newmexico
heallt'h ttinnections OPTUMRx
®
New Mexico Health Connections
2020 Formulary Reference
Guide List of Covered Drugs
NM HC0338-0919 myNMHC.org
OptumRx.com
2020 Essential Health Benefits Enhanced Formulary – Oral Chemo ParityEffective January 1, 2020
For the most current list of covered medications or if you have questions:
Visit mynmhc.org/Formulary.aspx to:
• Find a participating retail pharmacy by ZIP code.
• Look up possible lower-cost medication alternatives.
• Compare medication pricing and options.
EHB Enhanced – Oral Chemo Parity
Call New Mexico Health Connections Customer Service toll-free at 866-668-9002
2
Understanding your formulary
What is a formulary?A formulary is a list of prescribed medications or other pharmacy care products, services or supplies chosen for their safety, cost, and effectiveness. Medications are listed by categories or classes and are placed into cost levels known as tiers. It includes both brand and generic prescription medications.
To create the list, OptumRx® is guided by the Pharmacy and Therapeutics Committee. This group of doctors, nurses, and pharmacists reviews which medications will be covered, how well the drugs work, and overall value. They also make sure there are safe and covered options.
About this formulary Where differences between this formulary and your benefit plan exist, the benefit plan documents rule. This may not be a complete list of medications that are covered by your plan. Please review your benefit plan for full details.
How do I use my formulary?You and your doctor can use the formulary to help you choose the most cost-effective prescription medications. This guide tells you if a medication is generic or brand, and if special rules apply. Bring this list with you when you see your doctor. If your medication is not listed here, please visit mynmhc.org/Formulary.aspx or call 866-668-9002.
Some medications on your formulary have extra requirements before they can be covered. A few of the most common coverage programs are prior authorization (PA), step therapy (ST) and quantity limits (QL). We use programs like these to help make sure the medication you take is safe and effective. Check your plan documents for more information. Some Affordable Care Act (ACA) preventive medication may have coverage restrictions. If you want to learn more about these programs or to see if you take a medication in one of these programs, please visit mynmhc.org/Formulary.aspx or call 866-668-9002.
What are tiers?Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by your employer or plan sponsor. This is how much you will pay when you fill a prescription.
3
Understanding your formulary
When does the formulary change?• Medications may move to a lower tier at any time.
• Medications may move to a higher tier when a generic equal becomes available.
• Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 ofeach year.
When a medication changes tiers, you may have to pay a different amount for that medication.
Why are some medications excluded from coverage?A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication.
What if I don’t agree with a decision about an excluded medication?You or your authorized representative and your doctor can ask for a coverage request by calling 866-668-9002.
4
Medication tips
What is the difference between brand-name and generic medications?Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications, but they often cost less. Once the patent for a brand-name medication ends, the FDA can approve a generic version with the same active ingredients.
What if my doctor writes a brand-name prescription?If your doctor gives you a prescription for a brand-name medication, ask if a generic or lower-cost option could be right for you. Generic medications are usually your lowest-cost option.
Over-the-counter medicationsAn over-the-counter (OTC) medication may be the right treatment for some conditions. Talk to your doctor about available OTC options. Even though OTC medications may not be covered by your pharmacy benefit, they may cost less than a prescription medication.
What if I am taking a specialty medication?Specialty medications are for rare or complex conditions and are usually higher-cost medications. Please note, not all specialty medications are listed in the formulary. BriovaRx®, the OptumRx specialty pharmacy, can provide most of your specialty medications along with helpful programs and services. Call BriovaRx at 1-855-4BRIOVA (1-855-427-4682) and have your prescriptions delivered right to your home or doctor’s office.
5
Reading your formulary
The formulary gives you choices so you and your doctor can decide your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX) Generic medications are shown in lowercase (for example, clobetasol).
Tier informationUsing lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers.
Drug Tier Includes Helpful Tips
Tier CM Oral Chemotherapy Oral chemotherapy drugs may have a designatedcopayment or coinsurance based on state laws or client preference.
Tier LC $ Lower Cost Generic
Use Tier LC drugs for lower out-of-pocket costs.
Tier 1 $ Generic Use Tier 1 generic drugs instead of brand-name drugs to help reduce your out-of-pocket costs.
Tier 2 $$ Preferred Preferred brand-name drugs will generally have lower copayments than non-preferred brand-name drugs.
Tier 3 $$$ Non-Preferred Many Tier 3 drugs have lower-cost options in Tier LC, 1 or 2. Ask your doctor if they could work for you.
Tier 4 $$$$ Generic Specialty and Preferred Brand Specialty
Tier 4 is generally second highest in copayment and cost. These drugs are sometimes used for complex and chronic conditions and may require special monitoring or handling.
Tier 5 $$$$$ Non-Preferred Specialty
Tier 5 is generally highest in copayment and cost. These drugs are sometimes used for complex and chronic conditions and may require special monitoring and handling.
Drug list informationIn this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan decides how these medications may be covered.
M Authorized generic or cobranded product
PA Prior Authorization – Your doctor is required to give OptumRx more information to determine coverage.
PV Preventive drugs – May have coverage and no copayments when health care reform requirements are met.
PV* Preventive drugs – Available at $0 if prior authorization is approved.
QL Quantity Limit – Medication may be limited to a certain quantity.
ST Step Therapy – Must try lower-cost medication(s) before a higher-cost medication can be covered.
Table of Contents
Analgesics ....................................................................................................................................................... 11Anesthetics ...................................................................................................................................................... 13Anti-Addiction/Substance Abuse Treatment Agents ...................................................................................14Antibacterials ...................................................................................................................................................15Anticonvulsants .............................................................................................................................................. 18Antidementia Agents ...................................................................................................................................... 19Antidepressants .............................................................................................................................................. 19Antiemetics ...................................................................................................................................................... 21Antifungals .......................................................................................................................................................21Antigout Agents .............................................................................................................................................. 22Antimigraine Agents ....................................................................................................................................... 22Antimyasthenic Agents .................................................................................................................................. 23Antimycobacterials ......................................................................................................................................... 23Antineoplastics ................................................................................................................................................23Antiparasitics ...................................................................................................................................................27Antiparkinson Agents ..................................................................................................................................... 27Antipsychotics .................................................................................................................................................28Antispasticity Agents ......................................................................................................................................29Antivirals .......................................................................................................................................................... 29Anxiolytics ....................................................................................................................................................... 31Bipolar Agents .................................................................................................................................................31Blood Glucose Monitoring ............................................................................................................................. 31Blood Glucose Regulators ............................................................................................................................. 32Blood Products/Modifiers/Volume Expanders ............................................................................................. 34Cardiovascular Agents ................................................................................................................................... 35Central Nervous System Agents ....................................................................................................................40Dental and Oral Agents ...................................................................................................................................41Dermatological Agents ................................................................................................................................... 41Electrolytes/Minerals/Metals/Vitamins .......................................................................................................... 42Gastrointestinal Agents ..................................................................................................................................45Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment ............................................................ 47Genitourinary Agents ......................................................................................................................................48Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) ................................................................49Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) ...............................................................51Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) ................................................... 51Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) ................................... 51Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) ................................................................ 55Hormonal Agents, Suppressant (Adrenal) ....................................................................................................56Hormonal Agents, Suppressant (pituitary) ................................................................................................... 56Hormonal Agents, Suppressant (Thyroid) .................................................................................................... 56Immunological Agents ....................................................................................................................................56Inflammatory Bowel Disease Agents ............................................................................................................ 59Metabolic Bone Disease Agents .................................................................................................................... 59Miscellaneous Therapeutic Agents ............................................................................................................... 60Ophthalmic Agents ......................................................................................................................................... 62Otic Agents ...................................................................................................................................................... 64Respiratory Tract/Pulmonary Agents ............................................................................................................64Skeletal Muscle Relaxants ..............................................................................................................................67Sleep Disorder Agents ....................................................................................................................................68
9
10
Drug Name Drug Tier Notes
Analgesics
butalbital-acetaminophen oral tablet
1
butalbital-apap 1
butalbital-apap-caffeine 1
butalbital-aspirin-caffeine
1
duraxin 1
phrenilin forte 1
tencon 1
Nonsteroidal Anti-inflammatory Drugs
aspirin adult 1 PV
aspirin adult low strength oral tablet delayed release
1 PV
aspirin childrens 1 PV
aspirin ec low dose 1 PV
aspirin ec low strength 1 PV
aspirin low dose 1 PV
aspirin oral tablet 1 PV
aspirin oral tablet delayed release 325 mg
1 PV
bayer aspirin 1 PV
bayer aspirin ec low dose
1 PV
celecoxib oral 1 QL
diclofenac potassium 1
diclofenac sodium er 1
diclofenac sodium oral 1
diclofenac sodium transdermal gel 1 %
1 QL
diclofenac sodium transdermal solution
1 PA
diclofenac-misoprostol 1
diflunisal oral 1
Drug Name Drug Tier Notes
ec-naproxen 1
etodolac 1
etodolac er 1
fenoprofen calcium oral 3
fenortho 3
flurbiprofen oral 1
ibu LC
ibuprofen lysine 1
ibuprofen oral suspension
1
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
LC
indomethacin er 1
indomethacin oral capsule 25 mg
LC
indomethacin oral capsule 50 mg
1
indomethacin sodium 1
ketoprofen er 1
ketoprofen oral 1
ketorolac tromethamine injection
1
ketorolac tromethamine intramuscular
1
ketorolac tromethamine oral
1 QL
meclofenamate sodium oral
1
medique aspirin 1 PV
meloxicam oral LC
nabumetone oral 1
naproxen dr 1
naproxen oral tablet 250 mg
1
naproxen oral tablet 375 mg, 500 mg
LC
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
11
Drug Name Drug Tier Notes
naproxen sodium oral tablet 275 mg, 550 mg
1
oxaprozin 1
piroxicam oral 1
qc aspirin low dose oral tablet delayed release
1 PV
sulindac oral 1
tolmetin sodium 1
Opioid Analgesics, Long-acting
buprenorphine hcl injection
1
buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr
1 PA; QL
BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR
3 PA; QL
BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR
3 PA; QL
EMBEDA 2 PA; QL
fentanyl 1 PA; QL
hydromorphone hcl er 1 PA; QL
HYSINGLA ER 2 PA; QL
methadone hcl injection 1
methadone hcl intensol 1
methadone hcl oral concentrate
1
methadone hcl oral solution
1
methadone hcl oral tablet
1 PA
methadone hcl oral tablet soluble
1
Drug Name Drug Tier Notes
methadose oral concentrate 10 mg/ml
1
methadose oral tablet soluble
1
methadose sugar-free 1
mitigo 1
morphine sulfate er 1 PA; QL
morphine sulfate er beads
1 PA; QL
morphine sulfate intramuscular
1
OXYCODONE HCL ER 3 PA; M; QL
OXYCONTIN 2 PA; QL
oxymorphone hcl er 1 PA; QL
tramadol hcl er (biphasic)
1 QL
tramadol hcl er oral capsule extended release 24 hour 150 mg
1 PA; QL
tramadol hcl er oral tablet extended release 24 hour
1 QL
Opioid Analgesics, Short-acting
acetaminophen-codeine #2
1 QL
acetaminophen-codeine #3
1 QL
acetaminophen-codeine #4
1 QL
acetaminophen-codeine oral solution
1 QL
acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg
1 QL
alfentanil hcl 1
apap-caff-dihydrocodeine
1 PA; QL
ascomp-codeine 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
12
Drug Name Drug Tier Notes
butalbital-apap-caff-cod 1
butalbital-asa-caff-codeine
1
butorphanol tartrate injection
1
butorphanol tartrate nasal
1 QL
codeine sulfate 1 QL
duramorph 1
endocet 1 QL
fentanyl citrate buccal lozenge on a handle
1 PA; QL
hydrocodone-acetaminophen
1 QL
hydrocodone-ibuprofen 1 QL
hydromorphone hcl injection solution 1 mg/ml, 2 mg/ml, 4 mg/ml
1
hydromorphone hcl oral 1 QL
hydromorphone hcl pf 1
levorphanol tartrate oral tablet 2 mg
3 QL
lorcet 1 QL
lorcet hd 1 QL
lorcet plus 1 QL
meperidine hcl injection 1
meperidine hcl oral 1 QL
morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml
1 QL
morphine sulfate (pf) 1
morphine sulfate injection solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml
1
Drug Name Drug Tier Notes
morphine sulfate intravenous solution 1 mg/ml, 150 mg/30ml
1
morphine sulfate oral 1 QL
nalbuphine hcl injection 1
oxycodone hcl oral capsule
1 QL
oxycodone hcl oral concentrate 100 mg/5ml
1 QL
oxycodone hcl oral solution
1 QL
oxycodone hcl oral tablet
1 QL
oxycodone-acetaminophen
1 QL
oxycodone-aspirin 1 QL
oxycodone-ibuprofen 1 QL
oxymorphone hcl 1 QL
pentazocine-naloxone hcl
1 QL
remifentanil hcl 1
tramadol hcl ir 1 QL
tramadol-acetaminophen
1 QL
vicodin 1 QL
vicodin es 1 QL
vicodin hp 1 QL
Anesthetics
Local Anesthetics
bd pudendal/local tray/1% lido
1
bupivacaine hcl (pf) 1
bupivacaine hcl injection solution 0.25 %, 0.5 %
1
bupivacaine in dextrose intrathecal
1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
13
Drug Name Drug Tier Notes
bupivacaine spinal 1
bupivacaine-epinephrine
1
bupivacaine-epinephrine (pf)
1
chloroprocaine hcl (pf) 1
ethyl chloride 1
glydo 1
lidocaine external ointment
1
lidocaine external patch 1
lidocaine hcl (pf) 1
lidocaine hcl external solution
1
lidocaine hcl injection solution
1
lidocaine hcl mouth/throat
1
lidocaine hcl urethral/mucosal
1
lidocaine viscous mouth/throat solution 2 %
LC
lidocaine-epinephrine injection
1
lidocaine-prilocaine external cream
1
polocaine 1
polocaine-mpf 1
ropivacaine hcl injection solution 10 mg/ml, 2 mg/ml, 5 mg/ml, 7.5 mg/ml
1
sensorcaine 1
sensorcaine/epinephrine
1
sensorcaine-mpf 1
Drug Name Drug Tier Notes
sensorcaine-mpf/epinephrine injection solution 0.25% -1:200000, 0.5% -1:200000
1
xylocaine dental 1
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium 1
disulfiram oral 1
VIVITROL 5
Opioid Dependence Treatments
buprenorphine hcl sublingual
1 QL
buprenorphine hcl-naloxone hcl
1 QL
naltrexone hcl oral 1
Opioid Reversal Agents
naloxone hcl injection 1
NARCAN 2
Smoking Cessation Agents
bupropion hcl er (smoking det)
1 PV; QL
CHANTIX 3 ST; PV; QL
CHANTIX CONTINUING MONTH PAK
3 ST; PV; QL
CHANTIX STARTING MONTH PAK
3 ST; PV; QL
nicotine polacrilex mouth/throat gum
1 PV; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
14
Drug Name Drug Tier Notes
nicotine polacrilex mouth/throat lozenge 2 mg
1 PV; QL
nicotine step 1 1 PV; QL
nicotine step 2 1 PV; QL
nicotine step 3 1 PV; QL
NICOTROL 3 ST; PV; QL
NICOTROL NS 3 ST; PV; QL
Antibacterials
Aminoglycosides
amikacin sulfate injection
1
gentamicin in saline 1
gentamicin sulfate external
1
gentamicin sulfate injection
1
neomycin sulfate oral LC
paromomycin sulfate oral
1
streptomycin sulfate intramuscular
1
tobramycin sulfate injection
1
Antibacterials, Other
ALTABAX 3
baciim 1
bacitracin intramuscular 1
chloramphenicol sod succinate
1
clindamycin hcl oral 1
clindamycin palmitate hcl
1
clindamycin phosphate in d5w
1
clindamycin phosphate injection
1
Drug Name Drug Tier Notes
clindamycin phosphate intravenous
1
clindamycin phosphate vaginal
1
colistimethate sodium (cba)
1
CORTISPORIN 3
daptomycin 1
IMPAVIDO 3
iodine tincture external tincture 2 %
1
lincomycin hcl injection 1
linezolid in sodium chloride
1
linezolid intravenous 1
linezolid oral 1 QL
mafenide acetate external
1
methenamine hippurate 1
metronidazole in nacl intravenous solution 5-0.79 mg/ml-%, 500-0.79 mg/100ml-%
LC
metronidazole oral LC
metronidazole vaginal 1
mupirocin external 1
NEO-SYNALAR EXTERNAL CREAM
3
nitrofurantoin 1
nitrofurantoin macrocrystal oral
1
nitrofurantoin monohydrate macrocrystals
1
polymyxin b sulfate injection
1
PRIMSOL 3
silver sulfadiazine external
1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
15
Drug Name Drug Tier Notes
ssd 1
SULFAMYLON EXTERNAL CREAM
3
trimethoprim oral LC
vancomycin hcl in dextrose intravenous solution 1-5 gm/200ml-%, 500-5 mg/100ml-%, 750-5 mg/150ml-%
1
vancomycin hcl in nacl intravenous solution 1-0.9 gm/200ml-%, 500-0.9 mg/100ml-%
1
VANCOMYCIN HCL IN NACL SOLUTION 750-0.9 MG/150ML-% INTRAVENOUS
3
vancomycin hcl in nacl solution 750-0.9 mg/150ml-% intravenous
1
vancomycin hcl intravenous solution 1000 mg/200ml, 1500 mg/300ml, 2000 mg/400ml
1
vancomycin hcl intravenous solution reconstituted 1 gm, 1.25 gm, 10 gm, 100 gm, 250 mg, 5 gm, 500 mg, 750 mg
1
vancomycin hcl oral capsule
1
vandazole 1
XIFAXAN 3 PA
ZYVOX INTRAVENOUS SOLUTION 200 MG/100ML
3
Drug Name Drug Tier Notes
Beta-lactam, Cephalosporins
cefaclor 1
cefaclor er 1
cefadroxil 1
cefazolin sodium injection
1
cefazolin sodium intravenous solution reconstituted
1
cefazolin sodium-dextrose
1
cefdinir 1
cefditoren pivoxil 1
cefepime hcl 1
cefepime-dextrose 1
cefixime 1
cefotaxime sodium 1
cefotetan disodium 1
cefotetan disodium-dextrose
1
cefoxitin sodium 1
cefpodoxime proxetil 1
cefprozil 1
ceftazidime and dextrose
1
ceftazidime injection 1
ceftriaxone sodium in dextrose
1
ceftriaxone sodium injection
1
ceftriaxone sodium intravenous
1
ceftriaxone sodium-dextrose
1
cefuroxime axetil 1
cefuroxime sodium 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
16
Drug Name Drug Tier Notes
cephalexin oral capsule 250 mg, 500 mg
LC
cephalexin oral capsule 750 mg
1
cephalexin oral suspension reconstituted
1
cephalexin oral tablet 1
MAXIPIME INTRAVENOUS SOLUTION RECONSTITUTED 2 GM
3
tazicef injection 1
tazicef intravenous solution reconstituted
1
Beta-lactam, Other
aztreonam 1
ertapenem sodium 1
imipenem-cilastatin 1
meropenem 1
Beta-lactam, Penicillins
amoxicillin LC
amoxicillin-potassium clavulanate er
1
amoxicillin-potassium clavulanate oral
1
ampicillin 1
ampicillin sodium 1
ampicillin-sulbactam sodium
1
AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-31.25 MG/5ML
3
BICILLIN L-A 3
dicloxacillin sodium LC
Drug Name Drug Tier Notes
nafcillin sodium injection solution reconstituted 1 gm, 2 gm
1
nafcillin sodium intravenous
1
oxacillin sodium 1
penicillin g potassium 1
penicillin g procaine 1
penicillin g sodium 1
penicillin v potassium LC
piperacillin sod-tazobactam so
1
Macrolides
azithromycin intravenous
LC
azithromycin oral LC
clarithromycin er 1
clarithromycin oral 1
DIFICID 3
erythromycin base 1
erythromycin ethylsuccinate oral
1
ZITHROMAX ORAL PACKET
3
Quinolones
AVELOX 3
BAXDELA ORAL 3
CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%)
3
ciprofloxacin hcl oral tablet 100 mg, 750 mg
1
ciprofloxacin hcl oral tablet 250 mg, 500 mg
LC
ciprofloxacin in d5w 1
ciprofloxacin oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
17
Drug Name Drug Tier Notes
levofloxacin in d5w 1
levofloxacin intravenous
1
levofloxacin oral 1
moxifloxacin hcl in nacl 1
moxifloxacin hcl oral 1
ofloxacin oral 1
Sulfonamides
sulfadiazine oral 1
sulfamethoxazole-trimethoprim intravenous
1
sulfamethoxazole-trimethoprim oral
LC
sulfatrim pediatric LC
Tetracyclines
avidoxy 1
demeclocycline hcl 1
doxy 100 1
doxycycline hyclate intravenous
1
doxycycline hyclate oral capsule
1
doxycycline hyclate oral tablet 100 mg, 20 mg
1
doxycycline monohydrate oral
1
MINOCIN INTRAVENOUS
3
minocycline hcl oral 1
mondoxyne nl 1
morgidox oral 1
okebo 1
tetracycline hcl oral 1
tigecycline 1
Drug Name Drug Tier Notes
Anticonvulsants
Anticonvulsants, Other
BRIVIACT ORAL 3 ST
FYCOMPA 3
levetiracetam er 1
levetiracetam in nacl 1
levetiracetam intravenous
1
levetiracetam oral 1
roweepra 1
roweepra xr 1
Calcium Channel Modifying Agents
CELONTIN 3
ethosuximide oral 1
pregabalin oral 1 QL
zonisamide oral 1
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clobazam 1 PA
clonazepam oral 1 QL
diazepam rectal 1 QL
divalproex sodium er 1
divalproex sodium oral 1
gabapentin oral 1
phenobarbital oral 1
primidone oral LC
tiagabine hcl 1
valproate sodium intravenous
LC
valproic acid oral LC
vigabatrin 4 PA
vigadrone 4 PA
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
18
Drug Name Drug Tier Notes
Glutamate Reducing Agents
felbamate 1
lamotrigine er 1
lamotrigine oral 1
lamotrigine starter kit-blue
1
lamotrigine starter kit-green
1
lamotrigine starter kit-orange
1
subvenite 1
subvenite starter kit-blue
1
subvenite starter kit-green
1
subvenite starter kit-orange
1
topiramate er 1
topiramate oral 1
Sodium Channel Agents
BANZEL 3 PA
carbamazepine er 1
carbamazepine oral suspension
1
carbamazepine oral tablet
LC
carbamazepine oral tablet chewable
1
DILANTIN ORAL CAPSULE 30 MG
3
epitol LC
fosphenytoin sodium 1
oxcarbazepine 1
PEGANONE 3
phenytoin infatabs 1
phenytoin oral 1
Drug Name Drug Tier Notes
phenytoin sodium extended
1
phenytoin sodium injection
1
VIMPAT ORAL 3
Antidementia Agents
Antidementia Agents, Other
ergoloid mesylates oral 1
Cholinesterase Inhibitors
donepezil hcl 1
galantamine hydrobromide
1
galantamine hydrobromide er
1
rivastigmine 1
rivastigmine tartrate 1
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl er 1 QL
memantine hcl oral solution 2 mg/ml
1
memantine hcl oral tablet
1
NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR
2 QL
Antidepressants
Antidepressants, Other
APLENZIN 3 ST; QL
bupropion hcl er (sr) 1 QL
bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg
1 QL
bupropion hcl oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
19
Drug Name Drug Tier Notes
mirtazapine oral tablet LC
mirtazapine oral tablet dispersible 15 mg
LC
mirtazapine oral tablet dispersible 30 mg, 45 mg
1
Monoamine Oxidase Inhibitors
EMSAM 3 QL
MARPLAN 3
phenelzine sulfate oral 1
tranylcypromine sulfate 1
SSRI/SNRI (Selective Serotonin Reuptake Inhibitor/ Serotonin and Norepinephrine Reuptake Inhibitor)
citalopram hydrobromide oral solution
1
citalopram hydrobromide oral tablet
LC
desvenlafaxine succinate er
1 QL
duloxetine hcl oral 1 QL
escitalopram oxalate 1
FETZIMA 3 ST; QL
FETZIMA TITRATION 3 ST; QL
fluoxetine hcl (pmdd) 1
fluoxetine hcl oral capsule
LC
fluoxetine hcl oral capsule delayed release
1 QL
fluoxetine hcl oral solution
1
fluoxetine hcl oral tablet 10 mg
LC
Drug Name Drug Tier Notes
fluoxetine hcl oral tablet 20 mg, 60 mg
1
fluvoxamine maleate 1
fluvoxamine maleate er 1 QL
maprotiline hcl 1
nefazodone hcl 1
olanzapine-fluoxetine hcl
1 QL
paroxetine hcl LC
paroxetine hcl er 1
paroxetine mesylate 1 QL
PAXIL ORAL SUSPENSION
2 ST
sertraline hcl oral 1
trazodone hcl oral tablet 100 mg, 150 mg, 50 mg
LC
trazodone hcl oral tablet 300 mg
1
TRINTELLIX 3 ST; QL
venlafaxine hcl 1
venlafaxine hcl er oral capsule extended release 24 hour
1
venlafaxine hcl er oral tablet extended release 24 hour 225 mg
1
VIIBRYD 3 QL
VIIBRYD STARTER PACK
3 QL
Tricyclics
amitriptyline hcl oral LC
amoxapine 1
chlordiazepoxide-amitriptyline
1
clomipramine hcl oral 1
desipramine hcl oral 1
doxepin hcl oral LC
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
20
Drug Name Drug Tier Notes
imipramine hcl oral 1
imipramine pamoate 1
nortriptyline hcl oral capsule
LC
nortriptyline hcl oral solution
1
perphenazine-amitriptyline
1
protriptyline hcl 1
trimipramine maleate oral
1
Antiemetics
Antiemetics, Other
AKYNZEO ORAL 3 QL
compro 1
dimenhydrinate injection
1
doxylamine-pyridoxine 1 PA; QL
droperidol injection 1
meclizine hcl oral tablet LC
phenadoz 1
prochlorperazine 1
prochlorperazine edisylate injection
1
prochlorperazine maleate oral tablet 10 mg
LC
prochlorperazine maleate oral tablet 5 mg
1
promethazine hcl injection
1
promethazine hcl oral syrup
LC
promethazine hcl oral tablet 12.5 mg, 50 mg
1
promethazine hcl oral tablet 25 mg
LC
Drug Name Drug Tier Notes
promethazine hcl rectal 1
promethegan 1
scopolamine 1
trimethobenzamide hcl oral
1
Emetogenic Therapy Adjuncts
ANZEMET 3 QL
aprepitant 1 QL
dronabinol 1 PA; QL
granisetron hcl intravenous
1
granisetron hcl oral 1 QL
ondansetron hcl injection
1
ondansetron hcl oral solution
1 QL
ondansetron hcl oral tablet 24 mg
1 QL
ondansetron hcl oral tablet 4 mg, 8 mg
1
ondansetron odt 1
palonosetron hcl 1
Antifungals
ABELCET 3
AMBISOME 3
amphotericin b intravenous
1
caspofungin acetate 1
ciclodan 1
ciclopirox 1
ciclopirox olamine external
1
clotrimazole external LC
clotrimazole mouth/throat
1
clotrimazole-betamethasone
1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
21
Drug Name Drug Tier Notes
CRESEMBA 3
econazole nitrate external
1
exoderm external lotion 1
fluconazole in sodium chloride intravenous solution 200-0.9 mg/100ml-%
LC
fluconazole in sodium chloride intravenous solution 400-0.9 mg/200ml-%
1
fluconazole oral LC
flucytosine oral 1
griseofulvin microsize oral
1
griseofulvin ultramicrosize
1
GYNAZOLE-1 3
itraconazole oral 1 PA
KERYDIN 3 PA
ketoconazole external cream
1
ketoconazole external shampoo
1
ketoconazole oral LC
miconazole 3 vaginal suppository
1
naftifine hcl 1
NOXAFIL ORAL TABLET DELAYED RELEASE
3
nyamyc 1
nystatin external cream LC
nystatin external ointment
1
nystatin external powder
1
nystatin mouth/throat 1
Drug Name Drug Tier Notes
nystatin oral 1
nystatin-triamcinolone 1
nystop 1
OXISTAT EXTERNAL LOTION
3
terbinafine hcl oral LC QL
terconazole 1
voriconazole intravenous
1
voriconazole oral 1
Antigout Agents
allopurinol oral LC
allopurinol sodium 1
COLCHICINE ORAL TABLET
3 ST
colchicine-probenecid 1
COLCRYS 2
febuxostat 1 ST
probenecid 1
Antimigraine Agents
Ergot Alkaloids
dihydroergotamine mesylate injection
1
dihydroergotamine mesylate nasal
1 QL
ergotamine-caffeine 1
Serotonin (5-HT) 1b/1d Receptor Agonists
almotriptan malate 1 QL
eletriptan hydrobromide 1 QL
frovatriptan succinate 3 QL
naratriptan hcl 1 QL
rizatriptan benzoate 1 QL
sumatriptan nasal 1 QL
sumatriptan succinate oral
1 QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
22
Drug Name Drug Tier Notes
sumatriptan succinate refill
1 QL
sumatriptan succinate subcutaneous
1 QL
zolmitriptan oral 1 QL
ZOMIG NASAL 3 ST; QL
Antimyasthenic Agents
Parasympathomimetics
GUANIDINE HCL 3
neostigmine methylsulfate intravenous solution 10 mg/10ml, 5 mg/10ml
1
pyridostigmine bromide er
1
pyridostigmine bromide oral solution
1
pyridostigmine bromide oral tablet
1
Antimycobacterials
Antimycobacterials, Other
dapsone oral 1
rifabutin 1
Antituberculars
CAPASTAT SULFATE 3
cycloserine oral 1
ethambutol hcl oral 1
isoniazid injection 1
isoniazid oral syrup 1
isoniazid oral tablet 100 mg
1
isoniazid oral tablet 300 mg
LC
PASER 3
PRIFTIN 3
Drug Name Drug Tier Notes
pyrazinamide oral 1
rifampin intravenous 1
rifampin oral 1
RIFATER 3
SIRTURO 3
TRECATOR 3
Antineoplastics
Alkylating Agents
busulfan 4
carboplatin 4
carmustine 4
cisplatin intravenous solution
4
cyclophosphamide injection
4
cyclophosphamide oral CM
dacarbazine 4
GLEOSTINE CM
ifosfamide 4
LEUKERAN CM
MATULANE CM
melphalan CM
melphalan hcl 4
MYLERAN CM
oxaliplatin 4
TEMODAR INTRAVENOUS
4
temozolomide CM PA
thiotepa injection 4
TREANDA 4
VYXEOS 5 PA
ZANOSAR 4
Antiandrogens
abiraterone acetate CM PA
bicalutamide CM
flutamide CM
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
23
Drug Name Drug Tier Notes
nilutamide CM
XTANDI CM PA
ZYTIGA ORAL TABLET 500 MG
CM PA
Antiangiogenic Agents
POMALYST CM PA
REVLIMID CM PA
THALOMID CM PA
Antiestrogens/Modifiers
EMCYT CM
fulvestrant 4
SOLTAMOX CM
tamoxifen citrate oral CM PV*
toremifene citrate CM
Antimetabolites
adrucil 4
ALIMTA 4
ARRANON 4
capecitabine CM PA
cladribine 4
clofarabine 4
cytarabine 4
cytarabine (pf) 4
decitabine 4 PA
DROXIA 3
ELITEK 5
floxuridine injection 4
fludarabine phosphate 4
fluorouracil intravenous 4
FOLOTYN 4 PA
gemcitabine hcl 4
hydroxyurea oral CM
LONSURF CM PA
mercaptopurine oral CM
Drug Name Drug Tier Notes
NIPENT 5
TABLOID CM
Antineoplastics, Other
ABRAXANE 4
adriamycin 4
arsenic trioxide intravenous
4
azacitidine 4
BELEODAQ 5 PA
bleomycin sulfate 4
COTELLIC CM PA
dactinomycin 4
daunorubicin hcl 4
dexrazoxane hcl 4
dexrazoxane intravenous solution reconstituted 500 mg
4
diclofenac sodium transdermal gel 3 %
1 ST; QL
docetaxel 4
doxorubicin hcl 4
doxorubicin hcl liposomal
4
epirubicin hcl 4
ERWINAZE 5
ETHYOL 5
FARYDAK CM PA
FLUOROPLEX 3
FLUOROURACIL EXTERNAL CREAM 0.5 %
2
fluorouracil external cream 5 %
1
fluorouracil external solution
4
HALAVEN 4 PA
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
24
Drug Name Drug Tier Notes
IBRANCE CM PA
idarubicin hcl 4
ISTODAX (OVERFILL) 4 PA
IXEMPRA KIT 4
JEVTANA 4 PA
KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 10 MG
4 PA
leucovorin calcium injection
1
leucovorin calcium oral CM
levoleucovorin calcium 4
levoleucovorin calcium pf
4
LYNPARZA CM PA
MARQIBO 5
mesna 4
MESNEX ORAL CM
mitomycin intravenous 4
mitoxantrone hcl 4 PA
mutamycin 4
NINLARO CM PA
ONCASPAR 4
paclitaxel 4
PICATO 3 ST
PROLEUKIN 4
ROMIDEPSIN 4 PA
RUBRACA CM PA
SYLATRON 5 PA
SYNRIBO 5 PA
teniposide 4
TOTECT 5
TRISENOX 5
VELCADE 4 PA
Drug Name Drug Tier Notes
vinblastine sulfate 4
vincristine sulfate 4
vinorelbine tartrate 4
ZALTRAP 4 PA
ZOLINZA CM PA
Aromatase Inhibitors, 3rd Generation
anastrozole oral CM
exemestane CM
letrozole oral CM
Enzyme Inhibitors
CAMPTOSAR INTRAVENOUS SOLUTION 300 MG/15ML
5
etoposide intravenous 4
etoposide oral CM
HYCAMTIN ORAL CM
irinotecan hcl 4
KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 30 MG, 60 MG
4 PA
ONIVYDE 5
toposar 4
topotecan hcl 4
ZYDELIG CM PA
Molecular Target Inhibitors
AFINITOR CM PA; QL
AFINITOR DISPERZ CM PA
BOSULIF CM PA
CABOMETYX CM PA
CAPRELSA ORAL TABLET 100 MG
CM PA; QL
CAPRELSA ORAL TABLET 300 MG
CM PA
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
25
Drug Name Drug Tier Notes
COMETRIQ (100 MG DAILY DOSE)
CM PA
COMETRIQ (140 MG DAILY DOSE)
CM PA
COMETRIQ (60 MG DAILY DOSE)
CM PA
ERIVEDGE CM PA
erlotinib hcl oral tablet 100 mg, 150 mg
CM PA
erlotinib hcl oral tablet 25 mg
CM PA; QL
GILOTRIF CM PA; QL
ICLUSIG ORAL TABLET 15 MG
CM PA; QL
ICLUSIG ORAL TABLET 45 MG
CM PA
imatinib mesylate CM PA
IMBRUVICA CM PA
INLYTA CM PA
JAKAFI ORAL TABLET 10 MG
CM PA; QL
JAKAFI ORAL TABLET 15 MG, 20 MG, 25 MG, 5 MG
CM PA
LENVIMA (10 MG DAILY DOSE)
CM PA
LENVIMA (12 MG DAILY DOSE)
CM PA
LENVIMA (14 MG DAILY DOSE)
CM PA
LENVIMA (18 MG DAILY DOSE)
CM PA
LENVIMA (20 MG DAILY DOSE)
CM PA
LENVIMA (24 MG DAILY DOSE)
CM PA
LENVIMA (4 MG DAILY DOSE)
CM PA
Drug Name Drug Tier Notes
LENVIMA (8 MG DAILY DOSE)
CM PA
MEKINIST CM PA
NEXAVAR CM PA
RYDAPT CM PA
SPRYCEL CM PA
STIVARGA CM PA
SUTENT CM PA
TAFINLAR CM PA
TAGRISSO ORAL TABLET 40 MG
CM PA; QL
TAGRISSO ORAL TABLET 80 MG
CM PA
TASIGNA CM PA
temsirolimus 4
TYKERB CM PA
VENCLEXTA CM PA
VENCLEXTA STARTING PACK
CM PA
VOTRIENT CM PA
XALKORI CM PA
ZELBORAF CM PA
ZYKADIA CM PA
Monoclonal Antibody/Antibody-Drug Conjugate
ADCETRIS 4 PA
ARZERRA 4 PA
AVASTIN 4 PA
BAVENCIO 5 PA
BLINCYTO 5 PA
CYRAMZA 5 PA
DARZALEX 5 PA
EMPLICITI 5 PA
ERBITUX 4 PA
GAZYVA 5 PA
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
26
Drug Name Drug Tier Notes
HERCEPTIN 4 PA
KADCYLA 5 PA
OPDIVO 5 PA
PERJETA 4 PA
RITUXAN 5 PA
TECENTRIQ 5 PA
UNITUXIN 5 PA
YERVOY 4 PA
Retinoids
bexarotene CM PA
PANRETIN 3
TARGRETIN EXTERNAL
5 PA
tretinoin oral CM
Antiparasitics
Anthelmintics
albendazole oral 1 PA
EMVERM 2
ivermectin oral 1
praziquantel oral 1
Antiprotozoals
ALINIA 2
atovaquone oral 1
atovaquone-proguanil hcl
1
BENZNIDAZOLE 3
chloroquine phosphate oral
LC
COARTEM 3
DARAPRIM 5 PA
hydroxychloroquine sulfate oral
LC
mefloquine hcl 1
NEBUPENT 2
pentamidine isethionate 1
primaquine phosphate 1
Drug Name Drug Tier Notes
quinine sulfate oral 1 PA
tinidazole oral 1
Pediculicides/Scabicides
crotan 1
EURAX EXTERNAL CREAM
2
lindane 1
malathion 1
permethrin external 1
SKLICE 3
spinosad 1
sulfurated lime 1
ULESFIA 3
Antiparkinson Agents
Anticholinergics
benztropine mesylate injection
1
benztropine mesylate oral
LC
trihexyphenidyl hcl oral elixir
1
trihexyphenidyl hcl oral tablet 2 mg
LC
trihexyphenidyl hcl oral tablet 5 mg
1
Antiparkinson Agents, Other
entacapone 1
tolcapone 1
Dopamine Agonists
APOKYN 4 PA; QL
bromocriptine mesylate oral
1
NEUPRO 3 ST
pramipexole dihydrochloride
1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
27
Drug Name Drug Tier Notes
pramipexole dihydrochloride er
1
ropinirole hcl 1
ropinirole hcl er 1
Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors
carbidopa oral 1
carbidopa-levodopa 1
carbidopa-levodopa er 1
carbidopa-levodopa-entacapone
1
Monoamine Oxidase B (MAO-B) Inhibitors
rasagiline mesylate oral 1
selegiline hcl oral 1
Antipsychotics
1st Generation/Typical
chlorpromazine hcl injection
1
chlorpromazine hcl oral 1
fluphenazine decanoate injection
1
fluphenazine hcl injection
1
fluphenazine hcl oral concentrate
1
fluphenazine hcl oral elixir
1
fluphenazine hcl oral tablet 1 mg
LC
fluphenazine hcl oral tablet 10 mg, 2.5 mg, 5 mg
1
haloperidol decanoate intramuscular
1
haloperidol lactate 1
Drug Name Drug Tier Notes
haloperidol oral tablet 0.5 mg, 1 mg, 2 mg, 5 mg
LC
haloperidol oral tablet 10 mg, 20 mg
1
loxapine succinate 1
molindone hcl 1
perphenazine oral 1
pimozide 1
thioridazine hcl oral 1
thiothixene 1
trifluoperazine hcl 1
2nd Generation/Atypical
ABILIFY MAINTENA 3
aripiprazole 1 QL
FANAPT 3 ST; QL
FANAPT TITRATION PACK
3 ST; QL
GEODON INTRAMUSCULAR
3
INVEGA SUSTENNA 3
INVEGA TRINZA 3
LATUDA 3 QL
olanzapine intramuscular
1
olanzapine oral 1 QL
paliperidone er 1 QL
quetiapine fumarate 1 QL
quetiapine fumarate er 1 QL
REXULTI 3 QL
RISPERDAL CONSTA 3
risperidone 1 QL
SAPHRIS 2 QL
ziprasidone hcl 1 QL
ZYPREXA RELPREVV 3
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
28
Drug Name Drug Tier Notes
Treatment-Resistant
clozapine oral tablet 1 QL
clozapine oral tablet dispersible 100 mg, 150 mg, 200 mg, 25 mg
1 QL
clozapine oral tablet dispersible 12.5 mg
1 PA; QL
Antispasticity Agents
baclofen intrathecal 1
baclofen oral tablet 10 mg
LC
baclofen oral tablet 20 mg, 5 mg
1
BOTOX INJECTION SOLUTION RECONSTITUTED 200 UNIT
4PA; Non-Cosmetic
BOTOX SOLUTION RECONSTITUTED 100 UNIT INJECTION
4 PA
BOTOX SOLUTION RECONSTITUTED 100 UNIT INJECTION
4PA; Non-Cosmetic
dantrolene sodium oral 1
revonto 1
tizanidine hcl oral 1
Antivirals
Anti-cytomegalovirus (CMV) Agents
cidofovir intravenous 1
ganciclovir sodium 1
valganciclovir hcl 1
Anti-hepatitis B (HBV) Agents
adefovir dipivoxil 4
BARACLUDE ORAL SOLUTION
5 QL
entecavir 4 QL
Drug Name Drug Tier Notes
EPIVIR HBV ORAL SOLUTION
4
INTRON A 5 PA
lamivudine oral tablet 100 mg
4
VEMLIDY 5
Anti-hepatitis C (HBV) Agents
EPCLUSA 4 PA; QL
HARVONI 4 PA; QL
MAVYRET 4 PA; QL
PEGASYS 4 PA
PEGASYS PROCLICK 4 PA
REBETOL ORAL SOLUTION 40 MG/ML
5
ribasphere oral capsule 4
ribasphere oral tablet 200 mg
4
ribasphere oral tablet 400 mg, 600 mg
5
ribasphere ribapak oral tablet
5
RIBASPHERE RIBAPAK ORAL TABLET THERAPY PACK
5
ribavirin oral 4
ZEPATIER 5 PA; QL
Antiherpetic Agents
acyclovir external 1
acyclovir oral LC
acyclovir sodium 1
famciclovir 1
valacyclovir hcl oral 1 QL
Anti-HIV Agents, Integrase Inhibitors (INSTI)
BIKTARVY 3
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
29
Drug Name Drug Tier Notes
GENVOYA 3
ISENTRESS 2
ISENTRESS HD 2
JULUCA 2
STRIBILD 3
TIVICAY 2
TRIUMEQ 2
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
ATRIPLA 3 ST
COMPLERA 2
EDURANT 2
efavirenz 1
INTELENCE 2
nevirapine 1
nevirapine er 1
ODEFSEY 3
RESCRIPTOR 2
SYMFI 2
SYMFI LO 2
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
abacavir sulfate 1
abacavir sulfate-lamivudine
1
abacavir-lamivudine-zidovudine
1
CIMDUO 2
DESCOVY 3
didanosine 1
EMTRIVA 2
lamivudine oral solution 1
Drug Name Drug Tier Notes
lamivudine oral tablet 150 mg, 300 mg
1
lamivudine-zidovudine 1
RETROVIR INTRAVENOUS
2
stavudine 1
tenofovir disoproxil fumarate
1
TRUVADA 2
VIDEX 2
VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 MG
3
VIREAD ORAL POWDER
2
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG
2
zidovudine 1
Anti-HIV Agents, Other
FUZEON 2 QL
SELZENTRY 2 PA
TYBOST 2
Anti-HIV Agents, Protease Inhibitors
APTIVUS 2
atazanavir sulfate 1
CRIXIVAN 2
EVOTAZ 2
fosamprenavir calcium 1
INVIRASE 2
KALETRA ORAL TABLET
2
LEXIVA ORAL SUSPENSION
2
lopinavir-ritonavir 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
30
Drug Name Drug Tier Notes
NORVIR ORAL PACKET
2
NORVIR ORAL SOLUTION
2
PREZCOBIX 2
PREZISTA 2
REYATAZ ORAL PACKET
2
ritonavir 1
VIRACEPT 2
Anti-influenza Agents
amantadine hcl oral 1
oseltamivir phosphate oral
1 QL
RELENZA DISKHALER 3 QL
rimantadine hcl 1
Anxiolytics
Anxiolytics, Other
buspirone hcl oral tablet 10 mg, 5 mg
LC
buspirone hcl oral tablet 15 mg, 30 mg, 7.5 mg
1
meprobamate 1
Benzodiazepines
alprazolam er 1 QL
alprazolam oral tablet 1 QL
alprazolam xr 1 QL
chlordiazepoxide hcl 1 QL
clorazepate dipotassium
1 QL
diazepam injection 1
diazepam intensol 1
diazepam intramuscular
1
diazepam oral 1
estazolam 1 QL
Drug Name Drug Tier Notes
lorazepam injection 1
lorazepam intensol 1 QL
lorazepam oral 1 QL
oxazepam 1 QL
quazepam 1 QL
temazepam 1 QL
triazolam 1 QL
Bipolar Agents
Mood Stabilizers
lithium LC
lithium carbonate er LC
lithium carbonate oral LC
Blood Glucose Monitoring
ACCU-CHEK FASTCLIX LANCET KIT
2
ACCU-CHEK FASTCLIX LANCETS
2
ACCU-CHEK MULTICLIX LANCET DEVICE KIT
2
ACCU-CHEK MULTICLIX LANCETS
2
ACCU-CHEK SOFT TOUCH LANCETS
2
ACCU-CHEK SOFTCLIX LANCET DEVICE KIT
2
ACCU-CHEK SOFTCLIX LANCETS
2
CHEMSTRIP UGK 3
INPEN 100-BLUE-LILLY
3
INPEN 100-BLUE-NOVO
3
INPEN 100-GRAY-LILLY
3
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
31
Drug Name Drug Tier Notes
INPEN 100-GREY-NOVO
3
INPEN 100-PINK-LILLY
3
INPEN 100-PINK-NOVO
3
KETOCARE IN VITRO STRIP
3
KETOSTIX 3
LANCETS 2
NOVOPEN ECHO 3
ONETOUCH DELICA LANCING DEV
3
ONETOUCH DELICA PLUS LANCING
3
ONETOUCH ULTRA 2 2
ONETOUCH ULTRA BLUE TEST STRIPS
2 QL
ONETOUCH ULTRA MINI
2
ONE TOUCH VERIO KIT W/DEVICE
2
ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE
2
ONETOUCH VERIO IN VITRO SOLUTION HIGH
3
ONETOUCH VERIO TEST STRIPS
2 QL
ONETOUCH VERIO IQ SYSTEM
2
ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE
2
SURESTEP PRO HIGH GLUCOSE
3
SURESTEP PRO LOW GLUCOSE
3
Drug Name Drug Tier Notes
SURESTEP PRO NORMAL GLUCOSE
3
Blood Glucose Regulators
Antidiabetic Agents
acarbose oral 1
BYDUREON 2 ST; QL
BYDUREON BCISE AUTOINJECTOR
2 ST; QL
BYETTA 10 MCG PEN 2 ST; QL
BYETTA 5 MCG PEN 2 ST; QL
CYCLOSET 3 ST
glimepiride LC
glipizide er LC
glipizide ir LC
glipizide xl LC
glipizide-metformin hcl 1
glyburide micronized LC
glyburide oral LC
glyburide-metformin 1
GLYXAMBI 2 ST
INVOKAMET 2 ST
INVOKAMET XR 2 ST
INVOKANA 2 ST
JANUMET 2 ST
JANUMET XR 2 ST
JANUVIA 2 ST
JARDIANCE 2 ST
JENTADUETO 2 ST
JENTADUETO XR 2 ST
metformin hcl er oral tablet extended release 24 hour 500 mg
LC
metformin hcl er oral tablet extended release 24 hour 750 mg
1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
32
Drug Name Drug Tier Notes
metformin hcl oral tablet
LC
miglitol 1
nateglinide 1
OZEMPIC 2 ST; QL
pioglitazone hcl 1
pioglitazone hcl-glimepiride
1
pioglitazone hcl-metformin hcl
1
repaglinide 1
repaglinide-metformin hcl
1
SYNJARDY 2 ST
SYNJARDY XR 2 ST
tolbutamide 1
TRADJENTA 2 ST
TRULICITY 2 ST; QL
VICTOZA 2 ST; QL
Glycemic Agents
GLUCAGEN HYPOKIT 2
GLUCAGON EMERGENCY
2
PROGLYCEM 2
Insulins
HUMALOG KWIKPEN 2
HUMALOG MIX 50/50 KWIKPEN
2
HUMALOG MIX 50/50 VIAL
2
HUMALOG MIX 75/25 KWIKPEN
2
HUMALOG MIX 75/25 VIAL
2
HUMALOG U-100 JUNIOR KWIKPEN
2
HUMALOG U-100 VIAL AND CARTRIDGE
2
Drug Name Drug Tier Notes
HUMULIN 70/30 KWIKPEN
2
HUMULIN 70/30 VIAL 2
HUMULIN N KWIKPEN 2
HUMULIN N VIAL 2
HUMULIN R U-500 KWIKPEN
2
HUMULIN R U-500 VIAL (CONCENTRATED)
2
HUMULIN R VIAL 2
LANTUS SOLOSTAR 2
LANTUS U-100 VIAL 2
LEVEMIR U-100 FLEXTOUCH
2
LEVEMIR U-100 VIAL 2
NOVOLIN 70/30 FLEXPEN
3
NOVOLIN 70/30 FLEXPEN RELION
3
NOVOLIN 70/30 RELION
3
NOVOLIN 70/30 VIAL 3
NOVOLIN N RELION 3
NOVOLIN N VIAL 3
NOVOLIN R RELION 3
NOVOLIN R VIAL 3
NOVOLOG FLEXPEN 3
NOVOLOG MIX 70/30 FLEXPEN
3
NOVOLOG MIX 70/30 VIAL
3
NOVOLOG PENFILL 3
NOVOLOG U-100 VIAL 3
TOUJEO MAX SOLOSTAR
2
TOUJEO SOLOSTAR 2
TRESIBA 3
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
33
Drug Name Drug Tier Notes
TRESIBA FLEXTOUCH
3
Blood Products/Modifiers/Volume Expanders
SOLIRIS 4 PA
Anticoagulants
acd formula a 1
acd formula b in vitro solution 440-1.47-1.32
1
acd-a noclot-50 1
anticoagulant cit dext soln a
1
anticoagulant sodium citrate
1
argatroban 1
BEVYXXA 3 QL
bivalirudin trifluoroacetate
1
CEPROTIN 5
ELIQUIS 2 QL
ELIQUIS STARTER PACK
2 QL
enoxaparin sodium 1 QL
fondaparinux sodium 1 QL
heparin (porcine) in nacl injection
1
heparin (porcine) in nacl intravenous solution 1000-0.9 ut/500ml-%, 12500-0.45 ut/250ml-%, 2000-0.9 unit/l-%, 25000-0.45 ut/250ml-%, 25000-0.45 ut/500ml-%
1
heparin sod (porcine) in d5w
1
heparin sodium (porcine)
1
Drug Name Drug Tier Notes
heparin sodium (porcine) pf
1
jantoven LC
PRADAXA 2 QL
SAVAYSA 3 QL
THROMBATE III 5
warfarin sodium oral LC
XARELTO 2 QL
XARELTO STARTER PACK
2 QL
Blood Formation Modifiers
anagrelide hcl 1
ARANESP (ALBUMIN FREE)
4 PA
MOZOBIL 4 PA; QL
NEULASTA 5 PA
NEULASTA ONPRO 5 PA
NIVESTYM 4 PA
NPLATE 4 PA
PROMACTA 5 PA
RETACRIT 4 PA
Hemostasis Agents
ADVATE 4
aminocaproic acid intravenous
1
aminocaproic acid oral 1
BENEFIX 4
COAGADEX 5
CORIFACT 4
ELOCTATE 5
FEIBA 4
FIBRYGA 4
HELIXATE FS 5
HEMLIBRA 5
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
34
Drug Name Drug Tier Notes
hemofil m intravenous solution reconstituted 1000 unit, 250 unit, 500 unit
4
HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1700 UNIT
4
HUMATE-P 4
KOATE 4
KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT
4
koate-dvi intravenous solution reconstituted 250 unit
4
KOGENATE FS 5
NOVOSEVEN RT 4
OBIZUR 5
PROFILNINE 4
PROFILNINE SD 4
protamine sulfate intravenous
1
RECOMBINATE 5
RIASTAP 4
RIXUBIS 5
tranexamic acid intravenous
1
tranexamic acid oral 1
VONVENDI 5
XYNTHA 5
XYNTHA SOLOFUSE 5
Platelet Modifying Agents
aspirin-dipyridamole er 1
BRILINTA 2
Drug Name Drug Tier Notes
CABLIVI 5 PA; QL
cilostazol 1
clopidogrel bisulfate oral
1
dipyridamole oral 1
eptifibatide 1
prasugrel hcl 1
ZONTIVITY 3
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine 1
clonidine hcl oral tablet 0.1 mg, 0.2 mg
LC
clonidine hcl oral tablet 0.3 mg
1
guanfacine hcl LC
methyldopa LC
methyldopa-hydrochlorothiazide
1
phenylephrine hcl injection solution 10 mg/ml
1
phenylephrine hcl intravenous solution
1
Alpha-adrenergic Blocking Agents
phenoxybenzamine hcl oral
1
phentolamine mesylate injection
1
prazosin hcl oral LC
Angiotensin II Receptor Antagonists
amlodipine besylate-valsartan
1
amlodipine-olmesartan 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
35
Drug Name Drug Tier Notes
amlodipine-valsartan-hctz
1
candesartan cilexetil 1
candesartan cilexetil-hctz
1
eprosartan mesylate 1
irbesartan 1
irbesartan-hydrochlorothiazide
1
losartan potassium LC
losartan potassium-hctz LC
olmesartan medoxomil oral
1
olmesartan medoxomil-hctz
1
olmesartan-amlodipine-hctz
1
telmisartan 1
telmisartan-amlodipine 1
telmisartan-hctz 1
valsartan 1
valsartan-hydrochlorothiazide
1
Angiotensin-converting Enzyme (ACE) Inhibitors
amlodipine besylate-benazepril hcl
1
benazepril hcl oral LC
benazepril-hydrochlorothiazide
1
captopril oral 1
captopril-hydrochlorothiazide
1
enalapril maleate oral LC
enalaprilat 1
Drug Name Drug Tier Notes
enalapril-hydrochlorothiazide oral tablet 10-25 mg
1
enalapril-hydrochlorothiazide oral tablet 5-12.5 mg
LC
fosinopril sodium LC
fosinopril sodium-hctz 1
lisinopril oral LC
lisinopril-hydrochlorothiazide
LC
moexipril hcl LC
perindopril erbumine 1
quinapril hcl LC
quinapril-hydrochlorothiazide
1
ramipril LC
trandolapril LC
trandolapril-verapamil hcl er
1
Antiarrhythmics
adenosine intravenous solution 12 mg/4ml, 6 mg/2ml
1
amiodarone hcl 1
disopyramide phosphate
1
dofetilide 1
flecainide acetate 1
ibutilide fumarate 1
lidocaine hcl (cardiac) 1
lidocaine hcl (cardiac) pf
1
lidocaine in d5w intravenous solution 4-5 mg/ml-%, 8-5 mg/ml-%
1
mexiletine hcl oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
36
Drug Name Drug Tier Notes
pacerone oral tablet 200 mg
1
procainamide hcl injection
1
propafenone hcl 1
propafenone hcl er 1
quinidine gluconate er 1
quinidine sulfate 1
sorine oral tablet 120 mg, 160 mg, 240 mg
1
sorine oral tablet 80 mg LC
sotalol hcl (af) 1
sotalol hcl oral tablet 120 mg, 160 mg, 240 mg
1
sotalol hcl oral tablet 80 mg
LC
Beta-adrenergic Blocking Agents
acebutolol hcl oral 1
atenolol oral LC
atenolol-chlorthalidone LC
betaxolol hcl oral 1
bisoprolol fumarate LC
bisoprolol-hydrochlorothiazide
LC
BYSTOLIC 2
carvedilol LC
carvedilol phosphate er 1
esmolol hcl intravenous solution 100 mg/10ml
1
esmolol hcl-sodium chloride
1
labetalol hcl intravenous solution
1
labetalol hcl oral 1
metoprolol succinate er 1
Drug Name Drug Tier Notes
metoprolol tartrate intravenous
1
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
LC
metoprolol tartrate oral tablet 37.5 mg, 75 mg
1
metoprolol-hydrochlorothiazide
1
pindolol 1
propranolol hcl er 1
propranolol hcl intravenous
1
propranolol hcl oral solution
1
propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 80 mg
LC
propranolol hcl oral tablet 60 mg
1
propranolol-hctz 1
timolol maleate oral 1
Calcium Channel Blocking Agents
amlodipine besylate oral
LC
amlodipine-atorvastatin 1
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG
3
cartia xt 1
diltiazem hcl er beads 1
diltiazem hcl er coated beads
1
diltiazem hcl er oral capsule extended release 12 hour
1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
37
Drug Name Drug Tier Notes
diltiazem hcl er oral capsule extended release 24 hour 180 mg, 240 mg
1
diltiazem hcl intravenous
1
diltiazem hcl oral 1
dilt-xr 1
felodipine er 1
isradipine 1
matzim la 1
nicardipine hcl 1
nifedipine er 1
nifedipine er osmotic release
1
nifedipine oral 1
nimodipine oral 1
nisoldipine er 1
taztia xt 1
verapamil hcl er 1
verapamil hcl intravenous
1
verapamil hcl oral tablet 120 mg, 80 mg
LC
verapamil hcl oral tablet 40 mg
1
Cardiovascular Agents, Other
aliskiren fumarate 1
DEMSER 3
digitek LC
digox LC
digoxin injection 1
digoxin oral LC
dobutamine hcl 1
dobutamine in d5w 1
Drug Name Drug Tier Notes
dopamine hcl intravenous
1
dopamine in d5w 1
ENTRESTO 2 QL
ephedrine sulfate intravenous solution
1
epinephrine pf 1
GIAPREZA 3
mannitol intravenous 1
midodrine hcl 1
milrinone lactate 1
milrinone lactate in dextrose
1
norepinephrine bitartrate intravenous
1
osmitrol 1
pentoxifylline er 1
ranolazine er 1
VECAMYL 3
Diuretics, Loop
bumetanide LC
ethacrynate sodium 1
ethacrynic acid 1
furosemide injection LC
furosemide oral solution 10 mg/ml
LC
furosemide oral solution 8 mg/ml
1
furosemide oral tablet LC
torsemide LC
Diuretics, Potassium-sparing
amiloride hcl oral 1
amiloride-hydrochlorothiazide
LC
DYRENIUM ORAL CAPSULE 100 MG
3
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
38
Drug Name Drug Tier Notes
eplerenone 1
spironolactone oral LC
spironolactone-hctz LC
triamterene-hctz LC
Diuretics, Thiazide
chlorothiazide LC
chlorothiazide sodium 1
chlorthalidone LC
hydrochlorothiazide oral
LC
indapamide LC
metolazone 1
Dyslipidemics, Fibric Acid Derivatives
choline fenofibrate 1
fenofibrate micronized 1
fenofibrate oral capsule 1
fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg
1
fenofibric acid oral capsule delayed release
1
gemfibrozil oral LC
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium oral tablet 10 mg, 20 mg
LC PV*
atorvastatin calcium oral tablet 40 mg, 80 mg
LC
fluvastatin sodium 3
fluvastatin sodium er 3
LIVALO 3 ST
lovastatin 1 PV
PRALUENT 4 PA; QL
Drug Name Drug Tier Notes
pravastatin sodium 1
REPATHA 4 PA; QL
REPATHA PUSHTRONEX SYSTEM
4 PA; QL
REPATHA SURECLICK
4 PA; QL
rosuvastatin calcium 1
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg
LC PV*
simvastatin oral tablet 80 mg
LC
Dyslipidemics, Other
cholestyramine light 1
cholestyramine oral 1
colesevelam hcl 1
colestipol hcl 1
ezetimibe 1
ezetimibe-simvastatin 1
niacin er (antihyperlipidemic)
1
omega-3-acid ethyl esters
1
prevalite 1
Vasodilators, Direct-acting Arterial
hydralazine hcl injection
1
hydralazine hcl oral LC
minoxidil oral 1
Vasodilators, Direct-acting Arterial/Venous
DILATRATE-SR 3
isosorbide dinitrate 1
isosorbide dinitrate er 1
isosorbide mononitrate 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
39
Drug Name Drug Tier Notes
isosorbide mononitrate er oral tablet extended release 24 hour 120 mg
1
isosorbide mononitrate er oral tablet extended release 24 hour 30 mg, 60 mg
LC
minitran 1
NITRO-BID 3
nitroglycerin 1
nitroglycerin in d5w 1
NITROMIST 3
nitroprusside sodium 1
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
amphetamine sulfate 1 PA; QL
amphetamine-dextroamphetamine
1 PA; QL
amphetamine-dextroamphetamine er
1 PA; QL
dextroamphetamine sulfate
1 PA; QL
dextroamphetamine sulfate er
1 PA; QL
methamphetamine hcl 3 PA; QL
VYVANSE 2 PA; QL
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
atomoxetine hcl 1 QL
clonidine hcl er 1
DAYTRANA 3 ST; PA; QL
dexmethylphenidate hcl 1 PA; QL
Drug Name Drug Tier Notes
dexmethylphenidate hcl er
1 PA; QL
guanfacine hcl er 1
metadate er 1 PA; QL
methylphenidate hcl er 1 PA; QL
methylphenidate hcl er (cd)
1 PA; QL
methylphenidate hcl er (la)
1 PA; QL
methylphenidate hcl oral
1 PA; QL
QUILLIVANT XR 3 ST; PA; QL
relexxii 1 PA; QL
Central Nervous System, Other
caffeine citrate 1
flumazenil intravenous 1
GRALISE 3 ST; QL
GRALISE STARTER 3 ST; QL
riluzole 4 PA; QL
TEGSEDI 5 PA
tetrabenazine 4 PA
Fibromyalgia Agents
SAVELLA 3 ST; QL
SAVELLA TITRATION PACK
3 ST; QL
Multiple Sclerosis Agents
AVONEX PEN 4 PA; QL
AVONEX PREFILLED 4 PA; QL
BETASERON 4 PA; QL
COPAXONE 4 PA; QL
dalfampridine er 4 PA; QL
GILENYA 5 PA; QL
glatiramer acetate 4 PA; QL
glatopa 4 PA; QL
TECFIDERA 4 PA; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
40
Drug Name Drug Tier Notes
TYSABRI 5 PA; QL
Dental and Oral Agents
cavarest 1
cevimeline hcl 1
chlorhexidine gluconate mouth/throat
LC
clinpro 5000 1
DEBACTEROL 3
denta 5000 plus 1
dentagel 1
easygel 1
fluoridex 1
fluoridex daily renewal 1
fluoridex enhanced whitening
1
fluoridex sensitivity relief
1
neutral sodium fluoride 1
oralone 1
paroex LC
periogard LC
pilocarpine hcl oral 1
prevident mouth/throat 1
sf 1
sf 5000 plus 1
sodium fluoride 5000 plus
1
sodium fluoride dental 1
triamcinolone acetonide mouth/throat
1
Dermatological Agents
acitretin 1
adapalene external cream
1 PA
adapalene external gel 1 PA
Drug Name Drug Tier Notes
adapalene-benzoyl peroxide
1
ammonium lactate external
1
amnesteem 1 PA
avita 1 PA
azelaic acid external 1
AZELEX 3
benzoyl peroxide-erythromycin
1
calcipotriene 1
calcitriol external 1
claravis 1 PA
clindacin etz external swab
1
clindacin-p 1
clindamycin phosphate-benzoyl peroxide
1
clindamycin phosphate external
1
clindamycin-tretinoin 1
coal tar external 1
colocort 1
CONDYLOX 3
CORTIFOAM 3
COSENTYX (300 MG DOSE)
5 PA
COSENTYX 150 MG/ML
5 PA
COSENTYX SENSOREADY (300 MG)
5 PA
COSENTYX SENSOREADY PEN
5 PA
dapsone external 1
doxepin hcl external 3
doxycycline 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
41
Drug Name Drug Tier Notes
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML
4 PA; QL
EPIDUO FORTE 3
ery 1
erythromycin external 1
hydrocortisone ace-pramoxine rectal cream 1-1 %
1
hydrocortisone rectal 1
imiquimod external 1
isotretinoin oral 1 PA
lactic acid e 1
lactic acid external 1
methoxsalen oral 1
methoxsalen rapid 1
metronidazole external 1
MIRVASO 2
myorisan 1 PA
neuac external gel 1
pimecrolimus 1
podofilox external 1
procto-med hc 1
procto-pak 1
proctosol hc 1
proctozone-hc 1
RECTIV 3
REGRANEX 3 PA
rosadan external cream 1
rosadan external gel 1
SANTYL 3
selenium sulfide external lotion
1
silver nitrate external ointment 10 %
1
Drug Name Drug Tier Notes
STELARA SUBCUTANEOUS
4 PA
sulfacetamide sodium (acne)
1
TACLONEX EXTERNAL SUSPENSION
3 QL
tacrolimus external 1
tazarotene external 1
TAZORAC EXTERNAL CREAM 0.05 %
3
TAZORAC EXTERNAL GEL
3
TREMFYA 4 PA
tretinoin external 1 PA
tretinoin microsphere 1 PA
tretinoin microsphere pump
1 PA
zenatane 1 PA
Electrolytes/Minerals/Metals/Vitamins
Electrolyte/Mineral Replacement
calcium chloride 1
calcium gluconate intravenous solution
1
chromagen 1
chromic chloride intravenous
1
corvita 150 1
dehydrated alcohol 1
dextrose in lactated ringers
1
dextrose intravenous 1
dextrose-nacl 1
effer-k oral tablet effervescent 25 meq
1
ferocon 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
42
Drug Name Drug Tier Notes
ferotrinsic 1
ferraplus 90 1
ferrocite plus 1
fluoritab 1 PV
foltrin 1
glucose intravenous 1
hematinic plus vit/minerals
1
hematinic/folic acid 1
hematogen 1
hematogen forte 1
hemocyte-f 1
hemocyte-plus 1
iferex 150 forte 1
iodine strong oral 1
kcl in d5w lactated ringers
1
kcl in dextrose-nacl 1
kcl-lactated ringers-d5w 1
klor-con 1
klor-con 10 1
klor-con m10 1
KLOR-CON M15 3
klor-con m20 1
klor-con sprinkle 1
klor-con/ef 1
k-prime 1
k-tan plus 1
lactated ringers intravenous
1
ludent 1 PV
magnesium chloride injection
1
magnesium sulfate in d5w intravenous solution 1-5 gm/100ml-%
1
Drug Name Drug Tier Notes
magnesium sulfate injection
1
magnesium sulfate intravenous solution 2 gm/50ml, 20 gm/500ml, 4 gm/100ml, 4 gm/50ml, 40 gm/1000ml
1
multigen 1
multigen folic 1
multigen plus 1
na ferric gluc cplx in sucrose
1
nafrinse 1 PV
nafrinse drops 1 PV
phosphorous 1
poly-iron 150 forte 1
polysaccharide iron forte
1
pot bicarb-pot chloride 1
potassium acetate intravenous
1
potassium chloride crys er
1
potassium chloride er 1
potassium chloride in dextrose
1
potassium chloride in nacl
1
potassium chloride intravenous solution
1
potassium chloride oral 1
potassium citrate er 1
purevit dualfe plus 1
ringers 1
se-tan plus 1
sod citrate-citric acid LC
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
43
Drug Name Drug Tier Notes
sodium bicarbonate intravenous solution 4.2 %, 7.5 %
1
sodium chloride injection
1
sodium chloride intravenous
1
sodium fluoride oral 1 PV
sodium lactate intravenous
1
sodium phosphates intravenous solution 45 mmole/15ml
1
tl icon 1
tl-hem 150 1
tpn electrolytes 1
tricon 1
trigels-f forte 1
virt-phos 250 neutral 1
Electrolyte/Mineral/Metal Modifiers
CHEMET 3
deferasirox 1 PA
DEPEN TITRATABS 2
FERRIPROX ORAL TABLET 500 MG
5 PA
JADENU 3 PA
JADENU SPRINKLE 3 PA
kionex 1
penicillamine oral 4 PA
SAMSCA 4 QL
sodium polystyrene sulfonate
1
sps 1
trientine hcl 4 PA
VELTASSA 3
Drug Name Drug Tier Notes
Vitamins
adc/f (0.5mg/ml) 1
airavite 1
b-6 folic acid 1
biocel 1
bp vit 3 1
b-plex 1
b-plex plus 1
cod liver oil oral oil 1
corvita 1
corvite free 1
cyanocobalamin injection solution 1000 mcg/ml
1
decara oral capsule 50000 unit
1
dexifol 1
dialyvite 1
ergocalciferol oral capsule
1
fabb 1
fa-vitamin b-6-vitamin b-12
1
folbee 1
folbee plus 1
folbee plus cz 1
folic acid injection 1
folic acid oral tablet 1 mg
1
folic acid oral tablet 400 mcg, 800 mcg
1 PV
folplex 2.2 1
gnp folic acid 1 PV
hydroxocobalamin acetate
1
infuvite adult 1
infuvite pediatric 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
44
Drug Name Drug Tier Notes
lysiplex plus oral tablet 1
multi prenatal 1 PV
multi-vit/iron/fluoride 1
multi-vitamin/fluoride 1
multivitamin/fluoride oral solution
1
multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg
1
multivitamin/fluoride/iron
1
multi-vitamin/fluoride/iron
1
multivitamins/fluoride 1
mvc-fluoride 1
mynephron 1
NASCOBAL 3
nephronex oral tablet 1
nufol 1
nutricap 1
nutrifac zx 1
ONE-A-DAY WOMENS PRENATAL 1
3 PV
phytonadione injection 1
phytonadione oral 1
pnv prenatal plus multivit+dha
1
prenatal multi +dha 1 PV
prenatal oral tablet 27-0.8 mg, 28-0.8 mg
1 PV
prenatal oral tablet 27-1 mg
LC
prenatal plus iron 1
pyridoxine hcl injection 1
RAYALDEE 3
renal 1
siderol 1
Drug Name Drug Tier Notes
sodium acetate intravenous
1
thiamine hcl injection 1
tl gard rx 1
trinate 1
triphrocaps 1
tri-vitamin/fluoride 1
tri-vite/fluoride 1
v-c forte 1
vic-forte 1
virt-caps 1
virt-gard 1
vita s forte 1
vitacel 1
vitamax pediatric 1
vita-min 1
vitamin b complex 100 1
vitamin d (ergocalciferol) oral capsule 50000 unit
1
vitamin k1 injection 1
vitamins acd-fluoride 1
vp-pnv-dha 1
vp-vite rx 1
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
atropine sulfate injection solution 8 mg/20ml
1
atropine sulfate injection solution prefilled syringe
1
CUVPOSA 3
dicyclomine hcl intramuscular
1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
45
Drug Name Drug Tier Notes
dicyclomine hcl oral capsule
LC
dicyclomine hcl oral solution
1
dicyclomine hcl oral tablet
LC
ed-spaz 1
glycopyrrolate injection solution
1
glycopyrrolate oral tablet 1 mg, 2 mg
1
glycopyrrolate pf 1
hyoscyamine sulfate oral
1
hyoscyamine sulfate sl 1
hyoscyamine sulfate sublingual
1
methscopolamine bromide oral
1
nulev 1
oscimin 1
Gastrointestinal Agents, Other
amoxicill-clarithro-lansopraz
1
CHOLBAM 5 PA
cromolyn sodium oral 1
diphenoxylate-atropine 1
GATTEX 5 PA
loperamide hcl oral capsule
1
metoclopramide hcl injection
LC
metoclopramide hcl oral solution
LC
metoclopramide hcl oral tablet
LC
metoclopramide hcl oral tablet dispersible
1
Drug Name Drug Tier Notes
OMECLAMOX-PAK 2
PYLERA 2
sodium bicarbonate oral powder
1
SYMPROIC 2 ST; QL
ursodiol oral 1
Histamine2 (H2) receptor Antagonists
cimetidine hcl 1
cimetidine oral tablet 200 mg, 300 mg, 400 mg
1
cimetidine oral tablet 800 mg
LC
famotidine intravenous 1
famotidine oral suspension reconstituted
1
famotidine oral tablet 20 mg
LC
famotidine oral tablet 40 mg
1
famotidine premixed 1
nizatidine 1
ranitidine hcl injection 1
ranitidine hcl oral capsule
1
ranitidine hcl oral syrup 1
ranitidine hcl oral tablet 150 mg
1
ranitidine hcl oral tablet 300 mg
LC
Irritable Bowel Syndrome Agents
alosetron hcl 1 PA
AMITIZA 3 ST; QL
LINZESS 2 ST; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
46
Drug Name Drug Tier Notes
Laxatives
bisacodyl ec 1 PV; QL
cascara sagrada oral fluid extract
1
clearlax 1 PV; QL
constulose LC
enulose 1
ex-lax ultra 1 PV; QL
gavilax oral powder 1 PV; QL
gavilyte-c 1 PV; QL
gavilyte-g 1 PV; QL
gavilyte-h 1
gavilyte-n with flavor pack
1 PV; QL
generlac 1
gentle laxative oral 1 PV; QL
glycolax 1 PV; QL
lactulose encephalopathy
1
lactulose oral solution LC
magnesium citrate oral solution
1 PV; QL
mineral oil heavy oral 1
MOVIPREP 3
peg 3350/electrolytes 1 PV; QL
peg 3350-kcl-na bicarb-nacl
1 PV; QL
peg-3350/electrolytes 1 PV; QL
peg-prep 1
PREPOPIK 3
SUPREP BOWEL PREP KIT
3
trilyte 1 PV; QL
Protectants
CARAFATE ORAL SUSPENSION
3
misoprostol oral 1
Drug Name Drug Tier Notes
sucralfate oral tablet LC
Proton Pump Inhibitors
DEXILANT 2 QL
esomeprazole sodium 1
lansoprazole oral capsule delayed release
1 QL
lansoprazole oral tablet dispersible 15 mg
1 QL
omeprazole oral capsule delayed release
LC QL
pantoprazole sodium intravenous
LC QL
pantoprazole sodium oral
LC QL
rabeprazole sodium oral tablet delayed release
1 QL
Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment
ALDURAZYME 4 PA
CARBAGLU 4
CERDELGA 5 PA
CEREZYME 4 PA
CREON 2
CYSTADANE 5
CYSTAGON 5
ELAPRASE 4 PA
FABRAZYME 4 PA
KANUMA 5 PA
KUVAN 4 PA
LUMIZYME 4 PA
MEPSEVII 5 PA
miglustat 4 PA
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
47
Drug Name Drug Tier Notes
MYALEPT 5 PA
NAGLAZYME 4 PA
ORFADIN 5 PA
RAVICTI 5 PA
REVCOVI 5 PA
sod benz-sod phenylacet
1
sodium phenylbutyrate oral
4
STRENSIQ 5 PA
SUCRAID 5
VIMIZIM 5 PA
XIAFLEX 4 PA
ZENPEP 2
Genitourinary Agents
Antispasmodics, Urinary
darifenacin hydrobromide er
1
flavoxate hcl 1
GELNIQUE 3 ST
GELNIQUE PUMP 3 ST
MYRBETRIQ 2
oxybutynin chloride er 1
oxybutynin chloride oral 1
solifenacin succinate 1
tolterodine tartrate 1
tolterodine tartrate er 1
TOVIAZ 3
trospium chloride 1
trospium chloride er 1
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er 1
doxazosin mesylate oral
LC
Drug Name Drug Tier Notes
dutasteride oral 1
dutasteride-tamsulosin hcl
1
finasteride oral tablet 5 mg
LC
silodosin 1
tadalafil oral tablet 2.5 mg, 5 mg
1 PA; QL
tamsulosin hcl LC
terazosin hcl LC
Genitourinary Agents, Other
acetic acid irrigation 1
aminoacetic acid 1
argyle sterile saline 1
bethanechol chloride oral
1
ELMIRON 2
glycine irrigation 1
glycine urologic 1
neomycin-polymyxin b gu
1
phenazo oral tablet 200 mg
LC
phenazopyridine hcl oral tablet 100 mg, 200 mg
LC
RENACIDIN 3
sodium chloride irrigation
1
sorbitol irrigation solution 3.3 %
1
sorbitol-mannitol 1
vcf vaginal contraceptive vaginal gel
1 PV; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
48
Drug Name Drug Tier Notes
Phosphate Binders
calcium acetate (phos binder)
1
FOSRENOL ORAL PACKET
3
lanthanum carbonate 1
PHOSLYRA 3
sevelamer carbonate 1
sevelamer hcl 1
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
ala-cort external cream 1 %
1
ala-cort external cream 2.5 %
LC
alclometasone dipropionate
1
amcinonide external lotion
1
amcinonide external ointment
1
beser external lotion 1
betamethasone dipropionate aug
1
betamethasone dipropionate external
1
betamethasone sod phos & acet injection suspension 6 (3-3) mg/ml
1
betamethasone valerate external
1
clobetasol prop emollient base
1
clobetasol propionate e 1
clobetasol propionate emulsion
1
Drug Name Drug Tier Notes
clobetasol propionate external
1
clodan external shampoo
1
CORDRAN EXTERNAL TAPE
3
cortisone acetate oral 1
deltasone oral tablet 20 mg
LC
DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML
3
desonide external 1
desoximetasone external cream 0.25 %
1
desoximetasone external gel
1
desoximetasone external liquid
1
desoximetasone external ointment 0.25 %
1
DEXAMETHASONE INTENSOL
3
dexamethasone oral elixir
LC
dexamethasone oral solution
LC
dexamethasone oral tablet
LC
dexamethasone oral tablet therapy pack
1
dexamethasone sod phosphate pf
LC
dexamethasone sodium phosphate injection
LC
fludrocortisone acetate oral
1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
49
Drug Name Drug Tier Notes
fluocinolone acetonide body
1
fluocinolone acetonide external
1
fluocinolone acetonide scalp
1
fluocinonide emulsified base
1
fluocinonide external cream 0.05 %
1
fluocinonide external gel
1
fluocinonide external ointment
1
fluocinonide external solution
1
fluticasone propionate external
1
halobetasol propionate external cream
1
halobetasol propionate external ointment
1
hydrocortisone butyrate external cream
1
hydrocortisone butyrate external ointment
1
hydrocortisone butyrate external solution
1
hydrocortisone external cream 1 %
1
hydrocortisone external cream 2.5 %
LC
hydrocortisone external lotion 2.5 %
1
hydrocortisone external ointment 1 %, 2.5 %
1
hydrocortisone oral LC
hydrocortisone valerate 1
INTRAROSA 3
Drug Name Drug Tier Notes
methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml
LC
methylprednisolone oral
LC
methylprednisolone sodium succ
LC
mometasone furoate external
1
prednicarbate 1
prednisolone oral solution
LC
prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml
1
prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml
LC
prednisolone sodium phosphate oral tablet dispersible
1
PREDNISONE INTENSOL
2
prednisone oral LC
SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 1000 MG
3
TEXACORT 3
triamcinolone acetonide external cream
LC
triamcinolone acetonide external lotion
1
triamcinolone acetonide external ointment 0.025 %, 0.5 %
1
triamcinolone acetonide external ointment 0.1 %
LC
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
50
Drug Name Drug Tier Notes
triamcinolone acetonide injection suspension 40 mg/ml
1
triderm LC
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
ACTHAR 4 PA
cabergoline 1
chorionic gonadotropin intramuscular
4 PA
desmopressin ace spray refrig
1
desmopressin acetate injection
1
desmopressin acetate oral
1
desmopressin acetate spray
1
INCRELEX 4 PA
NORDITROPIN FLEXPRO
4 PA
NUTROPIN AQ NUSPIN 10
4 PA
NUTROPIN AQ NUSPIN 20
4 PA
NUTROPIN AQ NUSPIN 5
4 PA
oxytocin injection 1
pregnyl 4 PA
Hormonal Agents, Suppressant (Pituitary)
leuprolide acetate injection
4 PA
LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG
5 PA
Drug Name Drug Tier Notes
LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG
4 PA
LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG
5 PA
LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG
4 PA
LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG
4 PA
LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG
4 PA
ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG
4 QL
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)
alprostadil injection 1
carboprost tromethamine
1
KORLYM 5 PA; QL
mifepristone 1
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Anabolic Steroids
ANADROL-50 3 PA
oxandrolone oral 1 PA; QL
Androgens
danazol oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
51
Drug Name Drug Tier Notes
METHITEST 3 PA
methyltestosterone oral 1 PA
STRIANT 3 PA
testosterone cypionate intramuscular
1 PA
testosterone enanthate intramuscular
1 PA
testosterone transdermal gel 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%)
1 PA
testosterone transdermal solution
1 PA
Estrogens
afirmelle 1 PV
altavera 1 PV
alyacen 1/35 1 PV
alyacen 7/7/7 1 PV
amabelz 1
amethia 1 PV; QL
amethia lo 1 PV; QL
amethyst 1 PV
ANNOVERA 3 PV
apri 1 PV
aranelle 1 PV
ashlyna 1 PV; QL
aubra 1 PV
aubra eq 1 PV
aurovela 1.5/30 1 PV
aurovela 1/20 1 PV
aurovela 24 fe 1 PV
aurovela fe 1.5/30 1 PV
aurovela fe 1/20 1 PV
Drug Name Drug Tier Notes
aviane 1 PV
ayuna 1 PV
azurette 1 PV
balziva 1 PV
bekyree 1 PV
blisovi 24 fe 1 PV
blisovi fe 1.5/30 1 PV
briellyn 1 PV
camrese 1 PV; QL
camrese lo 1 PV; QL
caziant 1 PV
chateal 1 PV
chateal eq 1 PV
COMBIPATCH 3
cryselle-28 1 PV
cyclafem 1/35 1 PV
cyclafem 7/7/7 1 PV
cyred 1 PV
cyred eq 1 PV
dasetta 1/35 1 PV
dasetta 7/7/7 1 PV
daysee 1 PV; QL
delyla 1 PV
desogestrel-ethinyl estradiol
1 PV
DIVIGEL 3
dotti 1
drospiren-eth estrad-levomefol
1 PV
drospirenone-ethinyl estradiol
1 PV
DUAVEE 2
elinest 1 PV
emoquette 1 PV
enpresse-28 1 PV
enskyce 1 PV
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
52
Drug Name Drug Tier Notes
estarylla 1 PV
estradiol oral LC
estradiol transdermal 1
estradiol vaginal 1
estradiol valerate intramuscular
1
estradiol-norethindrone acet
1
ethynodiol diac-eth estradiol
1 PV
EVAMIST 3
falmina 1 PV
fayosim 1 PV; QL
femynor 1 PV
fyavolv 1
gianvi 1 PV
hailey 24 fe 1 PV
introvale 1 PV; QL
isibloom 1 PV
jasmiel 1 PV
jinteli 1
jolessa 1 PV; QL
juleber 1 PV
junel 1.5/30 1 PV
junel 1/20 1 PV
junel fe 1.5/30 1 PV
junel fe 1/20 1 PV
junel fe 24 1 PV
kaitlib fe 1 PV
kalliga 1 PV
kariva 1 PV
kelnor 1/35 1 PV
kelnor 1/50 1 PV
kurvelo 1 PV
larin 1.5/30 1 PV
larin 1/20 1 PV
Drug Name Drug Tier Notes
larin 24 fe 1 PV
larin fe 1.5/30 1 PV
larin fe 1/20 1 PV
larissia 1 PV
layolis fe 1 PV
leena 1 PV
lessina 1 PV
levonest 1 PV
levonorgest-eth est & eth est
1 PV; QL
levonorgest-eth estrad 91-day
1 PV; QL
levonorgestrel-ethinyl estrad
1 PV
levonorg-eth estrad triphasic
1 PV
levora 0.15/30 (28) 1 PV
lillow 1 PV
LO LOESTRIN FE 3
lopreeza 1
loryna 1 PV
low-ogestrel 1 PV
lo-zumandimine 1 PV
lutera 1 PV
marlissa 1 PV
melodetta 24 fe 1 PV
MENEST 2
mibelas 24 fe 1 PV
microgestin 1.5/30 1 PV
microgestin 1/20 1 PV
microgestin fe 1.5/30 1 PV
microgestin fe 1/20 1 PV
mili 1 PV
mimvey 1
mimvey lo 1
mono-linyah 1 PV
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
53
Drug Name Drug Tier Notes
NATAZIA 2 PV
necon 0.5/35 (28) 1 PV
nikki 1 PV
norethin ace-eth estrad-fe
1 PV
norethindrone acet-ethinyl est
1 PV
norethindrone-eth estradiol
1
norethin-eth estradiol-fe 1 PV
norgestimate-eth estradiol
1 PV
norgestimate-ethinyl estradiol triphasic
1 PV
nortrel 0.5/35 (28) 1 PV
nortrel 1/35 (21) 1 PV
nortrel 1/35 (28) 1 PV
nortrel 7/7/7 1 PV
NUVARING 2 PV
ocella 1 PV
ogestrel 1 PV
orsythia 1 PV
philith 1 PV
pimtrea 1 PV
pirmella 1/35 1 PV
pirmella 7/7/7 1 PV
portia-28 1 PV
PREMARIN ORAL 2
PREMPHASE 2
PREMPRO 2
previfem 1 PV
reclipsen 1 PV
rivelsa 1 PV; QL
setlakin 1 PV; QL
simliya 1 PV
simpesse 1 PV; QL
Drug Name Drug Tier Notes
sprintec 28 1 PV
sronyx 1 PV
syeda 1 PV
tarina 24 fe 1 PV
tarina fe 1/20 1 PV
tarina fe 1/20 eq 1 PV
tilia fe 1 PV
tri femynor 1 PV
tri-estarylla 1 PV
tri-legest fe 1 PV
tri-linyah 1 PV
tri-lo-estarylla 1 PV
tri-lo-marzia 1 PV
tri-lo-mili 1 PV
tri-lo-sprintec 1 PV
tri-mili 1 PV
tri-previfem 1 PV
tri-sprintec 1 PV
trivora (28) 1 PV
tri-vylibra 1 PV
tri-vylibra lo 1 PV
tydemy 1 PV
velivet 1 PV
vienva 1 PV
viorele 1 PV
vyfemla 1 PV
vylibra 1 PV
wera 1 PV
wymzya fe 1 PV
xulane 1 PV
yuvafem 1
zarah 1 PV
zovia 1/35e (28) 1 PV
zumandimine 1 PV
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
54
Drug Name Drug Tier Notes
Progesterone Agonists/Antagonists
ELLA 3 PV
Progestins
camila 1 PV
deblitane 1 PV
DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML
3
DEPO-SUBQ PROVERA 104
3 QL
errin 1 PV
heather 1 PV
hydroxyprogesterone caproate intramuscular oil
4 PA
incassia 1 PV
jencycla 1 PV
KYLEENA 4 PV
levonorgestrel 1 PV
LILETTA (52 MG) 4 PV
lyza 1 PV
MAKENA SUBCUTANEOUS
4 PA
medroxyprogesterone acetate intramuscular
1 PV; QL
medroxyprogesterone acetate oral
LC
megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml
CM
megestrol acetate oral suspension 625 mg/5ml
1
megestrol acetate oral tablet
CM
MIRENA (52 MG) 4 PV
NEXPLANON 3 PV
Drug Name Drug Tier Notes
nora-be 1 PV
norethindrone acetate oral
1
norethindrone oral 1 PV
norlyda 1 PV
norlyroc 1 PV
preventeza 1 PV
progesterone intramuscular
1
progesterone micronized oral
1
sharobel 1 PV
SKYLA 4 PV
SLYND 3 PV
tulana 1 PV
Selective Estrogen Receptor Modifying Agents
OSPHENA 3
raloxifene hcl 1 PV*
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
ARMOUR THYROID 3 ST
euthyrox LC
levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
LC
levo-t oral tablet 300 mcg
1
levothyroxine sodium intravenous
1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
55
Drug Name Drug Tier Notes
levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
LC
levothyroxine sodium oral tablet 300 mcg
1
levothyroxine-liothyronine oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg
1
levoxyl LC
liothyronine sodium intravenous
1
liothyronine sodium oral 1
np thyroid 1
THYROLAR-1 ORAL TABLET 60 (12.5-50) MG (MCG)
3
THYROLAR-1/2 ORAL TABLET 30 (6.25-25) MG (MCG)
3
THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) MG (MCG)
3
THYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG)
3
THYROLAR-3 ORAL TABLET 180 (37.5-150) MG (MCG)
3
unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
LC
unithroid oral tablet 300 mcg
1
WP THYROID 3 ST
Drug Name Drug Tier Notes
Hormonal Agents, Suppressant (Adrenal)
LYSODREN CM
Hormonal Agents, Suppressant (pituitary)
LUPANETA PACK 5 PA; QL
LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG
5 PA
LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 15 MG, 7.5 MG
4 PA
LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 11.25 MG (PED)
5 PA
LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 30 MG (PED)
4 PA
octreotide acetate 4 PA
SIGNIFOR 5 PA; QL
SOMATULINE DEPOT 5 PA
SOMAVERT 5 PA
SUPPRELIN LA 4 PA; QL
SYNAREL 2
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole oral 1
propylthiouracil oral 1
Immunological Agents
Angioedema Agents
BERINERT 5 PA
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
56
Drug Name Drug Tier Notes
CINRYZE 4 PA
icatibant acetate 4 PA
Immune Suppressants
AZASAN 3
azathioprine oral 1
azathioprine sodium 1
CIMZIA 4 PA
CIMZIA PREFILLED KIT
4 PA
CIMZIA STARTER KIT 4 PA
cyclosporine intravenous
1
cyclosporine modified 1
cyclosporine oral 1
ENBREL 5 PA
ENBREL MINI 5 PA
ENBREL SURECLICK 5 PA
gengraf 1
HUMIRA 4 PA
HUMIRA PEDIATRIC CROHNS START
4 PA
HUMIRA PEN 4 PA
HUMIRA PEN-CD/UC/HS STARTER
4 PA
HUMIRA PEN-PS/UV/ADOL HS START
4 PA
INFLECTRA 5 PA
KINERET 5 PA
methotrexate (anti-rheumatic) oral tablet 2.5 mg
1
methotrexate oral CM
methotrexate sodium (pf)
1
methotrexate sodium injection
1
Drug Name Drug Tier Notes
methotrexate sodium oral
CM
mycophenolate mofetil 1
mycophenolate mofetil hcl
1
mycophenolate sodium 1
ORENCIA 5 PA
ORENCIA CLICKJECT 5 PA
PROGRAF INTRAVENOUS
3
RENFLEXIS 5 PA
SANDIMMUNE ORAL SOLUTION
2
SIMPONI 4 PA
SIMPONI ARIA 4 PA
sirolimus oral 1
STELARA INTRAVENOUS
4 PA
tacrolimus oral 1
TREXALL CM
ZORTRESS 3 PA
Immunizing Agents, Passive
BIVIGAM 5 PA
CARIMUNE NF SOLUTION RECONSTITUTED 12 GM INTRAVENOUS
5 PA
carimune nf solution reconstituted 12 gm intravenous
5 PA
CARIMUNE NF SOLUTION RECONSTITUTED 6 GM INTRAVENOUS
5 PA
carimune nf solution reconstituted 6 gm intravenous
5 PA
CUVITRU 5 PA
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
57
Drug Name Drug Tier Notes
CYTOGAM 4 PA
FLEBOGAMMA DIF 5 PA
GAMASTAN 4 PA
gamastan s/d injectable intramuscular
5 PA
GAMASTAN S/D INJECTABLE INTRAMUSCULAR
4 PA
GAMMAGARD 5 PA
GAMMAGARD S/D LESS IGA
5 PA
GAMMAKED 5 PA
GAMMAPLEX 5 PA
GAMUNEX-C 5 PA
HEPAGAM B 5
HIZENTRA 5 PA
HYPERHEP B S/D 5
HYPERRHO S/D 4
HYQVIA 5 PA
MICRHOGAM ULTRA-FILTERED PLUS
4
nabi-hb 5
OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 GM/200ML, 25 GM/500ML, 5 GM/100ML, 5 GM/50ML
5 PA
PRIVIGEN 5 PA
RHOGAM ULTRA-FILTERED PLUS
4
RHOPHYLAC 4
SYNAGIS 4 PA
Drug Name Drug Tier Notes
THYMOGLOBULIN 3
WINRHO SDF 4
Immunomodulators
ACTEMRA 5 PA
ACTEMRA ACTPEN 5 PA
ACTIMMUNE 4 PA
ALFERON N 4
GAMIFANT 5 PA
ILARIS 5 PA; QL
leflunomide oral 1
OTEZLA 4 PA
XELJANZ 5 PA
XELJANZ XR 5 PA
Vaccines
ACTHIB 2 PV
ADACEL 2 PV
AFLURIA 2 PV
AFLURIA PRESERVATIVE FREE
2 PV
AFLURIA QUADRIVALENT
2 PV
BEXSERO 2 PV
BOOSTRIX 2 PV
DAPTACEL 2 PV
DIPHTHERIA-TETANUS TOXOIDS DT
2 PV
ENGERIX-B 2 PV
EZ FLU SHOT-FLUCELVAX QUAD
2 PV
FLUAD 2 PV
FLUARIX QUADRIVALENT
2 PV
FLUBLOK QUADRIVALENT
2 PV
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
58
Drug Name Drug Tier Notes
FLUCELVAX QUADRIVALENT
2 PV
FLULAVAL QUADRIVALENT
2 PV
FLUMIST QUADRIVALENT
2 PV
FLUZONE HIGH-DOSE
2 PV
FLUZONE QUADRIVALENT
2 PV
GARDASIL 9 2 PV
HAVRIX 2 PV
HEPLISAV-B 2 PV
HIBERIX 2 PV
INFANRIX 2 PV
IPOL 2 PV
KINRIX 2 PV
MENACTRA 2 PV
MENVEO 2 PV
M-M-R II 2 PV
PEDIARIX 2 PV
PEDVAX HIB 2 PV
PENTACEL 2 PV
pneumovax 23 injectable 25 mcg/0.5ml injection
2 PV
PNEUMOVAX 23 INJECTABLE 25 MCG/0.5ML INJECTION
2 PV
PREVNAR 13 2 PV
PROQUAD 2 PV
QUADRACEL 2 PV
RECOMBIVAX HB 2 PV
ROTARIX 2 PV
ROTATEQ 2 PV
SHINGRIX 2 PV
Drug Name Drug Tier Notes
TDVAX 2 PV
TENIVAC 2 PV
TRUMENBA 2 PV
TWINRIX 2 PV
VAQTA 2 PV
VARIVAX 2 PV
ZOSTAVAX 2 PV
Inflammatory Bowel Disease Agents
Aminosalicylates
APRISO 2
balsalazide disodium 1
DIPENTUM 3
mesalamine oral capsule delayed release
1
mesalamine oral tablet delayed release 1.2 gm
1
mesalamine rectal 1
mesalamine-cleanser 1
PENTASA 3
Glucocorticoids
budesonide er 1
budesonide oral 1
Sulfonamides
sulfasalazine oral 1
Metabolic Bone Disease Agents
alendronate sodium oral solution
1
alendronate sodium oral tablet 10 mg, 40 mg, 5 mg
1
alendronate sodium oral tablet 35 mg, 70 mg
LC QL
calcitonin (salmon) 1 QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
59
Drug Name Drug Tier Notes
calcitriol intravenous 1
calcitriol oral 1
cinacalcet hcl 1 PA
doxercalciferol intravenous
1
etidronate disodium 1
FORTEO 4 PA
FOSAMAX PLUS D 3 QL
ibandronate sodium 1 QL
MIACALCIN INJECTION
3
pamidronate disodium 4
paricalcitol 1
PROLIA 4 PA; QL
risedronate sodium oral tablet 150 mg, 35 mg
1 QL
risedronate sodium oral tablet 30 mg, 5 mg
1
risedronate sodium oral tablet delayed release
1 QL
zoledronic acid 4
Miscellaneous Therapeutic Agents
albumin human 1
albumin-zlb 1
alburx 1
alcohol prep pads pad , 70 %
3
argyle sterile water 1
bal in oil 1
BD AUTOSHIELD DUO PEN NEEDLES
2
bd posiflush 1
BD ULTRA-FINE INSULIN SYRINGES
2
BD ULTRA-FINE PEN NEEDLES
2
Drug Name Drug Tier Notes
benzalkonium chloride external solution
1
BREATHE EASE LARGE
2
BREATHE EASE MEDIUM
2
BREATHE EASE SMALL
2
BREATHERITE 2
CAYA 3 PV; QL
chlorhexidine gluconate solution 20 %
1
COMFORT EZ MICRO PEN NEEDLES
2
COMFORT EZ SHORT PEN NEEDLES
2
deferoxamine mesylate 1
DROPSAFE SAFETY PEN NEEDLES 31G X 8 MM
2
EASIVENT 2
EASY TOUCH SAFETY PEN NEEDLES
2
FEMCAP 3 PV; QL
FLEXICHAMBER ADULT MASK/SMALL
2
FLEXICHAMBER CHILD MASK/LARGE
2
FLEXICHAMBER CHILD MASK/SMALL
2
fomepizole 1
GOODSENSE CLICKFINE PEN NEEDLE
2
GOODSENSE PEN NEEDLE PENFINE
2
HEALTHWISE INSULIN SYR/NEEDLE
2
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
60
Drug Name Drug Tier Notes
HEALTHWISE MICRON PEN NEEDLES
2
heparin lock flush 1
heparin sodium flush 1
heparin sodium lock flush
1
hepatamine 1
hetastarch-nacl 1
INSPIREASE RESERVOIR BAGS
2
INSULIN PEN NEEDLES
2
INSULIN SYRINGES 2
intralipid intravenous emulsion 20 %
1
J-TIP KIT W/VIAL ADAPTERS
3
kedbumin 1
KEVEYIS 5 PA; QL
lactated ringers irrigation
1
levocarnitine oral solution
1
levocarnitine oral tablet 1
lmd in d5w 1
MASK VORTEX 2
MAXICOMFORT II PEN NEEDLE
2
MAXI-COMFORT SAFETY PEN NEEDLE
2
MAXICOMFORT SYR 27G X 1/2"
2
methergine 1
methylergonovine maleate
1
monoject flush syringe 1
Drug Name Drug Tier Notes
monoject sodium chloride flush
1
n-acetyl-l-cysteine oral 1
normal saline flush 1
NOVOFINE AUTOCOVER PEN NEEDLE
2
NOVOFINE PEN NEEDLE
2
NOVOFINE PLUS PEN NEEDLE
2
NOVOTWIST PEN NEEDLE
2
nutrilipid 1
PANDA MASK LARGE 2
PANDA MASK MEDIUM
2
PANDA MASK SMALL 2
PARAGARD INTRAUTERINE COPPER
3 PV
PEDIATRIC PANDA MASK
2
pocket spacer 1
pralidoxime chloride intramuscular
1
PREVENT SAFETY PEN NEEDLES
2
PRO COMFORT SPACER ADULT
2
PRO COMFORT SPACER CHILD
2
PROCARE SPACER/ADULT MASK
2
PROCARE SPACER/CHILD MASK
2
ringers irrigation 1
saline flush 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
61
Drug Name Drug Tier Notes
saline flush zr 1
SAPS HEALTH CARE ALCOHOL PREP
3
sash kit 1
SECURESAFE INSULIN SYRINGE
2
sodium chloride flush 1
sodium nitrite intravenous
1
sodium thiosulfate intravenous
1
sterile water for irrigation
1
swabflush saline flush 1
tis-u-sol 1
TRUE COMFORT ALCOHOL PREP PADS
3
TRUEPLUS 5-BEVEL PEN NEEDLES
2
ULTRACARE PEN NEEDLES
2
VISTOGARD 3
WIDE-SEAL DIAPHRAGM 60
3 PV; QL
Ophthalmic Agents
Aminoglycosides
gentak 1
gentamicin sulfate ophthalmic
1
neomycin-polymyxin-gramicidin
1
TOBRADEX OPHTHALMIC OINTMENT
3
TOBRADEX ST 3
tobramycin ophthalmic LC
tobramycin-dexamethasone
1
Drug Name Drug Tier Notes
TOBREX OPHTHALMIC OINTMENT
3
Antibacterials, Other
ak-poly-bac 1
bacitracin ophthalmic 1
bacitracin-polymyxin b ophthalmic
1
bacitra-neomycin-polymyxin-hc
1
neomycin-bacitracin zn-polymyx
1
neomycin-polymyxin-dexameth ophthalmic ointment
LC
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1
LC
neomycin-polymyxin-hc ophthalmic
1
neo-polycin 1
neo-polycin hc 1
polycin 1
polymyxin b-trimethoprim
LC
Anti-cytomegalovirus (CMV) Agents
ZIRGAN 3
Antifungals
NATACYN 2
Antiherpetic Agents
trifluridine 1
Macrolides
AZASITE 3
erythromycin ophthalmic
1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
62
Drug Name Drug Tier Notes
Ophthalmic Prostaglandin and Prostamide Analogs
bimatoprost ophthalmic 1 QL
latanoprost ophthalmic 1
LUMIGAN 2 QL
TRAVATAN Z 2 QL
Ophthalmic Agents, Other
altacaine 1
atropine sulfate ophthalmic ointment
1
atropine sulfate ophthalmic solution
LC
cyclopentolate hcl ophthalmic
1
CYSTARAN 5 PA; QL
homatropaire 1
homatropine hbr 1
OMIDRIA 3
proparacaine hcl ophthalmic
1
RESTASIS 2 PA
RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 %
2 PA
tetcaine 1
tetracaine hcl ophthalmic
1
tropicamide ophthalmic solution 0.5 %
1
XIIDRA 2 PA
Ophthalmic Anti-allergy Agents
ALOCRIL 3
ALOMIDE 3
altafrin 1
Drug Name Drug Tier Notes
azelastine hcl ophthalmic
1
BEPREVE 3 ST
cromolyn sodium ophthalmic
1
epinastine hcl 1
LASTACAFT 3 ST
olopatadine hcl ophthalmic
1
PAZEO 2
phenylephrine hcl ophthalmic
1
Ophthalmic Antiglaucoma Agents
acetazolamide er 1
acetazolamide oral 1
acetazolamide sodium 1
ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %
2
apraclonidine hcl 1
AZOPT 2
betaxolol hcl ophthalmic
1
BETIMOL 3
brimonidine tartrate ophthalmic
1
carteolol hcl 1
COMBIGAN 2
dorzolamide hcl ophthalmic
1
dorzolamide hcl-timolol mal
1
dorzolamide hcl-timolol mal pf ophthalmic solution 22.3-6.8 mg/ml
1
IOPIDINE 3
levobunolol hcl 1
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
63
Drug Name Drug Tier Notes
methazolamide oral 1
PHOSPHOLINE IODIDE
2
pilocarpine hcl ophthalmic
1
RHOPRESSA 2
SIMBRINZA 2
timolol maleate ophthalmic gel forming solution
1
timolol maleate ophthalmic solution 0.25 %, 0.5 %
LC
timolol maleate ophthalmic solution 0.5 % (daily)
1
Ophthalmic Anti-inflammatories
bromfenac sodium (once-daily)
1 QL
dexamethasone sodium phosphate ophthalmic
1
diclofenac sodium ophthalmic
1
DUREZOL 3
FLAREX 3
fluorometholone 1
flurbiprofen sodium 1
FML 2
ketorolac tromethamine ophthalmic
1
LOTEMAX SM 3
loteprednol etabonate 1
NEVANAC 3 ST; QL
PRED MILD 2
prednisolone acetate ophthalmic
1
Drug Name Drug Tier Notes
prednisolone sodium phosphate ophthalmic
1
PROLENSA 2 QL
sulfacetamide-prednisolone ophthalmic solution
1
Quinolones
BESIVANCE 3
ciprofloxacin hcl ophthalmic
1
gatifloxacin ophthalmic 1
levofloxacin ophthalmic 1
MOXEZA 2
moxifloxacin hcl ophthalmic
1
ofloxacin ophthalmic 1
Sulfonamides
sulfacetamide sodium ophthalmic
1
Otic Agents
acetic acid otic 1
CIPRO HC 3
CIPRODEX 2
ciprofloxacin hcl otic 1
COLY-MYCIN S 3
flac 1
fluocinolone acetonide otic
1
hydrocortisone-acetic acid
1
neomycin-polymyxin-hc otic
1
ofloxacin otic 1
Respiratory Tract/Pulmonary Agents
Antihistamines
azelastine hcl nasal 1 QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
64
Drug Name Drug Tier Notes
brompheniramine tannate
1
carbinoxamine maleate oral solution
1
carbinoxamine maleate oral tablet 4 mg
1
cetirizine hcl oral solution
1
clemastine fumarate oral tablet 2.68 mg
3
cyproheptadine hcl oral 1
desloratadine 1
dexchlorpheniramine maleate oral
3
diphenhydramine hcl injection
1
diphenhydramine hcl oral elixir
1
hydroxyzine hcl intramuscular solution 25 mg/ml
1
hydroxyzine hcl intramuscular solution 50 mg/ml
LC
hydroxyzine hcl oral LC
hydroxyzine pamoate oral
LC
levocetirizine dihydrochloride oral
1
olopatadine hcl nasal 1 QL
ryvent 1
TUZISTRA XR 3 PA; QL
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR HFA 2 QL
ARNUITY ELLIPTA 2 QL
BECONASE AQ 3 QL
BREO ELLIPTA 2 QL
Drug Name Drug Tier Notes
budesonide inhalation 1 QL
DYMISTA 2 QL
FLOVENT DISKUS 2 QL
FLOVENT HFA 2 QL
flunisolide nasal 1 QL
fluticasone propionate nasal
1
fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose
1 QL
FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT
1 QL
mometasone furoate nasal
1 QL
OMNARIS 3 QL
PULMICORT FLEXHALER
2 QL
SYMBICORT 2 QL
wixela inhub 1 QL
Antileukotrienes
montelukast sodium oral
LC
zafirlukast 1
zileuton er 3 ST
Bronchodilators, Anticholinergic
ANORO ELLIPTA 2 QL
ATROVENT HFA 3 QL
COMBIVENT RESPIMAT
2 QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
65
Drug Name Drug Tier Notes
INCRUSE ELLIPTA 2 QL
ipratropium bromide inhalation
LC QL
ipratropium bromide nasal
LC
ipratropium-albuterol 1 QL
SPIRIVA HANDIHALER
2 QL
SPIRIVA RESPIMAT 2 QL
STIOLTO RESPIMAT 2 QL
Bronchodilators, Sympathomimetic
albuterol sulfate er 1
albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/3ml
1 QL
albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%
LC QL
albuterol sulfate oral 1
AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 MG/0.1ML
3 QL
BROVANA 3 QL
EPINEPHRINE INJECTION SOLUTION 0.3 MG/0.3ML
1
EPINEPHRINE INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.15ML, 0.15 MG/0.3ML
1
EPINEPHRINE SOLUTION AUTO-INJECTOR 0.3 MG/0.3ML INJECTION
1 Made by Mylan
Drug Name Drug Tier Notes
epinephrine solution auto-injector 0.3 mg/0.3ml injection
1
isoproterenol hcl injection
1
levalbuterol hcl inhalation
1 QL
metaproterenol sulfate oral
1
PERFOROMIST 3 QL
PROAIR HFA 2 M; QL
PROAIR RESPICLICK 2 QL
SEREVENT DISKUS 2 QL
terbutaline sulfate injection
1
terbutaline sulfate oral 1
VENTOLIN HFA 2 M; QL
Cystic Fibrosis Agents
BETHKIS 4
CAYSTON 5 PA
KALYDECO 5 PA
ORKAMBI 5 PA; QL
PULMOZYME 4 PA
tobramycin inhalation 4 ST
Mast Cell Stabilizers
cromolyn sodium inhalation
1
Phosphodiesterase Inhibitors, Airways Disease
aminophylline intravenous
1
DALIRESP ORAL TABLET 500 MCG
3 PA
difil-g forte 1
ELIXOPHYLLIN 2
THEO-24 3
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
66
Drug Name Drug Tier Notes
theochron 1
theophylline 1
theophylline er 1
theophylline in d5w 1
Pulmonary Antihypertensives
ADEMPAS 4 PA; QL
alyq 4 PA; QL
ambrisentan 4 PA; QL
bosentan 4 PA; QL
epoprostenol sodium 4 PA
OPSUMIT 4 PA; QL
ORENITRAM 5 PA
sildenafil citrate intravenous
4 PA
sildenafil citrate oral suspension reconstituted
4 PA; QL
sildenafil citrate oral tablet 20 mg
4 PA; QL
tadalafil (pah) 4 PA; QL
TRACLEER 32 MG 4 PA; QL
treprostinil 4 PA; QL
TYVASO 5 PA; QL
TYVASO REFILL 5 PA; QL
TYVASO STARTER 5 PA; QL
UPTRAVI 5 PA; QL
VELETRI 5 PA
VENTAVIS 5 PA; QL
Pulmonary Fibrosis Agents
ESBRIET 5 PA
OFEV 5 PA
Respiratory Tract Agents, Other
acetylcysteine inhalation
1
Drug Name Drug Tier Notes
acetylcysteine intravenous
1
ARALAST NP 5 PA
benzonatate oral capsule 100 mg, 200 mg
LC
benzonatate oral capsule 150 mg
1
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/1.14ML
4 PA; QL
GLASSIA 5 PA
hydrocodone-homatropine
1 PA; QL
hydromet 1 PA; QL
nebusal inhalation nebulization solution 3 %
1
NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED
5 PA; QL
PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED
5 PA
pulmosal 1
sodium chloride inhalation
1
XOLAIR 4 PA
ZEMAIRA 5 PA
Skeletal Muscle Relaxants
atracurium besylate 1
carisoprodol oral tablet 250 mg
1
carisoprodol oral tablet 350 mg
LC
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
67
Drug Name Drug Tier Notes
chlorzoxazone 1
cisatracurium besylate (pf)
1
cisatracurium besylate intravenous solution 20 mg/10ml
1
cyclobenzaprine hcl er oral capsule extended release 24 hour 15 mg
1
cyclobenzaprine hcl oral tablet 10 mg, 5 mg
LC
cyclobenzaprine hcl oral tablet 7.5 mg
1
metaxall oral tablet 800 mg
1
metaxalone 1
methocarbamol injection
1
methocarbamol oral LC
orphenadrine citrate er 1
orphenadrine citrate injection
1
pancuronium bromide 1
rocuronium bromide intravenous solution
1
succinylcholine chloride injection solution
1
vecuronium bromide intravenous solution reconstituted
1
Sleep Disorder Agents
GABA Receptor Modulators
eszopiclone 1 QL
flurazepam hcl 1 PA; QL
zaleplon 1 QL
zolpidem tartrate oral 1 QL
Drug Name Drug Tier Notes
Sleep Disorders, Other
armodafinil 1 PA; QL
BELSOMRA 3 ST; QL
dexmedetomidine hcl in nacl
1
dexmedetomidine hcl intravenous solution 200 mcg/2ml
1
HETLIOZ 5 PA; QL
modafinil 1 PA; QL
pentobarbital sodium injection
1
ramelteon 1 QL
SILENOR 3 QL
For more information regarding the tiers and designations in this drug list, please see the Reading your formulary section of this booklet.
68
Index of Drugs
abacavir sulfate.........................30abacavir sulfate-lamivudine...... 30abacavir-lamivudine-zidovudine.................................30ABELCET..................................21ABILIFY MAINTENA................. 28abiraterone acetate................... 23ABRAXANE.............................. 24acamprosate calcium................ 14acarbose................................... 32ACCU-CHEK FASTCLIX LANCET KIT............................. 31ACCU-CHEK FASTCLIX LANCETS................................. 31ACCU-CHEK MULTICLIX LANCET DEVICE KIT...............31ACCU-CHEK MULTICLIX LANCETS................................. 31ACCU-CHEK SOFT TOUCH LANCETS................................. 31ACCU-CHEK SOFTCLIX LANCET DEVICE KIT...............31ACCU-CHEK SOFTCLIX LANCETS................................. 31acd formula a............................ 34acd formula b............................ 34acd-a noclot-50......................... 34acebutolol hcl............................ 37acetaminophen-codeine............12acetaminophen-codeine #2.......12acetaminophen-codeine #3.......12acetaminophen-codeine #4.......12acetazolamide...........................63acetazolamide er.......................63acetazolamide sodium.............. 63acetic acid........................... 48, 64acetylcysteine........................... 67acitretin..................................... 41ACTEMRA................................ 58ACTEMRA ACTPEN.................58ACTHAR................................... 51ACTHIB.....................................58ACTIMMUNE............................ 58acyclovir.................................... 29acyclovir sodium....................... 29ADACEL....................................58adapalene................................. 41adapalene-benzoyl peroxide.....41adc/f (0.5mg/ml)........................ 44ADCETRIS................................26adefovir dipivoxil ....................... 29ADEMPAS................................ 67adenosine................................. 36
adriamycin.................................24adrucil ....................................... 24ADVAIR HFA............................ 65ADVATE....................................34AFINITOR................................. 25AFINITOR DISPERZ.................25afirmelle.................................... 52AFLURIA...................................58AFLURIA PRESERVATIVE FREE........................................ 58AFLURIA QUADRIVALENT......58airavite...................................... 44ak-poly-bac............................... 62AKYNZEO.................................21ala-cort...................................... 49albendazole...............................27albumin human......................... 60albumin-zlb................................60alburx........................................ 60albuterol sulfate.........................66albuterol sulfate er.................... 66alclometasone dipropionate...... 49alcohol prep pads......................60ALDURAZYME......................... 47alendronate sodium.................. 59alfentanil hcl.............................. 12ALFERON N............................. 58alfuzosin hcl er.......................... 48ALIMTA..................................... 24ALINIA.......................................27aliskiren fumarate......................38allopurinol..................................22allopurinol sodium..................... 22almotriptan malate.................... 22ALOCRIL...................................63ALOMIDE..................................63alosetron hcl..............................46ALPHAGAN P........................... 63alprazolam................................ 31alprazolam er............................ 31alprazolam xr............................ 31alprostadil ..................................51ALTABAX..................................15altacaine....................................63altafrin....................................... 63altavera..................................... 52alyacen 1/35..............................52alyacen 7/7/7.............................52alyq........................................... 67amabelz.................................... 52amantadine hcl..........................31AMBISOME...............................21ambrisentan.............................. 67
amcinonide................................49amethia..................................... 52amethia lo................................. 52amethyst................................... 52amikacin sulfate........................ 15amiloride hcl..............................38amiloride-hydrochlorothiazide... 38aminoacetic acid....................... 48aminocaproic acid..................... 34aminophylline............................ 66amiodarone hcl......................... 36AMITIZA....................................46amitriptyline hcl......................... 20amlodipine besylate.................. 37amlodipine besylate-benazepril hcl............................................. 36amlodipine besylate-valsartan.. 35amlodipine-atorvastatin.............37amlodipine-olmesartan..............35amlodipine-valsartan-hctz......... 36ammonium lactate.....................41amnesteem............................... 41amoxapine................................ 20amoxicill-clarithro-lansopraz..... 46amoxicillin................................. 17amoxicillin-potassium clavulanate................................17amoxicillin-potassium clavulanate er............................17amphetamine sulfate.................40amphetamine-dextroamphetamine.................. 40amphetamine-dextroamphetamine er.............. 40amphotericin b.......................... 21ampicillin................................... 17ampicillin sodium.......................17ampicillin-sulbactam sodium..... 17ANADROL-50........................... 51anagrelide hcl............................34anastrozole............................... 25ANNOVERA..............................52ANORO ELLIPTA..................... 65anticoagulant cit dext soln a......34anticoagulant sodium citrate..... 34ANZEMET.................................21apap-caff-dihydrocodeine......... 12APLENZIN................................ 19APOKYN................................... 27apraclonidine hcl....................... 63aprepitant.................................. 21apri............................................ 52APRISO.................................... 59
69
APTIVUS...................................30ARALAST NP............................67aranelle..................................... 52ARANESP (ALBUMIN FREE)...34argatroban.................................34argyle sterile saline................... 48argyle sterile water....................60aripiprazole............................... 28armodafinil ................................ 68ARMOUR THYROID.................55ARNUITY ELLIPTA...................65ARRANON................................ 24arsenic trioxide..........................24ARZERRA.................................26ascomp-codeine........................12ashlyna......................................52aspirin....................................... 11aspirin adult...............................11aspirin adult low strength.......... 11aspirin childrens........................ 11aspirin ec low dose................... 11aspirin ec low strength.............. 11aspirin low dose........................ 11aspirin-dipyridamole er..............35atazanavir sulfate......................30atenolol..................................... 37atenolol-chlorthalidone..............37atomoxetine hcl.........................40atorvastatin calcium.................. 39atovaquone............................... 27atovaquone-proguanil hcl..........27atracurium besylate...................67ATRIPLA................................... 30atropine sulfate................... 45, 63ATROVENT HFA...................... 65aubra.........................................52aubra eq....................................52AUGMENTIN............................ 17aurovela 1.5/30......................... 52aurovela 1/20............................ 52aurovela 24 fe........................... 52aurovela fe 1.5/30..................... 52aurovela fe 1/20........................ 52AUVI-Q......................................66AVASTIN...................................26AVELOX....................................17aviane....................................... 52avidoxy......................................18avita.......................................... 41AVONEX PEN...........................40AVONEX PREFILLED.............. 40ayuna........................................ 52azacitidine................................. 24
AZASAN....................................57AZASITE................................... 62azathioprine.............................. 57azathioprine sodium..................57azelaic acid............................... 41azelastine hcl...................... 63, 64AZELEX.................................... 41azithromycin..............................17AZOPT...................................... 63aztreonam................................. 17azurette..................................... 52b-6 folic acid..............................44baciim........................................15bacitracin.............................15, 62bacitracin-polymyxin b.............. 62bacitra-neomycin-polymyxin-hc 62baclofen.................................... 29bal in oil .....................................60balsalazide disodium.................59balziva.......................................52BANZEL.................................... 19BARACLUDE............................ 29BAVENCIO............................... 26BAXDELA................................. 17bayer aspirin............................. 11bayer aspirin ec low dose......... 11BD AUTOSHIELD DUO PEN NEEDLES................................. 60bd posiflush...............................60bd pudendal/local tray/1% lido.. 13BD ULTRA-FINE INSULIN SYRINGES............................... 60BD ULTRA-FINE PEN NEEDLES................................. 60BECONASE AQ........................65bekyree..................................... 52BELEODAQ.............................. 24BELSOMRA.............................. 68benazepril hcl............................36benazepril-hydrochlorothiazide. 36BENEFIX...................................34benzalkonium chloride.............. 60BENZNIDAZOLE...................... 27benzonatate.............................. 67benzoyl peroxide-erythromycin. 41benztropine mesylate................27BEPREVE................................. 63BERINERT................................56beser......................................... 49BESIVANCE............................. 64betamethasone dipropionate.... 49betamethasone dipropionate aug............................................ 49
betamethasone sod phos & acet........................................... 49betamethasone valerate........... 49BETASERON............................40betaxolol hcl........................ 37, 63bethanechol chloride.................48BETHKIS...................................66BETIMOL.................................. 63BEVYXXA................................. 34bexarotene................................ 27BEXSERO.................................58bicalutamide..............................23BICILLIN L-A.............................17BIKTARVY................................ 29bimatoprost............................... 63biocel.........................................44bisacodyl ec.............................. 47bisoprolol fumarate................... 37bisoprolol-hydrochlorothiazide.. 37bivalirudin trifluoroacetate......... 34BIVIGAM................................... 57bleomycin sulfate...................... 24BLINCYTO................................ 26blisovi 24 fe............................... 52blisovi fe 1.5/30......................... 52BOOSTRIX............................... 58bosentan................................... 67BOSULIF...................................25BOTOX..................................... 29bp vit 3...................................... 44b-plex........................................ 44b-plex plus.................................44BREATHE EASE LARGE......... 60BREATHE EASE MEDIUM.......60BREATHE EASE SMALL..........60BREATHERITE.........................60BREO ELLIPTA........................ 65briellyn.......................................52BRILINTA..................................35brimonidine tartrate................... 63BRIVIACT................................. 18bromfenac sodium (once-daily).64bromocriptine mesylate.............27brompheniramine tannate......... 65BROVANA................................ 66budesonide......................... 59, 65budesonide er........................... 59bumetanide............................... 38bupivacaine hcl......................... 13bupivacaine hcl (pf)...................13bupivacaine in dextrose............ 13bupivacaine spinal.................... 14bupivacaine-epinephrine...........14
70
bupivacaine-epinephrine (pf).... 14buprenorphine...........................12BUPRENORPHINE...................12buprenorphine hcl............... 12, 14buprenorphine hcl-naloxone hcl............................................. 14bupropion hcl............................ 19bupropion hcl er (smoking det). 14bupropion hcl er (sr)..................19bupropion hcl er (xl).................. 19buspirone hcl.............................31busulfan.................................... 23butalbital-acetaminophen..........11butalbital-apap.......................... 11butalbital-apap-caff-cod............ 13butalbital-apap-caffeine.............11butalbital-asa-caff-codeine........13butalbital-aspirin-caffeine.......... 11butorphanol tartrate...................13BUTRANS.................................12BYDUREON..............................32BYDUREON BCISE AUTOINJECTOR...................... 32BYETTA 10 MCG PEN............. 32BYETTA 5 MCG PEN............... 32BYSTOLIC................................ 37cabergoline............................... 51CABLIVI.................................... 35CABOMETYX........................... 25caffeine citrate...........................40calcipotriene..............................41calcitonin (salmon).................... 59calcitriol............................... 41, 60calcium acetate (phos binder)...49calcium chloride........................ 42calcium gluconate..................... 42camila........................................55CAMPTOSAR........................... 25camrese.................................... 52camrese lo................................ 52candesartan cilexetil ................. 36candesartan cilexetil-hctz..........36CAPASTAT SULFATE..............23capecitabine..............................24CAPRELSA...............................25captopril .................................... 36captopril-hydrochlorothiazide.... 36CARAFATE...............................47CARBAGLU.............................. 47carbamazepine......................... 19carbamazepine er..................... 19carbidopa.................................. 28carbidopa-levodopa.................. 28
carbidopa-levodopa er.............. 28carbidopa-levodopa-entacapone............................... 28carbinoxamine maleate.............65carboplatin................................ 23carboprost tromethamine.......... 51CARDIZEM LA..........................37CARIMUNE NF......................... 57carimune nf............................... 57carisoprodol.............................. 67carmustine................................ 23carteolol hcl...............................63cartia xt..................................... 37carvedilol...................................37carvedilol phosphate er.............37cascara sagrada....................... 47caspofungin acetate..................21cavarest.................................... 41CAYA........................................ 60CAYSTON.................................66caziant.......................................52cefaclor..................................... 16cefaclor er................................. 16cefadroxil ...................................16cefazolin sodium....................... 16cefazolin sodium-dextrose........ 16cefdinir...................................... 16cefditoren pivoxil ....................... 16cefepime hcl..............................16cefepime-dextrose.................... 16cefixime.....................................16cefotaxime sodium.................... 16cefotetan disodium....................16cefotetan disodium-dextrose.....16cefoxitin sodium........................ 16cefpodoxime proxetil ................. 16cefprozil .....................................16ceftazidime................................16ceftazidime and dextrose.......... 16ceftriaxone sodium....................16ceftriaxone sodium in dextrose. 16ceftriaxone sodium-dextrose.....16cefuroxime axetil ....................... 16cefuroxime sodium....................16celecoxib................................... 11CELONTIN................................18cephalexin.................................17CEPROTIN............................... 34CERDELGA.............................. 47CEREZYME.............................. 47cetirizine hcl.............................. 65cevimeline hcl........................... 41CHANTIX.................................. 14
CHANTIX CONTINUING MONTH PAK.............................14CHANTIX STARTING MONTH PAK...........................................14chateal...................................... 52chateal eq................................. 52CHEMET...................................44CHEMSTRIP UGK.................... 31chloramphenicol sod succinate.15chlordiazepoxide hcl................. 31chlordiazepoxide-amitriptyline...20chlorhexidine gluconate...... 41, 60chloroprocaine hcl (pf).............. 14chloroquine phosphate..............27chlorothiazide............................39chlorothiazide sodium............... 39chlorpromazine hcl....................28chlorthalidone............................39chlorzoxazone...........................68CHOLBAM................................ 46cholestyramine..........................39cholestyramine light.................. 39choline fenofibrate.....................39chorionic gonadotropin..............51chromagen................................ 42chromic chloride........................42ciclodan.....................................21ciclopirox................................... 21ciclopirox olamine..................... 21cidofovir.....................................29cilostazol................................... 35CIMDUO................................... 30cimetidine..................................46cimetidine hcl............................ 46CIMZIA......................................57CIMZIA PREFILLED KIT...........57CIMZIA STARTER KIT............. 57cinacalcet hcl............................ 60CINRYZE.................................. 57CIPRO.......................................17CIPRO HC................................ 64CIPRODEX............................... 64ciprofloxacin.............................. 17ciprofloxacin hcl.................. 17, 64ciprofloxacin in d5w...................17cisatracurium besylate.............. 68cisatracurium besylate (pf)........68cisplatin..................................... 23citalopram hydrobromide.......... 20cladribine...................................24claravis......................................41clarithromycin............................17clarithromycin er........................17
71
clearlax......................................47clemastine fumarate..................65clindacin etz.............................. 41clindacin-p.................................41clindamycin hcl..........................15clindamycin palmitate hcl.......... 15clindamycin phosphate....... 15, 41clindamycin phosphate in d5w.. 15clindamycin phosphate-benzoyl peroxide.......................41clindamycin-tretinoin................. 41clinpro 5000.............................. 41clobazam...................................18clobetasol prop emollient base. 49clobetasol propionate................49clobetasol propionate e.............49clobetasol propionate emulsion 49clodan....................................... 49clofarabine................................ 24clomipramine hcl....................... 20clonazepam...............................18clonidine....................................35clonidine hcl.............................. 35clonidine hcl er.......................... 40clopidogrel bisulfate.................. 35clorazepate dipotassium........... 31clotrimazole...............................21clotrimazole-betamethasone.....21clozapine...................................29COAGADEX..............................34coal tar...................................... 41COARTEM................................ 27cod liver oil ................................ 44codeine sulfate..........................13COLCHICINE............................22colchicine-probenecid............... 22COLCRYS.................................22colesevelam hcl........................ 39colestipol hcl............................. 39colistimethate sodium (cba)...... 15colocort..................................... 41COLY-MYCIN S........................ 64COMBIGAN.............................. 63COMBIPATCH.......................... 52COMBIVENT RESPIMAT......... 65COMETRIQ (100 MG DAILY DOSE).......................................26COMETRIQ (140 MG DAILY DOSE).......................................26COMETRIQ (60 MG DAILY DOSE).......................................26COMFORT EZ MICRO PEN NEEDLES................................. 60
COMFORT EZ SHORT PEN NEEDLES................................. 60COMPLERA..............................30compro...................................... 21CONDYLOX..............................41constulose.................................47COPAXONE..............................40CORDRAN................................49CORIFACT................................34CORTIFOAM............................ 41cortisone acetate.......................49CORTISPORIN......................... 15corvita....................................... 44corvita 150................................ 42corvite free................................ 44COSENTYX (300 MG DOSE)...41COSENTYX 150 MG/ML.......... 41COSENTYX SENSOREADY (300 MG)...................................41COSENTYX SENSOREADY PEN...........................................41COTELLIC................................ 24CREON..................................... 47CRESEMBA..............................22CRIXIVAN................................. 30cromolyn sodium...........46, 63, 66crotan........................................ 27cryselle-28.................................52CUVITRU.................................. 57CUVPOSA................................ 45cyanocobalamin........................ 44cyclafem 1/35............................52cyclafem 7/7/7...........................52cyclobenzaprine hcl.................. 68cyclobenzaprine hcl er.............. 68cyclopentolate hcl..................... 63cyclophosphamide.................... 23cycloserine................................ 23CYCLOSET...............................32cyclosporine.............................. 57cyclosporine modified............... 57cyproheptadine hcl....................65CYRAMZA................................ 26cyred......................................... 52cyred eq.................................... 52CYSTADANE............................ 47CYSTAGON..............................47CYSTARAN.............................. 63cytarabine................................. 24cytarabine (pf)........................... 24CYTOGAM................................58dacarbazine.............................. 23dactinomycin............................. 24
dalfampridine er........................ 40DALIRESP................................ 66danazol..................................... 51dantrolene sodium.................... 29dapsone.............................. 23, 41DAPTACEL............................... 58daptomycin................................15DARAPRIM............................... 27darifenacin hydrobromide er..... 48DARZALEX............................... 26dasetta 1/35.............................. 52dasetta 7/7/7............................. 52daunorubicin hcl........................24daysee...................................... 52DAYTRANA.............................. 40DEBACTEROL..........................41deblitane................................... 55decara....................................... 44decitabine..................................24deferasirox................................ 44deferoxamine mesylate.............60dehydrated alcohol....................42deltasone.................................. 49delyla.........................................52demeclocycline hcl....................18DEMSER...................................38denta 5000 plus........................ 41dentagel.................................... 41DEPEN TITRATABS.................44DEPO-MEDROL....................... 49DEPO-PROVERA..................... 55DEPO-SUBQ PROVERA 104...55DESCOVY................................ 30desipramine hcl.........................20desloratadine............................ 65desmopressin ace spray refrig..51desmopressin acetate...............51desmopressin acetate spray..... 51desogestrel-ethinyl estradiol..... 52desonide................................... 49desoximetasone........................49desvenlafaxine succinate er......20dexamethasone........................ 49DEXAMETHASONE INTENSOL................................ 49dexamethasone sod phosphate pf............................. 49dexamethasone sodium phosphate........................... 49, 64dexchlorpheniramine maleate...65dexifol........................................44DEXILANT................................ 47dexmedetomidine hcl................ 68
72
dexmedetomidine hcl in nacl.....68dexmethylphenidate hcl............ 40dexmethylphenidate hcl er........ 40dexrazoxane............................. 24dexrazoxane hcl........................24dextroamphetamine sulfate.......40dextroamphetamine sulfate er.. 40dextrose.................................... 42dextrose in lactated ringers.......42dextrose-nacl............................ 42dialyvite..................................... 44diazepam............................ 18, 31diazepam intensol..................... 31diclofenac potassium................ 11diclofenac sodium......... 11, 24, 64diclofenac sodium er................. 11diclofenac-misoprostol.............. 11dicloxacillin sodium................... 17dicyclomine hcl....................45, 46didanosine.................................30DIFICID..................................... 17difil-g forte................................. 66diflunisal.................................... 11digitek........................................38digox......................................... 38digoxin.......................................38dihydroergotamine mesylate.....22DILANTIN..................................19DILATRATE-SR........................ 39diltiazem hcl.............................. 38diltiazem hcl er.................... 37, 38diltiazem hcl er beads............... 37diltiazem hcl er coated beads... 37dilt-xr......................................... 38dimenhydrinate......................... 21DIPENTUM............................... 59diphenhydramine hcl.................65diphenoxylate-atropine..............46DIPHTHERIA-TETANUS TOXOIDS DT............................ 58dipyridamole..............................35disopyramide phosphate...........36disulfiram...................................14divalproex sodium..................... 18divalproex sodium er.................18DIVIGEL....................................52dobutamine hcl..........................38dobutamine in d5w....................38docetaxel...................................24dofetilide....................................36donepezil hcl............................. 19dopamine hcl.............................38dopamine in d5w.......................38
dorzolamide hcl.........................63dorzolamide hcl-timolol mal...... 63dorzolamide hcl-timolol mal pf.. 63dotti ........................................... 52doxazosin mesylate.................. 48doxepin hcl..........................20, 41doxercalciferol...........................60doxorubicin hcl.......................... 24doxorubicin hcl liposomal..........24doxy 100................................... 18doxycycline............................... 41doxycycline hyclate................... 18doxycycline monohydrate......... 18doxylamine-pyridoxine.............. 21dronabinol................................. 21droperidol.................................. 21DROPSAFE SAFETY PEN NEEDLES................................. 60drospiren-eth estrad-levomefol. 52drospirenone-ethinyl estradiol...52DROXIA.................................... 24DUAVEE................................... 52duloxetine hcl............................ 20DUPIXENT..........................42, 67duramorph.................................13duraxin...................................... 11DUREZOL.................................64dutasteride................................ 48dutasteride-tamsulosin hcl........ 48DYMISTA.................................. 65DYRENIUM...............................38EASIVENT................................ 60EASY TOUCH SAFETY PEN NEEDLES................................. 60easygel......................................41ec-naproxen.............................. 11econazole nitrate.......................22ed-spaz..................................... 46EDURANT.................................30efavirenz................................... 30effer-k........................................42ELAPRASE............................... 47eletriptan hydrobromide............ 22elinest........................................52ELIQUIS....................................34ELIQUIS STARTER PACK....... 34ELITEK......................................24ELIXOPHYLLIN........................ 66ELLA......................................... 55ELMIRON..................................48ELOCTATE............................... 34EMBEDA...................................12EMCYT..................................... 24
emoquette................................. 52EMPLICITI................................ 26EMSAM.....................................20EMTRIVA.................................. 30EMVERM.................................. 27enalapril maleate.......................36enalaprilat................................. 36enalapril-hydrochlorothiazide.... 36ENBREL....................................57ENBREL MINI........................... 57ENBREL SURECLICK.............. 57endocet..................................... 13ENGERIX-B.............................. 58enoxaparin sodium....................34enpresse-28.............................. 52enskyce.....................................52entacapone............................... 27entecavir................................... 29ENTRESTO.............................. 38enulose..................................... 47EPCLUSA................................. 29ephedrine sulfate...................... 38EPIDUO FORTE....................... 42epinastine hcl............................ 63EPINEPHRINE..........................66epinephrine............................... 66epinephrine pf........................... 38epirubicin hcl............................. 24epitol......................................... 19EPIVIR HBV..............................29eplerenone................................ 39epoprostenol sodium.................67eprosartan mesylate................. 36eptifibatide.................................35ERBITUX.................................. 26ergocalciferol.............................44ergoloid mesylates.................... 19ergotamine-caffeine.................. 22ERIVEDGE............................... 26erlotinib hcl................................26errin...........................................55ertapenem sodium.................... 17ERWINAZE............................... 24ery............................................. 42erythromycin....................... 42, 62erythromycin base.....................17erythromycin ethylsuccinate......17ESBRIET...................................67escitalopram oxalate................. 20esmolol hcl................................ 37esmolol hcl-sodium chloride......37esomeprazole sodium...............47estarylla.....................................53
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estazolam..................................31estradiol.................................... 53estradiol valerate.......................53estradiol-norethindrone acet..... 53eszopiclone............................... 68ethacrynate sodium...................38ethacrynic acid.......................... 38ethambutol hcl...........................23ethosuximide.............................18ethyl chloride.............................14ethynodiol diac-eth estradiol..... 53ETHYOL....................................24etidronate disodium...................60etodolac.................................... 11etodolac er................................ 11etoposide.................................. 25EURAX......................................27euthyrox.................................... 55EVAMIST.................................. 53EVOTAZ....................................30exemestane.............................. 25ex-lax ultra................................ 47exoderm.................................... 22EZ FLU SHOT-FLUCELVAX QUAD........................................58ezetimibe...................................39ezetimibe-simvastatin............... 39fabb........................................... 44FABRAZYME............................ 47falmina...................................... 53famciclovir................................. 29famotidine................................. 46famotidine premixed..................46FANAPT....................................28FANAPT TITRATION PACK..... 28FARYDAK................................. 24fa-vitamin b-6-vitamin b-12....... 44fayosim......................................53febuxostat................................. 22FEIBA........................................34felbamate.................................. 19felodipine er.............................. 38FEMCAP................................... 60femynor..................................... 53fenofibrate................................. 39fenofibrate micronized...............39fenofibric acid............................39fenoprofen calcium....................11fenortho.....................................11fentanyl..................................... 12fentanyl citrate...........................13ferocon...................................... 42ferotrinsic.................................. 43
ferraplus 90............................... 43FERRIPROX............................. 44ferrocite plus............................. 43FETZIMA...................................20FETZIMA TITRATION...............20FIBRYGA.................................. 34finasteride................................. 48flac............................................ 64FLAREX.................................... 64flavoxate hcl.............................. 48FLEBOGAMMA DIF..................58flecainide acetate...................... 36FLEXICHAMBER ADULT MASK/SMALL........................... 60FLEXICHAMBER CHILD MASK/LARGE...........................60FLEXICHAMBER CHILD MASK/SMALL........................... 60FLOVENT DISKUS................... 65FLOVENT HFA......................... 65floxuridine..................................24FLUAD...................................... 58FLUARIX QUADRIVALENT......58FLUBLOK QUADRIVALENT.....58FLUCELVAX QUADRIVALENT...................... 59fluconazole................................22fluconazole in sodium chloride..22flucytosine................................. 22fludarabine phosphate.............. 24fludrocortisone acetate..............49FLULAVAL QUADRIVALENT... 59flumazenil ..................................40FLUMIST QUADRIVALENT......59flunisolide.................................. 65fluocinolone acetonide........ 50, 64fluocinolone acetonide body..... 50fluocinolone acetonide scalp.....50fluocinonide...............................50fluocinonide emulsified base.....50fluoridex.................................... 41fluoridex daily renewal.............. 41fluoridex enhanced whitening... 41fluoridex sensitivity relief........... 41fluoritab..................................... 43fluorometholone........................ 64FLUOROPLEX..........................24fluorouracil ................................ 24FLUOROURACIL......................24fluoxetine hcl............................. 20fluoxetine hcl (pmdd).................20fluphenazine decanoate............28fluphenazine hcl........................ 28
flurazepam hcl...........................68flurbiprofen................................ 11flurbiprofen sodium................... 64flutamide................................... 23fluticasone propionate.........50, 65fluticasone-salmeterol............... 65FLUTICASONE-SALMETEROL..........................65fluvastatin sodium..................... 39fluvastatin sodium er................. 39fluvoxamine maleate................. 20fluvoxamine maleate er.............20FLUZONE HIGH-DOSE............59FLUZONE QUADRIVALENT.... 59FML...........................................64folbee........................................ 44folbee plus.................................44folbee plus cz............................ 44folic acid.................................... 44FOLOTYN................................. 24folplex 2.2..................................44foltrin......................................... 43fomepizole.................................60fondaparinux sodium.................34FORTEO................................... 60FOSAMAX PLUS D.................. 60fosamprenavir calcium.............. 30fosinopril sodium....................... 36fosinopril sodium-hctz............... 36fosphenytoin sodium................. 19FOSRENOL.............................. 49frovatriptan succinate................22fulvestrant................................. 24furosemide................................ 38FUZEON................................... 30fyavolv.......................................53FYCOMPA................................ 18gabapentin................................ 18galantamine hydrobromide....... 19galantamine hydrobromide er... 19GAMASTAN..............................58gamastan s/d............................ 58GAMASTAN S/D.......................58GAMIFANT............................... 58GAMMAGARD.......................... 58GAMMAGARD S/D LESS IGA..58GAMMAKED............................. 58GAMMAPLEX........................... 58GAMUNEX-C............................ 58ganciclovir sodium.................... 29GARDASIL 9.............................59gatifloxacin................................ 64GATTEX....................................46
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gavilax.......................................47gavilyte-c...................................47gavilyte-g...................................47gavilyte-h...................................47gavilyte-n with flavor pack.........47GAZYVA................................... 26GELNIQUE............................... 48GELNIQUE PUMP.................... 48gemcitabine hcl......................... 24gemfibrozil .................................39generlac.................................... 47gengraf......................................57gentak....................................... 62gentamicin in saline.................. 15gentamicin sulfate............... 15, 62gentle laxative........................... 47GENVOYA................................ 30GEODON.................................. 28gianvi.........................................53GIAPREZA................................38GILENYA.................................. 40GILOTRIF................................. 26GLASSIA...................................67glatiramer acetate..................... 40glatopa...................................... 40GLEOSTINE............................. 23glimepiride.................................32glipizide er.................................32glipizide ir.................................. 32glipizide xl................................. 32glipizide-metformin hcl.............. 32GLUCAGEN HYPOKIT............. 33GLUCAGON EMERGENCY..... 33glucose......................................43glyburide................................... 32glyburide micronized................. 32glyburide-metformin.................. 32glycine.......................................48glycine urologic......................... 48glycolax..................................... 47glycopyrrolate............................46glycopyrrolate pf........................46glydo......................................... 14GLYXAMBI................................32gnp folic acid............................. 44GOODSENSE CLICKFINE PEN NEEDLE........................... 60GOODSENSE PEN NEEDLE PENFINE.................................. 60GRALISE.................................. 40GRALISE STARTER.................40granisetron hcl.......................... 21griseofulvin microsize................22
griseofulvin ultramicrosize.........22guanfacine hcl...........................35guanfacine hcl er.......................40GUANIDINE HCL......................23GYNAZOLE-1........................... 22hailey 24 fe................................53HALAVEN................................. 24halobetasol propionate..............50haloperidol................................ 28haloperidol decanoate...............28haloperidol lactate.....................28HARVONI..................................29HAVRIX.....................................59HEALTHWISE INSULIN SYR/NEEDLE........................... 60HEALTHWISE MICRON PEN NEEDLES................................. 61heather......................................55HELIXATE FS........................... 34hematinic plus vit/minerals........43hematinic/folic acid....................43hematogen................................ 43hematogen forte........................43HEMLIBRA................................34hemocyte-f................................ 43hemocyte-plus...........................43hemofil m.................................. 35HEMOFIL M.............................. 35HEPAGAM B.............................58heparin (porcine) in nacl........... 34heparin lock flush...................... 61heparin sod (porcine) in d5w.....34heparin sodium (porcine).......... 34heparin sodium (porcine) pf...... 34heparin sodium flush.................61heparin sodium lock flush......... 61hepatamine............................... 61HEPLISAV-B.............................59HERCEPTIN............................. 27hetastarch-nacl......................... 61HETLIOZ...................................68HIBERIX....................................59HIZENTRA................................ 58homatropaire.............................63homatropine hbr........................63HUMALOG KWIKPEN.............. 33HUMALOG MIX 50/50 KWIKPEN................................. 33HUMALOG MIX 50/50 VIAL......33HUMALOG MIX 75/25 KWIKPEN................................. 33HUMALOG MIX 75/25 VIAL......33
HUMALOG U-100 JUNIOR KWIKPEN................................. 33HUMALOG U-100 VIAL AND CARTRIDGE.............................33HUMATE-P............................... 35HUMIRA....................................57HUMIRA PEDIATRIC CROHNS START......................57HUMIRA PEN........................... 57HUMIRA PEN-CD/UC/HS STARTER................................. 57HUMIRA PEN-PS/UV/ADOL HS START................................ 57HUMULIN 70/30 KWIKPEN...... 33HUMULIN 70/30 VIAL...............33HUMULIN N KWIKPEN............ 33HUMULIN N VIAL..................... 33HUMULIN R U-500 KWIKPEN..33HUMULIN R U-500 VIAL (CONCENTRATED)..................33HUMULIN R VIAL..................... 33HYCAMTIN............................... 25hydralazine hcl.......................... 39hydrochlorothiazide...................39hydrocodone-acetaminophen... 13hydrocodone-homatropine........ 67hydrocodone-ibuprofen............. 13hydrocortisone.................... 42, 50hydrocortisone ace-pramoxine..42hydrocortisone butyrate............ 50hydrocortisone valerate.............50hydrocortisone-acetic acid........ 64hydromet................................... 67hydromorphone hcl................... 13hydromorphone hcl er............... 12hydromorphone hcl pf............... 13hydroxocobalamin acetate........ 44hydroxychloroquine sulfate....... 27hydroxyprogesterone caproate. 55hydroxyurea.............................. 24hydroxyzine hcl......................... 65hydroxyzine pamoate................65hyoscyamine sulfate................. 46hyoscyamine sulfate sl..............46HYPERHEP B S/D....................58HYPERRHO S/D.......................58HYQVIA.................................... 58HYSINGLA ER..........................12ibandronate sodium.................. 60IBRANCE.................................. 25ibu............................................. 11ibuprofen................................... 11ibuprofen lysine.........................11
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ibutilide fumarate.......................36icatibant acetate........................57ICLUSIG....................................26idarubicin hcl............................. 25iferex 150 forte.......................... 43ifosfamide..................................23ILARIS.......................................58imatinib mesylate...................... 26IMBRUVICA.............................. 26imipenem-cilastatin................... 17imipramine hcl...........................21imipramine pamoate................. 21imiquimod..................................42IMPAVIDO................................ 15incassia..................................... 55INCRELEX................................ 51INCRUSE ELLIPTA.................. 66indapamide............................... 39indomethacin.............................11indomethacin er........................ 11indomethacin sodium................ 11INFANRIX................................. 59INFLECTRA.............................. 57infuvite adult..............................44infuvite pediatric........................ 44INLYTA..................................... 26INPEN 100-BLUE-LILLY...........31INPEN 100-BLUE-NOVO..........31INPEN 100-GRAY-LILLY.......... 31INPEN 100-GREY-NOVO.........32INPEN 100-PINK-LILLY............32INPEN 100-PINK-NOVO...........32INSPIREASE RESERVOIR BAGS........................................ 61INSULIN PEN NEEDLES..........61INSULIN SYRINGES................ 61INTELENCE..............................30intralipid.....................................61INTRAROSA............................. 50INTRON A.................................29introvale.................................... 53INVEGA SUSTENNA................28INVEGA TRINZA...................... 28INVIRASE................................. 30INVOKAMET.............................32INVOKAMET XR.......................32INVOKANA............................... 32iodine strong............................. 43iodine tincture............................15IOPIDINE.................................. 63IPOL..........................................59ipratropium bromide.................. 66ipratropium-albuterol................. 66
irbesartan.................................. 36irbesartan-hydrochlorothiazide..36irinotecan hcl.............................25ISENTRESS..............................30ISENTRESS HD....................... 30isibloom.....................................53isoniazid.................................... 23isoproterenol hcl........................66isosorbide dinitrate....................39isosorbide dinitrate er................39isosorbide mononitrate..............39isosorbide mononitrate er......... 40isotretinoin.................................42isradipine...................................38ISTODAX (OVERFILL)............. 25itraconazole...............................22ivermectin..................................27IXEMPRA KIT........................... 25JADENU....................................44JADENU SPRINKLE.................44JAKAFI......................................26jantoven.................................... 34JANUMET................................. 32JANUMET XR........................... 32JANUVIA...................................32JARDIANCE..............................32jasmiel.......................................53jencycla..................................... 55JENTADUETO.......................... 32JENTADUETO XR.................... 32JEVTANA..................................25jinteli ..........................................53jolessa.......................................53J-TIP KIT W/VIAL ADAPTERS. 61juleber....................................... 53JULUCA.................................... 30junel 1.5/30............................... 53junel 1/20.................................. 53junel fe 1.5/30........................... 53junel fe 1/20.............................. 53junel fe 24................................. 53KADCYLA................................. 27kaitlib fe.....................................53KALETRA..................................30kalliga........................................53KALYDECO.............................. 66KANUMA...................................47kariva........................................ 53kcl in d5w lactated ringers.........43kcl in dextrose-nacl................... 43kcl-lactated ringers-d5w............ 43kedbumin.................................. 61kelnor 1/35................................ 53
kelnor 1/50................................ 53KERYDIN.................................. 22KETOCARE.............................. 32ketoconazole.............................22ketoprofen................................. 11ketoprofen er.............................11ketorolac tromethamine...... 11, 64KETOSTIX................................ 32KEVEYIS...................................61KINERET.................................. 57KINRIX...................................... 59kionex........................................44klor-con..................................... 43klor-con 10................................ 43klor-con m10............................. 43KLOR-CON M15....................... 43klor-con m20............................. 43klor-con sprinkle........................43klor-con/ef................................. 43KOATE......................................35KOATE-DVI...............................35koate-dvi................................... 35KOGENATE FS........................ 35KORLYM...................................51k-prime...................................... 43k-tan plus.................................. 43kurvelo...................................... 53KUVAN......................................47KYLEENA................................. 55KYPROLIS................................ 25labetalol hcl............................... 37lactated ringers................... 43, 61lactic acid.................................. 42lactic acid e............................... 42lactulose....................................47lactulose encephalopathy......... 47lamivudine...........................29, 30lamivudine-zidovudine.............. 30lamotrigine................................ 19lamotrigine er............................ 19lamotrigine starter kit-blue.........19lamotrigine starter kit-green...... 19lamotrigine starter kit-orange.... 19LANCETS................................. 32lansoprazole..............................47lanthanum carbonate................ 49LANTUS SOLOSTAR............... 33LANTUS U-100 VIAL................ 33larin 1.5/30................................ 53larin 1/20................................... 53larin 24 fe.................................. 53larin fe 1.5/30............................ 53larin fe 1/20............................... 53
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larissia.......................................53LASTACAFT............................. 63latanoprost................................ 63LATUDA....................................28layolis fe.................................... 53leena......................................... 53leflunomide................................58LENVIMA (10 MG DAILY DOSE).......................................26LENVIMA (12 MG DAILY DOSE).......................................26LENVIMA (14 MG DAILY DOSE).......................................26LENVIMA (18 MG DAILY DOSE).......................................26LENVIMA (20 MG DAILY DOSE).......................................26LENVIMA (24 MG DAILY DOSE).......................................26LENVIMA (4 MG DAILY DOSE).......................................26LENVIMA (8 MG DAILY DOSE).......................................26lessina.......................................53letrozole.................................... 25leucovorin calcium.................... 25LEUKERAN...............................23leuprolide acetate......................51levalbuterol hcl.......................... 66LEVEMIR U-100 FLEXTOUCH.33LEVEMIR U-100 VIAL...............33levetiracetam.............................18levetiracetam er........................ 18levetiracetam in nacl................. 18levobunolol hcl.......................... 63levocarnitine..............................61levocetirizine dihydrochloride....65levofloxacin......................... 18, 64levofloxacin in d5w....................18levoleucovorin calcium..............25levoleucovorin calcium pf..........25levonest.....................................53levonorgest-eth est & eth est.... 53levonorgest-eth estrad 91-day.. 53levonorgestrel........................... 55levonorgestrel-ethinyl estrad.....53levonorg-eth estrad triphasic.....53levora 0.15/30 (28)....................53levorphanol tartrate................... 13levo-t......................................... 55levothyroxine sodium.......... 55, 56levothyroxine-liothyronine......... 56levoxyl....................................... 56
LEXIVA..................................... 30lidocaine....................................14lidocaine hcl.............................. 14lidocaine hcl (cardiac)............... 36lidocaine hcl (cardiac) pf........... 36lidocaine hcl (pf)........................14lidocaine hcl urethral/mucosal...14lidocaine in d5w........................ 36lidocaine viscous.......................14lidocaine-epinephrine................14lidocaine-prilocaine................... 14LILETTA (52 MG)......................55lillow.......................................... 53lincomycin hcl............................15lindane...................................... 27linezolid..................................... 15linezolid in sodium chloride....... 15LINZESS................................... 46liothyronine sodium................... 56lisinopril ..................................... 36lisinopril-hydrochlorothiazide.....36lithium........................................31lithium carbonate.......................31lithium carbonate er.................. 31LIVALO..................................... 39lmd in d5w.................................61LO LOESTRIN FE.....................53LONSURF.................................24loperamide hcl...........................46lopinavir-ritonavir.......................30lopreeza.................................... 53lorazepam................................. 31lorazepam intensol....................31lorcet......................................... 13lorcet hd.................................... 13lorcet plus..................................13loryna........................................ 53losartan potassium....................36losartan potassium-hctz............ 36LOTEMAX SM.......................... 64loteprednol etabonate............... 64lovastatin...................................39low-ogestrel...............................53loxapine succinate.................... 28lo-zumandimine.........................53ludent........................................ 43LUMIGAN..................................63LUMIZYME............................... 47LUPANETA PACK.................... 56LUPRON DEPOT (1-MONTH)..51LUPRON DEPOT (3-MONTH)..51LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG..51
LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG..51LUPRON DEPOT-PED (1-MONTH)....................................56LUPRON DEPOT-PED (3-MONTH)....................................56lutera......................................... 53LYNPARZA............................... 25lysiplex plus...............................45LYSODREN.............................. 56lyza............................................55mafenide acetate...................... 15magnesium chloride..................43magnesium citrate.....................47magnesium sulfate....................43magnesium sulfate in d5w........ 43MAKENA...................................55malathion.................................. 27mannitol.................................... 38maprotiline hcl...........................20marlissa.....................................53MARPLAN.................................20MARQIBO................................. 25MASK VORTEX........................ 61MATULANE.............................. 23matzim la...................................38MAVYRET.................................29MAXICOMFORT II PEN NEEDLE....................................61MAXI-COMFORT SAFETY PEN NEEDLE........................... 61MAXICOMFORT SYR 27G X 1/2"............................................61MAXIPIME................................ 17meclizine hcl............................. 21meclofenamate sodium.............11medique aspirin.........................11medroxyprogesterone acetate.. 55mefloquine hcl...........................27megestrol acetate..................... 55MEKINIST................................. 26melodetta 24 fe......................... 53meloxicam.................................11melphalan................................. 23melphalan hcl............................23memantine hcl...........................19memantine hcl er...................... 19MENACTRA..............................59MENEST................................... 53MENVEO.................................. 59meperidine hcl...........................13meprobamate............................31MEPSEVII................................. 47
77
mercaptopurine......................... 24meropenem...............................17mesalamine...............................59mesalamine-cleanser................59mesna....................................... 25MESNEX...................................25metadate er...............................40metaproterenol sulfate.............. 66metaxall .....................................68metaxalone............................... 68metformin hcl er........................ 32metformin hcl ir ......................... 33methadone hcl.......................... 12methadone hcl intensol............. 12methadose................................ 12methadose sugar-free...............12methamphetamine hcl...............40methazolamide..........................64methenamine hippurate............ 15methergine................................ 61methimazole..............................56METHITEST..............................52methocarbamol......................... 68methotrexate............................. 57methotrexate (anti-rheumatic)...57methotrexate sodium................ 57methotrexate sodium (pf).......... 57methoxsalen..............................42methoxsalen rapid.....................42methscopolamine bromide........46methyldopa............................... 35methyldopa-hydrochlorothiazide...................35methylergonovine maleate........61methylphenidate hcl.................. 40methylphenidate hcl er..............40methylphenidate hcl er (cd).......40methylphenidate hcl er (la)........40methylprednisolone...................50methylprednisolone acetate...... 50methylprednisolone sodium succ...........................................50methyltestosterone....................52metoclopramide hcl...................46metolazone............................... 39metoprolol succinate er.............37metoprolol tartrate.....................37metoprolol-hydrochlorothiazide.37metronidazole..................... 15, 42metronidazole in nacl................ 15mexiletine hcl............................ 36MIACALCIN.............................. 60mibelas 24 fe.............................53
miconazole 3.............................22MICRHOGAM ULTRA-FILTERED PLUS...................... 58microgestin 1.5/30.....................53microgestin 1/20........................53microgestin fe 1.5/30.................53microgestin fe 1/20....................53midodrine hcl.............................38mifepristone.............................. 51miglitol.......................................33miglustat....................................47mili .............................................53milrinone lactate........................38milrinone lactate in dextrose..... 38mimvey......................................53mimvey lo..................................53mineral oil heavy....................... 47minitran..................................... 40MINOCIN.................................. 18minocycline hcl..........................18minoxidil .................................... 39MIRENA (52 MG)......................55mirtazapine............................... 20MIRVASO................................. 42misoprostol................................47mitigo........................................ 12mitomycin..................................25mitoxantrone hcl........................25M-M-R II.................................... 59modafinil ....................................68moexipril hcl.............................. 36molindone hcl............................28mometasone furoate........... 50, 65mondoxyne nl............................18monoject flush syringe.............. 61monoject sodium chloride flush.61mono-linyah.............................. 53montelukast sodium.................. 65morgidox................................... 18morphine sulfate................. 12, 13morphine sulfate (concentrate). 13morphine sulfate (pf)................. 13morphine sulfate er................... 12morphine sulfate er beads........ 12MOVIPREP............................... 47MOXEZA...................................64moxifloxacin hcl...................18, 64moxifloxacin hcl in nacl............. 18MOZOBIL..................................34multi prenatal............................ 45multigen.................................... 43multigen folic............................. 43multigen plus.............................43
multi-vit/iron/fluoride..................45multivitamin/fluoride.................. 45multi-vitamin/fluoride................. 45multivitamin/fluoride/iron........... 45multi-vitamin/fluoride/iron.......... 45multivitamins/fluoride................ 45mupirocin.................................. 15mutamycin.................................25mvc-fluoride.............................. 45MYALEPT................................. 48mycophenolate mofetil .............. 57mycophenolate mofetil hcl........ 57mycophenolate sodium............. 57MYLERAN.................................23mynephron................................ 45myorisan................................... 42MYRBETRIQ.............................48na ferric gluc cplx in sucrose.....43nabi-hb...................................... 58nabumetone.............................. 11n-acetyl-l-cysteine..................... 61nafcillin sodium......................... 17nafrinse..................................... 43nafrinse drops........................... 43naftifine hcl................................22NAGLAZYME............................48nalbuphine hcl...........................13naloxone hcl..............................14naltrexone hcl............................14NAMZARIC............................... 19naproxen................................... 11naproxen dr...............................11naproxen sodium...................... 12naratriptan hcl........................... 22NARCAN...................................14NASCOBAL.............................. 45NATACYN.................................62NATAZIA...................................54nateglinide.................................33NEBUPENT.............................. 27nebusal..................................... 67necon 0.5/35 (28)......................54nefazodone hcl..........................20neomycin sulfate....................... 15neomycin-bacitracin zn-polymyx.....................................62neomycin-polymyxin b gu......... 48neomycin-polymyxin-dexameth 62neomycin-polymyxin-gramicidin..................................62neomycin-polymyxin-hc...... 62, 64neo-polycin................................62neo-polycin hc...........................62
78
neostigmine methylsulfate........ 23NEO-SYNALAR........................ 15nephronex................................. 45neuac........................................ 42NEULASTA............................... 34NEULASTA ONPRO.................34NEUPRO...................................27neutral sodium fluoride..............41NEVANAC.................................64nevirapine................................. 30nevirapine er............................. 30NEXAVAR.................................26NEXPLANON............................55niacin er (antihyperlipidemic).... 39nicardipine hcl........................... 38nicotine polacrilex............... 14, 15nicotine step 1...........................15nicotine step 2...........................15nicotine step 3...........................15NICOTROL............................... 15NICOTROL NS......................... 15nifedipine...................................38nifedipine er.............................. 38nifedipine er osmotic release.... 38nikki...........................................54nilutamide..................................24nimodipine.................................38NINLARO.................................. 25NIPENT.....................................24nisoldipine er.............................38NITRO-BID................................40nitrofurantoin............................. 15nitrofurantoin macrocrystal........15nitrofurantoin monohydrate macrocrystals............................15nitroglycerin...............................40nitroglycerin in d5w................... 40NITROMIST.............................. 40nitroprusside sodium.................40NIVESTYM................................34nizatidine...................................46nora-be......................................55NORDITROPIN FLEXPRO....... 51norepinephrine bitartrate...........38norethin ace-eth estrad-fe.........54norethindrone............................55norethindrone acetate............... 55norethindrone acet-ethinyl est...54norethindrone-eth estradiol....... 54norethin-eth estradiol-fe............ 54norgestimate-eth estradiol........ 54norgestimate-ethinyl estradiol triphasic.....................................54
norlyda...................................... 55norlyroc..................................... 55normal saline flush.................... 61nortrel 0.5/35 (28)..................... 54nortrel 1/35 (21)........................ 54nortrel 1/35 (28)........................ 54nortrel 7/7/7...............................54nortriptyline hcl..........................21NORVIR.................................... 31NOVOFINE AUTOCOVER PEN NEEDLE........................... 61NOVOFINE PEN NEEDLE....... 61NOVOFINE PLUS PEN NEEDLE....................................61NOVOLIN 70/30 FLEXPEN...... 33NOVOLIN 70/30 FLEXPEN RELION.....................................33NOVOLIN 70/30 RELION......... 33NOVOLIN 70/30 VIAL............... 33NOVOLIN N RELION................33NOVOLIN N VIAL..................... 33NOVOLIN R RELION................33NOVOLIN R VIAL..................... 33NOVOLOG FLEXPEN.............. 33NOVOLOG MIX 70/30 FLEXPEN..................................33NOVOLOG MIX 70/30 VIAL......33NOVOLOG PENFILL................ 33NOVOLOG U-100 VIAL............ 33NOVOPEN ECHO.....................32NOVOSEVEN RT..................... 35NOVOTWIST PEN NEEDLE.... 61NOXAFIL...................................22np thyroid.................................. 56NPLATE.................................... 34NUCALA................................... 67nufol.......................................... 45nulev......................................... 46nutricap..................................... 45nutrifac zx..................................45nutrilipid.....................................61NUTROPIN AQ NUSPIN 10..... 51NUTROPIN AQ NUSPIN 20..... 51NUTROPIN AQ NUSPIN 5....... 51NUVARING............................... 54nyamyc......................................22nystatin......................................22nystatin-triamcinolone............... 22nystop....................................... 22OBIZUR.................................... 35ocella.........................................54OCTAGAM................................58octreotide acetate..................... 56
ODEFSEY.................................30OFEV........................................ 67ofloxacin..............................18, 64ogestrel..................................... 54okebo........................................ 18olanzapine.................................28olanzapine-fluoxetine hcl.......... 20olmesartan medoxomil..............36olmesartan medoxomil-hctz...... 36olmesartan-amlodipine-hctz......36olopatadine hcl....................63, 65OMECLAMOX-PAK.................. 46omega-3-acid ethyl esters.........39omeprazole............................... 47OMIDRIA...................................63OMNARIS................................. 65ONCASPAR..............................25ondansetron hcl........................ 21ondansetron odt........................ 21ONE TOUCH VERIO KIT W/DEVICE................................ 32ONE-A-DAY WOMENS PRENATAL 1............................ 45ONETOUCH DELICA LANCING DEV..........................32ONETOUCH DELICA PLUS LANCING.................................. 32ONETOUCH ULTRA 2..............32ONETOUCH ULTRA BLUE TEST STRIPS...........................32ONETOUCH ULTRA MINI........ 32ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE..........32ONETOUCH VERIO IQ SYSTEM................................... 32ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE..........32ONIVYDE..................................25OPDIVO.................................... 27OPSUMIT..................................67oralone...................................... 41ORENCIA..................................57ORENCIA CLICKJECT............. 57ORENITRAM............................ 67ORFADIN..................................48ORKAMBI................................. 66orphenadrine citrate.................. 68orphenadrine citrate er..............68orsythia..................................... 54oscimin......................................46oseltamivir phosphate............... 31osmitrol..................................... 38OSPHENA................................ 55
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OTEZLA.................................... 58oxacillin sodium.........................17oxaliplatin.................................. 23oxandrolone.............................. 51oxaprozin.................................. 12oxazepam................................. 31oxcarbazepine...........................19OXISTAT...................................22oxybutynin chloride................... 48oxybutynin chloride er............... 48oxycodone hcl........................... 13OXYCODONE HCL ER............ 12oxycodone-acetaminophen.......13oxycodone-aspirin.....................13oxycodone-ibuprofen................ 13OXYCONTIN.............................12oxymorphone hcl.......................13oxymorphone hcl er.................. 12oxytocin.....................................51OZEMPIC..................................33pacerone................................... 37paclitaxel................................... 25paliperidone er.......................... 28palonosetron hcl........................21pamidronate disodium...............60pancuronium bromide............... 68PANDA MASK LARGE............. 61PANDA MASK MEDIUM...........61PANDA MASK SMALL..............61PANRETIN................................27pantoprazole sodium.................47PARAGARD INTRAUTERINE COPPER...................................61paricalcitol................................. 60paroex....................................... 41paromomycin sulfate.................15paroxetine hcl............................20paroxetine hcl er....................... 20paroxetine mesylate..................20PASER......................................23PAXIL........................................20PAZEO......................................63PEDIARIX................................. 59PEDIATRIC PANDA MASK...... 61PEDVAX HIB............................ 59peg 3350/electrolytes................47peg 3350-kcl-na bicarb-nacl......47peg-3350/electrolytes................47PEGANONE..............................19PEGASYS.................................29PEGASYS PROCLICK............. 29peg-prep....................................47penicillamine............................. 44
penicillin g potassium................17penicillin g procaine.................. 17penicillin g sodium.....................17penicillin v potassium................ 17PENTACEL............................... 59pentamidine isethionate............ 27PENTASA................................. 59pentazocine-naloxone hcl......... 13pentobarbital sodium.................68pentoxifylline er......................... 38PERFOROMIST........................66perindopril erbumine................. 36periogard...................................41PERJETA..................................27permethrin.................................27perphenazine............................ 28perphenazine-amitriptyline........21phenadoz.................................. 21phenazo.................................... 48phenazopyridine hcl.................. 48phenelzine sulfate..................... 20phenobarbital............................ 18phenoxybenzamine hcl............. 35phentolamine mesylate............. 35phenylephrine hcl................35, 63phenytoin.................................. 19phenytoin infatabs.....................19phenytoin sodium......................19phenytoin sodium extended...... 19philith.........................................54PHOSLYRA.............................. 49PHOSPHOLINE IODIDE...........64phosphorous............................. 43phrenilin forte............................ 11phytonadione............................ 45PICATO.....................................25pilocarpine hcl..................... 41, 64pimecrolimus.............................42pimozide....................................28pimtrea...................................... 54pindolol......................................37pioglitazone hcl......................... 33pioglitazone hcl-glimepiride.......33pioglitazone hcl-metformin hcl.. 33piperacillin sod-tazobactam so..17pirmella 1/35............................. 54pirmella 7/7/7............................ 54piroxicam...................................12pneumovax 23.......................... 59PNEUMOVAX 23...................... 59pnv prenatal plus multivit+dha.. 45pocket spacer............................61podofilox....................................42
polocaine...................................14polocaine-mpf........................... 14polycin.......................................62poly-iron 150 forte..................... 43polymyxin b sulfate................... 15polymyxin b-trimethoprim..........62polysaccharide iron forte...........43POMALYST.............................. 24portia-28....................................54pot bicarb-pot chloride.............. 43potassium acetate.....................43potassium chloride.................... 43potassium chloride crys er........ 43potassium chloride er................43potassium chloride in dextrose. 43potassium chloride in nacl.........43potassium citrate er...................43PRADAXA.................................34pralidoxime chloride.................. 61PRALUENT...............................39pramipexole dihydrochloride..... 27pramipexole dihydrochloride er.28prasugrel hcl............................. 35pravastatin sodium....................39praziquantel.............................. 27prazosin hcl...............................35PRED MILD.............................. 64prednicarbate............................ 50prednisolone............................. 50prednisolone acetate.................64prednisolone sodium phosphate........................... 50, 64prednisone................................ 50PREDNISONE INTENSOL....... 50pregabalin................................. 18pregnyl...................................... 51PREMARIN............................... 54PREMPHASE........................... 54PREMPRO................................54prenatal..................................... 45prenatal multi +dha................... 45prenatal plus iron...................... 45PREPOPIK................................47prevalite.................................... 39PREVENT SAFETY PEN NEEDLES................................. 61preventeza................................ 55prevident................................... 41previfem.................................... 54PREVNAR 13............................59PREZCOBIX............................. 31PREZISTA................................ 31PRIFTIN.................................... 23
80
primaquine phosphate.............. 27primidone.................................. 18PRIMSOL..................................15PRIVIGEN.................................58PRO COMFORT SPACER ADULT...................................... 61PRO COMFORT SPACER CHILD....................................... 61PROAIR HFA............................ 66PROAIR RESPICLICK..............66probenecid................................ 22procainamide hcl.......................37PROCARE SPACER/ADULT MASK........................................61PROCARE SPACER/CHILD MASK........................................61prochlorperazine....................... 21prochlorperazine edisylate........ 21prochlorperazine maleate......... 21procto-med hc........................... 42procto-pak................................. 42proctosol hc...............................42proctozone-hc........................... 42PROFILNINE............................ 35PROFILNINE SD...................... 35progesterone.............................55progesterone micronized.......... 55PROGLYCEM........................... 33PROGRAF................................ 57PROLASTIN-C..........................67PROLENSA.............................. 64PROLEUKIN............................. 25PROLIA.....................................60PROMACTA..............................34promethazine hcl.......................21promethegan.............................21propafenone hcl........................ 37propafenone hcl er.................... 37proparacaine hcl....................... 63propranolol hcl.......................... 37propranolol hcl er...................... 37propranolol-hctz........................ 37propylthiouracil ..........................56PROQUAD................................59protamine sulfate...................... 35protriptyline hcl..........................21PULMICORT FLEXHALER.......65pulmosal....................................67PULMOZYME........................... 66purevit dualfe plus.....................43PYLERA....................................46pyrazinamide.............................23pyridostigmine bromide.............23
pyridostigmine bromide er.........23pyridoxine hcl............................ 45qc aspirin low dose................... 12QUADRACEL............................59quazepam................................. 31quetiapine fumarate.................. 28quetiapine fumarate er.............. 28QUILLIVANT XR....................... 40quinapril hcl...............................36quinapril-hydrochlorothiazide.... 36quinidine gluconate er...............37quinidine sulfate........................ 37quinine sulfate...........................27rabeprazole sodium.................. 47raloxifene hcl.............................55ramelteon.................................. 68ramipril ...................................... 36ranitidine hcl..............................46ranolazine er............................. 38rasagiline mesylate................... 28RAVICTI....................................48RAYALDEE...............................45REBETOL................................. 29reclipsen....................................54RECOMBINATE........................35RECOMBIVAX HB.................... 59RECTIV.....................................42REGRANEX..............................42RELENZA DISKHALER............ 31relexxii .......................................40remifentanil hcl..........................13RENACIDIN.............................. 48renal.......................................... 45RENFLEXIS.............................. 57repaglinide................................ 33repaglinide-metformin hcl..........33REPATHA................................. 39REPATHA PUSHTRONEX SYSTEM................................... 39REPATHA SURECLICK........... 39RESCRIPTOR.......................... 30RESTASIS................................ 63RESTASIS MULTIDOSE.......... 63RETACRIT................................ 34RETROVIR............................... 30REVCOVI..................................48REVLIMID................................. 24revonto...................................... 29REXULTI...................................28REYATAZ................................. 31RHOGAM ULTRA-FILTERED PLUS.........................................58RHOPHYLAC............................58
RHOPRESSA........................... 64RIASTAP...................................35ribasphere................................. 29ribasphere ribapak.................... 29RIBASPHERE RIBAPAK.......... 29ribavirin..................................... 29rifabutin..................................... 23rifampin..................................... 23RIFATER...................................23riluzole.......................................40rimantadine hcl..........................31ringers....................................... 43ringers irrigation........................ 61risedronate sodium................... 60RISPERDAL CONSTA..............28risperidone................................ 28ritonavir..................................... 31RITUXAN.................................. 27rivastigmine...............................19rivastigmine tartrate.................. 19rivelsa........................................54RIXUBIS....................................35rizatriptan benzoate.................. 22rocuronium bromide.................. 68ROMIDEPSIN........................... 25ropinirole hcl..............................28ropinirole hcl er......................... 28ropivacaine hcl.......................... 14rosadan..................................... 42rosuvastatin calcium................. 39ROTARIX.................................. 59ROTATEQ.................................59roweepra................................... 18roweepra xr............................... 18RUBRACA................................ 25RYDAPT................................... 26ryvent........................................ 65saline flush................................ 61saline flush zr............................ 62SAMSCA...................................44SANDIMMUNE......................... 57SANTYL.................................... 42SAPHRIS.................................. 28SAPS HEALTH CARE ALCOHOL PREP...................... 62sash kit ......................................62SAVAYSA................................. 34SAVELLA.................................. 40SAVELLA TITRATION PACK... 40scopolamine..............................21SECURESAFE INSULIN SYRINGE..................................62selegiline hcl............................. 28
81
selenium sulfide........................ 42SELZENTRY.............................30sensorcaine...............................14sensorcaine/epinephrine...........14sensorcaine-mpf....................... 14sensorcaine-mpf/epinephrine....14SEREVENT DISKUS................ 66sertraline hcl..............................20se-tan plus................................ 43setlakin......................................54sevelamer carbonate................ 49sevelamer hcl............................49sf............................................... 41sf 5000 plus...............................41sharobel.................................... 55SHINGRIX.................................59siderol....................................... 45SIGNIFOR.................................56sildenafil citrate......................... 67SILENOR.................................. 68silodosin.................................... 48silver nitrate...............................42silver sulfadiazine......................15SIMBRINZA.............................. 64simliya....................................... 54simpesse...................................54SIMPONI...................................57SIMPONI ARIA......................... 57simvastatin................................ 39sirolimus....................................57SIRTURO..................................23SKLICE..................................... 27SKYLA...................................... 55SLYND...................................... 55sod benz-sod phenylacet.......... 48sod citrate-citric acid................. 43sodium acetate..........................45sodium bicarbonate.............44, 46sodium chloride.............44, 48, 67sodium chloride flush................ 62sodium fluoride....................41, 44sodium fluoride 5000 plus......... 41sodium lactate...........................44sodium nitrite.............................62sodium phenylbutyrate..............48sodium phosphates...................44sodium polystyrene sulfonate... 44sodium thiosulfate..................... 62solifenacin succinate.................48SOLIRIS....................................34SOLTAMOX.............................. 24SOLU-CORTEF........................ 50SOMATULINE DEPOT............. 56
SOMAVERT..............................56sorbitol...................................... 48sorbitol-mannitol........................48sorine........................................ 37sotalol hcl.................................. 37sotalol hcl (af)............................37spinosad....................................27SPIRIVA HANDIHALER............66SPIRIVA RESPIMAT................ 66spironolactone...........................39spironolactone-hctz...................39sprintec 28................................ 54SPRYCEL................................. 26sps............................................ 44sronyx....................................... 54ssd............................................ 16stavudine...................................30STELARA............................42, 57sterile water for irrigation...........62STIOLTO RESPIMAT............... 66STIVARGA................................26STRENSIQ................................48streptomycin sulfate.................. 15STRIANT...................................52STRIBILD..................................30subvenite...................................19subvenite starter kit-blue...........19subvenite starter kit-green........ 19subvenite starter kit-orange...... 19succinylcholine chloride............ 68SUCRAID..................................48sucralfate.................................. 47sulfacetamide sodium............... 64sulfacetamide sodium (acne).... 42sulfacetamide-prednisolone...... 64sulfadiazine............................... 18sulfamethoxazole-trimethoprim.18SULFAMYLON..........................16sulfasalazine............................. 59sulfatrim pediatric......................18sulfurated lime...........................27sulindac.....................................12sumatriptan............................... 22sumatriptan succinate......... 22, 23sumatriptan succinate refill ....... 23SUPPRELIN LA........................ 56SUPREP BOWEL PREP KIT....47SURESTEP PRO HIGH GLUCOSE................................ 32SURESTEP PRO LOW GLUCOSE................................ 32SURESTEP PRO NORMAL GLUCOSE................................ 32
SUTENT....................................26swabflush saline flush............... 62syeda........................................ 54SYLATRON...............................25SYMBICORT.............................65SYMFI....................................... 30SYMFI LO................................. 30SYMPROIC...............................46SYNAGIS.................................. 58SYNAREL................................. 56SYNJARDY...............................33SYNJARDY XR.........................33SYNRIBO..................................25TABLOID...................................24TACLONEX...............................42tacrolimus............................42, 57tadalafil ......................................48tadalafil (pah)............................ 67TAFINLAR.................................26TAGRISSO............................... 26tamoxifen citrate........................24tamsulosin hcl........................... 48TARGRETIN............................. 27tarina 24 fe................................ 54tarina fe 1/20............................. 54tarina fe 1/20 eq........................ 54TASIGNA.................................. 26tazarotene................................. 42tazicef........................................17TAZORAC.................................42taztia xt......................................38TDVAX...................................... 59TECENTRIQ............................. 27TECFIDERA..............................40TEGSEDI.................................. 40telmisartan................................ 36telmisartan-amlodipine..............36telmisartan-hctz.........................36temazepam............................... 31TEMODAR................................ 23temozolomide............................23temsirolimus..............................26tencon....................................... 11teniposide..................................25TENIVAC.................................. 59tenofovir disoproxil fumarate.....30terazosin hcl..............................48terbinafine hcl............................22terbutaline sulfate......................66terconazole............................... 22testosterone.............................. 52testosterone cypionate..............52testosterone enanthate............. 52
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tetcaine..................................... 63tetrabenazine............................ 40tetracaine hcl.............................63tetracycline hcl.......................... 18TEXACORT.............................. 50THALOMID............................... 24THEO-24...................................66theochron.................................. 67theophylline...............................67theophylline er...........................67theophylline in d5w................... 67thiamine hcl...............................45thioridazine hcl.......................... 28thiotepa..................................... 23thiothixene.................................28THROMBATE III ....................... 34THYMOGLOBULIN...................58THYROLAR-1........................... 56THYROLAR-1/2........................ 56THYROLAR-1/4........................ 56THYROLAR-2........................... 56THYROLAR-3........................... 56tiagabine hcl..............................18tigecycline................................. 18tilia fe.........................................54timolol maleate....................37, 64tinidazole...................................27tis-u-sol..................................... 62TIVICAY.................................... 30tizanidine hcl............................. 29tl gard rx.................................... 45tl icon.........................................44tl-hem 150................................. 44TOBRADEX.............................. 62TOBRADEX ST.........................62tobramycin.......................... 62, 66tobramycin sulfate.....................15tobramycin-dexamethasone......62TOBREX................................... 62tolbutamide............................... 33tolcapone.................................. 27tolmetin sodium.........................12tolterodine tartrate.....................48tolterodine tartrate er.................48topiramate................................. 19topiramate er.............................19toposar...................................... 25topotecan hcl.............................25toremifene citrate...................... 24torsemide.................................. 38TOTECT....................................25TOUJEO MAX SOLOSTAR...... 33TOUJEO SOLOSTAR...............33
TOVIAZ..................................... 48tpn electrolytes..........................44TRACLEER...............................67TRADJENTA.............................33tramadol hcl er.......................... 12tramadol hcl er (biphasic)..........12tramadol hcl ir ........................... 13tramadol-acetaminophen.......... 13trandolapril ................................ 36trandolapril-verapamil hcl er......36tranexamic acid.........................35tranylcypromine sulfate............. 20TRAVATAN Z............................63trazodone hcl............................ 20TREANDA.................................23TRECATOR.............................. 23TREMFYA.................................42treprostinil ................................. 67TRESIBA...................................33TRESIBA FLEXTOUCH............34tretinoin............................... 27, 42tretinoin microsphere................ 42tretinoin microsphere pump...... 42TREXALL.................................. 57tri femynor................................. 54triamcinolone acetonide 41, 50, 51triamterene-hctz........................ 39triazolam................................... 31tricon......................................... 44triderm.......................................51trientine hcl................................44tri-estarylla................................ 54trifluoperazine hcl......................28trifluridine.................................. 62trigels-f forte.............................. 44trihexyphenidyl hcl.................... 27tri-legest fe................................ 54tri-linyah.................................... 54tri-lo-estarylla............................ 54tri-lo-marzia............................... 54tri-lo-mili .................................... 54tri-lo-sprintec............................. 54trilyte......................................... 47trimethobenzamide hcl..............21trimethoprim.............................. 16tri-mili ........................................ 54trimipramine maleate................ 21trinate........................................ 45TRINTELLIX..............................20triphrocaps................................ 45tri-previfem................................ 54TRISENOX................................25tri-sprintec................................. 54
TRIUMEQ................................. 30tri-vitamin/fluoride......................45tri-vite/fluoride........................... 45trivora (28).................................54tri-vylibra................................... 54tri-vylibra lo................................54tropicamide............................... 63trospium chloride.......................48trospium chloride er.................. 48TRUE COMFORT ALCOHOL PREP PADS............................. 62TRUEPLUS 5-BEVEL PEN NEEDLES................................. 62TRULICITY............................... 33TRUMENBA..............................59TRUVADA.................................30tulana........................................ 55TUZISTRA XR.......................... 65TWINRIX...................................59TYBOST....................................30tydemy...................................... 54TYKERB....................................26TYSABRI...................................41TYVASO................................... 67TYVASO REFILL...................... 67TYVASO STARTER..................67ULESFIA................................... 27ULTRACARE PEN NEEDLES.. 62unithroid.................................... 56UNITUXIN................................. 27UPTRAVI.................................. 67ursodiol..................................... 46valacyclovir hcl..........................29valganciclovir hcl.......................29valproate sodium.......................18valproic acid.............................. 18valsartan................................... 36valsartan-hydrochlorothiazide... 36vancomycin hcl......................... 16vancomycin hcl in dextrose.......16vancomycin hcl in nacl.............. 16VANCOMYCIN HCL IN NACL.. 16vandazole..................................16VAQTA......................................59VARIVAX.................................. 59v-c forte..................................... 45vcf vaginal contraceptive...........48VECAMYL.................................38vecuronium bromide................. 68VELCADE................................. 25VELETRI................................... 67velivet........................................54VELTASSA............................... 44
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VEMLIDY.................................. 29VENCLEXTA.............................26VENCLEXTA STARTING PACK........................................ 26venlafaxine hcl.......................... 20venlafaxine hcl er...................... 20VENTAVIS................................ 67VENTOLIN HFA........................66verapamil hcl.............................38verapamil hcl er.........................38vic-forte..................................... 45vicodin.......................................13vicodin es.................................. 13vicodin hp..................................13VICTOZA.................................. 33VIDEX....................................... 30VIDEX EC................................. 30vienva........................................54vigabatrin.................................. 18vigadrone.................................. 18VIIBRYD....................................20VIIBRYD STARTER PACK....... 20VIMIZIM.................................... 48VIMPAT.....................................19vinblastine sulfate..................... 25vincristine sulfate...................... 25vinorelbine tartrate.................... 25viorele....................................... 54VIRACEPT................................ 31VIREAD.....................................30virt-caps.................................... 45virt-gard.....................................45virt-phos 250 neutral................. 44VISTOGARD.............................62vita s forte................................. 45vitacel........................................45vitamax pediatric....................... 45vita-min..................................... 45vitamin b complex 100.............. 45vitamin d (ergocalciferol)...........45vitamin k1..................................45vitamins acd-fluoride................. 45VIVITROL..................................14VONVENDI............................... 35voriconazole..............................22VOTRIENT................................26vp-pnv-dha................................ 45vp-vite rx................................... 45vyfemla......................................54vylibra........................................54VYVANSE................................. 40VYXEOS................................... 23warfarin sodium.........................34
wera.......................................... 54WIDE-SEAL DIAPHRAGM 60.. 62WINRHO SDF...........................58wixela inhub.............................. 65WP THYROID........................... 56wymzya fe................................. 54XALKORI.................................. 26XARELTO................................. 34XARELTO STARTER PACK.....34XELJANZ.................................. 58XELJANZ XR............................ 58XIAFLEX................................... 48XIFAXAN...................................16XIIDRA...................................... 63XOLAIR.....................................67XTANDI.....................................24xulane....................................... 54xylocaine dental........................ 14XYNTHA................................... 35XYNTHA SOLOFUSE...............35YERVOY................................... 27yuvafem.................................... 54zafirlukast..................................65zaleplon.....................................68ZALTRAP..................................25ZANOSAR.................................23zarah......................................... 54ZELBORAF............................... 26ZEMAIRA.................................. 67zenatane................................... 42ZENPEP....................................48ZEPATIER................................ 29zidovudine.................................30zileuton er................................. 65ziprasidone hcl.......................... 28ZIRGAN.................................... 62ZITHROMAX.............................17ZOLADEX................................. 51zoledronic acid.......................... 60ZOLINZA...................................25zolmitriptan................................23zolpidem tartrate....................... 68ZOMIG...................................... 23zonisamide................................18ZONTIVITY............................... 35ZORTRESS.............................. 57ZOSTAVAX...............................59zovia 1/35e (28)........................ 54zumandimine.............................54ZYDELIG...................................25ZYKADIA...................................26ZYPREXA RELPREVV............. 28ZYTIGA..................................... 24
ZYVOX......................................16
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EHB Enhanced – Oral Chemo Parity