2015 comprehensive formulary - kaiser...

Kaiser Permanente

2015 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 10/01/14. For more recent information or other questions, please contact the number for your Kaiser Permanente Region listed below, seven days a week, 8 a.m. to 8 p.m., or visit kp.org/seniormedrx. Kaiser Permanente Regions CALIFORNIA REGIONS Kaiser Permanente Senior Advantage (HMO) and Senior Advantage Medicare Medi-Cal Plan (HMO SNP) Member Service Contact Center 1-800-443-0815 TTY 711 COLORADO REGION Kaiser Permanente Senior Advantage (HMO) and Senior Advantage Medicare Medicaid Plan (HMO SNP) Member Services 1-800-476-2167 TTY 711 GEORGIA REGION Kaiser Permanente Senior Advantage (HMO) and Senior Advantage Medicare Medicaid Plan (HMO SNP) Member Services 1-800-232-4404 TTY 711

HAWAII REGION Kaiser Permanente Senior Advantage (HMO)

Customer Service Center 1-800-805-2739 TTY 711 MID-ATLANTIC STATES REGION (District of Columbia, Maryland, and Virginia) Kaiser Permanente Medicare Plus (Cost)

Member Services 1-888-777-5536 TTY 711 NORTHWEST REGION Kaiser Permanente Senior Advantage (HMO)

Membership Services 1-877-221-8221 TTY 711

Y0043_N012124_Final01 approved HPMS Approved Formulary File Submission 00015136, Version 10

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us,” or “our,” it means Kaiser Permanente. When it refers to “plan” or “our plan,” it means Kaiser Permanente Senior Advantage or Medicare Plus, depending upon the region in which you are enrolled. This document includes a list of the drugs (formulary) for our plan which is current as of January 1, 2015. For an updated formulary, please visit our website at kp.org/seniormedrx or call us. Contact information for your Kaiser Permanente Region, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year. In California, Hawaii, Oregon, Washington, Colorado and Georgia, Kaiser Permanente is an HMO plan with a Medicare contract. In Virginia, Maryland, and the District of Columbia, Kaiser Permanente is a Cost plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal. This information is available for free in other languages. Please call the Member Services number listed on the front and back covers. Se puede obtener esta información gratis en otros idiomas. Por favor llame al número de Servicios a los Miembros que aparece en la portada y la contraportada. 此資訊免費以其他語言提供。請聯絡我們的會員服務聯絡中心，電話號碼列在封面和封底。 This document is available in a different format for the visually impaired by calling our plan at the number listed on the front and back covers for your Kaiser Permanente Region.

What is the Kaiser Permanente Formulary? A formulary is a list of covered drugs selected by Kaiser Permanente in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed on our formulary as long as the drug is medically necessary, the prescription is filled at a Kaiser Permanente network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Our plan covers all drugs that can be included in a Medicare Part D prescription drug plan according to Medicare requirements. Contact information for your Kaiser Permanente Region, along with the date we last updated the formulary, appears on the front and back cover pages. Can the formulary (drug list) change? Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the

formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of January 1, 2015. To get updated information about the drugs covered by our plan, please call us. Contact information for your Kaiser Permanente Region appears on the front and back cover pages. In the event of a midyear non-maintenance formulary change, we will provide details in the Medicare Part D Explanation of Benefits or Provision of Notice posted at kp.org/seniormedrx. How do I use the formulary? There are two ways to find your drug within the formulary: Medical condition The formulary begins on page 6. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Drugs”.

Kaiser Permanente 2015 Comprehensive Formulary • 1

If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug. Alphabetical listing If you are not sure what category to look under, you should look for your drug in the index that begins on page 52. The index provides an alphabetical list of all of the drugs included in this document. Preferred generic and brand-name drugs, nonpreferred generic and brand-name drugs, specialty-tier drugs, and injectable vaccines are listed in the index. Look in the index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list. What are generic drugs? Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name and specialty-tier drugs. Cost sharing for preferred generic drugs may be different than for nonpreferred generic drugs. Please see your Evidence of Coverage for more information. What are brand-name drugs? Brand-name drugs are manufactured and sold by the pharmaceutical company that originally researched and developed the drug. When the patent on a brand-name drug expires, other pharmaceutical companies may manufacture and sell an FDA-approved generic version of the drug with the same active ingredient(s) at lower prices. Cost

sharing for preferred brand-name drugs may be different than for nonpreferred brand-name drugs. Please see your Evidence of Coverage for more information. What are specialty-tier drugs? Specialty-tier drugs are very high-cost drugs approved by the FDA that are on our formulary. What are injectable Part D vaccines? Part D vaccines are certain injectable vaccines that are covered under Medicare Part D (for example, Zostavax for shingles, Adacel for Diphtheria, Tetanus, and Pertussis, which are approved by the FDA). Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

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

• Quantity Limits: For certain drugs,

Kaiser Permanente limits the amount of the drug that we will cover. For example, our plan provides 14 pills per prescription for Sovaldi. This may be in addition to a standard one-month or three-month supply.

2 • Kaiser Permanente 2015 Comprehensive Formulary

Note: If your prescription has more than one refill remaining, you can only get one refill at a time, unless authorized because you will be away from our service area for an extended period of time. For certain drugs, we may limit the amount of an extended day supply (amounts that exceed a 30-day supply) that you can receive. Also, if there is a shortage in the marketplace, we may charge one Part D cost sharing for a limited quantity. You can find out if your drug has any additional requirements or limits by looking on the formulary that begins on page 6. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization restriction. You may also ask us to send you a copy. Contact information for your Kaiser Permanente Region, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Kaiser Permanente formulary?” on this page for information about how to request an exception. What if my drug is not on the formulary? If your drug is not included on this formulary (list of covered drugs), you should first check our Kaiser Permanente 2015 Comprehensive Formulary at kp.org/seniormedrx or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region and confirm if your drug is covered.

Our plan covers all Medicare Part D drugs. In the rare case that your Medicare Part D prescription drug is not on our Kaiser Permanente 2015 Comprehensive Formulary, you have two options:

• You can ask your network provider to prescribe a similar drug that is included on our formulary.

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

How do I request an exception to the Kaiser Permanente Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it may not be on our Kaiser Permanente 2015 Comprehensive Formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a Part D formulary drug at a lower cost-sharing level if this drug is not on the specialty tier (Tier 5), subject to our tiering exception process. If approved this would lower the amount you may pay for your drug.

• You can ask us to waive coverage

restrictions or limits on your drug. For example, if your drug requires prior authorization, you can ask us to waive the prior authorization requirement for


your Part D drug. In addition, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your network provider supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your network provider believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your network provider or other prescriber. Please note: You can only request an exception for drugs that are considered Medicare Part D prescription drugs by the Centers for Medicare & Medicaid Services (CMS). You cannot get an exception for drugs that are excluded under Medicare Part D or for obtaining a brand-name drug (Tier 3) at the cost sharing that applies to generic drugs. Please refer to your Evidence of Coverage for

more information about requesting exceptions, including the appeals process. What do I do before I can talk to my network provider about changing my drugs or requesting an exception? In rare cases, you might be taking Medicare Part D drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your network provider to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your network provider to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your Part D drugs that may not be on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we may cover an additional refill, as medically necessary. After you have used these refills, we will not pay for these drugs. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with up to a 98-day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on


our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription written for fewer days) while you pursue a formulary exception. As a current member of our plan, if you have a covered inpatient stay in the hospital or in a skilled nursing facility, the drugs you obtain during your stay will be covered under your medical benefit rather than your Medicare Part D prescription drug coverage. When you are discharged home or to a custodial level of care at a long-term care facility, many outpatient prescription drugs you obtain at a pharmacy may be covered under your Medicare Part D coverage. Since your drug coverage is different depending on the setting where you obtain the drug, it is possible that a drug you were taking that was covered under your medical benefit might not be covered by Medicare Part D (for example, over-the-counter drugs, or cough medicine). If this happens, you will have to pay full price for that drug unless you have other coverage (for example, employer-sponsored group coverage).

For more information For more detailed information about your Kaiser Permanente prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please call us. Contact information for your Kaiser Permanente Region, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.


http://www.medicare.gov/

Kaiser Permanente’s Formulary The formulary below provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the index that begins on page 52. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., ALBENZA) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The second column, “Drug Tier,” will indicate what tier number the drug is in: Tier 1 – Preferred generic drugs Tier 2 – Nonpreferred generic drugs Tier 3 – Preferred brand-name drugs Tier 4 – Nonpreferred brand-name drugs Tier 5 – Specialty-tier drugs Tier 6 – Injectable Part D vaccines Generally, the cost sharing you will pay for your drugs depends on your coverage stage, the type of network pharmacy where you purchase your drugs, and your drug’s cost-sharing tier on our formulary. Please refer to your Evidence of Coverage for the details about your Medicare Part D prescription drug coverage, including your cost-sharing amounts. Note: If your coverage is through an employer-sponsored group plan (including a union or trust fund), you may have different drug benefits and cost sharing, and you may have coverage for other drugs that are not covered by Medicare Part D (non-Part D drugs). The amount you pay for non-Part D drugs does not count toward your total out-of-pocket expenditures, and if you are receiving Extra Help to pay for your Medicare Part D prescription drugs, you will not receive any Extra Help to pay for non-Part D drugs. Please check with your group benefits administrator or see your Evidence of Coverage. The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. Certain strengths or forms of the drug may be subject to the utilization management codes listed below. HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies. For more information, please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region. LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies. For more information, consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region.


MO = Mail-order drugs. You may order prescription refills of certain medications through our mail-order service online at kp.org/refill or by phone or mobile app, which may lower your costs for a three-month supply. Generally, you should receive them within 10 business days. If not, please contact the mail-order phone number for your Kaiser Permanente Region in the chart below. Additional drugs may be available for mail order. Not all drugs can be mailed; restrictions and limitations apply. For more information, please visit kp.org/seniormedrx or call the appropriate regional phone number below. Region

Mail-Order Contact Numbers (TTY 711)

California

Kaiser Permanente Mail Order Pharmacy Northern CA – 1-888-218-6245 Monday through Friday, 8 a.m. to 6 p.m. Southern CA – 1-866-206-2983 Monday through Friday, 7 a.m. to 7 p.m.

Colorado

Kaiser Permanente Mail Order Pharmacy 1-866-523-6059 (TTY/TDD 1-800-659-2656) Monday through Friday, 8 a.m. to 6 p.m.

Georgia

Kaiser Permanente Refill Pharmacy 770-434-2008 or toll free 1-888-662-4579 Seven days a week, 24 hours

Hawaii

Kaiser Permanente Automated Refill Center 808-643-7979 (Oahu and neighbor islands) Monday through Friday, 8:30 a.m. to 5 p.m.

Mid-Atlantic States

Kaiser Permanente Mid-Atlantic Automated Refill Center 703-466-4900 or toll-free 1-800-733-6345 Monday through Friday, 8 a.m. to 7 p.m.

Northwest

Kaiser Permanente Mail-Delivery Pharmacy 1-800-548-9809 Monday through Friday, 8 a.m. to 4:30 p.m.

PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (e.g., via infusion pump, nebulizer, or other Durable Medical Equipment device), where they are administered (at home or in a long-term care facility), and what medical condition they are administered for. Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered. QL = Quantity limits apply to certain drugs. Our plan will only cover a certain amount of these drugs (less than a 30-day supply) per prescription at one Part D cost share.


Drug Name Drug Tier

Requirements/Limits

ANTI-INFECTIVE AGENTS ANTHELMINTICS ALBENZA 3 BILTRICIDE 3 SKLICE 4 STROMECTOL 4 ANTIBACTERIALS amikacin sulfate 2 HI amoxicillin 2 amoxicillin & pot clavulanate 2 ampicillin 2 ampicillin & sulbactam sodium 2 HI

ampicillin sodium 2 HI AUGMENTIN 3 AVELOX 3 HI AVELOX ABC PACK 3 AZACTAM 3 HI AZACTAM IN ISO-OSMOTIC DEXTROSE 3 HI

azithromycin 2 HI AZITHROMYCIN POW 1GM PAK 3

aztreonam 2 HI AZULFIDINE 4 AZULFIDINE EN-TABS 4 bacitracin 2 BACTOCILL IN DEXTROSE 3 HI

BACTRIM 4 BACTRIM DS 4 BETHKIS 5 BIAXIN 4 BIAXIN XL 4 BIAXIN XL PAC 4 BICILLIN C-R 4 BICILLIN L-A 3 CAYSTON 5 LD CEDAX 4 cefaclor 2

Drug Name Drug Tier

Requirements/Limits

cefaclor monohydrate 2 cefadroxil 2 cefazolin in d5w 2 HI cefazolin sodium 2 HI CEFAZOLIN SODIUM/DEXTROSE 3 HI

cefdinir 2 CEFDITOREN PIVOXIL 4 MO cefepime hcl 2 HI cefixime 2 cefotaxime sodium 2 HI cefotetan disodium 2 HI cefoxitin sodium 2 HI CEFOXITIN SODIUM 3 HI cefpodoxime proxetil 2 cefprozil 2 ceftazidime 2 HI CEFTAZIDIME/ DEXTROSE 3 HI

CEFTIN SUS 125/5ML 4 CEFTIN SUS 250/5ML 3 CEFTIN TAB 250MG 4 CEFTIN TAB 500MG 4 ceftriaxone sodium 2 HI CEFTRIAXONE/ DEXTROSE 3 HI

cefuroxime axetil 2 cefuroxime sodium 2 HI CEFUROXIME/ DEXTROSE 3 HI

cephalexin 2 chloramphenicol sodium succinate 2 HI

CIPRO SUSP 3 CIPRO 4 CIPRO I.V.-IN D5W 4 HI ciprofloxacin 2 HI ciprofloxacin hcl 2 ciprofloxacin in d5w 2 HI ciprofloxacin-ciprofloxacin hcl 2

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 8 • Kaiser Permanente 2015 Comprehensive Formulary

Drug Name Drug Tier

Requirements/Limits

CLAFORAN 4 HI clarithromycin 2 CLEOCIN 4 CLEOCIN IN D5W 3 HI CLEOCIN PHOSPHATE 4 HI clindamycin hcl 2 clindamycin palmitate hydrochloride 2 clindamycin phosphate 2 HI clindamycin phosphate in d5w 2 HI

colistimethate sodium 2 HI COLY-MYCIN M 4 HI CUBICIN 5 HI DALVANCE 5 demeclocycline hcl 2 dicloxacillin sodium 2 DIFICID 5 DORIBAX 4 HI DORYX 4 doxycycline (monohydrate) 2 doxycycline hyclate 2 HI E.E.S. GRANULES 3 ERYPED 200 3 ERYPED 400 3 ERYTHROCIN LACTOBIONATE 3 HI

erythromycin base 2 erythromycin ethylsuccinate 2 erythromycin lactobionate 2 HI erythromycin stearate 2 erythromycin-sulfisoxazole 2

FACTIVE 4 MO FORTAZ INJ 1 GM 3 HI FORTAZ INJ 2GM 3 HI FORTAZ INJ 2GM 4 HI FORTAZ INJ 6GM 4 HI gentamicin in saline 2 HI

Drug Name Drug Tier

Requirements/Limits

gentamicin sulfate 2 HI imipenem-cilastatin 2 HI INVANZ 3 HI KEFLEX 4 KETEK 4 LEVAQUIN 4 HI levofloxacin 2 HI levofloxacin in d5w 2 HI LINCOCIN 4 HI MAXIPIME INJ 1GM 3 HI MAXIPIME INJ 1GM 4 HI MAXIPIME INJ 2GM 3 HI MAXIPIME INJ 2GM 4 HI meropenem 2 HI MERREM 4 HI minocycline hcl 2 MOXATAG 4 moxifloxacin hcl 2 nafcillin sodium 2 HI NALLPEN ISO-OSMOTIC IN DEXTROSE 3 HI

NALLPEN/DEXTROSE 3 HI neomycin sulfate 2 NOROXIN 4 ofloxacin 2 oxacillin sodium 2 HI PCE 4 penicillin g potassium 2 HI PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE

3 HI

penicillin g procaine 2 penicillin g sodium 2 HI penicillin v potassium 2 piperacillin sodium-tazobactam sodium 2 HI

polymyxin b sulfate 2 HI PRIMAXIN IV 4 HI SIVEXTRO 5 SOLODYN 4 SPECTRACEF 4 MO

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table.


Drug Name Drug Tier

Requirements/Limits

streptomycin sulfate 2 sulfadiazine 2 sulfamethoxazole-trimethoprim 2 HI

sulfasalazine 2 SUPRAX 4 SYNERCID 3 HI TEFLARO 4 HI TETRACYCLINE HCL 4 TIMENTIN 4 HI TOBI 5 TOBI PODHALER 5 tobramycin 2 tobramycin sulfate 2 HI tobramycin sulfate in saline 2 HI

TYGACIL 4 HI UNASYN 4 HI UNASYN BULK PACK 4 HI VANCOCIN HCL 5 vancomycin hcl 2 HI VANCOMYCIN HCL IN DEXTROSE 3 HI

VIBRAMYCIN 3 VIBRAMYCIN 4 XIFAXAN 4 ZINACEF IN ISO-OSMOTIC DEXTROSE 3 HI

ZINACEF IN ISO-OSMOTIC DILUENT 3 HI

ZINACEF INJ 1.5GM 4 HI ZINACEF INJ 7.5GM 4 HI ZINACEF INJ 750MG 3 HI ZINACEF INJ 750MG 4 HI ZITHROMAX INJ 500MG 4 HI ZITHROMAX POW 1GM PAK 3 ZITHROMAX SUS 100/5ML 4 ZITHROMAX SUS 200/5ML 4

Drug Name Drug Tier

Requirements/Limits

ZITHROMAX TAB 250MG 4 ZITHROMAX TAB 500MG 4 ZITHROMAX TAB 600MG 4 ZITHROMAX TRI-PAK TAB TRI-PAK 4 ZITHROMAX Z-PAK TAB Z-PAK 4 ZMAX SUS 2GM 4 ZOSYN 4 HI ZYVOX 5 HI ANTIFUNGALS ABELCET 4 HI AMBISOME 5 HI amphotericin b 2 HI ANCOBON 5 CANCIDAS 5 HI DIFLUCAN 4 ERAXIS 4 HI fluconazole 2 fluconazole in dextrose 2 HI flucytosine 2 GRIS-PEG 4 griseofulvin microsize 2 griseofulvin ultramicrosize 2 itraconazole 2 ketoconazole 2 LAMISIL 4 MYCAMINE 4 HI NOXAFIL 5 nystatin 2 nystatin (mouth-throat) 2 ONMEL TAB 200MG 4 SPORANOX CAP 100MG 4 SPORANOX PULSEPAK CAP PULSEPAK 4 SPORANOX SOL 10MG/ML 3 terbinafine hcl 2 VFEND IV INJ 200MG 3 HI


Drug Name Drug Tier

Requirements/Limits

VFEND SUS 40MG/ML 5 VFEND TAB 200MG 4 VFEND TAB 50MG 5 voriconazole 2 HI ANTIMYCOBACTERIALS aminosalicylic acid 2 CAPASTAT SULFATE 3 HI dapsone 2 ethambutol hcl 2 isoniazid 2 isoniazid & rifampin 2 MYAMBUTOL 4 MYCOBUTIN 3 PRIFTIN 4 pyrazinamide 2 rifabutin 2 RIFADIN 4 HI rifampin 2 HI RIFATER 4 SIRTURO 5 TRECATOR 4 ANTIPROTOZOALS ALINIA 3 atovaquone 2 atovaquone-proguanil hcl 2 MO chloroquine phosphate 2 COARTEM 3 DARAPRIM 3 FLAGYL 4 FLAGYL ER 4 hydroxychloroquine sulfate 2 MALARONE 4 mefloquine hcl 2 MEPRON 5 METRO IV 3 HI metronidazole 2 metronidazole in nacl 2 HI NEBUPENT INH 300MG 3 paromomycin sulfate 2 PENTAM 300 INJ 300MG 4

Drug Name Drug Tier

Requirements/Limits

PLAQUENIL 4 PRIMAQUINE PHOSPHATE 3 QUALAQUIN 4 quinine sulfate 2 tinidazole 2 ANTIVIRALS abacavir sulfate 2 MO abacavir sulfate-lamivudine-zidovudine 2 MO

acyclovir 2 MO acyclovir sodium 2 HI adefovir dipivoxil 2 MO APTIVUS 5 ATRIPLA 5 BARACLUDE SOL .05MG/ML 3 BARACLUDE TAB 0.5MG 5 BARACLUDE TAB 1MG 5 cidofovir 2 HI COMBIVIR 5 COMPLERA 5 COPEGUS 4 MO CRIXIVAN 3 MO CYTOVENE 4 HI didanosine 2 MO EDURANT 5 EMTRIVA 3 MO EPIVIR HBV SOL 5MG/ML 3 EPIVIR HBV TAB 100MG 4 MO EPIVIR SOL 10MG/ML 3 EPIVIR TAB 150MG 4 MO EPIVIR TAB 300MG 4 MO EPZICOM 5 famciclovir 2 MO FAMVIR 4 MO FLUMADINE 4 MO foscarnet sodium 2 HI FUZEON 5 ganciclovir sodium 2 HI



Drug Name Drug Tier

Requirements/Limits

HEPSERA 5 INCIVEK 5 INFERGEN 5 INTELENCE TAB 100MG 5 INTELENCE TAB 200MG 5 INTELENCE TAB 25MG 3 MO INVIRASE CAP 200MG 3 MO INVIRASE TAB 500MG 5 ISENTRESS CHW 100MG 3 MO

ISENTRESS CHW 25MG 3 MO ISENTRESS POW 100MG 4

ISENTRESS TAB 400MG 5 KALETRA SOL 5 KALETRA TAB 100-25MG 3 MO

KALETRA TAB 200-50MG 5 lamivudine 2 MO lamivudine-zidovudine 2 MO LEXIVA SUS 50MG/ML 4 LEXIVA TAB 700MG 5 nevirapine 2 MO NEVIRAPINE 4 MO NORVIR 3 MO OLYSIO 5 PA,QL PEG-INTRON 5 PEG-INTRON REDIPEN 5 PEGASYS 5 PEGASYS PROCLICK 5 PREZISTA SUS 100MG/ML 4 PREZISTA TAB 150MG 3 MO PREZISTA TAB 400MG 5 PREZISTA TAB 600MG 5 PREZISTA TAB 75MG 3 MO PREZISTA TAB 800MG 5 REBETOL 4 MO RELENZA DISKHALER 3 MO RESCRIPTOR 3 MO

Drug Name Drug Tier

Requirements/Limits

RETROVIR CAP 100MG 4 MO RETROVIR IV INFUSION INJ 10MG/ML 3 HI

RETROVIR SYP 50MG/5ML 4 REYATAZ CAP 100MG 3 MO REYATAZ CAP 150MG 5 REYATAZ CAP 200MG 5 REYATAZ CAP 300MG 5 ribavirin (hepatitis c) 2 MO rimantadine hydrochloride 2 MO SELZENTRY 5 SOVALDI 5 PA,QL stavudine 2 MO STRIBILD 5 SUSTIVA 3 MO SYNAGIS 5 TAMIFLU CAP 30MG 4 MO TAMIFLU CAP 45MG 4 MO TAMIFLU CAP 75MG 3 MO TAMIFLU SUS 12MG/ML 3 TAMIFLU SUS 6MG/ML 3 TIVICAY 5 TRIUMEQ 5 TRIZIVIR 5 TRUVADA 5 TYZEKA 4 MO valacyclovir hcl 2 MO VALCYTE SOL 50MG/ML 3 VALCYTE TAB 450MG 5 VALTREX 4 MO VICTRELIS 5 VIDEX EC CAP 125MG 4 MO VIDEX EC CAP 200MG 4 MO VIDEX EC CAP 250MG 4 MO VIDEX EC CAP 400MG 4 MO VIDEX PEDIATRIC SOL 2GM 3 VIRACEPT 5 VIRAMUNE 4 MO VIRAMUNE XR 4 MO


Drug Name Drug Tier

Requirements/Limits

VIRAZOLE 3 VIREAD 5 VISTIDE 5 HI ZERIT 4 MO ZIAGEN SOL 20MG/ML 3 ZIAGEN TAB 300MG 4 MO zidovudine 2 HI,MO ZOVIRAX 4 URINARY ANTI-INFECTIVES FURADANTIN 4 HIPREX 4 MACROBID 4 MACRODANTIN CAP 100MG 4 MACRODANTIN CAP 25MG 3 methenamine hippurate 2 MONUROL 4 nitrofurantoin 2 nitrofurantoin macrocrystal 2 nitrofurantoin monohyd macro 2 PRIMSOL 3 trimethoprim 2 ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS carbinoxamine maleate 2 cetirizine hcl 2 CLARINEX 4 CLARINEX-D 12 HOUR 4 CLARINEX-D 24 HOUR 4 clemastine fumarate 2 cyproheptadine hcl 2 desloratadine 2 diphenhydramine hcl 2 KARBINAL ER 4 levocetirizine dihydrochloride 2 promethazine & phenylephrine 2

Drug Name Drug Tier

Requirements/Limits

promethazine hcl 2 SEMPREX-D 4 MO XYZAL 4 ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS ABRAXANE 3 AFINITOR 5 AFINITOR DISPERZ 5 ALIMTA 3 ALKERAN 4 anastrozole 2 MO ARIMIDEX 4 MO AROMASIN 4 MO ARRANON 3 ARZERRA 4 AVASTIN 3 azacitidine 2 BCG VACCINE 3 BELEODAQ 5 bicalutamide 2 MO BICNU 3 bleomycin sulfate 2 BOSULIF 5 BUSULFEX 4 CAMPATH 3 CAMPTOSAR 4 CAPRELSA 3 LD carboplatin 2 CASODEX 4 MO CEENU 3 MO cisplatin 2 cladribine 2 CLOLAR 4 COMETRIQ 5 LD COSMEGEN 4 cyclophosphamide 2 PA,MO CYCLOPHOSPHAMIDE 4 PA,MO CYRAMZA 5 cytarabine 2 dacarbazine 2 DACOGEN 4



Drug Name Drug Tier

Requirements/Limits

daunorubicin hcl 2 DAUNOXOME 3 decitabine 2 DOCEFREZ INJ 20MG 4 DOCEFREZ INJ 80MG 4 DOCETAXEL INJ 80MG/4ML 4 DOCETAXEL INJ 80MG/8ML 3 DOXIL 4 doxorubicin hcl 2 DROXIA 4 MO ELIGARD INJ 22.5MG 4 ELIGARD INJ 30MG 4 ELIGARD INJ 45MG 4 ELIGARD INJ 7.5MG 4 ELLENCE 4 ELOXATIN INJ 100MG 4 ELOXATIN INJ 200MG 3 ELSPAR 3 EMCYT 3 epirubicin hcl 2 ERBITUX 3 ERIVEDGE 5 ERWINAZE 4 ETOPOPHOS 4 etoposide 2 exemestane 2 MO FARESTON 4 MO FASLODEX 5 FEMARA 4 MO FIRMAGON 4 fludarabine phosphate 2 fluorouracil 2 flutamide 2 MO FOLOTYN 4 GAZYVA 5 gemcitabine hcl 2 GEMZAR 4 GILOTRIF 5 GLEEVEC 5

Drug Name Drug Tier

Requirements/Limits

HALAVEN 4 HERCEPTIN 3 HEXALEN 5 HYCAMTIN 4 HYDREA 4 MO hydroxyurea 2 MO ICLUSIG 5 LD IDAMYCIN PFS 4 idarubicin hcl 2 IFEX 3 ifosfamide 2 IMBRUVICA 5 LD INLYTA 5 INTRON-A 5 INTRON-A W/DILUENT 5 irinotecan hcl 2 ISTODAX 3 IXEMPRA KIT 5 JAKAFI 5 JEVTANA 3 KADCYLA 5 KYPROLIS 5 letrozole 2 MO LEUKERAN 3 leuprolide acetate 2 LOMUSTINE 3 MO LUPANETA PACK 4 LUPRON DEPOT INJ 11.25MG 3 LUPRON DEPOT INJ 22.5MG 3 LUPRON DEPOT INJ 3.75MG 3 LUPRON DEPOT INJ 30MG 3 LUPRON DEPOT INJ 45MG 3

LUPRON DEPOT INJ 7.5MG 3 LUPRON DEPOT-PED 3 LYSODREN 3 MO MARQIBO 5


Drug Name Drug Tier

Requirements/Limits

MATULANE 5 MEGACE ORAL 4 megestrol acetate 2 MO MEKINIST 5 melphalan hcl 2 mercaptopurine 2 MO methotrexate sodium 2 PA,MO mitomycin 2 mitoxantrone hcl 2 MUSTARGEN 3 NEXAVAR 5 NILANDRON 3 NIPENT 4 ONCASPAR 3 oxaliplatin 2 paclitaxel 2 pentostatin 2 PERJETA 5 POMALYST 5 PROLEUKIN 5 PURINETHOL 4 MO REVLIMID 5 RHEUMATREX 4 PA RITUXAN 3 SOLTAMOX 4 SPRYCEL 5 STIVARGA 5 SUTENT 5 SYLATRON 4 SYLVANT 5 SYNRIBO 5 TABLOID 3 MO TAFINLAR 5 tamoxifen citrate 2 MO TARCEVA 5 TARGRETIN 5 MO TASIGNA 5 TAXOTERE INJ 20/0.5ML 3 TAXOTERE INJ 80MG/2ML 3

Drug Name Drug Tier

Requirements/Limits

TAXOTERE INJ 80MG/4ML 4 thiotepa 2 TICE BCG 3 topotecan hcl 2 TORISEL 3 TREANDA 3 TRELSTAR DEPOT MIXJECT 4 TRELSTAR LA MIXJECT 4 TRELSTAR MIXJECT 4 tretinoin (chemotherapy) 2 MO TRISENOX 3 TYKERB 5 VALSTAR 3 VANTAS 3 VECTIBIX 4 VELCADE 3 VIDAZA 4 vinblastine sulfate 2 vincristine sulfate 2 vinorelbine tartrate 2 VOTRIENT 5 VUMON 3 XALKORI 5 XTANDI 5 YERVOY 3 ZALTRAP 5 ZANOSAR 3 ZELBORAF 5 ZOLINZA 5 ZYDELIG 5 ZYKADIA 5 ZYTIGA 5 AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANORO ELLIPTA 4 MO atropine sulfate 2 ATROPINE SULFATE 3 ATROVENT 4 ATROVENT HFA 3 MO



Drug Name Drug Tier

Requirements/Limits

BENTYL 4 MO CANTIL 4 MO CUVPOSA SOL 1MG/5ML 3 dicyclomine hcl 2 MO glycopyrrolate 2 MO ipratropium bromide 1 ipratropium bromide (nasal) 2 methscopolamine bromide 2 MO

PAMINE 4 MO PAMINE FORTE 4 MO propantheline bromide 2 MO ROBINUL FORTE TAB 2MG 4 MO

ROBINUL TAB 1MG 4 MO SPIRIVA HANDIHALER 3 MO TUDORZA PRESSAIR 4 MO AUTONOMIC DRUGS, MISCELLANEOUS CHANTIX 4 MO CHANTIX STARTING MONTH PAK 4 MO

NICOTROL INHALER INH 3 MO

NICOTROL NS SPR 10MG/ML 4 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS ARICEPT 4 MO ARICEPT ODT 4 MO bethanechol chloride 2 MO cevimeline hcl 2 MO donepezil hydrochloride 2 MO EVOXAC 4 MO EXELON 4 MO galantamine hydrobromide 2 MO

GUANIDINE HCL 4 MO MESTINON SYP 60MG/5ML 3 MESTINON TAB 60MG 4 MO

Drug Name Drug Tier

Requirements/Limits

MESTINON TIMESPAN TAB TIMESPAN 3 MO

pilocarpine hcl (oral) 2 MO pyridostigmine bromide 2 MO RAZADYNE 4 MO RAZADYNE ER 4 MO REGONOL INJ 5MG/ML 3 rivastigmine tartrate 2 MO SALAGEN 4 MO SKELETAL MUSCLE RELAXANTS AMRIX 4 MO baclofen 2 PA,MO carisoprodol 2 PA,MO carisoprodol w/ aspirin 2 PA carisoprodol w/ aspirin & codeine 2 PA

chlorzoxazone 2 MO cyclobenzaprine hcl 2 MO DANTRIUM 4 MO dantrolene sodium 2 MO GABLOFEN 4 PA LIORESAL INTRATHECAL 4 PA

metaxalone 2 MO methocarbamol 2 MO orphenadrine citrate 2 MO PARAFON FORTE DSC 4 MO SKELAXIN 4 MO SOMA 4 PA,MO tizanidine hcl 2 MO ZANAFLEX 4 MO SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS alfuzosin hcl 2 MO DIBENZYLINE 3 MO dihydroergotamine mesylate 2 ergoloid mesylates 2 MO ergotamine tartrate 2 FLOMAX 4 MO MIGRANAL 3


Drug Name Drug Tier

Requirements/Limits

RAPAFLO 4 MO tamsulosin hcl 2 MO UROXATRAL 4 SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADRENALIN INJ 1MG/ML 4 ADVAIR DISKUS AER 100/50 3 MO

ADVAIR DISKUS AER 250/50 3 MO

ADVAIR DISKUS AER 500/50 3 MO

ADVAIR HFA AER 115/21 4 MO

ADVAIR HFA AER 230/21 4 MO

ADVAIR HFA AER 45/21 4 MO albuterol sulfate er tab 4mg er 2 MO

albuterol sulfate er tab 8mg er 2 MO

albuterol sulfate neb 0.083% 1 albuterol sulfate neb 0.5% 1 albuterol sulfate neb 0.63mg/3 2 albuterol sulfate neb 1.25mg/3 2 albuterol sulfate syp 2mg/5ml 2 albuterol sulfate tab 2mg 2 MO albuterol sulfate tab 4mg 2 MO ARCAPTA NEOHALER 4 MO AUVI-Q INJ 0.15MG 4 AUVI-Q INJ 0.3MG 4 BROVANA 4 COMBIVENT 3 MO COMBIVENT RESPIMAT 3 MO EPIPEN 2-PAK INJ 0.3MG 3 EPIPEN-JR 2-PAK INJ 2-PAK 3

Drug Name Drug Tier

Requirements/Limits

FORADIL AEROLIZER 4 MO ipratropium-albuterol 2 MO levalbuterol hcl 2 MAXAIR AUTOHALER 3 MO metaproterenol sulfate 2 MO midodrine hcl 2 MO PERFOROMIST 4 PROAIR HFA AER 3 MO PROVENTIL HFA AER HFA 4 MO

SEREVENT DISKUS 3 MO terbutaline sulfate 2 MO TWINJECT INJ 0.15MG 4 TWINJECT INJ 0.3MG 4 VENTOLIN HFA AER 4 MO vospire er tab 4mg 2 MO vospire er tab 8mg 2 MO XOPENEX 4 XOPENEX HFA 4 MO BLOOD FORMATION, COAGULATION, AND THROMBOSIS COAGULANTS AND ANTICOAGULANTS AGGRENOX 3 MO AGRYLIN 4 MO AMICAR 3 MO anagrelide hcl 2 MO argatroban 2 HI ARGATROBAN 4 HI ARIXTRA 4 BRILINTA 3 MO cilostazol 2 MO clopidogrel bisulfate 2 MO COUMADIN 4 HI,MO CYKLOKAPRON 4 HI EFFIENT 3 MO ELIQUIS 4 MO enoxaparin sodium 2 fondaparinux sodium 2 FRAGMIN 4 heparin (porcine) in sodium chloride 2



Drug Name Drug Tier

Requirements/Limits

heparin sod (porcine) in d5w 2 HI

heparin sodium (porcine) 2 HI INTEGRILIN 3 HI LOVENOX 3 LYSTEDA 4 MO pentoxifylline 2 MO PLAVIX 4 MO PLETAL 4 MO PRADAXA 3 MO ticlopidine hcl 2 MO tranexamic acid 2 HI,MO warfarin sodium 1 HI,MO XARELTO 4 MO ZONTIVITY 4 HEMATOPOIETIC AGENTS ARANESP ALBUMIN FREE 4 PA

EPOGEN INJ 10000/ML 3 PA EPOGEN INJ 2000/ML 4 PA EPOGEN INJ 20000/ML 4 PA EPOGEN INJ 3000/ML 4 PA EPOGEN INJ 4000/ML 4 PA GRANIX 5 LEUKINE 3 HI MOZOBIL 4 NEULASTA 5 NEUMEGA 5 NEUPOGEN 5 PROCRIT INJ 10000/ML 3 PA PROCRIT INJ 2000/ML 3 PA PROCRIT INJ 20000/ML 3 PA PROCRIT INJ 3000/ML 3 PA PROCRIT INJ 4000/ML 3 PA PROCRIT INJ 40000/ML 3 PA PROMACTA 5 CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS CARDURA 4 MO CARDURA XL 4 MO doxazosin mesylate 2 MO

Drug Name Drug Tier

Requirements/Limits

MINIPRESS 4 MO prazosin hcl 2 MO terazosin hcl 2 MO ANTILIPEMIC AGENTS ADVICOR 4 MO ALTOPREV 4 MO ANTARA 4 MO atorvastatin calcium 1 MO cholestyramine 2 MO cholestyramine light 2 MO choline fenofibrate 2 MO COLESTID 4 MO colestipol hcl 2 MO CRESTOR 4 MO fenofibrate 2 MO FENOFIBRATE 4 MO fenofibrate micronized 2 MO FENOGLIDE 4 MO FIBRICOR 4 MO fluvastatin sodium 2 MO gemfibrozil 2 MO JUXTAPID 5 LD KYNAMRO 5 LD LESCOL 4 MO LESCOL XL 4 MO LIPITOR 4 MO LIPOFEN 4 MO LIPTRUZET 4 MO LIVALO 4 MO LOPID 4 MO lovastatin 1 MO LOVAZA 4 MO niacin (antihyperlipidemic) 2 MO NIASPAN 4 MO omega-3-acid ethyl esters 2 MO PRAVACHOL 4 MO pravastatin sodium 1 MO SIMCOR 4 MO simvastatin 1 MO TRICOR 4 MO TRIGLIDE 4 MO


Drug Name Drug Tier

Requirements/Limits

TRILIPIX 4 MO VASCEPA 4 MO VYTORIN 4 MO WELCHOL 4 MO ZETIA 4 MO ZOCOR 4 MO CALCIUM-CHANNEL BLOCKING AGENTS ADALAT CC 4 MO amlodipine besylate 1 MO amlodipine besylate-atorvastatin calcium 2 MO

amlodipine besylate-benazepril hcl 2 MO

AZOR 4 MO CADUET 4 MO CALAN 4 MO CALAN SR 4 MO CARDENE IV 4 CARDENE SR 4 MO CARDIZEM 4 MO CARDIZEM CD 4 MO CARDIZEM LA 4 MO diltiazem hcl 2 HI,MO diltiazem hcl coated beads 2 MO

diltiazem hcl extended release beads 2 MO

EXFORGE 4 MO EXFORGE HCT 4 MO felodipine 2 MO isradipine 2 MO LOTREL 4 MO nicardipine hcl 2 HI,MO nifedipine 2 MO nimodipine 2 MO nisoldipine 2 MO NORVASC 4 MO PROCARDIA 4 MO PROCARDIA XL 4 MO SULAR 4 MO TARKA 4 MO

Drug Name Drug Tier

Requirements/Limits

telmisartan-amlodipine 2 MO TIAZAC 4 MO TRIBENZOR 4 MO TWYNSTA 4 MO verapamil hcl 2 HI,MO VERELAN 4 MO VERELAN PM 4 MO CARDIAC DRUGS amiodarone hcl 2 HI,MO CORDARONE 4 MO digoxin 2 MO DIGOXIN SOL 50MCG/ML 3 disopyramide phosphate 2 MO flecainide acetate 2 MO LANOXIN INJ 0.25MG/1 4 LANOXIN PEDIATRIC INJ 0.1MG/ML 3 LANOXIN TAB 0.0625MG 4 MO LANOXIN TAB 0.125MG 4 MO LANOXIN TAB 0.1875MG 4 MO LANOXIN TAB 0.25MG 4 MO mexiletine hcl 2 MO MULTAQ 4 MO NEXTERONE 4 HI NORPACE CAP 100MG 4 MO NORPACE CAP 150MG 4 MO NORPACE CR CAP 100MG CR 3 MO

NORPACE CR CAP 150MG CR 3 MO

procainamide hcl 2 propafenone hcl 2 MO quinidine gluconate 2 MO QUINIDINE GLUCONATE 3 quinidine sulfate 2 MO RANEXA 4 MO RYTHMOL 4 MO RYTHMOL SR 4 MO TIKOSYN 3 MO



Drug Name Drug Tier

Requirements/Limits

HYPOTENSIVE AGENTS CATAPRES 4 MO CATAPRES-TTS-1 4 MO CATAPRES-TTS-2 4 MO CATAPRES-TTS-3 4 MO clonidine & chlorthalidone 2 MO clonidine hcl 2 MO clonidine hcl (adhd) 2 MO guanfacine hcl 2 MO hydralazine hcl inj 20mg/ml 2 hydralazine hcl tab 100mg 2 MO

hydralazine hcl tab 10mg 1 MO hydralazine hcl tab 25mg 1 MO hydralazine hcl tab 50mg 2 MO KAPVAY 4 MO mecamylamine hcl 2 MO methyldopa 2 MO methyldopa & hydrochlorothiazide 2 MO

methyldopate hcl 2 HI minoxidil 2 MO PROGLYCEM 3 RESERPINE 3 MO TENEX 4 MO RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS ACCUPRIL 4 MO ACCURETIC 4 MO ALDACTAZIDE 4 MO ALDACTONE 4 MO ALTACE 4 MO AMTURNIDE 4 MO ATACAND 4 MO ATACAND HCT 4 MO AVALIDE 4 MO AVAPRO 4 MO benazepril & hydrochlorothiazide 2 MO

benazepril hcl 1 MO

Drug Name Drug Tier

Requirements/Limits

BENICAR 4 MO BENICAR HCT 4 MO candesartan cilexetil 2 MO candesartan cilexetil-hydrochlorothiazide 2 MO

captopril 1 MO captopril & hydrochlorothiazide 2 MO

COZAAR 4 MO DIOVAN 4 MO DIOVAN HCT 4 MO EDARBI 4 MO EDARBYCLOR 4 MO enalapril maleate 1 MO enalapril maleate & hydrochlorothiazide 2 MO

EPANED 4 eplerenone 2 MO eprosartan mesylate 2 MO fosinopril sodium 2 MO fosinopril sodium & hydrochlorothiazide 2 MO

HYZAAR 4 MO INSPRA 4 MO irbesartan 2 MO irbesartan-hydrochlorothiazide 2 MO

lisinopril & hydrochlorothiazide 1 MO

lisinopril tab 10mg 1 MO lisinopril tab 2.5mg 1 MO lisinopril tab 20mg 1 MO lisinopril tab 30mg 2 MO lisinopril tab 40mg 1 MO lisinopril tab 5mg 1 MO losartan potassium 2 MO losartan potassium & hydrochlorothiazide 2 MO

LOTENSIN 4 MO MAVIK 4 MO MICARDIS 4 MO


Drug Name Drug Tier

Requirements/Limits

MICARDIS HCT 4 MO moexipril hcl 2 MO moexipril-hydrochlorothiazide 2 MO

perindopril erbumine 2 MO PRINIVIL 4 MO quinapril hcl 2 MO quinapril-hydrochlorothiazide 2 MO

ramipril 2 MO spironolactone & hydrochlorothiazide 2 MO

spironolactone tab 100mg 2 MO spironolactone tab 25mg 1 MO spironolactone tab 50mg 2 MO TEKAMLO 4 MO TEKTURNA 4 MO TEKTURNA HCT 4 MO telmisartan 2 MO telmisartan-hydrochlorothiazide 2 MO

TEVETEN 4 MO TEVETEN HCT 4 MO trandolapril 2 MO UNIRETIC 4 MO UNIVASC 4 MO valsartan-hydrochlorothiazide 2 MO

VASERETIC 4 MO VASOTEC 4 MO ZESTORETIC 4 MO ZESTRIL 4 MO VASODILATING AGENTS ADCIRCA 5 PA BIDIL 4 MO CIALIS 4 PA,MO DILATRATE SR CAP 40MG 3 MO

dipyridamole 2 MO ISORDIL TITRADOSE TAB 40MG 3 MO

Drug Name Drug Tier

Requirements/Limits

ISORDIL TITRADOSE TAB 5MG 4 MO

isosorbide dinitrate 2 MO isosorbide mononitrate er tab 120mg er 2 MO

isosorbide mononitrate er tab 30mg er 1 MO

isosorbide mononitrate er tab 60mg er 1 MO

isosorbide mononitrate tab 10mg 2 MO

isosorbide mononitrate tab 20mg 2 MO

NITRO-DUR DIS 0.1MG/HR 4 MO






nitroglycerin 2 HI,MO NITROLINGUAL PUMPSPRAY SPR PUMPSPRA

4

NITROMIST AER 400MCG 4 MO

NITROSTAT SUB 0.3MG 3 MO NITROSTAT SUB 0.4MG 3 MO NITROSTAT SUB 0.6MG 3 MO PERSANTINE 4 MO REVATIO 5 PA sildenafil citrate (pulmonary hypertension) 2 PA,MO

ß-ADRENERGIC BLOCKING AGENTS acebutolol hcl 2 MO atenolol 1 MO atenolol & chlorthalidone 1 MO



Drug Name Drug Tier

Requirements/Limits

BETAPACE AF 4 MO betaxolol hcl 2 MO bisoprolol & hydrochlorothiazide 1 MO

bisoprolol fumarate 2 MO BYSTOLIC 4 MO carvedilol 1 MO COREG 4 MO COREG CR 4 MO CORGARD 4 MO CORZIDE 4 MO DUTOPROL 4 MO INDERAL LA 4 MO INNOPRAN XL 4 MO labetalol hcl 2 HI,MO LEVATOL 4 MO LOPRESSOR 4 HI LOPRESSOR HCT 4 MO metoprolol & hydrochlorothiazide 2 MO

metoprolol succinate 2 MO metoprolol tartrate inj 1mg/ml 2 HI

metoprolol tartrate tab 100mg 1 MO



nadolol & bendroflumethiazide 2 MO

nadolol tab 20mg 1 MO nadolol tab 40mg 1 MO nadolol tab 80mg 2 MO pindolol 2 MO propranolol & hydrochlorothiazide 2 MO

propranolol hcl er cap 120mg er 2 MO


Drug Name Drug Tier

Requirements/Limits



propranolol hcl inj 1mg/ml 2 HI propranolol hcl sol 20mg/5ml 2 propranolol hcl sol 40mg/5ml 2 propranolol hcl tab 10mg 1 MO propranolol hcl tab 20mg 1 MO propranolol hcl tab 40mg 1 MO propranolol hcl tab 60mg 2 MO propranolol hcl tab 80mg 1 MO SECTRAL 4 MO sotalol hcl 2 MO sotalol hcl (afib/afl) 2 MO TENORETIC 100 4 MO TENORETIC 50 4 MO TENORMIN 4 MO timolol maleate 2 MO TOPROL XL 4 MO ZEBETA 4 MO ZIAC 4 MO CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS ABSTRAL 4 PA acetaminophen w/ codeine 2 ACTIQ 4 PA ANAPROX 4 MO ANAPROX DS 4 MO ARTHROTEC 50 4 MO ARTHROTEC 75 4 MO AVINZA 4 BUPRENEX 4 buprenorphine hcl 2 butalbital-acetaminophen 2 butalbital-acetaminophen-caffeine 2


Drug Name Drug Tier

Requirements/Limits

butalbital-acetaminophen-caffeine w/ codeine 2 butalbital-aspirin-caffeine 2 butalbital-aspirin-caffeine w/cod 2 butorphanol tartrate 2 BUTRANS 4 CAMBIA 4 CATAFLAM 4 MO CELEBREX 4 MO CODEINE SULFATE TAB 15MG 3 CODEINE SULFATE TAB 30MG 3 CODEINE SULFATE TAB 60MG 4 CONZIP 4 DAYPRO 4 MO DEMEROL 4 diclofenac potassium 2 MO diclofenac sodium 2 MO diclofenac w/ misoprostol 2 MO diflunisal 2 MO DILAUDID INJ 1MG/ML 4 DILAUDID INJ 2MG/ML 4 DILAUDID INJ 4MG/ML 4 DILAUDID LIQ 1MG/ML 3 DILAUDID TAB 2MG 4 DILAUDID TAB 4MG 4 DILAUDID TAB 8MG 4 DILAUDID-HP INJ 10MG/ML 4 DOLOPHINE HCL TAB 5MG 4 DOLOPHINE TAB 10MG 4 DUEXIS 4 MO DURAGESIC 4 EC-NAPROSYN 4 MO etodolac 2 MO EXALGO TAB 12MG 4 EXALGO TAB 16MG 4

Drug Name Drug Tier

Requirements/Limits

EXALGO TAB 32MG 4 EXALGO TAB 8MG 4 FELDENE 4 MO fenoprofen calcium 2 MO fentanyl 2 PA fentanyl citrate 2 PA FENTORA 4 PA FIORINAL 4 FIORINAL/CODEINE #3 4 flurbiprofen 2 MO GRALISE 4 MO GRALISE STARTER 4 MO hydrocodone-acetaminophen 2 hydrocodone-ibuprofen 2 hydromorphone hcl 2 ibuprofen 2 MO ILARIS 5 INDOCIN 4 indomethacin 2 MO KADIAN CAP 100MG CR 4 KADIAN CAP 10MG CR 4 KADIAN CAP 130MG CR 4 KADIAN CAP 150MG CR 4 KADIAN CAP 200MG CR 4 KADIAN CAP 20MG CR 4 KADIAN CAP 30MG CR 4 KADIAN CAP 40MG CR 4 KADIAN CAP 50MG CR 4 KADIAN CAP 60MG CR 4 KADIAN CAP 70MG CR 4 KADIAN CAP 80MG CR 4 ketoprofen 2 MO ketorolac tromethamine 2 MO LAZANDA 4 PA levorphanol tartrate 2 meclofenamate sodium 2 MO mefenamic acid 2 MO meloxicam 2 MO MELOXICAM 4 meperidine hcl 2



Drug Name Drug Tier

Requirements/Limits

methadone hcl 2 METHADONE HCL INJ 10MG/ML 3 MOBIC 4 MO morphine sulfate 2 morphine sulfate beads 2 MORPHINE SULFATE INJ 2MG/ML 4

MORPHINE SULFATE INJ 4MG/ML 4

MORPHINE SULFATE TAB 15MG 3 MORPHINE SULFATE TAB 30MG 3 MS CONTIN TAB 100MG CR 4 MS CONTIN TAB 15MG CR 4 MS CONTIN TAB 200MG CR 4 MS CONTIN TAB 30MG CR 4 MS CONTIN TAB 60MG CR 4 nabumetone 2 MO nalbuphine hcl 2 NAPRELAN 4 MO NAPROSYN 4 MO naproxen 2 MO naproxen sodium 2 MO NUCYNTA 4 NUCYNTA ER 4 OPANA 4 OPANA ER (CRUSH RESISTANT) 4 oxaprozin 2 MO OXECTA 4 oxycodone hcl 2 oxycodone w/ acetaminophen 2 oxycodone-aspirin 2

Drug Name Drug Tier

Requirements/Limits

oxycodone-ibuprofen 2 OXYCONTIN 4 oxymorphone hcl 2 pentazocine w/ naloxone 2 PERCODAN 4 piroxicam 2 MO PONSTEL 4 MO ROXICODONE 4 SPRIX 4 SUBSYS 4 PA sulindac 2 MO SYNALGOS-DC 4 TALWIN 4 tolmetin sodium 2 MO tramadol hcl 2 tramadol-acetaminophen 2 ULTRACET 4 ULTRAM 4 ULTRAM ER 4 VICOPROFEN 4 VIMOVO 4 MO VOLTAREN-XR 4 MO XARTEMIS XR 4 ZIPSOR 4 MO ZOHYDRO ER 4 PA ZORVOLEX 4 MO ZUBSOLV 4 ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS ADDERALL XR 3 amphetamine-dextroamphetamine 2 CONCERTA TAB 18MG 4 CONCERTA TAB 27MG 4 CONCERTA TAB 36MG 4 CONCERTA TAB 54MG 4 DAYTRANA 4 DESOXYN 4 DEXEDRINE 4 dexmethylphenidate hcl 2


Drug Name Drug Tier

Requirements/Limits

dextroamphetamine sulfate 2 FOCALIN 4 FOCALIN XR 4 METADATE CD CAP 10MG 4 METADATE CD CAP 20MG 4 METADATE CD CAP 30MG 4 METADATE CD CAP 40MG 4 METADATE CD CAP 50MG 4 METADATE CD CAP 60MG 4 methamphetamine hcl 2 METHYLIN CHW 10MG 4 METHYLIN CHW 2.5MG 3 METHYLIN CHW 5MG 4 METHYLIN SOL 10MG/5ML 4 METHYLIN SOL 5MG/5ML 4 methylphenidate hcl 2 modafinil 2 PA NUVIGIL 4 PA PROVIGIL 4 PA QUILLIVANT XR SUS XR 4 RITALIN LA CAP 10MG 4 RITALIN LA CAP 20MG 4 RITALIN LA CAP 30MG 4 RITALIN LA CAP 40MG 4 RITALIN SR TAB 20MG SR 4 RITALIN TAB 10MG 4 RITALIN TAB 20MG 4 RITALIN TAB 5MG 4 VYVANSE 3 ANTICONVULSANTS APTIOM 4 MO

Drug Name Drug Tier

Requirements/Limits

BANZEL 4 MO carbamazepine 2 MO CARBATROL CAP 100MG 4 MO

CARBATROL CAP 200MG 4 MO

CARBATROL CAP 300MG 4 MO

CELONTIN 3 MO clonazepam 2 DEPACON 4 HI DEPAKENE 4 MO DEPAKOTE 4 MO DEPAKOTE ER 4 MO DEPAKOTE SPRINKLES 4 MO DILANTIN 4 MO divalproex sodium 2 MO EQUETRO 4 MO ethosuximide 2 MO felbamate 2 MO FELBATOL 5 fosphenytoin sodium 2 FYCOMPA 4 MO gabapentin 2 MO GABITRIL 4 MO HORIZANT 4 MO KEPPRA 4 MO KEPPRA XR 4 MO KLONOPIN 4 LAMICTAL CHEWABLE DISPERSIBLE CHW 25MG

4 MO

LAMICTAL CHEWABLE DISPERSIBLE CHW 5MG

4 MO

LAMICTAL ODT TAB 100MG 4 MO





Drug Name Drug Tier

Requirements/Limits


LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE KIT START 49

3 MO

LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE KIT START 98

3 MO

LAMICTAL STARTER/TAKING VALPROATE KIT START 35

3 MO

LAMICTAL TAB 100MG 4 MO LAMICTAL TAB 150MG 4 MO LAMICTAL TAB 200MG 4 MO LAMICTAL TAB 25MG 4 MO LAMICTAL XR KIT 4 MO LAMICTAL XR TAB 100MG 4 MO

LAMICTAL XR TAB 200MG 4 MO





lamotrigine 2 MO levetiracetam 2 HI,MO LEVETIRACETAM 3 HI,MO LYRICA 4 MO magnesium sulfate 2 HI MAGNESIUM SULFATE 3 HI MYSOLINE 4 MO NEURONTIN 4 MO ONFI 4 MO oxcarbazepine 2 MO

Drug Name Drug Tier

Requirements/Limits

OXTELLAR XR 4 MO PEGANONE 4 MO phenytoin 2 MO phenytoin sodium 2 phenytoin sodium extended 2 MO

POTIGA 4 MO primidone 2 MO QUDEXY XR 4 MO SABRIL 5 LD TEGRETOL SUS 100/5ML 4 TEGRETOL TAB 200MG 4 MO TEGRETOL-XR TAB 100MG 3 MO

TEGRETOL-XR TAB 200MG 4 MO

TEGRETOL-XR TAB 400MG 4 MO

tiagabine hcl 2 MO TOPAMAX 4 MO TOPAMAX SPRINKLE 4 MO topiramate 2 MO TRILEPTAL 4 MO TROKENDI XR 4 MO valproate sodium 2 HI valproic acid 2 MO VIMPAT 4 HI,MO ZARONTIN 4 MO ZONEGRAN 4 MO zonisamide 2 MO ANTIMIGRAINE AGENTS ALSUMA 4 AMERGE 4 AXERT 4 ergotamine w/ caffeine 2 FROVA 4 IMITREX 4 IMITREX STATDOSE REFILL 4 MAXALT 4


Drug Name Drug Tier

Requirements/Limits

MAXALT-MLT 4 naratriptan hcl 2 RELPAX 4 rizatriptan benzoate 2 SUMATRIPTAN 4 sumatriptan succinate 2 SUMAVEL DOSEPRO 4 TREXIMET 4 zolmitriptan 2 ZOMIG 4 ZOMIG NASAL SPRAY 4 ZOMIG ZMT 4 ANTIPARKINSONIAN AGENTS amantadine hcl 2 MO APOKYN 5 AZILECT 3 MO benztropine mesylate 2 MO bromocriptine mesylate 2 MO cabergoline 2 MO carbidopa 2 MO carbidopa-levodopa 2 MO CARBIDOPA/LEVODOPA/ENTACA PONE 4 MO

COGENTIN 4 COMTAN 3 MO ELDEPRYL 4 MO EMSAM 4 MO entacapone 2 MO LODOSYN 3 MO MIRAPEX 4 MO MIRAPEX ER 4 MO NEUPRO 4 MO PARLODEL 4 MO pramipexole dihydrochloride 2 MO

REQUIP 4 MO REQUIP XL 4 MO ropinirole hydrochloride 2 MO selegiline hcl 2 MO SINEMET 4 MO SINEMET CR 4 MO

Drug Name Drug Tier

Requirements/Limits

STALEVO 100 4 MO STALEVO 125 4 MO STALEVO 150 4 MO STALEVO 200 4 MO STALEVO 50 4 MO STALEVO 75 4 MO TASMAR 4 MO trihexyphenidyl hcl 2 MO ZELAPAR 4 MO ANXIOLYTICS, SEDATIVES, AND HYPNOTICS alprazolam 2 AMBIEN 4 AMBIEN CR 4 ATIVAN 4 buspirone hcl 2 butabarbital sodium 2 BUTISOL SODIUM 4 chlordiazepoxide hcl 2 clorazepate dipotassium 2 DIASTAT ACUDIAL 3 DIASTAT PEDIATRIC 3 diazepam 2 DIAZEPAM 3 EDLUAR 4 estazolam 2 eszopiclone 2 flurazepam hcl 2 HALCION 4 HETLIOZ 5 hydroxyzine hcl 2 hydroxyzine pamoate 2 INTERMEZZO 4 lorazepam 2 LUNESTA 4 meprobamate 2 oxazepam 2 phenobarbital 2 RESTORIL 4 ROZEREM 4 secobarbital sodium 2 SILENOR 4



Drug Name Drug Tier

Requirements/Limits

SONATA 4 temazepam 2 TRANXENE T 4 triazolam 2 VALIUM 4 VISTARIL 4 XANAX 4 XANAX XR 4 zaleplon 2 zolpidem tartrate 2 ZOLPIMIST 4 CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS acamprosate calcium 2 MO CAMPRAL 4 MO INTUNIV 4 MO NAMENDA SOL 10MG/5ML 3 NAMENDA TITRATION PAK TAB 5-10MG 3 MO

NAMENDA XR CAP 14MG 4 MO



NAMENDA XR CAP 7MG 4 MO NAMENDA XR TITRATION PACK CAP TITRATIO

4 MO

NUEDEXTA 3 MO RILUTEK 5 riluzole 2 MO SAVELLA 3 MO SAVELLA TITRATION PACK 3 MO

STRATTERA 4 MO XENAZINE 5 XYREM 5 LD OPIATE ANTAGONISTS buprenorphine hcl-naloxone hcl dihydrate 2

Drug Name Drug Tier

Requirements/Limits

EVZIO 4 naloxone hcl 2 naltrexone hcl 2 SUBOXONE 4 VIVITROL 4 PSYCHOTHERAPEUTIC AGENTS ABILIFY DISCMELT TAB 10MG 3 MO

ABILIFY DISCMELT TAB 15MG 3 MO

ABILIFY INJ 9.75MG 3 ABILIFY MAINTENA INJ 300MG 4 ABILIFY SOL 1MG/ML 3 ABILIFY TAB 10MG 3 MO ABILIFY TAB 15MG 3 MO ABILIFY TAB 20MG 3 MO ABILIFY TAB 2MG 3 MO ABILIFY TAB 30MG 3 MO ABILIFY TAB 5MG 3 MO amitriptyline hcl 2 MO amoxapine 2 MO ANAFRANIL 4 MO APLENZIN 4 MO BRINTELLIX 4 MO BRISDELLE 4 MO bupropion hcl 2 MO bupropion hcl (smoking deterrent) 2 MO

CELEXA 4 MO chlordiazepoxide-amitriptyline 2 chlorpromazine hcl 2 MO citalopram hydrobromide sol 10mg/5ml 2 citalopram hydrobromide tab 10mg 2 MO

citalopram hydrobromide tab 20mg 1 citalopram hydrobromide tab 40mg 1 MO


Drug Name Drug Tier

Requirements/Limits

clomipramine hcl 2 MO clozapine 2 MO CLOZARIL 4 CYMBALTA 4 MO desipramine hcl 2 MO DESVENLAFAXINE ER 4 MO doxepin hcl 2 MO duloxetine hcl 2 MO EFFEXOR XR 4 MO escitalopram oxalate 2 MO FANAPT 4 MO FANAPT TITRATION PACK 4 MO

FAZACLO 4 MO FETZIMA 4 MO FETZIMA TITRATION PACK 4 MO

fluoxetine dr cap 90mg dr 2 MO FLUOXETINE HCL 4 MO fluoxetine hcl cap 10mg 1 MO fluoxetine hcl cap 20mg 1 MO fluoxetine hcl cap 40mg 1 MO fluoxetine hcl sol 20mg/5ml 2 fluoxetine hcl tab 10mg 2 MO fluoxetine hcl tab 20mg 2 MO fluphenazine decanoate 2 fluphenazine hcl 2 MO fluvoxamine maleate 2 MO FORFIVO XL 4 MO GEODON 3 MO GEODON 4 MO HALDOL 4 HALDOL DECANOATE 100 4 HALDOL DECANOATE 50 4 haloperidol 2 MO haloperidol decanoate 2 haloperidol lactate 2 imipramine hcl 2 MO

Drug Name Drug Tier

Requirements/Limits

imipramine pamoate 2 MO INVEGA 4 MO INVEGA SUSTENNA 4 KHEDEZLA 4 MO LATUDA 4 MO LEXAPRO 4 MO lithium carbonate 2 MO LITHIUM CARBONATE CAP 600MG 3 MO

LITHIUM CITRATE 3 LITHOBID TAB 300MG CR 4 MO

loxapine succinate 2 MO LUVOX CR 4 MO maprotiline hcl 2 MO MARPLAN 4 MO mirtazapine 2 MO NARDIL 4 MO NAVANE 3 MO nefazodone hcl 2 MO NORPRAMIN 4 MO nortriptyline hcl cap 10mg 1 MO nortriptyline hcl cap 25mg 1 MO nortriptyline hcl cap 50mg 2 MO nortriptyline hcl cap 75mg 2 MO nortriptyline hcl sol 10mg/5ml 2

olanzapine 2 MO olanzapine-fluoxetine hcl 2 MO ORAP 3 MO PAMELOR 4 MO PARNATE 4 MO paroxetine hcl er tab 12.5mg 2 MO

paroxetine hcl er tab 25mg er 2 MO

paroxetine hcl er tab 37.5mg 2 MO

paroxetine hcl tab 10mg 1 MO paroxetine hcl tab 20mg 1 MO paroxetine hcl tab 30mg 2 MO



Drug Name Drug Tier

Requirements/Limits

paroxetine hcl tab 40mg 2 MO PAXIL 4 MO PAXIL CR 4 MO perphenazine 2 MO perphenazine-amitriptyline 2 MO

PEXEVA 4 MO phenelzine sulfate 2 MO PRISTIQ 4 MO prochlorperazine 2 MO prochlorperazine edisylate 2 prochlorperazine maleate 2 MO protriptyline hcl 2 MO PROZAC 4 MO PROZAC WEEKLY 4 MO quetiapine fumarate 2 MO REMERON 4 MO REMERON SOLTAB 4 MO RISPERDAL 4 MO RISPERDAL CONSTA 4 RISPERDAL M-TAB 4 MO risperidone 2 MO SAPHRIS 4 MO SARAFEM 4 MO SEROQUEL 4 MO SEROQUEL XR 4 MO sertraline hcl 2 MO SURMONTIL 4 MO SYMBYAX 4 MO thioridazine hcl 2 MO thiothixene 2 MO TOFRANIL-PM 4 MO tranylcypromine sulfate 2 MO trazodone hcl tab 100mg 1 MO trazodone hcl tab 150mg 1 MO trazodone hcl tab 300mg 2 MO trazodone hcl tab 50mg 1 MO trifluoperazine hcl 2 MO venlafaxine hcl 2 MO VENLAFAXINE HCL ER 4 MO

Drug Name Drug Tier

Requirements/Limits

VERSACLOZ 4 VIIBRYD 4 MO WELLBUTRIN 4 MO WELLBUTRIN SR 4 MO WELLBUTRIN XL 4 MO ziprasidone hcl 2 MO ZOLOFT 4 MO ZYBAN 4 MO ZYPREXA 4 MO ZYPREXA ZYDIS 4 MO DIABETIC SUPPLIES DIABETIC SUPPLIES alcohol swabs 2 gauze pads & dressings 2 insulin pen needle 2 MO insulin syringe/needle u-100 2 MO

ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS ammonium chloride 2 HI POTASSIUM CITRATE ER TAB 1080MG 3 MO

POTASSIUM CITRATE ER TAB 540MG ER 3 MO

SODIUM LACTATE INJ 1/6M 3 HI

SODIUM LACTATE INJ 5MEQ/ML 4 HI

UROCIT-K 10 TAB 4 MO UROCIT-K 15 TAB 4 MO UROCIT-K 5 TAB 4 MO AMMONIA DETOXICANTS BUPHENYL 5 CARBAGLU 4 LD lactulose 2 MO lactulose (encephalopathy) 2 LITHOSTAT 4 MO RAVICTI 5 sodium phenylbutyrate 2 MO


Drug Name Drug Tier

Requirements/Limits

CALORIC AGENTS amino acid electrolyte infusion 2 HI

amino acid infusion 2 HI AMINOSYN II INJ 10% 4 HI AMINOSYN II INJ 15% 4 HI AMINOSYN II INJ 7% 4 HI AMINOSYN II INJ 8.5% 4 HI AMINOSYN M INJ 3.5% 4 HI AMINOSYN-HBC INJ 7% 4 HI AMINOSYN-PF 7% INJ 7% 4 HI

AMINOSYN-PF INJ 10% 4 HI CLINIMIX 2.75%/DEXTROSE 5% 3 HI

CLINIMIX 4.25%/DEXTROSE 10% 3 HI




CLINIMIX 5%/DEXTROSE 15% 3 HI



CLINIMIX E 2.75%/DEXTROSE 10% 3 HI





CLINIMIX E 5%/DEXTROSE 15% 3 HI

Drug Name Drug Tier

Requirements/Limits



dextrose 2 HI fat emulsion 2 HI FREAMINE III 3% INJ 3% 3 HI INTRALIPID INJ 30% 4 HI LIPOSYN III INJ 10% 3 HI LIPOSYN III INJ 20% 4 HI NEPHRAMINE INJ 5.4% 3 HI PROCALAMINE INJ 3% 3 HI PROSOL INJ 20% 4 HI TROPHAMINE INJ 10% 3 HI TROPHAMINE INJ 6% 3 HI DIURETICS amiloride & hydrochlorothiazide 1 MO

amiloride hcl 2 MO bumetanide inj 0.25/ml 2 bumetanide tab 0.5mg 1 MO bumetanide tab 1mg 1 MO bumetanide tab 2mg 2 MO chlorothiazide 2 MO chlorothiazide sodium 2 HI chlorthalidone 2 MO DEMADEX 4 MO DIURIL 3 DYAZIDE 4 MO DYRENIUM 3 MO EDECRIN 3 MO furosemide inj 10mg/ml 2 HI furosemide sol 10mg/ml 2 furosemide sol 8mg/ml 2 furosemide tab 20mg 1 MO furosemide tab 40mg 1 MO furosemide tab 80mg 1 MO hydrochlorothiazide cap 12.5mg 1 MO

hydrochlorothiazide tab 12.5mg 2 MO



Drug Name Drug Tier

Requirements/Limits

hydrochlorothiazide tab 25mg 1 MO

hydrochlorothiazide tab 50mg 1 MO

indapamide 1 MO LASIX 4 MO MAXZIDE 4 MO MAXZIDE-25 4 MO methyclothiazide 2 MO metolazone 2 MO MICROZIDE 4 MO SAMSCA 4 MO SODIUM DIURIL 4 HI SODIUM EDECRIN 3 HI torsemide 2 HI,MO triamterene/hydrochlorothiazide cap 37.5-25 2 MO

triamterene/hydrochlorothiazide cap 50-25mg 2 MO

triamterene/hydrochlorothiazide tab 37.5-25 1 MO

triamterene/hydrochlorothiazide tab 75-50mg 1 MO

ZAROXOLYN 4 MO ION-REMOVING AGENTS FOSRENOL 5 KAYEXALATE 4 MO RENAGEL 4 MO RENVELA 4 MO sodium polystyrene sulfonate 2 MO

VELPHORO 4 MO IRRIGATING SOLUTIONS irrigation solutions, physiological 2 lactated ringer's (irrigation) 2 ringer's irrigation 2 sodium chloride (gu irrigant) 2 water for irrigation, sterile 2

Drug Name Drug Tier

Requirements/Limits

REPLACEMENT PREPARATIONS calcium acetate (phosphate binder) 2 MO

DEXTROSE 10%/NACL 0.45% INJ 0.45% 3 HI

DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX

3 HI



dextrose in lactated ringers 2 HI

dextrose w/ sodium chloride 2 HI

electrolyte-m in dextrose 2 HI IONOSOL-B/DEXTROSE 5% 4 HI

IONOSOL-MB/DEXTROSE 5% 4 HI

ISOLYTE-P/DEXTROSE 5% 4 HI

ISOLYTE-S 4 HI K-TAB TAB 10MEQ CR 3 MO K-TAB TAB 20MEQ 4 MO KCL 0.15%/D5W/LR 3 HI KCL 0.15%/D5W/NACL 0.225% INJ 0.15/0.2 4 HI

KCL 0.3%/D5W/NACL 0.9% INJ 0.3/0.9% 3 HI

lactated ringer's 2 HI MAGNESIUM SULFATE IN D5W 3 HI

NORMOSOL-R 4 HI NORMOSOL-R IN D5W 4 HI parenteral electrolytes 2 HI PHOSLO CAP 667MG 4 MO PHOSLYRA SOL 3 PLASMA-LYTE A 3 HI PLASMA-LYTE-148 3 HI PLASMA-LYTE-56/D5W 3 HI


Drug Name Drug Tier

Requirements/Limits

potassium chloride 2 HI,MO POTASSIUM CHLORIDE 0.15% /NACL 0.45% VIAFLEX INJ .15-0.45

3 HI

POTASSIUM CHLORIDE 0.15%/NACL 0.9% INJ 0.15-0.9

4 HI

POTASSIUM CHLORIDE 0.3%/ NACL 0.9% INJ 0.3-0.9

4 HI

potassium chloride in dextrose 2 HI

potassium chloride in dextrose & sodium chloride

2 HI

potassium chloride in nacl 2 HI POTASSIUM CHLORIDE INJ 10MEQ 4 HI

POTASSIUM CHLORIDE INJ 20MEQ 4 HI

POTASSIUM CHLORIDE INJ 40MEQ 4 HI

potassium chloride microencapsulated crystals cr

2 MO

ringer's inj 2 HI sodium chloride 2 HI ZINC TRACE METAL 3 HI URICOSURIC AGENTS colchicine w/ probenecid 2 MO probenecid 2 MO ENZYMES ENZYMES ADAGEN 3 LD ALDURAZYME 3 HI CEREZYME 5 HI ELAPRASE 5 ELELYSO 5 ELITEK 3 HI FABRAZYME 5 HI LUMIZYME 5 LD

Drug Name Drug Tier

Requirements/Limits

MYOZYME 5 NAGLAZYME 5 PULMOZYME 5 SUCRAID 4 LD VIMIZIM 5 VPRIV 5 EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES AZASITE 4 bacitracin (ophthalmic) 2 bacitracin-polymyxin b (ophth) 2 BESIVANCE 4 BLEPH-10 4 chlorhexidine gluconate (mouth-throat) 2 CILOXAN OIN 0.3% OP 3 CILOXAN SOL 0.3% OP 4 ciprofloxacin hcl (ophth) 2 erythromycin (ophth) 2 gatifloxacin (ophth) 2 gentamicin sulfate (ophth) 2 levofloxacin (ophth) 2 MOXEZA 4 NATACYN 3 neomycin-bacitracin zn-polymyxin 2 neomycin-polymyxin-gramicidin 2 OCUFLOX 4 ofloxacin (ophth) 2 ofloxacin (otic) 2 polymyxin b-trimethoprim 2 POLYTRIM 4 sulfacetamide sodium (ophth) 2 tobramycin (ophth) 2 TOBREX OIN 0.3% OP 3 TOBREX SOL 0.3% OP 4 trifluridine 2



Drug Name Drug Tier

Requirements/Limits

VIGAMOX 4 VIROPTIC 4 ZIRGAN 4 ZYMAXID 3 ANTI-INFLAMMATORY AGENTS ACULAR 4 ACULAR LS 4 ACUVAIL 4 ALREX 4 bacitracin-poly-neomycin-hc 2 MO

BECONASE AQ 4 BLEPHAMIDE 3 bromfenac sodium (ophth) 2 budesonide (nasal) 2 CIPRO HC 4 CIPRODEX 3 COLY-MYCIN S 3 CORTISPORIN 4 MO CORTISPORIN-TC 3 dexamethasone sodium phosphate (ophth) 2 diclofenac sodium (ophth) 2 DUREZOL 4 FLAREX 4 FLONASE 4 flunisolide (nasal) 2 fluocinolone acetonide (otic) 2 flurbiprofen sodium 2 fluticasone propionate (nasal) 2 FML FORTE SUS 0.25% OP 3 FML LIQUIFILM SUS 0.1% OP 4 FML OIN 0.1% OP 3 MO hydrocortisone w/acetic acid 2 ILEVRO 4

Drug Name Drug Tier

Requirements/Limits

ketorolac tromethamine (ophth) 2 LOTEMAX 4 MO MAXIDEX 4 MAXITROL 4 MO NASACORT AQ 4 MO NASONEX 4 neomycin-polymy-dexameth 2 MO

neomycin-polymyxin-hc (ophth) 2 neomycin-polymyxin-hc (otic) 2 NEVANAC 4 OCUFEN 4 OMNARIS 4 OMNIPRED SUS 1% OP 4 PRED FORTE SUS 1% OP 4 PRED MILD SUS 0.12% OP 3 PRED-G 3 PRED-G S.O.P. 3 MO prednisolone acetate (ophth) 2 prednisolone sodium phosphate (ophth) 2 PROLENSA 4 QNASL 4 MO RESTASIS 4 RHINOCORT AQUA 4 sulfacetamide sod-prednisolone 2 MO

TOBRADEX OIN 0.3-0.1% 3 MO

TOBRADEX ST SUS 0.3-0.05 4 TOBRADEX SUS 0.3-0.1% 4 tobramycin-dexamethasone 2 MO


Drug Name Drug Tier

Requirements/Limits

triamcinolone acetonide (nasal) 2 MO

VERAMYST 4 VEXOL 3 ZETONNA 4 MO ZYLET 4 ANTIALLERGIC AGENTS ALOCRIL 3 ALOMIDE 4 ASTELIN 4 ASTEPRO 4 azelastine hcl 2 azelastine hcl (ophth) 2 BEPREVE 4 cromolyn sodium (ophth) 2 DYMISTA 4 ELESTAT 4 EMADINE 4 epinastine hcl (ophth) 2 LASTACAFT 4 OPTIVAR 4 PATADAY 4 PATANASE 4 PATANOL 4 ANTIGLAUCOMA AGENTS acetazolamide 2 MO acetazolamide sodium 2 HI ALPHAGAN P 4 AZOPT 4 BETAGAN 4 betaxolol hcl (ophth) 2 BETIMOL 4 BETOPTIC-S 4 brimonidine tartrate 2 carteolol hcl (ophth) 2 COMBIGAN 4 COSOPT 4 DIAMOX 4 MO dorzolamide hcl 2 dorzolamide hcl-timolol maleate 2

Drug Name Drug Tier

Requirements/Limits

ISOPTO CARPINE SOL 1% OP 4 ISOPTO CARPINE SOL 2% OP 4 ISOPTO CARPINE SOL 4% OP 4 ISTALOL 4 latanoprost 2 levobunolol hcl 2 LUMIGAN 3 methazolamide 2 MO metipranolol 2 PHOSPHOLINE IODIDE 3 pilocarpine hcl 2 MO PILOPINE HS GEL 4% OP 3 MO

RESCULA 4 SIMBRINZA 4 timolol maleate (ophth) 2 TIMOPTIC OCUDOSE 4 TIMOPTIC-XE 4 TRAVATAN Z 4 travoprost 2 TRUSOPT 4 XALATAN 4 ZIOPTAN 4 EENT DRUGS, MISCELLANEOUS acetic acid (otic) 2 apraclonidine hcl 2 CYSTARAN 4 IOPIDINE SOL 0.5% OP 4 IOPIDINE SOL 1% OP 3 LACRISERT 3 MO LOCAL ANESTHETICS lidocaine hcl (mouth-throat) 2 proparacaine hcl 2 VASOCONSTRICTORS naphazoline hcl 2 tetrahydrozoline hcl 2



Drug Name Drug Tier

Requirements/Limits

GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS APRISO CAP 0.375GM 4 MO ASACOL HD TAB 800MG 4 MO balsalazide disodium 2 MO CANASA SUP 1000MG 3 MO COLAZAL 4 MO DELZICOL CAP 400MG 4 MO DIPENTUM 5 GIAZO 4 MO LIALDA TAB 1.2GM 3 MO LOTRONEX 4 MO mesalamine w/ cleanser 2 MO PENTASA CAP 250MG CR 3 MO

PENTASA CAP 500MG CR 3 MO

SFROWASA ENE 4GM 4 ANTIDIARRHEA AGENTS diphenoxylate w/ atropine 2 FULYZAQ 4 MO LOMOTIL 4 loperamide hcl 2 MO ANTIEMETICS ALOXI 4 HI ANZEMET 4 PA,HI CESAMET 4 PA dronabinol 2 EMEND CAP 125MG 3 PA EMEND CAP 40MG 4 PA EMEND CAP 80MG 3 PA EMEND PAK 80 & 125 4 PA granisetron hcl 2 PA,HI MARINOL 4 meclizine hcl 2 ondansetron 2 PA ondansetron hcl 2 PA SANCUSO 4 TIGAN 4 PA TRANSDERM-SCOP 3 trimethobenzamide hcl 2 PA

Drug Name Drug Tier

Requirements/Limits

ZOFRAN 4 PA ZOFRAN ODT 4 PA ANTIULCER AGENTS AND ACID SUPPRESSANTS ACIPHEX 4 MO ACIPHEX SPRINKLE 4 MO amoxicillin-clarithromycin w/ lansoprazole 2 MO

AXID 4 CARAFATE SUS 1GM/10ML 3 CARAFATE TAB 1GM 4 MO cimetidine 2 MO cimetidine hcl 2 CYTOTEC 4 MO DEXILANT 4 MO esomeprazole sodium 2 HI ESOMEPRAZOLE STRONTIUM 4 MO

famotidine 2 HI,MO famotidine in nacl 2 HI lansoprazole 2 MO misoprostol 2 MO NEXIUM 4 MO NEXIUM I.V. 4 HI nizatidine 2 MO OMECLAMOX-PAK 4 MO omeprazole 2 MO omeprazole-sodium bicarbonate 2 MO

pantoprazole sodium 2 HI,MO PEPCID 4 MO PREVACID 4 MO PREVACID SOLUTAB 4 MO PREVPAC 4 MO PRILOSEC 4 MO PROTONIX INJ 40MG 4 HI PROTONIX PAK 3 MO PROTONIX TAB 20MG 4 MO PROTONIX TAB 40MG 4 MO PYLERA 4 MO rabeprazole sodium 2 MO


Drug Name Drug Tier

Requirements/Limits

ranitidine hcl 2 HI,MO sucralfate 2 MO ZANTAC INJ 3 HI ZANTAC 4 HI,MO ZEGERID 4 MO CATHARTICS AND LAXATIVES COLYTE-FLAVOR PACKS 4 GOLYTELY 4 MOVIPREP 4 NULYTELY/FLAVOR PACKS 4 MO

OSMOPREP 4 MO peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 2 peg 3350-potassium chloride-sod bicarbonate-sod chloride

2 MO

polyethylene glycol 3350 2 MO PREPOPIK 4 MO SUCLEAR 4 MO SUPREP BOWEL PREP 4 DIGESTANTS CREON CAP 12000UNT 3 MO CREON CAP 24000UNT 3 MO CREON CAP 3000UNIT 3 MO CREON CAP 36000UNT 3 MO CREON CAP 6000UNIT 3 MO PANCREAZE CAP 10500UNT 4 MO

PANCREAZE CAP 16800UNT 4 MO

PANCREAZE CAP 21000UNT 4 MO

PANCREAZE CAP 4200UNIT 4 MO

PERTZYE CAP 4 MO ULTRESA CAP 13800UNT 4 MO

ULTRESA CAP 20700UNT 4 MO

Drug Name Drug Tier

Requirements/Limits

ULTRESA CAP 23000UNT 4 MO

VIOKACE TAB 4 MO ZENPEP CAP 10000UNT 3 MO ZENPEP CAP 15000UNT 3 MO ZENPEP CAP 20000UNT 3 MO ZENPEP CAP 25000UNT 4 MO ZENPEP CAP 3000UNIT 4 MO ZENPEP CAP 5000UNIT 3 MO GI DRUGS, MISCELLANEOUS ACTIGALL 4 MO AMITIZA 4 MO chenodiol 2 MO ENTYVIO 5 GATTEX 5 LINZESS 3 MO metoclopramide hcl 2 HI,MO METOZOLV ODT 4 MO NUTRESTORE 4 MO REGLAN 4 MO RELISTOR 4 URSO 250 4 MO URSO FORTE 4 MO ursodiol 2 MO GOLD COMPOUNDS GOLD COMPOUNDS RIDAURA 3 MO HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET 3 CUPRIMINE 3 DEPEN TITRATABS 3 EXJADE TAB 125MG 3 EXJADE TAB 250MG 5 EXJADE TAB 500MG 5 FERRIPROX 5 LD SYPRINE 4 HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ARISTOSPAN INTRA-ARTICULAR 3



Drug Name Drug Tier

Requirements/Limits

ARISTOSPAN INTRALESIONAL 3 budesonide 2 MO CELESTONE 3 CORTEF 4 MO cortisone acetate 2 MO DEPO-MEDROL INJ 20MG/ML 3 DEPO-MEDROL INJ 40MG/ML 4 DEPO-MEDROL INJ 80MG/ML 4 dexamethasone 2 PA,MO dexamethasone sodium phosphate 2 HI

ENTOCORT EC 5 FLO-PRED 4 fludrocortisone acetate 2 MO hydrocortisone 2 MO hydrocortisone sod succinate 2 KENALOG-10 3 KENALOG-40 3 MEDROL DOSEPAK PAK 4MG 4 MO

MEDROL TAB 16MG 4 MO MEDROL TAB 2MG 3 MO MEDROL TAB 32MG 4 MO MEDROL TAB 4MG 4 MO MEDROL TAB 8MG 4 MO methylprednisolone 2 MO methylprednisolone acetate 2 methylprednisolone sod succ 2 ORAPRED ODT 4 MO prednisolone 2 MO prednisolone sodium phosphate 2 MO

prednisone 2 PA,MO RAYOS 4 PA,MO

Drug Name Drug Tier

Requirements/Limits

SOLU-CORTEF 3 SOLU-MEDROL INJ 125MG 4 SOLU-MEDROL INJ 1GM 3 SOLU-MEDROL INJ 2GM 3 SOLU-MEDROL INJ 40MG 3 SOLU-MEDROL INJ 500MG 3 triamcinolone acetonide 2 UCERIS 5 ANDROGENS ANADROL-50 4 ANDRODERM DIS 2MG/24HR 3 ANDRODERM DIS 4MG/24HR 3 ANDROGEL GEL 1%(50MG) 4 ANDROGEL PUMP GEL 1.62% 4 ANDROGEL PUMP GEL PUMP 1% 4 AXIRON SOL 30MG/ACT 4 danazol 2 MO fluoxymesterone 2 FORTESTA GEL 10MG/ACT 4 methyltestosterone 2 oxandrolone 2 STRIANT MIS 30MG 4 TESTIM GEL 1%(50MG) 4 testosterone cypionate 2 testosterone enanthate 2 VOGELXO GEL 1%(50MG) 4

CONTRACEPTIVES BEYAZ 4 MO BREVICON-28 4 MO CYCLESSA 4 MO DESOGEN 4 MO


Drug Name Drug Tier

Requirements/Limits

desogestrel & ethinyl estradiol 2 MO

desogestrel-ethinyl estradiol (biphasic) 2 MO

desogestrel-ethinyl estradiol (triphasic) 2 MO

drospirenone-ethinyl estradiol 2 MO

ELLA 3 MO ESTROSTEP FE 4 MO ethynodiol diacet & eth estrad 2 MO

FEMCON FE 4 MO FEMHRT LOW DOSE 4 MO GENERESS FE 4 MO levonorgestrel & eth estradiol 2 MO

levonorgestrel-eth estradiol (triphasic) 2 MO

levonorgestrel-ethinyl estradiol (91-day) 2 MO

levonorgestrel-ethinyl estradiol (continuous) 2 MO

LO LOESTRIN FE 4 MO LO MINASTRIN FE 4 MO LOSEASONIQUE 4 MO MINASTRIN 24 FE 4 MO MODICON 4 MO NATAZIA 4 MO NECON 1/50-28 4 MO NOR-QD 4 MO norelgestromin-ethinyl estradiol 2 MO

norethin acet & estrad-fe 2 MO norethindrone & eth estradiol 2 MO

norethindrone & ethinyl estradiol-fe 2 MO

norethindrone (contraceptive) 2 MO

norethindrone acet & eth estra 2 MO

Drug Name Drug Tier

Requirements/Limits

norethindrone acetate-ethinyl estradiol-fe 2 MO

norethindrone-eth estradiol (biphasic) 2 MO

norethindrone-eth estradiol (triphasic) 2 MO

norgestimate-ethinyl estradiol 2 MO

norgestimate-ethinyl estradiol (triphasic) 2 MO

norgestrel & ethinyl estradiol 2 MO

NORINYL 1+35 4 MO NORINYL 1+50 4 MO NUVARING 3 MO ORTHO EVRA 4 MO ORTHO MICRONOR 4 MO ORTHO TRI-CYCLEN 4 MO ORTHO TRI-CYCLEN LO 4 MO ORTHO-CEPT 4 MO ORTHO-CYCLEN 4 MO ORTHO-NOVUM 1/35 4 MO ORTHO-NOVUM 7/7/7 4 MO PLAN B ONE-STEP 3 MO QUARTETTE 4 MO SAFYRAL 4 MO SEASONIQUE 4 MO TRI-NORINYL 28 4 MO YASMIN 28 4 MO YAZ 4 MO DIABETIC AGENTS acarbose 2 MO ACTOPLUS MET 4 MO ACTOPLUS MET XR 4 MO ACTOS 4 MO AMARYL 4 MO APIDRA 4 PA APIDRA SOLOSTAR 4 AVANDAMET 4 LD,MO AVANDARYL 4 LD,MO AVANDIA 4 LD,MO



Drug Name Drug Tier

Requirements/Limits

BYDUREON 4 BYETTA 4 chlorpropamide 2 MO CYCLOSET 4 MO DIABETA 4 MO DUETACT 4 MO FARXIGA 4 MO FORTAMET 4 MO glimepiride 1 MO glipizide er tab 10mg 2 MO glipizide er tab 2.5mg 2 MO glipizide er tab 5mg 2 glipizide tab 10mg 1 MO glipizide tab 5mg 1 MO glipizide-metformin hcl 2 MO GLUCAGEN HYPOKIT INJ HYPOKIT 4

GLUCAGEN INJ 1MG 3 GLUCAGON EMERGENCY KIT 3 GLUCOPHAGE 4 MO GLUCOPHAGE XR 4 MO GLUCOTROL 4 MO GLUCOTROL XL 4 MO GLUCOVANCE 4 MO GLUMETZA 4 MO glyburide 2 MO glyburide micronized 2 MO glyburide-metformin 2 MO GLYNASE 4 MO GLYSET 4 MO HUMALOG INJ 100/ML 3 HUMALOG INJ 100/ML 4 HUMALOG MIX 50/50 4 HUMALOG MIX 50/50 KWIKPEN 4 HUMALOG MIX 75/25 4 HUMALOG MIX 75/25 KWIKPEN 4 HUMULIN 70/30 INJ 70/30 3

Drug Name Drug Tier

Requirements/Limits

HUMULIN 70/30 PEN INJ 70/30 4 HUMULIN N INJ U-100 3 HUMULIN N U-100 PEN INJ U-100 4 HUMULIN R INJ U-100 3 PA HUMULIN R U-500 (CONCENTRATED) INJ U-500

3

INVOKANA 4 MO JANUMET 4 MO JANUMET XR 4 MO JANUVIA 4 MO JENTADUETO 4 MO KAZANO 4 MO KOMBIGLYZE XR 4 MO KORLYM 5 LD LANTUS INJ 100/ML 3 LANTUS SOLOSTAR INJ SOLOSTAR 4 LEVEMIR 4 LEVEMIR FLEXPEN 4 metformin hcl er tab 1000mg 2 MO

metformin hcl er tab 500mg er 1 MO

metformin hcl er tab 750mg er 2 MO

metformin hcl tab 1000mg 1 MO metformin hcl tab 500mg 1 MO metformin hcl tab 850mg 1 MO nateglinide 2 MO NESINA 4 MO NOVOLIN 70/30 INJ 70/30 4 NOVOLIN N INJ U-100 4 NOVOLIN R INJ U-100 4 PA NOVOLOG 4 PA NOVOLOG MIX 70/30 4 NOVOLOG MIX 70/30 PREFILLED FLEXPEN 4


Drug Name Drug Tier

Requirements/Limits

NOVOLOG PENFILL 4 ONGLYZA 4 MO OSENI 4 MO pioglitazone hcl 2 MO pioglitazone hcl-glimepiride 2 MO

pioglitazone hcl-metformin hcl 2 MO

PRANDIMET 4 MO PRANDIN 4 MO PRECOSE 4 MO repaglinide 2 MO RIOMET 4 STARLIX 4 MO SYMLINPEN 120 4 MO SYMLINPEN 60 4 TANZEUM 4 tolazamide 2 MO tolbutamide 2 MO TRADJENTA 4 MO VICTOZA 4 ESTROGENS AND ANTIESTROGENS ACTIVELLA 4 MO ALORA DIS 0.025MG 4 MO ALORA DIS 0.05MG 4 MO ALORA DIS 0.075MG 4 MO ALORA DIS 0.1MG 4 MO ANGELIQ 4 MO CENESTIN 4 MO CLIMARA DIS 0.025MG 3 MO CLIMARA DIS 0.0375MG 3 MO CLIMARA DIS 0.05MG 3 MO CLIMARA DIS 0.06MG 3 MO CLIMARA DIS 0.075MG 3 MO CLIMARA DIS 0.1MG 3 MO CLIMARA PRO 4 MO COMBIPATCH 4 MO DELESTROGEN 4 DIVIGEL GEL 1MG/GM 4 MO DUAVEE 4 MO ENJUVIA 4 MO

Drug Name Drug Tier

Requirements/Limits

esterified estrogens 2 MO estradiol 2 MO estradiol & norethindrone acetate 2 MO

estradiol cypionate 2 estradiol vaginal 2 MO estradiol valerate 2 estradiol-norgestimate 2 MO ESTRASORB EMU 4 MO ESTRING 3 MO estropipate 2 MO EVAMIST SPR 1.53MG 4 EVISTA 3 MO FEMRING 4 MO MENOSTAR DIS 14MCG 4 MO MINIVELLE DIS 0.0375MG 4 MO

MINIVELLE DIS 0.05MG 4 MO MINIVELLE DIS 0.075MG 4 MO MINIVELLE DIS 0.1MG 4 MO norethindrone acetate-ethinyl estradiol 2 MO

PREMARIN 3 MO PREMARIN INJ 25MG 3 PREMARIN TAB 0.3MG 4 MO PREMARIN TAB 0.45MG 4 MO PREMARIN TAB 0.625MG 4 MO

PREMARIN TAB 0.9MG 4 MO PREMARIN TAB 1.25MG 4 MO PREMPHASE 4 MO PREMPRO 4 MO raloxifene hcl 2 MO VAGIFEM 3 MO VIVELLE-DOT DIS 0.025MG 4 MO

VIVELLE-DOT DIS 0.0375MG 4 MO




Drug Name Drug Tier

Requirements/Limits



GONADOTROPINS chorionic gonadotropin 2 SYNAREL 3 PARATHYROID calcitonin (salmon) 2 FORTEO 5 PA FORTICAL SPR 200/ACT 3 MIACALCIN INJ 200/ML 3 MIACALCIN SPR 200/ACT 4 PITUITARY DDAVP 4 MO DDAVP INJ 4MCG/ML 4 DDAVP TAB 0.1MG 4 MO DDAVP TAB 0.2MG 4 MO desmopressin acetate 2 MO desmopressin acetate spray refrigerated 2 H.P. ACTHAR 5 PA STIMATE SOL 1.5MG/ML 3 PROGESTINS CRINONE 4 MO DEPO-PROVERA 3 DEPO-PROVERA CONTRACEPTIVE INJ 150MG/ML

4

DEPO-SUBQ PROVERA 104 INJ 104 3 ENDOMETRIN 4 MO medroxyprogesterone acetate 2 MO

medroxyprogesterone acetate (contraceptive) 2 MEGACE ES 4 norethindrone acetate 2 MO progesterone micronized 2 MO PROMETRIUM 4 MO

Drug Name Drug Tier

Requirements/Limits

PROVERA 4 MO SOMATOTROPIN AGONISTS AND ANTAGONISTS EGRIFTA 5 GENOTROPIN INJ 12MG 4 PA GENOTROPIN INJ 5MG 5 PA GENOTROPIN MINIQUICK INJ 0.2MG 4 PA

GENOTROPIN MINIQUICK INJ 0.4MG 4 PA







GENOTROPIN MINIQUICK INJ 1MG 4 PA

GENOTROPIN MINIQUICK INJ 2MG 4 PA

HUMATROPE COMBO PACK INJ 5MG 5 PA

HUMATROPE INJ 12MG 5 PA HUMATROPE INJ 24MG 5 PA HUMATROPE INJ 6MG 5 PA INCRELEX 5 NORDITROPIN FLEXPRO INJ 10/1.5ML 5 PA

NORDITROPIN FLEXPRO INJ 15/1.5ML 5 PA

NORDITROPIN FLEXPRO INJ 5/1.5ML 5 PA

NORDITROPIN NORDIFLEX PEN INJ 30/3ML

5 PA


Drug Name Drug Tier

Requirements/Limits

NUTROPIN AQ INJ 10MG/2ML 5 NUTROPIN AQ NUSPIN 5 INJ NUSPIN 5 5 PA

NUTROPIN AQ PEN INJ 10MG/2ML 5 PA

NUTROPIN AQ PEN INJ 20MG/2ML 5 PA

NUTROPIN INJ 10MG 5 OMNITROPE INJ 10/1.5ML 3 PA

OMNITROPE INJ 5.8MG 3 PA OMNITROPE INJ 5/1.5ML 3 PA

SAIZEN 5 PA SAIZEN CLICK.EASY 5 PA SEROSTIM 5 PA SIGNIFOR 5 SOMAVERT 5 LD TEV-TROPIN INJ 5MG 5 PA ZORBTIVE 5 PA THYROID AND ANTITHYROID AGENTS CYTOMEL 4 MO levothyroxine sodium 2 MO LEVOTHYROXINE SODIUM 4 MO

liothyronine sodium 2 HI,MO methimazole 2 MO propylthiouracil 2 MO SYNTHROID 4 MO THYROLAR-1 4 THYROLAR-1/2 4 THYROLAR-1/4 4 THYROLAR-2 4 THYROLAR-3 4 TIROSINT 4 MO MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS acetylcysteine 2 PA ACTEMRA INJ 162/0.9 5 ACTEMRA INJ 200/10ML 4 HI

Drug Name Drug Tier

Requirements/Limits

ACTIMMUNE 5 LD ACTONEL 4 MO alendronate sodium sol 70/75ml 2 alendronate sodium tab 10mg 1 MO

alendronate sodium tab 35mg 2 MO




allopurinol 2 MO ALOPRIM 4 HI amifostine crystalline 2 HI AMPYRA 5 ARAVA 4 MO ARCALYST 5 ASTAGRAF XL CAP 0.5MG 4 PA,MO

ASTAGRAF XL CAP 1MG 4 PA,MO

ASTAGRAF XL CAP 5MG 5 PA

ATELVIA 4 MO ATGAM 4 HI AUBAGIO 5 AVODART 4 MO AVONEX 5 AVONEX PEN 5 azathioprine 2 PA,MO BENLYSTA 5 BERINERT 5 BETASERON 5 BINOSTO 4 MO BONIVA 4 PA,HI,MO BOTOX 3 PA CARNITOR 4 PA,HI,MO CELLCEPT CAP 250MG 4 PA,MO



Drug Name Drug Tier

Requirements/Limits

CELLCEPT INTRAVENOUS 4 PA,HI

CELLCEPT SUS 200MG/ML 3 PA

CELLCEPT TAB 500MG 4 PA,MO CERDELGA 5 CIMZIA 5 CINRYZE 5 HI COLCRYS 3 MO COPAXONE 5 cyclosporine 2 PA,HI,MO cyclosporine modified (for microemulsion) 2 PA,MO

CYSTADANE 4 LD CYSTAGON CAP 150MG 3 MO CYSTAGON CAP 50MG 3 MO DEMSER 4 MO dexrazoxane 2 HI disulfiram 2 MO DYSPORT 4 PA ELMIRON 3 MO ENBREL 5 ENBREL SURECLICK 5 etidronate disodium 2 MO EXTAVIA 5 finasteride 2 MO FIRAZYR 5 fomepizole 2 HI FOSAMAX 4 MO FOSAMAX PLUS D 4 MO FUSILEV 4 HI GILENYA 5 GRASTEK 4 HEMABATE 3 HUMIRA 5 HUMIRA PEN-CROHNS DISEASE STARTER 5 ibandronate sodium 2 PA,HI,MO IMURAN 4 PA,MO JALYN 4 MO KINERET 5

Drug Name Drug Tier

Requirements/Limits

KUVAN 5 leflunomide 2 MO leucovorin calcium 2 HI,MO levocarnitine (metabolic modifiers) 2 PA,HI,MO

lidocaine hcl (local anesth.) 2 mesna 2 HI,MO MESNEX INJ 1GM 4 HI MESNEX TAB 400MG 3 MO methylergonovine maleate 2 MIFEPREX 3 MO MYALEPT 5 mycophenolate mofetil 2 PA,MO mycophenolate sodium 2 PA,MO MYFORTIC 4 PA.MO NEORAL CAP 100MG 4 PA,MO NEORAL CAP 25MG 4 PA,MO NEORAL SOL 100MG/ML 3 PA NULOJIX 5 PA,HI octreotide acetate 2 ORENCIA 5 ORFADIN 5 LD OTEZLA 5 OTREXUP 4 pamidronate disodium 2 HI PROCYSBI CAP 25MG 5 PROCYSBI CAP 75MG 5 PROGRAF CAP 0.5MG 4 PA,MO PROGRAF CAP 1MG 4 PA,MO PROGRAF CAP 5MG 4 PA,MO PROGRAF INJ 5MG/ML 3 PA,HI PROLIA SOL 60MG/ML 4 PROSCAR 4 MO RAGWITEK 4 RAPAMUNE 4 PA,MO REBIF 5 REBIF REBIDOSE 5 REBIF REBIDOSE TITRATION PACK 5


Drug Name Drug Tier

Requirements/Limits

REBIF TITRATION PACK 5 RECLAST 4 HI REMICADE 5 RIMSO-50 3 risedronate sodium 2 MO SANDIMMUNE 3 PA,HI,MO SANDOSTATIN INJ 1000MCG 4 SANDOSTATIN INJ 100MCG 4 SANDOSTATIN INJ 200MCG 4 SANDOSTATIN INJ 500MCG 4 SANDOSTATIN INJ 50MCG/ML 4 SANDOSTATIN LAR DEPOT KIT LAR 10MG 5 SANDOSTATIN LAR DEPOT KIT LAR 20MG 5 SANDOSTATIN LAR DEPOT KIT LAR 30MG 5 SENSIPAR TAB 30MG 3 MO SENSIPAR TAB 60MG 5 SENSIPAR TAB 90MG 5 SIMPONI 5 SIMPONI ARIA 5 SIMULECT 4 PA,HI sirolimus 2 PA,MO SODIUM FLUORIDE 3 MO SOMATULINE DEPOT 4 tacrolimus 2 PA,HI,MO TECFIDERA 5 TECFIDERA STARTER PACK 5 THALOMID 5 THIOLA 4 MO THYMOGLOBULIN 4 HI TYSABRI 5 ULORIC 4 MO VORAXAZE 5

Drug Name Drug Tier

Requirements/Limits

XELJANZ 5 XEOMIN 4 PA XGEVA INJ 5 XYLOCAINE 4 XYLOCAINE-MPF 4 ZAVESCA 5 LD ZINECARD 4 HI zoledronic acid 2 HI ZOMETA 4 HI ZORTRESS TAB 0.25MG 4 PA,MO ZORTRESS TAB 0.5MG 5 PA ZORTRESS TAB 0.75MG 5 PA ZYLOPRIM 4 MO RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS ACCOLATE 4 MO cromolyn sodium 2 cromolyn sodium (mastocytosis) 2 GASTROCROM 4 montelukast sodium 2 MO SINGULAIR 4 MO zafirlukast 2 MO ZYFLO CR TAB 600MG 5 ZYFLO TAB 600MG 4 MO RESPIRATORY AGENTS, MISCELLANEOUS AEROSPAN 4 MO ALVESCO 4 MO ARALAST NP 5 ASMANEX TWISTHALER 120 METERED DOSES AER 220MCG

3 MO

ASMANEX TWISTHALER 30 METERED DOSES AER 220MCG

4 MO


3 MO


3 MO

BREO ELLIPTA 4 MO



Drug Name Drug Tier

Requirements/Limits

budesonide (inhalation) 2 MO DALIRESP 4 MO DULERA 3 MO FLOVENT DISKUS 4 MO FLOVENT HFA AER 110MCG 4 MO

FLOVENT HFA AER 220MCG 4 MO

FLOVENT HFA AER 44MCG 3 MO

GLASSIA 5 KALYDECO 5 PROLASTIN-C 5 PULMICORT FLEXHALER INH 180MCG

3 MO

PULMICORT FLEXHALER INH 90MCG 4 MO

PULMICORT SUS 0.25MG/2 4 PULMICORT SUS 0.5MG/2 4 PULMICORT SUS 1MG/2ML 4 QVAR 3 MO SYMBICORT 4 MO XOLAIR 5 ZEMAIRA 5 VASODILATING AGENTS ADEMPAS 5 LETAIRIS 5 OPSUMIT 5 LD ORENITRAM TAB 0.125MG 4

ORENITRAM TAB 0.25MG 5

ORENITRAM TAB 1MG 5 ORENITRAM TAB 2.5MG 5 REMODULIN 5 LD TRACLEER 5 LD TYVASO 4 LD VENTAVIS 5 LD

Drug Name Drug Tier

Requirements/Limits

SERUMS, TOXOIDS, AND VACCINES SERUMS ANTIVENIN LATRODECTUS MAC TANS

3

BIVIGAM INJ 10% 3 PA,HI CARIMUNE NANOFILTERED INJ 12GM

4 HI

CARIMUNE NANOFILTERED INJ 3GM 4 PA,HI

CARIMUNE NANOFILTERED INJ 6GM 4 HI

CYTOGAM 3 HI FLEBOGAMMA DIF INJ DIF 5% 3 HI

GAMASTAN S/D 3 PA GAMMAGARD LIQUID 3 PA,HI GAMMAGARD S/D INJ 10GM HU 3 HI

GAMMAGARD S/D INJ 2.5GM HU 3 HI

GAMMAGARD S/D INJ 5GM HU 3 HI

GAMMAPLEX INJ 10GM 3 PA,HI GAMUNEX INJ 10% 3 HI GAMUNEX-C 3 HI HYPERRHO S/D 3 HYPERTET S/D 3 IMOGAM RABIES-HT 3 NABI-HB 3 OCTAGAM INJ 5GM 3 HI PRIVIGEN INJ 20GRAMS 3 PA,HI RHOPHYLAC 3 TOXOIDS DIPHTHERIA/TETANUS TOXOID S ADSORBED PEDIATRIC

6

TETANUS TOXOID ADSORBED 3 TETANUS/DIPHTHERIA TOXOID S-ADSORBED ADULT

6


Drug Name Drug Tier

Requirements/Limits

VACCINES ACTHIB 6 ADACEL 6 BOOSTRIX 6 CERVARIX 6 COMVAX 6 DAPTACEL 6 ENGERIX-B 6 PA GARDASIL 6 HAVRIX 6 IMOVAX RABIES (H.D.C.V.) 6 INFANRIX 6 IPOL INACTIVATED IPV 6 IXIARO 6 M-M-R II W/DILUENT 10 DOSE 6 MENACTRA 6 MENOMUNE-A/C/Y/W-135 6 MENVEO 6 PEDVAX HIB 6 PROQUAD 6 RABAVERT 6 RECOMBIVAX HB 6 PA ROTARIX 6 ROTATEQ 6 TWINRIX 6 TYPHIM VI 6 VAQTA 6 VARIVAX 6 YF-VAX 6 ZOSTAVAX 6 SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) ACANYA 4 acyclovir topical 2 AKNE-MYCIN 3 MO ALTABAX 4 AVC 3

Drug Name Drug Tier

Requirements/Limits

BACTROBAN 4 MO BACTROBAN NASAL 3 BENZAMYCIN 4 benzoyl peroxide-erythromycin 2 butoconazole nitrate (one dose) 2 ciclopirox 2 ciclopirox olamine 2 CLEOCIN CRE 2% VAG 4 CLEOCIN SUP 100MG 3 CLEOCIN-T 4 MO clindamycin phosphate & cleanser 2 MO

clindamycin phosphate (topical) 2 MO

clindamycin phosphate vaginal 2 clindamycin phosphate-benzoyl peroxide 2 MO

clotrimazole 2 clotrimazole (topical) 2 clotrimazole w/ betamethasone 2 DENAVIR 4 econazole nitrate 2 ERTACZO 4 erythromycin (acne aid) 2 MO EURAX 4 EXELDERM 4 EXTINA 4 MO gentamicin sulfate (topical) 2 JUBLIA 4 ketoconazole & cleanser 2 ketoconazole (topical) 2 MO KLARON 4 lindane 2 LOPROX SHAMPOO 4 LOTRISONE 4 LUZU 4



Drug Name Drug Tier

Requirements/Limits

mafenide acetate 2 malathion 2 MENTAX 4 METROCREAM 4 METROGEL 4 METROGEL-VAGINAL 4 METROLOTION 4 metronidazole (topical) 2 MO metronidazole vaginal 2 miconazole nitrate vaginal 2 mupirocin 2 MO mupirocin calcium (topical) 2 NAFTIN 4 neomycin/polymyxin b gu 2 NIZORAL 4 NORITATE 4 MO nystatin (topical) 2 OVIDE 4 OXISTAT 4 permethrin 2 PHISOHEX 3 selenium sulfide 2 SILVADENE 4 silver sulfadiazine 2 SPINOSAD 4 sulfacetamide sodium (acne) 2 SULFAMYLON CRE 85MG/GM 3 SULFAMYLON PAK 5% 4 TERAZOL 3 4 TERAZOL 7 4 terconazole vaginal 2 ULESFIA 4 XERESE 4 ZOVIRAX 4 ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) alclometasone dipropionate 2 MO

Drug Name Drug Tier

Requirements/Limits

amcinonide 2 MO betamethasone dipropionate (topical) 2 MO

betamethasone dipropionate augmented 2 MO

betamethasone valerate 2 MO calcipotriene-betamethasone dipropionate

2 MO

CAPEX 3 clobetasol propionate 2 MO clobetasol propionate emollient base 2 MO

CLOBEX 4 CLODERM PUMP 4 MO CORDRAN TAPE 3 MO CORTIFOAM 4 MO CORTISPORIN 3 MO CUTIVATE 4 MO DERMATOP 4 MO DESONATE 4 MO desonide 2 MO DESOWEN 4 MO desoximetasone 2 MO DESOXIMETASONE 4 MO diflorasone diacetate 2 MO diflorasone dicaetate emollient base 2 MO

DIPROLENE 4 MO DIPROLENE AF 4 MO ELOCON 4 MO fluocinolone acetonide 2 MO fluocinonide 2 MO fluocinonide emulsified base 2 MO

fluticasone propionate 2 MO halobetasol propionate 2 MO HALOG 4 MO hydrocortisone (intrarectal) 2 hydrocortisone (rectal) 2 MO hydrocortisone (topical) 2 MO


Drug Name Drug Tier

Requirements/Limits

hydrocortisone butyrate 2 MO hydrocortisone butyrate hydrophilic lipo base 2 MO

hydrocortisone valerate 2 MO KENALOG 3 MO mometasone furoate 2 MO nystatin-triamcinolone 2 MO OLUX 4 MO PANDEL 4 MO prednicarbate 2 MO SYNALAR CREAM KIT 4 MO TACLONEX OIN 5 TACLONEX SUS 4 TEMOVATE 4 MO TOPICORT 4 MO triamcinolone acetonide (mouth) 2 MO

triamcinolone acetonide (topical) 2 MO

ULTRAVATE 4 MO urea-hc acetate 2 MO VANOS 4 MO ANTIPRURITICS AND LOCAL ANESTHETICS EMLA 4 PA,MO lidocaine 2 PA,MO lidocaine hcl 2 MO lidocaine-prilocaine 2 PA,MO LIDODERM 4 PA SYNERA 4 XYLOCAINE 4 ZONALON 4 MO CELL STIMULANTS AND PROLIFERANTS ATRALIN GEL 0.05% 4 PA,MO KEPIVANCE 5 HI RETIN-A CRE 0.025% 3 PA,MO RETIN-A CRE 0.05% 3 PA,MO RETIN-A CRE 0.1% 3 PA,MO RETIN-A GEL 0.01% 3 PA,MO RETIN-A GEL 0.025% 3 PA,MO RETIN-A MICRO GEL 0.04% 3 PA,MO

Drug Name Drug Tier

Requirements/Limits

RETIN-A MICRO GEL 0.1% 3 PA,MO

RETIN-A MICRO PUMP GEL 0.04%PMP 4 PA,MO

RETIN-A MICRO PUMP GEL 0.08% 4 PA,MO

RETIN-A MICRO PUMP GEL 0.1%PUMP 4 PA,MO

tretinoin 2 PA,MO tretinoin w/ cleanser & moisturizer 2 PA,MO

SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS 8-MOP 3 MO ABSORICA 4 acitretin 2 ACZONE 4 MO adapalene 2 MO ALDARA 4 MO AZELEX 3 MO calcipotriene 2 MO CALCITRIOL 3 PA,HI,MO CARAC CRE 0.5% 3 MO CONDYLOX 3 MO diclofenac sodium (actinic keratoses) 2 MO

diclofenac sodium (topical) 2 MO

DIFFERIN CRE 0.1% 3 MO DIFFERIN GEL 0.1% 3 MO DIFFERIN GEL 0.3% 3 MO DIFFERIN LOT 0.1% 4 DOVONEX 4 MO EFUDEX CRE 5% 4 MO ELIDEL 3 MO EPIDUO 3 MO FABIOR 4 MO FINACEA 3 MO FLECTOR 4 PA,MO FLUOROPLEX CRE 1% 3 MO fluorouracil (topical) 2 MO imiquimod 2 MO



Drug Name Drug Tier

Requirements/Limits

isotretinoin 2 LAC-HYDRIN 4 MO lactic acid (ammonium lactate) 2 MO

methoxsalen rapid 2 MO MIRVASO 4 MO ORACEA 4 MO OXSORALEN 3 OXSORALEN ULTRA 3 MO PANRETIN 5 PENNSAID 4 PICATO 4 MO podofilox 2 MO PROTOPIC 3 MO PRUDOXIN 3 MO RECTIV 4 MO REGRANEX 5 SANTYL 3 MO SOLARAZE 4 MO SORIATANE 5 SORILUX 4 MO STELARA 5 TARGRETIN 3 MO TAZORAC CRE 0.05% 3 MO TAZORAC CRE 0.1% 3 MO TAZORAC GEL 0.05% 4 MO TAZORAC GEL 0.1% 4 MO UVADEX 4 VALCHLOR 5 VECTICAL 3 MO VELTIN 4 MO VEREGEN 4 MO VOLTAREN 4 MO ZIANA 4 MO ZYCLARA 4 MO ZYCLARA PUMP 4 MO

Drug Name Drug Tier

Requirements/Limits

SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS aminophylline 2 HI DETROL 4 MO DETROL LA 4 MO DITROPAN XL 4 MO dyphylline 2 MO ENABLEX 4 MO flavoxate hcl 2 MO GELNIQUE 4 MO MYRBETRIQ 4 MO oxybutynin chloride 2 MO OXYTROL 4 MO SANCTURA 4 MO SANCTURA XR 4 MO theophylline 2 MO tolterodine tartrate 2 MO TOVIAZ 4 MO trospium chloride 2 MO VESICARE 4 MO VITAMINS VITAMINS calcitriol 2 PA,HI,MO doxercalciferol 2 PA,HI,MO HECTOROL 4 PA,HI,MO niacin (antihyperlipidemic) 2 MO paricalcitol 2 PA,HI,MO ROCALTROL CAP 0.25MCG 3 PA,MO

ROCALTROL CAP 0.5MCG 3 PA,MO

ROCALTROL SOL 1MCG/ML 4 PA

TRINATAL RX 1 3 MO VINATE CALCIUM 3 MO VITASPIRE 3 MO ZEMPLAR 4 PA,HI,MO


The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. Certain strengths or forms of the drug may be subject to the utilization management codes listed below. HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies. For more information, please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region. LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies. For more information, consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region. MO = Mail-order drugs. You may order prescription refills of certain medications through our mail-order service online at kp.org/refill or by phone or mobile app, which may lower your costs for a three-month supply. Generally, you should receive them within 10 business days. If not, please contact the mail-order phone number for your Kaiser Permanente Region in the chart on page 7. Additional drugs may be available for mail order. Not all drugs can be mailed; restrictions and limitations apply. For more information, please visit kp.org/seniormedrx or call the appropriate regional phone number on page 7.

PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (e.g., via infusion pump, nebulizer, or other Durable Medical Equipment device), where they are administered (at home or in a long-term care facility), and what medical condition they are administered for. Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered. QL = Quantity limits apply to certain drugs. Our plan will only cover a certain amount of these drugs (less than a 30-day supply) per prescription at one Part D cost share.


Index of Drugs

8 8-MOP ........................................................ 49

A abacavir sulfate .......................................... 11 abacavir sulfate-lamivudine-zidovudine ...... 11 ABELCET ................................................... 10 ABILIFY DISCMELT TAB 10MG ................ 28 ABILIFY DISCMELT TAB 15MG ................ 28 ABILIFY INJ 9.75MG .................................. 28 ABILIFY MAINTENA INJ 300MG ................ 28 ABILIFY SOL 1MG/ML ............................... 28 ABILIFY TAB 10MG ................................... 28 ABILIFY TAB 15MG ................................... 28 ABILIFY TAB 20MG ................................... 28 ABILIFY TAB 2MG ..................................... 28 ABILIFY TAB 30MG ................................... 28 ABILIFY TAB 5MG ..................................... 28 ABRAXANE ................................................ 13 ABSORICA ................................................. 49 ABSTRAL ................................................... 22 acamprosate calcium.................................. 28 ACANYA .................................................... 47 acarbose .................................................... 39 ACCOLATE ................................................ 45 ACCUPRIL ................................................. 20 ACCURETIC .............................................. 20 acebutolol hcl ............................................. 21 acetaminophen w/ codeine ......................... 22 acetazolamide ............................................ 35 acetazolamide sodium ................................ 35 acetic acid (otic) ......................................... 35 acetylcysteine ............................................. 43 ACIPHEX ................................................... 36 ACIPHEX SPRINKLE ................................. 36 acitretin ....................................................... 49 ACTEMRA INJ 162/0.9 ............................... 43 ACTEMRA INJ 200/10ML ........................... 43 ACTHIB ...................................................... 47 ACTIGALL .................................................. 37 ACTIMMUNE .............................................. 43 ACTIQ ........................................................ 22 ACTIVELLA ................................................ 41 ACTONEL .................................................. 43 ACTOPLUS MET ....................................... 39

ACTOPLUS MET XR .................................. 39 ACTOS ....................................................... 39 ACULAR ..................................................... 34 ACULAR LS ................................................ 34 ACUVAIL .................................................... 34 acyclovir ...................................................... 11 acyclovir sodium ......................................... 11 acyclovir topical .......................................... 47 ACZONE ..................................................... 49 ADACEL ..................................................... 47 ADAGEN .................................................... 33 ADALAT CC ................................................ 19 adapalene ................................................... 49 ADCIRCA.................................................... 21 ADDERALL XR ........................................... 24 adefovir dipivoxil ......................................... 11 ADEMPAS .................................................. 46 ADRENALIN INJ 1MG/ML .......................... 17 ADVAIR DISKUS AER 100/50 .................... 17 ADVAIR DISKUS AER 250/50 .................... 17 ADVAIR DISKUS AER 500/50 .................... 17 ADVAIR HFA AER 115/21 .......................... 17 ADVAIR HFA AER 230/21 .......................... 17 ADVAIR HFA AER 45/21 ............................ 17 ADVICOR ................................................... 18 AEROSPAN ................................................ 45 AFINITOR ................................................... 13 AFINITOR DISPERZ ................................... 13 AGGRENOX ............................................... 17 AGRYLIN .................................................... 17 AKNE-MYCIN ............................................. 47 ALBENZA ..................................................... 8 albuterol sulfate er tab 4mg er .................... 17 albuterol sulfate er tab 8mg er .................... 17 albuterol sulfate neb 0.083% ...................... 17 albuterol sulfate neb 0.5% .......................... 17 albuterol sulfate neb 0.63mg/3 .................... 17 albuterol sulfate neb 1.25mg/3 .................... 17 albuterol sulfate syp 2mg/5ml ..................... 17 albuterol sulfate tab 2mg ............................. 17 albuterol sulfate tab 4mg ............................. 17 alclometasone dipropionate ........................ 48 alcohol swabs ............................................. 30 ALDACTAZIDE ........................................... 20 ALDACTONE .............................................. 20 ALDARA ..................................................... 49 ALDURAZYME ........................................... 33


alendronate sodium sol 70/75ml ................. 43 alendronate sodium tab 10mg .................... 43 alendronate sodium tab 35mg .................... 43 alendronate sodium tab 40mg .................... 43 alendronate sodium tab 5mg ...................... 43 alendronate sodium tab 70mg .................... 43 alfuzosin hcl ................................................ 16 ALIMTA ...................................................... 13 ALINIA ........................................................ 11 ALKERAN................................................... 13 allopurinol ................................................... 43 ALOCRIL .................................................... 35 ALOMIDE ................................................... 35 ALOPRIM ................................................... 43 ALORA DIS 0.025MG ................................. 41 ALORA DIS 0.05MG................................... 41 ALORA DIS 0.075MG ................................. 41 ALORA DIS 0.1MG .................................... 41 ALOXI ......................................................... 36 ALPHAGAN P ............................................ 35 alprazolam .................................................. 27 ALREX ....................................................... 34 ALSUMA .................................................... 26 ALTABAX ................................................... 47 ALTACE ..................................................... 20 ALTOPREV ................................................ 18 ALVESCO .................................................. 45 amantadine hcl ........................................... 27 AMARYL .................................................... 39 AMBIEN ..................................................... 27 AMBIEN CR ............................................... 27 AMBISOME ................................................ 10 amcinonide ................................................. 48 AMERGE .................................................... 26 AMICAR ..................................................... 17 amifostine crystalline .................................. 43 amikacin sulfate ............................................ 8 amiloride & hydrochlorothiazide .................. 31 amiloride hcl ............................................... 31 amino acid electrolyte infusion.................... 31 amino acid infusion ..................................... 31 aminophylline ............................................. 50 aminosalicylic acid ...................................... 11 AMINOSYN II INJ 10% ............................... 31 AMINOSYN II INJ 15% ............................... 31 AMINOSYN II INJ 7% ................................. 31 AMINOSYN II INJ 8.5% .............................. 31 AMINOSYN M INJ 3.5% ............................. 31 AMINOSYN-HBC INJ 7% ........................... 31 AMINOSYN-PF 7% INJ 7% ........................ 31

AMINOSYN-PF INJ 10% ............................ 31 amiodarone hcl ........................................... 19 AMITIZA ..................................................... 37 amitriptyline hcl ........................................... 28 amlodipine besylate .................................... 19 amlodipine besylate-atorvastatin calcium .... 19 amlodipine besylate-benazepril hcl ............. 19 ammonium chloride..................................... 30 amoxapine .................................................. 28 amoxicillin ..................................................... 8 amoxicillin & pot clavulanate ......................... 8 amoxicillin-clarithromycin w/ lansoprazole .. 36 amphetamine-dextroamphetamine ............. 24 amphotericin b ............................................ 10 ampicillin ....................................................... 8 ampicillin & sulbactam sodium ...................... 8 ampicillin sodium .......................................... 8 AMPYRA .................................................... 43 AMRIX ........................................................ 16 AMTURNIDE .............................................. 20 ANADROL-50 ............................................. 38 ANAFRANIL ................................................ 28 anagrelide hcl ............................................. 17 ANAPROX .................................................. 22 ANAPROX DS ............................................ 22 anastrozole ................................................. 13 ANCOBON.................................................. 10 ANDRODERM DIS 2MG/24HR ................... 38 ANDRODERM DIS 4MG/24HR ................... 38 ANDROGEL GEL 1%(50MG) ..................... 38 ANDROGEL PUMP GEL 1.62% ................. 38 ANDROGEL PUMP GEL PUMP 1% ........... 38 ANGELIQ .................................................... 41 ANORO ELLIPTA ....................................... 15 ANTARA ..................................................... 18 ANTIVENIN LATRODECTUS MAC TANS .. 46 ANZEMET................................................... 36 APIDRA ...................................................... 39 APIDRA SOLOSTAR .................................. 39 APLENZIN .................................................. 28 APOKYN ..................................................... 27 apraclonidine hcl ......................................... 35 APRISO CAP 0.375GM .............................. 36 APTIOM ...................................................... 25 APTIVUS .................................................... 11 ARALAST NP ............................................. 45 ARANESP ALBUMIN FREE ....................... 18 ARAVA ....................................................... 43 ARCALYST ................................................. 43 ARCAPTA NEOHALER .............................. 17


argatroban .................................................. 17 ARGATROBAN .......................................... 17 ARICEPT .................................................... 16 ARICEPT ODT ........................................... 16 ARIMIDEX .................................................. 13 ARISTOSPAN INTRA-ARTICULAR ........... 37 ARISTOSPAN INTRALESIONAL ............... 38 ARIXTRA .................................................... 17 AROMASIN ................................................ 13 ARRANON ................................................. 13 ARTHROTEC 50 ........................................ 22 ARTHROTEC 75 ........................................ 22 ARZERRA .................................................. 13 ASACOL HD TAB 800MG .......................... 36 ASMANEX TWISTHALER 120 METERED

DOSES AER 220MCG ........................... 45 ASMANEX TWISTHALER 30 METERED



DOSES AER 220MCG ........................... 45 ASTAGRAF XL CAP 0.5MG ....................... 43 ASTAGRAF XL CAP 1MG .......................... 43 ASTAGRAF XL CAP 5MG .......................... 43 ASTELIN .................................................... 35 ASTEPRO .................................................. 35 ATACAND .................................................. 20 ATACAND HCT .......................................... 20 ATELVIA .................................................... 43 atenolol ....................................................... 21 atenolol & chlorthalidone ............................ 21 ATGAM ...................................................... 43 ATIVAN ...................................................... 27 atorvastatin calcium .................................... 18 atovaquone................................................. 11 atovaquone-proguanil hcl ........................... 11 ATRALIN GEL 0.05% ................................. 49 ATRIPLA .................................................... 11 atropine sulfate ........................................... 15 ATROPINE SULFATE ................................ 15 ATROVENT ................................................ 15 ATROVENT HFA ........................................ 15 AUBAGIO ................................................... 43 AUGMENTIN ................................................ 8 AUVI-Q INJ 0.15MG ................................... 17 AUVI-Q INJ 0.3MG ..................................... 17 AVALIDE .................................................... 20 AVANDAMET ............................................. 39 AVANDARYL .............................................. 39

AVANDIA .................................................... 39 AVAPRO ..................................................... 20 AVASTIN .................................................... 13 AVC ............................................................ 47 AVELOX ....................................................... 8 AVELOX ABC PACK .................................... 8 AVINZA ....................................................... 22 AVODART .................................................. 43 AVONEX ..................................................... 43 AVONEX PEN ............................................ 43 AXERT ........................................................ 26 AXID ........................................................... 36 AXIRON SOL 30MG/ACT ........................... 38 azacitidine ................................................... 13 AZACTAM..................................................... 8 AZACTAM IN ISO-OSMOTIC DEXTROSE ... 8 AZASITE ..................................................... 33 azathioprine ................................................ 43 azelastine hcl .............................................. 35 azelastine hcl (ophth) .................................. 35 AZELEX ...................................................... 49 AZILECT ..................................................... 27 azithromycin .................................................. 8 AZITHROMYCIN POW 1GM PAK ................ 8 AZOPT ........................................................ 35 AZOR .......................................................... 19 aztreonam ..................................................... 8 AZULFIDINE ................................................. 8 AZULFIDINE EN-TABS ................................ 8

B bacitracin ...................................................... 8 bacitracin (ophthalmic) ................................ 33 bacitracin-polymyxin b (ophth) .................... 33 bacitracin-poly-neomycin-hc ....................... 34 baclofen ...................................................... 16 BACTOCILL IN DEXTROSE ......................... 8 BACTRIM...................................................... 8 BACTRIM DS ................................................ 8 BACTROBAN ............................................. 47 BACTROBAN NASAL ................................. 47 balsalazide disodium................................... 36 BANZEL ...................................................... 25 BARACLUDE SOL .05MG/ML .................... 11 BARACLUDE TAB 0.5MG .......................... 11 BARACLUDE TAB 1MG ............................. 11 BCG VACCINE ........................................... 13 BECONASE AQ .......................................... 34 BELEODAQ ................................................ 13


benazepril & hydrochlorothiazide ................ 20 benazepril hcl ............................................. 20 BENICAR ................................................... 20 BENICAR HCT ........................................... 20 BENLYSTA................................................. 43 BENTYL ..................................................... 16 BENZAMYCIN ............................................ 47 benzoyl peroxide-erythromycin ................... 47 benztropine mesylate ................................. 27 BEPREVE .................................................. 35 BERINERT ................................................. 43 BESIVANCE ............................................... 33 BETAGAN .................................................. 35 betamethasone dipropionate (topical) ........ 48 betamethasone dipropionate augmented ... 48 betamethasone valerate ............................. 48 BETAPACE AF ........................................... 22 BETASERON ............................................. 43 betaxolol hcl ............................................... 22 betaxolol hcl (ophth) ................................... 35 bethanechol chloride .................................. 16 BETHKIS ...................................................... 8 BETIMOL ................................................... 35 BETOPTIC-S .............................................. 35 BEYAZ ....................................................... 38 BIAXIN ......................................................... 8 BIAXIN XL .................................................... 8 BIAXIN XL PAC ............................................ 8 bicalutamide ............................................... 13 BICILLIN C-R ............................................... 8 BICILLIN L-A ................................................ 8 BICNU ........................................................ 13 BIDIL .......................................................... 21 BILTRICIDE .................................................. 8 BINOSTO ................................................... 43 bisoprolol & hydrochlorothiazide ................. 22 bisoprolol fumarate ..................................... 22 BIVIGAM INJ 10% ...................................... 46 bleomycin sulfate ........................................ 13 BLEPH-10 .................................................. 33 BLEPHAMIDE ............................................ 34 BONIVA ...................................................... 43 BOOSTRIX ................................................. 47 BOSULIF .................................................... 13 BOTOX ....................................................... 43 BREO ELLIPTA .......................................... 45 BREVICON-28 ........................................... 38 BRILINTA ................................................... 17 brimonidine tartrate .................................... 35 BRINTELLIX ............................................... 28

BRISDELLE ................................................ 28 bromfenac sodium (ophth) .......................... 34 bromocriptine mesylate ............................... 27 BROVANA .................................................. 17 budesonide ................................................. 38 budesonide (inhalation) ............................... 46 budesonide (nasal) ..................................... 34 bumetanide inj 0.25/ml ................................ 31 bumetanide tab 0.5mg ................................ 31 bumetanide tab 1mg ................................... 31 bumetanide tab 2mg ................................... 31 BUPHENYL ................................................ 30 BUPRENEX ................................................ 22 buprenorphine hcl ....................................... 22 buprenorphine hcl-naloxone hcl dihydrate .. 28 bupropion hcl .............................................. 28 bupropion hcl (smoking deterrent) .............. 28 buspirone hcl .............................................. 27 BUSULFEX ................................................. 13 butabarbital sodium..................................... 27 butalbital-acetaminophen ............................ 22 butalbital-acetaminophen-caffeine .............. 22 butalbital-acetaminophen-caffeine w/ codeine

................................................................ 23 butalbital-aspirin-caffeine ............................ 23 butalbital-aspirin-caffeine w/cod .................. 23 BUTISOL SODIUM ..................................... 27 butoconazole nitrate (one dose) .................. 47 butorphanol tartrate .................................... 23 BUTRANS................................................... 23 BYDUREON ............................................... 40 BYETTA ...................................................... 40 BYSTOLIC .................................................. 22

C cabergoline ................................................. 27 CADUET ..................................................... 19 CALAN ........................................................ 19 CALAN SR .................................................. 19 calcipotriene ................................................ 49 calcipotriene-betamethasone dipropionate . 48 calcitonin (salmon) ...................................... 42 calcitriol ....................................................... 50 CALCITRIOL ............................................... 49 calcium acetate (phosphate binder) ............ 32 CAMBIA ...................................................... 23 CAMPATH .................................................. 13 CAMPRAL .................................................. 28 CAMPTOSAR ............................................. 13


CANASA SUP 1000MG .............................. 36 CANCIDAS ................................................. 10 candesartan cilexetil ................................... 20 candesartan cilexetil-hydrochlorothiazide ... 20 CANTIL ...................................................... 16 CAPASTAT SULFATE ............................... 11 CAPEX ....................................................... 48 CAPRELSA ................................................ 13 captopril ...................................................... 20 captopril & hydrochlorothiazide................... 20 CARAC CRE 0.5% ..................................... 49 CARAFATE SUS 1GM/10ML ..................... 36 CARAFATE TAB 1GM ................................ 36 CARBAGLU ................................................ 30 carbamazepine ........................................... 25 CARBATROL CAP 100MG ........................ 25 CARBATROL CAP 200MG ........................ 25 CARBATROL CAP 300MG ........................ 25 carbidopa ................................................... 27 CARBIDOPA/LEVODOPA/ENTACA PONE 27 carbidopa-levodopa .................................... 27 carbinoxamine maleate .............................. 13 carboplatin .................................................. 13 CARDENE IV ............................................. 19 CARDENE SR ............................................ 19 CARDIZEM ................................................. 19 CARDIZEM CD .......................................... 19 CARDIZEM LA ........................................... 19 CARDURA.................................................. 18 CARDURA XL ............................................ 18 CARIMUNE NANOFILTERED INJ 12GM ... 46 CARIMUNE NANOFILTERED INJ 3GM ..... 46 CARIMUNE NANOFILTERED INJ 6GM ..... 46 carisoprodol ................................................ 16 carisoprodol w/ aspirin ................................ 16 carisoprodol w/ aspirin & codeine ............... 16 CARNITOR ................................................. 43 carteolol hcl (ophth) .................................... 35 carvedilol .................................................... 22 CASODEX .................................................. 13 CATAFLAM ................................................ 23 CATAPRES ................................................ 20 CATAPRES-TTS-1 ..................................... 20 CATAPRES-TTS-2 ..................................... 20 CATAPRES-TTS-3 ..................................... 20 CAYSTON .................................................... 8 CEDAX ......................................................... 8 CEENU ....................................................... 13 cefaclor ......................................................... 8 cefaclor monohydrate ................................... 8

cefadroxil ...................................................... 8 cefazolin in d5w ............................................ 8 cefazolin sodium ........................................... 8 CEFAZOLIN SODIUM/ DEXTROSE ............. 8 cefdinir .......................................................... 8 CEFDITOREN PIVOXIL ................................ 8 cefepime hcl .................................................. 8 cefixime ........................................................ 8 cefotaxime sodium ........................................ 8 cefotetan disodium ........................................ 8 cefoxitin sodium ............................................ 8 CEFOXITIN SODIUM ................................... 8 cefpodoxime proxetil ..................................... 8 cefprozil ........................................................ 8 ceftazidime.................................................... 8 CEFTAZIDIME-DEXTROSE ......................... 8 CEFTIN SUS 125/5ML .................................. 8 CEFTIN SUS 250/5ML .................................. 8 CEFTIN TAB 250MG .................................... 8 CEFTIN TAB 500MG .................................... 8 ceftriaxone sodium ........................................ 8 CEFTRIAXONE/ DEXTROSE ....................... 8 cefuroxime axetil ........................................... 8 cefuroxime sodium ........................................ 8 CEFUROXIME/ DEXTROSE ........................ 8 CELEBREX ................................................. 23 CELESTONE .............................................. 38 CELEXA ..................................................... 28 CELLCEPT CAP 250MG ............................ 43 CELLCEPT INTRAVENOUS ...................... 44 CELLCEPT SUS 200MG/ML ...................... 44 CELLCEPT TAB 500MG ............................. 44 CELONTIN.................................................. 25 CENESTIN.................................................. 41 cephalexin..................................................... 8 CERDELGA ................................................ 44 CEREZYME ................................................ 33 CERVARIX ................................................. 47 CESAMET .................................................. 36 cetirizine hcl ................................................ 13 cevimeline hcl ............................................. 16 CHANTIX .................................................... 16 CHANTIX STARTING MONTH PAK ........... 16 CHEMET .................................................... 37 chenodiol .................................................... 37 chloramphenicol sodium succinate ............... 8 chlordiazepoxide hcl ................................... 27 chlordiazepoxide-amitriptyline ..................... 28 chlorhexidine gluconate (mouth-throat) ....... 33 chloroquine phosphate ................................ 11


chlorothiazide ............................................. 31 chlorothiazide sodium ................................. 31 chlorpromazine hcl ..................................... 28 chlorpropamide ........................................... 40 chlorthalidone ............................................. 31 chlorzoxazone ............................................ 16 cholestyramine ........................................... 18 cholestyramine light .................................... 18 choline fenofibrate ...................................... 18 chorionic gonadotropin ............................... 42 CIALIS ........................................................ 21 ciclopirox .................................................... 47 ciclopirox olamine ....................................... 47 cidofovir ...................................................... 11 cilostazol .................................................... 17 CILOXAN OIN 0.3% OP ............................. 33 CILOXAN SOL 0.3% OP ............................ 33 cimetidine ................................................... 36 cimetidine hcl .............................................. 36 CIMZIA ....................................................... 44 CINRYZE ................................................... 44 CIPRO .......................................................... 8 CIPRO HC .................................................. 34 CIPRO I.V.-IN D5W ...................................... 8 CIPRO SUSP ............................................... 8 CIPRODEX................................................. 34 ciprofloxacin ................................................. 8 ciprofloxacin hcl ............................................ 8 ciprofloxacin hcl (ophth) .............................. 33 ciprofloxacin in d5w ...................................... 8 ciprofloxacin-ciprofloxacin hcl ....................... 8 cisplatin ...................................................... 13 citalopram hydrobromide sol 10mg/5ml ...... 28 citalopram hydrobromide tab 10mg ............ 28 citalopram hydrobromide tab 20mg ............ 28 citalopram hydrobromide tab 40mg ............ 28 cladribine .................................................... 13 CLAFORAN .................................................. 9 CLARINEX ................................................. 13 CLARINEX-D 12 HOUR ............................. 13 CLARINEX-D 24 HOUR ............................. 13 clarithromycin ............................................... 9 clemastine fumarate ................................... 13 CLEOCIN ..................................................... 9 CLEOCIN CRE 2% VAG ............................ 47 CLEOCIN IN D5W ........................................ 9 CLEOCIN PHOSPHATE .............................. 9 CLEOCIN SUP 100MG .............................. 47 CLEOCIN-T ................................................ 47 CLIMARA DIS 0.025MG ............................. 41

CLIMARA DIS 0.0375MG ........................... 41 CLIMARA DIS 0.05MG ............................... 41 CLIMARA DIS 0.06MG ............................... 41 CLIMARA DIS 0.075MG ............................. 41 CLIMARA DIS 0.1MG ................................. 41 CLIMARA PRO ........................................... 41 clindamycin hcl ............................................. 9 clindamycin palmitate hydrochloride ............. 9 clindamycin phosphate ................................. 9 clindamycin phosphate & cleanser .............. 47 clindamycin phosphate (topical) .................. 47 clindamycin phosphate in d5w ...................... 9 clindamycin phosphate vaginal ................... 47 clindamycin phosphate-benzoyl peroxide ... 47 CLINIMIX 2.75%/DEXTROSE 5% .............. 31 CLINIMIX 4.25%/DEXTROSE 10% ............ 31 CLINIMIX 4.25%/DEXTROSE 20% ............ 31 CLINIMIX 4.25%/DEXTROSE 25% ............ 31 CLINIMIX 4.25%/DEXTROSE 5% .............. 31 CLINIMIX 5%/DEXTROSE 15% ................. 31 CLINIMIX 5%/DEXTROSE 20% ................. 31 CLINIMIX 5%/DEXTROSE 25% ................. 31 CLINIMIX E 2.75%/DEXTROSE 10% ......... 31 CLINIMIX E 2.75%/DEXTROSE 5% ........... 31 CLINIMIX E 4.25%/DEXTROSE 10% ......... 31 CLINIMIX E 4.25%/DEXTROSE 25% ......... 31 CLINIMIX E 4.25%/DEXTROSE 5% ........... 31 CLINIMIX E 5%/DEXTROSE 15% .............. 31 CLINIMIX E 5%/DEXTROSE 20% .............. 31 CLINIMIX E 5%/DEXTROSE 25% .............. 31 clobetasol propionate .................................. 48 clobetasol propionate emollient base .......... 48 CLOBEX ..................................................... 48 CLODERM PUMP ...................................... 48 CLOLAR ..................................................... 13 clomipramine hcl ......................................... 29 clonazepam ................................................ 25 clonidine & chlorthalidone ........................... 20 clonidine hcl ................................................ 20 clonidine hcl (adhd) ..................................... 20 clopidogrel bisulfate .................................... 17 clorazepate dipotassium ............................. 27 clotrimazole ................................................. 47 clotrimazole (topical) ................................... 47 clotrimazole w/ betamethasone ................... 47 clozapine .................................................... 29 CLOZARIL .................................................. 29 COARTEM .................................................. 11 CODEINE SULFATE TAB 15MG ................ 23 CODEINE SULFATE TAB 30MG ................ 23


CODEINE SULFATE TAB 60MG ............... 23 COGENTIN ................................................ 27 COLAZAL ................................................... 36 colchicine w/ probenecid ............................ 33 COLCRYS .................................................. 44 COLESTID ................................................. 18 colestipol hcl ............................................... 18 colistimethate sodium ................................... 9 COLY-MYCIN M ........................................... 9 COLY-MYCIN S ......................................... 34 COLYTE-FLAVOR PACKS ........................ 37 COMBIGAN ................................................ 35 COMBIPATCH ........................................... 41 COMBIVENT .............................................. 17 COMBIVENT RESPIMAT ........................... 17 COMBIVIR.................................................. 11 COMETRIQ ................................................ 13 COMPLERA ............................................... 11 COMTAN .................................................... 27 COMVAX .................................................... 47 CONCERTA TAB 18MG ............................. 24 CONCERTA TAB 27MG ............................. 24 CONCERTA TAB 36MG ............................. 24 CONCERTA TAB 54MG ............................. 24 CONDYLOX ............................................... 49 CONZIP ...................................................... 23 COPAXONE ............................................... 44 COPEGUS ................................................. 11 CORDARONE ............................................ 19 CORDRAN TAPE ....................................... 48 COREG ...................................................... 22 COREG CR ................................................ 22 CORGARD ................................................. 22 CORTEF .................................................... 38 CORTIFOAM .............................................. 48 cortisone acetate ........................................ 38 CORTISPORIN .................................... 34, 48 CORTISPORIN-TC..................................... 34 CORZIDE ................................................... 22 COSMEGEN .............................................. 13 COSOPT .................................................... 35 COUMADIN ................................................ 17 COZAAR .................................................... 20 CREON CAP 12000UNT ............................ 37 CREON CAP 24000UNT ............................ 37 CREON CAP 3000UNIT ............................. 37 CREON CAP 36000UNT ............................ 37 CREON CAP 6000UNIT ............................. 37 CRESTOR .................................................. 18 CRINONE ................................................... 42

CRIXIVAN ................................................... 11 cromolyn sodium ......................................... 45 cromolyn sodium (mastocytosis) ................. 45 cromolyn sodium (ophth) ............................ 35 CUBICIN ....................................................... 9 CUPRIMINE ................................................ 37 CUTIVATE .................................................. 48 CUVPOSA SOL 1MG/5ML ......................... 16 CYCLESSA ................................................. 38 cyclobenzaprine hcl .................................... 16 cyclophosphamide ...................................... 13 CYCLOPHOSPHAMIDE ............................. 13 CYCLOSET ................................................ 40 cyclosporine ................................................ 44 cyclosporine modified (for microemulsion) .. 44 CYKLOKAPRON ........................................ 17 CYMBALTA ................................................ 29 cyproheptadine hcl ...................................... 13 CYRAMZA .................................................. 13 CYSTADANE .............................................. 44 CYSTAGON CAP 150MG ........................... 44 CYSTAGON CAP 50MG ............................. 44 CYSTARAN ................................................ 35 cytarabine ................................................... 13 CYTOGAM.................................................. 46 CYTOMEL .................................................. 43 CYTOTEC................................................... 36 CYTOVENE ................................................ 11

D dacarbazine ................................................ 13 DACOGEN.................................................. 13 DALIRESP .................................................. 46 DALVANCE .................................................. 9 danazol ....................................................... 38 DANTRIUM ................................................. 16 dantrolene sodium ...................................... 16 dapsone ...................................................... 11 DAPTACEL ................................................. 47 DARAPRIM ................................................. 11 daunorubicin hcl .......................................... 14 DAUNOXOME ............................................ 14 DAYPRO .................................................... 23 DAYTRANA ................................................ 24 DDAVP ....................................................... 42 DDAVP INJ 4MCG/ML ................................ 42 DDAVP TAB 0.1MG .................................... 42 DDAVP TAB 0.2MG .................................... 42 decitabine ................................................... 14


DELESTROGEN ........................................ 41 DELZICOL CAP 400MG ............................. 36 DEMADEX.................................................. 31 demeclocycline hcl ....................................... 9 DEMEROL.................................................. 23 DEMSER .................................................... 44 DENAVIR ................................................... 47 DEPACON.................................................. 25 DEPAKENE ................................................ 25 DEPAKOTE ................................................ 25 DEPAKOTE ER .......................................... 25 DEPAKOTE SPRINKLES ........................... 25 DEPEN TITRATABS .................................. 37 DEPO-MEDROL INJ 20MG/ML .................. 38 DEPO-MEDROL INJ 40MG/ML .................. 38 DEPO-MEDROL INJ 80MG/ML .................. 38 DEPO-PROVERA ...................................... 42 DEPO-PROVERA CONTRACEPTIVE INJ

150MG/ML .............................................. 42 DEPO-SUBQ PROVERA 104 INJ 104 ....... 42 DERMATOP ............................................... 48 desipramine hcl .......................................... 29 desloratadine .............................................. 13 desmopressin acetate ................................ 42 desmopressin acetate spray refrigerated .... 42 DESOGEN ................................................. 38 desogestrel & ethinyl estradiol .................... 39 desogestrel-ethinyl estradiol (biphasic) ...... 39 desogestrel-ethinyl estradiol (triphasic) ...... 39 DESONATE ................................................ 48 desonide ..................................................... 48 DESOWEN ................................................. 48 desoximetasone ......................................... 48 DESOXIMETASONE .................................. 48 DESOXYN .................................................. 24 DESVENLAFAXINE ER ............................. 29 DETROL ..................................................... 50 DETROL LA ............................................... 50 dexamethasone .......................................... 38 dexamethasone sodium phosphate ............ 38 dexamethasone sodium phosphate (ophth) 34 DEXEDRINE .............................................. 24 DEXILANT .................................................. 36 dexmethylphenidate hcl .............................. 24 dexrazoxane ............................................... 44 dextroamphetamine sulfate ........................ 25 dextrose ..................................................... 31 DEXTROSE 10%/NACL 0.2% INJ 0.2%..... 32 DEXTROSE 10%/NACL 0.45% INJ 0.45% . 32

DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX ................................................. 32

DEXTROSE 5%/NACL 0.225% INJ 0.225%32 dextrose in lactated ringers ......................... 32 dextrose w/ sodium chloride ....................... 32 DIABETA .................................................... 40 DIAMOX ..................................................... 35 DIASTAT ACUDIAL .................................... 27 DIASTAT PEDIATRIC ................................. 27 diazepam .................................................... 27 DIAZEPAM ................................................. 27 DIBENZYLINE ............................................ 16 diclofenac potassium .................................. 23 diclofenac sodium ....................................... 23 diclofenac sodium (actinic keratoses) ......... 49 diclofenac sodium (ophth) ........................... 34 diclofenac sodium (topical) ......................... 49 diclofenac w/ misoprostol ............................ 23 dicloxacillin sodium ....................................... 9 dicyclomine hcl ........................................... 16 didanosine .................................................. 11 DIFFERIN CRE 0.1% .................................. 49 DIFFERIN GEL 0.1% .................................. 49 DIFFERIN GEL 0.3% .................................. 49 DIFFERIN LOT 0.1% .................................. 49 DIFICID ......................................................... 9 diflorasone diacetate ................................... 48 diflorasone dicaetate emollient base ........... 48 DIFLUCAN .................................................. 10 diflunisal ...................................................... 23 digoxin ........................................................ 19 DIGOXIN SOL 50MCG/ML ......................... 19 dihydroergotamine mesylate ....................... 16 DILANTIN ................................................... 25 DILATRATE SR CAP 40MG ....................... 21 DILAUDID INJ 1MG/ML .............................. 23 DILAUDID INJ 2MG/ML .............................. 23 DILAUDID INJ 4MG/ML .............................. 23 DILAUDID LIQ 1MG/ML .............................. 23 DILAUDID TAB 2MG .................................. 23 DILAUDID TAB 4MG .................................. 23 DILAUDID TAB 8MG .................................. 23 DILAUDID-HP INJ 10MG/ML ...................... 23 diltiazem hcl ................................................ 19 diltiazem hcl coated beads .......................... 19 diltiazem hcl extended release beads ......... 19 DIOVAN ...................................................... 20 DIOVAN HCT .............................................. 20 DIPENTUM ................................................. 36 diphenhydramine hcl ................................... 13


diphenoxylate w/ atropine ........................... 36 DIPHTHERIA/TETANUS TOXOID S

ADSORBED PEDIATRIC........................ 46 DIPROLENE ............................................... 48 DIPROLENE AF ......................................... 48 dipyridamole ............................................... 21 disopyramide phosphate ............................ 19 disulfiram .................................................... 44 DITROPAN XL ........................................... 50 DIURIL ....................................................... 31 divalproex sodium ...................................... 25 DIVIGEL GEL 1MG/GM .............................. 41 DOCEFREZ INJ 20MG ............................... 14 DOCEFREZ INJ 80MG ............................... 14 DOCETAXEL INJ 80MG/4ML ..................... 14 DOCETAXEL INJ 80MG/8ML ..................... 14 DOLOPHINE HCL TAB 5MG ..................... 23 DOLOPHINE TAB 10MG ............................ 23 donepezil hydrochloride .............................. 16 DORIBAX ..................................................... 9 DORYX ........................................................ 9 dorzolamide hcl .......................................... 35 dorzolamide hcl-timolol maleate ................. 35 DOVONEX ................................................. 49 doxazosin mesylate .................................... 18 doxepin hcl ................................................. 29 doxercalciferol ............................................ 50 DOXIL ........................................................ 14 doxorubicin hcl ........................................... 14 doxycycline (monohydrate) ........................... 9 doxycycline hyclate ...................................... 9 dronabinol .................................................. 36 drospirenone-ethinyl estradiol..................... 39 DROXIA ..................................................... 14 DUAVEE .................................................... 41 DUETACT .................................................. 40 DUEXIS ...................................................... 23 DULERA ..................................................... 46 duloxetine hcl ............................................. 29 DURAGESIC .............................................. 23 DUREZOL .................................................. 34 DUTOPROL ............................................... 22 DYAZIDE .................................................... 31 DYMISTA ................................................... 35 dyphylline ................................................... 50 DYRENIUM ................................................ 31 DYSPORT .................................................. 44

E E.E.S. GRANULES ....................................... 9 EC-NAPROSYN ......................................... 23 econazole nitrate ........................................ 47 EDARBI ...................................................... 20 EDARBYCLOR ........................................... 20 EDECRIN.................................................... 31 EDLUAR ..................................................... 27 EDURANT .................................................. 11 EFFEXOR XR ............................................. 29 EFFIENT ..................................................... 17 EFUDEX CRE 5% ...................................... 49 EGRIFTA .................................................... 42 ELAPRASE ................................................. 33 ELDEPRYL ................................................. 27 electrolyte-m in dextrose ............................. 32 ELELYSO ................................................... 33 ELESTAT .................................................... 35 ELIDEL ....................................................... 49 ELIGARD INJ 22.5MG ................................ 14 ELIGARD INJ 30MG ................................... 14 ELIGARD INJ 45MG ................................... 14 ELIGARD INJ 7.5MG .................................. 14 ELIQUIS ..................................................... 17 ELITEK ....................................................... 33 ELLA ........................................................... 39 ELLENCE ................................................... 14 ELMIRON ................................................... 44 ELOCON .................................................... 48 ELOXATIN INJ 100MG ............................... 14 ELOXATIN INJ 200MG ............................... 14 ELSPAR ..................................................... 14 EMADINE ................................................... 35 EMCYT ....................................................... 14 EMEND CAP 125MG .................................. 36 EMEND CAP 40MG .................................... 36 EMEND CAP 80MG .................................... 36 EMEND PAK 80 & 125 ............................... 36 EMLA .......................................................... 49 EMSAM ...................................................... 27 EMTRIVA .................................................... 11 ENABLEX ................................................... 50 enalapril maleate ........................................ 20 enalapril maleate & hydrochlorothiazide ..... 20 ENBREL ..................................................... 44 ENBREL SURECLICK ................................ 44 ENDOMETRIN ............................................ 42 ENGERIX-B ................................................ 47 ENJUVIA .................................................... 41


enoxaparin sodium ..................................... 17 entacapone................................................. 27 ENTOCORT EC ......................................... 38 ENTYVIO ................................................... 37 EPANED .................................................... 20 EPIDUO ..................................................... 49 epinastine hcl (ophth) ................................. 35 EPIPEN 2-PAK INJ 0.3MG ......................... 17 EPIPEN-JR 2-PAK INJ 2-PAK .................... 17 epirubicin hcl .............................................. 14 EPIVIR HBV SOL 5MG/ML ........................ 11 EPIVIR HBV TAB 100MG ........................... 11 EPIVIR SOL 10MG/ML ............................... 11 EPIVIR TAB 150MG ................................... 11 EPIVIR TAB 300MG ................................... 11 eplerenone ................................................. 20 EPOGEN INJ 10000/ML ............................. 18 EPOGEN INJ 2000/ML ............................... 18 EPOGEN INJ 20000/ML ............................. 18 EPOGEN INJ 3000/ML ............................... 18 EPOGEN INJ 4000/ML ............................... 18 eprosartan mesylate ................................... 20 EPZICOM ................................................... 11 EQUETRO.................................................. 25 ERAXIS ...................................................... 10 ERBITUX .................................................... 14 ergoloid mesylates ..................................... 16 ergotamine tartrate ..................................... 16 ergotamine w/ caffeine ............................... 26 ERIVEDGE ................................................. 14 ERTACZO .................................................. 47 ERWINAZE ................................................ 14 ERYPED 200 ................................................ 9 ERYPED 400 ................................................ 9 ERYTHROCIN LACTOBIONATE ................. 9 erythromycin (acne aid) .............................. 47 erythromycin (ophth)................................... 33 erythromycin base ........................................ 9 erythromycin ethylsuccinate ......................... 9 erythromycin lactobionate ............................. 9 erythromycin stearate ................................... 9 erythromycin-sulfisoxazole ........................... 9 escitalopram oxalate................................... 29 esomeprazole sodium ................................ 36 ESOMEPRAZOLE STRONTIUM ................ 36 estazolam ................................................... 27 esterified estrogens .................................... 41 estradiol ...................................................... 41 estradiol & norethindrone acetate ............... 41 estradiol cypionate ..................................... 41

estradiol vaginal .......................................... 41 estradiol valerate ........................................ 41 estradiol-norgestimate ................................ 41 ESTRASORB EMU ..................................... 41 ESTRING .................................................... 41 estropipate .................................................. 41 ESTROSTEP FE ........................................ 39 eszopiclone ................................................. 27 ethambutol hcl ............................................ 11 ethosuximide ............................................... 25 ethynodiol diacet & eth estrad ..................... 39 etidronate disodium..................................... 44 etodolac ...................................................... 23 ETOPOPHOS ............................................. 14 etoposide .................................................... 14 EURAX ....................................................... 47 EVAMIST SPR 1.53MG .............................. 41 EVISTA ....................................................... 41 EVOXAC ..................................................... 16 EVZIO ......................................................... 28 EXALGO TAB 12MG .................................. 23 EXALGO TAB 16MG .................................. 23 EXALGO TAB 32MG .................................. 23 EXALGO TAB 8MG .................................... 23 EXELDERM ................................................ 47 EXELON ..................................................... 16 exemestane ................................................ 14 EXFORGE .................................................. 19 EXFORGE HCT .......................................... 19 EXJADE TAB 125MG ................................. 37 EXJADE TAB 250MG ................................. 37 EXJADE TAB 500MG ................................. 37 EXTAVIA .................................................... 44 EXTINA ....................................................... 47

F FABIOR ...................................................... 49 FABRAZYME .............................................. 33 FACTIVE ...................................................... 9 famciclovir ................................................... 11 famotidine ................................................... 36 famotidine in nacl ........................................ 36 FAMVIR ...................................................... 11 FANAPT ..................................................... 29 FANAPT TITRATION PACK ....................... 29 FARESTON ................................................ 14 FARXIGA .................................................... 40 FASLODEX ................................................. 14 fat emulsion ................................................ 31


FAZACLO ................................................... 29 felbamate ................................................... 25 FELBATOL ................................................. 25 FELDENE ................................................... 23 felodipine .................................................... 19 FEMARA .................................................... 14 FEMCON FE .............................................. 39 FEMHRT LOW DOSE ................................ 39 FEMRING ................................................... 41 fenofibrate .................................................. 18 FENOFIBRATE .......................................... 18 fenofibrate micronized ................................ 18 FENOGLIDE ............................................... 18 fenoprofen calcium ..................................... 23 fentanyl ....................................................... 23 fentanyl citrate ............................................ 23 FENTORA .................................................. 23 FERRIPROX .............................................. 37 FETZIMA .................................................... 29 FETZIMA TITRATION PACK...................... 29 FIBRICOR .................................................. 18 FINACEA .................................................... 49 finasteride ................................................... 44 FIORINAL ................................................... 23 FIORINAL/CODEINE #3 ............................. 23 FIRAZYR .................................................... 44 FIRMAGON ................................................ 14 FLAGYL ..................................................... 11 FLAGYL ER ................................................ 11 FLAREX ..................................................... 34 flavoxate hcl ............................................... 50 FLEBOGAMMA DIF INJ DIF 5% ................ 46 flecainide acetate ....................................... 19 FLECTOR................................................... 49 FLOMAX .................................................... 16 FLONASE................................................... 34 FLO-PRED ................................................. 38 FLOVENT DISKUS..................................... 46 FLOVENT HFA AER 110MCG ................... 46 FLOVENT HFA AER 220MCG ................... 46 FLOVENT HFA AER 44MCG ..................... 46 fluconazole ................................................. 10 fluconazole in dextrose ............................... 10 flucytosine .................................................. 10 fludarabine phosphate ................................ 14 fludrocortisone acetate ............................... 38 FLUMADINE ............................................... 11 flunisolide (nasal) ....................................... 34 fluocinolone acetonide ................................ 48 fluocinolone acetonide (otic) ....................... 34

fluocinonide................................................. 48 fluocinonide emulsified base ....................... 48 FLUOROPLEX CRE 1% ............................. 49 fluorouracil .................................................. 14 fluorouracil (topical)..................................... 49 fluoxetine dr cap 90mg dr ........................... 29 FLUOXETINE HCL ..................................... 29 fluoxetine hcl cap 10mg .............................. 29 fluoxetine hcl cap 20mg .............................. 29 fluoxetine hcl cap 40mg .............................. 29 fluoxetine hcl sol 20mg/5ml ......................... 29 fluoxetine hcl tab 10mg ............................... 29 fluoxetine hcl tab 20mg ............................... 29 fluoxymesterone ......................................... 38 fluphenazine decanoate .............................. 29 fluphenazine hcl .......................................... 29 flurazepam hcl ............................................ 27 flurbiprofen .................................................. 23 flurbiprofen sodium ..................................... 34 flutamide ..................................................... 14 fluticasone propionate ................................. 48 fluticasone propionate (nasal) ..................... 34 fluvastatin sodium ....................................... 18 fluvoxamine maleate ................................... 29 FML FORTE SUS 0.25% OP ...................... 34 FML LIQUIFILM SUS 0.1% OP ................... 34 FML OIN 0.1% OP ...................................... 34 FOCALIN .................................................... 25 FOCALIN XR .............................................. 25 FOLOTYN ................................................... 14 fomepizole .................................................. 44 fondaparinux sodium................................... 17 FORADIL AEROLIZER ............................... 17 FORFIVO XL .............................................. 29 FORTAMET ................................................ 40 FORTAZ INJ 1 GM ....................................... 9 FORTAZ INJ 2GM ........................................ 9 FORTAZ INJ 6GM ........................................ 9 FORTEO ..................................................... 42 FORTESTA GEL 10MG/ACT ...................... 38 FORTICAL SPR 200/ACT ........................... 42 FOSAMAX .................................................. 44 FOSAMAX PLUS D .................................... 44 foscarnet sodium ........................................ 11 fosinopril sodium ......................................... 20 fosinopril sodium & hydrochlorothiazide ...... 20 fosphenytoin sodium ................................... 25 FOSRENOL ................................................ 32 FRAGMIN ................................................... 17 FREAMINE III 3% INJ 3% ........................... 31


FROVA ....................................................... 26 FULYZAQ ................................................... 36 FURADANTIN ............................................ 13 furosemide inj 10mg/ml .............................. 31 furosemide sol 10mg/ml ............................. 31 furosemide sol 8mg/ml ............................... 31 furosemide tab 20mg .................................. 31 furosemide tab 40mg .................................. 31 furosemide tab 80mg .................................. 31 FUSILEV .................................................... 44 FUZEON .................................................... 11 FYCOMPA.................................................. 25

G gabapentin.................................................. 25 GABITRIL ................................................... 25 GABLOFEN ................................................ 16 galantamine hydrobromide ......................... 16 GAMASTAN S/D ........................................ 46 GAMMAGARD LIQUID ............................... 46 GAMMAGARD S/D INJ 10GM HU ............. 46 GAMMAGARD S/D INJ 2.5GM HU ............ 46 GAMMAGARD S/D INJ 5GM HU ............... 46 GAMMAPLEX INJ 10GM ............................ 46 GAMUNEX INJ 10% ................................... 46 GAMUNEX-C ............................................. 46 ganciclovir sodium ...................................... 11 GARDASIL ................................................. 47 GASTROCROM ......................................... 45 gatifloxacin (ophth) ..................................... 33 GATTEX ..................................................... 37 gauze pads & dressings ............................. 30 GAZYVA ..................................................... 14 GELNIQUE ................................................. 50 gemcitabine hcl .......................................... 14 gemfibrozil .................................................. 18 GEMZAR .................................................... 14 GENERESS FE .......................................... 39 GENOTROPIN INJ 12MG .......................... 42 GENOTROPIN INJ 5MG ............................ 42 GENOTROPIN MINIQUICK INJ 0.2MG ...... 42 GENOTROPIN MINIQUICK INJ 0.4MG ...... 42 GENOTROPIN MINIQUICK INJ 0.6MG ...... 42 GENOTROPIN MINIQUICK INJ 0.8MG ...... 42 GENOTROPIN MINIQUICK INJ 1.2MG ...... 42 GENOTROPIN MINIQUICK INJ 1.4MG ...... 42 GENOTROPIN MINIQUICK INJ 1.6MG ...... 42 GENOTROPIN MINIQUICK INJ 1.8MG ...... 42 GENOTROPIN MINIQUICK INJ 1MG......... 42

GENOTROPIN MINIQUICK INJ 2MG ......... 42 gentamicin in saline ...................................... 9 gentamicin sulfate ......................................... 9 gentamicin sulfate (ophth) ........................... 33 gentamicin sulfate (topical) ......................... 47 GEODON .................................................... 29 GIAZO ........................................................ 36 GILENYA .................................................... 44 GILOTRIF ................................................... 14 GLASSIA .................................................... 46 GLEEVEC ................................................... 14 glimepiride .................................................. 40 glipizide er tab 10mg ................................... 40 glipizide er tab 2.5mg .................................. 40 glipizide er tab 5mg ..................................... 40 glipizide tab 10mg ....................................... 40 glipizide tab 5mg ......................................... 40 glipizide-metformin hcl ................................ 40 GLUCAGEN HYPOKIT INJ HYPOKIT ........ 40 GLUCAGEN INJ 1MG ................................. 40 GLUCAGON EMERGENCY KIT ................. 40 GLUCOPHAGE .......................................... 40 GLUCOPHAGE XR..................................... 40 GLUCOTROL ............................................. 40 GLUCOTROL XL ........................................ 40 GLUCOVANCE ........................................... 40 GLUMETZA ................................................ 40 glyburide ..................................................... 40 glyburide micronized ................................... 40 glyburide-metformin .................................... 40 glycopyrrolate ............................................. 16 GLYNASE ................................................... 40 GLYSET ..................................................... 40 GOLYTELY ................................................. 37 GRALISE .................................................... 23 GRALISE STARTER ................................... 23 granisetron hcl ............................................ 36 GRANIX ...................................................... 18 GRASTEK................................................... 44 griseofulvin microsize .................................. 10 griseofulvin ultramicrosize ........................... 10 GRIS-PEG .................................................. 10 guanfacine hcl ............................................. 20 GUANIDINE HCL ........................................ 16

H H.P. ACTHAR ............................................. 42 HALAVEN ................................................... 14 HALCION .................................................... 27


HALDOL ..................................................... 29 HALDOL DECANOATE 100 ....................... 29 HALDOL DECANOATE 50 ......................... 29 halobetasol propionate ............................... 48 HALOG ....................................................... 48 haloperidol .................................................. 29 haloperidol decanoate ................................ 29 haloperidol lactate ...................................... 29 HAVRIX ...................................................... 47 HECTOROL ............................................... 50 HEMABATE ................................................ 44 heparin (porcine) in sodium chloride ........... 17 heparin sod (porcine) in d5w ...................... 18 heparin sodium (porcine) ............................ 18 HEPSERA .................................................. 12 HERCEPTIN ............................................... 14 HETLIOZ .................................................... 27 HEXALEN................................................... 14 HIPREX ...................................................... 13 HORIZANT ................................................. 25 HUMALOG INJ 100/ML .............................. 40 HUMALOG MIX 50/50 ................................ 40 HUMALOG MIX 50/50 KWIKPEN ............... 40 HUMALOG MIX 75/25 ................................ 40 HUMALOG MIX 75/25 KWIKPEN ............... 40 HUMATROPE COMBO PACK INJ 5MG .... 42 HUMATROPE INJ 12MG ........................... 42 HUMATROPE INJ 24MG ........................... 42 HUMATROPE INJ 6MG ............................. 42 HUMIRA ..................................................... 44 HUMIRA PEN-CROHNS DISEASE

STARTER ............................................... 44 HUMULIN 70/30 INJ 70/30 ......................... 40 HUMULIN 70/30 PEN INJ 70/30 ................. 40 HUMULIN N INJ U-100 .............................. 40 HUMULIN N U-100 PEN INJ U-100 ........... 40 HUMULIN R INJ U-100 .............................. 40 HUMULIN R U-500 (CONCENTRATED) INJ

U-500 ...................................................... 40 HYCAMTIN ................................................. 14 hydralazine hcl inj 20mg/ml ........................ 20 hydralazine hcl tab 100mg .......................... 20 hydralazine hcl tab 10mg ............................ 20 hydralazine hcl tab 25mg ............................ 20 hydralazine hcl tab 50mg ............................ 20 HYDREA .................................................... 14 hydrochlorothiazide cap 12.5mg ................. 31 hydrochlorothiazide tab 12.5mg.................. 31 hydrochlorothiazide tab 25mg .................... 32 hydrochlorothiazide tab 50mg .................... 32

hydrocodone-acetaminophen ..................... 23 hydrocodone-ibuprofen ............................... 23 hydrocortisone ............................................ 38 hydrocortisone (intrarectal) ......................... 48 hydrocortisone (rectal) ................................ 48 hydrocortisone (topical) ............................... 48 hydrocortisone butyrate .............................. 49 hydrocortisone butyrate hydrophilic lipo base

................................................................ 49 hydrocortisone sod succinate ..................... 38 hydrocortisone valerate ............................... 49 hydrocortisone w/acetic acid ....................... 34 hydromorphone hcl ..................................... 23 hydroxychloroquine sulfate ......................... 11 hydroxyurea ................................................ 14 hydroxyzine hcl ........................................... 27 hydroxyzine pamoate .................................. 27 HYPERRHO S/D ........................................ 46 HYPERTET S/D .......................................... 46 HYZAAR ..................................................... 20

I ibandronate sodium .................................... 44 ibuprofen ..................................................... 23 ICLUSIG ..................................................... 14 IDAMYCIN PFS .......................................... 14 idarubicin hcl ............................................... 14 IFEX ............................................................ 14 ifosfamide ................................................... 14 ILARIS ........................................................ 23 ILEVRO ...................................................... 34 IMBRUVICA ................................................ 14 imipenem-cilastatin ....................................... 9 imipramine hcl ............................................. 29 imipramine pamoate ................................... 29 imiquimod ................................................... 49 IMITREX ..................................................... 26 IMITREX STATDOSE REFILL .................... 26 IMOGAM RABIES-HT ................................. 46 IMOVAX RABIES (H.D.C.V.) ...................... 47 IMURAN ..................................................... 44 INCIVEK ..................................................... 12 INCRELEX .................................................. 42 indapamide ................................................. 32 INDERAL LA ............................................... 22 INDOCIN .................................................... 23 indomethacin .............................................. 23 INFANRIX ................................................... 47 INFERGEN ................................................. 12


INLYTA ....................................................... 14 INNOPRAN XL ........................................... 22 INSPRA ...................................................... 20 insulin pen needle ...................................... 30 insulin syringe/needle u-100 ....................... 30 INTEGRILIN ............................................... 18 INTELENCE TAB 100MG ........................... 12 INTELENCE TAB 200MG ........................... 12 INTELENCE TAB 25MG ............................. 12 INTERMEZZO ............................................ 27 INTRALIPID INJ 30% ................................. 31 INTRON-A .................................................. 14 INTRON-A W/DILUENT ............................. 14 INTUNIV ..................................................... 28 INVANZ ........................................................ 9 INVEGA ...................................................... 29 INVEGA SUSTENNA ................................. 29 INVIRASE CAP 200MG .............................. 12 INVIRASE TAB 500MG .............................. 12 INVOKANA ................................................. 40 IONOSOL-B/DEXTROSE 5% ..................... 32 IONOSOL-MB/DEXTROSE 5% .................. 32 IOPIDINE SOL 0.5% OP ............................ 35 IOPIDINE SOL 1% OP ............................... 35 IPOL INACTIVATED IPV ............................ 47 ipratropium bromide.................................... 16 ipratropium bromide (nasal) ........................ 16 ipratropium-albuterol................................... 17 irbesartan ................................................... 20 irbesartan-hydrochlorothiazide ................... 20 irinotecan hcl .............................................. 14 irrigation solutions, physiological ................ 32 ISENTRESS CHW 100MG ......................... 12 ISENTRESS CHW 25MG ........................... 12 ISENTRESS POW 100MG ......................... 12 ISENTRESS TAB 400MG .......................... 12 ISOLYTE-P/DEXTROSE 5% ...................... 32 ISOLYTE-S................................................. 32 isoniazid ..................................................... 11 isoniazid & rifampin .................................... 11 ISOPTO CARPINE SOL 1% OP ................. 35 ISOPTO CARPINE SOL 2% OP ................. 35 ISOPTO CARPINE SOL 4% OP ................. 35 ISORDIL TITRADOSE TAB 40MG ............. 21 ISORDIL TITRADOSE TAB 5MG ............... 21 isosorbide dinitrate ..................................... 21 isosorbide mononitrate er tab 120mg er ..... 21 isosorbide mononitrate er tab 30mg er ....... 21 isosorbide mononitrate er tab 60mg er ....... 21 isosorbide mononitrate tab 10mg ............... 21

isosorbide mononitrate tab 20mg ................ 21 isotretinoin .................................................. 50 isradipine .................................................... 19 ISTALOL ..................................................... 35 ISTODAX .................................................... 14 itraconazole ................................................ 10 IXEMPRA KIT ............................................. 14 IXIARO ....................................................... 47

J JAKAFI ....................................................... 14 JALYN ........................................................ 44 JANUMET ................................................... 40 JANUMET XR ............................................. 40 JANUVIA .................................................... 40 JENTADUETO ............................................ 40 JEVTANA.................................................... 14 JUBLIA ....................................................... 47 JUXTAPID .................................................. 18

K KADCYLA ................................................... 14 KADIAN CAP 100MG CR ........................... 23 KADIAN CAP 10MG CR ............................. 23 KADIAN CAP 130MG CR ........................... 23 KADIAN CAP 150MG CR ........................... 23 KADIAN CAP 200MG CR ........................... 23 KADIAN CAP 20MG CR ............................. 23 KADIAN CAP 30MG CR ............................. 23 KADIAN CAP 40MG CR ............................. 23 KADIAN CAP 50MG CR ............................. 23 KADIAN CAP 60MG CR ............................. 23 KADIAN CAP 70MG CR ............................. 23 KADIAN CAP 80MG CR ............................. 23 KALETRA SOL ........................................... 12 KALETRA TAB 100-25MG .......................... 12 KALETRA TAB 200-50MG .......................... 12 KALYDECO ................................................ 46 KAPVAY ..................................................... 20 KARBINAL ER ............................................ 13 KAYEXALATE ............................................ 32 KAZANO ..................................................... 40 KCL 0.15%/D5W/LR ................................... 32 KCL 0.15%/D5W/NACL 0.225% INJ 0.15/0.2

................................................................ 32 KCL 0.3%/D5W/NACL 0.9% INJ 0.3/0.9% .. 32 KEFLEX ........................................................ 9 KENALOG .................................................. 49 KENALOG-10 ............................................. 38


KENALOG-40 ............................................. 38 KEPIVANCE ............................................... 49 KEPPRA ..................................................... 25 KEPPRA XR ............................................... 25 KETEK ......................................................... 9 ketoconazole .............................................. 10 ketoconazole & cleanser ............................ 47 ketoconazole (topical) ................................. 47 ketoprofen .................................................. 23 ketorolac tromethamine .............................. 23 ketorolac tromethamine (ophth) .................. 34 KHEDEZLA ................................................ 29 KINERET .................................................... 44 KLARON .................................................... 47 KLONOPIN ................................................. 25 KOMBIGLYZE XR ...................................... 40 KORLYM .................................................... 40 K-TAB TAB 10MEQ CR .............................. 32 K-TAB TAB 20MEQ .................................... 32 KUVAN ....................................................... 44 KYNAMRO ................................................. 18 KYPROLIS ................................................. 14

L labetalol hcl ................................................ 22 LAC-HYDRIN ............................................. 50 LACRISERT ............................................... 35 lactated ringer's .......................................... 32 lactated ringer's (irrigation) ......................... 32 lactic acid (ammonium lactate) ................... 50 lactulose ..................................................... 30 lactulose (encephalopathy) ......................... 30 LAMICTAL CHEWABLE DISPERSIBLE CHW

25MG ...................................................... 25 LAMICTAL CHEWABLE DISPERSIBLE CHW

5MG ........................................................ 25 LAMICTAL ODT TAB 100MG ..................... 25 LAMICTAL ODT TAB 200MG ..................... 25 LAMICTAL ODT TAB 25MG ....................... 25 LAMICTAL ODT TAB 50MG ....................... 26 LAMICTAL STARTER/NOT TAKING

CARBAMAZEPINE KIT START 49 ......... 26 LAMICTAL STARTER/TAKING

CARBAMAZEPINE/NOT TAKING VALPROATE KIT START 98 .................. 26

LAMICTAL STARTER/TAKING VALPROATE KIT START 35 ........................................ 26

LAMICTAL TAB 100MG ............................. 26 LAMICTAL TAB 150MG ............................. 26

LAMICTAL TAB 200MG .............................. 26 LAMICTAL TAB 25MG ................................ 26 LAMICTAL XR KIT ...................................... 26 LAMICTAL XR TAB 100MG ........................ 26 LAMICTAL XR TAB 200MG ........................ 26 LAMICTAL XR TAB 250MG ........................ 26 LAMICTAL XR TAB 25MG .......................... 26 LAMICTAL XR TAB 300MG ........................ 26 LAMICTAL XR TAB 50MG .......................... 26 LAMISIL ...................................................... 10 lamivudine................................................... 12 lamivudine-zidovudine ................................ 12 lamotrigine .................................................. 26 LANOXIN INJ 0.25MG/1 ............................. 19 LANOXIN PEDIATRIC INJ 0.1MG/ML ........ 19 LANOXIN TAB 0.0625MG .......................... 19 LANOXIN TAB 0.125MG ............................ 19 LANOXIN TAB 0.1875MG .......................... 19 LANOXIN TAB 0.25MG .............................. 19 lansoprazole ............................................... 36 LANTUS INJ 100/ML .................................. 40 LANTUS SOLOSTAR INJ SOLOSTAR....... 40 LASIX ......................................................... 32 LASTACAFT ............................................... 35 latanoprost .................................................. 35 LATUDA ..................................................... 29 LAZANDA ................................................... 23 leflunomide ................................................. 44 LESCOL ..................................................... 18 LESCOL XL ................................................ 18 LETAIRIS .................................................... 46 letrozole ...................................................... 14 leucovorin calcium ...................................... 44 LEUKERAN ................................................ 14 LEUKINE .................................................... 18 leuprolide acetate ....................................... 14 levalbuterol hcl ............................................ 17 LEVAQUIN.................................................... 9 LEVATOL.................................................... 22 LEVEMIR .................................................... 40 LEVEMIR FLEXPEN ................................... 40 levetiracetam .............................................. 26 LEVETIRACETAM ...................................... 26 levobunolol hcl ............................................ 35 levocarnitine (metabolic modifiers) .............. 44 levocetirizine dihydrochloride ...................... 13 levofloxacin ................................................... 9 levofloxacin (ophth) ..................................... 33 levofloxacin in d5w ........................................ 9 levonorgestrel & eth estradiol...................... 39


levonorgestrel-eth estradiol (triphasic) ........ 39 levonorgestrel-ethinyl estradiol (91-day) ..... 39 levonorgestrel-ethinyl estradiol (continuous)

............................................................... 39 levorphanol tartrate .................................... 23 levothyroxine sodium .................................. 43 LEVOTHYROXINE SODIUM ...................... 43 LEXAPRO .................................................. 29 LEXIVA SUS 50MG/ML .............................. 12 LEXIVA TAB 700MG .................................. 12 LIALDA TAB 1.2GM ................................... 36 lidocaine ..................................................... 49 lidocaine hcl ................................................ 49 lidocaine hcl (local anesth.) ........................ 44 lidocaine hcl (mouth-throat) ........................ 35 lidocaine-prilocaine ..................................... 49 LIDODERM ................................................ 49 LINCOCIN .................................................... 9 lindane ........................................................ 47 LINZESS .................................................... 37 LIORESAL INTRATHECAL ........................ 16 liothyronine sodium .................................... 43 LIPITOR ..................................................... 18 LIPOFEN .................................................... 18 LIPOSYN III INJ 10% ................................. 31 LIPOSYN III INJ 20% ................................. 31 LIPTRUZET ................................................ 18 lisinopril & hydrochlorothiazide ................... 20 lisinopril tab 10mg ...................................... 20 lisinopril tab 2.5mg ..................................... 20 lisinopril tab 20mg ...................................... 20 lisinopril tab 30mg ...................................... 20 lisinopril tab 40mg ...................................... 20 lisinopril tab 5mg ........................................ 20 lithium carbonate ........................................ 29 LITHIUM CARBONATE CAP 600MG ......... 29 LITHIUM CITRATE ..................................... 29 LITHOBID TAB 300MG CR ........................ 29 LITHOSTAT ................................................ 30 LIVALO ....................................................... 18 LO LOESTRIN FE ...................................... 39 LO MINASTRIN FE .................................... 39 LODOSYN .................................................. 27 LOMOTIL ................................................... 36 LOMUSTINE .............................................. 14 loperamide hcl ............................................ 36 LOPID ........................................................ 18 LOPRESSOR ............................................. 22 LOPRESSOR HCT ..................................... 22 LOPROX SHAMPOO ................................. 47

lorazepam ................................................... 27 losartan potassium ...................................... 20 losartan potassium & hydrochlorothiazide ... 20 LOSEASONIQUE ....................................... 39 LOTEMAX................................................... 34 LOTENSIN .................................................. 20 LOTREL ...................................................... 19 LOTRISONE ............................................... 47 LOTRONEX ................................................ 36 lovastatin .................................................... 18 LOVAZA ..................................................... 18 LOVENOX .................................................. 18 loxapine succinate ...................................... 29 LUMIGAN ................................................... 35 LUMIZYME ................................................. 33 LUNESTA ................................................... 27 LUPANETA PACK ...................................... 14 LUPRON DEPOT INJ 11.25MG .................. 14 LUPRON DEPOT INJ 22.5MG.................... 14 LUPRON DEPOT INJ 3.75MG.................... 14 LUPRON DEPOT INJ 30MG ...................... 14 LUPRON DEPOT INJ 45MG ...................... 14 LUPRON DEPOT INJ 7.5MG...................... 14 LUPRON DEPOT-PED ............................... 14 LUVOX CR ................................................. 29 LUZU .......................................................... 47 LYRICA ....................................................... 26 LYSODREN ................................................ 14 LYSTEDA ................................................... 18

M MACROBID ................................................ 13 MACRODANTIN CAP 100MG .................... 13 MACRODANTIN CAP 25MG ...................... 13 mafenide acetate ........................................ 48 magnesium sulfate ...................................... 26 MAGNESIUM SULFATE ............................. 26 MAGNESIUM SULFATE IN D5W ............... 32 MALARONE ................................................ 11 malathion .................................................... 48 maprotiline hcl ............................................. 29 MARINOL ................................................... 36 MARPLAN .................................................. 29 MARQIBO ................................................... 14 MATULANE ................................................ 15 MAVIK ........................................................ 20 MAXAIR AUTOHALER ............................... 17 MAXALT ..................................................... 26 MAXALT-MLT ............................................. 27


MAXIDEX ................................................... 34 MAXIPIME INJ 1GM ..................................... 9 MAXIPIME INJ 2GM ..................................... 9 MAXITROL ................................................. 34 MAXZIDE ................................................... 32 MAXZIDE-25 .............................................. 32 mecamylamine hcl ...................................... 20 meclizine hcl ............................................... 36 meclofenamate sodium .............................. 23 MEDROL DOSEPAK PAK 4MG ................. 38 MEDROL TAB 16MG ................................. 38 MEDROL TAB 2MG ................................... 38 MEDROL TAB 32MG ................................. 38 MEDROL TAB 4MG ................................... 38 MEDROL TAB 8MG ................................... 38 medroxyprogesterone acetate .................... 42 medroxyprogesterone acetate (contraceptive)

............................................................... 42 mefenamic acid .......................................... 23 mefloquine hcl ............................................ 11 MEGACE ES .............................................. 42 MEGACE ORAL ......................................... 15 megestrol acetate ....................................... 15 MEKINIST .................................................. 15 meloxicam .................................................. 23 MELOXICAM .............................................. 23 melphalan hcl ............................................. 15 MENACTRA ............................................... 47 MENOMUNE-A/C/Y/W-135 ........................ 47 MENOSTAR DIS 14MCG ........................... 41 MENTAX .................................................... 48 MENVEO .................................................... 47 meperidine hcl ............................................ 23 meprobamate ............................................. 27 MEPRON ................................................... 11 mercaptopurine .......................................... 15 meropenem .................................................. 9 MERREM ..................................................... 9 mesalamine w/ cleanser ............................. 36 mesna ........................................................ 44 MESNEX INJ 1GM ..................................... 44 MESNEX TAB 400MG ................................ 44 MESTINON SYP 60MG/5ML ...................... 16 MESTINON TAB 60MG .............................. 16 MESTINON TIMESPAN TAB TIMESPAN .. 16 METADATE CD CAP 10MG ....................... 25 METADATE CD CAP 20MG ....................... 25 METADATE CD CAP 30MG ....................... 25 METADATE CD CAP 40MG ....................... 25 METADATE CD CAP 50MG ....................... 25

METADATE CD CAP 60MG ....................... 25 metaproterenol sulfate ................................ 17 metaxalone ................................................. 16 metformin hcl er tab 1000mg ...................... 40 metformin hcl er tab 500mg er .................... 40 metformin hcl er tab 750mg er .................... 40 metformin hcl tab 1000mg .......................... 40 metformin hcl tab 500mg ............................ 40 metformin hcl tab 850mg ............................ 40 methadone hcl ............................................ 24 METHADONE HCL INJ 10MG/ML .............. 24 methamphetamine hcl ................................. 25 methazolamide ........................................... 35 methenamine hippurate .............................. 13 methimazole ............................................... 43 methocarbamol ........................................... 16 methotrexate sodium .................................. 15 methoxsalen rapid ...................................... 50 methscopolamine bromide .......................... 16 methyclothiazide ......................................... 32 methyldopa ................................................. 20 methyldopa & hydrochlorothiazide .............. 20 methyldopate hcl ......................................... 20 methylergonovine maleate .......................... 44 METHYLIN CHW 10MG ............................. 25 METHYLIN CHW 2.5MG ............................ 25 METHYLIN CHW 5MG ............................... 25 METHYLIN SOL 10MG/5ML ....................... 25 METHYLIN SOL 5MG/5ML ......................... 25 methylphenidate hcl .................................... 25 methylprednisolone ..................................... 38 methylprednisolone acetate ........................ 38 methylprednisolone sod succ ...................... 38 methyltestosterone ..................................... 38 metipranolol ................................................ 35 metoclopramide hcl ..................................... 37 metolazone ................................................. 32 metoprolol & hydrochlorothiazide ................ 22 metoprolol succinate ................................... 22 metoprolol tartrate inj 1mg/ml...................... 22 metoprolol tartrate tab 100mg ..................... 22 metoprolol tartrate tab 25mg ....................... 22 metoprolol tartrate tab 50mg ....................... 22 METOZOLV ODT ....................................... 37 METRO IV .................................................. 11 METROCREAM .......................................... 48 METROGEL ................................................ 48 METROGEL-VAGINAL ............................... 48 METROLOTION ......................................... 48 metronidazole ............................................. 11


metronidazole (topical) ............................... 48 metronidazole in nacl.................................. 11 metronidazole vaginal ................................. 48 mexiletine hcl .............................................. 19 MIACALCIN INJ 200/ML ............................. 42 MIACALCIN SPR 200/ACT ........................ 42 MICARDIS .................................................. 20 MICARDIS HCT ......................................... 21 miconazole nitrate vaginal .......................... 48 MICROZIDE ............................................... 32 midodrine hcl .............................................. 17 MIFEPREX ................................................. 44 MIGRANAL................................................. 16 MINASTRIN 24 FE ..................................... 39 MINIPRESS ................................................ 18 MINIVELLE DIS 0.0375MG ........................ 41 MINIVELLE DIS 0.05MG ............................ 41 MINIVELLE DIS 0.075MG .......................... 41 MINIVELLE DIS 0.1MG .............................. 41 minocycline hcl ............................................. 9 minoxidil ..................................................... 20 MIRAPEX ................................................... 27 MIRAPEX ER ............................................. 27 mirtazapine ................................................. 29 MIRVASO ................................................... 50 misoprostol ................................................. 36 mitomycin ................................................... 15 mitoxantrone hcl ......................................... 15 M-M-R II W/DILUENT 10 DOSE ................. 47 MOBIC ....................................................... 24 modafinil ..................................................... 25 MODICON .................................................. 39 moexipril hcl ............................................... 21 moexipril-hydrochlorothiazide ..................... 21 mometasone furoate................................... 49 montelukast sodium.................................... 45 MONUROL ................................................. 13 morphine sulfate ......................................... 24 morphine sulfate beads .............................. 24 MORPHINE SULFATE INJ 2MG/ML .......... 24 MORPHINE SULFATE INJ 4MG/ML .......... 24 MORPHINE SULFATE TAB 15MG ............ 24 MORPHINE SULFATE TAB 30MG ............ 24 MOVIPREP ................................................ 37 MOXATAG ................................................... 9 MOXEZA .................................................... 33 moxifloxacin hcl ............................................ 9 MOZOBIL ................................................... 18 MS CONTIN TAB 100MG CR..................... 24 MS CONTIN TAB 15MG CR ...................... 24

MS CONTIN TAB 200MG CR ..................... 24 MS CONTIN TAB 30MG CR ....................... 24 MS CONTIN TAB 60MG CR ....................... 24 MULTAQ ..................................................... 19 mupirocin .................................................... 48 mupirocin calcium (topical) ......................... 48 MUSTARGEN ............................................. 15 MYALEPT ................................................... 44 MYAMBUTOL ............................................. 11 MYCAMINE ................................................ 10 MYCOBUTIN .............................................. 11 mycophenolate mofetil ................................ 44 mycophenolate sodium ............................... 44 MYFORTIC ................................................. 44 MYOZYME.................................................. 33 MYRBETRIQ .............................................. 50 MYSOLINE ................................................. 26

N NABI-HB ..................................................... 46 nabumetone ................................................ 24 nadolol & bendroflumethiazide .................... 22 nadolol tab 20mg ........................................ 22 nadolol tab 40mg ........................................ 22 nadolol tab 80mg ........................................ 22 nafcillin sodium ............................................. 9 NAFTIN ....................................................... 48 NAGLAZYME .............................................. 33 nalbuphine hcl ............................................. 24 NALLPEN ISO-OSMOTIC IN DEXTROSE ... 9 NALLPEN/DEXTROSE ................................. 9 naloxone hcl ................................................ 28 naltrexone hcl ............................................. 28 NAMENDA SOL 10MG/5ML ....................... 28 NAMENDA TITRATION PAK TAB 5-10MG 28 NAMENDA XR CAP 14MG ......................... 28 NAMENDA XR CAP 21MG ......................... 28 NAMENDA XR CAP 28MG ......................... 28 NAMENDA XR CAP 7MG ........................... 28 NAMENDA XR TITRATION PACK CAP

TITRATIO ................................................ 28 naphazoline hcl ........................................... 35 NAPRELAN ................................................ 24 NAPROSYN ................................................ 24 naproxen ..................................................... 24 naproxen sodium ........................................ 24 naratriptan hcl ............................................. 27 NARDIL ...................................................... 29 NASACORT AQ .......................................... 34


NASONEX .................................................. 34 NATACYN .................................................. 33 NATAZIA .................................................... 39 nateglinide .................................................. 40 NAVANE .................................................... 29 NEBUPENT INH 300MG ............................ 11 NECON 1/50-28 ......................................... 39 nefazodone hcl ........................................... 29 neomycin sulfate .......................................... 9 neomycin/polymyxin b gu ........................... 48 neomycin-bacitracin zn-polymyxin .............. 33 neomycin-polymy-dexameth ....................... 34 neomycin-polymyxin-gramicidin .................. 33 neomycin-polymyxin-hc (ophth) .................. 34 neomycin-polymyxin-hc (otic) ..................... 34 NEORAL CAP 100MG ................................ 44 NEORAL CAP 25MG .................................. 44 NEORAL SOL 100MG/ML .......................... 44 NEPHRAMINE INJ 5.4% ............................ 31 NESINA ...................................................... 40 NEULASTA ................................................ 18 NEUMEGA ................................................. 18 NEUPOGEN ............................................... 18 NEUPRO .................................................... 27 NEURONTIN .............................................. 26 NEVANAC .................................................. 34 nevirapine ................................................... 12 NEVIRAPINE .............................................. 12 NEXAVAR .................................................. 15 NEXIUM ..................................................... 36 NEXIUM I.V. ............................................... 36 NEXTERONE ............................................. 19 niacin (antihyperlipidemic) .................... 18, 50 NIASPAN ................................................... 18 nicardipine hcl ............................................ 19 NICOTROL INHALER INH ......................... 16 NICOTROL NS SPR 10MG/ML .................. 16 nifedipine .................................................... 19 NILANDRON .............................................. 15 nimodipine .................................................. 19 NIPENT ...................................................... 15 nisoldipine .................................................. 19 NITRO-DUR DIS 0.1MG/HR ...................... 21 NITRO-DUR DIS 0.2MG/HR ...................... 21 NITRO-DUR DIS 0.3MG/HR ...................... 21 NITRO-DUR DIS 0.4MG/HR ...................... 21 NITRO-DUR DIS 0.6MG/HR ...................... 21 NITRO-DUR DIS 0.8MG/HR ...................... 21 nitrofurantoin .............................................. 13 nitrofurantoin macrocrystal ......................... 13

nitrofurantoin monohyd macro .................... 13 nitroglycerin ................................................ 21 NITROLINGUAL PUMPSPRAY SPR

PUMPSPRA ............................................ 21 NITROMIST AER 400MCG ........................ 21 NITROSTAT SUB 0.3MG ........................... 21 NITROSTAT SUB 0.4MG ........................... 21 NITROSTAT SUB 0.6MG ........................... 21 nizatidine .................................................... 36 NIZORAL .................................................... 48 NORDITROPIN FLEXPRO INJ 10/1.5ML ... 42 NORDITROPIN FLEXPRO INJ 15/1.5ML ... 42 NORDITROPIN FLEXPRO INJ 5/1.5ML ..... 42 NORDITROPIN NORDIFLEX PEN INJ

30/3ML .................................................... 42 norelgestromin-ethinyl estradiol .................. 39 norethin acet & estrad-fe ............................. 39 norethindrone & eth estradiol ...................... 39 norethindrone & ethinyl estradiol-fe ............ 39 norethindrone (contraceptive) ..................... 39 norethindrone acet & eth estra .................... 39 norethindrone acetate ................................. 42 norethindrone acetate-ethinyl estradiol ....... 41 norethindrone acetate-ethinyl estradiol-fe ... 39 norethindrone-eth estradiol (biphasic) ......... 39 norethindrone-eth estradiol (triphasic) ........ 39 norgestimate-ethinyl estradiol ..................... 39 norgestimate-ethinyl estradiol (triphasic) ..... 39 norgestrel & ethinyl estradiol ....................... 39 NORINYL 1+35 ........................................... 39 NORINYL 1+50 ........................................... 39 NORITATE.................................................. 48 NORMOSOL-R ........................................... 32 NORMOSOL-R IN D5W .............................. 32 NOROXIN ..................................................... 9 NORPACE CAP 100MG ............................. 19 NORPACE CAP 150MG ............................. 19 NORPACE CR CAP 100MG CR ................. 19 NORPACE CR CAP 150MG CR ................. 19 NORPRAMIN .............................................. 29 NOR-QD ..................................................... 39 nortriptyline hcl cap 10mg ........................... 29 nortriptyline hcl cap 25mg ........................... 29 nortriptyline hcl cap 50mg ........................... 29 nortriptyline hcl cap 75mg ........................... 29 nortriptyline hcl sol 10mg/5ml...................... 29 NORVASC .................................................. 19 NORVIR ...................................................... 12 NOVOLIN 70/30 INJ 70/30 ......................... 40 NOVOLIN N INJ U-100 ............................... 40


NOVOLIN R INJ U-100 ............................... 40 NOVOLOG ................................................. 40 NOVOLOG MIX 70/30 ................................ 40 NOVOLOG MIX 70/30 PREFILLED

FLEXPEN ............................................... 40 NOVOLOG PENFILL .................................. 41 NOXAFIL .................................................... 10 NUCYNTA .................................................. 24 NUCYNTA ER ............................................ 24 NUEDEXTA ................................................ 28 NULOJIX .................................................... 44 NULYTELY/FLAVOR PACKS..................... 37 NUTRESTORE ........................................... 37 NUTROPIN AQ INJ 10MG/2ML .................. 43 NUTROPIN AQ NUSPIN 5 INJ NUSPIN 5 . 43 NUTROPIN AQ PEN INJ 10MG/2ML ......... 43 NUTROPIN AQ PEN INJ 20MG/2ML ......... 43 NUTROPIN INJ 10MG ................................ 43 NUVARING ................................................ 39 NUVIGIL ..................................................... 25 nystatin ....................................................... 10 nystatin (mouth-throat) ............................... 10 nystatin (topical) ......................................... 48 nystatin-triamcinolone ................................. 49

O OCTAGAM INJ 5GM .................................. 46 octreotide acetate ....................................... 44 OCUFEN .................................................... 34 OCUFLOX .................................................. 33 ofloxacin ....................................................... 9 ofloxacin (ophth) ......................................... 33 ofloxacin (otic) ............................................ 33 olanzapine .................................................. 29 olanzapine-fluoxetine hcl ............................ 29 OLUX ......................................................... 49 OLYSIO ...................................................... 12 OMECLAMOX-PAK .................................... 36 omega-3-acid ethyl esters .......................... 18 omeprazole................................................. 36 omeprazole-sodium bicarbonate ................ 36 OMNARIS................................................... 34 OMNIPRED SUS 1% OP ........................... 34 OMNITROPE INJ 10/1.5ML ....................... 43 OMNITROPE INJ 5.8MG ............................ 43 OMNITROPE INJ 5/1.5ML ......................... 43 ONCASPAR ............................................... 15 ondansetron ............................................... 36 ondansetron hcl .......................................... 36

ONFI ........................................................... 26 ONGLYZA................................................... 41 ONMEL TAB 200MG .................................. 10 OPANA ....................................................... 24 OPANA ER (CRUSH RESISTANT) ............ 24 OPSUMIT ................................................... 46 OPTIVAR .................................................... 35 ORACEA .................................................... 50 ORAP ......................................................... 29 ORAPRED ODT ......................................... 38 ORENCIA ................................................... 44 ORENITRAM TAB 0.125MG ....................... 46 ORENITRAM TAB 0.25MG ......................... 46 ORENITRAM TAB 1MG .............................. 46 ORENITRAM TAB 2.5MG ........................... 46 ORFADIN.................................................... 44 orphenadrine citrate .................................... 16 ORTHO EVRA ............................................ 39 ORTHO MICRONOR .................................. 39 ORTHO TRI-CYCLEN ................................ 39 ORTHO TRI-CYCLEN LO ........................... 39 ORTHO-CEPT ............................................ 39 ORTHO-CYCLEN ....................................... 39 ORTHO-NOVUM 1/35 ................................ 39 ORTHO-NOVUM 7/7/7 ............................... 39 OSENI ........................................................ 41 OSMOPREP ............................................... 37 OTEZLA ...................................................... 44 OTREXUP .................................................. 44 OVIDE ........................................................ 48 oxacillin sodium ............................................ 9 oxaliplatin .................................................... 15 oxandrolone ................................................ 38 oxaprozin .................................................... 24 oxazepam ................................................... 27 oxcarbazepine ............................................ 26 OXECTA ..................................................... 24 OXISTAT .................................................... 48 OXSORALEN ............................................. 50 OXSORALEN ULTRA ................................. 50 OXTELLAR XR ........................................... 26 oxybutynin chloride ..................................... 50 oxycodone hcl ............................................. 24 oxycodone w/ acetaminophen .................... 24 oxycodone-aspirin ....................................... 24 oxycodone-ibuprofen .................................. 24 OXYCONTIN .............................................. 24 oxymorphone hcl ........................................ 24


P

paclitaxel .................................................... 15 PAMELOR .................................................. 29 pamidronate disodium ................................ 44 PAMINE ..................................................... 16 PAMINE FORTE ........................................ 16 PANCREAZE CAP 10500UNT ................... 37 PANCREAZE CAP 16800UNT ................... 37 PANCREAZE CAP 21000UNT ................... 37 PANCREAZE CAP 4200UNIT .................... 37 PANDEL ..................................................... 49 PANRETIN ................................................. 50 pantoprazole sodium .................................. 36 PARAFON FORTE DSC ............................ 16 parenteral electrolytes ................................ 32 paricalcitol .................................................. 50 PARLODEL ................................................ 27 PARNATE .................................................. 29 paromomycin sulfate .................................. 11 paroxetine hcl er tab 12.5mg ...................... 29 paroxetine hcl er tab 25mg er ..................... 29 paroxetine hcl er tab 37.5mg ...................... 29 paroxetine hcl tab 10mg ............................. 29 paroxetine hcl tab 20mg ............................. 29 paroxetine hcl tab 30mg ............................. 29 paroxetine hcl tab 40mg ............................. 30 PATADAY................................................... 35 PATANASE ................................................ 35 PATANOL................................................... 35 PAXIL ......................................................... 30 PAXIL CR ................................................... 30 PCE .............................................................. 9 PEDVAX HIB .............................................. 47 peg 3350-kcl-sod bicarb-sod chloride-sod

sulfate ..................................................... 37 peg 3350-potassium chloride-sod

bicarbonate-sod chloride......................... 37 PEGANONE ............................................... 26 PEGASYS .................................................. 12 PEGASYS PROCLICK ............................... 12 PEG-INTRON ............................................. 12 PEG-INTRON REDIPEN ............................ 12 penicillin g potassium ................................... 9 PENICILLIN G POTASSIUM IN ISO-

OSMOTIC DEXTROSE ............................ 9 penicillin g procaine ...................................... 9 penicillin g sodium ........................................ 9 penicillin v potassium.................................... 9 PENNSAID ................................................. 50

PENTAM 300 INJ 300MG ........................... 11 PENTASA CAP 250MG CR ........................ 36 PENTASA CAP 500MG CR ........................ 36 pentazocine w/ naloxone ............................ 24 pentostatin .................................................. 15 pentoxifylline ............................................... 18 PEPCID ...................................................... 36 PERCODAN ............................................... 24 PERFOROMIST ......................................... 17 perindopril erbumine ................................... 21 PERJETA.................................................... 15 permethrin................................................... 48 perphenazine .............................................. 30 perphenazine-amitriptyline .......................... 30 PERSANTINE ............................................. 21 PERTZYE CAP ........................................... 37 PEXEVA ..................................................... 30 phenelzine sulfate ....................................... 30 phenobarbital .............................................. 27 phenytoin .................................................... 26 phenytoin sodium ........................................ 26 phenytoin sodium extended ........................ 26 PHISOHEX ................................................. 48 PHOSLO CAP 667MG ................................ 32 PHOSLYRA SOL ........................................ 32 PHOSPHOLINE IODIDE ............................. 35 PICATO ...................................................... 50 pilocarpine hcl ............................................. 35 pilocarpine hcl (oral).................................... 16 PILOPINE HS GEL 4% OP ......................... 35 pindolol ....................................................... 22 pioglitazone hcl ........................................... 41 pioglitazone hcl-glimepiride ......................... 41 pioglitazone hcl-metformin hcl..................... 41 piperacillin sodium-tazobactam sodium ........ 9 piroxicam .................................................... 24 PLAN B ONE-STEP .................................... 39 PLAQUENIL ................................................ 11 PLASMA-LYTE A ........................................ 32 PLASMA-LYTE-148 .................................... 32 PLASMA-LYTE-56/D5W ............................. 32 PLAVIX ....................................................... 18 PLETAL ...................................................... 18 podofilox ..................................................... 50 polyethylene glycol 3350 ............................. 37 polymyxin b sulfate ....................................... 9 polymyxin b-trimethoprim ............................ 33 POLYTRIM ................................................. 33 POMALYST ................................................ 15 PONSTEL ................................................... 24


potassium chloride ..................................... 33 POTASSIUM CHLORIDE 0.15% /NACL

0.45% VIAFLEX INJ .15-0.45 ................. 33 POTASSIUM CHLORIDE 0.15%/NACL 0.9%

INJ 0.15-0.9 ............................................ 33 POTASSIUM CHLORIDE 0.3%/ NACL 0.9%

INJ 0.3-0.9 .............................................. 33 potassium chloride in dextrose ................... 33 potassium chloride in dextrose & sodium

chloride ................................................... 33 potassium chloride in nacl .......................... 33 POTASSIUM CHLORIDE INJ 10MEQ........ 33 POTASSIUM CHLORIDE INJ 20MEQ........ 33 POTASSIUM CHLORIDE INJ 40MEQ........ 33 potassium chloride microencapsulated

crystals cr ............................................... 33 POTASSIUM CITRATE ER TAB 1080MG .. 30 POTASSIUM CITRATE ER TAB 540MG ER

............................................................... 30 POTIGA ...................................................... 26 PRADAXA .................................................. 18 pramipexole dihydrochloride ....................... 27 PRANDIMET .............................................. 41 PRANDIN ................................................... 41 PRAVACHOL ............................................. 18 pravastatin sodium ..................................... 18 prazosin hcl ................................................ 18 PRECOSE .................................................. 41 PRED FORTE SUS 1% OP ........................ 34 PRED MILD SUS 0.12% OP ...................... 34 PRED-G ..................................................... 34 PRED-G S.O.P. .......................................... 34 prednicarbate ............................................. 49 prednisolone ............................................... 38 prednisolone acetate (ophth) ...................... 34 prednisolone sodium phosphate ................. 38 prednisolone sodium phosphate (ophth)..... 34 prednisone.................................................. 38 PREMARIN ................................................ 41 PREMARIN INJ 25MG ............................... 41 PREMARIN TAB 0.3MG ............................. 41 PREMARIN TAB 0.45MG ........................... 41 PREMARIN TAB 0.625MG ......................... 41 PREMARIN TAB 0.9MG ............................. 41 PREMARIN TAB 1.25MG ........................... 41 PREMPHASE ............................................. 41 PREMPRO ................................................. 41 PREPOPIK ................................................. 37 PREVACID ................................................. 36 PREVACID SOLUTAB ............................... 36

PREVPAC................................................... 36 PREZISTA SUS 100MG/ML ....................... 12 PREZISTA TAB 150MG .............................. 12 PREZISTA TAB 400MG .............................. 12 PREZISTA TAB 600MG .............................. 12 PREZISTA TAB 75MG ................................ 12 PREZISTA TAB 800MG .............................. 12 PRIFTIN ...................................................... 11 PRILOSEC.................................................. 36 PRIMAQUINE PHOSPHATE ...................... 11 PRIMAXIN IV ................................................ 9 primidone .................................................... 26 PRIMSOL.................................................... 13 PRINIVIL ..................................................... 21 PRISTIQ ..................................................... 30 PRIVIGEN INJ 20GRAMS .......................... 46 PROAIR HFA AER...................................... 17 probenecid .................................................. 33 procainamide hcl ......................................... 19 PROCALAMINE INJ 3% ............................. 31 PROCARDIA .............................................. 19 PROCARDIA XL ......................................... 19 prochlorperazine ......................................... 30 prochlorperazine edisylate .......................... 30 prochlorperazine maleate ........................... 30 PROCRIT INJ 10000/ML ............................ 18 PROCRIT INJ 2000/ML .............................. 18 PROCRIT INJ 20000/ML ............................ 18 PROCRIT INJ 3000/ML .............................. 18 PROCRIT INJ 4000/ML .............................. 18 PROCRIT INJ 40000/ML ............................ 18 PROCYSBI CAP 25MG .............................. 44 PROCYSBI CAP 75MG .............................. 44 progesterone micronized ............................ 42 PROGLYCEM ............................................. 20 PROGRAF CAP 0.5MG .............................. 44 PROGRAF CAP 1MG ................................. 44 PROGRAF CAP 5MG ................................. 44 PROGRAF INJ 5MG/ML ............................. 44 PROLASTIN-C ............................................ 46 PROLENSA ................................................ 34 PROLEUKIN ............................................... 15 PROLIA SOL 60MG/ML .............................. 44 PROMACTA ............................................... 18 promethazine & phenylephrine ................... 13 promethazine hcl ........................................ 13 PROMETRIUM ........................................... 42 propafenone hcl .......................................... 19 propantheline bromide ................................ 16 proparacaine hcl ......................................... 35


propranolol & hydrochlorothiazide .............. 22 propranolol hcl er cap 120mg er ................. 22 propranolol hcl er cap 160mg er ................. 22 propranolol hcl er cap 60mg er ................... 22 propranolol hcl er cap 80mg er ................... 22 propranolol hcl inj 1mg/ml ........................... 22 propranolol hcl sol 20mg/5ml ...................... 22 propranolol hcl sol 40mg/5ml ...................... 22 propranolol hcl tab 10mg ............................ 22 propranolol hcl tab 20mg ............................ 22 propranolol hcl tab 40mg ............................ 22 propranolol hcl tab 60mg ............................ 22 propranolol hcl tab 80mg ............................ 22 propylthiouracil ........................................... 43 PROQUAD ................................................. 47 PROSCAR.................................................. 44 PROSOL INJ 20% ...................................... 31 PROTONIX INJ 40MG ................................ 36 PROTONIX PAK ........................................ 36 PROTONIX TAB 20MG .............................. 36 PROTONIX TAB 40MG .............................. 36 PROTOPIC................................................. 50 protriptyline hcl ........................................... 30 PROVENTIL HFA AER HFA ...................... 17 PROVERA .................................................. 42 PROVIGIL .................................................. 25 PROZAC .................................................... 30 PROZAC WEEKLY..................................... 30 PRUDOXIN ................................................ 50 PULMICORT FLEXHALER INH 180MCG .. 46 PULMICORT FLEXHALER INH 90MCG .... 46 PULMICORT SUS 0.25MG/2 ..................... 46 PULMICORT SUS 0.5MG/2 ....................... 46 PULMICORT SUS 1MG/2ML ..................... 46 PULMOZYME ............................................. 33 PURINETHOL ............................................ 15 PYLERA ..................................................... 36 pyrazinamide .............................................. 11 pyridostigmine bromide .............................. 16

Q QNASL ....................................................... 34 QUALAQUIN .............................................. 11 QUARTETTE .............................................. 39 QUDEXY XR .............................................. 26 quetiapine fumarate .................................... 30 QUILLIVANT XR SUS XR .......................... 25 quinapril hcl ................................................ 21 quinapril-hydrochlorothiazide ...................... 21

quinidine gluconate ..................................... 19 QUINIDINE GLUCONATE .......................... 19 quinidine sulfate .......................................... 19 quinine sulfate ............................................. 11 QVAR ......................................................... 46

R RABAVERT ................................................ 47 rabeprazole sodium .................................... 36 RAGWITEK ................................................. 44 raloxifene hcl ............................................... 41 ramipril ........................................................ 21 RANEXA ..................................................... 19 ranitidine hcl ................................................ 37 RAPAFLO ................................................... 17 RAPAMUNE ............................................... 44 RAVICTI ..................................................... 30 RAYOS ....................................................... 38 RAZADYNE ................................................ 16 RAZADYNE ER .......................................... 16 REBETOL ................................................... 12 REBIF ......................................................... 44 REBIF REBIDOSE ...................................... 44 REBIF REBIDOSE TITRATION PACK ....... 44 REBIF TITRATION PACK ........................... 45 RECLAST ................................................... 45 RECOMBIVAX HB ...................................... 47 RECTIV ...................................................... 50 REGLAN ..................................................... 37 REGONOL INJ 5MG/ML ............................. 16 REGRANEX ................................................ 50 RELENZA DISKHALER .............................. 12 RELISTOR .................................................. 37 RELPAX ..................................................... 27 REMERON ................................................. 30 REMERON SOLTAB .................................. 30 REMICADE ................................................. 45 REMODULIN .............................................. 46 RENAGEL................................................... 32 RENVELA ................................................... 32 repaglinide .................................................. 41 REQUIP ...................................................... 27 REQUIP XL ................................................. 27 RESCRIPTOR ............................................ 12 RESCULA ................................................... 35 RESERPINE ............................................... 20 RESTASIS .................................................. 34 RESTORIL .................................................. 27 RETIN-A CRE 0.025% ................................ 49


RETIN-A CRE 0.05% ................................. 49 RETIN-A CRE 0.1% ................................... 49 RETIN-A GEL 0.01% .................................. 49 RETIN-A GEL 0.025% ................................ 49 RETIN-A MICRO GEL 0.04% ..................... 49 RETIN-A MICRO GEL 0.1% ....................... 49 RETIN-A MICRO PUMP GEL 0.04%PMP .. 49 RETIN-A MICRO PUMP GEL 0.08% .......... 49 RETIN-A MICRO PUMP GEL 0.1%PUMP . 49 RETROVIR CAP 100MG ............................ 12 RETROVIR IV INFUSION INJ 10MG/ML .... 12 RETROVIR SYP 50MG/5ML ...................... 12 REVATIO ................................................... 21 REVLIMID .................................................. 15 REYATAZ CAP 100MG .............................. 12 REYATAZ CAP 150MG .............................. 12 REYATAZ CAP 200MG .............................. 12 REYATAZ CAP 300MG .............................. 12 RHEUMATREX .......................................... 15 RHINOCORT AQUA................................... 34 RHOPHYLAC ............................................. 46 ribavirin (hepatitis c) ................................... 12 RIDAURA ................................................... 37 rifabutin ...................................................... 11 RIFADIN ..................................................... 11 rifampin ...................................................... 11 RIFATER .................................................... 11 RILUTEK .................................................... 28 riluzole ........................................................ 28 rimantadine hydrochloride .......................... 12 RIMSO-50 .................................................. 45 ringer's inj ................................................... 33 ringer's irrigation ......................................... 32 RIOMET ..................................................... 41 risedronate sodium ..................................... 45 RISPERDAL ............................................... 30 RISPERDAL CONSTA ............................... 30 RISPERDAL M-TAB ................................... 30 risperidone.................................................. 30 RITALIN LA CAP 10MG ............................. 25 RITALIN LA CAP 20MG ............................. 25 RITALIN LA CAP 30MG ............................. 25 RITALIN LA CAP 40MG ............................. 25 RITALIN SR TAB 20MG SR ....................... 25 RITALIN TAB 10MG ................................... 25 RITALIN TAB 20MG ................................... 25 RITALIN TAB 5MG ..................................... 25 RITUXAN ................................................... 15 rivastigmine tartrate .................................... 16 rizatriptan benzoate .................................... 27

ROBINUL FORTE TAB 2MG ...................... 16 ROBINUL TAB 1MG ................................... 16 ROCALTROL CAP 0.25MCG ..................... 50 ROCALTROL CAP 0.5MCG ....................... 50 ROCALTROL SOL 1MCG/ML..................... 50 ropinirole hydrochloride ............................... 27 ROTARIX .................................................... 47 ROTATEQ .................................................. 47 ROXICODONE ........................................... 24 ROZEREM .................................................. 27 RYTHMOL .................................................. 19 RYTHMOL SR ............................................ 19

S SABRIL ....................................................... 26 SAFYRAL ................................................... 39 SAIZEN ....................................................... 43 SAIZEN CLICK.EASY ................................. 43 SALAGEN ................................................... 16 SAMSCA .................................................... 32 SANCTURA ................................................ 50 SANCTURA XR .......................................... 50 SANCUSO .................................................. 36 SANDIMMUNE ........................................... 45 SANDOSTATIN INJ 1000MCG ................... 45 SANDOSTATIN INJ 100MCG ..................... 45 SANDOSTATIN INJ 200MCG ..................... 45 SANDOSTATIN INJ 500MCG ..................... 45 SANDOSTATIN INJ 50MCG/ML ................. 45 SANDOSTATIN LAR DEPOT KIT LAR 10MG

................................................................ 45 SANDOSTATIN LAR DEPOT KIT LAR 20MG

................................................................ 45 SANDOSTATIN LAR DEPOT KIT LAR 30MG

................................................................ 45 SANTYL ...................................................... 50 SAPHRIS .................................................... 30 SARAFEM .................................................. 30 SAVELLA .................................................... 28 SAVELLA TITRATION PACK ..................... 28 SEASONIQUE ............................................ 39 secobarbital sodium .................................... 27 SECTRAL ................................................... 22 selegiline hcl ............................................... 27 selenium sulfide .......................................... 48 SELZENTRY ............................................... 12 SEMPREX-D .............................................. 13 SENSIPAR TAB 30MG ............................... 45 SENSIPAR TAB 60MG ............................... 45


SENSIPAR TAB 90MG ............................... 45 SEREVENT DISKUS .................................. 17 SEROQUEL ............................................... 30 SEROQUEL XR ......................................... 30 SEROSTIM................................................. 43 sertraline hcl ............................................... 30 SFROWASA ENE 4GM .............................. 36 SIGNIFOR .................................................. 43 sildenafil citrate (pulmonary hypertension) . 21 SILENOR ................................................... 27 SILVADENE ............................................... 48 silver sulfadiazine ....................................... 48 SIMBRINZA ................................................ 35 SIMCOR ..................................................... 18 SIMPONI .................................................... 45 SIMPONI ARIA ........................................... 45 SIMULECT ................................................. 45 simvastatin ................................................. 18 SINEMET ................................................... 27 SINEMET CR ............................................. 27 SINGULAIR ................................................ 45 sirolimus ..................................................... 45 SIRTURO ................................................... 11 SIVEXTRO ................................................... 9 SKELAXIN .................................................. 16 SKLICE ........................................................ 8 sodium chloride .......................................... 33 sodium chloride (gu irrigant) ....................... 32 SODIUM DIURIL ........................................ 32 SODIUM EDECRIN .................................... 32 SODIUM FLUORIDE .................................. 45 SODIUM LACTATE INJ 1/6M ..................... 30 SODIUM LACTATE INJ 5MEQ/ML ............. 30 sodium phenylbutyrate ............................... 30 sodium polystyrene sulfonate ..................... 32 SOLARAZE ................................................ 50 SOLODYN .................................................... 9 SOLTAMOX ............................................... 15 SOLU-CORTEF .......................................... 38 SOLU-MEDROL INJ 125MG ...................... 38 SOLU-MEDROL INJ 1GM .......................... 38 SOLU-MEDROL INJ 2GM .......................... 38 SOLU-MEDROL INJ 40MG ........................ 38 SOLU-MEDROL INJ 500MG ...................... 38 SOMA ......................................................... 16 SOMATULINE DEPOT ............................... 45 SOMAVERT ............................................... 43 SONATA .................................................... 28 SORIATANE ............................................... 50 SORILUX ................................................... 50

sotalol hcl .................................................... 22 sotalol hcl (afib/afl) ...................................... 22 SOVALDI .................................................... 12 SPECTRACEF .............................................. 9 SPINOSAD ................................................. 48 SPIRIVA HANDIHALER .............................. 16 spironolactone & hydrochlorothiazide ......... 21 spironolactone tab 100mg ........................... 21 spironolactone tab 25mg ............................. 21 spironolactone tab 50mg ............................. 21 SPORANOX CAP 100MG .......................... 10 SPORANOX PULSEPAK CAP PULSEPAK 10 SPORANOX SOL 10MG/ML ....................... 10 SPRIX ......................................................... 24 SPRYCEL ................................................... 15 STALEVO 100 ............................................ 27 STALEVO 125 ............................................ 27 STALEVO 150 ............................................ 27 STALEVO 200 ............................................ 27 STALEVO 50 .............................................. 27 STALEVO 75 .............................................. 27 STARLIX ..................................................... 41 stavudine .................................................... 12 STELARA ................................................... 50 STIMATE SOL 1.5MG/ML .......................... 42 STIVARGA.................................................. 15 STRATTERA .............................................. 28 streptomycin sulfate .................................... 10 STRIANT MIS 30MG .................................. 38 STRIBILD.................................................... 12 STROMECTOL ............................................. 8 SUBOXONE ............................................... 28 SUBSYS ..................................................... 24 SUCLEAR ................................................... 37 SUCRAID.................................................... 33 sucralfate .................................................... 37 SULAR ........................................................ 19 sulfacetamide sodium (acne) ...................... 48 sulfacetamide sodium (ophth) ..................... 33 sulfacetamide sod-prednisolone ................. 34 sulfadiazine ................................................. 10 sulfamethoxazole-trimethoprim ................... 10 SULFAMYLON CRE 85MG/GM .................. 48 SULFAMYLON PAK 5% ............................. 48 sulfasalazine ............................................... 10 sulindac ...................................................... 24 SUMATRIPTAN .......................................... 27 sumatriptan succinate ................................. 27 SUMAVEL DOSEPRO ................................ 27 SUPRAX ..................................................... 10


SUPREP BOWEL PREP ............................ 37 SURMONTIL .............................................. 30 SUSTIVA .................................................... 12 SUTENT ..................................................... 15 SYLATRON ................................................ 15 SYLVANT ................................................... 15 SYMBICORT .............................................. 46 SYMBYAX .................................................. 30 SYMLINPEN 120 ........................................ 41 SYMLINPEN 60 .......................................... 41 SYNAGIS ................................................... 12 SYNALAR CREAM KIT .............................. 49 SYNALGOS-DC ......................................... 24 SYNAREL................................................... 42 SYNERA .................................................... 49 SYNERCID ................................................. 10 SYNRIBO ................................................... 15 SYNTHROID .............................................. 43 SYPRINE ................................................... 37

T TABLOID .................................................... 15 TACLONEX OIN ......................................... 49 TACLONEX SUS ........................................ 49 tacrolimus ................................................... 45 TAFINLAR .................................................. 15 TALWIN ...................................................... 24 TAMIFLU CAP 30MG ................................. 12 TAMIFLU CAP 45MG ................................. 12 TAMIFLU CAP 75MG ................................. 12 TAMIFLU SUS 12MG/ML ........................... 12 TAMIFLU SUS 6MG/ML ............................. 12 tamoxifen citrate ......................................... 15 tamsulosin hcl ............................................. 17 TANZEUM .................................................. 41 TARCEVA .................................................. 15 TARGRETIN ......................................... 15, 50 TARKA ....................................................... 19 TASIGNA ................................................... 15 TASMAR .................................................... 27 TAXOTERE INJ 20/0.5ML .......................... 15 TAXOTERE INJ 80MG/2ML ....................... 15 TAXOTERE INJ 80MG/4ML ....................... 15 TAZORAC CRE 0.05% ............................... 50 TAZORAC CRE 0.1% ................................. 50 TAZORAC GEL 0.05% ............................... 50 TAZORAC GEL 0.1% ................................. 50 TECFIDERA ............................................... 45 TECFIDERA STARTER PACK ................... 45

TEFLARO ................................................... 10 TEGRETOL SUS 100/5ML ......................... 26 TEGRETOL TAB 200MG ............................ 26 TEGRETOL-XR TAB 100MG ...................... 26 TEGRETOL-XR TAB 200MG ...................... 26 TEGRETOL-XR TAB 400MG ...................... 26 TEKAMLO................................................... 21 TEKTURNA ................................................ 21 TEKTURNA HCT ........................................ 21 telmisartan .................................................. 21 telmisartan-amlodipine ................................ 19 telmisartan-hydrochlorothiazide .................. 21 temazepam ................................................. 28 TEMOVATE ................................................ 49 TENEX ........................................................ 20 TENORETIC 100 ........................................ 22 TENORETIC 50 .......................................... 22 TENORMIN ................................................. 22 TERAZOL 3 ................................................ 48 TERAZOL 7 ................................................ 48 terazosin hcl ................................................ 18 terbinafine hcl ............................................. 10 terbutaline sulfate ....................................... 17 terconazole vaginal ..................................... 48 TESTIM GEL 1%(50MG) ............................ 38 testosterone cypionate ................................ 38 testosterone enanthate ............................... 38 TETANUS TOXOID ADSORBED ............... 46 TETANUS/DIPHTHERIA TOXOID S-

ADSORBED ADULT ............................... 46 TETRACYCLINE HCL ................................ 10 tetrahydrozoline hcl ..................................... 35 TEVETEN ................................................... 21 TEVETEN HCT ........................................... 21 TEV-TROPIN INJ 5MG ............................... 43 THALOMID ................................................. 45 theophylline................................................. 50 THIOLA ....................................................... 45 thioridazine hcl ............................................ 30 thiotepa ....................................................... 15 thiothixene .................................................. 30 THYMOGLOBULIN ..................................... 45 THYROLAR-1 ............................................. 43 THYROLAR-1/2 .......................................... 43 THYROLAR-1/4 .......................................... 43 THYROLAR-2 ............................................. 43 THYROLAR-3 ............................................. 43 tiagabine hcl ................................................ 26 TIAZAC ....................................................... 19 TICE BCG ................................................... 15


ticlopidine hcl .............................................. 18 TIGAN ........................................................ 36 TIKOSYN ................................................... 19 TIMENTIN .................................................. 10 timolol maleate ........................................... 22 timolol maleate (ophth) ............................... 35 TIMOPTIC OCUDOSE ............................... 35 TIMOPTIC-XE ............................................ 35 tinidazole .................................................... 11 TIROSINT................................................... 43 TIVICAY ..................................................... 12 tizanidine hcl ............................................... 16 TOBI ........................................................... 10 TOBI PODHALER ...................................... 10 TOBRADEX OIN 0.3-0.1% ......................... 34 TOBRADEX ST SUS 0.3-0.05 .................... 34 TOBRADEX SUS 0.3-0.1% ........................ 34 tobramycin .................................................. 10 tobramycin (ophth) ..................................... 33 tobramycin sulfate ...................................... 10 tobramycin sulfate in saline ........................ 10 tobramycin-dexamethasone ....................... 34 TOBREX OIN 0.3% OP .............................. 33 TOBREX SOL 0.3% OP ............................. 33 TOFRANIL-PM ........................................... 30 tolazamide .................................................. 41 tolbutamide ................................................. 41 tolmetin sodium .......................................... 24 tolterodine tartrate ...................................... 50 TOPAMAX .................................................. 26 TOPAMAX SPRINKLE ............................... 26 TOPICORT ................................................. 49 topiramate .................................................. 26 topotecan hcl .............................................. 15 TOPROL XL ............................................... 22 TORISEL .................................................... 15 torsemide ................................................... 32 TOVIAZ ...................................................... 50 TRACLEER ................................................ 46 TRADJENTA .............................................. 41 tramadol hcl ................................................ 24 tramadol-acetaminophen ............................ 24 trandolapril.................................................. 21 tranexamic acid .......................................... 18 TRANSDERM-SCOP ................................. 36 TRANXENE T ............................................. 28 tranylcypromine sulfate ............................... 30 TRAVATAN Z ............................................. 35 travoprost ................................................... 35 trazodone hcl tab 100mg ............................ 30

trazodone hcl tab 150mg ............................ 30 trazodone hcl tab 300mg ............................ 30 trazodone hcl tab 50mg .............................. 30 TREANDA................................................... 15 TRECATOR ................................................ 11 TRELSTAR DEPOT MIXJECT .................... 15 TRELSTAR LA MIXJECT ........................... 15 TRELSTAR MIXJECT ................................. 15 tretinoin ....................................................... 49 tretinoin (chemotherapy) ............................. 15 tretinoin w/ cleanser & moisturizer .............. 49 TREXIMET.................................................. 27 triamcinolone acetonide .............................. 38 triamcinolone acetonide (mouth) ................. 49 triamcinolone acetonide (nasal) .................. 35 triamcinolone acetonide (topical) ................ 49 triamterene/hydrochlorothiazide cap 37.5-25

................................................................ 32 triamterene/hydrochlorothiazide cap 50-25mg

................................................................ 32 triamterene/hydrochlorothiazide tab 37.5-25

................................................................ 32 triamterene/hydrochlorothiazide tab 75-50mg

................................................................ 32 triazolam ..................................................... 28 TRIBENZOR ............................................... 19 TRICOR ...................................................... 18 trifluoperazine hcl ........................................ 30 trifluridine .................................................... 33 TRIGLIDE ................................................... 18 trihexyphenidyl hcl ...................................... 27 TRILEPTAL ................................................. 26 TRILIPIX ..................................................... 19 trimethobenzamide hcl ................................ 36 trimethoprim ................................................ 13 TRINATAL RX 1 ......................................... 50 TRI-NORINYL 28 ........................................ 39 TRISENOX ................................................. 15 TRIUMEQ ................................................... 12 TRIZIVIR ..................................................... 12 TROKENDI XR ........................................... 26 TROPHAMINE INJ 10% ............................. 31 TROPHAMINE INJ 6% ............................... 31 trospium chloride ........................................ 50 TRUSOPT................................................... 35 TRUVADA................................................... 12 TUDORZA PRESSAIR ............................... 16 TWINJECT INJ 0.15MG .............................. 17 TWINJECT INJ 0.3MG ................................ 17 TWINRIX .................................................... 47


TWYNSTA .................................................. 19 TYGACIL .................................................... 10 TYKERB ..................................................... 15 TYPHIM VI ................................................. 47 TYSABRI .................................................... 45 TYVASO ..................................................... 46 TYZEKA ..................................................... 12

U UCERIS ...................................................... 38 ULESFIA .................................................... 48 ULORIC ...................................................... 45 ULTRACET ................................................ 24 ULTRAM .................................................... 24 ULTRAM ER ............................................... 24 ULTRAVATE .............................................. 49 ULTRESA CAP 13800UNT ........................ 37 ULTRESA CAP 20700UNT ........................ 37 ULTRESA CAP 23000UNT ........................ 37 UNASYN .................................................... 10 UNASYN BULK PACK ............................... 10 UNIRETIC .................................................. 21 UNIVASC ................................................... 21 urea-hc acetate .......................................... 49 UROCIT-K 10 TAB ..................................... 30 UROCIT-K 15 TAB ..................................... 30 UROCIT-K 5 TAB ....................................... 30 UROXATRAL ............................................. 17 URSO 250 .................................................. 37 URSO FORTE ............................................ 37 ursodiol ....................................................... 37 UVADEX .................................................... 50

V VAGIFEM ................................................... 41 valacyclovir hcl ........................................... 12 VALCHLOR ................................................ 50 VALCYTE SOL 50MG/ML .......................... 12 VALCYTE TAB 450MG .............................. 12 VALIUM ...................................................... 28 valproate sodium ........................................ 26 valproic acid ............................................... 26 valsartan-hydrochlorothiazide ..................... 21 VALSTAR ................................................... 15 VALTREX ................................................... 12 VANCOCIN HCL ........................................ 10 vancomycin hcl ........................................... 10 VANCOMYCIN HCL IN DEXTROSE .......... 10 VANOS ....................................................... 49

VANTAS ..................................................... 15 VAQTA ....................................................... 47 VARIVAX .................................................... 47 VASCEPA ................................................... 19 VASERETIC ............................................... 21 VASOTEC................................................... 21 VECTIBIX ................................................... 15 VECTICAL .................................................. 50 VELCADE ................................................... 15 VELPHORO ................................................ 32 VELTIN ....................................................... 50 venlafaxine hcl ............................................ 30 VENLAFAXINE HCL ER ............................. 30 VENTAVIS .................................................. 46 VENTOLIN HFA AER ................................. 17 VERAMYST ................................................ 35 verapamil hcl ............................................... 19 VEREGEN .................................................. 50 VERELAN ................................................... 19 VERELAN PM ............................................. 19 VERSACLOZ .............................................. 30 VESICARE.................................................. 50 VEXOL ........................................................ 35 VFEND IV INJ 200MG ................................ 10 VFEND SUS 40MG/ML ............................... 11 VFEND TAB 200MG ................................... 11 VFEND TAB 50MG ..................................... 11 VIBRAMYCIN ............................................. 10 VICOPROFEN ............................................ 24 VICTOZA .................................................... 41 VICTRELIS ................................................. 12 VIDAZA ....................................................... 15 VIDEX EC CAP 125MG .............................. 12 VIDEX EC CAP 200MG .............................. 12 VIDEX EC CAP 250MG .............................. 12 VIDEX EC CAP 400MG .............................. 12 VIDEX PEDIATRIC SOL 2GM .................... 12 VIGAMOX ................................................... 34 VIIBRYD ..................................................... 30 VIMIZIM ...................................................... 33 VIMOVO ..................................................... 24 VIMPAT ...................................................... 26 VINATE CALCIUM ...................................... 50 vinblastine sulfate ....................................... 15 vincristine sulfate ........................................ 15 vinorelbine tartrate ...................................... 15 VIOKACE TAB ............................................ 37 VIRACEPT .................................................. 12 VIRAMUNE ................................................. 12 VIRAMUNE XR ........................................... 12


VIRAZOLE.................................................. 13 VIREAD ...................................................... 13 VIROPTIC .................................................. 34 VISTARIL ................................................... 28 VISTIDE ..................................................... 13 VITASPIRE................................................. 50 VIVELLE-DOT DIS 0.025MG ..................... 41 VIVELLE-DOT DIS 0.0375MG.................... 41 VIVELLE-DOT DIS 0.05MG ....................... 41 VIVELLE-DOT DIS 0.075MG ..................... 42 VIVELLE-DOT DIS 0.1MG ......................... 42 VIVITROL ................................................... 28 VOGELXO GEL 1%(50MG) ....................... 38 VOLTAREN ................................................ 50 VOLTAREN-XR .......................................... 24 VORAXAZE ................................................ 45 voriconazole ............................................... 11 vospire er tab 4mg ...................................... 17 vospire er tab 8mg ...................................... 17 VOTRIENT ................................................. 15 VPRIV ........................................................ 33 VUMON ...................................................... 15 VYTORIN ................................................... 19 VYVANSE .................................................. 25

W warfarin sodium .......................................... 18 water for irrigation, sterile ........................... 32 WELCHOL.................................................. 19 WELLBUTRIN ............................................ 30 WELLBUTRIN SR ...................................... 30 WELLBUTRIN XL ....................................... 30

X XALATAN ................................................... 35 XALKORI .................................................... 15 XANAX ....................................................... 28 XANAX XR ................................................. 28 XARELTO................................................... 18 XARTEMIS XR ........................................... 24 XELJANZ ................................................... 45 XENAZINE ................................................. 28 XEOMIN ..................................................... 45 XERESE ..................................................... 48 XGEVA INJ................................................. 45 XIFAXAN .................................................... 10 XOLAIR ...................................................... 46 XOPENEX .................................................. 17 XOPENEX HFA .......................................... 17

XTANDI ...................................................... 15 XYLOCAINE ......................................... 45, 49 XYLOCAINE-MPF ...................................... 45 XYREM ....................................................... 28 XYZAL ........................................................ 13

Y YASMIN 28 ................................................. 39 YAZ ............................................................. 39 YERVOY ..................................................... 15 YF-VAX ....................................................... 47

Z zafirlukast.................................................... 45 zaleplon ...................................................... 28 ZALTRAP.................................................... 15 ZANAFLEX ................................................. 16 ZANOSAR .................................................. 15 ZANTAC ..................................................... 37 ZANTAC INJ ............................................... 37 ZARONTIN ................................................. 26 ZAROXOLYN .............................................. 32 ZAVESCA ................................................... 45 ZEBETA ...................................................... 22 ZEGERID .................................................... 37 ZELAPAR ................................................... 27 ZELBORAF ................................................. 15 ZEMAIRA .................................................... 46 ZEMPLAR ................................................... 50 ZENPEP CAP 10000UNT ........................... 37 ZENPEP CAP 15000UNT ........................... 37 ZENPEP CAP 20000UNT ........................... 37 ZENPEP CAP 25000UNT ........................... 37 ZENPEP CAP 3000UNIT ............................ 37 ZENPEP CAP 5000UNIT ............................ 37 ZERIT ......................................................... 13 ZESTORETIC ............................................. 21 ZESTRIL ..................................................... 21 ZETIA ......................................................... 19 ZETONNA................................................... 35 ZIAC ........................................................... 22 ZIAGEN SOL 20MG/ML .............................. 13 ZIAGEN TAB 300MG .................................. 13 ZIANA ......................................................... 50 zidovudine................................................... 13 ZINACEF IN ISO-OSMOTIC DEXTROSE .. 10 ZINACEF IN ISO-OSMOTIC DILUENT ....... 10 ZINACEF INJ 1.5GM .................................. 10 ZINACEF INJ 7.5GM .................................. 10


ZINACEF INJ 750MG ................................. 10 ZINC TRACE METAL ................................. 33 ZINECARD ................................................. 45 ZIOPTAN .................................................... 35 ziprasidone hcl ........................................... 30 ZIPSOR ...................................................... 24 ZIRGAN ...................................................... 34 ZITHROMAX INJ 500MG ........................... 10 ZITHROMAX POW 1GM PAK .................... 10 ZITHROMAX SUS 100/5ML ....................... 10 ZITHROMAX SUS 200/5ML ....................... 10 ZITHROMAX TAB 250MG .......................... 10 ZITHROMAX TAB 500MG .......................... 10 ZITHROMAX TAB 600MG .......................... 10 ZITHROMAX TRI-PAK TAB TRI-PAK ........ 10 ZITHROMAX Z-PAK TAB Z-PAK ............... 10 ZMAX SUS 2GM ........................................ 10 ZOCOR ...................................................... 19 ZOFRAN .................................................... 36 ZOFRAN ODT ............................................ 36 ZOHYDRO ER ........................................... 24 zoledronic acid ........................................... 45 ZOLINZA .................................................... 15 zolmitriptan ................................................. 27 ZOLOFT ..................................................... 30 zolpidem tartrate ......................................... 28 ZOLPIMIST ................................................ 28 ZOMETA .................................................... 45 ZOMIG ....................................................... 27

ZOMIG NASAL SPRAY .............................. 27 ZOMIG ZMT ................................................ 27 ZONALON .................................................. 49 ZONEGRAN ............................................... 26 zonisamide.................................................. 26 ZONTIVITY ................................................. 18 ZORBTIVE .................................................. 43 ZORTRESS TAB 0.25MG ........................... 45 ZORTRESS TAB 0.5MG ............................. 45 ZORTRESS TAB 0.75MG ........................... 45 ZORVOLEX ................................................ 24 ZOSTAVAX ................................................. 47 ZOSYN ....................................................... 10 ZOVIRAX .............................................. 13, 48 ZUBSOLV ................................................... 24 ZYBAN ........................................................ 30 ZYCLARA ................................................... 50 ZYCLARA PUMP ........................................ 50 ZYDELIG .................................................... 15 ZYFLO CR TAB 600MG ............................. 45 ZYFLO TAB 600MG.................................... 45 ZYKADIA .................................................... 15 ZYLET ........................................................ 35 ZYLOPRIM ................................................. 45 ZYMAXID .................................................... 34 ZYPREXA ................................................... 30 ZYPREXA ZYDIS ....................................... 30 ZYTIGA ....................................................... 15 ZYVOX ....................................................... 10


This formulary was updated on 10/01/14. For more recent information or other questions, please contact the number for your Kaiser Permanente Region listed below, seven days a week, 8 a.m. to 8 p.m., or visit kp.org/seniormedrx.

Kaiser Permanente Regions

CALIFORNIA REGIONS Kaiser Foundation Health Plan, Inc. 393 E. Walnut St. Pasadena, CA 91188-8514 Kaiser Permanente Senior Advantage (HMO) and Senior Advantage Medicare Medi-Cal Plan (HMO SNP)

Member Service Contact Center 1-800-443-0815 TTY 711

COLORADO REGION Kaiser Foundation Health Plan of Colorado 2500 S. Havana Street Aurora, CO 80014-1622 Kaiser Permanente Senior Advantage (HMO) and Senior Advantage Medicare Medicaid Plan (HMO SNP)

Member Services 1-800-476-2167 TTY 711

GEORGIA REGION Kaiser Foundation Health Plan of Georgia, Inc. Nine Piedmont Center 3495 Piedmont Road NE Atlanta, GA 30305 Kaiser Permanente Senior Advantage (HMO) and Senior Advantage Medicare Medicaid Plan (HMO SNP)


kp.org/seniormedrx Please recycle

HAWAII REGION Kaiser Foundation Health Plan, Inc. 711 Kapiolani Blvd. Tower Suite 400 Honolulu, HI 96813 Kaiser Permanente Senior Advantage (HMO)

Customer Service Center 1-800-805-2739 TTY 711

MID-ATLANTIC STATES REGION (District of Columbia, Maryland, and Virginia) Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 2101 East Jefferson Street Rockville, MD 20852 Kaiser Permanente Medicare Plus (Cost)


NORTHWEST REGION Kaiser Foundation Health Plan of the Northwest 500 NE Multnomah Street, Suite 100 Portland, OR 97232 Kaiser Permanente Senior Advantage (HMO)

Membership Services 1-877-221-8221 TTY 711

60215409 09/2014

2015 comprehensive formulary - kaiser...

Documents