2016 601 4t copper comm eff 01/01/2016 · 2015-09-22 · 2016 601 4t copper comm eff 01/01/2016 pa...

2016 601 4T Copper Comm eff 01/01/2016

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access

1

Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol tab (generic of ZYLOPRIM)

1

ALOPRIM 3

colchicine w/ probenecid 1

COLCRYS QL (120 tabs / 30 days)

2 QL

probenecid 1

ULORIC 2 ST

ZYLOPRIM 3

MISCELLANEOUS ARTHROTEC 50 3

ARTHROTEC 75 3

diclofenac w/ misoprostol (generic of ARTHROTEC 50)

1

diclofenac w/ misoprostol (generic of ARTHROTEC 75)

1

DUEXIS 4 NM

VIMOVO 4 NM

NSAIDS ANAPROX 2

ANAPROX DS 2

CELEBREX CAP 50MG 3

CELEBREX CAP 100MG 3



celecoxib (generic of CELEBREX) CAPS

1

DAYPRO 2

diclofenac potassium 1

diclofenac sodium TB24; TBEC

1

diflunisal 1

EC-NAPROSYN 3

etodolac 1

etodolac er 1

FELDENE 3

fenoprofen calcium TABS 1

flurbiprofen TABS 1

ibuprofen SUSP 1

ibuprofen TABS 400mg, 600mg, 800mg

1

ketoprofen CAPS; CP24 1

Drug Name Drug Tier

Requirements/Limits

mefenamic acid (generic of PONSTEL) CAPS

1

MELOXICAM SUSP 1

meloxicam tabs (generic of MOBIC)

1

MOBIC 2

nabumetone TABS 1

NAPRELAN 4 NM

NAPROSYN TABS 2

naproxen SUSP 1

naproxen (generic of NAPROSYN) TABS

1

naproxen (generic of EC-NAPROSYN) TBEC

1

naproxen sodium (generic of ANAPROX) TABS 275mg

1

naproxen sodium (generic of ANAPROX DS) TABS 550mg

1

NAPROXEN SODIUM TB24 4 NM

oxaprozin (generic of DAYPRO)

1

piroxicam (generic of FELDENE) CAPS

1

PONSTEL 4 NM

sulindac TABS 1

tolmetin sodium 1

VOLTAREN-XR 3

ZIPSOR 3

ZORVOLEX 3

OPIOID ANALGESICS acetaminophen w/ codeine SOLN

QL (5000 mL / 30 days)

1 QL

acetaminophen w/ codeine TABS

QL (400 tabs / 30 days)

1 QL

acetaminophen w/ codeine (generic of TYLENOL/CODEINE #3) TABS


1 QL

acetaminophen w/ codeine (generic of TYLENOL/CODEINE #4) TABS


1 QL

2016 601 4T Copper Comm eff 01/01/2016


2

Drug Name Drug Tier

Requirements/Limits

ASPIRIN-CAFFEINE-DIHYDROCODEINE BITARTRATE

QL (360 caps / 30 days)

1 QL

butorphanol nasal spray QL (10 mL / 30 days)

1 QL

butorphanol tartrate SOLN 1

BUTRANS 5mcg/hr QL (16 patches / 28 days)

2 QL

BUTRANS 7.5mcg/hr, 10mcg/hr

QL (8 patches / 28 days)

2 QL

BUTRANS 15mcg/hr, 20mcg/hr


2 QL

capital and codeine QL (5000 mL / 30 days)

3 QL

CONZIP 100mg QL (90 caps / 30 days)

3 QL


3 QL


3 QL

nalbuphine hcl (generic of NUBAIN) SOLN 10mg/ml

1

nalbuphine hcl SOLN 20mg/ml

1

SYNALGOS-DC QL (360 caps / 30 days)

3 QL

TRAMADOL HCL CP24 100mg


1 QL



1 QL



1 QL

tramadol hcl er (generic of ULTRAM ER) TB24 100mg


1 QL

tramadol hcl er (generic of ULTRAM ER) TB24 200mg


1 QL

TRAMADOL HCL ER TB24 300mg


1 QL

Drug Name Drug Tier

Requirements/Limits

tramadol hcl er (biphasic) 100mg


1 QL



1 QL



1 QL

tramadol hcl tab 50 mg (generic of ULTRAM)


1 QL

tramadol-acetaminophen (generic of ULTRACET)


1 QL

trezix QL (360 caps / 30 days)

3 QL

tylenol with codeine QL (400 tabs / 30 days)

3 QL

ULTRACET QL (240 tabs / 30 days)

3 QL

ULTRAM QL (240 tabs / 30 days)

2 QL

ULTRAM ER 100mg QL (90 tabs / 30 days)

3 QL

ULTRAM ER 200mg, 300mg QL (30 tabs / 30 days)

3 QL

OPIOID ANALGESICS, CII ABSTRAL

QL (120 tabs / 30 days) 4 QL NM PA

ACTIQ QL (120 lozenges / 30 days)

4 QL NM PA

CODEINE SULFATE 15mg QL (720 tabs / 30 days)

1 QL


1 QL


1 QL

DILAUDID INJ 3 B/D

DILAUDID TAB QL (270 tabs / 30 days)

3 QL

DILAUDID-5 ORAL LIQD 3

DILAUDID-HP INJ 10MG/ML 3 B/D

DILAUDID-HP INJ 250MG 3 B/D

DOLOPHINE QL (240 tabs / 30 days)

3 QL

2016 601 4T Copper Comm eff 01/01/2016


3

Drug Name Drug Tier

Requirements/Limits

DURAGESIC 12mcg/hr, 25mcg/hr


3 QL

DURAGESIC 50mcg/hr, 75mcg/hr, 100mcg/hr


4 QL NM

DURAMORPH 1 B/D

EMBEDA QL (60 caps / 30 days)

3 QL

endocet (generic of PERCOCET)


1 QL

ENDODAN TAB QL (360 tabs / 30 days)

1 QL

EXALGO 8mg, 12mg QL (60 tabs / 30 days)

3 QL

EXALGO 16mg, 32mg QL (60 tabs / 30 days)

4 QL NM

fentanyl citrate (generic of ACTIQ) LPOP

QL (120 lozenges / 30 days)

4 QL NM PA

fentanyl patch 12 mcg/hr (generic of DURAGESIC)


1 QL



1 QL



1 QL



1 QL



1 QL

FENTORA QL (120 tabs / 30 days)

4 QL NM PA

hycet QL (5400 mL / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

hydrocodone-acetaminophen 2.5-325mg


1 QL

hydrocodone-acetaminophen 5-300mg (generic of XODOL)


1 QL

hydrocodone-acetaminophen 5-325mg (generic of NORCO)


1 QL

hydrocodone-acetaminophen 7.5-300mg (generic of XODOL)


1 QL

hydrocodone-acetaminophen 7.5-325 mg/15ml (generic of HYCET)

QL (5400 mL / 30 days)

1 QL

hydrocodone-acetaminophen 7.5-325mg (generic of NORCO)


1 QL

hydrocodone-acetaminophen 10-300mg (generic of XODOL)


1 QL

hydrocodone-acetaminophen tab 10-325mg (generic of NORCO)


1 QL

hydrocodone-ibuprofen tab 2.5-200mg (generic of REPREXAIN)


1 QL

hydrocodone-ibuprofen tab 7.5-200 mg (generic of VICOPROFEN)


1 QL

hydromorphone hcl (generic of DILAUDID) LIQD

1

HYDROMORPHONE HCL SOLN 1mg/ml

1 B/D

HYDROMORPHONE HCL SOLN 2mg/ml, 4mg/ml

1 B/D

hydromorphone hcl (generic of DILAUDID-HP) SOLN 500mg/50ml

1 B/D

hydromorphone hcl (generic of DILAUDID) TABS


1 QL

2016 601 4T Copper Comm eff 01/01/2016


4

Drug Name Drug Tier

Requirements/Limits

hydromorphone tab 8mg er (generic of EXALGO)


1 QL



1 QL



4 QL NM

HYDROMORPHONE TABS 32MG


4 QL NM

HYSINGLA ER 20mg, 30mg, 40mg, 60mg


3 QL

HYSINGLA ER 80mg, 100mg, 120mg


4 QL NM

ibudone tab 5-200mg (generic of REPREXAIN)


1 QL

ibudone tab 10-200mg QL (150 tabs / 30 days)

1 QL

INFUMORPH 200 3 B/D

INFUMORPH 500 3 B/D

KADIAN 10mg, 20mg, 30mg QL (60 caps / 30 days)

3 QL

KADIAN 40mg, 50mg, 60mg, 80mg, 100mg, 200mg


4 QL NM

LAZANDA QL (30 bottles / 30 days)

4 QL NM PA

levorphanol tartrate TABS QL (180 tabs / 30 days)

1 QL

lorcet hd tab 10-325mg (generic of NORCO)


1 QL

lorcet plus tab 7.5-325 (generic of NORCO)


1 QL

lorcet tab 5-325mg (generic of NORCO)


1 QL

lortab tab 5-325mg (generic of NORCO)


1 QL

Drug Name Drug Tier

Requirements/Limits

lortab tab 7.5-325 (generic of NORCO)


1 QL

lortab tab 10-325mg (generic of NORCO)


1 QL

methadone hcl (generic of METHADOSE) CONC

QL (120 mL / 30 days)

1 QL

methadone hcl SOLN QL (600 mL / 30 days)

1 QL

methadone hcl (generic of DOLOPHINE HCL) TABS 5mg


1 QL

methadone hcl (generic of DOLOPHINE) TABS 10mg


1 QL

METHADONE INJ 10MG/ML 3

METHADOSE CONC QL (120 mL / 30 days)

3 QL

MORPHINE SUL 20MG/ML ORAL SOL

1

morphine sulfate (generic of KADIAN) CP24 10mg, 20mg, 30mg, 50mg, 60mg


1 QL

morphine sulfate (generic of KADIAN) CP24 80mg, 100mg


4 QL NM

MORPHINE SULFATE SOLN 1mg/ml, 10mg/ml, 15mg/ml

1 B/D

MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 8mg/ml

3 B/D

MORPHINE SULFATE SOLN 10mg/5ml, 20mg/5ml

1

morphine sulfate SOLN .5mg/ml, 1mg/ml

1 B/D

MORPHINE SULFATE TABS


1 QL

morphine sulfate beads QL (60 caps / 30 days)

1 QL

2016 601 4T Copper Comm eff 01/01/2016


5

Drug Name Drug Tier

Requirements/Limits

morphine sulfate ext-rel tab (generic of MS CONTIN) 15mg, 30mg, 60mg, 100mg


1 QL

morphine sulfate ext-rel tab (generic of MS CONTIN) 200mg


1 QL

MS CONTIN 15mg, 30mg QL (90 tabs / 30 days)

3 QL

MS CONTIN 60mg, 100mg QL (90 tabs / 30 days)

4 QL NM

MS CONTIN 200mg QL (60 tabs / 30 days)

4 QL NM

norco QL (360 tabs / 30 days)

3 QL

NUCYNTA 50mg QL (360 tabs / 30 days)

2 QL


2 QL


2 QL

NUCYNTA ER 50mg, 100mg


2 QL

NUCYNTA ER 150mg, 200mg, 250mg


2 QL

OPANA TABS QL (180 tabs / 30 days)

3 QL

OPANA ER (CRUSH RESISTANT


2 QL

oxycodone hcl CAPS QL (180 caps / 30 days)

1 QL

oxycodone hcl CONC 1

OXYCODONE HCL SOLN 1

oxycodone hcl (generic of ROXICODONE) TABS 5mg, 15mg, 30mg


1 QL

oxycodone hcl TABS 10mg, 20mg


1 QL

oxycodone w/ acetaminophen 2.5-325mg (generic of PERCOCET)


1 QL

Drug Name Drug Tier

Requirements/Limits

oxycodone w/ acetaminophen 5-325mg (generic of PERCOCET)


1 QL

oxycodone w/ acetaminophen 7.5-325mg (generic of PERCOCET)


1 QL

oxycodone w/ acetaminophen 10-325mg (generic of PERCOCET)


1 QL

oxycodone-aspirin (generic of PERCODAN)


1 QL

oxycodone-ibuprofen QL (28 tabs / 30 days)

1 QL

OXYCONTIN QL (120 tabs / 30 days)

2 QL

oxymorphone hcl (generic of OPANA) TABS


1 QL

percocet 2.5/325 QL (360 tabs / 30 days)

3 QL

percocet 7.5/325 QL (360 tabs / 30 days)

4 QL NM

percocet 10/325 QL (360 tabs / 30 days)

4 QL NM

percocet tab 5-325mg QL (360 tabs / 30 days)

4 QL NM

PERCODAN QL (360 tabs / 30 days)

3 QL

reprexain tab 2.5-200mg QL (150 tabs / 30 days)

3 QL

reprexain tab 5-200mg QL (150 tabs / 30 days)

3 QL

reprexain tab 10-200mg QL (150 tabs / 30 days)

1 QL

roxicet soln QL (1800 mL / 30 days)

2 QL

roxicet tab 5-325mg (generic of PERCOCET)


1 QL

ROXICODONE 5mg, 15mg QL (180 tabs / 30 days)

3 QL

ROXICODONE 30mg QL (180 tabs / 30 days)

4 QL NM

2016 601 4T Copper Comm eff 01/01/2016


6

Drug Name Drug Tier

Requirements/Limits

SUBSYS QL (120 sprays / 30 days)

4 QL NM PA

vicodin (generic of XODOL) QL (400 tabs / 30 days)

1 QL

vicodin es (generic of XODOL)


1 QL

vicodin hp (generic of XODOL)


1 QL

VICOPROFEN QL (150 tabs / 30 days)

3 QL

XARTEMIS XR QL (120 tabs / 30 days)

3 QL

xodol tab 5-300mg QL (400 tabs / 30 days)

3 QL

xodol tab 7.5-300 QL (400 tabs / 30 days)

3 QL

xodol tab 10-300mg QL (400 tabs / 30 days)

4 QL NM

zamicet QL (5400 mL / 30 days)

1 QL

ZOHYDRO ER (ABUSE DETERRENT) 10mg, 15mg, 20mg


3 QL

ZOHYDRO ER (ABUSE DETERRENT) 30mg, 40mg, 50mg


3 QL

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) (generic of XYLOCAINE-MPF) 1%

1 B/D

lidocaine hcl (local anesth.) (generic of XYLOCAINE-MPF) 4%

1

lidocaine hcl (local anesth.) (generic of XYLOCAINE) .5%

1 B/D

lidocaine inj 0.5% (generic of XYLOCAINE-MPF)

1 B/D

lidocaine inj 1% (generic of XYLOCAINE)

1 B/D

lidocaine inj 1.5% (generic of XYLOCAINE-MPF)

1 B/D

Drug Name Drug Tier

Requirements/Limits

lidocaine inj 2% (generic of XYLOCAINE) 2%

1 B/D

lidocaine inj 2% (generic of XYLOCAINE-MPF) 2%

1 B/D

XYLOCAINE .5%, 1%, 2% 3 B/D

XYLOCAINE-MPF 4% 3

XYLOCAINE-MPF .5%, 1%, 1.5%, 2%

3 B/D

ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 1

BETHKIS 4 B/D NM

gentamicin in saline 0.8 mg/ml 1

gentamicin in saline 0.9mg/ml 3

gentamicin in saline 1 mg/ml 1


gentamicin in saline 1.4mg/ml 3


gentamicin in saline 2 mg/ml 1

gentamicin sulfate SOLN 1

neomycin sulfate TABS 1

paromomycin sulfate CAPS 1

streptomycin sulfate SOLR 1

sulfadiazine TABS 3

TOBI NEB 4 B/D NM

TOBI PODHALER 4 NM LA PA

tobramycin (generic of TOBI) NEBU

4 B/D NM

tobramycin sulfate SOLN; SOLR

1

tobramycin sulfate in saline 3

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 2

ALINIA 2

atovaquone (generic of MEPRON) SUSP

4 NM

AZACTAM 1gm 3

AZACTAM 2gm 4 NM

AZACTAM/DEX INJ 1GM 3

AZACTAM/DEX INJ 2GM 4 NM

aztreonam (generic of AZACTAM)

1

BACTRIM 2

BACTRIM DS 2

BILTRICIDE 2

2016 601 4T Copper Comm eff 01/01/2016


7

Drug Name Drug Tier

Requirements/Limits

CAYSTON 4 NM LA PA

cleocin SOLR 2

CLEOCIN CAP 75MG 2

CLEOCIN CAP 150MG 2

CLEOCIN CAP 300MG 2

CLEOCIN IN D5W 3

CLEOCIN INJ 3

CLEOCIN PHOSPHATE 9gm/60ml, 300mg/2ml, 600mg/4ml, 900mg/6ml

3

cleocin phosphate 150mg/ml, 600mg/4ml

3

clindamycin hcl (generic of CLEOCIN) CAPS

1

clindamycin palmitate hydrochloride (generic of CLEOCIN PEDIATRIC GRANULE)

1

clindamycin phosphate SOLN 150mg/ml

1

clindamycin phosphate (generic of CLEOCIN PHOSPHATE) SOLN 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml, 9000mg/60ml

1

clindamycin phosphate in d5w (generic of CLEOCIN IN D5W)

1

colistimethate sodium (generic of COLY-MYCIN M) SOLR

1

COLY-MYCIN M 3

CUBICIN 4 NM

DALVANCE 4 NM

dapsone TABS 1

DARAPRIM 3

DORIBAX 3

FLAGYL 3

FLAGYL ER 3

FURADANTIN 90 day limit per calendar year if 65 years and older

4 NM PA

HIPREX 3

imipenem-cilastatin (generic of PRIMAXIN IV)

1

INVANZ 3

Drug Name Drug Tier

Requirements/Limits

ivermectin (generic of STROMECTOL) TABS

1

linezolid (generic of ZYVOX) SOLN

4 NM

LINEZOLID TABS 4 NM

MACROBID 90 day limit per calendar year if 65 years and older

3 PA

MACRODANTIN 90 day limit per calendar year if 65 years and older

3 PA

MEPRON 4 NM

meropenem (generic of MERREM)

1

MERREM 3

methenamine hippurate (generic of HIPREX)

1

METRO IV 3

metronidazole (generic of FLAGYL) CAPS; TABS

1

metronidazole inj 1

NEBUPENT 3 B/D

nitrofurantoin (generic of FURADANTIN) SUSP

90 day limit per calendar year if 65 years and older

1 PA

nitrofurantoin macrocrystal (generic of MACRODANTIN)


3 PA

nitrofurantoin monohyd macro (generic of MACROBID)


3 PA

PENTAM 300 3

polymyxin b sulfate SOLR 1

PRIMAXIN 3

PRIMSOL SOL 50MG/5ML 3

SIVEXTRO 4 NM

STROMECTOL 3

sulfamethoxazole-trimethop SUSP

1

sulfamethoxazole-trimethop (generic of BACTRIM) TABS

1

sulfamethoxazole-trimethop (generic of BACTRIM DS) TABS

1

2016 601 4T Copper Comm eff 01/01/2016


8

Drug Name Drug Tier

Requirements/Limits

sulfamethoxazole-trimethoprim inj

1

SYNERCID 4 NM

trimethoprim TABS 1

TYGACIL 4 NM

VANCOCIN HCL 4 NM

vancomycin hcl (generic of VANCOCIN HCL) CAPS

4 NM

vancomycin hcl inj 5gm 1

vancomycin hcl inj 10gm 1

vancomycin hcl inj 500mg 1



XIFAXAN TAB 200MG 4 NM

ZYVOX 4 NM

ANTIFUNGALS ABELCET 4 B/D NM

AMBISOME 4 B/D NM

AMPHOTEC 3 B/D

amphotericin b SOLR 1 B/D

ANCOBON 4 NM

CANCIDAS 4 NM

CRESEMBA 4 NM

DIFLUCAN 3

ERAXIS 4 NM

fluconazole (generic of DIFLUCAN) SUSR; TABS

1

fluconazole in dextrose 1

fluconazole in nacl 1

flucytosine (generic of ANCOBON) CAPS

4 NM

GRIS-PEG 2

griseofulvin microsize SUSP 1

griseofulvin microsize (generic of GRIFULVIN V) TABS

1

griseofulvin ultramicrosize (generic of GRIS-PEG)

1

itraconazole (generic of SPORANOX) CAPS

1 PA

ketoconazole TABS 1 PA

LAMISIL PACK 3

LAMISIL TABS QL (90 tabs / 365 days)

3 QL

MYCAMINE 4 NM

NOXAFIL 4 NM

nystatin TABS 1

Drug Name Drug Tier

Requirements/Limits

ONMEL 4 NM PA

SPORANOX 4 NM PA

SPORANOX PULSEPAK 4 NM PA

SPORANOX SOL 10MG/ML 4 NM

terbinafine hcl (generic of LAMISIL) TABS


1 QL

VFEND IV 3

VFEND SUS 40MG/ML 4 NM

VFEND TAB 4 NM

voriconazole (generic of VFEND) SUSR; TABS

4 NM

voriconazole inj 200mg (generic of VFEND IV)

1

ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg (generic of MALARONE)

1

atovaquone-proguanil hcl tab 250-100 mg (generic of MALARONE)

1

chloroquine phosphate TABS 250mg

1

chloroquine phosphate (generic of ARALEN) TABS 500mg

1

COARTEM 2

MALARONE 2

mefloquine hcl 1

PRIMAQUINE PHOSPHATE 3

QUALAQUIN 3 PA

quinine sulfate (generic of QUALAQUIN) CAPS

1 PA

ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN)

1

APTIVUS 4 NM

CRIXIVAN 3

didanosine (generic of VIDEX EC)

1

EDURANT 4 NM

EMTRIVA 2

EPIVIR SOL 10MG/ML 3

EPIVIR TABS 3

FUZEON 4 NM

INTELENCE 25mg 2

2016 601 4T Copper Comm eff 01/01/2016


9

Drug Name Drug Tier

Requirements/Limits

INTELENCE 100mg, 200mg 4 NM

INVIRASE 4 NM

ISENTRESS CHEW 25mg 2

ISENTRESS CHEW 100mg 4 NM

ISENTRESS PACK 2

ISENTRESS TABS 4 NM

lamivudine (generic of EPIVIR)

1

LEXIVA SUSP 3

LEXIVA TABS 4 NM

NEVIRAPINE SUSP 1

nevirapine (generic of VIRAMUNE) TABS

1

nevirapine (generic of VIRAMUNE XR) TB24

1

NORVIR 2

PREZISTA SUSP 4 NM

PREZISTA TABS 75mg, 150mg

2

PREZISTA TABS 600mg, 800mg

4 NM

RESCRIPTOR 2

RETROVIR CAPS 2

RETROVIR IV INFUSION 3

RETROVIR SYRP 2

REYATAZ 4 NM

SELZENTRY 4 NM

stavudine (generic of ZERIT) 1

SUSTIVA CAPS 2

SUSTIVA TABS 4 NM

TIVICAY 4 NM

TYBOST 2

VIDEX EC 2

VIDEX PEDIATRIC 3

VIRACEPT 4 NM

VIRAMUNE SUSP 2

VIRAMUNE TABS 4 NM

VIRAMUNE XR 100mg 2

VIRAMUNE XR 400mg 4 NM

VIREAD 4 NM

VITEKTA 4 NM

ZERIT CAPS 2

ZERIT SOLR 4 NM

ZIAGEN SOLN 2

ZIAGEN TABS 3

Drug Name Drug Tier

Requirements/Limits

zidovudine (generic of RETROVIR) CAPS; SYRP

1

zidovudine TABS 1

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine (generic of TRIZIVIR)

4 NM

ATRIPLA 4 NM

COMBIVIR 4 NM

COMPLERA 4 NM

EPZICOM 4 NM

EVOTAZ 4 NM

KALETRA SOL 4 NM

KALETRA TAB 100-25MG 2

KALETRA TAB 200-50MG 4 NM

lamivudine-zidovudine (generic of COMBIVIR)

4 NM

PREZCOBIX 4 NM

STRIBILD 4 NM

TRIUMEQ 4 NM

TRIZIVIR 4 NM

TRUVADA QL (30 tabs / 30 days)

4 QL NM

ANTITUBERCULAR AGENTS CAPASTAT SULFATE 3

cycloserine CAPS 4 NM

ethambutol hcl (generic of MYAMBUTOL) TABS

1

isoniazid SOLN; SYRP 1

isoniazid tabs 1

MYAMBUTOL 2

MYCOBUTIN 3

paser d/r 3

PRIFTIN 3

pyrazinamide 1

rifabutin (generic of MYCOBUTIN)

1

rifadin CAPS 150mg 2

RIFADIN CAPS 300mg 2

RIFADIN SOLR 3

rifamate 3

rifampin (generic of RIFADIN) CAPS; SOLR

1

RIFATER 3

SIRTURO 4 NM LA PA

2016 601 4T Copper Comm eff 01/01/2016


10

Drug Name Drug Tier

Requirements/Limits

TRECATOR 3

ANTIVIRALS acyclovir (generic of ZOVIRAX) CAPS; SUSP; TABS

1

acyclovir sodium SOLN 1 B/D

acyclovir sodium SOLR 500mg

1 B/D

adefovir dipivoxil (generic of HEPSERA)

4 NM

BARACLUDE SOLN 2

BARACLUDE TABS 4 NM

cidofovir (generic of VISTIDE) 4 NM

COPEGUS 4 NM

CYTOVENE 3 B/D

entecavir (generic of BARACLUDE)

4 NM

EPIVIR HBV 2

famciclovir (generic of FAMVIR) TABS

1

FAMVIR 3

FLUMADINE 3

foscarnet sodium 1

ganciclovir inj 500mg (generic of CYTOVENE)

1 B/D

HARVONI 4 NM PA

HEPSERA 4 NM

lamivudine (hbv) (generic of EPIVIR HBV)

1

moderiba pak MISC 4 NM

moderiba pak TABS 400mg 4 NM

MODERIBA PAK TABS 600mg

4 NM

moderiba tab 200mg (generic of COPEGUS)

1 NM

PEG-INTRON 4 NM PA

PEG-INTRON REDIPEN 4 NM PA

PEGINTRON 80mcg/0.5ml, 120mcg/0.5ml, 150mcg/0.5ml

4 NM PA

REBETOL 4 NM

RELENZA DISKHALER 2

ribapak mis 600/day 4 NM

ribasphere (generic of REBETOL) CAPS

1 NM

ribasphere (generic of COPEGUS) TABS 200mg

1 NM

ribasphere TABS 400mg 1 NM

Drug Name Drug Tier

Requirements/Limits

ribasphere TABS 600mg 4 NM

ribasphere ribapak 800 4 NM



ribavirin 200mg (generic of REBETOL) CAPS

1 NM

ribavirin 200mg (generic of COPEGUS) TABS

1 NM

rimantadine hydrochloride (generic of FLUMADINE)

1

SOVALDI 4 NM PA

TAMIFLU 2

TYZEKA 4 NM

valacyclovir hcl (generic of VALTREX) TABS

1

VALCYTE 4 NM

valganciclovir hcl (generic of VALCYTE)

4 NM

VALTREX 3

ZOVIRAX CAPS; SUSP 3

CEPHALOSPORINS AVYCAZ 4 NM

CEDAX 3

cefaclor 1

cefaclor er tab 500mg 3

cefadroxil 1

cefazolin inj 1

cefazolin sodium 1gm, 20gm 1

cefazolin/dextrose 3

cefdinir 1

CEFEPIME 1GM SOLN 3

CEFEPIME 2GM SOLN 3

CEFEPIME HCL AND DEXTROSE

3

cefepime inj 1gm (generic of MAXIPIME)

1

cefepime inj 2gm (generic of MAXIPIME)

1

cefixime (generic of SUPRAX) 1

cefotaxime sodium (generic of CLAFORAN) 1gm, 2gm, 500mg

1

cefotetan disodium 3

cefoxitin sodium 1

CEFOXITIN SODIUM IN DEXTROSE

3

2016 601 4T Copper Comm eff 01/01/2016


11

Drug Name Drug Tier

Requirements/Limits

cefpodoxime proxetil 1

cefprozil 1

ceftazidime (generic of FORTAZ) 1gm, 2gm, 6gm

1

CEFTAZIDIME/DEXTROSE 3

CEFTIBUTEN 1

CEFTIN 3

ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg

1

ceftriaxone sodium (generic of ROCEPHIN) SOLR 1gm, 500mg

1

cefuroxime axetil SUSR 1

cefuroxime axetil (generic of CEFTIN) TABS

1

cefuroxime sodium (generic of ZINACEF) 1.5gm, 7.5gm, 750mg

1

cefuroxime sodium 7.5gm 3

cephalexin (generic of KEFLEX) CAPS

1

cephalexin SUSR; TABS 1

claforan 1gm, 2gm 3

CLAFORAN 1gm, 2gm, 10gm, 500mg

3

FORTAZ 3

KEFLEX 3

MAXIPIME 3

rocephin 3

SUPRAX CAPS 2

suprax CHEW 2

suprax SUSR 100mg/5ml, 200mg/5ml

2

SUPRAX SUSR 500mg/5ml 2

tazicef (generic of FORTAZ) SOLR

1

tazicef vial (generic of FORTAZ)

1

TEFLARO 3

ZERBAXA 4 NM

ZINACEF SOLR 3

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 1

azithromycin (generic of ZITHROMAX) SOLR 500mg

1

Drug Name Drug Tier

Requirements/Limits

azithromycin (generic of ZITHROMAX) SUSR

1

azithromycin (generic of ZITHROMAX) TABS

1

BIAXIN 3

clarithromycin SUSR 125mg/5ml

1

clarithromycin (generic of BIAXIN) SUSR 250mg/5ml

1

clarithromycin (generic of BIAXIN) TABS

1

clarithromycin (generic of BIAXIN XL) TB24

1

DIFICID 4 NM

e.e.s. 400 tab 400mg 1

E.E.S. GRANULES 3

ery-tab 3

ERYPED 200 3

ERYPED 400 3

erythrocin lactobionate 500mg

3

erythrocin stearate 1

erythromycin base 1

erythromycin cap 250mg ec 1

erythromycin ethylsuccinate 1

PCE 3

ZITHROMAX 3

ZITHROMAX TRI-PAK 3

ZITHROMAX Z-PAK 3

ZMAX 3

FLUOROQUINOLONES AVELOX 3

AVELOX ABC PACK 3

CIPRO SUSP 3

CIPRO TABS 3

CIPRO XR 3

ciprofloxacin SOLN 200mg/20ml

1

ciprofloxacin (generic of CIPRO) SUSR

1

ciprofloxacin er (generic of CIPRO XR)

1

ciprofloxacin hcl TABS 100mg, 750mg

1

2016 601 4T Copper Comm eff 01/01/2016


12

Drug Name Drug Tier

Requirements/Limits

ciprofloxacin hcl (generic of CIPRO) TABS 250mg, 500mg

1

ciprofloxacin in d5w (generic of CIPRO I.V.-IN D5W)

1

ciprofloxacn inj 400mg/40ml 1

FACTIVE 3

LEVAQUIN TABS 3

levofloxacin SOLN 25mg/ml 1

levofloxacin (generic of LEVAQUIN) SOLN 25mg/ml

1

levofloxacin (generic of LEVAQUIN) TABS

1

levofloxacin in d5w 1

levofloxacin in d5w (generic of LEVAQUIN)

1

moxifloxacin hcl (generic of AVELOX) TABS

1

PENICILLINS amoxicillin 1

amoxicillin & pot clavulanate CHEW

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) CHEW

1

amoxicillin & pot clavulanate SUSR

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) SUSR

1

amoxicillin & pot clavulanate (generic of AUGMENTIN ES-600) SUSR

1

amoxicillin & pot clavulanate TABS

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) TABS

1

amoxicillin & pot clavulanate (generic of AUGMENTIN XR) TB12

1

ampicillin & sulbactam sodium 1

ampicillin & sulbactam sodium (generic of UNASYN)

1

ampicillin & sulbactam sodium (generic of UNASYN BULK PACK)

1

Drug Name Drug Tier

Requirements/Limits

ampicillin cap 250mg 1

ampicillin cap 500 mg 1

ampicillin inj 1

ampicillin sodium 1

ampicillin susp 1

AUGMENTIN SUSR 3

AUGMENTIN TABS 4 NM

AUGMENTIN ES-600 3

AUGMENTIN XR 4 NM

BACTOCILL INJ DEX 1GM 3

BACTOCILL INJ DEX 2GM 4 NM

BICILLIN C-R 3

BICILLIN L-A 3

dicloxacillin sodium 1

nafcillin sodium 1gm 1

nafcillin sodium 2gm, 10gm 4 NM

NALLPEN ISO-OSMOTIC IN DE

3

NALLPEN/DEXTROSE 3

oxacillin sodium 1gm, 2gm 1

oxacillin sodium 10gm 4 NM

PENICILLIN G POT IN DEXTROSE

3

PENICILLIN G POTASSIUM IN

3

penicillin g procaine 3

penicillin g sodium 1

penicillin v potassium 1

penicilln gk inj 5mu 1

penicilln gk inj 20mu 1

pfizerpen g inj 5mu 1

pfizerpen-g inj 20mu 1

piperacillin sodium-tazobactam sodium (generic of ZOSYN)

1

UNASYN 3

UNASYN BULK PACK 3

ZOSYN 3

TETRACYCLINES adoxa CAPS 3

demeclocycline hcl 1

doxy 1

doxycycline (monohydrate) CAPS 50mg

1

2016 601 4T Copper Comm eff 01/01/2016


13

Drug Name Drug Tier

Requirements/Limits

doxycycline (monohydrate) (generic of MONODOX) CAPS 75mg, 100mg

1

doxycycline (monohydrate) (generic of ADOXA) CAPS 150mg

1

doxycycline (monohydrate) (generic of VIBRAMYCIN) SUSR

1

doxycycline (monohydrate) (generic of ADOXA) TABS 50mg, 75mg, 100mg

1

doxycycline (monohydrate) (generic of ADOXA PAK 1/150) TABS 150mg

1

doxycycline hyclate CAPS 50mg

1

doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg

1

doxycycline hyclate SOLR 1

doxycycline hyclate TABS 1

doxycycline hyclate TBEC 1

MINOCIN CAPS 3

minocycline hcl (generic of MINOCIN) CAPS

1

minocycline hcl TABS; TB24 1

SOLODYN 4 NM

TETRACYCLINE HCL CAPS

1

VIBRAMYCIN CAPS 3

VIBRAMYCIN SUSR; SYRP 2

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN SOLR 3 B/D

BICNU 3 B/D

BUSULFEX 4 B/D NM

CYCLOPHOSPHAMIDE CAPS

2 B/D

cyclophosphamide SOLR 1gm, 500mg

4 B/D NM

cyclophosphamide SOLR 2gm

1 B/D

dacarbazine 200mg 1 B/D

EMCYT 2

GLEOSTINE 3

HEXALEN 4 NM

Drug Name Drug Tier

Requirements/Limits

IFEX INJ 1GM 3 B/D

IFEX INJ 3GM 3 B/D

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

3 B/D

ifosfamide inj (generic of IFOSFAMIDE) 1gm/20ml, 3gm/60ml

1 B/D

ifosfamide inj 1gm (generic of IFEX)

1 B/D

IFOSFAMIDE INJ 3GM 3 B/D

LEUKERAN 2

LOMUSTINE 1

melphalan hcl (generic of ALKERAN)

4 B/D NM

MUSTARGEN 3 B/D

TREANDA 4 B/D NM

ZANOSAR 3 B/D

ANTHRACYCLINES adriamyc inj 50mg 1 B/D

daunorubicin hcl 1 B/D

DOXIL 4 B/D NM

doxorubicin hcl 50mg 1 B/D

doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml (generic of DOXIL)

4 B/D NM

doxorubicin inj 50mg 1 B/D

ELLENCE 4 B/D NM

epirubicin inj 50mg/25ml (generic of ELLENCE)

1 B/D

epirubicin inj 200mg (generic of ELLENCE)

1 B/D

IDAMYCIN PFS 3 B/D

idarubicin hcl (generic of IDAMYCIN PFS)

4 B/D NM

ANTIBIOTICS bleomycin sulfate 1 B/D

COSMEGEN 4 B/D NM

mitomycin SOLR 1 B/D

ANTIMETABOLITES adrucil 1 B/D

ALIMTA 4 B/D NM

ARRANON 4 B/D NM

azacitidine (generic of VIDAZA)

4 B/D NM

cladribine 4 B/D NM

CLOLAR 4 B/D NM

cytarabine inj 1 B/D

2016 601 4T Copper Comm eff 01/01/2016


14

Drug Name Drug Tier

Requirements/Limits

DACOGEN 4 B/D NM

decitabine (generic of DACOGEN)

4 B/D NM

fludarabine phosphate SOLN

1 B/D

fludarabine phosphate (generic of FLUDARA) SOLR

1 B/D

fluorouracil SOLN 1 B/D

GEMCITABINE 4 B/D NM

gemcitabine hcl (generic of GEMZAR) 1gm, 200mg

4 B/D NM

gemcitabine hcl 2gm 4 B/D NM

GEMZAR 4 B/D NM

mercaptopurine TABS 1

methotrexate sodium inj 1 B/D

NIPENT 4 B/D NM

PURIXAN 4 NM

TABLOID 2

VIDAZA 4 B/D NM

ANTIMITOTIC, TAXOIDS ABRAXANE 4 B/D NM

DOCETAXEL CONC 20mg/ml, 80mg/4ml

4 B/D NM

docetaxel CONC 140mg/7ml 4 B/D NM

DOCETAXEL SOLN 80mg/8ml, 200mg/20ml

4 B/D NM

paclitaxel 1 B/D

TAXOTERE 4 B/D NM

ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 1 B/D

vincasar 1 B/D

vincristine sulfate 1 B/D

vinorelbine tartrate (generic of NAVELBINE)

1 B/D

BIOLOGIC RESPONSE MODIFIERS ARZERRA 4 B/D NM

AVASTIN 4 B/D NM LA

BELEODAQ 4 NM PA

ERBITUX 4 B/D NM

ERIVEDGE 4 NM LA PA

FARYDAK 4 NM LA PA

HERCEPTIN 4 B/D NM

IBRANCE 4 NM LA PA

ISTODAX 4 B/D NM

KADCYLA 4 B/D NM

KEYTRUDA 4 NM PA

Drug Name Drug Tier

Requirements/Limits

LYNPARZA 4 NM LA PA

PERJETA 4 NM PA

PROLEUKIN 4 B/D NM

RITUXAN 4 NM LA PA

TORISEL 4 B/D NM

VECTIBIX 4 B/D NM

VELCADE 4 B/D NM

YERVOY 4 NM PA

ZOLINZA 4 NM PA

HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of ARIMIDEX) TABS

1

ARIMIDEX 2

AROMASIN 2

bicalutamide (generic of CASODEX)

1

CASODEX 2

DEPO-PROVERA INJ 400/ML 3 B/D

ELIGARD INJ 7.5MG 3 B/D NM

ELIGARD INJ 22.5MG 3 B/D NM

ELIGARD INJ 30MG 3 B/D NM

ELIGARD INJ 45MG 3 B/D NM

exemestane (generic of AROMASIN)

1

FARESTON 4 NM

FASLODEX 4 B/D NM

FEMARA 4 NM

FIRMAGON 80mg 3 B/D NM

FIRMAGON 120mg 4 B/D NM

flutamide 1

letrozole (generic of FEMARA) TABS

1

leuprolide acetate KIT 1 NM PA

LUPRON DEP INJ 11.25MG 4 NM PA

LUPRON DEP-PED INJ 7.5MG

4 NM PA

LUPRON DEP-PED INJ 11.25MG

4 NM PA

LUPRON DEP-PED INJ 15MG

4 NM PA

LUPRON DEP-PED INJ 30MG (3-MONTH)

4 NM PA

LUPRON DEPOT 3.75mg, 7.5mg

4 NM PA

LUPRON DEPOT INJ 22.5MG (3-MONTH)

4 NM PA

2016 601 4T Copper Comm eff 01/01/2016


15

Drug Name Drug Tier

Requirements/Limits

LUPRON DEPOT INJ 30MG (3-MONTH)

4 NM PA

LYSODREN 2

MEGACE ES 4 NM PA

MEGACE ORAL PA if 65 years and older

3 PA

megestrol acetate (generic of MEGACE ORAL) SUSP 40mg/ml

PA if 65 years and older

3 PA

megestrol acetate TABS PA if 65 years and older

3 PA

NILANDRON 4 NM

SOLTAMOX 3

tamoxifen citrate TABS 1

TRELSTAR MIXJECT 4 NM PA

XTANDI 4 NM LA PA

ZYTIGA 4 NM LA PA

KINASE INHIBITORS AFINITOR 4 NM PA

AFINITOR DISPERZ 4 NM PA

BOSULIF 4 NM PA

CAPRELSA 4 NM LA PA

COMETRIQ 4 NM LA PA

GILOTRIF TAB 20MG 4 NM LA PA



GLEEVEC 4 NM PA

ICLUSIG 4 NM LA PA

IMBRUVICA CAP 140MG 4 NM LA PA

INLYTA 4 NM LA PA

JAKAFI 4 NM LA PA

LENVIMA 10MG DAILY DOSE

4 NM LA PA


4 NM LA PA


4 NM LA PA


4 NM LA PA

MEKINIST 4 NM LA PA

NEXAVAR 4 NM LA PA

SPRYCEL 4 NM PA

STIVARGA 4 NM LA PA

SUTENT 4 NM PA

TAFINLAR 4 NM LA PA

TARCEVA 4 NM LA PA

Drug Name Drug Tier

Requirements/Limits

TASIGNA 4 NM PA

TYKERB 4 NM LA PA

VOTRIENT 4 NM LA PA

XALKORI 4 NM LA PA

ZELBORAF 4 NM LA PA

ZYDELIG 4 NM LA PA

ZYKADIA 4 NM LA PA

MISCELLANEOUS DROXIA 3

HALAVEN 4 B/D NM

HYDREA 2

hydroxyurea (generic of HYDREA) CAPS

1

IXEMPRA KIT 4 B/D NM

MATULANE 4 NM LA

mitoxantrone hcl 1 B/D NM

POMALYST 4 NM LA PA

SYLATRON KIT 200MCG 4 NM PA



SYNRIBO 4 NM PA

TARGRETIN CAPS 4 NM PA

tretinoin CAPS 4 NM

TRISENOX 4 B/D NM

UVADEX 3 B/D

PLATINUM-BASED AGENTS carboplatin 1 B/D

cisplatin 1 B/D

ELOXATIN 4 B/D NM

oxaliplatin 4 B/D NM

PROTECTIVE AGENTS amifostine crystalline (generic of ETHYOL)

4 B/D NM

dexrazoxane (generic of ZINECARD) 250mg

4 B/D NM

ELITEK 4 B/D NM

FUSILEV 4 B/D NM

KEPIVANCE 4 B/D NM

leucovorin calcium TABS 1

leucovorin calcium inj 50mg 1 B/D





levoleucovorin calcium 4 B/D NM

mesna (generic of MESNEX) 1 B/D

2016 601 4T Copper Comm eff 01/01/2016


16

Drug Name Drug Tier

Requirements/Limits

MESNEX SOLN 3 B/D

MESNEX TABS 4 NM

ZINECARD 3 B/D

TOPOISOMERASE INHIBITORS CAMPTOSAR 3 B/D

ETOPOPHOS 3 B/D

etoposide SOLN 500mg/25ml

1 B/D

HYCAMTIN 4 B/D NM

irinotecan inj 40mg/2ml (generic of CAMPTOSAR)

1 B/D

irinotecan inj 100/5ml (generic of CAMPTOSAR)

1 B/D

irinotecan inj 500mg/25ml 1 B/D

toposar 1gm/50ml 1 B/D

topotecan hcl (generic of HYCAMTIN) SOLR

4 B/D NM

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS ACCURETIC 3

amlodipine besylate-benazepril hcl

1

amlodipine besylate-benazepril hcl (generic of LOTREL)

1

benazepril & hydrochlorothiazide

1

benazepril & hydrochlorothiazide (generic of LOTENSIN HCT)

1

captopril & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide (generic of VASERETIC)

1

fosinopril sodium & hydrochlorothiazide

1

lisinopril & hydrochlorothiazide (generic of ZESTORETIC)

1

LOTREL 2

moexipril-hydrochlorothiazide 1

quinapril-hydrochlorothiazide (generic of ACCURETIC)

1

TARKA 2

Drug Name Drug Tier

Requirements/Limits

trandolapril-verapamil hcl (generic of TARKA)

1

VASERETIC 3

ZESTORETIC 3

ACE INHIBITORS ACCUPRIL 3

ALTACE 3

benazepril hcl TABS 5mg 1

benazepril hcl (generic of LOTENSIN) TABS 10mg, 20mg, 40mg

1

captopril TABS 1

enalapril maleate (generic of VASOTEC) TABS

1

fosinopril sodium 1

lisinopril (generic of ZESTRIL) TABS 2.5mg, 30mg, 40mg

1

lisinopril (generic of PRINIVIL) TABS 5mg, 10mg, 20mg

1

LOTENSIN 20mg, 40mg 3

MAVIK 3

moexipril hcl 1

perindopril erbumine 2mg 1

perindopril erbumine (generic of ACEON) 4mg, 8mg

1

PRINIVIL 3

quinapril hcl (generic of ACCUPRIL)

1

ramipril (generic of ALTACE) 1

trandolapril (generic of MAVIK)

1

VASOTEC 3

ZESTRIL 3

ALDOSTERONE RECEPTOR ANTAGONISTS ALDACTONE 2

eplerenone (generic of INSPRA)

1

INSPRA 2

spironolactone (generic of ALDACTONE) TABS

1

ALPHA BLOCKERS CARDURA 3

doxazosin mesylate (generic of CARDURA)

1

2016 601 4T Copper Comm eff 01/01/2016


17

Drug Name Drug Tier

Requirements/Limits

MINIPRESS 1mg, 2mg 3

MINIPRESS 5mg 4 NM

prazosin hcl (generic of MINIPRESS)

1

terazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan tab 5-160 mg (generic of EXFORGE)

1

amlodipine besylate-valsartan tab 5-320 mg (generic of EXFORGE)

1


1


1

amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg (generic of EXFORGE HCT)

1

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg (generic of EXFORGE HCT)

1

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg (generic of EXFORGE HCT)

1


1


1

ATACAND HCT 3

AVALIDE 3

AZOR 2

BENICAR HCT 2

candesartan cilexetil-hydrochlorothiazide (generic of ATACAND HCT)

1

DIOVAN HCT 3

EDARBYCLOR 3

EXFORGE 3

EXFORGE HCT 3

HYZAAR 3

Drug Name Drug Tier

Requirements/Limits

irbesartan-hydrochlorothiazide (generic of AVALIDE)

1

losartan-hydrochlorothiazide (generic of HYZAAR)

1

MICARDIS HCT 3

telmisartan-amlodipine (generic of TWYNSTA)

1

telmisartan-hydrochlorothiazide (generic of MICARDIS HCT)

1

TEVETEN HCT 3

TRIBENZOR 2

TWYNSTA 3

valsartan-hydrochlorothiazide (generic of DIOVAN HCT)

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND 3

AVAPRO 3

BENICAR 2

candesartan cilexetil (generic of ATACAND)

1

COZAAR 3

DIOVAN 3

EDARBI 3

eprosartan mesylate 1

irbesartan (generic of AVAPRO)

1

losartan potassium (generic of COZAAR)

1

MICARDIS 3

telmisartan (generic of MICARDIS)

1

TEVETEN 3

valsartan (generic of DIOVAN)

1

ANTIARRHYTHMICS amiodarone hcl SOLN 1

amiodarone hcl TABS 100mg, 400mg

1

amiodarone hcl (generic of CORDARONE) TABS 200mg

1

amiodarone inj 50mg/ml 1

BETAPACE 2

BETAPACE AF 2

2016 601 4T Copper Comm eff 01/01/2016


18

Drug Name Drug Tier

Requirements/Limits

disopyramide phosphate (generic of NORPACE)


3 PA

flecainide acetate 1

mexiletine hcl 1

MULTAQ 3

NORPACE PA if 65 years and older

3 PA

NORPACE CR PA if 65 years and older

3 PA

pacerone 100mg, 400mg 1

pacerone (generic of CORDARONE) 200mg

1

propafenone hcl (generic of RYTHMOL SR) CP12

1

propafenone hcl (generic of RYTHMOL) TABS 225mg

1

propafenone hcl TABS 300mg

1

propafenone hcl 12hr (generic of RYTHMOL SR) CP12

1

propafenone hcl 12hr (generic of RYTHMOL) TABS

1

quinidine gluconate TBCR 1

quinidine sulfate TABS 1

RYTHMOL 2

RYTHMOL SR 2

sorine (generic of BETAPACE) 80mg, 120mg, 160mg

1

sorine 240mg 1

sotalol hcl (generic of BETAPACE) 80mg, 120mg, 160mg

1

sotalol hcl 240mg 1

sotalol hcl (afib/afl) (generic of BETAPACE AF)

1

TIKOSYN 2 NM

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 3

atorvastatin calcium (generic of LIPITOR) TABS

1

CRESTOR 2

fluvastatin sodium (generic of LESCOL) 20mg

1

Drug Name Drug Tier

Requirements/Limits

fluvastatin sodium 40mg 1

LESCOL 3

LESCOL XL 3

LIPITOR 3

LIVALO 3

lovastatin 10mg, 20mg 1

lovastatin (generic of MEVACOR) 40mg

1

PRAVACHOL 3

pravastatin sodium 10mg 1

pravastatin sodium (generic of PRAVACHOL) 20mg, 40mg, 80mg

1

simvastatin (generic of ZOCOR) TABS 5mg, 10mg, 20mg, 40mg

1

simvastatin (generic of ZOCOR) TABS 80mg


1 QL

ZOCOR 5mg, 10mg, 20mg, 40mg

3

ZOCOR 80mg QL (30 tabs / 30 days)

3 QL

ANTILIPEMICS, MISCELLANEOUS ADVICOR 3

ANTARA 3

cholestyramine (generic of QUESTRAN)

1

cholestyramine light 1

choline fenofibrate (generic of TRILIPIX)

1

COLESTID 3

colestipol hcl (generic of COLESTID)

1

FENOFIBRATE CAPS 1

fenofibrate (generic of TRICOR) TABS 48mg, 145mg

1

fenofibrate (generic of LOFIBRA) TABS 54mg, 160mg

1

FENOFIBRATE TABS 120mg

1

fenofibrate micronized 43mg, 130mg

1

2016 601 4T Copper Comm eff 01/01/2016


19

Drug Name Drug Tier

Requirements/Limits

fenofibrate micronized (generic of LOFIBRA) 67mg, 134mg, 200mg

1

FENOFIBRIC ACID 1

FENOGLIDE 3

FIBRICOR 3

gemfibrozil (generic of LOPID) TABS

1

JUXTAPID 4 NM LA PA

KYNAMRO 4 NM PA

LIPOFEN 3

LIPTRUZET 3

lofibra 3

LOPID 3

LOVAZA CAP 1GM 3

niacin er (antihyperlipidemic) (generic of NIASPAN)

1

niacor 1

NIASPAN 3

omega-3-acid ethyl esters (generic of LOVAZA)

1

prevalite (generic of QUESTRAN LIGHT)

1

questran 3

questran light 3

SIMCOR 2

TRICOR 3

TRIGLIDE 3

TRILIPIX 3

VASCEPA 3

VYTORIN 2

WELCHOL 2

ZETIA TAB 10MG 2

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone (generic of TENORETIC 50)

1

atenolol & chlorthalidone (generic of TENORETIC 100)

1

bisoprolol & hydrochlorothiazide (generic of ZIAC)

1

CORZIDE 3

DUTOPROL 3

LOPRESSOR HCT 2

Drug Name Drug Tier

Requirements/Limits

metoprolol & hctz tab 50-25mg (generic of LOPRESSOR HCT)

1

metoprolol & hctz tab 100-25mg (generic of LOPRESSOR HCT)

1

metoprolol & hctz tab 100-50mg

1

nadolol & bendroflumethiazide (generic of CORZIDE)

1

propranolol & hydrochlorothiazide

1

TENORETIC 50 2

TENORETIC 100 2

ZIAC 2

BETA-BLOCKERS acebutolol hcl (generic of SECTRAL) CAPS

1

atenolol (generic of TENORMIN) TABS

1

betaxolol hcl (generic of KERLONE)

1

bisoprolol fumarate (generic of ZEBETA)

1

BYSTOLIC 2

carvedilol (generic of COREG)

1

COREG 3

COREG CR 2

CORGARD 3

INDERAL LA 3

labetalol hcl SOLN 1

labetalol hcl (generic of TRANDATE) TABS

1

LOPRESSOR 3

metoprolol succinate (generic of TOPROL XL)

1

metoprolol tartrate SOLN 1

metoprolol tartrate TABS 25mg

1

metoprolol tartrate (generic of LOPRESSOR) TABS 50mg, 100mg

1

nadolol (generic of CORGARD) TABS

1

pindolol 1

2016 601 4T Copper Comm eff 01/01/2016


20

Drug Name Drug Tier

Requirements/Limits

propranolol hcl er (generic of INDERAL LA)

1

propranolol inj 1mg/ml 1

propranolol sol 1

propranolol tab 1

SECTRAL 3

SOTYLIZE 4 NM

TENORMIN 3

timolol maleate TABS 1

TOPROL XL 3

TRANDATE 3

ZEBETA 3

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate/atorv (generic of CADUET)

1

CADUET 3

CALCIUM CHANNEL BLOCKERS ADALAT CC 3

afeditab cr (generic of ADALAT CC)

1

amlodipine besylate (generic of NORVASC) TABS

1

CALAN 3

CALAN SR 3

CARDIZEM 60mg, 120mg 3

CARDIZEM CD 120mg 3

CARDIZEM CD 180mg, 240mg, 300mg, 360mg

4 NM

CARDIZEM LA 3

cartia xt (generic of CARDIZEM CD)

1

dilt-xr cap 1

diltiazem cap 120mg/24hr 1

diltiazem cap er/12hr 1

diltiazem hcl (generic of CARDIZEM) TABS 30mg, 60mg, 120mg

1

diltiazem hcl TABS 90mg 1

diltiazem hcl coated beads (generic of CARDIZEM CD)

1

diltiazem hcl er (generic of TIAZAC)

1

diltiazem hcl extended release beads (generic of TIAZAC)

1

Drug Name Drug Tier

Requirements/Limits

diltiazem inj 25mg/5ml 1

diltiazem inj 50/10ml 1

diltiazem inj 100mg 3

diltiazem inj 125/25ml 1

diltzac (generic of TIAZAC) 1

felodipine 1

isradipine 1

matzim la (generic of CARDIZEM LA)

1

nicardipine hcl CAPS 1

nifedical (generic of PROCARDIA XL)

1

nifedipine (generic of ADALAT CC) TB24

1

nifedipine er (generic of PROCARDIA XL)

1

nimodipine CAPS 4 NM

nisoldipine (generic of SULAR) 8.5mg, 17mg, 34mg

1

nisoldipine 20mg, 25.5mg, 30mg, 40mg

1

NORVASC 3

NYMALIZE 4 NM

PROCARDIA XL 3

SULAR 3

taztia xt (generic of TIAZAC) 1

TIAZAC 3

verapamil hcl (generic of VERELAN PM) CP24 100mg, 200mg, 300mg

1

verapamil hcl (generic of VERELAN) CP24 120mg, 180mg, 240mg

1

VERAPAMIL HCL CP24 360mg

1

verapamil hcl SOLN 1

verapamil hcl TABS 40mg 1

verapamil hcl (generic of CALAN) TABS 80mg, 120mg

1

verapamil hcl (generic of CALAN SR) TBCR

1

VERELAN 3

VERELAN PM 3

DIGITALIS GLYCOSIDES

2016 601 4T Copper Comm eff 01/01/2016


21

Drug Name Drug Tier

Requirements/Limits

digitek (generic of LANOXIN) .25mg


1 PA

digitek (generic of LANOXIN) .125mg


1 QL

digoxin (generic of LANOXIN) 125mcg


1 QL

digoxin (generic of LANOXIN) 250mcg


1 PA

digoxin inj (generic of LANOXIN)

1

DIGOXIN SOL 50MCG/ML PA if 65 years and older

1 PA

LANOXIN 62.5mcg QL (60 tabs / 30 days)

2 QL

LANOXIN 187.5mcg PA if 65 years and older

2 PA

LANOXIN INJ 0.25MG/ML 3

LANOXIN PEDIATRIC 3

LANOXIN TAB 125mcg QL (30 tabs / 30 days)

2 QL

LANOXIN TAB 250mcg PA if 65 years and older

2 PA

DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA 2

TEKTURNA HCT 2

DIURETICS acetazolamide (generic of DIAMOX) CP12

1

acetazolamide TABS 1

acetazolamide sodium 1

ALDACTAZIDE 3

ALDACTAZIDE TAB 50/50 3

amiloride & hydrochlorothiazide

1

amiloride hcl 1

bumetanide 1

chlorothiazide tabs 1

chlorthalidone 25mg, 50mg 1

DEMADEX 3

DIAMOX 2

DIURIL SUS 250/5ML 3

Drug Name Drug Tier

Requirements/Limits

DYAZIDE 3

DYRENIUM 3

EDECRIN 3

furosemide SOLN 1

furosemide (generic of LASIX) TABS

1

furosemide inj 10mg/ml 1

FUROSEMIDE INJ 10mg/ml 1

furosemide oral soln 8 mg/ml 2

hydrochlorothiazide (generic of MICROZIDE) CAPS

1

hydrochlorothiazide TABS 1

indapamide 1

LASIX 3

MAXZIDE 3

MAXZIDE-25 3

methazolamide (generic of NEPTAZANE) TABS

1

methyclothiazide 1

metolazone 1

MICROZIDE 3

neptazane 3

SODIUM DIURIL 3

spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE)

1

torsemide inj 50mg/5ml 3

torsemide tabs (generic of DEMADEX) 5mg, 10mg, 20mg

1

torsemide tabs 100mg 1

triamt/hctz cap 37.5-25 (generic of DYAZIDE)

1

triamt/hctz cap 50-25mg 1

triamt/hctz tab 37.5-25 (generic of MAXZIDE-25)

1

triamt/hctz tab 75-50mg (generic of MAXZIDE)

1

MISCELLANEOUS BIDIL 2

CATAPRES TAB 2

CATAPRES-TTS DIS 0.1/24HR

2


2

2016 601 4T Copper Comm eff 01/01/2016


22

Drug Name Drug Tier

Requirements/Limits


2

clonidine hcl (generic of CATAPRES-TTS-1) PTWK .1mg/24hr

1


1


1

clonidine hcl (generic of CATAPRES) TABS

1

clorpres 1

CORLANOR 3

DEMSER 4 NM

DIBENZYLINE 4 NM

hydralazine hcl SOLN; TABS 1

midodrine hcl 1

minoxidil TABS 1

RANEXA 2

NITRATES DILATRATE SR 3

ISORDIL TITRADOSE 2

isosorbide dinitrate (generic of ISORDIL TITRADOSE) 5mg

1

isosorbide dinitrate 10mg, 20mg, 30mg

1

isosorbide dinitrate er 1

isosorbide mononitrate 1

isosorbide mononitrate er 1

minitran (generic of NITRO-DUR)

1

nitro-bid 3

NITRO-DUR 2

nitroglycerin (generic of NITROLINGUAL PUMPSPRAY) .4mg/spray

1

NITROGLYCERIN LINGUAL 1

nitroglycerin patches 1

NITROLINGUAL SPR PUMPSPRA

2

NITROMIST 3

NITROSTAT 2

PULMONARY ARTERIAL HYPERTENSION

Drug Name Drug Tier

Requirements/Limits

ADCIRCA 4 NM PA

ADEMPAS 4 NM LA PA

LETAIRIS 4 NM LA PA

OPSUMIT 4 NM LA PA

ORENITRAM TAB 0.25MG 4 NM LA PA


ORENITRAM TAB 1MG 4 NM LA PA


REMODULIN 4 B/D NM LA

REVATIO SUSR; TABS 4 NM PA

sildenafil citrate (pulmonary hypertension) (generic of REVATIO) TABS

1 NM PA

TRACLEER 4 NM LA PA

TYVASO 4 B/D NM

VENTAVIS 4 B/D NM

CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam CONC

QL (300 mL / 30 days) 3 QL

alprazolam (generic of XANAX) TABS 1mg


1 QL

alprazolam (generic of XANAX) TABS 2mg


1 QL

alprazolam (generic of XANAX) TABS .5mg


1 QL

alprazolam (generic of XANAX) TABS .25mg


1 QL

ATIVAN SOLN 3

ATIVAN TABS QL (150 tabs / 30 days)

4 QL NM

buspirone hcl TABS 1

fluvoxamine maleate 25mg, 50mg


1 QL

fluvoxamine maleate 100mg 1

fluvoxamine maleate er 100mg


1 QL

fluvoxamine maleate er 150mg


1 QL

2016 601 4T Copper Comm eff 01/01/2016


23

Drug Name Drug Tier

Requirements/Limits

lorazepam CONC QL (150 mL / 30 days)

1 QL

lorazepam (generic of ATIVAN) SOLN

1

lorazepam (generic of ATIVAN) TABS


1 QL

XANAX TAB 0.5MG QL (240 tabs / 30 days)

2 QL

XANAX TAB 0.25MG QL (480 tabs / 30 days)

2 QL

XANAX TAB 1MG QL (120 tabs / 30 days)

2 QL

XANAX TAB 2MG QL (150 tabs / 30 days)

2 QL

ANTICONVULSANTS APTIOM 200mg 3

APTIOM 400mg, 600mg, 800mg

4 NM

BANZEL SUS 40MG/ML 4 NM PA

BANZEL TAB 200MG 3 PA

BANZEL TAB 400MG 4 NM PA

carbamazepine CHEW 1

carbamazepine (generic of CARBATROL) CP12

1

carbamazepine (generic of TEGRETOL) SUSP; TABS

1

carbamazepine (generic of TEGRETOL-XR) TB12

1

CARBATROL 3

CELONTIN 3

clonazepam (generic of KLONOPIN) TABS 1mg


1 QL

clonazepam (generic of KLONOPIN) TABS 2mg


1 QL

clonazepam (generic of KLONOPIN) TABS .5mg


1 QL

clonazepam TBDP 1mg QL (120 tabs / 30 days)

1 QL

clonazepam TBDP 2mg QL (300 tabs / 30 days)

1 QL

clonazepam TBDP .5mg QL (240 tabs / 30 days)

1 QL


1 QL

Drug Name Drug Tier

Requirements/Limits


1 QL

clorazepate dipotassium (generic of TRANXENE T) 3.75mg, 7.5mg


1 QL PA

clorazepate dipotassium (generic of TRANXENE T) 15mg


1 QL PA

DEPACON 4 NM

DEPAKENE CAPS 4 NM

DEPAKENE SYRP 3

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLES 3

DIASTAT ACUDIAL 3

DIASTAT PEDIATRIC 3

diazepam CONC QL (240 mL / 30 days)

1 QL PA

diazepam SOLN 1mg/ml QL (1200 mL / 30 days)

1 QL PA

diazepam SOLN 5mg/ml 1

diazepam (generic of VALIUM) TABS


1 QL PA

DIAZEPAM GEL (ANTICONVULSANT)

1

dilantin 3

DILANTIN-125 3

divalproex sodium (generic of DEPAKOTE SPRINKLES) CPSP

1

divalproex sodium (generic of DEPAKOTE ER) TB24

1

divalproex sodium (generic of DEPAKOTE) TBEC

1

epitol (generic of TEGRETOL) 1

ethosuximide (generic of ZARONTIN) CAPS; SOLN

1

felbamate (generic of FELBATOL) SUSP

4 NM

felbamate (generic of FELBATOL) TABS

1

FELBATOL 4 NM

FYCOMPA 3 PA

2016 601 4T Copper Comm eff 01/01/2016


24

Drug Name Drug Tier

Requirements/Limits

gabapentin (generic of NEURONTIN) CAPS 100mg


1 QL



1 QL



1 QL

gabapentin (generic of NEURONTIN) SOLN

QL (2160 mL / 30 days)

1 QL

gabapentin (generic of NEURONTIN) TABS 600mg


1 QL

gabapentin (generic of NEURONTIN) TABS 800mg


1 QL

GABITRIL 2

KEPPRA SOLN 4 NM

KEPPRA TABS 250mg 3

KEPPRA TABS 500mg, 750mg, 1000mg

4 NM

KEPPRA XR 4 NM

KLONOPIN 1mg QL (120 tabs / 30 days)

2 QL

KLONOPIN 2mg QL (300 tabs / 30 days)

2 QL

KLONOPIN .5mg QL (240 tabs / 30 days)

2 QL

LAMICTAL TABS 4 NM

LAMICTAL CHEWABLE DISPERS 5mg

3

LAMICTAL CHEWABLE DISPERS 25mg

4 NM

LAMICTAL ODT 3

LAMICTAL STARTER 3

LAMICTAL XR KIT 2

LAMICTAL XR TB24 25mg, 50mg

2

LAMICTAL XR TB24 100mg, 200mg, 250mg, 300mg

4 NM

lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW

1

lamotrigine (generic of LAMICTAL) TABS

1

Drug Name Drug Tier

Requirements/Limits

lamotrigine (generic of LAMICTAL XR) TB24

1

lamotrigine (generic of LAMICTAL ODT) TBDP

1

levetiracetam (generic of KEPPRA) SOLN; TABS

1

levetiracetam (generic of KEPPRA XR) TB24

1

LEVETIRACETAM IV 3

levetiracetam oral soln 100 mg/ml (generic of KEPPRA)

1

LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg


2 QL

LYRICA CAPS 200mg QL (90 caps / 30 days)

2 QL

LYRICA CAPS 225mg, 300mg


2 QL

LYRICA SOLN QL (946 mL / 30 days)

2 QL

MYSOLINE 4 NM

NEURONTIN CAPS 100mg QL (1080 caps / 30 days)

3 QL


3 QL


3 QL

NEURONTIN SOLN QL (2160 mL / 30 days)

3 QL

NEURONTIN TABS 600mg QL (180 tabs / 30 days)

3 QL

NEURONTIN TABS 800mg QL (120 tabs / 30 days)

3 QL

ONFI SUSP 4 NM PA

ONFI TABS 10mg 3 PA

ONFI TABS 20mg 4 NM PA

oxcarbazepine (generic of TRILEPTAL)

1

OXTELLAR XR 3

PEGANONE 3

phenobarbital ELIX; TABS PA if 65 years and older

3 PA

PHENOBARBITAL SODIUM 65mg/ml


3 PA

2016 601 4T Copper Comm eff 01/01/2016


25

Drug Name Drug Tier

Requirements/Limits

phenobarbital sodium 130mg/ml


3 PA

phenytek 3

phenytoin (generic of DILANTIN INFATABS) CHEW

1

phenytoin (generic of DILANTIN-125) SUSP

1

phenytoin inj 50mg/ml 1

phenytoin sodium extended (generic of DILANTIN) 100mg

1

phenytoin sodium extended 200mg, 300mg

1

POTIGA 50mg 3

POTIGA 200mg QL (180 tabs / 30 days)

4 QL NM

POTIGA 300mg, 400mg QL (90 tabs / 30 days)

4 QL NM

primidone (generic of MYSOLINE) TABS

1

QUDEXY XR 3

SABRIL PACK QL (180 packets / 30 days)

4 QL NM LA PA

SABRIL TABS QL (180 tabs / 30 days)

4 QL NM LA PA

TEGRETOL 3

TEGRETOL-XR 3

tiagabine hcl (generic of GABITRIL)

1

TOPAMAX 25mg, 50mg 3

TOPAMAX 100mg, 200mg 4 NM

TOPAMAX SPRINKLE 15mg

3

TOPAMAX SPRINKLE 25mg

4 NM

topiramate (generic of TOPAMAX SPRINKLE) CPSP

1

TOPIRAMATE CS24 1

topiramate (generic of TOPAMAX) TABS

1

TRANXENE T 3.75mg, 7.5mg


3 QL PA

Drug Name Drug Tier

Requirements/Limits

TRANXENE T 15mg QL (180 tabs / 30 days)

3 QL PA

TRILEPTAL SUSP 3

TRILEPTAL TABS 3

TROKENDI XR 25mg, 50mg, 100mg

3

TROKENDI XR 200mg 4 NM

VALIUM QL (120 tabs / 30 days)

2 QL PA

valproate sodium (generic of DEPACON) SOLN

1

valproate sodium (generic of DEPAKENE) SYRP

1

valproic acid (generic of DEPAKENE) CAPS

1

VIMPAT SOLN 2

VIMPAT TABS 50mg 2

VIMPAT TABS 100mg, 150mg, 200mg

4 NM

ZARONTIN CAPS 3

zarontin SOLN 3

ZONEGRAN 25mg 3

ZONEGRAN 100mg 4 NM

zonisamide (generic of ZONEGRAN) CAPS 25mg, 100mg

1

zonisamide CAPS 50mg 1

ANTIDEMENTIA ARICEPT 3

donepezil odt 5mg 1

donepezil odt 10mg 1

donepezil tab hcl 23mg (generic of ARICEPT)

1

donepezil tabs 5mg (generic of ARICEPT)

1

donepezil tabs 10mg (generic of ARICEPT)

1

EXELON CAPS 3

EXELON PATCHES 2

galantamine hydrobromide (generic of RAZADYNE ER) CP24

1

galantamine hydrobromide SOLN

1

2016 601 4T Copper Comm eff 01/01/2016


26

Drug Name Drug Tier

Requirements/Limits

galantamine hydrobromide (generic of RAZADYNE) TABS

1

memantine hcl (generic of NAMENDA)

PA if < 30 yrs

1 PA

NAMENDA SOL 10MG/5ML PA if < 30 yrs

2 PA

NAMENDA TAB PA if < 30 yrs

2 PA

NAMENDA XR PA if < 30 yrs

2 PA

NAMENDA XR TITRATION PACK

PA if < 30 yrs

2 PA

NAMZARIC 3

RAZADYNE 3

RAZADYNE ER 3

rivastigmine tartrate (generic of EXELON)

1

ANTIDEPRESSANTS amitriptyline hcl TABS

PA if 65 years and older 3 PA

amoxapine 1

ANAFRANIL PA if 65 years and older

3 PA

APLENZIN 4 NM

BRINTELLIX 2

bupropion hcl (generic of WELLBUTRIN) TABS

1

bupropion hcl (generic of WELLBUTRIN SR) TB12

1

bupropion hcl (generic of WELLBUTRIN XL) TB24

1

CELEXA 3

citalopram hydrobromide SOLN

1

citalopram hydrobromide (generic of CELEXA) TABS

1

clomipramine hcl (generic of ANAFRANIL) CAPS


3 PA

CYMBALTA 3

desipramine hcl (generic of NORPRAMIN) TABS

1

doxepin hcl CAPS; CONC PA if 65 years and older

3 PA

Drug Name Drug Tier

Requirements/Limits

duloxetine hcl (generic of CYMBALTA) CPEP 20mg, 30mg, 60mg

1

EFFEXOR XR 3

EMSAM 4 NM PA

escitalopram oxalate (generic of LEXAPRO)

1

FETZIMA 3

FETZIMA TITRATION PACK 3

fluoxetine hcl (generic of PROZAC) CAPS

1

fluoxetine hcl (generic of PROZAC WEEKLY) CPDR

1

fluoxetine hcl SOLN 1

fluoxetine hcl TABS 10mg, 20mg

1

FLUOXETINE HCL TABS 60mg

2

FORFIVO XL QL (30 tabs / 30 days)

3 QL

imipramine hcl (generic of TOFRANIL) TABS


3 PA

imipramine pamoate (generic of TOFRANIL-PM)


3 PA

LEXAPRO 3

maprotiline hcl 1

MARPLAN 3

mirtazapine TABS 7.5mg 1

mirtazapine (generic of REMERON) TABS 15mg, 30mg, 45mg

1

mirtazapine (generic of REMERON SOLTAB) TBDP

1

NARDIL 2

nefazodone hcl 1

NORPRAMIN 2

nortriptyline hcl (generic of PAMELOR) CAPS

1

nortriptyline hcl SOLN 1

PAMELOR 4 NM

PARNATE 4 NM

paroxetine er tab (generic of PAXIL CR)

1

paroxetine hcl tabs (generic of PAXIL)

1

2016 601 4T Copper Comm eff 01/01/2016


27

Drug Name Drug Tier

Requirements/Limits

PAXIL 3

PAXIL CR 3

PEXEVA 3

phenelzine sulfate (generic of NARDIL) TABS

1

PRISTIQ 2

protriptyline hcl 1

PROZAC 3

PROZAC WEEKLY 3

REMERON 3

REMERON SOLTAB 3

sertraline hcl (generic of ZOLOFT) CONC; TABS

1

SURMONTIL PA if 65 years and older

3 PA

tofranil PA if 65 years and older

3 PA

TOFRANIL-PM PA if 65 years and older

3 PA

tranylcypromine sulfate (generic of PARNATE)

1

trazodone hcl TABS 1

venlafaxine cap er (generic of EFFEXOR XR)

1

venlafaxine hcl 1

VENLAFAXINE HCL ER TAB (VERT)

3

venlafaxine tab 1

VENLAFAXINE TAB 225MG ER

1

venlafaxine tab er (generic of VENLAFAXINE HCL ER)

1

VIIBRYD 2

WELLBUTRIN 3

WELLBUTRIN SR 3

WELLBUTRIN XL 4 NM

ZOLOFT 3

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS

1

APOKYN 4 NM LA PA

AZILECT 2

BENZTROPINE MESYLATE SOLN

1

benztropine mesylate TABS PA if 65 years and older

3 PA

Drug Name Drug Tier

Requirements/Limits

bromocriptine mesylate (generic of PARLODEL) CAPS

1

bromocriptine mesylate TABS

1

carbidopa (generic of LODOSYN) TABS

4 NM

carbidopa-levodopa (generic of SINEMET) TABS

1

carbidopa-levodopa (generic of SINEMET CR) TBCR

1

carbidopa-levodopa TBDP 1

CARBIDOPA/LEVODOPA/ENTACAPONE

1


1


1


1


1


1

COGENTIN 3

COMTAN 3

DUOPA 3 B/D NM

ELDEPRYL 3

ENTACAPONE 1

LODOSYN 4 NM

MIRAPEX 3

MIRAPEX ER .75mg, 1.5mg 3

MIRAPEX ER .375mg, 2.25mg, 3mg, 3.75mg, 4.5mg

2

NEUPRO 2

pramipexole dihydrochloride (generic of MIRAPEX) TABS

1

pramipexole dihydrochloride (generic of MIRAPEX ER) TB24

1

REQUIP 3

REQUIP XL 3

ropinirole hydrochloride (generic of REQUIP) TABS

1

ropinirole hydrochloride (generic of REQUIP XL) TB24

1

2016 601 4T Copper Comm eff 01/01/2016


28

Drug Name Drug Tier

Requirements/Limits

RYTARY 3

selegiline hcl (generic of ELDEPRYL) CAPS

1

selegiline hcl TABS 1

SINEMET 3

SINEMET CR 3

STALEVO 3

ZELAPAR 4 NM

ANTIPSYCHOTICS ABILIFY DISCMELT TAB 10MG


4 QL NM

ABILIFY MAINTENA QL (1 injection / 28 days)

4 QL NM

ABILIFY TABS QL (30 tabs / 30 days)

4 QL NM

aripiprazole tabs (generic of ABILIFY)


4 QL NM

chlorpromaz inj 25mg/ml 3

chlorpromazine hcl TABS 1

clozapine (generic of CLOZARIL) TABS 25mg

1

clozapine TABS 50mg 1

clozapine (generic of CLOZARIL) TABS 100mg


1 QL

clozapine TABS 200mg QL (135 tabs / 30 days)

1 QL

CLOZAPINE TBDP 150mg QL (180 tabs / 30 days)

4 QL NM PA

CLOZAPINE TBDP 200mg QL (135 tabs / 30 days)

4 QL NM PA

CLOZAPINE ODT 12.5mg, 25mg

1 PA

CLOZAPINE ODT 100mg QL (270 tabs / 30 days)

1 QL PA

CLOZARIL 25mg 3

CLOZARIL 100mg QL (270 tabs / 30 days)

4 QL NM

FANAPT QL (60 tabs / 30 days)

3 QL ST

FANAPT TITRATION PACK 3 ST

FAZACLO 12.5mg, 25mg 3 PA

FAZACLO 100mg QL (270 tabs / 30 days)

4 QL NM PA

Drug Name Drug Tier

Requirements/Limits


4 QL NM PA


4 QL NM PA

fluphenazine decanoate SOLN

1

fluphenazine hcl 1

GEODON 20mg, 40mg QL (60 caps / 30 days)

3 QL

GEODON 60mg, 80mg QL (90 caps / 30 days)

4 QL NM

GEODON INJ QL (6 mL / 3 days)

3 QL

HALDOL 3

HALDOL DECANOATE 50 3

HALDOL DECANOATE 100 3

haloperidol TABS 1

haloperidol decanoate (generic of HALDOL DECANOATE 50) SOLN 50mg/ml

1

haloperidol decanoate (generic of HALDOL DECANOATE 100) SOLN 100mg/ml

1

haloperidol lactate 1

haloperidol lactate inj 5 mg/ml (generic of HALDOL)

1

INVEGA 1.5mg, 3mg, 9mg QL (30 tabs / 30 days)

3 QL

INVEGA 6mg QL (60 tabs / 30 days)

3 QL

INVEGA SUST INJ 39 MG/0.25 ML

QL (1 injection / 28 days)

3 QL



4 QL NM



4 QL NM

INVEGA SUST INJ 156MG/ML


4 QL NM

2016 601 4T Copper Comm eff 01/01/2016


29

Drug Name Drug Tier

Requirements/Limits



4 QL NM

INVEGA TRINZA QL (1 syringe / 90 days)

4 QL NM

LATUDA 20mg QL (240 tabs / 30 days)

2 QL

LATUDA 40mg, 120mg QL (30 tabs / 30 days)

2 QL

LATUDA 60mg, 80mg QL (60 tabs / 30 days)

2 QL

loxapine succinate 1

olanzapine (generic of ZYPREXA) SOLR

QL (3 vials / 1 day)

1 QL

olanzapine (generic of ZYPREXA) TABS 2.5mg, 5mg, 7.5mg


1 QL

olanzapine (generic of ZYPREXA) TABS 10mg, 15mg, 20mg


1 QL

olanzapine odt (generic of ZYPREXA ZYDIS) 5mg


1 QL

olanzapine odt (generic of ZYPREXA ZYDIS) 10mg, 15mg, 20mg


1 QL

ORAP 3

perphenazine TABS 1

quetiapine fumarate (generic of SEROQUEL)


1 QL

RISPERDAL SOLN QL (240 mL / 30 days)

4 QL NM

RISPERDAL TABS 1mg, 2mg


3 QL

RISPERDAL TABS 3mg QL (60 tabs / 30 days)

4 QL NM

RISPERDAL TABS 4mg QL (120 tabs / 30 days)

4 QL NM

RISPERDAL TABS .25mg, .5mg


3 QL

Drug Name Drug Tier

Requirements/Limits

RISPERDAL INJ 12.5MG QL (2 injections / 28 days)

2 QL

RISPERDAL INJ 25MG QL (2 injections / 28 days)

2 QL

RISPERDAL INJ 37.5MG QL (2 injections / 28 days)

4 QL NM

RISPERDAL INJ 50MG QL (2 injections / 28 days)

4 QL NM

RISPERDAL M-TAB 1mg QL (60 tabs / 30 days)

3 QL

RISPERDAL M-TAB 2mg, 3mg


4 QL NM

RISPERDAL M-TAB 4mg QL (120 tabs / 30 days)

4 QL NM

RISPERDAL M-TAB .5mg QL (90 tabs / 30 days)

4 QL NM

risperidone (generic of RISPERDAL) SOLN

QL (240 mL / 30 days)

1 QL

risperidone (generic of RISPERDAL) TABS 1mg, 2mg, 3mg


1 QL

risperidone (generic of RISPERDAL) TABS 4mg


1 QL

risperidone (generic of RISPERDAL) TABS .25mg, .5mg


1 QL

risperidone odt (generic of RISPERDAL M-TAB) 1mg, 2mg, 3mg


1 QL

risperidone odt (generic of RISPERDAL M-TAB) 4mg


1 QL

risperidone odt (generic of RISPERDAL M-TAB) .5mg


1 QL

risperidone odt .25mg QL (90 tabs / 30 days)

1 QL

SAPHRIS 2.5mg QL (240 tabs / 30 days)

3 QL

2016 601 4T Copper Comm eff 01/01/2016


30

Drug Name Drug Tier

Requirements/Limits

SAPHRIS 5mg QL (120 tabs / 30 days)

3 QL

SAPHRIS 10mg QL (60 tabs / 30 days)

3 QL

SEROQUEL 25mg, 50mg, 100mg


3 QL

SEROQUEL 200mg, 300mg, 400mg


4 QL NM

SEROQUEL XR 50mg QL (120 tabs / 30 days)

2 QL

SEROQUEL XR 150mg, 200mg


2 QL

SEROQUEL XR 300mg, 400mg


2 QL

thioridazine hcl TABS PA if 65 years and older

3 PA

thiothixene 1

trifluoperazine hcl 1

VERSACLOZ QL (600 mL / 30 days)

4 QL NM PA

ziprasidone hcl (generic of GEODON) 20mg, 40mg


1 QL

ziprasidone hcl (generic of GEODON) 60mg, 80mg


1 QL

ZYPREXA SOLR QL (3 vials / 1 day)

3 QL

ZYPREXA TABS 2.5mg, 5mg, 7.5mg


3 QL

ZYPREXA TABS 10mg QL (60 tabs / 30 days)

3 QL

ZYPREXA TABS 15mg, 20mg


4 QL NM

ZYPREXA RELPREVV 300mg

QL (2 vials / 28 days)

4 QL NM PA

ZYPREXA RELPREVV 405mg

QL (1 vial / 28 days)

4 QL NM PA

Drug Name Drug Tier

Requirements/Limits

ZYPREXA RELPREVV INJ 210MG

QL (2 vials / 28 days)

4 QL NM PA

ZYPREXA ZYDI TAB 10MG QL (60 tabs / 30 days)

4 QL NM

ZYPREXA ZYDIS 5mg QL (30 tabs / 30 days)

3 QL

ZYPREXA ZYDIS 15mg, 20mg


4 QL NM

ATTENTION DEFICIT HYPERACTIVITY DISORDER adderall tab 5mg

QL (360 tabs / 30 days) 3 QL

adderall tab 7.5mg QL (240 tabs / 30 days)

3 QL

adderall tab 10mg QL (180 tabs / 30 days)

3 QL

adderall tab 12.5mg QL (144 tabs / 30 days)

3 QL


3 QL


3 QL


3 QL

ADDERALL XR CAP 5MG QL (90 caps / 30 days)

3 QL


3 QL


3 QL


3 QL


3 QL


3 QL

amphetamine cap 10mg er (generic of ADDERALL XR)


1 QL



1 QL



1 QL

2016 601 4T Copper Comm eff 01/01/2016


31

Drug Name Drug Tier

Requirements/Limits



1 QL



1 QL

amphetamine-dextroamphetamine cap sr 24hr 5 mg (generic of ADDERALL XR)


1 QL

amphetamine-dextroamphetamine tab 5 mg (generic of ADDERALL)


1 QL

amphetamine-dextroamphetamine tab 7.5 mg (generic of ADDERALL)


1 QL



1 QL

amphetamine-dextroamphetamine tab 12.5 mg (generic of ADDERALL)


1 QL



1 QL



1 QL



1 QL

APTENSIO XR 10mg, 15mg, 20mg, 30mg


3 QL

APTENSIO XR 40mg, 50mg, 60mg


3 QL

CONCERTA 18mg, 27mg, 36mg


3 QL

CONCERTA 54mg QL (30 tabs / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

DAYTRANA QL (30 patches / 30 days)

2 QL

guanfacine hcl (adhd) (generic of INTUNIV)


3 PA

INTUNIV PA if 65 years and older

3 PA

METADATE CD 10mg, 20mg, 30mg


3 QL

METADATE CD 40mg, 50mg, 60mg


3 QL

metadate er tab 20mg QL (90 tabs / 30 days)

1 QL

METHYLIN 5mg/5ml QL (1800 mL / 30 days)

3 QL

METHYLIN 10mg/5ml QL (900 mL / 30 days)

3 QL

METHYLIN CHEW TAB QL (180 tabs / 30 days)

2 QL

methylphenidate hcl (generic of METHYLIN) CHEW


1 QL

methylphenidate hcl (generic of RITALIN LA) CP24 20mg, 30mg


1 QL

methylphenidate hcl (generic of RITALIN LA) CP24 40mg


1 QL

methylphenidate hcl (generic of METADATE CD) CPCR 10mg, 20mg, 30mg


1 QL

methylphenidate hcl (generic of METADATE CD) CPCR 40mg, 50mg, 60mg


1 QL

methylphenidate hcl (generic of METHYLIN) SOLN 5mg/5ml

QL (1800 mL / 30 days)

1 QL

methylphenidate hcl (generic of METHYLIN) SOLN 10mg/5ml

QL (900 mL / 30 days)

1 QL

2016 601 4T Copper Comm eff 01/01/2016


32

Drug Name Drug Tier

Requirements/Limits

methylphenidate hcl (generic of RITALIN) TABS 5mg, 10mg


1 QL

methylphenidate hcl (generic of RITALIN) TABS 20mg


1 QL

methylphenidate hcl TBCR 10mg, 20mg


1 QL

methylphenidate hcl TBCR 18mg


1 QL

methylphenidate hcl er 27mg, 36mg


1 QL

methylphenidate hcl er 54mg QL (30 tabs / 30 days)

1 QL

QUILLIVANT XR QL (360 mL / 30 days)

2 QL

RITALIN 5mg, 10mg QL (180 tabs / 30 days)

3 QL

RITALIN 20mg QL (90 tabs / 30 days)

3 QL

RITALIN LA 10mg QL (180 tabs / 30 days)

3 QL

RITALIN LA 20mg, 30mg QL (60 caps / 30 days)

3 QL

RITALIN LA 40mg, 60mg QL (30 caps / 30 days)

3 QL

STRATTERA 10mg, 18mg, 25mg


2 QL

STRATTERA 40mg QL (60 caps / 30 days)

2 QL

STRATTERA 60mg, 80mg, 100mg


2 QL

VYVANSE 10mg, 20mg, 30mg


2 QL

VYVANSE 40mg, 50mg, 60mg, 70mg


2 QL

HYPNOTICS

Drug Name Drug Tier

Requirements/Limits

AMBIEN QL (30 tabs / 30 days)


3 QL PA

HETLIOZ 4 NM LA PA

RESTORIL 7.5mg QL (30 caps / 30 days)


3 QL PA

RESTORIL 15mg QL (60 caps / 30 days)


3 QL PA

ROZEREM QL (30 tabs / 30 days)

3 QL

SILENOR 3mg QL (60 tabs / 30 days)

2 QL

SILENOR 6mg QL (30 tabs / 30 days)

2 QL

temazepam (generic of RESTORIL) 7.5mg

QL (30 caps / 30 days) 90 day limit per calendar year if 65 years and older

1 QL PA

temazepam (generic of RESTORIL) 15mg

QL (60 caps / 30 days) 90 day limit per calendar year if 65 years and older

1 QL PA

zolpidem tartrate (generic of AMBIEN) TABS

QL (30 tabs / 30 days) 90 day limit per calendar year if 65 years and older

3 QL PA

MIGRAINE almotriptan malate (generic of AXERT)


1 QL

ALSUMA QL (12 injections / 30 days)

3 QL

AMERGE QL (9 tabs / 30 days)

3 QL

AXERT QL (12 tabs / 30 days)

3 QL

cafergot tab 1-100mg 3

D.H.E. 45 4 NM

2016 601 4T Copper Comm eff 01/01/2016


33

Drug Name Drug Tier

Requirements/Limits

dihydroergotamine mesylate (generic of D.H.E. 45) 1mg/ml

1

DIHYDROERGOTAMINE MESYLATE 4mg/ml

QL (8 mL / 30 days)

4 QL NM

ergomar 3

FROVA TAB 2.5MG QL (18 tabs / 30 days)

3 QL

IMITREX SOLN 5mg/act QL (24 inhalers / 30 days)

3 QL

IMITREX SOLN 20mg/act QL (12 inhalers / 30 days)

3 QL

IMITREX TABS QL (9 tabs / 30 days)

3 QL

IMITREX STATDOSE REFILL QL (12 injections / 30 days)

4 QL NM

IMITREX STATDOSE SYSTEM SOAJ

QL (12 injections / 30 days)

4 QL NM

IMITREX STATDOSE SYSTEM SOLN

QL (6 mL / 30 days)

3 QL

MAXALT 5mg QL (18 tabs / 30 days)

4 QL NM

MAXALT 10mg QL (18 tabs / 30 days)

3 QL

MAXALT-MLT QL (18 tabs / 30 days)

3 QL

migergot 4 NM

MIGRANAL QL (8 mL / 30 days)

4 QL NM

naratriptan hcl (generic of AMERGE)


1 QL

RELPAX QL (12 tabs / 30 days)

2 QL

rizatriptan benzoate (generic of MAXALT) TABS


1 QL

rizatriptan benzoate (generic of MAXALT-MLT) TBDP


1 QL

Drug Name Drug Tier

Requirements/Limits

SUMATRIPTAN INJ 4MG/0.5ML


1 QL

sumatriptan inj 6mg/0.5ml (generic of IMITREX STATDOSE SYSTEM) SOAJ


1 QL

SUMATRIPTAN INJ 6MG/0.5ML SOCT


1 QL

sumatriptan inj 6mg/0.5ml (generic of IMITREX) SOLN

QL (6 mL / 30 days)

1 QL

sumatriptan inj 6mg/0.5ml SOSY


1 QL

SUMATRIPTAN SUCCINATE SOLN 5mg/act

QL (24 inhalers / 30 days)

1 QL

SUMATRIPTAN SUCCINATE SOLN 20mg/act


1 QL

sumatriptan succinate (generic of IMITREX) TABS


1 QL

SUMAVEL DOSEPRO QL (12 injections / 30 days)

4 QL NM

TREXIMET QL (9 tabs / 30 days)

4 QL NM

zolmitriptan (generic of ZOMIG) TABS


1 QL

zolmitriptan odt (generic of ZOMIG ZMT)


1 QL

ZOMIG QL (12 tabs / 30 days)

3 QL

ZOMIG NASAL SPRAY QL (12 inhalers / 30 days)

2 QL

2016 601 4T Copper Comm eff 01/01/2016


34

Drug Name Drug Tier

Requirements/Limits

ZOMIG ZMT QL (12 tabs / 30 days)

3 QL

MISCELLANEOUS BRISDELLE 2

EQUETRO 3

GRALISE 300mg QL (180 tabs / 30 days)

2 QL

GRALISE 600mg QL (90 tabs / 30 days)

2 QL

GRALISE STARTER 2

HORIZANT 3

lithium carbonate CAPS 1

lithium carbonate TABS 1

lithium carbonate (generic of LITHOBID) TBCR 300mg

1

lithium carbonate TBCR 450mg

1

LITHIUM SOLN 8MEQ/5ML 3

LITHOBID 3

MESTINON 4 NM

MESTINON SYRUP 2

MESTINON TIMESPAN 2

NUEDEXTA 2

pyridostigmine bromide (generic of MESTINON) TABS

1

pyridostigmine bromide TBCR

1

RILUTEK 4 NM

riluzole (generic of RILUTEK) 1

SAVELLA 12.5mg QL (480 tabs / 30 days)

2 QL

SAVELLA 25mg QL (240 tabs / 30 days)

2 QL


2 QL


2 QL

SAVELLA TITRATION PACK 2

XENAZINE 12.5mg QL (240 tabs / 30 days)

4 QL NM LA PA

XENAZINE 25mg QL (120 tabs / 30 days)

4 QL NM LA PA

MULTIPLE SCLEROSIS AGENTS AMPYRA 4 NM LA PA

Drug Name Drug Tier

Requirements/Limits

AUBAGIO QL (30 tabs / 30 days)

4 QL NM LA PA

AVONEX QL (4 injections / 28 days)

4 QL NM PA

AVONEX PEN QL (4 injections / 28 days)

4 QL NM PA

BETASERON QL (14 syringes / 28 days)

4 QL NM PA

COPAXONE INJ 40MG/ML QL (12 syringes / 28 days)

4 QL NM PA

COPAXONE KIT 20MG/ML QL (30 syringes / 30 days)

4 QL NM PA

EXTAVIA QL (15 syringes / 30 days)

4 QL NM PA

GILENYA CAP 0.5MG QL (28 caps / 28 days)

4 QL NM PA

glatopa (generic of COPAXONE)

QL (30 syringes / 30 days)

4 QL NM PA

LEMTRADA 4 NM LA PA

PLEGRIDY SOPN QL (2 pens / 28 days)

4 QL NM PA

PLEGRIDY SOSY QL (2 syringes / 28 days)

4 QL NM PA

PLEGRIDY STARTER PACK SOPN

QL (2 pens / 28 days)

4 QL NM PA

PLEGRIDY STARTER PACK SOSY

QL (2 syringes / 28 days)

4 QL NM PA

REBIF QL (6 mL / 28 days)

4 QL NM PA

REBIF REBIDOSE QL (6 mL / 28 days)

4 QL NM PA

REBIF REBIDOSE TITRATION

QL (6 mL / 28 days)

4 QL NM PA

REBIF TITRATION PACK QL (6 mL / 30 days)

4 QL NM PA

2016 601 4T Copper Comm eff 01/01/2016


35

Drug Name Drug Tier

Requirements/Limits

TECFIDERA CAP 120MG QL (14 caps / 7 days)

4 QL NM LA PA

TECFIDERA CAP 240MG QL (60 caps / 30 days)

4 QL NM LA PA

TECFIDERA MIS STARTER 4 NM LA PA

TYSABRI 4 NM LA PA

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 1

BOTOX INJ 100UNIT 4 NM PA

BOTOX INJ 200UNIT 4 NM PA

cyclobenzaprine hcl TABS 5mg, 10mg


3 PA

DANTRIUM 2

dantrolene sodium (generic of DANTRIUM) CAPS 25mg, 50mg

1

dantrolene sodium CAPS 100mg

1

tizanidine (generic of ZANAFLEX) CAPS

1

tizanidine TABS 2mg 1

tizanidine (generic of ZANAFLEX) TABS 4mg

1

XEOMIN INJ 50 UNIT 3 NM PA

XEOMIN INJ 100 UNIT 4 NM PA

ZANAFLEX CAPS 3

ZANAFLEX TABS 2

NARCOLEPSY/CATAPLEXY modafinil (generic of PROVIGIL) 100mg


1 QL PA

modafinil (generic of PROVIGIL) 200mg


4 QL NM PA

NUVIGIL 50mg QL (150 tabs / 30 days)

2 QL PA

NUVIGIL 150mg QL (60 tabs / 30 days)

2 QL PA

NUVIGIL 200mg, 250mg QL (30 tabs / 30 days)

2 QL PA

PROVIGIL 100mg QL (30 tabs / 30 days)

4 QL NM PA

PROVIGIL 200mg QL (60 tabs / 30 days)

4 QL NM PA

XYREM QL (540 mL / 30 days)

4 QL NM LA PA

Drug Name Drug Tier

Requirements/Limits

PSYCHOTHERAPEUTIC-MISC acamprosate calcium 1

antabuse 2

BUNAVAIL MIS 2.1-0.3MG QL (120 buccal films / 30 days)

3 QL PA

BUNAVAIL MIS 4.2-0.7MG QL (120 buccal films / 30 days)

3 QL PA

BUNAVAIL MIS 6.3-1MG QL (60 buccal films / 30 days)

3 QL PA

buprenorphine hcl SUBL 1 PA

buprenorphine hcl-naloxone hcl sl


1 QL PA

buproban (generic of ZYBAN) 1

CHANTIX 2 PA

CHANTIX CONTINUING MONTH

2 PA

CHANTIX STARTER PACK 2 PA

disulfiram (generic of ANTABUSE) TABS

1

naloxone hcl SOLN 1

naltrexone hcl (generic of REVIA) TABS

1

NICOTROL INHALER 3

NICOTROL NS 3

SARAFEM 3

SUBOXONE MIS 2-0.5MG QL (120 SL films / 30 days)

3 QL PA

SUBOXONE MIS 4-1MG QL (120 SL films / 30 days)

3 QL PA


3 QL PA


3 QL PA

ZUBSOLV SUB 1.4-0.36MG QL (120 tabs / 30 days)

3 QL PA


3 QL PA


3 QL PA

2016 601 4T Copper Comm eff 01/01/2016


36

Drug Name Drug Tier

Requirements/Limits

ZYBAN 2

ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM


2 QL PA

ANDROGEL 20.25mg/1.25gm, 40.5mg/2.5gm

QL (150 grams / 30 days)

3 QL PA

ANDROGEL 25mg/2.5gm QL (300 grams / 30 days)

3 QL PA

ANDROGEL 1% QL (300 grams / 30 days)

3 QL PA

ANDROGEL 1.62% QL (150 grams / 30 days)

3 QL PA

ANDROGEL PUMP QL (300 grams / 30 days)

3 QL PA

AVEED 3 NM PA

AXIRON QL (440 mL / 30 days)

2 QL PA

depo-testosterone 3 PA

FORTESTA QL (120 grams / 30 days)

3 QL PA

oxandrolone (generic of OXANDRIN) TABS 2.5mg

1 PA

oxandrolone (generic of OXANDRIN) TABS 10mg

4 NM PA

STRIANT QL (60 buccal systems / 30 days)

3 QL PA

TESTIM QL (300 grams / 30 days)

3 QL PA

testosterone cypionate SOLN 100mg/ml

1 PA

testosterone cypionate (generic of DEPO-TESTOSTERONE) SOLN 200mg/ml

1 PA

testosterone enanthate SOLN

1 PA

Drug Name Drug Tier

Requirements/Limits

VOGELXO QL (300 grams / 30 days)

3 QL PA

VOGELXO PUMP QL (300 grams / 30 days)

3 QL PA

ANTIDIABETICS, INJECTABLE ALCOHOL SWABS 2

APIDRA 3

APIDRA SOLOSTAR 3

BYDUREON PEN QL (4 pens / 28 days)

3 QL

BYDUREON SUSR QL (4 vials / 28 days)

3 QL

BYETTA QL (1 pen / 30 days)

3 QL

GAUZE PADS 2X2 2

HUMALOG 3

HUMALOG KWIKPEN 3

HUMALOG MIX 50/50 3

HUMALOG MIX 50/50 KWIKPEN

3

HUMALOG MIX 75/25 3

HUMALOG MIX 75/25 KWIKPEN

3

HUMULIN 70/30 3

HUMULIN 70/30 KWIKPEN 3

HUMULIN N 3

HUMULIN N KWIKPEN 3

HUMULIN R 3

HUMULIN R U-500 (CONCENTRATE)

4 B/D NM

INSULIN PEN NEEDLES 2

INSULIN SAFETY NEEDLES 2

INSULIN SYRINGES 2

LANTUS 2

LANTUS SOLOSTAR 2

LEVEMIR 2

LEVEMIR FLEXTOUCH 2

NOVOLIN 70/30 2

NOVOLIN 70/30 RELION 3

NOVOLIN N 2

NOVOLIN N RELION 3

NOVOLIN R 2

NOVOLIN R RELION 3

2016 601 4T Copper Comm eff 01/01/2016


37

Drug Name Drug Tier

Requirements/Limits

NOVOLOG 2

NOVOLOG FLEXPEN 2

NOVOLOG MIX 70/30 2

NOVOLOG MIX 70/30 PREFILL

2

NOVOLOG PENFILL 2

SYMLINPEN 60 2 PA

SYMLINPEN 120 4 NM PA

TANZEUM QL (4 pens / 28 days)

3 QL

TOUJEO SOLOSTAR 2

TRULICITY QL (4 pens / 28 days)

3 QL

VICTOZA QL (3 pens / 30 days)

2 QL

ANTIDIABETICS, ORAL acarbose (generic of PRECOSE)

1

ACTOPLUS MET TAB 15-500MG


3 QL

ACTOPLUS MET TAB 15-850MG


3 QL

ACTOPLUS MET XR 15-1000MG


3 QL

ACTOPLUS MET XR 30-1000MG


3 QL

ACTOS QL (30 tabs / 30 days)

3 QL

AMARYL 1mg QL (240 tabs / 30 days)

3 QL


3 QL


3 QL

DUETACT QL (30 tabs / 30 days)

3 QL

FARXIGA 5mg QL (60 tabs / 30 days)

3 QL

FARXIGA 10mg QL (30 tabs / 30 days)

3 QL

FORTAMET 500mg QL (150 tabs / 30 days)

4 QL NM

Drug Name Drug Tier

Requirements/Limits

FORTAMET 1000mg QL (75 tabs / 30 days)

4 QL NM

glimepiride (generic of AMARYL) 1mg


1 QL



1 QL



1 QL

glipizide (generic of GLUCOTROL) TABS 5mg


1 QL

glipizide (generic of GLUCOTROL) TABS 10mg


1 QL

glipizide er (generic of GLUCOTROL XL) 2.5mg


1 QL

glipizide er (generic of GLUCOTROL XL) 5mg


1 QL

glipizide er (generic of GLUCOTROL XL) 10mg


1 QL

glipizide-metformin 2.5-250 mg


1 QL

glipizide-metformin 2.5-500 mg


1 QL

glipizide-metformin 5-500mg QL (120 tabs / 30 days)

1 QL

GLUCOPHAGE 500mg QL (150 tabs / 30 days)

3 QL


3 QL


3 QL

GLUCOPHAGE XR 500mg QL (120 tabs / 30 days)

3 QL

GLUCOPHAGE XR 750mg QL (60 tabs / 30 days)

3 QL

GLUCOTROL 5mg QL (240 tabs / 30 days)

3 QL

GLUCOTROL 10mg QL (120 tabs / 30 days)

3 QL

2016 601 4T Copper Comm eff 01/01/2016


38

Drug Name Drug Tier

Requirements/Limits

GLUCOTROL XL 2.5mg QL (240 tabs / 30 days)

3 QL

GLUCOTROL XL 5mg QL (120 tabs / 30 days)

3 QL

GLUCOTROL XL 10mg QL (60 tabs / 30 days)

3 QL

GLUMETZA 500mg QL (120 tabs / 30 days)

3 QL

GLUMETZA 1000mg QL (60 tabs / 30 days)

3 QL

GLYSET 3

GLYXAMBI QL (30 tabs / 30 days)

3 QL

INVOKAMET TAB 50-500MG QL (120 tabs / 30 days)

3 QL

INVOKAMET TAB 50-1000 QL (60 tabs / 30 days)

3 QL


3 QL


3 QL

INVOKANA TAB 100MG QL (90 tabs / 30 days)

3 QL

INVOKANA TAB 300MG QL (30 tabs / 30 days)

3 QL

JANUMET QL (60 tabs / 30 days)

2 QL

JANUMET XR TAB 50-500MG


2 QL

JANUMET XR TAB 50-1000 QL (60 tabs / 30 days)

2 QL

JANUMET XR TAB 100-1000 QL (30 tabs / 30 days)

2 QL

JANUVIA QL (30 tabs / 30 days)

2 QL

JARDIANCE 10mg QL (60 tabs / 30 days)

3 QL

JARDIANCE 25mg QL (30 tabs / 30 days)

3 QL

JENTADUETO QL (60 tabs / 30 days)

2 QL

KAZANO QL (60 tabs / 30 days)

3 QL

KOMBIGLYZE XR 2.5-1000MG


3 QL

Drug Name Drug Tier

Requirements/Limits

KOMBIGLYZE XR 5-500MG QL (30 tabs / 30 days)

3 QL

KOMBIGLYZE XR 5-1000MG QL (30 tabs / 30 days)

3 QL

metformin er (generic of GLUCOPHAGE XR) 500mg


1 QL

metformin er (generic of GLUCOPHAGE XR) 750mg


1 QL

metformin hcl (generic of GLUCOPHAGE) TABS 500mg


1 QL



1 QL



1 QL

metformin hcl (generic of FORTAMET) TB24 500mg


1 QL

metformin hcl (generic of FORTAMET) TB24 1000mg


1 QL

nateglinide (generic of STARLIX)


1 QL

NESINA 6.25mg QL (120 tabs / 30 days)

3 QL

NESINA 12.5mg QL (60 tabs / 30 days)

3 QL

NESINA 25mg QL (30 tabs / 30 days)

3 QL

ONGLYZA QL (30 tabs / 30 days)

3 QL

OSENI TAB 12.5-15MG QL (60 tabs / 30 days)

3 QL


3 QL


3 QL

OSENI TAB 25-15MG QL (30 tabs / 30 days)

3 QL

2016 601 4T Copper Comm eff 01/01/2016


39

Drug Name Drug Tier

Requirements/Limits


3 QL


3 QL

pioglitazone hcl (generic of ACTOS)


1 QL

pioglitazone hcl-glimepiride (generic of DUETACT)


1 QL

pioglitazone hcl-metformin hcl (generic of ACTOPLUS MET)


1 QL

PRANDIMET QL (150 tabs / 30 days)

3 QL

PRANDIN 2mg QL (240 tabs / 30 days)

3 QL

PRANDIN .5mg, 1mg QL (120 tabs / 30 days)

3 QL

PRECOSE 2

repaglinide (generic of PRANDIN) 2mg


1 QL

repaglinide (generic of PRANDIN) .5mg, 1mg


1 QL

RIOMET QL (946 mL / 30 days)

3 QL

STARLIX QL (90 tabs / 30 days)

3 QL

TRADJENTA QL (30 tabs / 30 days)

2 QL

XIGDUO XR TAB 5-500MG QL (60 tabs / 30 days)

3 QL


3 QL


3 QL


3 QL

BISPHOSPHONATES ACTONEL 5mg, 30mg, 35mg

3

ACTONEL 150mg 2

alendronate sodium SOLN QL (300 mL / 28 days)

1 QL

alendronate sodium TABS 5mg, 10mg, 35mg, 40mg

1

Drug Name Drug Tier

Requirements/Limits

alendronate sodium (generic of FOSAMAX) TABS 70mg

1

ATELVIA 3

BINOSTO 3

BONIVA SOLN QL (1 injection / 90 days)

3 B/D QL

BONIVA TABS 3 B/D

FOSAMAX 3

FOSAMAX PLUS D 3

ibandronate sodium (generic of BONIVA)


1 B/D QL

ibandronate tab 150mg (generic of BONIVA)

1 B/D

pamidronate disodium SOLN 6mg/ml

3 B/D

pamidronate disodium SOLN 30mg/10ml, 90mg/10ml

1 B/D

RECLAST 3 B/D NM

RISEDRONATE SODIUM TABS 5mg, 30mg

1

risedronate sodium (generic of ACTONEL) TABS 35mg, 150mg

1

risedronate sodium (generic of ATELVIA) TBEC

1

zoledronic inj 4mg/5ml (generic of ZOMETA)

1 B/D NM

zoledronic inj 5/100ml (generic of RECLAST)

1 B/D NM

ZOMETA 4 B/D NM

CALCIUM RECEPTOR AGONISTS SENSIPAR 30mg 2 NM

SENSIPAR 60mg, 90mg 4 NM

CHELATING AGENTS CHEMET 3

DEPEN TITRATABS 4 NM

EXJADE 4 NM LA PA

FERRIPROX 4 NM LA PA

JADENU 4 NM PA

KAYEXALATE 3

kionex (generic of KAYEXALATE)

1

sodium polystyrene sulfonate 1

sps susp 15gm/60ml 1

2016 601 4T Copper Comm eff 01/01/2016


40

Drug Name Drug Tier

Requirements/Limits

SYPRINE 4 NM

CONTRACEPTIVES altavera 1

amethia 91 day (generic of SEASONIQUE)

1

amethyst 28 day 1

apri 28 day (generic of DESOGEN)

1

aranelle 28 (generic of TRI-NORINYL 28)

1

ashlyna 91 day (generic of SEASONIQUE)

1

aubra 28 day 1

aviane 28 1

balziva 28 day (generic of OVCON-35)

1

BEYAZ 2

BREVICON-28 3

briellyn 28 day (generic of OVCON-35)

1

camila 28 day (generic of NOR-QD)

1

CAMRESE LO TAB 1

cryselle 28 1

cyclafem 1/35 28 day (generic of NORINYL 1+35)

1

cyclafem 7/7/7 28 day (generic of ORTHO-NOVUM 7/7/7)

1

CYCLESSA 3

deblitane 28 day (generic of NOR-QD)

1

delyla 28 day 1

DEPO-PROVERA CONTRACEPTIVE

2

DEPO-SUBQ PROVERA 104 2

DESOGEN 3

desogestrel-ethinyl estradiol (biphasic) (generic of MIRCETTE)

1

drospirenone-ethinyl estradiol (generic of YASMIN 28)

1

ELLA 3

emoquette (generic of DESOGEN)

1

enpresse 28 day 1

Drug Name Drug Tier

Requirements/Limits

errin 28 day (generic of ORTHO MICRONOR)

1

ESTROSTEP FE 3

falmina 28 day 1

FEMCON FE 3

GENERESS FE 3

GIANVI TAB 3-0.02MG 1

gildagia (generic of OVCON-35)

1

gildess 1.5/30 21 day (generic of LOESTRIN 1.5/30-21)

1

gildess 24 fe 28 day 1

heather (generic of NOR-QD) 1

introvale 91 day 1

JOLESSA TAB 0.15-0.03 MG 1

JOLIVETTE 1

junel 1.5/30 21 day (generic of LOESTRIN 1.5/30-21)

1

junel 1/20 21 day (generic of LOESTRIN 1/20-21)

1

junel fe 1.5/30 28 day (generic of LOESTRIN FE 1.5/30)

1

junel fe 1/20 28 day (generic of LOESTRIN FE 1/20)

1

junel fe 24 1/20 28 day 1

kariva 28 day (generic of MIRCETTE)

1

kelnor 1/35 28 day 1

kimidess (generic of MIRCETTE)

1

larin 1.5/30 (generic of LOESTRIN 1.5/30-21)

1

larin 1/20 (generic of LOESTRIN 1/20-21)

1

larin fe 1.5/30 (generic of LOESTRIN FE 1.5/30)

1

larin fe 1/20 (generic of LOESTRIN FE 1/20)

1

LEENA TAB 1

lessina 28 day 1

levonest 28 day 1

levonorgestrel & eth estradiol 1

levonorgestrel (emergency oc) (generic of PLAN B ONE-STEP) 1.5mg

1

2016 601 4T Copper Comm eff 01/01/2016


41

Drug Name Drug Tier

Requirements/Limits

levonorgestrel (emergency oc) .75mg

1

levonorgestrel-ethinyl estradiol (91-day)

1

levonorgestrel-ethinyl estradiol (91-day) (generic of SEASONIQUE)

1

levonorgestrel-ethinyl estradiol (continuous)

1

levora 0.15/30 28 day 1

LO LOESTRIN FE 2

loestrin 1.5/30 21 day 3

loestrin 1/20 21 day 3

loestrin fe 1.5/30 28 day 3

loestrin fe 1/20 28 day 3

lomedia 24 fe 1

loryna 28 day (generic of YAZ)

1

LOSEASONIQUE 3

low-ogestrel 1

lutera 28 day 1

lyza (generic of ORTHO MICRONOR)

1

marlissa 28 day 1

medroxyprogesterone acetate (contraceptive) (generic of DEPO-PROVERA CONTRACEPTIV)

1

MICROGESTIN 1.5/30 1

MICROGESTIN 1/20 1

MICROGESTIN FE 1.5/30 1

MICROGESTIN FE 1/20 1

MINASTRIN 24 FE 2

mircette 2

MODICON 3

MONONESSA 1

my way (generic of PLAN B ONE-STEP)

1

myzilra 1

necon 0.5/35 28 day (generic of BREVICON-28)

1

necon 1/35 28 day (generic of NORINYL 1+35)

1

NECON 7/7/7 1

necon 10/11 28 day 3

Drug Name Drug Tier

Requirements/Limits

NECON TAB 1/50-28 1

next choice tab 1.5mg (generic of PLAN B ONE-STEP)

1

nikki 28 day (generic of YAZ) 1

NOR-QD 2

NORA-BE TAB 1

norethin acet & estrad-fe 1

norethindrone & ethinyl estradiol-fe (generic of GENERESS FE)

1

norethindrone (contraceptive) (generic of NOR-QD)

1

norgestimate-ethinyl estradiol (triphasic) (generic of ORTHO TRI-CYCLEN)

1

NORINYL 1+35 3

NORINYL 1+50 3

norlyroc 28 day (generic of NOR-QD)

1

nortrel 0.5/35 28 day (generic of BREVICON-28)

1

nortrel 1/35 21 day (generic of NORINYL 1+35)

1

nortrel 1/35 28 day (generic of NORINYL 1+35)

1

nortrel 7/7/7 28 day (generic of ORTHO-NOVUM 7/7/7)

1

NUVARING 2

OCELLA TAB 3-0.03MG 1

ogestrel 28 day 1

orsythia 28 day 1

ORTHO MICRONOR 2

ORTHO TRI-CYCLEN LO 2

ORTHO-CYCLEN 3

ORTHO-NOVUM 1/35 3

ORTHO-NOVUM 7/7/7 3

ovcon 35 28 day 3

philith (generic of OVCON-35) 1

pimtrea pack (generic of MIRCETTE)

1

pirmella 1/35 28 day (generic of NORINYL 1+35)

1

portia 28 day 1

previfem 28 day (generic of ORTHO-CYCLEN)

1

2016 601 4T Copper Comm eff 01/01/2016


42

Drug Name Drug Tier

Requirements/Limits

QUARTETTE 3

quasense 91 day 1

reclipsen 28 day (generic of DESOGEN)

1

SEASONIQUE 3

sharobel 28 day (generic of ORTHO MICRONOR)

1

SOLIA 1

sprintec 28 day (generic of ORTHO-CYCLEN)

1

sronyx 28 day 1

syeda (generic of YASMIN 28)

1

tarina fe 1/20 28 day (generic of LOESTRIN FE 1/20)

1

tri-legest 28 day (generic of ESTROSTEP FE)

1

TRI-NORINYL 28 3

tri-previfem 28 day (generic of ORTHO TRI-CYCLEN)

1

tri-sprintec 28 day (generic of ORTHO TRI-CYCLEN)

1

TRINESSA 1

trivora 28 day 1

velivet 28 day (generic of CYCLESSA)

1

vestura (generic of YAZ) 1

viorele (generic of MIRCETTE)

1

vyfemla 28 day (generic of OVCON-35)

1

wymzya fe (generic of FEMCON FE)

1

xulane dis 150-35 (generic of ORTHO EVRA)

1

YASMIN 28 3

YAZ 3

zarah (generic of YASMIN 28) 1

zenchent fe 28 day (generic of FEMCON FE)

1

zenchent tab (generic of OVCON-35)

1

zovia 1/35e 28 day 1

zovia 1/50e 28 day 1

ENDOMETRIOSIS danazol CAPS 1

Drug Name Drug Tier

Requirements/Limits

LUPANETA PACK 4 NM PA

SYNAREL 4 NM

ENZYME REPLACEMENTS ADAGEN 4 NM LA PA

ALDURAZYME 4 NM LA PA

CARBAGLU 4 NM LA PA

CARNITOR SOLN 1gm/10ml

2 B/D

CARNITOR SOLN 200mg/ml

3 B/D

CARNITOR TABS 2 B/D

CERDELGA 4 NM PA

CEREZYME 4 NM LA PA

CYSTADANE 4 NM LA

CYSTAGON 3 NM LA PA

ELAPRASE 4 NM LA PA

ELELYSO 4 NM PA

FABRAZYME 4 NM LA PA

KUVAN 4 NM LA PA

levocarnitine (metabolic modifiers) (generic of CARNITOR)

1 B/D

LUMIZYME 4 NM LA PA

MYOZYME 4 NM LA PA

NAGLAZYME 4 NM LA PA

ORFADIN 4 NM LA PA

PROCYSBI 4 NM LA PA

RAVICTI 4 NM PA

sodium phenylbutyrate (generic of BUPHENYL)

4 NM

VIMIZIM 4 NM PA

VPRIV 4 NM PA

ZAVESCA 4 NM LA PA

ESTROGENS ALORA

PA if 65 years and older 3 PA

CLIMARA PA if 65 years and older

3 PA

DELESTROGEN 3

depo-estradiol 3

estrace CREA 2

estrace TABS PA if 65 years and older

3 PA

estradiol (generic of VIVELLE-DOT) PTTW


3 PA

2016 601 4T Copper Comm eff 01/01/2016


43

Drug Name Drug Tier

Requirements/Limits

estradiol (generic of CLIMARA) PTWK


3 PA

estradiol (generic of ESTRACE) TABS


3 PA

estradiol valerate (generic of DELESTROGEN) OIL

1

ESTRING 3

FEMRING 3

jinteli PA if 65 years and older

3 PA

MENOSTAR PA if 65 years and older

3 PA

MINIVELLE PA if 65 years and older

3 PA

norethindrone acetate-ethinyl estradiol


3 PA

PREMARIN CREAM 2

PREMARIN INJ 3

VAGIFEM 2

VIVELLE-DOT PA if 65 years and older

3 PA

GLUCOCORTICOIDS a-hydrocort 1

CORTEF 3

cortisone acetate TABS 1

DEPO-MEDROL INJ 20MG/ML

3 B/D


3 B/D


3 B/D

dexamethasone CONC 3

dexamethasone ELIX; SOLN; TABS

1

dexamethasone sodium phosphate

1

dexpak taperpak 13 day 2

FLO-PRED SUS 3 B/D

fludrocortisone acetate TABS

1

hydrocortisone (generic of CORTEF) TABS

1

MEDROL PAK 4MG 3 B/D

MEDROL TAB 2MG 3 B/D

Drug Name Drug Tier

Requirements/Limits





methylpr ace inj 40mg/ml (generic of DEPO-MEDROL)

1 B/D

methylpr ace inj 80mg/ml (generic of DEPO-MEDROL)

1 B/D

methylpr ss inj 1gm (generic of SOLU-MEDROL)

1 B/D

methylpr ss inj 40mg (generic of SOLU-MEDROL)

1 B/D

methylpr ss inj 125mg (generic of SOLU-MEDROL)

1 B/D

methylpred pak 4mg (generic of MEDROL DOSEPAK)

1 B/D

methylpred tab 4mg (generic of MEDROL)

1 B/D


1 B/D


1 B/D


1 B/D

millipred 3 B/D

ORAPRED ODT TAB 10MG 2 B/D



pediapred sol 6.7/5ml 3 B/D

pred sod pho sol 5mg/5ml (generic of PEDIAPRED)

1 B/D

prednisolone sodium phosphate (generic of ORAPRED ODT)

1 B/D

prednisolone sol 15mg/5ml 1 B/D

prednisolone sol 25mg/5ml 1 B/D

prednisolone syrup 15 mg/5ml 1 B/D

prednisone con 5mg/ml 3 B/D

prednisone pak 5mg 1 B/D

prednisone pak 10mg 1 B/D

prednisone sol 5mg/5ml 1 B/D

prednisone tab 1mg 1 B/D

prednisone tab 2.5mg 1 B/D





2016 601 4T Copper Comm eff 01/01/2016


44

Drug Name Drug Tier

Requirements/Limits

RAYOS TAB 1MG 4 B/D NM



SOLU-CORTEF 100MG 3

SOLU-CORTEF 250MG 3

SOLU-CORTEF 500MG 3

SOLU-CORTEF 1000MG 3

SOLU-MEDROL INJ 1GM 3 B/D

SOLU-MEDROL INJ 2GM 3 B/D

SOLU-MEDROL INJ 40MG 3 B/D



veripred 3 B/D

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT

2

KORLYM 4 NM LA PA

PROGLYCEM SUS 50MG/ML 3

HUMAN GROWTH HORMONES GENOTROPIN 4 NM LA PA

GENOTROPIN MINIQUICK .2mg

3 NM LA PA

GENOTROPIN MINIQUICK .4mg, .6mg, .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg

4 NM LA PA

HUMATROPE 4 NM LA PA

HUMATROPE COMBO PACK 4 NM LA PA

NORDITROPIN FLEXPRO 4 NM PA

NORDITROPIN NORDIFLEX PEN

4 NM PA

NUTROPIN AQ INJ 20MG/2ML

4 NM LA PA

NUTROPIN AQ NUSPIN 5 4 NM LA PA

NUTROPIN AQ PEN 4 NM LA PA

OMNITROPE 5.8MG 4 NM LA PA

OMNITROPE 5MG 4 NM LA PA

OMNITROPE 10MG 4 NM LA PA

SAIZEN 4 NM LA PA

SAIZEN CLICK.EASY 4 NM LA PA

SEROSTIM 4 NM LA PA

ZOMACTON 4 NM PA

ZORBTIVE 4 NM PA

MISCELLANEOUS AFREZZA 3

Drug Name Drug Tier

Requirements/Limits

cabergoline 1

calcitonin (salmon) nasal spray (generic of MIACALCIN)

1

CHORIONIC GONADOTROPIN SOLR

1 NM PA

EGRIFTA 1mg 4 NM LA PA

EVISTA 3

FORTICAL SPR 200/ACT 3

H.P. ACTHAR QL (1.5 ml / 1 day)

4 QL NM LA PA

INCRELEX 4 NM LA PA

methylergonovine maleate (generic of METHERGINE) TABS

1

MIACALCIN INJ 200U/ML 4 B/D NM

MIACALCIN SPR 200/ACT 3

NOVAREL INJ 10000UNT 1 NM PA

octreotide acetate (generic of SANDOSTATIN) 50mcg/ml, 100mcg/ml

1 NM PA

octreotide acetate (generic of SANDOSTATIN) 200mcg/ml, 500mcg/ml, 1000mcg/ml

4 NM PA

PREGNYL W/DILUENT BENZYL

1 NM PA

PROLIA QL (1 syringe / 180 days)

3 QL NM

raloxifene hcl (generic of EVISTA)

1

SAMSCA 4 NM PA

SANDOSTATIN 4 NM PA

SANDOSTATIN LAR DEPOT 4 NM PA

SIGNIFOR 4 NM LA PA

SIGNIFOR LAR 4 NM LA PA

SOMATULINE DEPOT 4 NM PA

SOMAVERT 4 NM LA PA

XGEVA 4 NM PA

PARATHYROID HORMONES FORTEO 4 NM PA

NATPARA 4 NM PA

PHOSPHATE BINDER AGENTS AURYXIA 4 NM

2016 601 4T Copper Comm eff 01/01/2016


45

Drug Name Drug Tier

Requirements/Limits

calcium acetate (phosphate binder) (generic of PHOSLO) CAPS

1

calcium acetate (phosphate binder) (generic of ELIPHOS) TABS

1

eliphos 3

FOSRENOL 4 NM

PHOSLO 3

PHOSLYRA 2

RENAGEL 400mg 3

RENAGEL 800mg 4 NM

RENVELA PAK 2

RENVELA TAB 800MG 2

VELPHORO 4 NM

PROGESTINS aygestin 3

CRINONE 2

medroxyprogesterone acetate (generic of PROVERA)

1

norethindrone acetate (generic of AYGESTIN) TABS

1

progesterone micronized (generic of PROMETRIUM) CAPS

1

PROMETRIUM 3

PROVERA 3

THYROID AGENTS CYTOMEL 2

levothyroxine sodium (generic of SYNTHROID) TABS

1

LEVOXYL 1

liothyronine sodium (generic of TRIOSTAT) SOLN

1

liothyronine sodium (generic of CYTOMEL) TABS

1

methimazole (generic of TAPAZOLE) TABS

1

propylthiouracil TABS 1

SYNTHROID 2

tapazole 2

TIROSINT 3

TRIOSTAT 3

UNITHROID 1

VASOPRESSINS

Drug Name Drug Tier

Requirements/Limits

DDAVP SOLN 4mcg/ml 4 NM

DDAVP SOLN .01% 2

DDAVP TABS 2

DESMOPRESSIN ACETATE SOLN

1

desmopressin acetate (generic of DDAVP) TABS

1

desmopressin acetate inj (generic of DDAVP)

1

desmopressin acetate spray (generic of DDAVP)

1

desmopressin acetate spray refrigerated

1

STIMATE 4 NM

GASTROINTESTINAL ANTIEMETICS AKYNZEO 3 B/D

ALOXI 4 NM

CESAMET QL (60 caps / 30 days)

4 B/D QL NM

compro supp 1

dronabinol (generic of MARINOL) 2.5mg, 5mg


1 B/D QL

dronabinol (generic of MARINOL) 10mg


4 B/D QL NM

EMEND CAP 40MG 3 B/D



EMEND PAK 80 & 125 3 B/D

granisetron hcl SOLN 1

granisetron hcl TABS 1 B/D

MARINOL 2.5mg QL (60 caps / 30 days)

3 B/D QL

MARINOL 5mg, 10mg QL (60 caps / 30 days)

4 B/D QL NM

meclizine hcl TABS 1

metoclopramide hcl SOLN 1

metoclopramide hcl (generic of REGLAN) TABS

1

metoclopramide hcl (generic of METOZOLV ODT) TBDP

1

metoclopramide hcl inj 5 mg/ml

1

METOZOLV ODT 3

2016 601 4T Copper Comm eff 01/01/2016


46

Drug Name Drug Tier

Requirements/Limits

ondansetron hcl (generic of ZOFRAN) TABS 4mg, 8mg

1 B/D

ondansetron hcl TABS 24mg 1 B/D

ondansetron hcl inj 4mg/2ml 1

ondansetron hcl inj (generic of ZOFRAN) 40mg/20ml

1

ondansetron hcl oral soln (generic of ZOFRAN)

1 B/D

ondansetron odt (generic of ZOFRAN ODT)

1 B/D

phenadoz PA if 65 years and older

3 PA

phenergan PA if 65 years and older

3 PA

phenergan inj PA if 65 years and older

3 PA

prochlorperazine inj 5 mg/ml 1

prochlorperazine maleate (generic of COMPAZINE) TABS

1

prochlorperazine supp 1

promethazine hcl (generic of PHENERGAN) SOLN


3 PA

promethazine hcl SUPP; SYRP; TABS


3 PA

promethegan PA if 65 years and older

3 PA

REGLAN 3

SANCUSO QL (4 patches / 30 days)

4 QL NM

TRANSDERM-SCOP QL (10 patches / 30 days)


3 QL PA

ZOFRAN SOLN 4mg/5ml 4 B/D NM

ZOFRAN TABS 4 B/D NM

ZOFRAN ODT 4 B/D NM

ZUPLENZ 4 B/D NM

ANTISPASMODICS ATROPINE SULFATE SOLN .05mg/ml, .1mg/ml

1

BENTYL CAPS; TABS 2

BENTYL SOLN 3

CANTIL 3

CUVPOSA 3

Drug Name Drug Tier

Requirements/Limits

dicyclomine hcl (generic of BENTYL) CAPS; TABS

1

dicyclomine hcl SOLN 1

glycate 3

glycopyrrolate (generic of ROBINUL) SOLN

1

glycopyrrolate (generic of ROBINUL) TABS 1mg

1

glycopyrrolate (generic of ROBINUL FORTE) TABS 2mg

1

methscopolamine bromide (generic of PAMINE) TABS 2.5mg

1

methscopolamine bromide (generic of PAMINE FORTE) TABS 5mg

1

PAMINE 3

PAMINE FORTE 3

ROBINUL 3

ROBINUL FORTE 3

H2-RECEPTOR ANTAGONISTS cimetidine TABS 1

cimetidine sol 300/5ml 1

famotidine (generic of PEPCID) SUSR

1

famotidine (generic of PEPCID) TABS 20mg, 40mg

1

famotidine inj 1

nizatidine CAPS 150mg 1

nizatidine (generic of AXID) CAPS 300mg

1

nizatidine SOLN 1

PEPCID SUSP 3

pepcid tab 3

ranitidine hcl CAPS 1

ranitidine hcl (generic of ZANTAC) SOLN

1

ranitidine hcl SYRP 1

ranitidine hcl (generic of ZANTAC) TABS 150mg, 300mg

1

ZANTAC 3

INFLAMMATORY BOWEL DISEASE APRISO 2

ASACOL HD 3

2016 601 4T Copper Comm eff 01/01/2016


47

Drug Name Drug Tier

Requirements/Limits

AZULFIDINE 3

AZULFIDINE EN-TABS 3

balsalazide disodium (generic of COLAZAL)

1

budesonide (generic of ENTOCORT EC) CP24

4 NM

CANASA 4 NM

COLAZAL 3

colocort (generic of CORTENEMA)

1

CORTENEMA 3

DELZICOL 3

DIPENTUM 4 NM

ENTOCORT EC 4 NM

ENTYVIO 4 NM PA

GIAZO 4 NM

HYDROCORTISONE (INTRARECTAL)

1

LIALDA 2

mesalamine enema ENEM 1

mesalamine enema (generic of ROWASA) KIT

1

PENTASA 2

ROWASA 3

SF-ROWASA 4 NM

sulfasalazine dr (generic of AZULFIDINE EN-TABS)

1

sulfasalazine ir (generic of AZULFIDINE)

1

UCERIS AER 2MG/ACT 3

UCERIS TAB 9MG 4 NM

LAXATIVES COLYTE-FLAVOR PACKS 3

constulose 1

enulose 1

gaviltye-g (generic of GOLYTELY)

1

gavilyte-c (generic of COLYTE-FLAVOR PACKS)

1

gavilyte-h 1

gavilyte-n (generic of NULYTELY/FLAVOR PACKS)

1

generlac 1

GOLYTELY 3

kristalose 3

lactulose 1

Drug Name Drug Tier

Requirements/Limits

lactulose (encephalopathy) 1

MOVIPREP 2

NULYTELY/FLAVOR PACKS 3

OSMOPREP 3

PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE

1

PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE

1

peg 3350-potassium chloride-sod bicarbonate-sod chloride (generic of NULYTELY/FLAVOR PACKS)

1

polyethylene glycol 3350 PACK; POWD

1

PREPOPIK 3

RELISTOR 4 NM PA

SUCLEAR 2

SUPREP BOWEL PREP 2

trilyte (generic of NULYTELY/FLAVOR PACKS)

1

MISCELLANEOUS ACTIGALL 2

alosetron hcl (generic of LOTRONEX)

4 NM PA

AMITIZA 2

amoxicillin-clarithromycin w/ lansoprazole (generic of PREVPAC)

1

CARAFATE 2

cromolyn sodium (mastocytosis) (generic of GASTROCROM)

4 NM

CYTOTEC 2

diphenoxylate w/ atropine LIQD

1

diphenoxylate w/ atropine (generic of LOMOTIL) TABS

1

GASTROCROM 4 NM

GATTEX 4 NM LA PA

LINZESS 2

LOMOTIL 2

loperamide hcl CAPS 1

LOTRONEX 4 NM PA

2016 601 4T Copper Comm eff 01/01/2016


48

Drug Name Drug Tier

Requirements/Limits

misoprostol (generic of CYTOTEC) TABS

1

MOVANTIK 2

OMECLAMOX-PAK 3

PREVPAC 4 NM

PYLERA 4 NM

SUCRAID 4 NM LA

sucralfate (generic of CARAFATE) TABS

1

URSO 250 2

URSO FORTE 2

ursodiol (generic of ACTIGALL) CAPS

1

ursodiol (generic of URSO 250) TABS 250mg

1

ursodiol (generic of URSO FORTE) TABS 500mg

1

XIFAXAN TAB 550MG 4 NM PA

PANCREATIC ENZYMES CREON 2

PANCREAZE 3

PERTZYE 3

ULTRESA 2

VIOKACE 10 2

VIOKACE 20 4 NM

ZENPEP 2

PROTON PUMP INHIBITORS ACIPHEX

QL (30 tabs / 30 days) 3 QL

ACIPHEX SPR CAP 5MG 3

ACIPHEX SPR CAP 10MG QL (60 caps / 30 days)

3 QL

DEXILANT 2

esomeprazole sodium inj 20mg

1

esomeprazole sodium inj (generic of NEXIUM I.V.) 40mg

1

lansoprazole (generic of PREVACID) CPDR


1 QL

NEXIUM CAP 20MG 2

NEXIUM CAP 40MG 2

NEXIUM GRA 2.5MG DR 2

NEXIUM GRA 5MG DR 2

NEXIUM GRA 10MG DR 2

Drug Name Drug Tier

Requirements/Limits



NEXIUM I.V. 3

omeprazole (generic of PRILOSEC) CPDR 10mg, 40mg


1 QL

omeprazole (generic of PRILOSEC) CPDR 20mg

1

OMEPRAZOLE-SODIUM BICARBONATE


1 QL

pantoprazole sodium (generic of PROTONIX)


1 QL

PREVACID QL (30 caps / 30 days)

3 QL

PREVACID SOLUTAB QL (30 tabs / 30 days)

3 QL

PRILOSEC CPDR 10mg, 40mg


3 QL

PRILOSEC CPDR 20mg QL (60 caps / 30 days)

3 QL

PRILOSEC PACK 3

PROTONIX PACK QL (30 packets / 30 days)

3 QL

PROTONIX TBEC QL (30 tabs / 30 days)

3 QL

PROTONIX INJ 3

rabeprazole sodium (generic of ACIPHEX)


1 QL

ZEGERID CAPS QL (30 caps / 30 days)

3 QL

ZEGERID PACK QL (30 packets / 30 days)

3 QL

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of UROXATRAL)

1

AVODART 2

CARDURA XL 3

finasteride (generic of PROSCAR) TABS 5mg

1

2016 601 4T Copper Comm eff 01/01/2016


49

Drug Name Drug Tier

Requirements/Limits

FLOMAX 3

JALYN 3

PROSCAR 3

RAPAFLO 2

tamsulosin hcl (generic of FLOMAX)

1

UROXATRAL 3

MISCELLANEOUS bethanechol chloride (generic of URECHOLINE) TABS

1

ELMIRON 3

potassium citrate (alkalinizer) (generic of UROCIT-K 15) 15meq

1

POTASSIUM CITRATE (ALKALINIZER) 540mg

1

POTASSIUM CITRATE (ALKALINIZER) 1080mg

1

urecholine 2

UROCIT-K 2

URINARY ANTISPASMODICS DETROL 3

DETROL LA 3

DITROPAN XL 3

ENABLEX 3

GELNIQUE 2

MYRBETRIQ 2

oxybutynin chloride SYRP; TABS

1

oxybutynin chloride (generic of DITROPAN XL) TB24

1

OXYTROL 3

tolterodine tartrate er (generic of DETROL LA)

1

tolterodine tartrate tab 1 mg (generic of DETROL)

1

tolterodine tartrate tab 2 mg (generic of DETROL)

1

TOVIAZ 3

trospium chloride 1

trospium chloride er 1

VESICARE 2

VAGINAL ANTI-INFECTIVES AVC 3

CLEOCIN CREA 2

Drug Name Drug Tier

Requirements/Limits

CLEOCIN VAG SUPP 100MG 3

clindamycin cre 2% vag (generic of CLEOCIN)

1

METROGEL-VAGINAL 2

metronidazole vaginal (generic of METROGEL-VAGINAL)

1

miconazole 3 sup 200mg 1

NUVESSA 3

TERAZOL 3 2

TERAZOL 7 2

terconazole vaginal (generic of TERAZOL 7) CREA .4%

1

terconazole vaginal (generic of TERAZOL 3) CREA .8%

1

terconazole vaginal SUPP 1

VANDAZOLE 1

zazole (generic of TERAZOL 7) .4%

1

ZAZOLE .8% 1

HEMATOLOGIC ANTICOAGULANTS ARIXTRA 2.5mg/0.5ml, 7.5mg/0.6ml, 10mg/0.8ml

4 NM

COUMADIN 3

ELIQUIS TAB 2.5MG 2

ELIQUIS TAB 5MG 2

enoxaparin sodium (generic of LOVENOX) 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 300mg/3ml

1

enoxaparin sodium (generic of LOVENOX) 100mg/ml, 120mg/0.8ml, 150mg/ml

4 NM

fondaparinux sodium (generic of ARIXTRA) 2.5mg/0.5ml

1

fondaparinux sodium (generic of ARIXTRA) 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml

4 NM

FRAGMIN 2500unit/0.2ml, 5000unit/0.2ml

2

FRAGMIN 7500unit/0.3ml, 10000unit/ml, 12500unit/0.5ml, 15000unit/0.6ml, 18000unt/0.72ml, 95000unit/3.8ml

4 NM

2016 601 4T Copper Comm eff 01/01/2016


50

Drug Name Drug Tier

Requirements/Limits

HEP SOD/NACL INJ 25000 1

HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML

1

heparin sod inj 1000u/ml 1 B/D

HEPARIN SOD INJ 2000U/ML

3 B/D

HEPARIN SOD INJ 2500U/ML

3 B/D

heparin sod inj 5000u/0.5ml 1 B/D




HEPARIN SODIUM/D5W 1

HEPARIN SODIUM/NACL 0.45%

3

jantoven (generic of COUMADIN)

1

LOVENOX 30mg/0.3ml, 40mg/0.4ml, 300mg/3ml

2

LOVENOX 60mg/0.6ml, 80mg/0.8ml, 100mg/ml, 120mg/0.8ml, 150mg/ml

4 NM

PRADAXA 2

SAVAYSA 3

warfarin sodium (generic of COUMADIN)

1

XARELTO 2

XARELTO STARTER PACK 2

HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 10mcg/0.4ml, 25mcg/0.42ml, 25mcg/ml, 40mcg/0.4ml, 40mcg/ml, 60mcg/0.3ml, 60mcg/ml

2 NM PA

ARANESP ALBUMIN FREE 100mcg/0.5ml, 100mcg/ml, 150mcg/0.3ml, 150mcg/0.75ml, 200mcg/0.4ml, 200mcg/ml, 300mcg/0.6ml, 300mcg/ml, 500mcg/ml

4 NM PA

EPOGEN 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

3 NM PA

EPOGEN 20000unit/ml 4 NM PA

GRANIX 4 NM PA

Drug Name Drug Tier

Requirements/Limits

LEUKINE 4 NM PA

MIRCERA 3 NM PA

MOZOBIL 4 NM PA

NEULASTA 4 NM PA

NEUMEGA 4 NM PA

NEUPOGEN 4 NM PA

PROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

2 NM PA

PROCRIT 20000unit/ml, 40000unit/ml

4 NM PA

MISCELLANEOUS AGRYLIN 2

anagrelide hcl 1mg 1

anagrelide hcl (generic of AGRYLIN) .5mg

1

BERINERT 4 NM PA

cilostazol (generic of PLETAL) 1

CINRYZE 4 NM LA PA

CYKLOKAPRON 3

FIRAZYR 4 NM PA

LYSTEDA 3

pentoxifylline TBCR 1

PLETAL 2

PROMACTA 12.5mg QL (360 tabs / 30 days)

4 QL NM LA PA

PROMACTA 25mg QL (180 tabs / 30 days)

4 QL NM LA PA


4 QL NM LA PA


4 QL NM LA PA

RUCONEST 4 NM PA

tranexamic acid (generic of CYKLOKAPRON) SOLN

1

tranexamic acid (generic of LYSTEDA) TABS

1

PLATELET AGGREGATION INHIBITORS AGGRENOX 2

ASPIRIN-DIPYRIDAMOLE 1

BRILINTA 2

clopidogrel bisulfate (generic of PLAVIX)

1

EFFIENT 2

PLAVIX 3

ZONTIVITY 3

2016 601 4T Copper Comm eff 01/01/2016


51

Drug Name Drug Tier

Requirements/Limits

IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA 4 NM PA

ARAVA 4 NM

CIMZIA 4 NM PA

ENBREL 4 NM PA

ENBREL SURECLICK 4 NM PA

HUMIRA 4 NM PA

HUMIRA PEN 4 NM PA

HUMIRA PEN-CROHNS STARTER KIT

4 NM PA

HUMIRA PEN-PSORIASIS STARTER KIT

4 NM PA

hydroxychloroquine sulfate (generic of PLAQUENIL)

1

KINERET 4 NM PA

leflunomide (generic of ARAVA) TABS

1

methotrexate sodium tabs 1

ORENCIA 4 NM PA

OTEZLA 4 NM PA

PLAQUENIL 2

REMICADE 4 NM PA

RHEUMATREX 2

SIMPONI 4 NM PA

SIMPONI ARIA 4 NM PA

trexall 2 B/D

XELJANZ 4 NM PA

IMMUNOGLOBULINS BIVIGAM 4 NM PA

CARIMUNE NANOFILTERED 12gm

4 NM PA

FLEBOGAMMA 4 NM PA

FLEBOGAMMA DIF 4 NM PA

GAMASTAN S/D 2 B/D NM

GAMMAGARD LIQUID 4 NM PA

GAMMAGARD S/D 4 NM PA

GAMMAGARD S/D IGA LESS TH

4 NM PA

GAMMAKED 4 NM PA

GAMMAPLEX 2.5gm/50ml, 5gm/100ml, 10gm/200ml

4 NM PA

GAMUNEX-C 4 NM PA

Drug Name Drug Tier

Requirements/Limits

OCTAGAM 1gm/20ml, 2gm/20ml, 2.5gm/50ml, 5gm/100ml, 10gm/200ml, 25gm/500ml

4 NM PA

PRIVIGEN 4 NM PA

IMMUNOMODULATORS ACTIMMUNE 4 NM LA PA

ARCALYST 4 NM PA

GRASTEK 2 PA

INTRON-A INJ 10MU 4 B/D NM




RAGWITEK 2 PA

REVLIMID 4 NM LA PA

THALOMID 4 NM PA

IMMUNOSUPPRESSANTS ASTAGRAF XL 5mg 4 B/D NM

ASTAGRAF XL .5mg, 1mg 3 B/D

ATGAM 4 B/D NM

azasan 2 B/D

azathioprine (generic of IMURAN) TABS

1 B/D

BENLYSTA 4 NM PA

CELLCEPT CAP 4 B/D NM

CELLCEPT INTRAVENOUS 3 B/D

CELLCEPT SUSP 4 B/D NM

CELLCEPT TAB 4 B/D NM

cyclosporine (generic of SANDIMMUNE) CAPS; SOLN

1 B/D

cyclosporine modified (for microemulsion) (generic of NEORAL) CAPS 25mg, 100mg

1 B/D

cyclosporine modified (for microemulsion) CAPS 50mg

1 B/D

cyclosporine modified (for microemulsion) (generic of NEORAL) SOLN

1 B/D

gengraf (generic of NEORAL) 1 B/D

IMURAN 2 B/D

mycophenolate mofetil (generic of CELLCEPT) CAPS; TABS

1 B/D

mycophenolate mofetil SUSR

4 B/D NM

2016 601 4T Copper Comm eff 01/01/2016


52

Drug Name Drug Tier

Requirements/Limits

mycophenolate sodium (generic of MYFORTIC) 180mg

1 B/D

mycophenolate sodium (generic of MYFORTIC) 360mg

4 B/D NM

MYFORTIC 180mg 2 B/D

MYFORTIC 360mg 4 B/D NM

NEORAL 2 B/D

NULOJIX 4 B/D NM

PROGRAF CAPS 5mg 4 B/D NM

PROGRAF CAPS .5mg, 1mg

2 B/D

PROGRAF SOLN 3 B/D

RAPAMUNE SOLN 4 B/D NM

RAPAMUNE TABS 1mg, 2mg

4 B/D NM

RAPAMUNE TABS .5mg 2 B/D

SANDIMMUNE CAPS 2 B/D

SANDIMMUNE INJ 3 B/D

SANDIMMUNE SOLN 2 B/D

SIMULECT 10mg 3 B/D

SIMULECT 20mg 4 B/D NM

SIROLIMUS TABS 2mg 4 B/D NM

sirolimus (generic of RAPAMUNE) TABS .5mg, 1mg

1 B/D

tacrolimus (generic of PROGRAF) CAPS 5mg

4 B/D NM

tacrolimus (generic of PROGRAF) CAPS .5mg, 1mg

1 B/D

THYMOGLOBULIN 4 B/D NM

ZORTRESS TAB 0.5MG 4 B/D NM

ZORTRESS TAB 0.25MG 3 B/D

ZORTRESS TAB 0.75MG 4 B/D NM

VACCINES ACTHIB 3

ADACEL 3

BCG VACCINE 3

BEXSERO 3

BOOSTRIX 3

CERVARIX 3

COMVAX 3

DAPTACEL 3

DIPHTHERIA/TETANUS TOXOID

3 B/D

Drug Name Drug Tier

Requirements/Limits

ENGERIX-B SUSP 3 B/D

GARDASIL 3

GARDASIL 9 3

HAVRIX 3

HIBERIX 3

IMOVAX RABIES (H.D.C.V.) 3

INFANRIX 3

IPOL INACTIVATED IPV 2

IXIARO 3

KINRIX 3

M-M-R II 3

MENACTRA 3

MENOMUNE-A/C/Y/W-135 3

MENVEO 3

PEDVAX HIB 3

PROQUAD 3

QUADRACEL 3

RABAVERT 3

RECOMBIVAX HB 3 B/D

ROTARIX 2

ROTATEQ 3

SYNAGIS 4 NM

TENIVAC 3 B/D

TETANUS/DIPHTHERIA TOXOID

3 B/D

TRUMENBA 3

TWINRIX INJ 3

TYPHIM VI 3

VAQTA 3

VARIVAX 3

YF-VAX 3

ZOSTAVAX 3

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES ammonium chloride SOLN 3

K-TAB 8meq, 20meq 3

K-TAB 10meq 2

KLOR-CON 8 1

KLOR-CON 10 1

klor-con m15 3

klor-con m20 1

klor-con pow 20meq 1

MAGNESIUM SULFATE SOLN 40mg/ml, 80mg/ml

3

2016 601 4T Copper Comm eff 01/01/2016


53

Drug Name Drug Tier

Requirements/Limits

magnesium sulfate SOLN 50%

1

MAGNESIUM SULFATE IN D5W

3

MAGNESIUM SULFATE INJ 50%

1

MICRO-K 2

POTASSIUM CHLORIDE LIQD

1

potassium chloride TBCR 8meq

1

POTASSIUM CHLORIDE TBCR 20meq

1

potassium chloride caps er (generic of MICRO-K)

1

potassium chloride microencapsulated crystals cr

1

POTASSIUM CHLORIDE TAB CR 10 MEQ

1

SODIUM CHLORIDE SOLN 2.5meq/ml

1

SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN

1

TPN ELECTROLYTES 1 B/D

IV NUTRITION AMINOSYN 3 B/D

AMINOSYN 7%/ELECTROLYTES

3 B/D

AMINOSYN II 3 B/D

AMINOSYN II 8.5%/ELECTROL

1 B/D

AMINOSYN INJ 8.5/LYTE 1 B/D

AMINOSYN M 3 B/D

AMINOSYN-HBC 3 B/D

AMINOSYN-PF 7% 3 B/D

AMINOSYN-PF INJ 10% 3 B/D

AMINOSYN-RF 3 B/D

CLINIMIX 2.75%/DEXTROSE 5%

3 B/D


3 B/D


3 B/D


3 B/D


3 B/D

Drug Name Drug Tier

Requirements/Limits

CLINIMIX 5%/DEXTROSE 15%

3 B/D


3 B/D


3 B/D

CLINIMIX E 2.75%/DEXTROSE 5%

3 B/D


3 B/D

CLINIMIX E 4.25%/D10 3 B/D


3 B/D


3 B/D

CLINIMIX E 5%/DEXTROSE 15%

3 B/D


3 B/D


3 B/D

clinisol 15 1 B/D

FREAMINE HBC 6.9% 3 B/D

FREAMINE III 3 B/D

HEPATAMINE 1 B/D

INTRALIPID INJ 20% 1 B/D

INTRALIPID INJ 30% 3 B/D

LIPOSYN II 3 B/D

LIPOSYN III 3 B/D

NEPHRAMINE 3 B/D

NUTRILIPID INJ 20% 1 B/D

premasol 6% 1 B/D

premasol 10% 3 B/D

PROCALAMINE 3 B/D

PROSOL 3 B/D

TRAVASOL 3 B/D

TROPHAMINE INJ 6% 3 B/D

TROPHAMINE INJ 10% 3 B/D

IV REPLACEMENT SOLUTIONS DEXTROSE SOLN 1

DEXTROSE 2.5%/NACL 0.45%

1

DEXTROSE 5% 1

DEXTROSE 5% /ELECTROLYTE

3

DEXTROSE 5%/LACTATED RING

1

2016 601 4T Copper Comm eff 01/01/2016


54

Drug Name Drug Tier

Requirements/Limits

DEXTROSE 5%/NACL 0.2% 1





DEXTROSE 5%/NACL 0.225%

1

DEXTROSE 5%/POTASSIUM CHL

1

DEXTROSE 10% FLEX CONTAIN

1

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

3

DEXTROSE 10%/NACL 0.45%

1

ELECTROLYTE-R IN DEXTROSE

3

IONOSOL-B/DEXTROSE 5% 3

IONOSOL-MB/DEXTROSE 5%

3

ISOLYTE P 3

ISOLYTE S 3

KCL0.15%/D5W/NACL0.2% 1

KCL0.15%/D5W/NACL0.225%

3

KCL 0.3%/D5W/LR IV LAC RI 3

KCL 0.3%/D5W/NACL 0.9% 3

KCL 0.3%/D5W/NACL 0.45% 1

KCL 0.15%/D5W/LR 3

KCL 0.15%/D5W/NACL 0.9% 1

KCL 0.075%/D5W/NACL 0.45%

1

KCL IN NACL INJ .15-0.45 1

KCL/D5W/NACL INJ 0.22%/0.45%

1

KCL/D5W/NACL INJ .15/.33% 1

KCL/D5W/NACL INJ .15/.45% 1

KCL/NACL INJ 0.15%-0.9% 1

LACTATED RINGERS VIAFLEX

1

NORMOSOL-M IN D5W 1

NORMOSOL-R 3

PLASMA-LYTE A 3

PLASMA-LYTE-56/D5W 3

PLASMA-LYTE-148 3

Drug Name Drug Tier

Requirements/Limits

pot chloride inj 2meq/ml 1

POTASSIUM CHLORIDE SOLN

1

POTASSIUM CHLORIDE 0.3%/D

1

potassium chloride in nacl 1

POTASSIUM CHLORIDE IN NACL

1

RINGER'S 1

SODIUM CHLORIDE SOLN .9%, 3%, 5%

1

SODIUM CHLORIDE 0.45% VIA

1

VITAMINS calcitriol (generic of ROCALTROL) CAPS

1 B/D

calcitriol SOLN 1mcg/ml 1 B/D

calcitriol (generic of ROCALTROL) SOLN 1mcg/ml

1 B/D

doxercalciferol (generic of HECTOROL) CAPS 1mcg, 2.5mcg

4 B/D NM

doxercalciferol (generic of HECTOROL) CAPS .5mcg

1 B/D

doxercalciferol (generic of HECTOROL) SOLN

1 B/D

HECTOROL CAPS 1mcg, 2.5mcg

4 B/D NM

HECTOROL CAPS .5mcg 2 B/D

HECTOROL SOLN 3 B/D

paricalcitol (generic of ZEMPLAR) CAPS 1mcg, 2mcg

1 B/D

paricalcitol CAPS 4mcg 1 B/D

PARICALCITOL SOLN 3 B/D

PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)

1

ROCALTROL 2 B/D

ZEMPLAR CAPS 1mcg 2 B/D

ZEMPLAR CAPS 2mcg 4 B/D NM

ZEMPLAR SOLN 3 B/D

OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 1

blephamide OINT 3

BLEPHAMIDE SUSP 3

2016 601 4T Copper Comm eff 01/01/2016


55

Drug Name Drug Tier

Requirements/Limits

MAXITROL 3

neomycin-polymy-dexameth (generic of MAXITROL)

1

neomycin-polymyxin-hc (ophth)

1

PRED-G 3

PRED-G S.O.P. 3

sulfacetamide sod-prednisolone

1

TOBRADEX OINT 2

TOBRADEX SUSP 3

TOBRADEX ST 2

tobramycin-dexamethasone (generic of TOBRADEX)

1

ZYLET 2

ANTI-INFECTIVES AZASITE 3

bacitracin (ophthalmic) 1

bacitracin-polymyxin b (ophth) 1

BESIVANCE 2

BLEPH-10 3

CILOXAN OIN 0.3% OP 3

CILOXAN SOL 0.3% OP 3

ciprofloxacin hcl (ophth) (generic of CILOXAN)

1

erythromycin (ophth) 1

garamycin 3

gatifloxacin (ophth) (generic of ZYMAXID)

1

gentak 1

gentamicin sulfate (ophth) OINT

1

gentamicin sulfate (ophth) (generic of GARAMYCIN) SOLN

1

ilotycin 1

levofloxacin (ophth) 1

MOXEZA 2

NATACYN 3

neomycin-bacitracin zn-polymyxin

1

neomycin-polymyxin-gramicidin (generic of NEOSPORIN)

1

neosporin solution 3

OCUFLOX 3

Drug Name Drug Tier

Requirements/Limits

ofloxacin (ophth) (generic of OCUFLOX)

1

polymyxin b-trimethoprim (generic of POLYTRIM)

1

POLYTRIM 3

sulfacet sod oin 10% op 1

sulfacetamide sodium (ophth) (generic of BLEPH-10)

1

tobramycin (ophth) (generic of TOBREX)

1

TOBREX OINT 0.3% 3

TOBREX SOL 0.3% OP 3

trifluridine (generic of VIROPTIC) SOLN

1

VIGAMOX 2

VIROPTIC 2

ZIRGAN 3

ZYMAXID 3

ANTI-INFLAMMATORIES ACULAR 3

ACULAR LS 3

ACUVAIL 3

ALREX 2

bromfenac sodium (ophth) 1

BROMFENAC SODIUM (OPHTH)(ONCE-DAILY)

1

dexamethasone sodium phosphate (ophth)

1

diclofenac sodium (ophth) 1

DUREZOL 2

FLAREX 3

FLUOROMETHOLONE (OPHTH)

1

flurbiprofen sodium (generic of OCUFEN)

1

FML 3

FML FORTE 3

FML LIQUIFILM 3

ILEVRO 3

ketorolac tromethamine (ophth) (generic of ACULAR LS) .4%

1

ketorolac tromethamine (ophth) (generic of ACULAR) .5%

1

LOTEMAX 2

2016 601 4T Copper Comm eff 01/01/2016


56

Drug Name Drug Tier

Requirements/Limits

MAXIDEX 3

OCUFEN 3

OMNIPRED 3

PRED FORTE 3

PRED MILD 3

PREDNISOLONE ACETATE (OPHTH)

1

prednisolone sodium phosphate (ophth)

3

VEXOL 3

ANTIALLERGICS ALOCRIL 3

ALOMIDE 3

azelastine drop 0.05% 1

BEPREVE 3

cromolyn sodium (ophth) 1

ELESTAT 3

EMADINE 3

epinastine hcl (ophth) (generic of ELESTAT)

1

LASTACAFT 3

PATADAY 2

PATANOL 2

PAZEO 3

ANTIGLAUCOMA ALPHAGAN P 0.1% 2

ALPHAGAN P 0.15% 2

AZOPT 2

BETAGAN 3

betaxolol hcl (ophth) 1

BETIMOL 2

BETOPTIC-S 2

brimonidine sol 0.2% 1

BRIMONIDINE SOL 0.15% 1

carteolol hcl (ophth) 1

COMBIGAN 2

COSOPT 3

COSOPT PF 2

dorzolamide hcl (generic of TRUSOPT)

1

dorzolamide hcl-timolol maleate (generic of COSOPT)

1

ISOPTO CARPINE 3

ISTALOL 3

Drug Name Drug Tier

Requirements/Limits

latanoprost (generic of XALATAN) SOLN

1

levobunolol hcl (generic of BETAGAN) .5%

1

LEVOBUNOLOL HCL .25% 1

LUMIGAN 3

metipranolol 1

OPTIPRANOLOL 3

PHOSPHOLINE IODIDE 3

PILOCARPINE HCL SOLN 1

SIMBRINZA SUS 1-0.2% 2

timolol maleate (ophth) (generic of TIMOPTIC)

1

TIMOLOL MALEATE GEL 1

TIMOPTIC 3

TIMOPTIC OCUDOSE 3

TIMOPTIC-XE 3

TRAVATAN Z 2

TRUSOPT 3

XALATAN 3

ZIOPTAN 2

MISCELLANEOUS alcaine 3

LACRISERT 3

naphazoline 0.1% 1

PROLENSA 2

proparacaine hcl (generic of ALCAINE) SOLN

1

RESTASIS 2

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPT AER 62.5-25

QL (60 inhalations / 30 days)

2 QL

COMBIVENT RESPIMAT QL (2 inhalers / 30 days)

2 QL

ipratropium-albuterol 1 B/D

STIOLTO RESPIMAT QL (1 inhaler / 30 days)

3 QL

ANTICHOLINERGICS ATROVENT 2

ATROVENT HFA QL (2 inhalers / 30 days)

3 QL

2016 601 4T Copper Comm eff 01/01/2016


57

Drug Name Drug Tier

Requirements/Limits

INCRUSE ELLIPTA QL (1 inhaler / 30 days)

3 QL

ipratropium bromide (nasal) (generic of ATROVENT)

1

ipratropium sol inhal 1 B/D

SPIRIVA HANDIHALER QL (30 caps / 30 days)

2 QL

SPIRIVA RESPIMAT QL (1 inhaler / 30 days)

2 QL

TUDORZA PRESSAIR QL (1 inhaler / 30 days)

3 QL

TUDORZA PRESSAIR (INSTITUTIONAL PACK)


3 QL

ANTIHISTAMINE COMBINATIONS CLARINEX-D TAB 2.5-120 3

DYMISTA SPR 137-50 QL (1 bottle / 30 days)

3 QL

SEMPREX-D 3

ANTIHISTAMINES ASTEPRO 3

azelastine spr 0.1% 1

azelastine spr 0.15% (generic of ASTEPRO)

1

cetirizine syrup 1

CLARINEX 3

desloratadine (generic of CLARINEX) TABS

1

desloratadine (generic of CLARINEX REDITABS) TBDP

1

diphenhydram inj 50mg/ml 1

hydroxyzine hcl SOLN 25mg/ml, 50mg/ml


3 PA

levocetirizine soln 2.5mg/5ml (generic of XYZAL)

1

levocetirizine tab 5 mg (generic of XYZAL)

1

olopatadine hcl (nasal) (generic of PATANASE)

1

PATANASE 3

XYZAL SOLN 3

XYZAL TABS 2

BETA AGONISTS albuterol sulfate NEBU 1 B/D

Drug Name Drug Tier

Requirements/Limits

albuterol sulfate SYRP; TABS

1

albuterol sulfate er (generic of VOSPIRE ER)

1

ARCAPTA NEOHALER QL (30 caps / 30 days)

2 QL

BROVANA 3 B/D

FORADIL AEROLIZER QL (60 caps / 30 days)

2 QL

levalbuterol conc 1.25mg/0.5ml (generic of XOPENEX CONCENTRATE)

1 B/D

LEVALBUTEROL HCL NEBU 1.25mg/3ml

1 B/D

levalbuterol hcl (generic of XOPENEX) NEBU .31mg/3ml, .63mg/3ml

1 B/D

PERFOROMIST 2 B/D

PROAIR HFA QL (2 inhalers / 30 days)

2 QL

PROAIR RESPICLICK QL (2 inhalers / 30 days)

3 QL

PROVENTIL HFA QL (2 inhalers / 30 days)

3 QL

SEREVENT DISKUS QL (60 inhalations / 30 days)

2 QL

STRIVERDI RESPIMAT QL (1 inhaler / 30 days)

3 QL

terbutaline sulfate SOLN 4 NM

terbutaline sulfate TABS 1

VENTOLIN HFA QL (2 inhalers / 30 days)

3 QL

vospire 2

XOPENEX 3 B/D

XOPENEX CONCENTRATE 3 B/D

XOPENEX HFA QL (2 inhalers / 30 days)

3 QL

LEUKOTRIENE RECEPTOR ANTAGONISTS ACCOLATE 3

montelukast sodium (generic of SINGULAIR) CHEW; PACK; TABS

1

SINGULAIR 3

zafirlukast (generic of ACCOLATE)

1

2016 601 4T Copper Comm eff 01/01/2016


58

Drug Name Drug Tier

Requirements/Limits

ZYFLO CR 4 NM

MAST CELL STABILIZERS cromolyn sodium NEBU 1 B/D

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

1 B/D

ADRENACLICK 3

ARALAST NP 4 NM LA PA

AUVI-Q 2

DALIRESP 2

EPINEPHRINE SOAJ 1

EPIPEN 2-PAK 2

EPIPEN-JR 2-PAK 2

ESBRIET 4 NM PA

GLASSIA 4 NM LA PA

KALYDECO 4 NM PA

OFEV 4 NM PA

ORKAMBI 4 NM PA

PROLASTIN-C 4 NM LA PA

PULMOZYME 4 B/D NM

tyzine .05% 3

XOLAIR 4 NM LA PA

ZEMAIRA 4 NM LA PA

NASAL STEROIDS BECONASE AQ

QL (2 inhalers / 30 days) 3 QL

budesonide (nasal) (generic of RHINOCORT AQUA)

QL (2 bottles / 30 days)

1 QL

flunisolide (nasal) QL (2 bottles / 30 days)

1 QL

fluticasone propionate (nasal) QL (1 bottle / 30 days)

1 QL

NASONEX QL (2 inhalers / 30 days)

2 QL

OMNARIS QL (1 inhaler / 30 days)

3 QL

QNASL QL (1 inhaler / 30 days)

3 QL

QNASL CHILDRENS QL (1 inhaler / 30 days)

3 QL

RHINOCORT AQUA QL (2 bottles / 30 days)

3 QL

triamcinolone acetonide (nasal)

QL (1 bottle / 30 days)

1 QL

Drug Name Drug Tier

Requirements/Limits

VERAMYST QL (1 bottle / 30 days)

3 QL

ZETONNA QL (1 inhaler / 30 days)

3 QL

STEROID INHALANTS AEROSPAN

QL (2 inhalers / 30 days) 3 QL

ALVESCO QL (2 inhalers / 30 days)

3 QL

ARNUITY ELLIPTA QL (30 inhalations / 30 days)

3 QL

ASMANEX QL (2 inhalers / 30 days)

2 QL

ASMANEX HFA 100mcg/act QL (2 inhalers / 30 days)

2 QL

ASMANEX HFA 200mcg/act QL (1 inhaler / 30 days)

2 QL

budesonide (inhalation) (generic of PULMICORT)

1 B/D

FLOVENT DISKUS 50mcg/blist, 100mcg/blist


2 QL

FLOVENT DISKUS 250mcg/blist


2 QL

FLOVENT HFA QL (2 inhalers / 30 days)

2 QL

PULMICORT FLEXHALER QL (2 inhalers / 30 days)

2 QL

PULMICORT INH SUSP 0.5MG/2 ML

3 B/D

PULMICORT INH SUSP 0.25MG/2 ML

3 B/D

PULMICORT INH SUSP 1MG/2ML

4 B/D NM

QVAR 40mcg/act QL (1 inhaler / 30 days)

2 QL

QVAR 80mcg/act QL (2 inhalers / 30 days)

2 QL

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS


2 QL

2016 601 4T Copper Comm eff 01/01/2016


59

Drug Name Drug Tier

Requirements/Limits

ADVAIR HFA QL (1 inhaler / 30 days)

2 QL

BREO ELLIPTA QL (60 inhalations / 30 days)

3 QL

DULERA QL (1 inhaler / 30 days)

2 QL

SYMBICORT QL (1 inhaler / 30 days)

3 QL

XANTHINES aminophylline inj 1

elixophyllin 3

theo-24 3

theophylline 1

TOPICAL DERMATOLOGY, ACNE ABSORICA 4 NM

ACANYA 2

ACZONE 3

adapalene (generic of DIFFERIN) CREA; GEL

1

amnesteem 1

ATRALIN 2

AVITA CREA 1

AVITA GEL 1

AZELEX 3

BENZACLIN 2

BENZAMYCIN 3

benzoyl peroxide-erythromycin (generic of BENZAMYCIN)

1

claravis 1

CLEOCIN-T 3

CLINDAGEL 3

clindamax (generic of CLEOCIN-T)

1

clindamycin phosphate (topical) (generic of EVOCLIN) FOAM

1

clindamycin phosphate (topical) (generic of CLEOCIN-T) GEL; LOTN; SOLN; SWAB

1

clindamycin phosphate-benzoyl peroxide (generic of BENZACLIN)

1

Drug Name Drug Tier

Requirements/Limits

clindamycin phosphate-benzoyl peroxide (refrigerate) (generic of DUAC)

1

DIFFERIN 2

DUAC 3

EPIDUO 2

ery pad 2% 1

erygel 3

erythromycin (acne aid) (generic of ERYGEL) GEL

1

erythromycin (acne aid) SOLN

1

EVOCLIN 3

FABIOR 3

KLARON 3

myorisan 1

neuac gel 1.2-5% (generic of DUAC)

1

ONEXTON 3

RETIN-A 3

RETIN-A MICRO 2

RETIN-A MICRO PUMP 2

sulfacetamide sodium (acne) (generic of KLARON)

1

tretin-x CREA 3

tretinoin (generic of RETIN-A) CREA

1

TRETINOIN GEL .01% 1

tretinoin (generic of RETIN-A) GEL .025%

1

TRETINOIN MICROSPHERE 1

VELTIN 3

zenatane 1

ZIANA 3

DERMATOLOGY, ANTIBIOTICS ALTABAX 3

BACTROBAN 2

BACTROBAN NASAL 3

CENTANY 3

CORTISPORIN CREA; OINT

3

gentamicin sulfate (topical) 1

mupirocin (generic of BACTROBAN) OINT

1

2016 601 4T Copper Comm eff 01/01/2016


60

Drug Name Drug Tier

Requirements/Limits

mupirocin calcium (topical) (generic of BACTROBAN)

1

SILVADENE 2

SILVER SULFADIAZINE CREA

1

SSD 1

SULFAMYLON CREA 3

SULFAMYLON PACK 4 NM

DERMATOLOGY, ANTIFUNGALS ciclopirox GEL 1

ciclopirox cre 0.77% 1

ciclopirox shampoo 1% (generic of LOPROX SHAMPOO)

1

ciclopirox sus 0.77% 1

clotrimazole (topical) 1

econazole nitrate CREA 1

ERTACZO 3

EXELDERM 3

EXTINA 3

ketoconazole (topical) 1

ketodan aer 2% (generic of EXTINA)

1

LOPROX SHAMPOO 3

LUZU 2

MENTAX 3

NAFTIFINE HCL 1

NAFTIN 2

nyamyc 1

nystatin (topical) 1

nystatin pow 100000 1

nystop 1

OXISTAT 3

DERMATOLOGY, ANTIPRURITIC anusol hc 2

CORTIFOAM 2

procto-pak 1

proctosol hc 2.5 % (generic of ANUSOL-HC)

1

proctozone hc (generic of ANUSOL-HC)

1

PRUDOXIN CRE 5% 1

ZONALON 3

DERMATOLOGY, ANTIPSORIATICS

Drug Name Drug Tier

Requirements/Limits

acitretin (generic of SORIATANE)

4 NM PA

calcipotriene (generic of DOVONEX) CREA

1

calcipotriene OINT; SOLN 1

calcitrene oin 0.005% 1

CALCITRIOL OINT 1

COSENTYX 4 NM PA

COSENTYX SENSOREADY PEN

4 NM PA

DOVONEX CRE 0.005% 3

methoxsalen rapid (generic of OXSORALEN ULTRA)

4 NM

8-MOP 3

OXSORALEN ULTRA 4 NM

SORIATANE 4 NM PA

SORILUX 2

STELARA 4 NM PA

TAZORAC 2 PA

VECTICAL 4 NM

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo (generic of NIZORAL)

1

NIZORAL 3

selenium sulfide LOTN 1

DERMATOLOGY, CORTICOSTEROIDS aclovate 2

ala-cort 1

ala-scalp 3

alclometasone dipropionate (generic of ACLOVATE) CREA

1

alclometasone dipropionate OINT

1

amcinonide CREA; LOTN 1

amcinonide OINT 3

apexicon 1

apexicon e cream 3

betamethasone dipropionate (topical)

1

betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA

1

betamethasone dipropionate augmented GEL

1

2016 601 4T Copper Comm eff 01/01/2016


61

Drug Name Drug Tier

Requirements/Limits

betamethasone dipropionate augmented (generic of DIPROLENE) LOTN; OINT

1

betamethasone valerate CREA; LOTN; OINT

1

betamethasone valerate (generic of LUXIQ) FOAM

1

calcipotriene/betamethasone (generic of TACLONEX)

4 NM

CAPEX 2

clobetasol e cream 0.05% (generic of TEMOVATE E)

1

clobetasol propionate (generic of TEMOVATE) CREA; GEL; OINT; SOLN

1

clobetasol propionate (generic of OLUX) FOAM

1

clobetasol propionate (generic of CLOBEX) LIQD; LOTN; SHAM

1

clobetasol propionate emulsion (generic of OLUX-E)

1

CLOBEX 4 NM

CLOCORTOLONE PIVALATE 1

clodan sha 0.05% (generic of CLOBEX)

1

CLODERM PUMP 2

CORDRAN TAPE 3

cormax (generic of TEMOVATE)

1

CUTIVATE CREA 3

CUTIVATE LOTN 4 NM

DERMATOP 3

DERMATOP CREAM 0.1% 3

DESONATE 3

DESONIDE CREA 1

desonide (generic of DESOWEN) LOTN; OINT

1

DESOWEN CREA 2

desowen LOTN 2

desoximetasone (generic of TOPICORT) CREA

1

desoximetasone (generic of TOPICORT) GEL

1

DESOXIMETASONE OINT .05%

1

Drug Name Drug Tier

Requirements/Limits

desoximetasone (generic of TOPICORT) OINT .25%

1

diflorasone diacetate 1

DIPROLENE LOTN 3

DIPROLENE OINT 2

DIPROLENE AF 3

ELOCON CREA; LOTN 3

ELOCON OINT 2

fluocinolone acetonide CREA .01%

1

fluocinolone acetonide (generic of SYNALAR) CREA .025%

1

fluocinolone acetonide (generic of DERMA-SMOOTHE/FS BODY) OIL .01%

1

fluocinolone acetonide (generic of DERMA-SMOOTHE/FS SCALP) OIL .01%

1

fluocinolone acetonide (generic of SYNALAR) OINT

1

fluocinolone acetonide (generic of SYNALAR) SOLN

1

fluocinonide (generic of VANOS) CREA .1%

4 NM

fluocinonide CREA .05% 1

fluocinonide GEL 1

fluocinonide OINT 1

fluocinonide SOLN 1

fluocinonide emulsified base 1

fluticasone propionate (generic of CUTIVATE) CREA; LOTN

1

fluticasone propionate OINT 1

halobetasol propionate (generic of ULTRAVATE)

1

HALOG 3

hydrocortisone (topical) 1

hydrocortisone butyrate (generic of LOCOID)

1

hydrocortisone butyrate hydrophilic lipo base (generic of LOCOID LIPOCREAM)

1

2016 601 4T Copper Comm eff 01/01/2016


62

Drug Name Drug Tier

Requirements/Limits

hydrocortisone valerate CREA

1

hydrocortisone valerate (generic of WESTCORT) OINT

1

KENALOG 3

LOCOID CREA 3

LOCOID LOTN; OINT; SOLN

2

LOCOID LIPOCREAM 4 NM

lokara (generic of DESOWEN)

1

mometasone furoate (generic of ELOCON) CREA; OINT; SOLN

1

OLUX 4 NM

PANDEL 3

PREDNICARBATE CREA 1

prednicarbate (generic of DERMATOP) OINT

1

SYNALAR CREA; OINT 3

SYNALAR SOLN 2

TACLONEX 4 NM

TEMOVATE CREAM 2

TEMOVATE E CREAM 2

TEMOVATE GEL 2

TEMOVATE OIN 2

TEMOVATE SOLN 3

texacort 2

topicort CREA 3

topicort GEL 2

TOPICORT OINT .05% 2

topicort OINT .25% 2

TOPICORT SPRAY 0.25% 3

triamcinolone acetonide (topical) (generic of KENALOG) AERS

1

triamcinolone acetonide (topical) CREA; LOTN; OINT

1

trianex 3

triderm 1

ULTRAVATE 2

VANOS 4 NM

DERMATOLOGY, LOCAL ANESTHETICS EMLA 3 B/D

Drug Name Drug Tier

Requirements/Limits

lidocaine OINT 1

lidocaine (generic of LIDODERM) PTCH

1 PA

lidocaine hcl GEL 1

lidocaine hcl (generic of XYLOCAINE) SOLN 4%

1

lidocaine-prilocaine (generic of EMLA)

1 B/D

LIDODERM 2 PA

SYNERA 3

XYLOCAINE 4% 3

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir topical (generic of ZOVIRAX)

1

ALDARA 4 NM

ammonium lactate (generic of LAC-HYDRIN) CREA; LOTN

1

CARAC 4 NM

CONDYLOX 2

DENAVIR 4 NM

diclofenac sodium (actinic keratoses) (generic of SOLARAZE)

4 NM PA

diclofenac sodium (topical) 1

DOXYCYCLINE (ROSACEA) 1

EFUDEX 3

ELIDEL 2 PA

FINACEA GEL 15% 2

fluorouracil (topical) (generic of EFUDEX) CREA 5%

1

FLUOROURACIL (TOPICAL) CREA .5%

4 NM

fluorouracil (topical) SOLN 1

imiquimod (generic of ALDARA) CREA

1

LAC-HYDRIN 2

laclotion lot 12% (generic of LAC-HYDRIN)

1

METROCREAM 3

METROGEL 3

METROLOTION 3

metronidazole (topical) (generic of METROCREAM) CREA

1

2016 601 4T Copper Comm eff 01/01/2016


63

Drug Name Drug Tier

Requirements/Limits

metronidazole (topical) (generic of METROGEL) GEL 1%

1

metronidazole (topical) GEL .75%

1

metronidazole (topical) (generic of METROLOTION) LOTN

1

NORITATE 4 NM

ORACEA 2

PANRETIN 4 NM

PENNSAID 3

PICATO 4 NM

podofilox (generic of CONDYLOX) SOLN

1

PROTOPIC 3 PA

RECTIV 3

rosadan cre 0.75% (generic of METROCREAM)

1

SOLARAZE 4 NM PA

SOOLANTRA 2

tacrolimus (topical) (generic of PROTOPIC)

1 PA

TARGRETIN GEL 4 NM PA

VALCHLOR 4 NM LA PA

VOLTAREN GEL 1% 2

XERESE 4 NM

ZOVIRAX CREA; OINT 4 NM

ZYCLARA 4 NM

DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 3

malathion (generic of OVIDE) 1

ovide 2

permethrin (generic of ELIMITE)

1

SKLICE 3

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 1

neomycin/polymyxin b gu (generic of NEOSPORIN GU IRRIGANT)

1

REGRANEX 4 NM PA

SANTYL 3

SODIUM CHLORIDE 0.9% 1

Drug Name Drug Tier

Requirements/Limits

STERILE WATER IRRIGATION

1

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl (generic of EVOXAC)

1

chlorhexidine gluconate (mouth-throat) (generic of PERIDEX)

1

clotrimazole TROC 1

EVOXAC 2

lidocaine hcl (mouth-throat) 1

nystatin (mouth-throat) 1

periogard soln 0.12% (generic of PERIDEX)

1

PILOCARPINE HCL (ORAL) 5mg

1

pilocarpine hcl (oral) (generic of SALAGEN) 7.5mg

1

SALAGEN 2

triamcinolone acetonide (mouth)

1

OTIC acetasol hc 1

acetic acid (otic) 1

acetic acid sol/hc 1

acetic acid-aluminum acetate 1

CIPRO HC 3

CIPRODEX 2

COLY-MYCIN S 3

CORTISPORIN SOLN 3

CORTISPORIN-TC 3

fluocinolone acetonide (otic) (generic of DERMOTIC)

1

neomycin-polymyxin-hc (otic) (generic of CORTISPORIN) SOLN

1

neomycin-polymyxin-hc (otic) SUSP

1

ofloxacin (otic) 1

2016 601 4T Copper Comm eff 01/01/2016

64

Index 8 8-MOP .............................. 60 A abacavir sulfate ...................8 abacavir sulfate-lamivudine-zidovudine ..........................................9 ABELCET............................8 ABILIFY

see aripiprazole tabs ..... 28 ABILIFY DISCMELT TAB 10MG ................................ 28 ABILIFY MAINTENA ......... 28 ABILIFY TABS .................. 28 ABRAXANE ...................... 14 ABSORICA ....................... 59 ABSTRAL............................2 acamprosate calcium ........ 35 ACANYA ........................... 59 acarbose ........................... 37 ACCOLATE ....................... 57

see zafirlukast ............... 57 ACCUPRIL ........................ 16

see quinapril hcl ............ 16 ACCURETIC ..................... 16

see quinapril-hydrochlorothiazide .................................. 16

acebutolol hcl .................... 19 ACEON

see perindopril erbumine ...................................... 16

acetaminophen w/ codeine .1 acetasol hc ........................ 63 acetazolamide ................... 21 acetazolamide sodium ...... 21 acetic acid ......................... 63 acetic acid (otic) ................ 63 acetic acid sol/hc ............... 63 acetic acid-aluminum acetate .......................................... 63 acetylcysteine ................... 58 ACIPHEX .......................... 48

see rabeprazole sodium 48 ACIPHEX SPR CAP 10MG .......................................... 48 ACIPHEX SPR CAP 5MG . 48

acitretin ............................. 60 aclovate ............................ 60 ACLOVATE

see alclometasone dipropionate .................. 60

ACTEMRA ........................ 51 ACTHIB ............................. 52 ACTIGALL ........................ 47

see ursodiol ................... 48 ACTIMMUNE .................... 51 ACTIQ ................................. 2

see fentanyl citrate .......... 3 ACTONEL ......................... 39

see risedronate sodium . 39 ACTOPLUS MET

see pioglitazone hcl-metformin hcl ........... 39

ACTOPLUS MET TAB 15-500MG ......................... 37 ACTOPLUS MET TAB 15-850MG ......................... 37 ACTOPLUS MET XR 15-1000MG ....................... 37 ACTOPLUS MET XR 30-1000MG ....................... 37 ACTOS ............................. 37

see pioglitazone hcl ....... 39 ACULAR ........................... 55

see ketorolac tromethamine (ophth) .... 55

ACULAR LS ...................... 55 see ketorolac tromethamine (ophth) .... 55

ACUVAIL .......................... 55 acyclovir ............................ 10 acyclovir sodium ............... 10 acyclovir topical ................ 62 ACZONE ........................... 59 ADACEL ........................... 52 ADAGEN ........................... 42 ADALAT CC ...................... 20

see afeditab cr ............... 20 see nifedipine ................ 20

adapalene ......................... 59 ADCIRCA .......................... 22 ADDERALL

see

amphetamine-dextroamphetamine tab 10 mg ........ 31 see amphetamine-dextroamphetamine tab 12.5 mg ..... 31 see amphetamine-dextroamphetamine tab 15 mg ........ 31 see amphetamine-dextroamphetamine tab 20 mg ........ 31 see amphetamine-dextroamphetamine tab 30 mg ........ 31 see amphetamine-dextroamphetamine tab 5 mg .......... 31 see amphetamine-dextroamphetamine tab 7.5 mg ....... 31

adderall tab 10mg ............. 30 adderall tab 12.5mg .......... 30 adderall tab 15mg ............. 30 adderall tab 20mg ............. 30 adderall tab 30mg ............. 30 adderall tab 5mg ............... 30 adderall tab 7.5mg ............ 30 ADDERALL XR

see amphetamine cap 10mg er ......................... 30 see amphetamine cap 15mg er ......................... 30 see amphetamine cap 20mg er ......................... 30 see amphetamine cap 25mg er ......................... 31 see amphetamine cap 30mg er ......................... 31 see amphetamine-dextroamphetamine cap sr 24hr 5 mg ...................................... 31

ADDERALL XR CAP 10MG.......................................... 30 ADDERALL XR CAP 15MG.......................................... 30 ADDERALL XR CAP 20MG

2016 601 4T Copper Comm eff 01/01/2016

65

.......................................... 30 ADDERALL XR CAP 25MG .......................................... 30 ADDERALL XR CAP 30MG .......................................... 30 ADDERALL XR CAP 5MG 30 adefovir dipivoxil ............... 10 ADEMPAS ........................ 22 adoxa ................................ 12 ADOXA

see doxycycline (monohydrate) ............... 13

ADOXA PAK 1/150 see doxycycline (monohydrate) ............... 13

ADRENACLICK ................ 58 adriamyc inj 50mg ............. 13 adrucil ............................... 13 ADVAIR DISKUS .............. 58 ADVAIR HFA .................... 59 ADVICOR.......................... 18 AEROSPAN ...................... 58 afeditab cr ......................... 20 AFINITOR ......................... 15 AFINITOR DISPERZ ......... 15 AFREZZA.......................... 44 AGGRENOX ..................... 50 AGRYLIN .......................... 50

see anagrelide hcl ......... 50 a-hydrocort ........................ 43 AKYNZEO ......................... 45 ala-cort .............................. 60 ala-scalp............................ 60 ALBENZA............................6 albuterol sulfate ................. 57 albuterol sulfate er ............ 57 alcaine .............................. 56 ALCAINE

see proparacaine hcl ..... 56 alclometasone dipropionate .......................................... 60 ALCOHOL SWABS ........... 36 ALDACTAZIDE ................. 21

see spironolactone & hydrochlorothiazide ....... 21

ALDACTAZIDE TAB 50/50 .......................................... 21 ALDACTONE .................... 16

see spironolactone ........ 16 ALDARA ........................... 62

see imiquimod ............... 62 ALDURAZYME ................. 42 alendronate sodium .......... 39 alfuzosin hcl ...................... 48 ALIMTA ............................. 13 ALINIA ................................ 6 ALKERAN ......................... 13

see melphalan hcl ......... 13 allopurinol tab ..................... 1 almotriptan malate ............ 32 ALOCRIL .......................... 56 ALOMIDE .......................... 56 ALOPRIM ............................ 1 ALORA .............................. 42 alosetron hcl ..................... 47 ALOXI ............................... 45 ALPHAGAN P 0.1% .......... 56 ALPHAGAN P 0.15% ........ 56 alprazolam ........................ 22 ALREX .............................. 55 ALSUMA ........................... 32 ALTABAX .......................... 59 ALTACE ............................ 16

see ramipril .................... 16 altavera ............................. 40 ALTOPREV ....................... 18 ALVESCO ......................... 58 amantadine hcl ................. 27 AMARYL ........................... 37

see glimepiride .............. 37 AMBIEN ............................ 32

see zolpidem tartrate ..... 32 AMBISOME ........................ 8 amcinonide ....................... 60 AMERGE .......................... 32

see naratriptan hcl ......... 33 amethia 91 day ................. 40 amethyst 28 day ............... 40 amifostine crystalline......... 15 amikacin sulfate .................. 6 amiloride & hydrochlorothiazide ........... 21 amiloride hcl ...................... 21 aminophylline inj ............... 59 AMINOSYN ....................... 53 AMINOSYN

7%/ELECTROLYTES ....... 53 AMINOSYN II ................... 53 AMINOSYN II 8.5%/ELECTROL.............. 53 AMINOSYN INJ 8.5/LYTE 53 AMINOSYN M .................. 53 AMINOSYN-HBC .............. 53 AMINOSYN-PF 7% ........... 53 AMINOSYN-PF INJ 10% .. 53 AMINOSYN-RF................. 53 amiodarone hcl ................. 17 amiodarone inj 50mg/ml ... 17 AMITIZA ........................... 47 amitriptyline hcl ................. 26 amlodipine besylate .......... 20 amlodipine besylate/atorv . 20 amlodipine besylate-benazepril hcl ..... 16 amlodipine besylate-valsartan tab 10-160 mg ........................ 17 amlodipine besylate-valsartan tab 10-320 mg ........................ 17 amlodipine besylate-valsartan tab 5-160 mg ..................................... 17 amlodipine besylate-valsartan tab 5-320 mg ..................................... 17 amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg.......................................... 17 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg.......................................... 17 amlodipine-valsartan-hydrochlorothiazide 10-320-25mg.......................................... 17 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg.......................................... 17 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg . 17 ammonium chloride .......... 52 ammonium lactate ............ 62 amnesteem ....................... 59 amoxapine ........................ 26

2016 601 4T Copper Comm eff 01/01/2016

66

amoxicillin ......................... 12 amoxicillin & pot clavulanate .......................................... 12 amoxicillin-clarithromycin w/ lansoprazole ...................... 47 amphetamine cap 10mg er .......................................... 30 amphetamine cap 15mg er .......................................... 30 amphetamine cap 20mg er .......................................... 30 amphetamine cap 25mg er .......................................... 31 amphetamine cap 30mg er .......................................... 31 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 31 amphetamine-dextroamphetamine tab 10 mg ............... 31 amphetamine-dextroamphetamine tab 12.5 mg ............ 31 amphetamine-dextroamphetamine tab 15 mg ............... 31 amphetamine-dextroamphetamine tab 20 mg ............... 31 amphetamine-dextroamphetamine tab 30 mg ............... 31 amphetamine-dextroamphetamine tab 5 mg ................. 31 amphetamine-dextroamphetamine tab 7.5 mg .............. 31 AMPHOTEC ........................8 amphotericin b ....................8 ampicillin & sulbactam sodium .............................. 12 ampicillin cap 250mg ........ 12 ampicillin cap 500 mg ....... 12 ampicillin inj ....................... 12 ampicillin sodium ............... 12 ampicillin susp ................... 12 AMPYRA ........................... 34 ANAFRANIL ...................... 26

see clomipramine hcl ..... 26 anagrelide hcl .................... 50 ANAPROX ..........................1

see naproxen sodium ......1 ANAPROX DS ....................1

see naproxen sodium ......1

anastrozole ....................... 14 ANCOBON .......................... 8

see flucytosine ................ 8 ANDRODERM .................. 36 ANDROGEL ...................... 36 ANDROGEL 1% ............... 36 ANDROGEL 1.62% .......... 36 ANDROGEL PUMP .......... 36 ANORO ELLIPT AER 62.5-25 .............................. 56 antabuse ........................... 35 ANTABUSE

see disulfiram ................ 35 ANTARA ........................... 18 anusol hc .......................... 60 ANUSOL-HC

see proctosol hc 2.5 % .. 60 see proctozone hc ......... 60

apexicon ........................... 60 apexicon e cream ............. 60 APIDRA ............................ 36 APIDRA SOLOSTAR ........ 36 APLENZIN ........................ 26 APOKYN ........................... 27 apri 28 day ........................ 40 APRISO ............................ 46 APTENSIO XR .................. 31 APTIOM ............................ 23 APTIVUS ............................ 8 ARALAST NP ................... 58 ARALEN

see chloroquine phosphate ....................... 8

aranelle 28 ........................ 40 ARANESP ALBUMIN FREE .......................................... 50 ARAVA .............................. 51

see leflunomide ............. 51 ARCALYST ....................... 51 ARCAPTA NEOHALER .... 57 ARICEPT .......................... 25

see donepezil tab hcl 23mg ............................. 25 see donepezil tabs 10mg ...................................... 25 see donepezil tabs 5mg 25

ARIMIDEX ........................ 14 see anastrozole ............. 14

aripiprazole tabs ............... 28 ARIXTRA .......................... 49

see fondaparinux sodium ...................................... 49

ARNUITY ELLIPTA ........... 58 AROMASIN ...................... 14

see exemestane ............ 14 ARRANON ........................ 13 ARTHROTEC 50 ................ 1

see diclofenac w/ misoprostol ...................... 1

ARTHROTEC 75 ................ 1 see diclofenac w/ misoprostol ...................... 1

ARZERRA ........................ 14 ASACOL HD ..................... 46 ashlyna 91 day ................. 40 ASMANEX ........................ 58 ASMANEX HFA ................ 58 ASPIRIN-CAFFEINE-DIHYDROCODEINE BITARTRATE............................................ 2 ASPIRIN-DIPYRIDAMOLE.......................................... 50 ASTAGRAF XL ................. 51 ASTEPRO ........................ 57

see azelastine spr 0.15% ...................................... 57

ATACAND ........................ 17 see candesartan cilexetil ...................................... 17

ATACAND HCT ................ 17 see candesartan cilexetil-hydrochlorothiazide .................................... 17

ATELVIA ........................... 39 see risedronate sodium . 39

atenolol ............................. 19 atenolol & chlorthalidone .. 19 ATGAM ............................. 51 ATIVAN ............................. 22

see lorazepam............... 23 atorvastatin calcium .......... 18 atovaquone ......................... 6 atovaquone-proguanil hcl tab 250-100 mg ........................ 8 atovaquone-proguanil hcl tab 62.5-25 mg ......................... 8

2016 601 4T Copper Comm eff 01/01/2016

67

ATRALIN ........................... 59 ATRIPLA .............................9 ATROPINE SULFATE ...... 46 ATROVENT ...................... 56

see ipratropium bromide (nasal) ........................... 57

ATROVENT HFA .............. 56 AUBAGIO.......................... 34 aubra 28 day ..................... 40 AUGMENTIN .................... 12

see amoxicillin & pot clavulanate .................... 12

AUGMENTIN ES-600 ....... 12 see amoxicillin & pot clavulanate .................... 12

AUGMENTIN XR .............. 12 see amoxicillin & pot clavulanate .................... 12

AURYXIA .......................... 44 AUVI-Q ............................. 58 AVALIDE ........................... 17

see irbesartan-hydrochlorothiazide ................................ 17

AVAPRO ........................... 17 see irbesartan ................ 17

AVASTIN........................... 14 AVC .................................. 49 AVEED .............................. 36 AVELOX............................ 11

see moxifloxacin hcl ...... 12 AVELOX ABC PACK ........ 11 aviane 28 .......................... 40 AVITA ............................... 59 AVODART ......................... 48 AVONEX ........................... 34 AVONEX PEN ................... 34 AVYCAZ............................ 10 AXERT .............................. 32

see almotriptan malate .. 32 AXID

see nizatidine ................ 46 AXIRON ............................ 36 aygestin............................. 45 AYGESTIN

see norethindrone acetate ...................................... 45

azacitidine ......................... 13

AZACTAM ........................... 6 see aztreonam ................ 6

AZACTAM/DEX INJ 1GM ... 6 AZACTAM/DEX INJ 2GM ... 6 azasan .............................. 51 AZASITE ........................... 55 azathioprine ...................... 51 azelastine drop 0.05% ...... 56 azelastine spr 0.1% .......... 57 azelastine spr 0.15%......... 57 AZELEX ............................ 59 AZILECT ........................... 27 azithromycin ...................... 11 AZITHROMYCIN .............. 11 AZOPT .............................. 56 AZOR ................................ 17 aztreonam ........................... 6 AZULFIDINE ..................... 47

see sulfasalazine ir ........ 47 AZULFIDINE EN-TABS .... 47

see sulfasalazine dr....... 47 B bacitracin (ophthalmic) ...... 55 bacitracin-polymyxin b (ophth) .............................. 55 bacitracin-poly-neomycin-hc .......................................... 54 baclofen ............................ 35 BACTOCILL INJ DEX 1GM .......................................... 12 BACTOCILL INJ DEX 2GM .......................................... 12 BACTRIM ............................ 6

see sulfamethoxazole-trimethop ...................................... 7

BACTRIM DS ...................... 6 see sulfamethoxazole-trimethop ...................................... 7

BACTROBAN ................... 59 see mupirocin ................ 59 see mupirocin calcium (topical) ......................... 60

BACTROBAN NASAL ....... 59 balsalazide disodium......... 47 balziva 28 day ................... 40 BANZEL SUS 40MG/ML ... 23

BANZEL TAB 200MG ....... 23 BANZEL TAB 400MG ....... 23 BARACLUDE .................... 10

see entecavir ................. 10 BCG VACCINE ................. 52 BECONASE AQ................ 58 BELEODAQ ...................... 14 benazepril & hydrochlorothiazide ........... 16 benazepril hcl ................... 16 BENICAR .......................... 17 BENICAR HCT ................. 17 BENLYSTA ....................... 51 BENTYL ............................ 46

see dicyclomine hcl ....... 46 BENZACLIN ..................... 59

see clindamycin phosphate-benzoyl peroxide ........................ 59

BENZAMYCIN .................. 59 see benzoyl peroxide-erythromycin ... 59

benzoyl peroxide-erythromycin ...... 59 benztropine mesylate ........ 27 BENZTROPINE MESYLATE.......................................... 27 BEPREVE ......................... 56 BERINERT ....................... 50 BESIVANCE ..................... 55 BETAGAN ........................ 56

see levobunolol hcl ........ 56 betamethasone dipropionate (topical) ............................. 60 betamethasone dipropionate augmented .................. 60, 61 betamethasone valerate ... 61 BETAPACE ...................... 17

see sorine ..................... 18 see sotalol hcl ............... 18

BETAPACE AF ................. 17 see sotalol hcl (afib/afl) . 18

BETASERON ................... 34 betaxolol hcl ...................... 19 betaxolol hcl (ophth) ......... 56 bethanechol chloride ......... 49 BETHKIS ............................ 6 BETIMOL .......................... 56

2016 601 4T Copper Comm eff 01/01/2016

68

BETOPTIC-S .................... 56 BEXSERO......................... 52 BEYAZ .............................. 40 BIAXIN .............................. 11

see clarithromycin ......... 11 BIAXIN XL

see clarithromycin ......... 11 bicalutamide ...................... 14 BICILLIN C-R .................... 12 BICILLIN L-A ..................... 12 BICNU ............................... 13 BIDIL ................................. 21 BILTRICIDE ........................6 BINOSTO .......................... 39 bisoprolol & hydrochlorothiazide ........... 19 bisoprolol fumarate ........... 19 BIVIGAM ........................... 51 bleomycin sulfate .............. 13 BLEPH-10 ......................... 55

see sulfacetamide sodium (ophth) ........................... 55

blephamide ....................... 54 BLEPHAMIDE ................... 54 BONIVA ............................ 39

see ibandronate sodium 39 see ibandronate tab 150mg ........................... 39

BOOSTRIX ....................... 52 BOSULIF........................... 15 BOTOX INJ 100UNIT ........ 35 BOTOX INJ 200UNIT ........ 35 BREO ELLIPTA ................ 59 BREVICON-28 .................. 40

see necon 0.5/35 28 day ...................................... 41 see nortrel 0.5/35 28 day ...................................... 41

briellyn 28 day ................... 40 BRILINTA .......................... 50 BRIMONIDINE SOL 0.15% .......................................... 56 brimonidine sol 0.2% ......... 56 BRINTELLIX ..................... 26 BRISDELLE ...................... 34 bromfenac sodium (ophth) 55 BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) ... 55

bromocriptine mesylate ..... 27 BROVANA ........................ 57 budesonide ....................... 47 budesonide (inhalation) ..... 58 budesonide (nasal) ........... 58 bumetanide ....................... 21 BUNAVAIL MIS 2.1-0.3MG .......................................... 35 BUNAVAIL MIS 4.2-0.7MG .......................................... 35 BUNAVAIL MIS 6.3-1MG .. 35 BUPHENYL

see sodium phenylbutyrate ...................................... 42

buprenorphine hcl ............. 35 buprenorphine hcl-naloxone hcl sl.................................. 35 buproban ........................... 35 bupropion hcl .................... 26 buspirone hcl .................... 22 BUSULFEX ....................... 13 butorphanol nasal spray ...... 2 butorphanol tartrate ............ 2 BUTRANS ........................... 2 BYDUREON ..................... 36 BYETTA ............................ 36 BYSTOLIC ........................ 19 C cabergoline ....................... 44 CADUET ........................... 20

see amlodipine besylate/atorv ................ 20

cafergot tab 1-100mg ........ 32 CALAN .............................. 20

see verapamil hcl .......... 20 CALAN SR ........................ 20

see verapamil hcl .......... 20 calcipotriene ...................... 60 calcipotriene/betamethasone .......................................... 61 calcitonin (salmon) nasal spray ................................. 44 calcitrene oin 0.005%........ 60 calcitriol ............................. 54 CALCITRIOL ..................... 60 calcium acetate (phosphate binder) ............................... 45 camila 28 day .................... 40

CAMPTOSAR ................... 16 see irinotecan inj 100/5ml ...................................... 16 see irinotecan inj 40mg/2ml ...................... 16

CAMRESE LO TAB .......... 40 CANASA ........................... 47 CANCIDAS ......................... 8 candesartan cilexetil ......... 17 candesartan cilexetil-hydrochlorothiazide.......................................... 17 CANTIL ............................. 46 CAPASTAT SULFATE ........ 9 CAPEX ............................. 61 capital

and codeine .................... 2 CAPRELSA ...................... 15 captopril ............................ 16 captopril & hydrochlorothiazide ........... 16 CARAC ............................. 62 CARAFATE ...................... 47

see sucralfate ................ 48 CARBAGLU ...................... 42 carbamazepine ................. 23 CARBATROL .................... 23

see carbamazepine ....... 23 carbidopa .......................... 27 CARBIDOPA/LEVODOPA/ENTACAPONE ................... 27 carbidopa-levodopa .......... 27 carboplatin ........................ 15 CARDIZEM ....................... 20

see diltiazem hcl ............ 20 CARDIZEM CD ................. 20

see cartia xt ................... 20 see diltiazem hcl coated beads ............................ 20

CARDIZEM LA.................. 20 see matzim la ................ 20

CARDURA ........................ 16 see doxazosin mesylate 16

CARDURA XL .................. 48 CARIMUNE NANOFILTERED .............. 51 CARNITOR ....................... 42

see levocarnitine

2016 601 4T Copper Comm eff 01/01/2016

69

(metabolic modifiers) ..... 42 carteolol hcl (ophth) .......... 56 cartia xt ............................. 20 carvedilol ........................... 19 CASODEX ........................ 14

see bicalutamide ........... 14 CATAPRES

see clonidine hcl ............ 22 CATAPRES TAB ............... 21 CATAPRES-TTS DIS 0.1/24HR ........................... 21 CATAPRES-TTS DIS 0.2/24HR ........................... 21 CATAPRES-TTS DIS 0.3/24HR ........................... 22 CATAPRES-TTS-1

see clonidine hcl ............ 22 CATAPRES-TTS-2

see clonidine hcl ............ 22 CATAPRES-TTS-3

see clonidine hcl ............ 22 CAYSTON ...........................7 CEDAX ............................. 10 cefaclor ............................. 10 cefaclor er tab 500mg ....... 10 cefadroxil........................... 10 cefazolin inj ....................... 10 cefazolin sodium ............... 10 cefazolin/dextrose ............. 10 cefdinir .............................. 10 CEFEPIME 1GM SOLN .... 10 CEFEPIME 2GM SOLN .... 10 CEFEPIME HCL AND DEXTROSE ...................... 10 cefepime inj 1gm ............... 10 cefepime inj 2gm ............... 10 cefixime ............................. 10 cefotaxime sodium ............ 10 cefotetan disodium ............ 10 cefoxitin sodium ................ 10 CEFOXITIN SODIUM IN DEXTROSE ...................... 10 cefpodoxime proxetil ......... 11 cefprozil............................. 11 ceftazidime ........................ 11 CEFTAZIDIME/DEXTROSE .......................................... 11 CEFTIBUTEN ................... 11

CEFTIN ............................. 11 see cefuroxime axetil ..... 11

ceftriaxone sodium ............ 11 cefuroxime axetil ............... 11 cefuroxime sodium ............ 11 CELEBREX

see celecoxib .................. 1 CELEBREX CAP 100MG .... 1 CELEBREX CAP 200MG .... 1 CELEBREX CAP 400MG .... 1 CELEBREX CAP 50MG ...... 1 celecoxib ............................. 1 CELEXA ............................ 26

see citalopram hydrobromide ................ 26

CELLCEPT see mycophenolate mofetil ...................................... 51

CELLCEPT CAP ............... 51 CELLCEPT INTRAVENOUS .......................................... 51 CELLCEPT SUSP ............ 51 CELLCEPT TAB ............... 51 CELONTIN ........................ 23 CENTANY ......................... 59 cephalexin ......................... 11 CERDELGA ...................... 42 CEREZYME ...................... 42 CERVARIX ....................... 52 CESAMET ........................ 45 cetirizine syrup .................. 57 cevimeline hcl ................... 63 CHANTIX .......................... 35 CHANTIX CONTINUING MONTH ............................. 35 CHANTIX STARTER PACK .......................................... 35 CHEMET ........................... 39 chlorhexidine gluconate (mouth-throat) ................... 63 chloroquine phosphate........ 8 chlorothiazide tabs ............ 21 chlorpromaz inj 25mg/ml ... 28 chlorpromazine hcl ............ 28 chlorthalidone ................... 21 cholestyramine .................. 18 cholestyramine light .......... 18 choline fenofibrate ............ 18

CHORIONIC GONADOTROPIN ............ 44 ciclopirox ........................... 60 ciclopirox cre 0.77% .......... 60 ciclopirox shampoo 1% ..... 60 ciclopirox sus 0.77% ......... 60 cidofovir ............................ 10 cilostazol ........................... 50 CILOXAN

see ciprofloxacin hcl (ophth) ........................... 55

CILOXAN OIN 0.3% OP ... 55 CILOXAN SOL 0.3% OP .. 55 cimetidine ......................... 46 cimetidine sol 300/5ml ...... 46 CIMZIA ............................. 51 CINRYZE .......................... 50 CIPRO

see ciprofloxacin ........... 11 see ciprofloxacin hcl ...... 12

CIPRO HC ........................ 63 CIPRO I.V.-IN D5W

see ciprofloxacin in d5w 12 CIPRO SUSP ................... 11 CIPRO TABS .................... 11 CIPRO XR ........................ 11

see ciprofloxacin er ....... 11 CIPRODEX ....................... 63 ciprofloxacin ...................... 11 ciprofloxacin er ................. 11 ciprofloxacin hcl .......... 11, 12 ciprofloxacin hcl (ophth) .... 55 ciprofloxacin in d5w .......... 12 ciprofloxacn inj 400mg/40ml.......................................... 12 cisplatin ............................. 15 citalopram hydrobromide .. 26 cladribine .......................... 13 claforan ............................. 11 CLAFORAN ...................... 11

see cefotaxime sodium . 10 claravis ............................. 59 CLARINEX ........................ 57

see desloratadine .......... 57 CLARINEX REDITABS

see desloratadine .......... 57 CLARINEX-D TAB 2.5-120.......................................... 57

2016 601 4T Copper Comm eff 01/01/2016

70

clarithromycin .................... 11 cleocin .................................7 CLEOCIN .......................... 49

see clindamycin cre 2% vag ................................ 49 see clindamycin hcl .........7

CLEOCIN CAP 150MG .......7 CLEOCIN CAP 300MG .......7 CLEOCIN CAP 75MG .........7 CLEOCIN IN D5W ..............7

see clindamycin phosphate in d5w ............7

CLEOCIN INJ ......................7 CLEOCIN PEDIATRIC GRANULE

see clindamycin palmitate hydrochloride ...................7

cleocin phosphate ...............7 CLEOCIN PHOSPHATE .....7

see clindamycin phosphate ........................7

CLEOCIN VAG SUPP 100MG .............................. 49 CLEOCIN-T ....................... 59

see clindamax ............... 59 see clindamycin phosphate (topical) ........ 59

CLIMARA .......................... 42 see estradiol .................. 43

CLINDAGEL ...................... 59 clindamax .......................... 59 clindamycin cre 2% vag .... 49 clindamycin hcl ....................7 clindamycin palmitate hydrochloride ......................7 clindamycin phosphate .......7 clindamycin phosphate (topical) ............................. 59 clindamycin phosphate in d5w .....................................7 clindamycin phosphate-benzoyl peroxide .......................................... 59 clindamycin phosphate-benzoyl peroxide (refrigerate) ....................... 59 CLINIMIX 2.75%/DEXTROSE 5% ..... 53

CLINIMIX 4.25%/DEXTROSE 10% ... 53 CLINIMIX 4.25%/DEXTROSE 20% ... 53 CLINIMIX 4.25%/DEXTROSE 25% ... 53 CLINIMIX 4.25%/DEXTROSE 5% ..... 53 CLINIMIX 5%/DEXTROSE 15%................................... 53 CLINIMIX 5%/DEXTROSE 20%................................... 53 CLINIMIX 5%/DEXTROSE 25%................................... 53 CLINIMIX E 2.75%/DEXTROSE 10% ... 53 CLINIMIX E 2.75%/DEXTROSE 5% ..... 53 CLINIMIX E 4.25%/D10 .... 53 CLINIMIX E 4.25%/DEXTROSE 25% ... 53 CLINIMIX E 4.25%/DEXTROSE 5% ..... 53 CLINIMIX E 5%/DEXTROSE 15%................................... 53 CLINIMIX E 5%/DEXTROSE 20%................................... 53 CLINIMIX E 5%/DEXTROSE 25%................................... 53 clinisol 15 .......................... 53 clobetasol e cream 0.05% . 61 clobetasol propionate ........ 61 clobetasol propionate emulsion ........................... 61 CLOBEX ........................... 61

see clobetasol propionate ...................................... 61 see clodan sha 0.05% ... 61

CLOCORTOLONE PIVALATE ......................... 61 clodan sha 0.05% ............. 61 CLODERM PUMP ............ 61 CLOLAR ........................... 13 clomipramine hcl ............... 26 clonazepam ...................... 23 clonidine hcl ...................... 22 clopidogrel bisulfate .......... 50 clorazepate dipotassium ... 23

clorpres ............................. 22 clotrimazole ...................... 63 clotrimazole (topical) ......... 60 clozapine .......................... 28 CLOZAPINE ..................... 28 CLOZAPINE ODT ............. 28 CLOZARIL ........................ 28

see clozapine ................ 28 COARTEM .......................... 8 codeine

and capital ....................... 2 CODEINE SULFATE .......... 2 COGENTIN ....................... 27 COLAZAL ......................... 47

see balsalazide disodium ...................................... 47

colchicine w/ probenecid ..... 1 COLCRYS .......................... 1 COLESTID ........................ 18

see colestipol hcl ........... 18 colestipol hcl ..................... 18 colistimethate sodium ......... 7 colocort ............................. 47 COLY-MYCIN M ................. 7

see colistimethate sodium ........................................ 7

COLY-MYCIN S ................ 63 COLYTE-FLAVOR PACKS.......................................... 47

see gavilyte-c ................ 47 COMBIGAN ...................... 56 COMBIVENT RESPIMAT . 56 COMBIVIR .......................... 9

see lamivudine-zidovudine ........................................ 9

COMETRIQ ...................... 15 COMPAZINE

see prochlorperazine maleate ......................... 46

COMPLERA ....................... 9 compro supp ..................... 45 COMTAN .......................... 27 COMVAX .......................... 52 CONCERTA ..................... 31 CONDYLOX ..................... 62

see podofilox ................. 63 constulose ........................ 47 CONZIP .............................. 2

2016 601 4T Copper Comm eff 01/01/2016

71

COPAXONE see glatopa .................... 34

COPAXONE INJ 40MG/ML .......................................... 34 COPAXONE KIT 20MG/ML .......................................... 34 COPEGUS ........................ 10

see moderiba tab 200mg ...................................... 10 see ribasphere ............... 10 see ribavirin 200mg ....... 10

CORDARONE see amiodarone hcl ....... 17 see pacerone ................. 18

CORDRAN ........................ 61 COREG ............................. 19

see carvedilol ................ 19 COREG CR ....................... 19 CORGARD ........................ 19

see nadolol .................... 19 CORLANOR ...................... 22 cormax .............................. 61 CORTEF ........................... 43

see hydrocortisone ........ 43 CORTENEMA ................... 47

see colocort ................... 47 CORTIFOAM .................... 60 cortisone acetate ............... 43 CORTISPORIN ........... 59, 63

see neomycin-polymyxin-hc (otic) .............................. 63

CORTISPORIN-TC ........... 63 CORZIDE .......................... 19

see nadolol & bendroflumethiazide ...... 19

COSENTYX ...................... 60 COSENTYX SENSOREADY PEN .................................. 60 COSMEGEN ..................... 13 COSOPT ........................... 56

see dorzolamide hcl-timolol maleate ........ 56

COSOPT PF ..................... 56 COUMADIN ...................... 49

see jantoven .................. 50 see warfarin sodium ...... 50

COZAAR ........................... 17

see losartan potassium . 17 CREON ............................. 48 CRESEMBA ........................ 8 CRESTOR ........................ 18 CRINONE ......................... 45 CRIXIVAN ........................... 8 cromolyn sodium ............... 58 cromolyn sodium (mastocytosis) ................... 47 cromolyn sodium (ophth) .. 56 cryselle 28 ......................... 40 CUBICIN ............................. 7 CUTIVATE ........................ 61

see fluticasone propionate ...................................... 61

CUVPOSA ........................ 46 cyclafem 1/35 28 day ........ 40 cyclafem 7/7/7 28 day ....... 40 CYCLESSA ....................... 40

see velivet 28 day ......... 42 cyclobenzaprine hcl .......... 35 cyclophosphamide ............ 13 CYCLOPHOSPHAMIDE ... 13 cycloserine .......................... 9 cyclosporine ...................... 51 cyclosporine modified (for microemulsion) ................. 51 CYKLOKAPRON .............. 50

see tranexamic acid ...... 50 CYMBALTA ...................... 26

see duloxetine hcl ......... 26 CYSTADANE .................... 42 CYSTAGON ...................... 42 cytarabine inj ..................... 13 CYTOMEL ........................ 45

see liothyronine sodium . 45 CYTOTEC ......................... 47

see misoprostol ............. 48 CYTOVENE ...................... 10

see ganciclovir inj 500mg ...................................... 10

D D.H.E. 45 .......................... 32

see dihydroergotamine mesylate ........................ 33

dacarbazine ...................... 13 DACOGEN ........................ 14

see decitabine ............... 14

DALIRESP ........................ 58 DALVANCE ........................ 7 danazol ............................. 42 DANTRIUM ....................... 35

see dantrolene sodium .. 35 dantrolene sodium ............ 35 dapsone .............................. 7 DAPTACEL ....................... 52 DARAPRIM ......................... 7 daunorubicin hcl................ 13 DAYPRO ............................ 1

see oxaprozin .................. 1 DAYTRANA ...................... 31 DDAVP ............................. 45

see desmopressin acetate ...................................... 45 see desmopressin acetate inj .................................. 45 see desmopressin acetate spray ............................. 45

deblitane 28 day ............... 40 decitabine ......................... 14 DELESTROGEN............... 42

see estradiol valerate .... 43 delyla 28 day .................... 40 DELZICOL ........................ 47 DEMADEX ........................ 21

see torsemide tabs ........ 21 demeclocycline hcl ............ 12 DEMSER .......................... 22 DENAVIR .......................... 62 DEPACON ........................ 23

see valproate sodium .... 25 DEPAKENE ...................... 23

see valproate sodium .... 25 see valproic acid ........... 25

DEPAKOTE ...................... 23 see divalproex sodium .. 23

DEPAKOTE ER ................ 23 see divalproex sodium .. 23

DEPAKOTE SPRINKLES . 23 see divalproex sodium .. 23

DEPEN TITRATABS ......... 39 depo-estradiol ................... 42 DEPO-MEDROL

see methylpr ace inj 40mg/ml ........................ 43 see methylpr ace inj

2016 601 4T Copper Comm eff 01/01/2016

72

80mg/ml ......................... 43 DEPO-MEDROL INJ 20MG/ML .......................... 43 DEPO-MEDROL INJ 40MG/ML .......................... 43 DEPO-MEDROL INJ 80MG/ML .......................... 43 DEPO-PROVERA CONTRACEPTIV

see medroxyprogesterone acetate (contraceptive) .. 41

DEPO-PROVERA CONTRACEPTIVE ........... 40 DEPO-PROVERA INJ 400/ML .............................. 14 DEPO-SUBQ PROVERA 104 .................................... 40 depo-testosterone ............. 36 DEPO-TESTOSTERONE

see testosterone cypionate ...................................... 36

DERMA-SMOOTHE/FS BODY

see fluocinolone acetonide ...................................... 61

DERMA-SMOOTHE/FS SCALP


DERMATOP ...................... 61 see prednicarbate .......... 62

DERMATOP CREAM 0.1% .......................................... 61 DERMOTIC

see fluocinolone acetonide (otic) .............................. 63

desipramine hcl ................. 26 desloratadine .................... 57 desmopressin acetate ....... 45 DESMOPRESSIN ACETATE .......................................... 45 desmopressin acetate inj .. 45 desmopressin acetate spray .......................................... 45 desmopressin acetate spray refrigerated ........................ 45 DESOGEN ........................ 40

see apri 28 day .............. 40

see emoquette .............. 40 see reclipsen 28 day ..... 42

desogestrel-ethinyl estradiol (biphasic) .......................... 40 DESONATE ...................... 61 desonide ........................... 61 DESONIDE ....................... 61 desowen ........................... 61 DESOWEN ....................... 61

see desonide ................. 61 see lokara ...................... 62

desoximetasone ................ 61 DESOXIMETASONE ........ 61 DETROL ........................... 49

see tolterodine tartrate tab 1 mg .............................. 49 see tolterodine tartrate tab 2 mg .............................. 49

DETROL LA ...................... 49 see tolterodine tartrate er ...................................... 49

dexamethasone ................ 43 dexamethasone sodium phosphate ......................... 43 dexamethasone sodium phosphate (ophth) ............. 55 DEXILANT ........................ 48 dexpak taperpak 13 day.... 43 dexrazoxane ..................... 15 DEXTROSE ...................... 53 DEXTROSE 10% FLEX CONTAIN .......................... 54 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% .......................................... 54 DEXTROSE 10%/NACL 0.45%................................ 54 DEXTROSE 2.5%/NACL 0.45%................................ 53 DEXTROSE 5% ................ 53 DEXTROSE 5% /ELECTROLYTE ............... 53 DEXTROSE 5%/LACTATED RING ................................. 53 DEXTROSE 5%/NACL 0.2% .......................................... 54 DEXTROSE 5%/NACL 0.225% .............................. 54

DEXTROSE 5%/NACL 0.3%.......................................... 54 DEXTROSE 5%/NACL 0.33% ............................... 54 DEXTROSE 5%/NACL 0.45% ............................... 54 DEXTROSE 5%/NACL 0.9%.......................................... 54 DEXTROSE 5%/POTASSIUM CHL ...... 54 DIAMOX ........................... 21

see acetazolamide ........ 21 DIASTAT ACUDIAL .......... 23 DIASTAT PEDIATRIC ...... 23 diazepam .......................... 23 DIAZEPAM GEL (ANTICONVULSANT) ....... 23 DIBENZYLINE .................. 22 diclofenac potassium .......... 1 diclofenac sodium ............... 1 diclofenac sodium (actinic keratoses) ......................... 62 diclofenac sodium (ophth) . 55 diclofenac sodium (topical) 62 diclofenac w/ misoprostol .... 1 dicloxacillin sodium ........... 12 dicyclomine hcl ................. 46 didanosine .......................... 8 DIFFERIN ......................... 59

see adapalene............... 59 DIFICID ............................. 11 diflorasone diacetate ......... 61 DIFLUCAN .......................... 8

see fluconazole ............... 8 diflunisal .............................. 1 digitek ............................... 21 digoxin .............................. 21 digoxin inj .......................... 21 DIGOXIN SOL 50MCG/ML.......................................... 21 dihydroergotamine mesylate.......................................... 33 DIHYDROERGOTAMINE MESYLATE ...................... 33 dilantin .............................. 23 DILANTIN

see phenytoin sodium extended ....................... 25

2016 601 4T Copper Comm eff 01/01/2016

73

DILANTIN INFATABS see phenytoin ................ 25

DILANTIN-125 .................. 23 see phenytoin ................ 25

DILATRATE SR ................ 22 DILAUDID

see hydromorphone hcl ...3 DILAUDID INJ .....................2 DILAUDID TAB ...................2 DILAUDID-5 ORAL LIQD ....2 DILAUDID-HP

see hydromorphone hcl ...3 DILAUDID-HP INJ 10MG/ML ............................................2 DILAUDID-HP INJ 250MG ..2 diltiazem cap 120mg/24hr . 20 diltiazem cap er/12hr ......... 20 diltiazem hcl ...................... 20 diltiazem hcl coated beads 20 diltiazem hcl er .................. 20 diltiazem hcl extended release beads ................... 20 diltiazem inj 100mg ........... 20 diltiazem inj 125/25ml ....... 20 diltiazem inj 25mg/5ml ...... 20 diltiazem inj 50/10ml ......... 20 dilt-xr cap .......................... 20 diltzac ................................ 20 DIOVAN ............................ 17

see valsartan ................. 17 DIOVAN HCT .................... 17

see valsartan-hydrochlorothiazide .................................. 17

DIPENTUM ....................... 47 diphenhydram inj 50mg/ml 57 diphenoxylate w/ atropine . 47 DIPHTHERIA/TETANUS TOXOID ............................ 52 DIPROLENE ..................... 61

see betamethasone dipropionate augmented 61

DIPROLENE AF ................ 61 see betamethasone dipropionate augmented 60

disopyramide phosphate ... 18 disulfiram........................... 35 DITROPAN XL .................. 49

see oxybutynin chloride . 49 DIURIL SUS 250/5ML ....... 21 divalproex sodium ............. 23 docetaxel .......................... 14 DOCETAXEL .................... 14 DOLOPHINE ....................... 2

see methadone hcl .......... 4 DOLOPHINE HCL

see methadone hcl .......... 4 donepezil odt 10mg .......... 25 donepezil odt 5mg ............ 25 donepezil tab hcl 23mg ..... 25 donepezil tabs 10mg ......... 25 donepezil tabs 5mg ........... 25 DORIBAX ............................ 7 dorzolamide hcl ................. 56 dorzolamide hcl-timolol maleate ............................. 56 DOVONEX

see calcipotriene ........... 60 DOVONEX CRE 0.005% .. 60 doxazosin mesylate .......... 16 doxepin hcl ........................ 26 doxercalciferol ................... 54 DOXIL ............................... 13

see doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ........... 13

doxorubicin hcl .................. 13 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ..... 13 doxorubicin inj 50mg ......... 13 doxy .................................. 12 doxycycline (monohydrate) .................................... 12, 13 DOXYCYCLINE (ROSACEA) ...................... 62 doxycycline hyclate ........... 13 dronabinol ......................... 45 drospirenone-ethinyl estradiol ............................ 40 DROXIA ............................ 15 DUAC ................................ 59

see clindamycin phosphate-benzoyl peroxide (refrigerate) ..... 59 see neuac gel 1.2-5% .... 59

DUETACT ......................... 37

see pioglitazone hcl-glimepiride ............... 39

DUEXIS .............................. 1 DULERA ........................... 59 duloxetine hcl .................... 26 DUOPA ............................. 27 DURAGESIC ...................... 3

see fentanyl patch 100 mcg/hr ............................. 3 see fentanyl patch 12 mcg/hr ............................. 3 see fentanyl patch 25 mcg/hr ............................. 3 see fentanyl patch 50 mcg/hr ............................. 3 see fentanyl patch 75 mcg/hr ............................. 3

DURAMORPH .................... 3 DUREZOL ........................ 55 DUTOPROL ...................... 19 DYAZIDE .......................... 21

see triamt/hctz cap 37.5-25 .......................... 21

DYMISTA SPR 137-50 ..... 57 DYRENIUM ...................... 21 E e.e.s. 400 tab 400mg ........ 11 E.E.S. GRANULES ........... 11 EC-NAPROSYN ................. 1

see naproxen .................. 1 econazole nitrate .............. 60 EDARBI ............................ 17 EDARBYCLOR ................. 17 EDECRIN ......................... 21 EDURANT .......................... 8 EFFEXOR XR ................... 26

see venlafaxine cap er .. 27 EFFIENT ........................... 50 EFUDEX ........................... 62

see fluorouracil (topical) 62 EGRIFTA .......................... 44 ELAPRASE ....................... 42 ELDEPRYL ....................... 27

see selegiline hcl ........... 28 ELECTROLYTE-R IN DEXTROSE ...................... 54 ELELYSO ......................... 42 ELESTAT .......................... 56

2016 601 4T Copper Comm eff 01/01/2016

74

see epinastine hcl (ophth) ...................................... 56

ELIDEL ............................. 62 ELIGARD INJ 22.5MG ...... 14 ELIGARD INJ 30MG ......... 14 ELIGARD INJ 45MG ......... 14 ELIGARD INJ 7.5MG ........ 14 ELIMITE

see permethrin .............. 63 eliphos .............................. 45 ELIPHOS

see calcium acetate (phosphate binder) ........ 45

ELIQUIS TAB 2.5MG ........ 49 ELIQUIS TAB 5MG ........... 49 ELITEK ............................. 15 elixophyllin ........................ 59 ELLA ................................. 40 ELLENCE.......................... 13

see epirubicin inj 200mg 13 see epirubicin inj 50mg/25ml ..................... 13

ELMIRON.......................... 49 ELOCON ........................... 61

see mometasone furoate ...................................... 62

ELOXATIN ........................ 15 EMADINE.......................... 56 EMBEDA .............................3 EMCYT ............................. 13 EMEND CAP 125MG ........ 45 EMEND CAP 40MG .......... 45 EMEND CAP 80MG .......... 45 EMEND PAK 80 & 125 ..... 45 EMLA ................................ 62

see lidocaine-prilocaine . 62 emoquette ......................... 40 EMSAM ............................. 26 EMTRIVA ............................8 ENABLEX ......................... 49 enalapril maleate ............... 16 enalapril maleate & hydrochlorothiazide ........... 16 ENBREL............................ 51 ENBREL SURECLICK ...... 51 endocet ...............................3 ENDODAN TAB ..................3 ENGERIX-B ...................... 52

enoxaparin sodium ........... 49 enpresse 28 day ............... 40 ENTACAPONE ................. 27 entecavir ........................... 10 ENTOCORT EC ................ 47

see budesonide ............. 47 ENTYVIO .......................... 47 enulose ............................. 47 EPIDUO ............................ 59 epinastine hcl (ophth)........ 56 EPINEPHRINE ................. 58 EPIPEN 2-PAK ................. 58 EPIPEN-JR 2-PAK ............ 58 epirubicin inj 200mg .......... 13 epirubicin inj 50mg/25ml ... 13 epitol ................................. 23 EPIVIR

see lamivudine ................ 9 EPIVIR HBV ...................... 10

see lamivudine (hbv) ..... 10 EPIVIR SOL 10MG/ML ....... 8 EPIVIR TABS ...................... 8 eplerenone ........................ 16 EPOGEN .......................... 50 eprosartan mesylate ......... 17 EPZICOM ........................... 9 EQUETRO ........................ 34 ERAXIS ............................... 8 ERBITUX .......................... 14 ergomar ............................ 33 ERIVEDGE ....................... 14 errin 28 day ....................... 40 ERTACZO ......................... 60 ery pad 2% ........................ 59 erygel ................................ 59 ERYGEL

see erythromycin (acne aid) ................................ 59

ERYPED 200 .................... 11 ERYPED 400 .................... 11 ery-tab ............................... 11 erythrocin lactobionate ...... 11 erythrocin stearate ............ 11 erythromycin (acne aid) .... 59 erythromycin (ophth) ......... 55 erythromycin base ............ 11 erythromycin cap 250mg ec .......................................... 11

erythromycin ethylsuccinate.......................................... 11 ESBRIET .......................... 58 escitalopram oxalate ......... 26 esomeprazole sodium inj .. 48 estrace .............................. 42 ESTRACE

see estradiol .................. 43 estradiol ...................... 42, 43 estradiol valerate .............. 43 ESTRING .......................... 43 ESTROSTEP FE .............. 40

see tri-legest 28 day ...... 42 ethambutol hcl .................... 9 ethosuximide .................... 23 ETHYOL

see amifostine crystalline ...................................... 15

etodolac .............................. 1 etodolac er .......................... 1 ETOPOPHOS ................... 16 etoposide .......................... 16 EURAX ............................. 63 EVISTA ............................. 44

see raloxifene hcl .......... 44 EVOCLIN .......................... 59

see clindamycin phosphate (topical) ........ 59

EVOTAZ ............................. 9 EVOXAC ........................... 63

see cevimeline hcl ......... 63 EXALGO ............................. 3

see hydromorphone tab 12mg er ........................... 4 see hydromorphone tab 16mg er ........................... 4 see hydromorphone tab 8mg er ............................. 4

EXELDERM ...................... 60 EXELON

see rivastigmine tartrate 26 EXELON CAPS ................ 25 EXELON PATCHES ......... 25 exemestane ...................... 14 EXFORGE ........................ 17

see amlodipine besylate-valsartan tab 10-160 mg ..................... 17

2016 601 4T Copper Comm eff 01/01/2016

75

see amlodipine besylate-valsartan tab 10-320 mg ..................... 17 see amlodipine besylate-valsartan tab 5-160 mg ....................... 17 see amlodipine besylate-valsartan tab 5-320 mg ....................... 17

EXFORGE HCT ................ 17 see amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg .............. 17 see amlodipine-valsartan-hydrochlorothiazide 10-160-25mg ................. 17 see amlodipine-valsartan-hydrochlorothiazide 10-320-25mg ................. 17 see amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg ................ 17 see amlodipine-valsartan-hydrochlorothiazide 5-160-25mg ................... 17

EXJADE ............................ 39 EXTAVIA ........................... 34 EXTINA ............................. 60

see ketodan aer 2% ...... 60 F FABIOR............................. 59 FABRAZYME .................... 42 FACTIVE ........................... 12 falmina 28 day ................... 40 famciclovir ......................... 10 famotidine ......................... 46 famotidine inj ..................... 46 FAMVIR ............................ 10

see famciclovir ............... 10 FANAPT ............................ 28 FANAPT TITRATION PACK .......................................... 28 FARESTON ...................... 14

FARXIGA .......................... 37 FARYDAK ......................... 14 FASLODEX ....................... 14 FAZACLO ......................... 28 felbamate .......................... 23 FELBATOL ....................... 23

see felbamate ................ 23 FELDENE ........................... 1

see piroxicam .................. 1 felodipine .......................... 20 FEMARA ........................... 14

see letrozole .................. 14 FEMCON FE ..................... 40

see wymzya fe .............. 42 see zenchent fe 28 day . 42

FEMRING ......................... 43 fenofibrate ......................... 18 FENOFIBRATE ................. 18 fenofibrate micronized. 18, 19 FENOFIBRIC ACID........... 19 FENOGLIDE ..................... 19 fenoprofen calcium ............. 1 fentanyl citrate .................... 3 fentanyl patch 100 mcg/hr ... 3 fentanyl patch 12 mcg/hr ..... 3 fentanyl patch 25 mcg/hr ..... 3 fentanyl patch 50 mcg/hr ..... 3 fentanyl patch 75 mcg/hr ..... 3 FENTORA ........................... 3 FERRIPROX ..................... 39 FETZIMA .......................... 26 FETZIMA TITRATION PACK .......................................... 26 FIBRICOR ......................... 19 FINACEA GEL 15% .......... 62 finasteride ......................... 48 FIRAZYR .......................... 50 FIRMAGON ...................... 14 FLAGYL .............................. 7

see metronidazole ........... 7 FLAGYL ER ........................ 7 FLAREX ............................ 55 FLEBOGAMMA ................ 51 FLEBOGAMMA DIF .......... 51 flecainide acetate .............. 18 FLOMAX ........................... 49

see tamsulosin hcl ......... 49 FLO-PRED SUS ............... 43

FLOVENT DISKUS ........... 58 FLOVENT HFA ................. 58 fluconazole ......................... 8 fluconazole in dextrose ....... 8 fluconazole in nacl .............. 8 flucytosine ........................... 8 FLUDARA

see fludarabine phosphate ...................................... 14

fludarabine phosphate ...... 14 fludrocortisone acetate ..... 43 FLUMADINE ..................... 10

see rimantadine hydrochloride................. 10

flunisolide (nasal) .............. 58 fluocinolone acetonide ...... 61 fluocinolone acetonide (otic).......................................... 63 fluocinonide ...................... 61 fluocinonide emulsified base.......................................... 61 FLUOROMETHOLONE (OPHTH) ........................... 55 fluorouracil ........................ 14 fluorouracil (topical) .......... 62 FLUOROURACIL (TOPICAL) ........................ 62 fluoxetine hcl ..................... 26 FLUOXETINE HCL ........... 26 fluphenazine decanoate .... 28 fluphenazine hcl ................ 28 flurbiprofen .......................... 1 flurbiprofen sodium ........... 55 flutamide ........................... 14 fluticasone propionate ....... 61 fluticasone propionate (nasal) ............................... 58 fluvastatin sodium ............. 18 fluvoxamine maleate ......... 22 fluvoxamine maleate er ..... 22 FML .................................. 55 FML FORTE ..................... 55 FML LIQUIFILM ................ 55 fondaparinux sodium ........ 49 FORADIL AEROLIZER ..... 57 FORFIVO XL .................... 26 FORTAMET ...................... 37

see metformin hcl .......... 38

2016 601 4T Copper Comm eff 01/01/2016

76

FORTAZ............................ 11 see ceftazidime ............. 11 see tazicef ..................... 11 see tazicef vial ............... 11

FORTEO ........................... 44 FORTESTA ....................... 36 FORTICAL SPR 200/ACT . 44 FOSAMAX ........................ 39

see alendronate sodium 39 FOSAMAX PLUS D .......... 39 foscarnet sodium ............... 10 fosinopril sodium ............... 16 fosinopril sodium & hydrochlorothiazide ........... 16 FOSRENOL ...................... 45 FRAGMIN ......................... 49 FREAMINE HBC 6.9% ...... 53 FREAMINE III ................... 53 FROVA TAB 2.5MG .......... 33 FURADANTIN .....................7

see nitrofurantoin .............7 furosemide ........................ 21 furosemide inj .................... 21 FUROSEMIDE INJ ............ 21 furosemide oral soln 8 mg/ml .......................................... 21 FUSILEV ........................... 15 FUZEON .............................8 FYCOMPA ........................ 23 G gabapentin ........................ 24 GABITRIL.......................... 24

see tiagabine hcl ........... 25 galantamine hydrobromide .................................... 25, 26 GAMASTAN S/D ............... 51 GAMMAGARD LIQUID ..... 51 GAMMAGARD S/D ........... 51 GAMMAGARD S/D IGA LESS TH ........................... 51 GAMMAKED ..................... 51 GAMMAPLEX ................... 51 GAMUNEX-C .................... 51 ganciclovir inj 500mg ........ 10 garamycin ......................... 55 GARAMYCIN

see gentamicin sulfate (ophth) ........................... 55

GARDASIL ........................ 52 GARDASIL 9 ..................... 52 GASTROCROM ................ 47

see cromolyn sodium (mastocytosis) ............... 47

gatifloxacin (ophth) ........... 55 GATTEX ........................... 47 GAUZE PADS 2X2 ........... 36 gaviltye-g .......................... 47 gavilyte-c ........................... 47 gavilyte-h .......................... 47 gavilyte-n .......................... 47 GELNIQUE ....................... 49 GEMCITABINE ................. 14 gemcitabine hcl ................. 14 gemfibrozil ........................ 19 GEMZAR .......................... 14

see gemcitabine hcl....... 14 GENERESS FE ................ 40

see norethindrone & ethinyl estradiol-fe ......... 41

generlac ............................ 47 gengraf .............................. 51 GENOTROPIN .................. 44 GENOTROPIN MINIQUICK .......................................... 44 gentak ............................... 55 gentamicin in saline 0.8 mg/ml .................................. 6 gentamicin in saline 0.9mg/ml ............................. 6 gentamicin in saline 1 mg/ml ............................................ 6 gentamicin in saline 1.2 mg/ml .................................. 6 gentamicin in saline 1.4mg/ml ............................. 6 gentamicin in saline 1.6 mg/ml .................................. 6 gentamicin in saline 2 mg/ml ............................................ 6 gentamicin sulfate ............... 6 gentamicin sulfate (ophth) . 55 gentamicin sulfate (topical) .......................................... 59 GEODON .......................... 28

see ziprasidone hcl........ 30 GEODON INJ ................... 28

GIANVI TAB 3-0.02MG ..... 40 GIAZO .............................. 47 gildagia ............................. 40 gildess 1.5/30 21 day ........ 40 gildess 24 fe 28 day .......... 40 GILENYA CAP 0.5MG ...... 34 GILOTRIF TAB 20MG ...... 15 GILOTRIF TAB 30MG ...... 15 GILOTRIF TAB 40MG ...... 15 GLASSIA .......................... 58 glatopa .............................. 34 GLEEVEC ......................... 15 GLEOSTINE ..................... 13 glimepiride ........................ 37 glipizide ............................. 37 glipizide er ........................ 37 glipizide-metformin 2.5-250 mg ..................................... 37 glipizide-metformin 2.5-500 mg ..................................... 37 glipizide-metformin 5-500mg.......................................... 37 GLUCAGEN HYPOKIT ..... 44 GLUCAGON EMERGENCY KIT .................................... 44 GLUCOPHAGE ................ 37

see metformin hcl .......... 38 GLUCOPHAGE XR .......... 37

see metformin er ........... 38 GLUCOTROL ................... 37

see glipizide .................. 37 GLUCOTROL XL .............. 38

see glipizide er .............. 37 GLUMETZA ...................... 38 glycate .............................. 46 glycopyrrolate ................... 46 GLYSET ........................... 38 GLYXAMBI ....................... 38 GOLYTELY ....................... 47

see gaviltye-g ................ 47 GRALISE .......................... 34 GRALISE STARTER ........ 34 granisetron hcl .................. 45 GRANIX ............................ 50 GRASTEK ........................ 51 GRIFULVIN V

see griseofulvin microsize ........................................ 8

2016 601 4T Copper Comm eff 01/01/2016

77

griseofulvin microsize ..........8 griseofulvin ultramicrosize ...8 GRIS-PEG ..........................8

see griseofulvin ultramicrosize ..................8

guanfacine hcl (adhd) ....... 31 H H.P. ACTHAR ................... 44 HALAVEN ......................... 15 HALDOL............................ 28

see haloperidol lactate inj 5 mg/ml.......................... 28

HALDOL DECANOATE 100 .......................................... 28

see haloperidol decanoate ...................................... 28

HALDOL DECANOATE 50 .......................................... 28

see haloperidol decanoate ...................................... 28

halobetasol propionate ...... 61 HALOG ............................. 61 haloperidol ........................ 28 haloperidol decanoate ....... 28 haloperidol lactate ............. 28 haloperidol lactate inj 5 mg/ml ................................ 28 HARVONI.......................... 10 HAVRIX............................. 52 heather .............................. 40 HECTOROL ...................... 54

see doxercalciferol ........ 54 HEP SOD/NACL INJ 25000 .......................................... 50 HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML ........................... 50 heparin sod inj 10000u/ml . 50 heparin sod inj 1000u/ml ... 50 heparin sod inj 20000u/ml . 50 HEPARIN SOD INJ 2000U/ML ......................... 50 HEPARIN SOD INJ 2500U/ML ......................... 50 heparin sod inj 5000u/0.5ml .......................................... 50 heparin sod inj 5000u/ml ... 50 HEPARIN SODIUM/D5W .. 50

HEPARIN SODIUM/NACL 0.45%................................ 50 HEPATAMINE .................. 53 HEPSERA ......................... 10

see adefovir dipivoxil ..... 10 HERCEPTIN ..................... 14 HETLIOZ ........................... 32 HEXALEN ......................... 13 HIBERIX ........................... 52 HIPREX .............................. 7

see methenamine hippurate ......................... 7

HORIZANT ....................... 34 HUMALOG ........................ 36 HUMALOG KWIKPEN ...... 36 HUMALOG MIX 50/50 ...... 36 HUMALOG MIX 50/50 KWIKPEN ......................... 36 HUMALOG MIX 75/25 ...... 36 HUMALOG MIX 75/25 KWIKPEN ......................... 36 HUMATROPE ................... 44 HUMATROPE COMBO PACK ................................ 44 HUMIRA ............................ 51 HUMIRA PEN ................... 51 HUMIRA PEN-CROHNS STARTER KIT .................. 51 HUMIRA PEN-PSORIASIS STARTER KIT .................. 51 HUMULIN 70/30 ............... 36 HUMULIN 70/30 KWIKPEN .......................................... 36 HUMULIN N ...................... 36 HUMULIN N KWIKPEN .... 36 HUMULIN R ...................... 36 HUMULIN R U-500 (CONCENTRATE) ............ 36 HYCAMTIN ....................... 16

see topotecan hcl .......... 16 hycet ................................... 3 HYCET

see hydrocodone-acetaminophen 7.5-325 mg/15ml ........ 3

hydralazine hcl .................. 22 HYDREA ........................... 15

see hydroxyurea ............ 15

hydrochlorothiazide ........... 21 hydrocodone-acetaminophen 10-300mg ........................... 3 hydrocodone-acetaminophen 2.5-325mg .......................... 3 hydrocodone-acetaminophen 5-300mg ............................. 3 hydrocodone-acetaminophen 5-325mg ............................. 3 hydrocodone-acetaminophen 7.5-300mg .......................... 3 hydrocodone-acetaminophen 7.5-325 mg/15ml ................. 3 hydrocodone-acetaminophen 7.5-325mg .......................... 3 hydrocodone-acetaminophen tab 10-325mg ..................... 3 hydrocodone-ibuprofen tab 2.5-200mg .......................... 3 hydrocodone-ibuprofen tab 7.5-200 mg ......................... 3 hydrocortisone .................. 43 HYDROCORTISONE (INTRARECTAL) .............. 47 hydrocortisone (topical) .... 61 hydrocortisone butyrate .... 61 hydrocortisone butyrate hydrophilic lipo base ......... 61 hydrocortisone valerate .... 62 hydromorphone hcl ............. 3 HYDROMORPHONE HCL . 3 hydromorphone tab 12mg er............................................ 4 hydromorphone tab 16mg er............................................ 4 hydromorphone tab 8mg er 4 HYDROMORPHONE TABS 32MG .................................. 4 hydroxychloroquine sulfate.......................................... 51 hydroxyurea ...................... 15 hydroxyzine hcl ................. 57 HYSINGLA ER.................... 4 HYZAAR ........................... 17

see losartan-hydrochlorothiazide .................................. 17

2016 601 4T Copper Comm eff 01/01/2016

78

I ibandronate sodium .......... 39 ibandronate tab 150mg ..... 39 IBRANCE .......................... 14 ibudone tab 10-200mg ........4 ibudone tab 5-200mg ..........4 ibuprofen .............................1 ICLUSIG............................ 15 IDAMYCIN PFS ................ 13

see idarubicin hcl ........... 13 idarubicin hcl ..................... 13 IFEX

see ifosfamide inj 1gm ... 13 IFEX INJ 1GM ................... 13 IFEX INJ 3GM ................... 13 IFOSFAMIDE

see ifosfamide inj ........... 13 ifosfamide inj ..................... 13 ifosfamide inj 1gm ............. 13 IFOSFAMIDE INJ 3GM ..... 13 ILEVRO ............................. 55 ilotycin ............................... 55 IMBRUVICA CAP 140MG . 15 imipenem-cilastatin .............7 imipramine hcl ................... 26 imipramine pamoate ......... 26 imiquimod.......................... 62 IMITREX ........................... 33

see sumatriptan inj 6mg/0.5ml ...................... 33 see sumatriptan succinate ...................................... 33

IMITREX STATDOSE REFILL .............................. 33 IMITREX STATDOSE SYSTEM ........................... 33

see sumatriptan inj 6mg/0.5ml ...................... 33

IMOVAX RABIES (H.D.C.V.) .......................................... 52 IMURAN ............................ 51

see azathioprine ............ 51 INCRELEX ........................ 44 INCRUSE ELLIPTA .......... 57 indapamide ....................... 21 INDERAL LA ..................... 19

see propranolol hcl er .... 20 INFANRIX ......................... 52

INFUMORPH 200 ............... 4 INFUMORPH 500 ............... 4 INLYTA ............................. 15 INSPRA ............................ 16

see eplerenone ............. 16 INSULIN PEN NEEDLES .. 36 INSULIN SAFETY NEEDLES ......................... 36 INSULIN SYRINGES ........ 36 INTELENCE .................... 8, 9 INTRALIPID INJ 20%........ 53 INTRALIPID INJ 30%........ 53 INTRON-A INJ 10MU........ 51 INTRON-A INJ 18MU........ 51 INTRON-A INJ 25MU........ 51 INTRON-A INJ 50MU........ 51 introvale 91 day ................ 40 INTUNIV ........................... 31

see guanfacine hcl (adhd) ...................................... 31

INVANZ ............................... 7 INVEGA ............................ 28 INVEGA SUST INJ 117 MG/0.75 ML ...................... 28 INVEGA SUST INJ 156MG/ML ........................ 28 INVEGA SUST INJ 234 MG/1.5 ML ........................ 29 INVEGA SUST INJ 39 MG/0.25 ML ...................... 28 INVEGA SUST INJ 78 MG/0.5 ML ........................ 28 INVEGA TRINZA .............. 29 INVIRASE ........................... 9 INVOKAMET TAB 150-1000 .......................................... 38 INVOKAMET TAB 150-500 .......................................... 38 INVOKAMET TAB 50-1000 .......................................... 38 INVOKAMET TAB 50-500MG ......................... 38 INVOKANA TAB 100MG ... 38 INVOKANA TAB 300MG ... 38 IONOSOL-B/DEXTROSE 5% .................................... 54 IONOSOL-MB/DEXTROSE 5% .................................... 54

IPOL INACTIVATED IPV .. 52 ipratropium bromide (nasal).......................................... 57 ipratropium sol inhal .......... 57 ipratropium-albuterol ......... 56 irbesartan .......................... 17 irbesartan-hydrochlorothiazide........................................ 17 irinotecan inj 100/5ml ........ 16 irinotecan inj 40mg/2ml ..... 16 irinotecan inj 500mg/25ml . 16 ISENTRESS ....................... 9 ISOLYTE P ....................... 54 ISOLYTE S ....................... 54 isoniazid .............................. 9 isoniazid tabs ...................... 9 ISOPTO CARPINE ........... 56 ISORDIL TITRADOSE ...... 22

see isosorbide dinitrate . 22 isosorbide dinitrate ............ 22 isosorbide dinitrate er ....... 22 isosorbide mononitrate ..... 22 isosorbide mononitrate er . 22 isradipine .......................... 20 ISTALOL ........................... 56 ISTODAX .......................... 14 itraconazole ........................ 8 ivermectin ........................... 7 IXEMPRA KIT ................... 15 IXIARO ............................. 52 J JADENU ........................... 39 JAKAFI ............................. 15 JALYN .............................. 49 jantoven ............................ 50 JANUMET ......................... 38 JANUMET XR TAB 100-1000 .......................... 38 JANUMET XR TAB 50-1000.......................................... 38 JANUMET XR TAB 50-500MG ......................... 38 JANUVIA .......................... 38 JARDIANCE ..................... 38 JENTADUETO .................. 38 jinteli ................................. 43 JOLESSA TAB 0.15-0.03 MG .................................... 40

2016 601 4T Copper Comm eff 01/01/2016

79

JOLIVETTE ....................... 40 junel 1.5/30 21 day ............ 40 junel 1/20 21 day ............... 40 junel fe 1.5/30 28 day ........ 40 junel fe 1/20 28 day ........... 40 junel fe 24 1/20 28 day ...... 40 JUXTAPID ......................... 19 K KADCYLA ......................... 14 KADIAN...............................4

see morphine sulfate .......4 KALETRA SOL ...................9 KALETRA TAB 100-25MG ..9 KALETRA TAB 200-50MG ..9 KALYDECO ...................... 58 kariva 28 day ..................... 40 KAYEXALATE ................... 39

see kionex ..................... 39 KAZANO ........................... 38 KCL 0.075%/D5W/NACL 0.45% ................................ 54 KCL 0.15%/D5W/LR ......... 54 KCL 0.15%/D5W/NACL 0.9% .................................. 54 KCL 0.3%/D5W/LR IV LAC RI ...................................... 54 KCL 0.3%/D5W/NACL 0.45% ................................ 54 KCL 0.3%/D5W/NACL 0.9% .......................................... 54 KCL IN NACL INJ .15-0.45 .......................................... 54 KCL/D5W/NACL INJ .15/.33% ............................ 54 KCL/D5W/NACL INJ .15/.45% ............................ 54 KCL/D5W/NACL INJ 0.22%/0.45% ..................... 54 KCL/NACL INJ 0.15%-0.9% .......................................... 54 KCL0.15%/D5W/NACL0.2% .......................................... 54 KCL0.15%/D5W/NACL0.225% ....................................... 54 KEFLEX ............................ 11

see cephalexin .............. 11 kelnor 1/35 28 day ............ 40 KENALOG......................... 62

see triamcinolone acetonide (topical) ......... 62

KEPIVANCE ..................... 15 KEPPRA ........................... 24

see levetiracetam .......... 24 see levetiracetam oral soln 100 mg/ml ..................... 24

KEPPRA XR ..................... 24 see levetiracetam .......... 24

KERLONE see betaxolol hcl ........... 19

ketoconazole ....................... 8 ketoconazole (topical) ....... 60 ketoconazole shampoo ..... 60 ketodan aer 2% ................. 60 ketoprofen ........................... 1 ketorolac tromethamine (ophth) .............................. 55 KEYTRUDA ...................... 14 kimidess ............................ 40 KINERET .......................... 51 KINRIX .............................. 52 kionex ............................... 39 KLARON ........................... 59

see sulfacetamide sodium (acne) ............................ 59

KLONOPIN ....................... 24 see clonazepam ............ 23

KLOR-CON 10 .................. 52 KLOR-CON 8 .................... 52 klor-con m15 ..................... 52 klor-con m20 ..................... 52 klor-con pow 20meq ......... 52 KOMBIGLYZE XR 2.5-1000MG ...................... 38 KOMBIGLYZE XR 5-1000MG ......................... 38 KOMBIGLYZE XR 5-500MG .......................................... 38 KORLYM ........................... 44 kristalose ........................... 47 K-TAB ............................... 52 KUVAN ............................. 42 KYNAMRO ........................ 19 L labetalol hcl ....................... 19 LAC-HYDRIN .................... 62

see ammonium lactate .. 62

see laclotion lot 12% ..... 62 laclotion lot 12%................ 62 LACRISERT ..................... 56 LACTATED RINGERS VIAFLEX ........................... 54 lactulose ........................... 47 lactulose (encephalopathy).......................................... 47 LAMICTAL ........................ 24

see lamotrigine .............. 24 LAMICTAL CHEWABLE DISPERS .......................... 24

see lamotrigine .............. 24 LAMICTAL ODT................ 24

see lamotrigine .............. 24 LAMICTAL STARTER ...... 24 LAMICTAL XR .................. 24

see lamotrigine .............. 24 LAMISIL .............................. 8

see terbinafine hcl ........... 8 lamivudine .......................... 9 lamivudine (hbv) ............... 10 lamivudine-zidovudine ........ 9 lamotrigine ........................ 24 LANOXIN .......................... 21

see digitek ..................... 21 see digoxin .................... 21 see digoxin inj ............... 21

LANOXIN INJ 0.25MG/ML 21 LANOXIN PEDIATRIC ...... 21 LANOXIN TAB .................. 21 lansoprazole ..................... 48 LANTUS ........................... 36 LANTUS SOLOSTAR ....... 36 larin 1.5/30 ........................ 40 larin 1/20 ........................... 40 larin fe 1.5/30 .................... 40 larin fe 1/20 ....................... 40 LASIX ............................... 21

see furosemide.............. 21 LASTACAFT ..................... 56 latanoprost ........................ 56 LATUDA ........................... 29 LAZANDA ........................... 4 LEENA TAB ...................... 40 leflunomide ....................... 51 LEMTRADA ...................... 34 LENVIMA 10MG DAILY

2016 601 4T Copper Comm eff 01/01/2016

80

DOSE ................................ 15 LENVIMA 14MG DAILY DOSE ................................ 15 LENVIMA 20MG DAILY DOSE ................................ 15 LENVIMA 24MG DAILY DOSE ................................ 15 LESCOL ............................ 18

see fluvastatin sodium ... 18 LESCOL XL ...................... 18 lessina 28 day ................... 40 LETAIRIS .......................... 22 letrozole ............................ 14 leucovorin calcium ............ 15 leucovorin calcium inj 100mg .......................................... 15 leucovorin calcium inj 200mg .......................................... 15 leucovorin calcium inj 350mg .......................................... 15 leucovorin calcium inj 500mg .......................................... 15 leucovorin calcium inj 50mg .......................................... 15 LEUKERAN ....................... 13 LEUKINE........................... 50 leuprolide acetate .............. 14 levalbuterol conc 1.25mg/0.5ml .................... 57 levalbuterol hcl .................. 57 LEVALBUTEROL HCL ...... 57 LEVAQUIN ........................ 12

see levofloxacin ............. 12 see levofloxacin in d5w.. 12

LEVEMIR .......................... 36 LEVEMIR FLEXTOUCH.... 36 levetiracetam ..................... 24 LEVETIRACETAM IV ........ 24 levetiracetam oral soln 100 mg/ml ................................ 24 levobunolol hcl .................. 56 LEVOBUNOLOL HCL ....... 56 levocarnitine (metabolic modifiers) .......................... 42 levocetirizine soln 2.5mg/5ml .......................................... 57 levocetirizine tab 5 mg ...... 57 levofloxacin ....................... 12

levofloxacin (ophth) ........... 55 levofloxacin in d5w ............ 12 levoleucovorin calcium ...... 15 levonest 28 day ................. 40 levonorgestrel & eth estradiol .......................................... 40 levonorgestrel (emergency oc) ............................... 40, 41 levonorgestrel-ethinyl estradiol (91-day) .............. 41 levonorgestrel-ethinyl estradiol (continuous)........ 41 levora 0.15/30 28 day ....... 41 levorphanol tartrate ............. 4 levothyroxine sodium ........ 45 LEVOXYL ......................... 45 LEXAPRO ......................... 26

see escitalopram oxalate ...................................... 26

LEXIVA ............................... 9 LIALDA ............................. 47 lidocaine ............................ 62 lidocaine hcl ...................... 62 lidocaine hcl (local anesth.) . 6 lidocaine hcl (mouth-throat) .......................................... 63 lidocaine inj 0.5% ................ 6 lidocaine inj 1% ................... 6 lidocaine inj 1.5% ................ 6 lidocaine inj 2% ................... 6 lidocaine-prilocaine ........... 62 LIDODERM ....................... 62

see lidocaine ................. 62 linezolid ............................... 7 LINEZOLID ......................... 7 LINZESS ........................... 47 liothyronine sodium ........... 45 LIPITOR ............................ 18

see atorvastatin calcium 18 LIPOFEN .......................... 19 LIPOSYN II ....................... 53 LIPOSYN III ...................... 53 LIPTRUZET ...................... 19 lisinopril ............................. 16 lisinopril & hydrochlorothiazide ........... 16 lithium carbonate .............. 34 LITHIUM SOLN 8MEQ/5ML

.......................................... 34 LITHOBID ......................... 34

see lithium carbonate .... 34 LIVALO ............................. 18 LO LOESTRIN FE ............ 41 LOCOID ............................ 62

see hydrocortisone butyrate ......................... 61

LOCOID LIPOCREAM ...... 62 see hydrocortisone butyrate hydrophilic lipo base .............................. 61

LODOSYN ........................ 27 see carbidopa................ 27

loestrin 1.5/30 21 day ....... 41 LOESTRIN 1.5/30-21

see gildess 1.5/30 21 day ...................................... 40 see junel 1.5/30 21 day . 40 see larin 1.5/30.............. 40

loestrin 1/20 21 day .......... 41 LOESTRIN 1/20-21

see junel 1/20 21 day .... 40 see larin 1/20................. 40

LOESTRIN FE 1.5/30 see junel fe 1.5/30 28 day ...................................... 40 see larin fe 1.5/30 .......... 40

loestrin fe 1.5/30 28 day ... 41 LOESTRIN FE 1/20

see junel fe 1/20 28 day 40 see larin fe 1/20............. 40 see tarina fe 1/20 28 day ...................................... 42

loestrin fe 1/20 28 day ...... 41 lofibra ................................ 19 LOFIBRA

see fenofibrate .............. 18 see fenofibrate micronized ...................................... 19

lokara ................................ 62 lomedia 24 fe .................... 41 LOMOTIL .......................... 47

see diphenoxylate w/ atropine ......................... 47

LOMUSTINE ..................... 13 loperamide hcl .................. 47 LOPID ............................... 19

2016 601 4T Copper Comm eff 01/01/2016

81

see gemfibrozil .............. 19 LOPRESSOR .................... 19

see metoprolol tartrate .. 19 LOPRESSOR HCT ........... 19

see metoprolol & hctz tab 100-25mg ...................... 19 see metoprolol & hctz tab 50-25mg ........................ 19

LOPROX SHAMPOO ........ 60 see ciclopirox shampoo 1% ................................. 60

lorazepam ......................... 23 lorcet hd tab 10-325mg .......4 lorcet plus tab 7.5-325 ........4 lorcet tab 5-325mg ..............4 lortab tab 10-325mg ............4 lortab tab 5-325mg ..............4 lortab tab 7.5-325 ................4 loryna 28 day .................... 41 losartan potassium ............ 17 losartan-hydrochlorothiazide .......................................... 17 LOSEASONIQUE ............. 41 LOTEMAX ......................... 55 LOTENSIN ........................ 16

see benazepril hcl ......... 16 LOTENSIN HCT

see benazepril & hydrochlorothiazide ....... 16

LOTREL ............................ 16 see amlodipine besylate-benazepril hcl .. 16

LOTRONEX ...................... 47 see alosetron hcl ........... 47

lovastatin ........................... 18 LOVAZA

see omega-3-acid ethyl esters............................. 19

LOVAZA CAP 1GM ........... 19 LOVENOX......................... 50

see enoxaparin sodium . 49 low-ogestrel ....................... 41 loxapine succinate ............ 29 LUMIGAN.......................... 56 LUMIZYME ....................... 42 LUPANETA PACK ............ 42 LUPRON DEP INJ 11.25MG .......................................... 14

LUPRON DEPOT ............. 14 LUPRON DEPOT INJ 22.5MG (3-MONTH) ......... 14 LUPRON DEPOT INJ 30MG (3-MONTH) ....................... 15 LUPRON DEP-PED INJ 11.25MG ........................... 14 LUPRON DEP-PED INJ 15MG ................................ 14 LUPRON DEP-PED INJ 30MG (3-MONTH) ............ 14 LUPRON DEP-PED INJ 7.5MG ............................... 14 lutera 28 day ..................... 41 LUXIQ

see betamethasone valerate ......................... 61

LUZU ................................ 60 LYNPARZA ....................... 14 LYRICA ............................. 24 LYSODREN ...................... 15 LYSTEDA ......................... 50

see tranexamic acid ...... 50 lyza ................................... 41 M MACROBID ........................ 7

see nitrofurantoin monohyd macro .............. 7

MACRODANTIN ................. 7 see nitrofurantoin macrocrystal .................... 7

magnesium sulfate ............ 53 MAGNESIUM SULFATE ... 52 MAGNESIUM SULFATE IN D5W .................................. 53 MAGNESIUM SULFATE INJ 50%................................... 53 MALARONE ........................ 8

see atovaquone-proguanil hcl tab 250-100 mg.......... 8 see atovaquone-proguanil hcl tab 62.5-25 mg........... 8

malathion .......................... 63 maprotiline hcl ................... 26 MARINOL ......................... 45

see dronabinol ............... 45 marlissa 28 day ................. 41 MARPLAN ........................ 26

MATULANE ...................... 15 matzim la .......................... 20 MAVIK .............................. 16

see trandolapril.............. 16 MAXALT ........................... 33

see rizatriptan benzoate 33 MAXALT-MLT ................... 33

see rizatriptan benzoate 33 MAXIDEX ......................... 56 MAXIPIME ........................ 11

see cefepime inj 1gm .... 10 see cefepime inj 2gm .... 10

MAXITROL ....................... 55 see neomycin-polymy-dexameth .................................... 55

MAXZIDE .......................... 21 see triamt/hctz tab 75-50mg ........................ 21

MAXZIDE-25 .................... 21 see triamt/hctz tab 37.5-25 ...................................... 21

meclizine hcl ..................... 45 MEDROL

see methylpred tab 16mg ...................................... 43 see methylpred tab 32mg ...................................... 43 see methylpred tab 4mg 43 see methylpred tab 8mg 43

MEDROL DOSEPAK see methylpred pak 4mg ...................................... 43

MEDROL PAK 4MG ......... 43 MEDROL TAB 16MG ........ 43 MEDROL TAB 2MG .......... 43 MEDROL TAB 32MG ........ 43 MEDROL TAB 4MG .......... 43 MEDROL TAB 8MG .......... 43 medroxyprogesterone acetate .............................. 45 medroxyprogesterone acetate (contraceptive) ..... 41 mefenamic acid................... 1 mefloquine hcl .................... 8 MEGACE ES .................... 15 MEGACE ORAL ............... 15

see megestrol acetate ... 15

2016 601 4T Copper Comm eff 01/01/2016

82

megestrol acetate ............. 15 MEKINIST ......................... 15 MELOXICAM ......................1 meloxicam tabs ...................1 melphalan hcl .................... 13 memantine hcl ................... 26 MENACTRA ...................... 52 MENOMUNE-A/C/Y/W-135 .......................................... 52 MENOSTAR ...................... 43 MENTAX ........................... 60 MENVEO .......................... 52 MEPRON ............................7

see atovaquone ...............6 mercaptopurine ................. 14 meropenem .........................7 MERREM ............................7

see meropenem ..............7 mesalamine enema ........... 47 mesna ............................... 15 MESNEX ........................... 16

see mesna ..................... 15 MESTINON ....................... 34

see pyridostigmine bromide ......................... 34

MESTINON SYRUP .......... 34 MESTINON TIMESPAN .... 34 METADATE CD ................ 31

see methylphenidate hcl 31 metadate er tab 20mg ....... 31 metformin er ...................... 38 metformin hcl .................... 38 methadone hcl ....................4 METHADONE INJ 10MG/ML ............................................4 METHADOSE .....................4

see methadone hcl ..........4 methazolamide .................. 21 methenamine hippurate ......7 METHERGINE

see methylergonovine maleate.......................... 44

methimazole ...................... 45 methotrexate sodium inj .... 14 methotrexate sodium tabs . 51 methoxsalen rapid ............. 60 methscopolamine bromide 46 methyclothiazide ............... 21

methylergonovine maleate 44 METHYLIN ........................ 31

see methylphenidate hcl 31 METHYLIN CHEW TAB .... 31 methylphenidate hcl .... 31, 32 methylphenidate hcl er ...... 32 methylpr ace inj 40mg/ml .. 43 methylpr ace inj 80mg/ml .. 43 methylpr ss inj 125mg ....... 43 methylpr ss inj 1gm ........... 43 methylpr ss inj 40mg ......... 43 methylpred pak 4mg ......... 43 methylpred tab 16mg ........ 43 methylpred tab 32mg ........ 43 methylpred tab 4mg .......... 43 methylpred tab 8mg .......... 43 metipranolol ...................... 56 metoclopramide hcl ........... 45 metoclopramide hcl inj 5 mg/ml ................................ 45 metolazone ....................... 21 metoprolol & hctz tab 100-25mg .......................... 19 metoprolol & hctz tab 100-50mg .......................... 19 metoprolol & hctz tab 50-25mg ............................ 19 metoprolol succinate ......... 19 metoprolol tartrate ............. 19 METOZOLV ODT ............. 45

see metoclopramide hcl 45 METRO IV .......................... 7 METROCREAM ................ 62

see metronidazole (topical) ......................... 62 see rosadan cre 0.75% . 63

METROGEL ...................... 62 see metronidazole (topical) ......................... 63

METROGEL-VAGINAL ..... 49 see metronidazole vaginal ...................................... 49

METROLOTION ............... 62 see metronidazole (topical) ......................... 63

metronidazole ..................... 7 metronidazole (topical) 62, 63 metronidazole inj ................. 7

metronidazole vaginal ....... 49 MEVACOR

see lovastatin ................ 18 mexiletine hcl .................... 18 MIACALCIN

see calcitonin (salmon) nasal spray .................... 44

MIACALCIN INJ 200U/ML 44 MIACALCIN SPR 200/ACT.......................................... 44 MICARDIS ........................ 17

see telmisartan .............. 17 MICARDIS HCT ................ 17

see telmisartan-hydrochlorothiazide ............................. 17

miconazole 3 sup 200mg .. 49 MICROGESTIN 1.5/30 ..... 41 MICROGESTIN 1/20 ........ 41 MICROGESTIN FE 1.5/30 41 MICROGESTIN FE 1/20 ... 41 MICRO-K .......................... 53

see potassium chloride caps er .......................... 53

MICROZIDE ..................... 21 see hydrochlorothiazide 21

midodrine hcl .................... 22 migergot ............................ 33 MIGRANAL ....................... 33 millipred ............................ 43 MINASTRIN 24 FE ........... 41 MINIPRESS ...................... 17

see prazosin hcl ............ 17 minitran ............................. 22 MINIVELLE ....................... 43 MINOCIN .......................... 13

see minocycline hcl ....... 13 minocycline hcl ................. 13 minoxidil ............................ 22 MIRAPEX ......................... 27

see pramipexole dihydrochloride .............. 27

MIRAPEX ER ................... 27 see pramipexole dihydrochloride .............. 27

MIRCERA ......................... 50 mircette ............................. 41 MIRCETTE

2016 601 4T Copper Comm eff 01/01/2016

83

see desogestrel-ethinyl estradiol (biphasic) ........ 40 see kariva 28 day .......... 40 see kimidess .................. 40 see pimtrea pack ........... 41 see viorele ..................... 42

mirtazapine ....................... 26 misoprostol ........................ 48 mitomycin .......................... 13 mitoxantrone hcl ................ 15 M-M-R II ............................ 52 MOBIC ................................1

see meloxicam tabs .........1 modafinil............................ 35 moderiba pak .................... 10 MODERIBA PAK ............... 10 moderiba tab 200mg ......... 10 MODICON ......................... 41 moexipril hcl ...................... 16 moexipril-hydrochlorothiazide ........................................ 16 mometasone furoate ......... 62 MONODOX

see doxycycline (monohydrate) ............... 13

MONONESSA ................... 41 montelukast sodium .......... 57 MORPHINE SUL 20MG/ML ORAL SOL ..........................4 morphine sulfate .................4 MORPHINE SULFATE .......4 morphine sulfate beads .......4 morphine sulfate ext-rel tab.5 MOVANTIK ....................... 48 MOVIPREP ....................... 47 MOXEZA ........................... 55 moxifloxacin hcl ................. 12 MOZOBIL .......................... 50 MS CONTIN ........................5

see morphine sulfate ext-rel tab ........................5

MULTAQ ........................... 18 mupirocin .......................... 59 mupirocin calcium (topical) 60 MUSTARGEN ................... 13 my way .............................. 41 MYAMBUTOL .....................9

see ethambutol hcl ..........9

MYCAMINE ........................ 8 MYCOBUTIN ...................... 9

see rifabutin ..................... 9 mycophenolate mofetil ...... 51 mycophenolate sodium ..... 52 MYFORTIC ....................... 52

see mycophenolate sodium ........................... 52

myorisan ........................... 59 MYOZYME ........................ 42 MYRBETRIQ .................... 49 MYSOLINE ....................... 24

see primidone ................ 25 myzilra .............................. 41 N nabumetone ........................ 1 nadolol .............................. 19 nadolol & bendroflumethiazide ......... 19 nafcillin sodium ................. 12 NAFTIFINE HCL ............... 60 NAFTIN ............................. 60 NAGLAZYME .................... 42 nalbuphine hcl ..................... 2 NALLPEN ISO-OSMOTIC IN DE ..................................... 12 NALLPEN/DEXTROSE ..... 12 naloxone hcl ...................... 35 naltrexone hcl ................... 35 NAMENDA

see memantine hcl ........ 26 NAMENDA SOL 10MG/5ML .......................................... 26 NAMENDA TAB ................ 26 NAMENDA XR .................. 26 NAMENDA XR TITRATION PACK ................................ 26 NAMZARIC ....................... 26 naphazoline 0.1% ............. 56 NAPRELAN ........................ 1 NAPROSYN

see naproxen .................. 1 NAPROSYN TABS ............. 1 naproxen ............................. 1 naproxen sodium ................ 1 NAPROXEN SODIUM ........ 1 naratriptan hcl ................... 33 NARDIL ............................. 26

see phenelzine sulfate .. 27 NASONEX ........................ 58 NATACYN ........................ 55 nateglinide ........................ 38 NATPARA ......................... 44 NAVELBINE

see vinorelbine tartrate .. 14 NEBUPENT ........................ 7 necon 0.5/35 28 day ......... 41 necon 1/35 28 day ............ 41 necon 10/11 28 day .......... 41 NECON 7/7/7 .................... 41 NECON TAB 1/50-28 ........ 41 nefazodone hcl ................. 26 neomycin sulfate ................. 6 neomycin/polymyxin b gu . 63 neomycin-bacitracin zn-polymyxin ..................... 55 neomycin-polymy-dexameth.......................................... 55 neomycin-polymyxin-gramicidin ..................................... 55 neomycin-polymyxin-hc (ophth) .............................. 55 neomycin-polymyxin-hc (otic).......................................... 63 NEORAL ........................... 52

see cyclosporine modified (for microemulsion) ....... 51 see gengraf ................... 51

NEOSPORIN see neomycin-polymyxin-gramicidin ............................... 55

NEOSPORIN GU IRRIGANT see neomycin/polymyxin b gu .................................. 63

neosporin solution............. 55 NEPHRAMINE .................. 53 neptazane ......................... 21 NEPTAZANE

see methazolamide ....... 21 NESINA ............................ 38 neuac gel 1.2-5% .............. 59 NEULASTA ....................... 50 NEUMEGA ....................... 50 NEUPOGEN ..................... 50 NEUPRO .......................... 27

2016 601 4T Copper Comm eff 01/01/2016

84

NEURONTIN ..................... 24 see gabapentin .............. 24

nevirapine ...........................9 NEVIRAPINE ......................9 NEXAVAR ......................... 15 NEXIUM CAP 20MG ......... 48 NEXIUM CAP 40MG ......... 48 NEXIUM GRA 10MG DR .. 48 NEXIUM GRA 2.5MG DR . 48 NEXIUM GRA 20MG DR .. 48 NEXIUM GRA 40MG DR .. 48 NEXIUM GRA 5MG DR .... 48 NEXIUM I.V. ...................... 48

see esomeprazole sodium inj ................................... 48

next choice tab 1.5mg ....... 41 niacin er (antihyperlipidemic) .......................................... 19 niacor ................................ 19 NIASPAN .......................... 19

see niacin er (antihyperlipidemic) ....... 19

nicardipine hcl ................... 20 NICOTROL INHALER ....... 35 NICOTROL NS ................. 35 nifedical ............................. 20 nifedipine........................... 20 nifedipine er ...................... 20 nikki 28 day ....................... 41 NILANDRON ..................... 15 nimodipine......................... 20 NIPENT ............................. 14 nisoldipine ......................... 20 nitro-bid ............................. 22 NITRO-DUR ...................... 22

see minitran ................... 22 nitrofurantoin .......................7 nitrofurantoin macrocrystal ..7 nitrofurantoin monohyd macro ..................................7 nitroglycerin ....................... 22 NITROGLYCERIN LINGUAL .......................................... 22 nitroglycerin patches ......... 22 NITROLINGUAL PUMPSPRAY

see nitroglycerin ............ 22 NITROLINGUAL SPR

PUMPSPRA ...................... 22 NITROMIST ...................... 22 NITROSTAT ..................... 22 nizatidine ........................... 46 NIZORAL .......................... 60

see ketoconazole shampoo ....................... 60

NORA-BE TAB ................. 41 norco ................................... 5 NORCO

see hydrocodone-acetaminophen 5-325mg ..................... 3 see hydrocodone-acetaminophen 7.5-325mg .................. 3 see hydrocodone-acetaminophen tab 10-325mg ............. 3 see lorcet hd tab 10-325mg ........................ 4 see lorcet plus tab 7.5-325 ........................................ 4 see lorcet tab 5-325mg .... 4 see lortab tab 10-325mg . 4 see lortab tab 5-325mg ... 4 see lortab tab 7.5-325 ..... 4

NORDITROPIN FLEXPRO .......................................... 44 NORDITROPIN NORDIFLEX PEN ............. 44 norethin acet & estrad-fe ... 41 norethindrone & ethinyl estradiol-fe ........................ 41 norethindrone (contraceptive) .................. 41 norethindrone acetate ....... 45 norethindrone acetate-ethinyl estradiol ............................ 43 norgestimate-ethinyl estradiol (triphasic) ........... 41 NORINYL 1+35 ................. 41

see cyclafem 1/35 28 day ...................................... 40 see necon 1/35 28 day .. 41 see nortrel 1/35 21 day .. 41 see nortrel 1/35 28 day .. 41 see pirmella 1/35 28 day

...................................... 41 NORINYL 1+50 ................. 41 NORITATE ....................... 63 norlyroc 28 day ................. 41 NORMOSOL-M IN D5W ... 54 NORMOSOL-R ................. 54 NORPACE ........................ 18

see disopyramide phosphate ..................... 18

NORPACE CR .................. 18 NORPRAMIN .................... 26

see desipramine hcl ...... 26 NOR-QD ........................... 41

see camila 28 day ......... 40 see deblitane 28 day ..... 40 see heather ................... 40 see norethindrone (contraceptive) .............. 41 see norlyroc 28 day ....... 41

nortrel 0.5/35 28 day ......... 41 nortrel 1/35 21 day ............ 41 nortrel 1/35 28 day ............ 41 nortrel 7/7/7 28 day ........... 41 nortriptyline hcl ................. 26 NORVASC ........................ 20

see amlodipine besylate 20 NORVIR .............................. 9 NOVAREL INJ 10000UNT 44 NOVOLIN 70/30................ 36 NOVOLIN 70/30 RELION . 36 NOVOLIN N ...................... 36 NOVOLIN N RELION ........ 36 NOVOLIN R ...................... 36 NOVOLIN R RELION ........ 36 NOVOLOG ....................... 37 NOVOLOG FLEXPEN ...... 37 NOVOLOG MIX 70/30 ...... 37 NOVOLOG MIX 70/30 PREFILL ........................... 37 NOVOLOG PENFILL ........ 37 NOXAFIL ............................ 8 NUBAIN

see nalbuphine hcl .......... 2 NUCYNTA .......................... 5 NUCYNTA ER .................... 5 NUEDEXTA ...................... 34 NULOJIX .......................... 52 NULYTELY/FLAVOR

2016 601 4T Copper Comm eff 01/01/2016

85

PACKS .............................. 47 see gavilyte-n ................ 47 see peg 3350-potassium chloride-sod bicarbonate-sod chloride ...................................... 47 see trilyte ....................... 47

NUTRILIPID INJ 20% ....... 53 NUTROPIN AQ INJ 20MG/2ML ........................ 44 NUTROPIN AQ NUSPIN 5 44 NUTROPIN AQ PEN ......... 44 NUVARING ....................... 41 NUVESSA ......................... 49 NUVIGIL............................ 35 nyamyc ............................. 60 NYMALIZE ........................ 20 nystatin ...............................8 nystatin (mouth-throat) ...... 63 nystatin (topical) ................ 60 nystatin pow 100000 ......... 60 nystop ............................... 60 O OCELLA TAB 3-0.03MG ... 41 OCTAGAM ........................ 51 octreotide acetate ............. 44 OCUFEN ........................... 56

see flurbiprofen sodium . 55 OCUFLOX ......................... 55

see ofloxacin (ophth) ..... 55 OFEV ................................ 58 ofloxacin (ophth) ............... 55 ofloxacin (otic) ................... 63 ogestrel 28 day ................. 41 olanzapine......................... 29 olanzapine odt ................... 29 olopatadine hcl (nasal) ...... 57 OLUX ................................ 62

see clobetasol propionate ...................................... 61

OLUX-E see clobetasol propionate emulsion ........................ 61

OMECLAMOX-PAK .......... 48 omega-3-acid ethyl esters . 19 omeprazole ....................... 48 OMEPRAZOLE-SODIUM BICARBONATE ................ 48

OMNARIS ......................... 58 OMNIPRED ...................... 56 OMNITROPE 10MG ......... 44 OMNITROPE 5.8MG ........ 44 OMNITROPE 5MG ........... 44 ondansetron hcl ................ 46 ondansetron hcl inj ............ 46 ondansetron hcl oral soln .. 46 ondansetron odt ................ 46 ONEXTON ........................ 59 ONFI ................................. 24 ONGLYZA ......................... 38 ONMEL ............................... 8 OPANA ............................... 5

see oxymorphone hcl ...... 5 OPANA ER (CRUSH RESISTANT ........................ 5 OPSUMIT ......................... 22 OPTIPRANOLOL .............. 56 ORACEA ........................... 63 ORAP ................................ 29 ORAPRED ODT

see prednisolone sodium phosphate ..................... 43

ORAPRED ODT TAB 10MG .......................................... 43 ORAPRED ODT TAB 15MG .......................................... 43 ORAPRED ODT TAB 30MG .......................................... 43 ORENCIA ......................... 51 ORENITRAM TAB 0.125MG .......................................... 22 ORENITRAM TAB 0.25MG .......................................... 22 ORENITRAM TAB 1MG .... 22 ORENITRAM TAB 2.5MG . 22 ORFADIN .......................... 42 ORKAMBI ......................... 58 orsythia 28 day ................. 41 ORTHO EVRA

see xulane dis 150-35 ... 42 ORTHO MICRONOR ........ 41

see errin 28 day ............ 40 see lyza ......................... 41 see sharobel 28 day ...... 42

ORTHO TRI-CYCLEN see norgestimate-ethinyl

estradiol (triphasic) ........ 41 see tri-previfem 28 day .. 42 see tri-sprintec 28 day ... 42

ORTHO TRI-CYCLEN LO 41 ORTHO-CYCLEN ............. 41

see previfem 28 day ...... 41 see sprintec 28 day ....... 42

ORTHO-NOVUM 1/35 ...... 41 ORTHO-NOVUM 7/7/7 ..... 41

see cyclafem 7/7/7 28 day ...................................... 40 see nortrel 7/7/7 28 day 41

OSENI TAB 12.5-15MG .... 38 OSENI TAB 12.5-30MG .... 38 OSENI TAB 12.5-45MG .... 38 OSENI TAB 25-15MG ....... 38 OSENI TAB 25-30MG ....... 39 OSENI TAB 25-45MG ....... 39 OSMOPREP ..................... 47 OTEZLA ............................ 51 ovcon 35 28 day ............... 41 OVCON-35

see balziva 28 day ........ 40 see briellyn 28 day ........ 40 see gildagia ................... 40 see philith ...................... 41 see vyfemla 28 day ....... 42 see zenchent tab ........... 42

ovide ................................. 63 OVIDE

see malathion ................ 63 oxacillin sodium ................ 12 oxaliplatin .......................... 15 OXANDRIN

see oxandrolone............ 36 oxandrolone ...................... 36 oxaprozin ............................ 1 oxcarbazepine .................. 24 OXISTAT .......................... 60 OXSORALEN ULTRA ....... 60

see methoxsalen rapid .. 60 OXTELLAR XR ................. 24 oxybutynin chloride ........... 49 oxycodone hcl ..................... 5 OXYCODONE HCL ............ 5 oxycodone w/ acetaminophen 10-325mg .. 5 oxycodone w/

2016 601 4T Copper Comm eff 01/01/2016

86

acetaminophen 2.5-325mg .5 oxycodone w/ acetaminophen 5-325mg ....5 oxycodone w/ acetaminophen 7.5-325mg .5 oxycodone-aspirin ...............5 oxycodone-ibuprofen ..........5 OXYCONTIN .......................5 oxymorphone hcl .................5 OXYTROL ......................... 49 P pacerone ........................... 18 paclitaxel ........................... 14 PAMELOR ........................ 26

see nortriptyline hcl ....... 26 pamidronate disodium ....... 39 PAMINE ............................ 46

see methscopolamine bromide ......................... 46

PAMINE FORTE ............... 46 see methscopolamine bromide ......................... 46

PANCREAZE .................... 48 PANDEL............................ 62 PANRETIN ........................ 63 pantoprazole sodium ......... 48 paricalcitol ......................... 54 PARICALCITOL ................ 54 PARLODEL

see bromocriptine mesylate ........................ 27

PARNATE ......................... 26 see tranylcypromine sulfate ............................ 27

paromomycin sulfate ...........6 paroxetine er tab ............... 26 paroxetine hcl tabs ............ 26 paser d/r ..............................9 PATADAY ......................... 56 PATANASE ....................... 57

see olopatadine hcl (nasal) ...................................... 57

PATANOL ......................... 56 PAXIL ................................ 27

see paroxetine hcl tabs.. 26 PAXIL CR.......................... 27

see paroxetine er tab ..... 26 PAZEO .............................. 56

PCE .................................. 11 PEDIAPRED

see pred sod pho sol 5mg/5ml ........................ 43

pediapred sol 6.7/5ml........ 43 PEDVAX HIB .................... 52 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE .......................................... 47 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 47 PEGANONE ..................... 24 PEGINTRON .................... 10 PEG-INTRON ................... 10 PEG-INTRON REDIPEN .. 10 PENICILLIN G POT IN DEXTROSE ...................... 12 PENICILLIN G POTASSIUM IN ...................................... 12 penicillin g procaine .......... 12 penicillin g sodium ............ 12 penicillin v potassium ........ 12 penicilln gk inj 20mu ......... 12 penicilln gk inj 5mu ........... 12 PENNSAID ....................... 63 PENTAM 300 ...................... 7 PENTASA ......................... 47 pentoxifylline ..................... 50 PEPCID

see famotidine ............... 46 PEPCID SUSP .................. 46 pepcid tab ......................... 46 PERCOCET

see endocet ..................... 3 see oxycodone w/ acetaminophen 10-325mg ........................................ 5 see oxycodone w/ acetaminophen 2.5-325mg ........................................ 5 see oxycodone w/ acetaminophen 5-325mg . 5 see oxycodone w/ acetaminophen 7.5-325mg ........................................ 5 see roxicet tab 5-325mg .. 5

percocet 10/325 .................. 5 percocet 2.5/325 ................. 5 percocet 7.5/325 ................. 5 percocet tab 5-325mg ......... 5 PERCODAN ....................... 5

see oxycodone-aspirin .... 5 PERFOROMIST ............... 57 PERIDEX

see chlorhexidine gluconate (mouth-throat) ...................................... 63 see periogard soln 0.12% ...................................... 63

perindopril erbumine ......... 16 periogard soln 0.12% ........ 63 PERJETA ......................... 14 permethrin ........................ 63 perphenazine .................... 29 PERTZYE ......................... 48 PEXEVA ........................... 27 pfizerpen g inj 5mu ........... 12 pfizerpen-g inj 20mu ......... 12 phenadoz .......................... 46 phenelzine sulfate ............. 27 phenergan ........................ 46 PHENERGAN

see promethazine hcl .... 46 phenergan inj .................... 46 phenobarbital .................... 24 phenobarbital sodium ....... 25 PHENOBARBITAL SODIUM.......................................... 24 phenytek ........................... 25 phenytoin .......................... 25 phenytoin inj 50mg/ml ....... 25 phenytoin sodium extended.......................................... 25 philith ................................ 41 PHOSLO ........................... 45

see calcium acetate (phosphate binder) ........ 45

PHOSLYRA ...................... 45 PHOSPHOLINE IODIDE .. 56 PICATO ............................ 63 PILOCARPINE HCL ......... 56 pilocarpine hcl (oral) ......... 63 PILOCARPINE HCL (ORAL).......................................... 63

2016 601 4T Copper Comm eff 01/01/2016

87

pimtrea pack ..................... 41 pindolol ............................. 19 pioglitazone hcl ................. 39 pioglitazone hcl-glimepiride .......................................... 39 pioglitazone hcl-metformin hcl ..................................... 39 piperacillin sodium-tazobactam sodium .......................................... 12 pirmella 1/35 28 day .......... 41 piroxicam.............................1 PLAN B ONE-STEP

see levonorgestrel (emergency oc) ............. 40 see my way ................... 41 see next choice tab 1.5mg ...................................... 41

PLAQUENIL ...................... 51 see hydroxychloroquine sulfate ............................ 51

PLASMA-LYTE A .............. 54 PLASMA-LYTE-148 .......... 54 PLASMA-LYTE-56/D5W ... 54 PLAVIX ............................. 50

see clopidogrel bisulfate 50 PLEGRIDY ........................ 34 PLEGRIDY STARTER PACK ................................ 34 PLETAL............................. 50

see cilostazol ................. 50 podofilox............................ 63 polyethylene glycol 3350 ... 47 polymyxin b sulfate .............7 polymyxin b-trimethoprim .. 55 POLYTRIM ........................ 55

see polymyxin b-trimethoprim ............... 55

POMALYST ...................... 15 PONSTEL ...........................1

see mefenamic acid ........1 portia 28 day ..................... 41 pot chloride inj 2meq/ml .... 54 potassium chloride ............ 53 POTASSIUM CHLORIDE 53, 54 POTASSIUM CHLORIDE 0.3%/D .............................. 54

potassium chloride caps er .......................................... 53 potassium chloride in nacl . 54 POTASSIUM CHLORIDE IN NACL ................................ 54 potassium chloride microencapsulated crystals cr ....................................... 53 POTASSIUM CHLORIDE TAB CR 10 MEQ .............. 53 potassium citrate (alkalinizer) .......................................... 49 POTASSIUM CITRATE (ALKALINIZER) ................ 49 POTIGA ............................ 25 PRADAXA ......................... 50 pramipexole dihydrochloride .......................................... 27 PRANDIMET ..................... 39 PRANDIN .......................... 39

see repaglinide .............. 39 PRAVACHOL .................... 18

see pravastatin sodium . 18 pravastatin sodium ............ 18 prazosin hcl ....................... 17 PRECOSE ........................ 39

see acarbose ................. 37 PRED FORTE ................... 56 PRED MILD ...................... 56 pred sod pho sol 5mg/5ml . 43 PRED-G ............................ 55 PRED-G S.O.P. ................ 55 prednicarbate .................... 62 PREDNICARBATE ........... 62 PREDNISOLONE ACETATE (OPHTH) ........................... 56 prednisolone sodium phosphate ......................... 43 prednisolone sodium phosphate (ophth) ............. 56 prednisolone sol 15mg/5ml .......................................... 43 prednisolone sol 25mg/5ml .......................................... 43 prednisolone syrup 15 mg/5ml .............................. 43 prednisone con 5mg/ml ..... 43 prednisone pak 10mg ....... 43

prednisone pak 5mg ......... 43 prednisone sol 5mg/5ml .... 43 prednisone tab 10mg ........ 43 prednisone tab 1mg .......... 43 prednisone tab 2.5mg ....... 43 prednisone tab 20mg ........ 43 prednisone tab 50mg ........ 43 prednisone tab 5mg .......... 43 PREGNYL W/DILUENT BENZYL ............................ 44 PREMARIN CREAM ......... 43 PREMARIN INJ ................ 43 premasol 10% ................... 53 premasol 6% ..................... 53 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC).......................................... 54 PREPOPIK ....................... 47 PREVACID ....................... 48

see lansoprazole ........... 48 PREVACID SOLUTAB ...... 48 prevalite ............................ 19 previfem 28 day ................ 41 PREVPAC ........................ 48

see amoxicillin-clarithromycin w/ lansoprazole ............. 47

PREZCOBIX ....................... 9 PREZISTA .......................... 9 PRIFTIN .............................. 9 PRILOSEC ....................... 48

see omeprazole............. 48 PRIMAQUINE PHOSPHATE............................................ 8 PRIMAXIN .......................... 7 PRIMAXIN IV

see imipenem-cilastatin ... 7 primidone .......................... 25 PRIMSOL SOL 50MG/5ML . 7 PRINIVIL ........................... 16

see lisinopril .................. 16 PRISTIQ ........................... 27 PRIVIGEN ........................ 51 PROAIR HFA .................... 57 PROAIR RESPICLICK ...... 57 probenecid .......................... 1 PROCALAMINE................ 53 PROCARDIA XL ............... 20

2016 601 4T Copper Comm eff 01/01/2016

88

see nifedical .................. 20 see nifedipine er ............ 20

prochlorperazine inj 5 mg/ml .......................................... 46 prochlorperazine maleate.. 46 prochlorperazine supp ...... 46 PROCRIT .......................... 50 procto-pak ......................... 60 proctosol hc 2.5 % ............ 60 proctozone hc ................... 60 PROCYSBI ....................... 42 progesterone micronized... 45 PROGLYCEM SUS 50MG/ML .......................... 44 PROGRAF ........................ 52

see tacrolimus ............... 52 PROLASTIN-C .................. 58 PROLENSA ...................... 56 PROLEUKIN ..................... 14 PROLIA ............................. 44 PROMACTA ...................... 50 promethazine hcl ............... 46 promethegan ..................... 46 PROMETRIUM ................. 45

see progesterone micronized ..................... 45

propafenone hcl ................ 18 propafenone hcl 12hr ........ 18 proparacaine hcl ............... 56 propranolol & hydrochlorothiazide ........... 19 propranolol hcl er .............. 20 propranolol inj 1mg/ml ....... 20 propranolol sol .................. 20 propranolol tab .................. 20 propylthiouracil .................. 45 PROQUAD ........................ 52 PROSCAR ........................ 49

see finasteride ............... 48 PROSOL ........................... 53 PROTONIX ....................... 48

see pantoprazole sodium ...................................... 48

PROTONIX INJ ................. 48 PROTOPIC ....................... 63

see tacrolimus (topical).. 63 protriptyline hcl .................. 27 PROVENTIL HFA ............. 57

PROVERA ........................ 45 see medroxyprogesterone acetate .......................... 45

PROVIGIL ......................... 35 see modafinil ................. 35

PROZAC ........................... 27 see fluoxetine hcl .......... 26

PROZAC WEEKLY ........... 27 see fluoxetine hcl .......... 26

PRUDOXIN CRE 5% ........ 60 PULMICORT

see budesonide (inhalation) .................... 58

PULMICORT FLEXHALER .......................................... 58 PULMICORT INH SUSP 0.25MG/2 ML .................... 58 PULMICORT INH SUSP 0.5MG/2 ML ...................... 58 PULMICORT INH SUSP 1MG/2ML .......................... 58 PULMOZYME ................... 58 PURIXAN .......................... 14 PYLERA ............................ 48 pyrazinamide ...................... 9 pyridostigmine bromide ..... 34 Q QNASL .............................. 58 QNASL CHILDRENS ........ 58 QUADRACEL ................... 52 QUALAQUIN ....................... 8

see quinine sulfate .......... 8 QUARTETTE .................... 42 quasense 91 day .............. 42 QUDEXY XR ..................... 25 questran ............................ 19 QUESTRAN

see cholestyramine ....... 18 questran light .................... 19 QUESTRAN LIGHT

see prevalite .................. 19 quetiapine fumarate .......... 29 QUILLIVANT XR ............... 32 quinapril hcl ....................... 16 quinapril-hydrochlorothiazide .......................................... 16 quinidine gluconate ........... 18 quinidine sulfate ................ 18

quinine sulfate .................... 8 QVAR ............................... 58 R RABAVERT ...................... 52 rabeprazole sodium .......... 48 RAGWITEK ...................... 51 raloxifene hcl .................... 44 ramipril .............................. 16 RANEXA ........................... 22 ranitidine hcl ..................... 46 RAPAFLO ......................... 49 RAPAMUNE ..................... 52

see sirolimus ................. 52 RAVICTI ........................... 42 RAYOS TAB 1MG ............ 44 RAYOS TAB 2MG ............ 44 RAYOS TAB 5MG ............ 44 RAZADYNE ...................... 26

see galantamine hydrobromide ................ 26

RAZADYNE ER ................ 26 see galantamine hydrobromide ................ 25

REBETOL ......................... 10 see ribasphere .............. 10 see ribavirin 200mg ....... 10

REBIF ............................... 34 REBIF REBIDOSE ............ 34 REBIF REBIDOSE TITRATION ....................... 34 REBIF TITRATION PACK 34 RECLAST ......................... 39

see zoledronic inj 5/100ml ...................................... 39

reclipsen 28 day................ 42 RECOMBIVAX HB ............ 52 RECTIV ............................ 63 REGLAN ........................... 46

see metoclopramide hcl 45 REGRANEX ..................... 63 RELENZA DISKHALER .... 10 RELISTOR ........................ 47 RELPAX ........................... 33 REMERON ....................... 27

see mirtazapine ............. 26 REMERON SOLTAB ........ 27

see mirtazapine ............. 26 REMICADE ....................... 51

2016 601 4T Copper Comm eff 01/01/2016

89

REMODULIN .................... 22 RENAGEL ......................... 45 RENVELA PAK ................. 45 RENVELA TAB 800MG .... 45 repaglinide ........................ 39 REPREXAIN

see hydrocodone-ibuprofen tab 2.5-200mg .......................3 see ibudone tab 5-200mg 4

reprexain tab 10-200mg ......5 reprexain tab 2.5-200mg .....5 reprexain tab 5-200mg ........5 REQUIP ............................ 27

see ropinirole hydrochloride ................. 27

REQUIP XL ....................... 27 see ropinirole hydrochloride ................. 27

RESCRIPTOR ....................9 RESTASIS ........................ 56 RESTORIL ........................ 32

see temazepam ............. 32 RETIN-A............................ 59

see tretinoin ................... 59 RETIN-A MICRO ............... 59 RETIN-A MICRO PUMP ... 59 RETROVIR

see zidovudine ................9 RETROVIR CAPS ...............9 RETROVIR IV INFUSION ...9 RETROVIR SYRP ...............9 REVATIO .......................... 22

see sildenafil citrate (pulmonary hypertension) ...................................... 22

REVIA see naltrexone hcl ......... 35

REVLIMID ......................... 51 REYATAZ ...........................9 RHEUMATREX ................. 51 RHINOCORT AQUA ......... 58

see budesonide (nasal) . 58 ribapak mis 600/day .......... 10 ribasphere ......................... 10 ribasphere ribapak 1000 ... 10 ribasphere ribapak 1200 ... 10 ribasphere ribapak 800 ..... 10

ribavirin 200mg ................. 10 rifabutin ............................... 9 rifadin .................................. 9 RIFADIN ............................. 9

see rifampin ..................... 9 rifamate ............................... 9 rifampin ............................... 9 RIFATER ............................ 9 RILUTEK ........................... 34

see riluzole .................... 34 riluzole .............................. 34 rimantadine hydrochloride . 10 RINGER'S ......................... 54 RIOMET ............................ 39 risedronate sodium ........... 39 RISEDRONATE SODIUM . 39 RISPERDAL ..................... 29

see risperidone .............. 29 RISPERDAL INJ 12.5MG . 29 RISPERDAL INJ 25MG .... 29 RISPERDAL INJ 37.5MG . 29 RISPERDAL INJ 50MG .... 29 RISPERDAL M-TAB ......... 29

see risperidone odt ........ 29 risperidone ........................ 29 risperidone odt .................. 29 RITALIN ............................ 32

see methylphenidate hcl 32 RITALIN LA ....................... 32

see methylphenidate hcl 31 RITUXAN .......................... 14 rivastigmine tartrate .......... 26 rizatriptan benzoate .......... 33 ROBINUL .......................... 46

see glycopyrrolate ......... 46 ROBINUL FORTE ............. 46

see glycopyrrolate ......... 46 ROCALTROL .................... 54

see calcitriol .................. 54 rocephin ............................ 11 ROCEPHIN

see ceftriaxone sodium . 11 ropinirole hydrochloride..... 27 rosadan cre 0.75% ............ 63 ROTARIX .......................... 52 ROTATEQ ........................ 52 ROWASA .......................... 47

see mesalamine enema 47

roxicet soln ......................... 5 roxicet tab 5-325mg ............ 5 ROXICODONE ................... 5

see oxycodone hcl .......... 5 ROZEREM ........................ 32 RUCONEST ..................... 50 RYTARY ........................... 28 RYTHMOL ........................ 18

see propafenone hcl ...... 18 see propafenone hcl 12hr ...................................... 18

RYTHMOL SR .................. 18 see propafenone hcl ...... 18 see propafenone hcl 12hr ...................................... 18

S SABRIL ............................. 25 SAIZEN ............................. 44 SAIZEN CLICK.EASY ....... 44 SALAGEN ......................... 63

see pilocarpine hcl (oral) ...................................... 63

SAMSCA .......................... 44 SANCUSO ........................ 46 SANDIMMUNE

see cyclosporine ........... 51 SANDIMMUNE CAPS ...... 52 SANDIMMUNE INJ ........... 52 SANDIMMUNE SOLN ...... 52 SANDOSTATIN ................ 44

see octreotide acetate ... 44 SANDOSTATIN LAR DEPOT ............................. 44 SANTYL ............................ 63 SAPHRIS .................... 29, 30 SARAFEM ........................ 35 SAVAYSA ......................... 50 SAVELLA .......................... 34 SAVELLA TITRATION PACK ................................ 34 SEASONIQUE .................. 42

see amethia 91 day ....... 40 see ashlyna 91 day ....... 40 see levonorgestrel-ethinyl estradiol (91-day) .......... 41

SECTRAL ......................... 20 see acebutolol hcl ......... 19

selegiline hcl ..................... 28

2016 601 4T Copper Comm eff 01/01/2016

90

selenium sulfide ................ 60 SELZENTRY .......................9 SEMPREX-D ..................... 57 SENSIPAR ........................ 39 SEREVENT DISKUS ........ 57 SEROQUEL ...................... 30

see quetiapine fumarate 29 SEROQUEL XR ................ 30 SEROSTIM ....................... 44 sertraline hcl ...................... 27 SF-ROWASA .................... 47 sharobel 28 day ................ 42 SIGNIFOR ......................... 44 SIGNIFOR LAR ................. 44 sildenafil citrate (pulmonary hypertension) .................... 22 SILENOR .......................... 32 SILVADENE ...................... 60 SILVER SULFADIAZINE... 60 SIMBRINZA SUS 1-0.2% .. 56 SIMCOR............................ 19 SIMPONI ........................... 51 SIMPONI ARIA ................. 51 SIMULECT ........................ 52 simvastatin ........................ 18 SINEMET .......................... 28

see carbidopa-levodopa 27 SINEMET CR .................... 28

see carbidopa-levodopa 27 SINGULAIR ....................... 57

see montelukast sodium 57 sirolimus ............................ 52 SIROLIMUS ...................... 52 SIRTURO ............................9 SIVEXTRO ..........................7 SKLICE ............................. 63 SODIUM CHLORIDE .. 53, 54 SODIUM CHLORIDE 0.45% VIA .................................... 54 SODIUM CHLORIDE 0.9% .......................................... 63 SODIUM DIURIL ............... 21 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN ................................ 53 sodium phenylbutyrate ...... 42 sodium polystyrene sulfonate .......................................... 39

SOLARAZE ....................... 63 see diclofenac sodium (actinic keratoses) ......... 62

SOLIA ............................... 42 SOLODYN ........................ 13 SOLTAMOX ...................... 15 SOLU-CORTEF 1000MG . 44 SOLU-CORTEF 100MG ... 44 SOLU-CORTEF 250MG ... 44 SOLU-CORTEF 500MG ... 44 SOLU-MEDROL

see methylpr ss inj 125mg ...................................... 43 see methylpr ss inj 1gm . 43 see methylpr ss inj 40mg ...................................... 43

SOLU-MEDROL INJ 125MG .......................................... 44 SOLU-MEDROL INJ 1GM 44 SOLU-MEDROL INJ 2GM 44 SOLU-MEDROL INJ 40MG .......................................... 44 SOLU-MEDROL INJ 500MG .......................................... 44 SOMATULINE DEPOT ..... 44 SOMAVERT ...................... 44 SOOLANTRA .................... 63 SORIATANE ..................... 60

see acitretin ................... 60 SORILUX .......................... 60 sorine ................................ 18 sotalol hcl .......................... 18 sotalol hcl (afib/afl) ............ 18 SOTYLIZE ........................ 20 SOVALDI .......................... 10 SPIRIVA HANDIHALER .... 57 SPIRIVA RESPIMAT ........ 57 spironolactone .................. 16 spironolactone & hydrochlorothiazide ........... 21 SPORANOX ....................... 8

see itraconazole .............. 8 SPORANOX PULSEPAK .... 8 SPORANOX SOL 10MG/ML ............................................ 8 sprintec 28 day ................. 42 SPRYCEL ......................... 15 sps susp 15gm/60ml ......... 39

sronyx 28 day ................... 42 SSD .................................. 60 STALEVO ......................... 28 STARLIX ........................... 39

see nateglinide .............. 38 stavudine ............................ 9 STELARA ......................... 60 STERILE WATER IRRIGATION ..................... 63 STIMATE .......................... 45 STIOLTO RESPIMAT ....... 56 STIVARGA ....................... 15 STRATTERA .................... 32 streptomycin sulfate ............ 6 STRIANT .......................... 36 STRIBILD ........................... 9 STRIVERDI RESPIMAT ... 57 STROMECTOL ................... 7

see ivermectin ................. 7 SUBOXONE MIS 12-3MG 35 SUBOXONE MIS 2-0.5MG.......................................... 35 SUBOXONE MIS 4-1MG .. 35 SUBOXONE MIS 8-2MG .. 35 SUBSYS ............................. 6 SUCLEAR ......................... 47 SUCRAID ......................... 48 sucralfate .......................... 48 SULAR .............................. 20

see nisoldipine .............. 20 sulfacet sod oin 10% op .... 55 sulfacetamide sodium (acne).......................................... 59 sulfacetamide sodium (ophth) .............................. 55 sulfacetamide sod-prednisolone .............. 55 sulfadiazine ......................... 6 sulfamethoxazole-trimethop 7 sulfamethoxazole-trimethoprim inj .................................... 8 SULFAMYLON ................. 60 sulfasalazine dr ................. 47 sulfasalazine ir .................. 47 sulindac .............................. 1 SUMATRIPTAN INJ 4MG/0.5ML ....................... 33 sumatriptan inj 6mg/0.5ml . 33

2016 601 4T Copper Comm eff 01/01/2016

91

SUMATRIPTAN INJ 6MG/0.5ML ....................... 33 sumatriptan succinate ....... 33 SUMATRIPTAN SUCCINATE ..................... 33 SUMAVEL DOSEPRO ...... 33 suprax ............................... 11 SUPRAX ........................... 11

see cefixime .................. 10 SUPREP BOWEL PREP... 47 SURMONTIL ..................... 27 SUSTIVA.............................9 SUTENT............................ 15 syeda ................................ 42 SYLATRON KIT 200MCG . 15 SYLATRON KIT 300MCG . 15 SYLATRON KIT 600MCG . 15 SYMBICORT ..................... 59 SYMLINPEN 120 .............. 37 SYMLINPEN 60 ................ 37 SYNAGIS .......................... 52 SYNALAR ......................... 62


SYNALGOS-DC ..................2 SYNAREL ......................... 42 SYNERA ........................... 62 SYNERCID .........................8 SYNRIBO .......................... 15 SYNTHROID ..................... 45

see levothyroxine sodium ...................................... 45

SYPRINE .......................... 40 T TABLOID........................... 14 TACLONEX ....................... 62

see calcipotriene/betamethasone .................................. 61

tacrolimus.......................... 52 tacrolimus (topical) ............ 63 TAFINLAR ......................... 15 TAMIFLU........................... 10 tamoxifen citrate ................ 15 tamsulosin hcl ................... 49 TANZEUM ......................... 37 tapazole ............................ 45 TAPAZOLE

see methimazole ........... 45 TARCEVA ......................... 15 TARGRETIN ............... 15, 63 tarina fe 1/20 28 day ......... 42 TARKA .............................. 16

see trandolapril-verapamil hcl.................................. 16

TASIGNA .......................... 15 TAXOTERE ...................... 14 tazicef ............................... 11 tazicef vial ......................... 11 TAZORAC ......................... 60 taztia xt ............................. 20 TECFIDERA CAP 120MG 35 TECFIDERA CAP 240MG 35 TECFIDERA MIS STARTER .......................................... 35 TEFLARO ......................... 11 TEGRETOL ...................... 25

see carbamazepine ....... 23 see epitol ....................... 23

TEGRETOL-XR ................ 25 see carbamazepine ....... 23

TEKTURNA ...................... 21 TEKTURNA HCT .............. 21 telmisartan ........................ 17 telmisartan-amlodipine ...... 17 telmisartan-hydrochlorothiazide ...................................... 17 temazepam ....................... 32 TEMOVATE

see clobetasol propionate ...................................... 61 see cormax .................... 61

TEMOVATE CREAM ........ 62 TEMOVATE E

see clobetasol e cream 0.05% ............................ 61

TEMOVATE E CREAM ..... 62 TEMOVATE GEL .............. 62 TEMOVATE OIN ............... 62 TEMOVATE SOLN ........... 62 TENIVAC .......................... 52 TENORETIC 100 .............. 19

see atenolol & chlorthalidone ................ 19

TENORETIC 50 ................ 19 see atenolol &

chlorthalidone ................ 19 TENORMIN ...................... 20

see atenolol ................... 19 TERAZOL 3 ...................... 49

see terconazole vaginal 49 TERAZOL 7 ...................... 49

see terconazole vaginal 49 see zazole ..................... 49

terazosin hcl ..................... 17 terbinafine hcl ..................... 8 terbutaline sulfate ............. 57 terconazole vaginal ........... 49 TESTIM ............................ 36 testosterone cypionate ...... 36 testosterone enanthate ..... 36 TETANUS/DIPHTHERIA TOXOID ............................ 52 TETRACYCLINE HCL ...... 13 TEVETEN ......................... 17 TEVETEN HCT ................. 17 texacort ............................. 62 THALOMID ....................... 51 theo-24 ............................. 59 theophylline ...................... 59 thioridazine hcl .................. 30 thiothixene ........................ 30 THYMOGLOBULIN ........... 52 tiagabine hcl ..................... 25 TIAZAC ............................. 20

see diltiazem hcl er ....... 20 see diltiazem hcl extended release beads................ 20 see diltzac ..................... 20 see taztia xt ................... 20

TIKOSYN .......................... 18 timolol maleate ................. 20 timolol maleate (ophth) ..... 56 TIMOLOL MALEATE GEL 56 TIMOPTIC ........................ 56

see timolol maleate (ophth) ........................... 56

TIMOPTIC OCUDOSE ..... 56 TIMOPTIC-XE................... 56 TIROSINT ......................... 45 TIVICAY .............................. 9 tizanidine .......................... 35 TOBI

see tobramycin ................ 6

2016 601 4T Copper Comm eff 01/01/2016

92

TOBI NEB ...........................6 TOBI PODHALER ...............6 TOBRADEX ...................... 55

see tobramycin-dexamethasone .................................... 55

TOBRADEX ST ................. 55 tobramycin ..........................6 tobramycin (ophth) ............ 55 tobramycin sulfate ...............6 tobramycin sulfate in saline .6 tobramycin-dexamethasone .......................................... 55 TOBREX

see tobramycin (ophth) .. 55 TOBREX OINT 0.3% ........ 55 TOBREX SOL 0.3% OP .... 55 tofranil ............................... 27 TOFRANIL

see imipramine hcl ........ 26 TOFRANIL-PM .................. 27

see imipramine pamoate ...................................... 26

tolmetin sodium ...................1 tolterodine tartrate er ......... 49 tolterodine tartrate tab 1 mg .......................................... 49 tolterodine tartrate tab 2 mg .......................................... 49 TOPAMAX ........................ 25

see topiramate ............... 25 TOPAMAX SPRINKLE ...... 25

see topiramate ............... 25 topicort .............................. 62 TOPICORT ....................... 62

see desoximetasone ..... 61 TOPICORT SPRAY 0.25% .......................................... 62 topiramate ......................... 25 TOPIRAMATE ................... 25 toposar .............................. 16 topotecan hcl ..................... 16 TOPROL XL ...................... 20

see metoprolol succinate ...................................... 19

TORISEL........................... 14 torsemide inj 50mg/5ml ..... 21 torsemide tabs .................. 21

TOUJEO SOLOSTAR ....... 37 TOVIAZ ............................. 49 TPN ELECTROLYTES ..... 53 TRACLEER ....................... 22 TRADJENTA ..................... 39 TRAMADOL HCL ................ 2 tramadol hcl er .................... 2 TRAMADOL HCL ER .......... 2 tramadol hcl er (biphasic) 100mg ................................. 2 tramadol hcl er (biphasic) 200mg ................................. 2 tramadol hcl er (biphasic) 300mg ................................. 2 tramadol hcl tab 50 mg ....... 2 tramadol-acetaminophen .... 2 TRANDATE ...................... 20

see labetalol hcl ............ 19 trandolapril ........................ 16 trandolapril-verapamil hcl .. 16 tranexamic acid ................. 50 TRANSDERM-SCOP ........ 46 TRANXENE T ................... 25

see clorazepate dipotassium ................... 23

tranylcypromine sulfate ..... 27 TRAVASOL ....................... 53 TRAVATAN Z ................... 56 trazodone hcl .................... 27 TREANDA ......................... 13 TRECATOR ...................... 10 TRELSTAR MIXJECT ....... 15 tretinoin ....................... 15, 59 TRETINOIN ...................... 59 TRETINOIN MICROSPHERE ............... 59 tretin-x ............................... 59 trexall ................................ 51 TREXIMET ........................ 33 trezix ................................... 2 triamcinolone acetonide (mouth) ............................. 63 triamcinolone acetonide (nasal) ............................... 58 triamcinolone acetonide (topical) ............................. 62 triamt/hctz cap 37.5-25 ..... 21 triamt/hctz cap 50-25mg ... 21

triamt/hctz tab 37.5-25 ...... 21 triamt/hctz tab 75-50mg .... 21 trianex ............................... 62 TRIBENZOR ..................... 17 TRICOR ............................ 19

see fenofibrate .............. 18 triderm .............................. 62 trifluoperazine hcl.............. 30 trifluridine .......................... 55 TRIGLIDE ......................... 19 tri-legest 28 day ................ 42 TRILEPTAL

see oxcarbazepine ........ 24 TRILEPTAL SUSP ............ 25 TRILEPTAL TABS ............ 25 TRILIPIX ........................... 19

see choline fenofibrate .. 18 trilyte ................................. 47 trimethoprim ........................ 8 TRINESSA ........................ 42 TRI-NORINYL 28 .............. 42

see aranelle 28.............. 40 TRIOSTAT ........................ 45

see liothyronine sodium 45 tri-previfem 28 day ............ 42 TRISENOX ....................... 15 tri-sprintec 28 day ............. 42 TRIUMEQ ........................... 9 trivora 28 day .................... 42 TRIZIVIR ............................. 9

see abacavir sulfate-lamivudine-zidovudine ................................... 9

TROKENDI XR ................. 25 TROPHAMINE INJ 10% ... 53 TROPHAMINE INJ 6% ..... 53 trospium chloride .............. 49 trospium chloride er .......... 49 TRULICITY ....................... 37 TRUMENBA ..................... 52 TRUSOPT ........................ 56

see dorzolamide hcl ...... 56 TRUVADA .......................... 9 TUDORZA PRESSAIR ..... 57 TUDORZA PRESSAIR (INSTITUTIONAL PACK) .. 57 TWINRIX INJ .................... 52 TWYNSTA ........................ 17

2016 601 4T Copper Comm eff 01/01/2016

93

see telmisartan-amlodipine ...................................... 17

TYBOST..............................9 TYGACIL.............................8 TYKERB............................ 15 tylenol with codeine .............2 TYLENOL/CODEINE #3

see acetaminophen w/ codeine ............................1

TYLENOL/CODEINE #4 see acetaminophen w/ codeine ............................1

TYPHIM VI ........................ 52 TYSABRI........................... 35 TYVASO ........................... 22 TYZEKA ............................ 10 tyzine ................................ 58 U UCERIS AER 2MG/ACT ... 47 UCERIS TAB 9MG ............ 47 ULORIC ..............................1 ULTRACET .........................2

see tramadol-acetaminophen .2

ULTRAM .............................2 see tramadol hcl tab 50 mg ...................................2

ULTRAM ER .......................2 see tramadol hcl er ..........2

ULTRAVATE ..................... 62 see halobetasol propionate ..................... 61

ULTRESA ......................... 48 UNASYN ........................... 12

see ampicillin & sulbactam sodium ........................... 12

UNASYN BULK PACK ...... 12 see ampicillin & sulbactam sodium ........................... 12

UNITHROID ...................... 45 urecholine ......................... 49 URECHOLINE

see bethanechol chloride ...................................... 49

UROCIT-K ......................... 49 UROCIT-K 15

see potassium citrate (alkalinizer) .................... 49

UROXATRAL .................... 49 see alfuzosin hcl ............ 48

URSO 250 ........................ 48 see ursodiol ................... 48

URSO FORTE .................. 48 see ursodiol ................... 48

ursodiol ............................. 48 UVADEX ........................... 15 V VAGIFEM .......................... 43 valacyclovir hcl .................. 10 VALCHLOR ...................... 63 VALCYTE ......................... 10

see valganciclovir hcl .... 10 valganciclovir hcl ............... 10 VALIUM ............................ 25

see diazepam ................ 23 valproate sodium .............. 25 valproic acid ...................... 25 valsartan ........................... 17 valsartan-hydrochlorothiazide ........................................ 17 VALTREX ......................... 10

see valacyclovir hcl ....... 10 VANCOCIN HCL ................. 8

see vancomycin hcl ......... 8 vancomycin hcl ................... 8 vancomycin hcl inj 1000mg . 8 vancomycin hcl inj 10gm ..... 8 vancomycin hcl inj 500mg ... 8 vancomycin hcl inj 5gm ....... 8 vancomycin hcl inj 750mg ... 8 VANDAZOLE .................... 49 VANOS ............................. 62

see fluocinonide ............ 61 VAQTA .............................. 52 VARIVAX .......................... 52 VASCEPA ......................... 19 VASERETIC ..................... 16

see enalapril maleate & hydrochlorothiazide ....... 16

VASOTEC ......................... 16 see enalapril maleate .... 16

VECTIBIX ......................... 14 VECTICAL ........................ 60 VELCADE ......................... 14 velivet 28 day .................... 42 VELPHORO ...................... 45

VELTIN ............................. 59 venlafaxine cap er............. 27 venlafaxine hcl .................. 27 VENLAFAXINE HCL ER

see venlafaxine tab er ... 27 VENLAFAXINE HCL ER TAB (VERT) ...................... 27 venlafaxine tab ................. 27 VENLAFAXINE TAB 225MG ER ..................................... 27 venlafaxine tab er ............. 27 VENTAVIS ........................ 22 VENTOLIN HFA................ 57 VERAMYST ...................... 58 verapamil hcl .................... 20 VERAPAMIL HCL ............. 20 VERELAN ......................... 20

see verapamil hcl .......... 20 VERELAN PM .................. 20

see verapamil hcl .......... 20 veripred ............................. 44 VERSACLOZ .................... 30 VESICARE ....................... 49 vestura .............................. 42 VEXOL .............................. 56 VFEND

see voriconazole ............. 8 VFEND IV ........................... 8

see voriconazole inj 200mg ............................. 8

VFEND SUS 40MG/ML ...... 8 VFEND TAB ....................... 8 VIBRAMYCIN ................... 13

see doxycycline (monohydrate) ............... 13 see doxycycline hyclate 13

vicodin ................................ 6 vicodin es ............................ 6 vicodin hp ........................... 6 VICOPROFEN .................... 6

see hydrocodone-ibuprofen tab 7.5-200 mg ...................... 3

VICTOZA .......................... 37 VIDAZA ............................. 14

see azacitidine .............. 13 VIDEX EC ........................... 9

see didanosine ................ 8

2016 601 4T Copper Comm eff 01/01/2016

94

VIDEX PEDIATRIC .............9 VIGAMOX ......................... 55 VIIBRYD............................ 27 VIMIZIM ............................ 42 VIMOVO..............................1 VIMPAT............................. 25 vinblastine sulfate ............. 14 vincasar............................. 14 vincristine sulfate .............. 14 vinorelbine tartrate ............ 14 VIOKACE 10 ..................... 48 VIOKACE 20 ..................... 48 viorele ............................... 42 VIRACEPT ..........................9 VIRAMUNE .........................9

see nevirapine .................9 VIRAMUNE XR ...................9

see nevirapine .................9 VIREAD...............................9 VIROPTIC ......................... 55

see trifluridine ................ 55 VISTIDE

see cidofovir .................. 10 VITEKTA .............................9 VIVELLE-DOT ................... 43

see estradiol .................. 42 VOGELXO ........................ 36 VOGELXO PUMP ............. 36 VOLTAREN GEL 1% ........ 63 VOLTAREN-XR ..................1 voriconazole ........................8 voriconazole inj 200mg .......8 vospire .............................. 57 VOSPIRE ER

see albuterol sulfate er .. 57 VOTRIENT ........................ 15 VPRIV ............................... 42 vyfemla 28 day .................. 42 VYTORIN .......................... 19 VYVANSE ......................... 32 W warfarin sodium ................. 50 WELCHOL ........................ 19 WELLBUTRIN ................... 27

see bupropion hcl .......... 26 WELLBUTRIN SR ............. 27

see bupropion hcl .......... 26 WELLBUTRIN XL ............. 27

see bupropion hcl .......... 26 WESTCORT

see hydrocortisone valerate ......................... 62

wymzya fe ......................... 42 X XALATAN ......................... 56

see latanoprost .............. 56 XALKORI .......................... 15 XANAX

see alprazolam .............. 22 XANAX TAB 0.25MG ........ 23 XANAX TAB 0.5MG .......... 23 XANAX TAB 1MG ............. 23 XANAX TAB 2MG ............. 23 XARELTO ......................... 50 XARELTO STARTER PACK .......................................... 50 XARTEMIS XR ................... 6 XELJANZ .......................... 51 XENAZINE ........................ 34 XEOMIN INJ 100 UNIT ..... 35 XEOMIN INJ 50 UNIT ....... 35 XERESE ........................... 63 XGEVA ............................. 44 XIFAXAN TAB 200MG ........ 8 XIFAXAN TAB 550MG ...... 48 XIGDUO XR TAB 10-1000MG ....................... 39 XIGDUO XR TAB 10-500MG .......................................... 39 XIGDUO XR TAB 5-1000MG .......................................... 39 XIGDUO XR TAB 5-500MG .......................................... 39 XODOL

see hydrocodone-acetaminophen 10-300mg ................... 3 see hydrocodone-acetaminophen 5-300mg ..................... 3 see hydrocodone-acetaminophen 7.5-300mg .................. 3 see vicodin ...................... 6 see vicodin es ................. 6 see vicodin hp ................. 6

xodol tab 10-300mg ............ 6 xodol tab 5-300mg .............. 6 xodol tab 7.5-300 ................ 6 XOLAIR ............................ 58 XOPENEX ........................ 57

see levalbuterol hcl ....... 57 XOPENEX CONCENTRATE.......................................... 57

see levalbuterol conc 1.25mg/0.5ml ................ 57

XOPENEX HFA ................ 57 XTANDI ............................ 15 xulane dis 150-35 ............. 42 XYLOCAINE ................. 6, 62

see lidocaine hcl ............ 62 see lidocaine hcl (local anesth.) ........................... 6 see lidocaine inj 1% ........ 6 see lidocaine inj 2% ........ 6

XYLOCAINE-MPF .............. 6 see lidocaine hcl (local anesth.) ........................... 6 see lidocaine inj 0.5% ..... 6 see lidocaine inj 1.5% ..... 6 see lidocaine inj 2% ........ 6

XYREM ............................. 35 XYZAL .............................. 57

see levocetirizine soln 2.5mg/5ml ..................... 57 see levocetirizine tab 5 mg ...................................... 57

Y YASMIN 28 ....................... 42

see drospirenone-ethinyl estradiol ........................ 40 see syeda ...................... 42 see zarah ...................... 42

YAZ ................................... 42 see loryna 28 day .......... 41 see nikki 28 day ............ 41 see vestura ................... 42

YERVOY ........................... 14 YF-VAX ............................. 52 Z zafirlukast ......................... 57 zamicet ............................... 6 ZANAFLEX ....................... 35

see tizanidine ................ 35

2016 601 4T Copper Comm eff 01/01/2016

95

ZANOSAR ......................... 13 ZANTAC............................ 46

see ranitidine hcl ........... 46 zarah ................................. 42 zarontin ............................. 25 ZARONTIN ........................ 25

see ethosuximide .......... 23 ZAVESCA ......................... 42 zazole ............................... 49 ZAZOLE ............................ 49 ZEBETA ............................ 20

see bisoprolol fumarate . 19 ZEGERID .......................... 48 ZELAPAR.......................... 28 ZELBORAF ....................... 15 ZEMAIRA .......................... 58 ZEMPLAR ......................... 54

see paricalcitol ............... 54 zenatane ........................... 59 zenchent fe 28 day ............ 42 zenchent tab ..................... 42 ZENPEP............................ 48 ZERBAXA ......................... 11 ZERIT .................................9

see stavudine ..................9 ZESTORETIC ................... 16

see lisinopril & hydrochlorothiazide ....... 16

ZESTRIL ........................... 16 see lisinopril ................... 16

ZETIA TAB 10MG ............. 19 ZETONNA ......................... 58 ZIAC .................................. 19

see bisoprolol & hydrochlorothiazide ....... 19

ZIAGEN...............................9 see abacavir sulfate ........8

ZIANA ............................... 59 zidovudine ...........................9 ZINACEF........................... 11

see cefuroxime sodium.. 11 ZINECARD ........................ 16

see dexrazoxane ........... 15 ZIOPTAN .......................... 56

ziprasidone hcl .................. 30 ZIPSOR .............................. 1 ZIRGAN ............................ 55 ZITHROMAX ..................... 11

see azithromycin ........... 11 ZITHROMAX TRI-PAK ...... 11 ZITHROMAX Z-PAK ......... 11 ZMAX ................................ 11 ZOCOR ............................. 18

see simvastatin ............. 18 ZOFRAN ........................... 46

see ondansetron hcl ...... 46 see ondansetron hcl inj . 46 see ondansetron hcl oral soln ................................ 46

ZOFRAN ODT .................. 46 see ondansetron odt...... 46

ZOHYDRO ER (ABUSE DETERRENT) ..................... 6 zoledronic inj 4mg/5ml ...... 39 zoledronic inj 5/100ml ....... 39 ZOLINZA ........................... 14 zolmitriptan ....................... 33 zolmitriptan odt ................. 33 ZOLOFT ............................ 27

see sertraline hcl ........... 27 zolpidem tartrate ............... 32 ZOMACTON ..................... 44 ZOMETA ........................... 39

see zoledronic inj 4mg/5ml ...................................... 39

ZOMIG .............................. 33 see zolmitriptan ............. 33

ZOMIG NASAL SPRAY .... 33 ZOMIG ZMT ...................... 34

see zolmitriptan odt ....... 33 ZONALON ........................ 60 ZONEGRAN ..................... 25

see zonisamide ............. 25 zonisamide ........................ 25 ZONTIVITY ....................... 50 ZORBTIVE ........................ 44 ZORTRESS TAB 0.25MG . 52 ZORTRESS TAB 0.5MG ... 52

ZORTRESS TAB 0.75MG 52 ZORVOLEX ........................ 1 ZOSTAVAX ...................... 52 ZOSYN ............................. 12

see piperacillin sodium-tazobactam sodium .......................... 12

zovia 1/35e 28 day............ 42 zovia 1/50e 28 day............ 42 ZOVIRAX .................... 10, 63

see acyclovir ................. 10 see acyclovir topical ...... 62

ZUBSOLV SUB 1.4-0.36MG.......................................... 35 ZUBSOLV SUB 5.7-1.4MG.......................................... 35 ZUBSOLV SUB 8.6-2.1MG.......................................... 35 ZUPLENZ ......................... 46 ZYBAN .............................. 36

see buproban ................ 35 ZYCLARA ......................... 63 ZYDELIG .......................... 15 ZYFLO CR ........................ 58 ZYKADIA .......................... 15 ZYLET .............................. 55 ZYLOPRIM ......................... 1

see allopurinol tab ........... 1 ZYMAXID .......................... 55

see gatifloxacin (ophth) . 55 ZYPREXA ......................... 30

see olanzapine .............. 29 ZYPREXA RELPREVV ..... 30 ZYPREXA RELPREVV INJ 210MG .............................. 30 ZYPREXA ZYDI TAB 10MG.......................................... 30 ZYPREXA ZYDIS ............. 30

see olanzapine odt ........ 29 ZYTIGA ............................. 15 ZYVOX ............................... 8

see linezolid .................... 7

2016 601 4t copper comm eff 01/01/2016 · 2015-09-22 · 2016 601 4t copper comm eff 01/01/2016 pa...

Documents