e n hanced formulary january 2017 … n hanced formulary january 2017 introduction ... ancillary...
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ENHANCED FORMULARY
January 2017 INTRODUCTION
Foreword
The HometownRx Enhanced Formulary is a useful reference for drug product selection. The goal of the
Drug Formulary is to enhance the physician and pharmacist’s abilities to provide optimal cost effective
drug therapy for patients. Ultimately, specific drug selection for an individual member is dependent on
your prescriber.
The Formulary is a continually reviewed and revised list of drugs, which mirror the prevailing clinical opinion of the Pharmaceutical & Therapeutics and Formulary Committees. Due to this continual review process, the HometownRx Enhanced Formulary may not be a complete list of all covered drug products and is not meant to be comprehensive in nature. Formulary change notices will be provided as necessary.
Benefit Coverage and Limitations The Drug Formulary is a list of covered and preferred drug products for members. The Enhanced Formulary is an open formulary but, HometownRx may impose restrictions or not reimburse for certain drug products. In addition, certain drug products have been excluded from this formulary. If you choose to use an excluded drug product HometownRx may not reimburse for these drug products and may require you to pay 100% of the cost. Furthermore, if you choose to use a drug that is excluded, the cost, does not accumulate towards meeting your annual deductible or out-of-pocket maximums. In addition, certain classes of medication are not covered under your pharmacy benefit. These medication classes include: non-FDA approved drugs, over the counter (OTC) medications, drugs to treat impotency or sexual disorders, fertility agents, weight loss drugs, hemantinics, reusable needles, disposable syringes, ostomy supplies, infant formulas, dietary supplements, hypopigmentation agents, diagnostic agents, cosmetic medications, and compounded medications. An ancillary charge/member paid difference may apply to brand medications when an equivalent generic is available. If a member or provider chooses a brand product over the generic the member may be responsible for their copay plus the cost difference between the brand medication and the generic medication. Ancillary charges do not apply toward your deductible or out-of-pocket maximum. The Drug Formulary applies only to outpatient drugs products provided to members, and does not apply to drug products used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact Hometown Rx at 1-844-373-0970.
How to Use the Formulary The Formulary is organized by sections either by drug class or disease state and then by the name of the drug product in alphabetical order. All drug names and strengths listed are included in the formulary. The formulary denotes all drug products by product name, strength and dosage form. Generics are denoted in lower case letters by the ingredient name and the formulary will only denote the proprietary - branded names in capital letters that are covered on the formulary.
LAST REVISED 03/16/2017
ENHANCED FORMULARY
January 2017 INTRODUCTION
For all products within the Drug Formulary, the tier level is denoted throughout the document using the following symbols in the legend below. See your schedule of Benefits for the cost sharing you will pay for a given tier.
For certain agents within the Drug Formulary, a recommended prescribing guideline may apply. These prescribing types include Quantity Limit, Prior Authorization, Step Therapy, Age Limits, Max Fill Limits, and Max Days’ Supply which are denoted throughout the document as described below.
S
ENHANCED FORMULARY
January 2017 INTRODUCTION
Formulary Drug descriptions* To assist in understanding which specific drug products are covered, examples are noted below. All covered strengths and dosages forms are specified within the Formulary. Preferred Generic Drugs:
Preferred Brand and Non-Preferred Generic Drugs:
Non - Preferred Brand and High Cost Generic Drugs:
Specialty Drugs:
* The examples described in this section are for demonstration purposes only and may not reflect what is actually on formulary.
LIST OF COVERED PRESCRIPTION MEDICATIONS
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
ANSAID 100 MG TABLETflurbiprofen 3
butalbital-asa-caffeine cap 1
celecoxib 100 mg capsule 1QL 30 / 30 DAYS
ST
celecoxib 200 mg capsule 1QL 30 / 30 DAYS
ST
celecoxib 400 mg capsule 1QL 30 / 30 DAYS
ST
celecoxib 50 mg capsule 1QL 30 / 30 DAYS
ST
choline mag trisal liquid 1
diclofenac pot 50 mg tablet 1
diclofenac sod dr 25 mg tab 1
diclofenac sod dr 50 mg tab 1
diclofenac sod dr 75 mg tab 1
diclofenac sod ec 25 mg tab 1
diclofenac sod ec 50 mg tab 1
diclofenac sod ec 75 mg tab 1
diclofenac sod er 100 mg tab 1
diclofenac-misoprost 50-0.2 tb 1
diclofenac-misoprost 50-200 tb 1
diclofenac-misoprost 75-0.2 tb 1
diclofenac-misoprost 75-200 tb 1
etodolac 200 mg capsule 1
etodolac 300 mg capsule 1
etodolac 400 mg tablet 1
PAGE 4 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
etodolac 500 mg tablet 1
etodolac er 400 mg tablet 1
etodolac er 500 mg tablet 1
etodolac er 600 mg tablet 1
fenoprofen 200 mg capsule 1
fenoprofen 400 mg capsule 1
fenoprofen 600 mg tablet 1
fenoprofen calcium 400 mg cap 1
FENORTHO 400 MG CAPSULEfenoprofen calcium 3
flurbiprofen 100 mg tablet 1
flurbiprofen 50 mg tablet 1
ibuprofen 100 mg/5 ml susp 1
ibuprofen 400 mg tablet 1
ibuprofen 600 mg tablet 1
ibuprofen 800 mg tablet 1
INDOCIN 25 MG/5 ML SUSPENSIONindomethacin 2
INDOCIN 50 MG SUPPOSITORYindomethacin 2
indomethacin 25 mg capsule 1
indomethacin 50 mg capsule 1
indomethacin er 75 mg capsule 1
ketoprofen 50 mg capsule 1
ketoprofen 75 mg capsule 1
ketoprofen er 200 mg capsule 1
ketorolac 10 mg tablet 1
meclofenamate 100 mg capsule 3 ST
meclofenamate 50 mg capsule 3 ST
mefenamic acid 250 mg capsule 3 ST
meloxicam 15 mg tablet 1
meloxicam 7.5 mg tablet 1
PAGE 5 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
meloxicam 7.5 mg/5 ml susp 1
nabumetone 500 mg tablet 1
nabumetone 750 mg tablet 1
NALFON 400 MG CAPSULEfenoprofen calcium 3
NAPROSYN 250 MG TABLETnaproxen 3
naproxen 125 mg/5 ml suspen 1
naproxen 250 mg tablet 1
naproxen 375 mg tablet 1
naproxen 500 mg kit 1
naproxen 500 mg tablet 1
naproxen dr 375 mg tablet 1
naproxen dr 500 mg tablet 1
naproxen ec 375 mg tablet 1
naproxen ec 500 mg tablet 1
naproxen sodium 275 mg tab 1
naproxen sodium 550 mg tab 1
naproxen sodium ds 550 mg tab 1
oxaprozin 600 mg caplet 1
oxaprozin 600 mg tablet 1
piroxicam 10 mg capsule 1
piroxicam 20 mg capsule 1
salsalate 500 mg tablet 1
salsalate 750 mg tablet 1
sulindac 150 mg tablet 1
sulindac 200 mg tablet 1
tolmetin sodium 400 mg cap 1
OPIOID ANALGESICS, LONG-ACTING
AVINZA 120 MG CAPSULEmorphine sulfate 4 ST
AVINZA 30 MG CAPSULEmorphine sulfate 4 ST
PAGE 6 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AVINZA 45 MG CAPSULEmorphine sulfate 4 ST
AVINZA 60 MG CAPSULEmorphine sulfate 4 ST
AVINZA 75 MG CAPSULEmorphine sulfate 4 ST
AVINZA 90 MG CAPSULEmorphine sulfate 4 ST
DURAGESIC 100 MCG/HR PATCHfentanyl 4
DURAGESIC 25 MCG/HR PATCHfentanyl 4
DURAGESIC 50 MCG/HR PATCHfentanyl 4
DURAGESIC 75 MCG/HR PATCHfentanyl 4
EMBEDA ER 100-4 MG CAPSULEmorphine sulfate/naltrexone hcl 3 PA
EMBEDA ER 20-0.8 MG CAPSULEmorphine sulfate/naltrexone hcl 3 PA
EMBEDA ER 30-1.2 MG CAPSULEmorphine sulfate/naltrexone hcl 3 PA
EMBEDA ER 50-2 MG CAPSULEmorphine sulfate/naltrexone hcl 3 PA
EMBEDA ER 60-2.4 MG CAPSULEmorphine sulfate/naltrexone hcl 3 PA
EMBEDA ER 80-3.2 MG CAPSULEmorphine sulfate/naltrexone hcl 3 PA
EXALGO ER 32 MG TABLEThydromorphone hcl 3 PA
fentanyl 100 mcg/hr patch 1
fentanyl 12 mcg/hr patch 4
fentanyl 25 mcg/hr patch 1
fentanyl 37.5 mcg/hr patch 4
fentanyl 50 mcg/hr patch 1
fentanyl 62.5 mcg/hr patch 4
fentanyl 75 mcg/hr patch 1
PAGE 7 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fentanyl 87.5 mcg/hr patch 4
hydromorphone hcl er 12 mg tab 3 PA
hydromorphone hcl er 16 mg tab 3 PA
hydromorphone hcl er 32 mg tab 3 PA
hydromorphone hcl er 8 mg tab 3 PA
methadone 10 mg/5 ml solution 1
methadone 10 mg/ml oral conc 1
methadone 40 mg tablet dispr 1
methadone 5 mg/5 ml solution 1
methadone hcl 10 mg tablet 1
methadone hcl 5 mg tablet 1
methadone intensol 10 mg/ml 1
METHADOSE 10 MG/ML ORAL CONCmethadone hcl 3
methadose 40 mg tablet dispr 1
morphine sulf er 100 mg tablet 1
morphine sulf er 15 mg tablet 1
morphine sulf er 200 mg tablet 1
morphine sulf er 30 mg tablet 1
morphine sulf er 60 mg tablet 1
morphine sulfate er 120 mg cap 1 ST
morphine sulfate er 30 mg cap 1 ST
morphine sulfate er 45 mg cap 1 ST
morphine sulfate er 50 mg cap 1 ST
morphine sulfate er 60 mg cap 1 ST
morphine sulfate er 75 mg cap 1 ST
morphine sulfate er 90 mg cap 1 ST
NUCYNTA ER 100 MG TABLETtapentadol hcl 3
QL 180 / 30 DAYS
ST
AL1 At least 18 yrs old
PAGE 8 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NUCYNTA ER 150 MG TABLETtapentadol hcl 3
QL 180 / 30 DAYS
ST
AL1 At least 18 yrs old
NUCYNTA ER 200 MG TABLETtapentadol hcl 3
QL 180 / 30 DAYS
ST
AL1 At least 18 yrs old
NUCYNTA ER 250 MG TABLETtapentadol hcl 3
QL 180 / 30 DAYS
ST
AL1 At least 18 yrs old
NUCYNTA ER 50 MG TABLETtapentadol hcl 3
QL 180 / 30 DAYS
ST
AL1 At least 18 yrs old
oxycodone hcl er 10 mg tablet 4QL 60 / 30 DAYS
ST
oxycodone hcl er 15 mg tablet 4QL 60 / 30 day(s)
ST
oxycodone hcl er 20 mg tablet 4QL 60 / 30 DAYS
ST
oxycodone hcl er 30 mg tablet 4QL 60 / 30 day(s)
ST
oxycodone hcl er 40 mg tablet 4QL 60 / 30 DAYS
ST
oxycodone hcl er 60 mg tablet 4QL 60 / 30 day(s)
ST
oxycodone hcl er 80 mg tablet 4QL 60 / 30 DAYS
ST
oxymorphone hcl er 10 mg tab 3 QL 60 / 30 DAYS
oxymorphone hcl er 15 mg tab 3 QL 60 / 30 DAYS
oxymorphone hcl er 20 mg tab 3 QL 60 / 30 DAYS
oxymorphone hcl er 30 mg tab 3 QL 60 / 30 DAYS
PAGE 9 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
oxymorphone hcl er 40 mg tab 3 QL 60 / 30 DAYS
oxymorphone hcl er 5 mg tablet 3 QL 60 / 30 DAYS
oxymorphone hcl er 7.5 mg tab 3 QL 60 / 30 DAYS
tramadol er 100 mg tablet 1 ST
tramadol er 200 mg tablet 1 ST
tramadol er 300 mg tablet 1 ST
tramadol hcl er 100 mg capsule 3
tramadol hcl er 100 mg tablet 1 ST
tramadol hcl er 150 mg capsule 3
tramadol hcl er 200 mg capsule 3
tramadol hcl er 200 mg tablet 1 ST
tramadol hcl er 300 mg capsule 3
tramadol hcl er 300 mg tablet 1 ST
ZOHYDRO ER 10 MG CAPSULEhydrocodone bitartrate 3 PA
ZOHYDRO ER 15 MG CAPSULEhydrocodone bitartrate 3 PA
ZOHYDRO ER 20 MG CAPSULEhydrocodone bitartrate 3 PA
ZOHYDRO ER 30 MG CAPSULEhydrocodone bitartrate 3 PA
ZOHYDRO ER 40 MG CAPSULEhydrocodone bitartrate 3 PA
ZOHYDRO ER 50 MG CAPSULEhydrocodone bitartrate 3 PA
OPIOID ANALGESICS, SHORT-ACTING
acetamin-codein 300-30 mg/12.5 1
acetaminop-codeine 120-12 mg/5 1
acetaminophen-cod #2 tablet 1
acetaminophen-cod #3 tablet 1
acetaminophen-cod #4 tablet 1
asa-butalb-caff-cod #3 capsule 1
PAGE 10 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ascomp with codeine capsule 1
butalb-acetaminoph-caff-codein 3
butalb-caff-acetaminoph-codein 1
butalbital comp-codeine #3 cap 1
CAPITAL WITH CODEINE SUSPacetaminophen with codeine phosphate 3
carisoprodol cpd-codeine tab 1
carisoprodol-aspirin-codein tb 1
codeine sulfate 15 mg tablet 1
codeine sulfate 30 mg tablet 1
codeine sulfate 60 mg tablet 1
endocet 10-325 mg tablet 1
endocet 2.5-325 mg tablet 1
endocet 5-325 tablet 1
endocet 7.5-325 mg tablet 1
fentanyl cit otfc 1,200 mcg 4 PA
fentanyl cit otfc 1,600 mcg 4 PA
fentanyl citrate otfc 200 mcg 4 PA
fentanyl citrate otfc 400 mcg 4 PA
fentanyl citrate otfc 600 mcg 4 PA
fentanyl citrate otfc 800 mcg 4 PA
hydrocodon-acetamin 7.5-325/15 1
hydrocodon-acetaminoph 2.5-325 1
hydrocodon-acetaminoph 7.5-300 1
hydrocodon-acetaminoph 7.5-325 1
hydrocodon-acetaminophen 5-300 1
hydrocodon-acetaminophen 5-325 1
hydrocodon-acetaminophn 10-300 1
hydrocodon-acetaminophn 10-325 1
hydrocodone-acetamin 10-325/15 1
hydrocodone-acetamin 2.5-108/5 1
PAGE 11 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hydrocodone-acetamin 2.5-167/5 1
hydrocodone-acetamin 5-163/7.5 1
hydrocodone-acetamin 5-217/10 1
hydrocodone-ibuprofen 10-200 1
hydrocodone-ibuprofen 2.5-200 1
hydrocodone-ibuprofen 5-200 mg 1
hydrocodone-ibuprofen 7.5-200 1
hydromorphone 1 mg/ml solution 1
hydromorphone 2 mg tablet 1
hydromorphone 3 mg suppos 1
hydromorphone 4 mg tablet 1
hydromorphone 5 mg/5 ml soln 1
hydromorphone 8 mg tablet 1
lorcet 5-325 mg tablet 1
lorcet hd 10-325 mg tablet 1
lorcet plus 7.5-325 mg tablet 1
lortab 10 mg-300 mg/15 ml elxr 3
lortab 10-325 mg tablet 3
lortab 5-325 mg tablet 3
lortab 7.5-325 mg tablet 3
meperidine 100 mg tablet 1
meperidine 50 mg tablet 1
meperidine 50 mg/5 ml solution 1
morphine 10 mg/ml carpuject 1
morphine 10 mg/ml syringe 1
morphine 15 mg/ml carpuject 1
morphine 15 mg/ml vial 1
morphine 30 mg/30 ml syringe 1
morphine 300 mg/20 ml vial 1
morphine 4 mg/ml carpuject 1
morphine 4 mg/ml syringe 1
PAGE 12 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
morphine 8 mg/ml syringe 1
morphine sulf 10 mg suppos 1
morphine sulf 10 mg/0.7 ml syr 1
morphine sulf 10 mg/5 ml soln 1
morphine sulf 100 mg/5 ml soln 1
morphine sulf 20 mg suppos 1
morphine sulf 20 mg/5 ml soln 1
morphine sulf 30 mg suppos 1
morphine sulf 5 mg suppos 1
morphine sulfate ir 15 mg tab 2
morphine sulfate ir 30 mg tab 2
NUCYNTA 100 MG TABLETtapentadol hcl 3 QL 180 / 30 DAYS
NUCYNTA 50 MG TABLETtapentadol hcl 3 QL 180 / 30 DAYS
NUCYNTA 75 MG TABLETtapentadol hcl 3 QL 180 / 30 DAYS
OXAYDO 5 MG TABLEToxycodone hcl 3 ST
OXAYDO 7.5 MG TABLEToxycodone hcl 3 ST
OXECTA 5 MG TABLEToxycodone hcl 3 ST
OXECTA 7.5 MG TABLEToxycodone hcl 3 ST
oxycodon-acetaminophen 2.5-325 1
oxycodon-acetaminophen 7.5-325 1
oxycodone hcl 10 mg tablet 1
oxycodone hcl 100 mg/5 ml soln 1
oxycodone hcl 15 mg tablet 1
oxycodone hcl 20 mg tablet 1
oxycodone hcl 30 mg tablet 1
oxycodone hcl 5 mg capsule 1
oxycodone hcl 5 mg tablet 1
PAGE 13 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
oxycodone hcl 5 mg/5 ml soln 1
oxycodone-acetaminophen 10-325 1
oxycodone-acetaminophen 5-325 1
oxycodone-acetaminophn 5-325/5 3
oxycodone-aspirin 4.8355-325 1
oxycodone-ibuprofen 5-400 tab 1
oxymorphone hcl 10 mg tablet 3QL 60 / 30 DAYS
ST
oxymorphone hcl 5 mg tablet 3QL 60 / 30 DAYS
ST
reprexain 10-200 mg tablet 1
REPREXAIN 2.5-200 MG TABLEThydrocodone/ibuprofen 1
REPREXAIN 5-200 MG TABLEThydrocodone/ibuprofen 1
ROXICET 5-325 ORAL SOLUTIONoxycodone hcl/acetaminophen 1
ROXICODONE 30 MG TABLEToxycodone hcl 3
tramadol hcl 50 mg tablet 1
tramadol-acetaminophn 37.5-325 1
verdrocet 2.5-325 mg tablet 3
vicodin 5-300 mg tablet 1
vicodin es 7.5-300 mg tablet 1
vicodin hp 10-300 mg tablet 1
xylon 10-200 mg tablet 1
ZAMICET 10-325 MG/15 ML SOLNhydrocodone bitartrate/acetaminophen 3
ANESTHETICS
LOCAL ANESTHETICS
glydo 2% jelly syringe 1
lidocaine 2% viscous soln 1
lidocaine 5% ointment 3
PAGE 14 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
lidocaine 5% patch 3
lidocaine hcl 2% jelly 1
lidocaine hcl 2% jelly 1
lidocaine hcl 4% solution 1
lidocaine-prilocaine cream 1
LIDOVEX 3.75% CREAMlidocaine 3
XYLOCAINE 4% SOLUTIONlidocaine hcl 3
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
acamprosate calc dr 333 mg tab 3
depade 50 mg tablet 1
naltrexone 50 mg tablet 1
revia 50 mg tablet 3
OPIOID DEPENDENCE TREATMENTS
BUNAVAIL 2.1-0.3 MG FILMbuprenorphine hcl/naloxone hcl 4
QL 1 / 1 day(s)
PA
BUNAVAIL 4.2-0.7 MG FILMbuprenorphine hcl/naloxone hcl 4
QL 2 / 1 day(s)
PA
BUNAVAIL 6.3-1 MG FILMbuprenorphine hcl/naloxone hcl 4
QL 2 / 1 day(s)
PA
BUPRENEX 0.3 MG/ML AMPULbuprenorphine hcl 4
buprenorphin-naloxon 8-2 mg sl 4 PA
buprenorphine 0.3 mg/ml syrn 4
buprenorphine 0.3 mg/ml vial 4
buprenorphine 2 mg tablet sl 4QL 3 / 1 day(s)
PA
buprenorphine 8 mg tablet sl 4QL 3 / 1 day(s)
PA
buprenorphn-naloxn 2-0.5 mg sl 4 PA
PAGE 15 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SUBOXONE 12 MG-3 MG SL FILMbuprenorphine hcl/naloxone hcl 4
QL 2 / 1 day(s)
PA
SUBOXONE 2 MG-0.5 MG SL FILMbuprenorphine hcl/naloxone hcl 4
QL 1 / 1 day(s)
PA
SUBOXONE 4 MG-1 MG SL FILMbuprenorphine hcl/naloxone hcl 4
QL 1 / 1 day(s)
PA
SUBOXONE 8 MG-2 MG SL FILMbuprenorphine hcl/naloxone hcl 4
QL 2 / 1 day(s)
PA
ZUBSOLV 1.4-0.36 MG TABLET SLbuprenorphine hcl/naloxone hcl 4
QL 1 / 1 day(s)
PA
ZUBSOLV 11.4-2.9 MG TABLET SLbuprenorphine hcl/naloxone hcl 4
QL 1 / 1 day(s)
PA
ZUBSOLV 2.9-0.71 MG TABLET SLbuprenorphine hcl/naloxone hcl 4
QL 1 / 1 day(s)
PA
ZUBSOLV 5.7-1.4 MG TABLET SLbuprenorphine hcl/naloxone hcl 4
QL 1 / 1 day(s)
PA
ZUBSOLV 8.6-2.1 MG TABLET SLbuprenorphine hcl/naloxone hcl 4
QL 2 / 1 day(s)
PA
ANTIBACTERIALS
AMINOGLYCOSIDES
GARAMYCIN 3 MG/GM EYE OINTMENTgentamicin sulfate 3
gentak 0.3 % eye ointment 1
gentamicin 0.1% cream 1
gentamicin 0.1% ointment 1
gentamicin 0.3% eye drops 1
gentamicin 0.3% eye ointment 1
gentamicin 3 mg/gm eye oint 1
gentamicin 3 mg/ml eye drops 1
neomycin 500 mg tablet 1
paromomycin 250 mg capsule 1
PAGE 16 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
tobramycin 0.3% eye drops 1
TOBREX 0.3% EYE OINTMENTtobramycin 2
ANTIBACTERIALS, OTHER
ALTABAX 1% OINTMENTretapamulin 3
bacitracin 500 unit/gm ophth 1
BACTROBAN 2% OINTMENTmupirocin 2 QL 1 / 7 DAYS
CLEOCIN 100 MG VAGINAL OVULEclindamycin phosphate 3
CLEOCIN 2% VAGINAL CREAMclindamycin phosphate 3
CLEOCIN 75 MG/5 ML GRANULESclindamycin palmitate hcl 3
clindacin etz 1% pledget 3
clindacin p 1% pledgets 3
clindamycin 2% vaginal cream 1
clindamycin 75 mg/5 ml soln 1
clindamycin hcl 150 mg capsule 1
clindamycin hcl 300 mg capsule 1
clindamycin hcl 75 mg capsule 1
clindamycin pediatr 75 mg/5 ml 1
clindamycin ph 1% gel 1
clindamycin ph 1% solution 1
clindamycin phos 1% pledget 1
clindamycin phosp 1% lotion 1
CLINDESSE 2% VAGINAL CREAMclindamycin phosphate 3
erythromycin-benzoyl gel 3
FLAGYL ER 750 MG TABLETmetronidazole 3
FURADANTIN 25 MG/5 ML SUSPnitrofurantoin 3
linezolid 100 mg/5 ml susp 2 PA
PAGE 17 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
linezolid 600 mg tablet 2 PA
methenamine hipp 1 gm tablet 1
methenamine md 1 gm tablet 1
methenamine md 500 mg tablet 1
metronidazole 250 mg tablet 1
metronidazole 375 mg capsule 1
metronidazole 500 mg tablet 1
metronidazole vaginal 0.75% gl 1
mupirocin 2% cream 1 QL 1 / 7 DAYS
mupirocin 2% ointment 1 QL 1 / 7 DAYS
nitrofurantoin 25 mg/5 ml susp 1
nitrofurantoin mcr 100 mg cap 1
nitrofurantoin mcr 25 mg cap 1
nitrofurantoin mcr 50 mg cap 1
nitrofurantoin mono-mcr 100 mg 1
phosphasal tablet 3
PRIMSOL 50 MG/5 ML ORAL SOLNtrimethoprim 3
SIVEXTRO 200 MG TABLETtedizolid phosphate 2 PA
TINDAMAX 500 MG TABLETtinidazole 3
tinidazole 500 mg tablet 1
trimethoprim 100 mg tablet 1
BETA-LACTAM, CEPHALOSPORINS
cefaclor 125 mg/5 ml susp 1
cefaclor 250 mg capsule 1
cefaclor 250 mg/5 ml susp 1
cefaclor 375 mg/5 ml suspen 1
cefaclor 500 mg capsule 1
cefaclor er 500 mg tablet 1
cefadroxil 1 gm tablet 1
PAGE 18 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
cefadroxil 250 mg/5 ml susp 1
cefadroxil 500 mg capsule 1
cefadroxil 500 mg/5 ml susp 1
cefdinir 125 mg/5 ml susp 1
cefdinir 250 mg/5 ml susp 1
cefdinir 300 mg capsule 1
cefixime 100 mg/5 ml susp 3
cefixime 200 mg/5 ml susp 3
cefpodoxime 100 mg tablet 1
cefpodoxime 100 mg/5 ml susp 1
cefpodoxime 200 mg tablet 1
cefpodoxime 50 mg/5 ml susp 1
cefprozil 125 mg/5 ml susp 1
cefprozil 250 mg tablet 1
cefprozil 250 mg/5 ml susp 1
cefprozil 500 mg tablet 1
ceftibuten 180 mg/5 ml susp 3
ceftibuten 400 mg capsule 3
CEFTIN 125 MG/5 ML ORAL SUSPcefuroxime axetil 3
CEFTIN 250 MG/5 ML ORAL SUSPcefuroxime axetil 3
CEFTIN 500 MG TABLETcefuroxime axetil 3
cefuroxime axetil 250 mg tab 1
cefuroxime axetil 500 mg tab 1
cephalexin 125 mg/5 ml susp 1
cephalexin 250 mg capsule 1
cephalexin 250 mg tablet 1
cephalexin 250 mg/5 ml susp 1
cephalexin 500 mg capsule 1
cephalexin 500 mg tablet 1
cephalexin 750 mg capsule 1
PAGE 19 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SUPRAX 100 MG TABLET CHEWABLEcefixime 3
SUPRAX 200 MG TABLET CHEWABLEcefixime 3
SUPRAX 400 MG CAPSULEcefixime 3
SUPRAX 500 MG/5 ML SUSPENSIONcefixime 3
BETA-LACTAM, PENICILLINS
amox-clav 200-28.5 mg tab chew 1
amox-clav 200-28.5 mg/5 ml sus 1
amox-clav 250-125 mg tablet 1
amox-clav 250-62.5 mg/5 ml sus 1
amox-clav 400-57 mg tab chew 1
amox-clav 400-57 mg/5 ml susp 1
amox-clav 500-125 mg tablet 1
amox-clav 600-42.9 mg/5 ml sus 1
amox-clav 875-125 mg tablet 1
amox-clav er 1,000-62.5 mg tab 1
amoxicillin 125 mg tab chew 1
amoxicillin 125 mg/5 ml susp 1
amoxicillin 200 mg/5 ml susp 1
amoxicillin 250 mg capsule 1
amoxicillin 250 mg tab chew 1
amoxicillin 250 mg/5 ml susp 1
amoxicillin 400 mg/5 ml susp 1
amoxicillin 500 mg capsule 1
amoxicillin 500 mg tablet 1
amoxicillin 875 mg tablet 1
ampicillin 125 mg/5 ml susp 1
ampicillin 250 mg capsule 1
ampicillin 250 mg/5 ml susp 1
ampicillin 500 mg capsule 1
PAGE 20 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AUGMENTIN 125-31.25 MG/5 MLamoxicillin/potassium clavulanate 3
dicloxacillin 250 mg capsule 1
dicloxacillin 500 mg capsule 1
penicillin vk 125 mg/5 ml soln 1
penicillin vk 250 mg tablet 1
penicillin vk 250 mg/5 ml soln 1
penicillin vk 500 mg tablet 1
MACROLIDES
AZASITE 1% EYE DROPSazithromycin 3
azithromycin 1 gm pwd packet 1
azithromycin 100 mg/5 ml susp 1
azithromycin 200 mg/5 ml susp 1 QL 3 / 10 DAYS
azithromycin 250 mg tablet 1 QL 8 / 1 FILL
azithromycin 500 mg tablet 1 QL 10 / 1 FILL
azithromycin 600 mg tablet 1
clarithromycin 125 mg/5 ml sus 1
clarithromycin 250 mg tablet 1
clarithromycin 250 mg/5 ml sus 1
clarithromycin 500 mg tablet 1
clarithromycin er 500 mg tab 1
DIFICID 200 MG TABLETfidaxomicin 2 PA
E.E.S. 200 MG/5 ML GRANULESerythromycin ethylsuccinate 1
E.E.S. 400 FILMTABerythromycin ethylsuccinate 1
ery 2% pads 1
ERY-TAB EC 250 MG TABLETerythromycin base 1
ERY-TAB EC 333 MG TABLETerythromycin base 2
PAGE 21 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ERY-TAB EC 500 MG TABLETerythromycin base 1
erygel 2% gel 3
ERYTHROCIN 250 MG FILMTABerythromycin stearate 1
erythromycin 0.5% eye ointment 1
erythromycin 2% gel 1
erythromycin 2% pledgets 1
erythromycin 2% solution 1
erythromycin 200 mg/5 ml gran 1
erythromycin 250 mg filmtab 1
erythromycin 500 mg filmtab 1
erythromycin dr 250 mg cap 1
erythromycin ec 250 mg cap 1
erythromycin es 400 mg tab 1
ZITHROMAX 250 MG Z-PAK TABLETazithromycin 3
ZITHROMAX TRI-PAK 500 MG TABazithromycin 3
ZMAX 2 G/60 ML ORAL SUSPENSIONazithromycin 3
QUINOLONES
BESIVANCE 0.6% SUSPbesifloxacin hcl 3
CILOXAN 0.3% OINTMENTciprofloxacin hcl 3
ciprofloxacin 0.2% otic soln 1
ciprofloxacin 0.3% eye drop 1
ciprofloxacin 250 mg/5 ml susp 3
ciprofloxacin 500 mg/5 ml susp 3
ciprofloxacin er 1,000 mg tab 1
ciprofloxacin er 500 mg tablet 1
ciprofloxacin hcl 100 mg tab 1
ciprofloxacin hcl 250 mg tab 1 QL 30 / 1 FILL
PAGE 22 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ciprofloxacin hcl 500 mg tab 1 QL 30 / 1 FILL
ciprofloxacin hcl 750 mg tab 1 QL 30 / 1 FILL
gatifloxacin 0.5% eye drops 3
LEVAQUIN 25 MG/ML SOLUTIONlevofloxacin 2
levofloxacin 0.5% eye drops 1
levofloxacin 25 mg/ml solution 1
levofloxacin 250 mg tablet 1
levofloxacin 250 mg/10 ml soln 1
levofloxacin 500 mg tablet 1
levofloxacin 500 mg/20 ml soln 1
levofloxacin 750 mg tablet 1
MOXEZA 0.5% EYE DROPSmoxifloxacin hcl 3 ST
moxifloxacin hcl 400 mg tablet 1
ofloxacin 0.3% ear drops 1
ofloxacin 0.3% eye drops 1
ofloxacin 400 mg tablet 1
VIGAMOX 0.5% EYE DROPSmoxifloxacin hcl 2
SULFONAMIDES
BLEPH-10 10% EYE DROPSsulfacetamide sodium 1
KLARON 10% LOTIONsulfacetamide sodium 3
silver sulfadiazine 1% cream 1
sodium sulfacetamide 10% lot 1
sodium sulfacetamide 10% lotn 1
SSD 1% CREAMsilver sulfadiazine 1
sulfacetamide 10% eye drops 1
sulfacetamide 10% eye ointment 1
sulfacetamide sod 10% top susp 1
PAGE 23 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
sulfamethoxazole-tmp ds tablet 1
sulfamethoxazole-tmp ss tablet 1
sulfamethoxazole-tmp susp 1
sulfamethoxazole-tmp susp 1
SULFATRIM PEDIATRIC SUSPENSIONsulfamethoxazole/trimethoprim 1
TETRACYCLINES
DORYX DR 150 MG TABLETdoxycycline hyclate 2
doxycycline 25 mg/5 ml susp 1
doxycycline hyc dr 100 mg tab 3
doxycycline hyc dr 150 mg tab 3
doxycycline hyc dr 200 mg tab 3
doxycycline hyc dr 50 mg tab 3
doxycycline hyc dr 75 mg tab 3
doxycycline hyclate 100 mg cap 1
doxycycline hyclate 100 mg tab 1
doxycycline hyclate 20 mg tab 1
doxycycline ir-dr 40 mg cap 3 ST
doxycycline mono 100 mg cap 3 ST
doxycycline mono 100 mg tablet 3 ST
doxycycline mono 150 mg cap 3 ST
doxycycline mono 150 mg tablet 3 ST
doxycycline mono 50 mg cap 3 ST
doxycycline mono 50 mg tablet 3 ST
doxycycline mono 75 mg capsule 3 ST
doxycycline mono 75 mg tablet 3 ST
dynacin 100 mg tablet 3
dynacin 50 mg tablet 3
minocycline 100 mg capsule 1
PAGE 24 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
minocycline 50 mg capsule 1
minocycline 75 mg capsule 1
minocycline hcl 100 mg tablet 3
minocycline hcl 50 mg tablet 3
minocycline hcl 75 mg tablet 3
tetracycline 250 mg capsule 1
tetracycline 500 mg capsule 1
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
BRIVIACT 10 MG TABLETbrivaracetam 3
BRIVIACT 10 MG/ML ORAL SOLNbrivaracetam 3
BRIVIACT 100 MG TABLETbrivaracetam 3
BRIVIACT 25 MG TABLETbrivaracetam 3
BRIVIACT 50 MG TABLETbrivaracetam 3
BRIVIACT 75 MG TABLETbrivaracetam 3
FYCOMPA 0.5 MG/ML ORAL SUSPperampanel 3
QL 2 / 1 day(s)
ST
FYCOMPA 10 MG TABLETperampanel 3
QL 1 / 1 DAYS
ST
FYCOMPA 12 MG TABLETperampanel 3
QL 1 / 1 DAYS
ST
FYCOMPA 2 MG TABLETperampanel 3
QL 4 / 1 DAYS
ST
FYCOMPA 4 MG TABLETperampanel 3
QL 2 / 1 DAYS
ST
FYCOMPA 6 MG TABLETperampanel 3
QL 2 / 1 DAYS
ST
PAGE 25 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FYCOMPA 8 MG TABLETperampanel 3
QL 1 / 1 DAYS
ST
KEPPRA 100 MG/ML ORAL SOLNlevetiracetam 3
levetiracetam 1,000 mg tablet 1
levetiracetam 100 mg/ml soln 1
levetiracetam 250 mg tablet 1
levetiracetam 500 mg tablet 1
levetiracetam 500 mg/5 ml soln 1
levetiracetam 750 mg tablet 1
levetiracetam er 500 mg tablet 1
levetiracetam er 750 mg tablet 1
roweepra 500 mg tablet 3
CALCIUM CHANNEL MODIFYING AGENTS
CELONTIN 300 MG KAPSEALmethsuximide 2
ethosuximide 250 mg capsule 1
ethosuximide 250 mg/5 ml soln 1
zonisamide 100 mg capsule 1
zonisamide 25 mg capsule 1
zonisamide 50 mg capsule 1
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
DEPAKOTE DR 125 MG SPRINKLE CPdivalproex sodium 3
divalproex dr 125 mg cap sprnk 1
divalproex sod dr 125 mg tab 1
divalproex sod dr 250 mg tab 1
divalproex sod dr 500 mg tab 1
divalproex sod er 250 mg tab 1
divalproex sod er 500 mg tab 1
gabapentin 100 mg capsule 1
gabapentin 250 mg/5 ml soln 1
PAGE 26 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
gabapentin 300 mg capsule 1
gabapentin 300 mg/6 ml soln 1
gabapentin 400 mg capsule 1
gabapentin 600 mg tablet 1
gabapentin 800 mg tablet 1
GABITRIL 12 MG TABLETtiagabine hcl 2
GABITRIL 16 MG TABLETtiagabine hcl 2
ONFI 10 MG TABLETclobazam 3 PA
ONFI 2.5 MG/ML SUSPENSIONclobazam 3 PA
ONFI 20 MG TABLETclobazam 3 PA
phenobarbital 100 mg tablet 1
phenobarbital 15 mg tablet 1
phenobarbital 16.2 mg tablet 1
phenobarbital 20 mg/5 ml elix 1
phenobarbital 20 mg/5 ml soln 1
phenobarbital 30 mg tablet 1
phenobarbital 32.4 mg tablet 1
phenobarbital 60 mg tablet 1
phenobarbital 64.8 mg tablet 1
phenobarbital 97.2 mg tablet 1
primidone 250 mg tablet 1
primidone 50 mg tablet 1
SABRIL 500 MG POWDER PACKETvigabatrin 4
SABRIL 500 MG TABLETvigabatrin 4
tiagabine hcl 2 mg tablet 2
tiagabine hcl 4 mg tablet 2
valproic acid 250 mg capsule 1
PAGE 27 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
valproic acid 250 mg/5 ml soln 1
valproic acid 500 mg/10 ml sol 1
GLUTAMATE REDUCING AGENTS
LAMICTAL TAB START KIT (GREEN)lamotrigine 3 AL1 At least 2 yrs old
LAMICTAL TB START KIT (ORANGE)lamotrigine 3 AL1 At least 2 yrs old
LAMICTAL XR START KIT (BLUE)lamotrigine 3 AL1 At least 2 yrs old
LAMICTAL XR START KIT (GREEN)lamotrigine 3 AL1 At least 2 yrs old
LAMICTAL XR START KIT (ORANGE)lamotrigine 3 AL1 At least 2 yrs old
lamotrigine 100 mg tablet 1QL 60 / 30 DAYS
AL1 At least 2 yrs old
lamotrigine 150 mg tablet 1QL 60 / 30 DAYS
AL1 At least 2 yrs old
lamotrigine 200 mg tablet 1QL 60 / 30 DAYS
AL1 At least 2 yrs old
lamotrigine 25 mg disper tab 1 AL1 At least 2 yrs old
lamotrigine 25 mg tablet 1 AL1 At least 2 yrs old
lamotrigine 25 mg tb start kit 1 AL1 At least 2 yrs old
lamotrigine 5 mg disper tablet 1 AL1 At least 2 yrs old
lamotrigine er 100 mg tablet 1 AL1 At least 2 yrs old
lamotrigine er 200 mg tablet 1 AL1 At least 2 yrs old
lamotrigine er 25 mg tablet 1 AL1 At least 2 yrs old
lamotrigine er 250 mg tablet 1 AL1 At least 2 yrs old
lamotrigine er 300 mg tablet 1 AL1 At least 2 yrs old
lamotrigine er 50 mg tablet 1 AL1 At least 2 yrs old
lamotrigine odt 100 mg tablet 3 AL1 At least 2 yrs old
lamotrigine odt 200 mg tablet 3 AL1 At least 2 yrs old
PAGE 28 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
lamotrigine odt 25 mg tablet 3 AL1 At least 2 yrs old
lamotrigine odt 50 mg tablet 3 AL1 At least 2 yrs old
lamotrigine odt kit (blue) 3 AL1 At least 2 yrs old
lamotrigine odt kit (green) 3 AL1 At least 2 yrs old
lamotrigine odt kit (orange) 3 AL1 At least 2 yrs old
topiragen 100 mg tablet 1
topiragen 200 mg tablet 1
topiragen 50 mg tablet 1
topiramate 100 mg tablet 1
topiramate 15 mg sprinkle cap 1
topiramate 200 mg tablet 1
topiramate 25 mg sprinkle cap 1
topiramate 25 mg tablet 1
topiramate 50 mg tablet 1
topiramate er 100 mg capsule 3
topiramate er 150 mg capsule 3
topiramate er 200 mg capsule 3
topiramate er 25 mg capsule 3
topiramate er 50 mg capsule 3
TROKENDI XR 100 MG CAPSULEtopiramate 3
TROKENDI XR 200 MG CAPSULEtopiramate 3
TROKENDI XR 25 MG CAPSULEtopiramate 3
TROKENDI XR 50 MG CAPSULEtopiramate 3
SODIUM CHANNEL AGENTS
APTIOM 200 MG TABLETeslicarbazepine acetate 3
QL 1 / 1 DAYS
ST
APTIOM 400 MG TABLETeslicarbazepine acetate 3
QL 1 / 1 DAYS
ST
PAGE 29 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
APTIOM 600 MG TABLETeslicarbazepine acetate 3
QL 2 / 1 DAYS
ST
APTIOM 800 MG TABLETeslicarbazepine acetate 3
QL 1 / 1 DAYS
ST
BANZEL 200 MG TABLETrufinamide 2
QL 240 / 30 DAYS
ST
AL1 At least 4 yrs old
BANZEL 40 MG/ML SUSPENSIONrufinamide 2
ST
AL1 At least 4 yrs old
BANZEL 400 MG TABLETrufinamide 2
ST
AL1 At least 4 yrs old
carbamazepine 100 mg tab chew 1
carbamazepine 100 mg/5 ml susp 1
carbamazepine 200 mg tablet 1
carbamazepine er 100 mg cap 1
carbamazepine er 100 mg tablet 1
carbamazepine er 200 mg cap 1
carbamazepine er 200 mg tablet 1
carbamazepine er 300 mg cap 1
carbamazepine er 400 mg tablet 1
DILANTIN 30 MG CAPSULEphenytoin sodium extended 2
epitol 200 mg tablet 1
oxcarbazepine 150 mg tablet 1
oxcarbazepine 300 mg tablet 1
oxcarbazepine 300 mg/5 ml susp 1
oxcarbazepine 600 mg tablet 1
OXTELLAR XR 150 MG TABLEToxcarbazepine 3 ST
OXTELLAR XR 300 MG TABLEToxcarbazepine 3
OXTELLAR XR 600 MG TABLEToxcarbazepine 3
PAGE 30 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PEGANONE 250 MG TABLETethotoin 2
phenytoin 100 mg/4 ml susp 1
phenytoin 125 mg/5 ml susp 1
phenytoin 50 mg infatab 1
phenytoin 50 mg tablet chew 1
phenytoin sod ext 100 mg cap 1
phenytoin sod ext 200 mg cap 1
phenytoin sod ext 300 mg cap 1
VIMPAT 10 MG/ML SOLUTIONlacosamide 3 AL1 At least 17 yrs old
VIMPAT 100 MG TABLETlacosamide 3 AL1 At least 17 yrs old
VIMPAT 150 MG TABLETlacosamide 3 AL1 At least 17 yrs old
VIMPAT 200 MG TABLETlacosamide 3 AL1 At least 17 yrs old
VIMPAT 50 MG TABLETlacosamide 3 AL1 At least 17 yrs old
ANTIDEMENTIA AGENTS
CHOLINESTERASE INHIBITORS
donepezil hcl 10 mg tablet 1
donepezil hcl 23 mg tablet 3
donepezil hcl 5 mg tablet 1
donepezil hcl odt 10 mg tablet 1
donepezil hcl odt 5 mg tablet 1
galantamine 4 mg/ml oral soln 2
galantamine er 16 mg capsule 1
galantamine er 24 mg capsule 1
galantamine er 8 mg capsule 1
galantamine hbr 12 mg tablet 1
galantamine hbr 4 mg tablet 1
galantamine hbr 8 mg tablet 1
NAMZARIC 14 MG-10 MG CAPSULEmemantine hcl/donepezil hcl 3
PAGE 31 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NAMZARIC 21 MG-10 MG CAPSULEmemantine hcl/donepezil hcl 3
NAMZARIC 28 MG-10 MG CAPSULEmemantine hcl/donepezil hcl 3
NAMZARIC 7 MG-10 MG CAPSULEmemantine hcl/donepezil hcl 3
NAMZARIC TITRATION PACKmemantine hcl/donepezil hcl 3
rivastigmine 1.5 mg capsule 1
rivastigmine 13.3 mg/24hr ptch 2
rivastigmine 3 mg capsule 1
rivastigmine 4.5 mg capsule 1
rivastigmine 4.6 mg/24hr patch 2
rivastigmine 6 mg capsule 1
rivastigmine 9.5 mg/24hr patch 2
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
memantine 5-10 mg titration pk 2
memantine hcl 10 mg tablet 1
memantine hcl 2 mg/ml solution 2
memantine hcl 5 mg tablet 1
NAMENDA XR 14 MG CAPSULEmemantine hcl 3 ST
NAMENDA XR 21 MG CAPSULEmemantine hcl 3 ST
NAMENDA XR 28 MG CAPSULEmemantine hcl 3 ST
NAMENDA XR 7 MG CAPSULEmemantine hcl 3 ST
NAMENDA XR TITRATION PACKmemantine hcl 3 ST
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
APLENZIN ER 174 MG TABLETbupropion hbr 3 ST
APLENZIN ER 348 MG TABLETbupropion hbr 3 ST
PAGE 32 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
APLENZIN ER 522 MG TABLETbupropion hbr 3 ST
bupropion hcl 100 mg tablet 1QL 60 / 30 DAYS
AL1 At least 18 yrs old
bupropion hcl 75 mg tablet 1QL 60 / 30 DAYS
AL1 At least 18 yrs old
bupropion hcl sr 100 mg tablet 1 AL1 At least 18 yrs old
bupropion hcl sr 150 mg tablet 1
QL 60 / 30 DAYS
PA
AL1 At least 18 yrs old
bupropion hcl sr 200 mg tab 1QL 60 / 30 DAYS
AL1 At least 18 yrs old
bupropion hcl sr 200 mg tablet 1QL 60 / 30 DAYS
AL1 At least 18 yrs old
bupropion hcl xl 150 mg tablet 1
QL 30 / 30 DAYS
ST
AL1 At least 18 yrs old
bupropion hcl xl 300 mg tablet 1
QL 30 / 30 DAYS
ST
AL1 At least 18 yrs old
chlordiazepo-amitriptyl 5-12.5 1
chlordiazepox-amitriptyl 10-25 1
mirtazapine 15 mg odt 1QL 30 / 30 DAYS
AL1 At least 18 yrs old
mirtazapine 15 mg tablet 1QL 30 / 30 DAYS
AL1 At least 18 yrs old
mirtazapine 30 mg odt 1QL 60 / 30 DAYS
AL1 At least 18 yrs old
mirtazapine 30 mg tablet 1QL 30 / 30 DAYS
AL1 At least 18 yrs old
mirtazapine 45 mg odt 1QL 30 / 30 DAYS
AL1 At least 18 yrs old
PAGE 33 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
mirtazapine 45 mg tablet 1 AL1 At least 18 yrs old
mirtazapine 7.5 mg tablet 1 AL1 At least 18 yrs old
olanzapine-fluoxetine 12-25 mg 1 ST
olanzapine-fluoxetine 12-50 mg 1 ST
olanzapine-fluoxetine 3-25 mg 1 ST
olanzapine-fluoxetine 6-25 mg 1 ST
olanzapine-fluoxetine 6-50 mg 1 ST
perphen-amitrip 2 mg-10 mg tab 1 AL1 At least 18 yrs old
perphen-amitrip 2 mg-25 mg tab 1 AL1 At least 18 yrs old
perphen-amitrip 4 mg-10 mg tab 1 AL1 At least 18 yrs old
perphen-amitrip 4 mg-25 mg tab 1 AL1 At least 18 yrs old
perphen-amitrip 4 mg-50 mg tab 1 AL1 At least 18 yrs old
WELLBUTRIN XL 300 MG TABLETbupropion hcl 3
QL 30 / 30 DAYS
AL1 At least 18 yrs old
MONOAMINE OXIDASE INHIBITORS
EMSAM 12 MG/24 HOURS PATCHselegiline 3
EMSAM 6 MG/24 HOURS PATCHselegiline 3
EMSAM 9 MG/24 HOURS PATCHselegiline 3
phenelzine sulfate 15 mg tab 1
tranylcypromine sulf 10 mg tab 1
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINEREUPTAKE INHIBITOR
BRINTELLIX 10 MG TABLETvortioxetine hydrobromide 3
QL 1 / 1 DAYS
ST
BRINTELLIX 20 MG TABLETvortioxetine hydrobromide 3
QL 1 / 1 DAYS
ST
BRINTELLIX 5 MG TABLETvortioxetine hydrobromide 3
QL 1 / 1 DAYS
ST
PAGE 34 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
citalopram hbr 10 mg tablet 1QL 30 / 30 DAYS
AL1 At least 18 yrs old
citalopram hbr 10 mg/5 ml soln 1 AL1 At least 18 yrs old
citalopram hbr 20 mg tablet 1QL 30 / 30 DAYS
AL1 At least 18 yrs old
citalopram hbr 40 mg tablet 1QL 30 / 30 DAYS
AL1 At least 18 yrs old
desvenlafaxine fum er 100 mg 3QL 1 / 1 DAYS
ST
desvenlafaxine fum er 50 mg 3QL 1 / 1 DAYS
ST
escitalopram 10 mg tablet 1 QL 1 / 1 DAYS
escitalopram 20 mg tablet 1 QL 1 / 1 DAYS
escitalopram 5 mg tablet 1 QL 1 / 1 DAYS
escitalopram oxalate 5 mg/5 ml 1
FETZIMA 20-40 MG TITRATION PAKlevomilnacipran hcl 3
QL 1 / 1 DAYS
ST
FETZIMA ER 120 MG CAPSULElevomilnacipran hcl 3
QL 1 / 1 DAYS
ST
FETZIMA ER 20 MG CAPSULElevomilnacipran hcl 3
QL 1 / 1 DAYS
ST
FETZIMA ER 40 MG CAPSULElevomilnacipran hcl 3
QL 1 / 1 DAYS
ST
FETZIMA ER 80 MG CAPSULElevomilnacipran hcl 3
QL 1 / 1 DAYS
ST
fluoxetine 20 mg/5 ml solution 1 AL1 At least 18 yrs old
fluoxetine dr 90 mg capsule 1
QL 4 / 28 DAYS
ST
AL1 At least 18 yrs old
PAGE 35 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fluoxetine hcl 10 mg capsule 1 AL1 At least 18 yrs old
fluoxetine hcl 10 mg tablet 1
QL 30 / 30 DAYS
ST
AL1 At least 18 yrs old
fluoxetine hcl 20 mg capsule 1 AL1 At least 18 yrs old
fluoxetine hcl 20 mg tablet 1QL 30 / 30 DAYS
AL1 At least 18 yrs old
fluoxetine hcl 40 mg capsule 1 AL1 At least 18 yrs old
nefazodone hcl 100 mg tablet 1 AL1 At least 18 yrs old
nefazodone hcl 150 mg tablet 1 AL1 At least 18 yrs old
nefazodone hcl 200 mg tablet 1 AL1 At least 18 yrs old
nefazodone hcl 250 mg tablet 1 AL1 At least 18 yrs old
nefazodone hcl 50 mg tablet 1 AL1 At least 18 yrs old
OLEPTRO ER 150 MG TABLETtrazodone hcl 3
QL 30 / 30 DAYS
AL1 At least 18 yrs old
OLEPTRO ER 300 MG TABLETtrazodone hcl 3
QL 30 / 30 DAYS
AL1 At least 18 yrs old
paroxetine cr 12.5 mg tablet 1 AL1 At least 18 yrs old
paroxetine cr 25 mg tablet 1 AL1 At least 18 yrs old
paroxetine cr 37.5 mg tablet 1 AL1 At least 18 yrs old
paroxetine er 12.5 mg tablet 1 AL1 At least 18 yrs old
paroxetine er 25 mg tablet 1 AL1 At least 18 yrs old
paroxetine er 37.5 mg tablet 1 AL1 At least 18 yrs old
paroxetine hcl 10 mg tablet 1QL 30 / 30 DAYS
AL1 At least 18 yrs old
paroxetine hcl 20 mg tablet 1QL 30 / 30 DAYS
AL1 At least 18 yrs old
paroxetine hcl 30 mg tablet 1QL 60 / 30 DAYS
AL1 At least 18 yrs old
PAGE 36 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
paroxetine hcl 40 mg tablet 1QL 30 / 30 DAYS
AL1 At least 18 yrs old
sertraline 20 mg/ml oral conc 1 AL1 At least 18 yrs old
sertraline hcl 100 mg tablet 1 AL1 At least 18 yrs old
sertraline hcl 25 mg tablet 1QL 30 / 30 DAYS
AL1 At least 18 yrs old
sertraline hcl 50 mg tablet 1QL 60 / 30 DAYS
AL1 At least 18 yrs old
trazodone 100 mg tablet 1 AL1 At least 18 yrs old
trazodone 150 mg tablet 1 AL1 At least 18 yrs old
trazodone 300 mg tablet 1 AL1 At least 18 yrs old
trazodone 50 mg tablet 1 AL1 At least 18 yrs old
TRINTELLIX 10 MG TABLETvortioxetine hydrobromide 3
TRINTELLIX 20 MG TABLETvortioxetine hydrobromide 3
TRINTELLIX 5 MG TABLETvortioxetine hydrobromide 3
venlafaxine hcl 100 mg tablet 1 AL1 At least 18 yrs old
venlafaxine hcl 25 mg tablet 1 AL1 At least 18 yrs old
venlafaxine hcl 37.5 mg tablet 1 AL1 At least 18 yrs old
venlafaxine hcl 50 mg tablet 1 AL1 At least 18 yrs old
venlafaxine hcl 75 mg tablet 1 AL1 At least 18 yrs old
venlafaxine hcl er 150 mg cap 1
QL 30 / 30 DAYS
ST
AL1 At least 18 yrs old
venlafaxine hcl er 150 mg tab 1QL 30 / 30 DAYS
AL1 At least 18 yrs old
venlafaxine hcl er 225 mg tab 1
PAGE 37 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
venlafaxine hcl er 37.5 mg tab 1QL 30 / 30 DAYS
AL1 At least 18 yrs old
venlafaxine hcl er 75 mg cap 1
QL 30 / 30 DAYS
ST
AL1 At least 18 yrs old
venlafaxine hcl er 75 mg tab 1QL 30 / 30 DAYS
AL1 At least 18 yrs old
VIIBRYD 10 MG TABLETvilazodone hcl 3 ST
VIIBRYD 10-20 MG STARTER PACKvilazodone hcl 3 ST
VIIBRYD 20 MG TABLETvilazodone hcl 3 ST
VIIBRYD 40 MG TABLETvilazodone hcl 3 ST
TRICYCLICS
amitriptyline hcl 10 mg tab 1
amitriptyline hcl 100 mg tab 1
amitriptyline hcl 150 mg tab 1
amitriptyline hcl 25 mg tab 1
amitriptyline hcl 50 mg tab 1
amitriptyline hcl 75 mg tab 1
amoxapine 100 mg tablet 1
amoxapine 150 mg tablet 1
amoxapine 25 mg tablet 1
amoxapine 50 mg tablet 1
clomipramine 25 mg capsule 3 ST
clomipramine 50 mg capsule 3 ST
clomipramine 75 mg capsule 3 ST
desipramine 10 mg tablet 1
desipramine 100 mg tablet 1
desipramine 150 mg tablet 1
PAGE 38 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
desipramine 25 mg tablet 1
desipramine 50 mg tablet 1
desipramine 75 mg tablet 1
doxepin 10 mg capsule 1
doxepin 10 mg/ml oral conc 1
doxepin 100 mg capsule 1
doxepin 150 mg capsule 1
doxepin 25 mg capsule 1
doxepin 50 mg capsule 1
doxepin 75 mg capsule 1
elavil 25 mg tablet 3
imipramine hcl 10 mg tablet 1
imipramine hcl 25 mg tablet 1
imipramine hcl 50 mg tablet 1
imipramine pamoate 100 mg cap 1
imipramine pamoate 125 mg cap 1
imipramine pamoate 150 mg cap 1
imipramine pamoate 75 mg cap 1
nortriptyline 10 mg/5 ml sol 1
nortriptyline hcl 10 mg cap 1
nortriptyline hcl 25 mg cap 1
nortriptyline hcl 50 mg cap 1
nortriptyline hcl 75 mg cap 1
SURMONTIL 100 MG CAPSULEtrimipramine maleate 3
TOFRANIL-PM 150 MG CAPSULEimipramine pamoate 3
trimipramine maleate 100 mg cp 1
trimipramine maleate 25 mg cap 1
trimipramine maleate 50 mg cap 1
PAGE 39 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIEMETICS
ANTIEMETICS, OTHER
AKYNZEO 300-0.5 MG CAPSULEnetupitant/palonosetron hcl 2 QL 1 / 21 DAYS
COMPAZINE 25 MG SUPPOSITORYprochlorperazine 3
compro 25 mg suppository 1
meclizine 12.5 mg tablet 1
meclizine 25 mg tablet 1
metoclopramide 10 mg tablet 1
metoclopramide 10 mg/10 ml sol 1
metoclopramide 5 mg tablet 1
metoclopramide 5 mg/5 ml soln 1
metoclopramide 5 mg/5 ml soln 1
metoclopramide 5 mg/5 ml syrup 1
perphenazine 16 mg tablet 1
perphenazine 2 mg tablet 1
perphenazine 4 mg tablet 1
perphenazine 8 mg tablet 1
phenadoz 12.5 mg suppository 1
phenadoz 25 mg suppository 1
prochlorperazine 10 mg tab 1
prochlorperazine 25 mg supp 1
prochlorperazine 5 mg tablet 1
promethazine 12.5 mg suppos 1
promethazine 25 mg suppository 1
promethazine 50 mg suppository 1
promethazine 50 mg tablet 1
promethegan 12.5 mg suppos 1
promethegan 25 mg suppository 1
promethegan 50 mg suppository 1
PAGE 40 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EMETOGENIC THERAPY ADJUNCTS
ANZEMET 100 MG TABLETdolasetron mesylate 3
ANZEMET 50 MG TABLETdolasetron mesylate 3
CESAMET 1 MG CAPSULEnabilone 3 ST
EMEND 125 MG CAPSULEaprepitant 2
EMEND 40 MG CAPSULEaprepitant 2
EMEND 80 MG CAPSULEaprepitant 2
EMEND TRIPACKaprepitant 2
granisetron hcl 1 mg tablet 1 QL 2 / 1 FILL
ondansetron 4 mg/5 ml solution 1
ondansetron hcl 24 mg tablet 1
ondansetron hcl 4 mg tablet 1 QL 12 / 30 DAYS
ondansetron hcl 8 mg tablet 1 QL 12 / 30 DAYS
ondansetron odt 4 mg tablet 1 QL 12 / 30 DAYS
ondansetron odt 8 mg tablet 1 QL 12 / 30 DAYS
SANCUSO 3.1 MG/24 HR PATCHgranisetron 3
VARUBI 90 MG TABLETrolapitant hcl 2
ZOFRAN 4 MG/5 ML ORAL SOLNondansetron hcl 3
ANTIFUNGALS
ciclodan 0.77% cream 3
ciclopirox 0.77% cream 1
ciclopirox 0.77% gel 1
ciclopirox 0.77% topical susp 1
ciclopirox 1% shampoo 1
PAGE 41 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ciclopirox 8% solution 1
clotrimazole 1% cream 1
clotrimazole 1% solution 1
clotrimazole 10 mg troche 1
CRESEMBA 186 MG CAPSULEisavuconazonium sulfate 3 PA
DIFLUCAN 40 MG/ML SUSPENSIONfluconazole 3
econazole nitrate 1% cream 1
ECOZA 1% FOAMeconazole nitrate 3
ERTACZO 2% CREAMsertaconazole nitrate 3
EXELDERM 1% CREAMsulconazole nitrate 3
EXELDERM 1% SOLUTIONsulconazole nitrate 3
fluconazole 10 mg/ml susp 1
fluconazole 100 mg tablet 1
fluconazole 150 mg tablet 1 QL 4 / 1 FILL
fluconazole 200 mg tablet 1 PA
fluconazole 40 mg/ml susp 1
fluconazole 50 mg tablet 1
GRIFULVIN V 500 MG TABLETgriseofulvin, microsize 2
griseofulvin 125 mg/5 ml susp 1
griseofulvin micro 500 mg tab 1
griseofulvin ultra 125 mg tab 1
griseofulvin ultra 250 mg tab 1
gynazole 1 2% cream 2
itraconazole 100 mg capsule 1QL 30 / 1 FILL
PA
ketoconazole 2% cream 1
ketoconazole 2% foam 3
PAGE 42 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ketoconazole 2% shampoo 1
ketoconazole 200 mg tablet 1
ketodan 2% foam 1
LUZU 1% CREAMluliconazole 3
QL 1 / 28 DAYS
ST
naftifine hcl 1% cream 3
naftifine hcl 2% cream 3
NAFTIN 1% GELnaftifine hcl 3
NAFTIN 2% GELnaftifine hcl 3
NOXAFIL 40 MG/ML SUSPENSIONposaconazole 3 AL1 At least 13 yrs old
NOXAFIL DR 100 MG TABLETposaconazole 3 AL1 At least 13 yrs old
nyamyc 100,000 units/gm powder 1
nystatin 100,000 unit/gm cream 1
nystatin 100,000 unit/gm powd 1
nystatin 100,000 unit/ml susp 1
nystatin 100,000 units/gm oint 1
nystatin 150,000,000 units pwd 1
nystatin 50,000,000 units pwd 1
nystatin 500,000 unit oral tab 1
nystatin 500,000 unit/5 ml sus 1
nystatin 500,000,000 units pwd 1
nystatin-triamcinolone ointm 1
nystop 100,000 units/gm powder 1
ONMEL 200 MG TABLETitraconazole 3
ORAVIG 50 MG BUCCAL TABLETmiconazole 3 ST
oxiconazole nitrate 1% cream 3
OXISTAT 1% LOTIONoxiconazole nitrate 3
PAGE 43 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
pedi-dri topical powder 1
PENLAC 8% SOLUTIONciclopirox 3
SPORANOX 10 MG/ML SOLUTIONitraconazole 3
terbinafine hcl 250 mg tablet 1
terconazole 0.4% cream 1
terconazole 0.8% cream 1
terconazole 80 mg suppository 1
voriconazole 200 mg tablet 2 PA
voriconazole 40 mg/ml susp 2 PA
voriconazole 50 mg tablet 2 PA
XOLEGEL 2% GELketoconazole 3 AL1 At least 12 yrs old
ANTIGOUT AGENTS
allopurinol 100 mg tablet 1
allopurinol 300 mg tablet 1
colchicine 0.6 mg tablet 1 QL 4 / 1 DAYS
probenecid 500 mg tablet 1
probenecid-colchicine tabs 1
ULORIC 40 MG TABLETfebuxostat 2
QL 30 / 30 DAYS
AL1 At least 18 yrs old
ULORIC 80 MG TABLETfebuxostat 2
QL 30 / 30 DAYS
AL1 At least 18 yrs old
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
dihydroergotamine 1 mg/ml am 4
dihydroergotamine 1 mg/ml vl 4
dihydroergotamine 4 mg/ml spry 2 QL 8 / 30 DAYS
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
almotriptan malate 12.5 mg tab 3QL 6 / 1 FILL
ST
PAGE 44 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
almotriptan malate 6.25 mg tab 3QL 6 / 1 FILL
ST
frovatriptan succ 2.5 mg tab 3 ST
naratriptan 1 mg tablet 1QL 9 / 1 FILL
ST
naratriptan 2.5 mg tablet 1QL 9 / 1 FILL
ST
naratriptan hcl 1 mg tablet 1QL 9 / 1 FILL
ST
naratriptan hcl 2.5 mg tablet 1QL 9 / 1 FILL
ST
RELPAX 20 MG TABLETeletriptan hbr 2
RELPAX 40 MG TABLETeletriptan hbr 2
rizatriptan 10 mg odt 1 QL 9 / 1 FILL
rizatriptan 10 mg tablet 1 QL 9 / 1 FILL
rizatriptan 5 mg odt 1 QL 9 / 1 FILL
rizatriptan 5 mg tablet 1 QL 9 / 1 FILL
sumatriptan 20 mg nasal spray 1 QL 6 / 1 FILL
sumatriptan 4 mg/0.5 ml cart 1
sumatriptan 4 mg/0.5 ml inject 2
sumatriptan 5 mg nasal spray 1 QL 6 / 1 FILL
sumatriptan 6 mg/0.5 ml inject 2 QL 1 / 1 FILL
sumatriptan 6 mg/0.5 ml refill 1
sumatriptan 6 mg/0.5 ml syrng 2
sumatriptan 6 mg/0.5 ml vial 1 QL 2.5 / 1 FILL
sumatriptan succ 100 mg tablet 1 QL 9 / 1 FILL
sumatriptan succ 25 mg tablet 1 QL 9 / 1 FILL
PAGE 45 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
sumatriptan succ 50 mg tablet 1 QL 9 / 1 FILL
TREXIMET 85-500 MG TABLETsumatriptan succinate/naproxen sodium 3 ST
zolmitriptan 2.5 mg odt 3QL 6 / 1 FILL
ST
zolmitriptan 2.5 mg tablet 3QL 6 / 1 FILL
ST
zolmitriptan 5 mg odt 3QL 3 / 1 FILL
ST
zolmitriptan 5 mg tablet 3QL 3 / 1 FILL
ST
ZOMIG 2.5 MG NASAL SPRAYzolmitriptan 3 ST
ZOMIG 5 MG NASAL SPRAYzolmitriptan 3 ST
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone 25 mg tablet 1
ANTITUBERCULARS
cycloserine 250 mg capsule 2
ethambutol hcl 100 mg tablet 1
ethambutol hcl 400 mg tablet 1
isoniazid 100 mg tablet 1
isoniazid 300 mg tablet 1
isoniazid 50 mg/5 ml solution 1
pyrazinamide 500 mg tablet 1
rifampin 150 mg capsule 1
rifampin 300 mg capsule 1
RIFATER TABLETrifampin/isoniazid/pyrazinamide 2
SIRTURO 100 MG TABLETbedaquiline fumarate 3 PA
PAGE 46 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRECATOR 250 MG TABLETethionamide 2
ANTINEOPLASTICS
ALKYLATING AGENTS
ALKERAN 2 MG TABLETmelphalan 2
HEXALEN 50 MG CAPSULEaltretamine 2
LEUKERAN 2 MG TABLETchlorambucil 2
MATULANE 50 MG CAPSULEprocarbazine hcl 2
MYLERAN 2 MG TABLETbusulfan 2
temozolomide 100 mg capsule 2
temozolomide 140 mg capsule 2
temozolomide 180 mg capsule 2
temozolomide 20 mg capsule 2
temozolomide 250 mg capsule 2
temozolomide 5 mg capsule 2
ANTIANDROGENS
bicalutamide 50 mg tablet 1
flutamide 125 mg capsule 1
nilutamide 150 mg tablet 2
XTANDI 40 MG CAPSULEenzalutamide 2
QL 4 / 1 DAYS
ST
ZYTIGA 250 MG TABLETabiraterone acetate 2 PA
ANTIANGIOGENIC AGENTS
POMALYST 1 MG CAPSULEpomalidomide 2
QL 21 / 28 DAYS
PA
POMALYST 2 MG CAPSULEpomalidomide 2
QL 21 / 28 DAYS
PA
PAGE 47 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
POMALYST 3 MG CAPSULEpomalidomide 2
QL 21 / 28 DAYS
PA
POMALYST 4 MG CAPSULEpomalidomide 2
QL 21 / 28 DAYS
PA
REVLIMID 10 MG CAPSULElenalidomide 2
REVLIMID 15 MG CAPSULElenalidomide 2
REVLIMID 2.5 MG CAPSULElenalidomide 2
REVLIMID 20 MG CAPSULElenalidomide 2
REVLIMID 25 MG CAPSULElenalidomide 2
REVLIMID 5 MG CAPSULElenalidomide 2
ANTIESTROGENS/MODIFIERS
SOLTAMOX 10 MG/5 ML SOLNtamoxifen citrate 2
tamoxifen 10 mg tablet 1
tamoxifen 20 mg tablet 1
ANTIMETABOLITES
capecitabine 150 mg tablet 2 PA
capecitabine 500 mg tablet 2 PA
fluorouracil 2% topical soln 1
fluorouracil 5% cream 1
fluorouracil 5% top solution 1
HYDREA 500 MG CAPSULEhydroxyurea 3
hydroxyurea 500 mg capsule 1
LONSURF 15 MG-6.14 MG TABLETtrifluridine/tipiracil hcl 2
LONSURF 20 MG-8.19 MG TABLETtrifluridine/tipiracil hcl 2
mercaptopurine 50 mg tablet 1
PAGE 48 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PURIXAN 20 MG/ML ORAL SUSPmercaptopurine 2
ST
AL1 Up to 5 yrs old
ANTINEOPLASTICS, OTHER
FARYDAK 10 MG CAPSULEpanobinostat lactate 2 PA
FARYDAK 15 MG CAPSULEpanobinostat lactate 2 PA
FARYDAK 20 MG CAPSULEpanobinostat lactate 2 PA
leucovorin calcium 10 mg tab 1
leucovorin calcium 15 mg tab 1
leucovorin calcium 25 mg tab 1
leucovorin calcium 5 mg tab 1
LYNPARZA 50 MG CAPSULEolaparib 2 PA
LYSODREN 500 MG TABLETmitotane 2
MESNEX 400 MG TABLETmesna 2
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole 1 mg tablet 1
exemestane 25 mg tablet 2
letrozole 2.5 mg tablet 1
MOLECULAR TARGET INHIBITORS
AFINITOR 10 MG TABLETeverolimus 2
QL 30 / 30 DAYS
PA
AFINITOR 2.5 MG TABLETeverolimus 2
QL 30 / 30 DAYS
PA
AFINITOR 5 MG TABLETeverolimus 2
QL 30 / 30 DAYS
PA
AFINITOR 7.5 MG TABLETeverolimus 2
QL 30 / 30 DAYS
PA
AFINITOR DISPERZ 2 MG TABLETeverolimus 2
QL 30 / 30 DAYS
PA
PAGE 49 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AFINITOR DISPERZ 3 MG TABLETeverolimus 2
QL 30 / 30 DAYS
PA
AFINITOR DISPERZ 5 MG TABLETeverolimus 2
QL 30 / 30 DAYS
PA
ALECENSA 150 MG CAPSULEalectinib hcl 2
BOSULIF 100 MG TABLETbosutinib 2 PA
BOSULIF 500 MG TABLETbosutinib 2 PA
CABOMETYX 20 MG TABLETcabozantinib s-malate 2
CABOMETYX 40 MG TABLETcabozantinib s-malate 2
CABOMETYX 60 MG TABLETcabozantinib s-malate 2
CAPRELSA 100 MG TABLETvandetanib 2 ST
CAPRELSA 300 MG TABLETvandetanib 2 ST
COMETRIQ 100 MG DAILY-DOSE PKcabozantinib s-malate 2 PA
COMETRIQ 140 MG DAILY-DOSE PKcabozantinib s-malate 2 PA
COMETRIQ 60 MG DAILY-DOSE PACKcabozantinib s-malate 2 PA
COTELLIC 20 MG TABLETcobimetinib fumarate 2
ERIVEDGE 150 MG CAPSULEvismodegib 2 PA
GILOTRIF 20 MG TABLETafatinib dimaleate 2
GILOTRIF 30 MG TABLETafatinib dimaleate 2
GILOTRIF 40 MG TABLETafatinib dimaleate 2
IBRANCE 100 MG CAPSULEpalbociclib 2 PA
PAGE 50 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
IBRANCE 125 MG CAPSULEpalbociclib 2 PA
IBRANCE 75 MG CAPSULEpalbociclib 2 PA
ICLUSIG 15 MG TABLETponatinib hcl 2 PA
ICLUSIG 45 MG TABLETponatinib hcl 2 PA
imatinib mesylate 100 mg tab 2 PA
imatinib mesylate 400 mg tab 2 PA
IMBRUVICA 140 MG CAPSULEibrutinib 2 PA
IRESSA 250 MG TABLETgefitinib 2
QL 2 / 1 DAYS
PA
JAKAFI 10 MG TABLETruxolitinib phosphate 2 PA
JAKAFI 15 MG TABLETruxolitinib phosphate 2 PA
JAKAFI 20 MG TABLETruxolitinib phosphate 2 PA
JAKAFI 25 MG TABLETruxolitinib phosphate 2 PA
JAKAFI 5 MG TABLETruxolitinib phosphate 2 PA
LENVIMA 10 MG DAILY DOSElenvatinib mesylate 2 PA
LENVIMA 14 MG DAILY DOSElenvatinib mesylate 2 PA
LENVIMA 18 MG DAILY DOSElenvatinib mesylate 2 PA
LENVIMA 20 MG DAILY DOSElenvatinib mesylate 2 PA
LENVIMA 24 MG DAILY DOSElenvatinib mesylate 2 PA
LENVIMA 8 MG DAILY DOSElenvatinib mesylate 2 PA
MEKINIST 0.5 MG TABLETtrametinib dimethyl sulfoxide 2 PA
PAGE 51 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MEKINIST 2 MG TABLETtrametinib dimethyl sulfoxide 2 PA
NEXAVAR 200 MG TABLETsorafenib tosylate 2 PA
NINLARO 2.3 MG CAPSULEixazomib citrate 2
NINLARO 3 MG CAPSULEixazomib citrate 2
NINLARO 4 MG CAPSULEixazomib citrate 2
ODOMZO 200 MG CAPSULEsonidegib phosphate 2
SPRYCEL 100 MG TABLETdasatinib 2 PA
SPRYCEL 140 MG TABLETdasatinib 2 PA
SPRYCEL 20 MG TABLETdasatinib 2 PA
SPRYCEL 50 MG TABLETdasatinib 2 PA
SPRYCEL 70 MG TABLETdasatinib 2 PA
SPRYCEL 80 MG TABLETdasatinib 2 PA
STIVARGA 40 MG TABLETregorafenib 2 PA
SUTENT 12.5 MG CAPSULEsunitinib malate 2 ST
SUTENT 25 MG CAPSULEsunitinib malate 2 ST
SUTENT 37.5 MG CAPSULEsunitinib malate 2 ST
SUTENT 50 MG CAPSULEsunitinib malate 2 ST
TAFINLAR 50 MG CAPSULEdabrafenib mesylate 2 PA
TAFINLAR 75 MG CAPSULEdabrafenib mesylate 2 PA
TAGRISSO 40 MG TABLETosimertinib mesylate 2
PAGE 52 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TAGRISSO 80 MG TABLETosimertinib mesylate 2
TARCEVA 100 MG TABLETerlotinib hcl 2 PA
TARCEVA 150 MG TABLETerlotinib hcl 2 PA
TARCEVA 25 MG TABLETerlotinib hcl 2 PA
TASIGNA 150 MG CAPSULEnilotinib hcl 2 PA
TASIGNA 200 MG CAPSULEnilotinib hcl 2 PA
TYKERB 250 MG TABLETlapatinib ditosylate 2 PA
VENCLEXTA 10 MG TABLETvenetoclax 2
VENCLEXTA 100 MG TABLETvenetoclax 2
VENCLEXTA 50 MG TABLETvenetoclax 2
VENCLEXTA STARTING PACKvenetoclax 2
VOTRIENT 200 MG TABLETpazopanib hcl 2
XALKORI 200 MG CAPSULEcrizotinib 2 PA
XALKORI 250 MG CAPSULEcrizotinib 2 PA
ZELBORAF 240 MG TABLETvemurafenib 2 PA
ZYDELIG 100 MG TABLETidelalisib 2 PA
ZYDELIG 150 MG TABLETidelalisib 2 PA
ZYKADIA 150 MG CAPSULEceritinib 2 PA
RETINOIDS
tretinoin 10 mg capsule 1
PAGE 53 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIPARASITICS
ANTIHELMINTHICS
SKLICE 0.5% LOTIONivermectin 2 ST
ANTIPROTOZOALS
ALINIA 100 MG/5 ML SUSPENSIONnitazoxanide 2
ALINIA 500 MG TABLETnitazoxanide 2
chloroquine ph 250 mg tablet 1
chloroquine ph 500 mg tablet 1
COARTEM TABLETSartemether/lumefantrine 2
DARAPRIM 25 MG TABLETpyrimethamine 4 PA
hydroxychloroquine 200 mg tab 1
mefloquine hcl 250 mg tablet 1
PLAQUENIL 200 MG TABLEThydroxychloroquine sulfate 3
quinine sulfate 324 mg capsule 2 PA
PEDICULICIDES/SCABICIDES
elimite 5% cream 3
ELIMITE 5% CREAMpermethrin 3
lindane 1% shampoo 1
permethrin 5% cream 1
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine mes 0.5 mg tab 1
benztropine mes 1 mg tablet 1
benztropine mes 2 mg tablet 1
trihexyphenidyl 2 mg tablet 1
trihexyphenidyl 2 mg/5 ml elx 1
PAGE 54 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
trihexyphenidyl 5 mg tablet 1
ANTIPARKINSON AGENTS, OTHER
amantadine 100 mg capsule 1
amantadine 100 mg tablet 1
amantadine 100 mg/10 ml soln 1
amantadine 50 mg/5 ml solution 1
carbidopa-levodopa-enta 100 mg 1 ST
carbidopa-levodopa-enta 125 mg 1 ST
carbidopa-levodopa-enta 150 mg 1 ST
carbidopa-levodopa-enta 200 mg 1 ST
carbidopa-levodopa-enta 50 mg 1 ST
carbidopa-levodopa-enta 75 mg 1 ST
DOPAMINE AGONISTS
APOKYN 30 MG/3 ML CARTRIDGEapomorphine hcl 4 PA
bromocriptine 2.5 mg tablet 3
NEUPRO 1 MG/24 HR PATCHrotigotine 3 ST
NEUPRO 2 MG/24 HR PATCHrotigotine 3 ST
NEUPRO 3 MG/24 HR PATCHrotigotine 3 ST
NEUPRO 4 MG/24 HR PATCHrotigotine 3 ST
NEUPRO 6 MG/24 HR PATCHrotigotine 3 ST
NEUPRO 8 MG/24 HR PATCHrotigotine 3 ST
pramipexole 0.125 mg tablet 1
pramipexole 0.25 mg tablet 1
pramipexole 0.5 mg tablet 1
pramipexole 0.75 mg tablet 1
pramipexole 1 mg tablet 1
PAGE 55 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
pramipexole 1.5 mg tablet 1
pramipexole er 0.375 mg tablet 3 ST
pramipexole er 0.75 mg tablet 3 ST
pramipexole er 1.5 mg tablet 3 ST
pramipexole er 2.25 mg tablet 3
pramipexole er 3 mg tablet 3 ST
pramipexole er 3.75 mg tablet 3
pramipexole er 4.5 mg tablet 3 ST
ropinirole hcl 0.25 mg tablet 1
ropinirole hcl 0.5 mg tablet 1
ropinirole hcl 1 mg tablet 1
ropinirole hcl 2 mg tablet 1
ropinirole hcl 3 mg tablet 1
ropinirole hcl 4 mg tablet 1
ropinirole hcl 5 mg tablet 1
ropinirole hcl er 12 mg tablet 1
ropinirole hcl er 2 mg tablet 1
ropinirole hcl er 4 mg tablet 1
ropinirole hcl er 6 mg tablet 1
ropinirole hcl er 8 mg tablet 1
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa-levo 10-100 mg odt 1
carbidopa-levo 25-100 mg odt 1
carbidopa-levo 25-250 mg odt 1
carbidopa-levo er 25-100 tab 1
carbidopa-levo er 50-200 tab 1
carbidopa-levodopa 10-100 tab 1
carbidopa-levodopa 25-100 tab 1
carbidopa-levodopa 25-250 tab 1
DUOPA 4.63 MG-20 MG/ML SUSPENScarbidopa/levodopa 3 PA
PAGE 56 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SINEMET CR 25-100 TABLETcarbidopa/levodopa 3
SINEMET CR 50-200 TABLETcarbidopa/levodopa 3
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
AZILECT 0.5 MG TABLETrasagiline mesylate 3 ST
AZILECT 1 MG TABLETrasagiline mesylate 3 ST
selegiline hcl 5 mg capsule 1
selegiline hcl 5 mg tablet 1
ZELAPAR 1.25 MG ODT TABLETselegiline hcl 2 ST
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
chlorpromazine 10 mg tablet 1
chlorpromazine 100 mg tablet 1
chlorpromazine 200 mg tablet 1
chlorpromazine 25 mg tablet 1
chlorpromazine 50 mg tablet 1
fluphenazine 1 mg tablet 1
fluphenazine 10 mg tablet 1
fluphenazine 2.5 mg tablet 1
fluphenazine 2.5 mg/5 ml elix 1
fluphenazine 5 mg tablet 1
fluphenazine 5 mg/ml conc 1
haloperidol 0.5 mg tablet 1
haloperidol 1 mg tablet 1
haloperidol 10 mg tablet 1
haloperidol 2 mg tablet 1
haloperidol 20 mg tablet 1
haloperidol 5 mg tablet 1
haloperidol lac 2 mg/ml conc 1
PAGE 57 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
loxapine 10 mg capsule 1
loxapine 25 mg capsule 1
loxapine 5 mg capsule 1
loxapine 50 mg capsule 1
pimozide 1 mg tablet 2
pimozide 2 mg tablet 2
thioridazine 10 mg tablet 1
thioridazine 100 mg tablet 1
thioridazine 25 mg tablet 1
thioridazine 50 mg tablet 1
thiothixene 1 mg capsule 1
thiothixene 10 mg capsule 1
thiothixene 2 mg capsule 1
thiothixene 5 mg capsule 1
trifluoperazine 1 mg tablet 1
trifluoperazine 10 mg tablet 1
trifluoperazine 2 mg tablet 1
trifluoperazine 5 mg tablet 1
2ND GENERATION/ATYPICAL
ABILIFY DISCMELT 15 MG TABLETaripiprazole 3 QL 30 / 30 DAYS
aripiprazole 1 mg/ml solution 3 QL 30 / 30 DAYS
aripiprazole 10 mg tablet 3 QL 30 / 30 DAYS
aripiprazole 15 mg tablet 3 QL 30 / 30 DAYS
aripiprazole 2 mg tablet 3 QL 30 / 30 DAYS
aripiprazole 20 mg tablet 3 QL 30 / 30 DAYS
aripiprazole 30 mg tablet 3 QL 30 / 30 DAYS
aripiprazole 5 mg tablet 3 QL 30 / 30 DAYS
aripiprazole odt 10 mg tablet 3 QL 30 / 30 DAYS
aripiprazole odt 15 mg tablet 3 QL 30 / 30 DAYS
PAGE 58 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FANAPT 1 MG TABLETiloperidone 3 ST
FANAPT 10 MG TABLETiloperidone 3 ST
FANAPT 12 MG TABLETiloperidone 3 ST
FANAPT 2 MG TABLETiloperidone 3 ST
FANAPT 4 MG TABLETiloperidone 3 ST
FANAPT 6 MG TABLETiloperidone 3 ST
FANAPT 8 MG TABLETiloperidone 3 ST
FANAPT TITRATION PACKiloperidone 3 ST
LATUDA 120 MG TABLETlurasidone hcl 3 ST
LATUDA 20 MG TABLETlurasidone hcl 3 ST
LATUDA 40 MG TABLETlurasidone hcl 3 ST
LATUDA 60 MG TABLETlurasidone hcl 3 ST
LATUDA 80 MG TABLETlurasidone hcl 3 ST
NUPLAZID 17 MG TABLETpimavanserin tartrate 4
olanzapine 10 mg tablet 1
olanzapine 15 mg tablet 1
olanzapine 2.5 mg tablet 1
olanzapine 20 mg tablet 1
olanzapine 5 mg tablet 1
olanzapine 7.5 mg tablet 1
olanzapine odt 10 mg tablet 1
olanzapine odt 15 mg tablet 1
olanzapine odt 20 mg tablet 1
PAGE 59 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
olanzapine odt 5 mg tablet 1
paliperidone er 1.5 mg tablet 3 ST
paliperidone er 3 mg tablet 3 ST
paliperidone er 6 mg tablet 3 ST
paliperidone er 9 mg tablet 3 ST
quetiapine er 150 mg tablet 3 ST
quetiapine er 200 mg tablet 3 ST
quetiapine er 300 mg tablet 3 ST
quetiapine er 400 mg tablet 3 ST
quetiapine er 50 mg tablet 3 ST
quetiapine fumarate 100 mg tab 1
quetiapine fumarate 200 mg tab 1
quetiapine fumarate 25 mg tab 1
quetiapine fumarate 300 mg tab 1
quetiapine fumarate 400 mg tab 1
quetiapine fumarate 50 mg tab 1
REXULTI 0.25 MG TABLETbrexpiprazole 3
QL 1 / 1 DAYS
ST
REXULTI 0.5 MG TABLETbrexpiprazole 3
QL 1 / 1 DAYS
ST
REXULTI 1 MG TABLETbrexpiprazole 3
QL 1 / 1 DAYS
ST
REXULTI 2 MG TABLETbrexpiprazole 3
QL 1 / 1 DAYS
ST
REXULTI 3 MG TABLETbrexpiprazole 3
QL 1 / 1 DAYS
ST
REXULTI 4 MG TABLETbrexpiprazole 3
QL 1 / 1 DAYS
ST
risperidone 0.25 mg odt 1
PAGE 60 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
risperidone 0.25 mg tablet 1
risperidone 0.5 mg odt 1
risperidone 0.5 mg tablet 1
risperidone 1 mg odt 1
risperidone 1 mg tablet 1
risperidone 1 mg/ml solution 1
risperidone 2 mg odt 1
risperidone 2 mg tablet 1
risperidone 3 mg odt 1
risperidone 3 mg tablet 1
risperidone 4 mg odt 1
risperidone 4 mg tablet 1
SAPHRIS 10 MG TAB SL BLK CHERYasenapine maleate 3
QL 2 / 1 DAYS
ST
AL1 At least 10 yrs old
SAPHRIS 10 MG TAB SUBLINGUALasenapine maleate 3
QL 2 / 1 DAYS
ST
AL1 At least 10 yrs old
SAPHRIS 2.5 MG TAB SL BLK CHRYasenapine maleate 3
QL 2 / 1 DAYS
ST
AL1 At least 10 yrs old
SAPHRIS 5 MG TAB SL BLK CHERRYasenapine maleate 3
QL 2 / 1 DAYS
ST
AL1 At least 10 yrs old
SAPHRIS 5 MG TABLET SUBLINGUALasenapine maleate 3
QL 2 / 1 DAYS
ST
AL1 At least 10 yrs old
VRAYLAR 1.5 MG CAPSULEcariprazine hcl 4
VRAYLAR 1.5 MG-3 MG PACKcariprazine hcl 4
VRAYLAR 3 MG CAPSULEcariprazine hcl 4
PAGE 61 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VRAYLAR 4.5 MG CAPSULEcariprazine hcl 4
VRAYLAR 6 MG CAPSULEcariprazine hcl 4
ziprasidone hcl 20 mg capsule 1 QL 60 / 1 FILL
ziprasidone hcl 40 mg capsule 1 QL 60 / 1 FILL
ziprasidone hcl 60 mg capsule 1 QL 60 / 1 FILL
ziprasidone hcl 80 mg capsule 1 QL 60 / 1 FILL
TREATMENT-RESISTANT
clozapine 100 mg tablet 1
clozapine 200 mg tablet 1
clozapine 25 mg tablet 1
clozapine 50 mg tablet 1
clozapine odt 100 mg tablet 3
clozapine odt 12.5 mg tablet 3
clozapine odt 150 mg tablet 3
clozapine odt 200 mg tablet 3
clozapine odt 25 mg tablet 3
VERSACLOZ 50 MG/ML SUSPENSIONclozapine 3
QL 18 / 1 DAYS
ST
ANTISPASTICITY AGENTS
baclofen 10 mg tablet 1
baclofen 20 mg tablet 1
tizanidine hcl 2 mg tablet 1
tizanidine hcl 4 mg tablet 1
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
valganciclovir 450 mg tablet 2 ST
valganciclovir hcl 50 mg/ml 2 ST
PAGE 62 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTI-HEPATITIS B (HBV) AGENTS
adefovir dipivoxil 10 mg tab 4
BARACLUDE 0.05 MG/ML SOLUTIONentecavir 2
entecavir 0.5 mg tablet 2
entecavir 1 mg tablet 2
EPIVIR HBV 25 MG/5 ML SOLNlamivudine 2
lamivudine 100 mg tablet 2
lamivudine hbv 100 mg tablet 2
TYZEKA 600 MG TABLETtelbivudine 2
ANTI-HEPATITIS C (HCV) AGENTS
DAKLINZA 30 MG TABLETdaclatasvir dihydrochloride 4
DAKLINZA 60 MG TABLETdaclatasvir dihydrochloride 4
DAKLINZA 90 MG TABLETdaclatasvir dihydrochloride 4 PA
EPCLUSA 400 MG-100 MG TABLETsofosbuvir/velpatasvir 4
HARVONI 90-400 MG TABLETledipasvir/sofosbuvir 4 PA
INTRON A 10 MILLION UNITS VIALinterferon alfa-2b,recomb. 4 PA
INTRON A 18 MILLION UNIT/3 MLinterferon alfa-2b,recomb. 4 PA
INTRON A 18 MILLION UNITS VIALinterferon alfa-2b,recomb. 4 PA
INTRON A 25 MILLION UNIT/2.5MLinterferon alfa-2b,recomb. 4 PA
INTRON A 50 MILLION UNITS VIALinterferon alfa-2b,recomb. 4 PA
OLYSIO 150 MG CAPSULEsimeprevir sodium 4 PA
PEGASYS 180 MCG/0.5 ML SYRINGEpeginterferon alfa-2a 4 PA
PAGE 63 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PEGASYS 180 MCG/ML VIALpeginterferon alfa-2a 4 PA
PEGASYS PROCLICK 135 MCG/0.5peginterferon alfa-2a 4 PA
PEGASYS PROCLICK 180 MCG/0.5peginterferon alfa-2a 4 PA
REBETOL 200 MG CAPSULEribavirin 4 PA
REBETOL 40 MG/ML SOLUTIONribavirin 4 PA
ribasphere 200 mg capsule 4 PA
ribasphere 200 mg tablet 4 PA
ribasphere 400 mg tablet 4 PA
ribasphere 600 mg tablet 4 PA
RIBASPHERE RIBAPAK 200-400 MGribavirin 4 PA
RIBASPHERE RIBAPAK 400-400 MGribavirin 4 PA
RIBASPHERE RIBAPAK 600-400 MGribavirin 4 PA
RIBASPHERE RIBAPAK 600-600 MGribavirin 4 PA
RIBATAB 400-400 MG DOSEPACKribavirin 4 PA
RIBATAB 400-600 MG DOSEPACKribavirin 4 PA
RIBATAB 600-600 MG DOSEPACKribavirin 4 PA
ribavirin 200 mg capsule 4 PA
ribavirin 200 mg tablet 4 PA
SOVALDI 400 MG TABLETsofosbuvir 4 PA
TECHNIVIE DOSE PACKombitasvir/paritaprevir/ritonavir 4
VIEKIRA PAKombitasvir/paritaprevir/ritonavir/dasabuvir sodium 4 PA
PAGE 64 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZEPATIER 50-100 MG TABLETelbasvir/grazoprevir 4
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
GENVOYA TABLETelvitegravir/cobicistat/emtricitabine/tenofovir alafenamide 2
ISENTRESS 100 MG POWDER PACKETraltegravir potassium 2
QL 60 / 30 DAYS
ST
AL1 At least 16 yrs old
ISENTRESS 100 MG TABLET CHEWraltegravir potassium 2
QL 60 / 30 DAYS
ST
AL1 At least 16 yrs old
ISENTRESS 25 MG TABLET CHEWraltegravir potassium 2
QL 60 / 30 DAYS
ST
AL1 At least 16 yrs old
ISENTRESS 400 MG TABLETraltegravir potassium 2
QL 60 / 30 DAYS
ST
AL1 At least 16 yrs old
STRIBILD TABLETelvitegravir/cobicistat/emtricitabine/tenofovir disoproxil 2
TIVICAY 10 MG TABLETdolutegravir sodium 2
TIVICAY 25 MG TABLETdolutegravir sodium 2
TIVICAY 50 MG TABLETdolutegravir sodium 2
VITEKTA 150 MG TABLETelvitegravir 2
QL 1 / 1 DAYS
ST
VITEKTA 85 MG TABLETelvitegravir 2
QL 1 / 1 DAYS
ST
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
ATRIPLA TABLETefavirenz/emtricitabine/tenofovir disoproxil fumarate 2 AL1 At least 18 yrs old
COMPLERA TABLETemtricitabine/rilpivirine hcl/tenofovir disoproxil fumarate 2 PA
PAGE 65 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EDURANT 25 MG TABLETrilpivirine hcl 2
INTELENCE 100 MG TABLETetravirine 2 ST
INTELENCE 200 MG TABLETetravirine 2 ST
INTELENCE 25 MG TABLETetravirine 2 ST
nevirapine 200 mg tablet 1
nevirapine 50 mg/5 ml susp 2
nevirapine er 100 mg tablet 3
nevirapine er 400 mg tablet 3
ODEFSEY TABLETemtricitabine/rilpivirine hcl/tenofovir alafenamide fumarate 2
RESCRIPTOR 100 MG TABLETdelavirdine mesylate 2
RESCRIPTOR 200 MG TABLETdelavirdine mesylate 2
SUSTIVA 200 MG CAPSULEefavirenz 2
SUSTIVA 50 MG CAPSULEefavirenz 2
SUSTIVA 600 MG TABLETefavirenz 2
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir 300 mg tablet 2
abacavir-lamivudine 600-300 mg 2
abacavir-lamivudine-zidov tab 2
DESCOVY 200-25 MG TABLETemtricitabine/tenofovir alafenamide fumarate 2
didanosine dr 125 mg capsule 1
didanosine dr 200 mg capsule 1
didanosine dr 250 mg capsule 1
didanosine dr 400 mg capsule 1
EMTRIVA 10 MG/ML SOLUTIONemtricitabine 2 ST
PAGE 66 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EMTRIVA 200 MG CAPSULEemtricitabine 2
QL 30 / 30 DAYS
ST
lamivudine 10 mg/ml oral soln 2
lamivudine 150 mg tablet 2
lamivudine 300 mg tablet 2
lamivudine-zidovudine tablet 2
stavudine 1 mg/ml solution 1
stavudine 15 mg capsule 1
stavudine 20 mg capsule 1
stavudine 30 mg capsule 1
stavudine 40 mg capsule 1
TRUVADA 100 MG-150 MG TABLETemtricitabine/tenofovir disoproxil fumarate 2
TRUVADA 133 MG-200 MG TABLETemtricitabine/tenofovir disoproxil fumarate 2
TRUVADA 167 MG-250 MG TABLETemtricitabine/tenofovir disoproxil fumarate 2
TRUVADA 200 MG-300 MG TABLETemtricitabine/tenofovir disoproxil fumarate 2
VIDEX 2 GM PEDIATRIC SOLNdidanosine 3
VIDEX 4 GM PEDIATRIC SOLNdidanosine 3
VIREAD 150 MG TABLETtenofovir disoproxil fumarate 2
VIREAD 200 MG TABLETtenofovir disoproxil fumarate 2
VIREAD 250 MG TABLETtenofovir disoproxil fumarate 2
VIREAD 300 MG TABLETtenofovir disoproxil fumarate 2
VIREAD POWDERtenofovir disoproxil fumarate 2
ZIAGEN 20 MG/ML SOLUTIONabacavir sulfate 2
zidovudine 100 mg capsule 1
PAGE 67 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
zidovudine 300 mg tablet 1
zidovudine 50 mg/5 ml syrup 1
ANTI-HIV AGENTS, OTHER
FUZEON 90 MG VIALenfuvirtide 3 PA
PREZCOBIX 800 MG-150 MG TABLETdarunavir ethanolate/cobicistat 2 QL 1 / 1 DAYS
SELZENTRY 150 MG TABLETmaraviroc 2 ST
SELZENTRY 300 MG TABLETmaraviroc 2 ST
TRIUMEQ TABLETabacavir sulfate/dolutegravir sodium/lamivudine 2 QL 1 / 1 DAYS
TYBOST 150 MG TABLETcobicistat 2 PA
ANTI-HIV AGENTS, PROTEASE INHIBITORS
APTIVUS 100 MG/ML SOLUTIONtipranavir/vitamin e tpgs 2
APTIVUS 250 MG CAPSULEtipranavir 2
CRIXIVAN 200 MG CAPSULEindinavir sulfate 2
CRIXIVAN 400 MG CAPSULEindinavir sulfate 2
EVOTAZ 300 MG-150 MG TABLETatazanavir sulfate/cobicistat 2 QL 1 / 1 DAYS
INVIRASE 200 MG CAPSULEsaquinavir mesylate 2
INVIRASE 500 MG TABLETsaquinavir mesylate 2
KALETRA 100-25 MG TABLETlopinavir/ritonavir 2
KALETRA 200-50 MG TABLETlopinavir/ritonavir 2
KALETRA 80 MG-20 MG/ML SOLNlopinavir/ritonavir 2
LEXIVA 50 MG/ML SUSPENSIONfosamprenavir calcium 2 ST
PAGE 68 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LEXIVA 700 MG TABLETfosamprenavir calcium 2
QL 30 / 30 DAYS
ST
NORVIR 100 MG SOFTGEL CAPritonavir 2
NORVIR 100 MG TABLETritonavir 2
NORVIR 80 MG/ML SOLUTIONritonavir 2
PREZISTA 100 MG/ML SUSPENSIONdarunavir ethanolate 2 ST
PREZISTA 150 MG TABLETdarunavir ethanolate 2 ST
PREZISTA 600 MG TABLETdarunavir ethanolate 2 ST
PREZISTA 75 MG TABLETdarunavir ethanolate 2 ST
PREZISTA 800 MG TABLETdarunavir ethanolate 2 ST
REYATAZ 150 MG CAPSULEatazanavir sulfate 2
QL 2 / 1 DAYS
ST
REYATAZ 200 MG CAPSULEatazanavir sulfate 2
QL 2 / 1 DAYS
ST
REYATAZ 300 MG CAPSULEatazanavir sulfate 2 ST
REYATAZ 50 MG POWDER PACKETatazanavir sulfate 2 ST
VIRACEPT 250 MG TABLETnelfinavir mesylate 2
VIRACEPT 625 MG TABLETnelfinavir mesylate 2
ANTI-INFLUENZA AGENTS
RELENZA 5 MG DISKHALERzanamivir 2
rimantadine hcl 100 mg tablet 1
TAMIFLU 30 MG CAPSULEoseltamivir phosphate 2
TAMIFLU 45 MG CAPSULEoseltamivir phosphate 2
PAGE 69 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TAMIFLU 6 MG/ML SUSPENSIONoseltamivir phosphate 2
TAMIFLU 75 MG CAPSULEoseltamivir phosphate 2
ANTIHERPETIC AGENTS
acyclovir 200 mg capsule 1
acyclovir 200 mg/5 ml susp 1
acyclovir 400 mg tablet 1
acyclovir 5% ointment 2
acyclovir 800 mg tablet 1
ALFERON N 5 MILLION UNITS VIALinterferon alfa-n3 4
famciclovir 125 mg tablet 1
famciclovir 250 mg tablet 1
famciclovir 500 mg tablet 1 QL 21 / 1 FILL
valacyclovir hcl 1 gram tablet 1 QL 30 / 30 DAYS
valacyclovir hcl 500 mg tablet 1 QL 30 / 30 DAYS
ZOVIRAX 5% CREAMacyclovir 2
ANXIOLYTICS
ANXIOLYTICS, OTHER
buspirone hcl 10 mg tablet 1
buspirone hcl 15 mg tablet 1
buspirone hcl 30 mg tablet 1
buspirone hcl 5 mg tablet 1
buspirone hcl 7.5 mg tablet 1
BENZODIAZEPINES
alprazolam 0.25 mg tablet 1
alprazolam 0.5 mg tablet 1
alprazolam 1 mg tablet 1
alprazolam 1 mg/ml oral conc 3
alprazolam 2 mg tablet 1
PAGE 70 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
alprazolam er 0.5 mg tablet 1
alprazolam er 1 mg tablet 1
alprazolam er 2 mg tablet 1
alprazolam er 3 mg tablet 1
alprazolam odt 0.25 mg tab 1
alprazolam odt 0.5 mg tab 1
alprazolam odt 1 mg tab 1
alprazolam odt 2 mg tab 1
alprazolam xr 0.5 mg tablet 1
alprazolam xr 1 mg tablet 1
alprazolam xr 2 mg tablet 1
alprazolam xr 3 mg tablet 1
chlordiazepoxide 10 mg capsule 1
chlordiazepoxide 25 mg capsule 1
chlordiazepoxide 5 mg capsule 1
clonazepam 0.125 mg dis tab 1
clonazepam 0.25 mg odt 1
clonazepam 0.5 mg dis tablet 1
clonazepam 0.5 mg tablet 1
clonazepam 1 mg dis tablet 1
clonazepam 1 mg tablet 1
clonazepam 2 mg odt 1
clonazepam 2 mg tablet 1
clorazepate 15 mg tablet 1
clorazepate 3.75 mg tablet 1
clorazepate 7.5 mg tablet 1
diazepam 10 mg tablet 1
diazepam 2 mg tablet 1
diazepam 5 mg tablet 1
diazepam 5 mg/5 ml solution 1
diazepam 5 mg/ml oral conc 1
PAGE 71 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
lorazepam 0.5 mg tablet 1
lorazepam 1 mg tablet 1
lorazepam 2 mg tablet 1
lorazepam 2 mg/ml oral concent 1
lorazepam intensol 2 mg/ml 1
oxazepam 10 mg capsule 1
oxazepam 15 mg capsule 1
oxazepam 30 mg capsule 1
BIPOLAR AGENTS
MOOD STABILIZERS
lithium 8 meq/5 ml solution 1
lithium carbonate 150 mg cap 1
lithium carbonate 300 mg cap 1
lithium carbonate 300 mg tab 1
lithium carbonate 600 mg cap 1
lithium carbonate er 300 mg tb 1
lithium carbonate er 450 mg tb 1
LITHOBID ER 300 MG TABLETlithium carbonate 3
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
acarbose 100 mg tablet 1
acarbose 25 mg tablet 1
acarbose 50 mg tablet 1
ACTOPLUS MET XR 15-1,000 MG TBpioglitazone hcl/metformin hcl 2
QL 30 / 30 DAYS
ST
ACTOPLUS MET XR 30-1,000 MG TBpioglitazone hcl/metformin hcl 2
QL 30 / 30 DAYS
ST
alogliptin 12.5 mg tablet 3 ST
alogliptin 25 mg tablet 3 ST
alogliptin 6.25 mg tablet 3 ST
PAGE 72 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
alogliptin-metformin 12.5-1000 3 ST
alogliptin-metformin 12.5-500 3 ST
AVANDAMET 2 MG-1,000 MG TABrosiglitazone maleate/metformin hcl 3 ST
AVANDIA 2 MG TABLETrosiglitazone maleate 3
QL 30 / 30 DAYS
ST
AVANDIA 4 MG TABLETrosiglitazone maleate 3
QL 30 / 30 DAYS
ST
BYDUREON 2 MG PEN INJECTexenatide microspheres 2 ST
BYDUREON 2 MG VIALexenatide microspheres 2 ST
BYETTA 10 MCG DOSE PEN INJexenatide 2 ST
BYETTA 5 MCG DOSE PEN INJexenatide 2 ST
CYCLOSET 0.8 MG TABLETbromocriptine mesylate 3 PA
FARXIGA 10 MG TABLETdapagliflozin propanediol 3
QL 1 / 1 DAYS
ST
FARXIGA 5 MG TABLETdapagliflozin propanediol 3
QL 1 / 1 DAYS
ST
glimepiride 1 mg tablet 1
glimepiride 2 mg tablet 1
glimepiride 4 mg tablet 1
glipizide 10 mg tablet 1
glipizide 5 mg tablet 1
glipizide er 10 mg tablet 1
glipizide er 2.5 mg tablet 1
glipizide er 5 mg tablet 1
glipizide xl 10 mg tablet 1
glipizide xl 2.5 mg tablet 1
glipizide xl 5 mg tablet 1
PAGE 73 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
glipizide-metformin 2.5-250 mg 1
glipizide-metformin 2.5-500 mg 1
glipizide-metformin 5-500 mg 1
GLUCOPHAGE 1,000 MG TABLETmetformin hcl 3
glyburid-metformin 1.25-250 mg 1
glyburide 2.5 mg tablet 1
glyburide 5 mg tablet 1
glyburide-metformin 2.5-500 mg 1
glyburide-metformin 5-500 mg 1
GLYXAMBI 10 MG-5 MG TABLETempagliflozin/linagliptin 3
QL 1 / 1 DAYS
ST
GLYXAMBI 25 MG-5 MG TABLETempagliflozin/linagliptin 3
QL 1 / 1 DAYS
ST
INVOKANA 100 MG TABLETcanagliflozin 2 ST
INVOKANA 300 MG TABLETcanagliflozin 2 ST
JANUMET 50-1,000 MG TABLETsitagliptin phosphate/metformin hcl 2 ST
JANUMET 50-500 MG TABLETsitagliptin phosphate/metformin hcl 2 ST
JANUMET XR 100-1,000 MG TABLETsitagliptin phosphate/metformin hcl 2 ST
JANUMET XR 50-1,000 MG TABLETsitagliptin phosphate/metformin hcl 2 ST
JANUMET XR 50-500 MG TABLETsitagliptin phosphate/metformin hcl 2 ST
JANUVIA 100 MG TABLETsitagliptin phosphate 2 ST
JANUVIA 25 MG TABLETsitagliptin phosphate 2 ST
JANUVIA 50 MG TABLETsitagliptin phosphate 2 ST
JARDIANCE 10 MG TABLETempagliflozin 3
QL 1 / 1 DAYS
ST
PAGE 74 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
JARDIANCE 25 MG TABLETempagliflozin 3
QL 1 / 1 DAYS
ST
JENTADUETO 2.5 MG-1000 MG TABlinagliptin/metformin hcl 2
QL 2 / 1 DAYS
ST
JENTADUETO 2.5 MG-500 MG TABlinagliptin/metformin hcl 2
QL 2 / 1 DAYS
ST
JENTADUETO 2.5 MG-850 MG TABlinagliptin/metformin hcl 2
QL 2 / 1 DAYS
ST
KOMBIGLYZE XR 2.5-1,000 MG TABsaxagliptin hcl/metformin hcl 3 ST
KOMBIGLYZE XR 5-1,000 MG TABsaxagliptin hcl/metformin hcl 3 ST
KOMBIGLYZE XR 5-500 MG TABLETsaxagliptin hcl/metformin hcl 3 ST
metformin er 1,000 mg osm-tab 1
metformin hcl 1,000 mg tablet 1
metformin hcl 500 mg tablet 1
metformin hcl 850 mg tablet 1
metformin hcl er 500 mg osm-tb 1
metformin hcl er 500 mg tablet 1
metformin hcl er 750 mg tablet 1
miglitol 100 mg tablet 3
miglitol 25 mg tablet 3
miglitol 50 mg tablet 3
nateglinide 120 mg tablet 1 ST
nateglinide 60 mg tablet 1 ST
ONGLYZA 2.5 MG TABLETsaxagliptin hcl 3 ST
ONGLYZA 5 MG TABLETsaxagliptin hcl 3 ST
pioglitazone hcl 15 mg tablet 1QL 30 / 30 DAYS
ST
PAGE 75 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
pioglitazone hcl 30 mg tablet 1QL 30 / 30 DAYS
ST
pioglitazone hcl 45 mg tablet 1QL 30 / 30 DAYS
ST
pioglitazone-glimepiride 30-2 1 ST
pioglitazone-glimepiride 30-4 1 ST
pioglitazone-metformin 15-500 1QL 30 / 30 DAYS
ST
pioglitazone-metformin 15-850 1QL 30 / 30 DAYS
ST
PRECOSE 25 MG TABLETacarbose 3
repaglinide 0.5 mg tablet 1 ST
repaglinide 1 mg tablet 1 ST
repaglinide 2 mg tablet 1 ST
RIOMET 500 MG/5 ML SOLUTIONmetformin hcl 3
SYMLINPEN 120 PEN INJECTORpramlintide acetate 2 ST
SYMLINPEN 60 PEN INJECTORpramlintide acetate 2 ST
SYNJARDY 12.5-1,000 MG TABLETempagliflozin/metformin hcl 3
SYNJARDY 12.5-500 MG TABLETempagliflozin/metformin hcl 3
SYNJARDY 5-1,000 MG TABLETempagliflozin/metformin hcl 3
SYNJARDY 5-500 MG TABLETempagliflozin/metformin hcl 3
TRADJENTA 5 MG TABLETlinagliptin 2 ST
TRULICITY 0.75 MG/0.5 ML PENdulaglutide 3
QL 4 / 28 DAYS
ST
PAGE 76 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRULICITY 1.5 MG/0.5 ML PENdulaglutide 3
QL 4 / 28 DAYS
ST
VICTOZA 2-PAK 18 MG/3 ML PENliraglutide 2 ST
VICTOZA 3-PAK 18 MG/3 ML PENliraglutide 2 ST
XIGDUO XR 10 MG-1,000 MG TABdapagliflozin propanediol/metformin hcl 3
QL 1 / 1 DAYS
ST
XIGDUO XR 10 MG-500 MG TABLETdapagliflozin propanediol/metformin hcl 3
QL 1 / 1 DAYS
ST
XIGDUO XR 5 MG-1,000 MG TABLETdapagliflozin propanediol/metformin hcl 3
QL 2 / 1 DAYS
ST
XIGDUO XR 5 MG-500 MG TABLETdapagliflozin propanediol/metformin hcl 3
QL 2 / 1 DAYS
ST
GLYCEMIC AGENTS
GLUCAGON 1 MG EMERGENCY KITglucagon,human recombinant 2
INSULINS
APIDRA 100 UNITS/ML VIALinsulin glulisine 3
QL 40 / 28 DAYS
ST
APIDRA SOLOSTAR 100 UNITS/MLinsulin glulisine 3
QL 30 / 28 DAYS
ST
BASAGLAR 100 UNIT/ML KWIKPENinsulin glargine,human recombinant analog 2
HUMALOG 100 UNITS/ML CARTRIDGEinsulin lispro 2 QL 30 / 28 DAYS
HUMALOG 100 UNITS/ML KWIKPENinsulin lispro 2 QL 40 / 28 DAYS
HUMALOG 100 UNITS/ML VIALinsulin lispro 2 QL 40 / 28 DAYS
HUMALOG 200 UNITS/ML KWIKPENinsulin lispro 2
HUMALOG MIX 50-50 KWIKPENinsulin lispro protamine and insulin lispro 2 QL 30 / 28 DAYS
PAGE 77 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HUMALOG MIX 50-50 VIALinsulin lispro protamine and insulin lispro 2 QL 40 / 28 DAYS
HUMALOG MIX 75-25 KWIKPENinsulin lispro protamine and insulin lispro 2 QL 30 / 28 DAYS
HUMALOG MIX 75-25 VIALinsulin lispro protamine and insulin lispro 2 QL 40 / 28 DAYS
HUMULIN R 500 UNITS/ML KWIKPENinsulin regular, human 2 QL 40 / 28 day(s)
HUMULIN R 500 UNITS/ML VIALinsulin regular, human 2 QL 40 / 28 DAYS
LANTUS 100 UNITS/ML VIALinsulin glargine,human recombinant analog 2 QL 40 / 28 DAYS
LANTUS SOLOSTAR 100 UNITS/MLinsulin glargine,human recombinant analog 2 QL 30 / 28 DAYS
LEVEMIR 100 UNITS/ML VIALinsulin detemir 3
QL 40 / 28 DAYS
ST
LEVEMIR FLEXPEN 100 UNITS/MLinsulin detemir 3
QL 30 / 28 DAYS
ST
LEVEMIR FLEXTOUCH 100 UNITS/MLinsulin detemir 3
QL 30 / 28 DAYS
ST
NOVOLOG 100 UNIT/ML CARTRIDGEinsulin aspart 2 QL 40 / 28 DAYS
NOVOLOG 100 UNIT/ML VIALinsulin aspart 2 QL 40 / 28 DAYS
NOVOLOG 100 UNITS/ML FLEXPENinsulin aspart 2 QL 30 / 28 DAYS
NOVOLOG MIX 70-30 FLEXPEN SYRNinsulin aspart protamine human/insulin aspart 2
NOVOLOG MIX 70-30 VIALinsulin aspart protamine human/insulin aspart 2
TOUJEO SOLOSTAR 300 UNITS/MLinsulin glargine,human recombinant analog 3
QL 7.5 / 30 DAYS
ST
TRESIBA FLEXTOUCH 100 UNITS/MLinsulin degludec 3
TRESIBA FLEXTOUCH 200 UNITS/MLinsulin degludec 3
PAGE 78 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
COUMADIN 3 MG TABLETwarfarin sodium 3
ELIQUIS 2.5 MG TABLETapixaban 2 QL 2 / 1 DAYS
ELIQUIS 5 MG TABLETapixaban 2 QL 2 / 1 DAYS
enoxaparin 100 mg/ml syringe 4 MDS1 14 / 1 DAYS
enoxaparin 120 mg/0.8 ml syr 4 MDS1 14 / 1 DAYS
enoxaparin 150 mg/ml syringe 4 MDS1 14 / 1 DAYS
enoxaparin 30 mg/0.3 ml syr 4 MDS1 14 / 1 DAYS
enoxaparin 300 mg/3 ml vial 4
enoxaparin 40 mg/0.4 ml syr 4 MDS1 14 / 1 DAYS
enoxaparin 60 mg/0.6 ml syr 4 MDS1 14 / 1 DAYS
enoxaparin 80 mg/0.8 ml syr 4 MDS1 14 / 1 DAYS
fondaparinux 10 mg/0.8 ml syr 4 PA
fondaparinux 2.5 mg/0.5 ml syr 4 PA
fondaparinux 5 mg/0.4 ml syr 4 PA
fondaparinux 7.5 mg/0.6 ml syr 4 PA
FRAGMIN 10,000 UNITS/ML SYRINGdalteparin sodium,porcine 4 PA
FRAGMIN 12,500 UNITS/0.5 MLdalteparin sodium,porcine 4 PA
FRAGMIN 15,000 UNITS/0.6 MLdalteparin sodium,porcine 4 PA
FRAGMIN 18,000 UNITS/0.72 MLdalteparin sodium,porcine 4 PA
FRAGMIN 2,500 UNITS/0.2 ML SYRdalteparin sodium,porcine 4 PA
FRAGMIN 25,000 UNITS/ML VIALdalteparin sodium,porcine 4 PA
FRAGMIN 5,000 UNITS/0.2 ML SYRdalteparin sodium,porcine 4 PA
PAGE 79 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FRAGMIN 7,500 UNITS/0.3 ML SYRdalteparin sodium,porcine 4 PA
FRAGMIN 95,000 UNITS/3.8 ML VLdalteparin sodium,porcine 4 PA
jantoven 1 mg tablet 1
jantoven 10 mg tablet 1
jantoven 2 mg tablet 1
jantoven 2.5 mg tablet 1
jantoven 3 mg tablet 1
jantoven 4 mg tablet 1
jantoven 5 mg tablet 1
jantoven 6 mg tablet 1
jantoven 7.5 mg tablet 1
PRADAXA 110 MG CAPSULEdabigatran etexilate mesylate 3 QL 2 / 1 day(s)
PRADAXA 150 MG CAPSULEdabigatran etexilate mesylate 3 QL 2 / 1 DAYS
PRADAXA 75 MG CAPSULEdabigatran etexilate mesylate 3 QL 2 / 1 DAYS
warfarin sodium 1 mg tablet 1
warfarin sodium 10 mg tablet 1
warfarin sodium 2 mg tablet 1
warfarin sodium 2.5 mg tablet 1
warfarin sodium 3 mg tablet 1
warfarin sodium 4 mg tablet 1
warfarin sodium 5 mg tablet 1
warfarin sodium 6 mg tablet 1
warfarin sodium 7.5 mg tablet 1
XARELTO 10 MG TABLETrivaroxaban 2
XARELTO 15 MG TABLETrivaroxaban 2
XARELTO 20 MG TABLETrivaroxaban 2
XARELTO STARTER PACKrivaroxaban 2
PAGE 80 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BLOOD FORMATION MODIFIERS
LEUKINE 250 MCG VIALsargramostim 2
NEULASTA 6 MG/0.6 ML SYRINGEpegfilgrastim 2 PA
NEUPOGEN 300 MCG/0.5 ML SYRfilgrastim 2
NEUPOGEN 300 MCG/ML VIALfilgrastim 2
NEUPOGEN 480 MCG/0.8 ML SYRfilgrastim 2
NEUPOGEN 480 MCG/1.6 ML VIALfilgrastim 2
PROMACTA 12.5 MG TABLETeltrombopag olamine 4 PA
PROMACTA 25 MG TABLETeltrombopag olamine 4 PA
PROMACTA 50 MG TABLETeltrombopag olamine 4 PA
PROMACTA 75 MG TABLETeltrombopag olamine 4 PA
ZARXIO 300 MCG/0.5 ML SYRINGEfilgrastim-sndz 2
ZARXIO 480 MCG/0.8 ML SYRINGEfilgrastim-sndz 2
COAGULANTS
tranexamic acid 650 mg tablet 3 PA
PLATELET MODIFYING AGENTS
aspirin-dipyridam er 25-200 mg 3 ST
clopidogrel 300 mg tablet 1
clopidogrel 75 mg tablet 1
dipyridamole 25 mg tablet 1
dipyridamole 50 mg tablet 1
dipyridamole 75 mg tablet 1
EFFIENT 10 MG TABLETprasugrel hcl 2
QL 30 / 1 FILL
PA
PAGE 81 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EFFIENT 5 MG TABLETprasugrel hcl 2
QL 30 / 1 FILL
PA
ZONTIVITY 2.08 MG TABLETvorapaxar sulfate 3 PA
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine 0.1 mg/day patch 1 QL 4 / 28 DAYS
clonidine 0.2 mg/day patch 1 QL 4 / 28 DAYS
clonidine 0.3 mg/day patch 1 QL 4 / 28 DAYS
clonidine hcl 0.1 mg tablet 1
clonidine hcl 0.2 mg tablet 1
clonidine hcl 0.3 mg tablet 1
guanfacine 1 mg tablet 1
guanfacine 2 mg tablet 1
methyldopa 250 mg tablet 1
methyldopa 500 mg tablet 1
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate 1 mg tab 1 QL 30 / 30 DAYS
doxazosin mesylate 2 mg tab 1 QL 30 / 30 DAYS
doxazosin mesylate 4 mg tab 1 QL 30 / 30 DAYS
doxazosin mesylate 8 mg tab 1 QL 60 / 30 DAYS
prazosin 1 mg capsule 1
prazosin 2 mg capsule 1
prazosin 5 mg capsule 1
terazosin 1 mg capsule 1
terazosin 10 mg capsule 1
terazosin 2 mg capsule 1
terazosin 5 mg capsule 1
PAGE 82 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANGIOTENSIN II RECEPTOR ANTAGONISTS
candesartan cilexetil 16 mg tb 3
candesartan cilexetil 32 mg tb 3
candesartan cilexetil 4 mg tab 3
candesartan cilexetil 8 mg tab 3
irbesartan 150 mg tablet 1
irbesartan 300 mg tablet 1
irbesartan 75 mg tablet 1
losartan potassium 100 mg tab 1 QL 30 / 30 DAYS
losartan potassium 25 mg tab 1 QL 30 / 30 DAYS
losartan potassium 50 mg tab 1 QL 30 / 30 DAYS
olmesartan medoxomil 20 mg tab 2
olmesartan medoxomil 40 mg tab 2
olmesartan medoxomil 5 mg tab 2
telmisartan 20 mg tablet 1
telmisartan 40 mg tablet 1
telmisartan 80 mg tablet 1
valsartan 160 mg tablet 1
valsartan 320 mg tablet 1
valsartan 40 mg tablet 1
valsartan 80 mg tablet 1
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
ACEON 8 MG TABLETperindopril erbumine 3
benazepril hcl 10 mg tablet 1
benazepril hcl 20 mg tablet 1
benazepril hcl 40 mg tablet 1
benazepril hcl 5 mg tablet 1
captopril 100 mg tablet 1
captopril 12.5 mg tablet 1
captopril 25 mg tablet 1
PAGE 83 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
captopril 50 mg tablet 1
enalapril maleate 10 mg tab 1
enalapril maleate 2.5 mg tab 1
enalapril maleate 20 mg tab 1
enalapril maleate 5 mg tablet 1
fosinopril sodium 10 mg tab 1
fosinopril sodium 20 mg tab 1
fosinopril sodium 40 mg tab 1
lisinopril 10 mg tablet 1
lisinopril 2.5 mg tablet 1
lisinopril 20 mg tablet 1
lisinopril 30 mg tablet 1
lisinopril 40 mg tablet 1
lisinopril 5 mg tablet 1
moexipril hcl 15 mg tablet 1
moexipril hcl 7.5 mg tablet 1
perindopril erbumine 2 mg tab 1
perindopril erbumine 4 mg tab 1
perindopril erbumine 8 mg tab 1
quinapril 10 mg tablet 1
quinapril 20 mg tablet 1
quinapril 40 mg tablet 1
quinapril 5 mg tablet 1
ramipril 1.25 mg capsule 1
ramipril 10 mg capsule 1
ramipril 2.5 mg capsule 1
ramipril 5 mg capsule 1
trandolapril 1 mg tablet 1
trandolapril 2 mg tablet 1
trandolapril 4 mg tablet 1
PAGE 84 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIARRHYTHMICS
amiodarone hcl 100 mg tablet 1
amiodarone hcl 200 mg tablet 1
amiodarone hcl 400 mg tablet 1
CORDARONE 200 MG TABLETamiodarone hcl 3
disopyramide 100 mg capsule 1
disopyramide 150 mg capsule 1
flecainide acetate 100 mg tab 1
flecainide acetate 150 mg tab 1
flecainide acetate 50 mg tab 1
mexiletine 150 mg capsule 1
mexiletine 200 mg capsule 1
mexiletine 250 mg capsule 1
MULTAQ 400 MG TABLETdronedarone hcl 2
QL 2 / 1 DAYS
PA
PACERONE 100 MG TABLETamiodarone hcl 1
pacerone 200 mg tablet 1
PACERONE 400 MG TABLETamiodarone hcl 1
propafenone hcl 150 mg tablet 1
propafenone hcl 225 mg tab 1
propafenone hcl 300 mg tab 1
propafenone hcl er 225 mg cap 1
propafenone hcl er 325 mg cap 1
propafenone hcl er 425 mg cap 1
quinidine sulfate 200 mg tab 1
quinidine sulfate 300 mg tab 1
sorine 120 mg tablet 1
sorine 160 mg tablet 1
sorine 240 mg tablet 1
PAGE 85 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
sorine 80 mg tablet 1
sotalol 120 mg tablet 1
sotalol 160 mg tablet 1
sotalol 240 mg tablet 1
sotalol 80 mg tablet 1
sotalol af 120 mg tablet 1
sotalol af 160 mg tablet 1
sotalol af 80 mg tablet 1
SOTYLIZE 5 MG/ML ORAL SOLUTIONsotalol hcl 3
QL 3840 / 30 DAYS
ST
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol 200 mg capsule 1
acebutolol 400 mg capsule 1
atenolol 100 mg tablet 1
atenolol 25 mg tablet 1
atenolol 50 mg tablet 1
betaxolol 10 mg tablet 1
betaxolol 20 mg tablet 1
bisoprolol fumarate 10 mg tab 1
bisoprolol fumarate 5 mg tab 1
BYSTOLIC 10 MG TABLETnebivolol hcl 3
BYSTOLIC 2.5 MG TABLETnebivolol hcl 3
BYSTOLIC 20 MG TABLETnebivolol hcl 3
BYSTOLIC 5 MG TABLETnebivolol hcl 3
carvedilol 12.5 mg tablet 1
carvedilol 25 mg tablet 1
carvedilol 3.125 mg tablet 1
carvedilol 6.25 mg tablet 1
COREG CR 10 MG CAPSULEcarvedilol phosphate 3 ST
PAGE 86 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
COREG CR 20 MG CAPSULEcarvedilol phosphate 3 ST
COREG CR 40 MG CAPSULEcarvedilol phosphate 3 ST
COREG CR 80 MG CAPSULEcarvedilol phosphate 3 ST
labetalol hcl 100 mg tablet 1
labetalol hcl 200 mg tablet 1
labetalol hcl 300 mg tablet 1
LEVATOL 20 MG TABLETpenbutolol sulfate 2
metoprolol succ er 100 mg tab 1
metoprolol succ er 200 mg tab 1
metoprolol succ er 25 mg tab 1
metoprolol succ er 50 mg tab 1
metoprolol tartrate 100 mg tab 1
metoprolol tartrate 25 mg tab 1
metoprolol tartrate 37.5 mg tb 1
metoprolol tartrate 50 mg tab 1
metoprolol tartrate 75 mg tab 1
nadolol 20 mg tablet 1
nadolol 40 mg tablet 1
nadolol 80 mg tablet 1
pindolol 10 mg tablet 1
pindolol 5 mg tablet 1
propranolol 10 mg tablet 1
propranolol 20 mg tablet 1
propranolol 20 mg/5 ml soln 1
propranolol 40 mg tablet 1
propranolol 40 mg/5 ml soln 1
propranolol 60 mg tablet 1
propranolol 80 mg tablet 1
propranolol er 120 mg capsule 1
PAGE 87 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
propranolol er 160 mg capsule 1
propranolol er 60 mg capsule 1
propranolol er 80 mg capsule 1
timolol maleate 10 mg tablet 1
timolol maleate 20 mg tablet 1
timolol maleate 5 mg tablet 1
CALCIUM CHANNEL BLOCKING AGENTS
ADALAT CC 90 MG TABLETnifedipine 3
afeditab cr 30 mg tablet 1
afeditab cr 60 mg tablet 1
amlodipine besylate 10 mg tab 1
amlodipine besylate 2.5 mg tab 1
amlodipine besylate 5 mg tab 1
CARDIZEM LA 120 MG TABLETdiltiazem hcl 3
cartia xt 120 mg capsule 1
cartia xt 180 mg capsule 1
cartia xt 240 mg capsule 1
cartia xt 300 mg capsule 1
dilt xr 120 mg capsule 1
dilt xr 180 mg capsule 1
dilt xr 240 mg capsule 1
dilt-cd 120 mg capsule 3
dilt-cd 180 mg capsule 3
dilt-cd 240 mg capsule 3
dilt-cd er 300 mg capsule 3
diltia xt 120 mg capsule 3
diltia xt 180 mg capsule 3
diltia xt 240 mg capsule 3
diltiazem 120 mg tablet 1
diltiazem 12hr er 120 mg cap 1
PAGE 88 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
diltiazem 12hr er 60 mg cap 1
diltiazem 12hr er 90 mg cap 1
diltiazem 24hr cd 120 mg cap 1
diltiazem 24hr cd 180 mg cap 1
diltiazem 24hr cd 240 mg cap 1
diltiazem 24hr cd 300 mg cap 1
diltiazem 24hr cd 360 mg cap 1
diltiazem 24hr er 120 mg cap 1
diltiazem 24hr er 180 mg cap 1
diltiazem 24hr er 240 mg cap 1
diltiazem 24hr er 300 mg cap 1
diltiazem 24hr er 360 mg cap 1
diltiazem 30 mg tablet 1
diltiazem 60 mg tablet 1
diltiazem 90 mg tablet 1
diltiazem er 120 mg capsule 1
diltiazem er 120 mg capsule 1
diltiazem er 180 mg capsule 1
diltiazem er 180 mg capsule 1
diltiazem er 180 mg tablet 1
diltiazem er 240 mg capsule 1
diltiazem er 240 mg tablet 1
diltiazem er 300 mg tablet 1
diltiazem er 360 mg tablet 1
diltiazem er 420 mg tablet 1
diltiazem hcl er 120 mg cap 1
diltiazem hcl er 180 mg cap 1
diltiazem hcl er 240 mg cap 1
diltiazem hcl er 300 mg cap 1
diltiazem hcl er 360 mg cap 1
diltiazem hcl er 420 mg cap 1
PAGE 89 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
diltzac er 120 mg capsule 3
diltzac er 180 mg capsule 3
diltzac er 240 mg capsule 3
diltzac er 300 mg capsule 3
diltzac er 360 mg capsule 3
felodipine er 10 mg tablet 1
felodipine er 2.5 mg tablet 1
felodipine er 5 mg tablet 1
matzim la 180 mg tablet 1
matzim la 240 mg tablet 1
matzim la 300 mg tablet 1
matzim la 360 mg tablet 1
matzim la 420 mg tablet 1
nifedical xl 30 mg tablet 1
nifedical xl 60 mg tablet 1
nifedipine 10 mg capsule 1
nifedipine 20 mg capsule 1
nifedipine er 30 mg tablet 1
nifedipine er 30 mg tablet 1
nifedipine er 60 mg tablet 1
nifedipine er 60 mg tablet 1
nifedipine er 90 mg tablet 1
nifedipine er 90 mg tablet 1
nisoldipine er 17 mg tablet 3
nisoldipine er 25.5 mg tablet 3
nisoldipine er 30 mg tablet 3
nisoldipine er 34 mg tablet 3
nisoldipine er 40 mg tablet 3
nisoldipine er 8.5 mg tablet 3
PROCARDIA 10 MG CAPSULEnifedipine 3
PROCARDIA XL 30 MG TABLETnifedipine 3
PAGE 90 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
taztia xt 120 mg capsule 1
taztia xt 180 mg capsule 1
taztia xt 240 mg capsule 1
taztia xt 300 mg capsule 1
taztia xt 360 mg capsule 1
TIAZAC ER 420 MG CAPSULEdiltiazem hcl 3
verapamil 120 mg tablet 1
verapamil 360 mg cap pellet 1
verapamil 40 mg tablet 1
verapamil 80 mg tablet 1
verapamil er 120 mg capsule 1
verapamil er 120 mg tablet 1
verapamil er 180 mg capsule 1
verapamil er 180 mg tablet 1
verapamil er 240 mg capsule 1
verapamil er 240 mg tablet 1
verapamil er pm 100 mg capsule 1
verapamil er pm 200 mg capsule 1
verapamil er pm 300 mg capsule 1
verapamil sr 120 mg capsule 1
verapamil sr 180 mg capsule 1
verapamil sr 240 mg capsule 1
CARDIOVASCULAR AGENTS, OTHER
amiloride hcl-hctz 5-50 mg tab 1
amlod-valsa-hctz 10-160-12.5mg 2
amlod-valsa-hctz 10-160-25 mg 2
amlod-valsa-hctz 10-320-25 mg 2
amlod-valsa-hctz 5-160-12.5 mg 2
amlod-valsa-hctz 5-160-25 mg 2
amlodipine-atorvast 10-10 mg 1 QL 30 / 30 DAYS
PAGE 91 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
amlodipine-atorvast 10-20 mg 1 QL 30 / 30 DAYS
amlodipine-atorvast 10-40 mg 1 QL 30 / 30 DAYS
amlodipine-atorvast 10-80 mg 1 QL 30 / 30 DAYS
amlodipine-atorvast 2.5-10 mg 1 QL 30 / 30 DAYS
amlodipine-atorvast 2.5-20 mg 1 QL 30 / 30 DAYS
amlodipine-atorvast 2.5-40 mg 1 QL 30 / 30 DAYS
amlodipine-atorvast 5-10 mg 1 QL 30 / 30 DAYS
amlodipine-atorvast 5-20 mg 1 QL 30 / 30 DAYS
amlodipine-atorvast 5-40 mg 1 QL 30 / 30 DAYS
amlodipine-atorvast 5-80 mg 1 QL 30 / 30 DAYS
amlodipine-benazepril 10-20 mg 1
amlodipine-benazepril 10-40 mg 1
amlodipine-benazepril 2.5-10 1
amlodipine-benazepril 5-10 mg 1
amlodipine-benazepril 5-20 mg 1
amlodipine-benazepril 5-40 mg 1
amlodipine-olmesartan 10-20 mg 2 ST
amlodipine-olmesartan 10-40 mg 2 ST
amlodipine-olmesartan 5-20 mg 2 ST
amlodipine-olmesartan 5-40 mg 2 ST
amlodipine-valsartan 10-160 mg 1QL 30 / 30 DAYS
ST
amlodipine-valsartan 10-320 mg 1QL 30 / 30 DAYS
ST
amlodipine-valsartan 5-160 mg 1QL 30 / 30 DAYS
ST
amlodipine-valsartan 5-320 mg 1QL 30 / 30 DAYS
ST
PAGE 92 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
atenolol-chlorthalidone 100-25 1
atenolol-chlorthalidone 50-25 1
benazepril-hctz 10-12.5 mg tab 1
benazepril-hctz 20-12.5 mg tab 1
benazepril-hctz 20-25 mg tab 1
benazepril-hctz 5-6.25 mg tab 1
bisoprolol-hctz 10-6.25 mg tab 1
bisoprolol-hctz 2.5-6.25 mg tb 1
bisoprolol-hctz 5-6.25 mg tab 1
candesartan-hctz 16-12.5 mg tb 3
candesartan-hctz 32-12.5 mg tb 3
candesartan-hctz 32-25 mg tab 3 QL 1 / 1 DAYS
captopril-hctz 25-15 mg tablet 1
captopril-hctz 25-25 mg tablet 1
captopril-hctz 50-15 mg tablet 1
captopril-hctz 50-25 mg tablet 1
clorpres 0.1-15 tablet 1
clorpres 0.2-15 tablet 1
clorpres 0.3-15 tablet 1
CORLANOR 5 MG TABLETivabradine hcl 3 PA
CORLANOR 7.5 MG TABLETivabradine hcl 3 PA
digitek 125 mcg tablet 1
digitek 250 mcg tablet 1
digox 125 mcg tablet 1
digox 250 mcg tablet 1
digoxin 0.05 mg/ml solution 2
digoxin 0.125 mg tablet 1
digoxin 0.25 mg tablet 1
digoxin 125 mcg tablet 1
digoxin 250 mcg tablet 1
PAGE 93 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
enalapril-hctz 10-25 mg tablet 1
enalapril-hctz 5-12.5 mg tab 1
ENTRESTO 24 MG-26 MG TABLETsacubitril/valsartan 3
QL 2 / 1 DAYS
PA
ENTRESTO 49 MG-51 MG TABLETsacubitril/valsartan 3
QL 2 / 1 DAYS
PA
ENTRESTO 97 MG-103 MG TABLETsacubitril/valsartan 3
QL 2 / 1 DAYS
PA
fosinopril-hctz 10-12.5 mg tab 1
fosinopril-hctz 20-12.5 mg tab 1
irbesartan-hctz 150-12.5 mg tb 1 QL 30 / 30 DAYS
irbesartan-hctz 300-12.5 mg tb 1 QL 30 / 30 DAYS
lisinopril-hctz 10-12.5 mg tab 1
lisinopril-hctz 20-12.5 mg tab 1
lisinopril-hctz 20-25 mg tab 1
losartan-hctz 100-12.5 mg tab 1 QL 30 / 30 DAYS
losartan-hctz 100-25 mg tab 1 QL 30 / 30 DAYS
losartan-hctz 50-12.5 mg tab 1 QL 30 / 30 DAYS
methyldopa-hctz 250-15 mg tab 1
methyldopa-hctz 250-25 mg tab 1
metoprolol-hctz 100-25 mg tab 1
metoprolol-hctz 100-50 mg tab 1
metoprolol-hctz 50-25 mg tab 1
moexipril-hctz 15-12.5 mg tab 1
moexipril-hctz 15-25 mg tablet 1
moexipril-hctz 7.5-12.5 mg tab 1
nadolol-bendroflu 40-5 mg tab 1
nadolol-bendroflu 80-5 mg tab 1
NORTHERA 100 MG CAPSULEdroxidopa 4 PA
PAGE 94 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NORTHERA 200 MG CAPSULEdroxidopa 4 PA
NORTHERA 300 MG CAPSULEdroxidopa 4 PA
olmesartan-hctz 20-12.5 mg tab 2 QL 30 / 30 DAYS
olmesartan-hctz 40-12.5 mg tab 2 QL 30 / 30 DAYS
olmesartan-hctz 40-25 mg tab 2 QL 30 / 30 DAYS
olmsrtn-amldpn-hctz 20-5-12.5 2 ST
olmsrtn-amldpn-hctz 40-10-12.5 2 ST
olmsrtn-amldpn-hctz 40-10-25mg 2 ST
olmsrtn-amldpn-hctz 40-5-12.5 2 ST
olmsrtn-amldpn-hctz 40-5-25 mg 2 ST
pentoxifylline er 400 mg tab 1
propranolol-hctz 40-25 mg tab 1
propranolol-hctz 80-25 mg tab 1
quinapril-hctz 10-12.5 mg tab 1
quinapril-hctz 20-12.5 mg tab 1
quinapril-hctz 20-25 mg tab 1
RANEXA ER 1,000 MG TABLETranolazine 2
RANEXA ER 500 MG TABLETranolazine 2
spironolactone-hctz 25-25 tab 1
TEKTURNA 150 MG TABLETaliskiren hemifumarate 2
QL 30 / 30 DAYS
ST
TEKTURNA 300 MG TABLETaliskiren hemifumarate 2
QL 30 / 30 DAYS
ST
TEKTURNA HCT 150-12.5 MG TABaliskiren hemifumarate/hydrochlorothiazide 2 ST
TEKTURNA HCT 150-25 MG TABLETaliskiren hemifumarate/hydrochlorothiazide 2 ST
TEKTURNA HCT 300-12.5 MG TABaliskiren hemifumarate/hydrochlorothiazide 2 ST
PAGE 95 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TEKTURNA HCT 300-25 MG TABLETaliskiren hemifumarate/hydrochlorothiazide 2 ST
telmisartan-amlodipine 40-10 3 ST
telmisartan-amlodipine 40-5 mg 3 ST
telmisartan-amlodipine 80-10 3 ST
telmisartan-amlodipine 80-5 mg 3 ST
telmisartan-hctz 40-12.5 mg tb 3
telmisartan-hctz 80-12.5 mg tb 3
telmisartan-hctz 80-25 mg tab 3
trandolapr-verapam er 1-240 mg 2QL 30 / 30 DAYS
ST
trandolapr-verapam er 2-180 mg 2QL 30 / 30 DAYS
ST
trandolapr-verapam er 2-240 mg 2QL 30 / 30 DAYS
ST
trandolapr-verapam er 4-240 mg 2QL 30 / 30 DAYS
ST
triamterene-hctz 37.5-25 mg cp 1
triamterene-hctz 37.5-25 mg tb 1
triamterene-hctz 50-25 mg cap 1
triamterene-hctz 75-50 mg tab 1
valsartan-hctz 160-12.5 mg tab 1 QL 30 / 30 DAYS
valsartan-hctz 160-25 mg tab 1 QL 30 / 30 DAYS
valsartan-hctz 320-12.5 mg tab 1 QL 30 / 30 DAYS
valsartan-hctz 320-25 mg tab 1 QL 30 / 30 DAYS
valsartan-hctz 80-12.5 mg tab 1 QL 30 / 30 DAYS
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
KEVEYIS 50 MG TABLETdichlorphenamide 4
PAGE 96 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DIURETICS, LOOP
bumetanide 0.5 mg tablet 1
bumetanide 1 mg tablet 1
bumetanide 2 mg tablet 1
furosemide 10 mg/ml solution 1
furosemide 20 mg tablet 1
furosemide 40 mg tablet 1
furosemide 40 mg/5 ml soln 1
furosemide 80 mg tablet 1
torsemide 10 mg tablet 1
torsemide 100 mg tablet 1
torsemide 20 mg tablet 1
torsemide 5 mg tablet 1
DIURETICS, POTASSIUM-SPARING
amiloride hcl 5 mg tablet 1
eplerenone 25 mg tablet 1
eplerenone 50 mg tablet 1
spironolactone 100 mg tablet 1
spironolactone 25 mg tablet 1
spironolactone 50 mg tablet 1
DIURETICS, THIAZIDE
chlorothiazide 250 mg tablet 1
chlorothiazide 500 mg tablet 1
chlorthalidone 25 mg tablet 1
chlorthalidone 50 mg tablet 1
DIURIL 250 MG/5 ML ORAL SUSPchlorothiazide 3
hydrochlorothiazide 12.5 mg cp 1
hydrochlorothiazide 12.5 mg tb 1
hydrochlorothiazide 25 mg tab 1
hydrochlorothiazide 50 mg tab 1
PAGE 97 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
indapamide 1.25 mg tablet 1
indapamide 2.5 mg tablet 1
metolazone 10 mg tablet 1
metolazone 2.5 mg tablet 1
metolazone 5 mg tablet 1
ZAROXOLYN 2.5 MG TABLETmetolazone 3
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
fenofibric acid 105 mg tablet 3 ST
fenofibric acid 35 mg tablet 3 ST
fenofibric acid dr 135 mg cap 3 ST
fenofibric acid dr 45 mg cap 3 ST
FENOGLIDE 120 MG TABLETfenofibrate 3
gemfibrozil 600 mg tablet 1
TRICOR 145 MG TABLETfenofibrate nanocrystallized 2
QL 30 / 30 DAYS
ST
TRICOR 48 MG TABLETfenofibrate nanocrystallized 2
QL 30 / 30 DAYS
ST
TRIGLIDE 160 MG TABLETfenofibrate nanocrystallized 3 ST
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
atorvastatin 10 mg tablet 1 QL 1 / 1 DAYS
atorvastatin 20 mg tablet 1 QL 1 / 1 DAYS
atorvastatin 40 mg tablet 1 QL 1 / 1 DAYS
atorvastatin 80 mg tablet 1 QL 1 / 1 DAYS
fluvastatin sodium 20 mg cap 3QL 30 / 30 DAYS
ST
fluvastatin sodium 40 mg cap 3QL 30 / 30 DAYS
ST
PAGE 98 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
lovastatin 10 mg tablet 1
lovastatin 20 mg tablet 1
lovastatin 40 mg tablet 1
pravastatin sodium 10 mg tab 1 QL 30 / 30 DAYS
pravastatin sodium 20 mg tab 1 QL 30 / 30 DAYS
pravastatin sodium 40 mg tab 1 QL 30 / 30 DAYS
pravastatin sodium 80 mg tab 1 QL 30 / 30 DAYS
rosuvastatin calcium 10 mg tab 1 ST
rosuvastatin calcium 20 mg tab 1 ST
rosuvastatin calcium 40 mg tab 1
rosuvastatin calcium 5 mg tab 1 ST
simvastatin 10 mg tablet 1 QL 30 / 30 DAYS
simvastatin 20 mg tablet 1 QL 30 / 30 DAYS
simvastatin 40 mg tablet 1 QL 30 / 30 DAYS
simvastatin 5 mg tablet 1 QL 30 / 30 DAYS
simvastatin 80 mg tablet 1 QL 30 / 30 DAYS
DYSLIPIDEMICS, OTHER
cholestyramine light packet 1
cholestyramine light powder 1
cholestyramine packet 1
cholestyramine powder 1
COLESTID FLAVORED GRANULEScolestipol hcl 3
colestipol hcl 1 gm tablet 1
colestipol hcl granules 1
colestipol hcl granules packet 1
colestipol micronized 1 gm tab 1
JUXTAPID 10 MG CAPSULElomitapide mesylate 4 PA
JUXTAPID 20 MG CAPSULElomitapide mesylate 4 PA
PAGE 99 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
JUXTAPID 30 MG CAPSULElomitapide mesylate 4 PA
JUXTAPID 40 MG CAPSULElomitapide mesylate 4 PA
JUXTAPID 5 MG CAPSULElomitapide mesylate 4 PA
JUXTAPID 60 MG CAPSULElomitapide mesylate 4 PA
KYNAMRO 200 MG/ML SYRINGEmipomersen sodium 4 PA
niacin er 1,000 mg tablet 1 ST
niacin er 500 mg tablet 1 ST
niacin er 750 mg tablet 1 ST
niacor 500 mg tablet 1
omega-3 ethyl esters 1 gm cap 3QL 120 / 30 DAYS
ST
PRALUENT 150 MG/ML PENalirocumab 4
PRALUENT 150 MG/ML SYRINGEalirocumab 4
PRALUENT 75 MG/ML PENalirocumab 4
PRALUENT 75 MG/ML SYRINGEalirocumab 4
prevalite packet 1
prevalite powder 1
REPATHA 140 MG/ML SURECLICKevolocumab 4
REPATHA 140 MG/ML SYRINGEevolocumab 4
REPATHA 420 MG/3.5ML PUSHTRONXevolocumab 4
VYTORIN 10-10 MG TABLETezetimibe/simvastatin 2
QL 30 / 30 DAYS
ST
VYTORIN 10-20 MG TABLETezetimibe/simvastatin 2
QL 30 / 30 DAYS
ST
PAGE 100 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VYTORIN 10-40 MG TABLETezetimibe/simvastatin 2
QL 30 / 30 DAYS
ST
VYTORIN 10-80 MG TABLETezetimibe/simvastatin 2
QL 30 / 30 DAYS
ST
WELCHOL 3.75G PACKETcolesevelam hcl 2 ST
WELCHOL 625 MG TABLETcolesevelam hcl 2 ST
ZETIA 10 MG TABLETezetimibe 2
QL 30 / 30 DAYS
ST
VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine 10 mg tablet 1
hydralazine 100 mg tablet 1
hydralazine 25 mg tablet 1
hydralazine 50 mg tablet 1
minoxidil 10 mg tablet 1
minoxidil 2.5 mg tablet 1
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
DILATRATE-SR 40 MG CAPSULEisosorbide dinitrate 2
IMDUR ER 120 MG TABLETisosorbide mononitrate 3
IMDUR ER 30 MG TABLETisosorbide mononitrate 3
IMDUR ER 60 MG TABLETisosorbide mononitrate 3
ISORDIL 40 MG TABLETisosorbide dinitrate 2
isosorbide dn 10 mg tablet 1
isosorbide dn 20 mg tablet 1
isosorbide dn 30 mg tablet 1
isosorbide dn 5 mg tablet 1
isosorbide dn er 40 mg tablet 1
isosorbide mn 10 mg tablet 1
PAGE 101 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
isosorbide mn 20 mg tablet 1
isosorbide mn er 120 mg tab 1
isosorbide mn er 30 mg tablet 1
isosorbide mn er 60 mg tablet 1
minitran 0.1 mg/hr patch 1
minitran 0.2 mg/hr patch 1
minitran 0.4 mg/hr patch 1
minitran 0.6 mg/hr patch 1
NITRO-BID 2% OINTMENTnitroglycerin 2
NITRO-DUR 0.3 MG/HR PATCHnitroglycerin 2
NITRO-DUR 0.8 MG/HR PATCHnitroglycerin 2
nitro-time er 2.5 mg capsule 1
nitro-time er 6.5 mg capsule 1
nitro-time er 9 mg capsule 1
nitroglycerin 0.1 mg/hr patch 1
nitroglycerin 0.2 mg/hr patch 1
nitroglycerin 0.3 mg tablet sl 1
nitroglycerin 0.4 mg tablet sl 1
nitroglycerin 0.4 mg/hr patch 1
nitroglycerin 0.6 mg tablet sl 1
nitroglycerin 0.6 mg/hr patch 1
nitroglycerin 400 mcg spray 1
nitroglycerin er 2.5 mg cap 1
nitroglycerin er 6.5 mg cap 1
nitroglycerin er 9 mg capsule 1
nitroglycerin lingual 0.4 mg 1
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
PAGE 102 LAST UPDATED 03/2017
d-amphetamine er 10 mg capsule 1
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
d-amphetamine er 15 mg capsule 1
QL 4 / 1 DAYS
ST
AL1 Up to 18 yrs old
d-amphetamine er 5 mg capsule 1
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
DEXEDRINE 10 MG TABLETdextroamphetamine sulfate 1
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
DEXEDRINE 5 MG TABLETdextroamphetamine sulfate 1
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
DEXEDRINE SPANSULE 10 MGdextroamphetamine sulfate 1
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
DEXEDRINE SPANSULE 15 MGdextroamphetamine sulfate 1
QL 4 / 1 DAYS
ST
AL1 Up to 18 yrs old
DEXEDRINE SPANSULE 5 MGdextroamphetamine sulfate 1
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
dextroamp-amphet er 10 mg cap 3
QL 30 / 30 DAYS
ST
AL1 Up to 18 yrs old
dextroamp-amphet er 15 mg cap 3
QL 30 / 30 DAYS
ST
AL1 Up to 18 yrs old
PAGE 103 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
dextroamp-amphet er 25 mg cap 3
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
dextroamp-amphet er 30 mg cap 3
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
dextroamp-amphet er 5 mg cap 3
QL 30 / 30 DAYS
ST
AL1 Up to 18 yrs old
dextroamp-amphetam 12.5 mg tab 1 AL1 Up to 18 yrs old
dextroamp-amphetam 7.5 mg tab 1 AL1 Up to 18 yrs old
dextroamp-amphetamin 10 mg tab 1 AL1 Up to 18 yrs old
dextroamp-amphetamin 15 mg tab 1 AL1 Up to 18 yrs old
dextroamp-amphetamin 20 mg tab 1 AL1 Up to 18 yrs old
dextroamp-amphetamin 30 mg tab 1 AL1 Up to 18 yrs old
dextroamp-amphetamine 5 mg tab 1 AL1 Up to 18 yrs old
dextroamphetamine 10 mg tab 1
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
dextroamphetamine 5 mg tab 1
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
dextroamphetamine 5 mg/5 ml 1 AL1 Up to 18 yrs old
procentra 5 mg/5 ml solution 1 AL1 Up to 18 yrs old
VYVANSE 10 MG CAPSULElisdexamfetamine dimesylate 3
PA
AL1 Up to 18 yrs old
VYVANSE 20 MG CAPSULElisdexamfetamine dimesylate 3
PA
AL1 Up to 18 yrs old
VYVANSE 30 MG CAPSULElisdexamfetamine dimesylate 3
PA
AL1 Up to 18 yrs old
PAGE 104 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VYVANSE 40 MG CAPSULElisdexamfetamine dimesylate 3
PA
AL1 Up to 18 yrs old
VYVANSE 50 MG CAPSULElisdexamfetamine dimesylate 3
PA
AL1 Up to 18 yrs old
VYVANSE 60 MG CAPSULElisdexamfetamine dimesylate 3
PA
AL1 Up to 18 yrs old
VYVANSE 70 MG CAPSULElisdexamfetamine dimesylate 3
PA
AL1 Up to 18 yrs old
zenzedi 10 mg tablet 3
QL 4 / 1 days
ST
AL1 Up to 18 yrs old
ZENZEDI 15 MG TABLETdextroamphetamine sulfate 3
QL 3 / 1 DAYS
ST
AL1 Up to 18 yrs old
ZENZEDI 2.5 MG TABLETdextroamphetamine sulfate 3
QL 3 / 1 DAYS
ST
AL1 Up to 18 yrs old
ZENZEDI 20 MG TABLETdextroamphetamine sulfate 3
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
ZENZEDI 30 MG TABLETdextroamphetamine sulfate 3
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
zenzedi 5 mg tablet 3
QL 4 / 1 days
ST
AL1 Up to 18 yrs old
ZENZEDI 7.5 MG TABLETdextroamphetamine sulfate 3
QL 3 / 1 DAYS
ST
AL1 Up to 18 yrs old
PAGE 105 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
APTENSIO XR 10 MG CAPSULEmethylphenidate hcl 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
APTENSIO XR 15 MG CAPSULEmethylphenidate hcl 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
APTENSIO XR 20 MG CAPSULEmethylphenidate hcl 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
APTENSIO XR 30 MG CAPSULEmethylphenidate hcl 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
APTENSIO XR 40 MG CAPSULEmethylphenidate hcl 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
APTENSIO XR 50 MG CAPSULEmethylphenidate hcl 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
APTENSIO XR 60 MG CAPSULEmethylphenidate hcl 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
dexmethylphenidate 10 mg tab 1QL 2 / 1 DAYS
AL1 Up to 18 yrs old
dexmethylphenidate 2.5 mg tab 1QL 2 / 1 DAYS
AL1 Up to 18 yrs old
dexmethylphenidate 5 mg tab 1QL 2 / 1 DAYS
AL1 Up to 18 yrs old
dexmethylphenidate er 10 mg cp 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
PAGE 106 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
dexmethylphenidate er 15 mg cp 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
dexmethylphenidate er 20 mg cp 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
dexmethylphenidate er 30 mg cp 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
dexmethylphenidate er 40 mg cp 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
dexmethylphenidate er 5 mg cap 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
FOCALIN XR 25 MG CAPSULEdexmethylphenidate hcl 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
FOCALIN XR 35 MG CAPSULEdexmethylphenidate hcl 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
guanfacine hcl er 1 mg tablet 1 AL1 Up to 18 yrs old
guanfacine hcl er 2 mg tablet 1 AL1 Up to 18 yrs old
guanfacine hcl er 3 mg tablet 1 AL1 Up to 18 yrs old
guanfacine hcl er 4 mg tablet 1 AL1 Up to 18 yrs old
INTUNIV ER 4 MG TABLETguanfacine hcl 3 AL1 Up to 18 yrs old
metadate er 20 mg tablet 3QL 3 / 1 DAYS
AL1 Up to 18 yrs old
methylphenidate 10 mg chew tab 3 AL1 Up to 18 yrs old
methylphenidate 10 mg tablet 1QL 3 / 1 DAYS
AL1 Up to 18 yrs old
PAGE 107 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
methylphenidate 10 mg/5 ml sol 1 AL1 Up to 18 yrs old
methylphenidate 2.5 mg chew tb 3 AL1 Up to 18 yrs old
methylphenidate 20 mg tablet 1QL 3 / 1 DAYS
AL1 Up to 18 yrs old
methylphenidate 5 mg chew tab 3 AL1 Up to 18 yrs old
methylphenidate 5 mg tablet 1QL 3 / 1 DAYS
AL1 Up to 18 yrs old
methylphenidate 5 mg/5 ml soln 1 AL1 Up to 18 yrs old
methylphenidate cd 10 mg cap 3
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
methylphenidate cd 20 mg cap 3
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
methylphenidate cd 30 mg cap 3
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
methylphenidate cd 40 mg cap 3
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
methylphenidate cd 50 mg cap 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
methylphenidate cd 60 mg cap 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
methylphenidate er 10 mg cap 3
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
methylphenidate er 10 mg tab 3QL 3 / 1 DAYS
AL1 Up to 18 yrs old
PAGE 108 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
methylphenidate er 18 mg tab 3
QL 30 / 30 DAYS
ST
AL1 Up to 18 yrs old
methylphenidate er 20 mg cap 3QL 1 / 1 DAYS
AL1 Up to 18 yrs old
methylphenidate er 20 mg cap 3
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
methylphenidate er 20 mg tab 3QL 3 / 1 DAYS
AL1 Up to 18 yrs old
methylphenidate er 27 mg tab 3
QL 30 / 30 DAYS
ST
AL1 Up to 18 yrs old
methylphenidate er 30 mg cap 3QL 1 / 1 DAYS
AL1 Up to 18 yrs old
methylphenidate er 30 mg cap 3
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
methylphenidate er 36 mg tab 3
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
methylphenidate er 40 mg cap 3 AL1 Up to 18 yrs old
methylphenidate er 40 mg cap 3
QL 2 / 1 DAYS
ST
AL1 Up to 18 yrs old
methylphenidate er 50 mg cap 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
methylphenidate er 54 mg tab 3
QL 30 / 30 DAYS
ST
AL1 Up to 18 yrs old
PAGE 109 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
methylphenidate er 60 mg cap 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
methylphenidate la 20 mg cap 3QL 1 / 1 DAYS
AL1 Up to 18 yrs old
methylphenidate la 30 mg cap 3QL 1 / 1 DAYS
AL1 Up to 18 yrs old
methylphenidate la 40 mg cap 3 AL1 Up to 18 yrs old
methylphenidate sr 20 mg tab 3QL 3 / 1 DAYS
AL1 Up to 18 yrs old
QUILLIVANT XR 25 MG/5 ML SUSPmethylphenidate hcl 3
QL 360 / 30 day(s)
ST
AL1 Up to 18 yrs old
RITALIN LA 10 MG CAPSULEmethylphenidate hcl 3
QL 1 / 1 DAYS
ST
AL1 Up to 18 yrs old
STRATTERA 10 MG CAPSULEatomoxetine hcl 2
QL 30 / 30 DAYS
AL1 Up to 18 yrs old
STRATTERA 100 MG CAPSULEatomoxetine hcl 2
QL 30 / 30 DAYS
AL1 Up to 18 yrs old
STRATTERA 18 MG CAPSULEatomoxetine hcl 2
QL 30 / 30 DAYS
AL1 Up to 18 yrs old
STRATTERA 25 MG CAPSULEatomoxetine hcl 2
QL 30 / 30 DAYS
AL1 Up to 18 yrs old
STRATTERA 40 MG CAPSULEatomoxetine hcl 2
QL 30 / 30 DAYS
AL1 Up to 18 yrs old
STRATTERA 60 MG CAPSULEatomoxetine hcl 2
QL 30 / 30 DAYS
AL1 Up to 18 yrs old
STRATTERA 80 MG CAPSULEatomoxetine hcl 2
QL 30 / 30 DAYS
AL1 Up to 18 yrs old
PAGE 110 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CENTRAL NERVOUS SYSTEM, OTHER
butalb-acetamin-caff 50-300-40 3
butalb-acetamin-caff 50-325-40 1
butalbit-acetaminophen-caff cp 1
butalbital-acetaminophn 50-325 1
capacet capsule 1
MARGESIC CAPSULEbutalbital/acetaminophen/caffeine 1
MARTEN-TAB 325-50 TABLETbutalbital/acetaminophen 1
NUEDEXTA 20-10 MG CAPSULEdextromethorphan hbr/quinidine sulfate 3 PA
tencon 50-325 mg tablet 1
tetrabenazine 12.5 mg tablet 4
tetrabenazine 25 mg tablet 4
ZEBUTAL 50-325-40 MG CAPSULEbutalbital/acetaminophen/caffeine 1
FIBROMYALGIA AGENTS
duloxetine hcl dr 20 mg cap 1
QL 30 / 30 DAYS
ST
AL1 At least 18 yrs old
duloxetine hcl dr 30 mg cap 1
QL 30 / 30 DAYS
ST
AL1 At least 18 yrs old
duloxetine hcl dr 60 mg cap 1
QL 30 / 30 DAYS
ST
AL1 At least 18 yrs old
LYRICA 100 MG CAPSULEpregabalin 3 ST
LYRICA 150 MG CAPSULEpregabalin 3 ST
LYRICA 20 MG/ML ORAL SOLUTIONpregabalin 3 ST
LYRICA 200 MG CAPSULEpregabalin 3 ST
PAGE 111 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LYRICA 225 MG CAPSULEpregabalin 3 ST
LYRICA 25 MG CAPSULEpregabalin 3 ST
LYRICA 300 MG CAPSULEpregabalin 3 ST
LYRICA 50 MG CAPSULEpregabalin 3 ST
LYRICA 75 MG CAPSULEpregabalin 3 ST
SAVELLA 100 MG TABLETmilnacipran hcl 2 AL1 At least 18 yrs old
SAVELLA 12.5 MG TABLETmilnacipran hcl 2 AL1 At least 18 yrs old
SAVELLA 25 MG TABLETmilnacipran hcl 2 AL1 At least 18 yrs old
SAVELLA 50 MG TABLETmilnacipran hcl 2 AL1 At least 18 yrs old
SAVELLA TITRATION PACKmilnacipran hcl 2 AL1 At least 18 yrs old
MULTIPLE SCLEROSIS AGENTS
AMPYRA ER 10 MG TABLETdalfampridine 4 PA
AUBAGIO 14 MG TABLETteriflunomide 4 PA
AUBAGIO 7 MG TABLETteriflunomide 4 PA
AVONEX 30 MCG VIAL KITinterferon beta-1a/albumin human 4
AVONEX PEN 30 MCG/0.5 ML KITinterferon beta-1a 4
AVONEX PREFILLED SYR 30 MCG KTinterferon beta-1a 4
BETASERON 0.3 MG KITinterferon beta-1b 4
QL 15 / 1 FILL
PA
EXTAVIA 0.3 MG KITinterferon beta-1b 4 PA
EXTAVIA 0.3 MG VIALinterferon beta-1b 4 PA
PAGE 112 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GILENYA 0.5 MG CAPSULEfingolimod hcl 4 PA
glatopa 20 mg/ml syringe 4 PA
PLEGRIDY 125 MCG/0.5 ML PENpeginterferon beta-1a 4 PA
PLEGRIDY 125 MCG/0.5 ML SYRINGpeginterferon beta-1a 4 PA
PLEGRIDY PEN INJ STARTER PACKpeginterferon beta-1a 4 PA
PLEGRIDY SYRINGE STARTER PACKpeginterferon beta-1a 4 PA
REBIF 22 MCG/0.5 ML SYRINGEinterferon beta-1a/albumin human 4
QL 15 / 30 DAYS
PA
REBIF 44 MCG/0.5 ML SYRINGEinterferon beta-1a/albumin human 4
QL 15 / 30 DAYS
PA
REBIF REBIDOSE 22 MCG/0.5 MLinterferon beta-1a/albumin human 4
QL 15 / 30 DAYS
PA
REBIF REBIDOSE 44 MCG/0.5 MLinterferon beta-1a/albumin human 4
QL 15 / 30 DAYS
PA
REBIF REBIDOSE TITRATION PACKinterferon beta-1a/albumin human 4
QL 15 / 30 DAYS
PA
REBIF TITRATION PACKinterferon beta-1a/albumin human 4
QL 15 / 30 DAYS
PA
TECFIDERA DR 120 MG CAPSULEdimethyl fumarate 4 PA
TECFIDERA DR 240 MG CAPSULEdimethyl fumarate 4 PA
TECFIDERA STARTER PACKdimethyl fumarate 4 PA
DENTAL AND ORAL AGENTS
EPISIL LIQUIDoral mucositis and stomatitis anti-inflammatory agent comb 2 2
oralone 0.1% paste 1
pilocarpine hcl 5 mg tablet 1
PAGE 113 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
pilocarpine hcl 7.5 mg tablet 1
triamcinolone 0.1% paste 1
DERMATOLOGICAL AGENTS
ABSORICA 10 MG CAPSULEisotretinoin 4 PA
ABSORICA 20 MG CAPSULEisotretinoin 4 PA
ABSORICA 25 MG CAPSULEisotretinoin 4
ABSORICA 30 MG CAPSULEisotretinoin 4 PA
ABSORICA 35 MG CAPSULEisotretinoin 4
ABSORICA 40 MG CAPSULEisotretinoin 4 PA
ACZONE 5% GELdapsone 3
ACZONE 7.5% GEL PUMPdapsone 3
QL 1 / 30 day(s)
ST
adapalene 0.1% cream 2QL 1 / 25 DAYS
AL1 Up to 30 yrs old
adapalene 0.1% gel 2QL 1 / 25 DAYS
AL1 Up to 30 yrs old
adapalene 0.1% lotion 3QL 1 / 25 DAYS
AL1 Up to 30 yrs old
adapalene 0.3% gel 2QL 1 / 25 DAYS
AL1 Up to 30 yrs old
adapalene 0.3% gel pump 2QL 1 / 25 DAYS
AL1 Up to 30 yrs old
ALA-QUIN 3-0.5% CREAMclioquinol/hydrocortisone 3
ALPHAQUIN HP 4% CREAMhydroquinone/sunscreens (oxybenzone/octinoxate) 1
amnesteem 10 mg capsule 4 PA
PAGE 114 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
amnesteem 20 mg capsule 4 PA
amnesteem 40 mg capsule 4 PA
ANALPRAM HC 1% CREAMhydrocortisone acetate/pramoxine hcl 3
ANALPRAM HC 2.5%-1% LOTIONhydrocortisone acetate/pramoxine hcl 3
avar cleanser 3
AZELEX 20% CREAMazelaic acid 3
blanche 4% cream 3
calcipotriene 0.005% cream 2
calcipotriene 0.005% ointment 3
calcipotriene 0.005% solution 2
calcitrene 0.005% ointment 3
calcitriol 3 mcg/g ointment 1 PA
claravis 10 mg capsule 4 PA
claravis 20 mg capsule 4 PA
claravis 30 mg capsule 4 PA
claravis 40 mg capsule 4 PA
clind ph-benzoyl perox 1.2-5% 3 ST
clinda-tretinoin 1.2%-0.025% 3
QL 1 / 30 day(s)
ST
AL1 Up to 30 yrs old
clindamycin-benzoyl perox 1-5% 3 ST
clotrimazole-betamethasone crm 1
clotrimazole-betamethasone lot 1
CONDYLOX 0.5% GELpodofilox 3
COSENTYX 150 MG/ML PEN INJECTsecukinumab 4 PA
COSENTYX 150 MG/ML SYRINGEsecukinumab 4 PA
PAGE 115 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
COSENTYX 300 MG DOSE-2 PENSsecukinumab 4 PA
COSENTYX 300 MG DOSE-2 SYRINGEsecukinumab 4 PA
dermazene cream 1
diclofenac sodium 3% gel 3 ST
DRITHOCREME HP 1% CREAManthralin 2
DUAC 1.2-5% GELclindamycin phosphate/benzoyl peroxide 3
ELIDEL 1% CREAMpimecrolimus 2
QL 1 / 10 DAYS
ST
ENSTILAR 0.005%-0.064% FOAMcalcipotriene/betamethasone dipropionate 3 ST
EPIDUO 0.1-2.5% GELadapalene/benzoyl peroxide 3
EPIDUO 0.1-2.5% GEL PUMPadapalene/benzoyl peroxide 3
EPIDUO FORTE 0.3-2.5% GEL PUMPadapalene/benzoyl peroxide 3
QL 45 / 30 DAYS
ST
AL1 Up to 25 yrs old
EPIFOAM FOAMhydrocortisone acetate/pramoxine hcl 3
FABIOR 0.1% FOAMtazarotene 3
FINACEA 15% FOAMazelaic acid 3
FINACEA 15% GELazelaic acid 3
FLECTOR 1.3% PATCHdiclofenac epolamine 3
QL 30 / 30 DAYS
AL1 At least 6 yrs old
fluorouracil 0.5% cream 1
hydrocort-pramoxine 1%-1% crm 1
hydrocort-pramoxine 2.5%-1% cm 1
hydrocort-pramoxine 2.5-1% crm 1
PAGE 116 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hydrocortisone-iodoquinol crm 1
hydrocortisone-pramoxine cream 1
hydroquinone 4% cream 1
hydroquinone tr 4% cream 1
imiquimod 5% cream packet 1
lustra 4% cream 3
melquin hp 4% cream 1
melquin-3 solution 1
METROLOTION TOPICAL 0.75%metronidazole 3
metronidazole 0.75% cream 1
metronidazole 0.75% lotion 1
metronidazole top 1% gel pump 1
metronidazole topical 0.75% gl 1
metronidazole topical 1% gel 1
myorisan 10 mg capsule 4 PA
myorisan 20 mg capsule 4 PA
myorisan 30 mg capsule 4 PA
myorisan 40 mg capsule 4 PA
neuac gel 3 ST
obagi elastiderm skin 4% cream 1
obagi nu-derm blender 4% cream 1
obagi nu-derm clear 4% cream 1
OBAGI NU-DERM SUNFADERhydroquinone/sunscreens (oxybenzone/octinoxate) 3
OVACE PLUS 10% CREAMsulfacetamide sodium 3 ST
OVACE PLUS 10% SHAMPOOsulfacetamide sodium 3 ST
OVACE PLUS 10% WASHsulfacetamide sodium 3 ST
OVACE PLUS 9.8% FOAMsulfacetamide sodium 3
PAGE 117 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
OVACE PLUS 9.8% LOTIONsulfacetamide sodium 3 ST
podofilox 0.5% topical soln 1
pramcort 1% cream 3
PRAMOSONE 1% CREAMhydrocortisone acetate/pramoxine hcl 3
PRAMOSONE 1% LOTIONhydrocortisone acetate/pramoxine hcl 3
PRAMOSONE 1% OINTMENThydrocortisone acetate/pramoxine hcl 3
PRAMOSONE 1%-1% CREAMhydrocortisone acetate/pramoxine hcl 3
PRAMOSONE 1%-1% OINTMENThydrocortisone acetate/pramoxine hcl 3
PRAMOSONE 2.5% LOTIONhydrocortisone acetate/pramoxine hcl 3
PRAMOSONE 2.5% OINTMENThydrocortisone acetate/pramoxine hcl 3
PRAMOSONE 2.5%-1% LOTIONhydrocortisone acetate/pramoxine hcl 3
PRAMOSONE 2.5%-1% OINTMENThydrocortisone acetate/pramoxine hcl 3
PROCORT 1.85%-1.15% CREAMhydrocortisone acetate/pramoxine hcl 3
PROCTOFOAM-HC 1%-1% FOAMhydrocortisone acetate/pramoxine hcl 3
rosadan 0.75% cream 1
rosanil cleanser lotion 3
seb-prev 10% wash 2 ST
selenium sulfide 2.25% shampoo 1
selenium sulfide 2.5% lotion 1
sod sulfacet-sulfur 10-5% clsr 1
sod sulfacetam 10% clnsng gel 3 ST
sod sulfacetamide 10% shampoo 3 ST
sodium sulf-sulfur cleanser 1
sodium sulf-sulfur cleanser 1
PAGE 118 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
sodium sulfacetamide 10% wash 2 ST
SORILUX 0.005% FOAMcalcipotriene 3
STELARA 45 MG/0.5 ML SYRINGEustekinumab 4 PA
STELARA 90 MG/ML SYRINGEustekinumab 4 PA
tacrolimus 0.03% ointment 2QL 1 / 10 DAYS
ST
tacrolimus 0.1% ointment 2QL 1 / 10 DAYS
ST
TALTZ 80 MG/ML AUTOINJ (2-PK)ixekizumab 4 PA
TALTZ 80 MG/ML AUTOINJ (3-PK)ixekizumab 4 PA
TALTZ 80 MG/ML AUTOINJECTORixekizumab 4 PA
TALTZ 80 MG/ML SYRINGEixekizumab 4 PA
TALTZ 80 MG/ML SYRINGE (2-PK)ixekizumab 4 PA
TALTZ 80 MG/ML SYRINGE (3-PK)ixekizumab 4 PA
TAZORAC 0.05% CREAMtazarotene 3
TAZORAC 0.05% GELtazarotene 3
TAZORAC 0.1% CREAMtazarotene 3
TAZORAC 0.1% GELtazarotene 3
tl hydroquinone 4% cream 1
TOLAK 4% CREAMfluorouracil 3
tretinoin 0.01% gel 1
tretinoin 0.025% cream 1
tretinoin 0.025% gel 1
PAGE 119 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
tretinoin 0.05% cream 1
tretinoin 0.1% cream 1
ULESFIA 5% LOTIONbenzyl alcohol 2
zenatane 10 mg capsule 4 PA
zenatane 20 mg capsule 4 PA
zenatane 30 mg capsule 4 PA
zenatane 40 mg capsule 4 PA
ZITHRANOL 1% SHAMPOOanthralin micronized 3
ZITHRANOL-RR 1.2% CREAManthralin 3
ENZYME REPLACEMENT/MODIFIERS
CERDELGA 84 MG CAPSULEeliglustat tartrate 4 PA
CREON DR 12,000 UNITS CAPSULElipase/protease/amylase 3
CREON DR 24,000 UNITS CAPSULElipase/protease/amylase 3
CREON DR 3,000 UNITS CAPSULElipase/protease/amylase 3
CREON DR 36,000 UNITS CAPSULElipase/protease/amylase 3
CREON DR 6,000 UNITS CAPSULElipase/protease/amylase 3
KUVAN 100 MG POWDER PACKETsapropterin dihydrochloride 4 PA
KUVAN 100 MG TABLETsapropterin dihydrochloride 4 PA
KUVAN 500 MG POWDER PACKETsapropterin dihydrochloride 4 PA
ORFADIN 10 MG CAPSULEnitisinone 4
ORFADIN 2 MG CAPSULEnitisinone 4
ORFADIN 20 MG CAPSULEnitisinone 4
PAGE 120 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ORFADIN 4 MG/ML SUSPENSIONnitisinone 4
ORFADIN 5 MG CAPSULEnitisinone 4
PANCREAZE DR 10,500 UNIT CAPlipase/protease/amylase 2
PANCREAZE DR 16,800 UNIT CAPlipase/protease/amylase 2
PANCREAZE DR 21,000 UNIT CAPlipase/protease/amylase 2
PANCREAZE DR 4,200 UNIT CAPlipase/protease/amylase 2
pancrelipase dr 5,000 unit cap 1
PERTZYE DR 16,000 UNITS CAPSlipase/protease/amylase 3
PERTZYE DR 8,000 UNITS CAPSULElipase/protease/amylase 3
RAVICTI 1.1 GRAM/ML LIQUIDglycerol phenylbutyrate 4 PA
STRENSIQ 18 MG/0.45 ML VIALasfotase alfa 4
STRENSIQ 28 MG/0.7 ML VIALasfotase alfa 4
STRENSIQ 40 MG/ML VIALasfotase alfa 4
STRENSIQ 80 MG/0.8 ML VIALasfotase alfa 4
VIOKACE 10,440-39,150 UNITS TBlipase/protease/amylase 2
VIOKACE 20,880-78,300 UNITS TBlipase/protease/amylase 2
ZAVESCA 100 MG CAPSULEmiglustat 2
ZENPEP DR 10,000 UNITS CAPSULElipase/protease/amylase 2
ZENPEP DR 15,000 UNITS CAPSULElipase/protease/amylase 2
ZENPEP DR 20,000 UNITS CAPSULElipase/protease/amylase 2
PAGE 121 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZENPEP DR 25,000 UNITS CAPSULElipase/protease/amylase 2
ZENPEP DR 3,000 UNITS CAPSULElipase/protease/amylase 2
ZENPEP DR 40,000 UNITS CAPSULElipase/protease/amylase 2
ZENPEP DR 5,000 UNITS CAPSULElipase/protease/amylase 2
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
BENTYL 20 MG TABLETdicyclomine hcl 3
chlordiazepoxide-clidinium cap 1
dicyclomine 10 mg capsule 1
dicyclomine 10 mg/5 ml soln 1
dicyclomine 20 mg tablet 1
ed-spaz 0.125 mg odt 1
glycopyrrolate 1 mg tablet 1
glycopyrrolate 2 mg tablet 1
hyoscyamine 0.125 mg odt 1
hyoscyamine 0.125 mg tab sl 1
hyoscyamine 0.125 mg/5 ml elix 1
hyoscyamine 0.125 mg/ml drop 1
hyoscyamine 125 mcg/5 ml elix 1
hyoscyamine er 0.375 mg tab 1
hyoscyamine sr 0.375 mg tab 1
hyoscyamine sulf 0.125 mg tab 1
hyosyne 0.125 mg/ml drop 1
hyosyne 125 mcg/5 ml elixir 1
LEVSIN 0.125 MG TABLEThyoscyamine sulfate 3
nulev 0.125 mg chewable melt 3
oscimin 0.125 mg odt 1
oscimin 0.125 mg tablet 1
PAGE 122 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
oscimin sl 0.125 mg tablet 1
oscimin sr 0.375 mg tablet 1
ROBINUL FORTE 2 MG TABLETglycopyrrolate 3
SYMAX DUOTABhyoscyamine sulfate 3
GASTROINTESTINAL AGENTS, OTHER
ACTIGALL 300 MG CAPSULEursodiol 4
CHOLBAM 250 MG CAPSULEcholic acid 4 PA
CHOLBAM 50 MG CAPSULEcholic acid 4 PA
cromolyn 100 mg/5 ml oral conc 1
diphenoxylat-atrop 2.5-0.025/5 1
diphenoxylate-atrop 2.5-0.025 1
FULYZAQ 125 MG DR TABLETcrofelemer 2 PA
GASTROCROM 100 MG/5 ML CONCcromolyn sodium 3
GATTEX 5 MG 30-VIAL KITteduglutide 4 PA
GATTEX 5 MG ONE-VIAL KITteduglutide 4 PA
lansoprazol-amoxicil-clarithro 2
LOMOTIL 2.5-0.025 MG TABLETdiphenoxylate hcl/atropine sulfate 3
loperamide 2 mg capsule 1
MOVANTIK 12.5 MG TABLETnaloxegol oxalate 2 PA
MOVANTIK 25 MG TABLETnaloxegol oxalate 2 PA
MYTESI 125 MG DR TABLETcrofelemer 2
OMECLAMOX-PAK COMBO PACKomeprazole/clarithromycin/amoxicillin trihydrate 2
PYLERA CAPSULEcolloidal bismuth subcitrate/metronidazole/tetracycline hcl 3 AL1 At least 18 yrs old
PAGE 123 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RELISTOR 12 MG/0.6 ML SYRINGEmethylnaltrexone bromide 3 PA
RELISTOR 12 MG/0.6 ML VIALmethylnaltrexone bromide 3 PA
RELISTOR 8 MG/0.4 ML SYRINGEmethylnaltrexone bromide 3 PA
URSO 250 MG TABLETursodiol 4
URSO FORTE 500 MG TABLETursodiol 4
ursodiol 250 mg tablet 1
ursodiol 300 mg capsule 1
ursodiol 500 mg tablet 1
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
cimetidine 200 mg tablet 1
cimetidine 300 mg tablet 1
cimetidine 300 mg/5 ml soln 1
cimetidine 400 mg tablet 1
cimetidine 800 mg tablet 1
famotidine 20 mg tablet 1
famotidine 40 mg tablet 1
famotidine 40 mg/5 ml susp 1
nizatidine 15 mg/ml solution 1
nizatidine 150 mg capsule 1
nizatidine 300 mg capsule 1
ranitidine 15 mg/ml syrup 1
ranitidine 150 mg capsule 1
ranitidine 150 mg tablet 1
ranitidine 150 mg/10 ml syrup 1
ranitidine 300 mg capsule 1
ranitidine 300 mg tablet 1
ZANTAC 150 MG TABLETranitidine hcl 3
PAGE 124 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
IRRITABLE BOWEL SYNDROME AGENTS
alosetron hcl 0.5 mg tablet 3
AMITIZA 24 MCG CAPSULESlubiprostone 3
ST
AL1 At least 18 yrs old
AMITIZA 8 MCG CAPSULElubiprostone 3
ST
AL1 At least 18 yrs old
LINZESS 145 MCG CAPSULElinaclotide 3
QL 30 / 30 DAYS
PA
LINZESS 290 MCG CAPSULElinaclotide 3
QL 30 / 30 DAYS
PA
LAXATIVES
constulose 10 gm/15 ml soln 1
enulose 10 gm/15 ml solution 1
gavilyte-c solution 1
gavilyte-g solution 1
gavilyte-h and bisacodyl kit 1
gavilyte-n solution 1
generlac 10 gm/15 ml solution 1
KRISTALOSE 10 GM PACKETlactulose 3
KRISTALOSE 20 GM PACKETlactulose 3
lactulose 10 gm/15 ml solution 1
lactulose 20 gm/30 ml solution 1
NULYTELY WITH FLAVOR PACKS SOLsodium chloride/sodium bicarbonate/potassium chloride/peg 3
peg 3350 electrolyte soln 1
peg 3350-electrolyte solution 1
peg-3350 and electrolytes soln 1
peg-3350 with flavor packs sol 1
peg-prep kit 2
polyethylene glycol 3350 powd 1
PAGE 125 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
polyethylene glycol 3350 powd 1
trilyte with flavor packets 1
PROTECTANTS
CARAFATE 1 GM TABLETsucralfate 3
misoprostol 200 mcg tablet 1
sucralfate 1 gm tablet 1
PROTON PUMP INHIBITORS
lansoprazole dr 15 mg capsule 1QL 30 / 30 DAYS
ST
lansoprazole dr 30 mg capsule 1QL 30 / 30 DAYS
ST
omeprazole dr 10 mg capsule 1 QL 30 / 30 DAYS
omeprazole dr 20 mg capsule 1 QL 2 / 1 DAYS
omeprazole dr 40 mg capsule 1 QL 30 / 30 DAYS
pantoprazole sod dr 20 mg tab 1 QL 30 / 30 DAYS
pantoprazole sod dr 40 mg tab 1 QL 30 / 30 DAYS
PROTONIX 40 MG SUSPENSIONpantoprazole sodium 2
rabeprazole sod dr 20 mg tab 3 QL 1 / 1 DAYS
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
darifenacin er 15 mg tablet 2
darifenacin er 7.5 mg tablet 2
GELNIQUE 10% GEL SACHETSoxybutynin chloride 3 QL 30 / 30 DAYS
MYRBETRIQ ER 25 MG TABLETmirabegron 3 ST
MYRBETRIQ ER 50 MG TABLETmirabegron 3 ST
oxybutynin 5 mg tablet 1
oxybutynin 5 mg/5 ml syrup 1
PAGE 126 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
oxybutynin cl er 10 mg tablet 1
oxybutynin cl er 15 mg tablet 1
oxybutynin cl er 5 mg tablet 1
OXYTROL 3.9 MG/24HR PATCHoxybutynin 3
tolterodine tart er 2 mg cap 2 QL 30 / 30 DAYS
tolterodine tart er 4 mg cap 2 QL 30 / 30 DAYS
tolterodine tartrate 1 mg tab 1 QL 60 / 30 DAYS
tolterodine tartrate 2 mg tab 1 QL 60 / 30 DAYS
TOVIAZ ER 4 MG TABLETfesoterodine fumarate 3
QL 30 / 30 DAYS
ST
TOVIAZ ER 8 MG TABLETfesoterodine fumarate 3
QL 30 / 30 DAYS
ST
VESICARE 10 MG TABLETsolifenacin succinate 2
VESICARE 5 MG TABLETsolifenacin succinate 2
BENIGN PROSTATIC HYPERTROPHY AGENTS
alfuzosin hcl er 10 mg tablet 1 ST
CARDURA XL 4 MG TABLETdoxazosin mesylate 3
CARDURA XL 8 MG TABLETdoxazosin mesylate 3
dutasteride 0.5 mg capsule 1 ST
dutasteride-tamsulosin 0.5-0.4 3 ST
finasteride 5 mg tablet 1
RAPAFLO 4 MG CAPSULEsilodosin 3
QL 30 / 30 DAYS
ST
RAPAFLO 8 MG CAPSULEsilodosin 3
QL 30 / 30 DAYS
ST
tamsulosin hcl 0.4 mg capsule 1 QL 30 / 30 DAYS
PAGE 127 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GENITOURINARY AGENTS, OTHER
bethanechol 10 mg tablet 1
bethanechol 25 mg tablet 1
bethanechol 5 mg tablet 1
bethanechol 50 mg tablet 1
CUPRIMINE 250 MG CAPSULEpenicillamine 4 PA
CYSTAGON 150 MG CAPSULEcysteamine bitartrate 3
CYSTAGON 50 MG CAPSULEcysteamine bitartrate 3
DEPEN 250 MG TITRATABpenicillamine 4 PA
ELMIRON 100 MG CAPSULEpentosan polysulfate sodium 2
phenazopyridine 100 mg tab 1
phenazopyridine 200 mg tab 1
phospha 250 neutral tablet 1
potassium citrate er 10 meq tb 1
potassium citrate er 15 meq tb 1
URECHOLINE 5 MG TABLETbethanechol chloride 3
virt-phos 250 neutral tablet 1
PHOSPHATE BINDERS
calcium acetate 667 mg capsule 1
calcium acetate 667 mg gelcap 1
calcium acetate 667 mg tablet 3
FOSRENOL 1,000 MG POWDER PACKlanthanum carbonate 2
FOSRENOL 1,000 MG TABLET CHEWlanthanum carbonate 2
FOSRENOL 500 MG TABLET CHEWlanthanum carbonate 2
FOSRENOL 750 MG POWDER PACKETlanthanum carbonate 2
PAGE 128 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FOSRENOL 750 MG TABLET CHEWlanthanum carbonate 2
PHOSLYRA 667 MG/5 ML SOLUTIONcalcium acetate 3
RENAGEL 400 MG TABLETsevelamer hcl 3
RENAGEL 800 MG TABLETsevelamer hcl 3
RENVELA 0.8 GM POWDER PACKETsevelamer carbonate 2 AL1 At least 16 yrs old
RENVELA 2.4 GM POWDER PACKETsevelamer carbonate 2 AL1 At least 16 yrs old
RENVELA 800 MG TABLETsevelamer carbonate 2 AL1 At least 16 yrs old
sevelamer carbonate 800 mg tab 1 AL1 At least 16 yrs old
VELPHORO 500 MG CHEWABLE TABsucroferric oxyhydroxide 3 QL 6 / 1 DAYS
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
ALA-CORT 1% CREAMhydrocortisone 1
alclometasone dipr 0.05% oint 1
alclometasone dipro 0.05% crm 1
amcinonide 0.1% cream 1
amcinonide 0.1% lotion 1
amcinonide 0.1% ointment 1
anucort-hc 25 mg suppository 1
betamethasone dp 0.05% crm 1
betamethasone dp 0.05% lot 1
betamethasone dp 0.05% oint 1
betamethasone dp aug 0.05% crm 1
betamethasone dp aug 0.05% gel 1
betamethasone dp aug 0.05% lot 1
betamethasone dp aug 0.05% oin 1
betamethasone va 0.1% cream 1
betamethasone va 0.1% lotion 1
PAGE 129 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
betamethasone valer 0.1% ointm 1
betamethasone valer 0.12% foam 1
clobetasol 0.05% cream 1
clobetasol 0.05% gel 1
clobetasol 0.05% ointment 1
clobetasol 0.05% shampoo 1
clobetasol 0.05% solution 1
clobetasol 0.05% topical lotn 1
clobetasol emollient 0.05% crm 1
clobetasol emollnt 0.05% foam 1
clobetasol emulsion 0.05% foam 1
clobetasol prop 0.05% foam 1
clocortolone 0.1% cream pump 3
clocortolone pivalate 0.1% crm 3
CORDRAN 0.05% OINTMENTflurandrenolide 3 QL 2 / 10 DAYS
CORDRAN 4 MCG/SQ CM TAPE LARGEflurandrenolide 3 QL 2 / 10 DAYS
cormax 0.05% solution 1
CORTEF 10 MG TABLEThydrocortisone 3
CORTEF 20 MG TABLEThydrocortisone 3
CORTEF 5 MG TABLEThydrocortisone 3
CUTIVATE 0.05% LOTIONfluticasone propionate 3
DELTASONE 20 MG TABLETprednisone 1
DESONATE 0.05% GELdesonide 3
desonide 0.05% cream 3
desonide 0.05% lotion 3
desonide 0.05% ointment 3
desoximetasone 0.05% cream 1
PAGE 130 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
desoximetasone 0.05% gel 1
desoximetasone 0.05% ointment 1
desoximetasone 0.25% cream 1
desoximetasone 0.25% ointment 1
dexamethasone 0.5 mg tablet 1
dexamethasone 0.5 mg/5 ml elx 1
dexamethasone 0.5 mg/5 ml liq 1
dexamethasone 0.75 mg tablet 1
dexamethasone 1 mg tablet 1
dexamethasone 1.5 mg tablet 1
dexamethasone 2 mg tablet 1
dexamethasone 4 mg tablet 1
dexamethasone 6 mg tablet 1
dexamethasone intensol 1mg/1ml 1
DEXPAK 10 DAY 1.5 MG TABLETdexamethasone 2
DEXPAK 13 DAY 1.5 MG TABLETdexamethasone 2
DEXPAK 6 DAY 1.5 MG TABLETdexamethasone 2
diflorasone 0.05% cream 1
diflorasone 0.05% ointment 1
ELOCON 0.1% LOTIONmometasone furoate 3
fludrocortisone 0.1 mg tablet 1
fluocinolone 0.01% body oil 1
fluocinolone 0.01% cream 1
fluocinolone 0.01% solution 1
fluocinolone 0.025% cream 1
fluocinolone 0.025% ointment 1
fluocinonide 0.05% cream 1
fluocinonide 0.05% gel 1
fluocinonide 0.05% ointment 1
PAGE 131 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fluocinonide 0.05% solution 1
fluocinonide 0.1% cream 1
fluocinonide-e 0.05% cream 1
fluocinonide-emol 0.05% cream 3
flurandrenolide 0.05% cream 3 QL 2 / 10 day(s)
flurandrenolide 0.05% lotion 3
fluticasone prop 0.005% oint 1
fluticasone prop 0.05% cream 1
fluticasone prop 0.05% lotion 1
grx hicort 25 mg suppository 1
halobetasol prop 0.05% cream 1
halobetasol prop 0.05% ointmnt 1
HALOG 0.1% CREAMhalcinonide 2
HALOG 0.1% OINTMENThalcinonide 2
hemmorex-hc 25 mg suppository 2
hydrocortisone 1% absorbase 1
hydrocortisone 1% cream 1
hydrocortisone 1% cream 1
hydrocortisone 1% ointment 1
hydrocortisone 10 mg tablet 1
hydrocortisone 2.5% cream 1
hydrocortisone 2.5% lotion 1
hydrocortisone 2.5% ointment 1
hydrocortisone 20 mg tablet 1
hydrocortisone 30 mg supp 1
hydrocortisone 5 mg tablet 1
hydrocortisone ac 25 mg supp 1
hydrocortisone buty 0.1% cream 1
hydrocortisone butyr 0.1% oint 1
hydrocortisone butyr 0.1% soln 1
PAGE 132 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hydrocortisone val 0.2% cream 1
hydrocortisone val 0.2% ointmt 1
KORLYM 300 MG TABLETmifepristone 3 PA
LOCOID 0.1% LOTIONhydrocortisone butyrate 3
MEDROL 2 MG TABLETmethylprednisolone 2
methylprednisolone 16 mg tab 1
methylprednisolone 32 mg tab 1
methylprednisolone 4 mg dosepk 1
methylprednisolone 4 mg tablet 1
methylprednisolone 8 mg tab 1
MILLIPRED 10 MG/5 ML SOLUTIONprednisolone sod phosphate 3
millipred 5 mg tablet 3
mometasone furoate 0.1% cream 1
mometasone furoate 0.1% oint 1
mometasone furoate 0.1% soln 1
PANDEL 0.1% CREAMhydrocortisone probutate 3
prednisolone 15 mg/5 ml soln 1
prednisolone 15 mg/5 ml soln 1
prednisolone 15 mg/5 ml syrup 1
prednisolone 5 mg/5 ml soln 1
prednisolone odt 10 mg tablet 2
prednisolone odt 15 mg tablet 2
prednisolone odt 30 mg tablet 2
prednisolone sod ph 25 mg/5 ml 1
prednisone 1 mg tablet 1
prednisone 10 mg tab dose pack 1
prednisone 10 mg tablet 1
prednisone 10 mg tablet 1
PAGE 133 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
prednisone 2.5 mg tablet 1
prednisone 20 mg tablet 1
prednisone 5 mg tab dose pack 1
prednisone 5 mg tablet 1
prednisone 5 mg tablet 1
prednisone 5 mg/5 ml solution 1
prednisone 5 mg/ml solution 1
prednisone 50 mg tablet 1
PRELONE 15 MG/5 ML SYRUPprednisolone 1
procto-pak 1% cream 1
triamcinolone 0.025% cream 1
triamcinolone 0.025% lotion 1
triamcinolone 0.025% oint 1
triamcinolone 0.1% cream 1
triamcinolone 0.1% lotion 1
triamcinolone 0.1% ointment 1
triamcinolone 0.5% cream 1
triamcinolone 0.5% ointment 1
trianex 0.05% ointment 1
triderm 0.1% cream 1
ULTRAVATE 0.05% CREAMhalobetasol propionate 2
ULTRAVATE 0.05% LOTIONhalobetasol propionate 2
ULTRAVATE 0.05% OINTMENThalobetasol propionate 2
VERDESO 0.05% FOAMdesonide 3 ST
VERIPRED 20 20 MG/5 ML SOLNprednisolone sod phosphate 3
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
desmopressin 0.01% solution 1 PA
PAGE 134 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
desmopressin 0.01% spray 1 PA
desmopressin 0.1 mg/ml sol 1 PA
desmopressin 0.1 mg/ml spray 1
desmopressin 10 mcg/0.1 ml spr 1
desmopressin acetate 0.1 mg tb 1 PA
desmopressin acetate 0.2 mg tb 1 PA
OMNITROPE 10 MG/1.5 ML CRTGsomatropin 4 PA
OMNITROPE 5 MG/1.5 ML CRTGsomatropin 4 PA
OMNITROPE 5.8 MG VIALsomatropin 4 PA
SAIZEN 5 MG VIALsomatropin 4 PA
SAIZEN 8.8 MG CLICK.EASY CARTGsomatropin 4 PA
SAIZEN 8.8 MG VIALsomatropin 4 PA
SEROSTIM 4 MG VIALsomatropin 4 PA
SEROSTIM 5 MG VIALsomatropin 4 PA
SEROSTIM 6 MG VIALsomatropin 4 PA
STIMATE 1.5 MG/ML NASAL SPRAYdesmopressin acetate 3 PA
TEV-TROPIN 5 MG VIALsomatropin 4 PA
ZOMACTON 5 MG VIALsomatropin 4 PA
ZORBTIVE 8.8 MG VIALsomatropin 4 PA
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANABOLIC STEROIDS
oxandrolone 10 mg tablet 3
oxandrolone 2.5 mg tablet 3
PAGE 135 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANDROGENS
ANDRODERM 2 MG/24HR PATCHtestosterone 3 PA
ANDRODERM 4 MG/24HR PATCHtestosterone 3 PA
ANDROGEL 1.62% GEL PUMPtestosterone 3 PA
ANDROGEL 1.62%(1.25G) GEL PCKTtestosterone 3 PA
ANDROGEL 1.62%(2.5G) GEL PCKTtestosterone 3 PA
AXIRON 30 MG/ACTUATION SOLNtestosterone 3 PA
danazol 100 mg capsule 1
danazol 200 mg capsule 1
danazol 50 mg capsule 1
METHITEST 10 MG TABLETmethyltestosterone 2 PA
methyltestosterone 10 mg cap 2 PA
testosteron cyp 1,000 mg/10 ml 1 PA
testosteron cyp 2,000 mg/10 ml 1 PA
testosteron enan 1,000 mg/5 ml 1
testosterone 10 mg gel pump 3 PA
testosterone 12.5 mg/1.25 gram 3 PA
testosterone 25 mg/2.5 gm pkt 3 PA
testosterone 50 mg/5 gram gel 3 PA
testosterone 50 mg/5 gram pkt 3 PA
testosterone cyp 100 mg/ml 1 PA
testosterone cyp 200 mg/ml 1 PA
testosterone enan 200 mg/ml 1
ESTROGENS
altavera-28 tablet 1
PAGE 136 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
alyacen 1-35-28 tablet 1
alyacen 7-7-7-28 tablet 1
amabelz 0.5 mg-0.1 mg tablet 1
amabelz 1 mg-0.5 mg tablet 1
amethia 0.15-0.03-0.01 mg tab 1 MDS1 91 / 1 DAYS
amethia lo tablet 1 MDS1 91 / 1 DAYS
amethyst 90-20 mcg tablet 3
ANGELIQ 0.25 MG-0.5 MG TABLETdrospirenone/estradiol 3 ST
ANGELIQ 0.5 MG-1 MG TABLETdrospirenone/estradiol 3 ST
apri 28 day tablet 1
aranelle 28 tablet 1
ashlyna 0.15-0.03-0.01 mg tab 1
aubra-28 tablet 1
aviane-28 tablet 1
azurette 28 day tablet 1
balziva 28 tablet 1
bekyree 28 day tablet 1
blisovi 24 fe tablet 1
blisovi fe 1-20 tablet 1
blisovi fe 1.5-30 tablet 1
BREVICON 28 TABLETnorethindrone-ethinyl estradiol 1
briellyn tablet 1
camrese 0.15-0.03-0.01 mg tab 1
camrese lo tablet 1 MDS1 91 / 1 DAYS
caziant 28 day tablet 1
chateal-28 tablet 1
CLIMARA PRO PATCHestradiol/levonorgestrel 3
COMBIPATCH 0.05-0.14 MG PTCHestradiol/norethindrone acetate 2
PAGE 137 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
COMBIPATCH 0.05-0.25 MG PTCHestradiol/norethindrone acetate 2
covaryx h.s. tablet 1
covaryx tablet 1
cryselle-28 tablet 1
cyclafem 1-35-28 tablet 1
cyclafem 7-7-7-28 tablet 1
cyred 28 day tablet 1
dasetta 1-35-28 tablet 1
dasetta 7/7/7-28 tablet 1
daysee 0.15-0.03-0.01 mg tab 1 MDS1 91 / 1 DAYS
delyla-28 tablet 1
desogestr-eth estrad eth estra 1
desogestrel-ethinyl estrad tab 1
DIVIGEL 0.25 MG GEL PACKETestradiol 3 ST
DIVIGEL 0.5 MG GEL PACKETestradiol 3 ST
DIVIGEL 1 MG GEL PACKETestradiol 3 ST
drosp-ee-levomef 3-0.02-0.451 3
drospirenone-ee 3-0.02 mg tab 1
drospirenone-ee 3-0.03 mg tab 1
DUAVEE 0.45-20 MG TABLETestrogens, conjugated/bazedoxifene acetate 3 QL 1 / 1 DAYS
eemt ds 1.25-2.5 mg tablet 3
eemt hs 0.625-1.25 mg tablet 3
ELESTRIN 0.06% GELestradiol 3 ST
elinest-28 tablet 1
emoquette 28 day tablet 1
enpresse-28 tablet 1
enskyce 28 tablet 1
estarylla 0.25-0.035 mg tablet 1
PAGE 138 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ESTRACE 0.01% CREAMestradiol 2
ESTRACE 2 MG TABLETestradiol 3
estradiol 0.025 mg patch 1 QL 8 / 28 DAYS
estradiol 0.0375 mg patch 1 QL 8 / 28 DAYS
estradiol 0.0375 mg/day patch 1 QL 4 / 28 DAYS
estradiol 0.05 mg patch 1 QL 8 / 28 DAYS
estradiol 0.05 mg/day patch 1 QL 4 / 28 DAYS
estradiol 0.06 mg/day patch 1 QL 4 / 28 DAYS
estradiol 0.075 mg patch 1 QL 8 / 28 DAYS
estradiol 0.075 mg/day patch 1 QL 4 / 28 DAYS
estradiol 0.1 mg patch 1 QL 8 / 28 DAYS
estradiol 0.1 mg/day patch 1 QL 4 / 28 DAYS
estradiol 0.5 mg tablet 1
estradiol 1 mg tablet 1
estradiol 2 mg tablet 1
estradiol tds 0.025 mg/day 1 QL 4 / 28 DAYS
estradiol tds 0.0375 mg/day 1 QL 4 / 28 DAYS
estradiol tds 0.05 mg/day 1 QL 4 / 28 DAYS
estradiol tds 0.06 mg/day 1 QL 4 / 28 DAYS
estradiol tds 0.075 mg/day 1 QL 4 / 28 DAYS
estradiol tds 0.1 mg/day 1 QL 4 / 28 DAYS
estradiol-noreth 0.5-0.1 mg tb 1
estradiol-noreth 1-0.5 mg tab 1
ESTRING 2 MG VAGINAL RINGestradiol 3
ESTROGEL 0.06% GELestradiol 3
estrogen-methyltestos f.s. tab 1
PAGE 139 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
estrogen-methyltestos h.s. tab 1
estrogen-methyltestos h.s. tab 1
estrogen-methyltestosterone tb 1
estropipate 0.625(0.75 mg) tab 1
estropipate 1.25(1.5 mg) tab 1
estropipate 2.5(3 mg) tab 1
EVAMIST 1.53 MG/SPRAYestradiol 3
falmina-28 tablet 1
FEMRING 0.05 MG VAGINAL RINGestradiol acetate 3
FEMRING 0.10 MG VAGINAL RINGestradiol acetate 3
femynor 28 tablet 1
gianvi 3 mg-0.02 mg tablet 1
gildagia 0.4 mg-0.035 mg tab 1
gildess 1 mg-20 mcg tablet 1
gildess 1.5 mg-30 mcg tablet 1
gildess 24 fe 1-0.02 mg tablet 1
gildess fe 1-20 tablet 1
gildess fe 1.5-30 tablet 1
introvale 0.15-0.03 mg tablet 1 MDS1 91 / 1 DAYS
jolessa 0.15 mg-0.03 mg tablet 1
juleber 28 day tablet 1
junel 1 mg-20 mcg tablet 1
junel 1.5 mg-30 mcg tablet 1
junel fe 1 mg-20 mcg tablet 1
junel fe 1.5 mg-30 mcg tablet 1
junel fe 24 tablet 1
kariva 28 day tablet 1
kelnor 1-35 28 tablet 1
kimidess 28 day tablet 1
PAGE 140 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
kurvelo tablet 1
larin 1.5 mg-30 mcg tablet 1
larin 21 1-20 tablet 1
larin 24 fe 1 mg-20 mcg tablet 1
larin fe 1-20 tablet 1
larin fe 1.5-30 tablet 1
larissia-28 tablet 1
leena 28 tablet 1
lessina-28 tablet 1
levonest-28 tablet 1
levono-e estrad 0.10-0.02-0.01 1 MDS1 91 / 1 DAYS
levono-e estrad 0.15-0.03-0.01 1
levonor-eth estra 0.09-0.02 mg 1
levonor-eth estrad 0.1-0.02 mg 1
levonor-eth estrad 0.15-0.03 1 MDS1 91 / 1 DAYS
levonor-eth estrad 0.15-0.03 1 MDS1 91 / 1 DAYS
levonor-eth estrad triphasic 1
levora-28 tablet 1
lomedia 24 fe 1 mg-20 mcg tab 1
lopreeza 0.5 mg-0.1 mg tablet 1
lopreeza 1 mg-0.5 mg tablet 1
loryna 3 mg-0.02 mg tablet 1
low-ogestrel-28 tablet 1
lutera-28 tablet 1
marlissa-28 tablet 1
MENEST 0.3 MG TABLETestrogens,esterified 3
MENEST 0.625 MG TABLETestrogens,esterified 3
MENEST 1.25 MG TABLETestrogens,esterified 3
MENEST 2.5 MG TABLETestrogens,esterified 3
PAGE 141 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MENOSTAR 14 MCG/DAY PATCHestradiol 3
microgestin 21 1-20 tablet 1
microgestin 21 1.5-30 tab 1
MICROGESTIN 24 FE 1 MG-20 MCGnorethindrone acetate-ethinyl estradiol/ferrous fumarate 3
microgestin fe 1-20 tablet 1
microgestin fe 1.5-30 tab 1
mimvey 1-0.5 mg tablet 1
mimvey lo 0.5-0.1 mg tablet 1
MINIVELLE 0.075 MG PATCHestradiol 3 QL 8 / 28 DAYS
mono-linyah 28 tablet 1
mononessa 28 tablet 1
myzilra-28 tablet 1
NATAZIA 28 TABLETestradiol valerate/dienogest 3
necon 0.5-35-28 tablet 1
necon 1-35-28 tablet 1
necon 1-50-28 tablet 1
necon 10-11-28 tablet 1
necon 7-7-7-28 tablet 1
nikki 3 mg-0.02 mg tablet 1
noret-estr-fe 0.4-0.035(21)-75 1
noreth-estrad-fe 1-0.02(21)-75 1
noreth-estrad-fe 1-0.02(24)-75 1
norethind-eth estrad 1-0.02 mg 1
norg-ee 0.18-0.215-0.25/0.025 1
norg-ee 0.18-0.215-0.25/0.035 1
norg-ethin estra 0.25-0.035 mg 1
NORINYL 1-35 28 TABLETnorethindrone-ethinyl estradiol 1
nortrel 0.5-35-28 tablet 1
PAGE 142 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
nortrel 1-35 21 tablet 1
nortrel 1-35 28 tablet 1
nortrel 7-7-7-28 tablet 1
NUVARING VAGINAL RINGetonogestrel/ethinyl estradiol 3
ocella 3 mg-0.03 mg tablet 1
OGEN 2.5 TABLETestropipate 3
ogestrel tablet 2
orsythia-28 tablet 1
ORTHO EVRA PATCHnorelgestromin/ethinyl estradiol 2
philith 0.4-0.035 mg tablet 1
pimtrea 28 day tablet 1
pirmella 1-35-28 tablet 1
pirmella 7-7-7-28 tablet 1
portia-28 tablet 1
PREFEST TABLETestradiol/norgestimate 2
PREMARIN 0.3 MG TABLETestrogens, conjugated 2
PREMARIN 0.45 MG TABLETestrogens, conjugated 2
PREMARIN 0.625 MG TABLETestrogens, conjugated 2
PREMARIN 0.9 MG TABLETestrogens, conjugated 2
PREMARIN 1.25 MG TABLETestrogens, conjugated 2
PREMARIN VAGINAL CREAM-APPLestrogens, conjugated 2
PREMPHASE 0.625-5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate 2
PREMPRO 0.3 MG-1.5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate 2
PREMPRO 0.45-1.5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate 2
PAGE 143 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PREMPRO 0.625-2.5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate 2
PREMPRO 0.625-5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate 2
previfem tablet 1
quasense 0.15-0.03 mg tablet 1
rajani 28 tablet 3
reclipsen 28 day tablet 1
setlakin 0.15 mg-0.03 mg tab 1
sprintec 28 day tablet 1
sronyx 0.10-0.02 mg tablet 1
syeda 28 tablet 1
tarina fe 1-20 tablet 1
tilia fe 28 tablet 1
tri-estarylla tablet 1
tri-legest fe-28 day tablet 1
tri-linyah tablet 1
tri-lo-estarylla tablet 1
tri-lo-marzia tablet 1
tri-lo-sprintec tablet 1
tri-previfem tablet 1
tri-sprintec tablet 1
trinessa lo tablet 1
trinessa tablet 1
trivora-28 tablet 1
velivet 28 day tablet 1
vestura 3 mg-0.02 mg tablet 1
vienva-28 tablet 1
viorele 28 day tablet 1
vyfemla 28 tablet 1
wera 0.5/0.035 mg 28 tablet 1
wymzya fe chewable tablet 1
PAGE 144 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
xulane patch 1
yuvafem 10 mcg vaginal insert 2
zarah tablet 1
zenchent 0.4 mg-35 mcg tablet 1
zenchent fe tablet chewable 1
zeosa chewable tablet 1
zovia 1-35e tablet 1
zovia 1-50e tablet 1
PROGESTINS
AYGESTIN 5 MG TABLETnorethindrone acetate 3
camila 0.35 mg tablet 1
deblitane 0.35 mg tablet 1
errin 0.35 mg tablet 1
heather tablet 1
jencycla 0.35 mg tablet 1
jolivette tablet 1
lyza 0.35 mg tablet 1
medroxyprogesterone 10 mg tab 1
medroxyprogesterone 150 mg/ml 1
medroxyprogesterone 150 mg/ml 1
medroxyprogesterone 2.5 mg tab 1
medroxyprogesterone 5 mg tab 1
megestrol 20 mg tablet 1
nora-be tablet 1
norethindrone 0.35 mg tablet 1
norethindrone 5 mg tablet 1
norlyroc 0.35 mg tablet 1
progesterone 100 mg capsule 1
progesterone 200 mg capsule 1
sharobel 0.35 mg tablet 1
PAGE 145 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
raloxifene hcl 60 mg tablet 1
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
ARMOUR THYROID 120 MG TABLETthyroid,pork 2
ARMOUR THYROID 15 MG TABLETthyroid,pork 2
ARMOUR THYROID 180 MG TABLETthyroid,pork 2
ARMOUR THYROID 240 MG TABLETthyroid,pork 2
ARMOUR THYROID 30 MG TABLETthyroid,pork 2
ARMOUR THYROID 300 MG TABLETthyroid,pork 2
ARMOUR THYROID 60 MG TABLETthyroid,pork 2
ARMOUR THYROID 90 MG TABLETthyroid,pork 2
CYTOMEL 25 MCG TABLETliothyronine sodium 2
CYTOMEL 5 MCG TABLETliothyronine sodium 2
CYTOMEL 50 MCG TABLETliothyronine sodium 2
LEVO-T 100 MCG TABLETlevothyroxine sodium 2
LEVO-T 112 MCG TABLETlevothyroxine sodium 2
LEVO-T 125 MCG TABLETlevothyroxine sodium 2
LEVO-T 137 MCG TABLETlevothyroxine sodium 2
LEVO-T 150 MCG TABLETlevothyroxine sodium 2
LEVO-T 175 MCG TABLETlevothyroxine sodium 2
LEVO-T 200 MCG TABLETlevothyroxine sodium 2
PAGE 146 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LEVO-T 25 MCG TABLETlevothyroxine sodium 2
LEVO-T 300 MCG TABLETlevothyroxine sodium 2
LEVO-T 50 MCG TABLETlevothyroxine sodium 2
LEVO-T 75 MCG TABLETlevothyroxine sodium 2
LEVO-T 88 MCG TABLETlevothyroxine sodium 2
levothyroxine 100 mcg tablet 1
levothyroxine 112 mcg tablet 1
levothyroxine 125 mcg tablet 1
levothyroxine 137 mcg tablet 1
levothyroxine 150 mcg tablet 1
levothyroxine 175 mcg tablet 1
levothyroxine 200 mcg tablet 1
levothyroxine 25 mcg tablet 1
levothyroxine 300 mcg tablet 1
levothyroxine 50 mcg tablet 1
levothyroxine 75 mcg tablet 1
levothyroxine 88 mcg tablet 1
LEVOXYL 100 MCG TABLETlevothyroxine sodium 2
LEVOXYL 112 MCG TABLETlevothyroxine sodium 2
LEVOXYL 125 MCG TABLETlevothyroxine sodium 2
LEVOXYL 137 MCG TABLETlevothyroxine sodium 2
LEVOXYL 150 MCG TABLETlevothyroxine sodium 2
LEVOXYL 175 MCG TABLETlevothyroxine sodium 2
LEVOXYL 200 MCG TABLETlevothyroxine sodium 2
PAGE 147 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LEVOXYL 25 MCG TABLETlevothyroxine sodium 2
LEVOXYL 50 MCG TABLETlevothyroxine sodium 2
LEVOXYL 75 MCG TABLETlevothyroxine sodium 2
LEVOXYL 88 MCG TABLETlevothyroxine sodium 2
liothyronine sod 25 mcg tab 1
liothyronine sod 5 mcg tab 1
liothyronine sod 50 mcg tab 1
NATURE-THROID 113.75 MG TABLETthyroid,pork 1
NATURE-THROID 130 MG TABLETthyroid,pork 1
NATURE-THROID 146.25 MG TABLETthyroid,pork 1
NATURE-THROID 16.25 MG TABLETthyroid,pork 1
NATURE-THROID 162.5 MG TABLETthyroid,pork 1
NATURE-THROID 195 MG TABLETthyroid,pork 1
NATURE-THROID 260 MG TABLETthyroid,pork 1
NATURE-THROID 32.5 MG TABLETthyroid,pork 1
NATURE-THROID 325 MG TABLETthyroid,pork 1
NATURE-THROID 48.75 MG TABLETthyroid,pork 1
NATURE-THROID 65 MG TABLETthyroid,pork 1
NATURE-THROID 81.25 MG TABLETthyroid,pork 1
NATURE-THROID 97.5 MG TABLETthyroid,pork 1
np thyroid 15 mg tablet 1
PAGE 148 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
np thyroid 30 mg tablet 1
np thyroid 60 mg tablet 1
np thyroid 90 mg tablet 1
SYNTHROID 100 MCG TABLETlevothyroxine sodium 2
SYNTHROID 112 MCG TABLETlevothyroxine sodium 2
SYNTHROID 125 MCG TABLETlevothyroxine sodium 2
SYNTHROID 137 MCG TABLETlevothyroxine sodium 2
SYNTHROID 150 MCG TABLETlevothyroxine sodium 2
SYNTHROID 175 MCG TABLETlevothyroxine sodium 2
SYNTHROID 200 MCG TABLETlevothyroxine sodium 2
SYNTHROID 25 MCG TABLETlevothyroxine sodium 2
SYNTHROID 300 MCG TABLETlevothyroxine sodium 2
SYNTHROID 50 MCG TABLETlevothyroxine sodium 2
SYNTHROID 75 MCG TABLETlevothyroxine sodium 2
SYNTHROID 88 MCG TABLETlevothyroxine sodium 2
THYROLAR-1 STRENGTH TABLETliotrix 2
THYROLAR-1/2 STRENGTH TABliotrix 2
THYROLAR-1/4 STRENGTH TABliotrix 2
THYROLAR-2 STRENGTH TABLETliotrix 2
THYROLAR-3 STRENGTH TABLETliotrix 2
UNITHROID 100 MCG TABLETlevothyroxine sodium 2
PAGE 149 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
UNITHROID 112 MCG TABLETlevothyroxine sodium 2
UNITHROID 125 MCG TABLETlevothyroxine sodium 2
UNITHROID 137 MCG TABLETlevothyroxine sodium 2
UNITHROID 150 MCG TABLETlevothyroxine sodium 2
UNITHROID 175 MCG TABLETlevothyroxine sodium 2
UNITHROID 200 MCG TABLETlevothyroxine sodium 2
UNITHROID 25 MCG TABLETlevothyroxine sodium 2
UNITHROID 300 MCG TABLETlevothyroxine sodium 2
UNITHROID 50 MCG TABLETlevothyroxine sodium 2
UNITHROID 75 MCG TABLETlevothyroxine sodium 2
UNITHROID 88 MCG TABLETlevothyroxine sodium 2
WESTHROID 130 MG TABLETthyroid,pork 1
WESTHROID 195 MG TABLETthyroid,pork 1
WESTHROID 32.5 MG TABLETthyroid,pork 1
WESTHROID 65 MG TABLETthyroid,pork 1
WESTHROID 97.5 MG TABLETthyroid,pork 1
WP THYROID 113.75 MG TABLETthyroid,pork 1
WP THYROID 130 MG TABLETthyroid,pork 1
WP THYROID 16.25 MG TABLETthyroid,pork 1
WP THYROID 32.5 MG TABLETthyroid,pork 1
PAGE 150 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
WP THYROID 48.75 MG TABLETthyroid,pork 1
WP THYROID 65 MG TABLETthyroid,pork 1
WP THYROID 81.25 MG TABLETthyroid,pork 1
WP THYROID 97.5 MG TABLETthyroid,pork 1
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)
SENSIPAR 30 MG TABLETcinacalcet hcl 4 PA
SENSIPAR 60 MG TABLETcinacalcet hcl 4 PA
SENSIPAR 90 MG TABLETcinacalcet hcl 4 PA
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
cabergoline 0.5 mg tablet 1
octreotide 1,000 mcg/5 ml vial 4
octreotide 1,000 mcg/ml vial 4
octreotide 5,000 mcg/5 ml vial 4
octreotide acet 0.05 mg/ml vl 4
octreotide acet 100 mcg/ml amp 4
octreotide acet 100 mcg/ml syr 4
octreotide acet 100 mcg/ml vl 4
octreotide acet 200 mcg/ml vl 4
octreotide acet 50 mcg/ml amp 4
octreotide acet 50 mcg/ml syr 4
octreotide acet 50 mcg/ml vial 4
octreotide acet 500 mcg/ml amp 4
octreotide acet 500 mcg/ml syr 4
octreotide acet 500 mcg/ml vl 4
PAGE 151 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole 10 mg tablet 1
methimazole 5 mg tablet 1
propylthiouracil 50 mg tablet 1
IMMUNOLOGICAL AGENTS
ANGIOEDEMA (HAE) AGENTS
BERINERT 500 UNIT KITc1 esterase inhibitor 4
RUCONEST 2,100 UNIT VIALc1 esterase inhibitor, recombinant 4
IMMUNE SUPPRESSANTS
ASTAGRAF XL 0.5 MG CAPSULEtacrolimus 3
ASTAGRAF XL 1 MG CAPSULEtacrolimus 3
ASTAGRAF XL 5 MG CAPSULEtacrolimus 3
AZASAN 100 MG TABLETazathioprine 3
AZASAN 75 MG TABLETazathioprine 3
azathioprine 50 mg tablet 1
CIMZIA 200 MG VIAL KITcertolizumab pegol 4 PA
CIMZIA 200 MG/ML STARTER KITcertolizumab pegol 4 PA
CIMZIA 200 MG/ML SYRINGE KITcertolizumab pegol 4 PA
cyclosporine 100 mg capsule 1
cyclosporine 100 mg/ml soln 1
cyclosporine 25 mg capsule 1
cyclosporine modified 100 mg 1
cyclosporine modified 25 mg 1
cyclosporine modified 50 mg 1
PAGE 152 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ENBREL 25 MG KITetanercept 4 PA
ENBREL 25 MG/0.5 ML SYRINGEetanercept 4 PA
ENBREL 50 MG/ML SURECLICK SYRetanercept 4 PA
ENBREL 50 MG/ML SYRINGEetanercept 4 PA
gengraf 100 mg capsule 1
gengraf 100 mg/ml solution 1
gengraf 25 mg capsule 1
gengraf 50 mg capsule 1
hecoria 0.5 mg capsule 2
hecoria 1 mg capsule 2
hecoria 5 mg capsule 2
HUMIRA 10 MG/0.2 ML SYRINGEadalimumab 4 PA
HUMIRA 20 MG/0.4 ML SYRINGEadalimumab 4 PA
HUMIRA 40 MG/0.8 ML PENadalimumab 4 PA
HUMIRA 40 MG/0.8 ML SYRINGEadalimumab 4 PA
HUMIRA PEDIATRIC CROHN'S STARTadalimumab 4 PA
HUMIRA PEN CROHN-UC-HS STARTERadalimumab 4 PA
HUMIRA PEN PSORIASIS-UVEITISadalimumab 4 PA
IMURAN 50 MG TABLETazathioprine 3
KINERET 100 MG/0.67 ML SYRINGEanakinra 4 PA
methotrexate 2.5 mg tablet 1
methotrexate 250 mg/10 ml vial 1
methotrexate 50 mg/2 ml vial 1
mycophenolate 200 mg/ml susp 3
PAGE 153 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
mycophenolate 250 mg capsule 1
mycophenolate 500 mg tablet 1
mycophenolic acid dr 180 mg tb 2
mycophenolic acid dr 360 mg tb 2
NEORAL 100 MG/ML SOLUTIONcyclosporine, modified 3
ORENCIA 125 MG/ML SYRINGEabatacept 4 PA
ORENCIA CLICKJECT 125 MG/MLabatacept 4 PA
OTREXUP 10 MG/0.4 ML AUTO-INJmethotrexate/pf 4
QL 1.6 / 28 DAYS
ST
OTREXUP 12.5 MG/0.4 ML AUTOINJmethotrexate/pf 4
OTREXUP 15 MG/0.4 ML AUTO-INJmethotrexate/pf 4
QL 1.6 / 28 DAYS
ST
OTREXUP 17.5 MG/0.4 ML AUTOINJmethotrexate/pf 4
OTREXUP 20 MG/0.4 ML AUTO-INJmethotrexate/pf 4
QL 1.6 / 28 DAYS
ST
OTREXUP 22.5 MG/0.4 ML AUTOINJmethotrexate/pf 4
OTREXUP 25 MG/0.4 ML AUTO-INJmethotrexate/pf 4
QL 1.6 / 28 DAYS
ST
RAPAMUNE 1 MG/ML ORAL SOLNsirolimus 3 PA
RASUVO 10 MG/0.2 ML AUTOINJmethotrexate/pf 4 ST
RASUVO 12.5 MG/0.25 ML AUTOINJmethotrexate/pf 4 ST
RASUVO 15 MG/0.3 ML AUTOINJmethotrexate/pf 4 ST
RASUVO 17.5 MG/0.35 ML AUTOINJmethotrexate/pf 4 ST
RASUVO 20 MG/0.4 ML AUTOINJmethotrexate/pf 4
QL 1.6 / 28 DAYS
ST
PAGE 154 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RASUVO 22.5 MG/0.45 ML AUTOINJmethotrexate/pf 4 ST
RASUVO 25 MG/0.5 ML AUTOINJmethotrexate/pf 4 ST
RASUVO 27.5 MG/0.55 ML AUTOINJmethotrexate/pf 4 ST
RASUVO 30 MG/0.6 ML AUTOINJmethotrexate/pf 4 ST
RASUVO 7.5 MG/0.15 ML AUTOINJmethotrexate/pf 4 ST
SANDIMMUNE 100 MG/ML SOLNcyclosporine 3
SIMPONI 100 MG/ML PEN INJECTORgolimumab 4 PA
SIMPONI 100 MG/ML SYRINGEgolimumab 4 PA
SIMPONI 50 MG/0.5 ML PEN INJECgolimumab 4 PA
SIMPONI 50 MG/0.5 ML SYRINGEgolimumab 4 PA
sirolimus 0.5 mg tablet 3 PA
sirolimus 1 mg tablet 3 PA
sirolimus 2 mg tablet 3 PA
tacrolimus 0.5 mg capsule 2
tacrolimus 1 mg capsule 2
tacrolimus 5 mg capsule 2
TREXALL 10 MG TABLETmethotrexate sodium 2
TREXALL 15 MG TABLETmethotrexate sodium 2
TREXALL 5 MG TABLETmethotrexate sodium 2
TREXALL 7.5 MG TABLETmethotrexate sodium 2
XELJANZ 5 MG TABLETtofacitinib citrate 4 PA
XELJANZ XR 11 MG TABLETtofacitinib citrate 4 PA
PAGE 155 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZORTRESS 0.25 MG TABLETeverolimus 2 PA
ZORTRESS 0.5 MG TABLETeverolimus 2 PA
ZORTRESS 0.75 MG TABLETeverolimus 2 PA
IMMUNOMODULATORS
ACTEMRA 162 MG/0.9 ML SYRINGEtocilizumab 4 PA
ACTIMMUNE 100 MCG/0.5 ML VIALinterferon gamma-1b,recomb. 4 PA
leflunomide 10 mg tablet 1
leflunomide 20 mg tablet 1
OTEZLA 28 DAY STARTER PACKapremilast 4 PA
OTEZLA 30 MG TABLETapremilast 4 PA
OTEZLA STARTER PACKapremilast 4 PA
RIDAURA 3 MG CAPSULEauranofin 4
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
APRISO ER 0.375 GRAM CAPSULEmesalamine 2 QL 120 / 30 DAYS
balsalazide disodium 750 mg cp 3
CANASA 1,000 MG SUPPOSITORYmesalamine 2
DELZICOL DR 400 MG CAPSULEmesalamine 3 ST
DIPENTUM 250 MG CAPSULEolsalazine sodium 3
GIAZO 1.1 GM TABLETbalsalazide disodium 3
LIALDA DR 1.2 GM TABLETmesalamine 3
mesalamine 4 gm/60 ml enema 1
PAGE 156 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
mesalamine 4 gm/60 ml kit 1
mesalamine 800 mg dr tablet 2
PENTASA 250 MG CAPSULEmesalamine 2
PENTASA 500 MG CAPSULEmesalamine 2
GLUCOCORTICOIDS
budesonide ec 3 mg capsule 3
colocort 100 mg enema 1
CORTIFOAM 10% AEROSOLhydrocortisone acetate 2
hydrocortisone 100 mg/60 ml 1
hydrocortisone 2.5% cream 1
procto-med hc 2.5% cream 1
proctosol-hc 2.5% cream 1
proctozone-hc 2.5% cream 1
UCERIS 9 MG ER TABLETbudesonide 3 ST
SULFONAMIDES
sulfasalazine 500 mg tablet 1
sulfasalazine dr 500 mg tab 1
METABOLIC BONE DISEASE AGENTS
alendronate sod 70 mg/75 ml 1
alendronate sodium 10 mg tab 1 QL 30 / 30 DAYS
alendronate sodium 35 mg tab 1 QL 4 / 28 DAYS
alendronate sodium 40 mg tab 1 QL 30 / 30 DAYS
alendronate sodium 5 mg tablet 1 QL 30 / 30 DAYS
alendronate sodium 70 mg tab 1 QL 4 / 28 DAYS
calcitonin-salmon 200 units sp 1
calcitriol 0.25 mcg capsule 1
calcitriol 0.5 mcg capsule 1
calcitriol 1 mcg/ml solution 1
PAGE 157 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DRISDOL 50,000 UNITS CAPSULEergocalciferol (vitamin d2) 3
FORTEO 600 MCG/2.4 ML PEN INJteriparatide 4 PA
ibandronate sodium 150 mg tab 1
MIACALCIN 200 UNIT NASAL SPRAYcalcitonin,salmon,synthetic 3
NATPARA 100 MCG DOSE CARTRIDGEparathyroid hormone 4 PA
NATPARA 25 MCG DOSE CARTRIDGEparathyroid hormone 4 PA
NATPARA 50 MCG DOSE CARTRIDGEparathyroid hormone 4 PA
NATPARA 75 MCG DOSE CARTRIDGEparathyroid hormone 4 PA
paricalcitol 1 mcg capsule 3
paricalcitol 2 mcg capsule 3
paricalcitol 4 mcg capsule 3
risedronate sod dr 35 mg tab 3 ST
risedronate sodium 150 mg tab 3
risedronate sodium 30 mg tab 3 QL 30 / 30 DAYS
risedronate sodium 35 mg tab 3 QL 4 / 28 DAYS
risedronate sodium 5 mg tablet 3 QL 30 / 30 DAYS
ROCALTROL 1 MCG/ML ORAL SOLNcalcitriol 3
vit d2 1.25 mg (50,000 unit) 1
MISCELLANEOUS THERAPEUTIC AGENTS
insulin syrin 0.5 ml 30gx1/2" 2
insulin syrin 0.5 ml 30gx5/16" 2
insulin syringe 1 ml 30gx1/2" 2
insulin syringe 1 ml 30gx5/16" 2
magellan insul syringe 0.3 ml 2
magellan insul syringe 0.5 ml 2
magellan insulin syr 0.3 ml 2
PAGE 158 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
magellan insulin syr 0.5 ml 2
magellan insulin syringe 1 ml 2
magellan insulin syringe 1 ml 2
monoject 0.5 ml syrn 28gx1/2" 2
monoject 1 ml syrn 28gx1/2" 2
monoject insulin syr 0.3 ml 2
monoject insulin syr 0.5 ml 2
monoject insulin syr 1 ml 2
monoject insulin syr u-100 2
monoject syringe 1 ml 2
MYALEPT 11.3 MG (5 MG/ML) VIALmetreleptin 3 QL 1 / 1 DAYS
pen needles 2
saccharin powder 3
sen-serter 3
sorbitol 70% solution 3
ulticare ins safety 1ml 29x1/2 2
ulticare safety 0.5 ml 29gx1/2 2
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
ak-poly-bac eye ointment 1
atropine 1% eye drops 1
atropine 1% eye ointment 1
bacitracin-polymyxin eye oint 1
BLEPHAMIDE EYE DROPSsulfacetamide sodium/prednisolone acetate 2
BLEPHAMIDE EYE OINTMENTsulfacetamide sodium/prednisolone acetate 2
cyclopentolate 1% eye drops 1
FLUCAINE EYE DROPSproparacaine hcl/fluorescein sodium 1
fluorescein-proparacaine drops 1
homatropaire 5% eye drops 1
PAGE 159 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
homatropine 5% eye drops 1
ISOPTO ATROPINE 1% EYE DROPSatropine sulfate 2
neo-bacit-poly-hc eye ointment 1
neo-polycin eye ointment 1
neo-polycin hc eye ointment 1
neomyc-bacit-polymix eye oint 1
neomyc-polym-gramicid eye drop 1
polycin eye ointment 1
polymyxin b-tmp eye drops 1
PRED-G 1% EYE DROPSgentamicin sulfate/prednisolone acetate 2
PRED-G S.O.P. EYE OINTMENTgentamicin sulfate/prednisolone acetate 2
RESTASIS 0.05% EYE EMULSIONcyclosporine 3
sulf-pred 10-0.23% eye drops 1
sulf-pred 10-0.25% eye drops 1
TOBRADEX EYE OINTMENTtobramycin/dexamethasone 2
TOBRADEX ST EYE DROPStobramycin/dexamethasone 3 ST
tobramycin-dexameth ophth susp 1
tropicamide 0.5% eye drops 1
tropicamide 1% eye drops 1
ZYLET EYE DROPStobramycin/loteprednol etabonate 3
OPHTHALMIC ANTI-ALLERGY AGENTS
ALOCRIL 2% EYE DROPSnedocromil sodium 3
ALOMIDE 0.1% EYE DROPSlodoxamide tromethamine 3
azelastine hcl 0.05% drops 1
cromolyn 4% eye drops 1
EMADINE 0.05% EYE DROPSemedastine difumarate 3
PAGE 160 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
epinastine hcl 0.05% eye drops 1
LASTACAFT 0.25% EYE DROPSalcaftadine 3 ST
olopatadine hcl 0.1% eye drops 1
PATADAY 0.2% EYE DROPSolopatadine hcl 3
PAZEO 0.7% EYE DROPSolopatadine hcl 3 ST
OPHTHALMIC ANTI-INFLAMMATORIES
ACUVAIL 0.45% OPHTH SOLUTIONketorolac tromethamine/pf 3
ALREX 0.2% EYE DROPSloteprednol etabonate 3
dexamethasone 0.1% eye drop 1
diclofenac 0.1% eye drops 1
DUREZOL 0.05% EYE DROPSdifluprednate 3
FLAREX 0.1% EYE DROPSfluorometholone acetate 2
fluorometholone 0.1% drops 1
flurbiprofen 0.03% eye drop 1
FML FORTE 0.25% EYE DROPSfluorometholone 3
FML S.O.P. 0.1% OINTMENTfluorometholone 3
ILEVRO 0.3% OPHTH DROPSnepafenac 3
ketorolac 0.4% ophth solution 1
ketorolac 0.5% ophth solution 1
LOTEMAX 0.5% EYE DROPSloteprednol etabonate 2
LOTEMAX 0.5% EYE OINTMENTloteprednol etabonate 2
LOTEMAX 0.5% OPHTHALMIC GELloteprednol etabonate 2
MAXIDEX 0.1% EYE DROPSdexamethasone 2
PAGE 161 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NEVANAC 0.1% DROPTAINERnepafenac 3
PRED MILD 0.12% EYE DROPSprednisolone acetate 2
prednisolone ac 1% eye drop 1
prednisolone sod 1% eye drop 1
OPHTHALMIC ANTIGLAUCOMA AGENTS
ALPHAGAN P 0.1% DROPSbrimonidine tartrate 2
apraclonidine hcl 0.5% drops 2
AZOPT 1% EYE DROPSbrinzolamide 2
betaxolol hcl 0.5% eye drop 1
BETOPTIC S 0.25% EYE DROPSbetaxolol hcl 2
brimonidine 0.2% eye drop 1
brimonidine tartrate 0.15% drp 1
COMBIGAN 0.2%-0.5% EYE DROPSbrimonidine tartrate/timolol maleate 3
COSOPT PF EYE DROPSdorzolamide hcl/timolol maleate/pf 3
dorzolamide hcl 2% eye drops 1
dorzolamide-timolol eye drops 1
IOPIDINE 1% EYE DROPSapraclonidine hcl 2
levobunolol 0.5% eye drops 1
metipranolol 0.3% eye drops 1
PHOSPHOLINE IODIDE 0.125%echothiophate iodide 2
pilocarpine 1% eye drops 1
pilocarpine 2% eye drops 1
pilocarpine 4% eye drops 1
SIMBRINZA 1%-0.2% EYE DROPSbrinzolamide/brimonidine tartrate 3
timolol 0.25% eye drops 1
PAGE 162 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
timolol 0.25% gel-solution 1
timolol 0.25% gfs gel-solution 1
timolol 0.5% eye drops 1
timolol 0.5% gel-solution 1
timolol 0.5% gfs gel-solution 1
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
bimatoprost 0.03% eye drops 3
latanoprost 0.005% eye drops 1
TRAVATAN Z 0.004% EYE DROPtravoprost 2
ZIOPTAN 0.0015% EYE DROPStafluprost/pf 3
OTIC AGENTS
acetasol hc ear drops 1
acetic acid 2% ear solution 1
CIPRO HC OTIC SUSPENSIONciprofloxacin hcl/hydrocortisone 2 ST
CIPRODEX OTIC SUSPENSIONciprofloxacin hcl/dexamethasone 2
ST
AL1 Up to 18 yrs old
fluocinolone oil 0.01% ear drp 1
hydrocortison-acetic acid soln 1
neomycin-polymyxin-hc ear soln 1
neomycin-polymyxin-hc ear susp 1
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
AEROSPAN 80 MCG INHALERflunisolide 3
QL 17.9 / 30 DAYS
ST
ALVESCO 160 MCG INHALERciclesonide 3
QL 12.2 / 30 DAYS
ST
AL1 At least 12 yrs old
ALVESCO 80 MCG INHALERciclesonide 3
QL 12.2 / 30 DAYS
ST
AL1 At least 12 yrs old
PAGE 163 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ARNUITY ELLIPTA 100 MCG INHfluticasone furoate 3
QL 1 / 1 DAYS
ST
ARNUITY ELLIPTA 200 MCG INHfluticasone furoate 3
QL 1 / 1 DAYS
ST
ASMANEX HFA 100 MCG INHALERmometasone furoate 2
ASMANEX HFA 200 MCG INHALERmometasone furoate 2
ASMANEX TWISTHALER 110 MCG #30mometasone furoate 2 QL 2 / 30 DAYS
ASMANEX TWISTHALER 220 MCG #14mometasone furoate 2 QL 2 / 30 DAYS
ASMANEX TWISTHALER 220 MCG #30mometasone furoate 2 QL 2 / 30 DAYS
ASMANEX TWISTHALER 220 MCG #60mometasone furoate 2 QL 2 / 30 DAYS
ASMANEX TWISTHALR 220 MCG #120mometasone furoate 2 QL 2 / 30 DAYS
BECONASE AQ 0.042% SPRAYbeclomethasone dipropionate 3 QL 50 / 30 DAYS
budesonide 0.25 mg/2 ml susp 1 AL1 Up to 8 yrs old
budesonide 0.5 mg/2 ml susp 1 AL1 Up to 8 yrs old
budesonide 1 mg/2 ml inh susp 1
budesonide 32 mcg nasal spray 3
FLOVENT 100 MCG DISKUSfluticasone propionate 2 QL 120 / 30 DAYS
FLOVENT 250 MCG DISKUSfluticasone propionate 2 QL 120 / 30 DAYS
FLOVENT 50 MCG DISKUSfluticasone propionate 2 QL 120 / 30 DAYS
FLOVENT HFA 110 MCG INHALERfluticasone propionate 2 QL 24 / 30 DAYS
FLOVENT HFA 220 MCG INHALERfluticasone propionate 2 QL 24 / 30 DAYS
FLOVENT HFA 44 MCG INHALERfluticasone propionate 2 QL 21.2 / 30 DAYS
PAGE 164 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
flunisolide 0.025% spray 1 QL 25 / 10 DAYS
fluticasone prop 50 mcg spray 1 QL 32 / 30 DAYS
mometasone furoate 50 mcg spry 1
NASONEX 50 MCG NASAL SPRAYmometasone furoate 2 QL 34 / 30 DAYS
OMNARIS 50 MCG NASAL SPRAYciclesonide 3
QL 12.5 / 30 DAYS
ST
AL1 At least 6 yrs old
PULMICORT 180 MCG FLEXHALERbudesonide 3 QL 2 / 30 DAYS
PULMICORT 90 MCG FLEXHALERbudesonide 3 QL 2 / 30 DAYS
QNASL 80 MCG NASAL SPRAYbeclomethasone dipropionate 3 ST
QNASL CHILDREN'S 40 MCG SPRAYbeclomethasone dipropionate 3
QVAR 40 MCG ORAL INHALERbeclomethasone dipropionate 2 QL 17.4 / 30 DAYS
QVAR 80 MCG ORAL INHALERbeclomethasone dipropionate 2 QL 17.4 / 30 DAYS
VERAMYST 27.5 MCG NASAL SPRAYfluticasone furoate 3 QL 20 / 30 DAYS
ZETONNA 37 MCG NASAL SPRAYciclesonide 3 ST
ANTIHISTAMINES
arbinoxa 4 mg tablet 1
arbinoxa 4 mg/5 ml liquid 1
azelastine 0.1% (137 mcg) spry 1 QL 60 / 30 DAYS
azelastine 0.15% nasal spray 1 QL 60 / 30 DAYS
carbinoxamine 4 mg/5 ml liquid 1
carbinoxamine maleate 4 mg tab 1
cyproheptadine 4 mg tablet 1
hydroxyzine 10 mg/5 ml soln 1
hydroxyzine 10 mg/5 ml syrup 1
PAGE 165 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hydroxyzine 50 mg/25 ml syrup 1
hydroxyzine hcl 10 mg tablet 1
hydroxyzine hcl 25 mg tablet 1
hydroxyzine hcl 50 mg tablet 1
hydroxyzine pam 100 mg cap 1
hydroxyzine pam 25 mg cap 1
hydroxyzine pam 50 mg cap 1
olopatadine 665 mcg nasal spry 3 QL 30.5 / 30 DAYS
promethazine 12.5 mg tablet 1
promethazine 25 mg tablet 1 AL1 At least 2 yrs old
promethazine 6.25 mg/5 ml syrp 1
ANTILEUKOTRIENES
montelukast sod 10 mg tablet 1
montelukast sod 4 mg granules 1
montelukast sod 4 mg tab chew 1
montelukast sod 5 mg tab chew 1
zafirlukast 10 mg tablet 1
zafirlukast 20 mg tablet 1
BRONCHODILATORS, ANTICHOLINERGIC
ATROVENT 0.03% SPRAYipratropium bromide 2
ATROVENT 0.06% SPRAYipratropium bromide 2
ATROVENT HFA INHALERipratropium bromide 2 QL 38.7 / 30 DAYS
INCRUSE ELLIPTA 62.5 MCG INHumeclidinium bromide 3
QL 1 / 1 DAYS
ST
ipratropium 0.03% spray 1
ipratropium 0.06% spray 1
ipratropium br 0.02% soln 1
SPIRIVA 18 MCG CP-HANDIHALERtiotropium bromide 2
QL 1 / 1 DAYS
ST
PAGE 166 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SPIRIVA RESPIMAT 1.25 MCG INHtiotropium bromide 2 ST
SPIRIVA RESPIMAT 2.5 MCG INHtiotropium bromide 2
QL 4 / 30 DAYS
ST
TUDORZA PRESSAIR 400 MCG INHaclidinium bromide 2
QL 1 / 30 DAYS
ST
BRONCHODILATORS, SYMPATHOMIMETIC
ACCUNEB 1.25 MG/3 ML INH SOLNalbuterol sulfate 3
albuterol 2.5 mg/0.5 ml sol 1
albuterol 5 mg/ml solution 1
albuterol sul 0.63 mg/3 ml sol 1
albuterol sul 1.25 mg/3 ml sol 1
albuterol sul 2.5 mg/3 ml soln 1
albuterol sulf 2 mg/5 ml syrup 1
albuterol sulfate 2 mg tab 1
albuterol sulfate 4 mg tab 1
albuterol sulfate er 4 mg tab 1
albuterol sulfate er 8 mg tab 1
ARCAPTA NEOHALER 75 MCG CAPindacaterol maleate 2 ST
BROVANA 15 MCG/2 ML SOLUTIONarformoterol tartrate 2
QL 60 / 1 FILL
PA
epinephrine 0.15 mg auto-injct 1
epinephrine 0.3 mg auto-inject 1
FORADIL AEROLIZER 12 MCG CAPformoterol fumarate 2 QL 120 / 30 DAYS
levalbuterol 0.31 mg/3 ml sol 3 ST
levalbuterol 0.63 mg/3 ml sol 3 ST
levalbuterol 1.25 mg/3 ml sol 3 ST
levalbuterol conc 1.25 mg/0.5 3 ST
levalbuterol tar hfa 45mcg inh 3
PAGE 167 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
metaproterenol 10 mg tablet 1
metaproterenol 10 mg/5 ml syr 1
metaproterenol 20 mg tablet 1
PERFOROMIST 20 MCG/2 ML SOLNformoterol fumarate 3
QL 60 / 30 DAYS
PA
PROAIR HFA 90 MCG INHALERalbuterol sulfate 2 QL 8.5 / 15 DAYS
PROAIR RESPICLICK INHAL POWDERalbuterol sulfate 2 QL 2 / 30 DAYS
PROVENTIL HFA 90 MCG INHALERalbuterol sulfate 3 QL 13.4 / 30 DAYS
SEREVENT DISKUS 50 MCGsalmeterol xinafoate 2 QL 120 / 30 DAYS
STRIVERDI RESPIMAT INHAL SPRAYolodaterol hcl 3
QL 1 / 30 DAYS
ST
terbutaline sulfate 2.5 mg tab 1
terbutaline sulfate 5 mg tab 1
VENTOLIN HFA 90 MCG INHALERalbuterol sulfate 2 QL 36 / 30 DAYS
CYSTIC FIBROSIS AGENTS
BETHKIS 300 MG/4 ML AMPULEtobramycin 4
KALYDECO 150 MG TABLETivacaftor 4 PA
KALYDECO 50 MG GRANULES PACKETivacaftor 4
KALYDECO 75 MG GRANULES PACKETivacaftor 4
KITABIS PAK 300 MG/5 MLtobramycin/nebulizer 4 PA
ORKAMBI 100 MG-125 MG TABLETlumacaftor/ivacaftor 4
ORKAMBI 200 MG-125 MG TABLETlumacaftor/ivacaftor 4
QL 4 / 1 DAYS
PA
AL1 At least 12 yrs old
PAGE 168 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TOBI PODHALER 28 MG INHALE CAPtobramycin 4 PA
tobramycin 300 mg/5 ml ampule 4
tobramycin pak 300 mg/5 ml 4 PA
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
DALIRESP 500 MCG TABLETroflumilast 3 PA
ELIXOPHYLLIN 80 MG/15 ML ELIXtheophylline anhydrous 1
theochron er 100 mg tablet 1
theochron er 200 mg tablet 1
theochron er 300 mg tablet 1
theophylline 80 mg/15 ml soln 1
theophylline er 100 mg tablet 1
theophylline er 200 mg tablet 1
theophylline er 300 mg tab 1
theophylline er 400 mg tablet 1
theophylline er 450 mg tab 1
theophylline er 600 mg tablet 1
PULMONARY ANTIHYPERTENSIVES
ADCIRCA 20 MG TABLETtadalafil 4 PA
ADEMPAS 0.5 MG TABLETriociguat 4 PA
ADEMPAS 1 MG TABLETriociguat 4 PA
ADEMPAS 1.5 MG TABLETriociguat 4 PA
ADEMPAS 2 MG TABLETriociguat 4 PA
ADEMPAS 2.5 MG TABLETriociguat 4 PA
LETAIRIS 10 MG TABLETambrisentan 4 PA
LETAIRIS 5 MG TABLETambrisentan 4 PA
PAGE 169 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
OPSUMIT 10 MG TABLETmacitentan 4 PA
ORENITRAM ER 0.125 MG TABLETtreprostinil diolamine 4
ORENITRAM ER 0.25 MG TABLETtreprostinil diolamine 4
ORENITRAM ER 1 MG TABLETtreprostinil diolamine 4
ORENITRAM ER 2.5 MG TABLETtreprostinil diolamine 4
REMODULIN 1 MG/ML VIALtreprostinil sodium 4
REMODULIN 10 MG/ML VIALtreprostinil sodium 4
REMODULIN 2.5 MG/ML VIALtreprostinil sodium 4
REMODULIN 5 MG/ML VIALtreprostinil sodium 4
REVATIO 10 MG/ML ORAL SUSPsildenafil citrate 4
sildenafil 20 mg tablet 1 PA
TRACLEER 125 MG TABLETbosentan 4
TRACLEER 62.5 MG TABLETbosentan 4
TYVASO 1.74 MG/2.9 ML SOLUTIONtreprostinil 4
TYVASO INHALATION REFILL KITtreprostinil/nebulizer accessories 4
TYVASO INHALATION STARTER KITtreprostinil/nebulizer and accessories 4 PA
TYVASO INSTITUTIONAL START KITtreprostinil/nebulizer and accessories 4 PA
UPTRAVI 1,000 MCG TABLETselexipag 4
UPTRAVI 1,200 MCG TABLETselexipag 4
UPTRAVI 1,400 MCG TABLETselexipag 4
PAGE 170 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
UPTRAVI 1,600 MCG TABLETselexipag 4
UPTRAVI 200 MCG TABLETselexipag 4
UPTRAVI 200-800 TITRATION PACKselexipag 4
UPTRAVI 400 MCG TABLETselexipag 4
UPTRAVI 600 MCG TABLETselexipag 4
UPTRAVI 800 MCG TABLETselexipag 4
VENTAVIS 10 MCG/1 ML SOLUTIONiloprost tromethamine 4 PA
VENTAVIS 20 MCG/1 ML SOLUTIONiloprost tromethamine 4 PA
RESPIRATORY TRACT AGENTS, OTHER
ADVAIR 100-50 DISKUSfluticasone propionate/salmeterol xinafoate 2
QL 60 / 30 DAYS
ST
ADVAIR 250-50 DISKUSfluticasone propionate/salmeterol xinafoate 2
QL 60 / 30 DAYS
ST
ADVAIR 500-50 DISKUSfluticasone propionate/salmeterol xinafoate 2
QL 60 / 30 DAYS
PA
ADVAIR HFA 115-21 MCG INHALERfluticasone propionate/salmeterol xinafoate 2
QL 12 / 30 DAYS
ST
ADVAIR HFA 230-21 MCG INHALERfluticasone propionate/salmeterol xinafoate 2
QL 12 / 30 DAYS
ST
ADVAIR HFA 45-21 MCG INHALERfluticasone propionate/salmeterol xinafoate 2
QL 12 / 30 DAYS
ST
ANORO ELLIPTA 62.5-25 MCG INHumeclidinium bromide/vilanterol trifenatate 2
QL 60 / 30 DAYS
ST
benzonatate 100 mg capsule 1
benzonatate 150 mg capsule 1
benzonatate 200 mg capsule 1
PAGE 171 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BREO ELLIPTA 100-25 MCG INHfluticasone furoate/vilanterol trifenatate 2
QL 60 / 30 DAYS
ST
BREO ELLIPTA 200-25 MCG INHfluticasone furoate/vilanterol trifenatate 2
COMBIVENT RESPIMAT INHAL SPRAYipratropium bromide/albuterol sulfate 2
DULERA 100 MCG/5 MCG INHALERmometasone furoate/formoterol fumarate 2
QL 26 / 30 DAYS
ST
AL1 At least 12 yrs old
DULERA 200 MCG/5 MCG INHALERmometasone furoate/formoterol fumarate 2
QL 26 / 30 DAYS
ST
AL1 At least 12 yrs old
ESBRIET 267 MG CAPSULEpirfenidone 4 PA
GRASTEK 2,800 BAU SL TABLETallergenic extract,grass pollen-timothy,standard 3 PA
hydrocod-homatrop 5-1.5 mg tab 1
hydrocodone-chlorphen er susp 1
hydrocodone-homatropine syrup 1
hydromet syrup 1
iprat-albut 0.5-3(2.5) mg/3 ml 1
OFEV 100 MG CAPSULEnintedanib esylate 4 PA
OFEV 150 MG CAPSULEnintedanib esylate 4 PA
ORALAIR 300 IR STARTER PACKgrass pollen-orchard/sweet vernal/rye/kentucky/timothy, std. 3 PA
ORALAIR 300 IR SUBLINGUAL TABgrass pollen-orchard/sweet vernal/rye/kentucky/timothy, std. 3 PA
promethazine vc syrup 1
promethazine vc-codeine syrup 1
promethazine-codeine syrup 1
promethazine-dm solution 1
promethazine-dm syrup 1
PAGE 172 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
promethazine-pe-codeine syrup 1
promethazine-phenylephrine syr 1
PULMOZYME 1 MG/ML AMPULdornase alfa 4 PA
RAGWITEK SUBLINGUAL TABLETallergenic extract-weed pollen-short ragweed 3 PA
SEMPREX-D 8 MG-60 MG CAPSULEpseudoephedrine hcl/acrivastine 3
STIOLTO RESPIMAT INHAL SPRAYtiotropium bromide/olodaterol hcl 3
QL 4 / 30 DAYS
ST
SYMBICORT 160-4.5 MCG INHALERbudesonide/formoterol fumarate 2
QL 20.4 / 30 DAYS
ST
AL1 At least 12 yrs old
SYMBICORT 80-4.5 MCG INHALERbudesonide/formoterol fumarate 2
QL 20.4 / 30 DAYS
ST
AL1 At least 12 yrs old
TUSNEL PEDIATRIC LIQUIDguaifenesin/dextromethorphan hbr/pseudoephedrine hcl 3
tussigon 5-1.5 mg tablet 3
SKELETAL MUSCLE RELAXANTS
carisoprodl-aspirin 200-325 mg 1
carisoprodol 250 mg tablet 1
carisoprodol 350 mg tablet 1
carisoprodol compound tab 1
chlorzoxazone 500 mg tablet 1
cyclobenzaprine 10 mg tablet 1
cyclobenzaprine 5 mg tablet 1
LORZONE 375 MG TABLETchlorzoxazone 3 ST
LORZONE 750 MG TABLETchlorzoxazone 3 ST
metaxall 800 mg tablet 2
metaxalone 400 mg tablet 2
metaxalone 800 mg tablet 2
PAGE 173 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
methocarbamol 500 mg tablet 1
methocarbamol 750 mg tablet 1
orphenadrine er 100 mg tablet 1
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
eszopiclone 1 mg tablet 1 QL 1 / 1 DAYS
eszopiclone 2 mg tablet 1 QL 1 / 1 DAYS
eszopiclone 3 mg tablet 1 QL 1 / 1 DAYS
temazepam 15 mg capsule 1 QL 1 / 1 DAYS
temazepam 22.5 mg capsule 3 QL 15 / 30 DAYS
temazepam 30 mg capsule 1 QL 1 / 1 DAYS
temazepam 7.5 mg capsule 3 QL 15 / 30 DAYS
triazolam 0.125 mg tablet 1 QL 15 / 30 DAYS
triazolam 0.25 mg tablet 1 QL 15 / 30 DAYS
zaleplon 10 mg capsule 1QL 1 / 1 DAYS
ST
zaleplon 5 mg capsule 1QL 1 / 1 DAYS
ST
zolpidem tart er 12.5 mg tab 3QL 15 / 30 DAYS
ST
zolpidem tart er 6.25 mg tab 3QL 15 / 30 DAYS
ST
zolpidem tartrate 10 mg tablet 3 QL 30 / 30 DAYS
zolpidem tartrate 5 mg tablet 3 QL 30 / 30 DAYS
SLEEP DISORDERS, OTHER
armodafinil 150 mg tablet 3QL 30 / fill(s)
PA
armodafinil 200 mg tablet 3QL 30 / fill(s)
PA
PAGE 174 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
armodafinil 250 mg tablet 3QL 30 / fill(s)
PA
armodafinil 50 mg tablet 3QL 30 / FILL
PA
BELSOMRA 15 MG TABLETsuvorexant 3
QL 1 / 1 DAYS
ST
BELSOMRA 20 MG TABLETsuvorexant 3
QL 1 / 1 DAYS
ST
BELSOMRA 5 MG TABLETsuvorexant 3
QL 1 / 1 DAYS
ST
flurazepam 15 mg capsule 1
flurazepam 30 mg capsule 1
modafinil 100 mg tablet 3QL 30 / 30 DAYS
AL1 At least 18 yrs old
modafinil 200 mg tablet 3QL 30 / 30 DAYS
AL1 At least 18 yrs old
XYREM 500 MG/ML ORAL SOLUTIONsodium oxybate 4
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL MODIFIERS
EXJADE 125 MG TABLETdeferasirox 4
EXJADE 250 MG TABLETdeferasirox 4
EXJADE 500 MG TABLETdeferasirox 4
JADENU 180 MG TABLETdeferasirox 4 PA
JADENU 360 MG TABLETdeferasirox 4 PA
JADENU 90 MG TABLETdeferasirox 4 PA
kionex 15 gm/60 ml suspension 1
PAGE 175 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
sod polystyren sulf 15 g/60 ml 1
sps 15 gm/60 ml suspension 1
SPS 15 GM/60 ML SUSPENSIONsodium polystyrene sulfonate/sorbitol solution 1
ELECTROLYTE/MINERAL REPLACEMENT
calcium-folic acid plus d wfer 1
FOLGARD OS TABLETcalcium carb/mag oxide/vitamin d3/vit b12/fa/vit b6/boron 2
KLOR-CON 25 MEQ PACKETpotassium chloride 3
klor-con m10 tablet 1
klor-con m15 tablet 1
KLOR-CON M15 TABLETpotassium chloride 1
klor-con m20 tablet 1
klor-con sprinkle er 10 meq cp 1
klor-con sprinkle er 8 meq cap 1
potassium cl 10% (20 meq/15 ml 1
potassium cl 10% (40 meq/30 ml 1
potassium cl 20 meq packet 2
potassium cl 20% (40 meq/15 ml 1
potassium cl 25 meq tab eff 1
potassium cl er 10 meq capsule 1
potassium cl er 10 meq tablet 1
potassium cl er 10 meq tablet 1
potassium cl er 20 meq tablet 1
potassium cl er 20 meq tablet 1
potassium cl er 8 meq capsule 1
potassium cl er 8 meq tablet 1
tl g-fol os tablet 1
calcium-pnv 28-1-250 mg sftgl 1
CITRANATAL B-CALM COMBO PACKprenatal vitamin no.48/iron,carbonyl,gluconate/folic acid/b6 2
PAGE 176 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
complete natal dha 2
cyanocobalamin 1,000 mcg/ml 1
cyanocobalamin 10,000 mcg/10 1
cyanocobalamin 30,000 mcg/30 1
DIALYVITE 3,000 TABLETfolic acid/vitamin b comp and c/selenium/min aa chel/zinc 1
DUET DHA 400 COMBO PACKprenatal vitamin no.106/sod ferede-iron poly/fa/om3/dha/epa 2
DUET DHA BALANCED (25 MG IRON)prenatal vitamin no.117/sod ferede-iron poly/fa/om3/dha/epa 2
elite ob dha softgel 1
fabb tablet 1
folbee ar tablet 1
folbee plus tablet 1
folbee tablet 1
FOLGARD RX TABLETcyanocobalamin/folic acid/pyridoxine 3
folic acid 1 mg tablet 1
folic acid-vit b6-vit b12 tab 1
folplex 2.2 tablet 1
MEPHYTON 5 MG TABLETphytonadione (vit k1) 2
multi-vit w-fluor 0.25 mg/ml 1
multi-vit w-fluor 0.5 mg/ml 1
multi-vit w-fluor 0.5 mg/ml 1
multivit & fluor 0.5 mg/ml drp 1
multivit-fluor 0.25 mg tab chw 1
multivit-fluor 0.25 mg tab chw 1
multivit-fluor 0.25 mg/ml drop 1
multivit-fluor 0.25 mg/ml drop 1
multivit-fluor 0.25 mg/ml drop 1
multivit-fluor 0.5 mg tab chew 1
multivit-fluor 0.5 mg tab chw 1
PAGE 177 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
multivit-fluor 0.5 mg/ml drop 1
multivit-fluor 0.5 mg/ml drop 1
multivit-fluor-iron 0.25 mg/ml 1
multivit-fluoride 1 mg tab chw 1
multivit-fluoride 1 mg tab chw 1
multivit-iron-fl 0.25 mg/ml 1
multivit-iron-fl 0.25 mg/ml 1
multivit-iron-fl 0.25 mg/ml 1
multivit-iron-fluor 0.25 mg/ml 1
MVC-FLUORIDE 0.25 MG TAB CHEWpediatric multivitamin no.12 with sodium fluoride 1
MVC-FLUORIDE 0.5 MG TAB CHEWpediatric multivitamin no.12 with sodium fluoride 1
MVC-FLUORIDE 1 MG TAB CHEWpediatric multivitamin no.12 with sodium fluoride 1
MYNATAL CAPSULEprenatal vitamins with calcium/ferrous fumarate/folic acid 1
mynatal plus captab 1
mynatal-z captab 1
mynephrocaps softgel 1
mynephron capsule 1
NATELLE ONE CAPSULEprenatal vits with calcium #70/ferrous fumarate/fa/dha 2
NEPHRO-VITE RX TABLETvitamin b complx no.3/folic acid/ascorbic acid/biotin 1
NICOMIDE TABLETmethyltetrahydrofolate glucosamine/niacinamide/cupric,zn ox 2
niva-plus tablet 1
O-CAL FA TABLETprenatal vitamins with calcium/ferrous fumarate/folic acid 1
OB COMPLETE CAPLETiron,carbonyl/folic acid/multivit with minerals 2
OB COMPLETE ONE SOFTGELpnv no.85/iron carb,aspart.glycinate/folic acid/dha/fish oil 2
OB COMPLETE PETITE SOFTGELprenatal no56/iron carbonyl,asparto glycinate/folic acid/dha 2
PAGE 178 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
OB COMPLETE PREMIER TABLETprenatal vitamins comb #83/iron,carbonyl/iron asparto gly/fa 2
pnv prenatal plus multivit tab 1
pnv-dha + docusate softgel 1
POLY-VI-FLOR 0.25 MG DROPSpediatric multivitamin no.37 with sodium fluoride 2
POLY-VI-FLOR 0.25 MG TAB CHEWpediatric multivitamin no.33 with sodium fluoride 2
POLY-VI-FLOR 0.5 MG TAB CHEWpediatric multivitamin no.33 with sodium fluoride 2
POLY-VI-FLOR 1 MG TAB CHEWpediatric multivitamin no.33 with sodium fluoride 2
POLY-VI-FLOR WITH IRON 0.25 MGpediatric multivit #37/sodium fluoride/iron bisglycinate hcl 2
POLY-VI-FLOR WITH IRON 0.5 MGpediatric multivitamin no.33/sodium fluoride/iron carbonyl 2
PREFERA-OB ONE SOFTGELprenatal vitamin no.19/iron polysac,iron heme/folic acid/dha 2
PRENATA CHEWABLE TABLETprenatal vitamins combo no.37/ferrous fumarate/folic acid 2
PRENATABS FA TABLETprenatal vits with calcium #78/ferrous fumarate/folic acid 1
PRENATABS RX TABLETprenatal vits with calcium #76/iron,carbonyl/folic acid 1
prenatal low iron tablet 1
prenatal plus multivitamin tab 1
prenatal plus tablet 1
prenatal vitamin plus low iron 1
PRENATE CHEWABLE TABLETprenatal vitamins no.112/methyltetrahydrofolate glucosami,fa 2
PRENATE DHA SOFTGELprenatal vitamins no.38/iron fumarate/folate comb no.6/dha 2
PRENATE ELITE TABLETprenatal vitamins combo #36/ferrous fumarate/folate combo #6 2
PRENATE ESSENTIAL SOFTGELprenatal vitamin no.35/iron fumarate/folate comb. no.6/dha 2
preplus ca-fe 27 mg-fa 1 mg tb 1
PAGE 179 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PREQUE 10 TABLETprenatal vit no.18/iron/folic acid/docusate sod./co-q10/dha 2
rena-vite rx tablet 1
renal caps softgel 1
reno caps softgel 1
se-natal 19 chewable tablet 1
tl gard rx tablet 1
TRI-VI-FLOR 0.25 MG DROPSpediatric multivitamin a,c,and d3 no.38 with sodium fluoride 2
TRI-VI-FLOR 0.5 MG DROPSpediatric multivitamin a,c,and d3 no.38 with sodium fluoride 2
tri-vit-fluor 0.25 mg/ml drop 1
trinatal rx 1 tablet 2
TRINATE TABLETprenatal vits with calcium #73/ferrous fumarate/folic acid 1
triphrocaps softgel 1
triple-vit w-fluor 0.25 mg/ml 1
trust natal dha 2
vemavite-prx 2 capsule 1
vinacal prenatal tablet 1
vinate one tablet 1
virt-caps (1 mg fa b comp w-c) 1
virt-caps softgel 1
virt-gard tablet 1
virt-vite tablet 1
vit a,c,d-fluoride 0.25 mg/ml 1
VITA-RESPA TABLETcyanocobalamin/folic acid/pyridoxine 3
VITAFOL-OB CAPLETprenatal vitamins comb 10/ferrous fumarate/folic acid 2
VITAFOL-ONE CAPSULEprenatal vitamins no.26/iron polysaccharides/fa/dha 2
vol-care rx tablet 1
vol-plus tablet 1
PAGE 180 LAST UPDATED 03/2017
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
vp-ch plus softgel 1
vp-heme one softgel 1
vp-vite rx tablet 1
XURIDEN GRANULE PACKETuridine triacetate 4
PAGE 181 LAST UPDATED 03/2017
Index of covered drugsAABACAVIR SULFATE 66,67
ABACAVIR SULFATE/DOLUTEGRAVIR
SODIUM/LAMIVUDINE 68
ABACAVIR SULFATE/LAMIVUDINE 66
ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE 66
ABATACEPT 154
ABILIFY DISCMELT 58
ABIRATERONE ACETATE 47
ABSORICA 114
ACAMPROSATE CALCIUM 15
ACARBOSE 72,76
ACCUNEB 167
ACEBUTOLOL HCL 86
ACEON 83
ACETAMINOPHEN WITH CODEINE
PHOSPHATE 10,11
ACETIC ACID 163
ACETIC ACID/HYDROCORTISONE 163
ACLIDINIUM BROMIDE 167
ACTEMRA 156
ACTIGALL 123
ACTIMMUNE 156
ACTOPLUS MET XR 72
ACUVAIL 161
ACYCLOVIR 70
ACZONE 114
ADALAT CC 88
ADALIMUMAB 153
ADAPALENE 114
ADAPALENE/BENZOYL PEROXIDE 116
ADCIRCA 169
ADEFOVIR DIPIVOXIL 63
ADEMPAS 169
ADVAIR DISKUS 171
ADVAIR HFA 171
AEROSPAN 163
AFATINIB DIMALEATE 50
AFINITOR 49
AFINITOR DISPERZ 49,50
AKYNZEO 40
ALA-CORT 129
ALA-QUIN 114
ALBUTEROL SULFATE 167,168
ALCAFTADINE 161
ALCLOMETASONE DIPROPIONATE 129
ALECENSA 50
ALECTINIB HCL 50
ALENDRONATE SODIUM 157
ALFERON N 70
ALFUZOSIN HCL 127
ALINIA 54
ALIROCUMAB 100
ALISKIREN HEMIFUMARATE 95
ALISKIREN
HEMIFUMARATE/HYDROCHLOROTHIAZIDE 95,96
ALKERAN 47
ALLERGENIC EXTRACT,GRASS POLLEN-
TIMOTHY,STANDARD 172
ALLERGENIC EXTRACT-WEED POLLEN-SHORT
RAGWEED 173
ALLOPURINOL 44
ALMOTRIPTAN MALATE 44,45
ALOCRIL 160
ALOGLIPTIN BENZOATE 72
ALOGLIPTIN BENZOATE/METFORMIN HCL 73
ALOMIDE 160
ALOSETRON HCL 125
ALPHAGAN P 162
ALPHAQUIN HP 114
ALPRAZOLAM 70,71
ALREX 161
ALTABAX 17
ALTRETAMINE 47
ALVESCO 163
AMANTADINE HCL 55
AMBRISENTAN 169
AMCINONIDE 129
AMILORIDE HCL 97
AMILORIDE HCL/HYDROCHLOROTHIAZIDE 91
AMIODARONE HCL 85
PAGE 182 LAST UPDATED 03/2017
AMITIZA 125
AMITRIPTYLINE HCL 38,39
AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE 33
AMLODIPINE BESYLATE 88
AMLODIPINE BESYLATE/ATORVASTATIN
CALCIUM 91,92
AMLODIPINE BESYLATE/BENAZEPRIL HCL 92
AMLODIPINE BESYLATE/OLMESARTAN
MEDOXOMIL 92
AMLODIPINE BESYLATE/VALSARTAN 92
AMLODIPINE
BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE
91
AMOXAPINE 38
AMOXICILLIN 20
AMOXICILLIN/POTASSIUM CLAVULANATE 20,21
AMPICILLIN TRIHYDRATE 20
AMPYRA 112
ANAKINRA 153
ANALPRAM HC 115
ANASTROZOLE 49
ANDRODERM 136
ANDROGEL 136
ANGELIQ 137
ANORO ELLIPTA 171
ANSAID 4
ANTHRALIN 116,120
ANTHRALIN MICRONIZED 120
ANZEMET 41
APIDRA 77
APIDRA SOLOSTAR 77
APIXABAN 79
APLENZIN 32,33
APOKYN 55
APOMORPHINE HCL 55
APRACLONIDINE HCL 162
APREMILAST 156
APREPITANT 41
APRISO 156
APTENSIO XR 106
APTIOM 29,30
APTIVUS 68
ARCAPTA NEOHALER 167
ARFORMOTEROL TARTRATE 167
ARIPIPRAZOLE 58
ARMODAFINIL 174,175
ARMOUR THYROID 146
ARNUITY ELLIPTA 164
ARTEMETHER/LUMEFANTRINE 54
ASENAPINE MALEATE 61
ASFOTASE ALFA 121
ASMANEX 164
ASMANEX HFA 164
ASPIRIN/DIPYRIDAMOLE 81
ASTAGRAF XL 152
ATAZANAVIR SULFATE 69
ATAZANAVIR SULFATE/COBICISTAT 68
ATENOLOL 86
ATENOLOL/CHLORTHALIDONE 93
ATOMOXETINE HCL 110
ATORVASTATIN CALCIUM 98
ATRIPLA 65
ATROPINE SULFATE 159,160
ATROVENT 166
ATROVENT HFA 166
AUBAGIO 112
AUGMENTIN 21
AURANOFIN 156
AVANDAMET 73
AVANDIA 73
AVINZA 6,7
AVONEX 112
AVONEX PEN 112
AXIRON 136
AYGESTIN 145
AZASAN 152
AZASITE 21
AZATHIOPRINE 152,153
AZELAIC ACID 115,116
AZELASTINE HCL 160,165
AZELEX 115
AZILECT 57
PAGE 183 LAST UPDATED 03/2017
AZITHROMYCIN 21,22
AZOPT 162
BBACITRACIN 17
BACITRACIN/POLYMYXIN B SULFATE 159,160
BACLOFEN 62
BACTROBAN 17
BALSALAZIDE DISODIUM 156
BANZEL 30
BARACLUDE 63
BASAGLAR KWIKPEN U-100 77
BECLOMETHASONE DIPROPIONATE 164,165
BECONASE AQ 164
BEDAQUILINE FUMARATE 46
BELSOMRA 175
BENAZEPRIL HCL 83
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE 93
BENTYL 122
BENZONATATE 171
BENZTROPINE MESYLATE 54
BENZYL ALCOHOL 120
BERINERT 152
BESIFLOXACIN HCL 22
BESIVANCE 22
BETAMETHASONE DIPROPIONATE 129
BETAMETHASONE DIPROPIONATE/PROPYLENE
GLYCOL 129
BETAMETHASONE VALERATE 129,130
BETASERON 112
BETAXOLOL HCL 86,162
BETHANECHOL CHLORIDE 128
BETHKIS 168
BETOPTIC S 162
BICALUTAMIDE 47
BIMATOPROST 163
BISACODYL/SODIUM CHLOR/SODIUM
BICARB/POTASSIUM CHL/PEG 3350 125
BISOPROLOL FUMARATE 86
BISOPROLOL
FUMARATE/HYDROCHLOROTHIAZIDE 93
BLEPH-10 23
BLEPHAMIDE 159
BLEPHAMIDE S.O.P. 159
BOSENTAN 170
BOSULIF 50
BOSUTINIB 50
BREO ELLIPTA 172
BREVICON 137
BREXPIPRAZOLE 60
BRIMONIDINE TARTRATE 162
BRIMONIDINE TARTRATE/TIMOLOL MALEATE 162
BRINTELLIX 34
BRINZOLAMIDE 162
BRINZOLAMIDE/BRIMONIDINE TARTRATE 162
BRIVARACETAM 25
BRIVIACT 25
BROMOCRIPTINE MESYLATE 55,73
BROVANA 167
BUDESONIDE 157,164,165
BUDESONIDE/FORMOTEROL FUMARATE 173
BUMETANIDE 97
BUNAVAIL 15
BUPRENEX 15
BUPRENORPHINE HCL 15
BUPRENORPHINE HCL/NALOXONE HCL 15,16
BUPROPION HBR 32,33
BUPROPION HCL 33,34
BUSPIRONE HCL 70
BUSULFAN 47
BUTALBITAL/ACETAMINOPHEN 111
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 111
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEIN
E PHOSPHATE 11
BUTALBITAL/ASPIRIN/CAFFEINE 4
BUTOCONAZOLE NITRATE 42
BYDUREON 73
BYDUREON PEN 73
BYETTA 73
BYSTOLIC 86
PAGE 184 LAST UPDATED 03/2017
CC1 ESTERASE INHIBITOR 152
C1 ESTERASE INHIBITOR, RECOMBINANT 152
CABERGOLINE 151
CABOMETYX 50
CABOZANTINIB S-MALATE 50
CALCIPOTRIENE 115,119
CALCIPOTRIENE/BETAMETHASONE
DIPROPIONATE 116
CALCITONIN,SALMON,SYNTHETIC 157,158
CALCITRIOL 115,157,158
CALCIUM ACETATE 128,129
CALCIUM CARB/MAG OXIDE/VITAMIN D3/VIT
B12/FA/VIT B6/BORON 176
CANAGLIFLOZIN 74
CANASA 156
CANDESARTAN CILEXETIL 83
CANDESARTAN
CILEXETIL/HYDROCHLOROTHIAZIDE 93
CAPECITABINE 48
CAPITAL W-CODEINE 11
CAPRELSA 50
CAPTOPRIL 83,84
CAPTOPRIL/HYDROCHLOROTHIAZIDE 93
CARAFATE 126
CARBAMAZEPINE 30
CARBIDOPA/LEVODOPA 56,57
CARBIDOPA/LEVODOPA/ENTACAPONE 55
CARBINOXAMINE MALEATE 165
CARDIZEM LA 88
CARDURA XL 127
CARIPRAZINE HCL 61,62
CARISOPRODOL 173
CARISOPRODOL/ASPIRIN 173
CARISOPRODOL/ASPIRIN/CODEINE
PHOSPHATE 11
CARVEDILOL 86
CARVEDILOL PHOSPHATE 86,87
CEFACLOR 18
CEFADROXIL 18,19
CEFDINIR 19
CEFIXIME 19,20
CEFPODOXIME PROXETIL 19
CEFPROZIL 19
CEFTIBUTEN 19
CEFTIN 19
CEFUROXIME AXETIL 19
CELECOXIB 4
CELONTIN 26
CEPHALEXIN 19
CERDELGA 120
CERITINIB 53
CERTOLIZUMAB PEGOL 152
CESAMET 41
CHLORAMBUCIL 47
CHLORDIAZEPOXIDE HCL 71
CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE 122
CHLOROQUINE PHOSPHATE 54
CHLOROTHIAZIDE 97
CHLORPROMAZINE HCL 57
CHLORTHALIDONE 97
CHLORZOXAZONE 173
CHOLBAM 123
CHOLESTYRAMINE (WITH SUGAR) 99
CHOLESTYRAMINE/ASPARTAME 99,100
CHOLIC ACID 123
CHOLINE SALICYLATE/MAGNESIUM SALICYLATE 4
CICLESONIDE 163,165
CICLOPIROX 41,42,44
CICLOPIROX OLAMINE 41
CILOXAN 22
CIMETIDINE 124
CIMETIDINE HCL 124
CIMZIA 152
CINACALCET HCL 151
CIPRO HC 163
CIPRODEX 163
CIPROFLOXACIN 22
CIPROFLOXACIN HCL 22,23
CIPROFLOXACIN HCL/DEXAMETHASONE 163
CIPROFLOXACIN HCL/HYDROCORTISONE 163
PAGE 185 LAST UPDATED 03/2017
CIPROFLOXACIN/CIPROFLOXACIN HCL 22
CITALOPRAM HYDROBROMIDE 35
CITRANATAL B-CALM 176
CLARITHROMYCIN 21
CLEOCIN 17
CLEOCIN PALMITATE 17
CLIMARA PRO 137
CLINDAMYCIN HCL 17
CLINDAMYCIN PALMITATE HCL 17
CLINDAMYCIN PHOSPHATE 17
CLINDAMYCIN PHOSPHATE/BENZOYL
PEROXIDE 115,116,117
CLINDAMYCIN PHOSPHATE/TRETINOIN 115
CLINDESSE 17
CLIOQUINOL/HYDROCORTISONE 114
CLOBAZAM 27
CLOBETASOL PROPIONATE 130
CLOBETASOL PROPIONATE/EMOLLIENT BASE 130
CLOCORTOLONE PIVALATE 130
CLOMIPRAMINE HCL 38
CLONAZEPAM 71
CLONIDINE 82
CLONIDINE HCL 82
CLONIDINE HCL/CHLORTHALIDONE 93
CLOPIDOGREL BISULFATE 81
CLORAZEPATE DIPOTASSIUM 71
CLOTRIMAZOLE 42
CLOTRIMAZOLE/BETAMETHASONE
DIPROPIONATE 115
CLOZAPINE 62
COARTEM 54
COBICISTAT 68
COBIMETINIB FUMARATE 50
CODEINE
PHOSPHATE/BUTALBITAL/ASPIRIN/CAFFEINE10,11
CODEINE SULFATE 11
COLCHICINE 44
COLESEVELAM HCL 101
COLESTID 99
COLESTIPOL HCL 99
COLLOIDAL BISMUTH
SUBCITRATE/METRONIDAZOLE/TETRACYCLINE
HCL 123
COMBIGAN 162
COMBIPATCH 137,138
COMBIVENT RESPIMAT 172
COMETRIQ 50
COMPAZINE 40
COMPLERA 65
CONDYLOX 115
CORDARONE 85
CORDRAN 130
COREG CR 86,87
CORLANOR 93
CORTEF 130
CORTIFOAM 157
COSENTYX (2 SYRINGES) 116
COSENTYX PEN 115
COSENTYX PEN (2 PENS) 116
COSENTYX SYRINGE 115
COSOPT PF 162
COTELLIC 50
COUMADIN 79
CREON 120
CRESEMBA 42
CRIXIVAN 68
CRIZOTINIB 53
CROFELEMER 123
CROMOLYN SODIUM 123,160
CUPRIMINE 128
CUTIVATE 130
CYANOCOBALAMIN (VITAMIN B-12) 177
CYANOCOBALAMIN/FOLIC
ACID/PYRIDOXINE 177,180
CYCLOBENZAPRINE HCL 173
CYCLOPENTOLATE HCL 159
CYCLOSERINE 46
CYCLOSET 73
CYCLOSPORINE 152,155,160
CYCLOSPORINE, MODIFIED 152,153,154
CYPROHEPTADINE HCL 165
PAGE 186 LAST UPDATED 03/2017
CYSTAGON 128
CYSTEAMINE BITARTRATE 128
CYTOMEL 146
DDABIGATRAN ETEXILATE MESYLATE 80
DABRAFENIB MESYLATE 52
DACLATASVIR DIHYDROCHLORIDE 63
DAKLINZA 63
DALFAMPRIDINE 112
DALIRESP 169
DALTEPARIN SODIUM,PORCINE 79,80
DANAZOL 136
DAPAGLIFLOZIN PROPANEDIOL 73
DAPAGLIFLOZIN PROPANEDIOL/METFORMIN
HCL 77
DAPSONE 46,114
DARAPRIM 54
DARIFENACIN HYDROBROMIDE 126
DARUNAVIR ETHANOLATE 69
DARUNAVIR ETHANOLATE/COBICISTAT 68
DASATINIB 52
DEFERASIROX 175
DELAVIRDINE MESYLATE 66
DELTASONE 130
DELZICOL 156
DEPAKOTE SPRINKLE 26
DEPEN 128
DESCOVY 66
DESIPRAMINE HCL 38,39
DESMOPRESSIN ACETATE 134,135
DESMOPRESSIN ACETATE (NON-
REFRIGERATED) 135
DESOGESTREL-ETHINYL
ESTRADIOL 137,138,140,144
DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL
ESTRADIOL 137,138,140,143,144
DESONATE 130
DESONIDE 130,134
DESOXIMETASONE 130,131
DESVENLAFAXINE FUMARATE 35
DEXAMETHASONE 131,161
DEXAMETHASONE SOD PHOSPHATE 161
DEXEDRINE 103
DEXMETHYLPHENIDATE HCL 106,107
DEXPAK 131
DEXTROAMPHETAMINE SULF-
SACCHARATE/AMPHETAMINE SULF-
ASPARTATE 103,104
DEXTROAMPHETAMINE SULFATE 102,103,104,105
DEXTROMETHORPHAN HBR/QUINIDINE
SULFATE 111
DIABETIC SUPPLIES,MISCELL 159
DIALYVITE 3000 177
DIAZEPAM 71
DICHLORPHENAMIDE 96
DICLOFENAC EPOLAMINE 116
DICLOFENAC POTASSIUM 4
DICLOFENAC SODIUM 4,116,161
DICLOFENAC SODIUM/MISOPROSTOL 4
DICLOXACILLIN SODIUM 21
DICYCLOMINE HCL 122
DIDANOSINE 66,67
DIFICID 21
DIFLORASONE DIACETATE 131
DIFLUCAN 42
DIFLUPREDNATE 161
DIGOXIN 93
DIHYDROERGOTAMINE MESYLATE 44
DILANTIN 30
DILATRATE-SR 101
DILTIAZEM HCL 88,89,90,91
DIMETHYL FUMARATE 113
DIPENTUM 156
DIPHENOXYLATE HCL/ATROPINE SULFATE 123
DIPYRIDAMOLE 81
DISOPYRAMIDE PHOSPHATE 85
DIURIL 97
DIVALPROEX SODIUM 26
DIVIGEL 138
DOLASETRON MESYLATE 41
DOLUTEGRAVIR SODIUM 65
PAGE 187 LAST UPDATED 03/2017
DONEPEZIL HCL 31
DORNASE ALFA 173
DORYX 24
DORZOLAMIDE HCL 162
DORZOLAMIDE HCL/TIMOLOL MALEATE 162
DORZOLAMIDE HCL/TIMOLOL MALEATE/PF 162
DOXAZOSIN MESYLATE 82,127
DOXEPIN HCL 39
DOXYCYCLINE HYCLATE 24
DOXYCYCLINE MONOHYDRATE 24
DRISDOL 158
DRITHOCREME HP 116
DRONEDARONE HCL 85
DROSPIRENONE/ESTRADIOL 137
DROSPIRENONE/ETHINYL
ESTRADIOL/LEVOMEFOLATE CALCIUM 138,144
DROXIDOPA 94,95
DUAC 116
DUAVEE 138
DUET DHA 400 177
DUET DHA BALANCED 177
DULAGLUTIDE 76,77
DULERA 172
DULOXETINE HCL 111
DUOPA 56
DURAGESIC 7
DUREZOL 161
DUTASTERIDE 127
DUTASTERIDE/TAMSULOSIN HCL 127
EE.E.S. 200 21
E.E.S. 400 21
ECHOTHIOPHATE IODIDE 162
ECONAZOLE NITRATE 42
ECOZA 42
EDURANT 66
EFAVIRENZ 66
EFAVIRENZ/EMTRICITABINE/TENOFOVIR
DISOPROXIL FUMARATE 65
EFFIENT 81,82
ELBASVIR/GRAZOPREVIR 65
ELESTRIN 138
ELETRIPTAN HBR 45
ELIDEL 116
ELIGLUSTAT TARTRATE 120
ELIMITE 54
ELIQUIS 79
ELIXOPHYLLIN 169
ELMIRON 128
ELOCON 131
ELTROMBOPAG OLAMINE 81
ELVITEGRAVIR 65
ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN
OFOVIR ALAFENAMIDE 65
ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN
OFOVIR DISOPROXIL 65
EMADINE 160
EMBEDA 7
EMEDASTINE DIFUMARATE 160
EMEND 41
EMPAGLIFLOZIN 74,75
EMPAGLIFLOZIN/LINAGLIPTIN 74
EMPAGLIFLOZIN/METFORMIN HCL 76
EMSAM 34
EMTRICITABINE 66,67
EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR
ALAFENAMIDE FUMARATE 66
EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR
DISOPROXIL FUMARATE 65
EMTRICITABINE/TENOFOVIR ALAFENAMIDE
FUMARATE 66
EMTRICITABINE/TENOFOVIR DISOPROXIL
FUMARATE 67
EMTRIVA 66,67
ENALAPRIL MALEATE 84
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE 94
ENBREL 153
ENFUVIRTIDE 68
ENOXAPARIN SODIUM 79
ENSTILAR 116
ENTECAVIR 63
PAGE 188 LAST UPDATED 03/2017
ENTRESTO 94
ENZALUTAMIDE 47
EPCLUSA 63
EPIDUO 116
EPIDUO FORTE 116
EPIFOAM 116
EPINASTINE HCL 161
EPINEPHRINE 167
EPISIL 113
EPIVIR HBV 63
EPLERENONE 97
ERGOCALCIFEROL (VITAMIN D2) 158
ERIVEDGE 50
ERLOTINIB HCL 53
ERTACZO 42
ERY-TAB 21,22
ERYTHROCIN STEARATE 22
ERYTHROMYCIN BASE 21,22
ERYTHROMYCIN BASE/BENZOYL PEROXIDE 17
ERYTHROMYCIN BASE/ETHYL ALCOHOL 21,22
ERYTHROMYCIN ETHYLSUCCINATE 21,22
ERYTHROMYCIN STEARATE 22
ESBRIET 172
ESCITALOPRAM OXALATE 35
ESLICARBAZEPINE ACETATE 29,30
ESTRACE 139
ESTRADIOL 138,139,140,142,145
ESTRADIOL ACETATE 140
ESTRADIOL VALERATE/DIENOGEST 142
ESTRADIOL/LEVONORGESTREL 137
ESTRADIOL/NORETHINDRONE
ACETATE 137,138,139,141,142
ESTRADIOL/NORGESTIMATE 143
ESTRING 139
ESTROGEL 139
ESTROGENS, CONJUGATED 143
ESTROGENS, CONJUGATED/BAZEDOXIFENE
ACETATE 138
ESTROGENS,
CONJUGATED/MEDROXYPROGESTERONE
ACETATE 143,144
ESTROGENS,ESTERIFIED 141
ESTROGENS,ESTERIFIED/METHYLTESTOSTERON
E 138,139,140
ESTROPIPATE 140,143
ESZOPICLONE 174
ETANERCEPT 153
ETHAMBUTOL HCL 46
ETHINYL
ESTRADIOL/DROSPIRENONE 138,140,141,142,143,1
44,145
ETHIONAMIDE 47
ETHOSUXIMIDE 26
ETHOTOIN 31
ETHYNODIOL DIACETATE-ETHINYL
ESTRADIOL 140,145
ETODOLAC 4,5
ETONOGESTREL/ETHINYL ESTRADIOL 143
ETRAVIRINE 66
EVAMIST 140
EVEROLIMUS 49,50,156
EVOLOCUMAB 100
EVOTAZ 68
EXALGO 7
EXELDERM 42
EXEMESTANE 49
EXENATIDE 73
EXENATIDE MICROSPHERES 73
EXJADE 175
EXTAVIA 112
EZETIMIBE 101
EZETIMIBE/SIMVASTATIN 100,101
FFABIOR 116
FAMCICLOVIR 70
FAMOTIDINE 124
FANAPT 59
FARXIGA 73
FARYDAK 49
FEBUXOSTAT 44
FELODIPINE 90
PAGE 189 LAST UPDATED 03/2017
FEMRING 140
FENOFIBRATE 98
FENOFIBRATE NANOCRYSTALLIZED 98
FENOFIBRIC ACID 98
FENOFIBRIC ACID (CHOLINE) 98
FENOGLIDE 98
FENOPROFEN CALCIUM 5,6
FENORTHO 5
FENTANYL 7,8
FENTANYL CITRATE 11
FESOTERODINE FUMARATE 127
FETZIMA 35
FIDAXOMICIN 21
FILGRASTIM 81
FILGRASTIM-SNDZ 81
FINACEA 116
FINASTERIDE 127
FINGOLIMOD HCL 113
FLAGYL ER 17
FLAREX 161
FLECAINIDE ACETATE 85
FLECTOR 116
FLOVENT DISKUS 164
FLOVENT HFA 164
FLUCAINE 159
FLUCONAZOLE 42
FLUDROCORTISONE ACETATE 131
FLUNISOLIDE 163,165
FLUOCINOLONE ACETONIDE 131
FLUOCINOLONE ACETONIDE OIL 163
FLUOCINONIDE 131,132
FLUOCINONIDE/EMOLLIENT BASE 132
FLUOROMETHOLONE 161
FLUOROMETHOLONE ACETATE 161
FLUOROURACIL 48,116,119
FLUOXETINE HCL 35,36
FLUPHENAZINE HCL 57
FLURANDRENOLIDE 130,132
FLURAZEPAM HCL 175
FLURBIPROFEN 4,5
FLURBIPROFEN SODIUM 161
FLUTAMIDE 47
FLUTICASONE FUROATE 164,165
FLUTICASONE FUROATE/VILANTEROL
TRIFENATATE 172
FLUTICASONE PROPIONATE 130,132,164,165
FLUTICASONE PROPIONATE/SALMETEROL
XINAFOATE 171
FLUVASTATIN SODIUM 98
FML FORTE 161
FML S.O.P. 161
FOCALIN XR 107
FOLGARD OS 176
FOLGARD RX 177
FOLIC ACID 177
FOLIC ACID/ARGININE
HCL/CYANOCOBALAMIN/PYRIDOXINE/PEPPER
EXT 177
FOLIC ACID/VITAMIN B COMP AND
C/SELENIUM/MIN AA CHEL/ZINC 177
FOLIC ACID/VITAMIN B COMPLEX AND VITAMIN
C 177
FONDAPARINUX SODIUM 79
FORADIL 167
FORMOTEROL FUMARATE 167,168
FORTEO 158
FOSAMPRENAVIR CALCIUM 68,69
FOSINOPRIL SODIUM 84
FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE 94
FOSRENOL 128,129
FRAGMIN 79,80
FROVATRIPTAN SUCCINATE 45
FULYZAQ 123
FURADANTIN 17
FUROSEMIDE 97
FUZEON 68
FYCOMPA 25,26
GGABAPENTIN 26,27
GABITRIL 27
GALANTAMINE HBR 31
PAGE 190 LAST UPDATED 03/2017
GARAMYCIN 16
GASTROCROM 123
GATIFLOXACIN 23
GATTEX 123
GEFITINIB 51
GELNIQUE 126
GEMFIBROZIL 98
GENTAMICIN SULFATE 16
GENTAMICIN SULFATE/PREDNISOLONE
ACETATE 160
GENVOYA 65
GIAZO 156
GILENYA 113
GILOTRIF 50
GLATIRAMER ACETATE 113
GLIMEPIRIDE 73
GLIPIZIDE 73
GLIPIZIDE/METFORMIN HCL 74
GLUCAGON EMERGENCY KIT 77
GLUCAGON,HUMAN RECOMBINANT 77
GLUCOPHAGE 74
GLYBURIDE 74
GLYBURIDE/METFORMIN HCL 74
GLYCEROL PHENYLBUTYRATE 121
GLYCOPYRROLATE 122,123
GLYXAMBI 74
GOLIMUMAB 155
GRANISETRON 41
GRANISETRON HCL 41
GRASS POLLEN-ORCHARD/SWEET
VERNAL/RYE/KENTUCKY/TIMOTHY, STD. 172
GRASTEK 172
GRIFULVIN V 42
GRISEOFULVIN ULTRAMICROSIZE 42
GRISEOFULVIN, MICROSIZE 42
GUAIFENESIN/DEXTROMETHORPHAN
HBR/PSEUDOEPHEDRINE HCL 173
GUANFACINE HCL 82,107
HHALCINONIDE 132
HALOBETASOL PROPIONATE 132,134
HALOG 132
HALOPERIDOL 57
HALOPERIDOL LACTATE 57
HARVONI 63
HEXALEN 47
HOMATROPINE HBR 159,160
HUMALOG 77
HUMALOG KWIKPEN U-100 77
HUMALOG KWIKPEN U-200 77
HUMALOG MIX 50-50 78
HUMALOG MIX 50-50 KWIKPEN 77
HUMALOG MIX 75-25 78
HUMALOG MIX 75-25 KWIKPEN 78
HUMIRA 153
HUMIRA PEDIATRIC CROHN'S 153
HUMIRA PEN 153
HUMIRA PEN CROHN-UC-HS STARTER 153
HUMIRA PEN PSORIASIS-UVEITIS 153
HUMULIN R U-500 78
HUMULIN R U-500 KWIKPEN 78
HYDRALAZINE HCL 101
HYDREA 48
HYDROCHLOROTHIAZIDE 97
HYDROCODONE BITARTRATE 10
HYDROCODONE
BITARTRATE/ACETAMINOPHEN 11,12,14
HYDROCODONE BITARTRATE/HOMATROPINE
METHYLBROMIDE 172,173
HYDROCODONE
POLISTIREX/CHLORPHENIRAMINE POLISTIREX172
HYDROCODONE/IBUPROFEN 12,14
HYDROCORTISONE 129,130,132,134,157
HYDROCORTISONE ACETATE 129,132,157
HYDROCORTISONE ACETATE/PRAMOXINE
HCL 115,116,117,118
HYDROCORTISONE BUTYRATE 132,133
HYDROCORTISONE PROBUTATE 133
HYDROCORTISONE VALERATE 133
HYDROCORTISONE/IODOQUINOL 116,117
PAGE 191 LAST UPDATED 03/2017
HYDROCORTISONE/MINERAL
OIL/PETROLATUM,WHITE 132
HYDROMORPHONE HCL 7,8,12
HYDROQUINONE 115,117,119
HYDROQUINONE MICROSPHERES 117
HYDROQUINONE/SUNSCREENS
(OXYBENZONE/OCTINOXATE) 114,117
HYDROXYCHLOROQUINE SULFATE 54
HYDROXYUREA 48
HYDROXYZINE HCL 165,166
HYDROXYZINE PAMOATE 166
HYOSCYAMINE SULFATE 122,123
IIBANDRONATE SODIUM 158
IBRANCE 50,51
IBRUTINIB 51
IBUPROFEN 5
IBUPROFEN/OXYCODONE HCL 14
ICLUSIG 51
IDELALISIB 53
ILEVRO 161
ILOPERIDONE 59
ILOPROST TROMETHAMINE 171
IMATINIB MESYLATE 51
IMBRUVICA 51
IMDUR 101
IMIPRAMINE HCL 39
IMIPRAMINE PAMOATE 39
IMIQUIMOD 117
IMURAN 153
INCRUSE ELLIPTA 166
INDACATEROL MALEATE 167
INDAPAMIDE 98
INDINAVIR SULFATE 68
INDOCIN 5
INDOMETHACIN 5
INSULIN ASPART 78
INSULIN ASPART PROTAMINE HUMAN/INSULIN
ASPART 78
INSULIN DEGLUDEC 78
INSULIN DETEMIR 78
INSULIN GLARGINE,HUMAN RECOMBINANT
ANALOG 77,78
INSULIN GLULISINE 77
INSULIN LISPRO 77
INSULIN LISPRO PROTAMINE AND INSULIN
LISPRO 77,78
INSULIN REGULAR, HUMAN 78
INTELENCE 66
INTERFERON ALFA-2B,RECOMB. 63
INTERFERON ALFA-N3 70
INTERFERON BETA-1A 112
INTERFERON BETA-1A/ALBUMIN HUMAN 112,113
INTERFERON BETA-1B 112
INTERFERON GAMMA-1B,RECOMB. 156
INTRON A 63
INTUNIV 107
INVIRASE 68
INVOKANA 74
IOPIDINE 162
IPRATROPIUM BROMIDE 166
IPRATROPIUM BROMIDE/ALBUTEROL
SULFATE 172
IRBESARTAN 83
IRBESARTAN/HYDROCHLOROTHIAZIDE 94
IRESSA 51
IRON,CARBONYL/FOLIC ACID/MULTIVIT WITH
MINERALS 178
ISAVUCONAZONIUM SULFATE 42
ISENTRESS 65
ISONIAZID 46
ISOPTO ATROPINE 160
ISORDIL 101
ISOSORBIDE DINITRATE 101
ISOSORBIDE MONONITRATE 101,102
ISOTRETINOIN 114,115,117,120
ITRACONAZOLE 42,43,44
IVABRADINE HCL 93
IVACAFTOR 168
IVERMECTIN 54
IXAZOMIB CITRATE 52
PAGE 192 LAST UPDATED 03/2017
IXEKIZUMAB 119
JJADENU 175
JAKAFI 51
JANUMET 74
JANUMET XR 74
JANUVIA 74
JARDIANCE 74,75
JENTADUETO 75
JUXTAPID 99,100
KKALETRA 68
KALYDECO 168
KEPPRA 26
KETOCONAZOLE 42,43,44
KETOPROFEN 5
KETOROLAC TROMETHAMINE 5,161
KETOROLAC TROMETHAMINE/PF 161
KEVEYIS 96
KINERET 153
KITABIS PAK 168
KLARON 23
KLOR-CON 176
KLOR-CON M15 176
KOMBIGLYZE XR 75
KORLYM 133
KRISTALOSE 125
KUVAN 120
KYNAMRO 100
LLABETALOL HCL 87
LACOSAMIDE 31
LACTULOSE 125
LAMICTAL (GREEN) 28
LAMICTAL (ORANGE) 28
LAMICTAL XR (BLUE) 28
LAMICTAL XR (GREEN) 28
LAMICTAL XR (ORANGE) 28
LAMIVUDINE 63,67
LAMIVUDINE/ZIDOVUDINE 67
LAMOTRIGINE 28,29
LANSOPRAZOLE 126
LANSOPRAZOLE/AMOXICILLIN
TRIHYDRATE/CLARITHROMYCIN 123
LANTHANUM CARBONATE 128,129
LANTUS 78
LANTUS SOLOSTAR 78
LAPATINIB DITOSYLATE 53
LASTACAFT 161
LATANOPROST 163
LATUDA 59
LEDIPASVIR/SOFOSBUVIR 63
LEFLUNOMIDE 156
LENALIDOMIDE 48
LENVATINIB MESYLATE 51
LENVIMA 51
LETAIRIS 169
LETROZOLE 49
LEUCOVORIN CALCIUM 49
LEUKERAN 47
LEUKINE 81
LEVALBUTEROL HCL 167
LEVALBUTEROL TARTRATE 167
LEVAQUIN 23
LEVATOL 87
LEVEMIR 78
LEVEMIR FLEXPEN 78
LEVEMIR FLEXTOUCH 78
LEVETIRACETAM 26
LEVO-T 146,147
LEVOBUNOLOL HCL 162
LEVOFLOXACIN 23
LEVOMILNACIPRAN HCL 35
LEVONORGESTREL-ETHINYL
ESTRADIOL 136,137,138,140,141,142,143,144
LEVONORGESTREL/ETHINYL ESTRADIOL AND
ETHINYL ESTRADIOL 137,138,141
LEVOTHYROXINE SODIUM 146,147,148,149,150
LEVOXYL 147,148
PAGE 193 LAST UPDATED 03/2017
LEVSIN 122
LEXIVA 68,69
LIALDA 156
LIDOCAINE 14,15
LIDOCAINE HCL 14,15
LIDOCAINE/PRILOCAINE 15
LIDOVEX 15
LINACLOTIDE 125
LINAGLIPTIN 76
LINAGLIPTIN/METFORMIN HCL 75
LINDANE 54
LINEZOLID 17,18
LINZESS 125
LIOTHYRONINE SODIUM 146,148
LIOTRIX 149
LIPASE/PROTEASE/AMYLASE 120,121,122
LIRAGLUTIDE 77
LISDEXAMFETAMINE DIMESYLATE 104,105
LISINOPRIL 84
LISINOPRIL/HYDROCHLOROTHIAZIDE 94
LITHIUM CARBONATE 72
LITHIUM CITRATE 72
LITHOBID 72
LOCOID 133
LODOXAMIDE TROMETHAMINE 160
LOMITAPIDE MESYLATE 99,100
LOMOTIL 123
LONSURF 48
LOPERAMIDE HCL 123
LOPINAVIR/RITONAVIR 68
LORAZEPAM 72
LORZONE 173
LOSARTAN POTASSIUM 83
LOSARTAN
POTASSIUM/HYDROCHLOROTHIAZIDE 94
LOTEMAX 161
LOTEPREDNOL ETABONATE 161
LOVASTATIN 99
LOXAPINE SUCCINATE 58
LUBIPROSTONE 125
LULICONAZOLE 43
LUMACAFTOR/IVACAFTOR 168
LURASIDONE HCL 59
LUZU 43
LYNPARZA 49
LYRICA 111,112
LYSODREN 49
MMACITENTAN 170
MARAVIROC 68
MARGESIC 111
MARTEN-TAB 111
MATULANE 47
MAXIDEX 161
MECLIZINE HCL 40
MECLOFENAMATE SODIUM 5
MEDROL 133
MEDROXYPROGESTERONE ACETATE 145
MEFENAMIC ACID 5
MEFLOQUINE HCL 54
MEGESTROL ACETATE 145
MEKINIST 51,52
MELOXICAM 5,6
MELPHALAN 47
MEMANTINE HCL 32
MEMANTINE HCL/DONEPEZIL HCL 31,32
MENEST 141
MENOSTAR 142
MEPERIDINE HCL 12
MEPHYTON 177
MERCAPTOPURINE 48,49
MESALAMINE 156,157
MESALAMINE WITH CLEANSING WIPES 157
MESNA 49
MESNEX 49
METAPROTERENOL SULFATE 168
METAXALONE 173
METFORMIN HCL 74,75,76
METHADONE HCL 8
METHADOSE 8
METHENAMINE HIPPURATE 18
PAGE 194 LAST UPDATED 03/2017
METHENAMINE MANDELATE 18
METHENAMINE/METHYLENE BLUE/SOD
PHOS/P.SALICYLATE/HYOSCYAMINE 18
METHIMAZOLE 152
METHITEST 136
METHOCARBAMOL 174
METHOTREXATE SODIUM 153,155
METHOTREXATE/PF 154,155
METHSUXIMIDE 26
METHYLDOPA 82
METHYLDOPA/HYDROCHLOROTHIAZIDE 94
METHYLNALTREXONE BROMIDE 124
METHYLPHENIDATE HCL 106,107,108,109,110
METHYLPREDNISOLONE 133
METHYLTESTOSTERONE 136
METHYLTETRAHYDROFOLATE
GLUCOSAMINE/NIACINAMIDE/CUPRIC,ZN OX 178
METIPRANOLOL 162
METOCLOPRAMIDE HCL 40
METOLAZONE 98
METOPROLOL SUCCINATE 87
METOPROLOL TARTRATE 87
METOPROLOL
TARTRATE/HYDROCHLOROTHIAZIDE 94
METRELEPTIN 159
METROLOTION 117
METRONIDAZOLE 17,18,117,118
MEXILETINE HCL 85
MIACALCIN 158
MICONAZOLE 43
MICROGESTIN 24 FE 142
MIFEPRISTONE 133
MIGLITOL 75
MIGLUSTAT 121
MILLIPRED 133
MILNACIPRAN HCL 112
MINIVELLE 142
MINOCYCLINE HCL 24,25
MINOXIDIL 101
MIPOMERSEN SODIUM 100
MIRABEGRON 126
MIRTAZAPINE 33,34
MISOPROSTOL 126
MITOTANE 49
MODAFINIL 175
MOEXIPRIL HCL 84
MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE 94
MOMETASONE FUROATE 131,133,164,165
MOMETASONE FUROATE/FORMOTEROL
FUMARATE 172
MONTELUKAST SODIUM 166
MORPHINE SULFATE 6,7,8,12,13
MORPHINE SULFATE/NALTREXONE HCL 7
MOVANTIK 123
MOXEZA 23
MOXIFLOXACIN HCL 23
MULTAQ 85
MUPIROCIN 17,18
MUPIROCIN CALCIUM 18
MVC-FLUORIDE 178
MYALEPT 159
MYCOPHENOLATE MOFETIL 153,154
MYCOPHENOLATE SODIUM 154
MYLERAN 47
MYNATAL 178
MYRBETRIQ 126
MYTESI 123
NNABILONE 41
NABUMETONE 6
NADOLOL 87
NADOLOL/BENDROFLUMETHIAZIDE 94
NAFTIFINE HCL 43
NAFTIN 43
NALFON 6
NALOXEGOL OXALATE 123
NALTREXONE HCL 15
NAMENDA XR 32
NAMZARIC 31,32
NAPROSYN 6
NAPROXEN 6
PAGE 195 LAST UPDATED 03/2017
NAPROXEN SODIUM 6
NARATRIPTAN HCL 45
NASONEX 165
NATAZIA 142
NATEGLINIDE 75
NATELLE ONE 178
NATPARA 158
NATURE-THROID 148
NEBIVOLOL HCL 86
NEDOCROMIL SODIUM 160
NEFAZODONE HCL 36
NELFINAVIR MESYLATE 69
NEOMYCIN SULFATE 16
NEOMYCIN SULFATE/BACITRACIN
ZINC/POLYMYXIN B/HYDROCORTISONE 160
NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN
B 160
NEOMYCIN SULFATE/POLYMYXIN B
SULFATE/GRAMICIDIN D 160
NEOMYCIN SULFATE/POLYMYXIN B
SULFATE/HYDROCORTISONE 163
NEORAL 154
NEPAFENAC 161,162
NEPHRO-VITE RX 178
NETUPITANT/PALONOSETRON HCL 40
NEULASTA 81
NEUPOGEN 81
NEUPRO 55
NEVANAC 162
NEVIRAPINE 66
NEXAVAR 52
NIACIN 100
NICOMIDE 178
NIFEDIPINE 88,90
NILOTINIB HCL 53
NILUTAMIDE 47
NINLARO 52
NINTEDANIB ESYLATE 172
NISOLDIPINE 90
NITAZOXANIDE 54
NITISINONE 120,121
NITRO-BID 102
NITRO-DUR 102
NITROFURANTOIN 17,18
NITROFURANTOIN MACROCRYSTAL 18
NITROFURANTOIN
MONOHYDRATE/MACROCRYSTALS 18
NITROGLYCERIN 102
NIZATIDINE 124
NORELGESTROMIN/ETHINYL ESTRADIOL 143,145
NORETHINDRONE 145
NORETHINDRONE ACETATE 145
NORETHINDRONE ACETATE-ETHINYL
ESTRADIOL 140,141,142
NORETHINDRONE ACETATE-ETHINYL
ESTRADIOL/FERROUS
FUMARATE 137,140,141,142,144
NORETHINDRONE-ETHINYL
ESTRADIOL 137,138,140,141,142,143,144,145
NORETHINDRONE-ETHINYL
ESTRADIOL/FERROUS FUMARATE 142,144,145
NORETHINDRONE-MESTRANOL 142
NORGESTIMATE-ETHINYL
ESTRADIOL 138,140,142,144
NORGESTREL-ETHINYL ESTRADIOL 138,141,143
NORINYL 1-35 142
NORTHERA 94,95
NORTRIPTYLINE HCL 39
NORVIR 69
NOVOLOG 78
NOVOLOG FLEXPEN 78
NOVOLOG MIX 70-30 78
NOVOLOG MIX 70-30 FLEXPEN 78
NOXAFIL 43
NU-DERM SUNFADER 117
NUCYNTA 13
NUCYNTA ER 8,9
NUEDEXTA 111
NULYTELY WITH FLAVOR PACKS 125
NUPLAZID 59
NUVARING 143
NYSTATIN 43,44
PAGE 196 LAST UPDATED 03/2017
NYSTATIN/TRIAMCINOLONE ACETONIDE 43
OO-CAL FA 178
OB COMPLETE 178
OB COMPLETE ONE 178
OB COMPLETE PETITE 178
OB COMPLETE PREMIER 179
OCTREOTIDE ACETATE 151
ODEFSEY 66
ODOMZO 52
OFEV 172
OFLOXACIN 23
OGEN 143
OLANZAPINE 59,60
OLANZAPINE/FLUOXETINE HCL 34
OLAPARIB 49
OLEPTRO ER 36
OLMESARTAN MEDOXOMIL 83
OLMESARTAN MEDOXOMIL/AMLODIPINE
BESYLATE/HYDROCHLOROTHIAZIDE 95
OLMESARTAN
MEDOXOMIL/HYDROCHLOROTHIAZIDE 95
OLODATEROL HCL 168
OLOPATADINE HCL 161,166
OLSALAZINE SODIUM 156
OLYSIO 63
OMBITASVIR/PARITAPREVIR/RITONAVIR 64
OMBITASVIR/PARITAPREVIR/RITONAVIR/DASABU
VIR SODIUM 64
OMECLAMOX-PAK 123
OMEGA-3 ACID ETHYL ESTERS 100
OMEPRAZOLE 126
OMEPRAZOLE/CLARITHROMYCIN/AMOXICILLIN
TRIHYDRATE 123
OMNARIS 165
OMNITROPE 135
ONDANSETRON 41
ONDANSETRON HCL 41
ONFI 27
ONGLYZA 75
ONMEL 43
OPSUMIT 170
ORAL MUCOSITIS AND STOMATITIS ANTI-
INFLAMMATORY AGENT COMB 2 113
ORALAIR 172
ORAVIG 43
ORENCIA 154
ORENCIA CLICKJECT 154
ORENITRAM ER 170
ORFADIN 120,121
ORKAMBI 168
ORPHENADRINE CITRATE 174
ORTHO EVRA 143
OSELTAMIVIR PHOSPHATE 69,70
OSIMERTINIB MESYLATE 52,53
OTEZLA 156
OTREXUP 154
OVACE PLUS 117,118
OXANDROLONE 135
OXAPROZIN 6
OXAYDO 13
OXAZEPAM 72
OXCARBAZEPINE 30
OXECTA 13
OXICONAZOLE NITRATE 43
OXISTAT 43
OXTELLAR XR 30
OXYBUTYNIN 127
OXYBUTYNIN CHLORIDE 126,127
OXYCODONE HCL 9,13,14
OXYCODONE HCL/ACETAMINOPHEN 11,13,14
OXYCODONE HCL/ASPIRIN 14
OXYMORPHONE HCL 9,10,14
OXYTROL 127
PPACERONE 85
PALBOCICLIB 50,51
PALIPERIDONE 60
PANCREAZE 121
PANDEL 133
PAGE 197 LAST UPDATED 03/2017
PANOBINOSTAT LACTATE 49
PANTOPRAZOLE SODIUM 126
PARATHYROID HORMONE 158
PARICALCITOL 158
PAROMOMYCIN SULFATE 16
PAROXETINE HCL 36,37
PATADAY 161
PAZEO 161
PAZOPANIB HCL 53
PEDIATRIC MULTIVIT #37/SODIUM
FLUORIDE/IRON BISGLYCINATE HCL 179
PEDIATRIC MULTIVIT WITH A,C,D3 NO.21/SODIUM
FLUORIDE 180
PEDIATRIC MULTIVITAMIN A,C,AND D3 NO.38
WITH SODIUM FLUORIDE 180
PEDIATRIC MULTIVITAMIN COMBINATION
NO.2/SODIUM FLUORIDE 177,178
PEDIATRIC MULTIVITAMIN NO.12 WITH SODIUM
FLUORIDE 178
PEDIATRIC MULTIVITAMIN NO.2/SODIUM
FLUORIDE 177
PEDIATRIC MULTIVITAMIN NO.33 WITH SODIUM
FLUORIDE 179
PEDIATRIC MULTIVITAMIN NO.33/SODIUM
FLUORIDE/IRON CARBONYL 179
PEDIATRIC MULTIVITAMIN NO.37 WITH SODIUM
FLUORIDE 179
PEDIATRIC MULTIVITAMIN NO.45/SODIUM
FLUORIDE/FERROUS SULFATE 178
PEDIATRIC MULTIVITAMIN NO.75/SODIUM
FLUORIDE/FERROUS SULFATE 178
PEDIATRIC MULTIVITAMIN NO.82 WITH SODIUM
FLUORIDE 177,178
PEDIATRIC MULTIVITAMINS NO.17 WITH SODIUM
FLUORIDE 177,178
PEG 3350/SOD SULF/SOD BICARB/SOD
CHLORIDE/POTASSIUM CHLORIDE 125
PEGANONE 31
PEGASYS 63,64
PEGASYS PROCLICK 64
PEGFILGRASTIM 81
PEGINTERFERON ALFA-2A 63,64
PEGINTERFERON BETA-1A 113
PEN NEEDLE, DIABETIC 159
PENBUTOLOL SULFATE 87
PENICILLAMINE 128
PENICILLIN V POTASSIUM 21
PENLAC 44
PENTASA 157
PENTOSAN POLYSULFATE SODIUM 128
PENTOXIFYLLINE 95
PERAMPANEL 25,26
PERFOROMIST 168
PERINDOPRIL ERBUMINE 83,84
PERMETHRIN 54
PERPHENAZINE 40
PERPHENAZINE/AMITRIPTYLINE HCL 34
PERTZYE 121
PHENAZOPYRIDINE HCL 128
PHENELZINE SULFATE 34
PHENOBARBITAL 27
PHENYLEPHRINE HCL/PROMETHAZINE
HCL 172,173
PHENYTOIN 31
PHENYTOIN SODIUM EXTENDED 30,31
PHOSLYRA 129
PHOSPHOLINE IODIDE 162
PHYTONADIONE (VIT K1) 177
PILOCARPINE HCL 113,114,162
PIMAVANSERIN TARTRATE 59
PIMECROLIMUS 116
PIMOZIDE 58
PINDOLOL 87
PIOGLITAZONE HCL 75,76
PIOGLITAZONE HCL/GLIMEPIRIDE 76
PIOGLITAZONE HCL/METFORMIN HCL 72,76
PIRFENIDONE 172
PIROXICAM 6
PLAQUENIL 54
PLEGRIDY 113
PLEGRIDY PEN 113
PAGE 198 LAST UPDATED 03/2017
PNV NO.85/IRON
CARB,ASPART.GLYCINATE/FOLIC ACID/DHA/FISH
OIL 178
PODOFILOX 115,118
POLY-VI-FLOR 179
POLY-VI-FLOR WITH IRON 179
POLYETHYLENE GLYCOL 3350 125,126
POLYMYXIN B SULFATE/TRIMETHOPRIM 160
POMALIDOMIDE 47,48
POMALYST 47,48
PONATINIB HCL 51
POSACONAZOLE 43
POTASSIUM CHLORIDE 176
POTASSIUM CHLORIDE/POTASSIUM
BICARBONATE/CITRIC ACID 176
POTASSIUM CITRATE 128
PRADAXA 80
PRALUENT PEN 100
PRALUENT SYRINGE 100
PRAMIPEXOLE DI-HCL 55,56
PRAMLINTIDE ACETATE 76
PRAMOSONE 118
PRASUGREL HCL 81,82
PRAVASTATIN SODIUM 99
PRAZOSIN HCL 82
PRECOSE 76
PRED MILD 162
PRED-G 160
PREDNISOLONE 133,134
PREDNISOLONE ACETATE 162
PREDNISOLONE SOD PHOSPHATE 133,134,162
PREDNISONE 130,133,134
PREFERA-OB ONE 179
PREFEST 143
PREGABALIN 111,112
PRELONE 134
PREMARIN 143
PREMPHASE 143
PREMPRO 143,144
PRENATA 179
PRENATABS FA 179
PRENATABS RX 179
PRENATAL NO56/IRON CARBONYL,ASPARTO
GLYCINATE/FOLIC ACID/DHA 178
PRENATAL VIT NO.18/IRON/FOLIC
ACID/DOCUSATE SOD./CO-Q10/DHA 180
PRENATAL VIT NO.2/IRON BG CHEL,SUCC-
PROT/FOLIC ACID/OMEGA-3 177,180
PRENATAL VIT NO.22/IRON CBN,GLUC/FOLIC
ACID/DOCUSATE SODIUM 180
PRENATAL VIT WITH CALCIUM NO.66/IRON
FUM/FOLIC ACID/DSS/DHA 179,180
PRENATAL VITAMIN 27 WITH CALCIUM/FERROUS
FUMARATE/FOLIC ACID 180
PRENATAL VITAMIN NO.106/SOD FEREDE-IRON
POLY/FA/OM3/DHA/EPA 177
PRENATAL VITAMIN NO.117/SOD FEREDE-IRON
POLY/FA/OM3/DHA/EPA 177
PRENATAL VITAMIN NO.19/IRON POLYSAC,IRON
HEME/FOLIC ACID/DHA 179,181
PRENATAL VITAMIN NO.35/IRON
FUMARATE/FOLATE COMB. NO.6/DHA 179
PRENATAL VITAMIN
NO.48/IRON,CARBONYL,GLUCONATE/FOLIC
ACID/B6 176
PRENATAL VITAMIN NO.7-FERROUS FUMARATE-
FOLIC ACID-DHA 177
PRENATAL VITAMINS COMB
#83/IRON,CARBONYL/IRON ASPARTO GLY/FA 179
PRENATAL VITAMINS COMB 10/FERROUS
FUMARATE/FOLIC ACID 180
PRENATAL VITAMINS COMBO #36/FERROUS
FUMARATE/FOLATE COMBO #6 179
PRENATAL VITAMINS COMBO NO.37/FERROUS
FUMARATE/FOLIC ACID 179
PRENATAL VITAMINS COMBO
NO.59/IRON,CARB/FOLIC ACID/DSS/DHA 181
PRENATAL VITAMINS
NO.112/METHYLTETRAHYDROFOLATE
GLUCOSAMI,FA 179
PRENATAL VITAMINS NO.26/IRON
POLYSACCHARIDES/FA/DHA 180
PAGE 199 LAST UPDATED 03/2017
PRENATAL VITAMINS NO.38/IRON
FUMARATE/FOLATE COMB NO.6/DHA 179
PRENATAL VITAMINS WITH CALCIUM/FERROUS
FUMARATE/FOLIC ACID 178
PRENATAL VITS WITH CALCIUM #70/FERROUS
FUMARATE/FA/DHA 176,178
PRENATAL VITS WITH CALCIUM #72/FERROUS
FUMARATE/FOLIC ACID 179
PRENATAL VITS WITH CALCIUM #73/FERROUS
FUMARATE/FOLIC ACID 180
PRENATAL VITS WITH CALCIUM #74/FERROUS
FUMARATE/FOLIC ACID 178,179,180
PRENATAL VITS WITH CALCIUM
#76/IRON,CARBONYL/FOLIC ACID 179
PRENATAL VITS WITH CALCIUM #78/FERROUS
FUMARATE/FOLIC ACID 179
PRENATAL VITS WITH CALCIUM#118/FERROUS
FUMARATE/FOLIC ACID 180
PRENATE CHEWABLE 179
PRENATE DHA 179
PRENATE ELITE 179
PRENATE ESSENTIAL 179
PREQUE 10 180
PREZCOBIX 68
PREZISTA 69
PRIMIDONE 27
PRIMSOL 18
PROAIR HFA 168
PROAIR RESPICLICK 168
PROBENECID 44
PROBENECID/COLCHICINE 44
PROCARBAZINE HCL 47
PROCARDIA 90
PROCARDIA XL 90
PROCHLORPERAZINE 40
PROCHLORPERAZINE MALEATE 40
PROCORT 118
PROCTOFOAM-HC 118
PROGESTERONE, MICRONIZED 145
PROMACTA 81
PROMETHAZINE HCL 40,166
PROMETHAZINE HCL/CODEINE 172
PROMETHAZINE HCL/DEXTROMETHORPHAN
HBR 172
PROMETHAZINE/PHENYLEPHRINE
HCL/CODEINE 172,173
PROPAFENONE HCL 85
PROPARACAINE HCL/FLUORESCEIN SODIUM 159
PROPRANOLOL HCL 87,88
PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE 95
PROPYLTHIOURACIL 152
PROTONIX 126
PROVENTIL HFA 168
PSEUDOEPHEDRINE HCL/ACRIVASTINE 173
PULMICORT FLEXHALER 165
PULMOZYME 173
PURIXAN 49
PYLERA 123
PYRAZINAMIDE 46
PYRIMETHAMINE 54
QQNASL 165
QNASL CHILDREN 165
QUETIAPINE FUMARATE 60
QUILLIVANT XR 110
QUINAPRIL HCL 84
QUINAPRIL HCL/HYDROCHLOROTHIAZIDE 95
QUINIDINE SULFATE 85
QUININE SULFATE 54
QVAR 165
RRABEPRAZOLE SODIUM 126
RAGWITEK 173
RALOXIFENE HCL 146
RALTEGRAVIR POTASSIUM 65
RAMIPRIL 84
RANEXA 95
RANITIDINE HCL 124
RANOLAZINE 95
RAPAFLO 127
PAGE 200 LAST UPDATED 03/2017
RAPAMUNE 154
RASAGILINE MESYLATE 57
RASUVO 154,155
RAVICTI 121
REBETOL 64
REBIF 113
REBIF REBIDOSE 113
REGORAFENIB 52
RELENZA 69
RELISTOR 124
RELPAX 45
REMODULIN 170
RENAGEL 129
RENVELA 129
REPAGLINIDE 76
REPATHA PUSHTRONEX 100
REPATHA SURECLICK 100
REPATHA SYRINGE 100
REPREXAIN 14
RESCRIPTOR 66
RESTASIS 160
RETAPAMULIN 17
REVATIO 170
REVLIMID 48
REXULTI 60
REYATAZ 69
RIBASPHERE RIBAPAK 64
RIBATAB 64
RIBAVIRIN 64
RIDAURA 156
RIFAMPIN 46
RIFAMPIN/ISONIAZID/PYRAZINAMIDE 46
RIFATER 46
RILPIVIRINE HCL 66
RIMANTADINE HCL 69
RIOCIGUAT 169
RIOMET 76
RISEDRONATE SODIUM 158
RISPERIDONE 60,61
RITALIN LA 110
RITONAVIR 69
RIVAROXABAN 80
RIVASTIGMINE 32
RIVASTIGMINE TARTRATE 32
RIZATRIPTAN BENZOATE 45
ROBINUL FORTE 123
ROCALTROL 158
ROFLUMILAST 169
ROLAPITANT HCL 41
ROPINIROLE HCL 56
ROSIGLITAZONE MALEATE 73
ROSIGLITAZONE MALEATE/METFORMIN HCL 73
ROSUVASTATIN CALCIUM 99
ROTIGOTINE 55
ROXICET 14
ROXICODONE 14
RUCONEST 152
RUFINAMIDE 30
RUXOLITINIB PHOSPHATE 51
SSABRIL 27
SACCHARIN 159
SACUBITRIL/VALSARTAN 94
SAIZEN 135
SALMETEROL XINAFOATE 168
SALSALATE 6
SANCUSO 41
SANDIMMUNE 155
SAPHRIS 61
SAPROPTERIN DIHYDROCHLORIDE 120
SAQUINAVIR MESYLATE 68
SARGRAMOSTIM 81
SAVELLA 112
SAXAGLIPTIN HCL 75
SAXAGLIPTIN HCL/METFORMIN HCL 75
SECUKINUMAB 115,116
SELEGILINE 34
SELEGILINE HCL 57
SELENIUM SULFIDE 118
SELEXIPAG 170,171
SELZENTRY 68
PAGE 201 LAST UPDATED 03/2017
SEMPREX-D 173
SENSIPAR 151
SEREVENT DISKUS 168
SEROSTIM 135
SERTACONAZOLE NITRATE 42
SERTRALINE HCL 37
SEVELAMER CARBONATE 129
SEVELAMER HCL 129
SILDENAFIL CITRATE 170
SILODOSIN 127
SILVER SULFADIAZINE 23
SIMBRINZA 162
SIMEPREVIR SODIUM 63
SIMPONI 155
SIMVASTATIN 99
SINEMET CR 57
SIROLIMUS 154,155
SIRTURO 46
SITAGLIPTIN PHOSPHATE 74
SITAGLIPTIN PHOSPHATE/METFORMIN HCL 74
SIVEXTRO 18
SKLICE 54
SODIUM CHLORIDE/SODIUM
BICARBONATE/POTASSIUM
CHLORIDE/PEG 125,126
SODIUM OXYBATE 175
SODIUM PHOSPHATE,DIBASIC/POT
PHOS,MONOB/SOD PHOSPHATE MONO 128
SODIUM POLYSTYRENE SULFONATE 176
SODIUM POLYSTYRENE SULFONATE/SORBITOL
SOLUTION 175,176
SOFOSBUVIR 64
SOFOSBUVIR/VELPATASVIR 63
SOLIFENACIN SUCCINATE 127
SOLTAMOX 48
SOMATROPIN 135
SONIDEGIB PHOSPHATE 52
SORAFENIB TOSYLATE 52
SORBITOL SOLUTION 159
SORILUX 119
SOTALOL HCL 85,86
SOTYLIZE 86
SOVALDI 64
SPIRIVA 166
SPIRIVA RESPIMAT 167
SPIRONOLACTONE 97
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 95
SPORANOX 44
SPRYCEL 52
SPS 176
SSD 23
STAVUDINE 67
STELARA 119
STIMATE 135
STIOLTO RESPIMAT 173
STIVARGA 52
STRATTERA 110
STRENSIQ 121
STRIBILD 65
STRIVERDI RESPIMAT 168
SUBOXONE 16
SUCRALFATE 126
SUCROFERRIC OXYHYDROXIDE 129
SULCONAZOLE NITRATE 42
SULFACETAMIDE SODIUM 23,117,118,119
SULFACETAMIDE SODIUM/PREDNISOLONE
ACETATE 159
SULFACETAMIDE SODIUM/PREDNISOLONE
SODIUM PHOSPHATE 160
SULFACETAMIDE SODIUM/SULFUR 115,118
SULFACETAMIDE SODIUM/SULFUR/UREA 118
SULFAMETHOXAZOLE/TRIMETHOPRIM 24
SULFASALAZINE 157
SULFATRIM 24
SULINDAC 6
SUMATRIPTAN 45
SUMATRIPTAN SUCCINATE 45,46
SUMATRIPTAN SUCCINATE/NAPROXEN
SODIUM 46
SUNITINIB MALATE 52
SUPRAX 20
SURMONTIL 39
PAGE 202 LAST UPDATED 03/2017
SUSTIVA 66
SUTENT 52
SUVOREXANT 175
SYMAX DUOTAB 123
SYMBICORT 173
SYMLINPEN 120 76
SYMLINPEN 60 76
SYNJARDY 76
SYNTHROID 149
SYRINGE WITH NEEDLE, INSULIN, SAFETY, 0.3
ML 158
SYRINGE WITH NEEDLE, INSULIN, SAFETY, 0.5
ML 158,159
SYRINGE WITH NEEDLE, INSULIN, SAFETY, 1
ML 159
SYRINGE WITH NEEDLE,DISPOSABLE,INSULIN 1
ML 158,159
SYRINGE WITH NEEDLE,INSULIN,0.3 ML 159
SYRINGE WITH NEEDLE,INSULIN,0.5 ML 158,159
TTACROLIMUS 119,152,153,155
TADALAFIL 169
TAFINLAR 52
TAFLUPROST/PF 163
TAGRISSO 52,53
TALTZ AUTOINJECTOR 119
TALTZ AUTOINJECTOR (2 PACK) 119
TALTZ AUTOINJECTOR (3 PACK) 119
TALTZ SYRINGE 119
TALTZ SYRINGE (2 PACK) 119
TALTZ SYRINGE (3 PACK) 119
TAMIFLU 69,70
TAMOXIFEN CITRATE 48
TAMSULOSIN HCL 127
TAPENTADOL HCL 8,9,13
TARCEVA 53
TASIGNA 53
TAZAROTENE 116,119
TAZORAC 119
TECFIDERA 113
TECHNIVIE 64
TEDIZOLID PHOSPHATE 18
TEDUGLUTIDE 123
TEKTURNA 95
TEKTURNA HCT 95,96
TELBIVUDINE 63
TELMISARTAN 83
TELMISARTAN/AMLODIPINE BESYLATE 96
TELMISARTAN/HYDROCHLOROTHIAZIDE 96
TEMAZEPAM 174
TEMOZOLOMIDE 47
TENOFOVIR DISOPROXIL FUMARATE 67
TERAZOSIN HCL 82
TERBINAFINE HCL 44
TERBUTALINE SULFATE 168
TERCONAZOLE 44
TERIFLUNOMIDE 112
TERIPARATIDE 158
TESTOSTERONE 136
TESTOSTERONE CYPIONATE 136
TESTOSTERONE ENANTHATE 136
TETRABENAZINE 111
TETRACYCLINE HCL 25
TEV-TROPIN 135
THEOPHYLLINE ANHYDROUS 169
THIORIDAZINE HCL 58
THIOTHIXENE 58
THYROID,PORK 146,148,149,150,151
THYROLAR-1 149
THYROLAR-1/2 149
THYROLAR-1/4 149
THYROLAR-2 149
THYROLAR-3 149
TIAGABINE HCL 27
TIAZAC 91
TIMOLOL MALEATE 88,162,163
TINDAMAX 18
TINIDAZOLE 18
TIOTROPIUM BROMIDE 166,167
TIOTROPIUM BROMIDE/OLODATEROL HCL 173
TIPRANAVIR 68
PAGE 203 LAST UPDATED 03/2017
TIPRANAVIR/VITAMIN E TPGS 68
TIVICAY 65
TIZANIDINE HCL 62
TOBI PODHALER 169
TOBRADEX 160
TOBRADEX ST 160
TOBRAMYCIN 17,168,169
TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE 169
TOBRAMYCIN/DEXAMETHASONE 160
TOBRAMYCIN/LOTEPREDNOL ETABONATE 160
TOBRAMYCIN/NEBULIZER 168,169
TOBREX 17
TOCILIZUMAB 156
TOFACITINIB CITRATE 155
TOFRANIL-PM 39
TOLAK 119
TOLMETIN SODIUM 6
TOLTERODINE TARTRATE 127
TOPIRAMATE 29
TORSEMIDE 97
TOUJEO SOLOSTAR 78
TOVIAZ 127
TRACLEER 170
TRADJENTA 76
TRAMADOL HCL 10,14
TRAMADOL HCL/ACETAMINOPHEN 14
TRAMETINIB DIMETHYL SULFOXIDE 51,52
TRANDOLAPRIL 84
TRANDOLAPRIL/VERAPAMIL HCL 96
TRANEXAMIC ACID 81
TRANYLCYPROMINE SULFATE 34
TRAVATAN Z 163
TRAVOPROST 163
TRAZODONE HCL 36,37
TRECATOR 47
TREPROSTINIL 170
TREPROSTINIL DIOLAMINE 170
TREPROSTINIL SODIUM 170
TREPROSTINIL/NEBULIZER ACCESSORIES 170
TREPROSTINIL/NEBULIZER AND
ACCESSORIES 170
TRESIBA FLEXTOUCH U-100 78
TRESIBA FLEXTOUCH U-200 78
TRETINOIN 53,119,120
TREXALL 155
TREXIMET 46
TRI-VI-FLOR 180
TRIAMCINOLONE ACETONIDE 113,114,134
TRIAMTERENE/HYDROCHLOROTHIAZIDE 96
TRIAZOLAM 174
TRICOR 98
TRIFLUOPERAZINE HCL 58
TRIFLURIDINE/TIPIRACIL HCL 48
TRIGLIDE 98
TRIHEXYPHENIDYL HCL 54,55
TRIMETHOPRIM 18
TRIMIPRAMINE MALEATE 39
TRINATE 180
TRINTELLIX 37
TRIUMEQ 68
TROKENDI XR 29
TROPICAMIDE 160
TRULICITY 76,77
TRUVADA 67
TUDORZA PRESSAIR 167
TUSNEL PEDIATRIC 173
TYBOST 68
TYKERB 53
TYVASO 170
TYVASO INSTITUTIONAL START KIT 170
TYVASO REFILL KIT 170
TYVASO STARTER KIT 170
TYZEKA 63
UUCERIS 157
ULESFIA 120
ULORIC 44
ULTRAVATE 134
UMECLIDINIUM BROMIDE 166
UMECLIDINIUM BROMIDE/VILANTEROL
TRIFENATATE 171
PAGE 204 LAST UPDATED 03/2017
UNITHROID 149,150
UPTRAVI 170,171
URECHOLINE 128
URIDINE TRIACETATE 181
URSO 124
URSO FORTE 124
URSODIOL 123,124
USTEKINUMAB 119
VVALACYCLOVIR HCL 70
VALGANCICLOVIR HCL 62
VALPROIC ACID 27
VALPROIC ACID (AS SODIUM SALT) (VALPROATE
SODIUM) 28
VALSARTAN 83
VALSARTAN/HYDROCHLOROTHIAZIDE 96
VANDETANIB 50
VARUBI 41
VELPHORO 129
VEMURAFENIB 53
VENCLEXTA 53
VENCLEXTA STARTING PACK 53
VENETOCLAX 53
VENLAFAXINE HCL 37,38
VENTAVIS 171
VENTOLIN HFA 168
VERAMYST 165
VERAPAMIL HCL 91
VERDESO 134
VERIPRED 20 134
VERSACLOZ 62
VESICARE 127
VICTOZA 2-PAK 77
VICTOZA 3-PAK 77
VIDEX 67
VIEKIRA PAK 64
VIGABATRIN 27
VIGAMOX 23
VIIBRYD 38
VILAZODONE HCL 38
VIMPAT 31
VIOKACE 121
VIRACEPT 69
VIREAD 67
VISMODEGIB 50
VITA-RESPA 180
VITAFOL-OB 180
VITAFOL-ONE 180
VITAMIN B COMPLEX AND VITAMIN C NO.20/FOLIC
ACID 178,180
VITAMIN B COMPLX NO.3/FOLIC ACID/ASCORBIC
ACID/BIOTIN 178,180,181
VITEKTA 65
VORAPAXAR SULFATE 82
VORICONAZOLE 44
VORTIOXETINE HYDROBROMIDE 34,37
VOTRIENT 53
VRAYLAR 61,62
VYTORIN 100,101
VYVANSE 104,105
WWARFARIN SODIUM 79,80
WELCHOL 101
WELLBUTRIN XL 34
WESTHROID 150
WP THYROID 150,151
XXALKORI 53
XARELTO 80
XELJANZ 155
XELJANZ XR 155
XIGDUO XR 77
XOLEGEL 44
XTANDI 47
XURIDEN 181
XYLOCAINE 15
XYREM 175
PAGE 205 LAST UPDATED 03/2017
ZZAFIRLUKAST 166
ZALEPLON 174
ZAMICET 14
ZANAMIVIR 69
ZANTAC 124
ZAROXOLYN 98
ZARXIO 81
ZAVESCA 121
ZEBUTAL 111
ZELAPAR 57
ZELBORAF 53
ZENPEP 121,122
ZENZEDI 105
ZEPATIER 65
ZETIA 101
ZETONNA 165
ZIAGEN 67
ZIDOVUDINE 67,68
ZIOPTAN 163
ZIPRASIDONE HCL 62
ZITHRANOL 120
ZITHRANOL-RR 120
ZITHROMAX 22
ZITHROMAX TRI-PAK 22
ZMAX 22
ZOFRAN 41
ZOHYDRO ER 10
ZOLMITRIPTAN 46
ZOLPIDEM TARTRATE 174
ZOMACTON 135
ZOMIG 46
ZONISAMIDE 26
ZONTIVITY 82
ZORBTIVE 135
ZORTRESS 156
ZOVIRAX 70
ZUBSOLV 16
ZYDELIG 53
ZYKADIA 53
ZYLET 160
ZYTIGA 47
PAGE 206 LAST UPDATED 03/2017