prescription drug formulary & network pharmacies

H5826_MA_47_2013_v_01_FormularyPharmacy3tier CMS Approved 09.17.2012
(List of Covered Drugs) Community HealthFirst MA Pharmacy Plan (HMO)
Community HealthFirst MA Extra Plan (HMO)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2013.
All beneficiaries must use their plan sponsor’s network pharmacies to access their prescription drug benefit, except under non-routine circumstances. Quantity limitations and restrictions may apply.
Community HealthFirst™ Medicare Advantage Plans are offered by Community Health Plan of Washington, which is a Federally-Qualified HMO with a Medicare contract. Please contact Community HealthFirst at 1-800-944-1247 (TTY Relay: Dial 7-1-1) if you need information in another format or language than what is listed above. Our Office hours are 8:00 a.m. – 8:00p.m., 7 days a week.
HPMS Approved Formulary File Submission ID 13226, Version 5
H5826_MA_047_2013_v_01_FormularyPharmacy3tier CMS Approved 09.17.2012
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What is the Community HealthFirst Formulary? A formulary is a list of covered drugs selected by Community HealthFirst in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Community HealthFirst will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Community HealthFirst network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary change? Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of August 28, 2012. To get updated information about the drugs covered by Community HealthFirst, please visit our web site at www.healthfirst.chpw.org or call Customer Service at 1-800-942-0247 (TTY Relay: Dial 7-1-1), 8:00 a.m. to 8:00 p.m., 7 days a week.
How do I use the Formulary? There are two ways to find your drug within the formulary:
Medical Condition The formulary begins on page 13.The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Medications”. If you know what your drug is used for, look for the category name in the list that begins on page 13. Then look under the category name for your drug.
Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 117.The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs? Community HealthFirst covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
• Prior Authorization: Community HealthFirst requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Community HealthFirst before you fill your prescriptions. If you don’t get approval, Community HealthFirst may not cover the drug.
• Quantity Limits: For certain drugs, Community HealthFirst limits the amount of the drug that Community HealthFirst will cover. For example, Community HealthFirst provides 68 tablets per prescription for bupropion hcl. This may be in addition to a standard one month or three month supply.
• Step Therapy: In some cases, Community HealthFirst requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Community HealthFirst may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Community HealthFirst will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 13. You can also get more information about the restrictions applied to specific covered drugs by visiting our web site at www.healthfirst.chpw.org.
You can ask Community HealthFirst to make an exception to these restrictions or limits. See the section, “How do I request an exception to the Community HealthFirst’s formulary?” on page 3 for information about how to request an exception.
What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact Customer Service and confirm that your drug is not covered. If you learn that Community HealthFirst does not cover your drug, you have two options:
• You can ask Customer Service for a list of similar drugs that are covered by Community HealthFirst. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Community HealthFirst.
• You can ask Community HealthFirst to make an exception and cover your drug. See below for information about how to request an exception.
How do I request an exception to the Community HealthFirst Formulary? You can ask Community HealthFirst to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
• You can ask us to cover your drug even if it is not on our formulary.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Community HealthFirst limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
Generally, Community HealthFirst will only approve your request for an exception if the alternative drugs included on the plan’s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you are requesting a formulary or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 34-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 34-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91 day supply and may be up to a 98 day supply, consistent with the dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 34-day emergency supply of that drug (unless you have a prescription written for fewer days) while you pursue a formulary exception.
Community HealthFirst will extend an override to current enrollees who experience level of care changes, such as a change in treatment settings. This allowance will be made for the 30-day period following the level of care change.
For more information For more detailed information about your Community HealthFirst prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about Community HealthFirst, please call Customer Service at 1-800-942-0247 (TTY Relay: Dial 7-1-1), 8:00 a.m. to 8:00 p.m., 7 days a week. Or visit www.healthfirst.chpw.org.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1- 800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.
Community HealthFirst Formulary The formulary that begins on page 13 provides coverage information about some of the drugs covered by Community HealthFirst. If you have trouble finding your drug in the list, turn to the Index that begins on page 117.
The information in the Requirements/Limits column tells you if Community HealthFirst has any special requirements for coverage of your drug.
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liana.cecil
Planes Medicare Advantage de Community HealthFirst™ Formulario de Medicamentos de Prescripción para 2013
Community HealthFirst MA Pharmacy Plan (HMO) Community HealthFirst MA Extra Plan (HMO)
POR FAVOR LEA. ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN.
Nota para los miembros existentes: Este formulario ha cambiado desde el año pasado. Por favor revise este documento para asegurarse de que todavía contiene los medicamentos que usted toma. Los beneficiarios deben utilizar las farmacias de la red para acceder a su beneficio de medicamentos recetados. Los beneficios, la lista farmacológica, la red de farmacias, las primas, los copagos y el coaseguro pueden cambiar el 1 de Enero de 2013.
Todos los beneficiarios deben utilizar las farmacias de la red del patrocinador de su plan para tener acceso a su beneficio de medicamentos con receta médica, excepto bajo circunstancias fuera de la rutina. Es posible que se apliquen limitaciones de cantidad y restricciones.
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Tricia.Piper
Typewritten Text
Los planes de Medicare Advantage de Community HealthFirst™ los ofrece Community Health Plan of Washington, que es una HMO calificada federalmente con un contrato de Medicare. Si necesita recibir la información en otro formato o idioma llame a Community HealthFirst al 1-800-944-1247 (TTY Relay: marque 7-1-1). Elhorario de la oficina es de 08:00 a.m. – 8:00 p.m., los 7 días de la semana.
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¿Qué es el Formulario de Community HealthFirst? Un formulario es una lista de los medicamentos seleccionados por Community HealthFirst en consulta con un equipo de proveedores de atención a la salud, el cual representa las terapias con receta médica que se considera que son una parte necesaria de un programa de tratamiento de calidad. Community HealthFirst generalmente cubrirá los medicamentos listados en nuestro formulario, siempre que el medicamento sea médicamente necesario, la receta médica sea abastecida en una farmacia de la red de Community HealthFirst, y se sigan las otras reglas del plan. Para mayor información sobre cómo abastecer sus recetas médicas, por favor examine su Evidencia de Cobertura.
¿Puede cambiar el Formulario? Generalmente, si usted está tomando un medicamento contenido en nuestro formulario 2013 que estaba cubierto a principios del año, nosotros no descontinuaremos ni reduciremos la cobertura del medicamento durante el año 2013 de cobertura, excepto cuando un nuevo medicamento genérico, menos caro, llegue a estar disponible o cuando se revele una nueva información adversa acerca de la seguridad o la efectividad de un medicamento. Otros tipos de cambio en el formulario, tales como el retirar un medicamento de nuestro formulario, no afectarán a los miembros que estén tomando el medicamento actualmente. Este permanecerá disponible al mismo costo compartido para aquellos miembros que lo estén tomando durante el resto del año de cobertura. Consideramos que es importante que usted tenga un acceso continuo durante el resto del año de cobertura a los medicamentos del formulario que estaban disponibles cuando usted eligió nuestro plan, excepto para los casos en los cuales usted puede ahorrar dinero adicional o podamos mejorar su seguridad.
Si retiramos los medicamentos de nuestro formulario, o aumentamos el requisito de autorización previa, los límites de cantidades y/o agregamos restricciones graduales en la terapia con un medicamento, debemos notificar a los miembros afectados por el cambio al menos 60 días antes de que el cambio llegue a entrar en vigencia, o en el momento en que el miembro solicite una nueva provisión del medicamento, en cuyo momento el miembro recibirá una provisión del medicamento para 60 días. Si la Administración de Alimentos y Medicamentos considera que un medicamento en nuestro formulario es peligroso o el fabricante del medicamento retira el medicamento del mercado, nosotros retiraremos inmediatamente el medicamento de nuestro formulario y proporcionaremos notificación a los miembros que estén tomando el medicamento. El formulario adjunto entra en vigencia a partir del 24 de agosto de 2012. Para obtener información actualizada acerca de los medicamentos cubiertos por Community HealthFirst, por favor visite nuestro sitio Web www.healthfirst.cphw.org o llame al Servicio al Cliente, durante las horas de 8 am a 8 pm, 7 días a la semana, al 1-800-942-0247, (Los usuarios con TTY deben marcar 711)
¿Cómo uso el Formulario?
Hay dos maneras de encontrar su medicamento dentro del formulario.
Afección médica El formulario comienza en la página 13. Los medicamentos en este formulario están agrupados en categorías, dependiendo del tipo de las afecciones médicas que se tratan con su uso. Por ejemplo, los medicamentos usados para tratar una afección cardiaca están listados bajo la categoría, “Medicamentos Cardiovasculares”. Si usted sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que empieza en la página 13. Luego busque su medicamento bajo el nombre de la categoría.
Listado alfabético Si no está seguro sobre qué categoría buscar, debe buscar su medicamento en el Índice que empieza en la página 117. El Índice proporciona un listado alfabético de todos los medicamentos que se incluyen en este documento. Tanto los medicamentos de marca, como los medicamentos genéricos están listados en el Índice. Busque en el Índice para encontrar su medicamento. Junto a su medicamento, verá el número de página donde puede encontrar la información de cobertura. Vaya a la página listada en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista.
¿Qué son las drogas genéricas? Community HealthFirst cubre los medicamentos de marca y los medicamentos genéricos. Un medicamento genérico está aprobado por la Administración de Alimentos y Medicamentos (FDA) ya que tiene los mismos ingredientes activos que el medicamento de marca. Los medicamentos genéricos normalmente cuestan menos que los medicamentos de marca. .
¿Existen algunas restricciones en mi cobertura? Es posible que algunos medicamentos cubiertos tengan requerimientos adicionales o límites de cobertura. Estos requerimientos y límites pueden incluir:
Autorización previa: Community HealthFirst requiere que usted o su médico obtengan una autorización previa para ciertos medicamentos. Esto significa que usted necesitará obtener aprobación de Community HealthFirst antes de abastecer sus recetas médicas. Si usted no obtiene aprobación, es posible que Community HealthFirst no cubra el medicamento.
Límites de cantidad: para ciertos medicamentos, Community HealthFirst limita la cantidad del medicamento que Community HealthFirst cubrirá. Por ejemplo, Community HealthFirst proporciona 68 tabletas por prescripción de Bupropion hcl. Esto puede ser en adición a una provisión normal para un mes o para tres meses.
Restricciones graduales en la terapia: En algunos casos, Community HealthFirst requiere que usted pruebe primero ciertos medicamentos para tratar su afección médica antes de que nosotros cubramos otro medicamento para esa afección. Por ejemplo, si el Medicamento A y el Medicamento B tratan su afección médica, es posible que Community HealthFirst no cubra el medicamento B a menos que usted pruebe primero el medicamento A. Si el medicamento A no funciona para usted, entonces Community HealthFirst cubrirá el medicamento B.
Para averiguar si su medicamento tiene algunos requerimientos adicionales o límites, consulte el formulario que empieza en la página 13. También puede obtener información adicional acerca de las restricciones que se aplican a medicamentos específicos cubiertos visitando nuestro sitio Web en www.healthfirst.chpw.org.
Usted puede pedir que Community HealthFirst haga una excepción a estas restricciones o límites. Vea la sección, “¿Cómo solicito una excepción al formulario de Community HealthFirst?” en la página 3 para información acerca de cómo solicitar una excepción.
¿Qué sucede si mi medicamento no está en el Formulario?
Si su medicamento no está incluido en este formulario, deberá ponerse en contacto primero con Servicio al Cliente y preguntar si su medicamento está cubierto. Si usted se entera que Community HealthFirst no cubre su medicamento, tiene dos opciones:
Puede pedir a Servicio al Cliente una lista de medicamentos similares que están cubiertos por Community HealthFirst. Cuando usted reciba la lista, muéstresela a su médico y pídale que prescriba un medicamento similar que está cubierto por Community HealthFirst.
Usted puede pedir a Community HealthFirst que haga una excepción y cobra su medicamento. Lea la siguiente sección para información sobre cómo solicitar una excepción.
¿Cómo puedo solicitar una excepción para el Formulario de Community HealthFirst? Usted puede pedir que Community HealthFirst haga una excepción a nuestras reglas de cobertura. Existen varios tipos de excepciones que usted puede pedirnos que hagamos.
Usted puede pedirnos que cubramos su medicamento incluso si no está en nuestro formulario.
Usted puede pedirnos que suspendamos las restricciones de cobertura o los límites sobre su medicamento. Por ejemplo, para ciertos medicamentos, Community HealthFirst limita la cantidad del medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, usted puede pedirnos que no apliquemos el límite y cubramos más.
Generalmente, Community HealthFirst aprobará su solicitud de una excepción solamente si los medicamentos alternativos incluidos en el formulario del plan, o las restricciones de utilización adicionales no serían tan eficaces para tratar su afección y/o causarían que usted tenga efectos médicos adversos.
Usted deberá comunicarse con nosotros para pedirnos una decisión inicial con respecto a una cobertura para un formulario, o una excepción para la restricción en el uso. Cuando esté solicitando un formulario, o esté utilizando una excepción a la restricción, deberá presentar una declaración de su médico apoyando su solicitud. Generalmente, nosotros debemos tomar nuestra decisión en menos de 72 horas de haber recibido la declaración de apoyo del médico que emitió la receta médica. Usted puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que su salud podría sufrir serios daños por esperar 72 horas para una decisión. Si se otorga su solicitud de apresurar la decisión, nosotros debemos darle una decisión no después de las 24 horas posteriores a cuando recibimos la declaración de apoyo del médico que emitió la receta médica.
¿Qué debo hacer antes de hablar con mi médico acerca de cambiar mis medicamentos o solicitar una excepción? Como miembro nuevo o continuo en nuestro plan, usted puede estar tomando medicamentos que no están en nuestro formulario. O, usted podría estar tomando un medicamento que se encuentra en nuestro formulario pero su posibilidad de obtenerlo es limitada. Por ejemplo, puede que necesite una autorización previa de nosotros antes de que pueda surtir su receta. Usted debe hablar con su médico para decidir si debe cambiar a un medicamento apropiado que cubramos o solicitar una excepción al formulario para que cubramos el medicamento que toma. Mientras que usted habla con su médico para determinar el curso correcto de acción para usted, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días que usted sea miembro de nuestro plan.
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Para cada uno de sus medicamentos que no esté en nuestro formulario o si su habilidad para obtener sus medicamentos es limitada, cubriremos un suministro temporal de 34 días (a menos que tenga una receta por menos días) cuando vaya a una farmacia de la red. Después de su primer suministro de 34 días, no pagaremos por estos medicamentos, incluso si usted ha sido miembro del plan por menos de 90 días.
Si usted es un residente de un centro de cuidado a largo plazo, le permitiremos surtir su receta hasta que hayamos proporcionado un suministro de 91 días y puede ser hasta un suministro de 98 días consistente con el incremento de suministro (a menos que tenga una receta por menos días). Cubriremos más de un suministro de estos medicamentos durante los primeros 90 días que usted sea un miembro de nuestro plan. Si usted necesita un medicamento que no esté en nuestro formulario o si su habilidad para obtener sus medicamentos es limitada, pero ya ha pasado los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia de 34 días de ese medicamento (a menos que tenga una receta por menos días) mientras solicita una excepción al formulario
Community HealthFirst extenderá una anulación a afiliados actuales que experimentan cambios en el nivel de cuidado, tal como un cambio en la configuración del tratamiento. Esta autorización se hará por el período de 30 días siguientes al cambio de nivel de cuidado.
Para mayor información Para obtener información más detallada acerca de su cobertura de medicamentos con receta médica de Community HealthFirst, por favor examine su Evidencia de Cobertura y los otros materiales del plan.
Si tiene preguntas acerca de Community HealthFirst, por favor llame a Servicio al Cliente al 1-800-942-0247 (Los usuarios con TTY deben marcar 711) de 8:00 a.m. a 8:00 p.m., los 7 días de la semana. O visite www.healthfirst.chpw.org.
Si tiene preguntas generales acerca de la cobertura de Medicare para medicamentos con receta médica, por favor llame a Medicare al 1-800-MEDICARE (1 800-633-4227) 24 horas al día / 7 días a la semana. Los usuarios de TTY/TDD deberán llamar al 1-877-486-2048. O visite www.medicare.gov.
El Formulario de Community HealthFirst El formulario que empieza en la página 13 proporciona información de cobertura acerca de algunos de los medicamentos cubiertos por Community HealthFirst. Si tiene dificultades para encontrar su medicamento en la lista, vaya al Índice que empieza en la página 117.
La primera columna de la tabla lista el nombre del medicamento. Los medicamentos de marca están en mayúsculas (como CRESTOR) y los medicamentos genéricos aparecen en cursiva en minúsculas (por ejemplo, simvastatina).
La información en la columna de Requerimientos/Límites, le indica si Community HealthFirst tiene algunos requerimientos especiales para la cobertura de su medicamento.
General Drug Table Drug Generic Tier Requirements/Limits
ANESTHETICS LOCAL ANESTHETICS bupivacaine hcl injection [INJ] 1
bupivacaine hcl-epinephrine [INJ] 1
lidocaine hcl injection [INJ] 1
lidocaine hcl-epinephrine [INJ] 1
1
ANTIINFECTIVES AMINOGLYCOSIDES amikacin sulfate injection [INJ] 1
gentamicin 80 mg/ns 100 ml pb, -90 mg/ns 100 ml pb, -100 mg/ns 100 ml, -60 mg/ns 50 ml pb, -70 mg/ns 50 ml pb, -80 mg/ns 50 ml pb [INJ]
1
gentamicin sulfate injection [INJ] 1
iso gentamicin 100 mg/100 ml, - isoton gentamicin 60 mg/50 ml, - isoton gentamicin 80 mg/50 ml [INJ][G]
1
neomycin sulfate tablet 1
tobramycin sulfate in ns [INJ] 1
tobramycin sulfate injection [INJ] 1
ANTHELMINTICS ALBENZA albendazole 2
metro iv [INJ] 1
metronidazole capsule, -tablet 1
metronidazole injection [INJ] 1
tinidazole tablet 1
APTIVUS tipranavir 3
ATRIPLA emtricitabine/tenofovir/efavir 3
COMPLERA emtricitab/rilpivirine/tenofov 3
CRIXIVAN indinavir 2
etravirine 3
INVIRASE CAPSULE saquinavir mesylate 2
INVIRASE TABLET saquinavir mesylate 3
ISENTRESS raltegravir potassium 3
KALETRA SOLUTION, -200-50 MG TABLET
ritonavir/lopinavir 3
lamivudine-zidovudine 1
LEXIVA TABLET fosamprenavir calcium 3
nevirapine 1
darunavir ethanolate 3
darunavir ethanolate 2
REYATAZ 100 MG CAPSULE atazanavir sulfate 2
REYATAZ 150 MG CAPSULE, -200 MG CAPSULE, -300 MG CAPSULE
atazanavir sulfate 3
SELZENTRY maraviroc 3
VIRAMUNE ORAL SUSP [G] nevirapine 2
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VIREAD tenofovir disproxil fumarate 3
ZERIT SOLUTION [G] stavudine 2
ZIAGEN SOLUTION abacavir sulfate 2
ZIAGEN TABLET [G] abacavir sulfate 2
zidovudine 1
CYCLOSERINE cycloserine 2
ethambutol hcl 1
cefadroxil 1
cefazolin [INJ] 1
cefazolin 20 gm bulk vial, -500 mg vial, -1 gm add-van vial, -1 gm vial, - 1 gm-d5w bag, -10 gm vial [INJ]
1
cefprozil 1
ceftazidime 1 gm vial, -2 gm vial, -6 gm vial [INJ]
1
cefuroxime injection [INJ] 1
cefuroxime sod 750 mg vial, -sod 1.5 gm vial, -sod 7.5 gm vial [INJ]
1
ERY-TAB erythromycin base 2
erythromycin ethylsuccinate tablet 1
fluconazole 150 mg tablet 1 [QLL, 2/7]
fluconazole 50 mg tablet, -100 mg tablet, -200 mg tablet
1 [PAR]
griseofulvin oral susp 1
GRIS-PEG griseofulvin ultramicrosize 2
ketoconazole tablet 1
Drug Generic Tier Requirements/Limits nystatin oral susp, -50,000,000 units pwd, -150,000,000 units pwd, - 500,000,000 units pwd, -tablet
1
voriconazole 200 mg tablet 3 [PAR]
voriconazole 50 mg tablet 1 [PAR]
OTHER ANTIINFECTIVE DRUGS ALINIA nitazoxanide 2
aztreonam [INJ] 1
baciim [INJ] 1
chloramphenicol sod succinate [INJ] 1
clindamycin 150 mg/ml addvan [INJ] 1
clindamycin hcl capsule 1
clindamycin palmitate hcl 1
clindamycin phosphate injection [INJ]
CUBICIN [INJ] daptomycin 3 [PAR]
DORIBAX 500 MG VIAL [INJ] doripenem 2
imipenem-cilastatin sodium [INJ] 1
20
meropenem [INJ] 1
SYNERCID [INJ] quinupristin/dalfopristin 3
TYGACIL [INJ] tigecycline 2
vancomycin 500 mg a/v vial, -500 mg vial, -750 mg vial, -1 gm add-van vial, -1 gm vial, -5 gm vial, -10 gm vial [INJ]
1 [PAR]
vancomycin hcl capsule 3
ZYVOX INJECTION [INJ] linezolid 3
ZYVOX ORAL SUSP, -TABLET linezolid 3 [PAR]
OTHER ANTIVIRAL DRUGS acyclovir capsule, -oral susp, -tablet 1
acyclovir sodium [INJ] 1
21
Drug Generic Tier Requirements/Limits famciclovir 500 mg tablet 1 [QLL, 21/7]
foscarnet sodium [INJ] 1
ganciclovir sodium [INJ] 1
HEPSERA adefovir dipivoxil 3
ribapak 200-400 mg dosepack 1
ribapak 400-400 mg dosepack, - 400-600 mg dosepack, -600-600 mg dosepack
3
ribasphere capsule, -200 mg tablet, -400 mg tablet
1
TAMIFLU 30 MG GELCAP oseltamivir phosphate 2 [QLL, 84/180]
TAMIFLU 45 MG GELCAP, -75 MG GELCAP
oseltamivir phosphate 2 [QLL, 42/180]
TAMIFLU 6 MG/ML SUSPENSION oseltamivir phosphate 2 [QLL, 600/180]
TYZEKA telbivudine 3
ZOVIRAX CREAM, -OINT acyclovir 2
OTHER MACROLIDES azithromycin injection [INJ] 1
azithromycin packet, -suspension, - tablet
ciclopirox cream, -gel, -lotion, - oil,shampoo,cleanser
1
econazole nitrate cream 1
1
1
23
Drug Generic Tier Requirements/Limits AMBISOME [INJ] amphotericin b liposome 3
AMPHOTEC 100 MG VIAL [INJ] ampho b c-s 2
amphotericin b injection [INJ] 1
CANCIDAS [INJ] caspofungin acetate 3
fluconazole in dextrose [INJ] 1
fluconazole in saline [INJ] 1
fluconazole-nacl [INJ] 1
VFEND IV [INJ][G] voriconazole 2
voriconazole injection [INJ] 1
amoxicillin 1
dicloxacillin sodium 1
nafcillin [INJ] 3
nafcillin 1 gm add-van vial, -2 gm add-vant vial, -2 gm vial, -10 gm bulk vial, -10 gm vial [INJ]
3
24
Drug Generic Tier Requirements/Limits oxacillin 1 gm add-vantage vl, -1 gm vial [INJ]
1
oxacillin 1 gm/ 50 ml inj [INJ] 1
oxacillin 2 gm add-vantage vl, -2 gm vial, -10 gm vial [INJ]
3
penicillin g potassium [INJ] 1
penicillin g procaine [INJ] 1
penicillin g sodium [INJ] 1
penicillin v potassium 1
CIPRO SUSPENSION ciprofloxacin 2
ciprofloxacin hcl tablet 1
doxycycline hyclate capsule, -e.c. cap, -e.c. tab, -100 mg tab
1
doxycycline monohydrate 1
1
1
nystatin-triamcinolone 1
1
PRIMSOL trimethoprim 2
trimethoprim tablet 1
VAGINAL ANTIFUNGALS miconazole 3 200 mg vag supp 1 [QLL, 3/3]
nystatin vaginal products 1
27
Drug Generic Tier Requirements/Limits terconazole 0.8% cream 1 [QLL, 20 gm/3]
terconazole 80 mg suppository 1 [QLL, 3/3]
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
AMEVIVE [INJ][LA] alefacept 3 [PAR]
amifostine [INJ] 3
anagrelide hcl 1
anastrozole tablet 1
AZASAN azathioprine 2 [PAR]
azathioprine tablet 1 [PAR]
bicalutamide 1
CAMPATH [INJ] alemtuzumab 3
CAPRELSA [LA] vandetanib 3
28
cyclosporine capsule, -solution 1 [PAR]
cyclosporine injection [INJ] 1 [PAR]
cyclosporine modified 1 [PAR]
medroxyprogesterone 2
ELITEK [INJ] rasburicase 3
EMCYT estramustine phosphate sodium 2
ENBREL 25 MG KIT, -25 MG/0.5 ML SYRINGE, -50 MG/ML SYRINGE [INJ]
etanercept 3 [PAR][QLL, 10/35]
ENBREL 50 MG/ML SURECLICK SYR [INJ]
etanercept 3 [PAR][QLL, 10 vials/35]
ERIVEDGE vismodegib 3
hecoria 0.5 mg capsule, -1 mg capsule
1 [PAR]
29
HUMIRA 20 MG/0.4 ML SYRINGE, -40 MG/0.8 ML SYRINGE [INJ]
adalimumab 3 [PAR][QLL, 5 syringes/35]
HUMIRA 40 MG/0.8 ML PEN, PSORIASIS STARTER PACK [INJ]
adalimumab 3 [PAR][QLL, 6/180]
HUMIRA CROHN'S STARTER PACK [INJ]
adalimumab 3 [PAR][QLL, 6 syringes/180]
hydroxyurea capsule 1
INLYTA axitinib 3
leucovorin calcium tablet 1
leuprolide 3 [PAR]
LYSODREN mitotane 2
MATULANE procarbazine 3
mercaptopurine tablet 1
mesna [INJ] 1
methotrexate tablet 1 [PAR]
mycophenolate mofetil 1 [PAR]
NILANDRON nilutamide 2
NULOJIX [INJ] belatacept 3 [PAR]
octreotide acet 200 mcg/ml vl, -acet 500 mcg/ml amp, -acet 500 mcg/ml syr, -acet 500 mcg/ml vl, -1,000 mcg/ml vial [INJ]
3
octreotide acet 50 mcg/ml amp, - acet 50 mcg/ml syr, -acet 50 mcg/ml vial, -acet 100 mcg/ml amp, -acet 100 mcg/ml syr, -acet 100 mcg/ml vl [INJ]
1
PROGRAF INJECTION [INJ] tacrolimus 2 [PAR]
RAPAMUNE 2 MG TABLET sirolimus 3 [PAR]
RAPAMUNE SOLUTION, -0.5 MG TABLET, -1 MG TABLET
sirolimus 2 [PAR]
REVLIMID [LA] lenalidomide 3
SANDOSTATIN LAR 10 MG KIT, 30 MG KIT [INJ]
octreotide 3 [QLL, 1/28]
Drug Generic Tier Requirements/Limits SANDOSTATIN LAR 20 MG KIT [INJ]
octreotide 3 [QLL, 2/28]
SPRYCEL dasatinib 3 [PAR]
SUTENT sunitinib malate 3
1 [PAR]
tamoxifen citrate tablet 1
TARCEVA erlotinib hcl 3
TRELSTAR DEPOT [INJ] triptorelin pamoate 2
TRELSTAR LA [INJ] triptorelin pamoate 2
tretinoin capsule 3
TYSABRI [INJ][LA] natalizumab 3 [PAR]
VANDETANIB [LA] vandetanib 3
VELCADE [INJ] bortezomib 3
VIDAZA [INJ] azacitidine 3
ZELBORAF vemurafenib 3 [PAR]
ZOLINZA vorinostat 3
everolimus 3 [PAR]
AUTONOMIC AND CNS MEDICATIONS ANALGESICS buprenorphine hcl injection [INJ] 1
butorphanol tartrate injection [INJ] 1
nalbuphine hcl injection [INJ] 1
PRIALT [INJ] ziconotide acetate 2
sufenta [INJ] 1
sufentanil citrate injection [INJ] 1
tramadol hcl er 100 mg tablet, -200 mg tablet, -300 mg tablet
1 [QLL, 34/34]
tramadol hcl-acetaminophen 1 [QLL, 272/34]
ANTIDEMENTIA DRUGS donepezil hcl 1
EXELON ADH. PATCH, SOLUTION
rivastigmine tartrate 2 [ST]
NAMENDA memantine hcl 2
benztropine mesylate tablet 1
trihexyphenidyl hcl elix 1
trihexyphenidyl hcl tablet 1
ANTIPSYCHOTIC DRUGS ABILIFY 10 MG TABLET aripiprazole 2 [QLL, 102/34]
ABILIFY 15 MG TABLET aripiprazole 2 [QLL, 68/34]
ABILIFY DISCMELT 10 MG TABLET
aripiprazole 2 [QLL, 102/34]
aripiprazole 2 [QLL, 68/34]
ABILIFY SOLUTION aripiprazole 2
chlorpromazine hcl tablet 1
34
Drug Generic Tier Requirements/Limits FANAPT 1 MG TABLET iloperidone 2 [QLL, 816/34]
FANAPT 12 MG TABLET iloperidone 2 [QLL, 68/34]
FANAPT 8 MG TABLET, -10 MG TABLET
iloperidone 2 [QLL, 102/34]
FAZACLO clozapine 2
1
haloperidol decanoate [INJ] 1
haloperidol injection [INJ] 1
haloperidol lactate solution 1
35
Drug Generic Tier Requirements/Limits INVEGA SUSTENNA 117 MG PREF SY, -156 MG PREF SY, -234 MG PREF SY [INJ]
paliperidone 3
INVEGA SUSTENNA 39 MG PREF SYR, -78 MG PREF SYR [INJ]
paliperidone 2
lurasidone hcl 2 [QLL, 34/34]
LATUDA 40 MG TABLET lurasidone hcl 2 [QLL, 68/34]
loxapine 1
olanzapine injection [INJ] 1
olanzapine-fluoxetine hcl 1
ORAP pimozide 2
36
Drug Generic Tier Requirements/Limits quetiapine fumarate 25 mg tab 1 [QLL, 1022/34]
quetiapine fumarate 300 mg tab 1 [QLL, 91/34]
RISPERDAL CONSTA 12.5 MG SYR, -25 MG SYR [INJ]
risperidone 2
risperidone 3
risperidone m-tab 0.5 mg odt 1 [QLL, 1088/34]
risperidone m-tab 1 mg odt 1 [QLL, 544/34]
37
Drug Generic Tier Requirements/Limits risperidone solution 1 [QLL, 544 ml/34]
SAPHRIS 10 MG TAB SUBLINGUAL
asenapine 2 [QLL, 68/34]
asenapine 2 [QLL, 136/34]
SEROQUEL XR 150 MG TABLET quetiapine fumarate 2 [QLL, 182/34]
thioridazine hcl 1
ZYPREXA RELPREVV [INJ][LA] olanzapine pamoate 3
ANTIVERTIGO AND ANTIEMETIC DRUGS ALOXI [INJ] palonosetron hcl 2 [QLL, 10/30]
CESAMET nabilone 3 [PAR][QLL, 30/5]
compro 1
38
Drug Generic Tier Requirements/Limits dronabinol 2.5 mg capsule, -5 mg capsule
1 [PAR]
aprepitant 2 [PAR][QLL, 1/1]
EMEND 80 MG CAPSULE aprepitant 2 [PAR][QLL, 2/2]
EMEND INJECTION [INJ] aprepitant 2
EMEND TRIFOLD PACK aprepitant 2 [PAR][QLL, 3/3]
granisetron hcl injection [INJ] 1
granisetron hcl tablet 1 [PAR][QLL, 2/1]
granisol 1 [PAR][QLL, 30 ml/3]
meclizine hcl tablet 1
ondansetron hcl 4 mg tablet, -8 mg tablet
1 [PAR][QLL, 12/5]
ondansetron hcl injection [INJ] 1
ondansetron hcl solution 1 [PAR][QLL, 150 ml/5]
ondansetron in sodium chloride [INJ]
1
phenadoz 1
trimethobenzamide hcl capsule 1
trimethobenzamide hcl injection [INJ]
clorazepate dipotassium 1 [PAR]
hydroxyzine hcl syrup, -tablet 1 [PAR]
hydroxyzine pamoate capsule 1 [PAR]
lorazepam injection [INJ] 1 [PAR]
lorazepam intensol 1 [PAR]
oxazepam 1 [PAR]
1
carbamazepine er 1
carbamazepine xr 1
40
Drug Generic Tier Requirements/Limits TEGRETOL XR 100 MG TABLET carbamazepine 2
TRILEPTAL SUSPENSION oxcarbazepine 2
codeine phosphate injection [INJ] 1
codeine sulfate 1
fentanyl citrate lozenge 3 [PAR][QLL, 120/30]
hydromorphone hcl injection [INJ] 1
hydromorphone hcl rectal, -solution, -tablet
1
methadone intensol 1
1 [QLL, 90/30]
1 [QLL, 120/30]
morphine sulfate injection [INJ] 1
morphine sulfate rectal, -solution, - tablet
1
OPANA ER 40 MG TABLET oxymorphone 3 [QLL, 90/30][ST]
OPANA ER 5 MG TABLET, -10 MG TABLET, -20 MG TABLET, -30 MG TABLET
oxymorphone 2 [QLL, 90/30][ST]
opium 1
oxycodone-acetaminophen 1
OXYCONTIN 10 MG TABLET, -15 MG TABLET, -20 MG TABLET, -30 MG TABLET, -40 MG TABLET, -60 MG TABLET
oxycodone 2 [QLL, 90/30][ST]
OXYCONTIN 80 MG TABLET oxycodone 3 [QLL, 90/30][ST]
oxymorphone hcl tablet 1
1 [QLL, 90/30]
roxicet tablet 1
sublimaze [INJ] 1
acetaminophen-codeine 1
co-gesic 1
trezix 1
zamicet 1
caffeine citrate injection [INJ] 1
dexmethylphenidate hcl 1
1
metadate er 1
methamphetamine hcl 1
methylphenidate er capsule sustained action, -10 mg tab, -20 mg tab
1
43
Drug Generic Tier Requirements/Limits methylphenidate hcl solution, -10 mg tab, -20 mg tab
1
DRUGS TO PREVENT AND TREAT HEADACHES ascomp with codeine 1
butalb-caff-acetaminoph-codein 1
dihydroergotamine mesylate injection [INJ]
naratriptan hcl 1 [QLL, 18/28]
sumatriptan 4 mg/0.5 ml cart, -4 mg/0.5 ml inject, -4 mg/0.5 ml kit, -4 mg/0.5 ml refill, -4 mg/0.5 ml vial, -6 mg/0.5 ml refill, -6 mg/0.5 ml syrng [INJ]
1 [QLL, 16 vials/28]
sumatriptan 6 mg/0.5 ml inject [INJ] 1 [QLL, 16 vials/28]
sumatriptan 6 mg/0.5 ml vial [INJ] 1 [QLL, 16 vials/28]
sumatriptan succinate tablet 1 [QLL, 18/28]
ZOMIG NASAL SPRAY zolmitriptan 2 [QLL, 18 nasal sprayers/28]
44
DILANTIN 30 MG CAPSULE, CHEW TAB
phenytoin 2
MARPLAN isocarboxazid 2
BANZEL ORAL SUSP, -200 MG TABLET
rufinamide 2
1
phenobarbital 15 mg tablet, -60 mg tablet, -100 mg tablet
1 [PAR]
phenobarbital elix, -16.2 mg tablet, - 30 mg tablet, -32.4 mg tablet, -64.8 mg tablet, -97.2 mg tablet
1 [PAR]
POTIGA ezogabine 2
primidone tablet 1
VIMPAT SOLUTION, -TABLET lacosamide 2 [PAR]
zonisamide 1 [PAR]
OTHER ANTIDEPRESSANTS budeprion sr 100 mg tablet 1 [QLL, 136/34]
budeprion sr 150 mg tablet 1 [QLL, 102/34]
budeprion xl 150 mg tablet 1 [QLL, 34/34]
budeprion xl 300 mg tablet 1 [QLL, 68/34]
bupropion hcl sr 100 mg tablet 1 [QLL, 136/34]
bupropion hcl sr 200 mg tab 1 [QLL, 68/34]
46
bupropion hcl xl 150 mg tablet 1 [QLL, 102/34]
bupropion hcl xl 300 mg tablet 1 [QLL, 68/34]
bupropion sr 150 mg tablet 1 [QLL, 102/34]
CYMBALTA 20 MG CAPSULE duloxetine 2 [PAR][QLL, 204/34]
maprotiline hcl 1
perphenazine-amitriptyline 1
PRISTIQ ER 100 MG TABLET desvenlafaxine succinate 2 [PAR][QLL, 136/34]
PRISTIQ ER 50 MG TABLET desvenlafaxine succinate 2 [PAR][QLL, 272/34]
SAVELLA 100 MG TABLET milnacipran hcl 2 [PAR][QLL, 68/34]
SAVELLA 12.5 MG TABLET milnacipran hcl 2 [PAR][QLL, 544/34]
SAVELLA TITRATION PACK milnacipran hcl 2 [PAR][QLL, 1/34]
trazodone hcl tablet 1
1 [QLL, 102/34]
47
Drug Generic Tier Requirements/Limits venlafaxine hcl er 150 mg cap 1 [QLL, 68/34]
venlafaxine hcl er 150 mg tab [G] (Schwarz Pharmac, Sun Pharma)
1 [PAR][QLL, 68/34]
venlafaxine hcl er 225 mg tab 1 [PAR][QLL, 34/34]
venlafaxine hcl er 37.5 mg cap (Schwarz Pharmac, Sun Pharma)
1 [QLL, 204/34]
venlafaxine hcl er 37.5 mg tab [G] (Schwarz Pharmac, Sun Pharma)
1 [PAR][QLL, 204/34]
venlafaxine hcl er 75 mg cap 1 [QLL, 102/34]
venlafaxine hcl er 75 mg tab [G] (Schwarz Pharmac, Sun Pharma)
1 [PAR][QLL, 102/34]
AZILECT rasagiline mesylate 2
bromocriptine mesylate capsule, - tablet
TASMAR tolcapone 3
48
disulfiram tablet 1
flumazenil [INJ] 1
guanidine hcl 1
1
pyridostigmine 2
naltrexone hcl tablet 1
neostigmine methylsulfate injection [INJ]
SECONDARY AMINES amoxapine 1
desipramine hcl tablet 1
protriptyline hcl 1
temazepam 1 [PAR]
zolpidem tartrate 1 [QLL, 34/34]
zolpidem tartrate er 1 [QLL, 34/34]
SELECTIVE SEROTONIN REUPTAKE INHIBITORS citalopram hbr 10 mg tablet 1 [QLL, 136/34]
citalopram hbr 20 mg tablet 1 [QLL, 68/34]
citalopram hbr 40 mg tablet 1 [QLL, 34/34]
citalopram hbr solution 1
escitalopram oxalate solution 1
fluoxetine hcl 10 mg capsule, -10 mg tablet
1 [QLL, 272/34]
1
50
Drug Generic Tier Requirements/Limits fluvoxamine maleate 100 mg tab 1 [QLL, 102/34]
fluvoxamine maleate 25 mg tab 1 [QLL, 408/34]
fluvoxamine maleate 50 mg tab 1 [QLL, 204/34]
paroxetine cr 12.5 mg tablet 1 [QLL, 204/34]
paroxetine cr 25 mg tablet 1 [QLL, 102/34]
paroxetine cr 37.5 mg tablet, -er 37.5 mg tablet
1 [QLL, 68/34]
PAXIL ORAL SUSP paroxetine 2 [ST]
sertraline hcl 100 mg tablet 1 [QLL, 68/34]
sertraline hcl solution 1
VIIBRYD 10 MG TABLET vilazodone hydrochloride 2 [QLL, 136/34][ST]
VIIBRYD TITRATION PACK vilazodone hydrochloride 2 [QLL, 30/30][ST]
SMOKING CESSATION PRODUCTS buproban 1
CHANTIX varenicline tartrate 2
NICOTROL nicotine inhaler 2
SUCCINIMIDES CELONTIN methsuximide 2
ethosuximide capsule, -syrup 1
clomipramine hcl capsule 1
imipramine hcl tablet 1
divalproex sodium er 1
CARDIOVASCULAR MEDICATIONS ANGIOTENSIN CONVERTING ENZYME INHIBITORS benazepril hcl tablet 1
captopril tablet 1
moexipril hcl 1
perindopril erbumine 1
quinapril hcl 1
irbesartan 1
mexiletine hcl capsule 1
propafenone hcl 1
1
1
atenolol tablet 1
bisoprolol fumarate 1
labetalol hcl tablet 1
metoprolol tartrate tablet 1
1
propranolol hcl solution 1
timolol maleate tablet 1
amlodipine besylate tablet 1
54
dilt-xr 1
nifediac cc 1
nifedical xl 1
nifedipine er 1
taztia xt 1
verapamil er 120 mg tablet, -180 mg tablet, -240 mg tablet
1
verapamil er pm 1
verapamil hcl capsule sustained action, -tablet, -er 120 mg tablet, -er 240 mg tablet
1
CENTRALLY ACTING ANTIHYPERTENSIVES clonidine patches 1 [QLL, 5/35]
clonidine hcl injection [INJ] 1
clonidine hcl tablet 1
methyldopa 1
DIBENZYLINE phenoxybenzamine 2
HMG-COA REDUCTASE INHIBITORS ADVICOR 500 MG-20 MG TABLET lovastatin/niacin 2 [QLL, 34/34]
ADVICOR 750 MG-20 MG TABLET, -1,000 MG-20 MG TABLET, -1,000 MG-40 MG TABLET
lovastatin/niacin 2 [QLL, 68/34]
amlodipine-atorvastatin 1 [QLL, 34/34]
CRESTOR 10 MG TABLET, -20 MG TABLET, -40 MG TABLET
rosuvastatin calcium 2 [QLL, 34/34]
CRESTOR 5 MG TABLET rosuvastatin calcium 2 [QLL, 34/34][ST]
fluvastatin sodium 20 mg cap 1 [QLL, 34/34]
fluvastatin sodium 40 mg cap 1 [QLL, 68/34]
lovastatin 10 mg tablet 1 [QLL, 34/34]
lovastatin 20 mg tablet, -40 mg tablet
1 [QLL, 68/34]
SIMCOR 500-20 MG TABLET, 500-40 MG TABLET, -1,000-40 MG TABLET
niacin/simvastatin 2 [QLL, 34/34]
Drug Generic Tier Requirements/Limits SIMCOR 750-20 MG TABLET, 1,000-20 MG TABLET
niacin/simvastatin 2 [QLL, 68/34]
HYPOLIPOPROTEINEMICS cholestyramine 1
cholestyramine light 1
colestipol hcl 1
NIASPAN niacin 2
bumetanide tablet 1
isosorbide dinitrate 1
isosorbide mononitrate 1
nitroglycerin injection [INJ] 1
amiodarone hcl tablet 1
ibutilide fumarate [INJ] 1
AMTURNIDE aliskiren/amlodipine/hctz 2 [ST]
captopril-hydrochlorothiazide 1
fosinopril-hydrochlorothiazide 1
irbesartan-hydrochlorothiazide 1
lisinopril-hydrochlorothiazide 1
losartan-hydrochlorothiazide 1
methyldopa-hydrochlorothiazide 1
metoprolol-hydrochlorothiazide 1
moexipril-hydrochlorothiazide 1
nadolol-bendroflumethiazide 1
propranolol-hydrochlorothiazid 1
quinapril-hydrochlorothiazide 1
TWYNSTA telmisartan/amlodipine 2 [ST]
digoxin injection [INJ] 1
dopamine hcl in 5% dextrose [INJ] 1
dopamine hcl injection [INJ] 1
kalexate 1
milrinone lactate [INJ] 1
norepinephrine bitartrate [INJ] 1
RANEXA ranolazine 2
OTHER VASODILATING DRUGS ADCIRCA adcirca (tadalafil) 3 [PAR][QLL, 68/34]
epoprostenol sodium [INJ] 1
REMODULIN [INJ][LA] treprostinil sodium 3 [PAR]
60
TRACLEER [LA] bosentan 3 [PAR]
veletri [INJ] 1
amiloride-hydrochlorothiazide 1
eplerenone 1
chlorothiazide sodium [INJ] 3
indapamide 1
methyclothiazide 1
metolazone 1
VASODILATOR ANTIHYPERTENSIVES doxazosin mesylate 1 mg tab, -2 mg tab, -4 mg tab
1 [QLL, 34/34]
61
hydralazine hcl tablet 1
terazosin 1 mg capsule, -2 mg capsule, -5 mg capsule
1 [QLL, 34/34]
bp 10-1 1
clenia emulsion 1
clindacin p 1
1
1
prascion 1
sodium sulfacetamide pad, medicated pad
1
1
1 [PAR]
vitazol 1
DOVONEX CREAM calcipotriene 2
DRITHOCREME HP anthralin 2
sodium sulfacetamide solution 1
amnesteem 1
claravis 1
myorisan 1
sotret 1
malathion 1
amcinonide 1
1
1
1
diflorasone diacetate 1
1
64
1
1
hydrocortisone 1% cream 1
hydrocortisone 1% cream, -2.5% cream, -2.5% lotion, -1% absorbase, -1% ointment, -2.5% ointment
1
1
1
1
ELIDEL pimecrolimus 2 [PAR]
fluorouracil cream, -soln, top 1
hypercare 1
remeven 1
SOLARAZE diclofenac sodium 2 [PAR]
u-kera e urea emollient 1
urea 40% cream, -45% cream, - 50% cream, -foam (non- contraceptive), -gel, -40% lotion, - soln, top, -50% emulsion, -50% topical suspension
1
CHEMET succimer 2
66
Drug Generic Tier Requirements/Limits EXJADE 250 MG TABLET, -500 MG TABLET [LA]
deferasirox 3
aminocaproic acid injection [INJ] 1
aminocaproic acid syrup, -500 mg tab
1
BUPHENYL sodium phenylbutyrate 3
CARBAGLU carglumic acid 3
ergoloid mesylates tablet 1
ORFADIN [LA] nitisinone 3
THALOMID thalidomide 3
XIAFLEX [INJ][LA] collagenase clostridium hist. 3
EAR-NOSE-THROAT MEDICATIONS DRUGS AFFECTING THE EAR acetasol hc 1
acetic acid otic drops 1
67
antipyrine-benzocaine 1
aurodex 1
auroguard 1
treagan otic 1
DRUGS AFFECTING THE NOSE azelastine hcl nasal drops/sprays 1 [QLL, 60 ml/34]
flunisolide nasal inhaled steroids 1 [QLL, 75 ml/34]
fluticasone propionate nasal inhaled steroids
1 [QLL, 32 gm/34]
triamcinolone acetonide nasal inhaled steroids
1 [QLL, 33 gm/34]
1
68
Drug Generic Tier Requirements/Limits doxycycline hyclate 20 mg tab 1
periogard 1
propylthiouracil tablet 1
baycadron 1
1
1
69
Drug Generic Tier Requirements/Limits prednisolone 15 mg/5 ml soln 1
prednisolone 5 mg/5 ml soln, -6.7 mg/5 ml soln, -15 mg/5 ml soln
1
1
GLUCAGON EMERGENCY KIT [INJ]
glucagon, human recombinant 2
exenatide 2 [PAR][QLL, 5 ml/34]
BYETTA 5 MCG DOSE PEN INJ [INJ]
exenatide 2 [PAR][QLL, 2 ml/34]
SYMLIN [INJ] pramlintide acetate 2 [PAR][QLL, 35 ml/34]
SYMLINPEN 120 [INJ] pramlintide acetate 2 [PAR][QLL, 22 ml/34]
SYMLINPEN 60 [INJ] pramlintide acetate 2 [PAR][QLL, 12 pens/34]
INSULIN LANTUS [INJ] 2
NOVOLIN 70-30 [INJ] 2
NOVOLIN R [INJ] 2
NOVOLOG MIX 70-30 [INJ] 2
ORAL HYPOGLYCEMICS AND COMBOS acarbose 100 mg tablet 1 [QLL, 102/34]
acarbose 25 mg tablet 1 [QLL, 408/34]
acarbose 50 mg tablet 1 [QLL, 204/34]
ACTOPLUS MET pioglitazone hcl/metformin hc 2 [QLL, 102/34][ST]
ACTOPLUS MET XR 15-1,000 MG TB
pioglitazone hcl/metformin hc 2 [QLL, 68/34][ST]
ACTOPLUS MET XR 30-1,000 MG TB
pioglitazone hcl/metformin hc 2 [QLL, 34/34][ST]
ACTOS pioglitazone hcl 2 [QLL, 34/34][ST]
DUETACT pioglitazone/glimepiride 2 [QLL, 34/34][ST]
glimepiride 1 mg tablet 1 [QLL, 272/34]
glipizide 10 mg tablet 1 [QLL, 136/34]
glipizide 5 mg tablet 1 [QLL, 272/34]
glipizide er 10 mg tablet 1 [QLL, 68/34]
glipizide er 2.5 mg tablet 1 [QLL, 272/34]
glipizide er 5 mg tablet 1 [QLL, 136/34]
glipizide xl 10 mg tablet 1 [QLL, 68/34]
71
Drug Generic Tier Requirements/Limits glipizide xl 2.5 mg tablet 1 [QLL, 272/34]
glipizide xl 5 mg tablet 1 [QLL, 136/34]
glipizide-metformin 2.5-250 mg 1 [QLL, 272/34]
glipizide-metformin 5-500 mg, -2.5- 500 mg
1 [QLL, 136/34]
glyburide micro 1.5 mg tab 1 [QLL, 272/34]
glyburide micro 3 mg tablet 1 [QLL, 136/34]
glyburide micro 6 mg tablet 1 [QLL, 68/34]
glyburide-metformin 2.5-500 mg, -5- 500 mg
1 [QLL, 136/34]
JANUMET sitagliptin phos/metformin hcl 2 [QLL, 68/34]
JANUMET XR 100-1,000 MG TABLET, -50-500 MG TABLET
sitagliptin phos/metformin hcl 2 [QLL, 34/34]
JANUMET XR 50-1,000 MG TABLET
sitagliptin phos/metformin hcl 2 [QLL, 68/34]
JANUVIA sitagliptin phosphate 2 [QLL, 34/34]
JUVISYNC sitagliptin/simvastatin 2 [QLL, 34/34]
KOMBIGLYZE XR 2.5-1,000 MG TAB
saxagliptin hcl/metformin hcl 2 [QLL, 68/34]
KOMBIGLYZE XR 5-500 MG TABLET, -5-1,000 MG TAB
saxagliptin hcl/metformin hcl 2 [QLL, 34/34]
metformin hcl 1,000 mg tablet 1 [QLL, 85/34]
72
Drug Generic Tier Requirements/Limits metformin hcl 500 mg tablet 1 [QLL, 170/34]
metformin hcl 850 mg tablet 1 [QLL, 102/34]
metformin hcl er 1,000 mg tab 1 [QLL, 68/34]
metformin hcl er 500 mg tab, -500 mg tablet
1 [QLL, 136/34]
nateglinide 120 mg tablet 1 [QLL, 102/34]
nateglinide 60 mg tablet 1 [QLL, 204/34]
ONGLYZA saxagliptin hydrochloride 2 [QLL, 34/34]
RIOMET metformin 2 [QLL, 867/34]
tolazamide 250 mg tablet 1 [QLL, 136/34]
tolazamide 500 mg tablet 1 [QLL, 68/34]
tolbutamide 1 [QLL, 204/34]
ALDURAZYME [INJ][LA] laronidase 3
alendronate sodium 35 mg tab, -70 mg tab
1 [QLL, 5/35]
alendronate sodium 5 mg tablet, -10 mg tab, -40 mg tab
1 [QLL, 34/34]
cabergoline 1 [QLL, 20/34]
73
1
etidronate disodium 1
EVISTA raloxifene 2
fludrocortisone acetate tablet 1
fortical 1
LUMIZYME [INJ][LA] alglucosidase alfa 3
MIACALCIN INJECTION [INJ] calcitonin 2 [PAR]
MYOZYME [INJ][LA] alglucosidase alfa 3
NAGLAZYME [INJ][LA] galsulfase 3
pamidronate disodium [INJ] 1 [PAR]
RECLAST [INJ] zoledronic acid 2 [PAR]
SAMSCA tolvaptan 3 [PAR][QLL, 68/34]
SENSIPAR 30 MG TABLET cinacalcet hcl 2
SENSIPAR 60 MG TABLET, -90 MG TABLET
cinacalcet hcl 3
XGEVA [INJ] denosumab 3
ZOMETA [INJ] zoledronic acid 3
THYROID SUPPLEMENTS ARMOUR THYROID thyroid 2
levothroid 1
levothyroxine sodium tablet 1
liothyronine sodium tablet 1
loperamide 2 mg capsule 1
paregoric 1
75
metoclopramide hcl injection [INJ] 1
metoclopramide hcl syrup 1
metoclopramide hcl tablet 1
cimetidine solution, -tablet 1
1
1
ranitidine hcl syrup 1
misoprostol 1
OTHER GI DRUGS AMITIZA lubiprostone 2
APRISO mesalamine 2
balsalazide disodium 1
CANASA mesalamine 2
LOTRONEX alosetron 3
PENTASA mesalamine 2
procto-pak 1
proctosol-hc 1
proctozone-hc 1
77
sulfasalazine dr 1
sulfasalazine tablet 1
ursodiol capsule, -tablet 1
ZENPEP amylase/lipase/protease 2
PROTON PUMP INHIBITORS lansoprazole dr 15 mg capsule 1 [QLL, 34/34]
lansoprazole dr 30 mg capsule 1
NEXIUM DR 20 MG CAPSULE, DR 10 MG PACKET, -DR 20 MG PACKET
esomeprazole mag trihyd 2 [QLL, 34/34][ST]
NEXIUM DR 40 MG CAPSULE, DR 40 MG PACKET
esomeprazole mag trihyd 2 [ST]
NEXIUM I.V. [INJ] esomeprazole mag trihyd 2
omeprazole dr 10 mg capsule, -dr 20 mg capsule
1 [QLL, 34/34]
omeprazole-bicarb 40-1,100 cap 1
pantoprazole sod dr 40 mg tab 1
78
Drug Generic Tier Requirements/Limits IMMUNOLOGICALS AND VACCINES
GROWTH HORMONES AND RELATED DRUGS EGRIFTA [INJ] tesamorelin acetate 3 [PAR]
OMNITROPE 5 MG/1.5 ML CRTG, -10 MG/1.5 ML CRTG [INJ]
somatropin 2 [PAR]
SAIZEN [INJ] somatropin 3 [PAR]
IMMUNOLOGICALS AND VACCINES ACTHIB [INJ] haemophilus b-tet toxoid 2
ADACEL [INJ] diphther,pertuss,tetanus vac 2
ATGAM [INJ] lymphocyte immune globulin 3 [PAR]
BCG VACCINE (TICE STRAIN) [INJ]
bcg vaccine 2
CARIMUNE NF NANOFILTERED [INJ]
CERVARIX [INJ] human papillomav vacc bival/pf 2
CINRYZE [INJ] c1 esterase inhibitor 3 [PAR]
COMVAX [INJ] hepatitis b/haemophilus b vacc 2
DAPTACEL [INJ] diphther,pertuss,tetanus vac 2
DECAVAC [INJ] tetanus,diphtheria toxoid 2
DIPHTHERIA-TETANUS TOXOID [INJ]
tetanus,diphtheria toxoid 2
FIRAZYR [INJ] icatibant acetate 3 [PAR]
FLEBOGAMMA [INJ] immune globulin - iv 3 [PAR]
79
Drug Generic Tier Requirements/Limits FLEBOGAMMA DIF [INJ] immune globulin - iv 3 [PAR]
GAMASTAN S-D [INJ] immune globulin - im 2
GAMMAGARD S-D [INJ] immune globulin - iv 3 [PAR]
GAMUNEX [INJ] immune globulin - iv 3 [PAR]
GAMUNEX-C 1 GRAM/10 ML VIAL, -10 GRAM/100 ML VIAL, -20 GRAM/200 ML VIAL [INJ]
immune globulin - iv/sq 3 [PAR]
GAMUNEX-C 2.5 GRAM/25 ML VIAL, -5 GRAM/50 ML VIAL [INJ]
immune globulin - iv/sq 2 [PAR]
GARDASIL [INJ] human papillomavirus vacc 2
HAVRIX [INJ] hepatatis a virus vaccine 2
HIZENTRA 1 GRAM/5 ML VIAL [INJ]
immune globulin- sq 2 [PAR]
HIZENTRA 2 GRAM/10 ML VIAL, -4 GRAM/20 ML VIAL [INJ]
immune globulin- sq 3 [PAR]
HYPERHEP B S-D [INJ] hepatitis b immune globulin 2
HYPERRHO S-D [INJ] rho(d) immune globulin 2
IMOGAM RABIES-HT [INJ] rabies immune globulin 2
IMOVAX RABIES VACCINE [INJ] rabies vaccine,human diploid 2
INFANRIX [INJ] diphther,pertuss,tetanus vac 2
INFANRIX PF [INJ] diphther,pertuss,tetanus vac 2
IPOL [INJ] poliomyelitis vac,killed 2
IXIARO [INJ] japanese encephalitis vaccine 2
JE-VAX [INJ] japanese encephalitis vaccine 2
MENACTRA [INJ] meningococcal vac a,c,y,w-135 2
MENOMUNE-A-C-Y-W-135 [INJ] meningococcal vac a,c,y,w-135 2
80
MOZOBIL [INJ] plerixafor 3
PEDVAXHIB [INJ] haemophilus b vaccine 2
PRIVIGEN [INJ] immune globulin - iv 3 [PAR]
PROCRIT 2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, -4,000 UNITS/ML VIAL, -10,000 UNITS/ML VIAL [INJ]
epoetin alfa 2 [PAR]
epoetin alfa 3 [PAR]
PROQUAD [INJ] measles,mumps,rub,varicella 2
RECOMBIVAX HB [INJ] hepatitis b virus vaccine 2
ROTATEQ rotavirus vac, live pentav 2
TETANUS DIPHTHERIA TOXOIDS [INJ]
TETANUS-DIPHTERIA-DECAVAC [INJ]
TRIPEDIA [INJ] diphther,pertuss,tetanus vac 2
TWINRIX [INJ] hep b vir recomb/hep a vir 2
TYPHIM VI [INJ] typhoid vaccine 2
81
Drug Generic Tier Requirements/Limits VAQTA [INJ] hepatatis a virus vaccine 2
VARIVAX VACCINE [INJ] varicella virus vaccine live 2
YF-VAX [INJ] yellow fever vaccine 2
ZOSTAVAX [INJ] varicella vacc/pf 2
INTERFERONS ACTIMMUNE [INJ][LA] interferon gamma-1b,recomb. 3
AVONEX [INJ] interferon beta-1a 3 [PAR][QLL, 4 kits/28]
AVONEX ADMINISTRATION PACK [INJ]
AVONEX PEN [INJ] interferon beta-1a 3 [PAR][QLL, 4 pens/28]
INFERGEN [INJ] interferon alfacon-1 3
INTRON A 3 MILLION UNIT/ML PEN, -6 MILLION UNIT/ML VL, -10 MILLION UNIT PEN, -10 MILLION UNIT/ML, -10 MILLION UNITS VIAL [INJ]
interferon alfa-2b , recomb. 2
INTRON A 5 MILLION UNIT/ML PEN, -18 MILLION UNITS VIAL, -50 MILLION UNITS VIAL [INJ]
interferon alfa-2b , recomb. 3
peginterferon alfa-2a 3 [PAR][QLL, 4 syringes/28]
PEGASYS 180 MCG/ML VIAL [INJ] peginterferon alfa-2a 3 [PAR][QLL, 4 vials/28]
PEGASYS PROCLICK 135 MCG/0.5 [INJ]
peginterferon alfa-2a 3 [PAR][QLL, 4/28]
PEGASYS PROCLICK 180 MCG/0.5 [INJ]
peginterferon alfa-2a 3 [PAR][QLL, 4 vials/28]
PEGINTRON 50 MCG KIT [INJ] peginterferon alfa-2b 3 [PAR][QLL, 5 kits/34]
PEGINTRON 80 MCG KIT, -120 MCG KIT, -150 MCG KIT [INJ]
peginterferon alfa-2b 3 [PAR][QLL, 5 pens/34]
82
REBIF 22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML SYRINGE [INJ]
interferon beta-1a/albumin 3 [PAR][QLL, 8 syringes/35]
REBIF TITRATION PACK [INJ] interferon beta-1a/albumin 3 [PAR][QLL, 12 syringes/28]
SYLATRON [INJ] peginterferon alfa-2b 3
SYLATRON 4-PACK [INJ] peginterferon alfa-2b 3
INTERLEUKIN RECPTR ANTAGONIST ACTEMRA 200 MG/10 ML VIAL, 400 MG/20 ML VIAL [INJ]
tocilizumab 3 [PAR]
ARCALYST [INJ][LA] rilonacept 3 [PAR]
ILARIS [INJ][LA] canakinumab 3 [PAR]
INTERLEUKINS NEUMEGA [INJ] oprelvekin 3 [QLL, 21 vials/21]
PROLEUKIN [INJ] aldesleukin 3
NEULASTA [INJ] pegfilgrastim 3 [PAR][QLL, 2 syringes/30]
NEUPOGEN [INJ] filgrastim 3 [PAR]
MEDICAL (MISCELLANEOUS) SUPPLIES DIABETIC SUPPLIES
AIMSCO INS SYR 0.3 ML 29GX1/2, 2 -AIMSCO INS SYR 0.3 ML 30GX5/16, -AIMSCO INS SYR 1 ML 29GX1/2, -AIMSCO SYRING 0.3 ML 31GX5/16, -AIMSCO
83
Drug Generic Tier Requirements/Limits SYRING 0.5 ML 31GX5/16, -BD INSUL SYR 0.3 ML 31GX15/64, BD INSUL SYR 0.5 ML 31GX15/64, -BD INSULIN SYR 0.3 ML 28GX1/2, -BD INSULIN SYR 0.3 ML 29GX1/2, -BD INSULIN SYR 0.3 ML 30GX1/2, -BD INSULIN SYR 0.5 ML 30GX1/2, -BD INSULIN SYR 0.5ML 31GX5/16, BD INSULIN SYR 1 ML 25GX1, BD INSULIN SYR 1 ML 25GX5/8, BD INSULIN SYR 1 ML 26GX1/2, BD INSULIN SYR 1 ML 27GX5/8, BD INSULIN SYR 1 ML 31GX15/64, -BD INSULIN SYR 1 ML 31GX5/16, -BD INSULIN SYRINGE 1 ML, -BD INSULIN U100-3/10 ML SYR, FIFTY50 INS SYR 1 ML 31GX5/16, -FIFTY50 INSULIN SYRINGE 0.3 ML, -FIFTY50 INSULIN SYRINGE 0.5 ML, -INS SYR 0.3 ML 29GX1/2, -INS SYR 0.3 ML 30GX5/16, -INS SYR 0.5 ML 28GX1/2, -INS SYR 0.5 ML 29GX1/2, -INS SYR 0.5 ML 30GX1/2, -INS SYR 0.5 ML 30GX5/16, -INS SYR 1 ML 28GX1/2, -INS SYR 1 ML 29GX1/2, -INS SYR 1 ML 30GX5/16, -INS SYR 1 ML 31GX5/16, -INS SYR U100 1 ML 28GX1/2, -INS SYRIN 0.3 ML 30GX1/2, -INS SYRIN 1 ML 29GX1/2, -INS SYRING 0.3 ML 30GX5/16, -INS SYRINGE 1 ML 28GX1/2, -INS SYRINGE 1 ML 30GX1/2, -INS SYRINGE 1 ML 30GX5/16, -INS SYRINGE 3/10 ML, -INSUL SYR 0.3 ML 31GX5/16, INSUL SYR 0.5 ML 28GX1/2, INSUL SYR 0.5 ML 30GX1/2, INSUL SYR 0.5 ML 31GX5/16, -0.3 ML SYRINGE, -0.5 ML SYRINGE, 1 ML SYRINGE, -3/10 ML SYRINGE, -SAFETY SYRINGE, SYR 0.3 ML 29GX1/2, -SYR 0.5 ML 28GX1/2, -SYR 1 ML 29GX1/2,
84
Drug Generic Tier Requirements/Limits SYR 1 ML 30GX5/16, -SYR 1 ML 31GX5/16, -SYRIN 0.3 ML 29GX1/2, -SYRIN 0.3 ML 30GX1/2, -SYRIN 0.3 ML 30GX5/16, -SYRIN 0.3 ML 31GX5/16, -SYRIN 0.3 ML 31GX5/16, -SYRIN 0.5 ML 30GX1/2, -SYRIN 0.5 ML 30GX5/16, -SYRIN 0.5 ML 31GX5/16, -SYRIN 1 ML 29GX1/2, 1 ML 29GX1/2, -1 ML 31GX5/16, -1 ML-HARD PK, -INSULN SYR 0.5 ML 30GX5/16, -KINRAY INS SYR 1 ML 31GX5/16, -KINRAY SYRING 0.3 ML 31GX5/16, -KINRAY SYRING 0.5 ML 31GX5/16, KMART VALU PLUS SYR 1/2 ML, KMART VALU PLUS SYR 3/10 ML, -KMART VALU PLUS SYRINGE 1 ML, -PREF PLUS SYRING 1 ML 29GX1/2, -PREFERRED PLUS 0.3 ML 30GX
1ST TIER UNIFINE PENTP 5MM 31G, -1ST TIER UNIFINE PNTIP 6MM 31G, -1ST TIER UNIFINE PNTIP 8MM 31G, -1ST TIER UNIFINE PNTP 12MM 29G
2
2
ALCOHOL PADS 2
ALCOHOL SWABS 2
ALCOHOL WIPES 2
ASSURE ID INSULIN SAFETY 2
AURORA PEN NEEDLE 6MM 31G, -AURORA PEN NEEDLES 12MM 29G, -AURORA PEN NEEDLES 8MM 31G, -BD PEN NEEDLE 29GX1/2, -BD PEN NEEDLE 29GX3/16, -BD PEN NEEDLE 29GX5/16, -BD PEN NEEDLE 30GX3/16, -BD PEN NEEDLE MINI 31GX3/16, -BD PEN NEEDLE NANO 32GX5/32, -BD PEN NEEDLE SHORT 31GX5/16, CLICKFINE PEN NDL 31GX1/4, CLICKFINE PEN NDL 31GX5/16, INSULIN PEN NEEDLE, -LIVE BETTER PEN NEEDLE 6MM 31G, -LIVE BETTER PEN NEEDLES 12MM, -LIVE BETTER PEN NEEDLES 8MM, -MS PEN NEEDLE 6MM 31G, -12MM 29G NEEDLES, -8MM 31G NEEDLES, 31G X 3/16, -31GX3/16, -31GX5/16, -6MM 31G, -S 12MM 29G, -S 29G, -S 31G, -S 31G X 5/16, -S 5MM 31G, -S 6MM 31G, -S 8MM 31G, RELION PEN 29G NEEDLE, RELION PEN 31G NEEDLE, TODAY'S HLT PN NEEDLE 12MM 29G, -TODAY'S HLTH PN NEEDLE 6MM 31G, -TODAY'S HLTH PN NEEDLE 8MM 31G, -UNIFINE PENTIP 12MM 29G, -UNIFINE PENTIP 6MM 31G, -UNIFINE PENTIP 8MM 31G
2
Drug Generic Tier Requirements/Limits AUTOPEN 2
BD SAFTGLD INS 0.3 ML 31GX5/16, -BD SAFTGLD INS SYR 0.5 ML 30G, -INSULIN SAFETY SYRINGE
2
2
2
2
EXEL INSULIN SYRINGE 2
INJECT-EASE 2
Drug Generic Tier Requirements/Limits INSUL PEN NEEDLES 8MM, 2
INSULIN SYR 1/2 ML BULK PACK, -1 ML SYRN 27X1/2, -1 ML SYRN 28GX1/2, -INSUL SYR U100, INSUL SYR U100 0.5 ML, -INSUL SYR U100 1 ML, -INSULIN SYR 0.3 ML, -INSULIN SYR 0.5 ML, INSULIN SYR 1 ML, -INSULIN SYR U-100, -INSULIN SYRN 3/10 ML, SYRINGE 0.3 ML, -SYRINGE 0.5 ML, -SYRINGE 1 ML
2
INSULIN SYRINGE 0.3 ML, INSULIN SYRINGE 0.5 ML, INSULIN SYRINGE 1 ML, -0.3 ML, 0.5 ML, -1 ML
2
2
2
2
2
2
NEEDLE FREE SYRINGE KIT A 2
NEEDLE FREE SYRINGE KIT B 2
NEEDLE FREE SYRINGE KIT C 2
NOVOFINE 32 2
NOVOFINE AUTOCOVER 2
NOVOPEN 3 2
NOVOPEN JR 2
2
SURE-FINE PEN NEEDLES 2
SURE-JECT INSULIN SYRINGE 2
SURE-PREP ALCOHOL PREP PADS
2
ULTIGUARD 30GX0.3 ML SYRINGE, -31GX0.3 ML SYRINGE, -31GX0.5 ML SYRINGE, -31GX1 ML SYRINGE, 30GX0.5 ML SYRINGE, -30GX1 ML SYRINGE
2
2
2
2
metaxalone 1 [PAR]
1 [PAR]
RILUTEK riluzole 3
dantrolene sodium capsule 1
GABLOFEN [INJ] baclofen 2
revonto [INJ] 1
DRUGS TO PREVENT AND TREAT GOUT allopurinol sodium [INJ] 1
allopurinol tablet 1
KRYSTEXXA [INJ] pegloticase 3
diclofenac potassium 1
1
1
ibuprofen 400 mg tablet, -600 mg tablet, -800 mg tablet
1
1
1
meclofenamate sodium capsule 1
meloxicam 15 mg tablet 1
meloxicam 7.5 mg tablet 1 [QLL, 34/34]
meloxicam oral susp 1
naproxen oral susp 1
1
OTHER DRUGS FOR ARTHRITIS choline mag trisalicylate 1
CUPRIMINE penicillamine 2
diflunisal tablet 1
RIDAURA auranofin 2
salsalate tablet 1
SYPRINE trientine 3
cilostazol 1
clopidogrel 1
alburx (human) 25% vial [INJ] 1
albutein [INJ] 1
AMINOSYN II [INJ] amino acids 2
AMINOSYN II 5% IN 25% DEXTROSE [INJ]
amino acids 2
AMINOSYN WITH ELECTROLYTES [INJ]
94
AMINOSYN-PF [INJ] amino acids 2
AMINOSYN-RF [INJ] amino acids 2
AMMONIUM CHLORIDE INJECTION [INJ]
calcium chloride injection [INJ] 1
CLINIMIX [INJ] amino acids 2
CLINIMIX E 2.75%-10% SOLUTION, -2.75%-5% SOLUTION, -4.25%-25% SOLUTION, -4.25%-5% SOLUTION, -5%-15% SOLUTION, -5%-20% SOLUTION, -5%-25% SOLUTION [INJ]
amino acids 2
CYSTAGON [LA] cysteamine 2
d5w-kcl 30 meq/l iv solution, - d5w/kcl 30 meq/l iv solution [INJ]
1
dextrose 5%-electrolyte #48 [INJ] 1
dextrose 5%-ns-kcl [INJ] 1
dextrose in lactated ringers [INJ] 1
dextrose in ringers injection [INJ] 1
dextrose in water [INJ] 1
95
Drug Generic Tier Requirements/Limits dextrose with sodium chloride [INJ] 1
FREAMINE III [INJ] amino acids 2
HEPATAMINE [INJ] amino acids 2
HEPATASOL [INJ] amino acids 2
IONOSOL B WITH DEXTROSE 5% [INJ]
electrolyte solutions 2
dextrose/electrolytes 2
ISOLYTE S WITH DEXTROSE [INJ]
LIPOSYN II 20% IV FAT EMULSION [INJ]
fat emulsions 2
MAGNESIUM SULFATE-D5W [INJ] magnesium sulfate/d5w 2
mannitol injection [INJ] 1
96
NORMOSOL-R AND DEXTROSE [INJ]
nutrilyte [INJ] 1
PLASMA-LYTE 56 IN DEXTROSE [INJ]
d5w/electrolyte-56 solution 2
potassium chl-normal saline [INJ] 1
potassium chloride-nacl [INJ] 1
PROCALAMINE [INJ] aa 3%/electrolyte-tpn/glycerin 2
R-GENE 10 [INJ] arginine 2
ringers injection [INJ] 1
saline 0.45% soln-excel con, -0.45% soln, -saline 0.9% soln-excel cont, - 0.9% soln, -0.9% soln., -0.9% solution, -cl 2.5 meq/ml vial, -3% iv soln, -4 meq/ml vl, -5% iv soln [INJ]
1
sodium chloride solution 1
97
TPN ELECTROLYTES II [INJ] electrolyte solutions 2
TRAVASOL [INJ] amino acids 2
TROPHAMINE [INJ] amino acids 2
FLUORIDE PRODUCTS denta 5000 plus 1
dentagel 1
epiflur 1
1
1
INJECTABLE ANTICOAGULANTS enoxaparin 120 mg/0.8 ml syr, -150 mg/ml syr [INJ]
3
98
Drug Generic Tier Requirements/Limits enoxaparin 30 mg/0.3 ml syr, -40 mg/0.4 ml syr, -60 mg/0.6 ml syr, - 80 mg/0.8 ml syr, -100 mg/ml syr, - 300 mg/3 ml vial [INJ]
1
fondaparinux 2.5 mg/0.5 ml syr [INJ] 1
fondaparinux 5 mg/0.4 ml syr, -7.5 mg/0.6 ml syr, -10 mg/0.8 ml syr [INJ]
3
heparin sodium injection [INJ] 1 [PAR]
heparin sodium-ns [INJ] 1 [PAR]
ORAL ANTICOAGULANTS, VITAMIN K jantoven 1
PRADAXA dabigatran etexilate mesylate 2 [PAR]
warfarin sodium tablet 1
XARELTO 15 MG TABLET, -20 MG TABLET
rivaroxaban 2 [PAR]
k effervescent 1
kcl 20 meq in d5w solution, -d5w/kcl 40 meq/l iv solution, -kcl 40 meq in d5w solution [INJ]
1
klor-con 8 1
klor-con m10 1
klor-con m15 1
klor-con m20 1
1
1
potassium chloride injection [INJ] 1
potassium chloride solution 1
THERAPEUTIC VITAMINS AND MINERALS calcitriol capsule, -solution 1 [PAR]
calcitriol injection [INJ] 1 [PAR]
calcium acetate capsule, -tablet 1
eliphos 1
100
Drug Generic Tier Requirements/Limits ZEMPLAR INJECTION [INJ] paricalcitol 2 [PAR]
OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS ABORTIFACIENTS
HEMABATE [INJ] carboprost tromethamine 2
PROSTIN E2 VAGINAL SUPPOSITORY
ANDROXY fluoxymesterone 2
danazol capsule 1
aviane 1
azurette 1
balziva 1
briellyn 1
camrese 1
levora-28 1
loryna 1
low-ogestrel 1
lutera 1
marlissa 1
microgestin 1
norethindrone-ethin estradiol 1
norgestimate-ethinyl estradiol 1
norgestrel-ethiny estra 1
sprintec 1
sronyx 1
syeda 1
estradiol adh. patch 1 [QLL, 5/35]
estradiol tablet 1
estropipate 1
VAGIFEM estradiol 2
jevantique 1
jinteli 1
mimvey 1
1
folbecal 1
ob-natal one 1
vinate gt 1
vinate ic 1
vinate ii 1
vinate one 1
medroxyprogesterone acetate injection [INJ]
1 [QLL, 1 ml/90]
medroxyprogesterone acetate tablet 1
1 [PAR]
leuprolide acetate injection [INJ] 1
LUPRON DEPOT 3.75 MG KIT, 7.5 MG KIT, -11.25 MG 3MO KIT, 22.5 MG 3MO KIT, --4 MONTH KIT [INJ]
leuprolide 3 [PAR]
methylergonovine maleate injection [INJ]
1
apraclonidine hcl 1
brimonidine tartrate 1
COMBIGAN brimonidine tartrate/timolol 2
OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS neomycin-bacitracin-poly-hc 1
1
PRED MILD prednisolone acetate 2
prednisolone acetate ophth drops 1
prednisolone sodium phosphate ophth drops
1
AZASITE azithromycin 2
bacitracin-polymyxin eye oint 1
erythromycin oint 1
1
sulfacetamide sodium oint 1
sulfamide 1
VIGAMOX moxifloxacin 2
akorn balanced salt 1
azelastine hcl ophth drops 1
BOTOX [INJ] botulinum toxin a 2 [PAR]
bromfenac sodium 1
epinastine hcl 1
LUCENTIS [INJ] ranibizumab 3
RESTASIS cyclosporine 2 [QLL, 60 vials/30]
trifluridine ophth drops 1
tropicamide ophth drops 1
VISUDYNE [INJ] verteporfin 2
carbinoxamine maleate 1
cetirizine hcl 1 mg/1 ml soln, -1 mg/ml soln, -5 mg/5 ml syrup
1
clemastine fumarate syrup, -fum 2.68 mg tab
1
desloratadine 1 [QLL, 34/34]
Drug Generic Tier Requirements/Limits diphenhydramine 50 mg capsule 1 [PAR]
diphenhydramine hcl injection [INJ] 1
diphenhydramine hcl elix 1 [PAR]
levocetirizine dihydrochloride solution
palgic 1
promethazine 25 mg/ml ampul, -25 mg/ml vial, -50 mg/ml ampul [INJ]
1
1
BETA-2 ADRENERGIC DRUGS albuterol sulfate nebs 1 [PAR]
albuterol sulfate syrup, -tablet, - tablet sustained action
1
metaproterenol sulfate syrup, -tablet 1
PROAIR HFA albuterol 2 [QLL, 26 gm/34]
PROVENTIL HFA albuterol 2 [QLL, 20 gm/34]
SEREVENT DISKUS salmeterol 2 [QLL, 120 doses/34]
terbutaline sulfate injection [INJ] 1
terbutaline sulfate tablet 1
113
caffeine citrate solution 1
1
OTHER DRUGS FOR ASTHMA ADVAIR DISKUS salmeterol/fluticasone 2 [PAR][QLL, 120 doses/30]
ADVAIR HFA salmeterol/fluticasone 2 [PAR][QLL, 24 gm/34]
ASMANEX TWISTHALER 110 MCG #30, -TWISTHALER 110 MCG #7, -TWISTHALER 220 MCG #30
mometasone 2 [QLL, 60 doses/30]
ASMANEX TWISTHALER 220 MCG #14
ASMANEX TWISTHALER 220 MCG #60
ASMANEX TWISTHALR 220 MCG #120
ATROVENT HFA ipratropium 2 [QLL, 26 gm/34]
COMBIVENT albuterol sulfate/ipratropium 2 [QLL, 44 gm/34]
cromolyn sodium nebs 1 [PAR]
cromolyn sodium solution 1
epinephrine 0.1 mg/ml syringe, -1 mg/ml ampul, -1 mg/ml vial [INJ]
1
114
Drug Generic Tier Requirements/Limits EPINEPHRINE 0.15 MG AUTO INJCT, -0.3 MG AUTO-INJECT [INJ]
epinephrine hcl 2 [QLL, 4 pens/2]
EPIPEN [INJ] epinephrine hcl 2 [QLL, 4 pens/2]
EPIPEN JR [INJ] epinephrine hcl 2 [QLL, 4 pens/2]
ipratropium bromide nebs 1 [PAR]
QVAR beclomethasone 2 [QLL, 22 gm/34]
SPIRIVA tiotropium bromide 2 [QLL, 60 capsules/30]
SYMBICORT budesonide/formoterol fum 2 [PAR][QLL, 20 gm/34]
XOLAIR [INJ][LA] omalizumab 3 [PAR][QLL, 6 vials/28]
zafirlukast 1
OTHER RESPIRATORY DRUGS ARALAST NP [INJ][LA] alpha-1-proteinase inhibitor 3 [PAR]
KALYDECO ivacaftor 3
PROLASTIN C [INJ][LA] alpha-1-proteinase inhibitor 3 [PAR]
PULMOZYME deoxyribonuclease 3 [PAR]
UROLOGICAL MEDICATIONS ANTICHOLINERGIC ANTISPASMODICS
flavoxate hcl 1
oxybutynin chloride syrup, -tablet 1
oxybutynin cl er 10 mg tablet, -cl er 15 mg tablet
1
115
Drug Generic Tier Requirements/Limits SANCTURA XR trospium chloride 2 [ST]
tolterodine tartrate 1
trospium chloride 1
alfuzosin hcl 1
finasteride tablet 1
glycine solution 1
K-PHOS ORIGINAL potassium acid phosphate 2
neomycin-polymyxin b [INJ] 1
1
tamsulosin hcl 1
Index 1ST TIER UNIFINE PENTP 5MM 31G,
-1ST TIER UNIFINE PNTIP 6MM 31G, -1ST TIER UNIFINE PNTIP 8MM 31G, -1ST TIER UNIFINE PNTP 12MM 29G, 85
1ST TIER UNIFINE PNTIP 8MM 31G, 85
8-MOP, 63 aa 3%/electrolyte-tpn/glycerin, 97 abacavir, 15 abacavir sulfate, 17 abacavir sulfate/lamivudine, 15 abatacept/maltose, 31 ABELCET, 23 ABILIFY 10 MG TABLET, 34 ABILIFY 15 MG TABLET, 34 ABILIFY 2 MG TABLET, 34 ABILIFY 20 MG TABLET, 34 ABILIFY 30 MG TABLET, 34 ABILIFY 5 MG TABLET, 34 ABILIFY DISCMELT 10 MG TABLET,
34 ABILIFY DISCMELT 15 MG TABLET,
34 ABILIFY INJECTION, 34 ABILIFY SOLUTION, 34 abiraterone acetate, 33 ABORTIFACIENTS, 101 acarbose 100 mg tablet, 71 acarbose 25 mg tablet, 71 acarbose 50 mg tablet, 71 acebutolol hcl capsule, 53 acetaminoph-caff-dihydrocodein, 43 acetaminophen-codeine, 43 acetasol hc, 67 acetazolamide capsule sustained ac
tion, -tablet, 108 acetazolamide sodium, 108 acetic acid 0.25% irrig soln, 116 acetic acid otic drops, 67 acetic acid-aluminum, 68 acitretin, 63 ACTEMRA 200 MG/10 ML VIAL, -400
MG/20 ML VIAL, 83 ACTEMRA 80 MG/4 ML VIAL, 83
ACTHAR H.P., 73 ACTHIB, 79 acticin, 64 ACTIMMUNE, 82 ACTOPLUS MET, 71 ACTOPLUS MET XR 15-1,000 MG TB,
71 ACTOPLUS MET XR 30-1,000 MG TB,
71 ACTOS, 71 acyclovir, 23 acyclovir capsule, -oral susp, -tablet, 21 acyclovir sodium, 21 acyclovir/hydrocortisone, 23 ADACEL, 79 ADAGEN, 67 adalimumab, 30 adapalene, 62 ADCIRCA, 60 adcirca (tadalafil), 60 adefovir dipivoxil, 22 ADVAIR DISKUS, 114 ADVAIR HFA, 114 ADVICOR 500 MG-20 MG TABLET, 56 ADVICOR 750 MG-20 MG TABLET,
-1,000 MG-20 MG TABLET, -1,000 MG-40 MG TABLET, 56
ADVOCATE PEN NEEDLES, 85 ADVOCATE SYRINGES, 85 afeditab cr, 54 AFINITOR, 28 aflibercept, 111 agalsidase, 74 AGGRENOX, 93 AIMSCO INS SYR 0.3 ML 29GX1/2,
-AIMSCO INS SYR 0.3 ML 30GX5/16, -AIMSCO INS SYR 1 ML 29GX1/2, -AIMSCO SYRING 0.3 ML 31GX5/16, -AIMSCO SY RING 0.5 ML 31GX5/16, -BD INSUL SYR 0.3 ML 31GX15/64, -BD INSUL SYR 0.5 ML 31GX15/64, -BD INSULIN SYR 0.3 ML 28GX1/2, -BD INSULIN SYR 0.3 ML 29GX1/2, -BD INSULIN SYR
0.3 ML 30GX1/2, -BD INSULIN SYR 0.5 ML 30GX1/2, -BD INSU LIN SYR 0.5ML 31GX5/16, -BD INSULIN SYR 1 ML 25GX1, -BD INSULIN SYR 1 ML 25GX5/8, -BD INSULIN SYR 1 ML 26GX1/2, -BD INSULIN SYR 1 ML 27GX5/8, -BD INSULIN SYR 1 ML 31GX15/64, -BD INSULIN SYR 1 ML 31GX5/16, -BD INSULIN SYRINGE 1 ML, -BD INSULIN U100-3/10 ML SYR, -FIFTY50 INS SYR 1 ML 31GX5/16, -FIFTY50 INSULIN SYRINGE 0.3 ML, -FIFTY50 INSULIN SYRINGE 0.5 ML, -INS SYR 0.3 ML 29GX1/2, -INS SYR 0.3 ML 30GX5/16, -INS SYR 0.5 ML 28GX1/2, -INS SYR 0.5 ML 29GX1/2, -INS SYR 0.5 ML 30GX1/2, -INS SYR 0.5 ML 30GX5/16, -INS SYR 1 ML 28GX1/2, -INS SYR 1 ML 29GX1/2, -INS SYR 1 ML 30GX5/16, -INS SYR 1 ML 31GX5/16, -INS SYR U100 1 ML 28GX1/2, -INS SYRIN 0.3 ML 30GX1/2, -INS SYRIN 1 ML 29GX1/2, -INS SYRING 0.3 ML 30GX5/16, -INS SYRINGE 1 ML 28GX1/2, -INS SYRINGE 1 ML 30GX1/2, -INS SYRINGE 1 ML 30GX5/16, -INS SYRINGE 3/10 ML, -INSUL SYR 0.3 ML 31GX5/16, -INSUL SYR 0.5 ML 28GX1/2, -INSUL SYR 0.5 ML 30GX1/2, -INSUL SYR 0.5 ML 31GX5/16, -0.3 ML SYRINGE, -0.5 ML SY RINGE, -1 ML SYRINGE, -3/10 ML SYRINGE, -SAFETY SYRINGE, -SYR 0.3 ML 29GX1/2, -SYR 0.5 ML 28GX1/2, -SYR 1 ML 29GX1/2, -SYR 1 ML 30GX5/16, -SYR 1 ML 31GX5/16, -SYRIN 0.3 ML 29GX1/2, -SYRIN 0.3 ML 30GX1/2, -SYRIN 0.3 ML 30GX5/16, -SYRIN 0.3 ML 31GX5/16, -SYRIN 0.3 ML 31GX5/16, -SYRIN
117
0.5 ML 30GX1/2, -SYRIN 0.5 ML 30GX5/16, -SYRIN 0.5 ML 31GX5/16, -SYRIN 1 ML 29GX1/2, -1 ML 29GX1/2, -1 ML 31GX5/16, -1 ML-HARD PK, -INSULN SYR 0.5 ML 30GX5/16, -KINRAY INS SYR 1 ML 31GX5/16, -KINRAY SYRING 0.3 ML 31GX5/16, -KIN RAY SYRING 0.5 ML 31GX5/16, -KMART VALU PLUS SYR 1/2 ML, -KMART VALU PLUS SYR 3/10 ML, -KMART VALU PLUS SYRINGE 1 ML, -PREF PLUS SYRING 1 ML 29GX1/2, -PREFERRED PLUS 0.3 ML 30GX, 83
AIMSCO MINI ULTRA-THIN II, 85 AIMSCO ULTRA THIN II, 85 ak-con, 111 akorn balanced salt, 111 ak-poly-bac, 110 albendazole, 14 ALBENZA, 14 albumin (human), 94 alburx (human) 25% vial, 94 albutein, 94 albuterol, 113 albuterol sulfate nebs, 113 albuterol sulfate syrup, -tablet, -tablet
sustained action, 113 albuterol sulfate/ipratropium, 114 alclometasone dipropionate, 64 ALCOHOL PADS, 85 ALCOHOL PREP PADS, 85 ALCOHOL PREP SWABS, 85 ALCOHOL SWAB, 86 ALCOHOL SWABS, 86 ALCOHOL WIPES, 86 aldesleukin, 83 ALDURAZYME, 73 alefacept, 28 alemtuzumab, 28 alendronate sodium 35 mg tab, -70 mg
tab, 73 alendronate sodium 5 mg tablet, -10
mg tab, -40 mg tab, 73 alfentanil hydrochloride, 41
alfuzosin hcl, 116 alglucosidase alfa, 74 ALIMTA, 28 ALINIA, 20 aliskiren hemifumarate, 59 aliskiren/amlodipine, 59 aliskiren/amlodipine/hctz, 58 aliskiren/hydrochlorothiazid, 59 alitretinoin, 66 allopurinol sodium, 91 allopurinol tablet, 91 alosetron, 77 ALOXI, 38 alpha-1-proteinase inhibitor, 115 ALPHAGAN P 0.1% DROPS, 108 alprostadil injection, 60 altafrin, 111 altavera, 101 altretamine, 30 alyacen, 101 amantadine, 21 AMBISOME, 24 ambrisentan, 60 amcinonide, 64 a-methapred, 69 amethia, 101 amethia lo, 101 amethyst, 101 AMEVIVE, 28 amifostine, 28 amikacin sulfate injection, 14 amiloride hcl tablet, 61 amiloride-hydrochlorothiazide, 61 amino acids, 94, 95, 96, 97, 98 aminocaproic acid injection, 67 aminocaproic acid syrup, -500 mg tab,
67 AMINOGLYCOSIDES, 14 aminophylline injection, 113 aminophylline tablet, 114 aminosalicylic acid, 17 AMINOSYN, 94 AMINOSYN II, 94 AMINOSYN II 5% IN 25% DEX
TROSE, 94 AMINOSYN M, 94
AMINOSYN WITH ELECTROLYTES, 94
95 ammonium lactate cream, -lotion, 65 amnesteem, 63 amox tr-potassium clavulanate, 24 amoxapine, 49 amoxicillin, 24 amoxicillin clavulanate, 24 amoxicillin-clavulanate er, 24 amphetamine salt combo, 43 ampho b c-s, 24 AMPHOTEC 100 MG VIAL, 24 amphotericin b injection, 24 amphotericin b lipid complex, 23 amphotericin b liposome, 24 ampicillin sodium, 24 ampicillin trihydrate, 24 ampicillin-sulbactam, 24 AMPYRA, 67 AMTURNIDE, 58 amylase/lipase/protease, 77, 78 ANADROL-50, 101 anagrelide hcl, 28 ANALGESICS, 33 anastrozole tablet, 28 ANDROGEN DRUGS, 101 ANDROXY, 101 ANESTHETICS, 13 ANGIOTENSIN CONVERTING EN
ZYME INHIBITORS, 52
ANTHELMINTICS, 14 anthralin, 63 ANTIACNE DRUGS, 62 ANTICHOLINERGIC ANTISPASMOD
ICS, 115 ANTIDEMENTIA DRUGS, 33 ANTIDIARRHEAL DRUGS, 75 ANTIDYSRHYTHMIC DRUGS, 53 ANTIGLAUCOMA DRUGS, 108 ANTIHISTAMINE AND DECONGES
TANT DRUGS, 112 ANTIINFECTIVES, 14 ANTIINFECTIVES SPECIALIZED
INDICATIONS, 14 ANTINEOPLASTIC/IMMUNOSUP
GIC DRUGS, 34 ANTIPLATELET DRUGS, 93 ANTIPSORIASIS AND ANTIECZEMA
DRUGS, 63 ANTIPSYCHOTIC DRUGS, 34 antipyrine-benzocaine, 68 ANTIRETROVIRALS AND PROTE
ASE INH, 15 ANTISPASMODICS/DRUGS AFFECT
GI MOTILITY, 75 ANTITHYROID DRUGS, 69 ANTITUBERCULOSIS DRUGS, 17 ANTIULCER DRUGS, 76 ANTIVERTIGO AND ANTIEMETIC
DRUGS, 38 ANXIOLYTICS, 40 APOKYN, 48 apomorphine hcl, 48 apraclonidine hcl, 108 aprepitant, 39 apri, 101 APRISO, 76 APTIVUS, 15 ARALAST NP, 115 aranelle, 102 arbinoxa, 112 ARCALYST, 83
arginine, 97 aripiprazole, 34 ARMOUR THYROID, 75 artemether/lumefantrine, 25 ascomp with codeine, 44 asenapine, 38 ASMANEX TWISTHALER 110 MCG
#30, -TWISTHALER 110 MCG #7, -TWISTHALER 220 MCG #30, 114
ASMANEX TWISTHALER 220 MCG #14, 114
ASMANEX TWISTHALER 220 MCG #60, 114
ASMANEX TWISTHALR 220 MCG #120, 114
aspirin/dipyridamole, 93 ASSURE ID INSULIN SAFETY, 86 atazanavir sulfate, 16 atenolol tablet, 53 atenolol-chlorthalidone, 58 ATGAM, 79 atomoxetine, 49 atorvastatin calcium, 56 atovaquone, 21 atovaquone-proguanil hcl, 25 ATRIPLA, 15 atropine care, 111 atropine sulfate injection, 48 atropine sulfate oint, -ophth drops, 111 ATROVENT HFA, 114 AUGMENTIN 125-31.25 MG/5 ML, 24 auranofin, 93 aurodex, 68 auroguard, 68 AURORA PEN NEEDLE 6MM 31G,
-AURORA PEN NEEDLES 12MM 29G, -AURORA PEN NEEDLES 8MM 31G, -BD PEN NEEDLE 29GX1/2, -BD PEN NEEDLE 29GX3/16, -BD PEN NEEDLE 29GX5/16, -BD PEN NEEDLE 30GX3/16, -BD PEN NEEDLE MINI 31GX3/16, -BD PEN NEE DLE NANO 32GX5/32, -BD PEN NEEDLE SHORT 31GX5/16, -CLICKFINE PEN NDL 31GX1/4,
-CLICKFINE PEN NDL 31GX5/16, -INSULIN PEN NEEDLE, -LIVE BETTER PEN NEEDLE 6MM 31G, -LIVE BETTER PEN NEEDLES 12MM, -LIVE BETTER PEN NEE DLES 8MM, -MS PEN NEEDLE 6MM 31G, -12MM 29G NEEDLES, -8MM 31G NEEDLES, -31G X 3/16, -31GX3/16, -31GX5/16, -6MM 31G, -S 12MM 29G, -S 29G, -S 31G, -S 31G X 5/16, -S 5MM 31G, -S 6MM 31G, -S 8MM 31G, -RELION PEN 29G NEEDLE, -RELION PEN 31G NEEDLE, -TODAY’S HLT PN NEEDLE 12MM 29G, -TODAY’S HLTH PN NEEDLE 6MM 31G, -TODAY’S HLTH PN NEEDLE 8MM 31G, -UNIFINE PENTIP 12MM 29G, -UNIFINE PENTIP 6MM 31G, -UNIFINE PENTIP 8MM 31G, 86
AUTO INJECTOR, 86 AUTOJECT 2, 86 AUTONOMIC AND CNS MEDICA
TIONS, 33 AUTOPEN, 87 AVASTIN 100 MG/4 ML VIAL, 28 AVASTIN 400 MG/16 ML VIAL, 28 AVELOX IV, 25 aviane, 102 AVONEX, 82 AVONEX ADMINISTRATION PACK,
82 AVONEX PEN, 82 axitinib, 30 azacitidine, 32 AZASAN, 28 AZASITE, 110 azathioprine, 28 azathioprine sodium, 28 azathioprine tablet, 28 azelastine hcl nasal drops/sprays, 68 azelastine hcl ophth drops, 111 AZILECT, 48 azithromycin, 110 azithromycin injection, 23 azithromycin packet, -suspension,
119
-tablet, 23 aztreonam, 20 aztreonam lysine, 20 azurette, 102 baciim, 20 bacitracin 500 unit/gm ointmnt, 110 bacitracin injection, 20 bacitracin-polymyxin eye oint, 110 baclofen, 91 baclofen tablet, 91 balsalazide disodium, 76 balziva, 102 BANZEL 400 MG TABLET, 45 BANZEL ORAL SUSP, -200 MG TAB
LET, 45 BARACLUDE SOLUTION, 21 BARACLUDE TABLET, 21 basiliximab, 32 baycadron, 69 bcg vaccine, 32, 79 BCG VACCINE (TICE STRAIN), 79 BD SAFTGLD INS 0.3 ML 31GX5/16,
-BD SAFTGLD INS SYR 0.5 ML 30G, -INSULIN SAFETY SYRINGE, 87
becaplermin, 66 beclomethasone, 115 belatacept, 31 belimumab, 28 benazepril hcl tablet, 52 benazepril-hydrochlorothiazide, 58 BENLYSTA 120 MG VIAL, 28 BENLYSTA 400 MG VIAL, 28 benzene hexachloride gamma, 64 benztropine mesylate injection, 34 benztropine mesylate tablet, 34 BETA-2 ADRENERGIC DRUGS, 113 BETA-ADRENERGIC ANTAGONIST
DRUGS, 53 betaine hcl, 116 betamethasone acetate-sod phos, 69 betamethasone dipropionate cream,
-gel, -lotion, -oint, 64 betamethasone valerate cream, -lotion,
-oint, 64 betaxolol hcl ophth drops, 108
betaxolol hcl tablet, 54 bethanechol chloride tablet, 116 bevacizumab, 28 bexarotene, 32 bicalutamide, 28 bisoprolol fumarate, 54 bisoprolol-hydrochlorothiazide, 59 BLOOD DETOXICANTS, 94 boceprevir, 16 BONIVA TABLET, 73 BOOSTRIX, 79 bortezomib, 32 bosentan, 61 BOTOX, 111 botulinum toxin a, 111 bp 10-1, 62 briellyn, 102 BRILINTA, 94 brimonidine tartrate, 108 brimonidine tartrate/timolol, 109 bromfenac sodium, 111 bromocriptine mesylate capsule, -tab
let, 48 budeprion sr 100 mg tablet, 46 budeprion sr 150 mg tablet, 46 budeprion xl 150 mg tablet, 46 budeprion xl 300 mg tablet, 46 budesonide ec, 77 budesonide/formoterol fum, 115 bumetanide injection, 57 bumetanide tablet, 57 BUPHENYL, 67 bupivacaine hcl injection, 13 bupivacaine hcl-epinephrine, 13 bupivacaine-dextrose, 13 buprenorphine hcl injection, 33 buprenorphine hcl tab, sl, 43 buprenorphine/naloxone, 43 buproban, 51 bupropion hcl sr 100 mg tablet, 46 bupropion hcl sr 200 mg tab, 46 bupropion hcl tablet, 47 bupropion hcl xl 150 mg tablet, 47 bupropion hcl xl 300 mg tablet, 47 bupropion sr 150 mg tablet, 47 buspirone hcl tablet, 40
butalb-caff-acetaminoph-codein, 44

butalbital compound-codeine, 44 butorphanol tartrate aerosol, 44 butorphanol tartrate injection, 33 BYETTA 10 MCG DOSE PEN INJ, 70 BYETTA 5 MCG DOSE PEN INJ, 70 c1 esterase inhibitor, 79 cabergoline, 73 caffeine citrate injection, 43 caffeine citrate solution, 114 calcipotriene, 63 calcitonin, 74 calcitonin-salmon, 73 calcitriol capsule, -solution, 100 calcitriol injection, 100 calcium acetate capsule, -tablet, 100 CALCIUM ANTAGONISTS, 54 calcium chloride injection, 95 calcium folinate injection, 28 camila, 107 CAMPATH, 28 camrese, 102 camrese lo, 102 canakinumab, 83 CANASA, 77 CANCIDAS, 24 CAPASTAT SULFATE, 17 CAPRELSA, 28 capreomycin, 17 captopril tablet, 52 captopril-hydrochlorothiazide, 59 CARAFATE ORAL SUSP, 76 CARBAGLU, 67 carbamazepine, 41 carbamazepine capsule sustained ac
tion, -oral susp, 40 carbamazepine chew tab, -tablet, 40 carbamazepine er, 40 carbamazepine xr, 40 CARBAMAZEPINES, 40 carbidopa, 48 carbidopa-levodopa, 48 carbidopa-levodopa-entacapone, 48 carbinoxamine maleate, 112 carboprost tromethamine, 101 CARDIOVASCULAR MEDICA

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