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Atrium Health
Table of Contents
Analgesics - Drugs for Pain............................................................................................................................................ 3Analgesics - Drugs for Pain and Inflammation................................................................................................................4Anesthetics..................................................................................................................................................................... 5Anti-Addiction / Substance Abuse Treatment Agents..................................................................................................... 6Antibacterials.................................................................................................................................................................. 6Anticoagulants................................................................................................................................................................ 9Anticonvulsants - Drugs for Seizures..............................................................................................................................9Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.......................................................................... 10Antidepressants............................................................................................................................................................ 10Antiemetics - Drugs for Nausea and Vomiting.............................................................................................................. 11Antifungals.................................................................................................................................................................... 12Antigout Agents.............................................................................................................................................................13Anti-inflammatory Agents..............................................................................................................................................13Antimigraine Agents......................................................................................................................................................13Antimyasthenic Agents................................................................................................................................................. 13Antimycobacterials........................................................................................................................................................13Antineoplastics - Drugs for Cancer............................................................................................................................... 14Antiparasitics.................................................................................................................................................................16Antiparkinson Agents.................................................................................................................................................... 17Antiplatelets.................................................................................................................................................................. 17Antipsychotics - Drugs for Mood Disorders...................................................................................................................17Antivirals....................................................................................................................................................................... 18Anxiolytics - Drugs for Anxiety...................................................................................................................................... 19Bipolar Agents - Drugs for Mood Disorders.................................................................................................................. 20Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders......................................................... 20Cardiovascular Agents - Drugs for Heart and Circulation Conditions........................................................................... 21Central Nervous System Agents - Drugs for Attention Deficit Disorder....................................................................... 25Central Nervous System Agents - Drugs for Multiple Sclerosis....................................................................................25Central Nervous System Agents - Miscellaneous.........................................................................................................26Dental and Oral Agents - Drugs for Mouth and Throat Conditions............................................................................... 26Dermatological Agents - Drugs for Skin Conditions......................................................................................................27Diabetes - Antidiabetic Agents......................................................................................................................................30Diabetes - Glucose Monitoring......................................................................................................................................31Diabetes - Glycemic Agents..........................................................................................................................................32Diabetes - Insulins........................................................................................................................................................ 33Electrolytes / Minerals / Metals / Vitamins.................................................................................................................... 33Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer........................................................................................... 35Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions............................................................ 35Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment......................................................... 37Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.................................................................. 37Genitourinary Agents - Drugs for Prostate Conditions..................................................................................................38Hormonal Agents - Adrenal...........................................................................................................................................38Hormonal Agents - Men's Health.................................................................................................................................. 39Hormonal Agents - Osteoporosis..................................................................................................................................39Hormonal Agents - Pituitary.......................................................................................................................................... 39Hormonal Agents - Prostaglandins............................................................................................................................... 40Hormonal Agents - Sex Hormones and Birth Control ................................................................................................... 40Hormonal Agents - Thyroid........................................................................................................................................... 44Immunological Agents - Drugs for Immune System Stimulation or Suppression..........................................................44Inflammatory Bowel Disease Agents............................................................................................................................ 45Metabolic Bone Disease Agents - Drugs for Osteoporosis...........................................................................................45Metabolic Bone Disease Agents - Other.......................................................................................................................46Miscellaneous Therapeutic Agents............................................................................................................................... 46Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...................................................................... 50
1
Ophthalmic Agents - Drugs for Glaucoma.................................................................................................................... 51Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions.....................................................................................52Otic Agents - Drugs for Ear Conditions.........................................................................................................................52Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold................................................................... 53Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions...............................................54Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis................................................................................55Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension................................................................56Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm.................................................................................. 56Sleep Disorder Agents.................................................................................................................................................. 56
2
Drug Name Drug Tier Notes
Analgesics - Drugs for Pain
acetaminophen-codeine TIER 01 QL
acetaminophen-codeine #2
TIER 01 QL
acetaminophen-codeine #3
TIER 01 QL
acetaminophen-codeine #4
TIER 01 QL
ACTIQ TIER 03 PA; QL
apap-caff-dihydrocodeine
TIER 01 QL
ascomp-codeine TIER 01
BELBUCA TIER 02 PA; QL
BUPRENEX TIER 03
buprenorphine hcl injection
TIER 01
buprenorphine transdermal
TIER 01 PA; QL
butalbital-acetaminophen TIER 01
butalbital-apap-caff-cod TIER 01
butalbital-apap-caffeine TIER 01
butalbital-asa-caff-codeine
TIER 01
butalbital-aspirin-caffeine TIER 01
butorphanol tartrate injection
TIER 01
butorphanol tartrate nasal
TIER 01 QL
BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR
TIER 03 PA; QL
carisoprodol-aspirin-codeine
TIER 01
codeine sulfate TIER 01 QL
DEMEROL TIER 03
DILAUDID INJECTION TIER 03
DOLOPHINE TIER 03 PA
duramorph TIER 01
duraxin TIER 01
endocet TIER 01 QL
ESGIC TIER 03
fentanyl TIER 01 PA; QL
Drug Name Drug Tier Notes
fentanyl citrate buccal lozenge on a handle
TIER 01 PA; QL
FIORINAL TIER 03
FIORINAL/CODEINE #3 TIER 03
hydrocodone bitartrate er TIER 01 PA; QL
hydrocodone-acetaminophen
TIER 01 QL
hydrocodone-ibuprofen TIER 01 QL
hydromorphone hcl er TIER 01 PA; QL
HYDROMORPHONE HCL INJECTION SOLUTION 0.2 MG/ML
TIER 03
hydromorphone hcl injection solution 2 mg/ml, 4 mg/ml
TIER 01
hydromorphone hcl oral TIER 01 QL
hydromorphone hcl pf TIER 01
HYDROMORPHONE HCL SOLUTION 1 MG/ML INJECTION
TIER 03
hydromorphone hcl solution 1 mg/ml injection
TIER 01
HYDROMORPHONE HCL-NACL INJECTION
TIER 03
HYSINGLA ER TIER 02 PA; QL
INFUMORPH 200 TIER 03
INFUMORPH 500 TIER 03
levorphanol tartrate oral TIER 01 QL
lorcet TIER 01 QL
lorcet hd TIER 01 QL
LORTAB TIER 03 QL
MEDROX-RX TIER 03
meperidine hcl injection TIER 01
meperidine hcl oral TIER 01 QL
methadone hcl injection TIER 01
methadone hcl intensol TIER 01
methadone hcl oral concentrate
TIER 01
methadone hcl oral solution
TIER 01
methadone hcl oral tablet TIER 01 PA
methadone hcl oral tablet soluble
TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
3
Drug Name Drug Tier Notes
methadose oral concentrate 10 mg/ml
TIER 01
methadose oral tablet soluble
TIER 01
methadose sugar-free TIER 01
mitigo TIER 01
morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml
TIER 01 QL
morphine sulfate (pf) injection
TIER 01
morphine sulfate er TIER 01 PA; QL
morphine sulfate er beads
TIER 01 PA; QL
MORPHINE SULFATE INJECTION SOLUTION 1 MG/ML
TIER 03
morphine sulfate injection solution 2 mg/ml, 4 mg/ml, 5 mg/ml
TIER 01
morphine sulfate intramuscular
TIER 01
morphine sulfate oral TIER 01 QL
MORPHINE SULFATE-NACL INJECTION
TIER 03
nalbuphine hcl injection TIER 01
oxycodone hcl oral capsule
TIER 01 QL
oxycodone hcl oral concentrate 100 mg/5ml
TIER 01 QL
oxycodone hcl oral solution
TIER 01 QL
oxycodone hcl oral tablet TIER 01 QL
oxycodone-acetaminophen
TIER 01 QL
oxycodone-aspirin TIER 01 QL
OXYCONTIN TIER 02 PA; QL
oxymorphone hcl TIER 01 QL
oxymorphone hcl er TIER 01 PA; QL
pentazocine-naloxone hcl
TIER 01 QL
PROBUPHINE IMPLANT KIT
TIER 03
Drug Name Drug Tier Notes
tencon TIER 01
tramadol hcl er (biphasic) TIER 01 QL
tramadol hcl er oral capsule extended release 24 hour 150 mg
TIER 01 PA; QL
tramadol hcl er oral tablet extended release 24 hour
TIER 01 QL
tramadol hcl ir TIER 01 QL
tramadol-acetaminophen TIER 01 QL
TREZIX TIER 03 QL
XTAMPZA ER TIER 02 PA; QL
ZEBUTAL TIER 03
Analgesics - Drugs for Pain and Inflammation
celecoxib oral TIER 01
DAYPRO TIER 03
DICLOFENAC EPOLAMINE
TIER 03
diclofenac potassium TIER 01
diclofenac sodium er TIER 01
diclofenac sodium oral TIER 01
diclofenac sodium transdermal gel 1 %
TIER 01
diclofenac sodium transdermal solution
TIER 01 PA
diclofenac-misoprostol TIER 01
DICLOFONO TIER 03
diflunisal oral TIER 01
EC-NAPROSYN TIER 03
ec-naproxen TIER 01
etodolac TIER 01
etodolac er TIER 01
FELDENE TIER 03
fenoprofen calcium oral TIER 01
fenortho TIER 01
flurbiprofen oral TIER 01
ibu TIER 01
ibuprofen oral suspension
TIER 01
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
4
Drug Name Drug Tier Notes
INDOCIN ORAL TIER 03 ST
indomethacin er TIER 01
indomethacin oral capsule 25 mg, 50 mg
TIER 01
ketoprofen er TIER 01
ketoprofen oral TIER 01
ketorolac tromethamine injection solution 15 mg/ml
TIER 01
ketorolac tromethamine intramuscular
TIER 01
ketorolac tromethamine oral
TIER 01
KETOROLAC TROMETHAMINE SOLUTION 30 MG/ML INJECTION
TIER 03
ketorolac tromethamine solution 30 mg/ml injection
TIER 01
LODINE TIER 03
meclofenamate sodium oral
TIER 01
mefenamic acid oral TIER 01
meloxicam oral TIER 01
nabumetone oral TIER 01
naproxen dr TIER 01
naproxen oral TIER 01
naproxen sodium er TIER 01
naproxen sodium oral tablet 275 mg, 550 mg
TIER 01
naproxen-esomeprazole TIER 01 PA
oxaprozin TIER 01
piroxicam oral TIER 01
sulindac oral TIER 01
tolmetin sodium TIER 01
Anesthetics
ARTICADENT DENTAL TIER 03
bupivacaine fisiopharma TIER 01
bupivacaine hcl (pf) TIER 01
bupivacaine hcl injection solution 0.25 %, 0.5 %
TIER 01
bupivacaine-epinephrine TIER 01
Drug Name Drug Tier Notes
bupivacaine-epinephrine (pf)
TIER 01
CARBOCAINE TIER 03
CARBOCAINE PRESERVATIVE-FREE
TIER 03
chloroprocaine hcl (pf) TIER 01
CITANEST FORTE DENTAL
TIER 03
CITANEST PLAIN DENTAL
TIER 03
COCAINE HCL NASAL TIER 03
D-CARE 100X TIER 03
ethyl chloride TIER 01
EXPAREL TIER 03
GEBAUERS PAIN EASE TIER 03
GEBAUERS SPRAY AND STRETCH
TIER 03
glydo TIER 01
L.E.T. TIER 03
lidocaine external ointment
TIER 01
lidocaine external patch 5 %
TIER 01
lidocaine hcl (pf) TIER 01
lidocaine hcl external solution
TIER 01
lidocaine hcl injection solution 0.5 %
TIER 01
LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE
TIER 03
lidocaine hcl solution 1 % injection
TIER 01
LIDOCAINE HCL SOLUTION 1 % INJECTION
TIER 03
lidocaine hcl solution 2 % injection
TIER 01
LIDOCAINE HCL SOLUTION 2 % INJECTION
TIER 03
lidocaine hcl urethral/mucosal
TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
5
Drug Name Drug Tier Notes
LIDOCAINE IN DEXTROSE
TIER 03
lidocaine-epinephrine injection
TIER 01
lidocaine-prilocaine external cream
TIER 01
LIDOCAINE-SODIUM BICARBONATE
TIER 03
LIDO-EPINEPHRINE-TETRACAINE
TIER 03
MARCAINE TIER 03
MARCAINE PRESERVATIVE FREE
TIER 03
MARCAINE/EPINEPHRINE
TIER 03
MARCAINE/EPINEPHRINE PF
TIER 03
NAROPIN TIER 03
NESACAINE TIER 03
NESACAINE-MPF TIER 03
ORABLOC TIER 03
polocaine TIER 01
polocaine-mpf TIER 01
PREPIV SUPPLY TIER 03
ropivacaine hcl injection solution 10 mg/ml, 2 mg/ml, 5 mg/ml, 7.5 mg/ml
TIER 01
sensorcaine TIER 01
sensorcaine/epinephrine TIER 01
sensorcaine-mpf TIER 01
sensorcaine-mpf/epinephrine injection solution 0.25% -1:200000, 0.5% -1:200000
TIER 01
SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 0.75-1:200000 %
TIER 03
tetracaine hcl injection TIER 01
VENIPUNCTURE PX1 PHLEBOTOMY
TIER 03
XYLOCAINE TIER 03
Drug Name Drug Tier Notes
xylocaine dental TIER 01
XYLOCAINE/EPINEPHRINE
TIER 03
XYLOCAINE-MPF TIER 03
XYLOCAINE-MPF/EPINEPHRINE
TIER 03
Anti-Addiction / Substance Abuse Treatment Agents
acamprosate calcium TIER 01
ANTABUSE TIER 03
BUNAVAIL TIER 03 QL
buprenorphine hcl sublingual
TIER 01 QL
buprenorphine hcl-naloxone hcl
TIER 01 QL
bupropion hcl er (smoking det)
TIER 01 QL
CHANTIX TIER 03 QL
CHANTIX CONTINUING MONTH PAK
TIER 03 QL
CHANTIX STARTING MONTH PAK
TIER 03 QL
disulfiram oral TIER 01
EVZIO TIER 03 ST
LUCEMYRA TIER 03 ST; QL
naloxone hcl injection solution
TIER 01
naloxone hcl injection solution cartridge
TIER 01
naloxone hcl injection solution prefilled syringe
TIER 01
naltrexone hcl oral TIER 01
NARCAN TIER 02
NICOTROL TIER 03 QL
NICOTROL NS TIER 03 QL
SUBLOCADE SPECIALTY
VIVITROL SPECIALTY
ZUBSOLV TIER 02 QL
Antibacterials
AEMCOLO TIER 03 PA
ALTABAX TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
6
Drug Name Drug Tier Notes
amikacin sulfate injection TIER 01
amoxicillin TIER 01
amoxicillin-potassium clavulanate er
TIER 01
amoxicillin-potassium clavulanate oral
TIER 01
ampicillin TIER 01
ampicillin sodium injection
TIER 01
ampicillin-sulbactam sodium injection
TIER 01
ARIKAYCE SPECIALTY
AUGMENTIN TIER 03
AUGMENTIN ES-600 TIER 03
avidoxy TIER 01
AZACTAM TIER 03
azithromycin oral TIER 01
aztreonam TIER 01
baciim TIER 01
bacitracin intramuscular TIER 01
BACTRIM TIER 03
BACTRIM DS TIER 03
BAXDELA ORAL TIER 03
benzalkonium chloride external solution
TIER 01
BICILLIN C-R TIER 03
BICILLIN C-R 900/300 TIER 03
BICILLIN L-A TIER 03
cefaclor TIER 01
cefaclor er TIER 01
cefadroxil TIER 01
cefazolin sodium injection
TIER 01
cefdinir TIER 01
cefditoren pivoxil TIER 01
cefepime hcl injection TIER 01
cefixime TIER 01
CEFOTAN TIER 03
cefotaxime sodium TIER 01
cefotetan disodium TIER 01
cefoxitin sodium injection TIER 01
Drug Name Drug Tier Notes
cefpodoxime proxetil TIER 01
cefprozil TIER 01
ceftazidime injection TIER 01
ceftriaxone sodium injection
TIER 01
cefuroxime axetil TIER 01
cefuroxime sodium injection
TIER 01
CENTANY TIER 03
cephalexin TIER 01
CIPRO TIER 03
ciprofloxacin hcl oral TIER 01
clarithromycin er TIER 01
clarithromycin oral TIER 01
CLEOCIN ORAL TIER 03
CLEOCIN PHOSPHATE TIER 03
CLEOCIN VAGINAL CREAM
TIER 03
CLEOCIN VAGINAL SUPPOSITORY
TIER 02
clindamycin hcl oral TIER 01
clindamycin palmitate hcl TIER 01
clindamycin phosphate injection
TIER 01
clindamycin phosphate vaginal
TIER 01
CLINDESSE TIER 03
colistimethate sodium (cba)
TIER 01
COLY-MYCIN M TIER 03
coremino TIER 01
demeclocycline hcl TIER 01
dicloxacillin sodium TIER 01
DIFICID TIER 03
doxycycline hyclate oral capsule
TIER 01
doxycycline hyclate oral tablet
TIER 01
doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 200 mg, 50 mg, 75 mg
TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
7
Drug Name Drug Tier Notes
doxycycline monohydrate oral
TIER 01
E.E.S. 400 TIER 03
E.E.S. GRANULES TIER 03
ertapenem sodium TIER 01
ERYPED 200 TIER 03
ERYPED 400 TIER 03
ERY-TAB TIER 03
ERYTHROCIN STEARATE
TIER 03
erythromycin base TIER 01
erythromycin ethylsuccinate oral
TIER 01
erythromycin oral TIER 01
FIRVANQ TIER 03
FLAGYL TIER 03
FORTAZ INJECTION TIER 03
gentamicin sulfate external
TIER 01
gentamicin sulfate injection
TIER 01
HIPREX TIER 03
hydrogen peroxide TIER 01
INVANZ TIER 03
iodine tincture external tincture 2 %
TIER 01
KEFLEX TIER 03
levofloxacin oral TIER 01
LINCOCIN TIER 03
lincomycin hcl injection TIER 01
linezolid oral TIER 01 QL
MACROBID TIER 03
MACRODANTIN TIER 03
mafenide acetate external
TIER 01
methenamine hippurate TIER 01
metronidazole oral TIER 01
metronidazole vaginal TIER 01
minocycline hcl er oral tablet extended release 24 hour
TIER 01
minocycline hcl oral TIER 01
Drug Name Drug Tier Notes
mondoxyne nl TIER 01
MONUROL TIER 03
morgidox oral TIER 01
moxifloxacin hcl oral TIER 01
mupirocin calcium TIER 01
mupirocin external TIER 01
nafcillin sodium injection solution reconstituted 1 gm, 2 gm
TIER 01
neomycin sulfate oral TIER 01
nitrofurantoin TIER 01
nitrofurantoin macrocrystal oral
TIER 01
nitrofurantoin monohydrate macrocrystals
TIER 01
NUZYRA ORAL TIER 03
ofloxacin oral TIER 01
oxacillin sodium injection TIER 01
paromomycin sulfate oral TIER 01
penicillin g potassium TIER 01
penicillin g procaine TIER 01
penicillin g sodium TIER 01
penicillin v potassium TIER 01
PFIZERPEN TIER 03
polymyxin b sulfate injection
TIER 01
PRIMSOL TIER 03
SEYSARA TIER 03 ST
silver sulfadiazine external
TIER 01
SOLOSEC TIER 03
ssd TIER 01
streptomycin sulfate intramuscular
TIER 01
sulfadiazine oral TIER 01
sulfamethoxazole-trimethoprim oral
TIER 01
SULFAMYLON EXTERNAL PACKET
TIER 03
sulfatrim pediatric TIER 01
SUPRAX TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
8
Drug Name Drug Tier Notes
tazicef injection TIER 01
tetracycline hcl oral TIER 01
tinidazole oral TIER 01
tobramycin sulfate injection
TIER 01
trimethoprim oral TIER 01
UNASYN INJECTION TIER 03
VANCOCIN TIER 03
VANCOCIN HCL TIER 03
vancomycin hcl oral TIER 01
vandazole TIER 01
VIBRAMYCIN TIER 03 ST
XENLETA ORAL TIER 03
XEPI TIER 03
XIFAXAN TIER 03 PA
XIMINO TIER 03
ZITHROMAX ORAL TIER 03
ZITHROMAX TRI-PAK TIER 03
ZITHROMAX Z-PAK TIER 03
ZYVOX ORAL SUSPENSION RECONSTITUTED
TIER 03 QL
Anticoagulants
acd formula a TIER 01
acd-a noclot-50 TIER 01
anticoagulant cit dext soln a
TIER 01
anticoagulant sodium citrate
TIER 01
ARIXTRA SPECIALTY
ELIQUIS TIER 02
ELIQUIS DVT/PE STARTER PACK
TIER 02
enoxaparin sodium SPECIALTY
fondaparinux sodium SPECIALTY
FRAGMIN SPECIALTY
heparin sodium (porcine) TIER 01
heparin sodium (porcine) pf
TIER 01
jantoven PREVENT
LOVENOX SPECIALTY
Drug Name Drug Tier Notes
PRADAXA TIER 02
SAVAYSA TIER 03
SODIUM CITRATE IN VITRO
TIER 03
TRICITRASOL TIER 03
warfarin sodium oral PREVENT
XARELTO TIER 02
XARELTO STARTER PACK
TIER 02
Anticonvulsants - Drugs for Seizures
BANZEL TIER 03 PA
BRIVIACT ORAL TIER 03 ST
carbamazepine er oral capsule extended release 12 hour
PREVENT
carbamazepine er oral tablet extended release 12 hour 100 mg
TIER 01
carbamazepine er oral tablet extended release 12 hour 200 mg, 400 mg
PREVENT
carbamazepine oral PREVENT
CELONTIN TIER 03
CEREBYX TIER 03
clobazam TIER 01 PA
DIACOMIT SPECIALTY PA
DIASTAT ACUDIAL TIER 03 QL
DIASTAT PEDIATRIC TIER 03 QL
diazepam rectal TIER 01 QL
DILANTIN ORAL CAPSULE 30 MG
TIER 02
divalproex sodium er TIER 01
divalproex sodium oral TIER 01
EPIDIOLEX SPECIALTY PA
epitol PREVENT
ethosuximide oral TIER 01
felbamate TIER 01
fosphenytoin sodium TIER 01
FYCOMPA TIER 03
gabapentin oral TIER 01
GABITRIL TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
9
Drug Name Drug Tier Notes
LAMICTAL XR ORAL KIT
TIER 03
lamotrigine er TIER 01
lamotrigine oral TIER 01
lamotrigine starter kit-blue
TIER 01
lamotrigine starter kit-green
TIER 01
lamotrigine starter kit-orange
TIER 01
levetiracetam er TIER 01
levetiracetam oral TIER 01
NAYZILAM TIER 03 QL
NEMBUTAL TIER 03
oxcarbazepine TIER 01
PEGANONE TIER 03
pentobarbital sodium injection
TIER 01
phenobarbital oral TIER 01
phenobarbital sodium injection
TIER 01
PHENYTEK TIER 02
phenytoin infatabs PREVENT
phenytoin oral PREVENT
phenytoin sodium extended
PREVENT
phenytoin sodium injection
TIER 01
primidone oral TIER 01
roweepra TIER 01
roweepra xr TIER 01
subvenite TIER 01
subvenite starter kit-blue TIER 01
subvenite starter kit-green
TIER 01
subvenite starter kit-orange
TIER 01
SYMPAZAN TIER 03 PA
tiagabine hcl TIER 01
topiramate er TIER 01
topiramate oral TIER 01
TROKENDI XR TIER 03 ST
Drug Name Drug Tier Notes
valproic acid oral capsule TIER 01
valproic acid oral solution PREVENT
VALTOCO 10 MG DOSE TIER 03 QL
VALTOCO 15 MG DOSE TIER 03 QL
VALTOCO 20 MG DOSE TIER 03 QL
VALTOCO 5 MG DOSE TIER 03 QL
vigabatrin SPECIALTY PA
vigadrone SPECIALTY PA
VIMPAT ORAL TIER 03
ZARONTIN TIER 02
zonisamide oral TIER 01
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia
ARICEPT TIER 03
donepezil hcl TIER 01
EXELON TIER 03
galantamine hydrobromide
TIER 01
galantamine hydrobromide er
TIER 01
memantine hcl er TIER 01
memantine hcl oral TIER 01
NAMENDA TIER 03
NAMENDA TITRATION PAK
TIER 03
NAMENDA XR TIER 03
NAMENDA XR TITRATION PACK
TIER 03
NAMZARIC TIER 02
RAZADYNE TIER 03
RAZADYNE ER TIER 03
rivastigmine TIER 01
rivastigmine tartrate TIER 01
Antidepressants
amitriptyline hcl oral PREVENT
amoxapine TIER 01
APLENZIN TIER 03 ST
bupropion hcl er (sr) TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
10
Drug Name Drug Tier Notes
bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg
TIER 01
BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG
TIER 02
bupropion hcl oral TIER 01
chlordiazepoxide-amitriptyline
TIER 01
citalopram hydrobromide PREVENT
clomipramine hcl oral TIER 01
desipramine hcl oral TIER 01
DESVENLAFAXINE ER TIER 03 ST; QL
desvenlafaxine succinate er
TIER 01
doxepin hcl oral capsule TIER 01
doxepin hcl oral concentrate
TIER 01
DRIZALMA SPRINKLE TIER 03
duloxetine hcl oral PREVENT
EMSAM TIER 03
escitalopram oxalate PREVENT
FETZIMA TIER 03 ST; QL
FETZIMA TITRATION TIER 03 ST; QL
fluoxetine hcl (pmdd) TIER 01
fluoxetine hcl oral capsule
PREVENT
fluoxetine hcl oral capsule delayed release
PREVENT
fluoxetine hcl oral solution
PREVENT
fluoxetine hcl oral tablet TIER 01
fluvoxamine maleate TIER 01
fluvoxamine maleate er TIER 01
FORFIVO XL TIER 03
imipramine hcl oral TIER 01
imipramine pamoate TIER 01
maprotiline hcl TIER 01
MARPLAN TIER 03
mirtazapine oral TIER 01
NARDIL TIER 03
Drug Name Drug Tier Notes
nefazodone hcl TIER 01
NORPRAMIN TIER 03
nortriptyline hcl oral TIER 01
olanzapine-fluoxetine hcl TIER 01
PARNATE TIER 03
paroxetine hcl PREVENT
paroxetine hcl er TIER 01
paroxetine mesylate TIER 01 QL
PAXIL ORAL SUSPENSION
TIER 02 ST
perphenazine-amitriptyline
TIER 01
PEXEVA TIER 03
phenelzine sulfate oral TIER 01
protriptyline hcl TIER 01
REMERON TIER 03
REMERON SOLTAB TIER 03
SARAFEM TIER 03
sertraline hcl oral PREVENT
SPRAVATO (56 MG DOSE)
SPECIALTY PA
SPRAVATO (84 MG DOSE)
SPECIALTY PA
SYMBYAX TIER 03
tranylcypromine sulfate TIER 01
trazodone hcl oral TIER 01
trimipramine maleate oral
TIER 01
TRINTELLIX TIER 03 ST; QL
venlafaxine hcl PREVENT
venlafaxine hcl er PREVENT
VIIBRYD TIER 03
VIIBRYD STARTER PACK
TIER 03
Antiemetics - Drugs for Nausea and Vomiting
AKYNZEO ORAL TIER 03 QL
ANZEMET TIER 03 QL
aprepitant TIER 01 QL
BONJESTA TIER 03 PA; QL
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
11
Drug Name Drug Tier Notes
compro TIER 01
DICLEGIS TIER 03 PA; QL
dimenhydrinate injection TIER 01
doxylamine-pyridoxine TIER 01 PA; QL
dronabinol TIER 01 PA; QL
droperidol injection TIER 01
EMEND ORAL TIER 03 QL
EMEND TRI-PACK TIER 03 QL
granisetron hcl oral TIER 01 QL
MARINOL TIER 03 PA; QL
meclizine hcl oral tablet TIER 01
metoclopramide hcl injection
TIER 01
metoclopramide hcl oral TIER 01
ondansetron hcl injection TIER 01
ondansetron hcl oral solution
TIER 01 QL
ondansetron hcl oral tablet 24 mg
TIER 01 QL
ondansetron hcl oral tablet 4 mg, 8 mg
TIER 01
ondansetron odt TIER 01
perphenazine oral TIER 01
prochlorperazine TIER 01
prochlorperazine edisylate injection
TIER 01
prochlorperazine maleate oral
TIER 01
REGLAN TIER 03
scopolamine TIER 01
SUSTOL TIER 03 QL
SYNDROS TIER 03 PA; QL
TIGAN TIER 03
TRANSDERM SCOP (1.5 MG)
TIER 03
TRANSDERM-SCOP (1.5 MG)
TIER 03
trimethobenzamide hcl oral
TIER 01
VARUBI (180 MG DOSE)
TIER 03 QL
Drug Name Drug Tier Notes
Antifungals
ANCOBON TIER 03
BIO-STATIN ORAL CAPSULE
TIER 03
ciclodan TIER 01
ciclopirox TIER 01
ciclopirox olamine external
TIER 01
clotrimazole external TIER 01
clotrimazole mouth/throat TIER 01
clotrimazole-betamethasone
TIER 01
CRESEMBA ORAL SPECIALTY
DIFLUCAN TIER 03
econazole nitrate external
TIER 01
exoderm external lotion TIER 01
fluconazole oral TIER 01
flucytosine oral TIER 01
griseofulvin microsize oral
TIER 01
griseofulvin ultramicrosize
TIER 01
GYNAZOLE-1 TIER 03
itraconazole oral TIER 01 PA
KERYDIN TIER 03 PA
ketoconazole external TIER 01
ketoconazole oral TIER 01
ketodan external foam TIER 01
LOPROX EXTERNAL CREAM
TIER 03
LOPROX EXTERNAL SHAMPOO
TIER 03
LOPROX EXTERNAL SUSPENSION
TIER 03
miconazole 3 vaginal suppository
TIER 01
naftifine hcl TIER 01
NAFTIN TIER 03
NOXAFIL ORAL SPECIALTY
nyamyc TIER 01
nystatin external TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
12
Drug Name Drug Tier Notes
nystatin mouth/throat TIER 01
nystatin oral TIER 01
nystatin-triamcinolone TIER 01
nystop TIER 01
oxiconazole nitrate TIER 01
posaconazole SPECIALTY
SPORANOX TIER 03 PA
SPORANOX PULSEPAK TIER 03 PA
terbinafine hcl oral TIER 01 QL
terconazole TIER 01
VFEND ORAL SUSPENSION RECONSTITUTED
SPECIALTY
voriconazole oral SPECIALTY
Antigout Agents
allopurinol oral TIER 01
colchicine oral tablet TIER 01
colchicine-probenecid TIER 01
COLCRYS TIER 02
febuxostat TIER 01 ST
probenecid TIER 01
ULORIC TIER 03 ST
ZYLOPRIM TIER 03
Anti-inflammatory Agents
EMFLAZA SPECIALTY PA
Antimigraine Agents
AIMOVIG SPECIALTY PA
almotriptan malate TIER 01 QL
AMERGE TIER 03 QL
CAFERGOT TIER 03
D.H.E. 45 TIER 03
dihydroergotamine mesylate injection
TIER 01
dihydroergotamine mesylate nasal
TIER 01 QL
eletriptan hydrobromide TIER 01 QL
EMGALITY SPECIALTY PA
EMGALITY (300 MG DOSE)
SPECIALTY PA
ERGOMAR TIER 03
Drug Name Drug Tier Notes
ergotamine-caffeine TIER 01
frovatriptan succinate TIER 01 QL
MIGERGOT TIER 03
MIGRANAL TIER 03 QL
naratriptan hcl TIER 01 QL
NURTEC TIER 02 PA
rizatriptan benzoate TIER 01 QL
sumatriptan nasal TIER 01 QL
sumatriptan succinate oral
TIER 01 QL
sumatriptan succinate refill
TIER 01 QL
sumatriptan succinate subcutaneous
TIER 01 QL
sumatriptan-naproxen sodium
TIER 01 QL
zolmitriptan oral TIER 01 QL
ZOMIG NASAL TIER 03 ST; QL
Antimyasthenic Agents
GUANIDINE HCL TIER 03
MESTINON ORAL SOLUTION
TIER 03
MESTINON ORAL TABLET EXTENDED RELEASE
TIER 03
pyridostigmine bromide er
TIER 01
pyridostigmine bromide oral
TIER 01
Antimycobacterials
CAPASTAT SULFATE TIER 03
cycloserine oral TIER 01
dapsone oral TIER 01
ethambutol hcl oral TIER 01
isoniazid injection TIER 01
isoniazid oral TIER 01
MYAMBUTOL TIER 03
MYCOBUTIN TIER 03
PASER TIER 03
PRETOMANID TIER 03
PRIFTIN TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
13
Drug Name Drug Tier Notes
pyrazinamide oral TIER 01
rifabutin TIER 01
RIFADIN ORAL TIER 03
rifampin oral TIER 01
SIRTURO TIER 03
TRECATOR TIER 03
Antineoplastics - Drugs for Cancer
abiraterone acetate SPECIALTY PA
AFINITOR DISPERZ SPECIALTY PA
AFINITOR ORAL TABLET 10 MG
SPECIALTY PA
ALECENSA SPECIALTY PA
ALKERAN ORAL SPECIALTY
ALUNBRIG SPECIALTY PA
anastrozole oral TIER 01
AROMASIN SPECIALTY
AYVAKIT SPECIALTY PA
azacitidine SPECIALTY
BALVERSA SPECIALTY PA
bexarotene SPECIALTY PA
bicalutamide TIER 01
bleomycin sulfate SPECIALTY
BOSULIF SPECIALTY PA
BRAFTOVI SPECIALTY PA
BRUKINSA SPECIALTY PA
CABOMETYX SPECIALTY PA
CALQUENCE SPECIALTY PA
capecitabine SPECIALTY PA
CAPRELSA SPECIALTY PA
CASODEX TIER 03
COMETRIQ (100 MG DAILY DOSE)
SPECIALTY PA
COMETRIQ (140 MG DAILY DOSE)
SPECIALTY PA
COMETRIQ (60 MG DAILY DOSE)
SPECIALTY PA
COPIKTRA SPECIALTY PA
COTELLIC SPECIALTY PA
cyclophosphamide injection
SPECIALTY
Drug Name Drug Tier Notes
cyclophosphamide oral SPECIALTY
cytarabine SPECIALTY
cytarabine (pf) SPECIALTY
DAURISMO SPECIALTY PA
DROXIA TIER 03
EMCYT SPECIALTY
ERIVEDGE SPECIALTY PA
erlotinib hcl SPECIALTY PA
ERWINAZE SPECIALTY
etoposide oral SPECIALTY
everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg
SPECIALTY PA
exemestane SPECIALTY
FARESTON SPECIALTY
FARYDAK SPECIALTY PA
FASLODEX SPECIALTY
FEMARA TIER 03
floxuridine injection SPECIALTY
flutamide TIER 01
fulvestrant SPECIALTY
GILOTRIF SPECIALTY PA
GLEOSTINE SPECIALTY
HERCEPTIN HYLECTA SPECIALTY PA
HYCAMTIN ORAL SPECIALTY
HYDREA TIER 03
hydroxyurea oral TIER 01
IBRANCE SPECIALTY PA
ICLUSIG SPECIALTY PA
IDHIFA SPECIALTY PA
imatinib mesylate SPECIALTY PA
IMBRUVICA SPECIALTY PA
IMLYGIC SPECIALTY
INLYTA SPECIALTY PA
INREBIC SPECIALTY PA
IRESSA SPECIALTY PA
JAKAFI SPECIALTY PA
KISQALI (200 MG DOSE)
SPECIALTY PA
KISQALI (400 MG DOSE)
SPECIALTY PA
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
14
Drug Name Drug Tier Notes
KISQALI (600 MG DOSE)
SPECIALTY PA
KISQALI FEMARA (400 MG DOSE)
SPECIALTY PA
KISQALI FEMARA (600 MG DOSE)
SPECIALTY PA
KISQALI FEMARA(200 MG DOSE)
SPECIALTY PA
KOSELUGO SPECIALTY PA
LENVIMA (10 MG DAILY DOSE)
SPECIALTY PA
LENVIMA (12 MG DAILY DOSE)
SPECIALTY PA
LENVIMA (14 MG DAILY DOSE)
SPECIALTY PA
LENVIMA (18 MG DAILY DOSE)
SPECIALTY PA
LENVIMA (20 MG DAILY DOSE)
SPECIALTY PA
LENVIMA (24 MG DAILY DOSE)
SPECIALTY PA
LENVIMA (4 MG DAILY DOSE)
SPECIALTY PA
LENVIMA (8 MG DAILY DOSE)
SPECIALTY PA
letrozole oral TIER 01
leucovorin calcium injection
TIER 01
leucovorin calcium oral TIER 01
LEUKERAN SPECIALTY
LONSURF SPECIALTY PA
LORBRENA SPECIALTY PA
LYNPARZA SPECIALTY PA
LYSODREN SPECIALTY
MATULANE SPECIALTY
MEKINIST SPECIALTY PA
MEKTOVI SPECIALTY PA
melphalan SPECIALTY
mercaptopurine oral TIER 01
MESNEX ORAL SPECIALTY
MYLERAN SPECIALTY
NERLYNX SPECIALTY PA
NEXAVAR SPECIALTY PA
Drug Name Drug Tier Notes
NILANDRON SPECIALTY
nilutamide SPECIALTY
NINLARO SPECIALTY PA
NUBEQA SPECIALTY PA
ODOMZO SPECIALTY PA
ONCASPAR SPECIALTY
PANRETIN SPECIALTY
PIQRAY (200 MG DAILY DOSE)
SPECIALTY PA
PIQRAY (250 MG DAILY DOSE)
SPECIALTY PA
PIQRAY (300 MG DAILY DOSE)
SPECIALTY PA
POMALYST SPECIALTY PA
PURIXAN SPECIALTY
QINLOCK SPECIALTY PA
REVLIMID SPECIALTY PA
RITUXAN HYCELA SPECIALTY PA
ROZLYTREK SPECIALTY PA
RUBRACA SPECIALTY PA
RYDAPT SPECIALTY PA
SIKLOS TIER 03 PA
SOLTAMOX TIER 03
SPRYCEL SPECIALTY PA
STIVARGA SPECIALTY PA
SUTENT SPECIALTY PA
SYNRIBO SPECIALTY PA
TABLOID SPECIALTY
TAFINLAR SPECIALTY PA
TAGRISSO SPECIALTY PA
TALZENNA SPECIALTY PA
tamoxifen citrate oral TIER 01
TARCEVA SPECIALTY PA
TARGRETIN EXTERNAL
SPECIALTY PA
TASIGNA SPECIALTY PA
TEMODAR ORAL SPECIALTY PA
temozolomide SPECIALTY PA
TEPADINA SPECIALTY
THALOMID SPECIALTY PA
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
15
Drug Name Drug Tier Notes
thiotepa injection SPECIALTY
TIBSOVO SPECIALTY PA
toremifene citrate SPECIALTY
tretinoin oral SPECIALTY
TUKYSA SPECIALTY PA
TURALIO SPECIALTY PA
TYKERB SPECIALTY PA
VALCHLOR SPECIALTY PA
valrubicin SPECIALTY
VALSTAR SPECIALTY
VELCADE SPECIALTY PA
VENCLEXTA SPECIALTY PA
VENCLEXTA STARTING PACK
SPECIALTY PA
VERZENIO SPECIALTY PA
VIDAZA SPECIALTY
VITRAKVI SPECIALTY PA
VIZIMPRO SPECIALTY PA
VOTRIENT SPECIALTY PA
XALKORI SPECIALTY PA
XELODA SPECIALTY PA
XOSPATA SPECIALTY PA
XPOVIO (100 MG ONCE WEEKLY)
SPECIALTY PA
XPOVIO (40 MG ONCE WEEKLY)
SPECIALTY PA
XPOVIO (40 MG TWICE WEEKLY)
SPECIALTY PA
XPOVIO (60 MG ONCE WEEKLY)
SPECIALTY PA
XPOVIO (60 MG TWICE WEEKLY)
SPECIALTY PA
XPOVIO (80 MG ONCE WEEKLY)
SPECIALTY PA
XPOVIO (80 MG TWICE WEEKLY)
SPECIALTY PA
XTANDI SPECIALTY PA
ZEJULA SPECIALTY PA
ZELBORAF SPECIALTY PA
ZOLINZA SPECIALTY PA
ZYDELIG SPECIALTY PA
ZYKADIA SPECIALTY PA
Drug Name Drug Tier Notes
Antiparasitics
albendazole oral TIER 01 PA
ALINIA TIER 02
ARAKODA TIER 03
atovaquone oral TIER 01
atovaquone-proguanil hcl TIER 01
BENZNIDAZOLE TIER 03
BILTRICIDE TIER 03
chloroquine phosphate oral
TIER 01
COARTEM TIER 03
crotan TIER 01
DARAPRIM SPECIALTY PA
EGATEN TIER 03
ELIMITE TIER 03
EMVERM TIER 02
hydroxychloroquine sulfate oral
TIER 01
IMPAVIDO TIER 03
ivermectin oral TIER 01
KRINTAFEL TIER 03
lindane TIER 01
MALARONE TIER 03
malathion TIER 01
mefloquine hcl TIER 01
MEPRON TIER 03
NEBUPENT TIER 03
OVIDE TIER 03
PENTAM TIER 03
pentamidine isethionate TIER 01
permethrin external TIER 01
PLAQUENIL TIER 02
praziquantel oral TIER 01
primaquine phosphate TIER 01
pyrimethamine oral SPECIALTY PA
PYRIMETHAMINE-LEUCOVORIN
TIER 03
QUALAQUIN TIER 03 PA
quinine sulfate oral TIER 01 PA
SKLICE TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
16
Drug Name Drug Tier Notes
spinosad TIER 01
STROMECTOL TIER 03
sulfurated lime TIER 01
Antiparkinson Agents
amantadine hcl oral TIER 01
APOKYN SPECIALTY PA
AZILECT TIER 03
benztropine mesylate TIER 01
bromocriptine mesylate oral
TIER 01
carbidopa oral TIER 01
carbidopa-levodopa TIER 01
carbidopa-levodopa er TIER 01
carbidopa-levodopa-entacapone
TIER 01
COGENTIN TIER 03
COMTAN TIER 03
DUOPA TIER 03 PA
entacapone TIER 01
INBRIJA SPECIALTY PA
MIRAPEX TIER 03
MIRAPEX ER TIER 03
NEUPRO TIER 03 ST
NOURIANZ TIER 03 PA
PARLODEL TIER 03
pramipexole dihydrochloride
TIER 01
pramipexole dihydrochloride er
TIER 01
rasagiline mesylate oral TIER 01
REQUIP XL TIER 03
ropinirole hcl TIER 01
ropinirole hcl er TIER 01
RYTARY TIER 03 ST
selegiline hcl oral TIER 01
SINEMET TIER 03
STALEVO 100 TIER 03
STALEVO 125 TIER 03
STALEVO 150 TIER 03
STALEVO 200 TIER 03
Drug Name Drug Tier Notes
STALEVO 50 TIER 03
STALEVO 75 TIER 03
TASMAR TIER 03
tolcapone TIER 01
trihexyphenidyl hcl TIER 01
XADAGO SPECIALTY ST
ZELAPAR TIER 03
Antiplatelets
AGGRENOX TIER 03
aspirin-dipyridamole er TIER 01
BRILINTA TIER 02
CABLIVI SPECIALTY PA
cilostazol TIER 01
clopidogrel bisulfate oral PREVENT
dipyridamole oral TIER 01
EFFIENT TIER 03
prasugrel hcl TIER 01
ZONTIVITY TIER 03
Antipsychotics - Drugs for Mood Disorders
ABILIFY MAINTENA TIER 03
ADASUVE TIER 03 PA
aripiprazole TIER 01
ARISTADA TIER 03
ARISTADA INITIO TIER 03
CAPLYTA TIER 03 ST; QL
chlorpromazine hcl injection
TIER 01
chlorpromazine hcl oral TIER 01
clozapine TIER 01
CLOZARIL TIER 03
FANAPT TIER 03 ST; QL
FANAPT TITRATION PACK
TIER 03 ST; QL
fluphenazine decanoate injection
TIER 01
fluphenazine hcl TIER 01
GEODON INTRAMUSCULAR
TIER 03
HALDOL TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
17
Drug Name Drug Tier Notes
HALDOL DECANOATE TIER 03
haloperidol decanoate intramuscular
TIER 01
haloperidol lactate TIER 01
haloperidol oral TIER 01
INVEGA TIER 03
INVEGA SUSTENNA TIER 03
INVEGA TRINZA TIER 03
LATUDA TIER 03
loxapine succinate TIER 01
molindone hcl TIER 01
NUPLAZID TIER 03 PA
olanzapine TIER 01
paliperidone er TIER 01
PERSERIS TIER 03
pimozide TIER 01
quetiapine fumarate TIER 01
quetiapine fumarate er TIER 01
REXULTI TIER 03
RISPERDAL CONSTA TIER 03
risperidone TIER 01
SAPHRIS TIER 02
thioridazine hcl oral TIER 01
thiothixene TIER 01
trifluoperazine hcl TIER 01
VERSACLOZ TIER 03
VRAYLAR TIER 03 ST; QL
ziprasidone hcl TIER 01
ziprasidone mesylate TIER 01
ZYPREXA RELPREVV TIER 03
ZYPREXA ZYDIS TIER 03
Antivirals
abacavir sulfate TIER 01
abacavir sulfate-lamivudine
TIER 01
abacavir-lamivudine-zidovudine
TIER 01
acyclovir external TIER 01
acyclovir oral TIER 01
adefovir dipivoxil SPECIALTY
Drug Name Drug Tier Notes
APTIVUS TIER 02
atazanavir sulfate TIER 01
BARACLUDE ORAL SOLUTION
SPECIALTY QL
BIKTARVY TIER 03
CIMDUO TIER 02
COMBIVIR TIER 03
COMPLERA TIER 02
CRIXIVAN TIER 02
DELSTRIGO TIER 03
DESCOVY TIER 03 PA
didanosine TIER 01
DOVATO TIER 02
EDURANT TIER 02
efavirenz TIER 01
EMTRIVA TIER 02
entecavir SPECIALTY QL
EPCLUSA SPECIALTY PA; QL
EPIVIR TIER 03
EPIVIR HBV SPECIALTY
EPZICOM TIER 03
EVOTAZ TIER 02
famciclovir oral TIER 01
FAVIPIRAVIR TIER 03
fosamprenavir calcium TIER 01
FUZEON SPECIALTY
GENVOYA TIER 03
HARVONI SPECIALTY PA; QL
HEPSERA SPECIALTY
INTELENCE TIER 02
INTRON A SPECIALTY PA
INVIRASE TIER 02
ISENTRESS TIER 02
ISENTRESS HD TIER 02
JULUCA TIER 02
KALETRA ORAL SOLUTION
TIER 03
KALETRA ORAL TABLET
TIER 02
lamivudine oral solution TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
18
Drug Name Drug Tier Notes
lamivudine oral tablet 100 mg
SPECIALTY
lamivudine oral tablet 150 mg, 300 mg
TIER 01
lamivudine-zidovudine TIER 01
LEXIVA ORAL SUSPENSION
TIER 02
LEXIVA ORAL TABLET TIER 03
lopinavir-ritonavir TIER 01
MAVYRET SPECIALTY PA; QL
nevirapine TIER 01
nevirapine er TIER 01
NORVIR ORAL PACKET TIER 02
NORVIR ORAL SOLUTION
TIER 02
NORVIR ORAL TABLET TIER 03
ODEFSEY TIER 03
oseltamivir phosphate oral
TIER 01 QL
PEGASYS SPECIALTY PA
PEGASYS PROCLICK SPECIALTY PA
PEGINTRON SPECIALTY PA
PIFELTRO TIER 03
PREVYMIS ORAL SPECIALTY
PREZCOBIX TIER 02
PREZISTA TIER 02
RELENZA DISKHALER TIER 03 QL
RETROVIR ORAL TIER 03
REYATAZ ORAL CAPSULE
TIER 03
REYATAZ ORAL PACKET
TIER 02
ribavirin inhalation TIER 01
ribavirin oral SPECIALTY
rimantadine hcl TIER 01
ritonavir TIER 01
SELZENTRY TIER 02 PA
SITAVIG TIER 03
SOVALDI SPECIALTY PA; QL
stavudine TIER 01
STRIBILD TIER 03
Drug Name Drug Tier Notes
SUSTIVA TIER 03
SYMFI TIER 02
SYMFI LO TIER 02
SYMTUZA TIER 03
tenofovir disoproxil fumarate
TIER 01
TIVICAY TIER 02
TIVICAY PD TIER 02
TRIUMEQ TIER 02
TRIZIVIR TIER 03
TRUVADA TIER 02
TYBOST TIER 02
valacyclovir hcl oral TIER 01
valganciclovir hcl TIER 01
VEMLIDY SPECIALTY
VIEKIRA PAK SPECIALTY PA; QL
VIRACEPT TIER 02
VIRAMUNE TIER 03
VIRAMUNE XR TIER 03
VIRAZOLE TIER 03
VIREAD ORAL POWDER
TIER 02
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG
TIER 02
VIREAD ORAL TABLET 300 MG
TIER 03
VOSEVI SPECIALTY PA; QL
XOFLUZA (40 MG DOSE)
TIER 03 QL
XOFLUZA (80 MG DOSE)
TIER 03 QL
ZEPATIER SPECIALTY PA
ZIAGEN TIER 03
zidovudine TIER 01
Anxiolytics - Drugs for Anxiety
alprazolam er TIER 01 QL
alprazolam intensol TIER 01 QL
alprazolam oral TIER 01 QL
alprazolam xr TIER 01 QL
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
19
Drug Name Drug Tier Notes
ATIVAN INJECTION TIER 03
buspirone hcl oral TIER 01
chlordiazepoxide hcl TIER 01 QL
clonazepam oral TIER 01 QL
clorazepate dipotassium TIER 01 QL
diazepam intensol TIER 01
diazepam intramuscular TIER 01
diazepam oral TIER 01
diazepam solution 5 mg/ml injection
TIER 01
DIAZEPAM SOLUTION 5 MG/ML INJECTION
TIER 03
DORAL TIER 03 QL
estazolam TIER 01 QL
HALCION TIER 03 QL
hydroxyzine hcl intramuscular
TIER 01
hydroxyzine hcl oral TIER 01
hydroxyzine pamoate oral
TIER 01
lorazepam injection TIER 01
lorazepam intensol TIER 01 QL
lorazepam oral concentrate 2 mg/ml
TIER 01 QL
lorazepam oral tablet TIER 01 QL
meprobamate TIER 01
oxazepam TIER 01 QL
quazepam TIER 01 QL
TRANXENE-T TIER 03 QL
triazolam TIER 01 QL
VISTARIL TIER 03
Bipolar Agents - Drugs for Mood Disorders
EQUETRO TIER 03
lithium TIER 01
lithium carbonate er TIER 01
lithium carbonate oral TIER 01
LITHOBID TIER 02
Drug Name Drug Tier Notes
Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders
ADVATE SPECIALTY
ADYNOVATE SPECIALTY
AFSTYLA SPECIALTY
AGRYLIN TIER 03
ALPHANATE/VWF COMPLEX/HUMAN
SPECIALTY
ALPHANINE SD SPECIALTY
ALPROLIX SPECIALTY
AMICAR SPECIALTY
aminocaproic acid oral SPECIALTY
anagrelide hcl TIER 01
ARANESP (ALBUMIN FREE)
SPECIALTY PA
ASTRINGYN TIER 03
BENEFIX SPECIALTY
COAGADEX SPECIALTY
CORIFACT SPECIALTY
DOPTELET SPECIALTY PA
ELOCTATE SPECIALTY
FEIBA SPECIALTY
FIBRYGA SPECIALTY
HEMLIBRA SPECIALTY
HEMOFIL M SPECIALTY
HUMATE-P SPECIALTY
IDELVION SPECIALTY
IXINITY SPECIALTY
JIVI SPECIALTY
KCENTRA TIER 03
KOATE SPECIALTY
KOATE-DVI SPECIALTY
KOGENATE FS SPECIALTY
KOVALTRY SPECIALTY
LEUKINE SPECIALTY PA
LYSTEDA TIER 03
MIRCERA SPECIALTY PA
MONONINE SPECIALTY
MOZOBIL SPECIALTY PA
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
20
Drug Name Drug Tier Notes
MULPLETA SPECIALTY PA
NEULASTA SPECIALTY PA
NEULASTA ONPRO SPECIALTY PA
NIVESTYM SPECIALTY PA
NOVOEIGHT SPECIALTY
NOVOSEVEN RT SPECIALTY
NPLATE SPECIALTY PA
NUWIQ SPECIALTY
OBIZUR SPECIALTY
PROFILNINE SPECIALTY
PROFILNINE SD SPECIALTY
PROMACTA SPECIALTY PA
REBINYN SPECIALTY
REBLOZYL SPECIALTY PA
RECOMBINATE SPECIALTY
RECOTHROM TIER 03
RECOTHROM SPRAY KIT
TIER 03
RETACRIT SPECIALTY PA
RIASTAP SPECIALTY
RIXUBIS SPECIALTY
TAVALISSE SPECIALTY PA
THROMBIN-JMI TIER 03
THROMBIN-JMI EPISTAXIS
TIER 03
THROMBOGEN TIER 03
tranexamic acid oral TIER 01
TRETTEN SPECIALTY
UDENYCA SPECIALTY PA
VONVENDI SPECIALTY
WILATE SPECIALTY
XYNTHA SPECIALTY
XYNTHA SOLOFUSE SPECIALTY
ZARXIO SPECIALTY PA
Cardiovascular Agents - Drugs for Heart and Circulation Conditions
ACCUPRIL TIER 03
ACCURETIC TIER 03
acebutolol hcl oral TIER 01
Drug Name Drug Tier Notes
acetazolamide sodium TIER 01
ALDACTAZIDE TIER 03
ALDACTONE TIER 03
aliskiren fumarate TIER 01
alprostadil injection TIER 01
amiloride hcl oral TIER 01
amiloride-hydrochlorothiazide
TIER 01
amiodarone hcl oral TIER 01
amlodipine besylate oral PREVENT
amlodipine besylate-benazepril hcl
PREVENT
amlodipine besylate-valsartan
PREVENT
amlodipine-atorvastatin TIER 01
amlodipine-olmesartan PREVENT
amlodipine-valsartan-hctz
PREVENT
ATACAND HCT TIER 03
atenolol oral PREVENT
atenolol-chlorthalidone TIER 01
atorvastatin calcium oral PREVENT
AVALIDE TIER 03
benazepril hcl oral PREVENT
benazepril-hydrochlorothiazide
PREVENT
BETAPACE AF TIER 03
betaxolol hcl oral TIER 01
BIDIL TIER 03
bisoprolol fumarate TIER 01
bisoprolol-hydrochlorothiazide
TIER 01
bumetanide TIER 01
BUMEX TIER 03
BYSTOLIC TIER 02
CADUET TIER 03
CALAN SR TIER 03
candesartan cilexetil PREVENT
candesartan cilexetil-hctz PREVENT
captopril oral TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
21
Drug Name Drug Tier Notes
captopril-hydrochlorothiazide
TIER 01
CARDIZEM TIER 03
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG
TIER 03
CARDURA TIER 03
CAROSPIR TIER 03
cartia xt PREVENT
carvedilol PREVENT
carvedilol phosphate er TIER 01
CATAPRES TIER 03
chlorthalidone TIER 01
cholestyramine light TIER 01
cholestyramine oral TIER 01
clonidine TIER 01
clonidine hcl oral TIER 01
colesevelam hcl TIER 01
colestipol hcl TIER 01
CORLANOR TIER 03 PA
DEMSER TIER 03
DIBENZYLINE TIER 03
digitek TIER 01
digox TIER 01
digoxin injection TIER 01
digoxin oral TIER 01
DILATRATE-SR TIER 03
diltiazem hcl er beads PREVENT
diltiazem hcl er coated beads
PREVENT
diltiazem hcl er oral capsule extended release 12 hour
PREVENT
diltiazem hcl oral PREVENT
dilt-xr PREVENT
disopyramide phosphate TIER 01
DIURIL TIER 03
dofetilide TIER 01
doxazosin mesylate oral TIER 01
DYRENIUM TIER 03
Drug Name Drug Tier Notes
EDARBI TIER 03 ST
EDARBYCLOR TIER 03 ST
EDECRIN TIER 03
enalapril maleate oral PREVENT
enalapril-hydrochlorothiazide
PREVENT
ENTRESTO TIER 02
EPHEDRINE SULFATE (PRESSORS)
TIER 03
epinephrine pf TIER 01
epinephrine solution prefilled syringe 1 mg/10ml injection
TIER 01
EPINEPHRINE SOLUTION PREFILLED SYRINGE 1 MG/10ML INJECTION
TIER 03
eplerenone TIER 01
ethacrynic acid TIER 01
EZALLOR SPRINKLE TIER 03 ST
ezetimibe TIER 01
ezetimibe-simvastatin TIER 01
felodipine er PREVENT
fenofibrate micronized PREVENT
fenofibrate oral capsule 134 mg, 200 mg, 67 mg
PREVENT
fenofibrate oral capsule 150 mg, 50 mg
TIER 01
fenofibrate oral tablet PREVENT
fenofibric acid TIER 01
FIBRICOR ORAL TABLET 105 MG
TIER 03 ST
FIBRICOR ORAL TABLET 35 MG
TIER 03
flecainide acetate TIER 01
FLOLIPID TIER 03 ST
fluvastatin sodium PREVENT
fluvastatin sodium er PREVENT
fosinopril sodium PREVENT
fosinopril sodium-hctz PREVENT
furosemide injection TIER 01
furosemide oral TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
22
Drug Name Drug Tier Notes
gemfibrozil oral PREVENT
GONITRO TIER 03
guanfacine hcl TIER 01
HEMANGEOL TIER 03
hydralazine hcl injection TIER 01
hydralazine hcl oral TIER 01
hydrochlorothiazide oral PREVENT
indapamide TIER 01
INSPRA TIER 03
irbesartan PREVENT
irbesartan-hydrochlorothiazide
PREVENT
isoproterenol hcl injection
TIER 01
ISORDIL TITRADOSE TIER 03
isosorbide dinitrate TIER 01
isosorbide mononitrate TIER 01
isosorbide mononitrate er
TIER 01
isradipine PREVENT
ISUPREL TIER 03
JUXTAPID SPECIALTY PA
labetalol hcl oral TIER 01
LANOXIN TIER 02
LANOXIN PEDIATRIC TIER 02
LIPOFEN TIER 03
lisinopril oral PREVENT
lisinopril-hydrochlorothiazide
PREVENT
LIVALO TIER 03 ST
LOPID TIER 03
LOPRESSOR TIER 03
LOPRESSOR HCT TIER 03
losartan potassium oral PREVENT
losartan potassium-hctz PREVENT
LOTENSIN TIER 03
LOTENSIN HCT TIER 03
lovastatin PREVENT
matzim la PREVENT
MAXZIDE TIER 03
Drug Name Drug Tier Notes
MAXZIDE-25 TIER 03
methyldopa TIER 01
methyldopa-hydrochlorothiazide
TIER 01
metolazone TIER 01
metoprolol succinate er PREVENT
metoprolol tartrate oral PREVENT
metoprolol-hydrochlorothiazide
TIER 01
metyrosine TIER 01
mexiletine hcl oral TIER 01
midodrine hcl TIER 01
MINIPRESS TIER 03
minitran TIER 01
minoxidil oral TIER 01
moexipril hcl PREVENT
MULTAQ TIER 03
nadolol oral TIER 01
niacin (antihyperlipidemic)
TIER 01
niacin er (antihyperlipidemic)
TIER 01
niacor TIER 01
nicardipine hcl oral TIER 01
nifedipine er PREVENT
nifedipine er osmotic release
PREVENT
nifedipine oral TIER 01
nimodipine oral TIER 01
nisoldipine er TIER 01
NITRO-BID TIER 03
NITRO-DUR TIER 03
nitroglycerin sublingual TIER 01
nitroglycerin transdermal TIER 01
nitroglycerin translingual TIER 01
NITROLINGUAL TIER 03
NITROMIST TIER 03
nitro-time oral capsule extended release 2.5 mg
TIER 01
NORPACE TIER 03
NORPACE CR TIER 02
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
23
Drug Name Drug Tier Notes
NORTHERA SPECIALTY PA
NYMALIZE TIER 03
olmesartan medoxomil oral
PREVENT
olmesartan medoxomil-hctz
PREVENT
olmesartan-amlodipine-hctz
PREVENT
omega-3-acid ethyl esters
TIER 01 PA
PACERONE ORAL TABLET 100 MG, 400 MG
TIER 03
pacerone oral tablet 200 mg
TIER 01
pentoxifylline er TIER 01
perindopril erbumine TIER 01
phenoxybenzamine hcl oral
TIER 01
phentolamine mesylate injection
TIER 01
pindolol TIER 01
PRALUENT TIER 02 PA
pravastatin sodium PREVENT
prazosin hcl oral TIER 01
PRESTALIA TIER 03
prevalite TIER 01
procainamide hcl injection
TIER 01
PROCARDIA TIER 03
PROCARDIA XL TIER 03
propafenone hcl TIER 01
propafenone hcl er TIER 01
propranolol hcl er PREVENT
propranolol hcl oral solution
TIER 01
propranolol hcl oral tablet PREVENT
propranolol-hctz TIER 01
PROSTIN VR TIER 03
quinapril hcl PREVENT
quinapril-hydrochlorothiazide
PREVENT
quinidine gluconate er TIER 01
Drug Name Drug Tier Notes
quinidine sulfate TIER 01
ramipril PREVENT
ranolazine er TIER 01
RECTIV TIER 03
REPATHA TIER 02 PA
REPATHA PUSHTRONEX SYSTEM
TIER 02 PA
REPATHA SURECLICK TIER 02 PA
rosuvastatin calcium PREVENT
RYTHMOL SR TIER 03
simvastatin oral PREVENT
sorine TIER 01
sotalol hcl (af) TIER 01
sotalol hcl oral TIER 01
SOTYLIZE TIER 03
spironolactone oral TIER 01
spironolactone-hctz TIER 01
SULAR TIER 03
TARKA TIER 03
taztia xt PREVENT
TEKTURNA TIER 02
TEKTURNA HCT TIER 02 ST
telmisartan PREVENT
telmisartan-amlodipine TIER 01
telmisartan-hctz PREVENT
TENORETIC 100 TIER 03
TENORETIC 50 TIER 03
tiadylt er PREVENT
TIAZAC TIER 03
timolol maleate oral TIER 01
torsemide TIER 01
trandolapril PREVENT
trandolapril-verapamil hcl er
TIER 01
triamterene oral TIER 01
triamterene-hctz TIER 01
TRILIPIX TIER 03
TWYNSTA TIER 03
valsartan PREVENT
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
24
Drug Name Drug Tier Notes
valsartan-hydrochlorothiazide
PREVENT
VASCEPA TIER 03 PA
VASERETIC TIER 03
VECAMYL TIER 03
verapamil hcl er PREVENT
verapamil hcl oral PREVENT
VERELAN TIER 03
VERELAN PM TIER 03
VYNDAMAX SPECIALTY PA
VYNDAQEL SPECIALTY PA
ZIAC TIER 03
Central Nervous System Agents - Drugs for Attention Deficit Disorder
ADZENYS ER TIER 03 PA
ADZENYS XR-ODT TIER 03 ST; QL
AMPHETAMINE ER TIER 03 PA
amphetamine sulfate TIER 01 PA
amphetamine-dextroamphetamine
TIER 01 PA
amphetamine-dextroamphetamine er
TIER 01 PA
APTENSIO XR TIER 03 ST; QL
atomoxetine hcl TIER 01
clonidine hcl er TIER 01
COTEMPLA XR-ODT TIER 03 ST; QL
DAYTRANA TIER 03 ST; QL
dexmethylphenidate hcl TIER 01 PA
dexmethylphenidate hcl er
TIER 01 PA
dextroamphetamine sulfate
TIER 01 PA
dextroamphetamine sulfate er
TIER 01 PA
DYANAVEL XR TIER 03 ST; QL
EVEKEO ODT TIER 03 PA
guanfacine hcl er TIER 01
JORNAY PM TIER 03 ST; QL
KAPVAY TIER 03 ST
metadate er TIER 01 PA
Drug Name Drug Tier Notes
methamphetamine hcl TIER 01 PA
METHYLIN TIER 03 ST; QL
methylphenidate hcl er TIER 01 PA
methylphenidate hcl er (cd)
TIER 01 PA
methylphenidate hcl er (la)
TIER 01 PA
methylphenidate hcl oral TIER 01 PA
MYDAYIS TIER 03 ST; QL
PROCENTRA TIER 03 ST; QL
QUILLICHEW ER TIER 03 ST; QL
QUILLIVANT XR TIER 03 ST; QL
relexxii TIER 01 PA
VYVANSE TIER 02 PA
ZENZEDI ORAL TABLET 10 MG, 5 MG
TIER 03 PA
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG
TIER 03 ST; QL
Central Nervous System Agents - Drugs for Multiple Sclerosis
AMPYRA SPECIALTY PA
AUBAGIO SPECIALTY PA; QL
AVONEX PEN SPECIALTY PA; QL
AVONEX PREFILLED SPECIALTY PA; QL
BAFIERTAM SPECIALTY PA
BETASERON SPECIALTY PA; QL
COPAXONE SPECIALTY PA; QL
dalfampridine er SPECIALTY PA
dimethyl fumarate oral SPECIALTY PA; QL
GILENYA SPECIALTY PA; QL
glatiramer acetate SPECIALTY PA; QL
glatopa SPECIALTY PA; QL
MAVENCLAD (10 TABS) SPECIALTY PA
MAVENCLAD (4 TABS) SPECIALTY PA
MAVENCLAD (5 TABS) SPECIALTY PA
MAVENCLAD (6 TABS) SPECIALTY PA
MAVENCLAD (7 TABS) SPECIALTY PA
MAVENCLAD (8 TABS) SPECIALTY PA
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
25
Drug Name Drug Tier Notes
MAVENCLAD (9 TABS) SPECIALTY PA
MAYZENT SPECIALTY PA
MAYZENT STARTER PACK
SPECIALTY PA
REBIF SPECIALTY PA; QL
REBIF REBIDOSE SPECIALTY PA; QL
REBIF REBIDOSE TITRATION PACK
SPECIALTY PA; QL
REBIF TITRATION PACK
SPECIALTY PA; QL
TECFIDERA SPECIALTY PA; QL
VUMERITY SPECIALTY PA
VUMERITY (STARTER) SPECIALTY PA
Central Nervous System Agents - Miscellaneous
ADDYI TIER 03 PA
ANECTINE TIER 03
AUSTEDO SPECIALTY PA
benzphetamine hcl TIER 01 PA
caffeine citrate oral TIER 01
CAFFEINE-SODIUM BENZOATE
TIER 03
CONTRAVE TIER 02 PA
diethylpropion hcl er TIER 01 PA
diethylpropion hcl oral TIER 01 PA
GRALISE TIER 03 ST; QL
HORIZANT TIER 03 PA; QL
INGREZZA SPECIALTY PA
LOMAIRA TIER 03 PA
LYRICA CR TIER 03 ST; QL
NUEDEXTA TIER 03 PA
phendimetrazine tartrate TIER 01 PA
phendimetrazine tartrate er
TIER 01 PA
phentermine hcl oral TIER 01 PA
pregabalin oral TIER 01 QL
QSYMIA TIER 03 PA
QUELICIN TIER 03
RILUTEK SPECIALTY PA
riluzole SPECIALTY PA
Drug Name Drug Tier Notes
SAVELLA TIER 03 ST; QL
SAVELLA TITRATION PACK
TIER 03 ST; QL
SAXENDA SPECIALTY PA
SUCCINYLCHOLINE CHLORIDE INJECTION SOLUTION PREFILLED SYRINGE
TIER 03
succinylcholine chloride solution 20 mg/ml injection
TIER 01
SUCCINYLCHOLINE CHLORIDE SOLUTION 20 MG/ML INJECTION
TIER 03
TEGSEDI SPECIALTY PA
tetrabenazine SPECIALTY PA
TIGLUTIK SPECIALTY PA
VYLEESI TIER 03 PA
XENICAL TIER 03 PA
Dental and Oral Agents - Drugs for Mouth and Throat Conditions
cavarest TIER 01
cevimeline hcl TIER 01
chlorhexidine gluconate mouth/throat
TIER 01
clinpro 5000 TIER 01
DEBACTEROL TIER 03
denta 5000 plus TIER 01
dentagel TIER 01
easygel TIER 01
EVOXAC TIER 03
fluoridex TIER 01
fluoridex daily renewal TIER 01
fluoridex enhanced whitening
TIER 01
fluoridex sensitivity relief TIER 01
lidocaine hcl mouth/throat
TIER 01
lidocaine viscous hcl TIER 01
MI PASTE TIER 03
MI PASTE PLUS TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
26
Drug Name Drug Tier Notes
NAFRINSE DAILY ACIDULATED
TIER 03
NAFRINSE DAILY/NEUTRAL
TIER 03
NAFRINSE WEEKLY TIER 03
neutral sodium fluoride TIER 01
oralone TIER 01
paroex TIER 01
PERIDEX TIER 03
periogard TIER 01
pilocarpine hcl oral TIER 01
PREVIDENT 5000 BOOSTER PLUS
TIER 03
PREVIDENT 5000 DRY MOUTH
TIER 03
PREVIDENT 5000 ENAMEL PROTECT
TIER 03
PREVIDENT 5000 ORTHO DEFENSE
TIER 03
PREVIDENT 5000 PLUS TIER 03
PREVIDENT 5000 SENSITIVE
TIER 03
PREVIDENT DENTAL TIER 03
prevident mouth/throat TIER 01
REMESENSE TIER 03
SALAGEN TIER 03
sf TIER 01
sf 5000 plus TIER 01
sodium fluoride 5000 plus
TIER 01
sodium fluoride 5000 ppm
TIER 01
sodium fluoride 5000 sensitive
TIER 01
sodium fluoride dental TIER 01
TOPEX TOPICAL ANESTHETIC
TIER 03
triamcinolone acetonide mouth/throat
TIER 01
Dermatological Agents - Drugs for Skin Conditions
ABSORICA LD TIER 03 PA
Drug Name Drug Tier Notes
acitretin TIER 01
ACTICOAT EXTERNAL SHEET 16"X16"
TIER 03
ACZONE EXTERNAL GEL 7.5 %
TIER 02
adapalene external cream
TIER 01 PA
adapalene external gel TIER 01 PA
ADAPALENE EXTERNAL SOLUTION
TIER 03 PA
adapalene-benzoyl peroxide
TIER 01
ala-cort TIER 01
alclometasone dipropionate
TIER 01
ALCOHOL PREP PADS EXTERNAL 70 %
TIER 03
ALTRENO TIER 03 PA
amcinonide TIER 01
ammonium lactate external
TIER 01
amnesteem TIER 01 PA
AMNIOCORE HUMAN TISSUE EXTERNAL DISK
TIER 03
AMNIOCORE HUMAN TISSUE EXTERNAL SHEET 2 CM X 12 CM , 6 CM X 16 CM , 6 CM X 9 CM , 9 CM X 20 CM
TIER 03
AMZEEQ TIER 03
ARIDA TIER 03
ATRALIN TIER 03 PA
avita TIER 01 PA
AZADROX TIER 03
azelaic acid external TIER 01
AZELEX TIER 03
balsam peru-castor oil TIER 01
benzoyl peroxide-erythromycin
TIER 01
beser external lotion TIER 01
betamethasone dipropionate aug
TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
27
Drug Name Drug Tier Notes
betamethasone dipropionate external
TIER 01
betamethasone valerate external
TIER 01
BIAFINE TIER 03
BIONECT EXTERNAL CREAM
TIER 03
BIOSTEP AG EXTERNAL SHEET 4"X4"
TIER 03
BPCO TIER 03
calcipotriene external cream
TIER 01
calcipotriene external ointment
TIER 01
calcipotriene external solution
TIER 01
calcipotriene-betameth diprop
TIER 01 QL
CALCITRENE TIER 03
calcitriol external TIER 01
CARAC TIER 03
claravis TIER 01 PA
CLEOCIN-T EXTERNAL LOTION
TIER 03
clindacin etz external swab
TIER 01
clindacin-p TIER 01
clindamycin phosphate-benzoyl peroxide
TIER 01
clindamycin phosphate external
TIER 01
clindamycin-tretinoin TIER 01
clobetasol prop emollient base
TIER 01
clobetasol propionate e TIER 01
clobetasol propionate emulsion
TIER 01
clobetasol propionate external
TIER 01
clocortolone pivalate TIER 01
clodan external shampoo TIER 01
coal tar external TIER 01
CONDYLOX TIER 03
Drug Name Drug Tier Notes
CORTISPORIN TIER 03
CUTIVATE TIER 03
dapsone external gel 5 %
TIER 01
DERMA-SMOOTHE/FS BODY
TIER 03
DERMA-SMOOTHE/FS SCALP
TIER 03
DERMULCERA TIER 03
desonide external TIER 01
DESOWEN TIER 03
desoximetasone external TIER 01
diclofenac sodium transdermal gel 3 %
TIER 01 ST; QL
diflorasone diacetate TIER 01
DIPROLENE TIER 03
DIPROLENE AF TIER 03
DOVONEX TIER 03
doxepin hcl external TIER 01
doxycycline TIER 01
DRYSOL TIER 03
DUPIXENT SPECIALTY PA
DURAFIBER TIER 03
EFUDEX TIER 03
EPIDUO FORTE TIER 03
EPIFOAM TIER 03
ery TIER 01
ERYGEL TIER 03
erythromycin external TIER 01
EUCRISA TIER 02 ST
EVOCLIN TIER 03
FINACEA EXTERNAL FOAM
TIER 03 ST
fluocinolone acetonide body
TIER 01
fluocinolone acetonide external
TIER 01
fluocinolone acetonide scalp
TIER 01
fluocinonide emulsified base
TIER 01
fluocinonide external TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
28
Drug Name Drug Tier Notes
FLUOROPLEX TIER 03
FLUOROURACIL EXTERNAL CREAM 0.5 %
TIER 02
fluorouracil external cream 5 %
TIER 01
fluorouracil external solution
TIER 01
flurandrenolide TIER 01
fluticasone propionate external
TIER 01
GORDOFILM TIER 03
halcinonide TIER 01
halobetasol propionate external cream
TIER 01
halobetasol propionate external ointment
TIER 01
hydrocortisone butyr lipo base
TIER 01
hydrocortisone butyrate TIER 01
hydrocortisone external cream 1 %, 2.5 %
TIER 01
hydrocortisone external lotion 2.5 %
TIER 01
hydrocortisone external ointment 1 %, 2.5 %
TIER 01
hydrocortisone valerate TIER 01
imiquimod external TIER 01
isotretinoin oral TIER 01 PA
KERAMATRIX REPLICINE 5CMX5CM
TIER 03
KLARON TIER 03
lactic acid e TIER 01
lactic acid external TIER 01
LEVULAN KERASTICK TIER 03
LUXIQ TIER 03
methoxsalen rapid TIER 01
METROCREAM TIER 03
METROLOTION TIER 03
metronidazole external TIER 01
MICROCYN EXTERNAL LIQUID 0.023 %
TIER 03
MIRVASO TIER 02
Drug Name Drug Tier Notes
mometasone furoate external
TIER 01
myorisan TIER 01 PA
NEO-SYNALAR EXTERNAL CREAM
TIER 03
neuac external gel TIER 01
nolix TIER 01
NORMLGEL AG TIER 03
NOVACHOR TIER 03
NUCEL INJECTION INJECTABLE 2.5 ML
TIER 03
NUSHIELD EXTERNAL DISK
TIER 03
OLUX TIER 03
OLUX-E TIER 03
ONEXTON TIER 03
OSTEOCONDUCTIVE MATRIX PLUS
TIER 03
OXSORALEN ULTRA TIER 03
PICATO TIER 03 ST
pimecrolimus TIER 01
podofilox external TIER 01
PRAMOSONE EXTERNAL CREAM 1-1 %
TIER 02
PRAMOSONE EXTERNAL LOTION
TIER 03
prednicarbate TIER 01
PROTOPIC TIER 03
PYROGALLIC ACID TIER 03
QBREXZA TIER 03 QL
RADIAPLEXRX TIER 03
REGENECARE TIER 03
REGRANEX TIER 03 PA
RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 %
TIER 02 PA
RHOFADE TIER 03
rosadan external cream TIER 01
rosadan external gel TIER 01
SANTYL TIER 03
SCENESSE SPECIALTY PA
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
29
Drug Name Drug Tier Notes
selenium sulfide external lotion
TIER 01
SERNIVO TIER 03
SILVERSEAL HYDROGEL DRESSING EXTERNAL PAD 2"X3"
TIER 03
SOOLANTRA TIER 02
SORIATANE TIER 03
sulfacetamide sodium (acne)
TIER 01
SYNALAR TIER 03
TACLONEX EXTERNAL SUSPENSION
TIER 03 QL
tacrolimus external ointment
TIER 01
tazarotene external TIER 01
TAZORAC EXTERNAL CREAM 0.05 %
TIER 03
TAZORAC EXTERNAL GEL
TIER 03
TEMOVATE TIER 03
TEXACORT TIER 03
THERAHONEY EXTERNAL SHEET
TIER 03
TOLAK TIER 03
TOPICORT EXTERNAL CREAM 0.25 %
TIER 03
TOPICORT EXTERNAL GEL
TIER 03
TOPICORT EXTERNAL OINTMENT
TIER 03
tovet external foam TIER 01
tretinoin external TIER 01 PA
tretinoin microsphere TIER 01 PA
tretinoin microsphere pump
TIER 01 PA
triamcinolone acetonide external
TIER 01
trianex TIER 01
TRI-CHLOR TIER 03
triderm TIER 01
TRIDESILON TIER 03
vashe cleansing TIER 01
Drug Name Drug Tier Notes
VENELEX TIER 03
XALIX TIER 03
XERAC AC TIER 03
XEROFORM OIL EMULSION 2"X2"
TIER 03
XEROFORM OIL EMULSION GAUZE
TIER 03
XEROFORM OIL EMULSION STRIP
TIER 03
XEROFORM OIL ROLL 4"X9'
TIER 03
XEROFORM PETROLAT GAUZE 1"X8"
TIER 03
XEROFORM PETROLAT GAUZE 5"X9"
TIER 03
XEROFORM PETROLAT PATCH 2"X2"
TIER 03
XEROFORM PETROLAT PATCH 4"X4"
TIER 03
XEROFORM PETROLATUM ROLL 4"X9'
TIER 03
zenatane TIER 01 PA
Diabetes - Antidiabetic Agents
acarbose oral TIER 01
ACTOPLUS MET TIER 03
ACTOS TIER 03
AMARYL TIER 03
AVANDIA TIER 03 ST
BYDUREON TIER 02 ST; QL
BYDUREON BCISE AUTOINJECTOR
TIER 02 ST; QL
BYETTA 10 MCG PEN TIER 02 ST; QL
BYETTA 5 MCG PEN TIER 02 ST; QL
CYCLOSET TIER 03 ST
DUETACT TIER 03
FARXIGA TIER 02 ST
glimepiride PREVENT
glipizide er PREVENT
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
30
Drug Name Drug Tier Notes
glipizide ir PREVENT
glipizide xl PREVENT
glipizide-metformin hcl PREVENT
GLUCOTROL TIER 03
GLUCOTROL XL TIER 03
glyburide micronized PREVENT
glyburide oral PREVENT
glyburide-metformin PREVENT
GLYNASE TIER 03
GLYSET TIER 03
GLYXAMBI TIER 02 ST
JANUMET TIER 02 ST
JANUMET XR TIER 02 ST
JANUVIA TIER 02 ST
JARDIANCE TIER 02 ST
JENTADUETO TIER 02 ST
JENTADUETO XR TIER 02 ST
metformin hcl er PREVENT
metformin hcl oral solution
TIER 01
metformin hcl oral tablet PREVENT
miglitol TIER 01
nateglinide TIER 01
OZEMPIC TIER 02 ST; QL
pioglitazone hcl PREVENT
pioglitazone hcl-glimepiride
TIER 01
pioglitazone hcl-metformin hcl
PREVENT
PRECOSE TIER 03
repaglinide PREVENT
RIOMET TIER 03 ST
RIOMET ER TIER 03 ST
RYBELSUS TIER 02 ST; QL
SOLIQUA TIER 02 ST; QL
STARLIX TIER 03
SYMLINPEN 120 TIER 03 PA
SYMLINPEN 60 TIER 03 PA
SYNJARDY TIER 02 ST
SYNJARDY XR TIER 02 ST
Drug Name Drug Tier Notes
tolbutamide TIER 01
TRADJENTA TIER 02 ST
TRIJARDY XR TIER 02 ST
TRULICITY TIER 02 ST; QL
VICTOZA TIER 02 ST; QL
XIGDUO XR TIER 02 ST
XULTOPHY TIER 03 ST; QL
Diabetes - Glucose Monitoring
ACCU-CHEK FASTCLIX LANCET KIT
TIER 02
ACCU-CHEK MULTICLIX LANCET DEVICE KIT
TIER 02
ACCU-CHEK SOFTCLIX LANCET DEVICE KIT
TIER 02
AUTOLET LANCING DEVICE
TIER 03
BLUESTAR TIER 03
CARETOUCH LANCING/EJECTOR
TIER 03
CEQUR SIMPLICITY 2U PREVENT
CEQUR SIMPLICITY INSERTER
TIER 03
CEQUR SIMPLICITY STARTER
TIER 03
CHEMSTRIP UGK TIER 03
DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC)
TIER 02
DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC) DEVICE
TIER 02
DIATHRIVE LANCING DEVICE
TIER 03
ENLITE GLUCOSE SENSOR
TIER 03
EVERSENSE SENSOR/HOLDER
TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
31
Drug Name Drug Tier Notes
EVERSENSE SMART TRANSMITTER
TIER 03
FREESTYLE LIBRE 14 DAY READER
PREVENT
FREESTYLE LIBRE 14 DAY SENSOR
PREVENT
FREESTYLE LIBRE 2 READER SYSTM
PREVENT
FREESTYLE LIBRE 2 SENSOR SYSTM
PREVENT
GENTEEL LANCING KIT (BLUE)
TIER 03
GOJJI LANCING DEVICE/CLEAR CAP
TIER 03
GUARDIAN CONNECT TRANSMITTER
TIER 03
GUARDIAN LINK 3 TRANSMITTER
TIER 03
GUARDIAN REAL-TIME SYSTEM
TIER 03
GUARDIAN SENSOR (3) TIER 03
INPEN 100-BLUE-LILLY TIER 03
INPEN 100-BLUE-NOVO TIER 03
INPEN 100-GRAY-LILLY TIER 03
INPEN 100-GREY-NOVO
TIER 03
INPEN 100-PINK-LILLY TIER 03
INPEN 100-PINK-NOVO TIER 03
KETONE TEST TIER 03
KETOSTIX TIER 03
LANCETS TIER 02
LANCETS TIER 03
LANCETS KIT TIER 03
MICROLET NEXT LANCING DEVICE
TIER 03
MINIMED GUARDIAN SENSOR 3
TIER 03
NOVOPEN ECHO TIER 03
OMNIPOD DASH SYSTEM
TIER 03
OMNIPOD STARTER TIER 03
ONETOUCH DELICA LANCING DEV
PREVENT
Drug Name Drug Tier Notes
ONETOUCH DELICA PLUS LANCING
TIER 03
ONETOUCH ULTRA TIER 02
ONETOUCH ULTRA 2 KIT W/DEVICE
TIER 02
ONETOUCH ULTRA MINI KIT W/DEVICE
TIER 02
ONETOUCH VERIO KIT W/DEVICE
PREVENT
ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE
PREVENT
ONETOUCH VERIO IN VITRO SOLUTION HIGH
TIER 03
ONETOUCH VERIO TEST STRIPS
PREVENT
ONETOUCH VERIO IQ SYSTEM
PREVENT
ONETOUCH VERIO REFLECT KIT W/DEVICE
PREVENT
ONETOUCH VERIO REFLECT KIT W/DEVICE
TIER 03
ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE
TIER 02
PARADIGM REAL-TIME STARTER
TIER 03
SOF-SENSOR TIER 03
SURESTEP PRO HIGH GLUCOSE
TIER 03
SURESTEP PRO LOW GLUCOSE
TIER 03
SURESTEP PRO NORMAL GLUCOSE
TIER 03
VIVAGUARD LANCING DEVICE
TIER 03
Diabetes - Glycemic Agents
BAQSIMI ONE PACK TIER 02
BAQSIMI TWO PACK TIER 02
diazoxide oral TIER 01
GLUCAGEN HYPOKIT TIER 03 ST
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
32
Drug Name Drug Tier Notes
GLUCAGON EMERGENCY KIT
TIER 02
GVOKE HYPOPEN 1-PACK
TIER 02
GVOKE HYPOPEN 2-PACK
TIER 02
GVOKE PFS TIER 02
PROGLYCEM TIER 03
Diabetes - Insulins
AFREZZA TIER 03 PA
BD AUTOSHIELD DUO PEN NEEDLES
PREVENT
BD ULTRA-FINE INSULIN SYRINGES 27G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML
TIER 02
BD ULTRA-FINE INSULIN SYRINGES
PREVENT
BD ULTRA-FINE PEN NEEDLES
PREVENT
BD ULTRA-FINE PEN NEEDLES
TIER 02
BD VEO INSULIN SYR U/F 1/2UNIT
PREVENT
DROPLET MICRON TIER 02
HUMALOG KWIKPEN PREVENT
HUMALOG MIX 50/50 KWIKPEN
PREVENT
HUMALOG MIX 50/50 VIAL
PREVENT
HUMALOG MIX 75/25 KWIKPEN
PREVENT
HUMALOG MIX 75/25 VIAL
PREVENT
HUMALOG U-100 JUNIOR KWIKPEN
PREVENT
HUMALOG VIAL PREVENT
HUMULIN 70/30 KWIKPEN
PREVENT
HUMULIN 70/30 VIAL PREVENT
HUMULIN N KWIKPEN PREVENT
HUMULIN N VIAL PREVENT
Drug Name Drug Tier Notes
HUMULIN R U-500 KWIKPEN
TIER 02
HUMULIN R U-500 VIAL TIER 02
HUMULIN R VIAL PREVENT
INSULIN LISPRO PROT & LISPRO
PREVENT
INSULIN PEN NEEDLES TIER 02
INSULIN SYRINGES TIER 02
LANTUS SOLOSTAR PREVENT
LANTUS U-100 VIAL PREVENT
LEVEMIR U-100 FLEXTOUCH
PREVENT
LEVEMIR U-100 VIAL PREVENT
MAXICOMFORT SYR 27G X 1/2"
TIER 02
NOVOFINE AUTOCOVER PEN NEEDLE
TIER 02
NOVOFINE PEN NEEDLE
TIER 02
NOVOFINE PLUS PEN NEEDLE
TIER 02
NOVOTWIST PEN NEEDLE
TIER 02
TOUJEO MAX SOLOSTAR
TIER 02
TOUJEO SOLOSTAR TIER 02
Electrolytes / Minerals / Metals / Vitamins
AQUASOL A TIER 03
ARGININE HCL INJECTION
TIER 03
CALCIFOL TIER 03
CARBAGLU SPECIALTY
CHEMET TIER 03
clovique SPECIALTY PA
cyanocobalamin injection solution 1000 mcg/ml
TIER 01
CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML
TIER 03
deferasirox SPECIALTY PA
deferasirox granules SPECIALTY PA
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
33
Drug Name Drug Tier Notes
dehydrated alcohol TIER 01
DEXPANTHENOL INJECTION
TIER 03
DRISDOL TIER 03
EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ
TIER 03
effer-k oral tablet effervescent 25 meq
TIER 01
ergocalciferol oral capsule
TIER 01
EXJADE SPECIALTY PA
FERRIPROX SPECIALTY PA
FERRIPROX TWICE-A-DAY
SPECIALTY PA
FLUORABON TIER 02
fluoritab TIER 01
FLURA-DROPS TIER 02
folic acid injection TIER 01
folic acid oral tablet 1 mg TIER 01
GALZIN TIER 03
GLUTATHIONE INJECTION SOLUTION 200 MG/ML
TIER 03
GLYCINE INJECTION TIER 03
hematinic/folic acid TIER 01
hemocyte-f TIER 01
hydroxocobalamin acetate
TIER 01
iodine strong oral TIER 01
JADENU SPECIALTY PA
JADENU SPRINKLE SPECIALTY PA
JYNARQUE SPECIALTY QL
kionex TIER 01
klor-con TIER 01
klor-con 10 TIER 01
klor-con m10 TIER 01
KLOR-CON M15 TIER 03
klor-con m20 TIER 01
klor-con sprinkle TIER 01
klor-con/ef TIER 01
Drug Name Drug Tier Notes
K-PHOS TIER 03
K-PHOS-NEUTRAL TIER 03
k-prime TIER 01
LEVOCARNITINE INJECTION
TIER 03
levocarnitine oral solution
TIER 01
levocarnitine oral tablet TIER 01
levocarnitine sf TIER 01
LIPO TIER 03
LIPO-C TIER 03
LOKELMA TIER 03
ludent TIER 01
LYSINE HCL INJECTION
TIER 03
MAGNEBIND 400 TIER 03
magnesium chloride injection
TIER 01
magnesium sulfate solution 50 % injection
TIER 01
MAGNESIUM SULFATE SOLUTION 50 % INJECTION
TIER 03
MEPHYTON TIER 03
METHYLCOBALAMIN INJECTION SOLUTION RECONSTITUTED
TIER 03
n-acetyl-l-cysteine oral TIER 01
nafrinse TIER 01
nafrinse drops TIER 01
NASCOBAL TIER 03
NEOKE ALCAR TIER 03
ORACIT TIER 03
phospha 250 neutral TIER 01
phosphorous TIER 01
phospho-trin 250 neutral TIER 01
phytonadione injection TIER 01
phytonadione oral TIER 01
pot bicarb-pot chloride TIER 01
potassium bicarbonate oral
TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
34
Drug Name Drug Tier Notes
potassium chloride crys er
TIER 01
potassium chloride er TIER 01
potassium chloride oral TIER 01
potassium citrate er TIER 01
prenatal oral tablet 27-1 mg
PREVENT
PYRIDOXINE HCL SOLUTION 100 MG/ML INJECTION
TIER 03
pyridoxine hcl solution 100 mg/ml injection
TIER 01
saline bacteriostatic TIER 01
SALINE-PHENOL TIER 03
SAMSCA SPECIALTY QL
sod citrate-citric acid TIER 01
sodium chloride (pf) TIER 01
sodium chloride bacteriostatic
TIER 01
sodium chloride injection TIER 01
sodium fluoride oral TIER 01
sodium polystyrene sulfonate
TIER 01
sps TIER 01
TAURINE INJECTION TIER 03
thiamine hcl injection TIER 01
tolvaptan SPECIALTY QL
TRI-AMINO TIER 03
trientine hcl SPECIALTY PA
TRIFERIC HEMODIALYSIS PACKET
TIER 03
UROCIT-K 10 TIER 03
UROCIT-K 15 TIER 03
UROCIT-K 5 TIER 03
VELTASSA TIER 03
virt-phos 250 neutral TIER 01
vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)
TIER 01
vitamin k1 injection TIER 01
Drug Name Drug Tier Notes
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer
CARAFATE ORAL SUSPENSION
TIER 03
cimetidine hcl TIER 01
cimetidine oral TIER 01
CYTOTEC TIER 03
DEXILANT TIER 02
esomeprazole magnesium
TIER 01
famotidine oral suspension reconstituted
TIER 01
famotidine oral tablet 20 mg, 40 mg
TIER 01
FIRST-LANSOPRAZOLE
TIER 03 ST
FIRST-OMEPRAZOLE TIER 03 ST
lansoprazole oral TIER 01
misoprostol oral TIER 01
NEXIUM ORAL PACKET TIER 03
nizatidine TIER 01
omeprazole oral capsule delayed release
TIER 01
OMEPRAZOLE+SYRSPEND SF ALKA
TIER 03 ST
pantoprazole sodium oral packet
TIER 01 ST; QL
pantoprazole sodium oral tablet delayed release
TIER 01
PRILOSEC TIER 03 ST; QL
PROTONIX ORAL PACKET
TIER 03 ST; QL
rabeprazole sodium oral tablet delayed release
TIER 01
sucralfate oral TIER 01
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions
ACTIGALL TIER 03
alosetron hcl TIER 01 PA
amoxicill-clarithro-lansopraz
TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
35
Drug Name Drug Tier Notes
ANASPAZ TIER 03
ATROPEN TIER 03
atropine sulfate injection solution 8 mg/20ml
TIER 01
atropine sulfate injection solution prefilled syringe
TIER 01
BENTYL TIER 03
cascara sagrada oral fluid extract
TIER 01
CHENODAL SPECIALTY PA
chlordiazepoxide-clidinium
TIER 01
CLENPIQ TIER 03
constulose TIER 01
cromolyn sodium oral TIER 01
CUVPOSA TIER 03
dicyclomine hcl intramuscular
TIER 01
dicyclomine hcl oral TIER 01
diphenoxylate-atropine TIER 01
ed-spaz TIER 01
ENTEREG TIER 03
enulose TIER 01
GASTROCROM TIER 03
GATTEX SPECIALTY PA
gavilyte-c TIER 01
gavilyte-g TIER 01
gavilyte-h TIER 01
gavilyte-n with flavor pack
TIER 01
generlac TIER 01
glycopyrrolate injection solution
TIER 01
GLYCOPYRROLATE INJECTION SOLUTION PREFILLED SYRINGE
TIER 03
glycopyrrolate oral tablet 1 mg, 2 mg
TIER 01
glycopyrrolate pf TIER 01
GLYRX-PF TIER 03
HELIDAC THERAPY TIER 03
hyoscyamine sulfate oral TIER 01
Drug Name Drug Tier Notes
hyoscyamine sulfate sl TIER 01
hyoscyamine sulfate sublingual
TIER 01
hyosyne TIER 01
lactulose TIER 01
lactulose encephalopathy
TIER 01
LINZESS TIER 02 ST; QL
LOMOTIL TIER 03
loperamide hcl oral capsule
TIER 01
methscopolamine bromide oral
TIER 01
mineral oil heavy oral TIER 01
MOTEGRITY TIER 03 ST; QL
MYTESI TIER 03 QL
nulev TIER 01
OMECLAMOX-PAK TIER 02
oscimin TIER 01
OSMOPREP TIER 03
peg 3350-kcl-na bicarb-nacl
TIER 01
peg-3350/electrolytes TIER 01
peg-prep TIER 01
phenobarbital-belladonna alk
TIER 01
PLENVU TIER 03
propantheline bromide oral
TIER 01
PYLERA TIER 02
RESTORA RX TIER 03
SEROSTIM SPECIALTY PA
sodium bicarbonate oral powder
TIER 01
SUPREP BOWEL PREP KIT
TIER 03
SYMPROIC SPECIALTY ST; QL
TALICIA TIER 03
trilyte TIER 01
URSO 250 TIER 03
URSO FORTE TIER 03
ursodiol oral TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
36
Drug Name Drug Tier Notes
VIBERZI TIER 03 PA
XERMELO SPECIALTY PA
ZELNORM TIER 03
ZORBTIVE SPECIALTY PA
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment
BRINEURA SPECIALTY PA
BUPHENYL SPECIALTY
CERDELGA SPECIALTY PA
CHOLBAM SPECIALTY PA
CREON TIER 02
CRYSVITA SPECIALTY PA
CYSTADANE SPECIALTY
CYSTAGON SPECIALTY
GALAFOLD SPECIALTY PA
KUVAN SPECIALTY PA
miglustat SPECIALTY PA
MYALEPT SPECIALTY PA
nitisinone SPECIALTY PA
NITYR SPECIALTY PA
OCALIVA SPECIALTY PA
ORFADIN SPECIALTY PA
PALYNZIQ SPECIALTY PA
PROCYSBI SPECIALTY PA
RAVICTI SPECIALTY PA
REVCOVI SPECIALTY PA
sodium phenylbutyrate oral
SPECIALTY
STRENSIQ SPECIALTY PA
SUCRAID SPECIALTY
XURIDEN SPECIALTY PA
ZAVESCA SPECIALTY PA
ZENPEP TIER 02
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions
AURYXIA TIER 03
Drug Name Drug Tier Notes
bethanechol chloride oral TIER 01
calcium acetate (phos binder)
TIER 01
calcium acetate oral tablet 667 mg
TIER 01
CUPRIMINE SPECIALTY PA
darifenacin hydrobromide er
TIER 01
DEPEN TITRATABS SPECIALTY
DETROL TIER 03
DETROL LA TIER 03
DITROPAN XL TIER 03
ELMIRON TIER 02
ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 7.5 MG
TIER 03
flavoxate hcl TIER 01
FOSRENOL TIER 03
GELNIQUE TIER 03 ST
INTRAROSA TIER 03
lanthanum carbonate TIER 01
LITHOSTAT TIER 03
MUSE TIER 03 QL
MYRBETRIQ TIER 02
oxybutynin chloride er TIER 01
oxybutynin chloride oral TIER 01
OXYTROL TIER 03 ST; QL
penicillamine oral capsule
SPECIALTY PA
penicillamine oral tablet SPECIALTY
phenazo oral tablet 200 mg
TIER 01
phenazopyridine hcl oral tablet 100 mg, 200 mg
TIER 01
PHOSLYRA TIER 03
RIMSO-50 TIER 03
sevelamer carbonate TIER 01
sevelamer hcl TIER 01
sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg
TIER 01 QL
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
37
Drug Name Drug Tier Notes
solifenacin succinate TIER 01
tadalafil oral TIER 01 QL
THIOLA SPECIALTY
THIOLA EC SPECIALTY
tolterodine tartrate TIER 01
tolterodine tartrate er TIER 01
TOVIAZ TIER 03
trospium chloride TIER 01
trospium chloride er TIER 01
uretron d/s TIER 01
urin ds TIER 01
utrona-c TIER 01
vardenafil hcl oral TIER 01 QL
VELPHORO TIER 03
Genitourinary Agents - Drugs for Prostate Conditions
alfuzosin hcl er TIER 01
CARDURA XL TIER 03 ST
dutasteride oral TIER 01
dutasteride-tamsulosin hcl
TIER 01
finasteride oral tablet 5 mg
TIER 01
JALYN TIER 03
PROSCAR TIER 03
RAPAFLO TIER 03
silodosin TIER 01
tamsulosin hcl PREVENT
terazosin hcl TIER 01
Hormonal Agents - Adrenal
betamethasone sod phos & acet injection suspension 6 (3-3) mg/ml
TIER 01
CELESTONE SOLUSPAN
TIER 03
cortisone acetate oral TIER 01
DEPO-MEDROL TIER 03
DEXAMETHASONE (LA) TIER 03
dexamethasone intensol TIER 01
Drug Name Drug Tier Notes
dexamethasone oral TIER 01
dexamethasone sod phosphate pf
TIER 01
dexamethasone sodium phosphate injection
TIER 01
DEXONTO 0.4% TIER 03
fludrocortisone acetate oral
TIER 01
hydrocortisone oral TIER 01
KENALOG INJECTION SUSPENSION 10 MG/ML
TIER 03
KENALOG-80 TIER 03
MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG
TIER 03
MEDROL ORAL TABLET 2 MG
TIER 02
MEDROL ORAL TABLET THERAPY PACK
TIER 03
METHYLPREDNISOLONE ACETATE INJECTION SUSPENSION 50 MG/ML
TIER 03
methylprednisolone acetate suspension 40 mg/ml injection
TIER 01
METHYLPREDNISOLONE ACETATE SUSPENSION 40 MG/ML INJECTION
TIER 03
methylprednisolone acetate suspension 80 mg/ml injection
TIER 01
METHYLPREDNISOLONE ACETATE SUSPENSION 80 MG/ML INJECTION
TIER 03
methylprednisolone oral TIER 01
methylprednisolone sodium succ
TIER 01
METHYLPREDNISOLONE-BUPIVACAINE
TIER 03
MILLIPRED TIER 02
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
38
Drug Name Drug Tier Notes
MILLIPRED DP 12-DAY TIER 03
ORAPRED ODT TIER 03
PEDIAPRED TIER 03
prednisolone oral solution
TIER 01
prednisolone sodium phosphate oral
TIER 01
prednisone intensol TIER 01
prednisone oral TIER 01
SOLU-CORTEF TIER 03
SOLU-MEDROL TIER 03
TRIAMCINOLONE ACETONIDE SUSPENSION 40 MG/ML INJECTION
TIER 03
triamcinolone acetonide suspension 40 mg/ml injection
TIER 01
TRIAMCINOLONE DIACETATE INJECTION SUSPENSION 80 MG/ML
TIER 03
TRIAMCINOLONE-BUPIVACAINE
TIER 03
Hormonal Agents - Men's Health
ANADROL-50 TIER 03 PA
ANDRODERM TIER 02 PA
danazol oral TIER 01
METHITEST TIER 03 PA
methyltestosterone oral TIER 01 PA
NATESTO TIER 03 PA
oxandrolone oral TIER 01 PA; QL
testosterone cypionate intramuscular
TIER 01 PA
testosterone enanthate intramuscular
TIER 01 PA
testosterone transdermal TIER 01 PA
XYOSTED TIER 03 PA
Hormonal Agents - Osteoporosis
EVISTA TIER 03
OSPHENA TIER 03
Drug Name Drug Tier Notes
raloxifene hcl TIER 01
Hormonal Agents - Pituitary
ACTHAR SPECIALTY PA
cabergoline TIER 01
chorionic gonadotropin intramuscular
SPECIALTY
clomiphene citrate oral TIER 01
DDAVP TIER 03
DDAVP RHINAL TUBE TIER 02
desmopressin ace spray refrig
TIER 01
desmopressin acetate injection
TIER 01
desmopressin acetate oral
TIER 01
desmopressin acetate spray
TIER 01
EGRIFTA SV SPECIALTY PA; QL
ELIGARD SUBCUTANEOUS KIT 22.5 MG, 45 MG
SPECIALTY PA; QL
ELIGARD SUBCUTANEOUS KIT 30 MG
SPECIALTY PA
ELIGARD SUBCUTANEOUS KIT 7.5 MG
SPECIALTY QL
FIRMAGON SPECIALTY PA; QL
FIRMAGON (240 MG DOSE)
SPECIALTY PA; QL
FOLLISTIM AQ SPECIALTY
ganirelix acetate SPECIALTY
INCRELEX SPECIALTY PA
leuprolide acetate injection
SPECIALTY
LEUPROLIDE ACETATE-BUPIVACAINE
TIER 03
LUPANETA PACK SPECIALTY PA; QL
LUPRON DEPOT (1-MONTH)
SPECIALTY
LUPRON DEPOT (3-MONTH)
SPECIALTY PA
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
39
Drug Name Drug Tier Notes
LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG
SPECIALTY PA
LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG
SPECIALTY PA
LUPRON DEPOT-PED (1-MONTH)
SPECIALTY PA
LUPRON DEPOT-PED (3-MONTH)
SPECIALTY PA
MENOPUR SPECIALTY
NOCDURNA TIER 03
NORDITROPIN FLEXPRO
SPECIALTY PA
novarel intramuscular solution reconstituted 10000 unit
SPECIALTY
NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT
SPECIALTY
NUTROPIN AQ NUSPIN 10
SPECIALTY PA
NUTROPIN AQ NUSPIN 20
SPECIALTY PA
NUTROPIN AQ NUSPIN 5
SPECIALTY PA
octreotide acetate SPECIALTY PA
ORILISSA TIER 02 PA
OVIDREL SPECIALTY
oxytocin injection TIER 01
PITOCIN TIER 03
pregnyl SPECIALTY
SIGNIFOR SPECIALTY PA
SIGNIFOR LAR SPECIALTY PA
SOMATULINE DEPOT SPECIALTY PA
SOMAVERT SPECIALTY PA
STIMATE SPECIALTY
SUPPRELIN LA SPECIALTY PA; QL
SYNAREL SPECIALTY
TRELSTAR MIXJECT SPECIALTY PA; QL
Drug Name Drug Tier Notes
TRIPTODUR SPECIALTY PA; QL
VANTAS SPECIALTY PA; QL
ZOLADEX SPECIALTY QL
Hormonal Agents - Prostaglandins
KORLYM SPECIALTY PA
Hormonal Agents - Sex Hormones and Birth Control
ACTIVELLA TIER 03
afirmelle TIER 01
ALORA TIER 03
altavera TIER 01
alyacen 1/35 TIER 01
alyacen 7/7/7 TIER 01
amabelz TIER 01
amethia TIER 01 QL
amethia lo TIER 01 QL
amethyst TIER 01
ANGELIQ TIER 03
apri TIER 01
aranelle TIER 01
ashlyna TIER 01 QL
aubra TIER 01
aubra eq TIER 01
aurovela 1.5/30 TIER 01
aurovela 1/20 TIER 01
aurovela 24 fe TIER 01
aurovela fe 1.5/30 TIER 01
aurovela fe 1/20 TIER 01
aviane TIER 01
AYGESTIN TIER 03
ayuna TIER 01
azurette TIER 01
balziva TIER 01
bekyree TIER 01
BIJUVA TIER 03
blisovi 24 fe TIER 01
blisovi fe 1.5/30 TIER 01
blisovi fe 1/20 TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
40
Drug Name Drug Tier Notes
briellyn TIER 01
camila TIER 01
camrese TIER 01 QL
camrese lo TIER 01 QL
caziant TIER 01
charlotte 24 fe TIER 01
chateal TIER 01
chateal eq TIER 01
CLIMARA PRO TIER 02
COMBIPATCH TIER 03
CRINONE TIER 03
cryselle-28 TIER 01
cyclafem 1/35 TIER 01
cyclafem 7/7/7 TIER 01
cyred TIER 01
cyred eq TIER 01
dasetta 1/35 TIER 01
dasetta 7/7/7 TIER 01
daysee TIER 01 QL
deblitane TIER 01
DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML
TIER 03
delyla TIER 01
DEPO-ESTRADIOL TIER 03
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML
TIER 03 QL
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML
TIER 03
DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE
TIER 03 QL
DEPO-SUBQ PROVERA 104
TIER 03 QL
desogestrel-ethinyl estradiol
TIER 01
DIVIGEL TIER 03
dotti TIER 01
Drug Name Drug Tier Notes
drospiren-eth estrad-levomefol
TIER 01
drospirenone-ethinyl estradiol
TIER 01
DUAVEE TIER 02
ELESTRIN TIER 03
elinest TIER 01
ELLA TIER 03
eluryng TIER 01
emoquette TIER 01
ENDOMETRIN TIER 02
enpresse-28 TIER 01
enskyce TIER 01
errin TIER 01
estarylla TIER 01
estradiol oral TIER 01
estradiol transdermal TIER 01
estradiol vaginal TIER 01
estradiol valerate intramuscular
TIER 01
estradiol-norethindrone acet
TIER 01
ESTRING TIER 03 QL
ESTROGEL TIER 03
ESTROSTEP FE TIER 03
ethynodiol diac-eth estradiol
TIER 01
etonogestrel-ethinyl estradiol
TIER 01
EVAMIST TIER 03
falmina TIER 01
fayosim TIER 01 QL
FEMHRT LOW DOSE TIER 03
FEMRING TIER 03 QL
femynor TIER 01
fyavolv TIER 01
gianvi TIER 01
hailey 1.5/30 TIER 01
hailey 24 fe TIER 01
hailey fe 1.5/30 TIER 01
hailey fe 1/20 TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
41
Drug Name Drug Tier Notes
heather TIER 01
hydroxyprogesterone caproate intramuscular oil
SPECIALTY
hydroxyprogesterone caproate intramuscular solution
SPECIALTY PA
IMVEXXY MAINTENANCE PACK
TIER 03
IMVEXXY STARTER PACK
TIER 03
incassia TIER 01
introvale TIER 01 QL
isibloom TIER 01
jaimiess TIER 01 QL
jasmiel TIER 01
jencycla TIER 01
jinteli TIER 01
jolessa TIER 01 QL
juleber TIER 01
junel 1.5/30 TIER 01
junel 1/20 TIER 01
junel fe 1.5/30 TIER 01
junel fe 1/20 TIER 01
junel fe 24 TIER 01
kaitlib fe TIER 01
kalliga TIER 01
kariva TIER 01
kelnor 1/35 TIER 01
kelnor 1/50 TIER 01
kurvelo TIER 01
larin 1.5/30 TIER 01
larin 1/20 TIER 01
larin 24 fe TIER 01
larin fe 1.5/30 TIER 01
larin fe 1/20 TIER 01
larissia TIER 01
layolis fe TIER 01
leena TIER 01
lessina TIER 01
levonest TIER 01
Drug Name Drug Tier Notes
levonorgest-eth est & eth est
TIER 01 QL
levonorgest-eth estrad 91-day
TIER 01 QL
levonorgestrel-ethinyl estrad
TIER 01
levonorg-eth estrad triphasic
TIER 01
levora 0.15/30 (28) TIER 01
lillow TIER 01
lojaimiess TIER 01 QL
lopreeza TIER 01
loryna TIER 01
LOSEASONIQUE TIER 03 QL
low-ogestrel TIER 01
lo-zumandimine TIER 01
lutera TIER 01
lyza TIER 01
MAKENA SPECIALTY
marlissa TIER 01
medroxyprogesterone acetate intramuscular
TIER 01 QL
medroxyprogesterone acetate oral
TIER 01
megestrol acetate oral TIER 01
melodetta 24 fe TIER 01
MENEST TIER 02
MENOSTAR TIER 03
mibelas 24 fe TIER 01
microgestin 1.5/30 TIER 01
microgestin 1/20 TIER 01
microgestin fe 1.5/30 TIER 01
microgestin fe 1/20 TIER 01
mili TIER 01
mimvey TIER 01
MINIVELLE TIER 03
MIRCETTE TIER 03
mono-linyah TIER 01
NATAZIA TIER 02
necon 0.5/35 (28) TIER 01
nikki TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
42
Drug Name Drug Tier Notes
nora-be TIER 01
norethin ace-eth estrad-fe
TIER 01
norethindrone acetate oral
TIER 01
norethindrone acet-ethinyl est
TIER 01
norethindrone oral TIER 01
norethindrone-eth estradiol
TIER 01
norethin-eth estradiol-fe TIER 01
norgestimate-eth estradiol
TIER 01
norgestimate-ethinyl estradiol triphasic
TIER 01
norlyda TIER 01
norlyroc TIER 01
nortrel 0.5/35 (28) TIER 01
nortrel 1/35 (21) TIER 01
nortrel 1/35 (28) TIER 01
nortrel 7/7/7 TIER 01
NUVARING TIER 03
ocella TIER 01
orsythia TIER 01
philith TIER 01
pimtrea TIER 01
pirmella 1/35 TIER 01
pirmella 7/7/7 TIER 01
portia-28 TIER 01
PREFEST TIER 03
PREMARIN INJECTION TIER 03
PREMARIN ORAL TIER 02
PREMARIN VAGINAL TIER 02
PREMPHASE TIER 02
PREMPRO TIER 02
previfem TIER 01
progesterone intramuscular
TIER 01
progesterone micronized oral
TIER 01
PROVERA TIER 03
QUARTETTE TIER 03 QL
Drug Name Drug Tier Notes
reclipsen TIER 01
rivelsa TIER 01 QL
setlakin TIER 01 QL
sharobel TIER 01
simliya TIER 01
simpesse TIER 01 QL
sprintec 28 TIER 01
sronyx TIER 01
syeda TIER 01
tarina 24 fe TIER 01
tarina fe 1/20 TIER 01
tarina fe 1/20 eq TIER 01
tilia fe TIER 01
tri femynor TIER 01
tri-estarylla TIER 01
tri-legest fe TIER 01
tri-linyah TIER 01
tri-lo-estarylla TIER 01
tri-lo-marzia TIER 01
tri-lo-mili TIER 01
tri-lo-sprintec TIER 01
tri-mili TIER 01
tri-previfem TIER 01
tri-sprintec TIER 01
trivora (28) TIER 01
tri-vylibra TIER 01
tri-vylibra lo TIER 01
tulana TIER 01
tydemy TIER 01
velivet TIER 01
vienva TIER 01
viorele TIER 01
volnea TIER 01
vyfemla TIER 01
vylibra TIER 01
wera TIER 01
wymzya fe TIER 01
xulane TIER 01
yuvafem TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
43
Drug Name Drug Tier Notes
zarah TIER 01
zovia 1/35e (28) TIER 01
zumandimine TIER 01
Hormonal Agents - Thyroid
ARMOUR THYROID TIER 03 ST
euthyrox PREVENT
levo-t PREVENT
levothyroxine sodium oral
PREVENT
levoxyl PREVENT
liothyronine sodium oral TIER 01
methimazole oral PREVENT
NATURE-THROID TIER 03 ST
np thyroid TIER 01
propylthiouracil oral TIER 01
TAPAZOLE TIER 03
unithroid PREVENT
WESTHROID TIER 03 ST
WP THYROID TIER 03 ST
Immunological Agents - Drugs for Immune System Stimulation or Suppression
ACTEMRA ACTPEN SPECIALTY PA
ACTEMRA SUBCUTANEOUS
SPECIALTY PA
ACTIMMUNE SPECIALTY PA
ALFERON N SPECIALTY
ARCALYST SPECIALTY PA
ASTAGRAF XL TIER 02
AZASAN TIER 03
azathioprine oral TIER 01
azathioprine sodium TIER 01
BENLYSTA SUBCUTANEOUS
SPECIALTY PA
CELLCEPT SPECIALTY
CIMZIA SPECIALTY PA
CIMZIA PREFILLED KIT SPECIALTY PA
CIMZIA STARTER KIT SPECIALTY PA
Drug Name Drug Tier Notes
CUVITRU SPECIALTY PA
cyclosporine modified TIER 01
cyclosporine oral TIER 01
ENBREL SPECIALTY PA
ENBREL MINI SPECIALTY PA
ENBREL SURECLICK SPECIALTY PA
ENSPRYNG TIER 03
ENVARSUS XR TIER 02
everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg
SPECIALTY PA
FIRAZYR SPECIALTY PA
GAMASTAN SPECIALTY PA
GAMMAGARD SPECIALTY PA
GAMMAKED SPECIALTY PA
GAMUNEX-C SPECIALTY PA
gengraf TIER 01
HIZENTRA SPECIALTY PA
HUMIRA SPECIALTY PA
HUMIRA PEDIATRIC CROHNS START
SPECIALTY PA
HUMIRA PEN SPECIALTY PA
HUMIRA PEN-CD/UC/HS STARTER
SPECIALTY PA
HUMIRA PEN-PS/UV/ADOL HS START
SPECIALTY PA
HYPERRHO S/D SPECIALTY
HYQVIA SPECIALTY PA
icatibant acetate SPECIALTY PA
ILARIS SPECIALTY PA
ILUMYA SPECIALTY PA
IMURAN TIER 03
KALBITOR SPECIALTY PA
KEVZARA SPECIALTY PA
KINERET SPECIALTY PA
leflunomide oral TIER 01
methotrexate (anti-rheumatic)
TIER 01
methotrexate oral TIER 01
methotrexate sodium TIER 01
methotrexate sodium (pf) TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
44
Drug Name Drug Tier Notes
MICRHOGAM ULTRA-FILTERED PLUS
SPECIALTY
mycophenolate mofetil SPECIALTY
mycophenolate sodium SPECIALTY
MYFORTIC SPECIALTY
NEORAL TIER 02
ORENCIA CLICKJECT SPECIALTY PA
ORENCIA SUBCUTANEOUS
SPECIALTY PA
OTEZLA SPECIALTY PA
OTREXUP SPECIALTY PA
PROGRAF ORAL TIER 02
RAPAMUNE SPECIALTY
RASUVO SPECIALTY PA
RHOGAM ULTRA-FILTERED PLUS
SPECIALTY
RHOPHYLAC TIER 02
RIDAURA SPECIALTY
RINVOQ SPECIALTY PA
SANDIMMUNE ORAL TIER 02
SILIQ SPECIALTY PA
SIMPONI SPECIALTY PA
sirolimus oral SPECIALTY
SKYRIZI (150 MG DOSE)
SPECIALTY PA
STELARA SUBCUTANEOUS
SPECIALTY PA
SYNAGIS SPECIALTY PA
tacrolimus oral TIER 01
TAKHZYRO SPECIALTY PA
TALTZ SPECIALTY PA
TICE BCG SPECIALTY
TREMFYA SPECIALTY PA
TREXALL TIER 03
WINRHO SDF SPECIALTY
XATMEP SPECIALTY
XELJANZ SPECIALTY PA
XELJANZ XR SPECIALTY PA
XEMBIFY SPECIALTY PA
ZORTRESS SPECIALTY PA
Drug Name Drug Tier Notes
Inflammatory Bowel Disease Agents
ANALPRAM-HC EXTERNAL CREAM
TIER 03
ANUSOL-HC EXTERNAL
TIER 03
APRISO TIER 02
AZULFIDINE TIER 03
AZULFIDINE EN-TABS TIER 03
balsalazide disodium TIER 01
budesonide er TIER 01
budesonide oral TIER 01
CORTENEMA TIER 03
CORTIFOAM TIER 03
ENTOCORT EC TIER 03
hydrocortisone (perianal) TIER 01
hydrocortisone ace-pramoxine external cream 1-1 %
TIER 01
hydrocortisone rectal TIER 01
mesalamine er TIER 01
mesalamine oral TIER 01
mesalamine rectal TIER 01
mesalamine-cleanser TIER 01
PENTASA TIER 03
PROCTOFOAM HC TIER 02
procto-med hc TIER 01
procto-pak TIER 01
proctosol hc TIER 01
proctozone-hc TIER 01
ROWASA TIER 03
SFROWASA TIER 02
sulfasalazine oral TIER 01
UCERIS RECTAL TIER 03
Metabolic Bone Disease Agents - Drugs for Osteoporosis
ACTONEL ORAL TABLET 150 MG, 35 MG
TIER 03 QL
ACTONEL ORAL TABLET 30 MG, 5 MG
TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
45
Drug Name Drug Tier Notes
alendronate sodium oral solution
TIER 01
alendronate sodium oral tablet 10 mg, 5 mg
PREVENT
alendronate sodium oral tablet 35 mg, 70 mg
PREVENT QL
ATELVIA TIER 03 QL
BINOSTO TIER 03 QL
BONIVA ORAL TIER 03 QL
calcitonin (salmon) TIER 01 QL
EVENITY SPECIALTY PA
FORTEO SPECIALTY PA
FOSAMAX TIER 03 QL
FOSAMAX PLUS D TIER 03 QL
ibandronate sodium oral PREVENT QL
MIACALCIN INJECTION TIER 03
PROLIA SPECIALTY PA
RAYALDEE TIER 03
risedronate sodium oral tablet 150 mg, 35 mg
TIER 01 QL
risedronate sodium oral tablet 30 mg, 5 mg
TIER 01
risedronate sodium oral tablet delayed release
TIER 01 QL
TYMLOS SPECIALTY PA
XGEVA SPECIALTY PA
Metabolic Bone Disease Agents - Other
calcitriol oral TIER 01
cinacalcet hcl SPECIALTY PA
doxercalciferol oral TIER 01
NATPARA SPECIALTY PA
paricalcitol oral SPECIALTY
ROCALTROL TIER 03
ZEMPLAR ORAL SPECIALTY
Miscellaneous Therapeutic Agents
ACCU-CHEK TENDER 1 INFUSION
TIER 03
ACTIFOAM COLLAGEN SPONGE
TIER 03
Drug Name Drug Tier Notes
AEROGEAR ACTION ASTHMA KIT
TIER 03
AIRS PEDIATRIC AEROSOL MASK
TIER 03
ALCOHOL PREP PADS PAD
TIER 03
ALCOHOL PREP PADS PAD 70 %
TIER 03
ALL FLOW 1000 PFT FILTER DEVICE
TIER 03
ALPHA-LIPOIC ACID INJECTION
TIER 03
AMD FOAM DRESSING TIER 03
AMD FOAM DRESSING TOPSHEET
TIER 03
AMPHADASE TIER 03
arnica flower TIER 01
ARTISS TIER 03
ASTHMAPACK III TIER 03
AURA PORTANEB TIER 03
AVITENE TIER 03
AVITENE FLOUR TIER 03
BACTERIOSTATIC WATER(BENZ ALC)
TIER 03
bal in oil TIER 01
BENTLEY THE BEAR PED NEBULIZER
TIER 03
BIOGUARD GAUZE SPONGES PAD 4"X4"
TIER 03
BIOGUARD ISLAND DRESSINGS
TIER 03
BIOGUARD NON-ADHERENT DRESSING
TIER 03
BOTOX SPECIALTY PA
BREATHE EASE LARGE
TIER 02
BREATHE EASE MEDIUM
TIER 02
BREATHE EASE NEB MASK/CHILD
TIER 03
BREATHE EASE NEB MASK/INFANT
TIER 03
BREATHE EASE SMALL TIER 02
BREATHERITE TIER 02
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
46
Drug Name Drug Tier Notes
BREATHERITE VALVED MDI CHAMBER
TIER 03
CALCIUM DISODIUM VERSENATE
TIER 03
CAPTAIN EAGLE PED NEBULIZER
TIER 03
CARETOUCH 2 CPAP HOSE HANGER
TIER 03
CARETOUCH CPAP & BIPAP HOSE
TIER 03
CARETOUCH CPAP MASK WIPES
TIER 03
CARETOUCH CPAP PRE-WASH SOLN
TIER 03
CARETOUCH CPAP TUBE BRUSH
TIER 03
CARETOUCH UNIVERSL CPAP FILTER
TIER 03
CEFALY KIT TIER 03
CHEMOPLUS LATEX GLOVES
TIER 03
CHEMOPLUS NEOPRENE GLOVE
TIER 03
CHLORHEXIDINE GLUCONATE SOLUTION 20 %
TIER 03
CLEVER CHOICE HOLDING CHAMBER
TIER 02
CLEVER CHOICE TENS UNIT
TIER 03
CLEVER CHOICE WHIS AIR PED NEB
TIER 03
CLEVER CHOICE WHISPER AIRE NEB
TIER 03
COAGUCHEK XS SYSTEM
TIER 03
COATAMAX PATCH TIER 03
COMP A-I-R NEBULIZER
TIER 03
COMPACT SPACE CHAMBER/LG MASK
TIER 02
COMPACT SPACE CHAMBER/MED MASK
TIER 02
Drug Name Drug Tier Notes
COMPACT SPACE CHAMBER/SM MASK
TIER 02
CONCEPTION KIT TIER 03
CURITY AMD ANTIMICROBIAL SPNGE PAD 4"X4"
TIER 03
CURITY AMD ANTIMICROBIAL STRIP
TIER 03
CURITY IODOFORM PACKING STRIP
TIER 03
CYTOTINE ORAL POWDER
TIER 03
deferoxamine mesylate TIER 01
DEFLUX TIER 03
DENTAL NEEDLE TIER 03
DESFERAL TIER 03
DOVER URETHRAL CATHETER
TIER 03
DUODOTE TIER 03
DYSPORT SPECIALTY PA
EASIVENT TIER 02
EMBRACE SEIZURE MONITORING SYS
TIER 03
EMJOI TENS TIER 03
ENDARI SPECIALTY PA
ENDO AVITENE TIER 03
ENEMA BOTTLE TIER 03
ENTRISTAR PEG ENTERAL CONNECT
TIER 03
EPISIL TIER 03
ergoloid mesylates oral TIER 01
EROS-CTD TIER 03
EXACTA-MED ORAL SYRINGE 5ML
TIER 03
EXCILON AMD DRAIN SPONGES
TIER 03
FACE MASK EARLOOP-STYLE
TIER 03
FACE MASK RESP N-100 PART
TIER 03
FACE MASK RESPIRATOR R-95 PART
TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
47
Drug Name Drug Tier Notes
FLEXICHAMBER ADULT MASK/SMALL
TIER 02
FLEXICHAMBER CHILD MASK/LARGE
TIER 02
FLEXICHAMBER CHILD MASK/SMALL
TIER 02
FLYP NEBULIZER TIER 03
FORA D40G GLUCOSE/PRESSURE
TIER 03
formaldehyde external solution 37 %
TIER 01
GAMMACORE TIER 03
GAMMACORE SAPPHIRE 31-DAY
TIER 03
GAMMACORE SAPPHIRE REFILL KIT
TIER 03
GELFILM EXTERNAL TIER 03
GEL-FLOW NT TIER 03
GELFOAM TIER 03
GELFOAM COMPRESSED SIZE 100
TIER 03
GELFOAM DENTAL PACK SIZE 4
TIER 03
GELFOAM SPONGE TIER 03
GELFOAM SPONGE SIZE 100
TIER 03
GELFOAM SPONGE SIZE 200
TIER 03
GELFOAM SPONGE SIZE 50
TIER 03
GELX TIER 03
GIVLAARI SPECIALTY PA
glutaraldehyde external TIER 01
HISTOACRYL TIER 03
HYLENEX TIER 03
INFED TIER 03
INSPIREASE RESERVOIR BAGS
TIER 02
INSTAT TIER 03
INSUFLON TIER 03
INTERCEED TIER 03
INTERCEED (TC7) TIER 03
Drug Name Drug Tier Notes
IV ADMINISTRATION SET
TIER 03
IV EXTENSION SET TIER 03
J-TIP KIT W/VIAL ADAPTERS
TIER 03
KANGAROO BALLOON 20FR/3.5CM
TIER 03
KANGAROO GASTROSTOMY TUBE
TIER 03
KANGAROO GRAVITY FEEDING BAG
TIER 03
KANGAROO JOEY ENTERAL PUMP
TIER 03
KANGAROO MULTI-FUNCTIONAL PORT
TIER 03
KANGAROO STOMA MEASURING DEV
TIER 03
KARAYA GUM POWDER
TIER 03
KENDALL SCD EXPRESS FOOT CUFF
TIER 03
KERLIX AMD ANTIMICROBIAL
TIER 03
KERLIX AMD SUPER SPONGES
TIER 03
LATEX GLOVES MEDIUM
TIER 03
LOOP TIER 03
MASK VORTEX TIER 02
MEDICAL COMPRESSION STOCKINGS
TIER 03
methergine TIER 01
methylergonovine maleate
TIER 01
MICROAIR VIBRATING MESH NEBUL
TIER 03
MICROCHAMBER DEVICE
TIER 02
MICRONEB TIER 03
MONARCH ETNS SYSTEM
TIER 03
MUCOTROL TIER 03
MUGARD TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
48
Drug Name Drug Tier Notes
MYOBLOC SPECIALTY PA
NEB-RITE4 TIER 03
NEBULIZER PED FROG TIER 03
NEBULIZER PED FROG KIT
TIER 03
NEBULIZER SYSTEM ALL-IN-ONE
TIER 03
NEOKE RA LIPOIC TIER 03
NERIVIO TIER 03
NEXAVIR TIER 03
NITRILE GLOVES LARGE
TIER 03
NORDIPEN 5 INJECTION DEVICE
TIER 03
NORM-JECT LUER SLIP SYRINGE
TIER 03
NOZIN NASAL SANITIZER POPSWAB
TIER 03
NS-2 ELECTRIC PATCH POUCH
TIER 03
OMNIPOD DASH 5 PACK PODS
TIER 03
ONE FLOW SPIROMETER DEVICE
TIER 03
ORAMAGICRX TIER 03
ORAPEUTIC TIER 03
PAIN RELIEF WITH TENS S2000
TIER 03
PANDA MASK LARGE TIER 02
PANDA MASK MEDIUM TIER 02
PANDA MASK SMALL TIER 02
PARI ALTERA NEBULIZER HANDSET
TIER 03
PARI MASK SET TIER 03
PARI TREK S COMBO PACK
TIER 03
PEDIATRIC PANDA MASK
TIER 02
PENTETATE CALCIUM TRISODIUM
TIER 03
PENTETATE ZINC TRISODIUM
TIER 03
PHOTREXA VISCOUS TIER 03
Drug Name Drug Tier Notes
PHOTREXA-PHOTREXA VISCOUS KIT
TIER 03
pocket spacer TIER 01
POLYTOZA PATCH TIER 03
POWDER FREE NITRILE GLOVES SM
TIER 03
pralidoxime chloride intramuscular
TIER 01
PRO COMFORT SPACER ADULT
TIER 02
PRO COMFORT SPACER CHILD
TIER 02
PRO COMFORT SPACER INFANT
TIER 02
PRO COMFORT TENS UNIT
TIER 03
PROCARE SPACER/ADULT MASK
TIER 02
PROCARE SPACER/CHILD MASK
TIER 02
PROVENT SLEEP APNEA THERAPY
TIER 03
PROVENT SR SLEEP APNEA THERAPY
TIER 03
RADIOGARDASE SPECIALTY
RAPPORT RLS TIER 03
RAPPORT VTD TIER 03
RUSCH FLOCATH QUICK 16FR
TIER 03
RUZURGI SPECIALTY PA
SALICEPT TIER 03
SAVI TIER 03
SHARPS CONTAINER TIER 03
SIDESTREAM ADULT FACE MASK
TIER 03
SIDESTREAM PEDIATRIC FACE MASK
TIER 03
sodium saccharin powder
TIER 01
SOLESTA SPECIALTY
SPARKY THE DOG PED NEBULIZER
TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
49
Drug Name Drug Tier Notes
sterile water for injection injection
TIER 01
SURGICEL FIBRILLAR TIER 03
SURGICEL NU-KNIT TIER 03
SYRINGE AVITENE TIER 03
SYRINGE LUER LOCK 30 ML
TIER 03
SYRINGE LUER SLIP 1 ML
TIER 03
SYRINGE PRECISEDOSE DISPENSER
TIER 03
TACHOSIL TIER 03
TELFA AMD ISLAND DRESSING
TIER 03
TELFA AMD NON-ADHERENT
TIER 03
THROMBI-GEL 10 TIER 03
THROMBI-GEL 100 TIER 03
THROMBI-GEL 40 TIER 03
THROMBI-PAD TIER 03
TISSEEL TIER 03
TRUZONE PEAK FLOW METER
TIER 03
ULTRAFOAM SPONGE 2X6.25X7CM
TIER 03
ULTRAFOAM SPONGE 8X12.5X1CM
TIER 03
ULTRAFOAM SPONGE 8X12.5X3CM
TIER 03
ULTRAFOAM SPONGE 8X25X1CM
TIER 03
ULTRAFOAM SPONGE 8X6.25X1CM
TIER 03
VAPRO PLUS CATHETER 12FR/8"
TIER 03
VAPRO PLUS CATHETER 14FR/8"
TIER 03
VISTOGARD TIER 03
VITRASE TIER 03
VORTEX HOLDING CHAMBER/MASK
TIER 03
XEOMIN SPECIALTY PA
XIAFLEX SPECIALTY PA
Drug Name Drug Tier Notes
ZEWA DIGITAL TENS UNIT
TIER 03
ZEWA TENS/EMS COMBO UNIT
TIER 03
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation
ACULAR TIER 03
ACULAR LS TIER 03
ALOMIDE TIER 03
AZASITE TIER 03
azelastine hcl ophthalmic TIER 01
BACIGUENT OPHTHALMIC OINTMENT 500 UNIT/GM
TIER 02
bacitracin ophthalmic TIER 01
BEPREVE TIER 03 ST
BESIVANCE TIER 03
BETADINE OPHTHALMIC PREP
TIER 03
BLEPH-10 TIER 03
bromfenac sodium (once-daily)
TIER 01 QL
CILOXAN TIER 03
ciprofloxacin hcl ophthalmic
TIER 01
cromolyn sodium ophthalmic
TIER 01
dexamethasone sodium phosphate ophthalmic
TIER 01
diclofenac sodium ophthalmic
TIER 01
epinastine hcl TIER 01
erythromycin ophthalmic TIER 01
FLAREX TIER 03
fluorometholone TIER 01
flurbiprofen sodium TIER 01
FML TIER 02
FML FORTE TIER 03
FML LIQUIFILM TIER 03
gatifloxacin ophthalmic TIER 01
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
50
Drug Name Drug Tier Notes
gentak TIER 01
gentamicin sulfate ophthalmic
TIER 01
INVELTYS TIER 03
ketorolac tromethamine ophthalmic
TIER 01
levofloxacin ophthalmic TIER 01
LOTEMAX SM TIER 03
loteprednol etabonate TIER 01
MAXIDEX TIER 03
MITOSOL TIER 03
MOXEZA TIER 02
moxifloxacin hcl (2x day) TIER 01
moxifloxacin hcl ophthalmic
TIER 01
NATACYN TIER 02
OCUFLOX TIER 03
ofloxacin ophthalmic TIER 01
olopatadine hcl ophthalmic
TIER 01
OZURDEX SPECIALTY
POVIDONE-IODINE OPHTHALMIC
TIER 03
PRED MILD TIER 03
prednisolone acetate ophthalmic
TIER 01
prednisolone sodium phosphate ophthalmic
TIER 01
PROLENSA TIER 02 QL
sulfacetamide sodium ophthalmic
TIER 01
tobramycin ophthalmic TIER 01
TOBREX TIER 03
trifluridine TIER 01
ZIRGAN TIER 03
ZYMAXID TIER 03
Ophthalmic Agents - Drugs for Glaucoma
acetazolamide er TIER 01
acetazolamide oral TIER 01
Drug Name Drug Tier Notes
ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %
TIER 02
apraclonidine hcl TIER 01
AZOPT TIER 02
betaxolol hcl ophthalmic TIER 01
BETIMOL TIER 03
BETOPTIC-S TIER 03
bimatoprost ophthalmic TIER 01 QL
brimonidine tartrate ophthalmic
PREVENT
carteolol hcl TIER 01
COMBIGAN TIER 02
dorzolamide hcl solution 2 % ophthalmic
TIER 01
DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC
TIER 03
dorzolamide hcl-timolol mal
TIER 01
dorzolamide hcl-timolol mal pf
TIER 01
IOPIDINE TIER 03
ISOPTO CARPINE TIER 03
ISTALOL TIER 03
KEVEYIS SPECIALTY PA
latanoprost ophthalmic PREVENT
levobunolol hcl TIER 01
LUMIGAN TIER 02 QL
methazolamide oral TIER 01
PHOSPHOLINE IODIDE TIER 02
pilocarpine hcl ophthalmic
TIER 01
RHOPRESSA TIER 02
ROCKLATAN TIER 02 QL
SIMBRINZA TIER 02
timolol maleate ophthalmic
PREVENT
TRAVATAN Z TIER 03 QL
travoprost (bak free) TIER 01 QL
TRUSOPT TIER 03
XELPROS TIER 03 ST; QL
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
51
Drug Name Drug Tier Notes
Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions
ak-poly-bac TIER 01
AKTEN TIER 03
ALCAINE TIER 03
altacaine TIER 01
altafrin TIER 01
atropine sulfate ophthalmic ointment
TIER 01
atropine sulfate ophthalmic solution 1 %
TIER 01
bacitracin-polymyxin b ophthalmic
TIER 01
bacitra-neomycin-polymyxin-hc
TIER 01
BLEPHAMIDE TIER 03
BLEPHAMIDE S.O.P. TIER 03
CYCLOGYL TIER 03
CYCLOMYDRIL TIER 03
cyclopentolate hcl ophthalmic
TIER 01
CYSTARAN SPECIALTY PA
EYLEA SPECIALTY
homatropaire TIER 01
ISOPTO ATROPINE TIER 03
LACRISERT TIER 03
LASTACAFT TIER 03 ST
LUCENTIS SPECIALTY
MAXITROL TIER 03
MEMBRANEBLUE TIER 03
neomycin-bacitracin zn-polymyx
TIER 01
neomycin-polymyxin-dexameth ophthalmic ointment
TIER 01
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1
TIER 01
neomycin-polymyxin-gramicidin
TIER 01
Drug Name Drug Tier Notes
neomycin-polymyxin-hc ophthalmic
TIER 01
neo-polycin TIER 01
neo-polycin hc TIER 01
OXERVATE SPECIALTY PA; QL
phenylephrine hcl ophthalmic
TIER 01
polycin TIER 01
polymyxin b-trimethoprim TIER 01
POLYTRIM TIER 03
PRED-G TIER 03
PRED-G S.O.P. TIER 03
proparacaine hcl ophthalmic
TIER 01
RESTASIS TIER 02 PA
RESTASIS MULTIDOSE TIER 02 PA
sulfacetamide-prednisolone ophthalmic solution
TIER 01
tetracaine hcl ophthalmic TIER 01
TOBRADEX OPHTHALMIC OINTMENT
TIER 03
TOBRADEX ST TIER 03
tobramycin-dexamethasone
TIER 01
TROPICAMIDE-CYCLOPENTOLATE-PE
TIER 03
VISIONBLUE TIER 03
XIIDRA TIER 02 PA
ZYLET TIER 03
Otic Agents - Drugs for Ear Conditions
acetic acid otic TIER 01
CETRAXAL TIER 03
CIPRO HC TIER 03
CIPRODEX TIER 03
ciprofloxacin hcl otic TIER 01
ciprofloxacin-dexamethasone
TIER 01
cortic-nd TIER 01
DERMOTIC TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
52
Drug Name Drug Tier Notes
exotic-hc TIER 01
flac TIER 01
fluocinolone acetonide otic
TIER 01
hydrocortisone-acetic acid
TIER 01
neomycin-polymyxin-hc otic
TIER 01
ofloxacin otic TIER 01
OTICIN HC NR TIER 03
PRAMOTIC TIER 03
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold
azelastine hcl nasal TIER 01 QL
azelastine-fluticasone TIER 01
BECONASE AQ TIER 03 QL
benzonatate TIER 01
bromfed dm TIER 01
brompheniramine tannate
TIER 01
carbinoxamine maleate TIER 01
cetirizine hcl oral solution TIER 01
clemastine fumarate oral tablet 2.68 mg
TIER 01
CUROSURF TIER 03
cyproheptadine hcl oral TIER 01
desloratadine TIER 01
dexchlorpheniramine maleate oral
TIER 01
diphen oral elixir TIER 01
diphenhydramine hcl injection
TIER 01
diphenhydramine hcl oral elixir
TIER 01
DYMISTA TIER 02
FASENRA SPECIALTY
FASENRA PEN SPECIALTY
flunisolide nasal TIER 01 QL
fluticasone propionate nasal
TIER 01
Drug Name Drug Tier Notes
guaiatussin ac TIER 01 PA; QL
guaifenesin ac TIER 01 PA; QL
hydrocodone polst-chlorphen polst er susp
TIER 01 PA; QL
hydrocodone-homatropine
TIER 01 PA; QL
hydromet TIER 01 PA; QL
HYPERSAL TIER 03
INFASURF TIER 03
ipratropium bromide nasal
TIER 01
levocetirizine dihydrochloride oral
TIER 01
maxi-tuss ac TIER 01 PA; QL
mometasone furoate nasal
TIER 01 QL
nebusal inhalation nebulization solution 3 %
TIER 01
NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %
TIER 03
NUCALA SPECIALTY QL
olopatadine hcl nasal TIER 01 QL
OMNARIS TIER 03 QL
PATANASE TIER 03 QL
PHENERGAN TIER 03
promethazine hcl injection
TIER 01
promethazine hcl oral TIER 01
promethazine hcl rectal TIER 01
promethazine-codeine TIER 01 PA; QL
promethazine-dm TIER 01
promethazine-phenyleph-codeine
TIER 01 PA; QL
promethazine-phenylephrine
TIER 01
promethegan TIER 01
pseudoephedrine-bromphen-dm
TIER 01
pulmosal TIER 01
QNASL TIER 03 QL
QNASL CHILDRENS TIER 03 QL
RYCLORA TIER 03
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
53
Drug Name Drug Tier Notes
ryvent TIER 01
SINUVA TIER 03
sodium chloride inhalation
TIER 01
SURVANTA TIER 03
TESSALON PERLES TIER 03
virtussin ac w/alc TIER 01 PA; QL
XOLAIR SPECIALTY
ZETONNA TIER 03 QL
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions
ACCOLATE TIER 03
acetylcysteine inhalation TIER 01
ADRENALIN INJECTION TIER 03
ADVAIR DISKUS TIER 02 QL
ADVAIR HFA TIER 02 QL
AIRDUO DIGIHALER TIER 03 QL
albuterol sulfate er TIER 01
albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation
PREVENT QL
albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation
TIER 01 QL
ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCG/ACT INHALATION
PREVENT QL
albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml
TIER 01 QL
albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%, 2.5 mg/0.5ml
TIER 01
albuterol sulfate oral TIER 01
ANORO ELLIPTA PREVENT QL
ARCAPTA NEOHALER TIER 03 ST
Drug Name Drug Tier Notes
ARMONAIR DIGIHALER TIER 03 QL
ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT
PREVENT QL
ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/ACT
TIER 02 QL
ATROVENT HFA PREVENT QL
AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 MG/0.1ML
TIER 03
BREO ELLIPTA PREVENT QL
BROVANA TIER 03 QL
budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml
PREVENT QL
budesonide inhalation suspension 1 mg/2ml
TIER 01 QL
COMBIVENT RESPIMAT
TIER 02 QL
cromolyn sodium inhalation
TIER 01
DALIRESP TIER 03 PA
difil-g forte TIER 01
ELIXOPHYLLIN TIER 02
epinephrine injection solution
TIER 01
epinephrine injection solution auto-injector
TIER 01
EPIPEN 2-PAK TIER 03 ST
ESBRIET SPECIALTY PA
FLOVENT DISKUS TIER 02 QL
FLOVENT HFA PREVENT QL
fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose
TIER 01 QL
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
54
Drug Name Drug Tier Notes
FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT
PREVENT QL
INCRUSE ELLIPTA PREVENT QL
ipratropium bromide inhalation
TIER 01 QL
ipratropium-albuterol TIER 01 QL
levalbuterol hcl inhalation TIER 01 QL
LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT
TIER 03 QL
LONHALA MAGNAIR REFILL KIT
TIER 03 QL
LONHALA MAGNAIR STARTER KIT
TIER 03 QL
metaproterenol sulfate oral
TIER 01
montelukast sodium oral TIER 01
OFEV SPECIALTY PA
PERFOROMIST TIER 03 QL
PROAIR DIGIHALER TIER 03 QL
PROAIR HFA TIER 02 QL
PROAIR RESPICLICK PREVENT QL
PROVENTIL HFA TIER 03 QL
PULMICORT FLEXHALER AEROSOL POWDER BREATH ACTIVATED 90 MCG/ACT INHALATION
PREVENT QL
PULMICORT FLEXHALER AEROSOL POWDER BREATH ACTIVATED 90 MCG/ACT INHALATION
TIER 02 QL
PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT
PREVENT QL
SCLEROSOL INTRAPLEURAL
TIER 03
Drug Name Drug Tier Notes
SEREVENT DISKUS TIER 02 QL
SPIRIVA HANDIHALER TIER 02 QL
SPIRIVA RESPIMAT TIER 02 QL
STERILE TALC POWDER
TIER 03
STERITALC TIER 03
STIOLTO RESPIMAT TIER 02 QL
STRIVERDI RESPIMAT TIER 02 ST; QL
SYMBICORT PREVENT QL
SYMJEPI TIER 03
terbutaline sulfate injection
TIER 01
terbutaline sulfate oral TIER 01
THEO-24 TIER 02
theophylline TIER 01
theophylline er TIER 01
TRELEGY ELLIPTA TIER 02 QL
VENTOLIN HFA TIER 02 QL
wixela inhub TIER 01 QL
XOPENEX TIER 03 QL
XOPENEX CONCENTRATE
TIER 03 QL
XOPENEX HFA TIER 03 QL
YUPELRI TIER 03 QL
zafirlukast TIER 01
zileuton er TIER 01 ST
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis
BETHKIS SPECIALTY
CAYSTON SPECIALTY PA
KALYDECO SPECIALTY PA
ORKAMBI SPECIALTY PA; QL
PULMOZYME SPECIALTY PA
SYMDEKO SPECIALTY PA; QL
TOBI PODHALER SPECIALTY QL
tobramycin inhalation SPECIALTY
TRIKAFTA SPECIALTY PA; QL
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
55
Drug Name Drug Tier Notes
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension
ADEMPAS SPECIALTY PA
alyq SPECIALTY PA
ambrisentan SPECIALTY PA
bosentan SPECIALTY PA
OPSUMIT SPECIALTY PA
ORENITRAM SPECIALTY PA
REVATIO ORAL SUSPENSION RECONSTITUTED
SPECIALTY PA
sildenafil citrate oral suspension reconstituted
SPECIALTY PA
sildenafil citrate oral tablet 20 mg
SPECIALTY PA
tadalafil (pah) SPECIALTY PA
TRACLEER 32 MG SPECIALTY PA
treprostinil SPECIALTY PA
TYVASO SPECIALTY PA
TYVASO REFILL SPECIALTY PA
TYVASO STARTER SPECIALTY PA
UPTRAVI SPECIALTY PA
VENTAVIS SPECIALTY PA
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm
baclofen oral TIER 01
carisoprodol oral TIER 01
carisoprodol-aspirin oral tablet 200-325 mg
TIER 01
chlorzoxazone TIER 01
cyclobenzaprine hcl er TIER 01
cyclobenzaprine hcl oral TIER 01
DANTRIUM ORAL TIER 03
dantrolene sodium oral TIER 01
FEXMID TIER 03
LORZONE TIER 03
metaxalone TIER 01
methocarbamol injection TIER 01
Drug Name Drug Tier Notes
methocarbamol oral TIER 01
orphenadrine citrate er TIER 01
orphenadrine citrate injection
TIER 01
orphenadrine-asa-caffeine
TIER 01
ROBAXIN TIER 03
ROBAXIN-750 TIER 03
tizanidine hcl oral TIER 01
Sleep Disorder Agents
armodafinil TIER 01 PA; QL
BELSOMRA TIER 03 ST; QL
doxepin hcl oral tablet TIER 01 QL
eszopiclone TIER 01 QL
flurazepam hcl TIER 01 PA; QL
HETLIOZ SPECIALTY PA
modafinil TIER 01 PA; QL
ramelteon TIER 01 QL
ROZEREM TIER 03 QL
SECONAL TIER 03
SILENOR TIER 03 QL
SUNOSI TIER 02 PA; QL
temazepam TIER 01 QL
WAKIX SPECIALTY PA
XYREM SPECIALTY PA; QL
zaleplon TIER 01 QL
zolpidem tartrate TIER 01 QL
zolpidem tartrate er TIER 01 QL
ZOLPIMIST TIER 03 ST; QL
TIER 01: GENERIC, TIER 02: PREFERRED, TIER 03: NON-PREFERRED, PREVENT: PREVENTIVE, SPECIALTY: SPECIALTY
56
Index of Drugs
abacavir sulfate.............................18abacavir sulfate-lamivudine.......... 18abacavir-lamivudine-zidovudine... 18ABILIFY MAINTENA.....................17abiraterone acetate.......................14ABSORICA LD..............................27acamprosate calcium......................6acarbose.......................................30ACCOLATE.................................. 54ACCU-CHEK FASTCLIX LANCET KIT.................................31ACCU-CHEK MULTICLIX LANCET DEVICE KIT...................31ACCU-CHEK SOFTCLIX LANCET DEVICE KIT...................31ACCU-CHEK TENDER 1 INFUSION.....................................46ACCUPRIL....................................21ACCURETIC.................................21acd formula a..................................9acd-a noclot-50...............................9acebutolol hcl ................................21acetaminophen-codeine................. 3acetaminophen-codeine #2............ 3acetaminophen-codeine #3............ 3acetaminophen-codeine #4............ 3acetazolamide...............................51acetazolamide er.......................... 51acetazolamide sodium..................21acetic acid.....................................52acetylcysteine............................... 54acitretin......................................... 27ACTEMRA.................................... 44ACTEMRA ACTPEN.....................44ACTHAR.......................................39ACTICOAT....................................27ACTIFOAM COLLAGEN SPONGE...................................... 46ACTIGALL.................................... 35ACTIMMUNE................................44ACTIQ.............................................3ACTIVELLA.................................. 40ACTONEL.....................................45ACTOPLUS MET..........................30ACTOS......................................... 30ACULAR....................................... 50ACULAR LS..................................50acyclovir ........................................18ACZONE.......................................27adapalene.....................................27ADAPALENE................................ 27adapalene-benzoyl peroxide.........27ADASUVE.....................................17ADDYI...........................................26adefovir dipivoxil ........................... 18ADEMPAS.................................... 56
ADRENALIN................................. 54ADVAIR DISKUS..........................54ADVAIR HFA................................ 54ADVATE....................................... 20ADYNOVATE................................20ADZENYS ER...............................25ADZENYS XR-ODT......................25AEMCOLO......................................6AEROGEAR ACTION ASTHMA KIT................................................ 46AFINITOR.....................................14AFINITOR DISPERZ.................... 14afirmelle........................................ 40AFREZZA..................................... 33AFSTYLA......................................20AGGRENOX.................................17AGRYLIN......................................20AIMOVIG...................................... 13AIRDUO DIGIHALER................... 54AIRS PEDIATRIC AEROSOL MASK............................................46ak-poly-bac................................... 52AKTEN..........................................52AKYNZEO.....................................11ala-cort ..........................................27albendazole.................................. 16albuterol sulfate............................ 54albuterol sulfate er........................ 54albuterol sulfate hfa...................... 54ALBUTEROL SULFATE HFA.......54ALCAINE...................................... 52alclometasone dipropionate..........27ALCOHOL PREP PADS.........27, 46ALDACTAZIDE.............................21ALDACTONE................................21ALECENSA...................................14alendronate sodium...................... 46ALFERON N................................. 44alfuzosin hcl er..............................38ALINIA.......................................... 16aliskiren fumarate......................... 21ALKERAN.....................................14ALL FLOW 1000 PFT FILTER......46allopurinol..................................... 13almotriptan malate........................ 13ALOMIDE......................................50ALORA..........................................40alosetron hcl ................................. 35ALPHAGAN P...............................51ALPHA-LIPOIC ACID................... 46ALPHANATE/VWF COMPLEX/HUMAN......................20ALPHANINE SD........................... 20alprazolam.................................... 19alprazolam er................................19alprazolam intensol.......................19
alprazolam xr................................ 19ALPROLIX.................................... 20alprostadil ..................................... 21ALTABAX........................................6altacaine....................................... 52altafrin...........................................52altavera.........................................40ALTRENO.....................................27ALUNBRIG................................... 14alyacen 1/35................................. 40alyacen 7/7/7................................ 40alyq............................................... 56amabelz........................................ 40amantadine hcl............................. 17AMARYL.......................................30ambrisentan..................................56amcinonide................................... 27AMD FOAM DRESSING...............46AMD FOAM DRESSING TOPSHEET.................................. 46AMERGE...................................... 13amethia.........................................40amethia lo..................................... 40amethyst....................................... 40AMICAR........................................20amikacin sulfate..............................7amiloride hcl ..................................21amiloride-hydrochlorothiazide.......21aminocaproic acid.........................20amiodarone hcl............................. 21amitriptyline hcl .............................10amlodipine besylate......................21amlodipine besylate-benazepril hcl ................................................. 21amlodipine besylate-valsartan...... 21amlodipine-atorvastatin.................21amlodipine-olmesartan................. 21amlodipine-valsartan-hctz.............21ammonium lactate........................ 27amnesteem...................................27AMNIOCORE HUMAN TISSUE... 27amoxapine.................................... 10amoxicill-clarithro-lansopraz......... 35amoxicillin....................................... 7amoxicillin-potassium clavulanate.. 7amoxicillin-potassium clavulanate er.....................................................7AMPHADASE............................... 46AMPHETAMINE ER..................... 25amphetamine sulfate.................... 25amphetamine-dextroamphetamine......................25amphetamine-dextroamphetamine er..................25ampicillin.........................................7ampicillin sodium............................ 7
57
ampicillin-sulbactam sodium...........7AMPYRA.......................................25AMZEEQ.......................................27ANADROL-50............................... 39anagrelide hcl............................... 20ANALPRAM-HC............................45ANASPAZ.....................................36anastrozole................................... 14ANCOBON....................................12ANDRODERM.............................. 39ANECTINE....................................26ANGELIQ......................................40ANORO ELLIPTA......................... 54ANTABUSE.................................... 6anticoagulant cit dext soln a........... 9anticoagulant sodium citrate...........9ANUSOL-HC.................................45ANZEMET.....................................11apap-caff-dihydrocodeine............... 3APLENZIN.................................... 10APOKYN.......................................17apraclonidine hcl...........................51aprepitant......................................11apri ................................................40APRISO........................................ 45APTENSIO XR..............................25APTIVUS...................................... 18AQUASOL A.................................33ARAKODA.................................... 16aranelle.........................................40ARANESP (ALBUMIN FREE).......20ARCALYST...................................44ARCAPTA NEOHALER................54ARGININE HCL............................ 33ARICEPT...................................... 10ARIDA...........................................27ARIKAYCE......................................7aripiprazole................................... 17ARISTADA....................................17ARISTADA INITIO........................ 17ARIXTRA........................................ 9armodafinil .................................... 56ARMONAIR DIGIHALER..............54ARMOUR THYROID.....................44arnica flower................................. 46ARNUITY ELLIPTA.......................54AROMASIN...................................14ARTICADENT DENTAL..................5ARTISS.........................................46ascomp-codeine............................. 3ashlyna......................................... 40aspirin-dipyridamole er................. 17ASTAGRAF XL.............................44ASTHMAPACK III .........................46ASTRINGYN.................................20ATACAND HCT............................ 21atazanavir sulfate..........................18
ATELVIA.......................................46atenolol ......................................... 21atenolol-chlorthalidone..................21ATIVAN.........................................20atomoxetine hcl.............................25atorvastatin calcium......................21atovaquone...................................16atovaquone-proguanil hcl ............. 16ATRALIN.......................................27ATROPEN.................................... 36atropine sulfate....................... 36, 52ATROVENT HFA..........................54AUBAGIO..................................... 25aubra.............................................40aubra eq........................................40AUGMENTIN.................................. 7AUGMENTIN ES-600..................... 7AURA PORTANEB.......................46aurovela 1.5/30.............................40aurovela 1/20................................40aurovela 24 fe...............................40aurovela fe 1.5/30.........................40aurovela fe 1/20............................40AURYXIA......................................37AUSTEDO.................................... 26AUTOLET LANCING DEVICE......31AUVI-Q......................................... 54AVALIDE.......................................21AVANDIA......................................30aviane........................................... 40avidoxy............................................7avita.............................................. 27AVITENE...................................... 46AVITENE FLOUR......................... 46AVONEX PEN.............................. 25AVONEX PREFILLED.................. 25AYGESTIN....................................40ayuna............................................40AYVAKIT.......................................14azacitidine.....................................14AZACTAM.......................................7AZADROX.................................... 27AZASAN....................................... 44AZASITE.......................................50azathioprine.................................. 44azathioprine sodium......................44azelaic acid...................................27azelastine hcl..........................50, 53azelastine-fluticasone................... 53AZELEX........................................27AZILECT.......................................17azithromycin....................................7AZOPT..........................................51aztreonam.......................................7AZULFIDINE.................................45AZULFIDINE EN-TABS................ 45azurette.........................................40
BACIGUENT.................................50baciim............................................. 7bacitracin.................................. 7, 50bacitracin-polymyxin b.................. 52bacitra-neomycin-polymyxin-hc.... 52baclofen........................................ 56BACTERIOSTATIC WATER(BENZ ALC).....................46BACTRIM........................................7BACTRIM DS..................................7BAFIERTAM................................. 25bal in oil .........................................46balsalazide disodium.................... 45balsam peru-castor oil .................. 27BALVERSA...................................14balziva...........................................40BANZEL..........................................9BAQSIMI ONE PACK................... 32BAQSIMI TWO PACK...................32BARACLUDE................................18BAXDELA....................................... 7BD AUTOSHIELD DUO PEN NEEDLES.....................................33BD ULTRA-FINE INSULIN SYRINGES................................... 33BD ULTRA-FINE PEN NEEDLES 33BD VEO INSULIN SYR U/F 1/2UNIT........................................ 33BECONASE AQ............................53bekyree.........................................40BELBUCA.......................................3BELSOMRA..................................56benazepril hcl ................................21benazepril-hydrochlorothiazide.....21BENEFIX...................................... 20BENLYSTA...................................44BENTLEY THE BEAR PED NEBULIZER..................................46BENTYL........................................36benzalkonium chloride....................7BENZNIDAZOLE.......................... 16benzonatate..................................53benzoyl peroxide-erythromycin.....27benzphetamine hcl ........................26benztropine mesylate....................17BEPREVE.....................................50beser.............................................27BESIVANCE................................. 50BETADINE OPHTHALMIC PREP 50betamethasone dipropionate........ 28betamethasone dipropionate aug. 27betamethasone sod phos & acet.. 38betamethasone valerate............... 28BETAPACE AF.............................21BETASERON................................25betaxolol hcl ............................21, 51bethanechol chloride.....................37
58
BETHKIS...................................... 55BETIMOL......................................51BETOPTIC-S................................ 51bexarotene....................................14BIAFINE........................................28bicalutamide..................................14BICILLIN C-R..................................7BICILLIN C-R 900/300....................7BICILLIN L-A...................................7BIDIL.............................................21BIJUVA......................................... 40BIKTARVY....................................18BILTRICIDE..................................16bimatoprost...................................51BINOSTO......................................46BIOGUARD GAUZE SPONGES.. 46BIOGUARD ISLAND DRESSINGS.................................46BIOGUARD NON-ADHERENT DRESSING...................................46BIONECT......................................28BIO-STATIN..................................12BIOSTEP AG................................28bisoprolol fumarate....................... 21bisoprolol-hydrochlorothiazide......21bleomycin sulfate..........................14BLEPH-10.....................................50BLEPHAMIDE...............................52BLEPHAMIDE S.O.P....................52blisovi 24 fe...................................40blisovi fe 1.5/30.............................40blisovi fe 1/20................................40BLUESTAR...................................31BONIVA........................................ 46BONJESTA...................................11bosentan.......................................56BOSULIF...................................... 14BOTOX......................................... 46BPCO............................................28BRAFTOVI....................................14BREATHE EASE LARGE.............46BREATHE EASE MEDIUM...........46BREATHE EASE NEB MASK/CHILD................................46BREATHE EASE NEB MASK/INFANT..............................46BREATHE EASE SMALL............. 46BREATHERITE.............................46BREATHERITE VALVED MDI CHAMBER....................................47BREO ELLIPTA............................ 54briellyn.......................................... 41BRILINTA......................................17brimonidine tartrate.......................51BRINEURA................................... 37BRIVIACT....................................... 9bromfed dm...................................53
bromfenac sodium (once-daily).... 50bromocriptine mesylate.................17brompheniramine tannate.............53BROVANA.................................... 54BRUKINSA................................... 14budesonide............................. 45, 54budesonide er...............................45bumetanide...................................21BUMEX.........................................21BUNAVAIL......................................6BUPHENYL.................................. 37bupivacaine fisiopharma.................5bupivacaine hcl...............................5bupivacaine hcl (pf) .........................5bupivacaine-epinephrine.................5bupivacaine-epinephrine (pf) .......... 5BUPRENEX....................................3buprenorphine.................................3buprenorphine hcl.......................3, 6buprenorphine hcl-naloxone hcl ......6bupropion hcl................................ 11bupropion hcl er (smoking det)....... 6bupropion hcl er (sr)......................10bupropion hcl er (xl) ......................11BUPROPION HCL ER (XL).......... 11buspirone hcl................................ 20butalbital-acetaminophen................3butalbital-apap-caff-cod.................. 3butalbital-apap-caffeine.................. 3butalbital-asa-caff-codeine..............3butalbital-aspirin-caffeine................3butorphanol tartrate........................ 3BUTRANS.......................................3BYDUREON................................. 30BYDUREON BCISE AUTOINJECTOR..........................30BYETTA 10 MCG PEN.................30BYETTA 5 MCG PEN...................30BYSTOLIC....................................21cabergoline................................... 39CABLIVI........................................17CABOMETYX............................... 14CADUET.......................................21CAFERGOT..................................13caffeine citrate.............................. 26CAFFEINE-SODIUM BENZOATE.................................. 26CALAN SR....................................21CALCIFOL.................................... 33calcipotriene..................................28calcipotriene-betameth diprop...... 28calcitonin (salmon)........................46CALCITRENE...............................28calcitriol ...................................28, 46calcium acetate.............................37calcium acetate (phos binder).......37
CALCIUM DISODIUM VERSENATE................................47CALQUENCE............................... 14camila........................................... 41camrese........................................41camrese lo.................................... 41candesartan cilexetil ..................... 21candesartan cilexetil-hctz............. 21CAPASTAT SULFATE..................13capecitabine..................................14CAPLYTA..................................... 17CAPRELSA...................................14CAPTAIN EAGLE PED NEBULIZER..................................47captopril ........................................ 21captopril-hydrochlorothiazide........22CARAC......................................... 28CARAFATE...................................35CARBAGLU..................................33carbamazepine............................... 9carbamazepine er...........................9carbidopa......................................17carbidopa-levodopa...................... 17carbidopa-levodopa er..................17carbidopa-levodopa-entacapone.. 17carbinoxamine maleate.................53CARBOCAINE................................5CARBOCAINE PRESERVATIVE-FREE................. 5CARDIZEM...................................22CARDIZEM LA..............................22CARDURA....................................22CARDURA XL...............................38CARETOUCH 2 CPAP HOSE HANGER...................................... 47CARETOUCH CPAP & BIPAP HOSE............................................47CARETOUCH CPAP MASK WIPES.......................................... 47CARETOUCH CPAP PRE-WASH SOLN................................ 47CARETOUCH CPAP TUBE BRUSH......................................... 47CARETOUCH LANCING/EJECTOR....................31CARETOUCH UNIVERSL CPAP FILTER......................................... 47carisoprodol.................................. 56carisoprodol-aspirin...................... 56carisoprodol-aspirin-codeine...........3CAROSPIR...................................22carteolol hcl ...................................51cartia xt......................................... 22carvedilol .......................................22carvedilol phosphate er.................22cascara sagrada........................... 36CASODEX.................................... 14
59
CATAPRES.................................. 22cavarest........................................ 26CAYSTON.................................... 55caziant.......................................... 41cefaclor........................................... 7cefaclor er.......................................7cefadroxil ........................................ 7CEFALY KIT................................. 47cefazolin sodium.............................7cefdinir ............................................ 7cefditoren pivoxil .............................7cefepime hcl....................................7cefixime...........................................7CEFOTAN.......................................7cefotaxime sodium..........................7cefotetan disodium..........................7cefoxitin sodium..............................7cefpodoxime proxetil .......................7cefprozil .......................................... 7ceftazidime......................................7ceftriaxone sodium..........................7cefuroxime axetil .............................7cefuroxime sodium..........................7celecoxib.........................................4CELESTONE SOLUSPAN........... 38CELLCEPT................................... 44CELONTIN......................................9CENTANY.......................................7cephalexin.......................................7CEQUR SIMPLICITY 2U.............. 31CEQUR SIMPLICITY INSERTER.31CEQUR SIMPLICITY STARTER..31CERDELGA..................................37CEREBYX.......................................9cetirizine hcl..................................53CETRAXAL...................................52cevimeline hcl............................... 26CHANTIX........................................6CHANTIX CONTINUING MONTH PAK.................................. 6CHANTIX STARTING MONTH PAK.................................................6charlotte 24 fe...............................41chateal.......................................... 41chateal eq..................................... 41CHEMET.......................................33CHEMOPLUS LATEX GLOVES...47CHEMOPLUS NEOPRENE GLOVE......................................... 47CHEMSTRIP UGK........................31CHENODAL..................................36chlordiazepoxide hcl..................... 20chlordiazepoxide-amitriptyline...... 11chlordiazepoxide-clidinium............36chlorhexidine gluconate................26CHLORHEXIDINE GLUCONATE.47chloroprocaine hcl (pf) .................... 5
chloroquine phosphate................. 16chlorpromazine hcl ........................17chlorthalidone............................... 22chlorzoxazone...............................56CHOLBAM....................................37cholestyramine..............................22cholestyramine light......................22chorionic gonadotropin................. 39ciclodan.........................................12ciclopirox.......................................12ciclopirox olamine......................... 12cilostazol.......................................17CILOXAN......................................50CIMDUO....................................... 18cimetidine......................................35cimetidine hcl................................35CIMZIA..........................................44CIMZIA PREFILLED KIT.............. 44CIMZIA STARTER KIT................. 44cinacalcet hcl ................................ 46CIPRO............................................ 7CIPRO HC.................................... 52CIPRODEX...................................52ciprofloxacin hcl .................. 7, 50, 52ciprofloxacin-dexamethasone.......52citalopram hydrobromide.............. 11CITANEST FORTE DENTAL..........5CITANEST PLAIN DENTAL........... 5claravis..........................................28clarithromycin..................................7clarithromycin er............................. 7clemastine fumarate..................... 53CLENPIQ......................................36CLEOCIN........................................7CLEOCIN PHOSPHATE.................7CLEOCIN-T.................................. 28CLEVER CHOICE HOLDING CHAMBER....................................47CLEVER CHOICE TENS UNIT.... 47CLEVER CHOICE WHIS AIR PED NEB......................................47CLEVER CHOICE WHISPER AIRE NEB.....................................47CLIMARA PRO.............................41clindacin etz..................................28clindacin-p.....................................28clindamycin hcl ............................... 7clindamycin palmitate hcl ................7clindamycin phosphate............. 7, 28clindamycin phosphate-benzoyl peroxide........................................28clindamycin-tretinoin.....................28CLINDESSE................................... 7clinpro 5000.................................. 26clobazam........................................ 9clobetasol prop emollient base..... 28clobetasol propionate....................28
clobetasol propionate e.................28clobetasol propionate emulsion.... 28clocortolone pivalate.....................28clodan........................................... 28clomiphene citrate.........................39clomipramine hcl...........................11clonazepam.................................. 20clonidine........................................22clonidine hcl ..................................22clonidine hcl er..............................25clopidogrel bisulfate......................17clorazepate dipotassium...............20clotrimazole...................................12clotrimazole-betamethasone.........12clovique.........................................33clozapine.......................................17CLOZARIL.................................... 17COAGADEX................................. 20COAGUCHEK XS SYSTEM.........47coal tar..........................................28COARTEM....................................16COATAMAX PATCH.................... 47COCAINE HCL............................... 5codeine sulfate................................3COGENTIN...................................17colchicine......................................13colchicine-probenecid...................13COLCRYS.................................... 13colesevelam hcl............................ 22colestipol hcl ................................. 22colistimethate sodium (cba)............7COLY-MYCIN M............................. 7COMBIGAN.................................. 51COMBIPATCH..............................41COMBIVENT RESPIMAT.............54COMBIVIR....................................18COMETRIQ (100 MG DAILY DOSE).......................................... 14COMETRIQ (140 MG DAILY DOSE).......................................... 14COMETRIQ (60 MG DAILY DOSE).......................................... 14COMP A-I-R NEBULIZER............ 47COMPACT SPACE CHAMBER/LG MASK...................47COMPACT SPACE CHAMBER/MED MASK................47COMPACT SPACE CHAMBER/SM MASK.................. 47COMPLERA..................................18compro..........................................12COMTAN...................................... 17CONCEPTION KIT....................... 47CONDYLOX..................................28constulose.....................................36CONTRAVE..................................26COPAXONE................................. 25
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COPIKTRA................................... 14coremino.........................................7CORIFACT................................... 20CORLANOR................................. 22CORTENEMA...............................45cortic-nd........................................52CORTIFOAM................................ 45cortisone acetate.......................... 38CORTISPORIN.............................28COTELLIC.................................... 14COTEMPLA XR-ODT................... 25CREON.........................................37CRESEMBA..................................12CRINONE..................................... 41CRIXIVAN.....................................18cromolyn sodium...............36, 50, 54crotan............................................16cryselle-28.................................... 41CRYSVITA....................................37CUPRIMINE..................................37CURITY AMD ANTIMICROBIAL SPNGE......................................... 47CURITY AMD ANTIMICROBIAL STRIP........................................... 47CURITY IODOFORM PACKING STRIP........................................... 47CUROSURF................................. 53CUTIVATE....................................28CUVITRU......................................44CUVPOSA.................................... 36cyanocobalamin............................33CYANOCOBALAMIN....................33cyclafem 1/35................................41cyclafem 7/7/7...............................41cyclobenzaprine hcl ...................... 56cyclobenzaprine hcl er..................56CYCLOGYL.................................. 52CYCLOMYDRIL............................52cyclopentolate hcl ......................... 52cyclophosphamide........................14cycloserine....................................13CYCLOSET.................................. 30cyclosporine..................................44cyclosporine modified................... 44cyproheptadine hcl........................53cyred.............................................41cyred eq........................................41CYSTADANE................................37CYSTAGON..................................37CYSTARAN.................................. 52cytarabine..................................... 14cytarabine (pf)...............................14CYTOTEC.....................................35CYTOTINE....................................47D.H.E. 45...................................... 13dalfampridine er............................25DALIRESP....................................54
danazol......................................... 39DANTRIUM...................................56dantrolene sodium........................ 56dapsone..................................13, 28DARAPRIM...................................16darifenacin hydrobromide er.........37dasetta 1/35..................................41dasetta 7/7/7.................................41DAURISMO.................................. 14DAYPRO.........................................4daysee.......................................... 41DAYTRANA.................................. 25D-CARE 100X.................................5DDAVP......................................... 39DDAVP RHINAL TUBE.................39DEBACTEROL............................. 26deblitane....................................... 41deferasirox....................................33deferasirox granules..................... 33deferoxamine mesylate.................47DEFLUX........................................47dehydrated alcohol....................... 34DELESTROGEN...........................41DELSTRIGO.................................18delyla............................................ 41demeclocycline hcl ..........................7DEMEROL......................................3DEMSER...................................... 22denta 5000 plus............................ 26dentagel........................................26DENTAL NEEDLE........................ 47DEPEN TITRATABS.....................37DEPO-ESTRADIOL......................41DEPO-MEDROL...........................38DEPO-PROVERA.........................41DEPO-SUBQ PROVERA 104.......41DERMA-SMOOTHE/FS BODY.....28DERMA-SMOOTHE/FS SCALP...28DERMOTIC...................................52DERMULCERA.............................28DESCOVY.................................... 18DESFERAL...................................47desipramine hcl.............................11desloratadine................................ 53desmopressin ace spray refrig......39desmopressin acetate...................39desmopressin acetate spray.........39desogestrel-ethinyl estradiol .........41desonide....................................... 28DESOWEN................................... 28desoximetasone............................28DESVENLAFAXINE ER................11desvenlafaxine succinate er......... 11DETROL....................................... 37DETROL LA..................................37dexamethasone............................ 38DEXAMETHASONE (LA)............. 38
dexamethasone intensol...............38dexamethasone sod phosphate pf...................................................38dexamethasone sodium phosphate...............................38, 50dexchlorpheniramine maleate.......53DEXCOM G4 / G5 / G6 RECEIVER, TRANSMITTER, SENSOR (INCLUDING PLATINUM, PLATINUM PEDIATRIC)................................. 31DEXILANT.................................... 35dexmethylphenidate hcl ................25dexmethylphenidate hcl er............25DEXONTO 0.4%...........................38DEXPANTHENOL........................ 34dextroamphetamine sulfate.......... 25dextroamphetamine sulfate er...... 25DIACOMIT...................................... 9DIASTAT ACUDIAL........................9DIASTAT PEDIATRIC.................... 9DIATHRIVE LANCING DEVICE... 31diazepam.................................. 9, 20DIAZEPAM................................... 20diazepam intensol.........................20diazoxide.......................................32DIBENZYLINE.............................. 22DICLEGIS.....................................12DICLOFENAC EPOLAMINE...........4diclofenac potassium...................... 4diclofenac sodium...............4, 28, 50diclofenac sodium er.......................4diclofenac-misoprostol ....................4DICLOFONO.................................. 4dicloxacillin sodium.........................7dicyclomine hcl............................. 36didanosine.................................... 18diethylpropion hcl..........................26diethylpropion hcl er......................26DIFICID...........................................7difil-g forte.....................................54diflorasone diacetate.....................28DIFLUCAN....................................12diflunisal..........................................4digitek........................................... 22digox............................................. 22digoxin.......................................... 22dihydroergotamine mesylate.........13DILANTIN....................................... 9DILATRATE-SR............................22DILAUDID.......................................3diltiazem hcl..................................22diltiazem hcl er..............................22diltiazem hcl er beads...................22diltiazem hcl er coated beads....... 22dilt-xr.............................................22dimenhydrinate............................. 12
61
dimethyl fumarate......................... 25diphen...........................................53diphenhydramine hcl.....................53diphenoxylate-atropine................. 36DIPROLENE.................................28DIPROLENE AF........................... 28dipyridamole................................. 17disopyramide phosphate...............22disulfiram........................................ 6DITROPAN XL..............................37DIURIL..........................................22divalproex sodium...........................9divalproex sodium er.......................9DIVIGEL........................................41dofetilide....................................... 22DOLOPHINE...................................3donepezil hcl .................................10DOPTELET...................................20DORAL......................................... 20dorzolamide hcl.............................51DORZOLAMIDE HCL................... 51dorzolamide hcl-timolol mal.......... 51dorzolamide hcl-timolol mal pf...... 51dotti ...............................................41DOVATO.......................................18DOVER URETHRAL CATHETER.................................. 47DOVONEX....................................28doxazosin mesylate...................... 22doxepin hcl ........................11, 28, 56doxercalciferol ...............................46doxycycline................................... 28doxycycline hyclate.........................7doxycycline monohydrate............... 8doxylamine-pyridoxine..................12DRISDOL......................................34DRIZALMA SPRINKLE.................11dronabinol.....................................12droperidol......................................12DROPLET MICRON..................... 33drospiren-eth estrad-levomefol.....41drospirenone-ethinyl estradiol .......41DROXIA........................................14DRYSOL.......................................28DUAVEE.......................................41DUETACT.....................................30duloxetine hcl................................11DUODOTE....................................47DUOPA.........................................17DUPIXENT....................................28DURAFIBER.................................28duramorph...................................... 3duraxin............................................3dutasteride....................................38dutasteride-tamsulosin hcl............38DYANAVEL XR.............................25DYMISTA......................................53
DYRENIUM...................................22DYSPORT.................................... 47E.E.S. 400.......................................8E.E.S. GRANULES.........................8EASIVENT....................................47easygel......................................... 26EC-NAPROSYN............................. 4ec-naproxen....................................4econazole nitrate.......................... 12EDARBI........................................ 22EDARBYCLOR.............................22EDECRIN......................................22ed-spaz.........................................36EDURANT.................................... 18efavirenz....................................... 18EFFER-K...................................... 34effer-k............................................34EFFIENT.......................................17EFUDEX....................................... 28EGATEN.......................................16EGRIFTA SV................................ 39ELESTRIN.................................... 41eletriptan hydrobromide................13ELIGARD......................................39ELIMITE........................................16elinest........................................... 41ELIQUIS..........................................9ELIQUIS DVT/PE STARTER PACK..............................................9ELIXOPHYLLIN............................ 54ELLA.............................................41ELMIRON..................................... 37ELOCTATE...................................20eluryng..........................................41EMBRACE SEIZURE MONITORING SYS...................... 47EMCYT......................................... 14EMEND.........................................12EMEND TRI-PACK.......................12EMFLAZA..................................... 13EMGALITY....................................13EMGALITY (300 MG DOSE)........ 13EMJOI TENS................................ 47emoquette.....................................41EMSAM.........................................11EMTRIVA......................................18EMVERM......................................16ENABLEX..................................... 37enalapril maleate.......................... 22enalapril-hydrochlorothiazide........22ENBREL....................................... 44ENBREL MINI...............................44ENBREL SURECLICK..................44ENDARI........................................ 47ENDO AVITENE...........................47endocet...........................................3ENDOMETRIN..............................41
ENEMA BOTTLE..........................47ENLITE GLUCOSE SENSOR...... 31enoxaparin sodium......................... 9enpresse-28..................................41enskyce.........................................41ENSPRYNG..................................44entacapone...................................17entecavir ....................................... 18ENTEREG.................................... 36ENTOCORT EC............................45ENTRESTO.................................. 22ENTRISTAR PEG ENTERAL CONNECT....................................47enulose......................................... 36ENVARSUS XR............................44EPCLUSA.....................................18EPHEDRINE SULFATE (PRESSORS)............................... 22EPIDIOLEX.....................................9EPIDUO FORTE...........................28EPIFOAM......................................28epinastine hcl................................50epinephrine.............................22, 54EPINEPHRINE............................. 22epinephrine pf...............................22EPIPEN 2-PAK............................. 54EPISIL...........................................47epitol ............................................... 9EPIVIR..........................................18EPIVIR HBV..................................18eplerenone....................................22EPZICOM..................................... 18EQUETRO....................................20ergocalciferol ................................ 34ergoloid mesylates........................47ERGOMAR................................... 13ergotamine-caffeine......................13ERIVEDGE................................... 14erlotinib hcl ....................................14EROS-CTD...................................47errin...............................................41ertapenem sodium..........................8ERWINAZE...................................14ery.................................................28ERYGEL....................................... 28ERYPED 200..................................8ERYPED 400..................................8ERY-TAB........................................ 8ERYTHROCIN STEARATE............8erythromycin....................... 8, 28, 50erythromycin base.......................... 8erythromycin ethylsuccinate........... 8ESBRIET...................................... 54escitalopram oxalate.....................11ESGIC.............................................3esomeprazole magnesium............35estarylla........................................ 41
62
estazolam..................................... 20estradiol ........................................ 41estradiol valerate.......................... 41estradiol-norethindrone acet.........41ESTRING......................................41ESTROGEL.................................. 41ESTROSTEP FE.......................... 41eszopiclone...................................56ethacrynic acid..............................22ethambutol hcl .............................. 13ethosuximide...................................9ethyl chloride...................................5ethynodiol diac-eth estradiol .........41etodolac.......................................... 4etodolac er......................................4etonogestrel-ethinyl estradiol ........41etoposide...................................... 14EUCRISA......................................28euthyrox........................................44EVAMIST......................................41EVEKEO ODT.............................. 25EVENITY...................................... 46everolimus.............................. 14, 44EVERSENSE SENSOR/HOLDER.......................31EVERSENSE SMART TRANSMITTER............................ 32EVISTA.........................................39EVOCLIN......................................28EVOTAZ....................................... 18EVOXAC.......................................26EVZIO.............................................6EXACTA-MED ORAL SYRINGE 5ML...............................................47EXCILON AMD DRAIN SPONGES....................................47EXELON....................................... 10exemestane.................................. 14EXJADE........................................34exoderm........................................12exotic-hc....................................... 53EXPAREL....................................... 5EYLEA.......................................... 52EZALLOR SPRINKLE...................22ezetimibe...................................... 22ezetimibe-simvastatin................... 22FACE MASK EARLOOP-STYLE..47FACE MASK RESP N-100 PART.47FACE MASK RESPIRATOR R-95 PART....................................... 47falmina.......................................... 41famciclovir .....................................18famotidine..................................... 35FANAPT........................................17FANAPT TITRATION PACK.........17FARESTON.................................. 14FARXIGA......................................30
FARYDAK.....................................14FASENRA.....................................53FASENRA PEN............................ 53FASLODEX...................................14FAVIPIRAVIR............................... 18fayosim......................................... 41febuxostat..................................... 13FEIBA........................................... 20felbamate........................................9FELDENE....................................... 4felodipine er.................................. 22FEMARA.......................................14FEMHRT LOW DOSE.................. 41FEMRING..................................... 41femynor.........................................41fenofibrate.....................................22fenofibrate micronized.................. 22fenofibric acid................................22fenoprofen calcium......................... 4fenortho...........................................4fentanyl........................................... 3fentanyl citrate................................ 3FERRIPROX.................................34FERRIPROX TWICE-A-DAY........34FETZIMA...................................... 11FETZIMA TITRATION.................. 11FEXMID........................................ 56FIBRICOR.....................................22FIBRYGA......................................20FINACEA...................................... 28finasteride..................................... 38FIORINAL....................................... 3FIORINAL/CODEINE #3.................3FIRAZYR...................................... 44FIRMAGON.................................. 39FIRMAGON (240 MG DOSE).......39FIRST-LANSOPRAZOLE............. 35FIRST-OMEPRAZOLE................. 35FIRVANQ........................................8flac................................................ 53FLAGYL..........................................8FLAREX........................................50flavoxate hcl ..................................37flecainide acetate..........................22FLEXICHAMBER ADULT MASK/SMALL...............................48FLEXICHAMBER CHILD MASK/LARGE.............................. 48FLEXICHAMBER CHILD MASK/SMALL...............................48FLOLIPID......................................22FLOVENT DISKUS.......................54FLOVENT HFA.............................54floxuridine..................................... 14fluconazole....................................12flucytosine.....................................12fludrocortisone acetate................. 38
flunisolide......................................53fluocinolone acetonide............28, 53fluocinolone acetonide body......... 28fluocinolone acetonide scalp.........28fluocinonide...................................28fluocinonide emulsified base.........28FLUORABON............................... 34fluoridex........................................ 26fluoridex daily renewal.................. 26fluoridex enhanced whitening....... 26fluoridex sensitivity relief ...............26fluoritab.........................................34fluorometholone............................50FLUOROPLEX..............................29FLUOROURACIL..........................29fluorouracil .................................... 29fluoxetine hcl .................................11fluoxetine hcl (pmdd).................... 11fluphenazine decanoate................17fluphenazine hcl............................17FLURA-DROPS............................34flurandrenolide..............................29flurazepam hcl.............................. 56flurbiprofen......................................4flurbiprofen sodium....................... 50flutamide....................................... 14fluticasone propionate.............29, 53fluticasone-salmeterol ...................54FLUTICASONE-SALMETEROL... 55fluvastatin sodium.........................22fluvastatin sodium er.....................22fluvoxamine maleate.....................11fluvoxamine maleate er.................11FLYP NEBULIZER........................48FML...............................................50FML FORTE................................. 50FML LIQUIFILM............................50folic acid........................................34FOLLISTIM AQ.............................39fondaparinux sodium...................... 9FORA D40G GLUCOSE/PRESSURE............... 48FORFIVO XL................................ 11formaldehyde................................48FORTAZ......................................... 8FORTEO.......................................46FOSAMAX.................................... 46FOSAMAX PLUS D...................... 46fosamprenavir calcium..................18fosinopril sodium...........................22fosinopril sodium-hctz...................22fosphenytoin sodium.......................9FOSRENOL..................................37FRAGMIN....................................... 9FREESTYLE LIBRE 14 DAY READER.......................................32
63
FREESTYLE LIBRE 14 DAY SENSOR.......................................32FREESTYLE LIBRE 2 READER SYSTM......................................... 32FREESTYLE LIBRE 2 SENSOR SYSTM......................................... 32frovatriptan succinate....................13fulvestrant..................................... 14furosemide....................................22FUZEON.......................................18fyavolv...........................................41FYCOMPA......................................9gabapentin......................................9GABITRIL....................................... 9GALAFOLD...................................37galantamine hydrobromide........... 10galantamine hydrobromide er.......10GALZIN.........................................34GAMASTAN..................................44GAMMACORE..............................48GAMMACORE SAPPHIRE 31-DAY.............................................. 48GAMMACORE SAPPHIRE REFILL KIT...................................48GAMMAGARD..............................44GAMMAKED.................................44GAMUNEX-C................................44ganirelix acetate............................39GASTROCROM............................36gatifloxacin....................................50GATTEX....................................... 36gavilyte-c.......................................36gavilyte-g...................................... 36gavilyte-h...................................... 36gavilyte-n with flavor pack.............36GEBAUERS PAIN EASE................5GEBAUERS SPRAY AND STRETCH.......................................5GELFILM...................................... 48GEL-FLOW NT............................. 48GELFOAM.................................... 48GELFOAM COMPRESSED SIZE 100................................................48GELFOAM DENTAL PACK SIZE 4....................................................48GELFOAM SPONGE....................48GELFOAM SPONGE SIZE 100....48GELFOAM SPONGE SIZE 200....48GELFOAM SPONGE SIZE 50......48GELNIQUE................................... 37GELX............................................ 48gemfibrozil .................................... 23generlac........................................36gengraf..........................................44gentak...........................................51gentamicin sulfate.....................8, 51GENTEEL LANCING KIT (BLUE).32
GENVOYA....................................18GEODON......................................17gianvi............................................ 41GILENYA...................................... 25GILOTRIF..................................... 14GIVLAARI..................................... 48glatiramer acetate.........................25glatopa..........................................25GLEOSTINE................................. 14glimepiride.................................... 30glipizide er.....................................30glipizide ir ......................................31glipizide xl ..................................... 31glipizide-metformin hcl ..................31GLUCAGEN HYPOKIT.................32GLUCAGON EMERGENCY KIT.. 33GLUCOTROL............................... 31GLUCOTROL XL..........................31glutaraldehyde.............................. 48GLUTATHIONE............................ 34glyburide....................................... 31glyburide micronized.....................31glyburide-metformin......................31GLYCINE......................................34glycopyrrolate............................... 36GLYCOPYRROLATE................... 36glycopyrrolate pf........................... 36glydo............................................... 5GLYNASE.....................................31GLYRX-PF....................................36GLYSET........................................31GLYXAMBI................................... 31GOJJI LANCING DEVICE/CLEAR CAP...................32GONITRO.....................................23GORDOFILM................................29GRALISE...................................... 26granisetron hcl .............................. 12griseofulvin microsize................... 12griseofulvin ultramicrosize............ 12guaiatussin ac...............................53guaifenesin ac...............................53guanfacine hcl ...............................23guanfacine hcl er.......................... 25GUANIDINE HCL..........................13GUARDIAN CONNECT TRANSMITTER............................ 32GUARDIAN LINK 3 TRANSMITTER............................ 32GUARDIAN REAL-TIME SYSTEM.......................................32GUARDIAN SENSOR (3)............. 32GVOKE HYPOPEN 1-PACK........ 33GVOKE HYPOPEN 2-PACK........ 33GVOKE PFS.................................33GYNAZOLE-1...............................12hailey 1.5/30................................. 41
hailey 24 fe................................... 41hailey fe 1.5/30............................. 41hailey fe 1/20................................ 41halcinonide....................................29HALCION......................................20HALDOL....................................... 17HALDOL DECANOATE................18halobetasol propionate................. 29haloperidol.................................... 18haloperidol decanoate.................. 18haloperidol lactate.........................18HARVONI..................................... 18heather..........................................42HELIDAC THERAPY.................... 36HEMANGEOL...............................23hematinic/folic acid....................... 34HEMLIBRA................................... 20hemocyte-f ....................................34HEMOFIL M..................................20heparin sodium (porcine)................9heparin sodium (porcine) pf............9HEPSERA.....................................18HERCEPTIN HYLECTA............... 14HETLIOZ.......................................56HIPREX.......................................... 8HISTOACRYL...............................48HIZENTRA....................................44homatropaire.................................52HORIZANT................................... 26HUMALOG KWIKPEN..................33HUMALOG MIX 50/50 KWIKPEN.33HUMALOG MIX 50/50 VIAL......... 33HUMALOG MIX 75/25 KWIKPEN.33HUMALOG MIX 75/25 VIAL......... 33HUMALOG U-100 JUNIOR KWIKPEN..................................... 33HUMALOG VIAL...........................33HUMATE-P...................................20HUMIRA........................................44HUMIRA PEDIATRIC CROHNS START..........................................44HUMIRA PEN............................... 44HUMIRA PEN-CD/UC/HS STARTER.....................................44HUMIRA PEN-PS/UV/ADOL HS START..........................................44HUMULIN 70/30 KWIKPEN..........33HUMULIN 70/30 VIAL...................33HUMULIN N KWIKPEN................ 33HUMULIN N VIAL.........................33HUMULIN R U-500 KWIKPEN..... 33HUMULIN R U-500 VIAL.............. 33HUMULIN R VIAL.........................33HYCAMTIN...................................14hydralazine hcl ..............................23HYDREA.......................................14hydrochlorothiazide.......................23
64
hydrocodone bitartrate er................3hydrocodone polst-chlorphen polst er susp................................. 53hydrocodone-acetaminophen......... 3hydrocodone-homatropine............53hydrocodone-ibuprofen...................3hydrocortisone.................. 29, 38, 45hydrocortisone (perianal)..............45hydrocortisone ace-pramoxine..... 45hydrocortisone butyr lipo base......29hydrocortisone butyrate................ 29hydrocortisone valerate................ 29hydrocortisone-acetic acid............53hydrogen peroxide..........................8hydromet.......................................53HYDROMORPHONE HCL............. 3hydromorphone hcl.........................3hydromorphone hcl er.....................3hydromorphone hcl pf.....................3HYDROMORPHONE HCL-NACL...3hydroxocobalamin acetate............34hydroxychloroquine sulfate...........16hydroxyprogesterone caproate.....42hydroxyurea..................................14hydroxyzine hcl.............................20hydroxyzine pamoate....................20HYLENEX.....................................48hyoscyamine sulfate..................... 36hyoscyamine sulfate sl ..................36hyosyne........................................ 36HYPERRHO S/D.......................... 44HYPERSAL...................................53HYQVIA........................................ 44HYSINGLA ER................................3ibandronate sodium...................... 46IBRANCE......................................14ibu...................................................4ibuprofen.........................................4icatibant acetate............................44ICLUSIG....................................... 14IDELVION.....................................20IDHIFA..........................................14ILARIS.......................................... 44ILUMYA........................................ 44imatinib mesylate..........................14IMBRUVICA..................................14imipramine hcl...............................11imipramine pamoate..................... 11imiquimod..................................... 29IMLYGIC.......................................14IMPAVIDO.................................... 16IMURAN........................................44IMVEXXY MAINTENANCE PACK............................................42IMVEXXY STARTER PACK......... 42INBRIJA........................................17incassia.........................................42
INCRELEX....................................39INCRUSE ELLIPTA...................... 55indapamide................................... 23INDOCIN.........................................5indomethacin.................................. 5indomethacin er.............................. 5INFASURF....................................53INFED...........................................48INFUMORPH 200...........................3INFUMORPH 500...........................3INGREZZA....................................26INLYTA......................................... 14INPEN 100-BLUE-LILLY...............32INPEN 100-BLUE-NOVO............. 32INPEN 100-GRAY-LILLY..............32INPEN 100-GREY-NOVO.............32INPEN 100-PINK-LILLY................32INPEN 100-PINK-NOVO.............. 32INREBIC....................................... 14INSPIREASE RESERVOIR BAGS............................................48INSPRA........................................ 23INSTAT.........................................48INSUFLON....................................48INSULIN LISPRO PROT & LISPRO.........................................33INSULIN PEN NEEDLES............. 33INSULIN SYRINGES....................33INTELENCE..................................18INTERCEED.................................48INTERCEED (TC7).......................48INTRAROSA.................................37INTRON A.....................................18introvale........................................ 42INVANZ...........................................8INVEGA........................................ 18INVEGA SUSTENNA....................18INVEGA TRINZA.......................... 18INVELTYS.................................... 51INVIRASE.....................................18iodine strong................................. 34iodine tincture................................. 8IOPIDINE......................................51ipratropium bromide................53, 55ipratropium-albuterol .....................55irbesartan......................................23irbesartan-hydrochlorothiazide..... 23IRESSA.........................................14ISENTRESS................................. 18ISENTRESS HD........................... 18isibloom.........................................42isoniazid........................................13isoproterenol hcl ........................... 23ISOPTO ATROPINE.....................52ISOPTO CARPINE....................... 51ISORDIL TITRADOSE..................23isosorbide dinitrate........................23
isosorbide mononitrate................. 23isosorbide mononitrate er............. 23isotretinoin.................................... 29isradipine...................................... 23ISTALOL.......................................51ISUPREL...................................... 23itraconazole.................................. 12IV ADMINISTRATION SET...........48IV EXTENSION SET.....................48ivermectin..................................... 16IXINITY......................................... 20JADENU....................................... 34JADENU SPRINKLE.....................34jaimiess.........................................42JAKAFI..........................................14JALYN...........................................38jantoven.......................................... 9JANUMET.....................................31JANUMET XR...............................31JANUVIA.......................................31JARDIANCE................................. 31jasmiel...........................................42jencycla.........................................42JENTADUETO..............................31JENTADUETO XR........................31jinteli ..............................................42JIVI................................................20jolessa...........................................42JORNAY PM.................................25J-TIP KIT W/VIAL ADAPTERS.....48juleber...........................................42JULUCA........................................18junel 1.5/30................................... 42junel 1/20...................................... 42junel fe 1.5/30............................... 42junel fe 1/20.................................. 42junel fe 24..................................... 42JUXTAPID.................................... 23JYNARQUE.................................. 34kaitlib fe.........................................42KALBITOR....................................44KALETRA..................................... 18kalliga............................................42KALYDECO.................................. 55KANGAROO BALLOON 20FR/3.5CM................................. 48KANGAROO GASTROSTOMY TUBE............................................ 48KANGAROO GRAVITY FEEDING BAG............................. 48KANGAROO JOEY ENTERAL PUMP........................................... 48KANGAROO MULTI-FUNCTIONAL PORT....................48KANGAROO STOMA MEASURING DEV........................48KAPVAY....................................... 25
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KARAYA GUM..............................48kariva............................................ 42KCENTRA.....................................20KEFLEX..........................................8kelnor 1/35....................................42kelnor 1/50....................................42KENALOG.................................... 38KENALOG-80............................... 38KENDALL SCD EXPRESS FOOT CUFF................................. 48KERAMATRIX REPLICINE 5CMX5CM.................................... 29KERLIX AMD ANTIMICROBIAL...48KERLIX AMD SUPER SPONGES....................................48KERYDIN......................................12ketoconazole.................................12ketodan.........................................12KETONE TEST.............................32ketoprofen.......................................5ketoprofen er...................................5ketorolac tromethamine............ 5, 51KETOROLAC TROMETHAMINE... 5KETOSTIX....................................32KEVEYIS...................................... 51KEVZARA.....................................44KINERET...................................... 44kionex........................................... 34KISQALI (200 MG DOSE)............ 14KISQALI (400 MG DOSE)............ 14KISQALI (600 MG DOSE)............ 15KISQALI FEMARA (400 MG DOSE).......................................... 15KISQALI FEMARA (600 MG DOSE).......................................... 15KISQALI FEMARA(200 MG DOSE).......................................... 15KLARON.......................................29klor-con.........................................34klor-con 10....................................34klor-con m10.................................34KLOR-CON M15...........................34klor-con m20.................................34klor-con sprinkle............................34klor-con/ef.....................................34KOATE..........................................20KOATE-DVI.................................. 20KOGENATE FS............................ 20KORLYM.......................................40KOSELUGO..................................15KOVALTRY...................................20K-PHOS........................................34K-PHOS-NEUTRAL......................34k-prime..........................................34KRINTAFEL..................................16kurvelo.......................................... 42KUVAN......................................... 37
L.E.T............................................... 5labetalol hcl ...................................23LACRISERT..................................52lactic acid......................................29lactic acid e...................................29lactulose........................................36lactulose encephalopathy............. 36LAMICTAL XR.............................. 10lamivudine...............................18, 19lamivudine-zidovudine.................. 19lamotrigine.................................... 10lamotrigine er................................10lamotrigine starter kit-blue............ 10lamotrigine starter kit-green..........10lamotrigine starter kit-orange........10LANCETS..................................... 32LANOXIN......................................23LANOXIN PEDIATRIC..................23lansoprazole................................. 35lanthanum carbonate....................37LANTUS SOLOSTAR...................33LANTUS U-100 VIAL....................33larin 1.5/30....................................42larin 1/20.......................................42larin 24 fe......................................42larin fe 1.5/30................................42larin fe 1/20...................................42larissia...........................................42LASTACAFT.................................52latanoprost....................................51LATEX GLOVES MEDIUM...........48LATUDA........................................18layolis fe........................................42leena.............................................42leflunomide................................... 44LENVIMA (10 MG DAILY DOSE). 15LENVIMA (12 MG DAILY DOSE). 15LENVIMA (14 MG DAILY DOSE). 15LENVIMA (18 MG DAILY DOSE). 15LENVIMA (20 MG DAILY DOSE). 15LENVIMA (24 MG DAILY DOSE). 15LENVIMA (4 MG DAILY DOSE)... 15LENVIMA (8 MG DAILY DOSE)... 15lessina...........................................42letrozole........................................ 15leucovorin calcium........................ 15LEUKERAN.................................. 15LEUKINE...................................... 20leuprolide acetate......................... 39LEUPROLIDE ACETATE-BUPIVACAINE..............................39levalbuterol hcl ..............................55LEVALBUTEROL HFA................. 55LEVEMIR U-100 FLEXTOUCH.... 33LEVEMIR U-100 VIAL.................. 33levetiracetam................................ 10levetiracetam er............................ 10
levobunolol hcl ..............................51LEVOCARNITINE.........................34levocarnitine..................................34levocarnitine sf..............................34levocetirizine dihydrochloride........53levofloxacin...............................8, 51levonest........................................ 42levonorgest-eth est & eth est........42levonorgest-eth estrad 91-day......42levonorgestrel-ethinyl estrad.........42levonorg-eth estrad triphasic........ 42levora 0.15/30 (28)........................42levorphanol tartrate.........................3levo-t .............................................44levothyroxine sodium....................44levoxyl...........................................44LEVULAN KERASTICK................29LEXIVA......................................... 19lidocaine..........................................5lidocaine hcl ..............................5, 26LIDOCAINE HCL............................ 5lidocaine hcl (pf) ..............................5lidocaine hcl urethral/mucosal........ 5LIDOCAINE IN DEXTROSE...........6lidocaine viscous hcl.....................26lidocaine-epinephrine......................6lidocaine-prilocaine.........................6LIDOCAINE-SODIUM BICARBONATE..............................6LIDO-EPINEPHRINE-TETRACAINE.................................6lillow..............................................42LINCOCIN.......................................8lincomycin hcl ................................. 8lindane.......................................... 16linezolid...........................................8LINZESS.......................................36liothyronine sodium.......................44LIPO..............................................34LIPO-C..........................................34LIPOFEN...................................... 23lisinopril .........................................23lisinopril-hydrochlorothiazide........ 23lithium........................................... 20lithium carbonate.......................... 20lithium carbonate er...................... 20LITHOBID..................................... 20LITHOSTAT..................................37LIVALO......................................... 23LODINE.......................................... 5lojaimiess......................................42LOKELMA.....................................34LOMAIRA......................................26LOMOTIL......................................36LONHALA MAGNAIR REFILL KIT................................................ 55
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LONHALA MAGNAIR STARTER KIT................................................ 55LONSURF.....................................15LOOP............................................48loperamide hcl.............................. 36LOPID...........................................23lopinavir-ritonavir .......................... 19lopreeza........................................42LOPRESSOR............................... 23LOPRESSOR HCT.......................23LOPROX.......................................12lorazepam.....................................20lorazepam intensol........................20LORBRENA..................................15lorcet...............................................3lorcet hd..........................................3LORTAB......................................... 3loryna............................................42LORZONE.................................... 56losartan potassium........................23losartan potassium-hctz................23LOSEASONIQUE......................... 42LOTEMAX SM.............................. 51LOTENSIN....................................23LOTENSIN HCT........................... 23loteprednol etabonate...................51lovastatin.......................................23LOVENOX...................................... 9low-ogestrel .................................. 42loxapine succinate........................ 18lo-zumandimine............................ 42LUCEMYRA....................................6LUCENTIS....................................52ludent............................................34LUMIGAN..................................... 51LUPANETA PACK........................39LUPRON DEPOT (1-MONTH)......39LUPRON DEPOT (3-MONTH)......39LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG..... 40LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG..... 40LUPRON DEPOT-PED (1-MONTH)....................................... 40LUPRON DEPOT-PED (3-MONTH)....................................... 40lutera.............................................42LUXIQ...........................................29LYNPARZA...................................15LYRICA CR...................................26LYSINE HCL.................................34LYSODREN..................................15LYSTEDA..................................... 20lyza............................................... 42MACROBID.................................... 8MACRODANTIN.............................8mafenide acetate............................ 8
MAGNEBIND 400.........................34magnesium chloride......................34magnesium sulfate........................34MAGNESIUM SULFATE.............. 34MAKENA.......................................42MALARONE..................................16malathion...................................... 16maprotiline hcl ...............................11MARCAINE.....................................6MARCAINE PRESERVATIVE FREE.............................................. 6MARCAINE/EPINEPHRINE........... 6MARCAINE/EPINEPHRINE PF......6MARINOL..................................... 12marlissa........................................ 42MARPLAN.................................... 11MASK VORTEX............................48MATULANE.................................. 15matzim la...................................... 23MAVENCLAD (10 TABS)..............25MAVENCLAD (4 TABS)................25MAVENCLAD (5 TABS)................25MAVENCLAD (6 TABS)................25MAVENCLAD (7 TABS)................25MAVENCLAD (8 TABS)................25MAVENCLAD (9 TABS)................26MAVYRET.................................... 19MAXICOMFORT SYR 27G X 1/2"............................................... 33MAXIDEX......................................51MAXITROL................................... 52maxi-tuss ac..................................53MAXZIDE......................................23MAXZIDE-25.................................23MAYZENT.....................................26MAYZENT STARTER PACK........26meclizine hcl ................................. 12meclofenamate sodium...................5MEDICAL COMPRESSION STOCKINGS.................................48MEDROL...................................... 38MEDROX-RX..................................3medroxyprogesterone acetate......42mefenamic acid...............................5mefloquine hcl ...............................16megestrol acetate......................... 42MEKINIST.....................................15MEKTOVI......................................15melodetta 24 fe.............................42meloxicam.......................................5melphalan..................................... 15memantine hcl .............................. 10memantine hcl er.......................... 10MEMBRANEBLUE........................52MENEST.......................................42MENOPUR................................... 40MENOSTAR................................. 42
meperidine hcl ................................ 3MEPHYTON................................. 34meprobamate................................20MEPRON......................................16mercaptopurine.............................15mesalamine.................................. 45mesalamine er.............................. 45mesalamine-cleanser....................45MESNEX.......................................15MESTINON...................................13metadate er...................................25metaproterenol sulfate..................55metaxalone................................... 56metformin hcl er............................31metformin hcl ir ............................. 31methadone hcl................................ 3methadone hcl intensol...................3methadose......................................4methadose sugar-free.....................4methamphetamine hcl.................. 25methazolamide............................. 51methenamine hippurate..................8methergine....................................48methimazole................................. 44METHITEST................................. 39methocarbamol.............................56methotrexate.................................44methotrexate (anti-rheumatic).......44methotrexate sodium.................... 44methotrexate sodium (pf)..............44methoxsalen rapid........................ 29methscopolamine bromide............36METHYLCOBALAMIN..................34methyldopa................................... 23methyldopa-hydrochlorothiazide...23methylergonovine maleate............48METHYLIN....................................25methylphenidate hcl ......................25methylphenidate hcl er..................25methylphenidate hcl er (cd).......... 25methylphenidate hcl er (la)........... 25methylprednisolone.......................38METHYLPREDNISOLONE ACETATE..................................... 38methylprednisolone acetate..........38methylprednisolone sodium succ..38METHYLPREDNISOLONE-BUPIVACAINE..............................38methyltestosterone....................... 39metoclopramide hcl.......................12metolazone................................... 23metoprolol succinate er.................23metoprolol tartrate.........................23metoprolol-hydrochlorothiazide.....23METROCREAM............................29METROLOTION........................... 29metronidazole........................... 8, 29
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metyrosine.................................... 23mexiletine hcl................................23MI PASTE.....................................26MI PASTE PLUS...........................26MIACALCIN.................................. 46mibelas 24 fe................................ 42miconazole 3.................................12MICRHOGAM ULTRA-FILTERED PLUS..........................45MICROAIR VIBRATING MESH NEBUL..........................................48MICROCHAMBER........................48MICROCYN.................................. 29microgestin 1.5/30........................ 42microgestin 1/20........................... 42microgestin fe 1.5/30.................... 42microgestin fe 1/20....................... 42MICROLET NEXT LANCING DEVICE........................................ 32MICRONEB.................................. 48midodrine hcl................................ 23MIGERGOT.................................. 13miglitol ...........................................31miglustat....................................... 37MIGRANAL...................................13mili ................................................ 42MILLIPRED...................................38MILLIPRED DP 12-DAY............... 39mimvey......................................... 42mineral oil heavy...........................36MINIMED GUARDIAN SENSOR 3....................................................32MINIPRESS..................................23minitran.........................................23MINIVELLE...................................42minocycline hcl............................... 8minocycline hcl er........................... 8minoxidil ........................................23MIRAPEX......................................17MIRAPEX ER................................17MIRCERA..................................... 20MIRCETTE................................... 42mirtazapine................................... 11MIRVASO..................................... 29misoprostol ................................... 35mitigo.............................................. 4MITOSOL......................................51modafinil ....................................... 56moexipril hcl ..................................23molindone hcl................................18mometasone furoate...............29, 53MONARCH ETNS SYSTEM.........48mondoxyne nl................................. 8mono-linyah.................................. 42MONONINE..................................20montelukast sodium......................55MONUROL..................................... 8
morgidox.........................................8MORPHINE SULFATE................... 4morphine sulfate............................. 4morphine sulfate (concentrate).......4morphine sulfate (pf) .......................4morphine sulfate er.........................4morphine sulfate er beads.............. 4MORPHINE SULFATE-NACL........ 4MOTEGRITY................................ 36MOXEZA.......................................51moxifloxacin hcl ........................ 8, 51moxifloxacin hcl (2x day).............. 51MOZOBIL......................................20MUCOTROL................................. 48MUGARD......................................48MULPLETA...................................21MULTAQ.......................................23mupirocin........................................ 8mupirocin calcium...........................8MUSE........................................... 37MYALEPT.....................................37MYAMBUTOL...............................13MYCOBUTIN................................ 13mycophenolate mofetil ..................45mycophenolate sodium.................45MYDAYIS......................................25MYFORTIC...................................45MYLERAN.................................... 15MYOBLOC....................................49myorisan....................................... 29MYRBETRIQ................................ 37MYTESI........................................ 36nabumetone....................................5n-acetyl-l-cysteine.........................34nadolol .......................................... 23nafcillin sodium............................... 8nafrinse.........................................34NAFRINSE DAILY ACIDULATED 27NAFRINSE DAILY/NEUTRAL...... 27nafrinse drops...............................34NAFRINSE WEEKLY....................27naftifine hcl....................................12NAFTIN.........................................12nalbuphine hcl .................................4naloxone hcl....................................6naltrexone hcl ................................. 6NAMENDA....................................10NAMENDA TITRATION PAK........10NAMENDA XR..............................10NAMENDA XR TITRATION PACK............................................10NAMZARIC...................................10naproxen.........................................5naproxen dr.....................................5naproxen sodium............................ 5naproxen sodium er........................5naproxen-esomeprazole.................5
naratriptan hcl...............................13NARCAN.........................................6NARDIL.........................................11NAROPIN....................................... 6NASCOBAL.................................. 34NATACYN.....................................51NATAZIA.......................................42nateglinide.................................... 31NATESTO.....................................39NATPARA.....................................46NATURE-THROID........................44NAYZILAM....................................10NEB-RITE4...................................49NEBULIZER PED FROG..............49NEBULIZER PED FROG KIT....... 49NEBULIZER SYSTEM ALL-IN-ONE..............................................49NEBUPENT.................................. 16nebusal......................................... 53NEBUSAL.....................................53necon 0.5/35 (28)..........................42nefazodone hcl............................. 11NEMBUTAL.................................. 10NEOKE ALCAR............................ 34NEOKE RA LIPOIC...................... 49neomycin sulfate.............................8neomycin-bacitracin zn-polymyx...52neomycin-polymyxin-dexameth.... 52neomycin-polymyxin-gramicidin....52neomycin-polymyxin-hc.......... 52, 53neo-polycin................................... 52neo-polycin hc...............................52NEORAL.......................................45NEO-SYNALAR............................29NERIVIO.......................................49NERLYNX.....................................15NESACAINE...................................6NESACAINE-MPF.......................... 6neuac............................................29NEULASTA...................................21NEULASTA ONPRO.....................21NEUPRO...................................... 17neutral sodium fluoride................. 27nevirapine..................................... 19nevirapine er.................................19NEXAVAR.....................................15NEXAVIR......................................49NEXIUM........................................35niacin (antihyperlipidemic)............ 23niacin er (antihyperlipidemic)........23niacor............................................23nicardipine hcl...............................23NICOTROL..................................... 6NICOTROL NS............................... 6nifedipine...................................... 23nifedipine er.................................. 23nifedipine er osmotic release........23
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nikki ...............................................42NILANDRON.................................15nilutamide..................................... 15nimodipine.................................... 23NINLARO......................................15nisoldipine er.................................23nitisinone.......................................37NITRILE GLOVES LARGE...........49NITRO-BID................................... 23NITRO-DUR..................................23nitrofurantoin...................................8nitrofurantoin macrocrystal ............. 8nitrofurantoin monohydrate macrocrystals..................................8nitroglycerin.................................. 23NITROLINGUAL........................... 23NITROMIST..................................23nitro-time.......................................23NITYR...........................................37NIVESTYM................................... 21nizatidine.......................................35NOCDURNA.................................40nolix.............................................. 29nora-be......................................... 43NORDIPEN 5 INJECTION DEVICE........................................ 49NORDITROPIN FLEXPRO...........40norethin ace-eth estrad-fe.............43norethindrone................................43norethindrone acetate...................43norethindrone acet-ethinyl est...... 43norethindrone-eth estradiol ...........43norethin-eth estradiol-fe................43norgestimate-eth estradiol ............ 43norgestimate-ethinyl estradiol triphasic........................................ 43norlyda..........................................43norlyroc.........................................43NORM-JECT LUER SLIP SYRINGE......................................49NORMLGEL AG........................... 29NORPACE....................................23NORPACE CR..............................23NORPRAMIN................................11NORTHERA..................................24nortrel 0.5/35 (28)......................... 43nortrel 1/35 (21)............................ 43nortrel 1/35 (28)............................ 43nortrel 7/7/7...................................43nortriptyline hcl..............................11NORVIR........................................19NOURIANZ...................................17NOVACHOR.................................29novarel..........................................40NOVAREL.....................................40NOVOEIGHT................................ 21
NOVOFINE AUTOCOVER PEN NEEDLE....................................... 33NOVOFINE PEN NEEDLE........... 33NOVOFINE PLUS PEN NEEDLE.33NOVOPEN ECHO........................ 32NOVOSEVEN RT......................... 21NOVOTWIST PEN NEEDLE........ 33NOXAFIL...................................... 12NOZIN NASAL SANITIZER POPSWAB....................................49np thyroid......................................44NPLATE........................................21NS-2 ELECTRIC PATCH POUCH.........................................49NUBEQA.......................................15NUCALA....................................... 53NUCEL..........................................29NUEDEXTA.................................. 26nulev............................................. 36NUPLAZID....................................18NURTEC.......................................13NUSHIELD....................................29NUTROPIN AQ NUSPIN 10......... 40NUTROPIN AQ NUSPIN 20......... 40NUTROPIN AQ NUSPIN 5........... 40NUVARING...................................43NUWIQ......................................... 21NUZYRA.........................................8nyamyc......................................... 12NYMALIZE....................................24nystatin................................... 12, 13nystatin-triamcinolone...................13nystop........................................... 13OBIZUR........................................ 21OCALIVA...................................... 37ocella............................................ 43octreotide acetate......................... 40OCUFLOX.................................... 51ODEFSEY.....................................19ODOMZO......................................15OFEV............................................55ofloxacin..............................8, 51, 53olanzapine.................................... 18olanzapine-fluoxetine hcl .............. 11olmesartan medoxomil ..................24olmesartan medoxomil-hctz..........24olmesartan-amlodipine-hctz..........24olopatadine hcl........................51, 53OLUX............................................29OLUX-E........................................ 29OMECLAMOX-PAK......................36omega-3-acid ethyl esters............ 24omeprazole...................................35OMEPRAZOLE+SYRSPEND SF ALKA.............................................35OMNARIS.....................................53OMNIPOD DASH 5 PACK PODS.49
OMNIPOD DASH SYSTEM..........32OMNIPOD STARTER...................32ONCASPAR..................................15ondansetron hcl............................ 12ondansetron odt............................12ONE FLOW SPIROMETER..........49ONETOUCH DELICA LANCING DEV.............................................. 32ONETOUCH DELICA PLUS LANCING......................................32ONETOUCH ULTRA.................... 32ONETOUCH ULTRA 2 KIT W/DEVICE....................................32ONETOUCH ULTRA MINI KIT W/DEVICE....................................32ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE..............32ONETOUCH VERIO IQ SYSTEM 32ONETOUCH VERIO KIT W/DEVICE....................................32ONETOUCH VERIO REFLECT....32ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE..............32ONEXTON....................................29OPSUMIT..................................... 56ORABLOC...................................... 6ORACIT........................................ 34oralone..........................................27ORAMAGICRX............................. 49ORAPEUTIC.................................49ORAPRED ODT........................... 39ORENCIA..................................... 45ORENCIA CLICKJECT.................45ORENITRAM................................ 56ORFADIN......................................37ORILISSA..................................... 40ORKAMBI..................................... 55orphenadrine citrate......................56orphenadrine citrate er..................56orphenadrine-asa-caffeine............56orsythia......................................... 43oscimin..........................................36oseltamivir phosphate...................19OSMOPREP.................................36OSPHENA.................................... 39OSTEOCONDUCTIVE MATRIX PLUS............................................ 29OTEZLA........................................45OTICIN HC NR............................. 53OTREXUP.................................... 45OVIDE...........................................16OVIDREL......................................40oxacillin sodium.............................. 8oxandrolone..................................39oxaprozin........................................ 5oxazepam..................................... 20oxcarbazepine.............................. 10
69
OXERVATE.................................. 52oxiconazole nitrate........................13OXSORALEN ULTRA...................29oxybutynin chloride.......................37oxybutynin chloride er...................37oxycodone hcl.................................4oxycodone-acetaminophen.............4oxycodone-aspirin...........................4OXYCONTIN.................................. 4oxymorphone hcl............................ 4oxymorphone hcl er........................ 4oxytocin.........................................40OXYTROL.....................................37OZEMPIC..................................... 31OZURDEX.................................... 51PACERONE..................................24pacerone.......................................24PAIN RELIEF WITH TENS S2000........................................... 49paliperidone er..............................18PALYNZIQ....................................37PANDA MASK LARGE.................49PANDA MASK MEDIUM...............49PANDA MASK SMALL................. 49PANRETIN....................................15pantoprazole sodium.................... 35PARADIGM REAL-TIME STARTER.....................................32PARI ALTERA NEBULIZER HANDSET.....................................49PARI MASK SET.......................... 49PARI TREK S COMBO PACK......49paricalcitol .....................................46PARLODEL...................................17PARNATE.....................................11paroex...........................................27paromomycin sulfate.......................8paroxetine hcl............................... 11paroxetine hcl er........................... 11paroxetine mesylate......................11PASER..........................................13PATANASE...................................53PAXIL............................................11PEDIAPRED.................................39PEDIATRIC PANDA MASK..........49peg 3350-kcl-na bicarb-nacl......... 36peg-3350/electrolytes................... 36PEGANONE................................. 10PEGASYS.....................................19PEGASYS PROCLICK................. 19PEGINTRON................................ 19peg-prep....................................... 36penicillamine.................................37penicillin g potassium......................8penicillin g procaine........................ 8penicillin g sodium.......................... 8penicillin v potassium......................8
PENTAM.......................................16pentamidine isethionate................16PENTASA.....................................45pentazocine-naloxone hcl...............4PENTETATE CALCIUM TRISODIUM..................................49PENTETATE ZINC TRISODIUM..49pentobarbital sodium.................... 10pentoxifylline er.............................24PERFOROMIST........................... 55PERIDEX......................................27perindopril erbumine.....................24periogard.......................................27permethrin.....................................16perphenazine................................12perphenazine-amitriptyline............11PERSERIS....................................18PEXEVA....................................... 11PFIZERPEN....................................8phenazo........................................37phenazopyridine hcl......................37phendimetrazine tartrate...............26phendimetrazine tartrate er...........26phenelzine sulfate.........................11PHENERGAN...............................53phenobarbital ................................10phenobarbital sodium................... 10phenobarbital-belladonna alk........36phenoxybenzamine hcl .................24phentermine hcl ............................ 26phentolamine mesylate.................24phenylephrine hcl..........................52PHENYTEK.................................. 10phenytoin...................................... 10phenytoin infatabs.........................10phenytoin sodium..........................10phenytoin sodium extended..........10philith............................................ 43PHOSLYRA.................................. 37phospha 250 neutral .....................34PHOSPHOLINE IODIDE.............. 51phosphorous.................................34phospho-trin 250 neutral ...............34PHOTREXA VISCOUS.................49PHOTREXA-PHOTREXA VISCOUS KIT...............................49phytonadione................................ 34PICATO........................................ 29PIFELTRO.................................... 19pilocarpine hcl .........................27, 51pimecrolimus.................................29pimozide....................................... 18pimtrea..........................................43pindolol ......................................... 24pioglitazone hcl.............................31pioglitazone hcl-glimepiride.......... 31pioglitazone hcl-metformin hcl ...... 31
PIQRAY (200 MG DAILY DOSE). 15PIQRAY (250 MG DAILY DOSE). 15PIQRAY (300 MG DAILY DOSE). 15pirmella 1/35................................. 43pirmella 7/7/7................................ 43piroxicam........................................ 5PITOCIN....................................... 40PLAQUENIL..................................16PLENVU....................................... 36pocket spacer............................... 49podofilox....................................... 29polocaine........................................ 6polocaine-mpf................................. 6polycin...........................................52polymyxin b sulfate......................... 8polymyxin b-trimethoprim..............52POLYTOZA PATCH..................... 49POLYTRIM................................... 52POMALYST.................................. 15portia-28........................................43posaconazole................................13pot bicarb-pot chloride.................. 34potassium bicarbonate..................34potassium chloride........................35potassium chloride crys er............35potassium chloride er....................35potassium citrate er...................... 35POVIDONE-IODINE..................... 51POWDER FREE NITRILE GLOVES SM.................................49PRADAXA.......................................9pralidoxime chloride......................49PRALUENT...................................24pramipexole dihydrochloride.........17pramipexole dihydrochloride er.....17PRAMOSONE.............................. 29PRAMOTIC...................................53prasugrel hcl ................................. 17pravastatin sodium........................24praziquantel .................................. 16prazosin hcl...................................24PRECOSE.................................... 31PRED MILD.................................. 51PRED-G........................................52PRED-G S.O.P............................. 52prednicarbate................................29prednisolone................................. 39prednisolone acetate.................... 51prednisolone sodium phosphate................................................ 39, 51prednisone....................................39prednisone intensol.......................39PREFEST..................................... 43pregabalin.....................................26pregnyl..........................................40PREMARIN...................................43PREMPHASE............................... 43
70
PREMPRO....................................43prenatal.........................................35PREPIV SUPPLY........................... 6PRESTALIA..................................24PRETOMANID..............................13prevalite........................................ 24PREVIDENT................................. 27prevident.......................................27PREVIDENT 5000 BOOSTER PLUS............................................ 27PREVIDENT 5000 DRY MOUTH. 27PREVIDENT 5000 ENAMEL PROTECT.....................................27PREVIDENT 5000 ORTHO DEFENSE.....................................27PREVIDENT 5000 PLUS..............27PREVIDENT 5000 SENSITIVE.... 27previfem........................................43PREVYMIS................................... 19PREZCOBIX.................................19PREZISTA.................................... 19PRIFTIN........................................13PRILOSEC....................................35primaquine phosphate.................. 16primidone......................................10PRIMSOL........................................8PRO COMFORT SPACER ADULT..........................................49PRO COMFORT SPACER CHILD...........................................49PRO COMFORT SPACER INFANT.........................................49PRO COMFORT TENS UNIT.......49PROAIR DIGIHALER....................55PROAIR HFA................................55PROAIR RESPICLICK..................55probenecid....................................13PROBUPHINE IMPLANT KIT.........4procainamide hcl...........................24PROCARDIA................................ 24PROCARDIA XL...........................24PROCARE SPACER/ADULT MASK............................................49PROCARE SPACER/CHILD MASK............................................49PROCENTRA............................... 25prochlorperazine...........................12prochlorperazine edisylate............12prochlorperazine maleate............. 12PROCTOFOAM HC......................45procto-med hc...............................45procto-pak.....................................45proctosol hc.................................. 45proctozone-hc...............................45PROCYSBI................................... 37PROFILNINE................................ 21PROFILNINE SD.......................... 21
progesterone.................................43progesterone micronized.............. 43PROGLYCEM...............................33PROGRAF....................................45PROLENSA.................................. 51PROLIA.........................................46PROMACTA................................. 21promethazine hcl .......................... 53promethazine-codeine.................. 53promethazine-dm..........................53promethazine-phenyleph-codeine 53promethazine-phenylephrine........ 53promethegan.................................53propafenone hcl ............................24propafenone hcl er........................24propantheline bromide..................36proparacaine hcl ........................... 52propranolol hcl .............................. 24propranolol hcl er..........................24propranolol-hctz............................24propylthiouracil ..............................44PROSCAR....................................38PROSTIN VR................................24PROTONIX...................................35PROTOPIC...................................29protriptyline hcl ..............................11PROVENT SLEEP APNEA THERAPY.....................................49PROVENT SR SLEEP APNEA THERAPY.....................................49PROVENTIL HFA......................... 55PROVERA.................................... 43pseudoephedrine-bromphen-dm.. 53PULMICORT FLEXHALER...........55pulmosal....................................... 53PULMOZYME...............................55PURIXAN......................................15PYLERA........................................36pyrazinamide................................ 14pyridostigmine bromide.................13pyridostigmine bromide er............ 13PYRIDOXINE HCL....................... 35pyridoxine hcl................................35pyrimethamine.............................. 16PYRIMETHAMINE-LEUCOVORIN..............................16PYROGALLIC ACID..................... 29QBREXZA.....................................29QINLOCK......................................15QNASL..........................................53QNASL CHILDRENS....................53QSYMIA........................................26QUALAQUIN.................................16QUARTETTE................................43quazepam.....................................20QUELICIN.....................................26quetiapine fumarate......................18
quetiapine fumarate er..................18QUILLICHEW ER......................... 25QUILLIVANT XR...........................25quinapril hcl ...................................24quinapril-hydrochlorothiazide........24quinidine gluconate er...................24quinidine sulfate............................24quinine sulfate...............................16rabeprazole sodium...................... 35RADIAPLEXRX.............................29RADIOGARDASE.........................49raloxifene hcl.................................39ramelteon......................................56ramipril ..........................................24ranolazine er.................................24RAPAFLO.....................................38RAPAMUNE................................. 45RAPPORT RLS............................ 49RAPPORT VTD............................ 49rasagiline mesylate.......................17RASUVO.......................................45RAVICTI........................................37RAYALDEE...................................46RAZADYNE.................................. 10RAZADYNE ER............................ 10REBIF........................................... 26REBIF REBIDOSE........................26REBIF REBIDOSE TITRATION PACK............................................26REBIF TITRATION PACK............ 26REBINYN......................................21REBLOZYL...................................21reclipsen....................................... 43RECOMBINATE........................... 21RECOTHROM.............................. 21RECOTHROM SPRAY KIT.......... 21RECTIV.........................................24REGENECARE.............................29REGLAN.......................................12REGRANEX..................................29RELENZA DISKHALER................19relexxii ...........................................25REMERON................................... 11REMERON SOLTAB.................... 11REMESENSE............................... 27repaglinide.................................... 31REPATHA.....................................24REPATHA PUSHTRONEX SYSTEM.......................................24REPATHA SURECLICK............... 24REQUIP XL...................................17RESTASIS....................................52RESTASIS MULTIDOSE..............52RESTORA RX.............................. 36RETACRIT....................................21RETIN-A MICRO PUMP...............29RETROVIR................................... 19
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REVATIO......................................56REVCOVI......................................37REVLIMID.....................................15REXULTI.......................................18REYATAZ..................................... 19RHOFADE.................................... 29RHOGAM ULTRA-FILTERED PLUS............................................ 45RHOPHYLAC............................... 45RHOPRESSA............................... 51RIASTAP...................................... 21ribavirin......................................... 19RIDAURA......................................45rifabutin.........................................14RIFADIN....................................... 14rifampin.........................................14RILUTEK.......................................26riluzole.......................................... 26rimantadine hcl............................. 19RIMSO-50.....................................37RINVOQ........................................45RIOMET........................................31RIOMET ER..................................31risedronate sodium....................... 46RISPERDAL CONSTA................. 18risperidone....................................18ritonavir .........................................19RITUXAN HYCELA.......................15rivastigmine...................................10rivastigmine tartrate...................... 10rivelsa........................................... 43RIXUBIS....................................... 21rizatriptan benzoate...................... 13ROBAXIN......................................56ROBAXIN-750.............................. 56ROCALTROL................................46ROCKLATAN................................51ropinirole hcl................................. 17ropinirole hcl er............................. 17ropivacaine hcl................................6rosadan.........................................29rosuvastatin calcium..................... 24ROWASA......................................45roweepra.......................................10roweepra xr...................................10ROZEREM....................................56ROZLYTREK................................ 15RUBRACA.................................... 15RUSCH FLOCATH QUICK 16FR.49RUZURGI..................................... 49RYBELSUS...................................31RYCLORA.................................... 53RYDAPT....................................... 15RYTARY....................................... 17RYTHMOL SR.............................. 24ryvent............................................54SALAGEN.....................................27
SALICEPT.................................... 49saline bacteriostatic...................... 35SALINE-PHENOL.........................35SAMSCA.......................................35SANDIMMUNE............................. 45SANTYL........................................29SAPHRIS......................................18SARAFEM.................................... 11SAVAYSA.......................................9SAVELLA......................................26SAVELLA TITRATION PACK.......26SAVI..............................................49SAXENDA.....................................26SCENESSE.................................. 29SCLEROSOL INTRAPLEURAL....55scopolamine..................................12SECONAL.....................................56selegiline hcl ................................. 17selenium sulfide............................30SELZENTRY.................................19sensorcaine.................................... 6sensorcaine/epinephrine.................6sensorcaine-mpf............................. 6sensorcaine-mpf/epinephrine......... 6SENSORCAINE-MPF/EPINEPHRINE.......................6SEREVENT DISKUS....................55SERNIVO......................................30SEROSTIM...................................36sertraline hcl ................................. 11setlakin..........................................43sevelamer carbonate.................... 37sevelamer hcl ................................37SEYSARA.......................................8sf...................................................27sf 5000 plus.................................. 27SFROWASA................................. 45sharobel........................................43SHARPS CONTAINER.................49SIDESTREAM ADULT FACE MASK............................................49SIDESTREAM PEDIATRIC FACE MASK.................................49SIGNIFOR.................................... 40SIGNIFOR LAR............................ 40SIKLOS.........................................15sildenafil citrate.......................37, 56SILENOR......................................56SILIQ.............................................45silodosin........................................38silver sulfadiazine........................... 8SILVERSEAL HYDROGEL DRESSING...................................30SIMBRINZA.................................. 51simliya...........................................43simpesse.......................................43SIMPONI.......................................45
simvastatin....................................24SINEMET......................................17SINUVA........................................ 54sirolimus........................................45SIRTURO......................................14SITAVIG........................................19SKLICE.........................................16SKYRIZI (150 MG DOSE)............ 45sod citrate-citric acid.....................35sodium bicarbonate...................... 36sodium chloride.......................35, 54sodium chloride (pf) ...................... 35sodium chloride bacteriostatic...... 35SODIUM CITRATE.........................9sodium fluoride....................... 27, 35sodium fluoride 5000 plus.............27sodium fluoride 5000 ppm............ 27sodium fluoride 5000 sensitive..... 27sodium phenylbutyrate..................37sodium polystyrene sulfonate....... 35sodium saccharin..........................49SOF-SENSOR..............................32SOLESTA..................................... 49solifenacin succinate.....................38SOLIQUA......................................31SOLOSEC...................................... 8SOLTAMOX..................................15SOLU-CORTEF............................39SOLU-MEDROL........................... 39SOMATULINE DEPOT.................40SOMAVERT..................................40SOOLANTRA................................30SORIATANE.................................30sorine............................................24sotalol hcl ......................................24sotalol hcl (af) ............................... 24SOTYLIZE.................................... 24SOVALDI...................................... 19SPARKY THE DOG PED NEBULIZER..................................49spinosad....................................... 17SPIRIVA HANDIHALER............... 55SPIRIVA RESPIMAT.................... 55spironolactone.............................. 24spironolactone-hctz.......................24SPORANOX................................. 13SPORANOX PULSEPAK............. 13SPRAVATO (56 MG DOSE).........11SPRAVATO (84 MG DOSE).........11sprintec 28.................................... 43SPRYCEL.....................................15sps................................................ 35sronyx........................................... 43ssd.................................................. 8STALEVO 100.............................. 17STALEVO 125.............................. 17STALEVO 150.............................. 17
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STALEVO 200.............................. 17STALEVO 50................................ 17STALEVO 75................................ 17STARLIX.......................................31stavudine...................................... 19STELARA..................................... 45STERILE TALC POWDER........... 55sterile water for injection...............50STERITALC..................................55STIMATE...................................... 40STIOLTO RESPIMAT...................55STIVARGA....................................15STRENSIQ................................... 37streptomycin sulfate........................8STRIBILD......................................19STRIVERDI RESPIMAT............... 55STROMECTOL.............................17SUBLOCADE..................................6subvenite...................................... 10subvenite starter kit-blue...............10subvenite starter kit-green............ 10subvenite starter kit-orange.......... 10SUCCINYLCHOLINE CHLORIDE................................... 26succinylcholine chloride................26SUCRAID......................................37sucralfate...................................... 35SULAR..........................................24sulfacetamide sodium...................51sulfacetamide sodium (acne)........30sulfacetamide-prednisolone..........52sulfadiazine.....................................8sulfamethoxazole-trimethoprim.......8SULFAMYLON............................... 8sulfasalazine.................................45sulfatrim pediatric............................8sulfurated lime.............................. 17sulindac...........................................5sumatriptan...................................13sumatriptan succinate...................13sumatriptan succinate refill ........... 13sumatriptan-naproxen sodium...... 13SUNOSI........................................56SUPPRELIN LA............................40SUPRAX.........................................8SUPREP BOWEL PREP KIT........36SURESTEP PRO HIGH GLUCOSE.................................... 32SURESTEP PRO LOW GLUCOSE.................................... 32SURESTEP PRO NORMAL GLUCOSE.................................... 32SURGICEL FIBRILLAR................ 50SURGICEL NU-KNIT....................50SURVANTA.................................. 54SUSTIVA...................................... 19SUSTOL....................................... 12
SUTENT....................................... 15syeda............................................ 43SYMBICORT................................ 55SYMBYAX.................................... 11SYMDEKO....................................55SYMFI...........................................19SYMFI LO.....................................19SYMJEPI...................................... 55SYMLINPEN 120..........................31SYMLINPEN 60............................31SYMPAZAN..................................10SYMPROIC...................................36SYMTUZA.....................................19SYNAGIS......................................45SYNALAR.....................................30SYNAREL.....................................40SYNDROS....................................12SYNJARDY...................................31SYNJARDY XR.............................31SYNRIBO......................................15SYRINGE AVITENE..................... 50SYRINGE LUER LOCK................ 50SYRINGE LUER SLIP.................. 50SYRINGE PRECISEDOSE DISPENSER.................................50TABLOID...................................... 15TACHOSIL....................................50TACLONEX.................................. 30tacrolimus............................... 30, 45tadalafil ......................................... 38tadalafil (pah)................................56TAFINLAR.................................... 15TAGRISSO................................... 15TAKHZYRO.................................. 45TALICIA........................................ 36TALTZ...........................................45TALZENNA...................................15tamoxifen citrate........................... 15tamsulosin hcl ...............................38TAPAZOLE...................................44TARCEVA.....................................15TARGRETIN.................................15tarina 24 fe....................................43tarina fe 1/20.................................43tarina fe 1/20 eq............................43TARKA..........................................24TASIGNA......................................15TASMAR.......................................17TAURINE......................................35TAVALISSE.................................. 21tazarotene.....................................30tazicef............................................. 9TAZORAC.....................................30taztia xt ......................................... 24TECFIDERA................................. 26TEGSEDI......................................26TEKTURNA.................................. 24
TEKTURNA HCT..........................24TELFA AMD ISLAND DRESSING...................................50TELFA AMD NON-ADHERENT....50telmisartan.................................... 24telmisartan-amlodipine..................24telmisartan-hctz............................ 24temazepam...................................56TEMODAR....................................15TEMOVATE..................................30temozolomide............................... 15tencon.............................................4tenofovir disoproxil fumarate.........19TENORETIC 100..........................24TENORETIC 50............................24TEPADINA....................................15terazosin hcl ..................................38terbinafine hcl............................... 13terbutaline sulfate......................... 55terconazole................................... 13TESSALON PERLES................... 54testosterone..................................39testosterone cypionate..................39testosterone enanthate.................39tetrabenazine................................26tetracaine hcl............................ 6, 52tetracycline hcl ................................9TEXACORT.................................. 30THALOMID................................... 15THEO-24.......................................55theophylline...................................55theophylline er.............................. 55THERAHONEY.............................30thiamine hcl...................................35THIOLA.........................................38THIOLA EC...................................38thioridazine hcl ..............................18thiotepa.........................................16thiothixene.................................... 18THROMBI-GEL 10........................50THROMBI-GEL 100......................50THROMBI-GEL 40........................50THROMBIN-JMI............................21THROMBIN-JMI EPISTAXIS........21THROMBI-PAD.............................50THROMBOGEN............................21tiadylt er........................................ 24tiagabine hcl ..................................10TIAZAC.........................................24TIBSOVO......................................16TICE BCG.....................................45TIGAN...........................................12TIGLUTIK......................................26tilia fe............................................ 43timolol maleate........................24, 51tinidazole.........................................9TISSEEL.......................................50
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TIVICAY........................................19TIVICAY PD..................................19tizanidine hcl .................................56TOBI PODHALER.........................55TOBRADEX..................................52TOBRADEX ST............................ 52tobramycin.............................. 51, 55tobramycin sulfate...........................9tobramycin-dexamethasone......... 52TOBREX.......................................51TOLAK..........................................30tolbutamide................................... 31tolcapone...................................... 17tolmetin sodium...............................5tolterodine tartrate.........................38tolterodine tartrate er.................... 38tolvaptan....................................... 35TOPEX TOPICAL ANESTHETIC. 27TOPICORT................................... 30topiramate.....................................10topiramate er.................................10toremifene citrate..........................16torsemide......................................24TOUJEO MAX SOLOSTAR..........33TOUJEO SOLOSTAR...................33tovet..............................................30TOVIAZ.........................................38TRACLEER...................................56TRADJENTA.................................31tramadol hcl er................................4tramadol hcl er (biphasic)............... 4tramadol hcl ir ................................. 4tramadol-acetaminophen................4trandolapril ....................................24trandolapril-verapamil hcl er......... 24tranexamic acid.............................21TRANSDERM SCOP (1.5 MG).....12TRANSDERM-SCOP (1.5 MG).... 12TRANXENE-T...............................20tranylcypromine sulfate.................11TRAVATAN Z............................... 51travoprost (bak free)..................... 51trazodone hcl................................ 11TRECATOR..................................14TRELEGY ELLIPTA......................55TRELSTAR MIXJECT...................40TREMFYA.....................................45treprostinil ..................................... 56tretinoin...................................16, 30tretinoin microsphere.................... 30tretinoin microsphere pump.......... 30TRETTEN..................................... 21TREXALL......................................45TREZIX...........................................4tri femynor.....................................43triamcinolone acetonide....27, 30, 39TRIAMCINOLONE ACETONIDE..39
TRIAMCINOLONE DIACETATE...39TRIAMCINOLONE-BUPIVACAINE..............................39TRI-AMINO...................................35triamterene....................................24triamterene-hctz............................24trianex...........................................30triazolam....................................... 20TRI-CHLOR.................................. 30TRICITRASOL................................9triderm...........................................30TRIDESILON................................ 30trientine hcl................................... 35tri-estarylla.................................... 43TRIFERIC..................................... 35trifluoperazine hcl..........................18trifluridine...................................... 51trihexyphenidyl hcl ........................ 17TRIJARDY XR.............................. 31TRIKAFTA.................................... 55tri-legest fe....................................43tri-linyah........................................ 43TRILIPIX....................................... 24tri-lo-estarylla................................ 43tri-lo-marzia...................................43tri-lo-mili ........................................ 43tri-lo-sprintec.................................43trilyte............................................. 36trimethobenzamide hcl ..................12trimethoprim....................................9tri-mili ............................................ 43trimipramine maleate.................... 11TRINTELLIX................................. 11tri-previfem....................................43TRIPTODUR.................................40tri-sprintec.....................................43TRIUMEQ..................................... 19trivora (28).................................... 43tri-vylibra....................................... 43tri-vylibra lo................................... 43TRIZIVIR.......................................19TROKENDI XR............................. 10TROPICAMIDE-CYCLOPENTOLATE-PE..............52trospium chloride.......................... 38trospium chloride er...................... 38TRULICITY................................... 31TRUSOPT.....................................51TRUVADA.....................................19TRUZONE PEAK FLOW METER.50TUKYSA....................................... 16tulana............................................43TURALIO...................................... 16TWYNSTA.................................... 24TYBOST....................................... 19tydemy.......................................... 43TYKERB....................................... 16
TYMLOS.......................................46TYVASO....................................... 56TYVASO REFILL..........................56TYVASO STARTER..................... 56UCERIS........................................ 45UDENYCA.................................... 21ULORIC........................................ 13ULTRAFOAM SPONGE 2X6.25X7CM................................ 50ULTRAFOAM SPONGE 8X12.5X1CM................................ 50ULTRAFOAM SPONGE 8X12.5X3CM................................ 50ULTRAFOAM SPONGE 8X25X1CM................................... 50ULTRAFOAM SPONGE 8X6.25X1CM................................ 50UNASYN.........................................9unithroid........................................44UPTRAVI...................................... 56uretron d/s.....................................38urin ds...........................................38UROCIT-K 10............................... 35UROCIT-K 15............................... 35UROCIT-K 5................................. 35URSO 250.................................... 36URSO FORTE.............................. 36ursodiol ......................................... 36utrona-c.........................................38valacyclovir hcl ..............................19VALCHLOR.................................. 16valganciclovir hcl ...........................19valproic acid..................................10valrubicin.......................................16valsartan....................................... 24valsartan-hydrochlorothiazide.......25VALSTAR..................................... 16VALTOCO 10 MG DOSE..............10VALTOCO 15 MG DOSE..............10VALTOCO 20 MG DOSE..............10VALTOCO 5 MG DOSE................10VANCOCIN.....................................9VANCOCIN HCL.............................9vancomycin hcl ............................... 9vandazole....................................... 9VANTAS....................................... 40VAPRO PLUS CATHETER 12FR/8".........................................50VAPRO PLUS CATHETER 14FR/8".........................................50vardenafil hcl .................................38VARUBI (180 MG DOSE).............12VASCEPA.....................................25VASERETIC................................. 25vashe cleansing............................30VECAMYL.....................................25VELCADE.....................................16
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velivet............................................43VELPHORO..................................38VELTASSA................................... 35VEMLIDY......................................19VENCLEXTA................................ 16VENCLEXTA STARTING PACK.. 16VENELEX..................................... 30VENIPUNCTURE PX1 PHLEBOTOMY...............................6venlafaxine hcl..............................11venlafaxine hcl er..........................11VENTAVIS....................................56VENTOLIN HFA............................55verapamil hcl .................................25verapamil hcl er............................ 25VERELAN.....................................25VERELAN PM...............................25VERSACLOZ................................18VERZENIO................................... 16VFEND..........................................13VIBERZI........................................37VIBRAMYCIN................................. 9VICTOZA...................................... 31VIDAZA.........................................16VIEKIRA PAK............................... 19vienva........................................... 43vigabatrin...................................... 10vigadrone......................................10VIIBRYD....................................... 11VIIBRYD STARTER PACK...........11VIMPAT........................................ 10viorele........................................... 43VIRACEPT....................................19VIRAMUNE...................................19VIRAMUNE XR.............................19VIRAZOLE....................................19VIREAD........................................ 19virt-phos 250 neutral .....................35virtussin ac w/alc...........................54VISIONBLUE................................ 52VISTARIL......................................20VISTOGARD.................................50vitamin d (ergocalciferol) ...............35vitamin k1......................................35VITRAKVI..................................... 16VITRASE...................................... 50VIVAGUARD LANCING DEVICE. 32VIVITROL....................................... 6VIZIMPRO.................................... 16volnea........................................... 43VONVENDI...................................21voriconazole..................................13VORTEX HOLDING CHAMBER/MASK.........................50VOSEVI........................................ 19VOTRIENT....................................16VRAYLAR.....................................18
VUMERITY................................... 26VUMERITY (STARTER)...............26vyfemla......................................... 43VYLEESI.......................................26vylibra........................................... 43VYNDAMAX..................................25VYNDAQEL.................................. 25VYVANSE.....................................25WAKIX.......................................... 56warfarin sodium.............................. 9wera..............................................43WESTHROID................................44WILATE........................................ 21WINRHO SDF...............................45wixela inhub..................................55WP THYROID...............................44wymzya fe.....................................43XADAGO...................................... 17XALIX............................................30XALKORI...................................... 16XARELTO.......................................9XARELTO STARTER PACK.......... 9XATMEP.......................................45XELJANZ......................................45XELJANZ XR................................45XELODA....................................... 16XELPROS.....................................51XEMBIFY......................................45XENICAL...................................... 26XENLETA....................................... 9XEOMIN........................................50XEPI................................................9XERAC AC................................... 30XERMELO.................................... 37XEROFORM OIL EMULSION 2"X2".............................................30XEROFORM OIL EMULSION GAUZE......................................... 30XEROFORM OIL EMULSION STRIP........................................... 30XEROFORM OIL ROLL 4"X9'...... 30XEROFORM PETROLAT GAUZE 1"X8"............................... 30XEROFORM PETROLAT GAUZE 5"X9"............................... 30XEROFORM PETROLAT PATCH 2"X2"................................30XEROFORM PETROLAT PATCH 4"X4"................................30XEROFORM PETROLATUM ROLL 4"X9'................................... 30XGEVA......................................... 46XIAFLEX.......................................50XIFAXAN........................................ 9XIGDUO XR..................................31XIIDRA..........................................52XIMINO...........................................9
XOFLUZA (40 MG DOSE)............19XOFLUZA (80 MG DOSE)............19XOLAIR.........................................54XOPENEX.................................... 55XOPENEX CONCENTRATE........55XOPENEX HFA............................ 55XOSPATA.....................................16XPOVIO (100 MG ONCE WEEKLY)......................................16XPOVIO (40 MG ONCE WEEKLY)......................................16XPOVIO (40 MG TWICE WEEKLY)......................................16XPOVIO (60 MG ONCE WEEKLY)......................................16XPOVIO (60 MG TWICE WEEKLY)......................................16XPOVIO (80 MG ONCE WEEKLY)......................................16XPOVIO (80 MG TWICE WEEKLY)......................................16XTAMPZA ER.................................4XTANDI.........................................16xulane........................................... 43XULTOPHY.................................. 31XURIDEN......................................37XYLOCAINE................................... 6xylocaine dental..............................6XYLOCAINE/EPINEPHRINE..........6XYLOCAINE-MPF.......................... 6XYLOCAINE-MPF/EPINEPHRINE.......................6XYNTHA....................................... 21XYNTHA SOLOFUSE...................21XYOSTED.....................................39XYREM.........................................56YUPELRI...................................... 55yuvafem........................................ 43zafirlukast......................................55zaleplon........................................ 56zarah.............................................44ZARONTIN................................... 10ZARXIO........................................ 21ZAVESCA.....................................37ZEBUTAL........................................4ZEJULA........................................ 16ZELAPAR..................................... 17ZELBORAF...................................16ZELNORM.................................... 37ZEMPLAR.....................................46zenatane.......................................30ZENPEP....................................... 37ZENZEDI...................................... 25ZEPATIER.................................... 19ZETONNA.....................................54ZEWA DIGITAL TENS UNIT........ 50
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ZEWA TENS/EMS COMBO UNIT............................................. 50ZIAC..............................................25ZIAGEN........................................ 19zidovudine.....................................19zileuton er..................................... 55ziprasidone hcl..............................18ziprasidone mesylate....................18ZIRGAN........................................ 51ZITHROMAX...................................9ZITHROMAX TRI-PAK................... 9ZITHROMAX Z-PAK.......................9ZOLADEX.....................................40ZOLINZA.......................................16zolmitriptan................................... 13zolpidem tartrate...........................56zolpidem tartrate er.......................56ZOLPIMIST...................................56ZOMIG..........................................13zonisamide....................................10ZONTIVITY...................................17ZORBTIVE....................................37ZORTRESS.................................. 45zovia 1/35e (28)............................44ZUBSOLV.......................................6zumandimine................................ 44ZYDELIG...................................... 16ZYKADIA...................................... 16ZYLET...........................................52ZYLOPRIM................................... 13ZYMAXID......................................51ZYPREXA RELPREVV.................18ZYPREXA ZYDIS......................... 18ZYVOX............................................9
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