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Formulary
IEHP DualChoice Cal MediConnect Plan
(Medicare-Medicaid Plan)
IEHP DualChoice
P.O. Box 1800, Rancho Cucamonga, CA 91729-1800
©2015 Inland Empire Health Plan. All Rights Reserved. Updated: July 28, 2015
H5355_CMC_15_03587_Final_2 Approved
1-877-273-IEHP (4347)
1-800-718-4347 TTY
August
2015
IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan)
| 2015 List of Covered Drugs (Formulary)
HPMS Approved Formulary File Submission ID 00015496, Version 15
This is a list of drugs that members can get in IEHP DualChoice.
 IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that
contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.
 Benefits, List of Covered Drugs, and pharmacy and provider networks, and/or copayments
may change from time to time throughout the year and on January 1 of each year.
 You can always check IEHP DualChoice’s up-to-date List of Covered Drugs online at
www.iehp.org or by calling 1-877-273-IEHP (4347), 8am – 8pm (PST) 7 days a week,
including holidays. TTY/TDD users should call 1-800-718-4347.
 You can ask for this information in other formats, such as Braille or large print. Call 1-877-273IEHP (4347), 8am – 8pm (PST) 7 days a week, including holidays. TTY/TDD users should call
1-800-718-4347. The call is free.
 Limitations, copays and restrictions may apply. For more information, call IEHP DualChoice
Member Services or read the IEHP DualChoice Member Handbook.
 Co-pays for prescription drugs may vary based on the level of Extra Help you receive. Please
contact the plan for more details.
 You can get this information for free in other languages. Call 1-877-273-IEHP (4347), 8am –
8pm (PST) 7 days a week, including holidays. TTY/TDD users should call 1-800-7184347.The call is free.
 Usted puede obtener esta información gratis en otros idiomas. Llame al 1-877-273-IEHP
(4347), 8 a.m. a 8 p.m. (Hora del Pacífico), los 7 días de la semana, incluidos días festivos.
Los usuarios de TTY/TDD deben llamar al 1-800-718-4347. La llamada es gratuita.
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If you have questions, please call IEHP DualChoice at 1-877-273-IEHP (4347), 8am – 8pm
(PST) 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347. The call is
free. For more information, visit www.iehp.org.
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Frequently Asked Questions (FAQ)
Find answers here to questions you have about this List of Covered Drugs. You can read all of
the FAQ to learn more, or look for a question and answer.
1.
What prescription drugs are on the List of Covered Drugs?
(We call the List of Covered Drugs the “Drug List” for short.)
The drugs on the Drug List are the drugs covered by IEHP DualChoice. The drugs are available
at pharmacies within our network. A pharmacy is in our network if we have an agreement with
them to work with us and provide you services. We refer to these pharmacies as “network
pharmacies.”
IEHP DualChoice will cover all medically necessary drugs on the Drug List if:
 your doctor or other prescriber says you need them to get better or stay healthy, and
 you fill the prescription at a IEHP DualChoice network pharmacy.
In some cases, you have to do something before you can get a drug (see question #5 below).
You can also see an up-to-date list of drugs that we cover on our website at www.iehp.org or call
Member Services at 1-877-273-IEHP (4347), 8am – 8pm (PST) 7 days a week, including
holidays. TTY/TDD users should call 1-800-718-4347.
2.
Does the Drug List ever change?
Yes. IEHP DualChoice may add or remove drugs on the Drug List during the year. Generally, the
Drug List will only change if:
 a cheaper drug comes along that works as well as a drug on the Drug List now, or
 we learn that a drug is not safe.
We may also change our rules about drugs. For example, we could:
 Decide to require or not require prior approval for a drug. (Prior approval is permission from
IEHP DualChoice before you can get a drug.)
 Add or change the amount of a drug you can get (called “quantity limits”).
 Add or change step therapy restrictions on a drug. (Step therapy means you must try one
drug before we will cover another drug.)
(For more information on these drug rules, see page 3.)
We will tell you when a drug you are taking is removed from the Drug List. We will also tell you
when we change our rules for covering a drug. Questions 3, 4, and 7 below have more
information on what happens when the Drug List changes.
→ You can always check IEHP DualChoice’s up to date Drug List online at www.iehp.org. You
can also call Member Services to check the current Drug List at 1-877-273-IEHP (4347), 8am
– 8pm (PST) 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347.
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3.
What happens when a cheaper drug comes along that works as
well as a drug on the Drug List now?
If you are taking a drug that is removed because a cheaper drug that works just as well comes
along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or
when you ask for a refill. Then you can get a 60-day supply of the drug before the drug is
removed from the drug list. You will receive a letter at least 60-days before the change is
effective. This information is also available on our website at www.iehp.org.
4.
What happens when we find out a drug is not safe?
If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it
off the Drug List right away. We will also send you a letter telling you that. Please contact the
prescribing doctor after you receive your letter.
5.
Are there any restrictions or limits on drug coverage? Or are there
any required actions to take in order to get certain drugs?
Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases
you must do something before you can get the drug. For example:
 Prior approval (or prior authorization): For some drugs, you or your doctor or other
prescriber must get approval from IEHP DualChoice before you fill your prescription. If you
don’t get approval, IEHP DualChoice may not cover the drug.
 Quantity limits: Sometimes IEHP DualChoice limits the amount of a drug you can get.
 Step therapy: Sometimes IEHP DualChoice requires you to do step therapy. This means
you will have to try drugs in a certain order for your medical condition. You might have to try
one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work
for you, then we will cover the second.
You can find out if your drug has any additional requirements or limits by looking in the tables on
pages 11-80. You can also get more information by visiting our web site at www.iehp.org. We
have posted online documents that explain prior authorization and step therapy restrictions. You
may also ask us to send you a copy.
You can ask for an “exception” from these limits. Please see Question 11 for more information on
exceptions.
 If you are in a nursing home or other long-term care facility and need a drug that is not on the
Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day
emergency supply of the drug you need (unless you have a prescription for fewer days),
whether or not you are a new IEHP DualChoice member. This will give you time to talk to your
doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug
List you can take instead or whether to request an exception. Please see Question 11 for
more information about exceptions.
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If you have questions, please call IEHP DualChoice at 1-877-273-IEHP (4347), 8am – 8pm
(PST) 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347. The call is
free. For more information, visit www.iehp.org.
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6.
How will you know if the drug you want has limitations or if there
are required actions to take to get the drug?
The List of Covered Drugs on page 11 has a column labeled “Necessary actions, restrictions, or
limits on use.”
7.
What happens if we change our rules on how we cover some of the
drugs? For example, if we add prior authorization (approval),
quantity limits, and/or step therapy restrictions on a drug.
We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug.
We will tell you at least 60 days before the restriction is added or when you next ask your
pharmacy for a refill. Then, you can get a 60-day supply of the drug before the change to the
coverage rules is made. This gives you time to talk to your doctor or other prescriber about what
to do next.
8.
How can you find a drug on the Drug List?
There are two ways to find a drug:
 You can search alphabetically (if you know how to spell the drug), or
 You can search by medical condition.
To search alphabetically, go to the Alphabetical Listing section. You can find the Index that
begins on page 81. Look in the Index and find your drug. Next to your drug, you will see the page
number where you can find the coverage information. Turn to the page listed in the Index and find
the name of your drug in the first column of the list.
To search by medical condition, find the section labeled “List of drugs by medical condition” on
page 9. Then find your medical condition. For example, if you have a heart condition, you should
look in that category. That is where you will find drugs that treat heart conditions.
9.
What if the drug you want to take is not on the Drug List?
If you don’t see your drug on the Drug List, call Member Services at 1-877-273-IEHP (4347), 8am
– 8pm (PST) 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347 and
ask about it. If you learn that IEHP DualChoice will not cover the drug, you can do one of these
things:
 Ask Member Services for a list of drugs like the one you want to take. Then show the list to
your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like
the one you want to take. Or
 You can ask the health plan to make an exception to cover your drug. Please see question
11 for more information about exceptions.
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10. What if you are a new IEHP DualChoice member and can’t find your
drug on the Drug List or have a problem getting your drug?
We can help. We may cover a temporary 31-day supply of your drug during the first 90 days you
are a member of IEHP DualChoice. This will give you time to talk to your doctor or other
prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take
instead or whether to request an exception.
We will cover a 31-day supply of your drug if:




you are taking a drug that is not on our Drug List, or
health plan rules do not let you get the amount ordered by your prescriber, or
the drug requires prior approval by IEHP DualChoice, or
you are taking a drug that is part of a step therapy restriction.
If you live in a nursing home or other long-term care facility, you may refill your prescription for as
long as a 98 day supply. You may refill the drug multiple times during the 98 days. This gives your
prescriber time to change your drugs to those on the Drug List or ask for an exception.
As a new or continuing member in our plan, you may be taking drugs that are not on our
formulary. Or, you may be taking drugs that are on our formulary that are hard for you to get. For
example, you may need our approval before you can get your drug. Either way, talk to your
doctor. He or she can help you choose the right course of action. This could be changing to a
drug we do cover or seeking a formulary exception so that we will cover the drug. While you talk
to your doctor to determine the right course of action for you, we may cover your drug in certain
cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or is hard for you to get, we will cover a
temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a
network pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you have
been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will cover your prescription refill until we have
provided you with 98-day transition supply, consistent with 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 of your membership. If you need a drug that is not on our formulary or it is hard
for you to get, 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 ask for a
formulary exception.
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If you have questions, please call IEHP DualChoice at 1-877-273-IEHP (4347), 8am – 8pm
(PST) 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347. The call is
free. For more information, visit www.iehp.org.
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11. Can you ask for an exception to cover your drug?
Yes. You can ask IEHP DualChoice to make an exception to cover a drug that is not on the Drug
List.
You can also ask us to change the rules on your drug.
 For example, IEHP DualChoice may limit the amount of a drug we will cover. If your drug
has a limit, you can ask us to change the limit and cover more.
 Other examples: You can ask us to drop step therapy restrictions or prior approval
requirements.
12. How long does it take to get an exception?
First, we must receive a statement from your prescriber supporting your request for an
exception. After we receive the statement, we will give you a decision on your exception request
within 72 hours.
If you or your prescriber think your health may be harmed if you have to wait 72 hours for a
decision, you can ask for an expedited exception. This is a faster decision. If your prescriber
supports your request, we will give you a decision within 24 hours of receiving your prescriber’s
supporting statement.
13. How can you ask for an exception?
To ask for an exception, call IEHP DualChoice Member Services. IEHP DualChoice Member
Services will work with you and your provider to help you ask for an exception.
14. What are generic drugs?
Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less
than the brand name drug and their names are less commonly known. Generic drugs are
approved by the Food and Drug Administration (FDA).
IEHP DualChoice covers both brand name drugs and generic drugs.
15. What are OTC drugs?
OTC stands for “over-the-counter”. IEHP DualChoice covers some OTC drugs when they are
written as prescriptions by your provider.
You can read the IEHP DualChoice Drug List to see what OTC drugs are covered.
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16. Does IEHP DualChoice cover OTC non-drug products?
IEHP DualChoice covers some OTC non-drug products when they are written as prescriptions by
your provider.
You can read the IEHP DualChoice Drug List to see what OTC non-drug products are covered.
17. What is your co-pay?
You can read the IEHP DualChoice Drug List to learn about the co-pay for each drug.
IEHP DualChoice members living in nursing homes or other long-term care facilities will have no
co-pays. Some members getting long-term care in the community will also have no co-pays.
Co-pays are listed by tiers. Tiers are groups of drugs with the same co-pay.
 Tier 1 drugs have the lowest co-pay. They are generic drugs. The co-pay will be from $0 to
$2.65, depending on your level of Medicaid eligibility.
Tier
2 drugs have a medium co-pay. They are brand name drugs. The co-pay will be from

$0 to $6.60, depending on your level of Medicaid eligibility.
 Tier 3 drugs have a co-pay of $0. They are non-Medicare/over-the-counter drugs.
List of Covered Drugs
The list of covered drugs that begins on page 11 gives you information about the drugs covered
by IEHP DualChoice. If you have trouble finding your drug in the list, turn to the Index that begins
on page 81.
The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g.,
NEXIUM) and generic drugs are listed in lower-case italics (e.g., omeprazole).
The information in the “Necessary actions, restrictions, or limits on use” column tells you if IEHP
DualChoice has any rules for covering your drug.
Below are the meanings of the codes used in the “Necessary actions, restrictions, or limits on
use” column:
UPPERCASE BOLD= Drug Tier
Requirements / Limits
Brand name drugs
1= Tier 1; 2= Tier 2;
PA= Prior Authorization
lowercase italics=
3= Tier 3
B vs D= Part B vs D Prior Authorization
Generic drugs
NC= Not Covered
ST= Step Therapy
NF= Non-Formulary
QL= Quantity Limit
Tier 1: Drugs in this tier have the lowest copay. They are generic drugs (including brand drugs
treated as generic). The copay is a set payment you make for these generic drugs. For example,
the copay is from $0 to $2.65. This amount depends on your income.
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If you have questions, please call IEHP DualChoice at 1-877-273-IEHP (4347), 8am – 8pm
(PST) 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347. The call is
free. For more information, visit www.iehp.org.
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Tier 2: Drugs in this tier have the highest copay. They are brand name drugs. The copay is from
$0 to $6.60. This amount depends on your income.
Tier 3: Drugs in this tier are drugs that are non-Medicare drugs/Over-the-Counter (OTC) drugs.
These drugs are covered by Medi-Cal. They have a $0 co-pay.
NC: Not covered. These are drugs not covered by IEHP DualChoice.
NF: Non-Formulary. Drugs that are not on our prescribed drugs list (known as a Formulary).
PA: Prior Authorization. IEHP DualChoice requires you or your physician to get approval from us
first before filling a certain drug. This extra step is called “prior authorization.” If you don't get
approval, IEHP DualChoice may not cover the drug.
B vs D: Part B vs D Prior Authorization. This is a drug that has a special “PA” requirement. It may
be covered under one or two benefit programs: 1) Medicare Part B, and/or 2) Medicare Part D.
This depends on many factors. Your physician may need to give us more details about the use
and setting of the drug.
QL: Quantity Limit. For certain drugs, IEHP DualChoice limits the amount of the drug that it will
cover. This may be in addition to a standard one month or three month supply.
ST: Step Therapy. In some cases, IEHP DualChoice requires you to first try certain drugs to treat
your medical condition. This is the process before we will cover another drug for that condition. For
example, either Drug A or Drug B may treat your medical condition. IEHP DualChoice may not cover
Drug B unless you try Drug A first. If Drug A does not work for you, IEHP DualChoice will then cover
Drug B.
Note: The 3 next to a drug means the drug is not a “Part D drug.” The amount you pay when you
fill a prescription for this drug does not count towards your total drug costs (that is, the amount
you pay does not help you qualify for catastrophic coverage). These drugs also have different
rules for appeals. An appeal is a formal way of asking us to review a decision we made about
your coverage and to change it if you think we made a mistake. For example, we might decide
that a drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or
your doctor disagrees with our decision, you can appeal. If you ever have a question, call Member
Services at 1-877-273-IEHP (4347), 8am – 8pm (PST) 7 days a week, including holidays.
TTY/TDD users should call 1-800-718-4347. You can also read the IEHP DualChoice Member
Handbook to learn how to appeal a decision.
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IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan)
2015 Formulary
Table of Contents
Additional Demonstration Drugs ....................................................................................................................... 11
Analgesics .......................................................................................................................................................... 18
Anesthetics ......................................................................................................................................................... 19
Anti-Addiction/ Substance Abuse Treatment Agents ........................................................................................ 20
Antibacterials ..................................................................................................................................................... 20
Anticonvulsants .................................................................................................................................................. 26
Antidementia Agents .......................................................................................................................................... 28
Antidepressants .................................................................................................................................................. 29
Antiemetics......................................................................................................................................................... 31
Antifungals ......................................................................................................................................................... 32
Antigout Agents ................................................................................................................................................. 33
Anti-Inflammatory Agents ................................................................................................................................. 33
Antimigraine Agents .......................................................................................................................................... 34
Antimyasthenic Agents ...................................................................................................................................... 34
Antimycobacterials............................................................................................................................................. 34
Antineoplastics ................................................................................................................................................... 35
Antiparasitics ...................................................................................................................................................... 40
Antiparkinson Agents ......................................................................................................................................... 40
Antipsychotics .................................................................................................................................................... 41
Antispasticity Agents ......................................................................................................................................... 43
Antivirals ............................................................................................................................................................ 43
Anxiolytics ......................................................................................................................................................... 47
Bipolar Agents.................................................................................................................................................... 47
Blood Glucose Regulators.................................................................................................................................. 47
Blood Products/ Modifiers/ Volume Expanders ................................................................................................ 49
Cardiovascular Agents ....................................................................................................................................... 51
Central Nervous System Agents ........................................................................................................................ 56
Dental And Oral Agents ..................................................................................................................................... 57
Dermatological Agents ....................................................................................................................................... 58
Enzyme Replacement/ Modifiers ....................................................................................................................... 59
Gastrointestinal Agents ...................................................................................................................................... 59
Genitourinary Agents ......................................................................................................................................... 61
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) ................................................................... 62
Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) .................................................................. 64
Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) ...................................... 64
Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) ................................................................... 67
Hormonal Agents, Suppressant (Adrenal) ......................................................................................................... 67
Hormonal Agents, Suppressant (Parathyroid).................................................................................................... 67
Hormonal Agents, Suppressant (Pituitary)......................................................................................................... 67
Hormonal Agents, Suppressant (Thyroid) ......................................................................................................... 68
Immunological Agents ....................................................................................................................................... 68
Inflammatory Bowel Disease Agents ................................................................................................................. 72
Metabolic Bone Disease Agents ........................................................................................................................ 72
Ophthalmic Agents ............................................................................................................................................. 73
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Otic Agents ......................................................................................................................................................... 75
Respiratory Tract/ Pulmonary Agents ................................................................................................................ 75
Skeletal Muscle Relaxants ................................................................................................................................. 78
Sleep Disorder Agents ........................................................................................................................................ 78
Therapeutic Nutrients/ Minerals/ Electrolytes ................................................................................................... 78
Index ................................................................................................................................................................... 81
10
Drug Name
Tier
Requirements / Limits
Additional Demonstration Drugs
Additional Demonstration Drugs
ABREVA TOPICAL CREAM 10 %
3
acetaminophen oral solution 160 mg/5 ml (5 ml)
3
acetaminophen oral tablet 325 mg
3
ALAWAY OPHTHALMIC DROPS 0.025 %
3
ALL DAY ALLERGY-D ORAL TABLET EXTENDED
RELEASE 12 HR 5-120 MG
3
ALLERGY (CHLORPHENIRAMINE) ORAL TABLET 4
MG
3
ALTALUBE OPHTHALMIC OINTMENT
3
ANTACID ANTI-GAS ORAL SUSPENSION 200-200-20
MG/5 ML, 400-400-40 MG/5 ML
3
ANTIBIOTIC + PAIN RELIEF TOPICAL CREAM 3.510,000-10 MG-UNIT-MG/GRAM
3
APRODINE ORAL TABLET 2.5-60 MG
3
aspirin oral tablet 325 mg
3
aspirin oral tablet, chewable 81 mg
3
aspirin oral tablet, delayed release (dr/ec) 325 mg, 81 mg
3
bacitracin topical ointment 500 unit/gram
3
bacitracin zinc topical ointment 500 unit/gram
3
bacitracin-polymyxin b topical ointment 500-10,000 unit/gram
3
benzonatate oral capsule 100 mg, 200 mg
3
benzoyl peroxide topical gel 2.5 %, 5 %
3
benzoyl peroxide topical lotion 10 %, 5 %
3
BETA-HC TOPICAL LOTION 1 %
3
BION TEARS (PF) OPHTHALMIC DROPPERETTE 0.10.3 %
3
bisacodyl oral tablet, delayed release (dr/ec) 5 mg
3
bisacodyl rectal suppository 10 mg
3
BISMATROL ORAL SUSPENSION 525 MG/15 ML
3
bismuth subsalicylate oral tablet, chewable 262 mg
3
BOUDREAUXS BUTT PASTE TOPICAL OINTMENT 40
%
3
BROMFED DM ORAL SYRUP 2-30-10 MG/5 ML
3
QL (480 ML per 30 days)
brompheniramine-pseudoeph-dm oral liquid 4-20-20 mg/5 ml
3
QL (480 ML per 30 days)
QL (62 EA per 31 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
11
Drug Name
Tier
Requirements / Limits
calamine topical lotion
3
calcium carbonate oral tablet 260 mg calcium (648 mg), 500
mg calcium (1,250 mg), 600 mg (1,500 mg)
3
calcium gluconate oral tablet 45 mg (500 mg)
3
calcium lactate oral tablet 84 mg (648 mg)
3
CARDEC DM (PHENYLEPH-CHLORPHN) ORAL
DROPS 1-3.5-3 MG/ML
3
cetirizine oral tablet 10 mg, 5 mg
3
QL (31 EA per 31 days)
cetirizine oral tablet, chewable 5 mg
3
QL (31 EA per 31 days)
cetirizine-pseudoephedrine oral tablet extended release 12 hr
5-120 mg
3
QL (60 EA per 30 days)
CHEMSTRIP 9 STRIP
3
chlorpheniramine maleate oral tablet extended release 12 mg
3
cholecalciferol (vitamin d3) oral capsule 1,000 unit, 10,000
unit, 5,000 unit, 50,000 unit
3
cholecalciferol (vitamin d3) oral tablet 2,000 unit, 5,000 unit
3
cholecalciferol (vitamin d3) oral tablet, chewable 400 unit
3
CITRUCEL ORAL TABLET 500 MG
3
clotrimazole vaginal cream 1 %
3
COLACE ORAL CAPSULE 50 MG
3
CONCEPTROL VAGINAL GEL 4 %
3
CONDOMS-PREM LUBRICATED DEVICE
3
cromolyn nasal spray, non-aerosol 5.2 mg/spray (4 %)
3
cyanocobalamin (vitamin b-12) injection solution 1,000
mcg/ml
3
cyanocobalamin (vitamin b-12) oral tablet extended release
1,000 mcg
3
DANDREX TOPICAL SUSPENSION 1 %
3
DESPEC EDA COUGH & COLD DROPS ORAL DROPS
2.5-5-50 MG/ML
3
DEXFERRUM INTRAVENOUS SOLUTION 100 MG/2
ML (50 MG/ML), 50 MG/ML (1 ML)
3
DIABETIC TUSSIN DM ORAL LIQUID 10-100 MG/5
ML, 10-200 MG/5 ML
3
DIMETAPP COLD-ALLERGY (PE) ORAL SOLUTION
1-2.5 MG/5 ML
3
DIMETAPP DM COLD-COUGH (PE) ORAL SOLUTION
1-2.5-5 MG/5 ML
3
12
Drug Name
Tier
DIOCTO ORAL LIQUID 50 MG/5 ML
3
DIPHENHIST ORAL TABLET 25 MG, 50 MG
3
diphenhydramine hcl oral capsule 25 mg
3
diphenhydramine hcl oral tablet 25 mg, 50 mg
3
docusate sodium oral capsule 100 mg
3
docusate sodium oral tablet 100 mg
3
DOCUSOL RECTAL ENEMA 283 MG
3
DSS ORAL CAPSULE 250 MG
3
DULCOLAX STOOL SOFTENER (DSS) ORAL
CAPSULE 100 MG
3
D-VI-SOL ORAL DROPS 400 UNIT/ML
3
EAR WAX REMOVAL SYSTEM OTIC DROPS 6.5 %
3
ED A-HIST DM ORAL LIQUID 4-10-15 MG/5 ML
3
ED CHLORPED JR ORAL SYRUP 2 MG/5 ML
3
ergocalciferol (vitamin d2) oral capsule 50,000 unit
3
ergocalciferol (vitamin d2) oral tablet 400 unit
3
EXCEDRIN EXTRA STRENGTH ORAL TABLET 250250-65 MG
3
EYE ITCH RELIEF OPHTHALMIC DROPS 0.025 %
3
famotidine oral tablet 10 mg
3
ferrous sulfate oral drops 15 mg iron (75 mg)/ml
3
ferrous sulfate oral liquid 300 mg (60 mg iron)/5 ml
3
ferrous sulfate oral solution 220 mg (44 mg iron)/5 ml
3
ferrous sulfate oral tablet, delayed release (dr/ec) 324 mg (65
mg iron), 325 mg (65 mg iron)
3
FERROUSUL ORAL TABLET 325 MG (65 MG IRON)
3
FEVERALL RECTAL SUPPOSITORY 120 MG, 325 MG,
80 MG
3
fexofenadine oral tablet 180 mg, 60 mg
3
FIBER-LAX ORAL TABLET 625 MG
3
folic acid oral tablet 400 mcg, 800 mcg
3
GAS RELIEF ORAL TABLET,CHEWABLE 80 MG
3
GENTEAL MILD OPHTHALMIC DROPS 0.2 %
3
GENTLE LAXATIVE ORAL TABLET,DELAYED
RELEASE (DR/EC) 5 MG
3
glucose oral tablet, chewable 4 gram
3
Requirements / Limits
QL (4 EA per 28 days)
QL (120 EA per 30 days)
QL (62 EA per 31 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
13
Drug Name
Tier
GUAIFENESIN AC ORAL LIQUID 10-100 MG/5 ML
3
guaifenesin oral liquid 100 mg/5 ml
3
GYNOL II VAGINAL GEL 3 %
3
HIBICLENS TOPICAL LIQUID 4 %
3
HYDRISALIC TOPICAL GEL 17 %
3
hydrocortisone topical cream 0.5 %
3
hydrocortisone topical ointment 0.5 %
3
hydrocortisone-aloe vera topical cream 1 %
3
HYDROMET ORAL SYRUP 5-1.5 MG/5 ML
3
INFANTS GAS RELIEF ORAL DROPS,SUSPENSION 40
MG/0.6 ML
3
ISOPTO TEARS OPHTHALMIC DROPS 0.5 %
3
KAO-TIN (BISMUTH SUBSALICYLAT) ORAL
SUSPENSION 262 MG/15 ML
3
LIQUID ANTACID EXTRA STRENGTH ORAL
SUSPENSION 500-450-40 MG/5 ML
3
LOHIST - D ORAL LIQUID 2-30 MG/5 ML
3
loperamide oral tablet 2 mg
3
loratadine oral solution 5 mg/5 ml
3
loratadine oral tablet 10 mg
3
LORATADINE-D ORAL TABLET EXTENDED
RELEASE 24 HR 10-240 MG
3
LUBRIFRESH PM OPHTHALMIC OINTMENT 83-15 %
3
magnesium oxide oral tablet 250 mg, 400 mg, 420 mg, 500 mg
3
MAGTAB ORAL TABLET EXTENDED RELEASE 84
MG
3
mapap (acetaminophen) oral capsule 500 mg
3
meclizine oral tablet, chewable 25 mg
3
MEDI-FIRST ANTI-FUNGAL TOPICAL PACKET 1 %
3
MEPHYTON ORAL TABLET 5 MG
3
METAMUCIL ORAL CAPSULE 0.52 GRAM
3
METAMUCIL ORAL POWDER 3.4 GRAM/7 GRAM
3
METAMUCIL SMOOTH (WITH SUGAR) ORAL
POWDER IN PACKET 3.4 GRAM
3
METAMUCIL SUGAR-FREE (ASPART) ORAL
POWDER 3.4 GRAM/5.8 GRAM
3
MICADERM TOPICAL CREAM 2 %
3
14
Requirements / Limits
QL (480 ML per 30 days)
QL (150 ML per 30 days)
QL (30 EA per 30 days)
Drug Name
Tier
Requirements / Limits
miconazole nitrate vaginal cream 2 %
3
miconazole nitrate vaginal suppository 100 mg
3
MICONAZOLE-3 VAGINAL KIT 200 MG- 2 % (9
GRAM)
3
MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5
ML
3
MONISTAT 3 VAGINAL CREAM 200 MG/5 GRAM (4
%)
3
MUCINEX COUGH MINI-MELTS ORAL GRANULES
IN PACKET 5-100 MG
3
MUCINEX DM ORAL TABLET EXTENDED RELEASE
12 HR 30-600 MG
3
MUCINEX DM ORAL TABLET, ER MULTIPHASE 12
HR 60-1,200 MG
3
MUCINEX ORAL TABLET EXTENDED RELEASE
12HR 1,200 MG, 600 MG
3
MURO 128 OPHTHALMIC DROPS 2 %
3
MY WAY ORAL TABLET 1.5 MG
3
NAPHCON-A OPHTHALMIC DROPS 0.025-0.3 %
3
NATURAL BALANCE OPHTHALMIC DROPS 0.4 %
3
NEPHRO-VITE ORAL TABLET 0.8 MG
3
NESSI SPACER SPACER
3
NEUTRAHIST ORAL DROPS 0.8-9 MG/ML
3
niacin oral capsule, extended release 250 mg, 500 mg
3
niacin oral tablet 100 mg
3
niacin oral tablet 500 mg
3
NICORETTE BUCCAL LOZENGE 4 MG
3
QL (372 EA per 30 days)
nicotine (polacrilex) buccal gum 4 mg
3
QL (372 EA per 30 days)
nicotine (polacrilex) buccal lozenge 2 mg
3
QL (372 EA per 31 days)
nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr,
7 mg/24 hr
3
QL (28 EA per 28 days)
OCEAN NASAL NASAL AEROSOL,SPRAY 0.65 %
3
omeprazole oral tablet, delayed release (dr/ec) 20 mg
3
PAIN & FEVER ORAL TABLET 500 MG
3
QL (240 EA per 30 days)
PANDA MASK DEVICE
3
QL (1 EA per 365 days)
PEAK AIR PEAK FLOW METER DEVICE
3
QL (1 EA per 365 days)
QL (8 EA per 31 days)
QL (120 EA per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
15
Drug Name
Tier
Requirements / Limits
PEDIA-LAX STOOL SOFTENER ORAL SYRUP 50
MG/15 ML
3
PEDIALYTE ORAL SOLUTION
3
PEDIATRIC ELECTROLYTE ORAL SOLUTION
3
PEDIATRIC MEDIUM MASK DEVICE
3
PEPTO-BISMOL ORAL TABLET 262 MG
3
permethrin topical liquid 1 %
3
PINK BISMUTH ORAL SUSPENSION 262 MG/15 ML
3
polyvinyl alcohol ophthalmic drops 1.4 %
3
povidone-iodine topical solution 10 %
3
povidone-iodine topical swab 10 %
3
PRENATAL VITAMIN ORAL TABLET 27-0.8 MG
3
PRENATAL VITAMIN WITH MINERALS ORAL
TABLET 28-0.8 MG
3
PRILOSEC OTC ORAL TABLET,DELAYED RELEASE
(DR/EC) 20 MG
3
PROMETHAZINE VC-CODEINE ORAL SYRUP 6.25-510 MG/5 ML
3
promethazine-codeine oral syrup 6.25-10 mg/5 ml
3
promethazine-dm oral syrup 6.25-15 mg/5 ml
3
propylene glycol topical solution
3
pseudoephedrine hcl oral tablet 30 mg
3
QL (62 EA per 31 days)
pseudoephedrine hcl oral tablet 60 mg
3
QL (60 EA per 30 days)
PURE & GENTLE EYE OPHTHALMIC DROPS 0.3 %
3
pyridoxine oral tablet 100 mg
3
Q-PAP ORAL DROPS 80 MG/0.8 ML
3
Q-PAP ORAL LIQUID 160 MG/5 ML
3
Q-TAPP DM ORAL ELIXIR 1-15-5 MG/5 ML
3
Q-TAPP ORAL LIQUID 1-15 MG/5 ML
3
Q-TUSSIN DM ORAL SYRUP 10-100 MG/5 ML
3
ranitidine hcl oral tablet 75 mg
3
REESE'S PINWORM MEDICINE ORAL SUSPENSION
50 MG/ML
3
REFRESH TEARS OPHTHALMIC DROPS 0.5 %
3
RID COMPLETE LICE ELIM KIT TOPICAL KIT 40.33-0.5 %
3
ROBITUSSIN PEDIATRIC ORAL SYRUP 7.5 MG/5 ML
3
16
QL (1 EA per 365 days)
QL (480 ML per 30 days)
Drug Name
Tier
SALACTIC FILM TOPICAL LIQUID 17 %
3
SANI-SUPP (ADULT) RECTAL SUPPOSITORY
3
SANI-SUPP (CHILD) RECTAL SUPPOSITORY
3
SCALPICIN ANTI-ITCH TOPICAL SOLUTION 1 %
3
SCOT-TUSSIN SENIOR ORAL LIQUID 15-200 MG/5
ML
3
SELSUN BLUE WITH MENTHOL TOPICAL
SUSPENSION 1 %
3
SENNA LAX ORAL TABLET 8.6 MG
3
SENNA ORAL SYRUP 8.8 MG/5 ML
3
SENNA PLUS ORAL TABLET 8.6-50 MG
3
SILACE ORAL SYRUP 60 MG/15 ML
3
simethicone oral capsule 180 mg
3
sodium chloride ophthalmic drops 5 %
3
sodium chloride ophthalmic ointment 5 %
3
STOOL SOFTENER ORAL CAPSULE 100 MG
3
SUDOGEST COLD & ALLERGY ORAL TABLET 4-60
MG
3
SYSTANE NIGHTTIME OPHTHALMIC OINTMENT
94-3 %
3
TEARS NATURALE II OPHTHALMIC DROPS
3
terbinafine hcl topical cream 1 %
3
thiamine hcl oral tablet 250 mg
3
thiamine mononitrate oral tablet 100 mg
3
tolnaftate topical cream 1 %
3
tolnaftate topical solution 1 %
3
TRIPLE ANTIBIOTIC PLUS TOPICAL OINTMENT 3.5500-10,000 MG-UNIT-UNIT/G
3
TRIPLE ANTIBIOTIC TOPICAL OINTMENT 3.5MG400 UNIT- 5,000 UNIT/GRAM
3
TRI-VI-SOL WITH IRON ORAL DROPS 1,500 UNIT- 10
MG IRON/ML
3
TRI-VITAMIN ORAL DROPS 1,500-35-400 UNIT-MGUNIT/ML
3
TUSSIN CF ORAL LIQUID 5-10-100 MG/5 ML
3
UNISOM SLEEPGELS ORAL CAPSULE 50 MG
3
Requirements / Limits
QL (480 ML per 31 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
17
Drug Name
Tier
VAGINAL CONTRACEPTIVE FILM VAGINAL FILM
28 %
3
VITAMIN B-1 ORAL TABLET 100 MG, 50 MG
3
VITAMIN B-12 ORAL TABLET 1,000 MCG, 100 MCG,
500 MCG
3
VITAMIN B-6 ORAL TABLET 100 MG, 25 MG, 50 MG
3
VITAMIN D3 ORAL CAPSULE 400 UNIT
3
VITAMIN D3 ORAL TABLET 1,000 UNIT, 400 UNIT
3
ZADITOR OPHTHALMIC DROPS 0.025 %
3
zinc gluconate oral tablet 50 mg
3
zinc oxide topical ointment 20 %
3
zinc oxide topical paste 25 %
3
Requirements / Limits
Analgesics
Analgesics
acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml
1
acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg
1
QL (400 EA per 30 days)
acetaminophen-codeine oral tablet 300-60 mg
1
QL (200 EA per 30 days)
ascomp with codeine oral capsule 30-50-325-40 mg
1
QL (186 EA per 31 days)
butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg
1
QL (186 EA per 31 days)
butalbital-acetaminophen-caff oral capsule 50-325-40 mg
1
QL (186 EA per 31 days)
butalbital-acetaminophen-caff oral tablet 50-325-40 mg
1
QL (186 EA per 31 days)
butalbital-aspirin-caffeine oral capsule 50-325-40 mg
1
QL (186 EA per 31 days)
hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg,
7.5-325 mg
1
QL (360 EA per 30 days)
hydrocodone-ibuprofen oral tablet 7.5-200 mg
1
QL (150 EA per 30 days)
oxycodone-acetaminophen oral tablet 5-325 mg
1
QL (360 EA per 30 days)
tramadol-acetaminophen oral tablet 37.5-325 mg
1
QL (240 EA per 30 days)
celecoxib oral capsule 100 mg, 200 mg, 400 mg
1
QL (62 EA per 31 days)
diclofenac sodium oral tablet, delayed release (dr/ec) 25 mg,
75 mg
1
diclofenac sodium topical drops 1.5 %
1
ibuprofen oral tablet 800 mg
1
indomethacin oral capsule 25 mg
1
meloxicam oral tablet 15 mg, 7.5 mg
1
nabumetone oral tablet 500 mg, 750 mg
1
Nonsteroidal Anti-Inflammatory Drugs
18
Drug Name
Tier
naproxen oral tablet 375 mg, 500 mg
1
naproxen oral tablet, delayed release (dr/ec) 375 mg, 500 mg
1
Requirements / Limits
Opioid Analgesics, Long-Acting
duramorph (pf) injection solution 0.5 mg/ml, 1 mg/ml
1
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25
mcg/hr, 50 mcg/hr, 75 mcg/hr
1
morphine concentrate oral solution 100 mg/5 ml (20 mg/ml)
1
morphine oral capsule, extend. release pellets 100 mg, 20 mg,
30 mg, 50 mg, 60 mg, 80 mg
1
morphine oral solution 10 mg/5 ml, 20 mg/5 ml
1
morphine oral tablet 15 mg, 30 mg
1
QL (180 EA per 31 days)
morphine oral tablet extended release 100 mg
1
QL (62 EA per 31 days)
morphine oral tablet extended release 15 mg, 30 mg, 60 mg
1
QL (90 EA per 30 days)
morphine oral tablet extended release 200 mg
1
QL (60 EA per 30 days)
tramadol oral tablet extended release 24 hr 100 mg, 200 mg
1
QL (240 EA per 31 days)
QL (10 EA per 30 days)
QL (60 EA per 30 days)
Opioid Analgesics, Short-Acting
butorphanol tartrate nasal spray, non-aerosol 10 mg/ml
1
fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600
mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg
1
hydromorphone (pf) injection solution 10 mg/ml
1
hydromorphone oral tablet 2 mg, 4 mg
1
LAZANDA NASAL SPRAY,NON-AEROSOL 100
MCG/SPRAY, 400 MCG/SPRAY
2
PA
nalbuphine injection solution 10 mg/ml, 20 mg/ml
1
PA
oxycodone oral tablet 10 mg, 20 mg, 30 mg, 5 mg
1
QL (180 EA per 30 days)
oxycodone oral tablet 15 mg
1
QL (180 EA per 31 days)
tramadol oral tablet 50 mg
1
QL (240 EA per 30 days)
PA; QL (120 EA per 30 days)
Anesthetics
Local Anesthetics
lidocaine (pf) injection solution 5 mg/ml (0.5 %)
1
lidocaine hcl mucous membrane gel 2 %
1
lidocaine hcl mucous membrane solution 2 %, 4 % (40 mg/ml)
1
lidocaine topical adhesive patch, medicated 5 %(700
mg/patch)
1
lidocaine topical ointment 5 %
1
lidocaine-prilocaine topical cream 2.5-2.5 %
1
PA; QL (93 EA per 31 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
19
Drug Name
Tier
Requirements / Limits
Anti-Addiction/ Substance Abuse Treatment Agents
Alcohol Deterrents/ Anti-Craving
acamprosate oral tablet, delayed release (dr/ec) 333 mg
1
disulfiram oral tablet 250 mg, 500 mg
1
PA
Opioid Dependence Treatments
buprenorphine hcl injection syringe 0.3 mg/ml
1
buprenorphine hcl sublingual tablet 2 mg, 8 mg
1
buprenorphine-naloxone sublingual tablet 2-0.5 mg
1
QL (372 EA per 31 days)
buprenorphine-naloxone sublingual tablet 8-2 mg
1
QL (93 EA per 31 days)
naltrexone oral tablet 50 mg
1
Opioid Reversal Agents
naloxone injection syringe 1 mg/ml
1
Smoking Cessation Agents
CHANTIX CONTINUING MONTH BOX ORAL
TABLET 1 MG
2
PA; QL (336 EA per 168 days)
CHANTIX ORAL TABLET 0.5 MG, 1 MG
2
PA; QL (336 EA per 168 days)
NICOTROL INHALATION CARTRIDGE 10 MG
2
PA
NICOTROL NS NASAL SPRAY,NON-AEROSOL 10
MG/ML
2
PA
Antibacterials
Aminoglycosides
amikacin injection solution 500 mg/2 ml
1
gentak ophthalmic ointment 0.3 % (3 mg/gram)
1
gentamicin in nacl (iso-osm) intravenous piggyback 100
mg/100 ml, 70 mg/50 ml, 80 mg/50 ml, 90 mg/100 ml
1
gentamicin injection solution 40 mg/ml
1
gentamicin ophthalmic drops 0.3 %
1
gentamicin sulfate (pf) intravenous solution 80 mg/8 ml
1
gentamicin topical cream 0.1 %
1
gentamicin topical ointment 0.1 %
1
neomycin oral tablet 500 mg
1
neomycin-polymyxin b gu irrigation solution 40 mg-200,000
unit/ml
1
paromomycin oral capsule 250 mg
1
streptomycin intramuscular recon soln 1 gram
1
TOBI PODHALER INHALATION CAPSULE,
W/INHALATION DEVICE 28 MG
2
20
PA; QL (224 EA per 28 days)
Drug Name
Tier
TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %
2
tobramycin in 0.225 % nacl inhalation solution for
nebulization 300 mg/5 ml
1
tobramycin ophthalmic drops 0.3 %
1
tobramycin sulfate injection solution 10 mg/ml
1
TOBREX OPHTHALMIC OINTMENT 0.3 %
2
ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM
2
Requirements / Limits
PA; QL (10 ML per 1 day)
PA
Antibacterials
colistin (colistimethate na) injection recon soln 150 mg
1
SYNERCID INTRAVENOUS RECON SOLN 500 MG
2
Antibacterials, Other
acetic acid otic solution 2 %
1
alcohol pads topical pads, medicated
1
bacitracin ophthalmic ointment 500 unit/gram
1
chloramphenicol sod succinate intravenous recon soln 1 gram
1
clindamycin hcl oral capsule 150 mg, 300 mg
1
clindamycin in 5 % dextrose intravenous piggyback 300 mg/50
ml, 600 mg/50 ml, 900 mg/50 ml
1
clindamycin phosphate intravenous solution 600 mg/4 ml
1
clindamycin phosphate topical foam 1 %
1
clindamycin phosphate topical gel 1 %
1
clindamycin phosphate topical lotion 1 %
1
clindamycin phosphate topical solution 1 %
1
clindamycin phosphate topical swab 1 %
1
clindamycin phosphate vaginal cream 2 %
1
CUBICIN INTRAVENOUS RECON SOLN 500 MG
2
LINCOCIN INJECTION SOLUTION 300 MG/ML
2
linezolid intravenous parenteral solution 600 mg/300 ml
1
MACRODANTIN ORAL CAPSULE 25 MG
2
metronidazole in nacl (iso-os) intravenous piggyback 500
mg/100 ml
1
metronidazole oral tablet 250 mg, 500 mg
1
metronidazole topical cream 0.75 %
1
metronidazole topical gel 0.75 %
1
metronidazole topical lotion 0.75 %
1
PA
PA
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
21
Drug Name
Tier
Requirements / Limits
metronidazole vaginal gel 0.75 %
1
mupirocin calcium topical cream 2 %
1
mupirocin topical ointment 2 %
1
nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg
1
nitrofurantoin monohyd/m-cryst oral capsule 100 mg
1
nitrofurantoin oral suspension 25 mg/5 ml
1
PRIMSOL ORAL SOLUTION 50 MG/5 ML
2
trimethoprim oral tablet 100 mg
1
TYGACIL INTRAVENOUS RECON SOLN 50 MG
2
PA
vancomycin intravenous recon soln 1,000 mg, 10 gram, 500
mg
1
B vs D
vancomycin oral capsule 125 mg
1
PA; QL (56 EA per 14 days)
vancomycin oral capsule 250 mg
1
PA; QL (40 EA per 10 days)
ZYVOX ORAL SUSPENSION FOR RECONSTITUTION
100 MG/5 ML
2
PA; QL (1680 ML per 28 days)
ZYVOX ORAL TABLET 600 MG
2
PA; QL (28 EA per 14 days)
Beta-Lactam, Cephalosporins
cefaclor oral capsule 250 mg, 500 mg
1
cefaclor oral tablet extended release 12 hr 500 mg
1
cefadroxil oral capsule 500 mg
1
cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500
mg/5 ml
1
cefadroxil oral tablet 1 gram
1
cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50
ml
1
cefazolin injection recon soln 1 gram, 10 gram, 500 mg
1
cefdinir oral capsule 300 mg
1
cefdinir oral suspension for reconstitution 125 mg/5 ml, 250
mg/5 ml
1
cefepime injection recon soln 1 gram, 2 gram
1
cefotaxime injection recon soln 1 gram, 500 mg
1
cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram
1
cefpodoxime oral suspension for reconstitution 100 mg/5 ml,
50 mg/5 ml
1
cefpodoxime oral tablet 100 mg, 200 mg
1
cefprozil oral suspension for reconstitution 125 mg/5 ml, 250
mg/5 ml
1
22
Drug Name
Tier
cefprozil oral tablet 250 mg, 500 mg
1
ceftazidime injection recon soln 1 gram, 2 gram, 6 gram
1
ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg
1
ceftriaxone intravenous recon soln 1 gram, 2 gram
1
cefuroxime axetil oral tablet 250 mg, 500 mg
1
cefuroxime sodium injection recon soln 1.5 gram, 750 mg
1
cefuroxime sodium intravenous recon soln 7.5 gram
1
cephalexin oral capsule 250 mg, 500 mg
1
cephalexin oral suspension for reconstitution 125 mg/5 ml, 250
mg/5 ml
1
cephalexin oral tablet 250 mg, 500 mg
1
SUPRAX ORAL CAPSULE 400 MG
2
SUPRAX ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML, 200 MG/5 ML, 500
MG/5 ML
2
SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG
2
TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600
MG
2
Requirements / Limits
Beta-Lactam, Other
aztreonam injection recon soln 1 gram
1
imipenem-cilastatin intravenous recon soln 250 mg, 500 mg
1
INVANZ INJECTION RECON SOLN 1 GRAM
2
meropenem intravenous recon soln 500 mg
1
PA
Beta-Lactam, Penicillins
amoxicillin oral capsule 250 mg, 500 mg
1
amoxicillin oral suspension for reconstitution 125 mg/5 ml,
200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml
1
amoxicillin oral tablet 500 mg, 875 mg
1
amoxicillin oral tablet, chewable 125 mg, 250 mg
1
amoxicillin-pot clavulanate oral suspension for reconstitution
200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 60042.9 mg/5 ml
1
amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125
mg, 875-125 mg
1
amoxicillin-pot clavulanate oral tablet extended release 12 hr
1,000-62.5 mg
1
amoxicillin-pot clavulanate oral tablet, chewable 200-28.5 mg,
400-57 mg
1
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
23
Drug Name
Tier
ampicillin oral capsule 250 mg, 500 mg
1
ampicillin oral suspension for reconstitution 125 mg/5 ml, 250
mg/5 ml
1
ampicillin sodium injection recon soln 1 gram, 10 gram, 125
mg
1
ampicillin-sulbactam injection recon soln 15 gram, 3 gram
1
BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000
UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2
ML(900K/300K)
2
BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000
UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML
2
dicloxacillin oral capsule 250 mg, 500 mg
1
nafcillin injection recon soln 10 gram
1
oxacillin injection recon soln 10 gram
1
oxacillin intravenous recon soln 2 gram
1
penicillin g potassium injection recon soln 5 million unit
1
penicillin g procaine intramuscular syringe 1.2 million unit/2
ml
1
penicillin g sodium injection recon soln 5 million unit
1
penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5
ml
1
penicillin v potassium oral tablet 250 mg, 500 mg
1
piperacillin-tazobactam intravenous recon soln 3.375 gram,
4.5 gram
1
Macrolides
azithromycin intravenous recon soln 500 mg
1
azithromycin oral suspension for reconstitution 100 mg/5 ml,
200 mg/5 ml
1
azithromycin oral tablet 250 mg, 500 mg, 600 mg
1
clarithromycin oral suspension for reconstitution 125 mg/5 ml,
250 mg/5 ml
1
clarithromycin oral tablet 250 mg, 500 mg
1
clarithromycin oral tablet extended release 24 hr 500 mg
1
ery pads topical swab 2 %
1
ERY-TAB ORAL TABLET,DELAYED RELEASE
(DR/EC) 250 MG, 333 MG, 500 MG
2
erythrocin (as stearate) oral tablet 250 mg
1
erythrocin intravenous recon soln 500 mg
1
24
Requirements / Limits
Drug Name
Tier
erythromycin ophthalmic ointment 5 mg/gram (0.5 %)
1
erythromycin oral tablet 250 mg, 500 mg
1
erythromycin with ethanol topical gel 2 %
1
erythromycin with ethanol topical solution 2 %
1
Requirements / Limits
Quinolones
ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000
mg, 500 mg
1
ciprofloxacin hcl ophthalmic drops 0.3 %
1
ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg
1
ciprofloxacin in 5 % dextrose intravenous piggyback 200
mg/100 ml
1
ciprofloxacin lactate intravenous solution 400 mg/40 ml
1
levofloxacin intravenous solution 25 mg/ml
1
levofloxacin ophthalmic drops 0.5 %
1
levofloxacin oral solution 250 mg/10 ml
1
levofloxacin oral tablet 250 mg, 500 mg, 750 mg
1
ofloxacin ophthalmic drops 0.3 %
1
ofloxacin oral tablet 300 mg, 400 mg
1
ofloxacin otic drops 0.3 %
1
VIGAMOX OPHTHALMIC DROPS 0.5 %
2
QL (14 EA per 23 days)
Sulfonamides
silver sulfadiazine topical cream 1 %
1
ssd topical cream 1 %
1
sulfacetamide sodium (acne) topical suspension 10 %
1
sulfacetamide sodium ophthalmic drops 10 %
1
sulfadiazine oral tablet 500 mg
1
sulfamethoxazole-trimethoprim intravenous solution 400-80
mg/5 ml
1
sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5
ml
1
sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160
mg
1
Tetracyclines
demeclocycline oral tablet 150 mg, 300 mg
1
doxycycline hyclate intravenous recon soln 100 mg
1
doxycycline hyclate oral capsule 100 mg, 50 mg
1
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
25
Drug Name
Tier
doxycycline hyclate oral tablet 100 mg, 20 mg
1
doxycycline monohydrate oral suspension for reconstitution 25
mg/5 ml
1
doxycycline monohydrate oral tablet 150 mg, 50 mg, 75 mg
1
minocycline oral capsule 100 mg, 50 mg, 75 mg
1
minocycline oral tablet 100 mg, 50 mg, 75 mg
1
VIBRAMYCIN ORAL SYRUP 50 MG/5 ML
2
Requirements / Limits
Anticonvulsants
Anticonvulsants, Other
DIAZEPAM RECTAL KIT 12.5-15-17.5-20 MG, 2.5 MG,
5-7.5-10 MG
2
levetiracetam intravenous solution 500 mg/5 ml
1
levetiracetam oral solution 100 mg/ml
1
levetiracetam oral tablet 1,000 mg, 250 mg
1
QL (62 EA per 31 days)
levetiracetam oral tablet 500 mg, 750 mg
1
QL (124 EA per 31 days)
levetiracetam oral tablet extended release 24 hr 500 mg, 750
mg
1
QL (124 EA per 31 days)
POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50
MG
2
PA; QL (93 EA per 31 days)
Calcium Channel Modifying Agents
CELONTIN ORAL CAPSULE 300 MG
2
ethosuximide oral capsule 250 mg
1
ethosuximide oral solution 250 mg/5 ml
1
LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG,
225 MG, 25 MG, 300 MG, 50 MG, 75 MG
2
LYRICA ORAL SOLUTION 20 MG/ML
2
zonisamide oral capsule 100 mg, 25 mg, 50 mg
1
Gamma-Aminobutyric Acid (GABA) Augmenting Agents
clonazepam oral tablet 0.5 mg, 1 mg, 2 mg
1
clonazepam oral tablet, disintegrating 0.125 mg, 0.25 mg, 0.5
mg, 1 mg, 2 mg
1
clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg
1
diazepam intensol oral concentrate 5 mg/ml
1
diazepam oral solution 5 mg/5 ml
1
diazepam oral tablet 10 mg, 2 mg, 5 mg
1
divalproex oral capsule, sprinkle 125 mg
1
divalproex oral tablet extended release 24 hr 250 mg, 500 mg
1
26
QL (124 EA per 31 days)
Drug Name
Tier
Requirements / Limits
divalproex oral tablet, delayed release (dr/ec) 125 mg, 250 mg,
500 mg
1
gabapentin oral capsule 100 mg, 300 mg, 400 mg
1
gabapentin oral solution 250 mg/5 ml
1
gabapentin oral tablet 600 mg, 800 mg
1
GABITRIL ORAL TABLET 12 MG, 16 MG
2
QL (93 EA per 31 days)
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg
1
QL (93 EA per 31 days)
ONFI ORAL SUSPENSION 2.5 MG/ML
2
PA
ONFI ORAL TABLET 10 MG, 20 MG
2
PA; QL (62 EA per 31 days)
phenobarbital oral elixir 20 mg/5 ml
1
phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4
mg, 60 mg, 64.8 mg, 97.2 mg
1
primidone oral tablet 250 mg, 50 mg
1
SABRIL ORAL POWDER IN PACKET 500 MG
2
PA
SABRIL ORAL TABLET 500 MG
2
PA
tiagabine oral tablet 2 mg, 4 mg
1
valproate sodium intravenous solution 500 mg/5 ml (100
mg/ml)
1
valproic acid (as sodium salt) oral solution 250 mg/5 ml
1
valproic acid oral capsule 250 mg
1
Glutamate Reducing Agents
felbamate oral suspension 600 mg/5 ml
1
felbamate oral tablet 400 mg, 600 mg
1
FYCOMPA ORAL TABLET 10 MG, 12 MG, 4 MG, 8 MG
2
PA; QL (31 EA per 31 days)
FYCOMPA ORAL TABLET 2 MG, 6 MG
2
PA; QL (62 EA per 31 days)
lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg
1
lamotrigine oral tablet extended release 24hr 100 mg, 200 mg,
25 mg, 250 mg, 300 mg, 50 mg
1
lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg
1
topiramate oral capsule, sprinkle 15 mg, 25 mg
1
topiramate oral tablet 100 mg, 200 mg, 50 mg
1
topiramate oral tablet 25 mg
1
QL (62 EA per 31 days)
Sodium Channel Agents
APTIOM ORAL TABLET 200 MG
2
PA; QL (186 EA per 31 days)
APTIOM ORAL TABLET 400 MG
2
PA; QL (93 EA per 31 days)
APTIOM ORAL TABLET 600 MG
2
PA; QL (62 EA per 31 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
27
Drug Name
Tier
Requirements / Limits
APTIOM ORAL TABLET 800 MG
2
PA; QL (47 EA per 31 days)
BANZEL ORAL SUSPENSION 40 MG/ML
2
BANZEL ORAL TABLET 200 MG, 400 MG
2
carbamazepine oral suspension 100 mg/5 ml
1
carbamazepine oral tablet 200 mg
1
carbamazepine oral tablet extended release 12 hr 200 mg, 400
mg
1
carbamazepine oral tablet, chewable 100 mg
1
DILANTIN EXTENDED ORAL CAPSULE 100 MG
2
DILANTIN INFATABS ORAL TABLET,CHEWABLE 50
MG
2
DILANTIN ORAL CAPSULE 30 MG
2
DILANTIN-125 ORAL SUSPENSION 125 MG/5 ML
2
fosphenytoin injection solution 100 mg pe/2 ml
1
oxcarbazepine oral suspension 300 mg/5 ml
1
oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg
1
PEGANONE ORAL TABLET 250 MG
2
PHENYTEK ORAL CAPSULE 200 MG, 300 MG
2
phenytoin oral suspension 125 mg/5 ml
1
phenytoin oral tablet, chewable 50 mg
1
phenytoin sodium extended oral capsule 100 mg, 200 mg, 300
mg
1
phenytoin sodium intravenous solution 50 mg/ml
1
trileptal oral suspension 300 mg/5 ml
1
VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML
2
QL (1200 ML per 30 days)
VIMPAT ORAL SOLUTION 10 MG/ML
2
QL (1200 ML per 30 days)
VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50
MG
2
QL (62 EA per 31 days)
QL (248 EA per 31 days)
Antidementia Agents
Antidementia Agents, Other
ergoloid oral tablet 1 mg
1
Cholinesterase Inhibitors
donepezil oral tablet 10 mg, 5 mg
1
QL (31 EA per 31 days)
donepezil oral tablet, disintegrating 10 mg, 5 mg
1
QL (31 EA per 31 days)
galantamine oral capsule, ext rel. pellets 24 hr 16 mg, 8 mg
1
QL (31 EA per 31 days)
galantamine oral capsule, ext rel. pellets 24 hr 24 mg
1
QL (62 EA per 31 days)
28
Drug Name
Tier
Requirements / Limits
galantamine oral solution 4 mg/ml
1
galantamine oral tablet 12 mg, 4 mg, 8 mg
1
QL (62 EA per 31 days)
rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg
1
QL (62 EA per 31 days)
NAMENDA ORAL SOLUTION 10 MG/5 ML
2
QL (310 ML per 31 days)
NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE
PACK 7-14-21-28 MG
2
QL (28 EA per 28 days)
NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR
14 MG, 21 MG, 28 MG, 7 MG
2
QL (31 EA per 31 days)
fluoxetine oral tablet 60 mg
1
QL (31 EA per 31 days)
olanzapine-fluoxetine oral capsule 12-25 mg, 12-50 mg, 3-25
mg, 6-25 mg, 6-50 mg
1
QL (31 EA per 31 days)
ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION,EXTENDED REL SYRING 300 MG, 400
MG
2
PA; QL (1 EA per 28 days)
buproban oral tablet extended release 150 mg
1
QL (62 EA per 31 days)
bupropion hcl oral tablet 100 mg
1
QL (124 EA per 31 days)
bupropion hcl oral tablet 75 mg
1
QL (93 EA per 31 days)
bupropion hcl oral tablet extended release 100 mg, 150 mg,
200 mg
1
QL (62 EA per 31 days)
bupropion hcl oral tablet extended release 24 hr 150 mg, 300
mg
1
QL (31 EA per 31 days)
maprotiline oral tablet 25 mg, 50 mg, 75 mg
1
mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg
1
QL (31 EA per 31 days)
mirtazapine oral tablet, disintegrating 15 mg, 30 mg, 45 mg
1
QL (31 EA per 31 days)
nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50
mg
1
QL (62 EA per 31 days)
trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg
1
N-Methyl-D-Aspartate (NMDA) Receptor Antagonist
Antidepressants
Antidepressants
Antidepressants, Other
Monoamine Oxidase Inhibitors
EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24
HR, 6 MG/24 HR, 9 MG/24 HR
2
MARPLAN ORAL TABLET 10 MG
2
phenelzine oral tablet 15 mg
1
tranylcypromine oral tablet 10 mg
1
PA
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
29
Drug Name
Tier
Requirements / Limits
SSRIs/ SNRIs
BRINTELLIX ORAL TABLET 10 MG
2
PA; QL (62 EA per 31 days)
BRINTELLIX ORAL TABLET 20 MG
2
PA; QL (31 EA per 31 days)
BRINTELLIX ORAL TABLET 5 MG
2
PA; QL (124 EA per 31 days)
citalopram oral solution 10 mg/5 ml
1
QL (600 ML per 30 days)
citalopram oral tablet 10 mg, 20 mg, 40 mg
1
QL (31 EA per 31 days)
desvenlafaxine oral tablet extended release 24 hr 100 mg, 50
mg
1
QL (124 EA per 31 days)
duloxetine oral capsule, delayed release(dr/ec) 20 mg, 30 mg,
60 mg
1
QL (62 EA per 31 days)
escitalopram oxalate oral solution 5 mg/5 ml
1
QL (620 ML per 31 days)
escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg
1
QL (31 EA per 31 days)
FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE
PACK 20 MG (2)- 40 MG (26)
2
PA; QL (28 EA per 28 days)
FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24
HR 120 MG, 20 MG, 40 MG, 80 MG
2
PA; QL (31 EA per 31 days)
fluoxetine oral capsule 10 mg, 40 mg
1
QL (31 EA per 31 days)
fluoxetine oral capsule 20 mg
1
QL (124 EA per 31 days)
fluoxetine oral capsule, delayed release(dr/ec) 90 mg
1
QL (31 EA per 31 days)
fluoxetine oral solution 20 mg/5 ml
1
QL (600 ML per 30 days)
fluoxetine oral tablet 10 mg
1
QL (31 EA per 31 days)
fluoxetine oral tablet 20 mg
1
QL (124 EA per 31 days)
fluvoxamine oral tablet 100 mg, 25 mg, 50 mg
1
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg
1
QL (62 EA per 31 days)
paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 37.5
mg
1
QL (62 EA per 31 days)
paroxetine hcl oral tablet extended release 24 hr 25 mg
1
QL (93 EA per 31 days)
PAXIL ORAL SUSPENSION 10 MG/5 ML
2
sertraline oral concentrate 20 mg/ml
1
QL (310 ML per 31 days)
sertraline oral tablet 100 mg
1
QL (62 EA per 31 days)
sertraline oral tablet 25 mg, 50 mg
1
QL (31 EA per 31 days)
venlafaxine oral capsule, extended release 24hr 150 mg, 37.5
mg, 75 mg
1
venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg
1
venlafaxine oral tablet extended release 24hr 150 mg, 225 mg,
37.5 mg, 75 mg
1
VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG
2
30
PA; QL (31 EA per 31 days)
Drug Name
Tier
Requirements / Limits
Tricyclics
amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50
mg, 75 mg
1
amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg
1
clomipramine oral capsule 25 mg, 50 mg, 75 mg
1
desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg,
75 mg
1
doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg,
75 mg
1
doxepin oral concentrate 10 mg/ml
1
imipramine hcl oral tablet 10 mg, 25 mg, 50 mg
1
imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75
mg
1
nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg
1
nortriptyline oral solution 10 mg/5 ml
1
protriptyline oral tablet 10 mg, 5 mg
1
SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG
2
Antiemetics
Antiemetics, Other
chlorpromazine injection solution 25 mg/ml
1
chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 50 mg
1
chlorpromazine oral tablet 25 mg
1
compro rectal suppository 25 mg
1
diphenhydramine hcl injection solution 50 mg/ml
1
hydroxyzine hcl oral solution 10 mg/5 ml
1
hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg
1
hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg
1
meclizine oral tablet 12.5 mg, 25 mg
1
perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg
1
prochlorperazine edisylate injection solution 10 mg/2 ml (5
mg/ml)
1
prochlorperazine maleate oral tablet 10 mg, 5 mg
1
prochlorperazine rectal suppository 25 mg
1
promethazine injection solution 25 mg/ml, 50 mg/ml
1
promethazine oral syrup 6.25 mg/5 ml
1
promethazine oral tablet 12.5 mg, 25 mg, 50 mg
1
B vs D
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
31
Drug Name
Tier
promethazine rectal suppository 12.5 mg, 25 mg
1
promethegan rectal suppository 25 mg, 50 mg
1
Requirements / Limits
Emetogenic Therapy Adjuncts
dronabinol oral capsule 10 mg, 2.5 mg, 5 mg
1
PA
EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG
2
B vs D
EMEND ORAL CAPSULE,DOSE PACK 125 MG (1)- 80
MG (2)
2
B vs D
granisetron (pf) intravenous solution 100 mcg/ml
1
B vs D
granisetron hcl intravenous solution 1 mg/ml (1 ml)
1
B vs D
granisetron hcl oral tablet 1 mg
1
B vs D
ondansetron hcl (pf) injection solution 4 mg/2 ml
1
ondansetron hcl oral solution 4 mg/5 ml
1
B vs D
ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg
1
B vs D
ondansetron oral tablet, disintegrating 4 mg, 8 mg
1
B vs D
ABELCET INTRAVENOUS SUSPENSION 5 MG/ML
2
PA
AMBISOME INTRAVENOUS SUSPENSION FOR
RECONSTITUTION 50 MG
2
amphotericin b injection recon soln 50 mg
1
PA
CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70
MG
2
PA
ciclopirox topical cream 0.77 %
1
ciclopirox topical gel 0.77 %
1
ciclopirox topical shampoo 1 %
1
ciclopirox topical suspension 0.77 %
1
clotrimazole mucous membrane troche 10 mg
1
clotrimazole topical cream 1 %
1
clotrimazole topical solution 1 %
1
econazole topical cream 1 %
1
fluconazole in dextrose(iso-o) intravenous piggyback 400
mg/200 ml
1
fluconazole oral suspension for reconstitution 10 mg/ml, 40
mg/ml
1
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg
1
flucytosine oral capsule 250 mg, 500 mg
1
griseofulvin microsize oral suspension 125 mg/5 ml
1
Antifungals
Antifungals
32
Drug Name
Tier
Requirements / Limits
itraconazole oral capsule 100 mg
1
QL (124 EA per 31 days)
ketoconazole oral tablet 200 mg
1
ketoconazole topical cream 2 %
1
ketoconazole topical shampoo 2 %
1
miconazole-3 vaginal suppository 200 mg
1
MYCAMINE INTRAVENOUS RECON SOLN 100 MG,
50 MG
2
NATACYN OPHTHALMIC DROPS,SUSPENSION 5 %
2
NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40
MG/ML)
2
nystatin oral suspension 100,000 unit/ml
1
nystatin oral tablet 500,000 unit
1
nystatin topical cream 100,000 unit/gram
1
nystatin topical ointment 100,000 unit/gram
1
nystatin topical powder 100,000 unit/gram
1
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR
8.8MCG/0.2ML-22 MCG/0.5ML (6)
2
PA
SPORANOX ORAL SOLUTION 10 MG/ML
2
PA
terbinafine hcl oral tablet 250 mg
1
terconazole vaginal cream 0.4 %, 0.8 %
1
terconazole vaginal suppository 80 mg
1
voriconazole intravenous solution 200 mg
1
PA
voriconazole oral tablet 200 mg, 50 mg
1
QL (62 EA per 31 days)
ZOLINZA ORAL CAPSULE 100 MG
2
PA; QL (124 EA per 31 days)
PA
PA
Antigout Agents
Antigout Agents
allopurinol oral tablet 100 mg, 300 mg
1
colchicine oral capsule 0.6 mg
1
colchicine oral tablet 0.6 mg
1
colchicine-probenecid oral tablet 0.5-500 mg
1
COLCRYS ORAL TABLET 0.6 MG
2
probenecid oral tablet 500 mg
1
QL (124 EA per 31 days)
Anti-Inflammatory Agents
Nonsteroidal Anti-Inflammatory Drugs
diclofenac potassium oral tablet 50 mg
1
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
33
Drug Name
Tier
diclofenac sodium oral tablet extended release 24 hr 100 mg
1
diclofenac sodium oral tablet, delayed release (dr/ec) 50 mg
1
flurbiprofen oral tablet 100 mg, 50 mg
1
ibuprofen oral suspension 100 mg/5 ml
1
ibuprofen oral tablet 400 mg, 600 mg
1
indomethacin oral capsule 50 mg
1
indomethacin oral capsule, extended release 75 mg
1
naproxen oral suspension 125 mg/5 ml
1
naproxen oral tablet 250 mg
1
sulindac oral tablet 150 mg, 200 mg
1
Requirements / Limits
Antimigraine Agents
Ergot Alkaloids
dihydroergotamine injection solution 1 mg/ml
1
ERGOMAR SUBLINGUAL TABLET 2 MG
2
QL (20 EA per 31 days)
MIGERGOT RECTAL SUPPOSITORY 2-100 MG
2
QL (20 EA per 31 days)
naratriptan oral tablet 1 mg, 2.5 mg
1
QL (9 EA per 31 days)
rizatriptan oral tablet 10 mg, 5 mg
1
QL (18 EA per 30 days)
rizatriptan oral tablet, disintegrating 10 mg, 5 mg
1
QL (18 EA per 30 days)
sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg
1
QL (18 EA per 30 days)
sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml
1
QL (4 ML per 28 days)
sumatriptan succinate subcutaneous solution 6 mg/0.5 ml
1
QL (4 ML per 28 days)
Serotonin (5-HT) 1B/1D Receptor Agonists
Antimyasthenic Agents
Parasympathomimetics
guanidine oral tablet 125 mg
1
pyridostigmine bromide oral tablet 60 mg
1
Antimycobacterials
Antimycobacterials, Other
dapsone oral tablet 100 mg, 25 mg
1
PRIFTIN ORAL TABLET 150 MG
2
rifabutin oral capsule 150 mg
1
Antituberculars
CAPASTAT INJECTION RECON SOLN 1 GRAM
2
ethambutol oral tablet 100 mg, 400 mg
1
isoniazid injection solution 100 mg/ml
1
34
PA
Drug Name
Tier
isoniazid oral solution 50 mg/5 ml
1
isoniazid oral tablet 100 mg, 300 mg
1
PASER ORAL GRANULES DR FOR SUSP IN PACKET
4 GRAM
2
pyrazinamide oral tablet 500 mg
1
RIFAMATE ORAL CAPSULE 300-150 MG
2
rifampin intravenous recon soln 600 mg
1
rifampin oral capsule 150 mg, 300 mg
1
RIFATER ORAL TABLET 50-120-300 MG
2
TRECATOR ORAL TABLET 250 MG
2
Requirements / Limits
Antineoplastics
Alkylating Agents
BUSULFEX INTRAVENOUS SOLUTION 60 MG/10 ML
2
B vs D
cyclophosphamide oral capsule 25 mg, 50 mg
1
B vs D
HEXALEN ORAL CAPSULE 50 MG
2
PA
LEUKERAN ORAL TABLET 2 MG
2
LOMUSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG
2
MATULANE ORAL CAPSULE 50 MG
2
melphalan hcl intravenous recon soln 50 mg
1
B vs D
Antiandrogens
bicalutamide oral tablet 50 mg
1
flutamide oral capsule 125 mg
1
NILANDRON ORAL TABLET 150 MG
2
XTANDI ORAL CAPSULE 40 MG
2
PA
ZYTIGA ORAL TABLET 250 MG
2
PA; QL (124 EA per 31 days)
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG
2
PA; QL (31 EA per 31 days)
REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5
MG
2
PA
THALOMID ORAL CAPSULE 100 MG, 150 MG, 200
MG, 50 MG
2
PA
EMCYT ORAL CAPSULE 140 MG
2
PA
FARESTON ORAL TABLET 60 MG
2
SOLTAMOX ORAL SOLUTION 10 MG/5 ML
2
Antiangiogenic Agents
Antiestrogens/Modifiers
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
35
Drug Name
tamoxifen oral tablet 10 mg, 20 mg
Tier
Requirements / Limits
1
Antimetabolites
gemcitabine intravenous recon soln 1 gram
1
hydroxyurea oral capsule 500 mg
1
PURIXAN ORAL SUSPENSION 20 MG/ML
2
TABLOID ORAL TABLET 40 MG
2
B vs D
PA
Antineoplastics
ALIMTA INTRAVENOUS RECON SOLN 500 MG
2
B vs D
ARRANON INTRAVENOUS SOLUTION 250 MG/50 ML
2
PA
AVASTIN INTRAVENOUS SOLUTION 25 MG/ML
2
PA
azacitidine injection recon soln 100 mg
1
B vs D
BELEODAQ INTRAVENOUS RECON SOLN 500 MG
2
PA
BICNU INTRAVENOUS RECON SOLN 100 MG
2
B vs D
bleomycin injection recon soln 30 unit
1
PA
carboplatin intravenous solution 10 mg/ml
1
B vs D
cisplatin intravenous solution 1 mg/ml
1
B vs D
cladribine intravenous solution 10 mg/10 ml
1
B vs D
COSMEGEN INTRAVENOUS RECON SOLN 0.5 MG
2
PA
cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml)
1
B vs D
cytarabine injection solution 20 mg/ml
1
B vs D
dacarbazine intravenous recon soln 200 mg
1
B vs D
daunorubicin intravenous solution 5 mg/ml
1
B vs D
DAUNOXOME INTRAVENOUS SOLUTION 2 MG/ML
2
PA
decitabine intravenous recon soln 50 mg
1
B vs D
dexrazoxane hcl intravenous recon soln 250 mg
1
PA
DOCEFREZ INTRAVENOUS RECON SOLN 20 MG
2
DOCETAXEL INTRAVENOUS SOLUTION 80 MG/4 ML
(20 MG/ML)
2
docetaxel intravenous solution 80 mg/8 ml (10 mg/ml)
1
DOXIL INTRAVENOUS SUSPENSION 2 MG/ML
2
doxorubicin intravenous solution 50 mg/25 ml
1
B vs D
ELITEK INTRAVENOUS RECON SOLN 1.5 MG
2
B vs D
epirubicin intravenous solution 50 mg/25 ml
1
PA
ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML
2
PA
ERWINAZE INTRAMUSCULAR RECON SOLN 10,000
UNIT
2
PA
36
PA
Drug Name
Tier
Requirements / Limits
FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5
ML
2
PA
HALAVEN INTRAVENOUS SOLUTION 1 MG/2 ML (0.5
MG/ML)
2
B vs D
HERCEPTIN INTRAVENOUS RECON SOLN 440 MG
2
B vs D
idarubicin intravenous solution 1 mg/ml
1
B vs D
IFEX INTRAVENOUS RECON SOLN 1 GRAM
2
PA
ifosfamide intravenous recon soln 1 gram
1
PA
irinotecan intravenous solution 100 mg/5 ml
1
PA
ISTODAX INTRAVENOUS RECON SOLN 10 MG/2 ML
2
PA
IXEMPRA INTRAVENOUS RECON SOLN 45 MG
2
PA
JEVTANA INTRAVENOUS SOLUTION 10 MG/ML
(FIRST DILUTION)
2
B vs D
KADCYLA INTRAVENOUS RECON SOLN 100 MG
2
PA
LYNPARZA ORAL CAPSULE 50 MG
2
PA
mesna intravenous solution 100 mg/ml
1
B vs D
MESNEX ORAL TABLET 400 MG
2
mitomycin intravenous recon soln 20 mg
1
B vs D
MUSTARGEN INJECTION RECON SOLN 10 MG
2
PA
oxaliplatin intravenous solution 100 mg/20 ml
1
PA
paclitaxel intravenous concentrate 6 mg/ml
1
B vs D
PERJETA INTRAVENOUS SOLUTION 420 MG/14 ML
(30 MG/ML)
2
PA
PROLEUKIN INTRAVENOUS RECON SOLN 22
MILLION UNIT
2
TREANDA INTRAVENOUS RECON SOLN 100 MG
2
PA
TREANDA INTRAVENOUS SOLUTION 45 MG/0.5 ML
2
PA
TRISENOX INTRAVENOUS SOLUTION 10 MG/10 ML
2
B vs D
VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML
(20 MG/ML)
2
B vs D
VELCADE INJECTION RECON SOLN 3.5 MG
2
B vs D
vinblastine intravenous solution 1 mg/ml
1
B vs D
vincasar pfs intravenous solution 1 mg/ml
1
vincristine intravenous solution 1 mg/ml
1
B vs D
vinorelbine intravenous solution 50 mg/5 ml
1
B vs D
Antineoplastics, Other
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
37
Drug Name
Tier
Requirements / Limits
ABRAXANE INTRAVENOUS SUSPENSION FOR
RECONSTITUTION 100 MG
2
PA
amifostine crystalline intravenous recon soln 500 mg
1
fludarabine intravenous recon soln 50 mg
1
PA
leucovorin calcium injection recon soln 100 mg, 350 mg
1
B vs D
leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg
1
mitoxantrone intravenous concentrate 2 mg/ml
1
B vs D
ONCASPAR INJECTION SOLUTION 750 UNIT/ML
2
PA
REVLIMID ORAL CAPSULE 2.5 MG, 20 MG
2
PA
SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG
2
PA
YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5
MG/ML)
2
PA
ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML
(25 MG/ML)
2
PA
anastrozole oral tablet 1 mg
1
QL (31 EA per 31 days)
exemestane oral tablet 25 mg
1
letrozole oral tablet 2.5 mg
1
QL (31 EA per 31 days)
etoposide intravenous solution 20 mg/ml
1
B vs D
FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG
2
PA
IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG
2
PA
toposar intravenous solution 20 mg/ml
1
B vs D
topotecan intravenous recon soln 4 mg
1
ZYDELIG ORAL TABLET 100 MG, 150 MG
2
PA
AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5
MG
2
PA; QL (31 EA per 31 days)
BOSULIF ORAL TABLET 100 MG, 500 MG
2
PA
CAPRELSA ORAL TABLET 100 MG, 300 MG
2
PA
COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG[1]20 MG[1]), 140 MG/DAY(80 MG[1]-20 MG[3]), 60
MG/DAY (20 MG [3]/DAY)
2
PA
ERIVEDGE ORAL CAPSULE 150 MG
2
PA; QL (31 EA per 31 days)
GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG
2
PA; QL (31 EA per 31 days)
GLEEVEC ORAL TABLET 100 MG
2
PA; QL (93 EA per 31 days)
GLEEVEC ORAL TABLET 400 MG
2
PA; QL (62 EA per 31 days)
Aromatase Inhibitors, 3RD Generation
Enzyme Inhibitors
Molecular Target Inhibitors
38
Drug Name
Tier
Requirements / Limits
ICLUSIG ORAL TABLET 15 MG
2
PA; QL (93 EA per 31 days)
ICLUSIG ORAL TABLET 45 MG
2
PA; QL (31 EA per 31 days)
IMBRUVICA ORAL CAPSULE 140 MG
2
PA; QL (124 EA per 31 days)
INLYTA ORAL TABLET 1 MG, 5 MG
2
PA; QL (62 EA per 31 days)
JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG,
5 MG
2
PA; QL (62 EA per 31 days)
LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG
[1]/DAY), 14 MG (10 MG[1] -4 MG[1])/DAY, 20 MG/DAY
(10 MG [2]/DAY)
2
PA; QL (60 EA per 30 days)
LENVIMA ORAL CAPSULE 24 MG (10 MG[2] -4
MG[1])/DAY
2
PA; QL (90 EA per 30 days)
MEKINIST ORAL TABLET 0.5 MG, 2 MG
2
PA; QL (310 EA per 31 days)
NEXAVAR ORAL TABLET 200 MG
2
PA; QL (124 EA per 31 days)
SPRYCEL ORAL TABLET 100 MG, 140 MG
2
PA; QL (31 EA per 31 days)
SPRYCEL ORAL TABLET 20 MG, 50 MG, 70 MG, 80
MG
2
PA; QL (62 EA per 31 days)
STIVARGA ORAL TABLET 40 MG
2
PA
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50
MG
2
PA; QL (31 EA per 31 days)
TAFINLAR ORAL CAPSULE 50 MG, 75 MG
2
PA
TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG
2
PA; QL (31 EA per 31 days)
TASIGNA ORAL CAPSULE 150 MG, 200 MG
2
PA; QL (124 EA per 31 days)
TYKERB ORAL TABLET 250 MG
2
PA; QL (186 EA per 31 days)
VOTRIENT ORAL TABLET 200 MG
2
PA
XALKORI ORAL CAPSULE 200 MG, 250 MG
2
PA; QL (62 EA per 31 days)
ZELBORAF ORAL TABLET 240 MG
2
PA; QL (248 EA per 31 days)
ZYKADIA ORAL CAPSULE 150 MG
2
PA; QL (155 EA per 31 days)
ARZERRA INTRAVENOUS SOLUTION 100 MG/5 ML
2
PA
KEYTRUDA INTRAVENOUS RECON SOLN 50 MG
2
PA
OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML
2
PA
RITUXAN INTRAVENOUS CONCENTRATE 10
MG/ML
2
B vs D
SYLVANT INTRAVENOUS RECON SOLN 100 MG
2
PA
Monoclonal Antibodies
Retinoids
PANRETIN TOPICAL GEL 0.1 %
2
TARGRETIN ORAL CAPSULE 75 MG
2
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
39
Drug Name
Tier
tretinoin (chemotherapy) oral capsule 10 mg
1
tretinoin topical cream 0.025 %, 0.05 %, 0.1 %
1
tretinoin topical gel 0.01 %, 0.025 %
1
Requirements / Limits
Antiparasitics
Anthelmintics
ALBENZA ORAL TABLET 200 MG
2
BILTRICIDE ORAL TABLET 600 MG
2
Antiprotozoals
ALINIA ORAL SUSPENSION FOR RECONSTITUTION
100 MG/5 ML
2
ALINIA ORAL TABLET 500 MG
2
atovaquone oral suspension 750 mg/5 ml
1
atovaquone-proguanil oral tablet 250-100 mg
1
chloroquine phosphate oral tablet 250 mg, 500 mg
1
COARTEM ORAL TABLET 20-120 MG
2
DARAPRIM ORAL TABLET 25 MG
2
hydroxychloroquine oral tablet 200 mg
1
mefloquine oral tablet 250 mg
1
NEBUPENT INHALATION RECON SOLN 300 MG
2
PENTAM INJECTION RECON SOLN 300 MG
2
primaquine oral tablet 26.3 mg
1
quinine sulfate oral capsule 324 mg
1
PA
B vs D
PA
Pediculicides/ Scabicides
malathion topical lotion 0.5 %
1
permethrin topical cream 5 %
1
Antiparkinson Agents
Anticholinergics
benztropine injection solution 2 mg/2 ml
1
benztropine oral tablet 0.5 mg, 1 mg, 2 mg
1
trihexyphenidyl oral elixir 0.4 mg/ml
1
trihexyphenidyl oral tablet 2 mg, 5 mg
1
Antiparkinson Agents, Other
entacapone oral tablet 200 mg
1
TASMAR ORAL TABLET 100 MG
2
PA
tolcapone oral tablet 100 mg
1
PA
40
Drug Name
Tier
Requirements / Limits
Dopamine Agonists
APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML
2
bromocriptine oral capsule 5 mg
1
bromocriptine oral tablet 2.5 mg
1
NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24
HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24
HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR
2
pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1
mg, 1.5 mg
1
ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg,
5 mg
1
PA
PA; QL (31 EA per 31 days)
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors
carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250
mg
1
carbidopa-levodopa oral tablet extended release 25-100 mg,
50-200 mg
1
carbidopa-levodopa oral tablet, disintegrating 10-100 mg, 25100 mg, 25-250 mg
1
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT ORAL TABLET 0.5 MG, 1 MG
2
selegiline hcl oral capsule 5 mg
1
selegiline hcl oral tablet 5 mg
1
ZELAPAR ORAL TABLET,DISINTEGRATING 1.25 MG
2
QL (31 EA per 31 days)
Antipsychotics
1ST Generation/ Typical
fluphenazine decanoate injection solution 25 mg/ml
1
fluphenazine hcl injection solution 2.5 mg/ml
1
fluphenazine hcl oral concentrate 5 mg/ml
1
fluphenazine hcl oral elixir 2.5 mg/5 ml
1
fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg
1
haloperidol decanoate intramuscular solution 100 mg/ml, 50
mg/ml
1
haloperidol lactate injection solution 5 mg/ml
1
haloperidol lactate oral concentrate 2 mg/ml
1
haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5
mg
1
loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg
1
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
41
Drug Name
Tier
ORAP ORAL TABLET 1 MG, 2 MG
2
thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg
1
thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg
1
trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg
1
Requirements / Limits
2ND Generation/ Atypical
ABILIFY DISCMELT ORAL
TABLET,DISINTEGRATING 10 MG, 15 MG
2
PA; QL (62 EA per 31 days)
ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION,EXTENDED REL RECON 300 MG
2
PA; QL (900 EA per 31 days)
ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG,
30 MG, 5 MG
2
PA; QL (31 EA per 31 days)
aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5
mg
1
PA; QL (31 EA per 31 days)
FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4
MG, 6 MG, 8 MG
2
PA; QL (62 EA per 31 days)
FANAPT ORAL TABLETS,DOSE PACK 1MG(2)2MG(2)- 4MG(2)-6MG(2)
2
PA; QL (8 EA per 4 days)
GEODON INTRAMUSCULAR RECON SOLN 20
MG/ML (FINAL CONC.)
2
PA
INVEGA ORAL TABLET EXTENDED RELEASE 24HR
1.5 MG, 3 MG, 9 MG
2
PA; QL (31 EA per 31 days)
INVEGA ORAL TABLET EXTENDED RELEASE 24HR
6 MG
2
PA; QL (62 EA per 31 days)
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117
MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 39 MG/0.25
ML, 78 MG/0.5 ML
2
PA
LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60
MG, 80 MG
2
PA; QL (31 EA per 31 days)
olanzapine intramuscular recon soln 10 mg
1
PA
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5
mg
1
QL (31 EA per 31 days)
olanzapine oral tablet, disintegrating 10 mg, 15 mg, 20 mg, 5
mg
1
QL (31 EA per 31 days)
quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400
mg, 50 mg
1
QL (62 EA per 31 days)
RISPERDAL CONSTA INTRAMUSCULAR SYRINGE
25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML
2
PA; QL (31 EA per 31 days)
risperidone oral solution 1 mg/ml
1
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4
mg
1
42
QL (62 EA per 31 days)
Drug Name
Tier
Requirements / Limits
risperidone oral tablet, disintegrating 0.25 mg, 0.5 mg, 1 mg, 2
mg, 3 mg, 4 mg
1
QL (62 EA per 31 days)
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET
10 MG, 2.5 MG, 5 MG
2
PA
ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg
1
QL (62 EA per 31 days)
ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 210 MG
2
PA
Treatment-Resistant
clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg
1
clozapine oral tablet, disintegrating 100 mg, 12.5 mg, 150 mg,
200 mg, 25 mg
1
FAZACLO ORAL TABLET,DISINTEGRATING 100
MG, 12.5 MG, 150 MG, 200 MG, 25 MG
2
PA
VERSACLOZ ORAL SUSPENSION 50 MG/ML
2
PA
Antispasticity Agents
Antispasticity Agents
baclofen oral tablet 10 mg, 20 mg
1
dantrolene oral capsule 100 mg, 25 mg, 50 mg
1
tizanidine oral tablet 2 mg, 4 mg
1
Antivirals
Anti-Cytomegalovirus (CMV) Agents
cidofovir intravenous solution 75 mg/ml
1
foscarnet intravenous solution 24 mg/ml
1
ganciclovir sodium intravenous recon soln 500 mg
1
VALCYTE ORAL RECON SOLN 50 MG/ML
2
valganciclovir oral tablet 450 mg
1
ZIRGAN OPHTHALMIC GEL 0.15 %
2
PA
Anti-Hepatitis B (HBV) Agents
adefovir oral tablet 10 mg
1
PA
BARACLUDE ORAL SOLUTION 0.05 MG/ML
2
PA
entecavir oral tablet 0.5 mg, 1 mg
1
PA; QL (31 EA per 31 days)
EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5
MG/ML)
2
INTRON A INJECTION RECON SOLN 10 MILLION
UNIT (1 ML)
2
PA
INTRON A INJECTION SOLUTION 6 MILLION
UNIT/ML
2
PA
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
43
Drug Name
Tier
Requirements / Limits
lamivudine oral tablet 100 mg, 150 mg, 300 mg
1
ribavirin oral capsule 200 mg
1
PA
ribavirin oral tablet 200 mg
1
PA
TYZEKA ORAL TABLET 600 MG
2
PA
VIRAZOLE INHALATION RECON SOLN 6 GRAM
2
PA
VIREAD ORAL POWDER 40 MG/SCOOP (40
MG/GRAM)
2
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300
MG
2
Anti-Hepatitis C (HCV) Agents
HARVONI ORAL TABLET 90-400 MG
2
PA
INTRON A INJECTION RECON SOLN 18 MILLION
UNIT (1 ML), 50 MILLION UNIT (1 ML)
2
PA
OLYSIO ORAL CAPSULE 150 MG
2
PA
PEGASYS PROCLICK SUBCUTANEOUS PEN
INJECTOR 135 MCG/0.5 ML
2
PA
PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML
2
PA
PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5
ML
2
PA
PEGINTRON REDIPEN SUBCUTANEOUS PEN
INJECTOR KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50
MCG/0.5 ML, 80 MCG/0.5 ML
2
PA
PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML
2
PA
SOVALDI ORAL TABLET 400 MG
2
PA
SYLATRON SUBCUTANEOUS KIT 200 MCG, 300
MCG, 600 MCG
2
PA; QL (4 EA per 28 days)
VICTRELIS ORAL CAPSULE 200 MG
2
PA
Antiherpetic Agents
acyclovir oral capsule 200 mg
1
acyclovir oral suspension 200 mg/5 ml
1
acyclovir oral tablet 400 mg, 800 mg
1
acyclovir sodium intravenous solution 50 mg/ml
1
acyclovir topical ointment 5 %
1
famciclovir oral tablet 125 mg, 250 mg
1
QL (62 EA per 31 days)
famciclovir oral tablet 500 mg
1
QL (21 EA per 30 days)
trifluridine ophthalmic drops 1 %
1
valacyclovir oral tablet 1 gram
1
44
QL (31 EA per 31 days)
Drug Name
Tier
Requirements / Limits
1
QL (42 EA per 30 days)
ISENTRESS ORAL POWDER IN PACKET 100 MG
2
QL (62 EA per 31 days)
ISENTRESS ORAL TABLET 400 MG
2
QL (62 EA per 31 days)
ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25
MG
2
QL (186 EA per 31 days)
STRIBILD ORAL TABLET 150-150-200-300 MG
2
QL (31 EA per 31 days)
TIVICAY ORAL TABLET 50 MG
2
QL (62 EA per 31 days)
VITEKTA ORAL TABLET 150 MG, 85 MG
2
QL (31 EA per 31 days)
valacyclovir oral tablet 500 mg
Anti-HIV Agents, Integrase Inhibitors (INSTI)
Anti-HIV Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI)
COMPLERA ORAL TABLET 200-25-300 MG
2
QL (31 EA per 31 days)
EDURANT ORAL TABLET 25 MG
2
QL (31 EA per 31 days)
INTELENCE ORAL TABLET 100 MG, 25 MG
2
QL (124 EA per 31 days)
INTELENCE ORAL TABLET 200 MG
2
QL (62 EA per 31 days)
nevirapine oral suspension 50 mg/5 ml
1
nevirapine oral tablet 200 mg
1
nevirapine oral tablet extended release 24 hr 400 mg
1
RESCRIPTOR ORAL TABLET 200 MG
2
RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG
2
SUSTIVA ORAL CAPSULE 200 MG, 50 MG
2
SUSTIVA ORAL TABLET 600 MG
2
VIRAMUNE XR ORAL TABLET EXTENDED
RELEASE 24 HR 100 MG
2
Anti-HIV Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (NRTI)
abacavir oral tablet 300 mg
1
abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg
1
ATRIPLA ORAL TABLET 600-200-300 MG
2
didanosine oral capsule, delayed release(dr/ec) 125 mg, 200
mg, 250 mg, 400 mg
1
EMTRIVA ORAL CAPSULE 200 MG
2
EMTRIVA ORAL SOLUTION 10 MG/ML
2
EPZICOM ORAL TABLET 600-300 MG
2
lamivudine oral solution 10 mg/ml
1
lamivudine-zidovudine oral tablet 150-300 mg
1
RETROVIR INTRAVENOUS SOLUTION 10 MG/ML
2
QL (31 EA per 31 days)
QL (62 EA per 31 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
45
Drug Name
Tier
stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg
1
stavudine oral recon soln 1 mg/ml
1
TRUVADA ORAL TABLET 200-300 MG
2
VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10
MG/ML (FINAL)
2
ZIAGEN ORAL SOLUTION 20 MG/ML
2
zidovudine oral capsule 100 mg
1
zidovudine oral syrup 10 mg/ml
1
zidovudine oral tablet 300 mg
1
Requirements / Limits
Anti-HIV Agents, Other
FUZEON SUBCUTANEOUS RECON SOLN 90 MG
2
QL (62 EA per 31 days)
SELZENTRY ORAL TABLET 150 MG
2
QL (62 EA per 31 days)
SELZENTRY ORAL TABLET 300 MG
2
QL (124 EA per 31 days)
TRIUMEQ ORAL TABLET 600-50-300 MG
2
QL (31 EA per 31 days)
TYBOST ORAL TABLET 150 MG
2
QL (31 EA per 31 days)
Anti-HIV Agents, Protease Inhibitors
APTIVUS ORAL CAPSULE 250 MG
2
APTIVUS ORAL SOLUTION 100 MG/ML
2
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
2
EVOTAZ ORAL TABLET 300-150 MG
2
INVIRASE ORAL CAPSULE 200 MG
2
INVIRASE ORAL TABLET 500 MG
2
KALETRA ORAL SOLUTION 400-100 MG/5 ML
2
KALETRA ORAL TABLET 100-25 MG, 200-50 MG
2
LEXIVA ORAL SUSPENSION 50 MG/ML
2
LEXIVA ORAL TABLET 700 MG
2
NORVIR ORAL CAPSULE 100 MG
2
NORVIR ORAL SOLUTION 80 MG/ML
2
NORVIR ORAL TABLET 100 MG
2
PREZCOBIX ORAL TABLET 800-150 MG-MG
2
PREZISTA ORAL SUSPENSION 100 MG/ML
2
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG,
800 MG
2
REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG
2
REYATAZ ORAL POWDER IN PACKET 50 MG
2
VIRACEPT ORAL TABLET 250 MG, 625 MG
2
46
QL (31 EA per 31 days)
QL (31 EA per 31 days)
Drug Name
Tier
Requirements / Limits
Anti-Influenza Agents
amantadine hcl oral capsule 100 mg
1
amantadine hcl oral solution 50 mg/5 ml
1
amantadine hcl oral tablet 100 mg
1
RELENZA DISKHALER INHALATION BLISTER
WITH DEVICE 5 MG/ACTUATION
2
rimantadine oral tablet 100 mg
1
TAMIFLU ORAL CAPSULE 45 MG
2
QL (42 EA per 180 days)
TAMIFLU ORAL CAPSULE 75 MG
2
QL (28 EA per 180 days)
QL (120 EA per 365 days)
Anxiolytics
Anxiolytics, Other
buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg
1
meprobamate oral tablet 200 mg, 400 mg
1
Benzodiazepines
alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg
1
alprazolam oral tablet extended release 24 hr 0.5 mg
1
DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG,
5-7.5-10 MG
2
DIASTAT RECTAL KIT 2.5 MG
2
Bipolar Agents
Mood Stabilizers
carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200
mg, 300 mg
1
lithium carbonate oral capsule 150 mg, 300 mg, 600 mg
1
lithium carbonate oral tablet 300 mg
1
lithium carbonate oral tablet extended release 300 mg, 450 mg
1
lithium citrate oral solution 8 meq/5 ml
1
Blood Glucose Regulators
Antidiabetic Agents
acarbose oral tablet 100 mg, 25 mg, 50 mg
1
BYETTA SUBCUTANEOUS PEN INJECTOR 10
MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250
MCG/ML) 1.2 ML
2
ST; QL (3 ML per 28 days)
CYCLOSET ORAL TABLET 0.8 MG
2
PA
glimepiride oral tablet 1 mg, 2 mg, 4 mg
1
glipizide oral tablet 10 mg
1
QL (124 EA per 31 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
47
Drug Name
Tier
Requirements / Limits
glipizide oral tablet 5 mg
1
QL (62 EA per 31 days)
glipizide oral tablet extended release 24hr 10 mg
1
QL (62 EA per 31 days)
glipizide oral tablet extended release 24hr 2.5 mg, 5 mg
1
QL (31 EA per 31 days)
glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg
1
glyburide oral tablet 1.25 mg, 2.5 mg
1
QL (124 EA per 31 days)
glyburide oral tablet 5 mg
1
QL (248 EA per 31 days)
JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG
2
QL (31 EA per 31 days)
metformin oral tablet 1,000 mg, 500 mg, 850 mg
1
metformin oral tablet extended release 24 hr 500 mg, 750 mg
1
nateglinide oral tablet 120 mg, 60 mg
1
QL (93 EA per 31 days)
pioglitazone oral tablet 15 mg, 30 mg, 45 mg
1
QL (31 EA per 31 days)
repaglinide oral tablet 0.5 mg, 1 mg, 2 mg
1
QL (248 EA per 31 days)
SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR
1,500 MCG/1.5 ML
2
PA
glipizide-metformin oral tablet 2.5-250 mg
1
QL (93 EA per 31 days)
glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg
1
QL (124 EA per 31 days)
glyburide-metformin oral tablet 1.25-250 mg
1
QL (93 EA per 31 days)
glyburide-metformin oral tablet 2.5-500 mg, 5-500 mg
1
QL (124 EA per 31 days)
JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG
2
ST; QL (62 EA per 31 days)
pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg
1
QL (31 EA per 31 days)
pioglitazone-metformin oral tablet 15-500 mg, 15-850 mg
1
QL (93 EA per 31 days)
Blood Glucose Regulators
Glycemic Agents
GLUCAGEN HYPOKIT INJECTION RECON SOLN 1
MG
2
GLUCAGON EMERGENCY KIT (HUMAN)
INJECTION KIT 1 MG
2
PROGLYCEM ORAL SUSPENSION 50 MG/ML
2
QL (2 EA per 30 days)
Insulins
APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN
100 UNIT/ML
2
QL (40 ML per 31 days)
APIDRA SUBCUTANEOUS SOLUTION 100 UNIT/ML
2
QL (40 ML per 31 days)
ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 X
1/2"
2
QL (100 EA per 31 days)
curity gauze topical bandage 2 x 2 "
1
HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION
100 UNIT/ML (50-50)
2
48
QL (40 ML per 31 days)
Drug Name
Tier
Requirements / Limits
HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION
100 UNIT/ML (75-25)
2
QL (40 ML per 31 days)
HUMALOG SUBCUTANEOUS SOLUTION 100
UNIT/ML
2
QL (40 ML per 31 days)
HUMULIN 70/30 SUBCUTANEOUS SUSPENSION 100
UNIT/ML (70-30)
2
QL (40 ML per 31 days)
HUMULIN N SUBCUTANEOUS SUSPENSION 100
UNIT/ML
2
QL (40 ML per 31 days)
HUMULIN R INJECTION SOLUTION 100 UNIT/ML
2
QL (40 ML per 31 days)
INSULIN PEN NEEDLE NEEDLE 31
2
QL (100 EA per 31 days)
INSULIN SYRINGE NEEDLELESS SYRINGE 1 ML
2
QL (100 EA per 31 days)
INSULIN SYRINGE SYRINGE 1/2 ML 29 X 1/2"
2
QL (100 EA per 31 days)
INSULIN SYRINGE-NEEDLE U-100 SYRINGE 0.3 ML
31 X 5/16"
2
QL (100 EA per 31 days)
LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN
100 UNIT/ML (3 ML)
2
LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML
2
LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML
2
QL (40 ML per 31 days)
NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 100
UNIT/ML (70-30)
2
QL (40 ML per 31 days)
NOVOLIN N SUBCUTANEOUS SUSPENSION 100
UNIT/ML
2
QL (40 ML per 31 days)
NOVOLIN R INJECTION SOLUTION 100 UNIT/ML
2
QL (40 ML per 31 days)
NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION
100 UNIT/ML (70-30)
2
QL (40 ML per 31 days)
NOVOLOG SUBCUTANEOUS SOLUTION 100
UNIT/ML
2
QL (40 ML per 31 days)
Blood Products/ Modifiers/ Volume Expanders
Anticoagulants
ARGATROBAN IN 0.9 % SOD CHLOR INTRAVENOUS
SOLUTION 125 MG/125 ML (1 MG/ML)
2
ARGATROBAN INTRAVENOUS SOLUTION 100
MG/ML
2
COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5
MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG
2
enoxaparin subcutaneous solution 300 mg/3 ml
1
QL (20 ML per 10 days)
enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml,
150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80
mg/0.8 ml
1
QL (20 ML per 10 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
49
Drug Name
Tier
Requirements / Limits
fondaparinux subcutaneous syringe 10 mg/0.8 ml, 2.5 mg/0.5
ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml
1
QL (20 ML per 20 days)
FRAGMIN SUBCUTANEOUS SOLUTION 25,000 ANTIXA UNIT/ML
2
PA
FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTIXA UNIT/ML, 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTIXA UNIT/0.2 ML, 7,500 ANTI-XA UNIT/0.3 ML
2
PA
heparin (porcine) in 5 % dex intravenous parenteral solution
20,000 unit/500 ml (40 unit/ml)
1
B vs D
heparin (porcine) injection solution 10,000 unit/ml, 20,000
unit/ml
1
B vs D
jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5
mg, 6 mg, 7.5 mg
1
PRADAXA ORAL CAPSULE 150 MG, 75 MG
2
warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5
mg, 6 mg, 7.5 mg
1
XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG
2
PA
XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)20 MG (9)
2
PA
Blood Formation Modifiers
anagrelide oral capsule 0.5 mg, 1 mg
1
EPOGEN INJECTION SOLUTION 2,000 UNIT/ML,
20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML,
4,000 UNIT/ML
2
PA
LEUKINE INJECTION RECON SOLN 250 MCG
2
PA
MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2
ML (20 MG/ML)
2
PA
NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML
2
PA
NEUMEGA SUBCUTANEOUS RECON SOLN 5 MG
2
PA
NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480
MCG/1.6 ML
2
PA
NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML,
480 MCG/0.8 ML
2
PA
PROCRIT INJECTION SOLUTION 10,000 UNIT/ML,
2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000
UNIT/ML, 40,000 UNIT/ML
2
PA
PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG,
75 MG
2
PA
Coagulants
tranexamic acid intravenous solution 1,000 mg/10 ml (100
mg/ml)
50
1
Drug Name
tranexamic acid oral tablet 650 mg
Tier
Requirements / Limits
1
Platelet Modifying Agents
AGGRENOX ORAL CAPSULE, ER MULTIPHASE 12
HR 25-200 MG
2
QL (62 EA per 31 days)
BRILINTA ORAL TABLET 90 MG
2
QL (62 EA per 31 days)
cilostazol oral tablet 100 mg, 50 mg
1
clopidogrel oral tablet 300 mg, 75 mg
1
dipyridamole oral tablet 25 mg, 50 mg, 75 mg
1
QL (31 EA per 31 days)
Cardiovascular Agents
Alpha-Adrenergic Agonists
clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg
1
clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24
hr, 0.3 mg/24 hr
1
guanfacine oral tablet 1 mg, 2 mg
1
methyldopa oral tablet 250 mg, 500 mg
1
midodrine oral tablet 10 mg, 2.5 mg, 5 mg
1
Alpha-Adrenergic Blocking Agents
DIBENZYLINE ORAL CAPSULE 10 MG
2
prazosin oral capsule 1 mg, 2 mg, 5 mg
1
Angiotensin II Receptor Antagonists
eprosartan oral tablet 600 mg
1
QL (62 EA per 31 days)
losartan oral tablet 100 mg, 25 mg, 50 mg
1
QL (31 EA per 31 days)
benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg
1
QL (62 EA per 31 days)
captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg
1
enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg
1
fosinopril oral tablet 10 mg, 20 mg, 40 mg
1
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5
mg
1
moexipril oral tablet 15 mg, 7.5 mg
1
quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg
1
QL (62 EA per 31 days)
ramipril oral capsule 10 mg, 2.5 mg, 5 mg
1
QL (62 EA per 31 days)
trandolapril oral tablet 1 mg, 2 mg, 4 mg
1
QL (62 EA per 31 days)
Angiotensin-Converting Enzyme (ACE) Inhibitors
QL (62 EA per 31 days)
Antiarrhythmics
amiodarone intravenous solution 50 mg/ml
1
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
51
Drug Name
Tier
amiodarone oral tablet 200 mg, 400 mg
1
disopyramide phosphate oral capsule 100 mg, 150 mg
1
flecainide oral tablet 100 mg, 150 mg, 50 mg
1
mexiletine oral capsule 150 mg, 200 mg, 250 mg
1
MULTAQ ORAL TABLET 400 MG
2
procainamide injection solution 500 mg/ml
1
propafenone oral capsule, extended release 12 hr 225 mg, 325
mg, 425 mg
1
propafenone oral tablet 150 mg, 225 mg, 300 mg
1
quinidine gluconate oral tablet extended release 324 mg
1
quinidine sulfate oral tablet 200 mg, 300 mg
1
sotalol af oral tablet 120 mg
1
sotalol oral tablet 160 mg, 240 mg, 80 mg
1
TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500
MCG
2
Requirements / Limits
PA
Beta-Adrenergic Blocking Agents
acebutolol oral capsule 200 mg, 400 mg
1
atenolol oral tablet 100 mg, 25 mg, 50 mg
1
betaxolol oral tablet 20 mg
1
bisoprolol fumarate oral tablet 10 mg, 5 mg
1
carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg
1
labetalol intravenous solution 5 mg/ml
1
labetalol oral tablet 100 mg, 200 mg, 300 mg
1
metoprolol succinate oral tablet extended release 24 hr 100
mg, 25 mg, 50 mg
1
QL (31 EA per 31 days)
metoprolol succinate oral tablet extended release 24 hr 200 mg
1
QL (62 EA per 31 days)
metoprolol tartrate intravenous solution 5 mg/5 ml
1
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg
1
nadolol oral tablet 20 mg, 40 mg, 80 mg
1
pindolol oral tablet 10 mg, 5 mg
1
propranolol intravenous solution 1 mg/ml
1
propranolol oral capsule, extended release 24 hr 120 mg, 160
mg, 60 mg, 80 mg
1
propranolol oral solution 20 mg/5 ml, 40 mg/5 ml
1
propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg
1
timolol maleate oral tablet 10 mg, 20 mg, 5 mg
1
52
Drug Name
Tier
Requirements / Limits
afeditab cr oral tablet extended release 30 mg, 60 mg
1
QL (62 EA per 31 days)
amlodipine oral tablet 10 mg, 2.5 mg, 5 mg
1
QL (31 EA per 31 days)
cartia xt oral capsule, extended release 24hr 120 mg, 180 mg,
240 mg, 300 mg
1
diltiazem hcl intravenous solution 5 mg/ml
1
diltiazem hcl oral capsule, extended release 180 mg, 360 mg
1
diltiazem hcl oral capsule, extended release 12 hr 120 mg, 60
mg, 90 mg
1
diltiazem hcl oral capsule, extended release 24hr 120 mg, 240
mg, 300 mg
1
diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg
1
dilt-xr oral capsule, ext release degradable 120 mg, 180 mg,
240 mg
1
felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5
mg
1
nicardipine oral capsule 20 mg, 30 mg
1
nifedical xl oral tablet extended release 24hr 30 mg, 60 mg
1
QL (62 EA per 31 days)
nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90
mg
1
QL (62 EA per 31 days)
taztia xt oral capsule, extended release 120 mg, 180 mg, 240
mg, 300 mg, 360 mg
1
verapamil intravenous solution 2.5 mg/ml
1
verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300
mg
1
verapamil oral capsule, ext rel. pellets 24 hr 120 mg, 180 mg,
240 mg
1
verapamil oral tablet 120 mg, 80 mg
1
verapamil oral tablet extended release 180 mg, 240 mg
1
Calcium Channel Blocking Agents
QL (31 EA per 31 days)
Cardiovascular Agents
amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.510 mg, 5-10 mg, 5-20 mg, 5-40 mg
1
atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg
1
benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 2012.5 mg, 20-25 mg, 5-6.25 mg
1
bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.56.25 mg, 5-6.25 mg
1
QL (31 EA per 31 days)
captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg,
1
50-15 mg, 50-25 mg
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
53
Drug Name
Tier
Requirements / Limits
DEMSER ORAL CAPSULE 250 MG
2
enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg
1
fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5
mg
1
lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5
mg, 20-25 mg
1
losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25
mg, 50-12.5 mg
1
methyldopa-hydrochlorothiazide oral tablet 250-15 mg, 25025 mg
1
metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg, 100-50
mg, 50-25 mg
1
moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25
mg, 7.5-12.5 mg
1
nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg
1
propranolol-hydrochlorothiazid oral tablet 40-25 mg, 80-25
mg
1
quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5
mg, 20-25 mg
1
spironolacton-hydrochlorothiaz oral tablet 25-25 mg
1
triamterene-hydrochlorothiazid oral capsule 37.5-25 mg, 5025 mg
1
triamterene-hydrochlorothiazid oral tablet 37.5-25 mg, 75-50
mg
1
valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25
mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg
1
QL (31 EA per 31 days)
VYTORIN 10-10 ORAL TABLET 10-10 MG
2
QL (31 EA per 31 days)
VYTORIN 10-20 ORAL TABLET 10-20 MG
2
QL (31 EA per 31 days)
VYTORIN 10-40 ORAL TABLET 10-40 MG
2
QL (31 EA per 31 days)
QL (124 EA per 31 days)
QL (31 EA per 31 days)
QL (62 EA per 31 days)
Cardiovascular Agents, Other
digitek oral tablet 125 mcg, 250 mcg
1
digoxin injection solution 250 mcg/ml
1
digoxin oral solution 50 mcg/ml
1
digoxin oral tablet 125 mcg, 250 mcg
1
LANOXIN ORAL TABLET 125 MCG, 250 MCG
2
pentoxifylline oral tablet extended release 400 mg
1
RANEXA ORAL TABLET EXTENDED RELEASE 12
HR 1,000 MG, 500 MG
2
Diuretics, Carbonic Anhydrase Inhibitors
54
PA
Drug Name
Tier
acetazolamide oral capsule, extended release 500 mg
1
acetazolamide oral tablet 125 mg, 250 mg
1
acetazolamide sodium injection recon soln 500 mg
1
methazolamide oral tablet 25 mg, 50 mg
1
Requirements / Limits
Diuretics, Loop
bumetanide injection solution 0.25 mg/ml
1
bumetanide oral tablet 0.5 mg, 1 mg, 2 mg
1
EDECRIN ORAL TABLET 25 MG
2
furosemide injection solution 10 mg/ml
1
furosemide oral solution 10 mg/ml, 40 mg/5 ml
1
furosemide oral tablet 20 mg, 40 mg, 80 mg
1
torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg
1
Diuretics, Potassium-Sparing
amiloride oral tablet 5 mg
1
DYRENIUM ORAL CAPSULE 50 MG
2
spironolactone oral tablet 100 mg, 25 mg, 50 mg
1
Diuretics, Thiazide
chlorothiazide oral tablet 250 mg, 500 mg
1
chlorthalidone oral tablet 50 mg
1
DIURIL ORAL SUSPENSION 250 MG/5 ML
2
hydrochlorothiazide oral capsule 12.5 mg
1
hydrochlorothiazide oral tablet 25 mg, 50 mg
1
indapamide oral tablet 1.25 mg, 2.5 mg
1
metolazone oral tablet 10 mg, 2.5 mg, 5 mg
1
Dyslipidemics, Fibric Acid Derivatives
fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg
1
QL (31 EA per 31 days)
fenofibrate nanocrystallized oral tablet 145 mg, 48 mg
1
QL (31 EA per 31 days)
fenofibrate oral tablet 160 mg, 54 mg
1
QL (31 EA per 31 days)
gemfibrozil oral tablet 600 mg
1
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg
1
lovastatin oral tablet 10 mg, 20 mg, 40 mg
1
pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg
1
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg
1
QL (31 EA per 31 days)
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
55
Drug Name
Tier
Requirements / Limits
Dyslipidemics, Other
cholestyramine light oral powder in packet 4 gram
1
colestipol oral granules 5 gram
1
colestipol oral tablet 1 gram
1
niacin oral tablet extended release 24 hr 1,000 mg, 500 mg,
750 mg
1
niacor oral tablet 500 mg
1
omega-3 acid ethyl esters oral capsule 1 gram
1
WELCHOL ORAL POWDER IN PACKET 3.75 GRAM
2
WELCHOL ORAL TABLET 625 MG
2
ZETIA ORAL TABLET 10 MG
2
QL (62 EA per 31 days)
QL (124 EA per 31 days)
QL (31 EA per 31 days)
Vasodilators, Direct-Acting Arterial
hydralazine injection solution 20 mg/ml
1
hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg
1
minoxidil oral tablet 10 mg, 2.5 mg
1
Vasodilators, Direct-Acting Arterial/ Venous
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg
1
isosorbide dinitrate oral tablet extended release 40 mg
1
isosorbide mononitrate oral tablet 10 mg, 20 mg
1
isosorbide mononitrate oral tablet extended release 24 hr 120
mg, 30 mg, 60 mg
1
nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml)
1
nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr,
0.4 mg/hr, 0.6 mg/hr
1
nitroglycerin translingual spray, non-aerosol 400 mcg/spray
1
NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG,
0.6 MG
2
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
amphetamine salt combo oral tablet 10 mg, 12.5 mg, 15 mg, 20
mg, 30 mg, 5 mg, 7.5 mg
1
dextroamphetamine oral capsule, extended release 10 mg, 15
mg, 5 mg
1
dextroamphetamine oral tablet 10 mg, 5 mg
1
Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines
clonidine hcl oral tablet extended release 12 hr 0.1 mg
56
1
QL (124 EA per 31 days)
Drug Name
Tier
Requirements / Limits
dexmethylphenidate oral capsule, er biphasic 50-50 10 mg, 15
mg, 30 mg, 40 mg, 5 mg
1
QL (31 EA per 31 days)
FOCALIN XR ORAL CAPSULE,ER BIPHASIC 50-50 20
MG
2
PA; QL (31 EA per 31 days)
guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3
mg, 4 mg
1
QL (31 EA per 31 days)
INTUNIV ER ORAL TABLET EXTENDED RELEASE 24
HR 1 MG, 2 MG, 3 MG, 4 MG
2
PA; QL (31 EA per 31 days)
methylphenidate oral capsule, er biphasic 50-50 20 mg, 30 mg,
40 mg
1
methylphenidate oral solution 10 mg/5 ml, 5 mg/5 ml
1
methylphenidate oral tablet 10 mg, 20 mg, 5 mg
1
methylphenidate oral tablet extended release 20 mg
1
STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG,
25 MG, 40 MG, 60 MG, 80 MG
2
Central Nervous System, Other
NUEDEXTA ORAL CAPSULE 20-10 MG
2
PA
riluzole oral tablet 50 mg
1
XENAZINE ORAL TABLET 12.5 MG, 25 MG
2
PA
AUBAGIO ORAL TABLET 14 MG, 7 MG
2
PA
AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT
30 MCG
2
PA
AVONEX INTRAMUSCULAR SYRINGE KIT 30
MCG/0.5 ML
2
PA
BETASERON SUBCUTANEOUS KIT 0.3 MG
2
PA
COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML
2
GILENYA ORAL CAPSULE 0.5 MG
2
PA
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE
22 MCG/0.5 ML, 44 MCG/0.5 ML
2
PA
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR
22 MCG/0.5 ML, 44 MCG/0.5 ML
2
PA
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE
8.8MCG/0.2ML-22 MCG/0.5ML (6)
2
PA
Multiple Sclerosis Agents
Dental And Oral Agents
Dental And Oral Agents
chlorhexidine gluconate mucous membrane mouthwash 0.12 %
1
pilocarpine hcl oral tablet 5 mg, 7.5 mg
1
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
57
Drug Name
triamcinolone acetonide dental paste 0.1 %
Tier
Requirements / Limits
1
Dermatological Agents
Dermatological Agents
8-MOP ORAL CAPSULE 10 MG
2
PA
acitretin oral capsule 10 mg, 17.5 mg, 25 mg
1
PA
amnesteem oral capsule 10 mg, 20 mg, 40 mg
1
betamethasone dipropionate topical lotion 0.05 %
1
calcipotriene topical cream 0.005 %
1
calcipotriene topical ointment 0.005 %
1
calcipotriene topical solution 0.005 %
1
clindamycin-benzoyl peroxide topical gel 1-5 %
1
clobetasol topical spray, non-aerosol 0.05 %
1
clotrimazole-betamethasone topical cream 1-0.05 %
1
clotrimazole-betamethasone topical lotion 1-0.05 %
1
diclofenac sodium topical gel 3 %
1
doxycycline monohydrate oral capsule 100 mg, 50 mg
1
doxycycline monohydrate oral tablet 100 mg
1
ELIDEL TOPICAL CREAM 1 %
2
erythromycin-benzoyl peroxide topical gel 3-5 %
1
fluorouracil intravenous solution 2.5 gram/50 ml
1
fluorouracil topical cream 5 %
1
fluorouracil topical solution 2 %, 5 %
1
fluticasone topical cream 0.05 %
1
fluticasone topical ointment 0.005 %
1
imiquimod topical cream in packet 5 %
1
methoxsalen rapid oral capsule 10 mg
1
nystatin-triamcinolone topical cream 100,000-0.1 unit/g-%
1
nystatin-triamcinolone topical ointment 100,000-0.1
unit/gram-%
1
OXSORALEN TOPICAL LOTION 1 %
2
podofilox topical solution 0.5 %
1
prednicarbate topical cream 0.1 %
1
risedronate oral tablet, delayed release (dr/ec) 35 mg
1
SANTYL TOPICAL OINTMENT 250 UNIT/GRAM
2
selenium sulfide topical suspension 2.5 %
1
58
QL (240 GM per 30 days)
PA
PA
PA
PA
QL (4 EA per 28 days)
Drug Name
Tier
Requirements / Limits
tacrolimus topical ointment 0.03 %, 0.1 %
1
PA
TAZORAC TOPICAL CREAM 0.05 %, 0.1 %
2
PA
TAZORAC TOPICAL GEL 0.05 %, 0.1 %
2
PA
UVADEX INJECTION SOLUTION 20 MCG/ML
2
B vs D
VALCHLOR TOPICAL GEL 0.016 %
2
PA
ADAGEN INTRAMUSCULAR SOLUTION 250
UNIT/ML
2
PA
ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5
ML
2
PA
CERDELGA ORAL CAPSULE 84 MG
2
PA
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT
2
PA
CREON ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,00076,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT
2
CYSTADANE ORAL POWDER 1 GRAM/1.7 ML
2
CYSTAGON ORAL CAPSULE 150 MG, 50 MG
2
PA
ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML
2
PA
FABRAZYME INTRAVENOUS RECON SOLN 35 MG
2
PA
KUVAN ORAL TABLET,SOLUBLE 100 MG
2
PA
MYOZYME INTRAVENOUS RECON SOLN 50 MG
2
PA
NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML
2
PA
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG
2
PA
PROCYSBI ORAL CAPSULE, DELAYED REL
SPRINKLE 25 MG, 75 MG
2
PA
ZAVESCA ORAL CAPSULE 100 MG
2
PA
ZENPEP ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 10,000-34,000 -55,000 UNIT, 15,00051,000 -82,000 UNIT, 20,000-68,000 -109,000 UNIT, 25,00085,000- 136,000 UNIT, 40,000-136,000- 218,000 UNIT,
5,000-17,000 -27,000 UNIT
2
Enzyme Replacement/ Modifiers
Enzyme Replacement/ Modifiers
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
atropine injection syringe 0.1 mg/ml
1
dicyclomine oral capsule 10 mg
1
dicyclomine oral solution 10 mg/5 ml
1
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
59
Drug Name
Tier
Requirements / Limits
dicyclomine oral tablet 20 mg
1
glycopyrrolate injection solution 0.2 mg/ml
1
glycopyrrolate oral tablet 1 mg, 2 mg
1
TRANSDERM-SCOP TRANSDERMAL PATCH 72
HOUR 1.5 MG (1 MG OVER 3 DAYS)
2
QL (11 EA per 31 days)
diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml
1
PA
diphenoxylate-atropine oral tablet 2.5-0.025 mg
1
PA
loperamide oral capsule 2 mg
1
metoclopramide hcl injection solution 5 mg/ml
1
metoclopramide hcl oral solution 5 mg/5 ml
1
metoclopramide hcl oral tablet 10 mg, 5 mg
1
proctozone-hc rectal cream 2.5 %
1
RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6
ML
2
ursodiol oral capsule 300 mg
1
Gastrointestinal Agents, Other
PA
Histamine2 (H2) Receptor Antagonists
cimetidine hcl oral solution 300 mg/5 ml
1
cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg
1
famotidine (pf) intravenous solution 20 mg/2 ml
1
famotidine oral suspension 40 mg/5 ml
1
famotidine oral tablet 20 mg, 40 mg
1
ranitidine hcl oral syrup 15 mg/ml
1
ranitidine hcl oral tablet 150 mg, 300 mg
1
Irritable Bowel Syndrome Agents
AMITIZA ORAL CAPSULE 24 MCG, 8 MCG
2
budesonide oral capsule, delayed, extend. release 3 mg
1
DELZICOL ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 400 MG
2
LOTRONEX ORAL TABLET 0.5 MG, 1 MG
2
Laxatives
gavilyte-c oral recon soln 240-22.72-6.72 gram
1
gavilyte-g oral recon soln 236-22.74-6.74 gram
1
gavilyte-n oral recon soln 420 gram
1
lactulose oral solution 10 gram/15 ml
1
polyethylene glycol 3350 oral powder 17 gram/dose
1
60
PA
Drug Name
trilyte with flavor packets oral recon soln 420 gram
Tier
Requirements / Limits
1
Protectants
misoprostol oral tablet 200 mcg
1
sucralfate oral tablet 1 gram
1
Proton Pump Inhibitors
esomeprazole sodium intravenous recon soln 20 mg, 40 mg
1
lansoprazole oral capsule, delayed release(dr/ec) 15 mg, 30
mg
1
QL (31 EA per 31 days)
omeprazole oral capsule, delayed release(dr/ec) 10 mg
1
QL (62 EA per 31 days)
omeprazole oral capsule, delayed release(dr/ec) 20 mg, 40 mg
1
QL (124 EA per 31 days)
pantoprazole oral tablet, delayed release (dr/ec) 20 mg, 40 mg
1
QL (31 EA per 31 days)
Genitourinary Agents
Antispasmodics, Urinary
flavoxate oral tablet 100 mg
1
oxybutynin chloride oral syrup 5 mg/5 ml
1
oxybutynin chloride oral tablet 5 mg
1
oxybutynin chloride oral tablet extended release 24hr 10 mg,
15 mg, 5 mg
1
tolterodine oral capsule, extended release 24hr 2 mg, 4 mg
1
QL (31 EA per 31 days)
tolterodine oral tablet 1 mg, 2 mg
1
QL (62 EA per 31 days)
trospium oral capsule, extended release 24hr 60 mg
1
QL (62 EA per 31 days)
trospium oral tablet 20 mg
1
QL (62 EA per 31 days)
AVODART ORAL CAPSULE 0.5 MG
2
QL (31 EA per 31 days)
doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg
1
finasteride oral tablet 5 mg
1
QL (31 EA per 31 days)
tamsulosin oral capsule, extended release 24hr 0.4 mg
1
QL (62 EA per 31 days)
terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg
1
Benign Prostatic Hypertrophy Agents
Genitourinary Agents, Other
bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg
1
DEPEN TITRATABS ORAL TABLET 250 MG
2
ELMIRON ORAL CAPSULE 100 MG
2
sodium phenylbutyrate oral powder 0.94 gram/gram
1
Phosphate Binders
calcium acetate oral capsule 667 mg
1
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
61
Drug Name
Tier
FOSRENOL ORAL POWDER IN PACKET 1,000 MG,
750 MG
2
FOSRENOL ORAL TABLET,CHEWABLE 1,000 MG,
500 MG, 750 MG
2
RENAGEL ORAL TABLET 400 MG
2
Requirements / Limits
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
a-hydrocort injection recon soln 100 mg
1
betamethasone dipropionate topical cream 0.05 %
1
betamethasone dipropionate topical ointment 0.05 %
1
betamethasone valerate topical cream 0.1 %
1
betamethasone valerate topical lotion 0.1 %
1
betamethasone valerate topical ointment 0.1 %
1
betamethasone, augmented topical cream 0.05 %
1
betamethasone, augmented topical gel 0.05 %
1
betamethasone, augmented topical lotion 0.05 %
1
betamethasone, augmented topical ointment 0.05 %
1
clobetasol topical foam 0.05 %
1
clobetasol topical gel 0.05 %
1
clobetasol topical lotion 0.05 %
1
clobetasol topical ointment 0.05 %
1
clobetasol topical shampoo 0.05 %
1
clobetasol topical solution 0.05 %
1
clobetasol-emollient topical cream 0.05 %
1
DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML
2
desonide topical cream 0.05 %
1
desonide topical lotion 0.05 %
1
desonide topical ointment 0.05 %
1
desoximetasone topical cream 0.05 %, 0.25 %
1
desoximetasone topical gel 0.05 %
1
desoximetasone topical ointment 0.25 %
1
dexamethasone intensol oral drops 1 mg/ml
1
dexamethasone oral elixir 0.5 mg/5 ml
1
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2
mg, 4 mg, 6 mg
1
dexamethasone sodium phosphate injection solution 10 mg/ml
1
62
B vs D
B vs D
B vs D
Drug Name
Tier
Requirements / Limits
dexamethasone sodium phosphate injection solution 4 mg/ml
1
fludrocortisone oral tablet 0.1 mg
1
fluocinolone topical cream 0.01 %, 0.025 %
1
fluocinolone topical ointment 0.025 %
1
fluocinolone topical solution 0.01 %
1
fluocinonide topical gel 0.05 %
1
fluocinonide topical ointment 0.05 %
1
fluocinonide topical solution 0.05 %
1
fluocinonide-e topical cream 0.05 %
1
halobetasol propionate topical cream 0.05 %
1
halobetasol propionate topical ointment 0.05 %
1
hydrocortisone butyrate topical ointment 0.1 %
1
hydrocortisone butyrate topical solution 0.1 %
1
hydrocortisone oral tablet 10 mg, 20 mg, 5 mg
1
hydrocortisone topical cream 1 %, 2.5 %
1
hydrocortisone topical lotion 2.5 %
1
hydrocortisone topical ointment 1 %, 2.5 %
1
hydrocortisone valerate topical cream 0.2 %
1
hydrocortisone valerate topical ointment 0.2 %
1
methylprednisolone acetate injection suspension 40 mg/ml, 80
mg/ml
1
methylprednisolone oral tablet 16 mg, 32 mg, 8 mg
1
methylprednisolone oral tablets, dose pack 4 mg
1
mometasone topical cream 0.1 %
1
mometasone topical ointment 0.1 %
1
mometasone topical solution 0.1 %
1
prednicarbate topical ointment 0.1 %
1
prednisolone sodium phosphate oral solution 15 mg/5 ml, 5 mg
base/5 ml (6.7 mg/5 ml)
1
prednisone intensol oral concentrate 5 mg/ml
1
prednisone oral solution 5 mg/5 ml
1
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg
1
prednisone oral tablet 50 mg
1
B vs D
SOLU-CORTEF (PF) INJECTION RECON SOLN 100
MG/2 ML, 250 MG/2 ML
2
B vs D
B vs D
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
63
Drug Name
Tier
Requirements / Limits
SOLU-MEDROL (PF) INJECTION RECON SOLN 125
MG/2 ML, 40 MG/ML
2
B vs D
SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN
500 MG/4 ML
2
B vs D
SOLU-MEDROL INTRAVENOUS RECON SOLN 2
GRAM
2
B vs D
triamcinolone acetonide topical cream 0.025 %, 0.1 %, 0.5 %
1
triamcinolone acetonide topical lotion 0.025 %, 0.1 %
1
triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5
%
1
Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)
Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)
desmopressin injection solution 4 mcg/ml
1
desmopressin nasal solution 0.1 mg/ml (refrigerate)
1
desmopressin oral tablet 0.1 mg, 0.2 mg
1
GENOTROPIN MINIQUICK SUBCUTANEOUS
SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25
ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML,
1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2
MG/0.25 ML
2
PA
GENOTROPIN SUBCUTANEOUS CARTRIDGE 12
MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML)
2
PA
INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML
2
PA
OMNITROPE SUBCUTANEOUS CARTRIDGE 10
MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)
2
PA
OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG
2
PA
STIMATE NASAL SPRAY,NON-AEROSOL 150
MCG/SPRAY (0.1 ML)
2
Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)
Anabolic Steroids
oxandrolone oral tablet 10 mg, 2.5 mg
1
PA
Androgens
ANDRODERM TRANSDERMAL PATCH 24 HOUR 2
MG/24 HOUR, 4 MG/24 HR
2
danazol oral capsule 100 mg, 200 mg, 50 mg
1
DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100
MG/ML
2
METHITEST ORAL TABLET 10 MG
2
testosterone cypionate intramuscular oil 200 mg/ml
1
64
PA
PA
Drug Name
Tier
testosterone enanthate intramuscular oil 200 mg/ml
1
TESTRED ORAL CAPSULE 10 MG
2
Requirements / Limits
PA
Estrogens
ENJUVIA ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG,
0.9 MG, 1.25 MG
2
estradiol oral tablet 0.5 mg, 1 mg, 2 mg
1
estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375
mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1
mg/24 hr
1
estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg
1
MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG,
2.5 MG
2
PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625
MG, 0.9 MG, 1.25 MG
2
PREMARIN VAGINAL CREAM 0.625 MG/GRAM
2
Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)
apri oral tablet 0.15-0.03 mg
1
aubra oral tablet 0.1-20 mg-mcg
1
aviane oral tablet 0.1-20 mg-mcg
1
balziva (28) oral tablet 0.4-35 mg-mcg
1
delyla (28) oral tablet 0.1-20 mg-mcg
1
enpresse oral tablet 50-30 (6)/75-40 (5)/125-30(10)
1
falmina (28) oral tablet 0.1-20 mg-mcg
1
gildess oral tablet 1.5-30 mg-mcg
1
jinteli oral tablet 1-5 mg-mcg
1
junel 1/20 (21) oral tablet 1-20 mg-mcg
1
junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7)
1
junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)
1
larin 1.5/30 (21) oral tablet 1.5-30 mg-mcg
1
leena 28 oral tablet 0.5/1/0.5-35 mg-mcg
1
lessina oral tablet 0.1-20 mg-mcg
1
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg
1
levora-28 oral tablet 0.15-0.03 mg
1
low-ogestrel (28) oral tablet 0.3-30 mg-mcg
1
microgestin 1.5/30 (21) oral tablet 1.5-30 mg-mcg
1
microgestin 1/20 (21) oral tablet 1-20 mg-mcg
1
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
65
Drug Name
Tier
microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75
mg (7)
1
microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg
(7)
1
necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg
1
necon 1/35 (28) oral tablet 1-35 mg-mcg
1
necon 10/11 (28) oral tablet 0.5-35/1-35 mg-mcg/mg-mcg
1
necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg
1
norlyroc oral tablet 0.35 mg
1
nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg
1
nortrel 1/35 (28) oral tablet 1-35 mg-mcg
1
nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg
1
portia oral tablet 0.15-0.03 mg
1
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG,
0.625-2.5 MG, 0.625-5 MG
2
previfem oral tablet 0.25-35 mg-mcg
1
quasense oral tablets, dose pack,3 month 0.15-30 mg-mcg
1
reclipsen (28) oral tablet 0.15-0.03 mg
1
sprintec (28) oral tablet 0.25-35 mg-mcg
1
sronyx oral tablet 0.1-20 mg-mcg
1
tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9)
1
trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28)
1
tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28)
1
tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28)
1
trivora (28) oral tablet 50-30 (6)/75-40 (5)/125-30(10)
1
zovia 1/35e (28) oral tablet 1-35 mg-mcg
1
zovia 1/50e (28) oral tablet 1-50 mg-mcg
1
Requirements / Limits
Progesterone Agonists/ Antagonists
ELLA ORAL TABLET 30 MG
2
Progestins
camila oral tablet 0.35 mg
1
DEPO-PROVERA INTRAMUSCULAR SOLUTION 400
MG/ML
2
errin oral tablet 0.35 mg
1
medroxyprogesterone intramuscular suspension 150 mg/ml
1
medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg
1
66
QL (1 ML per 80 days)
Drug Name
Tier
Requirements / Limits
megestrol oral suspension 400 mg/10 ml (40 mg/ml)
1
PA
megestrol oral tablet 20 mg, 40 mg
1
PA
norethindrone acetate oral tablet 5 mg
1
Selective Estrogen Receptor Modifying Agents
raloxifene oral tablet 60 mg
1
Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)
Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)
CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG
2
levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137
mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg,
75 mcg, 88 mcg
1
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150
mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
1
liothyronine intravenous solution 10 mcg/ml
1
liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg
1
SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125
MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25
MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG
2
unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg,
175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg
1
B vs D
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN ORAL TABLET 500 MG
2
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG
2
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
cabergoline oral tablet 0.5 mg
1
ELIGARD SUBCUTANEOUS SYRINGE 22.5 MG, 30
MG, 45 MG, 7.5 MG
2
B vs D
FIRMAGON KIT W DILUENT SYRINGE
SUBCUTANEOUS RECON SOLN 120 MG, 80 MG
2
B vs D
leuprolide subcutaneous kit 1 mg/0.2 ml
1
PA
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR
SYRINGE KIT 11.25 MG, 22.5 MG
2
PA
LUPRON DEPOT (4 MONTH) INTRAMUSCULAR
SYRINGE KIT 30 MG
2
PA
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
67
Drug Name
Tier
Requirements / Limits
LUPRON DEPOT (6 MONTH) INTRAMUSCULAR
SYRINGE KIT 45 MG
2
PA
LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT
3.75 MG, 7.5 MG
2
PA
LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.25
MG, 15 MG
2
PA
octreotide acetate injection solution 1,000 mcg/ml, 100
mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml
1
B vs D
SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT
10 MG, 20 MG, 30 MG
2
B vs D
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE
120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML
2
PA
SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG,
15 MG, 20 MG, 25 MG, 30 MG
2
PA
SYNAREL NASAL SPRAY,NON-AEROSOL 2 MG/ML
2
PA
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole oral tablet 10 mg, 5 mg
1
propylthiouracil oral tablet 50 mg
1
Immunological Agents
Angioedema (Hae) Agents
CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5
ML)
2
PA
FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML
2
PA
AFINITOR DISPERZ ORAL TABLET FOR
SUSPENSION 2 MG, 3 MG, 5 MG
2
PA
ATGAM INTRAVENOUS INJECTABLE 50 MG/ML
2
PA
azathioprine oral tablet 50 mg
1
B vs D
BENLYSTA INTRAVENOUS RECON SOLN 120 MG
2
PA
CELLCEPT INTRAVENOUS INTRAVENOUS RECON
SOLN 500 MG
2
B vs D
cyclosporine intravenous solution 250 mg/5 ml
1
B vs D
cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg
1
B vs D
cyclosporine modified oral solution 100 mg/ml
1
B vs D
cyclosporine oral capsule 100 mg, 25 mg
1
B vs D
ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1
ML)
2
PA
Immune Suppressants
68
Drug Name
Tier
Requirements / Limits
ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML
(0.51), 50 MG/ML (0.98 ML)
2
PA
gengraf oral capsule 100 mg, 25 mg
1
B vs D
gengraf oral solution 100 mg/ml
1
B vs D
HUMIRA CROHN'S DIS START PCK SUBCUTANEOUS
PEN INJECTOR KIT 40 MG/0.8 ML
2
PA
HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4
ML, 40 MG/0.8 ML
2
PA
KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67
ML
2
PA
mercaptopurine oral tablet 50 mg
1
methotrexate sodium (pf) injection recon soln 1 gram
1
B vs D
methotrexate sodium (pf) injection solution 25 mg/ml
1
B vs D
methotrexate sodium oral tablet 2.5 mg
1
B vs D
mycophenolate mofetil oral capsule 250 mg
1
B vs D
mycophenolate mofetil oral suspension for reconstitution 200
mg/ml
1
B vs D
mycophenolate mofetil oral tablet 500 mg
1
B vs D
mycophenolate sodium oral tablet, delayed release (dr/ec) 180
mg, 360 mg
1
B vs D
NULOJIX INTRAVENOUS RECON SOLN 250 MG
2
PA
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON
SOLN 250 MG
2
B vs D; QL (80 EA per 28 days)
ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML
2
PA; QL (8 ML per 28 days)
PROGRAF INTRAVENOUS SOLUTION 5 MG/ML
2
B vs D
RAPAMUNE ORAL SOLUTION 1 MG/ML
2
B vs D
REMICADE INTRAVENOUS RECON SOLN 100 MG
2
PA
SIMULECT INTRAVENOUS RECON SOLN 20 MG
2
PA
sirolimus oral tablet 0.5 mg, 1 mg, 2 mg
1
B vs D
tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg
1
B vs D
TORISEL INTRAVENOUS RECON SOLN 30 MG/3 ML
(10 MG/ML) (FIRST)
2
PA
ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG
2
B vs D; QL (62 EA per 31 days)
CARIMUNE NF NANOFILTERED INTRAVENOUS
RECON SOLN 6 GRAM
2
PA
GAMMAGARD LIQUID INJECTION SOLUTION 10 %
2
PA
Immunizing Agents, Passive
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
69
Drug Name
THYMOGLOBULIN INTRAVENOUS RECON SOLN 25
MG
Tier
2
Requirements / Limits
B vs D
Immunological Agents
leflunomide oral tablet 10 mg, 20 mg
1
SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5
ML
2
Immunomodulators
ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML
(20 MG/ML)
2
PA
ACTIMMUNE SUBCUTANEOUS SOLUTION 100
MCG/0.5 ML
2
PA
ARCALYST SUBCUTANEOUS RECON SOLN 220 MG
2
PA
ILARIS (PF) SUBCUTANEOUS RECON SOLN 180
MG/1.2 ML (150 MG/ML)
2
PA
RIDAURA ORAL CAPSULE 3 MG
2
TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML
2
PA
Vaccines
ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10
MCG/0.5 ML
2
ADACEL(TDAP ADOLESN/ADULT)(PF)
INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5
MCG)-5LF/0.5 ML
2
BEXSERO (PF) INTRAMUSCULAR SYRINGE 50-50-5025 MCG/0.5 ML
2
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION
2.5-8-5 LF-MCG-LF/0.5ML
2
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 2.5-85 LF-MCG-LF/0.5ML
2
CERVARIX VACCINE (PF) INTRAMUSCULAR
SYRINGE 20-20 MCG/0.5 ML
2
COMVAX (PF) INTRAMUSCULAR SUSPENSION 5-7.5125 MCG/0.5 ML
2
DAPTACEL (DTAP PEDIATRIC) (PF)
INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCGLF/0.5ML
2
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20
MCG/ML
2
PA
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR
SUSPENSION 10 MCG/0.5 ML
2
PA
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR
SYRINGE 10 MCG/0.5 ML
2
PA
70
PA
Drug Name
Tier
Requirements / Limits
GARDASIL (PF) INTRAMUSCULAR SUSPENSION 2040-40-20 MCG/0.5 ML
2
PA
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION
0.5 ML
2
PA
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5
ML
2
PA
HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440
ELISA UNIT/ML
2
HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA
UNIT/0.5 ML
2
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR
RECON SOLN 2.5 UNIT
2
INFANRIX (DTAP) (PF) INTRAMUSCULAR
SUSPENSION 25-58-10 LF-MCG-LF/0.5ML
2
IPOL INJECTION SUSPENSION 40-8-32 UNIT/0.5 ML
2
IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5
ML
2
MENACTRA (PF) INTRAMUSCULAR SOLUTION 4
MCG/0.5 ML
2
MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS
RECON SOLN 50 MCG
2
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR
KIT 10-5 MCG/0.5 ML
2
M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,00012,500 TCID50/0.5 ML
2
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5
MCG/0.5 ML
2
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR
RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5
2
QUADRACEL (PF) INTRAMUSCULAR SUSPENSION
15 LF-48 MCG- 5 LF UNIT/0.5ML
2
RABAVERT (PF) INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION 2.5 UNIT
2
RECOMBIVAX HB (PF) INTRAMUSCULAR
SUSPENSION 10 MCG/ML, 40 MCG/ML
2
ROTARIX ORAL SUSPENSION FOR
RECONSTITUTION 10EXP6 CCID50/ML
2
ROTATEQ VACCINE ORAL SUSPENSION 2 ML
2
TETANUS TOXOID,ADSORBED (PF)
INTRAMUSCULAR SUSPENSION 5 LF UNIT/0.5 ML
2
B vs D
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
71
Drug Name
Tier
tetanus, diphtheria tox ped(pf) intramuscular suspension 5-25
lf unit/0.5 ml
1
TETANUS-DIPHTHERIA TOXOIDS-TD
INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML
2
TRUMENBA INTRAMUSCULAR SYRINGE 120
MCG/0.5 ML
2
TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720
ELISA UNIT -20 MCG/ML
2
TYPHIM VI INTRAMUSCULAR SOLUTION 25
MCG/0.5 ML
2
VAQTA (PF) INTRAMUSCULAR SUSPENSION 25
UNIT/0.5 ML
2
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR
RECONSTITUTION 1,350 UNIT/0.5 ML
2
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR
RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML
2
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR
RECONSTITUTION 19,400 UNIT/0.65 ML
2
Requirements / Limits
QL (1 EA per 365 days)
Inflammatory Bowel Disease Agents
Aminosalicylates
balsalazide oral capsule 750 mg
1
CANASA RECTAL SUPPOSITORY 1,000 MG
2
DIPENTUM ORAL CAPSULE 250 MG
2
mesalamine with cleansing wipe rectal enema kit 4 gram/60 ml
1
Glucocorticoids
hydrocortisone rectal enema 100 mg/60 ml
1
methylprednisolone oral tablet 4 mg
1
proctosol hc rectal cream 2.5 %
1
Sulfonamides
sulfasalazine oral tablet 500 mg
1
sulfazine ec oral tablet, delayed release (dr/ec) 500 mg
1
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
ACTONEL ORAL TABLET 30 MG, 35 MG
2
QL (4 EA per 28 days)
ACTONEL ORAL TABLET 5 MG
2
QL (31 EA per 31 days)
alendronate oral tablet 10 mg, 40 mg, 5 mg
1
QL (30 EA per 30 days)
alendronate oral tablet 35 mg, 70 mg
1
QL (4 EA per 28 days)
72
Drug Name
Tier
Requirements / Limits
calcitonin (salmon) nasal spray, non-aerosol 200
unit/actuation
1
calcitriol intravenous solution 1 mcg/ml
1
B vs D
calcitriol oral capsule 0.25 mcg, 0.5 mcg
1
B vs D
calcitriol oral solution 1 mcg/ml
1
B vs D
etidronate disodium oral tablet 200 mg, 400 mg
1
FORTEO SUBCUTANEOUS PEN INJECTOR 20
MCG/DOSE - 600 MCG/2.4 ML
2
PA
ibandronate intravenous syringe 3 mg/3 ml
1
PA
ibandronate oral tablet 150 mg
1
MIACALCIN INJECTION SOLUTION 200 UNIT/ML
2
NATPARA SUBCUTANEOUS CARTRIDGE 100
MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75
MCG/DOSE
2
PA; QL (2 EA per 28 days)
pamidronate intravenous solution 30 mg/10 ml (3 mg/ml), 60
mg/10 ml (6 mg/ml), 90 mg/10 ml (9 mg/ml)
1
PA
paricalcitol hemodialysis port injection solution 2 mcg/ml, 5
mcg/ml
1
PA
paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg
1
PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML
2
PA
risedronate oral tablet 150 mg
1
QL (1 EA per 28 days)
XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7 ML
(70 MG/ML)
2
PA
zoledronic acid intravenous solution 4 mg/5 ml
1
B vs D; QL (15 ML per 21 days)
zoledronic acid-mannitol-water intravenous solution 5 mg/100
ml
1
B vs D; QL (15 ML per 21 days)
ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML
2
B vs D
Ophthalmic Agents
Ophthalmic Agents
bacitracin-polymyxin b ophthalmic ointment 500-10,000
unit/gram
1
BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 100.2 %
2
neomycin-bacitracin-poly-hc ophthalmic ointment 3.5-40010,000 mg-unit/g-1%
1
neomycin-polymyxin b-dexameth ophthalmic drops, suspension
3.5mg/ml-10,000 unit/ml-0.1 %
1
neomycin-polymyxin b-dexameth ophthalmic ointment 3.5
1
mg/g-10,000 unit/g-0.1 %
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
73
Drug Name
Tier
neomycin-polymyxin-gramicidin ophthalmic drops 1.75 mg10,000 unit-0.025mg/ml
1
neomycin-polymyxin-hc ophthalmic drops, suspension 3.510,000-10 mg-unit-mg/ml
1
polymyxin b sulf-trimethoprim ophthalmic drops 10,000 unit- 1
mg/ml
1
prednisolone acetate ophthalmic drops, suspension 1 %
1
sulfacetamide-prednisolone ophthalmic drops 10 %-0.23 %
(0.25 %)
1
tobramycin-dexamethasone ophthalmic drops, suspension 0.30.1 %
1
Ophthalmic Agents, Other
LACRISERT OPHTHALMIC INSERT 5 MG
2
naphazoline ophthalmic drops 0.1 %
1
proparacaine ophthalmic drops 0.5 %
1
RESTASIS OPHTHALMIC DROPPERETTE 0.05 %
2
Ophthalmic Anti-Allergy Agents
ALOMIDE OPHTHALMIC DROPS 0.1 %
2
azelastine ophthalmic drops 0.05 %
1
cromolyn ophthalmic drops 4 %
1
PATADAY OPHTHALMIC DROPS 0.2 %
2
PATANOL OPHTHALMIC DROPS 0.1 %
2
PAZEO OPHTHALMIC DROPS 0.7 %
2
Ophthalmic Antiglaucoma Agents
apraclonidine ophthalmic drops 0.5 %
1
betaxolol ophthalmic drops 0.5 %
1
BETOPTIC S OPHTHALMIC DROPS,SUSPENSION
0.25 %
2
brimonidine ophthalmic drops 0.15 %, 0.2 %
1
carteolol ophthalmic drops 1 %
1
dorzolamide ophthalmic drops 2 %
1
dorzolamide-timolol ophthalmic drops 22.3-6.8 mg/ml
1
levobunolol ophthalmic drops 0.5 %
1
metipranolol ophthalmic drops 0.3 %
1
phospholine iodide ophthalmic drops 0.125 %
1
timolol maleate ophthalmic drops 0.25 %, 0.5 %
1
timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 %
1
74
Requirements / Limits
Drug Name
Tier
Requirements / Limits
Ophthalmic Anti-Inflammatories
BROMFENAC OPHTHALMIC DROPS 0.09 %
2
dexamethasone sodium phosphate ophthalmic drops 0.1 %
1
diclofenac sodium ophthalmic drops 0.1 %
1
flurbiprofen sodium ophthalmic drops 0.03 %
1
FML FORTE OPHTHALMIC DROPS,SUSPENSION 0.25
%
2
ketorolac ophthalmic drops 0.4 %, 0.5 %
1
prednisolone sodium phosphate ophthalmic drops 1 %
1
Ophthalmic Prostaglandin And Prostamide Analogs
latanoprost ophthalmic drops 0.005 %
1
TRAVATAN Z OPHTHALMIC DROPS 0.004 %
2
travoprost (benzalkonium) ophthalmic drops 0.004 %
1
Otic Agents
Otic Agents
CIPRODEX OTIC DROPS,SUSPENSION 0.3-0.1 %
2
hydrocortisone-acetic acid otic drops 1-2 %
1
neomycin-polymyxin-hc otic drops, suspension 3.5-10,000-1
mg/ml-unit/ml-%
1
neomycin-polymyxin-hc otic solution 3.5-10,000-1 mg/mlunit/ml-%
1
Respiratory Tract/ Pulmonary Agents
Antihistamines
azelastine nasal aerosol, spray 137 mcg (0.1 %)
1
carbinoxamine maleate oral liquid 4 mg/5 ml
1
carbinoxamine maleate oral tablet 4 mg
1
cetirizine oral solution 1 mg/ml
1
clemastine oral tablet 2.68 mg
1
cyproheptadine oral syrup 2 mg/5 ml
1
cyproheptadine oral tablet 4 mg
1
levocetirizine oral solution 2.5 mg/5 ml
1
levocetirizine oral tablet 5 mg
1
QL (31 ML per 31 days)
Anti-Inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS INHALATION BLISTER WITH
DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50
MCG/DOSE
2
ST; QL (2 EA per 1 day)
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
75
Drug Name
Tier
Requirements / Limits
ADVAIR HFA INHALATION HFA AEROSOL
INHALER 115-21 MCG/ACTUATION, 230-21
MCG/ACTUATION, 45-21 MCG/ACTUATION
2
ST; QL (0.48 GM per 1 day)
ASMANEX TWISTHALER INHALATION AEROSOL
POWDR BREATH ACTIVATED 220 MCG (120 DOSES),
220 MCG (60 DOSES)
2
QL (1 EA per 25 days)
budesonide inhalation suspension for nebulization 0.25 mg/2
ml, 0.5 mg/2 ml
1
B vs D
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 110 MCG/ACTUATION
2
QL (0.96 GM per 1 day)
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 220 MCG/ACTUATION, 44
MCG/ACTUATION
2
QL (0.85 GM per 1 day)
flunisolide nasal spray, non-aerosol 25 mcg (0.025 %)
1
fluticasone nasal spray, suspension 50 mcg/actuation
1
PULMICORT FLEXHALER INHALATION AEROSOL
POWDR BREATH ACTIVATED 180
MCG/ACTUATION, 90 MCG/ACTUATION
2
QVAR INHALATION AEROSOL 40
MCG/ACTUATION, 80 MCG/ACTUATION
2
Antileukotrienes
montelukast oral tablet 10 mg
1
QL (31 EA per 31 days)
montelukast oral tablet, chewable 4 mg, 5 mg
1
QL (31 EA per 31 days)
zafirlukast oral tablet 10 mg, 20 mg
1
QL (62 EA per 31 days)
ATROVENT HFA INHALATION HFA AEROSOL
INHALER 17 MCG/ACTUATION
2
QL (31 GM per 31 days)
ipratropium bromide inhalation solution 0.02 %
1
B vs D
ipratropium bromide nasal spray, non-aerosol 0.03 %, 0.06 %
1
QL (31 ML per 31 days)
SPIRIVA RESPIMAT INHALATION MIST 2.5
MCG/ACTUATION
2
QL (4 GM per 30 days)
SPIRIVA WITH HANDIHALER INHALATION
CAPSULE, W/INHALATION DEVICE 18 MCG
2
QL (31 EA per 31 days)
TUDORZA PRESSAIR INHALATION AEROSOL
POWDR BREATH ACTIVATED 400 MCG/ACTUATION
2
QL (0.04 EA per 1 day)
TUDORZA PRESSAIR INHALATION AEROSOL
POWDR BREATH ACTIVATED 400 MCG/ACTUATION
(30 ACTUAT)
2
QL (2 EA per 30 days)
1
B vs D
Bronchodilators, Anticholinergic
Bronchodilators, Sympathomimetic
albuterol sulfate inhalation solution for nebulization 0.63 mg/3
ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml
76
Drug Name
Tier
Requirements / Limits
albuterol sulfate inhalation solution for nebulization 1.25 mg/3
ml
1
B vs D; QL (375 ML per 30 days)
albuterol sulfate oral syrup 2 mg/5 ml
1
albuterol sulfate oral tablet 2 mg, 4 mg
1
albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg
1
AUVI-Q INJECTION AUTO-INJECTOR 0.15 MG/0.15
ML (1:1,000), 0.3 MG/0.3 ML (1:1,000)
2
QL (2 EA per 31 days)
epinephrine injection auto-injector 0.15 mg/0.15 ml (1:1,000),
0.3 mg/0.3 ml (1:1,000)
1
QL (2 EA per 31 days)
EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3
MG/0.3 ML (1:1,000)
2
QL (2 EA per 30 days)
EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15
MG/0.3 ML (1:2,000)
2
QL (2 EA per 30 days)
levalbuterol hcl inhalation solution for nebulization 0.31 mg/3
ml, 0.63 mg/3 ml
1
B vs D
metaproterenol oral syrup 10 mg/5 ml
1
metaproterenol oral tablet 10 mg, 20 mg
1
SEREVENT DISKUS INHALATION BLISTER WITH
DEVICE 50 MCG/DOSE
2
terbutaline oral tablet 2.5 mg, 5 mg
1
terbutaline subcutaneous solution 1 mg/ml
1
VENTOLIN HFA INHALATION HFA AEROSOL
INHALER 90 MCG/ACTUATION
2
QL (54 GM per 31 days)
cromolyn inhalation solution for nebulization 20 mg/2 ml
1
B vs D
cromolyn oral solution 100 mg/5 ml
1
QL (2 EA per 1 day)
Mast Cell Stabilizers
Phosphodiesterase Inhibitors, Airways Disease
aminophylline intravenous solution 250 mg/10 ml
1
DALIRESP ORAL TABLET 500 MCG
2
theophylline oral tablet extended release 12 hr 100 mg, 200
mg, 300 mg, 450 mg
1
theophylline oral tablet extended release 400 mg, 600 mg
1
PA
Pulmonary Antihypertensives
ADCIRCA ORAL TABLET 20 MG
2
PA; QL (62 EA per 31 days)
LETAIRIS ORAL TABLET 10 MG, 5 MG
2
PA
REMODULIN INJECTION SOLUTION 1 MG/ML, 10
MG/ML, 2.5 MG/ML, 5 MG/ML
2
PA
sildenafil oral tablet 20 mg
1
PA
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
77
Drug Name
Tier
Requirements / Limits
2
PA; QL (62 EA per 31 days)
acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %)
1
B vs D
ANORO ELLIPTA INHALATION BLISTER WITH
DEVICE 62.5-25 MCG/ACTUATION
2
ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG
2
B vs D
COMBIVENT RESPIMAT INHALATION MIST 20-100
MCG/ACTUATION
2
QL (0.2 GM per 1 day)
ESBRIET ORAL CAPSULE 267 MG
2
PA
ipratropium-albuterol inhalation solution for nebulization 0.5
mg-3 mg(2.5 mg base)/3 ml
1
B vs D
OFEV ORAL CAPSULE 100 MG, 150 MG
2
PA
promethazine vc oral syrup 6.25-5 mg/5 ml
1
PULMOZYME INHALATION SOLUTION 1 MG/ML
2
B vs D
XOLAIR SUBCUTANEOUS RECON SOLN 150 MG
2
PA
carisoprodol oral tablet 350 mg
1
PA; QL (93 EA per 31 days)
cyclobenzaprine oral tablet 10 mg, 5 mg
1
QL (93 EA per 31 days)
methocarbamol oral tablet 500 mg, 750 mg
1
TRACLEER ORAL TABLET 125 MG, 62.5 MG
Respiratory Tract Agents, Other
Respiratory Tract/ Pulmonary Agents
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
Sleep Disorder Agents
GABA Receptor Modulators
zaleplon oral capsule 10 mg, 5 mg
1
QL (31 EA per 31 days)
zolpidem oral tablet 10 mg, 5 mg
1
QL (31 EA per 31 days)
zolpidem oral tablet, ext release multiphase 12.5 mg, 6.25 mg
1
QL (31 EA per 31 days)
modafinil oral tablet 100 mg, 200 mg
1
PA; QL (62 EA per 31 days)
ROZEREM ORAL TABLET 8 MG
2
QL (31 EA per 31 days)
XYREM ORAL SOLUTION 500 MG/ML
2
Sleep Disorders, Other
Therapeutic Nutrients/ Minerals/ Electrolytes
Electrolyte/ Mineral Modifiers
EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250
MG, 500 MG
2
sodium polystyrene (sorb free) oral suspension 15 gram/60 ml
1
SYPRINE ORAL CAPSULE 250 MG
2
78
PA
Drug Name
Tier
Requirements / Limits
Electrolyte/ Mineral Replacement
ISOLYTE-S INTRAVENOUS PARENTERAL
SOLUTION
2
klor-con 10 oral tablet extended release 10 meq
1
klor-con 8 oral tablet extended release 8 meq
1
klor-con m15 oral tablet, er particles/crystals 15 meq
1
klor-con m20 oral tablet, er particles/crystals 20 meq
1
k-tab oral tablet extended release 10 meq
1
physiolyte irrigation solution 140-5-3-98 meq/l
1
B vs D
PLASMA-LYTE 148 INTRAVENOUS PARENTERAL
SOLUTION
2
B vs D
PLASMA-LYTE A INTRAVENOUS PARENTERAL
SOLUTION
2
B vs D
potassium chloride intravenous piggyback 10 meq/100 ml, 40
meq/100 ml
1
potassium chloride intravenous solution 2 meq/ml
1
potassium chloride oral capsule, extended release 10 meq
1
potassium chloride oral tablet extended release 8 meq
1
potassium chloride oral tablet, er particles/crystals 10 meq, 20
meq
1
sodium chloride 0.9 % intravenous parenteral solution 0.9 %
1
B vs D
sodium chloride 3 % intravenous parenteral solution 3 %
1
B vs D
sodium chloride 5 % intravenous parenteral solution 5 %
1
sodium chloride intravenous parenteral solution 2.5 meq/ml
1
sodium chloride irrigation solution 0.9 %
1
sodium fluoride oral tablet 1 mg fluoride (2.2 mg)
1
Therapeutic Nutrients/ Minerals/ Electrolytes
aminosyn ii 8.5 %-electrolytes intravenous parenteral solution
8.5 %
1
B vs D
AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL
SOLUTION 7 %
2
B vs D
clinimix 4.25%-d25w sulf-free intravenous parenteral solution
4.25 %
1
B vs D
d10 % & 0.45 % sodium chloride intravenous parenteral
solution
1
d2.5 %-0.45 % sodium chloride intravenous parenteral
solution
1
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
79
Drug Name
Tier
d5 % and 0.9 % sodium chloride intravenous parenteral
solution
1
d5 %-0.45 % sodium chloride intravenous parenteral solution
1
dextrose 10 % and 0.2 % nacl intravenous parenteral solution
1
dextrose 10 % in water (d10w) intravenous parenteral solution
10 %
1
dextrose 5 % in water (d5w) intravenous parenteral solution
1
dextrose 5 %-lactated ringers intravenous parenteral solution
1
dextrose 5%-0.2 % sod chloride intravenous parenteral
solution
1
dextrose 5%-0.3 % sod. chloride intravenous parenteral
solution
1
dextrose with sodium chloride intravenous parenteral solution
5-0.2 %
1
dextrose-kcl-nacl intravenous solution 5-0.224-0.225 %
1
intralipid intravenous emulsion 20 %
1
lactated ringers irrigation solution
1
levocarnitine oral tablet 330 mg
1
potassium chlorid-d5-0.45%nacl intravenous parenteral
solution 20 meq/l, 30 meq/l, 40 meq/l
1
potassium chloride in 5 % dex intravenous parenteral solution
20 meq/l, 40 meq/l
1
potassium chloride-d5-0.3%nacl intravenous parenteral
solution 20 meq/l
1
potassium chloride-d5-0.9%nacl intravenous parenteral
solution 20 meq/l, 40 meq/l
1
prenatal vitamins low iron oral tablet 27 mg iron- 1 mg
1
ringers intravenous parenteral solution
1
ringers irrigation solution
1
80
Requirements / Limits
B vs D
PA
B vs D
Index
8
8-MOP .................................. 58
A
abacavir ................................ 45
abacavir-lamivudinezidovudine ........................ 45
ABELCET ............................ 32
ABILIFY .............................. 42
ABILIFY DISCMELT ......... 42
ABILIFY MAINTENA .. 29, 42
ABRAXANE........................ 38
ABREVA ............................. 11
acamprosate .......................... 20
acarbose ................................ 47
acebutolol ............................. 52
acetaminophen ...................... 11
acetaminophen-codeine ........ 18
acetazolamide ....................... 55
acetazolamide sodium .......... 55
acetic acid ............................. 21
acetylcysteine ....................... 78
acitretin ................................. 58
ACTEMRA .......................... 70
ACTHIB (PF) ....................... 70
ACTIMMUNE ..................... 70
ACTONEL ........................... 72
acyclovir ............................... 44
acyclovir sodium .................. 44
ADACEL(TDAP
ADOLESN/ADULT)(PF) 70
ADAGEN ............................. 59
ADCIRCA ............................ 77
adefovir................................. 43
ADVAIR DISKUS ............... 75
ADVAIR HFA ..................... 76
afeditab cr ............................. 53
AFINITOR ........................... 38
AFINITOR DISPERZ .......... 68
AGGRENOX ....................... 51
a-hydrocort ........................... 62
ALAWAY ............................ 11
ALBENZA ........................... 40
albuterol sulfate .............. 76, 77
alcohol pads .......................... 21
ALDURAZYME .................. 59
alendronate ........................... 72
ALIMTA .............................. 36
ALINIA ................................ 40
ALL DAY ALLERGY-D..... 11
ALLERGY
(CHLORPHENIRAMINE)
.......................................... 11
allopurinol ............................ 33
ALOMIDE............................ 74
alprazolam ............................ 47
ALTALUBE ......................... 11
amantadine hcl ...................... 47
AMBISOME ........................ 32
amifostine crystalline ........... 38
amikacin ............................... 20
amiloride............................... 55
aminophylline ....................... 77
aminosyn ii 8.5 %-electrolytes
.......................................... 79
AMINOSYN-HBC 7%......... 79
amiodarone ..................... 51, 52
AMITIZA ............................. 60
amitriptyline ......................... 31
amlodipine ............................ 53
amlodipine-benazepril .......... 53
amnesteem ............................ 58
amoxapine ............................ 31
amoxicillin ............................ 23
amoxicillin-pot clavulanate .. 23
amphetamine salt combo ...... 56
amphotericin b ...................... 32
ampicillin .............................. 24
ampicillin sodium ................. 24
ampicillin-sulbactam ............ 24
anagrelide ............................. 50
anastrozole ............................ 38
ANDRODERM .................... 64
ANORO ELLIPTA............... 78
ANTACID ANTI-GAS ........ 11
ANTIBIOTIC + PAIN
RELIEF ............................ 11
APIDRA ............................... 48
APIDRA SOLOSTAR ......... 48
APOKYN ............................. 41
apraclonidine ........................ 74
apri ........................................ 65
APRODINE .......................... 11
APTIOM ......................... 27, 28
APTIVUS ............................. 46
ARCALYST ......................... 70
ARGATROBAN .................. 49
ARGATROBAN IN 0.9 %
SOD CHLOR.................... 49
aripiprazole ...........................42
ARRANON ..........................36
ARZERRA ........................... 39
ascomp with codeine ............ 18
ASMANEX TWISTHALER 76
aspirin ................................... 11
ASSURE ID INSULIN
SAFETY ........................... 48
atenolol ................................. 52
atenolol-chlorthalidone ......... 53
ATGAM ............................... 68
atorvastatin ........................... 55
atovaquone ............................ 40
atovaquone-proguanil ........... 40
ATRIPLA ............................. 45
atropine ................................. 59
ATROVENT HFA................ 76
AUBAGIO ............................ 57
aubra ..................................... 65
AUVI-Q ................................ 77
AVASTIN............................. 36
aviane .................................... 65
AVODART........................... 61
AVONEX ............................. 57
AVONEX (WITH ALBUMIN)
.......................................... 57
azacitidine ............................. 36
azathioprine .......................... 68
azelastine ........................ 74, 75
AZILECT ............................. 41
azithromycin ......................... 24
aztreonam ............................. 23
B
bacitracin ........................ 11, 21
bacitracin zinc ....................... 11
bacitracin-polymyxin b ...11, 73
baclofen ................................43
balsalazide ............................72
balziva (28) ...........................65
BANZEL .............................. 28
BARACLUDE ...................... 43
BELEODAQ......................... 36
benazepril ............................. 51
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
81
benazepril-hydrochlorothiazide
.......................................... 53
BENLYSTA ......................... 68
benzonatate ........................... 11
benzoyl peroxide .................. 11
benztropine ........................... 40
BETA-HC............................. 11
betamethasone dipropionate 58,
62
betamethasone valerate ........ 62
betamethasone, augmented... 62
BETASERON ...................... 57
betaxolol ......................... 52, 74
bethanechol chloride ............ 61
BETOPTIC S........................ 74
BEXSERO (PF).................... 70
bicalutamide ......................... 35
BICILLIN C-R ..................... 24
BICILLIN L-A ..................... 24
BICNU ................................. 36
BILTRICIDE........................ 40
BION TEARS (PF) .............. 11
bisacodyl............................... 11
BISMATROL ....................... 11
bismuth subsalicylate ........... 11
bisoprolol fumarate .............. 52
bisoprolol-hydrochlorothiazide
.......................................... 53
bleomycin ............................. 36
BLEPHAMIDE S.O.P. ......... 73
BOOSTRIX TDAP .............. 70
BOSULIF ............................. 38
BOUDREAUXS BUTT
PASTE.............................. 11
BRILINTA ........................... 51
brimonidine .......................... 74
BRINTELLIX ...................... 30
BROMFED DM ................... 11
BROMFENAC ..................... 75
bromocriptine ....................... 41
brompheniramine-pseudoephdm ..................................... 11
budesonide...................... 60, 76
bumetanide ........................... 55
buprenorphine hcl ................. 20
buprenorphine-naloxone....... 20
buproban ............................... 29
bupropion hcl........................ 29
buspirone .............................. 47
BUSULFEX ......................... 35
82
butalbital-acetaminop-caf-cod
.......................................... 18
butalbital-acetaminophen-caff
.......................................... 18
butalbital-aspirin-caffeine .... 18
butorphanol tartrate .............. 19
BYETTA .............................. 47
C
cabergoline ........................... 67
calamine................................ 12
calcipotriene ......................... 58
calcitonin (salmon) ............... 73
calcitriol ................................ 73
calcium acetate ..................... 61
calcium carbonate ................. 12
calcium gluconate ................. 12
calcium lactate ...................... 12
camila ................................... 66
CANASA.............................. 72
CANCIDAS.......................... 32
CAPASTAT ......................... 34
CAPRELSA.......................... 38
captopril ................................ 51
captopril-hydrochlorothiazide
.......................................... 53
carbamazepine ................ 28, 47
carbidopa-levodopa .............. 41
carbinoxamine maleate ......... 75
carboplatin ............................ 36
CARDEC DM (PHENYLEPHCHLORPHN) ................... 12
CARIMUNE NF
NANOFILTERED............ 69
carisoprodol .......................... 78
carteolol ................................ 74
cartia xt ................................. 53
carvedilol .............................. 52
cefaclor ................................. 22
cefadroxil .............................. 22
cefazolin ............................... 22
cefazolin in dextrose (iso-os) 22
cefdinir.................................. 22
cefepime ............................... 22
cefotaxime ............................ 22
cefoxitin ................................ 22
cefpodoxime ......................... 22
cefprozil .......................... 22, 23
ceftazidime ........................... 23
ceftriaxone ............................ 23
cefuroxime axetil .................. 23
cefuroxime sodium ............... 23
celecoxib ............................... 18
CELLCEPT INTRAVENOUS
.......................................... 68
CELONTIN .......................... 26
cephalexin ............................. 23
CERDELGA ......................... 59
CEREZYME......................... 59
CERVARIX VACCINE (PF)
.......................................... 70
cetirizine ......................... 12, 75
cetirizine-pseudoephedrine ... 12
CHANTIX ............................ 20
CHANTIX CONTINUING
MONTH BOX .................. 20
CHEMSTRIP 9 ..................... 12
chloramphenicol sod succinate
.......................................... 21
chlorhexidine gluconate........ 57
chloroquine phosphate .......... 40
chlorothiazide ....................... 55
chlorpheniramine maleate .... 12
chlorpromazine ..................... 31
chlorthalidone ....................... 55
cholecalciferol (vitamin d3) . 12
cholestyramine light ............. 56
ciclopirox .............................. 32
cidofovir ............................... 43
cilostazol ............................... 51
cimetidine ............................. 60
cimetidine hcl ....................... 60
CINRYZE ............................. 68
CIPRODEX .......................... 75
ciprofloxacin (mixture) ......... 25
ciprofloxacin hcl ................... 25
ciprofloxacin in 5 % dextrose
.......................................... 25
ciprofloxacin lactate ............. 25
cisplatin................................. 36
citalopram ............................. 30
CITRUCEL........................... 12
cladribine .............................. 36
clarithromycin....................... 24
clemastine ............................. 75
clindamycin hcl .................... 21
clindamycin in 5 % dextrose 21
clindamycin phosphate ......... 21
clindamycin-benzoyl peroxide
.......................................... 58
clinimix 4.25%-d25w sulf-free
.......................................... 79
clobetasol ........................ 58, 62
clobetasol-emollient ............. 62
clomipramine........................ 31
clonazepam ........................... 26
clonidine ............................... 51
clonidine hcl ................... 51, 56
clopidogrel ............................ 51
clorazepate dipotassium ....... 26
clotrimazole .................... 12, 32
clotrimazole-betamethasone . 58
clozapine............................... 43
COARTEM .......................... 40
COLACE .............................. 12
colchicine ............................. 33
colchicine-probenecid .......... 33
COLCRYS ........................... 33
colestipol .............................. 56
colistin (colistimethate na) ... 21
COMBIVENT RESPIMAT . 78
COMETRIQ ......................... 38
COMPLERA ........................ 45
compro.................................. 31
COMVAX (PF) .................... 70
CONCEPTROL.................... 12
CONDOMS-PREM
LUBRICATED................. 12
COPAXONE ........................ 57
COSMEGEN ........................ 36
COUMADIN ........................ 49
CREON ................................ 59
CRIXIVAN .......................... 46
cromolyn................... 12, 74, 77
CUBICIN ............................. 21
curity gauze .......................... 48
cyanocobalamin (vitamin b-12)
.......................................... 12
cyclobenzaprine .................... 78
cyclophosphamide ................ 35
CYCLOSET ......................... 47
cyclosporine ......................... 68
cyclosporine modified .......... 68
cyproheptadine ..................... 75
CYSTADANE...................... 59
CYSTAGON ........................ 59
cytarabine ............................. 36
cytarabine (pf) ...................... 36
CYTOMEL........................... 67
D
d10 % & 0.45 % sodium
chloride ............................. 79
d2.5 %-0.45 % sodium
chloride ............................. 79
d5 % and 0.9 % sodium
chloride ............................. 80
d5 %-0.45 % sodium chloride
.......................................... 80
dacarbazine ........................... 36
DALIRESP ........................... 77
danazol.................................. 64
DANDREX .......................... 12
dantrolene ............................. 43
dapsone ................................. 34
DAPTACEL (DTAP
PEDIATRIC) (PF) ............ 70
DARAPRIM ......................... 40
daunorubicin ......................... 36
DAUNOXOME .................... 36
decitabine.............................. 36
delyla (28)............................. 65
DELZICOL .......................... 60
demeclocycline ..................... 25
DEMSER .............................. 54
DEPEN TITRATABS .......... 61
DEPO-MEDROL ................. 62
DEPO-PROVERA................ 66
DEPO-TESTOSTERONE .... 64
desipramine .......................... 31
desmopressin ........................ 64
desonide ................................ 62
desoximetasone .................... 62
DESPEC EDA COUGH &
COLD DROPS ................. 12
desvenlafaxine ...................... 30
dexamethasone ..................... 62
dexamethasone intensol ........ 62
dexamethasone sodium
phosphate .............. 62, 63, 75
DEXFERRUM ..................... 12
dexmethylphenidate.............. 57
dexrazoxane hcl .................... 36
dextroamphetamine .............. 56
dextrose 10 % and 0.2 % nacl
.......................................... 80
dextrose 10 % in water (d10w)
.......................................... 80
dextrose 5 % in water (d5w). 80
dextrose 5 %-lactated ringers80
dextrose 5%-0.2 % sod
chloride ............................. 80
dextrose 5%-0.3 %
sod.chloride ......................80
dextrose with sodium chloride
..........................................80
dextrose-kcl-nacl ..................80
DIABETIC TUSSIN DM .....12
DIASTAT ............................. 47
DIASTAT ACUDIAL .......... 47
diazepam ............................... 26
DIAZEPAM ......................... 26
diazepam intensol ................. 26
DIBENZYLINE ................... 51
diclofenac potassium ............ 33
diclofenac sodium .... 18, 34, 58,
75
dicloxacillin .......................... 24
dicyclomine .................... 59, 60
didanosine ............................. 45
digitek ................................... 54
digoxin .................................. 54
dihydroergotamine ................ 34
DILANTIN ........................... 28
DILANTIN EXTENDED ..... 28
DILANTIN INFATABS ...... 28
DILANTIN-125 .................... 28
diltiazem hcl ......................... 53
dilt-xr .................................... 53
DIMETAPP COLDALLERGY (PE) ............... 12
DIMETAPP DM COLDCOUGH (PE).................... 12
DIOCTO ............................... 13
DIPENTUM ......................... 72
DIPHENHIST....................... 13
diphenhydramine hcl ...... 13, 31
diphenoxylate-atropine ......... 60
dipyridamole ......................... 51
disopyramide phosphate ....... 52
disulfiram .............................. 20
DIURIL................................. 55
divalproex ....................... 26, 27
DOCEFREZ ......................... 36
docetaxel ............................... 36
DOCETAXEL ...................... 36
docusate sodium ................... 13
DOCUSOL ........................... 13
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
83
donepezil .............................. 28
dorzolamide .......................... 74
dorzolamide-timolol ............. 74
doxazosin.............................. 61
doxepin ................................. 31
DOXIL ................................. 36
doxorubicin........................... 36
doxycycline hyclate ........ 25, 26
doxycycline monohydrate ... 26,
58
dronabinol............................. 32
DSS....................................... 13
DULCOLAX STOOL
SOFTENER (DSS)........... 13
duloxetine ............................. 30
duramorph (pf) ..................... 19
D-VI-SOL............................. 13
DYRENIUM ........................ 55
E
EAR WAX REMOVAL
SYSTEM .......................... 13
econazole .............................. 32
ED A-HIST DM ................... 13
ED CHLORPED JR ............. 13
EDECRIN............................. 55
EDURANT ........................... 45
ELAPRASE.......................... 59
ELIDEL ................................ 58
ELIGARD ............................ 67
ELITEK ................................ 36
ELLA .................................... 66
ELMIRON............................ 61
EMCYT ................................ 35
EMEND................................ 32
EMSAM ............................... 29
EMTRIVA............................ 45
enalapril maleate .................. 51
enalapril-hydrochlorothiazide
.......................................... 54
ENBREL ........................ 68, 69
ENGERIX-B (PF) ................ 70
ENGERIX-B PEDIATRIC
(PF) ................................... 70
ENJUVIA ............................. 65
enoxaparin ............................ 49
enpresse ................................ 65
entacapone ............................ 40
entecavir ............................... 43
epinephrine ........................... 77
EPIPEN 2-PAK .................... 77
84
EPIPEN JR 2-PAK ............... 77
epirubicin .............................. 36
EPIVIR HBV ........................ 43
EPOGEN .............................. 50
eprosartan ............................. 51
EPZICOM ............................ 45
ERBITUX ............................. 36
ergocalciferol (vitamin d2) ... 13
ergoloid................................. 28
ERGOMAR .......................... 34
ERIVEDGE .......................... 38
errin ...................................... 66
ERWINAZE ......................... 36
ery pads................................. 24
ERY-TAB ............................. 24
erythrocin.............................. 24
erythrocin (as stearate) ......... 24
erythromycin ........................ 25
erythromycin with ethanol.... 25
erythromycin-benzoyl peroxide
.......................................... 58
ESBRIET .............................. 78
escitalopram oxalate ............. 30
esomeprazole sodium ........... 61
estradiol ................................ 65
estropipate ............................ 65
ethambutol ............................ 34
ethosuximide ........................ 26
etidronate disodium .............. 73
etoposide............................... 38
EVOTAZ .............................. 46
EXCEDRIN EXTRA
STRENGTH ..................... 13
exemestane ........................... 38
EXJADE ............................... 78
EYE ITCH RELIEF ............. 13
F
FABRAZYME ..................... 59
falmina (28) .......................... 65
famciclovir............................ 44
famotidine....................... 13, 60
famotidine (pf) ...................... 60
FANAPT .............................. 42
FARESTON ......................... 35
FARYDAK ........................... 38
FASLODEX ......................... 37
FAZACLO............................ 43
felbamate .............................. 27
felodipine .............................. 53
fenofibrate ............................ 55
fenofibrate micronized.......... 55
fenofibrate nanocrystallized . 55
fentanyl ................................. 19
fentanyl citrate ...................... 19
ferrous sulfate ....................... 13
FERROUSUL ....................... 13
FETZIMA ............................. 30
FEVERALL .......................... 13
fexofenadine ......................... 13
FIBER-LAX ......................... 13
finasteride ............................. 61
FIRAZYR ............................. 68
FIRMAGON KIT W
DILUENT SYRINGE ...... 67
flavoxate ............................... 61
flecainide .............................. 52
FLOVENT HFA ................... 76
fluconazole ........................... 32
fluconazole in dextrose(iso-o)
.......................................... 32
flucytosine ............................ 32
fludarabine ............................ 38
fludrocortisone ...................... 63
flunisolide ............................. 76
fluocinolone .......................... 63
fluocinonide .......................... 63
fluocinonide-e ....................... 63
fluorouracil ........................... 58
fluoxetine ........................ 29, 30
fluphenazine decanoate ........ 41
fluphenazine hcl.................... 41
flurbiprofen ........................... 34
flurbiprofen sodium ..............75
flutamide ...............................35
fluticasone.......................58, 76
fluvoxamine ..........................30
FML FORTE ........................ 75
FOCALIN XR ...................... 57
folic acid ............................... 13
fondaparinux ......................... 50
FORTEO............................... 73
foscarnet ............................... 43
fosinopril............................... 51
fosinopril-hydrochlorothiazide
.......................................... 54
fosphenytoin ......................... 28
FOSRENOL ......................... 62
FRAGMIN ............................ 50
furosemide ............................ 55
FUZEON .............................. 46
FYCOMPA .......................... 27
G
gabapentin ............................ 27
GABITRIL ........................... 27
galantamine .................... 28, 29
GAMMAGARD LIQUID .... 69
ganciclovir sodium ............... 43
GARDASIL (PF).................. 71
GARDASIL 9 (PF)............... 71
GAS RELIEF ....................... 13
gavilyte-c .............................. 60
gavilyte-g .............................. 60
gavilyte-n .............................. 60
gemcitabine .......................... 36
gemfibrozil ........................... 55
gengraf .................................. 69
GENOTROPIN .................... 64
GENOTROPIN MINIQUICK
.......................................... 64
gentak ................................... 20
gentamicin ............................ 20
gentamicin in nacl (iso-osm) 20
gentamicin sulfate (pf) ......... 20
GENTEAL MILD ................ 13
GENTLE LAXATIVE ......... 13
GEODON ............................. 42
gildess ................................... 65
GILENYA ............................ 57
GILOTRIF ............................ 38
GLEEVEC ............................ 38
glimepiride ........................... 47
glipizide .......................... 47, 48
glipizide-metformin.............. 48
GLUCAGEN HYPOKIT ..... 48
GLUCAGON EMERGENCY
KIT (HUMAN) ................ 48
glucose .................................. 13
glyburide............................... 48
glyburide micronized............ 48
glyburide-metformin ............ 48
glycopyrrolate....................... 60
granisetron (pf) ..................... 32
granisetron hcl ...................... 32
griseofulvin microsize .......... 32
guaifenesin ........................... 14
GUAIFENESIN AC ............. 14
guanfacine ...................... 51, 57
guanidine .............................. 34
GYNOL II ............................ 14
H
HALAVEN ........................... 37
halobetasol propionate .......... 63
haloperidol ............................ 41
haloperidol decanoate ........... 41
haloperidol lactate ................ 41
HARVONI............................ 44
HAVRIX (PF) ...................... 71
heparin (porcine) .................. 50
heparin (porcine) in 5 % dex 50
HERCEPTIN ........................ 37
HEXALEN ........................... 35
HIBICLENS ......................... 14
HUMALOG.......................... 49
HUMALOG MIX 50-50 ...... 48
HUMALOG MIX 75-25 ...... 49
HUMIRA .............................. 69
HUMIRA CROHN'S DIS
START PCK..................... 69
HUMULIN 70/30 ................. 49
HUMULIN N ....................... 49
HUMULIN R ....................... 49
hydralazine ........................... 56
HYDRISALIC ...................... 14
hydrochlorothiazide .............. 55
hydrocodone-acetaminophen 18
hydrocodone-ibuprofen ........ 18
hydrocortisone .......... 14, 63, 72
hydrocortisone butyrate ........ 63
hydrocortisone valerate ........ 63
hydrocortisone-acetic acid .... 75
hydrocortisone-aloe vera ...... 14
HYDROMET ....................... 14
hydromorphone .................... 19
hydromorphone (pf) ............. 19
hydroxychloroquine.............. 40
hydroxyurea .......................... 36
hydroxyzine hcl .................... 31
hydroxyzine pamoate ........... 31
I
ibandronate ........................... 73
IBRANCE ............................ 38
ibuprofen ........................ 18, 34
ICLUSIG .............................. 39
idarubicin .............................. 37
IFEX ..................................... 37
ifosfamide ............................. 37
ILARIS (PF) ......................... 70
IMBRUVICA ....................... 39
imipenem-cilastatin ..............23
imipramine hcl ......................31
imipramine pamoate .............31
imiquimod............................. 58
IMOVAX RABIES VACCINE
(PF) ................................... 71
INCRELEX .......................... 64
indapamide ........................... 55
indomethacin .................. 18, 34
INFANRIX (DTAP) (PF) ..... 71
INFANTS GAS RELIEF ......14
INLYTA ............................... 39
INSULIN PEN NEEDLE ..... 49
INSULIN SYRINGE ............ 49
INSULIN SYRINGE
NEEDLELESS ................. 49
INSULIN SYRINGENEEDLE U-100 ............... 49
INTELENCE ........................ 45
intralipid ............................... 80
INTRON A ..................... 43, 44
INTUNIV ER ....................... 57
INVANZ ............................... 23
INVEGA ............................... 42
INVEGA SUSTENNA ......... 42
INVIRASE ........................... 46
IPOL ..................................... 71
ipratropium bromide ............. 76
ipratropium-albuterol ............78
irinotecan .............................. 37
ISENTRESS ......................... 45
ISOLYTE-S .......................... 79
isoniazid .......................... 34, 35
ISOPTO TEARS .................. 14
isosorbide dinitrate ............... 56
isosorbide mononitrate ......... 56
ISTODAX............................. 37
itraconazole........................... 33
IXEMPRA ............................ 37
IXIARO (PF) ........................ 71
J
JAKAFI ................................ 39
jantoven ................................ 50
JANUMET ........................... 48
JANUVIA ............................. 48
JEVTANA ............................ 37
jinteli ..................................... 65
junel 1/20 (21) ...................... 65
junel fe 1.5/30 (28) ............... 65
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
85
junel fe 1/20 (28) .................. 65
K
KADCYLA .......................... 37
KALETRA ........................... 46
KAO-TIN (BISMUTH
SUBSALICYLAT)........... 14
ketoconazole ......................... 33
ketorolac ............................... 75
KEYTRUDA ........................ 39
KINERET ............................. 69
klor-con 10 ........................... 79
klor-con 8 ............................. 79
klor-con m15 ........................ 79
klor-con m20 ........................ 79
k-tab...................................... 79
KUVAN ............................... 59
L
labetalol ................................ 52
LACRISERT ........................ 74
lactated ringers ..................... 80
lactulose................................ 60
lamivudine ...................... 44, 45
lamivudine-zidovudine ......... 45
lamotrigine ........................... 27
LANOXIN ............................ 54
lansoprazole.......................... 61
LANTUS .............................. 49
LANTUS SOLOSTAR ........ 49
larin 1.5/30 (21) .................... 65
latanoprost ............................ 75
LATUDA ............................. 42
LAZANDA........................... 19
leena 28 ................................ 65
leflunomide........................... 70
LENVIMA ........................... 39
lessina ................................... 65
LETAIRIS ............................ 77
letrozole ................................ 38
leucovorin calcium ............... 38
LEUKERAN ........................ 35
LEUKINE............................. 50
leuprolide.............................. 67
levalbuterol hcl ..................... 77
LEVEMIR ............................ 49
levetiracetam ........................ 26
levobunolol ........................... 74
levocarnitine ......................... 80
levocetirizine ........................ 75
levofloxacin .......................... 25
levonorgestrel-ethinyl estrad 65
86
levora-28 ............................... 65
levothyroxine ........................ 67
levoxyl .................................. 67
LEXIVA ............................... 46
lidocaine ............................... 19
lidocaine (pf) ........................ 19
lidocaine hcl ......................... 19
lidocaine-prilocaine .............. 19
LINCOCIN ........................... 21
linezolid ................................ 21
liothyronine .......................... 67
LIQUID ANTACID EXTRA
STRENGTH ..................... 14
lisinopril................................ 51
lisinopril-hydrochlorothiazide
.......................................... 54
lithium carbonate .................. 47
lithium citrate ....................... 47
LOHIST - D.......................... 14
LOMUSTINE ....................... 35
loperamide ...................... 14, 60
loratadine .............................. 14
LORATADINE-D ................ 14
lorazepam ............................. 27
losartan ................................. 51
losartan-hydrochlorothiazide 54
LOTRONEX ........................ 60
lovastatin .............................. 55
low-ogestrel (28) .................. 65
loxapine succinate ................ 41
LUBRIFRESH PM ............... 14
LUPRON DEPOT ................ 68
LUPRON DEPOT (3
MONTH) .......................... 67
LUPRON DEPOT (4
MONTH) .......................... 67
LUPRON DEPOT (6
MONTH) .......................... 68
LUPRON DEPOT-PED ....... 68
LYNPARZA ......................... 37
LYRICA ............................... 26
LYSODREN ......................... 67
M
MACRODANTIN ................ 21
magnesium oxide.................. 14
MAGTAB ............................. 14
malathion .............................. 40
mapap (acetaminophen) ....... 14
maprotiline............................ 29
MARPLAN .......................... 29
MATULANE ........................ 35
meclizine......................... 14, 31
MEDI-FIRST ANTI-FUNGAL
.......................................... 14
medroxyprogesterone ........... 66
mefloquine ............................ 40
megestrol .............................. 67
MEKINIST ........................... 39
meloxicam ............................ 18
melphalan hcl........................ 35
MENACTRA (PF)................ 71
MENEST .............................. 65
MENOMUNE - A/C/Y/W-135
(PF) ...................................71
MENVEO A-C-Y-W-135-DIP
(PF) ...................................71
MEPHYTON ........................14
meprobamate ........................ 47
mercaptopurine ..................... 69
meropenem ........................... 23
mesalamine with cleansing
wipe .................................. 72
mesna .................................... 37
MESNEX .............................. 37
METAMUCIL ...................... 14
METAMUCIL SMOOTH
(WITH SUGAR) .............. 14
METAMUCIL SUGAR-FREE
(ASPART) ........................ 14
metaproterenol ...................... 77
metformin ............................. 48
methazolamide ...................... 55
methimazole ......................... 68
METHITEST ........................ 64
methocarbamol ..................... 78
methotrexate sodium ............ 69
methotrexate sodium (pf) ..... 69
methoxsalen rapid ................. 58
methyldopa ........................... 51
methyldopahydrochlorothiazide .......... 54
methylphenidate ................... 57
methylprednisolone ........ 63, 72
methylprednisolone acetate .. 63
metipranolol .......................... 74
metoclopramide hcl .............. 60
metolazone ............................ 55
metoprolol succinate ............. 52
metoprolol ta-hydrochlorothiaz
.......................................... 54
metoprolol tartrate ................ 52
metronidazole ................. 21, 22
metronidazole in nacl (iso-os)
.......................................... 21
mexiletine ............................. 52
MIACALCIN ....................... 73
MICADERM ........................ 14
miconazole nitrate ................ 15
miconazole-3 ........................ 33
MICONAZOLE-3 ................ 15
microgestin 1.5/30 (21) ........ 65
microgestin 1/20 (21) ........... 65
microgestin fe 1.5/30 (28) .... 66
microgestin fe 1/20 (28) ....... 66
midodrine ............................. 51
MIGERGOT ......................... 34
MILK OF MAGNESIA ....... 15
minocycline .......................... 26
minoxidil .............................. 56
mirtazapine ........................... 29
misoprostol ........................... 61
mitomycin............................. 37
mitoxantrone......................... 38
M-M-R II (PF)...................... 71
modafinil .............................. 78
moexipril .............................. 51
moexipril-hydrochlorothiazide
.......................................... 54
mometasone.......................... 63
MONISTAT 3 ...................... 15
montelukast .......................... 76
morphine............................... 19
morphine concentrate ........... 19
MOZOBIL............................ 50
MUCINEX ........................... 15
MUCINEX COUGH MINIMELTS ............................. 15
MUCINEX DM .................... 15
MULTAQ ............................. 52
mupirocin ............................. 22
mupirocin calcium ................ 22
MURO 128 ........................... 15
MUSTARGEN ..................... 37
MY WAY ............................. 15
MYCAMINE........................ 33
mycophenolate mofetil ......... 69
mycophenolate sodium ......... 69
MYOZYME ......................... 59
N
nabumetone .......................... 18
nadolol .................................. 52
nadolol-bendroflumethiazide 54
nafcillin................................. 24
NAGLAZYME ..................... 59
nalbuphine ............................ 19
naloxone ............................... 20
naltrexone ............................. 20
NAMENDA.......................... 29
NAMENDA XR ................... 29
naphazoline........................... 74
NAPHCON-A ...................... 15
naproxen ......................... 19, 34
naratriptan ............................. 34
NATACYN .......................... 33
nateglinide ............................ 48
NATPARA ........................... 73
NATURAL BALANCE ....... 15
NEBUPENT ......................... 40
necon 0.5/35 (28) .................. 66
necon 1/35 (28) ..................... 66
necon 10/11 (28) ................... 66
necon 7/7/7 (28).................... 66
nefazodone............................ 29
neomycin .............................. 20
neomycin-bacitracin-poly-hc 73
neomycin-polymyxin b gu.... 20
neomycin-polymyxin bdexameth .......................... 73
neomycin-polymyxingramicidin......................... 74
neomycin-polymyxin-hc 74, 75
NEPHRO-VITE.................... 15
NESSI SPACER ................... 15
NEULASTA ......................... 50
NEUMEGA .......................... 50
NEUPOGEN ........................ 50
NEUPRO .............................. 41
NEUTRAHIST ..................... 15
nevirapine ............................. 45
NEXAVAR .......................... 39
niacin .............................. 15, 56
niacor .................................... 56
nicardipine ............................ 53
NICORETTE ........................ 15
nicotine ................................. 15
nicotine (polacrilex) ............. 15
NICOTROL .......................... 20
NICOTROL NS .................... 20
nifedical xl ............................ 53
nifedipine .............................. 53
NILANDRON ...................... 35
nitrofurantoin ........................ 22
nitrofurantoin macrocrystal .. 22
nitrofurantoin monohyd/mcryst .................................. 22
nitroglycerin ......................... 56
NITROSTAT ........................ 56
norethindrone acetate............67
norlyroc.................................66
nortrel 0.5/35 (28) .................66
nortrel 1/35 (28) ....................66
nortrel 7/7/7 (28)...................66
nortriptyline ..........................31
NORVIR ...............................46
NOVOLIN 70/30 ..................49
NOVOLIN N ........................49
NOVOLIN R ........................49
NOVOLOG ..........................49
NOVOLOG MIX 70-30 .......49
NOXAFIL.............................33
NUEDEXTA ........................57
NULOJIX .............................69
nystatin .................................33
nystatin-triamcinolone ..........58
O
OCEAN NASAL ..................15
octreotide acetate ..................68
OFEV ....................................78
ofloxacin ...............................25
olanzapine .............................42
olanzapine-fluoxetine ........... 29
OLYSIO ...............................44
omega-3 acid ethyl esters .....56
omeprazole .....................15, 61
OMNITROPE ....................... 64
ONCASPAR ......................... 38
ondansetron........................... 32
ondansetron hcl ..................... 32
ondansetron hcl (pf) ..............32
ONFI .....................................27
OPDIVO ...............................39
ORAP ...................................42
ORENCIA ............................69
ORENCIA (WITH
MALTOSE) ......................69
ORFADIN ............................59
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
87
oxacillin ................................ 24
oxaliplatin ............................. 37
oxandrolone .......................... 64
oxcarbazepine ....................... 28
OXSORALEN...................... 58
oxybutynin chloride.............. 61
oxycodone ............................ 19
oxycodone-acetaminophen ... 18
P
paclitaxel .............................. 37
PAIN & FEVER ................... 15
pamidronate .......................... 73
PANDA MASK.................... 15
PANRETIN .......................... 39
pantoprazole ......................... 61
paricalcitol ............................ 73
paromomycin ........................ 20
paroxetine hcl ....................... 30
PASER ................................. 35
PATADAY ........................... 74
PATANOL ........................... 74
PAXIL .................................. 30
PAZEO ................................. 74
PEAK AIR PEAK FLOW
METER ............................ 15
PEDIA-LAX STOOL
SOFTENER ...................... 16
PEDIALYTE ........................ 16
PEDIATRIC ELECTROLYTE
.......................................... 16
PEDIATRIC MEDIUM
MASK .............................. 16
PEDVAX HIB (PF).............. 71
PEGANONE ........................ 28
PEGASYS ............................ 44
PEGASYS PROCLICK ....... 44
PEGINTRON ....................... 44
PEGINTRON REDIPEN ..... 44
penicillin g potassium........... 24
penicillin g procaine ............. 24
penicillin g sodium ............... 24
penicillin v potassium........... 24
PENTAM ............................. 40
pentoxifylline ....................... 54
PEPTO-BISMOL ................. 16
PERJETA ............................. 37
permethrin ...................... 16, 40
perphenazine......................... 31
phenelzine............................. 29
phenobarbital ........................ 27
88
PHENYTEK ......................... 28
phenytoin .............................. 28
phenytoin sodium ................. 28
phenytoin sodium extended .. 28
phospholine iodide ............... 74
physiolyte ............................. 79
pilocarpine hcl ...................... 57
pindolol................................. 52
PINK BISMUTH .................. 16
pioglitazone .......................... 48
pioglitazone-glimepiride ...... 48
pioglitazone-metformin ........ 48
piperacillin-tazobactam ........ 24
PLASMA-LYTE 148 ........... 79
PLASMA-LYTE A .............. 79
podofilox .............................. 58
polyethylene glycol 3350 ..... 60
polymyxin b sulf-trimethoprim
.......................................... 74
polyvinyl alcohol .................. 16
POMALYST ........................ 35
portia..................................... 66
potassium chlorid-d50.45%nacl ......................... 80
potassium chloride................ 79
potassium chloride in 5 % dex
.......................................... 80
potassium chloride-d50.3%nacl ........................... 80
potassium chloride-d50.9%nacl ........................... 80
POTIGA ............................... 26
povidone-iodine .................... 16
PRADAXA........................... 50
pramipexole .......................... 41
pravastatin ............................ 55
prazosin ................................ 51
prednicarbate .................. 58, 63
prednisolone acetate ............. 74
prednisolone sodium phosphate
.................................... 63, 75
prednisone ............................ 63
prednisone intensol ............... 63
PREMARIN ......................... 65
PREMPRO ........................... 66
PRENATAL VITAMIN ....... 16
PRENATAL VITAMIN WITH
MINERALS...................... 16
prenatal vitamins low iron .... 80
previfem................................ 66
PREZCOBIX ........................ 46
PREZISTA ........................... 46
PRIFTIN ...............................34
PRILOSEC OTC ..................16
primaquine ............................ 40
primidone .............................. 27
PRIMSOL ............................. 22
probenecid ............................ 33
procainamide ........................ 52
prochlorperazine ................... 31
prochlorperazine edisylate .... 31
prochlorperazine maleate......31
PROCRIT .............................50
proctosol hc .......................... 72
proctozone-hc ....................... 60
PROCYSBI........................... 59
PROGLYCEM ..................... 48
PROGRAF ............................ 69
PROLEUKIN ....................... 37
PROLIA ................................ 73
PROMACTA ........................ 50
promethazine .................. 31, 32
promethazine vc.................... 78
PROMETHAZINE VCCODEINE......................... 16
promethazine-codeine........... 16
promethazine-dm .................. 16
promethegan ......................... 32
propafenone .......................... 52
proparacaine ......................... 74
propranolol ........................... 52
propranolol-hydrochlorothiazid
.......................................... 54
propylene glycol ................... 16
propylthiouracil .................... 68
PROQUAD (PF) ................... 71
protriptyline .......................... 31
pseudoephedrine hcl ............. 16
PULMICORT FLEXHALER
.......................................... 76
PULMOZYME ..................... 78
PURE & GENTLE EYE ...... 16
PURIXAN ............................ 36
pyrazinamide ........................ 35
pyridostigmine bromide........34
pyridoxine ............................. 16
Q
Q-PAP................................... 16
Q-TAPP ................................ 16
Q-TAPP DM ......................... 16
Q-TUSSIN DM .................... 16
QUADRACEL (PF) ............. 71
quasense ............................... 66
quetiapine ............................. 42
quinapril ............................... 51
quinapril-hydrochlorothiazide
.......................................... 54
quinidine gluconate .............. 52
quinidine sulfate ................... 52
quinine sulfate ...................... 40
QVAR................................... 76
R
RABAVERT (PF) ................ 71
raloxifene.............................. 67
ramipril ................................. 51
RANEXA ............................. 54
ranitidine hcl ................... 16, 60
RAPAMUNE ....................... 69
REBIF (WITH ALBUMIN) . 57
REBIF REBIDOSE ........ 33, 57
REBIF TITRATION PACK 57
reclipsen (28) ........................ 66
RECOMBIVAX HB (PF) .... 71
REESE'S PINWORM
MEDICINE ...................... 16
REFRESH TEARS............... 16
RELENZA DISKHALER .... 47
RELISTOR ........................... 60
REMICADE ......................... 69
REMODULIN ...................... 77
RENAGEL ........................... 62
repaglinide ............................ 48
RESCRIPTOR ...................... 45
RESTASIS ........................... 74
RETROVIR .......................... 45
REVLIMID .................... 35, 38
REYATAZ ........................... 46
ribavirin ................................ 44
RID COMPLETE LICE ELIM
KIT ................................... 16
RIDAURA............................ 70
rifabutin ................................ 34
RIFAMATE ......................... 35
rifampin ................................ 35
RIFATER ............................. 35
riluzole.................................. 57
rimantadine ........................... 47
ringers ................................... 80
risedronate ...................... 58, 73
RISPERDAL CONSTA ....... 42
risperidone ...................... 42, 43
RITUXAN ............................ 39
rivastigmine tartrate .............. 29
rizatriptan.............................. 34
ROBITUSSIN PEDIATRIC 16
ropinirole .............................. 41
ROTARIX ............................ 71
ROTATEQ VACCINE......... 71
ROZEREM ........................... 78
S
SABRIL ................................ 27
SALACTIC FILM ................ 17
SANDOSTATIN LAR
DEPOT ............................. 68
SANI-SUPP (ADULT)......... 17
SANI-SUPP (CHILD) .......... 17
SANTYL .............................. 58
SAPHRIS (BLACK
CHERRY) ........................ 43
SCALPICIN ANTI-ITCH .... 17
SCOT-TUSSIN SENIOR ..... 17
selegiline hcl ......................... 41
selenium sulfide.................... 58
SELSUN BLUE WITH
MENTHOL ...................... 17
SELZENTRY ....................... 46
SENNA................................. 17
SENNA LAX ....................... 17
SENNA PLUS ...................... 17
SENSIPAR ........................... 67
SEREVENT DISKUS .......... 77
sertraline ............................... 30
SILACE ................................ 17
sildenafil ............................... 77
silver sulfadiazine ................. 25
simethicone........................... 17
SIMULECT .......................... 69
simvastatin ............................ 55
sirolimus ............................... 69
sodium chloride .............. 17, 79
sodium chloride 0.9 % .......... 79
sodium chloride 3 % ............. 79
sodium chloride 5 % ............. 79
sodium fluoride..................... 79
sodium phenylbutyrate ......... 61
sodium polystyrene (sorb free)
.......................................... 78
SOLTAMOX ........................ 35
SOLU-CORTEF (PF) ...........63
SOLU-MEDROL ................. 64
SOLU-MEDROL (PF) ......... 64
SOMATULINE DEPOT ...... 68
SOMAVERT ........................ 68
sotalol ................................... 52
sotalol af ............................... 52
SOVALDI............................. 44
SPIRIVA RESPIMAT .......... 76
SPIRIVA WITH
HANDIHALER ................ 76
spironolactone....................... 55
spironolacton-hydrochlorothiaz
.......................................... 54
SPORANOX......................... 33
sprintec (28) .......................... 66
SPRYCEL............................. 39
sronyx ................................... 66
ssd ......................................... 25
stavudine ............................... 46
STIMATE ............................. 64
STIVARGA .......................... 39
STOOL SOFTENER ............17
STRATTERA ....................... 57
streptomycin ......................... 20
STRIBILD ............................ 45
sucralfate............................... 61
SUDOGEST COLD &
ALLERGY ....................... 17
sulfacetamide sodium ........... 25
sulfacetamide sodium (acne) 25
sulfacetamide-prednisolone .. 74
sulfadiazine ........................... 25
sulfamethoxazole-trimethoprim
.......................................... 25
sulfasalazine ......................... 72
sulfazine ec ........................... 72
sulindac ................................. 34
sumatriptan succinate ........... 34
SUPRAX .............................. 23
SURMONTIL ....................... 31
SUSTIVA ............................. 45
SUTENT ............................... 39
SYLATRON ......................... 44
SYLVANT ........................... 39
SYMLINPEN 60 .................. 48
SYNAGIS ............................. 70
SYNAREL............................ 68
SYNERCID .......................... 21
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
89
SYNRIBO ............................ 38
SYNTHROID ....................... 67
SYPRINE ............................. 78
SYSTANE NIGHTTIME..... 17
T
TABLOID ............................ 36
tacrolimus ....................... 59, 69
TAFINLAR .......................... 39
TAMIFLU ............................ 47
tamoxifen.............................. 36
tamsulosin............................. 61
TARCEVA ........................... 39
TARGRETIN ....................... 39
TASIGNA ............................ 39
TASMAR ............................. 40
TAZORAC ........................... 59
taztia xt ................................. 53
TEARS NATURALE II ....... 17
TEFLARO ............................ 23
terazosin ............................... 61
terbinafine hcl ................. 17, 33
terbutaline ............................. 77
terconazole ........................... 33
testosterone cypionate .......... 64
testosterone enanthate .......... 65
TESTRED ............................ 65
TETANUS
TOXOID,ADSORBED (PF)
.......................................... 71
tetanus,diphtheria tox ped(pf)
.......................................... 72
TETANUS-DIPHTHERIA
TOXOIDS-TD.................. 72
THALOMID......................... 35
theophylline .......................... 77
thiamine hcl .......................... 17
thiamine mononitrate............ 17
thioridazine ........................... 42
thiothixene ............................ 42
THYMOGLOBULIN ........... 70
tiagabine ............................... 27
TIKOSYN ............................ 52
timolol maleate ............... 52, 74
TIVICAY ............................. 45
tizanidine .............................. 43
TOBI PODHALER .............. 20
TOBRADEX ........................ 21
tobramycin ............................ 21
tobramycin in 0.225 % nacl . 21
tobramycin sulfate ................ 21
90
tobramycin-dexamethasone .. 74
TOBREX .............................. 21
tolcapone .............................. 40
tolnaftate ............................... 17
tolterodine............................. 61
topiramate ............................. 27
toposar .................................. 38
topotecan .............................. 38
TORISEL.............................. 69
torsemide .............................. 55
TRACLEER ......................... 78
tramadol ................................ 19
tramadol-acetaminophen ...... 18
trandolapril ........................... 51
tranexamic acid............... 50, 51
TRANSDERM-SCOP .......... 60
tranylcypromine.................... 29
TRAVATAN Z..................... 75
travoprost (benzalkonium) ... 75
trazodone .............................. 29
TREANDA ........................... 37
TRECATOR ......................... 35
tretinoin ................................ 40
tretinoin (chemotherapy) ...... 40
triamcinolone acetonide . 58, 64
triamterene-hydrochlorothiazid
.......................................... 54
trifluoperazine ...................... 42
trifluridine............................. 44
trihexyphenidyl ..................... 40
tri-legest fe ............................ 66
trileptal.................................. 28
trilyte with flavor packets ..... 61
trimethoprim ......................... 22
trinessa (28) .......................... 66
TRIPLE ANTIBIOTIC......... 17
TRIPLE ANTIBIOTIC PLUS
.......................................... 17
tri-previfem (28) ................... 66
TRISENOX .......................... 37
tri-sprintec (28) ..................... 66
TRIUMEQ ............................ 46
TRI-VI-SOL WITH IRON ... 17
TRI-VITAMIN ..................... 17
trivora (28) ............................ 66
trospium ................................ 61
TRUMENBA........................ 72
TRUVADA .......................... 46
TUDORZA PRESSAIR ....... 76
TUSSIN CF .......................... 17
TWINRIX (PF) ..................... 72
TYBOST............................... 46
TYGACIL.............................22
TYKERB .............................. 39
TYPHIM VI.......................... 72
TYSABRI ............................. 70
TYZEKA .............................. 44
U
UNISOM SLEEPGELS........17
unithroid ...............................67
ursodiol .................................60
UVADEX .............................59
V
VAGINAL
CONTRACEPTIVE FILM
..........................................18
valacyclovir .................... 44, 45
VALCHLOR ........................ 59
VALCYTE ........................... 43
valganciclovir ....................... 43
valproate sodium .................. 27
valproic acid ......................... 27
valproic acid (as sodium salt)
.......................................... 27
valsartan-hydrochlorothiazide
.......................................... 54
vancomycin........................... 22
VAQTA (PF) ........................ 72
VARIVAX (PF).................... 72
VECTIBIX ........................... 37
VELCADE ........................... 37
venlafaxine ........................... 30
VENTOLIN HFA ................. 77
verapamil .............................. 53
VERSACLOZ....................... 43
VIBRAMYCIN .................... 26
VICTRELIS .......................... 44
VIDEX 2 GRAM PEDIATRIC
.......................................... 46
VIGAMOX ........................... 25
VIIBRYD ............................. 30
VIMPAT ............................... 28
vinblastine............................. 37
vincasar pfs ........................... 37
vincristine ............................. 37
vinorelbine ............................ 37
VIRACEPT........................... 46
VIRAMUNE XR .................. 45
VIRAZOLE .......................... 44
VIREAD ............................... 44
VITAMIN B-1...................... 18
VITAMIN B-12.................... 18
VITAMIN B-6...................... 18
VITAMIN D3....................... 18
VITEKTA............................. 45
voriconazole ......................... 33
VOTRIENT .......................... 39
VYTORIN 10-10.................. 54
VYTORIN 10-20.................. 54
VYTORIN 10-40.................. 54
W
warfarin ................................ 50
WELCHOL .......................... 56
X
XALKORI ............................ 39
XARELTO ........................... 50
XENAZINE .......................... 57
XGEVA ................................ 73
XOLAIR ............................... 78
XTANDI............................... 35
XYREM................................ 78
Y
YERVOY ............................. 38
YF-VAX (PF) ....................... 72
Z
ZADITOR ............................ 18
zafirlukast ............................. 76
zaleplon ................................ 78
ZALTRAP ............................ 38
ZANOSAR ........................... 21
ZAVESCA............................ 59
ZELAPAR ............................ 41
ZELBORAF ......................... 39
ZEMAIRA ............................ 78
ZENPEP ............................... 59
ZETIA .................................. 56
ZIAGEN ............................... 46
zidovudine ............................ 46
zinc gluconate ....................... 18
zinc oxide ............................. 18
ziprasidone hcl ......................43
ZIRGAN ...............................43
zoledronic acid......................73
zoledronic acid-mannitol-water
..........................................73
ZOLINZA .............................33
zolpidem ...............................78
ZOMETA .............................73
zonisamide ............................26
ZORTRESS ..........................69
ZOSTAVAX (PF) ................72
zovia 1/35e (28) .................... 66
zovia 1/50e (28) .................... 66
ZYDELIG ............................. 38
ZYKADIA ............................ 39
ZYPREXA RELPREVV ......43
ZYTIGA ............................... 35
ZYVOX ................................ 22
You can find information on what the symbols and abbreviations in this table mean by going to page 7.
91
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Formulary
IEHP DualChoice Cal MediConnect Plan
(Medicare-Medicaid Plan)
IEHP DualChoice
P.O. Box 1800, Rancho Cucamonga, CA 91729-1800
©2015 Inland Empire Health Plan. All Rights Reserved. Updated: July 28, 2015
H5355_CMC_15_03608_Final_2 Approved
1-877-273-IEHP (4347)
1-800-718-4347 TTY
August
2015