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2014 Formulary (List of Covered Drugs)

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Blue Medicare Access Value (Regional PPO)
2014 Formulary (List of Covered Drugs)
Please read: This document
contains information about the
drugs we cover in this plan.
Customer Service
This formulary was updated on October 1, 2014. For more recent information or other questions, please
contact Blue Medicare Access Value (Regional PPO) Customer Service at 1-800-467-1199 or, for TTY users,
711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through
February 14, and Monday to Friday (except holidays) from February 15 through September 30, or visit
www.anthem.com/medicare.
Y0071_14_17282_U_128 CMS Accepted 08/04/2013
38017WPSENMUB_128 R5941 008
Freedom 14251, V20
Note to existing members:
This formulary has changed since last year. Please review this document
to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us” or “our,” it means
Anthem Blue Cross and Blue Shield. When it refers to “plan” or “our
plan,” it means Blue Medicare Access Value (Regional PPO).
This document includes a list of the drugs (formulary) for our plan which
is current as of October 1, 2014. For an updated formulary,
please contact us. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription
drug benefit. Benefits, formulary, pharmacy network, premium and/or
copayments/coinsurance may change on January 1, 2015.
Freedom 14251, V20
2
Effective Date November 1, 2014
What is the Blue Medicare Access Value How do I use the formulary?
There are two ways to find your drug within the formulary:
(Regional PPO) formulary?
A formulary is a list of covered drugs selected by our plan
in consultation with a team of health care providers, which
represents the prescription therapies believed to be a
necessary part of a quality treatment program. Our plan
will generally cover the drugs listed in our formulary as long
as the drug is medically necessary, the prescription is filled
at a plan network pharmacy, and other plan rules are
followed. For more information on how to fill your
prescriptions, please review your Evidence of Coverage.
Medical Condition
The formulary begins on page 7. 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 7. Then look under the
category name for your drug.
Can the formulary (drug list) change?
Generally, if you are taking a drug on our 2014 formulary
that was covered at the beginning of the year, we will not
discontinue or reduce coverage of the drug during the
2014 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 forumulary 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.
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 48.
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?
Our plan covers both brand-name drugs and generic drugs.
A generic drug is approved by the FDA as having the same
active ingredient as the brand-name drug. Generally, generic
drugs cost less than brand-name drugs.
If we remove drugs from our formulary, or add prior
authorization, quantity limits and/or step-therapy
restrictions on a drug or move a drug to a higher
cost-sharing tier, we must notify affected members of the
change at least 60 days before the change becomes effective,
or at the time the member requests a refill of the drug, at
which time the member will receive a 60-day supply of the
drug. If the Food and Drug Administration (FDA) deems
a drug on our formulary to be unsafe or the drug’s
manufacturer removes the drug from the market, we will
immediately remove the drug from our formulary and
provide notice to members who take the drug. The enclosed
formulary is current as of October 1, 2014. To get updated
information about the drugs covered by our plan, please
contact us. Our contact information appears on the front
and back cover pages. If any other type of approved
formulary change (nonmaintenance change) is made during
the year, we will notify you by sending you a list of these
changes, or by sending you an updated formulary.
Freedom 14251, V20
Are there any restrictions on my
coverage?
Some covered drugs may have additional requirements or
limits on coverage. These requirements and limits may
include:
Prior Authorization: Our plan requires you or your
physician to get prior authorization for certain drugs. This
means that you will need to get approval from our plan
before you fill your prescriptions. If you don't get approval,
our plan may not cover the drug.
Quantity Limits: For certain drugs, our plan limits the
amount of the drug that our plan will cover. For example,
our plan provides 100 units per ml per prescription for
3
Effective Date November 1, 2014
HUMALOG. This may be in addition to a standard
one-month or three-month supply.
How do I request an exception to the
Blue Medicare Access Value (Regional
PPO)'s formulary?
Step Therapy: In some cases, our plan 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, our
plan may not cover Drug B unless you try Drug A first. If
Drug A does not work for you, our plan will then cover
Drug B.
You can ask our plan to make an exception to our coverage
rules. There are several types of exceptions that you can ask
us to make:
You can ask us to cover a drug even if it is not on our
formulary. If approved, this drug will be covered at a
predetermined cost-sharing level, and you would not be
able to ask us to provide the drug at a lower cost-sharing
level.
You can find out if your drug has any additional
requirements or limits by looking in the formulary that
begins on page 7. You can also get more information about
the restrictions applied to specific covered drugs by visiting
our website. Our contact information, along with the date
we last updated the formulary, appears on the front and
back cover pages.
You can ask us to cover a formulary drug at a lower
cost-sharing level if this drug is not on the specialty tier.
If approved this would lower the amount you must pay for
your drug.
You can ask our plan to make an exception to these
restrictions or limits or for a list of other, similar drugs that
may treat your health condition. See the section, “How do
I request an exception to the Blue Medicare Access Value
(Regional PPO)'s formulary?” on page 4 for information
about how to request an exception.
You can ask us to waive coverage restrictions or limits
on your drug. For example, for certain drugs, our plan
limits 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 a greater amount.
Generally, our plan will only approve your request for an
What if my drug is not on the formulary? exception if the alternative drugs included on the plan’s
If your drug is not included in this formulary (list of covered formulary, the lower cost-sharing drug or additional
drugs), you should first contact Customer Service and ask utilization restrictions would not be as effective in treating
your condition and/or would cause you to have adverse
if your drug is covered.
medical effects.
If you learn that our plan does not cover your drug, you
You should contact us to ask us for an initial coverage
have two options:
decision for a formulary, tiering or utilization restriction
You can ask Customer Service for a list of similar drugs that exception. When you request a formulary, tiering or
are covered by our plan. When you receive the list, show it utilization restriction exception, you should submit a
to your doctor and ask him or her to prescribe a similar drug statement from your prescriber or physician supporting
your request. Generally, we must make our decision within
that is covered by our plan.
72 hours of getting your prescriber’s supporting statement.
You can ask our plan to make an exception and cover your You can request an expedited (fast) exception if you or your
drug. See below for information about how to request an
doctor believe that your health could be seriously harmed
exception.
by waiting up to 72 hours for a decision. If your request to
expedite is granted, we must give you a decision no later
than 24 hours after we get a supporting statement from your
doctor or other prescriber.
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Effective Date November 1, 2014
What do I do before I can talk to my
doctor about changing my drugs or
requesting an exception?
For more information
For more detailed information about our plan prescription
drug coverage, please review your Evidence of Coverage and
other plan materials.
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.
If you have questions about our plan, please contact us. Our
contact information, along with the date we last updated
the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription
drug coverage, please call Medicare at 1-800-MEDICARE
(1-800-633-4227), 24 hours a day/7 days a week. TTY
users should call 1-877-486-2048. Or, visit
www.medicare.gov.
Our plan’s formulary
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 30-day supply (unless you have a prescription
written for fewer days) when you go to a network pharmacy.
After your first 30-day supply, we will not pay for these
drugs, even if you have been a member of the plan less than
90 days.
The formulary on page 7 provides coverage information
about some of the drugs covered by our plan. If you have
trouble finding your drug in the list, turn to the Index that
begins on page 48.
The first column of the chart lists the drug name.
Brand-name drugs are capitalized (e.g., HUMALOG) and
generic drugs are listed in lowercase italics (e.g., enalapril).
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 98-day transition supply, consistent with the
dispensing increment (unless you have a prescription written
for fewer days). We will cover more than one refill of these
drugs for the first 90 days you are a member of our plan. If
you need a drug that is not on our formulary, or if your
ability to get your drugs is limited, but you are past the first
90 days of membership in our plan, we will cover a 31-day
emergency supply of that drug (unless you have a
prescription for fewer days) while you pursue a formulary
exception.
The information in the Requirements/Limits column tells
you if our plan has any special requirements for coverage of
your drug.
QLL - Quantity Limits: Restricts the frequency, amount
or dosage of medication for which you can obtain benefits
each time you get a prescription filled (most often set on a
monthly basis).
PAR - Prior Authorization: The process of obtaining
approval for certain prescriptions before benefits will be
approved. You, your doctor or other network provider will
During the time when you are getting a temporary supply need to request prior authorization before you fill the
of a drug, you should talk to your prescriber or prescribing prescription.
physician to decide what to do when your supply runs out.
ST - Step Therapy: The process of first trying a certain
You can call Customer Service to ask for a list of covered
drug or drugs to determine if that drug or those drugs will
drugs that treat the same medical condition. This list can
help your doctor find a covered drug that might work for treat your medical condition before your plan will cover
you while you pursue a formulary exception. Please refer to another drug for that condition.
the Evidence of Coverage for more information about
B/D - Part B vs. Part D: This drug may be covered under
exceptions.
either your Part D prescripton drug benefits or as a Part B
drug under your medical benefits, as determined by
Medicare.
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Effective Date November 1, 2014
LA - Limited Access: This prescription may be available
INJ - Injectable: The drug is available in injectable form.
only at certain pharmacies. For more information, consult
MO - Mail Orders: Prescription drugs available through
your Pharmacy Directory or call Customer Service at
1-800-467-1199, 8 a.m. to 8 p.m., seven days a week (except mail order.
Thanksgiving and Christmas) from October 1 through
February 14, and Monday to Friday (except holidays) from
February 15 through September 30. TTY/TDD users should
call 711.
Cost-sharing for a one-month supply of a covered Part D prescription drug
during the Initial Coverage Stage:
Cost-Sharing Tier 1 Preferred Generic
Preferred Network Pharmacy* (30-day supply) or Mail-Order Pharmacy** (30-day supply)
Network Pharmacy (30-day supply) or Long-Term-Care Pharmacy (34-day supply)
$5.00
$10.00
Cost-Sharing Tier 2 Non-Preferred Generic
Preferred Network Pharmacy* (30-day supply) or Mail-Order Pharmacy** (30-day supply)
$15.00
Network Pharmacy (30-day supply) or Long-Term-Care Pharmacy (34-day supply)
$20.00
Cost-Sharing Tier 3 Preferred Brand
Preferred Network Pharmacy* (30-day supply) or Mail-Order Pharmacy** (30-day supply)
$40.00
Network Pharmacy (30-day supply) or Long-Term-Care Pharmacy (34-day supply)
$45.00
Cost-Sharing Tier 4 Non-Preferred Brand
Preferred Network Pharmacy* (30-day supply) or Mail-Order Pharmacy** (30-day supply)
$90.00
Network Pharmacy (30-day supply) or Long-Term-Care Pharmacy (34-day supply)
$95.00
Cost-Sharing Tier 5 Injectable Drugs
Preferred Network Pharmacy* (30-day supply) or Mail-Order Pharmacy** (30-day supply)
33%
Network Pharmacy (30-day supply) or Long-Term-Care Pharmacy (34-day supply)
33%
Cost-Sharing Tier 6 Specialty Tier
Preferred Network Pharmacy* (30-day supply) or Mail-Order Pharmacy** (30-day supply)
33%
Network Pharmacy (30-day supply) or Long-Term-Care Pharmacy (34-day supply)
33%
Please refer to our Evidence of Coverage for more information for cost sharing.
* Preferred Network Pharmacy – A network pharmacy that offers covered drugs to members of our plan that may
have lower cost-sharing levels than other network pharmacies.
** Mail-Order Pharmacy – Mail-order service allows you to order a 30–90-day supply of drugs. The drugs available through
our plan’s mail-order service are marked as “mail-order” drugs in our drug list.
Freedom 14251, V20
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Effective Date November 1, 2014
Covered Medications by Therapeutic Category
Legend
Generic drugs are shown in lower-case italics (e.g. enalapril)
Brand-name drugs are shown in capital letters (e.g. HUMALOG)
QLL - Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits
each time you get a prescription filled (most often set on a monthly basis).
PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved.
You, your doctor or other network provider will need to request prior authorization before you fill the prescription.
ST - Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or those drugs will treat
your medical condition before your plan will cover another drug for that condition.
B/D - Part B vs Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B
drug under your medical benefits, as determined by Medicare.
LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your
Pharmacy Directory or call Customer Service 1-800-467-1199, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving
and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through
September 30.. TTY/TDD users should call 711.
INJ - Injectable: The drug is available in injectable form.
MO - Mail Order: Prescription drugs available through mail order.
Drug Name
Anti - Infectives
abacavir
abacavir sulfate/lamivudine/
zidovudine
ABELCET
acyclovir caps
acyclovir sodium inj 500mg
acyclovir sodium inj 50mg/ml
acyclovir susp
acyclovir tabs
adefovir dipivoxil
ALBENZA
ALINIA
amantadine hcl caps
amantadine hcl tabs
AMBISOME
amikacin sulfate
amoxicillin
amoxicillin/clavulanate
potassium
amoxicillin/clavulanate
potassium er
amphotericin b
ampicillin
ampicillin sodium inj 10gm,
125mg, 1gm, 250mg, 2gm
ampicillin sodium inj 500mg
Freedom 14251, V20
Drug Requirements/
Tier Limits
3
6
MO
MO
6
2
5
5
2
2
6
4
4
2
2
6
5
1
3
B/D PAR MO
MO
B/D PAR MO
B/D PAR
MO
MO
MO
MO
MO
MO
MO
B/D PAR MO
MO
MO
MO
3
MO
5
1
5
B/D PAR MO
MO
MO
Drug Requirements/
Tier Limits
Drug Name
ampicillin-sulbactam inj 10gm;
5gm, 1gm; 0.5gm
ampicillin-sulbactam inj 2gm;
1gm
APTIVUS CAPS
APTIVUS ORAL SOLN
atovaquone
atovaquone/proguanil hcl
ATRIPLA
AVELOX ABC PACK
5
AVELOX INJ
AVELOX TABS
5
4
AZACTAM IN ISOOSMOTIC DEXTROSE INJ
1GM; 0
AZACTAM IN ISOOSMOTIC DEXTROSE INJ
2GM; 0
azithromycin inj 500mg
azithromycin pack
azithromycin susr 100mg/5ml
5
azithromycin susr 200mg/5ml
2
5
MO
6
6
6
4
6
4
MO
PAR MO
MO
MO
QLL(5 per 1 days)
MO
MO
QLL(21 per 1 days)
MO
6
5
2
2
MO
QLL(15 per 1 days)
MO
QLL(46 per 1 days)
MO
5
7
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
azithromycin tabs 250mg
2
azithromycin tabs 500mg
2
azithromycin tabs 600mg
2
aztreonam
baciim
bacitracin inj
bactocill in dextrose inj 0; 1gm/
50ml
bactocill in dextrose inj 0; 2gm/
50ml
BARACLUDE
BICILLIN C-R
BICILLIN L-A
BILTRICIDE
CANCIDAS
CAPASTAT SULFATE
CAYSTON
CEDAX CAPS
cefaclor
cefaclor er
cefadroxil
cefazolin sodium inj 100gm,
10gm, 1gm; 5%, 20gm, 500mg
cefazolin sodium inj 1gm
cefazolin sodium/dextrose
cefdinir
cefditoren pivoxil tabs 200mg
cefditoren pivoxil tabs 400mg
cefepime inj 1gm, 2gm
cefepime inj 1gm/50ml, 2gm/
100ml
cefotaxime sodium inj 10gm
cefotaxime sodium inj 1gm,
2gm, 500mg
cefotetan
cefoxitin sodium inj 10gm,
1gm; 4%, 2gm, 2gm; 2.2%
cefoxitin sodium inj 1gm
cefpodoxime proxetil
cefprozil
ceftazidime inj 1gm, 2gm
ceftazidime inj 6gm
5
5
5
5
Freedom 14251, V20
QLL(6 per 1 days)
MO
QLL(3 per 1 days)
MO
QLL(8 per 1 days)
MO
MO
MO
MO
6
6
5
5
4
6
5
6
4
2
2
2
5
PAR MO
MO
MO
MO
B/D PAR MO
5
5
3
4
4
5
5
MO
MO
MO
5
5
MO
LA MO
MO
MO
MO
MO
MO
MO
5
5
5
3
3
5
5
MO
MO
MO
MO
8
Drug Requirements/
Tier Limits
Drug Name
CEFTAZIDIME/
DEXTROSE
ceftibuten
CEFTIN SUSR
ceftriaxone in iso-osmotic
dextrose
ceftriaxone sodium inj 10gm
ceftriaxone sodium inj 1gm,
250mg, 2gm, 500mg
ceftriaxone/dextrose
cefuroxime axetil tabs
cefuroxime sodium inj 1.5gm,
750mg
cefuroxime sodium inj 7.5gm
cephalexin caps 250mg, 500mg
cephalexin susr
cephalexin tabs
chloramphenicol sodium
succinate
chloroquine phosphate
cidofovir
CIPRO I.V.-IN D5W
CIPRO SUSR
ciprofloxacin er tb24 1000mg;
0
ciprofloxacin er tb24 500mg; 0
5
ciprofloxacin hcl
ciprofloxacin i.v.-in d5w
ciprofloxacin inj 200mg/20ml
ciprofloxacin inj 400mg/40ml
ciprofloxacin susr
CLAFORAN INJ 10GM,
1GM, 2GM
CLAFORAN INJ 500MG
clarithromycin
clarithromycin er
2
5
5
5
4
5
CLEOCIN PEDIATRIC
GRANULES
clindamycin hcl
clindamycin phosphate addvantage
clindamycin phosphate in d5w
clindamycin phosphate inj
4
MO
QLL(28 per 1 days)
MO
MO
2
5
MO
MO
5
5
MO
MO
4
4
5
MO
MO
MO
5
5
MO
5
2
5
MO
MO
MO
5
2
2
2
5
MO
MO
MO
2
6
5
4
2
2
5
2
2
MO
B/D PAR MO
MO
QLL(14 per 1 days)
MO
QLL(3 per 1 days)
MO
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
clindamycin phosphate
pharmacy bulk package
clotrimazole troc
COARTEM
colistimethate sodium
COLY-MYCIN M
COMPLERA
CRIXIVAN
CUBICIN
DAPSONE
DARAPRIM
demeclocycline hcl tabs 150mg
demeclocycline hcl tabs 300mg
dicloxacillin sodium
didanosine
DIFICID
DORIBAX
doxy 100
doxycycline hyclate caps
doxycycline hyclate inj
doxycycline hyclate tabs
doxycycline monohydrate caps
100mg, 50mg
doxycycline monohydrate caps
75mg
doxycycline monohydrate susr
doxycycline monohydrate tabs
DYNACIN
E.E.S. GRANULES
EDURANT
EMTRIVA
entecavir
EPIVIR HBV
EPIVIR ORAL SOLN
EPZICOM
ery-tab tbec 250mg, 333mg
ERY-TAB TBEC 500MG
ERYPED 200
ERYPED 400
ERYTHROCIN
LACTOBIONATE INJ
500MG
erythrocin stearate
erythromycin
erythromycin base
erythromycin ethylsuccinate
Freedom 14251, V20
Drug Requirements/
Tier Limits
5
MO
2
4
5
5
6
3
6
4
3
3
4
2
2
6
5
5
2
5
2
2
MO
MO
MO
MO
MO
MO
B/D PAR MO
MO
MO
MO
MO
MO
MO
PAR MO
4
QLL(60 per 1 days)
MO
MO
MO
MO
MO
MO
MO
PAR
MO
MO
MO
MO
MO
MO
MO
4
2
4
4
6
4
6
3
4
6
4
4
4
4
5
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
9
Drug Requirements/
Tier Limits
Drug Name
ethambutol hcl
famciclovir tabs 125mg, 250mg
2
3
famciclovir tabs 500mg
3
FLAGYL CAPS
FLAGYL ER
fluconazole
fluconazole in dextrose
fluconazole in nacl
flucytosine
foscarnet sodium
FUZEON
4
4
2
5
5
6
5
6
ganciclovir
gentamicin sulfate inj
gentamicin sulfate pediatric
gentamicin sulfate/0.9% sodium
chloride
griseofulvin microsize susp
griseofulvin microsize tabs
griseofulvin ultramicrosize
HEPSERA
hydroxychloroquine sulfate
imipenem/cilastatin
INCIVEK
INTELENCE TABS 100MG,
200MG
INTELENCE TABS 25MG
INVANZ
INVIRASE
ISENTRESS CHEW
ISENTRESS PACK
ISENTRESS TABS
isoniazid inj
isoniazid syrp
isoniazid tabs
isotonic gentamicin inj 0.8mg/
ml; 0.9%, 1.2mg/ml; 0.9%,
1.6mg/ml; 0.9%, 1mg/ml;
0.9%
ISOTONIC GENTAMICIN
INJ 2MG/ML; 0.9%
itraconazole
KALETRA ORAL SOLN
KALETRA TABS
5
5
5
5
2
4
3
6
1
5
6
6
4
5
6
6
4
6
5
1
1
5
MO
QLL(60 per 30 days)
MO
QLL(21 per 7 days)
MO
MO
MO
MO
MO
B/D PAR MO
QLL(60 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PAR MO
MO
MO
MO
MO
MO
MO
MO
5
3
4
6
PAR MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
KETEK
3
ketoconazole tabs
LAMISIL PACK
lamivudine
lamivudine/zidovudine
levofloxacin in d5w
levofloxacin inj
levofloxacin oral soln
levofloxacin tabs
2
4
3
6
5
5
4
2
LEXIVA SUSP
LEXIVA TABS
LINCOCIN
MALARONE
mefloquine hcl
MEPRON
meropenem
methenamine hippurate
methenamine mandelate
metro iv
metronidazole caps
metronidazole in nacl 0.79%
metronidazole tabs
minocycline hcl
MONUROL
MOXATAG
moxifloxacin hcl
4
6
5
4
2
6
5
2
2
5
2
5
2
2
4
4
2
MYAMBUTOL
MYCAMINE
MYCOBUTIN
nafcillin sodium
nallpen iso-osmotic in dextrose
nallpen/dextrose
NEBUPENT
neomycin sulfate
nevirapine er
nevirapine susp
nevirapine tabs
nitrofurantoin macrocrystals
nitrofurantoin monohydrate
nitrofurantoin monohydrate/
macrocrystals
nitrofurantoin susp
NOROXIN
4
6
3
6
6
6
3
2
4
4
3
4
4
4
Freedom 14251, V20
4
4
QLL(20 per 1 days)
MO
MO
MO
MO
MO
MO
MO
QLL(14 per 1 days)
MO
MO
MO
MO
MO
MO
PAR MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(21 per 1 days)
MO
MO
MO
MO
MO
MO
B/D PAR MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
10
Drug Requirements/
Tier Limits
Drug Name
NORVIR
NOXAFIL SUSP
nystatin susp
nystatin tabs
ofloxacin
ORACEA
oxacillin sodium
paromomycin sulfate
PASER
PCE
PENICILLIN G
POTASSIUM IN ISOOSMOTIC DEXTROSE
penicillin g potassium inj
20000000unit, 5mu
penicillin g procaine
penicillin g sodium
penicillin v potassium
PENTAM 300
pfizerpen-g
piperacillin sodium/tazobactam
sodium inj 2gm; 0.25gm,
36gm; 4.5gm, 3gm; 0.375gm
piperacillin sodium/tazobactam
sodium inj 4gm; 0.5gm
piperacillin/tazobactam
polymyxin b sulfate
PREZISTA SUSP
PREZISTA TABS 150MG,
75MG
PREZISTA TABS 600MG,
800MG
PRIFTIN
PRIMAQUINE
PHOSPHATE
PRIMSOL
pyrazinamide
quinine sulfate
REBETOL
RELENZA DISKHALER
4
6
2
2
2
4
6
3
4
4
5
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
5
MO
5
5
1
5
5
5
MO
MO
MO
MO
MO
MO
RESCRIPTOR
RETROVIR IV INFUSION
RETROVIR SYRP
REYATAZ CAPS 100MG
4
5
4
4
5
5
5
6
4
MO
6
MO
3
3
MO
MO
4
2
4
6
3
MO
MO
PAR MO
MO
QLL(60 per 180 days)
MO
MO
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
Drug Requirements/
Tier Limits
Drug Name
REYATAZ CAPS 150MG,
200MG, 300MG
ribasphere caps
ribasphere ribapak
ribasphere tabs 200mg
ribasphere tabs 400mg
ribasphere tabs 600mg
RIBATAB
ribavirin
rifabutin
RIFADIN CAPS
RIFADIN INJ
RIFAMATE
rifampin caps
rifampin inj
RIFATER
rimantadine hcl
SELZENTRY
SEROMYCIN
stavudine caps
stavudine oral soln
STREPTOMYCIN
SULFATE
STRIBILD
STROMECTOL
sulfadiazine
sulfamethoxazole/trimethoprim
ds
sulfamethoxazole/trimethoprim
inj
sulfamethoxazole/trimethoprim
susp
sulfamethoxazole/trimethoprim
tabs
SUPRAX SUSR 100MG/
5ML, 200MG/5ML
SUPRAX SUSR 500MG/
5ML
SUPRAX TABS
SUSTIVA
TAMIFLU CAPS 30MG
6
MO
TAMIFLU SUSR
3
3
6
3
6
6
6
3
3
4
5
4
2
5
3
2
6
4
3
2
5
MO
MO
MO
3
2
5
6
3
3
1
MO
MO
MO
MO
terbinafine hcl tabs
tetracycline hcl
TIMENTIN INJ 0.1GM/
100ML; 3GM/100ML, 1GM;
30GM
TIMENTIN INJ 0.1GM;
3GM
tinidazole
TIVICAY
TOBI
tobramycin
tobramycin sulfate inj 1.2gm
tobramycin sulfate inj 1.2gm/
30ml, 10mg/ml, 40mg/ml,
80mg/2ml
tobramycin sulfate/sodium
chloride
TRECATOR
trimethoprim
TRIZIVIR
TRUVADA
TYGACIL
TYZEKA
valacyclovir hcl
6
6
6
TAMIFLU CAPS 45MG
3
TAMIFLU CAPS 75MG
3
Freedom 14251, V20
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
5
MO
VALCYTE
vancomycin hcl caps 125mg
1
MO
vancomycin hcl caps 250mg
1
MO
4
4
4
3
3
VANCOMYCIN HCL IN
DEXTROSE INJ 0; 1GM/
200ML
MO
VANCOMYCIN HCL IN
DEXTROSE INJ 0; 500MG/
100ML, 0; 750MG/150ML
vancomycin hcl inj 1000mg,
MO
10gm, 5000mg, 750mg
MO
vancomycin hcl inj 500mg
QLL(84 per 1 days)
VANCOMYCIN HCL INJ
MO
750MG
QLL(42 per 1 days)
VFEND SUSR
MO
QLL(56 per 365 days) VIBATIV INJ 250MG
VIBRAMYCIN
MO
VICTRELIS
11
QLL(360 per 180
days) MO
MO
MO
5
MO
2
6
6
6
5
5
MO
MO
B/D PAR MO
B/D PAR MO
5
MO
4
1
6
6
6
6
3
5
MO
MO
MO
MO
MO
PAR MO
QLL(30 per 1 days)
MO
MO
PAR QLL(40 per 1
days) MO
PAR QLL(80 per 1
days) MO
B/D PAR MO
5
B/D PAR
5
B/D PAR MO
5
5
B/D PAR
B/D PAR MO
6
6
4
6
PAR MO
PAR
MO
PAR MO
MO
Effective Date November 1, 2014
Drug Name
VIDEX EC
VIDEX PEDIATRIC
VIRACEPT
VIRAMUNE SUSP
VIRAMUNE XR
VIRAZOLE
VIREAD POWD
VIREAD TABS 150MG,
200MG, 250MG
VIREAD TABS 300MG
VISTIDE
voriconazole inj
voriconazole susr
voriconazole tabs
XIFAXAN TABS 200MG
ZERIT CAPS
ZIAGEN ORAL SOLN
zidovudine
ZMAX
ZYVOX INJ
ZYVOX SUSR
Drug Requirements/
Tier Limits
BUSULFEX
CAPRELSA
carboplatin inj 150mg/15ml,
450mg/45ml, 50mg/5ml,
600mg/60ml
CEENU
CELLCEPT
CELLCEPT
INTRAVENOUS
6 MO
cisplatin
6 B/D PAR MO
cladribine
5 MO
CLOLAR
6 PAR MO
COMETRIQ
6 PAR MO
COSMEGEN
cyclophosphamide tabs
6 MO
4 MO
cyclosporine caps
4 MO
cyclosporine inj
3 MO
cyclosporine modified caps
3 MO
100mg, 50mg
6 MO
cyclosporine modified caps 25mg
6 PAR QLL(1800 per 1 cyclosporine modified oral soln
days) MO
CYRAMZA
ZYVOX TABS
6 PAR QLL(28 per 1
cytarabine aqueous
days) MO
cytarabine inj 100mg/ml,
Antineoplastic & Immunosuppressant Drugs
20mg/ml
ABRAXANE
6 B/D PAR MO
dacarbazine
5 B/D PAR MO
adrucil
DACOGEN
AFINITOR
6 PAR MO
daunorubicin hcl
AFINITOR DISPERZ
6 PAR MO
decitabine
ALIMTA
6 PAR MO
dexrazoxane inj 250mg
ALKERAN INJ
5 B/D PAR
dexrazoxane inj 500mg
ALKERAN TABS
4 B/D PAR MO
DOCEFREZ
6 PAR MO
amifostine
docetaxel inj 160mg/16ml,
3 MO
anastrozole
20mg/0.5ml, 20mg/2ml, 80mg/
ARRANON
5 B/D PAR
2ml, 80mg/8ml
ARZERRA
6 B/D PAR MO
docetaxel inj 20mg/ml, 80mg/
ASTAGRAF XL
4 B/D PAR MO
4ml
AVASTIN
6 PAR MO
DOXIL
6 PAR MO
azacitidine
doxorubicin hcl inj 10mg,
AZASAN
4 B/D PAR MO
50mg
2 B/D PAR MO
azathioprine
doxorubicin hcl inj 2mg/ml
BELEODAQ
6 PAR MO
DROXIA
3 MO
bicalutamide
ELITEK
BICNU
5 B/D PAR MO
ELLENCE
5 B/D PAR MO
bleomycin sulfate
ELOXATIN INJ 100MG/
BOSULIF
6 PAR MO
20ML, 50MG/10ML
Freedom 14251, V20
4
3
6
4
4
6
6
4
MO
MO
MO
MO
MO
PAR MO
MO
MO
Drug Requirements/
Tier Limits
Drug Name
12
5
6
5
B/D PAR
LA PAR MO
B/D PAR MO
4
6
5
MO
B/D PAR MO
B/D PAR
5
6
6
6
6
2
3
5
3
B/D PAR MO
B/D PAR MO
B/D PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR
B/D PAR MO
2
3
6
5
5
B/D PAR MO
B/D PAR MO
PAR
B/D PAR MO
B/D PAR MO
5
6
5
6
6
6
6
6
B/D PAR MO
B/D PAR MO
B/D PAR
B/D PAR MO
B/D PAR
B/D PAR MO
B/D PAR
B/D PAR
6
B/D PAR MO
5
5
B/D PAR MO
B/D PAR
5
4
6
5
6
B/D PAR MO
MO
B/D PAR MO
B/D PAR MO
Effective Date November 1, 2014
Drug Name
ELSPAR
EMCYT
epirubicin hcl inj 200mg/
100ml, 50mg
epirubicin hcl inj 50mg/25ml
ERBITUX
ERIVEDGE
ERWINAZE
ETOPOPHOS
etoposide inj
exemestane
FARESTON
FASLODEX
FIRMAGON INJ 120MG
FIRMAGON INJ 80MG
fludarabine phosphate inj 50mg
fludarabine phosphate inj
50mg/2ml
fluorouracil inj
flutamide
FOLOTYN
FUSILEV
GAZYVA
gemcitabine
gemcitabine hcl inj 1gm,
200mg
gemcitabine hcl inj 2gm
gengraf
GILOTRIF
GLEEVEC
HALAVEN
hecoria caps 0.5mg, 1mg
hecoria caps 5mg
HERCEPTIN
HEXALEN
hydroxyurea
ICLUSIG
IDAMYCIN PFS
idarubicin hcl
IFEX
ifosfamide inj 1gm
ifosfamide inj 1gm/20ml, 3gm,
3gm/60ml
IMBRUVICA
INLYTA
Freedom 14251, V20
Drug Requirements/
Tier Limits
5
6
5
B/D PAR MO
MO
B/D PAR
5
6
6
6
5
5
3
4
6
6
5
5
5
B/D PAR MO
PAR MO
PAR MO
B/D PAR
B/D PAR MO
B/D PAR MO
MO
MO
PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR
5
3
6
5
6
6
6
B/D PAR MO
MO
B/D PAR MO
B/D PAR MO
PAR MO
B/D PAR
B/D PAR MO
6
2
6
6
6
2
6
6
6
2
6
6
6
5
5
5
B/D PAR
B/D PAR MO
PAR MO
PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
PAR MO
MO
MO
PAR MO
B/D PAR MO
B/D PAR
B/D PAR MO
B/D PAR MO
B/D PAR
6
6
PAR MO
PAR MO
Drug Requirements/
Tier Limits
Drug Name
irinotecan inj 100mg/5ml,
40mg/2ml
irinotecan inj 500mg/25ml
ISTODAX
IXEMPRA KIT
JAKAFI
JEVTANA
KADCYLA
letrozole
leucovorin calcium inj 100mg,
200mg, 350mg, 50mg
leucovorin calcium inj 500mg
leucovorin calcium tabs
LEUKERAN
leuprolide acetate
LOMUSTINE
LUPRON DEPOT INJ
3.75MG, 7.5MG
LUPRON DEPOT-PED INJ
7.5MG
LYSODREN
MATULANE
MEGACE ORAL
megestrol acetate
MEKINIST
melphalan hydrochloride
mercaptopurine
mesna
MESNEX INJ
MESNEX TABS
methotrexate
methotrexate sodium inj 1gm
methotrexate sodium inj 25mg/
ml, 50mg/2ml
mitomycin
mitoxantrone hcl
MUSTARGEN
mycophenolate mofetil
mycophenolic acid dr
MYFORTIC TBEC 180MG
MYFORTIC TBEC 360MG
NEXAVAR
NILANDRON
NIPENT
NULOJIX
13
5
B/D PAR MO
5
6
6
6
6
6
3
5
B/D PAR
PAR MO
B/D PAR MO
PAR MO
B/D PAR MO
PAR MO
MO
MO
5
2
3
5
4
6
MO
MO
PAR MO
MO
PAR MO
6
PAR MO
3
6
4
3
6
5
2
5
5
4
1
5
5
MO
MO
PAR MO
PAR MO
PAR MO
B/D PAR
MO
MO
5
5
5
3
4
4
6
6
4
6
6
B/D PAR MO
MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
LA PAR MO
MO
B/D PAR MO
B/D PAR MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
octreotide acetate inj 1000mcg/
ml
octreotide acetate inj 100mcg/
ml, 200mcg/ml, 500mcg/ml,
50mcg/ml
ONCASPAR
ONTAK
oxaliplatin inj 100mg, 100mg/
20ml, 50mg/10ml
oxaliplatin inj 50mg
paclitaxel
PERJETA
POMALYST
PROGRAF INJ
RAPAMUNE ORAL SOLN
RAPAMUNE TABS 0.5MG,
1MG
RAPAMUNE TABS 2MG
REVLIMID CAPS 10MG
6
PAR MO
5
PAR MO
6
6
6
B/D PAR MO
B/D PAR
B/D PAR MO
6
5
6
6
5
3
3
B/D PAR
B/D PAR MO
PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
6
6
REVLIMID CAPS 15MG,
20MG, 25MG
REVLIMID CAPS 2.5MG
REVLIMID CAPS 5MG
6
RHEUMATREX
RITUXAN
SANDOSTATIN LAR
DEPOT
SIMULECT INJ 10MG
SIMULECT INJ 20MG
sirolimus
SOLTAMOX
SPRYCEL
STIVARGA
SUTENT
SYNRIBO
TABLOID
tacrolimus caps 0.5mg, 1mg
tacrolimus caps 5mg
TAFINLAR
tamoxifen citrate
TARCEVA
TARGRETIN CAPS
TARGRETIN GEL
TASIGNA
4
6
6
B/D PAR MO
LA PAR QLL(60 per
30 days) MO
LA PAR QLL(30 per
30 days) MO
LA PAR MO
LA PAR QLL(150 per
30 days) MO
MO
PAR MO
PAR MO
6
6
3
4
6
6
6
6
4
3
6
6
2
6
6
6
6
B/D PAR
B/D PAR MO
B/D PAR MO
MO
PAR MO
PAR MO
PAR MO
MO
MO
B/D PAR MO
B/D PAR MO
PAR MO
MO
PAR MO
PAR MO
MO
PAR MO
Freedom 14251, V20
6
6
Drug Requirements/
Tier Limits
Drug Name
TAXOTERE
THALOMID
toposar
topotecan hcl inj 4mg
topotecan hcl inj 4mg/4ml
TORISEL
TREANDA
tretinoin caps
TREXALL
TRISENOX
TYKERB
VECTIBIX
VELCADE
VIDAZA
vinblastine sulfate inj 1mg/ml
vincasar pfs
vincristine sulfate
vinorelbine tartrate
VOTRIENT
XALKORI
XGEVA
6
6
5
6
6
6
6
6
4
6
6
6
6
6
5
5
5
5
6
6
6
XTANDI
YERVOY
ZALTRAP
ZANOSAR
ZELBORAF
ZOLINZA
ZORTRESS TABS 0.25MG
ZORTRESS TABS 0.5MG,
0.75MG
ZYDELIG
6
6
6
5
6
6
4
6
B/D PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR
B/D PAR MO
B/D PAR MO
MO
MO
B/D PAR MO
LA PAR MO
PAR MO
PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
PAR MO
PAR MO
PAR QLL(1.7 per 28
days) MO
PAR MO
PAR MO
PAR MO
B/D PAR MO
PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
PAR QLL(60 per 30
days) MO
ZYKADIA
6 PAR MO
ZYTIGA
6 PAR MO
Autonomic & Cns Drugs, Neurology & Psych
ABILIFY DISCMELT TBDP 6 QLL(90 per 30 days)
10MG
MO
ABILIFY DISCMELT TBDP 6 QLL(60 per 30 days)
15MG
MO
ABILIFY INJ
5 MO
ABILIFY MAINTENA
6 MO
ABILIFY ORAL SOLN
3 QLL(900 per 30 days)
MO
ABILIFY TABS 10MG
3 QLL(90 per 30 days)
MO
14
6
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
ABILIFY TABS 15MG
3
ABILIFY TABS 20MG
6
ABILIFY TABS 2MG
3
ABILIFY TABS 30MG
6
ABILIFY TABS 5MG
3
ABSTRAL SUBL 100MCG
4
ABSTRAL SUBL 200MCG,
300MCG, 400MCG,
600MCG, 800MCG
acetaminophen/codeine #2
6
acetaminophen/codeine #3
2
acetaminophen/codeine #4
2
acetaminophen/codeine oral soln
2
acetaminophen/codeine
phosphate
acetaminophen/codeine tabs
2
ACTIQ
6
ADASUVE
alprazolam tabs
4
3
amitriptyline hcl
amoxapine
amphetamine/
dextroamphetamine tabs
1.25mg; 1.25mg; 1.25mg;
1.25mg, 1.875mg; 1.875mg;
1.875mg; 1.875mg, 2.5mg;
2.5mg; 2.5mg; 2.5mg,
3.125mg; 3.125mg; 3.125mg;
3.125mg, 3.75mg; 3.75mg;
3.75mg; 3.75mg, 5mg; 5mg;
5mg; 5mg
amphetamine/
dextroamphetamine tabs 7.5mg;
7.5mg; 7.5mg; 7.5mg
3
2
3
Freedom 14251, V20
2
2
3
Drug Requirements/
Tier Limits
Drug Name
QLL(60 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(450 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(180 per 30 days)
MO
PAR QLL(120 per 30
days) MO
PAR QLL(120 per 30
days) MO
AMPYRA
6
APOKYN
APTIOM
ARICEPT TABS 23MG
6
4
3
aspirin-caffeine-dihydrocodeine
AZILECT
baclofen
BANZEL SUSP
4
3
2
4
BANZEL TABS 200MG
4
BANZEL TABS 400MG
4
QLL(390 per 30 days)
MO
QLL(390 per 30 days)
MO
QLL(390 per 30 days)
MO
QLL(4500 per 30
days)
QLL(390 per 30 days)
MO
QLL(390 per 30 days)
MO
PAR QLL(120 per 30
days) MO
benztropine mesylate inj
benztropine mesylate tabs
BRINTELLIX TABS 10MG
5
3
4
BRINTELLIX TABS 20MG
4
BRINTELLIX TABS 5MG
4
bromocriptine mesylate
budeprion sr tb12 150mg
BUPRENEX
buprenorphine hcl inj
buprenorphine hcl subl 2mg
2
2
5
5
3
buprenorphine hcl subl 8mg
3
buprenorphine hcl/naloxone hcl
subl 2mg; 0.5mg
buprenorphine hcl/naloxone hcl
subl 8mg; 2mg
bupropion hcl er tb12 100mg
3
bupropion hcl er tb12 150mg
bupropion hcl er tb12 200mg
2
2
bupropion hcl sr tb12 100mg
2
bupropion hcl sr tb12 150mg
bupropion hcl sr tb12 200mg
2
2
bupropion hcl tabs 100mg
2
QLL(90 per 30 days)
MO
PAR MO
MO
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
15
3
2
LA PAR QLL(60 per
30 days) MO
LA PAR MO
ST MO
QLL(30 per 30 days)
ST MO
QLL(240 per 30 days)
MO
MO
QLL(2400 per 30
days) MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
MO
QLL(60 per 30 days)
ST MO
QLL(30 per 30 days)
ST MO
QLL(120 per 30 days)
ST MO
MO
MO
MO
PAR QLL(240 per 30
days) MO
PAR QLL(60 per 30
days) MO
PAR QLL(360 per 30
days) MO
PAR QLL(90 per 30
days) MO
QLL(120 per 30 days)
MO
MO
QLL(60 per 30 days)
MO
QLL(120 per 30 days)
MO
MO
QLL(60 per 30 days)
MO
QLL(135 per 30 days)
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
bupropion hcl tabs 75mg
2
bupropion hcl xl tb24 150mg
2
bupropion hcl xl tb24 300mg
2
buspirone hcl
butalbital/acetaminophen/
caffeine/codeine caps 300mg;
50mg; 40mg; 30mg
butorphanol tartrate inj
butorphanol tartrate nasal soln
2
4
CAPITAL/CODEINE
4
carbamazepine
carbamazepine er
carbidopa
carbidopa/levodopa
carbidopa/levodopa er
carbidopa/levodopa odt
carbidopa/levodopa/entacapone
CELEBREX
2
2
4
2
2
2
3
4
CELONTIN
chlorpromazine hcl inj
chlorpromazine hcl tabs
citalopram hydrobromide oral
soln
citalopram hydrobromide tabs
10mg
citalopram hydrobromide tabs
20mg
citalopram hydrobromide tabs
40mg
clomipramine hcl
clonazepam odt tbdp 0.125mg
4
5
2
2
clonazepam odt tbdp 0.25mg
3
clonazepam odt tbdp 0.5mg
3
clonazepam odt tbdp 1mg
3
clonazepam odt tbdp 2mg
3
Freedom 14251, V20
5
3
2
2
2
4
3
QLL(180 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
MO
QLL(180 per 30 days)
MO
MO
QLL(10 per 30 days)
MO
QLL(5000 per 30
days) MO
MO
MO
ST MO
MO
MO
MO
MO
PAR QLL(60 per 30
days) MO
MO
MO
MO
QLL(600 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
QLL(4800 per 30
days) MO
QLL(2400 per 30
days) MO
QLL(1200 per 30
days) MO
QLL(600 per 30 days)
MO
QLL(300 per 30 days)
MO
16
Drug Requirements/
Tier Limits
Drug Name
clonazepam tabs 0.5mg
3
clonazepam tabs 1mg
3
clonazepam tabs 2mg
3
clorazepate dipotassium
3
clozapine odt tbdp 100mg
clozapine odt tbdp 12.5mg
4
4
clozapine odt tbdp 25mg
4
clozapine tabs 100mg
clozapine tabs 200mg
clozapine tabs 25mg
2
2
2
clozapine tabs 50mg
codeine sulfate tabs 15mg
2
3
codeine sulfate tabs 30mg
3
codeine sulfate tabs 60mg
3
COGENTIN
COPAXONE
cyclobenzaprine hcl tabs 10mg,
5mg
CYMBALTA CPEP 20MG
5
6
4
CYMBALTA CPEP 30MG
4
CYMBALTA CPEP 60MG
4
dantrolene sodium
DEPACON
DEPAKENE CAPS
desipramine hcl
DESVENLAFAXINE ER
TB24 100MG
DESVENLAFAXINE ER
TB24 50MG
dextroamphetamine sulfate tabs
10mg
dextroamphetamine sulfate tabs
5mg
3
5
4
2
4
4
4
3
3
QLL(1200 per 30
days) MO
QLL(600 per 30 days)
MO
QLL(300 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(270 per 30 days)
QLL(2160 per 30
days)
QLL(1080 per 30
days)
QLL(270 per 30 days)
QLL(135 per 30 days)
QLL(1080 per 30
days)
QLL(540 per 30 days)
QLL(720 per 30 days)
MO
QLL(360 per 30 days)
MO
QLL(180 per 30 days)
MO
MO
PAR MO
PAR MO
QLL(180 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
MO
MO
QLL(120 per 30 days)
MO
QLL(240 per 30 days)
MO
PAR QLL(180 per 30
days) MO
PAR QLL(90 per 30
days) MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
diazepam gel
3
diazepam intensol
3
diazepam oral soln
3
diazepam tabs 10mg
3
diazepam tabs 2mg
3
diazepam tabs 5mg
3
diclofenac potassium
diclofenac sodium dr
diclofenac sodium er
diclofenac sodium/misoprostol
diflunisal
dihydroergotamine mesylate inj
dihydroergotamine mesylate
nasal soln
DILANTIN CAPS 100MG
DILANTIN CAPS 30MG
DILANTIN INFATABS
DILANTIN SUSP
divalproex sodium
divalproex sodium dr
divalproex sodium er
dolophine hcl TABS 10MG
2
2
2
4
2
5
4
DOLOPHINE HCL TABS
5MG
donepezil hcl tabs 10mg, 5mg
donepezil hcl tabs 23mg
donepezil hcl tbdp
4
3
3
4
2
2
2
4
4
2
3
2
doxepin hcl
duloxetine hcl cpep 20mg
3
2
duloxetine hcl cpep 30mg
2
duloxetine hcl cpep 60mg
2
duramorph inj 0.5mg/ml
duramorph inj 1mg/ml
5
5
Freedom 14251, V20
QLL(2 per 1 days)
MO
QLL(240 per 30 days)
MO
QLL(1200 per 30
days) MO
QLL(120 per 30 days)
MO
QLL(600 per 30 days)
MO
QLL(240 per 30 days)
MO
MO
MO
MO
MO
MO
MO
QLL(8 per 28 days)
MO
MO
MO
MO
MO
MO
MO
MO
QLL(360 per 30 days)
MO
QLL(720 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
ST MO
QLL(30 per 30 days)
MO
PAR MO
QLL(180 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
B/D PAR MO
B/D PAR
17
Drug Requirements/
Tier Limits
Drug Name
EMSAM
4
endocet tabs 325mg; 10mg,
325mg; 5mg, 325mg; 7.5mg
endodan
2
entacapone
epitol
EQUETRO CP12 100MG
2
1
4
EQUETRO CP12 200MG
4
EQUETRO CP12 300MG
4
ERGOMAR
escitalopram oxalate oral soln
3
2
escitalopram oxalate tabs 10mg
2
escitalopram oxalate tabs 20mg
2
escitalopram oxalate tabs 5mg
2
ethosuximide
etodolac
etodolac er
EXELON PT24
2
2
2
3
FANAPT TABS 10MG
4
FANAPT TABS 12MG
4
FANAPT TABS 1MG
4
FANAPT TABS 2MG
4
FANAPT TABS 4MG
4
FANAPT TABS 6MG
4
FANAPT TABS 8MG
4
FANAPT TITRATION
PACK
FAZACLO TBDP 100MG
FAZACLO TBDP 12.5MG
4
2
4
4
QLL(30 per 30 days)
MO
QLL(360 per 30 days)
MO
QLL(360 per 30 days)
MO
MO
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(180 per 30 days)
MO
MO
QLL(600 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(120 per 30 days)
MO
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(72 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(720 per 30 days)
MO
QLL(360 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(8 per 30 days)
QLL(270 per 30 days)
QLL(2160 per 30
days)
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
FAZACLO TBDP 150MG
FAZACLO TBDP 200MG
FAZACLO TBDP 25MG
4
4
4
felbamate susp
felbamate tabs
FELDENE
fenoprofen calcium tabs
fentanyl citrate oral
transmucosal
fentanyl patches
6
3
4
2
6
FENTORA
6
FETZIMA CP24 120MG,
80MG
FETZIMA CP24 20MG
4
FETZIMA CP24 40MG
4
FETZIMA TITRATION
PACK
FIORICET/CODEINE
4
fluoxetine caps 10mg
2
fluoxetine caps 20mg
2
fluoxetine dr
4
fluoxetine hcl caps 10mg
2
fluoxetine hcl caps 20mg
2
fluoxetine hcl caps 40mg
2
4
4
4
fluoxetine hcl oral soln
2
fluoxetine hcl tabs 10mg
2
fluoxetine hcl tabs 20mg
2
FLUOXETINE HCL TABS
60MG
fluphenazine decanoate
fluphenazine hcl conc
fluphenazine hcl elix
4
Freedom 14251, V20
5
2
2
QLL(180 per 30 days)
QLL(135 per 30 days)
QLL(1080 per 30
days)
MO
MO
MO
MO
PAR QLL(120 per 30
days) MO
QLL(15 per 30 days)
MO
PAR QLL(120 per 30
days) MO
PAR QLL(30 per 30
days) MO
PAR QLL(180 per 30
days) MO
PAR QLL(90 per 30
days) MO
PAR QLL(28 per 365
days) MO
QLL(180 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(4 per 28 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(600 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
MO
18
Drug Requirements/
Tier Limits
Drug Name
fluphenazine hcl inj
fluphenazine hcl tabs
flurbiprofen
fluvoxamine maleate tabs
100mg
fluvoxamine maleate tabs 25mg
5
2
2
2
fluvoxamine maleate tabs 50mg
2
fosphenytoin sodium
FYCOMPA TABS 10MG,
12MG
FYCOMPA TABS 2MG
5
4
FYCOMPA TABS 4MG
4
FYCOMPA TABS 6MG
4
FYCOMPA TABS 8MG
4
gabapentin caps 100mg
2
gabapentin caps 300mg
2
gabapentin caps 400mg
2
gabapentin oral soln
2
gabapentin tabs 600mg
2
gabapentin tabs 800mg
2
GABITRIL
galantamine hydrobromide
cp24
galantamine hydrobromide oral
soln
galantamine hydrobromide tabs
4
2
GEODON INJ
GILENYA
5
6
guanidine hcl
haloperidol
haloperidol decanoate
haloperidol lactate
2
2
5
5
2
4
2
2
MO
MO
MO
QLL(90 per 30 days)
MO
QLL(360 per 30 days)
MO
QLL(180 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(1080 per 30
days) MO
QLL(360 per 30 days)
MO
QLL(270 per 30 days)
MO
QLL(2160 per 30
days) MO
QLL(180 per 30 days)
MO
QLL(135 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
PAR QLL(30 per 30
days) MO
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
HORIZANT TBCR 300MG
4
HORIZANT TBCR 600MG
4
hydrocodone/acetaminophen
oral soln 325mg/15ml; 10mg/
15ml
hydrocodone/acetaminophen
oral soln 325mg/15ml; 7.5mg/
15ml
hydrocodone/acetaminophen
tabs 325mg; 10mg, 325mg;
5mg, 325mg; 7.5mg
hydrocodone/ibuprofen tabs
7.5mg; 200mg
hydromorphone hcl inj 1mg/ml,
500mg/50ml
hydromorphone hcl inj 2mg/ml,
4mg/ml
hydromorphone hcl liqd
2
hydromorphone hcl tabs 2mg
hydromorphone hcl tabs 4mg
hydromorphone hcl tabs 8mg
2
2
2
5
5
4
3
3
3
ibuprofen susp
ibuprofen tabs 400mg, 600mg,
800mg
imipramine hcl
INTUNIV
1
1
INVEGA SUSTENNA INJ
117MG/0.75ML, 156MG/
ML, 234MG/1.5ML
INVEGA SUSTENNA INJ
39MG/0.25ML, 78MG/
0.5ML
INVEGA TB24 1.5MG
6
INVEGA TB24 3MG
4
INVEGA TB24 6MG
4
INVEGA TB24 9MG
6
Freedom 14251, V20
2
4
5
4
PAR QLL(120 per 30
days) MO
PAR QLL(60 per 30
days) MO
QLL(2700 per 30
days) MO
Drug Requirements/
Tier Limits
Drug Name
ketoprofen
ketoprofen er
KHEDEZLA TB24 100MG
2
2
4
KHEDEZLA TB24 50MG
4
LAMICTAL STARTER/
NOT TAKING
CARBAMAZEPINE
LAMICTAL STARTER/
QLL(360 per 30 days) TAKING
CARBAMAZEPINE/NOT
MO
TAKING VALPROATE
QLL(480 per 30 days) LAMICTAL STARTER/
TAKING VALPROATE
MO
lamotrigine
LATUDA TABS 120MG
MO
LATUDA TABS 20MG
QLL(1920 per 30
LATUDA TABS 40MG
days) MO
QLL(960 per 30 days)
LATUDA TABS 60MG
MO
QLL(480 per 30 days)
LATUDA TABS 80MG
MO
QLL(240 per 30 days)
LAZANDA
MO
MO
levetiracetam er tb24 500mg
MO
4
MO
MO
QLL(120 per 30 days)
MO
QLL(240 per 30 days)
MO
MO
4
MO
4
MO
2
6
levetiracetam er tb24 750mg
2
levetiracetam inj 500mg/5ml
levetiracetam oral soln
levetiracetam tabs
levorphanol tartrate
5
2
2
2
MO
QLL(30 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(75 per 30 days)
MO
QLL(60 per 30 days)
MO
LA PAR QLL(30 per
30 days) MO
QLL(180 per 30 days)
MO
QLL(120 per 30 days)
MO
MO
MO
MO
QLL(180 per 30 days)
MO
MO
MO
MO
ST MO
QLL(90 per 30 days)
MO
MO
MO
PAR QLL(180 per 30
days) MO
QLL(3600 per 30
days) MO
MO
QLL(30 per 30 days)
MO
QLL(2 per 28 days)
MO
QLL(2 per 28 days)
MO
lithium carbonate
lithium carbonate er
QLL(240 per 30 days) lithium citrate
LODOSYN
MO
QLL(120 per 30 days) lorazepam tabs
MO
QLL(60 per 30 days) loxapine
loxapine succinate
MO
QLL(40 per 30 days) LYRICA CAPS 100MG
MO
19
4
4
4
4
6
2
1
1
2
4
3
2
2
4
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
LYRICA CAPS 150MG
4
LYRICA CAPS 200MG
4
LYRICA CAPS 225MG,
300MG
LYRICA CAPS 25MG
4
4
LYRICA CAPS 50MG
4
LYRICA CAPS 75MG
4
LYRICA ORAL SOLN
4
maprotiline hcl tabs 25mg
2
maprotiline hcl tabs 50mg
2
maprotiline hcl tabs 75mg
MARPLAN
meclofenamate sodium
mefenamic acid
meloxicam susp
2
3
3
2
2
meloxicam tabs
2
MESTINON SYRP
MESTINON TIMESPAN
methadone hcl conc
3
3
3
methadone hcl inj
methadone hcl intensol
5
3
methadone hcl oral soln 10mg/
5ml
methadone hcl oral soln 5mg/
5ml
methadone hcl tabs 10mg
3
3
3
methadone hcl tabs 5mg
3
methadone hcl tbso
methadose conc
3
3
methadose sugar-free
3
methadose tbso
3
Freedom 14251, V20
PAR QLL(120 per 30
days) MO
PAR QLL(90 per 30
days) MO
PAR QLL(60 per 30
days) MO
PAR QLL(720 per 30
days) MO
PAR QLL(360 per 30
days) MO
PAR QLL(240 per 30
days) MO
PAR QLL(900 per 30
days) MO
QLL(270 per 30 days)
MO
QLL(135 per 30 days)
MO
MO
MO
MO
MO
QLL(300 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
QLL(360 per 30 days)
MO
QLL(360 per 30 days)
MO
QLL(1800 per 30
days) MO
QLL(3600 per 30
days) MO
QLL(360 per 30 days)
MO
QLL(720 per 30 days)
MO
MO
QLL(360 per 30 days)
MO
QLL(360 per 30 days)
MO
MO
20
Drug Requirements/
Tier Limits
Drug Name
methylphenidate hcl
3
migergot
MIGRANAL
3
6
mirtazapine odt tbdp 15mg
2
mirtazapine odt tbdp 30mg
2
mirtazapine odt tbdp 45mg
2
mirtazapine tabs 15mg
2
mirtazapine tabs 30mg
2
mirtazapine tabs 45mg
2
mirtazapine tabs 7.5mg
2
mirtazapine tbdp
2
modafinil tabs 100mg
3
modafinil tabs 200mg
6
morphine sulfate er tbcr 100mg,
200mg
morphine sulfate er tbcr 15mg,
30mg, 60mg
morphine sulfate inj 0.5mg/ml
morphine sulfate inj 10mg/ml,
150mg/30ml, 15mg/ml, 1mg/
ml, 50mg/ml
morphine sulfate inj 1mg/ml
morphine sulfate inj 25mg/ml,
2mg/ml, 4mg/ml
MORPHINE SULFATE INJ
8MG/ML
morphine sulfate oral soln
10mg/5ml
morphine sulfate oral soln
20mg/5ml
morphine sulfate oral soln
20mg/ml
morphine sulfate supp
morphine sulfate tabs 15mg
3
3
5
5
5
5
PAR QLL(90 per 30
days) MO
MO
QLL(8 per 28 days)
MO
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(90 per 30 days)
MO
PAR QLL(30 per 30
days) MO
PAR QLL(60 per 30
days) MO
QLL(180 per 30 days)
MO
QLL(120 per 30 days)
MO
B/D PAR
MO
B/D PAR MO
5
3
3
3
3
3
QLL(3600 per 30
days) MO
QLL(1800 per 30
days) MO
QLL(360 per 30 days)
MO
MO
QLL(480 per 30 days)
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
morphine sulfate tabs 30mg
3
nabumetone
nalbuphine hcl
naloxone hcl inj 0.4mg/ml
naloxone hcl inj 1mg/ml
naltrexone hcl
NAMENDA ORAL SOLN
2
5
5
5
2
3
NAMENDA TABS 10MG
NAMENDA TABS 5MG
NAMENDA TITRATION
PAK
NAMENDA XR
3
3
3
3
NAMENDA XR
TITRATION PACK
naproxen
naproxen dr
naproxen sodium tabs 275mg,
550mg
naratriptan hcl
3
nefazodone hcl tabs 100mg
2
nefazodone hcl tabs 150mg
2
nefazodone hcl tabs 200mg
2
nefazodone hcl tabs 250mg
2
nefazodone hcl tabs 50mg
2
nortriptyline hcl
NUEDEXTA
olanzapine inj
olanzapine odt tbdp 10mg
2
3
5
3
olanzapine odt tbdp 15mg
3
olanzapine odt tbdp 20mg
3
olanzapine odt tbdp 5mg
3
Freedom 14251, V20
2
2
2
3
Drug Requirements/
Tier Limits
Drug Name
QLL(240 per 30 days) olanzapine tabs 10mg
MO
MO
olanzapine tabs 15mg
MO
olanzapine tabs 2.5mg
MO
olanzapine tabs 20mg
MO
QLL(300 per 30 days)
olanzapine tabs 5mg
MO
QLL(60 per 30 days)
olanzapine tabs 7.5mg
MO
QLL(90 per 30 days)
ONFI SUSP
MO
QLL(60 per 30 days)
ONFI TABS 10MG
MO
PAR QLL(30 per 30
ONFI TABS 20MG
days) MO
PAR QLL(28 per 365
ORAP
days) MO
oxaprozin
MO
oxazepam
MO
MO
oxcarbazepine
OXTELLAR XR TB24
QLL(9 per 30 days)
150MG
MO
QLL(180 per 30 days) OXTELLAR XR TB24
300MG
MO
QLL(120 per 30 days) OXTELLAR XR TB24
600MG
MO
QLL(90 per 30 days) oxycodone hcl caps
MO
QLL(72 per 30 days) oxycodone hcl conc
MO
QLL(360 per 30 days) oxycodone hcl oral soln
oxycodone hcl tabs 10mg
MO
MO
oxycodone hcl tabs 15mg
MO
MO
QLL(60 per 30 days) oxycodone hcl tabs 20mg
MO
QLL(40 per 30 days) oxycodone hcl tabs 30mg
MO
QLL(30 per 30 days) oxycodone hcl tabs 5mg
MO
QLL(120 per 30 days) oxycodone/acetaminophen
MO
21
3
3
3
4
3
3
4
4
4
3
2
2
2
4
4
4
3
3
3
3
3
3
3
3
2
QLL(60 per 30 days)
MO
QLL(40 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(80 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
QLL(120 per 30 days)
MO
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(1620 per 30
days) MO
QLL(405 per 30 days)
MO
MO
QLL(810 per 30 days)
MO
QLL(540 per 30 days)
MO
QLL(390 per 30 days)
MO
QLL(270 per 30 days)
MO
QLL(1620 per 30
days) MO
QLL(360 per 30 days)
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
oxycodone/aspirin
2
oxycodone/ibuprofen
2
OXYCONTIN T12A 10MG,
15MG, 20MG, 30MG,
40MG
OXYCONTIN T12A 60MG
4
OXYCONTIN T12A 80MG
6
4
PAMELOR CAPS 10MG,
25MG, 50MG
PAMELOR CAPS 75MG
paroxetine hcl er tb24 12.5mg
6
paroxetine hcl er tb24 25mg
2
paroxetine hcl er tb24 37.5mg
2
paroxetine hcl tabs 10mg
2
paroxetine hcl tabs 20mg
2
paroxetine hcl tabs 30mg
2
paroxetine hcl tabs 40mg
2
PAXIL SUSP
4
PEGANONE
perphenazine
perphenazine/amitriptyline
PEXEVA TABS 10MG
4
2
3
4
PEXEVA TABS 20MG
4
PEXEVA TABS 30MG
4
PEXEVA TABS 40MG
4
phenelzine sulfate
phenobarbital elix
3
3
phenobarbital tabs 100mg
phenobarbital tabs 15mg
3
3
Freedom 14251, V20
4
2
Drug Requirements/
Tier Limits
Drug Name
QLL(360 per 30 days) phenobarbital tabs 16.2mg
MO
QLL(120 per 30 days) phenobarbital tabs 30mg
MO
QLL(60 per 30 days) phenobarbital tabs 32.4mg
ST MO
phenobarbital tabs 60mg
QLL(120 per 30 days)
ST MO
phenobarbital tabs 64.8mg
QLL(120 per 30 days)
ST MO
phenobarbital tabs 97.2mg
MO
phenytoin chew
MO
phenytoin infatabs
QLL(180 per 30 days) phenytoin sodium
MO
phenytoin sodium extended
QLL(90 per 30 days) phenytoin susp
MO
piroxicam
QLL(60 per 30 days) POTIGA TABS 200MG,
MO
300MG, 400MG
QLL(180 per 30 days) POTIGA TABS 50MG
MO
QLL(90 per 30 days) pramipexole dihydrochloride
MO
primidone
QLL(60 per 30 days) PRISTIQ TB24 100MG
MO
QLL(45 per 30 days) PRISTIQ TB24 50MG
MO
QLL(1200 per 30
protriptyline hcl
days) MO
pyridostigmine bromide
MO
quetiapine fumarate tabs
MO
100mg
MO
quetiapine fumarate tabs
QLL(180 per 30 days) 200mg
MO
quetiapine fumarate tabs 25mg
QLL(90 per 30 days)
MO
quetiapine fumarate tabs
QLL(60 per 30 days) 300mg
MO
quetiapine fumarate tabs
QLL(45 per 30 days) 400mg
MO
quetiapine fumarate tabs 50mg
MO
QLL(3000 per 30
regonol
days) MO
RISPERDAL CONSTA INJ
QLL(120 per 30 days) 12.5MG, 25MG
QLL(800 per 30 days) RISPERDAL CONSTA INJ
MO
37.5MG
22
3
3
3
3
3
3
3
3
5
2
2
2
4
4
2
2
4
4
2
2
3
3
3
3
3
3
5
5
6
QLL(741 per 30 days)
MO
QLL(400 per 30 days)
MO
QLL(370 per 30 days)
MO
QLL(200 per 30 days)
MO
QLL(185 per 30 days)
MO
QLL(123 per 30 days)
MO
MO
MO
MO
MO
MO
QLL(90 per 30 days)
MO
QLL(270 per 30 days)
MO
MO
MO
PAR QLL(120 per 30
days) MO
PAR QLL(240 per 30
days) MO
MO
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(960 per 30 days)
MO
QLL(80 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(2 per 28 days)
MO
QLL(2 per 28 days)
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
Drug Requirements/
Tier Limits
Drug Name
RISPERDAL CONSTA INJ
50MG
risperidone m-tab tbdp 0.5mg
6
MO
ROZEREM
4
3
SABRIL PACK
4
risperidone m-tab tbdp 1mg
3
SABRIL TABS
6
risperidone m-tab tbdp 2mg
3
SAPHRIS SUBL 10MG
4
risperidone m-tab tbdp 3mg
3
SAPHRIS SUBL 5MG
4
risperidone m-tab tbdp 4mg
3
SARAFEM TABS 10MG
4
risperidone odt tbdp 0.25mg
3
SARAFEM TABS 20MG
4
risperidone odt tbdp 0.5mg
3
3
risperidone odt tbdp 2mg
3
risperidone odt tbdp 3mg
3
selegiline hcl
SEROQUEL XR TB24
150MG
SEROQUEL XR TB24
200MG
SEROQUEL XR TB24
300MG
SEROQUEL XR TB24
400MG
SEROQUEL XR TB24
50MG
sertraline hcl conc
2
3
risperidone odt tbdp 1mg
QLL(960 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(160 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(1920 per 30
days) MO
QLL(960 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(160 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(1920 per 30
days) MO
QLL(960 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(160 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
QLL(1800 per 30
days) MO
QLL(360 per 30 days)
MO
sertraline hcl tabs 100mg
2
sertraline hcl tabs 25mg
2
sertraline hcl tabs 50mg
2
STRATTERA CAPS 100MG,
60MG, 80MG
STRATTERA CAPS 10MG,
18MG, 25MG, 40MG
SUBOXONE FILM 12MG;
3MG
SUBOXONE FILM 2MG;
0.5MG
SUBOXONE FILM 4MG;
1MG
SUBOXONE FILM 8MG;
2MG
SUBSYS
4
risperidone odt tbdp 4mg
3
risperidone oral soln
2
risperidone tabs 0.25mg
2
risperidone tabs 0.5mg
2
risperidone tabs 1mg
2
risperidone tabs 2mg
2
risperidone tabs 3mg
2
risperidone tabs 4mg
rivastigmine tartrate
ropinirole er
ropinirole hcl
ROXICET ORAL SOLN
roxicet tabs
Freedom 14251, V20
2
2
2
2
4
2
23
3
3
3
3
2
4
4
4
4
4
6
QLL(30 per 30 days)
MO
LA QLL(180 per 30
days) MO
LA QLL(180 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
MO
QLL(160 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(80 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(300 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
PAR QLL(30 per 30
days) MO
PAR QLL(60 per 30
days) MO
PAR QLL(60 per 30
days) MO
PAR QLL(360 per 30
days) MO
PAR QLL(180 per 30
days) MO
PAR QLL(90 per 30
days) MO
LA PAR QLL(360 per
30 days) MO
Effective Date November 1, 2014
Drug Name
sulindac
sumatriptan nasal soln 20mg/
act
sumatriptan nasal soln 5mg/act
Drug Requirements/
Tier Limits
2
3
3
sumatriptan succinate inj
5
sumatriptan succinate refill
5
sumatriptan succinate tabs
3
SURMONTIL
SYNALGOS-DC
4
4
TASMAR
TEGRETOL-XR
thioridazine hcl
thiothixene
tiagabine hydrochloride
tizanidine hcl caps
tizanidine hcl tabs
tolmetin sodium
topiramate cpsp
topiramate tabs 100mg
6
4
3
2
3
4
2
2
2
2
topiramate tabs 200mg
2
topiramate tabs 25mg
2
topiramate tabs 50mg
2
tramadol hcl
2
tramadol hcl er tb24
2
tramadol hydrochloride/
acetaminophen
tranylcypromine sulfate
trazodone hcl
trifluoperazine hcl
TYSABRI
valproate sodium
valproic acid
venlafaxine hcl er cp24 150mg
2
Freedom 14251, V20
3
1
2
6
5
2
2
MO
QLL(8 per 30 days)
MO
QLL(16 per 30 days)
MO
QLL(4 per 30 days)
MO
QLL(4 per 30 days)
MO
QLL(9 per 30 days)
MO
MO
QLL(240 per 30 days)
MO
MO
MO
PAR MO
MO
MO
MO
MO
MO
PAR MO
PAR QLL(480 per 30
days) MO
PAR QLL(240 per 30
days) MO
PAR QLL(1920 per
30 days) MO
PAR QLL(960 per 30
days) MO
QLL(240 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(300 per 30 days)
MO
MO
MO
MO
LA PAR MO
MO
MO
QLL(60 per 30 days)
MO
24
Drug Requirements/
Tier Limits
Drug Name
venlafaxine hcl er cp24 37.5mg
2
venlafaxine hcl er cp24 75mg
2
venlafaxine hcl er tb24 150mg
2
VENLAFAXINE HCL ER
TB24 225MG
venlafaxine hcl er tb24 37.5mg
3
venlafaxine hcl er tb24 75mg
2
venlafaxine hcl tabs 100mg
2
venlafaxine hcl tabs 25mg
2
venlafaxine hcl tabs 37.5mg
2
venlafaxine hcl tabs 50mg
2
venlafaxine hcl tabs 75mg
2
VERSACLOZ
6
VIIBRYD KIT
4
VIIBRYD TABS 10MG
4
VIIBRYD TABS 20MG
4
VIIBRYD TABS 40MG
4
VIMPAT INJ
5
VIMPAT ORAL SOLN
4
VIMPAT TABS 100MG
4
VIMPAT TABS 150MG
4
VIMPAT TABS 200MG
4
VIMPAT TABS 50MG
4
VOLTAREN GEL
3
XENAZINE
6
2
QLL(180 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(180 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(113 per 30 days)
MO
QLL(450 per 30 days)
MO
QLL(300 per 30 days)
MO
QLL(225 per 30 days)
MO
QLL(150 per 30 days)
MO
LA QLL(600 per 30
days)
QLL(30 per 30 days)
ST MO
QLL(120 per 30 days)
ST MO
QLL(60 per 30 days)
ST MO
QLL(30 per 30 days)
ST MO
QLL(1200 per 30
days)
QLL(1200 per 30
days) MO
QLL(120 per 30 days)
MO
QLL(80 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(1000 per 30
days) MO
LA PAR MO
Effective Date November 1, 2014
Drug Name
XYREM
Drug Requirements/
Tier Limits
LA PAR QLL(540 per
30 days) MO
3 QLL(60 per 30 days)
zaleplon caps 10mg
MO
3 QLL(30 per 30 days)
zaleplon caps 5mg
MO
3 QLL(2700 per 30
zamicet
days) MO
ZELAPAR
4 MO
3 PAR QLL(180 per 30
zenzedi tabs 10mg
days) MO
3 PAR QLL(90 per 30
zenzedi tabs 5mg
days) MO
3 QLL(240 per 30 days)
ziprasidone hcl caps 20mg
MO
3 QLL(120 per 30 days)
ziprasidone hcl caps 40mg
MO
3 QLL(60 per 30 days)
ziprasidone hcl caps 60mg,
MO
80mg
3 QLL(30 per 30 days)
zolpidem tartrate
MO
2 MO
zonisamide
ZYPREXA INJ
5 QLL(60 per 30 days)
MO
Cardiovascular, Hypertension & Lipids
1 MO
acebutolol hcl
ADVICOR TB24 20MG;
4 QLL(60 per 30 days)
1000MG, 20MG; 750MG
MO
ADVICOR TB24 20MG;
4 QLL(30 per 30 days)
500MG, 40MG; 1000MG
MO
2 MO
afeditab cr
AGGRENOX
3 QLL(60 per 30 days)
MO
ALDACTAZIDE
4 MO
ALTOPREV
4 PAR QLL(30 per 30
days) MO
2 MO
amiloride hcl
amiloride/hydrochlorothiazide 1 MO
2 MO
aminocaproic acid syrp
5 B/D PAR MO
amiodarone hcl inj
2 MO
amiodarone hcl tabs
amlodipine besylate tabs 10mg, 1 QLL(30 per 30 days)
MO
2.5mg
1 QLL(45 per 30 days)
amlodipine besylate tabs 5mg
MO
amlodipine besylate/atorvastatin 2 QLL(30 per 30 days)
MO
calcium
Freedom 14251, V20
6
25
Drug Requirements/
Tier Limits
Drug Name
amlodipine besylate/benazepril
hcl
amlodipine besylate/benazepril
hydrochloride
ATACAND HCT TABS
16MG; 12.5MG
ATACAND HCT TABS
32MG; 12.5MG, 32MG;
25MG
ATACAND TABS 16MG,
4MG, 8MG
ATACAND TABS 32MG
1
MO
1
MO
4
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
atenolol
atenolol/chlorthalidone
atorvastatin calcium
2
1
1
AZOR
4
benazepril hcl
benazepril hcl/
hydrochlorothiazide
BENICAR HCT
1
1
BENICAR TABS 20MG,
40MG
BENICAR TABS 5MG
4
betaxolol hcl tabs
BIDIL
bisoprolol fumarate
bisoprolol fumarate/
hydrochlorothiazide
bumetanide inj
bumetanide tabs
BYSTOLIC
CALAN
candesartan cilexetil tabs 16mg,
4mg, 8mg
candesartan cilexetil tabs 32mg
1
3
1
1
candesartan cilexetil/
hydrochlorothiazide tabs 16mg;
12.5mg
candesartan cilexetil/
hydrochlorothiazide tabs 32mg;
12.5mg, 32mg; 25mg
2
4
4
4
4
4
5
1
3
4
2
2
2
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
captopril
captopril/hydrochlorothiazide
CARDIZEM LA TB24
120MG
CARDURA XL
cartia xt
carvedilol
chlorothiazide
chlorothiazide sodium
chlorthalidone tabs 25mg,
50mg
cholestyramine
cholestyramine light
cilostazol
clonidine hcl ptwk
1
1
4
MO
MO
MO
4
2
1
1
5
1
MO
MO
MO
MO
MO
MO
2
2
2
2
clonidine hcl tabs
clopidogrel tabs 300mg
clopidogrel tabs 75mg
1
2
2
clorpres tabs 15mg; 0.1mg,
15mg; 0.2mg
CLORPRES TABS 15MG;
0.3MG
colestipol hcl for oral suspension
colestipol hcl gran
colestipol hcl tabs
COREG CR
COUMADIN INJ
COUMADIN TABS
CRESTOR
4
MO
MO
MO
QLL(4 per 28 days)
MO
MO
MO
QLL(30 per 30 days)
MO
MO
4
MO
3
3
2
4
5
4
3
DEMSER
DIBENZYLINE
digox tabs 125mcg
4
4
2
MO
MO
MO
ST MO
MO
MO
QLL(30 per 30 days)
ST MO
MO
MO
QLL(30 per 30 days)
MO
MO
MO
QLL(30 per 30 days)
MO
MO
MO
MO
MO
MO
MO
digox tabs 250mcg
digoxin oral soln
digoxin tabs 125mcg
digoxin tabs 250mcg
DILATRATE SR
dilt-cd
dilt-xr
diltiazem cd
diltiazem hcl cd
Freedom 14251, V20
2
2
2
2
4
2
2
2
2
26
Drug Requirements/
Tier Limits
Drug Name
diltiazem hcl er cp12
diltiazem hcl er cp24
diltiazem hcl er tb24
diltiazem hcl inj
diltiazem hcl tabs
DIOVAN TABS 160MG
2
2
4
5
2
3
DIOVAN TABS 320MG
3
DIOVAN TABS 40MG,
80MG
disopyramide phosphate
doxazosin mesylate
DYAZIDE
DYRENIUM
EFFIENT
3
ELIQUIS
3
enalapril maleate
enalapril maleate/
hydrochlorothiazide
enoxaparin sodium inj 100mg/
ml, 300mg/3ml, 30mg/0.3ml,
40mg/0.4ml, 60mg/0.6ml,
80mg/0.8ml
enoxaparin sodium inj 120mg/
0.8ml, 150mg/ml
eplerenone
eprosartan mesylate
1
1
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
5
MO
6
MO
2
4
EXFORGE
4
EXFORGE HCT
4
felodipine er
fenofibrate caps 130mg, 43mg
fenofibrate micronized caps
134mg, 200mg
fenofibrate micronized caps
67mg
fenofibrate tabs 145mg, 48mg
fenofibrate tabs 160mg
2
2
2
fenofibrate tabs 54mg
2
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
3
2
4
4
3
2
2
2
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
fenofibric acid dr
flecainide acetate
fluvastatin
2
2
2
fondaparinux sodium inj 10mg/
0.8ml, 5mg/0.4ml, 7.5mg/
0.6ml
fondaparinux sodium inj
2.5mg/0.5ml
fosinopril sodium
fosinopril sodium/
hydrochlorothiazide
FRAGMIN INJ 10000UNIT/
ML, 12500UNIT/0.5ML,
15000UNIT/0.6ML,
18000UNT/0.72ML,
25000UNIT/ML,
7500UNIT/0.3ML
FRAGMIN INJ 2500UNIT/
0.2ML, 5000UNIT/0.2ML
furosemide inj
furosemide oral soln
furosemide tabs
gemfibrozil
heparin sodium dcu
heparin sodium inj 10000unit/
ml, 1000unit/ml, 20000unit/
ml, 5000unit/0.5ml, 5000unit/
ml
heparin sodium/d5w inj 5%;
100unit/ml, 5%; 40unit/ml
heparin sodium/d5w inj 5%;
50unit/ml
heparin sodium/nacl 0.45%
heparin sodium/nacl 0.9%
heparin sodium/sodium chloride
0.9% premix
hydralazine hcl inj
hydralazine hcl tabs
hydrochlorothiazide
indapamide
INNOPRAN XL
irbesartan
6
MO
MO
QLL(60 per 30 days)
MO
MO
5
MO
1
1
MO
MO
irbesartan/hydrochlorothiazide
1
Freedom 14251, V20
6
ST MO
5
ST MO
5
1
1
1
5
5
MO
MO
MO
MO
B/D PAR MO
B/D PAR MO
5
B/D PAR
5
B/D PAR MO
5
5
5
B/D PAR
B/D PAR
B/D PAR
5
2
1
1
4
1
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
27
Drug Requirements/
Tier Limits
Drug Name
ISORDIL TITRADOSE
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate
isosorbide mononitrate er
isradipine
jantoven
labetalol hcl inj
labetalol hcl tabs
LANOXIN TABS 125MCG
4
2
2
1
2
2
1
5
2
3
LANOXIN TABS 250MCG,
62.5MCG
LESCOL XL
3
lidocaine hcl inj 20mg/ml
lisinopril
lisinopril/hydrochlorothiazide
LIVALO
5
1
1
4
LOFIBRA CAPS 67MG
4
LOPRESSOR HCT TABS
25MG; 50MG
LOPRESSOR INJ
losartan potassium tabs 100mg
4
losartan potassium tabs 25mg,
50mg
losartan potassium/
hydrochlorothiazide
lovastatin tabs 10mg, 20mg
1
lovastatin tabs 40mg
1
LOVAZA
matzim la
MAXZIDE
MAXZIDE-25
methyclothiazide
methyldopa
metolazone
metoprolol succinate er
metoprolol tartrate inj
metoprolol tartrate tabs
metoprolol/hydrochlorothiazide
3
4
4
4
1
2
1
2
5
1
2
4
5
1
1
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
MO
PAR QLL(30 per 30
days) MO
MO
MO
MO
PAR QLL(30 per 30
days) MO
QLL(90 per 30 days)
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
mexiletine hcl
MICARDIS HCT TABS
12.5MG; 40MG, 25MG;
80MG
MICARDIS HCT TABS
12.5MG; 80MG
MICARDIS TABS 20MG,
40MG
MICARDIS TABS 80MG
2
3
MO
QLL(30 per 30 days)
MO
3
micronized colestipol hcl
MINIPRESS
minoxidil tabs
moexipril hcl
moexipril/hydrochlorothiazide
nadolol
nadolol/bendroflumethiazide
niacin er tbcr
2
4
2
1
1
1
2
3
NIACOR
nicardipine hcl caps
nicardipine hcl inj
nifedical xl
nifedipine er
nimodipine
nitro-bid
nitroglycerin inj
nitroglycerin lingual
translingual soln
nitroglycerin pt24
nitroglycerin transdermal
NITROSTAT
omega-3-acid ethyl esters
pacerone
pentoxifylline er
perindopril erbumine
pindolol
PRADAXA
3
2
5
2
2
3
2
5
4
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
QLL(60 per 30 days)
MO
MO
MO
pravastatin sodium
1
prazosin hcl
prevalite
procainamide hcl inj 100mg/ml
procainamide hcl inj 500mg/ml
PROMACTA
Freedom 14251, V20
3
3
2
2
3
3
2
2
1
1
4
2
2
5
5
6
MO
MO
MO
MO
B/D PAR
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
MO
Drug Requirements/
Tier Limits
Drug Name
propafenone hcl
propafenone hcl er
propranolol hcl er
propranolol hcl inj
propranolol hcl oral soln
propranolol hcl tabs
propranolol/hydrochlorothiazide
quinapril hcl
quinapril/hydrochlorothiazide
quinidine gluconate cr
quinidine gluconate er
quinidine sulfate
quinidine sulfate er
ramipril
RANEXA
REMODULIN
reserpine tabs 0.1mg
SIMCOR TB24 1000MG;
20MG, 500MG; 20MG,
750MG; 20MG
SIMCOR TB24 1000MG;
40MG, 500MG; 40MG
simvastatin
2
4
2
5
2
2
1
1
1
2
2
1
1
1
3
6
1
4
MO
MO
MO
4
sorine
sotalol hcl
sotalol hcl (af)
spironolactone
spironolactone/
hydrochlorothiazide
TARKA
taztia xt
TEKTURNA
2
2
2
1
1
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
MO
MO
MO
TEKTURNA HCT
4
telmisartan tabs 20mg, 40mg
3
telmisartan tabs 80mg
3
telmisartan/amlodipine
3
telmisartan/hydrochlorothiazide
tabs 12.5mg; 40mg, 25mg;
80mg
2
1
4
2
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
LA PAR MO
MO
QLL(60 per 30 days)
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
LA PAR MO
28
Effective Date November 1, 2014
Drug Name
telmisartan/hydrochlorothiazide
tabs 12.5mg; 80mg
terazosin hcl
TEVETEN HCT
Drug Requirements/
Tier Limits
2
2
4
TEVETEN TABS 400MG
4
TIKOSYN
timolol maleate
torsemide inj 20mg/2ml
TORSEMIDE INJ 50MG/
5ML
torsemide tabs
trandolapril
tranexamic acid inj
triamterene/hydrochlorothiazide
caps 25mg; 37.5mg
triamterene/hydrochlorothiazide
tabs
TRILIPIX
TWYNSTA
4
1
5
5
valsartan tabs 160mg
3
valsartan tabs 320mg
3
valsartan tabs 40mg, 80mg
3
valsartan/hydrochlorothiazide
2
QLL(60 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
1
1
5
1
MO
MO
1
MO
3
3
verapamil hcl er
verapamil hcl inj
verapamil hcl sr
verapamil hcl tabs
VYTORIN
2
5
2
2
4
warfarin sodium
WELCHOL
XARELTO TABS 10MG,
20MG
XARELTO TABS 15MG
1
3
3
ZETIA
4
3
MO
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
MO
PAR QLL(30 per 30
days) MO
MO
MO
QLL(30 per 30 days)
MO
QLL(42 per 30 days)
MO
PAR QLL(30 per 30
days) MO
Dermatologicals/Topical Therapy
Freedom 14251, V20
29
Drug Requirements/
Tier Limits
Drug Name
8-MOP
acitretin
acyclovir oint
4
6
3
adapalene gel 0.1%
AKNE-MYCIN
ala cort
ALA SCALP
alclometasone dipropionate
ALTABAX
2
4
4
4
2
4
amcinonide
ammonium lactate
amnesteem caps 10mg
amnesteem caps 20mg, 40mg
apexicon e
augmented betamethasone
dipropionate
betamethasone dipropionate
betamethasone valerate crea
betamethasone valerate foam
betamethasone valerate lotn
betamethasone valerate oint
calcipotriene crea
3
2
3
4
4
2
calcipotriene external soln
3
calcipotriene oint
3
calcipotriene/betamethasone
dipropionate
CAPEX
CARAC
ciclodan crea
ciclodan external soln
ciclopirox
ciclopirox nail lacquer
ciclopirox olamine
ciclopirox topical solution kit
claravis
CLINDAGEL
clindamycin phosphate external
soln
clindamycin phosphate foam
clindamycin phosphate gel
clindamycin phosphate lotn
4
MO
MO
MO
MO
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(120 per 30 days)
MO
MO
4
4
3
3
3
3
3
3
3
4
2
MO
MO
MO
PAR MO
MO
PAR MO
MO
PAR MO
MO
MO
MO
4
2
2
MO
MO
MO
2
2
4
2
2
3
PAR MO
MO
QLL(30 per 1 days)
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
MO
MO
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
Drug Requirements/
Tier Limits
Drug Name
clindamycin phosphate swab
clindamycin/benzoyl peroxide
clobetasol propionate
clobetasol propionate e
clobetasol propionate emollient
CLOBEX LIQD
CLOCORTOLONE
PIVALATE
CLOCORTOLONE
PIVALATE PUMP
CLODERM
CLODERM PUMP
clotrimazole external crea
clotrimazole external soln
clotrimazole/betamethasone
dipropionate
CONDYLOX GEL
CORDRAN TAPE
cormax scalp application
CORTISPORIN CREA
CORTISPORIN OINT
DENAVIR
2
2
2
2
2
4
4
desonide
desoximetasone crea
desoximetasone gel
desoximetasone oint 0.05%
desoximetasone oint 0.25%
diclofenac sodium gel
2
3
3
4
3
3
diflorasone diacetate
econazole nitrate
ELIDEL
3
2
4
ery
erythromycin
erythromycin/benzoyl peroxide
EURAX
EXELDERM
FINACEA
fluocinolone acetonide body
fluocinolone acetonide crea
fluocinolone acetonide external
soln
fluocinolone acetonide oint
fluocinolone acetonide scalp
2
2
2
4
4
4
4
2
2
fluocinonide crea 0.05%
fluocinonide crea 0.1%
fluocinonide external soln
fluocinonide gel
fluocinonide oint
fluocinonide-e
fluorouracil crea 5%
fluorouracil external soln
fluticasone propionate crea
fluticasone propionate lotn
MO
fluticasone propionate oint
MO
gentamicin sulfate crea
MO
gentamicin sulfate oint 0.1%
MO
halobetasol propionate
MO
HALOG
hydrocortisone butyrate
MO
hydrocortisone butyrate
MO
(lipophilic)
MO
hydrocortisone crea 1%, 2.5%
MO
hydrocortisone in absorbase
MO
hydrocortisone lotn 2.5%
QLL(5 per 1 days)
hydrocortisone oint 1%, 2.5%
MO
hydrocortisone valerate
MO
imiquimod
MO
KENALOG
MO
ketoconazole crea
MO
ketoconazole sham
MO
lidocaine hcl external soln
PAR QLL(100 per 30 lidocaine hcl gel
days) MO
lidocaine hcl inj 2%
MO
lidocaine hcl jelly
MO
lidocaine hcl mouth/throat soln
PAR QLL(60 per 1
lidocaine hcl viscous
days) MO
lidocaine oint
MO
lidocaine ptch
MO
MO
lidocaine viscous
MO
lidocaine/prilocaine crea
MO
lidocaine/prilocaine kit
MO
LIDODERM
MO
MO
lindane
MO
LOKARA
2
4
MO
MO
Freedom 14251, V20
4
4
4
2
2
2
4
4
2
4
4
3
MO
MO
MO
MO
MO
MO
mafenide acetate
malathion
methoxsalen
30
2
4
2
2
2
2
3
2
2
2
2
1
1
2
4
2
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
2
2
2
2
3
4
2
2
1
1
5
1
1
1
2
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
1
2
2
3
4
4
4
3
6
MO
QLL(90 per 30 days)
MO
MO
MO
QLL(90 per 30 days)
MO
MO
MO
MO
MO
PAR MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
METROGEL
metronidazole crea
metronidazole gel 0.75%
metronidazole gel 1%
metronidazole lotn
mometasone furoate
mupirocin calcium
mupirocin crea
mupirocin oint
myorisan
NAFTIN
nyamyc
nystatin crea
nystatin oint
nystatin powd 100000unit/gm
nystatin/triamcinolone
nystop
OXISTAT
OXSORALEN ULTRA
PANDEL
PANRETIN
pedi-dri
permethrin crea
PHISOHEX
podofilox
prednicarbate
PROTOPIC
4
2
2
4
2
2
4
4
2
3
4
2
2
2
2
2
2
4
6
4
6
2
2
4
2
2
4
prudoxin
rosadan
SANTYL
4
2
4
selenium sulfide lotn
silver sulfadiazine
sodium sulfacetamide lotn
SOLARAZE
1
1
2
3
SORIATANE
ssd
STELARA
6
1
6
sulfacetamide sodium
SULFAMYLON CREA
TACLONEX OINT
TAZORAC
TOPICORT CREA 0.05%
2
4
4
4
4
Freedom 14251, V20
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PAR MO
MO
MO
MO
MO
MO
MO
MO
PAR QLL(60 per 1
days) MO
MO
MO
QLL(30 per 1 days)
MO
MO
MO
MO
PAR QLL(100 per 30
days) MO
MO
MO
PAR QLL(1 per 28
days) MO
MO
MO
MO
MO
MO
31
Drug Requirements/
Tier Limits
Drug Name
TOPICORT OINT 0.05%
tretinoin crea
4
3
tretinoin gel
3
triamcinolone acetonide crea
triamcinolone acetonide lotn
triamcinolone acetonide oint
trianex
triderm
U-CORT
UVADEX
VALCHLOR
VANOS
VELTIN
XYLOCAINE EXTERNAL
SOLN
zenatane
ZIANA
ZOVIRAX CREA
2
2
2
2
2
4
5
6
4
4
4
MO
QLL(90 per 30 days)
MO
QLL(90 per 30 days)
MO
MO
MO
MO
MO
MO
MO
B/D PAR
MO
MO
MO
3
4
3
MO
MO
QLL(5 per 1 days)
MO
Diagnostics & Miscellaneous Agents
2 MO
acetic acid 0.25%
2
acetylcysteine inj
ACTONEL TABS 30MG
4 QLL(30 per 30 days)
ST MO
ADAGEN
6 MO
alendronate sodium tabs 40mg 1 QLL(30 per 30 days)
MO
3 MO
anagrelide hydrochloride
ARALAST NP
6 LA MO
BUPHENYL TABS
6 PAR MO
2 MO
buproban
2 MO
bupropion hcl sr tb12 150mg
CARBAGLU
6 LA PAR MO
2 MO
cevimeline hcl
CHANTIX
4 PAR MO
CHANTIX CONTINUING 4 PAR MO
MONTH PAK
CHANTIX STARTING
4 PAR MO
MONTH PAK
CHEMET
4 MO
CLINIMIX 4.25%/
5
DEXTROSE 5%
CLINIMIX E 2.75%/
5
DEXTROSE 10%
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
CLINIMIX E 2.75%/
DEXTROSE 5%
dextrose 10%/nacl 0.45%
dextrose 10%
dextrose 10% flex container
dextrose 10%/nacl 0.2%
dextrose 2.5%/sodium chloride
0.45%
dextrose 25%
dextrose 30%
dextrose 40%
dextrose 5%
dextrose 5% viaflex
dextrose 5%/lactated ringers
dextrose 5%/nacl 0.2%
dextrose 5%/nacl 0.225%
dextrose 5%/nacl 0.3%
dextrose 5%/nacl 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
dextrose 5%/sodium chloride
0.2%
dextrose 5%/sodium chloride
0.33%
dextrose 5%/sodium chloride
0.45%
dextrose 50%
dextrose 70%
dextrose thermoject system
disulfiram
etidronate disodium
EXJADE
FERRIPROX
FOSRENOL
5
GLASSIA
INCRELEX
kionex
lactated ringers dextrose 5%
viaflex
lactated ringers irrigation
levocarnitine inj
levocarnitine oral soln
levocarnitine tabs
midodrine hcl
neomycin/polymyxin b sulfates
6
6
4
5
MO
MO
LA PAR MO
PAR MO
QLL(90 per 30 days)
ST MO
LA MO
LA PAR MO
MO
MO
5
5
2
2
3
5
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
MO
MO
Freedom 14251, V20
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
MO
MO
MO
MO
MO
MO
5
5
5
5
5
3
2
6
6
6
MO
MO
32
Drug Requirements/
Tier Limits
Drug Name
NICOTROL INHALER
NICOTROL NS
ORFADIN
PHYSIOLYTE
PHYSIOSOL IRRIGATION
pilocarpine hcl
pilocarpine hydrochloride
PROLASTIN-C
RENAGEL
RENVELA PACK
4
3
6
5
5
2
2
6
4
3
RENVELA TABS
3
6
riluzole
5
ringers irrigation
3
sevelamer carbonate
5
sodium chloride 0.9%
5
sodium chloride inj 0.9%
sodium chloride irrigation soln 5
5
sodium chloride pab
6
sodium phenylbutyrate
3
sodium polystyrene sulfonate
powd
3
sodium polystyrene sulfonate
susp 15gm/60ml, 30gm/120ml
3
sps
5
sterile water irrigation
5
sterile water irrigation plastic
bottle
sterile water irrigation w/hanger 5
SYPRINE
6
ZEMAIRA
6
Ear, Nose & Throat Medications
3
acetasol hc
1
acetic acid
1
acetic acid/aluminum acetate
ASTEPRO
3
azelastine hcl nasal soln 0.15%
3
azelastine hcl nasal soln
137mcg/spray
BACTROBAN NASAL
chlorhexidine gluconate mouth/
throat soln
2
4
1
MO
MO
LA MO
B/D PAR
B/D PAR
MO
MO
LA MO
ST MO
QLL(90 per 30 days)
MO
QLL(270 per 30 days)
MO
MO
B/D PAR MO
QLL(270 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
LA MO
MO
MO
MO
QLL(30 per 25 days)
MO
QLL(30 per 25 days)
MO
QLL(30 per 25 days)
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
chlorhexidine gluconate oral
rinse
CIPRO HC
CIPRODEX
COLY-MYCIN S
CORTISPORIN-TC
denta 5000 plus
dentagel
fluocinolone acetonide ear drops
fluocinolone acetonide oil
hydrocortisone/acetic acid
ipratropium bromide nasal soln
1
MO
4
3
4
4
2
2
3
3
3
2
neomycin/polymyxin/hc
neomycin/polymyxin/
hydrocortisone
neutral sodium fluoride
ofloxacin
paroex
PATANASE
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
MO
MO
periogard
sf 5000 plus
triamcinolone acetonide pste
triamcinolone in orabase
TYZINE
TYZINE PEDIATRIC
NASAL DROPS
Endocrine/Diabetes
a-hydrocort
acarbose tabs 100mg
1
2
2
2
3
4
acarbose tabs 25mg
2
acarbose tabs 50mg
2
ACTOPLUS MET XR TB24
1000MG; 15MG
ACTOPLUS MET XR TB24
1000MG; 30MG
alcohol preps pads
ALDURAZYME
ANDRODERM
3
ANDROGEL GEL 25MG/
2.5GM, 50MG/5GM
3
Freedom 14251, V20
2
2
1
4
5
2
3
1
6
4
Drug Requirements/
Tier Limits
Drug Name
ANDROGEL GEL
20.25MG/1.25GM
ANDROGEL GEL 40.5MG/
2.5GM
ANDROGEL PUMP GEL
1%
ANDROGEL PUMP GEL
1.62%
androxy
APIDRA
APIDRA SOLOSTAR
BYDUREON
3
BYETTA INJ 10MCG/
0.04ML
BYETTA INJ 5MCG/
0.02ML
cabergoline
calcitonin-salmon
3
calcitriol caps
calcitriol inj
calcitriol oral soln
CEREZYME INJ 200UNIT
CEREZYME INJ 400UNIT
cortisone acetate
CYCLOSET
2
5
2
6
6
2
4
danazol
DDAVP INJ
MO
QLL(90 per 30 days) desmopressin acetate inj
desmopressin acetate nasal soln
MO
QLL(360 per 30 days) desmopressin acetate tabs
dexamethasone
MO
QLL(180 per 30 days) dexamethasone intensol
dexamethasone sodium
MO
QLL(60 per 30 days) phosphate inj
DEXPAK 10 DAY
MO
QLL(45 per 30 days) DEXPAK 13 DAY
DEXPAK 6 DAY
MO
doxercalciferol inj
MO
ELAPRASE
PAR MO
PAR QLL(30 per 30 FABRAZYME
fludrocortisone acetate
days) MO
PAR QLL(300 per 30 fortical
days) MO
3
5
5
3
3
1
2
5
MO
MO
MO
QLL(31 per 30 days)
MO
MO
MO
MO
MO
MO
MO
33
3
3
3
4
4
4
3
3
3
2
4
4
4
5
6
6
1
2
PAR QLL(30 per 30
days) MO
PAR QLL(60 per 30
days) MO
PAR QLL(300 per 30
days) MO
PAR QLL(150 per 30
days) MO
PAR MO
ST MO
ST MO
QLL(4 per 28 days)
MO
QLL(2.4 per 30 days)
MO
QLL(1.2 per 30 days)
MO
MO
QLL(4 per 30 days)
MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
PAR
PAR MO
MO
QLL(180 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
B/D PAR
PAR MO
PAR MO
MO
QLL(4 per 30 days)
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
gauze pads 2"x2"
1
glimepiride tabs 1mg
2
glimepiride tabs 2mg
2
glimepiride tabs 4mg
2
glipizide er tb24 10mg
1
glipizide er tb24 2.5mg
1
glipizide er tb24 5mg
1
glipizide tabs 10mg
1
glipizide tabs 5mg
1
glipizide xl tb24 10mg
1
glipizide xl tb24 2.5mg
1
glipizide xl tb24 5mg
1
glipizide/metformin hcl tabs
2.5mg; 250mg
glipizide/metformin hcl tabs
2.5mg; 500mg, 5mg; 500mg
GLUCAGEN
GLUCAGEN HYPOKIT
GLUCAGON
EMERGENCY KIT
GLUMETZA TB24 1000MG
1
GLUMETZA TB24 500MG
4
GLYSET TABS 100MG
4
GLYSET TABS 25MG
4
GLYSET TABS 50MG
4
H.P. ACTHAR
HECTOROL INJ 2MCG/
ML
HECTOROL INJ 4MCG/
2ML
6
5
Freedom 14251, V20
1
5
5
5
4
5
QLL(200 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
MO
MO
MO
Drug Requirements/
Tier Limits
Drug Name
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50
KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25
KWIKPEN
HUMULIN 70/30
HUMULIN 70/30
KWIKPEN
HUMULIN 70/30 PEN
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN N U-100 PEN
HUMULIN R
HUMULIN R U-500
(CONCENTRATED)
hydrocortisone tabs
INSULIN PEN NEEDLE
3
3
3
3
MO
MO
MO
MO
3
3
MO
MO
3
3
MO
MO
3
3
3
3
3
3
MO
MO
MO
MO
MO
MO
2
3
INSULIN SYRINGE (DISP)
U-100 0.3 ML
INSULIN SYRINGE (DISP)
U-100 1 ML
INSULIN SYRINGE (DISP)
U-100 1/2 ML
JANUMET
3
MO
QLL(200 per 30 days)
MO
QLL(200 per 30 days)
MO
QLL(200 per 30 days)
MO
QLL(200 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
JANUMET XR TB24
1000MG; 100MG
JANUMET XR TB24
QLL(60 per 30 days) 1000MG; 50MG, 500MG;
MO
50MG
QLL(120 per 30 days) JANUVIA TABS 100MG
MO
QLL(90 per 30 days) JANUVIA TABS 25MG
MO
QLL(360 per 30 days) JANUVIA TABS 50MG
MO
QLL(180 per 30 days) KAZANO
MO
PAR MO
KOMBIGLYZE XR TB24
B/D PAR
1000MG; 2.5MG
KOMBIGLYZE XR TB24
B/D PAR MO
1000MG; 5MG, 500MG;
5MG
34
3
3
3
3
3
3
3
3
3
3
3
QLL(30 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
KUVAN TBSO
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXPEN
LEVEMIR FLEXTOUCH
levothyroxine sodium inj
200mcg
levothyroxine sodium tabs
levoxyl
liothyronine sodium inj
liothyronine sodium tabs
metformin hcl er tb24 1000mg
6
3
3
3
3
3
5
metformin hcl er tb24 500mg
1
1
1
6
2
1
metformin hcl er tb24 500mg
1
metformin hcl er tb24 750mg
1
metformin hcl tabs 1000mg
1
metformin hcl tabs 500mg
1
metformin hcl tabs 850mg
1
methimazole
methylprednisolone
methylprednisolone acetate
methylprednisolone dose pack
methylprednisolone
sodiumsuccinate inj 1000mg,
125mg
methylprednisolone
sodiumsuccinate inj 40mg
millipred dp
millipred tabs
NAGLAZYME
nateglinide tabs 120mg
1
2
5
2
5
nateglinide tabs 60mg
2
NEEDLES, INSULIN DISP.,
SAFETY
NESINA TABS 12.5MG
3
Freedom 14251, V20
5
4
4
6
2
3
LA PAR MO
MO
MO
MO
MO
MO
MO
Drug Requirements/
Tier Limits
Drug Name
NESINA TABS 25MG
3
NESINA TABS 6.25MG
3
NOVOLIN 70/30
NOVOLIN 70/30 RELION
NOVOLIN N
NOVOLIN N RELION
NOVOLIN R
MO
NOVOLIN R RELION
MO
NOVOLOG
NOVOLOG FLEXPEN
MO
QLL(75 per 30 days) NOVOLOG MIX 70/30
NOVOLOG MIX 70/30
MO
QLL(120 per 30 days) PREFILLED FLEXPEN
NOVOLOG PENFILL
MO
QLL(150 per 30 days) NOVOPEN ECHO
MO
QLL(80 per 30 days) ONGLYZA TABS 2.5MG
MO
QLL(76 per 30 days) ONGLYZA TABS 5MG
MO
QLL(153 per 30 days) ORAPRED
ORAPRED ODT TBDP
MO
QLL(90 per 30 days) 15MG, 30MG
OSENI TABS 12.5MG;
MO
15MG
MO
OSENI TABS 12.5MG;
MO
30MG, 12.5MG; 45MG,
MO
25MG; 15MG, 25MG;
MO
30MG, 25MG; 45MG
MO
oxandrolone tabs 10mg
oxandrolone tabs 2.5mg
pamidronate disodium
paricalcitol
pioglitazone hcl tabs 15mg
MO
MO
pioglitazone hcl tabs 30mg
LA PAR MO
QLL(90 per 30 days)
pioglitazone hcl tabs 45mg
MO
QLL(180 per 30 days)
pioglitazone hcl-glimepiride
MO
QLL(200 per 30 days)
pioglitazone hcl/metformin hcl
MO
QLL(60 per 30 days)
PRANDIMET
MO
35
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
3
3
6
3
5
4
2
2
2
3
2
4
QLL(30 per 30 days)
MO
QLL(120 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(200 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(150 per 30 days)
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
PRANDIN TABS 0.5MG
4
PRANDIN TABS 1MG
4
PRANDIN TABS 2MG
4
prednisolone
prednisolone sodium phosphate
oral soln 15mg/5ml, 5mg/5ml
prednisone
prednisone intensol
PROGLYCEM
propylthiouracil
repaglinide tabs 0.5mg
2
2
repaglinide tabs 1mg
4
repaglinide tabs 2mg
4
SAMSCA TABS 15MG
6
SAMSCA TABS 30MG
6
SENSIPAR TABS 30MG
3
SENSIPAR TABS 60MG
6
SENSIPAR TABS 90MG
6
SOMAVERT INJ 10MG,
15MG, 20MG
SOMAVERT INJ 25MG,
30MG
STIMATE
SYMLINPEN 120
SYMLINPEN 60
SYNAREL
SYNTHROID
TESTIM
6
MO
MO
MO
MO
QLL(960 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
PAR QLL(120 per 30
days) MO
PAR QLL(60 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(120 per 30 days)
MO
LA PAR MO
6
LA PAR
4
4
4
6
3
3
testosterone cypionate
testosterone enanthate
tolazamide tabs 250mg
5
5
2
tolazamide tabs 500mg
2
MO
PAR MO
PAR MO
PAR MO
MO
PAR QLL(300 per 30
days) MO
MO
MO
QLL(120 per 30 days)
MO
QLL(60 per 30 days)
MO
Freedom 14251, V20
1
2
3
2
4
QLL(960 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
MO
MO
36
Drug Requirements/
Tier Limits
Drug Name
tolbutamide
2
triamcinolone acetonide inj
10mg/ml
triamcinolone acetonide inj
40mg/ml
unithroid tabs 100mcg,
112mcg, 125mcg, 150mcg,
175mcg, 200mcg, 25mcg,
300mcg, 50mcg, 75mcg, 88mcg
veripred 20
VICTOZA
5
ZAVESCA
ZEMPLAR CAPS
zoledronic acid inj 4mg
zoledronic acid inj 4mg/5ml
ZOMETA
Gastroenterology
ALOXI
ANZEMET INJ
APRISO
ASACOL HD
atropine sulfate inj 0.05mg/ml,
0.1mg/ml
AXID ORAL SOLN
balsalazide disodium
budesonide cp24
CANASA
CANTIL
CESAMET
CIMZIA
6
4
6
6
6
CIMZIA STARTER KIT
6
colocort
compro
constulose
CORTIFOAM
CREON
cromolyn sodium conc
CYSTADANE
CYTOTEC
DELZICOL
DEXILANT
4
2
2
4
3
3
3
4
3
4
QLL(180 per 30 days)
MO
MO
5
1
MO
1
3
MO
QLL(9 per 30 days)
MO
LA PAR MO
B/D PAR MO
MO
MO
5
5
3
3
5
MO
MO
MO
MO
4
3
6
3
4
6
6
MO
MO
MO
MO
MO
B/D PAR MO
PAR QLL(6 per 28
days) MO
PAR QLL(6 per 28
days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
ST MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
dicyclomine hcl
DIPENTUM
diphenoxylate/atropine tabs
dronabinol
EMEND CAPS
3
6
2
3
3
EMEND CAPS 125MG
3
EMEND CAPS 40MG
3
EMEND CAPS 80MG
3
enulose
esomeprazole sodium
famotidine inj 200mg/20ml,
20mg/2ml, 40mg/4ml
famotidine premixed
famotidine susr
famotidine tabs 20mg, 40mg
GATTEX
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
generlac
glycopyrrolate inj
glycopyrrolate tabs
GOLYTELY ORAL SOLN
227.1GM; 2.82GM;
6.36GM; 5.53GM; 21.5GM
granisetron hcl inj
granisetron hcl tabs
2
5
5
HALFLYTELY BOWEL
PREP/FLAVOR PACKS
hydrocortisone enem
KRISTALOSE
lactulose
lansoprazole
3
LIALDA
loperamide hcl caps
LOTRONEX TABS 0.5MG
3
2
3
LOTRONEX TABS 1MG
6
meclizine hcl tabs
1
Freedom 14251, V20
5
2
2
6
1
1
1
2
5
2
4
5
3
2
4
2
3
MO
MO
MO
B/D PAR MO
B/D PAR QLL(12
per 30 days) MO
B/D PAR QLL(4 per
30 days) MO
B/D PAR QLL(1 per
1 days) MO
B/D PAR QLL(8 per
30 days) MO
MO
Drug Requirements/
Tier Limits
Drug Name
mesalamine
methscopolamine bromide
metoclopramide hcl inj
metoclopramide hcl oral soln
metoclopramide hcl tabs
misoprostol
MOTOFEN
MOVIPREP
NEXIUM
3
2
5
1
1
2
4
4
3
NEXIUM I.V. INJ 20MG
NEXIUM I.V. INJ 40MG
nizatidine caps
omeprazole cpdr
5
5
2
2
ondansetron hcl inj
ondansetron hcl oral soln
5
3
ondansetron hcl tabs 24mg
3
ondansetron hcl tabs 4mg, 8mg
3
ondansetron odt
3
opium
opium tincture
opium tincture (paregoric)
OSMOPREP
PAMINE
PAMINE FORTE
pantoprazole sodium inj
pantoprazole sodium tbec
2
2
2
4
4
4
5
2
peg-3350/electrolytes
peg-3350/nacl/na bicarbonate/
kcl
PENTASA
polyethylene glycol 3350
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
procto-pak
proctosol hc
proctozone-hc
propantheline bromide
2
2
MO
MO
QLL(30 per 30 days)
MO
MO
B/D PAR QLL(450
per 30 days) MO
B/D PAR QLL(30
per 30 days)
B/D PAR QLL(90
per 30 days) MO
B/D PAR QLL(90
per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
MO
MO
3
2
2
5
2
2
2
1
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
B/D PAR QLL(30
per 30 days) MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
MO
MO
PAR QLL(60 per 30
days) MO
PAR QLL(60 per 30
days) MO
MO
37
MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
Effective Date November 1, 2014
Drug Name
ranitidine hcl inj 150mg/6ml,
50mg/2ml
ranitidine hcl syrp
ranitidine hcl tabs
RELISTOR
REMICADE
SANCUSO
Drug Requirements/
Tier Limits
5
MO
MO
MO
PAR MO
PAR MO
PAR QLL(4 per 28
days) MO
SUCRAID
6 MO
2 MO
sucralfate tabs
1 MO
sulfasalazine
1 MO
sulfazine
1 MO
sulfazine ec
SUPREP BOWEL PREP
4 MO
1 MO
trilyte
UCERIS
6 MO
2 MO
ursodiol
ZENPEP
4 MO
ZOFRAN INJ
5 MO
Immunology, Vaccines & Biotechnology
ACTHIB
3 MO
ACTIMMUNE
6 PAR MO
ADACEL
3 MO
ARANESP ALBUMIN FREE 6 PAR MO
INJ 100MCG/0.5ML,
100MCG/ML, 150MCG/
0.3ML, 150MCG/0.75ML,
200MCG/0.4ML, 200MCG/
ML, 300MCG/0.6ML,
300MCG/ML, 500MCG/ML
ARANESP ALBUMIN FREE 5 PAR MO
INJ 25MCG/0.42ML,
25MCG/ML, 40MCG/
0.4ML, 40MCG/ML,
60MCG/0.3ML, 60MCG/
ML
ARCALYST
6 PAR MO
AVONEX
6 PAR MO
AVONEX PEN
6 PAR MO
BCG VACCINE
5
BETASERON
6 PAR MO
BIVIGAM
6 PAR MO
BOOSTRIX
3 MO
BOTOX
5 PAR MO
CARIMUNE
6 PAR MO
NANOFILTERED
CERVARIX
3 MO
Freedom 14251, V20
2
2
5
6
6
38
Drug Requirements/
Tier Limits
Drug Name
COMVAX
DAPTACEL
DIPHTHERIA/TETANUS
TOXOIDS ADSORBED
PEDIATRIC
DYSPORT
ENGERIX-B
EPOGEN
EXTAVIA
fomepizole
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAGARD S/D IGA
LESS THAN 1MCG/ML
GAMMAPLEX INJ 10GM/
200ML, 2.5GM/50ML,
5GM/100ML
GAMMAPLEX INJ 20GM/
400ML
GAMUNEX-C
GARDASIL
GENOTROPIN
GENOTROPIN
MINIQUICK INJ 0.2MG
GENOTROPIN
MINIQUICK INJ 0.4MG,
0.6MG, 0.8MG, 1.2MG,
1.4MG, 1.6MG, 1.8MG,
1MG, 2MG
HAVRIX INJ 1440ELU/ML
HAVRIX INJ 720ELU/
0.5ML
ILARIS
IMOVAX RABIES
(H.D.C.V.)
INFANRIX
INTRON-A INJ 10MU/ML
INTRON-A INJ
6000000UNIT/ML
INTRON-A W/DILUENT
INJ 10MU
INTRON-A W/DILUENT
INJ 18MU, 50MU
IPOL INACTIVATED IPV
IXIARO
LEUKINE
3
3
3
MO
MO
5
3
5
6
6
5
6
6
PAR MO
B/D PAR MO
PAR MO
PAR MO
MO
PAR MO
PAR MO
PAR MO
6
PAR MO
6
PAR
6
3
6
5
PAR MO
MO
PAR MO
PAR MO
6
PAR MO
3
3
MO
6
3
LA PAR MO
MO
3
5
6
MO
PAR MO
PAR MO
5
PAR MO
6
PAR MO
3
3
6
MO
MO
PAR MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
M-M-R II W/DILUENT 10
DOSE
MENACTRA
MENOMUNE-A/C/Y/W135
MENVEO
NEULASTA
3
MO
3
3
MO
MO
3
6
NEUMEGA
6
NEUPOGEN
PEDVAX HIB
PEG-INTRON
PEG-INTRON REDIPEN
PEG-INTRON REDIPEN
PAK 4
PEGASYS
PEGASYS PROCLICK
PRIVIGEN
PROCRIT INJ 10000UNIT/
ML, 2000UNIT/ML,
3000UNIT/ML, 4000UNIT/
ML
PROCRIT INJ 20000UNIT/
ML, 40000UNIT/ML
PROLEUKIN
PROQUAD
RABAVERT
REBIF
REBIF REBIDOSE
REBIF REBIDOSE
TITRATION PACK
REBIF TITRATION PACK
RECOMBIVAX HB INJ
10MCG/ML, 40MCG/ML
RECOMBIVAX HB INJ
5MCG/0.5ML
ROTATEQ
SYLATRON
tetanus toxoid adsorbed
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED
ADULT
TEV-TROPIN
THYMOGLOBULIN
TICE BCG
TWINRIX
6
3
6
6
6
MO
PAR QLL(2 per 28
days) MO
PAR QLL(21 per 21
days) MO
PAR MO
MO
PAR MO
PAR MO
PAR MO
6
6
6
5
PAR MO
PAR MO
PAR MO
PAR MO
6
PAR MO
6
3
5
6
6
6
MO
6
3
PAR MO
B/D PAR MO
3
B/D PAR
3
6
3
3
PAR MO
MO
MO
5
6
5
3
PAR MO
B/D PAR
MO
MO
Freedom 14251, V20
MO
PAR MO
PAR MO
PAR MO
39
Drug Name
Drug Requirements/
Tier Limits
TYPHIM VI
3
VAQTA
3 MO
VARIVAX
3 MO
VARIZIG
3
XEOMIN
5 PAR MO
YF-VAX
3 MO
ZOSTAVAX
3 MO
Musculoskeletal & Rheumatology
ACTEMRA INJ 200MG/
6 PAR MO
10ML, 400MG/20ML,
80MG/4ML
ACTONEL TABS 150MG
4 QLL(1 per 30 days)
ST MO
ACTONEL TABS 35MG
4 QLL(4 per 28 days)
ST MO
ACTONEL TABS 5MG
4 QLL(30 per 30 days)
ST MO
4 MO
alendronate sodium oral soln
alendronate sodium tabs 10mg, 1 QLL(30 per 30 days)
MO
5mg
alendronate sodium tabs 35mg, 1 QLL(4 per 28 days)
MO
70mg
1 MO
allopurinol
5
aloprim
BENLYSTA
6 PAR MO
BONIVA INJ
5 B/D PAR MO
BONIVA TABS
4 QLL(1 per 28 days)
ST MO
COLCRYS
4 PAR MO
DEPEN TITRATABS
4 MO
ENBREL INJ 25MG, 50MG/ 6 PAR QLL(8 per 28
ML
days) MO
ENBREL INJ 25MG/0.5ML 6 PAR QLL(4.08 per
28 days) MO
ENBREL SURECLICK
6 PAR QLL(8 per 28
days) MO
EVISTA
3 QLL(30 per 30 days)
MO
FORTEO
5 PAR QLL(3 per 28
days) MO
FOSAMAX
4 QLL(4 per 28 days)
ST MO
FOSAMAX PLUS D
4 QLL(4 per 28 days)
ST MO
HUMIRA INJ 20MG/0.4ML 6 PAR QLL(2 per 28
days) MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
HUMIRA INJ 40MG/0.8ML
6
HUMIRA PEN
6
HUMIRA PEN-CROHNS
DISEASESTARTER
HUMIRA PEN-PSORIASIS
STARTER
ibandronate sodium inj
ibandronate sodium tabs
6
KINERET
6
leflunomide
ORENCIA INJ 125MG/ML
3
6
ORENCIA INJ 250MG
probenecid
probenecid/colchicine
PROLIA
6
2
2
5
raloxifene hydrochloride
3
RIDAURA
risedronate sodium
4
3
SAVELLA TABS 100MG
3
SAVELLA TABS 12.5MG
3
SAVELLA TABS 25MG
3
SAVELLA TABS 50MG
3
SAVELLA TITRATION
PACK
SIMPONI
3
ULORIC
Obstetrics & Gynecology
altavera
alyacen 1/35
alyacen 7/7/7
apri
aranelle
aviane
azurette
3
PAR QLL(6 per 28
days) MO
PAR QLL(6 per 28
days) MO
PAR QLL(6 per 365
days) MO
PAR QLL(4 per 365
days) MO
B/D PAR
QLL(1 per 28 days)
MO
PAR QLL(28 per 28
days) MO
MO
PAR QLL(4 per 28
days) MO
PAR MO
MO
MO
PAR QLL(2 per 365
days) MO
QLL(30 per 30 days)
MO
MO
QLL(1 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(480 per 30 days)
MO
QLL(240 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(1 per 365 days)
MO
PAR QLL(1 per 28
days) MO
ST MO
3
3
3
3
3
3
3
MO
MO
MO
MO
MO
MO
MO
Freedom 14251, V20
6
5
2
6
40
Drug Requirements/
Tier Limits
Drug Name
balziva
BREVICON-28
briellyn
camila
caziant
CLEOCIN CREA
CLEOCIN SUPP
CLIMARA PRO
3
4
3
3
3
4
4
4
clindamycin phosphate crea
CRINONE
cryselle-28
cyclafem 1/35
cyclafem 7/7/7
CYCLESSA
dasetta 1/35
dasetta 7/7/7
DESOGEN
drospirenone/ethinyl estradiol
elinest
emoquette
enpresse-28
errin
estarylla
ESTRACE CREA
estradiol ptwk
2
4
3
3
3
4
3
3
4
3
3
3
3
3
3
4
3
estradiol tabs
estradiol valerate
ESTRING
3
5
4
ESTROSTEP FE
falmina
FEMRING
4
3
4
gianvi
gildagia
gildess 1.5/30
gildess 1/20
gildess fe 1.5/30
gildess fe 1/20
heather
introvale
jolessa
jolivette
junel 1.5/30
4
3
3
3
3
3
3
3
3
3
3
MO
MO
MO
MO
MO
MO
MO
PAR QLL(4 per 28
days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(4 per 28 days)
MO
PAR MO
MO
QLL(1 per 90 days)
MO
MO
MO
QLL(1 per 90 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
junel 1/20
junel fe 1.5/30
junel fe 1/20
kariva
kelnor 1/35
leena
lessina
levonest
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
LOESTRIN 24 FE
LOMEDIA 24 FE
loryna
low-ogestrel
lutera
lyza
marlissa
medroxyprogesterone acetate inj
medroxyprogesterone acetate tabs
MENEST
methylergonovine maleate tabs
metronidazole vaginal
miconazole 3
3
3
3
3
3
3
3
3
3
3
4
4
4
3
3
3
3
5
1
4
4
2
2
microgestin 1.5/30
microgestin 1/20
MODICON
mono-linyah
mononessa
myzilra
necon 0.5/35-28
necon 1/35
necon 1/50-28
necon 10/11-28
necon 7/7/7
NOR-QD
nora-be
norethindrone
norethindrone acetate
norgestimate/ethinyl estradiol
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
NUVARING
ocella
ogestrel
3
3
4
3
3
3
3
3
3
3
3
4
3
3
2
3
3
3
3
4
3
3
Freedom 14251, V20
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PAR MO
MO
MO
QLL(6 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
41
Drug Name
orsythia
ORTHO EVRA
philith
pirmella 1/35
portia-28
PREMARIN CREA
PREMARIN INJ
PREMARIN TABS
previfem
progesterone caps
quasense
reclipsen
sprintec 28
sronyx
syeda
terconazole
tilia fe
tri-estarylla
tri-legest fe
tri-linyah
TRI-NORINYL 28
tri-previfem
tri-sprintec
trinessa
trivora-28
VAGIFEM
vandazole
velivet
vestura
viorele
XULANE
zarah
zazole crea
zenchent
zenchent fe
zovia 1/35e
zovia 1/50e
Ophthalmology
acetazolamide
acetazolamide er
acetazolamide sodium
ak-poly-bac
ALCAINE
ALOCRIL
ALOMIDE
Drug Requirements/
Tier Limits
3
4
3
3
3
4
5
4
3
2
3
3
3
3
3
2
3
3
3
3
4
3
3
3
3
4
2
3
4
3
4
3
2
3
4
3
3
MO
MO
MO
MO
MO
MO
PAR MO
PAR MO
MO
ST MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
2
5
1
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
ALPHAGAN P
OPHTHALMIC SOLN
0.1%
ALPHAGAN P
OPHTHALMIC SOLN
0.15%
ALREX
apraclonidine
AZASITE
azelastine hcl ophthalmic soln
AZOPT
bacitracin ophthalmic oint
bacitracin/polymyxin b
BESIVANCE
BETAGAN
betaxolol hcl ophthalmic soln
BETIMOL
BETOPTIC-S
BLEPHAMIDE
BLEPHAMIDE S.O.P.
brimonidine tartrate
carteolol hcl
CILOXAN
ciprofloxacin hcl
COMBIGAN
cromolyn sodium ophthalmic
soln
dexamethasone sodium
phosphate ophthalmic soln
diclofenac sodium ophthalmic
soln
dorzolamide hcl
dorzolamide hcl/timolol maleate
DUREZOL
EMADINE
epinastine hcl
erythromycin
FLAREX
fluorometholone
flurbiprofen sodium
FML
FML FORTE
gentak
gentamicin sulfate oint 0.3%
gentamicin sulfate ophthalmic
soln
Freedom 14251, V20
Drug Requirements/
Tier Limits
3
MO
4
MO
4
2
4
2
4
2
1
4
4
2
4
4
4
4
2
1
4
2
3
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
1
MO
2
MO
2
2
3
4
2
2
4
2
1
4
4
1
2
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Requirements/
Tier Limits
Drug Name
IOPIDINE
ISTALOL
ketorolac tromethamine
ophthalmic soln
LACRISERT
latanoprost
levobunolol hcl
levofloxacin ophthalmic soln
LOTEMAX OINT
LOTEMAX SUSP
LUMIGAN
MAXIDEX
methazolamide
metipranolol
MOXEZA
naphazoline hcl
NATACYN
neo-polycin
neo-polycin hc
neomycin/bacitracin/polymyxin
neomycin/polymyxin/bacitracin
zinc
neomycin/polymyxin/bacitracin/
hydrocortisone
neomycin/polymyxin/
dexamethasone
neomycin/polymyxin/gramicidin
neomycin/polymyxin/
hydrocortisone
NEOSPORIN
NEVANAC
ofloxacin
PATADAY
PATANOL
PHOSPHOLINE IODIDE
pilocarpine hcl
polycin
polymyxin b sulfate/
trimethoprim sulfate
PRED MILD
PRED-G
PRED-G S.O.P.
prednisolone acetate
prednisolone sodium phosphate
ophthalmic soln
RESCULA
42
4
4
2
MO
MO
MO
3
2
1
2
4
4
3
4
2
2
3
1
3
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
MO
2
MO
1
2
MO
MO
4
3
2
3
3
4
2
2
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
4
4
2
2
MO
MO
MO
MO
MO
4
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
RESTASIS
3 MO
2 MO
sodium sulfacetamide
ophthalmic soln
2 MO
sulfacetamide sodium
1 MO
sulfacetamide sodium/
prednisolone sodium phosphate
1 MO
timolol maleate
timolol maleate ophthalmic gel 1 MO
forming
TIMOPTIC
4 MO
TIMOPTIC OCUDOSE
4 MO
TIMOPTIC-XE
4 MO
TOBRADEX OINT
3 MO
TOBRADEX ST
3 MO
tobramycin sulfate ophthalmic 1 MO
soln
2 MO
tobramycin/dexamethasone
TOBREX OINT
4 MO
TRAVATAN Z
3 MO
3 MO
travoprost
3 MO
trifluridine
trimethoprim sulfate/polymyxin 1 MO
b sulfate
2 MO
tropicamide
VEXOL
4 MO
VIGAMOX
3 MO
ZIOPTAN
4 MO
ZIRGAN
3 MO
ZYLET
4 MO
Respiratory, Allergy, Cough & Cold
2 B/D PAR MO
acetylcysteine inhalation soln
ADCIRCA
6 PAR QLL(60 per 30
days) MO
ADRENACLICK
5 QLL(2 per 1 days)
MO
ADVAIR DISKUS
3 QLL(60 per 30 days)
MO
ADVAIR HFA
3 QLL(12 per 30 days)
MO
2 MO
albuterol sulfate er
albuterol sulfate nebu 0.083%, 2 B/D PAR QLL(360
per 30 days) MO
0.63mg/3ml, 1.25mg/3ml
2 B/D PAR QLL(60
albuterol sulfate nebu 0.5%
per 30 days) MO
2 MO
albuterol sulfate syrp
2 MO
albuterol sulfate tabs
Freedom 14251, V20
43
Drug Requirements/
Tier Limits
Drug Name
aminophylline
ASMANEX TWISTHALER
120 METERED DOSES
ASMANEX TWISTHALER
14 METERED DOSES
ASMANEX TWISTHALER
30 METERED DOSES
AEPB 110MCG/INH
ASMANEX TWISTHALER
30 METERED DOSES
AEPB 220MCG/INH
ASMANEX TWISTHALER
60 METERED DOSES
ASMANEX TWISTHALER
7 METERED DOSES
ATROVENT HFA
5
3
BECONASE AQ
4
BREO ELLIPTA
3
BROVANA
4
cetirizine hcl syrp 1mg/ml
2
CINRYZE
COMBIVENT RESPIMAT
6
4
cromolyn sodium nebu
2
cyproheptadine hcl tabs
DALIRESP
4
4
diphenhydramine hcl inj
DULERA
5
3
ELIXOPHYLLIN
epinephrine
3
5
epinephrine hcl
EPIPEN 2-PAK
5
5
EPIPEN-JR 2-PAK
5
FIRAZYR
FLOVENT DISKUS AEPB
100MCG/BLIST
6
3
MO
QLL(0.24 per 30
days) MO
3
3
QLL(0.14 per 30
days) MO
3
QLL(0.24 per 30
days) MO
3
QLL(0.24 per 30
days) MO
MO
3
4
QLL(26 per 30 days)
MO
QLL(50 per 30 days)
ST MO
QLL(60 per 30 days)
MO
B/D PAR QLL(120
per 30 days) MO
QLL(300 per 30 days)
MO
PAR MO
QLL(8 per 30 days)
MO
B/D PAR QLL(240
per 30 days) MO
MO
QLL(30 per 30 days)
MO
MO
QLL(13 per 30 days)
MO
MO
QLL(2 per 1 days)
MO
MO
QLL(2 per 1 days)
MO
QLL(2 per 1 days)
MO
PAR MO
QLL(60 per 30 days)
MO
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
FLOVENT DISKUS AEPB
250MCG/BLIST, 50MCG/
BLIST
FLOVENT HFA AERO
110MCG/ACT
FLOVENT HFA AERO
220MCG/ACT
FLOVENT HFA AERO
44MCG/ACT
flunisolide
3
fluticasone propionate susp
2
FORADIL AEROLIZER
3
ipratropium bromide inhalation
soln
ipratropium bromide/albuterol
sulfate
KALYDECO
2
LETAIRIS
levalbuterol
6
3
levalbuterol hcl nebu 0.31mg/
3ml, 1.25mg/3ml
levalbuterol hcl nebu 0.63mg/
3ml
levocetirizine dihydrochloride
tabs
LUFYLLIN
metaproterenol sulfate
montelukast sodium chew
2
montelukast sodium pack
3
3
3
2
2
6
2
2
4
2
2
3
montelukast sodium tabs
2
NASONEX
3
OMNARIS
4
PERFOROMIST
4
PROAIR HFA
3
Freedom 14251, V20
Drug Requirements/
Tier Limits
Drug Name
QLL(240 per 30 days) PROVENTIL HFA
MO
PULMOZYME
QLL(12 per 30 days) QVAR
MO
QLL(24 per 30 days) REVATIO INJ
MO
QLL(11 per 30 days) RHINOCORT AQUA
MO
QLL(75 per 30 days) SEREVENT DISKUS
MO
QLL(16 per 30 days) sildenafil
MO
QLL(60 per 30 days) sildenafil citrate
MO
B/D PAR MO
SPIRIVA HANDIHALER
B/D PAR QLL(540
per 30 days) MO
PAR QLL(60 per 30
days) MO
LA PAR MO
B/D PAR QLL(45
per 30 days) MO
B/D PAR QLL(270
per 30 days) MO
B/D PAR QLL(540
per 30 days) MO
QLL(30 per 30 days)
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(34 per 30 days)
MO
QLL(13 per 30 days)
ST MO
B/D PAR QLL(120
per 30 days) MO
QLL(18 per 30 days)
MO
44
3
6
3
6
4
3
6
6
3
SYMBICORT
3
terbutaline sulfate inj
terbutaline sulfate tabs
theophylline
theophylline cr
theophylline er
TRACLEER
triamcinolone acetonide aero
5
2
2
2
2
6
4
TYVASO
TYVASO REFILL
TYVASO STARTER
VENTAVIS
VENTOLIN HFA
6
6
6
6
4
VERAMYST
4
XOLAIR
6
XOPENEX HFA
4
zafirlukast
3
ZYFLO
6
ZYFLO CR
6
QLL(14 per 30 days)
MO
B/D PAR MO
QLL(27 per 30 days)
MO
PAR QLL(1125 per
30 days) MO
QLL(18 per 30 days)
ST MO
QLL(60 per 30 days)
MO
PAR QLL(90 per 30
days) MO
PAR QLL(90 per 30
days) MO
QLL(30 per 30 days)
MO
QLL(11 per 30 days)
MO
MO
MO
MO
MO
LA PAR MO
QLL(34 per 30 days)
MO
PAR MO
PAR MO
PAR MO
PAR MO
QLL(36 per 30 days)
ST MO
QLL(10 per 30 days)
ST MO
LA PAR QLL(6 per
28 days) MO
QLL(45 per 30 days)
ST MO
QLL(60 per 30 days)
MO
QLL(120 per 30 days)
MO
QLL(120 per 30 days)
MO
Urologicals
Effective Date November 1, 2014
Drug Name
Drug Requirements/
Tier Limits
AMINOSYN II
AMINOSYN II 8.5%/
ELECTROLYTES
MO
AMINOSYN M
MO
PAR QLL(30 per 30 AMINOSYN-HBC
AMINOSYN-PF
days) MO
AMINOSYN-PF 7%
CYSTAGON
3 LA MO
AMINOSYN-RF
ELMIRON
4 MO
ENABLEX
4 QLL(30 per 30 days) bal-care dha
ST MO
calcium acetate caps
2 MO
finasteride tabs 5mg
CLINIMIX 2.75%/
DEXTROSE 5%
2 MO
flavoxate hcl
GELNIQUE GEL 10%
3 QLL(30 per 30 days) CLINIMIX 4.25%/
DEXTROSE 10%
ST MO
GELNIQUE GEL 3%
3 QLL(100 per 30 days) CLINIMIX 4.25%/
DEXTROSE 20%
ST MO
CLINIMIX 4.25%/
JALYN
3 MO
2 QLL(60 per 30 days) DEXTROSE 25%
oxybutynin chloride er tb24
CLINIMIX 5%/DEXTROSE
MO
10mg, 15mg
2 QLL(30 per 30 days) 15%
oxybutynin chloride er tb24
CLINIMIX 5%/DEXTROSE
MO
5mg
2 QLL(600 per 30 days) 20%
oxybutynin chloride syrp
CLINIMIX 5%/DEXTROSE
MO
1 QLL(120 per 30 days) 25%
oxybutynin chloride tabs
CLINIMIX E 4.25%/
MO
DEXTROSE 10%
OXYTROL
4 QLL(8 per 28 days)
CLINIMIX E 4.25%/
ST MO
DEXTROSE 25%
2 MO
potassium citrate er tbcr
CLINIMIX E 4.25%/
1080mg, 540mg
DEXTROSE 5%
RAPAFLO
4 MO
CLINIMIX E 5%/
2 MO
tamsulosin hcl
3 QLL(30 per 30 days) DEXTROSE 15%
tolterodine tartrate tabs 1mg
CLINIMIX E 5%/
MO
3 QLL(60 per 30 days) DEXTROSE 20%
tolterodine tartrate tabs 2mg
CLINIMIX E 5%/
MO
TOVIAZ
3 QLL(30 per 30 days) DEXTROSE 25%
CLINISOL SF 15%
MO
2 QLL(60 per 30 days) complete natal dha
trospium chloride
completenate
MO
VESICARE
4 QLL(30 per 30 days) dextrose 5%/potassium chloride
0.15%
ST MO
effervescent pot chloride
Vitamins, Hematinics & Electrolytes
fluoritab chew 1mg
AMINOSYN
5
folcal dha
AMINOSYN 7%/
5
folcaps omega 3
ELECTROLYTES
AMINOSYN 8.5%/
5
folivane-ob
ELECTROLYTES
folivane-prx dha nf
alfuzosin hcl er
AMMONIUM CHLORIDE
AVODART
bethanechol chloride
CIALIS TABS 2.5MG, 5MG
Freedom 14251, V20
2
5
3
3
4
MO
Drug Requirements/
Tier Limits
Drug Name
45
5
5
5
5
5
5
5
2
2
5
MO
MO
5
5
5
5
5
5
5
5
5
5
5
5
5
2
2
5
MO
MO
MO
2
2
2
2
2
2
MO
MO
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
freamine iii
hemenatal ob
hemenatal ob + dha
HEPATAMINE
HEPATASOL
inatal advance
inatal ultra
INTRALIPID INJ 1.7%;
30%
intralipid inj 2.25%; 20%
IONOSOL-B/DEXTROSE
5%
IONOSOL-MB/DEXTROSE
5%
ISOLYTE-P/DEXTROSE
5%
ISOLYTE-S
ISOLYTE-S PH 7.4
k-effervescent
k-vescent tbef
kcl 0.075%/d5w/nacl 0.45%
kcl 0.15%/d5w/ nacl 0.3%
kcl 0.15%/d5w/lr
kcl 0.15%/d5w/nacl 0.2%
kcl 0.15%/d5w/nacl 0.225%
kcl 0.15%/d5w/nacl 0.45%
kcl 0.15%/d5w/nacl 0.9%
kcl 0.3%/d5w/lr iv lac ring
kcl 0.3%/d5w/nacl 0.45%
kcl 0.3%/d5w/nacl 0.9%
klor-con 10
klor-con 8
klor-con m10
klor-con m15
klor-con m20
klor-con/ef
lactated ringers
lactated ringers viaflex
liposyn iii inj 2.5%; 10%,
2.5%; 30%
liposyn iii inj 2.5%; 20%
magnesium sulfate inj 40mg/ml,
80mg/ml
magnesium sulfate inj 50%
NEPHRAMINE
NORMOSOL-M IN D5W
Freedom 14251, V20
Drug Requirements/
Tier Limits
5
2
2
5
5
2
2
5
5
5
NORMOSOL-R
NORMOSOL-R
NORMOSOL-R IN D5W
PLASMA-LYTE A
PLASMA-LYTE-148
PLASMA-LYTE-56/D5W
pnv ob+dha
pnv prenatal plus multivitamin
pnv-dha
pnv-select
potassium chloride 0.15% /nacl
0.45% viaflex
potassium chloride 0.15% d5w/
nacl 0.33%
potassium chloride 0.15% d5w/
nacl 0.45%
potassium chloride 0.15% d5w/
nacl 0.45% viaflex
potassium chloride 0.15% nacl
0.9%
potassium chloride 0.15% w/
nacl 0.9% viaflex
potassium chloride 0.15%/d5w
potassium chloride 0.22% d5w/
nacl 0.45%
potassium chloride 0.224%/
d5w/nacl 0.45%
potassium chloride
0.224%d5w/nacl 0.45%
viaflex
potassium chloride 0.3%/ nacl
0.9%
potassium chloride 0.3%/d5w
potassium chloride 0.3%/nacl
0.9%/viaflex
potassium chloride cr
potassium chloride er
potassium chloride inj 0.4meq/
ml, 10meq/100ml, 10meq/
50ml, 20meq/100ml, 20meq/
50ml, 30meq/100ml, 40meq/
100ml
potassium chloride inj 2meq/ml
potassium chloride liqd
potassium chloride oral soln
potassium chloride sr
MO
MO
MO
MO
MO
5
5
5
5
1
1
5
5
5
5
5
5
5
5
5
5
1
1
1
2
2
1
5
5
5
5
5
5
5
5
Drug Requirements/
Tier Limits
Drug Name
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
46
5
5
5
5
5
5
2
2
2
2
5
MO
MO
MO
MO
5
5
MO
5
MO
5
5
5
5
5
5
5
5
5
2
2
5
MO
MO
5
1
1
2
MO
MO
MO
MO
Effective Date November 1, 2014
Drug Name
pr natal 400
pr natal 400 ec
pr natal 430
pr natal 430 ec
premasol inj 52meq/l; 1760mg/
100ml; 880mg/100ml; 34meq/
l; 1760mg/100ml; 372mg/
100ml; 406mg/100ml; 526mg/
100ml; 492mg/100ml; 492mg/
100ml; 526mg/100ml; 356mg/
100ml; 356mg/100ml; 390mg/
100ml; 34mg/100ml; 152mg/
100ml
PREMASOL INJ 56MEQ/L;
320MG/100ML; 730MG/
100ML; 190MG/100ML;
3MEQ/L; 20MG/100ML;
300MG/100ML; 220MG/
100ML; 290MG/100ML;
490MG/100ML; 840MG/
100ML; 490MG/100ML;
200MG/100ML; 290MG/
100ML; 410MG/100ML;
230MG/100ML; 5MEQ/L;
15MG/100ML; 250MG/
100ML; 120MG/100ML;
140MG/100ML; 470MG/
100ML
prenaissance
prenaissance plus
prenatabs fa
prenatabs obn
prenatal plus
prenatal tabs 120mg; 0; 0;
200mg; 400unit; 2mg; 12mcg;
27mg; 1mg; 20mg; 10mg; 3mg;
1.84mg; 22mg; 4000unit;
25mg
PROCALAMINE
PROSOL
relnate dha
ringers injection
se-natal 19
se-tan dha
sodium bicarbonate inj 4.2%,
7.5%
sodium bicarbonate inj 8.4%
Freedom 14251, V20
Drug Requirements/
Tier Limits
2
2
2
2
5
MO
MO
MO
MO
sodium bicarbonate partial fill
sodium chloride 0.45%
sodium chloride 0.45% viaflex
sodium chloride inj 2.5meq/ml,
3%, 4meq/ml
sodium chloride inj 5%
sodium fluoride chew 0.5mg
sodium fluoride tabs
sodium lactate
taron-prex
tl-care dha
tl-select
TPN ELECTROLYTES
travasol
triadvance
trinatal gt
trinatal rx 1
triveen-duo dha
triveen-prx rnf
TROPHAMINE
ultimatecare one nf
vemavite-prx 2
vena-bal dha
virt-pn
virt-pn dha
vol-nate
vol-plus
vp-ch-pnv
zatean-ch
zatean-pn
zatean-pn dha
zatean-pn plus
5
2
2
2
2
2
2
5
5
2
5
2
2
5
5
Drug Requirements/
Tier Limits
Drug Name
MO
MO
MO
MO
MO
5
5
5
5
5
2
2
5
2
2
2
5
5
2
2
2
2
2
5
2
2
2
2
2
2
2
2
2
2
2
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
47
Effective Date November 1, 2014
Index of Drugs:
Legend
Generic drugs are shown in lowercase italics (e.g. enalapril)
Brand-name drugs are shown in capital letters (e.g. HUMALOG)
The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and
generic drugs are listed. 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.
Drug Name
Page
8-MOP.............................................................................29
a-hydrocort........................................................................33
abacavir..............................................................................7
abacavir sulfate/lamivudine/zidovudine................................7
ABELCET.........................................................................7
ABILIFY DISCMELT TBDP 10MG..............................14
ABILIFY DISCMELT TBDP 15MG..............................14
ABILIFY INJ...................................................................14
ABILIFY MAINTENA....................................................14
ABILIFY ORAL SOLN...................................................14
ABILIFY TABS 10MG....................................................14
ABILIFY TABS 15MG....................................................15
ABILIFY TABS 20MG....................................................15
ABILIFY TABS 2MG......................................................15
ABILIFY TABS 30MG....................................................15
ABILIFY TABS 5MG......................................................15
ABRAXANE....................................................................12
ABSTRAL SUBL 100MCG.............................................15
ABSTRAL SUBL 200MCG, 300MCG, 400MCG,
600MCG, 800MCG.....................................................15
acarbose tabs 100mg..........................................................33
acarbose tabs 25mg............................................................33
acarbose tabs 50mg............................................................33
acebutolol hcl.....................................................................25
acetaminophen/codeine #2..................................................15
acetaminophen/codeine #3..................................................15
acetaminophen/codeine #4..................................................15
acetaminophen/codeine oral soln.........................................15
acetaminophen/codeine phosphate.......................................15
acetaminophen/codeine tabs................................................15
acetasol hc.........................................................................32
acetazolamide....................................................................41
acetazolamide er................................................................41
acetazolamide sodium........................................................41
acetic acid.........................................................................32
acetic acid 0.25%..............................................................31
acetic acid/aluminum acetate..............................................32
Freedom 14251, V20
48
Drug Name
Page
acetylcysteine inhalation soln..............................................43
acetylcysteine inj................................................................31
acitretin............................................................................29
ACTEMRA INJ 200MG/10ML, 400MG/20ML, 80MG/
4ML..............................................................................39
ACTHIB..........................................................................38
ACTIMMUNE...............................................................38
ACTIQ............................................................................15
ACTONEL TABS 150MG..............................................39
ACTONEL TABS 30MG................................................31
ACTONEL TABS 35MG................................................39
ACTONEL TABS 5MG..................................................39
ACTOPLUS MET XR TB24 1000MG; 15MG..............33
ACTOPLUS MET XR TB24 1000MG; 30MG..............33
acyclovir caps.......................................................................7
acyclovir oint.....................................................................29
acyclovir sodium inj 500mg..................................................7
acyclovir sodium inj 50mg/ml...............................................7
acyclovir susp.......................................................................7
acyclovir tabs.......................................................................7
ADACEL.........................................................................38
ADAGEN........................................................................31
adapalene gel 0.1%...........................................................29
ADASUVE......................................................................15
ADCIRCA.......................................................................43
adefovir dipivoxil.................................................................7
ADRENACLICK.............................................................43
adrucil..............................................................................12
ADVAIR DISKUS...........................................................43
ADVAIR HFA.................................................................43
ADVICOR TB24 20MG; 1000MG, 20MG;
750MG.........................................................................25
ADVICOR TB24 20MG; 500MG, 40MG;
1000MG.......................................................................25
afeditab cr.........................................................................25
AFINITOR......................................................................12
AFINITOR DISPERZ.....................................................12
Effective Date November 1, 2014
Drug Name
Page
AGGRENOX..................................................................25
ak-poly-bac........................................................................41
AKNE-MYCIN...............................................................29
ala cort.............................................................................29
ALA SCALP.....................................................................29
ALBENZA.........................................................................7
albuterol sulfate er.............................................................43
albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/
3ml................................................................................43
albuterol sulfate nebu 0.5%...............................................43
albuterol sulfate syrp..........................................................43
albuterol sulfate tabs..........................................................43
ALCAINE........................................................................41
alclometasone dipropionate.................................................29
alcohol preps pads..............................................................33
ALDACTAZIDE.............................................................25
ALDURAZYME..............................................................33
alendronate sodium oral soln..............................................39
alendronate sodium tabs 10mg, 5mg...................................39
alendronate sodium tabs 35mg, 70mg.................................39
alendronate sodium tabs 40mg...........................................31
alfuzosin hcl er..................................................................45
ALIMTA..........................................................................12
ALINIA.............................................................................7
ALKERAN INJ................................................................12
ALKERAN TABS............................................................12
allopurinol........................................................................39
ALOCRIL........................................................................41
ALOMIDE......................................................................41
aloprim.............................................................................39
ALOXI.............................................................................36
ALPHAGAN P OPHTHALMIC SOLN 0.1%...............42
ALPHAGAN P OPHTHALMIC SOLN 0.15%.............42
alprazolam tabs.................................................................15
ALREX............................................................................42
ALTABAX.......................................................................29
altavera.............................................................................40
ALTOPREV....................................................................25
alyacen 1/35......................................................................40
alyacen 7/7/7.....................................................................40
amantadine hcl caps.............................................................7
amantadine hcl tabs.............................................................7
AMBISOME.....................................................................7
amcinonide.......................................................................29
amifostine.........................................................................12
amikacin sulfate..................................................................7
amiloride hcl.....................................................................25
Freedom 14251, V20
49
Drug Name
Page
amiloride/hydrochlorothiazide............................................25
aminocaproic acid syrp.......................................................25
aminophylline...................................................................43
AMINOSYN...................................................................45
AMINOSYN 7%/ELECTROLYTES..............................45
AMINOSYN 8.5%/ELECTROLYTES...........................45
AMINOSYN II................................................................45
AMINOSYN II 8.5%/ELECTROLYTES.......................45
AMINOSYN M...............................................................45
AMINOSYN-HBC..........................................................45
AMINOSYN-PF..............................................................45
AMINOSYN-PF 7%.......................................................45
AMINOSYN-RF.............................................................45
amiodarone hcl inj.............................................................25
amiodarone hcl tabs...........................................................25
amitriptyline hcl................................................................15
amlodipine besylate tabs 10mg, 2.5mg................................25
amlodipine besylate tabs 5mg..............................................25
amlodipine besylate/atorvastatin calcium.............................25
amlodipine besylate/benazepril hcl......................................25
amlodipine besylate/benazepril hydrochloride.......................25
AMMONIUM CHLORIDE...........................................45
ammonium lactate.............................................................29
amnesteem caps 10mg........................................................29
amnesteem caps 20mg, 40mg..............................................29
amoxapine........................................................................15
amoxicillin..........................................................................7
amoxicillin/clavulanate potassium.........................................7
amoxicillin/clavulanate potassium er.....................................7
amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg;
1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg,
2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg;
3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg,
5mg; 5mg; 5mg; 5mg......................................................15
amphetamine/dextroamphetamine tabs 7.5mg; 7.5mg;
7.5mg; 7.5mg.................................................................15
amphotericin b....................................................................7
ampicillin...........................................................................7
ampicillin sodium inj 10gm, 125mg, 1gm, 250mg, 2gm.......7
ampicillin sodium inj 500mg...............................................7
ampicillin-sulbactam inj 10gm; 5gm, 1gm; 0.5gm................7
ampicillin-sulbactam inj 2gm; 1gm......................................7
AMPYRA.........................................................................15
anagrelide hydrochloride....................................................31
anastrozole........................................................................12
ANDRODERM..............................................................33
ANDROGEL GEL 20.25MG/1.25GM..........................33
Effective Date November 1, 2014
Drug Name
Page
ANDROGEL GEL 25MG/2.5GM, 50MG/5GM...........33
ANDROGEL GEL 40.5MG/2.5GM..............................33
ANDROGEL PUMP GEL 1%........................................33
ANDROGEL PUMP GEL 1.62%...................................33
androxy.............................................................................33
ANZEMET INJ..............................................................36
apexicon e.........................................................................29
APIDRA..........................................................................33
APIDRA SOLOSTAR.....................................................33
APOKYN.........................................................................15
apraclonidine....................................................................42
apri..................................................................................40
APRISO...........................................................................36
APTIOM.........................................................................15
APTIVUS CAPS................................................................7
APTIVUS ORAL SOLN...................................................7
ARALAST NP.................................................................31
aranelle.............................................................................40
ARANESP ALBUMIN FREE INJ 100MCG/0.5ML,
100MCG/ML, 150MCG/0.3ML, 150MCG/0.75ML,
200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML,
300MCG/ML, 500MCG/ML......................................38
ARANESP ALBUMIN FREE INJ 25MCG/0.42ML,
25MCG/ML, 40MCG/0.4ML, 40MCG/ML, 60MCG/
0.3ML, 60MCG/ML....................................................38
ARCALYST.....................................................................38
ARICEPT TABS 23MG..................................................15
ARRANON.....................................................................12
ARZERRA.......................................................................12
ASACOL HD..................................................................36
ASMANEX TWISTHALER 120 METERED
DOSES.........................................................................43
ASMANEX TWISTHALER 14 METERED
DOSES.........................................................................43
ASMANEX TWISTHALER 30 METERED DOSES
AEPB 110MCG/INH...................................................43
ASMANEX TWISTHALER 30 METERED DOSES
AEPB 220MCG/INH...................................................43
ASMANEX TWISTHALER 60 METERED
DOSES.........................................................................43
ASMANEX TWISTHALER 7 METERED DOSES.......43
aspirin-caffeine-dihydrocodeine...........................................15
ASTAGRAF XL...............................................................12
ASTEPRO.......................................................................32
ATACAND HCT TABS 16MG; 12.5MG......................25
ATACAND HCT TABS 32MG; 12.5MG, 32MG;
25MG...........................................................................25
Freedom 14251, V20
50
Drug Name
Page
ATACAND TABS 16MG, 4MG, 8MG..........................25
ATACAND TABS 32MG...............................................25
atenolol.............................................................................25
atenolol/chlorthalidone.......................................................25
atorvastatin calcium..........................................................25
atovaquone..........................................................................7
atovaquone/proguanil hcl.....................................................7
ATRIPLA...........................................................................7
atropine sulfate inj 0.05mg/ml, 0.1mg/ml...........................36
ATROVENT HFA..........................................................43
augmented betamethasone dipropionate...............................29
AVASTIN........................................................................12
AVELOX ABC PACK.......................................................7
AVELOX INJ....................................................................7
AVELOX TABS................................................................7
aviane...............................................................................40
AVODART.....................................................................45
AVONEX........................................................................38
AVONEX PEN...............................................................38
AXID ORAL SOLN........................................................36
azacitidine........................................................................12
AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 1GM;
0......................................................................................7
AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 2GM;
0......................................................................................7
AZASAN.........................................................................12
AZASITE.........................................................................42
azathioprine......................................................................12
azelastine hcl nasal soln 0.15%..........................................32
azelastine hcl nasal soln 137mcg/spray.................................32
azelastine hcl ophthalmic soln.............................................42
AZILECT........................................................................15
azithromycin inj 500mg.......................................................7
azithromycin pack...............................................................7
azithromycin susr 100mg/5ml..............................................7
azithromycin susr 200mg/5ml..............................................7
azithromycin tabs 250mg.....................................................8
azithromycin tabs 500mg.....................................................8
azithromycin tabs 600mg.....................................................8
AZOPT...........................................................................42
AZOR..............................................................................25
aztreonam...........................................................................8
azurette.............................................................................40
baciim................................................................................8
bacitracin inj.......................................................................8
bacitracin ophthalmic oint.................................................42
bacitracin/polymyxin b.......................................................42
Effective Date November 1, 2014
Drug Name
Page
baclofen............................................................................15
bactocill in dextrose inj 0; 1gm/50ml....................................8
bactocill in dextrose inj 0; 2gm/50ml....................................8
BACTROBAN NASAL...................................................32
bal-care dha......................................................................45
balsalazide disodium..........................................................36
balziva..............................................................................40
BANZEL SUSP...............................................................15
BANZEL TABS 200MG.................................................15
BANZEL TABS 400MG.................................................15
BARACLUDE...................................................................8
BCG VACCINE..............................................................38
BECONASE AQ.............................................................43
BELEODAQ...................................................................12
benazepril hcl....................................................................25
benazepril hcl/hydrochlorothiazide......................................25
BENICAR HCT..............................................................25
BENICAR TABS 20MG, 40MG.....................................25
BENICAR TABS 5MG...................................................25
BENLYSTA.....................................................................39
benztropine mesylate inj.....................................................15
benztropine mesylate tabs...................................................15
BESIVANCE...................................................................42
BETAGAN......................................................................42
betamethasone dipropionate................................................29
betamethasone valerate crea................................................29
betamethasone valerate foam..............................................29
betamethasone valerate lotn................................................29
betamethasone valerate oint................................................29
BETASERON.................................................................38
betaxolol hcl ophthalmic soln..............................................42
betaxolol hcl tabs...............................................................25
bethanechol chloride...........................................................45
BETIMOL.......................................................................42
BETOPTIC-S..................................................................42
bicalutamide.....................................................................12
BICILLIN C-R..................................................................8
BICILLIN L-A...................................................................8
BICNU............................................................................12
BIDIL..............................................................................25
BILTRICIDE....................................................................8
bisoprolol fumarate............................................................25
bisoprolol fumarate/hydrochlorothiazide..............................25
BIVIGAM........................................................................38
bleomycin sulfate...............................................................12
BLEPHAMIDE...............................................................42
BLEPHAMIDE S.O.P.....................................................42
Freedom 14251, V20
51
Drug Name
Page
BONIVA INJ..................................................................39
BONIVA TABS...............................................................39
BOOSTRIX.....................................................................38
BOSULIF........................................................................12
BOTOX...........................................................................38
BREO ELLIPTA..............................................................43
BREVICON-28...............................................................40
briellyn.............................................................................40
brimonidine tartrate..........................................................42
BRINTELLIX TABS 10MG............................................15
BRINTELLIX TABS 20MG............................................15
BRINTELLIX TABS 5MG..............................................15
bromocriptine mesylate.......................................................15
BROVANA......................................................................43
budeprion sr tb12 150mg...................................................15
budesonide cp24................................................................36
bumetanide inj..................................................................25
bumetanide tabs................................................................25
BUPHENYL TABS.........................................................31
BUPRENEX....................................................................15
buprenorphine hcl inj.........................................................15
buprenorphine hcl subl 2mg...............................................15
buprenorphine hcl subl 8mg...............................................15
buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg.................15
buprenorphine hcl/naloxone hcl subl 8mg; 2mg....................15
buproban..........................................................................31
bupropion hcl er tb12 100mg.............................................15
bupropion hcl er tb12 150mg.............................................15
bupropion hcl er tb12 200mg.............................................15
bupropion hcl sr tb12 100mg.............................................15
bupropion hcl sr tb12 150mg.............................................15
bupropion hcl sr tb12 150mg.............................................31
bupropion hcl sr tb12 200mg.............................................15
bupropion hcl tabs 100mg..................................................15
bupropion hcl tabs 75mg....................................................16
bupropion hcl xl tb24 150mg.............................................16
bupropion hcl xl tb24 300mg.............................................16
buspirone hcl.....................................................................16
BUSULFEX.....................................................................12
butalbital/acetaminophen/caffeine/codeine caps 300mg;
50mg; 40mg; 30mg........................................................16
butorphanol tartrate inj.....................................................16
butorphanol tartrate nasal soln...........................................16
BYDUREON..................................................................33
BYETTA INJ 10MCG/0.04ML......................................33
BYETTA INJ 5MCG/0.02ML........................................33
BYSTOLIC......................................................................25
Effective Date November 1, 2014
Drug Name
Page
cabergoline........................................................................33
CALAN...........................................................................25
calcipotriene crea...............................................................29
calcipotriene external soln...................................................29
calcipotriene oint...............................................................29
calcipotriene/betamethasone dipropionate............................29
calcitonin-salmon..............................................................33
calcitriol caps.....................................................................33
calcitriol inj.......................................................................33
calcitriol oral soln..............................................................33
calcium acetate caps...........................................................45
camila...............................................................................40
CANASA.........................................................................36
CANCIDAS......................................................................8
candesartan cilexetil tabs 16mg, 4mg, 8mg..........................25
candesartan cilexetil tabs 32mg...........................................25
candesartan cilexetil/hydrochlorothiazide tabs 16mg;
12.5mg..........................................................................25
candesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg,
32mg; 25mg...................................................................25
CANTIL..........................................................................36
CAPASTAT SULFATE.....................................................8
CAPEX............................................................................29
CAPITAL/CODEINE.....................................................16
CAPRELSA.....................................................................12
captopril............................................................................26
captopril/hydrochlorothiazide..............................................26
CARAC...........................................................................29
CARBAGLU....................................................................31
carbamazepine..................................................................16
carbamazepine er...............................................................16
carbidopa..........................................................................16
carbidopa/levodopa............................................................16
carbidopa/levodopa er........................................................16
carbidopa/levodopa odt.......................................................16
carbidopa/levodopa/entacapone...........................................16
carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml,
600mg/60ml..................................................................12
CARDIZEM LA TB24 120MG......................................26
CARDURA XL................................................................26
CARIMUNE NANOFILTERED....................................38
carteolol hcl.......................................................................42
cartia xt............................................................................26
carvedilol..........................................................................26
CAYSTON........................................................................8
caziant..............................................................................40
CEDAX CAPS...................................................................8
Freedom 14251, V20
52
Drug Name
Page
CEENU...........................................................................12
cefaclor................................................................................8
cefaclor er............................................................................8
cefadroxil............................................................................8
cefazolin sodium inj 100gm, 10gm, 1gm; 5%, 20gm,
500mg.............................................................................8
cefazolin sodium inj 1gm.....................................................8
cefazolin sodium/dextrose......................................................8
cefdinir...............................................................................8
cefditoren pivoxil tabs 200mg...............................................8
cefditoren pivoxil tabs 400mg...............................................8
cefepime inj 1gm, 2gm.........................................................8
cefepime inj 1gm/50ml, 2gm/100ml.....................................8
cefotaxime sodium inj 10gm.................................................8
cefotaxime sodium inj 1gm, 2gm, 500mg..............................8
cefotetan..............................................................................8
cefoxitin sodium inj 10gm, 1gm; 4%, 2gm, 2gm; 2.2%.........8
cefoxitin sodium inj 1gm......................................................8
cefpodoxime proxetil.............................................................8
cefprozil..............................................................................8
ceftazidime inj 1gm, 2gm.....................................................8
ceftazidime inj 6gm.............................................................8
CEFTAZIDIME/DEXTROSE..........................................8
ceftibuten............................................................................8
CEFTIN SUSR..................................................................8
ceftriaxone in iso-osmotic dextrose.........................................8
ceftriaxone sodium inj 10gm................................................8
ceftriaxone sodium inj 1gm, 250mg, 2gm, 500mg.................8
ceftriaxone/dextrose..............................................................8
cefuroxime axetil tabs...........................................................8
cefuroxime sodium inj 1.5gm, 750mg...................................8
cefuroxime sodium inj 7.5gm...............................................8
CELEBREX.....................................................................16
CELLCEPT.....................................................................12
CELLCEPT INTRAVENOUS........................................12
CELONTIN....................................................................16
cephalexin caps 250mg, 500mg............................................8
cephalexin susr.....................................................................8
cephalexin tabs....................................................................8
CEREZYME INJ 200UNIT............................................33
CEREZYME INJ 400UNIT............................................33
CERVARIX.....................................................................38
CESAMET......................................................................36
cetirizine hcl syrp 1mg/ml...................................................43
cevimeline hcl....................................................................31
CHANTIX......................................................................31
CHANTIX CONTINUING MONTH PAK.................31
Effective Date November 1, 2014
Drug Name
Page
CHANTIX STARTING MONTH PAK........................31
CHEMET........................................................................31
chloramphenicol sodium succinate.........................................8
chlorhexidine gluconate mouth/throat soln...........................32
chlorhexidine gluconate oral rinse.......................................33
chloroquine phosphate..........................................................8
chlorothiazide....................................................................26
chlorothiazide sodium........................................................26
chlorpromazine hcl inj.......................................................16
chlorpromazine hcl tabs......................................................16
chlorthalidone tabs 25mg, 50mg.........................................26
cholestyramine...................................................................26
cholestyramine light...........................................................26
CIALIS TABS 2.5MG, 5MG...........................................45
ciclodan crea......................................................................29
ciclodan external soln.........................................................29
ciclopirox...........................................................................29
ciclopirox nail lacquer........................................................29
ciclopirox olamine..............................................................29
ciclopirox topical solution kit..............................................29
cidofovir..............................................................................8
cilostazol...........................................................................26
CILOXAN.......................................................................42
CIMZIA..........................................................................36
CIMZIA STARTER KIT................................................36
CINRYZE.......................................................................43
CIPRO HC.....................................................................33
CIPRO I.V.-IN D5W........................................................8
CIPRO SUSR....................................................................8
CIPRODEX....................................................................33
ciprofloxacin er tb24 1000mg; 0..........................................8
ciprofloxacin er tb24 500mg; 0............................................8
ciprofloxacin hcl..................................................................8
ciprofloxacin hcl................................................................42
ciprofloxacin i.v.-in d5w......................................................8
ciprofloxacin inj 200mg/20ml..............................................8
ciprofloxacin inj 400mg/40ml..............................................8
ciprofloxacin susr.................................................................8
cisplatin............................................................................12
citalopram hydrobromide oral soln......................................16
citalopram hydrobromide tabs 10mg...................................16
citalopram hydrobromide tabs 20mg...................................16
citalopram hydrobromide tabs 40mg...................................16
cladribine..........................................................................12
CLAFORAN INJ 10GM, 1GM, 2GM..............................8
CLAFORAN INJ 500MG.................................................8
claravis.............................................................................29
Freedom 14251, V20
53
Drug Name
Page
clarithromycin.....................................................................8
clarithromycin er.................................................................8
CLEOCIN CREA............................................................40
CLEOCIN PEDIATRIC GRANULES.............................8
CLEOCIN SUPP............................................................40
CLIMARA PRO..............................................................40
CLINDAGEL..................................................................29
clindamycin hcl...................................................................8
clindamycin phosphate add-vantage......................................8
clindamycin phosphate crea................................................40
clindamycin phosphate external soln....................................29
clindamycin phosphate foam...............................................29
clindamycin phosphate gel..................................................29
clindamycin phosphate in d5w..............................................8
clindamycin phosphate inj....................................................8
clindamycin phosphate lotn................................................29
clindamycin phosphate pharmacy bulk package......................9
clindamycin phosphate swab...............................................30
clindamycin/benzoyl peroxide.............................................30
CLINIMIX 2.75%/DEXTROSE 5%..............................45
CLINIMIX 4.25%/DEXTROSE 10%............................45
CLINIMIX 4.25%/DEXTROSE 20%............................45
CLINIMIX 4.25%/DEXTROSE 25%............................45
CLINIMIX 4.25%/DEXTROSE 5%..............................31
CLINIMIX 5%/DEXTROSE 15%.................................45
CLINIMIX 5%/DEXTROSE 20%.................................45
CLINIMIX 5%/DEXTROSE 25%.................................45
CLINIMIX E 2.75%/DEXTROSE 10%.........................31
CLINIMIX E 2.75%/DEXTROSE 5%...........................32
CLINIMIX E 4.25%/DEXTROSE 10%.........................45
CLINIMIX E 4.25%/DEXTROSE 25%.........................45
CLINIMIX E 4.25%/DEXTROSE 5%...........................45
CLINIMIX E 5%/DEXTROSE 15%..............................45
CLINIMIX E 5%/DEXTROSE 20%..............................45
CLINIMIX E 5%/DEXTROSE 25%..............................45
CLINISOL SF 15%.........................................................45
clobetasol propionate..........................................................30
clobetasol propionate e........................................................30
clobetasol propionate emollient............................................30
CLOBEX LIQD..............................................................30
CLOCORTOLONE PIVALATE....................................30
CLOCORTOLONE PIVALATE PUMP........................30
CLODERM.....................................................................30
CLODERM PUMP.........................................................30
CLOLAR.........................................................................12
clomipramine hcl...............................................................16
clonazepam odt tbdp 0.125mg...........................................16
Effective Date November 1, 2014
Drug Name
Page
clonazepam odt tbdp 0.25mg.............................................16
clonazepam odt tbdp 0.5mg...............................................16
clonazepam odt tbdp 1mg..................................................16
clonazepam odt tbdp 2mg..................................................16
clonazepam tabs 0.5mg......................................................16
clonazepam tabs 1mg.........................................................16
clonazepam tabs 2mg.........................................................16
clonidine hcl ptwk.............................................................26
clonidine hcl tabs...............................................................26
clopidogrel tabs 300mg.......................................................26
clopidogrel tabs 75mg.........................................................26
clorazepate dipotassium......................................................16
clorpres tabs 15mg; 0.1mg, 15mg; 0.2mg............................26
CLORPRES TABS 15MG; 0.3MG.................................26
clotrimazole external crea...................................................30
clotrimazole external soln...................................................30
clotrimazole troc..................................................................9
clotrimazole/betamethasone dipropionate.............................30
clozapine odt tbdp 100mg..................................................16
clozapine odt tbdp 12.5mg.................................................16
clozapine odt tbdp 25mg....................................................16
clozapine tabs 100mg.........................................................16
clozapine tabs 200mg.........................................................16
clozapine tabs 25mg...........................................................16
clozapine tabs 50mg...........................................................16
COARTEM.......................................................................9
codeine sulfate tabs 15mg...................................................16
codeine sulfate tabs 30mg...................................................16
codeine sulfate tabs 60mg...................................................16
COGENTIN...................................................................16
COLCRYS.......................................................................39
colestipol hcl for oral suspension..........................................26
colestipol hcl gran...............................................................26
colestipol hcl tabs...............................................................26
colistimethate sodium...........................................................9
colocort.............................................................................36
COLY-MYCIN M.............................................................9
COLY-MYCIN S.............................................................33
COMBIGAN...................................................................42
COMBIVENT RESPIMAT............................................43
COMETRIQ...................................................................12
COMPLERA.....................................................................9
complete natal dha.............................................................45
completenate......................................................................45
compro..............................................................................36
COMVAX.......................................................................38
CONDYLOX GEL.........................................................30
Freedom 14251, V20
54
Drug Name
Page
constulose..........................................................................36
COPAXONE...................................................................16
CORDRAN TAPE..........................................................30
COREG CR....................................................................26
cormax scalp application....................................................30
CORTIFOAM................................................................36
cortisone acetate.................................................................33
CORTISPORIN CREA..................................................30
CORTISPORIN OINT..................................................30
CORTISPORIN-TC.......................................................33
COSMEGEN..................................................................12
COUMADIN INJ...........................................................26
COUMADIN TABS.......................................................26
CREON..........................................................................36
CRESTOR......................................................................26
CRINONE......................................................................40
CRIXIVAN........................................................................9
cromolyn sodium conc........................................................36
cromolyn sodium nebu.......................................................43
cromolyn sodium ophthalmic soln.......................................42
cryselle-28.........................................................................40
CUBICIN..........................................................................9
cyclafem 1/35....................................................................40
cyclafem 7/7/7...................................................................40
CYCLESSA......................................................................40
cyclobenzaprine hcl tabs 10mg, 5mg...................................16
cyclophosphamide tabs........................................................12
CYCLOSET....................................................................33
cyclosporine caps................................................................12
cyclosporine inj..................................................................12
cyclosporine modified caps 100mg, 50mg.............................12
cyclosporine modified caps 25mg.........................................12
cyclosporine modified oral soln............................................12
CYMBALTA CPEP 20MG.............................................16
CYMBALTA CPEP 30MG.............................................16
CYMBALTA CPEP 60MG.............................................16
cyproheptadine hcl tabs......................................................43
CYRAMZA......................................................................12
CYSTADANE.................................................................36
CYSTAGON...................................................................45
cytarabine aqueous.............................................................12
cytarabine inj 100mg/ml, 20mg/ml....................................12
CYTOTEC......................................................................36
dacarbazine.......................................................................12
DACOGEN....................................................................12
DALIRESP......................................................................43
danazol.............................................................................33
Effective Date November 1, 2014
Drug Name
Page
dantrolene sodium.............................................................16
DAPSONE........................................................................9
DAPTACEL....................................................................38
DARAPRIM......................................................................9
dasetta 1/35......................................................................40
dasetta 7/7/7.....................................................................40
daunorubicin hcl...............................................................12
DDAVP INJ....................................................................33
decitabine.........................................................................12
DELZICOL.....................................................................36
demeclocycline hcl tabs 150mg..............................................9
demeclocycline hcl tabs 300mg..............................................9
DEMSER.........................................................................26
DENAVIR.......................................................................30
denta 5000 plus................................................................33
dentagel............................................................................33
DEPACON.....................................................................16
DEPAKENE CAPS.........................................................16
DEPEN TITRATABS.....................................................39
desipramine hcl.................................................................16
desmopressin acetate inj......................................................33
desmopressin acetate nasal soln............................................33
desmopressin acetate tabs....................................................33
DESOGEN.....................................................................40
desonide............................................................................30
desoximetasone crea............................................................30
desoximetasone gel..............................................................30
desoximetasone oint 0.05%................................................30
desoximetasone oint 0.25%................................................30
DESVENLAFAXINE ER TB24 100MG.........................16
DESVENLAFAXINE ER TB24 50MG...........................16
dexamethasone...................................................................33
dexamethasone intensol......................................................33
dexamethasone sodium phosphate inj...................................33
dexamethasone sodium phosphate ophthalmic soln................42
DEXILANT.....................................................................36
DEXPAK 10 DAY...........................................................33
DEXPAK 13 DAY...........................................................33
DEXPAK 6 DAY.............................................................33
dexrazoxane inj 250mg......................................................12
dexrazoxane inj 500mg......................................................12
dextroamphetamine sulfate tabs 10mg.................................16
dextroamphetamine sulfate tabs 5mg...................................16
dextrose 10%.....................................................................32
dextrose 10% flex container................................................32
dextrose 10%/nacl 0.2%....................................................32
dextrose 10%/nacl 0.45%..................................................32
Freedom 14251, V20
55
Drug Name
Page
dextrose 2.5%/sodium chloride 0.45%................................32
dextrose 25%.....................................................................32
dextrose 30%.....................................................................32
dextrose 40%....................................................................32
dextrose 5%.......................................................................32
dextrose 5% viaflex............................................................32
dextrose 5%/lactated ringers...............................................32
dextrose 5%/nacl 0.2%......................................................32
dextrose 5%/nacl 0.225%..................................................32
dextrose 5%/nacl 0.3%......................................................32
dextrose 5%/nacl 0.33%....................................................32
dextrose 5%/nacl 0.45%....................................................32
dextrose 5%/nacl 0.9%......................................................32
dextrose 5%/potassium chloride 0.15%...............................45
dextrose 5%/sodium chloride 0.2%.....................................32
dextrose 5%/sodium chloride 0.33%...................................32
dextrose 5%/sodium chloride 0.45%...................................32
dextrose 50%.....................................................................32
dextrose 70%.....................................................................32
dextrose thermoject system...................................................32
diazepam gel.....................................................................17
diazepam intensol..............................................................17
diazepam oral soln.............................................................17
diazepam tabs 10mg..........................................................17
diazepam tabs 2mg............................................................17
diazepam tabs 5mg............................................................17
DIBENZYLINE..............................................................26
diclofenac potassium...........................................................17
diclofenac sodium dr..........................................................17
diclofenac sodium er...........................................................17
diclofenac sodium gel.........................................................30
diclofenac sodium ophthalmic soln......................................42
diclofenac sodium/misoprostol.............................................17
dicloxacillin sodium.............................................................9
dicyclomine hcl..................................................................37
didanosine...........................................................................9
DIFICID...........................................................................9
diflorasone diacetate...........................................................30
diflunisal...........................................................................17
digox tabs 125mcg.............................................................26
digox tabs 250mcg.............................................................26
digoxin oral soln................................................................26
digoxin tabs 125mcg..........................................................26
digoxin tabs 250mcg..........................................................26
dihydroergotamine mesylate inj...........................................17
dihydroergotamine mesylate nasal soln.................................17
DILANTIN CAPS 100MG.............................................17
Effective Date November 1, 2014
Drug Name
Page
DILANTIN CAPS 30MG...............................................17
DILANTIN INFATABS.................................................17
DILANTIN SUSP...........................................................17
DILATRATE SR.............................................................26
dilt-cd...............................................................................26
dilt-xr...............................................................................26
diltiazem cd......................................................................26
diltiazem hcl cd.................................................................26
diltiazem hcl er cp12.........................................................26
diltiazem hcl er cp24.........................................................26
diltiazem hcl er tb24..........................................................26
diltiazem hcl inj................................................................26
diltiazem hcl tabs...............................................................26
DIOVAN TABS 160MG................................................26
DIOVAN TABS 320MG................................................26
DIOVAN TABS 40MG, 80MG......................................26
DIPENTUM...................................................................37
diphenhydramine hcl inj....................................................43
diphenoxylate/atropine tabs................................................37
DIPHTHERIA/TETANUS TOXOIDS ADSORBED
PEDIATRIC.................................................................38
disopyramide phosphate......................................................26
disulfiram.........................................................................32
divalproex sodium..............................................................17
divalproex sodium dr.........................................................17
divalproex sodium er..........................................................17
DOCEFREZ...................................................................12
docetaxel inj 160mg/16ml, 20mg/0.5ml, 20mg/2ml, 80mg/
2ml, 80mg/8ml..............................................................12
docetaxel inj 20mg/ml, 80mg/4ml......................................12
dolophine hcl TABS 10MG................................................17
DOLOPHINE HCL TABS 5MG...................................17
donepezil hcl tabs 10mg, 5mg.............................................17
donepezil hcl tabs 23mg.....................................................17
donepezil hcl tbdp..............................................................17
DORIBAX.........................................................................9
dorzolamide hcl.................................................................42
dorzolamide hcl/timolol maleate.........................................42
doxazosin mesylate.............................................................26
doxepin hcl........................................................................17
doxercalciferol inj..............................................................33
DOXIL............................................................................12
doxorubicin hcl inj 10mg, 50mg.........................................12
doxorubicin hcl inj 2mg/ml................................................12
doxy 100.............................................................................9
doxycycline hyclate caps........................................................9
doxycycline hyclate inj..........................................................9
Freedom 14251, V20
56
Drug Name
Page
doxycycline hyclate tabs........................................................9
doxycycline monohydrate caps 100mg, 50mg.........................9
doxycycline monohydrate caps 75mg......................................9
doxycycline monohydrate susr................................................9
doxycycline monohydrate tabs...............................................9
dronabinol........................................................................37
drospirenone/ethinyl estradiol..............................................40
DROXIA.........................................................................12
DULERA.........................................................................43
duloxetine hcl cpep 20mg...................................................17
duloxetine hcl cpep 30mg...................................................17
duloxetine hcl cpep 60mg...................................................17
duramorph inj 0.5mg/ml...................................................17
duramorph inj 1mg/ml......................................................17
DUREZOL......................................................................42
DYAZIDE.......................................................................26
DYNACIN........................................................................9
DYRENIUM...................................................................26
DYSPORT.......................................................................38
E.E.S. GRANULES...........................................................9
econazole nitrate................................................................30
EDURANT.......................................................................9
effervescent pot chloride......................................................45
EFFIENT........................................................................26
ELAPRASE......................................................................33
ELIDEL...........................................................................30
elinest...............................................................................40
ELIQUIS.........................................................................26
ELITEK...........................................................................12
ELIXOPHYLLIN............................................................43
ELLENCE.......................................................................12
ELMIRON......................................................................45
ELOXATIN INJ 100MG/20ML, 50MG/10ML.............12
ELSPAR...........................................................................13
EMADINE......................................................................42
EMCYT...........................................................................13
EMEND CAPS................................................................37
EMEND CAPS 125MG..................................................37
EMEND CAPS 40MG....................................................37
EMEND CAPS 80MG....................................................37
emoquette..........................................................................40
EMSAM..........................................................................17
EMTRIVA.........................................................................9
ENABLEX.......................................................................45
enalapril maleate...............................................................26
enalapril maleate/hydrochlorothiazide.................................26
ENBREL INJ 25MG, 50MG/ML...................................39
Effective Date November 1, 2014
Drug Name
Page
ENBREL INJ 25MG/0.5ML...........................................39
ENBREL SURECLICK...................................................39
endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg;
7.5mg............................................................................17
endodan............................................................................17
ENGERIX-B....................................................................38
enoxaparin sodium inj 100mg/ml, 300mg/3ml, 30mg/0.3ml,
40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml..........................26
enoxaparin sodium inj 120mg/0.8ml, 150mg/ml.................26
enpresse-28........................................................................40
entacapone........................................................................17
entecavir.............................................................................9
enulose..............................................................................37
epinastine hcl.....................................................................42
epinephrine.......................................................................43
epinephrine hcl..................................................................43
EPIPEN 2-PAK...............................................................43
EPIPEN-JR 2-PAK..........................................................43
epirubicin hcl inj 200mg/100ml, 50mg..............................13
epirubicin hcl inj 50mg/25ml.............................................13
epitol................................................................................17
EPIVIR HBV.....................................................................9
EPIVIR ORAL SOLN.......................................................9
eplerenone.........................................................................26
EPOGEN........................................................................38
eprosartan mesylate............................................................26
EPZICOM........................................................................9
EQUETRO CP12 100MG..............................................17
EQUETRO CP12 200MG..............................................17
EQUETRO CP12 300MG..............................................17
ERBITUX........................................................................13
ERGOMAR.....................................................................17
ERIVEDGE.....................................................................13
errin.................................................................................40
ERWINAZE....................................................................13
ery....................................................................................30
ery-tab tbec 250mg, 333mg..................................................9
ERY-TAB TBEC 500MG..................................................9
ERYPED 200.....................................................................9
ERYPED 400.....................................................................9
ERYTHROCIN LACTOBIONATE INJ 500MG............9
erythrocin stearate................................................................9
erythromycin.......................................................................9
erythromycin.....................................................................30
erythromycin.....................................................................42
erythromycin base................................................................9
erythromycin ethylsuccinate..................................................9
Freedom 14251, V20
57
Drug Name
Page
erythromycin/benzoyl peroxide............................................30
escitalopram oxalate oral soln.............................................17
escitalopram oxalate tabs 10mg...........................................17
escitalopram oxalate tabs 20mg...........................................17
escitalopram oxalate tabs 5mg.............................................17
esomeprazole sodium..........................................................37
estarylla.............................................................................40
ESTRACE CREA............................................................40
estradiol ptwk....................................................................40
estradiol tabs.....................................................................40
estradiol valerate................................................................40
ESTRING........................................................................40
ESTROSTEP FE.............................................................40
ethambutol hcl.....................................................................9
ethosuximide.....................................................................17
etidronate disodium...........................................................32
etodolac.............................................................................17
etodolac er.........................................................................17
ETOPOPHOS................................................................13
etoposide inj......................................................................13
EURAX............................................................................30
EVISTA...........................................................................39
EXELDERM...................................................................30
EXELON PT24...............................................................17
exemestane........................................................................13
EXFORGE......................................................................26
EXFORGE HCT.............................................................26
EXJADE..........................................................................32
EXTAVIA........................................................................38
FABRAZYME..................................................................33
falmina.............................................................................40
famciclovir tabs 125mg, 250mg...........................................9
famciclovir tabs 500mg........................................................9
famotidine inj 200mg/20ml, 20mg/2ml, 40mg/4ml............37
famotidine premixed..........................................................37
famotidine susr..................................................................37
famotidine tabs 20mg, 40mg..............................................37
FANAPT TABS 10MG...................................................17
FANAPT TABS 12MG...................................................17
FANAPT TABS 1MG.....................................................17
FANAPT TABS 2MG.....................................................17
FANAPT TABS 4MG.....................................................17
FANAPT TABS 6MG.....................................................17
FANAPT TABS 8MG.....................................................17
FANAPT TITRATION PACK.......................................17
FARESTON....................................................................13
FASLODEX....................................................................13
Effective Date November 1, 2014
Drug Name
Page
FAZACLO TBDP 100MG..............................................17
FAZACLO TBDP 12.5MG.............................................17
FAZACLO TBDP 150MG..............................................18
FAZACLO TBDP 200MG..............................................18
FAZACLO TBDP 25MG................................................18
felbamate susp...................................................................18
felbamate tabs...................................................................18
FELDENE.......................................................................18
felodipine er......................................................................26
FEMRING......................................................................40
fenofibrate caps 130mg, 43mg............................................26
fenofibrate micronized caps 134mg, 200mg........................26
fenofibrate micronized caps 67mg.......................................26
fenofibrate tabs 145mg, 48mg............................................26
fenofibrate tabs 160mg......................................................26
fenofibrate tabs 54mg........................................................26
fenofibric acid dr...............................................................27
fenoprofen calcium tabs......................................................18
fentanyl citrate oral transmucosal........................................18
fentanyl patches.................................................................18
FENTORA......................................................................18
FERRIPROX...................................................................32
FETZIMA CP24 120MG, 80MG...................................18
FETZIMA CP24 20MG..................................................18
FETZIMA CP24 40MG..................................................18
FETZIMA TITRATION PACK.....................................18
FINACEA........................................................................30
finasteride tabs 5mg...........................................................45
FIORICET/CODEINE...................................................18
FIRAZYR........................................................................43
FIRMAGON INJ 120MG..............................................13
FIRMAGON INJ 80MG................................................13
FLAGYL CAPS..................................................................9
FLAGYL ER......................................................................9
FLAREX..........................................................................42
flavoxate hcl......................................................................45
flecainide acetate................................................................27
FLOVENT DISKUS AEPB 100MCG/BLIST................43
FLOVENT DISKUS AEPB 250MCG/BLIST, 50MCG/
BLIST...........................................................................44
FLOVENT HFA AERO 110MCG/ACT........................44
FLOVENT HFA AERO 220MCG/ACT........................44
FLOVENT HFA AERO 44MCG/ACT..........................44
fluconazole..........................................................................9
fluconazole in dextrose.........................................................9
fluconazole in nacl...............................................................9
flucytosine...........................................................................9
Freedom 14251, V20
58
Drug Name
Page
fludarabine phosphate inj 50mg.........................................13
fludarabine phosphate inj 50mg/2ml..................................13
fludrocortisone acetate........................................................33
flunisolide.........................................................................44
fluocinolone acetonide body................................................30
fluocinolone acetonide crea.................................................30
fluocinolone acetonide ear drops..........................................33
fluocinolone acetonide external soln.....................................30
fluocinolone acetonide oil...................................................33
fluocinolone acetonide oint.................................................30
fluocinolone acetonide scalp................................................30
fluocinonide crea 0.05%....................................................30
fluocinonide crea 0.1%......................................................30
fluocinonide external soln...................................................30
fluocinonide gel.................................................................30
fluocinonide oint................................................................30
fluocinonide-e....................................................................30
fluoritab chew 1mg............................................................45
fluorometholone.................................................................42
fluorouracil crea 5%..........................................................30
fluorouracil external soln....................................................30
fluorouracil inj..................................................................13
fluoxetine caps 10mg..........................................................18
fluoxetine caps 20mg..........................................................18
fluoxetine dr......................................................................18
fluoxetine hcl caps 10mg.....................................................18
fluoxetine hcl caps 20mg.....................................................18
fluoxetine hcl caps 40mg....................................................18
fluoxetine hcl oral soln........................................................18
fluoxetine hcl tabs 10mg.....................................................18
fluoxetine hcl tabs 20mg.....................................................18
FLUOXETINE HCL TABS 60MG................................18
fluphenazine decanoate......................................................18
fluphenazine hcl conc.........................................................18
fluphenazine hcl elix..........................................................18
fluphenazine hcl inj...........................................................18
fluphenazine hcl tabs.........................................................18
flurbiprofen.......................................................................18
flurbiprofen sodium...........................................................42
flutamide..........................................................................13
fluticasone propionate crea..................................................30
fluticasone propionate lotn..................................................30
fluticasone propionate oint..................................................30
fluticasone propionate susp..................................................44
fluvastatin.........................................................................27
fluvoxamine maleate tabs 100mg........................................18
fluvoxamine maleate tabs 25mg..........................................18
Effective Date November 1, 2014
Drug Name
Page
fluvoxamine maleate tabs 50mg..........................................18
FML................................................................................42
FML FORTE...................................................................42
folcal dha..........................................................................45
folcaps omega 3..................................................................45
folivane-ob........................................................................45
folivane-prx dha nf............................................................45
FOLOTYN......................................................................13
fomepizole.........................................................................38
fondaparinux sodium inj 10mg/0.8ml, 5mg/0.4ml, 7.5mg/
0.6ml.............................................................................27
fondaparinux sodium inj 2.5mg/0.5ml...............................27
FORADIL AEROLIZER.................................................44
FORTEO........................................................................39
fortical..............................................................................33
FOSAMAX......................................................................39
FOSAMAX PLUS D........................................................39
foscarnet sodium..................................................................9
fosinopril sodium...............................................................27
fosinopril sodium/hydrochlorothiazide.................................27
fosphenytoin sodium...........................................................18
FOSRENOL....................................................................32
FRAGMIN INJ 10000UNIT/ML, 12500UNIT/0.5ML,
15000UNIT/0.6ML, 18000UNT/0.72ML,
25000UNIT/ML, 7500UNIT/0.3ML..........................27
FRAGMIN INJ 2500UNIT/0.2ML, 5000UNIT/
0.2ML...........................................................................27
freamine iii.......................................................................46
furosemide inj....................................................................27
furosemide oral soln...........................................................27
furosemide tabs..................................................................27
FUSILEV.........................................................................13
FUZEON..........................................................................9
FYCOMPA TABS 10MG, 12MG...................................18
FYCOMPA TABS 2MG..................................................18
FYCOMPA TABS 4MG..................................................18
FYCOMPA TABS 6MG..................................................18
FYCOMPA TABS 8MG..................................................18
gabapentin caps 100mg......................................................18
gabapentin caps 300mg......................................................18
gabapentin caps 400mg......................................................18
gabapentin oral soln...........................................................18
gabapentin tabs 600mg......................................................18
gabapentin tabs 800mg......................................................18
GABITRIL......................................................................18
galantamine hydrobromide cp24.........................................18
galantamine hydrobromide oral soln...................................18
Freedom 14251, V20
59
Drug Name
Page
galantamine hydrobromide tabs..........................................18
GAMASTAN S/D...........................................................38
GAMMAGARD LIQUID...............................................38
GAMMAGARD S/D IGA LESS THAN 1MCG/ML.....38
GAMMAPLEX INJ 10GM/200ML, 2.5GM/50ML,
5GM/100ML................................................................38
GAMMAPLEX INJ 20GM/400ML................................38
GAMUNEX-C................................................................38
ganciclovir...........................................................................9
GARDASIL.....................................................................38
GATTEX.........................................................................37
gauze pads 2"x2"...............................................................34
gavilyte-c...........................................................................37
gavilyte-g...........................................................................37
gavilyte-n/flavor pack.........................................................37
GAZYVA.........................................................................13
GELNIQUE GEL 10%...................................................45
GELNIQUE GEL 3%.....................................................45
gemcitabine.......................................................................13
gemcitabine hcl inj 1gm, 200mg.........................................13
gemcitabine hcl inj 2gm.....................................................13
gemfibrozil........................................................................27
generlac.............................................................................37
gengraf..............................................................................13
GENOTROPIN..............................................................38
GENOTROPIN MINIQUICK INJ 0.2MG...................38
GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG,
0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG,
2MG.............................................................................38
gentak...............................................................................42
gentamicin sulfate crea.......................................................30
gentamicin sulfate inj...........................................................9
gentamicin sulfate oint 0.1%.............................................30
gentamicin sulfate oint 0.3%.............................................42
gentamicin sulfate ophthalmic soln......................................42
gentamicin sulfate pediatric..................................................9
gentamicin sulfate/0.9% sodium chloride..............................9
GEODON INJ................................................................18
gianvi...............................................................................40
gildagia.............................................................................40
gildess 1.5/30.....................................................................40
gildess 1/20........................................................................40
gildess fe 1.5/30.................................................................40
gildess fe 1/20....................................................................40
GILENYA........................................................................18
GILOTRIF......................................................................13
GLASSIA.........................................................................32
Effective Date November 1, 2014
Drug Name
Page
GLEEVEC.......................................................................13
glimepiride tabs 1mg..........................................................34
glimepiride tabs 2mg..........................................................34
glimepiride tabs 4mg..........................................................34
glipizide er tb24 10mg.......................................................34
glipizide er tb24 2.5mg......................................................34
glipizide er tb24 5mg.........................................................34
glipizide tabs 10mg............................................................34
glipizide tabs 5mg..............................................................34
glipizide xl tb24 10mg.......................................................34
glipizide xl tb24 2.5mg......................................................34
glipizide xl tb24 5mg.........................................................34
glipizide/metformin hcl tabs 2.5mg; 250mg.........................34
glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg;
500mg...........................................................................34
GLUCAGEN...................................................................34
GLUCAGEN HYPOKIT................................................34
GLUCAGON EMERGENCY KIT.................................34
GLUMETZA TB24 1000MG.........................................34
GLUMETZA TB24 500MG...........................................34
glycopyrrolate inj................................................................37
glycopyrrolate tabs..............................................................37
GLYSET TABS 100MG..................................................34
GLYSET TABS 25MG....................................................34
GLYSET TABS 50MG....................................................34
GOLYTELY ORAL SOLN 227.1GM; 2.82GM;
6.36GM; 5.53GM; 21.5GM.........................................37
granisetron hcl inj..............................................................37
granisetron hcl tabs............................................................37
griseofulvin microsize susp....................................................9
griseofulvin microsize tabs....................................................9
griseofulvin ultramicrosize....................................................9
guanidine hcl....................................................................18
H.P. ACTHAR................................................................34
HALAVEN......................................................................13
HALFLYTELY BOWEL PREP/FLAVOR PACKS.........37
halobetasol propionate........................................................30
HALOG..........................................................................30
haloperidol........................................................................18
haloperidol decanoate.........................................................18
haloperidol lactate..............................................................18
HAVRIX INJ 1440ELU/ML...........................................38
HAVRIX INJ 720ELU/0.5ML........................................38
heather..............................................................................40
hecoria caps 0.5mg, 1mg....................................................13
hecoria caps 5mg................................................................13
HECTOROL INJ 2MCG/ML........................................34
Freedom 14251, V20
60
Drug Name
Page
HECTOROL INJ 4MCG/2ML......................................34
hemenatal ob.....................................................................46
hemenatal ob + dha...........................................................46
heparin sodium dcu...........................................................27
heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/
ml, 5000unit/0.5ml, 5000unit/ml..................................27
heparin sodium/d5w inj 5%; 100unit/ml, 5%; 40unit/
ml..................................................................................27
heparin sodium/d5w inj 5%; 50unit/ml.............................27
heparin sodium/nacl 0.45%...............................................27
heparin sodium/nacl 0.9%.................................................27
heparin sodium/sodium chloride 0.9% premix.....................27
HEPATAMINE...............................................................46
HEPATASOL..................................................................46
HEPSERA.........................................................................9
HERCEPTIN..................................................................13
HEXALEN......................................................................13
HORIZANT TBCR 300MG..........................................19
HORIZANT TBCR 600MG..........................................19
HUMALOG....................................................................34
HUMALOG KWIKPEN.................................................34
HUMALOG MIX 50/50.................................................34
HUMALOG MIX 50/50 KWIKPEN..............................34
HUMALOG MIX 75/25.................................................34
HUMALOG MIX 75/25 KWIKPEN..............................34
HUMIRA INJ 20MG/0.4ML..........................................39
HUMIRA INJ 40MG/0.8ML..........................................40
HUMIRA PEN................................................................40
HUMIRA PEN-CROHNS DISEASESTARTER............40
HUMIRA PEN-PSORIASIS STARTER.........................40
HUMULIN 70/30...........................................................34
HUMULIN 70/30 KWIKPEN.......................................34
HUMULIN 70/30 PEN..................................................34
HUMULIN N.................................................................34
HUMULIN N KWIKPEN..............................................34
HUMULIN N U-100 PEN.............................................34
HUMULIN R.................................................................34
HUMULIN R U-500 (CONCENTRATED).................34
hydralazine hcl inj.............................................................27
hydralazine hcl tabs...........................................................27
hydrochlorothiazide...........................................................27
hydrocodone/acetaminophen oral soln 325mg/15ml; 10mg/
15ml..............................................................................19
hydrocodone/acetaminophen oral soln 325mg/15ml; 7.5mg/
15ml..............................................................................19
hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg;
5mg, 325mg; 7.5mg.......................................................19
Effective Date November 1, 2014
Drug Name
Page
hydrocodone/ibuprofen tabs 7.5mg; 200mg.........................19
hydrocortisone butyrate......................................................30
hydrocortisone butyrate (lipophilic).....................................30
hydrocortisone crea 1%, 2.5%............................................30
hydrocortisone enem...........................................................37
hydrocortisone in absorbase.................................................30
hydrocortisone lotn 2.5%...................................................30
hydrocortisone oint 1%, 2.5%............................................30
hydrocortisone tabs.............................................................34
hydrocortisone valerate.......................................................30
hydrocortisone/acetic acid...................................................33
hydromorphone hcl inj 1mg/ml, 500mg/50ml......................19
hydromorphone hcl inj 2mg/ml, 4mg/ml..............................19
hydromorphone hcl liqd......................................................19
hydromorphone hcl tabs 2mg..............................................19
hydromorphone hcl tabs 4mg..............................................19
hydromorphone hcl tabs 8mg..............................................19
hydroxychloroquine sulfate....................................................9
hydroxyurea.......................................................................13
ibandronate sodium inj......................................................40
ibandronate sodium tabs....................................................40
ibuprofen susp...................................................................19
ibuprofen tabs 400mg, 600mg, 800mg...............................19
ICLUSIG.........................................................................13
IDAMYCIN PFS.............................................................13
idarubicin hcl....................................................................13
IFEX................................................................................13
ifosfamide inj 1gm.............................................................13
ifosfamide inj 1gm/20ml, 3gm, 3gm/60ml..........................13
ILARIS.............................................................................38
IMBRUVICA..................................................................13
imipenem/cilastatin.............................................................9
imipramine hcl..................................................................19
imiquimod........................................................................30
IMOVAX RABIES (H.D.C.V.).......................................38
inatal advance...................................................................46
inatal ultra.......................................................................46
INCIVEK..........................................................................9
INCRELEX.....................................................................32
indapamide.......................................................................27
INFANRIX......................................................................38
INLYTA..........................................................................13
INNOPRAN XL..............................................................27
INSULIN PEN NEEDLE...............................................34
INSULIN SYRINGE (DISP) U-100 0.3 ML..................34
INSULIN SYRINGE (DISP) U-100 1 ML.....................34
INSULIN SYRINGE (DISP) U-100 1/2 ML..................34
Freedom 14251, V20
61
Drug Name
Page
INTELENCE TABS 100MG, 200MG.............................9
INTELENCE TABS 25MG..............................................9
INTRALIPID INJ 1.7%; 30%........................................46
intralipid inj 2.25%; 20%................................................46
INTRON-A INJ 10MU/ML...........................................38
INTRON-A INJ 6000000UNIT/ML..............................38
INTRON-A W/DILUENT INJ 10MU..........................38
INTRON-A W/DILUENT INJ 18MU, 50MU..............38
introvale...........................................................................40
INTUNIV.......................................................................19
INVANZ...........................................................................9
INVEGA SUSTENNA INJ 117MG/0.75ML, 156MG/
ML, 234MG/1.5ML.....................................................19
INVEGA SUSTENNA INJ 39MG/0.25ML, 78MG/
0.5ML...........................................................................19
INVEGA TB24 1.5MG...................................................19
INVEGA TB24 3MG......................................................19
INVEGA TB24 6MG......................................................19
INVEGA TB24 9MG......................................................19
INVIRASE.........................................................................9
IONOSOL-B/DEXTROSE 5%......................................46
IONOSOL-MB/DEXTROSE 5%...................................46
IOPIDINE......................................................................42
IPOL INACTIVATED IPV............................................38
ipratropium bromide inhalation soln..................................44
ipratropium bromide nasal soln..........................................33
ipratropium bromide/albuterol sulfate.................................44
irbesartan..........................................................................27
irbesartan/hydrochlorothiazide............................................27
irinotecan inj 100mg/5ml, 40mg/2ml.................................13
irinotecan inj 500mg/25ml................................................13
ISENTRESS CHEW.........................................................9
ISENTRESS PACK...........................................................9
ISENTRESS TABS............................................................9
ISOLYTE-P/DEXTROSE 5%.........................................46
ISOLYTE-S.....................................................................46
ISOLYTE-S PH 7.4.........................................................46
isoniazid inj........................................................................9
isoniazid syrp.......................................................................9
isoniazid tabs......................................................................9
ISORDIL TITRADOSE.................................................27
isosorbide dinitrate.............................................................27
isosorbide dinitrate er.........................................................27
isosorbide mononitrate.......................................................27
isosorbide mononitrate er....................................................27
isotonic gentamicin inj 0.8mg/ml; 0.9%, 1.2mg/ml; 0.9%,
1.6mg/ml; 0.9%, 1mg/ml; 0.9%.......................................9
Effective Date November 1, 2014
Drug Name
Page
ISOTONIC GENTAMICIN INJ 2MG/ML; 0.9%..........9
isradipine..........................................................................27
ISTALOL........................................................................42
ISTODAX.......................................................................13
itraconazole.........................................................................9
IXEMPRA KIT................................................................13
IXIARO...........................................................................38
JAKAFI............................................................................13
JALYN.............................................................................45
jantoven............................................................................27
JANUMET......................................................................34
JANUMET XR TB24 1000MG; 100MG.......................34
JANUMET XR TB24 1000MG; 50MG, 500MG;
50MG...........................................................................34
JANUVIA TABS 100MG................................................34
JANUVIA TABS 25MG..................................................34
JANUVIA TABS 50MG..................................................34
JEVTANA.......................................................................13
jolessa................................................................................40
jolivette.............................................................................40
junel 1.5/30......................................................................40
junel 1/20.........................................................................41
junel fe 1.5/30...................................................................41
junel fe 1/20......................................................................41
k-effervescent.....................................................................46
k-vescent tbef.....................................................................46
KADCYLA......................................................................13
KALETRA ORAL SOLN..................................................9
KALETRA TABS...............................................................9
KALYDECO...................................................................44
kariva...............................................................................41
KAZANO........................................................................34
kcl 0.075%/d5w/nacl 0.45%.............................................46
kcl 0.15%/d5w/ nacl 0.3%................................................46
kcl 0.15%/d5w/lr..............................................................46
kcl 0.15%/d5w/nacl 0.2%.................................................46
kcl 0.15%/d5w/nacl 0.225%.............................................46
kcl 0.15%/d5w/nacl 0.45%...............................................46
kcl 0.15%/d5w/nacl 0.9%.................................................46
kcl 0.3%/d5w/lr iv lac ring................................................46
kcl 0.3%/d5w/nacl 0.45%.................................................46
kcl 0.3%/d5w/nacl 0.9%...................................................46
kelnor 1/35.......................................................................41
KENALOG.....................................................................30
KETEK............................................................................10
ketoconazole crea...............................................................30
ketoconazole sham..............................................................30
Freedom 14251, V20
62
Drug Name
Page
ketoconazole tabs...............................................................10
ketoprofen.........................................................................19
ketoprofen er......................................................................19
ketorolac tromethamine ophthalmic soln..............................42
KHEDEZLA TB24 100MG............................................19
KHEDEZLA TB24 50MG..............................................19
KINERET.......................................................................40
kionex...............................................................................32
klor-con 10.......................................................................46
klor-con 8.........................................................................46
klor-con m10.....................................................................46
klor-con m15.....................................................................46
klor-con m20.....................................................................46
klor-con/ef.........................................................................46
KOMBIGLYZE XR TB24 1000MG; 2.5MG.................34
KOMBIGLYZE XR TB24 1000MG; 5MG, 500MG;
5MG.............................................................................34
KRISTALOSE.................................................................37
KUVAN TBSO...............................................................35
labetalol hcl inj..................................................................27
labetalol hcl tabs................................................................27
LACRISERT....................................................................42
lactated ringers..................................................................46
lactated ringers dextrose 5% viaflex.....................................32
lactated ringers irrigation...................................................32
lactated ringers viaflex........................................................46
lactulose............................................................................37
LAMICTAL STARTER/NOT TAKING
CARBAMAZEPINE.....................................................19
LAMICTAL STARTER/TAKING CARBAMAZEPINE/
NOT TAKING VALPROATE....................................19
LAMICTAL STARTER/TAKING VALPROATE..........19
LAMISIL PACK..............................................................10
lamivudine........................................................................10
lamivudine/zidovudine......................................................10
lamotrigine........................................................................19
LANOXIN TABS 125MCG............................................27
LANOXIN TABS 250MCG, 62.5MCG.........................27
lansoprazole.......................................................................37
LANTUS.........................................................................35
LANTUS SOLOSTAR....................................................35
latanoprost........................................................................42
LATUDA TABS 120MG................................................19
LATUDA TABS 20MG..................................................19
LATUDA TABS 40MG..................................................19
LATUDA TABS 60MG..................................................19
LATUDA TABS 80MG..................................................19
Effective Date November 1, 2014
Drug Name
Page
LAZANDA......................................................................19
leena.................................................................................41
leflunomide.......................................................................40
LESCOL XL....................................................................27
lessina...............................................................................41
LETAIRIS........................................................................44
letrozole............................................................................13
leucovorin calcium inj 100mg, 200mg, 350mg, 50mg.........13
leucovorin calcium inj 500mg............................................13
leucovorin calcium tabs......................................................13
LEUKERAN....................................................................13
LEUKINE.......................................................................38
leuprolide acetate...............................................................13
levalbuterol.......................................................................44
levalbuterol hcl nebu 0.31mg/3ml, 1.25mg/3ml..................44
levalbuterol hcl nebu 0.63mg/3ml.......................................44
LEVEMIR.......................................................................35
LEVEMIR FLEXPEN.....................................................35
LEVEMIR FLEXTOUCH..............................................35
levetiracetam er tb24 500mg..............................................19
levetiracetam er tb24 750mg..............................................19
levetiracetam inj 500mg/5ml..............................................19
levetiracetam oral soln........................................................19
levetiracetam tabs..............................................................19
levobunolol hcl...................................................................42
levocarnitine inj................................................................32
levocarnitine oral soln........................................................32
levocarnitine tabs...............................................................32
levocetirizine dihydrochloride tabs.......................................44
levofloxacin in d5w............................................................10
levofloxacin inj..................................................................10
levofloxacin ophthalmic soln...............................................42
levofloxacin oral soln..........................................................10
levofloxacin tabs................................................................10
levonest.............................................................................41
levonorgestrel/ethinyl estradiol.............................................41
levora 0.15/30-28.............................................................41
levorphanol tartrate...........................................................19
levothyroxine sodium inj 200mcg........................................35
levothyroxine sodium tabs...................................................35
levoxyl...............................................................................35
LEXIVA SUSP.................................................................10
LEXIVA TABS................................................................10
LIALDA...........................................................................37
lidocaine hcl external soln...................................................30
lidocaine hcl gel.................................................................30
lidocaine hcl inj 2%..........................................................30
Freedom 14251, V20
63
Drug Name
Page
lidocaine hcl inj 20mg/ml...................................................27
lidocaine hcl jelly...............................................................30
lidocaine hcl mouth/throat soln...........................................30
lidocaine hcl viscous...........................................................30
lidocaine oint....................................................................30
lidocaine ptch....................................................................30
lidocaine viscous................................................................30
lidocaine/prilocaine crea.....................................................30
lidocaine/prilocaine kit.......................................................30
LIDODERM...................................................................30
LINCOCIN.....................................................................10
lindane.............................................................................30
liothyronine sodium inj......................................................35
liothyronine sodium tabs....................................................35
liposyn iii inj 2.5%; 10%, 2.5%; 30%..............................46
liposyn iii inj 2.5%; 20%..................................................46
lisinopril...........................................................................27
lisinopril/hydrochlorothiazide.............................................27
lithium carbonate..............................................................19
lithium carbonate er..........................................................19
lithium citrate...................................................................19
LIVALO..........................................................................27
LODOSYN.....................................................................19
LOESTRIN 24 FE...........................................................41
LOFIBRA CAPS 67MG..................................................27
LOKARA.........................................................................30
LOMEDIA 24 FE............................................................41
LOMUSTINE.................................................................13
loperamide hcl caps............................................................37
LOPRESSOR HCT TABS 25MG; 50MG......................27
LOPRESSOR INJ...........................................................27
lorazepam tabs..................................................................19
loryna...............................................................................41
losartan potassium tabs 100mg...........................................27
losartan potassium tabs 25mg, 50mg...................................27
losartan potassium/hydrochlorothiazide...............................27
LOTEMAX OINT..........................................................42
LOTEMAX SUSP...........................................................42
LOTRONEX TABS 0.5MG............................................37
LOTRONEX TABS 1MG...............................................37
lovastatin tabs 10mg, 20mg...............................................27
lovastatin tabs 40mg..........................................................27
LOVAZA.........................................................................27
low-ogestrel........................................................................41
loxapine............................................................................19
loxapine succinate..............................................................19
LUFYLLIN......................................................................44
Effective Date November 1, 2014
Drug Name
Page
LUMIGAN......................................................................42
LUPRON DEPOT INJ 3.75MG, 7.5MG.......................13
LUPRON DEPOT-PED INJ 7.5MG.............................13
lutera................................................................................41
LYRICA CAPS 100MG...................................................19
LYRICA CAPS 150MG...................................................20
LYRICA CAPS 200MG...................................................20
LYRICA CAPS 225MG, 300MG....................................20
LYRICA CAPS 25MG.....................................................20
LYRICA CAPS 50MG.....................................................20
LYRICA CAPS 75MG.....................................................20
LYRICA ORAL SOLN....................................................20
LYSODREN....................................................................13
lyza...................................................................................41
M-M-R II W/DILUENT 10 DOSE................................39
mafenide acetate................................................................30
magnesium sulfate inj 40mg/ml, 80mg/ml...........................46
magnesium sulfate inj 50%................................................46
MALARONE..................................................................10
malathion.........................................................................30
maprotiline hcl tabs 25mg..................................................20
maprotiline hcl tabs 50mg..................................................20
maprotiline hcl tabs 75mg..................................................20
marlissa............................................................................41
MARPLAN......................................................................20
MATULANE...................................................................13
matzim la.........................................................................27
MAXIDEX......................................................................42
MAXZIDE......................................................................27
MAXZIDE-25.................................................................27
meclizine hcl tabs...............................................................37
meclofenamate sodium.......................................................20
medroxyprogesterone acetate inj..........................................41
medroxyprogesterone acetate tabs.........................................41
mefenamic acid.................................................................20
mefloquine hcl...................................................................10
MEGACE ORAL............................................................13
megestrol acetate................................................................13
MEKINIST.....................................................................13
meloxicam susp..................................................................20
meloxicam tabs..................................................................20
melphalan hydrochloride....................................................13
MENACTRA..................................................................39
MENEST........................................................................41
MENOMUNE-A/C/Y/W-135........................................39
MENVEO.......................................................................39
MEPRON.......................................................................10
Freedom 14251, V20
64
Drug Name
Page
mercaptopurine..................................................................13
meropenem........................................................................10
mesalamine.......................................................................37
mesna...............................................................................13
MESNEX INJ..................................................................13
MESNEX TABS..............................................................13
MESTINON SYRP.........................................................20
MESTINON TIMESPAN..............................................20
metaproterenol sulfate........................................................44
metformin hcl er tb24 1000mg...........................................35
metformin hcl er tb24 500mg.............................................35
metformin hcl er tb24 500mg.............................................35
metformin hcl er tb24 750mg.............................................35
metformin hcl tabs 1000mg...............................................35
metformin hcl tabs 500mg.................................................35
metformin hcl tabs 850mg.................................................35
methadone hcl conc............................................................20
methadone hcl inj..............................................................20
methadone hcl intensol.......................................................20
methadone hcl oral soln 10mg/5ml.....................................20
methadone hcl oral soln 5mg/5ml.......................................20
methadone hcl tabs 10mg...................................................20
methadone hcl tabs 5mg.....................................................20
methadone hcl tbso.............................................................20
methadose conc..................................................................20
methadose sugar-free..........................................................20
methadose tbso...................................................................20
methazolamide..................................................................42
methenamine hippurate.....................................................10
methenamine mandelate....................................................10
methimazole......................................................................35
methotrexate......................................................................13
methotrexate sodium inj 1gm..............................................13
methotrexate sodium inj 25mg/ml, 50mg/2ml.....................13
methoxsalen.......................................................................30
methscopolamine bromide..................................................37
methyclothiazide................................................................27
methyldopa........................................................................27
methylergonovine maleate tabs............................................41
methylphenidate hcl...........................................................20
methylprednisolone............................................................35
methylprednisolone acetate..................................................35
methylprednisolone dose pack..............................................35
methylprednisolone sodiumsuccinate inj 1000mg,
125mg...........................................................................35
methylprednisolone sodiumsuccinate inj 40mg.....................35
metipranolol......................................................................42
Effective Date November 1, 2014
Drug Name
Page
metoclopramide hcl inj.......................................................37
metoclopramide hcl oral soln...............................................37
metoclopramide hcl tabs.....................................................37
metolazone........................................................................27
metoprolol succinate er.......................................................27
metoprolol tartrate inj........................................................27
metoprolol tartrate tabs......................................................27
metoprolol/hydrochlorothiazide...........................................27
metro iv............................................................................10
METROGEL...................................................................31
metronidazole caps.............................................................10
metronidazole crea.............................................................31
metronidazole gel 0.75%...................................................31
metronidazole gel 1%........................................................31
metronidazole in nacl 0.79%.............................................10
metronidazole lotn.............................................................31
metronidazole tabs.............................................................10
metronidazole vaginal........................................................41
mexiletine hcl....................................................................28
MICARDIS HCT TABS 12.5MG; 40MG, 25MG;
80MG...........................................................................28
MICARDIS HCT TABS 12.5MG; 80MG......................28
MICARDIS TABS 20MG, 40MG..................................28
MICARDIS TABS 80MG...............................................28
miconazole 3.....................................................................41
microgestin 1.5/30.............................................................41
microgestin 1/20................................................................41
micronized colestipol hcl.....................................................28
midodrine hcl....................................................................32
migergot............................................................................20
MIGRANAL....................................................................20
millipred dp......................................................................35
millipred tabs....................................................................35
MINIPRESS....................................................................28
minocycline hcl..................................................................10
minoxidil tabs...................................................................28
mirtazapine odt tbdp 15mg................................................20
mirtazapine odt tbdp 30mg................................................20
mirtazapine odt tbdp 45mg................................................20
mirtazapine tabs 15mg......................................................20
mirtazapine tabs 30mg......................................................20
mirtazapine tabs 45mg......................................................20
mirtazapine tabs 7.5mg.....................................................20
mirtazapine tbdp...............................................................20
misoprostol........................................................................37
mitomycin.........................................................................13
mitoxantrone hcl................................................................13
Freedom 14251, V20
65
Drug Name
Page
modafinil tabs 100mg........................................................20
modafinil tabs 200mg........................................................20
MODICON....................................................................41
moexipril hcl.....................................................................28
moexipril/hydrochlorothiazide............................................28
mometasone furoate...........................................................31
mono-linyah......................................................................41
mononessa.........................................................................41
montelukast sodium chew...................................................44
montelukast sodium pack...................................................44
montelukast sodium tabs....................................................44
MONUROL....................................................................10
morphine sulfate er tbcr 100mg, 200mg..............................20
morphine sulfate er tbcr 15mg, 30mg, 60mg.......................20
morphine sulfate inj 0.5mg/ml............................................20
morphine sulfate inj 10mg/ml, 150mg/30ml, 15mg/ml, 1mg/
ml, 50mg/ml..................................................................20
morphine sulfate inj 1mg/ml...............................................20
morphine sulfate inj 25mg/ml, 2mg/ml, 4mg/ml..................20
MORPHINE SULFATE INJ 8MG/ML.........................20
morphine sulfate oral soln 10mg/5ml..................................20
morphine sulfate oral soln 20mg/5ml..................................20
morphine sulfate oral soln 20mg/ml....................................20
morphine sulfate supp........................................................20
morphine sulfate tabs 15mg................................................20
morphine sulfate tabs 30mg................................................21
MOTOFEN....................................................................37
MOVIPREP....................................................................37
MOXATAG....................................................................10
MOXEZA........................................................................42
moxifloxacin hcl................................................................10
mupirocin calcium.............................................................31
mupirocin crea..................................................................31
mupirocin oint..................................................................31
MUSTARGEN................................................................13
MYAMBUTOL...............................................................10
MYCAMINE...................................................................10
MYCOBUTIN................................................................10
mycophenolate mofetil........................................................13
mycophenolic acid dr..........................................................13
MYFORTIC TBEC 180MG...........................................13
MYFORTIC TBEC 360MG...........................................13
myorisan...........................................................................31
myzilra.............................................................................41
nabumetone......................................................................21
nadolol..............................................................................28
nadolol/bendroflumethiazide..............................................28
Effective Date November 1, 2014
Drug Name
Page
nafcillin sodium.................................................................10
NAFTIN..........................................................................31
NAGLAZYME................................................................35
nalbuphine hcl..................................................................21
nallpen iso-osmotic in dextrose............................................10
nallpen/dextrose.................................................................10
naloxone hcl inj 0.4mg/ml..................................................21
naloxone hcl inj 1mg/ml.....................................................21
naltrexone hcl....................................................................21
NAMENDA ORAL SOLN.............................................21
NAMENDA TABS 10MG..............................................21
NAMENDA TABS 5MG................................................21
NAMENDA TITRATION PAK.....................................21
NAMENDA XR..............................................................21
NAMENDA XR TITRATION PACK............................21
naphazoline hcl.................................................................42
naproxen...........................................................................21
naproxen dr.......................................................................21
naproxen sodium tabs 275mg, 550mg.................................21
naratriptan hcl..................................................................21
NASONEX......................................................................44
NATACYN......................................................................42
nateglinide tabs 120mg......................................................35
nateglinide tabs 60mg........................................................35
NEBUPENT...................................................................10
necon 0.5/35-28................................................................41
necon 1/35........................................................................41
necon 1/50-28...................................................................41
necon 10/11-28.................................................................41
necon 7/7/7.......................................................................41
NEEDLES, INSULIN DISP., SAFETY..........................35
nefazodone hcl tabs 100mg.................................................21
nefazodone hcl tabs 150mg.................................................21
nefazodone hcl tabs 200mg.................................................21
nefazodone hcl tabs 250mg.................................................21
nefazodone hcl tabs 50mg...................................................21
neo-polycin........................................................................42
neo-polycin hc....................................................................42
neomycin sulfate................................................................10
neomycin/bacitracin/polymyxin...........................................42
neomycin/polymyxin b sulfates............................................32
neomycin/polymyxin/bacitracin zinc....................................42
neomycin/polymyxin/bacitracin/hydrocortisone.....................42
neomycin/polymyxin/dexamethasone....................................42
neomycin/polymyxin/gramicidin.........................................42
neomycin/polymyxin/hc......................................................33
neomycin/polymyxin/hydrocortisone.....................................33
Freedom 14251, V20
66
Drug Name
Page
neomycin/polymyxin/hydrocortisone.....................................42
NEOSPORIN.................................................................42
NEPHRAMINE..............................................................46
NESINA TABS 12.5MG.................................................35
NESINA TABS 25MG....................................................35
NESINA TABS 6.25MG.................................................35
NEULASTA....................................................................39
NEUMEGA.....................................................................39
NEUPOGEN..................................................................39
neutral sodium fluoride......................................................33
NEVANAC.....................................................................42
nevirapine er.....................................................................10
nevirapine susp..................................................................10
nevirapine tabs..................................................................10
NEXAVAR......................................................................13
NEXIUM........................................................................37
NEXIUM I.V. INJ 20MG...............................................37
NEXIUM I.V. INJ 40MG...............................................37
niacin er tbcr.....................................................................28
NIACOR.........................................................................28
nicardipine hcl caps...........................................................28
nicardipine hcl inj.............................................................28
NICOTROL INHALER.................................................32
NICOTROL NS.............................................................32
nifedical xl........................................................................28
nifedipine er......................................................................28
NILANDRON................................................................13
nimodipine........................................................................28
NIPENT..........................................................................13
nitro-bid...........................................................................28
nitrofurantoin macrocrystals...............................................10
nitrofurantoin monohydrate...............................................10
nitrofurantoin monohydrate/macrocrystals...........................10
nitrofurantoin susp............................................................10
nitroglycerin inj.................................................................28
nitroglycerin lingual translingual soln.................................28
nitroglycerin pt24..............................................................28
nitroglycerin transdermal...................................................28
NITROSTAT..................................................................28
nizatidine caps..................................................................37
NOR-QD........................................................................41
nora-be.............................................................................41
norethindrone....................................................................41
norethindrone acetate.........................................................41
norgestimate/ethinyl estradiol..............................................41
NORMOSOL-M IN D5W.............................................46
NORMOSOL-R..............................................................46
Effective Date November 1, 2014
Drug Name
Page
NORMOSOL-R..............................................................46
NORMOSOL-R IN D5W..............................................46
NOROXIN.....................................................................10
nortrel 0.5/35 (28)............................................................41
nortrel 1/35.......................................................................41
nortrel 7/7/7......................................................................41
nortriptyline hcl.................................................................21
NORVIR.........................................................................10
NOVOLIN 70/30...........................................................35
NOVOLIN 70/30 RELION............................................35
NOVOLIN N.................................................................35
NOVOLIN N RELION..................................................35
NOVOLIN R..................................................................35
NOVOLIN R RELION..................................................35
NOVOLOG....................................................................35
NOVOLOG FLEXPEN..................................................35
NOVOLOG MIX 70/30.................................................35
NOVOLOG MIX 70/30 PREFILLED FLEXPEN..........35
NOVOLOG PENFILL...................................................35
NOVOPEN ECHO........................................................35
NOXAFIL SUSP.............................................................10
NUEDEXTA...................................................................21
NULOJIX........................................................................13
NUVARING...................................................................41
nyamyc..............................................................................31
nystatin crea......................................................................31
nystatin oint......................................................................31
nystatin powd 100000unit/gm...........................................31
nystatin susp......................................................................10
nystatin tabs......................................................................10
nystatin/triamcinolone.......................................................31
nystop...............................................................................31
ocella................................................................................41
octreotide acetate inj 1000mcg/ml.......................................14
octreotide acetate inj 100mcg/ml, 200mcg/ml, 500mcg/ml,
50mcg/ml.......................................................................14
ofloxacin...........................................................................10
ofloxacin...........................................................................33
ofloxacin...........................................................................42
ogestrel..............................................................................41
olanzapine inj...................................................................21
olanzapine odt tbdp 10mg..................................................21
olanzapine odt tbdp 15mg..................................................21
olanzapine odt tbdp 20mg..................................................21
olanzapine odt tbdp 5mg....................................................21
olanzapine tabs 10mg........................................................21
olanzapine tabs 15mg........................................................21
Freedom 14251, V20
67
Drug Name
Page
olanzapine tabs 2.5mg.......................................................21
olanzapine tabs 20mg........................................................21
olanzapine tabs 5mg..........................................................21
olanzapine tabs 7.5mg.......................................................21
omega-3-acid ethyl esters....................................................28
omeprazole cpdr.................................................................37
OMNARIS......................................................................44
ONCASPAR....................................................................14
ondansetron hcl inj............................................................37
ondansetron hcl oral soln....................................................37
ondansetron hcl tabs 24mg.................................................37
ondansetron hcl tabs 4mg, 8mg...........................................37
ondansetron odt.................................................................37
ONFI SUSP.....................................................................21
ONFI TABS 10MG.........................................................21
ONFI TABS 20MG.........................................................21
ONGLYZA TABS 2.5MG..............................................35
ONGLYZA TABS 5MG.................................................35
ONTAK..........................................................................14
opium...............................................................................37
opium tincture...................................................................37
opium tincture (paregoric)..................................................37
ORACEA.........................................................................10
ORAP..............................................................................21
ORAPRED......................................................................35
ORAPRED ODT TBDP 15MG, 30MG........................35
ORENCIA INJ 125MG/ML...........................................40
ORENCIA INJ 250MG..................................................40
ORFADIN......................................................................32
orsythia.............................................................................41
ORTHO EVRA...............................................................41
OSENI TABS 12.5MG; 15MG.......................................35
OSENI TABS 12.5MG; 30MG, 12.5MG; 45MG,
25MG; 15MG, 25MG; 30MG, 25MG; 45MG............35
OSMOPREP...................................................................37
oxacillin sodium................................................................10
oxaliplatin inj 100mg, 100mg/20ml, 50mg/10ml...............14
oxaliplatin inj 50mg..........................................................14
oxandrolone tabs 10mg......................................................35
oxandrolone tabs 2.5mg.....................................................35
oxaprozin..........................................................................21
oxazepam..........................................................................21
oxcarbazepine....................................................................21
OXISTAT........................................................................31
OXSORALEN ULTRA...................................................31
OXTELLAR XR TB24 150MG......................................21
OXTELLAR XR TB24 300MG......................................21
Effective Date November 1, 2014
Drug Name
Page
OXTELLAR XR TB24 600MG......................................21
oxybutynin chloride er tb24 10mg, 15mg............................45
oxybutynin chloride er tb24 5mg........................................45
oxybutynin chloride syrp.....................................................45
oxybutynin chloride tabs.....................................................45
oxycodone hcl caps..............................................................21
oxycodone hcl conc.............................................................21
oxycodone hcl oral soln.......................................................21
oxycodone hcl tabs 10mg....................................................21
oxycodone hcl tabs 15mg....................................................21
oxycodone hcl tabs 20mg....................................................21
oxycodone hcl tabs 30mg....................................................21
oxycodone hcl tabs 5mg......................................................21
oxycodone/acetaminophen...................................................21
oxycodone/aspirin...............................................................22
oxycodone/ibuprofen...........................................................22
OXYCONTIN T12A 10MG, 15MG, 20MG, 30MG,
40MG...........................................................................22
OXYCONTIN T12A 60MG..........................................22
OXYCONTIN T12A 80MG..........................................22
OXYTROL......................................................................45
pacerone............................................................................28
paclitaxel...........................................................................14
PAMELOR CAPS 10MG, 25MG, 50MG.......................22
PAMELOR CAPS 75MG................................................22
pamidronate disodium.......................................................35
PAMINE.........................................................................37
PAMINE FORTE...........................................................37
PANDEL.........................................................................31
PANRETIN.....................................................................31
pantoprazole sodium inj.....................................................37
pantoprazole sodium tbec...................................................37
paricalcitol........................................................................35
paroex...............................................................................33
paromomycin sulfate..........................................................10
paroxetine hcl er tb24 12.5mg............................................22
paroxetine hcl er tb24 25mg...............................................22
paroxetine hcl er tb24 37.5mg............................................22
paroxetine hcl tabs 10mg....................................................22
paroxetine hcl tabs 20mg....................................................22
paroxetine hcl tabs 30mg....................................................22
paroxetine hcl tabs 40mg....................................................22
PASER.............................................................................10
PATADAY.......................................................................42
PATANASE.....................................................................33
PATANOL......................................................................42
PAXIL SUSP....................................................................22
Freedom 14251, V20
68
Drug Name
Page
PCE.................................................................................10
pedi-dri.............................................................................31
PEDVAX HIB.................................................................39
peg-3350/electrolytes..........................................................37
peg-3350/nacl/na bicarbonate/kcl.......................................37
PEG-INTRON................................................................39
PEG-INTRON REDIPEN..............................................39
PEG-INTRON REDIPEN PAK 4..................................39
PEGANONE...................................................................22
PEGASYS........................................................................39
PEGASYS PROCLICK...................................................39
PENICILLIN G POTASSIUM IN ISO-OSMOTIC
DEXTROSE.................................................................10
penicillin g potassium inj 20000000unit, 5mu...................10
penicillin g procaine...........................................................10
penicillin g sodium.............................................................10
penicillin v potassium.........................................................10
PENTAM 300.................................................................10
PENTASA.......................................................................37
pentoxifylline er.................................................................28
PERFOROMIST.............................................................44
perindopril erbumine.........................................................28
periogard...........................................................................33
PERJETA.........................................................................14
permethrin crea.................................................................31
perphenazine.....................................................................22
perphenazine/amitriptyline.................................................22
PEXEVA TABS 10MG....................................................22
PEXEVA TABS 20MG....................................................22
PEXEVA TABS 30MG....................................................22
PEXEVA TABS 40MG....................................................22
pfizerpen-g........................................................................10
phenelzine sulfate...............................................................22
phenobarbital elix..............................................................22
phenobarbital tabs 100mg..................................................22
phenobarbital tabs 15mg....................................................22
phenobarbital tabs 16.2mg.................................................22
phenobarbital tabs 30mg....................................................22
phenobarbital tabs 32.4mg.................................................22
phenobarbital tabs 60mg....................................................22
phenobarbital tabs 64.8mg.................................................22
phenobarbital tabs 97.2mg.................................................22
phenytoin chew..................................................................22
phenytoin infatabs.............................................................22
phenytoin sodium...............................................................22
phenytoin sodium extended.................................................22
phenytoin susp...................................................................22
Effective Date November 1, 2014
Drug Name
Page
philith...............................................................................41
PHISOHEX....................................................................31
PHOSPHOLINE IODIDE.............................................42
PHYSIOLYTE.................................................................32
PHYSIOSOL IRRIGATION..........................................32
pilocarpine hcl...................................................................32
pilocarpine hcl...................................................................42
pilocarpine hydrochloride...................................................32
pindolol............................................................................28
pioglitazone hcl tabs 15mg.................................................35
pioglitazone hcl tabs 30mg.................................................35
pioglitazone hcl tabs 45mg.................................................35
pioglitazone hcl-glimepiride................................................35
pioglitazone hcl/metformin hcl............................................35
piperacillin sodium/tazobactam sodium inj 2gm; 0.25gm,
36gm; 4.5gm, 3gm; 0.375gm..........................................10
piperacillin sodium/tazobactam sodium inj 4gm; 0.5gm.......10
piperacillin/tazobactam......................................................10
pirmella 1/35....................................................................41
piroxicam..........................................................................22
PLASMA-LYTE A...........................................................46
PLASMA-LYTE-148.......................................................46
PLASMA-LYTE-56/D5W...............................................46
pnv ob+dha.......................................................................46
pnv prenatal plus multivitamin..........................................46
pnv-dha............................................................................46
pnv-select..........................................................................46
podofilox...........................................................................31
polycin..............................................................................42
polyethylene glycol 3350.....................................................37
polymyxin b sulfate............................................................10
polymyxin b sulfate/trimethoprim sulfate.............................42
POMALYST....................................................................14
portia-28..........................................................................41
potassium chloride 0.15% /nacl 0.45% viaflex....................46
potassium chloride 0.15% d5w/nacl 0.33%........................46
potassium chloride 0.15% d5w/nacl 0.45%........................46
potassium chloride 0.15% d5w/nacl 0.45% viaflex.............46
potassium chloride 0.15% nacl 0.9%.................................46
potassium chloride 0.15% w/nacl 0.9% viaflex...................46
potassium chloride 0.15%/d5w..........................................46
potassium chloride 0.22% d5w/nacl 0.45%........................46
potassium chloride 0.224%/d5w/nacl 0.45%......................46
potassium chloride 0.224%d5w/nacl 0.45% viaflex............46
potassium chloride 0.3%/ nacl 0.9%..................................46
potassium chloride 0.3%/d5w............................................46
potassium chloride 0.3%/nacl 0.9%/viaflex.........................46
Freedom 14251, V20
69
Drug Name
Page
potassium chloride cr..........................................................46
potassium chloride er..........................................................46
potassium chloride inj 0.4meq/ml, 10meq/100ml, 10meq/
50ml, 20meq/100ml, 20meq/50ml, 30meq/100ml,
40meq/100ml................................................................46
potassium chloride inj 2meq/ml..........................................46
potassium chloride liqd.......................................................46
potassium chloride oral soln................................................46
potassium chloride sr..........................................................46
potassium citrate er tbcr 1080mg, 540mg...........................45
POTIGA TABS 200MG, 300MG, 400MG....................22
POTIGA TABS 50MG....................................................22
pr natal 400......................................................................47
pr natal 400 ec..................................................................47
pr natal 430......................................................................47
pr natal 430 ec..................................................................47
PRADAXA.......................................................................28
pramipexole dihydrochloride...............................................22
PRANDIMET.................................................................35
PRANDIN TABS 0.5MG...............................................36
PRANDIN TABS 1MG..................................................36
PRANDIN TABS 2MG..................................................36
pravastatin sodium............................................................28
prazosin hcl.......................................................................28
PRED MILD...................................................................42
PRED-G..........................................................................42
PRED-G S.O.P................................................................42
prednicarbate....................................................................31
prednisolone......................................................................36
prednisolone acetate...........................................................42
prednisolone sodium phosphate ophthalmic soln...................42
prednisolone sodium phosphate oral soln 15mg/5ml, 5mg/
5ml................................................................................36
prednisone.........................................................................36
prednisone intensol.............................................................36
PREMARIN CREA.........................................................41
PREMARIN INJ.............................................................41
PREMARIN TABS..........................................................41
premasol inj 52meq/l; 1760mg/100ml; 880mg/100ml;
34meq/l; 1760mg/100ml; 372mg/100ml; 406mg/100ml;
526mg/100ml; 492mg/100ml; 492mg/100ml; 526mg/
100ml; 356mg/100ml; 356mg/100ml; 390mg/100ml;
34mg/100ml; 152mg/100ml...........................................47
PREMASOL INJ 56MEQ/L; 320MG/100ML; 730MG/
100ML; 190MG/100ML; 3MEQ/L; 20MG/100ML;
300MG/100ML; 220MG/100ML; 290MG/100ML;
490MG/100ML; 840MG/100ML; 490MG/100ML;
Effective Date November 1, 2014
Drug Name
Page
200MG/100ML; 290MG/100ML; 410MG/100ML;
230MG/100ML; 5MEQ/L; 15MG/100ML; 250MG/
100ML; 120MG/100ML; 140MG/100ML; 470MG/
100ML..........................................................................47
prenaissance......................................................................47
prenaissance plus................................................................47
prenatabs fa.......................................................................47
prenatabs obn....................................................................47
prenatal plus.....................................................................47
prenatal tabs 120mg; 0; 0; 200mg; 400unit; 2mg; 12mcg;
27mg; 1mg; 20mg; 10mg; 3mg; 1.84mg; 22mg; 4000unit;
25mg.............................................................................47
prevalite............................................................................28
previfem............................................................................41
PREZISTA SUSP............................................................10
PREZISTA TABS 150MG, 75MG..................................10
PREZISTA TABS 600MG, 800MG................................10
PRIFTIN.........................................................................10
PRIMAQUINE PHOSPHATE.......................................10
primidone.........................................................................22
PRIMSOL.......................................................................10
PRISTIQ TB24 100MG..................................................22
PRISTIQ TB24 50MG....................................................22
PRIVIGEN......................................................................39
PROAIR HFA.................................................................44
probenecid.........................................................................40
probenecid/colchicine..........................................................40
procainamide hcl inj 100mg/ml..........................................28
procainamide hcl inj 500mg/ml..........................................28
PROCALAMINE............................................................47
prochlorperazine................................................................37
prochlorperazine edisylate...................................................37
prochlorperazine maleate....................................................37
PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML,
3000UNIT/ML, 4000UNIT/ML.................................39
PROCRIT INJ 20000UNIT/ML, 40000UNIT/ML.......39
procto-pak.........................................................................37
proctosol hc........................................................................37
proctozone-hc....................................................................37
progesterone caps................................................................41
PROGLYCEM................................................................36
PROGRAF INJ...............................................................14
PROLASTIN-C...............................................................32
PROLEUKIN..................................................................39
PROLIA..........................................................................40
PROMACTA..................................................................28
propafenone hcl.................................................................28
Freedom 14251, V20
70
Drug Name
Page
propafenone hcl er..............................................................28
propantheline bromide.......................................................37
propranolol hcl er...............................................................28
propranolol hcl inj.............................................................28
propranolol hcl oral soln.....................................................28
propranolol hcl tabs............................................................28
propranolol/hydrochlorothiazide..........................................28
propylthiouracil.................................................................36
PROQUAD.....................................................................39
PROSOL.........................................................................47
PROTOPIC....................................................................31
protriptyline hcl.................................................................22
PROVENTIL HFA.........................................................44
prudoxin...........................................................................31
PULMOZYME...............................................................44
pyrazinamide....................................................................10
pyridostigmine bromide......................................................22
quasense............................................................................41
quetiapine fumarate tabs 100mg........................................22
quetiapine fumarate tabs 200mg........................................22
quetiapine fumarate tabs 25mg..........................................22
quetiapine fumarate tabs 300mg........................................22
quetiapine fumarate tabs 400mg........................................22
quetiapine fumarate tabs 50mg..........................................22
quinapril hcl.....................................................................28
quinapril/hydrochlorothiazide............................................28
quinidine gluconate cr........................................................28
quinidine gluconate er........................................................28
quinidine sulfate................................................................28
quinidine sulfate er............................................................28
quinine sulfate...................................................................10
QVAR..............................................................................44
RABAVERT....................................................................39
raloxifene hydrochloride.....................................................40
ramipril............................................................................28
RANEXA.........................................................................28
ranitidine hcl inj 150mg/6ml, 50mg/2ml............................38
ranitidine hcl syrp..............................................................38
ranitidine hcl tabs..............................................................38
RAPAFLO.......................................................................45
RAPAMUNE ORAL SOLN............................................14
RAPAMUNE TABS 0.5MG, 1MG.................................14
RAPAMUNE TABS 2MG..............................................14
REBETOL.......................................................................10
REBIF..............................................................................39
REBIF REBIDOSE.........................................................39
REBIF REBIDOSE TITRATION PACK.......................39
Effective Date November 1, 2014
Drug Name
Page
REBIF TITRATION PACK...........................................39
reclipsen............................................................................41
RECOMBIVAX HB INJ 10MCG/ML, 40MCG/
ML................................................................................39
RECOMBIVAX HB INJ 5MCG/0.5ML........................39
regonol..............................................................................22
RELENZA DISKHALER................................................10
RELISTOR......................................................................38
relnate dha........................................................................47
REMICADE....................................................................38
REMODULIN................................................................28
RENAGEL......................................................................32
RENVELA PACK............................................................32
RENVELA TABS............................................................32
repaglinide tabs 0.5mg.......................................................36
repaglinide tabs 1mg..........................................................36
repaglinide tabs 2mg..........................................................36
RESCRIPTOR................................................................10
RESCULA.......................................................................42
reserpine tabs 0.1mg..........................................................28
RESTASIS.......................................................................43
RETROVIR IV INFUSION...........................................10
RETROVIR SYRP...........................................................10
REVATIO INJ................................................................44
REVLIMID CAPS 10MG...............................................14
REVLIMID CAPS 15MG, 20MG, 25MG......................14
REVLIMID CAPS 2.5MG..............................................14
REVLIMID CAPS 5MG.................................................14
REYATAZ CAPS 100MG...............................................10
REYATAZ CAPS 150MG, 200MG, 300MG..................11
RHEUMATREX.............................................................14
RHINOCORT AQUA....................................................44
ribasphere caps...................................................................11
ribasphere ribapak.............................................................11
ribasphere tabs 200mg.......................................................11
ribasphere tabs 400mg.......................................................11
ribasphere tabs 600mg.......................................................11
RIBATAB........................................................................11
ribavirin...........................................................................11
RIDAURA.......................................................................40
rifabutin...........................................................................11
RIFADIN CAPS..............................................................11
RIFADIN INJ.................................................................11
RIFAMATE.....................................................................11
rifampin caps....................................................................11
rifampin inj......................................................................11
RIFATER........................................................................11
Freedom 14251, V20
71
Drug Name
Page
riluzole.............................................................................32
rimantadine hcl.................................................................11
ringers injection.................................................................47
ringers irrigation................................................................32
risedronate sodium.............................................................40
RISPERDAL CONSTA INJ 12.5MG, 25MG................22
RISPERDAL CONSTA INJ 37.5MG.............................22
RISPERDAL CONSTA INJ 50MG................................23
risperidone m-tab tbdp 0.5mg............................................23
risperidone m-tab tbdp 1mg...............................................23
risperidone m-tab tbdp 2mg...............................................23
risperidone m-tab tbdp 3mg...............................................23
risperidone m-tab tbdp 4mg...............................................23
risperidone odt tbdp 0.25mg...............................................23
risperidone odt tbdp 0.5mg.................................................23
risperidone odt tbdp 1mg....................................................23
risperidone odt tbdp 2mg....................................................23
risperidone odt tbdp 3mg....................................................23
risperidone odt tbdp 4mg....................................................23
risperidone oral soln...........................................................23
risperidone tabs 0.25mg.....................................................23
risperidone tabs 0.5mg.......................................................23
risperidone tabs 1mg..........................................................23
risperidone tabs 2mg..........................................................23
risperidone tabs 3mg..........................................................23
risperidone tabs 4mg..........................................................23
RITUXAN.......................................................................14
rivastigmine tartrate..........................................................23
ropinirole er......................................................................23
ropinirole hcl.....................................................................23
rosadan.............................................................................31
ROTATEQ.....................................................................39
ROXICET ORAL SOLN................................................23
roxicet tabs........................................................................23
ROZEREM.....................................................................23
SABRIL PACK................................................................23
SABRIL TABS.................................................................23
SAMSCA TABS 15MG...................................................36
SAMSCA TABS 30MG...................................................36
SANCUSO......................................................................38
SANDOSTATIN LAR DEPOT......................................14
SANTYL..........................................................................31
SAPHRIS SUBL 10MG...................................................23
SAPHRIS SUBL 5MG.....................................................23
SARAFEM TABS 10MG.................................................23
SARAFEM TABS 20MG.................................................23
SAVELLA TABS 100MG................................................40
Effective Date November 1, 2014
Drug Name
Page
SAVELLA TABS 12.5MG...............................................40
SAVELLA TABS 25MG..................................................40
SAVELLA TABS 50MG..................................................40
SAVELLA TITRATION PACK......................................40
se-natal 19........................................................................47
se-tan dha.........................................................................47
selegiline hcl......................................................................23
selenium sulfide lotn..........................................................31
SELZENTRY..................................................................11
SENSIPAR TABS 30MG................................................36
SENSIPAR TABS 60MG................................................36
SENSIPAR TABS 90MG................................................36
SEREVENT DISKUS.....................................................44
SEROMYCIN.................................................................11
SEROQUEL XR TB24 150MG......................................23
SEROQUEL XR TB24 200MG......................................23
SEROQUEL XR TB24 300MG......................................23
SEROQUEL XR TB24 400MG......................................23
SEROQUEL XR TB24 50MG........................................23
sertraline hcl conc..............................................................23
sertraline hcl tabs 100mg...................................................23
sertraline hcl tabs 25mg.....................................................23
sertraline hcl tabs 50mg.....................................................23
sevelamer carbonate...........................................................32
sf 5000 plus.......................................................................33
sildenafil...........................................................................44
sildenafil citrate.................................................................44
silver sulfadiazine..............................................................31
SIMCOR TB24 1000MG; 20MG, 500MG; 20MG,
750MG; 20MG............................................................28
SIMCOR TB24 1000MG; 40MG, 500MG; 40MG.......28
SIMPONI........................................................................40
SIMULECT INJ 10MG..................................................14
SIMULECT INJ 20MG..................................................14
simvastatin........................................................................28
sirolimus...........................................................................14
sodium bicarbonate inj 4.2%, 7.5%...................................47
sodium bicarbonate inj 8.4%.............................................47
sodium bicarbonate partial fill............................................47
sodium chloride 0.45%......................................................47
sodium chloride 0.45% viaflex...........................................47
sodium chloride 0.9%........................................................32
sodium chloride inj 0.9%...................................................32
sodium chloride inj 2.5meq/ml, 3%, 4meq/ml.....................47
sodium chloride inj 5%......................................................47
sodium chloride irrigation soln............................................32
sodium chloride pab...........................................................32
Freedom 14251, V20
72
Drug Name
Page
sodium fluoride chew 0.5mg...............................................47
sodium fluoride tabs...........................................................47
sodium lactate...................................................................47
sodium phenylbutyrate.......................................................32
sodium polystyrene sulfonate powd......................................32
sodium polystyrene sulfonate susp 15gm/60ml, 30gm/
120ml............................................................................32
sodium sulfacetamide lotn..................................................31
sodium sulfacetamide ophthalmic soln.................................43
SOLARAZE.....................................................................31
SOLTAMOX...................................................................14
SOMAVERT INJ 10MG, 15MG, 20MG.......................36
SOMAVERT INJ 25MG, 30MG....................................36
SORIATANE..................................................................31
sorine................................................................................28
sotalol hcl..........................................................................28
sotalol hcl (af)....................................................................28
SPIRIVA HANDIHALER...............................................44
spironolactone....................................................................28
spironolactone/hydrochlorothiazide......................................28
sprintec 28........................................................................41
SPRYCEL........................................................................14
sps.....................................................................................32
sronyx...............................................................................41
ssd.....................................................................................31
stavudine caps...................................................................11
stavudine oral soln.............................................................11
STELARA........................................................................31
sterile water irrigation........................................................32
sterile water irrigation plastic bottle....................................32
sterile water irrigation w/hanger.........................................32
STIMATE.......................................................................36
STIVARGA.....................................................................14
STRATTERA CAPS 100MG, 60MG, 80MG.................23
STRATTERA CAPS 10MG, 18MG, 25MG, 40MG......23
STREPTOMYCIN SULFATE........................................11
STRIBILD.......................................................................11
STROMECTOL.............................................................11
SUBOXONE FILM 12MG; 3MG..................................23
SUBOXONE FILM 2MG; 0.5MG.................................23
SUBOXONE FILM 4MG; 1MG....................................23
SUBOXONE FILM 8MG; 2MG....................................23
SUBSYS...........................................................................23
SUCRAID.......................................................................38
sucralfate tabs....................................................................38
sulfacetamide sodium.........................................................31
sulfacetamide sodium.........................................................43
Effective Date November 1, 2014
Drug Name
Page
sulfacetamide sodium/prednisolone sodium phosphate...........43
sulfadiazine.......................................................................11
sulfamethoxazole/trimethoprim ds.......................................11
sulfamethoxazole/trimethoprim inj......................................11
sulfamethoxazole/trimethoprim susp....................................11
sulfamethoxazole/trimethoprim tabs....................................11
SULFAMYLON CREA...................................................31
sulfasalazine......................................................................38
sulfazine............................................................................38
sulfazine ec........................................................................38
sulindac............................................................................24
sumatriptan nasal soln 20mg/act.........................................24
sumatriptan nasal soln 5mg/act...........................................24
sumatriptan succinate inj...................................................24
sumatriptan succinate refill................................................24
sumatriptan succinate tabs.................................................24
SUPRAX SUSR 100MG/5ML, 200MG/5ML.................11
SUPRAX SUSR 500MG/5ML........................................11
SUPRAX TABS...............................................................11
SUPREP BOWEL PREP.................................................38
SURMONTIL.................................................................24
SUSTIVA........................................................................11
SUTENT.........................................................................14
syeda.................................................................................41
SYLATRON....................................................................39
SYMBICORT..................................................................44
SYMLINPEN 120...........................................................36
SYMLINPEN 60.............................................................36
SYNALGOS-DC.............................................................24
SYNAREL.......................................................................36
SYNRIBO........................................................................14
SYNTHROID.................................................................36
SYPRINE.........................................................................32
TABLOID.......................................................................14
TACLONEX OINT........................................................31
tacrolimus caps 0.5mg, 1mg...............................................14
tacrolimus caps 5mg...........................................................14
TAFINLAR.....................................................................14
TAMIFLU CAPS 30MG.................................................11
TAMIFLU CAPS 45MG.................................................11
TAMIFLU CAPS 75MG.................................................11
TAMIFLU SUSR.............................................................11
tamoxifen citrate................................................................14
tamsulosin hcl....................................................................45
TARCEVA......................................................................14
TARGRETIN CAPS.......................................................14
TARGRETIN GEL.........................................................14
Freedom 14251, V20
73
Drug Name
Page
TARKA............................................................................28
taron-prex.........................................................................47
TASIGNA.......................................................................14
TASMAR.........................................................................24
TAXOTERE....................................................................14
TAZORAC......................................................................31
taztia xt............................................................................28
TEGRETOL-XR.............................................................24
TEKTURNA...................................................................28
TEKTURNA HCT.........................................................28
telmisartan tabs 20mg, 40mg.............................................28
telmisartan tabs 80mg........................................................28
telmisartan/amlodipine......................................................28
telmisartan/hydrochlorothiazide tabs 12.5mg; 40mg, 25mg;
80mg.............................................................................28
telmisartan/hydrochlorothiazide tabs 12.5mg; 80mg............29
terazosin hcl......................................................................29
terbinafine hcl tabs............................................................11
terbutaline sulfate inj.........................................................44
terbutaline sulfate tabs.......................................................44
terconazole........................................................................41
TESTIM..........................................................................36
testosterone cypionate..........................................................36
testosterone enanthate.........................................................36
tetanus toxoid adsorbed......................................................39
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED
ADULT........................................................................39
tetracycline hcl...................................................................11
TEV-TROPIN................................................................39
TEVETEN HCT.............................................................29
TEVETEN TABS 400MG..............................................29
THALOMID...................................................................14
theophylline.......................................................................44
theophylline cr...................................................................44
theophylline er...................................................................44
thioridazine hcl.................................................................24
thiothixene........................................................................24
THYMOGLOBULIN.....................................................39
tiagabine hydrochloride......................................................24
TICE BCG......................................................................39
TIKOSYN.......................................................................29
tilia fe...............................................................................41
TIMENTIN INJ 0.1GM/100ML; 3GM/100ML, 1GM;
30GM...........................................................................11
TIMENTIN INJ 0.1GM; 3GM......................................11
timolol maleate..................................................................29
timolol maleate..................................................................43
Effective Date November 1, 2014
Drug Name
Page
timolol maleate ophthalmic gel forming...............................43
TIMOPTIC.....................................................................43
TIMOPTIC OCUDOSE................................................43
TIMOPTIC-XE...............................................................43
tinidazole..........................................................................11
TIVICAY.........................................................................11
tizanidine hcl caps.............................................................24
tizanidine hcl tabs.............................................................24
tl-care dha.........................................................................47
tl-select..............................................................................47
TOBI...............................................................................11
TOBRADEX OINT........................................................43
TOBRADEX ST..............................................................43
tobramycin........................................................................11
tobramycin sulfate inj 1.2gm..............................................11
tobramycin sulfate inj 1.2gm/30ml, 10mg/ml, 40mg/ml,
80mg/2ml......................................................................11
tobramycin sulfate ophthalmic soln.....................................43
tobramycin sulfate/sodium chloride.....................................11
tobramycin/dexamethasone.................................................43
TOBREX OINT.............................................................43
tolazamide tabs 250mg......................................................36
tolazamide tabs 500mg......................................................36
tolbutamide.......................................................................36
tolmetin sodium.................................................................24
tolterodine tartrate tabs 1mg...............................................45
tolterodine tartrate tabs 2mg...............................................45
TOPICORT CREA 0.05%.............................................31
TOPICORT OINT 0.05%.............................................31
topiramate cpsp..................................................................24
topiramate tabs 100mg......................................................24
topiramate tabs 200mg......................................................24
topiramate tabs 25mg........................................................24
topiramate tabs 50mg........................................................24
toposar..............................................................................14
topotecan hcl inj 4mg.........................................................14
topotecan hcl inj 4mg/4ml..................................................14
TORISEL........................................................................14
torsemide inj 20mg/2ml.....................................................29
TORSEMIDE INJ 50MG/5ML......................................29
torsemide tabs....................................................................29
TOVIAZ..........................................................................45
TPN ELECTROLYTES..................................................47
TRACLEER.....................................................................44
tramadol hcl......................................................................24
tramadol hcl er tb24..........................................................24
tramadol hydrochloride/acetaminophen...............................24
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Drug Name
Page
trandolapril.......................................................................29
tranexamic acid inj............................................................29
tranylcypromine sulfate......................................................24
travasol.............................................................................47
TRAVATAN Z................................................................43
travoprost..........................................................................43
trazodone hcl.....................................................................24
TREANDA......................................................................14
TRECATOR...................................................................11
tretinoin caps.....................................................................14
tretinoin crea.....................................................................31
tretinoin gel.......................................................................31
TREXALL.......................................................................14
tri-estarylla........................................................................41
tri-legest fe.........................................................................41
tri-linyah..........................................................................41
TRI-NORINYL 28..........................................................41
tri-previfem.......................................................................41
tri-sprintec........................................................................41
triadvance.........................................................................47
triamcinolone acetonide aero..............................................44
triamcinolone acetonide crea...............................................31
triamcinolone acetonide inj 10mg/ml..................................36
triamcinolone acetonide inj 40mg/ml..................................36
triamcinolone acetonide lotn...............................................31
triamcinolone acetonide oint...............................................31
triamcinolone acetonide pste...............................................33
triamcinolone in orabase....................................................33
triamterene/hydrochlorothiazide caps 25mg; 37.5mg............29
triamterene/hydrochlorothiazide tabs...................................29
trianex..............................................................................31
triderm.............................................................................31
trifluoperazine hcl..............................................................24
trifluridine........................................................................43
TRILIPIX........................................................................29
trilyte................................................................................38
trimethoprim.....................................................................11
trimethoprim sulfate/polymyxin b sulfate.............................43
trinatal gt..........................................................................47
trinatal rx 1......................................................................47
trinessa..............................................................................41
TRISENOX.....................................................................14
triveen-duo dha.................................................................47
triveen-prx rnf...................................................................47
trivora-28.........................................................................41
TRIZIVIR.......................................................................11
TROPHAMINE..............................................................47
Effective Date November 1, 2014
Drug Name
Page
tropicamide.......................................................................43
trospium chloride...............................................................45
TRUVADA.....................................................................11
TWINRIX.......................................................................39
TWYNSTA......................................................................29
TYGACIL........................................................................11
TYKERB..........................................................................14
TYPHIM VI....................................................................39
TYSABRI.........................................................................24
TYVASO.........................................................................44
TYVASO REFILL...........................................................44
TYVASO STARTER.......................................................44
TYZEKA.........................................................................11
TYZINE..........................................................................33
TYZINE PEDIATRIC NASAL DROPS.........................33
U-CORT.........................................................................31
UCERIS...........................................................................38
ULORIC.........................................................................40
ultimatecare one nf............................................................47
unithroid tabs 100mcg, 112mcg, 125mcg, 150mcg, 175mcg,
200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg.............36
ursodiol.............................................................................38
UVADEX........................................................................31
VAGIFEM.......................................................................41
valacyclovir hcl..................................................................11
VALCHLOR...................................................................31
VALCYTE.......................................................................11
valproate sodium...............................................................24
valproic acid......................................................................24
valsartan tabs 160mg.........................................................29
valsartan tabs 320mg.........................................................29
valsartan tabs 40mg, 80mg................................................29
valsartan/hydrochlorothiazide.............................................29
vancomycin hcl caps 125mg................................................11
vancomycin hcl caps 250mg................................................11
VANCOMYCIN HCL IN DEXTROSE INJ 0; 1GM/
200ML..........................................................................11
VANCOMYCIN HCL IN DEXTROSE INJ 0; 500MG/
100ML, 0; 750MG/150ML..........................................11
vancomycin hcl inj 1000mg, 10gm, 5000mg, 750mg..........11
vancomycin hcl inj 500mg.................................................11
VANCOMYCIN HCL INJ 750MG...............................11
vandazole..........................................................................41
VANOS...........................................................................31
VAQTA...........................................................................39
VARIVAX........................................................................39
VARIZIG........................................................................39
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Drug Name
Page
VECTIBIX......................................................................14
VELCADE.......................................................................14
velivet...............................................................................41
VELTIN..........................................................................31
vemavite-prx 2..................................................................47
vena-bal dha.....................................................................47
venlafaxine hcl er cp24 150mg...........................................24
venlafaxine hcl er cp24 37.5mg..........................................24
venlafaxine hcl er cp24 75mg.............................................24
venlafaxine hcl er tb24 150mg...........................................24
VENLAFAXINE HCL ER TB24 225MG.......................24
venlafaxine hcl er tb24 37.5mg..........................................24
venlafaxine hcl er tb24 75mg.............................................24
venlafaxine hcl tabs 100mg................................................24
venlafaxine hcl tabs 25mg..................................................24
venlafaxine hcl tabs 37.5mg...............................................24
venlafaxine hcl tabs 50mg..................................................24
venlafaxine hcl tabs 75mg..................................................24
VENTAVIS.....................................................................44
VENTOLIN HFA...........................................................44
VERAMYST....................................................................44
verapamil hcl er.................................................................29
verapamil hcl inj...............................................................29
verapamil hcl sr.................................................................29
verapamil hcl tabs..............................................................29
veripred 20........................................................................36
VERSACLOZ..................................................................24
VESICARE......................................................................45
vestura..............................................................................41
VEXOL...........................................................................43
VFEND SUSR.................................................................11
VIBATIV INJ 250MG....................................................11
VIBRAMYCIN................................................................11
VICTOZA.......................................................................36
VICTRELIS.....................................................................11
VIDAZA..........................................................................14
VIDEX EC......................................................................12
VIDEX PEDIATRIC.......................................................12
VIGAMOX......................................................................43
VIIBRYD KIT.................................................................24
VIIBRYD TABS 10MG...................................................24
VIIBRYD TABS 20MG...................................................24
VIIBRYD TABS 40MG...................................................24
VIMPAT INJ...................................................................24
VIMPAT ORAL SOLN...................................................24
VIMPAT TABS 100MG.................................................24
VIMPAT TABS 150MG.................................................24
Effective Date November 1, 2014
Drug Name
Page
VIMPAT TABS 200MG.................................................24
VIMPAT TABS 50MG...................................................24
vinblastine sulfate inj 1mg/ml.............................................14
vincasar pfs.......................................................................14
vincristine sulfate...............................................................14
vinorelbine tartrate............................................................14
viorele...............................................................................41
VIRACEPT.....................................................................12
VIRAMUNE SUSP.........................................................12
VIRAMUNE XR.............................................................12
VIRAZOLE.....................................................................12
VIREAD POWD.............................................................12
VIREAD TABS 150MG, 200MG, 250MG.....................12
VIREAD TABS 300MG..................................................12
virt-pn..............................................................................47
virt-pn dha........................................................................47
VISTIDE.........................................................................12
vol-nate.............................................................................47
vol-plus.............................................................................47
VOLTAREN GEL...........................................................24
voriconazole inj.................................................................12
voriconazole susr................................................................12
voriconazole tabs................................................................12
VOTRIENT....................................................................14
vp-ch-pnv..........................................................................47
VYTORIN.......................................................................29
warfarin sodium................................................................29
WELCHOL.....................................................................29
XALKORI.......................................................................14
XARELTO TABS 10MG, 20MG....................................29
XARELTO TABS 15MG................................................29
XENAZINE.....................................................................24
XEOMIN........................................................................39
XGEVA...........................................................................14
XIFAXAN TABS 200MG................................................12
XOLAIR..........................................................................44
XOPENEX HFA.............................................................44
XTANDI.........................................................................14
XULANE.........................................................................41
XYLOCAINE EXTERNAL SOLN.................................31
XYREM...........................................................................25
YERVOY.........................................................................14
YF-VAX...........................................................................39
zafirlukast.........................................................................44
zaleplon caps 10mg............................................................25
zaleplon caps 5mg..............................................................25
ZALTRAP.......................................................................14
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Drug Name
Page
zamicet.............................................................................25
ZANOSAR......................................................................14
zarah................................................................................41
zatean-ch..........................................................................47
zatean-pn..........................................................................47
zatean-pn dha...................................................................47
zatean-pn plus...................................................................47
ZAVESCA.......................................................................36
zazole crea.........................................................................41
ZELAPAR........................................................................25
ZELBORAF.....................................................................14
ZEMAIRA.......................................................................32
ZEMPLAR CAPS............................................................36
zenatane...........................................................................31
zenchent............................................................................41
zenchent fe........................................................................41
ZENPEP..........................................................................38
zenzedi tabs 10mg.............................................................25
zenzedi tabs 5mg...............................................................25
ZERIT CAPS...................................................................12
ZETIA.............................................................................29
ZIAGEN ORAL SOLN...................................................12
ZIANA............................................................................31
zidovudine........................................................................12
ZIOPTAN.......................................................................43
ziprasidone hcl caps 20mg..................................................25
ziprasidone hcl caps 40mg..................................................25
ziprasidone hcl caps 60mg, 80mg........................................25
ZIRGAN.........................................................................43
ZMAX.............................................................................12
ZOFRAN INJ..................................................................38
zoledronic acid inj 4mg......................................................36
zoledronic acid inj 4mg/5ml...............................................36
ZOLINZA.......................................................................14
zolpidem tartrate...............................................................25
ZOMETA........................................................................36
zonisamide........................................................................25
ZORTRESS TABS 0.25MG............................................14
ZORTRESS TABS 0.5MG, 0.75MG..............................14
ZOSTAVAX....................................................................39
zovia 1/35e.......................................................................41
zovia 1/50e.......................................................................41
ZOVIRAX CREA............................................................31
ZYDELIG........................................................................14
ZYFLO............................................................................44
ZYFLO CR......................................................................44
ZYKADIA.......................................................................14
Effective Date November 1, 2014
Drug Name
Page
ZYLET............................................................................43
ZYPREXA INJ.................................................................25
ZYTIGA..........................................................................14
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Drug Name
Page
ZYVOX INJ....................................................................12
ZYVOX SUSR.................................................................12
ZYVOX TABS.................................................................12
Effective Date November 1, 2014
Anthem Blue Cross and Blue Shield is an RPPO plan with a Medicare contract. Enrollment in Anthem Blue Cross
and Blue Shield depends on contract renewal.
Anthem Insurance Companies, Inc. (AICI) is the legal entity that has contracted with the Centers for Medicare
& Medicaid Services (CMS) to offer the Medicare Advantage Regional PPO plan(s) (MAPD-RPPO) noted above
or herein. AICI is the risk-bearing entity licensed under applicable state law to offer the MAPD-RPPO plan(s)
noted. AICI has retained the services of its related companies and the authorized agents/brokers/producers to
provide administrative services and/or to make the MAPD-RPPO plan(s) available in this region.Anthem Blue
Cross and Blue Shield is the trade name of Community Insurance Company, Independent licensee of the Blue
Cross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
Association.
This information is available for free in other languages. Please contact our customer service number at
1-800-467-1199 or, for TTY users, 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas)
from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September
30.
Customer Service
This formulary was updated on October 1, 2014. For more recent information or other questions, please
contact Blue Medicare Access Value (Regional PPO) Customer Service at 1-800-467-1199 or, for TTY
users, 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1
through February 14, and Monday to Friday (except holidays) from February 15 through September
30, or visit www.anthem.com/medicare.
38017WPSENMUB_128 R5941 008
OH
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