaxine ER caps, ER tabs........................................6venlafaxine ER caps, ER tabs......................................13VENTOLIN HFA..............................................................27verapamil ER...................................................................17verapamil tabs.................................................................17VESICARE.......................................................................21VFEND IV.......................................................................... 6VFEND susp......................................................................6VICTOZA..........................................................................14VICTRELIS...................................................................... 13VIDAZA............................................................................ 10VIDEX...............................................................................13VIGAMOX eye soln........................................................26VIIBRYD............................................................................. 6VIMOVO............................................................................. 7VIMPAT.............................................................................. 5VINBLASTINE................................................................. 10vincristine......................................................................... 10vinorelbine........................................................................10VIOKACE......................................................................... 20VIRACEPT.......................................................................13VIRAMUNE......................................................................13VIRAMUNE XR...............................................................13VIREAD............................................................................ 13VISTIDE........................................................................... 13VIVELLE-DOT................................................................. 22VIVITROL...........................................................................2VOLTAREN gel.................................................................1VOLTAREN gel.................................................................7VOLTAREN gel...............................................................19

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voriconazole for inj........................................................... 6voriconazole tabs..............................................................6VOTRIENT.......................................................................10VPRIV...............................................................................20VYTORIN......................................................................... 18Wwarfarin tabs....................................................................15water for irrigation.......................................................... 19WELCHOL....................................................................... 14WELCHOL....................................................................... 18XXALKORI..........................................................................10XARELTO........................................................................ 15XENAZINE*..................................................................... 18XIFAXAN tabs................................................................... 4XOLAIR............................................................................ 24XTANDI............................................................................ 23XYREM*........................................................................... 27YYERVOY.......................................................................... 10YF-VAX............................................................................ 24Zzafirlukast.........................................................................27zaleplon............................................................................ 27ZALTRAP.........................................................................10ZANOSAR........................................................................10ZAVESCA*.......................................................................20ZELBORAF......................................................................10ZEMPLAR........................................................................ 25ZENPEP...........................................................................20ZERIT oral soln...............................................................13ZETIA................................................................................18ZIAGEN............................................................................ 13zidovudine........................................................................13ZINACEF inj in dextrose, inj in sterile water................. 4ziprasidone.......................................................................11ziprasidone.......................................................................13zoledronic acid conc for IV........................................... 25ZOLINZA.......................................................................... 10zolpidem...........................................................................27ZOMETA.......................................................................... 25zonisamide.........................................................................5ZORTRESS tabs............................................................ 24ZORTRESS tabs............................................................ 24ZOSTAVAX......................................................................24ZOSYN IV in dextrose..................................................... 4ZOVIRAX oint..................................................................19

ZYPREXA for inj.............................................................11ZYPREXA for inj.............................................................13ZYPREXA RELPREVV*................................................ 11ZYTIGA............................................................................ 10ZYTIGA............................................................................ 23ZYVOX................................................................................4

2013

2013 Supplemental Part D Eligible Drug List

Effective January 1, 2013

About supplemental drugs The Local Government Health Insurance Plan (LGHIP) includes two additional lists of drugs to provide additional coverage to your Part D benefit; a supplemental Part D eligible drug list and a supplemental non-Part D eligible drug list.

Supplemental Part D Eligible Drugs The Supplemental Part D Eligible Drug List provides coverage for a number of drugs that are allowed through the Medicare Part D program and will expand the Ideal Formulary. This supplemental coverage applies to select prescription drugs; those available over-the-counter will not be covered. These drugs will apply to your TrOOP and Drug Spend calculations.

This list begins on the following page of your formulary booklet.

If you have questions about the BlueRx (PDP) Supplemental Drug Lists, please call Member Services at 1-855-314-4990 (TTY 711) 7 a.m to 5:30 p.m., Monday through Friday. You can also go online to www.alseib.org.

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2013

Supplemental Part D Eligible Drug List

Drug Name Tier

Anticonvulsants NEURONTIN 100 mg caps 3

DILANTIN 100 mg caps 2

PHENYTEK 300 mg tablets 2

Antidepressants perphenazine-amitriptyline 2 mg-10 mg, 2 mg-25 mg, 4 mg-25 mg 3 tabletsAntifungals LAMISIL 250 mg tablets 3

Anti-inflammatories dexamethasone 0.5 mg/5 mL oral solution 3

CORTEF 10 mg tablets 3

methylprednisolone acetate 40 mg/mL injectable suspension 1

DEPO-MEDROL 40 mg/mL injectable suspension 3

MILLIPRED 5 mg tablets 3

Barbiturate combinations (headache analgesic) butalbital-acetaminophen-caffeine-codeine 50 mg-325mg-40 mg-30 mg caps 1

Benzodiazepines alprazolam 0.25 mg, 0.5 mg, 1 mg, 2 mg tablets 1

alprazolam extended release 0.5 mg, 1 mg, 2 mg, 3mg tablets 1

estazolam 2 mg tablets 1

lorazepam 0.5 mg, 1 mg, 2mg tablets 1

oxazepam 10 mg, 15 mg caps 1

Drug Name Tier

temazepam 15 mg, 30 mg caps 1

triazolam 0.125 mg, 0.25 mg tablets 1

Bipolar Agents lithium carbonate 150 mg caps 3

Blood modifiers ticlopidine 250 mg tablets 1

COUMADIN 3 mg, 10 mg tablets 3

Cardiovascular captopril/hydrochlorothiazide 25 mg-15 mg, 25 mg-25 mg, 1 50 mg-25 mg tabletsLANOXIN 0.125 mg, 0.25 mg tablets 2

TIAZAC 120 mg, 180 mg caps 3

LASIX 40 mg, 80 mg tablets 3

guanfacine 1 mg, 2 mg tablets 1

ZESTRIL 5 mg, 20 mg tablets 3

methyldopa/hydrochlorothiazide 250 mg-25 mg tablets 3

TOPROL XL 50 mg extended release tablets 3

ALDACTONE 25 mg tablets 3

DYRENIUM 50 mg caps 3

DYAZIDE 37.5 mg caps 3

MAXZIDE 25 mb tablets 3

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2013

Supplemental Part D Eligible Drug List

Drug Name Tier

Cholesterol Therapy fenofibric acid 35 mg tablets 3

Diabetes Agents AMARYL 1 mg tablets 3

GLUCOTROL XL 2.5 mg ER tablets 3

tolbutamide 500 mg tablets 3

Gastrointestinal DEXILANT 60 mg extended release caps 3

Hormone Replacement DEPO-ESTRADIOL 5 mg/mL injection in oil 3

DEPO-TESTOSTERONE 200 mg/mL injection in oil 3

Ophthalmic cyclopentolate 0.01 ophthalmic solution 1

FML FORTE 0.0025 ophthalmic suspension 3

PRED MILD 0.0012 ophthalmic suspension 2

Respiratory budesonide 0.5 mg/2 mL inhalation suspension 1

carbinoxamine maleate 4 mg tablets 1

cetirizine 1 mg/5 mL syrup 1

clemastine fumarate 2.68 mg tablets 1

FLUNISOLIDE 0.0025 nasal spray 3

flunisolide 29 mcg nasal spray 1

Drug Name Tier

ipratropium 0.0002 nebulizer solution 1

ipratropium/albuterol 0.5 mg-2.5 mg/3 mL nebulizer solution 1

promethazine/phenylephrine 6.25 mg-5 mg/5 mL syrup 1

sodium chloride 0.009 nebulizer solution 1

THEO-24 100 mg extended release caps 3

Skinclotrimazole 0.01 solution 1

fluocinolone acetonide 0.0001 topical oil 1

PHISOHEX 0.03 liquid 3

ELOCON 0.001 lotion 3

Thyroid Replacement SYNTHROID 25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 2 150 mcg, 175 mcg, 200 mcg, 300 mcg tabletsTIROSINT 13 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg, 125 mcg, 3

137 mg, 150 mcg capsMiscellaneous droperidol 2.5 mg/mL injectable soluion 1

59

2013

2013 Supplemental Non-Part D Eligible Drug List

Effective January 1, 2013

About supplemental drugs The Local Government Health Insurance Plan (LGHIP) includes two additional lists of drugs to provide additional coverage to your Part D benefit; a supplemental Part D eligible drug list and a supplemental non-Part D eligible drug list.

Supplemental Non-Part D Eligible Drug List The Supplemental Non-Part D Eligible Drug List includes certain generic and brand name prescription drugs that are otherwise excluded from the Medicare Part D program; those available over-the-counter will not be covered. The amount you will pay will be determined by whether the drug is generic or a brand name drug. Generic drugs have the Tier 1 copay and brand drugs have the Tier 3 coinsurance.

Since non-Part D drugs are excluded from the Part D program, the amount you spend on supplemental drugs does not count toward your TrOOP and Drug Spend. In addition, if you receive extra help to pay for your prescriptions, you will not get extra help to pay for these drugs. For this reason, you may wish to talk to your doctor to identify generic or alternate medications that are on the formulary or the Supplemental Part D Eligible Drug List.

This list begins on the following page of your formulary booklet.

If you have questions about the BlueRx (PDP) supplemental drug lists, please call Member Services at 1-855-314-4990 (TTY 711) 7 a.m. to 5:30 p.m., Monday through Friday. You can also go online to www.alseib.org.

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2013

Supplemental Non-Part D Eligible Drug List

Drug Name

Analgesicssalsalate 500 mg tabletsAntihistamines/decongestants chlorpheniramine/phenylephrine 8 mg-20 mg CR tabletschlorpheniramine/pyrilamine/phenylephrine 4 mg-25 mg-10 mg tablets (RU-HIST)Antitussives and Expectorants chlorpheniramine/phenylephrine/dextromethorphan syrupguaifenesin/codeine 100 mg-6.3 mg/5 mL solutionguaifenesin/codeine/pseudoephedrine 100 mg-10 mg-30 mg/5 mL solutionBarbiturate combinations (headache analgesic) butalbital-acetaminophen 50-325 mg tablets (PHRENILIN)butalbital-acetaminophen-caffeine 50-325-40 mg caps (ESGIC)butalbital-acetaminophen-caffeine 50-325-40 mg tablets (ESGIC, FIORICET)butalbital-acetaminophen-caffeine 50-500-40 mg tablets (ESGIC-PLUS)butalbital-aspirin-caffeine 50-325-40 mg tablets (FIORINAL)

Cough and Cold Products benzonatate 100 mg, 200 mg caps (TESSALON)dyphylline-guaifenesin 200 mg-200 mg tablets (DYFLEX-G)promethazine-codeine 6.25 mg-10 mg/5 mL syruppromethazine-dextromethorphan 6.25 mg-15 mg/5 mL syrupPrescription Supplements B-complex w/C, folic acid 1 mg capsules (NEPHROCAPS)B-complex w/C, folic acid 1 mg tablets (NEPHROVITE)

Drug Name

B-complex w/C, folic acid 5 mg tablets (FOLBEE PLUS)B-complex w/C, minerals, ferrous, folic acid 106 mg-1 mg capsules, tablets (HEMOCYTE PLUS, FERROCITE PLUS)B-complex w/C, zinc, folic acid 1 mg tablets(DIALYVITE/ZINC)B-complex w/C, biotin, D, zinc, folic acid 1 mg tablets (VITAL-D RX)B-complex w/C, biotin, minerals, folic acid 5 mg tablets (DIATX-ZN)cobalamin combination tablets (FOLTRATE)cyanocobalamin (Vitamin B12) 1000 mcg/mL injectable solutiondietary management product capsules (SENTRA AM)dietary management product tablets (MACUTEK)ergocalciferol 50,000 units capsules (DRISDOL)ferrous aspart-ferrous fumarate-succinic acid-vita-min C-threonic acid-vitamin B12-folic acid tablets (MULTIGEN PLUS)ferrous aspart-ferrous fumarate-succinic acid-vita-min C-threonic acid-vitamin B12-folic acid capsules (FERREX 150 PLUS)ferrous aspart-ferrous fumarate-vitamin B12-folic acid-vitamin C-succinic acid dispensing pack (FERREX 28)ferrous bisglycinate-polysaccharide iron complex-vitamin C-vitamin B12-folic acid 80 mg-70 mg-60 mg-25 mcg-1 mg capsules (MAXARON FORTE, TARON FORTE)ferrous carbonyl-ferrous gluconate-folic acid-vitamin B12-vitamin C-docusate sodium tablets (FERRALET 90)ferrous fumarate-folic acid 324 mg-1 mg tablets (HEMOCYTE-F)

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2013


Drug Name

ferrous fumarate-iron polysaccharide-folic acid-vitamin C-vitamin B3 62.5 mg-62.5 mg-1 mg-40 mg-3MG (125 mg FE) capsules (INTEGRA F)ferrous fumarate-iron polysaccharide-folic acid-B complex-vitamin C-biotin capsules (INTEGRA PLUS)ferrous fumarate-iron polysaccharide-folic acid-B complex-vitamin C-zinc-minerals-copper capsules (TANDEM PLUS)ferrous fumarate-vitamin C-vitamin B12-folic acid 151 mg-60 mg-0.1 mg-1 mg 460 mg-60 mg-10 mcg-1mgferrous fumarate-vitamin B12-vitamin C-folic acid-IFC 110 mg-0.015 mg-75 mg-0.5 mg-240 mg capsules (FOLTRIN)ferrous sulfate-vitamin C-folic acid 105 mg-500 mg-0.8 mg extended release tablets (FOLITAB)folic acid 1 mg tabletsfolic acid-pyridoxine-cyanocobalamin 2.5 mg-25 mg-2 mg tablets (FOLTX)folic acid-vitamin B12-vitamin B6-arginine 2 mg-0.5 mg-50 mg-500 mg tablets (CARDIOTEK)folic acid-vitamin B6-vitamin B12 2.2 mg-25 mg-0.5 mg tablets (FOLCAPS)folic acid-vitamin B6-vitamin B12 2.2 mg-25 mg-1 mg tablets (FOLGARD)folic acid-vitamin B6-vitamin B12 2.5 mg-25 mg-1 mg tablets (FOLBEE )folic acid-vitamin B6-vitamin B12-omega 3-phytosterols 1 mg capsules (ANIMI-3)genistein-zinc-amino acid chelate-vitamin D capsules (FOSTEUM)iron dextran 50 mg/mL injectable solution (DEXFERRUM)iron-folic acid-vitamin B12-vitamin C-docusate sodium tablets (FERRAPLUS 90)

Drug Name

iron polysaccharide-vitamin B6-vitamin B12-folic acid 150 mg-0.025 mg-1 mg capsules (IFEREX 150 FORTE)iron-vitamin C-vitamin B12-folic acid 100 mg-250 mg-0.025 mg-1 mg tabletsL-methylfolate-methylcobalamin-acetylcysteine 6 mg-2 mg-600 mg tablets (CEREFOLIN NAC)L-methylfolate-vitamin B6-vitamin B12 3 mg-35 mg-2 mg tablets (METANX)L-methylfolate-vitamin B12-vitamin B6-vitamin B2 6 mg-1 mg-50 mg-5 mg tablets (CEREFOLIN)multiple vitamin with minerals caps (OCUVITE, PRESERVISION)multiple vitamin with minerals tablets (CENTRUM, CEROVITE)pediatric multivitamin/fluoride 0.5 mg chewable tabletspolysaccharide iron complex-iron heme complex-folic acid-vitamin B12 22 mg-6 mg-1 mg-0.025 mg tablets (HEMETAB)potassium bicarbonate-citric acid 10 mEq tablets (EFFER-K)potassium bicarbonate 25 mEq tablets (KLOR-CON)potassium chloride 20 mEq/15 mL, 40 mEq/15 mL oral solutionpotassium chloride 20 mEq powder packets (KLOR-CON)potassium and sodium acid phosphates 155 mg/852 mg/130 mg tablets (K-PHOS NEUTRAL )prenatal vitamins/folic acid/iron (ferrous fumarate) 27 mg/1 mg tablets (PRENATAL PLUS)prenatal vitamins/folic acid/ferrous fumarate-without A 1 mg/130 mg/92.4 mg capsules (CONCEPT OB)sodium fluoride 1.1% cream, gel, paste (PREVIDENT)

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2013


Drug Name

sodium fluoride-potassium nitrate 1.1%-5% paste (FLUORIDEX DAILY DEFENSE)Miscellaneous Prescription Products aluminum chloride 6.25% solution (XERAC-AC)aluminum chloride 20% solution (DRYSOL)antipyrine-benzocaine 5.4%-1.4% otic soln (AURODEX)atropine sulfate 1% ophth soln (ISOPTO ATROPINE)hydrocortisone acetate 25 mg suppositories (ANUSOL-HC)papaverine hcl 30 mg/mL injectable solutionpramoxine-hydrocortisone-chloroxylenol 10 mg-10 mg-1 mg/mL otic solnprobiotics chewable tabletswater for injection, bacteriostatic injectable solutionantipyrine-benzocaine 5.4%-1.4% otic soln (AURODEX)atropine sulfate 1% ophth soln (ISOPTO ATROPINE)hydrocortisone acetate 25 mg suppositories (ANUSOL-HC)papaverine hcl 30 mg/mL injectable solutionpramoxine-hydrocortisone-chloroxylenol 10 mg-10 mg-1 mg/mL otic solnprobiotics chewable tabletswater for injection, bacteriostatic injectable solutionOther Respiratorysodium chloride 7% nebulized solutionbrompheniramine 6 mg SR tablets (LODRANE 12 HR)

Drug Name

brompheniramine/pseudoephedrine 6 mg-45 mg tablets (LODRANE 12 D)phenyltoloxamine-acetaminophen 50 mg-500 mg tablets (RHINOFLEX)phenyltoloxamine-acetaminophen 50 mg-650 mg tablets (RELAGESIC)Sedativeschloral hydrate 500 mg/5 mL syrupSkinbenzoyl peroxide 10% gelbismuth tribromophenate/petrolatum pads (XEROFOAM PETROLATUM DRESSING)cream base cream (LIPOBASE)iodoquinol-hydrocortisone 1% creamlactic acid-vitamin E 10%-3500 units/gram cream (LACTIC ACID E)sulfacetamide sodium/sulfur 10%-5% lotiontrypsin/castor oil/peruvian balsam aerosol (GRANULEX)urea 40% cream (CARMOL 40)zinc sulfate 220 mg capsulesUrinary phenazopyridine 100 mg, 200 mg tablets (PYRIDIUM)potassium citrate/citric acid 3300-1002 mg powder packetssodium citrate/citric acid 500 mg-334 mg/5 mL solution (SHOAL’S SOLUTION)

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BlueRx (PDP) is a Medicare-approved Part D sponsor.

BlueRx (PDP) is provided by Blue Cross and Blue Shield of Alabama, an independent licensee of the Blue Cross and Blue Shield Association.

formulary - blue cross and blue shield of alabama

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