2016 comprehensive formulary - kaiser...

Y0043_N014664_Final01 approved HPMS Approved Formulary File Submission 00016169, Version 10

Kaiser Permanente

2016 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 09/01/15. For more recent information or other questions, please contact the number for your Kaiser Permanente Region listed below, seven days a week, 8 a.m. to 8 p.m., or visit kp.org/seniormedrx.

Kaiser Permanente Regions

CALIFORNIA REGIONS Kaiser Permanente Senior Advantage (HMO) and Senior Advantage Medicare Medi-Cal Plan (HMO SNP)

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

COLORADO REGION Kaiser Permanente Senior Advantage (HMO) and Senior Advantage Medicare Medicaid Plan (HMO SNP)

Member Services 1-800-476-2167 TTY 711

GEORGIA REGION Kaiser Permanente Senior Advantage (HMO) and Senior Advantage Medicare Medicaid Plan (HMO SNP)


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

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

Membership Services 1-877-221-8221 TTY 711

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us,” or “our,” it means Kaiser Permanente. When it refers to “plan” or “our plan,” it means Kaiser Permanente Senior Advantage or Medicare Plus, depending upon the region in which you are enrolled. This document includes a list of the drugs (formulary) for our plan which is current as of January 1, 2016. For an updated formulary, please visit our website at kp.org/seniormedrx or call us. Contact information for your Kaiser Permanente Region, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits and/or copayments/coinsurance may change on January 1 of each year, and for group members, at other times in accord with your group’s contract with us. In California, Hawaii, Oregon, Washington, Colorado and Georgia, Kaiser Permanente is an HMO plan with a Medicare contract. In Virginia, Maryland, and the District of Columbia, Kaiser Permanente is a Cost plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal. This information is available for free in other languages. Please call the Member Services number listed on the front and back covers. Se puede obtener esta información gratis en otros idiomas. Por favor llame al número de Servicios a los Miembros que aparece en la portada y la contraportada. 此資訊免費以其他語言提供。請聯絡我們的會員服務聯絡中心，電話號碼列在封面和封底。 This document is available in a different format for the visually impaired by calling our plan at the number listed on the front and back covers for your Kaiser Permanente Region.

Kaiser Permanente 2016 Comprehensive Formulary • 1

What is the Kaiser Permanente Formulary? A formulary is a list of covered drugs selected by Kaiser Permanente in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed on our formulary as long as the drug is medically necessary, the prescription is filled at a Kaiser Permanente network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Our plan covers all drugs that can be included in a Medicare Part D prescription drug plan according to Medicare requirements. Contact information for your Kaiser Permanente Region, along with the date we last updated the formulary, appears on the front and back cover pages. Can the formulary (drug list) change? Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the

formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of January 1, 2016. To get updated information about the drugs covered by our plan, please call us. Contact information for your Kaiser Permanente Region appears on the front and back cover pages. In the event of a midyear non-maintenance formulary change, we will provide details in the Medicare Part D Explanation of Benefits or Provision of Notice posted at kp.org/seniormedrx. How do I use the formulary? There are two ways to find your drug within the formulary: Medical condition The formulary begins on page 6. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Drugs”.

2 • Kaiser Permanente 2016 Comprehensive Formulary

If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug. Alphabetical listing If you are not sure what category to look under, you should look for your drug in the index that begins on page 55. The index provides an alphabetical list of all of the drugs included in this document. Preferred generic and generic drugs, preferred brand-name and nonpreferred brand-name drugs, specialty-tier drugs, and injectable vaccines are listed in the index. Look in the index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list. What are generic drugs? Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name and specialty-tier drugs. Cost sharing for preferred generic drugs may be different than for generic drugs. Please see your Evidence of Coverage for more information. What are brand-name drugs? Brand-name drugs are manufactured and sold by the pharmaceutical company that originally researched and developed the drug. When the patent on a brand-name drug expires, other pharmaceutical companies may manufacture and sell an FDA-approved generic version of the drug with the same active ingredient(s) at lower prices. Cost

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

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


Note: If your prescription has more than one refill remaining, you can only get one refill at a time, unless authorized because you will be away from our service area for an extended period of time. For certain drugs, we may limit the amount of an extended day supply (amounts that exceed a 30-day supply) that you can receive. Also, if there is a shortage in the marketplace, we may fill your prescription for a limited quantity. You can find out if your drug has any additional requirements or limits by looking on the formulary that begins on page 6. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization restriction. You may also ask us to send you a copy. Contact information for your Kaiser Permanente Region, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Kaiser Permanente formulary?” on this page for information about how to request an exception. What if my drug is not on the formulary? If your drug is not included on this formulary (list of covered drugs), you should first check our Kaiser Permanente 2016 Comprehensive Formulary at kp.org/seniormedrx or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region and confirm if your drug is covered.

Our plan covers all Medicare Part D drugs. In the rare case that your Medicare Part D prescription drug is not on our Kaiser Permanente 2016 Comprehensive Formulary, you have two options:

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

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

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

• You can ask us to cover a drug even if it may not be on our Kaiser Permanente 2016 Comprehensive Formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

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

• You can ask us to waive coverage

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


the prior authorization requirement for your Part D drug.

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

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


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

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

http://www.medicare.gov/


Kaiser Permanente’s Formulary The formulary below provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the index that begins on page 55. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., ALBENZA) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The second column, “Drug Tier,” will indicate what tier number the drug is in: Tier 1 – Preferred generic drugs Tier 2 – Generic drugs Tier 3 – Preferred brand-name drugs Tier 4 – Nonpreferred brand-name drugs Tier 5 – Specialty-tier drugs Tier 6 – Injectable Part D vaccines Generally, the cost sharing you will pay for your drugs depends on your coverage stage, the type of network pharmacy where you purchase your drugs, and your drug’s cost-sharing tier on our formulary. Please refer to your Evidence of Coverage for the details about your Medicare Part D prescription drug coverage, including your cost-sharing amounts. Note: If your coverage is through an employer-sponsored group plan (including a union or trust fund), you may have different drug benefits and cost sharing, and you may have coverage for other drugs that are not covered by Medicare Part D (non-Part D drugs). The amount you pay for non-Part D drugs does not count toward your total out-of-pocket expenditures, and if you are receiving Extra Help to pay for your Medicare Part D prescription drugs, you will not receive any Extra Help to pay for non-Part D drugs. Please check with your group benefits administrator or see your Evidence of Coverage. The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. Certain strengths or forms of the drug may be subject to the utilization management codes listed below. HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies. For more information, please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region. LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies. For more information, consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region.


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

Mail-Order Contact Numbers (TTY 711)

California

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

Colorado

Kaiser Permanente Mail Order Pharmacy 1-866-523-6059 Monday through Friday, 8 a.m. to 6 p.m.

Georgia

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

Hawaii

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

Mid-Atlantic States

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

Northwest

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

PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (e.g., via infusion pump, nebulizer, or other Durable Medical Equipment device), where they are administered (at home or in a long-term care facility), and what medical condition they are administered for. Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered. .

You can find information on what the abbreviations on this table mean by going to the beginning or the end of this table. 8 • Kaiser Permanente 2016 Comprehensive Formulary

Drug Name Drug Tier

Requirements/Limits

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

ampicillin 2 ampicillin & sulbactam sodium 2 HI

ampicillin sodium 2 HI AUGMENTIN 3 AVELOX SOLN 3 HI AVELOX 4 AVELOX ABC PACK 4 AZACTAM 3 HI AZACTAM IN DEXTROSE 3 HI

azithromycin 2 HI,MO AZITHROMYCIN PACK 1GM 3 MO

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

BACTRIM 4 MO BACTRIM DS 4 MO BETHKIS 5 PA BIAXIN 4 BICILLIN C-R 4 BICILLIN C-R 900/300 4 BICILLIN L-A 3 CAYSTON 5 LD CEDAX 4 cefaclor 2

Drug Name Drug Tier

Requirements/Limits

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

cefdinir 2 CEFDITOREN PIVOXIL 4 cefepime hcl 2 HI CEFEPIME-DEXTROSE 4 HI cefixime 2 cefotaxime sodium 2 HI cefotetan disodium 2 HI cefoxitin sodium 2 HI CEFOXITIN SODIUM-DEXTROSE 3 HI

cefpodoxime proxetil 2 cefprozil 2 ceftazidime 2 HI CEFTAZIDIME AND DEXTROSE 3 HI

CEFTIN SUSR 125 MG/5ML 4

CEFTIN SUSR 250 MG/5ML 3

CEFTIN TABS 250 MG 4 CEFTIN TABS 500 MG 4 ceftriaxone sodium 2 HI CEFTRIAXONE SODIUM-DEXTROSE 3 HI

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

cephalexin 2 chloramphenicol sodium succinate 2 HI

CIPRO 4 CIPRO IN D5W 4 HI ciprofloxacin 2 HI ciprofloxacin hcl 2 ciprofloxacin in d5w 2 HI

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


Drug Name Drug Tier

Requirements/Limits

ciprofloxacin-ciprofloxacin hcl 2

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

clindamycin phosphate 2 HI clindamycin phosphate in d5w 2 HI

colistimethate sodium 2 HI CUBICIN 5 HI DALVANCE 5 demeclocycline hcl 2 dicloxacillin sodium 2 DIFICID 5 DORIBAX 4 HI DORYX 4 MO doxycycline (monohydrate) 2 MO

doxycycline hyclate 2 HI,MO E.E.S. GRANULES 4 ERYPED 200 4 ERYPED 400 4 erythromycin base 2 erythromycin ethylsuccinate 2

erythromycin lactobionate 2 HI

erythromycin stearate 2 FACTIVE 4 FORTAZ SOLR 1 GM 3 HI FORTAZ SOLR 2 GM 3 HI FORTAZ SOLR 2 GM 4 HI FORTAZ SOLR 6 GM 4 HI gentamicin in saline 2 HI gentamicin sulfate 2 HI imipenem-cilastatin 2 HI INVANZ 3 HI

Drug Name Drug Tier

Requirements/Limits

KEFLEX 4 KETEK 4 KITABIS PAK 5 PA LEVAQUIN 4 levofloxacin 2 HI levofloxacin in d5w 2 HI LINCOCIN 4 HI linezolid 2 HI MAXIPIME SOLR 1 GM 3 HI MAXIPIME SOLR 1 GM 4 HI MAXIPIME SOLR 2 GM 3 HI MAXIPIME SOLR 2 GM 4 HI meropenem 2 HI MERREM 4 HI MINOCIN 4 MO minocycline hcl 2 MO moxifloxacin hcl 2 nafcillin sodium 2 HI NALLPEN IN DEXTROSE 3 HI

neomycin sulfate 2 ofloxacin 2 ORBACTIV 5 oxacillin sodium 2 HI PCE 4 PENICILLIN G POT IN DEXTROSE 3 HI

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

polymyxin b sulfate 2 HI PRIMAXIN IV 4 HI SIVEXTRO 5 SOLODYN 4 MO SPECTRACEF 4 streptomycin sulfate 2 sulfadiazine 2 sulfamethoxazole-trimethoprim 2 HI,MO


Drug Name Drug Tier

Requirements/Limits

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

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

VIBRAMYCIN 4 MO XIFAXAN 4 ZERBAXA 4 ZINACEF IN D5W 3 HI ZINACEF IN STERILE WATER 3 HI

ZINACEF SOLR 1.5 GM 4 HI ZINACEF SOLR 7.5 GM 4 HI ZINACEF SOLR 750 MG 3 HI ZINACEF SOLR 750 MG 4 HI ZITHROMAX PACK 1 GM 3 MO

ZITHROMAX SOLR 500 MG 4 HI

ZITHROMAX SUSR 100 MG/5ML 4 MO

ZITHROMAX SUSR 200 MG/5ML 4 MO

ZITHROMAX TABS 250 MG 4 MO



ZITHROMAX TRI-PAK TABS 500 MG 4 MO

Drug Name Drug Tier

Requirements/Limits

ZITHROMAX Z-PAK TABS 250 MG 4 MO

ZMAX SUSR 2 MG 4 MO ZOSYN 4 HI ZYVOX 5 HI ANTIFUNGALS ABELCET 4 HI AMBISOME 5 HI amphotericin b 2 HI ANCOBON 5 CANCIDAS 5 HI CRESEMBA 5 DIFLUCAN 4 ERAXIS 4 HI fluconazole 2 fluconazole in dextrose 2 HI flucytosine 2 GRIS-PEG 4 griseofulvin microsize 2 griseofulvin ultramicrosize 2

itraconazole 2 ketoconazole 2 LAMISIL 4 MYCAMINE 4 HI NOXAFIL 5 nystatin 2 nystatin (mouth-throat) 2 ONMEL TABS 200 MG 4 SPORANOX CAPS 100 MG 4

SPORANOX PULSEPAK CAPS 100 MG

4

SPORANOX SOLN 10 MG/ML 3

terbinafine hcl 2 VFEND IV SOLR 200 MG 4 HI

VFEND SUSR 40 MG/ML 5

VFEND TABS 200 MG 5 VFEND TABS 50 MG 5



Drug Name Drug Tier

Requirements/Limits

voriconazole 2 HI ANTIMYCOBACTERIALS aminosalicylic acid 2 MO CAPASTAT SULFATE 3 HI dapsone 2 MO ethambutol hcl 2 MO isoniazid 2 MO isoniazid & rifampin 2 MO MYAMBUTOL 4 MO MYCOBUTIN 4 MO PRIFTIN 4 MO pyrazinamide 2 MO rifabutin 2 MO RIFADIN 4 HI,MO rifampin 2 HI,MO RIFATER 4 MO SIRTURO 5 TRECATOR 4 MO ANTIPROTOZOALS ALINIA 3 atovaquone 2 atovaquone-proguanil hcl 2

chloroquine phosphate 2 COARTEM 3 DARAPRIM 3 FLAGYL 4 FLAGYL ER 4 hydroxychloroquine sulfate 2

MALARONE 4 mefloquine hcl 2 MEPRON 5 METRO 3 HI metronidazole 2 metronidazole in nacl 2 HI NEBUPENT SOLR 300 MG 3 PA

paromomycin sulfate 2 PENTAM SOLR 300 MG 4 PLAQUENIL 4

Drug Name Drug Tier

Requirements/Limits

PRIMAQUINE PHOSPHATE 3

QUALAQUIN 4 quinine sulfate 2 TINDAMAX 4 tinidazole 2 ANTIVIRALS abacavir sulfate 2 MO abacavir sulfate-lamivudine-zidovudine 2 MO

acyclovir 2 MO acyclovir sodium 2 HI adefovir dipivoxil 2 MO APTIVUS 5 ATRIPLA 5 BARACLUDE SOLN 0.05 MG/ML 3 MO

BARACLUDE TAB 0.5 MG 5

BARACLUDE TABS 1 MG 5

cidofovir 2 HI COMBIVIR 5 COMPLERA 5 COPEGUS 4 MO CRIXIVAN 3 MO CYTOVENE 4 HI DAKLINZA 5 PA didanosine 2 MO EDURANT 5 EMTRIVA 3 MO entecavir 2 MO EPIVIR HBV SOLN 5 MG/ML 3 MO

EPIVIR HBV TABS 100 MG 4 MO

EPIVIR SOLN 10 MG/ML 3 MO

EPIVIR TABS 150 MG 4 MO EPIVIR TABS 300 MG 4 MO EPZICOM 5 EVOTAZ 5 famciclovir 2 MO


Drug Name Drug Tier

Requirements/Limits

FAMVIR 4 MO FLUMADINE 4 MO foscarnet sodium 2 HI FUZEON 5 ganciclovir sodium 2 HI HARVONI 5 PA HEPSERA 5 INCIVEK 5 INFERGEN 5 INTELENCE TABS 100 MG 5

INTELENCE TABS 200 MG 5

INTELENCE TABS 25 MG 3 MO

INVIRASE CAPS 200 MG 3 MO

INVIRASE TABS 500 MG 5

ISENTRESS CHEW 100 MG 3 MO

ISENTRESS CHEW 25 MG 3 MO

ISENTRESS PACK 100 MG 4 MO

ISENTRESS TABS 400 MG 5

KALETRA SOLN 400-100 MG/5ML 5

KALETRA TABS 100-25 MG 3 MO

KALETRA TABS 200-50 MG 5

lamivudine 2 MO lamivudine (hbv) 2 MO lamivudine-zidovudine 2 MO LEXIVA SUSP 50 MG/ML 4

LEXIVA TABS 700 MG 5 nevirapine 2 MO NORVIR 3 MO OLYSIO 5 PA PEG-INTRON 5 PEG-INTRON REDIPEN 5

Drug Name Drug Tier

Requirements/Limits

PEGASYS 5 PEGASYS PROCLICK 5 PEGINTRON 5 PLEGRIDY 5 PLEGRIDY STARTER PACK 5

PREZCOBIX 5 PREZISTA SUSP 100 MG/ML 4 MO

PREZISTA TABS 150 MG 3 MO

PREZISTA TABS 400 MG 5

PREZISTA TABS 600 MG 5

PREZISTA TABS 75 MG 3 MO PREZISTA TABS 800 MG 5

REBETOL 4 MO RELENZA DISKHALER 3 MO RESCRIPTOR 3 MO RETROVIR CAPS 100 MG 4 MO

RETROVIR SOLN 10 MG/ML 3 HI

RETROVIR SYRP 50 MG/5ML 4 MO

REYATAZ CAPS 100 MG 3 MO

REYATAZ CAPS 150 MG 5



REYATAZ PACK 50 MG 4 MO ribavirin (hepatitis c) 2 MO rimantadine hydrochloride 2 MO

SELZENTRY 5 SOVALDI 5 PA stavudine 2 MO STRIBILD 5 SUSTIVA 3 MO



Drug Name Drug Tier

Requirements/Limits

SYNAGIS 5 TAMIFLU 3 MO TECHNIVIE 5 PA TIVICAY 5 TRIUMEQ 5 TRIZIVIR 5 TRUVADA 5 TYZEKA 4 valacyclovir hcl 2 MO VALCYTE SOLR 50 MG/ML 3 MO

VALCYTE TABS 450 MG 5

valganciclovir hcl 2 MO VALTREX 4 MO VICTRELIS 5 VIDEX EC CPDR 125 MG 4 MO

VIDEX EC CPDR 200 MG 4 MO



VIDEX SOLR 2 GM 3 MO VIEKIRA PAK 5 PA VIRACEPT 5 VIRAMUNE 4 MO VIRAMUNE XR 4 MO VIRAZOLE 3 MO VIREAD 5 VISTIDE 5 HI VITEKTA 5 ZERIT 4 MO ZIAGEN SOLN 20 MG/ML 3 MO

ZIAGEN TABS 300 MG 4 MO zidovudine 2 MO ZOVIRAX 4 MO URINARY ANTI-INFECTIVES FURADANTIN 4 HIPREX 4 MACROBID 4

Drug Name Drug Tier

Requirements/Limits

MACRODANTIN CAPS 100 MG 4



methenamine hippurate 2 MONUROL 4 nitrofurantoin 2 nitrofurantoin macrocrystal 2

nitrofurantoin monohyd macro 2

PRIMSOL 3 MO trimethoprim 2 MO ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS carbinoxamine maleate 2 cetirizine hcl 2 CLARINEX 4 CLARINEX-D 12 HOUR 4 clemastine fumarate 2 cyproheptadine hcl 2 desloratadine 2 diphenhydramine hcl 2 KARBINAL ER 4 levocetirizine dihydrochloride 2

promethazine & phenylephrine 2

promethazine hcl 2 SEMPREX-D 4 XYZAL 4 ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS ABRAXANE 3 AFINITOR 5 AFINITOR DISPERZ 5 ALIMTA 3 ALKERAN 4 anastrozole 2 ARIMIDEX 4


Drug Name Drug Tier

Requirements/Limits

AROMASIN 4 ARRANON 3 ARZERRA 4 AVASTIN 3 azacitidine 2 BCG VACCINE 3 BELEODAQ 5 bicalutamide 2 BICNU 3 bleomycin sulfate 2 BLINCYTO 5 BOSULIF 5 BUSULFEX 4 CAMPATH 3 CAMPTOSAR 4 CAPRELSA 3 LD carboplatin 2 CASODEX 4 CEENU 3 cisplatin 2 cladribine 2 CLOLAR 4 COMETRIQ (100 MG DAILY DOSE) 5 LD

COMETRIQ (140 MG DAILY DOSE) 5 LD

COMETRIQ (60 MG DAILY DOSE) 5 LD

COSMEGEN 4 CYCLOPHOSPHAMIDE 4 PA CYRAMZA 5 cytarabine 2 dacarbazine 2 DACOGEN 4 daunorubicin hcl 2 DAUNOXOME 3 decitabine 2 DOCEFREZ SOLR 20 MG 4

DOCETAXEL CONC 20 MG/0.5ML 3

DOCETAXEL CONC 80 MG/2ML 3

Drug Name Drug Tier

Requirements/Limits

DOCETAXEL CONC 80 MG/4ML 4

DOCETAXEL SOLN 80 MG/8ML 3

DOXIL 4 doxorubicin hcl 2 DROXIA 4 ELIGARD KIT 22.5 MG 4 ELIGARD KIT 30 MG 4 ELIGARD KIT 45 MG 4 ELIGARD KIT 7.5 MG 4 ELLENCE 4 ELOXATIN SOLN 100 MG/20ML 4

ELOXATIN SOLN 200 MG/40ML 3

ELSPAR 3 EMCYT 3 epirubicin hcl 2 ERBITUX 3 ERIVEDGE 5 ERWINAZE 4 ETOPOPHOS 4 etoposide 2 exemestane 2 FARESTON 4 FARYDAK 5 LD FASLODEX 5 FEMARA 4 FIRMAGON 4 fludarabine phosphate 2 fluorouracil 2 HI flutamide 2 FOLOTYN 4 GAZYVA 5 gemcitabine hcl 2 GEMZAR 4 GILOTRIF 5 GLEEVEC 5 GLEOSTINE 3 HALAVEN 4 HERCEPTIN 3



Drug Name Drug Tier

Requirements/Limits

HEXALEN 5 HYCAMTIN 4 HYDREA 4 hydroxyurea 2 IBRANCE 5 LD ICLUSIG 5 LD IDAMYCIN PFS 4 idarubicin hcl 2 IFEX 3 ifosfamide 2 IMBRUVICA 5 LD INLYTA 5 INTRON A 5 IRESSA 5 irinotecan hcl 2 ISTODAX 3 IXEMPRA KIT 5 JAKAFI 5 JEVTANA 3 KADCYLA 5 KEYTRUDA 5 KYPROLIS 5 LENVIMA 10 MG DAILY DOSE 5

LENVIMA 14 MG DAILY DOSE 5



letrozole 2 LEUKERAN 3 leuprolide acetate 2 LOMUSTINE 3 LUPANETA PACK 4 LUPRON DEPOT KIT 11.25 MG 3

LUPRON DEPOT KIT 22.5 MG 3


LUPRON DEPOT KIT 30 MG 3

Drug Name Drug Tier

Requirements/Limits

LUPRON DEPOT KIT 45 MG 3


LUPRON DEPOT-PED 3 LYNPARZA 5 LD LYSODREN 3 MARQIBO 5 MATULANE 5 MEGACE ORAL 4 megestrol acetate 2 MEKINIST 5 melphalan hcl 2 mercaptopurine 2 methotrexate sodium 2 PA mitomycin 2 mitoxantrone hcl 2 MUSTARGEN 3 NEXAVAR 5 NILANDRON 3 NIPENT 4 ONCASPAR 3 OPDIVO 5 oxaliplatin 2 paclitaxel 2 PERJETA 5 POMALYST 5 PROLEUKIN 5 PURIXAN 5 REVLIMID 5 RHEUMATREX 4 PA RITUXAN 3 SOLTAMOX 4 SPRYCEL 5 STIVARGA 5 SUTENT 5 SYLATRON 4 SYLVANT 5 SYNRIBO 5 TABLOID 3 TAFINLAR 5 tamoxifen citrate 2


Drug Name Drug Tier

Requirements/Limits

TARCEVA 5 TARGRETIN 5 TASIGNA 5 TAXOTERE CONC 80 MG/4ML 4

TICE BCG 3 topotecan hcl 2 TORISEL 3 TREANDA SOLN 45 MG/0.5ML 4

TREANDA SOLR 100 MG 3

TRELSTAR MIXJECT 4 tretinoin (chemotherapy) 2 TRISENOX 3 TYKERB 5 UNITUXIN 5 VALSTAR 3 VANTAS 3 VECTIBIX 4 VELCADE 3 VIDAZA 4 vinblastine sulfate 2 vincristine sulfate 2 vinorelbine tartrate 2 VOTRIENT 5 VUMON 3 XALKORI 5 XTANDI 5 YERVOY 3 ZALTRAP 5 ZANOSAR 3 ZELBORAF 5 ZOLINZA 5 ZYDELIG 5 ZYKADIA 5 ZYTIGA 5 AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANORO ELLIPTA 4 MO atropine sulfate 2 MO ATROPINE SULFATE 3 MO

Drug Name Drug Tier

Requirements/Limits

ATROVENT 4 MO ATROVENT HFA 3 MO BENTYL 4 MO CANTIL 4 MO CUVPOSA SOLN 1 MG/5ML 3 MO

dicyclomine hcl 2 MO glycopyrrolate 2 MO INCRUSE ELLIPTA 4 MO ipratropium bromide 1 PA,MO ipratropium bromide (nasal) 2 MO

methscopolamine bromide 2 MO

propantheline bromide 2 MO ROBINUL TABS 1MG 4 MO ROBINUL-FORTE TABS 2MG 4 MO

SPIRIVA HANDIHALER 4 MO SPIRIVA RESPIMAT 4 MO STIOLTO RESPIMAT 4 MO TUDORZA PRESSAIR 4 MO AUTONOMIC DRUGS, MISCELLANEOUS CHANTIX 4 MO CHANTIX CONTINUING MONTH PAK 4 MO

CHANTIX STARTING MONTH PAK 4 MO

NICOTROL INHA 10 MG 3 MO NICOTROL NS SOLN 10 MG/ML 4 MO

PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS ARICEPT 4 MO bethanechol chloride 2 MO cevimeline hcl 2 MO donepezil hydrochloride 2 MO EVOXAC 4 MO EXELON 4 MO galantamine hydrobromide 2 MO

GUANIDINE HCL 4 MO



Drug Name Drug Tier

Requirements/Limits

MESTINON SYRP 60 MG/5ML 3 MO

MESTINON TABS 60 MG 4 MO

MESTINON TBCR 180 MG 3 MO

pilocarpine hcl (oral) 2 MO pyridostigmine bromide 2 MO RAZADYNE 4 MO RAZADYNE ER 4 MO REGONOL SOLN 10 MG/2ML 3 MO

rivastigmine tartrate 2 MO SALAGEN 4 MO SKELETAL MUSCLE RELAXANTS AMRIX 4 PA baclofen 2 PA,MO carisoprodol 2 PA carisoprodol w/ aspirin 2 PA carisoprodol w/ aspirin & codeine 2 PA

chlorzoxazone 2 cyclobenzaprine hcl 2 PA DANTRIUM 4 dantrolene sodium 2 GABLOFEN SOLN 10000 MCG/20ML 3 PA

GABLOFEN SOLN 20000 MCG/20ML 3 PA

GABLOFEN SOLN 40000 MCG/20ML 3 PA

GABLOFEN SOLN 50 MCG/ML 3 PA

LIORESAL SOLN 0.05 MG/ML 4 PA

LIORESAL SOLN 10 MG/20ML 4 PA



metaxalone 2 methocarbamol 2

Drug Name Drug Tier

Requirements/Limits

orphenadrine citrate 2 PARAFON FORTE DSC 4 SKELAXIN 4 SOMA 4 PA tizanidine hcl 2 ZANAFLEX 4 SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS alfuzosin hcl 2 MO DIBENZYLINE 3 MO dihydroergotamine mesylate 2

ergoloid mesylates 2 MO ergotamine tartrate 2 FLOMAX 4 MO MIGRANAL 3 RAPAFLO 4 MO tamsulosin hcl 2 MO UROXATRAL 4 MO SYMPATHOMIMETIC (ADRENERGIC) AGENTS ADRENALIN SOLN 1 MG/ML 4

ADVAIR DISKUS AEPB 100-50 MCG/DOSE 3 MO



ADVAIR HFA AERO 115-21 MCG/ACT 4 MO



albuterol sulfate er tb12 4 mg 2 MO

albuterol sulfate er tb12 8 mg 2 MO

albuterol sulfate nebu (2.5 mg/3ml) 0.083% 1 PA,MO

albuterol sulfate nebu (5 mg/ml) 0.5% 1 PA,MO


Drug Name Drug Tier

Requirements/Limits

albuterol sulfate nebu 0.63 mg/3ml 2 PA,MO

albuterol sulfate nebu 1.25 mg/3ml 2 PA,MO

albuterol sulfate syrp 2 mg/5ml 2 MO

albuterol sulfate tabs 2 mg 2 MO

albuterol sulfate tabs 4 mg 2 MO

ARCAPTA NEOHALER 4 MO AUVI-Q SOAJ 0.15 MG/0.15ML 4

AUVI-Q SOAJ 0.3 MG/0.3ML 3

BROVANA 4 PA,MO COMBIVENT 3 MO COMBIVENT RESPIMAT 3 MO

epinephrine 2 EPIPEN 2-PAK SOAJ 0.3 MG/0.3ML 3

EPIPEN JR 2-PAK SOAJ 0.15 MG/0.3ML 3

FORADIL AEROLIZER 4 MO ipratropium-albuterol 2 PA,MO levalbuterol hcl 2 PA,MO MAXAIR AUTOHALER 3 MO metaproterenol sulfate 2 MO midodrine hcl 2 MO NORTHERA 5 PERFOROMIST 4 PA,MO PROAIR HF AAERS 108 (90 BASE) MCG/ACT 3 MO

PROAIR RESPICLICK AEPB 108 (90 BASE) MCG/ACT

4 MO

PROVENTIL HFA AERS 108 (90 BASE) MCG/ACT

3 MO

SEREVENT DISKUS 4 MO STRIVERDI RESPIMAT 4 MO terbutaline sulfate 2 MO

Drug Name Drug Tier

Requirements/Limits

VENTOLIN HFA AERS 108 (90 BASE) MCG/ACT

3 MO

vospire er tb12 4 mg 2 MO vospire er tb12 8 mg 2 MO XOPENEX 4 PA,MO XOPENEX HFA 4 MO BLOOD FORMATION, COAGULATION, AND THROMBOSIS COAGULANTS AND ANTICOAGULANTS AGGRENOX 4 MO AGRYLIN 4 MO AMICAR 3 MO anagrelide hcl 2 MO argatroban 2 HI ARGATROBAN 4 HI ARIXTRA 4 BRILINTA 3 MO cilostazol 2 MO clopidogrel bisulfate 2 MO COUMADIN 4 MO CYKLOKAPRON 4 HI EFFIENT 3 MO ELIQUIS 4 MO enoxaparin sodium 2 fondaparinux sodium 2 FRAGMIN 4 heparin sod (porcine) in d5w 2 HI

heparin sodium (porcine) 2 HI INTEGRILIN 3 HI LOVENOX 3 LYSTEDA 4 MO pentoxifylline 2 MO PLAVIX 4 MO PLETAL 4 MO PRADAXA 3 MO SAVAYSA 4 MO ticlopidine hcl 2 MO tranexamic acid 2 HI,MO warfarin sodium 1 MO XARELTO 4 MO



Drug Name Drug Tier

Requirements/Limits

XARELTO STARTER PACK 4 MO

ZONTIVITY 4 MO HEMATOPOIETIC AGENTS ARANESP (ALBUMIN FREE) 4 PA

EPOGEN 3 PA GRANIX 5 LEUKINE 3 HI MIRCERA SOLN 100 MCG/0.3ML 4 PA

MIRCERA SOLN 200 MCG/0.3ML 5 PA



MOZOBIL 4 NEULASTA 5 NEUMEGA 5 NEUPOGEN 5 PROCRIT 3 PA PROMACTA 5 CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS CARDURA 4 MO CARDURA XL 4 MO doxazosin mesylate 2 MO MINIPRESS 4 MO prazosin hcl 2 MO SOTYLIZE 4 MO terazosin hcl 2 MO ANTILIPEMIC AGENTS ADVICOR 4 MO ALTOPREV 4 MO ANTARA 4 MO atorvastatin calcium 1 MO cholestyramine 2 MO cholestyramine light 2 MO choline fenofibrate 2 MO COLESTID 4 MO colestipol hcl 2 MO CRESTOR 4 MO

Drug Name Drug Tier

Requirements/Limits

fenofibrate 2 MO FENOFIBRATE 4 MO fenofibrate micronized 2 MO FENOGLIDE 4 MO FIBRICOR 4 MO fluvastatin sodium 2 MO gemfibrozil 2 MO JUXTAPID 5 LD KYNAMRO 5 LD LESCOL 4 MO LESCOL XL 4 MO LIPITOR 4 MO LIPOFEN 4 MO LIPTRUZET 4 MO LIVALO 4 MO LOPID 4 MO lovastatin 1 MO LOVAZA 4 MO niacin (antihyperlipidemic) 2 MO

NIASPAN 4 MO omega-3-acid ethyl esters 2 MO

PRALUENT 5 PRAVACHOL 4 MO pravastatin sodium 2 MO SIMCOR 4 MO simvastatin 1 MO TRICOR 4 MO TRIGLIDE 4 MO TRILIPIX 4 MO VASCEPA 4 MO VYTORIN 4 MO WELCHOL 4 MO ZETIA 4 MO ZOCOR 4 MO CALCIUM-CHANNEL BLOCKING AGENTS ADALAT CC 4 MO amlodipine besylate 1 MO amlodipine besylate-atorvastatin calcium 2 MO


Drug Name Drug Tier

Requirements/Limits

amlodipine besylate-benazepril hcl 2 MO

amlodipine besylate-valsartan 2 MO

amlodipine-valsartan-hydrochlorothiazide 2 MO

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

diltiazem hcl extended release beads 2 MO

EXFORGE 4 MO EXFORGE HCT 4 MO felodipine 2 MO isradipine 2 MO LOTREL 4 MO nicardipine hcl 2 HI,MO nifedipine 2 MO nimodipine 2 MO nisoldipine 2 MO NORVASC 4 MO PROCARDIA 4 MO PROCARDIA XL 4 MO SULAR 4 MO TARKA 4 MO telmisartan-amlodipine 2 MO TIAZAC 4 MO trandolapril-verapamil hcl 2 MO

TRIBENZOR 4 MO TWYNSTA 4 MO verapamil hcl 2 HI,MO VERELAN 4 MO VERELAN PM 4 MO

Drug Name Drug Tier

Requirements/Limits

CARDIAC DRUGS amiodarone hcl 2 HI,MO CORLANOR 4 MO digoxin 2 MO DIGOXIN SOLN 0.05 MG/ML 3 MO

disopyramide phosphate 2 MO flecainide acetate 2 MO LANOXIN PEDIATRIC SOLN 0.1 MG/ML 3

LANOXIN SOLN 0.25 MG/ML 4

LANOXIN TABS 125 MCG 4 MO

LANOXIN TABS 187.5 MCG 4 MO

LANOXIN TABS 250 MCG 4 MO

LANOXIN TABS 62.5 MCG 4 MO

mexiletine hcl 2 MO MULTAQ 4 MO NEXTERONE 4 HI NORPACE CAPS 100 MG 4 MO

NORPACE CAPS 150 MG 4 MO

NORPACE CR CP12 100 MG 3 MO

NORPACE CR CP12 150 MG 3 MO

procainamide hcl 2 propafenone hcl 2 MO quinidine gluconate 2 MO QUINIDINE GLUCONATE 3 MO

quinidine sulfate 2 MO RANEXA 4 MO RYTHMOL 4 MO RYTHMOL SR 4 MO TIKOSYN 3 MO HYPOTENSIVE AGENTS CATAPRES 4 MO



Drug Name Drug Tier

Requirements/Limits

CATAPRES-TTS-1 4 MO CATAPRES-TTS-2 4 MO CATAPRES-TTS-3 4 MO clonidine & chlorthalidone 2 MO

clonidine hcl 2 MO clonidine hcl (adhd) 2 MO guanfacine hcl 2 MO hydralazine hcl soln 20mg/ml 2

hydralazine hcl tabs 10 mg 1 MO




KAPVAY 4 MO mecamylamine hcl 2 MO methyldopa 2 MO methyldopa & hydrochlorothiazide 2 MO

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

benazepril hcl 1 MO

Drug Name Drug Tier

Requirements/Limits

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

captopril 1 MO captopril & hydrochlorothiazide 2 MO

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

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

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

lisinopril & hydrochlorothiazide 1 MO

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

LOTENSIN 4 MO MAVIK 4 MO MICARDIS 4 MO MICARDIS HCT 4 MO


Drug Name Drug Tier

Requirements/Limits

moexipril hcl 2 MO moexipril-hydrochlorothiazide 2 MO

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

ramipril 2 MO spironolactone & hydrochlorothiazide 2 MO

spironolactone tabs 100 mg 2 MO



TEKAMLO 4 MO TEKTURNA 4 MO TEKTURNA HCT 4 MO telmisartan 2 MO telmisartan-hydrochlorothiazide 2 MO

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

VASERETIC 4 MO VASOTEC 4 MO ZESTORETIC 4 MO ZESTRIL 4 MO VASODILATING AGENTS ADCIRCA 5 PA BIDIL 4 MO CIALIS 4 PA,MO dipyridamole 2 MO

ISORDIL TITRADOSE 4 MO isosorbide dinitrate 2 MO isosorbide mononitrate er tb24 120 mg 2 MO

Drug Name Drug Tier

Requirements/Limits

isosorbide mononitrate er tb24 30 mg 1 MO

isosorbide mononitrate er tb24 60 mg 1 MO

isosorbide mononitrate tabs 10 mg 2 MO

isosorbide mononitrate tabs 20 mg 2 MO

NITRO-DUR PT24 0.1 MG/HR 4 MO






nitroglycerin 2 HI,MO NITROLINGUAL SOLN 0.4 MG/SPRAY 4 MO

NITROMIST AERS 400 MCG/SPRAY 4 MO

NITROSTAT SUBL 0.3 MG 3 MO



PERSANTINE 4 MO REVATIO SOLN 10 MG/12.5ML 5

REVATIO SUSR 10 MG/ML 4 PA

REVATIO TABS 20 MG 5 PA sildenafil citrate (pulmonary hypertension)

2 PA,MO

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



Drug Name Drug Tier

Requirements/Limits

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

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

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

metoprolol tartrate tabs 100 mg 1 MO



nadolol & bendroflumethiazide 2 MO

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

propranolol hcl er cp24 120 mg 2 MO



Drug Name Drug Tier

Requirements/Limits


propranolol hcl soln 1 mg/ml 2 HI

propranolol hcl soln 20 mg/5ml 2 MO

propranolol hcl soln 40 mg/5ml 2 MO

propranolol hcl tabs 10 mg 1 MO





SECTRAL 4 MO sotalol hcl 2 MO sotalol hcl (afib/afl) 2 MO TENORETIC 100 4 MO TENORETIC 50 4 MO TENORMIN 4 MO timolol maleate 2 MO TOPROL XL 4 MO ZEBETA 4 MO ZIAC 4 MO CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS ABSTRAL 4 PA acetaminophen w/ codeine 2

acetaminophen-caff-dihydrocod 2

ACTIQ 4 PA ANAPROX 4 ANAPROX DS 4 ARTHROTEC 4 AVINZA 4 BUPRENEX 4 buprenorphine hcl 2


Drug Name Drug Tier

Requirements/Limits

butalbital-acetaminophen 2

butalbital-acetaminophen-caffeine 2

butalbital-acetaminophen-caffeine w/ codeine

2

butalbital-aspirin-caffeine 2 butalbital-aspirin-caffeine w/cod 2

butorphanol tartrate 2 BUTRANS 4 CAMBIA 4 CELEBREX 4 celecoxib 2 CODEINE SULFATE 3 CONZIP 4 DAYPRO 4 DEMEROL 4 diclofenac potassium 2 diclofenac sodium 2 diclofenac w/ misoprostol 2

diflunisal 2 DILAUDID 4 DILAUDID-HP 4 DOLOPHINE TABS 10 MG 4

DOLOPHINE TABS 5 MG 4

DUEXIS 4 DURAGESIC-100 4 DURAGESIC-12 4 DURAGESIC-25 4 DURAGESIC-50 4 DURAGESIC-75 4 EC-NAPROSYN 4 EMBEDA 4 etodolac 2 EXALGO 4 FELDENE 4 fenoprofen calcium 2 fentanyl 2 PA

Drug Name Drug Tier

Requirements/Limits

fentanyl citrate 2 PA FENTORA 4 PA FIORINAL 4 FIORINAL/CODEINE #3 4 flurbiprofen 2 GRALISE 4 GRALISE STARTER 4 hydrocodone-acetaminophen 2

hydrocodone-ibuprofen 2 hydromorphone hcl 2 HYSINGLA ER 4 PA ibuprofen 2 ILARIS 5 INDOCIN 4 indomethacin 2 KADIAN CP24 10 MG 4 KADIAN CP24 100 MG 4 KADIAN CP24 20 MG 4 KADIAN CP24 200 MG 4 KADIAN CP24 30 MG 4 KADIAN CP24 40 MG 4 KADIAN CP24 50 MG 4 KADIAN CP24 60 MG 4 KADIAN CP24 80 MG 4 ketoprofen 2 ketorolac tromethamine 2 LAZANDA 4 PA levorphanol tartrate 2 meclofenamate sodium 2 mefenamic acid 2 meloxicam 2 meperidine hcl 2 methadone hcl 2 METHADONE HCL SOLN 10 MG/ML 3

MOBIC 4 morphine sulfate 2 MORPHINE SULFATE (PF) SOLN 10 MG/ML 4

MORPHINE SULFATE (PF) SOLN 2 MG/ML 4



Drug Name Drug Tier

Requirements/Limits



morphine sulfate beads 2 MORPHINE SULFATE TABS 15 MG 3

MORPHINE SULFATE TABS 30 MG 3

MS CONTIN TBCR 100 MG 4



MS CONTIN TTBCR 30 MG 4


nabumetone 2 nalbuphine hcl 2 NAPRELAN 4 NAPROSYN 4 naproxen 2 naproxen sodium 2 NUCYNTA 4 NUCYNTA ER 4 OPANA 4 OPANA ER 4 oxaprozin 2 oxycodone hcl 2 oxycodone w/ acetaminophen 2

oxycodone-aspirin 2 oxycodone-ibuprofen 2 OXYCONTIN 4 oxymorphone hcl 2 pentazocine w/ naloxone 2 PERCODAN 4 piroxicam 2 PONSTEL 4 ROXICODONE 4 SPRIX 4

Drug Name Drug Tier

Requirements/Limits

SUBSYS 4 PA sulindac 2 SYNALGOS-DC 4 TALWIN 4 TIVORBEX 4 tolmetin sodium 2 tramadol hcl 2 tramadol-acetaminophen 2 ULTRACET 4 ULTRAM 4 ULTRAM ER 4 VICOPROFEN 4 VIMOVO 4 VOLTAREN-XR 4 XARTEMIS XR 4 ZIPSOR 4 ZOHYDRO ER 4 PA ZORVOLEX 4 ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS ADDERALL XR 3 amphetamine sulfate 2 amphetamine-dextroamphetamine 2

APTENSIO XR 4 CONCERTA 4 DAYTRANA 4 DESOXYN 4 DEXEDRINE 4 dexmethylphenidate hcl 2 dextroamphetamine sulfate 2

fentanyl 2 PA FOCALIN 4 FOCALIN XR 4 METADATE CD 4 methamphetamine hcl 2 METHYLIN 4 methylphenidate hcl 2 modafinil 2 PA NUVIGIL 4 PA PROVIGIL 4 PA


Drug Name Drug Tier

Requirements/Limits

QUILLIVANT XR 4 RITALIN 4 RITALIN LA 4 VYVANSE 4 ANTICONVULSANTS APTIOM 4 MO BANZEL 3 MO carbamazepine 2 MO CARBATROL CP12 100 MG 4 MO

CARBATROL CP12 200 MG 4 MO

CARBATROL CP12 300 MG 4 MO

CELONTIN 3 MO CEREBYX 4 clonazepam 2 DEPACON 4 HI DEPAKENE 4 MO DEPAKOTE 4 MO DEPAKOTE ER 4 MO DEPAKOTE SPRINKLES 4 MO

DILANTIN 4 MO divalproex sodium 2 MO EQUETRO 4 MO ethosuximide 2 MO felbamate 2 MO FELBATOL 5 fosphenytoin sodium 2 FYCOMPA 4 MO gabapentin 2 MO GABITRIL 4 MO HORIZANT 4 MO KEPPRA 4 MO KEPPRA XR 4 MO

KLONOPIN 4

LAMICTAL CHEW 25 MG 4 MO

LAMICTAL CHEW 5 MG 4 MO

Drug Name Drug Tier

Requirements/Limits

LAMICTAL ODT TBDP 100 MG 4 MO




LAMICTAL STARTER KIT 25 (35) MG 3 MO

LAMICTAL STARTER KIT 25 (42)-100 (7) MG 3 MO

LAMICTAL STARTER KIT 25 (84)-100 (14) MG 3 MO

LAMICTAL TABS 100 MG 4 MO



LAMICTAL TABS 25 MG 4 MO LAMICTAL XR KIT 25 & 50 & 100 MG 4 MO

LAMICTAL XR KIT 25 (21)-50 (7) MG 4 MO

LAMICTAL XR KIT 50 & 100 & 200 MG 4 MO

LAMICTAL XR TB24 100 MG 4 MO






lamotrigine 2 MO levetiracetam 2 HI,MO LEVETIRACETAM IN NACL 3

LYRICA 4



Drug Name Drug Tier

Requirements/Limits

magnesium sulfate 2 HI MAGNESIUM SULFATE 3 HI MYSOLINE 4 MO NEURONTIN 4 MO ONFI 4 oxcarbazepine 2 MO OXTELLAR XR 4 MO PEGANONE 4 MO phenytoin 2 MO phenytoin sodium 2 phenytoin sodium extended 2 MO

POTIGA 4 MO primidone 2 MO QUDEXY XR 4 MO SABRIL 5 LD TEGRETOL SUSP 100 MG/5ML 4 MO

TEGRETOL TABS 200 MG 4 MO

TEGRETOL-XR TB12 100 MG 3 MO



tiagabine hcl 2 MO TOPAMAX 4 MO TOPAMAX SPRINKLE 4 MO topiramate 2 MO TRILEPTAL 4 MO TROKENDI XR 4 MO valproate sodium 2 HI,MO valproic acid 2 MO VIMPAT 4 HI ZARONTIN 4 MO ZONEGRAN 4 MO zonisamide 2 MO ANTIMIGRAINE AGENTS ALSUMA 4 AMERGE 4 AXERT 4

Drug Name Drug Tier

Requirements/Limits

ergotamine w/ caffeine 2 FROVA 4 IMITREX 4 IMITREX STATDOSE REFILL 4

MAXALT 4 MAXALT-MLT 4 naratriptan hcl 2 RELPAX 4 rizatriptan benzoate 2 SUMATRIPTAN 4 sumatriptan succinate 2 SUMAVEL DOSEPRO 4 TREXIMET 4 zolmitriptan 2 ZOMIG 4 ZOMIG ZMT 4 ANTIPARKINSONIAN AGENTS amantadine hcl 2 MO APOKYN 5 AZILECT 3 MO benztropine mesylate 2 MO bromocriptine mesylate 2 MO cabergoline 2 MO carbidopa 2 MO carbidopa-levodopa 2 LD,MO carbidopa-levodopa-entacapone 2 MO

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

REQUIP 4 MO REQUIP XL 4 MO


Drug Name Drug Tier

Requirements/Limits

ropinirole hydrochloride 2 MO RYTARY 4 MO selegiline hcl 2 MO SINEMET 4 MO SINEMET CR 4 MO STALEVO 100 4 MO STALEVO 125 4 MO STALEVO 150 4 MO STALEVO 200 4 MO STALEVO 50 4 MO STALEVO 75 4 MO TASMAR 4 MO tolcapone 2 MO trihexyphenidyl hcl 2 MO ZELAPAR 4 MO ANXIOLYTICS, SEDATIVES, AND HYPNOTICS alprazolam 2 AMBIEN 4 AMBIEN CR 4 ATIVAN 4 BELSOMRA 4 buspirone hcl 2 BUTISOL SODIUM 4 chlordiazepoxide hcl 2 clorazepate dipotassium 2 DIASTAT ACUDIAL 3 DIASTAT PEDIATRIC 3 diazepam 2 diazepam (anticonvulsant) 2

EDLUAR 4 estazolam 2 eszopiclone 2 flurazepam hcl 2 HALCION 4 HETLIOZ 5 hydroxyzine hcl 2 hydroxyzine pamoate 2 INTERMEZZO 4 lorazepam 2 LUNESTA 4 meprobamate 2

Drug Name Drug Tier

Requirements/Limits

oxazepam 2 phenobarbital 2 PHENOBARBITAL 4 RESTORIL 4 ROZEREM 4 secobarbital sodium 2 SILENOR 4 SONATA 4 temazepam 2 TRANXENE-T 4 triazolam 2 VALIUM 4 VISTARIL 4 XANAX 4 XANAX XR 4 zaleplon 2 zolpidem tartrate 2 ZOLPIMIST 4 CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS acamprosate calcium 2 MO guanfacine hcl (adhd) 2 MO INTUNIV 4 MO NAMENDA SOLN 10 MG/5ML 3 MO

NAMENDA TABS 10 MG 4 MO

NAMENDA TABS 5 MG 4 MO NAMENDA TITRATION PAK TABS 5 (28)-10 (21) MG

4 MO

NAMENDA XR CP24 14 MG 4 MO




NAMENDA XR TITRATION PACK CP24 7 & 14 & 21 & 28 MG

4 MO

NUEDEXTA 3 MO



Drug Name Drug Tier

Requirements/Limits

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

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

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

ABILIFY DISCMELT TBDP 15 MG 3 MO

ABILIFY MAINTENA SUSR 300 MG 4

ABILIFY MAINTENA SUSR 400 MG 4

ABILIFY SOLN 1 MG/ML 4 MO ABILIFY SOLN 9.75 MG/1.3 ML 3

ABILIFY TABS 10 MG 4 MO ABILIFY TABS 15 MG 4 MO ABILIFY TABS 2 MG 4 MO ABILIFY TABS 20 MG 4 MO ABILIFY TABS 30 MG 4 MO ABILIFY TABS 5 MG 4 MO amitriptyline hcl 2 MO amoxapine 2 MO ANAFRANIL 4 MO APLENZIN 4 MO aripiprazole 2 MO BRINTELLIX 4 MO

Drug Name Drug Tier

Requirements/Limits

BRISDELLE 4 MO bupropion hcl 2 MO bupropion hcl (smoking deterrent) 2 MO

CELEXA 4 MO chlordiazepoxide-amitriptyline 2

chlorpromazine hcl 2 MO citalopram hydrobromide soln 10 mg/5ml 2 MO

citalopram hydrobromide tabs 10 mg 2 MO



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

FAZACLO 4 FETZIMA 4 MO FETZIMA TITRATION 4 MO FLUOXETINE HCL 4 MO fluoxetine hcl caps 10 mg 1 MO

fluoxetine hcl caps 20 mg 1 MO

fluoxetine hcl caps 40 mg 1 MO

fluoxetine hcl cpdr 90 mg 2 MO fluoxetine hcl soln 20 mg/5ml 2 MO


Drug Name Drug Tier

Requirements/Limits

fluoxetine hcl tabs 10 mg 2 MO fluoxetine hcl tabs 20 mg 2 MO fluphenazine decanoate 2 fluphenazine hcl 2 MO fluvoxamine maleate 2 MO FORFIVO XL 4 MO GEODON 3 MO GEODON 4 MO HALDOL 4 HALDOL DECANOATE 4 haloperidol 2 MO haloperidol decanoate 2 haloperidol lactate 2 MO imipramine hcl 2 MO imipramine pamoate 2 MO INVEGA 4 MO INVEGA SUSTENNA 4 KHEDEZLA 4 MO LATUDA 5 LEXAPRO 4 MO LITHIUM 3 MO lithium carbonate 2 MO LITHIUM CARBONATE CAPS 600 MG 3 MO

LITHOBID TBCR 300 MG 4 MO

loxapine succinate 2 MO maprotiline hcl 2 MO MARPLAN 4 MO methylphenidate hcl 2 mirtazapine 2 MO NARDIL 4 MO nefazodone hcl 2 MO NORPRAMIN 4 MO nortriptyline hcl caps 10 mg 1 MO

nortriptyline hcl caps 25 mg 1 MO



Drug Name Drug Tier

Requirements/Limits

nortriptyline hcl soln 10 mg/5ml 2 MO

olanzapine 2 MO olanzapine-fluoxetine hcl 2 MO ORAP 3 MO PAMELOR 4 MO PARNATE 4 MO paroxetine hcl er tb24 12.5 mg 2 MO

paroxetine hcl er tb24 25 mg 2 MO

paroxetine hcl er tb24 37.5 mg 2 MO

paroxetine hcl tabs 10 mg 1 MO




PAXIL 4 MO PAXIL CR 4 MO perphenazine 2 MO perphenazine-amitriptyline 2 MO

PEXEVA 4 MO phenelzine sulfate 2 MO PRISTIQ 4 MO prochlorperazine 2 MO prochlorperazine edisylate 2

prochlorperazine maleate 2

protriptyline hcl 2 MO PROZAC 4 MO PROZAC WEEKLY 4 MO quetiapine fumarate 2 MO REMERON 4 MO REMERON SOLTAB 4 MO RISPERDAL 4 MO RISPERDAL CONSTA 4 RISPERDAL M-TAB 4 MO



Drug Name Drug Tier

Requirements/Limits

risperidone 2 MO SAPHRIS 4 MO SARAFEM 4 MO SEROQUEL 4 MO SEROQUEL XR 4 MO sertraline hcl 2 MO SURMONTIL 4 MO SYMBYAX 4 MO thioridazine hcl 2 MO thiothixene 2 MO TOFRANIL-PM 4 MO tranylcypromine sulfate 2 MO trazodone hcl tabs 100 mg 1 MO

trazodone hcl tabs 150 mg 1 MO



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

Drug Name Drug Tier

Requirements/Limits

ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS ammonium chloride 2 HI potassium citrate (alkalinizer) 2 MO

SODIUM LACTATE SOLN 167 MEQ/L 3 HI

SODIUM LACTATE SOLN 5 MEQ/ML 4 HI

UROCIT-K 10 4 MO UROCIT-K 15 4 MO UROCIT-K 5 4 MO AMMONIA DETOXICANTS BUPHENYL 5 CARBAGLU 4 LD lactulose 2 MO lactulose (encephalopathy) 2 MO

LITHOSTAT 4 MO RAVICTI 5 sodium phenylbutyrate 2 MO CALORIC AGENTS amino acid electrolyte infusion 2 HI

amino acid infusion 2 HI AMINOSYN II SOLN 10 % 4 HI

AMINOSYN II SOLN 15 % 4 HI

AMINOSYN II SOLN 7 % 4 HI

AMINOSYN II SOLN 8.5 % 4 HI

AMINOSYN M SOLN 3.5 % 4 HI

AMINOSYN HBC SOLN 7 % 4 HI

AMINOSYN-PF SOLN 10 % 4 HI

AMINOSYN-PF SOLN 7 % 4 HI

AMINOSYN-RF SOLN 5.2 % 4 HI


Drug Name Drug Tier

Requirements/Limits

AMINOSYN/ELECTROLYTES SOLN 7 % 4 HI

CLINIMIX E/DEXTROSE (2.75/10) 3 HI





CLINIMIX E/DEXTROSE (5/15) 3 HI



CLINIMIX/DEXTROSE (2.75/5) 3 HI





CLINIMIX/DEXTROSE (5/15) 3 HI



dextrose 2 HI fat emulsion 2 HI FREAMINE HBC SOLN 6.9 % 4 HI

FREAMINE III SOLN 3 % 3 HI

INTRALIPID EMUL 30 % 4 HI LIPOSYN III EMUL 10 % 3 HI

Drug Name Drug Tier

Requirements/Limits

NEPHRAMINE SOLN 5.4 % 4 HI

PROCALAMINE SOLN 3 % 3 HI

PROSOL SOLN 20 % 3 HI TRAVASOL SOLN 10 % 4 HI TROPHAMINE SOLN 10 % 3 HI

TROPHAMINE SOLN 6 % 3 HI

DIURETICS amiloride & hydrochlorothiazide 1 MO

amiloride hcl 2 MO bumetanide soln 0.25 mg/ml 2

bumetanide tabs 0.5 mg 1 MO bumetanide tabs 1 mg 1 MO bumetanide tabs 2 mg 2 MO chlorothiazide 2 MO chlorothiazide sodium 2 HI chlorthalidone 2 MO DEMADEX 4 MO DIURIL 3 MO DYAZIDE 4 MO DYRENIUM 3 MO EDECRIN 3 MO furosemide soln 10 mg/ml 2 HI,MO

furosemide soln 8 mg/ml 2 MO furosemide tabs 20 mg 1 MO furosemide tabs 40 mg 1 MO furosemide tabs 80 mg 1 MO hydrochlorothiazide caps 12.5 mg 1 MO

hydrochlorothiazide tabs 12.5 mg 2 MO

hydrochlorothiazide tabs 25 mg 1 MO

hydrochlorothiazide tabs 50 mg 1 MO

indapamide 1 MO LASIX 4 MO



Drug Name Drug Tier

Requirements/Limits

MAXZIDE 4 MO MAXZIDE-25 4 MO methyclothiazide 2 MO metolazone 2 MO MICROZIDE 4 MO SAMSCA 4 MO SODIUM DIURIL 4 HI SODIUM EDECRIN 3 HI torsemide 2 HI triamterene-hctz caps 37.5-25 mg 2 MO

triamterene-hctz caps 50-25 mg 2 MO

triamterene-hctz tabs 37.5-25 mg 1 MO

triamterene-hctz tabs 75-50 mg 1 MO

ION-REMOVING AGENTS AURYXIA 4 MO FOSRENOL 5 KAYEXALATE 4 MO RENAGEL 3 MO RENVELA 3 MO sodium polystyrene sulfonate 2 MO

VELPHORO 4 MO IRRIGATING SOLUTIONS irrigation solutions, physiological 2 MO

lactated ringer's (irrigation) 2 MO

ringer's irrigation 2 MO sodium chloride (gu irrigant) 2 MO

water for irrigation, sterile 2 MO

REPLACEMENT PREPARATIONS calcium acetate (phosphate binder) 2 MO

DEXTROSE 5%/ELECTROLYTE #48 3 HI

dextrose in lactated ringers 2 HI

Drug Name Drug Tier

Requirements/Limits

dextrose w/ sodium chloride 2 HI

DEXTROSE-NACL SOLN 10-0.2 % 3 HI



electrolyte-m in dextrose 2 HI IONOSOL-B IN D5W 4 HI IONOSOL-MB IN D5W 4 HI ISOLYTE-P IN D5W 4 HI ISOLYTE-S 4 HI K-TAB TBCR 10 MEQ 3 MO K-TAB TBCR 20 MEQ 4 MO K-TAB TBCR 8 MEQ 4 MO KCL IN DEXTROSE-NACL SOLN 20-5-0.225 MEQ/L-%-%

4 HI

KCL IN DEXTROSE-NACL SOLN 40-5-0.9 MEQ/L-%-%

3 HI

KCL-LACTATED RINGERS-D5W 3 HI

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

NORMOSOL-R IN D5W 4 HI NORMOSOL-R PH 7.4 4 HI parenteral electrolytes 2 HI PHOSLO CAPS 667 MG 4 MO PHOSLYRA SOLN 667 MG/5ML 3 MO

PLASMA-LYTE 148 3 HI PLASMA-LYTE A 3 HI PLASMA-LYTE-56 IN D5W 3 HI

potassium chloride 2 HI,MO potassium chloride in dextrose 2 HI

potassium chloride in dextrose & sodium chloride

2 HI


Drug Name Drug Tier

Requirements/Limits

potassium chloride in nacl 2 HI

POTASSIUM CHLORIDE IN NACL SOLN 20-0.45 MEQ/L-%

4 HI


4 HI


4 HI

potassium chloride microencapsulated crystals cr

2 MO

POTASSIUM CHLORIDE SOLN 10 MEQ/100ML

4 HI


4 HI


4 HI

ringer's inj 2 HI sodium chloride 2 HI,MO ZINC TRACE METAL 3 HI URICOSURIC AGENTS colchicine w/ probenecid 2 MO probenecid 2 MO ENZYMES ENZYMES ADAGEN 3 LD ALDURAZYME 3 HI CEREZYME 5 HI ELAPRASE 5 ELELYSO 5 ELITEK 3 HI FABRAZYME 5 HI LUMIZYME 5 LD MYOZYME 5 NAGLAZYME 5 PULMOZYME 5 PA SUCRAID 4 LD VIMIZIM 5 HI

Drug Name Drug Tier

Requirements/Limits

VPRIV 5 EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES AZASITE 4 bacitracin (ophthalmic) 2 bacitracin-polymyxin b (ophth) 2

BESIVANCE 4 BLEPH-10 4 chlorhexidine gluconate (mouth-throat) 2

CILOXAN OINT 0.3 % 3 CILOXAN SOLN 0.3 % 4 ciprofloxacin hcl (ophth) 2 erythromycin (ophth) 2 gatifloxacin (ophth) 2 gentamicin sulfate (ophth) 2

levofloxacin (ophth) 2 MOXEZA 4 NATACYN 3 neomycin-bacitracin zn-polymyxin 2

neomycin-polymyxin-gramicidin 2

OCUFLOX 4 ofloxacin (ophth) 2 ofloxacin (otic) 2 polymyxin b-trimethoprim 2

POLYTRIM 4 sulfacetamide sodium (ophth) 2

tobramycin (ophth) 2 TOBREX OINT 0.3 % 3 TOBREX SOLN 0.3 % 4 trifluridine 2 VIGAMOX 4 VIROPTIC 4 ZIRGAN 4 ZYMAXID 3



Drug Name Drug Tier

Requirements/Limits

ANTI-INFLAMMATORY AGENTS ACULAR 4 MO ACULAR LS 4 MO ACUVAIL 4 MO ALREX 4 MO bacitracin-poly-neomycin-hc 2 MO

BECONASE AQ 4 MO BLEPHAMIDE 3 MO bromfenac sodium (ophth) 2 MO

budesonide (nasal) 2 MO CIPRO HC 4 MO CIPRODEX 3 MO COLY-MYCIN S 3 MO CORTISPORIN 4 MO CORTISPORIN-TC 3 MO dexamethasone sodium phosphate (ophth) 2 MO

diclofenac sodium (ophth) 2 MO

DUREZOL 4 MO FLAREX 4 MO flunisolide (nasal) 2 MO fluocinolone acetonide (otic) 2 MO

fluorometholone (ophth) 2 MO flurbiprofen sodium 2 MO fluticasone propionate (nasal) 2 MO

FML FORTE SUSP 0.25 % 3 MO

FML LIQUIFILM SUSP 0.1 % 4 MO

FML OINT 0.1 % 3 MO hydrocortisone w/acetic acid 2 MO

ILEVRO 4 MO ketorolac tromethamine (ophth) 2 MO

LOTEMAX 4 MO MAXIDEX 4 MO

Drug Name Drug Tier

Requirements/Limits

MAXITROL 4 MO NASONEX 4 MO neomycin-polymy-dexameth 2 MO

neomycin-polymyxin-hc (ophth) 2 MO

neomycin-polymyxin-hc (otic) 2 MO

NEVANAC 4 MO OCUFEN 4 MO OMNARIS 4 MO OMNIPRED SUSP 1 % 4 MO PRED FORTE SUSP 1 % 4 MO

PRED MILD SUSP 0.12 % 3 MO

PRED-G 3 MO PRED-G S.O.P. 3 MO prednisolone acetate (ophth) 2 MO

prednisolone sodium phosphate (ophth) 2 MO

PROLENSA 4 MO QNASL 4 MO QNASL CHILDRENS 4 MO RESTASIS 3 MO RHINOCORT AQUA 4 MO sulfacetamide sod-prednisolone 2 MO

TOBRADEX OINT 0.3-0.1 % 3 MO

TOBRADEX ST SUSP 0.3-0.5 % 4 MO

TOBRADEX SUSP 0.3-0.1 % 4 MO

tobramycin-dexamethasone 2 MO

triamcinolone acetonide (nasal) 2 MO

VERAMYST 4 MO VEXOL 3 MO ZETONNA 4 MO


Drug Name Drug Tier

Requirements/Limits

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

ISOPTO CARPINE SOLN 1 % 4 MO


Drug Name Drug Tier

Requirements/Limits


ISTALOL 4 MO latanoprost 2 MO levobunolol hcl 2 MO LUMIGAN 3 MO methazolamide 2 MO metipranolol 2 MO PHOSPHOLINE IODIDE 3 MO pilocarpine hcl 2 MO PILOPINE HS GEL 4 % 3 MO SIMBRINZA 4 MO timolol maleate (ophth) 2 MO TIMOPTIC OCUDOSE 4 MO TIMOPTIC-XE 4 MO TRAVATAN Z 4 MO travoprost 2 MO TRUSOPT 4 MO XALATAN 4 MO ZIOPTAN 4 MO EENT DRUGS, MISCELLANEOUS acetic acid (otic) 2 MO apraclonidine hcl 2 MO atropine sulfate (ophthalmic) 2 MO

CYSTARAN 4 IOPIDINE SOLN 0.5 % 4 MO IOPIDINE SOLN 1 % 3 MO LACRISERT 3 MO LOCAL ANESTHETICS lidocaine hcl (mouth-throat) 2 MO

proparacaine hcl 2 MO VASOCONSTRICTORS naphazoline hcl 2 MO tetrahydrozoline hcl 2 MO GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS alosetron hcl 2 MO APRISO CP24 0.375 GM 4 MO

ASACOL HD TBEC 800 MG 4 MO



Drug Name Drug Tier

Requirements/Limits

balsalazide disodium 2 MO CANASA SUPP 1000 MG 3 MO

COLAZAL 4 MO DELZICOL CPDR 400 MG 4 MO

DIPENTUM 5 GIAZO 4 MO LIALDA TBEC 1.2 GM 3 MO LOTRONEX 4 MO mesalamine w/ cleanser 2 MO PENTASA CPCR 250 MG 3 MO

PENTASA CPCR 500 MG 3 MO

SFROWASA ENEM 4 GM/60ML 4 MO

ANTIDIARRHEA AGENTS diphenoxylate w/ atropine 2

FULYZAQ 4 MO LOMOTIL 4 loperamide hcl 2 MO ANTIEMETICS AKYNZEO 4 PA ALOXI 4 HI ANZEMET 4 PA,HI CESAMET 4 PA dronabinol 2 PA EMEND CAPS 125 MG 3 PA EMEND CAPS 40 MG 4 PA EMEND CAPS 80 & 12 MG 4 PA

EMEND CAPS 80 MG 3 PA granisetron hcl 2 PA,HI MARINOL 4 PA meclizine hcl 2 ondansetron 2 PA ondansetron hcl 2 PA,HI SANCUSO 4 TIGAN 4 PA TRANSDERM-SCOP 3 trimethobenzamide hcl 2 PA

Drug Name Drug Tier

Requirements/Limits

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

CARAFATE SUSP 1 GM/10ML 3 MO

CARAFATE TABS 1 GM 4 MO cimetidine 2 MO cimetidine hcl 2 MO CYTOTEC 4 MO DEXILANT 4 MO esomeprazole magnesium 2 MO

esomeprazole sodium 2 HI ESOMEPRAZOLE STRONTIUM 4 MO

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

pantoprazole sodium 2 HI,MO PEPCID 4 MO PREVACID 4 MO PREVACID SOLUTAB 4 MO PREVPAC 4 MO PRILOSEC 4 MO PROTONIX 4 HI,MO PYLERA 4 MO rabeprazole sodium 2 MO ranitidine hcl 2 HI,MO sucralfate 2 MO


Drug Name Drug Tier

Requirements/Limits

ZANTAC 4 MO ZANTAC IN NACL 3 HI ZEGERID 4 MO CATHARTICS AND LAXATIVES COLYTE WITH FLAVOR PACKS 4 MO

GOLYTELY 4 MO MOVIPREP 4 MO NULYTELY WITH FLAVOR PACKS 4 MO

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

peg 3350-potassium chloride-sod bicarbonate-sod chloride

2 MO

polyethylene glycol 3350 2 MO PREPOPIK 4 MO SUCLEAR 4 MO SUPREP BOWEL PREP 4 MO DIGESTANTS CREON 4 MO PANCREAZE 4 MO PERTZYE 4 MO ULTRESA 4 MO VIOKACE 4 MO ZENPEP 4 MO GASTROINTESTINAL MISCELLANEOUS CHOLBAM 5 GI DRUGS, MISCELLANEOUS ACTIGALL 4 MO AMITIZA 4 MO chenodiol 2 MO ENTYVIO 5 GATTEX 5 LINZESS 3 MO metoclopramide hcl 2 HI,MO METOZOLV ODT 4 MO MOVANTIK 4 MO NUTRESTORE 4 MO REGLAN 4 MO RELISTOR 4

Drug Name Drug Tier

Requirements/Limits

URSO 250 4 MO URSO FORTE 4 MO ursodiol 2 MO GOLD COMPOUNDS GOLD COMPOUNDS RIDAURA 3 MO HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET 3 CUPRIMINE 3 DEPEN TITRATABS 3 EXJADE TBSO 125 MG 3 EXJADE TBSO 250 MG 5 EXJADE TBSO 500 MG 5 FERRIPROX 5 LD JADENU TABS 180 MG 5 JADENU TABS 360 MG 5 JADENU TABS 90 MG 5 SYPRINE 4 HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ARISTOSPAN INTRA-ARTICULAR 3

ARISTOSPAN INTRALESIONAL 3

BREO ELLIPTA 4 MO budesonide 2 PA,MO CELESTONE 3 MO CORTEF 4 MO cortisone acetate 2 MO DEPO-MEDROL SUSP 20 MG/ML 3

DEPO-MEDROL SUSP 40 MG/ML 4

DEPO-MEDROL SUSP 80 MG/ML 4

dexamethasone 2 PA,MO dexamethasone sodium phosphate 2 HI

ENTOCORT EC 5 FLO-PRED 4 MO fludrocortisone acetate 2 MO



Drug Name Drug Tier

Requirements/Limits

hydrocortisone 2 MO hydrocortisone sod succinate 2

KENALOG 3 MEDROL (PAK) TABS 4 MG 4 MO

MEDROL TABS 16 MG 4 MO MEDROL TABS 2 MG 3 MO MEDROL TABS 32 MG 4 MO MEDROL TABS 4 MG 4 MO MEDROL TABS 8 MG 4 MO methylprednisolone 2 MO methylprednisolone acetate 2

methylprednisolone sod succ 2

ORAPRED ODT 4 MO prednisolone 2 MO prednisolone sodium phosphate 2 MO

prednisone 2 PA,MO RAYOS 4 PA,MO SOLU-CORTEF 3 SOLU-MEDROL SOLR 1000 MG 3

SOLU-MEDROL SOLR 125 MG 4

SOLU-MEDROL SOLR 2 GM 3



UCERIS 5 MO ANDROGENS ANADROL-50 4 MO ANDRODERM PT24 2 MG/24HR 3 MO

ANDRODERM PT24 4 MG/24HR 3 MO

ANDROGEL GEL 20.25 MG/1.25GM (1.62%) 4 MO

Drug Name Drug Tier

Requirements/Limits

ANDROGEL GEL 25 MG/2.5GM (1%) 4 MO

ANDROGEL GEL 40.5 MG/2.5GM (1.62%) 4 MO

ANDROGEL GEL 50 MG/5GM (1%) 4 MO

ANDROGEL PUMP GEL 12.5 MG/ACT (1%) 4 MO

ANDROGEL PUMP GEL 20.25 MG/ACT (1.62%) 4 MO

AVEED 4 MO AXIRON SOLN 30 MG/ACT 4 MO

danazol 2 MO FORTESTA GEL 10 MG/ACT (2%) 4 MO

methyltestosterone 2 MO NATESTO GEL 5.5 MG/ACT 4 MO

oxandrolone 2 MO STRIANT MISC 30 MG 4 TESTIM GEL 50 MG/5GM (1%) 4 MO

testosterone 2 MO testosterone cypionate 2 MO testosterone enanthate 2 MO TESTOSTERONE GEL 25 MG/2.5GM (1%) 4 MO

VOGELXO GEL 50 MG/5GM (1%) 4 MO

VOGELXO PUMP GEL 12.5 MG/ACT (1%) 4 MO

CONTRACEPTIVES BEYAZ 4 MO BREVICON (28) 4 MO CYCLESSA 4 MO DESOGEN 4 MO desogestrel & ethinyl estradiol 2 MO

desogestrel-ethinyl estradiol (biphasic) 2 MO

desogestrel-ethinyl estradiol (triphasic) 2 MO


Drug Name Drug Tier

Requirements/Limits

drospirenone-ethinyl estradiol 2 MO

ELLA 3 MO ethynodiol diacet & eth estrad 2 MO

FEMCON FE 4 MO GENERESS FE 4 MO levonorgestrel & eth estradiol 2 MO

levonorgestrel-eth estradiol (triphasic) 2 MO

levonorgestrel-ethinyl estradiol (91-day) 2 MO

levonorgestrel-ethinyl estradiol (continuous) 2 MO

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

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

norethindrone & ethinyl estradiol-fe 2 MO

norethindrone (contraceptive) 2 MO

norethindrone acet & eth estra 2 MO

norethindrone acetate-ethinyl estradiol-fe 2 MO

norethindrone-eth estradiol (biphasic) 2 MO

norethindrone-eth estradiol (triphasic) 2 MO

norgestimate-ethinyl estradiol 2 MO

norgestimate-ethinyl estradiol (triphasic) 2 MO

Drug Name Drug Tier

Requirements/Limits

norgestrel & ethinyl estradiol 2 MO

NORINYL 1+35 (28) 4 MO NORINYL 1+50 (28) 4 MO NUVARING 3 MO ORTHO MICRONOR 4 MO ORTHO TRI-CYCLEN (28) 4 MO

ORTHO TRI-CYCLEN LO 4 MO

ORTHO-CEPT (28) 4 MO ORTHO-CYCLEN (28) 4 MO ORTHO-NOVUM 1/35 (28) 4 MO

ORTHO-NOVUM 7/7/7 (28) 4 MO

PLAN B ONE-STEP 3 QUARTETTE 4 MO SAFYRAL 4 MO SEASONIQUE 4 MO TRI-NORINYL (28) 4 MO YASMIN 28 4 MO YAZ 4 MO DIABETIC AGENTS acarbose 2 MO ACTOPLUS MET 4 MO ACTOPLUS MET XR 4 MO ACTOS 4 MO AFREZZA POWD 4 (30) & 8 (60) UNIT 4 MO

AFREZZA POWD 4 (60) & 8 (30) UNIT 4 MO

AFREZZA POWD 4 UNIT 4 MO

AMARYL 4 MO APIDRA 4 PA,MO APIDRA SOLOSTAR 4 MO AVANDAMET 4 LD,MO AVANDARYL 4 LD,MO AVANDIA 4 LD,MO BYDUREON 4 MO BYETTA 10 MCG PEN 4 MO BYETTA 5 MCG PEN 4 MO



Drug Name Drug Tier

Requirements/Limits

chlorpropamide 2 MO CYCLOSET 4 MO DIABETA 4 MO DUETACT 4 MO FARXIGA 4 MO FORTAMET 4 MO glimepiride 1 MO glipizide er tb24 10 mg 2 MO glipizide er tb24 2.5 mg 2 MO glipizide er tb24 5 mg 2 MO glipizide tabs 10 mg 1 MO glipizide tabs 5 mg 1 MO glipizide-metformin hcl 2 MO GLUCAGEN HYPOKIT 4 GLUCAGON EMERGENCY 3

GLUCOPHAGE 4 MO GLUCOPHAGE XR 4 MO GLUCOTROL 4 MO GLUCOTROL XL 4 MO GLUCOVANCE 4 MO GLUMETZA 4 MO glyburide 2 MO glyburide micronized 2 MO glyburide-metformin 2 MO GLYNASE 4 MO GLYSET 4 MO GLYXAMBI 4 MO HUMALOG KWIKPEN SOPN 100 UNIT/ML 4 MO

HUMALOG KWIKPEN SOPN 200 UNIT/ML 4 MO

HUMALOG MIX 50/50 4 MO HUMALOG MIX 50/50 KWIKPEN 4 MO

HUMALOG MIX 75/25 4 MO HUMALOG MIX 75/25 KWIKPEN 4 MO

HUMALOG SOCT 100 UNIT/ML 4 MO

HUMALOG SOLN 100 UNIT/ML 3 MO

Drug Name Drug Tier

Requirements/Limits

HUMULIN 70/30 KWIKPEN SUPN (70-30) 100 UNIT/ML

4 MO

HUMULIN 70/30 SUSP (70-30) 100 UNIT/ML 3 MO

HUMULIN N KWIKPEN SUPN 100 UNIT/ML 4 MO

HUMULIN N SUSP 100 UNIT/ML 3 MO

HUMULIN R SOLN 100 UNIT/ML 3 PA,MO

HUMULIN R U-500 (CONCENTRATED) SOLN 500 UNIT/ML

3 MO

INVOKAMET 4 MO INVOKANA 4 MO JANUMET 4 MO JANUMET XR 4 MO JANUVIA 4 MO JARDIANCE 4 MO JENTADUETO 4 MO KAZANO 4 MO KOMBIGLYZE XR 4 MO KORLYM 5 LD LANTUS SOLN 100 UNIT/ML 3 MO

LANTUS SOLOSTAR SOPN 100 UNIT/ML 4 MO

LEVEMIR 4 MO LEVEMIR FLEXTOUCH 4 MO metformin hcl er (osm) tb24 1000 mg 2 MO

metformin hcl er tb24 500 mg 1 MO

metformin hcl er tb24 750 mg 2 MO

metformin hcl tabs 1000 mg 1 MO



nateglinide 2 MO NESINA 4 MO


Drug Name Drug Tier

Requirements/Limits

NOVOLIN 70/30 SUSP (70-30) 100 UNIT/ML 3 MO

NOVOLIN N SUSP 100 UNIT/ML 3 MO

NOVOLIN R SOLN 100 UNIT/ML 3 PA,MO

NOVOLOG 4 PA,MO NOVOLOG FLEXPEN 4 MO NOVOLOG MIX 70/30 4 MO NOVOLOG MIX 70/30 FLEXPEN 4 MO

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

pioglitazone hcl-metformin hcl 2 MO

PRANDIMET 4 MO PRANDIN 4 MO PRECOSE 4 MO repaglinide 2 MO RIOMET 4 STARLIX 4 MO SYMLINPEN 120 4 MO SYMLINPEN 60 4 MO TANZEUM 4 MO tolazamide 2 MO tolbutamide 2 MO TOUJEO SOLOSTAR SOPN 300 UNIT/ML 4 MO

TRADJENTA 4 MO TRULICITY 4 MO VICTOZA 4 MO XIGDUO XR 4 MO ESTROGENS AND ANTIESTROGENS ACTIVELLA 4 MO ALORA PTTW 0.025 MG/24HR 4 MO

ALORA PTTW 0.05 MG/24HR 4 MO

Drug Name Drug Tier

Requirements/Limits



ANGELIQ 4 MO CLIMARA PRO 4 MO CLIMARA PTWK 0.025 MG/24HR 3 MO

CLIMARA PTWK 0.0375 MG/24HR 3 MO





COMBIPATCH 4 MO DELESTROGEN 4 DIVIGEL GEL 0.5 MG/0.5GM 4 MO

DUAVEE 4 MO ELESTRIN GEL 0.52 MG/0.87GM (0.06%) 4 MO

ENJUVIA 4 MO esterified estrogens 2 MO estradiol 2 MO estradiol & norethindrone acetate 2 MO

estradiol cypionate 2 estradiol vaginal 2 MO estradiol valerate 2 estradiol-norgestimate 2 MO ESTRING 3 MO estropipate 2 MO EVAMIST SOLN 1.53 MG/SPRAY 4 MO

EVISTA 4 MO FEMHRT LOW DOSE 4 MO FEMRING 4 MO MENOSTAR PTWK 14 MCG/24HR 4 MO



Drug Name Drug Tier

Requirements/Limits

MINIVELLE PTTW 0.025 MG/24HR 4 MO





norethindrone acetate-ethinyl estradiol 2 MO

PREMARIN 3 MO PREMARIN SOLR 25 MG 3

PREMARIN TABS 0.3 MG 4 MO


PREMARIN TABS 0.625 4 MO PREMARIN TABS 0.9 MG 4 MO


PREMPHASE 4 MO PREMPRO 4 MO raloxifene hcl 2 MO VAGIFEM 3 MO VIVELLE-DOT PTTW 0.025 MG/24HR 4 MO

VIVELLE-DOT PTTW 0.0375 MG/24HR 4 MO




GONADOTROPINS chorionic gonadotropin 2 SYNAREL 3 MO PARATHYROID calcitonin (salmon) 2 MO FORTEO 5 PA

Drug Name Drug Tier

Requirements/Limits

FORTICAL 3 MO MIACALCIN 3 MO NATPARA 5 LD PITUITARY DDAVP 4 MO DDAVP RHINAL TUBE 4 MO DDAVP SOLN 4 MG MCG/ML 4 MO

DDAVP TABS 0.1 MG 4 MO DDAVP TABS 0.2 MG 4 MO desmopressin acetate 2 MO desmopressin acetate refrigerated 2 MO

desmopressin acetate spray refrigerated 2 MO

HP ACTHAR 5 STIMATE SOLN 1.5 MG/ML 3 MO

PROGESTINS CRINONE 4 MO DEPO-PROVERA 3 DEPO-PROVERA SUSP 150 MG/ML 4

DEPO-SUBQ PROVERA 104 SUSP 104 MG/0.65ML

3

medroxyprogesterone acetate 2 MO

medroxyprogesterone acetate (contraceptive) 2

MEGACE ES 4 MO norethindrone acetate 2 MO progesterone micronized 2 MO PROMETRIUM 4 MO PROVERA 4 MO SOMATOTROPIN AGONISTS AND ANTAGONISTS EGRIFTA 5 GENOTROPIN MINIQUICK SOLR 0.2 MG

4 PA

GENOTROPIN MINIQUICK SOLR 0.4 MG

4 PA


Drug Name Drug Tier

Requirements/Limits


4 PA


4 PA

GENOTROPIN MINIQUICK SOLR 1 MG 4 PA


4 PA


4 PA


4 PA


4 PA

GENOTROPIN MINIQUICK SOLR 2 MG 4 PA

GENOTROPIN SOLR 12 MG 4 PA

GENOTROPIN SOLR 5 MG 5 PA

HUMATROPE SOLR 12 MG 5 PA




INCRELEX 5 NORDITROPIN FLEXPRO SOLN 10 MG/1.5 ML

5 PA

NORDITROPIN FLEXPRO SOLN 15 MG/1.5ML

5 PA

NORDITROPIN FLEXPRO SOLN 5 MG/1.5ML

5 PA

Drug Name Drug Tier

Requirements/Limits

NORDITROPIN NORDIFLEX PEN SOLN 30 MG/3ML

5 PA

NUTROPIN AQ NUSPIN 5 SOLN 5 MG/2ML 5 PA

NUTROPIN AQ PEN SOLN 10 MG/2ML 5 PA

NUTROPIN AQ PEN SOLN 20 MG/2ML 5 PA

NUTROPIN AQ SOLN 10 MG/2ML 5 PA

NUTROPIN SOLR 10 MG 5 PA

OMNITROPE SOLN 10 MG/1.5ML 3 PA

OMNITROPE SOLN 5 MG/1.5ML 3 PA

OMNITROPE SOLR 5.8 MG 3 PA

SAIZEN 5 PA SAIZEN CLICK.EASY 5 PA SEROSTIM 5 PA SIGNIFOR 5 SIGNIFOR LAR 5 SOMAVERT 5 LD TEV-TROPIN SOLR 5 MG 5 PA

ZOMACTON SOLR 10 MG 5 PA

ZOMACTON SOLR 5 MG 5 PA

ZORBTIVE 5 PA THYROID AND ANTITHYROID AGENTS CYTOMEL 4 MO levothyroxine sodium 2 MO LEVOTHYROXINE SODIUM 4 MO

liothyronine sodium 2 HI,MO methimazole 2 MO propylthiouracil 2 MO SYNTHROID 4 MO THYROLAR-1 4 THYROLAR-1/2 4



Drug Name Drug Tier

Requirements/Limits

THYROLAR-1/4 4 THYROLAR-2 4 THYROLAR-3 4 TIROSINT 4 MO TRIOSTAT 4 HI MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS acetylcysteine 2 PA,MO ACTEMRA SOLN 200 MG/10ML 4 HI

ACTEMRA SOSY 162 MG/0.9ML 5

ACTIMMUNE 5 LD ACTONEL 4 MO alendronate sodium soln 70mg/75ml 2 MO

alendronate sodium tabs 10 mg 1 MO

alendronate sodium 35 mg 2 MO




allopurinol 2 MO ALOPRIM 4 HI amifostine crystalline 2 HI AMPYRA 5 ARAVA 4 MO ARCALYST 5 ASTAGRAF XL CP24 0.5 MG 4 PA,MO

ASTAGRAF XL CP24 1 MG 4 PA,MO

ASTAGRAF XL CP24 5 MG 5 PA

ATELVIA 4 MO ATGAM 4 HI AUBAGIO 5 PA AVODART 4 MO AVONEX 5

Drug Name Drug Tier

Requirements/Limits

AVONEX PEN 5 AVONEX PREFILLED 5 azathioprine 2 PA,MO BENLYSTA 5 BERINERT 5 BETASERON 5 BINOSTO 4 MO BONIVA 4 PA,HI,MO BOTOX SOLR 100 UNIT 3 PA BOTOX SOLR 200 UNIT 4 PA CARNITOR 4 PA,HI,MO CELLCEPT 4 PA,MO CELLCEPT INTRAVENOUS 4 PA,HI

CERDELGA 5 CIMZIA 5 CIMZIA PREFILLED 5 CINRYZE 5 HI colchicine 2 MO COLCHICINE CAPS 0.6 MG 3 MO

COLCRYS TABS 0.6 MG 4 MO

COPAXONE 5 cyclosporine 2 PA,HI,MO cyclosporine modified (for microemulsion) 2 PA,MO

CYSTADANE 4 LD CYSTAGON CAPS 150 MG 3

CYSTAGON CAPS 50 MG 3

DEMSER 4 MO dexrazoxane 2 HI disulfiram 2 MO DYSPORT 4 PA ELMIRON 3 MO ENBREL 5 ENBREL SURECLICK 5 etidronate disodium 2 MO EXTAVIA 5 finasteride 2 MO FIRAZYR 5


Drug Name Drug Tier

Requirements/Limits

fomepizole 2 HI FOSAMAX 4 MO FOSAMAX PLUS D 4 MO FUSILEV 4 HI GILENYA 5 glatiramer acetate 2 GRASTEK 4 MO HEMABATE 3 HUMIRA 5 HUMIRA PEN-CROHNS STARTER 5

ibandronate sodium 2 PA,HI,MO IMURAN 4 PA,MO JALYN 4 MO KINERET 5 KUVAN 5 leflunomide 2 MO LEMTRADA 5 leucovorin calcium 2 HI levocarnitine (metabolic modifiers) 2 PA,HI,MO

levoleucovorin calcium 2 HI lidocaine hcl (local anesth.) 2

mesna 2 HI MESNEX SOLN 100 MG/ML 4 HI

MESNEX TABS 400 MG 3 MO methylergonovine maleate 2

MIFEPREX 3 MYALEPT 5 mycophenolate mofetil 2 PA,MO mycophenolate sodium 2 PA,MO MYFORTIC 4 PA,MO NEORAL CAPS 100 MG 4 PA,MO NEORAL CAPS 25 MG 4 PA,MO NEORAL SOLN 100 MG/ML 3 PA,MO

NULOJIX 5 PA,HI octreotide acetate 2 ORENCIA 5

Drug Name Drug Tier

Requirements/Limits

ORFADIN 5 LD OTEZLA 5 PA OTREXUP SOAJ 10 MG/0.4ML 4

OTREXUP SOAJ 15 MG/0/4ML 4

OTREXUP SOAJ 20 MG/0.4ML 4

OTREXUP SOAJ 25 MG/0.4ML 4

pamidronate disodium 2 HI PROCYSBI CPDR 25 MG 5

PROCYSBI CPDR 75 MG 5

PROGRAF CAPS 0.5 MG 4 PA,MO

PROGRAF CAPS 1 MG 4 PA,MO PROGRAF CAPS 5 MG 4 PA,MO PROGRAF SOLN 5 MG/ML 3 PA,HI

PROLIA SOLN 60 MG/ML 4 MO

PROSCAR 4 MO RAGWITEK 4 MO RAPAMUNE 4 PA,MO RASUVO SOAJ 10 MG/0.2ML 3

RASUVO SOAJ 12.5 MG/0.25ML 3

RASUVO SOAJ 15 MG/0.3ML 3

RASUVO SOAJ 17.5 MG MG/0.35ML 3








Drug Name Drug Tier

Requirements/Limits


REBIF 5 REBIF REBIDOSE 5 REBIF REBIDOSE TITRATION PACK 5

REBIF TITRATION PACK 5

RECLAST 4 HI REMICADE 5 RIMSO-50 3 risedronate sodium 2 MO RUCONEST 5 SANDIMMUNE 3 PA,HI,MO SANDOSTATIN LAR DEPOT KIT 10 MG 5

SANDOSTATIN LAR DEPOT KIT 20 MG 5

SANDOSTATIN LAR DEPOT KIT 30 MG 5

SANDOSTATIN SOLN 100 MCG/ML 4


SANDOSTATIN SOLN 200 MG/ML 4



SENSIPAR TABS 30 MG 3 MO

SENSIPAR TABS 60 MG 5

SENSIPAR TABS 90 MG 5

SIMPONI 5 SIMPONI ARIA 5 SIMULECT 4 PA,HI sirolimus 2 PA,MO SODIUM FLUORIDE 3 MO SOMATULINE DEPOT 4 tacrolimus 2 PA,HI,MO

Drug Name Drug Tier

Requirements/Limits

TECFIDERA 5 THALOMID 5 THIOLA 4 MO THYMOGLOBULIN 4 HI TYBOST 3 MO TYSABRI 5 ULORIC 4 MO VORAXAZE 5 XELJANZ 5 XEOMIN 4 PA XGEVA SOLN 120 MG/1.7ML 5

XYLOCAINE 4 ZAVESCA 5 LD ZINECARD 4 HI zoledronic acid 2 HI ZOMETA 4 HI ZORTRESS TABS 0.25 MG 4 PA,MO

ZORTRESS TABS 0.5 MG 5 PA

ZORTRESS TABS 0.75 MG 5 PA

ZYLOPRIM 4 MO RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS ACCOLATE 4 MO cromolyn sodium 2 PA.MO cromolyn sodium (mastocytosis) 2 MO

GASTROCROM 4 MO montelukast sodium 2 MO SINGULAIR 4 MO zafirlukast 2 MO ZYFLO CR TB12 600 MG 5

ZYFLO TABS 600 MG 4 MO RESPIRATORY AGENTS, MISCELLANEOUS AEROSPAN 4 MO ALVESCO 4 MO ARALAST NP 5 ARNUITY ELLIPTA 4 MO


Drug Name Drug Tier

Requirements/Limits

ASMANEX 120 METERED DOSES AEPB 220 MCG/INH

3 MO


3 MO


4 MO


3 MO

ASMANEX HFA AERO 100 MCG/ACT 4 MO

ASMANEX HFA AERO 200 MCG/ACT 4 MO

BREO ELLIPTA 4 MO budesonide (inhalation) 2 PA,MO DALIRESP 4 MO DULERA 3 MO ESBRIET 5 PA,LD FLOVENT DISKUS 4 MO FLOVENT HFA AERO 110 MCG/ACT 4 MO

FLOVENT HFA AERO 220 MCG/ACT 4 MO

FLOVENT HFA AERO 44 MCG/ACT 3 MO

GLASSIA 5 KALYDECO 5 PA OFEV 5 ORKAMBI 5 PROLASTIN-C 5 PULMICORT FLEXHALER AEPB 180 MCG/ACT

3 MO

PULMICORT FLEXHALER AEPB 90 MCG/ACT

4 MO

PULMICORT SUSP 0.25 MG/2ML 4 MO

PULMICORT SUSP 0.5 MG/2ML 4 MO

Drug Name Drug Tier

Requirements/Limits

PULMICORT SUSP 1 MG/2ML 4 MO

QVAR 4 MO SYMBICORT 4 MO XOLAIR 5 ZEMAIRA 5 VASODILATING AGENTS ADEMPAS 5 LETAIRIS 5 OPSUMIT 5 LD ORENITRAM TBCR 0.125 MG 4

ORENITRAM TBCR 0.25 MG 5

ORENITRAM TBCR 1 MG 5

ORENITRAM TBCR 2.5 MG 5

REMODULIN 5 PA,LD TRACLEER 5 LD TYVASO 4 PA,LD VENTAVIS 5 PA,LD SERUMS, TOXOIDS, AND VACCINES SERUMS BIVIGAM SOLN 10 GM/100ML 3 PA,HI

CARIMUNE NF SOLR 12 GM 4 PA,HI

CARIMUNE NF SOLR 6 GM 4 PA,HI

CYTOGAM 3 HI FLEBOGAMMA DIF SOLN 5 GM/100ML 3 PA,HI

FLEBOGAMMA DIF SOLN 5 GM/50ML 4 PA

GAMASTAN S/D 3 PA GAMMAGARD S/D SOLR 10 GM 3 PA,HI

GAMMAGARD S/D SOLR 2.5 GM 3 PA,HI

GAMMAGARD S/D SOLR 5 GM 3 PA,HI

GAMMAGARD SOLN 2.5 GM/25ML 3 PA,HI



Drug Name Drug Tier

Requirements/Limits

GAMMAKED SOLN 1 GM/10ML 3 PA

GAMMAPLEX SOLN 10 GM/200ML 3 PA,HI

GAMUNEX-C SOLN 1 GM/10ML 3 PA,HI


GAMUNEX-C SOLN 2.5 GM/25ML 3 PA,HI




HYPERRAB S/D 3 HYPERRHO S/D 3 HYPERTET S/D 3 HYQVIA 5 PA IMOGAM RABIES-HT 3 NABI-HB 3 OCTAGAM SOLN 2 GM/20ML 3 PA,HI

OCTAGAM SOLN 25 GM/500ML 3 PA,HI

OCTAGAM SOLN 5 GM/100ML 3 PA,HI

PRIVIGEN SOLN 20 GM/200ML 3 PA,HI

RHOPHYLAC 3 VARIZIG 6 TOXOIDS DIPHTHERIA-TETANUS TOXOID DT 6

QUADRACEL 6 TENIVAC 6 TETANUS TOXOID ADSORBED 3

TETANUS-DIPHTHERIA TOXOIDS TD 6

VACCINES ACTHIB 6 ADACEL 6

Drug Name Drug Tier

Requirements/Limits

BEXSERO 6 BOOSTRIX 6 CERVARIX 6 COMVAX 6 DAPTACEL 6 ENGERIX-B 6 PA GARDASIL 6 GARDASIL 9 6 HAVRIX 6 IMOVAX RABIES 6 INFANRIX 6 IPOL 6 IXIARO 6 M-M-R II 6 MENACTRA 6 MENOMUNE 6 MENVEO 6 PEDVAX HIB 6 PROQUAD 6 RABAVERT 6 RECOMBIVAX HB 6 PA ROTARIX 6 ROTATEQ 6 TRUMENBA 6 TWINRIX 6 TYPHIM VI 6 VAQTA 6 VARIVAX 6 YF-VAX 6 ZOSTAVAX 6 SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) ACANYA 4 MO acyclovir topical 2 AKNE-MYCIN 3 MO ALTABAX 4 AVC VAGINAL 3 BACTROBAN 4 BACTROBAN NASAL 3 BENZACLIN 4 MO BENZAMYCIN 4 MO


Drug Name Drug Tier

Requirements/Limits

benzoyl peroxide-erythromycin 2 MO

butoconazole nitrate (one dose) 2

ciclopirox 2 ciclopirox olamine 2 CLEOCIN CREA 2 % 4 CLEOCIN SUPP 100 MG 3

CLEOCIN-T 4 MO CLINDAGEL 4 MO clindamycin phosphate & cleanser 2 MO

clindamycin phosphate (topical) 2 MO

clindamycin phosphate vaginal 2

clindamycin phosphate-benzoyl peroxide 2 MO

clindamycin phosphate-benzoyl peroxide (refrigerate)

2 MO

clotrimazole 2 clotrimazole (topical) 2 clotrimazole w/ betamethasone 2

DENAVIR 4 DUAC 4 MO econazole nitrate 2 ERTACZO 4 erythromycin (acne aid) 2 MO EURAX 4 EVOCLIN 4 MO EXELDERM 4 EXTINA 4 gentamicin sulfate (topical) 2

JUBLIA 4 KERYDIN 4 ketoconazole & cleanser 2 ketoconazole (topical) 2 KLARON 4 MO lindane 2

Drug Name Drug Tier

Requirements/Limits

LOPROX 4 LOTRISONE 4 LUZU 4 malathion 2 MENTAX 4 METROCREAM 4 METROGEL 4 METROGEL-VAGINAL 4 METROLOTION 4 metronidazole (topical) 2 metronidazole vaginal 2 miconazole nitrate vaginal 2

mupirocin 2 mupirocin calcium (topical) 2

naftifine hcl 2 NAFTIN 4 neomycin/polymyxin b gu 2

NIZORAL 4 NORITATE 4 NUVESSA 4 nystatin (topical) 2 ONEXTON 4 MO OXISTAT 4 permethrin 2 PHISOHEX 3 selenium sulfide 2 SILVADENE 4 silver sulfadiazine 2 SOOLANTRA 4 sulfacetamide sodium (acne) 2 MO

SULFAMYLON CREA 85 MG/GM 3

SULFAMYLON PACK 5 % 4

TERAZOL 3 4 TERAZOL 7 4 terconazole vaginal 2 XERESE 4 ZOVIRAX 4 MO



Drug Name Drug Tier

Requirements/Limits

ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) alclometasone dipropionate 2 MO

amcinonide 2 MO betamethasone dipropionate (topical) 2 MO

betamethasone dipropionate augmented 2 MO

betamethasone valerate 2 MO calcipotriene-betamethasone dipropionate

2 MO

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

CLOBEX LOTN 0.05 % 3 MO CLOBEX SHAM 0.05 % 4 MO CLOBEX SPRAY LIQD 0.05 % 3 MO

CLODERM PUMP 4 MO CORDRAN 3 MO CORTIFOAM 4 MO CORTISPORIN 3 MO CUTIVATE 4 MO DERMATOP 4 MO DESONATE GEL 0.05 % 3 MO

desonide 2 MO DESOWEN CREA 0.05 % 4 MO

desoximetasone 2 MO DESOXIMETASONE 4 MO diflorasone diacetate 2 MO diflorasone diacetate emollient base 2 MO

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

Drug Name Drug Tier

Requirements/Limits

fluocinonide emulsified base 2 MO

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

hydrocortisone (rectal) 2 MO hydrocortisone (topical) 2 MO hydrocortisone butyrate 2 MO hydrocortisone butyrate hydrophilic lipo base 2 MO

hydrocortisone valerate 2 MO KENALOG 3 MO LOCOID 4 MO mometasone furoate 2 MO neomycin-fluocinolone 2 MO nystatin-triamcinolone 2 MO OLUX FOAM 0.05 % 4 MO PANDEL 4 MO prednicarbate 2 MO SYNALAR (CREAM) 4 MO TACLONEX OINT 0.005-0.064 % 5

TACLONEX SUSP 0.005-0.064 % 4 MO

TEMOVATE CREA 0.05 % 4 MO

TEMOVATE GEL 0.05 % 4 MO

TEMOVATE OINT 0.05 % 4 MO

TOPICORT 4 MO TOPICORT SPRAY 4 MO triamcinolone acetonide (mouth) 2 MO

triamcinolone acetonide (topical) 2 MO

UCERIS 4 MO ULTRAVATE 4 MO VANOS 4 MO ANTIPRURITICS AND LOCAL ANESTHETICS EMLA 4 PA,MO


Drug Name Drug Tier

Requirements/Limits

lidocaine 2 PA,MO lidocaine hcl 2 MO lidocaine-prilocaine 2 PA,MO LIDODERM 4 PA,MO XYLOCAINE 4 ZONALON 3 MO CELL STIMULANTS AND PROLIFERANTS ATRALIN GEL 0.05% 4 PA,MO KEPIVANCE 5 HI RETIN-A CREA 0.025 % 3 PA,MO RETIN-A CREA 0.05 % 3 PA,MO RETIN-A CREA 0.1 % 3 PA,MO RETIN-A GEL 0.01% 3 PA,MO RETIN-A GEL 0.025% 3 PA,MO RETIN-A MICRO 4 PA,MO RETIN-A MICRO PUMP 4 PA,MO tretinoin 2 PA,MO tretinoin microsphere 2 PA,MO tretinoin w/ cleanser & moisturizer 2 PA,MO

SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS 8-MOP 3 MO ABSORICA 4 acitretin 2 MO ACZONE 4 MO adapalene 2 MO ALDARA 4 MO AZELEX 3 MO calcipotriene 2 MO CALCITRIOL 3 PA,HI,MO CARAC CREA 0.05 % 3 MO CONDYLOX 3 MO COSENTYX 5 LD COSENTYX SENSOREADY PEN 5 LD

diclofenac sodium (actinic keratoses) 2 MO

diclofenac sodium (topical) 2 MO

DIFFERIN 4 MO DOVONEX 4 MO EFUDEX CREA 5% 4 MO

Drug Name Drug Tier

Requirements/Limits

ELIDEL 3 MO EPIDUO 3 MO FABIOR 4 MO FINACEA 3 MO FLECTOR 4 PA,MO FLUOROPLEX CREA 1 % 3 MO

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

methoxsalen rapid 2 MO MIRVASO 4 MO ORACEA 4 OXSORALEN 3 MO OXSORALEN ULTRA 3 MO PANRETIN 5 PENNSAID 4 MO PICATO 4 MO podofilox 2 MO PROTOPIC 4 MO PRUDOXIN 3 MO RECTIV 4 MO REGRANEX 5 SANTYL 3 MO SOLARAZE 4 MO SORIATANE 5 SORILUX 4 MO STELARA 5 PA tacrolimus (topical) 2 MO TARGRETIN 3 MO TAZORAC 3 PA,MO UVADEX 4 VALCHLOR 5 VECTICAL 3 MO VELTIN 4 MO VEREGEN 4 MO VOLTAREN 4 MO ZIANA 4 MO ZYCLARA 4 MO



Drug Name Drug Tier

Requirements/Limits

ZYCLARA PUMP 4 MO SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS aminophylline 2 HI DETROL 4 MO DETROL LA 4 MO DITROPAN XL 4 MO ENABLEX 4 MO flavoxate hcl 2 MO GELNIQUE 4 MO MYRBETRIQ 4 MO oxybutynin chloride 2 MO OXYTROL 4 MO theophylline 2 MO tolterodine tartrate 2 MO TOVIAZ 4 MO trospium chloride 2 MO VESICARE 4 MO VITAMINS VITAMINS calcitriol 2 PA,HI,MO

Drug Name Drug Tier

Requirements/Limits

doxercalciferol 2 PA,HI,MO HECTOROL 4 PA,HI,MO niacin (antihyperlipidemic) 2 MO

paricalcitol 2 PA,HI,MO PARICALCITOL 4 PA,HI,MO ROCALTROL CAPS 0.25 MCG 3 PA,MO

ROCALTROL CAPS 0.5 MCG 3 PA,MO

ROCALTROL SOLN 1 MCG/ML 4 PA,MO

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


The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. Certain strengths or forms of the drug may be subject to the utilization management codes listed below. HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies. For more information, please consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region. LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies. For more information, consult your pharmacy directory or call our plan at the number listed on the front and back cover pages for your Kaiser Permanente Region. MO = Mail-order drugs. You may order prescription refills of certain medications through our mail-order service online at kp.org/refill or by phone or mobile app, which may lower your costs for a

three-month supply. Please contact us 10 days before your refills run out. Generally, you should receive them within 10 days. If not, please contact the mail-order phone number for your Kaiser Permanente Region in the chart on page 7. Additional drugs may be available for mail order. Not all drugs can be mailed; restrictions and limitations apply. For more information, please visit kp.org/seniormedrx or call the appropriate regional phone number on page 7. PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (e.g., via infusion pump, nebulizer, or other Durable Medical Equipment device), where they are administered (at home or in a long-term care facility), and what medical condition they are administered for. Prior authorization may al apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered.


Index of Drugs

8 8-MOP ..................................................... 52

A abacavir sulfate ....................................... 11 abacavir sulfate-lamivudine-zidovudine ... 11 ABELCET ................................................ 10 ABILIFY DISCMELT TBDP 10 MG .......... 29 ABILIFY DISCMELT TBDP 15 MG .......... 29 ABILIFY MAINTENA SUSR 300 MG ....... 29 ABILIFY MAINTENA SUSR 400 MG ....... 29 ABILIFY SOLN 1 MG/ML ......................... 29 ABILIFY SOLN 9.75 MG/1.3 ML .............. 29 ABILIFY TABS 2 MG .............................. 29 ABILIFY TABS 10 MG ............................. 29 ABILIFY TABS 15 MG ............................. 29 ABILIFY TABS 20 MG ............................. 29 ABILIFY TABS 30 MG ............................. 29 ABILIFY TABS 5 MG ............................... 29 ABRAXANE ............................................. 13 ABSORICA .............................................. 52 ABSTRAL ................................................ 23 acamprosate calcium ............................... 28 ACANYA .................................................. 49 acarbose .................................................. 40 ACCOLATE ............................................. 47 ACCUPRIL .............................................. 21 ACCURETIC ............................................ 21 acebutolol hcl ........................................... 22 acetaminophen w/ codeine ...................... 23 acetaminophen-caff-dihydrocod ............... 23 acetazolamide ......................................... 36 acetazolamide sodium ............................. 36 acetic acid (otic) ....................................... 36 acetylcysteine .......................................... 45 ACIPHEX ................................................. 37 ACIPHEX SPRINKLE .............................. 37 acitretin .................................................... 52 ACTEMRA SOLN 200 MG/10ML ............. 45 ACTEMRA SOSY 162 MG/0.9ML ............ 45 ACTHIB ................................................... 49 ACTIGALL ............................................... 38 ACTIMMUNE ........................................... 45 ACTIQ ..................................................... 23

ACTIVELLA .............................................. 42 ACTONEL ................................................ 45 ACTOPLUS MET ..................................... 40 ACTOPLUS MET XR ............................... 40 ACTOS..................................................... 40 ACULAR .................................................. 35 ACULAR LS ............................................. 35 ACUVAIL .................................................. 35 acyclovir ................................................... 11 acyclovir sodium....................................... 11 acyclovir topical ........................................ 49 ACZONE .................................................. 52 ADACEL................................................... 49 ADAGEN .................................................. 34 ADALAT CC ............................................. 19 adapalene ................................................ 52 ADCIRCA ................................................. 22 ADDERALL XR ........................................ 25 adefovir dipivoxil ...................................... 11 ADEMPAS ............................................... 48 ADRENALIN SOLN 1 MG/ML .................. 17 ADVAIR DISKUS AEPB 100-50

MCG/DOSE .......................................... 17 ADVAIR DISKUS AEPB 250-50

MCG/DOSE .......................................... 17 ADVAIR DISKUS AEPB 500-50

MCG/DOSE .......................................... 17 ADVAIR HFA AERO 115-21 MCG/ACT ... 17 ADVAIR HFA AERO 230-21 MCG/ACT ... 17 ADVAIR HFA AERO 45-21 MCG/ACT ..... 17 ADVICOR ................................................. 19 AEROSPAN ............................................. 47 AFINITOR ................................................ 13 AFINITOR DISPERZ ................................ 13 AFREZZA POWD 4 (30) & 8 (60) UNIT ... 40 AFREZZA POWD 4 (60) & 8 (30) UNIT ... 40 AFREZZA POWD 4 UNIT ........................ 40 AGGRENOX ............................................ 18 AGRYLIN ................................................. 18 AKNE-MYCIN .......................................... 49 AKYNZEO ................................................ 37 ALBENZA ................................................... 8 albuterol sulfate er tb12 8 mg .................. 17 albuterol sulfate er tb12 4 mg ................... 17 albuterol sulfate nebu (2.5 mg/3ml) 0.083%

............................................................. 17


albuterol sulfate nebu (5 mg/ml) 0.5% ..... 17 albuterol sulfate nebu 0.63 mg/3ml .......... 18 albuterol sulfate nebu 1.25 mg/3ml .......... 18 albuterol sulfate syrp 2 mg/5ml ................ 18 albuterol sulfate tabs 2 mg ....................... 18 albuterol sulfate tabs 4 mg ....................... 18 alclometasone dipropionate ..................... 51 alcohol swabs .......................................... 31 ALDACTAZIDE ........................................ 21 ALDACTONE ........................................... 21 ALDARA .................................................. 52 ALDURAZYME ........................................ 34 alendronate sodium soln 70mg/75ml ....... 45 alendronate sodium tabs 10 mg ............... 45 alendronate sodium tabs 35 mg ............... 45 alendronate sodium tabs 40 mg ............... 45 alendronate sodium tabs 5 mg................. 45 alendronate sodium tabs 70 mg ............... 45 alfuzosin hcl ............................................. 17 ALIMTA ................................................... 13 ALINIA ..................................................... 11 ALKERAN ................................................ 13 allopurinol ................................................ 45 ALOCRIL ................................................. 36 ALOMIDE ................................................ 36 ALOPRIM ................................................ 45 ALORA PTTW 0.025 MG/24HR ............... 42 ALORA PTTW 0.05 MG/24HR ................. 42 ALORA PTTW 0.075 MG/24HR ............... 42 ALORA PTTW 0.1 MG/24HR................... 42 alosetron hcl ............................................ 36 ALOXI ...................................................... 37 ALPHAGAN P .......................................... 36 alprazolam ............................................... 28 ALREX ..................................................... 35 ALSUMA .................................................. 27 ALTABAX ................................................ 49 ALTACE .................................................. 21 ALTOPREV ............................................. 19 ALVESCO................................................ 47 amantadine hcl ........................................ 27 AMARYL .................................................. 40 AMBIEN ................................................... 28 AMBIEN CR ............................................. 28 AMBISOME ............................................. 10 amcinonide .............................................. 51 AMERGE ................................................. 27 AMICAR .................................................. 18 amifostine crystalline ............................... 45

amikacin sulfate ......................................... 8 amiloride & hydrochlorothiazide ............... 32 amiloride hcl ............................................. 32 amino acid electrolyte infusion ................. 31 amino acid infusion .................................. 31 aminophylline ........................................... 53 aminosalicylic acid ................................... 11 AMINOSYN -HBC SOLN 7 % .................. 31 AMINOSYN II SOLN 10 % ....................... 31 AMINOSYN II SOLN 15 % ....................... 31 AMINOSYN II SOLN 7 % ......................... 31 AMINOSYN II SOLN 8.5 % ...................... 31 AMINOSYN M SOLN 3.5 % ..................... 31 AMINOSYN/ELECTROLYTES SOLN 7 %

............................................................. 32 AMINOSYN-PF SOLN 10 % .................... 31 AMINOSYN-PF SOLN 7 % ...................... 31 AMINOSYN-RF SOLN 5.2 % ................... 31 amiodarone hcl ........................................ 20 AMITIZA ................................................... 38 amitriptyline hcl ........................................ 29 amlodipine besylate ................................. 19 amlodipine besylate-atorvastatin calcium . 19 amlodipine besylate-benazepril hcl .......... 20 amlodipine besylate-valsartan .................. 20 amlodipine-valsartan-hydrochlorothiazide 20 ammonium chloride .................................. 31 amoxapine ............................................... 29 amoxicillin .................................................. 8 amoxicillin & pot clavulanate ...................... 8 amoxicillin-clarithromycin w/ lansoprazole 37 amphetamine sulfate ................................ 25 amphetamine-dextroamphetamine ........... 25 amphotericin b ......................................... 10 ampicillin .................................................... 8 ampicillin & sulbactam sodium ................... 8 ampicillin sodium ........................................ 8 AMPYRA .................................................. 45 AMRIX ..................................................... 17 AMTURNIDE ............................................ 21 ANADROL-50 .......................................... 39 ANAFRANIL ............................................. 29 anagrelide hcl ........................................... 18 ANAPROX ............................................... 23 ANAPROX DS ......................................... 23 anastrozole .............................................. 13 ANCOBON ............................................... 10 ANDRODERM PT24 2 MG/24HR ............ 39 ANDRODERM PT24 4 MG/24HR ............ 39


ANDROGEL GEL 20.25 MG/1.25GM (1.62%) ................................................ 39

ANDROGEL GEL 25 MG/2.5GM (1%)..... 39 ANDROGEL GEL 40.5 MG/2.5GM (1.62%)

............................................................. 39 ANDROGEL GEL 50 MG/5GM (1%) ....... 39 ANDROGEL PUMP GEL 12.5 MG/ACT

(1%) ..................................................... 39 ANDROGEL PUMP GEL 12.5MG/ACT

(1%) ..................................................... 39 ANDROGEL PUMP GEL 20.25 MG/ACT

(1.62%) ................................................ 39 ANGELIQ................................................. 42 ANORO ELLIPTA .................................... 16 ANTARA .................................................. 19 ANZEMET ............................................... 37 APIDRA ................................................... 40 APIDRA SOLOSTAR ............................... 40 APLENZIN ............................................... 29 APOKYN.................................................. 27 apraclonidine hcl ...................................... 36 APRISO CP24 0.375 GM ........................ 36 APTENSIO XR ........................................ 25 APTIOM ................................................... 26 APTIVUS ................................................. 11 ARALAST NP .......................................... 47 ARANESP (ALBUMIN FREE) .................. 19 ARAVA .................................................... 45 ARCALYST .............................................. 45 ARCAPTA NEOHALER ........................... 18 argatroban ............................................... 18 ARGATROBAN ....................................... 18 ARICEPT ................................................. 16 ARIMIDEX ............................................... 13 aripiprazole .............................................. 29 ARISTOSPAN INTRA-ARTICULAR ........ 38 ARISTOSPAN INTRALESIONAL ............ 38 ARIXTRA ................................................. 18 ARNUITY ELLIPTA.................................. 47 AROMASIN ............................................. 14 ARRANON ............................................... 14 ARTHROTEC .......................................... 23 ARZERRA ............................................... 14 ASACOL HD TBEC 800 MG .................... 36 ASMANEX 120 METERED DOSES AEPB

220 MCG/INH ...................................... 48 ASMANEX 30 METERED DOSES AEPB

110 MCG/INH ...................................... 48

ASMANEX 30 METERED DOSES AEPB 220 MCG/INH ....................................... 48

ASMANEX 60 METERED DOSES AEPB 220 MCG/INH ....................................... 48

ASMANEX HFA AERO 100 MCG/ACT .... 48 ASMANEX HFA AERO 200 MCG/ACT .... 48 ASTAGRAF XL CP24 0.5 MG .................. 45 ASTAGRAF XL CP24 1 MG ..................... 45 ASTAGRAF XL CP24 5 MG ..................... 45 ASTELIN .................................................. 36 ASTEPRO ................................................ 36 ATACAND ................................................ 21 ATACAND HCT ....................................... 21 ATELVIA .................................................. 45 atenolol .................................................... 22 atenolol & chlorthalidone .......................... 22 ATGAM .................................................... 45 ATIVAN .................................................... 28 atorvastatin calcium ................................. 19 atovaquone .............................................. 11 atovaquone-proguanil hcl ......................... 11 ATRALIN GEL 0.05% ............................... 52 ATRIPLA .................................................. 11 atropine sulfate ........................................ 16 ATROPINE SULFATE .............................. 16 atropine sulfate (ophthalmic) .................... 36 ATROVENT ............................................. 16 ATROVENT HFA ..................................... 16 AUBAGIO ................................................. 45 AUGMENTIN ............................................. 8 AURYXIA ................................................. 33 AUVI-Q SOAJ 0.15 MG/0.15ML ............... 18 AUVI-Q SOAJ 0.3 MG/0.3ML ................... 18 AVALIDE .................................................. 21 AVANDAMET ........................................... 40 AVANDARYL ........................................... 40 AVANDIA ................................................. 40 AVAPRO .................................................. 21 AVASTIN .................................................. 14 AVC VAGINAL ......................................... 49 AVEED ..................................................... 39 AVELOX..................................................... 8 AVELOX ABC PACK .................................. 8 AVELOX SOLN .......................................... 8 AVINZA .................................................... 23 AVODART ................................................ 45 AVONEX .................................................. 45 AVONEX PEN .......................................... 45 AVONEX PREFILLED .............................. 45


AXERT .................................................... 27 AXIRON SOLN 30 MG/ACT .................... 39 azacitidine................................................ 14 AZACTAM ................................................. 8 AZACTAM IN DEXTROSE ........................ 8 AZASITE.................................................. 34 azathioprine ............................................. 45 azelastine hcl ........................................... 36 azelastine hcl (ophth) ............................... 36 AZELEX ................................................... 52 AZILECT .................................................. 27 azithromycin .............................................. 8 AZITHROMYCIN PACK 1GM .................... 8 AZOPT .................................................... 36 AZOR ...................................................... 20 aztreonam.................................................. 8 AZULFIDINE .............................................. 8 AZULFIDINE EN-TABS ............................. 8

B bacitracin ................................................... 8 bacitracin (ophthalmic) ............................. 34 bacitracin-polymyxin b (ophth) ................. 34 bacitracin-poly-neomycin-hc .................... 35 baclofen ................................................... 17 BACTOCILL IN DEXTROSE...................... 8 BACTRIM .................................................. 8 BACTRIM DS ............................................ 8 BACTROBAN .......................................... 49 BACTROBAN NASAL .............................. 49 balsalazide disodium ............................... 37 BANZEL .................................................. 26 BARACLUDE SOLN 0.05 MG/ML ........... 11 BARACLUDE TAB 0.5 MG ...................... 11 BARACLUDE TABS 1 MG ....................... 11 BCG VACCINE ........................................ 14 BECONASE AQ ...................................... 35 BELEODAQ ............................................. 14 BELSOMRA ............................................. 28 benazepril & hydrochlorothiazide ............. 21 benazepril hcl .......................................... 21 BENICAR................................................. 21 BENICAR HCT ........................................ 21 BENLYSTA .............................................. 45 BENTYL .................................................. 16 BENZACLIN ............................................ 49 BENZAMYCIN ......................................... 49 benzoyl peroxide-erythromycin ................ 50

benztropine mesylate ............................... 27 BEPREVE ................................................ 36 BERINERT ............................................... 45 BESIVANCE ............................................ 34 BETAGAN ................................................ 36 betamethasone dipropionate (topical) ...... 51 betamethasone dipropionate augmented . 51 betamethasone valerate ........................... 51 BETAPACE AF ........................................ 23 BETASERON ........................................... 45 betaxolol hcl ............................................. 23 betaxolol hcl (ophth) ................................. 36 bethanechol chloride ................................ 16 BETHKIS .................................................... 8 BETIMOL ................................................. 36 BETOPTIC-S ........................................... 36 BEXSERO ................................................ 49 BEYAZ ..................................................... 39 BIAXIN ....................................................... 8 bicalutamide ............................................. 14 BICILLIN C-R ............................................. 8 BICILLIN C-R 900/300 ............................... 8 BICILLIN L-A .............................................. 8 BICNU ...................................................... 14 BIDIL ........................................................ 22 BILTRICIDE ............................................... 8 bimatoprost .............................................. 36 BINOSTO ................................................. 45 bisoprolol & hydrochlorothiazide .............. 23 bisoprolol fumarate ................................... 23 BIVIGAM SOLN 10 GM/100ML ................ 48 bleomycin sulfate ..................................... 14 BLEPH-10 ................................................ 34 BLEPHAMIDE .......................................... 35 BLINCYTO ............................................... 14 BONIVA ................................................... 45 BOOSTRIX .............................................. 49 BOSULIF .................................................. 14 BOTOX SOLR 100 UNIT ......................... 45 BOTOX SOLR 200 UNIT ......................... 45 BREO ELLIPTA ................................. 38, 48 BREVICON (28) ....................................... 39 BRILINTA ................................................. 18 brimonidine tartrate .................................. 36 BRINTELLIX ............................................ 29 BRISDELLE ............................................. 29 bromfenac sodium (ophth) ....................... 35 bromocriptine mesylate ............................ 27 BROVANA ............................................... 18


budesonide .............................................. 38 budesonide (inhalation) ........................... 48 budesonide (nasal) .................................. 35 bumetanide soln 0.25 mg/ml .................... 32 bumetanide tabs 0.5 mg .......................... 32 bumetanide tabs 1 mg ............................. 32 bumetanide tabs 2 mg ............................. 32 BUNAVAIL ............................................... 29 BUPHENYL ............................................. 31 BUPRENEX ............................................. 23 buprenorphine hcl .................................... 23 buprenorphine hcl-naloxone hcl dihydrate 29 bupropion hcl ........................................... 29 bupropion hcl (smoking deterrent) ........... 29 buspirone hcl ........................................... 28 BUSULFEX .............................................. 14 butalbital-acetaminophen ......................... 24 butalbital-acetaminophen-caffeine ........... 24 butalbital-acetaminophen-caffeine w/

codeine ................................................ 24 butalbital-aspirin-caffeine ......................... 24 butalbital-aspirin-caffeine w/cod ............... 24 BUTISOL SODIUM .................................. 28 butoconazole nitrate (one dose) .............. 50 butorphanol tartrate ................................. 24 BUTRANS ............................................... 24 BYDUREON ............................................ 40 BYETTA 10 MCG PEN ............................ 40 BYETTA 5 MCG PEN .............................. 40 BYSTOLIC ............................................... 23

C cabergoline .............................................. 27 CADUET .................................................. 20 CALAN .................................................... 20 CALAN SR ............................................... 20 calcipotriene ............................................ 52 calcipotriene-betamethasone dipropionate

............................................................. 51 calcitonin (salmon) ................................... 43 calcitriol ................................................... 53 CALCITRIOL ........................................... 52 calcium acetate (phosphate binder) ......... 33 CAMBIA ................................................... 24 CAMPATH ............................................... 14 CAMPTOSAR .......................................... 14 CANASA SUPP 1000 MG ....................... 37 CANCIDAS .............................................. 10

candesartan cilexetil ................................. 21 candesartan cilexetil-hydrochlorothiazide . 21 CANTIL .................................................... 16 CAPASTAT SULFATE ............................. 11 CAPEX ..................................................... 51 CAPRELSA .............................................. 14 captopril ................................................... 21 captopril & hydrochlorothiazide ................ 21 CARAC CREA 0.05 % ............................. 52 CARAFATE SUSP 1 GM/10ML ................ 37 CARAFATE TABS 1 GM .......................... 37 CARBAGLU ............................................. 31 carbamazepine ........................................ 26 CARBATROL CP12 100 MG .................... 26 CARBATROL CP12 200 MG .................... 26 CARBATROL CP12 300 MG .................... 26 carbidopa ................................................. 27 carbidopa-levodopa .................................. 27 carbidopa-levodopa-entacapone .............. 27 carbinoxamine maleate ............................ 13 carboplatin ............................................... 14 CARDENE IV ........................................... 20 CARDIZEM .............................................. 20 CARDIZEM CD ........................................ 20 CARDIZEM LA ......................................... 20 CARDURA ............................................... 19 CARDURA XL .......................................... 19 CARIMUNE NF SOLR 12 GM .................. 48 CARIMUNE NF SOLR 6 GM .................... 48 carisoprodol ............................................. 17 carisoprodol w/ aspirin ............................. 17 carisoprodol w/ aspirin & codeine ............. 17 CARNITOR .............................................. 45 carteolol hcl (ophth) .................................. 36 carvedilol .................................................. 23 CASODEX ............................................... 14 CATAPRES .............................................. 20 CATAPRES-TTS-1 ................................... 21 CATAPRES-TTS-2 ................................... 21 CATAPRES-TTS-3 ................................... 21 CAYSTON .................................................. 8 CEDAX....................................................... 8 CEENU .................................................... 14 cefaclor ...................................................... 8 cefaclor monohydrate ................................. 8 cefadroxil .................................................... 8 cefazolin in d5w ......................................... 8 cefazolin sodium ........................................ 8 CEFAZOLIN SODIUM-DEXTROSE ........... 8


cefdinir ....................................................... 8 CEFDITOREN PIVOXIL ............................ 8 cefepime hcl .............................................. 8 CEFEPIME-DEXTROSE ........................... 8 cefixime ..................................................... 8 cefotaxime sodium ..................................... 8 cefotetan disodium..................................... 8 cefoxitin sodium ......................................... 8 CEFOXITIN SODIUM-DEXTROSE ........... 8 cefpodoxime proxetil .................................. 8 cefprozil ..................................................... 8 ceftazidime ................................................ 8 CEFTAZIDIME AND DEXTROSE .............. 8 CEFTIN SUSR 125 MG/5ML ..................... 8 CEFTIN SUSR 250 MG/5ML ..................... 8 CEFTIN TABS 250 MG .............................. 8 CEFTIN TABS 500 MG .............................. 8 ceftriaxone sodium..................................... 8 CEFTRIAXONE SODIUM-DEXTROSE ..... 8 cefuroxime axetil ........................................ 8 cefuroxime sodium..................................... 8 CEFUROXIME-DEXTROSE ...................... 8 CELEBREX ............................................. 24 celecoxib ................................................. 24 CELESTONE ........................................... 38 CELEXA .................................................. 29 CELLCEPT .............................................. 45 CELLCEPT INTRAVENOUS ................... 45 CELONTIN .............................................. 26 cephalexin ................................................. 8 CERDELGA ............................................. 45 CEREBYX ............................................... 26 CEREZYME ............................................. 34 CERVARIX .............................................. 49 CESAMET ............................................... 37 cetirizine hcl ............................................. 13 cevimeline hcl .......................................... 16 CHANTIX ................................................. 16 CHANTIX CONTINUING MONTH PAK ... 16 CHANTIX STARTING MONTH PAK ........ 16 CHEMET ................................................. 38 chenodiol ................................................. 38 chloramphenicol sodium succinate ............ 8 chlordiazepoxide hcl ................................ 28 chlordiazepoxide-amitriptyline .................. 29 chlorhexidine gluconate (mouth-throat).... 34 chloroquine phosphate ............................ 11 chlorothiazide .......................................... 32 chlorothiazide sodium .............................. 32

chlorpromazine hcl ................................... 29 chlorpropamide ........................................ 41 chlorthalidone ........................................... 32 chlorzoxazone .......................................... 17 CHOLBAM ............................................... 38 cholestyramine ......................................... 19 cholestyramine light ................................. 19 choline fenofibrate .................................... 19 chorionic gonadotropin ............................. 43 CIALIS ..................................................... 22 ciclopirox .................................................. 50 ciclopirox olamine..................................... 50 cidofovir.................................................... 11 cilostazol .................................................. 18 CILOXAN OINT 0.3 % .............................. 34 CILOXAN SOLN 0.3 % ............................ 34 cimetidine ................................................. 37 cimetidine hcl ........................................... 37 CIMZIA ..................................................... 45 CIMZIA PREFILLED ................................ 45 CINRYZE ................................................. 45 CIPRO ....................................................... 8 CIPRO HC ............................................... 35 CIPRO IN D5W .......................................... 8 CIPRODEX .............................................. 35 ciprofloxacin ............................................... 8 ciprofloxacin hcl ......................................... 8 ciprofloxacin hcl (ophth) ........................... 34 ciprofloxacin in d5w .................................... 8 ciprofloxacin-ciprofloxacin hcl ..................... 9 cisplatin .................................................... 14 citalopram hydrobromide soln 10 mg/5ml . 29 citalopram hydrobromide tabs 10 mg ....... 29 citalopram hydrobromide tabs 20 mg ....... 29 citalopram hydrobromide tabs 40 mg ....... 29 cladribine .................................................. 14 CLAFORAN ............................................... 9 CLARINEX ............................................... 13 CLARINEX-D 12 HOUR ........................... 13 clarithromycin ............................................. 9 clemastine fumarate ................................. 13 CLEOCIN ................................................... 9 CLEOCIN CREA 2 % ............................... 50 CLEOCIN IN D5W ...................................... 9 CLEOCIN PHOSPHATE ............................ 9 CLEOCIN SUPP 100 MG ......................... 50 CLEOCIN-T .............................................. 50 CLIMARA PRO ........................................ 42 CLIMARA PTWK 0.025 MG/24HR ........... 42


CLIMARA PTWK 0.0375 MG/24HR ......... 42 CLIMARA PTWK 0.05 MG/24HR ............. 42 CLIMARA PTWK 0.06 MG/24HR ............. 42 CLIMARA PTWK 0.075 MG/24HR ........... 42 CLIMARA PTWK 0.1 MG/24HR ............... 42 CLINDAGEL ............................................ 50 clindamycin hcl .......................................... 9 clindamycin palmitate hydrochloride .......... 9 clindamycin phosphate .............................. 9 clindamycin phosphate & cleanser .......... 50 clindamycin phosphate (topical) ............... 50 clindamycin phosphate in d5w ................... 9 clindamycin phosphate vaginal ................ 50 clindamycin phosphate-benzoyl peroxide 50 clindamycin phosphate-benzoyl peroxide

(refrigerate) .......................................... 50 CLINIMIX 4.25%/DEXTROSE 10% ......... 32 CLINIMIX E/DEXTROSE (2.75/10) .......... 32 CLINIMIX E/DEXTROSE (2.75/5) ............ 32 CLINIMIX E/DEXTROSE (4.25/10) .......... 32 CLINIMIX E/DEXTROSE (4.25/25) .......... 32 CLINIMIX E/DEXTROSE (4.25/5) ............ 32 CLINIMIX E/DEXTROSE (5/15) ............... 32 CLINIMIX E/DEXTROSE (5/20) ............... 32 CLINIMIX E/DEXTROSE (5/25) ............... 32 CLINIMIX/DEXTROSE (2.75/5) ............... 32 CLINIMIX/DEXTROSE (4.25/10) ............. 32 CLINIMIX/DEXTROSE (4.25/20) ............. 32 CLINIMIX/DEXTROSE (4.25/25) ............. 32 CLINIMIX/DEXTROSE (4.25/5) ............... 32 CLINIMIX/DEXTROSE (5/15) .................. 32 CLINIMIX/DEXTROSE (5/20) .................. 32 CLINIMIX/DEXTROSE (5/25) .................. 32 clobetasol propionate ............................... 51 clobetasol propionate emollient base ....... 51 CLOBEX LOTN 0.05 % ........................... 51 CLOBEX SHAM 0.05 % ........................... 51 CLOBEX SPRAY LIQD 0.05 % ................ 51 CLODERM PUMP ................................... 51 CLOLAR .................................................. 14 clomipramine hcl ...................................... 29 clonazepam ............................................. 26 clonidine & chlorthalidone ........................ 21 clonidine hcl ............................................. 21 clonidine hcl (adhd).................................. 21 clopidogrel bisulfate ................................. 18 clorazepate dipotassium .......................... 28 clotrimazole ............................................. 50 clotrimazole (topical) ................................ 50

clotrimazole w/ betamethasone ................ 50 clozapine .................................................. 29 CLOZARIL ............................................... 29 COARTEM ............................................... 11 CODEINE SULFATE ................................ 24 COGENTIN .............................................. 27 COLAZAL ................................................. 37 colchicine ................................................. 45 COLCHICINE CAPS 0.6 MG .................... 45 colchicine w/ probenecid .......................... 34 COLESTID ............................................... 19 colestipol hcl ............................................ 19 colistimethate sodium ................................. 9 COLY-MYCIN S ....................................... 35 COLYTE WITH FLAVOR PACKS ............ 38 COMBIGAN ............................................. 36 COMBIPATCH ......................................... 42 COMBIVENT ............................................ 18 COMBIVENT RESPIMAT......................... 18 COMBIVIR ............................................... 11 COMETRIQ .............................................. 14 COMETRIQ (100 MG DAILY DOSE) ....... 14 COMETRIQ (140 MG DAILY DOSE) ....... 14 COMETRIQ (60 MG DAILY DOSE) ......... 14 COMPLERA ............................................. 11 COMTAN ................................................. 27 COMVAX ................................................. 49 CONCERTA ............................................. 25 CONDYLOX ............................................. 52 CONZIP ................................................... 24 COPAXONE ............................................. 45 COPEGUS ............................................... 11 CORDRAN ............................................... 51 COREG .................................................... 23 COREG CR .............................................. 23 CORGARD ............................................... 23 CORLANOR ............................................. 20 CORTEF .................................................. 38 CORTIFOAM ........................................... 51 cortisone acetate ...................................... 38 CORTISPORIN .................................. 35, 51 CORTISPORIN-TC .................................. 35 CORZIDE ................................................. 23 COSENTYX ............................................. 52 COSENTYX SENSOREADY PEN ........... 52 COSMEGEN ............................................ 14 COSOPT .................................................. 36 COUMADIN ............................................. 18 COZAAR .................................................. 21


CREON ................................................... 38 CRESEMBA ............................................ 10 CRESTOR ............................................... 19 CRINONE ................................................ 43 CRIXIVAN................................................ 11 cromolyn sodium ..................................... 47 cromolyn sodium (mastocytosis) .............. 47 cromolyn sodium (ophth) ......................... 36 CUBICIN .................................................... 9 CUPRIMINE ............................................ 38 CUTIVATE ............................................... 51 CUVPOSA SOLN 1 MG/5ML ................... 16 CYCLESSA ............................................. 39 cyclobenzaprine hcl ................................. 17 CYCLOPHOSPHAMIDE .......................... 14 CYCLOSET ............................................. 41 cyclosporine ............................................. 45 cyclosporine modified (for microemulsion)45 CYKLOKAPRON ..................................... 18 CYMBALTA ............................................. 29 cyproheptadine hcl .................................. 13 CYRAMZA ............................................... 14 CYSTADANE ........................................... 45 CYSTAGON CAPS 150 MG .................... 45 CYSTAGON CAPS 50 MG ...................... 45 CYSTARAN ............................................. 36 cytarabine ................................................ 14 CYTOGAM .............................................. 48 CYTOMEL ............................................... 44 CYTOTEC ............................................... 37 CYTOVENE ............................................. 11

D dacarbazine ............................................. 14 DACOGEN .............................................. 14 DAKLINZA ............................................... 11 DALIRESP ............................................... 48 DALVANCE ............................................... 9 danazol .................................................... 39 DANTRIUM .............................................. 17 dantrolene sodium ................................... 17 dapsone ................................................... 11 DAPTACEL .............................................. 49 DARAPRIM .............................................. 11 daunorubicin hcl ...................................... 14 DAUNOXOME ......................................... 14 DAYPRO ................................................. 24 DAYTRANA ............................................. 25

DDAVP..................................................... 43 DDAVP RHINAL TUBE ............................ 43 DDAVP SOLN 4 MG MCG/ML ................. 43 DDAVP TABS 0.1 MG .............................. 43 DDAVP TABS 0.2 MG .............................. 43 decitabine ................................................. 14 DELESTROGEN ...................................... 42 DELZICOL CPDR 400 MG ....................... 37 DEMADEX ............................................... 32 demeclocycline hcl ..................................... 9 DEMEROL ............................................... 24 DEMSER .................................................. 45 DENAVIR ................................................. 50 DEPACON ............................................... 26 DEPAKENE ............................................. 26 DEPAKOTE ............................................. 26 DEPAKOTE ER ....................................... 26 DEPAKOTE SPRINKLES ........................ 26 DEPEN TITRATABS ................................ 38 DEPO-MEDROL SUSP 20 MG/ML .......... 38 DEPO-MEDROL SUSP 40 MG/ML .......... 38 DEPO-MEDROL SUSP 80 MG/ML .......... 38 DEPO-PROVERA .................................... 43 DEPO-PROVERA SUSP 150 MG/ML ...... 43 DEPO-SUBQ PROVERA 104 SUSP 104

MG/0.65ML .......................................... 43 DERMATOP ............................................. 51 desipramine hcl ........................................ 29 desloratadine ........................................... 13 desmopressin acetate .............................. 43 desmopressin acetate refrigerated ........... 43 desmopressin acetate spray refrigerated . 43 DESOGEN ............................................... 39 desogestrel & ethinyl estradiol ................. 39 desogestrel-ethinyl estradiol (biphasic) .... 39 desogestrel-ethinyl estradiol (triphasic) .... 39 DESONATE GEL 0.05 % ......................... 51 desonide .................................................. 51 DESOWEN CREA 0.05 %........................ 51 desoximetasone ....................................... 51 DESOXIMETASONE ............................... 51 DESOXYN ............................................... 25 DESVENLAFAXINE ER ........................... 29 DETROL .................................................. 53 DETROL LA ............................................. 53 dexamethasone ....................................... 38 dexamethasone sodium phosphate ......... 38 dexamethasone sodium phosphate (ophth)

............................................................. 35


DEXEDRINE ............................................ 25 DEXILANT ............................................... 37 dexmethylphenidate hcl ........................... 25 dexrazoxane ............................................ 45 dextroamphetamine sulfate ..................... 25 dextrose ................................................... 32 DEXTROSE 5%/ELECTROLYTE #48 ..... 33 dextrose in lactated ringers ...................... 33 dextrose w/ sodium chloride .................... 33 DEXTROSE-NACL SOLN 10-0.2 % ........ 33 DEXTROSE-NACL SOLN 10-0.45 % ...... 33 DEXTROSE-NACL SOLN 5-0.0225 % .... 33 DIABETA ................................................. 41 DIAMOX SEQUELS ................................. 36 DIASTAT ACUDIAL ................................. 28 DIASTAT PEDIATRIC ............................. 28 diazepam ................................................. 28 diazepam (anticonvulsant) ....................... 28 DIBENZYLINE ......................................... 17 diclofenac potassium ............................... 24 diclofenac sodium .................................... 24 diclofenac sodium (actinic keratoses) ...... 52 diclofenac sodium (ophth) ........................ 35 diclofenac sodium (topical) ...................... 52 diclofenac w/ misoprostol ......................... 24 dicloxacillin sodium .................................... 9 dicyclomine hcl ........................................ 16 didanosine ............................................... 11 DIFFERIN ................................................ 52 DIFICID ..................................................... 9 diflorasone diacetate ................................ 51 diflorasone diacetate emollient base ........ 51 DIFLUCAN ............................................... 10 diflunisal .................................................. 24 digoxin ..................................................... 20 DIGOXIN SOL 50MCG/ML ...................... 20 DIGOXIN SOLN 0.05 MG/ML .................. 20 dihydroergotamine mesylate .................... 17 DILANTIN ................................................ 26 DILAUDID ................................................ 24 DILAUDID-HP .......................................... 24 diltiazem hcl ............................................. 20 diltiazem hcl coated beads ...................... 20 diltiazem hcl extended release beads ...... 20 DIOVAN ................................................... 21 DIOVAN HCT .......................................... 21 DIPENTUM .............................................. 37 diphenhydramine hcl ................................ 13 diphenoxylate w/ atropine ........................ 37

DIPHTHERIA-TETANUS TOXOID DT ..... 49 DIPROLENE ............................................ 51 DIPROLENE AF ....................................... 51 dipyridamole ............................................. 22 disopyramide phosphate .......................... 20 disulfiram .................................................. 45 DITROPAN XL ......................................... 53 DIURIL ..................................................... 32 divalproex sodium .................................... 26 DIVIGEL GEL 0.5 MG/0.5GM .................. 42 DOCEFREZ SOLR 20 MG ...................... 14 DOCETAXEL CONC 20 MG/0.5ML ......... 14 DOCETAXEL CONC 80 MG/2ML ............ 14 DOCETAXEL CONC 80 MG/4ML ............ 14 DOCETAXEL SOLN 80 MG/8ML ............. 14 DOLOPHINE TABS 10 MG ...................... 24 DOLOPHINE TABS 5 MG ........................ 24 donepezil hydrochloride ........................... 16 DORIBAX ................................................... 9 DORYX ...................................................... 9 dorzolamide hcl ........................................ 36 dorzolamide hcl-timolol maleate ............... 36 DOVONEX ............................................... 52 doxazosin mesylate .................................. 19 doxepin hcl ............................................... 29 doxercalciferol .......................................... 53 DOXIL ...................................................... 14 doxorubicin hcl ......................................... 14 doxycycline (monohydrate) ........................ 9 doxycycline hyclate .................................... 9 dronabinol ................................................ 37 drospirenone-ethinyl estradiol .................. 40 DROXIA ................................................... 14 DUAC ....................................................... 50 DUAVEE .................................................. 42 DUETACT ................................................ 41 DUEXIS.................................................... 24 DULERA .................................................. 48 duloxetine hcl ........................................... 29 DUOPA .................................................... 27 DURAGESIC-100..................................... 24 DURAGESIC-12....................................... 24 DURAGESIC-25....................................... 24 DURAGESIC-50....................................... 24 DURAGESIC-75....................................... 24 DUREZOL ................................................ 35 DUTOPROL ............................................. 23 DYAZIDE ................................................. 32 DYMISTA ................................................. 36


DYRENIUM ............................................. 32 DYSPORT ............................................... 45

E E.E.S. GRANULES .................................... 9 EC-NAPROSYN ...................................... 24 econazole nitrate ..................................... 50 EDARBI ................................................... 21 EDARBYCLOR ........................................ 21 EDECRIN ................................................ 32 EDLUAR .................................................. 28 EDURANT ............................................... 11 EFFEXOR XR .......................................... 29 EFFIENT.................................................. 18 EFUDEX CREA 5% ................................. 52 EGRIFTA ................................................. 43 ELAPRASE .............................................. 34 ELDEPRYL .............................................. 27 electrolyte-m in dextrose .......................... 33 ELELYSO ................................................ 34 ELESTAT................................................. 36 ELESTRIN GEL 0.52 MG/0.87GM (0.06%)

............................................................. 42 ELIDEL .................................................... 52 ELIGARD KIT 22.5 MG ............................ 14 ELIGARD KIT 30 MG ............................... 14 ELIGARD KIT 45 MG ............................... 14 ELIGARD KIT 7.5 MG .............................. 14 ELIQUIS .................................................. 18 ELITEK .................................................... 34 ELLA ........................................................ 40 ELLENCE ................................................ 14 ELMIRON ................................................ 45 ELOCON ................................................. 51 ELOXATIN SOLN 100 MG/20ML ............. 14 ELOXATIN SOLN 200 MG/40ML ............. 14 ELSPAR .................................................. 14 EMADINE ................................................ 36 EMBEDA ................................................. 24 EMCYT .................................................... 14 EMEND CAPS 125 MG ........................... 37 EMEND CAPS 40 MG ............................. 37 EMEND CAPS 80 & 12 MG ..................... 37 EMEND CAPS 80 MG ............................. 37 EMLA ....................................................... 51 EMSAM ................................................... 27 EMTRIVA................................................. 11 ENABLEX ................................................ 53

enalapril maleate ...................................... 21 enalapril maleate & hydrochlorothiazide ... 21 ENBREL................................................... 45 ENBREL SURECLICK ............................. 45 ENGERIX-B ............................................. 49 ENJUVIA .................................................. 42 enoxaparin sodium ................................... 18 entacapone .............................................. 27 entecavir .................................................. 11 ENTOCORT EC ....................................... 38 ENTYVIO ................................................. 38 EPANED .................................................. 21 EPIDUO ................................................... 52 epinastine hcl (ophth) ............................... 36 epinephrine .............................................. 18 EPIPEN 2-PAK SOAJ 0.3 MG/0.3ML ....... 18 EPIPEN JR 2-PAK SOAJ 0.15 MG/0.3ML 18 epirubicin hcl ............................................ 14 EPIVIR HBV SOLN 5 MG/ML ................... 11 EPIVIR HBV TABS 100 MG ..................... 11 EPIVIR SOLN 10 MG/ML ......................... 11 EPIVIR TABS 150 MG ............................. 11 EPIVIR TABS 300 MG ............................. 11 eplerenone ............................................... 21 EPOGEN .................................................. 19 eprosartan mesylate ................................. 21 EPZICOM ................................................. 11 EQUETRO ............................................... 26 ERAXIS .................................................... 10 ERBITUX ................................................. 14 ergoloid mesylates ................................... 17 ergotamine tartrate ................................... 17 ergotamine w/ caffeine ............................. 27 ERIVEDGE .............................................. 14 ERTACZO ................................................ 50 ERWINAZE .............................................. 14 ERYPED 200 ............................................. 9 ERYPED 400 ............................................. 9 erythromycin (acne aid) ............................ 50 erythromycin (ophth) ................................ 34 erythromycin base ...................................... 9 erythromycin ethylsuccinate ....................... 9 erythromycin lactobionate .......................... 9 erythromycin stearate ................................. 9 ESBRIET .................................................. 48 escitalopram oxalate ................................ 29 esomeprazole magnesium ....................... 37 esomeprazole sodium .............................. 37 ESOMEPRAZOLE STRONTIUM ............. 37


estazolam ................................................ 28 esterified estrogens ................................. 42 estradiol ................................................... 42 estradiol & norethindrone acetate ............ 42 estradiol cypionate ................................... 42 estradiol vaginal ....................................... 42 estradiol valerate ..................................... 42 estradiol-norgestimate ............................. 42 ESTRING................................................. 42 estropipate ............................................... 42 eszopiclone .............................................. 28 ethambutol hcl ......................................... 11 ethosuximide ........................................... 26 ethynodiol diacet & eth estrad .................. 40 etidronate disodium ................................. 45 etodolac ................................................... 24 ETOPOPHOS .......................................... 14 etoposide ................................................. 14 EURAX .................................................... 50 EVAMIST SOLN 1.53 MG/SPRAY .......... 42 EVISTA .................................................... 42 EVOCLIN ................................................. 50 EVOTAZ .................................................. 11 EVOXAC.................................................. 16 EVZIO ...................................................... 29 EXALGO .................................................. 24 EXELDERM ............................................. 50 EXELON .................................................. 16 exemestane ............................................. 14 EXFORGE ............................................... 20 EXFORGE HCT ....................................... 20 EXJADE TBSO 125 MG .......................... 38 EXJADE TBSO 250 MG .......................... 38 EXJADE TBSO 500 MG .......................... 38 EXTAVIA ................................................. 45 EXTINA ................................................... 50

F FABIOR ................................................... 52 FABRAZYME ........................................... 34 FACTIVE ................................................... 9 famciclovir................................................ 11 famotidine ................................................ 37 famotidine in nacl ..................................... 37 FAMVIR ................................................... 12 FANAPT .................................................. 29 FANAPT TITRATION PACK .................... 29 FARESTON ............................................. 14

FARXIGA ................................................. 41 FARYDAK ................................................ 14 FASLODEX .............................................. 14 fat emulsion .............................................. 32 FAZACLO ................................................ 29 felbamate ................................................. 26 FELBATOL ............................................... 26 FELDENE ................................................ 24 felodipine .................................................. 20 FEMARA .................................................. 14 FEMCON FE ............................................ 40 FEMRING ................................................ 42 fenofibrate ................................................ 19 FENOFIBRATE ........................................ 19 fenofibrate micronized .............................. 19 FENOGLIDE ............................................ 19 fenoprofen calcium ................................... 24 fentanyl .............................................. 24, 25 fentanyl citrate .......................................... 24 FENTORA ................................................ 24 FERRIPROX ............................................ 38 FETZIMA .................................................. 29 FETZIMA TITRATION .............................. 29 FIBRICOR ................................................ 19 FINACEA ................................................. 52 finasteride ................................................ 45 FIORINAL ................................................ 24 FIORINAL/CODEINE #3 .......................... 24 FIRAZYR .................................................. 45 FIRMAGON .............................................. 14 FLAGYL ................................................... 11 FLAGYL ER ............................................. 11 FLAREX ................................................... 35 flavoxate hcl ............................................. 53 FLEBOGAMMA DIF SOLN 5 GM/100ML . 48 FLEBOGAMMA DIF SOLN 5 GM/50ML ... 48 flecainide acetate ..................................... 20 FLECTOR ................................................ 52 FLOMAX .................................................. 17 FLO-PRED ............................................... 38 FLOVENT DISKUS .................................. 48 FLOVENT HFA AERO 110 MCG/ACT ..... 48 FLOVENT HFA AERO 220 MCG/ACT ..... 48 FLOVENT HFA AERO 44 MCG/ACT ....... 48 fluconazole ............................................... 10 fluconazole in dextrose ............................ 10 flucytosine ................................................ 10 fludarabine phosphate .............................. 14 fludrocortisone acetate ............................. 38


FLUMADINE ............................................ 12 flunisolide (nasal) ..................................... 35 fluocinolone acetonide ............................. 51 fluocinolone acetonide (otic) .................... 35 fluocinonide ............................................. 51 fluocinonide emulsified base .................... 51 fluorometholone (ophth) ........................... 35 FLUOROPLEX CREA 1 % ...................... 52 fluorouracil ............................................... 14 fluorouracil (topical) ................................. 52 FLUOXETINE HCL .................................. 29 fluoxetine hcl tabs 20 mg ........................ 30 fluoxetine hcl caps 10 mg ........................ 29 fluoxetine hcl caps 20 mg ........................ 29 fluoxetine hcl caps 40 mg ........................ 29 fluoxetine hcl cpdr 90 mg ......................... 29 fluoxetine hcl soln 20 mg/5ml................... 29 fluoxetine hcl tabs 10 mg ......................... 30 fluphenazine decanoate ........................... 30 fluphenazine hcl ....................................... 30 flurazepam hcl ......................................... 28 flurbiprofen ............................................... 24 flurbiprofen sodium .................................. 35 flutamide .................................................. 14 fluticasone propionate .............................. 51 fluticasone propionate (nasal) .................. 35 fluvastatin sodium .................................... 19 fluvoxamine maleate ................................ 30 FML FORTE SUSP 0.25 % ..................... 35 FML LIQUIFILM SUSP 0.1 % .................. 35 FML OINT 0.1 % ...................................... 35 FOCALIN ................................................. 25 FOCALIN XR ........................................... 25 FOLOTYN................................................ 14 fomepizole ............................................... 46 fondaparinux sodium ............................... 18 FORADIL AEROLIZER ............................ 18 FORFIVO XL ........................................... 30 FORTAMET ............................................. 41 FORTAZ SOLR 1 GM ................................ 9 FORTAZ SOLR 2 GM ................................ 9 FORTAZ SOLR 6 GM ................................ 9 FORTEO.................................................. 43 FORTESTA GEL 10 MG/ACT (2%) ......... 39 FORTICAL ............................................... 43 FOSAMAX ............................................... 46 FOSAMAX PLUS D ................................. 46 foscarnet sodium ..................................... 12 fosinopril sodium ...................................... 21

fosinopril sodium & hydrochlorothiazide ... 21 fosphenytoin sodium ................................ 26 FOSRENOL ............................................. 33 FRAGMIN ................................................ 18 FREAMINE HBC SOLN 6.9 % ................. 32 FREAMINE III SOLN 3 % ......................... 32 FROVA..................................................... 27 FULYZAQ ................................................ 37 FURADANTIN .......................................... 13 furosemide soln 10 mg/ml ........................ 32 furosemide soln 8 mg/ml .......................... 32 furosemide tabs 20 mg ............................. 32 furosemide tabs 40 mg ............................. 32 furosemide tabs 80 mg ............................. 32 FUSILEV .................................................. 46 FUZEON .................................................. 12 FYCOMPA ............................................... 26

G gabapentin ............................................... 26 GABITRIL ................................................. 26 GABLOFEN SOLN 10000 MCG/20ML ..... 17 GABLOFEN SOLN 20000 MCG/20ML ..... 17 GABLOFEN SOLN 40000 MCG/20ML ..... 17 GABLOFEN SOLN 50 MCG/ML ............... 17 galantamine hydrobromide ....................... 16 GAMASTAN S/D ...................................... 48 GAMMAGARD S/D SOLR 10 GM ............ 48 GAMMAGARD S/D SOLR 2.5 GM ........... 48 GAMMAGARD S/D SOLR 5 GM .............. 48 GAMMAGARD SOLN 2.5 GM/25ML ........ 48 GAMMAKED SOLN 1 GM/10ML .............. 49 GAMMAPLEX SOLN 10 GM/200ML ........ 49 GAMUNEX-C SOLN 1 GM/10ML ............. 49 GAMUNEX-C SOLN 10 GM/100ML ......... 49 GAMUNEX-C SOLN 2.5 GM/25ML .......... 49 GAMUNEX-C SOLN 20 GM/200ML ......... 49 GAMUNEX-C SOLN 40 GM/400ML ......... 49 GAMUNEX-C SOLN 5 GM/50ML ............. 49 ganciclovir sodium .................................... 12 GARDASIL ............................................... 49 GARDASIL 9 ............................................ 49 GASTROCROM ....................................... 47 gatifloxacin (ophth) ................................... 34 GATTEX ................................................... 38 gauze pads & dressings ........................... 31 GAZYVA .................................................. 14 GELNIQUE .............................................. 53


gemcitabine hcl ........................................ 14 gemfibrozil ............................................... 19 GEMZAR ................................................. 14 GENERESS FE ....................................... 40 GENOTROPIN MINIQUICK SOLR 0.2 MG

............................................................. 43 GENOTROPIN MINIQUICK SOLR 0.4 MG



............................................................. 44 GENOTROPIN MINIQUICK SOLR 1 MG 44 GENOTROPIN MINIQUICK SOLR 1.4 MG



............................................................. 44 GENOTROPIN MINIQUICK SOLR 2 MG 44 GENOTROPIN SOLR 12 MG .................. 44 GENOTROPIN SOLR 5 MG .................... 44 gentamicin in saline ................................... 9 gentamicin sulfate ...................................... 9 gentamicin sulfate (ophth) ....................... 34 gentamicin sulfate (topical) ...................... 50 GEODON................................................. 30 GIAZO ..................................................... 37 GILENYA ................................................. 46 GILOTRIF ................................................ 14 GLASSIA ................................................. 48 glatiramer acetate .................................... 46 GLEEVEC................................................ 14 GLEOSTINE ............................................ 14 glimepiride ............................................... 41 glipizide er tb24 10 mg ............................. 41 glipizide er tb24 2.5 mg ............................ 41 glipizide er tb24 5 mg ............................... 41 glipizide tabs 10 mg ................................. 41 glipizide tabs 5 mg ................................... 41 glipizide-metformin hcl ............................. 41 GLUCAGEN HYPOKIT ............................ 41 GLUCAGON EMERGENCY .................... 41 GLUCOPHAGE ....................................... 41 GLUCOPHAGE XR ................................. 41 GLUCOTROL .......................................... 41 GLUCOTROL XL ..................................... 41 GLUCOVANCE ....................................... 41 GLUMETZA ............................................. 41

glyburide .................................................. 41 glyburide micronized ................................ 41 glyburide-metformin ................................. 41 glycopyrrolate ........................................... 16 GLYNASE ................................................ 41 GLYSET ................................................... 41 GLYXAMBI ............................................... 41 GOLYTELY .............................................. 38 GRALISE ................................................. 24 GRALISE STARTER ................................ 24 granisetron hcl ......................................... 37 GRANIX ................................................... 19 GRASTEK ................................................ 46 griseofulvin microsize ............................... 10 griseofulvin ultramicrosize ........................ 10 GRIS-PEG ............................................... 10 guanfacine hcl .......................................... 21 guanfacine hcl (adhd) ............................... 28 GUANIDINE HCL ..................................... 16

H HALAVEN ................................................ 14 HALCION ................................................. 28 HALDOL................................................... 30 HALDOL DECANOATE ........................... 30 halobetasol propionate ............................. 51 HALOG .................................................... 51 haloperidol ............................................... 30 haloperidol decanoate .............................. 30 haloperidol lactate .................................... 30 HARVONI ................................................. 12 HAVRIX.................................................... 49 HECTOROL ............................................. 53 HEMABATE ............................................. 46 heparin sod (porcine) in d5w .................... 18 heparin sodium (porcine) ......................... 18 HEPSERA ................................................ 12 HERCEPTIN ............................................ 14 HETLIOZ .................................................. 28 HEXALEN ................................................ 15 HIPREX.................................................... 13 HORIZANT ............................................... 26 HP ACTHAR ............................................ 43 HUMALOG KWIKPEN SOPN 100 UNIT/ML

............................................................. 41 HUMALOG KWIKPEN SOPN 200 UNIT/ML

............................................................. 41 HUMALOG MIX 50/50 .............................. 41


HUMALOG MIX 50/50 KWIKPEN ............ 41 HUMALOG MIX 75/25 ............................. 41 HUMALOG MIX 75/25 KWIKPEN ............ 41 HUMALOG SOCT 100 UNIT/ML ............. 41 HUMALOG SOLN 100 UNIT/ML .............. 41 HUMATROPE SOLR 12 MG ................... 44 HUMATROPE SOLR 24 MG ................... 44 HUMATROPE SOLR 5 MG ..................... 44 HUMATROPE SOLR 6 MG ..................... 44 HUMIRA .................................................. 46 HUMIRA PEN-CROHNS STARTER ........ 46 HUMULIN 70/30 KWIKPEN SUPN (70-30)

100 UNIT/ML ....................................... 41 HUMULIN 70/30 SUSP (70-30) 100

UNIT/ML .............................................. 41 HUMULIN N KWIKPEN SUPN 100

UNIT/ML .............................................. 41 HUMULIN N SUSP 100 UNIT/ML ............ 41 HUMULIN R SOLN 100 UNIT/ML ............ 41 HUMULIN R U-500 (CONCENTRATED)

SOLN 500 UNIT/ML ............................. 41 HYCAMTIN .............................................. 15 hydralazine hcl tabs 100 mg ................... 21 hydralazine hcl tabs 25 mg ..................... 21 hydralazine hcl soln 20mg/ml................... 21 hydralazine hcl tabs 10 mg ...................... 21 hydralazine hcl tabs 50 mg ...................... 21 HYDREA.................................................. 15 hydrochlorothiazide caps 12.5 mg ........... 32 hydrochlorothiazide tabs 12.5 mg ............ 32 hydrochlorothiazide tabs 25 mg ............... 32 hydrochlorothiazide tabs 50 mg ............... 32 hydrocodone-acetaminophen .................. 24 hydrocodone-ibuprofen ............................ 24 hydrocortisone ......................................... 39 hydrocortisone (intrarectal) ...................... 51 hydrocortisone (rectal) ............................. 51 hydrocortisone (topical) ........................... 51 hydrocortisone butyrate ........................... 51 hydrocortisone butyrate hydrophilic lipo

base ..................................................... 51 hydrocortisone sod succinate .................. 39 hydrocortisone valerate ........................... 51 hydrocortisone w/acetic acid .................... 35 hydromorphone hcl .................................. 24 hydroxychloroquine sulfate ...................... 11 hydroxyurea ............................................. 15 hydroxyzine hcl ........................................ 28 hydroxyzine pamoate ............................... 28

HYPERRAB S/D ...................................... 49 HYPERRHO S/D ...................................... 49 HYPERTET S/D ....................................... 49 HYQVIA ................................................... 49 HYSINGLA ER ......................................... 24 HYZAAR .................................................. 21

I ibandronate sodium .................................. 46 IBRANCE ................................................. 15 ibuprofen .................................................. 24 ICLUSIG ................................................... 15 IDAMYCIN PFS ....................................... 15 idarubicin hcl ............................................ 15 IFEX ......................................................... 15 ifosfamide ................................................. 15 ILARIS ..................................................... 24 ILEVRO .................................................... 35 IMBRUVICA ............................................. 15 imipenem-cilastatin .................................... 9 imipramine hcl .......................................... 30 imipramine pamoate ................................. 30 imiquimod ................................................. 52 IMITREX .................................................. 27 IMITREX STATDOSE REFILL ................. 27 IMOGAM RABIES-HT .............................. 49 IMOVAX RABIES ..................................... 49 IMURAN ................................................... 46 INCIVEK ................................................... 12 INCRELEX ............................................... 44 INCRUSE ELLIPTA .................................. 16 indapamide .............................................. 32 INDERAL LA ............................................ 23 INDOCIN .................................................. 24 indomethacin ............................................ 24 INFANRIX ................................................ 49 INFERGEN .............................................. 12 INLYTA .................................................... 15 INNOPRAN XL ......................................... 23 INSPRA.................................................... 21 insulin pen needle .................................... 31 insulin syringe/needle u-100..................... 31 INTEGRILIN ............................................. 18 INTELENCE TABS 100 MG ..................... 12 INTELENCE TABS 200 MG ..................... 12 INTELENCE TABS 25 MG ....................... 12 INTERMEZZO .......................................... 28 INTRALIPID EMUL 30 % ......................... 32


INTRON A ............................................... 15 INTUNIV .................................................. 28 INVANZ ..................................................... 9 INVEGA ................................................... 30 INVEGA SUSTENNA ............................... 30 INVIRASE CAPS 200 MG ....................... 12 INVIRASE TABS 500 MG ........................ 12 INVOKAMET ........................................... 41 INVOKANA .............................................. 41 IONOSOL-B IN D5W ............................... 33 IONOSOL-MB IN D5W ............................ 33 IOPIDINE SOLN 0.5 % ............................ 36 IOPIDINE SOLN 1 % ............................... 36 IPOL ........................................................ 49 ipratropium bromide ................................. 16 ipratropium bromide (nasal) ..................... 16 ipratropium-albuterol ................................ 18 irbesartan................................................. 21 irbesartan-hydrochlorothiazide................. 21 IRESSA ................................................... 15 irinotecan hcl ........................................... 15 irrigation solutions, physiological ............. 33 ISENTRESS CHEW 100 MG ................... 12 ISENTRESS CHEW 25 MG ..................... 12 ISENTRESS PACK 100 MG .................... 12 ISENTRESS TABS 400 MG .................... 12 ISOLYTE-P IN D5W ................................ 33 ISOLYTE-S .............................................. 33 isoniazid .................................................. 11 isoniazid & rifampin.................................. 11 ISOPTO CARPINE SOLN 2 % ................ 36 ISOPTO CARPINE SOLN 4 % ................ 36 ISORDIL TITRADOSE ............................. 22 isosorbide dinitrate................................... 22 isosorbide mononitrate tabs 10 mg ......... 22 isosorbide mononitrate tabs 20 mg ......... 22 isosorbide mononitrate er tb24 120 mg.... 22 isosorbide mononitrate er tb24 30 mg...... 22 isosorbide mononitrate er tb24 60 mg...... 22 isotretinoin ............................................... 52 isradipine ................................................. 20 ISTALOL .................................................. 36 ISTODAX ................................................. 15 itraconazole ............................................. 10 ivermectin .................................................. 8 IXEMPRA KIT .......................................... 15 IXIARO .................................................... 49

J JADENU TABS 180 MG ........................... 38 JADENU TABS 360 MG ........................... 38 JADENU TABS 90 MG ............................. 38 JAKAFI ..................................................... 15 JALYN ...................................................... 46 JANUMET ................................................ 41 JANUMET XR .......................................... 41 JANUVIA .................................................. 41 JARDIANCE ............................................. 41 JENTADUETO ......................................... 41 JEVTANA ................................................. 15 JUBLIA ..................................................... 50 JUXTAPID ................................................ 19

K KADCYLA ................................................ 15 KADIAN CP24 10 MG .............................. 24 KADIAN CP24 100 MG ............................ 24 KADIAN CP24 20 MG .............................. 24 KADIAN CP24 200 MG ............................ 24 KADIAN CP24 30 MG .............................. 24 KADIAN CP24 40 MG .............................. 24 KADIAN CP24 50 MG .............................. 24 KADIAN CP24 60 MG .............................. 24 KADIAN CP24 80 MG .............................. 24 KALETRA SOLN 400-100 MG/5ML ......... 12 KALETRA TABS 100-25 MG .................... 12 KALETRA TABS 200-50 MG .................... 12 KALYDECO ............................................. 48 KAPVAY................................................... 21 KARBINAL ER ......................................... 13 KAYEXALATE .......................................... 33 KAZANO .................................................. 41 KCL IN DEXTROSE-NACL SOLN 20-5-

0.225 MEQ/L-%-% ............................... 33 KCL IN DEXTROSE-NACL SOLN 40-5-0.9

MEQ/L-%-% ......................................... 33 KCL-LACTATED RINGERS-D5W ............ 33 KEFLEX ..................................................... 9 KENALOG .......................................... 39, 51 KEPIVANCE ............................................ 52 KEPPRA .................................................. 26 KEPPRA XR ............................................ 26 KERYDIN ................................................. 50 KETEK ....................................................... 9 ketoconazole ............................................ 10 ketoconazole & cleanser .......................... 50


ketoconazole (topical) .............................. 50 ketoprofen................................................ 24 ketorolac tromethamine ........................... 24 ketorolac tromethamine (ophth) ............... 35 KEYTRUDA ............................................. 15 KHEDEZLA .............................................. 30 KINERET ................................................. 46 KITABIS PAK ............................................. 9 KLARON .................................................. 50 KLONOPIN .............................................. 26 KOMBIGLYZE XR ................................... 41 KORLYM ................................................. 41 K-TAB TBCR 10 MEQ ............................. 33 K-TAB TBCR 20 MEQ ............................. 33 K-TAB TBCR 8 MEQ ............................... 33 KUVAN .................................................... 46 KYNAMRO .............................................. 19 KYPROLIS ............................................... 15

L labetalol hcl .............................................. 23 LAC-HYDRIN ........................................... 52 LACRISERT ............................................ 36 lactated ringer's ....................................... 33 lactated ringer's (irrigation) ...................... 33 lactic acid (ammonium lactate) ................ 52 lactulose .................................................. 31 lactulose (encephalopathy) ...................... 31 LAMICTAL CHEW 25 MG ....................... 26 LAMICTAL CHEW 5 MG ......................... 26 LAMICTAL ODT TAB 50MG .................... 26 LAMICTAL ODT TBDP 100 MG .............. 26 LAMICTAL ODT TBDP 200 MG .............. 26 LAMICTAL ODT TBDP 25 MG ................ 26 LAMICTAL STARTER KIT 25 (35) MG .... 26 LAMICTAL STARTER KIT 25 (42)-100 (7)

MG ....................................................... 26 LAMICTAL STARTER KIT 25 (84)-100 (14)

MG ....................................................... 26 LAMICTAL TABS 100 MG ....................... 26 LAMICTAL TABS 150 MG ....................... 26 LAMICTAL TABS 200 MG ....................... 26 LAMICTAL TABS 25 MG ......................... 26 LAMICTAL XR KIT 25 & 50 & 100 MG .... 26 LAMICTAL XR KIT 25 (21)-50 (7) MG ..... 26 LAMICTAL XR KIT 50 & 100 & 200 MG .. 26 LAMICTAL XR TB24 100 MG .................. 26 LAMICTAL XR TB24 200 MG .................. 26

LAMICTAL XR TB24 25 MG .................... 26 LAMICTAL XR TB24 250 MG .................. 26 LAMICTAL XR TB24 300 MG .................. 26 LAMICTAL XR TB24 50 MG .................... 26 LAMISIL ................................................... 10 lamivudine ................................................ 12 lamivudine (hbv) ....................................... 12 lamivudine-zidovudine .............................. 12 lamotrigine ............................................... 26 LANOXIN PEDIATRIC SOLN 0.1 MG/ML

............................................................. 20 LANOXIN SOLN 0.25 MG/ML .................. 20 LANOXIN TABS 125 MCG ....................... 20 LANOXIN TABS 187.5 MCG .................... 20 LANOXIN TABS 250 MCG ....................... 20 LANOXIN TABS 62.5 MCG ...................... 20 lansoprazole ............................................. 37 LANTUS SOLN 100 UNIT/ML .................. 41 LANTUS SOLOSTAR SOPN 100 UNIT/ML

............................................................. 41 LASIX ....................................................... 32 LASTACAFT ............................................ 36 latanoprost ............................................... 36 LATUDA ................................................... 30 LAZANDA ................................................ 24 leflunomide ............................................... 46 LEMTRADA ............................................. 46 LENVIMA 10 MG DAILY DOSE ............... 15 LENVIMA 14 MG DAILY DOSE ............... 15 LENVIMA 20 MG DAILY DOSE ............... 15 LENVIMA 24 MG DAILY DOSE ............... 15 LESCOL ................................................... 19 LESCOL XL ............................................. 19 LETAIRIS ................................................. 48 letrozole ................................................... 15 leucovorin calcium .................................... 46 LEUKERAN .............................................. 15 LEUKINE .................................................. 19 leuprolide acetate ..................................... 15 levalbuterol hcl ......................................... 18 LEVAQUIN ................................................. 9 LEVEMIR ................................................. 41 LEVEMIR FLEXTOUCH ........................... 41 levetiracetam ............................................ 26 LEVETIRACETAM IN NACL .................... 26 levobunolol hcl ......................................... 36 levocarnitine (metabolic modifiers) ........... 46 levocetirizine dihydrochloride ................... 13 levofloxacin ................................................ 9


levofloxacin (ophth).................................. 34 levofloxacin in d5w..................................... 9 levoleucovorin calcium ............................. 46 levonorgestrel & eth estradiol .................. 40 levonorgestrel-eth estradiol (triphasic) ..... 40 levonorgestrel-ethinyl estradiol (91-day) .. 40 levonorgestrel-ethinyl estradiol (continuous)

............................................................. 40 levorphanol tartrate .................................. 24 levothyroxine sodium ............................... 44 LEVOTHYROXINE SODIUM ................... 44 LEXAPRO................................................ 30 LEXIVA SUSP 50 MG/ML ........................ 12 LEXIVA TABS 700 MG ............................ 12 LIALDA TBEC 1.2 GM ............................. 37 lidocaine .................................................. 52 lidocaine hcl ............................................. 52 lidocaine hcl (local anesth.) ..................... 46 lidocaine hcl (mouth-throat) ..................... 36 lidocaine-prilocaine .................................. 52 LIDODERM .............................................. 52 LINCOCIN ................................................. 9 lindane ..................................................... 50 linezolid ..................................................... 9 LINZESS.................................................. 38 LIORESAL SOLN 0.05 MG/ML ................ 17 LIORESAL SOLN 10 MG/20ML ............... 17 LIORESAL SOLN 10 MG/5ML ................. 17 LIORESAL SOLN 40 MG/20ML ............... 17 liothyronine sodium .................................. 44 LIPITOR .................................................. 19 LIPOFEN ................................................. 19 LIPOSYN III EMUL 10 % ......................... 32 LIPTRUZET ............................................. 19 lisinopril tabs 30 mg ................................ 21 lisinopril & hydrochlorothiazide ................ 21 lisinopril tabs 10 mg ................................. 21 lisinopril tabs 2.5 mg ................................ 21 lisinopril tabs 20 mg ................................. 21 lisinopril tabs 40 mg ................................. 21 lisinopril tabs 5 mg ................................... 21 LITHIUM .................................................. 30 lithium carbonate ..................................... 30 LITHIUM CARBONATE CAPS 600 MG ... 30 LITHOBID TBCR 300 MG ........................ 30 LITHOSTAT ............................................. 31 LIVALO .................................................... 19 LO LOESTRIN FE ................................... 40 LOCOID ................................................... 51

LODOSYN ............................................... 27 LOMOTIL ................................................. 37 LOMUSTINE ............................................ 15 loperamide hcl .......................................... 37 LOPID ...................................................... 19 LOPRESSOR ........................................... 23 LOPRESSOR HCT .................................. 23 LOPROX .................................................. 50 lorazepam ................................................ 28 losartan potassium ................................... 21 losartan potassium & hydrochlorothiazide 21 LOSEASONIQUE..................................... 40 LOTEMAX ................................................ 35 LOTENSIN ............................................... 21 LOTREL ................................................... 20 LOTRISONE ............................................ 50 LOTRONEX ............................................. 37 lovastatin .................................................. 19 LOVAZA ................................................... 19 LOVENOX ................................................ 18 loxapine succinate.................................... 30 LUMIGAN ................................................. 36 LUMIZYME .............................................. 34 LUNESTA ................................................ 28 LUPANETA PACK ................................... 15 LUPRON DEPOT KIT 30 MG .................. 15 LUPRON DEPOT IKIT 3.75 MG ............... 15 LUPRON DEPOT KIT 11.25 MG .............. 15 LUPRON DEPOT KIT 22.5 MG ................ 15 LUPRON DEPOT KIT 3.75 MG ................ 15 LUPRON DEPOT KIT 45 MG ................... 15 LUPRON DEPOT KIT 7.5 MG .................. 15 LUPRON DEPOT-PED ............................ 15 LUZU ....................................................... 50 LYNPARZA .............................................. 15 LYRICA .................................................... 26 LYSODREN ............................................. 15 LYSTEDA ................................................. 18

M MACROBID .............................................. 13 MACRODANTIN CAPS 100 MG .............. 13 MACRODANTIN CAPS 25 MG ................ 13 MACRODANTIN CAPS 50 MG ................ 13 magnesium sulfate ................................... 27 MAGNESIUM SULFATE .......................... 27 MAGNESIUM SULFATE IN D5W ............ 33 MALARONE ............................................. 11


malathion ................................................. 50 maprotiline hcl ......................................... 30 MARINOL ................................................ 37 MARPLAN ............................................... 30 MARQIBO................................................ 15 MATULANE ............................................. 15 MAVIK ..................................................... 21 MAXAIR AUTOHALER ............................ 18 MAXALT .................................................. 27 MAXALT-MLT .......................................... 27 MAXIDEX ................................................ 35 MAXIPIME SOLR 1 GM ............................. 9 MAXIPIME SOLR 2 GM ............................. 9 MAXITROL .............................................. 35 MAXZIDE................................................. 33 MAXZIDE-25 ........................................... 33 mecamylamine hcl ................................... 21 meclizine hcl ............................................ 37 meclofenamate sodium ............................ 24 MEDROL (PAK) TABS 4 MG ................... 39 MEDROL TABS 16 MG ........................... 39 MEDROL TABS 2 MG ............................. 39 MEDROL TABS 32 MG ........................... 39 MEDROL TABS 4 MG ............................. 39 MEDROL TABS 8 MG ............................. 39 medroxyprogesterone acetate ................. 43 medroxyprogesterone acetate

(contraceptive) ..................................... 43 mefenamic acid ....................................... 24 mefloquine hcl ......................................... 11 MEGACE ES ........................................... 43 MEGACE ORAL ...................................... 15 megestrol acetate .................................... 15 MEKINIST................................................ 15 meloxicam ............................................... 24 melphalan hcl .......................................... 15 MENACTRA ............................................ 49 MENOMUNE ........................................... 49 MENOSTAR PTWK 14 MCG/24HR ......... 42 MENTAX.................................................. 50 MENVEO ................................................. 49 meperidine hcl ......................................... 24 meprobamate .......................................... 28 MEPRON ................................................. 11 mercaptopurine ........................................ 15 meropenem ............................................... 9 MERREM................................................... 9 mesalamine w/ cleanser .......................... 37 mesna ...................................................... 46

MESNEX SOLN 100 MG/ML .................... 46 MESNEX TABS 400 MG .......................... 46 MESTINON TABS 60 MG ....................... 17 MESTINON SYRP 60 MG/5ML ................ 17 MESTINON TBCR 180 MG ...................... 17 METADATE CD ....................................... 25 metaproterenol sulfate ............................. 18 metaxalone .............................................. 17 metformin hcl er (osm) tb24 1000 mg....... 41 metformin hcl er tab 750mg er ................. 41 metformin hcl er tb24 500 mg ................... 41 metformin hcl er tb24 750 mg ................... 41 metformin hcl tabs 1000 mg ..................... 41 metformin hcl tabs 500 mg ....................... 41 metformin hcl tabs 850 mg ....................... 41 methadone hcl ......................................... 24 METHADONE HCL SOLN 10 MG/ML ...... 24 methamphetamine hcl .............................. 25 methazolamide ......................................... 36 methenamine hippurate ........................... 13 methimazole ............................................. 44 methocarbamol ........................................ 17 methotrexate sodium ................................ 15 methoxsalen rapid .................................... 52 methscopolamine bromide ....................... 16 methyclothiazide ...................................... 33 methyldopa .............................................. 21 methyldopa & hydrochlorothiazide ........... 21 methyldopate hcl ...................................... 21 methylergonovine maleate ....................... 46 METHYLIN ............................................... 25 methylphenidate hcl ........................... 25, 30 methylprednisolone .................................. 39 methylprednisolone acetate ..................... 39 methylprednisolone sod succ ................... 39 methyltestosterone ................................... 39 metipranolol ............................................. 36 metoclopramide hcl .................................. 38 metolazone .............................................. 33 metoprolol & hydrochlorothiazide ............. 23 metoprolol succinate ................................ 23 metoprolol tartrate soln 1 mg/ml ............... 23 metoprolol tartrate tabs 100 mg ............... 23 metoprolol tartrate tabs 25 mg ................. 23 metoprolol tartrate tabs 50 mg ................. 23 METOZOLV ODT ..................................... 38 METRO .................................................... 11 METROCREAM ....................................... 50 METROGEL ............................................. 50


METROGEL-VAGINAL ............................ 50 METROLOTION ...................................... 50 metronidazole .......................................... 11 metronidazole (topical) ............................ 50 metronidazole in nacl ............................... 11 metronidazole vaginal .............................. 50 mexiletine hcl ........................................... 20 MIACALCIN ............................................. 43 MICARDIS ............................................... 21 MICARDIS HCT ....................................... 21 miconazole nitrate vaginal ....................... 50 MICROZIDE ............................................ 33 midodrine hcl ........................................... 18 MIFEPREX .............................................. 46 MIGRANAL .............................................. 17 MINASTRIN 24 FE .................................. 40 MINIPRESS ............................................. 19 MINIQUICK SOLR 1.2 MG ...................... 44 MINIVELLE PTTW 0.025 MG/24HR ........ 43 MINIVELLE PTTW 0.0375 MG/24HR ...... 43 MINIVELLE PTTW 0.05 MG/24HR .......... 43 MINIVELLE PTTW 0.075 MG/24HR ........ 43 MINIVELLE PTTW 0.1 MG/24HR ............ 43 MINOCIN ................................................... 9 minocycline hcl .......................................... 9 minoxidil .................................................. 21 MIRAPEX ................................................ 27 MIRAPEX ER .......................................... 27 MIRCERA SOLN 100 MCG/0.3ML .......... 19 MIRCERA SOLN 200 MCG/0.3ML .......... 19 MIRCERA SOLN 50 MCG/0.3ML ............ 19 MIRCERA SOLN 75 MCG/0.3ML ............ 19 mirtazapine .............................................. 30 MIRVASO ................................................ 52 misoprostol .............................................. 37 mitomycin ................................................ 15 mitoxantrone hcl ...................................... 15 M-M-R II .................................................. 49 MOBIC ..................................................... 24 modafinil .................................................. 25 MODICON (28) ........................................ 40 moexipril hcl ............................................. 22 moexipril-hydrochlorothiazide .................. 22 mometasone furoate ................................ 51 montelukast sodium ................................. 47 MONUROL .............................................. 13 morphine sulfate ...................................... 24 MORPHINE SULFATE (PF) SOLN 10

MG/ML ................................................. 24

MORPHINE SULFATE (PF) SOLN 2 MG/ML ................................................. 24



morphine sulfate beads ............................ 25 MORPHINE SULFATE TABS 15 MG ....... 25 MORPHINE SULFATE TABS 30 MG ....... 25 MOVANTIK .............................................. 38 MOVIPREP .............................................. 38 MOXEZA .................................................. 34 moxifloxacin hcl .......................................... 9 MOZOBIL ................................................. 19 MS CONTIN TBCR 100 MG ..................... 25 MS CONTIN TBCR 15 MG ....................... 25 MS CONTIN TBCR 200 MG ..................... 25 MS CONTIN TBCR 60 MG ....................... 25 MS CONTIN TTBCR 30 MG .................... 25 MULTAQ .................................................. 20 mupirocin ................................................. 50 mupirocin calcium (topical) ....................... 50 MUSTARGEN .......................................... 15 MYALEPT ................................................ 46 MYAMBUTOL .......................................... 11 MYCAMINE .............................................. 10 MYCOBUTIN ........................................... 11 mycophenolate mofetil ............................. 46 mycophenolate sodium ............................ 46 MYFORTIC .............................................. 46 MYOZYME ............................................... 34 MYRBETRIQ ............................................ 53 MYSOLINE .............................................. 27

N NABI-HB .................................................. 49 nabumetone ............................................. 25 nadolol tabs 40 mg .................................. 23 nadolol & bendroflumethiazide ................. 23 nadolol tabs 20 mg ................................... 23 nadolol tabs 80 mg ................................... 23 nafcillin sodium .......................................... 9 naftifine hcl ............................................... 50 NAFTIN .................................................... 50 NAGLAZYME ........................................... 34 nalbuphine hcl .......................................... 25 NALLPEN IN DEXTROSE.......................... 9 naloxone hcl ............................................. 29


naltrexone hcl .......................................... 29 NAMENDA SOLN 10 MG/5ML ................ 28 NAMENDA TABS 10 MG ......................... 28 NAMENDA TABS 5 MG ........................... 28 NAMENDA TITRATION PAK TABS 5 (28)-

10 (21) MG ........................................... 28 NAMENDA XR CP24 14 MG ................... 28 NAMENDA XR CP24 21 MG ................... 28 NAMENDA XR CP24 28 MG ................... 28 NAMENDA XR CP24 7 MG ..................... 28 NAMENDA XR TITRATION PACK CP24 7

& 14 & 21 & 28 MG .............................. 28 naphazoline hcl ........................................ 36 NAPRELAN ............................................. 25 NAPROSYN ............................................ 25 naproxen ................................................. 25 naproxen sodium ..................................... 25 naratriptan hcl .......................................... 27 NARDIL ................................................... 30 NASONEX ............................................... 35 NATACYN ............................................... 34 NATAZIA ................................................. 40 nateglinide ............................................... 41 NATESTO GEL 5.5 MG/ACT ................... 39 NATPARA................................................ 43 NEBUPENT SOLR 300 MG ..................... 11 NECON 1/50 (28) .................................... 40 nefazodone hcl ........................................ 30 neomycin sulfate ........................................ 9 neomycin/polymyxin b gu ........................ 50 neomycin-bacitracin zn-polymyxin ........... 34 neomycin-fluocinolone ............................. 51 neomycin-polymy-dexameth .................... 35 neomycin-polymyxin-gramicidin ............... 34 neomycin-polymyxin-hc (ophth) ............... 35 neomycin-polymyxin-hc (otic) .................. 35 NEORAL CAPS 100 MG ......................... 46 NEORAL CAPS 25 MG ........................... 46 NEORAL SOLN 100 MG/ML.................... 46 NEPHRAMINE SOLN 5.4 % .................... 32 NESINA ................................................... 41 NEULASTA .............................................. 19 NEUMEGA .............................................. 19 NEUPOGEN ............................................ 19 NEUPRO ................................................. 27 NEURONTIN ........................................... 27 NEVANAC ............................................... 35 NEVIRAPINE ........................................... 12 NEXAVAR ............................................... 15

NEXIUM ................................................... 37 NEXIUM I.V. ............................................. 37 NEXTERONE ........................................... 20 niacin (antihyperlipidemic) .................. 19, 53 NIASPAN ................................................. 19 nicardipine hcl .......................................... 20 NICOTROL INHA 10 MG ......................... 16 NICOTROL NS SOLN 10 MG/ML ............ 16 nifedipine .................................................. 20 NILANDRON ............................................ 15 nimodipine ................................................ 20 NIPENT .................................................... 15 nisoldipine ................................................ 20 NITRO-DUR PT24 0.1 MG/HR ................. 22 NITRO-DUR PT24 0.2 MG/HR ................. 22 NITRO-DUR PT24 0.3 MG/HR ................. 22 NITRO-DUR PT24 0.4 MG/HR ................. 22 NITRO-DUR PT24 0.6 MG/HR ................. 22 NITRO-DUR PT24 0.8 MG/HR ................. 22 nitrofurantoin ............................................ 13 nitrofurantoin macrocrystal ....................... 13 nitrofurantoin monohyd macro .................. 13 nitroglycerin .............................................. 22 NITROLINGUAL SOLN 0.4 MG/SPRAY .. 22 NITROMIST AERS 400 MCG/SPRAY ..... 22 NITROSTAT SUBL 0.3 MG ...................... 22 NITROSTAT SUBL 0.4 MG ...................... 22 NITROSTAT SUBL 0.6 MG ...................... 22 nizatidine .................................................. 37 NIZORAL ................................................. 50 NORDITROPIN FLEXPRO SOLN 10

MG/1.5 ML ........................................... 44 NORDITROPIN FLEXPRO SOLN 15

MG/1.5ML ............................................ 44 NORDITROPIN FLEXPRO SOLN 5

MG/1.5ML ............................................ 44 NORDITROPIN NORDIFLEX PEN SOLN

30 MG/3ML .......................................... 44 norelgestromin-ethinyl estradiol ............... 40 norethin acet & estrad-fe .......................... 40 norethindrone & eth estradiol ................... 40 norethindrone & ethinyl estradiol-fe .......... 40 norethindrone (contraceptive) .................. 40 norethindrone acet & eth estra ................. 40 norethindrone acetate .............................. 43 norethindrone acetate-ethinyl estradiol .... 43 norethindrone acetate-ethinyl estradiol-fe 40 norethindrone-eth estradiol (biphasic) ...... 40 norethindrone-eth estradiol (triphasic) ...... 40


norgestimate-ethinyl estradiol .................. 40 norgestimate-ethinyl estradiol (triphasic) . 40 norgestrel & ethinyl estradiol.................... 40 NORINYL 1+35 (28) ................................ 40 NORINYL 1+50 (28) ................................ 40 NORITATE .............................................. 50 NORMOSOL-R IN D5W .......................... 33 NORMOSOL-R PH 7.4 ............................ 33 NORPACE CAPS 100 MG ...................... 20 NORPACE CAPS 150 MG ...................... 20 NORPACE CR CP12 100 MG ................. 20 NORPACE CR CP12 150 MG ................. 20 NORPRAMIN ........................................... 30 NOR-QD .................................................. 40 NORTHERA ............................................ 18 nortriptyline hcl caps 10 mg ..................... 30 nortriptyline hcl caps 25 mg ..................... 30 nortriptyline hcl caps 50 mg ..................... 30 nortriptyline hcl caps 75 mg ..................... 30 nortriptyline hcl soln 10 mg/5ml ............... 30 NORVASC ............................................... 20 NORVIR .................................................. 12 NOVOLIN 70/30 SUSP (70-30) 100

UNIT/ML .............................................. 42 NOVOLIN N SUSP 100 UNIT/ML ............ 42 NOVOLIN R SOLN 100 UNIT/ML ............ 42 NOVOLOG .............................................. 42 NOVOLOG FLEXPEN ............................. 42 NOVOLOG MIX 70/30 ............................. 42 NOVOLOG MIX 70/30 FLEXPEN ............ 42 NOVOLOG PENFILL ............................... 42 NOXAFIL ................................................. 10 NUCYNTA ............................................... 25 NUCYNTA ER ......................................... 25 NUEDEXTA ............................................. 28 NULOJIX ................................................. 46 NULYTELY WITH FLAVOR PACKS ........ 38 NUTRESTORE ........................................ 38 NUTROPIN AQ NUSPIN 5 SOLN 5

MG/2ML ............................................... 44 NUTROPIN AQ PEN SOLN 10 MG/2ML . 44 NUTROPIN AQ PEN SOLN 20 MG/2ML . 44 NUTROPIN AQ SOLN 10 MG/2ML ......... 44 NUTROPIN SOLR 10 MG ....................... 44 NUVARING .............................................. 40 NUVESSA ............................................... 50 NUVIGIL .................................................. 25 nystatin .................................................... 10 nystatin (mouth-throat) ............................. 10

nystatin (topical) ....................................... 50 nystatin-triamcinolone .............................. 51

O OCTAGAM SOLN 2 GM/20ML ................. 49 OCTAGAM SOLN 25 GM/500ML ............. 49 OCTAGAM SOLN 5 GM/100ML ............... 49 octreotide acetate..................................... 46 OCUFEN .................................................. 35 OCUFLOX ................................................ 34 OFEV ....................................................... 48 ofloxacin ..................................................... 9 ofloxacin (ophth) ...................................... 34 ofloxacin (otic) .......................................... 34 olanzapine ................................................ 30 olanzapine-fluoxetine hcl .......................... 30 olopatadine hcl (nasal) ............................. 36 OLUX FOAM 0.05 % ................................ 51 OLYSIO.................................................... 12 OMECLAMOX-PAK ................................. 37 omega-3-acid ethyl esters ........................ 19 omeprazole .............................................. 37 omeprazole-sodium bicarbonate .............. 37 OMNARIS ................................................ 35 OMNIPRED SUSP 1 % ............................ 35 OMNITROPE SOLN 10 MG/1.5ML .......... 44 OMNITROPE SOLN 5 MG/1.5ML ............ 44 OMNITROPE SOLR 5.8 MG .................... 44 ONCASPAR ............................................. 15 ondansetron ............................................. 37 ondansetron hcl ....................................... 37 ONEXTON ............................................... 50 ONFI ........................................................ 27 ONGLYZA ................................................ 42 ONMEL TABS 200 MG ............................ 10 OPANA .................................................... 25 OPANA ER .............................................. 25 OPDIVO ................................................... 15 OPSUMIT ................................................. 48 ORACEA .................................................. 52 ORAP ....................................................... 30 ORAPRED ODT ....................................... 39 ORBACTIV ................................................. 9 ORENCIA ................................................. 46 ORENITRAM TAB 2.5MG ........................ 48 ORENITRAM TBCR 0.125 MG ................ 48 ORENITRAM TBCR 0.25 MG .................. 48 ORENITRAM TBCR 1 MG ....................... 48


ORENITRAM TBCR 2.5 MG .................... 48 ORFADIN ................................................ 46 ORKAMBI ................................................ 48 orphenadrine citrate ................................. 17 ORTHO MICRONOR ............................... 40 ORTHO TRI-CYCLEN (28) ...................... 40 ORTHO TRI-CYCLEN LO ....................... 40 ORTHO-CEPT (28).................................. 40 ORTHO-CYCLEN (28) ............................. 40 ORTHO-NOVUM 1/35 (28) ...................... 40 ORTHO-NOVUM 7/7/7 (28) ..................... 40 OSENI ..................................................... 42 OSMOPREP ............................................ 38 OTEZLA .................................................. 46 OTREXUP SOAJ 10 MG/0.4ML .............. 46 OTREXUP SOAJ 15 MG/0/4ML .............. 46 OTREXUP SOAJ 20 MG/0.4ML .............. 46 OTREXUP SOAJ 25 MG/0.4ML .............. 46 oxacillin sodium ......................................... 9 oxaliplatin................................................. 15 oxandrolone ............................................. 39 oxaprozin ................................................. 25 oxazepam ................................................ 28 oxcarbazepine ......................................... 27 OXISTAT ................................................. 50 OXSORALEN .......................................... 52 OXSORALEN ULTRA .............................. 52 OXTELLAR XR ........................................ 27 oxybutynin chloride .................................. 53 oxycodone hcl .......................................... 25 oxycodone w/ acetaminophen ................. 25 oxycodone-aspirin ................................... 25 oxycodone-ibuprofen ............................... 25 OXYCONTIN ........................................... 25 oxymorphone hcl ..................................... 25 OXYTROL ............................................... 53

P paclitaxel ................................................. 15 PAMELOR ............................................... 30 pamidronate disodium ............................. 46 PANCREAZE ........................................... 38 PANDEL .................................................. 51 PANRETIN .............................................. 52 pantoprazole sodium ............................... 37 PARAFON FORTE DSC .......................... 17 parenteral electrolytes ............................. 33 paricalcitol................................................ 53

PARICALCITOL ....................................... 53 PARNATE ................................................ 30 paromomycin sulfate ................................ 11 paroxetine hcl er tb24 12.5 mg ................. 30 paroxetine hcl er tb24 25 mg .................... 30 paroxetine hcl er tb24 37.5 mg ................. 30 paroxetine hcl tabs 10 mg ........................ 30 paroxetine hcl tabs 20 mg ........................ 30 paroxetine hcl tabs 30 mg ........................ 30 paroxetine hcl tabs 40 mg ........................ 30 PATADY ................................................... 36 PATANASE .............................................. 36 PATANOL ................................................ 36 PAXIL ....................................................... 30 PAXIL CR ................................................. 30 PAZEO ..................................................... 36 PCE ........................................................... 9 PEDVAX HIB ........................................... 49 peg 3350-kcl-sod bicarb-sod chloride-sod

sulfate ................................................... 38 peg 3350-potassium chloride-sod

bicarbonate-sod chloride ...................... 38 PEGANONE ............................................. 27 PEGASYS ................................................ 12 PEGASYS PROCLICK ............................. 12 PEGINTRON ............................................ 12 PEG-INTRON .......................................... 12 PEG-INTRON REDIPEN .......................... 12 PENICILLIN G POT IN DEXTROSE .......... 9 penicillin g potassium ................................. 9 penicillin g procaine .................................... 9 penicillin g sodium ...................................... 9 penicillin v potassium ................................. 9 PENNSAID ............................................... 52 PENTAM SOLR 300 MG .......................... 11 PENTASA CAP 500MG CR ..................... 37 PENTASA CPCR 250 MG........................ 37 PENTASA CPCR 500 MG........................ 37 pentazocine w/ naloxone .......................... 25 pentoxifylline ............................................ 18 PEPCID.................................................... 37 PERCODAN ............................................. 25 PERFOROMIST ....................................... 18 perindopril erbumine ................................ 22 PERJETA ................................................. 15 permethrin ................................................ 50 perphenazine ........................................... 30 perphenazine-amitriptyline ....................... 30 PERSANTINE .......................................... 22


PERTZYE ................................................ 38 PEXEVA .................................................. 30 phenelzine sulfate .................................... 30 phenobarbital ........................................... 28 PHENOBARBITAL................................... 28 phenytoin ................................................. 27 phenytoin sodium .................................... 27 phenytoin sodium extended ..................... 27 PHISOHEX .............................................. 50 PHOSLO CAPS 667 MG ......................... 33 PHOSLYRA SOLN 667 MG/5ML ............. 33 PHOSPHOLINE IODIDE ......................... 36 PICATO ................................................... 52 pilocarpine hcl .......................................... 36 pilocarpine hcl (oral) ................................ 17 PILOPINE HS GEL 4 % ........................... 36 pindolol .................................................... 23 pioglitazone hcl ........................................ 42 pioglitazone hcl-glimepiride ..................... 42 pioglitazone hcl-metformin hcl ................. 42 piperacillin sodium-tazobactam sodium ..... 9 piroxicam ................................................. 25 PLAN B ONE-STEP ................................. 40 PLAQUENIL ............................................ 11 PLASMA-LYTE 148 ................................. 33 PLASMA-LYTE A .................................... 33 PLASMA-LYTE-56 IN D5W ..................... 33 PLAVIX .................................................... 18 PLEGRIDY .............................................. 12 PLEGRIDY STARTER PACK .................. 12 PLETAL ................................................... 18 podofilox .................................................. 52 polyethylene glycol 3350 ......................... 38 polymyxin b sulfate .................................... 9 polymyxin b-trimethoprim ......................... 34 POLYTRIM .............................................. 34 POMALYST ............................................. 15 PONSTEL ................................................ 25 potassium chloride ................................... 33 potassium chloride in dextrose ................ 33 potassium chloride in dextrose & sodium

chloride ................................................ 33 potassium chloride in nacl ....................... 34 POTASSIUM CHLORIDE IN NACL SOLN

20-0.45 MEQ/L-% ................................ 34 POTASSIUM CHLORIDE IN NACL SOLN

20-0.9 MEQ/L-% .................................. 34 POTASSIUM CHLORIDE IN NACL SOLN

40-0.9 MEQ/L-% .................................. 34

potassium chloride microencapsulated crystals cr ............................................. 34

POTASSIUM CHLORIDE SOLN 10 MEQ/100ML ......................................... 34



potassium citrate (alkalinizer) ................... 31 POTIGA ................................................... 27 PRADAXA ................................................ 18 PRALUENT .............................................. 19 pramipexole dihydrochloride .................... 27 PRANDIMET ............................................ 42 PRANDIN ................................................. 42 PRAVACHOL ........................................... 19 pravastatin sodium ................................... 19 prazosin hcl .............................................. 19 PRECOSE ............................................... 42 PRED FORTE SUSP 1 % ........................ 35 PRED MILD SUSP 0.12 % ....................... 35 PRED-G ................................................... 35 PRED-G S.O.P. ....................................... 35 prednicarbate ........................................... 51 prednisolone ............................................ 39 prednisolone acetate (ophth) .................... 35 prednisolone sodium phosphate .............. 39 prednisolone sodium phosphate (ophth) .. 35 prednisone ............................................... 39 PREMARIN .............................................. 43 PREMARIN SOLR 25 MG ........................ 43 PREMARIN TABS 0.3 MG ....................... 43 PREMARIN TABS 0.45 MG ..................... 43 PREMARIN TABS 0.625 .......................... 43 PREMARIN TABS 0.9 MG ....................... 43 PREMARIN TABS 1.25 MG ..................... 43 PREMPHASE .......................................... 43 PREMPRO ............................................... 43 PREPOPIK ............................................... 38 PREVACID ............................................... 37 PREVACID SOLUTAB ............................. 37 PREVPAC ................................................ 37 PREZCOBIX ............................................ 12 PREZISTA TABS 150 MG........................ 12 PREZISTA TABS 400 MG........................ 12 PREZISTA TABS 600 MG........................ 12 PREZISTA TABS 75 MG ......................... 12 PREZISTA TABS 800 MG........................ 12 PRIFTIN ................................................... 11


PRILOSEC .............................................. 37 PRIMAQUINE PHOSPHATE ................... 11 PRIMAXIN IV ............................................. 9 primidone ................................................. 27 PRIMSOL ................................................ 13 PRINIVIL.................................................. 22 PRISTIQ .................................................. 30 PRIVIGEN SOLN 20 GM/200ML ............. 49 PROAIR HF AAERS 108 (90 BASE)

MCG/ACT ............................................ 18 PROAIR RESPICLICK AEPB 108 (90

BASE) MCG/ACT ................................. 18 probenecid ............................................... 34 procainamide hcl ..................................... 20 PROCALAMINE SOLN 3 % ..................... 32 PROCARDIA ........................................... 20 PROCARDIA XL ...................................... 20 prochlorperazine ...................................... 30 prochlorperazine edisylate ....................... 30 prochlorperazine maleate ........................ 30 PROCRIT ................................................ 19 PROCYSBI CPDR 25 MG ....................... 46 PROCYSBI CPDR 75 MG ....................... 46 progesterone micronized ......................... 43 PROGLYCEM .......................................... 21 PROGRAF CAPS 0.5 MG ....................... 46 PROGRAF CAPS 1 MG .......................... 46 PROGRAF CAPS 5 MG .......................... 46 PROGRAF SOLN 5 MG/ML..................... 46 PROLASTIN-C ........................................ 48 PROLENSA ............................................. 35 PROLEUKIN ............................................ 15 PROLIA SOLN 60 MG/ML ....................... 46 PROMACTA ............................................ 19 promethazine & phenylephrine ................ 13 promethazine hcl ..................................... 13 PROMETRIUM ........................................ 43 propafenone hcl ....................................... 20 propantheline bromide ............................. 16 proparacaine hcl ...................................... 36 propranolol & hydrochlorothiazide ........... 23 propranolol hcl er cp24 120 mg ............... 23 propranolol hcl er cp24 160 mg ............... 23 propranolol hcl er cp24 60 mg ................. 23 propranolol hcl er cp24 80 mg ................. 23 propranolol hcl soln 1 mg/ml .................... 23 propranolol hcl soln 20 mg/5ml ................ 23 propranolol hcl soln 40 mg/5ml ................ 23 propranolol hcl tabs 10 mg ...................... 23

propranolol hcl tabs 20 mg ....................... 23 propranolol hcl tabs 40 mg ....................... 23 propranolol hcl tabs 60 mg ....................... 23 propranolol hcl tabs 80 mg ....................... 23 propylthiouracil ......................................... 44 PROQUAD ............................................... 49 PROSCAR ............................................... 46 PROSOL SOLN 20 % .............................. 32 PROTONIX .............................................. 37 PROTOPIC .............................................. 52 protriptyline hcl ......................................... 30 PROVENTIL HFA AERS 108 (90 BASE)

MCG/ACT ............................................. 18 PROVERA ............................................... 43 PROVIGIL ................................................ 25 PROZAC .................................................. 30 PROZAC WEEKLY .................................. 30 PRUDOXIN .............................................. 52 PULMICORT FLEXHALER AEPB 180

MCG/ACT ............................................. 48 PULMICORT FLEXHALER AEPB 90

MCG/ACT ............................................. 48 PULMICORT SUSP 0.25 MG/2ML ........... 48 PULMICORT SUSP 0.5 MG/2ML ............. 48 PULMICORT SUSP 1 MG/2ML ................ 48 PULMOZYME .......................................... 34 PURIXAN ................................................. 15 PYLERA ................................................... 37 pyrazinamide ............................................ 11 pyridostigmine bromide ............................ 17

Q QNASL ..................................................... 35 QNASL CHILDRENS ............................... 35 QUADRACEL ........................................... 49 QUALAQUIN ............................................ 11 QUARTETTE ........................................... 40 QUDEXY XR ............................................ 27 quetiapine fumarate ................................. 30 QUILLIVANT XR ...................................... 26 quinapril hcl .............................................. 22 quinapril-hydrochlorothiazide ................... 22 quinidine gluconate .................................. 20 QUINIDINE GLUCONATE ....................... 20 quinidine sulfate ....................................... 20 quinine sulfate .......................................... 11 QVAR ....................................................... 48


R RABAVERT ............................................. 49 rabeprazole sodium ................................. 37 RAGWITEK ............................................. 46 raloxifene hcl ........................................... 43 ramipril ..................................................... 22 RANEXA .................................................. 20 ranitidine hcl ............................................ 37 RAPAFLO ................................................ 17 RAPAMUNE ............................................ 46 RASUVO SOAJ 10 MG/0.2ML ................. 46 RASUVO SOAJ 12.5 MG/0.25ML ............ 46 RASUVO SOAJ 15 MG/0.3ML ................. 46 RASUVO SOAJ 17.5 MG MG/0.35ML ..... 46 RASUVO SOAJ 20 MG/0.4ML ................. 46 RASUVO SOAJ 22.5 MG/0.45ML ............ 46 RASUVO SOAJ 25 MG/0.5ML ................. 46 RASUVO SOAJ 27.5 MG/0.055ML .......... 46 RASUVO SOAJ 30 MG/0.6ML ................. 46 RASUVO SOAJ 7.5 MG/0.15ML .............. 47 RAVICTI .................................................. 31 RAYOS .................................................... 39 RAZADYNE ............................................. 17 RAZADYNE ER ....................................... 17 REBETOL ................................................ 12 REBIF ...................................................... 47 REBIF REBIDOSE................................... 47 REBIF REBIDOSE TITRATION PACK .... 47 REBIF TITRATION PACK ....................... 47 RECLAST ................................................ 47 RECOMBIVAX HB ................................... 49 RECTIV ................................................... 52 REGLAN .................................................. 38 REGONOL SOLN 10 MG/2ML ............... 17 REGRANEX ............................................ 52 RELENZA DISKHALER ........................... 12 RELISTOR ............................................... 38 RELPAX .................................................. 27 REMERON .............................................. 30 REMERON SOLTAB ............................... 30 REMICADE .............................................. 47 REMODULIN ........................................... 48 RENAGEL ............................................... 33 RENVELA ................................................ 33 repaglinide ............................................... 42 REQUIP ................................................... 27 REQUIP XL ............................................. 27 RESCRIPTOR ......................................... 12

RESERPINE ............................................ 21 RESTASIS ............................................... 35 RESTORIL ............................................... 28 RETIN-A CREA 0.025 % .......................... 52 RETIN-A CREA 0.05 % ............................ 52 RETIN-A CREA 0.1 % .............................. 52 RETIN-A GEL 0.01% ............................... 52 RETIN-A GEL 0.025% ............................. 52 RETIN-A MICRO ...................................... 52 RETIN-A MICRO PUMP .......................... 52 RETROVIR CAPS 100 MG ...................... 12 RETROVIR SOLN 10 MG/ML .................. 12 RETROVIR SYRP 50 MG/5ML ................ 12 REVATIO SOLN 10 MG/12.5ML .............. 22 REVATIO SUSR 10 MG/ML ..................... 22 REVATIO TABS 20 MG ........................... 22 REVLIMID ................................................ 15 REYATAZ CAPS 200 MG ....................... 12 REYATAZ CAPS 100 MG ........................ 12 REYATAZ CAPS 150 MG ........................ 12 REYATAZ CAPS 300 MG ........................ 12 REYATAZ PACK 50 MG .......................... 12 RHEUMATREX ........................................ 15 RHINOCORT AQUA ................................ 35 RHOPHYLAC ........................................... 49 ribavirin (hepatitis c) ................................. 12 RIDAURA ................................................. 38 rifabutin .................................................... 11 RIFADIN ................................................... 11 rifampin .................................................... 11 RIFATER .................................................. 11 RILUTEK .................................................. 29 riluzole ..................................................... 29 rimantadine hydrochloride ........................ 12 RIMSO-50 ................................................ 47 ringer's inj ................................................. 34 ringer's irrigation ....................................... 33 RIOMET ................................................... 42 risedronate sodium ................................... 47 RISPERDAL ............................................. 30 RISPERDAL CONSTA ............................. 30 RISPERDAL M-TAB ................................. 30 risperidone ............................................... 31 RITALIN ................................................... 26 RITALIN LA .............................................. 26 RITUXAN ................................................. 15 rivastigmine tartrate .................................. 17 rizatriptan benzoate .................................. 27 ROBINUL -FORTE TABS 2MG ................ 16


ROBINUL TABS 1MG .............................. 16 ROCALTROL CAPS 0.25 MCG ............... 53 ROCALTROL CAPS 0.5 MCG ................. 53 ROCALTROL SOLN 1 MCG/ML .............. 53 ropinirole hydrochloride ........................... 28 ROTARIX................................................. 49 ROTATEQ ............................................... 49 ROXICODONE ........................................ 25 ROZEREM ............................................... 28 RUCONEST ............................................ 47 RYTARY .................................................. 28 RYTHMOL ............................................... 20 RYTHMOL SR ......................................... 20

S SABRIL .................................................... 27 SAFYRAL ................................................ 40 SAIZEN ................................................... 44 SAIZEN CLICK.EASY .............................. 44 SALAGEN................................................ 17 SAMSCA ................................................. 33 SANCUSO ............................................... 37 SANDIMMUNE ........................................ 47 SANDOSTATIN LAR DEPOT KIT 10 MG 47 SANDOSTATIN LAR DEPOT KIT 20 MG 47 SANDOSTATIN LAR DEPOT KIT 30 MG 47 SANDOSTATIN SOLN 100 MCG/ML ...... 47 SANDOSTATIN SOLN 1000 MCG/ML .... 47 SANDOSTATIN SOLN 200 MG/ML ......... 47 SANDOSTATIN SOLN 50 MCG/ML ........ 47 SANDOSTATIN SOLN 500 MCG/ML ...... 47 SANTYL .................................................. 52 SAPHRIS ................................................. 31 SARAFEM ............................................... 31 SAVAYSA ................................................ 18 SAVELLA................................................. 29 SAVELLA TITRATION PACK .................. 29 SEASONIQUE ......................................... 40 secobarbital sodium ................................. 28 SECTRAL ................................................ 23 selegiline hcl ............................................ 28 selenium sulfide ....................................... 50 SELZENTRY ........................................... 12 SEMPREX-D ........................................... 13 SENSIPAR TABS 30 MG ........................ 47 SENSIPAR TABS 60 MG ........................ 47 SENSIPAR TABS 90 MG ........................ 47 SEREVENT DISKUS ............................... 18

SEROQUEL ............................................. 31 SEROQUEL XR ....................................... 31 SEROSTIM .............................................. 44 sertraline hcl ............................................. 31 SFROWASA ENEM 4 GM/60ML .............. 37 SIGNIFOR ................................................ 44 SIGNIFOR LAR ........................................ 44 sildenafil citrate (pulmonary hypertension)

............................................................. 22 SILENOR ................................................. 28 SILVADENE ............................................. 50 silver sulfadiazine ..................................... 50 SIMBRINZA ............................................. 36 SIMCOR ................................................... 19 SIMPONI .................................................. 47 SIMPONI ARIA ........................................ 47 SIMULECT ............................................... 47 simvastatin ............................................... 19 SINEMET ................................................. 28 SINEMET CR ........................................... 28 SINGULAIR .............................................. 47 sirolimus ................................................... 47 SIRTURO ................................................. 11 SIVEXTRO ................................................. 9 SKELAXIN ............................................... 17 SKLICE ...................................................... 8 sodium chloride ........................................ 34 sodium chloride (gu irrigant) ..................... 33 SODIUM DIURIL ...................................... 33 SODIUM EDECRIN .................................. 33 SODIUM FLUORIDE ................................ 47 SODIUM LACTATE SOLN 167 MEQ/L ... 31 SODIUM LACTATE SOLN 5 MEQ/ML ..... 31 sodium phenylbutyrate ............................. 31 sodium polystyrene sulfonate ................... 33 SOLARAZE .............................................. 52 SOLODYN ................................................. 9 SOLTAMOX ............................................. 15 SOLU-CORTEF ....................................... 39 SOLU-MEDROL SOLR 1000 MG ............ 39 SOLU-MEDROL SOLR 125 MG .............. 39 SOLU-MEDROL SOLR 2 GM .................. 39 SOLU-MEDROL SOLR 40 MG ................ 39 SOLU-MEDROL SOLR 500 MG .............. 39 SOMA ...................................................... 17 SOMATULINE DEPOT ............................ 47 SOMAVERT ............................................. 44 SONATA .................................................. 28 SOOLANTRA ........................................... 50


SORIATANE ............................................ 52 SORILUX ................................................. 52 sotalol hcl................................................. 23 sotalol hcl (afib/afl) ................................... 23 SOTYLIZE ............................................... 19 SOVALDI ................................................. 12 SPECTRACEF .......................................... 9 SPIRIVA HANDIHALER .......................... 16 SPIRIVA RESPIMAT ............................... 16 spironolactone & hydrochlorothiazide ...... 22 spironolactone tabs 100 mg ..................... 22 spironolactone tabs 25 mg ....................... 22 spironolactone tabs 50 mg ....................... 22 SPORANOX CAPS 100 MG .................... 10 SPORANOX PULSEPAK CAPS 100 MG 10 SPORANOX SOLN 10 MG/ML ................ 10 SPRIX ...................................................... 25 SPRYCEL ................................................ 15 STALEVO 100 ......................................... 28 STALEVO 125 ......................................... 28 STALEVO 150 ......................................... 28 STALEVO 200 ......................................... 28 STALEVO 50 ........................................... 28 STALEVO 75 ........................................... 28 STARLIX.................................................. 42 stavudine ................................................. 12 STELARA ................................................ 52 STIMATE SOLN 1.5 MG/ML .................... 43 STIOLTO RESPIMAT .............................. 16 STIVARGA .............................................. 15 STRATTERA ........................................... 29 streptomycin sulfate ................................... 9 STRIANT MISC 30 MG ............................ 39 STRIBILD ................................................ 12 STRIVERDI RESPIMAT .......................... 18 STROMECTOL .......................................... 8 SUBOXONE ............................................ 29 SUBSYS .................................................. 25 SUCLEAR................................................ 38 SUCRAID ................................................ 34 sucralfate ................................................. 37 SULAR .................................................... 20 sulfacetamide sodium (acne) ................... 50 sulfacetamide sodium (ophth) .................. 34 sulfacetamide sod-prednisolone .............. 35 sulfadiazine ................................................ 9 sulfamethoxazole-trimethoprim .................. 9 SULFAMYLON CREA 85 MG/GM ........... 50 SULFAMYLON PACK 5 % ...................... 50

sulfasalazine ............................................ 10 sulindac .................................................... 25 SUMATRIPTAN ....................................... 27 sumatriptan succinate .............................. 27 SUMAVEL DOSEPRO ............................. 27 SUPRAX .................................................. 10 SUPREP BOWEL PREP .......................... 38 SURMONTIL ............................................ 31 SUSP 100 MG/ML .................................... 12 SUSTIVA .................................................. 12 SUTENT ................................................... 15 SYLATRON .............................................. 15 SYLVANT ................................................. 15 SYMBICORT ............................................ 48 SYMBYAX ................................................ 31 SYMLINPEN 120 ..................................... 42 SYMLINPEN 60 ....................................... 42 SYNAGIS ................................................. 13 SYNALAR (CREAM) ................................ 51 SYNALGOS-DC ....................................... 25 SYNAREL ................................................ 43 SYNERCID .............................................. 10 SYNRIBO ................................................. 15 SYNTHROID ............................................ 44 SYPRINE ................................................. 38

T TABLOID .................................................. 15 TACLONEX OINT 0.005-0.064 % ............ 51 TACLONEX SUSP 0.005-0.064 % ........... 51 tacrolimus ................................................. 47 tacrolimus (topical) ................................... 52 TAFINLAR ................................................ 15 TALWIN ................................................... 25 TAMIFLU .................................................. 13 tamoxifen citrate ....................................... 15 tamsulosin hcl .......................................... 17 TANZEUM ................................................ 42 TARCEVA ................................................ 16 TARGRETIN ...................................... 16, 52 TARKA ..................................................... 20 TASIGNA ................................................. 16 TASMAR .................................................. 28 TAXOTERE CONC 80 MG/4ML ............... 16 TAZORAC ................................................ 52 TECFIDERA ............................................. 47 TECHNIVIE .............................................. 13 TEFLARO ................................................ 10


TEGRETOL SUSP 100 MG/5ML ............. 27 TEGRETOL TABS 200 MG ..................... 27 TEGRETOL-XR TB12 100 MG ................ 27 TEGRETOL-XR TB12 200 MG ................ 27 TEGRETOL-XR TB12 400 MG ................ 27 TEKAMLO ............................................... 22 TEKTURNA ............................................. 22 TEKTURNA HCT ..................................... 22 telmisartan ............................................... 22 telmisartan-amlodipine ............................. 20 telmisartan-hydrochlorothiazide ............... 22 temazepam .............................................. 28 TEMOVATE CREA 0.05 % ...................... 51 TEMOVATE GEL 0.05 % ......................... 51 TEMOVATE OINT 0.05 % ....................... 51 TENEX .................................................... 21 TENIVAC ................................................. 49 TENORETIC 100 ..................................... 23 TENORETIC 50 ....................................... 23 TENORMIN ............................................. 23 TERAZOL 3 ............................................. 50 TERAZOL 7 ............................................. 50 terazosin hcl ............................................ 19 terbinafine hcl .......................................... 10 terbutaline sulfate .................................... 18 terconazole vaginal .................................. 50 TESTIM GEL 50 MG/5GM (1%) .............. 39 testosterone ............................................. 39 testosterone cypionate ............................. 39 testosterone enanthate ............................ 39 TESTOSTERONE GEL 25 MG/2.5GM (1%)

............................................................. 39 TETANUS TOXOID ADSORBED ............ 49 TETANUS-DIPHTHERIA TOXOIDS TD .. 49 TETRACYCLINE HCL ............................. 10 tetrahydrozoline hcl.................................. 36 TEVETEN ................................................ 22 TEVETEN HCT ........................................ 22 TEV-TROPIN SOLR 5 MG ...................... 44 THALOMID .............................................. 47 theophylline ............................................. 53 THIOLA ................................................... 47 thioridazine hcl ......................................... 31 thiothixene ............................................... 31 THYMOGLOBULIN.................................. 47 THYROLAR-1 .......................................... 44 THYROLAR-1/2 ....................................... 44 THYROLAR-1/4 ....................................... 45 THYROLAR-2 .......................................... 45

THYROLAR-3 .......................................... 45 tiagabine hcl ............................................. 27 TIAZAC .................................................... 20 TICE BCG ................................................ 16 ticlopidine hcl ........................................... 18 TIGAN ...................................................... 37 TIKOSYN ................................................. 20 timolol maleate ......................................... 23 timolol maleate (ophth) ............................. 36 TIMOPTIC OCUDOSE ............................. 36 TIMOPTIC-XE .......................................... 36 TINDAMAX .............................................. 11 tinidazole .................................................. 11 TIROSINT ................................................ 45 TIVICAY ................................................... 13 TIVORBEX ............................................... 25 tizanidine hcl ............................................ 17 TOBI ........................................................ 10 TOBI PODHALER .................................... 10 TOBRADEX OINT 0.3-0.1 % .................... 35 TOBRADEX ST SUSP 0.3-0.5 % ............. 35 TOBRADEX SUSP 0.3-0.1 % .................. 35 tobramycin ............................................... 10 tobramycin (ophth) ................................... 34 tobramycin sulfate .................................... 10 tobramycin sulfate in saline ...................... 10 tobramycin-dexamethasone ..................... 35 TOBREX OINT 0.3 % ............................... 34 TOBREX SOLN 0.3 % ............................. 34 TOFRANIL-PM ......................................... 31 tolazamide ................................................ 42 tolbutamide .............................................. 42 tolcapone ................................................. 28 tolmetin sodium ........................................ 25 tolterodine tartrate .................................... 53 TOPAMAX ............................................... 27 TOPAMAX SPRINKLE ............................. 27 TOPICORT .............................................. 51 TOPICORT SPRAY ................................. 51 topiramate ................................................ 27 topotecan hcl ............................................ 16 TOPROL XL ............................................. 23 TORISEL .................................................. 16 torsemide ................................................. 33 TOUJEO SOLOSTAR SOPN 300 UNIT/ML

............................................................. 42 TOVIAZ .................................................... 53 TRACLEER .............................................. 48 TRADJENTA ............................................ 42


tramadol hcl ............................................. 25 tramadol-acetaminophen ......................... 25 trandolapril ............................................... 22 trandolapril-verapamil hcl ......................... 20 tranexamic acid ....................................... 18 TRANSDERM-SCOP ............................... 37 TRANXENE-T .......................................... 28 tranylcypromine sulfate ............................ 31 TRAVASOL SOLN 10 % .......................... 32 TRAVATAN Z .......................................... 36 travoprost................................................. 36 trazodone hcl tabs 100 mg ...................... 31 trazodone hcl tabs 150 mg ...................... 31 trazodone hcl tabs 300 mg ...................... 31 trazodone hcl tabs 50 mg ........................ 31 TREANDA SOLN 45 MG/0.5ML .............. 16 TREANDA SOLR 100 MG ....................... 16 TRECATOR ............................................. 11 TRELSTAR MIXJECT .............................. 16 tretinoin .................................................... 52 tretinoin (chemotherapy) .......................... 16 tretinoin microsphere ............................... 52 tretinoin w/ cleanser & moisturizer ........... 52 TREXIMET .............................................. 27 triamcinolone acetonide (mouth) .............. 51 triamcinolone acetonide (nasal) ............... 35 triamcinolone acetonide (topical) ............. 51 triamterene-hctz caps 37.5-25 mg ........... 33 triamterene-hctz caps 50-25 mg .............. 33 triamterene-hctz tabs 37.5-25 mg ............ 33 triamterene-hctz tabs 75-50 mg ............... 33 triazolam .................................................. 28 TRIBENZOR ............................................ 20 TRICOR ................................................... 19 trifluoperazine hcl .................................... 31 trifluridine ................................................. 34 TRIGLIDE ................................................ 19 trihexyphenidyl hcl ................................... 28 TRILEPTAL ............................................. 27 TRILIPIX .................................................. 19 trimethobenzamide hcl ............................. 37 trimethoprim ............................................. 13 TRINATAL RX 1 ...................................... 53 TRI-NORINYL (28) .................................. 40 TRI-NORINYL 28 ..................................... 40 TRIOSTAT ............................................... 45 TRISENOX .............................................. 16 TRIUMEQ ................................................ 13 TRIZIVIR.................................................. 13

TROKENDI XR ........................................ 27 TROPHAMINE SOLN 10 % ..................... 32 TROPHAMINE SOLN 6 % ....................... 32 trospium chloride ...................................... 53 TRULICITY .............................................. 42 TRUMENBA ............................................. 49 TRUSOPT ................................................ 36 TRUVADA ................................................ 13 TUDORZA PRESSAIR ............................. 16 TWINRIX .................................................. 49 TWYNSTA ............................................... 20 TYBOST ................................................... 47 TYGACIL .................................................. 10 TYKERB ................................................... 16 TYPHIM VI ............................................... 49 TYSABRI .................................................. 47 TYVASO .................................................. 48 TYZEKA ................................................... 13

U UCERIS ............................................. 39, 51 ULORIC ................................................... 47 ULTRACET .............................................. 25 ULTRAM .................................................. 25 ULTRAM ER ............................................ 25 ULTRAVATE ............................................ 51 ULTRESA ................................................ 38 UNASYN .................................................. 10 UNITUXIN ................................................ 16 UROCIT-K 10 ........................................... 31 UROCIT-K 15 ........................................... 31 UROCIT-K 5 ............................................. 31 UROXATRAL ........................................... 17 URSO 250 ................................................ 38 URSO FORTE ......................................... 38 ursodiol .................................................... 38 UVADEX .................................................. 52

V VAGIFEM ................................................. 43 valacyclovir hcl ......................................... 13 VALCHLOR .............................................. 52 VALCYTE SOLR 50 MG/ML .................... 13 VALCYTE TABS 450 MG ......................... 13 valganciclovir hcl ...................................... 13 VALIUM.................................................... 28 valproate sodium ...................................... 27 valproic acid ............................................. 27


valsartan .................................................. 22 valsartan-hydrochlorothiazide .................. 22 VALSTAR ................................................ 16 VALTREX ................................................ 13 VANCOCIN HCL ..................................... 10 vancomycin hcl ........................................ 10 VANCOMYCIN HCL IN DEXTROSE ....... 10 VANOS .................................................... 51 VANTAS .................................................. 16 VAQTA .................................................... 49 VARIVAX ................................................. 49 VARIZIG .................................................. 49 VASCEPA................................................ 19 VASERETIC ............................................ 22 VASOTEC ............................................... 22 VECTIBIX ................................................ 16 VECTICAL ............................................... 52 VELCADE ................................................ 16 VELPHORO ............................................. 33 VELTIN .................................................... 52 venlafaxine hcl ......................................... 31 VENLAFAXINE HCL ER .......................... 31 VENTAVIS ............................................... 48 VENTOLIN HFA AERS 108 (90 BASE)

MCG/ACT ............................................ 18 VERAMYST ............................................. 35 verapamil hcl ........................................... 20 VEREGEN ............................................... 52 VERELAN ................................................ 20 VERELAN PM ......................................... 20 VERSACLOZ ........................................... 31 VESICARE .............................................. 53 VEXOL .................................................... 35 VFEND IV SOLR 200 MG ........................ 10 VFEND SUSR 40 MG/ML ........................ 10 VFEND TABS 200 MG ............................ 10 VFEND TABS 50 MG .............................. 10 VIBRAMYCIN .......................................... 10 VICOPROFEN ......................................... 25 VICTOZA ................................................. 42 VICTRELIS .............................................. 13 VIDAZA ................................................... 16 VIDEX EC CPDR 125 MG ....................... 13 VIDEX EC CPDR 200 MG ....................... 13 VIDEX EC CPDR 250 MG ....................... 13 VIDEX EC CPDR 400 MG ....................... 13 VIDEX SOLR 2 GM ................................. 13 VIEKIRA PAK .......................................... 13 VIGAMOX ................................................ 34

VIIBRYD ................................................... 31 VIMIZIM ................................................... 34 VIMOVO ................................................... 25 VIMPAT.................................................... 27 VINATE CALCIUM ................................... 53 vinblastine sulfate..................................... 16 vincristine sulfate...................................... 16 vinorelbine tartrate ................................... 16 VIOKACE ................................................. 38 VIRACEPT ............................................... 13 VIRAMUNE .............................................. 13 VIRAMUNE XR ........................................ 13 VIRAZOLE ............................................... 13 VIREAD.................................................... 13 VIROPTIC ................................................ 34 VISTARIL ................................................. 28 VISTIDE ................................................... 13 VITASPIRE .............................................. 53 VITEKTA .................................................. 13 VIVELLE-DOT PTTW 0.025 MG/24HR .... 43 VIVELLE-DOT PTTW 0.0375 MG/24HR .. 43 VIVELLE-DOT PTTW 0.05 MG/24HR ...... 43 VIVELLE-DOT PTTW 0.075 MG/24HR .... 43 VIVELLE-DOT PTTW 0.1 MG/24HR ........ 43 VIVITROL ................................................. 29 VOGELXO GEL 50 MG/5GM (1%)........... 39 VOGELXO PUMP GEL 12.5 MG/ACT (1%)

............................................................. 39 VOLTAREN .............................................. 52 VOLTAREN-XR ....................................... 25 VORAXAZE ............................................. 47 voriconazole ............................................. 11 vospire er tb12 8 mg ............................... 18 vospire er tb12 4 mg ................................ 18 VOTRIENT ............................................... 16 VPRIV ...................................................... 34 VUMON.................................................... 16 VYTORIN ................................................. 19 VYVANSE ................................................ 26

W warfarin sodium ........................................ 18 water for irrigation, sterile ......................... 33 WELCHOL ............................................... 19 WELLBUTRIN .......................................... 31 WELLBUTRIN SR .................................... 31 WELLBUTRIN XL..................................... 31


X XALATAN ................................................ 36 XALKORI ................................................. 16 XANAX .................................................... 28 XANAX XR .............................................. 28 XARELTO ................................................ 18 XARELTO STARTER PACK.................... 19 XARTEMIS XR ........................................ 25 XELJANZ ................................................. 47 XENAZINE ............................................... 29 XEOMIN .................................................. 47 XERESE .................................................. 50 XGEVA SOLN 120 MG/1.7ML ................. 47 XIFAXAN ................................................. 10 XIGDUO XR ............................................ 42 XOLAIR ................................................... 48 XOPENEX ............................................... 18 XOPENEX HFA ....................................... 18 XTANDI ................................................... 16 XYLOCAINE ...................................... 47, 52 XYREM .................................................... 29 XYZAL ..................................................... 13

Y YASMIN 28 .............................................. 40 YAZ ......................................................... 40 YERVOY.................................................. 16 YF-VAX ................................................... 49

Z zafirlukast ................................................ 47 zaleplon ................................................... 28 ZALTRAP ................................................ 16 ZANAFLEX .............................................. 17 ZANOSAR ............................................... 16 ZANTAC .................................................. 38 ZANTAC IN NACL ................................... 38 ZARONTIN .............................................. 27 ZAVESCA ................................................ 47 ZEBETA .................................................. 23 ZEGERID................................................. 38 ZELAPAR ................................................ 28 ZELBORAF .............................................. 16 ZEMAIRA................................................. 48 ZEMPLAR................................................ 53 ZENPEP .................................................. 38 ZERBAXA ................................................ 10

ZERIT ...................................................... 13 ZESTORETIC .......................................... 22 ZESTRIL .................................................. 22 ZETIA ....................................................... 19 ZETONNA ................................................ 35 ZIAC ......................................................... 23 ZIAGEN SOLN 20 MG/ML ....................... 13 ZIAGEN TABS 300 MG ............................ 13 ZIANA ...................................................... 52 zidovudine ................................................ 13 ZINACEF IN D5W .................................... 10 ZINACEF IN STERILE WATER ............... 10 ZINACEF SOLR 1.5 GM .......................... 10 ZINACEF SOLR 7.5 GM .......................... 10 ZINACEF SOLR 750 MG ......................... 10 ZINC TRACE METAL ............................... 34 ZINECARD ............................................... 47 ZIOPTAN ................................................. 36 ziprasidone hcl ......................................... 31 ZIPSOR.................................................... 25 ZIRGAN ................................................... 34 ZITHROMAX PACK 1 GM........................ 10 ZITHROMAX SOLR 500 MG .................... 10 ZITHROMAX SUSR 100 MG/5ML ........... 10 ZITHROMAX SUSR 200 MG/5ML ........... 10 ZITHROMAX TABS 250 MG .................... 10 ZITHROMAX TABS 500 MG .................... 10 ZITHROMAX TABS 600 MG .................... 10 ZITHROMAX TRI-PAK TABS 500 MG ..... 10 ZITHROMAX Z-PAK TABS 250 MG ......... 10 ZMAX SUSR 2 MG .................................. 10 ZOCOR .................................................... 19 ZOFRAN .................................................. 37 ZOFRAN ODT .......................................... 37 ZOHYDRO ER ......................................... 25 zoledronic acid ......................................... 47 ZOLINZA .................................................. 16 zolmitriptan ............................................... 27 ZOLOFT ................................................... 31 zolpidem tartrate ...................................... 28 ZOLPIMIST .............................................. 28 ZOMACTON SOLR 10 MG ...................... 44 ZOMACTON SOLR 5 MG ........................ 44 ZOMETA .................................................. 47 ZOMIG ..................................................... 27 ZOMIG ZMT ............................................. 27 ZONALON ................................................ 52 ZONEGRAN ............................................. 27 zonisamide ............................................... 27


ZONTIVITY .............................................. 19 ZORBTIVE ............................................... 44 ZORTRESS TABS 0.25 MG .................... 47 ZORTRESS TABS 0.5 MG ...................... 47 ZORTRESS TABS 0.75 MG .................... 47 ZORVOLEX ............................................. 25 ZOSTAVAX ............................................. 49 ZOSYN .................................................... 10 ZOVIRAX ........................................... 13, 50 ZUBSOLV ................................................ 29 ZUPLENZ ................................................ 37 ZYBAN .................................................... 31 ZYCLARA ................................................ 52

ZYCLARA PUMP ..................................... 53 ZYDELIG .................................................. 16 ZYFLO CR TB12 600 MG ........................ 47 ZYFLO TABS 600 MG ............................. 47 ZYKADIA .................................................. 16 ZYLET ...................................................... 36 ZYLOPRIM ............................................... 47 ZYMAXID ................................................. 34 ZYPREXA ................................................ 31 ZYPREXA RELPREVV ............................ 31 ZYPREXA ZYDIS ..................................... 31 ZYTIGA .................................................... 16 ZYVOX ..................................................... 10

60314612 09/2015

This formulary was updated on 09/01/15. For more recent information or other questions, please contact the number for your Kaiser Permanente Region listed below, seven days a week, 8 a.m. to 8 p.m., or visit kp.org/seniormedrx.

Kaiser Permanente Regions

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

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

COLORADO REGION Kaiser Foundation Health Plan of Colorado 10350 E. Dakota Ave. Denver, CO 80247 Kaiser Permanente Senior Advantage (HMO) and Senior Advantage Medicare Medicaid Plan (HMO SNP)


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


kp.org/seniormedrx Please recycle.

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

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

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


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

Membership Services 1-877-221-8221 TTY 711

2016 comprehensive formulary - kaiser...

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