list of covered drugs (formulary) - texas · 2020-03-12 · h6870_19_lod_approved_08292018 superior...

H6870_19_LOD_Approved_08292018

Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) 2019 List of Covered Drugs (Formulary) Introduction This document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter drugs and items are covered by Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP). The Drug List also tells you if there are any special rules or restrictions on any drugs covered by Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP). Key terms and their definitions appear in the last chapter of the Member Handbook.

If you have questions, please call Superior STAR+PLUS MMP Member Services at 1-866-896-1844 (TTY: 711), 8:00 a.m. to 8:00 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.SuperiorHealthPlan.com Updated 12/01/2019 HPMS Approved Formulary File Submission ID: 19537 Version Number: 20

Statement of Non-Discrimination

Declaración de no discriminación

Superior HealthPlan (Superior) STAR+PLUS Medicare-Medicaid Plan (MMP) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Superior STAR+PLUS MMP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.Superior STAR+PLUS MMP: • Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). • Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Superior STAR+PLUS MMP’s Member Services at 1-866-896-1844 (TTY: 711) from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free.If you believe that Superior STAR+PLUS MMP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Superior STAR+PLUS MMP’s Member Services is available to help you.You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800–368–1019, (TDD: 1-800–537–7697)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Superior HealthPlan (Superior) STAR+PLUS Medicare-Medicaid Plan (MMP) cumple con las leyes federales de derechos civiles aplicables y no discrimina por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo. Superior STAR+PLUS MMP no excluye a ninguna persona ni la trata de manera diferente por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.Superior STAR+PLUS MMP: • Brinda asistencia y servicios gratis a las personas con discapacidades para que puedan comunicarse de manera eficaz con nosotros como, por ejemplo, intérpretes de lenguaje de señas calificados e información escrita en otros formatos (letra grande, formatos electrónicos accesibles y otros formatos). • Brinda servicios lingüísticos gratis a aquellas personas cuya lengua materna no es el inglés, como intérpretes calificados e información escrita en otros idiomas. Si necesita estos servicios, póngase en contacto con Servicios para afiliados de Superior STAR+PLUS MMP al 1-866-896-1844 (los usuarios de TTY deben llamar al 711) de 8 a. m. a 8 p. m., de lunes a viernes. Luego del horario de atención, los fines de semana y los días feriados, es posible que se le pida que deje un mensaje. Le devolveremos la llamada el próximo día hábil. La llamada es gratuita.Si usted considera que Superior STAR+PLUS MMP no le ha brindado estos servicios o lo ha discriminado de alguna otra manera debido a su raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo llamando al número que aparece arriba e informando que necesita ayuda para presentar el reclamo; el Departamento de Servicios para afiliados de Superior STAR+PLUS MMP está disponible para ayudarlo.También puede presentar una queja sobre derechos civiles ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Sociales de los EE. UU. de manera electrónica a través del Office for Civil Rights Complaint Portal (Portal de quejas de la Oficina de Derechos Civiles) disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo electrónico o a los teléfonos que figuran a continuación: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800–368–1019, (TDD: 1-800–537–7697) Los formularios de quejas se encuentran disponibles en http://www.hhs.gov/ocr/office/file/index.html.SHP_20163857A-MMP

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SHP_20163857C-MMP

If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.SuperiorHealthPlan.com. i

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Table of Contents

A. Disclaimers ii

B. Frequently Asked Questions (FAQ) iii

B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.) iii

B2. Does the Drug List ever change? iii

B3. What happens when there is a change to the Drug List? iv

B4. Are there any restrictions or limits on drug coverage? Or are there any required actions to take to get certain drugs? v

B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? vi

B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)? vi

B7. How can you find a drug on the Drug List? vi

B8. What if the drug you want to take is not on the Drug List? vi

B9. What if you are a new Superior STAR+PLUS MMP member and can’t find your drug on the Drug List or have a problem getting your drug? vii

B10. Can you ask for an exception to cover your drug? viii

B11. How can you ask for an exception? viii

B12. How long does it take to get an exception? viii

B13. What are generic drugs? viii

B14. What are OTC drugs? viii

B15. Does Superior STAR+PLUS MMP cover OTC non-drug products? ix

B16. What is your copay? ix

B17. What are drug tiers? ix

C. List of Covered Drugs ix

D. List of Drugs by Medical Condition xii

E. Index of Covered Drugs Index 1

If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.SuperiorHealthPlan.com. ii

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A. Disclaimers

This is a list of drugs that members can get in Superior STAR+PLUS MMP. Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) is a health plan that

contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees.

ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-866-896-1844 (TTY: 711), 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-896-1844 (TTY: 711) de 8 a. m. a 8 p. m., lunes a viernes. Después de horas hábiles, los fines de semana y los días festivos, es posible que se le pida que deje un mensaje. Le devolveremos la llamada el próximo día hábil. La llamada es gratuita.

You can get this document for free in other formats, such as large print, braille, or audio. Call 1-866-896-1844 (TTY: 711), 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free.

If you would like us to send you member materials on an ongoing basis in other formats, such as Braille or large print, or in a language other than English, please call Member Services at the number at the bottom of the page. Tell Member Services that you would like to place a standing request to get your materials in another format or language.

If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.SuperiorHealthPlan.com. iii

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B. Frequently Asked Questions (FAQ)

Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.

B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.)

The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by Superior STAR+PLUS MMP. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

• Superior STAR+PLUS MMP will cover all medically necessary drugs on the Drug List if:

o your doctor or other prescriber says you need them to get better or stay healthy, and

o you fill the prescription at a Superior STAR+PLUS MMP network pharmacy.

• Superior STAR+PLUS MMP may have additional steps to access certain drugs (see question B4 below).

You can also see an up-to-date list of drugs that we cover on our website at mmp.SuperiorHealthPlan.com or call Member Services at 1-866-896-1844 (TTY: 711).

B2. Does the Drug List ever change? Yes. Superior STAR+PLUS MMP may add or remove drugs on the Drug List during the year.

We may also change our rules about drugs. For example, we could:

• Decide to require or not require prior approval for a drug. (Prior approval is permission from Superior STAR+PLUS MMP before you can get a drug.)

• Add or change the amount of a drug you can get (called quantity limits).

• Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

For more information on these drug rules, see question B4.

If you are taking a Medicare Part D drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless:

If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.SuperiorHealthPlan.com. iv

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• a new, cheaper drug comes along that works as well as a drug on the Drug List now, or

• we learn that a drug is not safe, or

• a drug is removed from the market.

Questions B3 and B6 below have more information on what happens when the Drug List changes.

• You can always check Superior STAR+PLUS MMP’s up to date Drug List online at mmp.SuperiorHealthPlan.com.

• You can also call Member Services to check the current Drug List at 1-866-896-1844 (TTY: 711).

B3. What happens when there is a change to the Drug List? Some changes to the Drug List will happen immediately. For example:

• A new generic drug becomes available. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. When that happens, we may remove the current drug, but your cost for the new drug will stay the same. When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits.

o We may not tell you before we make this change, but we will send you information about the specific change or changes we made.

o You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see question B10 for more information on exceptions.

• A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. If you have any questions after being notified of the change, you should contact the doctor who prescribed the drug for you.

We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if:

• The FDA provides new guidance or there are new clinical guidelines about a drug.

• We add a generic drug that is not new to the market and

o Replace a brand name drug currently on the Drug List or

If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.SuperiorHealthPlan.com. v

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o Change the coverage rules or limits for the brand name drug.

When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Then you can:

• Get a 30-day supply of the drug before the change to the Drug List is made, or

• Ask for an exception from these changes. Please see question B10 for more information about exceptions.

B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example:

• Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Superior STAR+PLUS MMP before you fill your prescription. Superior STAR+PLUS MMP may not cover the drug if you do not get approval.

• Quantity limits: Sometimes Superior STAR+PLUS MMP limits the amount of a drug you can get.

• Step therapy: Sometimes Superior STAR+PLUS MMP requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.

You can find out if your drug has any additional requirements or limits by looking in the tables on pages 1 – Index 1. You can also get more information by visiting our web site at mmp.SuperiorHealthPlan.com. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.

You can ask for an exception from these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions B10- B12 for more information about exceptions.

If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.SuperiorHealthPlan.com. vi

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B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 1 has a column labeled “Necessary actions, restrictions, or limits on use.”

B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)?

In some cases, we tell you in advance if we add or change prior approval, quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change.

B7. How can you find a drug on the Drug List? There are two ways to find a drug:

• You can search alphabetically (if you know how to spell the drug), or

• You can search by medical condition.

To search alphabetically, go to the Index of Covered Drugs section. You can find it in the Index that begins on page Index 1.

To search by medical condition, find the section labeled “List of drugs by medical condition” on page 1. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, CARDIOVASCULAR AGENTS - MISC. - Drugs to Treat Heart and Circulation Conditions. That is where you will find drugs that treat heart conditions.

B8. What if the drug you want to take is not on the Drug List? If you don’t see your drug on the Drug List, call Member Services at 1-866-896-1844 (TTY: 711) and ask about it. If you learn that Superior STAR+PLUS MMP will not cover the drug, you can do one of these things:

• Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or

• You can ask the health plan to make an exception to cover your drug. Please see questions B10-B12 for more information about exceptions.

If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.SuperiorHealthPlan.com. vii

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B9. What if you are a new Superior STAR+PLUS MMP member and can’t find your drug on the Drug List or have a problem getting your drug?

We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Superior STAR+PLUS MMP. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception.

If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication.

We will cover a 30-day supply of your drug if:

• you are taking a drug that is not on our Drug List, or

• health plan rules do not let you get the amount ordered by your prescriber, or

• the drug requires prior approval by Superior STAR+PLUS MMP, or

• you are taking a drug that is part of a step therapy restriction.

If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away:

• We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Superior STAR+PLUS MMP member.

• This is in addition to the temporary supply during the first 90 days you are a member of Superior STAR+PLUS MMP.

Level of Care Changes

If your level of care changes, we will cover a temporary supply of your drugs. A level of care change happens when you are released from a hospital. It also happens when you move to or from a long-term care facility.

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

• If you move from home or a hospital to a long-term care facility and need a temporary supply, we will cover one 31-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a total of a 31-day supply.

If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.SuperiorHealthPlan.com. viii

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B10. Can you ask for an exception to cover your drug? Yes. You can ask Superior STAR+PLUS MMP to make an exception to cover a drug that is not on the Drug List.

You can also ask us to change the rules on your drug.

• For example, Superior STAR+PLUS MMP may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.

• Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.

B11. How can you ask for an exception? To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception. You can also read Chapter 9, Sections 6.2 - 6.4 of the Member Handbook to learn more about exceptions.

B12. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber’s supporting statement.

B13. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA).

Superior STAR+PLUS MMP covers both brand name drugs and generic drugs.

B14. What are OTC drugs? OTC stands for “over-the-counter.” Superior STAR+PLUS MMP covers some OTC drugs when they are written as prescriptions by your provider.

You can read the Superior STAR+PLUS MMP Drug List to see what OTC drugs are covered.

If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.SuperiorHealthPlan.com. ix

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B15. Does Superior STAR+PLUS MMP cover OTC non-drug products? Superior STAR+PLUS MMP covers some OTC non-drug products when they are written as prescriptions by your provider.

Examples of OTC non-drug products include PEDIATRIC SMALL MASK MISC or AEROCHAMBER/FLOWSIGNAL MISC.

You can read the Superior STAR+PLUS MMP Drug List to see what OTC non-drug products are covered.

B16. What is your copay? As a Superior STAR+PLUS MMP member, you have no copays for prescription and OTC drugs as long as you follow Superior STAR+PLUS MMP’s rules.

B17. What are drug tiers? Tiers are groups of drugs on our Drug List.

• Tier 1 drugs are generic drugs.

• Tier 2 drugs are brand name drugs.

• Tier 3 drugs are non-Medicare prescription or over-the-counter drugs.

Copays for Tiers 1, 2 and 3 are all $0.

C. List of Covered Drugs

The following list of covered drugs gives you information about the drugs covered by Superior STAR+PLUS MMP. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page Index 1. The index alphabetically lists all drugs covered by Superior STAR+PLUS MMP.

The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., ELIQUIS TABS) and generic drugs are listed in lower-case italics (e.g., warfarin sodium tabs).

The information in the necessary actions, restrictions, or limits on use column tells you if Superior STAR+PLUS MMP has any rules for covering your drug. Here are the meanings of the codes used in the “Necessary actions, restrictions, or limits on use” column:

If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.SuperiorHealthPlan.com. x

?

Abbreviation What this means

How it works

AL Age Limit This drug may need prior authorization if your age does not meet drug maker, FDA or clinical guidelines.

B/D Medicare Part B vs. Part D

This drug may need prior authorization to decide if it should be covered under Medicare Part B or Part D. This is a Medicare rule. Your doctor or other prescriber may need to give more facts to help us make this decision.

LA Limited Access

This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-866-896-1844 (TTY: 711), Monday through Friday, 8:00 a.m. to 8:00 p.m. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day.

MO Mail Order This drug is available at our mail order pharmacy in addition to other network pharmacies.

NDS Non-Extended Day Supply

This prescription drug may not be available for an extended day supply. Call Member Services to ask if the drug is available as an extended supply.

NF Not Covered This drug is not covered on the Drug List. You can ask for an exception for the drug to be covered.

NT Not Part D This drug is not a “Part D drug.”

PA Prior Authorization

This drug requires prior authorization. This means that you or your doctor must get approval from us before you fill your prescription. If you don’t get approval, we may not cover the drug.

QL Quantity Limit

This drug has a limit on the amount that our plan will cover.

If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.SuperiorHealthPlan.com. xi

?

Abbreviation What this means

How it works

RX/OTC Prescription and Over-the-Counter (OTC)

This drug is made in both prescription form and OTC form.

SL Safety Limit This drug has a maximum daily dose limit for safety supported by the FDA. This means that we will not cover more than the maximum daily dose. For example, the FDA maximum daily dose of ibuprofen is 3200 mg. Therefore, we will only cover four tablets per day for ibuprofen 800 mg.

ST Step Therapy

This drug requires step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.

* Non-Preferred Drug

We will provide a 72-hour supply of this drug. This drug will require prior authorization for continued coverage.

Note: The NT next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage).

• In addition, if you are getting Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. For more information on Extra Help, please see the call-out box below.

• These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Texas Medicaid.

Extra Help is a Medicare program that helps people with limited incomes and resources reduce Medicare Part D prescription drug costs, such as premiums, deductibles, and copays. Extra Help is also called the “Low-Income Subsidy,” or “LIS.”

If you have questions, please call Superior STAR+PLUS MMP at 1-866-896-1844 (TTY: 711), 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.SuperiorHealthPlan.com. xii

?

• If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at 1-866-896-1844 (TTY: 711). You can also read Chapter 9 of the Member Handbook to learn how to appeal a decision.

D. List of Drugs by Medical Condition

The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, CARDIOVASCULAR AGENTS - MISC. - Drugs to Treat Heart and Circulation Conditions. That is where you will find drugs that treat heart conditions.

Name of drug

Whatthe

drugwillcostyou(tier

level)

Necessaryactions,restrictions, orlimits on use

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating DisordersAmphetamines

amphetamine-dextroamphetamine cp24

$0(Tier

1)

MO

amphetamine-dextroamphetamine tabs

$0(Tier

1)

MO

dextroamphetamine sulfatecp24 5 mg, 10 mg, 15 mg

$0(Tier

1)

MO

dextroamphetamine sulfatetabs 5 mg, 10 mg

$0(Tier

1)

MO

methamphetamine hcl tabs$0

(Tier1)

PA; MO

Anti-Obesity Agents

XENICAL CAPS$0

(Tier3)

MO; NT

Attention-Deficit/Hyperactivity Disorder (ADHD)

atomoxetine hcl caps 10mg

$0(Tier

1)

SL(10 ea daily);MO


$0(Tier

1)

SL(1 ea daily);MO


$0(Tier

1)

SL(5.55 eadaily); MO


$0(Tier

1)

SL(4 ea daily);MO


$0(Tier

1)

SL(2.5 eadaily); MO

Name of drug

Whatthe


level)



$0(Tier

1)



$0(Tier

1)


clonidine hcl (adhd) tb12$0

(Tier1)

MO

guanfacine hcl (adhd) tb24$0

(Tier1)

AL(Up to 64 yrsold); MO

Stimulants - Misc.

dexmethylphenidate hclcp24

$0(Tier

1)

MO

dexmethylphenidate hcltabs

$0(Tier

1)

MO

methylphenidate hcl cp2410 mg, 20 mg, 30 mg, 40mg, 60 mg

$0(Tier

1)

MO

methylphenidate hcl cpcr10 mg, 40 mg, 50 mg, 60mg

$0(Tier

1)

QL(1 ea daily);MO

methylphenidate hcl cpcr20 mg

$0(Tier

1)

QL(2 ea daily);MO

methylphenidate hcl cpcr30 mg

$0(Tier

1)

MO

methylphenidate hcl tabs 5mg, 10 mg, 20 mg

$0(Tier

1)

QL(3 ea daily);MO

methylphenidate hcl tb2427 mg, 36 mg

$0(Tier

1)

Non-OsmoticRelease

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

$0(Tier

1)

MO

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

2019 Superior STAR+PLUS MMP Drug List Updated 12/01/20191

Name of drug

Whatthe


level)


methylphenidate hcl tbcr 20mg

$0(Tier

1)

QL(3 ea daily);MO

modafinil tabs 100 mg$0

(Tier1)

PA; MO

modafinil tabs 200 mg$0

(Tier1)

PA; QL(1 eadaily); MO

AMINOGLYCOSIDES - Drugs to Treat BacterialInfectionsAminoglycosides

amikacin sulfate soln$0

(Tier1)

MO

ARIKAYCE SUSP$0

(Tier2)

PA; NDS;MO

BETHKIS NEBU$0

(Tier2)

B/D; NDS

gentamicin in saline soln0.9%-1mg/ml

$0(Tier

1)

gentamicin sulfate soln 10mg/ml, 40 mg/ml

$0(Tier

1)

MO

KITABIS PAK NEBU$0

(Tier2)

B/D; NDS

neomycin sulfate tabs$0

(Tier1)

MO

paromomycin sulfate caps$0

(Tier1)

MO

TOBI PODHALER CAPS$0

(Tier2)

NDS

tobramycin nebu$0

(Tier1)

B/D

Name of drug

Whatthe


level)


tobramycin sulfate soln 40mg/ml, 80 mg/2ml, 1.2gm/30ml

$0(Tier

1)

MO

tobramycin sulfate solr 1.2gm

$0(Tier

1)

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditionsAnti-TNF-alpha - Monoclonal AntibodiesHUMIRA PEDIATRICCROHNS DISEASESTARTER PACK PSKT

$0(Tier

2)

PA; NDS

HUMIRA PEN PNKT$0

(Tier2)

PA; NDS

HUMIRA PEN-CD/UC/HSSTARTER PNKT

$0(Tier

2)

PA; NDS

HUMIRA PEN-PS/UVSTARTER PNKT

$0(Tier

2)

PA; NDS

HUMIRA PSKT$0

(Tier2)

PA; NDS

SIMPONI ARIA SOLN$0

(Tier2)

PA; NDS

SIMPONI SOAJ$0

(Tier2)

PA; NDS

SIMPONI SOSY$0

(Tier2)

PA; NDS

Antirheumatic - Enzyme Inhibitors

OLUMIANT TABS 2 MG$0

(Tier2)

PA; NDS

XELJANZ TABS$0

(Tier2)

PA; NDS



Name of drug

Whatthe


level)


Antirheumatic Antimetabolites

OTREXUP SOAJ$0

(Tier2)

PA

RASUVO SOAJ$0

(Tier2)

PA

Gold Compounds

RIDAURA CAPS$0

(Tier2)

NDS;MO

Interleukin-1 Blockers

ARCALYST SOLR$0

(Tier2)

NDS;LA

Interleukin-1beta Blockers

ILARIS SOLN$0

(Tier2)

PA; NDS;LA

ILARIS SOLR$0

(Tier2)

PA; NDS;LA

Interleukin-6 Receptor Inhibitors

ACTEMRA SOSY SC 162MG/0.9ML

$0(Tier

2)

PA; NDS

KEVZARA SOAJ$0

(Tier2)

PA; NDS

KEVZARA SOSY$0

(Tier2)

PA; NDS

Nonsteroidal Anti-inflammatory Agents (NSAIDs)

celecoxib caps$0

(Tier1)

MO

diclofenac potassium tabs$0

(Tier1)

MO

Name of drug

Whatthe


level)


diclofenac sodium tb24$0

(Tier1)

MO

diclofenac sodium tbec$0

(Tier1)

MO

diclofenac w/ misoprostoltbec

$0(Tier

1)

MO

etodolac caps$0

(Tier1)

MO

etodolac tabs$0

(Tier1)

MO

etodolac tb24$0

(Tier1)

MO

flurbiprofen tabs$0

(Tier1)

MO

ibuprofen caps 200 mg$0

(Tier3)

MO; NT

ibuprofen chew 100 mg$0

(Tier3)

MO; NT

ibuprofen susp 100 mg/5ml$0

(Tier1)

RX/OTC; MO

ibuprofen susp 100 mg/5ml$0

(Tier3)

Over-the-counter;RX/OTC; MO; NT

ibuprofen susp 40 mg/ml,50 mg/1.25ml

$0(Tier

3)

NT

ibuprofen tabs 200 mg$0

(Tier3)

MO; NT


(Tier1)

SL(8 ea daily);MO



Name of drug

Whatthe


level)



(Tier1)



(Tier1)

SL(4 ea daily);MO

indomethacin caps$0

(Tier1)


indomethacin cpcr$0

(Tier1)


ketoprofen caps 75 mg$0

(Tier1)

ketorolac tromethaminesoln ij 15 mg/ml, 30 mg/ml

$0(Tier

1)


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

$0(Tier

1)


mefenamic acid caps$0

(Tier1)

MO

meloxicam tabs$0

(Tier1)

MO

nabumetone tabs$0

(Tier1)

MO

naproxen sodium tabs 220mg

$0(Tier

3)

MO; NT

naproxen sodium tabs 275mg, 550 mg

$0(Tier

1)

MO

naproxen tabs 250 mg, 375mg, 500 mg

$0(Tier

1)

MO

naproxen tbec 375 mg, 500mg

$0(Tier

1)

MO

Name of drug

Whatthe


level)


oxaprozin tabs$0

(Tier1)

MO

piroxicam caps$0

(Tier1)

MO

sulindac tabs$0

(Tier1)

MO

tolmetin sodium caps 400mg

$0(Tier

1)

MO

tolmetin sodium tabs 200mg

$0(Tier

1)

Pyrimidine Synthesis Inhibitors

leflunomide tabs$0

(Tier1)

MO

Soluble Tumor Necrosis Factor Receptor Agents

ENBREL MINI SOCT$0

(Tier2)

PA; NDS

ENBREL SOLR$0

(Tier2)

PA; NDS

ENBREL SOSY$0

(Tier2)

PA; NDS

ENBREL SURECLICKSOAJ

$0(Tier

2)

PA; NDS

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint ConditionsAnalgesics Other

acetaminophen caps or500 mg

$0(Tier

3)

MO; NT

acetaminophen chew or 80mg

$0(Tier

3)

MO; NT



Name of drug

Whatthe


level)


acetaminophen liqd or 160mg/5ml

$0(Tier

3)

MO; NT

acetaminophen liqd or 500mg/15ml

$0(Tier

3)

NT

acetaminophen soln or 160mg/5ml

$0(Tier

3)

MO; NT

acetaminophen supp re120 mg, 650 mg

$0(Tier

3)

MO; NT

acetaminophen susp or160 mg/5ml

$0(Tier

3)

MO; NT

acetaminophen tabs or 325mg, 500 mg

$0(Tier

3)

MO; NT

acetaminophen tbcr or 650mg

$0(Tier

3)

MO; NT

Salicylates

aspirin chew 81 mg$0

(Tier3)

MO; NT

aspirin tabs 325 mg$0

(Tier3)

MO; NT

aspirin tbec 81 mg, 325 mg$0

(Tier3)

MO; NT

diflunisal tabs$0

(Tier1)

MO

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

fentanyl citrate lpop bu 200mcg

$0(Tier

1)

PA; NDS;QL(8ea daily); MO

Name of drug

Whatthe


level)


fentanyl citrate lpop bu 400mcg, 600 mcg, 800 mcg,1200 mcg, 1600 mcg

$0(Tier

1)


fentanyl pt72 12 mcg/hr$0

(Tier1)

Limit 43patches permonth;QL(0.34ea daily); MO

fentanyl pt72 25 mcg/hr,100 mcg/hr

$0(Tier

1)

QL(0.34 eadaily); MO

fentanyl pt72 50 mcg/hr, 75mcg/hr

$0(Tier

1)

Limit 15patches permonth;QL(0.34ea daily); MO

hydromorphone hcl liqd or1 mg/ml

$0(Tier

1)

QL(50 mldaily); MO

hydromorphone hcl soln ij 1mg/ml, 2 mg/ml, 4 mg/ml

$0(Tier

1)

MO

hydromorphone hcl soln ij10 mg/ml, 50 mg/5ml, 500mg/50ml

$0(Tier

1)

hydromorphone hcl soln ij 2mg/ml

$0(Tier

1)

PreservativeFree

hydromorphone hcl tabs or2 mg, 4 mg

$0(Tier

1)

QL(9 ea daily);MO

hydromorphone hcl tabs or8 mg

$0(Tier

1)


HYDROMORPHONEHYDROCHLORIDE SOLN2 MG/ML

$0(Tier

2)

PreservativeFree

LAZANDA SOLN 100MCG/ACT

$0(Tier

2)



$0(Tier

2)

PA; NDS; Limit15 boxes permonth ;QL(0.5ea daily); MO



Name of drug

Whatthe


level)



$0(Tier

2)

PA; NDS; Limit8 bottles permonth;QL(0.27ea daily); MO

methadone hcl soln or 10mg/5ml

$0(Tier

1)

QL(33.34 mldaily); MO

methadone hcl soln or 5mg/5ml

$0(Tier

1)

QL(15 mldaily); MO

methadone hcl tabs or 5mg, 10 mg

$0(Tier

1)

QL(6 ea daily);MO

methadone hcl tbso or 40mg

$0(Tier

3)

*;NT

morphine sulfate cp24 or10 mg, 20 mg, 30 mg, 50mg

$0(Tier

1)

QL(3 ea daily);MO

morphine sulfate cp24 or100 mg

$0(Tier

1)

NDS;QL(2 eadaily); MO


$0(Tier

1)



$0(Tier

1)

QL(2.5 eadaily); MO

morphine sulfate soln ij 0.5mg/ml

$0(Tier

1)

morphine sulfate soln ij 1mg/ml

$0(Tier

1)

MO

morphine sulfate soln or 10mg/5ml

$0(Tier

1)

QL(100 mldaily); MO

morphine sulfate soln or 20mg/5ml

$0(Tier

1)

QL(50 mldaily); MO

Name of drug

Whatthe


level)


morphine sulfate soln or 20mg/ml, 100 mg/5ml

$0(Tier

1)

QL(10 mldaily); MO

morphine sulfate tabs or 15mg

$0(Tier

1)


MORPHINE SULFATETABS OR 15 MG(Morphine Sulfate)

$0(Tier

2)


morphine sulfate tabs or 30mg

$0(Tier

1)


MORPHINE SULFATETABS OR 30 MG(Morphine Sulfate)

$0(Tier

2)


morphine sulfate tbcr or100 mg, 200 mg

$0(Tier

1)

QL(2 ea daily);MO

morphine sulfate tbcr or 15mg, 30 mg, 60 mg

$0(Tier

1)

QL(3 ea daily);MO

oxycodone hcl caps 5 mg$0

(Tier1)

QL(6 ea daily);MO

oxycodone hcl conc 100mg/5ml

$0(Tier

1)

QL(6 ml daily);MO

oxycodone hcl tabs 30 mg$0

(Tier1)


oxycodone hcl tabs 5 mg,10 mg, 15 mg, 20 mg

$0(Tier

1)

QL(6 ea daily);MO

oxymorphone hcl tabs 5mg, 10 mg

$0(Tier

1)

QL(6 ea daily);MO

oxymorphone hcl tb12 15mg

$0(Tier

1)


oxymorphone hcl tb12 7.5mg

$0(Tier

1)




Name of drug

Whatthe


level)


SUBSYS LIQD 100 MCG$0

(Tier2)

PA;NDS;QL(16 eadaily); MO


(Tier2)

PA; NDS;QL(2ea daily)


(Tier2)


SUBSYS LIQD 400 MCG,600 MCG, 800 MCG, 1600MCG

$0(Tier

2)


tramadol hcl tabs 50 mg$0

(Tier1)

SL(8 ea daily);MO

tramadol hcl tb24 100 mg$0

(Tier1)

SL(3 ea daily);MO


(Tier1)

SL(1.5 eadaily); MO


(Tier1)

SL(1 ea daily);MO

ZOHYDRO ER C12A 10MG, 15 MG

$0(Tier

2)


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

$0(Tier

2)


Opioid Combinations

acetaminophen w/ codeinesoln 120mg/5ml-12mg/5ml

$0(Tier

1)

SL(150 mldaily); MO

acetaminophen w/ codeinetabs 300mg-15mg

$0(Tier

1)



$0(Tier

1)

SL(12 ea daily);MO

Name of drug

Whatthe


level)



$0(Tier

1)

SL(6 ea daily);MO

butalbital-aspirin-caffeinew/cod caps

$0(Tier

1)

AL(Up to 64 yrsold); SL(6 eadaily); MO

hydrocodone-acetaminophen soln2.5mg/5ml-108mg/5ml,5mg/10ml-217mg/10ml,7.5mg/15ml-325mg/15ml

$0(Tier

1)

Limit 5535mlspermonth;SL(184.5 ml daily); MO

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

$0(Tier

1)


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

$0(Tier

1)


hydrocodone-ibuprofentabs

$0(Tier

1)

QL(5 ea daily);MO

oxycodone w/acetaminophen tabs

$0(Tier

1)


oxycodone-aspirin tabs$0

(Tier1)

MO

tramadol-acetaminophentabs

$0(Tier

1)

SL(8 ea daily);MO

Opioid Partial Agonists

buprenorphine hcl subl sl 2mg

$0(Tier

1)

QL(12 eadaily); MO

buprenorphine hcl subl sl 8mg

$0(Tier

1)

QL(3 ea daily);MO

buprenorphine hcl-naloxone hcl dihydrate subl2mg-0.5mg

$0(Tier

1)

QL(12 eadaily); MO



Name of drug

Whatthe


level)


buprenorphine hcl-naloxone hcl dihydrate subl8mg-2mg

$0(Tier

1)

QL(4 ea daily);MO

butorphanol tartrate soln ij2 mg/ml

$0(Tier

1)

MO

butorphanol tartrate soln na10 mg/ml

$0(Tier

1)

Limit 210mlsper month;QL(7ml daily); MO

ANDROGENS-ANABOLIC - Drugs to RegulateHormonesAnabolic Steroids

ANADROL-50 TABS$0

(Tier2)

NDS;MO

oxandrolone tabs 10 mg$0

(Tier1)

NDS;MO

oxandrolone tabs 2.5 mg$0

(Tier1)

MO

Androgens

ANDRODERM PT24$0

(Tier2)

MO

AVEED SOLN$0

(Tier2)

LA

danazol caps$0

(Tier1)

MO

methyltestosterone caps$0

(Tier1)

MO

testosterone cypionate solnim 100 mg/ml, 200 mg/ml

$0(Tier

1)

MO

testosterone enanthatesoln im

$0(Tier

1)

MO

Name of drug

Whatthe


level)


testosterone gel td 1 %,1.62 %, 50 mg/5gm, 25mg/2.5gm, 40.5 mg/2.5gm,20.25 mg/1.25gm

$0(Tier

1)

MO

testosterone soln td 30mg/act

$0(Tier

1)

MO

ANORECTAL AGENTS - Rectal Drugs to TreatPain, Swelling and ItchingIntrarectal Steroids

hydrocortisone (intrarectal)enem

$0(Tier

1)

MO

UCERIS FOAM RE 2MG/ACT

$0(Tier

2)

MO

Rectal Combinations

phenylephrine in hard fatsupp

$0(Tier

3)

MO; NT

phenylephrine-cocoa buttersupp

$0(Tier

3)

MO; NT

phenylephrine-mineral oil-petrolatum oint

$0(Tier

3)

MO; NT

Rectal Local Anesthetics

dibucaine (rectal) oint$0

(Tier3)

MO; NT

Rectal Steroids

hydrocortisone (rectal) crea$0

(Tier1)

MO

Vasodilating Agents

RECTIV OINT$0

(Tier2)

MO

ANTACIDS



Name of drug

Whatthe


level)


Antacid Combinationsalum & mag hydrox-simethicone chew 200mg-25mg-200mg

$0(Tier

3)

NT

alum & mag hydrox-simethicone susp200mg/5ml-20mg/5ml-200mg/5ml, 400mg/5ml-40mg/5ml-400mg/5ml

$0(Tier

3)

MO; NT

aluminum hydroxide-magcarb susp

$0(Tier

3)

MO; NT

Antacids - Aluminum Salts

ALUMINUM HYDROXIDESUSP

$0(Tier

3)

NT

Antacids - Bicarbonatesodium bicarbonate(antacid) tabs 325 mg, 650mg

$0(Tier

3)

MO; NT

Antacids - Calcium Saltscalcium carbonate(antacid) chew 500 mg,750 mg

$0(Tier

3)

MO; NT

calcium carbonate(antacid) susp 1250mg/5ml

$0(Tier

3)

MO; NT

Antacids - Magnesium Salts

MAGNESIUM CAPS 500MG

$0(Tier

3)

NT

magnesium oxide tabs 250mg

$0(Tier

3)

NT

magnesium oxide tabs 400mg, 420 mg

$0(Tier

3)

MO; NT

ANTHELMINTICS - Drugs to Treat WormInfectionsAnthelmintics

Name of drug

Whatthe


level)


albendazole tabs$0

(Tier1)

MO

ALBENZA TABS(Albendazole)

$0(Tier

2)

MO

ivermectin tabs$0

(Tier1)

MO

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial InfectionsAnti-infective Agents - Misc.

IMPAVIDO CAPS$0

(Tier2)

NDS;MO

metronidazole caps or 375mg

$0(Tier

1)


metronidazole in nacl soln0.79%-500mg/100ml,0.79%-5mg/ml

$0(Tier

1)

metronidazole tabs or 250mg

$0(Tier

1)

SL(16 ea daily);MO

metronidazole tabs or 500mg

$0(Tier

1)

SL(8 ea daily);MO

NEBUPENT SOLR$0

(Tier2)

B/D; MO

PENTAM 300 SOLR(Pentamidine Isethionate)

$0(Tier

2)

MO

pentamidine isethionatesolr

$0(Tier

1)

MO

tinidazole tabs$0

(Tier1)

MO

trimethoprim tabs$0

(Tier1)

MO



Name of drug

Whatthe


level)


Anti-infective Misc. - Combinations

sulfamethoxazole-trimethoprim soln

$0(Tier

1)

MO

sulfamethoxazole-trimethoprim susp

$0(Tier

1)

MO

sulfamethoxazole-trimethoprim tabs

$0(Tier

1)

MO

Antiprotozoal Agents

ALINIA TABS 500 MG$0

(Tier2)

MO

atovaquone susp$0

(Tier1)

NDS;MO

Carbapenems

ertapenem sodium solr$0

(Tier1)

MO

imipenem-cilastatin solr$0

(Tier1)

MO

INVANZ SOLR IJ(Ertapenem Sodium)

$0(Tier

2)

MO

meropenem solr 1 gm$0

(Tier1)

MO

meropenem solr 500 mg$0

(Tier1)

VABOMERE SOLR$0

(Tier2)

Chloramphenicols

chloramphenicol sodiumsuccinate solr

$0(Tier

1)

Name of drug

Whatthe


level)


Cyclic Lipopeptides

daptomycin solr 500 mg$0

(Tier1)

NDS

Glycopeptides

FIRVANQ SOLR$0

(Tier2)

MO

ORBACTIV SOLR$0

(Tier2)

NDS

vancomycin hcl caps or125 mg

$0(Tier

1)

PA; MO

vancomycin hcl caps or250 mg

$0(Tier

1)

PA; NDS;MO

VANCOMYCIN HCL INDEXTROSE SOLN

$0(Tier

2)vancomycin hcl solr iv 1gm, 5 gm, 10 gm, 750 mg,1000 mg

$0(Tier

1)

vancomycin hcl solr iv 500mg

$0(Tier

1)

MO

VANCOMYCINHYDROCHLORIDE SOLRIV 750 MG

$0(Tier

2)VANCOMYCINHYDROCHLORIDE SOLROR 250 MG/5ML

$0(Tier

2)

MO

Leprostatics

dapsone tabs$0

(Tier1)

MO

LincosamidesCLEOCIN PHOSPHATESOLN IV 300 MG/2ML, 600MG/4ML, 900 MG/6ML

$0(Tier

2)



Name of drug

Whatthe


level)


clindamycin hcl caps$0

(Tier1)

MO

clindamycin palmitatehydrochloride solr

$0(Tier

1)

MO

clindamycin phosphate ind5w soln

$0(Tier

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

$0(Tier

1)

MO

clindamycin phosphatesoln ij 9 gm/60ml, 300mg/2ml, 9000 mg/60ml

$0(Tier

1)clindamycin phosphatesoln iv 300 mg/2ml, 600mg/4ml, 900 mg/6ml

$0(Tier

1)

lincomycin hcl soln$0

(Tier1)

MO

Monobactams

aztreonam solr$0

(Tier1)

MO

CAYSTON SOLR$0

(Tier2)

PA; NDS;LA

Oxazolidinones

linezolid soln iv 600mg/300ml

$0(Tier

1)

NDS

LINEZOLID SOLN IV600MG/300ML-0.9%

$0(Tier

2)

NDS

linezolid susr or 100mg/5ml

$0(Tier

1)

NDS;MO

linezolid tabs or 600 mg$0

(Tier1)

NDS;MO

Name of drug

Whatthe


level)


SIVEXTRO SOLR IV$0

(Tier2)

NDS

SIVEXTRO TABS OR$0

(Tier2)

NDS;MO

ZYVOX SOLN IV 200MG/100ML

$0(Tier

2)

NDS

Polymyxins

colistimethate sodium solr$0

(Tier1)

MO

polymyxin b sulfate solr$0

(Tier1)

Streptogramins

SYNERCID SOLR$0

(Tier2)

NDS

ANTIANGINAL AGENTS - Drugs to Treat ChestPainAntianginals-Other

ranolazine tb12$0

(Tier1)

MO

Nitrates

isosorbide dinitrate tabs$0

(Tier1)

MO

isosorbide dinitrate tbcr$0

(Tier1)

MO

isosorbide mononitrate tabs10 mg, 20 mg

$0(Tier

1)

MO

isosorbide mononitratetb24 30 mg, 60 mg, 120 mg

$0(Tier

1)

MO



Name of drug

Whatthe


level)


NITROGLYCERINLINGUAL AERS

$0(Tier

2)

MO

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

$0(Tier

1)

MO

nitroglycerin soln tl 0.4mg/spray

$0(Tier

1)

MO

nitroglycerin subl sl 0.3 mg,0.4 mg, 0.6 mg

$0(Tier

1)

MO

NITROSTAT SUBL(Nitroglycerin)

$0(Tier

2)

MO

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.

buspirone hcl tabs$0

(Tier1)

MO

hydroxyzine hcl soln im 50mg/ml

$0(Tier

1)


hydroxyzine hcl syrp or 10mg/5ml

$0(Tier

1)


hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg

$0(Tier

1)


hydroxyzine pamoate caps25 mg, 50 mg

$0(Tier

1)


Benzodiazepines

alprazolam tabs$0

(Tier1)

MO

alprazolam tb24$0

(Tier1)

MO

Name of drug

Whatthe


level)


alprazolam tbdp$0

(Tier1)

MO

clorazepate dipotassiumtabs

$0(Tier

1)

MO

diazepam conc or 5 mg/ml$0

(Tier1)

MO

diazepam soln or 5 mg/5ml$0

(Tier1)

MO

diazepam tabs or 2 mg, 5mg, 10 mg

$0(Tier

1)

MO

lorazepam conc$0

(Tier1)

MO

lorazepam soln$0

(Tier1)

MO

lorazepam tabs$0

(Tier1)

MO

oxazepam caps 10 mg, 15mg, 30 mg

$0(Tier

1)

MO

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythmsAntiarrhythmics Type I-A

disopyramide phosphatecaps

$0(Tier

1)


quinidine gluconate tbcr or324 mg

$0(Tier

1)

MO

quinidine sulfate tabs$0

(Tier1)

MO

Antiarrhythmics Type I-B



Name of drug

Whatthe


level)


mexiletine hcl caps$0

(Tier1)

MO

Antiarrhythmics Type I-C

flecainide acetate tabs 100mg

$0(Tier

1)

SL(4 ea daily);MO


$0(Tier

1)



$0(Tier

1)

SL(8 ea daily);MO

propafenone hcl cp12$0

(Tier1)

MO

propafenone hcl tabs$0

(Tier1)

MO

Antiarrhythmics Type III

amiodarone hcl tabs or 100mg, 200 mg, 400 mg

$0(Tier

1)

MO

dofetilide caps$0

(Tier1)

MULTAQ TABS$0

(Tier2)

MO

ANTIASTHMATIC AND BRONCHODILATORAGENTS - Drugs to Treat Lung ConditionsAnti-Inflammatory Agents

cromolyn sodium nebu$0

(Tier1)

B/D; MO

Antiasthmatic - Monoclonal Antibodies

CINQAIR SOLN$0

(Tier2)

PA; NDS;LA

Name of drug

Whatthe


level)


FASENRA SOSY$0

(Tier2)

PA; NDS

NUCALA SOLR 100 MG$0

(Tier2)

PA; NDS;LA

XOLAIR SOLR$0

(Tier2)

PA; NDS;LA

XOLAIR SOSY$0

(Tier2)

PA; NDS;LA

Bronchodilators - Anticholinergics

ATROVENT HFA AERS$0

(Tier2)

Limit 2 inhalerspermonth;QL(0.86gm daily); MO

ipratropium bromide soln$0

(Tier1)

B/D; MO

SPIRIVA HANDIHALERCAPS

$0(Tier

2)

QL(1 ea daily);MO

SPIRIVA RESPIMATAERS

$0(Tier

2)

Limit 1 inhalerper month (60actuations);SL(0.14 gm daily);MO

TUDORZA PRESSAIRAEPB

$0(Tier

2)

Limit 1 inhalerper month (60actuations);QL(0.04 ea daily);MO

TUDORZA PRESSAIRAEPB

$0(Tier

2)

Limit 2 inhalersper month (30actuations);QL(0.07 ea daily);MO

Leukotriene Modulators

montelukast sodium chew4 mg, 5 mg

$0(Tier

1)

MO



Name of drug

Whatthe


level)


montelukast sodium tabs10 mg

$0(Tier

1)

MO

zafirlukast tabs$0

(Tier1)

MO

zileuton tb12$0

(Tier1)

NDS;SL(4 eadaily); MO

Selective Phosphodiesterase 4 (PDE4) Inhibitors

DALIRESP TABS$0

(Tier2)

QL(1 ea daily);MO

Steroid Inhalants

ARNUITY ELLIPTA AEPB$0

(Tier2)

SL(1 ea daily);MO

budesonide (inhalation)susp 0.25 mg/2ml, 0.5mg/2ml

$0(Tier

1)

B/D; MO

FLOVENT DISKUS AEPB100 MCG/BLIST

$0(Tier

2)

SL(20 ea daily);MO


$0(Tier

2)

SL(8 ea daily);MO


$0(Tier

2)

SL(40 ea daily);MO

FLOVENT HFA AERO 110MCG/ACT, 220 MCG/ACT

$0(Tier

2)

Limit 2 inhalerspermonth;QL(0.8gm daily); MO

FLOVENT HFA AERO 44MCG/ACT

$0(Tier

2)

Limit 1 inhalerpermonth;QL(0.36gm daily); MO

Sympathomimetics

ADVAIR HFA AERO$0

(Tier2)

QL(4 gm daily);MO

Name of drug

Whatthe


level)


albuterol sulfate nebu in0.63 mg/3ml, 0.083 %, 0.5%, 1.25 mg/3ml

$0(Tier

1)

B/D; MO

albuterol sulfate syrp or 2mg/5ml

$0(Tier

1)

MO

albuterol sulfate tabs or 2mg, 4 mg

$0(Tier

1)

MO

albuterol sulfate tb12 or 4mg, 8 mg

$0(Tier

1)

MO

ANORO ELLIPTA AEPB$0

(Tier2)

QL(2 ea daily);MO

BREO ELLIPTA AEPB25MCG/INH-100MCG/INH,25MCG/INH-200MCG/INH

$0(Tier

2)

Limit 2 inhalersper month(InstitutionalPack);SL(2 eadaily); MO

BREO ELLIPTA AEPB25MCG/INH-100MCG/INH,25MCG/INH-200MCG/INH

$0(Tier

2)

Limit 1 inhalerper month;SL(2ea daily); MO

COMBIVENT RESPIMATAERS

$0(Tier

2)

Limit 3 inhalersper 2months;SL(0.2gm daily); MO

fluticasone-salmeterol aepb$0

(Tier1)

MO

ipratropium-albuterol soln$0

(Tier1)

B/D; MO

levalbuterol hcl nebu$0

(Tier1)

B/D; MO

levalbuterol tartrate aero$0

(Tier2)

MO

PROAIR HFA AERS$0

(Tier2)

MO



Name of drug

Whatthe


level)


PROAIR RESPICLICKAEPB

$0(Tier

2)

MO

S2 NEBU$0

(Tier3)

MO; NT

SEREVENT DISKUSAEPB

$0(Tier

2)

QL(2 ea daily);MO

STIOLTO RESPIMATAERS

$0(Tier

2)

Limit 1 inhalerpermonth;SL(0.14gm daily); MO

STRIVERDI RESPIMATAERS

$0(Tier

2)

Limit 1 inhalerpermonth;SL(0.14gm daily); MO

SYMBICORT AERO4.5MCG/ACT-160MCG/ACT

$0(Tier

2)

Limit 2 inhalersper month(InstitutionalPack);QL(0.4gm daily); MO

SYMBICORT AERO4.5MCG/ACT-80MCG/ACT

$0(Tier

2)

Limit 2 inhalersper month(InstitutionalPack);QL(0.46gm daily); MO

SYMBICORT AERO4.5MCG/ACT-80MCG/ACT,4.5MCG/ACT-160MCG/ACT

$0(Tier

2)

Limit 1 inhalerpermonth;QL(0.34gm daily); MO

terbutaline sulfate tabs or 5mg, 2.5 mg

$0(Tier

1)

MO

TRELEGY ELLIPTA AEPB$0

(Tier2)

MO

Xanthines

aminophylline soln$0

(Tier1)

Name of drug

Whatthe


level)


theophylline tb12 300 mg,450 mg

$0(Tier

1)

MO

theophylline tb24 400 mg,600 mg

$0(Tier

1)

MO

ANTICOAGULANTS - Blood Thinners

Coumarin Anticoagulants

warfarin sodium tabs$0

(Tier1)

MO

Direct Factor Xa Inhibitors

BEVYXXA CAPS 40 MG$0

(Tier2)

QL(1 ea daily)

BEVYXXA CAPS 80 MG$0

(Tier2)

QL(1 ea daily);MO

ELIQUIS STARTER PACKTABS

$0(Tier

2)

MO

ELIQUIS TABS$0

(Tier2)

MO

XARELTO STARTERPACK TBPK

$0(Tier

2)

MO

XARELTO TABS$0

(Tier2)

MO

Heparins And Heparinoid-Like Agents

enoxaparin sodium soln$0

(Tier1)

MO

fondaparinux sodium soln2.5 mg/0.5ml

$0(Tier

1)

MO

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

$0(Tier

1)

NDS;MO



Name of drug

Whatthe


level)


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

$0(Tier

2)

MO

FRAGMIN SOLN 7500UNIT/0.3ML, 12500UNIT/0.5ML, 15000UNIT/0.6ML, 18000UNT/0.72ML, 95000UNIT/3.8ML

$0(Tier

2)

NDS;MO

heparin sodium (porcine)soln

$0(Tier

1)

MO

HEPARIN SODIUM SOLNIJ 5000 UNIT/ML

$0(Tier

2)

Thrombin Inhibitors

argatroban soln 250mg/2.5ml

$0(Tier

1)

ARGATROBAN SOLN 250MG/2.5ML

$0(Tier

2)

PRADAXA CAPS$0

(Tier2)

MO

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor Antagonists

FYCOMPA SUSP$0

(Tier2)

MO

FYCOMPA TABS$0

(Tier2)

MO

Anticonvulsants - Benzodiazepines

clobazam susp 2.5 mg/ml$0

(Tier1)

MO

clobazam tabs 10 mg$0

(Tier1)

MO

Name of drug

Whatthe


level)


clobazam tabs 20 mg$0

(Tier1)

NDS;MO

clonazepam tabs 0.5 mg$0

(Tier1)

SL(40 ea daily);MO

clonazepam tabs 1 mg$0

(Tier1)

SL(20 ea daily);MO

clonazepam tabs 2 mg$0

(Tier1)

SL(10 ea daily);MO

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

$0(Tier

1)

MO

DIASTAT ACUDIAL GEL$0

(Tier2)

MO

DIASTAT PEDIATRIC GEL$0

(Tier2)

MO

diazepam (anticonvulsant)gel

$0(Tier

2)

MO

DIAZEPAM RECTAL GELGEL

$0(Tier

2)

MO

ONFI SUSP 2.5 MG/ML(Clobazam)

$0(Tier

2)

MO

ONFI TABS 10 MG(Clobazam)

$0(Tier

2)

MO

ONFI TABS 20 MG(Clobazam)

$0(Tier

2)

NDS;MO

SYMPAZAN FILM 10 MG,20 MG

$0(Tier

2)

PA; NDS;MO

SYMPAZAN FILM 5 MG$0

(Tier2)

PA; MO



Name of drug

Whatthe


level)


Anticonvulsants - Misc.

APTIOM TABS 200 MG$0

(Tier2)

MO

APTIOM TABS 400 MG,600 MG, 800 MG

$0(Tier

2)

NDS;MO

BANZEL SUSP 40 MG/ML$0

(Tier2)

MO

BANZEL TABS 200 MG$0

(Tier2)

MO

BANZEL TABS 400 MG$0

(Tier2)

NDS;MO

BRIVIACT SOLN IV 50MG/5ML

$0(Tier

2)

NDS;SL(20 mldaily)

BRIVIACT SOLN OR 10MG/ML

$0(Tier

2)

PA; NDS;SL(20ml daily); MO

BRIVIACT TABS OR 10MG

$0(Tier

2)

PA; NDS;SL(20ea daily); MO


$0(Tier

2)



$0(Tier

2)



$0(Tier

2)



$0(Tier

2)

PA;NDS;SL(2.67ea daily); MO

carbamazepine chew$0

(Tier1)

MO

Name of drug

Whatthe


level)


carbamazepine cp12$0

(Tier1)

MO

carbamazepine susp$0

(Tier1)

MO

carbamazepine tabs$0

(Tier1)

MO

carbamazepine tb12$0

(Tier1)

MO

EPIDIOLEX SOLN$0

(Tier2)

PA; NDS

gabapentin caps$0

(Tier1)

MO

gabapentin soln$0

(Tier1)

MO

gabapentin tabs$0

(Tier1)

MO

LAMICTAL XR KIT$0

(Tier2)

MO

lamotrigine chew 5 mg, 25mg

$0(Tier

1)

MO

lamotrigine tabs 25 mg,100 mg, 150 mg, 200 mg

$0(Tier

1)

MO

lamotrigine tb24 25 mg, 50mg, 100 mg, 200 mg, 250mg, 300 mg

$0(Tier

1)

MO

levetiracetam in sodiumchloride soln

$0(Tier

1)

levetiracetam soln iv 500mg/5ml

$0(Tier

1)

MO



Name of drug

Whatthe


level)


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

$0(Tier

1)

MO

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

$0(Tier

1)

MO

levetiracetam tb24 or 500mg, 750 mg

$0(Tier

1)

MO

oxcarbazepine susp$0

(Tier1)

MO

oxcarbazepine tabs$0

(Tier1)

MO

pregabalin caps 150 mg,200 mg, 225 mg

$0(Tier

1)

QL(2 ea daily);MO

pregabalin caps 25 mg, 50mg, 75 mg, 100 mg

$0(Tier

1)

QL(3 ea daily);MO

pregabalin caps 300 mg$0

(Tier1)

SL(2 ea daily);MO

pregabalin soln 20 mg/ml$0

(Tier1)

SL(30 ml daily);MO

primidone tabs$0

(Tier1)

MO

SPRITAM TB3D 1000 MG$0

(Tier2)

PA; SL(3 eadaily); MO


(Tier2)



(Tier2)



(Tier2)


Name of drug

Whatthe


level)


topiramate cpsp$0

(Tier1)

MO

topiramate tabs$0

(Tier1)

MO

VIMPAT SOLN IV 200MG/20ML

$0(Tier

2)

VIMPAT SOLN OR 10MG/ML

$0(Tier

2)

MO

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

$0(Tier

2)

MO

zonisamide caps$0

(Tier1)

MO

Carbamates

felbamate susp$0

(Tier1)

MO

felbamate tabs$0

(Tier1)

MO

GABA Modulators

tiagabine hcl tabs$0

(Tier1)

MO

vigabatrin pack$0

(Tier1)

NDS;LA; MO

vigabatrin tabs$0

(Tier1)

NDS;LA

Hydantoins

fosphenytoin sodium soln100 mg pe/2ml

$0(Tier

1)



Name of drug

Whatthe


level)


fosphenytoin sodium soln500 mg pe/10ml

$0(Tier

1)

MO

PEGANONE TABS$0

(Tier2)

MO

phenytoin chew$0

(Tier1)

MO

phenytoin sodium extendedcaps 30 mg, 100 mg, 200mg, 300 mg

$0(Tier

1)

MO

phenytoin sodium soln$0

(Tier1)

phenytoin susp$0

(Tier1)

MO

Succinimides

CELONTIN CAPS$0

(Tier2)

MO

ethosuximide caps$0

(Tier1)

MO

ethosuximide soln$0

(Tier1)

MO

Valproic Acid

divalproex sodium csdr$0

(Tier1)

MO

divalproex sodium tb24$0

(Tier1)

MO

divalproex sodium tbec$0

(Tier1)

MO

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

$0(Tier

1)

Name of drug

Whatthe


level)


valproate sodium soln or250 mg/5ml

$0(Tier

1)

MO

valproic acid caps$0

(Tier1)

MO

ANTIDEPRESSANTS - Drugs to TreatDepressionAlpha-2 Receptor Antagonists (Tetracyclics)

mirtazapine tabs$0

(Tier1)

MO

mirtazapine tbdp$0

(Tier1)

MO

Antidepressants - Misc.

bupropion hcl tabs 100 mg$0

(Tier1)

SL(4.5 eadaily); MO

bupropion hcl tabs 75 mg$0

(Tier1)

SL(6 ea daily);MO

bupropion hcl tb12 100 mg$0

(Tier1)

SL(4 ea daily);MO


(Tier1)



(Tier1)

SL(2 ea daily);MO


(Tier1)

SL(3 ea daily);MO


(Tier1)

SL(1.5 eadaily); MO

BUPROPIONHYDROCHLORIDE ER(XL) TB24

$0(Tier

2)

ST; MO



Name of drug

Whatthe


level)


FORFIVO XL TB24$0

(Tier2)

ST; MO

maprotiline hcl tabs$0

(Tier1)

MO

GABA Receptor Modulator - Neuroactive Steroid

ZULRESSO SOLN$0

(Tier2)

PA; NDS

Monoamine Oxidase Inhibitors (MAOIs)

EMSAM PT24$0

(Tier2)

NDS;MO

MARPLAN TABS$0

(Tier2)

MO

phenelzine sulfate tabs$0

(Tier1)

MO

tranylcypromine sulfatetabs

$0(Tier

1)

MO

N-Methyl-D-aspartic acid (NMDA) Receptor

SPRAVATO 56MG DOSESOPK

$0(Tier

2)

PA; NDS;MO

SPRAVATO 84MG DOSESOPK

$0(Tier

2)

PA; NDS;MO

Selective Serotonin Reuptake Inhibitors (SSRIs)

citalopram hydrobromidesoln 10 mg/5ml

$0(Tier

1)

SL(20 ml daily);MO

citalopram hydrobromidetabs 10 mg

$0(Tier

1)

SL(4 ea daily);MO


$0(Tier

1)

SL(2 ea daily);MO

Name of drug

Whatthe


level)



$0(Tier

1)

SL(1 ea daily);MO

escitalopram oxalate soln$0

(Tier1)

MO

escitalopram oxalate tabs$0

(Tier1)

MO

fluoxetine hcl caps$0

(Tier1)

MO

fluoxetine hcl cpdr$0

(Tier1)

MO

fluoxetine hcl soln$0

(Tier1)

MO

fluoxetine hcl tabs$0

(Tier1)

MO

fluvoxamine maleate cp24$0

(Tier1)

MO

fluvoxamine maleate tabs$0

(Tier1)

MO

paroxetine hcl tabs$0

(Tier1)

MO

paroxetine hcl tb24$0

(Tier1)

MO

PAXIL SUSP 10 MG/5ML$0

(Tier2)

MO

sertraline hcl conc$0

(Tier1)

MO

sertraline hcl tabs$0

(Tier1)

MO



Name of drug

Whatthe


level)


Serotonin Modulatorsnefazodone hcl tabs 50mg, 100 mg, 150 mg, 200mg, 250 mg

$0(Tier

1)

MO

trazodone hcl tabs$0

(Tier1)

MO

TRINTELLIX TABS 10 MG$0

(Tier2)

ST; QL(2 eadaily); MO


(Tier2)



(Tier2)


VIIBRYD STARTER PACKKIT

$0(Tier

2)

ST; MO

VIIBRYD TABS$0

(Tier2)

ST; MO

Serotonin-Norepinephrine Reuptake Inhibitors

DESVENLAFAXINE ERTB24 50 MG, 100 MG

$0(Tier

2)

ST; MO

desvenlafaxine succinatetb24

$0(Tier

1)

MO

duloxetine hcl cpep 20 mg,30 mg, 60 mg

$0(Tier

1)

MO

FETZIMA CP24 20 MG$0

(Tier2)


FETZIMA CP24 40 MG, 80MG, 120 MG

$0(Tier

2)


FETZIMA TITRATIONPACK C4PK

$0(Tier

2)

ST; MO

Name of drug

Whatthe


level)


KHEDEZLA TB24$0

(Tier2)

ST; MO

venlafaxine hcl cp24 150mg

$0(Tier

1)

SL(1.5 eadaily); MO

venlafaxine hcl cp24 37.5mg

$0(Tier

1)

SL(6 ea daily);MO

venlafaxine hcl cp24 75 mg$0

(Tier1)

SL(3 ea daily);MO

venlafaxine hcl tabs 100mg

$0(Tier

1)


venlafaxine hcl tabs 25 mg$0

(Tier1)

SL(15 ea daily);MO

venlafaxine hcl tabs 37.5mg

$0(Tier

1)

SL(10 ea daily);MO


(Tier1)

SL(7.5 eadaily); MO


(Tier1)

SL(5 ea daily);MO

venlafaxine hcl tb24 150mg

$0(Tier

1)

SL(1.5 eadaily); MO

venlafaxine hcl tb24 225mg

$0(Tier

1)

ST; SL(1 eadaily); MO

venlafaxine hcl tb24 37.5mg

$0(Tier

1)

SL(6 ea daily);MO

venlafaxine hcl tb24 75 mg$0

(Tier1)

SL(3 ea daily);MO

Tricyclic Agents



Name of drug

Whatthe


level)


amitriptyline hcl tabs$0

(Tier1)


amoxapine tabs$0

(Tier1)

MO

clomipramine hcl caps$0

(Tier1)


desipramine hcl tabs$0

(Tier1)

MO

doxepin hcl caps$0

(Tier1)


doxepin hcl conc$0

(Tier1)


imipramine hcl tabs$0

(Tier1)


imipramine pamoate caps$0

(Tier1)


nortriptyline hcl caps 10mg, 25 mg, 50 mg, 75 mg

$0(Tier

1)

MO

nortriptyline hcl soln 10mg/5ml

$0(Tier

1)

MO

protriptyline hcl tabs$0

(Tier1)

MO

trimipramine maleate caps$0

(Tier1)


ANTIDIABETICS - Drugs to Regulate BloodSugarAlpha-Glucosidase Inhibitors

acarbose tabs$0

(Tier1)

QL(3 ea daily);MO

Name of drug

Whatthe


level)


miglitol tabs$0

(Tier1)

QL(3 ea daily);MO

Antidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN$0

(Tier2)

PA; Limit 12mlspermonth;QL(0.4ml daily); MO

SYMLINPEN 60 SOPN$0

(Tier2)

PA; Limit 12mlspermonth;QL(0.4ml daily); MO

Antidiabetic Combinations

glipizide-metformin hcl tabs2.5mg-250mg

$0(Tier

1)

SL(8 ea daily);MO

glipizide-metformin hcl tabs5mg-500mg, 2.5mg-500mg

$0(Tier

1)

SL(4 ea daily);MO

glyburide-metformin tabs1.25mg-250mg

$0(Tier

1)


glyburide-metformin tabs5mg-500mg, 2.5mg-500mg

$0(Tier

1)


INVOKAMET TABS150MG-500MG, 50MG-1000MG, 150MG-1000MG

$0(Tier

2)

SL(2 ea daily);MO

INVOKAMET TABS 50MG-500MG

$0(Tier

2)

SL(4 ea daily);MO

INVOKAMET XR TB24150MG-500MG, 50MG-1000MG, 150MG-1000MG

$0(Tier

2)

SL(2 ea daily);MO

INVOKAMET XR TB2450MG-500MG

$0(Tier

2)

SL(4 ea daily);MO

JANUMET TABS$0

(Tier2)

SL(2 ea daily);MO



Name of drug

Whatthe


level)


JANUMET XR TB24100MG-1000MG

$0(Tier

2)

SL(1 ea daily);MO

JANUMET XR TB2450MG-500MG, 50MG-1000MG

$0(Tier

2)

SL(2 ea daily);MO

JENTADUETO TABS$0

(Tier2)

SL(2 ea daily);MO

JENTADUETO XR TB242.5MG-1000MG

$0(Tier

2)

SL(2 ea daily);MO

JENTADUETO XR TB245MG-1000MG

$0(Tier

2)

SL(1 ea daily);MO

pioglitazone hcl-glimepiridetabs

$0(Tier

1)

SL(1.5 eadaily); MO

pioglitazone hcl-metforminhcl tabs

$0(Tier

1)

SL(3 ea daily);MO

REPAGLINIDE/METFORMIN HYDROCHLORIDETABS

$0(Tier

2)

SL(5 ea daily);MO

SYNJARDY TABS 5MG-1000MG, 12.5MG-1000MG

$0(Tier

2)

SL(2 ea daily);MO

SYNJARDY TABS 5MG-500MG, 12.5MG-500MG

$0(Tier

2)

SL(4 ea daily);MO

SYNJARDY XR TB2425MG-1000MG

$0(Tier

2)

SL(1 ea daily);MO

SYNJARDY XR TB245MG-1000MG, 10MG-1000MG, 12.5MG-1000MG

$0(Tier

2)

SL(2 ea daily);MO

Biguanides

metformin hcl tabs 1000mg

$0(Tier

1)


Name of drug

Whatthe


level)


metformin hcl tabs 500 mg$0

(Tier1)

SL(5.1 eadaily); MO

metformin hcl tabs 850 mg$0

(Tier1)

SL(3 ea daily);MO

metformin hcl tb24 500 mg$0

(Tier1)

SL(4 ea daily);MO

metformin hcl tb24 750 mg$0

(Tier1)


Diabetic Other

GLUCAGEN HYPOKITSOLR

$0(Tier

2)

MO

GLUCAGONEMERGENCY KIT KIT

$0(Tier

2)

MO

KORLYM TABS$0

(Tier2)

PA; SL(4 eadaily); LA; MO

PROGLYCEM SUSP$0

(Tier2)

MO

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

JANUVIA TABS 100 MG$0

(Tier2)

QL(1 ea daily);MO


(Tier2)

QL(4 ea daily);MO


(Tier2)

QL(2 ea daily);MO

TRADJENTA TABS$0

(Tier2)

QL(1 ea daily);MO

Dopamine Receptor Agonists - Antidiabetic



Name of drug

Whatthe


level)


CYCLOSET TABS$0

(Tier2)

QL(6 ea daily);MO

Incretin Mimetic Agents (GLP-1 Receptor

BYDUREON BCISE AUIJ$0

(Tier2)

ST; MO

BYDUREON PEN PEN$0

(Tier2)

ST; MO

BYDUREON SRER$0

(Tier2)

ST

BYETTA SOPN$0

(Tier2)

ST; MO

VICTOZA SOPN$0

(Tier2)

ST; Limit 9mlspermonth;QL(0.3ml daily); MO

Insulin Sensitizing Agents

AVANDIA TABS 2 MG$0

(Tier2)

SL(4 ea daily);MO

AVANDIA TABS 4 MG$0

(Tier2)

SL(2 ea daily);MO

pioglitazone hcl tabs 15 mg$0

(Tier1)

SL(3 ea daily);MO


(Tier1)

SL(1.5 eadaily); MO


(Tier1)

SL(1 ea daily);MO

Insulin

HUMALOG JUNIORKWIKPEN SOPN

$0(Tier

2)

Limit 45mls permonth;QL(1.5ml daily); MO

Name of drug

Whatthe


level)


HUMALOG KWIKPENSOPN

$0(Tier

2)


HUMALOG MIX 50/50KWIKPEN SUPN

$0(Tier

2)


HUMALOG MIX 50/50SUSP

$0(Tier

2)


HUMALOG MIX 75/25KWIKPEN SUPN

$0(Tier

2)


HUMALOG MIX 75/25SUSP

$0(Tier

2)


HUMALOG SOCT$0

(Tier2)


HUMALOG SOLN$0

(Tier2)


HUMULIN 70/30 KWIKPENSUPN

$0(Tier

2)


HUMULIN 70/30 SUSP$0

(Tier2)


HUMULIN N KWIKPENSUPN

$0(Tier

2)


HUMULIN N SUSP$0

(Tier2)


HUMULIN R SOLN$0

(Tier2)


HUMULIN R U-500(CONCENTRATED) SOLN

$0(Tier

2)


HUMULIN R U-500KWIKPEN SOPN

$0(Tier

2)




Name of drug

Whatthe


level)


LANTUS SOLN$0

(Tier2)


LANTUS SOLOSTARSOPN

$0(Tier

2)


LEVEMIR FLEXTOUCHSOPN

$0(Tier

2)


LEVEMIR SOLN$0

(Tier2)


TOUJEO MAX SOLOSTARSOPN

$0(Tier

2)


TOUJEO SOLOSTARSOPN

$0(Tier

2)


TRESIBA FLEXTOUCHSOPN 100 UNIT/ML

$0(Tier

2)


TRESIBA FLEXTOUCHSOPN 200 UNIT/ML

$0(Tier

2)


Meglitinide Analogues

nateglinide tabs$0

(Tier1)

QL(3 ea daily);MO

repaglinide tabs 0.5 mg$0

(Tier1)

SL(32 ea daily);MO

repaglinide tabs 1 mg$0

(Tier1)

SL(16 ea daily);MO

repaglinide tabs 2 mg$0

(Tier1)

SL(8 ea daily);MO

Sodium-Glucose Co-Transporter 2 (SGLT2)

INVOKANA TABS$0

(Tier2)

MO

Name of drug

Whatthe


level)


JARDIANCE TABS$0

(Tier2)

MO

Sulfonylureas

glimepiride tabs 1 mg$0

(Tier1)

SL(8 ea daily);MO


(Tier1)

SL(4 ea daily);MO


(Tier1)

SL(2 ea daily);MO

glipizide tabs 10 mg$0

(Tier1)

SL(4 ea daily);MO

glipizide tabs 5 mg$0

(Tier1)

SL(8 ea daily);MO

glipizide tb24 10 mg$0

(Tier1)

SL(2 ea daily);MO

glipizide tb24 2.5 mg$0

(Tier1)

SL(8 ea daily);MO

glipizide tb24 5 mg$0

(Tier1)

SL(4 ea daily);MO

glyburide micronized tabs1.5 mg

$0(Tier

1)


glyburide micronized tabs 3mg

$0(Tier

1)


glyburide micronized tabs 6mg

$0(Tier

1)


glyburide tabs 1.25 mg$0

(Tier1)




Name of drug

Whatthe


level)


glyburide tabs 2.5 mg$0

(Tier1)


glyburide tabs 5 mg$0

(Tier1)


tolazamide tabs 250 mg$0

(Tier1)

SL(4 ea daily)

tolazamide tabs 500 mg$0

(Tier1)

SL(2 ea daily);MO

tolbutamide tabs$0

(Tier1)

SL(6 ea daily);MO

ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugsto Treat DiarrheaAntidiarrheal/Probiotic Agents - Misc.

bismuth subsalicylate chew262 mg

$0(Tier

3)

MO; NT

bismuth subsalicylate susp262 mg/15ml

$0(Tier

3)

MO; NT

bismuth subsalicylate susp525 mg/15ml

$0(Tier

3)

NT

Antiperistaltic Agents

diphenoxylate w/ atropinetabs

$0(Tier

1)

MO

loperamide hcl caps 2 mg$0

(Tier1)

RX/OTC; MO

loperamide hcl liqd 1mg/5ml, 1 mg/7.5ml

$0(Tier

3)

MO; NT

loperamide hcl susp 1mg/7.5ml

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


loperamide hcl tabs 2 mg$0

(Tier3)

MO; NT

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating Agents

deferasirox tbso$0

(Tier1)

NDS

FERRIPROX TABS 500MG, 1000 MG

$0(Tier

2)

PA; NDS;LA;MO

JADENU SPRINKLE PACK$0

(Tier2)

NDS

JADENU TABS$0

(Tier2)

NDS

Antidotes and Specific Antagonists

charcoal activated-sorbitolliqd

$0(Tier

3)

NT

IOSAT TABS$0

(Tier3)

NT

THYROSAFE TABS$0

(Tier3)

NT

VISTOGARD PACK$0

(Tier2)

NDS;MO

Opioid Antagonists

naloxone hcl sosy 2mg/2ml

$0(Tier

1)

naltrexone hcl tabs$0

(Tier1)

MO

ANTIEMETICS - Drugs to Treat Nausea andVomiting5-HT3 Receptor Antagonists



Name of drug

Whatthe


level)


granisetron hcl tabs or 1mg

$0(Tier

1)

B/D; MO

ondansetron hcl soln ij 4mg/2ml, 40 mg/20ml

$0(Tier

1)

MO

ondansetron hcl soln or 4mg/5ml

$0(Tier

1)

B/D; MO

ondansetron hcl tabs or 24mg

$0(Tier

1)

B/D

ondansetron hcl tabs or 4mg, 8 mg

$0(Tier

1)

B/D; MO

ondansetron tbdp$0

(Tier1)

B/D; MO

Antiemetics - Anticholinergic

dimenhydrinate tabs or 50mg

$0(Tier

3)

NT

meclizine hcl chew 25 mg$0

(Tier3)

MO; NT

meclizine hcl tabs 12.5 mg$0

(Tier3)


meclizine hcl tabs 25 mg,12.5 mg

$0(Tier

1)

RX/OTC; MO

scopolamine pt72$0

(Tier1)

MO

TIGAN SOLN IM 100MG/ML

$0(Tier

2)

MO

TRANSDERM SCOP PT72$0

(Tier2)

MO

Name of drug

Whatthe


level)


TRANSDERM-SCOP PT72$0

(Tier2)

MO

Antiemetics - Miscellaneous

CESAMET CAPS$0

(Tier2)

B/D; MO

dronabinol caps 10 mg$0

(Tier1)

B/D; NDS;MO

dronabinol caps 5 mg, 2.5mg

$0(Tier

1)

B/D; MO

fructose-dextrose-phosphoric acid soln

$0(Tier

3)

NT

SYNDROS SOLN$0

(Tier2)

B/D; NDS;MO

Substance P/Neurokinin 1 (NK1) Receptor

aprepitant caps 40 mg$0

(Tier1)

PA; MO

aprepitant caps 80 mg, 125mg

$0(Tier

1)

B/D; MO

VARUBI TABS OR 90 MG$0

(Tier2)

B/D

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungal - Glucan Synthesis Inhibitors

ERAXIS SOLR$0

(Tier2)

MYCAMINE SOLR 100 MG$0

(Tier2)

NDS

MYCAMINE SOLR 50 MG$0

(Tier2)

NDS;MO



Name of drug

Whatthe


level)


Antifungals

ABELCET SUSP$0

(Tier2)

PA

AMBISOME SUSR$0

(Tier2)

PA

amphotericin b solr$0

(Tier1)

PA; MO

flucytosine caps$0

(Tier1)

MO

griseofulvin microsize susp$0

(Tier1)

MO

griseofulvin microsize tabs$0

(Tier1)

MO

griseofulvin ultramicrosizetabs

$0(Tier

1)

MO

nystatin tabs$0

(Tier1)

MO

terbinafine hcl tabs$0

(Tier1)

MO

Imidazole-Related Antifungals

CRESEMBA CAPS OR186 MG

$0(Tier

2)

NDS;MO

CRESEMBA SOLR IV 372MG

$0(Tier

2)

NDS

fluconazole in dextrosesoln

$0(Tier

1)fluconazole in nacl soln200mg/100ml-0.9%,400mg/200ml-0.9%

$0(Tier

1)

Name of drug

Whatthe


level)


fluconazole susr$0

(Tier1)

MO

fluconazole tabs$0

(Tier1)

MO

itraconazole caps 100 mg$0

(Tier1)

MO

ketoconazole tabs$0

(Tier1)

MO

NOXAFIL SOLN IV 300MG/16.7ML

$0(Tier

2)

NDS

NOXAFIL SUSP OR 40MG/ML

$0(Tier

2)

NDS;MO

NOXAFIL TBEC OR 100MG (Posaconazole)

$0(Tier

2)

NDS;MO

posaconazole tbec$0

(Tier1)

NDS;MO

voriconazole solr iv 200 mg$0

(Tier1)

voriconazole susr or 40mg/ml

$0(Tier

1)

MO

voriconazole tabs or 50 mg,200 mg

$0(Tier

1)

NDS;MO

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamines

ALA-HIST IR TABS$0

(Tier3)

MO; NT

chlorpheniramine maleatesyrp 2 mg/5ml

$0(Tier

3)

*;NT



Name of drug

Whatthe


level)


chlorpheniramine maleatetabs 4 mg

$0(Tier

3)

MO; NT

chlorpheniramine maleatetabs 4 mg

$0(Tier

3)

*;MO; NT

chlorpheniramine maleatetbcr 12 mg

$0(Tier

3)

*;MO; NT

ED CHLORPED LIQD$0

(Tier3)

*;NT

HISTEX PD LIQD(Triprolidine HCl)

$0(Tier

3)

MO; NT

HISTEX SYRP (TriprolidineHCl)

$0(Tier

3)

MO; NT

triprolidine hcl liqd 0.313mg/ml

$0(Tier

3)

*;NT

triprolidine hcl liqd 0.625mg/ml

$0(Tier

3)

*;MO; NT

VANACLEAR PD LIQD(Triprolidine HCl)

$0(Tier

3)

*;NT

VANAHIST PD LIQD(Triprolidine HCl)

$0(Tier

3)

*;MO; NT

Antihistamines - Ethanolamines

carbinoxamine maleatesoln 4 mg/5ml

$0(Tier

1)


carbinoxamine maleatetabs 4 mg

$0(Tier

1)


clemastine fumarate tabs1.34 mg

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


clemastine fumarate tabs2.68 mg

$0(Tier

1)


diphenhydramine hcl capsor 25 mg, 50 mg

$0(Tier

3)

MO; NT

diphenhydramine hcl elix or12.5 mg/5ml

$0(Tier

1)

AL(Up to 64 yrsold); RX/OTC

diphenhydramine hcl liqd or12.5 mg/5ml

$0(Tier

3)

MO; NT

diphenhydramine hcl liqd or6.25 mg/ml

$0(Tier

3)

NT

diphenhydramine hcl soln ij50 mg/ml

$0(Tier

1)

MO

diphenhydramine hcl tabsor 25 mg

$0(Tier

3)

MO; NT

SILPHEN COUGH SYRP$0

(Tier3)

*;NT

VANAMINE PD LIQD(Diphenhydramine HCl)

$0(Tier

3)

*;NT

Antihistamines - Non-Sedating

cetirizine hcl chew 5 mg, 10mg

$0(Tier

3)

*;MO; NT

cetirizine hcl soln 1 mg/ml$0

(Tier1)

RX/OTC; MO

cetirizine hcl soln 1 mg/ml,5 mg/5ml

$0(Tier

3)


cetirizine hcl tabs 5 mg, 10mg

$0(Tier

3)

MO; NT



Name of drug

Whatthe


level)


desloratadine tabs$0

(Tier1)

MO

desloratadine tbdp$0

(Tier1)

MO

fexofenadine hcl susp 30mg/5ml

$0(Tier

3)

*;MO; NT

fexofenadine hcl tabs 60mg, 180 mg

$0(Tier

3)

*;MO; NT

levocetirizinedihydrochloride soln 2.5mg/5ml

$0(Tier

1)

RX/OTC; MO

levocetirizinedihydrochloride tabs 5 mg

$0(Tier

1)

RX/OTC; MO

levocetirizinedihydrochloride tabs 5 mg

$0(Tier

3)

Over-the-counter;*;RX/OTC; MO;NT

loratadine soln 5 mg/5ml$0

(Tier3)

MO; NT

loratadine syrp 5 mg/5ml$0

(Tier3)

MO; NT

loratadine tabs 10 mg$0

(Tier3)

MO; NT

Antihistamines - Phenothiazines

promethazine hcl soln ij 25mg/ml, 50 mg/ml

$0(Tier

1)


promethazine hcl soln or6.25 mg/5ml

$0(Tier

1)


promethazine hcl supp re25 mg, 12.5 mg

$0(Tier

1)


Name of drug

Whatthe


level)


promethazine hcl syrp or6.25 mg/5ml

$0(Tier

1)


promethazine hcl tabs or25 mg, 50 mg, 12.5 mg

$0(Tier

1)


Antihistamines - Piperidines

cyproheptadine hcl syrp$0

(Tier1)


cyproheptadine hcl tabs$0

(Tier1)


ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterolAntihyperlipidemics - Combinations

ezetimibe-simvastatin tabs10mg-10mg

$0(Tier

1)

QL(8 ea daily);MO


$0(Tier

1)

QL(4 ea daily);MO


$0(Tier

1)

QL(2 ea daily);MO


$0(Tier

1)

QL(1 ea daily);MO

VYTORIN TABS 10MG-10MG (Ezetimibe-Simvastatin)

$0(Tier

2)

QL(8 ea daily);MO


$0(Tier

2)

QL(4 ea daily);MO


$0(Tier

2)

QL(2 ea daily);MO


$0(Tier

2)

QL(1 ea daily);MO

Antihyperlipidemics - Misc.



Name of drug

Whatthe


level)


KYNAMRO SOSY$0

(Tier2)

PA; NDS;LA

omega-3-acid ethyl esterscaps

$0(Tier

1)

MO

VASCEPA CAPS$0

(Tier2)

ST; MO

Bile Acid Sequestrants

cholestyramine light pack$0

(Tier1)

MO

cholestyramine light powd$0

(Tier1)

MO

cholestyramine pack$0

(Tier1)

MO

cholestyramine powd$0

(Tier1)

MO

colesevelam hcl pack$0

(Tier1)

MO

colesevelam hcl tabs$0

(Tier1)

MO

colestipol hcl gran$0

(Tier1)

MO

colestipol hcl pack$0

(Tier1)

MO

colestipol hcl tabs$0

(Tier1)

MO

WELCHOL PACK 3.75 GM(Colesevelam HCl)

$0(Tier

2)

MO

Fibric Acid Derivatives

Name of drug

Whatthe


level)


ANTARA CAPS 30 MG$0

(Tier2)


ANTARA CAPS 90 MG$0

(Tier2)


choline fenofibrate cpdr$0

(Tier1)

MO

fenofibrate micronized caps130 mg

$0(Tier

1)

SL(1 ea daily);MO

fenofibrate micronized caps43 mg

$0(Tier

1)


fenofibrate micronized caps67 mg, 134 mg, 200 mg

$0(Tier

1)

MO

fenofibrate tabs 48 mg, 54mg, 145 mg, 160 mg

$0(Tier

1)

MO

gemfibrozil tabs$0

(Tier1)

MO

TRIGLIDE TABS$0

(Tier2)

MO

HMG CoA Reductase Inhibitors

atorvastatin calcium tabs$0

(Tier1)

MO

fluvastatin sodium caps 20mg

$0(Tier

1)

QL(3 ea daily);MO

fluvastatin sodium caps 40mg

$0(Tier

1)

QL(2 ea daily);MO

fluvastatin sodium tb24 80mg

$0(Tier

1)

MO



Name of drug

Whatthe


level)


lovastatin tabs 10 mg, 20mg

$0(Tier

1)

QL(1 ea daily);MO

lovastatin tabs 40 mg$0

(Tier1)

QL(2 ea daily);MO

pravastatin sodium tabs$0

(Tier1)

QL(1 ea daily);MO

rosuvastatin calcium tabs$0

(Tier1)

QL(1 ea daily);MO

simvastatin tabs 5 mg, 10mg, 20 mg, 40 mg

$0(Tier

1)

QL(1 ea daily);MO

simvastatin tabs 80 mg$0

(Tier1)

SL(1 ea daily);MO

Intestinal Cholesterol Absorption Inhibitors

ezetimibe tabs$0

(Tier1)

QL(1 ea daily);MO

Microsomal Triglyceride Transfer Protein (MTP)

JUXTAPID CAPS 10 MG$0

(Tier2)

PA; NDS;SL(6ea daily); LA;MO


(Tier2)



(Tier2)



(Tier2)

PA;NDS;SL(1.5 eadaily); LA; MO


(Tier2)



(Tier2)


Name of drug

Whatthe


level)


Nicotinic Acid Derivatives

niacin (antihyperlipidemic)tbcr

$0(Tier

1)

MO

Proprotein Convertase Subtilisin/Kexin Type 9

PRALUENT SOAJ 150MG/ML

$0(Tier

2)

PA; NDS; Limit2mls per 28days;SL(0.08ml daily); MO

PRALUENT SOAJ 75MG/ML

$0(Tier

2)

PA; NDS; Limit4mls per 28days;SL(0.15ml daily); MO

REPATHA PUSHTRONEXSYSTEM SOCT

$0(Tier

2)

PA; NDS;MO

REPATHA SOSY$0

(Tier2)

PA; NDS;MO

REPATHA SURECLICKSOAJ

$0(Tier

2)

PA; NDS;MO

ANTIHYPERTENSIVES - Drugs to Treat HighBlood PressureACE Inhibitors

benazepril hcl tabs$0

(Tier1)

MO

captopril tabs$0

(Tier1)

MO

enalapril maleate tabs 10mg

$0(Tier

1)

SL(4 ea daily);MO

enalapril maleate tabs 2.5mg

$0(Tier

1)

SL(16 ea daily);MO


$0(Tier

1)

SL(2 ea daily);MO



Name of drug

Whatthe


level)



$0(Tier

1)

SL(8 ea daily);MO

fosinopril sodium tabs$0

(Tier1)

MO

lisinopril tabs$0

(Tier1)

MO

moexipril hcl tabs$0

(Tier1)

MO

perindopril erbumine tabs 2mg

$0(Tier

1)

SL(8 ea daily);MO


$0(Tier

1)

SL(4 ea daily);MO


$0(Tier

1)

SL(2 ea daily);MO

quinapril hcl tabs$0

(Tier1)

MO

ramipril caps$0

(Tier1)

MO

trandolapril tabs$0

(Tier1)

MO

Agents for Pheochromocytoma

DEMSER CAPS$0

(Tier2)

NDS;MO

phenoxybenzamine hclcaps

$0(Tier

1)

MO

Angiotensin II Receptor Antagonists

candesartan cilexetil tabs$0

(Tier1)

MO

Name of drug

Whatthe


level)


eprosartan mesylate tabs$0

(Tier1)

MO

irbesartan tabs$0

(Tier1)

MO

losartan potassium tabs$0

(Tier1)

MO

valsartan tabs$0

(Tier1)

MO

Antiadrenergic Antihypertensives

clonidine hcl tabs$0

(Tier1)

MO

clonidine ptwk$0

(Tier1)

MO

doxazosin mesylate tabs$0

(Tier1)

MO

guanfacine hcl tabs$0

(Tier1)


prazosin hcl caps$0

(Tier1)

MO

terazosin hcl caps$0

(Tier1)

MO

Antihypertensive Combinations

amlodipine besylate-benazepril hcl caps

$0(Tier

1)

MO

atenolol & chlorthalidonetabs

$0(Tier

1)

MO

benazepril &hydrochlorothiazide tabs

$0(Tier

1)

MO



Name of drug

Whatthe


level)


bisoprolol &hydrochlorothiazide tabs

$0(Tier

1)

MO

candesartan cilexetil-hydrochlorothiazide tabs

$0(Tier

1)

MO

captopril &hydrochlorothiazide tabs

$0(Tier

1)

MO

enalapril maleate &hydrochlorothiazide tabs

$0(Tier

1)

MO

fosinopril sodium &hydrochlorothiazide tabs

$0(Tier

1)

MO

irbesartan-hydrochlorothiazide tabs

$0(Tier

1)

MO

lisinopril &hydrochlorothiazide tabs

$0(Tier

1)

MO

losartan potassium &hydrochlorothiazide tabs

$0(Tier

1)

MO

metoprolol &hydrochlorothiazide tabs

$0(Tier

1)

MO

moexipril-hydrochlorothiazide tabs15mg-12.5mg

$0(Tier

1)

MO

moexipril-hydrochlorothiazide tabs15mg-25mg

$0(Tier

1)

nadolol &bendroflumethiazide tabs

$0(Tier

1)

quinapril-hydrochlorothiazide tabs

$0(Tier

1)

MO

TEKTURNA HCT TABS$0

(Tier2)

MO

Name of drug

Whatthe


level)


valsartan-hydrochlorothiazide tabs

$0(Tier

1)

MO

Direct Renin Inhibitors

aliskiren fumarate tabs$0

(Tier1)

MO

Selective Aldosterone Receptor Antagonists

eplerenone tabs$0

(Tier1)

MO

Vasodilators

hydralazine hcl tabs or 10mg, 25 mg, 50 mg, 100 mg

$0(Tier

1)

MO

minoxidil tabs$0

(Tier1)

MO

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections)Antimalarial Combinations

atovaquone-proguanil hcltabs

$0(Tier

1)

MO

COARTEM TABS$0

(Tier2)

MO

Antimalarials

chloroquine phosphate tabs$0

(Tier1)

MO

DARAPRIM TABS$0

(Tier2)

hydroxychloroquine sulfatetabs

$0(Tier

1)

MO

KRINTAFEL TABS$0

(Tier2)

QL(0.067 eadaily)



Name of drug

Whatthe


level)


mefloquine hcl tabs$0

(Tier1)

MO

primaquine phosphate tabs$0

(Tier1)

MO

PRIMAQUINEPHOSPHATE TABS(Primaquine Phosphate)

$0(Tier

2)

MO

quinine sulfate caps$0

(Tier1)

PA; MO

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic Agents

FIRDAPSE TABS$0

(Tier2)


GUANIDINE HCL TABS$0

(Tier2)

pyridostigmine bromidetabs 60 mg

$0(Tier

1)

MO

pyridostigmine bromidetbcr 180 mg

$0(Tier

1)

MO

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections)Anti TB Combinations

isoniazid & rifampin caps$0

(Tier1)

MO

RIFATER TABS$0

(Tier2)

MO

Antimycobacterial Agents

aminosalicylic acid pack$0

(Tier1)

MO

Name of drug

Whatthe


level)


CAPASTAT SULFATESOLR

$0(Tier

2)

ethambutol hcl tabs$0

(Tier1)

MO

isoniazid tabs or 100 mg,300 mg

$0(Tier

1)

MO

PRIFTIN TABS$0

(Tier2)

MO

pyrazinamide tabs$0

(Tier1)

MO

rifabutin caps$0

(Tier1)

NDS;MO

rifampin caps or 150 mg,300 mg

$0(Tier

1)

MO

rifampin solr iv 600 mg$0

(Tier1)

SIRTURO TABS$0

(Tier2)

NDS;LA

TRECATOR TABS$0

(Tier2)

MO

ANTINEOPLASTICS AND ADJUNCTIVETHERAPIES - Drugs to Treat CancerAlkylating Agents

BENDEKA SOLN$0

(Tier2)

NDS

BICNU SOLR (Carmustine)$0

(Tier2)

busulfan soln$0

(Tier1)



Name of drug

Whatthe


level)


carboplatin soln$0

(Tier1)

carmustine solr$0

(Tier1)

cisplatin soln 50 mg/50ml,100 mg/100ml, 200mg/200ml

$0(Tier

1)

cyclophosphamide caps or25 mg, 50 mg

$0(Tier

1)

B/D; MO

EVOMELA SOLR$0

(Tier2)

NDS

GLEOSTINE CAPS 10 MG,40 MG, 100 MG

$0(Tier

2)

MO

HEXALEN CAPS$0

(Tier2)

NDS;MO

IFEX SOLR 3 GM$0

(Tier2)

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

$0(Tier

1)

ifosfamide solr 1 gm$0

(Tier1)

IFOSFAMIDE SOLR 3 GM$0

(Tier2)

LEUKERAN TABS$0

(Tier2)

MO

melphalan hcl solr$0

(Tier1)

melphalan tabs$0

(Tier1)

B/D; MO

Name of drug

Whatthe


level)


oxaliplatin soln 100mg/20ml

$0(Tier

1)

oxaliplatin soln 50 mg/10ml$0

(Tier1)

NDS

oxaliplatin solr 50 mg, 100mg

$0(Tier

1)

NDS

TEMODAR SOLR$0

(Tier2)

NDS

thiotepa solr$0

(Tier1)

NDS

TREANDA SOLR$0

(Tier2)

NDS

YONDELIS SOLR$0

(Tier2)

NDS;LA

ZANOSAR SOLR$0

(Tier2)

MO

Antimetabolites

ALIMTA SOLR$0

(Tier2)

NDS

ARRANON SOLN$0

(Tier2)

NDS

azacitidine susr$0

(Tier1)

NDS

cladribine soln$0

(Tier1)

PA

clofarabine soln$0

(Tier1)



Name of drug

Whatthe


level)


cytarabine soln$0

(Tier1)

PA

decitabine solr$0

(Tier1)

fludarabine phosphate solr50 mg

$0(Tier

1)fluorouracil soln iv 1gm/20ml, 5 gm/100ml, 2.5gm/50ml, 500 mg/10ml

$0(Tier

1)

PA

FOLOTYN SOLN$0

(Tier2)

NDS

gemcitabine hcl soln 1gm/26.3ml, 2 gm/52.6ml,200 mg/5.26ml

$0(Tier

1)

NDS

gemcitabine hcl solr 1 gm,2 gm

$0(Tier

1)

gemcitabine hcl solr 200mg

$0(Tier

1)

NDS

GEMCITABINEHYDROCHLORIDE SOLN1 GM/10ML, 2 GM/20ML,200 MG/2ML

$0(Tier

2)

INFUGEM SOLN$0

(Tier2)

NDS

mercaptopurine tabs$0

(Tier1)

MO

methotrexate sodium soln ij1 gm/40ml, 50 mg/2ml, 250mg/10ml

$0(Tier

1)

methotrexate sodium solr ij1 gm

$0(Tier

1)

Name of drug

Whatthe


level)


methotrexate sodium tabsor 5 mg, 10 mg, 15 mg, 2.5mg, 7.5 mg

$0(Tier

1)

MO

PURIXAN SUSP$0

(Tier2)

PA; NDS

TABLOID TABS$0

(Tier2)

MO

XATMEP SOLN$0

(Tier2)

PA; NDS;MO

Antineoplastic - Angiogenesis Inhibitors

AVASTIN SOLN$0

(Tier2)

NDS

CYRAMZA SOLN$0

(Tier2)

NDS;LA

MVASI SOLN$0

(Tier2)

NDS

ZALTRAP SOLN$0

(Tier2)

PA; NDS

Antineoplastic - Antibodies

ARZERRA CONC$0

(Tier2)

NDS

BAVENCIO SOLN$0

(Tier2)

NDS;LA

BESPONSA SOLR$0

(Tier2)

NDS;MO

BLINCYTO SOLR$0

(Tier2)

NDS

CAMPATH SOLN$0

(Tier2)

NDS



Name of drug

Whatthe


level)


DARZALEX SOLN$0

(Tier2)

NDS;LA

EMPLICITI SOLR$0

(Tier2)

NDS

ERBITUX SOLN$0

(Tier2)

NDS

GAZYVA SOLN$0

(Tier2)

NDS;LA

HERCEPTIN SOLR 150MG

$0(Tier

2)

PA; NDS

HERCEPTIN SOLR 440MG

$0(Tier

2)

NDS

IMFINZI SOLN$0

(Tier2)

NDS;LA

KADCYLA SOLR$0

(Tier2)

PA; NDS

KANJINTI SOLR 420 MG$0

(Tier2)

NDS

KEYTRUDA SOLN$0

(Tier2)

NDS

LARTRUVO SOLN$0

(Tier2)

NDS;LA; MO

LIBTAYO SOLN$0

(Tier2)

NDS;LA; MO

LUMOXITI SOLR$0

(Tier2)

NDS;LA

MYLOTARG SOLR$0

(Tier2)

NDS;MO

Name of drug

Whatthe


level)


OPDIVO SOLN$0

(Tier2)

NDS

PERJETA SOLN$0

(Tier2)

NDS

POLIVY SOLR$0

(Tier2)

NDS

PORTRAZZA SOLN$0

(Tier2)

NDS

POTELIGEO SOLN$0

(Tier2)

NDS

RITUXAN SOLN$0

(Tier2)

NDS

TECENTRIQ SOLN$0

(Tier2)

PA; NDS

VECTIBIX SOLN$0

(Tier2)

NDS

YERVOY SOLN$0

(Tier2)

PA; NDS

Antineoplastic - BCL-2 Inhibitors

VENCLEXTA STARTINGPACK TBPK

$0(Tier

2)

PA; LA; MO

VENCLEXTA TABS$0

(Tier2)

PA; LA; MO

Antineoplastic - Hedgehog Pathway Inhibitors

DAURISMO TABS$0

(Tier2)

PA; NDS

ERIVEDGE CAPS$0

(Tier2)

NDS;LA



Name of drug

Whatthe


level)


ODOMZO CAPS$0

(Tier2)

PA; NDS;LA

Antineoplastic - Hormonal and Related Agents

abiraterone acetate tabs$0

(Tier1)

PA; NDS

anastrozole tabs$0

(Tier1)

MO

bicalutamide tabs$0

(Tier1)

MO

DEPO-PROVERA SUSP$0

(Tier2)

MO

ELIGARD KIT$0

(Tier2)

EMCYT CAPS$0

(Tier2)

MO

ERLEADA TABS$0

(Tier2)

PA; NDS

exemestane tabs$0

(Tier1)

MO

FIRMAGON SOLR 120 MG$0

(Tier2)

NDS

FIRMAGON SOLR 80 MG$0

(Tier2)

flutamide caps$0

(Tier1)

MO

fulvestrant soln$0

(Tier1)

NDS;MO

Name of drug

Whatthe


level)


FULVESTRANT SOLN$0

(Tier2)

NDS;MO

HYDROXYPROGESTERONE CAPROATE SOLN1.25 GM/5ML

$0(Tier

2)

NDS

letrozole tabs$0

(Tier1)

MO

leuprolide acetate kit$0

(Tier1)

LUPRON DEPOT (1-MONTH) KIT

$0(Tier

2)

NDS


$0(Tier

2)

NDS


$0(Tier

2)

NDS


$0(Tier

2)

NDS

LYSODREN TABS$0

(Tier2)

megestrol acetate susp$0

(Tier1)


megestrol acetate tabs$0

(Tier1)


nilutamide tabs$0

(Tier1)

MO

NUBEQA TABS$0

(Tier2)

PA; NDS

SOLTAMOX SOLN$0

(Tier2)

MO



Name of drug

Whatthe


level)


tamoxifen citrate tabs$0

(Tier1)

MO

toremifene citrate tabs$0

(Tier1)

NDS;MO

TRELSTAR MIXJECTSUSR 22.5 MG, 3.75 MG,11.25 MG

$0(Tier

2)

NDS

VANTAS KIT$0

(Tier2)

NDS

XTANDI CAPS$0

(Tier2)

PA; NDS;LA

YONSA TABS$0

(Tier2)

PA; NDS

ZOLADEX IMPL$0

(Tier2)

ZYTIGA TABS 500 MG$0

(Tier2)

PA; NDS

Antineoplastic - Immunomodulators

POMALYST CAPS$0

(Tier2)

NDS;LA

Antineoplastic - XPO1 Inhibitors

XPOVIO 100 MG ONCEWEEKLY TBPK

$0(Tier

2)

PA; NDS;MO


$0(Tier

2)

PA; NDS;MO


$0(Tier

2)

PA; NDS;MO

XPOVIO 80 MG TWICEWEEKLY TBPK

$0(Tier

2)

PA; NDS;MO

Name of drug

Whatthe


level)


Antineoplastic Antibiotics

bleomycin sulfate solr$0

(Tier1)

PA

dactinomycin solr$0

(Tier1)

daunorubicin hcl soln$0

(Tier1)

DAUNORUBICINHYDROCHLORIDE SOLN

$0(Tier

2)

doxorubicin hcl liposomalinj

$0(Tier

1)

doxorubicin hcl soln 2mg/ml

$0(Tier

1)

doxorubicin hcl solr 10 mg,50 mg

$0(Tier

1)

epirubicin hcl soln$0

(Tier1)

idarubicin hcl soln$0

(Tier1)

mitomycin solr$0

(Tier1)

mitoxantrone hcl conc$0

(Tier1)

valrubicin soln$0

(Tier1)

NDS

Antineoplastic Combinations

HERCEPTIN HYLECTASOLN

$0(Tier

2)

NDS



Name of drug

Whatthe


level)


KISQALI FEMARA 200DOSE TBPK

$0(Tier

2)

PA; NDS


$0(Tier

2)

PA; NDS


$0(Tier

2)

PA; NDS

LONSURF TABS$0

(Tier2)

PA; NDS

RITUXAN HYCELA SOLN$0

(Tier2)

NDS

VYXEOS SUSR$0

(Tier2)

NDS;MO

Antineoplastic Enzyme Inhibitors

AFINITOR DISPERZ TBSO$0

(Tier2)

PA; NDS

AFINITOR TABS$0

(Tier2)

PA; NDS

ALECENSA CAPS$0

(Tier2)

PA; NDS;LA

ALIQOPA SOLR$0

(Tier2)

NDS;MO

ALUNBRIG TABS$0

(Tier2)

PA; NDS;LA

ALUNBRIG TBPK$0

(Tier2)

PA; NDS;LA

BALVERSA TABS$0

(Tier2)

PA; NDS;LA;MO

Name of drug

Whatthe


level)


BELEODAQ SOLR$0

(Tier2)

PA; NDS

BORTEZOMIB SOLR$0

(Tier2)

NDS

BOSULIF TABS$0

(Tier2)

PA; NDS

BRAFTOVI CAPS 75 MG$0

(Tier2)

PA; NDS;MO

CABOMETYX TABS$0

(Tier2)

PA; NDS

CALQUENCE CAPS$0

(Tier2)

PA; NDS;LA;MO

CAPRELSA TABS$0

(Tier2)

PA; NDS;LA;MO

COMETRIQ KIT$0

(Tier2)

PA; NDS;LA

COPIKTRA CAPS$0

(Tier2)

PA; NDS;MO

COTELLIC TABS$0

(Tier2)

PA; NDS;LA

erlotinib hcl tabs 100 mg,150 mg

$0(Tier

1)

PA; NDS

erlotinib hcl tabs 25 mg$0

(Tier1)

PA; NDS;MO

FARYDAK CAPS$0

(Tier2)

PA; NDS;LA

GILOTRIF TABS$0

(Tier2)

PA; NDS;LA;MO



Name of drug

Whatthe


level)


IBRANCE CAPS$0

(Tier2)

NDS;LA

ICLUSIG TABS$0

(Tier2)

PA; NDS;LA;MO

IDHIFA TABS$0

(Tier2)

PA; NDS

imatinib mesylate tabs$0

(Tier1)

PA; NDS

IMBRUVICA CAPS$0

(Tier2)

PA; NDS;LA;MO

IMBRUVICA TABS$0

(Tier2)

PA; NDS;LA;MO

INLYTA TABS$0

(Tier2)

PA; NDS;LA

INREBIC CAPS$0

(Tier2)

PA; NDS;LA

IRESSA TABS$0

(Tier2)

LA; MO

ISTODAX (OVERFILL)SOLR

$0(Tier

2)

NDS

JAKAFI TABS$0

(Tier2)

PA; NDS;LA

KISQALI TBPK$0

(Tier2)

PA; NDS

KYPROLIS SOLR$0

(Tier2)

NDS

LENVIMA 10 MG DAILYDOSE CPPK

$0(Tier

2)

PA; NDS;MO

Name of drug

Whatthe


level)


LENVIMA 12MG DAILYDOSE CPPK

$0(Tier

2)

PA; NDS;MO


$0(Tier

2)

PA; NDS;MO


$0(Tier

2)

PA; NDS;MO


$0(Tier

2)

PA; NDS;MO


$0(Tier

2)

PA; NDS;MO


$0(Tier

2)

PA; NDS;MO


$0(Tier

2)

PA; NDS;MO

LORBRENA TABS$0

(Tier2)

PA; NDS

LYNPARZA CAPS$0

(Tier2)

PA; NDS;LA

LYNPARZA TABS$0

(Tier2)

PA; NDS;LA

MEKINIST TABS$0

(Tier2)

PA; NDS

MEKTOVI TABS$0

(Tier2)

PA; NDS

NERLYNX TABS$0

(Tier2)

PA; NDS;LA

NEXAVAR TABS$0

(Tier2)

NDS;LA



Name of drug

Whatthe


level)


NINLARO CAPS$0

(Tier2)

PA; NDS

PIQRAY 200MG DAILYDOSE TBPK

$0(Tier

2)

PA; NDS


$0(Tier

2)

PA; NDS


$0(Tier

2)

PA; NDS

ROMIDEPSIN SOLR$0

(Tier2)

NDS

ROZLYTREK CAPS$0

(Tier2)

PA; NDS

RUBRACA TABS$0

(Tier2)

PA; NDS;LA

RYDAPT CAPS$0

(Tier2)

PA; NDS

SPRYCEL TABS$0

(Tier2)

PA; NDS

STIVARGA TABS$0

(Tier2)

PA; NDS;LA

SUTENT CAPS$0

(Tier2)

NDS

TAFINLAR CAPS$0

(Tier2)

NDS

TAGRISSO TABS$0

(Tier2)

PA; NDS;LA

TALZENNA CAPS$0

(Tier2)

PA; NDS

Name of drug

Whatthe


level)


TASIGNA CAPS$0

(Tier2)

PA; NDS

temsirolimus soln$0

(Tier1)

NDS

TIBSOVO TABS$0

(Tier2)

PA; NDS;LA

TORISEL SOLN(Temsirolimus)

$0(Tier

2)

NDS

TURALIO CAPS$0

(Tier2)

PA; NDS;LA;MO

TYKERB TABS$0

(Tier2)

NDS

VELCADE SOLR$0

(Tier2)

NDS

VERZENIO TABS$0

(Tier2)

PA; NDS

VITRAKVI CAPS$0

(Tier2)

PA; NDS

VITRAKVI SOLN$0

(Tier2)

PA; NDS

VIZIMPRO TABS$0

(Tier2)

PA; NDS

VOTRIENT TABS$0

(Tier2)

PA; NDS

XALKORI CAPS$0

(Tier2)

PA; NDS

XOSPATA TABS$0

(Tier2)

PA; NDS;LA;MO



Name of drug

Whatthe


level)


ZEJULA CAPS$0

(Tier2)

PA; NDS;LA;MO

ZELBORAF TABS$0

(Tier2)

PA; NDS;LA

ZOLINZA CAPS$0

(Tier2)

NDS

ZYDELIG TABS$0

(Tier2)

PA; NDS;LA

ZYKADIA CAPS$0

(Tier2)

PA; NDS;LA

ZYKADIA TABS$0

(Tier2)

PA; NDS;LA

Antineoplastic Enzymes

ERWINAZE SOLR$0

(Tier2)

NDS;MO

ONCASPAR SOLN$0

(Tier2)

NDS

Antineoplastics Misc.

ACTIMMUNE SOLN$0

(Tier2)

NDS;LA

arsenic trioxide soln$0

(Tier1)

NDS

bexarotene caps$0

(Tier1)

NDS

dacarbazine solr$0

(Tier1)

hydroxyurea caps$0

(Tier1)

MO

Name of drug

Whatthe


level)


INTRON A SOLN 10MU/ML

$0(Tier

2)

NDS

INTRON A SOLN 6000000UNIT/ML

$0(Tier

2)

INTRON A SOLR 10 MU,18 MU, 50 MU

$0(Tier

2)

NDS

MATULANE CAPS$0

(Tier2)

NDS;LA

NIPENT SOLR$0

(Tier2)

PROLEUKIN SOLR$0

(Tier2)

NDS

SYLATRON KIT$0

(Tier2)

NDS

SYNRIBO SOLR$0

(Tier2)

NDS;MO

TICE BCG SUSR$0

(Tier2)

NDS

tretinoin (chemotherapy)caps

$0(Tier

1)

NDS;MO

TRISENOX SOLN 10MG/10ML

$0(Tier

2)

NDS

UVADEX SOLN$0

(Tier2)

Chemotherapy Adjuncts

ELITEK SOLR$0

(Tier2)

NDS



Name of drug

Whatthe


level)


KEPIVANCE SOLR$0

(Tier2)

NDS

Chemotherapy Rescue/Antidote Agents

dexrazoxane hcl solr$0

(Tier1)

ETHYOL SOLR$0

(Tier2)

MO

KHAPZORY SOLR$0

(Tier2)

NDS

leucovorin calcium solr ij 50mg, 100 mg, 200 mg, 350mg, 500 mg

$0(Tier

1)

leucovorin calcium tabs or5 mg, 10 mg, 15 mg, 25 mg

$0(Tier

1)

MO

levoleucovorin calcium soln250 mg/25ml, 175mg/17.5ml

$0(Tier

1)

NDS

levoleucovorin calcium solr50 mg

$0(Tier

1)

mesna soln$0

(Tier1)

MESNEX TABS OR 400MG

$0(Tier

2)

NDS;MO

TOTECT SOLR$0

(Tier2)

Mitotic Inhibitors

ABRAXANE SUSR$0

(Tier2)

NDS;MO

DOCETAXEL CONC 20MG/ML, 80 MG/4ML

$0(Tier

2)

NDS

Name of drug

Whatthe


level)


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

$0(Tier

1)

NDS

docetaxel soln 20 mg/2ml,80 mg/8ml, 160 mg/16ml

$0(Tier

1)

NDS

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

$0(Tier

2)

NDS

ETOPOPHOS SOLR$0

(Tier2)

etoposide soln$0

(Tier1)

HALAVEN SOLN$0

(Tier2)

NDS

IXEMPRA KIT SOLR$0

(Tier2)

NDS

JEVTANA SOLN$0

(Tier2)

NDS

MARQIBO SUSP$0

(Tier2)

NDS;MO

paclitaxel conc$0

(Tier1)

vinblastine sulfate soln$0

(Tier1)

PA; MO

vincristine sulfate soln$0

(Tier1)

PA; MO

vinorelbine tartrate soln 10mg/ml

$0(Tier

1)

vinorelbine tartrate soln 50mg/5ml

$0(Tier

1)

MO



Name of drug

Whatthe


level)


Topoisomerase I Inhibitors

CAMPTOSAR SOLN 300MG/15ML

$0(Tier

2)

irinotecan hcl soln$0

(Tier1)

ONIVYDE INJ$0

(Tier2)

NDS;MO

topotecan hcl solr 4 mg$0

(Tier1)

ANTIPARKINSON AND RELATED THERAPYAGENTS - Drugs to Treat Parkinson's DiseaseAntiparkinson Adjuvants

carbidopa tabs$0

(Tier1)

MO

Antiparkinson Anticholinergics

benztropine mesylate solnij 1 mg/ml

$0(Tier

1)

MO

benztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg

$0(Tier

1)


trihexyphenidyl hcl soln$0

(Tier1)


trihexyphenidyl hcl tabs$0

(Tier1)


Antiparkinson COMT Inhibitors

entacapone tabs$0

(Tier1)

SL(8 ea daily);MO

tolcapone tabs$0

(Tier1)

MO

Antiparkinson Dopaminergics

Name of drug

Whatthe


level)


amantadine hcl caps$0

(Tier1)

MO

amantadine hcl syrp$0

(Tier1)

MO

amantadine hcl tabs$0

(Tier1)

MO

APOKYN SOCT$0

(Tier2)

NDS;LA

bromocriptine mesylatecaps

$0(Tier

1)

MO

bromocriptine mesylatetabs

$0(Tier

1)

MO

carbidopa-levodopa tabs$0

(Tier1)

MO

carbidopa-levodopa tbcr$0

(Tier1)

MO

carbidopa-levodopa tbdp$0

(Tier1)

MO

DUOPA SUSP$0

(Tier2)

B/D; MO

NEUPRO PT24$0

(Tier2)

MO

pramipexoledihydrochloride tabs 0.125mg, 0.25 mg, 0.75 mg, 0.5mg, 1 mg, 1.5 mg

$0(Tier

1)

MO

ropinirole hydrochloridetabs

$0(Tier

1)

MO



Name of drug

Whatthe


level)


ropinirole hydrochloridetb24

$0(Tier

1)

MO

Antiparkinson Monoamine Oxidase Inhibitors

rasagiline mesylate tabs$0

(Tier1)

MO

selegiline hcl caps$0

(Tier1)

MO

selegiline hcl tabs$0

(Tier1)

MO

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood DisordersAntimanic Agents

lithium carbonate caps 150mg, 300 mg, 600 mg

$0(Tier

1)

MO

lithium carbonate tabs 300mg

$0(Tier

1)

MO

lithium carbonate tbcr 300mg, 450 mg

$0(Tier

1)

MO

LITHIUM SOLN$0

(Tier2)

MO

Antipsychotics - Misc.

EQUETRO CP12$0

(Tier2)

MO

GEODON SOLR IM 20 MG$0

(Tier2)

MO

LATUDA TABS 120 MG$0

(Tier2)


LATUDA TABS 20 MG$0

(Tier2)


Name of drug

Whatthe


level)


LATUDA TABS 40 MG$0

(Tier2)


LATUDA TABS 60 MG$0

(Tier2)


LATUDA TABS 80 MG$0

(Tier2)


NUPLAZID CAPS$0

(Tier2)

PA; NDS;LA

NUPLAZID TABS$0

(Tier2)

PA; NDS;LA

VRAYLAR CAPS 1.5 MG$0

(Tier2)


VRAYLAR CAPS 3 MG$0

(Tier2)


VRAYLAR CAPS 4.5 MG$0

(Tier2)

PA; SL(1.4 eadaily); MO

VRAYLAR CAPS 6 MG$0

(Tier2)


VRAYLAR CPPK$0

(Tier2)

PA; MO

ziprasidone hcl caps$0

(Tier1)

MO

Benzisoxazoles

FANAPT TABS 1 MG, 2MG, 4 MG, 10 MG

$0(Tier

2)

MO

FANAPT TABS 6 MG, 8MG, 12 MG

$0(Tier

2)

NDS;MO



Name of drug

Whatthe


level)


INVEGA SUSTENNASUSY 156 MG/ML, 234MG/1.5ML, 117MG/0.75ML

$0(Tier

2)

NDS;MO

INVEGA SUSTENNASUSY 78 MG/0.5ML, 39MG/0.25ML

$0(Tier

2)

MO

INVEGA TRINZA SUSY$0

(Tier2)

NDS

paliperidone tb24 1.5 mg$0

(Tier1)


paliperidone tb24 3 mg$0

(Tier1)



(Tier1)



(Tier1)

NDS;SL(1.33ea daily); MO

PERSERIS PRSY$0

(Tier2)

PA; NDS

RISPERDAL CONSTASRER 12.5 MG

$0(Tier

2)

Limit 8 vials per28days;SL(0.29ea daily); MO

RISPERDAL CONSTASRER 25 MG

$0(Tier

2)

Limit 4 vials per28days;SL(0.15ea daily); MO

RISPERDAL CONSTASRER 37.5 MG

$0(Tier

2)

NDS; Limit 4vials per 42days;SL(0.1 eadaily); MO

RISPERDAL CONSTASRER 50 MG

$0(Tier

2)

NDS; Limit 2vials per 28days;SL(0.08ea daily); MO

Name of drug

Whatthe


level)


risperidone soln$0

(Tier1)

MO

risperidone tabs$0

(Tier1)

MO

risperidone tbdp$0

(Tier1)

MO

Butyrophenones

haloperidol decanoate soln$0

(Tier1)

MO

haloperidol lactate conc$0

(Tier1)

MO

haloperidol lactate soln$0

(Tier1)

MO

haloperidol tabs$0

(Tier1)

MO

Dibenzapines

CLOZAPINE ODT TBDP150 MG

$0(Tier

2)

CLOZAPINE ODT TBDP200 MG

$0(Tier

2)

NDS

clozapine tabs 25 mg, 50mg, 100 mg, 200 mg

$0(Tier

1)

clozapine tbdp 25 mg, 100mg, 12.5 mg

$0(Tier

1)

FAZACLO TBDP 12.5 MG(Clozapine)

$0(Tier

2)

FAZACLO TBDP 150 MG$0

(Tier2)



Name of drug

Whatthe


level)


FAZACLO TBDP 200 MG$0

(Tier2)

NDS

loxapine succinate caps$0

(Tier1)

MO

olanzapine solr$0

(Tier1)

MO

olanzapine tabs$0

(Tier1)

MO

olanzapine tbdp$0

(Tier1)

MO

quetiapine fumarate tabs25 mg, 50 mg, 100 mg, 200mg, 300 mg, 400 mg

$0(Tier

1)

MO

SAPHRIS SUBL 10 MG$0

(Tier2)


SAPHRIS SUBL 2.5 MG$0

(Tier2)

SL(8 ea daily);MO

SAPHRIS SUBL 5 MG$0

(Tier2)

SL(4 ea daily);MO

VERSACLOZ SUSP$0

(Tier2)

PA; NDS;SL(18ml daily)

ZYPREXA RELPREVVSUSR

$0(Tier

2)

Dihydroindolones

molindone hcl tabs$0

(Tier1)

Phenothiazines

chlorpromazine hcl soln ij25 mg/ml

$0(Tier

1)

MO

Name of drug

Whatthe


level)


chlorpromazine hcl soln ij50 mg/2ml

$0(Tier

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

$0(Tier

1)

MO

fluphenazine decanoatesoln

$0(Tier

1)

MO

fluphenazine hcl conc$0

(Tier1)

MO

fluphenazine hcl soln$0

(Tier1)

MO

fluphenazine hcl tabs$0

(Tier1)

MO

perphenazine tabs$0

(Tier1)

MO

prochlorperazine edisylatesoln 10 mg/2ml

$0(Tier

1)

MO

prochlorperazine edisylatesoln 50 mg/10ml

$0(Tier

1)

prochlorperazine maleatetabs

$0(Tier

1)

MO

prochlorperazine supp$0

(Tier1)

MO

thioridazine hcl tabs$0

(Tier1)

MO

trifluoperazine hcl tabs$0

(Tier1)

MO

Quinolinone Derivatives



Name of drug

Whatthe


level)


ABILIFY MAINTENA PRSY$0

(Tier2)

NDS;MO

ABILIFY MAINTENA SRER$0

(Tier2)

NDS;MO

aripiprazole soln 1 mg/ml$0

(Tier1)

SL(30 ml daily);MO

aripiprazole tabs 10 mg$0

(Tier1)

SL(3 ea daily);MO


(Tier1)

SL(2 ea daily);MO


(Tier1)

SL(15 ea daily);MO


(Tier1)

SL(1.5 eadaily); MO


(Tier1)

SL(1 ea daily);MO


(Tier1)

SL(6 ea daily);MO

aripiprazole tbdp 10 mg$0

(Tier1)


aripiprazole tbdp 15 mg$0

(Tier1)


ARISTADA INITIO PRSY$0

(Tier2)

NDS

ARISTADA PRSY$0

(Tier2)

NDS

REXULTI TABS 0.25 MG$0

(Tier2)


Name of drug

Whatthe


level)


REXULTI TABS 0.5 MG$0

(Tier2)


REXULTI TABS 1 MG$0

(Tier2)


REXULTI TABS 2 MG$0

(Tier2)


REXULTI TABS 3 MG$0

(Tier2)


REXULTI TABS 4 MG$0

(Tier2)


Thioxanthenes

thiothixene caps$0

(Tier1)

MO

ANTISEPTICS & DISINFECTANTS

Iodine Antiseptics

povidone-iodine oint$0

(Tier3)

NT

povidone-iodine soln$0

(Tier3)

*;MO; NT

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals

abacavir sulfate soln$0

(Tier1)

MO

abacavir sulfate tabs$0

(Tier1)

MO

abacavir sulfate-lamivudinetabs

$0(Tier

1)

NDS;MO



Name of drug

Whatthe


level)


abacavir sulfate-lamivudine-zidovudine tabs

$0(Tier

1)

NDS;MO

APTIVUS CAPS 250 MG$0

(Tier2)

NDS;MO

APTIVUS SOLN 100MG/ML

$0(Tier

2)

atazanavir sulfate caps$0

(Tier1)

NDS;MO

ATRIPLA TABS$0

(Tier2)

NDS;MO

BIKTARVY TABS$0

(Tier2)

NDS;MO

CIMDUO TABS$0

(Tier2)

NDS;MO

COMPLERA TABS$0

(Tier2)

NDS;MO

CRIXIVAN CAPS$0

(Tier2)

MO

DELSTRIGO TABS$0

(Tier2)

NDS;MO

DESCOVY TABS$0

(Tier2)

NDS;MO

didanosine cpdr 200 mg,250 mg, 400 mg

$0(Tier

1)

MO

DOVATO TABS$0

(Tier2)

NDS;MO

EDURANT TABS$0

(Tier2)

NDS;MO

Name of drug

Whatthe


level)


efavirenz caps$0

(Tier1)

MO

efavirenz tabs$0

(Tier1)

MO

EMTRIVA CAPS$0

(Tier2)

MO

EMTRIVA SOLN$0

(Tier2)

MO

EVOTAZ TABS$0

(Tier2)

NDS;MO

fosamprenavir calcium tabs$0

(Tier1)

NDS;MO

FUZEON SOLR$0

(Tier2)

NDS

GENVOYA TABS$0

(Tier2)

NDS;MO

INTELENCE TABS 100MG, 200 MG

$0(Tier

2)

NDS;MO

INTELENCE TABS 25 MG$0

(Tier2)

INVIRASE CAPS$0

(Tier2)

NDS;MO

INVIRASE TABS$0

(Tier2)

NDS;MO

ISENTRESS CHEW 100MG

$0(Tier

2)

SL(6 ea daily);MO

ISENTRESS CHEW 25 MG$0

(Tier2)

SL(24 ea daily);MO



Name of drug

Whatthe


level)


ISENTRESS HD TABS$0

(Tier2)

NDS;MO

ISENTRESS PACK 100MG

$0(Tier

2)

SL(2 ea daily);MO

ISENTRESS TABS 400MG

$0(Tier

2)

NDS;MO

JULUCA TABS$0

(Tier2)

NDS;MO

KALETRA TABS 100MG-25MG

$0(Tier

2)

MO

KALETRA TABS 200MG-50MG

$0(Tier

2)

NDS;MO

lamivudine soln$0

(Tier1)

MO

lamivudine tabs$0

(Tier1)

MO

lamivudine-zidovudine tabs$0

(Tier1)

MO

LEXIVA SUSP 50 MG/ML$0

(Tier2)

MO

lopinavir-ritonavir soln$0

(Tier1)

NDS;MO

nevirapine susp 50 mg/5ml$0

(Tier1)

MO

nevirapine tabs 200 mg$0

(Tier1)

MO

nevirapine tb24 100 mg$0

(Tier1)

Name of drug

Whatthe


level)


nevirapine tb24 400 mg$0

(Tier1)

MO

NORVIR PACK 100 MG$0

(Tier2)

MO

NORVIR SOLN 80 MG/ML$0

(Tier2)

MO

ODEFSEY TABS$0

(Tier2)

NDS;MO

PIFELTRO TABS$0

(Tier2)

NDS;MO

PREZCOBIX TABS$0

(Tier2)

NDS;MO

PREZISTA SUSP$0

(Tier2)

NDS;MO

PREZISTA TABS$0

(Tier2)

NDS;MO

RESCRIPTOR TABS 200MG

$0(Tier

2)

MO

RETROVIR IV INFUSIONSOLN

$0(Tier

2)

REYATAZ PACK 50 MG$0

(Tier2)

NDS;MO

ritonavir tabs$0

(Tier1)

MO

SELZENTRY SOLN 20MG/ML

$0(Tier

2)

SELZENTRY TABS 150MG, 300 MG

$0(Tier

2)

MO



Name of drug

Whatthe


level)


SELZENTRY TABS 25MG, 75 MG

$0(Tier

2)

stavudine caps$0

(Tier1)

MO

STRIBILD TABS$0

(Tier2)

NDS;MO

SYMFI LO TABS$0

(Tier2)

NDS;MO

SYMFI TABS$0

(Tier2)

NDS;MO

SYMTUZA TABS$0

(Tier2)

NDS;MO

TEMIXYS TABS$0

(Tier2)

NDS;MO

tenofovir disoproxilfumarate tabs

$0(Tier

1)

NDS;MO

TIVICAY TABS 10 MG$0

(Tier2)

MO

TIVICAY TABS 25 MG, 50MG

$0(Tier

2)

NDS;MO

TRIUMEQ TABS$0

(Tier2)

NDS;MO

TROGARZO SOLN$0

(Tier2)

NDS

TRUVADA TABS$0

(Tier2)

NDS;MO

TYBOST TABS$0

(Tier2)

MO

Name of drug

Whatthe


level)


VIDEX EC CPDR 125 MG$0

(Tier2)

MO

VIDEXPEDIATRIC SOLR$0

(Tier2)

MO

VIRACEPT TABS$0

(Tier2)

NDS;MO

VIRAMUNE SUSP 50MG/5ML (Nevirapine)

$0(Tier

2)

MO

VIREAD POWD 40 MG/GM$0

(Tier2)

NDS;MO

VIREAD TABS 150 MG,200 MG, 250 MG

$0(Tier

2)

NDS;MO

zidovudine caps$0

(Tier1)

MO

zidovudine syrp$0

(Tier1)

MO

zidovudine tabs$0

(Tier1)

MO

CMV Agents

cidofovir soln$0

(Tier1)

NDS

ganciclovir sodium solr$0

(Tier1)

PA; MO

PREVYMIS TABS$0

(Tier2)

PA; NDS;MO

valganciclovir hcl tabs 450mg

$0(Tier

1)

NDS;MO

Hepatitis Agents



Name of drug

Whatthe


level)


adefovir dipivoxil tabs$0

(Tier1)

NDS;MO

BARACLUDE SOLN 0.05MG/ML

$0(Tier

2)

MO

DAKLINZA TABS 30 MG,60 MG

$0(Tier

2)

PA; NDS

entecavir tabs$0

(Tier1)

NDS;MO

EPCLUSA TABS$0

(Tier2)

PA; NDS

EPIVIR HBV SOLN 5MG/ML

$0(Tier

2)

MO

HARVONI TABS 200MG-45MG, 400MG-90MG

$0(Tier

2)

PA; NDS

lamivudine (hbv) tabs$0

(Tier1)

MO

LEDIPASVIR/SOFOSBUVIR TABS

$0(Tier

2)

PA; NDS

MAVYRET TABS$0

(Tier2)

PA; NDS

PEGASYS PROCLICKSOLN 180 MCG/0.5ML

$0(Tier

2)

NDS

PEGASYS SOLN$0

(Tier2)

NDS

PEGINTRON KIT$0

(Tier2)

NDS

ribavirin (hepatitis c) caps$0

(Tier1)

Name of drug

Whatthe


level)


ribavirin (hepatitis c) tabs$0

(Tier1)

SOFOSBUVIR/VELPATASVIR TABS

$0(Tier

2)

PA; NDS

SOVALDI TABS$0

(Tier2)

PA; NDS

VEMLIDY TABS$0

(Tier2)

ST; NDS;MO

VOSEVI TABS$0

(Tier2)

PA; NDS

ZEPATIER TABS$0

(Tier2)

PA; NDS

Herpes Agents

acyclovir caps$0

(Tier1)

MO

acyclovir sodium soln 50mg/ml

$0(Tier

1)

PA

acyclovir susp$0

(Tier1)

MO

acyclovir tabs$0

(Tier1)

MO

famciclovir tabs$0

(Tier1)

MO

valacyclovir hcl tabs$0

(Tier1)

MO

Influenza Agents

oseltamivir phosphate caps30 mg

$0(Tier

1)

QL(4 ea daily);MO



Name of drug

Whatthe


level)


oseltamivir phosphate caps45 mg, 75 mg

$0(Tier

1)

MO

oseltamivir phosphate susr6 mg/ml

$0(Tier

1)

MO

RELENZA DISKHALERAEPB

$0(Tier

2)

MO

rimantadine hydrochloridetabs

$0(Tier

1)

MO

Respiratory Syncytial Virus (RSV) Agents

ribavirin solr$0

(Tier1)

BETA BLOCKERS - Drugs to Treat High BloodPressureAlpha-Beta Blockers

carvedilol phosphate cp24$0

(Tier1)

MO

carvedilol tabs 12.5 mg$0

(Tier1)

SL(8 ea daily);MO

carvedilol tabs 25 mg$0

(Tier1)

SL(4 ea daily);MO


(Tier1)

SL(32 ea daily);MO


(Tier1)

SL(16 ea daily);MO

labetalol hcl tabs or 100mg, 200 mg, 300 mg

$0(Tier

1)

MO

Beta Blockers Cardio-Selective

acebutolol hcl caps$0

(Tier1)

MO

Name of drug

Whatthe


level)


atenolol tabs$0

(Tier1)

MO

betaxolol hcl tabs$0

(Tier1)

MO

bisoprolol fumarate tabs$0

(Tier1)

MO

metoprolol succinate tb24$0

(Tier1)

MO

metoprolol tartrate tabs or25 mg, 50 mg, 75 mg, 100mg, 37.5 mg

$0(Tier

1)

MO

Beta Blockers Non-Selective

nadolol tabs$0

(Tier1)

MO

pindolol tabs$0

(Tier1)

MO

propranolol hcl cp24 or 60mg, 80 mg, 120 mg, 160mg

$0(Tier

1)

MO

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

$0(Tier

1)

MO

sotalol hcl (afib/afl) tabs$0

(Tier1)

MO

sotalol hcl tabs$0

(Tier1)

tabs;MO

SOTYLIZE SOLN$0

(Tier2)

MO

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood PressureCalcium Channel Blockers



Name of drug

Whatthe


level)


amlodipine besylate tabs10 mg

$0(Tier

1)

SL(1 ea daily);MO

amlodipine besylate tabs2.5 mg

$0(Tier

1)

SL(4 ea daily);MO

amlodipine besylate tabs 5mg

$0(Tier

1)

SL(2 ea daily);MO

diltiazem hcl coated beadscp24

$0(Tier

1)

MO

diltiazem hcl coated beadstb24

$0(Tier

1)

MO

diltiazem hcl cp12 or 60mg, 90 mg, 120 mg

$0(Tier

1)

MO

diltiazem hcl cp24 or 120mg, 180 mg, 240 mg

$0(Tier

1)

MO

diltiazem hcl extendedrelease beads cp24

$0(Tier

1)

MO

diltiazem hcl tabs or 30 mg,60 mg, 90 mg, 120 mg

$0(Tier

1)

MO

felodipine tb24$0

(Tier1)

MO

nicardipine hcl caps or 20mg, 30 mg

$0(Tier

1)

MO

nifedipine tb24 30 mg, 60mg, 90 mg

$0(Tier

1)

MO

nimodipine caps$0

(Tier1)

MO

nisoldipine tb24$0

(Tier1)

MO

Name of drug

Whatthe


level)


NYMALIZE SOLN$0

(Tier2)

NDS

verapamil hcl cp24 or 100mg, 120 mg, 180 mg, 200mg, 240 mg, 300 mg, 360mg

$0(Tier

1)

MO

verapamil hcl tabs or 40mg, 80 mg, 120 mg

$0(Tier

1)

MO

verapamil hcl tbcr or 120mg, 180 mg, 240 mg

$0(Tier

1)

MO

VERELAN CP24 360 MG$0

(Tier2)

MO

VERELAN PM CP24 100MG

$0(Tier

2)

MO

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart RhythmCardiac Glycosides

digoxin soln or 0.05 mg/ml$0

(Tier1)

MO

DIGOXIN SOLN OR 0.05MG/ML (Digoxin)

$0(Tier

2)

MO

digoxin tabs or 0.125 mg,0.25 mg, 125 mcg, 250mcg

$0(Tier

1)

MO

LANOXIN TABS OR 62.5MCG

$0(Tier

2)

MO

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation ConditionsCardiovascular Agents Misc. - Combinations

amlodipine besylate-atorvastatin calcium tabs

$0(Tier

1)

MO



Name of drug

Whatthe


level)


ENTRESTO TABS$0

(Tier2)

PA; MO

Prostaglandin Vasodilators

ORENITRAM TBCR 0.125MG

$0(Tier

2)

PA

ORENITRAM TBCR 0.25MG, 1 MG, 5 MG, 2.5 MG

$0(Tier

2)

PA; NDS

treprostinil soln$0

(Tier1)

B/D; NDS;LA

TYVASO REFILL SOLN$0

(Tier2)

B/D; NDS;LA

TYVASO SOLN$0

(Tier2)

B/D; NDS;LA

TYVASO STARTER SOLN$0

(Tier2)

B/D; NDS;LA

VENTAVIS SOLN 10MCG/ML

$0(Tier

2)

B/D; LA

VENTAVIS SOLN 20MCG/ML

$0(Tier

2)

B/D; NDS;LA

Pulmonary Hypertension - Endothelin Receptor

ambrisentan tabs$0

(Tier1)

NDS;LA

bosentan tabs 125 mg$0

(Tier1)

NDS;LA

bosentan tabs 62.5 mg$0

(Tier1)

NDS;LA; MO

OPSUMIT TABS$0

(Tier2)

PA; NDS

Name of drug

Whatthe


level)


TRACLEER TBSO 32 MG$0

(Tier2)

NDS;LA

Pulmonary Hypertension - Phosphodiesterase

ADCIRCA TABS (Tadalafil(Pulmonary Hypertension))

$0(Tier

2)

PA; NDS

sildenafil citrate (pulmonaryhypertension) soln iv 10mg/12.5ml

$0(Tier

1)

PA; NDS

sildenafil citrate (pulmonaryhypertension) tabs or 20mg

$0(Tier

1)

PA

tadalafil (pulmonaryhypertension) tabs

$0(Tier

1)

PA; NDS

Pulmonary Hypertension - Prostacyclin Receptor

UPTRAVI TABS$0

(Tier2)

PA; NDS;LA

UPTRAVI TBPK$0

(Tier2)

PA; NDS;LA

Pulmonary Hypertension - Sol Guanylate Cyclase

ADEMPAS TABS 0.5 MG$0

(Tier2)

PA; NDS;SL(15ea daily)

ADEMPAS TABS 1 MG$0

(Tier2)

PA;NDS;SL(7.5 eadaily)


(Tier2)


ADEMPAS TABS 2 MG$0

(Tier2)

PA;NDS;SL(3.75ea daily)


(Tier2)


Sinus Node Inhibitors



Name of drug

Whatthe


level)


CORLANOR TABS 5 MG$0

(Tier2)

SL(3 ea daily);MO

CORLANOR TABS 7.5 MG$0

(Tier2)

SL(2 ea daily);MO

CEPHALOSPORINS - Drugs to Treat BacterialInfectionsCephalosporins - 1st Generation

cefadroxil caps$0

(Tier1)

MO

cefadroxil susr$0

(Tier1)

MO

cefadroxil tabs$0

(Tier1)

MO

cefazolin sodium solr ij 1gm, 10 gm, 500 mg

$0(Tier

1)

MO

cephalexin caps 250 mg,500 mg, 750 mg

$0(Tier

1)

MO

cephalexin susr 125mg/5ml, 250 mg/5ml

$0(Tier

1)

MO

Cephalosporins - 2nd Generation

cefaclor caps 250 mg, 500mg

$0(Tier

1)

MO

cefoxitin sodium solr ij 10gm

$0(Tier

1)

cefoxitin sodium solr iv 1gm, 2 gm

$0(Tier

1)

cefprozil susr$0

(Tier1)

MO

Name of drug

Whatthe


level)


cefprozil tabs$0

(Tier1)

MO

cefuroxime axetil tabs$0

(Tier1)

MO

cefuroxime sodium solr ij7.5 gm

$0(Tier

1)

cefuroxime sodium solr ij750 mg

$0(Tier

1)

MO

cefuroxime sodium solr iv1.5 gm

$0(Tier

1)

Cephalosporins - 3rd Generation

cefdinir caps$0

(Tier1)

MO

cefdinir susr$0

(Tier1)

MO

cefixime caps 400 mg$0

(Tier1)

MO

cefpodoxime proxetil susr$0

(Tier1)

MO

cefpodoxime proxetil tabs$0

(Tier1)

MO

ceftazidime solr 1 gm, 2 gm$0

(Tier1)

MO

ceftazidime solr 6 gm$0

(Tier1)

ceftriaxone sodium solr ij 1gm

$0(Tier

1)

SL(4 ea daily);MO



Name of drug

Whatthe


level)


ceftriaxone sodium solr ij 2gm

$0(Tier

1)

SL(2 ea daily);MO

ceftriaxone sodium solr ij250 mg

$0(Tier

1)

SL(16 ea daily);MO

ceftriaxone sodium solr ij500 mg

$0(Tier

1)

SL(8 ea daily);MO

ceftriaxone sodium solr iv 1gm

$0(Tier

1)

SL(4 ea daily)

ceftriaxone sodium solr iv10 gm

$0(Tier

1)

MO

ceftriaxone sodium solr iv 2gm

$0(Tier

1)

SL(2 ea daily);MO

Cephalosporins - 4th Generation

cefepime hcl solr$0

(Tier1)

MO

CEFEPIME SOLN$0

(Tier2)

Cephalosporins - 5th Generation

TEFLARO SOLR$0

(Tier2)

CONTRACEPTIVES - Drugs to PreventPregnancyCombination Contraceptives - Oral

desogestrel & ethinylestradiol tabs

$0(Tier

1)

MO

desogestrel-ethinylestradiol (biphasic) tabs

$0(Tier

1)

MO

drospirenone-ethinylestradiol tabs

$0(Tier

1)

MO

Name of drug

Whatthe


level)


ethynodiol diacet & ethestrad tabs

$0(Tier

1)

MO

levonorgestrel & ethestradiol tabs

$0(Tier

1)

MO

levonorgestrel-eth estradiol(triphasic) tabs

$0(Tier

1)

MO

levonorgestrel-ethinylestradiol (91-day) tabs

$0(Tier

1)

biphasic;MO

norethin acet & estrad-fetabs 75mg-20mcg-1mg,75mg-30mcg-1.5mg

$0(Tier

1)

MO

norethindrone & ethestradiol tabs

$0(Tier

1)

MO

norethindrone & ethinylestradiol-fe chew 0.4mg-35mcg

$0(Tier

1)

MO

norethindrone acet & ethestra tabs

$0(Tier

1)

MO

norethindrone-eth estradiol(triphasic) tabs

$0(Tier

1)

MO

norgestimate-ethinylestradiol (triphasic) tabs

$0(Tier

1)

MO

norgestimate-ethinylestradiol tabs

$0(Tier

1)

MO

norgestrel & ethinylestradiol tabs

$0(Tier

1)

MO

Combination Contraceptives - Transdermal

norelgestromin-ethinylestradiol ptwk

$0(Tier

1)

MO

Combination Contraceptives - Vaginal



Name of drug

Whatthe


level)


NUVARING RING$0

(Tier2)

MO

Emergency Contraceptives

ELLA TABS$0

(Tier2)

levonorgestrel (emergencyoc) tabs

$0(Tier

3)

MO; NT

Progestin Contraceptives - Injectablemedroxyprogesteroneacetate (contraceptive)susp

$0(Tier

1)

MO

medroxyprogesteroneacetate (contraceptive)susy

$0(Tier

1)

MO

Progestin Contraceptives - Oral

norethindrone(contraceptive) tabs

$0(Tier

1)

MO

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling ConditionsGlucocorticosteroids

betamethasone sodphosphate & acetate susp

$0(Tier

1)

MO

budesonide cpep 3 mg$0

(Tier1)

NDS;MO

cortisone acetate tabs$0

(Tier1)

MO

DEPO-MEDROL SUSP 20MG/ML

$0(Tier

2)

MO

dexamethasone elix$0

(Tier1)

MO

Name of drug

Whatthe


level)


dexamethasone sodiumphosphate soln ij 10 mg/ml

$0(Tier

1)

dexamethasone sodiumphosphate soln ij 10 mg/ml

$0(Tier

1)

PreservativeFree;MO

dexamethasone sodiumphosphate soln ij 4 mg/ml,20 mg/5ml, 100 mg/10ml,120 mg/30ml

$0(Tier

1)

MO

dexamethasone soln$0

(Tier1)

MO

dexamethasone tabs$0

(Tier1)

MO

dexamethasone tbpk$0

(Tier1)

MO

EMFLAZA SUSP$0

(Tier2)

PA; NDS;LA;MO

EMFLAZA TABS$0

(Tier2)

PA; NDS;LA;MO

hydrocortisone tabs or 5mg, 10 mg, 20 mg

$0(Tier

1)

MO

KENALOG-10 SUSP$0

(Tier2)

MO

MEDROL TABS 2 MG$0

(Tier2)

MO

methylprednisolone acetatesusp 40 mg/ml, 80 mg/ml

$0(Tier

1)

MO

methylprednisolone sodsucc solr

$0(Tier

1)

MO



Name of drug

Whatthe


level)


methylprednisolone tabs$0

(Tier1)

MO

methylprednisolone tbpk$0

(Tier1)

MO

prednisolone sodiumphosphate soln or 5mg/5ml, 15 mg/5ml

$0(Tier

1)

MO

prednisolone sodiumphosphate tbdp or 10 mg,15 mg, 30 mg

$0(Tier

1)

MO

prednisolone soln 15mg/5ml

$0(Tier

1)

MO

prednisolone tabs 5 mg$0

(Tier1)

MO

prednisone conc 5 mg/ml$0

(Tier1)

MO

prednisone soln 5 mg/5ml$0

(Tier1)

MO

prednisone tabs 1 mg, 5mg, 10 mg, 20 mg, 50 mg,2.5 mg

$0(Tier

1)

MO

prednisone tbpk 5 mg$0

(Tier1)

Dose Pack;MO

prednisone tbpk 5 mg, 10mg

$0(Tier

1)

MO

SOLU-CORTEF SOLR 100MG, 250 MG, 500 MG

$0(Tier

2)

MO

SOLU-CORTEF SOLR1000 MG

$0(Tier

2)

SOLU-MEDROL SOLR500 MG

$0(Tier

2)

MO

Name of drug

Whatthe


level)


triamcinolone acetonidesusp 40 mg/ml

$0(Tier

1)

MO

Mineralocorticoids

fludrocortisone acetate tabs$0

(Tier1)

MO

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy SymptomsAntitussives

benzonatate caps 100 mg,150 mg, 200 mg

$0(Tier

3)

*;MO; NT

benzonatate caps 100 mg,200 mg

$0(Tier

3)

MO; NT

DELSYM COUGHCHILDRENS SUER(DextromethorphanPolistirex)

$0(Tier

3)

MO; NT

DELSYM SUER(DextromethorphanPolistirex)

$0(Tier

3)

MO; NT

dextromethorphan hbr caps$0

(Tier3)

*;NT

dextromethorphanpolistirex suer

$0(Tier

3)

MO; NT

hydrocodone w/homatropine syrp

$0(Tier

3)

*;MO; NT

hydrocodone w/homatropine tabs

$0(Tier

3)

*;MO; NT

Cough/Cold/Allergy CombinationsALA-HIST PE TABS(Dexbrompheniramine-Phenylephrine)

$0(Tier

3)

MO; NT



Name of drug

Whatthe


level)


ALAHIST CF TABS$0

(Tier3)

NT

ALAHIST DM LIQD$0

(Tier3)

NT

AP-HIST DM LIQD$0

(Tier3)

NT

brompheniramine &phenyleph elix

$0(Tier

3)

NT

brompheniramine &pseudoeph liqd

$0(Tier

3)

*;NT

brompheniramine &pseudoeph liqd

$0(Tier

3)

NT

BROTAPP DM LIQD$0

(Tier3)

NT

cetirizine-pseudoephedrinetb12

$0(Tier

3)

*;MO; NT

CHLO TUSS LIQD$0

(Tier3)

NT

chlorpheniramine &phenylephrine liqd

$0(Tier

3)

MO; NT

chlorpheniramine &phenylephrine tabs

$0(Tier

3)

MO; NT

chlorpheniramine &pseudoeph tabs

$0(Tier

3)

NT

CLARINEX-D 12 HOURTB12

$0(Tier

2)

MO

DALLERGY LIQD1MG/ML-2.5MG/ML

$0(Tier

3)

*;NT

Name of drug

Whatthe


level)


DALLERGY TABS 1MG-5MG

$0(Tier

3)

NT

DAY TIME MULTI-SYMPTOM COLD/FLURELIEF CAPS(Dextromethorphan-Phenylephrine-Acetaminophen)

$0(Tier

3)

*;NT

DECONEX DMX TABS17.5MG-385MG-10MG(Phenylephrine w/ DM-GG)

$0(Tier

3)

NT

DECONEX DMX TABS17.5MG-400MG-10MG

$0(Tier

3)

NT

DECONEX IR TABS$0

(Tier3)

NT

dextromethorphan-doxylamine-acetaminophencaps

$0(Tier

3)

*;NT

dextromethorphan-doxylamine-acetaminophenliqd

$0(Tier

3)

*;NT

dextromethorphan-guaifenesin liqd 5mg/5ml-100mg/5ml, 10mg/5ml-100mg/5ml, 20mg/20ml-400mg/20ml

$0(Tier

3)

MO; NT

dextromethorphan-guaifenesin syrp 10mg/5ml-100mg/5ml

$0(Tier

3)

MO; NT

dextromethorphan-guaifenesin tabs 20mg-400mg

$0(Tier

3)

*;NT

dextromethorphan-guaifenesin tb12 30mg-600mg, 60mg-1200mg

$0(Tier

3)

*;MO; NT

dextromethorphan-phenylephrine-acetaminophen caps

$0(Tier

3)

*;NT



Name of drug

Whatthe


level)


dextromethorphan-phenylephrine-acetaminophen tabs

$0(Tier

3)

*;NT

diphenhydramine-acetaminophen tabs

$0(Tier

3)

NT

diphenhydramine-phenylephrine-acetaminophen liqd12.5mg/10ml-325mg/10ml-5mg/10ml

$0(Tier

3)

*;MO; NT

diphenhydramine-phenylephrine-acetaminophen liqd12.5mg/10ml-325mg/10ml-5mg/10ml

$0(Tier

3)

MO; NT

diphenhydramine-phenylephrine-acetaminophen tabs 25mg-325mg-5mg

$0(Tier

3)

*;NT

DURAFLU TABS$0

(Tier3)

*;NT

ED A-HIST DM TABS$0

(Tier3)

*;NT

ED A-HIST LIQD(Chlorpheniramine &Phenylephrine)

$0(Tier

3)

MO; NT

ED BRON GP LIQD$0

(Tier3)

NT

ED CHLORPED D LIQD$0

(Tier3)

*;NT

FLOWTUSS SOLN$0

(Tier3)

*;MO; NT

guaifenesin-codeine soln$0

(Tier3)

MO; NT

Name of drug

Whatthe


level)


guaifenesin-codeine soln$0

(Tier3)

*;MO; NT

guaifenesin-codeine syrp$0

(Tier3)

MO; NT

HISTEX-DM SYRP$0

(Tier3)

NT

HISTEX-PE SYRP$0

(Tier3)

MO; NT

HYCOFENIX SOLN$0

(Tier3)

*;NT

HYDROCODONEBITARTRATE/CHLORPHENIRAMINE MALEATE/PSESOLN

$0(Tier

3)

*;NT

hydrocodone polistirex-chlorpheniramine polistirexsuer

$0(Tier

3)

*;MO; NT

LODRANE D CAPS$0

(Tier3)

*;MO; NT

LOHIST-D LIQD$0

(Tier3)

*;MO; NT

LOHIST-DM SYRP$0

(Tier3)

MO; NT

loratadine &pseudoephedrine tb125mg-120mg

$0(Tier

3)

*;MO; NT

loratadine &pseudoephedrine tb2410mg-240mg

$0(Tier

3)

*;MO; NT

LORTUSS DM LIQD$0

(Tier3)

*;NT



Name of drug

Whatthe


level)


LORTUSS EX LIQD$0

(Tier3)

*;NT

LORTUSS LQ LIQD$0

(Tier3)

*;NT

M-END DMX LIQD$0

(Tier3)

NT

MUCINEX CHILDRENSCOLD COUGH & SORETHROAT LIQD(Phenylephrine-DM-GG w/APAP)

$0(Tier

3)

NT

MUCINEX CHILDRENSMULTI-SYMPTOM COLD& FEVER LIQD(Phenylephrine-DM-GG w/APAP)

$0(Tier

3)

NT

MUCINEX CHILDRENSMULTI-SYMPTOM COLDLIQD (Phenylephrine w/DM-GG)

$0(Tier

3)

NT

MUCINEX CONGESTION& COUGH CHILDRENSLIQD (Phenylephrine w/DM-GG)

$0(Tier

3)

NT

MUCINEX COUGH FORKIDS PACK

$0(Tier

3)

NT

MUCINEX D MAXIMUMSTRENGTH TB12(Pseudoephedrine-Guaifenesin)

$0(Tier

3)

MO; NT

MUCINEX D TB12(Pseudoephedrine-Guaifenesin)

$0(Tier

3)

MO; NT

MUCINEX DM MAXIMUMSTRENGTH TB12(Dextromethorphan-Guaifenesin)

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


MUCINEX DM TB12(Dextromethorphan-Guaifenesin)

$0(Tier

3)

MO; NT

MUCINEX FAST-MAXCOLD FLU& SORETHROAT LIQD(Phenylephrine-DM-GG w/APAP)

$0(Tier

3)

NT

MUCINEX FAST-MAX DAYTIME/NIGHT TIME MISC(Phenylephrine-Diphenhydramine-DM-Guaifenesin-APAP)

$0(Tier

3)

*;NT

MUCINEX FAST-MAXDAY/NIGHT MAXIMUMSTRENGTH MISC

$0(Tier

3)

*;NT

MUCINEX FAST-MAXSEVERE COLD LIQD(Phenylephrine-DM-GG w/APAP)

$0(Tier

3)

NT

MUCINEX FAST-MAXSEVERE CONGESTION &COUGH TABS 10MG-200MG-5MG

$0(Tier

3)

NT

MUCINEX MULTI-SYMPTOM COLDDAY/NIGHT PACK MISC

$0(Tier

3)

NT

MUCINEX STUFFY NOSE& COLD CHILDRENSLIQD (Phenylephrine-Guaifenesin)

$0(Tier

3)

NT

NASOPEN PE LIQD$0

(Tier3)

NT

NINJACOF LIQD$0

(Tier3)

*;NT

NINJACOF-A LIQD$0

(Tier3)

*;NT

NINJACOF-XG LIQD$0

(Tier3)

*;NT



Name of drug

Whatthe


level)


PEDIATRICCOUGH/COLD LIQD

$0(Tier

3)

NT

PHENYLEPHRINEHCL/PYRILAMINEMALEATE TABS

$0(Tier

3)

*;NT

phenylephrine w/acetaminophen tabs

$0(Tier

3)

*;NT

phenylephrine w/ dm-ggliqd 10mg/5ml-100mg/5ml-5mg/5ml, 18mg/15ml-200mg/15ml-10mg/15ml

$0(Tier

3)

*;NT

phenylephrine w/ dm-ggtabs 17.5mg-385mg-10mg

$0(Tier

3)

*;NT

phenylephrine-acetaminophen-guaifenesin tabs

$0(Tier

3)

NT

phenylephrine-brompheniramine-dm elix1mg/5ml-5mg/5ml-2.5mg/5ml

$0(Tier

3)

*;NT

phenylephrine-brompheniramine-dm elix1mg/5ml-5mg/5ml-2.5mg/5ml

$0(Tier

3)

NT

phenylephrine-brompheniramine-dm liqd1mg/5ml-5mg/5ml-2.5mg/5ml

$0(Tier

3)

MO; NT

phenylephrine-brompheniramine-dm liqd4mg/5ml-15mg/5ml-7.5mg/5ml

$0(Tier

3)

NT

phenylephrine-chlorphen-dm liqd

$0(Tier

3)

MO; NT

phenylephrine-diphenhydramine-gg w/apap misc

$0(Tier

3)

*;NT

Name of drug

Whatthe


level)


phenylephrine-dm-gg w/apap liqd 10mg/10ml-325mg/10ml-200mg/10ml-5mg/10ml

$0(Tier

3)

NT

phenylephrine-dm-gg w/apap tabs 10mg-325mg-200mg-5mg

$0(Tier

3)

NT

phenylephrine-dm-gg w/apap tabs 10mg-325mg-200mg-5mg

$0(Tier

3)

*;NT

phenylephrine-guaifenesintabs

$0(Tier

3)

*;MO; NT

POLY HIST FORTE TABS10.5MG-10MG

$0(Tier

3)

NT

POLY HIST FORTE TABS7.5MG-10MG (Doxylamine-Phenylephrine)

$0(Tier

3)

NT

POLY-HIST DM LIQD$0

(Tier3)

NT

POLY-HIST PD LIQD$0

(Tier3)

*;NT

POLY-VENT DM TABS$0

(Tier3)

MO; NT

POLY-VENT IR TABS$0

(Tier3)

NT

POLYTUSSIN DM SYRP$0

(Tier3)

*;NT

promethazine &phenylephrine soln

$0(Tier

1)

MO

promethazine &phenylephrine syrp

$0(Tier

1)

MO



Name of drug

Whatthe


level)


promethazine w/codeinesoln

$0(Tier

3)

MO; NT

promethazine w/codeinesyrp

$0(Tier

3)

MO; NT

promethazine-phenylephrine-codeinesyrp

$0(Tier

3)

*;MO; NT

PROMETHAZINE/DEXTROMETHORPHAN SOLN

$0(Tier

3)

MO; NT

PROMETHAZINE/DEXTROMETHORPHAN SYRP

$0(Tier

3)

MO; NT

pseudoephed-bromphen-dm syrp

$0(Tier

3)

MO; NT

pseudoephed-bromphen-dm syrp

$0(Tier

3)

*;MO; NT

pseudoephedrine w/codeine-gg soln

$0(Tier

3)

*;NT

pseudoephedrine-chlorphen-dm liqd

$0(Tier

3)

NT

pseudoephedrine-guaifenesin tb12 60mg-600mg

$0(Tier

3)

MO; NT

pseudoephedrine-guaifenesin tb12 60mg-600mg

$0(Tier

3)

*;MO; NT

RESCON TABS$0

(Tier3)

*;NT

RESPAIRE-30 CAPS$0

(Tier3)

*;MO; NT

RONDEC-D LIQD$0

(Tier3)

*;NT

Name of drug

Whatthe


level)


RU-HIST D TABS$0

(Tier3)

*;NT

RYMED TABS$0

(Tier3)

*;MO; NT

STAHIST AD LIQD25MG/5ML-60MG/5ML

$0(Tier

3)

*;NT

STAHIST AD TABS 25MG-60MG

$0(Tier

3)

*;MO; NT

triprolidine &pseudoephedrine tabs

$0(Tier

3)

MO; NT

triprolidine &pseudoephedrine tabs

$0(Tier

3)

*;MO; NT

TUSSIONEXPENNKINETICEXTENDED RELEASESUER (HydrocodonePolistirex-ChlorpheniraminePolistirex)

$0(Tier

3)

*;MO; NT

VANACOF DM LIQD(Phenylephrine w/ DM-GG)

$0(Tier

3)

NT

VANACOF LIQD$0

(Tier3)

NT

VANACOF-8 LIQD$0

(Tier3)

*;NT

VANATAB AC TABS$0

(Tier3)

*;NT

VANATAB DM TABS$0

(Tier3)

*;NT

ZUTRIPRO SOLN(Pseudoephed-CPM w/Hydrocod)

$0(Tier

3)

*;NT



Name of drug

Whatthe


level)


Expectorants

guaifenesin liqd 100mg/5ml

$0(Tier

3)

*;MO; NT

guaifenesin liqd 100mg/5ml, 200 mg/10ml

$0(Tier

3)

MO; NT

guaifenesin syrp 100mg/5ml, 200 mg/10ml

$0(Tier

3)

MO; NT

guaifenesin tabs 200 mg,400 mg

$0(Tier

3)

MO; NT

guaifenesin tb12 600 mg,1200 mg

$0(Tier

3)

MO; NT

MUCINEX FOR KIDSPACK

$0(Tier

3)

NT

MUCINEX MAXIMUMSTRENGTH TB12(Guaifenesin)

$0(Tier

3)

MO; NT

MUCINEX TB12(Guaifenesin)

$0(Tier

3)

MO; NT

Mucolytics

acetylcysteine soln$0

(Tier1)

B/D; MO

DERMATOLOGICALS - Drugs to Treat SkinConditionsAcne Products

ABSORICA CAPS 10 MG,20 MG, 30 MG, 40 MG

$0(Tier

2)

ACNE MEDICATION 10LOTN

$0(Tier

3)

NT

ACNE MEDICATION 5LOTN

$0(Tier

3)

NT

Name of drug

Whatthe


level)


adapalene crea 0.1 %$0

(Tier1)

MO

adapalene gel 0.1 %$0

(Tier1)

RX/OTC; MO

benzoyl peroxide foam 5.3%

$0(Tier

3)

RX/OTC; MO;NT

benzoyl peroxide foam 9.8%

$0(Tier

3)

MO; NT

BENZOYL PEROXIDEGEL 2.5 %

$0(Tier

3)

MO; NT

benzoyl peroxide gel 5 %,10 %

$0(Tier

3)

MO; NT

benzoyl peroxide liqd 5 %,10 %

$0(Tier

3)

RX/OTC; MO;NT

benzoyl peroxide-erythromycin gel

$0(Tier

1)

MO

CLINDAGEL GEL$0

(Tier2)

MO

clindamycin phosphate(topical) foam

$0(Tier

1)

MO

clindamycin phosphate(topical) gel

$0(Tier

1)

MO

clindamycin phosphate(topical) lotn

$0(Tier

1)

MO

clindamycin phosphate(topical) soln

$0(Tier

1)

MO

clindamycin phosphate(topical) swab

$0(Tier

1)

MO



Name of drug

Whatthe


level)


clindamycin phosphate-benzoyl peroxide(refrigerate) gel

$0(Tier

1)

MO

clindamycin phosphate-benzoyl peroxide gel 1%-5%

$0(Tier

1)

MO

erythromycin (acne aid)soln

$0(Tier

1)

MO

isotretinoin caps$0

(Tier1)

sulfacetamide sodium(acne) lotn

$0(Tier

1)

MO

tretinoin crea 0.025 %, 0.05%, 0.1 %

$0(Tier

1)

MO

tretinoin gel 0.025 %, 0.01%

$0(Tier

1)

MO

tretinoin microsphere gel$0

(Tier1)

MO

Analgesics - Topical

menthol (topical analgesic)gel

$0(Tier

3)

MO; NT

Anti-inflammatory Agents - Topical

DICLOFENACEPOLAMINE PTCH

$0(Tier

2)

PA; MO

diclofenac sodium (topical)gel 1 %

$0(Tier

1)

MO

FLECTOR PTCH$0

(Tier2)

PA; MO

Antibiotics - Topical

Name of drug

Whatthe


level)


bacitracin (topical) oint$0

(Tier3)

MO; NT

bacitracin zinc oint$0

(Tier3)

MO; NT

bacitracin-polymyxin b oint500unit/gm-10000unit/gm

$0(Tier

3)

MO; NT

CENTANY OINT$0

(Tier2)

MO

gentamicin sulfate (topical)crea

$0(Tier

1)

MO

mupirocin calcium (topical)crea

$0(Tier

1)

MO

mupirocin oint$0

(Tier1)

MO

neomycin-bacitracin-polymyxin oint 400unit/gm-5000unit/gm-5mg/gm,400unit/gm-5000unit/gm-3.5mg/gm

$0(Tier

3)

MO; NT

neomycin-bacitracin-polymyxin-pramoxine oint500unit/gm-10000unit/gm-5mg/gm-10mg/gm

$0(Tier

3)

MO; NT

Antifungals - Topical

ciclopirox gel 0.77 %$0

(Tier1)

MO

ciclopirox olamine crea$0

(Tier1)

MO

ciclopirox olamine susp$0

(Tier1)

MO



Name of drug

Whatthe


level)


ciclopirox sham 1 %$0

(Tier1)

MO

ciclopirox soln 8 %$0

(Tier1)

MO

clotrimazole (topical) crea$0

(Tier3)


clotrimazole (topical) crea$0

(Tier1)

RX/OTC; MO

clotrimazole (topical) soln$0

(Tier1)

RX/OTC; MO

clotrimazole (topical) soln$0

(Tier3)


clotrimazole w/betamethasone crea

$0(Tier

1)

MO

clotrimazole w/betamethasone lotn

$0(Tier

1)

MO

econazole nitrate crea$0

(Tier1)

MO

FUNGOID TINCTURESOLN

$0(Tier

3)

*;MO; NT

ketoconazole (topical) crea$0

(Tier1)

MO

ketoconazole (topical) foam$0

(Tier1)

MO

ketoconazole (topical)sham

$0(Tier

1)

MO

miconazole nitrate (topical)crea

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


miconazole nitrate (topical)powd

$0(Tier

3)

MO; NT

naftifine hcl crea 2 %$0

(Tier1)

MO

naftifine hcl gel 1 %$0

(Tier1)

MO

NAFTIN GEL 1 % (NaftifineHCl)

$0(Tier

2)

MO

NAFTIN GEL 1 %, 2 %$0

(Tier2)

MO

nystatin (topical) crea$0

(Tier1)

MO

nystatin (topical) oint$0

(Tier1)

MO

nystatin (topical) powd$0

(Tier1)

MO

nystatin-triamcinolone crea$0

(Tier1)

MO

nystatin-triamcinolone oint$0

(Tier1)

MO

terbinafine hcl (topical) crea$0

(Tier3)

MO; NT

tolnaftate aero$0

(Tier3)

*;NT

tolnaftate crea$0

(Tier3)

MO; NT

tolnaftate powd$0

(Tier3)

MO; NT



Name of drug

Whatthe


level)


Antineoplastic or Premalignant Lesion Agents -

CARAC CREA$0

(Tier2)

NDS;MO

diclofenac sodium (actinickeratoses) gel

$0(Tier

1)

NDS;MO

fluorouracil (topical) crea$0

(Tier1)

MO

fluorouracil (topical) soln$0

(Tier1)

MO

FLUOROURACIL CREAEX 0.5 %

$0(Tier

2)

NDS;MO

PANRETIN GEL$0

(Tier2)

NDS;MO

PICATO GEL$0

(Tier2)

NDS;MO

TARGRETIN GEL EX 1 %$0

(Tier2)

NDS

VALCHLOR GEL$0

(Tier2)

PA; NDS;MO

Antipsoriatics

acitretin caps$0

(Tier1)

NDS;MO

calcipotriene crea$0

(Tier1)

MO

calcipotriene oint$0

(Tier1)

MO

calcipotriene soln$0

(Tier1)

MO

Name of drug

Whatthe


level)


ILUMYA SOSY$0

(Tier2)

PA; NDS

methoxsalen rapid caps$0

(Tier1)

NDS;MO

SILIQ SOSY$0

(Tier2)

PA; NDS

tazarotene crea$0

(Tier1)

MO

TAZORAC CREA 0.05 %$0

(Tier2)

MO

TAZORAC GEL 0.05 %,0.1 %

$0(Tier

2)

MO

TREMFYA SOSY$0

(Tier2)

PA; NDS

Antiseborrheic Products

selenium sulfide lotn 2.5 %$0

(Tier1)

MO

Antivirals - Topical

acyclovir topical crea$0

(Tier1)

NDS;MO

acyclovir topical oint$0

(Tier1)

MO

DENAVIR CREA$0

(Tier2)

NDS;MO

Burn Products

silver sulfadiazine crea$0

(Tier1)

MO



Name of drug

Whatthe


level)


SULFAMYLON CREA 85MG/GM

$0(Tier

2)

MO

Corticosteroids - Topical

alclometasone dipropionatecrea

$0(Tier

1)

MO

alclometasone dipropionateoint

$0(Tier

1)

MO

amcinonide crea$0

(Tier1)

MO

betamethasonedipropionate (topical) crea

$0(Tier

1)

MO

betamethasonedipropionate (topical) lotn

$0(Tier

1)

MO

betamethasonedipropionate (topical) oint

$0(Tier

1)

MO

betamethasonedipropionate augmentedcrea

$0(Tier

1)

MO

betamethasonedipropionate augmentedgel

$0(Tier

1)

MO

betamethasonedipropionate augmentedlotn

$0(Tier

1)

MO

betamethasonedipropionate augmentedoint

$0(Tier

1)

MO

betamethasone valeratecrea

$0(Tier

1)

MO

betamethasone valeratefoam

$0(Tier

1)

MO

Name of drug

Whatthe


level)


betamethasone valeratelotn

$0(Tier

1)

MO

betamethasone valerateoint

$0(Tier

1)

MO

clobetasol propionate crea$0

(Tier1)

MO

clobetasol propionateemollient base crea

$0(Tier

1)

MO

clobetasol propionateemulsion foam

$0(Tier

1)

MO

clobetasol propionate foam$0

(Tier1)

MO

clobetasol propionate gel$0

(Tier1)

MO

clobetasol propionate lotn$0

(Tier1)

MO

clobetasol propionate oint$0

(Tier1)

MO

clobetasol propionate sham$0

(Tier1)

MO

clobetasol propionate soln$0

(Tier1)

MO

desonide crea$0

(Tier1)

MO

desonide lotn$0

(Tier1)

MO

desonide oint$0

(Tier1)

MO



Name of drug

Whatthe


level)


desoximetasone crea 0.25%

$0(Tier

1)

MO

desoximetasone gel 0.05%

$0(Tier

1)

MO

desoximetasone oint 0.25%

$0(Tier

1)

MO

diflorasone diacetate oint$0

(Tier1)

MO

fluocinolone acetonide crea$0

(Tier1)

MO

fluocinolone acetonide oil$0

(Tier1)

MO

fluocinolone acetonide oint$0

(Tier1)

MO

fluocinolone acetonide soln$0

(Tier1)

MO

fluocinonide crea 0.05 %$0

(Tier1)

MO

fluocinonide emulsifiedbase crea

$0(Tier

1)

MO

fluocinonide gel 0.05 %$0

(Tier1)

MO

fluocinonide oint 0.05 %$0

(Tier1)

MO

fluocinonide soln 0.05 %$0

(Tier1)

MO

fluticasone propionate crea$0

(Tier1)

MO

Name of drug

Whatthe


level)


fluticasone propionate lotn$0

(Tier1)

MO

fluticasone propionate oint$0

(Tier1)

MO

halobetasol propionatecrea

$0(Tier

1)

MO

halobetasol propionate oint$0

(Tier1)

MO

hydrocortisone (topical)crea 0.5 %

$0(Tier

3)

MO; NT

hydrocortisone (topical)crea 1 %

$0(Tier

1)

RX/OTC; MO

hydrocortisone (topical)crea 1 %

$0(Tier

3)


hydrocortisone (topical)crea 2.5 %

$0(Tier

1)

MO

hydrocortisone (topical) lotn1 %

$0(Tier

3)

MO; NT

hydrocortisone (topical) lotn2.5 %

$0(Tier

1)

MO

hydrocortisone (topical) oint0.5 %

$0(Tier

3)

MO; NT

hydrocortisone (topical) oint1 %

$0(Tier

3)


hydrocortisone (topical) oint1 %

$0(Tier

1)

RX/OTC; MO

hydrocortisone (topical) oint2.5 %

$0(Tier

1)

MO



Name of drug

Whatthe


level)


hydrocortisone butyratecrea

$0(Tier

1)

MO

hydrocortisone butyratehydrophilic lipo base crea

$0(Tier

1)

MO

hydrocortisone butyrateoint

$0(Tier

1)

MO

hydrocortisone butyratesoln

$0(Tier

1)

MO

hydrocortisone valeratecrea

$0(Tier

1)

MO

hydrocortisone valerateoint

$0(Tier

1)

MO

hydrocortisone-aloe veracrea

$0(Tier

3)

NT

mometasone furoate crea$0

(Tier1)

MO

mometasone furoate oint$0

(Tier1)

MO

mometasone furoate soln$0

(Tier1)

MO

prednicarbate crea$0

(Tier1)

MO

triamcinolone acetonide(topical) aers

$0(Tier

1)

MO

triamcinolone acetonide(topical) crea

$0(Tier

1)

MO

triamcinolone acetonide(topical) lotn

$0(Tier

1)

MO

Name of drug

Whatthe


level)


triamcinolone acetonide(topical) oint

$0(Tier

1)

MO

Emollients

COATS ALOE CREMECREA

$0(Tier

3)

NT

COATS ALOE GELLY GEL$0

(Tier3)

NT

COATS ALOEMOISTURIZING LOTIONLOTN

$0(Tier

3)

NT

lactic acid (ammoniumlactate) crea

$0(Tier

1)

RX/OTC; MO

lactic acid (ammoniumlactate) lotn

$0(Tier

1)

RX/OTC; MO

vitamins a & d (topical) oint15.5%-53.4%

$0(Tier

3)

MO; NT

Enzymes - Topical

SANTYL OINT$0

(Tier2)

MO

Hair Growth Agents

bimatoprost (topical) soln$0

(Tier3)

MO; NT

finasteride (alopecia) tabs$0

(Tier3)

MO; NT

Immunomodulating Agents - Topical

imiquimod crea$0

(Tier1)

MO

IMIQUIMOD PUMP CREA$0

(Tier2)

NDS;MO



Name of drug

Whatthe


level)


ZYCLARA CREA$0

(Tier2)

NDS;MO

ZYCLARA PUMP CREA2.5 %, 3.75 %

$0(Tier

2)

NDS;MO

Immunosuppressive Agents - Topical

pimecrolimus crea$0

(Tier1)

PA; MO

tacrolimus (topical) oint$0

(Tier1)

PA; MO

Keratolytic/Antimitotic Agents

podofilox soln$0

(Tier1)

MO

Liniments

menthol-methyl salicylate(liniments) crea

$0(Tier

3)

MO; NT

Local Anesthetics - Topical

capsaicin crea$0

(Tier3)

MO; NT

lidocaine hcl gel ex 2 %$0

(Tier1)

MO

lidocaine hcl prsy ex 2 %$0

(Tier1)

MO

lidocaine hcl soln ex 4 %$0

(Tier1)

MO

lidocaine oint$0

(Tier1)

MO

lidocaine ptch$0

(Tier1)

PA; MO

Name of drug

Whatthe


level)


lidocaine-prilocaine crea$0

(Tier1)

MO

Misc. Topical

COLEMAN BOTANICALSINSECTREPELLENT LIQD

$0(Tier

3)

NT

COLEMAN INSECTREPELLENT/HIGH & DRYAERO

$0(Tier

3)

NT

COLEMAN SKINSMARTINSECTREPELLENTAERO

$0(Tier

3)

NT

COLEMAN SKINSMARTINSECTREPELLENT LIQD

$0(Tier

3)

NT

COZIMA CREA$0

(Tier3)

NT

CUTTER BACKWOODSAERO

$0(Tier

3)

NT

CUTTER BACKWOODSDRY AERO

$0(Tier

3)

NT

CUTTER BACKWOODSLIQD

$0(Tier

3)

NT

CUTTER LEMONEUCALYPTUS LIQD

$0(Tier

3)

NT

dimethicone (topical) lotn$0

(Tier3)

MO; NT

DR SMITHS DIAPER OINT(Zinc Oxide (Topical))

$0(Tier

3)

NT

DR SMITHS DIAPERRASH SPRAY AERO

$0(Tier

3)

NT



Name of drug

Whatthe


level)


NATRAPEL 12-HOURTICK & INSECTREPELLENTCONTINUOUS SPRAYAERO

$0(Tier

3)

NT

OFF DEEP WOODS AERO$0

(Tier3)

NT

OFF DEEP WOODS DRYAERO

$0(Tier

3)

NT

OFF DEEP WOODS LIQD$0

(Tier3)

NT

OFF DEEP WOODSSPORTSMEN AERO

$0(Tier

3)

NT

OFF DEEP WOODSSPORTSMEN LIQD

$0(Tier

3)

NT

REPEL HUNTERSFORMULA AERO

$0(Tier

3)

NT

REPEL LEMONEUCALYPTUS INSECTREPELLENT AERO

$0(Tier

3)

NT

REPEL SPORTSMENAERO

$0(Tier

3)

NT

REPEL SPORTSMEN DRYAERO

$0(Tier

3)

NT

REPEL SPORTSMENMAX AERO

$0(Tier

3)

NT

SAWYER PREMIUMINSECT REPELLENTLIQD

$0(Tier

3)

NT

ULTRATHON INSECTREPELLENT 8 AERO

$0(Tier

3)

NT

Name of drug

Whatthe


level)


witch hazel (hamamelisvirginiana) pads 50 %

$0(Tier

3)

MO; NT

Z-BUM CREA$0

(Tier3)

NT

zinc oxide (topical) oint$0

(Tier3)

MO; NT

Pigmenting-Depigmenting Agents

TRI-LUMA CREA$0

(Tier3)

MO; NT

Rosacea Agents

azelaic acid gel$0

(Tier1)

MO

metronidazole (topical)crea

$0(Tier

1)

MO

metronidazole (topical) gel$0

(Tier1)

MO

metronidazole (topical) lotn$0

(Tier1)

MO

MIRVASO GEL$0

(Tier2)

PA; MO

Scabicides & Pediculicides

malathion lotn$0

(Tier1)

MO

permethrin crea 5 %$0

(Tier1)

MO

permethrin liqd 1 %$0

(Tier3)

MO; NT

Wound Care Products



Name of drug

Whatthe


level)


REGRANEX GEL$0

(Tier2)

NDS;MO

DIETARY PRODUCTS/DIETARY MANAGEMENTPRODUCTSDietary Management Products

CARDIOTEK-RX TABS$0

(Tier3)

MO; NT

CEREFOLIN TABS$0

(Tier3)

MO; NT

ELFOLATE PLUS TABS$0

(Tier3)

MO; NT

ENLYTE CAPS$0

(Tier3)

MO; NT

folic acid-pyridoxine-cyanocobalamin tabs

$0(Tier

3)

MO; NT

FOLTANX TABS$0

(Tier3)

MO; NT

L-METHYL-B6-B12 TABS$0

(Tier3)

MO; NT

L-METHYL-MC TABS$0

(Tier3)

MO; NT

METAFOLBIC TABS$0

(Tier3)

MO; NT

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymesDigestive Enzymes

CREON CPEP$0

(Tier2)

MO

Name of drug

Whatthe


level)


PANCREAZE CPEP$0

(Tier2)

MO

SUCRAID SOLN$0

(Tier2)

LA

ZENPEP CPEP32000UNIT-10000UNIT-42000UNIT

$0(Tier

2)

MO

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood PressureCarbonic Anhydrase Inhibitors

acetazolamide cp12$0

(Tier1)

MO

acetazolamide tabs$0

(Tier1)

MO

methazolamide tabs$0

(Tier1)

MO

Diuretic Combinations

amiloride &hydrochlorothiazide tabs

$0(Tier

1)

MO

spironolactone &hydrochlorothiazide tabs

$0(Tier

1)

MO

triamterene &hydrochlorothiazide caps

$0(Tier

1)

MO

triamterene &hydrochlorothiazide tabs

$0(Tier

1)

MO

Loop Diuretics

bumetanide tabs or 0.5 mg,1 mg, 2 mg

$0(Tier

1)

MO

furosemide soln ij 10 mg/ml$0

(Tier1)

MO



Name of drug

Whatthe


level)


furosemide soln or 10mg/ml

$0(Tier

1)

MO

furosemide tabs or 20 mg,40 mg, 80 mg

$0(Tier

1)

MO

torsemide tabs$0

(Tier1)

MO

Potassium Sparing Diuretics

amiloride hcl tabs$0

(Tier1)

MO

spironolactone tabs$0

(Tier1)

MO

Thiazides and Thiazide-Like Diuretics

chlorothiazide tabs 500 mg$0

(Tier1)

MO

chlorthalidone tabs$0

(Tier1)

MO

hydrochlorothiazide caps$0

(Tier1)

MO

hydrochlorothiazide tabs$0

(Tier1)

MO

indapamide tabs$0

(Tier1)

MO

metolazone tabs$0

(Tier1)

MO

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate HormonesBone Density Regulators

Name of drug

Whatthe


level)


alendronate sodium tabs35 mg, 70 mg

$0(Tier

1)


alendronate sodium tabs 5mg, 10 mg

$0(Tier

1)

MO

calcitonin (salmon) soln$0

(Tier1)

MO

FORTEO SOLN$0

(Tier2)

PA; NDS; Limit2.4mls per 28days;QL(0.09ml daily)

ibandronate sodium soln iv3 mg/3ml

$0(Tier

1)

QL(0.036 mldaily); MO

ibandronate sodium tabs or150 mg

$0(Tier

1)

Limit 1 tab per28 days (3 per84);QL(0.036ea daily); MO

MIACALCIN SOLN$0

(Tier2)

MO

NATPARA CART$0

(Tier2)

PA; NDS;LA

PROLIA SOSY$0

(Tier2)

PA; QL(0.006ml daily)

TYMLOS SOPN$0

(Tier2)

PA; NDS

XGEVA SOLN$0

(Tier2)

NDS; Limit6.8mls per 28days;QL(0.243ml daily)

zoledronic acid conc 4mg/5ml

$0(Tier

1)

zoledronic acid soln 5mg/100ml

$0(Tier

1)

QL(0.28 mldaily)



Name of drug

Whatthe


level)


Fertility Regulators

chorionic gonadotropin solr$0

(Tier1)

PA

NOVAREL SOLR$0

(Tier2)

PA

GnRH/LHRH Antagonists

ORILISSA TABS$0

(Tier2)

PA; NDS;MO

Growth Hormone Receptor Antagonists

SOMAVERT SOLR$0

(Tier2)

PA; NDS;LA

Growth Hormone Releasing Hormones (GHRH)

EGRIFTA SOLR 2 MG$0

(Tier2)

Growth HormonesNORDITROPIN FLEXPROSOLN 5 MG/1.5ML, 10MG/1.5ML

$0(Tier

2)

PA; NDS

NUTROPIN AQ NUSPIN20 SOLN

$0(Tier

2)

PA; NDS

Hormone Receptor Modulators

OSPHENA TABS$0

(Tier2)

MO

raloxifene hcl tabs$0

(Tier1)

QL(1 ea daily);MO

Insulin-Like Growth Factors (Somatomedins)

INCRELEX SOLN$0

(Tier2)

LA

LHRH/GnRH Agonist Analog Pituitary

Name of drug

Whatthe


level)


LUPANETA PACK KIT$0

(Tier2)

NDS

LUPRON DEPOT-PED (1-MONTH) KIT 15 MG

$0(Tier

2)LUPRON DEPOT-PED (1-MONTH) KIT 7.5 MG,11.25 MG

$0(Tier

2)

NDS

LUPRON DEPOT-PED (3-MONTH) KIT

$0(Tier

2)

NDS

SYNAREL SOLN$0

(Tier2)

NDS;MO

TRIPTODUR SRER$0

(Tier2)

NDS;MO

Metabolic Modifiers

calcitriol caps or 0.25 mcg,0.5 mcg

$0(Tier

1)

MO

calcitriol soln or 1 mcg/ml$0

(Tier1)

MO

CARBAGLU TABS$0

(Tier2)

LA; MO

cinacalcet hcl tabs 30 mg$0

(Tier1)

cinacalcet hcl tabs 60 mg,90 mg

$0(Tier

1)

NDS

CRYSVITA SOLN$0

(Tier2)

PA; NDS;LA

FABRAZYME SOLR$0

(Tier2)

NDS;LA



Name of drug

Whatthe


level)


GALAFOLD CAPS$0

(Tier2)

PA; NDS;LA

KANUMA SOLN$0

(Tier2)

NDS;LA

KUVAN PACK$0

(Tier2)

PA; NDS;LA

KUVAN TBSO$0

(Tier2)

PA; NDS;LA

levocarnitine (metabolicmodifiers) tabs 330 mg

$0(Tier

1)

RX/OTC; MO

LUMIZYME SOLR$0

(Tier2)

NDS;LA

MYALEPT SOLR$0

(Tier2)

NDS;LA; MO

NAGLAZYME SOLN$0

(Tier2)

NDS;LA

nitisinone caps$0

(Tier1)

LA; MO

ORFADIN CAPS 2 MG, 5MG, 10 MG (Nitisinone)

$0(Tier

2)

LA; MO

ORFADIN CAPS 20 MG$0

(Tier2)

LA; MO

PALYNZIQ SOSY$0

(Tier2)

PA; NDS;LA

paricalcitol caps or 1 mcg,2 mcg, 4 mcg

$0(Tier

1)

MO

RAVICTI LIQD$0

(Tier2)

LA

Name of drug

Whatthe


level)


RAYALDEE CPCR$0

(Tier2)

PA; MO

REVCOVI SOLN$0

(Tier2)

PA; NDS;LA;MO

STRENSIQ SOLN$0

(Tier2)

PA; NDS;LA;MO

VIMIZIM SOLN$0

(Tier2)

NDS;LA

XURIDEN PACK$0

(Tier2)


Posterior Pituitary Hormones

DDAVP SOLN NA 0.01 %$0

(Tier2)

MO

desmopressin acetate soln$0

(Tier1)

MO

desmopressin acetatespray refrigerated soln

$0(Tier

1)

MO

desmopressin acetatespray soln

$0(Tier

1)

MO

desmopressin acetate tabs$0

(Tier1)

MO

Prolactin Inhibitors

cabergoline tabs$0

(Tier1)

MO

Somatostatic Agentsoctreotide acetate soln 50mcg/ml, 100 mcg/ml, 200mcg/ml, 500 mcg/ml, 1000mcg/ml, 1000 mcg/5ml

$0(Tier

1)



Name of drug

Whatthe


level)


SANDOSTATIN LARDEPOT KIT

$0(Tier

2)

NDS

SIGNIFOR LAR SRER 10MG

$0(Tier

2)

NDS; Limit 6vials per 28days ;SL(0.22ea daily); LA;MO


$0(Tier

2)

NDS; Limit 3vials per 28days;SL(0.11ea daily); LA;MO


$0(Tier

2)



$0(Tier

2)



$0(Tier

2)

NDS; Limit 1vial per 28days;SL(0.036ea daily); LA;MO

SIGNIFOR SOLN$0

(Tier2)

NDS;LA; MO

SOMATULINE DEPOTSOLN

$0(Tier

2)

NDS

Vasopressin Receptor Antagonists

JYNARQUE TABS 15 MG,30 MG

$0(Tier

2)

NDS;MO

JYNARQUE TBPK$0

(Tier2)

PA; NDS;LA

Name of drug

Whatthe


level)


SAMSCA TABS$0

(Tier2)

NDS;MO

ESTROGENS - Hormone Replacement/ModifyingDrugsEstrogen Combinations

estradiol & norethindroneacetate tabs

$0(Tier

1)


norethindrone acetate-ethinyl estradiol tabs2.5mcg-0.5mg

$0(Tier

1)


PREMPHASE TABS$0

(Tier2)


PREMPRO TABS$0

(Tier2)


Estrogens

DELESTROGEN OIL 10MG/ML

$0(Tier

2)

MO

DIVIGEL GEL$0

(Tier2)


estradiol ptwk td 0.025mg/24hr, 0.075 mg/24hr,0.05 mg/24hr, 0.06mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr

$0(Tier

1)


estradiol tabs or 0.5 mg, 1mg, 2 mg

$0(Tier

1)


estradiol valerate oil$0

(Tier1)

MO

estropipate tabs 0.75 mg,1.5 mg

$0(Tier

1)

AL(Up to 64 yrsold)



Name of drug

Whatthe


level)


PREMARIN TABS OR0.625 MG, 0.45 MG, 0.3MG, 0.9 MG, 1.25 MG

$0(Tier

2)


FLUOROQUINOLONES - Drugs to Treat BacterialInfectionsFluoroquinolones

BAXDELA SOLR IV 300MG

$0(Tier

2)

PA; NDS

BAXDELA TABS OR 450MG

$0(Tier

2)

ST; NDS;MO

ciprofloxacin hcl tabs$0

(Tier1)

MO

ciprofloxacin in d5w soln200mg/100ml-5%

$0(Tier

1)

ciprofloxacin in d5w soln400mg/200ml-5%

$0(Tier

1)

MO

levofloxacin in d5w soln$0

(Tier1)

levofloxacin soln iv 25mg/ml

$0(Tier

1)

levofloxacin soln or 25mg/ml

$0(Tier

1)

MO

levofloxacin tabs or 250mg, 750 mg

$0(Tier

1)

QL(1 ea daily);MO

levofloxacin tabs or 500 mg$0

(Tier1)

MO

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal DrugsAntiflatulents

Name of drug

Whatthe


level)


simethicone caps 125 mg,180 mg

$0(Tier

3)

MO; NT

simethicone chew 80 mg,125 mg

$0(Tier

3)

MO; NT

simethicone susp 20mg/0.3ml

$0(Tier

3)

MO; NT

Farnesoid X Receptor (FXR) Agonists

OCALIVA TABS 10 MG$0

(Tier2)


OCALIVA TABS 5 MG$0

(Tier2)


Gallstone Solubilizing Agents

chenodiol tabs$0

(Tier1)

NDS;LA

ursodiol caps$0

(Tier1)

MO

ursodiol tabs$0

(Tier1)

MO

Gastrointestinal Antiallergy Agents

cromolyn sodium(mastocytosis) conc

$0(Tier

1)

MO

Gastrointestinal Stimulants

metoclopramide hcl soln$0

(Tier1)

MO

metoclopramide hcl tabs$0

(Tier1)

MO

Inflammatory Bowel Agents



Name of drug

Whatthe


level)


balsalazide disodium caps$0

(Tier1)

MO

DIPENTUM CAPS$0

(Tier2)

NDS;MO

ENTYVIO SOLR$0

(Tier2)

PA; NDS

INFLECTRA SOLR$0

(Tier2)

PA; NDS

mesalamine enem re 4 gm$0

(Tier1)

MO

mesalamine tbec or 1.2gm, 800 mg

$0(Tier

1)

MO

mesalamine w/ cleanser kit$0

(Tier1)

MO

REMICADE SOLR$0

(Tier2)

PA; NDS

sulfasalazine tabs$0

(Tier1)

MO

sulfasalazine tbec$0

(Tier1)

MO

Intestinal Acidifiers

lactulose (encephalopathy)soln

$0(Tier

1)

MO

Irritable Bowel Syndrome (IBS) Agents

alosetron hcl tabs$0

(Tier1)

PA; NDS;MO

LINZESS CAPS$0

(Tier2)

MO

Name of drug

Whatthe


level)


VIBERZI TABS$0

(Tier2)

PA; NDS;MO

Peripheral Opioid Receptor Antagonists

MOVANTIK TABS$0

(Tier2)

MO

RELISTOR SOLN SC 8MG/0.4ML, 12 MG/0.6ML

$0(Tier

2)

NDS;MO

Phosphate Binder Agents

calcium acetate (phosphatebinder) caps

$0(Tier

1)

MO

lanthanum carbonate chew$0

(Tier1)

MO

sevelamer carbonate pack0.8 gm, 2.4 gm

$0(Tier

1)

NDS;MO

sevelamer carbonate tabs800 mg

$0(Tier

1)

MO

Short Bowel Syndrome (SBS) Agents

GATTEX KIT$0

(Tier2)

PA; NDS;LA

Tryptophan Hydroxylase Inhibitors

XERMELO TABS$0

(Tier2)

PA; NDS;LA;MO

GENITOURINARY AGENTS - MISCELLANEOUS- Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary SystemAlkalinizers

potassium citrate(alkalinizer) tbcr

$0(Tier

1)

MO

Cystinosis Agents



Name of drug

Whatthe


level)


CYSTAGON CAPS$0

(Tier2)

Genitourinary Irrigants

acetic acid soln$0

(Tier1)

MO

neomycin/polymyxin b gusoln

$0(Tier

1)

MO

sodium chloride (guirrigant) soln

$0(Tier

1)

MO

Prostatic Hypertrophy Agents

alfuzosin hcl tb24$0

(Tier1)

MO

dutasteride caps$0

(Tier1)

MO

dutasteride-tamsulosin hclcaps

$0(Tier

1)

MO

finasteride tabs$0

(Tier1)

MO

tamsulosin hcl caps$0

(Tier1)

MO

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinations

colchicine w/ probenecidtabs

$0(Tier

1)

MO

DUZALLO TABS 200MG-300MG

$0(Tier

2)

SL(1 ea daily);MO

Gout Agents

Name of drug

Whatthe


level)


allopurinol tabs 100 mg$0

(Tier1)

SL(8 ea daily);MO

allopurinol tabs 300 mg$0

(Tier1)


colchicine tabs$0

(Tier2)

MO

Uricosurics

probenecid tabs$0

(Tier1)

MO

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood DisordersBradykinin B2 Receptor Antagonists

icatibant acetate soln$0

(Tier1)

PA; NDS

Complement Inhibitors

CINRYZE SOLR$0

(Tier2)

PA; NDS;LA

HAEGARDA SOLR$0

(Tier2)

PA; NDS

Hemataologic - Tyrosine Kinase Inhibitors

TAVALISSE TABS$0

(Tier2)

PA; NDS

Hematorheologic Agents

pentoxifylline tbcr$0

(Tier1)

MO

Plasma Kallikrein Inhibitors

KALBITOR SOLN$0

(Tier2)

NDS



Name of drug

Whatthe


level)


TAKHZYRO SOLN$0

(Tier2)

PA; NDS

Platelet Aggregation Inhibitors

anagrelide hcl caps$0

(Tier1)

MO

aspirin-dipyridamole cp12$0

(Tier1)

MO

BRILINTA TABS$0

(Tier2)

MO

CABLIVI KIT$0

(Tier2)

PA; NDS;MO

cilostazol tabs$0

(Tier1)

MO

clopidogrel bisulfate tabs$0

(Tier1)

MO

dipyridamole tabs$0

(Tier1)


prasugrel hcl tabs$0

(Tier1)

MO

ZONTIVITY TABS$0

(Tier2)

MO

HEMATOPOIETIC AGENTS - Drugs to TreatBlood DisordersAgents for Gaucher Disease

CERDELGA CAPS$0

(Tier2)

PA; NDS

CEREZYME SOLR$0

(Tier2)

PA; NDS;LA

Name of drug

Whatthe


level)


ELELYSO SOLR$0

(Tier2)

NDS

miglustat caps$0

(Tier1)

NDS;LA; MO

VPRIV SOLR$0

(Tier2)

NDS

Agents for Sickle Cell Anemia

DROXIA CAPS$0

(Tier2)

MO

ENDARI PACK$0

(Tier2)

PA; NDS;MO

Cobalamins

B-12 DOTS TBDP$0

(Tier3)

NT

cyanocobalamin liqd or1000 mcg/15ml

$0(Tier

3)

NT

cyanocobalamin soln ij1000 mcg/ml

$0(Tier

3)

MO; NT

cyanocobalamin subl sl2500 mcg

$0(Tier

3)

MO; NT

cyanocobalamin tabs or100 mcg, 250 mcg, 500mcg, 1000 mcg

$0(Tier

3)

MO; NT

cyanocobalamin tabs or 50mcg

$0(Tier

3)

NT

cyanocobalamin tbcr or1000 mcg

$0(Tier

3)

MO; NT

cyanocobalamin tbcr or2000 mcg

$0(Tier

3)

NT



Name of drug

Whatthe


level)


NASCOBAL SOLN$0

(Tier3)

MO; NT

Folic Acid/Folates

FOLIC ACID SOLN IJ 5MG/ML

$0(Tier

3)

MO; NT

folic acid tabs or 1 mg$0

(Tier3)

RX/OTC; MO;NT

Hematopoietic Growth FactorsARANESP ALBUMINFREE SOLN 100 MCG/ML,200 MCG/ML, 300MCG/ML

$0(Tier

2)

PA; NDS

ARANESP ALBUMINFREE SOLN 25 MCG/ML,40 MCG/ML, 60 MCG/ML

$0(Tier

2)

PA

ARANESP ALBUMINFREE SOSY 10MCG/0.4ML, 40MCG/0.4ML, 60MCG/0.3ML, 25MCG/0.42ML

$0(Tier

2)

PA

ARANESP ALBUMINFREE SOSY 500 MCG/ML,100 MCG/0.5ML, 150MCG/0.3ML, 200MCG/0.4ML, 300MCG/0.6ML

$0(Tier

2)

PA; NDS

DOPTELET TABS$0

(Tier2)

PA; NDS;LA

EPOGEN SOLN 2000UNIT/ML, 3000 UNIT/ML,4000 UNIT/ML, 10000UNIT/ML

$0(Tier

2)

PA

EPOGEN SOLN 20000UNIT/ML

$0(Tier

2)

PA; NDS

Name of drug

Whatthe


level)


GRANIX SOSY$0

(Tier2)

PA; NDS

LEUKINE SOLR$0

(Tier2)

PA; NDS

MULPLETA TABS$0

(Tier2)

PA; NDS

NEULASTA ONPRO KITPSKT

$0(Tier

2)

PA; NDS

NEULASTA SOSY$0

(Tier2)

PA; NDS

NEUPOGEN SOLN$0

(Tier2)

PA; NDS

NEUPOGEN SOSY$0

(Tier2)

PA; NDS

NIVESTYM SOSY 300MCG/0.5ML, 480MCG/0.8ML

$0(Tier

2)

PA; NDS

PROCRIT SOLN 2000UNIT/ML, 3000 UNIT/ML,4000 UNIT/ML, 10000UNIT/ML

$0(Tier

2)

PA

PROCRIT SOLN 20000UNIT/ML, 40000 UNIT/ML

$0(Tier

2)

PA; NDS

PROMACTA PACK 12.5MG

$0(Tier

2)

PA; NDS;SL(12ea daily); LA

PROMACTA TABS 12.5MG

$0(Tier

2)


PROMACTA TABS 25 MG$0

(Tier2)




Name of drug

Whatthe


level)



(Tier2)



(Tier2)


RETACRIT SOLN 2000UNIT/ML, 3000 UNIT/ML,4000 UNIT/ML, 10000UNIT/ML, 40000 UNIT/ML

$0(Tier

2)

PA

ZARXIO SOSY$0

(Tier2)

PA; NDS

Hematopoietic Mixtures

ACTIVE FE TABS$0

(Tier3)

*;MO; NT

B COMPLEX/FOLIC ACIDTABS

$0(Tier

3)

NT

CENTRATEX CAPS$0

(Tier3)

MO; NT

CORVITE 150 TABS$0

(Tier3)

*;RX/OTC; MO;NT

CORVITE FE TABS$0

(Tier3)

*;RX/OTC; MO;NT

cyanocobalamin-methylcobalamin subl

$0(Tier

3)

NT

fe fum-iron polysacchcomplex-fa-b complex-c-zn-mn-cu caps

$0(Tier

3)

MO; NT

FEOSOL BIFERA TABS$0

(Tier3)

*;MO; NT

FERIVA 21/7 TABS$0

(Tier3)

*;MO; NT

Name of drug

Whatthe


level)


FERIVAFA CAPS$0

(Tier3)

*;MO; NT

FERRALET 90 TABS$0

(Tier3)

MO; NT

FERRAPLUS 90 TABS$0

(Tier3)

*;MO; NT

FERREX 150 FORTECAPS

$0(Tier

3)

*;MO; NT

ferrous fumarate-folic acidtabs

$0(Tier

3)

MO; NT

FOLGARD RX TABS (FolicAcid-Vitamin B6-VitaminB12)

$0(Tier

3)

MO; NT

folic acid-vitamin b6-vitaminb12 tabs

$0(Tier

3)

MO; NT

FOLITAB 500 TBCR$0

(Tier3)

*;MO; NT

FOLTRATE TABS$0

(Tier3)

RX/OTC; MO;NT

FUSION CAPS$0

(Tier3)

NT

FUSION PLUS CAPS$0

(Tier3)

*;MO; NT

HEMOCYTE PLUS CAPS$0

(Tier3)

MO; NT

ICAR-C TABS (Iron-Vitamin C)

$0(Tier

3)

*;MO; NT

INTEGRA CAPS$0

(Tier3)

MO; NT



Name of drug

Whatthe


level)


INTEGRA F CAPS$0

(Tier3)

MO; NT

INTEGRA PLUS CAPS$0

(Tier3)

MO; NT

iron polysaccharidecomplex-vit b12-folic acidcaps

$0(Tier

3)

*;MO; NT

iron polysaccharidecomplex-vit b12-folic acidcaps

$0(Tier

3)

MO; NT

iron-vitamin c tabs$0

(Tier3)

MO; NT

IROSPAN 24/6 MISC$0

(Tier3)

*;MO; NT

MTX SUPPORT TABS$0

(Tier3)

RX/OTC; MO;NT

NEPHRON FA TABS$0

(Tier3)

MO; NT

NEURIN-SL SUBL(Cyanocobalamin-Methylcobalamin)

$0(Tier

3)

NT

NOVAFERRUM 125 LIQD$0

(Tier3)

NT

PROFERRIN-FORTETABS

$0(Tier

3)

MO; NT

PROTECTIRON TABS$0

(Tier3)

NT

TANDEM CAPS$0

(Tier3)

MO; NT

Name of drug

Whatthe


level)


TANDEM PLUS CAPS (FeFum-Iron PolysacchComplex-FA-B Complex-C-Zn-Mn-Cu)

$0(Tier

3)

MO; NT

TARON FORTE CAPS$0

(Tier3)

*;MO; NT

Iron

carbonyl iron susp$0

(Tier3)

*;MO; NT

EZFE 200 CAPS$0

(Tier3)

MO; NT

FEOSOL TABS (FerrousSulfate Dried)

$0(Tier

3)

*;MO; NT

FER-IN-SOL SOLN(Ferrous Sulfate)

$0(Tier

3)

*;MO; NT

FERRETTS IPS SOLN$0

(Tier3)

NT

FERRETTS TABS$0

(Tier3)

MO; NT

FERRIMIN 150 TABS$0

(Tier3)

*;NT

ferrous fumarate tabs$0

(Tier3)

MO; NT

ferrous gluconate tabs 27mg, 240 mg, 324 mg

$0(Tier

3)

MO; NT

FERROUS GLUCONATETABS 324 MG

$0(Tier

3)

MO; NT

ferrous sulfate dried tabs$0

(Tier3)

MO; NT



Name of drug

Whatthe


level)


ferrous sulfate dried tbcr$0

(Tier3)

MO; NT

ferrous sulfate elix 220mg/5ml

$0(Tier

3)

MO; NT

FERROUS SULFATE LIQD220 MG/5ML

$0(Tier

3)

NT

ferrous sulfate soln 15mg/ml

$0(Tier

3)

MO; NT

FERROUS SULFATESYRP 300 MG/5ML

$0(Tier

3)

NT

ferrous sulfate tabs 27 mg$0

(Tier3)

NT

ferrous sulfate tabs 65 mg,325 mg

$0(Tier

3)

MO; NT

FERROUS SULFATETBCR 140 MG

$0(Tier

3)

MO; NT

ferrous sulfate tbcr 142 mg$0

(Tier3)

*;MO; NT

ferrous sulfate tbcr 143 mg,47.5 mg

$0(Tier

3)

NT

ferrous sulfate tbcr 45 mg,142 mg

$0(Tier

3)

MO; NT

FERROUS SULFATETBEC 324 MG

$0(Tier

3)

MO; NT

ferrous sulfate tbec 325 mg$0

(Tier3)

NT

HEMOCYTE TABS(Ferrous Fumarate)

$0(Tier

3)

*;MO; NT

Name of drug

Whatthe


level)


ICAR PEDIATRIC SUSP(Carbonyl Iron)

$0(Tier

3)

*;MO; NT

INFED SOLN$0

(Tier3)

MO; NT

IRON SLOW RELEASETBCR

$0(Tier

3)

MO; NT

IRON TABS 256 MG$0

(Tier3)

NT

IRON TBCR 140 MG$0

(Tier3)

MO; NT

NOVAFERRUM 50 CAPS$0

(Tier3)

NT

NOVAFERRUMPEDIATRIC DROPS LIQD

$0(Tier

3)

MO; NT

polysaccharide ironcomplex caps

$0(Tier

3)

MO; NT

polysaccharide ironcomplex caps

$0(Tier

3)

*;MO; NT

PROFE CAPS$0

(Tier3)

MO; NT

PROFERRIN ES TABS$0

(Tier3)

MO; NT

SM SLOW RELEASEIRON TBCR

$0(Tier

3)

NT

Stem Cell Mobilizers

MOZOBIL SOLN$0

(Tier2)

PA; NDS

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood Disorders



Name of drug

Whatthe


level)


Hemostatics - Systemic

aminocaproic acid soln or0.25 gm/ml

$0(Tier

1)

NDS;MO

aminocaproic acid tabs or500 mg

$0(Tier

1)

MO

tranexamic acid soln iv1000 mg/10ml

$0(Tier

1)

tranexamic acid tabs or650 mg

$0(Tier

1)

MO

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTSAntihistamine Hypnotics

diphenhydramine hcl(sleep) tabs

$0(Tier

3)

NT

diphenhydramine-acetaminophen (sleep)tabs

$0(Tier

3)

MO; NT

Barbiturate Hypnotics

BUTISOL SODIUM TABS$0

(Tier2)


phenobarbital elix$0

(Tier1)


phenobarbital soln$0

(Tier1)


phenobarbital tabs$0

(Tier1)


Hypnotics - Tricyclic Agents

SILENOR TABS 3 MG$0

(Tier2)

QL(2 ea daily);MO

Name of drug

Whatthe


level)


SILENOR TABS 6 MG$0

(Tier2)

QL(1 ea daily);MO

Non-Barbiturate Hypnotics

temazepam caps$0

(Tier1)

MO

triazolam tabs$0

(Tier1)

MO

zaleplon caps$0

(Tier1)


zolpidem tartrate tabs or 10mg

$0(Tier

1)


zolpidem tartrate tabs or 5mg

$0(Tier

1)


zolpidem tartrate tbcr or12.5 mg

$0(Tier

1)


zolpidem tartrate tbcr or6.25 mg

$0(Tier

1)


Orexin Receptor Antagonists

BELSOMRA TABS 10 MG$0

(Tier2)



(Tier2)

PA; SL(1.33 eadaily); MO


(Tier2)



(Tier2)


Selective Melatonin Receptor Agonists



Name of drug

Whatthe


level)


HETLIOZ CAPS$0

(Tier2)

PA; NDS;MO

ramelteon tabs$0

(Tier1)

MO

LAXATIVES - Bowel Treatment Drugs

Bulk Laxatives

calcium polycarbophil tabs$0

(Tier3)

MO; NT

psyllium caps$0

(Tier3)

MO; NT

psyllium powd$0

(Tier3)

MO; NT

Laxative Combinationsbisacodyl-peg 3350-potchloride-sod bicarb-sodchloride kit

$0(Tier

1)peg 3350-kcl-sod bicarb-sod chloride-sod sulfatesolr

$0(Tier

1)

MO

peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr

$0(Tier

1)

MO

sennosides-docusatesodium tabs

$0(Tier

3)

MO; NT

SUPREP BOWEL PREPKIT SOLN

$0(Tier

2)

MO

Laxatives - Miscellaneous

lactulose soln 10 gm/15ml,20 gm/30ml

$0(Tier

1)

MO

polyethylene glycol 3350pack

$0(Tier

1)

RX/OTC; MO

Name of drug

Whatthe


level)


polyethylene glycol 3350pack

$0(Tier

3)


polyethylene glycol 3350powd

$0(Tier

3)


polyethylene glycol 3350powd

$0(Tier

1)

RX/OTC; MO

Saline Laxatives

FLEET PEDIATRIC ENEM(Sodium Phosphates)

$0(Tier

3)

NT

magnesium hydroxide susp7.75 %, 400 mg/5ml, 2400mg/10ml

$0(Tier

3)

MO; NT

magnesium oxide (laxative)tabs

$0(Tier

3)

NT

PHILLIPS TABS(Magnesium Oxide(Laxative))

$0(Tier

3)

NT

sodium phosphates enem19gm/118ml-7gm/118ml

$0(Tier

3)

MO; NT

Stimulant Laxatives

bisacodyl supp re 10 mg$0

(Tier3)

MO; NT

bisacodyl tbec or 5 mg$0

(Tier3)

MO; NT

sennosides tabs$0

(Tier3)

MO; NT

Surfactant Laxatives

docusate calcium caps$0

(Tier3)

MO; NT



Name of drug

Whatthe


level)


docusate sodium caps or100 mg

$0(Tier

3)

MO; NT

docusate sodium enem re283 mg

$0(Tier

3)

MO; NT

docusate sodium tabs or100 mg

$0(Tier

3)

NT

DOCUSOL KIDS ENEM(Docusate Sodium)

$0(Tier

3)

NT

DOCUSOL PLUS MINI-ENEMA ENEM

$0(Tier

3)

MO; NT

ENEMEEZ PLUS ENEM$0

(Tier3)

MO; NT

LOCAL ANESTHETICS-Parenteral - Drugs forNumbingLocal Anesthetics - Amides

lidocaine hcl (local anesth.)soln

$0(Tier

1)

MACROLIDES - Drugs to Treat BacterialInfectionsAzithromycin

azithromycin solr iv 500 mg$0

(Tier1)

MO

azithromycin susr or 100mg/5ml

$0(Tier

1)

QL(3 ml daily);MO

azithromycin susr or 200mg/5ml

$0(Tier

1)

QL(4.5 mldaily); MO

azithromycin tabs or 250mg

$0(Tier

1)

QL(1.2 eadaily); MO

Name of drug

Whatthe


level)



$0(Tier

1)

QL(1 ea daily);MO


$0(Tier

1)


Clarithromycin

clarithromycin susr 250mg/5ml

$0(Tier

1)

MO

clarithromycin tabs 250 mg,500 mg

$0(Tier

1)

MO

clarithromycin tb24 500 mg$0

(Tier1)

MO

Erythromycins

erythromycin base tabs 250mg

$0(Tier

1)

SL(16 ea daily);MO

erythromycin base tabs 500mg

$0(Tier

1)

SL(8 ea daily);MO

erythromycinethylsuccinate tabs 400 mg

$0(Tier

1)

SL(10 ea daily);MO

erythromycin lactobionatesolr

$0(Tier

1)

SL(8 ea daily)

Fidaxomicin

DIFICID TABS$0

(Tier2)

NDS;MO

MEDICAL DEVICES AND SUPPLIES

Bandages-Dressings-Tape

gauze pads 2"x2"$0

(Tier1)

RX/OTC; MO

Misc. Devices



Name of drug

Whatthe


level)


ALCOHOL PADS$0

(Tier2)

RX/OTC; MO

Parenteral Therapy SuppliesBD ECLIPSESYRINGE/1ML/30GX1/2"MISC

$0(Tier

3)

MO; NT

BD SAFETYGLIDE 27G X5/8" MISC

$0(Tier

3)

MO; NT

INSULIN SYRINGES ANDPEN NEEDLES

$0(Tier

2)

RX/OTC; MO

Respiratory Aids

PEDIATRIC MEDIUMMASK MISC

$0(Tier

3)

RX/OTC; MO;NT

PEDIATRIC SMALL MASKMISC

$0(Tier

3)

RX/OTC; MO;NT

Respiratory Therapy SuppliesAEROCHAMBER MINIAEROSOLCHAMBERDEVI

$0(Tier

3)

RX/OTC; MO;NT

AEROCHAMBER MVMISC

$0(Tier

3)

RX/OTC; MO;NT

AEROCHAMBER PLUSFLOW VU MISC

$0(Tier

3)

RX/OTC; MO;NT

AEROCHAMBER PLUSFLOW-VU MISC

$0(Tier

3)

RX/OTC; MO;NT

AEROCHAMBER PLUSFLOW-VU/LARGE MASKMISC

$0(Tier

3)

RX/OTC; MO;NT

AEROCHAMBER PLUSFLOW-VU/MASK MISC

$0(Tier

3)

RX/OTC; MO;NT

Name of drug

Whatthe


level)


AEROCHAMBER PLUSFLOW-VU/MEDIUM MASKMISC

$0(Tier

3)

RX/OTC; MO;NT

AEROCHAMBER PLUSFLOW-VU/SMALL MASKMISC

$0(Tier

3)

RX/OTC; MO;NT

AEROCHAMBER Z-STATPLUS VALVED HOLDINGCHAMBER W/FLOW VUMISC

$0(Tier

3)

RX/OTC; MO;NT

AEROCHAMBER Z-STATPLUS/FLOWSIGNAL MISC

$0(Tier

3)

RX/OTC; MO;NT

AEROCHAMBER Z-STATPLUS/LARGE MASK MISC

$0(Tier

3)

RX/OTC; MO;NT

AEROCHAMBER Z-STATPLUS/MEDIUM MASKMISC

$0(Tier

3)

RX/OTC; MO;NT

AEROCHAMBER Z-STATPLUS/SMALL MASK MISC

$0(Tier

3)

RX/OTC; MO;NT

AEROCHAMBER/FLOWSIGNAL MISC

$0(Tier

3)

RX/OTC; MO;NT

AEROVENT PLUSHOLDINGCHAMBER/COLLAPSIBLEDEVI

$0(Tier

3)

RX/OTC; MO;NT

BREATHERITECOLLAPSIBLEADULTSPACER W/MASK MISC

$0(Tier

3)

RX/OTC; MO;NT

BREATHERITECOLLAPSIBLECHILDSPACER W/MASK MISC

$0(Tier

3)

RX/OTC; MO;NT

BREATHERITECOLLAPSIBLEINFANTSPACER W/MASK MISC

$0(Tier

3)

RX/OTC; MO;NT

BREATHERITECOLLAPSIBLESMALLCHILD SPACER W/MASKMISC

$0(Tier

3)

RX/OTC; MO;NT



Name of drug

Whatthe


level)


BREATHERITECOLLAPSIBLESPACERW/ NEONATE MASK MISC

$0(Tier

3)

RX/OTC; MO;NT

BREATHERITE MISC$0

(Tier3)

RX/OTC; MO;NT

BREATHERITE RIGIDSPACERW/MASK MISC

$0(Tier

3)

RX/OTC; MO;NT

BREATHERITE VALVEDMDICHAMBER/COLLAPSIBLEDEVI

$0(Tier

3)

RX/OTC; MO;NT

BREATHERITE VALVEDMDI CHAMBER/RIGIDDEVI

$0(Tier

3)

RX/OTC; MO;NT

CLEVER CHOICE ANTI-STATICVALVEDHOLDINGCHAMBER/ADULT LARGEDEVI

$0(Tier

3)

RX/OTC; MO;NT

CLEVER CHOICE ANTI-STATICVALVEDHOLDINGCHAMBER/MEDIUM DEVI

$0(Tier

3)

RX/OTC; MO;NT

CLEVER CHOICE ANTI-STATICVALVEDHOLDINGCHAMBER/SMALL DEVI

$0(Tier

3)

RX/OTC; MO;NT

COMPACT SPACECHAMBER/ANTI-STATICDEVI

$0(Tier

3)

RX/OTC; MO;NT

COMPACT SPACECHAMBER/ANTI-STATIC/LARGE MASKDEVI

$0(Tier

3)

RX/OTC; MO;NT

COMPACT SPACECHAMBER/ANTI-STATIC/MEDIUM MASKDEVI

$0(Tier

3)

RX/OTC; MO;NT

Name of drug

Whatthe


level)


COMPACT SPACECHAMBER/ANTI-STATIC/SMALL MASKDEVI

$0(Tier

3)

RX/OTC; MO;NT

EASIVENT MISC$0

(Tier3)

RX/OTC; MO;NT

EASIVENT/MASK-LARGEMISC

$0(Tier

3)

RX/OTC; MO;NT

EASIVENT/MASK-MEDIUM MISC

$0(Tier

3)

RX/OTC; MO;NT

EASIVENT/MASK-SMALLMISC

$0(Tier

3)

RX/OTC; MO;NT

FLEXICHAMBER ADULTMASK/SMALL MISC

$0(Tier

3)

RX/OTC; NT

FLEXICHAMBER CHILDMASK/LARGE MISC

$0(Tier

3)

RX/OTC; NT

FLEXICHAMBER CHILDMASK/SMALL MISC

$0(Tier

3)

RX/OTC; NT

FLEXICHAMBER DEVI$0

(Tier3)

RX/OTC; MO;NT

INSPIRACHAMBER/ANTI-STATICVALVED/MOUTHPIECEDEVI

$0(Tier

3)

RX/OTC; MO;NT

INSPIRACHAMBER/LARGE DEVI

$0(Tier

3)

RX/OTC; MO;NT

INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/MEDIUM DEVI

$0(Tier

3)

RX/OTC; MO;NT

INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/SMALL DEVI

$0(Tier

3)

RX/OTC; MO;NT



Name of drug

Whatthe


level)


LITEAIRE DEVI$0

(Tier3)

RX/OTC; MO;NT

MICROCHAMBER MISC$0

(Tier3)

RX/OTC; MO;NT

MICROSPACER MISC$0

(Tier3)

RX/OTC; MO;NT

ONE-WAY VALVEDEXPIRATORYMOUTHPIECE/DISPOSABLE MISC

$0(Tier

3)

RX/OTC; NT

ONE-WAY VALVEDINSPIRATORYMOUTHPIECE/DISPOSABLE MISC

$0(Tier

3)

RX/OTC; NT

OPTICHAMBERDIAMOND MISC

$0(Tier

3)

RX/OTC; MO;NT

OPTICHAMBERDIAMOND/LARGEFACEMASK DEVI

$0(Tier

3)

RX/OTC; MO;NT

OPTICHAMBERDIAMOND/MEDIUM FACEMASK MISC

$0(Tier

3)

RX/OTC; MO;NT

OPTICHAMBERDIAMOND/SMALLFACEMASK MISC

$0(Tier

3)

RX/OTC; MO;NT

PANDA MASK LARGEMISC

$0(Tier

3)

RX/OTC; NT

PANDA MASK MEDIUMMISC

$0(Tier

3)

RX/OTC; NT

PANDA MASK SMALLMISC

$0(Tier

3)

RX/OTC; NT

PEDIATRIC PANDA MASKMISC

$0(Tier

3)

RX/OTC; NT

Name of drug

Whatthe


level)


POCKET CHAMBER DEVI$0

(Tier3)

RX/OTC; MO;NT

PRIMEAIRE DUAL-VALVED HOLDINGCHAMBER DEVI

$0(Tier

3)

RX/OTC; MO;NT

RITEFLO DEVI$0

(Tier3)

RX/OTC; MO;NT

VALVED HOLDINGCHAMBER DEVI

$0(Tier

3)

RX/OTC; MO;NT

VORTEX HOLDINGCHAMBER/MASK/CHILDSDEVI

$0(Tier

3)

RX/OTC; MO;NT

VORTEX HOLDINGCHAMBER/MASK/CHILDS/FROG DEVI

$0(Tier

3)

RX/OTC; MO;NT

VORTEX HOLDINGCHAMBER/MASK/TODDLER DEVI

$0(Tier

3)

RX/OTC; MO;NT

VORTEX HOLDINGCHAMBER/MASK/TODDLER/LADY BUG DEVI

$0(Tier

3)

RX/OTC; MO;NT

VORTEX VALVEDHOLDING CHAMBERDEVI

$0(Tier

3)

RX/OTC; MO;NT

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadachesMigraine Combinations

ergotamine w/ caffeinesupp re 2mg-100mg

$0(Tier

1)

MO

sumatriptan-naproxensodium tabs

$0(Tier

1)

MO

TREXIMET TABS 10MG-60MG

$0(Tier

2)

Migraine Products - Monoclonal Antibodies



Name of drug

Whatthe


level)


AIMOVIG SOAJ$0

(Tier2)

PA; MO

AJOVY SOSY$0

(Tier2)

PA; MO

EMGALITY SOAJ 120MG/ML

$0(Tier

2)

PA; MO

EMGALITY SOSY 100MG/ML

$0(Tier

2)

PA; NDS

EMGALITY SOSY 120MG/ML

$0(Tier

2)

PA; MO

Migraine Products

dihydroergotaminemesylate soln ij 1 mg/ml

$0(Tier

1)

MO

dihydroergotaminemesylate soln na 4 mg/ml

$0(Tier

2)

NDS;MO

ergotamine tartrate subl$0

(Tier1)

MIGRANAL SOLN$0

(Tier2)

NDS;MO

Serotonin Agonists

almotriptan malate tabs$0

(Tier1)

MO

naratriptan hcl tabs$0

(Tier1)

QL(0.3 eadaily); MO

rizatriptan benzoate tabs$0

(Tier1)

QL(0.4 eadaily); MO

rizatriptan benzoate tbdp$0

(Tier1)

QL(0.4 eadaily); MO

Name of drug

Whatthe


level)


sumatriptan succinate soajsc 4 mg/0.5ml, 6 mg/0.5ml

$0(Tier

1)


sumatriptan succinate soctsc 4 mg/0.5ml, 6 mg/0.5ml

$0(Tier

1)


sumatriptan succinate solnsc 6 mg/0.5ml

$0(Tier

1)


sumatriptan succinate tabsor 25 mg, 50 mg, 100 mg

$0(Tier

1)

QL(0.3 eadaily); MO

zolmitriptan tabs 2.5 mg$0

(Tier1)

SL(4 ea daily);MO

zolmitriptan tabs 5 mg$0

(Tier1)

SL(2 ea daily);MO

zolmitriptan tbdp 2.5 mg$0

(Tier1)

SL(4 ea daily);MO

zolmitriptan tbdp 5 mg$0

(Tier1)

SL(2 ea daily);MO

MINERALS & ELECTROLYTES

Calcium

CALCET PETITES TABS$0

(Tier3)

MO; NT

CALCI-CHEW CHEW$0

(Tier3)

NT

CALCIUM CARBONATECHEW 500 MG

$0(Tier

3)

NT

calcium carbonate tabs1250 mg

$0(Tier

3)

NT

calcium carbonate tabs 600mg, 1500 mg

$0(Tier

3)

MO; NT



Name of drug

Whatthe


level)


calcium carbonate-cholecalciferol chew500mg-400unit

$0(Tier

3)

MO; NT

calcium carbonate-cholecalciferol tabs 500mg-5mcg, 250mg-125unit,500mg-200unit, 500mg-400unit, 600mg-200unit,600mg-400unit, 600mg-800unit, 600mg-600mg-800unit-400unit

$0(Tier

3)

MO; NT

calcium carbonate-cholecalciferol tabs 500mg-600unit

$0(Tier

3)

NT

calcium carbonate-vitamind chew 600mg-400unit

$0(Tier

3)

NT

calcium carbonate-vitamind tabs 125unit-250mg,400unit-600mg, 500mg-125unit, 500mg-400unit,600mg-400unit

$0(Tier

3)

NT

calcium carbonate-vitamind tabs 200unit-500mg,200unit-600mg, 500mg-200unit, 600mg-200unit

$0(Tier

3)

MO; NT

calcium carbonate-vitamind w/ minerals chew 1.8mg-250mcg-1mg-7.5mg-50mg-600mg-400unit, 1.8mg-40mg-250mcg-1mg-7.5mg-600mg-800unit, 1.8mg-50mg-250mcg-1mg-7.5mg-600mg-800unit

$0(Tier

3)

NT

calcium carbonate-vitamind w/ minerals tabs 1.8mg-1mg-250mcg-7.5mg-50mg-600mg-400unit, 1.8mg-1mg-50mg-250mcg-7.5mg-600mg-400unit, 1.8mg-250mcg-1mg-7.5mg-40mg-600mg-200unit, 1.8mg-50mg-250mcg-1mg-7.5mg-600mg-400unit

$0(Tier

3)

NT

Name of drug

Whatthe


level)


CALCIUM CHEW 500 MG$0

(Tier3)

NT

CALCIUM CITRATEMALATE/VITAMIN D TABS

$0(Tier

3)

NT

calcium citrate tabs$0

(Tier3)

MO; NT

CALCIUM CITRATE W/DTABS

$0(Tier

3)

NT

calcium citrate-vitamin dtabs

$0(Tier

3)

MO; NT

CALCIUM GLUCONATETABS OR 500 MG

$0(Tier

3)

NT

calcium tabs 600mg$0

(Tier3)

NT

calcium w/ vitamins d & kchew

$0(Tier

3)

NT

CALCIUM-FOLIC ACIDPLUS D WAFR

$0(Tier

3)

MO; NT

calcium-magnesium-zinctabs 333mg-5mg-133mg,5mg-133mg-333mg, 5mg-133.333mg-333.333mg

$0(Tier

3)

NT

CALCIUM/C/D CHEW$0

(Tier3)

NT

CALCIUM/VITAMIN DCAPS

$0(Tier

3)

NT

CALTRATE 600+D PLUSMINERALS TABS (CalciumCarbonate-Vitamin D w/Minerals)

$0(Tier

3)

MO; NT



Name of drug

Whatthe


level)


CALTRATE 600+D3 SOFTCHEWS CHEW

$0(Tier

3)

MO; NT

CALTRATE 600+D3 TABS(Calcium Carbonate-Cholecalciferol)

$0(Tier

3)

MO; NT

CITRACAL + D3MAXIMUM TABS (CalciumCitrate-Vitamin D)

$0(Tier

3)

MO; NT

CITRACAL MAXIMUMTABS (Calcium Citrate-Vitamin D)

$0(Tier

3)

MO; NT

CORAL CALCIUM CAPS$0

(Tier3)

NT

OSTEO-PORETICALTABS

$0(Tier

3)

NT

OYSTER SHELLCALCIUM/MAGNESIUMTABS

$0(Tier

3)

NT

oyster shell tabs$0

(Tier3)

MO; NT

RA CALCIUM/BORONTABS

$0(Tier

3)

NT

RA OYSTER SHELLCALCIUM/VITAMIN DTABS

$0(Tier

3)

NT

RISACAL-D TABS$0

(Tier3)

NT

Electrolyte Mixtures

dextrose in lactated ringerssoln

$0(Tier

1)dextrose w/ sodiumchloride soln 0.45%-2.5%,0.33%-5%, 0.45%-5%,0.2%-5%

$0(Tier

1)

Name of drug

Whatthe


level)


dextrose w/ sodiumchloride soln 0.9%-5%

$0(Tier

1)

MO

ENFAMIL ENFALYTESOLN 25MEQ/L-50MEQ/L-45MEQ/L-33MEQ/L

$0(Tier

3)

MO; NT

lactated ringer's soln28meq/l-4meq/l-130meq/l-109meq/l-3meq/l,20mg/100ml-600mg/100ml-30mg/100ml-310mg/100ml

$0(Tier

1)

oral electrolytes soln20meq/l-45meq/l-35meq/l-25gm/l, 35meq/l-45meq/l-20meq/l-25gm/l, 20meq/l-45meq/l-35meq/l-5gm/l-20gm/l, 20meq/l-45meq/l-35meq/l-7.8mg/l-25gm,20meq/l-45meq/l-35meq/l-30meq/l-25gm/l, 20meq/l-45meq/l-35meq/l-7.8mg/l-25gm/l, 35meq/l-45meq/l-20meq/l-30meq/l-25gm/l,35meq/l-45meq/l-20meq/l-30meq/l-30gm/l, 35meq/l-45meq/l-20meq/l-7.8mg/l-25gm/l, 35meq/l-7.8mg/l-45meq/l-20meq/l-25gm/l,20meq/l-45meq/l-35meq/l-7.8mg/l-25meq/l, 20meq/l-45meq/l-35meq/l-30meq/l-5gm/l-20gm/l, 20meq/l-45meq/l-35meq/l-30meq/l-5gm/l-25gm/l, 35meq/l-45meq/l-20meq/l-30meq/l-5gm/l-20gm/l, 20meq/l-45meq/l-35meq/l-7.8mg/l-30meq/l-16gm/l,20meq/1000ml-45meq/1000ml-35meq/1000ml-25gm/1000ml

$0(Tier

3)

MO; NT



Name of drug

Whatthe


level)


parenteral electrolytes soln20meq/20ml-5meq/20ml-35meq/20ml-35meq/20ml-4.5meq/20ml-29.5meq/20ml

$0(Tier

1)

B/D

PEDIALYTE ADVANCEDCARE SOLN (OralElectrolytes)

$0(Tier

3)

MO; NT

PEDIALYTE FREEZERPOPS SOLN (OralElectrolytes)

$0(Tier

3)

MO; NT

PEDIALYTE SINGLESSOLN (Oral Electrolytes)

$0(Tier

3)

MO; NT

PEDIALYTE SOLN (OralElectrolytes)

$0(Tier

3)

MO; NT

potassium chloride indextrose & sodium chloridesoln 0.45%-20meq/l-5%

$0(Tier

1)

Fluoride

MONOCAL TABS$0

(Tier3)

MO; NT

Magnesium

MAG-TAB SR TBCR(Magnesium Lactate)

$0(Tier

3)

MO; NT

MAGNESIUMELEMENTAL CAPS

$0(Tier

3)

NT

MAGNESIUMELEMENTAL TABS

$0(Tier

3)

NT

magnesium lactate tbcr$0

(Tier3)

MO; NT

magnesium oxide (mgsupplement) caps 500 mg

$0(Tier

3)

NT

Name of drug

Whatthe


level)


magnesium oxide (mgsupplement) tabs 250 mg,500 mg

$0(Tier

3)

MO; NT

MAGNESIUM OXIDETABS 420 MG

$0(Tier

3)

NT

magnesium sulfate soln ij50 %

$0(Tier

1)

magnesium tabs 250mg,250 mg

$0(Tier

3)

NT

NU-MAG TBEC$0

(Tier3)

MO; NT

SLOW-MAG TBEC$0

(Tier3)

MO; NT

Mineral Combinations

CAL-MAG-ZINC-D TABS$0

(Tier3)

MO; NT

multiple minerals tabs$0

(Tier3)

NT

multiple minerals w/vitamins tabs

$0(Tier

3)

MO; NT

Phosphatesodium phosphates(sodium phosphate dibasic& monobasic) soln

$0(Tier

1)

Potassium

K-TAB TBCR 8 MEQ, 20MEQ

$0(Tier

2)

MO

potassium chloride cpcr or8 meq, 10 meq

$0(Tier

1)

MO



Name of drug

Whatthe


level)


POTASSIUM CHLORIDEER TBCR

$0(Tier

2)

MO

potassium chloridemicroencapsulated crystalser tbcr

$0(Tier

1)

MO

potassium chloride soln iv2 meq/ml

$0(Tier

1)

MO

potassium chloride soln or10 %, 20 %

$0(Tier

1)

MO

potassium chloride tbcr or8 meq, 10 meq

$0(Tier

1)

MO

Sodium

sodium chloride soln ij 0.9%

$0(Tier

3)

MO; NT

sodium chloride soln iv0.45 %

$0(Tier

1)

sodium chloride soln iv 0.9%, 3 %, 5 %

$0(Tier

1)

MO

Trace Minerals

selenium tabs 200 mcg$0

(Tier3)

NT

selenium tabs 50 mcg$0

(Tier3)

MO; NT

Zinc

GALZIN CAPS$0

(Tier3)

MO; NT

ORAZINC TABS$0

(Tier3)

MO; NT

Name of drug

Whatthe


level)


ZINC 15 TABS$0

(Tier3)

NT

zinc gluconate tabs 30 mg,100 mg

$0(Tier

3)

NT

zinc gluconate tabs 50 mg$0

(Tier3)

MO; NT

ZINC LOZG MT 10 MG$0

(Tier3)

NT

zinc sulfate caps 220 mg$0

(Tier3)

MO; NT

ZINC SULFATE CAPS 50MG

$0(Tier

3)

MO; NT

zinc sulfate tabs 220 mg$0

(Tier3)

NT

zinc tabs or 50 mg$0

(Tier3)

MO; NT

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agents

DEPEN TITRATABS TABS$0

(Tier2)

MO

trientine hcl caps$0

(Tier1)

NDS;MO

Immunomodulators

REVLIMID CAPS$0

(Tier2)

PA; NDS;LA

THALOMID CAPS$0

(Tier2)

NDS

Immunosuppressive Agents



Name of drug

Whatthe


level)


ASTAGRAF XL CP24$0

(Tier2)

B/D; MO

AZATHIOPRINE SOLR IJ100 MG

$0(Tier

2)

B/D

azathioprine tabs or 50 mg,75 mg, 100 mg

$0(Tier

1)

B/D; MO

cyclosporine caps or 25mg, 100 mg

$0(Tier

1)

B/D; MO

cyclosporine modified (formicroemulsion) caps 25mg, 50 mg, 100 mg

$0(Tier

1)

B/D; MO

cyclosporine soln iv 50mg/ml

$0(Tier

1)

B/D

ENVARSUS XR TB24$0

(Tier2)

B/D; MO

mycophenolate mofetilcaps 250 mg

$0(Tier

1)

B/D; MO

mycophenolate mofetil hclsolr

$0(Tier

1)

B/D

mycophenolate mofetil susr200 mg/ml

$0(Tier

1)

B/D; NDS;MO

mycophenolate mofetil tabs500 mg

$0(Tier

1)

B/D; MO

mycophenolate sodiumtbec

$0(Tier

1)

B/D; MO

NULOJIX SOLR$0

(Tier2)

B/D; NDS

PROGRAF PACK OR 0.2MG

$0(Tier

2)

B/D; NDS;MO

Name of drug

Whatthe


level)


PROGRAF PACK OR 1MG

$0(Tier

2)

B/D; MO

PROGRAF SOLN IV 5MG/ML

$0(Tier

2)

B/D

SANDIMMUNE SOLN OR100 MG/ML

$0(Tier

2)

B/D; MO

SIMULECT SOLR$0

(Tier2)

B/D; NDS

sirolimus soln 1 mg/ml$0

(Tier1)

B/D; MO

sirolimus tabs 0.5 mg, 1 mg$0

(Tier1)

B/D; MO

sirolimus tabs 2 mg$0

(Tier1)

B/D; NDS;MO

tacrolimus caps$0

(Tier1)

B/D; MO

THYMOGLOBULIN SOLR$0

(Tier2)

B/D

ZORTRESS TABS 0.25MG

$0(Tier

2)

B/D; MO

ZORTRESS TABS 0.75MG, 0.5 MG, 1 MG

$0(Tier

2)

B/D; NDS;MO

Irrigation Solutions

irrigation solutions,physiological soln

$0(Tier

1)

water for irrigation, sterilesoln

$0(Tier

1)

MO

Potassium Removing Agents



Name of drug

Whatthe


level)


LOKELMA PACK$0

(Tier2)

ST; MO

sodium polystyrenesulfonate powd or

$0(Tier

1)

MO

sodium polystyrenesulfonate susp or 15gm/60ml

$0(Tier

1)

MO

VELTASSA PACK 16.8 GM$0

(Tier2)

ST; SL(1.5 eadaily); LA; MO


(Tier2)

ST; SL(1 eadaily); LA; MO


(Tier2)

ST; NDS;SL(3ea daily); LA;MO

Systemic Lupus Erythematosus Agents

BENLYSTA SOAJ$0

(Tier2)

PA; NDS

BENLYSTA SOLR$0

(Tier2)

PA; NDS

BENLYSTA SOSY$0

(Tier2)

PA; NDS

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical Oral

lidocaine hcl (mouth-throat)soln

$0(Tier

1)

MO

Anti-infectives - Throat

clotrimazole lozg$0

(Tier1)

MO

clotrimazole troc$0

(Tier1)

MO

Name of drug

Whatthe


level)


nystatin (mouth-throat)susp

$0(Tier

1)

MO

Antiseptics - Mouth/Throat

chlorhexidine gluconate(mouth-throat) soln

$0(Tier

1)

MO

Steroids - Mouth/Throat/Dental

triamcinolone acetonide(mouth) pste

$0(Tier

1)

MO

Throat Products - Misc.

cevimeline hcl caps$0

(Tier1)

MO

pilocarpine hcl (oral) tabs$0

(Tier1)

MO

MULTIVITAMINS

B-Complex Vitamins

APETEX ELIX$0

(Tier3)

NT

APETIGEN ELIX$0

(Tier3)

NT

b-complex vitamins caps$0

(Tier3)

MO; NT

b-complex vitamins tabs$0

(Tier3)

MO; NT

B-Complex w/ Cb complex w/ c caps 10mg-50mg-10mg-15mg-5mg-300mg, 10mg-50mg-10.2mg-15mg-5mg-300mg

$0(Tier

3)

NT



Name of drug

Whatthe


level)


b complex w/ c tabs 10mg-10mg-15mg-50mg-5mg-300mg, 15mg-10.2mg-10mg-50mg-5mg-300mg,50mg-10.2mg-10mg-15mg-5mg-300mg, 50mg-15mg-10mg-10.2mg-5mg-300mg,100mg-10mg-20mg-10mcg-15mg-5mg-500mg,15mg-150mg-10mg-50mg-10.2mg-5mg-300mg

$0(Tier

3)

MO; NT

b complex w/ c tbcr 15mg-10mg-50mg-10mg-5mg-300mg

$0(Tier

3)

NT

b-complex w/ c & calciumtabs

$0(Tier

3)

NT

b-complex w/ c & e + zntabs 23.9mg-3mg-30unit-100mg-10mg-20mg-12mcg-15mg-400mcg-45mg-5mg-600mg,23.9mg-3mg-30unit-100mg-10mg-20mg-12mcg-15mg-400mcg-45mcg-5mg-500mg,23.9mg-3mg-30unit-10mg-20mg-12mcg-5mg-100mg-15mg-400mcg-45mcg-500mg, 3mg-30unit-23.9mg-10mg-70mg-20mg-100mg-10mg-12mcg-400mcg-45mcg-5mg-500mg

$0(Tier

3)

MO; NT

B-Complex w/ Folic Acidb-complex w/ c & folic acidcaps 1.5mg-5mg-20mg-1.7mg-6mcg-1mg-150mcg-10mg-100mg, 5mg-1.7mg-6mcg-20mg-1.5mg-1mg-150mcg-10mg-100mg

$0(Tier

3)

RX/OTC; MO;NT

Name of drug

Whatthe


level)


b-complex w/ c & folic acidtabs 10mg-20mg-1.5mg-1mg-1.5mg-5mg-300mcg-50mg-60mg, 1.5mg-10mg-20mg-1.7mg-6mcg-800mcg-300mcg-10mg-60mg, 20mg-1.7mg-10mg-6mcg-1.5mg-800mcg-300mcg-10mg-60mg,1.7mg-10mg-0.006mg-10mg-20mg-1.5mg-0.8mg-0.3mg-60mg

$0(Tier

3)

MO; NT

b-complex w/ c & folic acidtabs 18mg-5mg-45mg-10mg-10mcg-400mcg-5mg-250mg, 15mg-50mg-10.2mg-10mg-400mcg-300mcg-5mg-300mg,1.5mg-10mg-20mg-1.7mg-6mcg-1mg-300mcg-10mg-60mg, 25mg-5mg-10mg-250mcg-5mg-400mcg-300mcg-5mg-120mg, 5mg-25mg-50mg-5mg-37.5mcg-200mcg-15mcg-5mg-150mg, 20mg-1.7mg-10mg-0.006mg-1.5mg-1mg-0.3mg-10mg-100mg

$0(Tier

3)

RX/OTC; MO;NT

b-complex w/ folic acidcaps 60mg-60mg-3mg-5mg-20mg-3mg-1mcg-400mcg-0.5mg

$0(Tier

3)

NT

b-complex w/ folic acid tabs1.5mg-20mg-1.7mg-6mcg-400mcg-2mg, 1.7mg-10mg-6mcg-1.2mg-20mg-0.4mg-2mg, 15mg-100mg-200mg-17mg-60mcg-400mcg-20mg, 50mg-50mg-50mg-50mcg-50mg-400mcg-50mcg-50mg,10mg-10mg-50mg-10mg-10mg-10mg-10mcg-10mg-400mcg-10mcg-10mg

$0(Tier

3)

MO; NT



Name of drug

Whatthe


level)


b-complex w/biotin & folicacid tabs

$0(Tier

3)

MO; NT

DIALYVITE 3000 TABS$0

(Tier3)

MO; NT

DIALYVITE 5000 TABS$0

(Tier3)

MO; NT

DIALYVITE 800/IRONTABS

$0(Tier

3)

NT

DIALYVITE/ZINC TABS$0

(Tier3)

MO; NT

FOLBEE PLUS CZ TABS$0

(Tier3)

MO; NT

FULL SPECTRUMB/VITAMIN C TABS

$0(Tier

3)

MO; NT

NEPHPLEX RX TABS$0

(Tier3)

MO; NT

NEPHRO-VITE RX TABS(B-Complex w/ C & FolicAcid)

$0(Tier

3)

RX/OTC; MO;NT

NEPHRO-VITE TABS (B-Complex w/ C & Folic Acid)

$0(Tier

3)

MO; NT

NEPHROCAPS CAPS (B-Complex w/ C & Folic Acid)

$0(Tier

3)

RX/OTC; MO;NT

NEPHRONEX LIQD$0

(Tier3)

NT

NUTRIVIT LIQD$0

(Tier3)

RX/OTC; NT

SM B-COMPLEX/VITAMINC TABS

$0(Tier

3)

RX/OTC; MO;NT

Name of drug

Whatthe


level)


SUPERVITE LIQD$0

(Tier3)

RX/OTC; NT

VITAL-D RX TABS$0

(Tier3)

MO; NT

WEST-VITE W/FOLICACID TABS

$0(Tier

3)

MO; NT

B-Complex w/ Iron

APETIGEN-PLUS SOLN$0

(Tier3)

NT

B-Complex w/ Minerals

APETIGEN-PLUS TABS$0

(Tier3)

NT

b-complex w/ minerals liqd150mg/15ml-33mcg/15ml-1mg/15ml-50mg/15ml-0.66mg/15ml-1mg/15ml-0.33mg/15ml

$0(Tier

3)

MO; NT

Bioflavonoid Products

bioflavonoid products tbcr$0

(Tier3)

NT

C1000/BIOFLAVONOIDS/ROSEHIPS CAPS

$0(Tier

3)

NT

PERIDIN-C TABS(Bioflavonoid Products)

$0(Tier

3)

RX/OTC; NT

VITAMIN C CHEW$0

(Tier3)

NT

Multiple Vitamins w/ Calcium

HM ONE DAILYESSENTIAL TABS

$0(Tier

3)

MO; NT



Name of drug

Whatthe


level)


multiple vitamins w/calcium tabs

$0(Tier

3)

MO; NT

ONE-A-DAY WOMENSFORMULA TABS (MultipleVitamins w/ Calcium)

$0(Tier

3)

MO; NT

Multiple Vitamins w/ Iron

multiple vitamins w/ irontabs

$0(Tier

3)

MO; NT

Multiple Vitamins w/ Minerals & Calcium-Folic

FOLGARD OS TABS$0

(Tier3)

MO; NT

Multiple Vitamins w/ Minerals

AQUADEKS CHEW$0

(Tier3)

MO; NT

BACMIN TABS$0

(Tier3)

RX/OTC; MO;NT

BIOCAL CAPS$0

(Tier3)

RX/OTC; MO;NT

BIOSUPP LIQD$0

(Tier3)

RX/OTC; MO;NT

BIOVOL SYRP$0

(Tier3)

NT

CENTRAVITES 50 PLUSTABS

$0(Tier

3)

RX/OTC; MO;NT

CENTRUM ADULTS TABS(Multiple Vitamins w/Minerals)

$0(Tier

3)

RX/OTC; MO;NT

CENTRUM LIQD (MultipleVitamins w/ Minerals)

$0(Tier

3)

RX/OTC; MO;NT

Name of drug

Whatthe


level)


CENTRUM SILVERADULT 50+ TABS (MultipleVitamins w/ Minerals)

$0(Tier

3)

RX/OTC; MO;NT

CENTRUM SILVER TABS(Multiple Vitamins w/Minerals)

$0(Tier

3)

RX/OTC; MO;NT

CENTRUM SILVERULTRA WOMENS TABS

$0(Tier

3)

RX/OTC; MO;NT

CENTRUM SPECIALISTHEART TABS

$0(Tier

3)

RX/OTC; MO;NT

CENTRUM ULTRA MENSTABS (Multiple Vitamins w/Minerals)

$0(Tier

3)

RX/OTC; MO;NT

CENTRUM ULTRAWOMENS TABS

$0(Tier

3)

RX/OTC; MO;NT

CERTAVITESENIOR/ANTIOXIDANTNUTRIENTS TABS

$0(Tier

3)

RX/OTC; MO;NT

CORVITA TABS$0

(Tier3)

MO; NT

CORVITE TABS$0

(Tier3)

MO; NT

CVS SPECTRAVITEADULT 50+ TABS

$0(Tier

3)

RX/OTC; MO;NT

CVS SPECTRAVITEULTRA MENS HEALTHTABS

$0(Tier

3)

RX/OTC; MO;NT

CVS SPECTRAVITEULTRA WOMEN TABS

$0(Tier

3)

RX/OTC; MO;NT

CVS SPECTRAVITEULTRA WOMENSHEALTH SENIOR TABS

$0(Tier

3)

RX/OTC; MO;NT

CVS SPECTRAVITEULTRA WOMENSHEALTH TABS

$0(Tier

3)

RX/OTC; MO;NT



Name of drug

Whatthe


level)


DEKAS PLUS CAPS75MCG-10MG-150UNIT-10MG-12MG-75MG-10MG-1000MCG-1.7MG-18167UNIT-12MCG-3000UNIT-1.5MG-200MCG-100MCG-1.9MG

$0(Tier

3)

RX/OTC; MO;NT

DIALYVITE SUPREME DTABS

$0(Tier

3)

MO; NT

EQ COMPLETEMULTIVITAMINADULTSUNDER 50 TABS

$0(Tier

3)

RX/OTC; MO;NT

EQ ONE DAILY WOMENSHEALTH TABS

$0(Tier

3)

RX/OTC; MO;NT

FORTAVIT CAPS$0

(Tier3)

RX/OTC; MO;NT

FOSFREE TABS (MultipleVitamins w/ Minerals)

$0(Tier

3)

RX/OTC; MO;NT

HM COMPLETE 50+WOMENS ULTIMATETABS

$0(Tier

3)

RX/OTC; MO;NT

HM COMPLETE MENTABS

$0(Tier

3)

RX/OTC; MO;NT

HM COMPLETE TABS$0

(Tier3)

RX/OTC; MO;NT

HM HAIR/SKIN/NAILSTABS 0.5MG-1MG-50MG-50MG-100MG-7.5MG-0.75MG-2500UNIT-250MCG-10MG-0.85MG-100UNIT-50MG-25MG-100MCG-30UNIT-1250MCG-50MG-60MG

$0(Tier

3)

RX/OTC; MO;NT

HM ONE DAILY WOMENSTABS

$0(Tier

3)

RX/OTC; MO;NT

Name of drug

Whatthe


level)


ICAPS AREDS FORMULATABS

$0(Tier

3)

RX/OTC; MO;NT

LIFE PACK MENS MISC$0

(Tier3)

NT

LIFE PACK WOMENSMISC

$0(Tier

3)

NT

MEGA MULTI FOR MENTABS

$0(Tier

3)

RX/OTC; MO;NT

MEGA MULTIVITAMINFOR WOMEN TABS

$0(Tier

3)

RX/OTC; MO;NT

MENS MULTI VITAMIN &MINERAL FORMULATABS

$0(Tier

3)

RX/OTC; MO;NT

MULTI-VITE LIQD$0

(Tier3)

RX/OTC; MO;NT

multiple vitamins w/minerals caps 25mg-100unit-45mg-500mg,50mcg-7.5mg-400unit-500mg, 70mg-4mg-80mg-50unit-10mg-10mg-25mg-5mg-8000unit-10mcg-1mg-2mg-150mg, 8000unit-70mg-4mg-80mg-50unit-10mg-10mg-25mg-5mg-10mcg-1mg-2mg-150mg,2.6mg-10mcg-100mg-150mcg-130mg-15mg-2mg-10mcg-37.5mg-10mcg-100mg-27mg-5000unit-30unit-400unit-1500unit-1.7mg-10mg-6mcg-1.5mg-20mg-0.4mg-30mcg-2mg-60mg

$0(Tier

3)

RX/OTC; MO;NT



Name of drug

Whatthe


level)


multiple vitamins w/minerals liqd1000mg/15ml-2mg/15ml-15mg/15ml-15mcg/15ml-10mg/15ml-50mg/15ml-15mg/15ml-50mg/15ml-5000unit/15ml-50mcg/15ml-50mg/15ml-800mcg/15ml-150mcg/15ml-50mg/15ml,1.7mg/15ml-25mcg/15ml-2mg/15ml-30unit/15ml-150mcg/15ml-25mcg/15ml-3mg/15ml-9mg/15ml-10mg/15ml-20mg/15ml-6mcg/15ml-1.5mg/15ml-300mcg/15ml-2mg/15ml-60mg/15ml, 250mcg/15ml-2mg/15ml-150mcg/15ml-25mcg/15ml-3mg/15ml-30unit/15ml-9mg/15ml-20mg/15ml-1.7mg/15ml-10mg/15ml-6mcg/15ml-400unit/15ml-1.5mg/15ml-300mcg/15ml-2mg/15ml-60mg/15ml, 25mcg/15ml-2mg/15ml-150mcg/15ml-25mcg/15ml-3mg/15ml-9mg/15ml-1.7mg/15ml-10mg/15ml-20mg/15ml-1300unit/15ml-6mcg/15ml-400unit/15ml-1.5mg/15ml-30unit/15ml-300mcg/15ml-2mg/15ml-60mg/15ml,2mg/15ml-30unit/15ml-150mcg/15ml-25mcg/15ml-25mcg/15ml-3mg/15ml-400unit/15ml-9mg/15ml-1.7mg/15ml-20mg/15ml-10mg/15ml-2500unit/15ml-6mcg/15ml-1.5mg/15ml-300mcg/15ml-2mg/15ml-60mg/15ml

$0(Tier

3)

RX/OTC; MO;NT

Name of drug

Whatthe


level)


multiple vitamins w/minerals tabs 0.5mg-0.37mg-1.5mg-80mg-15unit-75mcg-100mg-2.5mg-2.5mg-5000unit-15mg-2.5mg-5mg-1mcg-400unit-400mcg-1mg-60mg, 55mcg-60unit-1000unit-2mg-40mg-2mg-200mg, 22.5mg-27mg-45unit-400unit-2mg-5000unit-30mg-2.6mg-9mcg-0.4mg-20.6mg-90mg, 5000unit-450mg-15mg-27mg-30unit-1.5mg-1.7mg-10mg-6mcg-20mg-0.4mg-2mg-60mg-400unit,10unit-150mcg-125mg-1mg-5mg-400unit-5000unit-20mg-1.7mg-3mcg-1.5mg-100mcg-1mg-50mg, 5000unit-125mg-18mg-150mcg-160mg-100mg-15mg-400unit-1.7mg-6mcg-1.2mg-20mg-0.4mg-2mg-60mg, 30unit-450mg-15mg-27mg-2500unit-2500unit-20mg-1.7mg-10mg-6mcg-1.5mg-400mcg-2mg-60mg-400unit, 5mcg-5mcg-1mg-15.8mg-11.6mg-4.5mg-150mcg-3.75mg-10mg-1mg-5000unit-20mg-2.5mg-1mcg-400unit-2mg-1mg-50mg, 1mg-5mg-45mg-150mcg-60mg-15mg-2mg-16mg-1.5mg-5000unit-1.7mg-10mg-6mcg-400unit-20mg-400mcg-30unit-2mg-60mg,20mcg-5250unit-120mcg-2mg-2mg-15mg-1.5mg-450mg-27mg-10mg-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30unit-

$0(Tier

3)

RX/OTC; MO;NT



Name of drug

Whatthe


level)


30mcg-2mg-60mg, 1mg-150mcg-125unit-125mcg-35mg-35mg-10mg-25mg-125mcg-35mg-400mcg-35mg-3.4mg-5mg-70mcg-400unit-1.25mg-75mcg-35mg-500mg, 6.25mcg-72.5mg-50mg-30unit-100mg-2.5mg-0.5mg-7.5mg-0.75mg-2500unit-250mcg-10mg-0.85mg-500unit-50mg-100mcg-1500mcg-60mg, 20mcg-120mcg-2mg-2mg-30unit-15mg-50mg-1.5mg-450mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-1000unit-400mcg-30mcg-2mg-60mg, 20mcg-120mcg-2mg-2mg-30unit-50mg-15mg-1.5mg-450mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-1000unit-400mcg-30mcg-2mg-60mg, 20mcg-120mcg-2mg-2mg-22.5unit-15mg-50mg-1.5mg-500mg-18mg-5mg-2500unit-10mg-25mcg-1.7mg-6mcg-1000unit-400mcg-30mcg-2mg-60mg, 20mcg-120mcg-2mg-2mg-22.5unit-15mg-50mg-1.5mg-500mg-18mg-5mg-2500unit-25mcg-1.7mg-6mcg-1000unit-10mg-400mcg-30mcg-2mg-60mg, 20mcg-120mcg-2mg-2mg-30unit-300mg-50mg-15mg-2.3mg-18mg-10mg-2500unit-30mg-25mcg-2.6mg-9mcg-800unit-400mcg-300mcg-3mg-120mg, 20mcg-120mcg-2mg-2mg-22.5unit-150mcg-500mg-

Name of drug

Whatthe


level)


15mg-1.5mg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-1000unit-400mcg-300mcg-2mg-60mg, 10mg-70mcg-20mcg-120mcg-2mg-33unit-100mg-2mg-15mg-120mg-1.1mg-240mg-5mg-3000unit-14mg-1.7mg-18mcg-400unit-400mcg-30mcg-3mg-75mg,105mcg-120mcg-2mg-45unit-100mg-120mg-2mg-15mg-1.2mg-0.6mg-210mg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-400mcg-30mcg-3mg-90mg-400unit,110mcg-120mcg-2mg-22.5unit-100mg-2mg-15mg-120mg-1.2mg-300mcg-210mg-5mg-3500unit-16mg-20mcg-1.7mg-18mcg-700unit-400mcg-30mcg-3mg-60mg,20mcg-120mcg-150mcg-75mcg-10mcg-2mg-250mcg-2mg-15mg-100mg-5mg-100mg-10mg-20mg-100mg-5mg-3500unit-30mcg-400mcg-30unit-30mcg-5mg-100mg,8mg-30unit-10mcg-150mcg-40mg-15mg-2mg-15mcg-8mg-15mcg-2mg-60mg-9mg-10mg-5000unit-20mg-1.7mg-6mcg-400unit-1.5mg-400mcg-30mcg-2mg-90mg, 70mcg-120mcg-4mg-2mg-50unit-150mcg-75mcg-100mg-15mg-1.5mg-162mg-18mg-10mg-2500unit-20mg-80mcg-1.7mg-6mcg-1000unit-400mcg-30mg-2mg-180mg, 120mg-



Name of drug

Whatthe


level)


20mcg-100mcg-33unit-150mcg-90mcg-4mg-2mg-22.5mg-50mg-4.5mg-405mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-800unit-400mcg-30mcg-6mg-60mg, 120mg-20mcg-180mcg-4mg-2mg-33unit-150mcg-90mcg-22.5mg-50mg-4.5mg-405mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-800unit-400mcg-30mcg-6mg-60mg, 120mg-20mcg-2500unit-4mg-180mcg-2mg-33unit-150mcg-90mcg-22.5mg-50mg-4.5mg-405mg-15mg-20mg-20mcg-3.4mg-25mcg-800unit-400mcg-30mcg-6mg-60mg, 7.5mg-10mcg-15mcg-5mg-31mg-30unit-150mcg-15mcg-44mg-7.5mg-2mg-15mg-100mg-18mg-10mg-5500unit-30mg-3.4mg-9mcg-400unit-3mg-400mcg-15mcg-3mg-120mg, 34mg-10mcg-100mg-150mcg-130mg-15mg-2mg-10mcg-37.5mg-10mcg-2.5mg-100mg-18mg-30unit-400unit-5000unit-1.7mg-10mg-6mcg-1.5mg-20mg-400mcg-30mcg-2mg-60mg, 7.5mg-10mcg-31mg-150mcg-40mg-15mg-2mg-15mcg-7.5mg-15mcg-5mg-100mg-27mg-1250unit-30unit-400unit-5000unit-30mg-3.4mg-10mg-9mcg-3mg-0.4mg-35mcg-3mg-90mg, 120mg-105mcg-180mcg-4mg-2mg-33unit-150mcg-

Name of drug

Whatthe


level)


90mcg-40mg-22.5mg-100mg-4.5mg-600mcg-120mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-400unit-400mcg-30mcg-6mg-120mg,120mg-105mcg-4mg-180mcg-2mg-33unit-150mcg-90mcg-40mg-22.5mg-100mg-4.5mg-600mcg-120mg-15mg-2500unit-20mg-20mcg-3.4mg-25mcg-400unit-400mcg-30mcg-6mg-120mg, 100mcg-70mcg-150mcg-75mcg-10mcg-2mg-60unit-250mcg-2mg-15mg-100mg-10mg-100mg-18mg-10mg-25mg-100mg-100mcg-10mg-3000unit-25mcg-2000unit-400mcg-30mcg-6mg-100mg, 5mg-90mg-10mcg-45mcg-3500unit-2mg-10mcg-5mcg-30unit-150mcg-25mcg-2mg-100mcg-99mg-40mg-150mcg-15mg-3mg-250mg-9mg-10mg-40mg-25mcg-3.4mg-12mcg-400unit-400mcg-300mcg-4mg-60mg, 10mcg-0.5mg-35mg-107.5unit-37.5mcg-30mcg-18.75mcg-0.9mg-21.15mg-25mg-0.38mg-0.075mg-83.25mg-0.83mg-2.5mg-1.67mg-2.5mg-6.25mcg-2.5mg-1.5mcg-100unit-0.5mg-100mcg-7.5mcg-128mg, 32mcg-2mg-72mg-10mcg-18mcg-1.8mg-10mcg-5mcg-0.5mg-20mg-35unit-150mcg-50mcg-80mg-100mg-8mg-1.1mg-200mg-18mg-15mg-3500unit-



Name of drug

Whatthe


level)


14mg-50mcg-1.1mg-6mcg-800unit-400mcg-40mcg-2mg-75mg, 52mcg-2mg-72mg-10mcg-50mcg-22mcg-2.3mg-5mcg-0.5mg-20mg-150mcg-80mg-100mg-35unit-15mg-1.1mg-300mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 2mg-7.5mg-10mcg-70mcg-50mcg-2mg-10mcg-5mcg-31mg-60unit-150mcg-75mcg-7.5mg-40mg-150mcg-2mg-15mg-100mg-9mg-10mg-5000unit-20mg-28mcg-3.4mg-12mcg-400unit-3mg-400mcg-30mcg-6mg-90mg, 2mg-7.5mg-10mcg-70mcg-50mcg-2mg-10mcg-5mcg-40mg-31mg-60unit-150mcg-75mcg-7.5mg-150mcg-2mg-15mg-100mg-9mg-10mg-5000unit-20mg-28mcg-3.4mg-12mcg-400unit-3mg-400mcg-30mcg-6mg-90mg, 7.5mg-10mcg-70mcg-50mcg-2mg-10mcg-5mcg-2mg-31mg-60unit-150mcg-75mcg-40mg-2mg-7.5mg-100mg-150mcg-15mg-3mg-9mg-10mg-5000unit-20mg-28mcg-3.4mg-12mcg-400unit-400mcg-30mcg-6mg-90mg, 7.5mg-28mcg-5000unit-21mcg-31mg-150mcg-40mg-15mg-10mcg-2mg-26mcg-150mcg-10mcg-2mg-7.5mg-5mcg-32mcg-3.5mg-100mg-18mg-30unit-400unit-3.4mg-

Name of drug

Whatthe


level)


10mg-9mcg-3mg-20mg-3mg-400mcg-30mcg-90mg,35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-200mg-80mg-50mg-75mcg-11mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-80mg-200mg-50mg-75mcg-11mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,35mcg-2mg-72mg-10mcg-55mcg-75mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-200mg-80mg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,35mcg-2mg-72mg-10mcg-55mcg-75mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-80mg-200mg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,35mcg-2mg-72mg-10mcg-55mcg-75mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-80mg-200mg-50mg-11mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-



Name of drug

Whatthe


level)


400mcg-30mcg-2mg-60mg, 35mcg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-200mg-80mg-2mg-75mcg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 35mcg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-80mg-200mg-2mg-50mg-75mcg-11mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 45mcg-2mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-220mg-150mcg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 45mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.9mg-50unit-45mcg-150mcg-220mg-80mg-2mg-150mcg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-500mcg-30mcg-3mg-90mg, 25mcg-72mg-10mcg-55mcg-1.8mg-10mcg-5mcg-0.9mg-20mg-35unit-150mcg-50mcg-80mg-500mg-2mg-100mg-150mcg-8mg-1.1mg-18mg-15mg-3500unit-14mg-50mcg-1.1mg-6mcg-

Name of drug

Whatthe


level)


800unit-400mcg-40mcg-2mg-75mg, 72mg-25mcg-5000unit-20mcg-109mg-150mcg-162mg-15mg-10mcg-2mg-65mcg-150mcg-10mcg-2mg-80mg-5mcg-160mg-3.5mg-100mg-18mg-30unit-400unit-20mg-1.7mg-10mg-6mcg-2mg-1.5mg-400mcg-30mcg-60mg,2mg-72mg-10mcg-20mcg-3.5mg-65mcg-10mcg-5mcg-2mg-109mg-30unit-150mcg-160mcg-80mg-162mg-150mcg-15mg-100mg-1.5mg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg,50mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-35unit-150mcg-50mcg-500mg-150mcg-80mg-15mg-50mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 50mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-35unit-150mcg-50mcg-500mg-80mg-50mg-150mcg-15mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg,50mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-35unit-150mcg-50mcg-80mg-500mg-50mg-150mcg-15mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-



Name of drug

Whatthe


level)


50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 50mcg-2mg-72mg-10mcg-55mcg-3500unit-2.3mg-5mcg-0.5mg-20mg-8mg-150mcg-50mcg-500mg-80mg-150mcg-15mg-50mg-1.1mg-5mg-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-35unit-30mcg-5mg-100mg,50mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-35unit-150mcg-50mcg-80mg-500mg-2mg-50mg-150mcg-15mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 72mg-10mcg-20mcg-65mcg-3.5mg-10mcg-5mcg-2mg-109mg-30unit-150mcg-160mcg-162mg-2mg-80mg-150mcg-15mg-100mg-1.5mg-18mg-10mg-20mg-25mcg-1.7mg-2500unit-6mcg-400unit-400mcg-30mcg-2mg-50mg, 50mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.05mg-20mg-35unit-150mcg-50mcg-500mg-80mg-150mcg-15mg-50mg-1.1mg-8mg-5mg-3500unit-300mcg-14mg-50mcg-1.1mg-50mcg-800unit-400mcg-30mcg-5mg-100mg, 72mg-10mcg-3500unit-20mcg-48mg-150mcg-200mg-15mg-10mcg-2mg-150mcg-150mcg-2mg-80mg-5mcg-75mcg-2mg-

Name of drug

Whatthe


level)


100mg-45unit-400unit-300mcg-250mcg-1.7mg-10mg-25mcg-20mg-1.5mg-400mcg-30mcg-3mg-60mg,72mg-20mcg-3500unit-45unit-2mg-48mg-150mcg-75mcg-80mg-200mg-10mcg-2mg-150mcg-150mcg-2mg-5mcg-15mg-100mg-1.5mg-300mcg-10mg-250mcg-20mg-10mcg-1.7mg-25mcg-400unit-400mcg-30mcg-3mg-60mg, 45mg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-220mg-150mcg-80mg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg,2mg-7.5mg-10mcg-70mcg-120mcg-2mg-10mcg-5mcg-31mg-60unit-150mcg-75mcg-40mg-150mcg-7.5mg-2mg-15mg-100mg-9mg-10mg-5000unit-250mcg-20mg-28mcg-3.4mg-12mcg-400unit-3mg-400mcg-30mcg-6mg-90mg, 2mg-72mg-10mcg-55mcg-45mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-50mg-150mcg-11mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 35mcg-2mg-72mg-10mcg-55mcg-75mcg-2.3mg-10mcg-5mcg-0.5mg-20mg-30unit-150mcg-45mcg-200mg-



Name of drug

Whatthe


level)


80mg-15mg-11mg-50mg-1.5mg-18mg-10mg-3500unit-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-150mcg-45mcg-80mg-50mg-50unit-150mcg-11mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-220mg-150mcg-80mg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-220mg-80mg-150mcg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-220mg-150mcg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-

Name of drug

Whatthe


level)


50unit-150mcg-45mcg-80mg-220mg-50mg-150mcg-11mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg,45mcg-2mg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-50mg-150mcg-11mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 45mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-150mcg-45mcg-80mg-220mg-2mg-50mg-150mcg-11mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg,45mcg-72mg-10mcg-55mcg-2.3mg-5mcg-0.5mg-20mg-50unit-45mcg-100mcg-80mg-2mg-150mcg-11mg-50mg-1.5mg-300mcg-220mg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-400mcg-30mcg-3mg-60mg, 36mg-10mcg-25mcg-25mcg-120mcg-2mg-10mcg-5mcg-77mg-50unit-150mcg-25mcg-100mg-2mg-40mg-100mg-20mg-150mcg-2mg-15mg-1.5mg-9mg-10mg-3000unit-250mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-120mg, 45mcg-2mg-72mg-



Name of drug

Whatthe


level)


10mcg-55mcg-2.3mg-5mcg-0.9mg-110mg-50unit-150mcg-45mcg-220mg-150mcg-80mg-11mg-50mg-1.5mg-300mcg-10mg-2500unit-250mcg-20mg-30mcg-1.7mg-25mcg-500unit-500mcg-30mcg-3mg-90mg, 10mcg-20mcg-25mcg-120mcg-2mg-10mcg-5mcg-72mg-2mg-108mg-30unit-75mcg-150mcg-162mg-150mcg-2mg-80mg-15mg-100mg-1.5mg-18mg-10mg-5000unit-250mcg-20mg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 2mg-72mg-10mcg-20mcg-65mcg-3.5mg-10mcg-5mcg-109mg-30unit-150mcg-160mcg-162mg-80mg-150mcg-2mg-15mg-100mg-1.5mg-600mcg-18mg-10mg-2500unit-20mg-25mcg-1.7mg-6mcg-400mcg-30mcg-2mg-60mg-400unit,35mcg-2mg-72mg-10mcg-100mcg-150mcg-2.3mg-10mcg-5mcg-0.9mg-20mg-45unit-150mcg-50mcg-210mg-80mg-11mg-100mg-1.2mg-600mcg-8mg-15mg-3500unit-16mg-60mcg-1.3mg-6mcg-600unit-200mcg-40mcg-2mg-90mg, 35mcg-72mg-10mcg-100mcg-2.3mg-10mcg-5mcg-0.9mg-20mg-45unit-150mcg-50mcg-80mg-210mg-2mg-100mg-150mcg-11mg-1.2mg-600mcg-8mg-15mg-3500unit-16mg-60mcg-

Name of drug

Whatthe


level)


1.3mg-6mcg-600unit-200mcg-40mcg-2mg-90mg,60mg-50mg-72mg-10mcg-70mcg-4mg-10mcg-5mcg-48mg-60unit-150mcg-75mcg-80mg-120mcg-4mg-40mg-60mcg-2mg-15mg-4.5mg-100mg-18mg-10mg-3500unit-40mg-25mcg-5.1mg-16mcg-400mcg-40mcg-6mg-120mg-400unit, 25mg-1mg-12.5mg-1mg-75mcg-50mcg-1mg-50mcg-1mg-25mcg-2.5mg-13.5mg-12.5mg-7.5mg-100mg-40mg-250mg-5mg-40mg-250mcg-40mg-10mcg-5mg-37.5mcg-40mg-5000unit-40mcg-200unit-200mcg-50unit-40mcg-40mg-100mg, 2mg-10mcg-20mcg-120mcg-2mg-10mcg-5mcg-2mg-109mg-30unit-150mcg-75mcg-72mg-162mg-150mcg-80mg-15mg-100mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 72mg-10mcg-20mcg-25mcg-2mg-10mcg-5mcg-109mg-75mcg-150mcg-162mg-120mcg-2mg-80mg-100mg-30unit-150mcg-2mg-15mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-1.7mg-6mcg-400mcg-30mcg-2mg-60mg-400unit,2mg-72mg-10mcg-55mcg-200mg-35mcg-2.3mg-10mcg-5mcg-0.9mg-109mg-30unit-150mcg-45mcg-80mg-150mcg-



Name of drug

Whatthe


level)


11mg-100mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-500mcg-30mcg-2mg-90mg, 35mcg-2mg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.9mg-109mg-30unit-150mcg-45mcg-200mg-150mcg-80mg-11mg-100mg-1.5mg-300mcg-18mg-3500unit-250mcg-20mg-25mcg-1.7mg-10mg-6mcg-400unit-500mcg-30mcg-2mg-90mg, 35mcg-72mg-10mcg-55mcg-2.3mg-10mcg-5mcg-0.9mg-109mg-30unit-150mcg-45mcg-200mg-80mg-2mg-150mcg-11mg-100mg-1.5mg-300mcg-18mg-10mg-3500unit-250mcg-20mg-25mcg-1.7mg-6mcg-400unit-500mcg-30mcg-2mg-90mg, 25mcg-12.5mg-2.5mg-1mg-5mcg-50mcg-250mg-75mcg-2mg-50mcg-1mg-25mcg-2.5mg-13.5mcg-12.5mg-7.5mg-50mg-40mg-5mg-40mg-250mcg-40mg-10mcg-5mg-37.5mcg-40mg-5000unit-40mg-200unit-200mg-50unit-40mg-40mg-100mg, 25mg-25mg-35mg-50mcg-12.5mg-35mg-25mcg-15mg-15mg-35mg-5mcg-25mg-100mg-75mcg-5000unit-2.5mg-1mg-12.5mg-50mg-2.5mg-15mg-175mcg-5mg-15mg-250mcg-15mg-5mg-5mg-37.5mcg-15mg-15mcg-100unit-5mg-200mcg-

Name of drug

Whatthe


level)


50unit-125mcg-15mg-25mg-150mgNO IRON MULTIPLEVITAMIN/MINERALSTABS

$0(Tier

3)

RX/OTC; MO;NT

ONCOVITE TABS$0

(Tier3)

RX/OTC; MO;NT

ONE-A-DAY MENS 50+ADVANTAGE TABS

$0(Tier

3)

RX/OTC; MO;NT

ONE-A-DAY TEENADVANTAGEFOR HIMTABS

$0(Tier

3)

RX/OTC; MO;NT

QUINTABS-M TABS$0

(Tier3)

RX/OTC; MO;NT

SENTRY SENIOR TABS$0

(Tier3)

RX/OTC; MO;NT

SENTRY TABS$0

(Tier3)

RX/OTC; MO;NT

SIDEROL TABS$0

(Tier3)

RX/OTC; MO;NT

SM ONE DAILY WOMENSTABS

$0(Tier

3)

RX/OTC; MO;NT

STROVITE FORTE TABS(Multiple Vitamins w/Minerals)

$0(Tier

3)

RX/OTC; MO;NT

STROVITE ONE TABS$0

(Tier3)

RX/OTC; MO;NT

SUPPORT LIQD$0

(Tier3)

RX/OTC; MO;NT

THERA M PLUS TABS$0

(Tier3)

RX/OTC; MO;NT



Name of drug

Whatthe


level)


THERA-M TABS$0

(Tier3)

RX/OTC; MO;NT

THEREMS-H TABS$0

(Tier3)

RX/OTC; MO;NT

THEREMS-M TABS$0

(Tier3)

RX/OTC; MO;NT

UNICOMPLEX-M TABS$0

(Tier3)

RX/OTC; MO;NT

VITAMIN & MINERALSUPPLEMENT LIQD

$0(Tier

3)

RX/OTC; MO;NT

VITATRUM TABS$0

(Tier3)

RX/OTC; MO;NT

VITRUM 50+ SENIORMULTI TABS

$0(Tier

3)

RX/OTC; MO;NT

YELETS TEENAGEFORMULA TABS

$0(Tier

3)

RX/OTC; MO;NT

ZINC LOZG OR 50MG-15MG-500UNIT-100MG

$0(Tier

3)

NT

Multivitamins

DEKAS ESSENTIAL CAPS$0

(Tier3)

NT

Name of drug

Whatthe


level)


multiple vitamin tabs5000unit-20mg-1.7mg-6mcg-125unit-1.5mg-2mg-60mg, 5000unit-20mg-1.7mg-6mcg-400unit-1.5mg-2mg-60mg,5000unit-400unit-20mg-2.5mg-1mg-1mcg-1mg-2mg-50mg, 7mg-5000unit-20mg-2.5mg-1mcg-2mg-1mg-50mg-400unit,5000unit-20mg-1.7mg-6mcg-400unit-1.5mg-0.4mg-2mg-60mg,5000unit-20mg-1.7mg-6mcg-400unit-1.5mg-400mcg-2mg-60mg, 75mg-5000unit-20mg-2.5mg-1mg-1mcg-400unit-2mg-1mg-50mg, 28.5mg-1.5mg-1mg-5000unit-20mg-2mg-400unit-0.1mg-37.5mg,30unit-100mg-10mg-20mg-12mcg-15mg-400mcg-45mcg-5mg-500mg, 30unit-10mg-100mg-10mg-20mg-12mcg-400mcg-45mcg-3mg-500mg, 60mg-4000unit-1.7mg-1mg-3mcg-400unit-1.5mg-1mg-20mg-50mg, 30unit-1.5mg-10mg-5000unit-20mg-1.7mg-6mcg-400unit-2mg-60mg, 5000unit-30unit-1.5mg-10mg-20mg-1.7mg-400unit-400mcg-2mg-60mg, 30unit-400unit-20mg-1.7mg-10mg-5000unit-6mcg-1.5mg-0.4mg-2mg-60mg, 15unit-20mg-5000unit-20mg-1.7mg-6mcg-400unit-1.5mg-400mcg-2mg-60mg,30unit-1.5mg-10mg-3000unit-20mg-1.7mg-6mcg-400unit-400mcg-

$0(Tier

3)

MO; NT



Name of drug

Whatthe


level)


2mg-60mg, 30unit-1.5mg-10mg-5000unit-20mg-1.7mg-6mcg-400mcg-2mg-60mg-400unit, 30unit-1.5mg-10mg-5000unit-20mg-1.7mg-6mcg-400unit-400mcg-2mg-60mg, 30unit-400unit-1.5mg-5000unit-20mg-1.7mg-10mg-6mcg-2mg-400mcg-60mg, 30unit-5000unit-20mg-1.7mg-10mg-6mcg-400unit-1.5mg-400mcg-2mg-60mg,30unit-1.5mg-5000unit-3000unit-20mg-1.7mg-6mcg-400unit-400mcg-2mg-60mg, 30unit-3.4mg-10mg-5000unit-9mcg-400unit-20mg-3mg-400mcg-30mcg-3mg-90mg, 5000unit-30unit-400unit-3.4mg-10mg-9mcg-20mg-3mg-400mcg-30mcg-3mg-90mg, 30unit-1.5mg-75mg-10mg-5000unit-20mg-1.7mg-6mcg-400unit-400mcg-2mg-60mg, 30unit-45mg-1.5mg-10mg-3000unit-20mg-1.7mg-6mcg-400unit-400mcg-2mg-60mg, 30unit-1.5mg-10mg-5000unit-20mg-1.7mg-6mcg-400unit-400mcg-30mcg-2mg-60mg, 10mg-20mg-1.7mg-5000unit-6mcg-1.5mg-400mcg-30unit-300mcg-2mg-60mg-400unit, 30unit-10mg-20mg-1.7mg-5000unit-6mcg-1.5mg-400mcg-300mcg-2mg-60mg-400unit, 45mg-30unit-10mg-5000unit-20mg-3.4mg-10mg-9mcg-

Name of drug

Whatthe


level)


400unit-3mg-400mcg-30mcg-3mg-90mg

OMNICAP TABS$0

(Tier3)

MO; NT

ONE-A-DAY ESSENTIALTABS (Multiple Vitamin)

$0(Tier

3)

MO; NT

Ped MV w/ Iron

ANIMAL SHAPES/IRONCHEW

$0(Tier

3)

MO; NT

MULTI-DELYN/IRON LIQD$0

(Tier3)

NT

pediatric multiple vitaminsw/ iron chew

$0(Tier

3)

MO; NT

POLY-VI-SOL/IRON SOLN(Pediatric Multiple Vitaminsw/ Iron)

$0(Tier

3)

MO; NT

SCOOBY-DOO ONE ADAY CHEW

$0(Tier

3)

NT

Ped Multi Vitamins w/Fl & FE

ESCAVITE CHEW$0

(Tier3)

*;NT

Ped Multiple Vitamins w/ MineralsDEKAS PLUS LIQD10MCG/ML-5MG/ML-50UNIT/ML-2MG/ML-0.6MG/ML-3MG/ML-6MG/ML-500MCG/ML-5751UNIT/ML-750UNIT/ML-0.6MG/ML-15MCG/ML-0.6MG/ML-45MG/ML

$0(Tier

3)

NT

HEALTHY KIDS GUMMIESCHEW

$0(Tier

3)

MO; NT



Name of drug

Whatthe


level)


pediatric multiple vitamin w/minerals & c chew 10unit-20mcg-1.25mg-10mcg-15mcg-1000unit-2.5mcg-100unit-37.5mcg-0.5mg-15mg, 20unit-40mcg-2.5mg-5mg-2000unit-20mcg-38mg-5mcg-200unit-200mcg-75mcg-1mg-30mg, 15mcg-1mg-2mg-1mg-1.25mg-5mcg-5mcg-1250unit-1.5mcg-25unit-100mcg-7.5unit-22.5mcg-0.25mg-7.5mg,100mg-100mg-150mcg-20mg-2mg-12mg-1.5mg-18mg-10mg-60mg-3000unit-15mg-38mg-1.7mg-6mcg-400unit-400mcg-30unit-40mcg-2mg, 100mg-150mcg-100mg-10mg-20mg-400unit-2mg-12mg-1.5mg-18mg-10mg-3000unit-15mg-38mg-1.7mg-6mcg-400mcg-30unit-40mcg-2mg-60mg

$0(Tier

3)

MO; NT

pediatric multiple vitamin w/minerals & c liqd 0.6mg/ml-5751unit/ml-3mg/ml-5mg/ml-10mcg/ml-15mg/ml-2mg/ml-3mg/ml-6mg/ml-400mcg/ml-400unit/ml-0.6mg/ml-50unit/ml-15mcg/ml-0.6mg/ml-45mg/ml

$0(Tier

3)

RX/OTC; MO;NT

Name of drug

Whatthe


level)


VITALETS CHILDRENSCHEW 60MG-80MG-0.1MG-15UNIT-20MG-0.8MG-10MG-10MG-0.85MG-5MG-2500UNIT-3MCG-0.75MG-200MCG-150MCG-1MG-40MG-200UNIT, 60MG-80MG-0.1MG-20MG-0.8MG-10MG-5MG-10MG-0.85MG-2500UNIT-3MCG-0.75MG-200MCG-15UNIT-150MCG-1MG-40MG-200UNIT

$0(Tier

3)

MO; NT

Pediatric Multiple Vitamins



Name of drug

Whatthe


level)


pediatric multiple vitamin w/c & fa chew 15unit-400unit-13.5mg-1.2mg-2500unit-4.5mcg-0.3mg-60mg,15unit-0.75mg-2500unit-5mg-0.85mg-3mcg-200unit-200mcg-1mg-30mg, 15unit-5mg-1.05mg-10mg-1.2mg-4.5mcg-400unit-300mcg-1.05mg-60mg, 15unit-1.05mg-1998unit-10mg-1.2mg-4.5mcg-400unit-300mcg-1.05mg-60mg, 15unit-1.05mg-60mg-1998unit-10mg-1.2mg-4.5mcg-400unit-300mcg-1.05mg,15unit-1.05mg-13.5mg-1.2mg-2500unit-4.5mcg-400unit-0.3mg-1.05mg-60mg, 15unit-1.05mg-60mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-0.3mg-1.05mg, 15unit-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-1.05mg-60mg,15unit-1.05mg-2500unit-13.5mg-1.2mg-4.5mcg-300mcg-1.05mg-60mg-400unit, 15unit-2500unit-1.2mg-4.5mcg-400unit-1.05mg-13.5mg-300mcg-1.05mg-60mg, 10mg-400unit-1.05mg-60mg-1998unit-10mg-1.2mg-4.5mcg-300mcg-15unit-1.05mg

$0(Tier

3)

MO; NT

pediatric multiple vitamin w/c soln

$0(Tier

3)

MO; NT

pediatric multiple vitamin w/extra c & fa chew

$0(Tier

3)

NT

Name of drug

Whatthe


level)


POLY-VI-SOL SOLN(Pediatric Multiple Vitaminw/ C)

$0(Tier

3)

MO; NT

Pediatric Vitamins

HONEY BEARS CHEW$0

(Tier3)

NT

pediatric vitamins adc soln$0

(Tier3)

MO; NT

TRI-VI-SOL SOLN(Pediatric Vitamins ADC)

$0(Tier

3)

MO; NT

Specialty Vitamins Products

CVS HAIR/SKIN/NAILSTABS

$0(Tier

3)

RX/OTC; MO;NT

ICAPSLUTEIN/ZEAXANTHINTBEC

$0(Tier

3)

NT

specialty vitamins productstabs

$0(Tier

3)

RX/OTC; MO;NT

SUPPORT-500 CAPS$0

(Tier3)

RX/OTC; NT

Vitamin Mixtures

vitamins c & e caps$0

(Tier3)

MO; NT

Vitamins w/ Lipotropicsvitamins w/ lipotropics caps10000unit-3mg-0.5mg-2mg-75mg-58mg-30mg-2unit-0.5mg-4mg-40mg-15mg-31.4mg-2.5mg-2mcg-5mg-1mg-75mg-400unit

$0(Tier

3)

NT



Name of drug

Whatthe


level)


vitamins w/ lipotropics tabs20mg-50mg-30mg-10mg-10mcg-30mg-8mg, 100mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-200mcg-100mcg-100mg, 10000unit-10mg-18mg-100unit-225mcg-10mg-150mg-100mg-30mg-10mg-25mg-25mg-50mg-50mg-10mg-50mg-50mg-200mcg-400unit-50mg-400mcg-50mg-250mg

$0(Tier

3)

MO; NT

vitamins w/ lipotropics tbcr100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-200mcg-100mcg-100mg

$0(Tier

3)

NT

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat SpasmsCentral Muscle Relaxants

baclofen tabs or 10 mg$0

(Tier1)

SL(8 ea daily);MO

baclofen tabs or 20 mg$0

(Tier1)

SL(4 ea daily);MO

BACLOFEN TABS OR 5MG

$0(Tier

2)

SL(16 ea daily);MO

carisoprodol tabs 350 mg$0

(Tier1)


chlorzoxazone tabs 500 mg$0

(Tier1)


cyclobenzaprine hcl tabs 5mg, 10 mg

$0(Tier

1)


metaxalone tabs$0

(Tier1)


Name of drug

Whatthe


level)


methocarbamol tabs or 500mg, 750 mg

$0(Tier

1)


tizanidine hcl caps 2 mg$0

(Tier1)

SL(18 ea daily);MO


(Tier1)

SL(9 ea daily);MO


(Tier1)

SL(6 ea daily);MO

tizanidine hcl tabs 2 mg$0

(Tier1)

SL(18 ea daily);MO

tizanidine hcl tabs 4 mg$0

(Tier1)

SL(9 ea daily);MO

Direct Muscle Relaxants

dantrolene sodium caps$0

(Tier1)

MO

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or SinusNasal Agents - Misc.

saline soln$0

(Tier3)

MO; NT

Nasal Antiallergy

azelastine hcl soln$0

(Tier1)

MO

cromolyn sodium (nasal)aers

$0(Tier

3)

MO; NT

olopatadine hcl (nasal) soln$0

(Tier1)

MO

Nasal Anticholinergics



Name of drug

Whatthe


level)


ipratropium bromide (nasal)soln

$0(Tier

1)

MO

Nasal Steroids

budesonide (nasal) susp$0

(Tier3)

*;MO; NT

flunisolide (nasal) soln$0

(Tier1)

MO

fluticasone propionate(nasal) susp

$0(Tier

1)

RX/OTC; MO

fluticasone propionate(nasal) susp

$0(Tier

3)


triamcinolone acetonide(nasal) aero

$0(Tier

3)

*;RX/OTC; MO;NT

Sympathomimetic Decongestants

NASAL DECONGESTANTSYRP

$0(Tier

3)

NT

oxymetazoline hcl soln$0

(Tier3)

MO; NT

oxymetazoline hcl soln$0

(Tier3)

*;MO; NT

phenylephrine hcl (oral)tabs

$0(Tier

3)

MO; NT

phenylephrine hcl soln$0

(Tier3)

*;NT

pseudoephedrine hcl liqd15 mg/5ml

$0(Tier

3)

MO; NT

pseudoephedrine hcl tabs30 mg, 60 mg

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


pseudoephedrine hcl tb12120 mg

$0(Tier

3)

MO; NT

NEUROMUSCULAR AGENTS - Drugs toRelax/Paralyze MusclesALS Agents

RADICAVA SOLN$0

(Tier2)

PA; NDS;MO

riluzole tabs$0

(Tier1)

MO

Muscular Dystrophy Agents

EXONDYS 51 SOLN$0

(Tier2)

PA; NDS;LA;MO

Neuromuscular Blocking Agent - Neurotoxins

BOTOX SOLR$0

(Tier2)

PA; MO

XEOMIN SOLR$0

(Tier2)

PA; MO

NUTRIENTS

Carbohydrates

dextrose soln 10 %, 50 %,70 %

$0(Tier

1)

B/D

dextrose soln 5 %$0

(Tier1)

B/D; MO

Lipids

CLINOLIPID EMUL$0

(Tier2)

B/D

fat emulsion plant basedemul

$0(Tier

1)

B/D

Misc. Nutritional Substances



Name of drug

Whatthe


level)


ALBA-LYBE NR LIQD$0

(Tier3)

NT

Proteins

amino acid infusion 15%$0

(Tier1)

B/D

CLINIMIX4.25%/DEXTROSE 5%SOLN

$0(Tier

2)

B/D

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricants

artificial tear ointment oint$0

(Tier3)

MO; NT

carboxymethylcellulosesodium (ophth) gel

$0(Tier

3)

MO; NT

carboxymethylcellulosesodium (ophth) soln

$0(Tier

3)

MO; NT

dextran 70-hypromellosesoln

$0(Tier

3)

MO; NT

ISOPTO TEARS SOLN$0

(Tier3)

MO; NT

polyethylene glycol-propylene glycol (ophth)soln

$0(Tier

3)

MO; NT

polyvinyl alcohol soln$0

(Tier3)

MO; NT

REFRESH OPTIVE MEGA-3 SOLN

$0(Tier

3)

MO; NT

REFRESH PLUS SOLN(CarboxymethylcelluloseSodium (Ophth))

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


white petrolatum-mineral oiloint 15%-83%, 15%-85%,55%-56.8%-42.5%

$0(Tier

3)

MO; NT

Beta-blockers - Ophthalmic

betaxolol hcl (ophth) soln$0

(Tier1)

MO

carteolol hcl (ophth) soln$0

(Tier1)

MO

COMBIGAN SOLN$0

(Tier2)

MO

dorzolamide hcl-timololmaleate soln 2%-0.5%,20mg/ml-5mg/ml,22.3mg/ml-6.8mg/ml

$0(Tier

1)

MO

levobunolol hcl soln$0

(Tier1)

MO

timolol maleate (ophth) solg0.25 %, 0.5 %

$0(Tier

1)

MO

timolol maleate (ophth) soln0.25 %, 0.5 %

$0(Tier

1)

MO

TIMOLOL MALEATEOPHTHALMIC GELFORMING SOLG

$0(Tier

2)

MO

Cycloplegic Mydriatics

CYCLOMYDRIL SOLN$0

(Tier3)

MO; NT

cyclopentolate hcl soln$0

(Tier1)

MO

MYDRIACYL SOLN(Tropicamide)

$0(Tier

3)

MO; NT

tropicamide soln$0

(Tier3)

MO; NT



Name of drug

Whatthe


level)


Miotics

PHOSPHOLINE IODIDESOLR

$0(Tier

2)

pilocarpine hcl soln$0

(Tier1)

MO

Ophthalmic Adrenergic Agents

ALPHAGAN P SOLN 0.1 %$0

(Tier2)

MO

apraclonidine hcl soln$0

(Tier1)

MO

brimonidine tartrate soln$0

(Tier1)

MO

SIMBRINZA SUSP$0

(Tier2)

MO

Ophthalmic Anti-infectives

AZASITE SOLN$0

(Tier2)

MO

bacitracin (ophthalmic) oint$0

(Tier1)

MO

bacitracin-polymyxin b(ophth) oint

$0(Tier

1)

MO

ciprofloxacin hcl (ophth)soln

$0(Tier

1)

MO

erythromycin (ophth) oint$0

(Tier1)

MO

gatifloxacin (ophth) soln$0

(Tier1)

MO

Name of drug

Whatthe


level)


gentamicin sulfate (ophth)oint

$0(Tier

1)

MO

gentamicin sulfate (ophth)soln

$0(Tier

1)

MO

levofloxacin (ophth) soln$0

(Tier1)

MO

moxifloxacin hcl (ophth)soln

$0(Tier

1)

MO

NATACYN SUSP$0

(Tier2)

MO

neomycin-bacitracin zn-polymyxin oint

$0(Tier

1)

MO

neomycin-polymyxin-gramicidin soln

$0(Tier

1)

MO

ofloxacin (ophth) soln$0

(Tier1)

MO

polymyxin b-trimethoprimsoln

$0(Tier

1)

MO

sulfacetamide sodium(ophth) soln

$0(Tier

1)

MO

tobramycin (ophth) soln$0

(Tier1)

MO

trifluridine soln$0

(Tier1)

MO

ZIRGAN GEL$0

(Tier2)

MO

Ophthalmic Decongestants



Name of drug

Whatthe


level)


tetrahydrozoline hcl (ophth)soln

$0(Tier

3)

MO; NT

Ophthalmic Immunomodulators

RESTASIS EMUL$0

(Tier2)

PA; MO

RESTASIS MULTIDOSEEMUL

$0(Tier

2)

PA; MO

Ophthalmic Local Anesthetics

proparacaine hcl soln$0

(Tier1)

MO

Ophthalmic Nerve Growth Factors

OXERVATE SOLN$0

(Tier2)

PA; NDS;MO

Ophthalmic Steroids

ALREX SUSP$0

(Tier2)

MO

bacitracin-poly-neomycin-hc oint

$0(Tier

1)

MO

dexamethasone sodiumphosphate (ophth) soln

$0(Tier

1)

MO

DUREZOL EMUL$0

(Tier2)

MO

fluorometholone (ophth)susp

$0(Tier

1)

MO

LOTEMAX GEL$0

(Tier2)

MO

LOTEMAX OINT$0

(Tier2)

MO

Name of drug

Whatthe


level)


loteprednol etabonate susp$0

(Tier1)

MO

neomycin-polymy-dexameth oint

$0(Tier

1)

MO

neomycin-polymy-dexameth susp

$0(Tier

1)

MO

PRED FORTE SUSP$0

(Tier2)

MO

prednisolone acetate(ophth) susp

$0(Tier

1)

MO

sulfacetamide sod-prednisolone soln

$0(Tier

1)

MO

tobramycin-dexamethasone susp

$0(Tier

1)

MO

Ophthalmics - Misc.

azelastine hcl (ophth) soln$0

(Tier1)

MO

AZOPT SUSP$0

(Tier2)

MO

bromfenac sodium (ophth)soln

$0(Tier

1)

Once dailydosing;MO

cromolyn sodium (ophth)soln

$0(Tier

1)

MO

CYSTARAN SOLN$0

(Tier2)

Limit 60mls per28days;QL(2.15ml daily); LA;MO

diclofenac sodium (ophth)soln

$0(Tier

1)

MO



Name of drug

Whatthe


level)


dorzolamide hcl soln$0

(Tier1)

MO

epinastine hcl (ophth) soln$0

(Tier1)

MO

flurbiprofen sodium soln$0

(Tier1)

MO

ILEVRO SUSP$0

(Tier2)

MO

ketorolac tromethamine(ophth) soln

$0(Tier

1)

MO

ketotifen fumarate (ophth)soln

$0(Tier

3)

*;MO; NT

MURO 128 SOLN 2 %$0

(Tier3)

MO; NT

MURO 128 SOLN 5 %(Sodium ChlorideHypertonic)

$0(Tier

3)

MO; NT

NEVANAC SUSP$0

(Tier2)

MO

olopatadine hcl soln 0.2 %$0

(Tier1)

MO

sodium chloride hypertonicoint

$0(Tier

3)

MO; NT

sodium chloride hypertonicsoln

$0(Tier

3)

MO; NT

Prostaglandins - Ophthalmic

bimatoprost soln$0

(Tier1)

MO

Name of drug

Whatthe


level)


latanoprost soln$0

(Tier1)

MO

LUMIGAN SOLN$0

(Tier2)

MO

TRAVATAN Z SOLN$0

(Tier2)

MO

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous

acetic acid (otic) soln$0

(Tier1)

MO

carbamide peroxide (otic)soln

$0(Tier

3)

MO; NT

Otic Anti-infectives

CETRAXAL SOLN$0

(Tier2)

MO

CIPROFLOXACIN SOLNOT 0.2 %

$0(Tier

2)

MO

ofloxacin (otic) soln$0

(Tier1)

MO

Otic Combinations

CIPRODEX SUSP$0

(Tier2)

MO

neomycin-polymyxin-hc(otic) soln

$0(Tier

1)

MO

neomycin-polymyxin-hc(otic) susp

$0(Tier

1)

MO

Otic Steroids



Name of drug

Whatthe


level)


fluocinolone acetonide(otic) oil

$0(Tier

1)

MO

hydrocortisone w/aceticacid soln

$0(Tier

1)

MO

OXYTOCICS - Drugs to Prevent/Control UterineBleedingOxytocics

methylergonovine maleatetabs

$0(Tier

1)

MO

PASSIVE IMMUNIZING AND TREATMENTAGENTS - Antibody Drugs to Treat Low ImmuneSystemImmune Serums

BIVIGAM SOLN$0

(Tier2)

B/D; NDS

CUVITRU SOLN 1GM/5ML

$0(Tier

2)

B/D; LA

CUVITRU SOLN 10GM/50ML

$0(Tier

2)

B/D; NDS

CUVITRU SOLN 2GM/10ML, 4 GM/20ML, 8GM/40ML

$0(Tier

2)

B/D; NDS;LA

FLEBOGAMMA DIF SOLN10 %

$0(Tier

2)

B/D; NDS; 5GM/50 ML

FLEBOGAMMA DIF SOLN10 %

$0(Tier

2)

B/D; NDS

GAMASTAN INJ$0

(Tier2)

B/D

GAMASTAN S/D INJ$0

(Tier2)

B/D

Name of drug

Whatthe


level)


GAMMAGARD LIQUIDSOLN

$0(Tier

2)

B/D; NDS

GAMMAKED SOLN$0

(Tier2)

B/D; NDS

GAMMAPLEX SOLN 5GM/50ML, 10 GM/100ML,20 GM/200ML

$0(Tier

2)

B/D; NDS

GAMUNEX-C SOLN$0

(Tier2)

B/D; NDS

HIZENTRA SOLN 1GM/5ML

$0(Tier

2)

B/D; LA

HIZENTRA SOLN 10GM/50ML

$0(Tier

2)

B/D; NDS

HIZENTRA SOLN 2GM/10ML, 4 GM/20ML

$0(Tier

2)

B/D; NDS;LA

HYPERRAB S/D SOLN$0

(Tier2)

IMOGAM RABIES-HTSOLN 300 UNIT/2ML

$0(Tier

2)

KEDRAB SOLN$0

(Tier2)

OCTAGAM SOLN 2GM/20ML, 5 GM/50ML, 10GM/100ML, 20 GM/200ML,30 GM/300ML

$0(Tier

2)

B/D; NDS

PRIVIGEN SOLN$0

(Tier2)

B/D; NDS

VARIZIG SOLN$0

(Tier2)

NDS

Monoclonal Antibodies



Name of drug

Whatthe


level)


SYNAGIS SOLN$0

(Tier2)

NDS

ZINPLAVA SOLN$0

(Tier2)

PA; NDS

Passive Immunizing Agents - Combinations

HYQVIA KIT$0

(Tier2)

B/D; NDS

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins

amoxicillin caps 250 mg,500 mg

$0(Tier

1)

MO

amoxicillin susr 125mg/5ml, 200 mg/5ml, 250mg/5ml, 400 mg/5ml

$0(Tier

1)

MO

amoxicillin tabs 500 mg,875 mg

$0(Tier

1)

MO

ampicillin caps$0

(Tier1)

MO

ampicillin sodium solr ij 1gm, 2 gm, 500 mg

$0(Tier

1)

MO

ampicillin sodium solr ij 250mg

$0(Tier

1)

ampicillin sodium solr iv 2gm, 10 gm

$0(Tier

1)

Natural Penicillins

BICILLIN L-A SUSP$0

(Tier2)

MO

penicillin g potassium solr$0

(Tier1)

MO

Name of drug

Whatthe


level)


penicillin v potassium solr250 mg/5ml

$0(Tier

1)

MO

penicillin v potassium tabs250 mg, 500 mg

$0(Tier

1)

MO

Penicillin Combinations

amoxicillin & potclavulanate chew

$0(Tier

1)

MO

amoxicillin & potclavulanate susr

$0(Tier

1)

MO

amoxicillin & potclavulanate tabs

$0(Tier

1)

MO

amoxicillin & potclavulanate tb12

$0(Tier

1)

MO

ampicillin & sulbactamsodium solr ij 0.5gm-1gm

$0(Tier

1)

ampicillin & sulbactamsodium solr ij 1gm-2gm

$0(Tier

1)

MO

ampicillin & sulbactamsodium solr iv 5gm-10gm

$0(Tier

1)

piperacillin sodium-tazobactam sodium solr

$0(Tier

1)

Penicillinase-Resistant Penicillins

dicloxacillin sodium caps$0

(Tier1)

MO

nafcillin sodium solr ij 1 gm$0

(Tier1)

NAFCILLIN SODIUMSOLR IJ 10 GM

$0(Tier

2)

NDS



Name of drug

Whatthe


level)


nafcillin sodium solr ij 2 gm$0

(Tier1)

MO

nafcillin sodium solr iv 10gm

$0(Tier

1)

NDS

PHARMACEUTICAL ADJUVANTS

Liquid Vehicles

bacteriostatic sodiumchloride soln

$0(Tier

3)

MO; NT

BACTERIOSTATICWATERFORINJECTION/BENZYLALCOHOL SOLN

$0(Tier

3)

MO; NT

glycine diluent soln$0

(Tier3)

LA; MO; NT

SUSPENDOL-S LIQD$0

(Tier3)

MO; NT

water for injection, sterilesoln ij

$0(Tier

3)

MO; NT

water for injection, sterilesoln iv

$0(Tier

3)

NT

Semi Solid Vehicles

PETROLATUM OINT$0

(Tier3)

RX/OTC; NT

WHITE PETROLATUMOINT EX

$0(Tier

3)

RX/OTC; MO;NT

PROGESTINS - Hormone Replacement/ModifyingDrugsProgestins

medroxyprogesteroneacetate tabs

$0(Tier

1)

MO

Name of drug

Whatthe


level)


megestrol acetate(appetite) susp

$0(Tier

1)


norethindrone acetate tabs$0

(Tier1)

MO

progesterone micronizedcaps

$0(Tier

1)

MO

PSYCHOTHERAPEUTIC AND NEUROLOGICALAGENTS - MISC. - Drugs to Treat Mental andEmotional ConditionsAgents for Chemical Dependency

acamprosate calcium tbec$0

(Tier1)

MO

disulfiram tabs$0

(Tier1)

MO

LUCEMYRA TABS$0

(Tier2)


Anti-Cataplectic Agents

XYREM SOLN$0

(Tier2)

NDS;LA; MO

Antidementia Agents

donepezil hydrochloridetabs

$0(Tier

1)

MO

donepezil hydrochloridetbdp

$0(Tier

1)

MO

galantamine hydrobromidecp24

$0(Tier

1)

MO

galantamine hydrobromidesoln

$0(Tier

1)

MO



Name of drug

Whatthe


level)


galantamine hydrobromidetabs

$0(Tier

1)

MO

memantine hcl cp24 14 mg$0

(Tier1)

AL(At least 60yrs old); SL(2ea daily); MO


(Tier1)

AL(At least 60yrs old);SL(1.33 eadaily); MO


(Tier1)



(Tier1)


memantine hcl soln 2mg/ml, 10 mg/5ml

$0(Tier

1)

AL(At least 60yrs old); MO

memantine hcl tabs 5 mg,10 mg

$0(Tier

1)

MO

NAMENDA XR TITRATIONPACK CP24

$0(Tier

2)

AL(At least 60yrs old); MO

rivastigmine pt24$0

(Tier1)

MO

rivastigmine tartrate caps$0

(Tier1)

MO

Combination Psychotherapeutics

chlordiazepoxide-amitriptyline tabs

$0(Tier

1)


olanzapine-fluoxetine hclcaps

$0(Tier

1)

MO

perphenazine-amitriptylinetabs

$0(Tier

1)


Movement Disorder Drug Therapy

Name of drug

Whatthe


level)


AUSTEDO TABS 12 MG$0

(Tier2)


AUSTEDO TABS 6 MG$0

(Tier2)


AUSTEDO TABS 9 MG$0

(Tier2)

PA;NDS;SL(5.33ea daily); LA

INGREZZA CAPS$0

(Tier2)

NDS;LA; MO

INGREZZA CPPK$0

(Tier2)

NDS;LA; MO

tetrabenazine tabs$0

(Tier1)

PA; NDS

Multiple Sclerosis Agents

AMPYRA TB12(Dalfampridine)

$0(Tier

2)

PA; NDS

AUBAGIO TABS 14 MG$0

(Tier2)

PA; NDS;MO

AUBAGIO TABS 7 MG$0

(Tier2)

PA; NDS

AVONEX KIT$0

(Tier2)

PA; NDS

AVONEX PEN AJKT$0

(Tier2)

PA; NDS;Limited to 1box per 28days;QL(0.036ea daily)

AVONEX PSKT$0

(Tier2)

PA; NDS

BETASERON KIT$0

(Tier2)

PA; NDS



Name of drug

Whatthe


level)


COPAXONE SOSY 40MG/ML (GlatiramerAcetate)

$0(Tier

2)

PA; NDS

dalfampridine tb12$0

(Tier1)

PA; NDS

GILENYA CAPS 0.5 MG$0

(Tier2)

PA; NDS

glatiramer acetate sosy 20mg/ml

$0(Tier

1)

PA; NDS

LEMTRADA SOLN$0

(Tier2)

PA; NDS;LA

MAVENCLAD TBPK$0

(Tier2)

PA; NDS;LA

OCREVUS SOLN$0

(Tier2)

PA; NDS

REBIF REBIDOSE SOAJ$0

(Tier2)

PA; NDS

REBIF REBIDOSETITRATIONPACK SOAJ

$0(Tier

2)

PA; NDS

REBIF SOSY$0

(Tier2)

PA; NDS

REBIF TITRATION PACKSOSY

$0(Tier

2)

PA; NDS

TECFIDERA CPDR$0

(Tier2)

PA; NDS

TECFIDERA STARTERPACK MISC

$0(Tier

2)

PA; NDS

TYSABRI CONC$0

(Tier2)

PA; NDS

Name of drug

Whatthe


level)


Pseudobulbar Affect (PBA) Agents

NUEDEXTA CAPS$0

(Tier2)

PA; MO

Psychotherapeutic and Neurological Agents -

ergoloid mesylates tabs$0

(Tier1)


pimozide tabs$0

(Tier1)

MO

Smoking Deterrents

bupropion hcl (smokingdeterrent) tb12

$0(Tier

1)

SL(2 ea daily);MO

CHANTIX CONTINUINGMONTHPAK TABS

$0(Tier

2)

MO

CHANTIX STARTINGMONTH PAK TABS

$0(Tier

2)

MO

CHANTIX TABS$0

(Tier2)

MO

NICODERM CQ PT24(Nicotine)

$0(Tier

3)

*;MO; NT

NICORETTE GUM 2 MG, 4MG (Nicotine Polacrilex)

$0(Tier

3)

MO; NT

NICORETTE LOZG 2 MG,4 MG (Nicotine Polacrilex)

$0(Tier

3)

MO; NT

NICORETTE MINI LOZG(Nicotine Polacrilex)

$0(Tier

3)

MO; NT

NICORETTE STARTERKIT GUM (NicotinePolacrilex)

$0(Tier

3)

MO; NT



Name of drug

Whatthe


level)


nicotine polacrilex gum 2mg, 4 mg

$0(Tier

3)

MO; NT

nicotine polacrilex lozg 2mg, 4 mg

$0(Tier

3)

MO; NT

nicotine pt24 7 mg/24hr, 14mg/24hr, 21 mg/24hr

$0(Tier

3)

MO; NT

NICOTINETRANSDERMAL SYSTEMKIT

$0(Tier

3)

NT

NICOTROL INHALERINHA

$0(Tier

2)

SL(17 ea daily);MO

NICOTROL NS SOLN$0

(Tier2)

MO

Transthyretin Amyloidosis Agents

TEGSEDI SOSY$0

(Tier2)

PA; NDS;LA;MO

Vasomotor Symptom Agents

paroxetine mesylate(vasomotor) caps

$0(Tier

1)

MO

RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung ConditionsAlpha-Proteinase Inhibitor (Human)

ARALAST NP SOLR 1000MG

$0(Tier

2)

NDS;LA; MO

ARALAST NP SOLR 500MG

$0(Tier

2)

NDS;LA

PROLASTIN-C SOLN 1000MG/20ML

$0(Tier

2)

PA; NDS;LA;MO

PROLASTIN-C SOLR 1000MG

$0(Tier

2)

NDS;LA; MO

Name of drug

Whatthe


level)


ZEMAIRA SOLR$0

(Tier2)

NDS;LA; MO

Cystic Fibrosis Agents

KALYDECO PACK$0

(Tier2)

PA; NDS;MO

KALYDECO TABS$0

(Tier2)

PA; NDS;MO

ORKAMBI PACK$0

(Tier2)

PA; NDS;LA;MO

ORKAMBI TABS$0

(Tier2)

PA; NDS;LA;MO

PULMOZYME SOLN$0

(Tier2)

B/D; NDS

SYMDEKO TBPK$0

(Tier2)

PA; NDS;LA

Pulmonary Fibrosis Agents

ESBRIET CAPS$0

(Tier2)

PA; NDS;LA

ESBRIET TABS$0

(Tier2)

PA; NDS;LA

OFEV CAPS$0

(Tier2)

PA; NDS;LA

SULFONAMIDES - Drugs to Treat BacterialInfectionsSulfonamides

sulfadiazine tabs$0

(Tier1)

MO

TETRACYCLINES - Drugs to Treat BacterialInfections



Name of drug

Whatthe


level)


Aminomethylcyclines

NUZYRA TABS OR 150MG

$0(Tier

2)

PA; NDS;MO

Glycylcyclines

tigecycline solr$0

(Tier1)

NDS

TIGECYCLINE SOLR$0

(Tier2)

NDS

Tetracyclines

demeclocycline hcl tabs$0

(Tier1)

MO

doxycycline (monohydrate)caps

$0(Tier

1)

MO

doxycycline (monohydrate)susr

$0(Tier

1)

MO

doxycycline (monohydrate)tabs

$0(Tier

1)

MO

doxycycline hyclate caps or50 mg, 100 mg

$0(Tier

1)

MO

doxycycline hyclate solr iv100 mg

$0(Tier

1)

MO

doxycycline hyclate tabs or20 mg, 100 mg

$0(Tier

1)

MO

doxycycline hyclate tbec or150 mg

$0(Tier

1)

MO

minocycline hcl caps 50mg, 75 mg, 100 mg

$0(Tier

1)

MO

Name of drug

Whatthe


level)


minocycline hcl tabs 50 mg,75 mg, 100 mg

$0(Tier

1)

MO

tetracycline hcl caps$0

(Tier1)

MO

THYROID AGENTS - Drugs to Regulate ThyroidHormonesAntithyroid Agents

methimazole tabs$0

(Tier1)

MO

propylthiouracil tabs$0

(Tier1)

MO

Thyroid Hormoneslevothyroxine sodium tabsor 25 mcg, 50 mcg, 75mcg, 88 mcg, 100 mcg,112 mcg, 125 mcg, 137mcg, 150 mcg, 175 mcg,200 mcg, 300 mcg

$0(Tier

1)

MO

liothyronine sodium tabs or5 mcg, 25 mcg, 50 mcg

$0(Tier

1)

MO

TOXOIDS

Toxoid Combinations

ADACEL SUSP$0

(Tier2)

BOOSTRIX SUSP$0

(Tier2)

DAPTACEL SUSP$0

(Tier2)

DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC SUSP

$0(Tier

2)

B/D



Name of drug

Whatthe


level)


INFANRIX SUSP$0

(Tier2)

KINRIX SUSP$0

(Tier2)

PEDIARIX SUSP$0

(Tier2)

PENTACEL SUSR$0

(Tier2)

QUADRACEL SUSP$0

(Tier2)

TDVAX SUSP$0

(Tier2)

B/D

TENIVAC INJ$0

(Tier2)

B/D

ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach ConditionsAntispasmodics

dicyclomine hcl caps or 10mg

$0(Tier

1)

MO

dicyclomine hcl tabs or 20mg

$0(Tier

1)

MO

glycopyrrolate soln ij 0.2mg/ml, 1 mg/5ml, 4mg/20ml

$0(Tier

1)

MO

glycopyrrolate soln ij 0.4mg/2ml

$0(Tier

1)

glycopyrrolate tabs or 1 mg$0

(Tier1)

SL(8 ea daily);MO

glycopyrrolate tabs or 2 mg$0

(Tier1)

SL(4 ea daily);MO

Name of drug

Whatthe


level)


methscopolamine bromidetabs

$0(Tier

1)

MO

H-2 Antagonists

cimetidine tabs 200 mg$0

(Tier1)

RX/OTC; MO

cimetidine tabs 300 mg,400 mg, 800 mg

$0(Tier

1)

MO

famotidine soln iv 20mg/2ml, 40 mg/4ml, 200mg/20ml

$0(Tier

1)

famotidine susr or 40mg/5ml

$0(Tier

1)

MO

famotidine tabs or 10 mg$0

(Tier3)

MO; NT


(Tier1)

RX/OTC; MO


(Tier3)



(Tier1)

MO

nizatidine caps 150 mg,300 mg

$0(Tier

1)

MO

ranitidine hcl caps or 150mg, 300 mg

$0(Tier

1)

MO

ranitidine hcl syrp or 15mg/ml, 75 mg/5ml, 150mg/10ml

$0(Tier

1)

MO

ranitidine hcl tabs or 150mg

$0(Tier

3)




Name of drug

Whatthe


level)



$0(Tier

1)

RX/OTC; MO


$0(Tier

1)

MO

ranitidine hcl tabs or 75 mg$0

(Tier3)

MO; NT

Misc. Anti-Ulcer

sucralfate tabs$0

(Tier1)

MO

Proton Pump Inhibitors

DEXILANT CPDR$0

(Tier2)

ST; MO

esomeprazole magnesiumcpdr 20 mg

$0(Tier

3)



$0(Tier

1)

RX/OTC; MO


$0(Tier

1)

MO

esomeprazole sodium solr40 mg

$0(Tier

1)

lansoprazole cpdr 15 mg$0

(Tier3)



(Tier1)

RX/OTC; MO


(Tier1)

MO

Name of drug

Whatthe


level)


NEXIUM PACK 5 MG, 10MG, 20 MG, 40 MG, 2.5MG

$0(Tier

2)

ST; MO

omeprazole cpdr 10 mg, 40mg

$0(Tier

1)

MO

omeprazole cpdr 20 mg$0

(Tier1)

RX/OTC; MO

omeprazole magnesiumcpdr

$0(Tier

3)

*;NT

omeprazole tbec 20 mg$0

(Tier3)

*;MO; NT

pantoprazole sodium solr iv40 mg

$0(Tier

1)

pantoprazole sodium tbecor 20 mg, 40 mg

$0(Tier

1)

MO

Ulcer Drugs - Prostaglandins

misoprostol tabs$0

(Tier1)

MO

Ulcer Therapy Combinations

amoxicillin-clarithromycinw/ lansoprazole misc

$0(Tier

1)

MO

omeprazole-sodiumbicarbonate caps 40mg-1100mg

$0(Tier

1)

MO

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney InfectionsUrinary Anti-infectives

methenamine hippuratetabs

$0(Tier

1)

MO

nitrofurantoin macrocrystalcaps

$0(Tier

1)




Name of drug

Whatthe


level)


nitrofurantoin monohydmacro caps

$0(Tier

1)

MO

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder SpasmsUrinary Antispasmodic - Antimuscarinics

oxybutynin chloride syrp$0

(Tier1)

MO

oxybutynin chloride tabs$0

(Tier1)

MO

oxybutynin chloride tb24$0

(Tier1)

MO

tolterodine tartrate cp24$0

(Tier1)

MO

tolterodine tartrate tabs$0

(Tier1)

MO

trospium chloride cp24$0

(Tier1)

MO

trospium chloride tabs$0

(Tier1)

MO

Urinary Antispasmodics - Beta-3 Adrenergic

MYRBETRIQ TB24$0

(Tier2)

MO

Urinary Antispasmodics - Cholinergic Agonists

bethanechol chloride tabs$0

(Tier1)

MO

Urinary Antispasmodics - Direct Muscle Relaxants

flavoxate hcl tabs$0

(Tier1)

MO

VACCINES

Name of drug

Whatthe


level)


Bacterial Vaccines

ACTHIB SOLR$0

(Tier2)

BCG VACCINE INJ$0

(Tier2)

BEXSERO SUSY$0

(Tier2)

HIBERIX SOLR$0

(Tier2)

MENACTRA INJ$0

(Tier2)

MENVEO SOLR$0

(Tier2)

PEDVAX HIB SUSP$0

(Tier2)

TRUMENBA SUSY$0

(Tier2)

TYPHIM VI SOLN$0

(Tier2)

Viral Vaccines

ENGERIX-B SUSP IJ 20MCG/ML, 10 MCG/0.5ML

$0(Tier

2)

B/D

GARDASIL 9 SUSP$0

(Tier2)

GARDASIL 9 SUSY$0

(Tier2)

HAVRIX SUSP$0

(Tier2)



Name of drug

Whatthe


level)


IMOVAX RABIES(H.D.C.V.) INJ

$0(Tier

2)

B/D

IPOL INACTIVATED IPVINJ

$0(Tier

2)

IXIARO SUSP$0

(Tier2)

M-M-R II SOLR$0

(Tier2)

PROQUAD SUSR$0

(Tier2)

RABAVERT SUSR$0

(Tier2)

B/D

RECOMBIVAX HB SUSP$0

(Tier2)

B/D

ROTARIX SUSR$0

(Tier2)

ROTATEQ SOLN$0

(Tier2)

SHINGRIX SUSR$0

(Tier2)

TWINRIX SUSP$0

(Tier2)

TWINRIX SUSY$0

(Tier2)

VAQTA SUSP$0

(Tier2)

VARIVAX INJ$0

(Tier2)

Name of drug

Whatthe


level)


YF-VAX INJ$0

(Tier2)

ZOSTAVAX SUSR$0

(Tier2)

VAGINAL AND RELATED PRODUCTS

Vaginal Anti-infectives

clindamycin phosphatevaginal crea

$0(Tier

1)

MO

clotrimazole vaginal crea$0

(Tier3)

MO; NT

metronidazole vaginal gel$0

(Tier1)

MO

miconazole nitrate vaginalcrea 2 %

$0(Tier

3)

MO; NT

miconazole nitrate vaginalsupp 100 mg

$0(Tier

3)

MO; NT

terconazole vaginal crea0.4 %, 0.8 %

$0(Tier

1)

MO

terconazole vaginal supp80 mg

$0(Tier

1)

MO

tioconazole vaginal oint$0

(Tier3)

NT

Vaginal Estrogens

estradiol vaginal crea 0.1mg/gm

$0(Tier

1)

MO

PREMARIN CREA VA0.625 MG/GM

$0(Tier

2)

MO



Name of drug

Whatthe


level)


VASOPRESSORS - Drugs to Treat Heart andCirculation ConditionsAnaphylaxis Therapy Agents

epinephrine (anaphylaxis)soaj

$0(Tier

2)

MO

EPIPEN 2-PAK SOAJ(Epinephrine(Anaphylaxis))

$0(Tier

2)

MO

EPIPEN-JR 2-PAK SOAJ(Epinephrine(Anaphylaxis))

$0(Tier

2)

MO

Neurogenic Orthostatic Hypotension (NOH) -

NORTHERA CAPS 100MG

$0(Tier

2)


NORTHERA CAPS 200MG

$0(Tier

2)


NORTHERA CAPS 300MG

$0(Tier

2)


Vasopressors

dobutamine hcl soln$0

(Tier1)

midodrine hcl tabs$0

(Tier1)

MO

VITAMINS

Oil Soluble Vitamins

beta carotene caps 15 mg$0

(Tier3)

NT

beta carotene caps 25000unit

$0(Tier

3)

MO; NT

cholecalciferol liqd$0

(Tier3)

MO; NT

Name of drug

Whatthe


level)


D-VI-SOL LIQD(Cholecalciferol)

$0(Tier

3)

MO; NT

ergocalciferol caps 50000unit

$0(Tier

3)

MO; NT

ergocalciferol soln 8000unit/ml

$0(Tier

3)

MO; NT

MEPHYTON TABS(Phytonadione)

$0(Tier

3)

MO; NT

phytonadione soln$0

(Tier3)

MO; NT

phytonadione tabs$0

(Tier3)

MO; NT

vitamin a caps 10000 unit$0

(Tier3)

MO; NT

vitamin a caps 8000 unit$0

(Tier3)

NT

vitamin e caps 100 unit,200 unit, 400 unit, 1000unit

$0(Tier

3)

MO; NT

vitamin e oil 100 unt/0.25ml$0

(Tier3)

NT

vitamin e soln 50 unit/ml,15 unit/0.3ml

$0(Tier

3)

MO; NT

Water Soluble Vitamins

ascorbic acid chew or500mg, 250 mg, 500 mg

$0(Tier

3)

MO; NT

ascorbic acid cpcr or 500mg

$0(Tier

3)

MO; NT



Name of drug

Whatthe


level)


ascorbic acid liqd or 500mg/5ml

$0(Tier

3)

NT

ascorbic acid lozg mt 60mg$0

(Tier3)

NT

ASCORBIC ACID POWDOR

$0(Tier

3)

NT

ascorbic acid tabs or500mg, 1000mg, 250 mg,500 mg, 1000 mg, 10mg-500mg, 37mg-500mg,37mg-1000mg, 14mg-25mg-500mg

$0(Tier

3)

MO; NT

ascorbic acid tbcr or500mg, 500 mg, 1000 mg,1500 mg

$0(Tier

3)

NT

biotin caps 2500 mcg$0

(Tier3)

NT

biotin caps 5 mg, 5000 mcg$0

(Tier3)

MO; NT

biotin tabs 300 mcg, 1000mcg

$0(Tier

3)

MO; NT

calcium pantothenate tabs$0

(Tier3)

NT

HARD NAILS CAPS(Biotin)

$0(Tier

3)

NT

niacin cpcr 250 mg$0

(Tier3)

MO; NT

niacin tabs 100 mg$0

(Tier3)

*;MO; NT

niacin tabs 100 mg, 500mg

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


niacin tabs 50 mg$0

(Tier3)

NT

niacin tbcr 250 mg, 500 mg$0

(Tier3)

MO; NT

POTABA CAPS$0

(Tier3)

MO; NT

pyridoxine hcl tabs 25 mg,50 mg, 100 mg

$0(Tier

3)

MO; NT

riboflavin tabs 25 mg, 100mg

$0(Tier

3)

MO; NT

riboflavin tabs 50 mg$0

(Tier3)

NT

SLO-NIACIN TBCR(Niacin)

$0(Tier

3)

MO; NT

thiamine hcl tabs 250 mg$0

(Tier3)

NT

thiamine hcl tabs 50 mg,100 mg

$0(Tier

3)

MO; NT

thiamine mononitrate tabs$0

(Tier3)

NT

VITAMIN C POWD$0

(Tier3)

NT



Indexabacavir sulfate 50abacavir sulfate-lamivudine 50abacavir sulfate-lamivudine-zidovudine 51ABELCET 28ABILIFY MAINTENA 50abiraterone acetate 39ABRAXANE 45ABSORICA 67acamprosate calcium 127acarbose 22acebutolol hcl 55acetaminophen 4,5acetaminophen w/ codeine 7acetazolamide 76acetic acid 83acetic acid (otic) 124acetylcysteine 67acitretin 70ACNE MEDICATION 10 67ACNE MEDICATION 5 67ACTEMRA 3ACTHIB 134ACTIMMUNE 44ACTIVE FE 86acyclovir 54acyclovir sodium 54acyclovir topical 70ADACEL 131adapalene 67ADCIRCA 57adefovir dipivoxil 54ADEMPAS 57ADVAIR HFA 14AEROCHAMBER MINIAEROSOLCHAMBER 92AEROCHAMBER MV 92AEROCHAMBER PLUS FLOWVU 92AEROCHAMBER PLUS FLOW-VU 92AEROCHAMBER PLUS FLOW-VU/LARGE MASK 92AEROCHAMBER PLUS FLOW-VU/MASK 92AEROCHAMBER PLUS FLOW-VU/MEDIUM MASK 92AEROCHAMBER PLUS FLOW-VU/SMALL MASK 92

AEROCHAMBER Z-STATPLUS VALVED HOLDINGCHAMBER W/FLOW VU 92AEROCHAMBER Z-STATPLUS/FLOWSIGNAL 92AEROCHAMBER Z-STATPLUS/LARGE MASK 92AEROCHAMBER Z-STATPLUS/MEDIUM MASK 92AEROCHAMBER Z-STATPLUS/SMALL MASK 92AEROCHAMBER/FLOWSIGNAL 92AEROVENT PLUS HOLDINGCHAMBER/COLLAPSIBLE

92AFINITOR 41AFINITOR DISPERZ 41AIMOVIG 95AJOVY 95ALA-HIST IR 28ALA-HIST PE 61ALAHIST CF 62ALAHIST DM 62ALBA-LYBE NR 121albendazole 9ALBENZA 9albuterol sulfate 14alclometasonedipropionate 71ALCOHOL PADS 92ALECENSA 41alendronate sodium 77alfuzosin hcl 83ALIMTA 36ALINIA 10ALIQOPA 41aliskiren fumarate 34allopurinol 83almotriptan malate 95alosetron hcl 82ALPHAGAN P 122alprazolam 12ALREX 123alum & mag hydrox-simethicone 9ALUMINUM HYDROXIDE 9aluminum hydroxide-magcarb 9ALUNBRIG 41amantadine hcl 46

AMBISOME 28ambrisentan 57amcinonide 71amikacin sulfate 2amiloride &hydrochlorothiazide 76amiloride hcl 77amino acid infusion 15% 121aminocaproic acid 89aminophylline 15aminosalicylic acid 35amiodarone hcl 13amitriptyline hcl 22amlodipine besylate 56amlodipine besylate-atorvastatincalcium 56amlodipine besylate-benazeprilhcl 33amoxapine 22amoxicillin 126amoxicillin & potclavulanate 126amoxicillin-clarithromycin w/lansoprazole 133amphetamine-dextroamphetamine 1amphotericin b 28ampicillin 126ampicillin & sulbactamsodium 126ampicillin sodium 126AMPYRA 128ANADROL-50 8anagrelide hcl 84anastrozole 39ANDRODERM 8ANIMAL SHAPES/IRON 116ANORO ELLIPTA 14ANTARA 31AP-HIST DM 62APETEX 101APETIGEN 101APETIGEN-PLUS 103APOKYN 46apraclonidine hcl 122aprepitant 27APTIOM 17APTIVUS 51AQUADEKS 104

Index 1

ARALAST NP 130ARANESP ALBUMIN FREE 85ARCALYST 3argatroban 16ARGATROBAN 16ARIKAYCE 2aripiprazole 50ARISTADA 50ARISTADA INITIO 50ARNUITY ELLIPTA 14ARRANON 36arsenic trioxide 44artificial tear ointment 121ARZERRA 37ascorbic acid 136,137ASCORBIC ACID 137ascorbic acid 137aspirin 5aspirin-dipyridamole 84ASTAGRAF XL 100atazanavir sulfate 51atenolol 55atenolol & chlorthalidone 33atomoxetine hcl 1atorvastatin calcium 31atovaquone 10atovaquone-proguanil hcl 34ATRIPLA 51ATROVENT HFA 13AUBAGIO 128AUSTEDO 128AVANDIA 24AVASTIN 37AVEED 8AVONEX 128AVONEX PEN 128azacitidine 36AZASITE 122AZATHIOPRINE 100azathioprine 100azelaic acid 75azelastine hcl 119azelastine hcl (ophth) 123azithromycin 91AZOPT 123aztreonam 11

b complex w/ c 101,102B COMPLEX/FOLIC ACID 86B-12 DOTS 84b-complex vitamins 101b-complex w/ c & calcium 102b-complex w/ c & e + zn 102b-complex w/ c & folicacid 102b-complex w/ folic acid 102b-complex w/ minerals 103b-complex w/biotin & folicacid 103bacitracin (ophthalmic) 122bacitracin (topical) 68bacitracin zinc 68bacitracin-poly-neomycin-hc

123bacitracin-polymyxin b 68bacitracin-polymyxin b(ophth) 122baclofen 119BACLOFEN 119BACMIN 104bacteriostatic sodiumchloride 127BACTERIOSTATIC WATERFORINJECTION/BENZYLALCOHOL 127balsalazide disodium 82BALVERSA 41BANZEL 17BARACLUDE 54BAVENCIO 37BAXDELA 81BCG VACCINE 134BD ECLIPSESYRINGE/1ML/30GX1/2" 92BD SAFETYGLIDE 27G X5/8" 92BELEODAQ 41BELSOMRA 89benazepril &hydrochlorothiazide 33benazepril hcl 32BENDEKA 35BENLYSTA 101benzonatate 61benzoyl peroxide 67BENZOYL PEROXIDE 67benzoyl peroxide 67

benzoyl peroxide-erythromycin 67benztropine mesylate 46BESPONSA 37beta carotene 136betamethasone dipropionate(topical) 71betamethasone dipropionateaugmented 71betamethasone sod phosphate &acetate 60betamethasone valerate 71BETASERON 128betaxolol hcl 55betaxolol hcl (ophth) 121bethanechol chloride 134BETHKIS 2BEVYXXA 15bexarotene 44BEXSERO 134bicalutamide 39BICILLIN L-A 126BICNU 35BIKTARVY 51bimatoprost 124bimatoprost (topical) 73BIOCAL 104bioflavonoid products 103BIOSUPP 104biotin 137BIOVOL 104bisacodyl 90bisacodyl-peg 3350-pot chloride-sod bicarb-sod chloride 90bismuth subsalicylate 26bisoprolol &hydrochlorothiazide 34bisoprolol fumarate 55BIVIGAM 125bleomycin sulfate 40BLINCYTO 37BOOSTRIX 131BORTEZOMIB 41bosentan 57BOSULIF 41BOTOX 120BRAFTOVI 41BREATHERITE 93

Index 2

BREATHERITECOLLAPSIBLEADULT SPACERW/MASK 92BREATHERITECOLLAPSIBLECHILD SPACERW/MASK 92BREATHERITECOLLAPSIBLEINFANT SPACERW/MASK 92BREATHERITECOLLAPSIBLESMALL CHILDSPACER W/MASK 92BREATHERITECOLLAPSIBLESPACER W/NEONATE MASK 93BREATHERITE RIGIDSPACERW/MASK 93BREATHERITE VALVED MDICHAMBER/COLLAPSIBLE 93BREATHERITE VALVED MDICHAMBER/RIGID 93BREO ELLIPTA 14BRILINTA 84brimonidine tartrate 122BRIVIACT 17bromfenac sodium (ophth) 123bromocriptine mesylate 46brompheniramine &phenyleph 62brompheniramine &pseudoeph 62BROTAPP DM 62budesonide 60budesonide (inhalation) 14budesonide (nasal) 120bumetanide 76buprenorphine hcl 7buprenorphine hcl-naloxone hcldihydrate 7,8bupropion hcl 19bupropion hcl (smokingdeterrent) 129BUPROPIONHYDROCHLORIDE ER (XL) 19buspirone hcl 12busulfan 35butalbital-aspirin-caffeinew/cod 7BUTISOL SODIUM 89butorphanol tartrate 8BYDUREON 24BYDUREON BCISE 24BYDUREON PEN 24

BYETTA 24C1000/BIOFLAVONOIDS/ROSEHIPS 103cabergoline 79CABLIVI 84CABOMETYX 41CAL-MAG-ZINC-D 98CALCET PETITES 95CALCI-CHEW 95calcipotriene 70calcitonin (salmon) 77calcitriol 78CALCIUM 96calcium 96calcium acetate (phosphatebinder) 82CALCIUM CARBONATE 95calcium carbonate 95calcium carbonate (antacid) 9calcium carbonate-cholecalciferol 96calcium carbonate-vitamind 96calcium carbonate-vitamin d w/minerals 96calcium citrate 96CALCIUM CITRATEMALATE/VITAMIN D 96CALCIUM CITRATE W/D 96calcium citrate-vitamin d 96CALCIUM GLUCONATE 96calcium pantothenate 137calcium polycarbophil 90calcium w/ vitamins d & k 96CALCIUM-FOLIC ACID PLUSD 96calcium-magnesium-zinc 96CALCIUM/C/D 96CALCIUM/VITAMIN D 96CALQUENCE 41CALTRATE 600+D PLUSMINERALS 96CALTRATE 600+D3 97CALTRATE 600+D3 SOFTCHEWS 97CAMPATH 37CAMPTOSAR 46candesartan cilexetil 33candesartan cilexetil-hydrochlorothiazide 34

CAPASTAT SULFATE 35CAPRELSA 41capsaicin 74captopril 32captopril &hydrochlorothiazide 34CARAC 70CARBAGLU 78carbamazepine 17carbamide peroxide (otic) 124carbidopa 46carbidopa-levodopa 46carbinoxamine maleate 29carbonyl iron 87carboplatin 36carboxymethylcellulose sodium(ophth) 121CARDIOTEK-RX 76carisoprodol 119carmustine 36carteolol hcl (ophth) 121carvedilol 55carvedilol phosphate 55CAYSTON 11cefaclor 58cefadroxil 58cefazolin sodium 58cefdinir 58CEFEPIME 59cefepime hcl 59cefixime 58cefoxitin sodium 58cefpodoxime proxetil 58cefprozil 58ceftazidime 58ceftriaxone sodium 58,59cefuroxime axetil 58cefuroxime sodium 58celecoxib 3CELONTIN 19CENTANY 68CENTRATEX 86CENTRAVITES 50 PLUS 104CENTRUM 104CENTRUM ADULTS 104CENTRUM SILVER 104

Index 3

CENTRUM SILVER ADULT50+ 104CENTRUM SILVER ULTRAWOMENS 104CENTRUM SPECIALISTHEART 104CENTRUM ULTRA MENS 104CENTRUM ULTRAWOMENS 104cephalexin 58CERDELGA 84CEREFOLIN 76CEREZYME 84CERTAVITESENIOR/ANTIOXIDANTNUTRIENTS 104CESAMET 27cetirizine hcl 29cetirizine-pseudoephedrine 62CETRAXAL 124cevimeline hcl 101CHANTIX 129CHANTIX CONTINUINGMONTHPAK 129CHANTIX STARTING MONTHPAK 129charcoal activated-sorbitol 26chenodiol 81CHLO TUSS 62chloramphenicol sodiumsuccinate 10chlordiazepoxide-amitriptyline

128chlorhexidine gluconate (mouth-throat) 101chloroquine phosphate 34chlorothiazide 77chlorpheniramine &phenylephrine 62chlorpheniramine &pseudoeph 62chlorpheniraminemaleate 28,29chlorpromazine hcl 49chlorthalidone 77chlorzoxazone 119cholecalciferol 136cholestyramine 31cholestyramine light 31choline fenofibrate 31chorionic gonadotropin 78ciclopirox 68,69

ciclopirox olamine 68cidofovir 53cilostazol 84CIMDUO 51cimetidine 132cinacalcet hcl 78CINQAIR 13CINRYZE 83CIPRODEX 124CIPROFLOXACIN 124ciprofloxacin hcl 81ciprofloxacin hcl (ophth) 122ciprofloxacin in d5w 81cisplatin 36citalopram hydrobromide 20CITRACAL + D3MAXIMUM 97CITRACAL MAXIMUM 97cladribine 36CLARINEX-D 12 HOUR 62clarithromycin 91clemastine fumarate 29CLEOCIN PHOSPHATE 10CLEVER CHOICE ANTI-STATICVALVED HOLDINGCHAMBER/ADULTLARGE 93CLEVER CHOICE ANTI-STATICVALVED HOLDINGCHAMBER/MEDIUM 93CLEVER CHOICE ANTI-STATICVALVED HOLDINGCHAMBER/SMALL 93CLINDAGEL 67clindamycin hcl 11clindamycin palmitatehydrochloride 11clindamycin phosphate 11clindamycin phosphate(topical) 67clindamycin phosphate ind5w 11clindamycin phosphatevaginal 135clindamycin phosphate-benzoylperoxide 68clindamycin phosphate-benzoylperoxide (refrigerate) 68CLINIMIX 4.25%/DEXTROSE5% 121CLINOLIPID 120clobazam 16

clobetasol propionate 71clobetasol propionate emollientbase 71clobetasol propionateemulsion 71clofarabine 36clomipramine hcl 22clonazepam 16clonidine 33clonidine hcl 33clonidine hcl (adhd) 1clopidogrel bisulfate 84clorazepate dipotassium 12clotrimazole 101clotrimazole (topical) 69clotrimazole vaginal 135clotrimazole w/betamethasone 69clozapine 48CLOZAPINE ODT 48COARTEM 34COATS ALOE CREME 73COATS ALOE GELLY 73COATS ALOE MOISTURIZINGLOTION 73colchicine 83colchicine w/ probenecid 83COLEMAN BOTANICALSINSECTREPELLENT 74COLEMAN INSECTREPELLENT/HIGH & DRY 74COLEMAN SKINSMARTINSECTREPELLENT 74colesevelam hcl 31colestipol hcl 31colistimethate sodium 11COMBIGAN 121COMBIVENT RESPIMAT 14COMETRIQ 41COMPACT SPACECHAMBER/ANTI-STATIC 93COMPACT SPACECHAMBER/ANTI-STATIC/LARGE MASK 93COMPACT SPACECHAMBER/ANTI-STATIC/MEDIUM MASK 93COMPACT SPACECHAMBER/ANTI-STATIC/SMALLMASK 93COMPLERA 51COPAXONE 129

Index 4

COPIKTRA 41CORAL CALCIUM 97CORLANOR 58cortisone acetate 60CORVITA 104CORVITE 104CORVITE 150 86CORVITE FE 86COTELLIC 41COZIMA 74CREON 76CRESEMBA 28CRIXIVAN 51cromolyn sodium 13cromolyn sodium(mastocytosis) 81cromolyn sodium (nasal) 119cromolyn sodium (ophth) 123CRYSVITA 78CUTTER BACKWOODS 74CUTTER BACKWOODSDRY 74CUTTER LEMONEUCALYPTUS 74CUVITRU 125CVS HAIR/SKIN/NAILS 118CVS SPECTRAVITE ADULT50+ 104CVS SPECTRAVITE ULTRAMENS HEALTH 104CVS SPECTRAVITE ULTRAWOMEN 104CVS SPECTRAVITE ULTRAWOMENS HEALTH 104CVS SPECTRAVITE ULTRAWOMENS HEALTHSENIOR 104cyanocobalamin 84cyanocobalamin-methylcobalamin 86cyclobenzaprine hcl 119CYCLOMYDRIL 121cyclopentolate hcl 121cyclophosphamide 36CYCLOSET 24cyclosporine 100cyclosporine modified (formicroemulsion) 100cyproheptadine hcl 30CYRAMZA 37CYSTAGON 83

CYSTARAN 123cytarabine 37D-VI-SOL 136dacarbazine 44dactinomycin 40DAKLINZA 54dalfampridine 129DALIRESP 14DALLERGY 62danazol 8dantrolene sodium 119dapsone 10DAPTACEL 131daptomycin 10DARAPRIM 34DARZALEX 38daunorubicin hcl 40DAUNORUBICINHYDROCHLORIDE 40DAURISMO 38DAY TIME MULTI-SYMPTOMCOLD/FLU RELIEF 62DDAVP 79decitabine 37DECONEX DMX 62DECONEX IR 62deferasirox 26DEKAS ESSENTIAL 115DEKAS PLUS 105,116DELESTROGEN 80DELSTRIGO 51DELSYM 61DELSYM COUGHCHILDRENS 61demeclocycline hcl 131DEMSER 33DENAVIR 70DEPEN TITRATABS 99DEPO-MEDROL 60DEPO-PROVERA 39DESCOVY 51desipramine hcl 22desloratadine 30desmopressin acetate 79desmopressin acetatespray 79desmopressin acetate sprayrefrigerated 79

desogestrel & ethinylestradiol 59desogestrel-ethinyl estradiol(biphasic) 59desonide 71desoximetasone 72DESVENLAFAXINE ER 21desvenlafaxine succinate 21dexamethasone 60dexamethasone sodiumphosphate 60dexamethasone sodiumphosphate (ophth) 123DEXILANT 133dexmethylphenidate hcl 1dexrazoxane hcl 45dextran 70-hypromellose 121dextroamphetamine sulfate 1dextromethorphan hbr 61dextromethorphan polistirex 61dextromethorphan-doxylamine-acetaminophen 62dextromethorphan-guaifenesin

62dextromethorphan-phenylephrine-acetaminophen

62dextrose 120dextrose in lactated ringers 97dextrose w/ sodium chloride 97DIALYVITE 3000 103DIALYVITE 5000 103DIALYVITE 800/IRON 103DIALYVITE SUPREME D 105DIALYVITE/ZINC 103DIASTAT ACUDIAL 16DIASTAT PEDIATRIC 16diazepam 12diazepam (anticonvulsant) 16DIAZEPAM RECTAL GEL 16dibucaine (rectal) 8DICLOFENAC EPOLAMINE 68diclofenac potassium 3diclofenac sodium 3diclofenac sodium (actinickeratoses) 70diclofenac sodium (ophth) 123diclofenac sodium (topical) 68diclofenac w/ misoprostol 3dicloxacillin sodium 126

Index 5

dicyclomine hcl 132didanosine 51DIFICID 91diflorasone diacetate 72diflunisal 5digoxin 56DIGOXIN 56digoxin 56dihydroergotamine mesylate 95diltiazem hcl 56diltiazem hcl coated beads 56diltiazem hcl extended releasebeads 56dimenhydrinate 27dimethicone (topical) 74DIPENTUM 82diphenhydramine hcl 29diphenhydramine hcl (sleep) 89diphenhydramine-acetaminophen

63diphenhydramine-acetaminophen(sleep) 89diphenhydramine-phenylephrine-acetaminophen 63diphenoxylate w/ atropine 26DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC 131dipyridamole 84disopyramide phosphate 12disulfiram 127divalproex sodium 19DIVIGEL 80dobutamine hcl 136DOCETAXEL 45docetaxel 45DOCETAXEL 45docusate calcium 90docusate sodium 91DOCUSOL KIDS 91DOCUSOL PLUS MINI-ENEMA 91dofetilide 13donepezil hydrochloride 127DOPTELET 85dorzolamide hcl 124dorzolamide hcl-timololmaleate 121DOVATO 51

doxazosin mesylate 33doxepin hcl 22doxorubicin hcl 40doxorubicin hcl liposomal 40doxycycline(monohydrate) 131doxycycline hyclate 131DR SMITHS DIAPER 74DR SMITHS DIAPER RASHSPRAY 74dronabinol 27drospirenone-ethinylestradiol 59DROXIA 84duloxetine hcl 21DUOPA 46DURAFLU 63DUREZOL 123dutasteride 83dutasteride-tamsulosin hcl 83DUZALLO 83EASIVENT 93EASIVENT/MASK-LARGE 93EASIVENT/MASK-MEDIUM

93EASIVENT/MASK-SMALL 93econazole nitrate 69ED A-HIST 63ED A-HIST DM 63ED BRON GP 63ED CHLORPED 29ED CHLORPED D 63EDURANT 51efavirenz 51EGRIFTA 78ELELYSO 84ELFOLATE PLUS 76ELIGARD 39ELIQUIS 15ELIQUIS STARTER PACK 15ELITEK 44ELLA 60EMCYT 39EMFLAZA 60EMGALITY 95EMPLICITI 38EMSAM 20EMTRIVA 51

enalapril maleate 32,33enalapril maleate &hydrochlorothiazide 34ENBREL 4ENBREL MINI 4ENBREL SURECLICK 4ENDARI 84ENEMEEZ PLUS 91ENFAMIL ENFALYTE 97ENGERIX-B 134ENLYTE 76enoxaparin sodium 15entacapone 46entecavir 54ENTRESTO 57ENTYVIO 82ENVARSUS XR 100EPCLUSA 54EPIDIOLEX 17epinastine hcl (ophth) 124epinephrine (anaphylaxis) 136EPIPEN 2-PAK 136EPIPEN-JR 2-PAK 136epirubicin hcl 40EPIVIR HBV 54eplerenone 34EPOGEN 85eprosartan mesylate 33EQ COMPLETEMULTIVITAMINADULTS UNDER50 105EQ ONE DAILY WOMENSHEALTH 105EQUETRO 47ERAXIS 27ERBITUX 38ergocalciferol 136ergoloid mesylates 129ergotamine tartrate 95ergotamine w/ caffeine 94ERIVEDGE 38ERLEADA 39erlotinib hcl 41ertapenem sodium 10ERWINAZE 44erythromycin (acne aid) 68erythromycin (ophth) 122erythromycin base 91

Index 6

erythromycin ethylsuccinate 91erythromycin lactobionate 91ESBRIET 130ESCAVITE 116escitalopram oxalate 20esomeprazole magnesium 133esomeprazole sodium 133estradiol 80estradiol & norethindroneacetate 80estradiol vaginal 135estradiol valerate 80estropipate 80ethambutol hcl 35ethosuximide 19ethynodiol diacet & ethestrad 59ETHYOL 45etodolac 3ETOPOPHOS 45etoposide 45EVOMELA 36EVOTAZ 51exemestane 39EXONDYS 51 120ezetimibe 32ezetimibe-simvastatin 30EZFE 200 87FABRAZYME 78famciclovir 54famotidine 132FANAPT 47FARYDAK 41FASENRA 13fat emulsion plant based 120FAZACLO 48,49fe fum-iron polysacch complex-fa-b complex-c-zn-mn-cu 86felbamate 18felodipine 56fenofibrate 31fenofibrate micronized 31fentanyl 5fentanyl citrate 5FEOSOL 87FEOSOL BIFERA 86FER-IN-SOL 87

FERIVA 21/7 86FERIVAFA 86FERRALET 90 86FERRAPLUS 90 86FERRETTS 87FERRETTS IPS 87FERREX 150 FORTE 86FERRIMIN 150 87FERRIPROX 26ferrous fumarate 87ferrous fumarate-folic acid 86ferrous gluconate 87FERROUS GLUCONATE 87ferrous sulfate 88FERROUS SULFATE 88ferrous sulfate 88FERROUS SULFATE 88ferrous sulfate 88FERROUS SULFATE 88ferrous sulfate 88FERROUS SULFATE 88ferrous sulfate 88ferrous sulfate dried 87FETZIMA 21FETZIMA TITRATIONPACK 21fexofenadine hcl 30finasteride 83finasteride (alopecia) 73FIRDAPSE 35FIRMAGON 39FIRVANQ 10flavoxate hcl 134FLEBOGAMMA DIF 125flecainide acetate 13FLECTOR 68FLEET PEDIATRIC 90FLEXICHAMBER 93FLEXICHAMBER ADULTMASK/SMALL 93FLEXICHAMBER CHILDMASK/LARGE 93FLEXICHAMBER CHILDMASK/SMALL 93FLOVENT DISKUS 14FLOVENT HFA 14FLOWTUSS 63fluconazole 28

fluconazole in dextrose 28fluconazole in nacl 28flucytosine 28fludarabine phosphate 37fludrocortisone acetate 61flunisolide (nasal) 120fluocinolone acetonide 72fluocinolone acetonide(otic) 125fluocinonide 72fluocinonide emulsified base 72fluorometholone (ophth) 123fluorouracil 37FLUOROURACIL 70fluorouracil (topical) 70fluoxetine hcl 20fluphenazine decanoate 49fluphenazine hcl 49flurbiprofen 3flurbiprofen sodium 124flutamide 39fluticasone propionate 72fluticasone propionate(nasal) 120fluticasone-salmeterol 14fluvastatin sodium 31fluvoxamine maleate 20FOLBEE PLUS CZ 103FOLGARD OS 104FOLGARD RX 86FOLIC ACID 85folic acid 85folic acid-pyridoxine-cyanocobalamin 76folic acid-vitamin b6-vitaminb12 86FOLITAB 500 86FOLOTYN 37FOLTANX 76FOLTRATE 86fondaparinux sodium 15FORFIVO XL 20FORTAVIT 105FORTEO 77fosamprenavir calcium 51FOSFREE 105fosinopril sodium 33

Index 7

fosinopril sodium &hydrochlorothiazide 34fosphenytoin sodium 18,19FRAGMIN 16fructose-dextrose-phosphoricacid 27FULL SPECTRUM B/VITAMINC 103fulvestrant 39FULVESTRANT 39FUNGOID TINCTURE 69furosemide 76,77FUSION 86FUSION PLUS 86FUZEON 51FYCOMPA 16gabapentin 17GALAFOLD 79galantamine hydrobromide 127GALZIN 99GAMASTAN 125GAMASTAN S/D 125GAMMAGARD LIQUID 125GAMMAKED 125GAMMAPLEX 125GAMUNEX-C 125ganciclovir sodium 53GARDASIL 9 134gatifloxacin (ophth) 122GATTEX 82gauze pads 2"x2" 91GAZYVA 38gemcitabine hcl 37GEMCITABINEHYDROCHLORIDE 37gemfibrozil 31gentamicin in saline 2gentamicin sulfate 2gentamicin sulfate (ophth) 122gentamicin sulfate (topical) 68GENVOYA 51GEODON 47GILENYA 129GILOTRIF 41glatiramer acetate 129GLEOSTINE 36glimepiride 25glipizide 25

glipizide-metformin hcl 22GLUCAGEN HYPOKIT 23GLUCAGON EMERGENCYKIT 23glyburide 25,26glyburide micronized 25glyburide-metformin 22glycine diluent 127glycopyrrolate 132granisetron hcl 27GRANIX 85griseofulvin microsize 28griseofulvin ultramicrosize 28guaifenesin 67guaifenesin-codeine 63guanfacine hcl 33guanfacine hcl (adhd) 1GUANIDINE HCL 35HAEGARDA 83HALAVEN 45halobetasol propionate 72haloperidol 48haloperidol decanoate 48haloperidol lactate 48HARD NAILS 137HARVONI 54HAVRIX 134HEALTHY KIDSGUMMIES 116HEMOCYTE 88HEMOCYTE PLUS 86HEPARIN SODIUM 16heparin sodium (porcine) 16HERCEPTIN 38HERCEPTIN HYLECTA 40HETLIOZ 90HEXALEN 36HIBERIX 134HISTEX 29HISTEX PD 29HISTEX-DM 63HISTEX-PE 63HIZENTRA 125HM COMPLETE 105HM COMPLETE 50+WOMENS ULTIMATE 105HM COMPLETE MEN 105

HM HAIR/SKIN/NAILS 105HM ONE DAILYESSENTIAL 103HM ONE DAILY WOMENS 105HONEY BEARS 118HUMALOG 24HUMALOG JUNIORKWIKPEN 24HUMALOG KWIKPEN 24HUMALOG MIX 50/50 24HUMALOG MIX 50/50KWIKPEN 24HUMALOG MIX 75/25 24HUMALOG MIX 75/25KWIKPEN 24HUMIRA 2HUMIRA PEDIATRIC CROHNSDISEASE STARTER PACK 2HUMIRA PEN 2HUMIRA PEN-CD/UC/HSSTARTER 2HUMIRA PEN-PS/UVSTARTER 2HUMULIN 70/30 24HUMULIN 70/30 KWIKPEN 24HUMULIN N 24HUMULIN N KWIKPEN 24HUMULIN R 24HUMULIN R U-500(CONCENTRATED) 24HUMULIN R U-500KWIKPEN 24HYCOFENIX 63hydralazine hcl 34hydrochlorothiazide 77HYDROCODONEBITARTRATE/CHLORPHENIRAMINE MALEATE/PSE 63hydrocodone polistirex-chlorpheniramine polistirex 63hydrocodone w/homatropine 61hydrocodone-acetaminophen 7hydrocodone-ibuprofen 7hydrocortisone 60hydrocortisone (intrarectal) 8hydrocortisone (rectal) 8hydrocortisone (topical) 72hydrocortisone butyrate 73hydrocortisone butyratehydrophilic lipo base 73hydrocortisone valerate 73

Index 8

hydrocortisone w/aceticacid 125hydrocortisone-aloe vera 73hydromorphone hcl 5HYDROMORPHONEHYDROCHLORIDE 5hydroxychloroquine sulfate 34HYDROXYPROGESTERONECAPROATE 39hydroxyurea 44hydroxyzine hcl 12hydroxyzine pamoate 12HYPERRAB S/D 125HYQVIA 126ibandronate sodium 77IBRANCE 42ibuprofen 3,4ICAPS AREDS FORMULA 105ICAPSLUTEIN/ZEAXANTHIN 118ICAR PEDIATRIC 88ICAR-C 86icatibant acetate 83ICLUSIG 42idarubicin hcl 40IDHIFA 42IFEX 36ifosfamide 36IFOSFAMIDE 36ILARIS 3ILEVRO 124ILUMYA 70imatinib mesylate 42IMBRUVICA 42IMFINZI 38imipenem-cilastatin 10imipramine hcl 22imipramine pamoate 22imiquimod 73IMIQUIMOD PUMP 73IMOGAM RABIES-HT 125IMOVAX RABIES(H.D.C.V.) 135IMPAVIDO 9INCRELEX 78indapamide 77indomethacin 4INFANRIX 132

INFED 88INFLECTRA 82INFUGEM 37INGREZZA 128INLYTA 42INREBIC 42INSPIRACHAMBER/ANTI-STATICVALVED/MOUTHPIECE 93INSPIRACHAMBER/LARGE

93INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/MEDIUM 93INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/SMALL 93INSULIN SYRINGES AND PENNEEDLES 92INTEGRA 86INTEGRA F 87INTEGRA PLUS 87INTELENCE 51INTRON A 44INVANZ 10INVEGA SUSTENNA 48INVEGA TRINZA 48INVIRASE 51INVOKAMET 22INVOKAMET XR 22INVOKANA 25IOSAT 26IPOL INACTIVATED IPV 135ipratropium bromide 13ipratropium bromide(nasal) 120ipratropium-albuterol 14irbesartan 33irbesartan-hydrochlorothiazide

34IRESSA 42irinotecan hcl 46IRON 88iron polysaccharide complex-vitb12-folic acid 87IRON SLOW RELEASE 88iron-vitamin c 87IROSPAN 24/6 87irrigation solutions,physiological 100ISENTRESS 51,52

ISENTRESS HD 52isoniazid 35isoniazid & rifampin 35ISOPTO TEARS 121isosorbide dinitrate 11isosorbide mononitrate 11isotretinoin 68ISTODAX (OVERFILL) 42itraconazole 28ivermectin 9IXEMPRA KIT 45IXIARO 135JADENU 26JADENU SPRINKLE 26JAKAFI 42JANUMET 22JANUMET XR 23JANUVIA 23JARDIANCE 25JENTADUETO 23JENTADUETO XR 23JEVTANA 45JULUCA 52JUXTAPID 32JYNARQUE 80K-TAB 98KADCYLA 38KALBITOR 83KALETRA 52KALYDECO 130KANJINTI 38KANUMA 79KEDRAB 125KENALOG-10 60KEPIVANCE 45ketoconazole 28ketoconazole (topical) 69ketoprofen 4ketorolac tromethamine 4ketorolac tromethamine(ophth) 124ketotifen fumarate (ophth) 124KEVZARA 3KEYTRUDA 38KHAPZORY 45KHEDEZLA 21

Index 9

KINRIX 132KISQALI 42KISQALI FEMARA 200DOSE 41KISQALI FEMARA 400DOSE 41KISQALI FEMARA 600DOSE 41KITABIS PAK 2KORLYM 23KRINTAFEL 34KUVAN 79KYNAMRO 31KYPROLIS 42L-METHYL-B6-B12 76L-METHYL-MC 76labetalol hcl 55lactated ringer's 97lactic acid (ammoniumlactate) 73lactulose 90lactulose (encephalopathy) 82LAMICTAL XR 17lamivudine 52lamivudine (hbv) 54lamivudine-zidovudine 52lamotrigine 17LANOXIN 56lansoprazole 133lanthanum carbonate 82LANTUS 25LANTUS SOLOSTAR 25LARTRUVO 38latanoprost 124LATUDA 47LAZANDA 5,6LEDIPASVIR/SOFOSBUVIR

54leflunomide 4LEMTRADA 129LENVIMA 10 MG DAILYDOSE 42LENVIMA 12MG DAILYDOSE 42LENVIMA 14 MG DAILYDOSE 42LENVIMA 18 MG DAILYDOSE 42LENVIMA 20 MG DAILYDOSE 42

LENVIMA 24 MG DAILYDOSE 42LENVIMA 4 MG DAILYDOSE 42LENVIMA 8 MG DAILYDOSE 42letrozole 39leucovorin calcium 45LEUKERAN 36LEUKINE 85leuprolide acetate 39levalbuterol hcl 14levalbuterol tartrate 14LEVEMIR 25LEVEMIR FLEXTOUCH 25levetiracetam 17,18levetiracetam in sodiumchloride 17levobunolol hcl 121levocarnitine (metabolicmodifiers) 79levocetirizinedihydrochloride 30levofloxacin 81levofloxacin (ophth) 122levofloxacin in d5w 81levoleucovorin calcium 45levonorgestrel & ethestradiol 59levonorgestrel (emergencyoc) 60levonorgestrel-eth estradiol(triphasic) 59levonorgestrel-ethinyl estradiol(91-day) 59levothyroxine sodium 131LEXIVA 52LIBTAYO 38lidocaine 74lidocaine hcl 74lidocaine hcl (localanesth.) 91lidocaine hcl (mouth-throat) 101lidocaine-prilocaine 74LIFE PACK MENS 105LIFE PACK WOMENS 105lincomycin hcl 11linezolid 11LINEZOLID 11linezolid 11

LINZESS 82liothyronine sodium 131lisinopril 33lisinopril &hydrochlorothiazide 34LITEAIRE 94LITHIUM 47lithium carbonate 47LODRANE D 63LOHIST-D 63LOHIST-DM 63LOKELMA 101LONSURF 41loperamide hcl 26lopinavir-ritonavir 52loratadine 30loratadine &pseudoephedrine 63lorazepam 12LORBRENA 42LORTUSS DM 63LORTUSS EX 64LORTUSS LQ 64losartan potassium 33losartan potassium &hydrochlorothiazide 34LOTEMAX 123loteprednol etabonate 123lovastatin 32loxapine succinate 49LUCEMYRA 127LUMIGAN 124LUMIZYME 79LUMOXITI 38LUPANETA PACK 78LUPRON DEPOT (1-MONTH) 39LUPRON DEPOT (3-MONTH) 39LUPRON DEPOT (4-MONTH) 39LUPRON DEPOT (6-MONTH) 39LUPRON DEPOT-PED (1-MONTH) 78LUPRON DEPOT-PED (3-MONTH) 78LYNPARZA 42LYSODREN 39M-END DMX 64

Index 10

M-M-R II 135MAG-TAB SR 98MAGNESIUM 9magnesium 98MAGNESIUM ELEMENTAL 98magnesium hydroxide 90magnesium lactate 98magnesium oxide 9MAGNESIUM OXIDE 98magnesium oxide (laxative) 90magnesium oxide (mgsupplement) 98magnesium sulfate 98malathion 75maprotiline hcl 20MARPLAN 20MARQIBO 45MATULANE 44MAVENCLAD 129MAVYRET 54meclizine hcl 27MEDROL 60medroxyprogesteroneacetate 127medroxyprogesterone acetate(contraceptive) 60mefenamic acid 4mefloquine hcl 35MEGA MULTI FOR MEN 105MEGA MULTIVITAMIN FORWOMEN 105megestrol acetate 39megestrol acetate(appetite) 127MEKINIST 42MEKTOVI 42meloxicam 4melphalan 36melphalan hcl 36memantine hcl 128MENACTRA 134MENS MULTI VITAMIN &MINERAL FORMULA 105menthol (topical analgesic) 68menthol-methyl salicylate(liniments) 74MENVEO 134MEPHYTON 136mercaptopurine 37

meropenem 10mesalamine 82mesalamine w/ cleanser 82mesna 45MESNEX 45METAFOLBIC 76metaxalone 119metformin hcl 23methadone hcl 6methamphetamine hcl 1methazolamide 76methenamine hippurate 133methimazole 131methocarbamol 119methotrexate sodium 37methoxsalen rapid 70methscopolaminebromide 132methylergonovinemaleate 125methylphenidate hcl 1methylprednisolone 61methylprednisoloneacetate 60methylprednisolone sodsucc 60methyltestosterone 8metoclopramide hcl 81metolazone 77metoprolol &hydrochlorothiazide 34metoprolol succinate 55metoprolol tartrate 55metronidazole 9metronidazole (topical) 75metronidazole in nacl 9metronidazole vaginal 135mexiletine hcl 13MIACALCIN 77miconazole nitrate (topical)69miconazole nitratevaginal 135MICROCHAMBER 94MICROSPACER 94midodrine hcl 136miglitol 22miglustat 84MIGRANAL 95minocycline hcl 131

minoxidil 34mirtazapine 19MIRVASO 75misoprostol 133mitomycin 40mitoxantrone hcl 40modafinil 2moexipril hcl 33moexipril-hydrochlorothiazide

34molindone hcl 49mometasone furoate 73MONOCAL 98montelukast sodium 13,14morphine sulfate 6MORPHINE SULFATE 6morphine sulfate 6MORPHINE SULFATE 6morphine sulfate 6MOVANTIK 82moxifloxacin hcl (ophth) 122MOZOBIL 88MTX SUPPORT 87MUCINEX 67MUCINEX CHILDRENS COLDCOUGH & SORE THROAT 64MUCINEX CHILDRENS MULTI-SYMPTOM COLD 64MUCINEX CHILDRENS MULTI-SYMPTOM COLD & FEVER 64MUCINEX CONGESTION &COUGH CHILDRENS 64MUCINEX COUGH FORKIDS 64MUCINEX D 64MUCINEX D MAXIMUMSTRENGTH 64MUCINEX DM 64MUCINEX DM MAXIMUMSTRENGTH 64MUCINEX FAST-MAX COLDFLU& SORE THROAT 64MUCINEX FAST-MAX DAYTIME/NIGHT TIME 64MUCINEX FAST-MAXDAY/NIGHT MAXIMUMSTRENGTH 64MUCINEX FAST-MAX SEVERECOLD 64MUCINEX FAST-MAX SEVERECONGESTION & COUGH 64MUCINEX FOR KIDS 67

Index 11

MUCINEX MAXIMUMSTRENGTH 67MUCINEX MULTI-SYMPTOMCOLD DAY/NIGHT PACK 64MUCINEX STUFFY NOSE &COLD CHILDRENS 64MULPLETA 85MULTAQ 13MULTI-DELYN/IRON 116MULTI-VITE 105multiple minerals 98multiple minerals w/ vitamins 98multiple vitamin 115multiple vitamins w/ calcium104multiple vitamins w/ iron 104multiple vitamins w/minerals 105,106mupirocin 68mupirocin calcium (topical) 68MURO 128 124MVASI 37MYALEPT 79MYCAMINE 27mycophenolate mofetil 100mycophenolate mofetil hcl 100mycophenolate sodium 100MYDRIACYL 121MYLOTARG 38MYRBETRIQ 134nabumetone 4nadolol 55nadolol &bendroflumethiazide 34nafcillin sodium 126NAFCILLIN SODIUM 126nafcillin sodium 127naftifine hcl 69NAFTIN 69NAGLAZYME 79naloxone hcl 26naltrexone hcl 26NAMENDA XR TITRATIONPACK 128naproxen 4naproxen sodium 4naratriptan hcl 95NASAL DECONGESTANT 120NASCOBAL 85NASOPEN PE 64

NATACYN 122nateglinide 25NATPARA 77NATRAPEL 12-HOUR TICK &INSECT REPELLENTCONTINUOUS SPRAY 75NEBUPENT 9nefazodone hcl 21neomycin sulfate 2neomycin-bacitracin zn-polymyxin 122neomycin-bacitracin-polymyxin

68neomycin-bacitracin-polymyxin-pramoxine 68neomycin-polymy-dexameth 123neomycin-polymyxin-gramicidin

122neomycin-polymyxin-hc(otic) 124neomycin/polymyxin b gu 83NEPHPLEX RX 103NEPHRO-VITE 103NEPHRO-VITE RX 103NEPHROCAPS 103NEPHRON FA 87NEPHRONEX 103NERLYNX 42NEULASTA 85NEULASTA ONPRO KIT 85NEUPOGEN 85NEUPRO 46NEURIN-SL 87NEVANAC 124nevirapine 52NEXAVAR 42NEXIUM 133niacin 137niacin (antihyperlipidemic) 32nicardipine hcl 56NICODERM CQ 129NICORETTE 129NICORETTE MINI 129NICORETTE STARTERKIT 129nicotine 130nicotine polacrilex 130NICOTINE TRANSDERMALSYSTEM 130

NICOTROL INHALER 130NICOTROL NS 130nifedipine 56nilutamide 39nimodipine 56NINJACOF 64NINJACOF-A 64NINJACOF-XG 64NINLARO 43NIPENT 44nisoldipine 56nitisinone 79nitrofurantoin macrocrystal 133nitrofurantoin monohydmacro 134nitroglycerin 12NITROGLYCERIN LINGUAL12NITROSTAT 12NIVESTYM 85nizatidine 132NO IRON MULTIPLEVITAMIN/MINERALS 114NORDITROPIN FLEXPRO 78norelgestromin-ethinylestradiol 59norethin acet & estrad-fe 59norethindrone & eth estradiol59norethindrone & ethinyl estradiol-fe 59norethindrone(contraceptive) 60norethindrone acet & ethestra 59norethindrone acetate 127norethindrone acetate-ethinylestradiol 80norethindrone-eth estradiol(triphasic) 59norgestimate-ethinylestradiol 59norgestimate-ethinyl estradiol(triphasic) 59norgestrel & ethinyl estradiol 59NORTHERA 136nortriptyline hcl 22NORVIR 52NOVAFERRUM 125 87NOVAFERRUM 50 88NOVAFERRUM PEDIATRICDROPS 88NOVAREL 78

Index 12

NOXAFIL 28NU-MAG 98NUBEQA 39NUCALA 13NUEDEXTA 129NULOJIX 100NUPLAZID 47NUTRIVIT 103NUTROPIN AQ NUSPIN 20 78NUVARING 60NUZYRA 131NYMALIZE 56nystatin 28nystatin (mouth-throat) 101nystatin (topical) 69nystatin-triamcinolone 69OCALIVA 81OCREVUS 129OCTAGAM 125octreotide acetate 79ODEFSEY 52ODOMZO 39OFEV 130OFF DEEP WOODS 75OFF DEEP WOODS DRY 75OFF DEEP WOODSSPORTSMEN 75ofloxacin (ophth) 122ofloxacin (otic) 124olanzapine 49olanzapine-fluoxetine hcl 128olopatadine hcl 124olopatadine hcl (nasal) 119OLUMIANT 2omega-3-acid ethyl esters 31omeprazole 133omeprazole magnesium 133omeprazole-sodiumbicarbonate 133OMNICAP 116ONCASPAR 44ONCOVITE 114ondansetron 27ondansetron hcl 27ONE-A-DAY ESSENTIAL 116ONE-A-DAY MENS 50+ADVANTAGE 114

ONE-A-DAY TEENADVANTAGEFOR HIM 114ONE-A-DAY WOMENSFORMULA 104ONE-WAY VALVEDEXPIRATORYMOUTHPIECE/DISPOSABLE 94ONE-WAY VALVEDINSPIRATORYMOUTHPIECE/DISPOSABLE

94ONFI 16ONIVYDE 46OPDIVO 38OPSUMIT 57OPTICHAMBERDIAMOND 94OPTICHAMBERDIAMOND/LARGEFACEMASK 94OPTICHAMBERDIAMOND/MEDIUM FACEMASK 94OPTICHAMBERDIAMOND/SMALLFACEMASK 94oral electrolytes 97ORAZINC 99ORBACTIV 10ORENITRAM 57ORFADIN 79ORILISSA 78ORKAMBI 130oseltamivir phosphate 54,55OSPHENA 78OSTEO-PORETICAL 97OTREXUP 3oxaliplatin 36oxandrolone 8oxaprozin 4oxazepam 12oxcarbazepine 18OXERVATE 123oxybutynin chloride 134oxycodone hcl 6oxycodone w/acetaminophen 7oxycodone-aspirin 7oxymetazoline hcl 120oxymorphone hcl 6oyster shell 97

OYSTER SHELLCALCIUM/MAGNESIUM 97paclitaxel 45paliperidone 48PALYNZIQ 79PANCREAZE 76PANDA MASK LARGE 94PANDA MASK MEDIUM 94PANDA MASK SMALL 94PANRETIN 70pantoprazole sodium 133parenteral electrolytes 98paricalcitol 79paromomycin sulfate 2paroxetine hcl 20paroxetine mesylate(vasomotor) 130PAXIL 20PEDIALYTE 98PEDIALYTE ADVANCEDCARE 98PEDIALYTE FREEZERPOPS 98PEDIALYTE SINGLES 98PEDIARIX 132PEDIATRIC COUGH/COLD 65PEDIATRIC MEDIUM MASK92pediatric multiple vitamin w/c 118pediatric multiple vitamin w/ c &fa 118pediatric multiple vitamin w/ extrac & fa 118pediatric multiple vitamin w/minerals & c 117pediatric multiple vitamins w/iron 116PEDIATRIC PANDA MASK 94PEDIATRIC SMALL MASK 92pediatric vitamins adc 118PEDVAX HIB 134peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 90peg 3350-potassium chloride-sodbicarbonate-sod chloride 90PEGANONE 19PEGASYS 54PEGASYS PROCLICK 54PEGINTRON 54penicillin g potassium 126penicillin v potassium 126

Index 13

PENTACEL 132PENTAM 300 9pentamidine isethionate 9pentoxifylline 83PERIDIN-C 103perindopril erbumine 33PERJETA 38permethrin 75perphenazine 49perphenazine-amitriptyline 128PERSERIS 48PETROLATUM 127phenelzine sulfate 20phenobarbital 89phenoxybenzamine hcl 33phenylephrine hcl 120phenylephrine hcl (oral) 120PHENYLEPHRINEHCL/PYRILAMINEMALEATE 65phenylephrine in hard fat 8phenylephrine w/acetaminophen 65phenylephrine w/ dm-gg 65phenylephrine-acetaminophen-guaifenesin 65phenylephrine-brompheniramine-dm 65phenylephrine-chlorphen-dm

65phenylephrine-cocoa butter 8phenylephrine-diphenhydramine-gg w/ apap 65phenylephrine-dm-gg w/apap 65phenylephrine-guaifenesin 65phenylephrine-mineral oil-petrolatum 8phenytoin 19phenytoin sodium 19phenytoin sodium extended 19PHILLIPS 90PHOSPHOLINE IODIDE 122phytonadione 136PICATO 70PIFELTRO 52pilocarpine hcl 122pilocarpine hcl (oral) 101pimecrolimus 74pimozide 129

pindolol 55pioglitazone hcl 24pioglitazone hcl-glimepiride 23pioglitazone hcl-metforminhcl 23piperacillin sodium-tazobactamsodium 126PIQRAY 200MG DAILYDOSE 43PIQRAY 250MG DAILYDOSE 43PIQRAY 300MG DAILYDOSE 43piroxicam 4POCKET CHAMBER 94podofilox 74POLIVY 38POLY HIST FORTE 65POLY-HIST DM 65POLY-HIST PD 65POLY-VENT DM 65POLY-VENT IR 65POLY-VI-SOL 118POLY-VI-SOL/IRON 116polyethylene glycol 3350 90polyethylene glycol-propyleneglycol (ophth) 121polymyxin b sulfate 11polymyxin b-trimethoprim 122polysaccharide ironcomplex 88POLYTUSSIN DM 65polyvinyl alcohol 121POMALYST 40PORTRAZZA 38posaconazole 28POTABA 137potassium chloride 98,99POTASSIUM CHLORIDEER 99potassium chloride in dextrose& sodium chloride 98potassium chloridemicroencapsulated crystalser 99potassium citrate(alkalinizer) 82POTELIGEO 38povidone-iodine 50PRADAXA 16PRALUENT 32

pramipexole dihydrochloride 46prasugrel hcl 84pravastatin sodium 32prazosin hcl 33PRED FORTE 123prednicarbate 73prednisolone 61prednisolone acetate(ophth) 123prednisolone sodiumphosphate 61prednisone 61pregabalin 18PREMARIN 81,135PREMPHASE 80PREMPRO 80PREVYMIS 53PREZCOBIX 52PREZISTA 52PRIFTIN 35primaquine phosphate 35PRIMAQUINE PHOSPHATE35PRIMEAIRE DUAL-VALVEDHOLDING CHAMBER 94primidone 18PRIVIGEN 125PROAIR HFA 14PROAIR RESPICLICK 15probenecid 83prochlorperazine 49prochlorperazine edisylate 49prochlorperazine maleate 49PROCRIT 85PROFE 88PROFERRIN ES 88PROFERRIN-FORTE 87progesterone micronized 127PROGLYCEM 23PROGRAF 100PROLASTIN-C 130PROLEUKIN 44PROLIA 77PROMACTA 85,86promethazine &phenylephrine 65promethazine hcl 30promethazine w/codeine 66

Index 14

promethazine-phenylephrine-codeine 66PROMETHAZINE/DEXTROMETHORPHAN 66propafenone hcl 13proparacaine hcl 123propranolol hcl 55propylthiouracil 131PROQUAD 135PROTECTIRON 87protriptyline hcl 22pseudoephed-bromphen-dm 66pseudoephedrine hcl 120pseudoephedrine w/ codeine-gg 66pseudoephedrine-chlorphen-dm

66pseudoephedrine-guaifenesin

66psyllium 90PULMOZYME 130PURIXAN 37pyrazinamide 35pyridostigmine bromide 35pyridoxine hcl 137QUADRACEL 132quetiapine fumarate 49quinapril hcl 33quinapril-hydrochlorothiazide

34quinidine gluconate 12quinidine sulfate 12quinine sulfate 35QUINTABS-M 114RA CALCIUM/BORON 97RA OYSTER SHELLCALCIUM/VITAMIN D 97RABAVERT 135RADICAVA 120raloxifene hcl 78ramelteon 90ramipril 33ranitidine hcl 132,133ranolazine 11rasagiline mesylate 47RASUVO 3RAVICTI 79RAYALDEE 79REBIF 129

REBIF REBIDOSE 129REBIF REBIDOSETITRATIONPACK 129REBIF TITRATION PACK129RECOMBIVAX HB 135RECTIV 8REFRESH OPTIVE MEGA-3 121REFRESH PLUS 121REGRANEX 76RELENZA DISKHALER 55RELISTOR 82REMICADE 82repaglinide 25REPAGLINIDE/METFORMINHYDROCHLORIDE 23REPATHA 32REPATHA PUSHTRONEXSYSTEM 32REPATHA SURECLICK 32REPEL HUNTERSFORMULA 75REPEL LEMON EUCALYPTUSINSECT REPELLENT 75REPEL SPORTSMEN 75REPEL SPORTSMENDRY 75REPEL SPORTSMENMAX 75RESCON 66RESCRIPTOR 52RESPAIRE-30 66RESTASIS 123RESTASIS MULTIDOSE 123RETACRIT 86RETROVIR IV INFUSION 52REVCOVI 79REVLIMID 99REXULTI 50REYATAZ 52ribavirin 55ribavirin (hepatitis c) 54riboflavin 137RIDAURA 3rifabutin 35rifampin 35RIFATER 35riluzole 120rimantadine hydrochloride 55RISACAL-D 97

RISPERDAL CONSTA 48risperidone 48RITEFLO 94ritonavir 52RITUXAN 38RITUXAN HYCELA 41rivastigmine 128rivastigmine tartrate 128rizatriptan benzoate 95ROMIDEPSIN 43RONDEC-D 66ropinirole hydrochloride 46rosuvastatin calcium 32ROTARIX 135ROTATEQ 135ROZLYTREK 43RU-HIST D 66RUBRACA 43RYDAPT 43RYMED 66S2 15saline 119SAMSCA 80SANDIMMUNE 100SANDOSTATIN LARDEPOT 80SANTYL 73SAPHRIS 49SAWYER PREMIUM INSECTREPELLENT 75SCOOBY-DOO ONE ADAY 116scopolamine 27selegiline hcl 47selenium 99selenium sulfide 70SELZENTRY 52,53sennosides 90sennosides-docusatesodium 90SENTRY 114SENTRY SENIOR 114SEREVENT DISKUS 15sertraline hcl 20sevelamer carbonate 82SHINGRIX 135SIDEROL 114SIGNIFOR 80

Index 15

SIGNIFOR LAR 80sildenafil citrate (pulmonaryhypertension) 57SILENOR 89SILIQ 70SILPHEN COUGH 29silver sulfadiazine 70SIMBRINZA 122simethicone 81SIMPONI 2SIMPONI ARIA 2SIMULECT 100simvastatin 32sirolimus 100SIRTURO 35SIVEXTRO 11SLO-NIACIN 137SLOW-MAG 98SM B-COMPLEX/VITAMINC 103SM ONE DAILY WOMENS 114SM SLOW RELEASE IRON 88sodium bicarbonate (antacid) 9sodium chloride 99sodium chloride (gu irrigant) 83sodium chloride hypertonic 124sodium phosphates 90sodium phosphates (sodiumphosphate dibasic &monobasic) 98sodium polystyrenesulfonate 101SOFOSBUVIR/VELPATASVIR

54SOLTAMOX 39SOLU-CORTEF 61SOLU-MEDROL 61SOMATULINE DEPOT 80SOMAVERT 78sotalol hcl 55sotalol hcl (afib/afl) 55SOTYLIZE 55SOVALDI 54specialty vitamins products 118SPIRIVA HANDIHALER 13SPIRIVA RESPIMAT 13spironolactone 77spironolactone &hydrochlorothiazide 76

SPRAVATO 56MG DOSE 20SPRAVATO 84MG DOSE 20SPRITAM 18SPRYCEL 43STAHIST AD 66stavudine 53STIOLTO RESPIMAT 15STIVARGA 43STRENSIQ 79STRIBILD 53STRIVERDI RESPIMAT 15STROVITE FORTE 114STROVITE ONE 114SUBSYS 7SUCRAID 76sucralfate 133sulfacetamide sod-prednisolone 123sulfacetamide sodium(acne) 68sulfacetamide sodium(ophth) 122sulfadiazine 130sulfamethoxazole-trimethoprim

10SULFAMYLON 71sulfasalazine 82sulindac 4sumatriptan succinate 95sumatriptan-naproxensodium 94SUPERVITE 103SUPPORT 114SUPPORT-500 118SUPREP BOWEL PREPKIT 90SUSPENDOL-S 127SUTENT 43SYLATRON 44SYMBICORT 15SYMDEKO 130SYMFI 53SYMFI LO 53SYMLINPEN 120 22SYMLINPEN 60 22SYMPAZAN 16SYMTUZA 53SYNAGIS 126SYNAREL 78

SYNDROS 27SYNERCID 11SYNJARDY 23SYNJARDY XR 23SYNRIBO 44TABLOID 37tacrolimus 100tacrolimus (topical) 74tadalafil (pulmonaryhypertension) 57TAFINLAR 43TAGRISSO 43TAKHZYRO 84TALZENNA 43tamoxifen citrate 40tamsulosin hcl 83TANDEM 87TANDEM PLUS 87TARGRETIN 70TARON FORTE 87TASIGNA 43TAVALISSE 83tazarotene 70TAZORAC 70TDVAX 132TECENTRIQ 38TECFIDERA 129TECFIDERA STARTERPACK 129TEFLARO 59TEGSEDI 130TEKTURNA HCT 34temazepam 89TEMIXYS 53TEMODAR 36temsirolimus 43TENIVAC 132tenofovir disoproxil fumarate 53terazosin hcl 33terbinafine hcl 28terbinafine hcl (topical) 69terbutaline sulfate 15terconazole vaginal 135testosterone 8testosterone cypionate 8testosterone enanthate 8tetrabenazine 128

Index 16

tetracycline hcl 131tetrahydrozoline hcl (ophth) 123THALOMID 99theophylline 15THERA M PLUS 114THERA-M 115THEREMS-H 115THEREMS-M 115thiamine hcl 137thiamine mononitrate 137thioridazine hcl 49thiotepa 36thiothixene 50THYMOGLOBULIN 100THYROSAFE 26tiagabine hcl 18TIBSOVO 43TICE BCG 44TIGAN 27tigecycline 131TIGECYCLINE 131timolol maleate (ophth) 121TIMOLOL MALEATEOPHTHALMIC GELFORMING 121tinidazole 9tioconazole vaginal 135TIVICAY 53tizanidine hcl 119TOBI PODHALER 2tobramycin 2tobramycin (ophth) 122tobramycin sulfate 2tobramycin-dexamethasone 123tolazamide 26tolbutamide 26tolcapone 46tolmetin sodium 4tolnaftate 69tolterodine tartrate 134topiramate 18topotecan hcl 46toremifene citrate 40TORISEL 43torsemide 77TOTECT 45

TOUJEO MAXSOLOSTAR 25TOUJEO SOLOSTAR 25TRACLEER 57TRADJENTA 23tramadol hcl 7tramadol-acetaminophen 7trandolapril 33tranexamic acid 89TRANSDERM SCOP 27TRANSDERM-SCOP 27tranylcypromine sulfate 20TRAVATAN Z 124trazodone hcl 21TREANDA 36TRECATOR 35TRELEGY ELLIPTA 15TRELSTAR MIXJECT 40TREMFYA 70treprostinil 57TRESIBA FLEXTOUCH 25tretinoin 68tretinoin (chemotherapy) 44tretinoin microsphere 68TREXIMET 94TRI-LUMA 75TRI-VI-SOL 118triamcinolone acetonide 61triamcinolone acetonide(mouth) 101triamcinolone acetonide(nasal) 120triamcinolone acetonide(topical) 73triamterene &hydrochlorothiazide 76triazolam 89trientine hcl 99trifluoperazine hcl 49trifluridine 122TRIGLIDE 31trihexyphenidyl hcl 46trimethoprim 9trimipramine maleate 22TRINTELLIX 21triprolidine &pseudoephedrine 66triprolidine hcl 29TRIPTODUR 78

TRISENOX 44TRIUMEQ 53TROGARZO 53tropicamide 121trospium chloride 134TRUMENBA 134TRUVADA 53TUDORZA PRESSAIR 13TURALIO 43TUSSIONEX PENNKINETICEXTENDED RELEASE 66TWINRIX 135TYBOST 53TYKERB 43TYMLOS 77TYPHIM VI 134TYSABRI 129TYVASO 57TYVASO REFILL 57TYVASO STARTER 57UCERIS 8ULTRATHON INSECTREPELLENT 8 75UNICOMPLEX-M 115UPTRAVI 57ursodiol 81UVADEX 44VABOMERE 10valacyclovir hcl 54VALCHLOR 70valganciclovir hcl 53valproate sodium 19valproic acid 19valrubicin 40valsartan 33valsartan-hydrochlorothiazide

34VALVED HOLDINGCHAMBER 94VANACLEAR PD 29VANACOF 66VANACOF DM 66VANACOF-8 66VANAHIST PD 29VANAMINE PD 29VANATAB AC 66VANATAB DM 66vancomycin hcl 10

Index 17

VANCOMYCIN HCL INDEXTROSE 10VANCOMYCINHYDROCHLORIDE 10VANTAS 40VAQTA 135VARIVAX 135VARIZIG 125VARUBI 27VASCEPA 31VECTIBIX 38VELCADE 43VELTASSA 101VEMLIDY 54VENCLEXTA 38VENCLEXTA STARTINGPACK 38venlafaxine hcl 21VENTAVIS 57verapamil hcl 56VERELAN 56VERELAN PM 56VERSACLOZ 49VERZENIO 43VIBERZI 82VICTOZA 24VIDEX EC 53VIDEXPEDIATRIC 53vigabatrin 18VIIBRYD 21VIIBRYD STARTER PACK 21VIMIZIM 79VIMPAT 18vinblastine sulfate 45vincristine sulfate 45vinorelbine tartrate 45VIRACEPT 53VIRAMUNE 53VIREAD 53VISTOGARD 26VITAL-D RX 103VITALETS CHILDRENS 117VITAMIN & MINERALSUPPLEMENT 115vitamin a 136VITAMIN C 103vitamin e 136vitamins a & d (topical) 73

vitamins c & e 118vitamins w/lipotropics 118,119VITATRUM 115VITRAKVI 43VITRUM 50+ SENIORMULTI 115VIZIMPRO 43voriconazole 28VORTEX HOLDINGCHAMBER/MASK/CHILDS

94VORTEX HOLDINGCHAMBER/MASK/CHILDS/FROG 94VORTEX HOLDINGCHAMBER/MASK/TODDLER

94VORTEX HOLDINGCHAMBER/MASK/TODDLER/LADY BUG 94VORTEX VALVED HOLDINGCHAMBER 94VOSEVI 54VOTRIENT 43VPRIV 84VRAYLAR 47VYTORIN 30VYXEOS 41warfarin sodium 15water for injection, sterile 127water for irrigation, sterile 100WELCHOL 31WEST-VITE W/FOLICACID 103WHITE PETROLATUM 127white petrolatum-mineraloil 121witch hazel (hamamelisvirginiana) 75XALKORI 43XARELTO 15XARELTO STARTERPACK 15XATMEP 37XELJANZ 2XENICAL 1XEOMIN 120XERMELO 82XGEVA 77XOLAIR 13XOSPATA 43

XPOVIO 100 MG ONCEWEEKLY 40XPOVIO 60 MG ONCEWEEKLY 40XPOVIO 80 MG ONCEWEEKLY 40XPOVIO 80 MG TWICEWEEKLY 40XTANDI 40XURIDEN 79XYREM 127YELETS TEENAGEFORMULA 115YERVOY 38YF-VAX 135YONDELIS 36YONSA 40Z-BUM 75zafirlukast 14zaleplon 89ZALTRAP 37ZANOSAR 36ZARXIO 86ZEJULA 44ZELBORAF 44ZEMAIRA 130ZENPEP 76ZEPATIER 54zidovudine 53zileuton 14ZINC 99zinc 99ZINC 115ZINC 15 99zinc gluconate 99zinc oxide (topical) 75zinc sulfate 99ZINC SULFATE 99ZINPLAVA 126ziprasidone hcl 47ZIRGAN 122ZOHYDRO ER 7ZOLADEX 40zoledronic acid 77ZOLINZA 44zolmitriptan 95zolpidem tartrate 89zonisamide 18

Index 18

ZONTIVITY 84ZORTRESS 100ZOSTAVAX 135ZULRESSO 20ZUTRIPRO 66ZYCLARA 74ZYCLARA PUMP 74ZYDELIG 44ZYKADIA 44ZYPREXA RELPREVV 49ZYTIGA 40ZYVOX 11

Index 19

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