frontmatter 2015 value - health net accepted 07202014 2015 value formulary (list of covered drugs)...

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN

Health Net Healthy Heart (HMO) in Alameda, Los Angeles, Orange, Placer, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, Stanislaus and Yolo Counties, Health Net Jade (HMO SNP) in Arizona, Health Net Jade Cardiovascular (HMO SNP), Health Net Ruby (HMO), Health Net Ruby 1 (HMO), Health Net Ruby 4 (HMO), Health Net Ruby Select (HMO), Health Net Seniority Plus Ruby (HMO), Health Net Violet (PPO), Health Net Violet Option 1 (PPO), Health Net Violet Option 2 (PPO), and Health Net Violet Option 3 (PPO)

HPMS Approved Formulary File Submission ID 15441, Version Number

This formulary was updated on For more recent information or other questions, please contact Health Net at:

Arizona Plans: 1-800-977-7522

California HMO Plans: 1-800-275-4737 California HMO SNP Plans: 1-800-431-9007 California PPO Plans: 1-800-960-4638

Oregon/Washington Plans: 1-888-445-8913

or, for TTY users, 711, 8:00 a.m. - 8:00 p.m., seven days a week (automated telephone service is used on some weekends and holidays), or visit www.healthnet.com/medicare.

Material ID# Y0035_2015_0011 (H0351, H0562, H5439, H5520, H6815, EG) CMS Accepted 07202014

2015 Value Formulary(List of Covered Drugs)

12/01/2015.

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Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Health Net. When it refers to “plan” or “our plan,” it means Health Net Healthy Heart (HMO) in Alameda, Los Angeles, Orange, Placer, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, Stanislaus and Yolo Counties, Health Net Jade (HMO SNP) in Arizona, Health Net Jade Cardiovascular (HMO SNP), Health Net Ruby (HMO), Health Net Ruby 1 (HMO), Health Net Ruby 4 (HMO), Health Net Ruby Select (HMO), Health Net Seniority Plus Ruby (HMO), Health Net Violet (PPO), Health Net Violet Option 1 (PPO), Health Net Violet Option 2 (PPO), and Health Net Violet Option 3 (PPO).

This document includes a list of the drugs (formulary) for our plan which is current as of the date on the front and back cover pages. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year.

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What is the Health Net Healthy Heart (HMO) in Alameda, Los Angeles, Orange, Placer, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, Stanislaus and Yolo Counties, Health Net Jade (HMO SNP) in Arizona, Health Net Jade Cardiovascular (HMO SNP), Health Net Ruby (HMO), Health Net Ruby 1 (HMO), Health Net Ruby 4 (HMO), Health Net Ruby Select (HMO), Health Net Seniority Plus Ruby (HMO), Health Net Violet (PPO), Health Net Violet Option 1 (PPO), Health Net Violet Option 2 (PPO), and Health Net Violet Option 3 (PPO) Value Formulary?A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Health Net network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current

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as of the date on the front and back cover pages. To get updated information about the drugs covered by us, please contact us. Our contact information appears on the front and back cover pages.

If we make any other negative formulary changes during the year, you will be notified via mail and the changes will be posted on our website.

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

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

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page Index 1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

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

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

• Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

• Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides two each per day per prescription for simvastatin 40 mg. This may be in addition to a standard one-month or three-month supply.

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

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You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Health Net Healthy Heart (HMO) in Alameda, Los Angeles, Orange, Placer, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, Stanislaus and Yolo Counties, Health Net Jade (HMO SNP) in Arizona, Health Net Jade Cardiovascular (HMO SNP), Health Net Ruby (HMO), Health Net Ruby 1 (HMO), Health Net Ruby 4 (HMO), Health Net Ruby Select (HMO), Health Net Seniority Plus Ruby (HMO), Health Net Violet (PPO), Health Net Violet Option 1 (PPO), Health Net Violet Option 2 (PPO), and Health Net Violet Option 3 (PPO) Value Formulary?” on page iv for information about how to request an exception.

What if my drug is not on the formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered.

If you learn that our plan does not cover your drug, you have two options

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

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

How do I request an exception to the Health Net Healthy Heart (HMO) in Alameda, Los Angeles, Orange, Placer, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, Stanislaus and Yolo Counties, Health Net Jade (HMO SNP) in Arizona, Health Net Jade Cardiovascular (HMO SNP), Health Net Ruby (HMO), Health Net Ruby 1 (HMO), Health Net Ruby 4 (HMO), Health Net Ruby Select (HMO), Health Net Seniority Plus Ruby (HMO), Health Net Violet (PPO),

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Health Net Violet Option 1 (PPO), Health Net Violet Option 2 (PPO), and Health Net Violet Option 3 (PPO) Value Formulary?You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level. If approved this would lower the amount you must pay for your drug.

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

Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit

a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

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

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy.

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After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 102-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 34-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Level of care changesIf you experience a change in your level of care, we will cover a transition supply of your drugs. A level of care change occurs when you are discharged from a hospital or moved to or from a long-term care facility.

• If you move home from a long-term care facility or hospital and need a transition supply, we will cover one 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a total of a 30-day supply.

• If you move from home or a hospital to a long-term care facility and need a transition supply, we will cover one 34-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a total of a 34-day supply.

We understand that there are other circumstances when an override may be granted. These situations are managed on a case-by-case basis through communication between the dispensing pharmacy and Health Net.

For more informationFor more detailed information about your plan’s prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

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

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Health Net Healthy Heart (HMO) in Alameda, Los Angeles, Orange, Placer, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, Stanislaus and Yolo Counties, Health Net Jade (HMO SNP) in Arizona, Health Net Jade Cardiovascular (HMO SNP), Health Net Ruby (HMO), Health Net Ruby 1 (HMO), Health Net Ruby 4 (HMO), Health Net Ruby Select (HMO), Health Net Seniority Plus Ruby (HMO), Health Net Violet (PPO), Health Net Violet Option 1 (PPO), Health Net Violet Option 2 (PPO), and Health Net Violet Option 3 (PPO) Value FormularyThe formulary that begins on page 1 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page Index 1.

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

The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug.

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Formulary tier descriptions To figure out how much you pay for a drug, the abbreviations below appear in the Drug Tier column on the formulary. The copayment or coinsurance level is shown in the Copayment/Coinsurance column. To find out your copayment or coinsurance for each tier, please check your Evidence of Coverage.

Abbreviation Copayment/Coinsurance Description1 Tier 1 copayment Preferred generic drugs.

These drugs are not eligible for exceptions for payment at a lower tier.

2 Tier 2 copayment Non-Preferred generic drugs.

3 Tier 3 copayment Preferred brand drugs and may include some non-preferred generic drugs. Brand drugs in this tier are not eligible for exceptions for payment at a lower tier.

4 Tier 4 copayment Non-Preferred brand drugs and may include some non-preferred generic drugs.

5 (Specialty)

Tier 5 copayment or coinsurance

High-cost drugs. These drugs are not eligible for exceptions for payment at a lower tier.

6 (Select Care)

$0 copayment Some brand and generic drugs used to treat specific chronic conditions.

NF Non-formulary - If an exception request is approved for a non-formulary drug; the Non-Preferred brand tier (Tier 4) copayment applies. You may not ask us to provide the drug at a lower cost-sharing level.

Drugs not covered on Health Net’s Medicare Part D formulary. You may request an exception from Health Net to cover these drugs. See the section, “How do I request an exception to the Health Net Medicare Part D Value Formulary?”

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AbbreviationsThe abbreviations below may appear in the Requirement/Limits column on the formulary.

Abbreviation Definition DescriptionAL Age Limit Some drugs may require prior authorization if

your age does not meet manufacturer, FDA, or clinical recommendations.

B/D Medicare Part B vs. Part D

Some drugs require prior authorization to determine coverage under the Medicare Part B or Part D benefit, according to Medicare guidelines. Your doctor or other prescriber may need to supply additional information to help us make the coverage determination.

GL Gender Limit Some drugs are only covered for males or females based on manufacturer, FDA, or clinical recommendations.

LA Limited Access Some drugs may be subject to limited access or restricted access. This means that a drug may only be available at one or a limited number of pharmacies. Limited access may be due to the following reasons:• The FDA has restricted distribution of a drug to

certain facilities, pharmacies or prescribers, or • Certain drugs require special handling,

coordination of care, or patient education that cannot be provided at a retail pharmacy

You should talk to your doctor, or other prescriber, or pharmacist for details about getting limited access drugs.

MO Mail Order This drug is available at Health Net’s mail order pharmacy in addition to other network pharmacies.

PA Prior Authorization Health Net requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

QL Quantity Limit For certain drugs, Health Net limits the amount of the drug that we will cover. For example, Health Net covers two each per day per prescription for simvastatin 40 mg. This may be in addition to a standard one-month or three-month supply limits.

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Abbreviation Definition DescriptionRX/OTC Prescription and

Over-The-CounterCertain drugs are available both in a prescription form and in an OTC form. Other than some insulins and insulin supplies, only prescription drugs are covered by Health Net Medicare Part D plans.

ST Step Therapy In some cases, Health Net requires you to first try certain drugs to treat your medical condition before covering another drug for that condition.

For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

* Additional Gap Coverage

Only for Health Net Healthy Heart (HMO) plans in Los Angeles, Orange, Riverside, and San Bernardino counties and Health Net Seniority Plus Ruby (HMO) plan in San Diego County:We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage.

Drug Name DrugTier

Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating DisordersAmphetaminesADDERALL XR (UseAmphetamine-Dextroamphetamine)

NFMO

amphetamine-dextroamphetamine cp241.25mg-1.25mg-1.25mg-1.25mg, 2.5mg-2.5mg-2.5mg-2.5mg, 3.75mg-3.75mg-3.75mg-3.75mg,5mg-5mg-5mg-5mg,6.25mg-6.25mg-6.25mg-6.25mg, 7.5mg-7.5mg-7.5mg-7.5mg

3

MO

amphetamine-dextroamphetamine tabs1.25mg-1.25mg-1.25mg-1.25mg, 1.875mg-1.875mg-1.875mg-1.875mg, 2.5mg-2.5mg-2.5mg-2.5mg, 3.125mg-3.125mg-3.125mg-3.125mg, 3.75mg-3.75mg-3.75mg-3.75mg, 5mg-5mg-5mg-5mg, 7.5mg-7.5mg-7.5mg-7.5mg

2

MO; *

DESOXYN (UseMethamphetamine HCl) NF MO

DEXEDRINE 10 MG,15MG,5 MG (UseDextroamphetamineSulfate)

NF

MO

dextroamphetamine sulfatecp24 10 mg, 15 mg, 5 mg 3 MO

dextroamphetamine sulfatetabs 10 mg, 5 mg 3 MO

methamphetamine hcl 4 MO

VYVANSE 10 MG 4 QL(7 ea daily);MO



Drug Name DrugTier

Requirements/Limits

VYVANSE 40 MG, 50 MG,60 MG, 70 MG 4 QL(1 ea daily);

MOAttention-Deficit/Hyperactivity Disorder (ADHD)clonidine hcl (adhd) 2 MO; *

guanfacine hcl (adhd) 2 AL; MO; *

INTUNIV (Use GuanfacineHCl (ADHD)) 4 AL; MO

KAPVAY (Use ClonidineHCl (ADHD)) NF MO

STRATTERA 10 MG 3 QL(10 eadaily); MO

STRATTERA 100 MG, 60MG, 80 MG 3 QL(1 ea daily);

MO

STRATTERA 18 MG 3 QL(5 ea daily);MO



Stimulants - Misc.CONCERTA (UseMethylphenidate HCl) NF MO

DAYTRANA 30 MG/9HR 4 MO

dexmethylphenidate hclcp24 10 mg, 15 mg, 20 mg 2 MO; *

dexmethylphenidate hcltabs 10 mg, 2.5 mg, 5 mg 1 MO; *

FOCALIN (UseDexmethylphenidate HCl) NF MO

FOCALIN XR 10 MG, 20MG (UseDexmethylphenidate HCl)

4MO

FOCALIN XR 15 MG (UseDexmethylphenidate HCl) NF MO

METADATE CD (UseMethylphenidate HCl) NF MO

methylphenidate hcl cp24or 20 mg, 40 mg 3 MO

methylphenidate hcl cp24or 30 mg 2 MO; *

methylphenidate hcl cpcr or10 mg, 20 mg, 30 mg, 40mg, 50 mg, 60 mg

2MO; *

You can find information on what the symbols and abbreviations on this table mean by going topage ix.

Health Net 2015 Value Formulary

1

Drug Name DrugTier

Requirements/Limits

methylphenidate hcl tabs or10 mg, 20 mg, 5 mg 2 MO; *

methylphenidate hcl tb24or 18 mg, 27 mg, 36 mg,54 mg

3MO

methylphenidate hcl tbcr or10 mg 2 MO; *

methylphenidate hcl tbcr or18 mg, 20 mg, 27 mg, 36mg, 54 mg

3MO

modafinil 100 mg 2 PA; MO; *

modafinil 200 mg 5 PA; MO

NUVIGIL 3 PA; MO

PROVIGIL (Use Modafinil) 5 PA; MO

RITALIN (UseMethylphenidate HCl) NF MO

RITALIN LA 10 MG 4 MO

RITALIN LA 20 MG, 30MG, 40 MG (UseMethylphenidate HCl)

NFMO

RITALIN SR (UseMethylphenidate HCl) NF MO

AMINOGLYCOSIDES - Drugs to Treat BacterialInfectionsAminoglycosidesamikacin sulfate soln ij 1gm/4ml, 500 mg/2ml 1 MO; *

BETHKIS 5 B/D

gentamicin in saline 0.9%-0.8mg/ml 2 MO; *

gentamicin in saline 0.9%-0.9mg/ml, 0.9%-1.4mg/ml,0.9%-1.6mg/ml, 0.9%-1mg/ml, 0.9%-2mg/ml

2

*

gentamicin in saline 0.9%-1.2mg/ml 1 *

gentamicin sulfate soln ij10 mg/ml, 40 mg/ml 1 MO; *

gentamicin sulfate soln iv10 mg/ml 2 *

Drug Name DrugTier

Requirements/Limits

neomycin sulfate tabs or 1 MO; *

paromomycin sulfate 3 MO

TOBI (Use Tobramycin) 5 B/D

TOBI PODHALER 5

tobramycin nebu in 2 B/D; *

tobramycin sulfate in saline 2 *

tobramycin sulfate soln ij1.2 gm/30ml, 40 mg/ml, 80mg/2ml

1MO; *

tobramycin sulfate soln ij10 mg/ml 2 *

tobramycin sulfate solr ij1.2 gm 1 *

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditionsAnti-TNF-alpha - Monoclonal AntibodiesHUMIRA 5 PA

HUMIRA PEDIATRICCROHNS DISEASESTARTER PACK

5PA

HUMIRA PEN 5 PA

HUMIRA PEN-CROHNSDISEASESTARTER 5 PA

HUMIRA PEN-PSORIASISSTARTER 5 PA

SIMPONI 5 PA

SIMPONI ARIA 5 PA

Antirheumatic - Enzyme InhibitorsXELJANZ 5 PA

Antirheumatic AntimetabolitesOTREXUP 4 PA

RASUVO 4 PA



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Drug Name DrugTier

Requirements/Limits

RHEUMATREX 3 MO

Gold CompoundsRIDAURA 5 MO

Interleukin-1 BlockersARCALYST 5 LA

Interleukin-1 Receptor Antagonist (IL-1Ra)KINERET 5 PA

Interleukin-1beta BlockersILARIS 5 LA

Interleukin-6 Receptor InhibitorsACTEMRA 5 PA

Nonsteroidal Anti-inflammatory Agents (NSAIDs)ANAPROX (Use NaproxenSodium) NF MO

ANAPROX DS (UseNaproxen Sodium) NF MO

ARTHROTEC 50 (UseDiclofenac w/ Misoprostol) NF MO

ARTHROTEC 75 (UseDiclofenac w/ Misoprostol) NF MO

CATAFLAM (UseDiclofenac Potassium) NF MO

CELEBREX (UseCelecoxib) 3 MO

celecoxib 2 MO; *

DAYPRO (Use Oxaprozin) NF MO

diclofenac potassium 2 MO; *

diclofenac sodium tb24 or100 mg 2 MO; *

diclofenac sodium tbec or25 mg, 50 mg, 75 mg 2 MO; *

diclofenac w/ misoprostol 3 MO

DUEXIS 4 MO

EC-NAPROSYN (UseNaproxen) NF MO

Drug Name DrugTier

Requirements/Limits

etodolac caps or 200 mg,300 mg 2 MO; *

etodolac tabs or 400 mg,500 mg 2 MO; *

etodolac tb24 or 400 mg,500 mg, 600 mg 2 MO; *

FELDENE (Use Piroxicam) NF MO

fenoprofen calcium tabs600 mg 2 MO; *

flurbiprofen tabs or 100 mg,50 mg 1 MO; *

ibuprofen susp or 100mg/5ml 2 RX/OTC; MO; *

ibuprofen tabs or 400 mg 1 QL(8 ea daily);MO; *



INDOCIN SUSP OR 25MG/5ML 4 AL; MO

indomethacin caps or 25mg, 50 mg 2 AL; MO; *

indomethacin cpcr or 75mg 2 AL; MO; *

ketoprofen caps or 50 mg,75 mg 2 MO; *

ketoprofen cp24 or 200 mg 3 MO

ketorolac tromethaminesoln ij 15 mg/ml, 30 mg/ml 2 AL; MO; *

ketorolac tromethaminesoln im 30 mg/ml, 60mg/2ml

1AL; MO; *

ketorolac tromethaminetabs or 10 mg 2 AL; MO; *

meclofenamate sodiumcaps or 50 mg 2 MO; *

mefenamic acid caps or 4 MO

meloxicam tabs or 15 mg,7.5 mg 1 MO; *

MOBIC TABS 15 MG, 7.5MG (Use Meloxicam) NF MO



3

Drug Name DrugTier

Requirements/Limits

nabumetone 2 MO; *

NAPRELAN 375 MG (UseNaproxen Sodium) 4 MO

NAPRELAN 375 MG, 750MG 4 MO

NAPROSYN (UseNaproxen) NF MO

naproxen sodium tabs or275 mg, 550 mg 2 MO; *

naproxen sodium tb24 or375 mg 2 MO; *

naproxen tabs or 250 mg,375 mg, 500 mg 1 MO; *

naproxen tbec or 375 mg,500 mg 2 MO; *

oxaprozin 3 MO

piroxicam caps or 10 mg,20 mg 2 MO; *

PONSTEL (Use MefenamicAcid) 5 MO

SPRIX 4 AL; MO

sulindac tabs or 150 mg,200 mg 2 MO; *

tolmetin sodium caps 400mg 1 MO; *

tolmetin sodium tabs 200mg 1 MO; *

tolmetin sodium tabs 600mg 2 MO; *

VIMOVO 4 MO

VOLTAREN-XR (UseDiclofenac Sodium) NF MO

ZIPSOR 4 MO

Phosphodiesterase 4 (PDE4) InhibitorsOTEZLA 5 PA

Pyrimidine Synthesis InhibitorsARAVA (Use Leflunomide) NF MO

leflunomide 3 MO

Drug Name DrugTier

Requirements/Limits

Selective Costimulation ModulatorsORENCIA 5 PA

Soluble Tumor Necrosis Factor Receptor AgentsENBREL 5 PA

ENBREL SURECLICK 5 PA

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint ConditionsSalicylatesdiflunisal 1 MO; *

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint ConditionsOpioid Agonists

ABSTRAL 100 MCG 4 PA; QL(6 eadaily)

ABSTRAL 200 MCG 5 PA; QL(6 eadaily)

ABSTRAL 300 MCG, 400MCG, 600 MCG, 800 MCG 5 PA; QL(4 ea

daily)ACTIQ 1200 MCG, 1600MCG, 400 MCG, 600 MCG,800 MCG (Use FentanylCitrate)

5

PA; QL(4 eadaily); MO

ACTIQ 200 MCG (UseFentanyl Citrate) 5 PA; QL(6 ea

daily); MOAVINZA (Use MorphineSulfate Beads) 4 QL(5 ea daily);

MO

codeine sulfate 15 mg 2 QL(24 eadaily); MO; *

CODEINE SULFATE 15MG (Use Codeine Sulfate) 4 QL(24 ea

daily); MO

codeine sulfate 30 mg 2 QL(12 eadaily); MO; *

codeine sulfate 60 mg 2 QL(6 ea daily);MO; *

DEMEROL TABS OR 100MG, 50 MG (UseMeperidine HCl)

NFAL; MO

DILAUDID LIQD OR 1MG/ML (UseHydromorphone HCl)

NFQL(30 mldaily); MO



4

Drug Name DrugTier

Requirements/Limits

DILAUDID TABS OR 2 MG(Use Hydromorphone HCl) NF QL(29 ea

daily); MODILAUDID TABS OR 4 MG(Use Hydromorphone HCl) NF QL(14 ea

daily); MODILAUDID TABS OR 8 MG(Use Hydromorphone HCl) NF QL(7 ea daily);

MODILAUDID-HP SOLN 10MG/ML (UseHydromorphone HCl)

NFMO

DOLOPHINE 10 MG (UseMethadone HCl) NF QL(19 ea

daily); MODOLOPHINE 5 MG (UseMethadone HCl) NF QL(38 ea

daily); MODURAGESIC 100 MCG/HR(Use Fentanyl) NF QL(1 ea daily);

MODURAGESIC 12 MCG/HR(Use Fentanyl) NF QL(1.44 ea

daily); MODURAGESIC 25 MCG/HR(Use Fentanyl) NF QL(0.7 ea



daily); MOEXALGO 12 MG (UseHydromorphone HCl) 4 QL(4 ea daily);

MOEXALGO 16 MG (UseHydromorphone HCl) 4 QL(3.67 ea

daily); MO

EXALGO 32 MG 4 QL(2 ea daily);MO

EXALGO 8 MG (UseHydromorphone HCl) 4 QL(7 ea daily);

MO

fentanyl 100 mcg/hr 4 QL(1 ea daily);MO

fentanyl 12 mcg/hr 4 QL(1.44 eadaily); MO




fentanyl citrate lpop bu1200 mcg, 1600 mcg, 400mcg, 600 mcg, 800 mcg

5PA; QL(4 eadaily); MO

fentanyl citrate lpop bu 200mcg 5 PA; QL(6 ea

daily); MO

Drug Name DrugTier

Requirements/Limits

FENTORA 100 MCG, 200MCG 5 PA; QL(6 ea

daily); MOFENTORA 400 MCG, 600MCG, 800 MCG 5 PA; QL(4 ea

daily); MOHYDROMORPHONE HCLER 4 QL(2 ea daily);

MOhydromorphone hcl liqd or1 mg/ml 3 QL(30 ml

daily); MOhydromorphone hcl soln ij10 mg/ml, 2 mg/ml, 50mg/5ml, 500 mg/50ml

3MO

hydromorphone hcl t24a or12 mg 2 QL(4 ea daily);

MO; *hydromorphone hcl t24a or16 mg 2 QL(3.67 ea

daily); MO; *hydromorphone hcl t24a or8 mg 2 QL(7 ea daily);

MO; *hydromorphone hcl tabs or2 mg 3 QL(29 ea

daily); MOhydromorphone hcl tabs or4 mg 3 QL(14 ea

daily); MOhydromorphone hcl tabs or8 mg 3 QL(7 ea daily);

MOHYSINGLA ER 100 MG,120 MG 4 PA; QL(2 ea

daily)HYSINGLA ER 20 MG, 30MG, 40 MG, 60 MG, 80 MG 4 PA; QL(2 ea

daily); MOKADIAN 10 MG (UseMorphine Sulfate) NF QL(6 ea daily);

MOKADIAN 100 MG (UseMorphine Sulfate) 5 QL(6 ea daily);

MO

KADIAN 130 MG, 150 MG 4 PA; QL(1 eadaily)

KADIAN 20 MG, 30 MG, 50MG, 60 MG, 80 MG (UseMorphine Sulfate)

NFQL(5 ea daily);MO

KADIAN 40 MG, 70 MG 4 PA; QL(5 eadaily); MO

LAZANDA 100 MCG/ACT 5 PA; QL(6 eadaily); MO

LAZANDA 400 MCG/ACT 5 PA; QL(4 eadaily)

meperidine hcl tabs or 100mg, 50 mg 2 AL; MO; *

methadone hcl soln or 10mg/5ml 2 QL(20 ml

daily); MO; *



5

Drug Name DrugTier

Requirements/Limits

methadone hcl soln or 5mg/5ml 2 QL(40 ml

daily); MO; *methadone hcl tabs or 10mg 2 QL(19 ea

daily); MO; *methadone hcl tabs or 5mg 2 QL(38 ea

daily); MO; *

morphine sulfate beads 2 QL(5 ea daily);MO; *

morphine sulfate cp24 or10 mg 2 QL(6 ea daily);

MO; *morphine sulfate cp24 or100 mg 5 QL(6 ea daily);

MOmorphine sulfate cp24 or20 mg, 30 mg, 50 mg, 60mg, 80 mg

4QL(5 ea daily);MO

morphine sulfate soln ij 0.5mg/ml 2 *

morphine sulfate soln ij 1mg/ml 2 MO; *

morphine sulfate soln or 10mg/5ml 2 QL(60 ml

daily); MO; *morphine sulfate soln or100 mg/5ml, 20 mg/ml 2 QL(6 ml daily);

MO; *morphine sulfate soln or 20mg/5ml 2 QL(30 ml

daily); MO; *morphine sulfate tabs or 15mg 2 QL(8 ea daily);

MO; *morphine sulfate tabs or 30mg 2 QL(14 ea

daily); MO; *morphine sulfate tbcr or100 mg 3 QL(6 ea daily);

MOmorphine sulfate tbcr or 15mg 3 QL(8 ea daily);

MOmorphine sulfate tbcr or200 mg 3 QL(3 ea daily);

MOmorphine sulfate tbcr or 30mg, 60 mg 3 QL(5 ea daily);

MOMS CONTIN 100 MG (UseMorphine Sulfate) NF QL(6 ea daily);



MOMS CONTIN 30 MG, 60MG (Use Morphine Sulfate) NF QL(5 ea daily);

MO

Drug Name DrugTier

Requirements/Limits

NUCYNTA 100 MG 4 QL(6 ea daily);MO

NUCYNTA 50 MG 4 QL(12 eadaily); MO

NUCYNTA 75 MG 4 QL(8 ea daily);MO

NUCYNTA ER 100 MG 3 QL(4 ea daily);MO

NUCYNTA ER 150 MG,200 MG, 250 MG 3 QL(2 ea daily);

MO

NUCYNTA ER 50 MG 3 QL(8 ea daily);MO

OPANA 10 MG (UseOxymorphone HCl) NF QL(4 ea daily);

MOOPANA 5 MG (UseOxymorphone HCl) NF QL(8 ea daily);

MO

OXAYDO 5 MG 4 QL(17 eadaily); MO

OXAYDO 7.5 MG 4 QL(11 ea daily)

OXECTA 5 MG 4 QL(17 eadaily); MO

OXECTA 7.5 MG 4 QL(11 ea daily)

oxycodone hcl caps or 5mg 2 QL(17 ea

daily); MO; *oxycodone hcl conc or 100mg/5ml, 20 mg/ml 4 QL(4 ml daily);

MOOXYCODONE HCL ER 10MG, 20 MG, 40 MG 3 QL(2 ea daily);

MOOXYCODONE HCL ER 80MG 3 QL(7 ea daily);

MOoxycodone hcl tabs or 10mg 3 QL(16 ea

daily); MOoxycodone hcl tabs or 15mg 3 QL(11 ea

daily); MOoxycodone hcl tabs or 20mg 3 QL(8 ea daily);

MOoxycodone hcl tabs or 30mg 3 QL(15 ea

daily); MO

oxycodone hcl tabs or 5 mg 3 QL(17 eadaily); MO

OXYCONTIN 10 MG, 15MG, 20 MG, 30 MG, 40MG, 60 MG

3QL(2 ea daily);MO



6

Drug Name DrugTier

Requirements/Limits

OXYCONTIN 80 MG 3 QL(7 ea daily);MO

oxymorphone hcl tabs 10mg 3 QL(4 ea daily);

MOoxymorphone hcl tabs 5mg 3 QL(8 ea daily);

MOoxymorphone hcl tb12 10mg 4 QL(4 ea daily);

MOoxymorphone hcl tb12 15mg 4 QL(2.67 ea

daily); MOoxymorphone hcl tb12 20mg 4 QL(2 ea daily);

MOoxymorphone hcl tb12 30mg, 40 mg 2 QL(2 ea daily);

MO; *oxymorphone hcl tb12 5mg 1 QL(8 ea daily);

MO; *oxymorphone hcl tb12 7.5mg 4 QL(5 ea daily);

MOROXICODONE 15 MG(Use Oxycodone HCl) NF QL(11 ea

daily); MOROXICODONE 30 MG(Use Oxycodone HCl) NF QL(15 ea

daily); MOROXICODONE 5 MG (UseOxycodone HCl) NF QL(17 ea

daily); MOSUBSYS 100 MCG, 200MCG 5 PA; QL(6 ea

daily); MOSUBSYS 1200 MCG, 1600MCG 5 PA; QL(4 ea

daily)SUBSYS 400 MCG, 600MCG, 800 MCG 5 PA; QL(4 ea

daily); MO

tramadol hcl tabs or 50 mg 2 QL(8 ea daily);MO; *

tramadol hcl tb24 or 100mg 3 QL(3 ea daily);

MOtramadol hcl tb24 or 200mg, 300 mg 3 QL(1 ea daily);

MOtramadol hcl tb24 or 200mg, 300 mg 2 Biphasic;QL(1

ea daily); MO; *ULTRAM (Use TramadolHCl) NF QL(8 ea daily);

MOULTRAM ER 100 MG (UseTramadol HCl) NF QL(3 ea daily);

MOULTRAM ER 200 MG, 300MG (Use Tramadol HCl) NF QL(1 ea daily);

MO

Drug Name DrugTier

Requirements/Limits

ZOHYDRO ER C12A 10MG, 15 MG, 20 MG, 30MG, 40 MG, 50 MG


ZOHYDRO ER CP12 10MG, 15 MG, 20 MG, 30MG, 40 MG, 50 MG

4PA; QL(2 eadaily)

Opioid Combinationsacetaminophen w/ codeinesoln 120mg/5ml-12mg/5ml 2 QL(166 ml

daily); MO; *acetaminophen w/ codeinetabs 300mg-15mg, 300mg-30mg, 300mg-60mg

2QL(13 eadaily); MO; *

butalbital-acetaminophen-caffeine w/ codeine 300mg-50mg-40mg-30mg

4AL; QL(13 eadaily); MO

butalbital-acetaminophen-caffeine w/ codeine 325mg-50mg-40mg-30mg

4AL; QL(12 eadaily); MO

butalbital-aspirin-caffeinew/cod 2 AL; MO; *

FIORINAL/CODEINE #3(Use Butalbital-Aspirin-Caffeine w/Cod)

NFAL; MO

hydrocodone-acetaminophen caps 5mg-500mg

2QL(8 ea daily);MO; *

hydrocodone-acetaminophen soln10mg/15ml-325mg/15ml,2.5mg/5ml-108mg/5ml,5mg/10ml-217mg/10ml,7.5mg/15ml-325mg/15ml

2

QL(184 mldaily); MO; *

hydrocodone-acetaminophen tabs 10mg-300mg, 5mg-300mg,7.5mg-300mg

2

QL(13 eadaily); MO; *

hydrocodone-acetaminophen tabs 10mg-325mg, 5mg-325mg,7.5mg-325mg

2


hydrocodone-ibuprofen200mg-10mg, 200mg-5mg,200mg-7.5mg

3MO

oxycodone w/acetaminophen soln5mg/5ml-325mg/5ml

2QL(61 mldaily); *



7

Drug Name DrugTier

Requirements/Limits

oxycodone w/acetaminophen tabs 10mg-325mg

3QL(12 eadaily); MO

oxycodone w/acetaminophen tabs2.5mg-325mg, 5mg-325mg, 7.5mg-325mg

2


oxycodone-aspirin 1 MO; *

PERCODAN (UseOxycodone-Aspirin) NF MO

tramadol-acetaminophen 2 QL(8 ea daily);MO; *

ULTRACET (UseTramadol-Acetaminophen) NF QL(8 ea daily);

MOVICOPROFEN (UseHydrocodone-Ibuprofen) NF MO

Opioid Partial AgonistsBUNAVAIL 4 PA

buprenorphine hcl subl sl 2mg 3 PA; QL(16 ea

daily); MObuprenorphine hcl subl sl 8mg 3 PA; QL(4 ea

daily); MObuprenorphine hcl-naloxone hcl dihydrate2mg-0.5mg


buprenorphine hcl-naloxone hcl dihydrate8mg-2mg


butorphanol tartrate soln na10 mg/ml 1 QL(4.2 ml

daily); MO; *

BUTRANS 10 MCG/HR 3 QL(0.29 eadaily); MO


BUTRANS 20 MCG/HR,7.5 MCG/HR 3 QL(0.15 ea

daily); MO


pentazocine w/ naloxone 3 AL; MO

SUBOXONE 4 PA; MO

TALWIN 4 AL

Drug Name DrugTier

Requirements/Limits

ZUBSOLV 1.4MG-0.36MG,5.7MG-1.4MG, 8.6MG-2.1MG

4PA; MO

ZUBSOLV 11.4MG-2.9MG,2.9MG-0.71MG 4 PA

ANDROGENS-ANABOLIC - Drugs to RegulateHormonesAnabolic SteroidsANADROL-50 5 MO

OXANDRIN 10 MG (UseOxandrolone) 5 MO

OXANDRIN 2.5 MG (UseOxandrolone) NF MO

oxandrolone tabs or 10 mg 5 MO

oxandrolone tabs or 2.5 mg 2 MO; *

AndrogensANDRODERM 3 GL; MO

ANDROGEL 20.25MG/1.25GM,40.5MG/2.5GM

3GL; MO

ANDROGEL 25MG/2.5GM,50 MG/5GM(Use Testosterone)

3GL; MO

ANDROGEL PUMP 3 GL; MO

AVEED 4 LA

AXIRON 4 GL; MO

danazol caps or 100 mg,200 mg 3 MO

danazol caps or 50 mg 1 MO; *

fluoxymesterone tabs or 2 *

FORTESTA 4 GL; MO

methyltestosterone caps or 2 MO; *

methyltestosterone tabs or 2 *

NATESTO 4 GL; MO



8

Drug Name DrugTier

Requirements/Limits

TESTIM 3 GL; MO

testosterone cypionate 2 MO; *

testosterone enanthatesoln im 1 MO; *

TESTOSTERONE GEL TD1 %, 10 MG/ACT, 50MG/5GM

4GL; MO

TESTOSTERONE GEL TD25 MG/2.5GM 3 GL; MO

testosterone gel td 25mg/2.5gm, 50 mg/5gm 2 GL; MO; *

TESTOSTERONE PUMP 4 GL; MO

VOGELXO 4 GL; MO

VOGELXO PUMP 4 GL; MO

ANORECTAL AGENTS - Rectal Drugs to TreatPain, Swelling and ItchingIntrarectal SteroidsCORTENEMA (UseHydrocortisone(Intrarectal))

NFMO

CORTIFOAM 4 MO

hydrocortisone (intrarectal) 3 MO

UCERIS FOAM RE 2MG/ACT 4

Rectal CombinationsANALPRAM-HC SINGLES1%-1% (UseHydrocortisone Acetate w/Pramoxine)

NF

MO

hydrocortisone acetate w/pramoxine crea 1%-1% 2 MO; *

Rectal Steroidshydrocortisone (rectal) 1 MO; *

PROCTOCORT CREA 1 %(Use Hydrocortisone(Rectal))

NFMO

Vasodilating Agents

Drug Name DrugTier

Requirements/Limits

RECTIV 4 MO

ANTHELMINTICS - Drugs to Treat WormInfectionsAnthelminticsALBENZA 4 MO

BILTRICIDE 3 MO

ivermectin tabs or 2 MO; *

STROMECTOL (UseIvermectin) 4 MO

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial InfectionsAnti-infective Agents - Misc.AZACTAM (UseAztreonam) NF MO

aztreonam 2 MO; *

CAYSTON 5

colistimethate sodium solr ij 1 MO; *

COLY-MYCIN M (UseColistimethate Sodium) NF MO

FLAGYL CAPS 375 MG(Use Metronidazole) NF QL(10 ea

daily); MO

FLAGYL ER 4 QL(5 ea daily)

FLAGYL TABS 250 MG(Use Metronidazole) NF QL(16 ea

daily); MOFLAGYL TABS 500 MG(Use Metronidazole) NF QL(8 ea daily);

MOmetronidazole caps or 375mg 2 QL(10 ea

daily); MO; *

metronidazole in nacl 1 *

metronidazole tabs or 250mg 2 QL(16 ea

daily); MO; *metronidazole tabs or 500mg 2 QL(8 ea daily);

MO; *

NEBUPENT 3 MO; B/D

PENTAM 300 4 MO



9

Drug Name DrugTier

Requirements/Limits

PRIMSOL 3 MO

TINDAMAX (UseTinidazole) NF MO

tinidazole tabs or 250 mg,500 mg 1 MO; *

trimethoprim tabs or 2 MO; *

VANCOCIN HCL (UseVancomycin HCl) 5 PA; MO

vancomycin hcl caps or125 mg, 250 mg 5 PA; MO

VANCOMYCIN HCL INDEXTROSE 4

vancomycin hcl solr iv 10gm, 1000 mg, 5000 mg,750 mg

2*

vancomycin hcl solr iv 500mg 2 MO; *

XIFAXAN 5 MO

Anti-infective Misc. - CombinationsBACTRIM (UseSulfamethoxazole-Trimethoprim)

NFMO

BACTRIM DS (UseSulfamethoxazole-Trimethoprim)

NFMO

sulfamethoxazole-trimethoprim soln iv80mg/5ml-400mg/5ml

2MO; *

sulfamethoxazole-trimethoprim susp or40mg/5ml-200mg/5ml

2MO; *

sulfamethoxazole-trimethoprim tabs or160mg-800mg, 80mg-400mg

1

MO; *

Antiprotozoal AgentsALINIA TABS 500 MG 4 MO

atovaquone 5 MO

MEPRON (UseAtovaquone) 5 MO

Carbapenems

Drug Name DrugTier

Requirements/Limits

DORIBAX 500 MG 4

imipenem-cilastatin 250mg-250mg 1 MO; *

imipenem-cilastatin 500mg-500mg 3 MO

INVANZ IJ 4 MO

meropenem 1 gm 5 MO

meropenem 500 mg 1 MO; *

MERREM 1 GM (UseMeropenem) 5 MO

MERREM 500 MG (UseMeropenem) NF MO

PRIMAXIN IV (UseImipenem-Cilastatin) NF MO

Chloramphenicolschloramphenicol sodiumsuccinate 2 *

Cyclic LipopeptidesCUBICIN 5

GlycylcyclinesTYGACIL 5

KetolidesKETEK 300 MG 4

KETEK 400 MG 4 MO

Leprostaticsdapsone tabs or 100 mg,25 mg 2 MO; *

LincosamidesCLEOCIN CAPS OR 150MG, 300 MG, 75 MG (UseClindamycin HCl)

NFMO

CLEOCIN IN D5W (UseClindamycin Phosphate inD5W)

4

CLEOCIN PHOSPHATE IJ600 MG/4ML, 900 MG/6ML(Use ClindamycinPhosphate)

NF

MO



10

Drug Name DrugTier

Requirements/Limits

CLEOCIN PHOSPHATE IV300MG/50ML-5%,600MG/50ML-5%,900MG/50ML-5% (UseClindamycin Phosphate inD5W)

4

clindamycin hcl caps or150 mg, 300 mg, 75 mg 2 MO; *

clindamycin palmitatehydrochloride 3 MO

clindamycin phosphate ind5w 2 *

clindamycin phosphatesoln ij 150 mg/ml, 9000mg/60ml

1*

clindamycin phosphatesoln ij 600 mg/4ml, 900mg/6ml

1MO; *

clindamycin phosphatesoln iv 150 mg/ml, 600mg/4ml

2*

LINCOCIN 4 MO

Oxazolidinoneslinezolid soln iv 2 mg/ml 5

linezolid tabs or 600 mg 5 MO

SIVEXTRO SOLR IV 5

SIVEXTRO TABS OR 5 MO

ZYVOX SOLN IV 2 MG/ML(Use Linezolid) 5

ZYVOX SUSR OR 100MG/5ML 5 MO

ZYVOX TABS OR 600 MG(Use Linezolid) 5 MO

Polymyxinspolymyxin b sulfate solr ij 2 *

StreptograminsSYNERCID 5

ANTIANGINAL AGENTS - Drugs to Treat ChestPain

Drug Name DrugTier

Requirements/Limits

Antianginals-OtherRANEXA 4 PA; MO

NitratesDILATRATE SR 4 MO

ISORDIL TITRADOSE 40MG 4 MO

ISORDIL TITRADOSE 5MG (Use IsosorbideDinitrate)

NFMO

isosorbide dinitrate subl sl2.5 mg 1 *

isosorbide dinitrate tabs or10 mg, 20 mg, 30 mg, 5 mg 1 MO; *

isosorbide dinitrate tbcr or40 mg 1 MO; *

isosorbide mononitrate tabs10 mg 2 MO; *

isosorbide mononitrate tabs20 mg 1 MO; *

isosorbide mononitratetb24 120 mg, 30 mg, 60 mg 1 MO; *

NITRO-DUR 0.1 MG/HR,0.2 MG/HR, 0.4 MG/HR,0.6 MG/HR (UseNitroglycerin)

NF

MO

NITRO-DUR 0.3 MG/HR,0.8 MG/HR 4 MO

NITROGLYCERINLINGUAL 4 MO

nitroglycerin pt24 td 0.1mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr

1MO; *

nitroglycerin soln iv 5mg/ml 2 *

nitroglycerin soln tl 0.4mg/spray 2 MO; *

NITROLINGUALPUMPSPRAY (UseNitroglycerin)

NFMO

NITROMIST 4 MO

NITROSTAT 3 MO



11

Drug Name DrugTier

Requirements/Limits

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.buspirone hcl tabs or 10mg, 15 mg, 30 mg, 5 mg,7.5 mg

2MO; *

hydroxyzine hcl soln im 25mg/ml, 50 mg/ml 2 AL; MO; *

hydroxyzine hcl soln or 10mg/5ml 2 AL; MO; *

hydroxyzine hcl syrp or 10mg/5ml 2 AL; MO; *

hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg 2 AL; MO; *

hydroxyzine pamoate capsor 100 mg, 25 mg, 50 mg 2 AL; MO; *

meprobamate 3 AL; MO

VISTARIL (UseHydroxyzine Pamoate) NF AL; MO

Benzodiazepinesalprazolam tabs or 0.25mg, 0.5 mg, 1 mg, 2 mg 2 MO; *

alprazolam tb24 or 0.5 mg,1 mg, 2 mg, 3 mg 2 MO; *

alprazolam tbdp or 0.25mg, 0.5 mg, 1 mg, 2 mg 2 MO; *

ATIVAN SOLN IJ 2 MG/ML(Use Lorazepam) NF MO

ATIVAN SOLN IJ 4 MG/ML(Use Lorazepam) NF

ATIVAN TABS OR 0.5 MG,1 MG, 2 MG (UseLorazepam)

NFMO

chlordiazepoxide hcl 1 MO; *

clorazepate dipotassium 1 MO; *

diazepam conc or 5 mg/ml 2 MO; *

diazepam soln ij 5 mg/ml 2 MO; *

diazepam soln or 1 mg/ml 2 MO; *

diazepam tabs or 10 mg, 2mg, 5 mg 2 MO; *

Drug Name DrugTier

Requirements/Limits

lorazepam conc or 2 mg/ml 2 MO; *

lorazepam soln ij 2 mg/ml,20 mg/10ml 2 MO; *

lorazepam soln ij 4 mg/ml 2 *

lorazepam tabs or 0.5 mg,1 mg, 2 mg 2 MO; *

NIRAVAM (UseAlprazolam) NF MO

oxazepam 1 MO; *

TRANXENE T (UseClorazepate Dipotassium) NF MO

VALIUM (Use Diazepam) NF MO

XANAX (Use Alprazolam) NF MO

XANAX XR (UseAlprazolam) NF MO

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythmsAntiarrhythmics Type I-Adisopyramide phosphate 2 AL; MO; *

NORPACE (UseDisopyramide Phosphate) NF AL; MO

NORPACE CR 100 MG 4 AL; MO

procainamide hcl soln ij500 mg/ml 2 *

quinidine gluconate tbcr or324 mg 1 MO; *

quinidine sulfate 1 MO; *

Antiarrhythmics Type I-Blidocaine hcl (cardiac) 1 MO; *

mexiletine hcl 1 MO; *

XYLOCAINE IV 20 MG/ML(Use Lidocaine HCl(Cardiac))

NFMO

Antiarrhythmics Type I-C

flecainide acetate 100 mg 1 QL(4 ea daily);MO; *



12

Drug Name DrugTier

Requirements/Limits



propafenone hcl 1 MO; *

RYTHMOL (UsePropafenone HCl) NF MO

RYTHMOL SR (UsePropafenone HCl) NF MO

Antiarrhythmics Type IIIamiodarone hcl soln iv 900mg/18ml 2 *

amiodarone hcl tabs or 100mg, 200 mg, 400 mg 1 MO; *

CORDARONE (UseAmiodarone HCl) NF MO

MULTAQ 3 MO

TIKOSYN 4

ANTIASTHMATIC AND BRONCHODILATORAGENTS - Drugs to Treat Lung ConditionsAnti-Inflammatory Agentscromolyn sodium nebu in 1 MO; B/D; *

Antiasthmatic - Monoclonal AntibodiesXOLAIR 5 PA; LA

Bronchodilators - Anticholinergics

ATROVENT HFA 4 QL(0.86 gmdaily); MO

INCRUSE ELLIPTA 3 QL(1 ea daily);MO

ipratropium bromide soln in 1 MO; B/D; *

SPIRIVA HANDIHALER 3 QL(1 ea daily);MO

SPIRIVA RESPIMAT 1.25MCG/ACT 3

60actuations;QL(0.14 gm daily)


28actuations;QL(0.28 gm daily);MO

Drug Name DrugTier

Requirements/Limits


60actuations;QL(0.14 gm daily);MO

TUDORZA PRESSAIR 3 QL(0.04 eadaily); MO

Leukotriene ModulatorsACCOLATE (UseZafirlukast) NF MO

montelukast sodium chew4 mg, 5 mg 3 QL(1 ea daily);

MOmontelukast sodium tabs10 mg 3 QL(1 ea daily);

MOSINGULAIR CHEW 4 MG,5 MG (Use MontelukastSodium)

NFQL(1 ea daily);MO

SINGULAIR TABS 10 MG(Use Montelukast Sodium) NF QL(1 ea daily);

MO

zafirlukast 1 MO; *

ZYFLO CR 5 QL(4 ea daily);MO

Selective Phosphodiesterase 4 (PDE4) Inhibitors

DALIRESP 4 QL(1 ea daily);MO

Steroid Inhalants

AEROSPAN 3 QL(0.6 gmdaily); MO

ALVESCO 160 MCG/ACT 4 QL(0.41 gmdaily); MO

ALVESCO 80 MCG/ACT 4 QL(0.82 gmdaily); MO

ARNUITY ELLIPTA 3 QL(1 ea daily);MO

ASMANEX HFA 100MCG/ACT 3 QL(0.87 gm

daily); MOASMANEX HFA 200MCG/ACT 3 QL(0.44 gm

daily); MOASMANEX TWISTHALER120 METERED DOSES 3 QL(0.04 ea


daily); MOASMANEX TWISTHALER30 METERED DOSES 110MCG/INH

3QL(0.04 eadaily); MO



13

Drug Name DrugTier

Requirements/Limits

ASMANEX TWISTHALER30 METERED DOSES 220MCG/INH

3QL(0.14 eadaily); MO

ASMANEX TWISTHALER60 METERED DOSES 3 QL(0.07 ea


daily); MObudesonide (inhalation)0.25 mg/2ml 1 QL(8 ml daily);

MO; B/D; *budesonide (inhalation) 0.5mg/2ml 1 QL(4 ml daily);

MO; B/D; *budesonide (inhalation) 1mg/2ml 2 QL(2 ml daily);

MO; B/D; *FLOVENT DISKUS 100MCG/BLIST 3 QL(20 ea

daily); MOFLOVENT DISKUS 250MCG/BLIST 3 QL(8 ea daily);

MOFLOVENT DISKUS 50MCG/BLIST 3 QL(40 ea

daily); MOFLOVENT HFA 110MCG/ACT, 220 MCG/ACT 3 QL(0.8 gm

daily); MOFLOVENT HFA 44MCG/ACT 3 QL(0.36 gm

daily); MOPULMICORT 0.25 MG/2ML(Use Budesonide(Inhalation))

NFQL(8 ml daily);MO; B/D

PULMICORT 0.5 MG/2ML(Use Budesonide(Inhalation))

NFQL(4 ml daily);MO; B/D

PULMICORT 1 MG/2ML(Use Budesonide(Inhalation))

4QL(2 ml daily);MO; B/D

PULMICORT FLEXHALER180 MCG/ACT 4 QL(0.07 ea

daily); MOPULMICORT FLEXHALER90 MCG/ACT 4 QL(0.27 ea

daily); MO

QVAR 3 QL(0.87 gmdaily); MO

Sympathomimetics

ADVAIR DISKUS 3 QL(2 ea daily);MO

ADVAIR HFA 3 QL(4 gm daily);MO

albuterol sulfate nebu in0.083 %, 0.5 %, 0.63mg/3ml, 1.25 mg/3ml

1MO; B/D; *

Drug Name DrugTier

Requirements/Limits

albuterol sulfate syrp or 2mg/5ml 1 MO; *

albuterol sulfate tabs or 2mg, 4 mg 1 MO; *

albuterol sulfate tb12 or 4mg, 8 mg 1 MO; *

ANORO ELLIPTA 3 QL(2 ea daily);MO

ARCAPTA NEOHALER 4 QL(1 ea daily);MO

BREO ELLIPTA25MCG/INH-100MCG/INH,25MCG/INH-200MCG/INH

3

Limited to 2inhalers permonth(InstitutionalPack);QL(2 eadaily); MO

BREO ELLIPTA25MCG/INH-100MCG/INH,25MCG/INH-200MCG/INH

3Limit 1 inhalerper month;QL(2ea daily); MO

BROVANA 4 MO; B/D

COMBIVENT RESPIMAT 4 QL(0.2 gmdaily); MO

DULERA 3 QL(4 gm daily);MO

DUONEB (UseIpratropium-Albuterol) NF MO; B/D

epinephrine hcl sosy 0.1mg/ml 2 MO; *

FORADIL AEROLIZER 3 QL(2 ea daily);MO

ipratropium-albuterol 1 MO; B/D; *

levalbuterol hcl nebu in0.31 mg/3ml, 0.63 mg/3ml,1.25 mg/0.5ml, 1.25mg/3ml

1

MO; B/D; *

PERFOROMIST 4 QL(4 ml daily);MO; B/D

PROAIR HFA 3 MO

PROAIR RESPICLICK 3 MO

PROVENTIL HFA 3 MO

SEREVENT DISKUS 3 QL(2 ea daily);MO



14

Drug Name DrugTier

Requirements/Limits

STIOLTO RESPIMAT 3

Limited to 1inhaler permonth;QL(0.14gm daily); MO

STRIVERDI RESPIMAT 3 QL(0.14 gmdaily); MO

STRIVERDI RESPIMAT 3InstitutionalPack;QL(0.28gm daily); MO

SYMBICORT 4 QL(0.34 gmdaily); MO

terbutaline sulfate tabs or2.5 mg, 5 mg 1 MO; *

VENTOLIN HFA 4 MO

XOPENEX (UseLevalbuterol HCl) NF MO; B/D

XOPENEXCONCENTRATE (UseLevalbuterol HCl)

NFMO; B/D

XOPENEX HFA 4 MO

Xanthinesaminophylline 2 MO; *

theophylline tb12 100 mg,200 mg, 300 mg, 450 mg 1 MO; *

theophylline tb24 400 mg,600 mg 1 MO; *

ANTICOAGULANTS - Blood Thinners

Coumarin AnticoagulantsCOUMADIN TABS OR 1MG, 10 MG, 2 MG, 2.5 MG,3 MG, 4 MG, 5 MG, 6 MG,7.5 MG (Use WarfarinSodium)

4

MO

warfarin sodium 1 MO; *

Direct Factor Xa InhibitorsELIQUIS 4 MO

SAVAYSA 4 MO

XARELTO 3 MO

Drug Name DrugTier

Requirements/Limits

XARELTO STARTERPACK 3 MO

Heparins And Heparinoid-Like AgentsARIXTRA 10 MG/0.8ML, 5MG/0.4ML, 7.5 MG/0.6ML(Use FondaparinuxSodium)

5

MO

ARIXTRA 2.5 MG/0.5ML(Use FondaparinuxSodium)

NFMO

enoxaparin sodium ij 300mg/3ml 4 MO

enoxaparin sodium sc 100mg/ml, 60 mg/0.6ml, 80mg/0.8ml

3MO

enoxaparin sodium sc 120mg/0.8ml, 150 mg/ml 5 MO

enoxaparin sodium sc 30mg/0.3ml, 40 mg/0.4ml 4 MO

fondaparinux sodium 10mg/0.8ml, 5 mg/0.4ml, 7.5mg/0.6ml

5MO

fondaparinux sodium 2.5mg/0.5ml 1 MO; *

FRAGMIN 10000 UNIT/ML,2500 UNIT/0.2ML, 5000UNIT/0.2ML

4MO

FRAGMIN 12500UNIT/0.5ML, 15000UNIT/0.6ML, 18000UNT/0.72ML, 25000UNIT/ML, 7500UNIT/0.3ML

5

MO

FRAGMIN 95000UNIT/3.8ML 5

heparin sodium (porcine)1000 unit/ml 2 MO; *

heparin sodium (porcine)10000 unit/ml, 20000unit/ml, 5000 unit/0.5ml,5000 unit/ml

1

MO; *

LOVENOX IJ 300 MG/3ML(Use Enoxaparin Sodium) NF MO



15

Drug Name DrugTier

Requirements/Limits

LOVENOX SC 100 MG/ML,30 MG/0.3ML, 40MG/0.4ML, 60 MG/0.6ML,80 MG/0.8ML (UseEnoxaparin Sodium)

NF

MO

LOVENOX SC 120MG/0.8ML, 150 MG/ML(Use Enoxaparin Sodium)

4MO

Thrombin Inhibitorsargatroban 250 mg/2.5ml 2 MO; *

PRADAXA 3 MO

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor Antagonists

FYCOMPA 10 MG 4 QL(1.2 eadaily); MO

FYCOMPA 12 MG 4 QL(1 ea daily);MO




FYCOMPA 8 MG 4 QL(1.5 eadaily); MO

Anticonvulsants - Benzodiazepines

clonazepam tabs or 0.5 mg 2 QL(40 eadaily); MO; *

clonazepam tabs or 1 mg 2 QL(20 eadaily); MO; *

clonazepam tabs or 2 mg 2 QL(10 eadaily); MO; *

clonazepam tbdp or 0.125mg, 0.25 mg, 0.5 mg, 1 mg,2 mg

2MO; *

DIASTAT ACUDIAL 4 MO

DIASTAT PEDIATRIC 4 MO

DIAZEPAM GEL RE 10MG, 2.5 MG, 20 MG 4 MO

KLONOPIN 0.5 MG (UseClonazepam) 4 QL(40 ea

daily); MO

Drug Name DrugTier

Requirements/Limits

KLONOPIN 1 MG (UseClonazepam) 4 QL(20 ea

daily); MOKLONOPIN 2 MG (UseClonazepam) 4 QL(10 ea

daily); MO

ONFI SUSP 2.5 MG/ML 4 MO

ONFI TABS 10 MG, 5 MG 4 MO

ONFI TABS 20 MG 5 MO

Anticonvulsants - Misc.

APTIOM 200 MG 4 QL(6 ea daily);MO




BANZEL SUSP 40 MG/ML 4 MO

BANZEL TABS 200 MG 4 MO

BANZEL TABS 400 MG 5 MO

carbamazepine chew or100 mg 2 MO; *

carbamazepine cp12 or100 mg, 200 mg, 300 mg 3 MO

carbamazepine susp or100 mg/5ml 2 MO; *

carbamazepine tabs or 200mg 2 MO; *

carbamazepine tb12 or 200mg, 400 mg 2 MO; *

CARBATROL (UseCarbamazepine) NF MO

gabapentin caps or 100mg, 300 mg, 400 mg 2 MO; *

gabapentin soln or 250mg/5ml 2 MO; *

gabapentin tabs or 600 mg,800 mg 2 MO; *

KEPPRA (UseLevetiracetam) 4 MO



16

Drug Name DrugTier

Requirements/Limits

KEPPRA XR (UseLevetiracetam) 4 MO

LAMICTAL CHEWABLEDISPERSIBLE (UseLamotrigine)

4MO

LAMICTAL ODT TBDP 100MG, 200 MG, 25 MG, 50MG (Use Lamotrigine)

4MO

LAMICTAL STARTER/NOTTAKINGCARBAMAZEPINE

4MO

LAMICTALSTARTER/TAKINGCARBAMAZEPINE/NOTTAKING VALPROATE

4

MO

LAMICTALSTARTER/TAKINGVALPROATE

4MO

LAMICTAL TABS 100 MG,150 MG, 200 MG, 25 MG(Use Lamotrigine)

4MO

LAMICTAL XR KIT 4 MO

LAMICTAL XR TB24 100MG, 250 MG (UseLamotrigine)

4MO

LAMICTAL XR TB24 200MG, 25 MG, 300 MG, 50MG (Use Lamotrigine)

NFMO

lamotrigine chew 25 mg, 5mg 2 MO; *

lamotrigine tabs 100 mg,150 mg, 200 mg, 25 mg 2 MO; *

lamotrigine tb24 100 mg,250 mg 2 MO; *

lamotrigine tb24 200 mg,25 mg, 300 mg, 50 mg 4 MO

lamotrigine tbdp 100 mg,200 mg, 25 mg, 50 mg 2 MO; *

LEVETIRACETAM SOLNIV 1000MG/100ML-750MG/100ML,1500MG/100ML-540MG/100ML,500MG/100ML-820MG/100ML

4

levetiracetam soln iv 500mg/5ml 3 MO

Drug Name DrugTier

Requirements/Limits

levetiracetam soln or 100mg/ml, 500 mg/5ml 3 MO

levetiracetam tabs or 1000mg, 250 mg, 500 mg, 750mg

3MO

levetiracetam tb24 or 500mg, 750 mg 3 MO

LYRICA CAPS 100 MG 3 QL(6 ea daily);MO



LYRICA CAPS 225 MG,300 MG 3 QL(2 ea daily);

MO

LYRICA CAPS 25 MG 3 QL(24 eadaily); MO

LYRICA CAPS 50 MG 3 QL(12 eadaily); MO


LYRICA SOLN 20 MG/ML 3 QL(30 mldaily); MO

MYSOLINE (UsePrimidone) 4 MO

NEURONTIN (UseGabapentin) 4 MO

oxcarbazepine susp 300mg/5ml, 60 mg/ml 3 MO

oxcarbazepine tabs 150mg, 300 mg, 600 mg 2 MO; *

POTIGA 200 MG 5 QL(6 ea daily);MO



POTIGA 50 MG 5 QL(24 eadaily); MO

primidone tabs or 250 mg,50 mg 2 MO; *

TEGRETOL (UseCarbamazepine) 4 MO

TEGRETOL-XR 100 MG 4 MO



17

Drug Name DrugTier

Requirements/Limits

TEGRETOL-XR 200MG,400 MG (UseCarbamazepine)

4MO

TOPAMAX (UseTopiramate) 4 MO

TOPAMAX SPRINKLE(Use Topiramate) 4 MO

topiramate cpsp or 15 mg,25 mg 2 MO; *

topiramate tabs or 100 mg,200 mg, 25 mg, 50 mg 2 MO; *

TRILEPTAL SUSP 300MG/5ML (UseOxcarbazepine)

NFMO

TRILEPTAL TABS 150MG, 300 MG, 600 MG (UseOxcarbazepine)

4MO

VIMPAT SOLN IV 200MG/20ML 4

VIMPAT SOLN OR 10MG/ML 4 MO

VIMPAT TABS OR 100MG, 150 MG, 200 MG, 50MG

4MO

ZONEGRAN (UseZonisamide) 4 MO

zonisamide 2 MO; *

Carbamatesfelbamate susp 600mg/5ml 2 MO; *

felbamate tabs 400 mg 2 MO; *

felbamate tabs 600 mg 5 MO

FELBATOL SUSP 600MG/5ML (Use Felbamate) 4 MO

FELBATOL TABS 400 MG(Use Felbamate) 4 MO

FELBATOL TABS 600 MG(Use Felbamate) 5 MO

GABA ModulatorsGABITRIL 12 MG, 16 MG 4 MO

GABITRIL 2 MG, 4 MG(Use Tiagabine HCl) NF MO

Drug Name DrugTier

Requirements/Limits

SABRIL 5 LA

tiagabine hcl 4 MO

HydantoinsCEREBYX 100 MGPE/2ML (Use FosphenytoinSodium)

4

CEREBYX 500 MGPE/10ML (UseFosphenytoin Sodium)

4MO

DILANTIN-125 (UsePhenytoin) 4 MO

fosphenytoin sodium 100mg pe/2ml 2 *

fosphenytoin sodium 500mg pe/10ml 2 MO; *

PEGANONE 4 MO

phenytoin chew or 50 mg 2 MO; *

phenytoin sodium extended 2 MO; *

phenytoin sodium soln ij 2 *

phenytoin susp or 125mg/5ml 2 MO; *

SuccinimidesCELONTIN 4 MO

ethosuximide caps or 250mg 1 MO; *

ethosuximide soln or 250mg/5ml 2 MO; *

ZARONTIN 250 MG (UseEthosuximide) 4 MO

Valproic AcidDEPACON (Use ValproateSodium) 4

DEPAKENE (UseValproate Sodium) 4 MO

DEPAKENE (Use ValproicAcid) 4 MO

DEPAKOTE (UseDivalproex Sodium) 4 MO



18

Drug Name DrugTier

Requirements/Limits

DEPAKOTE ER (UseDivalproex Sodium) 4 MO

DEPAKOTE SPRINKLES(Use Divalproex Sodium) 4 MO

divalproex sodium 2 MO; *

valproate sodium soln iv100 mg/ml, 500 mg/5ml 2 *

valproate sodium soln or250 mg/5ml 2 MO; *

valproate sodium syrp or250 mg/5ml 2 MO; *

valproic acid caps or 2 MO; *

ANTIDEPRESSANTS - Drugs to Treat Depression

Alpha-2 Receptor Antagonists (Tetracyclics)mirtazapine 2 MO; *

REMERON (UseMirtazapine) NF MO

REMERON SOLTAB (UseMirtazapine) NF MO

Antidepressants - Misc.

APLENZIN 174 MG 4 ST; QL(3 eadaily); MO

APLENZIN 348 MG, 522MG 4 ST; QL(1 ea

daily); MObupropion hcl tabs or 100mg 3 QL(4.5 ea

daily); MObupropion hcl tabs or 75mg 3 QL(6 ea daily);

MObupropion hcl tb12 or 100mg 3 QL(4 ea daily);

MObupropion hcl tb12 or 150mg, 200 mg 3 QL(2 ea daily);



MO

FORFIVO XL 4 ST; MO

maprotiline hcl 25 mg, 50mg 1 MO; *

maprotiline hcl 75 mg 2 MO; *

Drug Name DrugTier

Requirements/Limits

WELLBUTRIN 100 MG(Use Bupropion HCl) NF QL(4.5 ea

daily); MOWELLBUTRIN 75 MG (UseBupropion HCl) NF QL(6 ea daily);

MOWELLBUTRIN SR 100 MG(Use Bupropion HCl) NF QL(4 ea daily);

MOWELLBUTRIN SR 150 MG,200 MG (Use BupropionHCl)

NFQL(2 ea daily);MO

WELLBUTRIN XL 150 MG(Use Bupropion HCl) NF QL(3 ea daily);

MOWELLBUTRIN XL 300 MG(Use Bupropion HCl) NF QL(1 ea daily);

MOMonoamine Oxidase Inhibitors (MAOIs)EMSAM 5 MO

MARPLAN 4 MO

NARDIL (Use PhenelzineSulfate) NF MO

PARNATE (UseTranylcypromine Sulfate) NF MO

phenelzine sulfate tabs or 4 MO

tranylcypromine sulfate 3 MO

Selective Serotonin Reuptake Inhibitors (SSRIs)CELEXA 10 MG (UseCitalopram Hydrobromide) NF QL(4 ea daily);

MOCELEXA 20 MG (UseCitalopram Hydrobromide) NF QL(2 ea daily);

MOCELEXA 40 MG (UseCitalopram Hydrobromide) NF QL(1 ea daily);

MOcitalopram hydrobromidesoln 10 mg/5ml 4 QL(20 ml

daily); MOcitalopram hydrobromidetabs 10 mg 1 QL(4 ea daily);

MO; *citalopram hydrobromidetabs 20 mg 1 QL(2 ea daily);

MO; *citalopram hydrobromidetabs 40 mg 1 QL(1 ea daily);

MO; *

escitalopram oxalate 3 MO

fluoxetine hcl caps or 10mg, 20 mg, 40 mg 2 MO; *



19

Drug Name DrugTier

Requirements/Limits

fluoxetine hcl cpdr or 90mg 2 MO; *

fluoxetine hcl soln or 20mg/5ml 2 MO; *

fluoxetine hcl tabs or 10mg, 20 mg 2 MO; *

FLUOXETINE HCL TABSOR 60 MG 4 MO

fluvoxamine maleate cp24100 mg, 150 mg 3 MO

fluvoxamine maleate tabs100 mg, 25 mg, 50 mg 2 MO; *

LEXAPRO (UseEscitalopram Oxalate) NF MO

LUVOX CR (UseFluvoxamine Maleate) NF MO

paroxetine hcl 2 MO; *

PAXIL CR (Use ParoxetineHCl) NF MO

PAXIL SUSP 10 MG/5ML 4 MO

PAXIL TABS 10 MG, 20MG, 30 MG, 40 MG (UseParoxetine HCl)

NFMO

PEXEVA 4 ST; MO

PROZAC (Use FluoxetineHCl) NF MO

PROZAC WEEKLY (UseFluoxetine HCl) NF MO

sertraline hcl conc or 20mg/ml 2 MO; *

sertraline hcl tabs or 100mg, 25 mg, 50 mg 1 MO; *

ZOLOFT (Use SertralineHCl) NF MO

Serotonin Modulators

BRINTELLIX 10 MG 4 ST; QL(2 eadaily); MO



nefazodone hcl 2 MO; *

Drug Name DrugTier

Requirements/Limits

OLEPTRO 4 MO

trazodone hcl tabs or 100mg, 150 mg, 300 mg, 50mg

1MO; *

VIIBRYD 4 ST; MO

VIIBRYD STARTER PACK 4 ST

Serotonin-Norepinephrine Reuptake InhibitorsCYMBALTA (UseDuloxetine HCl) NF MO

DESVENLAFAXINE ER100 MG, 50 MG 4 ST; Fumarate

DESVENLAFAXINE ER100 MG, 50 MG 4 ST; MO

duloxetine hcl 20 mg, 30mg, 60 mg 3 MO

EFFEXOR XR 150 MG(Use Venlafaxine HCl) NF QL(1 ea daily);

MOEFFEXOR XR 37.5 MG(Use Venlafaxine HCl) NF QL(6 ea daily);

MOEFFEXOR XR 75 MG (UseVenlafaxine HCl) NF QL(3 ea daily);

MOFETZIMA 120 MG, 40 MG,80 MG 4 ST; QL(1 ea

daily); MO

FETZIMA 20 MG 4 ST; QL(2 eadaily); MO

FETZIMA TITRATIONPACK 4 ST; MO

KHEDEZLA 4 ST; MO

PRISTIQ 4 ST; MO

venlafaxine hcl cp24 150mg 3 QL(1 ea daily);

MOvenlafaxine hcl cp24 37.5mg 3 QL(6 ea daily);

MO

venlafaxine hcl cp24 75 mg 3 QL(3 ea daily);MO

VENLAFAXINE HCL ER 4 ST; QL(1 eadaily); MO

venlafaxine hcl tabs 100mg 2 QL(3.5 ea

daily); MO; *

venlafaxine hcl tabs 25 mg 2 QL(15 eadaily); MO; *



20

Drug Name DrugTier

Requirements/Limits

venlafaxine hcl tabs 37.5mg 2 QL(10 ea

daily); MO; *

venlafaxine hcl tabs 50 mg 2 QL(7.5 eadaily); MO; *

venlafaxine hcl tabs 75 mg 2 QL(5 ea daily);MO; *

venlafaxine hcl tb24 150mg 2 QL(1 ea daily);

MO; *venlafaxine hcl tb24 37.5mg 2 QL(6 ea daily);

MO; *

venlafaxine hcl tb24 75 mg 2 QL(3 ea daily);MO; *

Tricyclic Agentsamitriptyline hcl 2 AL; MO; *

amoxapine 100 mg, 25 mg,50 mg 1 MO; *

amoxapine 150 mg 2 MO; *

ANAFRANIL (UseClomipramine HCl) NF AL; MO

clomipramine hcl caps or25 mg, 50 mg 3 AL; MO

clomipramine hcl caps or75 mg 2 AL; MO; *

desipramine hcl tabs or 10mg, 100 mg, 150 mg, 25mg, 50 mg, 75 mg

4MO

doxepin hcl caps or 10 mg,100 mg, 150 mg, 25 mg, 50mg, 75 mg

2AL; MO; *

doxepin hcl conc or 10mg/ml 2 AL; MO; *

imipramine hcl tabs or 10mg, 25 mg, 50 mg 2 AL; MO; *

imipramine pamoate 4 AL; MO

NORPRAMIN (UseDesipramine HCl) NF MO

nortriptyline hcl caps or 10mg, 25 mg, 50 mg, 75 mg 1 MO; *

nortriptyline hcl soln or 10mg/5ml 2 MO; *

PAMELOR (UseNortriptyline HCl) NF MO

Drug Name DrugTier

Requirements/Limits

protriptyline hcl 1 MO; *

SURMONTIL (UseTrimipramine Maleate) 4 AL; MO

TOFRANIL-PM (UseImipramine Pamoate) NF AL; MO

trimipramine maleate capsor 100 mg 2 AL; MO; *

trimipramine maleate capsor 25 mg, 50 mg 4 AL; MO

ANTIDIABETICS - Drugs to Regulate Blood Sugar

Alpha-Glucosidase Inhibitors

acarbose 6 QL(3 ea daily);MO; *

GLYSET 6 QL(3 ea daily);MO; *

PRECOSE (Use Acarbose) NF QL(3 ea daily);MO

Antidiabetic - Amylin Analogs

SYMLINPEN 120 4 QL(0.4 mldaily); MO

SYMLINPEN 60 4 QL(0.4 mldaily); MO

Antidiabetic CombinationsACTOPLUS MET (UsePioglitazone HCl-MetforminHCl)

NFQL(3 ea daily);MO

ACTOPLUS MET XR15MG-1000MG 6 QL(2 ea daily);

MO; *ACTOPLUS MET XR30MG-1000MG 6 QL(1 ea daily);

MO; *AVANDAMET 2MG-1000MG 6 QL(2 ea daily);

LA; MO; *

AVANDAMET 2MG-500MG 6 QL(4 ea daily);LA; *

AVANDAMET 4MG-1000MG, 4MG-500MG 6 QL(2 ea daily);

LA; *AVANDARYL 4MG-1MG,4MG-2MG 6 QL(2 ea daily);

LA; *AVANDARYL 4MG-4MG,8MG-4MG 6 QL(1 ea daily);

LA; MO; *

AVANDARYL 8MG-2MG 6 QL(1 ea daily);LA; *



21

Drug Name DrugTier

Requirements/Limits

DUETACT (UsePioglitazone HCl-Glimepiride)

NFQL(1.5 eadaily); MO

glipizide-metformin hcl2.5mg-250mg 6 QL(8 ea daily);

MO; *glipizide-metformin hcl2.5mg-500mg, 5mg-500mg 6 QL(4 ea daily);

MO; *GLUCOVANCE 1.25MG-250MG (Use Glyburide-Metformin)

NFAL; QL(8 eadaily); MO

GLUCOVANCE 2.5MG-500MG, 5MG-500MG (UseGlyburide-Metformin)

NFAL; QL(4 eadaily); MO

glyburide-metformin1.25mg-250mg 2 AL; QL(8 ea

daily); MO; *glyburide-metformin 2.5mg-500mg, 5mg-500mg 2 AL; QL(4 ea

daily); MO; *INVOKAMET 150MG-1000MG, 150MG-500MG,50MG-1000MG

3QL(2 ea daily);MO

INVOKAMET 50MG-500MG 3 QL(4 ea daily);

MO

JANUMET 6 QL(2 ea daily);MO; *

JANUMET XR 100MG-1000MG 6 QL(1 ea daily);

MO; *JANUMET XR 50MG-1000MG, 50MG-500MG 6 QL(2 ea daily);

MO; *

JENTADUETO 6 QL(2 ea daily);MO; *

KAZANO 3 QL(2 ea daily);MO

KOMBIGLYZE XR 2.5MG-1000MG 3 QL(2 ea daily);

MOKOMBIGLYZE XR 5MG-1000MG, 5MG-500MG 3 QL(1 ea daily);

MO

OSENI 12.5MG-15MG 3 QL(2 ea daily);MO

OSENI 12.5MG-30MG,12.5MG-45MG, 25MG-15MG, 25MG-30MG,25MG-45MG

3

QL(1 ea daily);MO

pioglitazone hcl-glimepiride 6 QL(1.5 eadaily); MO; *

pioglitazone hcl-metforminhcl 6 QL(3 ea daily);

MO; *

Drug Name DrugTier

Requirements/Limits

PRANDIMET 6 QL(5 ea daily);MO; *

XIGDUO XR 10MG-1000MG, 10MG-500MG 4 QL(1 ea daily);

MOXIGDUO XR 5MG-1000MG, 5MG-500MG 4 QL(2 ea daily);

MOBiguanidesFORTAMET 1000 MG (UseMetformin HCl) NF Osmotic;QL(2

ea daily); MOFORTAMET 500 MG (UseMetformin HCl) NF Osmotic;QL(5

ea daily); MOGLUCOPHAGE 1000 MG(Use Metformin HCl) NF QL(2.5 ea

daily); MOGLUCOPHAGE 500 MG(Use Metformin HCl) NF QL(5 ea daily);

MOGLUCOPHAGE 850 MG(Use Metformin HCl) NF QL(3 ea daily);

MOGLUCOPHAGE XR 500MG (Use Metformin HCl) NF QL(4 ea daily);

MOGLUCOPHAGE XR 750MG (Use Metformin HCl) NF QL(2 ea daily);

MO

GLUMETZA 1000 MG 6 QL(2 ea daily);MO; *

GLUMETZA 500 MG 6 QL(4 ea daily);MO; *

metformin hcl tabs or 1000mg 6 QL(2.5 ea

daily); MO; *metformin hcl tabs or 500mg 6 QL(5 ea daily);

MO; *metformin hcl tabs or 850mg 6 QL(3 ea daily);

MO; *metformin hcl tb24 or 1000mg 6 Osmotic;QL(2

ea daily); MO; *metformin hcl tb24 or 500mg 6 QL(4 ea daily);

MO; *metformin hcl tb24 or 500mg 6 Osmotic;QL(5

ea daily); MO; *metformin hcl tb24 or 750mg 6 QL(2 ea daily);

MO; *

RIOMET 6 QL(25.5 mldaily); MO; *

Diabetic OtherGLUCAGEN HYPOKIT 3 MO



22

Drug Name DrugTier

Requirements/Limits

glucagon (rdna) 1 MO; *

PROGLYCEM 4 MO

Dipeptidyl Peptidase-4 (DPP-4) InhibitorsJANUVIA 6 MO; *

NESINA 3 MO

ONGLYZA 3 MO

TRADJENTA 6 MO; *

Dopamine Receptor Agonists - Antidiabetic

CYCLOSET 4 QL(6 ea daily);MO

Incretin Mimetic Agents (GLP-1 ReceptorBYDUREON 6 ST; MO; *

BYETTA 6 ST; MO; *

TANZEUM 4 ST; MO

TRULICITY 4 ST; MO

VICTOZA 6 ST; MO; *

Insulin Sensitizing AgentsACTOS 15 MG (UsePioglitazone HCl) NF QL(3 ea daily);

MOACTOS 30 MG, 45 MG(Use Pioglitazone HCl) NF QL(1 ea daily);

MO

AVANDIA 2 MG 6 QL(4 ea daily);LA; MO; *



pioglitazone hcl 15 mg 6 QL(3 ea daily);MO; *

pioglitazone hcl 30 mg, 45mg 6 QL(1 ea daily);

MO; *Insulin

AFREZZA 4 QL(3 ea daily);MO

Drug Name DrugTier

Requirements/Limits

APIDRA 4 QL(1.5 mldaily); MO

APIDRA SOLOSTAR 4 QL(1.5 mldaily); MO

HUMALOG 3 QL(1.5 mldaily); MO

HUMALOG KWIKPEN 3 QL(1.5 mldaily); MO

HUMALOG MIX 50/50 3 QL(1.5 mldaily); MO

HUMALOG MIX 50/50KWIKPEN 3 QL(1.5 ml

daily); MO

HUMALOG MIX 75/25 3 QL(1.5 mldaily); MO

HUMALOG MIX 75/25KWIKPEN 3 QL(1.5 ml

daily); MO

HUMULIN 70/30 3 QL(1.5 mldaily); MO

HUMULIN 70/30 KWIKPEN 3 QL(1.5 mldaily); MO

HUMULIN 70/30 PEN 3 QL(1.5 mldaily); MO

HUMULIN N 3 QL(1.5 mldaily); MO

HUMULIN N KWIKPEN 3 QL(1.5 mldaily); MO

HUMULIN N U-100 PEN 3 QL(1.5 mldaily); MO

HUMULIN R 3 QL(1.5 mldaily); MO

HUMULIN R U-500(CONCENTRATED) 3 QL(1.5 ml

daily); MO

LANTUS 3 QL(1.5 mldaily); MO

LANTUS SOLOSTAR 3 QL(1.5 mldaily); MO

LEVEMIR 3 QL(1.5 mldaily); MO

LEVEMIR FLEXPEN 3 QL(1.5 mldaily); MO

LEVEMIR FLEXTOUCH 3 QL(1.5 mldaily); MO

NOVOLIN 70/30 4 QL(1.5 mldaily); MO

NOVOLIN 70/30 RELION 4 QL(1.5 mldaily); MO



23

Drug Name DrugTier

Requirements/Limits

NOVOLIN N 4 QL(1.5 mldaily); MO

NOVOLIN N RELION 4 QL(1.5 mldaily); MO

NOVOLIN R 4 QL(1.5 mldaily); MO

NOVOLIN R RELION 4 QL(1.5 mldaily); MO

NOVOLOG 4 QL(1.5 mldaily); MO

NOVOLOG FLEXPEN 4 QL(1.5 mldaily); MO

NOVOLOG MIX 70/30 4 QL(1.5 mldaily); MO

NOVOLOG MIX 70/30PREFILLED FLEXPEN 4 QL(1.5 ml

daily); MO

NOVOLOG PENFILL 4 QL(1.5 mldaily); MO

TOUJEO SOLOSTAR 3Limit 15mL permonth;QL(0.5ml daily); MO

Meglitinide Analogues

nateglinide 6 QL(3 ea daily);MO; *

PRANDIN 0.5 MG (UseRepaglinide) NF QL(32 ea

daily); MOPRANDIN 1 MG (UseRepaglinide) NF QL(16 ea

daily); MOPRANDIN 2 MG (UseRepaglinide) NF QL(8 ea daily);

MO

repaglinide 0.5 mg 6 QL(32 eadaily); MO; *

repaglinide 1 mg 6 QL(16 eadaily); MO; *

repaglinide 2 mg 6 QL(8 ea daily);MO; *

STARLIX (Use Nateglinide) NF QL(3 ea daily);MO

Sodium-Glucose Co-Transporter 2 (SGLT2)FARXIGA 4 MO

INVOKANA 3 MO

JARDIANCE 10 MG 3 QL(2 ea daily);MO

Drug Name DrugTier

Requirements/Limits

JARDIANCE 25 MG 3 QL(1 ea daily);MO

SulfonylureasAMARYL 1 MG (UseGlimepiride) NF QL(8 ea daily);

MOAMARYL 2 MG (UseGlimepiride) NF QL(4 ea daily);

MOAMARYL 4 MG (UseGlimepiride) NF QL(2 ea daily);

MO

chlorpropamide 100 mg 2 AL; QL(7.5 eadaily); MO; *

chlorpropamide 250 mg 2 AL; QL(3 eadaily); MO; *

DIABETA 1.25 MG (UseGlyburide) 4 AL; QL(16 ea

daily); MODIABETA 2.5 MG (UseGlyburide) 4 AL; QL(8 ea

daily); MODIABETA 5 MG (UseGlyburide) 4 AL; QL(4 ea

daily); MO

glimepiride 1 mg 6 QL(8 ea daily);MO; *



glipizide tabs or 10 mg 6 QL(4 ea daily);MO; *

glipizide tabs or 5 mg 6 QL(8 ea daily);MO; *

glipizide tb24 or 10 mg 6 QL(2 ea daily);MO; *

glipizide tb24 or 2.5 mg 6 QL(8 ea daily);MO; *

glipizide tb24 or 5 mg 6 QL(4 ea daily);MO; *

GLUCOTROL 10 MG (UseGlipizide) NF QL(4 ea daily);

MOGLUCOTROL 5 MG (UseGlipizide) NF QL(8 ea daily);

MOGLUCOTROL XL 10 MG(Use Glipizide) NF QL(2 ea daily);

MOGLUCOTROL XL 2.5 MG(Use Glipizide) NF QL(8 ea daily);

MOGLUCOTROL XL 5 MG(Use Glipizide) NF QL(4 ea daily);

MO



24

Drug Name DrugTier

Requirements/Limits

glyburide 1.25 mg 2 AL; QL(16 eadaily); MO; *

glyburide 2.5 mg 2 AL; QL(8 eadaily); MO; *

glyburide 5 mg 2 AL; QL(4 eadaily); MO; *

glyburide micronized 1.5mg 2 AL; QL(8 ea

daily); MO; *

glyburide micronized 3 mg 2 AL; QL(4 eadaily); MO; *

glyburide micronized 6 mg 2 AL; QL(2 eadaily); MO; *

GLYNASE 1.5 MG (UseGlyburide Micronized) NF AL; QL(8 ea

daily); MOGLYNASE 3 MG (UseGlyburide Micronized) NF AL; QL(4 ea

daily); MOGLYNASE 6 MG (UseGlyburide Micronized) NF AL; QL(2 ea

daily); MO

tolazamide 250 mg 6 QL(4 ea daily);MO; *

tolazamide 500 mg 6 QL(2 ea daily);MO; *

tolbutamide 6 QL(6 ea daily);MO; *

ANTIDIARRHEALS - Drugs to Treat Diarrhea

Antidiarrheal - Chloride Channel Antagonists

FULYZAQ 4 PA; QL(2 eadaily); MO

Antiperistaltic Agentsdiphenoxylate w/ atropine 2 MO; *

LOMOTIL (UseDiphenoxylate w/ Atropine) NF MO

loperamide hcl caps or 2mg 2 RX/OTC; MO; *

MOTOFEN 4 MO

opium tincture 5 MO

ANTIDOTES - Drugs to Treat Overdose orToxicityAntidotes - Chelating AgentsCHEMET 4 MO

Drug Name DrugTier

Requirements/Limits

EXJADE 5 LA

JADENU 5

Opioid AntagonistsEVZIO 4 PA; MO

naloxone hcl soln ij 1 mg/ml 2 MO; *

naltrexone hcl tabs or 1 MO; *

ANTIEMETICS - Drugs to Treat Nausea andVomiting5-HT3 Receptor Antagonistsgranisetron hcl tabs or 1mg 3 MO; B/D

ondansetron 2 MO; B/D; *

ondansetron hcl soln ij 4mg/2ml 3 MO

ondansetron hcl soln ij 40mg/20ml 2 MO; *

ondansetron hcl soln or 4mg/5ml 2 MO; B/D; *

ondansetron hcl tabs or 24mg, 4 mg, 8 mg 2 MO; B/D; *

SANCUSO 5 MO

ZOFRAN ODT (UseOndansetron) NF MO; B/D

ZOFRAN SOLN IJ 40MG/20ML (UseOndansetron HCl)

NFMO

ZOFRAN SOLN OR 4MG/5ML (Use OndansetronHCl)

NFMO; B/D

ZOFRAN TABS OR 4 MG,8 MG (Use OndansetronHCl)

NFMO; B/D

Antiemetics - Anticholinergicdimenhydrinate soln ij 50mg/ml 2 *

meclizine hcl tabs 12.5 mg,25 mg 2 RX/OTC; MO; *

TIGAN 300 MG (UseTrimethobenzamide HCl) NF AL; MO



25

Drug Name DrugTier

Requirements/Limits

TRANSDERM-SCOP 4 MO

trimethobenzamide hclcaps or 300 mg 2 AL; MO; *

trimethobenzamide hcl solnim 100 mg/ml 1 AL; MO; *

Antiemetics - MiscellaneousAKYNZEO 4 MO; B/D

CESAMET 4 MO; B/D

dronabinol 10 mg 5 MO; B/D

dronabinol 2.5 mg 2 MO; B/D; *

dronabinol 5 mg 4 MO; B/D

MARINOL 10 MG, 5 MG(Use Dronabinol) 5 MO; B/D

MARINOL 2.5 MG (UseDronabinol) NF MO; B/D

Substance P/Neurokinin 1 (NK1) ReceptorEMEND CAPS OR 125MG, 80 MG 4 MO; B/D

EMEND CAPS OR 40 MG 4 PA; MO

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungal - Glucan Synthesis InhibitorsERAXIS 100 MG 4

MYCAMINE 100 MG 5 MO

AntifungalsABELCET 5

AMBISOME 5

amphotericin b solr ij 50 mg 1 MO; *

ANCOBON (UseFlucytosine) NF MO

flucytosine 2 MO; *

GRIS-PEG (UseGriseofulvin Ultramicrosize) NF MO

Drug Name DrugTier

Requirements/Limits

griseofulvin microsize susp125 mg/5ml 2 MO; *

griseofulvin microsize tabs500 mg 3 MO

griseofulvin ultramicrosize125 mg 1 MO; *

griseofulvin ultramicrosize250 mg 3 MO

LAMISIL PACK 125 MG,187.5 MG 3 PA; MO

LAMISIL TABS 250 MG(Use Terbinafine HCl) NF MO

nystatin tabs or 1 MO; *

terbinafine hcl tabs or 2 MO; *

Imidazole-Related AntifungalsCRESEMBA CAPS OR186 MG 5 MO

CRESEMBA SOLR IV 372MG 5

DIFLUCAN (UseFluconazole) NF MO

fluconazole in dextrose 2 *

fluconazole in nacl 1 *

fluconazole susr or 10mg/ml 2 MO; *

fluconazole susr or 40mg/ml 3 MO

fluconazole tabs or 100 mg,150 mg, 200 mg, 50 mg 1 MO; *

itraconazole caps or 4 MO

ketoconazole tabs or 2 MO; *

NOXAFIL SOLN IV 300MG/16.7ML 5

NOXAFIL SUSP OR 40MG/ML 5 MO

NOXAFIL TBEC OR 100MG 5 MO

ONMEL 4 MO

SPORANOX CAPS 100MG (Use Itraconazole) NF MO



26

Drug Name DrugTier

Requirements/Limits

SPORANOX PULSEPAK(Use Itraconazole) NF MO

SPORANOX SOLN 10MG/ML 5 MO

VFEND IV (UseVoriconazole) NF

VFEND TABS 200 MG, 50MG (Use Voriconazole) 5 MO

voriconazole solr iv 200 mg 2 *

voriconazole tabs or 200mg, 50 mg 5 MO

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Ethanolaminescarbinoxamine maleate 2 AL; MO; *

clemastine fumarate syrpor 0.67 mg/5ml 2 AL; *

clemastine fumarate tabsor 2.68 mg 2 AL; MO; *

diphenhydramine hcl soln ij50 mg/ml 1 AL; MO; *

Antihistamines - Non-Sedatingcetirizine hcl soln 1 mg/ml 1 RX/OTC; MO; *

cetirizine hcl syrp 1 mg/ml,5 mg/5ml 1 RX/OTC; MO; *

CLARINEX REDITABS 5MG (Use Desloratadine) NF MO

CLARINEX TABS 5 MG(Use Desloratadine) NF MO

desloratadine tabs 5 mg 3 MO

desloratadine tbdp 5 mg 3 MO

levocetirizinedihydrochloride soln 2.5mg/5ml

3MO

levocetirizinedihydrochloride tabs 5 mg 2 MO; *

XYZAL (Use LevocetirizineDihydrochloride) NF MO

Antihistamines - Phenothiazinespromethazine hcl soln ij 25mg/ml, 50 mg/ml 2 AL; MO; *

Drug Name DrugTier

Requirements/Limits

promethazine hcl soln or6.25 mg/5ml 2 AL; MO; *

promethazine hcl supp re12.5 mg, 25 mg, 50 mg 2 AL; MO; *

promethazine hcl syrp or6.25 mg/5ml 2 AL; MO; *

promethazine hcl tabs or12.5 mg, 25 mg, 50 mg 2 AL; MO; *

Antihistamines - Piperidinescyproheptadine hcl syrp or2 mg/5ml 2 AL; MO; *

cyproheptadine hcl tabs or4 mg 2 AL; MO; *

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterolAntihyperlipidemics - CombinationsLIPTRUZET 3

VYTORIN 10MG-10MG 3 QL(8 ea daily);MO



VYTORIN 80MG-10MG 3 PA; QL(1 eadaily); MO

Antihyperlipidemics - Misc.KYNAMRO 5 PA; LA

LOVAZA (Use Omega-3-acid Ethyl Esters) 4 MO

omega-3-acid ethyl esters 2 MO; *

VASCEPA 4 MO

Bile Acid Sequestrantscholestyramine light 1 MO; *

cholestyramine pack or 4gm 2 MO; *

cholestyramine powd or 4gm/dose 2 Powder

Canister;MO; *COLESTID (Use ColestipolHCl) NF MO



27

Drug Name DrugTier

Requirements/Limits

COLESTID FLAVOREDGRAN 5 GM (UseColestipol HCl)

NFMO

colestipol hcl gran 5 gm 1 MO; *

colestipol hcl pack 5 gm 2 MO; *

colestipol hcl tabs 1 gm 1 MO; *

WELCHOL 4 MO

Fibric Acid DerivativesANTARA 130 MG (UseFenofibrate Micronized) NF QL(1 ea daily);

MO

ANTARA 30 MG 4 QL(3 ea daily);MO

ANTARA 43 MG (UseFenofibrate Micronized) NF QL(3 ea daily);

MO

ANTARA 90 MG 4 QL(1 ea daily);MO

choline fenofibrate 2 MO; *

FENOFIBRATE CAPS 150MG, 50 MG 4 MO

fenofibrate micronized 130mg 2 QL(1 ea daily);

MO; *fenofibrate micronized 134mg, 200 mg, 67 mg 1 MO; *

fenofibrate micronized 43mg 2 QL(3 ea daily);

MO; *FENOFIBRATE TABS 120MG, 40 MG 4 MO

fenofibrate tabs 145 mg, 48mg 2 MO; *

fenofibrate tabs 160 mg, 54mg 1 MO; *

FENOGLIDE 4 MO

gemfibrozil tabs or 1 MO; *

LIPOFEN 4 MO

LOPID (Use Gemfibrozil) NF MO

TRICOR (Use Fenofibrate) NF MO

Drug Name DrugTier

Requirements/Limits

TRILIPIX (Use CholineFenofibrate) NF MO

HMG CoA Reductase InhibitorsADVICOR 4 MO

ALTOPREV 4 MO

atorvastatin calcium 6 MO; *

CRESTOR 4 ST; MO

fluvastatin sodium caps 20mg, 40 mg 6 MO; *

fluvastatin sodium tb24 80mg 2 MO; *

LESCOL (Use FluvastatinSodium) NF MO

LESCOL XL (UseFluvastatin Sodium) 4 MO

LIPITOR (Use AtorvastatinCalcium) NF MO

LIVALO 4 MO

lovastatin 6 MO; *

MEVACOR (UseLovastatin) NF MO

PRAVACHOL (UsePravastatin Sodium) NF MO

pravastatin sodium 6 MO; *

SIMCOR 20MG-1000MG,20MG-500MG, 20MG-750MG

4QL(2 ea daily);MO

SIMCOR 40MG-1000MG,40MG-500MG 4 QL(1 ea daily);

MO

simvastatin tabs or 10 mg 6 QL(8 ea daily);MO; *



simvastatin tabs or 5 mg 6 QL(16 eadaily); MO; *




28

Drug Name DrugTier

Requirements/Limits

ZOCOR 10 MG (UseSimvastatin) NF QL(8 ea daily);

MOZOCOR 20 MG (UseSimvastatin) NF QL(4 ea daily);

MOZOCOR 40 MG (UseSimvastatin) NF QL(2 ea daily);

MOZOCOR 5 MG (UseSimvastatin) NF QL(16 ea

daily); MOZOCOR 80 MG (UseSimvastatin) NF QL(1 ea daily);

MOIntestinal Cholesterol Absorption InhibitorsZETIA 3 MO

Microsomal Triglyceride Transfer Protein (MTP)

JUXTAPID 10 MG 5 PA; QL(6 eadaily); LA



JUXTAPID 40 MG, 60 MG 5 PA; QL(1 eadaily); LA


Nicotinic Acid Derivativesniacin (antihyperlipidemic) 2 MO; *

NIASPAN (Use Niacin(Antihyperlipidemic)) NF MO

Proprotein Convertase Subtilisin/Kexin Type 9PRALUENT SOPN 150MG/ML 5 PA; QL(0.08 ml

daily); MOPRALUENT SOPN 75MG/ML 5 PA; QL(0.15 ml

daily); MOPRALUENT SOSY 150MG/ML 5 PA; QL(0.08 ml

daily); MOPRALUENT SOSY 75MG/ML 5 PA; QL(0.15 ml

daily); MOANTIHYPERTENSIVES - Drugs to Treat HighBlood PressureACE InhibitorsACCUPRIL (Use QuinaprilHCl) NF MO

Drug Name DrugTier

Requirements/Limits

ACEON 4 MG (UsePerindopril Erbumine) NF QL(4 ea daily);

MOACEON 8 MG (UsePerindopril Erbumine) NF QL(2 ea daily);

MO

ALTACE (Use Ramipril) NF MO

benazepril hcl tabs or 10mg, 20 mg, 40 mg, 5 mg 6 MO; *

captopril tabs or 100 mg,12.5 mg, 25 mg, 50 mg 6 MO; *

enalapril maleate tabs or10 mg 6 QL(4 ea daily);

MO; *enalapril maleate tabs or2.5 mg 6 QL(16 ea

daily); MO; *enalapril maleate tabs or20 mg 6 QL(2 ea daily);

MO; *enalapril maleate tabs or 5mg 6 QL(8 ea daily);

MO; *

enalaprilat 6 *

fosinopril sodium 6 MO; *

lisinopril tabs or 10 mg, 2.5mg, 20 mg, 30 mg, 40 mg,5 mg

6MO; *

LOTENSIN (UseBenazepril HCl) NF MO

MAVIK (Use Trandolapril) NF MO

moexipril hcl 6 MO; *

perindopril erbumine 2 mg 6 QL(8 ea daily);MO; *



PRINIVIL (Use Lisinopril) NF MO

quinapril hcl 6 MO; *

ramipril 6 MO; *

trandolapril 6 MO; *

UNIVASC (Use MoexiprilHCl) NF MO



29

Drug Name DrugTier

Requirements/Limits

VASOTEC 10 MG (UseEnalapril Maleate) NF QL(4 ea daily);

MOVASOTEC 2.5 MG (UseEnalapril Maleate) NF QL(16 ea

daily); MOVASOTEC 20 MG (UseEnalapril Maleate) NF QL(2 ea daily);

MOVASOTEC 5 MG (UseEnalapril Maleate) NF QL(8 ea daily);

MO

ZESTRIL (Use Lisinopril) NF MO

Agents for PheochromocytomaDEMSER 5 MO

DIBENZYLINE (UsePhenoxybenzamine HCl) 4 MO

phenoxybenzamine hclcaps or 2 MO; *

Angiotensin II Receptor AntagonistsATACAND (UseCandesartan Cilexetil) NF MO

AVAPRO (Use Irbesartan) NF MO

BENICAR 3 MO

candesartan cilexetil 6 MO; *

COZAAR (Use LosartanPotassium) NF MO

DIOVAN (Use Valsartan) 3 MO

EDARBI 4 MO

EPROSARTANMESYLATE 6 MO; *

irbesartan 6 MO; *

losartan potassium 6 MO; *

MICARDIS (UseTelmisartan) 4 MO

telmisartan 2 MO; *

valsartan 6 MO; *

Antiadrenergic AntihypertensivesCARDURA (UseDoxazosin Mesylate) NF MO

Drug Name DrugTier

Requirements/Limits

CATAPRES (Use ClonidineHCl) NF MO

CATAPRES-TTS-1 (UseClonidine HCl) NF MO



clonidine hcl ptwk td 0.1mg/24hr, 0.2 mg/24hr, 0.3mg/24hr

1MO; *

clonidine hcl tabs or 0.1mg, 0.2 mg, 0.3 mg 1 MO; *

doxazosin mesylate 1 MO; *

guanfacine hcl 2 AL; MO; *

methyldopa 2 AL; MO; *

MINIPRESS (Use PrazosinHCl) NF MO

prazosin hcl 1 MO; *

reserpine tabs or 0.1 mg,0.25 mg 2 MO; *

TENEX (Use GuanfacineHCl) NF AL; MO

terazosin hcl 1 MO; *

Antihypertensive CombinationsACCURETIC (UseQuinapril-Hydrochlorothiazide)

NFMO

amlodipine besylate-benazepril hcl 6 MO; *

amlodipine besylate-valsartan 2 MO; *

amlodipine-valsartan-hydrochlorothiazide 2 MO; *

AMTURNIDE 300MG-10MG-12.5MG, 300MG-10MG-25MG

3

AMTURNIDE 300MG-5MG-12.5MG, 300MG-5MG-25MG

3MO



30

Drug Name DrugTier

Requirements/Limits

ATACAND HCT (UseCandesartan Cilexetil-Hydrochlorothiazide)

NFMO

atenolol & chlorthalidone 1 MO; *

AVALIDE (Use Irbesartan-Hydrochlorothiazide) NF MO

AZOR 3 MO

benazepril &hydrochlorothiazide 6 MO; *

BENICAR HCT 3 MO

bisoprolol &hydrochlorothiazide 1 MO; *

candesartan cilexetil-hydrochlorothiazide 6 MO; *

CAPTOPRIL/HYDROCHLOROTHIAZIDE 6 MO; *

CORZIDE (Use Nadolol &Bendroflumethiazide) NF MO

DIOVAN HCT (UseValsartan-Hydrochlorothiazide)

NFMO

EDARBYCLOR 4 MO

enalapril maleate &hydrochlorothiazide 6 MO; *

EXFORGE (UseAmlodipine Besylate-Valsartan)

3MO

EXFORGE HCT (UseAmlodipine-Valsartan-Hydrochlorothiazide)

3MO

fosinopril sodium &hydrochlorothiazide 6 MO; *

HYZAAR (Use LosartanPotassium &Hydrochlorothiazide)

NFMO

irbesartan-hydrochlorothiazide 6 MO; *

lisinopril &hydrochlorothiazide 6 MO; *

LOPRESSOR HCT (UseMetoprolol &Hydrochlorothiazide)

NFMO

Drug Name DrugTier

Requirements/Limits

losartan potassium &hydrochlorothiazide 6 MO; *

LOTENSIN HCT (UseBenazepril &Hydrochlorothiazide)

NFMO

LOTREL (Use AmlodipineBesylate-Benazepril HCl) NF MO

methyldopa &hydrochlorothiazide 2 AL; MO; *

metoprolol &hydrochlorothiazide100mg-25mg, 50mg-25mg

1MO; *

metoprolol &hydrochlorothiazide100mg-50mg

2MO; *

MICARDIS HCT (UseTelmisartan-Hydrochlorothiazide)

4MO

moexipril-hydrochlorothiazide 6 MO; *

nadolol &bendroflumethiazide 40mg-5mg

1MO; *

nadolol &bendroflumethiazide 80mg-5mg

2MO; *

quinapril-hydrochlorothiazide 6 MO; *

TEKAMLO 150MG-10MG 3 MO

TEKAMLO 150MG-5MG 3

TEKTURNA HCT 3 MO

telmisartan-amlodipine 2 MO; *

telmisartan-hydrochlorothiazide 2 MO; *

TENORETIC 100 (UseAtenolol & Chlorthalidone) NF MO

TENORETIC 50 (UseAtenolol & Chlorthalidone) NF MO

TRIBENZOR 3 MO

TWYNSTA (UseTelmisartan-Amlodipine) 4 MO



31

Drug Name DrugTier

Requirements/Limits

UNIRETIC (Use Moexipril-Hydrochlorothiazide) NF MO

valsartan-hydrochlorothiazide 6 MO; *

VASERETIC (Use EnalaprilMaleate &Hydrochlorothiazide)

NFMO

ZESTORETIC (UseLisinopril &Hydrochlorothiazide)

NFMO

ZIAC (Use Bisoprolol &Hydrochlorothiazide) NF MO

Direct Renin InhibitorsTEKTURNA 3 MO

Selective Aldosterone Receptor Antagonistseplerenone 25 mg 1 MO; *

eplerenone 50 mg 2 MO; *

INSPRA (Use Eplerenone) NF MO

Vasodilatorshydralazine hcl tabs or 10mg, 100 mg, 25 mg, 50 mg 1 MO; *

minoxidil tabs or 10 mg, 2.5mg 1 MO; *

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections)Antimalarial Combinationsatovaquone-proguanil hcl250mg-100mg 3 MO

atovaquone-proguanil hcl62.5mg-25mg 2 MO; *

COARTEM 3 MO

MALARONE 250MG-100MG (Use Atovaquone-Proguanil HCl)

NFMO

MALARONE 62.5MG-25MG (Use Atovaquone-Proguanil HCl)

4MO

AntimalarialsARALEN (Use ChloroquinePhosphate) NF MO

Drug Name DrugTier

Requirements/Limits

chloroquine phosphate tabsor 250 mg, 500 mg 1 MO; *

DARAPRIM 4 MO

hydroxychloroquine sulfatetabs or 2 MO; *

mefloquine hcl 1 MO; *

PLAQUENIL (UseHydroxychloroquineSulfate)

NFMO

PRIMAQUINEPHOSPHATE 4 MO

QUALAQUIN (Use QuinineSulfate) NF PA; MO

quinine sulfate caps or 3 PA; MO

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic Agentsguanidine hcl 2 *

MESTINON TABS 60 MG(Use PyridostigmineBromide)

NFMO

MESTINON TIMESPAN(Use PyridostigmineBromide)

4MO

pyridostigmine bromidetabs or 60 mg 2 MO; *

pyridostigmine bromide tbcror 180 mg 2 MO; *

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections)Anti TB Combinationsisoniazid & rifampin 2 MO; *

RIFATER 4 MO

Antimycobacterial Agentsaminosalicylic acid pack or 2 MO; *

CAPASTAT SULFATE 4

ethambutol hcl tabs or 100mg, 400 mg 1 MO; *



32

Drug Name DrugTier

Requirements/Limits

isoniazid syrp or 50 mg/5ml 2 MO; *

isoniazid tabs or 100 mg,300 mg 1 MO; *

MYAMBUTOL (UseEthambutol HCl) NF MO

MYCOBUTIN (UseRifabutin) 4 MO

PRIFTIN 4 MO

pyrazinamide 1 MO; *

rifabutin 2 MO; *

RIFADIN 300 MG,600 MG(Use Rifampin) NF MO

rifampin caps or 150 mg,300 mg 2 MO; *

rifampin solr iv 600 mg 2 MO; *

SIRTURO 5

TRECATOR 4 MO

ANTINEOPLASTICS AND ADJUNCTIVETHERAPIES - Drugs to Treat CancerAlkylating AgentsALKERAN SOLR IV 50 MG(Use Melphalan HCl) 4

ALKERAN TABS OR 2 MG 4 MO; B/D

BICNU 4

BUSULFEX 4

carboplatin 150 mg/15ml,600 mg/60ml 1 *

carboplatin 450 mg/45ml,50 mg/5ml 1 MO; *

cisplatin 4

CISPLATIN 4

cyclophosphamide solr ij 1gm, 500 mg 1 MO; *

cyclophosphamide tabs or25 mg, 50 mg 1 B/D; *

Drug Name DrugTier

Requirements/Limits

ELOXATIN 100 MG/20ML(Use Oxaliplatin) NF MO

ELOXATIN 50 MG/10ML(Use Oxaliplatin) 5 MO

GLEOSTINE 3

HEXALEN 5 MO

IFEX 1 GM (UseIfosfamide) 4

IFEX 3 GM 4

ifosfamide soln 1 gm/20ml,3 gm/60ml 2 *

ifosfamide solr 1 gm 2 *

IFOSFAMIDE SOLR 3 GM 4

LEUKERAN 4 MO

lomustine 10 mg 1 *

lomustine 100 mg, 40 mg 2 *

melphalan hcl 2 *

MUSTARGEN 4

oxaliplatin soln 100mg/20ml 2 MO; *

oxaliplatin soln 50 mg/10ml 5 MO

oxaliplatin solr 100 mg, 50mg 5

TEMODAR SOLR IV 100MG 5

THIOTEPA SOLR IJ 5

TREANDA 5

YONDELIS 5

ZANOSAR 4 MO

AntimetabolitesALIMTA 100 MG 5



33

Drug Name DrugTier

Requirements/Limits

ALIMTA 500 MG 5 MO

ARRANON 5

azacitidine 5

cladribine 2 MO; *

CLOLAR 4

cytarabine soln 100 mg/ml 1 *

cytarabine soln 20 mg/ml 1 PreservativeFree;MO; *

cytarabine soln 20 mg/ml 2 MO; *

DACOGEN (UseDecitabine) NF

decitabine 2 *

FLUDARA (UseFludarabine Phosphate) 4 MO

fludarabine phosphate soln50 mg/2ml 2 *

fludarabine phosphate solr50 mg 2 MO; *

fluorouracil soln iv 1gm/20ml 4

fluorouracil soln iv 2.5gm/50ml, 500 mg/10ml 4 MO

FOLOTYN 5

GEMCITABINE 5

gemcitabine hcl 1 gm 1 MO; *

gemcitabine hcl 2 gm 5

gemcitabine hcl 200 mg 5 MO

GEMZAR 1 GM (UseGemcitabine HCl) NF MO

GEMZAR 200 MG (UseGemcitabine HCl) 5 MO

mercaptopurine tabs or 2 MO; *

Drug Name DrugTier

Requirements/Limits

methotrexate sodium soln ij1 gm/40ml, 100 mg/4ml,200 mg/8ml, 25 mg/ml, 250mg/10ml, 50 mg/2ml

1

PreservativeFree; *

methotrexate sodium soln ij25 mg/ml 2 *

methotrexate sodium solr ij1 gm 2 *

methotrexate sodium tabsor 10 mg, 15 mg, 2.5 mg 1 MO; *

methotrexate sodium tabsor 5 mg, 7.5 mg 2 MO; *

PURINETHOL (UseMercaptopurine) NF MO

PURIXAN 5

TABLOID 3 MO

VIDAZA (Use Azacitidine) 5

Antineoplastic - Angiogenesis InhibitorsAVASTIN 5

CYRAMZA 5 LA

ZALTRAP 5

Antineoplastic - AntibodiesARZERRA 5

BLINCYTO 5 PA

ERBITUX 5

GAZYVA 5 LA

HERCEPTIN 5

KADCYLA 5

KEYTRUDA 5

OPDIVO 5

PERJETA 5

RITUXAN 5



34

Drug Name DrugTier

Requirements/Limits

VECTIBIX 5

YERVOY 5

Antineoplastic - Hedgehog Pathway InhibitorsERIVEDGE 5 LA

ODOMZO 5 PA

Antineoplastic - Hormonal and Related Agentsanastrozole tabs or 2 MO; *

ARIMIDEX (UseAnastrozole) NF MO

AROMASIN (UseExemestane) NF MO

bicalutamide 2 MO; *

CASODEX (UseBicalutamide) NF MO

DEPO-PROVERA 4 MO

ELIGARD 4

EMCYT 4 MO

exemestane 3 MO

FARESTON 5 MO

FASLODEX 5 MO

FEMARA (Use Letrozole) NF MO

FIRMAGON 120 MG 5

FIRMAGON 80 MG 4

flutamide 3 MO

letrozole 2 MO; *

leuprolide acetate kit ij 1 *

LUPRON DEPOT 5

LYSODREN 3 MO

Drug Name DrugTier

Requirements/Limits

MEGACE ORAL (UseMegestrol Acetate) NF AL; MO

megestrol acetate susp or40 mg/ml, 400 mg/10ml 2 AL; MO; *

megestrol acetate tabs or20 mg, 40 mg 2 AL; MO; *

NILANDRON 5 MO

SOLTAMOX 4 MO

tamoxifen citrate tabs or 10mg, 20 mg 2 MO; *

TRELSTAR 5

TRELSTAR MIXJECT 5

VANTAS 5

XTANDI 5 PA; LA

ZOLADEX 4

ZYTIGA 5

Antineoplastic - ImmunomodulatorsPOMALYST 5 LA

Antineoplastic Antibioticsbleomycin sulfate 15 unit 2 MO; *

bleomycin sulfate 30 unit 2 *

COSMEGEN 4 MO

daunorubicin hcl 2 *

DAUNOXOME 4

DOXIL (Use DoxorubicinHCl Liposomal) NF

doxorubicin hcl liposomal 2 *

doxorubicin hcl soln 2mg/ml 1 MO; *

doxorubicin hcl solr 10 mg 1 *

doxorubicin hcl solr 50 mg 1 MO; *



35

Drug Name DrugTier

Requirements/Limits

ELLENCE (Use EpirubicinHCl) 4 MO

epirubicin hcl soln 200mg/100ml 4 MO

epirubicin hcl soln 50mg/25ml 2 MO; *

IDAMYCIN PFS (UseIdarubicin HCl) 4

idarubicin hcl 2 *

mitomycin solr iv 20 mg, 40mg, 5 mg 2 MO; *

mitoxantrone hcl 2 *

VALSTAR 5

Antineoplastic Enzyme InhibitorsAFINITOR 5

AFINITOR DISPERZ 5

BELEODAQ 5

BOSULIF 5 PA

CAPRELSA 5 LA

COMETRIQ 5

COMETRIQ 5 140 MG DoseKit;MO

FARYDAK 5 PA; LA

GILOTRIF 5 LA

GLEEVEC 5

IBRANCE 5 LA

ICLUSIG 5 LA

IMBRUVICA 5 PA

INLYTA 5 PA; LA

IRESSA 5 LA

Drug Name DrugTier

Requirements/Limits

ISTODAX 5

JAKAFI 5 LA

LENVIMA 10MG DAILYDOSE 5 PA




LYNPARZA 5 PA; LA

MEKINIST 5

NEXAVAR 5 LA

SPRYCEL 5

STIVARGA 5 PA; LA

SUTENT 5

TAFINLAR 5

TARCEVA 5

TASIGNA 5

TORISEL 5

TYKERB 5

VELCADE 5

VOTRIENT 5

XALKORI 5

ZELBORAF 5 LA

ZOLINZA 5

ZYDELIG 5 PA

ZYKADIA 5 PA; LA

Antineoplastic Enzymes



36

Drug Name DrugTier

Requirements/Limits

ERWINAZE 5

ONCASPAR 5

Antineoplastics Misc.ACTIMMUNE 5 LA

bexarotene 5

dacarbazine 100 mg 2 *

dacarbazine 200 mg 2 MO; *

HYDREA (UseHydroxyurea) NF MO

hydroxyurea caps or 2 MO; *

INTRON A SOLN 10MU/ML 5

INTRON A SOLN 6000000UNIT/ML 4

INTRON A SOLR 10 MU,18 MU, 50 MU 5

INTRON A W/DILUENT 5

MATULANE 5 LA

NIPENT 4

PROLEUKIN 5

SYLATRON 5

SYNRIBO 5

TARGRETIN 1 %,75 MG 5

TARGRETIN 75 MG (UseBexarotene) 5

THERACYS 5 MO

TICE BCG 5 MO

tretinoin (chemotherapy) 5 MO

TRISENOX 4 MO

UVADEX 4

Drug Name DrugTier

Requirements/Limits

Chemotherapy AdjunctsELITEK 5

KEPIVANCE 5 MO

Chemotherapy Rescue/Antidote Agentsamifostine crystalline 2 MO; *

dexrazoxane 2 *

ETHYOL (Use AmifostineCrystalline) 4 MO

FUSILEV 4

leucovorin calcium solr ij100 mg, 200 mg, 350 mg 2 MO; *

leucovorin calcium solr ij 50mg, 500 mg 2 *

leucovorin calcium tabs or10 mg, 15 mg, 25 mg, 5 mg 2 MO; *

LEVOLEUCOVORIN 5

levoleucovorin calcium 5

mesna 2 MO; *

MESNEX SOLN IV 100MG/ML (Use Mesna) 4 MO

MESNEX TABS OR 400MG 5 MO

TOTECT 4

ZINECARD (UseDexrazoxane) 4

Mitotic InhibitorsABRAXANE 5 MO

DOCEFREZ 5

DOCETAXEL CONC 140MG/7ML, 20 MG/0.5ML, 20MG/ML, 80 MG/2ML, 80MG/4ML

5

docetaxel conc 20 mg/ml,80 mg/4ml 5



37

Drug Name DrugTier

Requirements/Limits

DOCETAXEL SOLN 160MG/16ML, 20 MG/2ML,200 MG/20ML, 80 MG/8ML

5

ETOPOPHOS 4 MO

etoposide soln iv 1gm/50ml, 100 mg/5ml 2 MO; *

etoposide soln iv 500mg/25ml 2 *

HALAVEN 5

IXEMPRA KIT 5

JEVTANA 5

NAVELBINE (UseVinorelbine Tartrate) NF MO

paclitaxel 100 mg/16.7ml,30 mg/5ml, 300 mg/50ml 2 MO; *

paclitaxel 150 mg/25ml 2 *

TAXOL (Use Paclitaxel) 4 MO

TAXOTERE (UseDocetaxel) 5

vinblastine sulfate 2 MO; *

vincristine sulfate 1 MO; *

vinorelbine tartrate 2 MO; *

Topoisomerase I InhibitorsCAMPTOSAR 100MG/5ML, 40 MG/2ML (UseIrinotecan HCl)

4MO

CAMPTOSAR 300MG/15ML 4

HYCAMTIN SOLR IV 4 MG(Use Topotecan HCl) 4 MO

irinotecan hcl 100 mg/5ml,40 mg/2ml 2 MO; *

irinotecan hcl 500 mg/25ml 2 *

topotecan hcl solr 4 mg 2 MO; *

ANTIPARKINSON AGENTS - Drugs to TreatParkinson's Disease

Drug Name DrugTier

Requirements/Limits

Antiparkinson Adjuvantscarbidopa tabs or 2 MO; *

LODOSYN (UseCarbidopa) 4 MO

Antiparkinson Anticholinergicsbenztropine mesylate solnij 1 mg/ml 2 MO; *

benztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg 2 AL; MO; *

COGENTIN (UseBenztropine Mesylate) 4 MO

trihexyphenidyl hcl 2 AL; MO; *

Antiparkinson COMT InhibitorsCOMTAN (UseEntacapone) NF QL(8 ea daily);

MO

entacapone 4 QL(8 ea daily);MO

TASMAR (Use Tolcapone) 4 MO

tolcapone 2 MO; *

Antiparkinson Dopaminergicsamantadine hcl caps or 100mg 2 MO; *

amantadine hcl syrp or 50mg/5ml 2 MO; *

amantadine hcl tabs or 100mg 2 MO; *

APOKYN 5 LA

bromocriptine mesylatecaps or 5 mg 1 MO; *

bromocriptine mesylatetabs or 2.5 mg 1 MO; *

carbidopa-levodopa 2 MO; *

carbidopa-levodopa-entacapone 2 MO; *

DUOPA 5 B/D

MIRAPEX (UsePramipexoleDihydrochloride)

NFMO



38

Drug Name DrugTier

Requirements/Limits

MIRAPEX ER 0.375MG,0.75 MG,1.5 MG,3MG,4.5 MG (UsePramipexoleDihydrochloride)

4

MO

MIRAPEX ER 2.25MG,3.75 MG 4 MO

NEUPRO 4 MO

PARLODEL (UseBromocriptine Mesylate) NF MO

pramipexoledihydrochloride 2 MO; *

REQUIP (Use RopiniroleHydrochloride) NF MO

REQUIP XL (UseRopinirole Hydrochloride) NF MO

ropinirole hydrochloridetabs 0.25 mg, 0.5 mg, 1mg, 2 mg, 3 mg, 4 mg, 5mg

2

MO; *

ropinirole hydrochloridetb24 12 mg, 2 mg, 4 mg, 6mg, 8 mg

3MO

RYTARY 4 MO

SINEMET (Use Carbidopa-Levodopa) NF MO

SINEMET CR (UseCarbidopa-Levodopa) NF MO

STALEVO 100 (UseCarbidopa-Levodopa-Entacapone)

NFMO


NFMO


NFMO


NFMO


NFMO

Drug Name DrugTier

Requirements/Limits


NFMO

Antiparkinson Monoamine Oxidase InhibitorsAZILECT 3 MO

ELDEPRYL (Use SelegilineHCl) NF MO

selegiline hcl caps or 2 MO; *

selegiline hcl tabs or 2 MO; *

ZELAPAR 4 MO

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood DisordersAntimanic Agentslithium 1 MO; *

lithium carbonate caps or150 mg, 300 mg, 600 mg 2 MO; *

lithium carbonate tabs or300 mg 2 MO; *

lithium carbonate tbcr or300 mg, 450 mg 2 MO; *

LITHOBID (Use LithiumCarbonate) NF MO

Antipsychotics - Misc.EQUETRO 4 MO

GEODON CAPS OR 20MG, 40 MG, 60 MG, 80 MG(Use Ziprasidone HCl)

NFMO

GEODON SOLR IM 20 MG 4 MO

LATUDA 120 MG 5 PA; QL(1 eadaily); MO



LATUDA 60 MG 4 PA; QL(2.67 eadaily); MO




39

Drug Name DrugTier

Requirements/Limits

ziprasidone hcl 4 MO

BenzisoxazolesFANAPT 1 MG, 10 MG, 12MG, 2 MG, 4 MG 4 MO

FANAPT 6 MG, 8 MG 5 MO

FANAPT TITRATIONPACK 4

INVEGA 1.5 MG (UsePaliperidone) 5 QL(8 ea daily);

MOINVEGA 3 MG (UsePaliperidone) 5 QL(4 ea daily);



MOINVEGA SUSTENNA 117MG/0.75ML, 156 MG/ML,234 MG/1.5ML

5MO

INVEGA SUSTENNA 39MG/0.25ML, 78 MG/0.5ML 4 MO

INVEGA TRINZA 5

paliperidone 1.5 mg 2 QL(8 ea daily);MO; *

paliperidone 3 mg 2 QL(4 ea daily);MO; *

paliperidone 6 mg 2 QL(2 ea daily);MO; *

paliperidone 9 mg 5 QL(1 ea daily);MO

RISPERDAL (UseRisperidone) NF MO

RISPERDAL CONSTA12.5 MG 4 QL(0.29 ea

daily); MORISPERDAL CONSTA 25MG 4 QL(0.15 ea

daily); MORISPERDAL CONSTA37.5 MG, 50 MG 5 QL(0.08 ea

daily); MORISPERDAL M-TAB (UseRisperidone) NF MO

risperidone soln 1 mg/ml 3 MO

Drug Name DrugTier

Requirements/Limits

risperidone tabs 0.25 mg,0.5 mg, 1 mg, 2 mg, 3 mg,4 mg

2MO; *

risperidone tbdp 0.25 mg, 3mg, 4 mg 2 MO; *

risperidone tbdp 0.5 mg, 1mg, 2 mg 3 MO

ButyrophenonesHALDOL (Use HaloperidolLactate) NF MO

HALDOL DECANOATE100 (Use HaloperidolDecanoate)

NFMO

HALDOL DECANOATE 50(Use HaloperidolDecanoate)

NFMO

haloperidol 2 MO; *

haloperidol decanoate 2 MO; *

haloperidol lactate 1 MO; *

DibenzapinesADASUVE 4

CLOZAPINE ODT 4

clozapine tabs 100 mg, 25mg 3

clozapine tabs 200 mg, 50mg 2 *

clozapine tbdp 100 mg, 25mg 2 *

CLOZARIL (UseClozapine) NF

FAZACLO 100 MG,25 MG(Use Clozapine) 4

FAZACLO 12.5 MG,150MG,200 MG 4

loxapine succinate 10 mg,25 mg, 5 mg, 50 mg 2 MO; *

olanzapine solr im 10 mg 3 MO

olanzapine tabs or 10 mg,15 mg, 2.5 mg, 20 mg, 5mg, 7.5 mg

3MO



40

Drug Name DrugTier

Requirements/Limits

olanzapine tbdp or 10 mg,15 mg, 20 mg, 5 mg 4 MO

quetiapine fumarate 3 MO

SAPHRIS 10 MG 4 QL(2 ea daily);MO

SAPHRIS 2.5 MG 4 QL(8 ea daily);MO

SAPHRIS 5 MG 4 QL(4 ea daily);MO

SEROQUEL (UseQuetiapine Fumarate) NF MO

SEROQUEL XR 150 MG,200 MG, 300 MG, 50 MG 4 PA; MO

SEROQUEL XR 400 MG 5 PA; MO

VERSACLOZ 5 PA; QL(18 mldaily)

ZYPREXA (UseOlanzapine) NF MO

ZYPREXA ZYDIS (UseOlanzapine) NF MO

Phenothiazineschlorpromazine hcl soln ij25 mg/ml 2 MO; *

chlorpromazine hcl soln ij50 mg/2ml 2 *

chlorpromazine hcl tabs or10 mg, 100 mg, 200 mg, 25mg, 50 mg

3MO

fluphenazine decanoatesoln ij 2 MO; *

fluphenazine hcl conc or 5mg/ml 2 MO; *

fluphenazine hcl soln ij 2.5mg/ml 2 MO; *

fluphenazine hcl tabs or 1mg, 10 mg, 2.5 mg, 5 mg 2 MO; *

perphenazine tabs or 16mg, 2 mg, 4 mg, 8 mg 2 MO; *

prochlorperazine 2 MO; *

prochlorperazine edisylatesoln ij 2 MO; *

prochlorperazine maleatetabs or 10 mg, 5 mg 2 MO; *

Drug Name DrugTier

Requirements/Limits

thioridazine hcl tabs or 10mg, 100 mg, 25 mg, 50 mg 2 AL; MO; *

trifluoperazine hcl 1 MO; *

Quinolinone DerivativesABILIFY DISCMELT 10MG 5 QL(3 ea daily)

ABILIFY DISCMELT 15MG 5 QL(2 ea daily)

ABILIFY MAINTENA 5 MO

ABILIFY SOLN IM 9.75MG/1.3ML 4 QL(4 ml daily);

MOABILIFY SOLN OR 1MG/ML 5 QL(30 ml

daily); MOABILIFY TABS OR 10 MG(Use Aripiprazole) 5 QL(3 ea daily);

MOABILIFY TABS OR 15 MG(Use Aripiprazole) 5 QL(2 ea daily);

MOABILIFY TABS OR 2 MG(Use Aripiprazole) 5 QL(15 ea

daily); MOABILIFY TABS OR 20 MG,30 MG (Use Aripiprazole) 5 QL(1 ea daily);

MOABILIFY TABS OR 5 MG(Use Aripiprazole) 5 QL(6 ea daily);

MOARIPIPRAZOLE ODT 10MG 5 QL(3 ea daily)

ARIPIPRAZOLE ODT 15MG 5 QL(2 ea daily)

aripiprazole soln 1 mg/ml 2 QL(30 mldaily); MO; *

aripiprazole tabs 10 mg 2 QL(3 ea daily);MO; *


aripiprazole tabs 2 mg 2 QL(15 eadaily); MO; *

aripiprazole tabs 20 mg, 30mg 5 QL(1 ea daily);

MO


REXULTI 0.25 MG 5 PA; QL(16 eadaily); MO

REXULTI 0.5 MG 5 PA; QL(8 eadaily); MO



41

Drug Name DrugTier

Requirements/Limits

REXULTI 1 MG 5 PA; QL(4 eadaily); MO

REXULTI 2 MG 5 PA; QL(2 eadaily); MO

REXULTI 3 MG, 4 MG 5 PA; QL(1 eadaily); MO

Thioxanthenesthiothixene 2 MO; *

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretroviralsabacavir sulfate 4 MO

abacavir sulfate-lamivudine-zidovudine 5 MO

APTIVUS CAPS 250 MG 5 MO

APTIVUS SOLN 100MG/ML 3

ATRIPLA 5 MO

COMBIVIR (UseLamivudine-Zidovudine) 5 MO

COMPLERA 5 MO

CRIXIVAN 4 MO

didanosine 125 mg 2 MO; *

didanosine 200 mg, 250mg, 400 mg 1 MO; *

EDURANT 5 MO

EMTRIVA 4 MO

EPIVIR SOLN 10 MG/ML(Use Lamivudine) 3 MO

EPIVIR TABS 150 MG, 300MG (Use Lamivudine) NF MO

EPZICOM 5 MO

EVOTAZ 5 MO

FUZEON 5

Drug Name DrugTier

Requirements/Limits

INTELENCE 100 MG, 200MG 5 MO

INTELENCE 25 MG 4

INVIRASE 5 MO

ISENTRESS CHEW 100MG 4 QL(6 ea daily);

MO

ISENTRESS CHEW 25 MG 3 QL(24 eadaily); MO

ISENTRESS PACK 100MG 4 QL(2 ea daily)

ISENTRESS TABS 400MG 5 MO

KALETRA SOLN400MG/5ML-100MG/5ML 5 MO

KALETRA TABS 100MG-25MG 4 MO

KALETRA TABS 200MG-50MG 5 MO

lamivudine soln 10 mg/ml 2 MO; *

lamivudine tabs 150 mg,300 mg 3 MO

lamivudine-zidovudine 5 MO

LEXIVA SUSP 50 MG/ML 3 MO

LEXIVA TABS 700 MG 5 MO

NEVIRAPINE SUSP 50MG/5ML 4 MO

nevirapine tabs 200 mg 3 MO

nevirapine tb24 100 mg 2 *

nevirapine tb24 400 mg 2 MO; *

NORVIR 4 MO

PREZCOBIX 5 MO

PREZISTA SUSP 100MG/ML 5 MO

PREZISTA TABS 150 MG 4 MO

PREZISTA TABS 400 MG 5



42

Drug Name DrugTier

Requirements/Limits

PREZISTA TABS 600 MG,800 MG 5 MO

PREZISTA TABS 75 MG 4

RESCRIPTOR 100 MG 3 MO

RESCRIPTOR 200 MG 4 MO

RETROVIR (UseZidovudine) NF MO

RETROVIR IV INFUSION 4

REYATAZ CAPS 150 MG,200 MG, 300 MG 5 MO

REYATAZ PACK 50 MG 5

SELZENTRY 5 MO

stavudine caps 15 mg 2 MO; *

stavudine caps 20 mg, 30mg, 40 mg 1 MO; *

stavudine solr 1 mg/ml 2 MO; *

STRIBILD 5 MO

SUSTIVA CAPS 200 MG,50 MG 4 MO

SUSTIVA TABS 600 MG 5 MO

TIVICAY 5 MO

TRIUMEQ 5 MO

TRIZIVIR (Use AbacavirSulfate-Lamivudine-Zidovudine)

5MO

TRUVADA 5 MO

TYBOST 4 MO

VIDEX EC (UseDidanosine) NF MO

VIDEXPEDIATRIC 4 MO

VIRACEPT 5 MO

Drug Name DrugTier

Requirements/Limits

VIRAMUNE SUSP 50MG/5ML 4 MO

VIRAMUNE TABS 200 MG(Use Nevirapine) NF MO

VIRAMUNE XR 100 MG 4

VIRAMUNE XR 400 MG(Use Nevirapine) 5 MO

VIREAD POWD 40 MG/GM 5 MO

VIREAD TABS 150 MG,200 MG, 300 MG 5 MO

VIREAD TABS 250 MG 5

VITEKTA 5

ZERIT (Use Stavudine) NF MO

ZIAGEN SOLN 20 MG/ML 3 MO

ZIAGEN TABS 300 MG(Use Abacavir Sulfate) NF MO

zidovudine caps 100 mg 1 MO; *

zidovudine syrp 50 mg/5ml 2 MO; *

zidovudine tabs 300 mg 1 MO; *

CMV Agentscidofovir 5

CYTOVENE (UseGanciclovir Sodium) NF MO

ganciclovir sodium 2 MO; *

VALCYTE 450 MG (UseValganciclovir HCl) 5 MO

VALCYTE 50 MG/ML 5 MO

valganciclovir hcl 5 MO

VISTIDE (Use Cidofovir) 5

Hepatitis Agentsadefovir dipivoxil 5 MO

BARACLUDE SOLN 0.05MG/ML 4 MO



43

Drug Name DrugTier

Requirements/Limits

BARACLUDE TABS 0.5MG, 1 MG (Use Entecavir) 5 MO

COPEGUS (Use Ribavirin(Hepatitis C)) NF

entecavir 5 MO

EPIVIR HBV 100 MG (UseLamivudine (HBV)) 3 MO

EPIVIR HBV 5 MG/ML 3 MO

HARVONI 5 PA

HEPSERA (Use AdefovirDipivoxil) 5 MO

INCIVEK 5 PA

lamivudine (hbv) 2 MO; *

OLYSIO 5 PA

PEG-INTRON 5

PEG-INTRON REDIPEN 5

PEG-INTRON REDIPENPAK 4 5

PEGASYS 5

PEGASYS PROCLICK 5

PEGINTRON 5

REBETOL CAPS 200 MG(Use Ribavirin (HepatitisC))

NF

REBETOL SOLN 40MG/ML 3

ribavirin (hepatitis c) caps200 mg 4

ribavirin (hepatitis c) misc 2 *

ribavirin (hepatitis c) tabs200 mg 4

ribavirin (hepatitis c) tabs400 mg, 600 mg 2 *

SOVALDI 5 PA

Drug Name DrugTier

Requirements/Limits

TYZEKA 5 MO

VICTRELIS 5 PA

VIEKIRA PAK 5 PA

Herpes Agentsacyclovir caps or 200 mg 2 MO; *

acyclovir sodium soln 50mg/ml 2 *

acyclovir sodium solr 500mg 2 MO; *

acyclovir susp or 200mg/5ml 2 MO; *

acyclovir tabs or 400 mg,800 mg 2 MO; *

famciclovir 125 mg 2 MO; *

famciclovir 250 mg, 500 mg 3 MO

FAMVIR (Use Famciclovir) NF MO

valacyclovir hcl tabs or 1gm, 1000 mg, 500 mg 3 MO

VALTREX (UseValacyclovir HCl) NF MO

ZOVIRAX CAPS OR 200MG (Use Acyclovir) NF MO

ZOVIRAX SUSP OR 200MG/5ML (Use Acyclovir) NF MO

ZOVIRAX TABS OR 400MG, 800 MG (UseAcyclovir)

NFMO

Influenza AgentsFLUMADINE (UseRimantadineHydrochloride)

NFMO

RELENZA DISKHALER 4 MO

rimantadine hydrochloride 1 MO; *

TAMIFLU 4 MO

Respiratory Syncytial Virus (RSV) AgentsVIRAZOLE 4



44

Drug Name DrugTier

Requirements/Limits

ASSORTED CLASSES - Miscellaneous Drugs

Chelating AgentsDEPEN TITRATABS 3 MO

SYPRINE 5 MO

EnzymesXIAFLEX 5

ImmunomodulatorsREVLIMID 5 LA

THALOMID 5

Immunosuppressive AgentsASTAGRAF XL 4 MO; B/D

ATGAM 4 B/D

azathioprine tabs or 100mg, 50 mg, 75 mg 2 MO; B/D; *

CELLCEPT CAPS 250 MG(Use MycophenolateMofetil)

NFMO; B/D

CELLCEPTINTRAVENOUS 4 B/D

CELLCEPT SUSR 200MG/ML (UseMycophenolate Mofetil)

5MO; B/D

CELLCEPT TABS 500 MG(Use MycophenolateMofetil)

NFMO; B/D

cyclosporine caps or 100mg, 25 mg 3 MO; B/D

cyclosporine modified (formicroemulsion) caps 100mg, 25 mg

3MO; B/D

cyclosporine modified (formicroemulsion) caps 50 mg 2 MO; B/D; *

cyclosporine soln iv 50mg/ml 2 B/D; *

IMURAN (UseAzathioprine) 4 MO; B/D

mycophenolate mofetilcaps 250 mg 3 MO; B/D

Drug Name DrugTier

Requirements/Limits

mycophenolate mofetil susr200 mg/ml 5 MO; B/D

mycophenolate mofetil tabs500 mg 3 MO; B/D

mycophenolate sodium 180mg 2 MO; B/D; *

mycophenolate sodium 360mg 5 MO; B/D

MYFORTIC 180 MG (UseMycophenolate Sodium) 4 MO; B/D

MYFORTIC 360 MG (UseMycophenolate Sodium) 5 MO; B/D

NEORAL CAPS 100 MG,25 MG (Use CyclosporineModified (ForMicroemulsion))

NF

MO; B/D

NULOJIX 5 B/D

PROGRAF CAPS OR 0.5MG, 1 MG, 5 MG (UseTacrolimus)

NFMO; B/D

PROGRAF SOLN IV 5MG/ML 4 B/D

RAPAMUNE SOLN 1MG/ML 3 MO; B/D

RAPAMUNE TABS 0.5 MG(Use Sirolimus) 3 MO; B/D

RAPAMUNE TABS 1 MG,2 MG (Use Sirolimus) 5 MO; B/D

SANDIMMUNE CAPS OR100 MG, 25 MG (UseCyclosporine)

NFMO; B/D

SANDIMMUNE SOLN IV50 MG/ML (UseCyclosporine)

4B/D

SANDIMMUNE SOLN OR100 MG/ML 4 MO; B/D

SIMULECT 5 B/D

sirolimus 0.5 mg, 1 mg 2 MO; B/D; *

sirolimus 2 mg 5 MO; B/D

tacrolimus caps or 0.5 mg,1 mg, 5 mg 3 MO; B/D

THYMOGLOBULIN 3 B/D



45

Drug Name DrugTier

Requirements/Limits

ZORTRESS 0.25 MG 3 MO; B/D

ZORTRESS 0.5 MG, 0.75MG 5 MO; B/D

Irrigation Solutionsirrigation solutions,physiological 2 *

water for irrigation, sterile 1 MO; *

Potassium Removing ResinsKAYEXALATE (UseSodium PolystyreneSulfonate)

NFMO

sodium polystyrenesulfonate powd or 3 MO

sodium polystyrenesulfonate susp or 15gm/60ml

2MO; *

Systemic Lupus Erythematosus AgentsBENLYSTA 5

BETA BLOCKERS - Drugs to Treat High BloodPressureAlpha-Beta Blockers

carvedilol 12.5 mg 1 QL(8 ea daily);MO; *

carvedilol 25 mg 1 QL(4 ea daily);MO; *

carvedilol 3.125 mg 1 QL(32 eadaily); MO; *

carvedilol 6.25 mg 1 QL(16 eadaily); MO; *

COREG 12.5 MG (UseCarvedilol) NF QL(8 ea daily);

MOCOREG 25 MG (UseCarvedilol) NF QL(4 ea daily);

MOCOREG 3.125 MG (UseCarvedilol) NF QL(32 ea

daily); MOCOREG 6.25 MG (UseCarvedilol) NF QL(16 ea

daily); MO

COREG CR 4 MO

labetalol hcl tabs or 100mg, 200 mg, 300 mg 1 MO; *

Drug Name DrugTier

Requirements/Limits

TRANDATE (Use LabetalolHCl) NF MO

Beta Blockers Cardio-Selectiveacebutolol hcl caps or 200mg, 400 mg 1 MO; *

atenolol tabs or 100 mg, 25mg, 50 mg 1 MO; *

betaxolol hcl 10 mg 1 MO; *

betaxolol hcl 20 mg 2 MO; *

bisoprolol fumarate 1 MO; *

BYSTOLIC 4 MO

KERLONE (Use BetaxololHCl) NF MO

LOPRESSOR TABS OR100 MG, 50 MG (UseMetoprolol Tartrate)

NFMO

metoprolol succinate 1 MO; *

metoprolol tartrate tabs or100 mg, 25 mg, 50 mg 1 MO; *

SECTRAL (Use AcebutololHCl) NF MO

TENORMIN (Use Atenolol) NF MO

TOPROL XL (UseMetoprolol Succinate) NF MO

ZEBETA (Use BisoprololFumarate) NF MO

Beta Blockers Non-SelectiveBETAPACE (Use SotalolHCl) NF tabs;MO

BETAPACE AF (UseSotalol HCl (AFIB/AFL)) NF MO

CORGARD (Use Nadolol) NF MO

INDERAL LA (UsePropranolol HCl) NF MO

INDERAL XL 4 MO

INNOPRAN XL 4 MO

LEVATOL 4 MO



46

Drug Name DrugTier

Requirements/Limits

nadolol tabs or 20 mg, 40mg, 80 mg 1 MO; *

pindolol 1 MO; *

propranolol hcl cp24 or 120mg, 160 mg, 60 mg, 80 mg 1 MO; *

propranolol hcl tabs or 10mg, 20 mg, 40 mg, 60 mg,80 mg

1MO; *

sotalol hcl 1 tabs;MO; *

sotalol hcl (afib/afl) 2 MO; *

Sotalol Hcl IV Soln NF

SOTYLIZE 4

BIOLOGICALS MISC - Drugs to Treat LowEnzymesAllergenic ExtractsGRASTEK 4 PA; MO

RAGWITEK 4 PA; MO

Biologicals MiscADAGEN 5 LA

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood PressureCalcium Channel BlockersADALAT CC (UseNifedipine) NF MO

amlodipine besylate tabs or10 mg 1 QL(1 ea daily);

MO; *amlodipine besylate tabs or2.5 mg 1 QL(4 ea daily);

MO; *amlodipine besylate tabs or5 mg 1 QL(2 ea daily);

MO; *CALAN (Use VerapamilHCl) NF MO

CALAN SR (Use VerapamilHCl) NF MO

CARDIZEM (Use DiltiazemHCl) NF MO

Drug Name DrugTier

Requirements/Limits

CARDIZEM CD (UseDiltiazem HCl CoatedBeads)

NFMO

CARDIZEM LA 120 MG 4 MO

CARDIZEM LA 180 MG,240 MG, 300 MG, 360 MG,420 MG (Use Diltiazem HClCoated Beads)

NF

MO

diltiazem hcl coated beads 1 MO; *

diltiazem hcl cp12 or 120mg, 60 mg, 90 mg 1 MO; *

diltiazem hcl cp24 or 120mg, 180 mg, 240 mg 1 MO; *

diltiazem hcl extendedrelease beads 1 MO; *

diltiazem hcl solr iv 100 mg 2 *

diltiazem hcl tabs or 120mg, 30 mg, 60 mg, 90 mg 1 MO; *

felodipine 1 MO; *

nicardipine hcl caps or 20mg, 30 mg 1 MO; *

nifedipine caps or 10 mg,20 mg 2 AL; MO; *

nifedipine tb24 or 30 mg,60 mg, 90 mg 1 MO; *

nimodipine caps or 2 MO; *

nisoldipine 17 mg, 34 mg,8.5 mg 1 MO; *

NORVASC 10 MG (UseAmlodipine Besylate) NF QL(1 ea daily);

MONORVASC 2.5 MG (UseAmlodipine Besylate) NF QL(4 ea daily);

MONORVASC 5 MG (UseAmlodipine Besylate) NF QL(2 ea daily);

MO

NYMALIZE 5

PROCARDIA (UseNifedipine) NF AL; MO

PROCARDIA XL (UseNifedipine) NF MO

SULAR (Use Nisoldipine) NF MO



47

Drug Name DrugTier

Requirements/Limits

TIAZAC (Use Diltiazem HClExtended Release Beads) NF MO

verapamil hcl cp24 or 100mg, 120 mg, 180 mg, 200mg, 240 mg, 300 mg, 360mg

1

MO; *

verapamil hcl tabs or 120mg, 40 mg, 80 mg 1 MO; *

verapamil hcl tbcr or 120mg, 180 mg, 240 mg 1 MO; *

VERELAN (Use VerapamilHCl) NF MO

VERELAN PM (UseVerapamil HCl) NF MO

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart RhythmCardiac GlycosidesDIGOXIN SOLN OR 0.05MG/ML 4 MO

digoxin tabs or 0.125 mg,0.25 mg, 125 mcg, 250mcg

2MO; *

LANOXIN PEDIATRIC 4

LANOXIN TABS OR 125MCG, 250 MCG (UseDigoxin)

4MO

LANOXIN TABS OR 187.5MCG, 62.5 MCG 4 MO

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation ConditionsCardiovascular Agents Misc. - Combinationsamlodipine besylate-atorvastatin calcium 2 MO; *

BIDIL 4 MO

CADUET (Use AmlodipineBesylate-AtorvastatinCalcium)

4MO

ENTRESTO 4 PA; MO

Prostaglandin VasodilatorsORENITRAM 0.125 MG 4 PA

ORENITRAM 0.25 MG, 1MG, 2.5 MG 5 PA

Drug Name DrugTier

Requirements/Limits

REMODULIN 5 LA; B/D

TYVASO 5 LA; B/D

TYVASO REFILL 5 LA; B/D

TYVASO STARTER 5 LA; B/D

VENTAVIS 10 MCG/ML 3 LA; B/D

VENTAVIS 20 MCG/ML 5 LA; B/D

Pulmonary Hypertension - Endothelin ReceptorLETAIRIS 5 LA

OPSUMIT 5

TRACLEER 5 LA

Pulmonary Hypertension - PhosphodiesteraseADCIRCA 5 PA

REVATIO SOLN IV 10MG/12.5ML (Use SildenafilCitrate (PulmonaryHypertension))

5

PA

REVATIO TABS OR 20MG (Use Sildenafil Citrate(Pulmonary Hypertension))

5PA

sildenafil citrate (pulmonaryhypertension) 5 PA

Pulmonary Hypertension - Sol Guanylate Cyclase

ADEMPAS 0.5 MG 5 PA; QL(15 eadaily)

ADEMPAS 1 MG 5 PA; QL(7.5 eadaily)


ADEMPAS 2 MG 5 PA; QL(3.75 eadaily)


Sinus Node Inhibitors

CORLANOR 4 QL(2 ea daily);MO



48

Drug Name DrugTier

Requirements/Limits

CEPHALOSPORINS - Drugs to Treat BacterialInfectionsCephalosporins - 1st Generationcefadroxil caps 500 mg 1 MO; *

cefadroxil susr 250 mg/5ml 2 MO; *

cefadroxil susr 500 mg/5ml 1 MO; *

cefadroxil tabs 1 gm 1 MO; *

cefazolin sodium solr ij 1gm, 10 gm 1 MO; *

cefazolin sodium solr ij 500mg 2 MO; *

cephalexin caps 250 mg,500 mg 1 MO; *

cephalexin caps 750 mg 2 MO; *

cephalexin susr 125mg/5ml, 250 mg/5ml 2 MO; *

KEFLEX 250 MG, 500 MG(Use Cephalexin) NF MO

KEFLEX 750 MG (UseCephalexin) 4 MO

Cephalosporins - 2nd Generationcefaclor caps 250 mg, 500mg 1 MO; *

cefotetan disodium 2 *

cefprozil susr 125 mg/5ml 2 MO; *

cefprozil susr 250 mg/5ml 1 MO; *

cefprozil tabs 250 mg, 500mg 1 MO; *

CEFTIN TABS 250 MG,500 MG (Use CefuroximeAxetil)

NFMO

cefuroxime axetil 2 MO; *

cefuroxime sodium ij 1.5gm 1 *

cefuroxime sodium ij 7.5gm 2 *

Drug Name DrugTier

Requirements/Limits

cefuroxime sodium ij 750mg 1 MO; *

cefuroxime sodium iv 7.5gm 2 *

ZINACEF SOLR IJ 1.5 GM,7.5 GM (Use CefuroximeSodium)

NF

ZINACEF SOLR IJ 750 MG(Use Cefuroxime Sodium) NF MO

Cephalosporins - 3rd Generation

CEDAX CAPS 400 MG 4 QL(1 ea daily);MO

cefdinir caps 300 mg 2 MO; *

cefdinir susr 125 mg/5ml 2 MO; *

cefdinir susr 250 mg/5ml 3 MO

cefixime chew 100 mg 2 *

cefixime chew 200 mg 2 MO; *

cefotaxime sodium 1 gm 1 MO; *

cefotaxime sodium 10 gm 2 MO; *

cefotaxime sodium 2 gm,500 mg 2 *

cefpodoxime proxetil 2 MO; *

ceftazidime ij 1 gm, 2 gm 3 MO

ceftazidime ij 6 gm 1 *

CEFTIBUTEN CAPS 400MG 4 QL(1 ea daily);

MOceftriaxone sodium solr ij 1gm 3 QL(4 ea daily);

MOceftriaxone sodium solr ij 2gm 3 QL(2 ea daily);

MOceftriaxone sodium solr ij250 mg 1 QL(16 ea

daily); MO; *ceftriaxone sodium solr ij500 mg 3 QL(8 ea daily);

MOceftriaxone sodium solr iv 1gm 1 QL(4 ea daily);

*



49

Drug Name DrugTier

Requirements/Limits

ceftriaxone sodium solr iv10 gm 3 MO

ceftriaxone sodium solr iv 2gm 2 QL(2 ea daily);

MO; *CLAFORAN IJ 1 GM, 10GM (Use CefotaximeSodium)

NFMO

CLAFORAN IJ 2 GM, 500MG (Use CefotaximeSodium)

NF

FORTAZ SOLR IJ 1 GM, 2GM (Use Ceftazidime) NF MO

FORTAZ SOLR IJ 6 GM(Use Ceftazidime) NF

SUPRAX CAPS 400 MG 4 MO

SUPRAX SUSR 500MG/5ML 4

Cephalosporins - 4th Generationcefepime hcl 3 MO

CEFEPIME SOLN 1GM/50ML, 2 GM/100ML 4

MAXIPIME IJ 1 GM, 2 GM(Use Cefepime HCl) NF MO

Cephalosporins - 5th GenerationTEFLARO 4

CONTRACEPTIVES - Drugs to PreventPregnancyCombination Contraceptives - OralBEYAZ 4 MO

BREVICON-28 (UseNorethindrone & EthEstradiol)

NFMO

DESOGEN (UseDesogestrel & EthinylEstradiol)

NFMO

desogestrel & ethinylestradiol 1 MO; *

desogestrel-ethinylestradiol (biphasic) 1 MO; *

drospirenone-ethinylestradiol 1 MO; *

Drug Name DrugTier

Requirements/Limits

ethynodiol diacet & ethestrad 1mg-35mcg 1 MO; *

ethynodiol diacet & ethestrad 1mg-50mcg 2 MO; *

FEMCON FE (UseNorethindrone & EthinylEstradiol-Fe)

NFMO

GENERESS FE (UseNorethindrone & EthinylEstradiol-Fe)

4MO

levonorgestrel & ethestradiol 1 MO; *

levonorgestrel-eth estradiol(triphasic) 1 MO; *

levonorgestrel-ethinylestradiol (91-day) 1 MO; *

LO LOESTRIN FE 4 MO

LO MINASTRIN FE 4

LOSEASONIQUE (UseLevonorgestrel-EthinylEstradiol (91-Day))

NF MO

MINASTRIN 24 FE 4 MO

MODICON (UseNorethindrone & EthEstradiol)

NFMO

norethin acet & estrad-fe75mg-20mcg-1mg, 75mg-30mcg-1.5mg

1MO; *

norethindrone & ethestradiol 0.4mg-35mcg,1mg-35mcg

1MO; *

norethindrone & ethestradiol 0.5mg-35mcg 2 MO; *

norethindrone & ethinylestradiol-fe 2 MO; *

norethindrone acet & ethestra 1 MO; *

norethindrone-eth estradiol(triphasic) 2 MO; *

norgestimate-ethinylestradiol 1 MO; *

norgestimate-ethinylestradiol (triphasic) 1 MO; *



50

Drug Name DrugTier

Requirements/Limits

norgestrel & ethinylestradiol 1 MO; *

NORINYL 1+35 (UseNorethindrone & EthEstradiol)

NFMO

ORTHO TRI-CYCLEN (UseNorgestimate-EthinylEstradiol (Triphasic))

NFMO

ORTHO-CEPT (UseDesogestrel & EthinylEstradiol)

NFMO

ORTHO-CYCLEN (UseNorgestimate-EthinylEstradiol)

NFMO

ORTHO-NOVUM 1/35(Use Norethindrone & EthEstradiol)

NFMO

ORTHO-NOVUM 7/7/7(Use Norethindrone-EthEstradiol (Triphasic))

NFMO

QUARTETTE 4 MO

SAFYRAL 4 MO

SEASONIQUE (UseLevonorgestrel-EthinylEstradiol (91-Day))

NF MO

YASMIN 28 (UseDrospirenone-EthinylEstradiol)

NFMO

YAZ (Use Drospirenone-Ethinyl Estradiol) NF MO

Combination Contraceptives - Transdermalnorelgestromin-ethinylestradiol 2 MO; *

ORTHO EVRA (UseNorelgestromin-EthinylEstradiol)

3MO

Combination Contraceptives - VaginalNUVARING 3 MO

Emergency ContraceptivesELLA 3

levonorgestrel (emergencyoc) 0.75 mg 1 *

Drug Name DrugTier

Requirements/Limits

levonorgestrel (emergencyoc) 1.5 mg 1 RX/OTC; *

PLAN B ONE-STEP (UseLevonorgestrel (EmergencyOC))

4RX/OTC

Progestin Contraceptives - InjectableDEPO-PROVERACONTRACEPTIVE (UseMedroxyprogesteroneAcetate (Contraceptive))

NF

MO

DEPO-SUBQ PROVERA104 4 MO

medroxyprogesteroneacetate (contraceptive) 1 MO; *

Progestin Contraceptives - OralNOR-QD (UseNorethindrone(Contraceptive))

NFMO

norethindrone(contraceptive) 1 MO; *

ORTHO MICRONOR (UseNorethindrone(Contraceptive))

NFMO

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling ConditionsGlucocorticosteroidsbetamethasone sodphosphate & acetate 1 MO; *

budesonide cp24 or 5 MO

CELESTONE-SOLUSPAN(Use Betamethasone SodPhosphate & Acetate)

4MO

CORTEF (UseHydrocortisone) NF MO

cortisone acetate tabs or 1 MO; *

DEPO-MEDROL 20MG/ML 4 MO

DEPO-MEDROL 40MG/ML, 80 MG/ML (UseMethylprednisoloneAcetate)

NF

MO

dexamethasone conc or 1mg/ml 2 MO; *



51

Drug Name DrugTier

Requirements/Limits

dexamethasone elix or 0.5mg/5ml 2 MO; *

dexamethasone sodiumphosphate soln ij 10 mg/ml 1 Preservative

Free;MO; *dexamethasone sodiumphosphate soln ij 10 mg/ml,120 mg/30ml

1*

dexamethasone sodiumphosphate soln ij 100mg/10ml, 20 mg/5ml, 4mg/ml

1

MO; *

dexamethasone soln or 0.5mg/5ml 2 MO; *

dexamethasone tabs or 0.5mg, 0.75 mg, 1 mg, 1.5 mg,2 mg, 4 mg, 6 mg

1MO; *

dexamethasone tabs or 1.5mg 2 MO; *

ENTOCORT EC (UseBudesonide) 5 MO

FLO-PRED 4 MO

hydrocortisone sodsuccinate 1 MO; *

hydrocortisone tabs or 10mg, 20 mg, 5 mg 2 MO; *

KENALOG-10 4 MO

KENALOG-40 4 MO

MEDROL 16 MG, 32 MG, 4MG, 8 MG (UseMethylprednisolone)

NFMO

MEDROL 2 MG 3 MO

MEDROL DOSEPAK (UseMethylprednisolone) NF MO

methylprednisolone acetatesusp ij 40 mg/ml, 80 mg/ml 1 MO; *

methylprednisolone sodsucc 1 MO; *

methylprednisolone tabs or16 mg, 32 mg, 4 mg, 8 mg 2 MO; *

MILLIPRED TABS 5 MG 4 MO

ORAPRED ODT 10 MG,15MG,30 MG 4 MO

Drug Name DrugTier

Requirements/Limits

ORAPRED ODT 10 MG,15MG,30 MG (UsePrednisolone SodiumPhosphate)

4

MO

prednisolone sodiumphosphate soln or 15mg/5ml, 5 mg/5ml, 6.7mg/5ml

1

MO; *

prednisolone sodiumphosphate soln or 20mg/5ml, 25 mg/5ml

2MO; *

prednisolone sodiumphosphate tbdp or 10 mg,15 mg, 30 mg

2MO; *

prednisolone soln 15mg/5ml 1 MO; *

prednisolone syrp 15mg/5ml 1 MO; *

prednisolone tabs 5 mg 2 MO; *

prednisone conc or 5mg/ml 2 MO; *

prednisone soln or 5mg/5ml 2 MO; *

prednisone tabs or 1 mg,10 mg, 2.5 mg, 20 mg, 5mg, 50 mg

1MO; *

prednisone tabs or 10 mg,5 mg 2 Dose Pack;MO;

*

RAYOS 2 MG, 5 MG 4 MO

SOLU-CORTEF 100 MG,250 MG 4 MO

SOLU-MEDROL 1000 MG,125 MG, 40 MG (UseMethylprednisolone SodSucc)

NF

MO

SOLU-MEDROL 2 GM 4

UCERIS TB24 OR 9 MG 5 MO

Mineralocorticoidsfludrocortisone acetate tabsor 2 MO; *

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy SymptomsCough/Cold/Allergy Combinations



52

Drug Name DrugTier

Requirements/Limits

CLARINEX-D 12 HOUR 4 MO

CLARINEX-D 24 HOUR 4 MO

promethazine &phenylephrine 2 AL; MO; *

SEMPREX-D 4 MO

Mucolyticsacetylcysteine soln in 10%, 20 % 1 MO; B/D; *

DERMATOLOGICALS - Drugs to Treat SkinConditionsAcne ProductsABSORICA 30 MG (UseIsotretinoin) NF

ACANYA 4 MO

adapalene crea 0.1 % 1 MO; *

adapalene gel 0.1 % 3 MO

adapalene gel 0.3 % 2 MO; *

ATRALIN (Use Tretinoin) 4 MO

AZELEX 4 MO

BENZACLIN (UseClindamycin Phosphate-Benzoyl Peroxide)

NFMO

BENZACLIN WITH PUMP(Use ClindamycinPhosphate-BenzoylPeroxide)

NF

MO

BENZAMYCIN (UseBenzoyl Peroxide-Erythromycin)

NFMO

benzoyl peroxide-erythromycin 1 MO; *

CLEOCIN-T (UseClindamycin Phosphate(Topical))

NFMO

clindamycin phosphate(topical) foam 3 MO

clindamycin phosphate(topical) gel 2 MO; *

Drug Name DrugTier

Requirements/Limits

clindamycin phosphate(topical) lotn 2 MO; *

clindamycin phosphate(topical) soln 2 MO; *

clindamycin phosphate(topical) swab 2 MO; *

clindamycin phosphate-benzoyl peroxide 3 MO

clindamycin phosphate-benzoyl peroxide(refrigerate)

3MO

DIFFERIN CREA 0.1 %(Use Adapalene) NF MO

DIFFERIN GEL 0.1 % (UseAdapalene) NF MO

DIFFERIN GEL 0.3 % (UseAdapalene) 4 MO

DUAC (Use ClindamycinPhosphate-BenzoylPeroxide (Refrigerate))

NFMO

EPIDUO 4 MO

erythromycin (acne aid) gel 1 MO; *

erythromycin (acne aid)soln 1 MO; *

EVOCLIN (UseClindamycin Phosphate(Topical))

NFMO

FABIOR 4 QL(3.34 gmdaily); MO

isotretinoin caps or 10 mg,30 mg 2 *

isotretinoin caps or 20 mg 1 *

isotretinoin caps or 40 mg 4

KLARON (UseSulfacetamide Sodium(Acne))

NFMO

RETIN-A (Use Tretinoin) NF MO

RETIN-A MICRO (UseTretinoin Microsphere) NF MO

RETIN-A MICRO PUMP0.04 %, 0.1 % (UseTretinoin Microsphere)

NFMO



53

Drug Name DrugTier

Requirements/Limits

RETIN-A MICRO PUMP0.08 % 4 MO

sulfacetamide sodium(acne) 1 MO; *

tretinoin crea ex 0.025 %,0.05 %, 0.1 % 2 MO; *

tretinoin crea ex 0.038 % 2 *

tretinoin gel ex 0.01 %,0.025 %, 0.05 % 2 MO; *

tretinoin microsphere 4 MO

VELTIN 4 MO

ZIANA 4 MO

Agents for External Genital and Perianal WartsVEREGEN 4 MO

Anti-inflammatory Agents - Topicaldiclofenac sodium (topical) 2 MO; *

FLECTOR 4 PA; MO

PENNSAID 1.5 % (UseDiclofenac Sodium(Topical))

4MO

PENNSAID 2 % 4 MO

VOLTAREN 4 MO

Antibiotics - TopicalALTABAX 4 MO

BACTROBAN (UseMupirocin Calcium(Topical))

NFMO

BACTROBAN (UseMupirocin) NF MO

CORTISPORIN CREA EX10000UNIT/GM-0.5%-0.5% 3 MO

CORTISPORIN OINT EX400UNIT/GM-5000UNIT/GM-0.5%-1%

3MO

gentamicin sulfate (topical) 1 MO; *

Drug Name DrugTier

Requirements/Limits

mupirocin calcium (topical) 2 MO; *

mupirocin oint ex 2 MO; *

Antifungals - Topicalciclopirox gel 0.77 % 3 MO

ciclopirox olamine crea ex 2 MO; *

ciclopirox olamine susp ex 2 MO; *

ciclopirox sham 1 % 3 MO

ciclopirox soln 8 % 2 MO; *

clotrimazole (topical) 2 RX/OTC; MO; *

clotrimazole w/betamethasone crea 2 MO; *

clotrimazole w/betamethasone lotn 3 MO

econazole nitrate 2 MO; *

EXELDERM SOLN 4 MO

EXTINA (UseKetoconazole (Topical)) NF MO

JUBLIA 4 PA; MO

KERYDIN 4 PA; MO

ketoconazole (topical) crea 2 MO; *

ketoconazole (topical) foam 3 MO

ketoconazole (topical)sham 2 MO; *

LOPROX (Use Ciclopirox) NF MO

LOPROX SHAMPOO (UseCiclopirox) NF MO

LOTRISONE (UseClotrimazole w/Betamethasone)

NFMO

LUZU 4 MO

naftifine hcl 2 MO; *



54

Drug Name DrugTier

Requirements/Limits

NAFTIN 1 % (Use NaftifineHCl) 4 MO

NAFTIN 1 %,2 % 4 MO

NIZORAL (UseKetoconazole (Topical)) NF MO

nystatin (topical) 2 MO; *

nystatin-triamcinolone 3 MO

OXISTAT 4 MO

PENLAC NAIL LACQUER(Use Ciclopirox) NF MO

Antineoplastic or Premalignant Lesion Agents -CARAC 3 MO

diclofenac sodium (actinickeratoses) 5 MO

EFUDEX (Use Fluorouracil(Topical)) NF MO

fluorouracil (topical) 4 MO

FLUOROURACIL CREAEX 0.5 % 3 MO

PANRETIN 5 MO

PICATO 5 MO

SOLARAZE (UseDiclofenac Sodium (ActinicKeratoses))

5MO

TARGRETIN 1 %,75 MG 5

VALCHLOR 5 PA

Antipsoriaticsacitretin 5 MO

calcipotriene crea 4 MO

calcipotriene oint 4 MO

calcipotriene soln 3 MO

CALCITRIOL OINT EX 3MCG/GM 4 MO

Drug Name DrugTier

Requirements/Limits

COSENTYX 5 PA; LA

COSENTYXSENSOREADY PEN 5 PA; LA

DOVONEX (UseCalcipotriene) NF MO

methoxsalen rapid 5 MO

OXSORALEN ULTRA (UseMethoxsalen Rapid) 5 MO

SORIATANE (UseAcitretin) 5 MO

SORILUX 4 MO

STELARA 5 PA;

TAZORAC 3 MO

VECTICAL 4 MO

Antiseborrheic Productsselenium sulfide lotn ex 2.5% 2 MO; *

Antivirals - Topicalacyclovir topical 4 MO

DENAVIR 4 MO

XERESE 4 MO

ZOVIRAX CREA EX 5 % 4 MO

ZOVIRAX OINT EX 5 %(Use Acyclovir Topical) NF MO

Burn ProductsSILVADENE (Use SilverSulfadiazine) NF MO

silver sulfadiazine crea ex 2 MO; *

SULFAMYLON CREA 85MG/GM 4 MO

Corticosteroids - Topicalalclometasone dipropionate 1 MO; *

amcinonide crea 3 MO



55

Drug Name DrugTier

Requirements/Limits

amcinonide lotn 2 MO; *

amcinonide oint 2 MO; *

betamethasonedipropionate (topical) 2 MO; *

betamethasonedipropionate augmentedcrea

2MO; *

betamethasonedipropionate augmentedgel

2MO; *

betamethasonedipropionate augmentedlotn

3MO

betamethasonedipropionate augmentedoint

3MO

betamethasone valeratecrea ex 0.1 % 2 MO; *

betamethasone valeratefoam ex 0.12 % 3 MO

betamethasone valeratelotn ex 0.1 % 2 MO; *

betamethasone valerateoint ex 0.1 % 2 MO; *

calcipotriene-betamethasonedipropionate

2MO; *

CAPEX 4 MO

clobetasol propionate creaex 2 MO; *

clobetasol propionateemollient base 2 MO; *

clobetasol propionateemulsion 4 MO

clobetasol propionate foamex 3 MO

clobetasol propionate gelex 2 MO; *

clobetasol propionate liqdex 2 MO; *

clobetasol propionate lotnex 4 MO

clobetasol propionate ointex 2 MO; *

Drug Name DrugTier

Requirements/Limits

clobetasol propionate shamex 3 MO

clobetasol propionate solnex 2 MO; *

CLOBEX LIQD (UseClobetasol Propionate) 4 MO

CLOBEX LOTN (UseClobetasol Propionate) NF MO

CLOBEX SHAM (UseClobetasol Propionate) NF MO

CLOCORTOLONEPIVALATE 4 MO

CLOCORTOLONEPIVALATE PUMP 4 MO

CLODERM 4 MO

CLODERM PUMP 4 MO

CORDRAN TAPE 4 MO

CUTIVATE (UseFluticasone Propionate) NF MO

DERMA-SMOOTHE/FSBODY (Use FluocinoloneAcetonide)

NFMO

DERMA-SMOOTHE/FSSCALP (Use FluocinoloneAcetonide)

NFMO

DERMATOP CREA (UsePrednicarbate) NF MO

DESONATE 4 MO

desonide crea ex 3 MO

desonide lotn ex 3 MO

desonide oint ex 2 MO; *

DESOWEN 0.05 % (UseDesonide) NF MO

desoximetasone crea ex0.25 % 3 MO

desoximetasone gel ex0.05 % 3 MO

DESOXIMETASONE OINTEX 0.05 % 4 MO



56

Drug Name DrugTier

Requirements/Limits

desoximetasone oint ex0.25 % 3 MO

diflorasone diacetate oint 1 MO; *

DIPROLENE (UseBetamethasoneDipropionate Augmented)

NFMO

DIPROLENE AF (UseBetamethasoneDipropionate Augmented)

NFMO

ELOCON CREA (UseMometasone Furoate) NF MO

ELOCON OINT (UseMometasone Furoate) NF MO

fluocinolone acetonide creaex 0.01 %, 0.025 % 2 MO; *

fluocinolone acetonide oilex 0.01 % 2 MO; *

fluocinolone acetonide ointex 0.025 % 2 MO; *

fluocinolone acetonide solnex 0.01 % 3 MO

fluocinonide crea ex 0.05%, 0.1 % 2 MO; *

fluocinonide emulsifiedbase 1 MO; *

fluocinonide gel ex 0.05 % 2 MO; *

fluocinonide oint ex 0.05 % 2 MO; *

fluocinonide soln ex 0.05 % 2 MO; *

fluticasone propionate creaex 0.05 % 1 MO; *

fluticasone propionate lotnex 0.05 % 4 MO

fluticasone propionate ointex 0.005 % 1 MO; *

halobetasol propionate 3 MO

HALOG CREA 4 MO

hydrocortisone (topical)crea 1 % 1 RX/OTC; MO; *

hydrocortisone (topical)crea 2.5 % 1 MO; *

Drug Name DrugTier

Requirements/Limits

hydrocortisone (topical) lotn2.5 % 2 MO; *

hydrocortisone (topical) oint1 % 1 RX/OTC; MO; *

hydrocortisone (topical) oint2.5 % 1 MO; *

hydrocortisone butyrate 1 MO; *

hydrocortisone butyratehydrophilic lipo base 2 MO; *

hydrocortisone valeratecrea 2 MO; *

hydrocortisone valerate oint 3 MO

KENALOG (UseTriamcinolone Acetonide(Topical))

3MO

LOCOID CREA (UseHydrocortisone Butyrate) NF MO

LOCOID LIPOCREAM(Use HydrocortisoneButyrate Hydrophilic LipoBase)

NF

MO

LOCOID LOTN 4 MO

LOCOID OINT (UseHydrocortisone Butyrate) NF MO

LOCOID SOLN (UseHydrocortisone Butyrate) NF MO

LUXIQ (UseBetamethasone Valerate) NF MO

mometasone furoate creaex 2 MO; *

mometasone furoate ointex 2 MO; *

mometasone furoate solnex 2 MO; *

OLUX (Use ClobetasolPropionate) NF MO

OLUX-E (Use ClobetasolPropionate Emulsion) NF MO

pramoxine-hc 1%-1% 1 MO; *

prednicarbate crea 1 MO; *

SYNALAR (UseFluocinolone Acetonide) NF MO



57

Drug Name DrugTier

Requirements/Limits

TACLONEX OINT (UseCalcipotriene-BetamethasoneDipropionate)

4

MO

TACLONEX SUSP 5 MO

TEMOVATE (UseClobetasol Propionate) NF MO

TEMOVATE E (UseClobetasol PropionateEmollient Base)

NFMO

TOPICORT LIQD 0.25 % 4 MO

TOPICORT OINT 0.05 % 4 MO

triamcinolone acetonide(topical) 2 MO; *

ULTRAVATE (UseHalobetasol Propionate) NF MO

VANOS (Use Fluocinonide) 4 MO

WESTCORT (UseHydrocortisone Valerate) NF MO

EmollientsLAC-HYDRIN (Use LacticAcid (Ammonium Lactate)) NF RX/OTC; MO

lactic acid (ammoniumlactate) crea 12 % 2 RX/OTC; MO; *

lactic acid (ammoniumlactate) lotn 12 % 2 RX/OTC; MO; *

Enzymes - TopicalSANTYL 3 MO

Immunomodulating Agents - TopicalALDARA (Use Imiquimod) NF MO

imiquimod crea ex 4 MO

ZYCLARA 5 MO

ZYCLARA PUMP 5 MO

Immunosuppressive Agents - TopicalELIDEL 4 MO

Drug Name DrugTier

Requirements/Limits

PROTOPIC (UseTacrolimus (Topical)) 4 MO

tacrolimus (topical) 2 MO; *

Keratolytic/Antimitotic AgentsCONDYLOX GEL 4 MO

CONDYLOX SOLN (UsePodofilox) NF MO

podofilox soln ex 1 MO; *

Local Anesthetics - TopicalEMLA (Use Lidocaine-Prilocaine) NF MO

lidocaine hcl gel ex 2 % 2 RX/OTC; MO; *

lidocaine hcl soln ex 4 % 2 MO; *

lidocaine oint ex 5 % 2 MO; *

lidocaine ptch ex 5 % 3 PA; MO

lidocaine-prilocaine crea 3 MO

LIDODERM (UseLidocaine) NF PA; MO

XYLOCAINE EX 4 % (UseLidocaine HCl) NF MO

Pigmenting-Depigmenting AgentsOXSORALEN 4 MO

Rosacea AgentsDOXYCYCLINE 4 MO

FINACEA GEL 4 MO

METROCREAM (UseMetronidazole (Topical)) NF MO

METROGEL (UseMetronidazole (Topical)) NF MO

METROLOTION (UseMetronidazole (Topical)) NF MO

metronidazole (topical) 3 MO

MIRVASO 4 PA; MO



58

Drug Name DrugTier

Requirements/Limits

NORITATE 4 MO

ORACEA 4 MO

SOOLANTRA 4 MO

Scabicides & PediculicidesEURAX 4 MO

lindane lotn 1 MO; *

malathion 3 MO

OVIDE 0.5 % (UseMalathion) NF MO

permethrin crea ex 5 % 2 MO; *

Wound Care ProductsREGRANEX 5 MO

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymesDigestive EnzymesCREON 3 MO

PANCREAZE 3 MO

PANCRELIPASE 4 MO

PERTZYE 4 MO

VIOKACE 4 MO

ZENPEP 10000UNIT-3000UNIT-16000UNIT,17000UNIT-5000UNIT-27000UNIT, 34000UNIT-10000UNIT-55000UNIT,51000UNIT-15000UNIT-82000UNIT, 68000UNIT-20000UNIT-109000UNIT,85000UNIT-25000UNIT-136000UNIT

4

MO

ZENPEP 136000UNIT-40000UNIT-218000UNIT 5 MO

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood Pressure

Drug Name DrugTier

Requirements/Limits

Carbonic Anhydrase Inhibitorsacetazolamide cp12 or 500mg 1 MO; *

acetazolamide tabs or 125mg 2 MO; *

acetazolamide tabs or 250mg 1 MO; *

DIAMOX (UseAcetazolamide) NF MO

methazolamide tabs or 25mg, 50 mg 1 MO; *

Diuretic CombinationsALDACTAZIDE 25MG-25MG (Use Spironolactone& Hydrochlorothiazide)

NFMO

ALDACTAZIDE 50MG-50MG 3 MO

amiloride &hydrochlorothiazide 1 MO; *

DYAZIDE (UseTriamterene &Hydrochlorothiazide)

NFMO

MAXZIDE (UseTriamterene &Hydrochlorothiazide)

NFMO

MAXZIDE-25 (UseTriamterene &Hydrochlorothiazide)

NFMO

spironolactone &hydrochlorothiazide 1 MO; *

triamterene &hydrochlorothiazide caps37.5mg-25mg

1MO; *

triamterene &hydrochlorothiazide caps50mg-25mg

2MO; *

triamterene &hydrochlorothiazide tabs37.5mg-25mg, 75mg-50mg

1MO; *

Loop Diureticsbumetanide tabs or 0.5 mg,1 mg, 2 mg 1 MO; *

BUMEX (Use Bumetanide) NF MO

DEMADEX (UseTorsemide) NF MO



59

Drug Name DrugTier

Requirements/Limits

EDECRIN 4 MO

furosemide soln ij 10 mg/ml 1 MO; *

furosemide soln or 10mg/ml 1 MO; *

furosemide soln or 8 mg/ml 2 MO; *

furosemide tabs or 20 mg,40 mg, 80 mg 1 MO; *

LASIX (Use Furosemide) NF MO

torsemide tabs or 10 mg,100 mg, 20 mg, 5 mg 1 MO; *

Potassium Sparing DiureticsALDACTONE (UseSpironolactone) NF MO

amiloride hcl 1 MO; *

DYRENIUM 4 MO

spironolactone tabs or 100mg, 25 mg, 50 mg 1 MO; *

Thiazides and Thiazide-Like Diureticschlorothiazide 500 mg 1 MO; *

chlorthalidone 25 mg, 50mg 2 MO; *

hydrochlorothiazide caps or12.5 mg 1 MO; *

hydrochlorothiazide tabs or12.5 mg, 25 mg, 50 mg 1 MO; *

indapamide 1 MO; *

methyclothiazide 2 MO; *

metolazone 1 MO; *

MICROZIDE (UseHydrochlorothiazide) NF MO

ZAROXOLYN (UseMetolazone) NF MO

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate HormonesBone Density Regulators

Drug Name DrugTier

Requirements/Limits

ACTONEL 150 MG (UseRisedronate Sodium) 3 QL(0.04 ea

daily); MOACTONEL 30 MG, 5 MG(Use Risedronate Sodium) 3 QL(1 ea daily);

MOACTONEL 35 MG (UseRisedronate Sodium) 3 QL(0.15 ea

daily); MOalendronate sodium tabs10 mg, 5 mg 1 MO; *

alendronate sodium tabs35 mg, 70 mg 1 QL(0.15 ea

daily); MO; *ATELVIA (Use RisedronateSodium) 3 QL(0.15 ea

daily); MOBONIVA SOLN IV 3MG/3ML (Use IbandronateSodium)

4QL(0.04 mldaily); MO

BONIVA TABS OR 150 MG(Use Ibandronate Sodium) NF QL(0.036 ea

daily); MO

calcitonin (salmon) 2 MO; *

etidronate disodium 200mg 2 MO; *

FORTEO 3 QL(0.09 mldaily)

FOSAMAX (UseAlendronate Sodium) NF QL(0.15 ea

daily); MO

FOSAMAX PLUS D 4 QL(0.15 eadaily); MO

ibandronate sodium soln iv3 mg/3ml 2 QL(0.04 ml

daily); MO; *ibandronate sodium tabs or150 mg 2 QL(0.036 ea

daily); MO; *MIACALCIN IJ 200UNIT/ML 4 MO

MIACALCIN NA 200UNIT/ACT (Use Calcitonin(Salmon))

NFMO

NATPARA 5 PA; LA

PROLIA 3 QL(0.01 mldaily)

RECLAST (Use ZoledronicAcid) NF QL(0.28 ml

daily)risedronate sodium tabs150 mg 2 QL(0.04 ea

daily); MO; *risedronate sodium tabs 30mg, 5 mg 2 QL(1 ea daily);

MO; *



60

Drug Name DrugTier

Requirements/Limits

risedronate sodium tabs 35mg 2 QL(0.15 ea

daily); MO; *risedronate sodium tbec 35mg 2 QL(0.15 ea

daily); MO; *

XGEVA 5 QL(0.243 mldaily)

zoledronic acid conc 4mg/5ml 5

zoledronic acid soln 5mg/100ml 2 QL(0.28 ml

daily); *ZOLEDRONIC ACID SOLR4 MG 5

ZOMETA CONC 4MG/5ML (Use ZoledronicAcid)

5

CorticotropinH.P. ACTHAR 5 PA; LA

Fertility Regulatorschorionic gonadotropin solrim 4

Growth Hormone Receptor AntagonistsSOMAVERT 5 LA

Growth Hormone Releasing Hormones (GHRH)EGRIFTA 5

Growth HormonesGENOTROPIN 5 MG 5 PA

GENOTROPIN MINIQUICK0.4 MG 5 PA

HUMATROPE 5 PA

HUMATROPE COMBOPACK 5 PA

NORDITROPIN FLEXPRO10 MG/1.5ML, 5 MG/1.5ML 5 PA

NUTROPIN AQ NUSPIN20 5 PA

NUTROPIN AQ PEN 20MG/2ML 5 PA

OMNITROPE SOLN 10MG/1.5ML, 5 MG/1.5ML 5 PA

Drug Name DrugTier

Requirements/Limits

SEROSTIM 4 MG, 6 MG 5 PA

TEV-TROPIN 5 PA

ZOMACTON 5 MG 5 PA

Hormone Receptor ModulatorsEVISTA (Use RaloxifeneHCl) NF QL(1 ea daily);

MO

raloxifene hcl 2 QL(1 ea daily);MO; *

Insulin-Like Growth Factors (Somatomedins)INCRELEX 4 LA

LHRH/GnRH Agonist Analog PituitaryLUPRON DEPOT-PED11.25 MG 5 3 Month Kit;

LUPRON DEPOT-PED11.25 MG, 7.5 MG 5

LUPRON DEPOT-PED 15MG 4

LUPRON DEPOT-PED 30MG 5

SYNAREL 5 MO

Metabolic Modifierscalcitriol caps or 0.25 mcg,0.5 mcg 2 MO; *

calcitriol soln or 1 mcg/ml 2 MO; *

CARNITOR TABS OR 330MG (Use Levocarnitine(Metabolic Modifiers))

NFMO

CYSTADANE 4 LA

doxercalciferol caps or 0.5mcg, 1 mcg, 2.5 mcg 2 MO; *

FABRAZYME 35 MG 5 LA

HECTOROL CAPS OR 0.5MCG, 2.5 MCG (UseDoxercalciferol)

4MO

HECTOROL CAPS OR 1MCG (Use Doxercalciferol) 5 MO

KUVAN TBSO 100 MG 5 LA



61

Drug Name DrugTier

Requirements/Limits

levocarnitine (metabolicmodifiers) tabs or 330 mg 1 MO; *

LUMIZYME 5 LA

MYALEPT 5 LA

MYOZYME 5 LA

NAGLAZYME 5 LA

ORFADIN 3 LA

paricalcitol caps or 1 mcg 3 MO

paricalcitol caps or 2 mcg,4 mcg 2 MO; *

ROCALTROL (UseCalcitriol) NF MO

SENSIPAR 30 MG 3

SENSIPAR 60 MG, 90 MG 5

VIMIZIM 5

ZEMPLAR CAPS OR 1MCG, 2 MCG, 4 MCG (UseParicalcitol)

NFMO

Posterior Pituitary HormonesDDAVP (UseDesmopressin AcetateRefrigerated)

NFMO

DDAVP (UseDesmopressin AcetateSpray)

NFMO

DDAVP (UseDesmopressin Acetate) NF MO

desmopressin acetaterefrigerated 1 MO; *

desmopressin acetate solnij 4 mcg/ml 2 MO; *

desmopressin acetatespray 3 MO

desmopressin acetatespray refrigerated 3 MO

desmopressin acetate tabsor 0.1 mg, 0.2 mg 2 MO; *

Drug Name DrugTier

Requirements/Limits

STIMATE 4

Prolactin Inhibitorscabergoline 3 MO

Somatostatic Agentsoctreotide acetate 100mcg/ml 4

octreotide acetate 1000mcg/5ml, 200 mcg/ml, 50mcg/ml

1*

SANDOSTATIN 100MCG/ML (Use OctreotideAcetate)

5

SANDOSTATIN 200MCG/ML, 50 MCG/ML(Use Octreotide Acetate)

NF

SANDOSTATIN LARDEPOT 20 MG, 30 MG 5

SIGNIFOR 5 LA

SIGNIFOR LAR 20 MG 5 QL(0.11 eadaily)

SIGNIFOR LAR 40 MG, 60MG 5 QL(0.036 ea

daily)

SOMATULINE DEPOT 5

Vasopressin Receptor AntagonistsSAMSCA 5

ESTROGENS - Hormone Replacement/ModifyingDrugsEstrogen CombinationsACTIVELLA (Use Estradiol& Norethindrone Acetate) NF AL; MO

ANGELIQ 0.5MG-1MG 4 AL; MO

CLIMARA PRO 4 AL; MO

COMBIPATCH 4 AL; MO

DUAVEE 4 MO

estradiol & norethindroneacetate 2 AL; MO; *



62

Drug Name DrugTier

Requirements/Limits

estradiol-norgestimate 2 AL; MO; *

FEMHRT LOW DOSE (UseNorethindrone Acetate-Ethinyl Estradiol)

4AL; MO

norethindrone acetate-ethinyl estradiol 2.5mcg-0.5mg

2AL; MO; *

PREMPHASE 4 AL; MO

PREMPRO 4 AL; MO

EstrogensALORA 4 AL; MO

CENESTIN 4 AL

CLIMARA (Use Estradiol) NF AL; MO

DELESTROGEN 20MG/ML,40 MG/ML (UseEstradiol Valerate)

NFMO

DIVIGEL 4 MO

ELESTRIN 4 AL; MO

ENJUVIA 0.3 MG, 0.45MG, 0.9 MG, 1.25 MG 4 AL; MO

ENJUVIA 0.625 MG 4 AL

estradiol cypionate oil im 2 MO; *

estradiol pttw td 0.025mg/24hr, 0.0375 mg/24hr,0.05 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr

2

AL; MO; *

estradiol ptwk td 0.025mg/24hr, 0.05 mg/24hr,0.06 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr

2

AL; MO; *

estradiol tabs or 0.5 mg, 1mg, 2 mg 2 AL; MO; *

estradiol valerate oil im 10mg/ml, 20 mg/ml, 40 mg/ml 1 MO; *

estropipate 0.75 mg, 1.5mg 2 AL; MO; *

Drug Name DrugTier

Requirements/Limits

EVAMIST 4 AL; MO

MENOSTAR 4 AL; MO

MINIVELLE 4 AL; MO

PREMARIN TABS OR 0.3MG, 0.45 MG, 0.625 MG,0.9 MG, 1.25 MG

4AL; MO

VIVELLE-DOT (UseEstradiol) 4 AL; MO

FLUOROQUINOLONES - Drugs to Treat BacterialInfectionsFluoroquinolonesAVELOX ABC PACK (UseMoxifloxacin HCl) 4 MO

AVELOX TABS OR 400MG (Use Moxifloxacin HCl) 4 MO

CIPRO I.V.-IN D5W200MG/100ML-5% (UseCiprofloxacin in D5W)

NF

CIPRO I.V.-IN D5W400MG/200ML-5% (UseCiprofloxacin in D5W)

NFMO

CIPRO SUSR 5GM/100ML, 500 MG/5ML(Use Ciprofloxacin)

3MO

CIPRO TABS 250 MG, 500MG (Use CiprofloxacinHCl)

NFMO

CIPRO XR (UseCiprofloxacin-CiprofloxacinHCl)

NFMO

ciprofloxacin hcl tabs or100 mg, 250 mg, 500 mg,750 mg

1MO; *

ciprofloxacin in d5w200mg/100ml-5% 2 *

ciprofloxacin in d5w400mg/200ml-5% 1 MO; *

ciprofloxacin susr or 250mg/5ml, 500 mg/5ml 2 MO; *

ciprofloxacin-ciprofloxacinhcl 3 MO



63

Drug Name DrugTier

Requirements/Limits

LEVAQUIN SOLN IV250MG/50ML-5%,500MG/100ML-5% (UseLevofloxacin in D5W)

NF

LEVAQUIN SOLN IV750MG/150ML-5% (UseLevofloxacin in D5W)

NFMO

LEVAQUIN SOLN OR 25MG/ML (Use Levofloxacin) NF MO

LEVAQUIN TABS OR 250MG, 750 MG (UseLevofloxacin)

NFMO

LEVAQUIN TABS OR 500MG (Use Levofloxacin) 4 MO

levofloxacin in d5w250mg/50ml-5%,500mg/100ml-5%

1*

levofloxacin in d5w750mg/150ml-5% 1 MO; *

levofloxacin soln iv 25mg/ml 2 *

levofloxacin soln or 25mg/ml 3 MO

levofloxacin tabs or 250mg, 500 mg, 750 mg 2 MO; *

moxifloxacin hcl tabs or400 mg 2 MO; *

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal DrugsGallstone Solubilizing AgentsACTIGALL (Use Ursodiol) NF MO

CHENODAL 5 LA

URSO 250 (Use Ursodiol) NF MO

URSO FORTE (UseUrsodiol) NF MO

ursodiol caps or 300 mg 2 MO; *

ursodiol tabs or 250 mg,500 mg 3 MO

Gastrointestinal Antiallergy Agentscromolyn sodium(mastocytosis) 4 MO

Drug Name DrugTier

Requirements/Limits

GASTROCROM (UseCromolyn Sodium(Mastocytosis))

NFMO

Gastrointestinal Chloride Channel ActivatorsAMITIZA 3 MO

Gastrointestinal Stimulantsmetoclopramide hcl soln ij5 mg/ml 2 MO; *

metoclopramide hcl soln or10 mg/10ml, 5 mg/5ml 2 MO; *

metoclopramide hcl tabs or10 mg, 5 mg 1 MO; *

REGLAN (UseMetoclopramide HCl) NF MO

Inflammatory Bowel AgentsAPRISO 3 MO

ASACOL HD 3 MO

AZULFIDINE (UseSulfasalazine) NF MO

AZULFIDINE EN-TABS(Use Sulfasalazine) NF MO

balsalazide disodium 3 MO

CANASA 3 MO

CIMZIA 5 PA

CIMZIA STARTER KIT 5 PA

COLAZAL (UseBalsalazide Disodium) NF MO

DELZICOL 3 MO

DIPENTUM 5 MO

ENTYVIO 5 PA

LIALDA 3 MO

mesalamine enem re 4 MO

mesalamine w/ cleanser 4 MO



64

Drug Name DrugTier

Requirements/Limits

PENTASA 4 MO

REMICADE 5 PA

ROWASA (UseMesalamine w/ Cleanser) NF MO

sulfasalazine tabs or 2 MO; *

sulfasalazine tbec or 2 MO; *

Intestinal Acidifierslactulose (encephalopathy) 2 MO; *

Irritable Bowel Syndrome (IBS) Agentsalosetron hcl 5 MO

LINZESS 3 MO

LOTRONEX (UseAlosetron HCl) 5 MO

Peripheral Opioid Receptor AntagonistsMOVANTIK 4 MO

RELISTOR KIT 12MG/0.6ML 4

RELISTOR SOLN 12MG/0.6ML 4 MO

RELISTOR SOLN 8MG/0.4ML 5 MO

Phosphate Binder AgentsAURYXIA 5 MO

calcium acetate (phosphatebinder) 2 MO; *

FOSRENOL 3 MO

PHOSLO (Use CalciumAcetate (PhosphateBinder))

NFMO

PHOSLYRA 4 MO

RENAGEL 800 MG 4 MO

RENVELA 3 MO

SEVELAMERCARBONATE 3 MO

Drug Name DrugTier

Requirements/Limits

VELPHORO 5 MO

Short Bowel Syndrome (SBS) AgentsGATTEX 5 PA; LA

GENITOURINARY AGENTS - MISCELLANEOUS- Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary SystemAlkalinizerspotassium citrate(alkalinizer) 1080 mg 2 MO; *

potassium citrate(alkalinizer) 540 mg 1 MO; *

UROCIT-K 10 (UsePotassium Citrate(Alkalinizer))

NFMO

UROCIT-K 5 (UsePotassium Citrate(Alkalinizer))

NFMO

Cystinosis AgentsCYSTAGON 4

PROCYSBI 4 LA

Genitourinary Irrigantsacetic acid ir 0.25 % 1 MO; *

neomycin/polymyxin b gu 1 MO; *

sodium chloride (guirrigant) 2 MO; *

Interstitial Cystitis AgentsELMIRON 4 MO

Prostatic Hypertrophy Agentsalfuzosin hcl 2 MO; *

AVODART (UseDutasteride) 3 GL; MO

CARDURA XL 4 MO

dutasteride 2 GL; MO; *

finasteride tabs or 2 GL; MO; *



65

Drug Name DrugTier

Requirements/Limits

FLOMAX (Use TamsulosinHCl) NF MO

JALYN 3 GL; MO

PROSCAR (UseFinasteride) NF GL; MO

RAPAFLO 4 MO

tamsulosin hcl 2 MO; *

UROXATRAL (UseAlfuzosin HCl) NF MO

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinationscolchicine w/ probenecid 1 MO; *

Gout Agents

allopurinol tabs or 100 mg 1 QL(8 ea daily);MO; *

allopurinol tabs or 300 mg 1 QL(2 ea daily);MO; *

COLCHICINE TABS OR 3 MO

COLCRYS 3 MO

ULORIC 3 MO

ZYLOPRIM 100 MG (UseAllopurinol) NF QL(8 ea daily);

MOZYLOPRIM 300 MG (UseAllopurinol) NF QL(2 ea daily);

MOUricosuricsprobenecid 2 MO; *

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood DisordersBradykinin B2 Receptor AntagonistsFIRAZYR 5

Complement InhibitorsBERINERT 5

CINRYZE 5 LA

Drug Name DrugTier

Requirements/Limits

RUCONEST 5

Hematorheologic Agentspentoxifylline tbcr or 2 MO; *

Plasma Kallikrein InhibitorsKALBITOR 5

Platelet Aggregation InhibitorsAGGRENOX 3 MO

AGRYLIN (Use AnagrelideHCl) NF MO

anagrelide hcl 1 MO; *

ASPIRIN/DIPYRIDAMOLE 3 MO

BRILINTA 3 MO

cilostazol 1 MO; *

clopidogrel bisulfate 300mg 2 *

clopidogrel bisulfate 75 mg 2 MO; *

dipyridamole tabs or 25mg, 50 mg, 75 mg 2 AL; MO; *

EFFIENT 3 MO

PERSANTINE (UseDipyridamole) NF AL; MO

PLAVIX 300 MG (UseClopidogrel Bisulfate) NF

PLAVIX 75 MG (UseClopidogrel Bisulfate) NF MO

PLETAL (Use Cilostazol) NF MO

ticlopidine hcl 2 AL; *

ZONTIVITY 3 MO

HEMATOPOIETIC AGENTS - Drugs to TreatBlood DisordersAgents for Gaucher DiseaseCERDELGA 5 PA



66

Drug Name DrugTier

Requirements/Limits

CEREZYME 5 LA

ELELYSO 5

VPRIV 5

ZAVESCA 5 LA

Agents for Sickle Cell AnemiaDROXIA 4 MO

Hematopoietic Growth FactorsARANESP ALBUMINFREE SOLN 10MCG/0.4ML, 25 MCG/ML,40 MCG/ML, 60 MCG/ML

4

PA

ARANESP ALBUMINFREE SOLN 100 MCG/ML,150 MCG/0.75ML, 200MCG/ML, 300 MCG/ML

5

PA

ARANESP ALBUMINFREE SOSY 100MCG/0.5ML, 150MCG/0.3ML, 200MCG/0.4ML, 300MCG/0.6ML, 500 MCG/ML

5

PA

ARANESP ALBUMINFREE SOSY 25MCG/0.42ML, 40MCG/0.4ML, 60MCG/0.3ML

4

PA

EPOGEN 10000 UNIT/ML,20000 UNIT/ML, 3000UNIT/ML, 4000 UNIT/ML

4PA

EPOGEN 2000 UNIT/ML 4 PA; ProcritPreferred

GRANIX 5 PA

LEUKINE 5 PA

MIRCERA 100MCG/0.3ML, 50MCG/0.3ML, 75MCG/0.3ML

4

PA

MIRCERA 200 MCG/0.3ML 5 PA

NEULASTA 5 PA

Drug Name DrugTier

Requirements/Limits

NEULASTA DELIVERYKIT 5 PA

NEUMEGA 3 PA

NEUPOGEN 5 PA

PROCRIT 10000 UNIT/ML,2000 UNIT/ML, 3000UNIT/ML, 4000 UNIT/ML

3PA

PROCRIT 20000 UNIT/ML,40000 UNIT/ML 5 PA

PROMACTA 12.5 MG 5 QL(12 eadaily); LA

PROMACTA 25 MG 5 QL(6 ea daily);LA



ZARXIO 5 PA

Stem Cell MobilizersMOZOBIL 5

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood DisordersHemostatics - SystemicAMICAR TABS 1000 MG 5 MO

AMINOCAPROIC ACIDTABS OR 1000 MG 5 MO

aminocaproic acid tabs or500 mg 3 MO

CYKLOKAPRON (UseTranexamic Acid) NF

LYSTEDA (UseTranexamic Acid) NF MO

tranexamic acid soln iv 100mg/ml 1 *

tranexamic acid tabs or 650mg 3 MO

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTSBarbiturate Hypnotics



67

Drug Name DrugTier

Requirements/Limits

BUTISOL SODIUM 4 AL; MO

pentobarbital sodium soln ij 2 *

phenobarbital elix or 20mg/5ml 2 AL; MO; *

phenobarbital soln or 20mg/5ml 2 AL; MO; *

phenobarbital tabs or 100mg, 15 mg, 16.2 mg, 30mg, 32.4 mg, 60 mg, 64.8mg, 97.2 mg

2

AL; MO; *

Hypnotics - Tricyclic AgentsSILENOR 4 MO

Non-Barbiturate HypnoticsAMBIEN 10 MG (UseZolpidem Tartrate) NF AL; QL(1 ea

daily); MOAMBIEN 5 MG (UseZolpidem Tartrate) NF AL; QL(2 ea

daily); MOAMBIEN CR 12.5 MG (UseZolpidem Tartrate) NF AL; QL(1 ea

daily); MOAMBIEN CR 6.25 MG (UseZolpidem Tartrate) NF AL; QL(2 ea

daily); MO

EDLUAR 4 AL; MO

eszopiclone 2 AL; MO; *

flurazepam hcl 1 MO; *

HALCION (Use Triazolam) NF MO

INTERMEZZO 4 AL; MO

LUNESTA (UseEszopiclone) 4 AL; MO

RESTORIL (UseTemazepam) NF MO

SONATA (Use Zaleplon) NF AL; MO

temazepam 2 MO; *

triazolam 2 MO; *

zaleplon 2 AL; MO; *

Drug Name DrugTier

Requirements/Limits

zolpidem tartrate tabs 10mg 2 AL; QL(1 ea

daily); MO; *

zolpidem tartrate tabs 5 mg 2 AL; QL(2 eadaily); MO; *

zolpidem tartrate tbcr 12.5mg 4 AL; QL(1 ea

daily); MOzolpidem tartrate tbcr 6.25mg 4 AL; QL(2 ea

daily); MO

ZOLPIMIST 4 AL; MO

Orexin Receptor Antagonists

BELSOMRA 10 MG 4 PA; QL(2 eadaily); MO

BELSOMRA 15 MG, 20MG 4 PA; QL(1 ea

daily); MO

BELSOMRA 5 MG 4 PA; QL(4 eadaily); MO

Selective Melatonin Receptor AgonistsHETLIOZ 5 PA

ROZEREM 4 MO

LAXATIVES - Bowel Treatment Drugs

Laxative Combinationsbisacodyl-peg 3350-potchloride-sod bicarb-sodchloride

2MO; *

COLYTE-FLAVOR PACKS227.1GM-21.5GM-5.53GM-2.82GM-6.36GM

4

COLYTE-FLAVOR PACKS240GM-22.72GM-5.84GM-2.98GM-6.72GM (Use PEG3350-KCl-Sod Bicarb-SodChloride-Sod Sulfate)

NF

MO

GOLYTELY 227.1GM-21.5GM-5.53GM-2.82GM-6.36GM

4MO

GOLYTELY 236GM-22.74GM-5.86GM-2.97GM-6.74GM (Use PEG 3350-KCl-Sod Bicarb-SodChloride-Sod Sulfate)

NF

MO

MOVIPREP 4 MO



68

Drug Name DrugTier

Requirements/Limits

NULYTELY/FLAVORPACKS (Use PEG 3350-Potassium Chloride-SodBicarbonate-Sod Chloride)

NF

MO

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 2 MO; *

peg 3350-potassiumchloride-sod bicarbonate-sod chloride

2MO; *

PREPOPIK 4 MO

SUPREP BOWEL PREP 4 MO

Laxatives - Miscellaneouslactulose 2 MO; *

polyethylene glycol 3350pack or 2 RX/OTC; MO; *

polyethylene glycol 3350powd or 2 RX/OTC; MO; *

Saline LaxativesOSMOPREP 4 MO

LOCAL ANESTHETICS-Parenteral - Drugs forNumbingLocal Anesthetics - Amideslidocaine hcl (local anesth.)1 %, 2 % 1 MO; *

XYLOCAINE IJ 1 %, 2 %(Use Lidocaine HCl (LocalAnesth.))

NFMO

XYLOCAINE-MPF 1 %(Use Lidocaine HCl (LocalAnesth.))

NFMO

MACROLIDES - Drugs to Treat BacterialInfectionsAzithromycinazithromycin solr iv 500 mg 2 MO; *

azithromycin susr or 100mg/5ml, 200 mg/5ml 2 MO; *

azithromycin tabs or 250mg, 500 mg, 600 mg 2 MO; *

ZITHROMAX SOLR IV 500MG (Use Azithromycin) NF MO

Drug Name DrugTier

Requirements/Limits

ZITHROMAX SUSR OR100 MG/5ML, 200 MG/5ML(Use Azithromycin)

NFMO

ZITHROMAX TABS OR250 MG, 500 MG, 600 MG(Use Azithromycin)

NFMO

ZITHROMAX TRI-PAK(Use Azithromycin) NF MO

ZITHROMAX Z-PAK (UseAzithromycin) NF MO

ZMAX 4 MO

ClarithromycinBIAXIN (UseClarithromycin) NF MO

BIAXIN XL (UseClarithromycin) NF MO

BIAXIN XL PAC (UseClarithromycin) NF MO

clarithromycin susr or 125mg/5ml 2 MO; *

clarithromycin susr or 250mg/5ml 3 MO

clarithromycin tabs or 250mg, 500 mg 2 MO; *

clarithromycin tb24 or 500mg 2 MO; *

Erythromycins

E.E.S. GRANULES 4 QL(100 mldaily); MO

ERYPED 200 4 QL(100 mldaily); MO

ERYPED 400 4 QL(50 mldaily); MO

erythromycin base cpep250 mg 2 QL(16 ea

daily); MO; *erythromycin base tabs 250mg 2 QL(16 ea

daily); MO; *erythromycin base tabs 500mg 2 QL(8 ea daily);

MO; *erythromycinethylsuccinate tabs or 2 QL(10 ea

daily); MO; *

erythromycin lactobionate 2 500 MG;QL(8ea daily); *



69

Drug Name DrugTier

Requirements/Limits

PCE 333 MG 4 QL(12 eadaily); MO

PCE 500 MG 4 QL(8 ea daily);MO

FidaxomicinDIFICID 5 MO

MEDICAL DEVICES

Bandages-Dressings-Tapegauze pads 2" x 2" 1 RX/OTC; MO

Misc. DevicesALCOHOL PADS 3 RX/OTC; MO

Parenteral Therapy SuppliesINSULIN SYRINGES ANDPEN NEEDLES 3 MO

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadachesMigraine CombinationsMIGERGOT 4 MO

TREXIMET 4 MO

Migraine Products - NSAIDsCAMBIA 4 MO

Migraine ProductsD.H.E. 45 (UseDihydroergotamineMesylate)

NFMO

dihydroergotaminemesylate soln ij 1 mg/ml 1 MO; *

DIHYDROERGOTAMINEMESYLATE SOLN NA 4MG/ML

5MO

ERGOMAR 4

MIGRANAL 5 MO

Serotonin Agonists

almotriptan malate 2 QL(0.4 eadaily); MO; *

Drug Name DrugTier

Requirements/Limits

AMERGE (Use NaratriptanHCl) NF QL(0.3 ea

daily); MOAXERT (Use AlmotriptanMalate) 4 QL(0.4 ea

daily); MO

FROVA 4 QL(0.6 eadaily); MO

IMITREX SOLN SC 6MG/0.5ML (UseSumatriptan Succinate)

NFQL(0.27 mldaily); MO

IMITREX STATDOSEREFILL 4 MG/0.5ML (UseSumatriptan Succinate)


IMITREX STATDOSEREFILL 6 MG/0.5ML (UseSumatriptan Succinate)


IMITREX STATDOSESYSTEM 4 MG/0.5ML (UseSumatriptan Succinate)


IMITREX STATDOSESYSTEM 6 MG/0.5ML (UseSumatriptan Succinate)


IMITREX TABS OR 100MG (Use SumatriptanSuccinate)


IMITREX TABS OR 25 MG(Use SumatriptanSuccinate)


IMITREX TABS OR 50 MG(Use SumatriptanSuccinate)


MAXALT 10 MG (UseRizatriptan Benzoate) NF QL(0.4 ea

daily); MOMAXALT 5 MG (UseRizatriptan Benzoate) NF QL(0.8 ea

daily); MOMAXALT-MLT 10 MG (UseRizatriptan Benzoate) NF QL(0.4 ea

daily); MOMAXALT-MLT 5 MG (UseRizatriptan Benzoate) NF QL(0.8 ea

daily); MO

naratriptan hcl 1 QL(0.3 eadaily); MO; *

RELPAX 4 QL(0.2 eadaily); MO

rizatriptan benzoate tabs10 mg 2 QL(0.4 ea

daily); MO; *rizatriptan benzoate tabs 5mg 2 QL(0.8 ea

daily); MO; *



70

Drug Name DrugTier

Requirements/Limits

rizatriptan benzoate tbdp10 mg 3 QL(0.4 ea

daily); MOrizatriptan benzoate tbdp 5mg 3 QL(0.8 ea

daily); MOsumatriptan succinate soajsc 4 mg/0.5ml 2 QL(0.14 ml

daily); MO; *sumatriptan succinate soajsc 6 mg/0.5ml 2 QL(0.27 ml

daily); MO; *sumatriptan succinate soctsc 4 mg/0.5ml 2 QL(0.14 ml

daily); MO; *sumatriptan succinate soctsc 6 mg/0.5ml 2 QL(0.27 ml

daily); MO; *sumatriptan succinate solnsc 6 mg/0.5ml 4 QL(0.27 ml

daily); MOsumatriptan succinate sosysc 6 mg/0.5ml 2 *

sumatriptan succinate tabsor 100 mg 2 QL(0.3 ea

daily); MO; *sumatriptan succinate tabsor 25 mg 2 QL(0.9 ea

daily); MO; *sumatriptan succinate tabsor 50 mg 2 QL(0.6 ea

daily); MO; *SUMAVEL DOSEPRO 4MG/0.5ML 4 QL(0.14 ml

daily)SUMAVEL DOSEPRO 6MG/0.5ML 4 QL(0.14 ml

daily); MO

zolmitriptan tabs 2.5 mg 2 QL(4 ea daily);MO; *

zolmitriptan tabs 5 mg 2 QL(2 ea daily);MO; *

zolmitriptan tbdp 2.5 mg 2 QL(4 ea daily);MO; *

zolmitriptan tbdp 5 mg 2 QL(2 ea daily);MO; *

ZOMIG NASAL SPRAY 4 QL(2 ea daily);MO

ZOMIG SOLN NA 2.5 MG 4 QL(4 ea daily);MO

ZOMIG TABS OR 2.5 MG(Use Zolmitriptan) NF QL(4 ea daily);

MOZOMIG TABS OR 5 MG(Use Zolmitriptan) NF QL(2 ea daily);

MOZOMIG ZMT 2.5 MG (UseZolmitriptan) NF QL(4 ea daily);

MOZOMIG ZMT 5 MG (UseZolmitriptan) NF QL(2 ea daily);

MO

Drug Name DrugTier

Requirements/Limits

MINERALS & ELECTROLYTES

Chlorideammonium chloride soln iv 2 MO; *

Electrolyte Mixturesdextrose in lactated ringers 1 *

dextrose w/ sodiumchloride 0.45%-2.5% 2 *

dextrose w/ sodiumchloride 0.45%-5% 1 *

dextrose w/ sodiumchloride 0.9%-5% 1 MO; *

lactated ringer's 1 *

parenteral electrolytes 2 B/D; *

potassium chloride indextrose & sodium chloride0.45%-20meq/l-5%

1*

Fluoridesodium fluoride tabs or 1mg 1 *

Magnesiummagnesium sulfate soln ij50 % 1 MO; *

PotassiumK-TAB 10 MEQ (UsePotassium Chloride) NF MO

MICRO-K (Use PotassiumChloride) NF MO

potassium chloride cpcr or10 meq, 8 meq 2 MO; *

POTASSIUM CHLORIDEER 2 MO; *

potassium chloridemicroencapsulated crystalscr

2MO; *

potassium chloride soln iv 2meq/ml 1 MO; *

potassium chloride soln or10 % 2 *

potassium chloride soln or20 % 2 MO; *



71

Drug Name DrugTier

Requirements/Limits

potassium chloride tbcr or10 meq, 8 meq 2 MO; *

Sodiumsodium chloride soln iv0.45 % 2 *

sodium chloride soln iv 0.9% 2 MO; *

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical Orallidocaine hcl (mouth-throat)2 % 2 MO; *

Anti-infectives - Throatclotrimazole lozg mt 2 MO; *

clotrimazole troc mt 2 MO; *

nystatin (mouth-throat) 2 MO; *

Antiseptics - Mouth/Throatchlorhexidine gluconate(mouth-throat) 1 MO; *

PERIDEX (UseChlorhexidine Gluconate(Mouth-Throat))

NFMO

Steroids - Mouth/Throattriamcinolone acetonide(mouth) 2 MO; *

Throat Products - Misc.cevimeline hcl 3 MO

EVOXAC (Use CevimelineHCl) NF MO

pilocarpine hcl (oral) 2 MO; *

SALAGEN (UsePilocarpine HCl (Oral)) NF MO

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat SpasmsCentral Muscle Relaxants

baclofen tabs or 10 mg 2 QL(8 ea daily);MO; *

baclofen tabs or 20 mg 2 QL(4 ea daily);MO; *

Drug Name DrugTier

Requirements/Limits

carisoprodol tabs or 250mg, 350 mg 2 AL; MO; *

chlorzoxazone 2 AL; MO; *

cyclobenzaprine hcl tabs or10 mg, 5 mg, 7.5 mg 2 AL; MO; *

metaxalone 3 AL; MO

methocarbamol tabs or 500mg, 750 mg 2 AL; MO; *

orphenadrine citrate soln ij30 mg/ml 2 AL; MO; *

orphenadrine citrate tb12 or100 mg 2 AL; MO; *

PARAFON FORTE DSC(Use Chlorzoxazone) NF AL; MO

ROBAXIN TABS OR 500MG (Use Methocarbamol) NF AL; MO

ROBAXIN-750 (UseMethocarbamol) NF AL; MO

SKELAXIN (UseMetaxalone) NF AL; MO

SOMA 350 MG (UseCarisoprodol) NF AL; MO

tizanidine hcl caps or 2 mg 3 QL(18 eadaily); MO

tizanidine hcl caps or 4 mg 3 QL(9 ea daily);MO

tizanidine hcl caps or 6 mg 3 QL(6 ea daily);MO

tizanidine hcl tabs or 2 mg 2 QL(18 eadaily); MO; *

tizanidine hcl tabs or 4 mg 2 QL(9 ea daily);MO; *

ZANAFLEX CAPS 2 MG(Use Tizanidine HCl) NF QL(18 ea

daily); MOZANAFLEX CAPS 4 MG(Use Tizanidine HCl) NF QL(9 ea daily);

MOZANAFLEX CAPS 6 MG(Use Tizanidine HCl) NF QL(6 ea daily);

MOZANAFLEX TABS 4 MG(Use Tizanidine HCl) NF QL(9 ea daily);

MODirect Muscle RelaxantsDANTRIUM (UseDantrolene Sodium) NF MO



72

Drug Name DrugTier

Requirements/Limits

dantrolene sodium caps or100 mg, 50 mg 1 MO; *

dantrolene sodium caps or25 mg 3 MO

Muscle Relaxant Combinationscarisoprodol w/ aspirin 3 AL; MO

carisoprodol w/ aspirin &codeine 2 AL; MO; *

orphenadrine w/ aspirin &caff 2 AL; *

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or SinusNasal Agent CombinationsDYMISTA 4 MO

Nasal Anti-infectivesBACTROBAN NASAL 4 MO

Nasal AntiallergyASTEPRO (Use AzelastineHCl) 3 MO

azelastine hcl 2 MO; *

olopatadine hcl (nasal) 2 MO; *

PATANASE (UseOlopatadine HCl (Nasal)) 4 MO

Nasal AnticholinergicsATROVENT (UseIpratropium Bromide(Nasal))

NFMO

ipratropium bromide (nasal) 2 MO; *

Nasal SteroidsBECONASE AQ 4 MO

budesonide (nasal) 2 MO; *

FLONASE (UseFluticasone Propionate(Nasal))

NFRX/OTC; MO

flunisolide (nasal) 2 MO; *

Drug Name DrugTier

Requirements/Limits

fluticasone propionate(nasal) 2 RX/OTC; MO; *

NASONEX 3 MO

OMNARIS 4 MO

QNASL 4 MO

QNASL CHILDRENS 4 MO

RHINOCORT AQUA (UseBudesonide (Nasal)) 4 MO

triamcinolone acetonide(nasal) 2 RX/OTC; MO; *

VERAMYST 4 MO

ZETONNA 4 MO

Sympathomimetic Decongestantstetrahydrozoline hcl soln na 2 *

NEUROMUSCULAR AGENTS - Drugs toRelax/Paralyze MusclesALS AgentsRILUTEK (Use Riluzole) 5 MO

riluzole 2 MO; *

Neuromuscular Blocking Agent - NeurotoxinsBOTOX 4 PA

XEOMIN 4 PA

NUTRIENTS

Carbohydratesdextrose soln iv 10 % 2 B/D; *

dextrose soln iv 5 % 1 MO; B/D; *

Lipidsfat emulsion 20 gm/100ml 3 B/D

Proteinsamino acid infusion 15% 4 B/D



73

Drug Name DrugTier

Requirements/Limits

AMINOSYN II 15% (Useamino acid infusion) 4 B/D

CLINIMIX2.75%/DEXTROSE 5% 4 B/D

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Beta-blockers - OphthalmicBETAGAN (UseLevobunolol HCl) NF MO

betaxolol hcl (ophth) 1 MO; *

BETIMOL 4 MO

BETOPTIC-S 3 MO

carteolol hcl (ophth) 1 MO; *

COMBIGAN 4 MO

COSOPT (UseDorzolamide HCl-TimololMaleate)

NFMO

COSOPT PF 4 MO

dorzolamide hcl-timololmaleate 2 MO; *

ISTALOL 3 MO

levobunolol hcl 0.5 % 2 MO; *

metipranolol 1 MO; *

timolol maleate (ophth)solg 0.25 %, 0.5 % 2 Gel Forming

Soln;MO; *timolol maleate (ophth)soln 0.25 %, 0.5 % 1 MO; *

TIMOPTIC (Use TimololMaleate (Ophth)) NF MO

TIMOPTIC-XE (UseTimolol Maleate (Ophth)) NF Gel Forming

Soln;MOCycloplegic Mydriaticscyclopentolate hcl soln op0.5 % 2 MO; *

cyclopentolate hcl soln op1 %, 2 % 1 MO; *

Miotics

Drug Name DrugTier

Requirements/Limits

ISOPTO CARPINE (UsePilocarpine HCl) 4 MO

PHOSPHOLINE IODIDE 4

pilocarpine hcl soln op 1 %,2 %, 4 % 2 MO; *

Ophthalmic - Angiogenesis InhibitorsEYLEA 5 LA

Ophthalmic Adrenergic AgentsALPHAGAN P 0.1 % 3 MO

ALPHAGAN P 0.15 % (UseBrimonidine Tartrate) NF MO

apraclonidine hcl 1 MO; *

brimonidine tartrate 2 MO; *

IOPIDINE 0.5 % (UseApraclonidine HCl) NF MO

IOPIDINE 1 % 4 MO

SIMBRINZA 4 MO

Ophthalmic Anti-infectivesAZASITE 4 MO

bacitracin-polymyxin b(ophth) 1 MO; *

BESIVANCE 4 MO

BLEPH-10 (UseSulfacetamide Sodium(Ophth))

NFMO

CILOXAN OINT 4 MO

CILOXAN SOLN (UseCiprofloxacin HCl (Ophth)) NF MO

ciprofloxacin hcl (ophth) 2 MO; *

erythromycin (ophth) 2 MO; *

gatifloxacin (ophth) 2 MO; *

gentamicin sulfate (ophth) 2 MO; *



74

Drug Name DrugTier

Requirements/Limits

levofloxacin (ophth) 1 MO; *

MOXEZA 3 MO

NATACYN 3 MO

neomycin-bacitracin zn-polymyxin 1 MO; *

neomycin-polymyxin-gramicidin 1 MO; *

OCUFLOX (Use Ofloxacin(Ophth)) NF MO

ofloxacin (ophth) 2 MO; *

polymyxin b-trimethoprim 2 MO; *

POLYTRIM (UsePolymyxin B-Trimethoprim) NF MO

sulfacetamide sodium(ophth) 2 MO; *

tobramycin (ophth) 2 MO; *

TOBREX OINT 4 MO

TOBREX SOLN (UseTobramycin (Ophth)) NF MO

trifluridine soln op 3 MO

VIGAMOX 3 MO

VIROPTIC (UseTrifluridine) NF MO

ZIRGAN 4 MO

ZYMAXID (UseGatifloxacin (Ophth)) NF MO

Ophthalmic Decongestantsnaphazoline hcl 1 MO; *

Ophthalmic ImmunomodulatorsRESTASIS 3 MO

Ophthalmic Local Anestheticsproparacaine hcl soln op 1 MO; *

Ophthalmic Steroids

Drug Name DrugTier

Requirements/Limits

ALREX 4 MO

bacitracin-poly-neomycin-hc 1 MO; *

BLEPHAMIDE 4 MO

dexamethasone sodiumphosphate (ophth) 1 MO; *

DUREZOL 3 MO

FLAREX 3 MO

fluorometholone (ophth) 2 MO; *

FML 3 MO

FML FORTE 3 MO

FML LIQUIFILM (UseFluorometholone (Ophth)) NF MO

LOTEMAX 4 MO

MAXIDEX 4 MO

MAXITROL (UseNeomycin-Polymy-Dexameth)

NFMO

neomycin-polymy-dexameth 2 MO; *

neomycin-polymyxin-hc(ophth) 2 MO; *

OMNIPRED (UsePrednisolone Acetate(Ophth))

NFMO

PRED FORTE (UsePrednisolone Acetate(Ophth))

NFMO

PRED MILD 3 MO

prednisolone acetate(ophth) 2 MO; *

prednisolone sodiumphosphate (ophth) 2 MO; *

sulfacetamide sod-prednisolone oint 10%-0.2%

2MO; *



75

Drug Name DrugTier

Requirements/Limits

sulfacetamide sod-prednisolone soln 10%-0.23%

1MO; *

TOBRADEX OINT 4 MO

TOBRADEX ST 4 MO

TOBRADEX SUSP (UseTobramycin-Dexamethasone)

NFMO

tobramycin-dexamethasone 2 MO; *

VEXOL 4 MO

ZYLET 3 MO

Ophthalmics - Misc.ACULAR (Use KetorolacTromethamine (Ophth)) NF MO

ACULAR LS (UseKetorolac Tromethamine(Ophth))

NFMO

ACUVAIL 4 MO

ALOCRIL 4 MO

ALOMIDE 4 MO

azelastine hcl (ophth) 2 MO; *

AZOPT 3 MO

BEPREVE 4 MO

bromfenac sodium (ophth) 1 MO; *

bromfenac sodium (ophth) 2 Once dailydosing;MO; *

cromolyn sodium (ophth) 2 MO; *

CYSTARAN 4

Limited to 60ml per 28days;QL(2.15ml daily); LA

diclofenac sodium (ophth) 3 MO

dorzolamide hcl 2 MO; *

Drug Name DrugTier

Requirements/Limits

ELESTAT (Use EpinastineHCl (Ophth)) NF MO

epinastine hcl (ophth) 1 MO; *

flurbiprofen sodium 1 MO; *

ILEVRO 3 MO

ketorolac tromethamine(ophth) 2 MO; *

LASTACAFT 4 MO

NEVANAC 3 MO

OCUFEN (Use FlurbiprofenSodium) NF MO

OPTIVAR (Use AzelastineHCl (Ophth)) NF MO

PATADAY 3 MO

PATANOL 4 MO

PROLENSA 4 MO

TRUSOPT (UseDorzolamide HCl) NF MO

Prostaglandins - OphthalmicBIMATOPROST 3 MO

latanoprost 2 MO; *

LUMIGAN 3 MO

RESCULA 4

TRAVATAN Z 3 MO

XALATAN (UseLatanoprost) NF MO

ZIOPTAN 4 MO

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneousacetic acid (otic) 1 MO; *

acetic acid-aluminumacetate 1 MO; *



76

Drug Name DrugTier

Requirements/Limits

Otic Anti-infectivesofloxacin (otic) 2 MO; *

Otic CombinationsCIPRO HC 4 MO

CIPRODEX 3 MO

COLY-MYCIN S 4 MO

CORTISPORIN SOLN OT10000UNIT/ML-3.5MG/ML-1% (Use Neomycin-Polymyxin-HC (Otic))

NF

MO

CORTISPORIN-TC 4 MO

neomycin-polymyxin-hc(otic) 2 MO; *

Otic SteroidsDERMOTIC (UseFluocinolone Acetonide(Otic))

NFMO

fluocinolone acetonide(otic) 2 MO; *

hydrocortisone w/aceticacid 3 MO

VOSOL HC (UseHydrocortisone w/AceticAcid)

NFMO

OXYTOCICS - Drugs to Prevent/Control UterineBleedingOxytocicsmethylergonovine maleatetabs or 0.2 mg 3 MO

PASSIVE IMMUNIZING AGENTS - AntibodyDrugs to Treat Low Immune SystemImmune SerumsBIVIGAM 5 B/D

FLEBOGAMMA DIF 10 % 5 B/D

GAMASTAN S/D 4 B/D

GAMMAGARD LIQUID 5 B/D

Drug Name DrugTier

Requirements/Limits

GAMMAKED 5 B/D

GAMUNEX-C 5 B/D

HIZENTRA 1 GM/5ML 4 B/D

HIZENTRA 10 GM/50ML, 2GM/10ML, 4 GM/20ML 5 B/D

OCTAGAM 10 GM/100ML,2 GM/20ML, 20GM/200ML, 5 GM/50ML

5B/D

PRIVIGEN 5 B/D

VARIZIG 5

Monoclonal AntibodiesSYNAGIS 5

Passive Immunizing Agents - CombinationsHYQVIA 5 B/D

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillinsamoxicillin caps 250 mg,500 mg 1 MO; *

amoxicillin susr 125mg/5ml, 200 mg/5ml, 250mg/5ml, 400 mg/5ml

2MO; *

amoxicillin tabs 500 mg,875 mg 2 MO; *

ampicillin caps 250 mg,500 mg 2 MO; *

ampicillin sodium ij 1 gm 2 MO; *

ampicillin sodium ij 125 mg 2 *

ampicillin sodium ij 2 gm 1 MO; *

ampicillin sodium iv 10 gm 2 *

Natural PenicillinsBICILLIN L-A 1200000UNIT/2ML, 2400000UNIT/4ML

4MO

penicillin g potassium 20mu, 20000000 unit 1 MO; *



77

Drug Name DrugTier

Requirements/Limits

penicillin g potassium5000000 unit 4 MO

penicillin v potassium 2 MO; *

PFIZERPEN-G 5000000UNIT (Use Penicillin GPotassium)

4MO

Penicillin Combinationsamoxicillin & potclavulanate 2 MO; *

ampicillin & sulbactamsodium ij 1gm-2gm 1 MO; *

ampicillin & sulbactamsodium iv 5gm-10gm 2 *

AUGMENTIN ES-600 (UseAmoxicillin & PotClavulanate)

NFMO

AUGMENTIN SUSR250MG/5ML-62.5MG/5ML(Use Amoxicillin & PotClavulanate)

NF

MO

AUGMENTIN TABS500MG-125MG, 875MG-125MG (Use Amoxicillin &Pot Clavulanate)

NF

MO

AUGMENTIN XR (UseAmoxicillin & PotClavulanate)

NFMO

piperacillin sodium-tazobactam sodium0.25gm-2gm, 0.375gm-3gm, 4.5gm-36gm

3

piperacillin sodium-tazobactam sodium 0.5gm-4gm

1*

UNASYN 1GM-2GM (UseAmpicillin & SulbactamSodium)

NFMO

ZOSYN SOLN0.25GM/50ML-2GM/50ML-5%, 0.375GM/50ML-3GM/50ML-5%,0.5GM/100ML-4GM/100ML-5%

4

Drug Name DrugTier

Requirements/Limits

ZOSYN SOLR 0.25GM-2GM, 0.375GM-3GM,0.5GM-4GM, 4.5GM-36GM(Use Piperacillin Sodium-Tazobactam Sodium)

NF

Penicillinase-Resistant Penicillinsdicloxacillin sodium 2 MO; *

nafcillin sodium ij 1 gm 2 *

nafcillin sodium ij 10 gm 5

nafcillin sodium ij 2 gm 5 MO

nafcillin sodium iv 2 gm 2 *

PROGESTINS - Hormone Replacement/ModifyingDrugsProgestinsmedroxyprogesteroneacetate 1 MO; *

MEGACE ES (UseMegestrol Acetate(Appetite))

4AL; MO

megestrol acetate(appetite) 2 AL; MO; *

norethindrone acetate tabsor 1 MO; *

progesterone micronizedcaps or 100 mg, 200 mg 2 MO; *

PROMETRIUM (UseProgesterone Micronized) NF MO

PROVERA (UseMedroxyprogesteroneAcetate)

NFMO

PSYCHOTHERAPEUTIC AND NEUROLOGICALAGENTS - MISC. - Drugs to Treat Mental andEmotional ConditionsAgents for Chemical Dependencyacamprosate calcium 3 MO

CAMPRAL (UseAcamprosate Calcium) NF MO

disulfiram tabs or 250 mg,500 mg 3 MO

Anti-Cataplectic Agents



78

Drug Name DrugTier

Requirements/Limits

XYREM 5 LA

Antidementia AgentsARICEPT (Use DonepezilHydrochloride) NF MO

ARICEPT ODT (UseDonepezil Hydrochloride) NF MO

donepezil hydrochloride 2 MO; *

EXELON CAPS OR 1.5MG, 3 MG, 4.5 MG, 6 MG(Use Rivastigmine Tartrate)

NFMO

EXELON PT24 TD 13.3MG/24HR, 4.6 MG/24HR,9.5 MG/24HR (UseRivastigmine)

3

MO

galantamine hydrobromidecp24 16 mg, 24 mg, 8 mg 3 MO

galantamine hydrobromidesoln 4 mg/ml 2 MO; *

galantamine hydrobromidetabs 12 mg, 4 mg, 8 mg 3 MO

memantine hcl soln 2mg/ml 2 AL; MO; *

memantine hcl tabs 10 mg,5 mg 2 MO; *

NAMENDA SOLN 10MG/5ML (Use MemantineHCl)

4AL; MO

NAMENDA TABS 10 MG, 5MG (Use Memantine HCl) 4 MO

NAMENDA TITRATIONPAK (Use Memantine HCl) 4 MO

NAMENDA XR 14 MG 4 AL; QL(2 eadaily); MO

NAMENDA XR 21 MG, 28MG 4 AL; QL(1 ea

daily); MO

NAMENDA XR 7 MG 4 AL; QL(4 eadaily); MO

NAMENDA XR TITRATIONPACK 4 AL; MO

RAZADYNE (UseGalantamineHydrobromide)

NFMO

Drug Name DrugTier

Requirements/Limits

RAZADYNE ER (UseGalantamineHydrobromide)

NFMO

rivastigmine 2 MO; *

rivastigmine tartrate 3 MO

Combination Psychotherapeuticschlordiazepoxide-amitriptyline 2 AL; MO; *

olanzapine-fluoxetine hcl 4 MO

perphenazine-amitriptyline 2 AL; MO; *

SYMBYAX (UseOlanzapine-Fluoxetine HCl) NF MO

Fibromyalgia AgentsSAVELLA 4 PA; MO

SAVELLA TITRATIONPACK 4 PA; MO

Movement Disorder Drug Therapytetrabenazine 5

XENAZINE (UseTetrabenazine) 5 LA

Multiple Sclerosis AgentsAMPYRA 5

AUBAGIO 5 PA

AVONEX 5 PA

AVONEX PEN 5 PA

BETASERON 5 PA

COPAXONE 20 MG/ML(Use Glatiramer Acetate) 5 PA

COPAXONE 40 MG/ML 5 PA

EXTAVIA 5 PA

GILENYA 5 PA

glatiramer acetate 5 PA



79

Drug Name DrugTier

Requirements/Limits

LEMTRADA 5 PA; LA

PLEGRIDY 5 PA

PLEGRIDY STARTERPACK 5 PA

REBIF 5 PA

REBIF REBIDOSE 5 PA

REBIF REBIDOSETITRATIONPACK 5 PA

REBIF TITRATION PACK 5 PA

TECFIDERA 5 PA

TECFIDERA STARTERPACK 5 PA

TYSABRI 5 PA

Postherpetic Neuralgia (PHN) AgentsGRALISE 4 MO

GRALISE STARTER 4 MO

Premenstrual Dysphoric Disorder (PMDD) Agentsfluoxetine hcl (pmdd) cap10 mg, 20 mg NF

Pseudobulbar Affect (PBA) AgentsNUEDEXTA 3 MO

Psychotherapeutic and Neurological Agents -ergoloid mesylates tabs or 2 AL; MO; *

ORAP (Use Pimozide) 4 MO

pimozide 2 MO; *

Restless Leg Syndrome (RLS) AgentsHORIZANT 4 MO

Smoking Deterrentsbupropion hcl (smokingdeterrent) 1 QL(2 ea daily);

MO; *

CHANTIX 4 PA; MO

Drug Name DrugTier

Requirements/Limits

CHANTIX CONTINUINGMONTHPAK 4 PA; MO

CHANTIX STARTINGMONTH PAK 4 PA; MO

NICOTROL INHALER 4 QL(17 eadaily); MO

NICOTROL NS 4 MO

ZYBAN (Use BupropionHCl (Smoking Deterrent)) NF QL(2 ea daily);

MOVasomotor Symptom AgentsBRISDELLE 4 MO

RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung ConditionsAlpha-Proteinase Inhibitor (Human)ARALAST NP 1000 MG 5 LA

GLASSIA 4 LA

PROLASTIN-C 5 LA

ZEMAIRA 5 LA

Cystic Fibrosis AgentsKALYDECO PACK 50 MG,75 MG 5 PA

KALYDECO TABS 150 MG 5 PA; LA

ORKAMBI 5 PA

PULMOZYME 5 B/D

Pulmonary Fibrosis AgentsESBRIET 5 PA; LA

OFEV 5 PA; QL(2 eadaily); LA

SULFONAMIDES - Drugs to Treat BacterialInfectionsSulfonamidessulfadiazine tabs or 2 MO; *

TETRACYCLINES - Drugs to Treat BacterialInfections



80

Drug Name DrugTier

Requirements/Limits

TetracyclinesADOXA PAK 1/100 (UseDoxycycline(Monohydrate))

NFMO

ADOXA PAK 1/150 (UseDoxycycline(Monohydrate))

NFMO

ADOXA PAK 2/100 (UseDoxycycline(Monohydrate))

NFMO

ADOXA TABS 100 MG, 50MG, 75 MG (UseDoxycycline(Monohydrate))

NF

MO

demeclocycline hcl 1 MO; *

DORYX 150 MG (UseDoxycycline Hyclate) NF MO

DORYX 200 MG 4 PA; MO

doxycycline (monohydrate)caps 100 mg, 50 mg, 75mg

2MO; *

doxycycline (monohydrate)susr 25 mg/5ml 2 MO; *

doxycycline (monohydrate)tabs 100 mg, 150 mg, 50mg, 75 mg

2MO; *

doxycycline hyclate caps or100 mg, 50 mg 1 MO; *

doxycycline hyclate solr iv100 mg 2 MO; *

doxycycline hyclate tabs or100 mg, 20 mg 1 MO; *

doxycycline hyclate tbec or100 mg, 150 mg 3 MO

doxycycline hyclate tbec or75 mg 2 MO; *

MINOCIN CAPS OR 100MG, 50 MG, 75 MG (UseMinocycline HCl)

NFMO

minocycline hcl caps or100 mg, 50 mg, 75 mg 2 MO; *

minocycline hcl tabs or 100mg, 50 mg 3 MO

Drug Name DrugTier

Requirements/Limits

MONODOX (UseDoxycycline(Monohydrate))

NFMO

tetracycline hcl caps or 250mg, 500 mg 1 MO; *

VIBRAMYCIN CAPS 100MG (Use DoxycyclineHyclate)

NFMO

VIBRAMYCIN SUSR 25MG/5ML (Use Doxycycline(Monohydrate))

4MO

VIBRAMYCIN SYRP 50MG/5ML 4 MO

THYROID AGENTS - Drugs to Regulate ThyroidHormonesAntithyroid Agentsmethimazole tabs or 10mg, 5 mg 2 MO; *

propylthiouracil tabs or 2 MO; *

Thyroid HormonesCYTOMEL (UseLiothyronine Sodium) NF MO

levothyroxine sodium tabsor 100 mcg, 112 mcg, 125mcg, 137 mcg, 150 mcg,175 mcg, 200 mcg, 25mcg, 300 mcg, 50 mcg, 75mcg, 88 mcg

2

MO; *

liothyronine sodium tabs or25 mcg, 5 mcg, 50 mcg 2 MO; *

SYNTHROID (UseLevothyroxine Sodium) 4 MO

TOXOIDS

Toxoid CombinationsADACEL 4

BOOSTRIX 4

DAPTACEL 4

DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC

4



81

Drug Name DrugTier

Requirements/Limits

INFANRIX 4

TENIVAC 4 B/D

TETANUS/DIPHTHERIATOXOIDS-ADSORBED 4 B/D

TETANUS/DIPHTHERIATOXOIDS-ADSORBEDADULT

4B/D

ToxoidsTETANUS TOXOIDADSORBED 4 B/D

ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach ConditionsAntispasmodicsBENTYL CAPS OR 10 MG(Use Dicyclomine HCl) NF MO

BENTYL TABS OR 20 MG(Use Dicyclomine HCl) NF MO

CANTIL 4 MO

dicyclomine hcl caps 10 mg 2 MO; *

dicyclomine hcl tabs 20 mg 2 MO; *

glycopyrrolate soln ij 0.2mg/ml 2 MO; *

glycopyrrolate tabs or 1 mg 1 QL(8 ea daily);MO; *

glycopyrrolate tabs or 2 mg 1 QL(4 ea daily);MO; *

methscopolamine bromidetabs or 2.5 mg, 5 mg 1 MO; *

PAMINE (UseMethscopolamine Bromide) NF MO

PAMINE FORTE (UseMethscopolamine Bromide) NF MO

propantheline bromide tabsor 2 MO; *

ROBINUL FORTE (UseGlycopyrrolate) NF QL(4 ea daily);

MOROBINUL SOLN IJ 0.2MG/ML (UseGlycopyrrolate)

NFMO

ROBINUL TABS OR 1 MG(Use Glycopyrrolate) NF QL(8 ea daily);

MO

Drug Name DrugTier

Requirements/Limits

H-2 Antagonistscimetidine tabs or 200 mg 1 RX/OTC; MO; *

cimetidine tabs or 300 mg,400 mg, 800 mg 1 MO; *

famotidine soln iv 20mg/2ml, 200 mg/20ml, 40mg/4ml

1*

famotidine susr or 40mg/5ml 3 MO

famotidine tabs or 20 mg 1 RX/OTC; MO; *

famotidine tabs or 40 mg 1 MO; *

nizatidine caps 150 mg,300 mg 1 MO; *

PEPCID 20 MG,40MG/5ML (Use Famotidine) NF MO

ranitidine hcl caps or 150mg, 300 mg 2 MO; *

ranitidine hcl syrp or 15mg/ml, 150 mg/10ml, 75mg/5ml

3MO

ranitidine hcl tabs or 150mg 1 RX/OTC; MO; *

ranitidine hcl tabs or 300mg 1 MO; *

ZANTAC SYRP OR 15MG/ML (Use RanitidineHCl)

NFMO

ZANTAC TABS OR 150MG (Use Ranitidine HCl) NF RX/OTC; MO

ZANTAC TABS OR 300MG (Use Ranitidine HCl) NF MO

Misc. Anti-UlcerCARAFATE SUSP 1GM/10ML 4 MO

CARAFATE TABS 1 GM(Use Sucralfate) NF MO

sucralfate tabs or 2 MO; *

Proton Pump InhibitorsDEXILANT 3 ST; MO

esomeprazole magnesium20 mg 2 ST; RX/OTC;

MO; *



82

Drug Name DrugTier

Requirements/Limits

esomeprazole magnesium40 mg 2 ST; MO; *

ESOMEPRAZOLESTRONTIUM 4 ST

lansoprazole cpdr or 15 mg 4 RX/OTC; MO

lansoprazole cpdr or 30 mg 4 MO

NEXIUM CPDR 20 MG 4 ST; RX/OTC;MO

NEXIUM CPDR 20 MG(Use EsomeprazoleMagnesium)

4ST; RX/OTC;MO

NEXIUM CPDR 40 MG 4 ST; MO

NEXIUM CPDR 40 MG(Use EsomeprazoleMagnesium)

4ST; MO

NEXIUM PACK 10 MG, 2.5MG, 20 MG, 40 MG, 5 MG 4 ST; MO

omeprazole cpdr or 10 mg,20 mg, 40 mg 2 MO; *

pantoprazole sodium solr iv40 mg 2 *

pantoprazole sodium tbecor 20 mg, 40 mg 1 MO; *

PREVACID 15 MG (UseLansoprazole) NF RX/OTC; MO

PREVACID 30 MG (UseLansoprazole) NF MO

PRILOSEC CPDR 10 MG,20 MG, 40 MG (UseOmeprazole)

NFMO

PROTONIX PACK OR 40MG 4 QL(1 ea daily);

MOPROTONIX SOLR IV 40MG (Use PantoprazoleSodium)

NF

PROTONIX TBEC OR 20MG, 40 MG (UsePantoprazole Sodium)

NFMO

Ulcer Drugs - ProstaglandinsCYTOTEC (UseMisoprostol) NF MO

misoprostol tabs or 100mcg, 200 mcg 2 MO; *

Drug Name DrugTier

Requirements/Limits

Ulcer Therapy Combinationsamoxicillin-clarithromycinw/ lansoprazole 4 MO

omeprazole-sodiumbicarbonate 20mg-1100mg 2 RX/OTC; MO; *

omeprazole-sodiumbicarbonate 40mg-1100mg 4 MO

PREVPAC (UseAmoxicillin-Clarithromycinw/ Lansoprazole)

NFMO

PYLERA 4 MO

ZEGERID CAPS 20MG-1100MG (Use Omeprazole-Sodium Bicarbonate)

NFRX/OTC; MO

ZEGERID CAPS 40MG-1100MG (Use Omeprazole-Sodium Bicarbonate)

NFMO

ZEGERID PACK 20MG-1680MG 4 ST; MO

ZEGERID PACK 40MG-1680MG 4 MO

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney InfectionsUrinary Anti-infectivesFURADANTIN (UseNitrofurantoin) NF AL; MO

HIPREX (UseMethenamine Hippurate) NF MO

MACROBID (UseNitrofurantoin MonohydMacro)

NFMO

MACRODANTIN 100 MG,50 MG (Use NitrofurantoinMacrocrystal)

NFAL; MO

MACRODANTIN 25 MG(Use NitrofurantoinMacrocrystal)

4AL; MO

methenamine hippurate 2 MO; *

MONUROL 4 MO

nitrofurantoin macrocrystalcaps or 100 mg, 25 mg, 50mg

2AL; MO; *



83

Drug Name DrugTier

Requirements/Limits

nitrofurantoin monohydmacro 2 MO; *

nitrofurantoin susp or 4 AL; MO

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder SpasmsUrinary Antispasmodic - AntimuscarinicsDETROL (Use TolterodineTartrate) NF MO

DETROL LA (UseTolterodine Tartrate) NF MO

DITROPAN XL (UseOxybutynin Chloride) NF MO

ENABLEX 3 MO

GELNIQUE 4 MO

oxybutynin chloride syrp 5mg/5ml 2 MO; *

oxybutynin chloride tabs 5mg 3 MO

oxybutynin chloride tb24 10mg, 15 mg, 5 mg 3 MO

OXYTROL 4 RX/OTC; MO

SANCTURA (UseTrospium Chloride) 4 MO

SANCTURA XR (UseTrospium Chloride) NF MO

tolterodine tartrate cp24 2mg, 4 mg 2 MO; *

tolterodine tartrate tabs 1mg, 2 mg 3 MO

TOVIAZ 3 MO

trospium chloride cp24 60mg 3 MO

trospium chloride tabs 20mg 2 MO; *

VESICARE 3 MO

Urinary Antispasmodics - Beta-3 AdrenergicMYRBETRIQ 4 MO

Urinary Antispasmodics - Cholinergic Agonists

Drug Name DrugTier

Requirements/Limits

bethanechol chloride 10mg, 25 mg, 5 mg, 50 mg 2 MO; *

Urinary Antispasmodics - Direct Muscle Relaxantsflavoxate hcl 1 MO; *

VACCINES

Bacterial VaccinesACTHIB 4

MENACTRA 4

MENOMUNE-A/C/Y/W-135 4

MENVEO 4

PEDVAX HIB 4

TYPHIM VI 4

Mixed Vaccine CombinationsCOMVAX 4

Viral VaccinesCERVARIX 4

ENGERIX-B SUSP IJ 10MCG/0.5ML, 20 MCG/ML 4 B/D

GARDASIL 4

HAVRIX 4

IMOVAX RABIES(H.D.C.V.) 4 B/D

IPOL INACTIVATED IPV 4

IXIARO 4

M-M-R II 4

PROQUAD 4

RABAVERT 4 B/D

RECOMBIVAX HB 4 B/D

ROTARIX 4



84

Drug Name DrugTier

Requirements/Limits

ROTATEQ 3

TWINRIX 4

VAQTA 4

VARIVAX 4

YF-VAX 4

ZOSTAVAX 4

VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low HormonesVaginal Anti-infectivesbutoconazole nitrate (onedose) 2 MO; *

CLEOCIN CREA VA 2 %(Use ClindamycinPhosphate Vaginal)

NFMO

CLEOCIN SUPP VA 100MG 4 MO

clindamycin phosphatevaginal 1 MO; *

METROGEL-VAGINAL(Use MetronidazoleVaginal)

NFMO

metronidazole vaginal 2 MO; *

miconazole nitrate vaginalsupp 200 mg 2 MO; *

TERAZOL 3 (UseTerconazole Vaginal) NF MO

TERAZOL 7 (UseTerconazole Vaginal) NF MO

terconazole vaginal 2 MO; *

Vaginal EstrogensESTRING 4 MO

FEMRING 4 MO

PREMARIN CREA VA0.625 MG/GM 3 MO

VAGIFEM 4 MO

Vaginal Progestins

Drug Name DrugTier

Requirements/Limits

CRINONE 4 MO

ENDOMETRIN 4 MO

VASOPRESSORS - Drugs to Treat Heart andCirculation ConditionsAnaphylaxis Therapy AgentsADRENACLICK 3 MO

AUVI-Q 3 MO

EPINEPHRINE SOAJ IJ0.15 MG/0.15ML, 0.3MG/0.3ML

3MO

EPIPEN 2-PAK 3 MO

EPIPEN-JR 2-PAK 3 MO

Neurogenic Orthostatic Hypotension (NOH) -

NORTHERA 100 MG 5 PA; QL(18 eadaily)



Vasopressorsdobutamine hcl 1 *

dopamine hcl 80 mg/ml 2 *

midodrine hcl 3 MO



85

Indexabacavir sulfate 42abacavir sulfate-lamivudine-zidovudine 42ABELCET 26ABILIFY 1 MG/ML 41ABILIFY 10 MG 41ABILIFY 15 MG 41ABILIFY 2 MG 41ABILIFY 20 MG, 30 MG 41ABILIFY 5 MG 41ABILIFY 9.75 MG/1.3ML 41ABILIFY DISCMELT 10 MG 41ABILIFY DISCMELT 15 MG 41ABILIFY MAINTENA 41ABRAXANE 37ABSORICA 30 MG 53ABSTRAL 100 MCG 4ABSTRAL 200 MCG 4ABSTRAL 300 MCG, 400 MCG,600 MCG, 800 MCG 4acamprosate calcium 78ACANYA 53acarbose 21ACCOLATE 13ACCUPRIL 29ACCURETIC 30acebutolol hcl 200 mg, 400mg 46ACEON 4 MG 29ACEON 8 MG 29acetaminophen w/ codeine120mg/5ml-12mg/5ml 7acetaminophen w/ codeine300mg-15mg, 300mg-30mg,300mg-60mg 7acetazolamide 125 mg 59acetazolamide 250 mg 59acetazolamide 500 mg 59acetic acid (otic) 76acetic acid 0.25 % 65acetic acid-aluminumacetate 76acetylcysteine 10 %, 20 % 53acitretin 55ACTEMRA 3ACTHIB 84ACTIGALL 64ACTIMMUNE 37

ACTIQ 1200 MCG, 1600 MCG,400 MCG, 600 MCG, 800MCG 4ACTIQ 200 MCG 4ACTIVELLA 62ACTONEL 150 MG 60ACTONEL 30 MG, 5 MG 60ACTONEL 35 MG 60ACTOPLUS MET 21ACTOPLUS MET XR 15MG-1000MG 21ACTOPLUS MET XR 30MG-1000MG 21ACTOS 15 MG 23ACTOS 30 MG, 45 MG 23ACULAR 76ACULAR LS 76ACUVAIL 76acyclovir 200 mg 44acyclovir 200 mg/5ml 44acyclovir 400 mg, 800 mg 44acyclovir sodium 50 mg/ml 44acyclovir sodium 500 mg 44acyclovir topical 55ADACEL 81ADAGEN 47ADALAT CC 47adapalene 0.1 % 53adapalene 0.3 % 53ADASUVE 40ADCIRCA 48ADDERALL XR 1adefovir dipivoxil 43ADEMPAS 0.5 MG 48ADEMPAS 1 MG 48ADEMPAS 1.5 MG 48ADEMPAS 2 MG 48ADEMPAS 2.5 MG 48ADOXA 100 MG, 50 MG, 75MG 81ADOXA PAK 1/100 81ADOXA PAK 1/150 81ADOXA PAK 2/100 81ADRENACLICK 85ADVAIR DISKUS 14ADVAIR HFA 14ADVICOR 28AEROSPAN 13

AFINITOR 36AFINITOR DISPERZ 36AFREZZA 23AGGRENOX 66AGRYLIN 66AKYNZEO 26ALBENZA 9albuterol sulfate 0.083 %, 0.5 %,0.63 mg/3ml, 1.25 mg/3ml 14albuterol sulfate 2 mg, 4 mg 14albuterol sulfate 2 mg/5ml 14albuterol sulfate 4 mg, 8 mg 14alclometasone dipropionate 55ALCOHOL PADS 70ALDACTAZIDE 25MG-25MG 59ALDACTAZIDE 50MG-50MG 59ALDACTONE 60ALDARA 58alendronate sodium 10 mg, 5mg 60alendronate sodium 35 mg, 70mg 60alfuzosin hcl 65ALIMTA 100 MG 33ALIMTA 500 MG 34ALINIA 500 MG 10ALKERAN 2 MG 33ALKERAN 50 MG 33allopurinol 100 mg 66allopurinol 300 mg 66almotriptan malate 70ALOCRIL 76ALOMIDE 76ALORA 63alosetron hcl 65ALPHAGAN P 0.1 % 74ALPHAGAN P 0.15 % 74alprazolam 0.25 mg, 0.5 mg, 1mg, 2 mg 12alprazolam 0.5 mg, 1 mg, 2 mg, 3mg 12ALREX 75ALTABAX 54ALTACE 29ALTOPREV 28ALVESCO 160 MCG/ACT 13ALVESCO 80 MCG/ACT 13

Index 1

amantadine hcl 100 mg 38amantadine hcl 50 mg/5ml 38AMARYL 1 MG 24AMARYL 2 MG 24AMARYL 4 MG 24AMBIEN 10 MG 68AMBIEN 5 MG 68AMBIEN CR 12.5 MG 68AMBIEN CR 6.25 MG 68AMBISOME 26amcinonide 55AMERGE 70AMICAR 1000 MG 67amifostine crystalline 37amikacin sulfate 1 gm/4ml, 500mg/2ml 2amiloride &hydrochlorothiazide 59amiloride hcl 60amino acid infusion 15% 73AMINOCAPROIC ACID 1000MG 67aminocaproic acid 500 mg 67aminophylline 15aminosalicylic acid 32AMINOSYN II 15% (Use aminoacid infusion) 74amiodarone hcl 100 mg, 200 mg,400 mg 13amiodarone hcl 900mg/18ml 13AMITIZA 64amitriptyline hcl 21amlodipine besylate 10 mg 47amlodipine besylate 2.5 mg 47amlodipine besylate 5 mg 47amlodipine besylate-atorvastatincalcium 48amlodipine besylate-benazeprilhcl 30amlodipine besylate-valsartan 30amlodipine-valsartan-hydrochlorothiazide 30ammonium chloride 71amoxapine 100 mg, 25 mg, 50mg 21amoxapine 150 mg 21amoxicillin & pot clavulanate 78amoxicillin 125 mg/5ml, 200mg/5ml, 250 mg/5ml, 400mg/5ml 77

amoxicillin 250 mg, 500mg 77amoxicillin 500 mg, 875mg 77amoxicillin-clarithromycin w/lansoprazole 83amphetamine-dextroamphetamine 1.25mg-1.25mg-1.25mg-1.25mg,1.875mg-1.875mg-1.875mg-1.875mg, 2.5mg-2.5mg-2.5mg-2.5mg, 3.125mg-3.125mg-3.125mg-3.125mg, 3.75mg-3.75mg-3.75mg-3.75mg, 5mg-5mg-5mg-5mg, 7.5mg-7.5mg-7.5mg-7.5mg 1amphetamine-dextroamphetamine 1.25mg-1.25mg-1.25mg-1.25mg,2.5mg-2.5mg-2.5mg-2.5mg,3.75mg-3.75mg-3.75mg-3.75mg, 5mg-5mg-5mg-5mg,6.25mg-6.25mg-6.25mg-6.25mg, 7.5mg-7.5mg-7.5mg-7.5mg 1amphotericin b 50 mg 26ampicillin & sulbactam sodium1gm-2gm 78ampicillin & sulbactam sodium5gm-10gm 78ampicillin 250 mg, 500 mg 77ampicillin sodium 1 gm 77ampicillin sodium 10 gm 77ampicillin sodium 125 mg 77ampicillin sodium 2 gm 77AMPYRA 79AMTURNIDE 300MG-10MG-12.5MG, 300MG-10MG-25MG 30AMTURNIDE 300MG-5MG-12.5MG, 300MG-5MG-25MG 30ANADROL-50 8ANAFRANIL 21anagrelide hcl 66ANALPRAM-HC SINGLES 1%-1% 9ANAPROX 3ANAPROX DS 3anastrozole 35ANCOBON 26ANDRODERM 8ANDROGEL 8ANDROGEL PUMP 8

ANGELIQ 0.5MG-1MG 62ANORO ELLIPTA 14ANTARA 130 MG 28ANTARA 30 MG 28ANTARA 43 MG 28ANTARA 90 MG 28APIDRA 23APIDRA SOLOSTAR 23APLENZIN 174 MG 19APLENZIN 348 MG, 522 MG19APOKYN 38apraclonidine hcl 74APRISO 64APTIOM 200 MG 16APTIOM 400 MG 16APTIOM 600 MG 16APTIOM 800 MG 16APTIVUS 100 MG/ML 42APTIVUS 250 MG 42ARALAST NP 1000 MG 80ARALEN 32ARANESP ALBUMIN FREE 10MCG/0.4ML, 25 MCG/ML, 40MCG/ML, 60 MCG/ML 67ARANESP ALBUMIN FREE 100MCG/0.5ML, 150 MCG/0.3ML,200 MCG/0.4ML, 300MCG/0.6ML, 500 MCG/ML 67ARANESP ALBUMIN FREE 100MCG/ML, 150 MCG/0.75ML, 200MCG/ML, 300 MCG/ML 67ARANESP ALBUMIN FREE 25MCG/0.42ML, 40 MCG/0.4ML, 60MCG/0.3ML 67ARAVA 4ARCALYST 3ARCAPTA NEOHALER 14argatroban 250 mg/2.5ml 16ARICEPT 79ARICEPT ODT 79ARIMIDEX 35aripiprazole 1 mg/ml 41aripiprazole 10 mg 41aripiprazole 15 mg 41aripiprazole 2 mg 41aripiprazole 20 mg, 30 mg 41aripiprazole 5 mg 41ARIPIPRAZOLE ODT 10MG 41

Index 2

ARIPIPRAZOLE ODT 15MG 41ARIXTRA 10 MG/0.8ML, 5MG/0.4ML, 7.5 MG/0.6ML 15ARIXTRA 2.5 MG/0.5ML 15ARNUITY ELLIPTA 13AROMASIN 35ARRANON 34ARTHROTEC 50 3ARTHROTEC 75 3ARZERRA 34ASACOL HD 64ASMANEX HFA 100MCG/ACT 13ASMANEX HFA 200MCG/ACT 13ASMANEX TWISTHALER 120METERED DOSES 13ASMANEX TWISTHALER 14METERED DOSES 13ASMANEX TWISTHALER 30METERED DOSES 110MCG/INH 13ASMANEX TWISTHALER 30METERED DOSES 220MCG/INH 14ASMANEX TWISTHALER 60METERED DOSES 14ASMANEX TWISTHALER 7METERED DOSES 14ASPIRIN/DIPYRIDAMOLE 66ASTAGRAF XL 45ASTEPRO 73ATACAND 30ATACAND HCT 31ATELVIA 60atenolol & chlorthalidone 31atenolol 100 mg, 25 mg, 50mg 46ATGAM 45ATIVAN 0.5 MG, 1 MG, 2MG 12ATIVAN 2 MG/ML 12ATIVAN 4 MG/ML 12atorvastatin calcium 28atovaquone 10atovaquone-proguanil hcl 250mg-100mg 32atovaquone-proguanil hcl62.5mg-25mg 32ATRALIN 53ATRIPLA 42ATROVENT 73

ATROVENT HFA 13AUBAGIO 79AUGMENTIN 250MG/5ML-62.5MG/5ML 78AUGMENTIN 500MG-125MG,875MG-125MG 78AUGMENTIN ES-600 78AUGMENTIN XR 78AURYXIA 65AUVI-Q 85AVALIDE 31AVANDAMET 2MG-1000MG 21AVANDAMET 2MG-500MG 21AVANDAMET 4MG-1000MG,4MG-500MG 21AVANDARYL 4MG-1MG, 4MG-2MG 21AVANDARYL 4MG-4MG, 8MG-4MG 21AVANDARYL 8MG-2MG 21AVANDIA 2 MG 23AVANDIA 4 MG 23AVANDIA 8 MG 23AVAPRO 30AVASTIN 34AVEED 8AVELOX 400 MG 63AVELOX ABC PACK 63AVINZA 4AVODART 65AVONEX 79AVONEX PEN 79AXERT 70AXIRON 8azacitidine 34AZACTAM 9AZASITE 74azathioprine 100 mg, 50 mg, 75mg 45azelastine hcl 73azelastine hcl (ophth) 76AZELEX 53AZILECT 39azithromycin 100 mg/5ml, 200mg/5ml 69azithromycin 250 mg, 500 mg,600 mg 69azithromycin 500 mg 69

AZOPT 76AZOR 31aztreonam 9AZULFIDINE 64AZULFIDINE EN-TABS 64bacitracin-poly-neomycin-hc 75bacitracin-polymyxin b(ophth) 74baclofen 10 mg 72baclofen 20 mg 72BACTRIM 10BACTRIM DS 10BACTROBAN 54BACTROBAN NASAL 73balsalazide disodium 64BANZEL 200 MG 16BANZEL 40 MG/ML 16BANZEL 400 MG 16BARACLUDE 0.05 MG/ML 43BARACLUDE 0.5 MG, 1 MG 44BECONASE AQ 73BELEODAQ 36BELSOMRA 10 MG 68BELSOMRA 15 MG, 20 MG 68BELSOMRA 5 MG 68benazepril &hydrochlorothiazide 31benazepril hcl 10 mg, 20 mg, 40mg, 5 mg 29BENICAR 30BENICAR HCT 31BENLYSTA 46BENTYL 10 MG 82BENTYL 20 MG 82BENZACLIN 53BENZACLIN WITH PUMP 53BENZAMYCIN 53benzoyl peroxide-erythromycin 53benztropine mesylate 0.5 mg, 1mg, 2 mg 38benztropine mesylate 1mg/ml 38BEPREVE 76BERINERT 66BESIVANCE 74BETAGAN 74betamethasone dipropionate(topical) 56

Index 3

betamethasone dipropionateaugmented 56betamethasone sod phosphate &acetate 51betamethasone valerate 0.1% 56betamethasone valerate 0.12% 56BETAPACE 46BETAPACE AF 46BETASERON 79betaxolol hcl (ophth) 74betaxolol hcl 10 mg 46betaxolol hcl 20 mg 46bethanechol chloride 10 mg, 25mg, 5 mg, 50 mg 84BETHKIS 2BETIMOL 74BETOPTIC-S 74bexarotene 37BEYAZ 50BIAXIN 69BIAXIN XL 69BIAXIN XL PAC 69bicalutamide 35BICILLIN L-A 1200000UNIT/2ML, 2400000UNIT/4ML 77BICNU 33BIDIL 48BILTRICIDE 9BIMATOPROST 76bisacodyl-peg 3350-pot chloride-sod bicarb-sod chloride 68bisoprolol &hydrochlorothiazide 31bisoprolol fumarate 46BIVIGAM 77bleomycin sulfate 15 unit 35bleomycin sulfate 30 unit 35BLEPH-10 74BLEPHAMIDE 75BLINCYTO 34BONIVA 150 MG 60BONIVA 3 MG/3ML 60BOOSTRIX 81BOSULIF 36BOTOX 73

BREO ELLIPTA 25MCG/INH-100MCG/INH, 25MCG/INH-200MCG/INH 14BREVICON-28 50BRILINTA 66brimonidine tartrate 74BRINTELLIX 10 MG 20BRINTELLIX 20 MG 20BRINTELLIX 5 MG 20BRISDELLE 80bromfenac sodium (ophth) 76bromocriptine mesylate 2.5mg 38bromocriptine mesylate 5mg 38BROVANA 14budesonide 51budesonide (inhalation) 0.25mg/2ml 14budesonide (inhalation) 0.5mg/2ml 14budesonide (inhalation) 1mg/2ml 14budesonide (nasal) 73bumetanide 0.5 mg, 1 mg, 2mg 59BUMEX 59BUNAVAIL 8buprenorphine hcl 2 mg 8buprenorphine hcl 8 mg 8buprenorphine hcl-naloxone hcldihydrate 2mg-0.5mg 8buprenorphine hcl-naloxone hcldihydrate 8mg-2mg 8bupropion hcl (smokingdeterrent) 80bupropion hcl 100 mg 19bupropion hcl 150 mg 19bupropion hcl 150 mg, 200mg 19bupropion hcl 300 mg 19bupropion hcl 75 mg 19buspirone hcl 10 mg, 15 mg, 30mg, 5 mg, 7.5 mg 12BUSULFEX 33butalbital-acetaminophen-caffeine w/ codeine 300mg-50mg-40mg-30mg 7butalbital-acetaminophen-caffeine w/ codeine 325mg-50mg-40mg-30mg 7butalbital-aspirin-caffeinew/cod 7

BUTISOL SODIUM 68butoconazole nitrate (onedose) 85butorphanol tartrate 10 mg/ml 8BUTRANS 10 MCG/HR 8BUTRANS 15 MCG/HR 8BUTRANS 20 MCG/HR, 7.5MCG/HR 8BUTRANS 5 MCG/HR 8BYDUREON 23BYETTA 23BYSTOLIC 46cabergoline 62CADUET 48CALAN 47CALAN SR 47calcipotriene 55calcipotriene-betamethasonedipropionate 56calcitonin (salmon) 60calcitriol 0.25 mcg, 0.5 mcg 61calcitriol 1 mcg/ml 61CALCITRIOL 3 MCG/GM 55calcium acetate (phosphatebinder) 65CAMBIA 70CAMPRAL 78CAMPTOSAR 100 MG/5ML, 40MG/2ML 38CAMPTOSAR 300MG/15ML 38CANASA 64candesartan cilexetil 30candesartan cilexetil-hydrochlorothiazide 31CANTIL 82CAPASTAT SULFATE 32CAPEX 56CAPRELSA 36captopril 100 mg, 12.5 mg, 25mg, 50 mg 29CAPTOPRIL/HYDROCHLOROTHIAZIDE 31CARAC 55CARAFATE 1 GM 82CARAFATE 1 GM/10ML 82carbamazepine 100 mg 16carbamazepine 100 mg, 200 mg,300 mg 16carbamazepine 100 mg/5ml 16

Index 4

carbamazepine 200 mg 16carbamazepine 200 mg, 400mg 16CARBATROL 16carbidopa 38carbidopa-levodopa 38carbidopa-levodopa-entacapone

38carbinoxamine maleate 27carboplatin 150 mg/15ml, 600mg/60ml 33carboplatin 450 mg/45ml, 50mg/5ml 33CARDIZEM 47CARDIZEM CD 47CARDIZEM LA 120 MG 47CARDIZEM LA 180 MG, 240 MG,300 MG, 360 MG, 420 MG 47CARDURA 30CARDURA XL 65carisoprodol 250 mg, 350mg 72carisoprodol w/ aspirin 73carisoprodol w/ aspirin &codeine 73CARNITOR 330 MG 61carteolol hcl (ophth) 74carvedilol 12.5 mg 46carvedilol 25 mg 46carvedilol 3.125 mg 46carvedilol 6.25 mg 46CASODEX 35CATAFLAM 3CATAPRES 30CATAPRES-TTS-1 30CATAPRES-TTS-2 30CATAPRES-TTS-3 30CAYSTON 9CEDAX 400 MG 49cefaclor 250 mg, 500 mg 49cefadroxil 1 gm 49cefadroxil 250 mg/5ml 49cefadroxil 500 mg 49cefadroxil 500 mg/5ml 49cefazolin sodium 1 gm, 10gm 49cefazolin sodium 500 mg 49cefdinir 125 mg/5ml 49cefdinir 250 mg/5ml 49cefdinir 300 mg 49

CEFEPIME 1 GM/50ML, 2GM/100ML 50cefepime hcl 50cefixime 100 mg 49cefixime 200 mg 49cefotaxime sodium 1 gm 49cefotaxime sodium 10 gm 49cefotaxime sodium 2 gm, 500mg 49cefotetan disodium 49cefpodoxime proxetil 49cefprozil 125 mg/5ml 49cefprozil 250 mg, 500 mg 49cefprozil 250 mg/5ml 49ceftazidime 1 gm, 2 gm 49ceftazidime 6 gm 49CEFTIBUTEN 400 MG 49CEFTIN 250 MG, 500 MG 49ceftriaxone sodium 1 gm 49ceftriaxone sodium 10 gm 50ceftriaxone sodium 2 gm 49ceftriaxone sodium 250 mg49ceftriaxone sodium 500 mg49cefuroxime axetil 49cefuroxime sodium 1.5 gm 49cefuroxime sodium 7.5 gm 49cefuroxime sodium 750 mg49CELEBREX 3celecoxib 3CELESTONE-SOLUSPAN 51CELEXA 10 MG 19CELEXA 20 MG 19CELEXA 40 MG 19CELLCEPT 200 MG/ML 45CELLCEPT 250 MG 45CELLCEPT 500 MG 45CELLCEPTINTRAVENOUS 45CELONTIN 18CENESTIN 63cephalexin 125 mg/5ml, 250mg/5ml 49cephalexin 250 mg, 500mg 49cephalexin 750 mg 49CERDELGA 66CEREBYX 100 MGPE/2ML 18

CEREBYX 500 MGPE/10ML 18CEREZYME 67CERVARIX 84CESAMET 26cetirizine hcl 1 mg/ml 27cetirizine hcl 1 mg/ml, 5mg/5ml 27cevimeline hcl 72CHANTIX 80CHANTIX CONTINUINGMONTHPAK 80CHANTIX STARTING MONTHPAK 80CHEMET 25CHENODAL 64chloramphenicol sodiumsuccinate 10chlordiazepoxide hcl 12chlordiazepoxide-amitriptyline

79chlorhexidine gluconate (mouth-throat) 72chloroquine phosphate 250 mg,500 mg 32chlorothiazide 500 mg 60chlorpromazine hcl 10 mg, 100mg, 200 mg, 25 mg, 50 mg 41chlorpromazine hcl 25 mg/ml41chlorpromazine hcl 50mg/2ml 41chlorpropamide 100 mg 24chlorpropamide 250 mg 24chlorthalidone 25 mg, 50 mg 60chlorzoxazone 72cholestyramine 4 gm 27cholestyramine 4 gm/dose 27cholestyramine light 27choline fenofibrate 28chorionic gonadotropin 61ciclopirox 0.77 % 54ciclopirox 1 % 54ciclopirox 8 % 54ciclopirox olamine 54cidofovir 43cilostazol 66CILOXAN 74cimetidine 200 mg 82cimetidine 300 mg, 400 mg, 800mg 82CIMZIA 64

Index 5

CIMZIA STARTER KIT 64CINRYZE 66CIPRO 250 MG, 500 MG 63CIPRO 5 GM/100ML, 500MG/5ML 63CIPRO HC 77CIPRO I.V.-IN D5W200MG/100ML-5% 63CIPRO I.V.-IN D5W400MG/200ML-5% 63CIPRO XR 63CIPRODEX 77ciprofloxacin 250 mg/5ml, 500mg/5ml 63ciprofloxacin hcl (ophth) 74ciprofloxacin hcl 100 mg, 250 mg,500 mg, 750 mg 63ciprofloxacin in d5w200mg/100ml-5% 63ciprofloxacin in d5w400mg/200ml-5% 63ciprofloxacin-ciprofloxacinhcl 63cisplatin 33CISPLATIN 33citalopram hydrobromide 10mg 19citalopram hydrobromide 10mg/5ml 19citalopram hydrobromide 20mg 19citalopram hydrobromide 40mg 19cladribine 34CLAFORAN 1 GM, 10 GM 50CLAFORAN 2 GM, 500 MG 50CLARINEX 5 MG 27CLARINEX REDITABS 5MG 27CLARINEX-D 12 HOUR 53CLARINEX-D 24 HOUR 53clarithromycin 125 mg/5ml 69clarithromycin 250 mg, 500mg 69clarithromycin 250 mg/5ml 69clarithromycin 500 mg 69clemastine fumarate 0.67mg/5ml 27clemastine fumarate 2.68 mg27CLEOCIN 100 MG 85CLEOCIN 150 MG, 300 MG, 75MG 10CLEOCIN 2 % 85

CLEOCIN IN D5W 10CLEOCIN PHOSPHATE300MG/50ML-5%,600MG/50ML-5%,900MG/50ML-5% 11CLEOCIN PHOSPHATE 600MG/4ML, 900 MG/6ML 10CLEOCIN-T 53CLIMARA 63CLIMARA PRO 62clindamycin hcl 150 mg, 300mg, 75 mg 11clindamycin palmitatehydrochloride 11clindamycin phosphate(topical) 53clindamycin phosphate 150mg/ml, 600 mg/4ml 11clindamycin phosphate 150mg/ml, 9000 mg/60ml 11clindamycin phosphate 600mg/4ml, 900 mg/6ml 11clindamycin phosphate ind5w 11clindamycin phosphatevaginal 85clindamycin phosphate-benzoylperoxide 53clindamycin phosphate-benzoylperoxide (refrigerate) 53CLINIMIX 2.75%/DEXTROSE5% 74clobetasol propionate 56clobetasol propionate emollientbase 56clobetasol propionateemulsion 56CLOBEX 56CLOCORTOLONEPIVALATE 56CLOCORTOLONE PIVALATEPUMP 56CLODERM 56CLODERM PUMP 56CLOLAR 34clomipramine hcl 25 mg, 50mg 21clomipramine hcl 75 mg 21clonazepam 0.125 mg, 0.25mg, 0.5 mg, 1 mg, 2 mg 16clonazepam 0.5 mg 16clonazepam 1 mg 16clonazepam 2 mg 16clonidine hcl (adhd) 1

clonidine hcl 0.1 mg, 0.2 mg, 0.3mg 30clonidine hcl 0.1 mg/24hr, 0.2mg/24hr, 0.3 mg/24hr 30clopidogrel bisulfate 300 mg 66clopidogrel bisulfate 75 mg 66clorazepate dipotassium 12clotrimazole 72clotrimazole (topical) 54clotrimazole w/betamethasone 54clozapine 100 mg, 25 mg 40clozapine 200 mg, 50 mg 40CLOZAPINE ODT 40CLOZARIL 40COARTEM 32codeine sulfate 15 mg 4CODEINE SULFATE 15 MG 4codeine sulfate 30 mg 4codeine sulfate 60 mg 4COGENTIN 38COLAZAL 64COLCHICINE 66colchicine w/ probenecid 66COLCRYS 66COLESTID 27COLESTID FLAVORED 5GM 28colestipol hcl 1 gm 28colestipol hcl 5 gm 28colistimethate sodium 9COLY-MYCIN M 9COLY-MYCIN S 77COLYTE-FLAVOR PACKS227.1GM-21.5GM-5.53GM-2.82GM-6.36GM 68COLYTE-FLAVOR PACKS240GM-22.72GM-5.84GM-2.98GM-6.72GM 68COMBIGAN 74COMBIPATCH 62COMBIVENT RESPIMAT 14COMBIVIR 42COMETRIQ 36COMPLERA 42COMTAN 38COMVAX 84CONCERTA 1CONDYLOX 58

Index 6

COPAXONE 79COPEGUS 44CORDARONE 13CORDRAN TAPE 56COREG 12.5 MG 46COREG 25 MG 46COREG 3.125 MG 46COREG 6.25 MG 46COREG CR 46CORGARD 46CORLANOR 48CORTEF 51CORTENEMA 9CORTIFOAM 9cortisone acetate 51CORTISPORIN 10000UNIT/GM-0.5%-0.5% 54CORTISPORIN 10000UNIT/ML-3.5MG/ML-1% 77CORTISPORIN 400UNIT/GM-5000UNIT/GM-0.5%-1% 54CORTISPORIN-TC 77CORZIDE 31COSENTYX 55COSENTYX SENSOREADYPEN 55COSMEGEN 35COSOPT 74COSOPT PF 74COUMADIN 1 MG, 10 MG, 2 MG,2.5 MG, 3 MG, 4 MG, 5 MG, 6MG, 7.5 MG 15COZAAR 30CREON 59CRESEMBA 186 MG 26CRESEMBA 372 MG 26CRESTOR 28CRINONE 85CRIXIVAN 42cromolyn sodium 13cromolyn sodium(mastocytosis) 64cromolyn sodium (ophth) 76CUBICIN 10CUTIVATE 56cyclobenzaprine hcl 10 mg, 5 mg,7.5 mg 72cyclopentolate hcl 0.5 % 74cyclopentolate hcl 1 %, 2 % 74

cyclophosphamide 1 gm, 500mg 33cyclophosphamide 25 mg, 50mg 33CYCLOSET 23cyclosporine 100 mg, 25mg 45cyclosporine 50 mg/ml 45cyclosporine modified (formicroemulsion) 100 mg, 25mg 45cyclosporine modified (formicroemulsion) 50 mg 45CYKLOKAPRON 67CYMBALTA 20cyproheptadine hcl 2mg/5ml 27cyproheptadine hcl 4 mg 27CYRAMZA 34CYSTADANE 61CYSTAGON 65CYSTARAN 76cytarabine 100 mg/ml 34cytarabine 20 mg/ml 34CYTOMEL 81CYTOTEC 83CYTOVENE 43D.H.E. 45 70dacarbazine 100 mg 37dacarbazine 200 mg 37DACOGEN 34DALIRESP 13danazol 100 mg, 200 mg 8danazol 50 mg 8DANTRIUM 72dantrolene sodium 100 mg, 50mg 73dantrolene sodium 25 mg 73dapsone 100 mg, 25 mg 10DAPTACEL 81DARAPRIM 32daunorubicin hcl 35DAUNOXOME 35DAYPRO 3DAYTRANA 30 MG/9HR 1DDAVP 62decitabine 34DELESTROGEN 63DELZICOL 64

DEMADEX 59demeclocycline hcl 81DEMEROL 100 MG, 50 MG 4DEMSER 30DENAVIR 55DEPACON 18DEPAKENE 18DEPAKOTE 18DEPAKOTE ER 19DEPAKOTE SPRINKLES 19DEPEN TITRATABS 45DEPO-MEDROL 20 MG/ML 51DEPO-MEDROL 40 MG/ML, 80MG/ML 51DEPO-PROVERA 35DEPO-PROVERACONTRACEPTIVE 51DEPO-SUBQ PROVERA104 51DERMA-SMOOTHE/FSBODY 56DERMA-SMOOTHE/FSSCALP 56DERMATOP 56DERMOTIC 77desipramine hcl 10 mg, 100 mg,150 mg, 25 mg, 50 mg, 75mg 21desloratadine 5 mg 27desmopressin acetate 0.1 mg,0.2 mg 62desmopressin acetate 4mcg/ml 62desmopressin acetaterefrigerated 62desmopressin acetate spray 62desmopressin acetate sprayrefrigerated 62DESOGEN 50desogestrel & ethinylestradiol 50desogestrel-ethinyl estradiol(biphasic) 50DESONATE 56desonide 56DESOWEN 56desoximetasone 0.05 % 56DESOXIMETASONE 0.05 %56desoximetasone 0.25 % 56DESOXYN 1DESVENLAFAXINE ER 100 MG,50 MG 20

Index 7

DETROL 84DETROL LA 84dexamethasone 0.5 mg, 0.75 mg,1 mg, 1.5 mg, 2 mg, 4 mg, 6mg 52dexamethasone 0.5 mg/5ml 52dexamethasone 1 mg/ml 51dexamethasone 1.5 mg 52dexamethasone sodiumphosphate (ophth) 75dexamethasone sodiumphosphate 10 mg/ml 52dexamethasone sodiumphosphate 10 mg/ml, 120mg/30ml 52dexamethasone sodiumphosphate 100 mg/10ml, 20mg/5ml, 4 mg/ml 52DEXEDRINE 1DEXILANT 82dexmethylphenidate hcl 10 mg,15 mg, 20 mg 1dexmethylphenidate hcl 10 mg,2.5 mg, 5 mg 1dexrazoxane 37dextroamphetamine sulfate 10mg, 15 mg, 5 mg 1dextroamphetamine sulfate 10mg, 5 mg 1dextrose 10 % 73dextrose 5 % 73dextrose in lactated ringers 71dextrose w/ sodium chloride0.45%-2.5% 71dextrose w/ sodium chloride0.45%-5% 71dextrose w/ sodium chloride0.9%-5% 71DIABETA 1.25 MG 24DIABETA 2.5 MG 24DIABETA 5 MG 24DIAMOX 59DIASTAT ACUDIAL 16DIASTAT PEDIATRIC 16diazepam 1 mg/ml 12diazepam 10 mg, 2 mg, 5mg 12DIAZEPAM 10 MG, 2.5 MG, 20MG 16diazepam 5 mg/ml 12DIBENZYLINE 30diclofenac potassium 3

diclofenac sodium (actinickeratoses) 55diclofenac sodium (ophth) 76diclofenac sodium (topical) 54diclofenac sodium 100 mg 3diclofenac sodium 25 mg, 50mg, 75 mg 3diclofenac w/ misoprostol 3dicloxacillin sodium 78dicyclomine hcl 10 mg 82dicyclomine hcl 20 mg 82didanosine 125 mg 42didanosine 200 mg, 250 mg,400 mg 42DIFFERIN 0.1 % 53DIFFERIN 0.3 % 53DIFICID 70diflorasone diacetate 57DIFLUCAN 26diflunisal 4DIGOXIN 0.05 MG/ML 48digoxin 0.125 mg, 0.25 mg, 125mcg, 250 mcg 48dihydroergotamine mesylate 1mg/ml 70DIHYDROERGOTAMINEMESYLATE 4 MG/ML 70DILANTIN-125 18DILATRATE SR 11DILAUDID 1 MG/ML 4DILAUDID 2 MG 5DILAUDID 4 MG 5DILAUDID 8 MG 5DILAUDID-HP 10 MG/ML 5diltiazem hcl 100 mg 47diltiazem hcl 120 mg, 180 mg,240 mg 47diltiazem hcl 120 mg, 30 mg, 60mg, 90 mg 47diltiazem hcl 120 mg, 60 mg, 90mg 47diltiazem hcl coated beads 47diltiazem hcl extended releasebeads 47dimenhydrinate 50 mg/ml 25DIOVAN 30DIOVAN HCT 31DIPENTUM 64diphenhydramine hcl 50mg/ml 27diphenoxylate w/ atropine 25

DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC 81DIPROLENE 57DIPROLENE AF 57dipyridamole 25 mg, 50 mg, 75mg 66disopyramide phosphate 12disulfiram 250 mg, 500 mg 78DITROPAN XL 84divalproex sodium 19DIVIGEL 63dobutamine hcl 85DOCEFREZ 37DOCETAXEL 140 MG/7ML, 20MG/0.5ML, 20 MG/ML, 80MG/2ML, 80 MG/4ML 37DOCETAXEL 160 MG/16ML, 20MG/2ML, 200 MG/20ML, 80MG/8ML 38docetaxel 20 mg/ml, 80mg/4ml 37DOLOPHINE 10 MG 5DOLOPHINE 5 MG 5donepezil hydrochloride 79dopamine hcl 80 mg/ml 85DORIBAX 500 MG 10DORYX 150 MG 81DORYX 200 MG 81dorzolamide hcl 76dorzolamide hcl-timololmaleate 74DOVONEX 55doxazosin mesylate 30doxepin hcl 10 mg, 100 mg, 150mg, 25 mg, 50 mg, 75 mg 21doxepin hcl 10 mg/ml 21doxercalciferol 0.5 mcg, 1 mcg,2.5 mcg 61DOXIL 35doxorubicin hcl 10 mg 35doxorubicin hcl 2 mg/ml 35doxorubicin hcl 50 mg 35doxorubicin hcl liposomal 35DOXYCYCLINE 58doxycycline (monohydrate) 100mg, 150 mg, 50 mg, 75 mg 81doxycycline (monohydrate) 100mg, 50 mg, 75 mg 81doxycycline (monohydrate) 25mg/5ml 81doxycycline hyclate 100 mg 81

Index 8

doxycycline hyclate 100 mg, 150mg 81doxycycline hyclate 100 mg, 20mg 81doxycycline hyclate 100 mg, 50mg 81doxycycline hyclate 75 mg 81dronabinol 10 mg 26dronabinol 2.5 mg 26dronabinol 5 mg 26drospirenone-ethinylestradiol 50DROXIA 67DUAC 53DUAVEE 62DUETACT 22DUEXIS 3DULERA 14duloxetine hcl 20 mg, 30 mg, 60mg 20DUONEB 14DUOPA 38DURAGESIC 100 MCG/HR 5DURAGESIC 12 MCG/HR 5DURAGESIC 25 MCG/HR 5DURAGESIC 50 MCG/HR 5DURAGESIC 75 MCG/HR 5DUREZOL 75dutasteride 65DYAZIDE 59DYMISTA 73DYRENIUM 60E.E.S. GRANULES 69EC-NAPROSYN 3econazole nitrate 54EDARBI 30EDARBYCLOR 31EDECRIN 60EDLUAR 68EDURANT 42EFFEXOR XR 150 MG 20EFFEXOR XR 37.5 MG 20EFFEXOR XR 75 MG 20EFFIENT 66EFUDEX 55EGRIFTA 61ELDEPRYL 39ELELYSO 67

ELESTAT 76ELESTRIN 63ELIDEL 58ELIGARD 35ELIQUIS 15ELITEK 37ELLA 51ELLENCE 36ELMIRON 65ELOCON 57ELOXATIN 100 MG/20ML 33ELOXATIN 50 MG/10ML 33EMCYT 35EMEND 125 MG, 80 MG 26EMEND 40 MG 26EMLA 58EMSAM 19EMTRIVA 42ENABLEX 84enalapril maleate &hydrochlorothiazide 31enalapril maleate 10 mg 29enalapril maleate 2.5 mg 29enalapril maleate 20 mg 29enalapril maleate 5 mg 29enalaprilat 29ENBREL 4ENBREL SURECLICK 4ENDOMETRIN 85ENGERIX-B 10 MCG/0.5ML,20 MCG/ML 84ENJUVIA 0.3 MG, 0.45 MG, 0.9MG, 1.25 MG 63ENJUVIA 0.625 MG 63enoxaparin sodium 100 mg/ml,60 mg/0.6ml, 80 mg/0.8ml 15enoxaparin sodium 120mg/0.8ml, 150 mg/ml 15enoxaparin sodium 30mg/0.3ml, 40 mg/0.4ml 15enoxaparin sodium 300mg/3ml 15entacapone 38entecavir 44ENTOCORT EC 52ENTRESTO 48ENTYVIO 64EPIDUO 53epinastine hcl (ophth) 76

EPINEPHRINE 0.15 MG/0.15ML,0.3 MG/0.3ML 85epinephrine hcl 0.1 mg/ml 14EPIPEN 2-PAK 85EPIPEN-JR 2-PAK 85epirubicin hcl 200 mg/100ml 36epirubicin hcl 50 mg/25ml 36EPIVIR 10 MG/ML 42EPIVIR 150 MG, 300 MG 42EPIVIR HBV 44eplerenone 25 mg 32eplerenone 50 mg 32EPOGEN 10000 UNIT/ML, 20000UNIT/ML, 3000 UNIT/ML, 4000UNIT/ML 67EPOGEN 2000 UNIT/ML 67EPROSARTAN MESYLATE 30EPZICOM 42EQUETRO 39ERAXIS 100 MG 26ERBITUX 34ergoloid mesylates 80ERGOMAR 70ERIVEDGE 35ERWINAZE 37ERYPED 200 69ERYPED 400 69erythromycin (acne aid) 53erythromycin (ophth) 74erythromycin base 250 mg 69erythromycin base 500 mg 69erythromycin ethylsuccinate 69erythromycin lactobionate 69ESBRIET 80escitalopram oxalate 19esomeprazole magnesium 20mg 82esomeprazole magnesium 40mg 83ESOMEPRAZOLESTRONTIUM 83estradiol & norethindroneacetate 62estradiol 0.025 mg/24hr, 0.0375mg/24hr, 0.05 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr 63estradiol 0.025 mg/24hr, 0.05mg/24hr, 0.06 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr 63

Index 9

estradiol 0.5 mg, 1 mg, 2 mg 63estradiol cypionate 63estradiol valerate 10 mg/ml, 20mg/ml, 40 mg/ml 63estradiol-norgestimate 63ESTRING 85estropipate 0.75 mg, 1.5 mg 63eszopiclone 68ethambutol hcl 100 mg, 400mg 32ethosuximide 250 mg 18ethosuximide 250 mg/5ml 18ethynodiol diacet & eth estrad1mg-35mcg 50ethynodiol diacet & eth estrad1mg-50mcg 50ETHYOL 37etidronate disodium 200 mg 60etodolac 200 mg, 300 mg 3etodolac 400 mg, 500 mg 3etodolac 400 mg, 500 mg, 600mg 3ETOPOPHOS 38etoposide 1 gm/50ml, 100mg/5ml 38etoposide 500 mg/25ml 38EURAX 59EVAMIST 63EVISTA 61EVOCLIN 53EVOTAZ 42EVOXAC 72EVZIO 25EXALGO 12 MG 5EXALGO 16 MG 5EXALGO 32 MG 5EXALGO 8 MG 5EXELDERM 54EXELON 1.5 MG, 3 MG, 4.5 MG,6 MG 79EXELON 13.3 MG/24HR, 4.6MG/24HR, 9.5 MG/24HR 79exemestane 35EXFORGE 31EXFORGE HCT 31EXJADE 25EXTAVIA 79EXTINA 54EYLEA 74FABIOR 53

FABRAZYME 35 MG 61famciclovir 125 mg 44famciclovir 250 mg, 500mg 44famotidine 20 mg 82famotidine 20 mg/2ml, 200mg/20ml, 40 mg/4ml 82famotidine 40 mg 82famotidine 40 mg/5ml 82FAMVIR 44FANAPT 1 MG, 10 MG, 12 MG,2 MG, 4 MG 40FANAPT 6 MG, 8 MG 40FANAPT TITRATIONPACK 40FARESTON 35FARXIGA 24FARYDAK 36FASLODEX 35fat emulsion 20 gm/100ml 73FAZACLO 40felbamate 400 mg 18felbamate 600 mg 18felbamate 600 mg/5ml 18FELBATOL 400 MG 18FELBATOL 600 MG 18FELBATOL 600 MG/5ML 18FELDENE 3felodipine 47FEMARA 35FEMCON FE 50FEMHRT LOW DOSE 63FEMRING 85FENOFIBRATE 120 MG, 40MG 28fenofibrate 145 mg, 48 mg 28FENOFIBRATE 150 MG, 50MG 28fenofibrate 160 mg, 54 mg 28fenofibrate micronized 130mg 28fenofibrate micronized 134 mg,200 mg, 67 mg 28fenofibrate micronized 43mg 28FENOGLIDE 28fenoprofen calcium 600 mg 3fentanyl 100 mcg/hr 5fentanyl 12 mcg/hr 5fentanyl 25 mcg/hr 5

fentanyl 50 mcg/hr 5fentanyl 75 mcg/hr 5fentanyl citrate 1200 mcg, 1600mcg, 400 mcg, 600 mcg, 800mcg 5fentanyl citrate 200 mcg 5FENTORA 100 MCG, 200MCG 5FENTORA 400 MCG, 600 MCG,800 MCG 5FETZIMA 120 MG, 40 MG, 80MG 20FETZIMA 20 MG 20FETZIMA TITRATION PACK20FINACEA 58finasteride 65FIORINAL/CODEINE #3 7FIRAZYR 66FIRMAGON 120 MG 35FIRMAGON 80 MG 35FLAGYL 250 MG 9FLAGYL 375 MG 9FLAGYL 500 MG 9FLAGYL ER 9FLAREX 75flavoxate hcl 84FLEBOGAMMA DIF 10 % 77flecainide acetate 100 mg 12flecainide acetate 150 mg 13flecainide acetate 50 mg 13FLECTOR 54FLO-PRED 52FLOMAX 66FLONASE 73FLOVENT DISKUS 100MCG/BLIST 14FLOVENT DISKUS 250MCG/BLIST 14FLOVENT DISKUS 50MCG/BLIST 14FLOVENT HFA 110 MCG/ACT,220 MCG/ACT 14FLOVENT HFA 44MCG/ACT 14fluconazole 10 mg/ml 26fluconazole 100 mg, 150 mg, 200mg, 50 mg 26fluconazole 40 mg/ml 26fluconazole in dextrose 26fluconazole in nacl 26flucytosine 26

Index 10

FLUDARA 34fludarabine phosphate 50mg 34fludarabine phosphate 50mg/2ml 34fludrocortisone acetate 52FLUMADINE 44flunisolide (nasal) 73fluocinolone acetonide (otic) 77fluocinolone acetonide 0.01% 57fluocinolone acetonide 0.01 %,0.025 % 57fluocinolone acetonide 0.025% 57fluocinonide 0.05 % 57fluocinonide 0.05 %, 0.1 % 57fluocinonide emulsified base 57fluorometholone (ophth) 75fluorouracil (topical) 55FLUOROURACIL 0.5 % 55fluorouracil 1 gm/20ml 34fluorouracil 2.5 gm/50ml, 500mg/10ml 34fluoxetine hcl (PMDD) cap 10 mg,20 mg 80fluoxetine hcl 10 mg, 20 mg 20fluoxetine hcl 10 mg, 20 mg, 40mg 19fluoxetine hcl 20 mg/5ml 20FLUOXETINE HCL 60 MG 20fluoxetine hcl 90 mg 20fluoxymesterone 8fluphenazine decanoate 41fluphenazine hcl 1 mg, 10 mg, 2.5mg, 5 mg 41fluphenazine hcl 2.5 mg/ml 41fluphenazine hcl 5 mg/ml 41flurazepam hcl 68flurbiprofen 100 mg, 50 mg 3flurbiprofen sodium 76flutamide 35fluticasone propionate(nasal) 73fluticasone propionate 0.005% 57fluticasone propionate 0.05% 57fluvastatin sodium 20 mg, 40mg 28fluvastatin sodium 80 mg 28

fluvoxamine maleate 100 mg,150 mg 20fluvoxamine maleate 100 mg,25 mg, 50 mg 20FML 75FML FORTE 75FML LIQUIFILM 75FOCALIN 1FOCALIN XR 10 MG, 20MG 1FOCALIN XR 15 MG 1FOLOTYN 34fondaparinux sodium 10mg/0.8ml, 5 mg/0.4ml, 7.5mg/0.6ml 15fondaparinux sodium 2.5mg/0.5ml 15FORADIL AEROLIZER 14FORFIVO XL 19FORTAMET 1000 MG 22FORTAMET 500 MG 22FORTAZ 1 GM, 2 GM 50FORTAZ 6 GM 50FORTEO 60FORTESTA 8FOSAMAX 60FOSAMAX PLUS D 60fosinopril sodium 29fosinopril sodium &hydrochlorothiazide 31fosphenytoin sodium 100 mgpe/2ml 18fosphenytoin sodium 500 mgpe/10ml 18FOSRENOL 65FRAGMIN 10000 UNIT/ML,2500 UNIT/0.2ML, 5000UNIT/0.2ML 15FRAGMIN 12500 UNIT/0.5ML,15000 UNIT/0.6ML, 18000UNT/0.72ML, 25000 UNIT/ML,7500 UNIT/0.3ML 15FRAGMIN 95000UNIT/3.8ML 15FROVA 70FULYZAQ 25FURADANTIN 83furosemide 10 mg/ml 60furosemide 20 mg, 40 mg, 80mg 60furosemide 8 mg/ml 60FUSILEV 37

FUZEON 42FYCOMPA 10 MG 16FYCOMPA 12 MG 16FYCOMPA 2 MG 16FYCOMPA 4 MG 16FYCOMPA 6 MG 16FYCOMPA 8 MG 16gabapentin 100 mg, 300 mg, 400mg 16gabapentin 250 mg/5ml 16gabapentin 600 mg, 800 mg 16GABITRIL 12 MG, 16 MG 18GABITRIL 2 MG, 4 MG 18galantamine hydrobromide 12mg, 4 mg, 8 mg 79galantamine hydrobromide 16mg, 24 mg, 8 mg 79galantamine hydrobromide 4mg/ml 79GAMASTAN S/D 77GAMMAGARD LIQUID 77GAMMAKED 77GAMUNEX-C 77ganciclovir sodium 43GARDASIL 84GASTROCROM 64gatifloxacin (ophth) 74GATTEX 65gauze pads 2" X 2" 70GAZYVA 34GELNIQUE 84GEMCITABINE 34gemcitabine hcl 1 gm 34gemcitabine hcl 2 gm 34gemcitabine hcl 200 mg 34gemfibrozil 28GEMZAR 1 GM 34GEMZAR 200 MG 34GENERESS FE 50GENOTROPIN 5 MG 61GENOTROPIN MINIQUICK 0.4MG 61gentamicin in saline 0.9%-0.8mg/ml 2gentamicin in saline 0.9%-0.9mg/ml, 0.9%-1.4mg/ml, 0.9%-1.6mg/ml, 0.9%-1mg/ml, 0.9%-2mg/ml 2gentamicin in saline 0.9%-1.2mg/ml 2

Index 11

gentamicin sulfate (ophth) 74gentamicin sulfate (topical) 54gentamicin sulfate 10 mg/ml 2gentamicin sulfate 10 mg/ml, 40mg/ml 2GEODON 20 MG 39GEODON 20 MG, 40 MG, 60MG, 80 MG 39GILENYA 79GILOTRIF 36GLASSIA 80glatiramer acetate 79GLEEVEC 36GLEOSTINE 33glimepiride 1 mg 24glimepiride 2 mg 24glimepiride 4 mg 24glipizide 10 mg 24glipizide 2.5 mg 24glipizide 5 mg 24glipizide-metformin hcl 2.5mg-250mg 22glipizide-metformin hcl 2.5mg-500mg, 5mg-500mg 22GLUCAGEN HYPOKIT 22glucagon (rdna) 23GLUCOPHAGE 1000 MG 22GLUCOPHAGE 500 MG 22GLUCOPHAGE 850 MG 22GLUCOPHAGE XR 500 MG 22GLUCOPHAGE XR 750 MG 22GLUCOTROL 10 MG 24GLUCOTROL 5 MG 24GLUCOTROL XL 10 MG 24GLUCOTROL XL 2.5 MG 24GLUCOTROL XL 5 MG 24GLUCOVANCE 1.25MG-250MG 22GLUCOVANCE 2.5MG-500MG,5MG-500MG 22GLUMETZA 1000 MG 22GLUMETZA 500 MG 22glyburide 1.25 mg 25glyburide 2.5 mg 25glyburide 5 mg 25glyburide micronized 1.5 mg 25glyburide micronized 3 mg 25glyburide micronized 6 mg 25

glyburide-metformin 1.25mg-250mg 22glyburide-metformin 2.5mg-500mg, 5mg-500mg 22glycopyrrolate 0.2 mg/ml 82glycopyrrolate 1 mg 82glycopyrrolate 2 mg 82GLYNASE 1.5 MG 25GLYNASE 3 MG 25GLYNASE 6 MG 25GLYSET 21GOLYTELY 227.1GM-21.5GM-5.53GM-2.82GM-6.36GM 68GOLYTELY 236GM-22.74GM-5.86GM-2.97GM-6.74GM 68GRALISE 80GRALISE STARTER 80granisetron hcl 1 mg 25GRANIX 67GRASTEK 47GRIS-PEG 26griseofulvin microsize 125mg/5ml 26griseofulvin microsize 500mg 26griseofulvin ultramicrosize 125mg 26griseofulvin ultramicrosize 250mg 26guanfacine hcl 30guanfacine hcl (adhd) 1guanidine hcl 32H.P. ACTHAR 61HALAVEN 38HALCION 68HALDOL 40HALDOL DECANOATE100 40HALDOL DECANOATE 50 40halobetasol propionate 57HALOG 57haloperidol 40haloperidol decanoate 40haloperidol lactate 40HARVONI 44HAVRIX 84HECTOROL 0.5 MCG, 2.5MCG 61HECTOROL 1 MCG 61heparin sodium (porcine) 1000unit/ml 15

heparin sodium (porcine) 10000unit/ml, 20000 unit/ml, 5000unit/0.5ml, 5000 unit/ml 15HEPSERA 44HERCEPTIN 34HETLIOZ 68HEXALEN 33HIPREX 83HIZENTRA 1 GM/5ML 77HIZENTRA 10 GM/50ML, 2GM/10ML, 4 GM/20ML 77HORIZANT 80HUMALOG 23HUMALOG KWIKPEN 23HUMALOG MIX 50/50 23HUMALOG MIX 50/50KWIKPEN 23HUMALOG MIX 75/25 23HUMALOG MIX 75/25KWIKPEN 23HUMATROPE 61HUMATROPE COMBOPACK 61HUMIRA 2HUMIRA PEDIATRIC CROHNSDISEASE STARTER PACK 2HUMIRA PEN 2HUMIRA PEN-CROHNSDISEASESTARTER 2HUMIRA PEN-PSORIASISSTARTER 2HUMULIN 70/30 23HUMULIN 70/30 KWIKPEN 23HUMULIN 70/30 PEN 23HUMULIN N 23HUMULIN N KWIKPEN 23HUMULIN N U-100 PEN 23HUMULIN R 23HUMULIN R U-500(CONCENTRATED) 23HYCAMTIN 4 MG 38hydralazine hcl 10 mg, 100 mg,25 mg, 50 mg 32HYDREA 37hydrochlorothiazide 12.5 mg 60hydrochlorothiazide 12.5 mg, 25mg, 50 mg 60hydrocodone-acetaminophen10mg-300mg, 5mg-300mg,7.5mg-300mg 7

Index 12

hydrocodone-acetaminophen10mg-325mg, 5mg-325mg,7.5mg-325mg 7hydrocodone-acetaminophen10mg/15ml-325mg/15ml,2.5mg/5ml-108mg/5ml,5mg/10ml-217mg/10ml,7.5mg/15ml-325mg/15ml 7hydrocodone-acetaminophen5mg-500mg 7hydrocodone-ibuprofen 200mg-10mg, 200mg-5mg, 200mg-7.5mg 7hydrocortisone (intrarectal) 9hydrocortisone (rectal) 9hydrocortisone (topical) 1 % 57hydrocortisone (topical) 2.5% 57hydrocortisone 10 mg, 20 mg, 5mg 52hydrocortisone acetate w/pramoxine 1%-1% 9hydrocortisone butyrate 57hydrocortisone butyratehydrophilic lipo base 57hydrocortisone sodsuccinate 52hydrocortisone valerate 57hydrocortisone w/acetic acid 77hydromorphone hcl 1 mg/ml 5hydromorphone hcl 10 mg/ml, 2mg/ml, 50 mg/5ml, 500mg/50ml 5hydromorphone hcl 12 mg 5hydromorphone hcl 16 mg 5hydromorphone hcl 2 mg 5hydromorphone hcl 4 mg 5hydromorphone hcl 8 mg 5HYDROMORPHONE HCL ER5hydroxychloroquine sulfate 32hydroxyurea 37hydroxyzine hcl 10 mg, 25 mg, 50mg 12hydroxyzine hcl 10 mg/5ml 12hydroxyzine hcl 25 mg/ml, 50mg/ml 12hydroxyzine pamoate 100 mg, 25mg, 50 mg 12HYQVIA 77HYSINGLA ER 100 MG, 120MG 5HYSINGLA ER 20 MG, 30 MG,40 MG, 60 MG, 80 MG 5HYZAAR 31

ibandronate sodium 150mg 60ibandronate sodium 3mg/3ml 60IBRANCE 36ibuprofen 100 mg/5ml 3ibuprofen 400 mg 3ibuprofen 600 mg 3ibuprofen 800 mg 3ICLUSIG 36IDAMYCIN PFS 36idarubicin hcl 36IFEX 33ifosfamide 1 gm 33ifosfamide 1 gm/20ml, 3gm/60ml 33IFOSFAMIDE 3 GM 33ILARIS 3ILEVRO 76IMBRUVICA 36imipenem-cilastatin 250mg-250mg 10imipenem-cilastatin 500mg-500mg 10imipramine hcl 10 mg, 25 mg,50 mg 21imipramine pamoate 21imiquimod 58IMITREX 100 MG 70IMITREX 25 MG 70IMITREX 50 MG 70IMITREX 6 MG/0.5ML 70IMITREX STATDOSE REFILL4 MG/0.5ML 70IMITREX STATDOSE REFILL6 MG/0.5ML 70IMITREX STATDOSE SYSTEM4 MG/0.5ML 70IMITREX STATDOSE SYSTEM6 MG/0.5ML 70IMOVAX RABIES(H.D.C.V.) 84IMURAN 45INCIVEK 44INCRELEX 61INCRUSE ELLIPTA 13indapamide 60INDERAL LA 46INDERAL XL 46INDOCIN 25 MG/5ML 3indomethacin 25 mg, 50 mg 3

indomethacin 75 mg 3INFANRIX 82INLYTA 36INNOPRAN XL 46INSPRA 32INSULIN SYRINGES AND PENNEEDLES 70INTELENCE 100 MG, 200MG 42INTELENCE 25 MG 42INTERMEZZO 68INTRON A 10 MU, 18 MU, 50MU 37INTRON A 10 MU/ML 37INTRON A 6000000UNIT/ML 37INTRON A W/DILUENT 37INTUNIV 1INVANZ 10INVEGA 1.5 MG 40INVEGA 3 MG 40INVEGA 6 MG 40INVEGA 9 MG 40INVEGA SUSTENNA 117MG/0.75ML, 156 MG/ML, 234MG/1.5ML 40INVEGA SUSTENNA 39MG/0.25ML, 78 MG/0.5ML 40INVEGA TRINZA 40INVIRASE 42INVOKAMET 150MG-1000MG,150MG-500MG, 50MG-1000MG 22INVOKAMET 50MG-500MG 22INVOKANA 24IOPIDINE 0.5 % 74IOPIDINE 1 % 74IPOL INACTIVATED IPV 84ipratropium bromide 13ipratropium bromide (nasal) 73ipratropium-albuterol 14irbesartan 30irbesartan-hydrochlorothiazide

31IRESSA 36irinotecan hcl 100 mg/5ml, 40mg/2ml 38irinotecan hcl 500 mg/25ml 38irrigation solutions,physiological 46ISENTRESS 100 MG 42

Index 13

ISENTRESS 25 MG 42ISENTRESS 400 MG 42isoniazid & rifampin 32isoniazid 100 mg, 300 mg 33isoniazid 50 mg/5ml 33ISOPTO CARPINE 74ISORDIL TITRADOSE 40MG 11ISORDIL TITRADOSE 5 MG 11isosorbide dinitrate 10 mg, 20mg, 30 mg, 5 mg 11isosorbide dinitrate 2.5 mg 11isosorbide dinitrate 40 mg 11isosorbide mononitrate 10mg 11isosorbide mononitrate 120 mg,30 mg, 60 mg 11isosorbide mononitrate 20mg 11isotretinoin 10 mg, 30 mg 53isotretinoin 20 mg 53isotretinoin 40 mg 53ISTALOL 74ISTODAX 36itraconazole 26ivermectin 9IXEMPRA KIT 38IXIARO 84JADENU 25JAKAFI 36JALYN 66JANUMET 22JANUMET XR 100MG-1000MG 22JANUMET XR 50MG-1000MG,50MG-500MG 22JANUVIA 23JARDIANCE 10 MG 24JARDIANCE 25 MG 24JENTADUETO 22JEVTANA 38JUBLIA 54JUXTAPID 10 MG 29JUXTAPID 20 MG 29JUXTAPID 30 MG 29JUXTAPID 40 MG, 60 MG 29JUXTAPID 5 MG 29K-TAB 10 MEQ 71KADCYLA 34

KADIAN 10 MG 5KADIAN 100 MG 5KADIAN 130 MG, 150 MG 5KADIAN 20 MG, 30 MG, 50MG, 60 MG, 80 MG 5KADIAN 40 MG, 70 MG 5KALBITOR 66KALETRA 100MG-25MG 42KALETRA 200MG-50MG 42KALETRA 400MG/5ML-100MG/5ML 42KALYDECO 150 MG 80KALYDECO 50 MG, 75MG 80KAPVAY 1KAYEXALATE 46KAZANO 22KEFLEX 250 MG, 500 MG 49KEFLEX 750 MG 49KENALOG 57KENALOG-10 52KENALOG-40 52KEPIVANCE 37KEPPRA 16KEPPRA XR 17KERLONE 46KERYDIN 54KETEK 300 MG 10KETEK 400 MG 10ketoconazole 26ketoconazole (topical) 54ketoprofen 200 mg 3ketoprofen 50 mg, 75 mg 3ketorolac tromethamine(ophth) 76ketorolac tromethamine 10mg 3ketorolac tromethamine 15mg/ml, 30 mg/ml 3ketorolac tromethamine 30mg/ml, 60 mg/2ml 3KEYTRUDA 34KHEDEZLA 20KINERET 3KLARON 53KLONOPIN 0.5 MG 16KLONOPIN 1 MG 16KLONOPIN 2 MG 16KOMBIGLYZE XR 2.5MG-1000MG 22

KOMBIGLYZE XR 5MG-1000MG, 5MG-500MG 22KUVAN 100 MG 61KYNAMRO 27labetalol hcl 100 mg, 200 mg, 300mg 46LAC-HYDRIN 58lactated ringer's 71lactic acid (ammonium lactate) 12% 58lactulose 69lactulose (encephalopathy) 65LAMICTAL 100 MG, 150 MG,200 MG, 25 MG 17LAMICTAL CHEWABLEDISPERSIBLE 17LAMICTAL ODT 100 MG, 200MG, 25 MG, 50 MG 17LAMICTAL STARTER/NOTTAKING CARBAMAZEPINE 17LAMICTAL STARTER/TAKINGCARBAMAZEPINE/NOT TAKINGVALPROATE 17LAMICTAL STARTER/TAKINGVALPROATE 17LAMICTAL XR 17LAMICTAL XR 100 MG, 250MG 17LAMICTAL XR 200 MG, 25 MG,300 MG, 50 MG 17LAMISIL 125 MG, 187.5 MG 26LAMISIL 250 MG 26lamivudine (hbv) 44lamivudine 10 mg/ml 42lamivudine 150 mg, 300 mg 42lamivudine-zidovudine 42lamotrigine 100 mg, 150 mg, 200mg, 25 mg 17lamotrigine 100 mg, 200 mg, 25mg, 50 mg 17lamotrigine 100 mg, 250 mg 17lamotrigine 200 mg, 25 mg, 300mg, 50 mg 17lamotrigine 25 mg, 5 mg 17LANOXIN 125 MCG, 250MCG 48LANOXIN 187.5 MCG, 62.5MCG 48LANOXIN PEDIATRIC 48lansoprazole 15 mg 83lansoprazole 30 mg 83LANTUS 23LANTUS SOLOSTAR 23

Index 14

LASIX 60LASTACAFT 76latanoprost 76LATUDA 120 MG 39LATUDA 20 MG 39LATUDA 40 MG 39LATUDA 60 MG 39LATUDA 80 MG 39LAZANDA 100 MCG/ACT 5LAZANDA 400 MCG/ACT 5leflunomide 4LEMTRADA 80LENVIMA 10MG DAILYDOSE 36LENVIMA 14MG DAILYDOSE 36LENVIMA 20MG DAILYDOSE 36LENVIMA 24MG DAILYDOSE 36LESCOL 28LESCOL XL 28LETAIRIS 48letrozole 35leucovorin calcium 10 mg, 15 mg,25 mg, 5 mg 37leucovorin calcium 100 mg, 200mg, 350 mg 37leucovorin calcium 50 mg, 500mg 37LEUKERAN 33LEUKINE 67leuprolide acetate 35levalbuterol hcl 0.31 mg/3ml, 0.63mg/3ml, 1.25 mg/0.5ml, 1.25mg/3ml 14LEVAQUIN 25 MG/ML 64LEVAQUIN 250 MG, 750MG 64LEVAQUIN 250MG/50ML-5%,500MG/100ML-5% 64LEVAQUIN 500 MG 64LEVAQUIN 750MG/150ML-5% 64LEVATOL 46LEVEMIR 23LEVEMIR FLEXPEN 23LEVEMIR FLEXTOUCH 23levetiracetam 100 mg/ml, 500mg/5ml 17levetiracetam 1000 mg, 250 mg,500 mg, 750 mg 17

LEVETIRACETAM1000MG/100ML-750MG/100ML,1500MG/100ML-540MG/100ML, 500MG/100ML-820MG/100ML 17levetiracetam 500 mg, 750mg 17levetiracetam 500 mg/5ml 17levobunolol hcl 0.5 % 74levocarnitine (metabolicmodifiers) 330 mg 62levocetirizine dihydrochloride2.5 mg/5ml 27levocetirizine dihydrochloride 5mg 27levofloxacin (ophth) 75levofloxacin 25 mg/ml 64levofloxacin 250 mg, 500 mg,750 mg 64levofloxacin in d5w250mg/50ml-5%,500mg/100ml-5% 64levofloxacin in d5w750mg/150ml-5% 64LEVOLEUCOVORIN 37levoleucovorin calcium 37levonorgestrel & ethestradiol 50levonorgestrel (emergency oc)0.75 mg 51levonorgestrel (emergency oc)1.5 mg 51levonorgestrel-eth estradiol(triphasic) 50levonorgestrel-ethinyl estradiol(91-day) 50levothyroxine sodium 100 mcg,112 mcg, 125 mcg, 137 mcg,150 mcg, 175 mcg, 200 mcg,25 mcg, 300 mcg, 50 mcg, 75mcg, 88 mcg 81LEXAPRO 20LEXIVA 50 MG/ML 42LEXIVA 700 MG 42LIALDA 64lidocaine 5 % 58lidocaine hcl (cardiac) 12lidocaine hcl (local anesth.) 1%, 2 % 69lidocaine hcl (mouth-throat) 2% 72lidocaine hcl 2 % 58lidocaine hcl 4 % 58lidocaine-prilocaine 58

LIDODERM 58LINCOCIN 11lindane 59linezolid 2 mg/ml 11linezolid 600 mg 11LINZESS 65liothyronine sodium 25 mcg, 5mcg, 50 mcg 81LIPITOR 28LIPOFEN 28LIPTRUZET 27lisinopril &hydrochlorothiazide 31lisinopril 10 mg, 2.5 mg, 20 mg,30 mg, 40 mg, 5 mg 29lithium 39lithium carbonate 150 mg, 300mg, 600 mg 39lithium carbonate 300 mg 39lithium carbonate 300 mg, 450mg 39LITHOBID 39LIVALO 28LO LOESTRIN FE 50LO MINASTRIN FE 50LOCOID 57LOCOID LIPOCREAM 57LODOSYN 38LOMOTIL 25lomustine 10 mg 33lomustine 100 mg, 40 mg 33loperamide hcl 2 mg 25LOPID 28LOPRESSOR 100 MG, 50MG 46LOPRESSOR HCT 31LOPROX 54LOPROX SHAMPOO 54lorazepam 0.5 mg, 1 mg, 2mg 12lorazepam 2 mg/ml 12lorazepam 2 mg/ml, 20mg/10ml 12lorazepam 4 mg/ml 12losartan potassium 30losartan potassium &hydrochlorothiazide 31LOSEASONIQUE 50LOTEMAX 75LOTENSIN 29

Index 15

LOTENSIN HCT 31LOTREL 31LOTRISONE 54LOTRONEX 65lovastatin 28LOVAZA 27LOVENOX 100 MG/ML, 30MG/0.3ML, 40 MG/0.4ML, 60MG/0.6ML, 80 MG/0.8ML 16LOVENOX 120 MG/0.8ML, 150MG/ML 16LOVENOX 300 MG/3ML 15loxapine succinate 10 mg, 25 mg,5 mg, 50 mg 40LUMIGAN 76LUMIZYME 62LUNESTA 68LUPRON DEPOT 35LUPRON DEPOT-PED 11.25MG 61LUPRON DEPOT-PED 11.25MG, 7.5 MG 61LUPRON DEPOT-PED 15MG 61LUPRON DEPOT-PED 30MG 61LUVOX CR 20LUXIQ 57LUZU 54LYNPARZA 36LYRICA 100 MG 17LYRICA 150 MG 17LYRICA 20 MG/ML 17LYRICA 200 MG 17LYRICA 225 MG, 300 MG 17LYRICA 25 MG 17LYRICA 50 MG 17LYRICA 75 MG 17LYSODREN 35LYSTEDA 67M-M-R II 84MACROBID 83MACRODANTIN 100 MG, 50MG 83MACRODANTIN 25 MG 83magnesium sulfate 50 % 71MALARONE 250MG-100MG32MALARONE 62.5MG-25MG 32malathion 59maprotiline hcl 25 mg, 50 mg19

maprotiline hcl 75 mg 19MARINOL 10 MG, 5 MG 26MARINOL 2.5 MG 26MARPLAN 19MATULANE 37MAVIK 29MAXALT 10 MG 70MAXALT 5 MG 70MAXALT-MLT 10 MG 70MAXALT-MLT 5 MG 70MAXIDEX 75MAXIPIME 1 GM, 2 GM 50MAXITROL 75MAXZIDE 59MAXZIDE-25 59meclizine hcl 12.5 mg, 25mg 25meclofenamate sodium 50mg 3MEDROL 16 MG, 32 MG, 4MG, 8 MG 52MEDROL 2 MG 52MEDROL DOSEPAK 52medroxyprogesteroneacetate 78medroxyprogesterone acetate(contraceptive) 51mefenamic acid 3mefloquine hcl 32MEGACE ES 78MEGACE ORAL 35megestrol acetate(appetite) 78megestrol acetate 20 mg, 40mg 35megestrol acetate 40 mg/ml,400 mg/10ml 35MEKINIST 36meloxicam 15 mg, 7.5 mg 3melphalan hcl 33memantine hcl 10 mg, 5mg 79memantine hcl 2 mg/ml 79MENACTRA 84MENOMUNE-A/C/Y/W-135

84MENOSTAR 63MENVEO 84meperidine hcl 100 mg, 50mg 5meprobamate 12

MEPRON 10mercaptopurine 34meropenem 1 gm 10meropenem 500 mg 10MERREM 1 GM 10MERREM 500 MG 10mesalamine 64mesalamine w/ cleanser 64mesna 37MESNEX 100 MG/ML 37MESNEX 400 MG 37MESTINON 60 MG 32MESTINON TIMESPAN 32METADATE CD 1metaxalone 72metformin hcl 1000 mg 22metformin hcl 500 mg 22metformin hcl 750 mg 22metformin hcl 850 mg 22methadone hcl 10 mg 6methadone hcl 10 mg/5ml 5methadone hcl 5 mg 6methadone hcl 5 mg/5ml 6methamphetamine hcl 1methazolamide 25 mg, 50mg 59methenamine hippurate 83methimazole 10 mg, 5 mg 81methocarbamol 500 mg, 750mg 72methotrexate sodium 1 gm 34methotrexate sodium 1 gm/40ml,100 mg/4ml, 200 mg/8ml, 25mg/ml, 250 mg/10ml, 50mg/2ml 34methotrexate sodium 10 mg, 15mg, 2.5 mg 34methotrexate sodium 25mg/ml 34methotrexate sodium 5 mg, 7.5mg 34methoxsalen rapid 55methscopolamine bromide 2.5mg, 5 mg 82methyclothiazide 60methyldopa 30methyldopa &hydrochlorothiazide 31methylergonovine maleate 0.2mg 77

Index 16

methylphenidate hcl 10 mg 2methylphenidate hcl 10 mg, 20mg, 30 mg, 40 mg, 50 mg, 60mg 1methylphenidate hcl 10 mg, 20mg, 5 mg 2methylphenidate hcl 18 mg, 20mg, 27 mg, 36 mg, 54 mg 2methylphenidate hcl 18 mg, 27mg, 36 mg, 54 mg 2methylphenidate hcl 20 mg, 40mg 1methylphenidate hcl 30 mg 1methylprednisolone 16 mg, 32mg, 4 mg, 8 mg 52methylprednisolone acetate 40mg/ml, 80 mg/ml 52methylprednisolone sodsucc 52methyltestosterone 8metipranolol 74metoclopramide hcl 10 mg, 5mg 64metoclopramide hcl 10 mg/10ml,5 mg/5ml 64metoclopramide hcl 5 mg/ml 64metolazone 60metoprolol & hydrochlorothiazide100mg-25mg, 50mg-25mg 31metoprolol & hydrochlorothiazide100mg-50mg 31metoprolol succinate 46metoprolol tartrate 100 mg, 25mg, 50 mg 46METROCREAM 58METROGEL 58METROGEL-VAGINAL 85METROLOTION 58metronidazole (topical) 58metronidazole 250 mg 9metronidazole 375 mg 9metronidazole 500 mg 9metronidazole in nacl 9metronidazole vaginal 85MEVACOR 28mexiletine hcl 12MIACALCIN 200 UNIT/ACT 60MIACALCIN 200 UNIT/ML 60MICARDIS 30MICARDIS HCT 31miconazole nitrate vaginal 200mg 85

MICRO-K 71MICROZIDE 60midodrine hcl 85MIGERGOT 70MIGRANAL 70MILLIPRED 5 MG 52MINASTRIN 24 FE 50MINIPRESS 30MINIVELLE 63MINOCIN 100 MG, 50 MG, 75MG 81minocycline hcl 100 mg, 50mg 81minocycline hcl 100 mg, 50 mg,75 mg 81minoxidil 10 mg, 2.5 mg 32MIRAPEX 38MIRAPEX ER 39MIRCERA 100 MCG/0.3ML, 50MCG/0.3ML, 75MCG/0.3ML 67MIRCERA 200MCG/0.3ML 67mirtazapine 19MIRVASO 58misoprostol 100 mcg, 200mcg 83mitomycin 20 mg, 40 mg, 5mg 36mitoxantrone hcl 36MOBIC 15 MG, 7.5 MG 3modafinil 100 mg 2modafinil 200 mg 2MODICON 50moexipril hcl 29moexipril-hydrochlorothiazide

31mometasone furoate 57MONODOX 81montelukast sodium 10 mg13montelukast sodium 4 mg, 5mg 13MONUROL 83morphine sulfate 0.5 mg/ml 6morphine sulfate 1 mg/ml 6morphine sulfate 10 mg 6morphine sulfate 10 mg/5ml 6morphine sulfate 100 mg 6morphine sulfate 100 mg/5ml,20 mg/ml 6morphine sulfate 15 mg 6

morphine sulfate 20 mg, 30 mg,50 mg, 60 mg, 80 mg 6morphine sulfate 20 mg/5ml 6morphine sulfate 200 mg 6morphine sulfate 30 mg 6morphine sulfate 30 mg, 60mg 6morphine sulfate beads 6MOTOFEN 25MOVANTIK 65MOVIPREP 68MOXEZA 75moxifloxacin hcl 400 mg 64MOZOBIL 67MS CONTIN 100 MG 6MS CONTIN 15 MG 6MS CONTIN 200 MG 6MS CONTIN 30 MG, 60 MG 6MULTAQ 13mupirocin 54mupirocin calcium (topical) 54MUSTARGEN 33MYALEPT 62MYAMBUTOL 33MYCAMINE 100 MG 26MYCOBUTIN 33mycophenolate mofetil 200mg/ml 45mycophenolate mofetil 250mg 45mycophenolate mofetil 500mg 45mycophenolate sodium 180mg 45mycophenolate sodium 360mg 45MYFORTIC 180 MG 45MYFORTIC 360 MG 45MYOZYME 62MYRBETRIQ 84MYSOLINE 17nabumetone 4nadolol & bendroflumethiazide40mg-5mg 31nadolol & bendroflumethiazide80mg-5mg 31nadolol 20 mg, 40 mg, 80mg 47nafcillin sodium 1 gm 78nafcillin sodium 10 gm 78

Index 17

nafcillin sodium 2 gm 78naftifine hcl 54NAFTIN 55NAGLAZYME 62naloxone hcl 1 mg/ml 25naltrexone hcl 25NAMENDA 10 MG, 5 MG 79NAMENDA 10 MG/5ML 79NAMENDA TITRATION PAK79NAMENDA XR 14 MG 79NAMENDA XR 21 MG, 28MG 79NAMENDA XR 7 MG 79NAMENDA XR TITRATIONPACK 79naphazoline hcl 75NAPRELAN 375 MG 4NAPRELAN 375 MG, 750 MG4NAPROSYN 4naproxen 250 mg, 375 mg, 500mg 4naproxen 375 mg, 500 mg 4naproxen sodium 275 mg, 550mg 4naproxen sodium 375 mg 4naratriptan hcl 70NARDIL 19NASONEX 73NATACYN 75nateglinide 24NATESTO 8NATPARA 60NAVELBINE 38NEBUPENT 9nefazodone hcl 20neomycin sulfate 2neomycin-bacitracin zn-polymyxin 75neomycin-polymy-dexameth 75neomycin-polymyxin-gramicidin

75neomycin-polymyxin-hc(ophth) 75neomycin-polymyxin-hc(otic) 77neomycin/polymyxin b gu 65NEORAL 100 MG, 25 MG 45NESINA 23NEULASTA 67NEULASTA DELIVERY KIT 67

NEUMEGA 67NEUPOGEN 67NEUPRO 39NEURONTIN 17NEVANAC 76nevirapine 100 mg 42nevirapine 200 mg 42nevirapine 400 mg 42NEVIRAPINE 50 MG/5ML 42NEXAVAR 36NEXIUM 10 MG, 2.5 MG, 20MG, 40 MG, 5 MG 83NEXIUM 20 MG 83NEXIUM 40 MG 83niacin (antihyperlipidemic) 29NIASPAN 29nicardipine hcl 20 mg, 30mg 47NICOTROL INHALER 80NICOTROL NS 80nifedipine 10 mg, 20 mg 47nifedipine 30 mg, 60 mg, 90mg 47NILANDRON 35nimodipine 47NIPENT 37NIRAVAM 12nisoldipine 17 mg, 34 mg, 8.5mg 47NITRO-DUR 0.1 MG/HR, 0.2MG/HR, 0.4 MG/HR, 0.6MG/HR 11NITRO-DUR 0.3 MG/HR, 0.8MG/HR 11nitrofurantoin 84nitrofurantoin macrocrystal 100mg, 25 mg, 50 mg 83nitrofurantoin monohydmacro 84nitroglycerin 0.1 mg/hr, 0.2mg/hr, 0.4 mg/hr, 0.6mg/hr 11nitroglycerin 0.4 mg/spray 11nitroglycerin 5 mg/ml 11NITROGLYCERINLINGUAL 11NITROLINGUALPUMPSPRAY 11NITROMIST 11NITROSTAT 11nizatidine 150 mg, 300 mg 82

NIZORAL 55NOR-QD 51NORDITROPIN FLEXPRO 10MG/1.5ML, 5 MG/1.5ML 61norelgestromin-ethinylestradiol 51norethin acet & estrad-fe 75mg-20mcg-1mg, 75mg-30mcg-1.5mg 50norethindrone & eth estradiol0.4mg-35mcg, 1mg-35mcg 50norethindrone & eth estradiol0.5mg-35mcg 50norethindrone & ethinyl estradiol-fe 50norethindrone(contraceptive) 51norethindrone acet & ethestra 50norethindrone acetate 78norethindrone acetate-ethinylestradiol 2.5mcg-0.5mg 63norethindrone-eth estradiol(triphasic) 50norgestimate-ethinylestradiol 50norgestimate-ethinyl estradiol(triphasic) 50norgestrel & ethinyl estradiol 51NORINYL 1+35 51NORITATE 59NORPACE 12NORPACE CR 100 MG 12NORPRAMIN 21NORTHERA 100 MG 85NORTHERA 200 MG 85NORTHERA 300 MG 85nortriptyline hcl 10 mg, 25 mg, 50mg, 75 mg 21nortriptyline hcl 10 mg/5ml 21NORVASC 10 MG 47NORVASC 2.5 MG 47NORVASC 5 MG 47NORVIR 42NOVOLIN 70/30 23NOVOLIN 70/30 RELION 23NOVOLIN N 24NOVOLIN N RELION 24NOVOLIN R 24NOVOLIN R RELION 24NOVOLOG 24NOVOLOG FLEXPEN 24

Index 18

NOVOLOG MIX 70/30 24NOVOLOG MIX 70/30PREFILLED FLEXPEN 24NOVOLOG PENFILL 24NOXAFIL 100 MG 26NOXAFIL 300 MG/16.7ML 26NOXAFIL 40 MG/ML 26NUCYNTA 100 MG 6NUCYNTA 50 MG 6NUCYNTA 75 MG 6NUCYNTA ER 100 MG 6NUCYNTA ER 150 MG, 200 MG,250 MG 6NUCYNTA ER 50 MG 6NUEDEXTA 80NULOJIX 45NULYTELY/FLAVORPACKS 69NUTROPIN AQ NUSPIN 20 61NUTROPIN AQ PEN 20MG/2ML 61NUVARING 51NUVIGIL 2NYMALIZE 47nystatin 26nystatin (mouth-throat) 72nystatin (topical) 55nystatin-triamcinolone 55OCTAGAM 10 GM/100ML, 2GM/20ML, 20 GM/200ML, 5GM/50ML 77octreotide acetate 100mcg/ml 62octreotide acetate 1000 mcg/5ml,200 mcg/ml, 50 mcg/ml 62OCUFEN 76OCUFLOX 75ODOMZO 35OFEV 80ofloxacin (ophth) 75ofloxacin (otic) 77olanzapine 10 mg 40olanzapine 10 mg, 15 mg, 2.5mg, 20 mg, 5 mg, 7.5 mg 40olanzapine 10 mg, 15 mg, 20 mg,5 mg 41olanzapine-fluoxetine hcl 79OLEPTRO 20olopatadine hcl (nasal) 73OLUX 57

OLUX-E 57OLYSIO 44omega-3-acid ethyl esters 27omeprazole 10 mg, 20 mg, 40mg 83omeprazole-sodiumbicarbonate 20mg-1100mg83omeprazole-sodiumbicarbonate 40mg-1100mg83OMNARIS 73OMNIPRED 75OMNITROPE 10 MG/1.5ML, 5MG/1.5ML 61ONCASPAR 37ondansetron 25ondansetron hcl 24 mg, 4 mg, 8mg 25ondansetron hcl 4 mg/2ml 25ondansetron hcl 4 mg/5ml 25ondansetron hcl 40mg/20ml 25ONFI 10 MG, 5 MG 16ONFI 2.5 MG/ML 16ONFI 20 MG 16ONGLYZA 23ONMEL 26OPANA 10 MG 6OPANA 5 MG 6OPDIVO 34opium tincture 25OPSUMIT 48OPTIVAR 76ORACEA 59ORAP 80ORAPRED ODT 52ORENCIA 4ORENITRAM 0.125 MG 48ORENITRAM 0.25 MG, 1 MG,2.5 MG 48ORFADIN 62ORKAMBI 80orphenadrine citrate 100mg 72orphenadrine citrate 30mg/ml 72orphenadrine w/ aspirin &caff 73ORTHO EVRA 51ORTHO MICRONOR 51ORTHO TRI-CYCLEN 51

ORTHO-CEPT 51ORTHO-CYCLEN 51ORTHO-NOVUM 1/35 51ORTHO-NOVUM 7/7/7 51OSENI 12.5MG-15MG 22OSENI 12.5MG-30MG, 12.5MG-45MG, 25MG-15MG, 25MG-30MG, 25MG-45MG 22OSMOPREP 69OTEZLA 4OTREXUP 2OVIDE 59oxaliplatin 100 mg, 50 mg 33oxaliplatin 100 mg/20ml 33oxaliplatin 50 mg/10ml 33OXANDRIN 10 MG 8OXANDRIN 2.5 MG 8oxandrolone 10 mg 8oxandrolone 2.5 mg 8oxaprozin 4OXAYDO 5 MG 6OXAYDO 7.5 MG 6oxazepam 12oxcarbazepine 150 mg, 300 mg,600 mg 17oxcarbazepine 300 mg/5ml, 60mg/ml 17OXECTA 5 MG 6OXECTA 7.5 MG 6OXISTAT 55OXSORALEN 58OXSORALEN ULTRA 55oxybutynin chloride 10 mg, 15mg, 5 mg 84oxybutynin chloride 5 mg 84oxybutynin chloride 5mg/5ml 84oxycodone hcl 10 mg 6oxycodone hcl 100 mg/5ml, 20mg/ml 6oxycodone hcl 15 mg 6oxycodone hcl 20 mg 6oxycodone hcl 30 mg 6oxycodone hcl 5 mg 6OXYCODONE HCL ER 10 MG,20 MG, 40 MG 6OXYCODONE HCL ER 80MG 6oxycodone w/ acetaminophen10mg-325mg 8

Index 19

oxycodone w/ acetaminophen2.5mg-325mg, 5mg-325mg,7.5mg-325mg 8oxycodone w/ acetaminophen5mg/5ml-325mg/5ml 7oxycodone-aspirin 8OXYCONTIN 10 MG, 15 MG, 20MG, 30 MG, 40 MG, 60 MG 6OXYCONTIN 80 MG 7oxymorphone hcl 10 mg 7oxymorphone hcl 15 mg 7oxymorphone hcl 20 mg 7oxymorphone hcl 30 mg, 40mg 7oxymorphone hcl 5 mg 7oxymorphone hcl 7.5 mg 7OXYTROL 84paclitaxel 100 mg/16.7ml, 30mg/5ml, 300 mg/50ml 38paclitaxel 150 mg/25ml 38paliperidone 1.5 mg 40paliperidone 3 mg 40paliperidone 6 mg 40paliperidone 9 mg 40PAMELOR 21PAMINE 82PAMINE FORTE 82PANCREAZE 59PANCRELIPASE 59PANRETIN 55pantoprazole sodium 20 mg, 40mg 83pantoprazole sodium 40 mg 83PARAFON FORTE DSC 72parenteral electrolytes 71paricalcitol 1 mcg 62paricalcitol 2 mcg, 4 mcg 62PARLODEL 39PARNATE 19paromomycin sulfate 2paroxetine hcl 20PATADAY 76PATANASE 73PATANOL 76PAXIL 10 MG, 20 MG, 30 MG, 40MG 20PAXIL 10 MG/5ML 20PAXIL CR 20PCE 333 MG 70

PCE 500 MG 70PEDVAX HIB 84peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 69peg 3350-potassium chloride-sod bicarbonate-sodchloride 69PEG-INTRON 44PEG-INTRON REDIPEN 44PEG-INTRON REDIPEN PAK4 44PEGANONE 18PEGASYS 44PEGASYS PROCLICK 44PEGINTRON 44penicillin g potassium 20 mu,20000000 unit 77penicillin g potassium 5000000unit 78penicillin v potassium 78PENLAC NAIL LACQUER 55PENNSAID 54PENTAM 300 9PENTASA 65pentazocine w/ naloxone 8pentobarbital sodium 68pentoxifylline 66PEPCID 82PERCODAN 8PERFOROMIST 14PERIDEX 72perindopril erbumine 2 mg 29perindopril erbumine 4 mg 29perindopril erbumine 8 mg 29PERJETA 34permethrin 5 % 59perphenazine 16 mg, 2 mg, 4mg, 8 mg 41perphenazine-amitriptyline 79PERSANTINE 66PERTZYE 59PEXEVA 20PFIZERPEN-G 78phenelzine sulfate 19phenobarbital 100 mg, 15 mg,16.2 mg, 30 mg, 32.4 mg, 60mg, 64.8 mg, 97.2 mg 68phenobarbital 20 mg/5ml 68phenoxybenzamine hcl 30phenytoin 125 mg/5ml 18

phenytoin 50 mg 18phenytoin sodium 18phenytoin sodium extended 18PHOSLO 65PHOSLYRA 65PHOSPHOLINE IODIDE 74PICATO 55pilocarpine hcl (oral) 72pilocarpine hcl 1 %, 2 %, 4% 74pimozide 80pindolol 47pioglitazone hcl 15 mg 23pioglitazone hcl 30 mg, 45mg 23pioglitazone hcl-glimepiride 22pioglitazone hcl-metforminhcl 22piperacillin sodium-tazobactamsodium 0.25gm-2gm, 0.375gm-3gm, 4.5gm-36gm 78piperacillin sodium-tazobactamsodium 0.5gm-4gm 78piroxicam 10 mg, 20 mg 4PLAN B ONE-STEP 51PLAQUENIL 32PLAVIX 300 MG 66PLAVIX 75 MG 66PLEGRIDY 80PLEGRIDY STARTERPACK 80PLETAL 66podofilox 58polyethylene glycol 3350 69polymyxin b sulfate 11polymyxin b-trimethoprim 75POLYTRIM 75POMALYST 35PONSTEL 4potassium chloride 10 % 71potassium chloride 10 meq, 8meq 71potassium chloride 2 meq/ml 71potassium chloride 20 % 71POTASSIUM CHLORIDEER 71potassium chloride in dextrose &sodium chloride 0.45%-20meq/l-5% 71

Index 20

potassium chloridemicroencapsulated crystalscr 71potassium citrate (alkalinizer)1080 mg 65potassium citrate (alkalinizer) 540mg 65POTIGA 200 MG 17POTIGA 300 MG 17POTIGA 400 MG 17POTIGA 50 MG 17PRADAXA 16PRALUENT 150 MG/ML 29PRALUENT 75 MG/ML 29pramipexole dihydrochloride 39pramoxine-hc 1%-1% 57PRANDIMET 22PRANDIN 0.5 MG 24PRANDIN 1 MG 24PRANDIN 2 MG 24PRAVACHOL 28pravastatin sodium 28prazosin hcl 30PRECOSE 21PRED FORTE 75PRED MILD 75prednicarbate 57prednisolone 15 mg/5ml 52prednisolone 5 mg 52prednisolone acetate (ophth) 75prednisolone sodium phosphate(ophth) 75prednisolone sodium phosphate10 mg, 15 mg, 30 mg 52prednisolone sodium phosphate15 mg/5ml, 5 mg/5ml, 6.7mg/5ml 52prednisolone sodium phosphate20 mg/5ml, 25 mg/5ml 52prednisone 1 mg, 10 mg, 2.5 mg,20 mg, 5 mg, 50 mg 52prednisone 10 mg, 5 mg 52prednisone 5 mg/5ml 52prednisone 5 mg/ml 52PREMARIN 0.3 MG, 0.45 MG,0.625 MG, 0.9 MG, 1.25 MG 63PREMARIN 0.625 MG/GM 85PREMPHASE 63PREMPRO 63PREPOPIK 69

PREVACID 15 MG 83PREVACID 30 MG 83PREVPAC 83PREZCOBIX 42PREZISTA 100 MG/ML 42PREZISTA 150 MG 42PREZISTA 400 MG 42PREZISTA 600 MG, 800MG 43PREZISTA 75 MG 43PRIFTIN 33PRILOSEC 10 MG, 20 MG, 40MG 83PRIMAQUINEPHOSPHATE 32PRIMAXIN IV 10primidone 250 mg, 50 mg 17PRIMSOL 10PRINIVIL 29PRISTIQ 20PRIVIGEN 77PROAIR HFA 14PROAIR RESPICLICK 14probenecid 66procainamide hcl 500mg/ml 12PROCARDIA 47PROCARDIA XL 47prochlorperazine 41prochlorperazine edisylate 41prochlorperazine maleate 10mg, 5 mg 41PROCRIT 10000 UNIT/ML,2000 UNIT/ML, 3000 UNIT/ML,4000 UNIT/ML 67PROCRIT 20000 UNIT/ML,40000 UNIT/ML 67PROCTOCORT 1 % 9PROCYSBI 65progesterone micronized 100mg, 200 mg 78PROGLYCEM 23PROGRAF 0.5 MG, 1 MG, 5MG 45PROGRAF 5 MG/ML 45PROLASTIN-C 80PROLENSA 76PROLEUKIN 37PROLIA 60PROMACTA 12.5 MG 67

PROMACTA 25 MG 67PROMACTA 50 MG 67PROMACTA 75 MG 67promethazine &phenylephrine 53promethazine hcl 12.5 mg, 25mg, 50 mg 27promethazine hcl 25 mg/ml, 50mg/ml 27promethazine hcl 6.25mg/5ml 27PROMETRIUM 78propafenone hcl 13propantheline bromide 82proparacaine hcl 75propranolol hcl 10 mg, 20 mg, 40mg, 60 mg, 80 mg 47propranolol hcl 120 mg, 160 mg,60 mg, 80 mg 47propylthiouracil 81PROQUAD 84PROSCAR 66PROTONIX 20 MG, 40 MG 83PROTONIX 40 MG 83PROTOPIC 58protriptyline hcl 21PROVENTIL HFA 14PROVERA 78PROVIGIL 2PROZAC 20PROZAC WEEKLY 20PULMICORT 0.25 MG/2ML 14PULMICORT 0.5 MG/2ML 14PULMICORT 1 MG/2ML 14PULMICORT FLEXHALER 180MCG/ACT 14PULMICORT FLEXHALER 90MCG/ACT 14PULMOZYME 80PURINETHOL 34PURIXAN 34PYLERA 83pyrazinamide 33pyridostigmine bromide 180mg 32pyridostigmine bromide 60mg 32QNASL 73QNASL CHILDRENS 73QUALAQUIN 32

Index 21

QUARTETTE 51quetiapine fumarate 41quinapril hcl 29quinapril-hydrochlorothiazide

31quinidine gluconate 324 mg 12quinidine sulfate 12quinine sulfate 32QVAR 14RABAVERT 84RAGWITEK 47raloxifene hcl 61ramipril 29RANEXA 11ranitidine hcl 15 mg/ml, 150mg/10ml, 75 mg/5ml 82ranitidine hcl 150 mg 82ranitidine hcl 150 mg, 300mg 82ranitidine hcl 300 mg 82RAPAFLO 66RAPAMUNE 0.5 MG 45RAPAMUNE 1 MG, 2 MG 45RAPAMUNE 1 MG/ML 45RASUVO 2RAYOS 2 MG, 5 MG 52RAZADYNE 79RAZADYNE ER 79REBETOL 200 MG 44REBETOL 40 MG/ML 44REBIF 80REBIF REBIDOSE 80REBIF REBIDOSETITRATIONPACK 80REBIF TITRATION PACK 80RECLAST 60RECOMBIVAX HB 84RECTIV 9REGLAN 64REGRANEX 59RELENZA DISKHALER 44RELISTOR 12 MG/0.6ML 65RELISTOR 8 MG/0.4ML 65RELPAX 70REMERON 19REMERON SOLTAB 19REMICADE 65REMODULIN 48

RENAGEL 800 MG 65RENVELA 65repaglinide 0.5 mg 24repaglinide 1 mg 24repaglinide 2 mg 24REQUIP 39REQUIP XL 39RESCRIPTOR 100 MG 43RESCRIPTOR 200 MG 43RESCULA 76reserpine 0.1 mg, 0.25 mg 30RESTASIS 75RESTORIL 68RETIN-A 53RETIN-A MICRO 53RETIN-A MICRO PUMP 0.04%, 0.1 % 53RETIN-A MICRO PUMP 0.08% 54RETROVIR 43RETROVIR IV INFUSION 43REVATIO 10 MG/12.5ML 48REVATIO 20 MG 48REVLIMID 45REXULTI 0.25 MG 41REXULTI 0.5 MG 41REXULTI 1 MG 42REXULTI 2 MG 42REXULTI 3 MG, 4 MG 42REYATAZ 150 MG, 200 MG,300 MG 43REYATAZ 50 MG 43RHEUMATREX 3RHINOCORT AQUA 73ribavirin (hepatitis c) 44ribavirin (hepatitis c) 200mg 44ribavirin (hepatitis c) 400 mg,600 mg 44RIDAURA 3rifabutin 33RIFADIN 33rifampin 150 mg, 300 mg 33rifampin 600 mg 33RIFATER 32RILUTEK 73riluzole 73rimantadine hydrochloride 44

RIOMET 22risedronate sodium 150 mg 60risedronate sodium 30 mg, 5mg 60risedronate sodium 35 mg 61RISPERDAL 40RISPERDAL CONSTA 12.5MG 40RISPERDAL CONSTA 25MG 40RISPERDAL CONSTA 37.5 MG,50 MG 40RISPERDAL M-TAB 40risperidone 0.25 mg, 0.5 mg, 1mg, 2 mg, 3 mg, 4 mg 40risperidone 0.25 mg, 3 mg, 4mg 40risperidone 0.5 mg, 1 mg, 2mg 40risperidone 1 mg/ml 40RITALIN 2RITALIN LA 10 MG 2RITALIN LA 20 MG, 30 MG, 40MG 2RITALIN SR 2RITUXAN 34rivastigmine 79rivastigmine tartrate 79rizatriptan benzoate 10 mg 70rizatriptan benzoate 5 mg 70ROBAXIN 500 MG 72ROBAXIN-750 72ROBINUL 0.2 MG/ML 82ROBINUL 1 MG 82ROBINUL FORTE 82ROCALTROL 62ropinirole hydrochloride 0.25 mg,0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg,5 mg 39ropinirole hydrochloride 12 mg, 2mg, 4 mg, 6 mg, 8 mg 39ROTARIX 84ROTATEQ 85ROWASA 65ROXICODONE 15 MG 7ROXICODONE 30 MG 7ROXICODONE 5 MG 7ROZEREM 68RUCONEST 66RYTARY 39RYTHMOL 13

Index 22

RYTHMOL SR 13SABRIL 18SAFYRAL 51SALAGEN 72SAMSCA 62SANCTURA 84SANCTURA XR 84SANCUSO 25SANDIMMUNE 100 MG, 25MG 45SANDIMMUNE 100 MG/ML 45SANDIMMUNE 50 MG/ML 45SANDOSTATIN 100MCG/ML 62SANDOSTATIN 200 MCG/ML, 50MCG/ML 62SANDOSTATIN LAR DEPOT 20MG, 30 MG 62SANTYL 58SAPHRIS 10 MG 41SAPHRIS 2.5 MG 41SAPHRIS 5 MG 41SAVAYSA 15SAVELLA 79SAVELLA TITRATIONPACK 79SEASONIQUE 51SECTRAL 46selegiline hcl 39selenium sulfide 2.5 % 55SELZENTRY 43SEMPREX-D 53SENSIPAR 30 MG 62SENSIPAR 60 MG, 90 MG 62SEREVENT DISKUS 14SEROQUEL 41SEROQUEL XR 150 MG, 200MG, 300 MG, 50 MG 41SEROQUEL XR 400 MG 41SEROSTIM 4 MG, 6 MG 61sertraline hcl 100 mg, 25 mg, 50mg 20sertraline hcl 20 mg/ml 20SEVELAMER CARBONATE 65SIGNIFOR 62SIGNIFOR LAR 20 MG 62SIGNIFOR LAR 40 MG, 60MG 62sildenafil citrate (pulmonaryhypertension) 48

SILENOR 68SILVADENE 55silver sulfadiazine 55SIMBRINZA 74SIMCOR 20MG-1000MG,20MG-500MG, 20MG-750MG 28SIMCOR 40MG-1000MG,40MG-500MG 28SIMPONI 2SIMPONI ARIA 2SIMULECT 45simvastatin 10 mg 28simvastatin 20 mg 28simvastatin 40 mg 28simvastatin 5 mg 28simvastatin 80 mg 28SINEMET 39SINEMET CR 39SINGULAIR 10 MG 13SINGULAIR 4 MG, 5 MG 13sirolimus 0.5 mg, 1 mg 45sirolimus 2 mg 45SIRTURO 33SIVEXTRO 11SKELAXIN 72sodium chloride (guirrigant) 65sodium chloride 0.45 % 72sodium chloride 0.9 % 72sodium fluoride 1 mg 71sodium polystyrenesulfonate 46sodium polystyrene sulfonate15 gm/60ml 46SOLARAZE 55SOLTAMOX 35SOLU-CORTEF 100 MG, 250MG 52SOLU-MEDROL 1000 MG, 125MG, 40 MG 52SOLU-MEDROL 2 GM 52SOMA 350 MG 72SOMATULINE DEPOT 62SOMAVERT 61SONATA 68SOOLANTRA 59SORIATANE 55SORILUX 55

sotalol hcl 47sotalol hcl (afib/afl) 47Sotalol Hcl IV Soln 47SOTYLIZE 47SOVALDI 44SPIRIVA HANDIHALER 13SPIRIVA RESPIMAT 1.25MCG/ACT 13SPIRIVA RESPIMAT 2.5MCG/ACT 13spironolactone &hydrochlorothiazide 59spironolactone 100 mg, 25 mg,50 mg 60SPORANOX 10 MG/ML 27SPORANOX 100 MG 26SPORANOX PULSEPAK 27SPRIX 4SPRYCEL 36STALEVO 100 39STALEVO 125 39STALEVO 150 39STALEVO 200 39STALEVO 50 39STALEVO 75 39STARLIX 24stavudine 1 mg/ml 43stavudine 15 mg 43stavudine 20 mg, 30 mg, 40mg 43STELARA 55STIMATE 62STIOLTO RESPIMAT 15STIVARGA 36STRATTERA 10 MG 1STRATTERA 100 MG, 60 MG, 80MG 1STRATTERA 18 MG 1STRATTERA 25 MG 1STRATTERA 40 MG 1STRIBILD 43STRIVERDI RESPIMAT 15STROMECTOL 9SUBOXONE 8SUBSYS 100 MCG, 200 MCG7SUBSYS 1200 MCG, 1600MCG 7SUBSYS 400 MCG, 600 MCG,800 MCG 7sucralfate 82

Index 23

SULAR 47sulfacetamide sod-prednisolone10%-0.2% 75sulfacetamide sod-prednisolone10%-0.23% 76sulfacetamide sodium (acne)54sulfacetamide sodium(ophth) 75sulfadiazine 80sulfamethoxazole-trimethoprim160mg-800mg, 80mg-400mg 10sulfamethoxazole-trimethoprim40mg/5ml-200mg/5ml 10sulfamethoxazole-trimethoprim80mg/5ml-400mg/5ml 10SULFAMYLON 85 MG/GM 55sulfasalazine 65sulindac 150 mg, 200 mg 4sumatriptan succinate 100mg 71sumatriptan succinate 25 mg71sumatriptan succinate 4mg/0.5ml 71sumatriptan succinate 50 mg71sumatriptan succinate 6mg/0.5ml 71SUMAVEL DOSEPRO 4MG/0.5ML 71SUMAVEL DOSEPRO 6MG/0.5ML 71SUPRAX 400 MG 50SUPRAX 500 MG/5ML 50SUPREP BOWEL PREP 69SURMONTIL 21SUSTIVA 200 MG, 50 MG 43SUSTIVA 600 MG 43SUTENT 36SYLATRON 37SYMBICORT 15SYMBYAX 79SYMLINPEN 120 21SYMLINPEN 60 21SYNAGIS 77SYNALAR 57SYNAREL 61SYNERCID 11SYNRIBO 37SYNTHROID 81SYPRINE 45TABLOID 34

TACLONEX 58tacrolimus (topical) 58tacrolimus 0.5 mg, 1 mg, 5mg 45TAFINLAR 36TALWIN 8TAMIFLU 44tamoxifen citrate 10 mg, 20mg 35tamsulosin hcl 66TANZEUM 23TARCEVA 36TARGRETIN 37TASIGNA 36TASMAR 38TAXOL 38TAXOTERE 38TAZORAC 55TECFIDERA 80TECFIDERA STARTERPACK 80TEFLARO 50TEGRETOL 17TEGRETOL-XR 17TEKAMLO 150MG-10MG 31TEKAMLO 150MG-5MG 31TEKTURNA 32TEKTURNA HCT 31telmisartan 30telmisartan-amlodipine 31telmisartan-hydrochlorothiazide

31temazepam 68TEMODAR 100 MG 33TEMOVATE 58TEMOVATE E 58TENEX 30TENIVAC 82TENORETIC 100 31TENORETIC 50 31TENORMIN 46TERAZOL 3 85TERAZOL 7 85terazosin hcl 30terbinafine hcl 26terbutaline sulfate 2.5 mg, 5mg 15terconazole vaginal 85

TESTIM 9TESTOSTERONE 1 %, 10MG/ACT, 50 MG/5GM 9TESTOSTERONE 25MG/2.5GM 9testosterone 25 mg/2.5gm, 50mg/5gm 9testosterone cypionate 9testosterone enanthate 9TESTOSTERONE PUMP 9TETANUS TOXOIDADSORBED 82TETANUS/DIPHTHERIATOXOIDS-ADSORBED 82TETANUS/DIPHTHERIATOXOIDS-ADSORBEDADULT 82tetrabenazine 79tetracycline hcl 250 mg, 500mg 81tetrahydrozoline hcl 73TEV-TROPIN 61THALOMID 45theophylline 100 mg, 200 mg,300 mg, 450 mg 15theophylline 400 mg, 600 mg15THERACYS 37thioridazine hcl 10 mg, 100 mg,25 mg, 50 mg 41THIOTEPA 33thiothixene 42THYMOGLOBULIN 45tiagabine hcl 18TIAZAC 48TICE BCG 37ticlopidine hcl 66TIGAN 25TIKOSYN 13timolol maleate (ophth) 0.25 %,0.5 % 74TIMOPTIC 74TIMOPTIC-XE 74TINDAMAX 10tinidazole 250 mg, 500 mg 10TIVICAY 43tizanidine hcl 2 mg 72tizanidine hcl 4 mg 72tizanidine hcl 6 mg 72TOBI 2TOBI PODHALER 2TOBRADEX 76

Index 24

TOBRADEX ST 76tobramycin 2tobramycin (ophth) 75tobramycin sulfate 1.2 gm 2tobramycin sulfate 1.2 gm/30ml,40 mg/ml, 80 mg/2ml 2tobramycin sulfate 10 mg/ml 2tobramycin sulfate in saline 2tobramycin-dexamethasone 76TOBREX 75TOFRANIL-PM 21tolazamide 250 mg 25tolazamide 500 mg 25tolbutamide 25tolcapone 38tolmetin sodium 200 mg 4tolmetin sodium 400 mg 4tolmetin sodium 600 mg 4tolterodine tartrate 1 mg, 2mg 84tolterodine tartrate 2 mg, 4mg 84TOPAMAX 18TOPAMAX SPRINKLE 18TOPICORT 0.05 % 58TOPICORT 0.25 % 58topiramate 100 mg, 200 mg, 25mg, 50 mg 18topiramate 15 mg, 25 mg 18topotecan hcl 4 mg 38TOPROL XL 46TORISEL 36torsemide 10 mg, 100 mg, 20 mg,5 mg 60TOTECT 37TOUJEO SOLOSTAR 24TOVIAZ 84TRACLEER 48TRADJENTA 23tramadol hcl 100 mg 7tramadol hcl 200 mg, 300 mg 7tramadol hcl 50 mg 7tramadol-acetaminophen 8TRANDATE 46trandolapril 29tranexamic acid 100 mg/ml 67tranexamic acid 650 mg 67TRANSDERM-SCOP 26

TRANXENE T 12tranylcypromine sulfate 19TRAVATAN Z 76trazodone hcl 100 mg, 150 mg,300 mg, 50 mg 20TREANDA 33TRECATOR 33TRELSTAR 35TRELSTAR MIXJECT 35tretinoin (chemotherapy) 37tretinoin 0.01 %, 0.025 %, 0.05% 54tretinoin 0.025 %, 0.05 %, 0.1% 54tretinoin 0.038 % 54tretinoin microsphere 54TREXIMET 70triamcinolone acetonide(mouth) 72triamcinolone acetonide(nasal) 73triamcinolone acetonide(topical) 58triamterene &hydrochlorothiazide 37.5mg-25mg 59triamterene &hydrochlorothiazide 37.5mg-25mg, 75mg-50mg 59triamterene &hydrochlorothiazide 50mg-25mg 59triazolam 68TRIBENZOR 31TRICOR 28trifluoperazine hcl 41trifluridine 75trihexyphenidyl hcl 38TRILEPTAL 150 MG, 300 MG,600 MG 18TRILEPTAL 300 MG/5ML 18TRILIPIX 28trimethobenzamide hcl 100mg/ml 26trimethobenzamide hcl 300mg 26trimethoprim 10trimipramine maleate 100mg 21trimipramine maleate 25 mg, 50mg 21TRISENOX 37TRIUMEQ 43

TRIZIVIR 43trospium chloride 20 mg 84trospium chloride 60 mg 84TRULICITY 23TRUSOPT 76TRUVADA 43TUDORZA PRESSAIR 13TWINRIX 85TWYNSTA 31TYBOST 43TYGACIL 10TYKERB 36TYPHIM VI 84TYSABRI 80TYVASO 48TYVASO REFILL 48TYVASO STARTER 48TYZEKA 44UCERIS 2 MG/ACT 9UCERIS 9 MG 52ULORIC 66ULTRACET 8ULTRAM 7ULTRAM ER 100 MG 7ULTRAM ER 200 MG, 300MG 7ULTRAVATE 58UNASYN 1GM-2GM 78UNIRETIC 32UNIVASC 29UROCIT-K 10 65UROCIT-K 5 65UROXATRAL 66URSO 250 64URSO FORTE 64ursodiol 250 mg, 500 mg 64ursodiol 300 mg 64UVADEX 37VAGIFEM 85valacyclovir hcl 1 gm, 1000 mg,500 mg 44VALCHLOR 55VALCYTE 43valganciclovir hcl 43VALIUM 12valproate sodium 100 mg/ml, 500mg/5ml 19

Index 25

valproate sodium 250mg/5ml 19valproic acid 19valsartan 30valsartan-hydrochlorothiazide

32VALSTAR 36VALTREX 44VANCOCIN HCL 10vancomycin hcl 10 gm, 1000 mg,5000 mg, 750 mg 10vancomycin hcl 125 mg, 250mg 10vancomycin hcl 500 mg 10VANCOMYCIN HCL INDEXTROSE 10VANOS 58VANTAS 35VAQTA 85VARIVAX 85VARIZIG 77VASCEPA 27VASERETIC 32VASOTEC 10 MG 30VASOTEC 2.5 MG 30VASOTEC 20 MG 30VASOTEC 5 MG 30VECTIBIX 35VECTICAL 55VELCADE 36VELPHORO 65VELTIN 54venlafaxine hcl 100 mg 20venlafaxine hcl 150 mg 20venlafaxine hcl 25 mg 20venlafaxine hcl 37.5 mg 20venlafaxine hcl 50 mg 21venlafaxine hcl 75 mg 20VENLAFAXINE HCL ER 20VENTAVIS 10 MCG/ML 48VENTAVIS 20 MCG/ML 48VENTOLIN HFA 15VERAMYST 73verapamil hcl 100 mg, 120 mg,180 mg, 200 mg, 240 mg, 300mg, 360 mg 48verapamil hcl 120 mg, 180 mg,240 mg 48verapamil hcl 120 mg, 40 mg, 80mg 48

VEREGEN 54VERELAN 48VERELAN PM 48VERSACLOZ 41VESICARE 84VEXOL 76VFEND 200 MG, 50 MG 27VFEND IV 27VIBRAMYCIN 100 MG 81VIBRAMYCIN 25 MG/5ML 81VIBRAMYCIN 50 MG/5ML 81VICOPROFEN 8VICTOZA 23VICTRELIS 44VIDAZA 34VIDEX EC 43VIDEXPEDIATRIC 43VIEKIRA PAK 44VIGAMOX 75VIIBRYD 20VIIBRYD STARTER PACK20VIMIZIM 62VIMOVO 4VIMPAT 10 MG/ML 18VIMPAT 100 MG, 150 MG, 200MG, 50 MG 18VIMPAT 200 MG/20ML 18vinblastine sulfate 38vincristine sulfate 38vinorelbine tartrate 38VIOKACE 59VIRACEPT 43VIRAMUNE 200 MG 43VIRAMUNE 50 MG/5ML 43VIRAMUNE XR 100 MG 43VIRAMUNE XR 400 MG 43VIRAZOLE 44VIREAD 150 MG, 200 MG, 300MG 43VIREAD 250 MG 43VIREAD 40 MG/GM 43VIROPTIC 75VISTARIL 12VISTIDE 43VITEKTA 43VIVELLE-DOT 63VOGELXO 9

VOGELXO PUMP 9VOLTAREN 54VOLTAREN-XR 4voriconazole 200 mg 27voriconazole 200 mg, 50 mg 27VOSOL HC 77VOTRIENT 36VPRIV 67VYTORIN 10MG-10MG 27VYTORIN 10MG-20MG 27VYTORIN 40MG-10MG 27VYTORIN 80MG-10MG 27VYVANSE 10 MG 1VYVANSE 20 MG 1VYVANSE 30 MG 1VYVANSE 40 MG, 50 MG, 60MG, 70 MG 1warfarin sodium 15water for irrigation, sterile 46WELCHOL 28WELLBUTRIN 100 MG 19WELLBUTRIN 75 MG 19WELLBUTRIN SR 100 MG 19WELLBUTRIN SR 150 MG, 200MG 19WELLBUTRIN XL 150 MG 19WELLBUTRIN XL 300 MG 19WESTCORT 58XALATAN 76XALKORI 36XANAX 12XANAX XR 12XARELTO 15XARELTO STARTER PACK 15XELJANZ 2XENAZINE 79XEOMIN 73XERESE 55XGEVA 61XIAFLEX 45XIFAXAN 10XIGDUO XR 10MG-1000MG,10MG-500MG 22XIGDUO XR 5MG-1000MG,5MG-500MG 22XOLAIR 13XOPENEX 15XOPENEX CONCENTRATE 15

Index 26

XOPENEX HFA 15XTANDI 35XYLOCAINE 1 %, 2 % 69XYLOCAINE 20 MG/ML 12XYLOCAINE 4 % 58XYLOCAINE-MPF 1 % 69XYREM 79XYZAL 27YASMIN 28 51YAZ 51YERVOY 35YF-VAX 85YONDELIS 33zafirlukast 13zaleplon 68ZALTRAP 34ZANAFLEX 2 MG 72ZANAFLEX 4 MG 72ZANAFLEX 6 MG 72ZANOSAR 33ZANTAC 15 MG/ML 82ZANTAC 150 MG 82ZANTAC 300 MG 82ZARONTIN 18ZAROXOLYN 60ZARXIO 67ZAVESCA 67ZEBETA 46ZEGERID 20MG-1100MG 83ZEGERID 20MG-1680MG 83ZEGERID 40MG-1100MG 83ZEGERID 40MG-1680MG 83ZELAPAR 39ZELBORAF 36ZEMAIRA 80ZEMPLAR 1 MCG, 2 MCG, 4MCG 62ZENPEP 10000UNIT-3000UNIT-16000UNIT, 17000UNIT-5000UNIT-27000UNIT,34000UNIT-10000UNIT-55000UNIT, 51000UNIT-15000UNIT-82000UNIT,68000UNIT-20000UNIT-109000UNIT, 85000UNIT-25000UNIT-136000UNIT 59ZENPEP 136000UNIT-40000UNIT-218000UNIT 59ZERIT 43

ZESTORETIC 32ZESTRIL 30ZETIA 29ZETONNA 73ZIAC 32ZIAGEN 20 MG/ML 43ZIAGEN 300 MG 43ZIANA 54zidovudine 100 mg 43zidovudine 300 mg 43zidovudine 50 mg/5ml 43ZINACEF 1.5 GM, 7.5 GM 49ZINACEF 750 MG 49ZINECARD 37ZIOPTAN 76ziprasidone hcl 40ZIPSOR 4ZIRGAN 75ZITHROMAX 100 MG/5ML, 200MG/5ML 69ZITHROMAX 250 MG, 500 MG,600 MG 69ZITHROMAX 500 MG 69ZITHROMAX TRI-PAK 69ZITHROMAX Z-PAK 69ZMAX 69ZOCOR 10 MG 29ZOCOR 20 MG 29ZOCOR 40 MG 29ZOCOR 5 MG 29ZOCOR 80 MG 29ZOFRAN 4 MG, 8 MG 25ZOFRAN 4 MG/5ML 25ZOFRAN 40 MG/20ML 25ZOFRAN ODT 25ZOHYDRO ER 10 MG, 15 MG,20 MG, 30 MG, 40 MG, 50MG 7ZOLADEX 35ZOLEDRONIC ACID 4 MG61zoledronic acid 4 mg/5ml 61zoledronic acid 5mg/100ml 61ZOLINZA 36zolmitriptan 2.5 mg 71zolmitriptan 5 mg 71ZOLOFT 20zolpidem tartrate 10 mg 68

zolpidem tartrate 12.5 mg 68zolpidem tartrate 5 mg 68zolpidem tartrate 6.25 mg 68ZOLPIMIST 68ZOMACTON 5 MG 61ZOMETA 4 MG/5ML 61ZOMIG 2.5 MG 71ZOMIG 5 MG 71ZOMIG NASAL SPRAY 71ZOMIG ZMT 2.5 MG 71ZOMIG ZMT 5 MG 71ZONEGRAN 18zonisamide 18ZONTIVITY 66ZORTRESS 0.25 MG 46ZORTRESS 0.5 MG, 0.75MG 46ZOSTAVAX 85ZOSYN 0.25GM-2GM, 0.375GM-3GM, 0.5GM-4GM, 4.5GM-36GM 78ZOSYN 0.25GM/50ML-2GM/50ML-5%, 0.375GM/50ML-3GM/50ML-5%, 0.5GM/100ML-4GM/100ML-5% 78ZOVIRAX 200 MG 44ZOVIRAX 200 MG/5ML 44ZOVIRAX 400 MG, 800 MG 44ZOVIRAX 5 % 55ZUBSOLV 1.4MG-0.36MG,5.7MG-1.4MG, 8.6MG-2.1MG 8ZUBSOLV 11.4MG-2.9MG,2.9MG-0.71MG 8ZYBAN 80ZYCLARA 58ZYCLARA PUMP 58ZYDELIG 36ZYFLO CR 13ZYKADIA 36ZYLET 76ZYLOPRIM 100 MG 66ZYLOPRIM 300 MG 66ZYMAXID 75ZYPREXA 41ZYPREXA ZYDIS 41ZYTIGA 35ZYVOX 100 MG/5ML 11ZYVOX 2 MG/ML 11ZYVOX 600 MG 11

Index 27

This formulary was updated on For more recent information or other questions, please contact Health Net Medicare Part D at:

Arizona Plans: 1-800-977-7522

California HMO Plans: 1-800-275-4737 California HMO SNP Plans: 1-800-431-9007 California PPO Plans: 1-800-960-4638

Oregon/Washington Plans: 1-888-445-8913

or, for TTY users, 711, 8:00 a.m. - 8:00 p.m., seven days a week (automated telephone service is used on some weekends and holidays), or visit www.healthnet.com/medicare.

This information is available for free in other languages. Please call Member Services at the phone number listed above.

Esta información está disponible en forma gratuita en otros idiomas. Por favor llame a nuestro número de servicio al cliente al número de teléfono que aparece arriba.

Health Net has a contract with Medicare to offer HMO, PPO and HMO SNP plans. Enrollment in a Health Net Medicare Advantage plan depends on contract renewal.

12/01/2015.

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