blue medicare rx sm premier (pdp) 2020 formulary · sm premier (pdp) 2020 formulary (list of...

Blue MedicareRxSM Premier (PDP) 2020 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION

ABOUT THE DRUGS WE COVER IN THIS PLAN

This formulary was updated on 06/01/2020. For more recent information or other questions, please contact Blue MedicareRx Premier, at:

Connecticut 1-888-620-1747 Rhode Island 1-888-620-1748

Massachusetts 1-888-543-4917 Vermont 1-888-620-1746

or, for TTY/TDD users, 711, 24 hours a day, 7 days a week, or visit www.RxMedicarePlans.com.

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 Blue

MedicareRxSM (PDP). When it refers to “plan” or “our plan,” it means Blue MedicareRx Premier.

This document includes a list of the drugs (formulary) for our plan which is current as of June 1, 2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year.

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www.RxMedicarePlans.com

What is the Blue MedicareRx Premier Formulary?

A formulary is a list of covered drugs selected by Blue MedicareRx Premier 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. Blue MedicareRx Premier will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Blue MedicareRx Premier network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?

Most changes in drug coverage happen on January 1, but Blue MedicareRx Premier may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.

Changes that can affect you this year: In the below cases, you will be affected bycoverage changes during the year:

· New generic drugs. We may immediately remove a brand name drug on our DrugList if we are replacing it with a new generic drug that will appear on the same orlower cost-sharing tier and with the same or fewer restrictions. Also, when adding thenew generic drug, we may decide to keep the brand name drug on our Drug List,but immediately move it to a different cost-sharing tier or add new restrictions. Ifyou are currently taking that brand name drug, we may not tell you in advancebefore we make that change, but we will later provide you with information aboutthe specific change(s) we have made.

o If we make such a change, you or your prescriber can ask us to make anexception and continue to cover the brand name drug for you. Thenotice we provide you will also include information on how to request anexception, and you can also find information in the section belowentitled “How do I request an exception to the Blue MedicareRxPremier Formulary?”

· Drugs removed from the market. If the Food and Drug Administration deems adrug on our formulary to be unsafe or the drug’s manufacturer removes the drugfrom the market, we will immediately remove the drug from our formulary andprovide notice to members who take the drug.

· Other changes. We may make other changes that affect members currently taking adrug. For instance, we may add a generic drug that is not new to market to replace abrand name drug currently on the formulary or add new restrictions to the brandname drug or move it to a different cost-sharing tier. Or we may make changes basedon new clinical guidelines. If we remove drugs from our formulary, add priorauthorization, quantity limits and/or step therapy restrictions on a drug or move adrug to a higher cost-sharing tier, we must notify affected members of the change atleast 30 days before the change becomes effective, or at the time the memberrequests a refill of the drug, at which time the member will receive a 30-day supplyof the drug.

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o If we make these other changes, you or your prescriber can ask us tomake an exception and continue to cover the brand name drug for you.The notice we provide you will also include information on how torequest an exception, and you can also find the information in thesection below entitled “How do I request an exception to the BlueMedicareRx Premier Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year.

The enclosed formulary is current as of June 1, 2020. To get updated information about the drugs covered by Blue MedicareRx Premier, please contact us. Our contact information appears on the front and back cover pages. If we have other types of mid-year non-maintenance formulary changes unrelated to the reasons stated above (e.g. remove drugs from our formulary, add prior authorization requirements, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier), we will notify you by mail. You may also access our formulary on our website at www.RxMedicarePlans.com to get information showing changes to, additions, and/or deletions of medications contained in our formulary.

How do I use the Formulary?

There are two ways to find your drug within the formulary:

Medical Condition

The formulary begins on page 1. 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.” If you know what your drug is used for, look for the category name in the list that begins on page number 1. 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 theIndex that begins at the back of this document. The Index provides an alphabetical listof all of the drugs included in this document. Both brand name drugs and generic drugsare listed in the Index. Look in the Index and find your drug. Next to your drug, youwill see the page number where you can find coverage information. Turn to the pagelisted in the Index and find the name of your drug in the first column of the list.

What are generic drugs?

Blue MedicareRx Premier 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 drugs.

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Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. Theserequirements and limits may include:

· Prior Authorization: Blue MedicareRx Premier requires you or your physician toget prior authorization for certain drugs. This means that you will need to getapproval from our plan before you fill your prescriptions. If you don’t get approval,we may not cover the drug.

· Quantity Limits: For certain drugs, Blue MedicareRx Premier limits the amount ofthe drug that we will cover. For example, our plan provides 2 units per prescriptionfor FLOVENT HFA. This may be in addition to a standard one-month orthree-month supply.

· Step Therapy: In some cases, Blue MedicareRx Premier requires you to first trycertain drugs to treat your medical condition before we will cover another drug forthat condition. For example, if Drug A and Drug B both treat your medicalcondition, our plan may not cover Drug B unless you try Drug A first. If Drug A doesnot work for you, we will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in theformulary that begins on page 1. You can also get more information about the restrictionsapplied to specific covered drugs by visiting our website. We have posted online documentsthat explain our prior authorization and step therapy restrictions. You may also ask us tosend you a copy. Our contact information, along with the date we last updated theformulary, appears on the front and back cover pages.

You can ask Blue MedicareRx Premier 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 Blue MedicareRx Premier formulary?” on page III for information about how to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contactCustomer Care and ask if your drug is covered.

If you learn that Blue MedicareRx Premier does not cover your drug, you have two options:

· You can ask Customer Care for a list of similar drugs that are covered by BlueMedicareRx Premier. When you receive the list, show it to your doctor and ask himor her to prescribe a similar drug that is covered by our plan.

· You can ask Blue MedicareRx Premier to make an exception and cover your drug.See below for information about how to request an exception.

Compounds may or may not be covered by your plan benefit.

How do I request an exception to the Blue MedicareRx Premier Formulary?

You can ask us to make an exception to our coverage rules. There are several types ofexceptions that you can ask us to make.

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· You can ask us to cover a drug even if it is not on our formulary. If approved, thisdrug will be covered at a pre-determined cost-sharing level, and you would not beable to ask us to provide the drug at a lower cost-sharing level.

· You can ask us to cover a formulary drug at a lower cost-sharing level if this drug isnot on the specialty tier. If approved this would lower the amount you must pay foryour drug.

· You can ask us to waive coverage restrictions or limits on your drug. For example, forcertain drugs, Blue MedicareRx Premier limits the amount of the drug that we willcover. If your drug has a quantity limit, you can ask us to waive the limit and cover agreater amount.

Generally, Blue MedicareRx Premier will only approve your request for an exception if the alternative drug is included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/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 orutilization restriction exception. When you request a formulary, tiering or utilization

restriction exception you should submit a statement from your prescriber orphysician supporting your request. Generally, we must make our decision within 72hours of getting your prescriber’s supporting statement. You can request an expedited (fast)exception if you or your doctor believe that your health could be seriously harmed bywaiting up to 72 hours for a decision. If your request to expedite is granted, we must giveyou a decision no later than 24 hours after we get a supporting statement from your doctoror other prescriber.

What do I do before I can talk to my doctor about changing my drugs or

requesting an exception?

As a new or continuing member in our plan you may be taking drugs that are not on ourformulary. Or, you may be taking a drug that is on our formulary but your ability to get it islimited. For example, you may need a prior authorization from us before you can fill yourprescription. You should talk to your doctor to decide if you should switch to an appropriatedrug that we cover or request a formulary exception so that we will cover the drug you take.While you talk to your doctor to determine the right course of action for you, we may coveryour drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs islimited, we will cover a temporary 30-day supply. If your prescription is written for fewerdays, we’ll allow refills to provide up to a maximum 30-day supply of medication. After yourfirst 30-day supply, we will not pay for these drugs, even if you have been a member of theplan less than 90 days.

If you are a resident of a long-term care facility, and you need a drug that is not on ourformulary or if your ability to get your drugs is limited, but you are past the first 90 days ofmembership in our plan, we will cover a 31-day emergency supply of that drug while youpursue a formulary exception.

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If you change your level of care, such as a move from a hospital to a home setting, and youneed a drug that is not on our formulary or if your ability to get your drugs is limited, butyou are past the first 90 days of membership in our plan, we will cover up to a temporary30-day supply when you go to a network pharmacy. After your first 30-day supply, you arerequired to use the plan's exception process.

Our transition supply will not cover drugs that Medicare does not allow Part D plans tocover or drugs that are covered under Medicare Part B.

For more information

For more detailed information about your Blue MedicareRx Premier prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Blue MedicareRx Premier, please contact us. Our contact information, 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/TDD users should call 1-877-486-2048. Or, visit https://www.medicare.gov.

Blue MedicareRx Premier Formulary

The formulary that begins on page 1 provides coverage information about the drugs covered by Blue MedicareRx Premier. If you have trouble finding your drug in the list, turn to the Index that begins at the back of this document.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,ADVAIR DISKUS) and generic drugs are listed in lower-case italics (e.g., atorvastatin).

The information in the Requirements/Limits column tells you if Blue MedicareRx Premier has any special requirements for coverage of your drug. The abbreviations you may see in the drug listing include:

o B/D stands for drugs covered under Medicare Part B or D.

o QL stands for Quantity Limits.

o PA stands for Prior Authorization.

o ST stands for Step Therapy.

o LA stands for Limited Access. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Care at the numbers that appear on the front and back cover pages, 24 hours a day, 7 days a week. TTY/TDD users should call 711.

o NMO stands for No Mail Order. This prescription drug is not available throughmail order service.

o GC stands for Gap Coverage. We provide additional coverage of this prescriptiondrug in the coverage gap. Please refer to our Evidence of Coverage for moreinformation about this coverage.

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https://www.medicare.gov

Explanation of Tiers and Copayments/Coinsurance:

Blue MedicareRx Premier Initial Coverage Stage

Tier Label Retail Cost-Sharing or

Out-of-Network (OON)

Cost-Sharing*

30-day supply/ Long-term Care (LTC)**

31-day supply

Mail Order

Cost-Sharing

90-day supply

Preferred Retail Standard Retail Cost-Sharing Cost-Sharing/

OON/LTC

Tier 1: Preferred Generic $1 $6 $1

Certain generic drugs that are available at the lowest copayment

Tier 2: Generic $7 $12 $14

Higher cost generic drugs available at a higher copayment than Tier 1 generic drugs

Tier 3: Preferred Brand $30 $40 $60

Many common brand name drugs and some higher cost generic drugs

Tier 4: Non-Preferred Drug

Higher cost generic and non-preferred drugs, many of which may have lower cost options available on Tier 1, Tier 2, and Tier 3

35% 45% 35%

Tier 5: Specialty Tier

Unique and/or very high-cost brand and some generic drugs of which you pay a percentage of the total drug cost which may require special handling and/or close monitoring

33% 33% Not Applicable†

* In addition to your copayment, at an out-of-network pharmacy you will pay the differencebetween the actual charge and what you would have paid at a network pharmacy. Amountsyou pay may vary at out-of-network pharmacies.

** Standard Retail Cost-Sharing applies to all Out-of-Network (OON) and Long-term Care (LTC) Cost-Sharing.

† Specialty Tier drugs are not available for a 90-day retail or mail order supply.

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Blue MedicareRx Premier 2020 Comprehensive Drug List

You can find information on what symbols and abbreviations on this table mean by going to page V. B/D – Covered under Medicare Part B or D QL – Quantity Limits PA – Prior Authorization ST – Step Therapy LA – Limited Access NMO – No Mail Order GC - We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. 00020362_v11_06/2020

1

Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol tab (generic of ZYLOPRIM)

Tier 2 GC

colchicine w/ probenecid Tier 3

COLCRYS QL (120 tabs / 30 days)

Tier 3 QL

MITIGARE QL (60 caps / 30 days)

Tier 3 QL

probenecid Tier 2 GC

NSAIDS celecoxib (generic of CELEBREX) CAPS 50mg

QL (240 caps / 30 days)

Tier 3 QL

celecoxib (generic of CELEBREX) CAPS 100mg


Tier 3 QL



Tier 3 QL



Tier 3 QL

diclofenac potassium QL (120 tabs / 30 days)

Tier 3 QL

diclofenac sodium TB24 Tier 3

diclofenac sodium TBEC Tier 2 GC

diflunisal TABS Tier 3

etodolac CAPS Tier 3

etodolac (generic of LODINE) TABS 400mg

Tier 3

etodolac TABS 500mg Tier 3

etodolac TB24 Tier 3

flurbiprofen TABS 100mg Tier 2 GC

ibu tab 600mg Tier 1 GC

ibu tab 800mg Tier 1 GC

ibuprofen SUSP Tier 3

ibuprofen TABS 400mg, 600mg, 800mg

Tier 1 GC

Drug Name Drug Tier

Requirements/Limits

meloxicam (generic of MOBIC) TABS

Tier 1 GC

nabumetone TABS Tier 2 GC

naproxen (generic of NAPROSYN) TABS 250mg

Tier 1 GC

naproxen TABS 375mg, 500mg

Tier 1 GC

naproxen dr (generic of EC-NAPROSYN) 375mg

Tier 2 GC

naproxen dr (generic of EC-NAPROXEN) 500mg

Tier 2 GC

naproxen sodium TABS 275mg

Tier 3

naproxen sodium (generic of ANAPROX DS) TABS 550mg

Tier 3

piroxicam (generic of FELDENE) CAPS

Tier 3

sulindac TABS Tier 2 GC

OPIOID ANALGESICS acetaminophen w/ codeine 300-15mg

QL (400 tabs / 30 days)

Tier 2 GC QL

acetaminophen w/ codeine 300-30mg (generic of TYLENOL/CODEINE #3)


Tier 2 GC QL

acetaminophen w/ codeine 300-60mg


Tier 2 GC QL

acetaminophen w/ codeine soln

QL (2700 mL / 30 days)

Tier 2 GC QL

butorphanol tartrate SOLN 1mg/ml, 2mg/ml

Tier 4

nalbuphine hcl SOLN Tier 4

tramadol hcl tab 50 mg (generic of ULTRAM)


Tier 2 GC QL



2

Drug Name Drug Tier

Requirements/Limits

tramadol-acetaminophen (generic of ULTRACET)


Tier 3 QL

OPIOID ANALGESICS, CII endocet 2.5-325mg (generic of PERCOCET)


Tier 3 QL

endocet 5-325mg (generic of PERCOCET)


Tier 3 QL

endocet 7.5-325mg (generic of PERCOCET)


Tier 3 QL

endocet 10-325mg (generic of PERCOCET)


Tier 3 QL

fentanyl citrate (generic of ACTIQ) LPOP

QL (120 lozenges / 30 days)

Tier 5 QL PA

fentanyl patch 12 mcg/hr (generic of DURAGESIC)

QL (10 patches / 30 days)

Tier 4 QL PA



Tier 4 QL PA



Tier 4 QL PA



Tier 4 QL PA



Tier 4 QL PA

Drug Name Drug Tier

Requirements/Limits

hydroco/apap tab 5-325mg (generic of NORCO,LORCET)


Tier 3 QL

hydroco/apap tab 7.5-325 (generic of NORCO,LORCET PLUS)


Tier 3 QL

hydroco/apap tab 10-325mg (generic of NORCO,LORCET HD)


Tier 3 QL

hydrocodone-acetaminophen 7.5-325 mg/15ml

QL (2700 mL / 30 days)

Tier 4 QL

hydrocodone-ibuprofen tab 7.5-200 mg


Tier 3 QL

hydromorphone hcl (generic of DILAUDID) LIQD

QL (600 mL / 30 days)

Tier 4 QL

hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml

Tier 4 B/D

hydromorphone hcl (generic of DILAUDID) TABS


Tier 3 QL

HYSINGLA ER QL (30 tabs / 30 days)

Tier 3 QL PA

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


Tier 3 QL

lorcet plus tab 7.5-325 (generic of NORCO)


Tier 3 QL



3

Drug Name Drug Tier

Requirements/Limits

lorcet tab 5-325mg (generic of NORCO)


Tier 3 QL

methadone hcl SOLN 5mg/5ml, 10mg/5ml

QL (450 mL / 30 days)

Tier 3 QL PA

methadone hcl 5mg (generic of DOLOPHINE)


Tier 3 QL PA

methadone hcl 10mg (generic of DOLOPHINE)


Tier 3 QL PA

methadone hcl intensol (generic of METHADOSE)

QL (90 mL / 30 days)

Tier 3 QL PA

morphine ext-rel tab (generic of MS CONTIN)


Tier 3 QL PA

morphine sul inj 1mg/ml Tier 4 B/D

MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml

Tier 4 B/D

morphine sulfate (generic of MORPHINE SULFATE) SOLN 4mg/ml, 8mg/ml, 10mg/ml

Tier 4 B/D

morphine sulfate TABS QL (180 tabs / 30 days)

Tier 3 QL

morphine sulfate oral soln 10mg/5ml

QL (900 mL / 30 days)

Tier 3 QL


QL (900 mL / 30 days)

Tier 3 QL


QL (180 mL / 30 days)

Tier 3 QL

NUCYNTA ER QL (60 tabs / 30 days)

Tier 3 QL PA

oxycodone hcl CAPS QL (180 caps / 30 days)

Tier 4 QL

Drug Name Drug Tier

Requirements/Limits

oxycodone hcl CONC QL (180 mL / 30 days)

Tier 4 QL

oxycodone hcl SOLN QL (900 mL / 30 days)

Tier 4 QL

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


Tier 3 QL

oxycodone hcl TABS 10mg, 20mg


Tier 3 QL

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


Tier 3 QL

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


Tier 3 QL

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


Tier 3 QL

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


Tier 3 QL

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) (generic of XYLOCAINE) 2%

Tier 2 GC B/D

lidocaine hcl (local anesth.) (generic of XYLOCAINE-MPF) .5%, 1%

Tier 2 GC B/D

lidocaine inj 0.5% (generic of XYLOCAINE)

Tier 2 GC B/D

lidocaine inj 1% (generic of XYLOCAINE)

Tier 2 GC B/D



4

Drug Name Drug Tier

Requirements/Limits

lidocaine inj 1.5% preservative free (pf) (generic of XYLOCAINE-MPF)

Tier 2 GC B/D

ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN Tier 4

gentamicin in saline Tier 2 GC

gentamicin sulfate SOLN Tier 2 GC

neomycin sulfate TABS Tier 2 GC

paromomycin sulfate CAPS Tier 4

streptomycin sulfate SOLR Tier 5

SULFADIAZINE TABS Tier 4

tobramycin (generic of KITABIS PAK) NEBU

Tier 5 NMO PA

tobramycin inj 1.2 gm/30ml Tier 3

tobramycin inj 1.2gm Tier 5

tobramycin inj 10mg/ml Tier 3

tobramycin inj 80mg/2ml Tier 3

tobramycin sulfate SOLN Tier 3

ANTI-INFECTIVES - MISCELLANEOUS albendazole (generic of ALBENZA) TABS

Tier 5

ALINIA Tier 5

atovaquone (generic of MEPRON) SUSP

Tier 5

aztreonam (generic of AZACTAM)

Tier 4

CAYSTON Tier 5 NMO LA PA

clindamycin cap 75mg (generic of CLEOCIN)

Tier 1 GC

clindamycin cap 300 mg (generic of CLEOCIN)

Tier 1 GC

clindamycin hcl cap 150 mg (generic of CLEOCIN)

Tier 1 GC

clindamycin phosphate in d5w

Tier 4

CLINDAMYCIN PHOSPHATE IN NACL

Tier 4

clindamycin phosphate inj (generic of CLEOCIN PHOSPHATE)

Tier 3

Drug Name Drug Tier

Requirements/Limits

clindamycin soln 75mg/5ml (generic of CLEOCIN PEDIATRIC GRANULE)

Tier 4

colistimethate sodium (generic of COLY-MYCIN M) SOLR

Tier 4

dapsone TABS Tier 3

daptomycin (generic of DAPTOMYCIN) 350mg

Tier 5

daptomycin (generic of CUBICIN) 500mg

Tier 5

EMVERM QL (12 tabs / 365 days)

Tier 5 QL

ertapenem sodium (generic of INVANZ)

Tier 4

imipenem-cilastatin Tier 3

imipenem-cilastatin (generic of PRIMAXIN IV)

Tier 3

ivermectin (generic of STROMECTOL) TABS

Tier 3

linezolid in sodium chloride Tier 4

linezolid inj (generic of ZYVOX)

Tier 4

linezolid susp (generic of ZYVOX)

Tier 5

linezolid tab 600mg (generic of ZYVOX)

Tier 4

meropenem (generic of MERREM)

Tier 4

methenamine hippurate (generic of HIPREX)

Tier 3

metronidazole (generic of FLAGYL) TABS

Tier 2 GC

metronidazole in nacl Tier 2 GC

nitrofurantoin macrocrystal (generic of MACRODANTIN) 50mg, 100mg

Tier 3

nitrofurantoin monohyd macro (generic of MACROBID)

Tier 3

pentamidine isethionate inh (generic of NEBUPENT)

Tier 4 B/D



5

Drug Name Drug Tier

Requirements/Limits

pentamidine isethionate inj (generic of PENTAM 300)

Tier 4

praziquantel (generic of BILTRICIDE) TABS

Tier 3

SIVEXTRO Tier 5

sulfamethoxazole-trimethop ds (generic of BACTRIM DS)

Tier 1 GC

sulfamethoxazole-trimethoprim inj

Tier 4

sulfamethoxazole-trimethoprim susp

Tier 3

sulfamethoxazole-trimethoprim tab 400-80mg (generic of BACTRIM)

Tier 1 GC

SYNERCID Tier 5

tigecycline (generic of TYGACIL)

Tier 5

trimethoprim TABS Tier 2 GC

vancomycin hcl (generic of VANCOCIN HCL) CAPS 125mg


Tier 4 QL

vancomycin hcl (generic of VANCOCIN) CAPS 250mg


Tier 5 QL

vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg

Tier 4

VANCOMYCIN IN NACL Tier 4

ANTIFUNGALS ABELCET Tier 5 B/D

AMBISOME Tier 5 B/D

amphotericin b SOLR Tier 4 B/D

caspofungin acetate (generic of CANCIDAS)

Tier 5

fluconazole (generic of DIFLUCAN) SUSR

Tier 3

fluconazole (generic of DIFLUCAN) TABS 50mg, 100mg, 200mg

Tier 3

fluconazole (generic of DIFLUCAN) TABS 150mg

Tier 1 GC

Drug Name Drug Tier

Requirements/Limits

fluconazole inj nacl 200 Tier 3

fluconazole inj nacl 400 Tier 3

flucytosine (generic of ANCOBON) CAPS

Tier 5

griseofulvin microsize Tier 4

griseofulvin ultramicrosize Tier 4

itraconazole (generic of SPORANOX) CAPS

Tier 4 PA

ketoconazole TABS Tier 3 PA

MYCAMINE Tier 5

NOXAFIL SUSP QL (630 mL / 30 days)

Tier 5 QL

nystatin TABS Tier 3

posaconazole (generic of NOXAFIL)


Tier 5 QL

terbinafine hcl (generic of LAMISIL) TABS

QL (90 tabs / year)

Tier 1 GC QL

voriconazole (generic of VFEND IV) SOLR

Tier 5 PA

voriconazole (generic of VFEND) SUSR

Tier 5 PA

voriconazole (generic of VFEND) TABS 50mg

Tier 4

voriconazole (generic of VFEND) TABS 200mg

Tier 5

ANTIMALARIALS atovaquone-proguanil hcl (generic of MALARONE)

Tier 4

chloroquine phosphate TABS

Tier 3

COARTEM Tier 4

mefloquine hcl Tier 3

PRIMAQUINE PHOSPHATE 26.3mg

Tier 3

primaquine phosphate (generic of PRIMAQUINE PHOSPHATE) 26.3mg

Tier 3

quinine sulfate (generic of QUALAQUIN) CAPS

Tier 4 PA



6

Drug Name Drug Tier

Requirements/Limits

ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN) SOLN

Tier 4 NMO

abacavir sulfate (generic of ZIAGEN) TABS

Tier 3 NMO

APTIVUS Tier 5 NMO

atazanavir sulfate (generic of REYATAZ)

Tier 4 NMO

CRIXIVAN Tier 4 NMO

didanosine Tier 4 NMO

EDURANT Tier 5 NMO

efavirenz (generic of SUSTIVA) CAPS 50mg

Tier 4 NMO

efavirenz (generic of SUSTIVA) CAPS 200mg

Tier 5 NMO

efavirenz (generic of SUSTIVA) TABS

Tier 5 NMO

EMTRIVA Tier 3 NMO

fosamprenavir tab 700 mg (generic of LEXIVA)

Tier 5 NMO

FUZEON Tier 5 NMO

INTELENCE 25mg Tier 4 NMO

INTELENCE 100mg, 200mg

Tier 5 NMO

INVIRASE Tier 5 NMO

ISENTRESS CHEW 25mg Tier 3 NMO

ISENTRESS CHEW 100mg Tier 5 NMO

ISENTRESS PACK Tier 3 NMO

ISENTRESS TABS Tier 5 NMO

ISENTRESS HD Tier 5 NMO

lamivudine (generic of EPIVIR)

Tier 3 NMO

LEXIVA SUSP Tier 4 NMO

nevirapine susp 50 mg/5ml (generic of VIRAMUNE)

Tier 4 NMO

nevirapine tab 100mg er Tier 4 NMO

nevirapine tab 200mg (generic of VIRAMUNE)

Tier 3 NMO

nevirapine tab 400mg er (generic of VIRAMUNE XR)

Tier 4 NMO

NORVIR PACK Tier 4 NMO

NORVIR SOLN Tier 4 NMO

PIFELTRO Tier 5 NMO

Drug Name Drug Tier

Requirements/Limits

PREZISTA SUSP QL (400 mL / 30 days)

Tier 5 QL NMO

PREZISTA TABS 75mg QL (480 tabs / 30 days)

Tier 4 QL NMO


Tier 5 QL NMO


Tier 5 QL NMO


Tier 5 QL NMO

REYATAZ PACK Tier 5 NMO

ritonavir (generic of NORVIR)

Tier 3 NMO

SELZENTRY SOLN Tier 5 NMO

SELZENTRY TABS 25mg Tier 4 NMO

SELZENTRY TABS 75mg, 150mg, 300mg

Tier 5 NMO

stavudine 15mg, 20mg Tier 3 NMO

stavudine (generic of ZERIT) 30mg, 40mg

Tier 3 NMO

tenofovir disoproxil fumarate (generic of VIREAD)

Tier 3 NMO

TIVICAY 10mg Tier 3 NMO

TIVICAY 25mg, 50mg Tier 5 NMO

TROGARZO Tier 5 NMO LA

TYBOST Tier 4 NMO

VIDEX EC 125MG Tier 4 NMO

VIDEX PEDIATRIC Tier 4 NMO

VIRACEPT Tier 5 NMO

VIREAD POWD Tier 5 NMO

VIREAD TABS 150mg, 200mg, 250mg

Tier 5 NMO

zidovudine cap 100mg (generic of RETROVIR)

Tier 4 NMO

zidovudine syp 50mg/5ml (generic of RETROVIR)

Tier 4 NMO

zidovudine tab 300mg Tier 3 NMO

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine (generic of EPZICOM)

Tier 3 NMO



7

Drug Name Drug Tier

Requirements/Limits

abacavir sulfate-lamivudine-zidovudine (generic of TRIZIVIR)

Tier 5 NMO

ATRIPLA Tier 5 NMO

BIKTARVY Tier 5 NMO

CIMDUO Tier 5 NMO

COMPLERA Tier 5 NMO

DELSTRIGO Tier 5 NMO

DESCOVY Tier 5 NMO

DOVATO Tier 5 NMO

EVOTAZ Tier 5 NMO

GENVOYA Tier 5 NMO

JULUCA Tier 5 NMO

KALETRA TAB 100-25MG Tier 4 NMO

KALETRA TAB 200-50MG Tier 5 NMO

lamivudine-zidovudine (generic of COMBIVIR)

Tier 4 NMO

lopinavir-ritonavir (generic of KALETRA)

Tier 4 NMO

ODEFSEY Tier 5 NMO

PREZCOBIX Tier 5 NMO

STRIBILD Tier 5 NMO

SYMFI Tier 5 NMO

SYMFI LO Tier 5 NMO

SYMTUZA Tier 5 NMO

TEMIXYS Tier 5 NMO

TRIUMEQ Tier 5 NMO

TRUVADA TAB 100-150 QL (30 tabs / 30 days)

Tier 5 QL NMO


Tier 5 QL NMO


Tier 5 QL NMO


Tier 5 QL NMO

ANTITUBERCULAR AGENTS cycloserine CAPS Tier 5

ethambutol hcl TABS 100mg

Tier 3

ethambutol hcl (generic of MYAMBUTOL) TABS 400mg

Tier 3

isoniazid TABS Tier 1 GC

isoniazid syp 50mg/5ml Tier 4

Drug Name Drug Tier

Requirements/Limits

PASER D/R Tier 4

PRIFTIN Tier 4

pyrazinamide TABS Tier 4

rifabutin (generic of MYCOBUTIN)

Tier 4

rifampin (generic of RIFADIN) CAPS

Tier 3

rifampin (generic of RIFADIN) SOLR

Tier 4

RIFATER Tier 4

SIRTURO Tier 5 LA PA

TRECATOR Tier 4

ANTIVIRALS acyclovir CAPS Tier 2 GC

acyclovir (generic of ZOVIRAX) SUSP

Tier 4

acyclovir (generic of ZOVIRAX) TABS

Tier 2 GC

acyclovir sodium Tier 4 B/D

adefovir dipivoxil (generic of HEPSERA)

Tier 5 NMO

BARACLUDE SOLN Tier 5 NMO

entecavir (generic of BARACLUDE)

Tier 4 NMO

EPCLUSA Tier 5 NMO PA

EPIVIR HBV SOLN Tier 4 NMO

famciclovir TABS Tier 3

ganciclovir sodium (generic of CYTOVENE)

Tier 4 B/D

HARVONI Tier 5 NMO PA

lamivudine (hbv) (generic of EPIVIR HBV)

Tier 4 NMO

MAVYRET Tier 5 NMO PA

oseltamivir phosphate (generic of TAMIFLU) CAPS 30mg

QL (168 caps / year)

Tier 3 QL

oseltamivir phosphate (generic of TAMIFLU) CAPS 45mg, 75mg

QL (84 caps / year)

Tier 3 QL



8

Drug Name Drug Tier

Requirements/Limits

oseltamivir phosphate (generic of TAMIFLU) SUSR

QL (1080 mL / year)

Tier 3 QL

PEGASYS Tier 5 NMO PA

PEGASYS PROCLICK Tier 5 NMO PA

RELENZA DISKHALER QL (6 inhalers / year)

Tier 3 QL

ribavirin cap 200mg Tier 3 NMO

ribavirin tab 200mg Tier 4 NMO

rimantadine hydrochloride Tier 3

valacyclovir hcl (generic of VALTREX) TABS

Tier 3

valganciclovir hcl (generic of VALCYTE)

Tier 5

VEMLIDY Tier 5 NMO

VOSEVI Tier 5 NMO PA

CEPHALOSPORINS cefaclor CAPS Tier 3

cefaclor SUSR Tier 4

CEFACLOR ER TAB 500MG

Tier 4

cefadroxil CAPS Tier 2 GC

cefadroxil SUSR Tier 3

cefadroxil TABS Tier 4

CEFAZOLIN IN DEXTROSE 2GM/100ML-4%

Tier 3

cefazolin inj Tier 3

cefazolin sodium SOLR 1gm

Tier 3

CEFAZOLIN SODIUM 1 GM/50ML

Tier 3

cefdinir CAPS Tier 2 GC

cefdinir SUSR Tier 4

cefepime for inj Tier 4

cefixime (generic of SUPRAX) SUSR

Tier 4

cefoxitin for inj Tier 4

cefpodoxime proxetil SUSR Tier 4

cefpodoxime proxetil TABS Tier 3

cefprozil Tier 3

ceftazidime SOLR Tier 3

CEFTAZIDIME/DEXTROSE Tier 4

Drug Name Drug Tier

Requirements/Limits

ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

Tier 3

cefuroxime axetil Tier 3

cefuroxime sodium Tier 3

cephalexin (generic of KEFLEX) CAPS 250mg, 500mg

Tier 1 GC

cephalexin SUSR Tier 3

tazicef SOLR Tier 3

TEFLARO Tier 5

ERYTHROMYCINS/MACROLIDES azithromycin PACK Tier 3

azithromycin (generic of ZITHROMAX) SOLR

Tier 3

azithromycin (generic of ZITHROMAX) SUSR

Tier 3

azithromycin (generic of ZITHROMAX) TABS 250mg, 500mg

Tier 1 GC

azithromycin TABS 600mg Tier 1 GC

clarithromycin TABS Tier 3

clarithromycin er (generic of BIAXIN XL)

Tier 3

clarithromycin for susp Tier 4

DIFICID Tier 5

e.e.s. 400 Tier 4

ery-tab Tier 4

ERYTHROCIN LACTOBIONATE

Tier 4

erythrocin stearate Tier 4

erythromycin base Tier 4

erythromycin cap 250mg ec Tier 4

erythromycin ethylsuccinate TABS

Tier 4

erythromycin tab ec Tier 4

FLUOROQUINOLONES CIPRO SUSR 500mg/5ml Tier 4

ciprofloxacin hcl tab 100mg Tier 4

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

Tier 1 GC

ciprofloxacin hcl tab 750mg Tier 1 GC



9

Drug Name Drug Tier

Requirements/Limits

ciprofloxacin in d5w Tier 3

levofloxacin (generic of LEVAQUIN) TABS

Tier 1 GC

levofloxacin in d5w Tier 3

levofloxacin inj 25mg/ml Tier 4

levofloxacin oral soln 25 mg/ml

Tier 4

PENICILLINS amoxicillin CAPS; SUSR; TABS

Tier 1 GC

amoxicillin CHEW Tier 2 GC

amoxicillin & pot clavulanate 200-28.5 chw tabs

Tier 4

amoxicillin & pot clavulanate 200/5ml susr

Tier 3

amoxicillin & pot clavulanate 250-125 tabs

Tier 4

amoxicillin & pot clavulanate 250/5ml susr (generic of AUGMENTIN)

Tier 4

amoxicillin & pot clavulanate 400-57 chw tabs

Tier 4


Tier 3

amoxicillin & pot clavulanate 500-125 tabs (generic of AUGMENTIN)

Tier 2 GC


Tier 3

amoxicillin & pot clavulanate 875-125 tabs

Tier 2 GC

amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs

Tier 4

ampicillin & sulbactam sodium (generic of UNASYN)

Tier 4

ampicillin & sulbactam sodium (generic of UNASYN BULK PACK)

Tier 4

ampicillin cap 500mg Tier 2 GC

ampicillin inj Tier 4

ampicillin sodium Tier 4

BICILLIN L-A Tier 4

dicloxacillin sodium Tier 3

Drug Name Drug Tier

Requirements/Limits

nafcillin sodium for inj 1gm, 2gm

Tier 4

nafcillin sodium for inj 10gm Tier 5

NAFCILLIN SODIUM FOR INJ 10GM

Tier 4

oxacillin sodium SOLR 1gm, 2gm

Tier 4

oxacillin sodium SOLR 10gm

Tier 5

PENICILLIN G POT IN DEXTROSE 2MU

Tier 4

PENICILLIN G POT IN DEXTROSE 3MU

Tier 4

PENICILLIN G PROCAINE Tier 4

penicillin g sodium Tier 4

penicillin v potassium SOLR

Tier 2 GC

penicillin v potassium TABS Tier 1 GC

penicilln gk inj 5mu Tier 4

penicilln gk inj 20mu Tier 4

pfizerpen-g inj 5mu Tier 4

pfizerpen-g inj 20mu Tier 4

piper/tazoba inj 2-0.25gm Tier 4





TETRACYCLINES doxy 100 Tier 4

doxycycline (monohydrate) CAPS 50mg, 100mg

Tier 2 GC

doxycycline (monohydrate) TABS 50mg, 75mg, 100mg

Tier 3

doxycycline hyclate CAPS 50mg

Tier 3

doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg

Tier 3

doxycycline hyclate SOLR Tier 4

doxycycline hyclate 20 mg Tier 3

doxycycline hyclate 100 mg Tier 3



10

Drug Name Drug Tier

Requirements/Limits

minocycline hcl (generic of MINOCIN) CAPS 50mg, 100mg

Tier 2 GC

minocycline hcl CAPS 75mg

Tier 2 GC

mondoxyne nl cap 100mg Tier 2 GC

tetracycline hcl CAPS Tier 4

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA Tier 5 B/D NMO

cyclophosphamide CAPS Tier 3 B/D

cyclophosphamide SOLR Tier 5 B/D

EMCYT Tier 4

GLEOSTINE 10mg Tier 4

GLEOSTINE 40mg, 100mg Tier 5

LEUKERAN Tier 5

ANTHRACYCLINES adriamycin SOLN Tier 4 B/D

doxorubicin hcl Tier 4 B/D

doxorubicin hcl liposomal (generic of DOXIL)

Tier 5 B/D

epirubicin hcl 50mg/25ml Tier 4 B/D

epirubicin hcl (generic of ELLENCE) 200mg/100ml

Tier 4 B/D

ANTIMETABOLITES adrucil inj Tier 3 B/D

ALIMTA Tier 5 B/D

azacitidine (generic of VIDAZA)

Tier 5 B/D NMO

cytarabine 20mg/ml Tier 3 B/D

fluorouracil SOLN Tier 3 B/D

gemcitabine inj soln (generic of GEMCITABINE)

Tier 4 B/D

gemcitabine inj solr Tier 4 B/D

mercaptopurine TABS Tier 3

methotrexate sodium inj soln

Tier 2 GC B/D

methotrexate sodium inj solr Tier 2 GC B/D

PURIXAN Tier 5 NMO

TABLOID Tier 5

ANTIMITOTIC, TAXOIDS ABRAXANE Tier 5 B/D

docetaxel CONC 20mg/ml Tier 5 B/D

Drug Name Drug Tier

Requirements/Limits

docetaxel (generic of TAXOTERE) CONC 80mg/4ml

Tier 5 B/D

DOCETAXEL CONC 80mg/4ml, 160mg/8ml, 200mg/10ml

Tier 5 B/D

docetaxel (generic of DOCETAXEL) CONC 160mg/8ml

Tier 5 B/D

DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

Tier 5 B/D

docetaxel (generic of DOCETAXEL) SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

Tier 5 B/D

paclitaxel Tier 4 B/D

TAXOTERE Tier 5 B/D

ANTIMITOTIC, VINCA ALKALOIDS vincristine sulfate Tier 2 GC B/D

vinorelbine tartrate Tier 3 B/D

BIOLOGIC RESPONSE MODIFIERS AVASTIN Tier 5 NMO LA PA

BORTEZOMIB Tier 5 NMO PA

DAURISMO Tier 5 NMO LA PA

ERIVEDGE Tier 5 NMO LA PA

FARYDAK Tier 5 NMO LA PA

HERCEPTIN Tier 5 NMO PA

HERCEPTIN HYLECTA Tier 5 NMO PA

IBRANCE CAPS QL (21 caps / 28 days)

Tier 5 QL NMO LA PA

IBRANCE TABS QL (21 tabs / 28 days)

Tier 5 QL NMO LA PA

IDHIFA QL (30 tabs / 30 days)

Tier 5 QL NMO LA PA

KADCYLA Tier 5 B/D NMO

KANJINTI Tier 5 NMO PA

KEYTRUDA Tier 5 NMO PA

KISQALI Tier 5 NMO PA

KISQALI FEMARA 200 DOSE

Tier 5 NMO PA


Tier 5 NMO PA



11

Drug Name Drug Tier

Requirements/Limits


Tier 5 NMO PA

LYNPARZA Tier 5 NMO LA PA

MVASI Tier 5 NMO LA PA

NINLARO Tier 5 NMO PA

ODOMZO Tier 5 NMO LA PA

OGIVRI Tier 5 NMO PA

RITUXAN Tier 5 NMO LA PA

RITUXAN HYCELA Tier 5 NMO LA PA

RUBRACA Tier 5 NMO LA PA

RUXIENCE Tier 5 NMO PA

TALZENNA Tier 5 NMO LA PA

TECENTRIQ Tier 5 NMO LA PA

TIBSOVO Tier 5 NMO LA PA

TRAZIMERA Tier 5 NMO PA

TRUXIMA Tier 5 NMO PA

VELCADE Tier 5 NMO PA

VENCLEXTA 10mg Tier 4 NMO LA PA

VENCLEXTA 50mg, 100mg Tier 5 NMO LA PA

VENCLEXTA STARTING PACK

Tier 5 NMO LA PA

VERZENIO Tier 5 NMO LA PA

ZEJULA Tier 5 NMO LA PA

ZIRABEV Tier 5 NMO PA

ZOLINZA Tier 5 NMO PA

HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate (generic of ZYTIGA)

Tier 5 NMO PA

anastrozole (generic of ARIMIDEX) TABS

Tier 1 GC

bicalutamide (generic of CASODEX)

Tier 2 GC

DEPO-PROVERA INJ 400/ML

Tier 4 B/D

ERLEADA Tier 5 NMO LA PA

exemestane (generic of AROMASIN)

Tier 4

flutamide Tier 3

fulvestrant (generic of FASLODEX)

Tier 5 B/D

letrozole (generic of FEMARA) TABS

Tier 1 GC

leuprolide inj 1mg/0.2 Tier 3 NMO PA

Drug Name Drug Tier

Requirements/Limits

LUPRON DEPOT (1-MONTH) 3.75mg

Tier 5 NMO PA

LUPRON DEPOT INJ 11.25MG (3-MONTH)

Tier 5 NMO PA

LYSODREN Tier 3

megestrol ac sus 40mg/ml Tier 3

megestrol ac tab 20mg Tier 3

megestrol ac tab 40mg Tier 3

megestrol sus 625mg/5ml Tier 4 PA

nilutamide (generic of NILANDRON)

Tier 5

NUBEQA Tier 5 NMO LA PA

SOLTAMOX Tier 5

tamoxifen citrate TABS Tier 1 GC

toremifene citrate (generic of FARESTON)

Tier 5

TRELSTAR DEP INJ 3.75MG

Tier 5 NMO PA

TRELSTAR LA INJ 11.25MG

Tier 5 NMO PA

XTANDI Tier 5 NMO LA PA

ZYTIGA 500mg Tier 5 NMO LA PA

IMMUNOMODULATORS POMALYST 1mg, 2mg

QL (21 caps / 21 days) Tier 5 QL NMO LA

PA

POMALYST 3mg, 4mg QL (21 caps / 28 days)

Tier 5 QL NMO LA PA

REVLIMID QL (28 caps / 28 days)

Tier 5 QL NMO LA PA

THALOMID 50mg, 100mg QL (28 caps / 28 days)

Tier 5 QL NMO PA

THALOMID 150mg, 200mg QL (56 caps / 28 days)

Tier 5 QL NMO PA

KINASE INHIBITORS AFINITOR 10mg

QL (30 tabs / 30 days) Tier 5 QL NMO PA

AFINITOR DISPERZ 2mg QL (150 tabs / 30 days)

Tier 5 QL NMO PA


Tier 5 QL NMO PA


Tier 5 QL NMO PA

ALECENSA Tier 5 NMO LA PA



12

Drug Name Drug Tier

Requirements/Limits

ALUNBRIG Tier 5 NMO LA PA

AYVAKIT QL (30 tabs / 30 days)

Tier 5 QL NMO LA PA

BALVERSA Tier 5 NMO LA PA

BOSULIF Tier 5 NMO PA

BRAFTOVI Tier 5 NMO LA PA

BRUKINSA Tier 5 NMO LA PA

CABOMETYX QL (30 tabs / 30 days)

Tier 5 QL NMO LA PA

CALQUENCE Tier 5 NMO LA PA

CAPRELSA Tier 5 NMO LA PA

COMETRIQ Tier 5 NMO LA PA

COPIKTRA Tier 5 NMO LA PA

COTELLIC Tier 5 NMO LA PA

erlotinib hcl (generic of TARCEVA) 25mg


Tier 5 QL NMO PA

erlotinib hcl (generic of TARCEVA) 100mg, 150mg


Tier 5 QL NMO PA

everolimus (generic of AFINITOR)


Tier 5 QL NMO PA

GILOTRIF TAB 20MG Tier 5 NMO LA PA



ICLUSIG Tier 5 NMO LA PA

imatinib mesylate (generic of GLEEVEC) 100mg


Tier 5 QL NMO PA

imatinib mesylate (generic of GLEEVEC) 400mg


Tier 5 QL NMO PA

IMBRUVICA Tier 5 NMO LA PA

INLYTA 1mg QL (180 tabs / 30 days)

Tier 5 QL NMO LA PA

INLYTA 5mg QL (120 tabs / 30 days)

Tier 5 QL NMO LA PA

INREBIC Tier 5 NMO LA PA

IRESSA Tier 5 NMO LA PA

JAKAFI QL (60 tabs / 30 days)

Tier 5 QL NMO LA PA

Drug Name Drug Tier

Requirements/Limits

LENVIMA 4 MG DAILY DOSE

Tier 5 NMO LA PA


Tier 5 NMO LA PA


Tier 5 NMO LA PA

LENVIMA 12MG DAILY DOSE

Tier 5 NMO LA PA


Tier 5 NMO LA PA


Tier 5 NMO LA PA


Tier 5 NMO LA PA


Tier 5 NMO LA PA

LORBRENA Tier 5 NMO LA PA

MEKINIST Tier 5 NMO LA PA

MEKTOVI Tier 5 NMO LA PA

NERLYNX Tier 5 NMO LA PA

NEXAVAR Tier 5 NMO LA PA

PIQRAY 200MG DAILY DOSE

Tier 5 NMO PA


Tier 5 NMO PA


Tier 5 NMO PA

ROZLYTREK Tier 5 NMO LA PA

RYDAPT Tier 5 NMO PA

SPRYCEL Tier 5 NMO PA

STIVARGA Tier 5 NMO LA PA

SUTENT QL (30 caps / 30 days)

Tier 5 QL NMO PA

TAFINLAR Tier 5 NMO LA PA

TAGRISSO QL (30 tabs / 30 days)

Tier 5 QL NMO LA PA

TASIGNA Tier 5 NMO PA

TURALIO Tier 5 NMO LA PA

TYKERB Tier 5 NMO LA PA

VITRAKVI Tier 5 NMO LA PA

VIZIMPRO Tier 5 NMO LA PA

VOTRIENT Tier 5 NMO LA PA

XALKORI Tier 5 NMO LA PA

XOSPATA Tier 5 NMO LA PA



13

Drug Name Drug Tier

Requirements/Limits

ZELBORAF Tier 5 NMO LA PA

ZYDELIG Tier 5 NMO LA PA

ZYKADIA Tier 5 NMO LA PA

MISCELLANEOUS bexarotene (generic of TARGRETIN)

Tier 5 NMO PA

hydroxyurea (generic of HYDREA) CAPS

Tier 2 GC

LONSURF Tier 5 NMO PA

MATULANE Tier 5 LA

SYLATRON 200mcg, 300mcg

Tier 5 NMO PA

SYNRIBO Tier 5 NMO PA

TAZVERIK Tier 5 NMO LA PA

tretinoin (chemotherapy) Tier 5

XPOVIO 60 MG ONCE WEEKLY

Tier 5 NMO LA PA


Tier 5 NMO LA PA

XPOVIO 80 MG TWICE WEEKLY

Tier 5 NMO LA PA


Tier 5 NMO LA PA

PLATINUM-BASED AGENTS carboplatin Tier 3 B/D

cisplatin SOLN Tier 3 B/D

oxaliplatin inj 50mg Tier 5 B/D

oxaliplatin inj 50mg/10ml Tier 4 B/D

oxaliplatin inj 100mg Tier 5 B/D

oxaliplatin inj 100mg/20ml Tier 4 B/D

PROTECTIVE AGENTS leucovorin calcium SOLN 500mg/50ml

Tier 4 B/D

leucovorin calcium SOLR Tier 4 B/D

leucovorin calcium TABS 5mg, 10mg

Tier 3

leucovorin calcium TABS 15mg, 25mg

Tier 4

MESNEX TABS Tier 5

TOPOISOMERASE INHIBITORS etoposide SOLN Tier 3 B/D

Drug Name Drug Tier

Requirements/Limits

irinotecan hcl (generic of CAMPTOSAR) 40mg/2ml, 100mg/5ml

Tier 4 B/D

irinotecan hcl 300mg/15ml, 500mg/25ml

Tier 4 B/D

toposar Tier 3 B/D

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5-10 mg

Tier 1 GC

amlodipine besylate-benazepril hcl cap 5-10 mg (generic of LOTREL)

Tier 1 GC


Tier 1 GC

amlodipine besylate-benazepril hcl cap 5-40 mg

Tier 1 GC


Tier 1 GC


Tier 1 GC

benazepril & hydrochlorothiazide

Tier 1 GC

benazepril & hydrochlorothiazide (generic of LOTENSIN HCT)

Tier 1 GC

captopril & hydrochlorothiazide

Tier 1 GC

enalapril maleate & hydrochlorothiazide

Tier 1 GC

enalapril maleate & hydrochlorothiazide (generic of VASERETIC)

Tier 1 GC

fosinopril sodium & hydrochlorothiazide

Tier 1 GC

lisinopril & hydrochlorothiazide (generic of ZESTORETIC)

Tier 1 GC

quinapril-hydrochlorothiazide (generic of ACCURETIC)

Tier 1 GC



14

Drug Name Drug Tier

Requirements/Limits

ACE INHIBITORS benazepril hcl TABS 5mg Tier 1 GC

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

Tier 1 GC

captopril TABS Tier 1 GC

enalapril maleate (generic of VASOTEC) TABS

Tier 1 GC

fosinopril sodium Tier 1 GC

lisinopril (generic of ZESTRIL) TABS 2.5mg, 5mg, 30mg, 40mg

Tier 1 GC

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

Tier 1 GC

moexipril hcl Tier 1 GC

perindopril erbumine Tier 1 GC

quinapril hcl (generic of ACCUPRIL)

Tier 1 GC

ramipril (generic of ALTACE)

Tier 1 GC

trandolapril 1mg, 2mg Tier 1 GC

trandolapril (generic of MAVIK) 4mg

Tier 1 GC

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone (generic of INSPRA)

Tier 3

spironolactone (generic of ALDACTONE) TABS

Tier 1 GC

ALPHA BLOCKERS doxazosin mesylate (generic of CARDURA) TABS

Tier 2 GC

prazosin hcl (generic of MINIPRESS)

Tier 3

terazosin hcl 1mg, 2mg, 5mg

Tier 1 GC

terazosin hcl 10mg Tier 2 GC

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil (generic of AZOR)

Tier 1 GC

Drug Name Drug Tier

Requirements/Limits

amlodipine besylate-valsartan tab (generic of EXFORGE)

Tier 1 GC

amlodipine-valsartan-hydrochlorothiazide tab (generic of EXFORGE HCT)

Tier 1 GC

ENTRESTO Tier 3

irbesartan-hydrochlorothiazide (generic of AVALIDE)

Tier 1 GC

losartan-hydrochlorothiazide (generic of HYZAAR)

Tier 1 GC

olmesartan medoxomil-amlodipine-hydrochlorothiazide (generic of TRIBENZOR)

Tier 1 GC

olmesartan medoxomil-hydrochlorothiazide (generic of BENICAR HCT)

Tier 1 GC

valsartan-hydrochlorothiazide (generic of DIOVAN HCT)

Tier 1 GC

ANGIOTENSIN II RECEPTOR ANTAGONISTS irbesartan (generic of AVAPRO)

Tier 1 GC

losartan potassium (generic of COZAAR) TABS

Tier 1 GC

olmesartan medoxomil (generic of BENICAR) TABS

Tier 1 GC

telmisartan (generic of MICARDIS)

Tier 1 GC

valsartan (generic of DIOVAN)

Tier 1 GC

ANTIARRHYTHMICS amiodarone hcl soln Tier 2 GC

amiodarone tab 100mg Tier 4

amiodarone tab 200mg Tier 1 GC

amiodarone tab 400mg Tier 4

disopyramide phosphate (generic of NORPACE)

Tier 4

dofetilide (generic of TIKOSYN)

Tier 4 NMO



15

Drug Name Drug Tier

Requirements/Limits

flecainide acetate Tier 3

MULTAQ Tier 4

NORPACE CR Tier 4

pacerone 100mg, 400mg Tier 4

pacerone 200mg Tier 1 GC

propafenone hcl Tier 2 GC

propafenone hcl 12hr (generic of RYTHMOL SR)

Tier 4

quinidine sulfate Tier 2 GC

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

Tier 2 GC

sorine 240mg Tier 2 GC

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

Tier 2 GC

sotalol hcl 240mg Tier 2 GC

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

Tier 2 GC

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium (generic of LIPITOR) TABS

Tier 1 GC

lovastatin Tier 1 GC

pravastatin sodium 10mg, 80mg

Tier 1 GC

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

Tier 1 GC

rosuvastatin calcium (generic of CRESTOR)


Tier 1 GC QL

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

Tier 1 GC

simvastatin (generic of ZOCOR) TABS 80mg


Tier 1 GC QL

ANTILIPEMICS, MISCELLANEOUS cholestyramine (generic of QUESTRAN)

Tier 3

cholestyramine light pack Tier 4

Drug Name Drug Tier

Requirements/Limits

cholestyramine light powd (generic of QUESTRAN LIGHT)

Tier 3

colesevelam hcl (generic of WELCHOL)

Tier 4

colestipol hcl gran (generic of COLESTID)

Tier 4

colestipol hcl pack (generic of COLESTID)

Tier 4

colestipol hcl tabs (generic of COLESTID)

Tier 3

ezetimibe (generic of ZETIA)

Tier 3

ezetimibe-simvastatin (generic of VYTORIN)

Tier 1 GC

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

Tier 3

fenofibrate TABS 54mg, 160mg

Tier 3

fenofibrate micronized 67mg, 134mg, 200mg

Tier 3

gemfibrozil (generic of LOPID) TABS

Tier 1 GC

JUXTAPID Tier 5 NMO LA PA

niacin (antihyperlipidemic) Tier 4

niacin er (antihyperlipidemic) (generic of NIASPAN) 500mg


Tier 4 QL

niacin er (antihyperlipidemic) (generic of NIASPAN) 750mg, 1000mg

Tier 4

niacor Tier 4

PRALUENT Tier 3 NMO PA

prevalite PACK Tier 4

prevalite (generic of QUESTRAN LIGHT) POWD

Tier 3

VASCEPA Tier 4



16

Drug Name Drug Tier

Requirements/Limits

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

Tier 2 GC

atenolol & chlorthalidone (generic of TENORETIC 100)

Tier 2 GC

bisoprolol & hydrochlorothiazide (generic of ZIAC)

Tier 1 GC

metoprolol & hydrochlorothiazide

Tier 3

metoprolol & hydrochlorothiazide (generic of LOPRESSOR HCT)

Tier 3

propranolol & hydrochlorothiazide

Tier 3

BETA-BLOCKERS acebutolol hcl CAPS Tier 2 GC

atenolol (generic of TENORMIN) TABS

Tier 1 GC

bisoprolol fumarate Tier 2 GC

BYSTOLIC 2.5mg, 5mg, 10mg


Tier 4 QL

BYSTOLIC 20mg QL (60 tabs / 30 days)

Tier 4 QL

carvedilol (generic of COREG)

Tier 1 GC

labetalol hcl TABS Tier 3

metoprolol succinate (generic of TOPROL XL)

Tier 2 GC

metoprolol tartrate SOCT Tier 3

metoprolol tartrate SOLN Tier 3

metoprolol tartrate TABS 25mg

Tier 1 GC

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

Tier 1 GC

nadolol (generic of CORGARD) TABS

Tier 3

pindolol Tier 3

propranolol cap er (generic of INDERAL LA)

Tier 3

Drug Name Drug Tier

Requirements/Limits

propranolol hcl TABS Tier 2 GC

propranolol oral sol Tier 3

timolol maleate TABS Tier 3

CALCIUM CHANNEL BLOCKERS amlodipine besylate (generic of NORVASC) TABS

Tier 1 GC

cartia xt (generic of CARDIZEM CD)

Tier 2 GC

dilt-xr cap Tier 2 GC

diltiazem cap 240mg cd (generic of CARDIZEM CD)

Tier 2 GC

diltiazem cap 360mg cd (generic of CARDIZEM CD)

Tier 4

diltiazem cap er/12hr Tier 4

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

Tier 2 GC

diltiazem hcl TABS 90mg Tier 2 GC

diltiazem hcl coated beads (generic of CARDIZEM CD) CP24

Tier 4

diltiazem hcl coated beads cap sr 24hr (generic of CARDIZEM CD)

Tier 2 GC

diltiazem hcl extended release beads cap sr (generic of TIAZAC) 120mg, 180mg, 240mg, 300mg, 360mg, 420mg

Tier 2 GC

diltiazem hcl extended release beads cap sr (generic of CARDIZEM CD) 180mg

Tier 2 GC

diltiazem inj Tier 2 GC

felodipine Tier 2 GC

isradipine Tier 3

nicardipine hcl CAPS Tier 4

nifedipine (generic of PROCARDIA XL) TB24

Tier 2 GC

nifedipine er Tier 2 GC

nimodipine CAPS Tier 5

NYMALIZE 60mg/20ml Tier 5

taztia xt (generic of TIAZAC) Tier 2 GC



17

Drug Name Drug Tier

Requirements/Limits

tiadylt er (generic of TIAZAC)

Tier 2 GC

verapamil cap er (generic of VERELAN PM) 100mg, 200mg

Tier 4

verapamil cap er (generic of VERELAN) 120mg, 180mg, 240mg

Tier 3

verapamil cap er 300mg, 360mg

Tier 4

verapamil hcl SOLN Tier 4

verapamil hcl TABS Tier 1 GC

verapamil hcl (generic of CALAN SR) TBCR

Tier 2 GC

verapamil tab er 180mg Tier 2 GC

verapamil tab er (generic of CALAN SR) 240mg

Tier 2 GC

DIGITALIS GLYCOSIDES digitek (generic of LANOXIN) .25mg

PA if 70 years and older

Tier 2 GC PA

digitek (generic of LANOXIN) .125mg


Tier 2 GC QL

digox (generic of LANOXIN) 125mcg


Tier 2 GC QL

digox (generic of LANOXIN) 250mcg


Tier 2 GC PA

digoxin (generic of LANOXIN) TABS 125mcg


Tier 2 GC QL

digoxin (generic of LANOXIN) TABS 250mcg


Tier 2 GC PA

digoxin inj (generic of LANOXIN)

Tier 4

digoxin sol 50mcg/ml PA if 70 years and older

Tier 4 PA

DIURETICS acetazolamide CP12 Tier 4

acetazolamide TABS Tier 3

Drug Name Drug Tier

Requirements/Limits

amiloride & hydrochlorothiazide

Tier 2 GC

amiloride hcl TABS Tier 2 GC

bumetanide inj 0.25/ml Tier 3

bumetanide tab (generic of BUMEX)

Tier 3

chlorothiazide TABS Tier 3

chlorthalidone Tier 2 GC

furosemide SOLN Tier 2 GC

furosemide (generic of LASIX) TABS

Tier 1 GC

furosemide inj Tier 2 GC

hydrochlorothiazide CAPS; TABS

Tier 1 GC

indapamide Tier 2 GC

methazolamide TABS Tier 4

metolazone Tier 3

spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE)

Tier 3

torsemide tabs Tier 2 GC

triamterene & hydrochlorothiazide cap 37.5-25 mg (generic of DYAZIDE)

Tier 1 GC

triamterene & hydrochlorothiazide tabs (generic of MAXZIDE)

Tier 1 GC

triamterene & hydrochlorothiazide tabs (generic of MAXZIDE-25)

Tier 1 GC

MISCELLANEOUS aliskiren fumarate (generic of TEKTURNA)

Tier 4

clonidine hcl (generic of CATAPRES) TABS

Tier 1 GC

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

Tier 4


Tier 4



18

Drug Name Drug Tier

Requirements/Limits


Tier 4

CORLANOR Tier 4

DEMSER Tier 5 PA

hydralazine hcl SOLN Tier 4

hydralazine hcl TABS Tier 2 GC

midodrine hcl Tier 3

minoxidil TABS Tier 2 GC

NORTHERA 100mg QL (90 caps / 30 days)

Tier 5 QL NMO LA PA

NORTHERA 200mg, 300mg


Tier 5 QL NMO LA PA

RANEXA Tier 4

ranolazine (generic of RANEXA)

Tier 4

NITRATES isosorb mononitrate tab Tier 2 GC

isosorbide dinitrate (generic of ISORDIL TITRADOSE) 5mg

Tier 3

isosorbide dinitrate 10mg, 20mg, 30mg

Tier 3

isosorbide mononitrate er Tier 1 GC

minitran (generic of NITRO-DUR)

Tier 2 GC

NITRO-BID Tier 3

NITRO-DUR DIS 0.3MG/HR Tier 4

NITRO-DUR DIS 0.8MG/HR Tier 4

nitroglycerin (generic of NITROSTAT) SUBL

Tier 3

nitroglycerin td patch .1mg/hr

Tier 2 GC

nitroglycerin td patch (generic of NITRO-DUR) .2mg/hr, .4mg/hr, .6mg/hr

Tier 2 GC

PULMONARY ARTERIAL HYPERTENSION ADCIRCA


ADEMPAS QL (90 tabs / 30 days)

Tier 5 QL NMO LA PA

Drug Name Drug Tier

Requirements/Limits

alyq (generic of ADCIRCA) QL (60 tabs / 30 days)

Tier 5 QL NMO PA

ambrisentan (generic of LETAIRIS)


Tier 5 QL NMO LA PA

bosentan (generic of TRACLEER) 62.5mg


Tier 5 QL NMO LA PA

bosentan (generic of TRACLEER) 125mg


Tier 5 QL NMO LA PA

OPSUMIT QL (30 tabs / 30 days)

Tier 5 QL NMO LA PA

sildenafil citrate tab 20 mg (pulmonary hypertension) (generic of REVATIO)


Tier 3 QL NMO PA

tadalafil (pulmonary hypertension) (generic of ADCIRCA)


Tier 5 QL NMO PA

treprostinil Tier 5 NMO LA PA

VENTAVIS Tier 5 NMO PA

CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam tab 0.5mg (generic of XANAX)


Tier 2 GC QL

alprazolam tab 0.25mg (generic of XANAX)


Tier 2 GC QL

alprazolam tab 1mg (generic of XANAX)


Tier 2 GC QL

alprazolam tab 2 mg (generic of XANAX)


Tier 2 GC QL

buspirone hcl TABS 5mg, 10mg, 15mg

Tier 1 GC



19

Drug Name Drug Tier

Requirements/Limits

buspirone hcl TABS 7.5mg, 30mg

Tier 3

fluvoxamine maleate TABS Tier 2 GC

lorazepam (generic of ATIVAN) SOLN

Tier 2 GC

lorazepam (generic of ATIVAN) TABS


Tier 2 GC QL

lorazepam intensol QL (150 mL / 30 days)

Tier 3 QL

ANTICONVULSANTS APTIOM

QL (60 tabs / 30 days) Tier 5 QL

BANZEL SUS 40MG/ML Tier 5 PA

BANZEL TAB 200MG Tier 5 PA

BANZEL TAB 400MG Tier 5 PA

BRIVIACT INJ 50MG/5ML Tier 4 PA

BRIVIACT SOL 10MG/ML Tier 5 PA

BRIVIACT TAB 10MG Tier 5 PA





carbamazepine CHEW Tier 3

carbamazepine (generic of CARBATROL) CP12

Tier 4

carbamazepine (generic of TEGRETOL) SUSP

Tier 4

carbamazepine (generic of TEGRETOL) TABS

Tier 3

carbamazepine (generic of TEGRETOL-XR) TB12

Tier 4

CELONTIN Tier 4

clobazam (generic of ONFI) Tier 4 PA

clonazepam (generic of KLONOPIN) TABS 2mg


Tier 2 GC QL

clonazepam (generic of KLONOPIN) TABS .5mg, 1mg


Tier 2 GC QL

Drug Name Drug Tier

Requirements/Limits

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

Tier 3 QL

clonazepam TBDP .125mg, .25mg, .5mg, 1mg


Tier 3 QL

clorazepate dipotassium QL (180 tabs / 30 days)


Tier 4 QL PA

DIASTAT ACUDIAL Tier 4

DIASTAT PEDIATRIC Tier 4

diazepam (generic of VALIUM) TABS



Tier 2 GC QL PA

diazepam gel Tier 4

diazepam inj Tier 3

diazepam intensol QL (240 mL / 30 days)


Tier 3 QL PA

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


Tier 3 QL PA

DILANTIN CAP 30MG Tier 3

DILANTIN CAP 100MG Tier 3

DILANTIN CHEW TAB 50MG

Tier 3

DILANTIN-125 SUSP Tier 4

divalproex sodium (generic of DEPAKOTE SPRINKLES) CSDR

Tier 4

divalproex sodium (generic of DEPAKOTE ER) TB24

Tier 3

divalproex sodium (generic of DEPAKOTE) TBEC

Tier 3

EPIDIOLEX QL (600 mL / 30 days)

Tier 5 QL NMO LA PA

epitol (generic of TEGRETOL)

Tier 3

ethosuximide (generic of ZARONTIN) CAPS; SOLN

Tier 4



20

Drug Name Drug Tier

Requirements/Limits

felbamate (generic of FELBATOL) SUSP

Tier 5

felbamate (generic of FELBATOL) TABS

Tier 4

FYCOMPA SUSP QL (720 mL / 30 days)

Tier 5 QL PA

FYCOMPA TABS 2mg QL (60 tabs / 30 days)

Tier 4 QL PA

FYCOMPA TABS 4mg, 6mg


Tier 5 QL PA

FYCOMPA TABS 8mg, 10mg, 12mg


Tier 5 QL PA

gabapentin (generic of NEURONTIN) CAPS 100mg


Tier 2 GC QL



Tier 2 GC QL



Tier 2 GC QL

gabapentin (generic of NEURONTIN) SOLN

QL (2160 mL / 30 days)

Tier 3 QL

gabapentin (generic of NEURONTIN) TABS 600mg


Tier 3 QL

gabapentin (generic of NEURONTIN) TABS 800mg


Tier 3 QL

Drug Name Drug Tier

Requirements/Limits

lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW

Tier 3

lamotrigine (generic of LAMICTAL) TABS

Tier 1 GC

lamotrigine (generic of LAMICTAL XR) TB24

Tier 4

levetiracetam (generic of KEPPRA) SOLN

Tier 4

levetiracetam (generic of KEPPRA) TABS

Tier 2 GC

levetiracetam (generic of KEPPRA XR) TB24

Tier 3

levetiracetam in sodium chloride (generic of LEVETIRACETAM)

Tier 4

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

Tier 3

NAYZILAM Tier 4

oxcarbazepine (generic of TRILEPTAL) SUSP

Tier 4

oxcarbazepine (generic of TRILEPTAL) TABS

Tier 3

PEGANONE Tier 4

phenobarbital ELIX PA if 70 years and older

Tier 4 PA

phenobarbital TABS PA if 70 years and older

Tier 3 PA

phenobarbital sodium SOLN


Tier 4 PA

PHENYTEK Tier 3

phenytoin (generic of DILANTIN INFATABS) CHEW

Tier 3

phenytoin (generic of DILANTIN-125) SUSP

Tier 3

phenytoin sodium extended (generic of DILANTIN) 100mg

Tier 3

phenytoin sodium extended (generic of PHENYTEK) 200mg, 300mg

Tier 3



21

Drug Name Drug Tier

Requirements/Limits

phenytoin sodium inj 50mg/ml

Tier 3

pregabalin (generic of LYRICA) CAPS 25mg, 50mg, 75mg, 100mg, 150mg


Tier 3 QL PA

pregabalin (generic of LYRICA) CAPS 200mg


Tier 3 QL PA

pregabalin (generic of LYRICA) CAPS 225mg, 300mg


Tier 3 QL PA

pregabalin (generic of LYRICA) SOLN

QL (900 mL / 30 days)

Tier 4 QL PA

primidone (generic of MYSOLINE) TABS

Tier 2 GC

roweepra (generic of KEPPRA)

Tier 2 GC

roweepra xr (generic of KEPPRA XR)

Tier 3

SPRITAM Tier 4

subvenite tab (generic of LAMICTAL)

Tier 1 GC

SYMPAZAN 5mg Tier 4 PA

SYMPAZAN 10mg, 20mg Tier 5 PA

tiagabine hcl (generic of GABITRIL)

Tier 4

topiramate (generic of TOPAMAX SPRINKLE) CPSP

Tier 3

topiramate (generic of TOPAMAX) TABS

Tier 2 GC

valproate sodium SOLN Tier 3

valproate sodium oral soln Tier 3

valproic acid CAPS Tier 3

VALTOCO Tier 4

vigabatrin powd pack 500mg (generic of SABRIL)

QL (180 packets / 30 days)

Tier 5 QL NMO LA PA

Drug Name Drug Tier

Requirements/Limits

vigabatrin tab 500mg (generic of SABRIL)


Tier 5 QL NMO LA PA

vigadrone (generic of SABRIL)


Tier 5 QL NMO LA PA

VIMPAT 50mg QL (120 tabs / 30 days)

Tier 4 QL

VIMPAT 100mg, 150mg, 200mg


Tier 5 QL

VIMPAT INJ 200MG/20ML Tier 5

VIMPAT SOL 10MG/ML QL (1200 mL / 30 days)

Tier 5 QL

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

Tier 2 GC

zonisamide CAPS 50mg Tier 2 GC

ANTIDEMENTIA donepezil hydrochloride (generic of ARICEPT) TABS 5mg


Tier 2 GC QL

donepezil hydrochloride (generic of ARICEPT) TABS 10mg

Tier 2 GC

donepezil hydrochloride TBDP 5mg


Tier 2 GC QL

donepezil hydrochloride TBDP 10mg

Tier 2 GC

galantamine hydrobromide SOLN

Tier 4

galantamine hydrobromide (generic of RAZADYNE) TABS 4mg


Tier 3 QL

galantamine hydrobromide TABS 8mg, 12mg


Tier 3 QL



22

Drug Name Drug Tier

Requirements/Limits

galantamine hydrobromide er (generic of RAZADYNE ER)


Tier 3 QL

memantine hcl cp24 (generic of NAMENDA XR)

PA if < 30 yrs

Tier 4 PA

memantine soln PA if < 30 yrs

Tier 4 PA

memantine tabs (generic of NAMENDA)

PA if < 30 yrs

Tier 3 PA

NAMZARIC Tier 4

rivastigmine tartrate 1.5mg, 3mg


Tier 4 QL

rivastigmine tartrate 4.5mg, 6mg


Tier 4 QL

rivastigmine td patch 24hr 4.6 mg/24hr (generic of EXELON)


Tier 4 QL



Tier 4 QL



Tier 4 QL

ANTIDEPRESSANTS amitriptyline hcl TABS Tier 3

amoxapine Tier 3

bupropion hcl TABS Tier 3

bupropion hcl (generic of WELLBUTRIN SR) TB12

Tier 2 GC

bupropion hcl (generic of WELLBUTRIN XL) TB24 150mg, 300mg

Tier 3

Drug Name Drug Tier

Requirements/Limits

citalopram hydrobromide SOLN

Tier 3

citalopram hydrobromide (generic of CELEXA) TABS

Tier 1 GC

clomipramine hcl (generic of ANAFRANIL) CAPS

Tier 4 PA

desipramine hcl (generic of NORPRAMIN) TABS 10mg, 25mg

Tier 4

desipramine hcl TABS 50mg, 75mg, 100mg, 150mg

Tier 4

desvenlafaxine succinate (generic of PRISTIQ)


Tier 4 QL PA

doxepin hcl CAPS; CONC Tier 3

DRIZALMA SPRINKLE 20mg, 30mg, 60mg


Tier 4 QL PA

DRIZALMA SPRINKLE 40mg


Tier 4 QL PA

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


Tier 3 QL

EMSAM QL (30 patches / 30 days)

Tier 5 QL PA

escitalopram oxalate SOLN Tier 4

escitalopram oxalate (generic of LEXAPRO) TABS

Tier 1 GC

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

Tier 4 QL PA

FETZIMA 80mg, 120mg QL (30 caps / 30 days)

Tier 4 QL PA

FETZIMA TITRATION PACK

Tier 4 PA

fluoxetine cap 10mg (generic of PROZAC)

Tier 1 GC


Tier 1 GC


Tier 2 GC



23

Drug Name Drug Tier

Requirements/Limits

fluoxetine hcl SOLN Tier 2 GC

imipramine hcl TABS Tier 2 GC

maprotiline hcl Tier 3

MARPLAN TAB 10MG QL (180 tabs / 30 days)

Tier 4 QL

mirtazapine TABS 7.5mg Tier 3

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

Tier 1 GC

mirtazapine TABS 45mg Tier 1 GC

mirtazapine (generic of REMERON SOLTAB) TBDP

Tier 3

nefazodone hcl Tier 4

nortriptyline hcl (generic of PAMELOR) CAPS

Tier 2 GC

nortriptyline hcl SOLN Tier 4

paroxetine hcl tabs (generic of PAXIL)

Tier 2 GC

PAXIL SUSP QL (900 mL / 30 days)

Tier 4 QL

phenelzine sulfate (generic of NARDIL) TABS

Tier 3

protriptyline hcl Tier 4

sertraline hcl (generic of ZOLOFT) CONC

Tier 4

sertraline hcl (generic of ZOLOFT) TABS

Tier 1 GC

tranylcypromine sulfate (generic of PARNATE)

Tier 4

trazodone hcl TABS 50mg, 100mg, 150mg

Tier 1 GC

trimipramine maleate CAPS 25mg


Tier 4 QL



Tier 4 QL



Tier 4 QL

Drug Name Drug Tier

Requirements/Limits

TRINTELLIX 5mg QL (120 tabs / 30 days)

Tier 4 QL


Tier 4 QL


Tier 4 QL

venlafaxine hcl (generic of EFFEXOR XR) CP24

Tier 2 GC

venlafaxine hcl TABS Tier 2 GC

VIIBRYD STARTER PACK Tier 4

VIIBRYD TAB QL (30 tabs / 30 days)

Tier 4 QL

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS


Tier 3 QL

amantadine hcl SYRP Tier 2 GC

amantadine hcl TABS Tier 3

APOKYN QL (20 cartridges / 30 days)

Tier 5 QL NMO LA PA

benztropine mesylate inj (generic of COGENTIN)

Tier 4

benztropine mesylate tab 0.5mg


Tier 3 PA

benztropine mesylate tab 1mg


Tier 3 PA

benztropine mesylate tab 2mg


Tier 3 PA

bromocriptine mesylate (generic of PARLODEL) CAPS; TABS

Tier 4

carbidopa-levodopa (generic of SINEMET) TABS

Tier 2 GC

carbidopa-levodopa TBCR Tier 3

carbidopa-levodopa TBDP Tier 4

carbidopa/levodopa/entacapone

Tier 4



24

Drug Name Drug Tier

Requirements/Limits

carbidopa/levodopa/entacapone (generic of STALEVO 100)

Tier 4

carbidopa/levodopa/entacapone (generic of STALEVO 150)

Tier 4

entacapone (generic of COMTAN)

Tier 4

NEUPRO Tier 4

pramipexole tab 0.5mg (generic of MIRAPEX)

Tier 1 GC

pramipexole tab 0.25mg Tier 1 GC


Tier 1 GC


Tier 1 GC

pramipexole tab 1.5mg Tier 1 GC

pramipexole tab 1mg (generic of MIRAPEX)

Tier 1 GC

rasagiline mesylate (generic of AZILECT) TABS

Tier 4

ropinirole tab 0.5mg Tier 2 GC

ropinirole tab 0.25mg Tier 2 GC

ropinirole tab 1mg Tier 2 GC





selegiline hcl CAPS; TABS Tier 3

trihexyphenidyl hcl PA if 70 years and older

Tier 3 PA

ANTIPSYCHOTICS ABILIFY MAINTENA

QL (1 injection / 28 days)

Tier 5 QL

aripiprazole odt QL (60 tabs / 30 days)

Tier 5 QL

aripiprazole oral solution 1 mg/ml

QL (900 mL / 30 days)

Tier 5 QL

aripiprazole tab (generic of ABILIFY)


Tier 4 QL

Drug Name Drug Tier

Requirements/Limits

ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml


Tier 5 QL

ARISTADA 1064mg/3.9ml QL (1 injection / 56 days)

Tier 5 QL

ARISTADA INITIO Tier 5

CAPLYTA QL (30 caps / 30 days)

Tier 4 QL

chlorpromazine hcl TABS Tier 4

CHLORPROMAZINE INJ Tier 4

clozapine odt 12.5mg, 25mg

Tier 4 PA

clozapine odt 100mg QL (270 tabs / 30 days)

Tier 4 QL PA


Tier 4 QL PA


Tier 4 QL PA

clozapine tab 25mg (generic of CLOZARIL)

Tier 3


Tier 3



Tier 4 QL



Tier 4 QL

FANAPT QL (60 tabs / 30 days)

Tier 4 QL PA

FANAPT TITRATION PACK Tier 4 PA

fluphenazine decanoate SOLN

Tier 4

fluphenazine hcl Tier 4

GEODON SOLR QL (6 mL / 3 days)

Tier 4 QL

haloperidol TABS Tier 3



25

Drug Name Drug Tier

Requirements/Limits

haloperidol conc 2mg/ml Tier 2 GC

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

Tier 3

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

Tier 3

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

Tier 3

INVEGA SUST INJ 39 MG/0.25 ML


Tier 4 QL



Tier 5 QL



Tier 5 QL

INVEGA SUST INJ 156MG/ML


Tier 5 QL



Tier 5 QL

INVEGA TRINZA QL (1 injection / 90 days)

Tier 5 QL

LATUDA 20mg, 40mg, 60mg, 120mg


Tier 4 QL

LATUDA 80mg QL (60 tabs / 30 days)

Tier 4 QL

loxapine succinate Tier 3

molindone hcl Tier 4

NUPLAZID CAPS QL (30 caps / 30 days)

Tier 5 QL NMO LA PA

Drug Name Drug Tier

Requirements/Limits

NUPLAZID TABS 10MG QL (30 tabs / 30 days)

Tier 5 QL NMO LA PA

olanzapine (generic of ZYPREXA) SOLR

QL (3 vials / 1 day)

Tier 4 QL

olanzapine (generic of ZYPREXA) TABS 2.5mg, 5mg, 10mg


Tier 2 GC QL

olanzapine (generic of ZYPREXA) TABS 7.5mg, 15mg, 20mg


Tier 2 GC QL

olanzapine (generic of ZYPREXA ZYDIS) TBDP 5mg, 15mg, 20mg


Tier 4 QL

olanzapine (generic of ZYPREXA ZYDIS) TBDP 10mg


Tier 4 QL

paliperidone (generic of INVEGA) 1.5mg, 3mg, 9mg


Tier 4 QL

paliperidone (generic of INVEGA) 6mg


Tier 4 QL

perphenazine TABS Tier 3

PERSERIS QL (1 injection / 30 days)

Tier 5 QL

pimozide Tier 4

quetiapine fumarate (generic of SEROQUEL) TABS

Tier 2 GC

quetiapine fumarate (generic of SEROQUEL XR) TB24 50mg, 300mg, 400mg


Tier 4 QL PA

quetiapine fumarate (generic of SEROQUEL XR) TB24 150mg, 200mg


Tier 4 QL PA

REXULTI 3mg, 4mg QL (30 tabs / 30 days)

Tier 5 QL



26

Drug Name Drug Tier

Requirements/Limits

REXULTI .25mg, .5mg, 1mg, 2mg


Tier 5 QL

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

Tier 4 QL

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

Tier 4 QL

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

Tier 5 QL

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

Tier 5 QL

risperidone (generic of RISPERDAL) SOLN

QL (240 mL / 30 days)

Tier 3 QL

risperidone (generic of RISPERDAL) TABS .5mg, 1mg, 2mg, 3mg, 4mg

Tier 2 GC

risperidone TABS .25mg Tier 2 GC

risperidone TBDP 1mg, 2mg, 3mg, 4mg


Tier 4 QL

risperidone TBDP .25mg, .5mg


Tier 4 QL

SAPHRIS QL (60 tabs / 30 days)

Tier 4 QL

SECUADO QL (30 patches / 30 days)

Tier 4 QL

thioridazine hcl TABS Tier 3

thiothixene Tier 4

trifluoperazine hcl Tier 3

VERSACLOZ QL (600 mL / 30 days)

Tier 5 QL PA

VRAYLAR 1.5mg QL (60 caps / 30 days)

Tier 5 QL PA

VRAYLAR 3mg, 4.5mg, 6mg


Tier 5 QL PA

VRAYLAR THERAPY PACK Tier 4 PA

Drug Name Drug Tier

Requirements/Limits

ziprasidone hcl (generic of GEODON)


Tier 4 QL

ziprasidone mesylate (generic of GEODON)

QL (6 injections / 3 days)

Tier 4 QL

ZYPREXA RELPREVV 300mg

QL (2 vials / 28 days)

Tier 5 QL PA

ZYPREXA RELPREVV 405mg

QL (1 vial / 28 days)

Tier 5 QL PA

ZYPREXA RELPREVV INJ 210MG

QL (2 vials / 28 days)

Tier 4 QL PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap sr 24hr 5 mg (generic of ADDERALL XR)


Tier 4 QL

amphetamine-dextroamphetamine cap sr 24hr 10 mg (generic of ADDERALL XR)


Tier 4 QL



Tier 4 QL



Tier 4 QL



Tier 4 QL



27

Drug Name Drug Tier

Requirements/Limits



Tier 4 QL

amphetamine-dextroamphetamine tab 5 mg (generic of ADDERALL)


Tier 3 QL

amphetamine-dextroamphetamine tab 7.5 mg (generic of ADDERALL)


Tier 3 QL



Tier 3 QL

amphetamine-dextroamphetamine tab 12.5 mg (generic of ADDERALL)


Tier 3 QL



Tier 3 QL



Tier 3 QL



Tier 3 QL

atomoxetine hcl (generic of STRATTERA) 10mg, 18mg, 25mg


Tier 4 QL

Drug Name Drug Tier

Requirements/Limits

atomoxetine hcl (generic of STRATTERA) 40mg


Tier 4 QL

atomoxetine hcl (generic of STRATTERA) 60mg, 80mg, 100mg


Tier 4 QL

dexmethylphenidate hcl (generic of FOCALIN) TABS 2.5mg, 5mg


Tier 3 QL

dexmethylphenidate hcl (generic of FOCALIN) TABS 10mg


Tier 3 QL

guanfacine er (adhd) (generic of INTUNIV)


Tier 3 PA

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

Tier 4 QL

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


Tier 3 QL

methylphenidate hcl (generic of RITALIN) TABS 20mg


Tier 3 QL

methylphenidate hcl oral soln (generic of METHYLIN) 5mg/5ml

QL (1800 mL / 30 days)

Tier 4 QL

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

QL (900 mL / 30 days)

Tier 4 QL

methylphenidate hcl tbcr 10 mg


Tier 4 QL

methylphenidate hcl tbcr 20mg


Tier 4 QL



28

Drug Name Drug Tier

Requirements/Limits

HYPNOTICS BELSOMRA


doxepin hcl (sleep) (generic of SILENOR)


Tier 3 QL

HETLIOZ Tier 5 NMO LA PA

temazepam (generic of RESTORIL) 7.5mg

QL (30 caps / 30 days) PA applies if 65 years and older after a 90 day supply in a calendar year

Tier 4 QL PA

temazepam (generic of RESTORIL) 15mg

QL (60 caps / 30 days) PA applies if 65 years and older after a 90 day supply in a calendar year

Tier 4 QL PA

zolpidem tartrate (generic of AMBIEN) TABS

QL (30 tabs / 30 days) PA applies if 70 years and older after a 90 day supply in a calendar year

Tier 2 GC QL PA

MIGRAINE AIMOVIG

QL (1 pen / 30 days) Tier 3 QL NMO PA

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

Tier 5

dihydroergotamine mesylate nasal spr 4 mg/ml (generic of MIGRANAL)

QL (8 mL / 30 days)

Tier 5 QL PA

eletriptan hydrobromide (generic of RELPAX)


Tier 4 QL

EMGALITY SOAJ QL (2 pens / 30 days)

Tier 3 QL NMO PA

EMGALITY SOSY 120mg/ml

QL (2 syringes / 30 days)

Tier 3 QL NMO PA

Drug Name Drug Tier

Requirements/Limits

ergotamine w/ caffeine (generic of CAFERGOT) TABS

Tier 4

naratriptan hcl (generic of AMERGE)


Tier 3 QL

rizatriptan benzoate 5mg QL (18 tabs / 30 days)

Tier 3 QL

rizatriptan benzoate (generic of MAXALT) 10mg


Tier 3 QL

rizatriptan benzoate odt 5mg


Tier 3 QL

rizatriptan benzoate odt (generic of MAXALT-MLT) 10mg


Tier 3 QL

sumatriptan (generic of IMITREX) SOLN 5mg/act

QL (24 inhalers / 30 days)

Tier 4 QL

sumatriptan (generic of IMITREX) SOLN 20mg/act


Tier 4 QL

sumatriptan inj 4mg/0.5ml (generic of IMITREX STATDOSE SYSTEM) SOAJ


Tier 4 QL

sumatriptan inj 4mg/0.5ml (generic of IMITREX STATDOSE REFILL) SOCT


Tier 4 QL

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


Tier 4 QL



29

Drug Name Drug Tier

Requirements/Limits

sumatriptan inj 6mg/0.5ml (generic of IMITREX STATDOSE REFILL) SOCT


Tier 4 QL

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


Tier 4 QL

sumatriptan inj 6mg/0.5ml SOSY


Tier 4 QL

sumatriptan succinate (generic of IMITREX) TABS


Tier 2 GC QL

zolmitriptan (generic of ZOMIG) TABS


Tier 4 QL

zolmitriptan odt (generic of ZOMIG ZMT)


Tier 4 QL

MISCELLANEOUS AUSTEDO 6mg


AUSTEDO 9mg, 12mg QL (120 tabs / 30 days)

Tier 5 QL NMO PA

lithium carbonate CAPS Tier 1 GC

lithium carbonate TABS Tier 2 GC

lithium carbonate er (generic of LITHOBID) 300mg

Tier 2 GC

lithium carbonate er 450mg Tier 2 GC

LITHIUM SOLN 8MEQ/5ML Tier 4

LYRICA CR QL (60 tabs / 30 days)

Tier 3 QL PA

NUEDEXTA QL (60 caps / 30 days)

Tier 4 QL PA

pyridostigmine tab 60mg (generic of MESTINON)

Tier 3

riluzole (generic of RILUTEK)

Tier 3

Drug Name Drug Tier

Requirements/Limits

tetrabenazine (generic of XENAZINE) 12.5mg


Tier 5 QL NMO PA

tetrabenazine (generic of XENAZINE) 25mg


Tier 5 QL NMO PA

MULTIPLE SCLEROSIS AGENTS BETASERON


Tier 5 QL NMO PA

dalfampridine (generic of AMPYRA) TB12

Tier 5 NMO PA

GILENYA QL (28 caps / 28 days)

Tier 5 QL NMO PA

glatiramer acetate 20mg/ml (generic of COPAXONE)


Tier 5 QL NMO PA

glatiramer acetate 40mg/ml (generic of COPAXONE)


Tier 5 QL NMO PA

glatopa (generic of COPAXONE) 20mg/ml


Tier 5 QL NMO PA

glatopa (generic of COPAXONE) 40mg/ml


Tier 5 QL NMO PA

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 10mg, 20mg

Tier 3

cyclobenzaprine hcl TABS 5mg, 10mg


Tier 3 PA

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

Tier 4

dantrolene sodium CAPS 100mg

Tier 4

tizanidine hcl TABS 2mg Tier 2 GC



30

Drug Name Drug Tier

Requirements/Limits

tizanidine hcl (generic of ZANAFLEX) TABS 4mg

Tier 2 GC

NARCOLEPSY/CATAPLEXY armodafinil (generic of NUVIGIL) 50mg


Tier 3 QL PA

armodafinil (generic of NUVIGIL) 150mg, 200mg, 250mg


Tier 3 QL PA

XYREM QL (540 mL / 30 days)

Tier 5 QL NMO LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium Tier 4

buprenorphine hcl SUBL QL (90 tabs / 30 days)

Tier 3 QL PA

buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg (generic of SUBOXONE)

QL (90 films / 30 days)

Tier 4 QL

buprenorphine hcl-naloxone hcl dihydrate 4-1mg (generic of SUBOXONE)


Tier 4 QL



Tier 4 QL



Tier 4 QL

buprenorphine hcl-naloxone hcl sl


Tier 2 GC QL

bupropion hcl (smoking deterrent)

Tier 3

CHANTIX Tier 4 PA

CHANTIX CONTINUING MONTH

Tier 4 PA

CHANTIX STARTER PACK Tier 4 PA

disulfiram (generic of ANTABUSE) TABS

Tier 3

naloxone inj 0.4mg/ml Tier 2 GC

Drug Name Drug Tier

Requirements/Limits

naloxone inj 1mg/ml Tier 2 GC

naltrexone hcl TABS Tier 3

NARCAN Tier 3

NICOTROL INHALER Tier 4

NICOTROL NS Tier 4

VIVITROL Tier 5 NMO

ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 Tier 5 PA

ANDRODERM QL (30 patches / 30 days)

Tier 4 QL PA

oxandrolone tab 2.5mg Tier 3 PA

oxandrolone tab 10mg Tier 4 PA

testosterone GEL 1% QL (300 grams / 30 days)

Tier 4 QL PA

testosterone (generic of ANDROGEL) GEL 25mg/2.5gm, 50mg/5gm

QL (300 grams / 30 days)

Tier 4 QL PA

testosterone cypionate (generic of DEPO-TESTOSTERONE) SOLN

Tier 3 PA

testosterone enanthate SOLN

Tier 3 PA

ANTIDIABETICS, INJECTABLE BASAGLAR KWIKPEN Tier 3

BD ALCOHOL SWABS Tier 3

BD ULTRAFINE INSULIN SYRINGE

Tier 3

BD ULTRAFINE/NANO PEN NEEDLES

Tier 3

BYDUREON BCISE QL (4 pens / 28 days)

Tier 3 QL

BYDUREON PEN QL (4 pens / 28 days)

Tier 3 QL

BYETTA QL (1 pen / 30 days)

Tier 4 QL

FIASP Tier 3

FIASP FLEXTOUCH Tier 3

FIASP PENFILL Tier 3



31

Drug Name Drug Tier

Requirements/Limits

GAUZE PADS 2" X 2" Tier 3

HUMULIN R INJ U-500 Tier 5 B/D

HUMULIN R U-500 KWIKPEN

Tier 5

INSULIN PEN NEEDLE Tier 3

INSULIN SAFETY NEEDLES

Tier 3

INSULIN SYRINGE Tier 3

LEVEMIR Tier 3

LEVEMIR FLEXTOUCH Tier 3

NOVOLIN 70/30 (brand RELION not covered)

Tier 3

NOVOLIN 70/30 FLEXPEN (brand RELION not covered)

Tier 3

NOVOLIN N (brand RELION not covered)

Tier 3

NOVOLIN N FLEXPEN (brand RELION not covered)

Tier 3

NOVOLIN R (brand RELION not covered)

Tier 3

NOVOLIN R FLEXPEN (brand RELION not covered)

Tier 3

NOVOLOG Tier 3

NOVOLOG 70/30 FLEXPEN Tier 3

NOVOLOG FLEXPEN Tier 3

NOVOLOG MIX 70/30 Tier 3

NOVOLOG PENFILL Tier 3

OZEMPIC INJ 0.25 OR 0.5MG/DOSE

QL (1 pen / 28 days)

Tier 3 QL

OZEMPIC INJ 1MG/DOSE QL (2 pens / 28 days)

Tier 3 QL

SOLIQUA 100/33 QL (10 pens / 30 days)

Tier 3 QL

SYMLINPEN 60 Tier 5 PA

SYMLINPEN 120 Tier 5 PA

TRESIBA FLEXTOUCH Tier 3

Drug Name Drug Tier

Requirements/Limits

TRESIBA INJ Tier 3

TRULICITY QL (4 pens / 28 days)

Tier 3 QL

VICTOZA QL (3 pens / 30 days)

Tier 3 QL

XULTOPHY 100/3.6 QL (5 pens / 30 days)

Tier 3 QL

ANTIDIABETICS, ORAL acarbose (generic of PRECOSE) TABS

Tier 3

FARXIGA QL (30 tabs / 30 days)

Tier 3 QL

glimepiride (generic of AMARYL) 1mg, 2mg


Tier 2 GC QL

glimepiride (generic of AMARYL) 4mg


Tier 2 GC QL

glip/metform tab 2.5-250mg QL (240 tabs / 30 days)

Tier 1 GC QL

glip/metform tab 2.5-500mg QL (120 tabs / 30 days)

Tier 1 GC QL

glip/metform tab 5-500mg QL (120 tabs / 30 days)

Tier 1 GC QL

glipizide (generic of GLUCOTROL) TABS 5mg


Tier 1 GC QL

glipizide (generic of GLUCOTROL) TABS 10mg


Tier 1 GC QL

glipizide (generic of GLUCOTROL XL) TB24 2.5mg, 5mg


Tier 1 GC QL

glipizide (generic of GLUCOTROL XL) TB24 10mg


Tier 1 GC QL



32

Drug Name Drug Tier

Requirements/Limits

glipizide xl (generic of GLUCOTROL XL) 2.5mg, 5mg


Tier 1 GC QL

glipizide xl (generic of GLUCOTROL XL) 10mg


Tier 1 GC QL

GLYXAMBI QL (30 tabs / 30 days)

Tier 3 QL

JANUMET QL (60 tabs / 30 days)

Tier 3 QL

JANUMET XR TAB 50-500MG


Tier 3 QL

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

Tier 3 QL

JANUMET XR TAB 100-1000


Tier 3 QL

JANUVIA QL (30 tabs / 30 days)

Tier 3 QL

JARDIANCE 10mg QL (60 tabs / 30 days)

Tier 3 QL

JARDIANCE 25mg QL (30 tabs / 30 days)

Tier 3 QL

JENTADUETO QL (60 tabs / 30 days)

Tier 3 QL

JENTADUETO TAB XR 2.5-1000 MG


Tier 3 QL

JENTADUETO TAB XR 5-1000 MG


Tier 3 QL

metformin er 500mg QL (120 tabs / 30 days)

(generic of GLUCOPHAGE XR)

Tier 1 GC QL

metformin er 750mg QL (60 tabs / 30 days)

(generic of GLUCOPHAGE XR)

Tier 1 GC QL

metformin hcl TABS 500mg QL (150 tabs / 30 days)

Tier 1 GC QL

Drug Name Drug Tier

Requirements/Limits

metformin hcl TABS 850mg QL (90 tabs / 30 days)

Tier 1 GC QL

metformin hcl TABS 1000mg


Tier 1 GC QL

nateglinide (generic of STARLIX)


Tier 1 GC QL

pioglitazone hcl (generic of ACTOS)


Tier 1 GC QL

repaglinide 2mg QL (240 tabs / 30 days)

Tier 1 GC QL

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

Tier 1 GC QL

SYNJARDY TAB 5-500MG QL (120 tabs / 30 days)

Tier 3 QL

SYNJARDY TAB 5-1000MG QL (60 tabs / 30 days)

Tier 3 QL

SYNJARDY TAB 12.5-500MG


Tier 3 QL

SYNJARDY TAB 12.5-1000MG


Tier 3 QL

SYNJARDY XR TAB 5-1000MG


Tier 3 QL



Tier 3 QL

SYNJARDY XR TAB 12.5-1000MG


Tier 3 QL



Tier 3 QL

TRADJENTA QL (30 tabs / 30 days)

Tier 3 QL

XIGDUO XR TAB 2.5-1000MG


Tier 3 QL



33

Drug Name Drug Tier

Requirements/Limits

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

Tier 3 QL

XIGDUO XR TAB 5-1000MG


Tier 3 QL



Tier 3 QL



Tier 3 QL

BISPHOSPHONATES ACTONEL 5mg, 35mg, 150mg

Tier 4

alendronate sodium tab 5 mg

Tier 1 GC


Tier 1 GC


Tier 1 GC


Tier 3

alendronate sodium tab 70 mg (generic of FOSAMAX)

Tier 1 GC

ibandronate sodium tabs (generic of BONIVA)

Tier 3 B/D

PAMIDRONATE DISODIUM 6mg/ml

Tier 3 B/D

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

Tier 3 B/D

pamidronate inj 30mg Tier 3 B/D

pamidronate inj 90mg Tier 3 B/D

risedronate sodium (generic of ACTONEL) TABS 5mg, 35mg, 150mg

Tier 4

zoledronic acid inj 4mg/100ml

Tier 4 B/D NMO

zoledronic acid inj 5mg/100ml (generic of RECLAST)

Tier 4 B/D NMO

zoledronic inj 4mg/5ml Tier 4 B/D NMO

CHELATING AGENTS CHEMET Tier 4

Drug Name Drug Tier

Requirements/Limits

clovique (generic of SYPRINE)

Tier 5 PA

deferasirox (generic of JADENU) TABS 90mg, 360mg

Tier 5 NMO PA

deferasirox (generic of EXJADE) TBSO

Tier 5 NMO PA

EXJADE Tier 5 NMO LA PA

JADENU 180mg Tier 5 NMO LA PA

JADENU SPRINKLE Tier 5 NMO LA PA

kionex sus 15gm/60ml Tier 3

LOKELMA Tier 3

penicillamine (generic of DEPEN TITRATABS) TABS

Tier 5

sodium polystyrene sulfonate powder

Tier 3

sodium polystyrene sulfonate susp

Tier 3

sps susp 15gm/60ml Tier 3

trientine hcl (generic of SYPRINE)

Tier 5 PA

VELTASSA Tier 4 LA PA

CONTRACEPTIVES altavera tab Tier 2 GC

alyacen 1/35 Tier 2 GC

apri Tier 2 GC

aranelle Tier 3

aubra Tier 2 GC

aviane Tier 2 GC

balziva Tier 3

bekyree (generic of MIRCETTE)

Tier 3

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

Tier 2 GC

briellyn Tier 3

camila Tier 2 GC

caziant pak Tier 2 GC

cryselle-28 Tier 2 GC

cyclafem 1/35 Tier 2 GC

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

Tier 2 GC

cyred tab Tier 2 GC



34

Drug Name Drug Tier

Requirements/Limits

dasetta 1/35 Tier 2 GC

dasetta 7/7/7 (generic of ORTHO-NOVUM 7/7/7)

Tier 2 GC

deblitane Tier 2 GC

desogestrel & ethinyl estradiol

Tier 2 GC

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

Tier 3

drospirenone-ethinyl estradiol (generic of YASMIN 28)

Tier 3

drospirenone-ethinyl estradiol (generic of YAZ)

Tier 3

ELLA Tier 3

eluryng (generic of NUVARING)

Tier 4

emoquette Tier 2 GC

enpresse-28 Tier 2 GC

enskyce Tier 2 GC

errin (generic of ORTHO MICRONOR)

Tier 2 GC

estarylla tab 0.25-35 Tier 2 GC

ethynodiol diacet & eth estrad

Tier 2 GC

ethynodiol tab 1-50 Tier 3

etonogestrel-ethinyl estradiol (generic of NUVARING)

Tier 4

falmina Tier 2 GC

femynor Tier 2 GC

gianvi tab 3-0.02mg (generic of YAZ)

Tier 3

heather Tier 2 GC

incassia Tier 2 GC

introvale Tier 3

isibloom Tier 2 GC

jasmiel (generic of YAZ) Tier 3

jolessa tab 0.15-0.03 mg Tier 3

jolivette (generic of ORTHO MICRONOR)

Tier 2 GC

juleber Tier 2 GC

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

Tier 2 GC

Drug Name Drug Tier

Requirements/Limits

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

Tier 2 GC

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

Tier 2 GC

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

Tier 2 GC

kariva (generic of MIRCETTE)

Tier 3

kelnor 1/35 Tier 2 GC

kelnor 1/50 Tier 3

kurvelo Tier 2 GC

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

Tier 2 GC

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

Tier 2 GC

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

Tier 2 GC

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

Tier 2 GC

larissia tab Tier 2 GC

leena tab Tier 3

lessina Tier 2 GC

levonest Tier 2 GC

levonor/ethi tab Tier 2 GC

levonorgestrel & eth estradiol

Tier 2 GC

levonorgestrel-ethinyl estradiol (91-day)

Tier 3

levora 0.15/30-28 Tier 2 GC

loryna (generic of YAZ) Tier 3

low-ogestrel Tier 2 GC

lutera Tier 2 GC

lyza (generic of ORTHO MICRONOR)

Tier 2 GC

marlissa Tier 2 GC

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

Tier 2 GC

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

Tier 2 GC

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

Tier 2 GC



35

Drug Name Drug Tier

Requirements/Limits

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

Tier 2 GC

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

Tier 2 GC

mili Tier 2 GC

mono-linyah tab 0.25-35 Tier 2 GC

necon 0.5/35-28 Tier 3

nikki (generic of YAZ) Tier 3

nora-be tab 0.35mg Tier 2 GC

norethindrone (contraceptive) (generic of ORTHO MICRONOR)

Tier 2 GC

norethindrone acet & eth estra (generic of LOESTRIN 1/20-21)

Tier 2 GC

norgest/ethi tab 0.25/35 Tier 2 GC

norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg (generic of ORTHO TRI-CYCLEN LO)

Tier 3

norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg

Tier 2 GC

nortrel 0.5/35 (28) Tier 3

nortrel 1/35 Tier 2 GC

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

Tier 2 GC

ocella tab 3-0.03mg (generic of YASMIN 28)

Tier 3

orsythia Tier 2 GC

philith Tier 3

pimtrea (generic of MIRCETTE)

Tier 3

pirmella 1/35 Tier 2 GC

portia-28 Tier 2 GC

previfem Tier 2 GC

reclipsen Tier 2 GC

setlakin tab Tier 3

sharobel (generic of ORTHO MICRONOR)

Tier 2 GC

sprintec 28 Tier 2 GC

Drug Name Drug Tier

Requirements/Limits

sronyx Tier 2 GC

syeda (generic of YASMIN 28)

Tier 3

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

Tier 2 GC

tilia fe (generic of ESTROSTEP FE)

Tier 3

tri-estarylla Tier 2 GC

tri-legest fe (generic of ESTROSTEP FE)

Tier 3

tri-linyah Tier 2 GC

tri-lo marzia (generic of ORTHO TRI-CYCLEN LO)

Tier 3

tri-lo-estarylla (generic of ORTHO TRI-CYCLEN LO)

Tier 3

tri-lo-sprintec (generic of ORTHO TRI-CYCLEN LO)

Tier 3

tri-mili Tier 2 GC

tri-previfem Tier 2 GC

tri-sprintec Tier 2 GC

tri-vylibra Tier 2 GC

tri-vylibra lo (generic of ORTHO TRI-CYCLEN LO)

Tier 3

trivora-28 Tier 2 GC

tulana Tier 2 GC

velivet Tier 2 GC

vienva Tier 2 GC

viorele (generic of MIRCETTE)

Tier 3

vyfemla Tier 3

vylibra Tier 2 GC

xulane dis 150-35 Tier 4

zarah (generic of YASMIN 28)

Tier 3

zovia 1/35e Tier 2 GC

ENDOMETRIOSIS danazol CAPS Tier 4

SYNAREL Tier 5

ENZYME REPLACEMENTS ALDURAZYME Tier 5 NMO LA PA

CARBAGLU Tier 5 NMO LA PA

CERDELGA Tier 5 NMO PA

CEREZYME Tier 5 NMO LA PA



36

Drug Name Drug Tier

Requirements/Limits

CYSTADANE Tier 5 NMO LA

CYSTAGON Tier 4 NMO LA PA

FABRAZYME Tier 5 NMO LA PA

KUVAN Tier 5 NMO LA PA

levocarnitine (metabolic modifiers) (generic of CARNITOR)

Tier 4 B/D

LUMIZYME Tier 5 NMO LA PA

miglustat (generic of ZAVESCA)

Tier 5 NMO PA

NAGLAZYME Tier 5 NMO LA PA

nitisinone (generic of ORFADIN)

Tier 5 NMO PA

NITYR Tier 5 NMO LA PA

ORFADIN Tier 5 NMO LA PA

sodium phenylbutyrate (generic of BUPHENYL)

Tier 5 NMO PA

ESTROGENS DELESTROGEN 10mg/ml Tier 4

estradiol (generic of CLIMARA) PTWK

Tier 3

estradiol (generic of ESTRACE) TABS

Tier 2 GC

estradiol vaginal cream (generic of ESTRACE)

Tier 3

estradiol vaginal tab (generic of VAGIFEM)

Tier 4

estradiol valerate inj (generic of DELESTROGEN)

Tier 4

fyavolv Tier 3

fyavolv (generic of FEMHRT LOW DOSE)

Tier 3

jinteli Tier 3

norethindrone acetate-ethinyl estradiol

Tier 3

norethindrone acetate-ethinyl estradiol (generic of FEMHRT LOW DOSE)

Tier 3

yuvafem vaginal tablet 10mcg (generic of VAGIFEM)

Tier 4

GLUCOCORTICOIDS cortisone acetate TABS Tier 4

Drug Name Drug Tier

Requirements/Limits

DEXAMETHASONE CONC Tier 4

dexamethasone ELIX; SOLN

Tier 3

dexamethasone TABS Tier 2 GC

dexamethasone sodium phosphate 4mg/ml, 10mg/ml, 20mg/5ml, 100mg/10ml, 120mg/30ml

Tier 2 GC

dexamethasone sodium phosphate (generic of DEXAMETHASONE SODIUM PHOS) 10mg/ml

Tier 2 GC

fludrocortisone acetate TABS

Tier 2 GC

hydrocortisone (generic of CORTEF) TABS

Tier 3

methylpr ss inj (generic of SOLU-MEDROL)

Tier 3 B/D

methylpred pak 4mg (generic of MEDROL DOSEPAK)

Tier 2 GC

methylpred tab 4mg (generic of MEDROL)

Tier 3 B/D


Tier 3 B/D


Tier 3 B/D


Tier 3 B/D

methylprednisolone acetate (generic of DEPO-MEDROL)

Tier 2 GC B/D

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

Tier 4 B/D

prednisolone sodium phosphate SOLN 15mg/5ml

Tier 2 GC B/D

prednisolone sol 15mg/5ml Tier 2 GC B/D

prednisolone sol 25mg/5ml Tier 4 B/D

PREDNISONE CON 5MG/ML

Tier 4 B/D

prednisone pak 5mg Tier 3

prednisone pak 10mg Tier 3

prednisone sol 5mg/5ml Tier 4 B/D

prednisone tab 1mg Tier 1 GC B/D



37

Drug Name Drug Tier

Requirements/Limits

prednisone tab 2.5mg Tier 1 GC B/D





SOLU-CORTEF Tier 4

GLUCOSE ELEVATING AGENTS diazoxide (generic of PROGLYCEM) SUSP

Tier 4

GLUCAGEN HYPOKIT Tier 3

GLUCAGON EMERGENCY KIT

Tier 3

GVOKE PFS Tier 3

PROGLYCEM SUS 50MG/ML

Tier 4

MISCELLANEOUS cabergoline Tier 3

calcitonin (salmon) (generic of MIACALCIN)

Tier 3 B/D

cinacalcet hcl (generic of SENSIPAR) 30mg, 90mg


Tier 5 B/D QL NMO

cinacalcet hcl (generic of SENSIPAR) 60mg


Tier 5 B/D QL NMO

FORTEO Tier 5 NMO PA

GENOTROPIN Tier 5 NMO PA

GENOTROPIN MINIQUICK .2mg

Tier 3 NMO PA

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

Tier 5 NMO PA

INCRELEX Tier 5 NMO LA PA

KORLYM Tier 5 NMO LA PA

LUPRON DEP-PED INJ 7.5MG

Tier 5 NMO PA

LUPRON DEP-PED INJ 11.25MG (3-MONTH)

Tier 5 NMO PA

LUPRON DEPOT-PED (1-MONTH

Tier 5 NMO PA

LUPRON DEPOT-PED (3-MONTH

Tier 5 NMO PA

Drug Name Drug Tier

Requirements/Limits

NATPARA Tier 5 NMO PA

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

Tier 4 NMO PA

octreotide acetate 200mcg/ml

Tier 4 NMO PA

octreotide acetate (generic of SANDOSTATIN) 500mcg/ml

Tier 5 NMO PA

octreotide acetate 1000mcg/ml

Tier 5 NMO PA

OSPHENA Tier 3 PA

PROLIA QL (1 injection / 180 days)

Tier 4 QL NMO

raloxifene tab 60mg (generic of EVISTA)

Tier 3

SIGNIFOR Tier 5 NMO LA PA

SOMATULINE DEPOT Tier 5 NMO PA

SOMAVERT Tier 5 NMO LA PA

TYMLOS Tier 5 NMO PA

XGEVA Tier 5 NMO PA

PHOSPHATE BINDER AGENTS AURYXIA


Tier 5 QL PA

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


Tier 3 QL

calcium acetate (phosphate binder) TABS


Tier 3 QL

sevelamer carbonate (generic of RENVELA) PACK 2.4gm


Tier 5 QL

sevelamer carbonate (generic of RENVELA) PACK .8gm


Tier 5 QL



38

Drug Name Drug Tier

Requirements/Limits

sevelamer carbonate (generic of RENVELA) TABS


Tier 4 QL

PROGESTINS medroxyprogesterone acetate tab (generic of PROVERA)

Tier 1 GC

norethindrone acetate (generic of AYGESTIN) TABS

Tier 3

THYROID AGENTS euthyrox (generic of SYNTHROID)

Tier 2 GC

levo-t (generic of SYNTHROID)

Tier 2 GC

levothyroxine sodium (generic of SYNTHROID) TABS

Tier 2 GC

levoxyl (generic of SYNTHROID)

Tier 2 GC

liothyronine sodium (generic of CYTOMEL) TABS

Tier 3

methimazole (generic of TAPAZOLE) TABS

Tier 1 GC

propylthiouracil TABS Tier 3

SYNTHROID Tier 4

unithroid (generic of SYNTHROID)

Tier 2 GC

VASOPRESSINS desmopressin acetate spray (generic of DDAVP)

Tier 4

desmopressin acetate spray refrigerated

Tier 4

desmopressin acetate tabs (generic of DDAVP)

Tier 3

desmopressin inj 4mcg/ml (generic of DDAVP)

Tier 4

STIMATE Tier 5 NMO

GASTROINTESTINAL ANTIEMETICS aprepitant (generic of EMEND) 40mg, 80mg

Tier 4 B/D

Drug Name Drug Tier

Requirements/Limits

aprepitant 125mg Tier 4 B/D

aprepitant pak 80mg & 125mg

Tier 4 B/D

compro supp Tier 4

dronabinol (generic of MARINOL)


Tier 4 B/D QL

EMEND SUSR Tier 4 B/D

granisetron hcl SOLN Tier 3

granisetron hcl TABS Tier 4 B/D

meclizine hcl TABS Tier 2 GC

metoclopramide hcl SOLN Tier 2 GC

metoclopramide hcl (generic of REGLAN) TABS

Tier 1 GC

metoclopramide hcl inj Tier 2 GC

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

Tier 3 B/D

ondansetron hcl TABS 24mg

Tier 3 B/D

ondansetron hcl inj Tier 2 GC

ondansetron hcl oral soln Tier 4 B/D

ondansetron odt Tier 2 GC B/D

prochlorperazine inj Tier 4

prochlorperazine maleate TABS

Tier 2 GC

prochlorperazine supp Tier 4

promethazine hcl SYRP; TABS


Tier 2 GC PA

promethazine hcl inj (generic of PHENERGAN)


Tier 4 PA

scopolamine (generic of TRANSDERM SCOP)



Tier 4 QL PA

ANTISPASMODICS dicyclomine hcl cap 10mg Tier 3

dicyclomine hcl soln 10mg/5ml

Tier 4

dicyclomine hcl tab 20mg Tier 3

glycopyrrolate tab 1mg Tier 3



39

Drug Name Drug Tier

Requirements/Limits

glycopyrrolate tab 2mg Tier 3

H2-RECEPTOR ANTAGONISTS famotidine SUSR Tier 4

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

Tier 1 GC

famotidine in nacl Tier 2 GC

famotidine inj Tier 2 GC

nizatidine CAPS Tier 3

INFLAMMATORY BOWEL DISEASE balsalazide disodium (generic of COLAZAL)

Tier 3

budesonide ec (generic of ENTOCORT EC)

Tier 4

colocort (generic of CORTENEMA)

Tier 4

hydrocortisone (enema) (generic of CORTENEMA)

Tier 4

mesalamine (generic of DELZICOL) CPDR

Tier 4

mesalamine ENEM Tier 4

mesalamine (generic of CANASA) SUPP

Tier 5

mesalamine (generic of LIALDA) TBEC 1.2gm

Tier 4

mesalamine w/ cleanser (generic of ROWASA)

Tier 4

sulfasalazine (generic of AZULFIDINE) TABS

Tier 2 GC

sulfasalazine ec (generic of AZULFIDINE EN-TABS)

Tier 3

LAXATIVES constulose Tier 3

enulose Tier 3

gavilyte-c Tier 2 GC

gavilyte-g (generic of GOLYTELY)

Tier 2 GC

gavilyte-n/flavor pack (generic of NULYTELY/FLAVOR PACKS)

Tier 2 GC

generlac Tier 3

GOLYTELY Tier 3

Drug Name Drug Tier

Requirements/Limits

lactulose SOLN Tier 3

lactulose (encephalopathy) Tier 3

NULYTELY/FLAVOR PACKS

Tier 3

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

Tier 2 GC

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate (generic of GOLYTELY)

Tier 2 GC

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

Tier 2 GC

PLENVU Tier 4

SUPREP BOWEL PREP KIT

Tier 4

trilyte (generic of NULYTELY/FLAVOR PACKS)

Tier 2 GC

MISCELLANEOUS alosetron hcl (generic of LOTRONEX)

Tier 5 PA

AMITIZA CAP 8MCG QL (180 caps / 30 days)

Tier 3 QL

AMITIZA CAP 24MCG QL (60 caps / 30 days)

Tier 3 QL

cromolyn sodium (mastocytosis) (generic of GASTROCROM)

Tier 5

diphenoxylate w/ atropine LIQD

Tier 4

diphenoxylate w/ atropine (generic of LOMOTIL) TABS

Tier 3

GATTEX Tier 5 NMO LA PA

LINZESS QL (30 caps / 30 days)

Tier 4 QL

loperamide hcl CAPS Tier 3

misoprostol (generic of CYTOTEC) TABS

Tier 3

MOVANTIK 12.5mg QL (60 tabs / 30 days)

Tier 3 QL



40

Drug Name Drug Tier

Requirements/Limits

MOVANTIK 25mg QL (30 tabs / 30 days)

Tier 3 QL

RELISTOR SOLN Tier 5 PA

sucralfate (generic of CARAFATE) TABS

Tier 2 GC

ursodiol (generic of ACTIGALL) CAPS

Tier 3

ursodiol (generic of URSO 250) TABS 250mg

Tier 4

ursodiol (generic of URSO FORTE) TABS 500mg

Tier 4

XIFAXAN 550mg Tier 5 PA

PANCREATIC ENZYMES CREON Tier 3

ZENPEP Tier 4

PROTON PUMP INHIBITORS DEXILANT

QL (30 caps / 30 days) Tier 4 QL

esomeprazole magnesium (generic of NEXIUM) CPDR


Tier 4 QL ST

lansoprazole (generic of PREVACID) CPDR


Tier 3 QL

omeprazole cap 10mg Tier 1 GC



pantoprazole sodium (generic of PROTONIX) SOLR

Tier 4

pantoprazole sodium tbec (generic of PROTONIX)

Tier 1 GC

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of UROXATRAL)


Tier 2 GC QL

dutasteride (generic of AVODART) CAPS


Tier 3 QL

dutasteride-tamsulosin hcl (generic of JALYN)


Tier 4 QL

Drug Name Drug Tier

Requirements/Limits

finasteride (generic of PROSCAR) TABS 5mg

Tier 1 GC

tamsulosin hcl (generic of FLOMAX)

Tier 2 GC

MISCELLANEOUS bethanechol chloride TABS 5mg, 10mg

Tier 3

bethanechol chloride (generic of URECHOLINE) TABS 25mg, 50mg

Tier 3

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

Tier 4

potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 5) 540mg

Tier 4

potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 10) 1080mg

Tier 4

URINARY ANTISPASMODICS MYRBETRIQ


oxybutynin chloride SYRP Tier 3

oxybutynin chloride TABS Tier 3

oxybutynin chloride (generic of DITROPAN XL) TB24 5mg


Tier 3 QL

oxybutynin chloride (generic of DITROPAN XL) TB24 10mg


Tier 3 QL

oxybutynin chloride TB24 15mg


Tier 3 QL

solifenacin succinate (generic of VESICARE)


Tier 4 QL

tolterodine tartrate (generic of DETROL LA) CP24


Tier 4 QL ST

tolterodine tartrate (generic of DETROL) TABS

Tier 4 ST



41

Drug Name Drug Tier

Requirements/Limits

TOVIAZ QL (30 tabs / 30 days)

Tier 3 QL

trospium chloride TABS QL (60 tabs / 30 days)

Tier 3 QL

VESICARE QL (30 tabs / 30 days)

Tier 4 QL

VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal (generic of CLEOCIN)

Tier 3

metronidazole vaginal Tier 4

terconazole vaginal Tier 3

vandazole Tier 4

HEMATOLOGIC ANTICOAGULANTS COUMADIN Tier 3

ELIQUIS 2.5mg QL (60 tabs / 30 days)

Tier 3 QL

ELIQUIS 5mg QL (74 tabs / 30 days)

Tier 3 QL

ELIQUIS STARTER PACK QL (74 tabs / 30 days)

Tier 3 QL

enoxaparin sodium (generic of LOVENOX)

Tier 4

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

Tier 4

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

Tier 5

heparin sod (porcine) in d5w Tier 3

heparin sod inj 1000/ml Tier 3 B/D




HEPARIN SODIUM/NACL 0.45%

Tier 3

jantoven (generic of COUMADIN) 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg

Tier 1 GC

jantoven 10mg Tier 1 GC

Drug Name Drug Tier

Requirements/Limits

PRADAXA QL (60 caps / 30 days)

Tier 4 QL

warfarin sodium (generic of COUMADIN) 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg

Tier 1 GC

warfarin sodium 10mg Tier 1 GC

XARELTO 2.5mg QL (60 tabs / 30 days)

Tier 3 QL

XARELTO 10mg, 15mg, 20mg


Tier 3 QL

XARELTO STARTER PACK QL (51 tabs / 30 days)

Tier 3 QL

HEMATOPOIETIC GROWTH FACTORS PROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

Tier 3 NMO PA

PROCRIT 20000unit/ml, 40000unit/ml

Tier 5 NMO PA

ZARXIO Tier 5 NMO PA

MISCELLANEOUS anagrelide hcl 1mg Tier 4

anagrelide hcl (generic of AGRYLIN) .5mg

Tier 4

BERINERT QL (24 boxes / 30 days)

Tier 5 QL NMO LA PA

cilostazol Tier 2 GC

DROXIA Tier 3

ENDARI Tier 5 NMO LA PA

HAEGARDA 2000unit QL (30 vials / 30 days)

Tier 5 QL NMO LA PA

HAEGARDA 3000unit QL (20 vials / 30 days)

Tier 5 QL NMO LA PA

icatibant acetate (generic of FIRAZYR)


Tier 5 QL NMO PA

pentoxifylline TBCR Tier 2 GC

PROMACTA PACK 12.5mg QL (360 packets / 30 days)

Tier 5 QL NMO LA PA



42

Drug Name Drug Tier

Requirements/Limits

PROMACTA TABS 12.5mg, 25mg


Tier 5 QL NMO LA PA

PROMACTA TABS 50mg, 75mg


Tier 5 QL NMO LA PA

tranexamic acid (generic of CYKLOKAPRON) SOLN

Tier 4

tranexamic acid (generic of LYSTEDA) TABS

Tier 3

PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole (generic of AGGRENOX)

Tier 4

BRILINTA Tier 3

clopidogrel tab 75mg (generic of PLAVIX)

Tier 1 GC

prasugrel hcl (generic of EFFIENT)

Tier 3

IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ENBREL SOLR

QL (16 vials / 28 days) Tier 5 QL NMO PA

ENBREL SOSY 25mg/0.5ml


Tier 5 QL NMO PA

ENBREL SOSY 50mg/ml QL (8 syringes / 28 days)

Tier 5 QL NMO PA

ENBREL MINI QL (8 injections / 28 days)

Tier 5 QL NMO PA

ENBREL SURECLICK QL (8 injections / 28 days)

Tier 5 QL NMO PA

HUMIRA 10mg/0.1ml, 20mg/0.2ml


Tier 5 QL NMO PA

HUMIRA 40mg/0.4ml QL (6 injections / 28 days)

Tier 5 QL NMO PA

Drug Name Drug Tier

Requirements/Limits

HUMIRA INJ 10MG/0.2ML QL (2 syringes / 28 days)

Tier 5 QL NMO PA

HUMIRA KIT 20MG/0.4ML QL (2 syringes / 28 days)

Tier 5 QL NMO PA

HUMIRA KIT 40MG/0.8ML QL (6 syringes / 28 days)

Tier 5 QL NMO PA

HUMIRA PEDIATRIC CROHNS DISEASE

Tier 5 NMO PA

HUMIRA PEN QL (6 pens / 28 days)

Tier 5 QL NMO PA

HUMIRA PEN CD/UC/HS STARTER

Tier 5 NMO PA

HUMIRA PEN INJ CD/UC/HS STARTER

Tier 5 NMO PA

HUMIRA PEN INJ PS/UV STARTER

Tier 5 NMO PA

HUMIRA PEN-PS/UV STARTER

Tier 5 NMO PA

hydroxychloroquine sulfate (generic of PLAQUENIL)

Tier 3

leflunomide (generic of ARAVA) TABS


Tier 3 QL

methotrexate sodium tabs Tier 3

REMICADE Tier 5 NMO PA

RENFLEXIS Tier 5 NMO LA PA

RINVOQ QL (30 tabs / 30 days)

Tier 5 QL NMO PA

SKYRIZI QL (7 injections / year)

Tier 5 QL NMO PA

STELARA SOLN 45mg/0.5ml

QL (1 vial / 28 days)

Tier 5 QL NMO LA PA

STELARA SOSY QL (1 syringe / 28 days)

Tier 5 QL NMO PA

XATMEP Tier 4 B/D

XELJANZ QL (60 tabs / 30 days)

Tier 5 QL NMO PA

XELJANZ XR QL (30 tabs / 30 days)

Tier 5 QL NMO PA



43

Drug Name Drug Tier

Requirements/Limits

IMMUNOGLOBULINS BIVIGAM Tier 5 NMO PA

GAMASTAN S/D Tier 3 B/D NMO

GAMMAGARD LIQUID Tier 5 NMO PA

GAMMAGARD S/D Tier 5 NMO PA

GAMMAKED Tier 5 NMO PA

GAMMAPLEX Tier 5 NMO PA

GAMMAPLEX 10GM/100ML Tier 5 NMO PA

GAMUNEX-C Tier 5 NMO PA

OCTAGAM Tier 5 NMO PA

PANZYGA Tier 5 NMO PA

PRIVIGEN Tier 5 NMO PA

IMMUNOMODULATORS ACTIMMUNE Tier 5 NMO LA PA

ARCALYST Tier 5 NMO PA

INTRON-A INJ 10MU Tier 5 B/D NMO




IMMUNOSUPPRESSANTS azathioprine (generic of IMURAN) TABS

Tier 3 B/D

BENLYSTA Tier 5 NMO PA

cyclosporine (generic of SANDIMMUNE) CAPS; SOLN

Tier 4 B/D NMO

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

Tier 4 B/D NMO

cyclosporine modified (for microemulsion) CAPS 50mg

Tier 4 B/D NMO

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

Tier 4 B/D NMO

everolimus (immunosuppressant) (generic of ZORTRESS) .5mg, .75mg

Tier 5 B/D NMO

everolimus (immunosuppressant) (generic of ZORTRESS) .25mg

Tier 4 B/D NMO

Drug Name Drug Tier

Requirements/Limits

gengraf (generic of NEORAL)

Tier 4 B/D NMO

mycophenolate mofetil (generic of CELLCEPT) CAPS; TABS

Tier 3 B/D NMO

mycophenolate mofetil (generic of CELLCEPT) SUSR

Tier 5 B/D NMO

mycophenolate sodium tbec (generic of MYFORTIC)

Tier 4 B/D NMO

NULOJIX Tier 5 B/D NMO

PROGRAF PACK Tier 4 B/D NMO

SANDIMMUNE SOLN 100mg/ml

Tier 3 B/D NMO

sirolimus (generic of RAPAMUNE) SOLN

Tier 5 B/D NMO

sirolimus (generic of RAPAMUNE) TABS 2mg

Tier 5 B/D NMO

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

Tier 4 B/D NMO

tacrolimus (generic of PROGRAF) CAPS

Tier 4 B/D NMO

ZORTRESS TAB 0.5MG Tier 5 B/D NMO



ZORTRESS TAB 1MG Tier 5 B/D NMO

VACCINES ACTHIB Tier 3

ADACEL Tier 3

BCG VACCINE Tier 3

BEXSERO Tier 3

BOOSTRIX Tier 3

DAPTACEL Tier 3

DIPHTHERIA/TETANUS TOXOID

Tier 3 B/D

ENGERIX-B SUSP Tier 3 B/D

GARDASIL 9 Tier 3

HAVRIX Tier 3

HIBERIX Tier 3

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

Tier 3 B/D

INFANRIX Tier 3



44

Drug Name Drug Tier

Requirements/Limits

IPOL INACTIVATED IPV Tier 3

IXIARO Tier 3

KINRIX Tier 3

M-M-R II Tier 3

MENACTRA Tier 3

MENVEO Tier 3

PEDIARIX Tier 3

PEDVAX HIB Tier 3

PENTACEL Tier 3

PROQUAD Tier 3

QUADRACEL Tier 3

RABAVERT Tier 3 B/D

RECOMBIVAX HB Tier 3 B/D

ROTARIX Tier 3

ROTATEQ Tier 3

SHINGRIX QL (2 vials per lifetime)

Tier 3 QL

TDVAX Tier 3 B/D

TENIVAC Tier 3 B/D

TRUMENBA Tier 3

TWINRIX INJ Tier 3

TYPHIM VI Tier 3

VAQTA Tier 3

VARIVAX Tier 3

YF-VAX Tier 3

ZOSTAVAX QL (1 vial per lifetime)

Tier 3 QL

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES klor-con 8 Tier 2 GC

klor-con 10 Tier 2 GC

klor-con m10 Tier 2 GC



klor-con pak 20meq Tier 4

klor-con spr cap 8meq Tier 3

klor-con spr cap 10meq Tier 3

MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

Tier 3

Drug Name Drug Tier

Requirements/Limits

magnesium sulfate (generic of MAGNESIUM SULFATE) SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

Tier 3

magnesium sulfate SOLN 50%

Tier 3

MAGNESIUM SULFATE IN D5W

Tier 3

magnesium sulfate in dextrose (generic of MAGNESIUM SULFATE IN D5W)

Tier 3

magnesium sulfate inj 50% Tier 3

potassium chloride CPCR Tier 3

potassium chloride PACK Tier 4

potassium chloride SOLN 10%, 20%

Tier 4

potassium chloride TBCR 8meq, 10meq

Tier 2 GC

potassium chloride (generic of K-TAB) TBCR 20meq

Tier 2 GC

potassium chloride microencapsulated crystals er

Tier 2 GC

sodium chloride SOLN 2.5meq/ml

Tier 3

sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln

Tier 2 GC

TPN ELECTROLYTES Tier 4 B/D

IV NUTRITION AMINOSYN II INJ 10% Tier 4 B/D

AMINOSYN-PF 7% Tier 4 B/D

AMINOSYN-PF INJ 10% Tier 4 B/D

CLINIMIX 4.25%/DEXTROSE 5%

Tier 4 B/D

CLINIMIX 5%/DEXTROSE 15%

Tier 4 B/D

CLINIMIX 5%/DEXTROSE 20%

Tier 4 B/D

CLINIMIX INJ 4.25/D10 Tier 4 B/D

clinisol sf 15% Tier 4 B/D

CLINOLIPID Tier 4 B/D

FREAMINE HBC 6.9% Tier 4 B/D



45

Drug Name Drug Tier

Requirements/Limits

FREAMINE III Tier 4 B/D

hepatamine Tier 4 B/D

INTRALIPID 30% Tier 4 B/D

INTRALIPID INJ 20% Tier 4 B/D

NEPHRAMINE Tier 4 B/D

NUTRILIPID INJ 20% Tier 4 B/D

plenamine Tier 4 B/D

PREMASOL 10% Tier 4 B/D

PROCALAMINE Tier 4 B/D

PROSOL Tier 4 B/D

TRAVASOL Tier 4 B/D

TROPHAMINE INJ 10% Tier 4 B/D

IV REPLACEMENT SOLUTIONS dextrose 2.5%/nacl 0.45% Tier 2 GC

dextrose 5% Tier 2 GC

DEXTROSE 5% /ELECTROLYTE

Tier 3

dextrose 5%/nacl 0.2% Tier 2 GC

DEXTROSE 5%/NACL 0.3%

Tier 4




dextrose 5%/potassium chl Tier 2 GC

dextrose 10% flex contain Tier 2 GC

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

Tier 3


dextrose 50% Tier 2 GC

dextrose in lactated ringers Tier 2 GC

dextrose inj 70% Tier 2 GC

ISOLYTE P Tier 4

ISOLYTE S Tier 4

kcl0.15%/d5w/nacl0.2% Tier 3

KCL 0.3%/D5W/NACL 0.9% Tier 4

kcl 0.3%/d5w/nacl 0.45% Tier 3


KCL 0.15%/D5W/NACL 0.225%

Tier 4


kcl/d5w inj 0.3% Tier 2 GC

kcl/d5w/nacl inj 0.22%/0.45%

Tier 3

Drug Name Drug Tier

Requirements/Limits

kcl/d5w/nacl inj .15/.45% Tier 3

kcl/nacl inj 0.3-0.9 Tier 2 GC

kcl/nacl inj 0.15%-0.9% Tier 2 GC

lactated ringer's Tier 2 GC

NORMOSOL-M IN D5W Tier 4

NORMOSOL-R Tier 4

NORMOSOL-R IN D5W Tier 4

PLASMA-LYTE A Tier 4

PLASMA-LYTE-148 Tier 4

pot chloride inj 2meq/ml Tier 2 GC

potassium chloride SOLN 2meq/ml

Tier 2 GC

POTASSIUM CHLORIDE SOLN .4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

Tier 2 GC

potassium chloride in nacl Tier 2 GC

sodium chloride SOLN 3%, 5%

Tier 3

sodium chloride 0.45% Tier 3

sodium chloride inj 0.9% Tier 3

VITAMINS calcitriol (generic of ROCALTROL) CAPS

Tier 2 GC B/D

calcitriol inj Tier 4 B/D

calcitriol oral soln 1 mcg/ml (generic of ROCALTROL)

Tier 4 B/D

M-NATAL PLUS Tier 3

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

Tier 4 B/D

paricalcitol CAPS 4mcg Tier 4 B/D

PNV FOLIC ACID + IRON MUL

Tier 3

PRENATAL Tier 3

PRENATAL PLUS Tier 3

PRENATAL PLUS LOW IRON

Tier 3

RAYALDEE Tier 5

TRICARE Tier 3

OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc Tier 3



46

Drug Name Drug Tier

Requirements/Limits

BLEPHAMIDE OINT Tier 4

neomycin-polymy-dexameth (generic of MAXITROL)

Tier 2 GC

neomycin-polymyxin-hc (ophth)

Tier 4

sulfacetamide sod-prednisolone

Tier 2 GC

TOBRADEX OINT Tier 3

TOBRADEX ST Tier 3

tobramycin-dexamethasone (generic of TOBRADEX)

Tier 4

ZYLET Tier 3

ANTI-INFECTIVES AZASITE Tier 4

bacitracin (ophthalmic) Tier 3

bacitracin-polymyxin b (ophth)

Tier 2 GC

BESIVANCE Tier 3

CILOXAN OINT Tier 3

ciprofloxacin hcl (ophth) (generic of CILOXAN)

Tier 2 GC

erythromycin (ophth) Tier 2 GC

gatifloxacin (ophth) (generic of ZYMAXID)

Tier 3

gentak Tier 2 GC

gentamicin sulfate soln (ophth)

Tier 2 GC

MOXEZA Tier 3

moxifloxacin hcl (ophth) (generic of MOXEZA) .5%

Tier 3

moxifloxacin hcl (ophth) (generic of VIGAMOX) .5%

Tier 3

NATACYN Tier 4

neomycin-bacitracin zn-polymyxin

Tier 3

neomycin-polymyxin-gramicidin

Tier 3

ofloxacin (ophth) (generic of OCUFLOX)

Tier 2 GC

polymyxin b-trimethoprim (generic of POLYTRIM)

Tier 2 GC

sulfacetamide sodium (ophth) OINT

Tier 3

Drug Name Drug Tier

Requirements/Limits

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

Tier 3

tobramycin (ophth) (generic of TOBREX)

Tier 2 GC

trifluridine Tier 3

ZIRGAN Tier 4

ANTI-INFLAMMATORIES ALREX Tier 3

bromfenac sodium (ophth) Tier 4

BROMSITE Tier 4

dexamethasone sodium phosphate (ophth)

Tier 3

diclofenac sodium (ophth) Tier 3

DUREZOL Tier 3

fluorometholone Tier 3

flurbiprofen sodium Tier 3

ILEVRO Tier 3

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

Tier 3

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

Tier 2 GC

LOTEMAX GEL; OINT Tier 3

loteprednol etabonate (generic of LOTEMAX)

Tier 3

prednisolone acetate (ophth) (generic of PRED FORTE)

Tier 3

PREDNISOLONE SODIUM PHOSPHATE (OPHTH)

Tier 3

PROLENSA Tier 3

ANTIALLERGICS azelastine drop 0.05% Tier 3

BEPREVE Tier 3

cromolyn sodium (ophth) Tier 1 GC

LASTACAFT Tier 4

olopatadine hcl 0.2% Tier 4

PAZEO Tier 3

ANTIGLAUCOMA ALPHAGAN P SOL 0.1% Tier 3



47

Drug Name Drug Tier

Requirements/Limits

AZOPT Tier 3

betaxolol hcl (ophth) Tier 3

BETOPTIC-S Tier 3

brimonidine sol 0.2% Tier 1 GC

brimonidine sol 0.15% (generic of ALPHAGAN P)

Tier 4

carteolol hcl (ophth) Tier 2 GC

COMBIGAN Tier 3

dorzolamide hcl (generic of TRUSOPT)

Tier 2 GC

dorzolamide hcl-timolol maleate (generic of COSOPT)

Tier 2 GC

latanoprost (generic of XALATAN) SOLN

Tier 2 GC

levobunolol hcl Tier 2 GC

LUMIGAN Tier 3

PHOSPHOLINE IODIDE Tier 4

pilocarpine hcl (generic of ISOPTO CARPINE) SOLN

Tier 3

RHOPRESSA Tier 3

SIMBRINZA Tier 3

timolol maleate (ophth) soln (generic of TIMOPTIC)

Tier 1 GC

timolol maleate gel (generic of TIMOPTIC-XE)

Tier 4

timolol maleate ophth soln 0.5% (once-daily) (generic of ISTALOL)

Tier 4

travoprost (generic of TRAVATAN Z)

Tier 4

MISCELLANEOUS ATROPINE SULFATE SOLN 1%

Tier 3

CYSTARAN Tier 5 NMO LA PA

proparacaine hcl (generic of ALCAINE) SOLN

Tier 3

RESTASIS QL (60 single use vials / 30 days)

Tier 3 QL

RESTASIS MULTIDOSE QL (1 bottle / 30 days)

Tier 3 QL

Drug Name Drug Tier

Requirements/Limits

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA

QL (60 blisters / 30 days)

Tier 3 QL

BEVESPI AEROSPHERE QL (1 inhaler / 30 days)

Tier 3 QL

COMBIVENT RESPIMAT QL (2 inhalers / 30 days)

Tier 4 QL

ipratropium-albuterol nebu Tier 3 B/D

TRELEGY ELLIPTA QL (60 blisters / 30 days)

Tier 3 QL

ANTICHOLINERGICS ATROVENT HFA


Tier 4 QL

INCRUSE ELLIPTA QL (30 blisters / 30 days)

Tier 3 QL

ipratropium bromide SOLN Tier 2 GC B/D

ipratropium bromide (nasal) Tier 3

ANTIHISTAMINES azelastine spr 0.1% Tier 3

azelastine spr 0.15% Tier 3

cetirizine syrup Tier 2 GC

cyproheptadine hcl SYRP; TABS


Tier 3 PA

diphenhydramine hcl inj 50mg/ml

Tier 3

hydroxyzine hcl SYRP PA if 70 years and older

Tier 3 PA

hydroxyzine hcl TABS PA if 70 years and older

Tier 2 GC PA

hydroxyzine hcl inj PA if 70 years and older

Tier 4 PA

hydroxyzine pamoate (generic of VISTARIL) CAPS 25mg, 50mg


Tier 2 GC PA



48

Drug Name Drug Tier

Requirements/Limits

levocetirizine dihydrochloride SOLN

Tier 4

levocetirizine dihydrochloride TABS

Tier 2 GC

BETA AGONISTS albuterol sulfate AERS 108mcg/act


(generic of Ventolin HFA)

Tier 3 QL

albuterol sulfate (generic of PROAIR HFA) AERS 108mcg/act


(generic of Proair HFA)

Tier 3 QL

albuterol sulfate NEBU .63mg/3ml, 1.25mg/3ml, 2.5mg/0.5ml

Tier 3 B/D

albuterol sulfate NEBU .083%

Tier 2 GC B/D

albuterol sulfate SYRP Tier 2 GC

albuterol sulfate TABS Tier 4

albuterol sulfate TB12 Tier 3

levalbuterol hcl (generic of XOPENEX) NEBU 1.25mg/3ml

Tier 4 B/D

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

Tier 4 B/D

levalbuterol tartrate hfa QL (2 inhalers / 30 days)

Tier 3 QL

SEREVENT DISKUS QL (60 inhalations / 30 days)

Tier 3 QL

terbutaline sulfate TABS Tier 4

VENTOLIN HFA QL (2 inhalers / 30 days)

Tier 3 QL

Drug Name Drug Tier

Requirements/Limits

LEUKOTRIENE MODULATORS montelukast sodium (generic of SINGULAIR) CHEW

Tier 2 GC

montelukast sodium (generic of SINGULAIR) PACK

Tier 4

montelukast sodium (generic of SINGULAIR) TABS

Tier 1 GC

zafirlukast (generic of ACCOLATE)

Tier 3

MAST CELL STABILIZERS cromolyn sod neb 20mg/2ml Tier 3 B/D

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

Tier 3 B/D

ARALAST NP Tier 5 NMO LA PA

DALIRESP Tier 4

epinephrine (anaphylaxis) (generic of EPIPEN 2-PAK) .3mg/0.3ml

(generic of EpiPen)

Tier 3

epinephrine (anaphylaxis) (generic of EPIPEN-JR 2-PAK) .15mg/0.3ml

(generic of EpiPen)

Tier 3

epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml

(generic of Adrenaclick)

Tier 3

ESBRIET Tier 5 NMO PA

FASENRA Tier 5 NMO LA PA

FASENRA PEN Tier 5 NMO LA PA

KALYDECO Tier 5 NMO PA

NUCALA Tier 5 NMO LA PA

OFEV Tier 5 NMO PA

ORKAMBI Tier 5 NMO PA

PROLASTIN-C Tier 5 NMO LA PA

PULMOZYME Tier 5 NMO PA

SYMDEKO Tier 5 NMO LA PA

SYMJEPI Tier 4

THEO-24 Tier 4

theophylline Tier 4



49

Drug Name Drug Tier

Requirements/Limits

theophylline tab er 12hr 300 mg

Tier 4

theophylline tab er 12hr 450 mg

Tier 4

theophylline tab sr 24hr Tier 3

TRIKAFTA Tier 5 NMO LA PA

XOLAIR Tier 5 NMO LA PA

ZEMAIRA Tier 5 NMO LA PA

NASAL STEROIDS flunisolide (nasal)

QL (3 bottles / 30 days)

Tier 3 QL

fluticasone propionate (nasal)

QL (1 bottle / 30 days)

Tier 2 GC QL

STEROID INHALANTS ARNUITY ELLIPTA

QL (30 inhalations / 30 days)

Tier 3 QL

budesonide (inhalation) (generic of PULMICORT) .25mg/2ml, .5mg/2ml

Tier 4 B/D

FLOVENT DISKUS 50mcg/blist, 100mcg/blist


Tier 3 QL

FLOVENT DISKUS 250mcg/blist


Tier 3 QL

FLOVENT HFA QL (2 inhalers / 30 days)

Tier 3 QL

PULMICORT FLEXHALER QL (2 inhalers / 30 days)

Tier 4 QL

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS


Tier 3 QL

ADVAIR HFA QL (1 inhaler / 30 days)

Tier 3 QL

Drug Name Drug Tier

Requirements/Limits

BREO ELLIPTA QL (60 blisters / 30 days)

Tier 3 QL

SYMBICORT QL (1 inhaler / 30 days)

Tier 3 QL

TOPICAL DERMATOLOGY, ACNE amnesteem Tier 4 PA

avita (generic of RETIN-A) CREA


Tier 4 QL PA

avita GEL QL (45 grams / 30 days)

Tier 4 QL PA

benzoyl peroxide-erythromycin (generic of BENZAMYCIN)

Tier 4

claravis Tier 4 PA

clindamycin phosphate (topical) (generic of CLEOCIN-T) GEL


Tier 4 QL

clindamycin phosphate (topical) (generic of CLEOCIN-T) LOTN

Tier 3

clindamycin phosphate (topical) SOLN


Tier 4 QL

ery pad 2% Tier 3

erythromycin (acne aid) (generic of ERYGEL) GEL

Tier 4

erythromycin (acne aid) SOLN

Tier 3

isotretinoin CAPS Tier 4 PA

myorisan Tier 4 PA

sulfacetamide sodium (acne) (generic of KLARON)

Tier 4

tretinoin (generic of RETIN-A) CREA


Tier 4 QL PA



50

Drug Name Drug Tier

Requirements/Limits

tretinoin (generic of RETIN-A) GEL .01%, .025%


Tier 4 QL PA

zenatane Tier 4 PA

DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) CREA

Tier 4

gentamicin sulfate (topical) OINT

Tier 3

mupirocin OINT QL (220 grams / 30 days)

Tier 2 GC QL

silver sulfadiazine (generic of SILVADENE) CREA

Tier 2 GC

ssd (generic of SILVADENE)

Tier 2 GC

SULFAMYLON CREA Tier 4

DERMATOLOGY, ANTIFUNGALS ciclopirox (generic of LOPROX) CREA


Tier 3 QL

ciclopirox (generic of LOPROX) SUSP


Tier 3 QL

clotrimazole (topical) CREA Tier 3

clotrimazole (topical) SOLN QL (30 mL / 30 days)

Tier 3 QL

clotrimazole w/ betamethasone CREA

Tier 3

ketoconazole cream QL (60 grams / 30 days)

Tier 3 QL

nyamyc QL (60 grams / 30 days)

Tier 3 QL

nystatin (topical) CREA; OINT

Tier 3

nystatin (topical) POWD QL (60 grams / 30 days)

Tier 3 QL

Drug Name Drug Tier

Requirements/Limits

nystop QL (60 grams / 30 days)

Tier 3 QL

DERMATOLOGY, ANTIPSORIATICS acitretin (generic of SORIATANE) 10mg, 25mg

Tier 4 PA

acitretin 17.5mg Tier 4 PA

calcipotriene (generic of DOVONEX) CREA


Tier 4 QL PA

calcipotriene OINT QL (120 grams / 30 days)

Tier 4 QL PA

calcipotriene SOLN QL (120 mL / 30 days)

Tier 4 QL PA

calcitrene QL (120 grams / 30 days)

Tier 4 QL PA

tazarotene (generic of TAZORAC) CREA


Tier 3 QL PA

TAZORAC CREA .05% QL (60 grams / 30 days)

Tier 4 QL PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo Tier 2 GC

selenium sulfide LOTN Tier 2 GC

DERMATOLOGY, CORTICOSTEROIDS ala-cort cre 1% Tier 1 GC

ala-cort cre 2.5% Tier 2 GC

alclometasone dipropionate CREA

Tier 4

alclometasone dipropionate OINT

Tier 3

betamethasone dipropionate (topical) CREA; LOTN

Tier 3

betamethasone dipropionate (topical) OINT

Tier 4

betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA

Tier 3



51

Drug Name Drug Tier

Requirements/Limits

betamethasone dipropionate augmented GEL; LOTN

Tier 4

betamethasone dipropionate augmented (generic of DIPROLENE) OINT

Tier 4

betamethasone valerate CREA; LOTN; OINT

Tier 3

ENSTILAR QL (120 grams / 30 days)

Tier 4 QL PA

fluocinolone acetonide CREA .01%

Tier 3

fluocinolone acetonide (generic of SYNALAR) CREA .025%

Tier 3

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

Tier 4

fluocinolone acetonide (generic of SYNALAR) OINT

Tier 3

fluocinolone acetonide (generic of SYNALAR) SOLN


Tier 4 QL

fluocinolone acetonide oil body (generic of DERMA-SMOOTHE/FS SCALP)

Tier 4

fluocinonide CREA .05% QL (120 grams / 30 days)

Tier 4 QL

fluocinonide GEL QL (60 grams / 30 days)

Tier 4 QL

fluocinonide OINT QL (60 grams / 30 days)

Tier 4 QL

fluocinonide SOLN QL (60 mL / 30 days)

Tier 4 QL

fluocinonide emulsified base QL (120 grams / 30 days)

Tier 4 QL

fluticasone propionate CREA; OINT

Tier 3

Drug Name Drug Tier

Requirements/Limits

halobetasol propionate CREA; OINT


Tier 4 QL

hydrocortisone (topical) cream 1%

Tier 1 GC

hydrocortisone (topical) cream 2.5%

Tier 2 GC

hydrocortisone (topical) lotion 2.5%

Tier 3

hydrocortisone (topical) oint 2.5%

Tier 2 GC

hydrocortisone butyrate cream 0.1% (generic of LOCOID)


Tier 4 QL

hydrocortisone butyrate oint 0.1%


Tier 4 QL

mometasone furoate CREA; OINT; SOLN

Tier 3

TEXACORT SOLN 2.5% Tier 4

triamcinolone acetonide (topical) CREA .1%


Tier 2 GC QL

triamcinolone acetonide (topical) CREA .025%, .5%

Tier 2 GC

triamcinolone acetonide (topical) LOTN

Tier 3

triamcinolone acetonide (topical) OINT .025%, .1%, .5%

Tier 2 GC

DERMATOLOGY, LOCAL ANESTHETICS glydo

QL (30 mL / 30 days) Tier 3 QL PA

lidocaine (generic of LIDODERM) PTCH 5%

QL (3 patches / 1 day)

Tier 4 QL PA

lidocaine hcl GEL QL (30 mL / 30 days)

Tier 3 QL PA

lidocaine hcl SOLN 4% QL (50 mL / 30 days)

Tier 3 QL PA



52

Drug Name Drug Tier

Requirements/Limits

lidocaine oint 5% QL (50 grams / 30 days)

Tier 4 QL PA

lidocaine-prilocaine QL (30 grams / 30 days)

Tier 3 QL PA

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate CREA Tier 2 GC

ammonium lactate LOTN Tier 3

diclofenac sodium (topical) 1% gel (generic of VOLTAREN)


Tier 3 QL PA

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


Tier 4 QL

fluorouracil (topical) SOLN QL (10 mL / 30 days)

Tier 3 QL

imiquimod (generic of ALDARA) CREA 5%


Tier 3 QL

metronidazole (topical) (generic of METROCREAM) CREA

Tier 4

metronidazole (topical) (generic of METROLOTION) LOTN

Tier 4

metronidazole gel 0.75% Tier 4

PANRETIN QL (60 grams / 30 days)

Tier 5 QL

PICATO .05% QL (2 tubes / 30 days)

Tier 4 QL

PICATO .015% QL (3 tubes / 30 days)

Tier 4 QL

podofilox SOLN Tier 3

procto-med hc (generic of ANUSOL-HC)

Tier 3

procto-pak (generic of PROCTOCORT)

Tier 3

Drug Name Drug Tier

Requirements/Limits

proctosol hc cre 2.5% (generic of ANUSOL-HC)

Tier 3

proctozone-hc (generic of ANUSOL-HC)

Tier 3

RECTIV QL (30 grams / 30 days)

Tier 4 QL

rosadan cre 0.75% (generic of METROCREAM)

Tier 4

tacrolimus (topical) (generic of PROTOPIC)


Tier 4 QL

TARGRETIN GEL QL (60 grams / 30 days)

Tier 5 QL NMO PA

VALCHLOR QL (60 grams / 30 days)

Tier 5 QL NMO LA PA

DERMATOLOGY, SCABICIDES AND PEDICULIDES malathion Tier 4

permethrin cre 5% (generic of ELIMITE)

Tier 3

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% Tier 2 GC

REGRANEX QL (30 grams / 30 days)

Tier 5 QL PA

SANTYL Tier 4

sodium chlor sol 0.9% irr Tier 2 GC

water for irrigation, sterile Tier 2 GC

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

Tier 4

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

Tier 1 GC

clotrimazole LOZG Tier 4

lidocaine hcl (mouth-throat) Tier 2 GC

nystatin (mouth-throat) Tier 3

paroex sol 0.12% (generic of PERIDEX)

Tier 1 GC



53

Drug Name Drug Tier

Requirements/Limits

periogard (generic of PERIDEX)

Tier 1 GC

pilocarpine hcl (oral) (generic of SALAGEN)

Tier 4

triamcinolone acetonide (mouth)

Tier 3

OTIC acetic acid (otic) Tier 3

CIPRODEX Tier 3

flac (generic of DERMOTIC) Tier 4

fluocinolone acetonide (otic) (generic of DERMOTIC)

Tier 4

neomycin-polymyxin-hc (otic)

Tier 3

ofloxacin (otic) Tier 4


54

Index A abacavir sulfate ................... 6

abacavir sulfate-lamivudine ........................................... 6

abacavir sulfate-lamivudine-zidovudine ... 7

ABELCET ............................. 5

ABILIFY

see aripiprazole tab ...... 24

ABILIFY MAINTENA ........ 24

abiraterone acetate .......... 11

ABRAXANE ....................... 10

acamprosate calcium ....... 30

acarbose ............................ 31

ACCOLATE

see zafirlukast ............... 48

ACCUPRIL

see quinapril hcl ............ 14

ACCURETIC

see quinapril-hydrochlorothiazide .. 13

acebutolol hcl .................... 16

acetaminophen w/ codeine 300-15mg ......................... 1



acetaminophen w/ codeine soln.................................... 1

acetazolamide ................... 17

acetic acid .......................... 52

acetic acid (otic) ................ 53

acetylcysteine .................... 48

acitretin ............................... 50

ACTHIB .............................. 43

ACTIGALL

see ursodiol ................... 40

ACTIMMUNE ..................... 43

ACTIQ

see fentanyl citrate ......... 2

ACTONEL .......................... 33

see risedronate sodium ..................................... 33

ACTOS see pioglitazone hcl ...... 32

ACULAR

see ketorolac tromethamine (ophth) .................................... 46

ACULAR LS

see ketorolac tromethamine (ophth) .................................... 46

acyclovir ............................... 7

acyclovir sodium ................. 7

ADACEL ............................ 43

ADCIRCA .......................... 18

see alyq ......................... 18

see tadalafil (pulmonary hypertension) ............ 18

ADDERALL

see amphetamine-dextroamphetamine tab 10 mg .................. 27

see amphetamine-dextroamphetamine tab 12.5 mg ............... 27




see amphetamine-dextroamphetamine tab 5 mg ..................... 27

see amphetamine-dextroamphetamine tab 7.5 mg ................. 27

ADDERALL XR

see amphetamine-dextroamphetamine cap sr 24hr 10 mg .... 26





see amphetamine-dextroamphetamine cap sr 24hr 5 mg ....... 26

adefovir dipivoxil ................. 7

ADEMPAS ......................... 18

adriamycin ......................... 10

adrucil inj ............................ 10

ADVAIR DISKUS .............. 49

ADVAIR HFA ..................... 49

AFINITOR .......................... 11

see everolimus .............. 12

AFINITOR DISPERZ ........ 11

AGGRENOX

see aspirin-dipyridamole ..................................... 42

AGRYLIN

see anagrelide hcl ........ 41

AIMOVIG ............................ 28

ala-cort cre 1% .................. 50

ala-cort cre 2.5% .............. 50

albendazole ......................... 4

ALBENZA

see albendazole .............. 4

albuterol sulfate ................ 48

ALCAINE

see proparacaine hcl .... 47

alclometasone dipropionate ......................................... 50

ALDACTAZIDE

see spironolactone & hydrochlorothiazide .. 17

ALDACTONE

see spironolactone ....... 14

ALDARA

see imiquimod ............... 52

ALDURAZYME ................. 35

ALECENSA ....................... 11

alendronate sodium tab 10 mg ................................... 33



55




alfuzosin hcl ....................... 40

ALIMTA .............................. 10

ALINIA .................................. 4

aliskiren fumarate ............. 17

allopurinol tab ...................... 1

alosetron hcl ...................... 39

ALPHAGAN P see brimonidine sol

0.15% ......................... 47

ALPHAGAN P SOL 0.1% 46

alprazolam tab 0.25mg .... 18

alprazolam tab 0.5mg ...... 18

alprazolam tab 1mg .......... 18

alprazolam tab 2 mg ......... 18

ALREX ................................ 46

ALTACE

see ramipril .................... 14

altavera tab ........................ 33

ALUNBRIG ........................ 12

alyacen 1/35 ...................... 33

alyq...................................... 18

amantadine hcl .................. 23

AMARYL

see glimepiride .............. 31

AMBIEN

see zolpidem tartrate ... 28

AMBISOME ......................... 5

ambrisentan ....................... 18

AMERGE

see naratriptan hcl ........ 28

amikacin sulfate .................. 4

amiloride & hydrochlorothiazide ...... 17

amiloride hcl ...................... 17

AMINOSYN II INJ 10% .... 44

AMINOSYN-PF 7% .......... 44

AMINOSYN-PF INJ 10% . 44

amiodarone hcl soln ......... 14

amiodarone tab 100mg .... 14



AMITIZA CAP 24MCG ..... 39

AMITIZA CAP 8MCG ...... 39

amitriptyline hcl ................. 22

amlodipine besylate ......... 16

amlodipine besylate-benazepril hcl cap 10-20 mg ................................... 13


amlodipine besylate-benazepril hcl cap 2.5-10 mg ................................... 13




amlodipine besylate-olmesartan medoxomil 14

amlodipine besylate-valsartan tab ................. 14

amlodipine-valsartan-hydrochlorothiazide tab 14

ammonium lactate ............ 52

amnesteem ....................... 49

amoxapine ......................... 22

amoxicillin ............................ 9

amoxicillin & pot clavulanate 200/5ml susr .......................................... 9

amoxicillin & pot clavulanate 200-28.5 chw tabs ................................... 9


amoxicillin & pot clavulanate 250-125 tabs .......................................... 9


amoxicillin & pot clavulanate 400-57 chw tabs ................................... 9

amoxicillin & pot clavulanate 500-125 tabs ........................................... 9

amoxicillin & pot clavulanate 600/5ml susr ........................................... 9

amoxicillin & pot clavulanate 875-125 tabs ........................................... 9

amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs .......................... 9

amphetamine-dextroamphetamine cap sr 24hr 10 mg ................ 26





amphetamine-dextroamphetamine cap sr 24hr 5 mg .................. 26

amphetamine-dextroamphetamine tab 10 mg .............................. 27

amphetamine-dextroamphetamine tab 12.5 mg .......................... 27





56

amphetamine-dextroamphetamine tab 5 mg ................................... 27

amphetamine-dextroamphetamine tab 7.5 mg ............................. 27

amphotericin b ..................... 5

ampicillin & sulbactam sodium .............................. 9

ampicillin cap 500mg ......... 9

ampicillin inj ......................... 9

ampicillin sodium ................ 9

AMPYRA

see dalfampridine ......... 29

ANADROL-50 .................... 30

ANAFRANIL

see clomipramine hcl ... 22

anagrelide hcl .................... 41

ANAPROX DS

see naproxen sodium ..... 1

anastrozole ........................ 11

ANCOBON

see flucytosine ................ 5

ANDRODERM ................... 30

ANDROGEL

see testosterone ........... 30

ANORO ELLIPTA ............. 47

ANTABUSE

see disulfiram ................ 30

ANUSOL-HC

see procto-med hc ........ 52

see proctosol hc cre 2.5% ............................ 52

see proctozone-hc ........ 52

APOKYN ............................ 23

aprepitant ........................... 38

aprepitant pak 80mg & 125mg ............................. 38

apri ...................................... 33

APTIOM.............................. 19

APTIVUS .............................. 6

ARALAST NP .................... 48

aranelle ............................... 33

ARAVA

see leflunomide ............. 42

ARCALYST ........................ 43

ARICEPT

see donepezil hydrochloride ............ 21

ARIMIDEX

see anastrozole ............ 11

aripiprazole odt ................. 24

aripiprazole oral solution 1 mg/ml ............................. 24

aripiprazole tab ................. 24

ARISTADA ........................ 24

ARISTADA INITIO ........... 24

ARIXTRA

see fondaparinux sodium .................................... 41

armodafinil ......................... 30

ARNUITY ELLIPTA .......... 49

AROMASIN

see exemestane ........... 11

aspirin-dipyridamole ........ 42

atazanavir sulfate ............... 6

atenolol .............................. 16

atenolol & chlorthalidone 16

ATIVAN

see lorazepam .............. 19

atomoxetine hcl ................ 27

atorvastatin calcium ......... 15

atovaquone ......................... 4

atovaquone-proguanil hcl . 5

ATRIPLA .............................. 7

ATROPINE SULFATE ..... 47

ATROVENT HFA ............. 47

aubra .................................. 33

AUGMENTIN

see amoxicillin & pot clavulanate 250/5ml susr ............................... 9

see amoxicillin & pot clavulanate 500-125 tabs ............................... 9

AURYXIA ........................... 37

AUSTEDO ......................... 29

AVALIDE

see irbesartan-hydrochlorothiazide .. 14

AVAPRO

see irbesartan ............... 14

AVASTIN ........................... 10

aviane ................................ 33

avita .................................... 49

AVODART

see dutasteride ............. 40

AYGESTIN

see norethindrone acetate ........................ 38

AYVAKIT ............................ 12

azacitidine .......................... 10

AZACTAM

see aztreonam ................ 4

AZASITE ............................ 46

azathioprine ....................... 43

azelastine drop 0.05% ..... 46

azelastine spr 0.1% .......... 47

azelastine spr 0.15% ........ 47

AZILECT

see rasagiline mesylate ..................................... 24

azithromycin ........................ 8

AZOPT ............................... 47

AZOR

see amlodipine besylate-olmesartan medoxomil ..................................... 14

aztreonam ............................ 4

AZULFIDINE

see sulfasalazine .......... 39

AZULFIDINE EN-TABS

see sulfasalazine ec ..... 39

B bacitracin (ophthalmic) .... 46

bacitracin-polymyxin b (ophth) ............................ 46

bacitracin-poly-neomycin-hc .................................... 45

baclofen .............................. 29

BACTRIM

see sulfamethoxazole-trimethoprim tab 400-80mg ............................. 5

BACTRIM DS

see sulfamethoxazole-trimethop ds ................. 5

balsalazide disodium ........ 39

BALVERSA ........................ 12

balziva ................................ 33

BANZEL SUS 40MG/ML . 19

BANZEL TAB 200MG ...... 19

BANZEL TAB 400MG ...... 19


57

BARACLUDE ...................... 7

see entecavir ................... 7

BASAGLAR KWIKPEN .... 30

BCG VACCINE ................. 43

BD ALCOHOL SWABS ... 30

BD ULTRAFINE INSULIN SYRINGE ....................... 30

BD ULTRAFINE/NANO PEN NEEDLES ............. 30

bekyree ............................... 33

BELSOMRA ....................... 28

benazepril & hydrochlorothiazide ...... 13

benazepril hcl .................... 14

BENDEKA .......................... 10

BENICAR

see olmesartan medoxomil ................. 14

BENICAR HCT

see olmesartan medoxomil-hydrochlorothiazide .. 14

BENLYSTA ........................ 43

BENZAMYCIN

see benzoyl peroxide-erythromycin .............. 49

benzoyl peroxide-erythromycin .................. 49

benztropine mesylate inj .. 23

benztropine mesylate tab 0.5mg .............................. 23

benztropine mesylate tab 1mg ................................. 23

benztropine mesylate tab 2mg ................................. 23

BEPREVE .......................... 46

BERINERT ......................... 41

BESIVANCE ...................... 46

betamethasone dipropionate (topical) ... 50

betamethasone dipropionate augmented ................................... 50, 51

betamethasone valerate .. 51

BETAPACE

see sorine ...................... 15

see sotalol hcl ............... 15

BETAPACE AF

see sotalol hcl (afib/afl) 15

BETASERON .................... 29

betaxolol hcl (ophth) ........ 47

bethanechol chloride ....... 40

BETOPTIC-S .................... 47

BEVESPI AEROSPHERE ........................................ 47

bexarotene ........................ 13

BEXSERO ......................... 43

BIAXIN XL

see clarithromycin er ..... 8

bicalutamide ...................... 11

BICILLIN L-A ....................... 9

BIKTARVY .......................... 7

BILTRICIDE

see praziquantel ............. 5

bisoprolol & hydrochlorothiazide ...... 16

bisoprolol fumarate .......... 16

BIVIGAM ............................ 43

BLEPH-10

see sulfacetamide sodium (ophth) .......... 46

BLEPHAMIDE .................. 46

blisovi fe 1.5/30 ................ 33

BONIVA

see ibandronate sodium tabs ............................. 33

BOOSTRIX ........................ 43

BORTEZOMIB .................. 10

bosentan ............................ 18

BOSULIF ........................... 12

BRAFTOVI ........................ 12

BREO ELLIPTA ................ 49

briellyn ................................ 33

BRILINTA .......................... 42

brimonidine sol 0.15% ..... 47

brimonidine sol 0.2% ....... 47

BRIVIACT INJ 50MG/5ML ........................................ 19

BRIVIACT SOL 10MG/ML ........................................ 19

BRIVIACT TAB 100MG ... 19

BRIVIACT TAB 10MG ..... 19




bromfenac sodium (ophth) ......................................... 46

bromocriptine mesylate ... 23

BROMSITE ........................ 46

BRUKINSA ........................ 12

budesonide (inhalation) ... 49

budesonide ec ................... 39

bumetanide inj 0.25/ml .... 17

bumetanide tab ................. 17

BUMEX

see bumetanide tab ...... 17

BUPHENYL

see sodium phenylbutyrate .......... 36

buprenorphine hcl ............. 30

buprenorphine hcl-naloxone hcl dihydrate 12-3mg ........................... 30

buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg .............................. 30

buprenorphine hcl-naloxone hcl dihydrate 4-1mg ................................. 30

buprenorphine hcl-naloxone hcl dihydrate 8-2mg ................................. 30

buprenorphine hcl-naloxone hcl sl .............. 30

bupropion hcl ..................... 22

bupropion hcl (smoking deterrent) ....................... 30

buspirone hcl ............... 18, 19

butorphanol tartrate ............ 1

BYDUREON BCISE ......... 30

BYDUREON PEN ............. 30

BYETTA ............................. 30

BYSTOLIC ......................... 16

C cabergoline ........................ 37

CABOMETYX .................... 12

CAFERGOT

see ergotamine w/ caffeine ....................... 28

CALAN SR

see verapamil hcl .......... 17

see verapamil tab er .... 17

calcipotriene ...................... 50


58

calcitonin (salmon) ........... 37

calcitrene ............................ 50

calcitriol .............................. 45

calcitriol inj ......................... 45

calcitriol oral soln 1 mcg/ml ......................................... 45

calcium acetate (phosphate binder) ............................ 37

CALQUENCE .................... 12

camila ................................. 33

CAMPTOSAR

see irinotecan hcl .......... 13

CANASA

see mesalamine ............ 39

CANCIDAS

see caspofungin acetate 5

CAPLYTA ........................... 24

CAPRELSA ....................... 12

captopril .............................. 14

captopril & hydrochlorothiazide ...... 13

CARAFATE

see sucralfate ................ 40

CARBAGLU ....................... 35

carbamazepine ................. 19

CARBATROL

see carbamazepine ...... 19

carbidopa/levodopa/entacapone .......................... 23, 24

carbidopa-levodopa .......... 23

carboplatin ......................... 13

CARDIZEM

see diltiazem hcl ........... 16

CARDIZEM CD

see cartia xt ................... 16

see diltiazem cap 240mg cd ................................. 16

see diltiazem cap 360mg cd ................................. 16

see diltiazem hcl coated beads .......................... 16

see diltiazem hcl coated beads cap sr 24hr ..... 16

see diltiazem hcl extended release beads cap sr .............. 16

CARDURA

see doxazosin mesylate .................................... 14

CARNITOR

see levocarnitine (metabolic modifiers) 36

carteolol hcl (ophth) ......... 47

cartia xt .............................. 16

carvedilol ........................... 16

CASODEX

see bicalutamide .......... 11

caspofungin acetate .......... 5

CATAPRES

see clonidine hcl ........... 17

CATAPRES-TTS-1

see clonidine hcl ptwk . 17

CATAPRES-TTS-2


CATAPRES-TTS-3


CAYSTON ........................... 4

caziant pak ........................ 33

cefaclor ................................ 8

CEFACLOR ER TAB 500MG ............................. 8

cefadroxil ............................. 8

CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ............. 8

cefazolin inj ......................... 8

cefazolin sodium ................ 8

CEFAZOLIN SODIUM 1 GM/50ML ......................... 8

cefdinir ................................. 8

cefepime for inj ................... 8

cefixime ................................ 8

cefoxitin for inj ..................... 8

cefpodoxime proxetil .......... 8

cefprozil ............................... 8

ceftazidime .......................... 8

CEFTAZIDIME/DEXTROSE ........................................ 8

ceftriaxone sodium ............. 8

cefuroxime axetil ................ 8

cefuroxime sodium ............. 8

CELEBREX

see celecoxib .................. 1

celecoxib .............................. 1

CELEXA

see citalopram hydrobromide ............ 22

CELLCEPT

see mycophenolate mofetil ......................... 43

CELONTIN ........................ 19

cephalexin ............................ 8

CERDELGA ....................... 35

CEREZYME ...................... 35

cetirizine syrup .................. 47

cevimeline hcl .................... 52

CHANTIX ........................... 30

CHANTIX CONTINUING MONTH .......................... 30

CHANTIX STARTER PACK ......................................... 30

CHEMET ............................ 33

chlorhexidine gluconate (mouth-throat) ............... 52

chloroquine phosphate ...... 5

chlorothiazide .................... 17

chlorpromazine hcl ........... 24

CHLORPROMAZINE INJ 24

chlorthalidone .................... 17

cholestyramine .................. 15

cholestyramine light pack 15

cholestyramine light powd ......................................... 15

ciclopirox ............................ 50

cilostazol ............................ 41

CILOXAN ........................... 46

see ciprofloxacin hcl (ophth) ........................ 46

CIMDUO .............................. 7

cinacalcet hcl ..................... 37

CIPRO .................................. 8

see ciprofloxacin hcl tab 8

CIPRODEX ........................ 53

ciprofloxacin hcl (ophth) .. 46

ciprofloxacin hcl tab ............ 8

ciprofloxacin in d5w ............ 9

cisplatin .............................. 13

citalopram hydrobromide . 22

claravis ............................... 49

clarithromycin ...................... 8

clarithromycin er ................. 8

clarithromycin for susp ....... 8

CLEOCIN


59

see clindamycin cap 300 mg ................................. 4

see clindamycin cap 75mg ............................. 4

see clindamycin hcl cap 150 mg ......................... 4

see clindamycin phosphate vaginal .... 41

CLEOCIN PEDIATRIC GRANULE

see clindamycin soln 75mg/5ml ..................... 4

CLEOCIN PHOSPHATE

see clindamycin phosphate inj ............... 4

CLEOCIN-T

see clindamycin phosphate (topical) ... 49

CLIMARA

see estradiol .................. 36

clindamycin cap 300 mg .... 4

clindamycin cap 75mg ....... 4

clindamycin hcl cap 150 mg ........................................... 4

clindamycin phosphate (topical) ........................... 49

clindamycin phosphate in d5w.................................... 4

CLINDAMYCIN PHOSPHATE IN NACL . 4

clindamycin phosphate inj . 4

clindamycin phosphate vaginal ............................ 41

clindamycin soln 75mg/5ml ........................................... 4

CLINIMIX 4.25%/DEXTROSE 5% 44

CLINIMIX 5%/DEXTROSE 15% ................................. 44

CLINIMIX 5%/DEXTROSE 20% ................................. 44

CLINIMIX INJ 4.25/D10 ... 44

clinisol sf 15% ................... 44

CLINOLIPID ....................... 44

clobazam ............................ 19

clomipramine hcl ............... 22

clonazepam ....................... 19

clonidine hcl ....................... 17

clonidine hcl ptwk ....... 17, 18

clopidogrel tab 75mg ....... 42

clorazepate dipotassium . 19

clotrimazole ....................... 52

clotrimazole (topical) ........ 50

clotrimazole w/ betamethasone ............. 50

clovique .............................. 33

clozapine odt ..................... 24

clozapine tab 100mg ....... 24

clozapine tab 200mg ....... 24

clozapine tab 25mg .......... 24

clozapine tab 50mg .......... 24

CLOZARIL

see clozapine tab 100mg .................................... 24




COARTEM .......................... 5

COGENTIN

see benztropine mesylate inj ............... 23

COLAZAL

see balsalazide disodium .................................... 39

colchicine w/ probenecid ... 1

COLCRYS ........................... 1

colesevelam hcl ................ 15

COLESTID

see colestipol hcl gran . 15

see colestipol hcl pack 15

see colestipol hcl tabs . 15

colestipol hcl gran ............ 15

colestipol hcl pack ............ 15

colestipol hcl tabs ............. 15

colistimethate sodium ........ 4

colocort .............................. 39

COLY-MYCIN M

see colistimethate sodium ......................... 4

COMBIGAN ...................... 47

COMBIVENT RESPIMAT 47

COMBIVIR

see lamivudine-zidovudine .................... 7

COMETRIQ ....................... 12

COMPLERA ........................ 7

compro supp ...................... 38

COMTAN

see entacapone ............ 24

constulose .......................... 39

COPAXONE

see glatiramer acetate 20mg/ml ..................... 29

see glatiramer acetate 40mg/ml ..................... 29

see glatopa .................... 29

COPIKTRA ........................ 12

COREG

see carvedilol ................ 16

CORGARD

see nadolol .................... 16

CORLANOR ...................... 18

CORTEF

see hydrocortisone ....... 36

CORTENEMA

see colocort ................... 39

see hydrocortisone (enema) ...................... 39

cortisone acetate .............. 36

COSOPT

see dorzolamide hcl-timolol maleate .......... 47

COTELLIC ......................... 12

COUMADIN ....................... 41

see jantoven .................. 41

see warfarin sodium ..... 41

COZAAR

see losartan potassium 14

CREON .............................. 40

CRESTOR

see rosuvastatin calcium ..................................... 15

CRIXIVAN ............................ 6

cromolyn sod neb 20mg/2ml ....................... 48

cromolyn sodium (mastocytosis) ............... 39

cromolyn sodium (ophth) . 46

cryselle-28 ......................... 33

CUBICIN


60

see daptomycin ............... 4

cyclafem 1/35 .................... 33

cyclafem 7/7/7 ................... 33

cyclobenzaprine hcl .......... 29

cyclophosphamide ............ 10

cycloserine ........................... 7

cyclosporine ....................... 43

cyclosporine modified (for microemulsion) .............. 43

CYKLOKAPRON

see tranexamic acid ..... 42

CYMBALTA

see duloxetine hcl ......... 22

cyproheptadine hcl ........... 47

cyred tab ............................ 33

CYSTADANE .................... 36

CYSTAGON ...................... 36

CYSTARAN ....................... 47

cytarabine .......................... 10

CYTOMEL

see liothyronine sodium ..................................... 38

CYTOTEC

see misoprostol ............. 39

CYTOVENE

see ganciclovir sodium .. 7

D D.H.E. 45

see dihydroergotamine mesylate inj 1 mg/ml 28

dalfampridine ..................... 29

DALIRESP ......................... 48

danazol ............................... 35

DANTRIUM

see dantrolene sodium 29

dantrolene sodium ............ 29

dapsone ............................... 4

DAPTACEL ........................ 43

daptomycin .......................... 4

DAPTOMYCIN

see daptomycin ............... 4

dasetta 1/35 ....................... 34

dasetta 7/7/7 ...................... 34

DAURISMO ....................... 10

DDAVP

see desmopressin acetate spray ............. 38

see desmopressin acetate tabs .............. 38

see desmopressin inj 4mcg/ml ..................... 38

deblitane ............................ 34

deferasirox ........................ 33

DELESTROGEN .............. 36

see estradiol valerate inj .................................... 36

DELSTRIGO ....................... 7

DELZICOL

see mesalamine ........... 39

DEMSER ........................... 18

DEPAKOTE

see divalproex sodium 19

DEPAKOTE ER


DEPAKOTE SPRINKLES


DEPEN TITRATABS

see penicillamine .......... 33

DEPO-MEDROL

see methylprednisolone acetate ....................... 36

DEPO-PROVERA CONTRACEPTIV

see medroxyprogesterone acetate (contraceptive) .................................... 34

DEPO-PROVERA INJ 400/ML ........................... 11

DEPO-TESTOSTERONE see testosterone

cypionate ................... 30

DERMA-SMOOTHE/FS BODY

see fluocinolone acetonide ................... 51

DERMA-SMOOTHE/FS SCALP

see fluocinolone acetonide oil body .... 51

DERMOTIC

see flac .......................... 53

see fluocinolone acetonide (otic) ......... 53

DESCOVY ........................... 7

desipramine hcl ................. 22

desmopressin acetate spray ............................... 38

desmopressin acetate spray refrigerated ......... 38

desmopressin acetate tabs ......................................... 38

desmopressin inj 4mcg/ml ......................................... 38

desogestrel & ethinyl estradiol .......................... 34

desogestrel-ethinyl estradiol (biphasic) ....... 34

desvenlafaxine succinate 22

DETROL

see tolterodine tartrate . 40

DETROL LA

see tolterodine tartrate . 40

dexamethasone ................ 36

DEXAMETHASONE ........ 36

DEXAMETHASONE SODIUM PHOS

see dexamethasone sodium phosphate .... 36

dexamethasone sodium phosphate ...................... 36

dexamethasone sodium phosphate (ophth) ........ 46

DEXILANT ......................... 40

dexmethylphenidate hcl ... 27

dextrose 10% flex contain ......................................... 45

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% ................................ 45

dextrose 10%/nacl 0.45%45

dextrose 2.5%/nacl 0.45% ......................................... 45

dextrose 5% ...................... 45

DEXTROSE 5% /ELECTROLYTE ........... 45

dextrose 5%/nacl 0.2% .... 45

dextrose 5%/nacl 0.225%45

DEXTROSE 5%/NACL 0.3% ................................ 45

dextrose 5%/nacl 0.45% .. 45

dextrose 5%/nacl 0.9% .... 45


61

dextrose 5%/potassium chl ......................................... 45

dextrose 50% .................... 45

dextrose in lactated ringers ......................................... 45

dextrose inj 70% ............... 45

DIASTAT ACUDIAL ......... 19

DIASTAT PEDIATRIC ..... 19

diazepam ........................... 19

diazepam gel ..................... 19

diazepam inj ...................... 19

diazepam intensol ............. 19

diazepam oral soln 1 mg/ml ......................................... 19

diazoxide ............................ 37

diclofenac potassium ......... 1

diclofenac sodium ............... 1

diclofenac sodium (ophth) ......................................... 46

diclofenac sodium (topical) 1% gel ............................. 52

dicloxacillin sodium ............. 9

dicyclomine hcl cap 10mg ......................................... 38

dicyclomine hcl soln 10mg/5ml ....................... 38

dicyclomine hcl tab 20mg 38

didanosine ........................... 6

DIFICID ................................ 8

DIFLUCAN

see fluconazole ............... 5

diflunisal ............................... 1

digitek ................................. 17

digox ................................... 17

digoxin ................................ 17

digoxin inj ........................... 17

digoxin sol 50mcg/ml ....... 17

dihydroergotamine mesylate inj 1 mg/ml .... 28

dihydroergotamine mesylate nasal spr 4 mg/ml .............................. 28

DILANTIN

see phenytoin sodium extended .................... 20

DILANTIN CAP 100MG ... 19

DILANTIN CAP 30MG ..... 19

DILANTIN CHEW TAB 50MG ............................. 19

DILANTIN INFATABS

see phenytoin ............... 20

DILANTIN-125 see phenytoin ............... 20

DILANTIN-125 SUSP ...... 19

DILAUDID

see hydromorphone hcl 2

diltiazem cap 240mg cd .. 16

diltiazem cap 360mg cd .. 16

diltiazem cap er/12hr ....... 16

diltiazem hcl ...................... 16

diltiazem hcl coated beads ........................................ 16

diltiazem hcl coated beads cap sr 24hr .................... 16

diltiazem hcl extended release beads cap sr ... 16

diltiazem inj ....................... 16

dilt-xr cap ........................... 16

DIOVAN

see valsartan ................ 14

DIOVAN HCT

see valsartan-hydrochlorothiazide .. 14

diphenhydramine hcl inj 50mg/ml ......................... 47

diphenoxylate w/ atropine 39

DIPHTHERIA/TETANUS TOXOID ......................... 43

DIPROLENE

see betamethasone dipropionate augmented ................ 51

DIPROLENE AF

see betamethasone dipropionate augmented ................ 50

disopyramide phosphate . 14

disulfiram ........................... 30

DITROPAN XL

see oxybutynin chloride .................................... 40

divalproex sodium ............ 19

docetaxel ........................... 10

DOCETAXEL .................... 10

see docetaxel ................ 10

dofetilide ............................. 14

DOLOPHINE

see methadone hcl 10mg ....................................... 3

see methadone hcl 5mg 3

donepezil hydrochloride .. 21

dorzolamide hcl ................. 47

dorzolamide hcl-timolol maleate .......................... 47

DOVATO .............................. 7

DOVONEX

see calcipotriene ........... 50

doxazosin mesylate .......... 14

doxepin hcl ........................ 22

doxepin hcl (sleep) ........... 28

DOXIL

see doxorubicin hcl liposomal .................... 10

doxorubicin hcl .................. 10

doxorubicin hcl liposomal 10

doxy 100 .............................. 9

doxycycline (monohydrate) ........................................... 9

doxycycline hyclate ............ 9

doxycycline hyclate 100 mg ........................................... 9

doxycycline hyclate 20 mg 9

DRIZALMA SPRINKLE .... 22

dronabinol .......................... 38

drospirenone-ethinyl estradiol .......................... 34

DROXIA ............................. 41

duloxetine hcl .................... 22

DURAGESIC

see fentanyl patch 100 mcg/hr .......................... 2





DUREZOL .......................... 46

dutasteride ......................... 40

dutasteride-tamsulosin hcl ......................................... 40


62

DYAZIDE

see triamterene & hydrochlorothiazide cap 37.5-25 mg ......... 17

E e.e.s. 400 ............................. 8

EC-NAPROSYN

see naproxen dr .............. 1

EC-NAPROXEN

see naproxen dr .............. 1

EDURANT............................ 6

efavirenz ............................... 6

EFFEXOR XR

see venlafaxine hcl ....... 23

EFFIENT

see prasugrel hcl .......... 42

EFUDEX

see fluorouracil (topical) ..................................... 52

eletriptan hydrobromide ... 28

ELIMITE

see permethrin cre 5% . 52

ELIQUIS ............................. 41

ELIQUIS STARTER PACK ......................................... 41

ELLA ................................... 34

ELLENCE

see epirubicin hcl .......... 10

eluryng ................................ 34

EMCYT ............................... 10

EMEND .............................. 38

see aprepitant ............... 38

EMGALITY ......................... 28

emoquette .......................... 34

EMSAM .............................. 22

EMTRIVA ............................. 6

EMVERM ............................. 4

enalapril maleate .............. 14

enalapril maleate & hydrochlorothiazide ...... 13

ENBREL ............................. 42

ENBREL MINI ................... 42

ENBREL SURECLICK ..... 42

ENDARI .............................. 41

endocet 10-325mg ............. 2

endocet 2.5-325mg ............ 2

endocet 5-325mg ................ 2

endocet 7.5-325mg ............ 2

ENGERIX-B ...................... 43

enoxaparin sodium .......... 41

enpresse-28 ...................... 34

enskyce .............................. 34

ENSTILAR ......................... 51

entacapone ....................... 24

entecavir .............................. 7

ENTOCORT EC

see budesonide ec ....... 39

ENTRESTO ...................... 14

enulose .............................. 39

EPCLUSA ............................ 7

EPIDIOLEX ....................... 19

epinephrine (anaphylaxis) ........................................ 48

EPIPEN 2-PAK

see epinephrine (anaphylaxis) ............ 48

EPIPEN-JR 2-PAK

see epinephrine (anaphylaxis) ............ 48

epirubicin hcl ..................... 10

epitol ................................... 19

EPIVIR

see lamivudine ................ 6

EPIVIR HBV ........................ 7

see lamivudine (hbv) ..... 7

eplerenone ........................ 14

EPZICOM

see abacavir sulfate-lamivudine ................... 6

ergotamine w/ caffeine .... 28

ERIVEDGE ........................ 10

ERLEADA .......................... 11

erlotinib hcl ........................ 12

errin .................................... 34

ertapenem sodium ............. 4

ery pad 2% ........................ 49

ERYGEL

see erythromycin (acne aid) .............................. 49

ery-tab .................................. 8

ERYTHROCIN LACTOBIONATE ........... 8

erythrocin stearate ............. 8

erythromycin (acne aid) .. 49

erythromycin (ophth) ........ 46

erythromycin base .............. 8

erythromycin cap 250mg ec ........................................... 8

erythromycin ethylsuccinate ........................................... 8

erythromycin tab ec ............ 8

ESBRIET ............................ 48

escitalopram oxalate ........ 22

esomeprazole magnesium ......................................... 40

estarylla tab 0.25-35 ........ 34

ESTRACE

see estradiol .................. 36

see estradiol vaginal cream .......................... 36

estradiol .............................. 36

estradiol vaginal cream .... 36

estradiol vaginal tab ......... 36

estradiol valerate inj ......... 36

ESTROSTEP FE

see tilia fe ....................... 35

see tri-legest fe ............. 35

ethambutol hcl ..................... 7

ethosuximide ..................... 19

ethynodiol diacet & eth estrad .............................. 34

ethynodiol tab 1-50 ........... 34

etodolac ................................ 1

etonogestrel-ethinyl estradiol .......................... 34

etoposide ........................... 13

euthyrox ............................. 38

everolimus ......................... 12

everolimus (immunosuppressant) .. 43

EVISTA

see raloxifene tab 60mg ..................................... 37

EVOTAZ ............................... 7

EVOXAC

see cevimeline hcl ........ 52

EXELON

see rivastigmine td patch 24hr 13.3 mg/24hr .... 22

see rivastigmine td patch 24hr 4.6 mg/24hr ...... 22

see rivastigmine td patch 24hr 9.5 mg/24hr ...... 22

exemestane ....................... 11


63

EXFORGE

see amlodipine besylate-valsartan tab .............. 14

EXFORGE HCT

see amlodipine-valsartan-hydrochlorothiazide tab ..................................... 14

EXJADE ............................. 33

see deferasirox ............. 33

ezetimibe ............................ 15

ezetimibe-simvastatin ...... 15

F FABRAZYME .................... 36

falmina ................................ 34

famciclovir ............................ 7

famotidine .......................... 39

famotidine in nacl .............. 39

famotidine inj ..................... 39

FANAPT ............................. 24

FANAPT TITRATION PACK .............................. 24

FARESTON

see toremifene citrate .. 11

FARXIGA ........................... 31

FARYDAK .......................... 10

FASENRA .......................... 48

FASENRA PEN ................. 48

FASLODEX

see fulvestrant ............... 11

felbamate ........................... 20

FELBATOL

see felbamate ................ 20

FELDENE

see piroxicam .................. 1

felodipine ............................ 16

FEMARA

see letrozole .................. 11

FEMHRT LOW DOSE

see fyavolv ..................... 36

see norethindrone acetate-ethinyl estradiol ...................... 36

femynor .............................. 34

fenofibrate .......................... 15

fenofibrate micronized ..... 15

fentanyl citrate ..................... 2

fentanyl patch 100 mcg/hr . 2

fentanyl patch 12 mcg/hr .. 2




FETZIMA ........................... 22

FETZIMA TITRATION PACK ............................. 22

FIASP ................................. 30

FIASP FLEXTOUCH ....... 30

FIASP PENFILL ............... 30

finasteride .......................... 40

FIRAZYR

see icatibant acetate .... 41

flac ...................................... 53

FLAGYL

see metronidazole .......... 4

flecainide acetate ............. 15

FLOMAX

see tamsulosin hcl ....... 40

FLOVENT DISKUS .......... 49

FLOVENT HFA ................. 49

fluconazole .......................... 5

fluconazole inj nacl 200 ..... 5

fluconazole inj nacl 400 ..... 5

flucytosine ........................... 5

fludrocortisone acetate .... 36

flunisolide (nasal) ............. 49

fluocinolone acetonide .... 51

fluocinolone acetonide (otic) ............................... 53

fluocinolone acetonide oil body ................................ 51

fluocinonide ....................... 51

fluocinonide emulsified base ................................ 51

fluorometholone ................ 46

fluorouracil ......................... 10

fluorouracil (topical) ......... 52

fluoxetine cap 10mg ........ 22



fluoxetine hcl ..................... 23

fluphenazine decanoate .. 24

fluphenazine hcl ............... 24

flurbiprofen .......................... 1

flurbiprofen sodium .......... 46

flutamide ............................ 11

fluticasone propionate ..... 51

fluticasone propionate (nasal) ............................ 49

fluvoxamine maleate ........ 19

FOCALIN

see dexmethylphenidate hcl ................................ 27

fondaparinux sodium ........ 41

FORTEO ............................ 37

FOSAMAX

see alendronate sodium tab 70 mg ................... 33

fosamprenavir tab 700 mg 6

fosinopril sodium ............... 14

fosinopril sodium & hydrochlorothiazide ...... 13

FREAMINE HBC 6.9% .... 44

FREAMINE III .................... 45

fulvestrant .......................... 11

furosemide ......................... 17

furosemide inj .................... 17

FUZEON .............................. 6

fyavolv ................................ 36

FYCOMPA ......................... 20

G gabapentin ......................... 20

GABITRIL

see tiagabine hcl ........... 21

galantamine hydrobromide ......................................... 21

galantamine hydrobromide er ..................................... 22

GAMASTAN S/D .............. 43

GAMMAGARD LIQUID .... 43

GAMMAGARD S/D .......... 43

GAMMAKED ..................... 43

GAMMAPLEX ................... 43

GAMMAPLEX 10GM/100ML ................ 43

GAMUNEX-C .................... 43

ganciclovir sodium .............. 7

GARDASIL 9 ..................... 43

GASTROCROM

see cromolyn sodium (mastocytosis) ........... 39

gatifloxacin (ophth) ........... 46

GATTEX ............................. 39

GAUZE PADS 2 ................ 31

gavilyte-c ............................ 39


64

gavilyte-g ............................ 39

gavilyte-n/flavor pack ....... 39

GEMCITABINE

see gemcitabine inj soln ..................................... 10

gemcitabine inj soln .......... 10

gemcitabine inj solr ........... 10

gemfibrozil ......................... 15

generlac ............................. 39

gengraf ............................... 43

GENOTROPIN .................. 37

GENOTROPIN MINIQUICK ......................................... 37

gentak ................................. 46

gentamicin in saline ............ 4

gentamicin sulfate ............... 4

gentamicin sulfate (topical) ......................................... 50

gentamicin sulfate soln (ophth) ............................ 46

GENVOYA ........................... 7

GEODON ........................... 24

see ziprasidone hcl ....... 26

see ziprasidone mesylate ..................................... 26

gianvi tab 3-0.02mg .......... 34

GILENYA ........................... 29

GILOTRIF TAB 20MG ..... 12



glatiramer acetate 20mg/ml ......................................... 29

glatiramer acetate 40mg/ml ......................................... 29

glatopa ................................ 29

GLEEVEC

see imatinib mesylate .. 12

GLEOSTINE ...................... 10

glimepiride ......................... 31

glip/metform tab 2.5-250mg ......................................... 31

glip/metform tab 2.5-500mg ......................................... 31

glip/metform tab 5-500mg ......................................... 31

glipizide .............................. 31

glipizide xl .......................... 32

GLUCAGEN HYPOKIT .... 37

GLUCAGON EMERGENCY KIT ....... 37

GLUCOTROL

see glipizide .................. 31

GLUCOTROL XL see glipizide .................. 31

see glipizide xl .............. 32

glycopyrrolate tab 1mg .... 38

glycopyrrolate tab 2mg .... 39

glydo ................................... 51

GLYXAMBI ........................ 32

GOLYTELY ....................... 39

see gavilyte-g ................ 39

see peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ................. 39

granisetron hcl .................. 38

griseofulvin microsize ........ 5

griseofulvin ultramicrosize 5

guanfacine er (adhd) ....... 27

GVOKE PFS ..................... 37

H HAEGARDA ...................... 41

HALDOL

see haloperidol lactate inj 5mg/ml ....................... 25

HALDOL DECANOATE 100

see haloperidol decanoate .................. 25

HALDOL DECANOATE 50

see haloperidol decanoate .................. 25

halobetasol propionate .... 51

haloperidol ......................... 24

haloperidol conc 2mg/ml . 25

haloperidol decanoate ..... 25

haloperidol lactate inj 5mg/ml ........................... 25

HARVONI ............................ 7

HAVRIX ............................. 43

heather ............................... 34

heparin sod (porcine) in d5w ................................. 41

heparin sod inj 1000/ml ... 41

heparin sod inj 10000/ml . 41

heparin sod inj 20000/ml . 41

heparin sod inj 5000/ml ... 41

HEPARIN SODIUM/NACL 0.45% ............................. 41

hepatamine ........................ 45

HEPSERA

see adefovir dipivoxil ...... 7

HERCEPTIN ...................... 10

HERCEPTIN HYLECTA .. 10

HETLIOZ ............................ 28

HIBERIX ............................. 43

HIPREX

see methenamine hippurate ...................... 4

HUMIRA ............................. 42

HUMIRA INJ 10MG/0.2ML ......................................... 42

HUMIRA KIT 20MG/0.4ML ......................................... 42

HUMIRA KIT 40MG/0.8ML ......................................... 42

HUMIRA PEDIATRIC CROHNS DISEASE ..... 42

HUMIRA PEN .................... 42

HUMIRA PEN CD/UC/HS STARTER ...................... 42

HUMIRA PEN INJ CD/UC/HS STARTER .. 42

HUMIRA PEN INJ PS/UV STARTER ...................... 42

HUMIRA PEN-PS/UV STARTER ...................... 42

HUMULIN R INJ U-500 ... 31

HUMULIN R U-500 KWIKPEN ...................... 31

hydralazine hcl .................. 18

HYDREA

see hydroxyurea ........... 13

hydrochlorothiazide .......... 17

hydroco/apap tab 10-325mg .............................. 2

hydroco/apap tab 5-325mg ........................................... 2

hydroco/apap tab 7.5-325 . 2

hydrocodone-acetaminophen 7.5-325 mg/15ml ........................... 2

hydrocodone-ibuprofen tab 7.5-200 mg ...................... 2

hydrocortisone .................. 36


65

hydrocortisone (enema) ... 39

hydrocortisone (topical) cream 1% ....................... 51

hydrocortisone (topical) cream 2.5% ................... 51

hydrocortisone (topical) lotion 2.5% ..................... 51

hydrocortisone (topical) oint 2.5% ................................ 51

hydrocortisone butyrate cream 0.1% ................... 51

hydrocortisone butyrate oint 0.1% ................................ 51

hydromorphone hcl ............. 2

hydroxychloroquine sulfate ......................................... 42

hydroxyurea ....................... 13

hydroxyzine hcl ................. 47

hydroxyzine hcl inj ............ 47

hydroxyzine pamoate ....... 47

HYSINGLA ER .................... 2

HYZAAR

see losartan-hydrochlorothiazide .. 14

I ibandronate sodium tabs . 33

IBRANCE ........................... 10

ibu tab 600mg ..................... 1

ibu tab 800mg ..................... 1

ibuprofen .............................. 1

icatibant acetate ................ 41

ICLUSIG ............................. 12

IDHIFA ................................ 10

ILEVRO .............................. 46

imatinib mesylate .............. 12

IMBRUVICA ....................... 12

imipenem-cilastatin ............. 4

imipramine hcl ................... 23

imiquimod ........................... 52

IMITREX

see sumatriptan ............ 28

see sumatriptan inj 6mg/0.5ml .................. 29

see sumatriptan succinate .................... 29

IMITREX STATDOSE REFILL



IMITREX STATDOSE SYSTEM



IMOVAX RABIES (H.D.C.V.) ...................... 43

IMURAN

see azathioprine ........... 43

incassia .............................. 34

INCRELEX ........................ 37

INCRUSE ELLIPTA ......... 47

indapamide ........................ 17

INDERAL LA

see propranolol cap er 16

INFANRIX .......................... 43

INLYTA .............................. 12

INREBIC ............................ 12

INSPRA

see eplerenone ............. 14

INSULIN PEN NEEDLE .. 31

INSULIN SAFETY NEEDLES ...................... 31

INSULIN SYRINGE ......... 31

INTELENCE ........................ 6

INTRALIPID 30% ............. 45

INTRALIPID INJ 20% ...... 45

INTRON-A INJ 10MU ...... 43




introvale ............................. 34

INTUNIV

see guanfacine er (adhd) .................................... 27

INVANZ

see ertapenem sodium .. 4

INVEGA

see paliperidone ........... 25

INVEGA SUST INJ 117 MG/0.75 ML .................. 25

INVEGA SUST INJ 156MG/ML .................... 25

INVEGA SUST INJ 234 MG/1.5 ML ..................... 25

INVEGA SUST INJ 39 MG/0.25 ML ................... 25

INVEGA SUST INJ 78 MG/0.5 ML ..................... 25

INVEGA TRINZA .............. 25

INVIRASE ............................ 6

IPOL INACTIVATED IPV. 44

ipratropium bromide ......... 47

ipratropium bromide (nasal) ......................................... 47

ipratropium-albuterol nebu ......................................... 47

irbesartan ........................... 14

irbesartan-hydrochlorothiazide ...... 14

IRESSA .............................. 12

irinotecan hcl ..................... 13

ISENTRESS ........................ 6

ISENTRESS HD ................. 6

isibloom .............................. 34

ISOLYTE P ........................ 45

ISOLYTE S ........................ 45

isoniazid ............................... 7

isoniazid syp 50mg/5ml ..... 7

ISOPTO CARPINE

see pilocarpine hcl ........ 47

ISORDIL TITRADOSE

see isosorbide dinitrate 18

isosorb mononitrate tab ... 18

isosorbide dinitrate ........... 18

isosorbide mononitrate er 18

isotretinoin ......................... 49

isradipine ............................ 16

ISTALOL

see timolol maleate ophth soln 0.5% (once-daily) ........................... 47

itraconazole ......................... 5

ivermectin ............................ 4

IXIARO ............................... 44

J JADENU ............................. 33

see deferasirox ............. 33

JADENU SPRINKLE ........ 33

JAKAFI ............................... 12

JALYN


66

see dutasteride-tamsulosin hcl ........... 40

jantoven .............................. 41

JANUMET .......................... 32

JANUMET XR TAB 100-1000 ................................ 32

JANUMET XR TAB 50-1000 ................................ 32

JANUMET XR TAB 50-500MG ............................ 32

JANUVIA ............................ 32

JARDIANCE ...................... 32

jasmiel ................................ 34

JENTADUETO .................. 32

JENTADUETO TAB XR 2.5-1000 MG ................. 32

JENTADUETO TAB XR 5-1000 MG ........................ 32

jinteli .................................... 36

jolessa tab 0.15-0.03 mg . 34

jolivette ............................... 34

juleber ................................. 34

JULUCA ............................... 7

junel 1.5/30 ........................ 34

junel 1/20 ........................... 34

junel fe 1.5/30 .................... 34

junel fe 1/20 ....................... 34

JUXTAPID.......................... 15

K KADCYLA .......................... 10

KALETRA

see lopinavir-ritonavir ..... 7

KALETRA TAB 100-25MG 7

KALETRA TAB 200-50MG 7

KALYDECO ....................... 48

KANJINTI ........................... 10

kariva .................................. 34

kcl 0.075%/d5w/nacl 0.45% ......................................... 45

KCL 0.15%/D5W/NACL 0.225% ........................... 45

kcl 0.15%/d5w/nacl 0.9% 45

kcl 0.3%/d5w/nacl 0.45% 45

KCL 0.3%/D5W/NACL 0.9% ................................ 45

kcl/d5w inj 0.3% ................ 45

kcl/d5w/nacl inj .15/.45% . 45

kcl/d5w/nacl inj 0.22%/0.45% ................ 45

kcl/nacl inj 0.15%-0.9% ... 45

kcl/nacl inj 0.3-0.9 ............ 45

kcl0.15%/d5w/nacl0.2% .. 45

KEFLEX

see cephalexin ................ 8

kelnor 1/35 ........................ 34

kelnor 1/50 ........................ 34

KEPPRA

see levetiracetam ......... 20

see levetiracetam oral soln 100 mg/ml ......... 20

see roweepra ................ 21

KEPPRA XR

see levetiracetam ......... 20

see roweepra xr ............ 21

ketoconazole ....................... 5

ketoconazole cream ........ 50

ketoconazole shampoo ... 50

ketorolac tromethamine (ophth) ............................ 46

KEYTRUDA ...................... 10

KINRIX ............................... 44

kionex sus 15gm/60ml .... 33

KISQALI ............................. 10

KISQALI FEMARA 200 DOSE ............................. 10



KITABIS PAK

see tobramycin ............... 4

KLARON

see sulfacetamide sodium (acne) ........... 49

KLONOPIN

see clonazepam ........... 19

klor-con 10 ........................ 44

klor-con 8 ........................... 44

klor-con m10 ..................... 44

klor-con m15 ..................... 44

klor-con m20 ..................... 44

klor-con pak 20meq ......... 44

klor-con spr cap 10meq .. 44

klor-con spr cap 8meq ..... 44

KORLYM ........................... 37

K-TAB

see potassium chloride 44

kurvelo ................................ 34

KUVAN ............................... 36

L labetalol hcl ........................ 16

lactated ringer's ................. 45

lactulose ............................. 39

lactulose (encephalopathy) ......................................... 39

LAMICTAL

see lamotrigine .............. 20

see subvenite tab ......... 21

LAMICTAL CHEWABLE DISPERS


LAMICTAL XR


LAMISIL

see terbinafine hcl .......... 5

lamivudine ............................ 6

lamivudine (hbv) ................. 7

lamivudine-zidovudine ....... 7

lamotrigine ......................... 20

LANOXIN

see digitek ...................... 17

see digox ........................ 17

see digoxin .................... 17

see digoxin inj ............... 17

lansoprazole ...................... 40

larin 1.5/30 ......................... 34

larin 1/20 ............................ 34

larin fe 1.5/30 .................... 34

larin fe 1/20 ........................ 34

larissia tab .......................... 34

LASIX

see furosemide ............. 17

LASTACAFT ...................... 46

latanoprost ......................... 47

LATUDA ............................. 25

leena tab ............................ 34

leflunomide ........................ 42

LENVIMA 10 MG DAILY DOSE ............................. 12

LENVIMA 12MG DAILY DOSE ............................. 12

LENVIMA 14 MG DAILY DOSE ............................. 12


67

LENVIMA 18 MG DAILY DOSE.............................. 12





lessina ................................ 34

LETAIRIS

see ambrisentan ........... 18

letrozole .............................. 11

leucovorin calcium ............ 13

LEUKERAN ....................... 10

leuprolide inj 1mg/0.2 ....... 11

levalbuterol hcl .................. 48

levalbuterol hcl soln nebu conc 1.25 mg/0.5ml ...... 48

levalbuterol tartrate hfa .... 48

LEVAQUIN

see levofloxacin .............. 9

LEVEMIR ........................... 31

LEVEMIR FLEXTOUCH .. 31

levetiracetam ..................... 20

LEVETIRACETAM

see levetiracetam in sodium chloride ......... 20

levetiracetam in sodium chloride ........................... 20

levetiracetam oral soln 100 mg/ml .............................. 20

levobunolol hcl .................. 47

levocarnitine (metabolic modifiers) ....................... 36

levocetirizine dihydrochloride .............. 48

levofloxacin .......................... 9

levofloxacin in d5w ............. 9

levofloxacin inj 25mg/ml .... 9

levofloxacin oral soln 25 mg/ml ................................ 9

levonest .............................. 34

levonor/ethi tab ................. 34

levonorgestrel & eth estradiol .......................... 34

levonorgestrel-ethinyl estradiol (91-day) ......... 34

levora 0.15/30-28 ............. 34

levo-t .................................. 38

levothyroxine sodium ....... 38

levoxyl ................................ 38

LEXAPRO

see escitalopram oxalate .................................... 22

LEXIVA ................................ 6

see fosamprenavir tab 700 mg ......................... 6

LIALDA

see mesalamine ........... 39

lidocaine ............................ 51

lidocaine hcl ...................... 51

lidocaine hcl (local anesth.) .......................................... 3

lidocaine hcl (mouth-throat) ........................................ 52

lidocaine inj 0.5% ............... 3

lidocaine inj 1% .................. 3

lidocaine inj 1.5% preservative free (pf) ..... 4

lidocaine oint 5% .............. 52

lidocaine-prilocaine .......... 52

LIDODERM

see lidocaine ................. 51

linezolid in sodium chloride .......................................... 4

linezolid inj ........................... 4

linezolid susp ...................... 4

linezolid tab 600mg ............ 4

LINZESS ............................ 39

liothyronine sodium .......... 38

LIPITOR

see atorvastatin calcium .................................... 15

lisinopril .............................. 14

lisinopril & hydrochlorothiazide ...... 13

lithium carbonate .............. 29

lithium carbonate er ......... 29

LITHIUM SOLN 8MEQ/5ML ........................................ 29

LITHOBID

see lithium carbonate er .................................... 29

LOCOID

see hydrocortisone butyrate cream 0.1% 51

LODINE

see etodolac .................... 1

LOESTRIN 1.5/30-21

see junel 1.5/30 ............ 34

see larin 1.5/30 ............. 34

see microgestin 1.5/30 34

LOESTRIN 1/20-21

see junel 1/20 ................ 34

see larin 1/20 ................. 34

see microgestin 1/20 .... 34

see norethindrone acet & eth estra ..................... 35

LOESTRIN FE 1.5/30

see blisovi fe 1.5/30 ..... 33

see junel fe 1.5/30 ........ 34

see larin fe 1.5/30 ......... 34

see microgestin fe 1.5/30 ..................................... 35

LOESTRIN FE 1/20

see junel fe 1/20 ........... 34

see larin fe 1/20 ............ 34

see microgestin fe 1/20 35

see tarina fe 1/20 .......... 35

LOKELMA .......................... 33

LOMOTIL

see diphenoxylate w/ atropine ...................... 39

LONSURF .......................... 13

loperamide hcl ................... 39

LOPID

see gemfibrozil .............. 15

lopinavir-ritonavir ................ 7

LOPRESSOR

see metoprolol tartrate . 16

LOPRESSOR HCT

see metoprolol & hydrochlorothiazide .. 16

LOPROX

see ciclopirox ................ 50

lorazepam .......................... 19

lorazepam intensol ........... 19

LORBRENA ....................... 12

lorcet hd tab 10-325mg ...... 2

lorcet plus tab 7.5-325 ....... 2

lorcet tab 5-325mg ............. 3


68

loryna .................................. 34

losartan potassium ........... 14

losartan-hydrochlorothiazide ...... 14

LOTEMAX .......................... 46

see loteprednol etabonate ................... 46

LOTENSIN

see benazepril hcl ......... 14

LOTENSIN HCT

see benazepril & hydrochlorothiazide .. 13

loteprednol etabonate ...... 46

LOTREL

see amlodipine besylate-benazepril hcl cap 10-20 mg .......................... 13

see amlodipine besylate-benazepril hcl cap 10-40 mg .......................... 13

see amlodipine besylate-benazepril hcl cap 5-10 mg ............................... 13

see amlodipine besylate-benazepril hcl cap 5-20 mg ............................... 13

LOTRONEX

see alosetron hcl ........... 39

lovastatin ............................ 15

LOVENOX

see enoxaparin sodium 41

low-ogestrel ....................... 34

loxapine succinate ............ 25

LUMIGAN ........................... 47

LUMIZYME ........................ 36

LUPRON DEPOT (1-MONTH) ......................... 11

LUPRON DEPOT INJ 11.25MG (3-MONTH) .. 11

LUPRON DEPOT-PED (1-MONTH .......................... 37

LUPRON DEPOT-PED (3-MONTH .......................... 37

LUPRON DEP-PED INJ 11.25MG (3-MONTH) .. 37

LUPRON DEP-PED INJ 7.5MG ............................. 37

lutera ................................... 34

LYNPARZA ....................... 11

LYRICA

see pregabalin .............. 21

LYRICA CR ....................... 29

LYSODREN ...................... 11

LYSTEDA

see tranexamic acid ..... 42

lyza ..................................... 34

M MACROBID

see nitrofurantoin monohyd macro .......... 4

MACRODANTIN

see nitrofurantoin macrocrystal ................ 4

magnesium sulfate ........... 44

MAGNESIUM SULFATE 44

see magnesium sulfate 44

MAGNESIUM SULFATE IN D5W ............................... 44

see magnesium sulfate in dextrose ..................... 44

magnesium sulfate in dextrose ......................... 44

magnesium sulfate inj 50% ........................................ 44

MALARONE

see atovaquone-proguanil hcl ................ 5

malathion ........................... 52

maprotiline hcl .................. 23

MARINOL

see dronabinol .............. 38

marlissa ............................. 34

MARPLAN TAB 10MG .... 23

MATULANE ...................... 13

MAVIK

see trandolapril ............. 14

MAVYRET ........................... 7

MAXALT

see rizatriptan benzoate .................................... 28

MAXALT-MLT

see rizatriptan benzoate odt ............................... 28

MAXITROL

see neomycin-polymy-dexameth ................... 46

MAXZIDE

see triamterene & hydrochlorothiazide tabs ............................. 17

MAXZIDE-25

see triamterene & hydrochlorothiazide tabs ............................. 17

meclizine hcl ...................... 38

MEDROL

see methylpred tab 16mg ..................................... 36




MEDROL DOSEPAK

see methylpred pak 4mg ..................................... 36

medroxyprogesterone acetate (contraceptive) 34

medroxyprogesterone acetate tab ..................... 38

mefloquine hcl ..................... 5

megestrol ac sus 40mg/ml ......................................... 11

megestrol ac tab 20mg .... 11

megestrol ac tab 40mg .... 11

megestrol sus 625mg/5ml ......................................... 11

MEKINIST .......................... 12

MEKTOVI ........................... 12

meloxicam ............................ 1

memantine hcl cp24 ......... 22

memantine soln ................ 22

memantine tabs ................ 22

MENACTRA ...................... 44

MENVEO ........................... 44

MEPRON

see atovaquone .............. 4

mercaptopurine ................. 10

meropenem ......................... 4

MERREM

see meropenem .............. 4

mesalamine ....................... 39

mesalamine w/ cleanser .. 39


69

MESNEX ............................ 13

MESTINON

see pyridostigmine tab 60mg ........................... 29

metadate er tab 20mg ...... 27

metformin er ...................... 32

metformin hcl ..................... 32

methadone hcl ..................... 3

methadone hcl 10mg ......... 3

methadone hcl 5mg ............ 3

methadone hcl intensol ...... 3

METHADOSE

see methadone hcl intensol ......................... 3

methazolamide .................. 17

methenamine hippurate ..... 4

methimazole ...................... 38

methotrexate sodium inj soln.................................. 10

methotrexate sodium inj solr .................................. 10

methotrexate sodium tabs ......................................... 42

METHYLIN

see methylphenidate hcl oral soln ...................... 27

methylphenidate hcl ......... 27

methylphenidate hcl oral soln.................................. 27

methylphenidate hcl tbcr 10 mg ................................... 27

methylphenidate hcl tbcr 20mg ............................... 27

methylpr ss inj ................... 36

methylpred pak 4mg ......... 36

methylpred tab 16mg ....... 36

methylpred tab 32mg ....... 36

methylpred tab 4mg ......... 36

methylpred tab 8mg ......... 36

methylprednisolone acetate ......................................... 36

metoclopramide hcl .......... 38

metoclopramide hcl inj ..... 38

metolazone ........................ 17

metoprolol & hydrochlorothiazide ...... 16

metoprolol succinate ........ 16

metoprolol tartrate ............ 16

METROCREAM

see metronidazole (topical) ...................... 52

see rosadan cre 0.75% 52

METROLOTION see metronidazole

(topical) ...................... 52

metronidazole ..................... 4

metronidazole (topical) .... 52

metronidazole gel 0.75% 52

metronidazole in nacl ........ 4

metronidazole vaginal ..... 41

MIACALCIN

see calcitonin (salmon) 37

MICARDIS

see telmisartan ............. 14

microgestin 1.5/30 ............ 34

microgestin 1/20 ............... 34

microgestin fe 1.5/30 ....... 35

microgestin fe 1/20 .......... 35

midodrine hcl .................... 18

miglustat ............................ 36

MIGRANAL

see dihydroergotamine mesylate nasal spr 4 mg/ml ......................... 28

mili ...................................... 35

MINIPRESS

see prazosin hcl ........... 14

minitran .............................. 18

MINOCIN

see minocycline hcl ...... 10

minocycline hcl ................. 10

minoxidil ............................. 18

MIRAPEX

see pramipexole tab 0.125mg ..................... 24

see pramipexole tab 0.5mg ......................... 24

see pramipexole tab 0.75mg ....................... 24

see pramipexole tab 1mg .................................... 24

MIRCETTE

see bekyree .................. 33

see desogestrel-ethinyl estradiol (biphasic) ... 34

see kariva ...................... 34

see pimtrea .................... 35

see viorele ..................... 35

mirtazapine ........................ 23

misoprostol ........................ 39

MITIGARE ........................... 1

M-M-R II ............................. 44

M-NATAL PLUS ................ 45

MOBIC

see meloxicam ................ 1

moexipril hcl ...................... 14

molindone hcl .................... 25

mometasone furoate ........ 51

mondoxyne nl cap 100mg ......................................... 10

mono-linyah tab 0.25-35 .. 35

montelukast sodium ......... 48

morphine ext-rel tab ........... 3

morphine sul inj 1mg/ml .... 3

morphine sulfate ................. 3

MORPHINE SULFATE ...... 3

see morphine sulfate ...... 3

morphine sulfate oral soln 100mg/5ml ....................... 3

morphine sulfate oral soln 10mg/5ml ......................... 3

morphine sulfate oral soln 20mg/5ml ......................... 3

MOVANTIK .................. 39, 40

MOXEZA ............................ 46

see moxifloxacin hcl (ophth) ........................ 46

moxifloxacin hcl (ophth) ... 46

MS CONTIN

see morphine ext-rel tab 3

MULTAQ ............................ 15

mupirocin ........................... 50

MVASI ................................ 11

MYAMBUTOL

see ethambutol hcl ......... 7

MYCAMINE ......................... 5

MYCOBUTIN

see rifabutin ..................... 7

mycophenolate mofetil ..... 43

mycophenolate sodium tbec ................................. 43

MYFORTIC

see mycophenolate sodium tbec ............... 43


70

myorisan ............................. 49

MYRBETRIQ ..................... 40

MYSOLINE

see primidone ................ 21

N nabumetone ......................... 1

nadolol ................................ 16

nafcillin sodium for inj ......... 9

NAFCILLIN SODIUM FOR INJ 10GM ......................... 9

NAGLAZYME .................... 36

nalbuphine hcl ..................... 1

naloxone inj 0.4mg/ml ...... 30

naloxone inj 1mg/ml ......... 30

naltrexone hcl .................... 30

NAMENDA

see memantine tabs ..... 22

NAMENDA XR

see memantine hcl cp24 ..................................... 22

NAMZARIC ........................ 22

NAPROSYN

see naproxen ................... 1

naproxen .............................. 1

naproxen dr ......................... 1

naproxen sodium ................ 1

naratriptan hcl ................... 28

NARCAN ............................ 30

NARDIL

see phenelzine sulfate . 23

NATACYN .......................... 46

nateglinide ......................... 32

NATPARA .......................... 37

NAYZILAM ......................... 20

NEBUPENT

see pentamidine isethionate inh ............. 4

necon 0.5/35-28 ................ 35

nefazodone hcl .................. 23

neomycin sulfate ................. 4

neomycin-bacitracin zn-polymyxin ....................... 46

neomycin-polymy-dexameth ....................... 46

neomycin-polymyxin-gramicidin ....................... 46

neomycin-polymyxin-hc (ophth) ............................ 46

neomycin-polymyxin-hc (otic) ............................... 53

NEORAL

see cyclosporine modified (for microemulsion) ......... 43

see gengraf ................... 43

NEPHRAMINE .................. 45

NERLYNX ......................... 12

NEUPRO ........................... 24

NEURONTIN

see gabapentin ............. 20

nevirapine susp 50 mg/5ml .......................................... 6

nevirapine tab 100mg er ... 6

nevirapine tab 200mg ........ 6

nevirapine tab 400mg er ... 6

NEXAVAR ......................... 12

NEXIUM

see esomeprazole magnesium ................ 40

niacin (antihyperlipidemic) ........................................ 15

niacin er (antihyperlipidemic) ...... 15

niacor ................................. 15

NIASPAN

see niacin er (antihyperlipidemic) .. 15

nicardipine hcl ................... 16

NICOTROL INHALER ..... 30

NICOTROL NS ................. 30

nifedipine ........................... 16

nifedipine er ...................... 16

nikki .................................... 35

NILANDRON

see nilutamide .............. 11

nilutamide .......................... 11

nimodipine ......................... 16

NINLARO .......................... 11

nitisinone ........................... 36

NITRO-BID ........................ 18

NITRO-DUR

see minitran .................. 18

see nitroglycerin td patch .................................... 18

NITRO-DUR DIS 0.3MG/HR ..................... 18

NITRO-DUR DIS 0.8MG/HR ...................... 18

nitrofurantoin macrocrystal 4

nitrofurantoin monohyd macro ................................ 4

nitroglycerin ....................... 18

nitroglycerin td patch ........ 18

NITROSTAT

see nitroglycerin ............ 18

NITYR ................................. 36

nizatidine ............................ 39

nora-be tab 0.35mg .......... 35

NORCO see hydroco/apap tab 10-

325mg .......................... 2

see hydroco/apap tab 5-325mg .......................... 2

see hydroco/apap tab 7.5-325 ......................... 2

see lorcet hd tab 10-325mg .......................... 2

see lorcet plus tab 7.5-325 ................................ 2

see lorcet tab 5-325mg .. 3

norethindrone (contraceptive) .............. 35

norethindrone acet & eth estra ................................ 35

norethindrone acetate ...... 38

norethindrone acetate-ethinyl estradiol ............. 36

norgest/ethi tab 0.25/35 ... 35

norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ................................. 35

norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg ................................. 35

NORMOSOL-M IN D5W .. 45

NORMOSOL-R ................. 45

NORMOSOL-R IN D5W .. 45

NORPACE

see disopyramide phosphate .................. 14

NORPACE CR .................. 15

NORPRAMIN


71

see desipramine hcl ..... 22

NORTHERA ...................... 18

nortrel 0.5/35 (28) ............. 35

nortrel 1/35 ......................... 35

nortrel 7/7/7 ....................... 35

nortriptyline hcl .................. 23

NORVASC

see amlodipine besylate ..................................... 16

NORVIR

see ritonavir ..................... 6

NORVIR PACK ................... 6

NORVIR SOLN ................... 6

NOVOLIN 70/30 ................ 31

NOVOLIN 70/30 FLEXPEN ......................................... 31

NOVOLIN N ....................... 31

NOVOLIN N FLEXPEN.... 31

NOVOLIN R ....................... 31

NOVOLIN R FLEXPEN.... 31

NOVOLOG ......................... 31

NOVOLOG 70/30 FLEXPEN ....................... 31

NOVOLOG FLEXPEN ..... 31

NOVOLOG MIX 70/30 ..... 31

NOVOLOG PENFILL ....... 31

NOXAFIL .............................. 5

see posaconazole ........... 5

NUBEQA ............................ 11

NUCALA ............................. 48

NUCYNTA ER ..................... 3

NUEDEXTA ....................... 29

NULOJIX ............................ 43

NULYTELY/FLAVOR PACKS ........................... 39

see gavilyte-n/flavor pack ..................................... 39

see peg 3350-potassium chloride-sod bicarbonate-sod chloride ....................... 39

see trilyte ........................ 39

NUPLAZID CAPS ............. 25

NUPLAZID TABS 10MG . 25

NUTRILIPID INJ 20% ...... 45

NUVARING

see eluryng .................... 34

see etonogestrel-ethinyl estradiol ..................... 34

NUVIGIL

see armodafinil ............. 30

nyamyc .............................. 50

NYMALIZE ........................ 16

nystatin ................................ 5

nystatin (mouth-throat) .... 52

nystatin (topical) ............... 50

nystop ................................ 50

O ocella tab 3-0.03mg ......... 35

OCTAGAM ........................ 43

octreotide acetate ............ 37

OCUFLOX

see ofloxacin (ophth) ... 46

ODEFSEY ........................... 7

ODOMZO .......................... 11

OFEV ................................. 48

ofloxacin (ophth) ............... 46

ofloxacin (otic) .................. 53

OGIVRI .............................. 11

olanzapine ......................... 25

olmesartan medoxomil .... 14

olmesartan medoxomil-amlodipine-hydrochlorothiazide ...... 14

olmesartan medoxomil-hydrochlorothiazide ...... 14

olopatadine hcl 0.2% ....... 46

omeprazole cap 10mg ..... 40



ondansetron hcl ................ 38

ondansetron hcl inj ........... 38

ondansetron hcl oral soln 38

ondansetron odt ............... 38

ONFI see clobazam ................ 19

OPSUMIT .......................... 18

ORFADIN .......................... 36

see nitisinone ................ 36

ORKAMBI .......................... 48

orsythia .............................. 35

ORTHO MICRONOR

see errin ......................... 34

see jolivette ................... 34

see lyza .......................... 34

see norethindrone (contraceptive) .......... 35

see sharobel .................. 35

ORTHO TRI-CYCLEN LO

see norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg ................. 35

see tri-lo marzia ............ 35

see tri-lo-estarylla ......... 35

see tri-lo-sprintec .......... 35

see tri-vylibra lo ............. 35

ORTHO-NOVUM 7/7/7

see cyclafem 7/7/7 ....... 33

see dasetta 7/7/7 .......... 34

see nortrel 7/7/7 ............ 35

oseltamivir phosphate .... 7, 8

OSPHENA ......................... 37

oxacillin sodium .................. 9

oxaliplatin inj 100mg ........ 13

oxaliplatin inj 100mg/20ml ......................................... 13

oxaliplatin inj 50mg ........... 13

oxaliplatin inj 50mg/10ml . 13

oxandrolone tab 10mg ..... 30

oxandrolone tab 2.5mg .... 30

oxcarbazepine ................... 20

oxybutynin chloride .......... 40

oxycodone hcl ..................... 3

oxycodone w/ acetaminophen 10-325mg .............................. 3

oxycodone w/ acetaminophen 2.5-325mg .............................. 3

oxycodone w/ acetaminophen 5-325mg ........................................... 3

oxycodone w/ acetaminophen 7.5-325mg .............................. 3

OZEMPIC INJ 0.25 OR 0.5MG/DOSE ................ 31

OZEMPIC INJ 1MG/DOSE ......................................... 31

P pacerone ............................ 15

paclitaxel ............................ 10


72

paliperidone ....................... 25

PAMELOR

see nortriptyline hcl ...... 23

pamidronate disodium ..... 33

PAMIDRONATE DISODIUM ..................... 33

pamidronate inj 30mg ...... 33

pamidronate inj 90mg ...... 33

PANRETIN ......................... 52

pantoprazole sodium ........ 40

pantoprazole sodium tbec ......................................... 40

PANZYGA .......................... 43

paricalcitol .......................... 45

PARLODEL

see bromocriptine mesylate ..................... 23

PARNATE

see tranylcypromine sulfate ......................... 23

paroex sol 0.12% .............. 52

paromomycin sulfate .......... 4

paroxetine hcl tabs ........... 23

PASER D/R ......................... 7

PAXIL ................................. 23

see paroxetine hcl tabs 23

PAZEO ............................... 46

PEDIAPRED

see pred sod pho sol 5mg/5ml...................... 36

PEDIARIX .......................... 44

PEDVAX HIB ..................... 44

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ......................................... 39

peg 3350-potassium chloride-sod bicarbonate-sod chloride ................... 39

PEGANONE ...................... 20

PEGASYS ............................ 8

PEGASYS PROCLICK ...... 8

penicillamine ...................... 33

PENICILLIN G POT IN DEXTROSE 2MU ........... 9

PENICILLIN G POT IN DEXTROSE 3MU ........... 9

PENICILLIN G PROCAINE ........................................... 9

penicillin g sodium .............. 9

penicillin v potassium ........ 9

penicilln gk inj 20mu .......... 9

penicilln gk inj 5mu ............ 9

PENTACEL ....................... 44

PENTAM 300

see pentamidine isethionate inj .............. 5

pentamidine isethionate inh .......................................... 4

pentamidine isethionate inj 5

pentoxifylline ..................... 41

PEPCID

see famotidine .............. 39

PERCOCET

see endocet 10-325mg . 2

see endocet 2.5-325mg 2

see endocet 5-325mg .... 2

see endocet 7.5-325mg 2

see oxycodone w/ acetaminophen 10-325mg .......................... 3

see oxycodone w/ acetaminophen 2.5-325mg .......................... 3

see oxycodone w/ acetaminophen 5-325mg .......................... 3

see oxycodone w/ acetaminophen 7.5-325mg .......................... 3

PERIDEX

see chlorhexidine gluconate (mouth-throat) ......................... 52

see paroex sol 0.12% .. 52

see periogard ................ 53

perindopril erbumine ........ 14

periogard ........................... 53

permethrin cre 5% ............ 52

perphenazine .................... 25

PERSERIS ........................ 25

pfizerpen-g inj 20mu .......... 9

pfizerpen-g inj 5mu ............ 9

phenelzine sulfate ............ 23

PHENERGAN

see promethazine hcl inj .................................... 38

phenobarbital .................... 20

phenobarbital sodium ...... 20

PHENYTEK ....................... 20

see phenytoin sodium extended .................... 20

phenytoin ........................... 20

phenytoin sodium extended ......................................... 20

phenytoin sodium inj 50mg/ml ......................... 21

philith .................................. 35

PHOSLO

see calcium acetate (phosphate binder) ... 37

PHOSPHOLINE IODIDE . 47

PICATO .............................. 52

PIFELTRO ........................... 6

pilocarpine hcl ................... 47

pilocarpine hcl (oral) ......... 53

pimozide ............................. 25

pimtrea ............................... 35

pindolol ............................... 16

pioglitazone hcl ................. 32

piper/tazoba inj 12-1.5gm .. 9


piper/tazoba inj 3-0.375gm9


piper/tazoba inj 4-0.5gm .... 9

PIQRAY 200MG DAILY DOSE ............................. 12



pirmella 1/35 ...................... 35

piroxicam .............................. 1

PLAQUENIL

see hydroxychloroquine sulfate ......................... 42

PLASMA-LYTE A ............. 45

PLASMA-LYTE-148 ......... 45

PLAVIX

see clopidogrel tab 75mg ..................................... 42

plenamine .......................... 45

PLENVU ............................. 39

PNV FOLIC ACID + IRON MUL ................................ 45


73

podofilox ............................. 52

polymyxin b-trimethoprim 46

POLYTRIM

see polymyxin b-trimethoprim ............... 46

POMALYST ....................... 11

portia-28 ............................. 35

posaconazole ...................... 5

pot chloride inj 2meq/ml ... 45

potassium chloride ..... 44, 45

POTASSIUM CHLORIDE 45

potassium chloride in nacl ......................................... 45

potassium chloride microencapsulated crystals er ....................... 44

potassium citrate (alkalinizer) er tabs ....... 40

PRADAXA .......................... 41

PRALUENT........................ 15

pramipexole tab 0.125mg 24

pramipexole tab 0.25mg .. 24

pramipexole tab 0.5mg .... 24

pramipexole tab 0.75mg .. 24

pramipexole tab 1.5mg .... 24

pramipexole tab 1mg ....... 24

prasugrel hcl ...................... 42

PRAVACHOL

see pravastatin sodium 15

pravastatin sodium ........... 15

praziquantel ......................... 5

prazosin hcl ....................... 14

PRECOSE

see acarbose ................. 31

PRED FORTE

see prednisolone acetate (ophth) ........................ 46

pred sod pho sol 5mg/5ml ......................................... 36

prednisolone acetate (ophth) ............................ 46

prednisolone sodium phosphate ...................... 36

PREDNISOLONE SODIUM PHOSPHATE (OPHTH) ......................................... 46

prednisolone sol 15mg/5ml ......................................... 36

prednisolone sol 25mg/5ml ........................................ 36

PREDNISONE CON 5MG/ML ......................... 36

prednisone pak 10mg ...... 36

prednisone pak 5mg ........ 36

prednisone sol 5mg/5ml .. 36

prednisone tab 10mg ....... 37

prednisone tab 1mg ......... 36

prednisone tab 2.5mg ...... 37



prednisone tab 5mg ......... 37

pregabalin .......................... 21

PREMASOL 10% ............. 45

PRENATAL ....................... 45

PRENATAL PLUS ............ 45

PRENATAL PLUS LOW IRON .............................. 45

PREVACID

see lansoprazole .......... 40

prevalite ............................. 15

previfem ............................. 35

PREZCOBIX ....................... 7

PREZISTA ........................... 6

PRIFTIN ............................... 7

primaquine phosphate ....... 5

PRIMAQUINE PHOSPHATE .................. 5

see primaquine phosphate .................... 5

PRIMAXIN IV

see imipenem-cilastatin 4

primidone ........................... 21

PRINIVIL

see lisinopril .................. 14

PRISTIQ

see desvenlafaxine succinate ................... 22

PRIVIGEN ......................... 43

PROAIR HFA

see albuterol sulfate .... 48

probenecid .......................... 1

PROCALAMINE ............... 45

PROCARDIA XL

see nifedipine ................ 16

prochlorperazine inj ......... 38

prochlorperazine maleate 38

prochlorperazine supp ..... 38

PROCRIT ........................... 41

PROCTOCORT

see procto-pak .............. 52

procto-med hc ................... 52

procto-pak .......................... 52

proctosol hc cre 2.5% ...... 52

proctozone-hc ................... 52

PROGLYCEM

see diazoxide ................ 37

PROGLYCEM SUS 50MG/ML ....................... 37

PROGRAF ......................... 43

see tacrolimus ............... 43

PROLASTIN-C .................. 48

PROLENSA ....................... 46

PROLIA .............................. 37

PROMACTA ................ 41, 42

promethazine hcl .............. 38

promethazine hcl inj ......... 38

propafenone hcl ................ 15

propafenone hcl 12hr ....... 15

proparacaine hcl ............... 47

propranolol & hydrochlorothiazide ...... 16

propranolol cap er ............ 16

propranolol hcl .................. 16

propranolol oral sol ........... 16

propylthiouracil .................. 38

PROQUAD ........................ 44

PROSCAR

see finasteride ............... 40

PROSOL ............................ 45

PROTONIX

see pantoprazole sodium ..................................... 40

see pantoprazole sodium tbec ............................. 40

PROTOPIC

see tacrolimus (topical) 52

protriptyline hcl .................. 23

PROVERA

see medroxyprogesterone acetate tab ................. 38

PROZAC

see fluoxetine cap 10mg ..................................... 22


74



PULMICORT

see budesonide (inhalation) ................. 49

PULMICORT FLEXHALER ......................................... 49

PULMOZYME.................... 48

PURIXAN ........................... 10

pyrazinamide ....................... 7

pyridostigmine tab 60mg . 29

Q QUADRACEL .................... 44

QUALAQUIN

see quinine sulfate ......... 5

QUESTRAN

see cholestyramine ...... 15

QUESTRAN LIGHT

see cholestyramine light powd ........................... 15

see prevalite .................. 15

quetiapine fumarate ......... 25

quinapril hcl ....................... 14

quinapril-hydrochlorothiazide ...... 13

quinidine sulfate ................ 15

quinine sulfate ..................... 5

R RABAVERT ....................... 44

raloxifene tab 60mg .......... 37

ramipril ................................ 14

RANEXA ............................ 18

see ranolazine ............... 18

ranolazine .......................... 18

RAPAMUNE

see sirolimus ................. 43

rasagiline mesylate ........... 24

RAYALDEE ....................... 45

RAZADYNE

see galantamine hydrobromide ............ 21

RAZADYNE ER

see galantamine hydrobromide er ........ 22

RECLAST

see zoledronic acid inj 5mg/100ml ................ 33

reclipsen ............................ 35

RECOMBIVAX HB ........... 44

RECTIV .............................. 52

REGLAN

see metoclopramide hcl .................................... 38

REGRANEX ...................... 52

RELENZA DISKHALER .... 8

RELISTOR ........................ 40

RELPAX

see eletriptan hydrobromide ............ 28

REMERON

see mirtazapine ............ 23

REMERON SOLTAB

see mirtazapine ............ 23

REMICADE ....................... 42

RENFLEXIS ...................... 42

RENVELA

see sevelamer carbonate .............................. 37, 38

repaglinide ......................... 32

RESTASIS ........................ 47

RESTASIS MULTIDOSE 47

RESTORIL

see temazepam ............ 28

RETIN-A

see avita ........................ 49

see tretinoin ............ 49, 50

RETROVIR

see zidovudine cap 100mg .......................... 6

see zidovudine syp 50mg/5ml ..................... 6

REVATIO

see sildenafil citrate tab 20 mg (pulmonary hypertension) ............ 18

REVLIMID ......................... 11

REXULTI ..................... 25, 26

REYATAZ ............................ 6

see atazanavir sulfate ... 6

RHOPRESSA ................... 47

ribavirin cap 200mg ........... 8

ribavirin tab 200mg ............ 8

rifabutin ................................ 7

RIFADIN

see rifampin ..................... 7

rifampin ................................ 7

RIFATER .............................. 7

RILUTEK

see riluzole .................... 29

riluzole ................................ 29

rimantadine hydrochloride . 8

RINVOQ ............................. 42

risedronate sodium ........... 33

RISPERDAL

see risperidone ............. 26

RISPERDAL INJ 12.5MG 26

RISPERDAL INJ 25MG ... 26

RISPERDAL INJ 37.5MG 26

RISPERDAL INJ 50MG ... 26

risperidone ......................... 26

RITALIN

see methylphenidate hcl ..................................... 27

ritonavir ................................ 6

RITUXAN ........................... 11

RITUXAN HYCELA .......... 11

rivastigmine tartrate .......... 22

rivastigmine td patch 24hr 13.3 mg/24hr ................. 22

rivastigmine td patch 24hr 4.6 mg/24hr ................... 22

rivastigmine td patch 24hr 9.5 mg/24hr ................... 22

rizatriptan benzoate .......... 28

rizatriptan benzoate odt ... 28

ROCALTROL

see calcitriol ................... 45

see calcitriol oral soln 1 mcg/ml ........................ 45

ropinirole tab 0.25mg ....... 24

ropinirole tab 0.5mg ......... 24

ropinirole tab 1mg ............. 24





rosadan cre 0.75% ........... 52

rosuvastatin calcium ........ 15

ROTARIX ........................... 44

ROTATEQ ......................... 44

ROWASA


75

see mesalamine w/ cleanser ...................... 39

roweepra ............................ 21

roweepra xr ........................ 21

ROXICODONE

see oxycodone hcl .......... 3

ROZLYTREK ..................... 12

RUBRACA ......................... 11

RUXIENCE ........................ 11

RYDAPT ............................. 12

RYTHMOL SR

see propafenone hcl 12hr ..................................... 15

S SABRIL

see vigabatrin powd pack 500mg ......................... 21

see vigabatrin tab 500mg ..................................... 21

see vigadrone ................ 21

SALAGEN

see pilocarpine hcl (oral) ..................................... 53

SANDIMMUNE.................. 43

see cyclosporine ........... 43

SANDOSTATIN

see octreotide acetate . 37

SANTYL ............................. 52

SAPHRIS ........................... 26

scopolamine ...................... 38

SECUADO ......................... 26

selegiline hcl ...................... 24

selenium sulfide ................ 50

SELZENTRY ....................... 6

SENSIPAR

see cinacalcet hcl ......... 37

SEREVENT DISKUS ....... 48

SEROQUEL

see quetiapine fumarate ..................................... 25

SEROQUEL XR

see quetiapine fumarate ..................................... 25

sertraline hcl ...................... 23

setlakin tab ......................... 35

sevelamer carbonate . 37, 38

sharobel ............................. 35

SHINGRIX.......................... 44

SIGNIFOR ......................... 37

sildenafil citrate tab 20 mg (pulmonary hypertension) ........................................ 18

SILENOR

see doxepin hcl (sleep) 28

SILVADENE

see silver sulfadiazine . 50

see ssd .......................... 50

silver sulfadiazine ............. 50

SIMBRINZA ...................... 47

simvastatin ........................ 15

SINEMET

see carbidopa-levodopa .................................... 23

SINGULAIR

see montelukast sodium .................................... 48

sirolimus ............................ 43

SIRTURO ............................ 7

SIVEXTRO .......................... 5

SKYRIZI ............................. 42

sodium chlor sol 0.9% irr 52

sodium chloride .......... 44, 45

sodium chloride 0.45% .... 45

sodium chloride inj 0.9% . 45

sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln ... 44

sodium phenylbutyrate .... 36

sodium polystyrene sulfonate powder .......... 33

sodium polystyrene sulfonate susp .............. 33

solifenacin succinate ....... 40

SOLIQUA 100/33 ............. 31

SOLTAMOX ...................... 11

SOLU-CORTEF ................ 37

SOLU-MEDROL

see methylpr ss inj ....... 36

SOMATULINE DEPOT ... 37

SOMAVERT ...................... 37

SORIATANE

see acitretin ................... 50

sorine ................................. 15

sotalol hcl .......................... 15

sotalol hcl (afib/afl) ........... 15

spironolactone .................. 14

spironolactone & hydrochlorothiazide ...... 17

SPORANOX

see itraconazole .............. 5

sprintec 28 ......................... 35

SPRITAM ........................... 21

SPRYCEL .......................... 12

sps susp 15gm/60ml ........ 33

sronyx ................................. 35

ssd ...................................... 50

STALEVO 100

see carbidopa/levodopa/entacapone .................... 24

STALEVO 150

see carbidopa/levodopa/entacapone .................... 24

STARLIX

see nateglinide .............. 32

stavudine .............................. 6

STELARA .......................... 42

STIMATE ........................... 38

STIVARGA ........................ 12

STRATTERA

see atomoxetine hcl ..... 27

streptomycin sulfate ........... 4

STRIBILD ............................. 7

STROMECTOL

see ivermectin ................. 4

SUBOXONE

see buprenorphine hcl-naloxone hcl dihydrate 12-3mg ....................... 30

see buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg ...................... 30

see buprenorphine hcl-naloxone hcl dihydrate 4-1mg ......................... 30

see buprenorphine hcl-naloxone hcl dihydrate 8-2mg ......................... 30

subvenite tab ..................... 21

sucralfate ........................... 40

sulfacetamide sodium (acne) ............................. 49


76

sulfacetamide sodium (ophth) ............................ 46

sulfacetamide sod-prednisolone .................. 46

SULFADIAZINE .................. 4

sulfamethoxazole-trimethop ds ....................................... 5

sulfamethoxazole-trimethoprim inj ............... 5

sulfamethoxazole-trimethoprim susp ........... 5

sulfamethoxazole-trimethoprim tab 400-80mg ................................. 5

SULFAMYLON .................. 50

sulfasalazine ...................... 39

sulfasalazine ec ................ 39

sulindac ................................ 1

sumatriptan ........................ 28

sumatriptan inj 4mg/0.5ml ......................................... 28

sumatriptan inj 6mg/0.5ml ................................... 28, 29

sumatriptan succinate ...... 29

SUPRAX

see cefixime ..................... 8

SUPREP BOWEL PREP KIT ................................... 39

SUSTIVA

see efavirenz ................... 6

SUTENT ............................. 12

syeda .................................. 35

SYLATRON ....................... 13

SYMBICORT ..................... 49

SYMDEKO ......................... 48

SYMFI ................................... 7

SYMFI LO ............................ 7

SYMJEPI ............................ 48

SYMLINPEN 120 .............. 31

SYMLINPEN 60 ................ 31

SYMPAZAN ....................... 21

SYMTUZA ............................ 7

SYNALAR

see fluocinolone acetonide ................... 51

SYNAREL .......................... 35

SYNERCID .......................... 5

SYNJARDY TAB 12.5-1000MG ......................... 32

SYNJARDY TAB 12.5-500MG ........................... 32

SYNJARDY TAB 5-1000MG ......................... 32

SYNJARDY TAB 5-500MG ........................................ 32

SYNJARDY XR TAB 10-1000MG ......................... 32

SYNJARDY XR TAB 12.5-1000MG ......................... 32



SYNRIBO .......................... 13

SYNTHROID ..................... 38

see euthyrox ................. 38

see levo-t ....................... 38

see levothyroxine sodium .................................... 38

see levoxyl .................... 38

see unithroid ................. 38

SYPRINE

see clovique .................. 33

see trientine hcl ............ 33

T TABLOID ........................... 10

tacrolimus .......................... 43

tacrolimus (topical) ........... 52

tadalafil (pulmonary hypertension) ................ 18

TAFINLAR ......................... 12

TAGRISSO ........................ 12

TALZENNA ....................... 11

TAMIFLU

see oseltamivir phosphate ................ 7, 8

tamoxifen citrate ............... 11

tamsulosin hcl ................... 40

TAPAZOLE

see methimazole .......... 38

TARCEVA

see erlotinib hcl ............ 12

TARGRETIN ..................... 52

see bexarotene ............. 13

tarina fe 1/20 ..................... 35

TASIGNA ........................... 12

TAXOTERE ....................... 10

see docetaxel ................ 10

tazarotene .......................... 50

tazicef ................................... 8

TAZORAC .......................... 50

see tazarotene .............. 50

taztia xt ............................... 16

TAZVERIK ......................... 13

TDVAX ............................... 44

TECENTRIQ ...................... 11

TEFLARO ............................ 8

TEGRETOL


see epitol ........................ 19

TEGRETOL-XR


TEKTURNA

see aliskiren fumarate .. 17

telmisartan ......................... 14

temazepam ........................ 28

TEMIXYS ............................. 7

TENIVAC ........................... 44

tenofovir disoproxil fumarate ........................... 6

TENORETIC 100

see atenolol & chlorthalidone ............ 16

TENORETIC 50

see atenolol & chlorthalidone ............ 16

TENORMIN

see atenolol ................... 16

terazosin hcl ...................... 14

terbinafine hcl ...................... 5

terbutaline sulfate ............. 48

terconazole vaginal .......... 41

testosterone ....................... 30

testosterone cypionate .... 30

testosterone enanthate .... 30

tetrabenazine .................... 29

tetracycline hcl .................. 10

TEXACORT SOLN 2.5% . 51

THALOMID ........................ 11

THEO-24 ............................ 48

theophylline ....................... 48

theophylline tab er 12hr 300 mg ........................... 49


77

theophylline tab er 12hr 450 mg ........................... 49

theophylline tab sr 24hr ... 49

thioridazine hcl .................. 26

thiothixene ......................... 26

tiadylt er .............................. 17

tiagabine hcl ...................... 21

TIAZAC

see diltiazem hcl extended release beads cap sr .............. 16

see taztia xt ................... 16

see tiadylt er .................. 17

TIBSOVO ........................... 11

tigecycline ............................ 5

TIKOSYN

see dofetilide ................. 14

tilia fe .................................. 35

timolol maleate .................. 16

timolol maleate (ophth) soln ......................................... 47

timolol maleate gel ........... 47

timolol maleate ophth soln 0.5% (once-daily) .......... 47

TIMOPTIC

see timolol maleate (ophth) soln ................ 47

TIMOPTIC-XE

see timolol maleate gel 47

TIVICAY ............................... 6

tizanidine hcl ................ 29, 30

TOBRADEX ....................... 46

see tobramycin-dexamethasone ........ 46

TOBRADEX ST ................. 46

tobramycin ........................... 4

tobramycin (ophth) ........... 46

tobramycin inj 1.2 gm/30ml ........................................... 4

tobramycin inj 1.2gm .......... 4

tobramycin inj 10mg/ml ...... 4

tobramycin inj 80mg/2ml ... 4

tobramycin sulfate .............. 4

tobramycin-dexamethasone ......................................... 46

TOBREX

see tobramycin (ophth) 46

tolterodine tartrate ............ 40

TOPAMAX

see topiramate .............. 21

TOPAMAX SPRINKLE

see topiramate .............. 21

topiramate ......................... 21

toposar ............................... 13

TOPROL XL

see metoprolol succinate .................................... 16

toremifene citrate ............. 11

torsemide tabs .................. 17

TOVIAZ .............................. 41

TPN ELECTROLYTES .... 44

TRACLEER

see bosentan ................ 18

TRADJENTA ..................... 32

tramadol hcl tab 50 mg ...... 1

tramadol-acetaminophen .. 2

trandolapril ........................ 14

tranexamic acid ................ 42

TRANSDERM SCOP

see scopolamine .......... 38

tranylcypromine sulfate ... 23

TRAVASOL ....................... 45

TRAVATAN Z

see travoprost ............... 47

travoprost .......................... 47

TRAZIMERA ..................... 11

trazodone hcl .................... 23

TRECATOR ........................ 7

TRELEGY ELLIPTA ........ 47

TRELSTAR DEP INJ 3.75MG .......................... 11

TRELSTAR LA INJ 11.25MG ........................ 11

treprostinil .......................... 18

TRESIBA FLEXTOUCH .. 31

TRESIBA INJ .................... 31

tretinoin ........................ 49, 50

tretinoin (chemotherapy) . 13

triamcinolone acetonide (mouth) .......................... 53

triamcinolone acetonide (topical) .......................... 51

triamterene & hydrochlorothiazide cap 37.5-25 mg .................... 17

triamterene & hydrochlorothiazide tabs ......................................... 17

TRIBENZOR

see olmesartan medoxomil-amlodipine-hydrochlorothiazide .. 14

TRICARE ........................... 45

TRICOR

see fenofibrate .............. 15

trientine hcl ........................ 33

tri-estarylla ......................... 35

trifluoperazine hcl ............. 26

trifluridine ........................... 46

trihexyphenidyl hcl ............ 24

TRIKAFTA ......................... 49

tri-legest fe ......................... 35

TRILEPTAL

see oxcarbazepine ....... 20

tri-linyah .............................. 35

tri-lo marzia ........................ 35

tri-lo-estarylla ..................... 35

tri-lo-sprintec ...................... 35

trilyte ................................... 39

trimethoprim ........................ 5

tri-mili .................................. 35

trimipramine maleate ....... 23

TRINTELLIX ...................... 23

tri-previfem ......................... 35

tri-sprintec .......................... 35

TRIUMEQ ............................ 7

trivora-28 ............................ 35

tri-vylibra ............................ 35

tri-vylibra lo ........................ 35

TRIZIVIR

see abacavir sulfate-lamivudine-zidovudine ....................................... 7

TROGARZO ........................ 6

TROPHAMINE INJ 10% .. 45

trospium chloride .............. 41

TRULICITY ........................ 31

TRUMENBA ...................... 44

TRUSOPT

see dorzolamide hcl ..... 47

TRUVADA TAB 100-150 ... 7




78


TRUXIMA ........................... 11

tulana .................................. 35

TURALIO............................ 12

TWINRIX INJ ..................... 44

TYBOST ............................... 6

TYGACIL

see tigecycline ................. 5

TYKERB ............................. 12

TYLENOL/CODEINE #3

see acetaminophen w/ codeine 300-30mg ...... 1

TYMLOS ............................ 37

TYPHIM VI ......................... 44

U ULTRACET

see tramadol-acetaminophen ........... 2

ULTRAM

see tramadol hcl tab 50 mg ................................. 1

UNASYN

see ampicillin & sulbactam sodium ....... 9

UNASYN BULK PACK

see ampicillin & sulbactam sodium ....... 9

unithroid ............................. 38

URECHOLINE

see bethanechol chloride ..................................... 40

UROCIT-K 10

see potassium citrate (alkalinizer) er tabs ... 40

UROCIT-K 15


UROCIT-K 5


UROXATRAL

see alfuzosin hcl ........... 40

URSO 250

see ursodiol ................... 40

URSO FORTE

see ursodiol ................... 40

ursodiol ............................... 40

V VAGIFEM

see estradiol vaginal tab .................................... 36

see yuvafem vaginal tablet 10mcg ............. 36

valacyclovir hcl ................... 8

VALCHLOR ....................... 52

VALCYTE

see valganciclovir hcl .... 8

valganciclovir hcl ................ 8

VALIUM

see diazepam ............... 19

valproate sodium .............. 21

valproate sodium oral soln ........................................ 21

valproic acid ...................... 21

valsartan ............................ 14

valsartan-hydrochlorothiazide ...... 14

VALTOCO ......................... 21

VALTREX

see valacyclovir hcl ........ 8

VANCOCIN

see vancomycin hcl ....... 5

VANCOCIN HCL

see vancomycin hcl ....... 5

vancomycin hcl ................... 5

VANCOMYCIN IN NACL .. 5

vandazole .......................... 41

VAQTA ............................... 44

VARIVAX ........................... 44

VASCEPA ......................... 15

VASERETIC

see enalapril maleate & hydrochlorothiazide .. 13

VASOTEC

see enalapril maleate .. 14

VELCADE .......................... 11

velivet ................................. 35

VELTASSA ........................ 33

VEMLIDY ............................. 8

VENCLEXTA .................... 11

VENCLEXTA STARTING PACK ............................. 11

venlafaxine hcl .................. 23

VENTAVIS ........................ 18

VENTOLIN HFA ............... 48

verapamil cap er ............... 17

verapamil hcl ..................... 17

verapamil tab er ................ 17

VERELAN

see verapamil cap er .... 17

VERELAN PM

see verapamil cap er .... 17

VERSACLOZ .................... 26

VERZENIO ........................ 11

VESICARE ........................ 41

see solifenacin succinate ..................................... 40

VFEND

see voriconazole ............. 5

VFEND IV

see voriconazole ............. 5

VIBRAMYCIN

see doxycycline hyclate . 9

VICTOZA ........................... 31

VIDAZA

see azacitidine .............. 10

VIDEX EC 125MG .............. 6

VIDEX PEDIATRIC ............ 6

vienva ................................. 35

vigabatrin powd pack 500mg ............................ 21

vigabatrin tab 500mg ....... 21

vigadrone ........................... 21

VIGAMOX

see moxifloxacin hcl (ophth) ........................ 46

VIIBRYD STARTER PACK ......................................... 23

VIIBRYD TAB .................... 23

VIMPAT .............................. 21

VIMPAT INJ 200MG/20ML ......................................... 21

VIMPAT SOL 10MG/ML .. 21

vincristine sulfate .............. 10

vinorelbine tartrate ............ 10

viorele ................................. 35

VIRACEPT ........................... 6

VIRAMUNE

see nevirapine susp 50 mg/5ml .......................... 6

see nevirapine tab 200mg .......................... 6

VIRAMUNE XR


79

see nevirapine tab 400mg er ...................... 6

VIREAD ................................ 6

see tenofovir disoproxil fumarate ....................... 6

VISTARIL

see hydroxyzine pamoate ..................... 47

VITRAKVI ........................... 12

VIVITROL ........................... 30

VIZIMPRO.......................... 12

VOLTAREN

see diclofenac sodium (topical) 1% gel ......... 52

voriconazole ........................ 5

VOSEVI ................................ 8

VOTRIENT ......................... 12

VRAYLAR .......................... 26

VRAYLAR THERAPY PACK .............................. 26

vyfemla ............................... 35

vylibra ................................. 35

VYTORIN

see ezetimibe-simvastatin ................. 15

W warfarin sodium ................. 41

water for irrigation, sterile ......................................... 52

WELCHOL

see colesevelam hcl ..... 15

WELLBUTRIN SR

see bupropion hcl ......... 22

WELLBUTRIN XL

see bupropion hcl ......... 22

X XALATAN

see latanoprost ............. 47

XALKORI ........................... 12

XANAX

see alprazolam tab 0.25mg ....................... 18

see alprazolam tab 0.5mg .......................... 18

see alprazolam tab 1mg ..................................... 18

see alprazolam tab 2 mg ..................................... 18

XARELTO .......................... 41

XARELTO STARTER PACK ............................. 41

XATMEP ............................ 42

XELJANZ ........................... 42

XELJANZ XR .................... 42

XENAZINE

see tetrabenazine ........ 29

XGEVA .............................. 37

XIFAXAN ........................... 40

XIGDUO XR TAB 10-1000MG ......................... 33

XIGDUO XR TAB 10-500MG ........................... 33

XIGDUO XR TAB 2.5-1000MG ......................... 32

XIGDUO XR TAB 5-1000MG ......................... 33

XIGDUO XR TAB 5-500MG ........................................ 33

XOLAIR .............................. 49

XOPENEX

see levalbuterol hcl ...... 48

XOPENEX CONCENTRATE

see levalbuterol hcl soln nebu conc 1.25 mg/0.5ml .................... 48

XOSPATA ......................... 12

XPOVIO 100 MG ONCE WEEKLY ........................ 13



XPOVIO 80 MG TWICE WEEKLY ........................ 13

XTANDI .............................. 11

xulane dis 150-35 ............. 35

XULTOPHY 100/3.6 ........ 31

XYLOCAINE

see lidocaine hcl (local anesth.) ........................ 3

see lidocaine inj 0.5% .... 3

see lidocaine inj 1% ....... 3

XYLOCAINE-MPF

see lidocaine hcl (local anesth.) ........................ 3

see lidocaine inj 1.5% preservative free (pf) .. 4

XYREM .............................. 30

Y YASMIN 28

see drospirenone-ethinyl estradiol ...................... 34

see ocella tab 3-0.03mg ..................................... 35

see syeda ...................... 35

see zarah ....................... 35

YAZ

see drospirenone-ethinyl estradiol ...................... 34

see gianvi tab 3-0.02mg ..................................... 34

see jasmiel ..................... 34

see loryna ...................... 34

see nikki ......................... 35

YF-VAX .............................. 44

yuvafem vaginal tablet 10mcg ............................. 36

Z zafirlukast ........................... 48

ZANAFLEX

see tizanidine hcl .......... 30

zarah ................................... 35

ZARONTIN

see ethosuximide .......... 19

ZARXIO .............................. 41

ZAVESCA

see miglustat ................. 36

ZEJULA .............................. 11

ZELBORAF ........................ 13

ZEMAIRA ........................... 49

ZEMPLAR

see paricalcitol .............. 45

zenatane ............................ 50

ZENPEP ............................. 40

ZERIT

see stavudine .................. 6

ZESTORETIC

see lisinopril & hydrochlorothiazide .. 13

ZESTRIL

see lisinopril ................... 14

ZETIA

see ezetimibe ................ 15


80

ZIAC

see bisoprolol & hydrochlorothiazide .. 16

ZIAGEN

see abacavir sulfate ....... 6

zidovudine cap 100mg ....... 6

zidovudine syp 50mg/5ml .. 6

zidovudine tab 300mg ........ 6

ziprasidone hcl .................. 26

ziprasidone mesylate ....... 26

ZIRABEV ............................ 11

ZIRGAN .............................. 46

ZITHROMAX see azithromycin ............. 8

ZOCOR

see simvastatin ............. 15

ZOFRAN

see ondansetron hcl ..... 38

zoledronic acid inj 4mg/100ml ..................... 33

zoledronic acid inj 5mg/100ml ..................... 33

zoledronic inj 4mg/5ml ..... 33

ZOLINZA ............................ 11

zolmitriptan ........................ 29

zolmitriptan odt ................. 29

ZOLOFT

see sertraline hcl .......... 23

zolpidem tartrate .............. 28

ZOMIG

see zolmitriptan ............ 29

ZOMIG ZMT

see zolmitriptan odt ...... 29

ZONEGRAN

see zonisamide ............ 21

zonisamide ........................ 21

ZORTRESS

see everolimus (immunosuppressant) .................................... 43

ZORTRESS TAB 0.25MG ........................................ 43

ZORTRESS TAB 0.5MG 43

ZORTRESS TAB 0.75MG ........................................ 43

ZORTRESS TAB 1MG .... 43

ZOSTAVAX ....................... 44

zovia 1/35e ........................ 35

ZOVIRAX

see acyclovir .................... 7

ZYDELIG ............................ 13

ZYKADIA ............................ 13

ZYLET ................................ 46

ZYLOPRIM

see allopurinol tab .......... 1

ZYMAXID

see gatifloxacin (ophth) 46

ZYPREXA

see olanzapine .............. 25

ZYPREXA RELPREVV .... 26

ZYPREXA RELPREVV INJ 210MG ............................ 26

ZYPREXA ZYDIS

see olanzapine .............. 25

ZYTIGA .............................. 11

see abiraterone acetate ..................................... 11

ZYVOX

see linezolid inj ................ 4

see linezolid susp ........... 4

see linezolid tab 600mg . 4

P.O. Box 30011, Pittsburgh, PA 15222-0330

This formulary was updated on 06/01/2020. For more recent information or other questions, please contact Blue MedicareRx Premier, at:

Connecticut 1-888-620-1747 Rhode Island 1-888-620-1748

Massachusetts 1-888-543-4917 Vermont 1-888-620-1746

or, for TTY/TDD users, 711, 24 hours a day, 7 days a week, or visit www.RxMedicarePlans.com

You can get prescription drugs shipped to your home through our network mail order delivery programwhich is called CVS Caremark Mail Service Pharmacy.

You also have the option to enroll your prescriptions in an automatic refill program. Under thisprogram, we will start to process your next refill automatically when our records show that you shouldbe close to running out of your drug. And, when your prescription is going to expire or is out of refills,we’ll contact your doctor for a new one. We’ll contact you by phone, text message or email (yourchoice) before we mail your medication.

For new prescriptions, we’ll let you know before we send the first fill of your medication. There maybe times when Medicare requires us to get your approval before sending your prescription to you. Onevery order, you’ll have time to make changes or cancel, and you won’t be charged until it ships. Youcan start or stop automatic refills at any time.

Typically, you should expect to receive your prescription drugs within 10 calendar days from the time that the mail order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please contact us at the number listed in the table above. TTY/TDD users should call 711.

Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare Contract. Blue MedicareRxValue Plus (PDP) and Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plansavailable to service residents of Connecticut, Massachusetts, Rhode Island, and Vermont.

Coverage is available to residents of the service area or members of an employer or union group andseparately issued by one of the following plans: Anthem Blue Cross® and Blue Shield® ofConnecticut, Blue Cross Blue Shield of Massachusetts, Blue Cross and Blue Shield of Rhode Island,and Blue Cross and Blue Shield of Vermont.

Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross &Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities whichhave contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) andare the risk-bearing entities for Blue MedicareRx (PDP) plans. The joint enterprise is aMedicare-approved Part D Sponsor. Enrollment in Blue MedicareRx (PDP) depends on contractrenewal.

Independent Licensees of the Blue Cross and Blue Shield Association ®Registered Marks of the Blue Cross and Blue Shield Association. ®´, SM, TM Registered Marks and Trademarks are property of their respective owners. ©2020 All Rights Reserved.


blue medicare rx sm premier (pdp) 2020 formulary · sm premier (pdp) 2020 formulary (list of...

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