Friday Health Plans

2018

lowercase italics = Generic drugsUPPERCASE = Brand name drugs

Formulary TiersT1 = Preferred GenericT2 = Preferred BrandT3 = Non Preferred Generic and BrandT4 = Specialty

RestrictionsPA = Prior AuthorizationST = Step Therapy

Drug Name Formulary Tiers Restrictions

ALTERNATIVE THERAPY

ALTERNATIVE THERAPY - ANDROGENIC AGENTS

prasterone (dhea), micro(bulk) T3

ALTERNATIVE THERAPY - ANTIARTHRITICS

LIMBREL T3

LIMBREL250 T3

LIMBREL500 T3

ALTERNATIVE THERAPY - ESTROGENIC AGENTS

VP-GSTN T1

FOSTEUM T3

FOSTEUM PLUS T3

ALTERNATIVE THERAPY - UNCLASSIFIED

epigallocatechin gallate(bulk) T1

creatine (bulk) T3

s-adenosylmeth sulf tos (bulk) T3

CERENX T3

ENTERAGAM T3

NUMOISYN T3

VAYACOG T3

VAYARIN T3

ANALGESIC, ANTI-INFLAMMATORY OR ANTIPYRETIC

ANALGESIC - CENTRAL ALPHA-2 RECEPTOR AGONISTS

clonidine (pf) T1

ANALGESIC - NEUROLYSIS AGENTS

ethanol (ethyl alcohol) T1

ANALGESIC - NEURONAL (N)-TYPE CALCIUM CHANNEL BLOCKERS (NCCBS)

PRIALT T4 PA

ANALGESIC NARCOTIC AGONISTS

alfentanil T1

codeine sulfate T1

fentanyl citrate (pf) T1

fentanyl citrate buccal lozenge on a handle 1,600 mcg T1 PA

fentanyl citrate-0.9%nacl (pf) T1

fentanyl transdermal patch 72 hour 37.5 mcg/hour, 62.5 mcg/hour, 87.5 mcg/hour

T1

hydromorph(pf)-ropiv-0.9% nacl T1

hydromorphone (pf) T1

hydromorphone (pf)-0.9% nacl T1

hydromorphone in 0.9 % nacl T1

hydromorphone injection T1

2018

1

Drug Name Formulary Tiers Restrictions

hydromorphone intravenous T1

hydromorphone oral liquid T1

hydromorphone oral tablet T1

hydromorphone oral tablet extended release 24 hr 16 mg, 32 mg T1

hydromorphone rectal T1

levorphanol tartrate T1

meperidine T1

meperidine (pf) T1

meperidine (pf) in 0.9 % nacl T1

methadone T1

morphine (pf) T1

morphine (pf) in 0.9 % nacl T1

morphine (pf) in dextrose 5 % T1

morphine concentrate T1

morphine in 0.9 % nacl T1

morphine injection T1

morphine intramuscular T1

morphine intravenous T1

morphine oral capsule, er multiphase 24 hr T1

morphine oral capsule,extend.release pellets 100 mg T1

morphine oral solution T1

morphine oral tablet T1

morphine oral tablet extended release T1

morphine rectal T1

oxycodone oral capsule T1

oxycodone oral solution T1

oxycodone oral tablet T1

oxycodone oral tablet,oral only,ext.rel.12 hr T1

oxymorphone T1

tramadol T1

HYSINGLA ER T2

NUCYNTA T2

OXYCONTIN T2

fentanyl citrate buccal lozenge on a handle 200 mcg, 400 mcg T3 PA

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

T3

hydromorphone oral tablet extended release 24 hr 12 mg, 8 mg T3

morphine oral capsule,extend.release pellets 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg

T3

oxycodone oral concentrate T3

oxycodone oral syringe T3

ABSTRAL SUBLINGUAL TABLET 100 MCG, 200 MCG, 300 MCG, 400 MCG, 600 MCG

T3 PA

ACTIQ T3 PA

ARYMO ER T3 ST

ASTRAMORPH-PF T3

CONZIP T3

DEMEROL T3

2018

2

Drug Name Formulary Tiers Restrictions

DEMEROL (PF) T3

EMBEDA T3 ST

EXALGO ER T3 ST

INFUMORPH P/F T3

LAZANDA T3 PA

MORPHABOND ER T3 ST

NUCYNTA ER T3 ST

OPANA T3

XTAMPZA ER T3 ST

ZOHYDRO ER T3 ST

fentanyl citrate buccal lozenge on a handle 1,200 mcg, 600 mcg, 800 mcg

T4 PA

ABSTRAL SUBLINGUAL TABLET 800 MCG T4 PA

FENTORA T4 PA

SUBSYS T4 PA

ANALGESIC NARCOTIC CODEINE COMBINATIONS

acetaminophen-codeine T1

butalbital-acetaminop-caf-cod T1

ASCOMP WITH CODEINE T1

FIORINAL-CODEINE #3 T1

CAPITAL WITH CODEINE T3

ANALGESIC NARCOTIC DIHYDROCODEINE COMBINATIONS

aspirin-caffeine-dihydrocodein T1

TREZIX T3

ANALGESIC NARCOTIC DIHYDROCODEINE, NON-SALICYLATE ANALGESIC,XANTHINE

TREZIX T3

ANALGESIC NARCOTIC DIHYDROCODEINE, SALICYLATE ANALGESIC, XANTHINE COMB

aspirin-caffeine-dihydrocodein T1

ANALGESIC NARCOTIC FENTANYL COMBINATIONS

fentanyl (pf)-bupivacaine-nacl T1

ANALGESIC NARCOTIC HYDROCODONE AND NON-SALICYLATE COMBINATIONS

hydrocodone-acetaminophen T1

LORTAB ELIXIR T1

ANALGESIC NARCOTIC HYDROCODONE AND NSAID COMBINATIONS

hydrocodone-ibuprofen T1

ANALGESIC NARCOTIC HYDROCODONE COMBINATIONS

hydrocodone-acetaminophen T1

hydrocodone-ibuprofen T1

LORTAB ELIXIR T1

ANALGESIC NARCOTIC HYDROMORPHONE COMBINATIONS

hydromorphone-bupiv (pf)-nacl T1

ANALGESIC NARCOTIC OXYCODONE AND NON-SALICYLATE COMBINATIONS

oxycodone-acetaminophen T1

ENDOCET T1

2018

3

Drug Name Formulary Tiers Restrictions

ANALGESIC NARCOTIC OXYCODONE AND NSAID COMBINATIONS

ibuprofen-oxycodone T1

ANALGESIC NARCOTIC OXYCODONE AND SALICYLATE COMBINATIONS

oxycodone-aspirin T1

ANALGESIC NARCOTIC OXYCODONE COMBINATIONS

ibuprofen-oxycodone T1

oxycodone-acetaminophen T1

oxycodone-aspirin T1

ENDOCET T1

ANALGESIC NARCOTIC PARTIAL-MIXED AGONISTS

buprenorphine T1

buprenorphine hcl T1

butorphanol tartrate injection solution 1 mg/ml T1

butorphanol tartrate nasal T1

pentazocine-naloxone T1

BELBUCA T2 PA

butorphanol tartrate injection solution 2 mg/ml T3

nalbuphine T3

BUPRENEX T3

TALWIN T3

ANALGESIC NARCOTIC TRAMADOL AND NON-SALICYLATE COMBINATIONS

tramadol-acetaminophen T1

ANALGESIC NARCOTIC TRAMADOL COMBINATIONS

tramadol-acetaminophen T1

ANALGESIC OR ANTIPYRETIC NON-NARCOTIC

OFIRMEV T3

ANALGESIC OR ANTIPYRETIC NON-NARCOTIC/SEDATIVE COMBINATIONS

butalbital-acetaminophen T1

butalbital-acetaminophen-caff T1

FIORICET T1

ZEBUTAL T3

ANTI-INFLAMMATORY - INTERLEUKIN-1 BETA BLOCKERS

ILARIS (PF) T4 PA

ANTI-INFLAMMATORY - INTERLEUKIN-1 RECEPTOR ANTAGONIST

ARCALYST T4 PA

ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITING AGNTS,NON-SEIECTIVE

ENBREL T4

ENBREL SURECLICK T4

ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITING AGNTS,TNF-ALPHA SEL

CIMZIA T4 ST

CIMZIA POWDER FOR RECONST T4 ST

CIMZIA STARTER KIT T4 ST

HUMIRA T4

2018

4

Drug Name Formulary Tiers Restrictions

HUMIRA PEDIATRIC CROHN'S START T4

HUMIRA PEN T4

HUMIRA PEN CROHN'S-UC-HS START T4

HUMIRA PEN PSORIASIS-UVEITIS T4

REMICADE T4 ST

RENFLEXIS T4 PA

SIMPONI T4 ST

SIMPONI ARIA T4 ST

DMARD - ANTIMALARIALS

hydroxychloroquine T1

DMARD - ANTIMETABOLITES

methotrexate sodium T1

XATMEP T2 PA

OTREXUP (PF) T3

RASUVO (PF) T3 ST

TREXALL T3

DMARD - ANTINFLAMMATORY, SELECT. COSTIMULATION MODULATOR,T-CELL INHIB.

ORENCIA T4 ST

ORENCIA (WITH MALTOSE) T4 ST

ORENCIA CLICKJECT T4 ST

DMARD - B CELL TARGETED AGENTS

RITUXAN T4 PA

DMARD - GOLD COMPOUNDS

RIDAURA T2

DMARD - IMMUNOSUPPRESSIVES

azathioprine T1

cyclophosphamide intravenous recon soln 500 mg T1

cyclosporine T1

cyclosporine modified T1

mycophenolate mofetil T1

CELLCEPT T3

CELLCEPT INTRAVENOUS T3

cyclophosphamide intravenous recon soln 1 gram, 2 gram T4

cyclophosphamide oral T4

AZASAN T4

DMARD - INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA)

KINERET T4 ST

DMARD - INTERLEUKIN-6 (IL-6) RECEPTOR INHIBITORS, MONOCLONAL ANTIBODY

ACTEMRA T4 ST

KEVZARA T4 PA

DMARD - JANUS KINASE (JAK) INHIBITORS

XELJANZ T4 ST

XELJANZ XR T4 ST

DMARD - OTHER

minocycline T1

sulfasalazine T1

2018

5

Drug Name Formulary Tiers Restrictions

DEPEN TITRATABS T3

CUPRIMINE T4

DMARD - PHOSPHODIESTERASE-4 (PDE4) INHIBITORS

OTEZLA T4 ST

OTEZLA STARTER T4 ST

DMARD - PYRIMIDINE SYNTHESIS INHIBITORS

leflunomide T1

IMMUNOMODULATOR B-LYMPHOCYTE STIMULATOR (BLYS)-SPECIFIC INHIBITOR MCAB

BENLYSTA T4 PA

NSAID ANALGESIC AND PROSTAGLANDIN ANALOG COMBINATIONS

diclofenac-misoprostol T3

NSAID ANALGESIC AND TOPICAL IRRITANT COUNTER-IRRITANT COMBINATIONS

COMFORT PAC-IBUPROFEN T1

COMFORT PAC-MELOXICAM T3

COMFORT PAC-NAPROXEN T3

NSAID ANALGESIC, CYCLOOXYGENASE-2 (COX-2) SELECTIVE INHIBITORS

celecoxib T1

CELEBREX T3

NSAID ANALGESICS (COX NON-SPECIFIC) - ANTHRANILIC ACID DERIVATIVES

meclofenamate T1

mefenamic acid T3

NSAID ANALGESICS (COX NON-SPECIFIC) - OTHER

ketorolac T1

nabumetone T1

sulindac T1

tolmetin T1

NSAID ANALGESICS (COX NON-SPECIFIC) - OXICAM DERIVATIVES

meloxicam T1

piroxicam T1

NSAID ANALGESICS (COX NON-SPECIFIC) - PHENYLACETIC ACID DERIVATIVES

diclofenac potassium T3

diclofenac sodium T3

CAMBIA T3 PA

DYLOJECT T3

ZORVOLEX T3 ST

NSAID ANALGESICS (COX NON-SPECIFIC) - PROPIONIC ACID DERIVATIVES

fenoprofen T1

flurbiprofen T1

ibuprofen T1

ketoprofen T1

naproxen T1

naproxen sodium T1

oxaprozin T1

2018

6

Drug Name Formulary Tiers Restrictions

FENORTHO T1

CALDOLOR T3

NALFON T3

NAPRELAN CR T3

NSAID ANALGESICS, (COX NON-SPECIFIC) - INDOLE ACETIC ACID DERIVATIVES

etodolac T1

indomethacin T1

INDOCIN T3

TIVORBEX T3 ST

SALICYLATE ANALGESIC AND SEDATIVE COMBINATIONS

butalbital-aspirin-caffeine T1

SALICYLATE ANALGESIC COMBINATIONS

choline,magnesium salicylate T3

SALICYLATE ANALGESICS

diflunisal T1

salsalate T1

ANESTHETICS

GENERAL ANESTHETIC - INHALANT VOLATILE

isoflurane T1

sevoflurane T1

SUPRANE T3

GENERAL ANESTHETIC - PARENTERAL, ARYLCYCLOHEXYLAMINES

ketamine T1

ketamine in 0.9 % sod chloride T1

GENERAL ANESTHETIC - PARENTERAL, BARBITURATES

BREVITAL T3

GENERAL ANESTHETIC - PARENTERAL, BENZODIAZEPINES

midazolam injection solution 1 mg/ml T1

midazolam (pf) T3

midazolam injection solution 5 mg/ml T3

GENERAL ANESTHETIC - PARENTERAL, OTHERS

etomidate T1

AMIDATE T3

GENERAL ANESTHETIC - PARENTERAL, PHENOL DERIVATIVES

propofol T1

GENERAL ANESTHETIC ADJUNCTS - NARCOTIC

fentanyl citrate (pf) T1

sufentanil citrate T1

ULTIVA T3

GENERAL ANESTHETIC ADJUNCTS - NEUROLEPTIC, BUTYROPHENONE DERIVATIVE

droperidol T1

LOCAL ANESTHETIC - AMIDES

bupivacaine T1

bupivacaine (pf) T1

bupivacaine in nacl(pf) T1

2018

7

Drug Name Formulary Tiers Restrictions

bupivacaine-dextrose-water(pf) T1

lidocaine (pf) in d7.5w T1

lidocaine (pf) T1

lidocaine hcl T1

lidocaine hcl(pf) in 0.9% nacl T1

mepivacaine (pf) T1

ropivacaine (pf) T1

POLOCAINE-MPF INJECTION SOLUTION 10 MG/ML (1 %), 15 MG/ML (1.5 %)

T1

XYLOCAINE-MPF T1

lidocaine T3

CARBOCAINE T3

CARBOCAINE (PF) T3

CITANEST PLAIN DENTAL T3

EXPAREL (PF) T3

NAROPIN (PF) T3

POLOCAINE T3

POLOCAINE-MPF INJECTION SOLUTION 20 MG/ML (2 %) T3

LOCAL ANESTHETIC - ESTERS

tetracaine hcl (pf) T1

NESACAINE T3

LOCAL ANESTHETIC - SYMPATHOMIMETIC COMBINATIONS

bupivacaine-epinephrine T1

bupivacaine-epinephrine (pf) T1

lidocaine-epinephrine T1

lidocaine-epinephrine bit T1

SENSORCAINE-MPF/EPINEPHRINE T1

ARTICADENT DENTAL T3

XYLOCAINE-MPF/EPINEPHRINE T3

ANORECTAL PREPARATIONS

ANAL FISSURE PAIN/TREATMENT AGENTS - NITRATES

RECTIV T3

ANORECTAL - GLUCOCORTICOIDS

hydrocortisone acetate T1

ANUCORT-HC T1

PROCTO-PAK T1

PROCTOZONE-HC T1

PROCTOCORT T3

ANORECTAL - HEMORRHOIDAL RECTAL GLUCOCORTICOID-LOCAL ANESTHETIC COMB

hydrocortisone-pramoxine T1

lidocaine hcl-hydrocortison ac T1

lidocaine-hydrocortisone-aloe T1

PROCTOFOAM HC T2

ANA-LEX KIT T3

PROCORT T3

ZYPRAM T3

2018

8

Drug Name Formulary Tiers Restrictions

ANTIDOTES AND OTHER REVERSAL AGENTS

ANTIDOTE - ACETAMINOPHEN POISONING

acetylcysteine T1

acetylcysteine (bulk) T1

ANTIDOTE - ALCOHOL DEHYDROGENASE ENZYME INHIBITOR

fomepizole T1

ANTIDOTE - ANTICHOLINESTERASE AGENTS

physostigmine salicylate T1

ANTIDOTE - ANTICHOLINESTERASE AND MUSCARINIC ANTAGONIST COMBINATIONS

ENLON-PLUS T3

ANTIDOTE - CHOLINESTERASE REACTIVATING AGENT

pralidoxime T1

PROTOPAM CHLORIDE T3

ANTIDOTE - CHOLINESTERASE REACTIVATING AGENT AND MUSCARINIC ANTAGONIST

DUODOTE T3

ANTIDOTE - CYANIDE POISONING

sodium nitrite T1

sodium thiosulfate T1

CYANOKIT T3

NITHIODOTE T3

ANTIDOTE - DIGITALIS GLYCOSIDE TOXICITY AGENTS

DIGIFAB T3

ANTIDOTE - METHEMOGLOBINEMIA

methylene blue (antidote) T1

ANTIDOTE OTHERS

GALZIN T3

BENZODIAZEPINE REVERSAL AGENTS - BENZODIAZEPINE ANTAGONISTS

flumazenil T1

CHELATING AGENTS - COPPER

DEPEN TITRATABS T3

CUPRIMINE T4 PA

SYPRINE T4

CHELATING AGENTS - IRON

deferoxamine T1

JADENU SPRINKLE T3 PA

EXJADE T4 PA

FERRIPROX T4 PA

JADENU T4 PA

CHELATING AGENTS - LEAD POISONING

CHEMET T2

BAL IN OIL T3

CHELATING AGENTS - OTHERS

betadex (bulk) T1

BAL IN OIL T3

CA-DTPA T3

2018

9

Drug Name Formulary Tiers Restrictions

ZN-DTPA T3

EMETICS

ipecac T1

MU-OPIOID RECEPTOR ANTAGONISTS, PERIPHERALLY-ACTING

MOVANTIK T2

ENTEREG T3

RELISTOR T3 PA

OPIATE/NARCOTIC REVERSAL AGENTS - OPIATE ANTAGONISTS

naloxone T1

naltrexone T1

NARCAN T2

REVERSAL AGENTS - HEPARIN ANTAGONISTS

protamine T1

ANTI-INFECTIVE AGENTS

AMEBICIDES

paromomycin T1

AMINOGLYCOSIDE ANTIBIOTIC

amikacin T1

gentamicin T1

gentamicin (bulk) T1

gentamicin in nacl (iso-osm) T1

gentamicin sulfate (ped) (pf) T1

gentamicin sulfate (pf) T1

neomycin T1

streptomycin T1

tobramycin in 0.9 % nacl T1

tobramycin sulfate T1

AMINOPENICILLIN ANTIBIOTIC

amoxicillin T1

ampicillin T1

ampicillin sodium T1

MOXATAG T3

AMINOPENICILLIN ANTIBIOTIC - BETA-LACTAMASE INHIBITOR COMBINATIONS

amoxicillin-pot clavulanate T1

ampicillin-sulbactam T1

AUGMENTIN T2

ANTHELMINTIC AGENTS - BENZIMIDAZOLE DERIVATIVES

ALBENZA T2

ANTHELMINTIC AGENTS OTHER

ivermectin T1

BILTRICIDE T2

STROMECTOL T3

ANTIBACTERIAL FOLATE ANTAGONIST - OTHER COMBINATIONS

sulfamethoxazole-trimethoprim T1

2018

10

Drug Name Formulary Tiers Restrictions

ANTIBACTERIAL FOLATE ANTAGONIST OTHERS

trimethoprim T1

PRIMSOL T3

ANTIFUNGAL - ALLYLAMINES

terbinafine hcl T1

ANTIFUNGAL - AMPHOTERIC POLYENE MACROLIDES

amphotericin b T1

nystatin T1

ABELCET T3

AMBISOME T3

ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)

caspofungin T1

CANCIDAS T3

ERAXIS(WATER DILUENT) T3

MYCAMINE T3

ANTIFUNGAL - IMIDAZOLES

ketoconazole T1

ORAVIG T3

ANTIFUNGAL - TRIAZOLES

fluconazole T1

fluconazole in dextrose(iso-o) T1

fluconazole in nacl (iso-osm) T1

voriconazole intravenous T1

voriconazole oral suspension for reconstitution T1

CRESEMBA T2 PA

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) T2

itraconazole T3

voriconazole oral tablet T3

NOXAFIL INTRAVENOUS T3

NOXAFIL ORAL SUSPENSION T3

ONMEL T3

SPORANOX T3 PA

SPORANOX PULSEPAK T3 PA

VFEND T3

ANTIFUNGAL OTHER

flucytosine T1

griseofulvin microsize oral suspension T1

griseofulvin microsize oral tablet T3

griseofulvin ultramicrosize T3

ANTI-INFECTIVE IMMUNOLOGIC ADJUVANTS - INTERFERONS

ACTIMMUNE T4 PA

ANTILEPROTIC - IMMUNOMODULATORS

THALOMID T4 PA

ANTILEPROTIC - SULFONE AGENTS

dapsone T1

2018

11

Drug Name Formulary Tiers Restrictions

ANTIMALARIAL COMBINATIONS

atovaquone-proguanil T1

COARTEM T2

ANTIMALARIALS

chloroquine phosphate T1

hydroxychloroquine T1

mefloquine T1

primaquine T1

quinine sulfate T1

ANTIPROTOZOAL AGENTS - OTHER

ALINIA T2 PA

MEPRON T3

IMPAVIDO T4 PA

ANTIPROTOZOAL-ANTIBACTERIAL 1ST GENERATION 2-METHYL-5-NITROIMIDAZOLE

metronidazole T1

metronidazole (bulk) T1

metronidazole in nacl (iso-os) T1

FLAGYL T3

ANTIPROTOZOAL-ANTIBACTERIAL 2ND GENERATION 2-METHYL-5-NITROIMIDAZOLE

tinidazole T1

TINDAMAX T2

ANTIRETROVIRAL - CCR5 CO-RECEPTOR ANTAGONIST

SELZENTRY T2

ANTIRETROVIRAL - HIV-1 FUSION INHIBITORS

FUZEON T4

ANTIRETROVIRAL - HIV-1 INTEGRASE STRAND TRANSFER INHIBITORS

ISENTRESS T2

ISENTRESS HD T2

TIVICAY ORAL TABLET 10 MG, 25 MG T2

TIVICAY ORAL TABLET 50 MG T4

ANTIRETROVIRAL - NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIB (NNRTI)

nevirapine oral suspension T1

nevirapine oral tablet T1

SUSTIVA T2

nevirapine oral tablet extended release 24 hr T3

EDURANT T3

INTELENCE T3

VIRAMUNE T3

VIRAMUNE XR T3

RESCRIPTOR T4

ANTIRETROVIRAL - NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)

abacavir oral solution T1

didanosine T1

lamivudine oral solution T1

2018

12

Drug Name Formulary Tiers Restrictions

stavudine T1

zidovudine T1

abacavir oral tablet T3

lamivudine oral tablet T3

EMTRIVA T3

EPIVIR T3

RETROVIR T3

ZIAGEN T3

VIDEX 2 GRAM PEDIATRIC T4

VIDEX 4 GRAM PEDIATRIC T4

ANTIRETROVIRAL - NUCLEOTIDE ANALOG REVERSE TRANSCRIPTASE INHIBITORS

VIREAD ORAL POWDER T3

VIREAD ORAL TABLET T4

ANTIRETROVIRAL COMBINATIONS - NRTI'S

lamivudine-zidovudine T3

abacavir-lamivudine T4

abacavir-lamivudine-zidovudine T4

EPZICOM T4

TRIZIVIR T4

ANTIRETROVIRAL COMBINATIONS - NUCLEOSIDE AND NUCLEOTIDE ANALOG RTIS

DESCOVY T4

TRUVADA T4

ANTIRETROVIRAL COMBINATIONS - PROTEASE INHIBITORS

EVOTAZ T4

KALETRA T4

PREZCOBIX T4

ANTIRETROVIRAL COMBINATIONS-NUCLEOSIDE ANALOGS AND INTEGRASE INHIBITOR

TRIUMEQ T4

ANTIRETROVIRAL- NUCLEOSIDE AND NUCLEOTIDE ANALOGS,INTEGRASE INHIBITORS

GENVOYA T4

STRIBILD T4

ANTIRETROVIRAL-NUCLEOSIDE, NUCLEOTIDE ANALOGS AND NON-NUCLEOSIDE RTI

COMPLERA T3

ATRIPLA T4

ODEFSEY T4

ANTITUBERCULAR - AMINOBENZOIC ACID ANALOGS

PASER T3

ANTITUBERCULAR - CYCLIC PEPTIDE ANTIBIOTICS

CAPASTAT T3

ANTITUBERCULAR - D-ALANINE ANALOGS

cycloserine T1

ANTITUBERCULAR - DIARYLQUINOLINE ANTIBIOTICS

SIRTURO T4 PA

ANTITUBERCULAR - ISONICOTINIC ACID DERIVATIVES

isoniazid T1

2018

13

Drug Name Formulary Tiers Restrictions

ANTITUBERCULAR - NIACINAMIDE DERIVATIVES

pyrazinamide T1

ANTITUBERCULAR - RIFAMYCIN AND DERIVATIVES

rifabutin T1

rifampin oral T1

rifampin intravenous T3

MYCOBUTIN T3

PRIFTIN T3

ANTITUBERCULAR AGENTS OTHER

ethambutol T1

TRECATOR T3

ANTITUBERCULAR COMBINATIONS

RIFAMATE T3

RIFATER T3

CARBAPENEM ANTIBIOTIC COMBINATIONS

imipenem-cilastatin T3

PRIMAXIN IV T3

CARBAPENEM ANTIBIOTICS (THIENAMYCINS)

doripenem T1

meropenem T1

meropenem-0.9% sodium chloride T1

INVANZ T3

CEPHALOSPORIN ANTIBIOTIC AND BETA-LACTAMASE INHIBITOR COMBINATIONS

ZERBAXA T3 PA

AVYCAZ T4

CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION

cefadroxil T1

cefazolin T1

cefazolin in dextrose (iso-os) T1

cefazolin in sterile water T1

cephalexin T1

CEPHALOSPORIN ANTIBIOTICS - 2ND GENERATION

cefaclor oral suspension for reconstitution T1

cefaclor oral tablet extended release 12 hr T1

cefotetan T1

cefotetan in dextrose, iso-osm T1

cefoxitin T1

cefoxitin in dextrose, iso-osm T1

cefprozil T1

cefuroxime axetil T1

cefuroxime sodium T1

cefaclor oral capsule T3

MEFOXIN IN DEXTROSE (ISO-OSM) T3

ZINACEF T3

ZINACEF IN STERILE WATER T3

CEPHALOSPORIN ANTIBIOTICS - 3RD GENERATION

cefdinir T1

2018

14

Drug Name Formulary Tiers Restrictions

cefditoren pivoxil T1

cefotaxime T1

cefpodoxime T1

ceftazidime T1

ceftazidime in d5w T1

ceftriaxone T1

ceftriaxone in dextrose,iso-os T1

TAZICEF T1

cefixime T3

CEDAX T3

CLAFORAN T3

FORTAZ T3

FORTAZ IN DEXTROSE 5 % T3

SPECTRACEF T3

SUPRAX T3

CEPHALOSPORIN ANTIBIOTICS - 4TH GENERATION

cefepime T1

cefepime in dextrose 5 % T1

cefepime in dextrose,iso-osm T1

MAXIPIME T3

CEPHALOSPORIN ANTIBIOTICS - 5TH GENERATION

TEFLARO T3

CHLORAMPHENICOL ANTIBIOTICS AND DERIVATIVES - SINGLE AGENTS

chloramphenicol sod succinate T1

CMV ANTIVIRAL AGENT - INORGANIC PYROPHOSPHATE ANALOGS

foscarnet T4

CMV ANTIVIRAL AGENT - NUCLEOSIDE ANALOGS

valganciclovir T1 PA

ganciclovir sodium T4

CMV ANTIVIRAL AGENT - NUCLEOTIDE ANALOGS

cidofovir T1

CYCLIC LIPOPEPTIDE ANTIBIOTICS

daptomycin T4

FLUOROQUINOLONE ANTIBIOTICS

ciprofloxacin T1

ciprofloxacin hcl T1

ciprofloxacin in 5 % dextrose T1

ciprofloxacin lactate T1

levofloxacin in d5w T1

levofloxacin oral tablet T1

moxifloxacin T1

ofloxacin T1

CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 250 MG/5 ML

T1

moxifloxacin hcl (bulk) T2

CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 500 MG/5 ML

T2

2018

15

Drug Name Formulary Tiers Restrictions

levofloxacin intravenous T3

levofloxacin oral solution T3

moxifloxacin-sod.ace,sul-water T3

AVELOX T3

AVELOX IN NACL (ISO-OSMOTIC) T3

BAXDELA T3 PA

GLYCOPEPTIDE ANTIBIOTICS

vancomycin T1

vancomycin in 0.9% sodium cl T1

vancomycin in dextrose 5 % T1

GLYCYLCYCLINE ANTIBIOTICS

TYGACIL T3

HEPATITIS B TREATMENT- NUCLEOSIDE ANALOGS (ANTIVIRAL)

entecavir T1

BARACLUDE ORAL TABLET T2

EPIVIR HBV T3

BARACLUDE ORAL SOLUTION T4

HEPATITIS B TREATMENT- NUCLEOTIDE ANALOGS (ANTIVIRAL)

adefovir T1

HEPSERA T4

HEPATITIS C - INTERFERONS

PEGASYS T4 PA

PEGASYS PROCLICK T4 PA

PEGINTRON T4 PA

HEPATITIS C - NS5A INHIBITOR AND NS3/4A PROTEASE INHIBITOR COMBINATION

MAVYRET T4 PA

HEPATITIS C - NS5A, NS3/4A PROTEASE, NUCLEO.NS5B POLYMERASE INHIB COMB

VOSEVI T4 PA

HEPATITIS C - NS5B POLYMERASE AND NS5A INHIBITOR COMBINATIONS

EPCLUSA T4 PA

HEPATITIS C - NUCLEOS(T)IDE ANALOG NS5B POLYMERASE INHIBITORS

SOVALDI T4 PA

HEPATITIS C - NUCLEOSIDE ANALOGS

ribavirin oral tablet T3

MODERIBA T3

RIBASPHERE T3

ribavirin oral capsule T4

REBETOL T4

RIBASPHERE RIBAPAK T4

HERPES ANTIVIRAL AGENT - PURINE ANALOGS

acyclovir oral capsule T1

acyclovir oral tablet T1

acyclovir sodium intravenous recon soln 500 mg T1

valacyclovir T1

2018

16

Drug Name Formulary Tiers Restrictions

acyclovir oral suspension T3

acyclovir sodium intravenous recon soln 1,000 mg T3

acyclovir sodium intravenous solution T3

SITAVIG T3

HERPES ANTIVIRAL AGENT - THYMIDINE ANALOGS

famciclovir T1

INFLUENZA ANTIVIRAL AGENTS - NEURAMINIDASE INHIBITORS

oseltamivir T1

RELENZA DISKHALER T3

TAMIFLU T3

INFLUENZA-A ANTIVIRAL AGENTS

rimantadine T1

LINCOSAMIDE ANTIBIOTICS

clindamycin hcl T1

clindamycin in 5 % dextrose T1

clindamycin palmitate hcl T1

clindamycin phosphate T1

CLIN SINGLE USE T3

LINCOCIN T3

LIPOGLYCOPEPTIDE ANTIBIOTICS

DALVANCE T2 PA

ORBACTIV T2 PA

MACROLIDES

azithromycin T1

clarithromycin T1

erythromycin ethylsuccinate oral tablet T1

erythromycin oral tablet T1

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG

T1

erythromycin ethylsuccinate oral suspension for reconstitution T3

erythromycin oral capsule,delayed release(dr/ec) T3

ERYPED 400 T3

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 250 MG, 500 MG

T3

ERYTHROCIN T3

ERYTHROCIN (AS STEARATE) T3

PCE T3

ZMAX T3

DIFICID T4 PA

MISC ANTI-INFECTIVE

NEBUPENT T2

PENTAM T3

MONOBACTAM ANTIBIOTICS

aztreonam injection recon soln 2 gram T1

aztreonam injection recon soln 1 gram T3

AZACTAM IN DEXTROSE (ISO-OSM) T3

2018

17

Drug Name Formulary Tiers Restrictions

OXAZOLIDINONE ANTIBIOTICS

linezolid oral T1

linezolid intravenous T3

linezolid-0.9% sodium chloride T3

ZYVOX T3

SIVEXTRO T4 PA

PENICILLIN ANTIBIOTIC - NATURAL

penicillin g pot in dextrose T1

penicillin g potassium T1

penicillin g procaine T1

penicillin g sodium T1

penicillin v potassium T1

BICILLIN L-A T3

PENICILLIN ANTIBIOTIC - PENICILLINASE-RESISTANT

dicloxacillin T1

nafcillin in dextrose iso-osm T1

nafcillin injection recon soln 10 gram, 2 gram T1

nafcillin intravenous T1

oxacillin in dextrose(iso-osm) T1

oxacillin injection recon soln 1 gram, 10 gram T1

oxacillin intravenous recon soln 1 gram T1

nafcillin injection recon soln 1 gram T3

oxacillin injection recon soln 2 gram T3

oxacillin intravenous recon soln 2 gram T3

PENICILLIN ANTIBIOTIC, EXTENDED-SPECTRUM AND BETA-LACTAMASE INHIB COMB

piperacillin-tazobactam T1

ZOSYN IN DEXTROSE (ISO-OSM) T3

PENICILLIN NATURAL ANTIBIOTIC COMBINATIONS - EXTENDED RELEASE

BICILLIN C-R T3

POLYMYXINS AND DERIVATIVES - SINGLE AGENTS

bacitracin T1

polymyxin b sulfate T1

colistin (colistimethate na) T3

PROTEASE INHIBITORS (NON-PEPTIDIC) ANTIRETROVIRAL

PREZISTA ORAL SUSPENSION T2

PREZISTA ORAL TABLET 150 MG, 75 MG, 800 MG T2

APTIVUS T3

PREZISTA ORAL TABLET 600 MG T4

PROTEASE INHIBITORS (PEPTIDIC) ANTIRETROVIRAL

fosamprenavir T1

NORVIR T2

REYATAZ ORAL CAPSULE 150 MG, 300 MG T2

REYATAZ ORAL POWDER IN PACKET T2

INVIRASE T3

LEXIVA T3

CRIXIVAN T4

2018

18

Drug Name Formulary Tiers Restrictions

REYATAZ ORAL CAPSULE 200 MG T4

VIRACEPT T4

RIFAMYCINS AND RELATED DERIVATIVE ANTIBIOTICS

rifabutin T1

rifampin oral T1

XIFAXAN T2 PA

rifampin intravenous T3

MYCOBUTIN T3

PRIFTIN T3

STREPTOGRAMIN ANTIBIOTICS

SYNERCID T3

SULFONAMIDE ANTIBIOTIC

sulfadiazine T1

TETRACYCLINE AND TETRACYCLINE ANTIBIOTIC COMBINATIONS

AVIDOXY DK T3

TETRACYCLINE ANTIBIOTICS

demeclocycline T1

doxycycline hyclate oral capsule T1

doxycycline hyclate oral tablet T1

doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg

T1

doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg T1

doxycycline monohydrate oral capsule,ir - delay rel,biphase T1

doxycycline monohydrate oral suspension for reconstitution T1

doxycycline monohydrate oral tablet T1

minocycline T1

doxycycline hyclate oral tablet,delayed release (dr/ec) 200 mg, 50 mg

T3 PA

doxycycline monohydrate oral capsule 150 mg T3

tetracycline T3

DORYX MPC T3 ST

MINOCIN T3

MONODOX T3

MORGIDOX T3 ST

MORGIDOX 1X100 T3 ST

MORGIDOX 2X100 T3 ST

ORACEA T3 ST

VIBRAMYCIN T3

ANTINEOPLASTICS

ANP - HUMAN VASCULAR ENDOTHELIAL GROWTH FACTOR INHIB REC-MC ANTIBODY

AVASTIN T4 PA

ANP-PLATELET-DERIVED GROWTH FACTOR RECEPTOR (PDGFR) ALPHA BLOCKER MC

LARTRUVO T4 PA

ANTINEOPLASIC-EPIDERM.GROWTH FACTOR-EGFR (ERBB1),HER-2 (ERBB2)R.INHIB

TYKERB T4 PA

2018

19

Drug Name Formulary Tiers Restrictions

ANTINEOPLASTIC - CYP17 (17 ALPHA-HYDROXYLASE/C17,20-LYASE) INHIBITOR

ZYTIGA T4 PA

ANTINEOPLASTIC - 1ST GENERATION EGFR TYROSINE KINASE INHIBITOR

TARCEVA T4 PA

ANTINEOPLASTIC - 2ND GENERATION EGFR TYROSINE KINASE INHIBITOR

GILOTRIF T4 PA

NERLYNX T4 PA

ANTINEOPLASTIC - 3RD GENERATION EGFR TYROSINE KINASE INHIBITOR

TAGRISSO T4 PA

ANTINEOPLASTIC - ALKYLATING AGENT - ALKYL SULFONATES

MYLERAN T2

busulfan T4 PA

ANTINEOPLASTIC - ALKYLATING AGENT - ETHYLENIMINES AND METHYLMELAMINES

thiotepa T4 PA

HEXALEN T4

TEPADINA T4 PA

ANTINEOPLASTIC - ALKYLATING AGENT - METHYLHYDRAZINES

MATULANE T4

ANTINEOPLASTIC - ALKYLATING AGENT - NITROGEN MUSTARD WITH RESCUE AGENT

ifosfamide-mesna T4

ANTINEOPLASTIC - ALKYLATING AGENT - NITROGEN MUSTARDS

cyclophosphamide intravenous recon soln 500 mg T1

melphalan T1

LEUKERAN T2

ifosfamide intravenous recon soln 1 gram T3

ALKERAN T3

cyclophosphamide intravenous recon soln 1 gram, 2 gram T4

cyclophosphamide oral T4

ifosfamide intravenous recon soln 3 gram T4

ifosfamide intravenous solution T4

melphalan hcl T4

MUSTARGEN T4

ANTINEOPLASTIC - ALKYLATING AGENT - NITROSOUREAS

GLIADEL WAFER T3

BICNU T4

ANTINEOPLASTIC - ALKYLATING AGENT - OTHER

BENDEKA T4 PA

TREANDA T4 PA

ANTINEOPLASTIC - ALKYLATING AGENT - TETRAHYDROISOQUINOLINES

YONDELIS T4

ANTINEOPLASTIC - ALKYLATING AGENT - TRIAZENES

dacarbazine T4

2018

20

Drug Name Formulary Tiers Restrictions

temozolomide T4

TEMODAR T4 PA

ANTINEOPLASTIC - ANAPLASTIC LYMPHOMA KINASE (ALK) INHIBITORS

ALECENSA T4 PA

ALUNBRIG T4 PA

ANTINEOPLASTIC - ANTIADRENALS

LYSODREN T2

ANTINEOPLASTIC - ANTIANDROGENS

bicalutamide T1

flutamide T1

NILANDRON T4

XTANDI T4 PA

ZYTIGA T4 PA

ANTINEOPLASTIC - ANTIBIOTIC AND ANTIMETABOLITE COMBINATIONS

VYXEOS T4 PA

ANTINEOPLASTIC - ANTIBODY-DRUG CONJUGATES (ADCS)

ADCETRIS T4 PA

BESPONSA T4 PA

KADCYLA T4 PA

ANTINEOPLASTIC - ANTI-GD2 GANGLIOSIDE MONOCLONAL ANTIBODY

UNITUXIN T4 PA

ANTINEOPLASTIC - ANTIMETABOLITE - FOLIC ACID ANALOGS

methotrexate sodium T1

methotrexate sodium (pf) T1

XATMEP T2 PA

TREXALL T3

ALIMTA T4 PA

FOLOTYN T4 PA

ANTINEOPLASTIC - ANTIMETABOLITE - PURINE ANALOGS

mercaptopurine T1

fludarabine intravenous recon soln T3

cladribine T4

clofarabine T4 PA

fludarabine intravenous solution T4

ARRANON T4

CLOLAR T4

PURIXAN T4

TABLOID T4

ANTINEOPLASTIC - ANTIMETABOLITE - PYRIMIDINE ANALOGS

capecitabine T1

cytarabine T1

cytarabine (pf) T1

gemcitabine intravenous recon soln 2 gram, 200 mg T1

gemcitabine intravenous solution T1

2018

21

Drug Name Formulary Tiers Restrictions

fluorouracil (bulk) T3

gemcitabine intravenous recon soln 1 gram T3

decitabine T4

floxuridine T4

fluorouracil T4

VIDAZA T4

XELODA T4 PA

ANTINEOPLASTIC - ANTIMETABOLITE - UREA DERIVATIVES

hydroxyurea T1

ANTINEOPLASTIC - ANTIMETABOLITES - PYRIMIDINE ANALOG COMBINATIONS

LONSURF T4 PA

ANTINEOPLASTIC - ANTI-SLAMF7 MONOCLONAL ANTIBODY AGENTS

EMPLICITI T4 PA

ANTINEOPLASTIC - AROMATASE INHIBITORS

anastrozole T1

letrozole T1

exemestane T3

ANTINEOPLASTIC - ARSENIC COMPOUNDS

TRISENOX T4

ANTINEOPLASTIC - ASPARAGINASE ENZYME THERAPY AGENTS

ERWINAZE T4 PA

ANTINEOPLASTIC - B-CELL LYMPHOMA-2 (BCL-2) INHIBITORS

VENCLEXTA T4 PA

VENCLEXTA STARTING PACK T4 PA

ANTINEOPLASTIC - BRAF KINASE INHIBITORS

TAFINLAR T4 PA

ZELBORAF T4 PA

ANTINEOPLASTIC - BRUTON'S TYROSINE KINASE (BTK) INHIBITOR

IMBRUVICA T4 PA

ANTINEOPLASTIC - CD20 SPECIFIC RECOMBINANT MONOCLONAL ANTIBODY AGENTS

ARZERRA T4 PA

GAZYVA T4 PA

RITUXAN T4 PA

RITUXAN HYCELA T4 PA

ANTINEOPLASTIC - CD38 SPECIFIC RECOMBINANT MONOCLONAL ANTIBODY AGENTS

DARZALEX T4 PA

ANTINEOPLASTIC - CYCLIN-DEPENDENT KINASE (CDK) 4/6 INHIBITORS

IBRANCE T4 PA

KISQALI T4 PA

ANTINEOPLASTIC - CYTOTOXIC T-LYMPHOCYTE ANTIGEN (CTLA-4),R-MC ANTIBODY

YERVOY T4 PA

2018

22

Drug Name Formulary Tiers Restrictions

ANTINEOPLASTIC - EPIPODOPHYLLOTOXINS

etoposide T4

teniposide T4

ETOPOPHOS T4

ANTINEOPLASTIC - EPOTHILONES AND ANALOGS

IXEMPRA T4 PA

ANTINEOPLASTIC - ESTROGEN RECEPTOR ANTAGONIST

FASLODEX T4

ANTINEOPLASTIC - ESTROGENS

EMCYT T4

ANTINEOPLASTIC - HALICHONDRIN B ANALOGS, MICROTUBULE INHIBITORS

HALAVEN T4 PA

ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITOR

ERIVEDGE T4 PA

ODOMZO T4 PA

ANTINEOPLASTIC - HISTONE DEACETYLASE (HDAC) INHIBITORS

BELEODAQ T4 PA

FARYDAK T4 PA

ISTODAX T4 PA

ZOLINZA T4 PA

ANTINEOPLASTIC - IMMUNOTHERAPY, THERAPEUTIC VACCINES

PROVENGE T4 PA

ANTINEOPLASTIC - IMMUNOTHERAPY, VIRUS-BASED

IMLYGIC T4

ANTINEOPLASTIC - INTERFERONS

INTRON A T4

SYLATRON T4 PA

ANTINEOPLASTIC - INTERLEUKIN-6 (IL-6) INHIBITORS, MONOCLONAL ANTIBODY

SYLVANT T4 PA

ANTINEOPLASTIC - INTERLEUKINS

PROLEUKIN T4

ANTINEOPLASTIC - JANUS KINASE (JAK) INHIBITORS

JAKAFI T4 PA

ANTINEOPLASTIC - KINASE INHIBITOR AND AROMATASE INHIBITOR COMBINATION

KISQALI FEMARA CO-PACK T4 PA

ANTINEOPLASTIC - LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS

leuprolide T4

ELIGARD T4

ELIGARD (3 MONTH) T4

ELIGARD (4 MONTH) T4

ELIGARD (6 MONTH) T4

LUPRON DEPOT T4

LUPRON DEPOT (3 MONTH) T4

LUPRON DEPOT (4 MONTH) T4

2018

23

Drug Name Formulary Tiers Restrictions

LUPRON DEPOT (6 MONTH) T4

TRELSTAR T4

ZOLADEX T4

ANTINEOPLASTIC - LHRH (GNRH) ANTAGONIST PITUITARY SUPPRESSANTS

FIRMAGON KIT W DILUENT SYRINGE T4

ANTINEOPLASTIC - MAST CELL STABILIZERS

cromolyn T3

ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORS

COTELLIC T4 PA

ANTINEOPLASTIC - MONOCLONAL ANTIBODIES FOR RADIOPHARMACEUTICAL THERAPY

ZEVALIN (Y-90) T4 PA

ANTINEOPLASTIC - MTOR KINASE INHIBITORS

AFINITOR T4 PA

AFINITOR DISPERZ T4 PA

TORISEL T4 PA

ANTINEOPLASTIC - MULTIKINASE INHIBITORS

CABOMETYX T4 PA

COMETRIQ T4 PA

ICLUSIG T4 PA

NEXAVAR T4 PA

STIVARGA T4 PA

ANTINEOPLASTIC - MUTANT ISOCITRATE DEHYDROGENASE 2 (MIDH2) INHIBITORS

IDHIFA T4 PA

ANTINEOPLASTIC - OTHER

TICE BCG T2

ANTINEOPLASTIC - PAN-CLASS I PI3K INHIBITORS

ALIQOPA T4 PA

ANTINEOPLASTIC - PHOTOSENSITIZERS

UVADEX T3

PHOTOFRIN T4 PA

ANTINEOPLASTIC - PI3K-DELTA INHIBITORS

ZYDELIG T4 PA

ANTINEOPLASTIC - PLATINUM COMPLEXES

oxaliplatin intravenous solution 100 mg/20 ml T3

carboplatin T4

cisplatin T4

oxaliplatin intravenous recon soln T4

oxaliplatin intravenous solution 50 mg/10 ml (5 mg/ml) T4

ANTINEOPLASTIC - POLY (ADP-RIBOSE) POLYMERASE (PARP) INHIBITORS

LYNPARZA T4 PA

RUBRACA T4 PA

ZEJULA T4 PA

ANTINEOPLASTIC - PROGESTINS

megestrol T1

DEPO-PROVERA T4

2018

24

Drug Name Formulary Tiers Restrictions

ANTINEOPLASTIC - PROTEASOME ENZYME INHIBITORS

KYPROLIS T4 PA

NINLARO T4 PA

VELCADE T4 PA

ANTINEOPLASTIC - PROTEIN-TYROSINE KINASE INHIBITORS

BOSULIF T4 PA

CAPRELSA T4 PA

GLEEVEC T4 PA

IMBRUVICA T4 PA

INLYTA T4 PA

LENVIMA T4 PA

OFEV T4 PA

RYDAPT T4 PA

SPRYCEL T4 PA

SUTENT T4 PA

TASIGNA T4 PA

VOTRIENT T4 PA

ANTINEOPLASTIC - RADIOPHARMACEUTICALS

METASTRON T3

HICON T4

XOFIGO T4 PA

ANTINEOPLASTIC - RETINOIDS

tretinoin (chemotherapy) T1

ANTINEOPLASTIC - SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)

tamoxifen T1

FARESTON T3

SOLTAMOX T3

ANTINEOPLASTIC - SELECTIVE RETINOID X RECEPTOR AGONISTS

bexarotene T4 PA

TARGRETIN T4 PA

ANTINEOPLASTIC - TAXANES

DOCEFREZ T3

docetaxel T4

paclitaxel T4

ABRAXANE T4

JEVTANA T4 PA

ANTINEOPLASTIC - THALIDOMIDE ANALOGS

POMALYST T4 PA

REVLIMID T4 PA

THALOMID T4 PA

ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS

irinotecan T1

topotecan T4

CAMPTOSAR T4

HYCAMTIN T4

ONIVYDE T4 PA

2018

25

Drug Name Formulary Tiers Restrictions

ANTINEOPLASTIC - VASC ENDOTHELIAL GROWTH FACTOR RECEPTOR (VEGFR) ANTAG

CYRAMZA T4 PA

ANTINEOPLASTIC - VINCA ALKALOIDS AND ANALOGS

vinorelbine T1

vinblastine T4

vincristine T4

MARQIBO T4

ANTINEOPLASTIC ANTIBIOTIC - ANTHRACYCLINES

daunorubicin T3

doxorubicin T4

doxorubicin, peg-liposomal T4

epirubicin T4

idarubicin T4

mitoxantrone T4

VALSTAR T4

ANTINEOPLASTIC ANTIBIOTIC - OTHERS

bleomycin T4

mitomycin T4

ZANOSAR T4 PA

ANTINEOPLASTIC -CEPHALOTAXINES

SYNRIBO T4 PA

ANTINEOPLASTIC-ANTI-PROGRAMMED CELL DEATH LIGAND-1 (PD-L1) MC ANTIB.

BAVENCIO T4 PA

TECENTRIQ T4 PA

ANTINEOPLASTIC-ANTI-PROGRAMMED CELL DEATH RECEPTOR-1 (PD-1) MC ANTIB.

KEYTRUDA T4 PA

OPDIVO T4 PA

ANTINEOPLASTIC-CD22 SPECIFIC ANTIBODY / CYTOTOXIC ANTIBIOTIC CONJUGATE

BESPONSA T4 PA

ANTINEOPLASTIC-CD30 DIRECTED ANTIBODY-MICROTUBULE DISRUPTING CONJUGATE

ADCETRIS T4 PA

ANTINEOPLASTIC-HER2 TARGETED ANTIBODY-MICROTUBULE INHIBITOR CONJUGATE

KADCYLA INTRAVENOUS RECON SOLN 100 MG T4

KADCYLA INTRAVENOUS RECON SOLN 160 MG T4 PA

ANTINEOPLASTIC-VASC ENDOTHELIAL GROWTH FAC(VEGF-A,B AND PLGF)INHIBITOR

ZALTRAP T4 PA

BISPECIFIC CD19-DIRECTED CD3 T-CELL ENGAGER, MONOCLONAL ANTIBODY

BLINCYTO T4 PA

CARDIAC PROTECTIVE AGENTS USED IN CONJUNCTION WITH CHEMOTHERAPY

dexrazoxane hcl T1

EPIDERMAL GROWTH FACTOR RECEPT (HER-2) SUBDOMAIN II BLOCKER, REC-MC AB

PERJETA T4 PA

2018

26

Drug Name Formulary Tiers Restrictions

EPIDERMAL GROWTH FACTOR RECEPT BLOCKER (HER-1 TYPE), REC-MC ANTIBODY

ERBITUX T4 PA

PORTRAZZA T4 PA

VECTIBIX T4 PA

EPIDERMAL GROWTH FACTOR RECEPT BLOCKER (HER-2 TYPE), REC-MC ANTIBODY

HERCEPTIN T4

METHOTREXATE RESCUE AGENTS

leucovorin calcium injection recon soln 50 mg, 500 mg T1

leucovorin calcium oral T1

leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg T3

FUSILEV T3

VORAXAZE T4

METHOTREXATE RESCUE AGENTS - CARBOXYPEPTIDASE G2 TYPE

VORAXAZE T4

METHOTREXATE RESCUE AGENTS - FOLIC ACID ANTAGONIST TYPE

leucovorin calcium injection recon soln 50 mg, 500 mg T1

leucovorin calcium oral T1

levoleucovorin intravenous recon soln T1

leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg T3

FUSILEV T3

levoleucovorin intravenous solution T4

URINARY TRACT PROTECTIVE AGENTS USED IN CONJUNCTION WITH CHEMOTHERAPY

mesna T1

amifostine crystalline T4

MESNEX T4

ANTISEPTICS AND DISINFECTANTS

ANTISEPTIC - ALCOHOLS

alcohol swabs T1

ANTISEPTIC - IODINE/IODOPHORES

IODOFLEX T3

IODOSORB T3

ANTISEPTIC - OTHERS

formaldehyde T1

glutaraldehyde T3

FORMADON T3

FORMA-RAY T3

ANTISEPTIC - PHENOL DERIVATIVES

phenol T1

DISINFECTANTS - ALDEHYDES

FORMADON T3

BIOLOGICALS

ALLERGENIC EXTRACT OTHERS

CANDIN T3

ALLERGENIC EXTRACTS - GRASS POLLEN

GRASTEK T3 PA

2018

27

Drug Name Formulary Tiers Restrictions

ORALAIR T3 PA

ALLERGENIC EXTRACTS - WEED POLLEN

RAGWITEK T3 PA

ANTIVIRAL MONOCLONAL ANTIBODIES

SYNAGIS T4 PA

HEPATITIS A AND HEPATITIS B VACCINE COMBINATIONS

TWINRIX (PF) T2

HEPATITIS A VACCINE - SINGLE AGENTS

HAVRIX (PF) T2

VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML T2

VAQTA (PF) INTRAMUSCULAR SYRINGE T2

VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML

T3

HEPATITIS B VACCINE COMBINATIONS

PEDIARIX (PF) T2

HEPATITIS B VACCINES - SINGLE AGENTS

ENGERIX-B (PF) T2

ENGERIX-B PEDIATRIC (PF) T2

RECOMBIVAX HB (PF) T2

IMMUNE GLOBULIN - CYTOMEGALOVIRUS (CMV)

CYTOGAM T4

IMMUNE GLOBULIN - GAMMA GLOBULIN (IGG), HUMAN

BIVIGAM T4 PA

CARIMUNE NF NANOFILTERED T4 PA

CUVITRU T4 PA

FLEBOGAMMA DIF T4 PA

GAMASTAN S/D T4 PA

GAMMAGARD LIQUID T4 PA

GAMMAGARD S-D (IGA < 1 MCG/ML) T4 PA

GAMMAKED T4 PA

GAMMAPLEX T4 PA

GAMMAPLEX (WITH SORBITOL) T4 PA

GAMUNEX-C T4 PA

HIZENTRA T4 PA

HYQVIA T4 PA

HYQVIA IG COMPONENT T4 PA

OCTAGAM T4 PA

PRIVIGEN T4 PA

IMMUNE GLOBULIN - HEPATITIS B

HEPAGAM B T4

HYPERHEP B S/D T4

HYPERHEP B S-D NEONATAL T4

NABI-HB T4

IMMUNE GLOBULIN - RABIES

HYPERRAB S/D (PF) T4

IMOGAM RABIES-HT (PF) T4

IMMUNE GLOBULIN - RHO(D)

HYPERRHO S/D T4

2018

28

Drug Name Formulary Tiers Restrictions

MICRHOGAM ULTRA-FILTERED PLUS T4

RHOGAM ULTRA-FILTERED PLUS T4

RHOPHYLAC T4

WINRHO SDF T4

IMMUNE GLOBULIN - TETANUS

HYPERTET S/D (PF) T4

IMMUNE GLOBULIN - VARICELLA-ZOSTER

VARIZIG T2

IMMUNE SERUMS

ATGAM T4

THYMOGLOBULIN T4

IMMUNE SERUMS - BOTULINUM ANTITOXINS

botulism antitoxin heptavalent T1

LIVE VACCINES

bcg vaccine, live (pf) T1

FLUMIST QUAD 2017-2018 T2

M-M-R II (PF) T2

PROQUAD (PF) T2

ROTARIX T2

ROTATEQ VACCINE T2

TICE BCG T2

VARIVAX (PF) T2

VIVOTIF BERNA VACCINE T2

YF-VAX (PF) T2

ZOSTAVAX (PF) T2

IMLYGIC T4 PA

TOXOID VACCINE COMBINATIONS

tetanus,diphtheria tox ped(pf) T1

tetanus-diphtheria toxoids-td T1

ADACEL(TDAP ADOLESN/ADULT)(PF) T2

BOOSTRIX TDAP T2

DAPTACEL (DTAP PEDIATRIC) (PF) T2

INFANRIX (DTAP) (PF) T2

KINRIX (PF) T2

PEDIARIX (PF) T2

PENTACEL DTAP-IPV COMPNT (PF) T2

TENIVAC (PF) T2

VACCINE BACTERIAL - GRAM NEGATIVE BACILLI (NON-ENTERIC)

ACTHIB (PF) T2

PEDVAX HIB (PF) T2

TYPHIM VI T2

VIVOTIF BERNA VACCINE T2

VACCINE BACTERIAL - GRAM NEGATIVE COCCI

MENACTRA (PF) T2

MENOMUNE - A/C/Y/W-135 T2

MENOMUNE - A/C/Y/W-135 (PF) T2

MENVEO A-C-Y-W-135-DIP (PF) T3

2018

29

Drug Name Formulary Tiers Restrictions

VACCINE BACTERIAL - GRAM NEGATIVE COCCI AND BACILLI

MENHIBRIX (PF) T2

VACCINE BACTERIAL - GRAM POSITIVE COCCI

PNEUMOVAX 23 T2

PREVNAR 13 (PF) T2

VACCINE BACTERIAL - MENINGOCOCCAL GROUP B VACCINES

TRUMENBA T2

BEXSERO T4

VACCINE BACTERIAL - OTHER

bcg vaccine, live (pf) T1

VACCINE BACTERIAL - TOXIN-PRODUCING BACILLI

BIOTHRAX T2

VAXCHORA VACCINE T2

VACCINE MIXED COMBINATIONS (BACTERIAL AND VIRAL)

PENTACEL (PF) T2

VACCINE VIRAL - HUMAN PAPILLOMAVIRUS (HPV) VACCINES

GARDASIL 9 (PF) T2

VACCINE VIRAL - INFLUENZA A AND B

AFLURIA 2017-2018 T2

AFLURIA 2017-2018 (PF) T2

AFLURIA QUAD 2017-2018 T2

AFLURIA QUAD 2017-2018 (PF) T2

FLUAD 2017-2018 (65 YR UP)(PF) T2

FLUARIX QUAD 2017-2018 (PF) T2

FLUBLOK 2017-2018 (PF) T2

FLUBLOK QUAD 2017-2018 (PF) T2

FLUCELVAX QUAD 2017-2018 T2

FLUCELVAX QUAD 2017-2018 (PF) T2

FLULAVAL QUAD 2017-2018 T2

FLULAVAL QUAD 2017-2018 (PF) T2

FLUMIST QUAD 2017-2018 T2

FLUVIRIN 2017-2018 T2

FLUVIRIN 2017-2018 (PF) T2

FLUZONE HIGH-DOSE 2017-18 (PF) T2

FLUZONE INTRADERM QUAD 2017-18 T2

FLUZONE QUAD 2017-2018 T2

FLUZONE QUAD 2017-2018 (PF) T2

FLUZONE QUAD PEDI 2017-18 (PF) T2

VACCINE VIRAL - JAPANESE ENCEPHALITIS

IXIARO (PF) T3

VACCINE VIRAL - MEASLES

M-M-R II (PF) T2

PROQUAD (PF) T2

VACCINE VIRAL - MUMPS AND RELATED

M-M-R II (PF) T2

PROQUAD (PF) T2

2018

30

Drug Name Formulary Tiers Restrictions

VACCINE VIRAL - POLIOMYELITIS

IPOL T2

VACCINE VIRAL - RABIES

IMOVAX RABIES VACCINE (PF) T2

RABAVERT (PF) T2

VACCINE VIRAL - ROTAVIRUS

ROTARIX T2

ROTATEQ VACCINE T2

VACCINE VIRAL - RUBELLA

M-M-R II (PF) T2

PROQUAD (PF) T2

VACCINE VIRAL - VARICELLA

PROQUAD (PF) T2

VARIVAX (PF) T2

ZOSTAVAX (PF) T2

VACCINE VIRAL - YELLOW FEVER

YF-VAX (PF) T2

VACCINE VIRAL COMBINATIONS

M-M-R II (PF) T2

PROQUAD (PF) T2

CARDIOVASCULAR THERAPY AGENTS

ACE INHIBITOR AND CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine-benazepril T1

trandolapril-verapamil T1

PRESTALIA T3

TARKA T3

ACE INHIBITOR AND DIURETIC COMBINATIONS

benazepril-hydrochlorothiazide T1

captopril-hydrochlorothiazide T1

enalapril-hydrochlorothiazide T1

fosinopril-hydrochlorothiazide T1

lisinopril-hydrochlorothiazide T1

moexipril-hydrochlorothiazide T1

quinapril-hydrochlorothiazide T1

ACE INHIBITORS

benazepril T1

captopril T1

enalapril maleate T1

enalaprilat T1

fosinopril T1

lisinopril T1

moexipril T1

perindopril erbumine T1

quinapril T1

ramipril T1

trandolapril T1

EPANED T3

2018

31

Drug Name Formulary Tiers Restrictions

QBRELIS T3 PA

ALDOSTERONE RECEPTOR ANTAGONISTS

eplerenone T1

spironolactone T1

ALPHA-BETA BLOCKERS

carvedilol T1

labetalol T1

COREG CR T2

ANGIOTENSIN II RECEPTOR BLOCKER (ARB)-CALCIUM CHANNEL BLOCKER COMB.

amlodipine-olmesartan T1

amlodipine-valsartan T1

telmisartan-amlodipine T1

AZOR T3

EXFORGE T3

TWYNSTA T3

ANGIOTENSIN II RECEPTOR BLOCKER (ARB)-CALCIUM CHANNEL BLOCKER-DIURETIC

amlodipine-valsartan-hcthiazid T1

olmesartan-amlodipin-hcthiazid T1

EXFORGE HCT T3

TRIBENZOR T3

ANGIOTENSIN II RECEPTOR BLOCKER (ARB)-DIURETIC COMBINATIONS

candesartan-hydrochlorothiazid T1

irbesartan-hydrochlorothiazide T1

losartan-hydrochlorothiazide T1

olmesartan-hydrochlorothiazide T1

telmisartan-hydrochlorothiazid T1

valsartan-hydrochlorothiazide T1

BENICAR HCT T3

EDARBYCLOR T3 ST

MICARDIS HCT T3

ANGIOTENSIN II RECEPTOR BLOCKER-NEPRILYSIN INHIBITOR COMB. (ARNI)

ENTRESTO T2

ANGIOTENSIN II RECEPTOR BLOCKERS (ARBS)

candesartan T1

eprosartan T1

irbesartan T1

losartan T1

olmesartan T1

telmisartan T1

valsartan T1

AVAPRO T3

BENICAR T3

EDARBI T3 ST

MICARDIS T3

2018

32

Drug Name Formulary Tiers Restrictions

ANTIANGINAL - CORONARY VASODILATORS (NITRATES)

isosorbide dinitrate T1

isosorbide mononitrate T1

nitroglycerin in 5 % dextrose T1

nitroglycerin intravenous T1

nitroglycerin oral T1

nitroglycerin sublingual T1

nitroglycerin transdermal T1

NITROLINGUAL T2

nitroglycerin translingual T3

GONITRO T3

ISORDIL T3

NITRO-BID T3

NITRO-DUR T3

ANTIANGINAL AND ANTI-ISCHEMIC AGENTS, NON-HEMODYNAMIC

RANEXA T2

ANTIARRHYTHMIC - CLASS IA

disopyramide phosphate T1

procainamide T1

quinidine gluconate injection T1

quinidine sulfate T1

quinidine gluconate oral T3

NORPACE CR T3

ANTIARRHYTHMIC - CLASS IB

lidocaine (pf) T1

lidocaine in 5 % dextrose (pf) T1

mexiletine T1

phenytoin sodium T1

XYLOCAINE (CARDIAC) (PF) T3

ANTIARRHYTHMIC - CLASS IC

flecainide T1

propafenone oral tablet T1

propafenone oral capsule,extended release 12 hr T3

ANTIARRHYTHMIC - CLASS II

esmolol T1

sotalol T1

SOTALOL AF T1

BREVIBLOC IN NACL (ISO-OSM) T3

SOTYLIZE T3

ANTIARRHYTHMIC - CLASS III

amiodarone T1

amiodarone in dextrose 5 % T1

ibutilide fumarate T1

MULTAQ T2

dofetilide T3

NEXTERONE T3

2018

33

Drug Name Formulary Tiers Restrictions

ANTIARRHYTHMIC - CLASS IV

diltiazem hcl T1

verapamil T1

ANTIARRHYTHMIC OTHERS

adenosine T1

ANTIHYPERLIPIDEMIC - APOLIPOPROTEIN B-100 SYNTHESIS INHIBITOR

KYNAMRO T4 PA

ANTIHYPERLIPIDEMIC - BILE ACID SEQUESTRANTS

cholestyramine (with sugar) T1

colestipol T1

CHOLESTYRAMINE LIGHT T1

PREVALITE T1

WELCHOL T2

COLESTID FLAVORED T3

QUESTRAN LIGHT T3

ANTIHYPERLIPIDEMIC - FIBRIC ACID DERIVATIVES

fenofibrate T1

fenofibrate micronized T1

fenofibrate nanocrystallized T1

fenofibric acid T1

fenofibric acid (choline) T1

gemfibrozil T1

FENOGLIDE ORAL TABLET 40 MG T2

TRIGLIDE T2

FENOGLIDE ORAL TABLET 120 MG T3

LIPOFEN T3

ANTIHYPERLIPIDEMIC - HMG COA REDUCTASE INHIBITORS (STATINS)

atorvastatin T1

fluvastatin T1 ST

lovastatin T1

pravastatin T1

rosuvastatin T1

simvastatin T1

ALTOPREV T2

LIVALO T2 ST

FLOLIPID T3 PA

LESCOL XL T3

ANTIHYPERLIPIDEMIC - NICOTINIC ACID DERIVATIVES

niacin T1

NIACOR T3

NIASPAN EXTENDED-RELEASE T3

ANTIHYPERLIPIDEMIC - SELECTIVE CHOLESTEROL ABSORPTION INHIBITOR

ezetimibe T1 ST

ANTIHYPERLIPIDEMIC AGENTS - DIETARY SOURCE

TRIKLO T1

omega-3 acid ethyl esters T3

2018

34

Drug Name Formulary Tiers Restrictions

LOVAZA T3

VASCEPA T3

ANTIHYPERLIPIDEMIC AGENTS - DIETARY SOURCE COMBINATIONS

vitamin e T1

CARDIOVID PLUS T3

LIPOCHOL PLUS T3

VASCAZEN T3

VAYAROL T3

ANTIHYPERLIPIDEMIC HMG COA REDUCT INHIB AND CALCIUM CHANNEL BLOCKER

amlodipine-atorvastatin T1

ANTIHYPERLIPIDEMIC-HMG COA REDUCT INHIB AND CHOLESTEROL ABSORP INHIBIT

ezetimibe-simvastatin T1

ANTIHYPERLIPIDEMIC-MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP)INHIB

JUXTAPID T4 PA

ANTI-PCSK9 MONOCLONAL ANTIBODIES

PRALUENT PEN T4 PA

REPATHA PUSHTRONEX T4 PA

REPATHA SURECLICK T4 PA

REPATHA SYRINGE T4 PA

BETA BLOCKERS CARDIAC SELECTIVE

atenolol T1

betaxolol T1

bisoprolol fumarate T1

esmolol T1

metoprolol succinate T1

metoprolol tartrate T1

BYSTOLIC T2

BREVIBLOC IN NACL (ISO-OSM) T3

BETA BLOCKERS CARDIAC SELECTIVE, INTRINSIC SYMPATHOMIMETIC ACTIVITY

acebutolol T1

BETA BLOCKERS NON-CARDIAC SELECT., INTRINSIC SYMPATHOMIMETIC ACTIVITY

pindolol T1

LEVATOL T3

BETA BLOCKERS NON-CARDIAC SELECTIVE

nadolol T1

propranolol T1

sotalol T1

timolol maleate T1

SOTALOL AF T1

HEMANGEOL T3

INNOPRAN XL T3

SOTYLIZE T3

BRADYKININ B2 RECEPTOR ANTAGONISTS

FIRAZYR T4 PA

2018

35

Drug Name Formulary Tiers Restrictions

CALCIUM CHANNEL BLOCKERS - BENZOTHIAZEPINES

diltiazem hcl T1

diltiazem hcl in 0.9% nacl T1

CARTIA XT T1

TAZTIA XT T1

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG

T2

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

T3

CALCIUM CHANNEL BLOCKERS - DIHYDROPYRIDINES

amlodipine T1

felodipine T1

nicardipine intravenous syringe T1

nifedipine T1

isradipine T3

nicardipine intravenous solution T3

nicardipine oral T3

nisoldipine T3

CARDENE IV IN DEXTROSE T3

CARDENE IV IN SODIUM CHLORIDE T3

CLEVIPREX T3

CALCIUM CHANNEL BLOCKERS - DIHYDROPYRIDINES - CEREBROVASCULAR SPECIFIC

nimodipine T1

NYMALIZE T3 PA

CALCIUM CHANNEL BLOCKERS - PHENYLAKYLAMINES

verapamil T1

CARDIAC INOTROPES - PHOSPHODIESTERASE INHIBITORS

milrinone T1

milrinone in 5 % dextrose T1

CARDIAC SELECTIVE BETA BLOCKER-THIAZIDE DIURETIC AND RELATED COMB.

atenolol-chlorthalidone T1

bisoprolol-hydrochlorothiazide T1

metoprolol ta-hydrochlorothiaz T1

CARDIOVASCULAR SYMPATHOMIMETIC - ANAPHYLAXIS THERAPY SINGLE AGENTS

epinephrine T1

ADYPHREN T1

ADRENALIN T3

CARDIOVASCULAR SYMPATHOMIMETIC - BETA-ADRENERGIC AGONISTS

ISUPREL T3

CARDIOVASCULAR SYMPATHOMIMETICS

dobutamine T1

dobutamine in d5w T1

dopamine T1

dopamine in 5 % dextrose T1

ephedrine sulfate T1

ephedrine sulfate-0.9%nacl(pf) T1

2018

36

Drug Name Formulary Tiers Restrictions

epinephrine T1

midodrine T1

norepinephrine bitartrate T1

phenylephrine hcl T1

phenylephrine hcl in 0.9% nacl intravenous solution 40 mg/250 ml (160 mcg/ml)

T1

phenylephrine hcl in 0.9% nacl intravenous syringe T1

phenylephrine hcl in 0.9% nacl intravenous solution 50 mg/250 ml (200 mcg/ml)

T3

ADRENALIN T3

VAZCULEP T3

NORTHERA T4 PA

CENTRAL ALPHA-2 AGONISTS-THIAZIDE DIURETIC AND RELATED COMB.

methyldopa-hydrochlorothiazide T1

CLORPRES T3

CENTRAL ALPHA-2 RECEPTOR AGONISTS

clonidine T1

clonidine hcl T1

guanfacine T1

methyldopa T1

methyldopate T1

CATAPRES-TTS-1 T3

CATAPRES-TTS-2 T3

CATAPRES-TTS-3 T3

DIGITALIS GLYCOSIDES

digoxin T1

LANOXIN T3

DIRECT ACTING VASODILATORS

hydralazine oral T1

hydralazine injection T3

minoxidil T3

DIURETIC - ALDOSTERONE RECEPTOR ANTAGONIST, NON-SELECTIVE

spironolactone T1

DIURETIC - ALDOSTERONE RECEPTOR ANTAGONIST, SELECTIVE

eplerenone T1

DIURETIC - ARGININE VASOPRESSIN V1A/V2 RECEPTOR ANTAGONISTS

VAPRISOL T3

DIURETIC - CARBONIC ANHYDRASE INHIBITORS

acetazolamide T1

acetazolamide sodium T1

methazolamide T1

DIURETIC - INORGANIC SALT

ammonium chloride T1

DIURETIC - LOOP

bumetanide T1

ethacrynate sodium T1

2018

37

Drug Name Formulary Tiers Restrictions

furosemide T1

torsemide T1

EDECRIN T3 PA

SODIUM EDECRIN T3

DIURETIC - OSMOTIC

mannitol 10 % T1

mannitol 20 % T1

mannitol 25 % T1

mannitol 5 % T1

OSMITROL 15 % T3

DIURETIC - POTASSIUM SPARING

amiloride T1

DYRENIUM T3

DIURETIC - POTASSIUM SPARING-THIAZIDE AND RELATED COMBINATIONS

amiloride-hydrochlorothiazide T1

spironolacton-hydrochlorothiaz T1

triamterene-hydrochlorothiazid T1

ALDACTAZIDE T3

DIURETIC - SELECTIVE ARGININE VASOPRESSIN V2 RECEPTOR ANTAGONISTS

SAMSCA T4 PA

DIURETIC - THIAZIDES AND RELATED

chlorothiazide T1

chlorthalidone T1

hydrochlorothiazide T1

indapamide T1

methyclothiazide T1

metolazone T1

chlorothiazide sodium T3

DIURIL T3

DOPAMINE D1 RECEPTOR AGONISTS, ANTIHYPERTENSIVE

CORLOPAM T3

GANGLIONIC BLOCKING, NON-DEPOLARIZING

VECAMYL T1

HYPERPOLARIZATION-ACTIVATED CYCLIC NUCLEOTIDE-GATED CHANNEL INHIBITORS

CORLANOR T3 ST

MUSCARINIC RECEPTOR ANTAGONISTS (ANTICHOLINERGIC)

atropine T1

atropine (bulk) T1

ATROPEN T3

NON-CARDIAC SELECTIVE BETA BLOCKER-THIAZIDE DIURETIC AND RELATED COMB.

nadolol-bendroflumethiazide T1

propranolol-hydrochlorothiazid T1

PAH AGENTS - SELECTIVE PROSTACYCLIN RECEPTOR (IP) AGONISTS

UPTRAVI T4 PA

2018

38

Drug Name Formulary Tiers Restrictions

PATENT DUCTUS ARTERIOSUS (PDA) TREATMENT AGENTS , NSAID-TYPE

indomethacin sodium T1

PATENT DUCTUS ARTERIOSUS (PDA) TREATMENT AGENTS, PROSTAGLANDIN-TYPE

alprostadil T1

PROSTIN VR PEDIATRIC T3

PERIPHERAL ALPHA-1 RECEPTOR BLOCKERS

doxazosin T1

prazosin T1

terazosin T1

doxazosin mesylate (bulk) T3

CARDURA XL T3

phenoxybenzamine T4 PA

DIBENZYLINE T4 PA

PERIPHERAL VASODILATORS, SINGLE AGENTS

isoxsuprine T1

papaverine T1

PHEOCHROMOCYTOMA, AGENTS TO TREAT

DEMSER T2

PLASMA KALLIKREIN INHIBITOR AGENTS

KALBITOR T4 PA

PULMONARY ANTIHYPERTENSIVE AGENTS - PROSTACYCLIN-TYPE

epoprostenol (glycine) T1 PA

ORENITRAM T4 PA

REMODULIN T4 PA

TYVASO T4 PA

TYVASO INSTITUTIONAL START KIT T4 PA

TYVASO REFILL KIT T4 PA

TYVASO STARTER KIT T4 PA

VELETRI T4 PA

VENTAVIS T4 PA

PULMONARY ANTIHYPERTENSIVE AGENTS-SOLUBLE GUANYLATE CYCLASE STIMULATOR

ADEMPAS T4 PA

PULMONARY ARTERIAL HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS

LETAIRIS T4 PA

OPSUMIT T4 PA

TRACLEER T4 PA

PULMONARY ARTERIAL HYPERTENSION AGENTS-SELECTIVE CGMP-PDE5 INHIBITORS

sildenafil T4 PA

ADCIRCA T4 PA

REVATIO T4 PA

RENIN INHIBITOR, DIRECT

TEKTURNA T2

RENIN INHIBITOR, DIRECT AND DIURETIC COMBINATIONS

TEKTURNA HCT T2

2018

39

Drug Name Formulary Tiers Restrictions

SCLEROSING AGENTS

ASCLERA T3

SOTRADECOL T3

VARITHENA T3

ETHAMOLIN T4

VASOACTIVE NATRIURETIC PEPTIDES

NATRECOR T3

VASODILATOR COMBINATIONS

BIDIL T2

CENTRAL NERVOUS SYSTEM AGENTS

ANTIANXIETY AGENT - ANTIHISTAMINE TYPE

hydroxyzine hcl T1

hydroxyzine pamoate T1

ANTIANXIETY AGENT - BENZODIAZEPINES

alprazolam T1

chlordiazepoxide hcl T1

clonazepam T1

clorazepate dipotassium T1

diazepam T1

lorazepam T1

oxazepam T1

ALPRAZOLAM INTENSOL T1

DIAZEPAM INTENSOL T1

ANTIANXIETY AGENT - DICARBAMATE TYPE

meprobamate T1

ANTIANXIETY AGENT - NON-BENZODIAZEPINE

buspirone T1

ANTICONVULSANT - AMPA-TYPE GLUTAMATE RECEPTOR ANTAGONISTS

FYCOMPA ORAL SUSPENSION T3 PA; ST

FYCOMPA ORAL TABLET T3 ST

ANTICONVULSANT - BARBITURATES AND DERIVATIVES

phenobarbital T1

phenobarbital sodium T1

primidone T1

ANTICONVULSANT - BENZODIAZEPINES

clonazepam T1

diazepam T1

ONFI T3 PA

ANTICONVULSANT - CARBAMATES

felbamate oral suspension T1

felbamate oral tablet T3

ANTICONVULSANT - CARBOXYLIC ACID DERIVATIVES

divalproex T1

valproic acid T1

valproic acid (as sodium salt) T1

valproate sodium T3

2018

40

Drug Name Formulary Tiers Restrictions

ANTICONVULSANT - FUNCTIONALIZED AMINO ACID

VIMPAT T3 ST

ANTICONVULSANT - GABA ANALOGS

gabapentin T1

LYRICA T2

ANTICONVULSANT - GABA RE-UPTAKE INHIBITOR, NIPECOTIC ACID DERIVATIVES

GABITRIL T2

tiagabine T3

ANTICONVULSANT - GABA TRANSAMINASE (GABA-T) INHIBITOR

vigabatrin T4 PA

SABRIL T4 PA

ANTICONVULSANT - HYDANTOINS

fosphenytoin T1

phenytoin T1

phenytoin sodium T1

phenytoin sodium extended T1

DILANTIN T2

PEGANONE T2

ANTICONVULSANT - IMINOSTILBENE DERIVATIVES

carbamazepine T1

oxcarbazepine oral tablet T1

oxcarbazepine oral suspension T3

APTIOM T3 ST

EQUETRO T3

OXTELLAR XR T3 ST

TEGRETOL XR T3

TRILEPTAL T3

ANTICONVULSANT - MONOSACCHARIDE DERIVATIVES

topiramate T1

topiramate (bulk) T2

QUDEXY XR T3 ST

ANTICONVULSANT - PHENYLTRIAZINE DERIVATIVES

lamotrigine oral tablet T1

lamotrigine oral tablet disintegrating, dose pk T1

lamotrigine oral tablet, chewable dispersible T1

lamotrigine oral tablets,dose pack T1

LAMICTAL ODT T2

LAMICTAL XR STARTER (BLUE) T2

LAMICTAL XR STARTER (GREEN) T2

LAMICTAL XR STARTER (ORANGE) T2

lamotrigine oral tablet extended release 24hr T3

lamotrigine oral tablet,disintegrating T3

LAMICTAL ODT STARTER (BLUE) T3

LAMICTAL ODT STARTER (GREEN) T3

LAMICTAL ODT STARTER (ORANGE) T3

2018

41

Drug Name Formulary Tiers Restrictions

ANTICONVULSANT - PYRROLIDINE DERIVATIVES

levetiracetam oral T1

levetiracetam in nacl (iso-os) T3

levetiracetam intravenous T3

BRIVIACT T3 ST

SPRITAM T3 PA

ANTICONVULSANT - SUCCINIMIDES

ethosuximide T1

CELONTIN T2

ANTICONVULSANT - SULFONAMIDE DERIVATIVES

zonisamide T1

ANTICONVULSANT - TRIAZOLE DERIVATIVES

BANZEL T2

ANTIDEPRESSANT - ALPHA-2 RECEPTOR ANTAGONISTS (NASSA)

mirtazapine T1

ANTIDEPRESSANT - MAO INHIBITOR NONSELECTIVE AND IRREVERSIBLE-TYPES A,B

phenelzine T1

tranylcypromine T3

EMSAM T3

MARPLAN T3

ANTIDEPRESSANT - SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)

citalopram T1

escitalopram oxalate T1

fluoxetine T1

fluvoxamine oral tablet T1

paroxetine hcl T1

sertraline T1

fluvoxamine oral capsule,extended release 24hr T3

PEXEVA T3

ANTIDEPRESSANT - SEROTONIN-2 ANTAGONIST-REUPTAKE INHIBITORS (SARIS)

nefazodone oral tablet 100 mg, 150 mg, 200 mg T1

trazodone T1

nefazodone oral tablet 250 mg, 50 mg T3

ANTIDEPRESSANT - SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)

desvenlafaxine T1

desvenlafaxine fumarate T1

desvenlafaxine succinate T1

duloxetine T1

venlafaxine T1

duloxetine hcl (bulk) T2

CYMBALTA T3

FETZIMA T3 ST

KHEDEZLA T3 ST

SAVELLA T3 ST

2018

42

Drug Name Formulary Tiers Restrictions

ANTIDEPRESSANT - SSRI AND 5HT1A PARTIAL AGONIST

VIIBRYD T3 ST

ANTIDEPRESSANT - SSRI AND SEROTONIN (5-HT) RECEPTOR MODULATOR

TRINTELLIX T3 ST

ANTIDEPRESSANT - TRICYCLIC AND ANTIPSYCHOTIC, PHENOTHIAZINE COMB

perphenazine-amitriptyline T1

ANTIDEPRESSANT - TRICYCLIC-BENZODIAZEPINE COMBINATIONS

amitriptyline-chlordiazepoxide T1

ANTIDEPRESSANT- SSRI AND ATYPICAL ANTIPSYCH,DOPAMINE,SEROTONIN ANTAGON

olanzapine-fluoxetine T3

ANTIDEPRESSANT-NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIBITORS (NDRIS)

bupropion hcl T1

FORFIVO XL T3 ST

ANTIDEPRESSANT-TRICYCLICS AND RELATED (NON-SELECT REUPTAKE INHIBITORS)

amitriptyline T1

amoxapine T1

clomipramine T1 PA

desipramine T1

doxepin T1

imipramine hcl T1

imipramine pamoate T1

maprotiline T1

nortriptyline T1

protriptyline T1

SURMONTIL T3

ANTIPARKINSON - DOPAMINERGIC-PERIPH COMT-DOPA-DECARBOXYLASE INHIB COMB

carbidopa-levodopa-entacapone T1

ANTIPARKINSON - DOPAMINERG-PERIPHERAL DOPA-DECARBOXYLASE INHIBIT COMB

carbidopa-levodopa T1

RYTARY T3

ANTIPARKINSON ADJUVANT - CENTRAL/PERIPHERAL COMT INHIBITORS

TASMAR T3 PA

tolcapone T4 PA

ANTIPARKINSON ADJUVANT - PERIPHERAL COMT INHIBITORS

entacapone T1

ANTIPARKINSON ADJUVANT - PERIPHERAL DOPA-DECARBOXYLASE INHIBITORS

LODOSYN T2

ANTIPARKINSON THERAPY - ANTICHOLINERGIC AGENTS

benztropine T1

trihexyphenidyl T1

2018

43

Drug Name Formulary Tiers Restrictions

ANTIPARKINSON THERAPY - ERGOT ALKALOIDS AND DERIVATIVES

bromocriptine T3

ANTIPARKINSON THERAPY - MONOAMINE OXIDASE INHIBITOR(MAO-B)

rasagiline T1

selegiline hcl T1

XADAGO T3 PA

ZELAPAR T3

ANTIPARKINSON THERAPY - NON-ERGOT DOPAMINE AGONIST AGENTS

amantadine hcl T1

pramipexole oral tablet T1

ropinirole T1

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR 3.75 MG, 4.5 MG

T2

pramipexole oral tablet extended release 24 hr T3

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR 0.375 MG, 0.75 MG, 1.5 MG, 2.25 MG, 3 MG

T3

NEUPRO T3 ST

APOKYN T4 PA

GOCOVRI T4 PA

ANTIPSYCHOTIC - ATYP DOPAMINE-SEROTONIN ANTAG DIBENZO-OXEPINO PYRROLES

SAPHRIS (BLACK CHERRY) T3 ST

ANTIPSYCHOTIC - ATYPICAL DOPAMINE-SEROTONIN ANTAG- BENZISOTHIAZOLONES

ziprasidone hcl T1

LATUDA T2 ST

GEODON T3

ANTIPSYCHOTIC - ATYPICAL DOPAMINE-SEROTONIN ANTAG- BENZISOXAZOLE DERIV

paliperidone T1

risperidone T1

FANAPT T3 ST

INVEGA T3 ST

INVEGA SUSTENNA T4

INVEGA TRINZA T4

RISPERDAL CONSTA T4

ANTIPSYCHOTIC - ATYPICAL DOPAMINE-SEROTONIN ANTAG-DIBENZODIAZEPINE DER

clozapine oral tablet T1

clozapine oral tablet,disintegrating 12.5 mg, 150 mg, 200 mg T1

clozapine oral tablet,disintegrating 100 mg, 25 mg T3

FAZACLO T3

VERSACLOZ T3

ANTIPSYCHOTIC - BUTYROPHENONE DERIVATIVES

haloperidol T1

haloperidol decanoate T1

haloperidol lactate T1

2018

44

Drug Name Formulary Tiers Restrictions

ANTIPSYCHOTIC - DIBENZOXAZEPINE DERIVATIVES

loxapine succinate T1

ADASUVE T3

ANTIPSYCHOTIC - DIPHENYLBUTYLPIPERIDINE DERIVATIVES

pimozide T3

ORAP T3

ANTIPSYCHOTIC - PHENOTHIAZINES, ALIPHATIC

chlorpromazine injection T1

chlorpromazine oral T3

ANTIPSYCHOTIC - PHENOTHIAZINES, PIPERAZINE

fluphenazine hcl oral concentrate T1

fluphenazine hcl oral tablet 1 mg, 10 mg, 5 mg T1

perphenazine T1

prochlorperazine maleate T1

trifluoperazine T1

fluphenazine hcl injection T2

fluphenazine hcl oral elixir T2

fluphenazine hcl oral tablet 2.5 mg T2

ANTIPSYCHOTIC - PHENOTHIAZINES, PIPERIDINE

thioridazine T1

ANTIPSYCHOTIC - THIOXANTHENES

thiothixene T1

ANTIPSYCHOTIC -ATYPICAL DOPAMINE-SEROTONIN ANTAG-DIBENZOTHIAZEPINE DER

quetiapine oral tablet T1

quetiapine oral tablet extended release 24 hr 400 mg T1

quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 300 mg, 50 mg

T3

ANTIPSYCHOTIC -ATYPICAL DOPAMINE-SEROTONIN ANTAG-THIENOBENZODIAZEPINES

olanzapine T1

ZYPREXA RELPREVV T4

ANTIPSYCHOTIC-ATYP SELECTIVE SEROTONIN 5-HT2A INVERSE AGONISTS (SSIA)

NUPLAZID T3 ST

ANTIPSYCHOTIC-ATYPICAL,D2 RECEPTOR PARTIAL AGONIST-5HT SEROTONIN MIXED

aripiprazole oral solution T1

aripiprazole oral tablet,disintegrating T1

aripiprazole oral tablet T3

REXULTI T3 ST

ABILIFY MAINTENA T4

ARISTADA T4

ATTENTION DEFICIT-HYPERACT. DISORDER (ADHD)- ALPHA-2 RECEPTOR AGONIST

clonidine hcl T3

guanfacine T3

INTUNIV ER T3

KAPVAY T3

2018

45

Drug Name Formulary Tiers Restrictions

ATTENTION DEFICIT-HYPERACTIVITY (ADHD) THERAPY, STIMULANT-TYPE

dexmethylphenidate oral tablet T1

dextroamphetamine T1

dextroamphetamine-amphetamine T1

methylphenidate hcl oral capsule,er biphasic 50-50 30 mg, 60 mg T1

methylphenidate hcl oral tablet T1

methylphenidate hcl oral tablet extended release 24hr T1

methylphenidate hcl oral tablet,chewable T1

DAYTRANA T2 ST

VYVANSE T2

dexmethylphenidate oral capsule,er biphasic 50-50 T3

methylphenidate hcl oral capsule, er biphasic 30-70 T3

methylphenidate hcl oral capsule,er biphasic 50-50 20 mg, 40 mg T3

methylphenidate hcl oral solution T3

methylphenidate hcl oral tablet extended release T3

ADDERALL T3

APTENSIO XR T3 ST

COTEMPLA XR-ODT T3 PA

DYANAVEL XR T3 ST

EVEKEO T3

FOCALIN XR T3

METADATE ER T3

MYDAYIS T3 PA

QUILLICHEW ER T3

QUILLIVANT XR T3 ST

RITALIN LA T3

ZENZEDI T3

ATTENTION DEFICIT-HYPERACTIVITY DISORDER (ADHD) THERAPY, NRI-TYPE

atomoxetine T1

STRATTERA T3

BENZODIAZEPINES

amitriptyline-chlordiazepoxide T1

chlordiazepoxide-clidinium T1

diazepam T1

lorazepam T1

DIAZEPAM INTENSOL T1

ONFI T3 PA

BIPOLAR THERAPY AGENTS - ANTICONVULSANT TYPE

carbamazepine T1

divalproex T1

lamotrigine T1

valproic acid T1

valproic acid (as sodium salt) T1

LAMICTAL ODT T2

EQUETRO T3

LAMICTAL ODT STARTER (BLUE) T3

2018

46

Drug Name Formulary Tiers Restrictions

LAMICTAL ODT STARTER (GREEN) T3

LAMICTAL ODT STARTER (ORANGE) T3

BIPOLAR THERAPY AGENTS - ATYPICAL ANTIPSYCHOTICS

aripiprazole oral solution T1

aripiprazole oral tablet,disintegrating T1

olanzapine T1

quetiapine oral tablet T1

quetiapine oral tablet extended release 24 hr 400 mg T1

risperidone T1

ziprasidone hcl T1

aripiprazole oral tablet T3

quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 300 mg, 50 mg

T3

GEODON T3

SAPHRIS (BLACK CHERRY) T3 ST

VRAYLAR T3 ST

BIPOLAR THERAPY AGENTS - LITHIUM

lithium carbonate T1

lithium citrate T3

CNS STIMULANT - AMPHETAMINE COMBINATIONS

dextroamphetamine-amphetamine T1

ADDERALL T3

ADZENYS XR-ODT T3 ST

DYANAVEL XR T3 ST

MYDAYIS T3 PA

CNS STIMULANT - AMPHETAMINES

dextroamphetamine T1

DEXEDRINE SPANSULE T1

EVEKEO T3 ST

ZENZEDI T3 ST

CNS STIMULANT - ANALEPTICS

caffeine citrate T1

caffeine-sodium benzoate T1

doxapram T1

FIBROMYALGIA AGENTS - GABA ANALOGS

LYRICA T2

FIBROMYALGIA AGENTS - SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS)

duloxetine T1

duloxetine hcl (bulk) T2

CYMBALTA T3

SAVELLA T3 ST

HSDD AGENTS-MIXED SEROTONIN AGONIST/ANTAGONISTS

ADDYI T3 PA

HYPNOTICS - MELATONIN M1/M2 RECEPTOR AGONISTS

ROZEREM T3

HETLIOZ T4 PA

2018

47

Drug Name Formulary Tiers Restrictions

MIGRAINE THERAPY - ANALGESIC-VASOCONSTRICTORS

isomethepten-caf-acetaminophen T1

PRODRIN T3

MIGRAINE THERAPY - ANALGESIC-VASOCONSTRICTOR-SEDATIVE COMBINATIONS

isometh-dichloral-acetaminophn T1

MIGRAINE THERAPY - CARBOXYLIC ACID DERIVATIVES

divalproex T1

MIGRAINE THERAPY - ERGOT ALKALOIDS AND DERIVATIVES

dihydroergotamine T1

MIGRAINE THERAPY - ERGOT COMBINATIONS

MIGERGOT T1

CAFERGOT T3

MIGRAINE THERAPY - SELECTIVE SEROTONIN AGONISTS 5-HT(1)

eletriptan hbr T1

naratriptan T1

rizatriptan T1

sumatriptan succinate oral T1

zolmitriptan T1

almotriptan malate T3

frovatriptan T3

sumatriptan T3

sumatriptan succinate subcutaneous T3

AMERGE T3

AXERT T3

FROVA T3

IMITREX T3

MAXALT T3

MAXALT-MLT T3

ONZETRA XSAIL T3 PA

RELPAX T3 ST

SUMAVEL DOSEPRO T3 ST

ZEMBRACE SYMTOUCH T3 PA

ZOMIG T3

ZOMIG ZMT T3

MIGRAINE THERAPY - SEROTONIN AGONIST 5-HT(1) AND NSAID COMB.

TREXIMET T3 ST

MOVEMENT DISORDER DRUG THERAPY

tetrabenazine T4

AUSTEDO T4 PA

INGREZZA T4 PA

XENAZINE T4

MOVEMENT DISORDER THERAPY - HUNTINGTON'S DISEASE

tetrabenazine T4

AUSTEDO T4 PA

XENAZINE T4 PA

2018

48

Drug Name Formulary Tiers Restrictions

MOVEMENT DISORDER THERAPY - RESTLESS LEGS SYNDROME

HORIZANT T3 ST

MOVEMENT DISORDER THERAPY - TARDIVE DYSKINESIA

INGREZZA T4 PA

NARCOLEPSY AND CATAPLEXY THERAPY AGENTS - SEDATIVE-TYPE

XYREM T4 PA

NARCOLEPSY THERAPY AGENTS - NON-SYMPATHOMIMETIC

armodafinil T3 PA

modafinil T3 PA

NUVIGIL T3 PA

NARCOLEPSY THERAPY AGENTS - STIMULANT-TYPE, PIPERADINE DERIVATIVE

methylphenidate hcl oral tablet T1

methylphenidate hcl oral solution T3

NARCOLEPSY THERAPY AGENTS- STIMULANT-TYPE,SYMPATHOMIMETIC,AMPHETAMINES

dextroamphetamine T1

ADDERALL T3

ZENZEDI T3

PSEUDOBULBAR AFFECT (PBA) AGENTS, NMDA ANTAGONISTS TYPE

NUEDEXTA T2 PA

SEDATIVE-HYPNOTIC - BARBITURATES

phenobarbital T1

phenobarbital sodium T1

AMYTAL T3

BUTISOL T3

SECONAL SODIUM T3

SEDATIVE-HYPNOTIC - BENZODIAZEPINES

estazolam T1

flurazepam T1

lorazepam T1

midazolam T1

quazepam T1

temazepam T1

triazolam T1

SEDATIVE-HYPNOTIC - GABA-RECEPTOR MODULATORS

eszopiclone T1

zaleplon T1

zolpidem T1

EDLUAR T3

LUNESTA T3

ZOLPIMIST T3

SEDATIVE-HYPNOTIC - OREXIN RECEPTOR ANTAGONIST

BELSOMRA T3 ST

2018

49

Drug Name Formulary Tiers Restrictions

SEDATIVE-HYPNOTIC - SELECTIVE ALPHA2-ADRENORECEPTOR AGONISTS

dexmedetomidine T1

PRECEDEX T3

PRECEDEX IN 0.9 % SODIUM CHLOR INTRAVENOUS SOLUTION 200 MCG/50 ML (4 MCG/ML), 400 MCG/100 ML (4 MCG/ML)

T3

PRECEDEX IN 0.9 % SODIUM CHLOR INTRAVENOUS SOLUTION 80 MCG/20 ML (4 MCG/ML)

T4

SEDATIVE-HYPNOTIC - TRICYCLIC ANTIDEPRESSANT TYPE

SILENOR T2

CHEMICAL DEPENDENCY, AGENTS TO TREAT

AGENTS FOR NARCOTIC WITHDRAWAL

buprenorphine hcl T1 ST

buprenorphine-naloxone T3 PA

BUNAVAIL T3 PA

SUBOXONE T3 PA

ZUBSOLV T3 PA

ALCOHOL ABSTINENCE THERAPY - GLUTAMATE AND GABA SYSTEM TYPE

acamprosate T1

ALCOHOL ABSTINENCE THERAPY - OPIOID RECEPTOR ANTAGONIST-TYPE

VIVITROL T4

ALCOHOL DETERRENTS

disulfiram T1

SMOKING DETERRENTS - NE AND DOPAMINE REUPTAKE INHIBITOR (NDRI)-TYPE

bupropion hcl T1

SMOKING DETERRENTS - NICOTINE-TYPE

nicotine (polacrilex) T1

NICOTROL T2

NICOTROL NS T2

SMOKING DETERRENTS - NICOTINIC RECEPTOR PARTIAL AGONIST, ALPHA4BETA2

CHANTIX T2

CHANTIX CONTINUING MONTH BOX T2

CHANTIX STARTING MONTH BOX T2

CHEMICALS-PHARMACEUTICAL ADJUVANTS

BULK CHEMICALS

belladonna tincture (bulk) T1

alprostadil (bulk) T3

fluorouracil (bulk) T3

prasterone (dhea), micro(bulk) T3

CHEMICALS - ACIDS

glycolic acid (bulk) T1

hydrochloric acid (bulk) T3

CHEMICALS - BASES

sodium hydroxide (bulk) T1

CHEMICALS - CRYOPRESERVATIVE AGENTS

CRYOSERV T3

2018

50

Drug Name Formulary Tiers Restrictions

CHEMICALS - SOLVENTS

ethyl alcohol (bulk) T1

sodium succinate T1

MURI-LUBE T3

PHARMACEUTICAL ADJUVANT - ANTICORROSIVE AGENTS

butylated hydroxytoluene T1

sodium bisulfite T1

PHARMACEUTICAL ADJUVANT - FLAVORING AGENTS

banana creme flavor (bulk) T1

ethyl acetate T1

PHARMACEUTICAL ADJUVANT - INHALATION VEHICLES

sodium chloride T1

HYPER-SAL T3

NEBUSAL T3

PHARMACEUTICAL ADJUVANT - ORAL VEHICLES

sorbitol T1

PHARMACEUTICAL ADJUVANT - PARENTERAL VEHICLES

BACTERIOSTATIC WATER(PARABENS) T3

DILUENT FOR EPOPROSTENOL/FLOLA T3

PHARMACEUTICAL ADJUVANT - SUSPENDING AGENTS

oleic acid T1

PHARMACEUTICAL ADJUVANT - TABLETING

cellulose (bulk) T1

lactose (bulk) T1

magnesium stearate T1

COGNITIVE DISORDER THERAPY

ALZHEIMER'S DISEASE THERAPY - CHOLINESTERASE INHIBITORS

donepezil oral tablet 10 mg, 5 mg T1

donepezil oral tablet,disintegrating T1

galantamine T1

rivastigmine tartrate T1

donepezil oral tablet 23 mg T3

rivastigmine T3

EXELON T3

ALZHEIMER'S DISEASE THERAPY - NMDA RECEPTOR ANTAGONISTS

memantine T1

memantine hcl (bulk) T2

NAMENDA XR T2

NAMENDA T3

NAMENDA TITRATION PAK T3

ALZHEIMER'S THX - NMDA RECEPTOR ANTAG. AND CHOLINESTERASE INHIB. COMB

NAMZARIC T3

COGNITIVE DISORDER THERAPY - CEREBRAL VASODILATORS

ergoloid T1

2018

51

Drug Name Formulary Tiers Restrictions

CONTRACEPTIVES

CONTRACEPTIVE INJECTABLE - PROGESTIN

medroxyprogesterone T1

DEPO-SUBQ PROVERA 104 T3

CONTRACEPTIVE INTRAUTERINE - COPPER IUD

PARAGARD T 380A T3

CONTRACEPTIVE INTRAUTERINE - PROGESTERONE IUD

KYLEENA T3

LILETTA T3

MIRENA T3

SKYLA T3

CONTRACEPTIVE ORAL - BIPHASIC

DAYSEE T1

KARIVA (28) T1

VIORELE (28) T1

AMETHIA T3

AMETHIA LO T3

AZURETTE (28) T3

CAMRESE T3

CAMRESE LO T3

LOSEASONIQUE T3

MIRCETTE (28) T3

SEASONIQUE T3

CONTRACEPTIVE ORAL - MONOPHASIC

desogestrel-ethinyl estradiol T1

drospirenone-e.estradiol-lm.fa T1

drospirenone-ethinyl estradiol T1

ethynodiol diac-eth estradiol T1

levonorgestrel-ethinyl estrad oral tablet T1

mibelas 24 fe T1

noreth-ethinyl estradiol-iron T1

norethindrone-e.estradiol-iron T1

norgestimate-ethinyl estradiol T1

AMETHYST T1

APRI T1

AVIANE T1

BRIELLYN T1

CYCLAFEM 1/35 (28) T1

ELINEST T1

EMOQUETTE T1

GIANVI (28) T1

GILDAGIA T1

ISIBLOOM T1

JOLESSA T1

JUNEL 1.5/30 (21) T1

JUNEL 1/20 (21) T1

JUNEL FE 1.5/30 (28) T1

2018

52

Drug Name Formulary Tiers Restrictions

JUNEL FE 1/20 (28) T1

KELNOR 1/35 (28) T1

LILLOW T1

LORYNA (28) T1

MELODETTA 24 FE T1

MICROGESTIN FE 1.5/30 (28) T1

MICROGESTIN FE 1/20 (28) T1

MONONESSA (28) T1

NORTREL 0.5/35 (28) T1

NORTREL 1/35 (21) T1

NORTREL 1/35 (28) T1

OCELLA T1

ORSYTHIA T1

PHILITH T1

PIRMELLA T1

QUASENSE T1

RAJANI T1

SPRINTEC (28) T1

SRONYX T1

ZARAH T1

ZOVIA 1/35E (28) T1

ZOVIA 1/50E (28) T1

SAFYRAL T2

TAYTULLA T2

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month T3

ALTAVERA (28) T3

BALZIVA (28) T3

BREVICON (28) T3

CRYSELLE (28) T3

DELYLA (28) T3

FALMINA (28) T3

GENERESS FE T3

INTROVALE T3

KURVELO T3

LARIN 1.5/30 (21) T3

LARIN 1/20 (21) T3

LARIN FE 1.5/30 (28) T3

LARIN FE 1/20 (28) T3

LESSINA T3

LEVORA-28 T3

LOESTRIN 1.5/30 (21) T3

LOESTRIN 1/20 (21) T3

LOESTRIN FE 1.5/30 (28-DAY) T3

LOESTRIN FE 1/20 (28-DAY) T3

LOW-OGESTREL (28) T3

LUTERA (28) T3

MARLISSA T3

2018

53

Drug Name Formulary Tiers Restrictions

MICROGESTIN 1.5/30 (21) T3

MICROGESTIN 1/20 (21) T3

NECON 0.5/35 (28) T3

NECON 1/50 (28) T3

OGESTREL (28) T3

ORTHO-CYCLEN (28) T3

ORTHO-NOVUM 1/35 (28) T3

OVCON-35 (28) T3

PORTIA T3

PREVIFEM T3

RECLIPSEN (28) T3

SYEDA T3

VESTURA (28) T3

WYMZYA FE T3

YASMIN (28) T3

YAZ (28) T3

ZENCHENT (28) T3

CONTRACEPTIVE ORAL - PROGESTIN

CAMILA T1

HEATHER T1

NORLYDA T1

ERRIN T3

JOLIVETTE T3

NORA-BE T3

ORTHO MICRONOR T3

CONTRACEPTIVE ORAL - QUADRAPHASIC

FAYOSIM T1

RIVELSA T1

NATAZIA T3

QUARTETTE T3

CONTRACEPTIVE ORAL - TRIPHASIC

norgestimate-ethinyl estradiol T1

ALYACEN 7/7/7 (28) T1

ARANELLE (28) T1

CAZIANT (28) T1

CYCLAFEM 7/7/7 (28) T1

DASETTA 7/7/7 (28) T1

LEVONEST (28) T1

MYZILRA T1

NECON 7/7/7 (28) T1

NORTREL 7/7/7 (28) T1

TILIA FE T1

TRI FEMYNOR T1

TRINESSA (28) T1

TRI-PREVIFEM (28) T1

TRI-SPRINTEC (28) T1

CYCLESSA (28) T3

2018

54

Drug Name Formulary Tiers Restrictions

ENPRESSE T3

ESTROSTEP FE-28 T3

LEENA 28 T3

ORTHO TRI-CYCLEN (28) T3

ORTHO TRI-CYCLEN LO (28) T3

ORTHO-NOVUM 7/7/7 (28) T3

TRI-LEGEST FE T3

TRI-NORINYL (28) T3

TRIVORA (28) T3

VELIVET TRIPHASIC REGIMEN (28) T3

CONTRACEPTIVE TRANSDERMAL COMBINATIONS

XULANE T1

CONTRACEPTIVE TRANSDERMAL COMBINATIONS - ESTROGEN AND PROGESTIN COMB.

XULANE T1

CONTRACEPTIVES - INTRAVAGINAL, SYSTEMIC

NUVARING T2

CONTRACEPTIVES - INTRAVAGINAL, SYSTEMIC - ESTROGEN AND PROGESTIN COMB.

NUVARING T2

EMERGENCY CONTRACEPTIVES

MY WAY T1

NEXT CHOICE ONE DOSE T1

ELLA T3

EMERGENCY CONTRACEPTIVES - PROGESTERONE AGONIST/ANTAGONIST TYPE

ELLA T3

EMERGENCY CONTRACEPTIVES - PROGESTIN TYPE

MY WAY T1

NEXT CHOICE ONE DOSE T1

DERMATOLOGICAL

ACNE THERAPY SYSTEMIC - RETINOIDS AND DERIVATIVES

CLARAVIS T3 ST

MYORISAN T3 ST

ZENATANE T3 ST

ACNE THERAPY SYSTEMIC - TETRACYCLINES

minocycline T1

ACNE THERAPY TOPICAL - ANTI-INFECTIVE

clindamycin phosphate T1

erythromycin with ethanol T1

metronidazole T1

AZELEX T2

azelaic acid (bulk) T3

sulfacetamide sodium (acne) T3

ACZONE T3 ST

CLINDAGEL T3 ST

FINACEA T3

NORITATE T3

2018

55

Drug Name Formulary Tiers Restrictions

ACNE THERAPY TOPICAL - ANTI-INFECTIVE COMBINATIONS OTHER

CLINDACIN ETZ T3

CLINDACIN PAC T3

ACNE THERAPY TOPICAL - ANTI-INFECTIVE-KERATOLYTIC COMBINATIONS

erythromycin-benzoyl peroxide T1

sulfacetamide sodium-sulfur T1

sulfacetamide sod-sulfur-urea T1

sulfacetamide-sulfur-cleansr23 T1

sulfact na-sul-avobnz-otn-ocsa T1

clindamycin-benzoyl peroxide topical gel 1.2 %(1 % base) -5 % T3

clindamycin-benzoyl peroxide topical gel 1-5 % T3 ST

clindamycin-benzoyl peroxide topical gel with pump T3 ST

ACANYA T3 ST

AKTIPAK T3 PA

AVAR T3

AVAR LS T3

AVAR-E LS T3

BENZACLIN T3 ST

BENZACLIN PUMP T3 ST

NEUAC T3

NEUAC KIT T3

PLEXION T3

SUMADAN XLT T3

SUMAXIN CP T3

ACNE THERAPY TOPICAL - ANTI-INFECTIVE-RETINOID COMBINATIONS

clindamycin-tretinoin T3

VELTIN T3

ZIANA T3 ST

ACNE THERAPY TOPICAL - KERATOLYTIC

benzoyl peroxide topical cleanser T1

benzoyl peroxide topical foam T1

benzoyl peroxide topical gel 2.5 % T1

potassium hydroxide T1

BP WASH ACNE TREATMENT T1

benzoyl peroxide topical gel 5 % T3

BENZEFOAM T3

BENZEFOAM ULTRA T3

BENZEPRO T3

BENZEPRO (MICROSPHERES) T3

BP FOAM T3

BP WASH T3

BPO T3

INOVA T3

PACNEX HP T3

PACNEX LP T3

2018

56

Drug Name Formulary Tiers Restrictions

RIAX T3

ACNE THERAPY TOPICAL - KERATOLYTIC COMBINATIONS OTHER

INOVA 4-1 T3

INOVA 8-2 T3

ACNE THERAPY TOPICAL - KERATOLYTIC MIXTURES

NUOX T3

ACNE THERAPY TOPICAL - KERATOLYTIC-GLUCOCORTICOID COMBINATIONS

VANOXIDE-HC T3

ACNE THERAPY TOPICAL - RETINOID COMBINATIONS OTHER

adapalene-benzoyl peroxide T1

EPIDUO FORTE T2

EPIDUO T3

ACNE THERAPY TOPICAL - RETINOIDS AND DERIVATIVES

adapalene T1

tretinoin T3

tretinoin microspheres T3

AVITA T3

DIFFERIN T3 ST

FABIOR T3 ST

RETIN-A T3 ST

RETIN-A MICRO T3 ST

RETIN-A MICRO PUMP T3 ST

TRETIN-X T3 ST

TRETIN-X CREAM KIT T3 ST

ANTIPSORIATIC - VITAMIN D ANALOG - GLUCOCORTICOID COMBINATIONS

calcipotriene-betamethasone T3

TACLONEX T3

ANTIPSORIATIC AGENTS - INTERLEUKIN 12 AND IL-23 INHIBITORS,MC ANTIBODY

STELARA T4 ST

ANTIPSORIATIC AGENTS - INTERLEUKIN-23 (IL-23) ANTAGONIST, MC ANTIBODY

TREMFYA T4 PA

ANTIPSORIATIC AGENTS-INTERLEUKIN-17 (IL-17) ANTAGONIST, MC ANTIBODY

COSENTYX T4 ST

COSENTYX (2 SYRINGES) T4 ST

COSENTYX PEN T4 ST

COSENTYX PEN (2 PENS) T4 ST

SILIQ T4 ST

TALTZ AUTOINJECTOR T4 ST

TALTZ AUTOINJECTOR (2 PACK) T4 ST

TALTZ AUTOINJECTOR (3 PACK) T4 ST

TALTZ SYRINGE T4 ST

TALTZ SYRINGE (2 PACK) T4 ST

TALTZ SYRINGE (3 PACK) T4 ST

2018

57

Drug Name Formulary Tiers Restrictions

DERMATITIS OR ECZEMA AGENTS, SYSTEMIC-INTERLEUKIN-4 (IL-4RA) ANTAG.MAB

DUPIXENT T4 PA

DERMATITIS OR ECZEMA AGENTS, TOPICAL - PHOSPHODIESTERASE-4 INHIBITORS

EUCRISA T2 ST

DERMATOLOGICAL - ANTIBACTERIAL AMINOGLYCOSIDES

gentamicin T1

DERMATOLOGICAL - ANTIBACTERIAL AND ANTIFUNGAL AGENTS

ALOQUIN T3

DERMATOLOGICAL - ANTIBACTERIAL OTHER

mupirocin T1

mupirocin calcium T1

silver nitrate T1

NORMLGEL AG T1

CENTANY AT T3

SILVRSTAT T3

DERMATOLOGICAL - ANTIBACTERIAL PLEUROMUTILIN DERIVATIVES

ALTABAX T3

DERMATOLOGICAL - ANTIBACTERIAL SULFONAMIDES

sulfacetamide sodium-sulfur T1

DERMATOLOGICAL - ANTIBACTERIAL,ANTIFUNGAL AGENT WITH GLUCOCORTICOID

ALA-QUIN T3

DERMASORB AF COMPLETE KIT T3

VYTONE T3

DERMATOLOGICAL - ANTIBACTERIAL-GLUCOCORTICOID COMBINATIONS

CORTISPORIN T3

NEO-SYNALAR T3

NEO-SYNALAR KIT T3

DERMATOLOGICAL - ANTIFUNGAL ALLYLAMINES

naftifine T3

NAFTIN T3

DERMATOLOGICAL - ANTIFUNGAL AMPHOTERIC POLYENE MACROLIDES

nystatin T1

DERMATOLOGICAL - ANTIFUNGAL BENZYLAMINES

MENTAX T3

DERMATOLOGICAL - ANTIFUNGAL COMBINATIONS OTHER

EXODERM T1

DERMATOLOGICAL - ANTIFUNGAL HYDROXYPYRIDINONE

ciclopirox T1

ciclopirox-ure-camph-menth-euc T1

CICLODAN KIT T3

DERMATOLOGICAL - ANTIFUNGAL IMIDAZOLE AND RELATED AGENTS

clotrimazole T1

ketoconazole topical cream T1

2018

58

Drug Name Formulary Tiers Restrictions

ketoconazole topical shampoo T1

oxiconazole T1

econazole T3

ketoconazole topical foam T3

ERTACZO T3

EXELDERM T3

EXTINA T3

LUZU T3

OXISTAT T3 PA

VUSION T3

XOLEGEL T3

DERMATOLOGICAL - ANTIFUNGAL MIXTURES

TRIPLE DYE T3

DERMATOLOGICAL - ANTIFUNGAL-GLUCOCORTICOID COMBINATIONS

clotrimazole-betamethasone T1

iodoquinol-hc T1

nystatin-triamcinolone T1

DERMATOLOGICAL - ANTIFUNGALS OTHER

triacetin T1

DERMATOLOGICAL - ANTINEOPLASTIC ALKYLATING AGENTS

VALCHLOR T4 PA

DERMATOLOGICAL - ANTINEOPLASTIC ANTIMETABOLITES

fluorouracil topical cream 0.5 % T1

CARAC T3

TOLAK T3

fluorouracil topical cream 5 % T4

fluorouracil topical solution T4

DERMATOLOGICAL - ANTINEOPLASTIC OR PREMALIG. LESIONS -DITERPENE ESTERS

PICATO T2

DERMATOLOGICAL - ANTINEOPLASTIC RETINOIDS

PANRETIN T4 PA

DERMATOLOGICAL - ANTINEOPLASTIC SELECTIVE RETINOID X RECEPTOR AGONIST

TARGRETIN T4

DERMATOLOGICAL - ANTIPERSPIRANTS

XERAC AC T3

DERMATOLOGICAL - ANTIPSORIATIC AGENTS SYSTEMIC, PHOTOSENSITIZING

OXSORALEN ULTRA T2

DERMATOLOGICAL - ANTIPSORIATIC AGENTS SYSTEMIC, VITAMIN A DERIVATIVES

acitretin oral capsule 17.5 mg T1

acitretin oral capsule 10 mg, 25 mg T3

DERMATOLOGICAL - ANTIPSORIATIC AGENTS TOPICAL

calcipotriene scalp T1

calcitriol T1

tazarotene T1

2018

59

Drug Name Formulary Tiers Restrictions

TAZORAC T2

calcipotriene topical T3

DOVONEX T3

DRITHOCREME HP T3

SORILUX T3

ZITHRANOL T3

DERMATOLOGICAL - ANTIPSORIATICS SYSTEMIC, PHOSPHODIESTERASE 4 INHIB.

OTEZLA T4 ST

OTEZLA STARTER T4 ST

DERMATOLOGICAL - ANTISEBORRHEIC

selenium sulfide T1

sulfacetamide sodium T1

OVACE PLUS SHAMPOO T2

LOUTREX T3

OVACE PLUS T3

OVACE PLUS WASH T3

PROMISEB T3

PROMISEB COMPLETE T3

SELRX T3

TERSI FOAM T3

DERMATOLOGICAL - ANTIVIRAL, HERPES

ZOVIRAX T2

acyclovir T3

DENAVIR T3

DERMATOLOGICAL - BURN PRODUCTS ANTI-INFECTIVE

silver sulfadiazine T1

SULFAMYLON T3

DERMATOLOGICAL - CALCINEURIN INHIBITORS

ELIDEL T2 ST

tacrolimus T3

PROTOPIC T3

DERMATOLOGICAL - DEPIGMENTING AGENTS

hydroquinone T1

hydroquinone microspheres T1

DERMATOLOGICAL - DEPIGMENTING COMBINATIONS

OBAGI NU-DERM SUNFADER T3

OBAGI-C CLARIFYING SERUM T3

OBAGI-C THERAPY NIGHT T3

TRI-LUMA T3

DERMATOLOGICAL - EMOLLIENT COMBINATIONS OTHER

HPR PLUS-MB HYDROGEL T1

MB HYDROGEL T1

MB HYDROGEL (CYCLOMETHICONE) T1

DERMATOLOGICAL - EMOLLIENT MIXTURES

AVO CREAM T1

EMULSION SB T1

HPR T1

2018

60

Drug Name Formulary Tiers Restrictions

HPR PLUS T1

PRUCLAIR T1

PRUMYX T1

PRUTECT T1

SONAFINE T1

ATOPICLAIR T3

ATRAPRO CP T3

BIAFINE EMULSION T3

ELETONE T3

EPICERAM T3

HYLATOPIC T3

HYLATOPICPLUS T3

LOUTREX T3

NEOSALUS T3

PRESERA T3

PROMISEB T3

PROMISEB COMPLETE T3

RADIGEL ACEMANNAN HYDROGEL T3

XCLAIR T3

DERMATOLOGICAL - EMOLLIENTS

ammonium lactate T1

urea T1

GORDONS UREA T3

DERMATOLOGICAL - ENZYMES

SANTYL T3

DERMATOLOGICAL - GLUCOCORTICOID

alclometasone T1

amcinonide T1

betamethasone dipropionate T1

betamethasone valerate topical cream T1

betamethasone valerate topical lotion T1

betamethasone valerate topical ointment T1

betamethasone, augmented T1

desonide T1

diflorasone T1

fluocinolone T1

fluocinolone and shower cap T1

fluocinonide T1

fluticasone T1

halobetasol propionate T1

hydrocortisone T1

hydrocortisone butyrate T1

hydrocortisone valerate T1

hydrocortisone-pramoxine T1

mometasone T1

prednicarbate T1

triamcinolone acetonide topical cream T1

2018

61

Drug Name Formulary Tiers Restrictions

triamcinolone acetonide topical lotion T1

triamcinolone acetonide topical ointment T1

FLUOCINONIDE-E T1

PROCTO-PAK T1

PROCTOZONE-HC T1

SCALACORT T1

TRIDERM T1

CAPEX T2

betamethasone valerate topical foam T3

clobetasol T3

clobetasol-emollient T3

desoximetasone T3

flurandrenolide T3

triamcinolone acetonide topical aerosol T3

ALA-SCALP T3

CLOBEX T3

CLODAN T3

CLODERM T3

CORDRAN T3

CORMAX T3

DESONATE T3

HALOG T3

KENALOG T3

PANDEL T3

PREPARATION H HYDROCORTISONE T3

PROCTOCORT T3

SCALACORT DK T3

TEXACORT T3

TOPICORT T3

TRIANEX T3

VANOS T3

VERDESO T3

DERMATOLOGICAL - GLUCOCORTICOID-EMOLLIENT COMBINATIONS

hydrocortisone-min oil-wht pet T1

DERMASORB TA COMPLETE KIT T3

SYNALAR CREAM KIT T3

SYNALAR OINTMENT KIT T3

ULTRAVATE X T3

DERMATOLOGICAL - GLUCOCORTICOID-LOCAL ANESTHETIC COMBINATIONS

hydrocortisone-pramoxine T1

lidocaine hcl-hydrocortison ac T1

PRAMOSONE E T2

PRAMOSONE TOPICAL LOTION T2

PRAMOSONE TOPICAL OINTMENT T2

EPIFOAM T3

PRAMOSONE TOPICAL CREAM T3

2018

62

Drug Name Formulary Tiers Restrictions

DERMATOLOGICAL - GLUCOCORTICOID-SKIN CLEANSER COMBINATIONS

AQUA GLYCOLIC HC T3

CLODAN KIT T3

DERMASORB HC COMPLETE KIT T3

SYNALAR TS T3

DERMATOLOGICAL - IMMUNOMODULATOR - CATECHINS - GENITAL WART/HPV TX

VEREGEN T3

DERMATOLOGICAL - IMMUNOMODULATOR - IMIDAZOQUINOLINAMINES

imiquimod T1

DERMATOLOGICAL - IMMUNOMODULATOR - INTERFERONS

ALFERON N T4

DERMATOLOGICAL - KERATOLYTIC COMBINATIONS OTHER

URAMAXIN GT T3

DERMATOLOGICAL - KERATOLYTIC-ANTIMITOTIC COMBINATIONS

silver nitrate applicators T1

SALVAX DUO PLUS T3

DERMATOLOGICAL - KERATOLYTIC-ANTIMITOTIC SINGLE AGENTS

podofilox T1

salicylic acid T1

salicylic acid er-ceramides T1

trichloroacetic acid T1

urea topical cream T1

urea topical gel T1

urea topical lotion T1

BP-50% UREA T1

UMECTA T1

CONDYLOX T2

urea topical foam T3

BENSAL HP T3

HYDRO 40 T3

KERAFOAM T3

KERALAC T3

KERALYT SCALP COMPLETE T3

PODOCON T3

TRI-CHLOR T3

URAMAXIN T3

URAMAXIN GT T3

UTOPIC T3

DERMATOLOGICAL - KERATOPLASTIC TAR PRODUCTS

coal tar T1

DERMATOLOGICAL - LIVER DERIVATIVE COMPLEX

NEXAVIR T3

DERMATOLOGICAL - LOCAL ANESTHETIC COMBINATIONS

lidocaine-prilocaine T1

2018

63

Drug Name Formulary Tiers Restrictions

CETACAINE T3

CETACAINE ANESTHETIC T3

LENZAPATCH T3

PUROXCIN T3

DERMATOLOGICAL - LOCAL ANESTHETIC GAS COMBINATIONS

PAIN EASE T3

SPRAY AND STRETCH T3

DERMATOLOGICAL - LOCAL ANESTHETIC GAS SINGLE AGENTS

ethyl chloride T1

DERMATOLOGICAL - MISCELLANEOUS SINGLE AGENTS

PYROGALLIC ACID T3

DERMATOLOGICAL - NSAID SINGLE AGENTS

diclofenac sodium T3

FLECTOR T3 ST

PENNSAID T3 ST

VOLTAREN T3

DERMATOLOGICAL - ORNITHINE DECARBOXYLASE (ODC) INHIBITORS

VANIQA T3

DERMATOLOGICAL - PHOTODYNAMIC THERAPY AGENTS TOPICAL

aminolevulinic acid hcl (bulk) T2

LEVULAN T3

DERMATOLOGICAL - PROTECTANT COMBINATIONS

HYGEL T1

PR CREAM T1

BEAU RX T3

RADIAPLEXRX T3

DERMATOLOGICAL - PROTECTANTS

white petrolatum T3

BIONECT T3

NUVAIL T3

DERMATOLOGICAL - RETINOIDS (VITAMIN A DERIVATIVES) - TOPICAL COSMETIC

tretinoin (emollient) T3

RENOVA T3

DERMATOLOGICAL - ROSACEA THERAPY, SYSTEMIC

ORACEA T3 ST

DERMATOLOGICAL - ROSACEA THERAPY, TOPICAL

metronidazole T1

sulfacetamide sod-sulfur-urea T1

sulfact na-sul-avobnz-otn-ocsa T1

AZELEX T2

FINACEA T3

MIRVASO T3

RHOFADE T3

ROSADAN T3

2018

64

Drug Name Formulary Tiers Restrictions

SOOLANTRA T3

SUMADAN XLT T3

DERMATOLOGICAL - TISSUE/WOUND ADHESIVES - FIBRIN SEALANTS

ARTISS T3

DERMATOLOGICAL - TOPICAL LOCAL ANESTHETIC AMIDES

lidocaine hcl T1

lidocaine-tetracaine T1

lidocaine T3

LIDODERM T3

LIDOPIN T3

LIDORX T3

PLIAGLIS T3

REGENECARE T3

REGENECARE WITH ALOE T3

SYNERA T3

DERMATOLOGICAL - TOPICAL LOCAL ANESTHETIC ESTERS

cocaine T1

ANACAINE T3

PONTOCAINE T3

DERMATOLOGICAL IRRITANTS-COUNTER-IRRITANT COMBINATIONS

MEDROX (WITHOUT METHYL SALICY) T3

DERMATOLOGICAL IRRITANTS-COUNTER-IRRITANT SINGLE AGENTS

methyl salicylate T1

QUTENZA T4

HAIR GROWTH, TOPICAL HYPERTRICHOTIC AGENTS, EYELASHES

LATISSE T3

HUMAN CELLULAR REGENERATIVE TISSUE MATRIX

EPIFIX AMNIOTIC MEMBRANE T3

GRAFIX CORE T3

GRAFIX PRIME T3

NAIL PROTECTIVES

GENADUR T3

GENADUR (WITH LEXINAL) T3

SCABICIDE AND PEDICULICIDE COMBINATIONS

LYCELLE T3

SCABICIDE AND PEDICULICIDE SINGLE AGENTS

lindane T1

permethrin T1

spinosad T1

EURAX T2

ULESFIA T2

malathion T3

SKLICE T3

SKIN REPLACEMENT, LIVE TISSUE DRESSINGS

APLIGRAF T3

2018

65

Drug Name Formulary Tiers Restrictions

DERMAGRAFT T3

WOUND CARE - CLEANSER COMBINATIONS

ATRAPRO DERMAL SPRAY T3

WOUND CARE - DRESSINGS

MEDIHONEY (HONEY) T3

WOUND CARE COMBINATIONS OTHER

RADIGEL ACEMANNAN HYDROGEL T3

DIAGNOSTIC AGENTS

CONTRAST MEDIA - BARIUM

LIQUID E-Z PAQUE T1

ENTERO VU T3

E-Z DISK T3

E-Z-CAT DRY T3

E-Z-HD BARIUM T3

E-Z-PAQUE T3

E-Z-PASTE T3

LIQUID POLIBAR PLUS T3

POLIBAR ACB T3

READI-CAT 2 T3

TAGITOL V T3

VARIBAR HONEY T3

VARIBAR NECTAR T3

VARIBAR PUDDING T3

VARIBAR THIN HONEY T3

VARIBAR THIN LIQUID T3

VOLUMEN T3

CONTRAST MEDIA - IODINATED IONIC

MD-GASTROVIEW T1

CONRAY T3

CONRAY 43 T3

CONRAY-30 T3

CYSTO-CONRAY II T3

CYSTOGRAFIN T3

CYSTOGRAFIN-DILUTE T3

GASTROGRAFIN T3

MD-76 R T3

SINOGRAFIN T3

CONTRAST MEDIA - IODINATED NONIONIC

ISOVUE-200 T3

ISOVUE-250 T3

ISOVUE-300 T3

ISOVUE-370 T3

ISOVUE-M 200 T3

ISOVUE-M 300 T3

OMNIPAQUE 140 T3

OMNIPAQUE 180 T3

OMNIPAQUE 240 T3

2018

66

Drug Name Formulary Tiers Restrictions

OMNIPAQUE 300 T3

OMNIPAQUE 350 T3

OPTIRAY 300 T3

OPTIRAY 320 T3

OPTIRAY 350 T3

ULTRAVIST T3

VISIPAQUE T3

CONTRAST MEDIA - MAGNETIC RESONANCE GADOLINIUM COMPLEXES

DOTAREM T3

EOVIST T3

GADAVIST T3

MAGNEVIST T3

MULTIHANCE T3

MULTIHANCE MULTIPACK T3

OMNISCAN T3

OMNISCAN PREFILL PLUS T3

OPTIMARK T3

PROHANCE T3

PROHANCE MULTIPACK T3

CONTRAST MEDIA - MAGNETIC RESONANCE IRON COMPOUNDS

FERIDEX IV T3

GASTROMARK T3

CONTRAST MEDIA - ULTRASOUND AGENTS

DEFINITY T3

OPTISON T3

DIAGNOSTIC - OTHER

SITZMARKS T3

DIAGNOSTIC BIOLOGICALS

APLISOL T3

TUBERSOL T3

DIAGNOSTIC DRUGS - CARDIOVASCULAR

dipyridamole T1

ADENOSCAN T3

LEXISCAN T3

DIAGNOSTIC DRUGS - GASTROINTESTINAL RADIOLOGICAL ADJUNCT

GLUCAGEN DIAGNOSTIC KIT T2

DIAGNOSTIC DRUGS - IN VIVO OTHER

isosulfan blue T1

KINEVAC T3

DIAGNOSTIC DRUGS - METABOLIC FUNCTION

CHIRHOSTIM T3

METOPIRONE T3

R-GENE 10 T3

DIAGNOSTIC DRUGS - PITUITARY FUNCTION

cosyntropin T1

ACTHREL T3

2018

67

Drug Name Formulary Tiers Restrictions

DIAGNOSTIC DRUGS - PULMONARY

PROVOCHOLINE T3

DIAGNOSTIC DRUGS - RENAL FUNCTION

INDIGO CARMINE T3

DIAGNOSTIC DRUGS - THYROID FUNCTION

THYROGEN T3

DIAGNOSTIC RADIOPHARMACEUTICALS - BONE OR SKELETAL IMAGING

kit prep of tc-99m-sod pyroph T1

kit prep tc-99m-medronate sod T1

DRAXIMAGE MDP-25 T3

DIAGNOSTIC RADIOPHARMACEUTICALS - BRAIN, AMYLOID PLAQUE IMAGING

AMYVID T3

DIAGNOSTIC RADIOPHARMACEUTICALS - CEREBRAL PERFUSION IMAGING

CERETEC T3

INDIUM IN-111 DTPA T3

DIAGNOSTIC RADIOPHARMACEUTICALS - DOPAMINE TRANSPORTER (DAT) IMAGING

DATSCAN T3

DIAGNOSTIC RADIOPHARMACEUTICALS - ENDOCRINE

ADREVIEW T3

OCTREOSCAN T3

DIAGNOSTIC RADIOPHARMACEUTICALS - HEPATOBILIARY IMAGING

kit prep of tc-99m-mebrofenin T1

DIAGNOSTIC RADIOPHARMACEUTICALS - MISC.

kit for tc 99m-sod thiosulfate T1

DIAGNOSTIC RADIOPHARMACEUTICALS - MYOCARDIAL PERFUSION IMAGING

kit for tc 99m-sestamibi no.1 T1

kit prep of tc-99m-sod pyroph T1

thallous chloride tl-201 T1

DIAGNOSTIC RADIOPHARMACEUTICALS - PROSTATIC

PROSTASCINT T3

DIAGNOSTIC RADIOPHARMACEUTICALS - PULMONARY PERFUSION IMAGING

DRAXIMAGE MAA T3

DIAGNOSTIC RADIOPHARMACEUTICALS - RADIOLABELING AUTOLOGOUS LEUKOCYTES

indium in-111 oxyquinoline T1

DIAGNOSTIC RADIOPHARMACEUTICALS - RADIOLABELING REAGENTS

INDICLOR T3

DIAGNOSTIC RADIOPHARMACEUTICALS - RENAL IMAGING

DMSA T3

DRAXIMAGE DTPA T3

DIAGNOSTIC SKIN TESTS

PRE-PEN T3

2018

68

Drug Name Formulary Tiers Restrictions

DRUGS TO TREAT ERECTILE DYSFUNCTION

ERECTILE DYSFUNCTION (ED) DRUGS - PROSTAGLANDINS

CAVERJECT T4

ERECTILE DYSFUNCTION (ED) DRUGS-SEL.CGMP PHOSPHODIESTERASE TYPE5 INHIB

CIALIS ORAL TABLET 2.5 MG, 5 MG T2 PA

CIALIS ORAL TABLET 20 MG T2

EATING DISORDER THERAPY

ANOREXIANTS

diethylpropion T1

phendimetrazine tartrate oral capsule, extended release T1

benzphetamine T3

phendimetrazine tartrate oral tablet T3

REGIMEX T3

APPETITE STIMULANTS - CANNABINOIDS

dronabinol T3 PA

SYNDROS T4 PA

APPETITE STIMULANTS - PROGESTIN HORMONE TYPE

megestrol T1

MEGACE ES T3

ELECTROLYTE BALANCE-NUTRITIONAL PRODUCTS

AMINO ACIDS, SINGLE INGREDIENT, ORAL (NON-INJECTABLE)

ENDARI T3 PA

NUTRESTORE T3

B-COMPLEX VITAMIN COMBINATIONS

FOLBEE PLUS T1

MYNEPHROCAPS T1

RENAL CAPS T1

RENO CAPS T1

TRIPHROCAPS T1

VIRT-VITE PLUS T1

CARDIOTEK-RX (BIOPERINE) T3

DIALYVITE T3

DIALYVITE 3000 T3

DIALYVITE SUPREME D T3

LYSIPLEX PLUS T3

SUPER B/C T3

SUPERVITE T3

B-COMPLEX VITAMINS

B COMPLEX 100 T3

PODIAPN T3

B-COMPLEX VITAMINS AND COMBINATIONS

RENA-VITE RX T1

VOL-CARE RX T1

DIALYVITE T3

NEPHPLEX RX T3

NEPHRO-VITE RX T3

2018

69

Drug Name Formulary Tiers Restrictions

BIOFLAVONOID COMBINATIONS

VASCULERA T3

DEXTROSE AND LACTATED RINGER'S SOLUTIONS

dextrose 5 %-lactated ringers T1

DEXTROSE AND SODIUM CHLORIDE SOLUTIONS

d10 %-0.45 % sodium chloride T1

d2.5 %-0.45 % sodium chloride T1

d5 % and 0.9 % sodium chloride T1

d5 %-0.45 % sodium chloride T1

dextrose 10 % and 0.2 % nacl T1

dextrose 5%-0.2 % sod chloride T1

dextrose 5%-0.3 % sod.chloride T1

DEXTROSE SOLUTIONS

dextrose 10 % in water (d10w) T1

dextrose 20 % in water (d20w) T1

dextrose 25 % in water (d25w) T1

dextrose 30 % in water (d30w) T1

dextrose 40 % in water (d40w) T1

dextrose 5 % in water (d5w) T1

dextrose 50 % in water (d50w) T1

dextrose 70 % in water (d70w) T1

DEXTROSE SOLUTIONS, CONCENTRATED

dextrose 20 % in water (d20w) T1

dextrose 25 % in water (d25w) T1

dextrose 30 % in water (d30w) T1

dextrose 40 % in water (d40w) T1

dextrose 50 % in water (d50w) T1

dextrose 70 % in water (d70w) T1

DIETARY PRODUCT - DIETARY SUPPLEMENTS

VP-ZEL T1

TOZAL T3

DIETARY PRODUCT - SWEETENERS

saccharin T3

DILUENTS - SODIUM CHLORIDE

sodium chloride 0.9 % T1

SWABFLUSH T3

DILUENTS - STERILE WATER FOR INJECTION

water for inject, bacteriostat T1

water for injection, sterile T1

DILUENTS - VACCINE DILUENTS

DILUENT FOR ACTHIB T2

DILUENT FOR HIBERIX T2

DILUENT FOR IMOVAX T2

DILUENT FOR MENHIBRIX T2

DILUENT FOR MENOMUNE T2

DILUENT FOR MENOMUNE (PF) T2

DILUENT FOR RABAVERT T2

2018

70

Drug Name Formulary Tiers Restrictions

DILUENT FOR ROTARIX T2

DILUENT FOR YF-VAX (1 DOSE) T2

DILUENT FOR YF-VAX (5 DOSE) T2

DILUENT-MERCK LIVE VIRUS VACC T2

ELECTROLYTE DEPLETERS - ION EXCHANGE RESIN

sodium polystyrene sulfonate T1

KIONEX (WITH SORBITOL) T1

SPS (WITH SORBITOL) T1

VELTASSA T2

GERIATRIC VITAMINS

REQ49+ T3

IRRIGATION SOLUTIONS

lactated ringers T1

ringer's T1

water for irrigation, sterile T1

PHYSIOLYTE T3

PHYSIOSOL IRRIGATION T3

MINERALS AND ELECTROLYTES - BICARBONATE PRODUCING OR CONTAINING AGENTS

sodium acetate T1

sodium bicarbonate T1

sodium lactate T1

NEUT T3

THAM T3

MINERALS AND ELECTROLYTES - CALCIUM REPLACEMENT

calcium acetate T1

calcium chloride T1

calcium gluconate T1

calcium gluconate in 0.9% nacl T1

calcium gluconate in d5w T1

MINERALS AND ELECTROLYTES - CALCIUM REPLACEMENT COMBINATIONS

CALCIUM-FOLIC ACID-VITAMIN D T1

TL G-FOL OS T1

FOLGARD OS T3

MINERALS AND ELECTROLYTES - ELECTROLYTES AND DEXTROSE

dextrose 5 % in ringer's T1

electrolyte-48 in d5w T1

ELLIOTTS B (PF) T3

IONOSOL-B IN D5W T3

IONOSOL-MB IN D5W T3

ISOLYTE-P IN 5 % DEXTROSE T3

NORMOSOL-M IN 5 % DEXTROSE T3

NORMOSOL-R IN 5 % DEXTROSE T3

PLASMA-LYTE-56 IN 5 % DEXTROSE T3

MINERALS AND ELECTROLYTES - IODINE

LUGOLS T1

2018

71

Drug Name Formulary Tiers Restrictions

STRONG IODINE T1

IODOPEN T3

SSKI T3

MINERALS AND ELECTROLYTES - IRON

sodium ferric gluconat-sucrose T1

FERAHEME T3

ICAR-C PLUS T3

INFED T3

INJECTAFER T3

VENOFER T4

MINERALS AND ELECTROLYTES - IRON COMBINATIONS

CENTRATEX T1

CORVITA 150 T1

FEROCON T1

FERRAPLUS 90 T1

FERREX 150 FORTE T1

FERREX 150 FORTE PLUS T1

FERREX 28 T1

FERROCITE PLUS T1

FOLIVANE-F T1

FOLIVANE-PLUS T1

HEMATINIC PLUS VIT/MINERALS T1

HEMATINIC/FOLIC ACID T1

HEMATOGEN FA T1

HEMATOGEN FORTE T1

HEMETAB T1

IFEREX 150 FORTE T1

MULTIGEN T1

MULTIGEN FOLIC T1

MULTIGEN PLUS T1

POLY-IRON 150 FORTE T1

TARON FORTE T1

TL ICON T1

TL-HEM 150 T1

TRIGELS-F FORTE T1

ACTIVE FE T3

BIFERA RX T3

FERRALET 90 DUAL-IRON DELIVERY T3

FUSION PLUS T3

HEMATOGEN T3

HEMATRON-AF T3

HEMOCYTE-F T3

HEMOCYTE-PLUS T3

INTEGRA F T3

INTEGRA PLUS T3

MAXFE (FOLATE-DOCUSATE) T3

NEPHRON FA T3

2018

72

Drug Name Formulary Tiers Restrictions

OB COMPLETE T3

OB COMPLETE PREMIER T3

PROFERRIN-FORTE T3

SIDEROL T3

MINERALS AND ELECTROLYTES - MAGNESIUM

magnesium chloride T1

magnesium sulfate T1

magnesium sulfate in d5w T1

magnesium sulfate in lr T1

magnesium sulfate in water T1

magnesium glycinate (bulk) T3

MINERALS AND ELECTROLYTES - MANGANESE

manganese chloride T1

MINERALS AND ELECTROLYTES - PARENTERAL ELECTROLYTE COMBINATIONS

HYPERLYTE CR T3

ISOLYTE S PH 7.4 T3

ISOLYTE-S T3

NORMOSOL-R T3

NORMOSOL-R PH 7.4 T3

NUTRILYTE T3

PLASMA-LYTE 148 T3

PLASMA-LYTE A T3

TPN ELECTROLYTES T3

TPN ELECTROLYTES II T3

MINERALS AND ELECTROLYTES - PHOSPHATE

potassium phosphate m-/d-basic T1

sodium phosphate T1

sodium phosphate in 0.9 % nacl T1

GLYCOPHOS T3

PHOSPHA 250 NEUTRAL T3

MINERALS AND ELECTROLYTES - POTASSIUM COMBINATIONS

potassium bicarb and chloride T1

MINERALS AND ELECTROLYTES - POTASSIUM FOR INJECTION

potassium acetate T1

potassium chlorid-d5-0.45%nacl T1

potassium chloride T1

potassium chloride in 0.9%nacl T1

potassium chloride in 5 % dex T1

potassium chloride in lr-d5 T1

potassium chloride-0.45 % nacl T1

potassium chloride-d5-0.2%nacl T1

potassium chloride-d5-0.3%nacl T1

potassium chloride-d5-0.9%nacl T1

MINERALS AND ELECTROLYTES - POTASSIUM, ORAL

potassium bicarb-citric acid T1

2018

73

Drug Name Formulary Tiers Restrictions

potassium chloride T1

EFFER-K T2

KLOR-CON T3

KLOR-CON M15 T3

KLOR-CON/25 T3

MINERALS AND ELECTROLYTES - TRACE MINERAL COMBINATIONS

MULTITRACE-4 T1

MULTITRACE-4 CONCENTRATE T1

MULTITRACE-4 NEONATAL T1

MULTITRACE-5 T1

MULTITRACE-5 CONCENTRATE T1

ADDAMEL N T3

MULTITRACE-4 PEDIATRIC T3

PEDITRACE T3

TRACE ELEMENTS 4/PEDIATRIC T3

MINERALS AND ELECTROLYTES - TRACE MINERALS

chromium chloride T1

selenium T1

COPPER CHLORIDE T1

chromium polynicotinate (bulk) T3

MINERALS AND ELECTROLYTES - ZINC

zinc chloride T1

zinc sulfate T1

MULTIVITAMIN AND MINERAL COMBINATIONS

ADVANCED AM-PM T1

V-C FORTE T1

VIC-FORTE T1

BACMIN T3

CORVITE FREE T3

DIALYVITE 5000 T3

NICOMIDE T3

NUTRICAP T3

OCUVEL T3

PROTECT IRON T3

REQ49+ T3

STROVITE FORTE T3

STROVITE ONE T3

UDAMIN SP T3

VITAL-D RX T3

MULTIVITAMINS

L-METHYL-MC T1

METAFOLBIC T1

PUREVIT DUALFE PLUS T1

SE-TAN PLUS T1

VIT 3 T1

ANIMI-3 WITH VITAMIN D T3

2018

74

Drug Name Formulary Tiers Restrictions

CEREFOLIN T3

DIALYVITE 800 WITH IRON T3

FORTAVIT T3

INFUVITE ADULT T3

M.V.I. ADULT T3

TANDEM PLUS T3

NUTRITIONAL PRODUCT - MEDICAL CONDITION SPECIFIC FORMULATION

ENDARI T3 PA

NUTRESTORE T3

NUTRITIONAL PRODUCT - MSUD SPECIFIC FORMULATION

CAMINO PRO 15 PE MSUD T3

NUTRITIONAL PRODUCT - NUTRITIONAL THERAPY

VITAL HIGH PROTEIN T3

NUTRITIONAL PRODUCT - PHENYLKETONURIA (PKU) SPECIFIC FORMULATION

PHENYLADE GMP T3

PKU EASY MICROTABS T3

PKU PERIFLEX JUNIOR PLUS T3

NUTRITIONAL PRODUCT - TYROSINEMIA SPECIFIC FORMULATION

TYLACTIN RESTORE 10 PE T3

TYLACTIN RTD 15 PE T3

TYR ANAMIX NEXT T3

PARENTERAL NUTRITION - AMINO ACID AND DEXTROSE COMBINATIONS

CLINIMIX 5%/D15W SULFITE FREE T3

CLINIMIX 5%/D25W SULFITE-FREE T3

CLINIMIX 2.75%/D5W SULFIT FREE T3

CLINIMIX 4.25%/D10W SULF FREE T3

CLINIMIX 4.25%/D5W SULFIT FREE T3

CLINIMIX 4.25%-D20W SULF-FREE T3

CLINIMIX 4.25%-D25W SULF-FREE T3

CLINIMIX 5%-D20W(SULFITE-FREE) T3

PARENTERAL NUTRITION - AMINO ACID AND ELECTROLYTES COMBINATION

AMINOSYN 7 % WITH ELECTROLYTES T3

AMINOSYN 8.5 %-ELECTROLYTES T3

AMINOSYN II 8.5 %-ELECTROLYTES T3

PARENTERAL NUTRITION - AMINO ACID SOLUTIONS

cysteine (l-cysteine) T1

CLINISOL SF 15 % T1

AMINO ACIDS 15 % T3

AMINOSYN 10 % T3

AMINOSYN 3.5 % T3

AMINOSYN 7 % T3

AMINOSYN 8.5 % T3

AMINOSYN II 10 % T3

AMINOSYN II 15 % T3

2018

75

Drug Name Formulary Tiers Restrictions

AMINOSYN M 3.5 % T3

AMINOSYN-HBC 7% T3

AMINOSYN-PF 10 % T3

AMINOSYN-PF 7 % (SULFITE-FREE) T3

CLINIMIX E 2.75%/D10W SUL FREE T3

CLINIMIX E 2.75%/D5W SULF FREE T3

CLINIMIX E 4.25%/D10W SUL FREE T3

CLINIMIX E 4.25%/D25W SUL FREE T3

CLINIMIX E 4.25%/D5W SULF FREE T3

CLINIMIX E 5%/D15W SULFIT FREE T3

CLINIMIX E 5%/D20W SULFIT FREE T3

CLINIMIX E 5%/D25W SULFIT FREE T3

FREAMINE HBC 6.9 % T3

FREAMINE III 10 % T3

HEPATAMINE 8% T3

NEPHRAMINE 5.4 % T3

PREMASOL 10 % T3

PREMASOL 6 % T3

PROCALAMINE 3% T3

PROSOL 20 % T3

TRAVASOL 10 % T3

TROPHAMINE 10 % T3

TROPHAMINE 6% T3

PARENTERAL NUTRITION - AMINO ACID, DEXTROSE, E-LYTES AND FAT EMUL COMB

KABIVEN T3

PERIKABIVEN T3

PARENTERAL NUTRITION - INTRAVENOUS FAT EMULSIONS

INTRALIPID T3

LIPOSYN II T3

LIPOSYN III T3

NUTRILIPID T3

PEDIATRIC VITAMINS

MVW COMPLETE FORMUL PEDIATRIC T1

INFUVITE PEDIATRIC T3

M.V.I. PEDIATRIC T3

MVW COMPLETE FORMULATION D3000 T3

PEDIATRIC VITAMINS WITH FLUORIDE AND MINERALS COMBINATIONS

TRI-VIT WITH FLUORIDE AND IRON T3

PEDIATRIC VITAMINS WITH FLUORIDE COMBINATIONS

MULTIVITAMIN WITH FLUORIDE T1

MULTI-VITAMIN WITH FLUORIDE T1

MULTIVITAMINS WITH FLUORIDE T1

TRIPLE VITAMIN WITH FLUORIDE T1

TRI-VITAMIN WITH FLUORIDE T1

VITAMINS A,C,D AND FLUORIDE T1

ESCAVITE T3

2018

76

Drug Name Formulary Tiers Restrictions

ESCAVITE D T3

FLORIVA (FLUORIDE-VITAMIN D3) T3

MVC-FLUORIDE T3

POLY-VI-FLOR T3

POLY-VI-FLOR WITH IRON T3

QUFLORA FE (FERROUS SULFATE) T3

QUFLORA PEDIATRIC DROPS T3

TEXAVITE LQ T3

TRI-VI-FLOR T3

PRENATAL VITAMINS AND MINERALS

C-NATE DHA T1

COMPLETE NATAL DHA T1

COMPLETENATE T1

ELITE OB WITH DHA T1

ELITE-OB 400 T1

EXTRA-VIRT PLUS DHA T1

FOLIVANE-OB T1

HEMENATAL OB T1

HEMENATAL OB + DHA T1

LEVOMEFOLATE DHA T1

MYNATAL ADVANCE T1

MYNATAL ORAL TABLET T1

MYNATAL PLUS T1

MYNATAL-Z T1

MYNATE 90 PLUS T1

OBSTETRIX DHA T1

PNV OB+DHA T1

PNV-DHA T1

PNV-DHA + DOCUSATE T1

PNV-OMEGA T1

PNV-SELECT T1

PR NATAL 400 T1

PR NATAL 400 EC T1

PR NATAL 430 T1

PR NATAL 430 EC T1

PRENA1 TRUE T1

PRENAISSANCE T1

PRENAISSANCE PLUS T1

PRENATAL 19 (WITH DOCUSATE) T1

PRENATAL LOW IRON T1

PRENATAL PLUS T1

PRENATAL PLUS (CALCIUM CARB) T1

PRENATAL-U T1

RELNATE DHA T1

SE-NATAL 19 T1

SE-NATAL 19 (WITH DOCUSATE) T1

TARON-C DHA T1

2018

77

Drug Name Formulary Tiers Restrictions

TARON-PREX PRENATAL-DHA T1

TL-SELECT T1

TRIADVANCE T1

TRINATAL GT T1

TRINATAL RX 1 T1

TRIVEEN-DUO DHA T1

TRIVEEN-ONE T1

TRIVEEN-PRX RNF T1

TRUST NATAL DHA T1

ULTIMATECARE ONE T1

ULTIMATECARE ONE NF T1

VEMAVITE-PRX-2 T1

VENA-BAL DHA T1

VINACAL T1

VINATE GT T1

VINATE II T1

VINATE M T1

VINATE ONE T1

VINATE PN CARE T1

VINATE ULTRA T1

VIRT-PN T1

VIRT-PN DHA T1

VIRT-PN PLUS T1

VIRT-SELECT T1

VOL-NATE T1

VOL-TAB RX T1

VP-CH PLUS T1

VP-CH-PNV T1

VP-HEME ONE T1

VP-PNV-DHA T1

ZATEAN-CH T1

ZATEAN-PN DHA T1

ZATEAN-PN PLUS T1

ATABEX EC T3

BAL-CARE DHA T3

BAL-CARE DHA ESSENTIAL T3

CITRANATAL (DUAL-IRON) T3

CITRANATAL 90 DHA (ALGAL OIL) T3

CITRANATAL ASSURE T3

CITRANATAL B-CALM (FE GLUC) T3

CITRANATAL DHA (ALGAL OIL) T3

CONCEPT DHA T3

CONCEPT OB T3

DUET DHA BALANCED T3

DUET DHA WITH OMEGA-3 T3

FOCALGIN CA T3

MARNATAL-F T3

2018

78

Drug Name Formulary Tiers Restrictions

MYNATAL ORAL CAPSULE T3

NESTABS T3

NESTABS ABC T3

NESTABS DHA T3

OB COMPLETE T3

OB COMPLETE WITH DHA T3

OBSTETRIX EC T3

OBTREX DHA T3

O-CAL FA T3

O-CAL PRENATAL T3

PREFERA-OB PLUS DHA T3

PRENATA T3

PRENATABS FA T3

PRENATABS RX T3

PRENATAL 19 T3

PROVIDA DHA T3

PROVIDA OB T3

PUREFE OB PLUS T3

PUREFE PLUS T3

SELECT-OB (FOLIC ACID) T3

SELECT-OB + DHA T3

TRICARE T3

TRICARE PRENATAL DHA ONE T3

TRINATE T3

VINATE CARE T3

VITAFOL GUMMIES T3

VITAFOL-OB+DHA T3

VIVA DHA T3

PRENATAL VITAMINS WITHOUT IRON

VP-GGR-B6 T1

ZINGIBER T1

RINGER'S AND LACTATED RINGER'S SOLUTIONS

lactated ringers T1

ringer's T1

SODIUM CHLORIDE FLUSHES

sodium chloride 0.9 % T1

SWABFLUSH T3

SODIUM CHLORIDE SOLUTIONS, CONCENTRATED

sodium chloride T1

sodium chloride 3 % T1

sodium chloride 5 % T1

SODIUM CHLORIDE, PARENTERAL

sodium chloride T1

sodium chloride 0.45 % T1

sodium chloride 0.9 % T1

sodium chloride 3 % T1

sodium chloride 5 % T1

2018

79

Drug Name Formulary Tiers Restrictions

SWABFLUSH T3

STERILE WATER FOR INJECTION

water for injection, sterile T1

VITAMINS - A

AQUASOL A T3

VITAMINS - B PREPARATION COMBINATIONS

folic acid-vit b6-vit b12 T1

FABB T1

FOLBIC RF T1

LMTHF-PYRIDOXINE-CYANOCOBALAMN T1

TL GARD RX T1

FOLGARD RX T3

FOLTX T3

NEURIN-SL T3

VITA-RESPA T3

VITAMINS - B-1, THIAMINE AND DERIVATIVES

thiamine hcl (vitamin b1) T1

VITAMINS - B-12 AND FOLIC ACID COMBINATIONS

FOLTRATE T3

VITAMINS - B-12, CYANOCOBALAMIN AND DERIVATIVES

cyanocobalamin (vitamin b-12) T1

hydroxocobalamin T1

PHYSICIANS EZ USE B-12 T1

B-12 COMPLIANCE T3

ELIGEN B12 T3

NASCOBAL T3 ST

NEURIN-SL T3

VITAMINS - B-3, NIACIN AND DERIVATIVES

niacin T1

niacinamide (bulk) T1

VITAMINS - B-6, PYRIDOXINE AND DERIVATIVES

pyridoxine (vitamin b6) T1

VITAMINS - C, ASCORBIC ACID AND DERIVATIVES

ascorbic acid (vitamin c) T1

VITAMINS - D DERIVATIVES

calcitriol T1

ergocalciferol (vitamin d2) T1

calcitriol (bulk) T2

VITAL-D RX T3

VITAMINS - E

vitamin e T1

wheat germ oil T1

NATURAL MIXED TOCOPHEROLS T3

VITAMINS - FOLIC ACID AND DERIVATIVES

folic acid T1

levomefolate calcium T1

METHYLTETRAHYDROFOLIC ACID T2

DEPLIN (ALGAL OIL) T3

2018

80

Drug Name Formulary Tiers Restrictions

L-METHYLFOLATE FORTE T3

VITAMINS - FOLIC ACID COMBINATIONS

folic acid-vit b6-vit b12 T1

FABB T1

TL GARD RX T1

FOLGARD RX T3

PURALOR CI T3

VITA-RESPA T3

VITAMINS - K, PHYTONADIONE AND DERIVATIVES

phytonadione (vit k1) (bulk) T1

phytonadione (vitamin k1) T1

VITAMIN K T1

VITAMIN K1 T1

VITAMINS - PABA

POTABA T3

ENDOCRINE

ABORTIFACIENTS OR CERVICAL RIPENING AGENTS - PROSTAGLANDIN ANALOGS

CERVIDIL T3

HEMABATE T3

PREPIDIL T3

PROSTIN E2 T3

ABORTIFACIENTS- PROGESTERONE RECEPTOR ANTAGONIST

MIFEPREX T3

ADRENOCORTICOTROPHIC HORMONES

ACTHAR H.P. T4 PA

AGENTS TO TREAT HYPOGLYCEMIA (HYPERGLYCEMICS)

glucagon hcl T1

GLUCAGEN HYPOKIT T2

GLUCAGON EMERGENCY KIT (HUMAN) T2

PROGLYCEM T3

ANABOLIC STEROID - SINGLE AGENTS

oxandrolone T3

ANADROL-50 T3

ANDROGEN - SINGLE AGENTS

methyltestosterone T1

testosterone T1

testosterone (bulk) T1

testosterone cypionate T1

testosterone enanthate T1

ANDROGEL T2

ANDRODERM T3 ST

AVEED T3 ST

AXIRON T3 ST

DEPO-TESTOSTERONE T3 ST

FORTESTA T3 ST

NATESTO T3 ST

2018

81

Drug Name Formulary Tiers Restrictions

STRIANT T3 ST

TESTIM T3 ST

VOGELXO T3 ST

ANTIDIURETIC AND VASOPRESSOR HORMONES

desmopressin T1 PA

vasopressin T1

VASOSTRICT T3

STIMATE T4

ANTIHYPERGLYCEMIC - ALPHA-GLUCOSIDASE INHIBITORS

acarbose T1

miglitol T3

ANTIHYPERGLYCEMIC - DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS

alogliptin T1

TRADJENTA T2

JANUVIA T3 ST

NESINA T3 ST

ONGLYZA T3 ST

ANTIHYPERGLYCEMIC - DOPAMINE RECEPTOR AGONISTS

CYCLOSET T3

ANTIHYPERGLYCEMIC - GLUCOCORTICOID (CORTISOL) RECEPTOR BLOCKER (GR-II)

KORLYM T4 PA

ANTIHYPERGLYCEMIC - MEGLITINIDE ANALOG AND BIGUANIDE COMBINATIONS

repaglinide-metformin T1

ANTIHYPERGLYCEMIC - MEGLITINIDE ANALOGS

nateglinide T1

repaglinide T1

ANTIHYPERGLYCEMIC - SGLT-2 INHIBITOR AND BIGUANIDE COMBINATIONS

INVOKAMET T2

INVOKAMET XR T2

SYNJARDY T2

SYNJARDY XR T2

XIGDUO XR T3 ST

ANTIHYPERGLYCEMIC - SGLT-2 INHIBITOR AND DPP-4 INHIBITOR COMBINATIONS

GLYXAMBI T2

ANTIHYPERGLYCEMIC - SODIUM GLUCOSE COTRANSPORTER-2 (SGLT2) INHIBITORS

INVOKANA T2

JARDIANCE T2

FARXIGA T3 ST

ANTIHYPERGLYCEMIC - SULFONYLUREA AND BIGUANIDE COMBINATIONS

glipizide-metformin T1

glyburide-metformin T1

ANTIHYPERGLYCEMIC - SULFONYLUREA DERIVATIVES

chlorpropamide T1

2018

82

Drug Name Formulary Tiers Restrictions

glimepiride T1

glipizide T1

glyburide T1

glyburide micronized T1

tolazamide T1

tolbutamide T1

ANTIHYPERGLYCEMIC - THIAZOLIDINEDIONE AND BIGUANIDE COMBINATIONS

ACTOPLUS MET XR T3

AVANDAMET T4

ANTIHYPERGLYCEMIC - THIAZOLIDINEDIONE AND SULFONYLUREA COMBINATIONS

pioglitazone-glimepiride T1

ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPE

SYMLINPEN 120 T3 PA

SYMLINPEN 60 T3 PA

ANTIHYPERGLYCEMIC, INCRETIN MIMETIC,GLP-1 RECEPTOR AGONIST ANALOG-TYPE

TRULICITY T2 ST

VICTOZA 2-PAK T2 ST

VICTOZA 3-PAK T2 ST

ADLYXIN T3 ST

BYDUREON T3 ST

BYETTA T3 ST

TANZEUM T3 ST

ANTIHYPERGLYCEMIC-DIPEPTIDYL PEPTIDASE-4 INHIBIT AND THIAZOLIDINEDIONE

alogliptin-pioglitazone T1

OSENI T3 ST

ANTIHYPERGLYCEMIC-DIPEPTIDYL PEPTIDASE-4(DPP-4)INHIBITOR AND BIGUANIDE

alogliptin-metformin T1

JENTADUETO T2

JENTADUETO XR T2

JANUMET T3 ST

JANUMET XR T3 ST

KAZANO T3 ST

KOMBIGLYZE XR T3 ST

ANTIHYPERGLYCEMIC-INSULIN, LONG ACTING AND GLP-1 RECEPTOR AGONIST COMB

SOLIQUA 100/33 T2 ST

ANTITHYROID AGENTS, THIONAMIDES - IMIDAZOLE DERIVATIVES

methimazole T1

ANTITHYROID AGENTS, THIONAMIDES - THIOURACIL DERIVATIVES

propylthiouracil T1

BONE FORMATION STIMULATING AGENTS - PARATHYROID HORMONE REL PEPTIDES

TYMLOS T4 PA

2018

83

Drug Name Formulary Tiers Restrictions

BONE FORMATION STIMULATING AGENTS - PARATHYROID HORMONE-TYPE

FORTEO T4 PA

BONE RESORPTION INHIBITORS - BISPHOSPHONATE AND VITAMIN D COMBINATIONS

FOSAMAX PLUS D T2

BONE RESORPTION INHIBITORS - BISPHOSPHONATES

alendronate T1

etidronate disodium T1

ibandronate T1

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

risedronate oral tablet T3

zoledronic acid-mannitol-water T3

ACTONEL T3

ATELVIA T3

BINOSTO T3

BONIVA T3

pamidronate T4

zoledronic acid T4

zoledronic ac-mannitol-0.9nacl T4 PA

CALCIMIMETIC, PARATHYROID CALCIUM RECEPTOR SENSITIVITY ENHANCER

SENSIPAR T4

CALCITONINS

calcitonin (salmon) T1

MIACALCIN T3

ESTROGEN AND PROGESTIN WITH ANTIMINERALOCORTICOID ACTIVITY,COMBINATION

ANGELIQ T3

ESTROGEN AND SELECTIVE ESTROGEN RECEPTOR MODULATOR (SERM) COMBINATIONS

DUAVEE T2

ESTROGEN-ANDROGEN

estrogens-methyltestosterone T1

ESTROGEN-PROGESTIN

estradiol-norethindrone acet T1

norethindrone ac-eth estradiol T1

AMABELZ T1

JINTELI T1

COMBIPATCH T2

PREMPHASE T2

PREMPRO T2

CLIMARA PRO T3

FEMHRT LOW DOSE T3

PREFEST T3

ESTROGENS

estradiol T1

estradiol valerate T1

estropipate T1

2018

84

Drug Name Formulary Tiers Restrictions

ALORA T2

DIVIGEL T2

EVAMIST T2

MINIVELLE T2

PREMARIN ORAL T2

CLIMARA T3

DEPO-ESTRADIOL T3

ELESTRIN T3

ESTROGEL T3

MENEST T3

MENOSTAR T3

PREMARIN INJECTION T3

VIVELLE-DOT T3

FERTILITY ENHANCER - LUTEAL PHASE SUPPORTING, PROGESTERONE-TYPE

ENDOMETRIN T3

FERTILITY ENHANCER - OVULATION STIMULANT - SYNTHETIC (NON-FSH)

clomiphene citrate T1

FOLLICLE-STIMULATING AND LUTEINIZING HORMONES

MENOPUR T4

FOLLICLE-STIMULATING HORMONE (FSH)

BRAVELLE T4

FOLLISTIM AQ T4 ST

GONAL-F T4

GONAL-F RFF T4

GLUCOCORTICOID SALT COMBINATIONS

betamethasone acet,sod phos T1

GLUCOCORTICOIDS

cortisone T1

dexamethasone T1

dexamethasone in 0.9 % sod chl T1

dexamethasone sodium phos (pf) T1

dexamethasone sodium phosphate T1

hydrocortisone T1

methylprednisolone T1

methylprednisolone acetate T1

methylprednisolone sodium succ T1

prednisolone T1

prednisolone sodium phosphate T1

prednisone T1

DEXAMETHASONE INTENSOL T1

MILLIPRED DP T1

PREDNISONE INTENSOL T1

triamcinolone hexaceton (bulk) T3

ARISTOSPAN INTRA-ARTICULAR T3

ARISTOSPAN INTRALESIONAL T3

DEPO-MEDROL T3

2018

85

Drug Name Formulary Tiers Restrictions

KENALOG T3

MEDROL T3

MILLIPRED T3

ORAPRED ODT T3

SOLU-CORTEF T3

SOLU-CORTEF (PF) T3

SOLU-MEDROL T3

SOLU-MEDROL (PF) T3

VERIPRED 20 T3

ZODEX T3

EMFLAZA T4 PA

GONADOTROPIN INHIBITOR PITUITARY SUPPRESSANTS

danazol T1

GROWTH HORMONE RECEPTOR ANTAGONISTS

SOMAVERT T4 PA

GROWTH HORMONE RELEASING HORMONES (GHRH)

EGRIFTA T4 PA

GROWTH HORMONES

NORDITROPIN FLEXPRO T4 PA

HUMAN CHORIONIC GONADOTROPIN (HCG)

chorionic gonadotropin, human T3

NOVAREL INTRAMUSCULAR RECON SOLN 10,000 UNIT T3

PREGNYL T3

NOVAREL INTRAMUSCULAR RECON SOLN 5,000 UNIT T4

HUMAN INSULINS - FIXED COMBINATIONS

NOVOLIN 70/30 T2

HUMAN INSULINS - INTERMEDIATE ACTING

NOVOLIN N T2

HUMAN INSULINS - SHORT ACTING

NOVOLIN R T2

INSULIN ANALOGS - FIXED COMBINATIONS

NOVOLOG MIX 70-30 T2

NOVOLOG MIX 70-30 FLEXPEN T2

INSULIN ANALOGS - LONG ACTING

LANTUS T2

LANTUS SOLOSTAR T2

LEVEMIR T2

LEVEMIR FLEXTOUCH T2

TOUJEO SOLOSTAR T2

TRESIBA FLEXTOUCH U-100 T2

TRESIBA FLEXTOUCH U-200 T2

INSULIN ANALOGS - RAPID ACTING

NOVOLOG T2

NOVOLOG FLEXPEN T2

NOVOLOG PENFILL T2

INSULIN RESPONSE ENHANCERS - BIGUANIDES

metformin T1

RIOMET T3

2018

86

Drug Name Formulary Tiers Restrictions

INSULIN RESPONSE ENHANCERS - THIAZOLIDINEDIONES (PPAR-GAMMA AGONISTS)

pioglitazone T1

AVANDIA T4

INSULIN-LIKE GROWTH FACTOR-1 (IGF-1)

INCRELEX T4 PA

LEPTIN HORMONE ANALOGS

MYALEPT T4 PA

LHRH (GNRH) AGONIST ANALOG PIT SUPPRES - CENTRAL PRECOCIOUS PUBERTY

LUPRON DEPOT-PED T4

LUPRON DEPOT-PED (3 MONTH) T4

TRIPTODUR T4

LHRH (GNRH) AGONIST ANALOG PITUITARY SUPP. AND PROGESTIN COMB.

LUPANETA PACK (1 MONTH) T4

LUPANETA PACK (3 MONTH) T4

LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS

LUPRON DEPOT T4

LUPRON DEPOT (3 MONTH) T4

SYNAREL T4

LHRH (GNRH) ANTAGONISTS

ganirelix T4

CETROTIDE T4

MENOPAUSAL SYMPTOMS SUPPRESSANT-SELECTIVE ESTROGEN RECEPTOR MODULATORS

OSPHENA T3

MENOPAUSAL SYMPTOMS SUPPRESSANT-SSRI ANTIDEPRESSANT TYPE

paroxetine mesylate T1

BRISDELLE T3 ST

MENOPAUSAL SYMPTOMS SUPRESSANT - HORMONAL AGENTS

INTRAROSA T3

MINERALOCORTICOIDS

fludrocortisone T1

OXYTOCIC - ERGOT ALKALOIDS

methylergonovine T1

OXYTOCIC - OXYTOCIN AND ANALOGS

oxytocin T1

oxytocin in dextrose 5 % in lr T1

PARATHYROID HORMONES

NATPARA T4 PA

PROGESTINS

medroxyprogesterone T1

norethindrone acetate T1

progesterone T1

progesterone micronized T1

hydroxyprogesterone caproate T4 PA

MAKENA T4 PA

2018

87

Drug Name Formulary Tiers Restrictions

PROLACTIN INHIBITOR - ERGOT DERIVATIVE DOPAMINE RECEPTOR AGONISTS

cabergoline T1

RANK LIGAND (RANKL) INHIBITOR, MC ANTIBODY

PROLIA T4 PA

XGEVA T4 PA

SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)

raloxifene T1

EVISTA T3

SOMATOSTATIC AGENTS

octreotide acetate T3

SANDOSTATIN LAR DEPOT T4 PA

SIGNIFOR T4 PA

SIGNIFOR LAR T4 PA

SOMATULINE DEPOT T4 PA

THYROID HORMONE COMBINATIONS - SYNTHETIC T3 AND T4

THYROLAR-1 T3

THYROLAR-1/2 T3

THYROLAR-1/4 T3

THYROLAR-2 T3

THYROLAR-3 T3

THYROID HORMONES - ANIMAL SOURCE (PORCINE)

ARMOUR THYROID T3

NATURE-THROID T3

NP THYROID T3

WESTHROID T3

WP THYROID T3

THYROID HORMONES - SYNTHETIC T3 (TRIIODOTHYRONINE)

liothyronine oral T1

liothyronine intravenous T3

THYROID HORMONES - SYNTHETIC T4 (THYROXINE)

levothyroxine T1

LEVOXYL T2

SYNTHROID T2

TIROSINT T3

ENZYMES

ENZYMES

HYLENEX T3

VITRASE T3

HYQVIA HY COMPONENT T4 PA

GASTROINTESTINAL THERAPY AGENTS

ANTACID - ALUMINUM

aluminum hydroxide gel T1

ANTIDIARRHEAL - ANTIPERISTALTIC AGENTS

opium tincture T1

paregoric T1

2018

88

Drug Name Formulary Tiers Restrictions

ANTIDIARRHEAL - GASTROINTESTINAL CHLORIDE CHANNEL INHIBITORS

MYTESI T3

ANTIDIARRHEAL - TRYPTOPHAN HYDROXYLASE INHIBITOR

XERMELO T4 PA

ANTIDIARRHEAL ANTIPERISTALTIC-ANTICHOLINERGIC COMBINATIONS

diphenoxylate-atropine T1

MOTOFEN T2

ANTIEMETIC - ANTICHOLINERGICS

scopolamine base T1

TRANSDERM-SCOP T3

ANTIEMETIC - ANTIHISTAMINES

dimenhydrinate T1

meclizine T1

ANTIEMETIC - CANNABINOIDS

dronabinol T3 PA

CESAMET T3

SYNDROS T4 PA

ANTIEMETIC - DOPAMINE (D2)/5-HT3 ANTAGONISTS

trimethobenzamide T3

ANTIEMETIC - PHENOTHIAZINES

prochlorperazine T1

prochlorperazine maleate T1

promethazine T1

prochlorperazine edisylate T3

PROMETHEGAN T3

ANTIEMETIC - SELECTIVE SEROTONIN 5-HT3 ANTAGONISTS

granisetron (pf) T1

granisetron hcl T1

ondansetron T1

ondansetron hcl T1

ondansetron hcl (pf) T1

ondansetron in 0.9 % sod chlor T1

ALOXI T3

ANZEMET T3

SANCUSO T3

SUSTOL T3

ZUPLENZ T3

ANTIEMETIC - SUBSTANCE P-NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS

aprepitant T1

EMEND T2

EMEND (FOSAPREPITANT) T2

VARUBI T3

ANTIEMETIC - SUBSTANCE P-NEUROKININ 1 AND 5-HT3 RECEPT ANTAGONIST COMB

AKYNZEO T3

2018

89

Drug Name Formulary Tiers Restrictions

BILE ACIDS

CHOLBAM ORAL CAPSULE 250 MG T3 PA

CHOLBAM ORAL CAPSULE 50 MG T4 PA

CHRONIC IIDOPATHIC CONST. AGENTS - GUANYLATE CYCLASE-C (GC-C) AGONISTS

LINZESS T2

TRULANCE T3

COLONIC ACIDIFIER (AMMONIA INHIBITOR)

lactulose T1

DIGESTIVE ENZYME MIXTURES

CREON T2

PANCREAZE T2

ZENPEP T2

PERTZYE T3

VIOKACE T3

DIGESTIVE ENZYMES

SUCRAID T4 PA

GALLSTONE SOLUBILIZING (LITHOLYSIS) AGENTS

ursodiol oral capsule T1

ursodiol oral tablet T3

CHENODAL T4 ST

GASTRIC ACID SECRETION REDUCERS - HISTAMINE H2-RECEPTOR ANTAGONISTS

cimetidine T1

cimetidine hcl T1

famotidine T1

famotidine (pf) T1

famotidine (pf)-nacl (iso-os) T1

nizatidine T1

ranitidine hcl T1

GASTRIC ACID SECRETION REDUCING AGENTS - PROTON PUMP INHIBITORS (PPIS)

pantoprazole T1

rabeprazole T1

NEXIUM PACKET T2

PREVACID SOLUTAB T2

esomeprazole magnesium T3

esomeprazole sodium T3

ACIPHEX T3

ACIPHEX SPRINKLE T3

DEXILANT T3

NEXIUM IV T3

PRILOSEC T3

PROTONIX T3

GASTRIC MUCOSA - CYTOPROTECTIVE PROSTAGLANDIN ANALOGS

misoprostol T1

2018

90

Drug Name Formulary Tiers Restrictions

GASTROINTESTINAL PROKINETIC AGENTS - D2 ANTAGONIST/5-HT4 AGONISTS

metoclopramide hcl injection T1

metoclopramide hcl oral solution T1

metoclopramide hcl oral tablet T1

metoclopramide hcl oral tablet,disintegrating 5 mg T1

metoclopramide hcl oral tablet,disintegrating 10 mg T3

GI ANTISPASMODIC - BELLADONNA ALKALOIDS

atropine T1

atropine (bulk) T1

belladonna tincture (bulk) T1

hyoscyamine sulfate T1

scopolamine hbr T1

methscopolamine T3

LEVSIN T3

SYMAX DUOTAB T3

GI ANTISPASMODIC - QUATERNARY AMMONIUM COMPOUNDS

glycopyrrolate intravenous T1

glycopyrrolate oral T1

propantheline T1

glycopyrrolate injection T3

GI ANTISPASMODIC - SYNTHETIC TERTIARY AMINES

dicyclomine T1

BENTYL T3

GI ANTISPASMODIC AND BENZODIAZEPINE COMBINATIONS

chlordiazepoxide-clidinium T1

GI ANTISPASMODIC COMBINATIONS OTHER

belladonna alkaloids-opium T1

chlordiazepoxide-clidinium T1

BELLADONNA-OPIUM T1

phenobarb-hyoscy-atropine-scop T3

DONNATAL T3

IBS AGENT - GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATOR AGENTS

AMITIZA T2

IBS AGENT - GUANYLATE CYCLASE-C (GC-C) AGONISTS

LINZESS T2

IBS AGENT - MIXED OPIOID RECEPTOR AGONIST AND ANTAGONIST

VIBERZI T2 PA

IBS AGENT - SELECTIVE 5-HT3 RECEPTOR ANTAGONISTS

LOTRONEX T3

INFLAMMATORY BOWEL AGENT - INTERLEUKIN-12 AND IL-23 INHIBITORS, MC AB

STELARA T4 ST

INFLAMMATORY BOWEL AGENT - AMINOSALICYLATES AND RELATED AGENTS

balsalazide T1

mesalamine oral T1

2018

91

Drug Name Formulary Tiers Restrictions

sulfasalazine T1

APRISO T2

CANASA T2

DELZICOL T2

LIALDA T2

PENTASA T2

mesalamine rectal T3

mesalamine with cleansing wipe T3

DIPENTUM T3

GIAZO T3

INFLAMMATORY BOWEL AGENT - GLUCOCORTICOIDS

hydrocortisone T1

CORTIFOAM T2

budesonide T3

UCERIS T3

INFLAMMATORY BOWEL AGENT - INTEGRIN RECEPTOR ANTAGONIST, MC ANTIBODY

ENTYVIO T4 ST

INFLAMMATORY BOWEL AGENT - TUMOR NECROSIS FACTOR ALPHA BLOCKERS

CIMZIA T4 ST

CIMZIA POWDER FOR RECONST T4 ST

CIMZIA STARTER KIT T4 ST

HUMIRA T4

HUMIRA PEDIATRIC CROHN'S START T4

REMICADE T4 ST

RENFLEXIS T4 PA

IRRITABLE BOWEL SYNDROME (IBS) AGENTS

alosetron T1 PA

AMITIZA T2

LINZESS T2

VIBERZI T2 PA

LOTRONEX T3

KERATINOCYTE GROWTH FACTOR (KGF)

KEPIVANCE T4 PA

LAXATIVE - SALINE AND OSMOTIC

lactulose T1

polyethylene glycol 3350 T1

sorbitol T1

KRISTALOSE T2

LAXATIVE - SALINE/OSMOTIC MIXTURES

peg 3350-electrolytes T1

peg-electrolyte soln T1

GOLYTELY ORAL POWDER IN PACKET T2

GOLYTELY ORAL RECON SOLN T3

MOVIPREP T3

OSMOPREP T3

SUPREP BOWEL PREP KIT T3

2018

92

Drug Name Formulary Tiers Restrictions

LAXATIVE - STIMULANT AND SALINE/OSMOTIC COMBINATIONS

PREPOPIK T3

PEPTIC ULCER - GASTRIC LUMEN ADHERENT CYTOPROTECTIVES

sucralfate T1

CARAFATE T2

PEPTIC ULCER - TREATMENT OF H. PYLORI: ANTIBIOTIC-BISMUTH COMBINATIONS

PYLERA T2

PEPTIC ULCER-TREATMENT H. PYLORI-PROTON PUMP INHIBITOR AND ANTIBIOTICS

amoxicil-clarithromy-lansopraz T3

OMECLAMOX-PAK T3

PREVPAC T3

SHORT BOWEL SYNDROME (SBS) - GLUCAGON-LIKE PEPTIDE-2 (GLP-2) ANALOG

GATTEX 30-VIAL T3 PA

GATTEX ONE-VIAL T3 PA

SHORT BOWEL SYNDROME (SBS) AGENTS

octreotide acetate T3

ENDARI T3 PA

NUTRESTORE T3

SANDOSTATIN LAR DEPOT T4

GENITOURINARY THERAPY

BPH AGENT- 5-ALPHA REDUCTASE INHIB AND ALPHA-1 ADRENOCEPTOR ANTAG COMB

dutasteride-tamsulosin T3

JALYN T3

CYSTINOSIS THERAPY (CYSTINE DEPLETING AGENTS)

CYSTAGON T4

PROCYSBI T4 PA

G.U. IRRIGANTS

acetic acid T1

glycine urologic solution T1

sorbitol T1

sorbitol-mannitol T1

RESECTISOL T3

G.U. IRRIGANTS - ANTI-INFECTIVE

neomycin-polymyxin b gu T1

INTERSTITIAL CYSTITIS AGENTS

ELMIRON T2

RIMSO-50 T3

KIDNEY STONE AGENTS

THIOLA T4 PA

OVERACTIVE BLADDER AGENTS - BETA -3 ADRENERGIC RECEPTOR AGONIST

MYRBETRIQ T2

PHOSPHATE BINDERS

calcium acetate T1

sevelamer carbonate T1

2018

93

Drug Name Formulary Tiers Restrictions

FOSRENOL ORAL POWDER IN PACKET T2

RENAGEL T2

RENVELA T2

AURYXIA T3

FOSRENOL ORAL TABLET,CHEWABLE T3

MAGNEBIND 400 T3

PHOSLYRA T3

PHOSPHATE BINDERS - IRON-BASED

AURYXIA T3

PROSTATIC HYPERTROPHY AGENT - ALPHA-1-ADRENOCEPTOR ANTAGONISTS

alfuzosin T1

tamsulosin T1

RAPAFLO T3

PROSTATIC HYPERTROPHY AGENT - TYPE II 5-ALPHA REDUCTASE INHIBITORS

finasteride T1

PROSTATIC HYPERTROPHY AGENT-SEL.CGMP PHOSPHODIESTERASE TYPE5 INHIBITOR

CIALIS T2 PA

PROSTATIC HYPERTROPHY AGENT-TYPE I AND II 5-ALPHA REDUCTASE INHIBITORS

dutasteride T3

AVODART T3

URINARY ACIDIFIER - OTHERS

ammonium chloride T1

URINARY ACIDIFIER - PHOSPHATES

K-PHOS NO 2 T3

K-PHOS ORIGINAL T3

PHOSPHA 250 NEUTRAL T3

URINARY ALKALINIZER - CITRATES

potassium citrate T1

sodium citrate-citric acid T1

CYTRA-3 T1

SHOHL'S MODIFIED T1

TRICITRATES T1

UROCIT-K 15 T2

CYTRA K CRYSTALS T3

CYTRA-K T3

ORACIT T3

UROCIT-K 10 T3

UROCIT-K 5 T3

URINARY ANALGESICS

phenazopyridine T1

URINARY ANTIBACTERIAL - METHENAMINE AND SALTS

methenamine hippurate T1

methenamine mandelate T1

UROQID-ACID NO.2 T3

2018

94

Drug Name Formulary Tiers Restrictions

URINARY ANTIBACTERIAL - NITROFURAN DERIVATIVES

MACRODANTIN T1

nitrofurantoin T3

nitrofurantoin macrocrystal T3

nitrofurantoin monohyd/m-cryst T3

URINARY ANTIBACTERIAL - QUINOLONES

ciprofloxacin (mixture) T1

URINARY ANTIBACTERIALS OTHER

MONUROL T3

URINARY ANTI-INFECTIVE METHENAMINE-ANTISPAS-ANALG COMBINATIONS

HYOPHEN T1

PHOSPHASAL T1

UR N-C T1

URIN DS T1

URO-MP T1

USTELL T1

URELLE T3

URETRON D-S T3

URIBEL T3

URINARY ANTI-INFECTIVE METHENAMINE-ANTISPASMODIC COMBINATIONS

URYL T1

UROGESIC-BLUE T3

URINARY ANTISPASMODIC - ANTICHOL., M(3) MUSCARINIC SELECTIVE (BLADDER)

VESICARE T2

darifenacin T3

URINARY ANTISPASMODIC - SMOOTH MUSCLE RELAXANTS

flavoxate T1

oxybutynin chloride T1

tolterodine T1

trospium T1

DETROL LA ORAL CAPSULE,EXTENDED RELEASE 24HR 4 MG

T2

DETROL LA ORAL CAPSULE,EXTENDED RELEASE 24HR 2 MG

T3

GELNIQUE T3 ST

TOVIAZ T3 ST

URINARY RETENTION THERAPY - PARASYMPATHOMIMETIC AGENTS

bethanechol chloride T1

GOUT AND HYPERURICEMIA THERAPY

GOUT ACUTE THERAPY - ANTIMITOTICS

colchicine T1

COLCRYS T3

MITIGARE T3

GOUT AND HYPERURICEMIA - ANTIMITOTIC-URICOSURIC COMBINATIONS

probenecid-colchicine T1

2018

95

Drug Name Formulary Tiers Restrictions

HYPERURICEMIA THERAPY - URATE-OXIDASE ENZYME-TYPE

ELITEK T4

KRYSTEXXA T4

HYPERURICEMIA THERAPY - URIC ACID TRANSPORTER 1 (URAT1) INHIBITORS

ZURAMPIC T3 ST

HYPERURICEMIA THERAPY - URICOSURICS

probenecid T1

HYPERURICEMIA THERAPY - XANTHINE OXIDASE INHIBITORS

allopurinol T1

ULORIC T2 ST

allopurinol sodium T3

HEMATOLOGICAL AGENTS

ANTICOAGULANTS - CITRATE-BASED

anticoag citrate phos dextrose T1

ACD T3

ACD-A T3

TRICITRASOL T3

ANTICOAGULANTS - COUMARIN

warfarin T1

ANTIPORPHYRIA FACTORS

PANHEMATIN T4 PA

C1 ESTERASE INHIBITOR AGENTS

BERINERT T4 PA

CINRYZE T4 PA

HAEGARDA T4 PA

RUCONEST T4 PA

CXCR4 CHEMOKINE RECEPTOR ANTAGONISTS

MOZOBIL T4

DIRECT FACTOR XA INHIBITORS

ELIQUIS T2

XARELTO T2

BEVYXXA T3 PA

SAVAYSA T3

ERYTHROPOIETINS

ARANESP (IN POLYSORBATE) T4

EPOGEN T4

MIRCERA T4

PROCRIT T4

FACTOR IX COMPLEX (PROTHROMBIN COMPLEX CONCENTRATE) PREPARATIONS

KCENTRA T4

GRANULOCYTE COLONY-STIMULATING FACTOR (G-CSF)

GRANIX T4

NEULASTA T4

NEUPOGEN T4

ZARXIO T4 PA

2018

96

Drug Name Formulary Tiers Restrictions

GRANULOCYTE-MACROPHAGE COLONY-STIMULATING FACTOR (GM-CSF)

LEUKINE T4

HEMATORHEOLOGIC AGENTS

pentoxifylline T3

HEMOSTATIC SYSTEMIC - ANTIFIBRINOLYTIC AGENTS

aminocaproic acid T1

tranexamic acid intravenous T1

tranexamic acid oral T3

RIASTAP T4

HEMOSTATIC TOPICAL AGENTS

AVITENE FLOUR T1

SYRINGE AVITENE T1

ULTRAFOAM T1

ASTRINGYN T3

AVITENE T3

ENDO AVITENE T3

GELFILM T3

GELFOAM T3

GELFOAM COMPRESSED SIZE 100 T3

GELFOAM SPONGE SIZE 100 T3

GELFOAM SPONGE SIZE 12-7MM T3

GELFOAM SPONGE SIZE 200 T3

GELFOAM SPONGE SIZE 50 T3

MONSEL'S T3

RECOTHROM T3

RECOTHROM SPRAY KIT T3

THROMBI-GEL T3

THROMBIN-JMI T3

THROMBI-PAD T3

HEMOSTATIC TOPICAL COMBINATIONS

TACHOSIL T3

TISSEEL VHSD T4

HEPARIN FLUSH FORMULATIONS

heparin (porcine) in 0.9% nacl T1

heparin (porcine) in nacl (pf) T1

heparin flush(porcine)-0.9nacl T1

heparin lock flush (porcine) T1

heparin, porcine (pf) T1

HEP FLUSH-10 (PF) T1

HEPARINS

heparin (porcine) T1

heparin (porcine) (bulk) T1

heparin (porcine) in 0.9% nacl T1

heparin (porcine) in 5 % dex T1

heparin (porcine) in nacl (pf) T1

heparin flush(porcine)-0.9nacl T1

heparin lock flush (porcine) T1

2018

97

Drug Name Formulary Tiers Restrictions

heparin(porcine) in 0.45% nacl T1

heparin, porcine (pf) T1

HEP FLUSH-10 (PF) T1

HUMAN ALBUMIN

albumin, human 25 % T1

albumin, human 5 % T1

PLASBUMIN 5 % T3

HUMAN MONOCLONAL ANTIBODY COMPLEMENT (C5) INHIBITORS

SOLIRIS T4

INDIRECT FACTOR XA INHIBITORS

fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

T1

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml T3

LOW MOLECULAR WEIGHT HEPARINS

enoxaparin subcutaneous syringe 150 mg/ml T1

FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML

T1

enoxaparin subcutaneous solution T3

enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml

T3

FRAGMIN SUBCUTANEOUS SYRINGE 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML

T4

PLASMA EXPANDERS

hetastarch 6 % in 0.9 % nacl T1

HEXTEND T3

LMD 10 % IN 0.9 % SODIUM CHLOR T3

LMD 10 % IN 5 % DEXTROSE T3

VOLUVEN 6 % T3

PLASMA FRACTIONS

OCTAPLAS (BLOOD GROUP A) T4

OCTAPLAS (BLOOD GROUP AB) T4

OCTAPLAS (BLOOD GROUP B) T4

OCTAPLAS (BLOOD GROUP O) T4

PLASMANATE T4

PLASMA PROTEINS WHICH FACILITATE ANTICOAGULATION

ATRYN T4

THROMBATE III T4

PLATELET AGGREGATION INHIB - CYCLOPENTYL-TRIAZOLO-PYRIMIDINES (CPTPS)

BRILINTA T2

PLATELET AGGREGATION INHIBITOR COMBINATIONS

aspirin-dipyridamole T1

PLATELET AGGREGATION INHIBITORS - GLYCOPROTEIN IIB/IIIA RECEPTOR INHIB

AGGRASTAT IN SODIUM CHLORIDE T3

INTEGRILIN T3

2018

98

Drug Name Formulary Tiers Restrictions

PLATELET AGGREGATION INHIBITORS - MONOCLONAL AGENTS

REOPRO T4

PLATELET AGGREGATION INHIBITORS - PHOSPHODIESTERASE III INHIBITORS

cilostazol T1

PLATELET AGGREGATION INHIBITORS - QUINAZOLINE AGENTS

anagrelide T1

PLATELET AGGREGATION INHIBITORS - THIENOPYRIDINE AGENTS

clopidogrel T1

prasugrel T1

ticlopidine T1

EFFIENT T2

PLATELET AGGREGATION INHIB-PDESTERASE AND ADENOSINE DEAMINASE INHIBITR

dipyridamole T1

PLATELET AGGREGATION INHIB-PROTEASE-ACTIV.RECEPTOR-1(PAR-1) ANTAGONIST

ZONTIVITY T3 ST

PROTEIN C PREPARATIONS

CEPROTIN (BLUE BAR) T3

CEPROTIN (GREEN BAR) T3

SICKLE CELL ANEMIA AGENTS

DROXIA T2

ENDARI T3 PA

NUTRESTORE T3

THROMBIN INHIBITOR - SELECTIVE DIRECT AND REVERSIBLE

argatroban T1

argatroban in 0.9 % sod chlor intravenous solution T1

argatroban in nacl (iso-os) T1

PRADAXA T3

argatroban in 0.9 % sod chlor intravenous parenteral solution T4

THROMBIN INHIBITOR - SELECTIVE DIRECT AND REVERSIBLE - HIRUDIN TYPE

bivalirudin T1

ANGIOMAX T3

IPRIVASK T3

THROMBOLYTIC - TISSUE PLASMINOGEN ACTIVATORS

ACTIVASE T3

CATHFLO ACTIVASE T4

TNKASE T4

THROMBOPOIETIN RECEPTOR AGONISTS

NPLATE T4

PROMACTA T4 PA

HEPATOBILIARY SYSTEM TREATMENT AGENTS

FARNESOID X RECEPTOR (FXR) AGONIST, BILE ACID ANALOG

OCALIVA T4 PA

2018

99

Drug Name Formulary Tiers Restrictions

IMMUNOSUPPRESSIVE AGENTS

IMMUNOSUPPRESSIVE - CALCINEURIN INHIBITORS

cyclosporine T1

cyclosporine (bulk) T1

cyclosporine modified T1

tacrolimus T1

ASTAGRAF XL T3

ENVARSUS XR T3

PROGRAF T3

IMMUNOSUPPRESSIVE - INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS

mycophenolate mofetil T1

mycophenolate sodium T3

CELLCEPT T3

CELLCEPT INTRAVENOUS T3

MYFORTIC T3

IMMUNOSUPPRESSIVE - MAMMALIAN TARGET OF RAPAMYCIN (MTOR) INHIBITORS

RAPAMUNE ORAL TABLET 0.5 MG T2

sirolimus oral tablet 0.5 mg, 1 mg T3

ZORTRESS T3 PA

sirolimus oral tablet 2 mg T4

RAPAMUNE ORAL SOLUTION T4

RAPAMUNE ORAL TABLET 1 MG, 2 MG T4

IMMUNOSUPPRESSIVE - MONOCLONAL ANTIBODIES

SIMULECT T4

IMMUNOSUPPRESSIVE - PURINE ANALOGS

azathioprine T1

AZASAN T4

IMMUNOSUPPRESSIVE - SELECTIVE T-CELL COSTIMULATION BLOCKER

NULOJIX T4

LOCOMOTOR SYSTEM

AGENTS TO TREAT PERIODIC PARALYSIS - CARBONIC ANHYDRASE INHIBITORS

KEVEYIS T4 PA

ALS AGENT - BENZATHIAZOLES

riluzole T4

ANTIMYASTHENIC AGENT - REVERSIBLE CHOLINESTERASE INHIBITORS

neostigmine methylsulfate intravenous syringe T1

pyridostigmine bromide oral tablet T1

MESTINON T2

pyridostigmine bromide oral tablet extended release T3

MESTINON TIMESPAN T3

REGONOL T3

neostigmine methylsulfate intravenous solution T4

ANTIMYASTHENIC AGENTS OTHER

guanidine T1

2018

100

Drug Name Formulary Tiers Restrictions

DUCHENNE MUSCULAR DYSTROPHY - EXON SKIPPING ANTISENSE OLIGONUCLEOTIDE

EXONDYS 51 T4 PA

MUSCULOSKELETAL THERAPY AGENT - JOINT TISSUE REPLACEMENT

CARTICEL T3

MUSCULOSKELETAL THERAPY AGENT - VISCOSUPPLEMENTS

EUFLEXXA T4

SYNVISC T4

SYNVISC-ONE T4

MUSCULOSKELETAL TX AGENT-JOINT CONTRACTURE THERAPY, COLLAGENASE ENZYME

XIAFLEX T4 PA

NEUROMUSCULAR BLOCKER - DEPOLARIZING AGENTS

succinylcholine chloride T1

QUELICIN T3

NEUROMUSCULAR BLOCKER - NEUROTOXINS

BOTOX T4 PA

DYSPORT T4 PA

MYOBLOC T4 PA

XEOMIN T4 PA

NEUROMUSCULAR BLOCKER - NONDEPOLARIZING AGENTS

atracurium T1

cisatracurium T1

pancuronium T1

rocuronium T1

vecuronium bromide T1

SKELETAL MUSCLE RELAXANT - ANALGESIC SALICYLATE COMBINATIONS

carisoprodol-aspirin T1

SKELETAL MUSCLE RELAXANT - CENTRAL MUSCLE RELAXANTS

baclofen T1

chlorzoxazone T1

cyclobenzaprine T1

metaxalone T1

methocarbamol T1

orphenadrine citrate T1

tizanidine T1

carisoprodol T3

GABLOFEN T3

LIORESAL T3

LORZONE T3

ROBAXIN T3

SKELETAL MUSCLE RELAXANT - DIRECT MUSCLE RELAXANTS

dantrolene T1

REVONTO T1

DANTRIUM T3

2018

101

Drug Name Formulary Tiers Restrictions

RYANODEX T3

SKELETAL MUSCLE RELAXANT - NARCOTIC ANALGESIC COMBINATIONS

carisoprodol-asa-codeine T1

SKELETAL MUSCLE RELAXANT AND TOPICAL IRRITANT COUNTER-IRRITANT COMB.

COMFORT PAC-CYCLOBENZAPRINE T3

COMFORT PAC-TIZANIDINE T3

SKELETAL MUSCLE RELAXANT, SALICYLATE, AND NARCOTIC ANALGESIC COMB.

carisoprodol-asa-codeine T1

MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT (DME)

MEDICAL SUPPLIES AND DME - BLOOD GLUCOSE TESTS

FREESTYLE INSULINX T2

FREESTYLE INSULINX TEST STRIPS T2

FREESTYLE LITE STRIPS T2

FREESTYLE TEST T2

PRECISION XTRA TEST T2

MEDICAL SUPPLIES AND DME - GLUCOSE MONITORING TEST SUPPLIES

blood glucose contrl hi,normal T1

lancets T1

lancing device T1

lancing device with lancets T1

MEDICAL SUPPLIES AND DME - INSULIN NEEDLES-SYRINGES AND ADMIN SUPPLIES

insulin syr/ndl u100 half mark T1

insulin syringe needleless T1

insulin syringe-needle u-100 T1

insulin syringes (disposable) T1

pen needle, diabetic T1

BD ULTRA-FINE MICRO PEN NEEDLE T2

MEDICAL SUPPLIES AND DME - NEEDLES AND SYRINGES

huber safety needles (disp.) T1

needle (disp) 16 g T1

needle (disp) 18 g T1

needle (disp) 19 g T1

needle (disp) 23 gauge T1

needles, huber disposable T1

safety needles T1

syringe (disposable) T1

syringe (reusable) T1

syringe with needle T1

syringe with needle, safety T1

tuberculin-allergy syringes T1

MEDICAL SUPPLIES AND DME - TISSUE BULKING IMPLANTS

SCULPTRA T3

SOLESTA T4

2018

102

Drug Name Formulary Tiers Restrictions

MEDICAL SUPPLY, FDB SUPERSET

MEDICAL SUPPLY, FDB SUPERSET

blood glucose contrl hi,normal T1

huber safety needles (disp.) T1

insulin syr/ndl u100 half mark T1

insulin syringe needleless T1

insulin syringe-needle u-100 T1

insulin syringes (disposable) T1

lancets T1

lancing device T1

lancing device with lancets T1

needle (disp) 16 g T1

needle (disp) 18 g T1

needle (disp) 19 g T1

needle (disp) 23 gauge T1

needles, huber disposable T1

pen needle, diabetic T1

safety needles T1

syringe (disposable) T1

syringe (reusable) T1

syringe with needle T1

syringe with needle, safety T1

tuberculin-allergy syringes T1

BD ULTRA-FINE MICRO PEN NEEDLE T2

PRECISION XTRA TEST T2

METABOLIC DISEASE ENZYME REPLACEMENT AGENTS

METABOLIC DISEASE ENZYME REPLACEMENT, FABRY'S DISEASE

FABRAZYME T4 PA

METABOLIC DISEASE ENZYME REPLACEMENT, GAUCHER'S DISEASE

CEREZYME T4

ELELYSO T4

VPRIV T4

METABOLIC DISEASE ENZYME REPLACEMENT, HYPOPHOSPHATASIA

STRENSIQ T4 PA

METABOLIC DISEASE ENZYME REPLACEMENT, MUCOPOLYSACCHARIDOSIS

ALDURAZYME T4

ELAPRASE T4

NAGLAZYME T4

VIMIZIM T4

METABOLIC DISEASE ENZYME REPLACEMENT, POMPE DISEASE

LUMIZYME T4

METABOLIC DX ENZYME REPLACEMENT, SEVERE COMBINED IMMUNE DEFICIENCY

ADAGEN T4

2018

103

Drug Name Formulary Tiers Restrictions

METABOLIC MODIFIERS

HYPERPARATHYROID TREATMENT AGENTS - VITAMIN D ANALOG-TYPE

doxercalciferol intravenous T1

paricalcitol oral T1

HECTOROL ORAL T2

doxercalciferol oral T3

paricalcitol hemodialysis port injection T3

paricalcitol intravenous T3

HECTOROL INTRAVENOUS T3

RAYALDEE T3 PA

ZEMPLAR INTRAVENOUS SOLUTION 2 MCG/ML T3

ZEMPLAR ORAL T3

ZEMPLAR INTRAVENOUS SOLUTION 5 MCG/ML T4

METABOLIC MODIFIER - CARNITINE REPLENISHER AGENTS

levocarnitine T1

levocarnitine (with sugar) T1

CARNITOR (SUGAR-FREE) T3

METABOLIC MODIFIER - GAUCHER'S DISEASE, TYPE-1, SUBSTRATE REDUCTION TX

CERDELGA T4 PA

ZAVESCA T4 PA

METABOLIC MODIFIER - HEREDITARY TYROSINEMIA TREATMENT AGENTS

ORFADIN ORAL SUSPENSION T2

NITYR T4 PA

ORFADIN ORAL CAPSULE T4

METABOLIC MODIFIER - HOMOCYSTINURIA TREATMENT AGENTS

CYSTADANE T4

METABOLIC MODIFIER - UREA CYCLE DISORDER AGENTS-CONJUGATING AGENTS

sodium benzoate-sod phenylacet T1

sodium phenylbutyrate T1

BUPHENYL T2

RAVICTI T4 PA

METABOLIC MODIFIER-CARBAMOYL PHOSPHATE SYNTHETASE 1 (CPS 1) ACTIVATOR

CARBAGLU T4

PHARMACOENHANCER - CYTOCHROME P450 INHIBITORS

TYBOST T2

PHENYLKETONURIA(PKU) TX AGENTS - COFACTOR OF PHENYLALANINE HYDROXYLASE

KUVAN T4 PA

MOUTH-THROAT-DENTAL - PREPARATIONS

DENTAL PRODUCT - FLUORIDE PREPARATIONS

fluoride (sodium) T1

FLURA-DROPS T1

FLUORABON T2

FLUOR-A-DAY (WITH XYLITOL) ORAL TABLET,CHEWABLE 0.25 MG F (0.55 MG)-236.79MG

T2

2018

104

Drug Name Formulary Tiers Restrictions

FLORIVA (FLUORIDE-VITAMIN D3) T3

FLUOR-A-DAY T3

FLUOR-A-DAY (WITH XYLITOL) ORAL TABLET,CHEWABLE 1 MG F (2.2 MG)-236.79 MG

T3

PREVIDENT 5000 DRY MOUTH T3

PREVIDENT 5000 PLUS T3

PREVIDENT 5000 SENSITIVE T3

DENTAL PRODUCT - LOCAL ANESTHETICS

bupivacaine-epinephrine bitart T1

lidocaine-epinephrine bit T1

mepivacaine (pf) T1

ARTICADENT DENTAL T3

CITANEST PLAIN DENTAL T3

MOUTH AND THROAT - ANTIFUNGALS

clotrimazole T1

nystatin T1

MOUTH AND THROAT - ANTI-INFECTIVE MIXTURES

DEBACTEROL T3

MOUTH AND THROAT - ANTI-INFECTIVE-LOCAL ANESTHETIC COMBINATIONS

BUCALSEP T3

MOUTH AND THROAT - ANTISEPTICS

chlorhexidine gluconate T1

MOUTH AND THROAT - ARTIFICIAL SALIVA

AQUORAL T3

CAPHOSOL T3

NEUTRASAL T3

NUMOISYN T3

MOUTH AND THROAT - GLUCOCORTICOIDS

triamcinolone acetonide T1

MOUTH AND THROAT - LOCAL ANESTHETIC AMIDES

lidocaine hcl T1

ADVANCED DNA MEDICATED COLLECT T3

MOUTH AND THROAT - MUCOSITIS-STOMATITIS AGENTS

EPISIL T3

GELCLAIR T3

GELX T3

ORAMAGICRX T3

MUGARD T4

MOUTH AND THROAT - PROTECTANTS

GELX T3

MUGARD T4

MOUTH AND THROAT - SALIVA STIMULANTS

pilocarpine hcl T1

cevimeline T3

PERIODONTAL PRODUCT - TETRACYCLINE-TYPE, COLLAGENASE INHIBITORS

doxycycline hyclate T1

2018

105

Drug Name Formulary Tiers Restrictions

THERAPY FOR DROOLING- PRIMARY OR SECONDARY SIALORRHEA-ANTICHOLINERGIC

CUVPOSA T3

MULTIPLE SCLEROSIS AGENTS

LEUKOCYTE ADHESION INHIBITORS, ALPHA4-MEDIATED, IGG4K MC ANTIBODY

TYSABRI T4 PA

MULTIPLE SCLEROSIS AGENT - CD20 SPECIFIC MONOCLONAL ANTIBODY

OCREVUS T4 PA

MULTIPLE SCLEROSIS AGENT - INTERFERONS

AVONEX T4

AVONEX (WITH ALBUMIN) T4

BETASERON T4 PA

EXTAVIA T4 PA; ST

PLEGRIDY T4

REBIF (WITH ALBUMIN) T4 ST

REBIF REBIDOSE T4 ST

REBIF TITRATION PACK T4 ST

MULTIPLE SCLEROSIS AGENT - OTHERS

COPAXONE T4

TECFIDERA T4

MULTIPLE SCLEROSIS AGENT - POTASSIUM CHANNEL BLOCKER

AMPYRA T4 PA

MULTIPLE SCLEROSIS AGENT - PYRIMIDINE SYNTHESIS INHIBITORS

AUBAGIO T4 ST

MULTIPLE SCLEROSIS AGENT - SPHINGOSINE 1-PHOSPHATE RECEPTOR MODULATOR

GILENYA T4 ST

MULTIPLE SCLEROSIS AGENT-INTERLEUKIN-2 RECEPTOR MODULATOR, MC ANTIBODY

ZINBRYTA T4 ST

OPHTHALMIC AGENTS

ARTIFICIAL TEARS AND LUBRICANT SINGLE AGENTS

LACRISERT T2

MIOTICS - CHOLINESTERASE INHIBITORS

PHOSPHOLINE IODIDE T2

MIOTICS - DIRECT ACTING

pilocarpine hcl T1

MIOCHOL-E T3

MIOSTAT T3

MYDRIATIC AND CYCLOPLEGIC COMBINATIONS

CYCLOMYDRIL T3

PAREMYD T3

OPHTHALMIC - ADRENERGIC-CARBONIC ANHYDRASE INHIBITOR COMBINATIONS

SIMBRINZA T3

2018

106

Drug Name Formulary Tiers Restrictions

OPHTHALMIC - ANTIBACTERIAL-GLUCOCORTICOID COMBINATIONS

neomycin-bacitracin-poly-hc T1

neomycin-polymyxin b-dexameth T1

neomycin-polymyxin-hc T1

sulfacetamide-prednisolone T1

tobramycin-dexamethasone T1

BLEPHAMIDE S.O.P. T2

TOBRADEX T2

TOBRADEX ST T2

ZYLET T2

BLEPHAMIDE T3

PRED-G T3

PRED-G S.O.P. T3

OPHTHALMIC - ANTICHOLINERGICS

atropine T1

cyclopentolate T1

homatropine hbr T1

tropicamide T1

CYCLOGYL T3

OPHTHALMIC - ANTIFIBROTIC AGENTS

MITOSOL T3

OPHTHALMIC - ANTIHISTAMINES

azelastine T1

epinastine T1

olopatadine T1

BEPREVE T3

EMADINE T3

LASTACAFT T3

PATADAY T3

PATANOL T3

PAZEO T3

OPHTHALMIC - ANTI-INFLAMMATORY, GLUCOCORTICOIDS

dexamethasone sodium phosphate T1

fluorometholone T1

prednisolone acetate T1

prednisolone sodium phosphate T1

ALREX T2

FML S.O.P. T2

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL T2

LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION T2

PRED MILD T2

DUREZOL T3

FLAREX T3

FML FORTE T3

ILUVIEN T3

LOTEMAX OPHTHALMIC (EYE) OINTMENT T3

2018

107

Drug Name Formulary Tiers Restrictions

MAXIDEX T3

TRIESENCE (PF) T3

OZURDEX T4

RETISERT T4

OPHTHALMIC - ANTI-INFLAMMATORY, IMMUNOMODULATORS

RESTASIS T2

RESTASIS MULTIDOSE T2

OPHTHALMIC - ANTI-INFLAMMATORY, NSAIDS

bromfenac T1

diclofenac sodium T1

flurbiprofen sodium T1

ketorolac T1

ACUVAIL (PF) T3

BROMSITE T3

ILEVRO T3

NEVANAC T3

PROLENSA T3

OPHTHALMIC - BETA BLOCKERS-ADRENERGIC COMBINATIONS

COMBIGAN T3

OPHTHALMIC - BETA BLOCKERS-CARBONIC ANHYDRASE INHIBITOR COMBINATIONS

dorzolamide-timolol T1

COSOPT (PF) T3

OPHTHALMIC - CARBONIC ANHYDRASE INHIBITORS

dorzolamide T1

AZOPT T2

OPHTHALMIC - CYSTINE DEPLETING AGENTS

CYSTARAN T4 PA

OPHTHALMIC - DECONGESTANTS

phenylephrine hcl T1

OPHTHALMIC - DIAGNOSTIC AGENTS

fluorescein (bulk) T1

fluorescein-proparacaine T1

FLUORESCITE T1

FUL-GLO OPHTHALMIC (EYE) STRIP 1 MG T1

AK-FLUOR T3

FLUCAINE T3

FUL-GLO OPHTHALMIC (EYE) STRIP 0.6 MG T3

OPHTHALMIC - INTRAOCULAR PRESSURE REDUCING AGENTS, BETA-BLOCKERS

betaxolol T1

carteolol T1

levobunolol T1

metipranolol T1

timolol maleate T1

BETOPTIC S T2

BETIMOL T3

2018

108

Drug Name Formulary Tiers Restrictions

ISTALOL T3

TIMOPTIC OCUDOSE (PF) T3

OPHTHALMIC - IRRIGATION SOLUTIONS

BSS PLUS T3

OPHTHALMIC - LOCAL ANESTHETIC ESTERS

proparacaine T1

tetracaine hcl T1

tetracaine hcl (pf) T1

TETRAVISC T3

TETRAVISC FORTE T3

OPHTHALMIC - LOCAL ANESTHETIC, AMIDES

AKTEN (PF) T3

OPHTHALMIC - MACULAR DEGENERATION, AGE-RELATED, THERAPY AGENTS

EYLEA T4 PA

LUCENTIS T4 PA

MACUGEN T4 PA

OPHTHALMIC - MAST CELL STABILIZERS

cromolyn T1

ALOCRIL T3

ALOMIDE T3

OPHTHALMIC - PHOTODYNAMIC THERAPY AGENTS

VISUDYNE T4

OPHTHALMIC - SURGICAL AID COMBINATIONS

DISCOVISC T3

DUOVISC VISCO ELASTIC T3

VISCOAT T3

OPHTHALMIC - SURGICAL AIDS OTHER

OCUCOAT T1

CELLUGEL T3

GELFILM T3

MEMBRANEBLUE T3

VISIONBLUE T3

OPHTHALMIC - VISCOELASTIC AGENTS

AMVISC T4

AMVISC PLUS T4

PROVISC T4

OPHTHALMIC ANTIBACTERIAL MIXTURES

bacitracin-polymyxin b T1

neomycin-bacitracin-polymyxin T1

neomycin-polymyxin-gramicidin T1

polymyxin b sulf-trimethoprim T1

OPHTHALMIC ANTIBIOTIC - AMINOGLYCOSIDES

gentamicin T1

tobramycin T1

TOBREX T2

2018

109

Drug Name Formulary Tiers Restrictions

OPHTHALMIC ANTIBIOTIC - DEHYDROPEPTIDASE INHIBITORS

bacitracin T1

OPHTHALMIC ANTIBIOTIC - FLUOROQUINOLONES

ciprofloxacin hcl T1

levofloxacin T1

moxifloxacin T1

ofloxacin T1

BESIVANCE T2

CILOXAN T2

MOXEZA T3

VIGAMOX T3

ZYMAXID T3

OPHTHALMIC ANTIBIOTIC - MACROLIDES

erythromycin T1

AZASITE T3

OPHTHALMIC ANTIBIOTIC - SULFONAMIDES

sulfacetamide sodium T1

OPHTHALMIC ANTIFUNGALS

NATACYN T3

OPHTHALMIC ANTIVIRALS

trifluridine T1

ZIRGAN T3

OPHTHALMIC-INTRAOCULAR PRESS. REDUCING, SEL. ALPHA ADRENERGIC AGONISTS

apraclonidine T1

brimonidine T1

ALPHAGAN P T2

IOPIDINE T3

OPHTHALMIC-INTRAOCULAR PRESSURE REDUCING AGENTS, PROSTAGLANDIN ANALOGS

bimatoprost T1

latanoprost T1

LUMIGAN T2

TRAVATAN Z T2

ZIOPTAN (PF) T3

SELECTIVE VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) ANTAGONISTS

MACUGEN T4 PA

VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF-A) RECEPTOR ANTAGONISTS

LUCENTIS T4 PA

VASCULAR ENDOTHELIAL GROWTH FACTOR(VEGF-A AND PLGF)RECEPTOR INHIBITORS

EYLEA T4 PA

ORGAN PRESERVATION SOLUTIONS

CARDIOPLEGIC SOLUTIONS

cardioplegic soln T1

2018

110

Drug Name Formulary Tiers Restrictions

OTIC

OTIC - ANTI-INFECTIVE-GLUCOCORTICOID COMBINATIONS

neomycin-polymyxin-hc T1

CIPRODEX T2

CIPRO HC T3

OTIC - ANTI-INFECTIVES OTHER

acetic acid T1

OTIC - FLUOROQUINOLONES

ciprofloxacin hcl T1

ofloxacin T1

OTIC - GLUCOCORTICOIDS

fluocinolone acetonide oil T1

hydrocortisone-acetic acid T1

OTIC - PINNA COMBINATIONS

CORTANE-B T3

PROSTAGLANDINS

PROSTAGLANDINS

alprostadil (bulk) T3

RENAL REPLACEMENT THERAPY

HEMODIALYSIS AND HEMOFILTRATE SOLUTIONS

PRISMASOL B22GK T3

PRISMASOL BGK T3

PRISMASOL BK T3

PERITONEAL DIALYSIS SOLUTIONS

DELFLEX WITH 2.5 % DEXTROSE T3

DELFLEX-LC/1.5% DEXTROSE T3

DELFLEX-LC/2.5% DEXTROSE T3

DELFLEX-LC/4.25% DEXTROSE T3

DELFLEX-SM WITH 1.5% DEXTROSE T3

DIANEAL LOW CALCIUM/1.5% DEX T3

DIANEAL LOW CALCIUM/4.25% DEX T3

DIANEAL PD-2 WITH 2.5 % DEX T3

DIANEAL PD-2 WITH 4.25 % DEX T3

DIANEAL WITH 1.5% DEXTROSE T3

DIANEAL WITH 2.5 % DEXTROSE T3

DIANEAL WITH 4.25 % DEXTROSE T3

EXTRANEAL 7.5 % T3

RESPIRATORY THERAPY AGENTS

1ST GENERATION ANTIHISTAMINE-DECONGESTANT COMBINATIONS

CENTERGY T1

PROMETHAZINE VC T1

1ST GENERATION ANTIHISTAMINE-DECONGESTANT-ANTICHOLINERGIC COMBINATIONS

RESPA-AR T3

2ND GENERATION ANTIHISTAMINE-DECONGESTANT COMBINATIONS

CLARINEX-D 12 HOUR T3

SEMPREX-D T3

2018

111

Drug Name Formulary Tiers Restrictions

ANTIHISTAMINE - 1ST GENERATION - ETHANOLAMINES

carbinoxamine maleate T1

clemastine T1

diphenhydramine hcl T1

KARBINAL ER T3

ANTIHISTAMINE - 1ST GENERATION - ETHYLENEDIAMINES

tripelennamine (bulk) T1

ANTIHISTAMINE - 1ST GENERATION - PHENOTHIAZINES

promethazine T1

ANTIHISTAMINE - 1ST GENERATION - PIPERIDINES

cyproheptadine T1

ANTIHISTAMINES - 1ST GENERATION

carbinoxamine maleate T1

clemastine T1

cyproheptadine T1

diphenhydramine hcl T1

promethazine T1

KARBINAL ER T3

ANTIHISTAMINES - 2ND GENERATION

desloratadine oral tablet,disintegrating 2.5 mg T1

levocetirizine T1

loratadine, micronized (bulk) T2

desloratadine oral tablet T3

desloratadine oral tablet,disintegrating 5 mg T3

CLARINEX T3

ANTIHISTAMINES - 2ND GENERATION - PIPERAZINES

levocetirizine T1

ALL DAY ALLERGY (CETIRIZINE) T3

ANTIHISTAMINES - 2ND GENERATION - PIPERIDINES

desloratadine oral tablet,disintegrating 2.5 mg T1

loratadine, micronized (bulk) T2

desloratadine oral tablet T3

desloratadine oral tablet,disintegrating 5 mg T3

CLARINEX T3

ANTITUSSIVES - NONNARCOTIC

benzonatate T1

ZONATUSS T3

ASTHMA THERAPY - 5-LIPOXYGENASE INHIBITORS

ZYFLO T3

ASTHMA THERAPY - ALPHA/BETA ADRENERGIC AGENTS

epinephrine T1

ASTHMA THERAPY - INHALED CORTICOSTEROIDS (GLUCOCORTICOIDS)

ARNUITY ELLIPTA T2

ASMANEX HFA T2

ASMANEX TWISTHALER T2

FLOVENT DISKUS T2

FLOVENT HFA T2

2018

112

Drug Name Formulary Tiers Restrictions

PULMICORT FLEXHALER T2

QVAR T2

budesonide T3

AEROSPAN T3

ALVESCO T3

PULMICORT T3

ASTHMA THERAPY - LEUKOTRIENE RECEPTOR ANTAGONISTS

montelukast oral tablet T1

montelukast oral tablet,chewable T1

zafirlukast T1

montelukast oral granules in packet T3

ASTHMA THERAPY - MONOCLONAL ANTIBODIES TO IMMUNOGLOBULIN E (IGE)

XOLAIR T4 PA

ASTHMA THERAPY - XANTHINES

aminophylline T1

aminophylline (bulk) T1

theophylline T1

theophylline in dextrose 5 % T1

THEO-24 T3

ASTHMA THERAPY- MONOCLONAL ANTIBODY - INTERLEUKIN-5 (IL-5) ANTAGONISTS

CINQAIR T4 PA

NUCALA T4 PA

ASTHMA/COPD - PHOSPHODIESTERASE-4 (PDE4) INHIBITORS

DALIRESP T3 ST

ASTHMA/COPD - ANTICHOLINERGIC AGENTS, INHALED LONG ACTING

INCRUSE ELLIPTA T2

SPIRIVA RESPIMAT T2

SPIRIVA WITH HANDIHALER T2

TUDORZA PRESSAIR T3 ST

ASTHMA/COPD - ANTICHOLINERGIC AGENTS, INHALED SHORT ACTING

ATROVENT HFA T2

ASTHMA/COPD - BETA 2-ADRENERGIC AGENTS, INHALED, ULTRA-LONG ACTING

STRIVERDI RESPIMAT T2

ARCAPTA NEOHALER T3 ST

ASTHMA/COPD THERAPY - BETA 2-ADRENERGIC AGENTS, INHALED, LONG ACTING

PERFOROMIST T2

SEREVENT DISKUS T2

BROVANA T3

ASTHMA/COPD THERAPY - BETA 2-ADRENERGIC AGENTS, INHALED, SHORT ACTING

albuterol sulfate T1

levalbuterol hcl T1

levalbuterol tartrate T1

2018

113

Drug Name Formulary Tiers Restrictions

VENTOLIN HFA T2

PROAIR HFA T3 ST

PROAIR RESPICLICK T3 ST

PROVENTIL HFA T3 ST

ASTHMA/COPD THERAPY - BETA ADRENERGIC AGENTS

metaproterenol T1

terbutaline subcutaneous T1

albuterol sulfate T3

terbutaline oral T3

ASTHMA/COPD THERAPY - BETA ADRENERGIC-ANTICHOLINERGIC COMBINATIONS

ipratropium-albuterol T1

ANORO ELLIPTA T2

COMBIVENT RESPIMAT T2

STIOLTO RESPIMAT T2

BEVESPI AEROSPHERE T3 ST

ASTHMA/COPD THERAPY - BETA ADRENERGIC-GLUCOCORTICOID COMBINATIONS

fluticasone-salmeterol T1

ADVAIR DISKUS T2

ADVAIR HFA T2

BREO ELLIPTA T2

SYMBICORT T2

AIRDUO RESPICLICK T3

DULERA T3 ST

CYSTIC FIBROSIS - INHALED AMINOGLYCOSIDES

BETHKIS T3

tobramycin in 0.225 % nacl T4

tobramycin with nebulizer T4 PA

KITABIS PAK T4 PA

TOBI T4 PA

TOBI PODHALER T4 PA

CYSTIC FIBROSIS - INHALED MONOBACTAMS

CAYSTON T2 PA

CYSTIC FIBROSIS-TRANSMEMBRANE CONDUCTANCE REGULATOR (CFTR) POTENTIATOR

KALYDECO T4 PA

CYSTIC FIB-TRANSMEMB CONDUCT. REG.(CFTR) POTENTIATOR AND CORRECTOR CMB

ORKAMBI T4 PA

ELASTASE INHIBITORS

ARALAST NP T4

GLASSIA T4

PROLASTIN-C T4

ZEMAIRA T4

LUNG SURFACTANTS

CUROSURF T3

INFASURF T3

SURFAXIN T3

2018

114

Drug Name Formulary Tiers Restrictions

SURVANTA T3

MUCOLYTICS

acetylcysteine T1

acetylcysteine (bulk) T1

PULMOZYME T4

NARCOTIC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT COMBINATIONS

CAPCOF T3

PROMETHAZINE VC-CODEINE T3

ZUTRIPRO T3

NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE COMBINATIONS

hydrocodone-chlorpheniramine T1

promethazine-codeine T1

TUSSICAPS T2

TUZISTRA XR T3

VITUZ T3

NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATIONS

hydrocodone-homatropine T1

NARCOTIC ANTITUSSIVE-DECONGESTANT COMBINATIONS

REZIRA T3

NARCOTIC ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMBINATIONS

HYCOFENIX T3

NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATIONS

codeine-guaifenesin T1

M-CLEAR WC T1

RELCOF C T1

OBREDON T3

NASAL ANTIBIOTICS

BACTROBAN NASAL T3

NASAL ANTICHOLINERGICS

ipratropium bromide T1

NASAL ANTIHISTAMINES

azelastine T1

olopatadine T3

ASTEPRO T3

PATANASE T3

NASAL CORTICOSTEROIDS

mometasone T3

NASAL SYMPATHOMIMETIC DECONGESTANTS (INTRANASAL)

ADRENALIN T3

TYZINE T3

NON-NARC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT COMBINATIONS

CENTERGY DM T1

brompheniramin-phenylephrin-dm T3

BROMFED DM T3

2018

115

Drug Name Formulary Tiers Restrictions

NON-NARCOTIC ANTITUSSIVE-ANTIHISTAMINE COMBINATIONS

promethazine-dm T1

NON-NARCOTIC ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMBINATIONS

TUSNEL PEDIATRIC T3

PLEURAL SCLEROSING AGENTS

sterile talc T1

SCLEROSOL INTRAPLEURAL T3

PULMONARY FIBROSIS TREATMENT AGENTS - ANTIFIBROTIC THERAPY

ESBRIET T4 PA

PULMONARY FIBROSIS TREATMENT AGENTS - MULTIKINASE INHIBITORS

OFEV T4 PA

VAGINAL PRODUCTS

VAGINAL ANTIBACTERIAL - LINCOSAMIDES

clindamycin phosphate T1

CLINDESSE T2

CLEOCIN T3

VAGINAL ANTIFUNGAL - IMIDAZOLES

GYNAZOLE-1 T1

MICONAZOLE-3 T1

VAGINAL ANTIFUNGAL - TRIAZOLES

terconazole T1

VAGINAL ANTIPROTOZOAL-ANTIBACTERIAL - NITROIMIDAZOLE DERIVATIVES

metronidazole T1

NUVESSA T3

VAGINAL ANTISEPTIC MIXTURES

RELAGARD T1

FEM PH T3

VAGINAL ESTROGENS

estradiol T1

ESTRACE T2

ESTRING T2

FEMRING T3

PREMARIN T3

VAGIFEM T3

YUVAFEM T3

VAGINAL PROGESTINS

CRINONE T2

2018

116

Indexabacavir ................................................... 12, 13abacavir-lamivudine ...................................... 13abacavir-lamivudine-zidovudine ....................13ABELCET......................................................11ABILIFY MAINTENA..................................45ABRAXANE................................................. 25ABSTRAL................................................... 2, 3acamprosate ................................................... 50ACANYA.......................................................56acarbose ......................................................... 82ACD............................................................... 96ACD-A........................................................... 96acebutolol .......................................................35acetaminophen-codeine ................................... 3acetazolamide .................................................37acetazolamide sodium .................................... 37acetic acid .............................................. 93, 111acetylcysteine ........................................... 9, 115acetylcysteine (bulk) .................................9, 115ACIPHEX...................................................... 90ACIPHEX SPRINKLE.................................. 90acitretin .......................................................... 59ACTEMRA...................................................... 5ACTHAR H.P. ............................................... 81ACTHIB (PF) .................................................29ACTHREL..................................................... 67ACTIMMUNE............................................... 11ACTIQ............................................................. 2ACTIVASE....................................................99ACTIVE FE................................................... 72ACTONEL..................................................... 84ACTOPLUS MET XR................................... 83ACUVAIL (PF) ............................................108acyclovir .............................................16, 17, 60acyclovir sodium ...................................... 16, 17ACZONE....................................................... 55ADACEL(TDAP ADOLESN/ADULT)(PF) .29ADAGEN.....................................................103adapalene ....................................................... 57adapalene-benzoyl peroxide .......................... 57ADASUVE.....................................................45ADCETRIS.............................................. 21, 26ADCIRCA......................................................39ADDAMEL N................................................74ADDERALL...................................... 46, 47, 49ADDYI...........................................................47adefovir .......................................................... 16ADEMPAS.....................................................39ADENOSCAN............................................... 67adenosine ....................................................... 34ADLYXIN..................................................... 83ADRENALIN.................................. 36, 37, 115ADREVIEW.................................................. 68ADVAIR DISKUS.......................................114ADVAIR HFA............................................. 114ADVANCED AM-PM...................................74ADVANCED DNA MEDICATED COLLECT....................................................105ADYPHREN..................................................36ADZENYS XR-ODT.....................................47AEROSPAN.................................................113AFINITOR..................................................... 24AFINITOR DISPERZ....................................24AFLURIA 2017-2018.................................... 30AFLURIA 2017-2018 (PF) ............................30AFLURIA QUAD 2017-2018....................... 30AFLURIA QUAD 2017-2018 (PF) ............... 30AGGRASTAT IN SODIUM CHLORIDE.... 98AIRDUO RESPICLICK.............................. 114

AK-FLUOR................................................. 108AKTEN (PF) ................................................ 109AKTIPAK...................................................... 56AKYNZEO.................................................... 89ALA-QUIN.................................................... 58ALA-SCALP..................................................62ALBENZA..................................................... 10albumin, human 25 % .................................... 98albumin, human 5 % ...................................... 98albuterol sulfate ................................... 113, 114alclometasone .................................................61alcohol swabs .................................................27ALDACTAZIDE........................................... 38ALDURAZYME..........................................103ALECENSA...................................................21alendronate .................................................... 84alfentanil .......................................................... 1ALFERON N................................................. 63alfuzosin ......................................................... 94ALIMTA........................................................ 21ALINIA..........................................................12ALIQOPA...................................................... 24ALKERAN.....................................................20ALL DAY ALLERGY (CETIRIZINE) .......112allopurinol ......................................................96allopurinol sodium ......................................... 96almotriptan malate .........................................48ALOCRIL.................................................... 109alogliptin ........................................................ 82alogliptin-metformin ...................................... 83alogliptin-pioglitazone ................................... 83ALOMIDE................................................... 109ALOQUIN..................................................... 58ALORA..........................................................85alosetron .........................................................92ALOXI........................................................... 89ALPHAGAN P............................................ 110alprazolam ..................................................... 40ALPRAZOLAM INTENSOL........................40alprostadil ...................................................... 39alprostadil (bulk) ....................................50, 111ALREX........................................................ 107ALTABAX.....................................................58ALTAVERA (28) .......................................... 53ALTOPREV...................................................34aluminum hydroxide gel .................................88ALUNBRIG................................................... 21ALVESCO................................................... 113ALYACEN 7/7/7 (28) ....................................54AMABELZ.................................................... 84amantadine hcl ...............................................44AMBISOME.................................................. 11amcinonide ..................................................... 61AMERGE.......................................................48AMETHIA..................................................... 52AMETHIA LO...............................................52AMETHYST..................................................52AMIDATE....................................................... 7amifostine crystalline ..................................... 27amikacin ......................................................... 10amiloride ........................................................ 38amiloride-hydrochlorothiazide ...................... 38AMINO ACIDS 15 %....................................75aminocaproic acid ..........................................97aminolevulinic acid hcl (bulk) ........................64aminophylline ...............................................113aminophylline (bulk) .................................... 113AMINOSYN 10 %.........................................75AMINOSYN 3.5 %........................................75

AMINOSYN 7 %...........................................75AMINOSYN 7 % WITH ELECTROLYTES......................................... 75AMINOSYN 8.5 %........................................75AMINOSYN 8.5 %-ELECTROLYTES........ 75AMINOSYN II 10 %..................................... 75AMINOSYN II 15 %..................................... 75AMINOSYN II 8.5 %-ELECTROLYTES.... 75AMINOSYN M 3.5 %................................... 76AMINOSYN-HBC 7%.................................. 76AMINOSYN-PF 10 %................................... 76AMINOSYN-PF 7 % (SULFITE-FREE) ...... 76amiodarone .................................................... 33amiodarone in dextrose 5 % .......................... 33AMITIZA.................................................91, 92amitriptyline ................................................... 43amitriptyline-chlordiazepoxide ................ 43, 46amlodipine ......................................................36amlodipine-atorvastatin ................................. 35amlodipine-benazepril ................................... 31amlodipine-olmesartan .................................. 32amlodipine-valsartan ..................................... 32amlodipine-valsartan-hcthiazid ..................... 32ammonium chloride ..................................37, 94ammonium lactate .......................................... 61amoxapine ...................................................... 43amoxicil-clarithromy-lansopraz .....................93amoxicillin ......................................................10amoxicillin-pot clavulanate ............................10amphotericin b ............................................... 11ampicillin ....................................................... 10ampicillin sodium ...........................................10ampicillin-sulbactam ......................................10AMPYRA.....................................................106AMVISC...................................................... 109AMVISC PLUS........................................... 109AMYTAL.......................................................49AMYVID....................................................... 68ANACAINE...................................................65ANADROL-50...............................................81anagrelide ...................................................... 99ANA-LEX KIT................................................ 8anastrozole ..................................................... 22ANDRODERM..............................................81ANDROGEL..................................................81ANGELIQ......................................................84ANGIOMAX................................................. 99ANIMI-3 WITH VITAMIN D.......................74ANORO ELLIPTA...................................... 114anticoag citrate phos dextrose ....................... 96ANUCORT-HC............................................... 8ANZEMET.....................................................89APLIGRAF.................................................... 65APLISOL....................................................... 67APOKYN....................................................... 44apraclonidine ............................................... 110aprepitant ....................................................... 89APRI ...............................................................52APRISO......................................................... 92APTENSIO XR..............................................46APTIOM........................................................ 41APTIVUS.......................................................18AQUA GLYCOLIC HC................................ 63AQUASOL A.................................................80AQUORAL.................................................. 105ARALAST NP............................................. 114ARANELLE (28) ...........................................54ARANESP (IN POLYSORBATE) ................96ARCALYST.....................................................4

117

ARCAPTA NEOHALER............................ 113argatroban ..................................................... 99argatroban in 0.9 % sod chlor ....................... 99argatroban in nacl (iso-os) ............................ 99aripiprazole ..............................................45, 47ARISTADA................................................... 45ARISTOSPAN INTRA-ARTICULAR..........85ARISTOSPAN INTRALESIONAL.............. 85armodafinil .....................................................49ARMOUR THYROID................................... 88ARNUITY ELLIPTA.................................. 112ARRANON....................................................21ARTICADENT DENTAL....................... 8, 105ARTISS..........................................................65ARYMO ER.....................................................2ARZERRA..................................................... 22ASCLERA..................................................... 40ASCOMP WITH CODEINE........................... 3ascorbic acid (vitamin c) ................................80ASMANEX HFA.........................................112ASMANEX TWISTHALER....................... 112aspirin-caffeine-dihydrocodein ........................3aspirin-dipyridamole ......................................98ASTAGRAF XL.......................................... 100ASTEPRO....................................................115ASTRAMORPH-PF.........................................2ASTRINGYN.................................................97ATABEX EC................................................. 78ATELVIA...................................................... 84atenolol ...........................................................35atenolol-chlorthalidone ..................................36ATGAM......................................................... 29atomoxetine .................................................... 46ATOPICLAIR................................................61atorvastatin .................................................... 34atovaquone-proguanil ....................................12atracurium ....................................................101ATRAPRO CP............................................... 61ATRAPRO DERMAL SPRAY..................... 66ATRIPLA.......................................................13ATROPEN..................................................... 38atropine ............................................ 38, 91, 107atropine (bulk) ..........................................38, 91ATROVENT HFA....................................... 113ATRYN..........................................................98AUBAGIO................................................... 106AUGMENTIN............................................... 10AURYXIA..................................................... 94AUSTEDO..................................................... 48AVANDAMET..............................................83AVANDIA..................................................... 87AVAPRO....................................................... 32AVAR............................................................ 56AVAR LS.......................................................56AVAR-E LS...................................................56AVASTIN...................................................... 19AVEED.......................................................... 81AVELOX....................................................... 16AVELOX IN NACL (ISO-OSMOTIC) .........16AVIANE........................................................ 52AVIDOXY DK.............................................. 19AVITA........................................................... 57AVITENE...................................................... 97AVITENE FLOUR........................................ 97AVO CREAM................................................60AVODART.................................................... 94AVONEX.....................................................106AVONEX (WITH ALBUMIN)................... 106AVYCAZ....................................................... 14AXERT.......................................................... 48

AXIRON........................................................ 81AZACTAM IN DEXTROSE (ISO-OSM).....17AZASAN................................................. 5, 100AZASITE..................................................... 110azathioprine ............................................. 5, 100azelaic acid (bulk) ..........................................55azelastine ..............................................107, 115AZELEX.................................................. 55, 64azithromycin ...................................................17AZOPT.........................................................108AZOR.............................................................32aztreonam .......................................................17AZURETTE (28) ........................................... 52B COMPLEX 100..........................................69B-12 COMPLIANCE.....................................80bacitracin ............................................... 18, 110bacitracin-polymyxin b ................................ 109baclofen ........................................................101BACMIN........................................................74BACTERIOSTATIC WATER(PARABENS) ..................................51BACTROBAN NASAL...............................115BAL IN OIL.....................................................9BAL-CARE DHA.......................................... 78BAL-CARE DHA ESSENTIAL....................78balsalazide ..................................................... 91BALZIVA (28) .............................................. 53banana creme flavor (bulk) ............................51BANZEL........................................................42BARACLUDE............................................... 16BAVENCIO................................................... 26BAXDELA.....................................................16bcg vaccine, live (pf) ................................ 29, 30BD ULTRA-FINE MICRO PEN NEEDLE.............................................................. 102, 103BEAU RX...................................................... 64BELBUCA....................................................... 4BELEODAQ.................................................. 23belladonna alkaloids-opium ...........................91belladonna tincture (bulk) ........................50, 91BELLADONNA-OPIUM.............................. 91BELSOMRA..................................................49benazepril .......................................................31benazepril-hydrochlorothiazide ..................... 31BENDEKA.....................................................20BENICAR...................................................... 32BENICAR HCT............................................. 32BENLYSTA.....................................................6BENSAL HP.................................................. 63BENTYL........................................................91BENZACLIN................................................. 56BENZACLIN PUMP..................................... 56BENZEFOAM............................................... 56BENZEFOAM ULTRA.................................56BENZEPRO................................................... 56BENZEPRO (MICROSPHERES) ................. 56benzonatate .................................................. 112benzoyl peroxide ............................................ 56benzphetamine ................................................69benztropine .....................................................43BEPREVE....................................................107BERINERT.................................................... 96BESIVANCE............................................... 110BESPONSA............................................. 21, 26betadex (bulk) ...................................................9betamethasone acet,sod phos .........................85betamethasone dipropionate .......................... 61betamethasone valerate ............................61, 62betamethasone, augmented ............................ 61BETASERON.............................................. 106

betaxolol .................................................35, 108bethanechol chloride ......................................95BETHKIS.....................................................114BETIMOL....................................................108BETOPTIC S ............................................... 108BEVESPI AEROSPHERE...........................114BEVYXXA.................................................... 96bexarotene ......................................................25BEXSERO..................................................... 30BIAFINE EMULSION.................................. 61bicalutamide ...................................................21BICILLIN C-R...............................................18BICILLIN L-A...............................................18BICNU........................................................... 20BIDIL............................................................. 40BIFERA RX...................................................72BILTRICIDE................................................. 10bimatoprost .................................................. 110BINOSTO...................................................... 84BIONECT...................................................... 64BIOTHRAX................................................... 30bisoprolol fumarate ........................................35bisoprolol-hydrochlorothiazide ..................... 36bivalirudin ......................................................99BIVIGAM...................................................... 28bleomycin ....................................................... 26BLEPHAMIDE............................................107BLEPHAMIDE S.O.P. .................................107BLINCYTO................................................... 26blood glucose contrl hi,normal ............ 102, 103BONIVA........................................................ 84BOOSTRIX TDAP........................................ 29BOSULIF....................................................... 25BOTOX........................................................101botulism antitoxin heptavalent ....................... 29BP FOAM...................................................... 56BP WASH...................................................... 56BP WASH ACNE TREATMENT.................56BP-50% UREA.............................................. 63BPO................................................................56BRAVELLE...................................................85BREO ELLIPTA..........................................114BREVIBLOC IN NACL (ISO-OSM)......33, 35BREVICON (28) ............................................53BREVITAL......................................................7BRIELLYN....................................................52BRILINTA..................................................... 98brimonidine .................................................. 110BRISDELLE.................................................. 87BRIVIACT.....................................................42BROMFED DM...........................................115bromfenac .....................................................108bromocriptine .................................................44brompheniramin-phenylephrin-dm .............. 115BROMSITE................................................. 108BROVANA..................................................113BSS PLUS....................................................109BUCALSEP................................................. 105budesonide ............................................. 92, 113bumetanide ..................................................... 37BUNAVAIL...................................................50BUPHENYL................................................ 104bupivacaine ...................................................... 7bupivacaine (pf) ............................................... 7bupivacaine in nacl(pf) .................................... 7bupivacaine-dextrose-water(pf) ....................... 8bupivacaine-epinephrine ..................................8bupivacaine-epinephrine (pf) ...........................8bupivacaine-epinephrine bitart ....................105BUPRENEX.....................................................4

118

buprenorphine ..................................................4buprenorphine hcl ...................................... 4, 50buprenorphine-naloxone ................................50bupropion hcl ........................................... 43, 50buspirone ........................................................40busulfan ..........................................................20butalbital-acetaminop-caf-cod .........................3butalbital-acetaminophen ................................ 4butalbital-acetaminophen-caff ......................... 4butalbital-aspirin-caffeine ............................... 7BUTISOL.......................................................49butorphanol tartrate .........................................4butylated hydroxytoluene ............................... 51BYDUREON................................................. 83BYETTA........................................................83BYSTOLIC.................................................... 35cabergoline .....................................................88CABOMETYX.............................................. 24CA-DTPA........................................................ 9CAFERGOT...................................................48caffeine citrate ................................................47caffeine-sodium benzoate ...............................47calcipotriene .............................................59, 60calcipotriene-betamethasone ......................... 57calcitonin (salmon) ........................................ 84calcitriol ................................................... 59, 80calcitriol (bulk) .............................................. 80calcium acetate ........................................ 71, 93calcium chloride .............................................71calcium gluconate .......................................... 71calcium gluconate in 0.9% nacl .....................71calcium gluconate in d5w .............................. 71CALCIUM-FOLIC ACID-VITAMIN D....... 71CALDOLOR....................................................7CAMBIA..........................................................6CAMILA........................................................54CAMINO PRO 15 PE MSUD....................... 75CAMPTOSAR............................................... 25CAMRESE.....................................................52CAMRESE LO.............................................. 52CANASA....................................................... 92CANCIDAS................................................... 11candesartan ....................................................32candesartan-hydrochlorothiazid ....................32CANDIN........................................................ 27CAPASTAT................................................... 13CAPCOF...................................................... 115capecitabine ................................................... 21CAPEX...........................................................62CAPHOSOL.................................................105CAPITAL WITH CODEINE...........................3CAPRELSA................................................... 25captopril ......................................................... 31captopril-hydrochlorothiazide ....................... 31CARAC..........................................................59CARAFATE...................................................93CARBAGLU................................................104carbamazepine ......................................... 41, 46carbidopa-levodopa ....................................... 43carbidopa-levodopa-entacapone ................... 43carbinoxamine maleate ................................ 112CARBOCAINE................................................8CARBOCAINE (PF) ........................................8carboplatin ..................................................... 24CARDENE IV IN DEXTROSE.................... 36CARDENE IV IN SODIUM CHLORIDE.... 36cardioplegic soln ..........................................110CARDIOTEK-RX (BIOPERINE) ................. 69CARDIOVID PLUS...................................... 35CARDIZEM LA............................................ 36

CARDURA XL..............................................39CARIMUNE NF NANOFILTERED.............28carisoprodol ................................................. 101carisoprodol-asa-codeine ............................ 102carisoprodol-aspirin .................................... 101CARNITOR (SUGAR-FREE) .....................104carteolol ....................................................... 108CARTIA XT.................................................. 36CARTICEL.................................................. 101carvedilol ....................................................... 32caspofungin .................................................... 11CATAPRES-TTS-1 ....................................... 37CATAPRES-TTS-2 ....................................... 37CATAPRES-TTS-3 ....................................... 37CATHFLO ACTIVASE................................ 99CAVERJECT................................................. 69CAYSTON...................................................114CAZIANT (28) .............................................. 54CEDAX..........................................................15cefaclor ...........................................................14cefadroxil ....................................................... 14cefazolin ......................................................... 14cefazolin in dextrose (iso-os) ......................... 14cefazolin in sterile water ................................ 14cefdinir ........................................................... 14cefditoren pivoxil ............................................15cefepime ......................................................... 15cefepime in dextrose 5 % ............................... 15cefepime in dextrose,iso-osm ......................... 15cefixime .......................................................... 15cefotaxime ...................................................... 15cefotetan ......................................................... 14cefotetan in dextrose, iso-osm ........................14cefoxitin ..........................................................14cefoxitin in dextrose, iso-osm .........................14cefpodoxime ................................................... 15cefprozil ..........................................................14ceftazidime ..................................................... 15ceftazidime in d5w ..........................................15ceftriaxone ......................................................15ceftriaxone in dextrose,iso-os ........................ 15cefuroxime axetil ............................................ 14cefuroxime sodium ......................................... 14CELEBREX..................................................... 6celecoxib ...........................................................6CELLCEPT..............................................5, 100CELLCEPT INTRAVENOUS................ 5, 100CELLUGEL................................................. 109cellulose (bulk) ...............................................51CELONTIN....................................................42CENTANY AT.............................................. 58CENTERGY................................................ 111CENTERGY DM.........................................115CENTRATEX................................................72cephalexin ...................................................... 14CEPROTIN (BLUE BAR).............................99CEPROTIN (GREEN BAR)..........................99CERDELGA................................................ 104CEREFOLIN..................................................75CERENX..........................................................1CERETEC......................................................68CEREZYME................................................ 103CERVIDIL..................................................... 81CESAMET..................................................... 89CETACAINE................................................. 64CETACAINE ANESTHETIC....................... 64CETROTIDE................................................. 87cevimeline .....................................................105CHANTIX......................................................50CHANTIX CONTINUING MONTH BOX.. 50

CHANTIX STARTING MONTH BOX........50CHEMET......................................................... 9CHENODAL..................................................90CHIRHOSTIM...............................................67chloramphenicol sod succinate ......................15chlordiazepoxide hcl ...................................... 40chlordiazepoxide-clidinium ......................46, 91chlorhexidine gluconate ...............................105chloroquine phosphate ...................................12chlorothiazide .................................................38chlorothiazide sodium .................................... 38chlorpromazine .............................................. 45chlorpropamide ..............................................82chlorthalidone ................................................ 38chlorzoxazone ...............................................101CHOLBAM....................................................90cholestyramine (with sugar) ...........................34CHOLESTYRAMINE LIGHT...................... 34choline,magnesium salicylate .......................... 7chorionic gonadotropin, human .....................86chromium chloride ......................................... 74chromium polynicotinate (bulk) ..................... 74CIALIS.....................................................69, 94CICLODAN KIT........................................... 58ciclopirox ....................................................... 58ciclopirox-ure-camph-menth-euc ...................58cidofovir ......................................................... 15cilostazol ........................................................ 99CILOXAN....................................................110cimetidine ....................................................... 90cimetidine hcl ................................................. 90CIMZIA..................................................... 4, 92CIMZIA POWDER FOR RECONST........4, 92CIMZIA STARTER KIT........................... 4, 92CINQAIR..................................................... 113CINRYZE...................................................... 96CIPRO............................................................15CIPRO HC................................................... 111CIPRODEX..................................................111ciprofloxacin .................................................. 15ciprofloxacin (mixture) .................................. 95ciprofloxacin hcl ............................ 15, 110, 111ciprofloxacin in 5 % dextrose ........................ 15ciprofloxacin lactate ...................................... 15cisatracurium ............................................... 101cisplatin ..........................................................24citalopram ...................................................... 42CITANEST PLAIN DENTAL.................8, 105CITRANATAL (DUAL-IRON).................... 78CITRANATAL 90 DHA (ALGAL OIL) .......78CITRANATAL ASSURE..............................78CITRANATAL B-CALM (FE GLUC)......... 78CITRANATAL DHA (ALGAL OIL) ............78cladribine ....................................................... 21CLAFORAN.................................................. 15CLARAVIS....................................................55CLARINEX................................................. 112CLARINEX-D 12 HOUR............................111clarithromycin ................................................17clemastine .....................................................112CLEOCIN.................................................... 116CLEVIPREX..................................................36CLIMARA..................................................... 85CLIMARA PRO............................................ 84CLIN SINGLE USE.......................................17CLINDACIN ETZ......................................... 56CLINDACIN PAC.........................................56CLINDAGEL.................................................55clindamycin hcl .............................................. 17clindamycin in 5 % dextrose .......................... 17

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clindamycin palmitate hcl .............................. 17clindamycin phosphate .....................17, 55, 116clindamycin-benzoyl peroxide ........................56clindamycin-tretinoin ..................................... 56CLINDESSE................................................ 116CLINIMIX 5%/D15W SULFITE FREE...... 75CLINIMIX 5%/D25W SULFITE-FREE...... 75CLINIMIX 2.75%/D5W SULFIT FREE.......75CLINIMIX 4.25%/D10W SULF FREE.........75CLINIMIX 4.25%/D5W SULFIT FREE.......75CLINIMIX 4.25%-D20W SULF-FREE........ 75CLINIMIX 4.25%-D25W SULF-FREE........ 75CLINIMIX 5%-D20W(SULFITE-FREE) ..... 75CLINIMIX E 2.75%/D10W SUL FREE....... 76CLINIMIX E 2.75%/D5W SULF FREE....... 76CLINIMIX E 4.25%/D10W SUL FREE....... 76CLINIMIX E 4.25%/D25W SUL FREE....... 76CLINIMIX E 4.25%/D5W SULF FREE....... 76CLINIMIX E 5%/D15W SULFIT FREE...... 76CLINIMIX E 5%/D20W SULFIT FREE...... 76CLINIMIX E 5%/D25W SULFIT FREE...... 76CLINISOL SF 15 %.......................................75clobetasol ....................................................... 62clobetasol-emollient ....................................... 62CLOBEX........................................................62CLODAN....................................................... 62CLODAN KIT............................................... 63CLODERM.................................................... 62clofarabine ..................................................... 21CLOLAR........................................................21clomiphene citrate ..........................................85clomipramine ................................................. 43clonazepam .....................................................40clonidine .........................................................37clonidine (pf) .................................................... 1clonidine hcl .............................................37, 45clopidogrel ..................................................... 99clorazepate dipotassium .................................40CLORPRES................................................... 37clotrimazole ............................................58, 105clotrimazole-betamethasone .......................... 59clozapine ........................................................ 44C-NATE DHA............................................... 77coal tar ........................................................... 63COARTEM.................................................... 12cocaine ........................................................... 65codeine sulfate ..................................................1codeine-guaifenesin ..................................... 115colchicine ....................................................... 95COLCRYS..................................................... 95COLESTID FLAVORED.............................. 34colestipol ........................................................ 34colistin (colistimethate na) .............................18COMBIGAN................................................108COMBIPATCH............................................. 84COMBIVENT RESPIMAT......................... 114COMETRIQ...................................................24COMFORT PAC-CYCLOBENZAPRINE..102COMFORT PAC-IBUPROFEN...................... 6COMFORT PAC-MELOXICAM....................6COMFORT PAC-NAPROXEN...................... 6COMFORT PAC-TIZANIDINE................. 102COMPLERA..................................................13COMPLETE NATAL DHA.......................... 77COMPLETENATE........................................77CONCEPT DHA............................................78CONCEPT OB...............................................78CONDYLOX................................................. 63CONRAY.......................................................66CONRAY 43..................................................66

CONRAY-30................................................. 66CONZIP........................................................... 2COPAXONE................................................106COPPER CHLORIDE................................... 74CORDRAN.................................................... 62COREG CR....................................................32CORLANOR..................................................38CORLOPAM................................................. 38CORMAX...................................................... 62CORTANE-B...............................................111CORTIFOAM................................................ 92cortisone .........................................................85CORTISPORIN............................................. 58CORVITA 150 ...............................................72CORVITE FREE............................................74COSENTYX.................................................. 57COSENTYX (2 SYRINGES) ........................ 57COSENTYX PEN..........................................57COSENTYX PEN (2 PENS) ......................... 57COSOPT (PF) .............................................. 108cosyntropin .....................................................67COTELLIC.................................................... 24COTEMPLA XR-ODT.................................. 46creatine (bulk) .................................................. 1CREON.......................................................... 90CRESEMBA.................................................. 11CRINONE....................................................116CRIXIVAN.................................................... 18cromolyn .................................................24, 109CRYOSERV.................................................. 50CRYSELLE (28) ............................................53CUPRIMINE................................................6, 9CUROSURF.................................................114CUVITRU......................................................28CUVPOSA................................................... 106cyanocobalamin (vitamin b-12) ..................... 80CYANOKIT.....................................................9CYCLAFEM 1/35 (28) .................................. 52CYCLAFEM 7/7/7 (28) ................................. 54CYCLESSA (28) ............................................54cyclobenzaprine ........................................... 101CYCLOGYL................................................107CYCLOMYDRIL........................................ 106cyclopentolate .............................................. 107cyclophosphamide ......................................5, 20cycloserine ..................................................... 13CYCLOSET................................................... 82cyclosporine ............................................. 5, 100cyclosporine (bulk) .......................................100cyclosporine modified .............................. 5, 100CYMBALTA........................................... 42, 47cyproheptadine .............................................112CYRAMZA....................................................26CYSTADANE............................................. 104CYSTAGON..................................................93CYSTARAN................................................ 108cysteine (l-cysteine) ........................................75CYSTO-CONRAY II .....................................66CYSTOGRAFIN............................................66CYSTOGRAFIN-DILUTE............................66cytarabine .......................................................21cytarabine (pf) ................................................21CYTOGAM................................................... 28CYTRA K CRYSTALS.................................94CYTRA-3.......................................................94CYTRA-K......................................................94d10 %-0.45 % sodium chloride ......................70d2.5 %-0.45 % sodium chloride .....................70d5 % and 0.9 % sodium chloride ................... 70d5 %-0.45 % sodium chloride ........................70

dacarbazine ....................................................20DALIRESP...................................................113DALVANCE..................................................17danazol ........................................................... 86DANTRIUM................................................ 101dantrolene .................................................... 101dapsone .......................................................... 11DAPTACEL (DTAP PEDIATRIC) (PF) .......29daptomycin ..................................................... 15darifenacin ..................................................... 95DARZALEX.................................................. 22DASETTA 7/7/7 (28) .....................................54DATSCAN.....................................................68daunorubicin .................................................. 26DAYSEE........................................................52DAYTRANA................................................. 46DEBACTEROL........................................... 105decitabine ....................................................... 22deferoxamine ....................................................9DEFINITY..................................................... 67DELFLEX WITH 2.5 % DEXTROSE........ 111DELFLEX-LC/1.5% DEXTROSE.............. 111DELFLEX-LC/2.5% DEXTROSE.............. 111DELFLEX-LC/4.25% DEXTROSE............ 111DELFLEX-SM WITH 1.5% DEXTROSE.. 111DELYLA (28) ................................................ 53DELZICOL.................................................... 92demeclocycline ............................................... 19DEMEROL...................................................... 2DEMEROL (PF) .............................................. 3DEMSER....................................................... 39DENAVIR......................................................60DEPEN TITRATABS..................................6, 9DEPLIN (ALGAL OIL) .................................80DEPO-ESTRADIOL......................................85DEPO-MEDROL........................................... 85DEPO-PROVERA......................................... 24DEPO-SUBQ PROVERA 104.......................52DEPO-TESTOSTERONE............................. 81DERMAGRAFT............................................ 66DERMASORB AF COMPLETE KIT...........58DERMASORB HC COMPLETE KIT.......... 63DERMASORB TA COMPLETE KIT...........62DESCOVY.....................................................13desipramine ....................................................43desloratadine ................................................112desmopressin ..................................................82desogestrel-ethinyl estradiol .......................... 52DESONATE...................................................62desonide ......................................................... 61desoximetasone .............................................. 62desvenlafaxine ................................................42desvenlafaxine fumarate ................................ 42desvenlafaxine succinate ................................42DETROL LA..................................................95dexamethasone ............................................... 85dexamethasone in 0.9 % sod chl .................... 85DEXAMETHASONE INTENSOL............... 85dexamethasone sodium phos (pf) ................... 85dexamethasone sodium phosphate ......... 85, 107DEXEDRINE SPANSULE............................47DEXILANT................................................... 90dexmedetomidine ............................................50dexmethylphenidate ........................................46dexrazoxane hcl ..............................................26dextroamphetamine ............................46, 47, 49dextroamphetamine-amphetamine ........... 46, 47dextrose 10 % and 0.2 % nacl ........................70dextrose 10 % in water (d10w) ...................... 70dextrose 20 % in water (d20w) ...................... 70

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dextrose 25 % in water (d25w) ...................... 70dextrose 30 % in water (d30w) ...................... 70dextrose 40 % in water (d40w) ...................... 70dextrose 5 % in ringer's ................................. 71dextrose 5 % in water (d5w) .......................... 70dextrose 5 %-lactated ringers ........................ 70dextrose 5%-0.2 % sod chloride .................... 70dextrose 5%-0.3 % sod.chloride .................... 70dextrose 50 % in water (d50w) ...................... 70dextrose 70 % in water (d70w) ...................... 70DIALYVITE.................................................. 69DIALYVITE 3000......................................... 69DIALYVITE 5000......................................... 74DIALYVITE 800 WITH IRON.....................75DIALYVITE SUPREME D...........................69DIANEAL LOW CALCIUM/1.5% DEX....111DIANEAL LOW CALCIUM/4.25% DEX..111DIANEAL PD-2 WITH 2.5 % DEX........... 111DIANEAL PD-2 WITH 4.25 % DEX......... 111DIANEAL WITH 1.5% DEXTROSE......... 111DIANEAL WITH 2.5 % DEXTROSE........ 111DIANEAL WITH 4.25 % DEXTROSE...... 111diazepam .................................................. 40, 46DIAZEPAM INTENSOL........................ 40, 46DIBENZYLINE............................................. 39diclofenac potassium ........................................6diclofenac sodium .............................. 6, 64, 108diclofenac-misoprostol .....................................6dicloxacillin ....................................................18dicyclomine .................................................... 91didanosine ...................................................... 12diethylpropion ................................................ 69DIFFERIN......................................................57DIFICID......................................................... 17diflorasone ..................................................... 61diflunisal ...........................................................7DIGIFAB......................................................... 9digoxin ............................................................37dihydroergotamine ......................................... 48DILANTIN.....................................................41diltiazem hcl ............................................. 34, 36diltiazem hcl in 0.9% nacl ..............................36DILUENT FOR ACTHIB..............................70DILUENT FOR EPOPROSTENOL/FLOLA........................... 51DILUENT FOR HIBERIX............................ 70DILUENT FOR IMOVAX............................ 70DILUENT FOR MENHIBRIX......................70DILUENT FOR MENOMUNE..................... 70DILUENT FOR MENOMUNE (PF) .............70DILUENT FOR RABAVERT....................... 70DILUENT FOR ROTARIX...........................71DILUENT FOR YF-VAX (1 DOSE) ............ 71DILUENT FOR YF-VAX (5 DOSE) ............ 71DILUENT-MERCK LIVE VIRUS VACC....71dimenhydrinate ...............................................89DIPENTUM................................................... 92diphenhydramine hcl ....................................112diphenoxylate-atropine .................................. 89dipyridamole ............................................ 67, 99DISCOVISC.................................................109disopyramide phosphate ................................ 33disulfiram ....................................................... 50DIURIL.......................................................... 38divalproex ...........................................40, 46, 48DIVIGEL....................................................... 85DMSA............................................................ 68dobutamine .....................................................36dobutamine in d5w ......................................... 36DOCEFREZ................................................... 25

docetaxel ........................................................ 25dofetilide .........................................................33donepezil ........................................................ 51DONNATAL................................................. 91dopamine ........................................................36dopamine in 5 % dextrose ..............................36doripenem .......................................................14DORYX MPC................................................ 19dorzolamide ..................................................108dorzolamide-timolol ..................................... 108DOTAREM....................................................67DOVONEX....................................................60doxapram ....................................................... 47doxazosin ........................................................39doxazosin mesylate (bulk) .............................. 39doxepin ........................................................... 43doxercalciferol ............................................. 104doxorubicin .................................................... 26doxorubicin, peg-liposomal ........................... 26doxycycline hyclate ................................ 19, 105doxycycline monohydrate ...............................19DRAXIMAGE DTPA....................................68DRAXIMAGE MAA.....................................68DRAXIMAGE MDP-25................................ 68DRITHOCREME HP.....................................60dronabinol ................................................69, 89droperidol .........................................................7drospirenone-e.estradiol-lm.fa .......................52drospirenone-ethinyl estradiol .......................52DROXIA........................................................ 99DUAVEE....................................................... 84DUET DHA BALANCED.............................78DUET DHA WITH OMEGA-3.....................78DULERA..................................................... 114duloxetine ................................................. 42, 47duloxetine hcl (bulk) .................................42, 47DUODOTE...................................................... 9DUOVISC VISCO ELASTIC..................... 109DUPIXENT....................................................58DUREZOL................................................... 107dutasteride ......................................................94dutasteride-tamsulosin ................................... 93DYANAVEL XR.....................................46, 47DYLOJECT..................................................... 6DYRENIUM.................................................. 38DYSPORT................................................... 101econazole ........................................................59EDARBI.........................................................32EDARBYCLOR.............................................32EDECRIN...................................................... 38EDLUAR....................................................... 49EDURANT.....................................................12EFFER-K....................................................... 74EFFIENT........................................................99EGRIFTA.......................................................86ELAPRASE................................................. 103electrolyte-48 in d5w ......................................71ELELYSO....................................................103ELESTRIN.....................................................85ELETONE......................................................61eletriptan hbr ..................................................48ELIDEL..........................................................60ELIGARD...................................................... 23ELIGARD (3 MONTH).................................23ELIGARD (4 MONTH).................................23ELIGARD (6 MONTH).................................23ELIGEN B12..................................................80ELINEST....................................................... 52ELIQUIS........................................................ 96ELITE OB WITH DHA.................................77

ELITEK..........................................................96ELITE-OB 400...............................................77ELLA............................................................. 55ELLIOTTS B (PF) ......................................... 71ELMIRON..................................................... 93EMADINE................................................... 107EMBEDA.........................................................3EMCYT..........................................................23EMEND......................................................... 89EMEND (FOSAPREPITANT)...................... 89EMFLAZA.....................................................86EMOQUETTE............................................... 52EMPLICITI ....................................................22EMSAM......................................................... 42EMTRIVA..................................................... 13EMULSION SB............................................. 60enalapril maleate ........................................... 31enalaprilat ......................................................31enalapril-hydrochlorothiazide ....................... 31ENBREL.......................................................... 4ENBREL SURECLICK...................................4ENDARI.......................................69, 75, 93, 99ENDO AVITENE.......................................... 97ENDOCET................................................... 3, 4ENDOMETRIN............................................. 85ENGERIX-B (PF) .......................................... 28ENGERIX-B PEDIATRIC (PF) .................... 28ENLON-PLUS................................................. 9enoxaparin ..................................................... 98ENPRESSE.................................................... 55entacapone ..................................................... 43entecavir .........................................................16ENTERAGAM.................................................1ENTEREG..................................................... 10ENTERO VU................................................. 66ENTRESTO................................................... 32ENTYVIO......................................................92ENVARSUS XR.......................................... 100EOVIST......................................................... 67EPANED........................................................31EPCLUSA......................................................16ephedrine sulfate ............................................ 36ephedrine sulfate-0.9%nacl(pf) ......................36EPICERAM................................................... 61EPIDUO......................................................... 57EPIDUO FORTE........................................... 57EPIFIX AMNIOTIC MEMBRANE.............. 65EPIFOAM...................................................... 62epigallocatechin gallate(bulk) ......................... 1epinastine ..................................................... 107epinephrine .......................................36, 37, 112epirubicin ....................................................... 26EPISIL..........................................................105EPIVIR...........................................................13EPIVIR HBV................................................. 16eplerenone ................................................32, 37EPOGEN........................................................96epoprostenol (glycine) ....................................39eprosartan ...................................................... 32EPZICOM...................................................... 13EQUETRO............................................... 41, 46ERAXIS(WATER DILUENT) ...................... 11ERBITUX...................................................... 27ergocalciferol (vitamin d2) ............................ 80ergoloid .......................................................... 51ERIVEDGE....................................................23ERRIN............................................................54ERTACZO..................................................... 59ERWINAZE...................................................22ERYPED 400................................................. 17

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ERY-TAB...................................................... 17ERYTHROCIN..............................................17ERYTHROCIN (AS STEARATE) ................17erythromycin .......................................... 17, 110erythromycin ethylsuccinate .......................... 17erythromycin with ethanol ............................. 55erythromycin-benzoyl peroxide ......................56ESBRIET..................................................... 116ESCAVITE.................................................... 76ESCAVITE D................................................ 77escitalopram oxalate ...................................... 42esmolol ..................................................... 33, 35esomeprazole magnesium .............................. 90esomeprazole sodium ..................................... 90estazolam ........................................................49ESTRACE....................................................116estradiol ................................................. 84, 116estradiol valerate ........................................... 84estradiol-norethindrone acet ..........................84ESTRING.....................................................116ESTROGEL................................................... 85estrogens-methyltestosterone ......................... 84estropipate ......................................................84ESTROSTEP FE-28 .......................................55eszopiclone ..................................................... 49ethacrynate sodium ........................................ 37ethambutol ......................................................14ETHAMOLIN................................................40ethanol (ethyl alcohol) ..................................... 1ethosuximide ...................................................42ethyl acetate ................................................... 51ethyl alcohol (bulk) ........................................ 51ethyl chloride ..................................................64ethynodiol diac-eth estradiol ......................... 52etidronate disodium ........................................84etodolac ............................................................7etomidate ..........................................................7ETOPOPHOS.................................................23etoposide ........................................................ 23EUCRISA.......................................................58EUFLEXXA.................................................101EURAX..........................................................65EVAMIST......................................................85EVEKEO..................................................46, 47EVISTA......................................................... 88EVOTAZ........................................................13EXALGO ER................................................... 3EXELDERM..................................................59EXELON........................................................51exemestane ..................................................... 22EXFORGE..................................................... 32EXFORGE HCT............................................ 32EXJADE...........................................................9EXODERM....................................................58EXONDYS 51 ..............................................101EXPAREL (PF) ................................................8EXTAVIA....................................................106EXTINA.........................................................59EXTRANEAL 7.5 %................................... 111EXTRA-VIRT PLUS DHA........................... 77EYLEA.................................................109, 110E-Z DISK....................................................... 66E-Z-CAT DRY...............................................66ezetimibe .........................................................34ezetimibe-simvastatin ..................................... 35E-Z-HD BARIUM......................................... 66E-Z-PAQUE...................................................66E-Z-PASTE....................................................66FABB....................................................... 80, 81FABIOR......................................................... 57

FABRAZYME............................................. 103FALMINA (28) ..............................................53famciclovir ..................................................... 17famotidine .......................................................90famotidine (pf) ................................................90famotidine (pf)-nacl (iso-os) ......................... 90FANAPT........................................................ 44FARESTON................................................... 25FARXIGA......................................................82FARYDAK.................................................... 23FASLODEX...................................................23FAYOSIM......................................................54FAZACLO..................................................... 44felbamate ........................................................40felodipine ........................................................36FEM PH....................................................... 116FEMHRT LOW DOSE..................................84FEMRING....................................................116fenofibrate ...................................................... 34fenofibrate micronized ................................... 34fenofibrate nanocrystallized ...........................34fenofibric acid ................................................ 34fenofibric acid (choline) .................................34FENOGLIDE................................................. 34fenoprofen ........................................................ 6FENORTHO.................................................... 7fentanyl .........................................................1, 2fentanyl (pf)-bupivacaine-nacl .........................3fentanyl citrate ......................................... 1, 2, 3fentanyl citrate (pf) .......................................1, 7fentanyl citrate-0.9%nacl (pf) .......................... 1FENTORA....................................................... 3FERAHEME.................................................. 72FERIDEX IV..................................................67FEROCON..................................................... 72FERRALET 90 DUAL-IRON DELIVERY.. 72FERRAPLUS 90 ............................................ 72FERREX 150 FORTE....................................72FERREX 150 FORTE PLUS.........................72FERREX 28 ................................................... 72FERRIPROX....................................................9FERROCITE PLUS....................................... 72FETZIMA...................................................... 42FINACEA................................................ 55, 64finasteride .......................................................94FIORICET........................................................4FIORINAL-CODEINE #3 ............................... 3FIRAZYR.......................................................35FIRMAGON KIT W DILUENT SYRINGE. 24FLAGYL........................................................12FLAREX...................................................... 107flavoxate ......................................................... 95FLEBOGAMMA DIF....................................28flecainide ........................................................33FLECTOR......................................................64FLOLIPID......................................................34FLORIVA (FLUORIDE-VITAMIN D3)................................................................ 77, 105FLOVENT DISKUS.................................... 112FLOVENT HFA.......................................... 112floxuridine ...................................................... 22FLUAD 2017-2018 (65 YR UP)(PF) .............30FLUARIX QUAD 2017-2018 (PF) ............... 30FLUBLOK 2017-2018 (PF) ...........................30FLUBLOK QUAD 2017-2018 (PF) .............. 30FLUCAINE..................................................108FLUCELVAX QUAD 2017-2018................. 30FLUCELVAX QUAD 2017-2018 (PF) .........30fluconazole ..................................................... 11fluconazole in dextrose(iso-o) ........................11

fluconazole in nacl (iso-osm) ......................... 11flucytosine ...................................................... 11fludarabine ..................................................... 21fludrocortisone ............................................... 87FLULAVAL QUAD 2017-2018....................30FLULAVAL QUAD 2017-2018 (PF) ............30flumazenil ......................................................... 9FLUMIST QUAD 2017-2018..................29, 30fluocinolone ....................................................61fluocinolone acetonide oil ............................111fluocinolone and shower cap ......................... 61fluocinonide ....................................................61FLUOCINONIDE-E...................................... 62FLUORABON............................................. 104FLUOR-A-DAY.......................................... 105FLUOR-A-DAY (WITH XYLITOL) ..104, 105fluorescein (bulk) ......................................... 108fluorescein-proparacaine .............................108FLUORESCITE........................................... 108fluoride (sodium) ..........................................104fluorometholone ........................................... 107fluorouracil .............................................. 22, 59fluorouracil (bulk) ....................................22, 50fluoxetine ........................................................42fluphenazine hcl ............................................. 45FLURA-DROPS.......................................... 104flurandrenolide ...............................................62flurazepam ......................................................49flurbiprofen ...................................................... 6flurbiprofen sodium ......................................108flutamide .........................................................21fluticasone ...................................................... 61fluticasone-salmeterol ..................................114fluvastatin .......................................................34FLUVIRIN 2017-2018...................................30FLUVIRIN 2017-2018 (PF) ...........................30fluvoxamine .................................................... 42FLUZONE HIGH-DOSE 2017-18 (PF) ........ 30FLUZONE INTRADERM QUAD 2017-18 ..30FLUZONE QUAD 2017-2018.......................30FLUZONE QUAD 2017-2018 (PF) .............. 30FLUZONE QUAD PEDI 2017-18 (PF) .........30FML FORTE................................................107FML S.O.P. .................................................. 107FOCALGIN CA.............................................78FOCALIN XR................................................46FOLBEE PLUS..............................................69FOLBIC RF....................................................80FOLGARD OS...............................................71FOLGARD RX........................................ 80, 81folic acid .........................................................80folic acid-vit b6-vit b12 ............................ 80, 81FOLIVANE-F................................................ 72FOLIVANE-OB.............................................77FOLIVANE-PLUS.........................................72FOLLISTIM AQ............................................ 85FOLOTYN..................................................... 21FOLTRATE................................................... 80FOLTX...........................................................80fomepizole ........................................................ 9fondaparinux .................................................. 98FORFIVO XL................................................ 43FORMADON.................................................27formaldehyde ..................................................27FORMA-RAY................................................27FORTAVIT....................................................75FORTAZ........................................................ 15FORTAZ IN DEXTROSE 5 %......................15FORTEO........................................................ 84FORTESTA................................................... 81

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FOSAMAX PLUS D..................................... 84fosamprenavir ................................................ 18foscarnet .........................................................15fosinopril ........................................................ 31fosinopril-hydrochlorothiazide ...................... 31fosphenytoin ................................................... 41FOSRENOL................................................... 94FOSTEUM....................................................... 1FOSTEUM PLUS............................................ 1FRAGMIN..................................................... 98FREAMINE HBC 6.9 %................................76FREAMINE III 10 %.....................................76FREESTYLE INSULINX............................102FREESTYLE INSULINX TEST STRIPS...102FREESTYLE LITE STRIPS........................102FREESTYLE TEST.....................................102FROVA.......................................................... 48frovatriptan .................................................... 48FUL-GLO.....................................................108furosemide ......................................................38FUSILEV....................................................... 27FUSION PLUS.............................................. 72FUZEON........................................................12FYCOMPA.................................................... 40gabapentin ......................................................41GABITRIL..................................................... 41GABLOFEN................................................ 101GADAVIST................................................... 67galantamine ....................................................51GALZIN...........................................................9GAMASTAN S/D..........................................28GAMMAGARD LIQUID..............................28GAMMAGARD S-D (IGA < 1 MCG/ML) ...28GAMMAKED................................................28GAMMAPLEX..............................................28GAMMAPLEX (WITH SORBITOL) ........... 28GAMUNEX-C............................................... 28ganciclovir sodium .........................................15ganirelix ......................................................... 87GARDASIL 9 (PF) ........................................ 30GASTROGRAFIN.........................................66GASTROMARK............................................67GATTEX 30-VIAL........................................93GATTEX ONE-VIAL....................................93GAZYVA.......................................................22GELCLAIR..................................................105GELFILM.............................................. 97, 109GELFOAM.................................................... 97GELFOAM COMPRESSED SIZE 100 .........97GELFOAM SPONGE SIZE 100................... 97GELFOAM SPONGE SIZE 12-7MM...........97GELFOAM SPONGE SIZE 200................... 97GELFOAM SPONGE SIZE 50 ..................... 97GELNIQUE................................................... 95GELX........................................................... 105gemcitabine .............................................. 21, 22gemfibrozil ..................................................... 34GENADUR.................................................... 65GENADUR (WITH LEXINAL) ....................65GENERESS FE..............................................53gentamicin ........................................10, 58, 109gentamicin (bulk) ........................................... 10gentamicin in nacl (iso-osm) ..........................10gentamicin sulfate (ped) (pf) .......................... 10gentamicin sulfate (pf) ................................... 10GENVOYA....................................................13GEODON.................................................44, 47GIANVI (28) ..................................................52GIAZO........................................................... 92GILDAGIA.................................................... 52

GILENYA....................................................106GILOTRIF..................................................... 20GLASSIA.....................................................114GLEEVEC..................................................... 25GLIADEL WAFER....................................... 20glimepiride ..................................................... 83glipizide ..........................................................83glipizide-metformin ........................................ 82GLUCAGEN DIAGNOSTIC KIT.................67GLUCAGEN HYPOKIT............................... 81GLUCAGON EMERGENCY KIT (HUMAN)......................................................81glucagon hcl ...................................................81glutaraldehyde ............................................... 27glyburide ........................................................ 83glyburide micronized ......................................83glyburide-metformin .......................................82glycine urologic solution ................................93glycolic acid (bulk) .........................................50GLYCOPHOS................................................73glycopyrrolate ................................................ 91GLYXAMBI.................................................. 82GOCOVRI..................................................... 44GOLYTELY.................................................. 92GONAL-F...................................................... 85GONAL-F RFF.............................................. 85GONITRO......................................................33GORDONS UREA........................................ 61GRAFIX CORE............................................. 65GRAFIX PRIME............................................65granisetron (pf) .............................................. 89granisetron hcl ............................................... 89GRANIX........................................................ 96GRASTEK..................................................... 27griseofulvin microsize .................................... 11griseofulvin ultramicrosize ............................ 11guanfacine ................................................37, 45guanidine ......................................................100GYNAZOLE-1 .............................................116HAEGARDA................................................. 96HALAVEN.................................................... 23halobetasol propionate .................................. 61HALOG..........................................................62haloperidol ..................................................... 44haloperidol decanoate ....................................44haloperidol lactate ......................................... 44HAVRIX (PF) ................................................ 28HEATHER..................................................... 54HECTOROL................................................ 104HEMABATE................................................. 81HEMANGEOL.............................................. 35HEMATINIC PLUS VIT/MINERALS......... 72HEMATINIC/FOLIC ACID..........................72HEMATOGEN.............................................. 72HEMATOGEN FA........................................ 72HEMATOGEN FORTE.................................72HEMATRON-AF...........................................72HEMENATAL OB........................................ 77HEMENATAL OB + DHA........................... 77HEMETAB.................................................... 72HEMOCYTE-F..............................................72HEMOCYTE-PLUS...................................... 72HEP FLUSH-10 (PF) ............................... 97, 98HEPAGAM B................................................ 28heparin (porcine) ........................................... 97heparin (porcine) (bulk) .................................97heparin (porcine) in 0.9% nacl ...................... 97heparin (porcine) in 5 % dex ......................... 97heparin (porcine) in nacl (pf) .........................97heparin flush(porcine)-0.9nacl ...................... 97

heparin lock flush (porcine) ...........................97heparin(porcine) in 0.45% nacl ..................... 98heparin, porcine (pf) ................................ 97, 98HEPATAMINE 8%....................................... 76HEPSERA......................................................16HERCEPTIN..................................................27hetastarch 6 % in 0.9 % nacl ......................... 98HETLIOZ.......................................................47HEXALEN.....................................................20HEXTEND.....................................................98HICON........................................................... 25HIZENTRA....................................................28homatropine hbr ...........................................107HORIZANT................................................... 49HPR................................................................60HPR PLUS..................................................... 61HPR PLUS-MB HYDROGEL.......................60huber safety needles (disp.) ..................102, 103HUMIRA................................................... 4, 92HUMIRA PEDIATRIC CROHN'S START.................................................................... 5, 92HUMIRA PEN.................................................5HUMIRA PEN CROHN'S-UC-HS START....5HUMIRA PEN PSORIASIS-UVEITIS........... 5HYCAMTIN.................................................. 25HYCOFENIX...............................................115hydralazine .....................................................37HYDRO 40.................................................... 63hydrochloric acid (bulk) .................................50hydrochlorothiazide ....................................... 38hydrocodone-acetaminophen ........................... 3hydrocodone-chlorpheniramine ...................115hydrocodone-homatropine ........................... 115hydrocodone-ibuprofen ....................................3hydrocortisone ................................... 61, 85, 92hydrocortisone acetate .....................................8hydrocortisone butyrate ................................. 61hydrocortisone valerate ................................. 61hydrocortisone-acetic acid ...........................111hydrocortisone-min oil-wht pet ......................62hydrocortisone-pramoxine ................... 8, 61, 62hydromorph(pf)-ropiv-0.9% nacl .....................1hydromorphone ............................................ 1, 2hydromorphone (pf) ......................................... 1hydromorphone (pf)-0.9% nacl ........................1hydromorphone in 0.9 % nacl ..........................1hydromorphone-bupiv (pf)-nacl .......................3hydroquinone ................................................. 60hydroquinone microspheres ...........................60hydroxocobalamin ..........................................80hydroxychloroquine ................................... 5, 12hydroxyprogesterone caproate ...................... 87hydroxyurea ................................................... 22hydroxyzine hcl .............................................. 40hydroxyzine pamoate ......................................40HYGEL.......................................................... 64HYLATOPIC................................................. 61HYLATOPICPLUS....................................... 61HYLENEX.....................................................88HYOPHEN.....................................................95hyoscyamine sulfate ....................................... 91HYPERHEP B S/D........................................ 28HYPERHEP B S-D NEONATAL................. 28HYPERLYTE CR.......................................... 73HYPERRAB S/D (PF) ................................... 28HYPERRHO S/D...........................................28HYPER-SAL..................................................51HYPERTET S/D (PF) ....................................29HYQVIA........................................................28HYQVIA HY COMPONENT....................... 88

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HYQVIA IG COMPONENT.........................28HYSINGLA ER............................................... 2ibandronate .................................................... 84IBRANCE...................................................... 22ibuprofen .......................................................... 6ibuprofen-oxycodone ........................................4ibutilide fumarate ...........................................33ICAR-C PLUS............................................... 72ICLUSIG........................................................24idarubicin ....................................................... 26IDHIFA.......................................................... 24IFEREX 150 FORTE..................................... 72ifosfamide ....................................................... 20ifosfamide-mesna ........................................... 20ILARIS (PF) .....................................................4ILEVRO....................................................... 108ILUVIEN..................................................... 107IMBRUVICA...........................................22, 25imipenem-cilastatin ........................................14imipramine hcl ............................................... 43imipramine pamoate ...................................... 43imiquimod .......................................................63IMITREX....................................................... 48IMLYGIC.................................................23, 29IMOGAM RABIES-HT (PF) .........................28IMOVAX RABIES VACCINE (PF) ............. 31IMPAVIDO....................................................12INCRELEX....................................................87INCRUSE ELLIPTA................................... 113indapamide .....................................................38INDICLOR.....................................................68INDIGO CARMINE...................................... 68INDIUM IN-111 DTPA.................................68indium in-111 oxyquinoline ........................... 68INDOCIN.........................................................7indomethacin ....................................................7indomethacin sodium ..................................... 39INFANRIX (DTAP) (PF) .............................. 29INFASURF.................................................. 114INFED............................................................72INFUMORPH P/F ............................................3INFUVITE ADULT.......................................75INFUVITE PEDIATRIC............................... 76INGREZZA..............................................48, 49INJECTAFER................................................ 72INLYTA.........................................................25INNOPRAN XL.............................................35INOVA...........................................................56INOVA 4-1 .................................................... 57INOVA 8-2 .................................................... 57insulin syr/ndl u100 half mark ............. 102, 103insulin syringe needleless .....................102, 103insulin syringe-needle u-100 ................102, 103insulin syringes (disposable) ................102, 103INTEGRA F...................................................72INTEGRA PLUS........................................... 72INTEGRILIN................................................. 98INTELENCE..................................................12INTRALIPID................................................. 76INTRAROSA.................................................87INTRON A.....................................................23INTROVALE.................................................53INTUNIV ER.................................................45INVANZ........................................................ 14INVEGA........................................................ 44INVEGA SUSTENNA.................................. 44INVEGA TRINZA.........................................44INVIRASE..................................................... 18INVOKAMET............................................... 82INVOKAMET XR.........................................82

INVOKANA.................................................. 82IODOFLEX....................................................27IODOPEN...................................................... 72iodoquinol-hc ................................................. 59IODOSORB................................................... 27IONOSOL-B IN D5W................................... 71IONOSOL-MB IN D5W................................71IOPIDINE.................................................... 110ipecac ............................................................. 10IPOL...............................................................31ipratropium bromide .................................... 115ipratropium-albuterol .................................. 114IPRIVASK..................................................... 99irbesartan ....................................................... 32irbesartan-hydrochlorothiazide ..................... 32irinotecan ....................................................... 25ISENTRESS...................................................12ISENTRESS HD............................................ 12ISIBLOOM.................................................... 52isoflurane ......................................................... 7ISOLYTE S PH 7.4 ........................................73ISOLYTE-P IN 5 % DEXTROSE................. 71ISOLYTE-S................................................... 73isometh-dichloral-acetaminophn ................... 48isomethepten-caf-acetaminophen ...................48isoniazid ......................................................... 13ISORDIL........................................................33isosorbide dinitrate ........................................ 33isosorbide mononitrate .................................. 33isosulfan blue ................................................. 67ISOVUE-200..................................................66ISOVUE-250..................................................66ISOVUE-300..................................................66ISOVUE-370..................................................66ISOVUE-M 200............................................. 66ISOVUE-M 300............................................. 66isoxsuprine ..................................................... 39isradipine ....................................................... 36ISTALOL..................................................... 109ISTODAX...................................................... 23ISUPREL....................................................... 36itraconazole ....................................................11ivermectin .......................................................10IXEMPRA......................................................23IXIARO (PF) ..................................................30JADENU.......................................................... 9JADENU SPRINKLE...................................... 9JAKAFI ..........................................................23JALYN........................................................... 93JANUMET..................................................... 83JANUMET XR.............................................. 83JANUVIA...................................................... 82JARDIANCE................................................. 82JENTADUETO..............................................83JENTADUETO XR....................................... 83JEVTANA......................................................25JINTELI ......................................................... 84JOLESSA....................................................... 52JOLIVETTE...................................................54JUNEL 1.5/30 (21) .........................................52JUNEL 1/20 (21) ............................................52JUNEL FE 1.5/30 (28) ................................... 52JUNEL FE 1/20 (28) ...................................... 53JUXTAPID.....................................................35KABIVEN......................................................76KADCYLA.............................................. 21, 26KALBITOR................................................... 39KALETRA..................................................... 13KALYDECO................................................114KAPVAY....................................................... 45

KARBINAL ER...........................................112KARIVA (28) ................................................ 52KAZANO.......................................................83KCENTRA.....................................................96KELNOR 1/35 (28) ........................................53KENALOG.............................................. 62, 86KEPIVANCE................................................. 92KERAFOAM................................................. 63KERALAC.....................................................63KERALYT SCALP COMPLETE................. 63ketamine ........................................................... 7ketamine in 0.9 % sod chloride ........................7ketoconazole .......................................11, 58, 59ketoprofen .........................................................6ketorolac ...................................................6, 108KEVEYIS.....................................................100KEVZARA.......................................................5KEYTRUDA..................................................26KHEDEZLA.................................................. 42KINERET.........................................................5KINEVAC......................................................67KINRIX (PF) ..................................................29KIONEX (WITH SORBITOL) ......................71KISQALI ........................................................22KISQALI FEMARA CO-PACK................... 23kit for tc 99m-sestamibi no.1 ..........................68kit for tc 99m-sod thiosulfate ......................... 68kit prep of tc-99m-mebrofenin ........................68kit prep of tc-99m-sod pyroph ........................68kit prep tc-99m-medronate sod ...................... 68KITABIS PAK.............................................114KLOR-CON................................................... 74KLOR-CON M15.......................................... 74KLOR-CON/25..............................................74KOMBIGLYZE XR.......................................83KORLYM...................................................... 82K-PHOS NO 2 ............................................... 94K-PHOS ORIGINAL.....................................94KRISTALOSE............................................... 92KRYSTEXXA............................................... 96KURVELO.....................................................53KUVAN....................................................... 104KYLEENA.....................................................52KYNAMRO................................................... 34KYPROLIS.................................................... 25labetalol ......................................................... 32LACRISERT................................................106lactated ringers ........................................ 71, 79lactose (bulk) ..................................................51lactulose ................................................... 90, 92LAMICTAL ODT....................................41, 46LAMICTAL ODT STARTER (BLUE) ...41, 46LAMICTAL ODT STARTER (GREEN) 41, 47LAMICTAL ODT STARTER (ORANGE).................................................................. 41, 47LAMICTAL XR STARTER (BLUE) ............41LAMICTAL XR STARTER (GREEN).........41LAMICTAL XR STARTER (ORANGE)..... 41lamivudine ................................................12, 13lamivudine-zidovudine ................................... 13lamotrigine ............................................... 41, 46lancets .................................................. 102, 103lancing device ...................................... 102, 103lancing device with lancets .................. 102, 103LANOXIN..................................................... 37LANTUS........................................................86LANTUS SOLOSTAR.................................. 86LARIN 1.5/30 (21) .........................................53LARIN 1/20 (21) ............................................53LARIN FE 1.5/30 (28) ................................... 53

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LARIN FE 1/20 (28) ...................................... 53LARTRUVO..................................................19LASTACAFT...............................................107latanoprost ................................................... 110LATISSE........................................................65LATUDA....................................................... 44LAZANDA...................................................... 3LEENA 28......................................................55leflunomide .......................................................6LENVIMA..................................................... 25LENZAPATCH............................................. 64LESCOL XL.................................................. 34LESSINA....................................................... 53LETAIRIS......................................................39letrozole ..........................................................22leucovorin calcium .........................................27LEUKERAN.................................................. 20LEUKINE...................................................... 97leuprolide ....................................................... 23levalbuterol hcl ............................................ 113levalbuterol tartrate ..................................... 113LEVATOL..................................................... 35LEVEMIR......................................................86LEVEMIR FLEXTOUCH............................. 86levetiracetam ..................................................42levetiracetam in nacl (iso-os) .........................42levobunolol ...................................................108levocarnitine .................................................104levocarnitine (with sugar) ............................104levocetirizine ................................................ 112levofloxacin ...................................... 15, 16, 110levofloxacin in d5w ........................................ 15levoleucovorin ................................................27levomefolate calcium ......................................80LEVOMEFOLATE DHA.............................. 77LEVONEST (28) ........................................... 54levonorgestrel-ethinyl estrad ................... 52, 53LEVORA-28.................................................. 53levorphanol tartrate ......................................... 2levothyroxine ..................................................88LEVOXYL.....................................................88LEVSIN......................................................... 91LEVULAN.....................................................64LEXISCAN....................................................67LEXIVA.........................................................18LIALDA.........................................................92lidocaine .....................................................8, 65lidocaine (pf) in d7.5w .................................... 8lidocaine (pf) .............................................. 8, 33lidocaine hcl .......................................8, 65, 105lidocaine hcl(pf) in 0.9% nacl ..........................8lidocaine hcl-hydrocortison ac .................. 8, 62lidocaine in 5 % dextrose (pf) ........................ 33lidocaine-epinephrine ...................................... 8lidocaine-epinephrine bit ......................... 8, 105lidocaine-hydrocortisone-aloe ......................... 8lidocaine-prilocaine ....................................... 63lidocaine-tetracaine ....................................... 65LIDODERM...................................................65LIDOPIN........................................................65LIDORX.........................................................65LILETTA....................................................... 52LILLOW........................................................ 53LIMBREL........................................................ 1LIMBREL250.................................................. 1LIMBREL500.................................................. 1LINCOCIN.....................................................17lindane ............................................................65linezolid ..........................................................18linezolid-0.9% sodium chloride ..................... 18

LINZESS............................................90, 91, 92LIORESAL.................................................. 101liothyronine .................................................... 88LIPOCHOL PLUS......................................... 35LIPOFEN....................................................... 34LIPOSYN II ................................................... 76LIPOSYN III ..................................................76LIQUID E-Z PAQUE.................................... 66LIQUID POLIBAR PLUS............................. 66lisinopril ......................................................... 31lisinopril-hydrochlorothiazide ....................... 31lithium carbonate ........................................... 47lithium citrate .................................................47LIVALO.........................................................34LMD 10 % IN 0.9 % SODIUM CHLOR.......98LMD 10 % IN 5 % DEXTROSE................... 98L-METHYLFOLATE FORTE...................... 81L-METHYL-MC............................................74LMTHF-PYRIDOXINE-CYANOCOBALAMN...................................80LODOSYN.....................................................43LOESTRIN 1.5/30 (21) ..................................53LOESTRIN 1/20 (21) .....................................53LOESTRIN FE 1.5/30 (28-DAY)..................53LOESTRIN FE 1/20 (28-DAY).....................53LONSURF..................................................... 22loratadine, micronized (bulk) .......................112lorazepam ...........................................40, 46, 49LORTAB ELIXIR............................................3LORYNA (28) ............................................... 53LORZONE................................................... 101losartan .......................................................... 32losartan-hydrochlorothiazide .........................32LOSEASONIQUE......................................... 52LOTEMAX.................................................. 107LOTRONEX............................................ 91, 92LOUTREX............................................... 60, 61lovastatin ........................................................34LOVAZA....................................................... 35LOW-OGESTREL (28) ................................. 53loxapine succinate ..........................................45LUCENTIS.......................................... 109, 110LUGOLS........................................................71LUMIGAN...................................................110LUMIZYME................................................ 103LUNESTA..................................................... 49LUPANETA PACK (1 MONTH)..................87LUPANETA PACK (3 MONTH)..................87LUPRON DEPOT....................................23, 87LUPRON DEPOT (3 MONTH).............. 23, 87LUPRON DEPOT (4 MONTH).................... 23LUPRON DEPOT (6 MONTH).................... 24LUPRON DEPOT-PED.................................87LUPRON DEPOT-PED (3 MONTH)............87LUTERA (28) ................................................ 53LUZU............................................................. 59LYCELLE......................................................65LYNPARZA.................................................. 24LYRICA...................................................41, 47LYSIPLEX PLUS.......................................... 69LYSODREN.................................................. 21M.V.I. ADULT.............................................. 75M.V.I. PEDIATRIC....................................... 76MACRODANTIN..........................................95MACUGEN......................................... 109, 110MAGNEBIND 400........................................ 94magnesium chloride ....................................... 73magnesium glycinate (bulk) ........................... 73magnesium stearate ........................................51magnesium sulfate ..........................................73

magnesium sulfate in d5w .............................. 73magnesium sulfate in lr .................................. 73magnesium sulfate in water ............................73MAGNEVIST................................................ 67MAKENA...................................................... 87malathion ....................................................... 65manganese chloride ....................................... 73mannitol 10 % ................................................ 38mannitol 20 % ................................................ 38mannitol 25 % ................................................ 38mannitol 5 % .................................................. 38maprotiline ..................................................... 43MARLISSA................................................... 53MARNATAL-F............................................. 78MARPLAN.................................................... 42MARQIBO.....................................................26MATULANE................................................. 20MAVYRET....................................................16MAXALT.......................................................48MAXALT-MLT.............................................48MAXFE (FOLATE-DOCUSATE) ................ 72MAXIDEX...................................................108MAXIPIME................................................... 15MB HYDROGEL.......................................... 60MB HYDROGEL (CYCLOMETHICONE)..60M-CLEAR WC............................................ 115MD-76 R........................................................ 66MD-GASTROVIEW..................................... 66meclizine .........................................................89meclofenamate ................................................. 6MEDIHONEY (HONEY)..............................66MEDROL.......................................................86MEDROX (WITHOUT METHYL SALICY) ........................................................65medroxyprogesterone ...............................52, 87mefenamic acid ................................................ 6mefloquine ......................................................12MEFOXIN IN DEXTROSE (ISO-OSM)...... 14MEGACE ES................................................. 69megestrol ..................................................24, 69MELODETTA 24 FE.....................................53meloxicam ........................................................ 6melphalan .......................................................20melphalan hcl .................................................20memantine ...................................................... 51memantine hcl (bulk) ......................................51MEMBRANEBLUE.................................... 109MENACTRA (PF) ......................................... 29MENEST........................................................85MENHIBRIX (PF) .........................................30MENOMUNE - A/C/Y/W-135......................29MENOMUNE - A/C/Y/W-135 (PF) ..............29MENOPUR.................................................... 85MENOSTAR..................................................85MENTAX.......................................................58MENVEO A-C-Y-W-135-DIP (PF) .............. 29meperidine ........................................................2meperidine (pf) .................................................2meperidine (pf) in 0.9 % nacl ...........................2mepivacaine (pf) .......................................8, 105meprobamate ..................................................40MEPRON....................................................... 12mercaptopurine .............................................. 21meropenem ..................................................... 14meropenem-0.9% sodium chloride ................ 14mesalamine ...............................................91, 92mesalamine with cleansing wipe ....................92mesna ............................................................. 27MESNEX....................................................... 27MESTINON................................................. 100

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MESTINON TIMESPAN............................ 100METADATE ER............................................46METAFOLBIC.............................................. 74metaproterenol ............................................. 114METASTRON............................................... 25metaxalone ................................................... 101metformin ....................................................... 86methadone ........................................................ 2methazolamide ............................................... 37methenamine hippurate ..................................94methenamine mandelate .................................94methimazole ................................................... 83methocarbamol .............................................101methotrexate sodium .................................. 5, 21methotrexate sodium (pf) ............................... 21methscopolamine ............................................91methyclothiazide .............................................38methyl salicylate .............................................65methyldopa ..................................................... 37methyldopa-hydrochlorothiazide ................... 37methyldopate .................................................. 37methylene blue (antidote) .................................9methylergonovine ........................................... 87methylphenidate hcl ................................. 46, 49methylprednisolone ........................................ 85methylprednisolone acetate ............................85methylprednisolone sodium succ ................... 85methyltestosterone ..........................................81METHYLTETRAHYDROFOLIC ACID......80metipranolol ................................................. 108metoclopramide hcl ........................................91metolazone ..................................................... 38METOPIRONE..............................................67metoprolol succinate ...................................... 35metoprolol ta-hydrochlorothiaz ..................... 36metoprolol tartrate .........................................35metronidazole .............................12, 55, 64, 116metronidazole (bulk) ...................................... 12metronidazole in nacl (iso-os) ........................12mexiletine ....................................................... 33MIACALCIN................................................. 84mibelas 24 fe .................................................. 52MICARDIS.................................................... 32MICARDIS HCT........................................... 32MICONAZOLE-3........................................116MICRHOGAM ULTRA-FILTERED PLUS. 29MICROGESTIN 1.5/30 (21) ..........................54MICROGESTIN 1/20 (21) .............................54MICROGESTIN FE 1.5/30 (28) ....................53MICROGESTIN FE 1/20 (28) .......................53midazolam .................................................. 7, 49midazolam (pf) ................................................. 7midodrine ....................................................... 37MIFEPREX....................................................81MIGERGOT...................................................48miglitol ........................................................... 82MILLIPRED.................................................. 86MILLIPRED DP............................................ 85milrinone ........................................................ 36milrinone in 5 % dextrose .............................. 36MINIVELLE..................................................85MINOCIN...................................................... 19minocycline .......................................... 5, 19, 55minoxidil .........................................................37MIOCHOL-E............................................... 106MIOSTAT....................................................106MIRAPEX ER................................................44MIRCERA..................................................... 96MIRCETTE (28) ............................................ 52MIRENA........................................................52

mirtazapine .....................................................42MIRVASO..................................................... 64misoprostol .....................................................90MITIGARE.................................................... 95mitomycin ....................................................... 26MITOSOL....................................................107mitoxantrone .................................................. 26M-M-R II (PF) ................................... 29, 30, 31modafinil ........................................................ 49MODERIBA.................................................. 16moexipril ........................................................ 31moexipril-hydrochlorothiazide .......................31mometasone ............................................61, 115MONODOX...................................................19MONONESSA (28) ....................................... 53MONSEL'S .................................................... 97montelukast .................................................. 113MONUROL................................................... 95MORGIDOX..................................................19MORGIDOX 1X100......................................19MORGIDOX 2X100......................................19MORPHABOND ER....................................... 3morphine .......................................................... 2morphine (pf) ....................................................2morphine (pf) in 0.9 % nacl ............................. 2morphine (pf) in dextrose 5 % ..........................2morphine concentrate ...................................... 2morphine in 0.9 % nacl .................................... 2MOTOFEN.................................................... 89MOVANTIK..................................................10MOVIPREP................................................... 92MOXATAG................................................... 10MOXEZA.....................................................110moxifloxacin ........................................... 15, 110moxifloxacin hcl (bulk) ...................................15moxifloxacin-sod.ace,sul-water ..................... 16MOZOBIL..................................................... 96MUGARD....................................................105MULTAQ.......................................................33MULTIGEN...................................................72MULTIGEN FOLIC...................................... 72MULTIGEN PLUS........................................ 72MULTIHANCE............................................. 67MULTIHANCE MULTIPACK.....................67MULTITRACE-4 ...........................................74MULTITRACE-4 CONCENTRATE............ 74MULTITRACE-4 NEONATAL....................74MULTITRACE-4 PEDIATRIC.....................74MULTITRACE-5 ...........................................74MULTITRACE-5 CONCENTRATE............ 74MULTIVITAMIN WITH FLUORIDE......... 76MULTI-VITAMIN WITH FLUORIDE........ 76MULTIVITAMINS WITH FLUORIDE....... 76mupirocin ....................................................... 58mupirocin calcium ..........................................58MURI-LUBE................................................. 51MUSTARGEN...............................................20MVC-FLUORIDE......................................... 77MVW COMPLETE FORMUL PEDIATRIC...................................................76MVW COMPLETE FORMULATION D3000.............................................................76MY WAY.......................................................55MYALEPT.....................................................87MYCAMINE................................................. 11MYCOBUTIN......................................... 14, 19mycophenolate mofetil ............................. 5, 100mycophenolate sodium .................................100MYDAYIS............................................... 46, 47MYFORTIC................................................. 100

MYLERAN....................................................20MYNATAL..............................................77, 79MYNATAL ADVANCE............................... 77MYNATAL PLUS.........................................77MYNATAL-Z................................................77MYNATE 90 PLUS.......................................77MYNEPHROCAPS....................................... 69MYOBLOC..................................................101MYORISAN.................................................. 55MYRBETRIQ................................................ 93MYTESI .........................................................89MYZILRA..................................................... 54NABI-HB....................................................... 28nabumetone ...................................................... 6nadolol ........................................................... 35nadolol-bendroflumethiazide ......................... 38nafcillin .......................................................... 18nafcillin in dextrose iso-osm .......................... 18naftifine .......................................................... 58NAFTIN......................................................... 58NAGLAZYME............................................ 103nalbuphine ........................................................4NALFON......................................................... 7naloxone ......................................................... 10naltrexone .......................................................10NAMENDA................................................... 51NAMENDA TITRATION PAK....................51NAMENDA XR.............................................51NAMZARIC.................................................. 51NAPRELAN CR.............................................. 7naproxen ...........................................................6naproxen sodium .............................................. 6naratriptan ..................................................... 48NARCAN.......................................................10NAROPIN (PF) ................................................8NASCOBAL.................................................. 80NATACYN.................................................. 110NATAZIA......................................................54nateglinide ......................................................82NATESTO..................................................... 81NATPARA.....................................................87NATRECOR.................................................. 40NATURAL MIXED TOCOPHEROLS.........80NATURE-THROID....................................... 88NEBUPENT...................................................17NEBUSAL..................................................... 51NECON 0.5/35 (28) ....................................... 54NECON 1/50 (28) .......................................... 54NECON 7/7/7 (28) ......................................... 54needle (disp) 16 g .................................102, 103needle (disp) 18 g .................................102, 103needle (disp) 19 g .................................102, 103needle (disp) 23 gauge ......................... 102, 103needles, huber disposable .................... 102, 103nefazodone ..................................................... 42neomycin ........................................................ 10neomycin-bacitracin-poly-hc ....................... 107neomycin-bacitracin-polymyxin ...................109neomycin-polymyxin b gu ...............................93neomycin-polymyxin b-dexameth .................107neomycin-polymyxin-gramicidin ..................109neomycin-polymyxin-hc ....................... 107, 111NEOSALUS...................................................61neostigmine methylsulfate ............................ 100NEO-SYNALAR........................................... 58NEO-SYNALAR KIT....................................58NEPHPLEX RX.............................................69NEPHRAMINE 5.4 %................................... 76NEPHRON FA...............................................72NEPHRO-VITE RX.......................................69

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NERLYNX.....................................................20NESACAINE................................................... 8NESINA......................................................... 82NESTABS......................................................79NESTABS ABC.............................................79NESTABS DHA............................................ 79NEUAC..........................................................56NEUAC KIT.................................................. 56NEULASTA...................................................96NEUPOGEN.................................................. 96NEUPRO........................................................44NEURIN-SL...................................................80NEUT............................................................. 71NEUTRASAL..............................................105NEVANAC.................................................. 108nevirapine .......................................................12NEXAVAR.................................................... 24NEXAVIR......................................................63NEXIUM IV.................................................. 90NEXIUM PACKET....................................... 90NEXT CHOICE ONE DOSE........................ 55NEXTERONE................................................33niacin ........................................................34, 80niacinamide (bulk) ......................................... 80NIACOR........................................................ 34NIASPAN EXTENDED-RELEASE............. 34nicardipine ..................................................... 36NICOMIDE....................................................74nicotine (polacrilex) .......................................50NICOTROL................................................... 50NICOTROL NS............................................. 50nifedipine ........................................................36NILANDRON................................................21nimodipine ......................................................36NINLARO......................................................25nisoldipine ......................................................36NITHIODOTE................................................. 9NITRO-BID................................................... 33NITRO-DUR..................................................33nitrofurantoin ................................................. 95nitrofurantoin macrocrystal ...........................95nitrofurantoin monohyd/m-cryst .................... 95nitroglycerin ...................................................33nitroglycerin in 5 % dextrose .........................33NITROLINGUAL..........................................33NITYR......................................................... 104nizatidine ........................................................90NORA-BE......................................................54NORDITROPIN FLEXPRO..........................86norepinephrine bitartrate ...............................37noreth-ethinyl estradiol-iron ..........................52norethindrone acetate .................................... 87norethindrone ac-eth estradiol .......................84norethindrone-e.estradiol-iron ...................... 52norgestimate-ethinyl estradiol ................. 52, 54NORITATE....................................................55NORLYDA.................................................... 54NORMLGEL AG...........................................58NORMOSOL-M IN 5 % DEXTROSE..........71NORMOSOL-R............................................. 73NORMOSOL-R IN 5 % DEXTROSE...........71NORMOSOL-R PH 7.4 ................................. 73NORPACE CR...............................................33NORTHERA..................................................37NORTREL 0.5/35 (28) .................................. 53NORTREL 1/35 (21) ..................................... 53NORTREL 1/35 (28) ..................................... 53NORTREL 7/7/7 (28) .................................... 54nortriptyline ................................................... 43NORVIR........................................................ 18

NOVAREL.....................................................86NOVOLIN 70/30 ........................................... 86NOVOLIN N..................................................86NOVOLIN R..................................................86NOVOLOG....................................................86NOVOLOG FLEXPEN................................. 86NOVOLOG MIX 70-30 .................................86NOVOLOG MIX 70-30 FLEXPEN.............. 86NOVOLOG PENFILL...................................86NOXAFIL...................................................... 11NP THYROID................................................88NPLATE........................................................ 99NUCALA..................................................... 113NUCYNTA...................................................... 2NUCYNTA ER................................................ 3NUEDEXTA..................................................49NULOJIX.....................................................100NUMOISYN............................................ 1, 105NUOX............................................................ 57NUPLAZID....................................................45NUTRESTORE............................69, 75, 93, 99NUTRICAP....................................................74NUTRILIPID................................................. 76NUTRILYTE................................................. 73NUVAIL........................................................ 64NUVARING.................................................. 55NUVESSA................................................... 116NUVIGIL....................................................... 49NYMALIZE...................................................36nystatin ............................................. 11, 58, 105nystatin-triamcinolone ................................... 59OB COMPLETE...................................... 73, 79OB COMPLETE PREMIER..........................73OB COMPLETE WITH DHA.......................79OBAGI NU-DERM SUNFADER................. 60OBAGI-C CLARIFYING SERUM............... 60OBAGI-C THERAPY NIGHT...................... 60OBREDON.................................................. 115OBSTETRIX DHA........................................ 77OBSTETRIX EC............................................79OBTREX DHA.............................................. 79O-CAL FA..................................................... 79O-CAL PRENATAL......................................79OCALIVA......................................................99OCELLA........................................................53OCREVUS................................................... 106OCTAGAM................................................... 28OCTAPLAS (BLOOD GROUP A) ............... 98OCTAPLAS (BLOOD GROUP AB) ............ 98OCTAPLAS (BLOOD GROUP B) ............... 98OCTAPLAS (BLOOD GROUP O) ............... 98OCTREOSCAN............................................. 68octreotide acetate .....................................88, 93OCUCOAT.................................................. 109OCUVEL....................................................... 74ODEFSEY......................................................13ODOMZO...................................................... 23OFEV..................................................... 25, 116OFIRMEV........................................................4ofloxacin .........................................15, 110, 111OGESTREL (28) ............................................54olanzapine ................................................ 45, 47olanzapine-fluoxetine ..................................... 43oleic acid ........................................................ 51olmesartan ......................................................32olmesartan-amlodipin-hcthiazid .................... 32olmesartan-hydrochlorothiazide ....................32olopatadine ...........................................107, 115OMECLAMOX-PAK.................................... 93omega-3 acid ethyl esters ...............................34

OMNIPAQUE 140.........................................66OMNIPAQUE 180.........................................66OMNIPAQUE 240.........................................66OMNIPAQUE 300.........................................67OMNIPAQUE 350.........................................67OMNISCAN.................................................. 67OMNISCAN PREFILL PLUS.......................67ondansetron ....................................................89ondansetron hcl ..............................................89ondansetron hcl (pf) ....................................... 89ondansetron in 0.9 % sod chlor ..................... 89ONFI ........................................................ 40, 46ONGLYZA.................................................... 82ONIVYDE..................................................... 25ONMEL......................................................... 11ONZETRA XSAIL........................................ 48OPANA............................................................3OPDIVO.........................................................26opium tincture ................................................ 88OPSUMIT...................................................... 39OPTIMARK...................................................67OPTIRAY 300............................................... 67OPTIRAY 320............................................... 67OPTIRAY 350............................................... 67OPTISON.......................................................67ORACEA................................................. 19, 64ORACIT.........................................................94ORALAIR......................................................28ORAMAGICRX.......................................... 105ORAP............................................................. 45ORAPRED ODT............................................86ORAVIG........................................................ 11ORBACTIV................................................... 17ORENCIA........................................................5ORENCIA (WITH MALTOSE) ......................5ORENCIA CLICKJECT..................................5ORENITRAM................................................39ORFADIN....................................................104ORKAMBI...................................................114orphenadrine citrate .................................... 101ORSYTHIA................................................... 53ORTHO MICRONOR................................... 54ORTHO TRI-CYCLEN (28) ......................... 55ORTHO TRI-CYCLEN LO (28) ................... 55ORTHO-CYCLEN (28) .................................54ORTHO-NOVUM 1/35 (28) ..........................54ORTHO-NOVUM 7/7/7 (28) .........................55oseltamivir ......................................................17OSENI............................................................83OSMITROL 15 %..........................................38OSMOPREP...................................................92OSPHENA..................................................... 87OTEZLA.................................................... 6, 60OTEZLA STARTER................................. 6, 60OTREXUP (PF) ............................................... 5OVACE PLUS............................................... 60OVACE PLUS SHAMPOO...........................60OVACE PLUS WASH.................................. 60OVCON-35 (28) ............................................ 54oxacillin ..........................................................18oxacillin in dextrose(iso-osm) ........................18oxaliplatin ...................................................... 24oxandrolone ................................................... 81oxaprozin ..........................................................6oxazepam ........................................................40oxcarbazepine ................................................ 41oxiconazole .....................................................59OXISTAT.......................................................59OXSORALEN ULTRA................................. 59OXTELLAR XR............................................ 41

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oxybutynin chloride ........................................95oxycodone .........................................................2oxycodone-acetaminophen ...........................3, 4oxycodone-aspirin ............................................4OXYCONTIN..................................................2oxymorphone ....................................................2oxytocin .......................................................... 87oxytocin in dextrose 5 % in lr ........................ 87OZURDEX...................................................108paclitaxel ........................................................25PACNEX HP..................................................56PACNEX LP.................................................. 56PAIN EASE................................................... 64paliperidone ................................................... 44pamidronate ................................................... 84PANCREAZE................................................ 90pancuronium ................................................ 101PANDEL........................................................62PANHEMATIN............................................. 96PANRETIN....................................................59pantoprazole ...................................................90papaverine ......................................................39PARAGARD T 380A.................................... 52paregoric ........................................................88PAREMYD.................................................. 106paricalcitol ................................................... 104paromomycin ..................................................10paroxetine hcl .................................................42paroxetine mesylate ........................................87PASER........................................................... 13PATADAY...................................................107PATANASE.................................................115PATANOL................................................... 107PAZEO.........................................................107PCE................................................................ 17PEDIARIX (PF) .......................................28, 29PEDITRACE..................................................74PEDVAX HIB (PF) ....................................... 29peg 3350-electrolytes ..................................... 92PEGANONE.................................................. 41PEGASYS......................................................16PEGASYS PROCLICK................................. 16peg-electrolyte soln ........................................ 92PEGINTRON................................................. 16pen needle, diabetic ..............................102, 103penicillin g pot in dextrose .............................18penicillin g potassium .................................... 18penicillin g procaine ...................................... 18penicillin g sodium ......................................... 18penicillin v potassium .....................................18PENNSAID....................................................64PENTACEL (PF) ........................................... 30PENTACEL DTAP-IPV COMPNT (PF) ...... 29PENTAM....................................................... 17PENTASA......................................................92pentazocine-naloxone .......................................4pentoxifylline ..................................................97PERFOROMIST.......................................... 113PERIKABIVEN............................................. 76perindopril erbumine ..................................... 31PERJETA....................................................... 26permethrin ......................................................65perphenazine .................................................. 45perphenazine-amitriptyline ............................ 43PERTZYE...................................................... 90PEXEVA........................................................42phenazopyridine ............................................. 94phendimetrazine tartrate ................................69phenelzine .......................................................42phenobarb-hyoscy-atropine-scop ...................91

phenobarbital ........................................... 40, 49phenobarbital sodium .............................. 40, 49phenol .............................................................27phenoxybenzamine ......................................... 39PHENYLADE GMP...................................... 75phenylephrine hcl ...................................37, 108phenylephrine hcl in 0.9% nacl ......................37phenytoin ........................................................41phenytoin sodium ..................................... 33, 41phenytoin sodium extended ............................ 41PHILITH........................................................ 53PHOSLYRA...................................................94PHOSPHA 250 NEUTRAL.....................73, 94PHOSPHASAL..............................................95PHOSPHOLINE IODIDE............................106PHOTOFRIN................................................. 24PHYSICIANS EZ USE B-12 .........................80PHYSIOLYTE............................................... 71PHYSIOSOL IRRIGATION......................... 71physostigmine salicylate .................................. 9phytonadione (vit k1) (bulk) ...........................81phytonadione (vitamin k1) ............................. 81PICATO......................................................... 59pilocarpine hcl ..................................... 105, 106pimozide ......................................................... 45pindolol .......................................................... 35pioglitazone ....................................................87pioglitazone-glimepiride ................................ 83piperacillin-tazobactam ................................. 18PIRMELLA....................................................53piroxicam ......................................................... 6PKU EASY MICROTABS............................75PKU PERIFLEX JUNIOR PLUS.................. 75PLASBUMIN 5 %......................................... 98PLASMA-LYTE 148 .....................................73PLASMA-LYTE A........................................ 73PLASMA-LYTE-56 IN 5 % DEXTROSE.... 71PLASMANATE.............................................98PLEGRIDY..................................................106PLEXION.......................................................56PLIAGLIS......................................................65PNEUMOVAX 23......................................... 30PNV OB+DHA.............................................. 77PNV-DHA......................................................77PNV-DHA + DOCUSATE............................ 77PNV-OMEGA................................................77PNV-SELECT................................................77PODIAPN...................................................... 69PODOCON.................................................... 63podofilox .........................................................63POLIBAR ACB............................................. 66POLOCAINE................................................... 8POLOCAINE-MPF..........................................8polyethylene glycol 3350 ................................92POLY-IRON 150 FORTE............................. 72polymyxin b sulfate .........................................18polymyxin b sulf-trimethoprim ..................... 109POLY-VI-FLOR............................................ 77POLY-VI-FLOR WITH IRON......................77POMALYST.................................................. 25PONTOCAINE.............................................. 65PORTIA......................................................... 54PORTRAZZA................................................ 27POTABA........................................................81potassium acetate ...........................................73potassium bicarb and chloride .......................73potassium bicarb-citric acid .......................... 73potassium chlorid-d5-0.45%nacl ................... 73potassium chloride ................................... 73, 74potassium chloride in 0.9%nacl .....................73

potassium chloride in 5 % dex ....................... 73potassium chloride in lr-d5 ............................ 73potassium chloride-0.45 % nacl .....................73potassium chloride-d5-0.2%nacl ................... 73potassium chloride-d5-0.3%nacl ................... 73potassium chloride-d5-0.9%nacl ................... 73potassium citrate ............................................ 94potassium hydroxide ...................................... 56potassium phosphate m-/d-basic ....................73PR CREAM....................................................64PR NATAL 400............................................. 77PR NATAL 400 EC....................................... 77PR NATAL 430............................................. 77PR NATAL 430 EC....................................... 77PRADAXA.................................................... 99pralidoxime ...................................................... 9PRALUENT PEN.......................................... 35pramipexole ....................................................44PRAMOSONE............................................... 62PRAMOSONE E............................................62prasterone (dhea), micro(bulk) .................. 1, 50prasugrel ........................................................ 99pravastatin ..................................................... 34prazosin ..........................................................39PRECEDEX................................................... 50PRECEDEX IN 0.9 % SODIUM CHLOR.... 50PRECISION XTRA TEST...................102, 103PRED MILD................................................ 107PRED-G....................................................... 107PRED-G S.O.P. ............................................107prednicarbate ................................................. 61prednisolone ...................................................85prednisolone acetate .................................... 107prednisolone sodium phosphate .............85, 107prednisone ......................................................85PREDNISONE INTENSOL.......................... 85PREFERA-OB PLUS DHA...........................79PREFEST....................................................... 84PREGNYL..................................................... 86PREMARIN........................................... 85, 116PREMASOL 10 %......................................... 76PREMASOL 6 %........................................... 76PREMPHASE................................................ 84PREMPRO..................................................... 84PRENA1 TRUE............................................. 77PRENAISSANCE..........................................77PRENAISSANCE PLUS............................... 77PRENATA..................................................... 79PRENATABS FA.......................................... 79PRENATABS RX..........................................79PRENATAL 19 ..............................................79PRENATAL 19 (WITH DOCUSATE) ......... 77PRENATAL LOW IRON..............................77PRENATAL PLUS........................................ 77PRENATAL PLUS (CALCIUM CARB)...... 77PRENATAL-U...............................................77PREPARATION H HYDROCORTISONE...62PRE-PEN....................................................... 68PREPIDIL...................................................... 81PREPOPIK.....................................................93PRESERA...................................................... 61PRESTALIA.................................................. 31PREVACID SOLUTAB................................ 90PREVALITE..................................................34PREVIDENT 5000 DRY MOUTH............. 105PREVIDENT 5000 PLUS............................105PREVIDENT 5000 SENSITIVE................. 105PREVIFEM....................................................54PREVNAR 13 (PF) ........................................30PREVPAC......................................................93

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PREZCOBIX................................................. 13PREZISTA..................................................... 18PRIALT............................................................1PRIFTIN...................................................14, 19PRILOSEC.....................................................90primaquine ..................................................... 12PRIMAXIN IV...............................................14primidone ....................................................... 40PRIMSOL...................................................... 11PRISMASOL B22GK..................................111PRISMASOL BGK......................................111PRISMASOL BK.........................................111PRIVIGEN..................................................... 28PROAIR HFA.............................................. 114PROAIR RESPICLICK............................... 114probenecid ......................................................96probenecid-colchicine ....................................95procainamide ................................................. 33PROCALAMINE 3%.................................... 76prochlorperazine ............................................89prochlorperazine edisylate .............................89prochlorperazine maleate ........................ 45, 89PROCORT....................................................... 8PROCRIT.......................................................96PROCTOCORT......................................... 8, 62PROCTOFOAM HC........................................8PROCTO-PAK...........................................8, 62PROCTOZONE-HC.................................. 8, 62PROCYSBI .................................................... 93PRODRIN...................................................... 48PROFERRIN-FORTE....................................73progesterone ...................................................87progesterone micronized ................................87PROGLYCEM............................................... 81PROGRAF................................................... 100PROHANCE.................................................. 67PROHANCE MULTIPACK..........................67PROLASTIN-C............................................114PROLENSA................................................. 108PROLEUKIN................................................. 23PROLIA......................................................... 88PROMACTA................................................. 99promethazine ..........................................89, 112PROMETHAZINE VC................................ 111PROMETHAZINE VC-CODEINE............. 115promethazine-codeine .................................. 115promethazine-dm ..........................................116PROMETHEGAN......................................... 89PROMISEB..............................................60, 61PROMISEB COMPLETE........................60, 61propafenone ................................................... 33propantheline ................................................. 91proparacaine ................................................109propofol ............................................................7propranolol .................................................... 35propranolol-hydrochlorothiazid .................... 38propylthiouracil ............................................. 83PROQUAD (PF) ................................ 29, 30, 31PROSOL 20 %............................................... 76PROSTASCINT.............................................68PROSTIN E2..................................................81PROSTIN VR PEDIATRIC...........................39protamine ....................................................... 10PROTECT IRON........................................... 74PROTONIX................................................... 90PROTOPAM CHLORIDE...............................9PROTOPIC.................................................... 60protriptyline ................................................... 43PROVENGE.................................................. 23PROVENTIL HFA...................................... 114

PROVIDA DHA............................................ 79PROVIDA OB............................................... 79PROVISC.....................................................109PROVOCHOLINE.........................................68PRUCLAIR....................................................61PRUMYX.......................................................61PRUTECT......................................................61PULMICORT...............................................113PULMICORT FLEXHALER...................... 113PULMOZYME............................................ 115PURALOR CI ................................................ 81PUREFE OB PLUS....................................... 79PUREFE PLUS.............................................. 79PUREVIT DUALFE PLUS........................... 74PURIXAN......................................................21PUROXCIN................................................... 64PYLERA........................................................ 93pyrazinamide ..................................................14pyridostigmine bromide ............................... 100pyridoxine (vitamin b6) ..................................80PYROGALLIC ACID....................................64QBRELIS....................................................... 32QUARTETTE................................................ 54QUASENSE...................................................53quazepam ....................................................... 49QUDEXY XR................................................ 41QUELICIN...................................................101QUESTRAN LIGHT..................................... 34quetiapine .................................................45, 47QUFLORA FE (FERROUS SULFATE) .......77QUFLORA PEDIATRIC DROPS................. 77QUILLICHEW ER........................................ 46QUILLIVANT XR.........................................46quinapril .........................................................31quinapril-hydrochlorothiazide ....................... 31quinidine gluconate ........................................33quinidine sulfate .............................................33quinine sulfate ................................................ 12QUTENZA.....................................................65QVAR.......................................................... 113RABAVERT (PF) .......................................... 31rabeprazole .................................................... 90RADIAPLEXRX........................................... 64RADIGEL ACEMANNAN HYDROGEL.................................................................. 61, 66RAGWITEK.................................................. 28RAJANI......................................................... 53raloxifene ....................................................... 88ramipril .......................................................... 31RANEXA....................................................... 33ranitidine hcl .................................................. 90RAPAFLO..................................................... 94RAPAMUNE............................................... 100rasagiline ....................................................... 44RASUVO (PF) ................................................. 5RAVICTI ..................................................... 104RAYALDEE................................................ 104READI-CAT 2 ............................................... 66REBETOL......................................................16REBIF (WITH ALBUMIN) .........................106REBIF REBIDOSE......................................106REBIF TITRATION PACK........................ 106RECLIPSEN (28) ...........................................54RECOMBIVAX HB (PF) .............................. 28RECOTHROM...............................................97RECOTHROM SPRAY KIT......................... 97RECTIV........................................................... 8REGENECARE............................................. 65REGENECARE WITH ALOE...................... 65REGIMEX..................................................... 69

REGONOL...................................................100RELAGARD................................................116RELCOF C...................................................115RELENZA DISKHALER..............................17RELISTOR.....................................................10RELNATE DHA............................................77RELPAX........................................................ 48REMICADE...............................................5, 92REMODULIN................................................39RENAGEL..................................................... 94RENAL CAPS............................................... 69RENA-VITE RX............................................69RENFLEXIS.............................................. 5, 92RENO CAPS..................................................69RENOVA....................................................... 64RENVELA..................................................... 94REOPRO........................................................99repaglinide ..................................................... 82repaglinide-metformin ................................... 82REPATHA PUSHTRONEX..........................35REPATHA SURECLICK.............................. 35REPATHA SYRINGE...................................35REQ49+................................................... 71, 74RESCRIPTOR............................................... 12RESECTISOL................................................93RESPA-AR.................................................. 111RESTASIS................................................... 108RESTASIS MULTIDOSE........................... 108RETIN-A........................................................57RETIN-A MICRO..........................................57RETIN-A MICRO PUMP..............................57RETISERT................................................... 108RETROVIR....................................................13REVATIO...................................................... 39REVLIMID.................................................... 25REVONTO...................................................101REXULTI .......................................................45REYATAZ............................................... 18, 19REZIRA....................................................... 115R-GENE 10 .................................................... 67RHOFADE.....................................................64RHOGAM ULTRA-FILTERED PLUS.........29RHOPHYLAC............................................... 29RIASTAP....................................................... 97RIAX..............................................................57RIBASPHERE............................................... 16RIBASPHERE RIBAPAK.............................16ribavirin ......................................................... 16RIDAURA....................................................... 5rifabutin ....................................................14, 19RIFAMATE................................................... 14rifampin ....................................................14, 19RIFATER....................................................... 14riluzole ......................................................... 100rimantadine .................................................... 17RIMSO-50......................................................93ringer's ..................................................... 71, 79RIOMET........................................................ 86risedronate ..................................................... 84RISPERDAL CONSTA.................................44risperidone ............................................... 44, 47RITALIN LA................................................. 46RITUXAN..................................................5, 22RITUXAN HYCELA.................................... 22rivastigmine ....................................................51rivastigmine tartrate ...................................... 51RIVELSA.......................................................54rizatriptan .......................................................48ROBAXIN................................................... 101rocuronium ...................................................101

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ropinirole ....................................................... 44ropivacaine (pf) ................................................8ROSADAN.................................................... 64rosuvastatin ....................................................34ROTARIX................................................29, 31ROTATEQ VACCINE............................ 29, 31ROZEREM.....................................................47RUBRACA.................................................... 24RUCONEST...................................................96RYANODEX............................................... 102RYDAPT........................................................25RYTARY....................................................... 43SABRIL......................................................... 41saccharin ........................................................70s-adenosylmeth sulf tos (bulk) ..........................1safety needles ....................................... 102, 103SAFYRAL..................................................... 53salicylic acid .................................................. 63salicylic acid er-ceramides ............................ 63salsalate ........................................................... 7SALVAX DUO PLUS................................... 63SAMSCA....................................................... 38SANCUSO..................................................... 89SANDOSTATIN LAR DEPOT...............88, 93SANTYL........................................................61SAPHRIS (BLACK CHERRY)...............44, 47SAVAYSA.....................................................96SAVELLA............................................... 42, 47SCALACORT................................................62SCALACORT DK......................................... 62SCLEROSOL INTRAPLEURAL................116scopolamine base ........................................... 89scopolamine hbr .............................................91SCULPTRA................................................. 102SEASONIQUE...............................................52SECONAL SODIUM.................................... 49SELECT-OB (FOLIC ACID) ........................ 79SELECT-OB + DHA..................................... 79selegiline hcl .................................................. 44selenium ......................................................... 74selenium sulfide ..............................................60SELRX........................................................... 60SELZENTRY.................................................12SEMPREX-D............................................... 111SE-NATAL 19 ............................................... 77SE-NATAL 19 (WITH DOCUSATE) ...........77SENSIPAR.....................................................84SENSORCAINE-MPF/EPINEPHRINE..........8SEREVENT DISKUS..................................113sertraline ........................................................ 42SE-TAN PLUS...............................................74sevelamer carbonate ...................................... 93sevoflurane ....................................................... 7SHOHL'S MODIFIED...................................94SIDEROL.......................................................73SIGNIFOR..................................................... 88SIGNIFOR LAR............................................ 88sildenafil .........................................................39SILENOR.......................................................50SILIQ............................................................. 57silver nitrate ................................................... 58silver nitrate applicators ................................63silver sulfadiazine .......................................... 60SILVRSTAT.................................................. 58SIMBRINZA................................................106SIMPONI......................................................... 5SIMPONI ARIA.............................................. 5SIMULECT..................................................100simvastatin ..................................................... 34SINOGRAFIN............................................... 66

sirolimus .......................................................100SIRTURO.......................................................13SITAVIG........................................................17SITZMARKS................................................. 67SIVEXTRO....................................................18SKLICE..........................................................65SKYLA.......................................................... 52sodium acetate ................................................71sodium benzoate-sod phenylacet ..................104sodium bicarbonate ........................................71sodium bisulfite .............................................. 51sodium chloride ........................................51, 79sodium chloride 0.45 % ................................. 79sodium chloride 0.9 % ............................. 70, 79sodium chloride 3 % ...................................... 79sodium chloride 5 % ...................................... 79sodium citrate-citric acid ............................... 94SODIUM EDECRIN......................................38sodium ferric gluconat-sucrose ......................72sodium hydroxide (bulk) .................................50sodium lactate ................................................ 71sodium nitrite ................................................... 9sodium phenylbutyrate ................................. 104sodium phosphate ...........................................73sodium phosphate in 0.9 % nacl .................... 73sodium polystyrene sulfonate ......................... 71sodium succinate ............................................ 51sodium thiosulfate ............................................ 9SOLESTA.................................................... 102SOLIQUA 100/33 .......................................... 83SOLIRIS.........................................................98SOLTAMOX................................................. 25SOLU-CORTEF.............................................86SOLU-CORTEF (PF) .................................... 86SOLU-MEDROL........................................... 86SOLU-MEDROL (PF) ...................................86SOMATULINE DEPOT................................88SOMAVERT..................................................86SONAFINE....................................................61SOOLANTRA............................................... 65sorbitol ............................................... 51, 92, 93sorbitol-mannitol ............................................93SORILUX...................................................... 60sotalol .......................................................33, 35SOTALOL AF......................................... 33, 35SOTRADECOL............................................. 40SOTYLIZE...............................................33, 35SOVALDI...................................................... 16SPECTRACEF...............................................15spinosad ......................................................... 65SPIRIVA RESPIMAT................................. 113SPIRIVA WITH HANDIHALER............... 113spironolactone ..........................................32, 37spironolacton-hydrochlorothiaz .....................38SPORANOX.................................................. 11SPORANOX PULSEPAK.............................11SPRAY AND STRETCH.............................. 64SPRINTEC (28) ............................................. 53SPRITAM...................................................... 42SPRYCEL...................................................... 25SPS (WITH SORBITOL) .............................. 71SRONYX....................................................... 53SSKI ............................................................... 72stavudine ........................................................ 13STELARA................................................57, 91sterile talc .....................................................116STIMATE...................................................... 82STIOLTO RESPIMAT................................ 114STIVARGA................................................... 24STRATTERA.................................................46

STRENSIQ...................................................103streptomycin ................................................... 10STRIANT.......................................................82STRIBILD......................................................13STRIVERDI RESPIMAT............................ 113STROMECTOL............................................. 10STRONG IODINE.........................................72STROVITE FORTE.......................................74STROVITE ONE........................................... 74SUBOXONE..................................................50SUBSYS...........................................................3succinylcholine chloride .............................. 101SUCRAID...................................................... 90sucralfate ........................................................93sufentanil citrate .............................................. 7sulfacetamide sodium .............................60, 110sulfacetamide sodium (acne) ..........................55sulfacetamide sodium-sulfur .................... 56, 58sulfacetamide sod-sulfur-urea ..................56, 64sulfacetamide-prednisolone ......................... 107sulfacetamide-sulfur-cleansr23 ......................56sulfact na-sul-avobnz-otn-ocsa ................ 56, 64sulfadiazine .................................................... 19sulfamethoxazole-trimethoprim ..................... 10SULFAMYLON............................................ 60sulfasalazine ...............................................5, 92sulindac ............................................................ 6SUMADAN XLT.....................................56, 65sumatriptan .................................................... 48sumatriptan succinate .................................... 48SUMAVEL DOSEPRO................................. 48SUMAXIN CP............................................... 56SUPER B/C....................................................69SUPERVITE.................................................. 69SUPRANE....................................................... 7SUPRAX........................................................15SUPREP BOWEL PREP KIT........................92SURFAXIN..................................................114SURMONTIL................................................ 43SURVANTA................................................115SUSTIVA.......................................................12SUSTOL.........................................................89SUTENT........................................................ 25SWABFLUSH................................... 70, 79, 80SYEDA.......................................................... 54SYLATRON.................................................. 23SYLVANT..................................................... 23SYMAX DUOTAB........................................91SYMBICORT.............................................. 114SYMLINPEN 120..........................................83SYMLINPEN 60 ............................................83SYNAGIS...................................................... 28SYNALAR CREAM KIT..............................62SYNALAR OINTMENT KIT....................... 62SYNALAR TS............................................... 63SYNAREL..................................................... 87SYNDROS............................................... 69, 89SYNERA........................................................65SYNERCID....................................................19SYNJARDY...................................................82SYNJARDY XR............................................ 82SYNRIBO...................................................... 26SYNTHROID.................................................88SYNVISC.....................................................101SYNVISC-ONE........................................... 101SYPRINE......................................................... 9syringe (disposable) ............................. 102, 103syringe (reusable) ................................ 102, 103SYRINGE AVITENE.................................... 97syringe with needle ...............................102, 103

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syringe with needle, safety ................... 102, 103TABLOID...................................................... 21TACHOSIL....................................................97TACLONEX.................................................. 57tacrolimus ...............................................60, 100TAFINLAR....................................................22TAGITOL V.................................................. 66TAGRISSO.................................................... 20TALTZ AUTOINJECTOR............................ 57TALTZ AUTOINJECTOR (2 PACK)...........57TALTZ AUTOINJECTOR (3 PACK)...........57TALTZ SYRINGE.........................................57TALTZ SYRINGE (2 PACK)....................... 57TALTZ SYRINGE (3 PACK)....................... 57TALWIN..........................................................4TAMIFLU......................................................17tamoxifen ........................................................25tamsulosin ...................................................... 94TANDEM PLUS............................................75TANZEUM.................................................... 83TARCEVA.....................................................20TARGRETIN........................................... 25, 59TARKA..........................................................31TARON FORTE............................................ 72TARON-C DHA............................................ 77TARON-PREX PRENATAL-DHA.............. 78TASIGNA...................................................... 25TASMAR....................................................... 43TAYTULLA.................................................. 53tazarotene .......................................................59TAZICEF....................................................... 15TAZORAC.....................................................60TAZTIA XT...................................................36TECENTRIQ................................................. 26TECFIDERA................................................106TEFLARO......................................................15TEGRETOL XR............................................ 41TEKTURNA.................................................. 39TEKTURNA HCT......................................... 39telmisartan ..................................................... 32telmisartan-amlodipine .................................. 32telmisartan-hydrochlorothiazid ..................... 32temazepam ......................................................49TEMODAR....................................................21temozolomide ................................................. 21teniposide ....................................................... 23TENIVAC (PF) .............................................. 29TEPADINA....................................................20terazosin ......................................................... 39terbinafine hcl ................................................ 11terbutaline .................................................... 114terconazole ................................................... 116TERSI FOAM................................................ 60TESTIM......................................................... 82testosterone .................................................... 81testosterone (bulk) ..........................................81testosterone cypionate ....................................81testosterone enanthate ....................................81tetanus,diphtheria tox ped(pf) ........................ 29tetanus-diphtheria toxoids-td ......................... 29tetrabenazine ..................................................48tetracaine hcl ................................................109tetracaine hcl (pf) .....................................8, 109tetracycline .....................................................19TETRAVISC................................................109TETRAVISC FORTE.................................. 109TEXACORT.................................................. 62TEXAVITE LQ..............................................77thallous chloride tl-201 ..................................68THALOMID............................................ 11, 25

THAM............................................................71THEO-24......................................................113theophylline ..................................................113theophylline in dextrose 5 % ........................113thiamine hcl (vitamin b1) ............................... 80THIOLA.........................................................93thioridazine .................................................... 45thiotepa ...........................................................20thiothixene ......................................................45THROMBATE III ..........................................98THROMBI-GEL............................................ 97THROMBIN-JMI...........................................97THROMBI-PAD............................................97THYMOGLOBULIN.....................................29THYROGEN..................................................68THYROLAR-1...............................................88THYROLAR-1/2 ........................................... 88THYROLAR-1/4 ........................................... 88THYROLAR-2...............................................88THYROLAR-3...............................................88tiagabine .........................................................41TICE BCG................................................24, 29ticlopidine .......................................................99TILIA FE........................................................54timolol maleate .......................................35, 108TIMOPTIC OCUDOSE (PF) .......................109TINDAMAX..................................................12tinidazole ........................................................12TIROSINT..................................................... 88TISSEEL VHSD............................................ 97TIVICAY....................................................... 12TIVORBEX..................................................... 7tizanidine ......................................................101TL GARD RX..........................................80, 81TL G-FOL OS................................................71TL ICON........................................................ 72TL-HEM 150..................................................72TL-SELECT...................................................78TNKASE........................................................99TOBI ............................................................ 114TOBI PODHALER...................................... 114TOBRADEX................................................107TOBRADEX ST.......................................... 107tobramycin ................................................... 109tobramycin in 0.225 % nacl ......................... 114tobramycin in 0.9 % nacl ............................... 10tobramycin sulfate ..........................................10tobramycin with nebulizer ............................114tobramycin-dexamethasone ......................... 107TOBREX......................................................109TOLAK.......................................................... 59tolazamide ...................................................... 83tolbutamide .....................................................83tolcapone ........................................................43tolmetin .............................................................6tolterodine ...................................................... 95TOPICORT.................................................... 62topiramate ...................................................... 41topiramate (bulk) ............................................41topotecan ........................................................25TORISEL....................................................... 24torsemide ........................................................38TOUJEO SOLOSTAR...................................86TOVIAZ.........................................................95TOZAL...........................................................70TPN ELECTROLYTES.................................73TPN ELECTROLYTES II ............................. 73TRACE ELEMENTS 4/PEDIATRIC............74TRACLEER................................................... 39TRADJENTA.................................................82

tramadol ........................................................... 2tramadol-acetaminophen ................................. 4trandolapril .................................................... 31trandolapril-verapamil ...................................31tranexamic acid ..............................................97TRANSDERM-SCOP....................................89tranylcypromine ............................................. 42TRAVASOL 10 %......................................... 76TRAVATAN Z............................................ 110trazodone ........................................................42TREANDA.....................................................20TRECATOR...................................................14TRELSTAR................................................... 24TREMFYA.....................................................57TRESIBA FLEXTOUCH U-100................... 86TRESIBA FLEXTOUCH U-200................... 86tretinoin ..........................................................57tretinoin (chemotherapy) ................................25tretinoin (emollient) ....................................... 64tretinoin microspheres ................................... 57TRETIN-X..................................................... 57TRETIN-X CREAM KIT.............................. 57TREXALL................................................. 5, 21TREXIMET................................................... 48TREZIX........................................................... 3TRI FEMYNOR.............................................54triacetin .......................................................... 59TRIADVANCE..............................................78triamcinolone acetonide ...................61, 62, 105triamcinolone hexaceton (bulk) ..................... 85triamterene-hydrochlorothiazid ..................... 38TRIANEX...................................................... 62triazolam ........................................................ 49TRIBENZOR................................................. 32TRICARE.......................................................79TRICARE PRENATAL DHA ONE..............79TRI-CHLOR.................................................. 63trichloroacetic acid ........................................ 63TRICITRASOL..............................................96TRICITRATES.............................................. 94TRIDERM......................................................62TRIESENCE (PF) ........................................ 108trifluoperazine ................................................45trifluridine .................................................... 110TRIGELS-F FORTE...................................... 72TRIGLIDE..................................................... 34trihexyphenidyl ...............................................43TRIKLO......................................................... 34TRI-LEGEST FE........................................... 55TRILEPTAL.................................................. 41TRI-LUMA.................................................... 60trimethobenzamide ......................................... 89trimethoprim ...................................................11TRINATAL GT............................................. 78TRINATAL RX 1 .......................................... 78TRINATE.......................................................79TRINESSA (28) .............................................54TRI-NORINYL (28) ...................................... 55TRINTELLIX................................................ 43tripelennamine (bulk) ...................................112TRIPHROCAPS.............................................69TRIPLE DYE.................................................59TRIPLE VITAMIN WITH FLUORIDE........76TRI-PREVIFEM (28) .................................... 54TRIPTODUR................................................. 87TRISENOX....................................................22TRI-SPRINTEC (28) ..................................... 54TRIUMEQ..................................................... 13TRIVEEN-DUO DHA...................................78TRIVEEN-ONE............................................. 78

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TRIVEEN-PRX RNF.....................................78TRI-VI-FLOR................................................ 77TRI-VIT WITH FLUORIDE AND IRON.....76TRI-VITAMIN WITH FLUORIDE.............. 76TRIVORA (28) .............................................. 55TRIZIVIR.......................................................13TROPHAMINE 10 %.................................... 76TROPHAMINE 6%....................................... 76tropicamide .................................................. 107trospium ......................................................... 95TRULANCE.................................................. 90TRULICITY...................................................83TRUMENBA................................................. 30TRUST NATAL DHA...................................78TRUVADA.................................................... 13tuberculin-allergy syringes .................. 102, 103TUBERSOL................................................... 67TUDORZA PRESSAIR...............................113TUSNEL PEDIATRIC................................ 116TUSSICAPS.................................................115TUZISTRA XR............................................115TWINRIX (PF) .............................................. 28TWYNSTA.................................................... 32TYBOST...................................................... 104TYGACIL...................................................... 16TYKERB........................................................19TYLACTIN RESTORE 10 PE...................... 75TYLACTIN RTD 15 PE................................ 75TYMLOS....................................................... 83TYPHIM VI ................................................... 29TYR ANAMIX NEXT...................................75TYSABRI.....................................................106TYVASO....................................................... 39TYVASO INSTITUTIONAL START KIT...39TYVASO REFILL KIT................................. 39TYVASO STARTER KIT............................. 39TYZINE....................................................... 115UCERIS......................................................... 92UDAMIN SP..................................................74ULESFIA....................................................... 65ULORIC.........................................................96ULTIMATECARE ONE............................... 78ULTIMATECARE ONE NF......................... 78ULTIVA...........................................................7ULTRAFOAM...............................................97ULTRAVATE X............................................62ULTRAVIST................................................. 67UMECTA.......................................................63UNITUXIN.................................................... 21UPTRAVI...................................................... 38UR N-C.......................................................... 95URAMAXIN..................................................63URAMAXIN GT........................................... 63urea .......................................................... 61, 63URELLE........................................................ 95URETRON D-S............................................. 95URIBEL......................................................... 95URIN DS........................................................95UROCIT-K 10 ................................................94UROCIT-K 15 ................................................94UROCIT-K 5 ..................................................94UROGESIC-BLUE........................................95URO-MP........................................................ 95UROQID-ACID NO.2 ................................... 94ursodiol .......................................................... 90URYL.............................................................95USTELL.........................................................95UTOPIC......................................................... 63UVADEX.......................................................24VAGIFEM................................................... 116

valacyclovir ....................................................16VALCHLOR..................................................59valganciclovir .................................................15valproate sodium ............................................40valproic acid ............................................ 40, 46valproic acid (as sodium salt) ..................40, 46valsartan .........................................................32valsartan-hydrochlorothiazide .......................32VALSTAR..................................................... 26vancomycin .....................................................16vancomycin in 0.9% sodium cl .......................16vancomycin in dextrose 5 % ...........................16VANIQA........................................................64VANOS..........................................................62VANOXIDE-HC............................................57VAPRISOL.................................................... 37VAQTA (PF) ..................................................28VARIBAR HONEY.......................................66VARIBAR NECTAR.....................................66VARIBAR PUDDING...................................66VARIBAR THIN HONEY............................ 66VARIBAR THIN LIQUID............................ 66VARITHENA................................................ 40VARIVAX (PF) ....................................... 29, 31VARIZIG....................................................... 29VARUBI........................................................ 89VASCAZEN.................................................. 35VASCEPA..................................................... 35VASCULERA................................................70vasopressin .....................................................82VASOSTRICT............................................... 82VAXCHORA VACCINE.............................. 30VAYACOG......................................................1VAYARIN....................................................... 1VAYAROL.................................................... 35VAZCULEP...................................................37V-C FORTE................................................... 74VECAMYL....................................................38VECTIBIX..................................................... 27vecuronium bromide .................................... 101VELCADE..................................................... 25VELETRI ....................................................... 39VELIVET TRIPHASIC REGIMEN (28) ...... 55VELTASSA................................................... 71VELTIN......................................................... 56VEMAVITE-PRX-2...................................... 78VENA-BAL DHA..........................................78VENCLEXTA................................................22VENCLEXTA STARTING PACK............... 22venlafaxine ..................................................... 42VENOFER..................................................... 72VENTAVIS....................................................39VENTOLIN HFA........................................ 114verapamil ................................................. 34, 36VERDESO..................................................... 62VEREGEN..................................................... 63VERIPRED 20 ............................................... 86VERSACLOZ................................................ 44VESICARE.................................................... 95VESTURA (28) ..............................................54VFEND.......................................................... 11VIBERZI ..................................................91, 92VIBRAMYCIN..............................................19VIC-FORTE...................................................74VICTOZA 2-PAK..........................................83VICTOZA 3-PAK..........................................83VIDAZA........................................................ 22VIDEX 2 GRAM PEDIATRIC..................... 13VIDEX 4 GRAM PEDIATRIC..................... 13vigabatrin ....................................................... 41

VIGAMOX.................................................. 110VIIBRYD....................................................... 43VIMIZIM..................................................... 103VIMPAT........................................................ 41VINACAL......................................................78VINATE CARE............................................. 79VINATE GT.................................................. 78VINATE II ..................................................... 78VINATE M.................................................... 78VINATE ONE................................................78VINATE PN CARE....................................... 78VINATE ULTRA.......................................... 78vinblastine ...................................................... 26vincristine .......................................................26vinorelbine ..................................................... 26VIOKACE......................................................90VIORELE (28) ...............................................52VIRACEPT.................................................... 19VIRAMUNE.................................................. 12VIRAMUNE XR............................................12VIREAD.........................................................13VIRT-PN........................................................78VIRT-PN DHA.............................................. 78VIRT-PN PLUS............................................. 78VIRT-SELECT.............................................. 78VIRT-VITE PLUS......................................... 69VISCOAT.................................................... 109VISIONBLUE..............................................109VISIPAQUE...................................................67VISUDYNE................................................. 109VIT 3 .............................................................. 74VITAFOL GUMMIES...................................79VITAFOL-OB+DHA.....................................79VITAL HIGH PROTEIN...............................75VITAL-D RX...........................................74, 80vitamin e ...................................................35, 80VITAMIN K.................................................. 81VITAMIN K1................................................ 81VITAMINS A,C,D AND FLUORIDE.......... 76VITA-RESPA.......................................... 80, 81VITRASE.......................................................88VITUZ..........................................................115VIVA DHA.................................................... 79VIVELLE-DOT............................................. 85VIVITROL.....................................................50VIVOTIF BERNA VACCINE...................... 29VOGELXO.................................................... 82VOL-CARE RX.............................................69VOL-NATE................................................... 78VOL-TAB RX................................................78VOLTAREN.................................................. 64VOLUMEN....................................................66VOLUVEN 6 %............................................. 98VORAXAZE..................................................27voriconazole ................................................... 11VOSEVI......................................................... 16VOTRIENT....................................................25VP-CH PLUS.................................................78VP-CH-PNV.................................................. 78VP-GGR-B6...................................................79VP-GSTN.........................................................1VP-HEME ONE.............................................78VP-PNV-DHA............................................... 78VPRIV..........................................................103VP-ZEL..........................................................70VRAYLAR.................................................... 47VUSION.........................................................59VYTONE....................................................... 58VYVANSE.....................................................46VYXEOS....................................................... 21

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warfarin ..........................................................96water for inject, bacteriostat ..........................70water for injection, sterile ........................70, 80water for irrigation, sterile ............................ 71WELCHOL.................................................... 34WESTHROID................................................ 88wheat germ oil ................................................80white petrolatum ............................................ 64WINRHO SDF...............................................29WP THYROID...............................................88WYMZYA FE................................................54XADAGO...................................................... 44XARELTO..................................................... 96XATMEP................................................... 5, 21XCLAIR.........................................................61XELJANZ........................................................ 5XELJANZ XR..................................................5XELODA....................................................... 22XENAZINE................................................... 48XEOMIN......................................................101XERAC AC....................................................59XERMELO.................................................... 89XGEVA..........................................................88XIAFLEX.....................................................101XIFAXAN......................................................19XIGDUO XR................................................. 82XOFIGO.........................................................25XOLAIR.......................................................113XOLEGEL..................................................... 59XTAMPZA ER................................................ 3XTANDI........................................................ 21XULANE....................................................... 55XYLOCAINE (CARDIAC) (PF) ...................33XYLOCAINE-MPF......................................... 8XYLOCAINE-MPF/EPINEPHRINE.............. 8XYREM......................................................... 49YASMIN (28) ................................................ 54YAZ (28) ........................................................54YERVOY....................................................... 22YF-VAX (PF) .......................................... 29, 31YONDELIS....................................................20YUVAFEM..................................................116zafirlukast .....................................................113zaleplon .......................................................... 49ZALTRAP......................................................26ZANOSAR.....................................................26ZARAH..........................................................53ZARXIO.........................................................96ZATEAN-CH.................................................78ZATEAN-PN DHA........................................78ZATEAN-PN PLUS...................................... 78ZAVESCA................................................... 104ZEBUTAL....................................................... 4ZEJULA......................................................... 24ZELAPAR......................................................44ZELBORAF................................................... 22ZEMAIRA................................................... 114ZEMBRACE SYMTOUCH.......................... 48ZEMPLAR................................................... 104ZENATANE.................................................. 55ZENCHENT (28) ...........................................54ZENPEP......................................................... 90ZENZEDI...........................................46, 47, 49ZERBAXA.....................................................14ZEVALIN (Y-90) .......................................... 24ZIAGEN.........................................................13ZIANA........................................................... 56zidovudine ...................................................... 13ZINACEF.......................................................14ZINACEF IN STERILE WATER................. 14

ZINBRYTA................................................. 106zinc chloride ...................................................74zinc sulfate ......................................................74ZINGIBER..................................................... 79ZIOPTAN (PF) ............................................ 110ziprasidone hcl ......................................... 44, 47ZIRGAN.......................................................110ZITHRANOL.................................................60ZMAX............................................................17ZN-DTPA.......................................................10ZODEX.......................................................... 86ZOHYDRO ER................................................ 3ZOLADEX.....................................................24zoledronic acid ...............................................84zoledronic acid-mannitol-water .....................84zoledronic ac-mannitol-0.9nacl ..................... 84ZOLINZA...................................................... 23zolmitriptan .................................................... 48zolpidem ......................................................... 49ZOLPIMIST...................................................49ZOMIG...........................................................48ZOMIG ZMT................................................. 48ZONATUSS.................................................112zonisamide ......................................................42ZONTIVITY.................................................. 99ZORTRESS..................................................100ZORVOLEX.................................................... 6ZOSTAVAX (PF) .................................... 29, 31ZOSYN IN DEXTROSE (ISO-OSM)........... 18ZOVIA 1/35E (28) ......................................... 53ZOVIA 1/50E (28) ......................................... 53ZOVIRAX......................................................60ZUBSOLV..................................................... 50ZUPLENZ......................................................89ZURAMPIC................................................... 96ZUTRIPRO.................................................. 115ZYDELIG...................................................... 24ZYFLO.........................................................112ZYLET......................................................... 107ZYMAXID...................................................110ZYPRAM......................................................... 8ZYPREXA RELPREVV................................45ZYTIGA...................................................20, 21ZYVOX..........................................................18

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