Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
2015 Lististahan ng
Mga Sakop na Gamot
(Formulary)
Ini-update ang listahan ng gamot na ito noong .
12/1/2015 Kung mayroon kayong mga
katanungan, mangyaring tawagan ang Health Net Cal MediConnect sa 1-855-464-3571
para sa Los Angeles County o sa 1-855-464-3572 para sa San Diego County, TTY: 711,
24 oras bawat araw, 7 araw bawat linggo. Libre ang tawag. Para sa karagdagang
impormasyon, pumunta sa www.healthnet.com/calmediconnect.
Formulary ID: 15417 Version: 37
Material ID #H3237_2015_0095_A_TAG CMS Approved 09112014
Listahan ito ng mga gamot na makukuha ng mga miyembro sa
Health Net Cal MediConnect.
• "OH )FBMUI /FU $Bl MFEJ$POOFDU
BZ JTBOH QMBOPOH QBOHLBMVTVHBO OB
OBLBLPOUSBUB TB .FEJDBSF BU .FEJ$BM
VQBOH NBHCJHBZ OH NHB CFOFQJTZP OH
LBQXBOH QSPHSBNB TB NHB OBLBFOSPM
• "OH NHB #FOFQJTZP -JTUBIBO OH .HB
4BLPQ OB (BNPU NHB OFUXPSL OH
UBHBQBHMBBO BUP NHB DPQBZNFOU BZ
NBBBSJOH NBHCBHP QBOBQBOBIPO TB
CVPOH UBPO BU TB &OFSP OH CBXBU UBPO
• "OVNBOH PSBT BZ NBUJUJOHOBO NP
POMJOF BOH OBTBTBQBOBIPOH -JTUBIBO
OH .HB 4BLPQ OB (BNPU OH )FBMUI /FU
$Bl .FEJ$POOFDU TB XXXIFBMUIOFUDPN
DBMNFEJDPOOFDU P TB QBNBNBHJUBO OH
QBHUBXBH TB QBSB TB
-PT "OHFMFT $PVOUZ P TB QBSB TB 4BO %JFHP $PVOUZ 55: • .BBBSJ NPOH IJOHJO BOH JNQPSNBTZPO
OB JUP TB JCBOH NHB BZPT UVMBE OH
#SBJMMF P NBMBLJOH MFUSB 5VNBXBH
TB QBSB TB -PT "OHFMFT
$PVOUZ P TB QBSB TB
4BO %JFHP $PVOUZ 55: -JCSF BOg tBXBH
• .BBBSJOH QBJSBMJO BOH NHB MJNJUBTZPO
DPQBZ BU SFTUSJLTZPO 1BSB TB
LBSBHEBHBOH JNQPSNBTZPO UBXBHBO
BOH )FBMUI /FU $Bl MFEJ$POOFDU
.FNCFS 4FSWJDFT P CBTBIJO BOH
)BOECPPL OH .JZFNCSP OH )FBMUI /FU
$Bl MFEJ$POOFDU
• "OH NHB DPQBZ QBSB TB NHB JOJSFTFUBOH
HBNPU BZ NBBBSJOH NBHJCB CBUBZ TB
BOUBT OH %BHEBH OB 5VMPOH OB JOZPOH
OBUBUBOHHBQ .BOHZBSJOH NBLJQBH
VHOBZBOBO TB QMBOP QBSB TB NHB EFUBMZF
• :PV DBO HFU UIJT JOGPSNBUJPO GPS GSFF JO
PUIFS MBOHVBHFT $BMM GPS
-PT "OHFMFT $PVOUZ PS GPS 4BO %JFHP $PVOUZ 55: ThF DBMM
JT GSFF
?
Kung mayroon kayong mga katanungan, mangyaring tawagan ang Health Net
Cal MediConnect sa 1-855-464-3571 para sa Los Angeles County o sa 1-855-464-3572
para sa San Diego County, TTY: 711, 24 oras bawat araw, 7 araw bawat linggo. Libre
ang tawag. Para sa karagdagang impormasyon, pumunta sa www.healthnet.com/
calmediconnect.
i
Mga Madalas
*UBOPOH
(FAQ)
.BHIBOBQ OH NHB TBHPU EJUP QBSB TB NHB
UBOPOH OB NBZSPPO LB UVOHLPL TB -JTUBIBO
OH .HB 4BLPQ OB (BNPU OB JUP .BCBCBTB
NP BOH MBIBU OH '"2 QBSB NBUVUP QB P
NBHIBOBQ OH UBOPOH BU TBHPU
1. Ang mga de-resetang gamot ang nasa
Listahan ng Mga Sakop na Gamot?
(Tinatawag namin ang Listahan ng
Mga Sakop na Gamot na maikling
pangalang “Listahan ng Gamot”.)
"OH NHB HBNPU TB -JTUBIBO OH (BNPU BZ
BOH NHB HBNPU OB TBLPQ OH )FBMUI /FU
$Bl MFEJ$POOFDU .BCJCJMJ BOH NHB
HBNPU TB NHB QBSNBTZB TB MPPC OH BNJOH
OFUXPSL "OH QBSNBTZB BZ OBTB OFUXPSL
OBNJO LVOH NBZSPPO LBNJOH LBTVOEVBO
TB LBOJMB OB NBHUSBCBIP OBOH LBTBNB
LBNJ BU NBHMBBO OH NHB TFSCJTZP TB JZP
5JOVUVLPZ OBNJO BOH NHB QBSNBTZBOH JUP
CJMBOH iNHB QBSNBTZB OH OFUXPSLw
4BTBLVQJO OH )FBMUI /FU $Bl MFEJ$POOFDU
MBIBU OH NFEJLBM OB LBJMBOHBOH HBNPU TB
-JTUBIBO OH (BNPU LVOH
• TJOBCJ OH JZPOH EPLUPS P OBHSFTFUB
OB LBJMBOHBO NP JUP QBSB HVNBMJOH P
NBOBUJMJOH NBMVTPH at
• QJOVOBO NP BOH SFTFUB TB JTBOH
QBSNBTZB OH OFUXPSL OH )FBMUI /FU
$Bl MFEJ$POOFDU
4B JMBOH NHB LBTP NBZ LBJMBOHBO LBOH
HBXJO CBHP LB NBLBLVIB OH HBNPU
UJOHOBO BOH UBOPOH TB JCBCB
.BUJUJOHOBO NP SJO TB BNJOH XFCTJUF BOH
OBTBTBQBOBIPOH MJTUBIBO OH NHB HBNPU OB
BNJOH TJOBTBLPQ TB XXXIFBMUIOFUDPN
DBMNFEJDPOOFDU P UVNBXBH TB
.FNCFS 4FSWJDFT TB QBSB
TB -PT "OHFMFT $PVOUZ P TB QBSB TB 4BO %JFHP $PVOUZ 55: ii
2. Nagbabago ba ang Listahan ng Gamot?
0P .BBBSJOH NBHEBHEBH P NBH
BMJT OH NHB HBNPU BOH )FBMUI /FU
$Bl MFEJ$POOFDU TB -JTUBIBO OH (BNPU TB
UBPO 4B QBOHLBMBIBUBO NBHCBCBHP MBOH
BOH -JTUBIBO OH (BNPU LVOH
• NBZSPPOH NBT NVSBOH HBNPU OB
EVNBUJOH OB LBTJOHCJTB OH HBNPU OB
OBTB -JTUBIBO OH (BNPU OHBZPO o
• OBMBNBO OBNJO OB IJOEJ MJHUBT BOH JTBOH
HBNPU
.BBBSJ SJO OBNJOH CBHVIJO BOH NHB
QBUBLBSBO OBNJO UVOHLPM TB NHB HBNPU
)BMJNCBXB NBBBSJ LBNJOH
• .BHQBTZBOH JBUBT P IJOEJ JBUBT BOH
QBVOBOH QBIJOUVMPU QBSB TB JTBOH HBNPU
Ang paunang pahintulot BZ QBIJOUVMPU
NVMB TB )FBMUI /FU $Bl MFEJ$POOFDU
CBHP LB NBLBLVIB OH HBNPU
• .BHEBHEBH P NBHCBHP OH EBNJ OH
HBNPU OB NBLVLVIB NP UJOBUBXBH OB
iNHB MJNJUBTZPO TB EBNJw
• .BHEBHEBH P NBHCBHP OH NHB
SFTUSJLTJZPO OH TUFQ UIFSBQZ TB JTBOH
HBNPU "OH LBIVMVHBO OH step therapy
BZ LBJMBOHBOJO NPOH TVCVLBO BOH JTBOH
HBNPU CBHP OBNJO TBTBLVQJO BOH JCBOH
HBNPU
1BSB TB EBHEBH OB JNQPSNBTZPO TB NHB
QBUBLBSBO TB HBNPU OB JUP UJOHOBO BOH
QBIJOB JW
4BTBCJIJO OBNJO TB JZP LBQBH BOH HBNPU OB
JOJJOPN NP BZ JOBMJT NVMB TB -JTUBIBO OH
(BNPU 4BTBCJIJO EJO OBNJO TB JZP LBQBH
CJOBHP OBNJO BOH NHB QBUBLBSBO OBNJO TB
QBHTBLPQ OH JTBOH HBNPU "OH NHB UBOPOH
BU TB JCBCB BZ NBZ NBT NBSBNJOH
JNQPSNBTZPO UVOHLPM TB LVOH BOP BOH
NBOHZBZBSJ LBQBH OBHCBHP BOH -JTUBIBO
Og GaNPU
• "OVNBOH PSBT BZ NBBBSJ NPOH
UJOHOBO BOH POMJOF OB OBTBTBQBOBIPOH
-JTUBIBO OH (BNPU OH )FBMUI /FU
$Bl .FEJ$POOFDU TB XXXIFBMUIOFUDPN
DBMNFEJDPOOFDU .BBBSJ LB SJOH UVNBXBH
TB .FNCFS 4FSWJDFT QBSB UJOHOBO BOH
LBTBMVLVZBOH -JTUBIBO OH (BNPU TB
QBSB TB -PT "OHFMFT
$PVOUZ P TB QBSB TB
4BO %JFHP $PVOUZ 55: 3. Ano ang mangyayari kapag may mas
murang gamot na dumating na kasingbisa ng gamot na nasa Listahan ng
Gamot ngayon?
,VOH VNJJOPN LB OH HBNPU OB JOBMJT EBIJM
NBZ NBT NVSBOH HBNPU OB LBTJOH CJTB
BOH EVNBUJOH TBTBCJIJO OBNJO TB JZP
4BTBCJIJO OBNJO TB JZP OBOH IJOEJ CBCBCB
TB BSBX CBHP OBNJO JUP BMJTJO NVMB
TB -JTUBIBO OH (BNPU o LBQBH IVNJOHJ
LB OH SefiMM 1BHLBUBQPT BZ NBLBLBLVIB
LB OH BSBX OB TVQQMZ OH HBNPU CBHP
BMJTJO BOH HBNPU NVMB TB MJTUBIBO OH
HBNPU ,VOH HVNBXB LBNJ OH BOVNBOH
JCBOH OFHBUJCPOH QBHCBCBHP TB -JTUBIBO
OH (BNPU QBEBEBMIBO LB OBNJO OH
MJIBN OB OBHTBTBCJ TB JZP UVOHLPM TB
NHB QBHCBCBHPOH JUP *MBMBHBZ EJO OBNJO
BOH NHB QBHCBCBHP TB BNJOH XFCTJUF TB
XXXIFBMUIOFUDPNDBMNFEJDPOOFDU
4. Ano ang mangyayari kapag nalaman
naming hindi ligtas ang isang gamot?
,VOH TJOBCJ OH 'PPE BOE %SVH
"ENJOJTUSBUJPO '%"
OB IJOEJ MJHUBT BOH
HBNPU OB JOJJOPN NP BBMJTJO OBNJO JUP
BHBE TB -JTUBIBO OH (BNPU .BHQBQBEBMB
EJO LBNJ OH TVMBU TB JZP OB JZBO BOH
TJOBTBCJ ,VOH NBLBUBOHHBQ LB OH JTB TB
NHB MJIBN OB JUP NBOHZBSJOH UBXBHBO BOH
EPLUPS NP QBSB QBHVTBQBO BOH NHB JCBOH
PQTZPO TB HBNPU
?
Kung mayroon kayong mga katanungan, mangyaring tawagan ang Health Net
Cal MediConnect sa 1-855-464-3571 para sa Los Angeles County o sa 1-855-464-3572
para sa San Diego County, TTY: 711, 24 oras bawat araw, 7 araw bawat linggo. Libre
ang tawag. Para sa karagdagang impormasyon, pumunta sa www.healthnet.com/
calmediconnect.
iii
5. Mayroon bang anumang restriksiyon
o limitasyon sa sakop sa gamot? O
may anubang inaatas na pagkilos na
gagawin upang makuha ang ilang mga
gamot?
0P BOH JMBOH NHB HBNPU BZ NBZ NHB
QBUBLBSBO TB TBLPQ P NBZ NHB MJNJUBTZPO
TB EBNJ OH NBLVLVIB NP 4B JMBOH NHB
LBTP NBZ EBQBU LBOH HBXJO CBHP NP
NBLVIB BOH HBNPU )BMJNCBXB
• Paunang pag-apruba (o paunang
pahintulot): 1BSB TB JMBOH NHB HBNPU
JLBX P BOH JZPOH EPLUPS P JCBOH
OBHSFTFUB BZ EBQBU LVNVIB OH QBIJOUVMPU
NVMB TB )FBMUI /FU $Bl MFEJ$POOFDU
CBHP NP QVOBO BOH JZPOH SFTFUB ,BQBH
IJOEJ LB OBLBLVIB BOH QBIJOUVMPU
NBBBSJOH IJOEJ TBLVQJO OH )FBMUI /FU
$Bl MFEJ$POOFDU BOH HBNPU
• Mga limitasyon sa dami: .JOTBO
OJMJMJNJUB OH )FBMUI /FU $Bl MFEJ$POOFDU
BOH EBNJ OH HBNPU OB NBLVLVIB NP
• Step therapy: .JOTBO BBUBTBO LB OH
)FBMUI /FU $Bl MFEJ$POOFDU OB HVNBXB
OH TUFQ UIFSBQZ /BOHBOHBIVMVHBO JUP OB
LBLBJMBOHBOJO NPOH TVCVLBO BOH NHB
HBNPU TB QBSUJLVMBS OB QBHLBLBTVOPE
TVOPE QBSB TB JZPOH NFEJLBM OB
LBMBHBZBO .BBBSJOH LBJMBOHBOJO NPOH
TVCVLBO BOH JTBOH HBNPU CBHP OBNJO
TBTBLVQJO BOH JCBOH HBNPU ,VOH TB
QBMBHBZ OH EPLUPS NP BZ IJOEJ HVNBHBOB
BOH VOBOH HBNPU QBSB TB JZP TBTBLVQJO
OBNJO BOH QBOHBMBXB
.BMBMBNBO NP LVOH BOH HBNPU NP BZ
NBZ BOVNBOH NHB LBSBHEBHBOH JOBBUBT
P NHB MJNJUBTZPO TB QBNBNBHJUBO OH
QBHUJOHJO TB NHB UBMBIBOBZBO TB QBIJOB o
*OEJTF .BLBLBLVIB LB SJO OH IJHJU QBOH
JNQPSNBTZPO TB QBNBNBHJUBO OH QBHCJTJUB
TB BNJOH XFCTJUF TB XXXIFBMUIOFUDPN
DBMNFEJDPOOFDU /BHQBTLJM LBNJ OH NHB
POMJOF OB EPLVNFOUP OB OBHQBQBMJXBOBH
TB BNJOH QBVOBOH QBIJOUVMPU BU NHB
SFTUSJLTJZPO TB TUFQ UIFSBQZ .BBBSJ NP SJO
LBNJOH IJMJOHBO OB QBEBMIBO LB OH LPQZB
.BBBSJ LB SJOH IVNJOHJ OH iQBHXBXBMBZw P
IJOEJ QBHTBNB NVMB TB NHB MJNJUBTZPOH JUP
.BOHZBSJOH UJOHOBO BOH 5BOPOH QBSB
TB IJHJU QBOH JNQPSNBTZPO TB NHB IJOEJ
QBHTBNB
iv
• ,VOH JLBX BZ OBTB JTBOH OVSTJOH IPNF
P JCBOH QBTJMJEBE TB QBOHNBUBHBMBOH
QBHBBMBHB BU LBJMBOHBO OH HBNPU OB XBMB
TB -JTUBIBO OH (BNPU P LVOH IJOEJ NP
NBEBMJOH NBLVIB BOH LBJMBOHBO NPOH
HBNPU NBLBLBUVMPOH LBNJ 4BTBLVQJO
OBNJO BOH BSBX OB FNFSIFOTJZBOH
TVQQMZ OH LBJMBOHBO OJOZPOH HBNPU
NBMJCBO LVOH NBZSPPO LBOH HBNPU
QBSB TB JMBOH BSBX
JLBX NBO BZ CBHPOH
NJZFNCSP P IJOEJ OH )FBMUI /FU
$Bl MFEJ$POOFDU #JCJHZBO LB OJUP OH
PSBT QBSB NBLJQBHVTBQ TB JZPOH EPLUPS
P JCBOH OBHSFSFTFUB .BUVUVMVOHBO LB
OJZBOH NBHEFTJTZPO LVOH NBZSPPOH
LBUVMBE OB HBNPU TB -JTUBIBO OH (BNPU
OB NBBBSJ NPOH JOVNJO TB IBMJQ P
LVOH IJIJMJOH OH IJOEJ QBHTBTBNB
.BOHZBSJOH UJOHOBO BOH 5BOPOH QBSB
TB LBSBHEBHBOH JNQPSNBTZPO UVOHLPM TB
NHB IJOEJ LBTBNB
6. Paano mo malalaman kung ang
ninanais mong gamot ay mayroong
mga limitasyon o kung mayroong mga
kailangang gawin na pagkilos para
makuha ang gamot?
"OH -JTUBIBO OH NHB 4BLPQ OB (BNPU TB
QBIJOB BZ NBZ IBOBZ OB NBZ NBSLBOH
i.HB LJOBLBJMBOHBOH QBHLJMPT QBHIJIJHQJU
P MJNJUBTZPO TB QBHHBNJUw
7. Ano ang mangyayari kung babaguhin
namin ang aming mga tuntunin sa
kung paano namin sinasakop ang
ilan sa mga gamot? Halimbawa,
kung magdadagdag kami ng
paunang pahintulot (pag-apruba),
mga limitasyon sa dami at/o mga
paghihigpit ng step therapy sa isang
gamot.
4BTBCJIJO OBNJO TB JZP LVOH NBHEBEBHEBH
LBNJ OH QBVOBOH QBHBQSVCB NHB
MJNJUBTZPO TB EBNJ BUP NHB QBHIJIJHQJU
OH TUFQ UIFSBQZ TB JTBOH HBNPU 4BTBCJIJO
OBNJO TB JZP OBOH IJOEJ CBCBCB TB BSBX
CBHP JEBHEBH BOH QBHIJIJHQJU P TB TVTVOPE
OB IVNJOHJ LB OH SefiMM TB JZPOH QBSNBTZB
1BHLBUBQPT NBBBSJ LBOH NBLBLVIB OH BSBX OB TVQQMZ OH HBNPU CBHP HBXJO BOH
QBHCBCBHP TB NHB UVOUVOJO OH QBHTBLPQ
#JOJCJHZBO LB OJUP OB PSBT QBSB NBLJQBH
VTBQ TB JZPOH EPLUPS P JCBOH OBHSFSFTFUB
UVOHLPM TB LVOH BOP BOH TVTVOPE OB EBQBU
HBXJO
8. Paano ka makakahanap ng gamot sa
Listahan ng Gamot?
.BZ EBMBXBOH QBSBBO QBSB NBHIBOBQ OH
HBNPU
• .BBBSJ LBOH NBHIBOBQ OBOH OBLBBZPT
TB BMQBCFUP LVOH BMBN NP LVOH QBBOP
CBZCBZJO BOH HBNPU
o
• .BBBSJ LBOH NBHIBOBQ TB QBNBNBHJUBO
OH NFEJLBM OB LPOEJTZPO
1BSB NBHIBOBQ OBOH nakaayos sa
alpabeto TB TFLTZPO OH -JTUBIBO OB
/BLBBZPT TB "MQBCFUP .BIBIBOBQ NP
JUP TB *OEJTF OB OBHTJTJNVMB TB QBIJOB
*OEJTF 1BSB NBHIBOBQ sa pamamagitan
ng medikal na kondisyon IBOBQJO BOH
TFLTZPO OB NBZ NBSLBOH i-JTUBIBO OH NHB
HBNPU BZPO TB NFEJLBM OB LPOEJTZPOw TB
QBIJOB 1BHLBUBQPT IBOBQJO BOH JZPOH
NFEJLBM OB LPOEJTZPO )BMJNCBXB LVOH
NBZSPPO LBOH LBSBNEBNBO TB QVTP
LBJMBOHBO NPOH NBHIBOBQ TB LBUFHPSZBOH
JZPO %PPO NP NBIBIBOBQ BOH NHB
HBNPU OB HVNBHBNPU TB NHB LBSBNEBNBO
Ta pVTP
QBHTBTBNB QBSB TBLVQJO BOH JZPOH
HBNPU .BOHZBSJOH UJOHOBO BOH 5BOPOH
QBSB TB LBSBHEBHBOH JNQPSNBTZPO
UVOHLPM TB NHB IJOEJ LBTBNB
10. Paano kung isa kang bagong
miyembro ng Health Net
Cal MediConnect at hindi mahanap
ang iyong gamot sa Listahan ng
Gamot o mayroong problema sa
pagkuha ng iyong gamot?
.BLBLBUVMPOH LBNJ .BBBSJ OBNJO
TBLVQJO BOH QBOTBNBOUBMBOH BSBX
OB TVQQMZ OH JZPOH HBNPU TB QBOBIPO
OH VOBOH BSBX OB NJZFNCSP LBZP OH
)FBMUI /FU $Bl MFEJ$POOFDU #JCJHZBO LB
OJUP OH PSBT QBSB NBLJQBHVTBQ TB JZPOH
EPLUPS P JCBOH OBHSFSFTFUB .BUVUVMVOHBO
LB OJZBOH NBHEFTJTZPO LVOH NBZSPPOH
LBUVMBE OB HBNPU TB -JTUBIBO OH (BNPU
OB NBBBSJ NPOH JOVNJO TB IBMJQ P LVOH
IJIJMJOH OH IJOEJ QBHTBTBNB
4BTBLVQJO OBNJO BOH BSBX OB TVQQMZ OH
JZPOH HBNPU LVOH
9. Paano kung ang gamot na gusto mong
inumin ay wala sa Listahan ng Gamot?
,VOH IJOEJ NP NBLJLJUB BOH JZPOH HBNPU
TB -JTUBIBO OH (BNPU UBXBHBO BOH
.FNCFS 4FSWJDFT TB QBSB TB
-PT "OHFMFT $PVOUZ P QBSB
TB 4BO %JFHP $PVOUZ 55: BU UBOVOHJO
BOH UVOHLPM EJUP ,VOH NBMBMBNBO
NP OB IJOEJ TBTBLVQJO OH )FBMUI /FU
$Bl MFEJ$POOFDU BOH HBNPU NBBBSJ NPOH
HBXJO BOH JTB TB NHB CBHBZ OB JUP
• VNJJOPN LB OH HBNPU OB XBMB TB BNJOH
-JTUBIBO OH (BNPU o
• IJOEJ LB QJOBQBZBHBO OH NHB UVOUVOJO
OH QMBOPOH QBOHLBMVTVHBO OB NBLVIB
BOH EBNJ OB JOVUPT OH OBHSFSFTFUB TB JZP
o
• BOH HBNPU BZ OBOHBOHBJMBOHBO OH
QBVOBOH QBHBQSVCB OH )FBMUI /FU
$Bl MFEJ$POOFDU o
• VNJJOPN LB OH HBNPU OB CBIBHJ OH
QBHIJIJHQJU OH TUFQ UIFSBQZ
• )VNJOHJ OH MJTUBIBO OH NHB HBNPU
TB .FNCFS 4FSWJDFT LBUVMBE OH JTB OB
HVTUP NPOH JOVNJO 1BHLBUBQPT JQBLJUB
BOH MJTBIBO TB JZPOH EPLUPS P JCBOH
OBHSFSFTFUB .BBBSJ TJZBOH NBHSFTFUB
OH HBNPU OB OBTB -JTUBIBO OH (BNPU OB
LBUVMBE OH JTB OB HVTUP NPOH JOVNJO O
• .BBBSJ NPOH IJMJOHJO TB QMBOPOH
QBOHLBMVTVHBO OB HVNBXB OH IJOEJ
,VOH OBLBUJSB LB TB JTBOH OVSTJOH IPNF
P JCBOH QBTJMJEBE QBSB TB QBOHNBUBHBMBOH
QBOHBOHBMBHB NBBBSJ NPOH JQBSefiMM
BOH JOZPOH HBNPU OH LBTJOH IBCB OH BSBX .BBBSJ NPOH JQBSefiMM BOH HBNPU
OBOH NBSBNJOH CFTFT TB QBOBIPO OH BSBX #JOJCJHZBO OJUP OH QBOBIPO BOH
OBHSFSFTFUB TB JZP OB QBMJUBO BOH NHB
HBNPU NP OH NHB OBTB -JTUBIBO OH (BNPU
P IVNJMJOH OH IJOEJ QBHTBTBNB
?
Kung mayroon kayong mga katanungan, mangyaring tawagan ang Health Net
Cal MediConnect sa 1-855-464-3571 para sa Los Angeles County o sa 1-855-464-3572
para sa San Diego County, TTY: 711, 24 oras bawat araw, 7 araw bawat linggo. Libre
ang tawag. Para sa karagdagang impormasyon, pumunta sa www.healthnet.com/
calmediconnect.
v
Mga Pagbabago sa Antas ng
Pangangalaga
,VOH NBHCBCBHP BOH BOUBT OH JZPOH
QBOHBOHBMBHB TBTBLVQJO OBNJO BOH
TVQQMZ OH NHB JZPOH NHB HBNPU QBSB
TB QBHMJQBU /BOHZBZBSJ BOH QBHCBCBHP
TB BOUBT OH QBOHBOHBMBHB LBQBH JLBX BZ
QJOBMBCBT TB JTBOH PTQJUBM /BOHZBZBSJ SJO
JUP LBQBH JLBX BZ MVNJQBU TB P OBOHHBMJOH
TB JTBOH QBTJMJEBE OH QBOHNBUBHBMBOH
QBOHBOHBMBHB
t ,VOH MJMJQBU LB TB CBIBZ NVMB TB
JTBOH QBTJMJEBE OH QBOHNBUBHBMBOH
QBOHBOHBMBHB P PTQJUBM BU LBJMBOHBO OH
TVQQMZ QBSB TB QBHMJQBU TBTBLVQJO OBNJO
BOH JTBOH BSBX OB TVQQMZ ,VOH
JTJOVMBU BOH JZPOH SFTFUB QBSB TB NBT
LBVOUJOH BSBX QBIJIJOUVMVUBO OBNJO BOH
NHB NVMJOH QBHQVQVOP QBSB NBHCJHBZ
OH IBOHHBOH TB BSBX OB TVQQMZ
t ,VOH MJMJQBU LB TB CBIBZ NVMB TB
JTBOH QBTJMJEBE OH QBOHNBUBHBMBOH
QBOHBOHBMBHB P PTQJUBM BU LBJMBOHBO OH
TVQQMZ QBSB TB QBHMJQBU TBTBLVQJO OBNJO
BOH JTBOH OBBSBX OB TVQQMZ ,VOH
JTJOVMBU BOH JZPOH SFTFUB QBSB TB NBT
LBVOUJOH BSBX QBIJIJOUVMVUBO OBNJO BOH
NHB NVMJOH QBHQVQVOP QBSB NBHCJHBZ
OH IBOHHBOH TB OBBSBX OB TVQQMZ
11. Maaari ka bang humingi ng hindi
pagsasama para sakupin ang iyong
gamot?
0P .BBBSJ NPOH IJMJOHJO TB )FBMUI /FU
$Bl MFEJ$POOFDU OB HVNBXB OH IJOEJ
QBHTBTBNB QBSB TBLVQJO BOH HBNPU OB XBMB
TB -JTUBIBO OH (BNPU
.BBBSJ NP SJOH IJMJOHJO TB BNJO OB
CBHVIJO BOH NHB UVOUVOJO TB JZPOH HBNPU
• )BMJNCBXB NBBBSJOH MJNJUBIBO OH
)FBMUI /FU $Bl MFEJ$POOFDU BOH EBNJ
OH HBNPU OB BNJOH TBTBLVQJO ,VOH
NBZ MJNJUBTZPO BOH JZPOH HBNPU NBBBSJ
NPOH IJMJOHJO TB BNJO OB CBHVIJO BOH
MJNJUBTZPO BU EBHEBHBO BOH QBHTBLPQ
• *CBOH NHB IBMJNCBXB .BBBSJ NPOH
IJMJOHJO TB BNJO OB BMJTJO BOH NHB
QBHIJIJHQJU OH TUFQ UIFSBQZ P NHB
QBOHBOHBJMBOHBO OH QBVOBOH QBH
BQSVCB
vi
12. Gaano katagal ang pagkuha ng hindi
pagsasama?
6OB LBJMBOHBO NBLBUBOHHBQ LBNJ OH
QBIBZBH NVMB TB OBHSFSFTFUB TB JZP OB
TVNVTVQPSUB TB JZPOH LBIJMJOHBO QBSB
TB JTBOH IJOEJ QBHTBTBNB 1BHLBUBQPT
OBNJO NBUBOHHBQ BOH QBIBZBH CJCJHZBO
LB OBNJO OH EFTJTZPO TB JZPOH IJOJMJOH OB
IJOEJ QBHTBTBNB TB MPPC OH PSBT
,VOH TB JZPOH QBMBHBZ P OH OBHSFSFTFUB TB
JZP OB BOH JZPOH LBMVTVHBO BZ NBBBSJOH
NBQJOTBMB LVOH LBJMBOHBO OJOZPOH
NBHIJOUBZ OH PSBT QBSB TB EFTJTZPO
NBBBSJ LBOH IVNJMJOH OH QJOBCJMJT OB IJOEJ
QBHTBTBNB *UP BZ NBT NBCJMJT OB EFTJTZPO
,VOH TJOVTVQPSUBIBO OH OBHSFSFTFUB TB
JZP BOH JZPOH LBIJMJOHBO CJCJHZBO LB
OBNJO OH EFTJTZPO TB MPPC OH PSBT OB
NBUBOHHBQ BOH QBIBZBH OH QBHTVQPSUB OH
OBHSFSFTFUa sB JOZP
13. Paano ka hihiling ng hindi
pagsasama?
1BSB IVNJMJOH OH IJOEJ QBHTBTBNB
UBXBHBO BOH .FNCFS 4FSWJDFT
"OH .FNCFS 4FSWJDFT BZ NBBBSJOH
NBLJQBHUVMVOHBO TB JZP BU TB JZPOH
UBHBQBHMBBO VQBOH UVMVOHBO LBOH IVNJMJOH
OH JTBOH IJOEJ QBHTBTBNB
14. Ano ang mga generic na gamot?
Ang mga generic na gamot BZ CJOVCVP OH
QBSFIPOH NHB TBOHLBQ LBUVMBE OH NHB
HBNPU OB NBZ UBUBL ,BSBOJXBO NBT NVSB
BOH NHB JUP LBZTB TB HBNPU OB NBZ UBUBL
BU BOH LBOJMBOH NHB QBOHBMBO BZ IJOEJ
NBTZBEPOH LJMBMB "OH NHB HFOFSJD OB
HBNPU BZ BQSVCBEP OH 'PPE BOE %SVH
"ENJOJTUSBUJPO '%"
4JOBTBLPQ OH )FBMUI /FU $Bl MFEJ$POOFDU
BOH QBSFIPOH NHB HBNPU OB NBZ UBUBL BU
HFOFSJD
15. Ano ang mga OTC na gamot?
"OH OTC BZ OBOHBOHBIVMVHBOH
iPWFSUIFDPVOUFSw
4JOBTBLPQ OH )FBMUI /FU $Bl MFEJ$POOFDU
BOH JMBOH NHB 05$ OB HBNPU LBQBH
JTJOVMBU BOH NHB JUP OH JOZPOH UBHBQBHMBBO
CJMBOH NHB SFTFUB
.BBBSJ NPOH CBTBIJO BOH -JTUBIBO OH
(BNPU OH )FBMUI /FU $Bl MFEJ$POOFDU
QBSB NBLJUB LVOH BOVBOPOH NHB 05$ OB
HBNPU BOH TJOBTBLPQ
16. Sakop ba ng Health Net
Cal MediConnect ang mga OTC na
hindi gamot na produkto?
4JOBTBLPQ OH )FBMUI /FU $Bl MFEJ$POOFDU
BOH JMBOH NHB 05$ OB IJOEJ HBNPU OB
QSPEVLUP LBQBH JTJOVMBU BOH NHB JUP OH
JOZPOH UBHBQBHMBBO CJMBOH NHB SFTFUB
.BBBSJ NPOH CBTBIJO BOH -JTUBIBO OH
(BNPU OH )FBMUI /FU $Bl MFEJ$POOFDU
QBSB NBLJUB LVOH BOVBOPOH NHB 05$ OB
HBNPU BOH TJOBTBLPQ
17. Ano ang iyong co-pay?
.BBBSJ NPOH CBTBIJO BOH -JTUBIBO OH
(BNPU OH )FBMUI /FU $Bl MFEJ$POOFDU
QBSB NBMBNBO BOH UVOHLPM TB DPQBZ QBSB
TB CBXBU HBNPU
"OH NHB NJZFNCSP OH )FBMUI /FU
$Bl MFEJ$POOFDU OB OBLBUJSB TB NHB
OVSTJOH IPNF P JCBOH NHB QBTJMJEBE QBSB
TB QBOHNBUBHBMBOH QBOHBOHBMBHB BZ XBMBOH
NHB DPQBZ "OH JMBOH NHB NJZFNCSP
OB OBLBLBLVIB OH QBOHNBUBHBMBOH
QBOHBOHBMBHB TB LPNVOJEBE BZ XBMB SJOH
NHB DPQBZ
"OH NHB DPQBZ BZ OBLBMJTUB TB BZPO TB
NHB BOUBT "OH NHB "OUBT BZ NHB QBOHLBU
OH HBNPU OB NBZ QBSFIPOH DPQBZ
• "OH NHB HBNPU OB OBTB "OUBT BZ NBZ
NBCBCBOH DPQBZ "OH NHB JUP BZ NHB
HFOFSJD OB HBNPU "OH DPQBZ BZ NVMB
IBOHHBOH %FQFOEF JUP TB
JZPOH BOUBT OH QBHTBLPQ OH .FEJ$BM
• "OH NHB HBNPU OB OBTB "OUBT BZ NBZ
NBT NBUBBT OB DPQBZ "OH NHB JUP BZ
NHB HBNPU OB NBZ UBUBL "OH DPQBZ BZ
NVMB IBOHHBOH %FQFOEF JUP
TB JZPOH BOUBT OH QBHTBLPQ OH .FEJ$BM
• "OH NHB HBNPU OB OBTB "OUBT BZ NBZ
OB DPQBZ "OH NHB JUP BZ NHB
JOJSFTFUB BU 05$ OB HBNPU OB TJOBTBLPQ
OH .FEJ$BM
?
Kung mayroon kayong mga katanungan, mangyaring tawagan ang Health Net
Cal MediConnect sa 1-855-464-3571 para sa Los Angeles County o sa 1-855-464-3572
para sa San Diego County, TTY: 711, 24 oras bawat araw, 7 araw bawat linggo. Libre
ang tawag. Para sa karagdagang impormasyon, pumunta sa www.healthnet.com/
calmediconnect.
vii
Listahan ng .HB 4BLPQ OB (BNPU
"OH MJTUBIBO OH NHB TBLPQ OB HBNPU
TB QBIJOB BZ NBHCJCJHBZ TB JZP OH
JNQPSNBTZPO UVOHLPM TB NHB HBNPU OB
TBLPQ OH )FBMUI /FU $Bl MFEJ$POOFDU
,VOH NBZSPPO LBOH QSPCMFNB TB
QBHIBIBOBQ OH JZPOH HBNPU TB MJTUBIBO
QVNVOUB TB *OEJTF OB OBHTJTJNVMB TB
QBIJOB *OEJTF *OJMJMJTUB OH VOBOH IBOBZ OH UTBSU BOH
QBOHBMBO OH HBNPU /BLBTVMBU TB NBMBLJOH
MFUSB BOH NHB HBNPU OB NBZ UBUBL IBM
-*1*503
BU OBLBMJTUB BOH NHB HBNPU
OB HFOFSJD TB NBMJJU OB JUBMJDT IBM
atorvastatin calcium
"OH JNQPSNBTZPO TB IBOBZ OH i.HB
LJOBLBJMBOHBO OB QBHLJMPT QBHIJIJHQJU P
MJNJUBTZPO TB QBHHBNJUw BZ TJOBTBCJ TB JZP
LVOH BOH )FBMUI /FU $Bl MFEJ$POOFDU BZ
NBZSPPOH BOVNBOH NHB UVOUVOJO QBSB TB
QBHTBLPQ OH JZPOH HBNPU
Mga
Pagpapaikli
Ano ang kahulugan
Paano ito gumagana
nito
"-
Limitasyon ng Edad
#%
Medicare Bahagi B
vs. Bahagi D
(-
Limitasyon sa
Kasarian
Limitadong Access
-"
Ang ilang mga gamot ay maaaring kailangan
ng paunang pahintulot kung hindi umabot
ang edad mo sa gabay ng gumawa ng gamot,
ng FDA o klinika.
Ang ilang mga gamot at nangangailangan ng
paunang pahintulot para magpasya kung ang
gamot ay dapat sakupin sa ilalim ng Medicare
Bahagi B o Bahagi D. Ito ay patakaran ng
Medicare. Ang doktor mo o ang ibang
nagreseta ay maaaring kailangang magbigay
ng mas marami pang katotohanan para
tulungan kaming gawin ang pasyang ito.
Ang ilang mga gamot ay maaaring ligtas lang
sa mga lalaki o mga babae.
Ang ilang mga gamot ay maaaring mahanap
lang sa isa o sa ilang mga parmasya, dahil:
t/JMJMJNJUBOH'%"BOHHBNPUTBJMBOHNHB
pasilidad, parmasya o mga nagrereseta, o
t"OHJMBOHNHBHBNPUBZOBOHBOHBJMBOHBO
ng espesyal na pag-aalaga o pagsasanay
sa pasyente na hindi maibibigay sa tingiang
parmasya.
.0
viii
Mail Order
Dapat mong kausapin ang iyong doktor o
ibang nagrereseta tungkol sa pagkuha ng
ilang gamot na limitado ang access.
Makukuha mo ang gamot na ito sa mail order
na parmasya ng Health Net Cal MediConnect.
Mga
Pagpapaikli
Ano ang kahulugan
Paano ito gumagana
nito
/'
Hindi Sakop
/5
Hindi Bahagi D
1"
Paunang Pahintulot
2-
Limitasyon sa Dami
3905$
Reseta at OTC
45
Step Therapy
Hindi sakop ang gamot na ito sa Listahan
ng Gamot. Maaari kang humingi ng hindi
pagsama para masakop ang gamot.
Ang gamot na ito ay hindi isang “Bahagi D na
gamot.” Ang halagang binabayad mo kapag
pinunan mo ang reseta sa gamot na ito ay
hindi mabibilang patungo sa mga kabuuan
mong gastos sa gamot (iyon ay, ang halagang
binabayad mo ay hindi nakakatulong na
maging kwalipikado ka para sa sakop sa
sakuna).
Para sa ilang mga gamot, ikaw o ang iyong
doktor ay dapat kumuha ng pahintulot mula sa
Health Net Cal MediConnect bago mo punan
ang iyong reseta. Kapag hindi ka nakakuhan
ang pahintulot, maaaring hindi namin sakupin
ang gamot.
Minsan, nililimita ng Health Net
Cal MediConnect ang dami ng gamot na
makukuha mo.
Ang ilang mga gamot ay ginagawa sa kapwa
de-resetang uri at OTC na uri.
Minsan, pagagawin ka ng Health Net
Cal MediConnect ng step therapy.
Nangangahulugan ito na kakailanganin mong
subukan ang mga gamot sa partikular na
pagkakasunod-sunod para sa iyong medikal
na kalagayan. Maaaring kailanganin mong
subukan ang isang gamot bago namin
sasakupin ang ibang gamot. Kung sa palagay
ng doktor mo ay hindi gumagana ang unang
gamot para sa iyo, sasakupin namin ang
pangalawa.
?
Kung mayroon kayong mga katanungan, mangyaring tawagan ang Health Net
Cal MediConnect sa 1-855-464-3571 para sa Los Angeles County o sa 1-855-464-3572
para sa San Diego County, TTY: 711, 24 oras bawat araw, 7 araw bawat linggo. Libre
ang tawag. Para sa karagdagang impormasyon, pumunta sa www.healthnet.com/
calmediconnect.
ix
Tandaan: "OH /5 TB UBCJ OH JTBOH HBNPU
BZ OBOHBOHBIVMVHBO OB BOH HBNPU BZ IJOEJ
JTBOH i#BIBHJ % OB HBNPUw "OH IBMBHBOH
CJOBCBZBE NP LBQBH QJOVOBO NP BOH
SFTFUB TB HBNPU OB JUP BZ IJOEJ NBCJCJMBOH
QBUVOHP TB NHB LBCVVBO NPOH HBTUPT TB
HBNPU JZPO BZ BOH IBMBHBOH CJOBCBZBE
NP BZ IJOEJ OBLBLBUVMPOH OB NBHJOH
LXBMJQJLBEP LB QBSB TB TBLPQ TB TBLVOB
.BZ NBHLBLBJCB SJOH NHB UVOUVOJO BOH
NHB HBNPU OB JUP QBSB TB NHB BQFMB "OH
JTBOH apela BZ JTBOH QPSNBM OB QBSBBO
OH QBHIJMJOH TB BNJO OB TVSJJO BOH JTBOH
EFTJTZPO OB HJOBXB OBNJO UVOHLPM TB
QBHTBLPQ TB JZP BU QBHIJMJOH TB BNJO OB
x
QBMJUBO JUP LVOH TB JZPOH QBMBHBZ LBNJ BZ
OBHLBNBMJ )BMJNCBXB NBBBSJ LBNJOH
NBHEFTJTZPO OB BOH JTBOH HBNPU OB
OJOBOBJT NP BZ IJOEJ TBTBLVQJO P IJOEJ
OB TJOBTBLPQ OH .FEJDBSF P OH .FEJ$BM
,VOH BOH JZPOH EPLUPS P JCBOH UBHBQBHMBBO
BZ IJOEJ TVNBTBOHBZPO TB BNJOH
QBHQBQBTJZB NBBBSJ LBOH VNBQFMB ,VOH
NBZSPPO LBOH LBUBOVOHBO UBXBHBO BOH
.FNCFS 4FSWJDFT TB QBSB
TB -PT "OHFMFT $PVOUZ P TB QBSB TB 4BO %JFHP $PVOUZ 55: .BBBSJ SJO NPOH CBTBIJO BOH )BOECPPL
OH .JZFNCSP QBSB NBMBNBO LVOH QBBOP
VNBQFMB TB JTBOH EFTJTZPO
List of drugs by medical condition
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
ADHD/ANTI-NARCOLEPSY/ANTIOBESITY/ANOREXIANTS - Drugs to Treat
ADHD, Sleep and Eating Disorders
Amphetamines
ADDERALL XR (Use
AmphetamineDextroamphetamine)
amphetaminedextroamphetamine
DESOXYN (Use
Methamphetamine HCl)
DEXEDRINE 10 MG,15
MG,5 MG (Use
Dextroamphetamine
Sulfate)
MO
phentermine hcl
QSYMIA
NF
$0- MO
$2.65
(Tier
1)
NF MO
MO
NF
$0dextroamphetamine sulfate $2.65
(Tier
cp24 10 mg, 15 mg, 5 mg
1)
$0dextroamphetamine sulfate $2.65
(Tier
tabs 10 mg, 5 mg
1)
$0$2.65
methamphetamine hcl
(Tier
1)
Anorexiants Non-Amphetamine
ADIPEX-P (Use
NF
Phentermine HCl)
$0
diethylpropion hcl tabs 25
(Tier
mg
3)
MO
DIETHYLPROPION HCL
TABS 25 MG (Use
Diethylpropion HCl)
PA; MO; NT
diethylpropion hcl tb24 75
mg
Name of drug
REGIMEX
SUPRENZA
ALLI
BELVIQ
MO
SAXENDA
PA; MO; NT
PA; MO; NT
NF
$0 PA; MO; NT
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
PA; MO; NT
PA; NT
PA; MO; NT
PA; MO; NT
Anti-Obesity Agents
CONTRAVE
MO
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
PA; NT
PA; MO; NT
PA; MO; NT
PA; MO; NT
Attention-Deficit/Hyperactivity Disorder (ADHD)
$0- MO
$2.65
clonidine hcl (adhd)
(Tier
1)
$0- AL; MO
$2.65
guanfacine hcl (adhd)
(Tier
1)
$0- AL; MO
INTUNIV (Use Guanfacine $6.60
(Tier
HCl (ADHD))
2)
KAPVAY (Use Clonidine
NF MO
HCl (ADHD))
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
1
Name of drug
STRATTERA
Stimulants - Misc.
CONCERTA 27 MG, 36
MG (Use Methylphenidate
HCl)
dexmethylphenidate hcl
cp24 15 mg
dexmethylphenidate hcl
tabs 10 mg, 2.5 mg, 5 mg
FOCALIN (Use
Dexmethylphenidate HCl)
FOCALIN XR 15 MG (Use
Dexmethylphenidate HCl)
METADATE CD (Use
Methylphenidate HCl)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
modafinil
MO
NF
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
NF MO
NF MO
NF MO
$0$2.65
(Tier
1)
$0methylphenidate hcl cpcr or $2.65
10 mg, 20 mg, 30 mg, 40
(Tier
mg, 50 mg, 60 mg
1)
$0methylphenidate hcl tabs or $2.65
(Tier
10 mg, 20 mg, 5 mg
1)
$0$2.65
methylphenidate hcl tb24
(Tier
or 27 mg, 36 mg
1)
$0methylphenidate hcl tbcr or $2.65
(Tier
20 mg, 27 mg, 36 mg
1)
Name of drug
MO
methylphenidate hcl cp24
or 20 mg, 30 mg, 40 mg
MO
MO
PA; MO
NF PA; MO
RITALIN (Use
Methylphenidate HCl)
RITALIN LA 20 MG, 30
MG, 40 MG (Use
Methylphenidate HCl)
NF MO
RITALIN LA 60 MG
MO
NF
$0$6.60
(Tier
2)
RITALIN SR (Use
Methylphenidate HCl)
NF MO
ALTERNATIVE MEDICINES
Alternative Medicine - A's
ALPHA LIPOIC ACID
CAPS OR 50 MG
alpha-lipoic acid (thioctic
acid) caps 100 mg
$0 NT
(Tier
3)
$0 NT
(Tier
3)
$0 MO; NT
(Tier
3)
Alternative Medicine - C's
CHEW Q 100 MG
MO
Necessary
actions,
restrictions, or
limits on use
PROVIGIL (Use Modafinil)
ALPHA-LIPOIC ACID
MO
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
coenzyme q10
(ubidecarenone) caps 10
mg, 60 mg
coenzyme q10
(ubidecarenone) caps 150
mg, 30 mg
COENZYME Q10 CHEW
OR 60 MG
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
NT
NT
MO; NT
NT
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
2
Name of drug
COENZYME Q10 TABS
OR 25 MG
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
Alternative Medicine - G's
$0 MO; NT
(Tier
3)
$0 NT
glucosamine sulfate tabs or (Tier
500 mg
3)
glucosamine sulfate caps
or 500 mg
Alternative Medicine - L's
lutein caps or 6 mg
$0 NT
(Tier
3)
Alternative Medicine Combinations
$0 NT
glucosamine-chondroitin
(Tier
caps 200mg-250mg
3)
glucosamine-chondroitin
tabs 200mg-250mg
LIQ-10 50MG/5ML15UNIT/5ML
VITALINE
COQ10/VITAMIN E
100MG-300UNIT
$0 MO; NT
(Tier
3)
$0 NT
(Tier
3)
$0 NT
(Tier
3)
AMINOGLYCOSIDES - Drugs to Treat Bacterial
Infections
Aminoglycosides
amikacin sulfate soln ij 1
gm/4ml, 500 mg/2ml
BETHKIS
$0- MO
$2.65
(Tier
1)
$0- B/D
$6.60
(Tier
2)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0gentamicin in saline 0.9%- $2.65
(Tier
0.8mg/ml
1)
$0gentamicin in saline 0.9%- $2.65
1.2mg/ml, 0.9%-1.6mg/ml, (Tier
0.9%-1mg/ml
1)
$0gentamicin sulfate soln ij 40 $2.65
(Tier
mg/ml
1)
$0$2.65
gentamicin sulfate soln iv
(Tier
10 mg/ml
1)
$0$2.65
neomycin sulfate tabs or
(Tier
1)
$0$2.65
paromomycin sulfate
(Tier
1)
TOBI (Use Tobramycin)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
NF B/D
$0$6.60
TOBI PODHALER
(Tier
2)
$0- B/D
$2.65
tobramycin nebu in
(Tier
1)
$0- MO
tobramycin sulfate soln ij
$2.65
1.2 gm/30ml, 40 mg/ml, 80 (Tier
mg/2ml
1)
$0$2.65
tobramycin sulfate soln ij
(Tier
10 mg/ml
1)
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
3
Name of drug
tobramycin sulfate solr ij
1.2 gm
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
ANALGESICS - ANTI-INFLAMMATORY - Drugs
to Treat Pain, Swelling, Muscle and Joint
Conditions
Anti-TNF-alpha - Monoclonal Antibodies
$0- PA
$6.60
HUMIRA
(Tier
2)
$0- PA
HUMIRA PEDIATRIC
$6.60
CROHNS DISEASE
(Tier
STARTER PACK
2)
$0- PA
$6.60
HUMIRA PEN
(Tier
2)
$0- PA
$6.60
HUMIRA PEN-CROHNS
(Tier
DISEASESTARTER
2)
$0- PA
HUMIRA PEN-PSORIASIS $6.60
(Tier
STARTER
2)
$0- PA
$6.60
SIMPONI
(Tier
2)
$0- PA
$6.60
SIMPONI ARIA
(Tier
2)
Antirheumatic - Enzyme Inhibitors
$0- PA
$6.60
XELJANZ
(Tier
2)
Antirheumatic Antimetabolites
Name of drug
OTREXUP
RASUVO
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA
PA
Gold Compounds
RIDAURA
$0- MO
$6.60
(Tier
2)
Interleukin-1 Blockers
ARCALYST
$0- LA
$6.60
(Tier
2)
Interleukin-1 Receptor Antagonist (IL-1Ra)
$0- PA
$6.60
KINERET
(Tier
2)
Interleukin-1beta Blockers
ILARIS
$0- LA
$6.60
(Tier
2)
Interleukin-6 Receptor Inhibitors
$0- PA
$6.60
ACTEMRA
(Tier
2)
Nonsteroidal Anti-inflammatory Agents (NSAIDs)
NF MO; NT
ADVIL (Use Ibuprofen)
ADVIL MIGRAINE (Use
Ibuprofen)
ALEVE CAPS (Use
Naproxen Sodium)
NF MO; NT
NF NT
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
4
Name of drug
ANAPROX (Use Naproxen
Sodium)
ANAPROX DS (Use
Naproxen Sodium)
ARTHROTEC 50 (Use
Diclofenac w/ Misoprostol)
ARTHROTEC 75 (Use
Diclofenac w/ Misoprostol)
CATAFLAM (Use
Diclofenac Potassium)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
NF MO
NF MO
NF MO
NF MO
$0- MO
$6.60
(Tier
2)
$0- MO
$2.65
celecoxib
(Tier
1)
$0 NT
CHILDRENS MOTRIN
(Tier
CHEW 50 MG
3)
CHILDRENS MOTRIN
MO; NT
JUNIOR STRENGTH (Use NF
Ibuprofen)
CHILDRENS MOTRIN
NT
NF
SUSP 40 MG/ML (Use
Ibuprofen)
DAYPRO (Use Oxaprozin) NF MO
CELEBREX (Use
Celecoxib)
diclofenac potassium
diclofenac sodium tb24 or
100 mg
diclofenac sodium tbec or
25 mg, 50 mg, 75 mg
Name of drug
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
diclofenac w/ misoprostol
EC-NAPROSYN (Use
Naproxen)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
etodolac tabs or 400 mg,
(Tier
500 mg
1)
$0- MO
$2.65
etodolac tb24 or 400 mg,
(Tier
500 mg, 600 mg
1)
FELDENE (Use Piroxicam) NF MO
etodolac caps or 200 mg,
300 mg
$0flurbiprofen tabs or 100 mg, $2.65
(Tier
50 mg
1)
$0
(Tier
ibuprofen caps or 200 mg
3)
$0
ibuprofen chew or 100 mg (Tier
3)
$0$2.65
ibuprofen susp or 100
(Tier
mg/5ml
1)
$0
ibuprofen susp or 40
(Tier
mg/ml, 50 mg/1.25ml
3)
ibuprofen tabs or 100 mg
ibuprofen tabs or 200 mg
MO
MO; NT
MO; NT
RX/OTC; MO
NT
$0 NT
(Tier
3)
$0 MO; NT
(Tier
3)
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
5
Name of drug
ibuprofen tabs or 400 mg
ibuprofen tabs or 600 mg
ibuprofen tabs or 800 mg
indomethacin caps or 25
mg, 50 mg
indomethacin cpcr or 75
mg
INFANTS ADVIL (Use
Ibuprofen)
ketoprofen caps or 50 mg,
75 mg
ketorolac tromethamine
soln ij 15 mg/ml, 30 mg/ml
ketorolac tromethamine
soln im 30 mg/ml, 60
mg/2ml
mefenamic acid caps or
meloxicam tabs or 15 mg,
7.5 mg
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(8 ea daily);
MO
QL(5 ea daily);
MO
QL(4 ea daily);
MO
AL; MO
MOBIC TABS 15 MG, 7.5
MG (Use Meloxicam)
MOTRIN INFANTS (Use
Ibuprofen)
MOTRIN INFANTS
DROPS (Use Ibuprofen)
MOTRIN JUNIOR
STRENGTH CHEW (Use
Ibuprofen)
MOTRIN JUNIOR
STRENGTH TABS (Use
Ibuprofen)
nabumetone
AL; MO
NF NT
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Name of drug
MO
AL; MO
AL; MO
NAPROSYN (Use
Naproxen)
naproxen sodium caps or
220 mg
naproxen sodium tabs or
275 mg, 550 mg
naproxen tabs or 250 mg,
375 mg, 500 mg
naproxen tbec or 375 mg,
500 mg
MO
oxaprozin
MO
piroxicam caps or 10 mg,
20 mg
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
NF NT
NF NT
MO; NT
NF
NT
NF
$0- MO
$2.65
(Tier
1)
NF MO
$0
(Tier
3)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
NT
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
6
Name of drug
PONSTEL (Use Mefenamic
Acid)
sulindac tabs or 150 mg,
200 mg
tolmetin sodium caps 400
mg
tolmetin sodium tabs 200
mg
VOLTAREN-XR (Use
Diclofenac Sodium)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
NF MO
Phosphodiesterase 4 (PDE4) Inhibitors
$0- PA
$6.60
OTEZLA
(Tier
2)
Pyrimidine Synthesis Inhibitors
ARAVA (Use Leflunomide)
Name of drug
NF MO
$0- MO
leflunomide tabs or 10 mg, $2.65
(Tier
20 mg
1)
Selective Costimulation Modulators
$0- PA
$6.60
ORENCIA
(Tier
2)
Soluble Tumor Necrosis Factor Receptor Agents
$0- PA
$6.60
ENBREL
(Tier
2)
ENBREL SURECLICK
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA
ANALGESICS - NonNarcotic - Drugs to Treat
Pain, Muscle and Joint Conditions
Analgesic Combinations
acetaminophen-caffeinepyrilamine
BIPHENOX
MIDOL COMPLETE
500MG-15MG-60MG (Use
Acetaminophen-CaffeinePyrilamine)
MIDOL MAXIMUM
STRENGTH MENSTRUAL
(Use AcetaminophenCaffeine-Pyrilamine)
MIDOL MAXIMUM
STRENGTH MENSTRUAL
FORMULA (Use
Acetaminophen-CaffeinePyrilamine)
$0 NT
(Tier
3)
$0 NT
(Tier
3)
NT
NF
NT
NF
NT
NF
Analgesics Other
$0
(Tier
3)
$0
acetaminophen chew or 80 (Tier
mg
3)
$0
acetaminophen elix or 160 (Tier
mg/5ml, 80 mg/2.5ml
3)
$0
acetaminophen liqd or 160 (Tier
mg/5ml
3)
acetaminophen soln or 100 $0
(Tier
mg/ml, 160 mg/5ml, 80
3)
mg/0.8ml
acetaminophen chew or
160 mg
NT
MO; NT
NT
MO; NT
MO; NT
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
7
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
acetaminophen supp re
(Tier
120 mg
3)
$0
acetaminophen susp or
(Tier
160 mg/5ml, 80 mg/2.5ml
3)
$0
acetaminophen susp or 80 (Tier
mg/0.8ml
3)
$0
acetaminophen tbdp or 160 (Tier
mg
3)
$0
acetaminophen tbdp or 80 (Tier
mg
3)
$0
(Tier
ELIXSURE FEVER/PAIN
3)
$0
(Tier
FEVERALL INFANTS
3)
TYLENOL CHILDRENS
NF
(Use Acetaminophen)
TYLENOL
CHILDRENS/FLAVORCRE NF
ATOR (Use
Acetaminophen)
TYLENOL INFANTS 160
NF
MG/5ML (Use
Acetaminophen)
TYLENOL INFANTS 80
NF
MG/0.8ML (Use
Acetaminophen)
TYLENOL JR
NF
MELTAWAYS (Use
Acetaminophen)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
NT
MO; NT
NT
NT
NT
MO; NT
MO; NT
MO; NT
NT
MO; NT
Salicylates
ASCRIPTIN
$0 NT
(Tier
3)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
aspirin buffered (cal carb(Tier
mag carb-mag oxide)
3)
$0
ASPIRIN SUPP RE 120
(Tier
MG, 200 MG
3)
$0
aspirin supp re 300 mg,
(Tier
600 mg
3)
$0
(Tier
aspirin tabs or 325 mg
3)
$0
(Tier
aspirin tabs or 81 mg
3)
$0
aspirin tbec or 324 mg, 325 (Tier
mg, 500 mg, 81 mg
3)
BUFFERIN (Use Aspirin
NF
Buffered (Cal Carb-Mag
Carb-Mag Oxide))
$0$2.65
diflunisal
(Tier
1)
ECOTRIN MAXIMUM
NF
STRENGTH (Use Aspirin)
ECOTRIN REGULAR
NF
STRENGTH (Use Aspirin)
Necessary
actions,
restrictions, or
limits on use
MO; NT
NT
NT
MO; NT
NT
MO; NT
MO; NT
MO
MO; NT
MO; NT
ANALGESICS - OPIOID - Drugs to Treat Pain,
Muscle and Joint Conditions
Opioid Agonists
ACTIQ 1200 MCG, 1600
MCG, 400 MCG, 600 MCG,
800 MCG (Use Fentanyl
Citrate)
ACTIQ 200 MCG (Use
Fentanyl Citrate)
DEMEROL SOLN IJ 100
MG/ML, 50 MG/ML (Use
Meperidine HCl)
PA; QL(4 ea
NF daily); MO
NF PA; QL(6 ea
daily); MO
MO
NF
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
8
Name of drug
DEMEROL SOLN IJ 25
MG/ML (Use Meperidine
HCl)
DILAUDID LIQD OR 1
MG/ML (Use
Hydromorphone HCl)
DILAUDID SOLN IJ 2
MG/ML
DILAUDID TABS OR 2 MG
(Use Hydromorphone HCl)
DILAUDID TABS OR 4 MG
(Use Hydromorphone HCl)
DILAUDID TABS OR 8 MG
(Use Hydromorphone HCl)
DILAUDID-HP SOLN 10
MG/ML (Use
Hydromorphone HCl)
DOLOPHINE 10 MG (Use
Methadone HCl)
DOLOPHINE 5 MG (Use
Methadone HCl)
DURAGESIC 100 MCG/HR
(Use Fentanyl)
DURAGESIC 12 MCG/HR
(Use Fentanyl)
DURAGESIC 25 MCG/HR
(Use Fentanyl)
DURAGESIC 50 MCG/HR
(Use Fentanyl)
DURAGESIC 75 MCG/HR
(Use Fentanyl)
fentanyl 100 mcg/hr
fentanyl 12 mcg/hr
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF
Name of drug
fentanyl 25 mcg/hr
QL(30 ml
NF daily); MO
$0- MO
$6.60
(Tier
2)
NF QL(29 ea
daily); MO
NF QL(14 ea
daily); MO
NF QL(7 ea daily);
MO
MO
NF
NF QL(19 ea
daily); MO
NF QL(38 ea
daily); MO
NF QL(1 ea daily);
MO
NF QL(1.44 ea
daily); MO
NF QL(0.7 ea
daily); MO
NF QL(0.74 ea
daily); MO
NF QL(0.61 ea
daily); MO
$0- QL(1 ea daily);
$2.65 MO
(Tier
1)
$0- QL(1.44 ea
$2.65 daily); MO
(Tier
1)
fentanyl 50 mcg/hr
fentanyl 75 mcg/hr
fentanyl citrate lpop bu
1200 mcg, 1600 mcg, 400
mcg, 600 mcg, 800 mcg
fentanyl citrate lpop bu 200
mcg
hydromorphone hcl liqd or
1 mg/ml
hydromorphone hcl soln ij
10 mg/ml, 2 mg/ml, 50
mg/5ml, 500 mg/50ml
hydromorphone hcl tabs or
2 mg
hydromorphone hcl tabs or
4 mg
hydromorphone hcl tabs or
8 mg
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(0.7 ea
daily); MO
QL(0.74 ea
daily); MO
QL(0.61 ea
daily); MO
PA; QL(4 ea
daily); MO
PA; QL(6 ea
daily); MO
QL(30 ml
daily); MO
MO
QL(29 ea
daily); MO
QL(14 ea
daily); MO
QL(7 ea daily);
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
9
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$6.60
HYSINGLA ER 100 MG,
(Tier
120 MG
2)
$0HYSINGLA ER 20 MG, 30 $6.60
MG, 40 MG, 60 MG, 80 MG (Tier
2)
KADIAN 100 MG (Use
NF
Morphine Sulfate)
KADIAN 20 MG, 30 MG, 50
NF
MG, 60 MG, 80 MG (Use
Morphine Sulfate)
$0$6.60
LAZANDA 100 MCG/ACT (Tier
2)
$0$6.60
LAZANDA 400 MCG/ACT (Tier
2)
$0meperidine hcl soln ij 100 $2.65
(Tier
mg/ml, 50 mg/ml
1)
$0$2.65
meperidine hcl soln ij 25
(Tier
mg/ml
1)
$0meperidine hcl soln or 50 $2.65
(Tier
mg/5ml
1)
$0methadone hcl conc or 10 $2.65
(Tier
mg/ml
1)
$0methadone hcl soln or 10 $2.65
(Tier
mg/5ml
1)
Necessary
actions,
restrictions, or
limits on use
PA; QL(2 ea
daily)
PA; QL(2 ea
daily); MO
Name of drug
methadone hcl soln or 5
mg/5ml
methadone hcl tabs or 10
mg
QL(6 ea daily);
MO
QL(5 ea daily);
MO
methadone hcl tabs or 5
mg
PA; QL(6 ea
daily); MO
METHADOSE 10 MG/ML
(Use Methadone HCl)
METHADOSE SUGARFREE (Use Methadone
HCl)
PA; QL(4 ea
daily)
MO
AL; MO
QL(4 ml daily);
MO
QL(20 ml
daily); MO
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
QL(40 ml
daily); MO
QL(19 ea
daily); MO
QL(38 ea
daily); MO
NF QL(4 ml daily);
MO
QL(4 ml daily);
NF MO
$0$2.65
(Tier
1)
$0morphine sulfate cp24 or
$2.65
20 mg, 30 mg, 50 mg, 60
(Tier
mg, 80 mg
1)
$0morphine sulfate soln ij 0.5 $2.65
(Tier
mg/ml
1)
$0$2.65
morphine sulfate soln ij 1
(Tier
mg/ml
1)
$0morphine sulfate soln or 10 $2.65
(Tier
mg/5ml
1)
$0$2.65
morphine sulfate soln or
(Tier
100 mg/5ml, 20 mg/ml
1)
morphine sulfate cp24 or
100 mg
Necessary
actions,
restrictions, or
limits on use
QL(6 ea daily);
MO
QL(5 ea daily);
MO
MO
QL(60 ml
daily); MO
QL(6 ml daily);
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
10
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0morphine sulfate soln or 20 $2.65
(Tier
mg/5ml
1)
$0$6.60
MORPHINE SULFATE
(Tier
TABS OR 15 MG
2)
$0$6.60
MORPHINE SULFATE
(Tier
TABS OR 30 MG
2)
$0morphine sulfate tbcr or
$2.65
100 mg, 200 mg, 30 mg, 60 (Tier
mg
1)
$0morphine sulfate tbcr or 15 $2.65
(Tier
mg
1)
MS CONTIN 100 MG, 200
NF
MG, 30 MG, 60 MG (Use
Morphine Sulfate)
MS CONTIN 15 MG (Use
NF
Morphine Sulfate)
OPANA TABS OR 10 MG
NF
(Use Oxymorphone HCl)
OPANA TABS OR 5 MG
NF
(Use Oxymorphone HCl)
$0$2.65
oxycodone hcl caps or 5
(Tier
mg
1)
$0oxycodone hcl conc or 100 $2.65
(Tier
mg/5ml, 20 mg/ml
1)
$0$2.65
oxycodone hcl tabs or 15
(Tier
mg
1)
Necessary
actions,
restrictions, or
limits on use
QL(30 ml
daily); MO
QL(8 ea daily);
MO
QL(14 ea
daily); MO
MO
QL(8 ea daily);
MO
MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
QL(8 ea daily);
MO
QL(17 ea
daily); MO
QL(4 ml daily);
MO
QL(11 ea
daily); MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
oxycodone hcl tabs or 30
(Tier
mg
1)
$0oxycodone hcl tabs or 5 mg $2.65
(Tier
1)
$0$2.65
oxymorphone hcl tabs 10
(Tier
mg
1)
$0$2.65
oxymorphone hcl tabs 5 mg (Tier
1)
$0oxymorphone hcl tb12 15 $2.65
(Tier
mg
1)
$0oxymorphone hcl tb12 7.5 $2.65
(Tier
mg
1)
ROXICODONE 15 MG
NF
(Use Oxycodone HCl)
ROXICODONE 30 MG
NF
(Use Oxycodone HCl)
ROXICODONE 5 MG (Use NF
Oxycodone HCl)
$0$6.60
SUBSYS 100 MCG, 200
(Tier
MCG
2)
$0SUBSYS 1200 MCG, 1600 $6.60
(Tier
MCG
2)
$0$6.60
SUBSYS 400 MCG, 600
(Tier
MCG, 800 MCG
2)
Necessary
actions,
restrictions, or
limits on use
QL(15 ea
daily); MO
QL(17 ea
daily); MO
QL(4 ea daily);
MO
QL(8 ea daily);
MO
QL(2.67 ea
daily); MO
QL(5 ea daily);
MO
QL(11 ea
daily); MO
QL(15 ea
daily); MO
QL(17 ea
daily); MO
PA; QL(6 ea
daily); MO
PA; QL(4 ea
daily)
PA; QL(4 ea
daily); MO
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
11
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
tramadol hcl tabs or 50 mg (Tier
1)
$0$2.65
tramadol hcl tb24 or 100
(Tier
mg
1)
$0$2.65
tramadol hcl tb24 or 200
(Tier
mg, 300 mg
1)
ULTRAM (Use Tramadol
NF
HCl)
ULTRAM ER 100 MG (Use NF
Tramadol HCl)
ULTRAM ER 200 MG, 300 NF
MG (Use Tramadol HCl)
$0ZOHYDRO ER C12A 10
$6.60
MG, 15 MG, 20 MG, 30
(Tier
MG, 40 MG, 50 MG
2)
$0ZOHYDRO ER CP12 10
$6.60
MG, 15 MG, 20 MG, 30
(Tier
MG, 40 MG, 50 MG
2)
Necessary
actions,
restrictions, or
limits on use
QL(8 ea daily);
MO
QL(3 ea daily);
MO
QL(1 ea daily);
MO
QL(8 ea daily);
MO
QL(3 ea daily);
MO
QL(1 ea daily);
MO
PA; QL(2 ea
daily); MO
PA; QL(2 ea
daily)
Opioid Combinations
$0acetaminophen w/ codeine $2.65
soln 120mg/5ml-12mg/5ml (Tier
1)
$0acetaminophen w/ codeine $2.65
tabs 300mg-15mg, 300mg- (Tier
30mg, 300mg-60mg
1)
$0$2.65
butalbital-aspirin-caffeine
(Tier
w/cod
1)
FIORINAL/CODEINE #3
NF
(Use Butalbital-AspirinCaffeine w/Cod)
QL(166 ml
daily); MO
QL(13 ea
daily); MO
AL; MO
AL; MO
Name of drug
hydrocodoneacetaminophen soln
2.5mg/5ml-108mg/5ml,
5mg/10ml-217mg/10ml,
7.5mg/15ml-325mg/15ml
hydrocodoneacetaminophen tabs 10mg300mg, 5mg-300mg,
7.5mg-300mg
hydrocodoneacetaminophen tabs 10mg325mg, 5mg-325mg,
7.5mg-325mg
What
the
drug
will
cost
you
(tier
level)
$0- QL(184 ml
$2.65 daily); MO
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
hydrocodone-ibuprofen
(Tier
1)
$0oxycodone w/
$2.65
acetaminophen soln
(Tier
5mg/5ml-325mg/5ml
1)
$0oxycodone w/
acetaminophen tabs 10mg- $2.65
(Tier
325mg, 2.5mg-325mg,
5mg-325mg, 7.5mg-325mg 1)
$0$2.65
oxycodone-aspirin
(Tier
1)
PERCODAN (Use
NF
Oxycodone-Aspirin)
$0$2.65
tramadol-acetaminophen
(Tier
1)
ULTRACET (Use
Tramadol-Acetaminophen) NF
VICOPROFEN (Use
NF
Hydrocodone-Ibuprofen)
Opioid Partial Agonists
BUPRENEX (Use
Buprenorphine HCl)
Necessary
actions,
restrictions, or
limits on use
QL(13 ea
daily); MO
QL(12 ea
daily); MO
MO
QL(61 ml daily)
QL(12 ea
daily); MO
MO
MO
QL(12 ea
daily); MO
QL(12 ea
daily); MO
MO
NF MO
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
12
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
buprenorphine hcl soln ij
(Tier
0.3 mg/ml
1)
$0buprenorphine hcl subl sl 2 $2.65
(Tier
mg
1)
$0buprenorphine hcl subl sl 8 $2.65
(Tier
mg
1)
$0buprenorphine hcl$2.65
naloxone hcl dihydrate
(Tier
2mg-0.5mg
1)
$0buprenorphine hcl$2.65
naloxone hcl dihydrate
(Tier
8mg-2mg
1)
$0butorphanol tartrate soln ij $2.65
(Tier
2 mg/ml
1)
$0butorphanol tartrate soln na $2.65
(Tier
10 mg/ml
1)
$0$2.65
nalbuphine hcl soln ij 10
(Tier
mg/ml, 20 mg/ml
1)
Necessary
actions,
restrictions, or
limits on use
MO
PA; QL(16 ea
daily); MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0oxandrolone tabs or 10 mg, $2.65
(Tier
2.5 mg
1)
ANDRODERM
PA; QL(4 ea
daily); MO
ANDROGEL 20.25
MG/1.25GM,40.5
MG/2.5GM
ANDROGEL 25
MG/2.5GM,50 MG/5GM
(Use Testosterone)
ANDROGEL PUMP
MO
AVEED
QL(4.2 ml
daily); MO
MO
danazol caps or 100 mg,
200 mg, 50 mg
fluoxymesterone tabs or
ANDROGENS-ANABOLIC - Drugs to Regulate
Hormones
Anabolic Steroids
ANADROL-50
OXANDRIN (Use
Oxandrolone)
TESTIM
$0- MO
$6.60
(Tier
2)
NF MO
MO
Androgens
PA; QL(4 ea
daily); MO
PA; QL(16 ea
daily); MO
Necessary
actions,
restrictions, or
limits on use
testosterone cypionate
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
GL; MO
GL; MO
GL; MO
GL; MO
LA
MO
GL; MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
13
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
testosterone enanthate
(Tier
soln im
1)
$0TESTOSTERONE GEL TD $6.60
1 %, 25 MG/2.5GM, 50
(Tier
MG/5GM
2)
$0$2.65
testosterone gel td 25
(Tier
mg/2.5gm, 50 mg/5gm
1)
$0$6.60
TESTOSTERONE PUMP
(Tier
2)
$0$6.60
VOGELXO
(Tier
2)
$0$6.60
VOGELXO PUMP
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
Rectal Products - Misc.
starch (topical)
GL; MO
Necessary
actions,
restrictions, or
limits on use
$0 MO; NT
(Tier
3)
NF MO; NT
Rectal Steroids
GL; MO
GL; MO
GL; MO
$0- MO
$2.65
hydrocortisone (rectal)
(Tier
1)
PROCTOCORT CREA 1 %
MO
NF
(Use Hydrocortisone
(Rectal))
Vasodilating Agents
RECTIV
GL; MO
$0- MO
$6.60
(Tier
2)
ANTACIDS - Ulcer and Stomach Acid Drugs
Antacid Combinations
ANORECTAL AGENTS - Rectal Drugs to Treat
Pain, Swelling and Itching
Intrarectal Steroids
CORTENEMA (Use
Hydrocortisone
(Intrarectal))
TUCKS (Use Starch
(topical))
What
the
drug
will
cost
you
(tier
level)
MO
NF
$0- MO
$2.65
hydrocortisone (intrarectal) (Tier
1)
$0$6.60
UCERIS FOAM RE 2
(Tier
MG/ACT
2)
ALMACONE
alum & mag hydroxsimethicone chew 200mg25mg-200mg
alum & mag hydroxsimethicone liqd
200mg/5ml-20mg/5ml200mg/5ml, 400mg/5ml40mg/5ml-400mg/5ml
$0 NT
(Tier
3)
$0 NT
(Tier
3)
MO; NT
$0
(Tier
3)
Rectal Combinations
phenylephrine-shark liver
oil-glycerin-petrolatum
$0 NT
(Tier
3)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
14
Name of drug
alum & mag hydroxsimethicone susp
200mg/5ml-200mg/5ml20mg/5ml-20mg/5ml200mg/5ml-200mg/5ml,
200mg/5ml-20mg/5ml200mg/5ml, 400mg/5ml400mg/5ml-40mg/5ml40mg/5ml-400mg/5ml400mg/5ml, 400mg/5ml40mg/5ml-400mg/5ml
aluminum hydroxide-mag
trisil
GELUSIL 200MG-25MG200MG (Use Alum & Mag
Hydrox-Simethicone)
HYVEE ADVANCED
ANTACID MAXIMUM
STRENGTH (Use Alum &
Mag Hydrox-Simethicone)
MYLANTA DOUBLESTRENGTH (Use Alum &
Mag Hydrox-Simethicone)
MYLANTA SUSP
200MG/5ML-20MG/5ML200MG/5ML (Use Alum &
Mag Hydrox-Simethicone)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO; NT
$0
(Tier
3)
$0 NT
(Tier
3)
NT
NF
MO; NT
NF
MO; NT
NF
calcium carbonate
(antacid) 600 mg
CALCIUM CARBONATE
TABS OR 648 MG
NF NT
NF MO; NT
MO; NT
NF
NF MO; NT
MO; NT
NF
MO; NT
NF
ANTHELMINTICS - Drugs to Treat Worm
Infections
ALBENZA
MO; NT
NF
$0 NT
(Tier
3)
Antacids - Calcium Salts
calcium carbonate
(antacid) 500 mg, 750 mg
MAALOX (Use Calcium
Carbonate (Antacid))
TUMS (Use Calcium
Carbonate (Antacid))
TUMS E-X 750 (Use
Calcium Carbonate
(Antacid))
TUMS KIDS (Use Calcium
Carbonate (Antacid))
TUMS LASTING EFFECTS
(Use Calcium Carbonate
(Antacid))
TUMS SMOOTHIES 750
MG (Use Calcium
Carbonate (Antacid))
Necessary
actions,
restrictions, or
limits on use
Anthelmintics
Antacids - Aluminum Salts
ALUMINUM HYDROXIDE
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0 MO; NT
(Tier
3)
$0 NT
(Tier
3)
$0 MO; NT
(Tier
3)
ivermectin tabs or
STROMECTOL (Use
Ivermectin)
$0- MO
$6.60
(Tier
2)
$0- MO
$2.65
(Tier
1)
$0- MO
$6.60
(Tier
2)
ANTI-INFECTIVE AGENTS - MISC. - Drugs to
Treat Bacterial Infections
Anti-infective Agents - Misc.
AZACTAM (Use
NF MO
Aztreonam)
$0- MO
$2.65
aztreonam
(Tier
1)
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
15
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$6.60
CAYSTON
(Tier
2)
$0colistimethate sodium solr ij $2.65
(Tier
1)
COLY-MYCIN M (Use
NF
Colistimethate Sodium)
FLAGYL (Use
NF
Metronidazole)
$0metronidazole caps or 375 $2.65
(Tier
mg
1)
$0$2.65
metronidazole in nacl
(Tier
1)
$0metronidazole tabs or 250 $2.65
(Tier
mg, 500 mg
1)
$0$6.60
NEBUPENT
(Tier
2)
$0$6.60
PENTAM 300
(Tier
2)
TINDAMAX (Use
NF
Tinidazole)
$0tinidazole tabs or 250 mg, $2.65
(Tier
500 mg
1)
$0$2.65
trimethoprim tabs or
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
VANCOCIN HCL (Use
Vancomycin HCl)
MO
vancomycin hcl caps or
125 mg, 250 mg
MO
VANCOMYCIN HCL IN
DEXTROSE
MO
MO
vancomycin hcl solr iv 10
gm, 1000 mg, 5000 mg
vancomycin hcl solr iv 500
mg
MO
MO; B/D
MO
MO
MO
XIFAXAN
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF PA; MO
$0- PA; MO
$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$6.60
(Tier
2)
Anti-infective Misc. - Combinations
BACTRIM (Use
MO
NF
SulfamethoxazoleTrimethoprim)
BACTRIM DS (Use
MO
NF
SulfamethoxazoleTrimethoprim)
$0- MO
$2.65
sulfamethoxazole(Tier
trimethoprim
1)
Antiprotozoal Agents
ALINIA TABS 500 MG
MO
atovaquone
$0- MO
$6.60
(Tier
2)
$0- MO
$2.65
(Tier
1)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
16
Name of drug
MEPRON (Use
Atovaquone)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
Carbapenems
imipenem-cilastatin
INVANZ IJ
meropenem
MERREM (Use
Meropenem)
PRIMAXIN IV (Use
Imipenem-Cilastatin)
$0- MO
$2.65
(Tier
1)
$0- MO
$6.60
(Tier
2)
$0- MO
$2.65
(Tier
1)
NF MO
NF MO
Chloramphenicols
chloramphenicol sodium
succinate
$0$2.65
(Tier
1)
Cyclic Lipopeptides
CUBICIN
$0$6.60
(Tier
2)
Glycylcyclines
TYGACIL
$0$6.60
(Tier
2)
Leprostatics
dapsone tabs or 100 mg,
25 mg
$0- MO
$2.65
(Tier
1)
Name of drug
CLEOCIN CAPS OR 150
MG, 300 MG, 75 MG (Use
Clindamycin HCl)
CLEOCIN IN D5W (Use
Clindamycin Phosphate in
D5W)
CLEOCIN PHOSPHATE IJ
600 MG/4ML, 900 MG/6ML
(Use Clindamycin
Phosphate)
CLEOCIN PHOSPHATE IV
300MG/50ML-5%,
600MG/50ML-5%,
900MG/50ML-5% (Use
Clindamycin Phosphate in
D5W)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO
NF
NF
MO
NF
NF
$0- MO
clindamycin hcl caps or 150 $2.65
(Tier
mg, 300 mg, 75 mg
1)
$0- MO
$2.65
clindamycin palmitate
(Tier
hydrochloride
1)
$0clindamycin phosphate in $2.65
(Tier
d5w
1)
$0clindamycin phosphate soln $2.65
ij 150 mg/ml, 9000 mg/60ml (Tier
1)
$0- MO
clindamycin phosphate soln $2.65
ij 600 mg/4ml, 900 mg/6ml (Tier
1)
$0clindamycin phosphate soln $2.65
iv 150 mg/ml, 600 mg/4ml (Tier
1)
Lincosamides
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
17
Name of drug
LINCOCIN
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
SYNERCID
Oxazolidinones
$0$2.65
linezolid soln iv 2 mg/ml
(Tier
1)
$0$2.65
linezolid tabs or 600 mg
(Tier
1)
$0$6.60
SIVEXTRO SOLR IV
(Tier
2)
$0$6.60
SIVEXTRO TABS OR
(Tier
2)
$0ZYVOX SOLN IV 2 MG/ML $6.60
(Tier
(Use Linezolid)
2)
$0$6.60
ZYVOX SUSR OR 100
(Tier
MG/5ML
2)
$0ZYVOX TABS OR 600 MG $6.60
(Tier
(Use Linezolid)
2)
Necessary
actions,
restrictions, or
limits on use
ANTIANGINAL AGENTS - Drugs to Treat Chest
Pain
Antianginals-Other
MO
RANEXA
Nitrates
ISORDIL TITRADOSE 5
MG (Use Isosorbide
Dinitrate)
MO
MO
MO
Polymyxins
polymyxin b sulfate solr ij
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
Streptogramins
$0- PA; MO
$6.60
(Tier
2)
MO
NF
$0isosorbide dinitrate tabs or $2.65
10 mg, 20 mg, 30 mg, 5 mg (Tier
1)
$0isosorbide dinitrate tbcr or $2.65
(Tier
40 mg
1)
$0isosorbide mononitrate tabs $2.65
(Tier
10 mg, 20 mg
1)
$0$2.65
isosorbide mononitrate
tb24 120 mg, 30 mg, 60 mg (Tier
1)
NITRO-DUR 0.1 MG/HR,
0.2 MG/HR, 0.4 MG/HR,
NF
0.6 MG/HR (Use
Nitroglycerin)
$0$6.60
NITROGLYCERIN
(Tier
LINGUAL
2)
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
18
Name of drug
nitroglycerin pt24 td 0.1
mg/hr, 0.2 mg/hr, 0.4
mg/hr, 0.6 mg/hr
nitroglycerin soln tl 0.4
mg/spray
NITROLINGUAL
PUMPSPRAY (Use
Nitroglycerin)
NITROMIST
NITROSTAT
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
NF
$0- MO
$6.60
(Tier
2)
$0- MO
$6.60
(Tier
2)
Antianxiety Agents - Misc.
$0$2.65
(Tier
1)
$0hydroxyzine hcl soln im 25 $2.65
(Tier
mg/ml, 50 mg/ml
1)
$0hydroxyzine hcl soln or 10 $2.65
(Tier
mg/5ml
1)
$0hydroxyzine hcl syrp or 10 $2.65
(Tier
mg/5ml
1)
$0hydroxyzine hcl tabs or 10 $2.65
(Tier
mg, 25 mg, 50 mg
1)
Necessary
actions,
restrictions, or
limits on use
AL; MO
AL; MO
Benzodiazepines
ANTIANXIETY AGENTS - Drugs to Treat Anxiety
buspirone hcl tabs or 10
mg, 15 mg, 30 mg, 5 mg,
7.5 mg
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0hydroxyzine pamoate caps $2.65
(Tier
or 25 mg, 50 mg
1)
VISTARIL (Use
NF
Hydroxyzine Pamoate)
MO
AL; MO
AL; MO
AL; MO
AL; MO
$0- MO
$2.65
(Tier
1)
$0- MO
alprazolam tb24 or 0.5 mg, $2.65
(Tier
1 mg, 2 mg, 3 mg
1)
$0- MO
$2.65
alprazolam tbdp or 0.25
(Tier
mg, 0.5 mg, 1 mg, 2 mg
1)
ATIVAN SOLN IJ 2 MG/ML NF MO
(Use Lorazepam)
ATIVAN SOLN IJ 4 MG/ML NF
(Use Lorazepam)
ATIVAN TABS OR 0.5 MG,
MO
NF
1 MG, 2 MG (Use
Lorazepam)
$0- MO
$2.65
clorazepate dipotassium
(Tier
1)
$0- MO
diazepam conc or 5 mg/ml $2.65
(Tier
1)
$0- MO
$2.65
diazepam soln or 1 mg/ml (Tier
1)
$0- MO
diazepam tabs or 10 mg, 2 $2.65
(Tier
mg, 5 mg
1)
alprazolam tabs or 0.25
mg, 0.5 mg, 1 mg, 2 mg
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
19
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
lorazepam conc or 2 mg/ml (Tier
1)
$0lorazepam soln ij 2 mg/ml, $2.65
(Tier
20 mg/10ml
1)
$0$2.65
lorazepam soln ij 4 mg/ml
(Tier
1)
$0lorazepam tabs or 0.5 mg, $2.65
(Tier
1 mg, 2 mg
1)
NIRAVAM (Use
NF
Alprazolam)
$0$2.65
oxazepam
(Tier
1)
TRANXENE T (Use
NF
Clorazepate Dipotassium)
Necessary
actions,
restrictions, or
limits on use
MO
quinidine gluconate tbcr or
324 mg
MO
quinidine sulfate
mexiletine hcl
MO
MO
MO
$0- MO
$2.65
(Tier
1)
Antiarrhythmics Type I-C
MO
flecainide acetate 100 mg
MO
flecainide acetate 150 mg
MO
NF MO
XANAX (Use Alprazolam)
NF MO
XANAX XR (Use
Alprazolam)
NF MO
ANTIARRHYTHMICS - Drugs to treat abnormal
heart rhythms
Antiarrhythmics Type I-A
NORPACE (Use
Disopyramide Phosphate)
Necessary
actions,
restrictions, or
limits on use
Antiarrhythmics Type I-B
VALIUM (Use Diazepam)
disopyramide phosphate
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0- AL; MO
$2.65
(Tier
1)
NF AL; MO
flecainide acetate 50 mg
propafenone hcl
RYTHMOL (Use
Propafenone HCl)
RYTHMOL SR (Use
Propafenone HCl)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(8 ea daily);
MO
MO
NF MO
NF MO
Antiarrhythmics Type III
$0- MO
amiodarone hcl tabs or 100 $2.65
(Tier
mg, 200 mg, 400 mg
1)
CORDARONE (Use
NF MO
Amiodarone HCl)
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
20
Name of drug
MULTAQ
TIKOSYN
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
SPIRIVA RESPIMAT 1.25
MCG/ACT
SPIRIVA RESPIMAT 2.5
MCG/ACT
ANTIASTHMATIC AND BRONCHODILATOR
AGENTS - Drugs to Treat Lung Conditions
Anti-Inflammatory Agents
cromolyn sodium nebu in
$0- MO; B/D
$2.65
(Tier
1)
Antiasthmatic - Monoclonal Antibodies
$0- PA; LA
$6.60
XOLAIR
(Tier
2)
Asthma and Bronchodilator Agent Combinations
$0 NT
(Tier
dyphylline-guaifenesin
3)
Bronchodilators - Anticholinergics
$0$6.60
ATROVENT HFA
(Tier
2)
$0$6.60
INCRUSE ELLIPTA
(Tier
2)
$0$2.65
ipratropium bromide soln in (Tier
1)
$0$6.60
SPIRIVA HANDIHALER
(Tier
2)
Name of drug
QL(0.86 gm
daily); MO
QL(1 ea daily);
MO
SPIRIVA RESPIMAT 2.5
MCG/ACT
TUDORZA PRESSAIR
Leukotriene Modulators
ACCOLATE (Use
Zafirlukast)
montelukast sodium chew
4 mg, 5 mg
montelukast sodium tabs
10 mg
SINGULAIR CHEW 4 MG,
5 MG (Use Montelukast
Sodium)
SINGULAIR TABS 10 MG
(Use Montelukast Sodium)
zafirlukast
MO; B/D
QL(1 ea daily);
MO
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
60
actuations;QL(
0.14 gm daily)
60
actuations;QL(
0.14 gm daily);
MO
28
actuations;QL(
0.28 gm daily);
MO
QL(0.04 ea
daily); MO
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
MO
NF
NF MO
$0- MO
$2.65
(Tier
1)
Selective Phosphodiesterase 4 (PDE4) Inhibitors
$0- QL(1 ea daily);
$6.60 MO
DALIRESP
(Tier
2)
Steroid Inhalants
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
21
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$6.60
AEROSPAN
(Tier
2)
$0$6.60
ARNUITY ELLIPTA
(Tier
2)
$0$2.65
budesonide (inhalation)
(Tier
0.25 mg/2ml, 0.5 mg/2ml
1)
$0$6.60
FLOVENT DISKUS 100
(Tier
MCG/BLIST
2)
$0$6.60
FLOVENT DISKUS 250
(Tier
MCG/BLIST
2)
$0$6.60
FLOVENT DISKUS 50
(Tier
MCG/BLIST
2)
$0$6.60
FLOVENT HFA 110
MCG/ACT, 220 MCG/ACT (Tier
2)
$0$6.60
FLOVENT HFA 44
(Tier
MCG/ACT
2)
PULMICORT 0.25
MG/2ML, 0.5 MG/2ML
NF
(Use Budesonide
(Inhalation))
$0$6.60
QVAR
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
QL(0.6 gm
daily); MO
QL(1 ea daily);
MO
MO; B/D
QL(20 ea
daily); MO
QL(8 ea daily);
MO
QL(40 ea
daily); MO
QL(0.8 gm
daily); MO
QL(0.36 gm
daily); MO
MO; B/D
QL(0.87 gm
daily); MO
Sympathomimetics
Name of drug
ADVAIR DISKUS
ADVAIR HFA
albuterol sulfate nebu in
0.083 %, 0.5 %, 0.63
mg/3ml, 1.25 mg/3ml
albuterol sulfate syrp or 2
mg/5ml
albuterol sulfate tabs or 2
mg, 4 mg
albuterol sulfate tb12 or 4
mg, 8 mg
ANORO ELLIPTA
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
QL(4 gm daily);
MO
MO; B/D
MO
MO
MO
QL(2 ea daily);
MO
Limited to 2
inhalers per
month
(Institutional
Pack);QL(2 ea
daily); MO
$0- Limit 1 inhaler
BREO ELLIPTA
$6.60 per month;QL(2
25MCG/INH-100MCG/INH, (Tier
ea daily); MO
25MCG/INH-200MCG/INH
2)
$0- MO
$6.60
COMBIVENT RESPIMAT
(Tier
2)
$0BREO ELLIPTA
$6.60
25MCG/INH-100MCG/INH, (Tier
25MCG/INH-200MCG/INH
2)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
22
Name of drug
DULERA
DUONEB (Use
Ipratropium-Albuterol)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
QL(4 gm daily);
MO
Name of drug
SEREVENT DISKUS
NF MO; B/D
$0
EPHEDRINE HCL TABS
(Tier
OR
3)
$0
EPHEDRINE SULFATE
(Tier
CAPS OR
3)
$0$2.65
epinephrine hcl sosy 0.1
(Tier
mg/ml
1)
$0$6.60
FORADIL AEROLIZER
(Tier
2)
$0$2.65
ipratropium-albuterol
(Tier
1)
$0levalbuterol hcl nebu in
0.31 mg/3ml, 0.63 mg/3ml, $2.65
(Tier
1.25 mg/0.5ml, 1.25
1)
mg/3ml
$0$6.60
PROAIR HFA
(Tier
2)
$0$6.60
PROAIR RESPICLICK
(Tier
2)
$0$6.60
PROVENTIL HFA
(Tier
2)
NT
MO; NT
STIOLTO RESPIMAT
STRIVERDI RESPIMAT
MO
STRIVERDI RESPIMAT
QL(2 ea daily);
MO
MO; B/D
MO; B/D
terbutaline sulfate tabs or
2.5 mg, 5 mg
XOPENEX (Use
Levalbuterol HCl)
XOPENEX
CONCENTRATE (Use
Levalbuterol HCl)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(2 ea daily);
MO
Limited to 1
inhaler per
month;QL(0.14
gm daily); MO
QL(0.14 gm
daily); MO
Institutional
Pack;QL(0.28
gm daily); MO
MO
NF MO; B/D
MO; B/D
NF
Xanthines
MO
aminophylline
MO
theophylline tb12 100 mg,
200 mg, 300 mg, 450 mg
MO
theophylline tb24 400 mg,
600 mg
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
ANTICOAGULANTS - Blood Thinners
Coumarin Anticoagulants
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
23
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
COUMADIN TABS OR 1
MO
MG, 10 MG, 2 MG, 2.5 MG,
NF
3 MG, 4 MG, 5 MG, 6 MG,
7.5 MG (Use Warfarin
Sodium)
$0- MO
$2.65
warfarin sodium
(Tier
1)
Direct Factor Xa Inhibitors
ELIQUIS
XARELTO
XARELTO STARTER
PACK
$0- MO
$6.60
(Tier
2)
$0- MO
$6.60
(Tier
2)
$0- MO
$6.60
(Tier
2)
Heparins And Heparinoid-Like Agents
ARIXTRA (Use
NF MO
Fondaparinux Sodium)
$0- MO
$2.65
enoxaparin sodium
(Tier
1)
$0- MO
$2.65
fondaparinux sodium
(Tier
1)
FRAGMIN 10000 UNIT/ML,
MO
12500 UNIT/0.5ML, 15000
$0UNIT/0.6ML, 18000
$6.60
UNT/0.72ML, 2500
(Tier
UNIT/0.2ML, 25000
2)
UNIT/ML, 5000
UNIT/0.2ML, 7500
UNIT/0.3ML
Name of drug
FRAGMIN 95000
UNIT/3.8ML
heparin sodium (porcine)
LOVENOX (Use
Enoxaparin Sodium)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
NF MO
Thrombin Inhibitors
argatroban 250 mg/2.5ml
PRADAXA
$0- MO
$2.65
(Tier
1)
$0- MO
$6.60
(Tier
2)
ANTICONVULSANTS - Drugs to Treat Seizures
AMPA Glutamate Receptor Antagonists
$0- QL(1.2 ea
$6.60 daily); MO
FYCOMPA 10 MG
(Tier
2)
$0- QL(1 ea daily);
$6.60 MO
FYCOMPA 12 MG
(Tier
2)
$0- QL(6 ea daily);
$6.60 MO
FYCOMPA 2 MG
(Tier
2)
$0- QL(3 ea daily);
$6.60 MO
FYCOMPA 4 MG
(Tier
2)
$0- QL(2 ea daily);
$6.60 MO
FYCOMPA 6 MG
(Tier
2)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
24
Name of drug
FYCOMPA 8 MG
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
QL(1.5 ea
daily); MO
Anticonvulsants - Benzodiazepines
$0- QL(40 ea
$2.65 daily); MO
clonazepam tabs or 0.5 mg (Tier
1)
$0- QL(20 ea
$2.65 daily); MO
clonazepam tabs or 1 mg
(Tier
1)
$0- QL(10 ea
$2.65 daily); MO
clonazepam tabs or 2 mg
(Tier
1)
$0- MO
clonazepam tbdp or 0.125 $2.65
mg, 0.25 mg, 0.5 mg, 1 mg, (Tier
2 mg
1)
$0- MO
$6.60
DIASTAT ACUDIAL
(Tier
2)
$0- MO
$6.60
DIASTAT PEDIATRIC
(Tier
2)
$0- MO
$6.60
DIAZEPAM GEL RE 10
(Tier
MG, 2.5 MG, 20 MG
2)
KLONOPIN 0.5 MG (Use
NF QL(40 ea
Clonazepam)
daily); MO
KLONOPIN 1 MG (Use
NF QL(20 ea
Clonazepam)
daily); MO
KLONOPIN 2 MG (Use
NF QL(10 ea
Clonazepam)
daily); MO
Name of drug
ONFI
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
Anticonvulsants - Misc.
$0$6.60
APTIOM 200 MG
(Tier
2)
$0$6.60
APTIOM 400 MG
(Tier
2)
$0$6.60
APTIOM 600 MG
(Tier
2)
$0$6.60
APTIOM 800 MG
(Tier
2)
$0$6.60
BANZEL
(Tier
2)
$0$2.65
carbamazepine chew or
(Tier
100 mg
1)
$0$2.65
carbamazepine cp12 or
(Tier
100 mg, 200 mg, 300 mg
1)
$0$2.65
carbamazepine susp or
(Tier
100 mg/5ml
1)
$0carbamazepine tabs or 200 $2.65
(Tier
mg
1)
QL(6 ea daily);
MO
QL(3 ea daily);
MO
QL(2 ea daily);
MO
QL(1 ea daily);
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
25
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0carbamazepine tb12 or 200 $2.65
(Tier
mg, 400 mg
1)
CARBATROL (Use
NF
Carbamazepine)
$0$2.65
gabapentin caps or 100
(Tier
mg, 300 mg, 400 mg
1)
$0$2.65
gabapentin soln or 250
(Tier
mg/5ml
1)
$0gabapentin tabs or 600 mg, $2.65
(Tier
800 mg
1)
KEPPRA (Use
NF
Levetiracetam)
KEPPRA XR (Use
NF
Levetiracetam)
LAMICTAL CHEWABLE
NF
DISPERSIBLE (Use
Lamotrigine)
LAMICTAL TABS 100 MG,
NF
150 MG, 200 MG, 25 MG
(Use Lamotrigine)
$0$6.60
LAMICTAL XR KIT
(Tier
2)
LAMICTAL XR TB24 100
MG, 200 MG, 25 MG, 250
NF
MG, 300 MG, 50 MG (Use
Lamotrigine)
$0lamotrigine chew 25 mg, 5 $2.65
(Tier
mg
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
lamotrigine tabs 100 mg,
150 mg, 200 mg, 25 mg
MO
MO
MO
MO
lamotrigine tb24 100 mg,
200 mg, 25 mg, 250 mg,
300 mg, 50 mg
LEVETIRACETAM SOLN
IV 1000MG/100ML750MG/100ML,
1500MG/100ML540MG/100ML,
500MG/100ML820MG/100ML
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
levetiracetam soln or 100
(Tier
mg/ml, 500 mg/5ml
1)
$0levetiracetam tabs or 1000 $2.65
mg, 250 mg, 500 mg, 750
(Tier
mg
1)
$0levetiracetam tb24 or 500 $2.65
(Tier
mg, 750 mg
1)
$0$6.60
LYRICA CAPS 100 MG
(Tier
2)
$0$6.60
LYRICA CAPS 150 MG
(Tier
2)
$0$6.60
LYRICA CAPS 200 MG
(Tier
2)
MO
levetiracetam soln iv 500
mg/5ml
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL(6 ea daily);
MO
QL(4 ea daily);
MO
QL(3 ea daily);
MO
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
26
Name of drug
LYRICA CAPS 225 MG,
300 MG
LYRICA CAPS 25 MG
LYRICA CAPS 50 MG
LYRICA CAPS 75 MG
LYRICA SOLN 20 MG/ML
MYSOLINE (Use
Primidone)
NEURONTIN (Use
Gabapentin)
oxcarbazepine
POTIGA 200 MG
POTIGA 300 MG
POTIGA 400 MG
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
QL(2 ea daily);
MO
QL(24 ea
daily); MO
QL(12 ea
daily); MO
QL(8 ea daily);
MO
QL(30 ml
daily); MO
NF MO
NF MO
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
MO
QL(6 ea daily);
MO
QL(4 ea daily);
MO
QL(3 ea daily);
MO
Name of drug
POTIGA 50 MG
primidone tabs or 250 mg,
50 mg
TEGRETOL (Use
Carbamazepine)
TEGRETOL-XR 100 MG
TEGRETOL-XR 200 MG,
400 MG (Use
Carbamazepine)
TOPAMAX (Use
Topiramate)
TOPAMAX SPRINKLE
(Use Topiramate)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(24 ea
daily); MO
MO
NF MO
$0- MO
$6.60
(Tier
2)
MO
NF
NF MO
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
topiramate tabs or 100 mg, $2.65
(Tier
200 mg, 25 mg, 50 mg
1)
TRILEPTAL (Use
NF MO
Oxcarbazepine)
$0$6.60
VIMPAT SOLN IV 200
(Tier
MG/20ML
2)
$0- MO
$6.60
VIMPAT SOLN OR 10
(Tier
MG/ML
2)
$0- MO
VIMPAT TABS OR 100
$6.60
MG, 150 MG, 200 MG, 50 (Tier
MG
2)
topiramate cpsp or 15 mg,
25 mg
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
27
Name of drug
ZONEGRAN (Use
Zonisamide)
zonisamide
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0- MO
$2.65
(Tier
1)
Carbamates
felbamate
FELBATOL (Use
Felbamate)
$0- MO
$2.65
(Tier
1)
NF MO
GABA Modulators
GABITRIL 12 MG, 16 MG
GABITRIL 2 MG, 4 MG
(Use Tiagabine HCl)
SABRIL
tiagabine hcl
Hydantoins
CEREBYX 100 MG
PE/2ML (Use Fosphenytoin
Sodium)
CEREBYX 500 MG
PE/10ML (Use
Fosphenytoin Sodium)
DILANTIN-125 (Use
Phenytoin)
fosphenytoin sodium 100
mg pe/2ml
$0- MO
$6.60
(Tier
2)
NF MO
$0- LA
$6.60
(Tier
2)
$0- MO
$2.65
(Tier
1)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
fosphenytoin sodium 500
(Tier
mg pe/10ml
1)
$0$6.60
PEGANONE
(Tier
2)
$0$2.65
phenytoin chew or 50 mg
(Tier
1)
$0$2.65
phenytoin sodium extended (Tier
1)
$0$2.65
phenytoin sodium soln ij
(Tier
1)
$0$2.65
phenytoin susp or 125
(Tier
mg/5ml
1)
MO
NF
NF MO
$0$2.65
(Tier
1)
MO
MO
MO
MO
MO
Succinimides
CELONTIN
ethosuximide caps or 250
mg
NF
Necessary
actions,
restrictions, or
limits on use
ethosuximide soln or 250
mg/5ml
ZARONTIN 250 MG (Use
Ethosuximide)
Valproic Acid
DEPACON (Use Valproate
Sodium)
$0- MO
$6.60
(Tier
2)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
NF MO
NF
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
28
Name of drug
DEPAKENE (Use
Valproate Sodium)
DEPAKENE (Use Valproic
Acid)
DEPAKOTE (Use
Divalproex Sodium)
DEPAKOTE ER (Use
Divalproex Sodium)
DEPAKOTE SPRINKLES
(Use Divalproex Sodium)
divalproex sodium
STAVZOR
valproate sodium soln iv
100 mg/ml, 500 mg/5ml
valproate sodium soln or
250 mg/5ml
valproate sodium syrp or
250 mg/5ml
valproic acid caps or
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
NF MO
Name of drug
REMERON (Use
Mirtazapine)
REMERON SOLTAB (Use
Mirtazapine)
NF MO
Antidepressants - Misc.
NF MO
bupropion hcl tabs or 100
mg
NF MO
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
MO
bupropion hcl tabs or 75
mg
bupropion hcl tb12 or 100
mg
bupropion hcl tb12 or 150
mg, 200 mg
MO
bupropion hcl tb24 or 150
mg
MO
bupropion hcl tb24 or 300
mg
MO
FORFIVO XL
ANTIDEPRESSANTS - Drugs to Treat Depression
maprotiline hcl
Alpha-2 Receptor Antagonists (Tetracyclics)
$0- MO
$2.65
mirtazapine
(Tier
1)
WELLBUTRIN 100 MG
(Use Bupropion HCl)
WELLBUTRIN 75 MG (Use
Bupropion HCl)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
NF MO
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
QL(4.5 ea
daily); MO
QL(6 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(3 ea daily);
MO
QL(1 ea daily);
MO
MO
MO
NF QL(4.5 ea
daily); MO
NF QL(6 ea daily);
MO
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
29
Name of drug
WELLBUTRIN SR 100 MG
(Use Bupropion HCl)
WELLBUTRIN SR 150 MG,
200 MG (Use Bupropion
HCl)
WELLBUTRIN XL 150 MG
(Use Bupropion HCl)
WELLBUTRIN XL 300 MG
(Use Bupropion HCl)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF QL(4 ea daily);
MO
QL(2 ea daily);
NF MO
NF QL(3 ea daily);
MO
NF QL(1 ea daily);
MO
Monoamine Oxidase Inhibitors (MAOIs)
$0- MO
$6.60
EMSAM
(Tier
2)
$0- MO
$6.60
MARPLAN
(Tier
2)
NARDIL (Use Phenelzine
NF MO
Sulfate)
PARNATE (Use
NF MO
Tranylcypromine Sulfate)
$0- MO
$2.65
phenelzine sulfate tabs or (Tier
1)
$0- MO
$2.65
tranylcypromine sulfate
(Tier
1)
Selective Serotonin Reuptake Inhibitors (SSRIs)
CELEXA 10 MG (Use
NF QL(4 ea daily);
Citalopram Hydrobromide)
MO
CELEXA 20 MG (Use
NF QL(2 ea daily);
Citalopram Hydrobromide)
MO
CELEXA 40 MG (Use
NF QL(1 ea daily);
Citalopram Hydrobromide)
MO
$0- QL(20 ml
$2.65 daily); MO
citalopram hydrobromide
(Tier
soln 10 mg/5ml
1)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
citalopram hydrobromide
(Tier
tabs 10 mg
1)
$0$2.65
citalopram hydrobromide
(Tier
tabs 20 mg
1)
$0$2.65
citalopram hydrobromide
(Tier
tabs 40 mg
1)
$0$2.65
escitalopram oxalate
(Tier
1)
$0$2.65
fluoxetine hcl caps or 10
(Tier
mg, 20 mg, 40 mg
1)
$0$2.65
fluoxetine hcl cpdr or 90 mg (Tier
1)
$0$2.65
fluoxetine hcl soln or 20
(Tier
mg/5ml
1)
$0$2.65
fluoxetine hcl tabs or 10
(Tier
mg, 20 mg
1)
$0$2.65
fluvoxamine maleate
(Tier
1)
LEXAPRO (Use
NF
Escitalopram Oxalate)
LUVOX CR (Use
NF
Fluvoxamine Maleate)
Necessary
actions,
restrictions, or
limits on use
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(1 ea daily);
MO
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
30
Name of drug
paroxetine hcl
PAXIL CR (Use Paroxetine
HCl)
PAXIL SUSP 10 MG/5ML
PAXIL TABS 10 MG, 20
MG, 30 MG, 40 MG (Use
Paroxetine HCl)
PROZAC (Use Fluoxetine
HCl)
PROZAC WEEKLY (Use
Fluoxetine HCl)
sertraline hcl conc or 20
mg/ml
sertraline hcl tabs or 100
mg, 25 mg, 50 mg
ZOLOFT (Use Sertraline
HCl)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
NF MO
$0- MO
$6.60
(Tier
2)
MO
NF
NF MO
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
NF MO
Serotonin Modulators
BRINTELLIX 10 MG
BRINTELLIX 20 MG
BRINTELLIX 5 MG
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
ST; QL(2 ea
daily); MO
ST; QL(1 ea
daily); MO
ST; QL(4 ea
daily); MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
nefazodone hcl
(Tier
1)
$0trazodone hcl tabs or 100 $2.65
mg, 150 mg, 300 mg, 50
(Tier
mg
1)
$0$6.60
VIIBRYD
(Tier
2)
$0$6.60
VIIBRYD STARTER PACK (Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
ST; MO
ST
Serotonin-Norepinephrine Reuptake Inhibitors
CYMBALTA (Use
NF MO
Duloxetine HCl)
$0- ST; MO
$6.60
DESVENLAFAXINE ER
(Tier
100 MG, 50 MG
2)
$0- ST; Fumarate
$6.60
DESVENLAFAXINE ER
(Tier
100 MG, 50 MG
2)
$0- MO
$2.65
duloxetine hcl 20 mg, 30
(Tier
mg, 60 mg
1)
EFFEXOR XR 150 MG
NF QL(1 ea daily);
(Use Venlafaxine HCl)
MO
EFFEXOR XR 37.5 MG
NF QL(6 ea daily);
(Use Venlafaxine HCl)
MO
EFFEXOR XR 75 MG (Use NF QL(3 ea daily);
Venlafaxine HCl)
MO
$0- ST; QL(1 ea
FETZIMA 120 MG, 40 MG, $6.60 daily); MO
(Tier
80 MG
2)
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
31
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$6.60
FETZIMA 20 MG
(Tier
2)
$0$6.60
FETZIMA TITRATION
(Tier
PACK
2)
$0$6.60
KHEDEZLA
(Tier
2)
$0$6.60
PRISTIQ
(Tier
2)
$0$2.65
venlafaxine hcl cp24 150
(Tier
mg
1)
$0venlafaxine hcl cp24 37.5 $2.65
(Tier
mg
1)
$0venlafaxine hcl cp24 75 mg $2.65
(Tier
1)
$0$6.60
VENLAFAXINE HCL ER
(Tier
2)
$0$2.65
venlafaxine hcl tabs 100
(Tier
mg
1)
$0$2.65
venlafaxine hcl tabs 25 mg (Tier
1)
Necessary
actions,
restrictions, or
limits on use
ST; QL(2 ea
daily); MO
ST; MO
ST; MO
ST; MO
QL(1 ea daily);
MO
QL(6 ea daily);
MO
QL(3 ea daily);
MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
venlafaxine hcl tabs 37.5
(Tier
mg
1)
$0venlafaxine hcl tabs 50 mg $2.65
(Tier
1)
$0$2.65
venlafaxine hcl tabs 75 mg (Tier
1)
$0$2.65
venlafaxine hcl tb24 150
(Tier
mg
1)
$0$2.65
venlafaxine hcl tb24 37.5
(Tier
mg
1)
$0$2.65
venlafaxine hcl tb24 75 mg (Tier
1)
ST; QL(1 ea
daily); MO
amoxapine
QL(15 ea
daily); MO
QL(10 ea
daily); MO
QL(7.5 ea
daily); MO
QL(5 ea daily);
MO
QL(1 ea daily);
MO
QL(6 ea daily);
MO
QL(3 ea daily);
MO
Tricyclic Agents
amitriptyline hcl
QL(3.5 ea
daily); MO
Necessary
actions,
restrictions, or
limits on use
ANAFRANIL (Use
Clomipramine HCl)
clomipramine hcl caps or
25 mg, 50 mg, 75 mg
desipramine hcl tabs or 10
mg, 100 mg, 150 mg, 25
mg, 50 mg, 75 mg
$0- AL; MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
NF AL; MO
$0- AL; MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
32
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0doxepin hcl caps or 10 mg, $2.65
100 mg, 150 mg, 25 mg, 50 (Tier
mg, 75 mg
1)
$0$2.65
doxepin hcl conc or 10
(Tier
mg/ml
1)
$0imipramine hcl tabs or 10 $2.65
(Tier
mg, 25 mg, 50 mg
1)
$0$2.65
imipramine pamoate
(Tier
1)
NORPRAMIN (Use
NF
Desipramine HCl)
$0nortriptyline hcl caps or 10 $2.65
mg, 25 mg, 50 mg, 75 mg (Tier
1)
$0nortriptyline hcl soln or 10 $2.65
(Tier
mg/5ml
1)
PAMELOR (Use
NF
Nortriptyline HCl)
$0$2.65
protriptyline hcl
(Tier
1)
$0$6.60
SURMONTIL
(Tier
2)
TOFRANIL-PM (Use
NF
Imipramine Pamoate)
$0trimipramine maleate caps $2.65
(Tier
or 100 mg, 25 mg, 50 mg
1)
Necessary
actions,
restrictions, or
limits on use
AL; MO
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
ANTIDIABETICS - Drugs to Regulate Blood Sugar
Alpha-Glucosidase Inhibitors
AL; MO
AL; MO
AL; MO
acarbose
GLYSET
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
QL(3 ea daily);
MO
QL(3 ea daily);
MO
NF QL(3 ea daily);
MO
PRECOSE (Use Acarbose)
Antidiabetic - Amylin Analogs
MO
SYMLINPEN 120
MO
SYMLINPEN 60
MO
MO
MO
AL; MO
AL; MO
AL; MO
Antidiabetic Combinations
ACTOPLUS MET (Use
Pioglitazone HCl-Metformin
HCl)
DUETACT (Use
Pioglitazone HClGlimepiride)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
QL(0.4 ml
daily); MO
QL(3 ea daily);
NF MO
QL(1.5 ea
NF daily); MO
$0$2.65
(Tier
1)
$0$2.65
glipizide-metformin hcl
2.5mg-500mg, 5mg-500mg (Tier
1)
GLUCOVANCE 1.25MGNF
250MG (Use GlyburideMetformin)
glipizide-metformin hcl
2.5mg-250mg
QL(0.4 ml
daily); MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
AL; QL(8 ea
daily); MO
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
33
Name of drug
GLUCOVANCE 2.5MG500MG, 5MG-500MG (Use
Glyburide-Metformin)
What
the
drug
will
cost
you
(tier
level)
AL; QL(4 ea
NF daily); MO
$0$2.65
(Tier
1)
$0glyburide-metformin 2.5mg- $2.65
(Tier
500mg, 5mg-500mg
1)
$0INVOKAMET 150MG$6.60
1000MG, 150MG-500MG, (Tier
50MG-1000MG
2)
$0$6.60
INVOKAMET 50MG(Tier
500MG
2)
$0$6.60
JANUMET
(Tier
2)
$0$6.60
JANUMET XR 100MG(Tier
1000MG
2)
$0$6.60
JANUMET XR 50MG(Tier
1000MG, 50MG-500MG
2)
$0$6.60
JENTADUETO
(Tier
2)
$0$6.60
KAZANO
(Tier
2)
$0KOMBIGLYZE XR 2.5MG- $6.60
(Tier
1000MG
2)
glyburide-metformin
1.25mg-250mg
Necessary
actions,
restrictions, or
limits on use
AL; QL(8 ea
daily); MO
AL; QL(4 ea
daily); MO
QL(2 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(1 ea daily);
MO
QL(2 ea daily);
MO
QL(2 ea daily);
MO
QL(2 ea daily);
MO
QL(2 ea daily);
MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$6.60
KOMBIGLYZE XR 5MG(Tier
1000MG, 5MG-500MG
2)
$0$6.60
OSENI 12.5MG-15MG
(Tier
2)
$0OSENI 12.5MG-30MG,
$6.60
12.5MG-45MG, 25MG(Tier
15MG, 25MG-30MG,
2)
25MG-45MG
$0$2.65
pioglitazone hcl-glimepiride (Tier
1)
$0pioglitazone hcl-metformin $2.65
(Tier
hcl
1)
$0$6.60
PRANDIMET
(Tier
2)
Biguanides
FORTAMET 1000 MG (Use
Metformin HCl)
FORTAMET 500 MG (Use
Metformin HCl)
GLUCOPHAGE 1000 MG
(Use Metformin HCl)
GLUCOPHAGE 500 MG
(Use Metformin HCl)
GLUCOPHAGE 850 MG
(Use Metformin HCl)
GLUCOPHAGE XR 500
MG (Use Metformin HCl)
GLUCOPHAGE XR 750
MG (Use Metformin HCl)
Necessary
actions,
restrictions, or
limits on use
QL(1 ea daily);
MO
QL(2 ea daily);
MO
QL(1 ea daily);
MO
QL(1.5 ea
daily); MO
QL(3 ea daily);
MO
QL(5 ea daily);
MO
NF QL(2 ea daily);
MO
NF Osmotic;QL(5
ea daily); MO
NF QL(2.5 ea
daily); MO
NF QL(5 ea daily);
MO
NF QL(3 ea daily);
MO
NF QL(4 ea daily);
MO
NF QL(2 ea daily);
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
34
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$6.60
GLUMETZA 1000 MG
(Tier
2)
$0$6.60
GLUMETZA 500 MG
(Tier
2)
$0metformin hcl tabs or 1000 $2.65
(Tier
mg
1)
$0metformin hcl tabs or 500 $2.65
(Tier
mg
1)
$0metformin hcl tabs or 850 $2.65
(Tier
mg
1)
$0metformin hcl tb24 or 1000 $2.65
(Tier
mg, 750 mg
1)
$0metformin hcl tb24 or 500 $2.65
(Tier
mg
1)
$0metformin hcl tb24 or 500 $2.65
(Tier
mg
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
QL(2 ea daily);
MO
dextrose (diabetic use) gel
15 gm/38gm, 40 %
QL(4 ea daily);
MO
GLUCAGEN HYPOKIT
QL(2.5 ea
daily); MO
glucagon (rdna)
QL(5 ea daily);
MO
GLUCOSE CHEW 4 GM
GNP GLUCOSE 4 GM
QL(3 ea daily);
MO
QL(2 ea daily);
MO
Osmotic;QL(5
ea daily); MO
QL(4 ea daily);
MO
GNP QUICK DISSOLVE
GLUCOSE
LEADER QUICK
DISSOLVE GLUCOSE
MS QUICK DISSOLVE
GLUCOSE
PROGLYCEM
SM GLUCOSE 4 GM
Diabetic Other
BD GLUCOSE
CVS GLUCOSE 4 GM
DEX4 QUICK DISSOLVE
GLUCOSE
$0 NT
(Tier
3)
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
ULTILET GLUCOSE
WALGREENS GLUCOSE
4 GM
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0$6.60
(Tier
2)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO
MO
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO
MO; NT
MO; NT
MO; NT
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
35
Name of drug
JANUVIA
NESINA
ONGLYZA
TRADJENTA
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
AVANDIA 2 MG
MO
AVANDIA 4 MG
MO
AVANDIA 8 MG
MO
Dopamine Receptor Agonists - Antidiabetic
$0- QL(6 ea daily);
$6.60 MO
CYCLOSET
(Tier
2)
Incretin Mimetic Agents (GLP-1 Receptor
$0- ST; MO
$6.60
BYDUREON
(Tier
2)
$0- ST; MO
$6.60
BYETTA
(Tier
2)
$0- ST; QL(0.3 ml
$6.60 daily); MO
VICTOZA
(Tier
2)
Insulin Sensitizing Agents
ACTOS 15 MG (Use
Pioglitazone HCl)
ACTOS 30 MG, 45 MG
(Use Pioglitazone HCl)
Name of drug
NF QL(3 ea daily);
MO
NF QL(1 ea daily);
MO
pioglitazone hcl 15 mg
pioglitazone hcl 30 mg, 45
mg
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(4 ea daily);
LA; MO
QL(2 ea daily);
LA; MO
QL(1 ea daily);
LA; MO
QL(3 ea daily);
MO
QL(1 ea daily);
MO
Insulin
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50
KWIKPEN
HUMALOG MIX 75/25
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
36
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$6.60
HUMALOG MIX 75/25
(Tier
KWIKPEN
2)
$0$6.60
HUMULIN 70/30
(Tier
2)
$0$6.60
HUMULIN 70/30 KWIKPEN (Tier
2)
$0$6.60
HUMULIN 70/30 PEN
(Tier
2)
$0$6.60
HUMULIN N
(Tier
2)
$0$6.60
HUMULIN N KWIKPEN
(Tier
2)
$0$6.60
HUMULIN N U-100 PEN
(Tier
2)
$0$6.60
HUMULIN R
(Tier
2)
$0$6.60
HUMULIN R U-500
(Tier
(CONCENTRATED)
2)
$0$6.60
LANTUS
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
Name of drug
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXPEN
LEVEMIR FLEXTOUCH
TOUJEO SOLOSTAR
QL(1.5 ml
daily); MO
Necessary
actions,
restrictions, or
limits on use
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
QL(1.5 ml
daily); MO
Limited to
15mls per
month;QL(0.5
ml daily); MO
Meglitinide Analogues
nateglinide
QL(1.5 ml
daily); MO
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
PRANDIN 0.5 MG (Use
Repaglinide)
PRANDIN 1 MG (Use
Repaglinide)
PRANDIN 2 MG (Use
Repaglinide)
QL(1.5 ml
daily); MO
repaglinide 0.5 mg
QL(1.5 ml
daily); MO
repaglinide 1 mg
$0- QL(3 ea daily);
$2.65 MO
(Tier
1)
NF QL(32 ea
daily); MO
NF QL(16 ea
daily); MO
NF QL(8 ea daily);
MO
$0- QL(32 ea
$2.65 daily); MO
(Tier
1)
$0- QL(16 ea
$2.65 daily); MO
(Tier
1)
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
37
Name of drug
repaglinide 2 mg
STARLIX (Use Nateglinide)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(8 ea daily);
MO
NF QL(3 ea daily);
MO
Sodium-Glucose Co-Transporter 2 (SGLT2)
$0- MO
$6.60
FARXIGA
(Tier
2)
$0- MO
$6.60
INVOKANA
(Tier
2)
$0- QL(2 ea daily);
$6.60 MO
JARDIANCE 10 MG
(Tier
2)
$0- QL(1 ea daily);
$6.60 MO
JARDIANCE 25 MG
(Tier
2)
Sulfonylureas
AMARYL 1 MG (Use
Glimepiride)
AMARYL 2 MG (Use
Glimepiride)
AMARYL 4 MG (Use
Glimepiride)
DIABETA 1.25 MG (Use
Glyburide)
DIABETA 2.5 MG (Use
Glyburide)
DIABETA 5 MG (Use
Glyburide)
NF
NF
NF
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
QL(8 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
AL; QL(16 ea
daily); MO
AL; QL(8 ea
daily); MO
AL; QL(4 ea
daily); MO
Name of drug
glimepiride 1 mg
glimepiride 2 mg
glimepiride 4 mg
glipizide tabs or 10 mg
glipizide tabs or 5 mg
glipizide tb24 or 10 mg
glipizide tb24 or 2.5 mg
glipizide tb24 or 5 mg
GLUCOTROL 10 MG (Use
Glipizide)
GLUCOTROL 5 MG (Use
Glipizide)
GLUCOTROL XL 10 MG
(Use Glipizide)
GLUCOTROL XL 2.5 MG
(Use Glipizide)
GLUCOTROL XL 5 MG
(Use Glipizide)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(8 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(4 ea daily);
MO
QL(8 ea daily);
MO
QL(2 ea daily);
MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
NF QL(4 ea daily);
MO
NF QL(8 ea daily);
MO
NF QL(2 ea daily);
MO
NF QL(8 ea daily);
MO
NF QL(4 ea daily);
MO
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
38
Name of drug
glyburide 1.25 mg
glyburide 2.5 mg
glyburide 5 mg
glyburide micronized 1.5
mg
glyburide micronized 3 mg
glyburide micronized 6 mg
GLYNASE 1.5 MG (Use
Glyburide Micronized)
GLYNASE 3 MG (Use
Glyburide Micronized)
GLYNASE 6 MG (Use
Glyburide Micronized)
tolazamide 250 mg
tolazamide 500 mg
tolbutamide
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
NF
NF
NF
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Necessary
actions,
restrictions, or
limits on use
Name of drug
AL; QL(16 ea
daily); MO
ANTIDIARRHEALS - Drugs to Treat Diarrhea
Antidiarrheal Agents - Misc.
AL; QL(8 ea
daily); MO
AL; QL(4 ea
daily); MO
AL; QL(8 ea
daily); MO
AL; QL(4 ea
daily); MO
AL; QL(2 ea
daily); MO
AL; QL(8 ea
daily); MO
AL; QL(4 ea
daily); MO
AL; QL(2 ea
daily); MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(6 ea daily);
MO
$0 MO; NT
bismuth subsalicylate chew (Tier
or 262 mg
3)
bismuth subsalicylate susp $0 MO; NT
(Tier
or 262 mg/15ml, 525
3)
mg/15ml, 527 mg/30ml
$0 NT
bismuth subsalicylate tabs (Tier
or 262 mg
3)
PEPTO BISMOL (Use
Bismuth Subsalicylate)
PEPTO-BISMOL (Use
Bismuth Subsalicylate)
PEPTO-BISMOL
INSTACOOL (Use Bismuth
Subsalicylate)
PEPTO-BISMOL MAX
STRENGTH (Use Bismuth
Subsalicylate)
PEPTO-BISMOL TO-GO
(Use Bismuth
Subsalicylate)
NF NT
NF MO; NT
MO; NT
NF
MO; NT
NF
MO; NT
NF
Antiperistaltic Agents
diphenoxylate w/ atropine
LOMOTIL (Use
Diphenoxylate w/ Atropine)
loperamide hcl caps or 2
mg
$0- MO
$2.65
(Tier
1)
NF MO
$0- RX/OTC; MO
$2.65
(Tier
1)
ANTIDOTES - Drugs to Treat Overdose or
Toxicity
Antidotes - Chelating Agents
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
39
Name of drug
EXJADE
FERRIPROX
JADENU
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
LA
PA; LA
Antidotes
$0 NT
(Tier
3)
$0 NT
(Tier
3)
IPECAC
SM IPECAC SYRUP
Opioid Antagonists
naloxone hcl soln ij 1
mg/ml
naltrexone hcl tabs or
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
ANTIEMETICS - Drugs to Treat Nausea and
Vomiting
5-HT3 Receptor Antagonists
granisetron hcl tabs or 1
mg
ondansetron
$0- MO; B/D
$2.65
(Tier
1)
$0- MO; B/D
$2.65
(Tier
1)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
ondansetron hcl soln ij 4
(Tier
mg/2ml, 40 mg/20ml
1)
$0ondansetron hcl soln or 4 $2.65
(Tier
mg/5ml
1)
$0ondansetron hcl tabs or 24 $2.65
(Tier
mg, 4 mg, 8 mg
1)
ZOFRAN ODT (Use
NF
Ondansetron)
ZOFRAN SOLN IJ 40
NF
MG/20ML (Use
Ondansetron HCl)
ZOFRAN SOLN OR 4
MG/5ML (Use Ondansetron NF
HCl)
ZOFRAN TABS OR 4 MG,
NF
8 MG (Use Ondansetron
HCl)
Necessary
actions,
restrictions, or
limits on use
MO
MO; B/D
MO; B/D
MO; B/D
MO
MO; B/D
MO; B/D
Antiemetics - Anticholinergic
$0
(Tier
3)
$0meclizine hcl tabs 12.5 mg, $2.65
(Tier
25 mg
1)
$0$6.60
TIGAN SOLN IM 100
(Tier
MG/ML
2)
$0$6.60
TRANSDERM-SCOP
(Tier
2)
MO; NT
meclizine hcl chew 25 mg
RX/OTC; MO
AL; MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
40
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0trimethobenzamide hcl soln $2.65
(Tier
im 100 mg/ml
1)
Necessary
actions,
restrictions, or
limits on use
AL; MO
Antiemetics - Miscellaneous
CESAMET
dronabinol
MARINOL (Use
Dronabinol)
Name of drug
MYCAMINE
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
Antifungals
$0- MO; B/D
$6.60
(Tier
2)
$0- MO; B/D
$2.65
(Tier
1)
NF MO; B/D
Substance P/Neurokinin 1 (NK1) Receptor
$0- MO; B/D
$6.60
EMEND CAPS OR 125
(Tier
MG, 80 MG
2)
$0- PA; MO
$6.60
EMEND CAPS OR 40 MG (Tier
2)
ANTIFUNGALS - Drugs to Treat Fungal Infections
Antifungal - Glucan Synthesis Inhibitors
$0$6.60
CANCIDAS 50 MG
(Tier
2)
$0- MO
$6.60
CANCIDAS 70 MG
(Tier
2)
$0$6.60
ERAXIS 100 MG
(Tier
2)
$0$6.60
ABELCET
(Tier
2)
$0$6.60
AMBISOME
(Tier
2)
$0- MO
$2.65
amphotericin b solr ij 50 mg (Tier
1)
ANCOBON (Use
NF MO
Flucytosine)
$0- MO
$2.65
flucytosine
(Tier
1)
GRIS-PEG (Use
MO
Griseofulvin Ultramicrosize) NF
$0- MO
$2.65
griseofulvin microsize
(Tier
1)
$0- MO
$2.65
griseofulvin ultramicrosize (Tier
1)
LAMISIL TABS 250 MG
NF MO
(Use Terbinafine HCl)
$0- MO
$2.65
nystatin tabs or
(Tier
1)
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
41
Name of drug
terbinafine hcl tabs or
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Imidazole-Related Antifungals
$0$6.60
CRESEMBA CAPS OR
(Tier
186 MG
2)
$0CRESEMBA SOLR IV 372 $6.60
(Tier
MG
2)
DIFLUCAN (Use
NF
Fluconazole)
$0$2.65
fluconazole in dextrose
(Tier
1)
$0fluconazole in nacl
$2.65
200mg/100ml-0.9%,
(Tier
400mg/200ml-0.9%
1)
$0$2.65
fluconazole susr or 10
(Tier
mg/ml, 40 mg/ml
1)
$0fluconazole tabs or 100
$2.65
mg, 150 mg, 200 mg, 50
(Tier
mg
1)
$0$2.65
itraconazole caps or
(Tier
1)
$0$2.65
ketoconazole tabs or
(Tier
1)
$0$6.60
NOXAFIL SOLN IV 300
(Tier
MG/16.7ML
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
NOXAFIL SUSP OR 40
MG/ML
MO
MO
MO
NOXAFIL TBEC OR 100
MG
SPORANOX CAPS 100
MG (Use Itraconazole)
SPORANOX PULSEPAK
(Use Itraconazole)
VFEND IV (Use
Voriconazole)
VFEND TABS 200 MG, 50
MG (Use Voriconazole)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
NF MO
NF MO
NF
NF MO
$0$2.65
voriconazole solr iv 200 mg (Tier
1)
$0- MO
$2.65
voriconazole tabs or 200
(Tier
mg, 50 mg
1)
ANTIHISTAMINES - Drugs to Treat Allergies
MO
MO
MO
Antihistamines - Alkylamines
CHLOR-TRIMETON (Use
Chlorpheniramine Maleate) NF
$0
chlorpheniramine maleate (Tier
syrp or 2 mg/5ml
3)
$0
chlorpheniramine maleate (Tier
tabs or 4 mg
3)
$0
(Tier
ED CHLORPED
3)
AL; MO; NT
AL; MO; NT
AL; MO; NT
AL; NT
Antihistamines - Ethanolamines
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
42
Name of drug
ALER-DRYL
BENADRYL (Use
Diphenhydramine HCl)
BENADRYL ALLERGY
(Use Diphenhydramine
HCl)
BENADRYL ALLERGY
CHILDRENS CHEW 12.5
MG (Use Diphenhydramine
HCl)
BENADRYL ALLERGY
CHILDRENS LIQD 12.5
MG/5ML (Use
Diphenhydramine HCl)
BENADRYL DYE-FREE
ALLERGYLIQUID-GELS
(Use Diphenhydramine
HCl)
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
AL; NT
NF AL; MO; NT
AL; MO; NT
NF
AL; NT
NF
AL; MO; NT
NF
AL; MO; NT
NF
$0$2.65
carbinoxamine maleate
(Tier
1)
$0clemastine fumarate tabs $2.65
(Tier
or 2.68 mg
1)
$0
diphenhydramine hcl caps (Tier
or 25 mg
3)
$0
diphenhydramine hcl chew (Tier
or 12.5 mg
3)
$0diphenhydramine hcl elix or $2.65
(Tier
12.5 mg/5ml
1)
diphenhydramine hcl liqd or $0
12.5 mg/5ml, 25 mg/10ml, (Tier
3)
50 mg/20ml
AL; MO
AL; MO
AL; MO; NT
AL; NT
RX/OTC
AL; MO; NT
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0diphenhydramine hcl soln ij $2.65
(Tier
50 mg/ml
1)
$0
diphenhydramine hcl syrp
(Tier
or 12.5 mg/5ml
3)
$0
diphenhydramine hcl tabs
(Tier
or 25 mg
3)
$0
TRIAMINIC COUGH &
(Tier
RUNNY NOSE
3)
Antihistamines - Non-Sedating
$0$2.65
cetirizine hcl soln 1 mg/ml (Tier
1)
$0cetirizine hcl syrp 1 mg/ml, $2.65
(Tier
5 mg/5ml
1)
CLARINEX REDITABS 5
NF
MG (Use Desloratadine)
CLARINEX TABS 5 MG
NF
(Use Desloratadine)
$0$2.65
desloratadine tabs 5 mg
(Tier
1)
$0$2.65
desloratadine tbdp 5 mg
(Tier
1)
$0$2.65
levocetirizine
(Tier
dihydrochloride
1)
XYZAL (Use Levocetirizine NF
Dihydrochloride)
Necessary
actions,
restrictions, or
limits on use
AL; MO
AL; RX/OTC;
NT
AL; MO; NT
AL; NT
RX/OTC; MO
RX/OTC; MO
MO
MO
MO
MO
MO
MO
Antihistamines - Phenothiazines
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
43
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0promethazine hcl soln ij 25 $2.65
(Tier
mg/ml, 50 mg/ml
1)
$0$2.65
promethazine hcl soln or
(Tier
6.25 mg/5ml
1)
$0promethazine hcl supp re $2.65
(Tier
12.5 mg, 25 mg
1)
$0$2.65
promethazine hcl syrp or
(Tier
6.25 mg/5ml
1)
$0$2.65
promethazine hcl tabs or
(Tier
12.5 mg, 25 mg, 50 mg
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
AL; MO
LOVAZA (Use Omega-3acid Ethyl Esters)
AL; MO
omega-3-acid ethyl esters
AL; MO
VASCEPA
AL; MO
AL; MO
Antihistamines - Piperidines
$0- AL; MO
cyproheptadine hcl syrp or $2.65
(Tier
2 mg/5ml
1)
$0- AL; MO
cyproheptadine hcl tabs or $2.65
(Tier
4 mg
1)
ANTIHYPERLIPIDEMICS - Drugs to Treat High
Cholesterol
Antihyperlipidemics - Combinations
$0$6.60
LIPTRUZET
(Tier
2)
Antihyperlipidemics - Misc.
$0- PA; LA
$6.60
KYNAMRO
(Tier
2)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
Bile Acid Sequestrants
$0- MO
$2.65
cholestyramine light
(Tier
1)
$0- MO
$2.65
cholestyramine pack or 4
(Tier
gm
1)
$0- MO
cholestyramine powd or 4 $2.65
(Tier
gm/dose
1)
COLESTID (Use Colestipol NF MO
HCl)
COLESTID FLAVORED
MO
NF
GRAN 5 GM (Use
Colestipol HCl)
$0- MO
$2.65
colestipol hcl
(Tier
1)
$0- MO
$6.60
WELCHOL
(Tier
2)
Fibric Acid Derivatives
ANTARA 130 MG, 43 MG
(Use Fenofibrate
Micronized)
MO
NF
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
44
Name of drug
ANTARA 30 MG
ANTARA 90 MG
choline fenofibrate
fenofibrate micronized
fenofibrate tabs 145 mg,
160 mg, 48 mg, 54 mg
gemfibrozil tabs or
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(3 ea daily);
MO
QL(1 ea daily);
MO
MO
MO
MO
MO
LOPID (Use Gemfibrozil)
NF MO
TRICOR (Use Fenofibrate)
NF MO
TRIGLIDE
TRILIPIX (Use Choline
Fenofibrate)
$0- MO
$6.60
(Tier
2)
NF MO
HMG CoA Reductase Inhibitors
$0- MO
$2.65
atorvastatin calcium
(Tier
1)
$0- ST; MO
$6.60
CRESTOR
(Tier
2)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0fluvastatin sodium caps 20 $2.65
(Tier
mg, 40 mg
1)
LESCOL (Use Fluvastatin
NF
Sodium)
LIPITOR (Use Atorvastatin NF
Calcium)
$0$2.65
lovastatin
(Tier
1)
MEVACOR (Use
NF
Lovastatin)
PRAVACHOL (Use
NF
Pravastatin Sodium)
$0$2.65
pravastatin sodium
(Tier
1)
$0simvastatin tabs or 10 mg $2.65
(Tier
1)
$0$2.65
simvastatin tabs or 20 mg
(Tier
1)
$0$2.65
simvastatin tabs or 40 mg
(Tier
1)
$0$2.65
simvastatin tabs or 5 mg
(Tier
1)
$0simvastatin tabs or 80 mg $2.65
(Tier
1)
ZOCOR 10 MG (Use
NF
Simvastatin)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(16 ea
daily); MO
QL(1 ea daily);
MO
QL(8 ea daily);
MO
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
45
Name of drug
ZOCOR 20 MG (Use
Simvastatin)
ZOCOR 40 MG (Use
Simvastatin)
ZOCOR 5 MG (Use
Simvastatin)
ZOCOR 80 MG (Use
Simvastatin)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF QL(4 ea daily);
MO
NF QL(2 ea daily);
MO
NF QL(16 ea
daily); MO
NF QL(1 ea daily);
MO
Intestinal Cholesterol Absorption Inhibitors
$0- MO
$6.60
ZETIA
(Tier
2)
Microsomal Triglyceride Transfer Protein (MTP)
$0- PA; QL(6 ea
$6.60 daily); LA
JUXTAPID 10 MG
(Tier
2)
$0- PA; QL(3 ea
$6.60 daily); LA
JUXTAPID 20 MG
(Tier
2)
$0- PA; QL(2 ea
$6.60 daily); LA
JUXTAPID 30 MG
(Tier
2)
$0- PA; QL(1 ea
$6.60 daily); LA
JUXTAPID 40 MG, 60 MG (Tier
2)
$0- PA; QL(12 ea
$6.60 daily); LA
JUXTAPID 5 MG
(Tier
2)
Nicotinic Acid Derivatives
niacin (antihyperlipidemic)
NIASPAN (Use Niacin
(Antihyperlipidemic))
$0- MO
$2.65
(Tier
1)
NF MO
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Proprotein Convertase Subtilisin/Kexin Type 9
$0- PA; QL(0.08 ml
$6.60 daily); MO
PRALUENT SOPN 150
(Tier
MG/ML
2)
$0- PA; QL(0.15 ml
$6.60 daily); MO
PRALUENT SOPN 75
(Tier
MG/ML
2)
$0- PA; QL(0.08 ml
$6.60 daily); MO
PRALUENT SOSY 150
(Tier
MG/ML
2)
$0- PA; QL(0.15 ml
$6.60 daily); MO
PRALUENT SOSY 75
(Tier
MG/ML
2)
ANTIHYPERTENSIVES - Drugs to Treat High
Blood Pressure
ACE Inhibitors
ACCUPRIL (Use Quinapril
HCl)
ACEON 4 MG (Use
Perindopril Erbumine)
ACEON 8 MG (Use
Perindopril Erbumine)
ALTACE (Use Ramipril)
benazepril hcl tabs or 10
mg, 20 mg, 40 mg, 5 mg
captopril tabs or 100 mg,
12.5 mg, 25 mg, 50 mg
enalapril maleate tabs or
10 mg, 2.5 mg, 20 mg, 5
mg
NF MO
NF QL(4 ea daily);
MO
NF QL(2 ea daily);
MO
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
46
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
fosinopril sodium
(Tier
1)
$0lisinopril tabs or 10 mg, 2.5 $2.65
mg, 20 mg, 30 mg, 40 mg, (Tier
5 mg
1)
LOTENSIN (Use
NF
Benazepril HCl)
MAVIK (Use Trandolapril)
moexipril hcl
perindopril erbumine 2 mg
perindopril erbumine 4 mg
perindopril erbumine 8 mg
PRINIVIL (Use Lisinopril)
quinapril hcl
ramipril
trandolapril
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
NF MO
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
MO
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
UNIVASC (Use Moexipril
HCl)
VASOTEC (Use Enalapril
Maleate)
NF MO
ZESTRIL (Use Lisinopril)
NF MO
NF MO
Agents for Pheochromocytoma
$0- MO
$6.60
DEMSER
(Tier
2)
$0- MO
$6.60
DIBENZYLINE (Use
(Tier
Phenoxybenzamine HCl)
2)
$0- MO
$2.65
phenoxybenzamine hcl
(Tier
caps or
1)
Angiotensin II Receptor Antagonists
ATACAND (Use
NF MO
Candesartan Cilexetil)
NF MO
AVAPRO (Use Irbesartan)
candesartan cilexetil
COZAAR (Use Losartan
Potassium)
DIOVAN (Use Valsartan)
eprosartan mesylate
irbesartan
$0- MO
$2.65
(Tier
1)
NF MO
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
47
Name of drug
losartan potassium
TEVETEN (Use Eprosartan
Mesylate)
valsartan
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
NF MO
$0- MO
$2.65
(Tier
1)
Antiadrenergic Antihypertensives
CARDURA (Use
NF
Doxazosin Mesylate)
CATAPRES (Use Clonidine NF
HCl)
CATAPRES-TTS-1 (Use
NF
Clonidine HCl)
CATAPRES-TTS-2 (Use
NF
Clonidine HCl)
CATAPRES-TTS-3 (Use
NF
Clonidine HCl)
$0clonidine hcl ptwk td 0.1
$2.65
mg/24hr, 0.2 mg/24hr, 0.3 (Tier
mg/24hr
1)
$0$2.65
clonidine hcl tabs or 0.1
(Tier
mg, 0.2 mg, 0.3 mg
1)
$0$2.65
doxazosin mesylate
(Tier
1)
$0$2.65
guanfacine hcl
(Tier
1)
MINIPRESS (Use Prazosin NF
HCl)
MO
MO
MO
MO
MO
MO
MO
MO
AL; MO
MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
prazosin hcl
(Tier
1)
$0RESERPINE TABS OR 0.1 $6.60
(Tier
MG, 0.25 MG
2)
TENEX (Use Guanfacine
NF
HCl)
$0$2.65
terazosin hcl
(Tier
1)
Antihypertensive Combinations
ACCURETIC (Use
NF
QuinaprilHydrochlorothiazide)
$0$2.65
amlodipine besylate(Tier
benazepril hcl
1)
ATACAND HCT (Use
NF
Candesartan CilexetilHydrochlorothiazide)
$0$2.65
atenolol & chlorthalidone
(Tier
1)
AVALIDE (Use IrbesartanNF
Hydrochlorothiazide)
$0$2.65
benazepril &
(Tier
hydrochlorothiazide
1)
$0$2.65
bisoprolol &
(Tier
hydrochlorothiazide
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
AL; MO
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to
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48
Name of drug
candesartan cilexetilhydrochlorothiazide
captopril &
hydrochlorothiazide
CORZIDE (Use Nadolol &
Bendroflumethiazide)
DIOVAN HCT (Use
ValsartanHydrochlorothiazide)
enalapril maleate &
hydrochlorothiazide
fosinopril sodium &
hydrochlorothiazide
HYZAAR (Use Losartan
Potassium &
Hydrochlorothiazide)
irbesartanhydrochlorothiazide
lisinopril &
hydrochlorothiazide
LOPRESSOR HCT (Use
Metoprolol &
Hydrochlorothiazide)
losartan potassium &
hydrochlorothiazide
LOTENSIN HCT (Use
Benazepril &
Hydrochlorothiazide)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
LOTREL (Use Amlodipine
Besylate-Benazepril HCl)
MO
methyldopa &
hydrochlorothiazide
NF MO
metoprolol &
hydrochlorothiazide
MO
NF
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
MO
NF
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
MO
NF
$0- MO
$2.65
(Tier
1)
MO
NF
moexiprilhydrochlorothiazide
nadolol &
bendroflumethiazide
quinaprilhydrochlorothiazide
TEKTURNA HCT
TENORETIC 100 (Use
Atenolol & Chlorthalidone)
TENORETIC 50 (Use
Atenolol & Chlorthalidone)
UNIRETIC (Use MoexiprilHydrochlorothiazide)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
AL; MO
MO
MO
MO
MO
MO
NF MO
NF MO
NF MO
$0- MO
$2.65
(Tier
1)
VASERETIC (Use Enalapril
MO
NF
Maleate &
Hydrochlorothiazide)
ZESTORETIC (Use
MO
NF
Lisinopril &
Hydrochlorothiazide)
valsartanhydrochlorothiazide
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
49
Name of drug
ZIAC (Use Bisoprolol &
Hydrochlorothiazide)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
Direct Renin Inhibitors
TEKTURNA
$0- MO
$6.60
(Tier
2)
Selective Aldosterone Receptor Antagonists
$0- MO
$2.65
eplerenone
(Tier
1)
INSPRA (Use Eplerenone) NF MO
Vasodilators
$0- MO
hydralazine hcl tabs or 10 $2.65
mg, 100 mg, 25 mg, 50 mg (Tier
1)
$0- MO
minoxidil tabs or 10 mg, 2.5 $2.65
(Tier
mg
1)
ANTIMALARIALS - Drugs to Treat Malaria
(Parasitic Infections)
Antimalarial Combinations
atovaquone-proguanil hcl
250mg-100mg
COARTEM
MALARONE 250MG100MG (Use AtovaquoneProguanil HCl)
Antimalarials
ARALEN (Use Chloroquine
Phosphate)
$0- MO
$2.65
(Tier
1)
$0- MO
$6.60
(Tier
2)
MO
NF
NF MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0chloroquine phosphate tabs $2.65
(Tier
or 250 mg, 500 mg
1)
$0$6.60
DARAPRIM
(Tier
2)
$0hydroxychloroquine sulfate $2.65
(Tier
tabs or
1)
$0$2.65
mefloquine hcl
(Tier
1)
PLAQUENIL (Use
NF
Hydroxychloroquine
Sulfate)
$0$6.60
PRIMAQUINE
(Tier
PHOSPHATE
2)
QUALAQUIN (Use Quinine NF
Sulfate)
$0$2.65
quinine sulfate caps or
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
PA; MO
PA; MO
ANTIMYASTHENIC/CHOLINERGIC AGENTS
Antimyasthenic/Cholinergic Agents
$0$2.65
guanidine hcl
(Tier
1)
MESTINON TABS 60 MG
MO
NF
(Use Pyridostigmine
Bromide)
$0- MO
MESTINON TIMESPAN
$6.60
(Use Pyridostigmine
(Tier
Bromide)
2)
You can find information on what the symbols and abbreviations on this table mean by going to
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50
Name of drug
pyridostigmine bromide
tabs or 60 mg
pyridostigmine bromide
tbcr or 180 mg
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
PRIFTIN
MO
ANTIMYCOBACTERIAL AGENTS - Drugs to
Treat Tuberculosis (Bacterial Infections)
pyrazinamide
rifabutin
Anti TB Combinations
isoniazid & rifampin
RIFATER
$0- MO
$2.65
(Tier
1)
$0- MO
$6.60
(Tier
2)
Antimycobacterial Agents
$0- MO
$2.65
aminosalicylic acid pack or (Tier
1)
$0$6.60
CAPASTAT SULFATE
(Tier
2)
$0- MO
ethambutol hcl tabs or 100 $2.65
(Tier
mg, 400 mg
1)
$0- MO
$2.65
isoniazid tabs or 100 mg,
(Tier
300 mg
1)
MYAMBUTOL (Use
NF MO
Ethambutol HCl)
$0- MO
$6.60
MYCOBUTIN (Use
(Tier
Rifabutin)
2)
RIFADIN 300 MG,600 MG
(Use Rifampin)
rifampin caps or 150 mg,
300 mg
rifampin solr iv 600 mg
TRECATOR
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$6.60
(Tier
2)
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES - Drugs to Treat Cancer
Alkylating Agents
ALKERAN SOLR IV 50 MG
(Use Melphalan HCl)
NF
$0- MO; B/D
$6.60
ALKERAN TABS OR 2 MG (Tier
2)
$0$6.60
BICNU
(Tier
2)
You can find information on what the symbols and abbreviations on this table mean by going to
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51
Name of drug
BUSULFEX
carboplatin 150 mg/15ml,
600 mg/60ml
carboplatin 450 mg/45ml,
50 mg/5ml
cisplatin
cyclophosphamide tabs or
25 mg, 50 mg
ELOXATIN (Use
Oxaliplatin)
GLEOSTINE
HEXALEN
IFEX 1 GM (Use
Ifosfamide)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
B/D
NF MO
$0$6.60
(Tier
2)
$0- MO
$6.60
(Tier
2)
NF
$0$6.60
IFEX 3 GM
(Tier
2)
$0ifosfamide soln 1 gm/20ml, $2.65
(Tier
3 gm/60ml
1)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
ifosfamide solr 1 gm
(Tier
1)
$0$6.60
IFOSFAMIDE SOLR 3 GM (Tier
2)
$0$6.60
LEUKERAN
(Tier
2)
$0$2.65
lomustine 10 mg
(Tier
1)
$0LOMUSTINE 100 MG, 40 $6.60
(Tier
MG
2)
$0$2.65
melphalan hcl
(Tier
1)
$0$6.60
MUSTARGEN
(Tier
2)
$0$2.65
oxaliplatin soln 100
(Tier
mg/20ml, 50 mg/10ml
1)
$0oxaliplatin solr 100 mg, 50 $2.65
(Tier
mg
1)
$0$6.60
TEMODAR
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to
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52
Name of drug
THIOTEPA SOLR IJ
TREANDA
YONDELIS
ZANOSAR
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
cytarabine soln 100 mg/ml
cytarabine soln 20 mg/ml
DACOGEN (Use
Decitabine)
MO
Antimetabolites
ALIMTA 100 MG
ALIMTA 500 MG
ARRANON
azacitidine
cladribine
CLOLAR
Name of drug
$0$6.60
(Tier
2)
$0- MO
$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0$6.60
(Tier
2)
decitabine
FLUDARA (Use
Fludarabine Phosphate)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
NF
$0$2.65
(Tier
1)
NF MO
$0- MO
fludarabine phosphate solr $2.65
(Tier
50 mg
1)
$0$2.65
fluorouracil soln iv 1
(Tier
gm/20ml
1)
$0- MO
fluorouracil soln iv 2.5
$2.65
gm/50ml, 5 gm/100ml, 500 (Tier
mg/10ml
1)
$0$6.60
FOLOTYN
(Tier
2)
$0$6.60
GEMCITABINE
(Tier
2)
$0- MO
gemcitabine hcl 1 gm, 200 $2.65
(Tier
mg
1)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
53
Name of drug
gemcitabine hcl 2 gm
GEMZAR (Use
Gemcitabine HCl)
mercaptopurine tabs or
methotrexate sodium soln ij
1 gm/40ml, 100 mg/4ml,
200 mg/8ml, 25 mg/ml, 250
mg/10ml, 50 mg/2ml
methotrexate sodium solr ij
1 gm
methotrexate sodium tabs
or 10 mg, 15 mg, 2.5 mg, 5
mg, 7.5 mg
PURINETHOL (Use
Mercaptopurine)
PURIXAN
TABLOID
VIDAZA (Use Azacitidine)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0- MO
$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
NF MO
$0$6.60
(Tier
2)
$0- MO
$6.60
(Tier
2)
Name of drug
ZALTRAP
Necessary
actions,
restrictions, or
limits on use
Antineoplastic - Antibodies
ARZERRA
BLINCYTO
ERBITUX
GAZYVA
HERCEPTIN
KADCYLA
KEYTRUDA
NF
Antineoplastic - Angiogenesis Inhibitors
$0$6.60
AVASTIN
(Tier
2)
$0- LA
$6.60
CYRAMZA
(Tier
2)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
OPDIVO
PERJETA
$0$6.60
(Tier
2)
$0- PA
$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0- LA
$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
54
Name of drug
RITUXAN
VECTIBIX
YERVOY
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Antineoplastic - Hedgehog Pathway Inhibitors
$0- LA
$6.60
ERIVEDGE
(Tier
2)
$0- PA
$6.60
ODOMZO
(Tier
2)
Antineoplastic - Hormonal and Related Agents
$0- MO
$2.65
anastrozole tabs or
(Tier
1)
ARIMIDEX (Use
NF MO
Anastrozole)
AROMASIN (Use
NF MO
Exemestane)
$0- MO
$2.65
bicalutamide
(Tier
1)
CASODEX (Use
NF MO
Bicalutamide)
$0- MO
$6.60
DEPO-PROVERA
(Tier
2)
Name of drug
ELIGARD
EMCYT
exemestane
FARESTON
FASLODEX
FEMARA (Use Letrozole)
FIRMAGON
flutamide
letrozole
leuprolide acetate kit ij
LUPRON DEPOT
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
NF MO
$0$6.60
(Tier
2)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
55
Name of drug
LYSODREN
MEGACE ORAL (Use
Megestrol Acetate)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
ZOLADEX
NF AL; MO
$0megestrol acetate susp or $2.65
(Tier
40 mg/ml, 400 mg/10ml
1)
$0megestrol acetate tabs or $2.65
(Tier
20 mg, 40 mg
1)
$0$6.60
NILANDRON
(Tier
2)
$0$6.60
SOLTAMOX
(Tier
2)
$0tamoxifen citrate tabs or 10 $2.65
(Tier
mg, 20 mg
1)
$0$6.60
TRELSTAR
(Tier
2)
$0$6.60
TRELSTAR MIXJECT
(Tier
2)
$0$6.60
VANTAS
(Tier
2)
$0$6.60
XTANDI
(Tier
2)
AL; MO
AL; MO
MO
ZYTIGA
Necessary
actions,
restrictions, or
limits on use
Antineoplastic - Immunomodulators
$0- LA
$6.60
POMALYST
(Tier
2)
Antineoplastic Antibiotics
bleomycin sulfate 15 unit
MO
bleomycin sulfate 30 unit
MO
COSMEGEN
daunorubicin hcl
DAUNOXOME
PA; LA
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0- MO
$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0- MO
$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
DOXIL (Use Doxorubicin
HCl Liposomal)
NF
doxorubicin hcl liposomal
$0$2.65
(Tier
1)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
56
Name of drug
doxorubicin hcl soln 2
mg/ml
doxorubicin hcl solr 10 mg
doxorubicin hcl solr 50 mg
ELLENCE (Use Epirubicin
HCl)
epirubicin hcl soln 200
mg/100ml, 50 mg/25ml
IDAMYCIN PFS (Use
Idarubicin HCl)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
AFINITOR DISPERZ
BELEODAQ
MO
BOSULIF
NF MO
$0- MO
$2.65
(Tier
1)
CAPRELSA
COMETRIQ
NF
$0$2.65
idarubicin hcl
(Tier
1)
$0- MO
mitomycin solr iv 20 mg, 40 $2.65
(Tier
mg, 5 mg
1)
$0$2.65
mitoxantrone hcl
(Tier
1)
$0$6.60
VALSTAR
(Tier
2)
Antineoplastic Enzyme Inhibitors
$0$6.60
AFINITOR
(Tier
2)
COMETRIQ
FARYDAK
GILOTRIF
GLEEVEC
IBRANCE
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA
LA
140 MG Dose
Kit;MO
PA; LA
LA
LA
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
57
Name of drug
ICLUSIG
IMBRUVICA
INLYTA
IRESSA
ISTODAX
JAKAFI
LENVIMA 10MG DAILY
DOSE
LENVIMA 14MG DAILY
DOSE
LENVIMA 20MG DAILY
DOSE
LENVIMA 24MG DAILY
DOSE
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
LA
LYNPARZA
PA
MEKINIST
PA; LA
NEXAVAR
LA
SPRYCEL
STIVARGA
LA
SUTENT
PA
TAFINLAR
PA
TARCEVA
PA
TASIGNA
PA
TORISEL
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA; LA
LA
PA; LA
You can find information on what the symbols and abbreviations on this table mean by going to
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58
Name of drug
TYKERB
VELCADE
VOTRIENT
XALKORI
ZELBORAF
ZOLINZA
ZYDELIG
ZYKADIA
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
ACTIMMUNE
bexarotene
dacarbazine 100 mg
dacarbazine 200 mg
LA
ONCASPAR
HYDREA (Use
Hydroxyurea)
hydroxyurea caps or
PA
INTRON A
PA; LA
INTRON A W/DILUENT
Antineoplastic Enzymes
ERWINAZE
Name of drug
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Antineoplastics Misc.
MATULANE
PROLEUKIN
SYLATRON
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
LA
MO
NF MO
$0- MO
$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0- LA
$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
You can find information on what the symbols and abbreviations on this table mean by going to
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59
Name of drug
SYNRIBO
TARGRETIN 1 %,75 MG
TARGRETIN 75 MG (Use
Bexarotene)
THERACYS
TICE BCG
tretinoin (chemotherapy)
TRISENOX
UVADEX
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
amifostine crystalline
dexrazoxane
ETHYOL (Use Amifostine
Crystalline)
MO
MO
MO
MO
Chemotherapy Adjuncts
ELITEK
KEPIVANCE
Name of drug
$0$6.60
(Tier
2)
$0- MO
$6.60
(Tier
2)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
NF MO
$0$6.60
FUSILEV
(Tier
2)
$0- MO
$2.65
leucovorin calcium solr ij
(Tier
100 mg, 200 mg, 350 mg
1)
$0leucovorin calcium solr ij 50 $2.65
(Tier
mg, 500 mg
1)
$0- MO
leucovorin calcium tabs or $2.65
10 mg, 15 mg, 25 mg, 5 mg (Tier
1)
$0$6.60
LEVOLEUCOVORIN
(Tier
2)
$0$2.65
levoleucovorin calcium
(Tier
1)
$0- MO
$2.65
mesna
(Tier
1)
MESNEX SOLN IV 100
NF MO
MG/ML (Use Mesna)
Chemotherapy Rescue/Antidote Agents
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60
Name of drug
MESNEX TABS OR 400
MG
TOTECT
ZINECARD (Use
Dexrazoxane)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
HALAVEN
IXEMPRA KIT
NF
JEVTANA
Mitotic Inhibitors
$0- MO
$6.60
ABRAXANE
(Tier
2)
$0$6.60
DOCEFREZ
(Tier
2)
$0docetaxel conc 140
$2.65
mg/7ml, 20 mg/ml, 80
(Tier
mg/4ml
1)
$0$6.60
DOCETAXEL CONC 20
(Tier
MG/ML, 80 MG/4ML
2)
$0DOCETAXEL SOLN 160
$6.60
MG/16ML, 20 MG/2ML,
(Tier
200 MG/20ML, 80 MG/8ML 2)
$0- MO
$6.60
ETOPOPHOS
(Tier
2)
$0- MO
$2.65
etoposide soln iv 1
(Tier
gm/50ml, 100 mg/5ml
1)
$0$2.65
etoposide soln iv 500
(Tier
mg/25ml
1)
NAVELBINE (Use
Vinorelbine Tartrate)
paclitaxel 100 mg/16.7ml,
30 mg/5ml, 300 mg/50ml
paclitaxel 150 mg/25ml
TAXOL (Use Paclitaxel)
TAXOTERE (Use
Docetaxel)
vinblastine sulfate
vincristine sulfate
vinorelbine tartrate
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0- MO
$2.65
(Tier
1)
$0$2.65
(Tier
1)
NF MO
$0$6.60
(Tier
2)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
Topoisomerase I Inhibitors
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61
Name of drug
CAMPTOSAR 100
MG/5ML, 40 MG/2ML (Use
Irinotecan HCl)
CAMPTOSAR 300
MG/15ML
HYCAMTIN (Use
Topotecan HCl)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
NF
$0$6.60
(Tier
2)
NF MO
$0- MO
irinotecan hcl 100 mg/5ml, $2.65
(Tier
40 mg/2ml
1)
$0$2.65
irinotecan hcl 500 mg/25ml (Tier
1)
$0TOPOTECAN HCL SOLN $6.60
(Tier
4 MG/4ML
2)
$0- MO
$2.65
topotecan hcl solr 4 mg
(Tier
1)
ANTIPARKINSON AGENTS - Drugs to Treat
Parkinson's Disease
Antiparkinson Adjuvants
$0- MO
$2.65
carbidopa tabs or
(Tier
1)
LODOSYN (Use
NF MO
Carbidopa)
Antiparkinson Anticholinergics
$0- MO
benztropine mesylate soln $2.65
(Tier
ij 1 mg/ml
1)
benztropine mesylate tabs
or 0.5 mg, 1 mg, 2 mg
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
COGENTIN (Use
Benztropine Mesylate)
trihexyphenidyl hcl
Necessary
actions,
restrictions, or
limits on use
AL; MO
NF MO
$0- AL; MO
$2.65
(Tier
1)
Antiparkinson COMT Inhibitors
COMTAN (Use
NF
Entacapone)
$0$2.65
entacapone
(Tier
1)
$0$6.60
TASMAR (Use Tolcapone) (Tier
2)
$0$2.65
tolcapone
(Tier
1)
MO
MO
MO
MO
Antiparkinson Dopaminergics
$0amantadine hcl caps or 100 $2.65
(Tier
mg
1)
$0amantadine hcl syrp or 50 $2.65
(Tier
mg/5ml
1)
$0amantadine hcl tabs or 100 $2.65
(Tier
mg
1)
$0$6.60
APOKYN
(Tier
2)
MO
MO
MO
LA
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62
Name of drug
bromocriptine mesylate
caps or 5 mg
bromocriptine mesylate
tabs or 2.5 mg
carbidopa-levodopa
DUOPA
MIRAPEX (Use
Pramipexole
Dihydrochloride)
NEUPRO
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
SINEMET CR (Use
Carbidopa-Levodopa)
MO
MO
B/D
MO
NF
$0- MO
$6.60
(Tier
2)
NF MO
PARLODEL (Use
Bromocriptine Mesylate)
$0- MO
pramipexole
dihydrochloride tabs 0.125 $2.65
mg, 0.25 mg, 0.5 mg, 0.75 (Tier
1)
mg, 1 mg, 1.5 mg
REQUIP (Use Ropinirole
NF MO
Hydrochloride)
REQUIP XL (Use
NF MO
Ropinirole Hydrochloride)
$0- MO
$2.65
ropinirole hydrochloride
(Tier
1)
$0- MO
$6.60
RYTARY
(Tier
2)
SINEMET (Use Carbidopa- NF MO
Levodopa)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
Antiparkinson Monoamine Oxidase Inhibitors
$0- MO
$6.60
AZILECT
(Tier
2)
ELDEPRYL (Use Selegiline NF MO
HCl)
$0- MO
$2.65
selegiline hcl caps or
(Tier
1)
$0- MO
$2.65
selegiline hcl tabs or
(Tier
1)
ANTIPSYCHOTICS/ANTIMANIC AGENTS Drugs to Treat Mood Disorders
Antimanic Agents
lithium
lithium carbonate caps or
150 mg, 300 mg, 600 mg
LITHIUM CARBONATE
CAPS OR 600 MG (Use
Lithium Carbonate)
lithium carbonate tabs or
300 mg
lithium carbonate tbcr or
300 mg, 450 mg
LITHOBID (Use Lithium
Carbonate)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
MO
NF
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
NF MO
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63
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Antipsychotics - Misc.
$0- MO
$6.60
EQUETRO
(Tier
2)
GEODON CAPS OR 20
MO
MG, 40 MG, 60 MG, 80 MG NF
(Use Ziprasidone HCl)
$0- MO
$6.60
GEODON SOLR IM 20 MG (Tier
2)
$0- QL(1 ea daily);
$6.60 MO
LATUDA 120 MG
(Tier
2)
$0- QL(8 ea daily);
$6.60 MO
LATUDA 20 MG
(Tier
2)
$0- QL(4 ea daily);
$6.60 MO
LATUDA 40 MG
(Tier
2)
$0- QL(2.67 ea
$6.60 daily); MO
LATUDA 60 MG
(Tier
2)
$0- QL(2 ea daily);
$6.60 MO
LATUDA 80 MG
(Tier
2)
$0- MO
$2.65
ziprasidone hcl
(Tier
1)
Benzisoxazoles
FANAPT
$0- MO
$6.60
(Tier
2)
Name of drug
INVEGA 1.5 MG (Use
Paliperidone)
INVEGA 3 MG (Use
Paliperidone)
INVEGA 6 MG (Use
Paliperidone)
INVEGA 9 MG (Use
Paliperidone)
INVEGA SUSTENNA
INVEGA TRINZA
paliperidone 1.5 mg
paliperidone 3 mg
paliperidone 6 mg
paliperidone 9 mg
RISPERDAL (Use
Risperidone)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(8 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(1 ea daily);
MO
MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(1 ea daily);
MO
NF MO
You can find information on what the symbols and abbreviations on this table mean by going to
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64
Name of drug
RISPERDAL CONSTA
12.5 MG
RISPERDAL CONSTA 25
MG
RISPERDAL CONSTA
37.5 MG, 50 MG
RISPERDAL M-TAB (Use
Risperidone)
risperidone
Butyrophenones
HALDOL (Use Haloperidol
Lactate)
HALDOL DECANOATE
100 (Use Haloperidol
Decanoate)
HALDOL DECANOATE 50
(Use Haloperidol
Decanoate)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
QL(0.29 ea
daily); MO
clozapine
QL(0.15 ea
daily); MO
CLOZAPINE ODT
QL(0.08 ea
daily); MO
CLOZARIL (Use
Clozapine)
NF MO
$0- MO
$2.65
(Tier
1)
NF MO
FAZACLO 100 MG,25 MG
(Use Clozapine)
FAZACLO 12.5 MG,150
MG,200 MG
loxapine succinate 10 mg,
25 mg, 5 mg, 50 mg
MO
NF
olanzapine
MO
NF
$0- MO
$2.65
haloperidol
(Tier
1)
$0- MO
haloperidol decanoate soln $2.65
(Tier
im 100 mg/ml, 50 mg/ml
1)
$0- MO
$2.65
haloperidol lactate
(Tier
1)
Dibenzapines
quetiapine fumarate
SAPHRIS 10 MG
SAPHRIS 2.5 MG
SAPHRIS 5 MG
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
NF
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
MO
MO
MO
QL(2 ea daily);
MO
QL(8 ea daily);
MO
QL(4 ea daily);
MO
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Name of drug
SEROQUEL (Use
Quetiapine Fumarate)
VERSACLOZ
ZYPREXA (Use
Olanzapine)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0- PA; QL(18 ml
$6.60 daily)
(Tier
2)
NF MO
$0ZYPREXA RELPREVV 210 $6.60
(Tier
MG
2)
ZYPREXA ZYDIS (Use
NF MO
Olanzapine)
Phenothiazines
$0$2.65
(Tier
1)
$0chlorpromazine hcl soln ij $2.65
(Tier
50 mg/2ml
1)
$0chlorpromazine hcl tabs or $2.65
10 mg, 100 mg, 200 mg, 25 (Tier
mg, 50 mg
1)
$0$2.65
fluphenazine decanoate
(Tier
soln ij
1)
$0fluphenazine hcl conc or 5 $2.65
(Tier
mg/ml
1)
$0fluphenazine hcl soln ij 2.5 $2.65
(Tier
mg/ml
1)
MO
chlorpromazine hcl soln ij
25 mg/ml
MO
MO
MO
MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0fluphenazine hcl tabs or 1 $2.65
(Tier
mg, 10 mg, 2.5 mg, 5 mg
1)
$0$2.65
perphenazine tabs or 16
(Tier
mg, 2 mg, 4 mg, 8 mg
1)
$0$2.65
prochlorperazine
(Tier
1)
$0prochlorperazine edisylate $2.65
(Tier
soln ij
1)
$0prochlorperazine maleate $2.65
(Tier
tabs or 10 mg, 5 mg
1)
$0thioridazine hcl tabs or 10 $2.65
mg, 100 mg, 25 mg, 50 mg (Tier
1)
$0$2.65
trifluoperazine hcl
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
AL; MO
MO
Quinolinone Derivatives
ABILIFY DISCMELT 10
MG
ABILIFY DISCMELT 15
MG
ABILIFY MAINTENA
$0- QL(3 ea daily)
$6.60
(Tier
2)
$0- QL(2 ea daily)
$6.60
(Tier
2)
$0- MO
$6.60
(Tier
2)
You can find information on what the symbols and abbreviations on this table mean by going to
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$6.60
ABILIFY SOLN IM 9.75
(Tier
MG/1.3ML
2)
$0$6.60
ABILIFY SOLN OR 1
(Tier
MG/ML
2)
$0ABILIFY TABS OR 10 MG $6.60
(Tier
(Use Aripiprazole)
2)
$0ABILIFY TABS OR 15 MG $6.60
(Tier
(Use Aripiprazole)
2)
$0$6.60
ABILIFY TABS OR 2 MG
(Tier
(Use Aripiprazole)
2)
$0ABILIFY TABS OR 20 MG, $6.60
(Tier
30 MG (Use Aripiprazole)
2)
$0$6.60
ABILIFY TABS OR 5 MG
(Tier
(Use Aripiprazole)
2)
$0$6.60
ARIPIPRAZOLE ODT 10
(Tier
MG
2)
$0$6.60
ARIPIPRAZOLE ODT 15
(Tier
MG
2)
$0$2.65
aripiprazole soln 1 mg/ml
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(4 ml daily);
MO
QL(30 ml
daily); MO
QL(3 ea daily);
MO
QL(2 ea daily);
MO
QL(15 ea
daily); MO
QL(1 ea daily);
MO
QL(6 ea daily);
MO
QL(3 ea daily)
QL(2 ea daily)
QL(30 ml
daily); MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
aripiprazole tabs 10 mg
(Tier
1)
$0$2.65
aripiprazole tabs 15 mg
(Tier
1)
$0$2.65
aripiprazole tabs 2 mg
(Tier
1)
$0aripiprazole tabs 20 mg, 30 $2.65
(Tier
mg
1)
$0$2.65
aripiprazole tabs 5 mg
(Tier
1)
$0$6.60
REXULTI 0.25 MG
(Tier
2)
$0$6.60
REXULTI 0.5 MG
(Tier
2)
$0$6.60
REXULTI 1 MG
(Tier
2)
$0$6.60
REXULTI 2 MG
(Tier
2)
$0$6.60
REXULTI 3 MG, 4 MG
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
QL(3 ea daily);
MO
QL(2 ea daily);
MO
QL(15 ea
daily); MO
QL(1 ea daily);
MO
QL(6 ea daily);
MO
PA; QL(16 ea
daily); MO
PA; QL(8 ea
daily); MO
PA; QL(4 ea
daily); MO
PA; QL(2 ea
daily); MO
PA; QL(1 ea
daily); MO
Thioxanthenes
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Name of drug
thiothixene
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
COMBIVIR (Use
Lamivudine-Zidovudine)
ANTISEPTICS & DISINFECTANTS - Drugs to
Prevent Bacterial Skin Infections
COMPLERA
Chlorine Antiseptics
$0
(Tier
3)
$0
CETAPHIL
(Tier
ANTIBACTERIAL
3)
$0
dakin's solution 0.25 %, 0.5 (Tier
%
3)
$0
PEDI-WHIRL
(Tier
CONCENTRATE
3)
BENZALKONIUM
CHLORIDE SOLN
RX/OTC; NT
NT
CRIXIVAN
didanosine
MO; NT
EDURANT
RX/OTC; NT
EMTRIVA
ANTIVIRALS - Drugs to Treat Viral Infections
Antiretrovirals
abacavir sulfate
abacavir sulfatelamivudine-zidovudine
APTIVUS CAPS 250 MG
APTIVUS SOLN 100
MG/ML
ATRIPLA
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
MO
MO
EPIVIR SOLN 10 MG/ML
(Use Lamivudine)
EPIVIR TABS 150 MG, 300
MG (Use Lamivudine)
EPZICOM
MO
EVOTAZ
FUZEON
MO
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
MO
MO
MO
MO
MO
MO
NF MO
$0- MO
$6.60
(Tier
2)
$0- MO
$6.60
(Tier
2)
$0$6.60
(Tier
2)
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0INTELENCE 100 MG, 200 $6.60
(Tier
MG
2)
$0$6.60
INTELENCE 25 MG
(Tier
2)
$0$6.60
INVIRASE
(Tier
2)
$0$6.60
ISENTRESS CHEW 100
(Tier
MG
2)
$0$6.60
ISENTRESS CHEW 25 MG (Tier
2)
$0$6.60
ISENTRESS PACK 100
(Tier
MG
2)
$0$6.60
ISENTRESS TABS 400
(Tier
MG
2)
$0$6.60
KALETRA
(Tier
2)
$0$2.65
lamivudine
(Tier
1)
$0$2.65
lamivudine-zidovudine
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
QL(6 ea daily);
MO
QL(24 ea
daily); MO
QL(2 ea daily)
MO
MO
MO
MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$6.60
LEXIVA
(Tier
2)
$0$6.60
NEVIRAPINE SUSP 50
(Tier
MG/5ML
2)
$0$2.65
nevirapine tabs 200 mg
(Tier
1)
$0$2.65
nevirapine tb24 100 mg
(Tier
1)
$0$2.65
nevirapine tb24 400 mg
(Tier
1)
$0$6.60
NORVIR
(Tier
2)
$0$6.60
PREZCOBIX
(Tier
2)
$0$6.60
PREZISTA SUSP 100
(Tier
MG/ML
2)
$0PREZISTA TABS 150 MG, $6.60
(Tier
600 MG, 800 MG
2)
$0PREZISTA TABS 400 MG, $6.60
(Tier
75 MG
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
69
Name of drug
RESCRIPTOR
RETROVIR (Use
Zidovudine)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
NF MO
$0$6.60
RETROVIR IV INFUSION (Tier
2)
$0REYATAZ CAPS 150 MG, $6.60
(Tier
200 MG, 300 MG
2)
$0$6.60
REYATAZ PACK 50 MG
(Tier
2)
$0$6.60
SELZENTRY
(Tier
2)
$0$2.65
stavudine
(Tier
1)
$0$6.60
STRIBILD
(Tier
2)
$0$6.60
SUSTIVA
(Tier
2)
$0$6.60
TIVICAY
(Tier
2)
$0$6.60
TRIUMEQ
(Tier
2)
Name of drug
TRIZIVIR (Use Abacavir
Sulfate-LamivudineZidovudine)
TRUVADA
TYBOST
MO
VIDEX EC (Use
Didanosine)
MO
MO
MO
MO
MO
MO
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO
NF
$0- MO
$6.60
(Tier
2)
$0- MO
$6.60
(Tier
2)
NF MO
$0- MO
$6.60
VIDEXPEDIATRIC
(Tier
2)
$0- MO
$6.60
VIRACEPT
(Tier
2)
$0- MO
$6.60
VIRAMUNE SUSP 50
(Tier
MG/5ML
2)
VIRAMUNE TABS 200 MG NF MO
(Use Nevirapine)
$0$6.60
VIRAMUNE XR 100 MG
(Tier
2)
VIRAMUNE XR 400 MG
NF MO
(Use Nevirapine)
$0- MO
$6.60
VIREAD POWD 40 MG/GM (Tier
2)
$0- MO
$6.60
VIREAD TABS 150 MG,
(Tier
200 MG, 300 MG
2)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
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Name of drug
VIREAD TABS 250 MG
VITEKTA
ZERIT (Use Stavudine)
ZIAGEN SOLN 20 MG/ML
ZIAGEN TABS 300 MG
(Use Abacavir Sulfate)
zidovudine
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
NF MO
$0- MO
$6.60
(Tier
2)
NF MO
$0- MO
$2.65
(Tier
1)
CMV Agents
cidofovir
CYTOVENE (Use
Ganciclovir Sodium)
ganciclovir sodium
VALCYTE TABS 450 MG
(Use Valganciclovir HCl)
valganciclovir hcl
VISTIDE (Use Cidofovir)
$0$2.65
(Tier
1)
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
$6.60
(Tier
2)
$0- MO
$2.65
(Tier
1)
NF
Hepatitis Agents
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
adefovir dipivoxil
(Tier
1)
$0$6.60
BARACLUDE 0.05 MG/ML (Tier
2)
$0$6.60
BARACLUDE 0.5 MG,1
(Tier
MG (Use Entecavir)
2)
COPEGUS (Use Ribavirin
NF
(Hepatitis C))
$0$2.65
entecavir
(Tier
1)
$0$6.60
EPIVIR HBV SOLN 5
(Tier
MG/ML
2)
EPIVIR HBV TABS 100
NF
MG (Use Lamivudine
(HBV))
$0$6.60
HARVONI
(Tier
2)
HEPSERA (Use Adefovir
NF
Dipivoxil)
$0$6.60
INCIVEK
(Tier
2)
$0$2.65
lamivudine (hbv)
(Tier
1)
$0$6.60
OLYSIO
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
PA
MO
PA
MO
PA
You can find information on what the symbols and abbreviations on this table mean by going to
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71
Name of drug
PEG-INTRON
PEG-INTRON REDIPEN
PEG-INTRON REDIPEN
PAK 4
PEGASYS
PEGASYS PROCLICK
PEGINTRON
REBETOL CAPS 200 MG
(Use Ribavirin (Hepatitis
C))
ribavirin (hepatitis c)
SOVALDI
TYZEKA
VICTRELIS
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
VIEKIRA PAK
Necessary
actions,
restrictions, or
limits on use
PA
Herpes Agents
acyclovir caps or 200 mg
acyclovir sodium soln 50
mg/ml
acyclovir sodium solr 500
mg
acyclovir susp or 200
mg/5ml
acyclovir tabs or 400 mg,
800 mg
NF
$0$2.65
(Tier
1)
$0- PA
$6.60
(Tier
2)
$0- MO
$6.60
(Tier
2)
$0- PA
$6.60
(Tier
2)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
famciclovir
FAMVIR (Use Famciclovir)
valacyclovir hcl tabs or 1
gm, 1000 mg, 500 mg
VALTREX (Use
Valacyclovir HCl)
ZOVIRAX CAPS OR 200
MG (Use Acyclovir)
ZOVIRAX SUSP OR 200
MG/5ML (Use Acyclovir)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
MO
MO
MO
MO
MO
NF MO
$0- MO
$2.65
(Tier
1)
NF MO
NF MO
NF MO
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
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Name of drug
ZOVIRAX TABS OR 400
MG, 800 MG (Use
Acyclovir)
Influenza Agents
FLUMADINE (Use
Rimantadine
Hydrochloride)
RELENZA DISKHALER
rimantadine hydrochloride
TAMIFLU
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO
NF
DEPEN TITRATABS
MO
NF
$0- MO
$6.60
(Tier
2)
$0- MO
$2.65
(Tier
1)
$0- MO
$6.60
(Tier
2)
Respiratory Syncytial Virus (RSV) Agents
$0$6.60
VIRAZOLE
(Tier
2)
ASSORTED CLASSES - Miscellaneous Drugs
Assorted Classes
gelatin caps or 650 mg
NULLO
$0 NT
(Tier
3)
$0 NT
(Tier
3)
Chelating Agents
CUPRIMINE
Name of drug
$0- MO
$6.60
(Tier
2)
SYPRINE
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
Enzymes
papaya chew 5mg-5mg3mg-2mg-20mg
$0 NT
(Tier
3)
Immunomodulators
REVLIMID
THALOMID
$0- LA
$6.60
(Tier
2)
$0$6.60
(Tier
2)
Immunosuppressive Agents
$0- MO; B/D
$6.60
ASTAGRAF XL
(Tier
2)
$0- MO; B/D
$2.65
azathioprine tabs or 100
(Tier
mg, 50 mg, 75 mg
1)
CELLCEPT CAPS 250 MG
MO; B/D
NF
(Use Mycophenolate
Mofetil)
$0- B/D
$6.60
CELLCEPT
(Tier
INTRAVENOUS
2)
$0- MO; B/D
CELLCEPT SUSR 200
$6.60
MG/ML (Use
(Tier
Mycophenolate Mofetil)
2)
You can find information on what the symbols and abbreviations on this table mean by going to
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Name of drug
CELLCEPT TABS 500 MG
(Use Mycophenolate
Mofetil)
cyclosporine caps or 100
mg, 25 mg
cyclosporine modified (for
microemulsion) caps 100
mg, 25 mg, 50 mg
cyclosporine soln iv 50
mg/ml
IMURAN (Use
Azathioprine)
mycophenolate mofetil
mycophenolate sodium
MYFORTIC (Use
Mycophenolate Sodium)
NEORAL CAPS 100 MG,
25 MG (Use Cyclosporine
Modified (For
Microemulsion))
NULOJIX
PROGRAF CAPS OR 0.5
MG, 1 MG, 5 MG (Use
Tacrolimus)
PROGRAF SOLN IV 5
MG/ML
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO; B/D
RAPAMUNE SOLN 1
MG/ML
NF
$0- MO; B/D
$2.65
(Tier
1)
$0- MO; B/D
$2.65
(Tier
1)
$0- B/D
$2.65
(Tier
1)
NF MO; B/D
$0- MO; B/D
$2.65
(Tier
1)
$0- MO; B/D
$2.65
(Tier
1)
NF MO; B/D
RAPAMUNE TABS 0.5 MG
(Use Sirolimus)
RAPAMUNE TABS 1 MG,
2 MG (Use Sirolimus)
SANDIMMUNE CAPS OR
100 MG, 25 MG (Use
Cyclosporine)
SANDIMMUNE SOLN IV
50 MG/ML (Use
Cyclosporine)
SANDIMMUNE SOLN OR
100 MG/ML
SIMULECT
sirolimus
MO; B/D
NF
$0- B/D
$6.60
(Tier
2)
MO; B/D
NF
$0- B/D
$6.60
(Tier
2)
tacrolimus caps or 0.5 mg,
1 mg, 5 mg
THYMOGLOBULIN
ZORTRESS
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO; B/D
NF MO; B/D
$0- MO; B/D
$6.60
(Tier
2)
MO; B/D
NF
B/D
NF
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
MO; B/D
B/D
MO; B/D
MO; B/D
B/D
MO; B/D
Irrigation Solutions
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74
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
irrigation solutions,
(Tier
physiological
1)
$0PHYSIOSOL IRRIGATION $6.60
(Tier
PH 7.4
2)
$0$2.65
water for irrigation, sterile
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
labetalol hcl tabs or 100
mg, 200 mg, 300 mg
TRANDATE (Use Labetalol
HCl)
MO
Potassium Removing Resins
KAYEXALATE (Use
MO
NF
Sodium Polystyrene
Sulfonate)
$0- MO
$2.65
sodium polystyrene
(Tier
sulfonate powd or
1)
$0- MO
sodium polystyrene
$2.65
sulfonate susp or 15
(Tier
gm/60ml
1)
Systemic Lupus Erythematosus Agents
$0$6.60
BENLYSTA 120 MG
(Tier
2)
BETA BLOCKERS - Drugs to Treat High Blood
Pressure
Alpha-Beta Blockers
carvedilol
COREG (Use Carvedilol)
COREG CR
Name of drug
$0- MO
$2.65
(Tier
1)
NF MO
$0- MO
$6.60
(Tier
2)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
NF MO
Beta Blockers Cardio-Selective
$0acebutolol hcl caps or 200 $2.65
(Tier
mg, 400 mg
1)
$0atenolol tabs or 100 mg, 25 $2.65
(Tier
mg, 50 mg
1)
$0$2.65
betaxolol hcl
(Tier
1)
$0$2.65
bisoprolol fumarate
(Tier
1)
KERLONE (Use Betaxolol
NF
HCl)
LOPRESSOR TABS OR
NF
100 MG, 50 MG (Use
Metoprolol Tartrate)
$0$2.65
metoprolol succinate
(Tier
1)
$0metoprolol tartrate tabs or $2.65
(Tier
100 mg, 25 mg, 50 mg
1)
SECTRAL (Use Acebutolol NF
HCl)
MO
MO
MO
MO
MO
MO
MO
MO
MO
TENORMIN (Use Atenolol)
NF MO
TOPROL XL (Use
Metoprolol Succinate)
NF MO
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Health Net Cal MediConnect 2015 Drug List
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Name of drug
ZEBETA (Use Bisoprolol
Fumarate)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
Beta Blockers Non-Selective
BETAPACE (Use Sotalol
NF tabs;MO
HCl)
BETAPACE AF (Use
NF MO
Sotalol HCl (AFIB/AFL))
NF MO
CORGARD (Use Nadolol)
INDERAL LA (Use
Propranolol HCl)
NF MO
$0nadolol tabs or 20 mg, 40 $2.65
(Tier
mg, 80 mg
1)
$0$2.65
pindolol
(Tier
1)
$0propranolol hcl cp24 or 120 $2.65
mg, 160 mg, 60 mg, 80 mg (Tier
1)
$0propranolol hcl tabs or 10 $2.65
mg, 20 mg, 40 mg, 60 mg, (Tier
80 mg
1)
$0$2.65
sotalol hcl
(Tier
1)
$0$2.65
sotalol hcl (afib/afl)
(Tier
1)
Sotalol Hcl IV Soln
SOTYLIZE
MO
MO
MO
MO
tabs;MO
MO
NF
$0$6.60
(Tier
2)
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
BIOLOGICALS MISC - Drugs to Treat Low
Enzymes
Biologicals Misc
ADAGEN
$0- LA
$6.60
(Tier
2)
CALCIUM CHANNEL BLOCKERS - Drugs to
Treat High Blood Pressure
Calcium Channel Blockers
ADALAT CC (Use
Nifedipine)
NF MO
$0amlodipine besylate tabs or $2.65
(Tier
10 mg
1)
$0amlodipine besylate tabs or $2.65
(Tier
2.5 mg
1)
$0amlodipine besylate tabs or $2.65
(Tier
5 mg
1)
CALAN (Use Verapamil
NF
HCl)
CALAN SR (Use Verapamil NF
HCl)
CARDIZEM (Use Diltiazem NF
HCl)
CARDIZEM CD (Use
NF
Diltiazem HCl Coated
Beads)
CARDIZEM LA 180 MG,
240 MG, 300 MG, 360 MG, NF
420 MG (Use Diltiazem HCl
Coated Beads)
$0$2.65
diltiazem hcl coated beads (Tier
1)
QL(1 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
MO
MO
MO
MO
MO
MO
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Name of drug
diltiazem hcl cp12 or 120
mg, 60 mg, 90 mg
diltiazem hcl cp24 or 120
mg, 180 mg, 240 mg
diltiazem hcl extended
release beads
diltiazem hcl tabs or 120
mg, 30 mg, 60 mg, 90 mg
felodipine
nicardipine hcl caps or 20
mg, 30 mg
nifedipine tb24 or 30 mg,
60 mg, 90 mg
nimodipine caps or
nisoldipine 17 mg, 34 mg,
8.5 mg
NORVASC 10 MG (Use
Amlodipine Besylate)
NORVASC 2.5 MG (Use
Amlodipine Besylate)
NORVASC 5 MG (Use
Amlodipine Besylate)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
NYMALIZE
MO
MO
MO
MO
MO
MO
MO
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PROCARDIA XL (Use
Nifedipine)
NF MO
SULAR (Use Nisoldipine)
NF MO
TIAZAC (Use Diltiazem HCl NF
Extended Release Beads)
$0verapamil hcl cp24 or 100
mg, 120 mg, 180 mg, 200 $2.65
(Tier
mg, 240 mg, 300 mg, 360
1)
mg
$0$2.65
verapamil hcl tabs or 120
(Tier
mg, 40 mg, 80 mg
1)
$0$2.65
verapamil hcl tbcr or 120
(Tier
mg, 180 mg, 240 mg
1)
VERELAN (Use Verapamil NF
HCl)
VERELAN PM (Use
NF
Verapamil HCl)
MO
MO
MO
MO
MO
MO
CARDIOTONICS - Drugs to Treat Heart Failure
and Abnormal Heart Rhythm
Cardiac Glycosides
MO
NF QL(1 ea daily);
MO
NF QL(4 ea daily);
MO
NF QL(2 ea daily);
MO
DIGOXIN SOLN OR 0.05
MG/ML
digoxin tabs or 0.125 mg,
0.25 mg, 125 mcg, 250
mcg
LANOXIN TABS OR 125
MCG, 250 MCG (Use
Digoxin)
$0- MO
$6.60
(Tier
2)
$0- MO
$2.65
(Tier
1)
MO
NF
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Health Net Cal MediConnect 2015 Drug List
77
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0LANOXIN TABS OR 187.5 $6.60
(Tier
MCG, 62.5 MCG
2)
Necessary
actions,
restrictions, or
limits on use
MO
TRACLEER
CARDIOVASCULAR AGENTS - MISC. - Drugs to
Treat Heart and Circulation Conditions
Cardiovascular Agents Misc. - Combinations
$0- PA; MO
$6.60
ENTRESTO
(Tier
2)
Prostaglandin Vasodilators
REMODULIN
TYVASO
TYVASO REFILL
TYVASO STARTER
VENTAVIS
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Name of drug
LA; B/D
LA; B/D
LA; B/D
Necessary
actions,
restrictions, or
limits on use
LA
Pulmonary Hypertension - Phosphodiesterase
$0- PA
$6.60
ADCIRCA
(Tier
2)
$0- PA
REVATIO SOLN IV 10
MG/12.5ML (Use Sildenafil $6.60
(Tier
Citrate (Pulmonary
2)
Hypertension))
REVATIO TABS OR 20
PA
NF
MG (Use Sildenafil Citrate
(Pulmonary Hypertension))
$0- PA
sildenafil citrate (pulmonary $2.65
(Tier
hypertension)
1)
Sinus Node Inhibitors
CORLANOR
LA; B/D
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0- QL(2 ea daily);
$6.60 MO
(Tier
2)
CEPHALOSPORINS - Drugs to Treat Bacterial
Infections
LA; B/D
Pulmonary Hypertension - Endothelin Receptor
$0- LA
$6.60
LETAIRIS
(Tier
2)
$0$6.60
OPSUMIT
(Tier
2)
Cephalosporins - 1st Generation
$0- MO
$2.65
cefadroxil
(Tier
1)
$0- MO
$2.65
cefazolin sodium solr ij 1
(Tier
gm, 10 gm, 500 mg
1)
$0- MO
$2.65
cephalexin caps 250 mg,
(Tier
500 mg, 750 mg
1)
You can find information on what the symbols and abbreviations on this table mean by going to
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78
Name of drug
cephalexin susr 125
mg/5ml, 250 mg/5ml
KEFLEX (Use Cephalexin)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
cefdinir
NF MO
Cephalosporins - 2nd Generation
$0cefaclor caps 250 mg, 500 $2.65
(Tier
mg
1)
$0$2.65
cefprozil
(Tier
1)
$0$6.60
CEFTIN SUSR 125
(Tier
MG/5ML
2)
CEFTIN TABS 250 MG,
NF
500 MG (Use Cefuroxime
Axetil)
$0$2.65
cefuroxime axetil
(Tier
1)
$0$2.65
cefuroxime sodium ij 1.5
(Tier
gm, 7.5 gm
1)
$0$2.65
cefuroxime sodium ij 750
(Tier
mg
1)
ZINACEF SOLR IJ 1.5 GM,
NF
7.5 GM (Use Cefuroxime
Sodium)
ZINACEF SOLR IJ 750 MG NF
(Use Cefuroxime Sodium)
cefixime chew 100 mg
MO
cefixime chew 200 mg
MO
cefixime susr 100 mg/5ml,
200 mg/5ml
MO
cefixime tabs 400 mg
MO
MO
cefotaxime sodium 1 gm,
10 gm
cefotaxime sodium 2 gm,
500 mg
cefpodoxime proxetil
MO
ceftazidime ij 1 gm, 2 gm
MO
ceftazidime ij 6 gm
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
Cephalosporins - 3rd Generation
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
79
Name of drug
ceftriaxone sodium solr ij 1
gm
ceftriaxone sodium solr ij 2
gm
ceftriaxone sodium solr ij
250 mg
ceftriaxone sodium solr ij
500 mg
ceftriaxone sodium solr iv 1
gm
ceftriaxone sodium solr iv
10 gm
ceftriaxone sodium solr iv 2
gm
CLAFORAN IJ 1 GM, 10
GM (Use Cefotaxime
Sodium)
CLAFORAN IJ 2 GM, 500
MG (Use Cefotaxime
Sodium)
FORTAZ SOLR IJ 1 GM, 2
GM (Use Ceftazidime)
FORTAZ SOLR IJ 6 GM
(Use Ceftazidime)
SUPRAX CAPS 400 MG
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(16 ea
daily); MO
QL(8 ea daily);
MO
QL(4 ea daily)
MO
Name of drug
SUPRAX SUSR 500
MG/5ML
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Cephalosporins - 4th Generation
$0- MO
$2.65
cefepime hcl
(Tier
1)
$0$6.60
CEFEPIME SOLN 1
(Tier
GM/50ML, 2 GM/100ML
2)
MAXIPIME IJ 1 GM, 2 GM
NF MO
(Use Cefepime HCl)
Cephalosporins - 5th Generation
$0$6.60
TEFLARO 400 MG
(Tier
2)
CHEMICALS
Acids, Bases, & Buffers
QL(2 ea daily);
MO
LACTIC ACID
MO
LACTIC ACID RACEMIC
NF
$0
(Tier
3)
$0
(Tier
3)
RX/OTC; MO;
NT
RX/OTC; MO;
NT
Bulk Chemicals - S's
NF
NF MO
NF
$0- MO
$6.60
(Tier
2)
SODIUM CITRATE
DIHYDRATE
$0 NT
(Tier
3)
Liquids
GLYCERIN LIQD 99 %,
99.5 %
GLYCERINE
$0
(Tier
3)
$0
(Tier
3)
RX/OTC; MO;
NT
RX/OTC; MO;
NT
You can find information on what the symbols and abbreviations on this table mean by going to
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Name of drug
GLYCEROL FORMAL
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
Name of drug
RX/OTC; MO;
NT
FEMCON FE (Use
Norethindrone & Ethinyl
Estradiol-Fe)
Semi-Solids
COAL TAR SOLN XX
Solids
SODIUM
CHLORIDE/SODIUM
BICARBONATE
THYMOL
$0 RX/OTC; MO;
(Tier NT
3)
$0 NT
(Tier
3)
$0 RX/OTC; MO;
(Tier NT
3)
CONTRACEPTIVES - Drugs to Prevent
Pregnancy
Combination Contraceptives - Oral
BREVICON-28 (Use
MO
NF
Norethindrone & Eth
Estradiol)
DESOGEN (Use
MO
NF
Desogestrel & Ethinyl
Estradiol)
$0- MO
$2.65
desogestrel & ethinyl
(Tier
estradiol
1)
$0- MO
$2.65
desogestrel-ethinyl
(Tier
estradiol (biphasic)
1)
$0- MO
$2.65
drospirenone-ethinyl
(Tier
estradiol
1)
$0- MO
$2.65
ethynodiol diacet & eth
(Tier
estrad
1)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO
NF
$0- MO
$2.65
(Tier
1)
$0- MO
levonorgestrel-eth estradiol $2.65
(Tier
(triphasic)
1)
$0- MO
$2.65
levonorgestrel-ethinyl
(Tier
estradiol (91-day)
1)
LOSEASONIQUE (Use
MO
NF
Levonorgestrel-Ethinyl
Estradiol (91-Day))
MODICON (Use
MO
NF
Norethindrone & Eth
Estradiol)
$0- MO
norethin acet & estrad-fe
$2.65
75mg-20mcg-1mg, 75mg- (Tier
30mcg-1.5mg
1)
$0- MO
$2.65
norethindrone & eth
(Tier
estradiol
1)
$0- MO
$2.65
norethindrone & ethinyl
(Tier
estradiol-fe 0.4mg-35mcg
1)
$0- MO
$2.65
norethindrone acet & eth
(Tier
estra
1)
$0- MO
norethindrone-eth estradiol $2.65
(Tier
(triphasic)
1)
levonorgestrel & eth
estradiol
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
81
Name of drug
norgestimate-ethinyl
estradiol
norgestimate-ethinyl
estradiol (triphasic)
norgestrel & ethinyl
estradiol
NORINYL 1+35 (Use
Norethindrone & Eth
Estradiol)
ORTHO TRI-CYCLEN (Use
Norgestimate-Ethinyl
Estradiol (Triphasic))
ORTHO-CEPT (Use
Desogestrel & Ethinyl
Estradiol)
ORTHO-CYCLEN (Use
Norgestimate-Ethinyl
Estradiol)
ORTHO-NOVUM 1/35
(Use Norethindrone & Eth
Estradiol)
ORTHO-NOVUM 7/7/7
(Use Norethindrone-Eth
Estradiol (Triphasic))
SEASONIQUE (Use
Levonorgestrel-Ethinyl
Estradiol (91-Day))
YASMIN 28 (Use
Drospirenone-Ethinyl
Estradiol)
YAZ (Use DrospirenoneEthinyl Estradiol)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
norelgestromin-ethinyl
estradiol
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
ORTHO EVRA (Use
Norelgestromin-Ethinyl
Estradiol)
MO
Combination Contraceptives - Vaginal
$0- MO
$6.60
NUVARING
(Tier
2)
MO
NF
MO
Emergency Contraceptives
MO
NF
MO
NF
MO
NF
MO
NF
MO
NF
MO
NF
MO
NF
NF MO
Combination Contraceptives - Transdermal
$0$6.60
ELLA
(Tier
2)
$0levonorgestrel (emergency $2.65
(Tier
oc) 0.75 mg
1)
$0- RX/OTC
levonorgestrel (emergency $2.65
(Tier
oc) 1.5 mg
1)
PLAN B ONE-STEP (Use
RX/OTC
Levonorgestrel (Emergency NF
OC))
Progestin Contraceptives - Injectable
DEPO-PROVERA
MO
CONTRACEPTIVE (Use
NF
Medroxyprogesterone
Acetate (Contraceptive))
$0- MO
$2.65
medroxyprogesterone
(Tier
acetate (contraceptive)
1)
Progestin Contraceptives - Oral
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82
Name of drug
NOR-QD (Use
Norethindrone
(Contraceptive))
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
NF
$0- MO
$2.65
(Tier
1)
ORTHO MICRONOR (Use
MO
NF
Norethindrone
(Contraceptive))
norethindrone
(contraceptive)
CORTICOSTEROIDS - Steroid Hormone Drugs to
Treat Systemic Swelling Conditions
Glucocorticosteroids
$0- MO
$6.60
(Tier
2)
$0- MO
$2.65
betamethasone sod
(Tier
phosphate & acetate
1)
$0- MO
$2.65
budesonide cp24 or
(Tier
1)
CELESTONE-SOLUSPAN
MO
NF
(Use Betamethasone Sod
Phosphate & Acetate)
CORTEF (Use
NF MO
Hydrocortisone)
$0- MO
$2.65
cortisone acetate tabs or
(Tier
1)
$0- MO
$6.60
DEPO-MEDROL 20
(Tier
MG/ML
2)
DEPO-MEDROL 40
MO
MG/ML, 80 MG/ML (Use
NF
Methylprednisolone
Acetate)
ARISTOSPAN INTRAARTICULAR
dexamethasone elix or 0.5
mg/5ml
dexamethasone sodium
phosphate soln ij 10 mg/ml
dexamethasone sodium
phosphate soln ij 10 mg/ml,
120 mg/30ml
dexamethasone sodium
phosphate soln ij 100
mg/10ml, 20 mg/5ml, 4
mg/ml
dexamethasone soln or 0.5
mg/5ml
dexamethasone tabs or 0.5
mg, 0.75 mg, 1 mg, 1.5 mg,
2 mg, 4 mg, 6 mg
ENTOCORT EC (Use
Budesonide)
hydrocortisone sod
succinate
hydrocortisone tabs or 10
mg, 20 mg, 5 mg
KENALOG-10
KENALOG-40
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
Preservative
Free;MO
MO
MO
MO
NF MO
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
MO
MO
MO
MO
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83
Name of drug
MEDROL 16 MG, 32 MG, 4
MG, 8 MG (Use
Methylprednisolone)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
NF
$0- MO
$6.60
MEDROL 2 MG
(Tier
2)
MEDROL DOSEPAK (Use NF MO
Methylprednisolone)
$0- MO
methylprednisolone acetate $2.65
susp ij 40 mg/ml, 80 mg/ml (Tier
1)
$0- MO
$2.65
methylprednisolone sod
(Tier
succ
1)
$0- MO
methylprednisolone tabs or $2.65
16 mg, 32 mg, 4 mg, 8 mg (Tier
1)
ORAPRED ODT 10 MG,15
MO
MG,30 MG (Use
NF
Prednisolone Sodium
Phosphate)
$0- MO
$2.65
prednisolone
(Tier
1)
$0- MO
prednisolone sodium
$2.65
phosphate soln or 15
(Tier
mg/5ml, 5 mg/5ml, 6.7
1)
mg/5ml
$0- MO
prednisolone sodium
$2.65
phosphate tbdp or 10 mg, (Tier
15 mg, 30 mg
1)
$0- MO
$2.65
prednisone conc or 5
(Tier
mg/ml
1)
prednisone soln or 5
mg/5ml
prednisone tabs or 1 mg,
10 mg, 2.5 mg, 20 mg, 5
mg, 50 mg
SOLU-CORTEF 100 MG,
250 MG, 500 MG
SOLU-CORTEF 1000 MG
SOLU-MEDROL 1000 MG,
125 MG, 40 MG (Use
Methylprednisolone Sod
Succ)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
NF
Mineralocorticoids
$0- MO
fludrocortisone acetate tabs $2.65
(Tier
or
1)
COUGH/COLD/ALLERGY - Drugs to Treat
Cough, Cold and Allergy Symptoms
Antitussives
$0 MO; NT
benzonatate 100 mg, 200
(Tier
mg
3)
hydrocodone w/
homatropine
TESSALON PERLES (Use
Benzonatate)
$0 MO; NT
(Tier
3)
NF MO; NT
Cough/Cold/Allergy Combinations
$0 AL; NT
ADVIL ALLERGY &
(Tier
CONGESTION
3)
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Health Net Cal MediConnect 2015 Drug List
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Name of drug
ALBATUSSIN NN
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
NT
BENADRYL ALLERGY &
AL; NT
COLD (Use
NF
DiphenhydraminePhenylephrineAcetaminophen)
BENADRYL ALLERGY &
AL; NT
SINUSHEADACHE (Use
NF
DiphenhydraminePhenylephrineAcetaminophen)
BENADRYL-D ALLERGY &
AL; NT
SINUS (Use
NF
DiphenhydraminePhenylephrine)
$0 AL; NT
brompheniramine &
(Tier
phenyleph
3)
$0
(Tier
3)
$0
(Tier
BRONCOPECTOL
3)
$0
chlorpheniramine &
(Tier
phenylephrine
3)
$0
chlorpheniramine &
pseudoeph syrp 15mg/5ml- (Tier
3)
1mg/5ml
$0
chlorpheniramine w/
(Tier
codeine
3)
chlorpheniramine$0
phenylephrine(Tier
acetaminophen susp
3)
1mg/5ml-160mg/5ml2.5mg/5ml
$0
DECON-A ELIX 2MG/5ML- (Tier
5MG/5ML
3)
brompheniramine &
pseudoeph
AL; NT
AL; NT
AL; NT
AL; NT
AL; RX/OTC;
NT
AL; NT
Name of drug
dexbrompheniramine &
pseudoephedrine
DIMETAPP COLD &
ALLERGY ELIX 1MG/5ML2.5MG/5ML (Use
Brompheniramine &
Phenyleph)
diphenhydraminephenylephrine liqd
12.5mg/5ml-5mg/5ml
diphenhydraminephenylephrine soln
12.5mg/5ml-5mg/5ml
diphenhydraminephenylephrine tabs 25mg10mg
diphenhydraminephenylephrineacetaminophen susp
12.5mg/5ml-160mg/5ml2.5mg/5ml
diphenhydraminephenylephrineacetaminophen tabs
12.5mg-12.5mg-325mg325mg-5mg-5mg, 12.5mg325mg-5mg
diphenhydraminepseudoephedrineacetaminophen
DRIXORAL
COLD/ALLERGY (Use
Dexbrompheniramine &
Pseudoephedrine)
ED CHLORPED D
GILTUSS PED-C
AL; NT
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
AL; MO; NT
AL; NT
NF
$0 AL; NT
(Tier
3)
$0 AL; NT
(Tier
3)
$0 AL; NT
(Tier
3)
AL; NT
$0
(Tier
3)
AL; NT
$0
(Tier
3)
$0 AL; NT
(Tier
3)
AL; MO; NT
NF
$0 AL; NT
(Tier
3)
$0 NT
(Tier
3)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
guaifenesin-codeine liqd
(Tier
100mg/5ml-10mg/5ml
3)
$0
guaifenesin-codeine soln
(Tier
100mg/5ml-10mg/5ml
3)
$0
guaifenesin-codeine syrp
(Tier
100mg/5ml-10mg/5ml
3)
$0
hydrocodone polistirex(Tier
chlorpheniramine polistirex
3)
$0
(Tier
LEXUSS 210
3)
$0
NEXAFED SINUS
(Tier
PRESSURE +PAIN
3)
PEDIATEX TD (Use
NF
Triprolidine &
Pseudoephedrine)
$0
phenyleph-promethazine
(Tier
w/ cod
3)
$0
(Tier
promethazine w/codeine
3)
$0
(Tier
promethazine-dm
3)
$0
pseudoephedrine(Tier
acetaminophen
3)
$0
pseudoephedrine-ibuprofen (Tier
susp 100mg/5ml-15mg/5ml 3)
$0
(Tier
RYMED
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
MO; NT
AL; MO; NT
Name of drug
SUDAFED PE SEVERE
COLD MULTI-SYMPTOM
(Use DiphenhydraminePhenylephrineAcetaminophen)
triprolidine &
pseudoephedrine liqd
0.938mg/ml-10mg/ml
triprolidine &
pseudoephedrine tabs
2.5mg-2.5mg-60mg-60mg,
2.5mg-60mg
AL; RX/OTC;
NT
TUSNEL CAPS 2MG15MG-200MG
NT
TUSSIONEX
PENNKINETIC
EXTENDED RELEASE
(Use Hydrocodone
Polistirex-Chlorpheniramine
Polistirex)
TYLENOL CHILDRENS
PLUS COLD & ALLERGY
(Use DiphenhydraminePhenylephrineAcetaminophen)
TYLENOL CHILDRENS
PLUS COLD (Use
ChlorpheniraminePhenylephrineAcetaminophen)
AL; RX/OTC;
NT
AL; MO; NT
AL; MO; NT
AL; MO; NT
NT
NT
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
AL; NT
NF
$0 AL; RX/OTC;
(Tier NT
3)
$0 AL; MO; NT
(Tier
3)
$0 AL; NT
(Tier
3)
AL; MO; NT
NF
AL; NT
NF
AL; NT
NF
Misc. Respiratory Inhalants
sodium chloride (inhalant)
$0 NT
(Tier
3)
Mucolytics
AL; NT
$0- MO; B/D
acetylcysteine soln in 10 %, $2.65
(Tier
20 %
1)
DERMATOLOGICALS - Drugs to Treat Skin
Conditions
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Health Net Cal MediConnect 2015 Drug List
86
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Acne Products
ABSORICA 10 MG,20
MG,25 MG,35 MG,40 MG
ABSORICA 30 MG (Use
Isotretinoin)
ACNE MEDICATION
ACNE MEDICATION 10
adapalene crea 0.1 %
adapalene gel 0.1 %
ADULT ACNOMEL
BENSULFOID
BENZACLIN (Use
Clindamycin PhosphateBenzoyl Peroxide)
BENZACLIN WITH PUMP
(Use Clindamycin
Phosphate-Benzoyl
Peroxide)
BENZAMYCIN (Use
Benzoyl PeroxideErythromycin)
benzoyl peroxide gel ex 5
%
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0
(Tier
3)
$0
(Tier
3)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0
(Tier
3)
$0
(Tier
3)
Name of drug
benzoyl peroxideerythromycin
CLEOCIN-T (Use
Clindamycin Phosphate
(Topical))
CLINDAGEL
MO; NT
MO; NT
clindamycin phosphate
(topical)
MO
clindamycin phosphatebenzoyl peroxide
MO
clindamycin phosphatebenzoyl peroxide
(refrigerate)
NT
MO
DIFFERIN CREA 0.1 %
(Use Adapalene)
DIFFERIN GEL 0.1 % (Use
Adapalene)
DUAC (Use Clindamycin
Phosphate-Benzoyl
Peroxide (Refrigerate))
MO
erythromycin (acne aid)
soln
MO
EVOCLIN (Use
Clindamycin Phosphate
(Topical))
NT
NF
NF
NF
$0 RX/OTC; MO;
(Tier NT
3)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
NF
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
MO
MO
MO
MO
NF MO
NF MO
MO
NF
$0- MO
$2.65
(Tier
1)
MO
NF
$0isotretinoin caps or 10 mg, $2.65
(Tier
20 mg, 30 mg, 40 mg
1)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
87
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
KLARON (Use
Sulfacetamide Sodium
(Acne))
NF
RETIN-A (Use Tretinoin)
NF MO
RETIN-A MICRO (Use
Tretinoin Microsphere)
RETIN-A MICRO PUMP
0.04 %, 0.1 % (Use
Tretinoin Microsphere)
REZAMID
sulfacetamide sodium
(acne)
tretinoin crea ex 0.025 %,
0.05 %, 0.1 %
tretinoin gel ex 0.01 %,
0.025 %
tretinoin microsphere
MO
NF MO
bacitracin (topical)
bacitracin zinc oint ex
MO; NT
bacitracin-polymyxin b
MO
MO
MO
MO
Analgesics - Topical
menthol (topical analgesic)
pads 5 %
Antibiotics - Topical
BACIGUENT (Use
Bacitracin (Topical))
MO
NF
$0
(Tier
3)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Name of drug
$0 MO; NT
(Tier
3)
Anti-inflammatory Agents - Topical
$0- PA; MO
$6.60
FLECTOR
(Tier
2)
$0- MO
$6.60
VOLTAREN
(Tier
2)
BACTROBAN (Use
Mupirocin Calcium
(Topical))
BACTROBAN (Use
Mupirocin)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO; NT
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
MO
NF
NF MO
$0$6.60
CENTANY
(Tier
2)
$0$2.65
gentamicin sulfate (topical) (Tier
1)
$0$2.65
mupirocin calcium (topical) (Tier
1)
$0$2.65
mupirocin oint ex
(Tier
1)
$0
neomycin-bacitracin(Tier
polymyxin w/ lidocaine
3)
POLYSPORIN OINT (Use
NF
Bacitracin-Polymyxin B)
MO
MO
MO
MO
NT
MO; NT
Antifungals - Topical
ALEVAZOL
$0 NT
(Tier
3)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
88
Name of drug
ciclopirox gel 0.77 %
ciclopirox olamine crea ex
ciclopirox olamine susp ex
ciclopirox sham 1 %
ciclopirox soln 8 %
clotrimazole (topical) crea
clotrimazole (topical) soln
clotrimazole w/
betamethasone
CLOVERINE SALVE
econazole nitrate
EXTINA (Use
Ketoconazole (Topical))
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0
(Tier
3)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
ketoconazole (topical)
MO
MO
MO
MO
RX/OTC; MO
RX/OTC; MO
MO
NT
MO
NF MO
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
LAMISIL AT CREA (Use
Terbinafine HCl (Topical))
LAMISIL AT JOCK ITCH
(Use Terbinafine HCl
(Topical))
NF MO; NT
LOPROX (Use Ciclopirox)
NF MO
LOPROX SHAMPOO (Use
Ciclopirox)
LOTRISONE (Use
Clotrimazole w/
Betamethasone)
MICATIN (Use Miconazole
Nitrate (Topical))
NF MO
MO; NT
NF
MO
NF
NF RX/OTC; MO;
NT
$0 RX/OTC; MO;
miconazole nitrate (topical) (Tier
NT
crea
3)
$0- MO
$6.60
NAFTIN CREA 2 %
(Tier
2)
$0- MO
$6.60
NAFTIN GEL 2 %
(Tier
2)
NIZORAL (Use
NF MO
Ketoconazole (Topical))
$0 MO; NT
(Tier
NIZORAL A-D
3)
$0- MO
$2.65
nystatin (topical)
(Tier
1)
$0- MO
$2.65
nystatin-triamcinolone
(Tier
1)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
89
Name of drug
PENLAC NAIL LACQUER
(Use Ciclopirox)
terbinafine hcl (topical)
TINACTIN CREA (Use
Tolnaftate)
TINACTIN JOCK ITCH
CREA (Use Tolnaftate)
tolnaftate crea ex
tolnaftate liqd ex
tolnaftate soln ex
UNDELENIC TINCTURE
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
NF MO
$0 MO; NT
(Tier
3)
NF MO; NT
fluorouracil (topical)
FLUOROURACIL CREA
EX 0.5 %
NF MO; NT
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
MO; NT
MO; NT
MO; NT
NT
PANRETIN
PICATO
SOLARAZE (Use
Diclofenac Sodium (Actinic
Keratoses))
TARGRETIN 1 %,75 MG
Antihistamines-Topical
diphenhydramine hcl
(topical) crea
diphenhydramine-zinc
acetate crea 0.1%-1%
$0 NT
(Tier
3)
$0 NT
(Tier
3)
Antineoplastic or Premalignant Lesion Agents $0- MO
$6.60
CARAC
(Tier
2)
$0- MO
diclofenac sodium (actinic $2.65
(Tier
keratoses)
1)
EFUDEX (Use Fluorouracil NF MO
(Topical))
VALCHLOR
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
NF
$0$6.60
(Tier
2)
$0- PA
$6.60
(Tier
2)
Antipsoriatics
acitretin
calcipotriene
COSENTYX
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- PA; LA
$6.60
(Tier
2)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
90
Name of drug
COSENTYX
SENSOREADY PEN
DOVONEX (Use
Calcipotriene)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA; LA
NF MO
$0- MO
$2.65
methoxsalen rapid
(Tier
1)
$0- MO
OXSORALEN ULTRA (Use $6.60
(Tier
Methoxsalen Rapid)
2)
SORIATANE (Use
NF MO
Acitretin)
$0- PA;
$6.60
STELARA
(Tier
2)
$0- MO
$6.60
TAZORAC
(Tier
2)
Antiseborrheic Products
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
DERMAZINC SCALP
3)
DERMAZINC SPRAY (Use NF MO; NT
Pyrithione Zinc)
DHS ZINC (Use Pyrithione NF MO; NT
Zinc)
$0
NOBLE FORMULA BAR 2 (Tier NT
%
3)
DERMAZINC BABY
P & S LIQD
$0 MO; NT
(Tier
3)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
pyrithione zinc liqd 0.25 % (Tier
3)
$0
(Tier
pyrithione zinc sham 2 %
3)
$0selenium sulfide lotn ex 2.5 $2.65
(Tier
%
1)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
MO
Antivirals - Topical
acyclovir topical
DENAVIR
ZOVIRAX CREA EX 5 %
ZOVIRAX OINT EX 5 %
(Use Acyclovir Topical)
$0- MO
$2.65
(Tier
1)
$0- MO
$6.60
(Tier
2)
$0- MO
$6.60
(Tier
2)
NF MO
Bath Products
$0
(Tier
3)
$0
bath products oil 40%-40%- (Tier
40%-40%, 5%-5%-5%
3)
$0
(Tier
BODI WHIRL OIL
3)
$0
(Tier
GERISILK BATH OIL
3)
$0
(Tier
ULTRA DERM BATH OIL
3)
AVEENO SKIN RELIEF
SHOWER& BATH
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
91
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Burn Products
mafenide acetate pack ex
SILVADENE (Use Silver
Sulfadiazine)
$0- MO
$2.65
(Tier
1)
NF MO
$0- MO
$2.65
silver sulfadiazine crea ex (Tier
1)
SULFAMYLON PACK 5 % NF MO
(Use Mafenide Acetate)
Corticosteroids - Topical
$0$2.65
alclometasone dipropionate (Tier
1)
$0$2.65
amcinonide crea
(Tier
1)
$0$2.65
betamethasone
(Tier
dipropionate (topical)
1)
$0$2.65
betamethasone
(Tier
dipropionate augmented
1)
$0$2.65
betamethasone valerate
(Tier
crea ex 0.1 %
1)
$0$2.65
betamethasone valerate
(Tier
foam ex 0.12 %
1)
$0$2.65
betamethasone valerate
(Tier
lotn ex 0.1 %
1)
MO
MO
MO
MO
MO
MO
MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
betamethasone valerate
(Tier
oint ex 0.1 %
1)
$0clobetasol propionate crea $2.65
(Tier
ex
1)
$0$2.65
clobetasol propionate
(Tier
emollient base
1)
$0$2.65
clobetasol propionate
(Tier
emulsion
1)
$0clobetasol propionate foam $2.65
(Tier
ex
1)
$0$2.65
clobetasol propionate gel
(Tier
ex
1)
$0clobetasol propionate lotn $2.65
(Tier
ex
1)
$0clobetasol propionate oint $2.65
(Tier
ex
1)
$0clobetasol propionate sham $2.65
(Tier
ex
1)
$0clobetasol propionate soln $2.65
(Tier
ex
1)
CLOBEX LOTN (Use
NF
Clobetasol Propionate)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
92
Name of drug
CLOBEX SHAM (Use
Clobetasol Propionate)
CUTIVATE (Use
Fluticasone Propionate)
CVS HDYROCORTISONE
ACETATE
DERMA-SMOOTHE/FS
BODY (Use Fluocinolone
Acetonide)
DERMA-SMOOTHE/FS
SCALP (Use Fluocinolone
Acetonide)
DERMATOP CREA (Use
Prednicarbate)
desonide crea ex
desonide lotn ex
desonide oint ex
DESOWEN 0.05 % (Use
Desonide)
desoximetasone crea ex
0.25 %
desoximetasone gel ex
0.05 %
desoximetasone oint ex
0.25 %
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
NF MO
NF MO
$0 NT
(Tier
3)
MO
NF
MO
NF
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
diflorasone diacetate oint
DIPROLENE (Use
Betamethasone
Dipropionate Augmented)
DIPROLENE AF (Use
Betamethasone
Dipropionate Augmented)
ELOCON CREA (Use
Mometasone Furoate)
ELOCON OINT (Use
Mometasone Furoate)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
NF
MO
NF
NF MO
NF MO
$0fluocinolone acetonide crea $2.65
(Tier
ex 0.01 %, 0.025 %
1)
$0fluocinolone acetonide oil $2.65
(Tier
ex 0.01 %
1)
$0fluocinolone acetonide oint $2.65
(Tier
ex 0.025 %
1)
$0fluocinolone acetonide soln $2.65
(Tier
ex 0.01 %
1)
$0$2.65
fluocinonide crea ex 0.05 % (Tier
1)
$0$2.65
fluocinonide emulsified
(Tier
base
1)
$0fluocinonide gel ex 0.05 % $2.65
(Tier
1)
MO
MO
MO
MO
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to
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93
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
fluocinonide oint ex 0.05 % (Tier
1)
$0fluocinonide soln ex 0.05 % $2.65
(Tier
1)
$0fluticasone propionate crea $2.65
(Tier
ex 0.05 %
1)
$0fluticasone propionate lotn $2.65
(Tier
ex 0.05 %
1)
$0fluticasone propionate oint $2.65
(Tier
ex 0.005 %
1)
$0$2.65
halobetasol propionate
(Tier
1)
$0
hydrocortisone (topical)
(Tier
crea 0.5 %
3)
$0$2.65
hydrocortisone (topical)
(Tier
crea 1 %
1)
$0$2.65
hydrocortisone (topical)
(Tier
crea 2.5 %
1)
$0
hydrocortisone (topical)
(Tier
lotn 1 %
3)
$0$2.65
hydrocortisone (topical)
(Tier
lotn 2.5 %
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
MO; NT
RX/OTC; MO
MO
MO; NT
MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
hydrocortisone (topical) oint (Tier
0.5 %
3)
$0hydrocortisone (topical) oint $2.65
(Tier
1%
1)
$0hydrocortisone (topical) oint $2.65
(Tier
2.5 %
1)
$0
hydrocortisone (topical)
(Tier
soln 1 %
3)
$0
hydrocortisone acetate
(Tier
(topical)
3)
$0$2.65
hydrocortisone butyrate
(Tier
1)
$0$2.65
hydrocortisone butyrate
(Tier
hydrophilic lipo base
1)
$0$2.65
hydrocortisone valerate
(Tier
1)
$0
(Tier
hydrocortisone-aloe vera
3)
LOCOID CREA (Use
NF
Hydrocortisone Butyrate)
LOCOID LIPOCREAM
(Use Hydrocortisone
NF
Butyrate Hydrophilic Lipo
Base)
LOCOID OINT (Use
NF
Hydrocortisone Butyrate)
LOCOID SOLN (Use
NF
Hydrocortisone Butyrate)
Necessary
actions,
restrictions, or
limits on use
MO; NT
RX/OTC; MO
MO
NT
NT
MO
MO
MO
NT
MO
MO
MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to
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Name of drug
LUXIQ (Use
Betamethasone Valerate)
mometasone furoate crea
ex
mometasone furoate oint
ex
mometasone furoate soln
ex
OLUX (Use Clobetasol
Propionate)
OLUX-E (Use Clobetasol
Propionate Emulsion)
prednicarbate crea
SYNALAR (Use
Fluocinolone Acetonide)
TEMOVATE (Use
Clobetasol Propionate)
TEMOVATE E (Use
Clobetasol Propionate
Emollient Base)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
TUCKS ANTI-ITCH
MO
MO
ULTRAVATE (Use
Halobetasol Propionate)
WESTCORT (Use
Hydrocortisone Valerate)
CARMOL 20 (Use Urea)
ULTRA MIDE 25 (Use
Urea)
NF MO
urea crea ex 20 %
NF MO
$0- MO
$2.65
(Tier
1)
NF MO
NF MO
urea lotn ex 25 %
Emollients
LAC-HYDRIN (Use Lactic
Acid (Ammonium Lactate))
lactic acid (ammonium
lactate) crea 12 %
MO
NF
$0- MO
triamcinolone acetonide
$2.65
(topical) crea 0.025 %, 0.1 (Tier
%, 0.5 %
1)
$0- MO
triamcinolone acetonide
(topical) lotn 0.025 %, 0.1 $2.65
(Tier
%
1)
$0- MO
triamcinolone acetonide
$2.65
(topical) oint 0.025 %, 0.1
(Tier
%, 0.5 %
1)
Necessary
actions,
restrictions, or
limits on use
NT
NF MO
NF MO
Emollient/Keratolytic Agents
CARMOL
MO
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
lactic acid (ammonium
lactate) lotn 12 %
lactic acid (ammonium
lactate) lotn 5 %
PANTHODERM
PETROLATUM
$0 NT
(Tier
3)
NF MO; NT
NF MO; NT
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
NF RX/OTC; MO
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
RX/OTC; MO
RX/OTC; MO
MO; NT
NT
NT
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
(Tier
SUPER E CREA
3)
$0
(Tier
SUPER E DAY
3)
$0
(Tier
SUPER E EYE
3)
$0
(Tier
SUPER E NIGHT
3)
$0
vitamin e (topical) crea
1000 unit, 1500 unit/30gm, (Tier
30000 unit/60gm, 6000 unit 3)
vitamin e (topical) oil 100
unit/5drop, 12000 unit,
$0
20000 unit, 28000 unit,
(Tier
28000 unit/29ml, 400
3)
unit/ml, 4000 unit, 49000
unit/52ml, 933.333 unit/ml
Necessary
actions,
restrictions, or
limits on use
MO; NT
ELIDEL
MO; NT
MO; NT
tacrolimus (topical)
MO; NT
Keratolytic/Antimitotic Agents
CONDYLOX SOLN (Use
NF
Podofilox)
$0
(Tier
MEDIPLAST
3)
$0
MOSCO CALLUS/CORN
(Tier
REMOVER
3)
$0
(Tier
P & S SHAM
3)
$0$2.65
podofilox soln ex
(Tier
1)
NT
$0- MO
$6.60
(Tier
2)
Immunomodulating Agents - Topical
NF MO
ALDARA (Use Imiquimod)
imiquimod crea ex
ZYCLARA
ZYCLARA PUMP
PROTOPIC (Use
Tacrolimus (Topical))
MO; NT
Enzymes - Topical
SANTYL
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$6.60
(Tier
2)
$0- MO
$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
NT
NT
NT
MO
Liniments
$0
ARTHRICARE DOUBLE
(Tier
ICE PAIN RELIEVING RUB 3)
$0
ARTHRICARE PAIN
(Tier
RELIEVINGRUB
3)
$0
ARTHRICARE TRIPLE
(Tier
MEDICATED PAIN
3)
RELIEVING RUB
$0
(Tier
BIOFLEXOR
3)
NT
NT
NT
NT
Immunosuppressive Agents - Topical
You can find information on what the symbols and abbreviations on this table mean by going to
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96
Name of drug
BLUE-EMU SUPER
STRENGTH
DEEP BLUE RELIEF
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
lidocaine hcl gel ex 0.5 %
NT
lidocaine hcl gel ex 2 %
liniments & rubs crea
0.01%-5%-10%, 1.2%2.6%-4.7%, 10%-0.025%15%
$0 MO; NT
(Tier
3)
liniments & rubs oint
0.25%, 8%-2%
$0 NT
(Tier
3)
$0 NT
(Tier
3)
$0 MO; NT
(Tier
3)
SM PAIN
RELIEF/MENTHOL
VICKS BABYRUB
Name of drug
lidocaine hcl soln ex 4 %
lidocaine oint ex 5 %
lidocaine ptch ex 5 %
Local Anesthetics - Topical
AXSAIN
capsaicin in lidocaine
vehicle
DERMOPLAST
DERMOPLAST PAIN
RELIEVINGSPRAY
EMLA (Use LidocainePrilocaine)
ITCH-X GEL
LANACANE
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
NT
lidocaine-prilocaine crea
NT
LIDODERM (Use
Lidocaine)
NT
pramoxine-camphor-zinc
acetate
NT
NF MO
$0 MO; NT
(Tier
3)
$0 NT
(Tier
3)
REGENECARE HA
SOLARCAINE ALOE
EXTRA GEL (Use
Lidocaine HCl)
SOLARCAINE ALOE
VERA
XYLOCAINE EX 4 % (Use
Lidocaine HCl)
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
NT
RX/OTC; MO
MO
MO
PA; MO
MO
NF PA; MO
$0 NT
(Tier
3)
$0 NT
(Tier
3)
NT
NF
$0 NT
(Tier
3)
NF MO
Misc. Dermatological Products
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
97
Name of drug
ATOPICLAIR
AURSTAT ANTI-ITCH
HYDROGEL
BURN SPRAY
DERMAGRAN AERO
DERMAREST ROSACEA
dermatological products,
misc. crea 0.17%-2.7%,
4%-2%-0.5%
ELETONE
ELETONE TWINPACK
FRESH'N FEMININE
DEODORANT
HPR PLUS CREA
HYLATOPIC PLUS CREA
NASALGUARD
NEOSALUS CP
NEOSALUS CREA
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
Name of drug
RX/OTC; MO;
NT
NEW SKIN
RX/OTC; MO;
NT
NIVATOPIC PLUS
MO; NT
NONYX
MO; NT
OC8
RX/OTC; MO;
NT
PRUCLAIR
RX/OTC; MO;
NT
PRUMYX
RX/OTC; MO;
NT
SUMMERS EVE
DEODORANT SPRAY
RX/OTC; MO;
NT
SUMMERS EVE
DEODORANT SPRAY
ULTRA
MO; NT
YODORA DEODORANT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
Misc. Topical
A & D ZINC OXIDE (Use
Dimethicone-Zinc OxideVitamin A-Vitamin D)
A-MANTLE
ACNE-AID
ACUICYN DAILY EYELID
& EYELASH CLEANSER
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
MO; NT
MO; NT
RX/OTC; MO;
NT
NT
NF
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
$0 RX/OTC; NT
(Tier
3)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
98
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
ALOE VESTA MULTI
(Tier
PURPOSECLEANSING
3)
$0
ALUMINUM ACETATE
(Tier
SOLN EX
3)
$0
(Tier
aluminum hydroxide
3)
$0
aluminum sulfate & calcium (Tier
acetate
3)
$0
AMBI COCOA BUTTER
(Tier
CLEANSING
3)
$0
AMBI COMPLEXION
(Tier
CLEANSING
3)
$0
ANTI-BACTERIAL HAND
(Tier
LOTION
3)
$0
AQUANIL SKIN
(Tier
CLEANSER
3)
$0
AVEENO ACTIVE
(Tier
NATURALS PURE
3)
RENEWAL SHAMPOO
$0
AVEENO MOISTURIZING (Tier
3)
$0
AVEENO POSITIVELY
(Tier
AGELESSDAILY
EXFOLIATING CLEANSER 3)
$0
AVEENO POSITIVELY
(Tier
RADIANTCLEANSER
3)
$0
AVEENO ULTRA(Tier
CALMING CLEANSER
3)
$0
(Tier
AVENOVA
3)
Necessary
actions,
restrictions, or
limits on use
NT
MO; NT
NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
NT
RX/OTC; NT
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
(Tier
BASIS ALL CLEAR
3)
$0
(Tier
BASIS COMBINATION
3)
$0
(Tier
BASIS EXTRA DRY
3)
$0
(Tier
BASIS NORMAL/DRY
3)
$0
(Tier
BASIS SENSITIVE SKIN
3)
$0
BODY WASH &
(Tier
SHAMPOO
3)
$0
(Tier
CALAMINE LOTN EX
3)
$0
(Tier
CALAMINE LOTN EX
3)
$0
CALAMINE PHENOLATED (Tier
3)
$0
(Tier
CARRAFOAM FOAM
3)
$0
CAVILON NO STING
(Tier
BARRIERFILM
3)
$0
CETAPHIL GENTLE
(Tier
CLEANSER
3)
$0
CETAPHIL GENTLE
(Tier
CLEANSING
3)
$0
(Tier
CONTI CASTILE SOAP
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
NT
NT
Calamine-Zinc
Oxide
Lotion;MO; NT
NT
NT
MO; NT
MO; NT
MO; NT
MO; NT
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
99
Name of drug
CVS SALINE WOUND
WASH
DARA
DERMAGRAN OINT (Use
Aluminum Hydroxide)
DHS
DHS COLOR SAFE
SHAMPOO
DHS CONDITIONING
RINSE
DIABETIDERM
CLEANSING
dimethicone-zinc oxidevitamin a-vitamin d
DOMEBORO 1347MG952MG (Use Aluminum
Sulfate & Calcium Acetate)
ELTA CLEANSE FOAM
FORMULA 405 FACIAL &
BODYCLEANSING
FORMULA 405
MOISTURIZINGSOAP
FREE & CLEAR
GENTLE RAIN EXTRA
MILD
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
NT
MO; NT
NF NT
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
MO; NT
MO; NT
MO; NT
MO; NT
NT
MO; NT
NF
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
NT
MO; NT
MO; NT
MO; NT
MO; NT
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
GENTLE RAIN SHAMPOO (Tier
AND SKIN CLEANSER
3)
$0
GENTLE SKIN CLEANSER (Tier
3)
$0
GERI-SHAMPOO/SHEA
(Tier
BUTTER
3)
$0
(Tier
GNP CALAMINE
3)
$0
GNP CALAMINE
(Tier
PHENOLATED
3)
$0
GNP SALINE WOUND
(Tier
WASH
3)
$0
GRANDPAS BAKING
(Tier
SODA SOAP
3)
$0
GRANDPAS INDIAN
(Tier
CORN SOAP
3)
$0
GRANDPAS LOVE MY
(Tier
LOOFAH SOAP
3)
$0
GRANDPAS OATMEAL
(Tier
SOAP
3)
$0
GRANDPAS ORANGE
(Tier
ESSENCE SOAP
3)
$0
GRANDPAS PATCHOULI (Tier
SOAP
3)
$0
GRANDPAS SHEA
(Tier
BUTTER SOAP
3)
$0
GRANDPAS WITCH
(Tier
HAZEL SOAP
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
MO; NT
Calamine-Zinc
Oxide
Lotion;MO; NT
NT
NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
(Tier
HM CALAMINE
3)
$0
(Tier
HYDROPEL
3)
$0
(Tier
JOHNSONS BABY BAR
3)
$0
JOHNSONS BUDDIES
(Tier
EASY-GRIP SUDZING
3)
$0
JOHNSONS KIDS SUPER (Tier
SUDZER E-Z GRIP SOAP
3)
$0
(Tier
lanolin (topical)
3)
$0
LOBOB CONTACT LENS (Tier
WEARERS SOAP
3)
$0
(Tier
LOWILA
3)
$0
(Tier
MEIJER CALAMINE
3)
$0
NATURE DE FRANCE
(Tier
ALGOLI SOAP
3)
$0
NATURE DE FRANCE
(Tier
ARGILE BLANCHE SOAP
3)
$0
NATURE DE FRANCE
(Tier
ARGIMIEL SOAP
3)
$0
NEUTROGENA ACNE
(Tier
CLEANSING SOAP
3)
$0
NEUTROGENA CLEAN
(Tier
REPLENISHING
3)
Necessary
actions,
restrictions, or
limits on use
Calamine-Zinc
Oxide
Lotion;MO; NT
NT
MO; NT
MO; NT
MO; NT
NT
MO; NT
MO; NT
NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
NEUTROGENA FACIAL
(Tier
SOAP ORIGINAL
3)
FORMULA
$0
NEUTROGENA
(Tier
NATURALS FACE& BODY 3)
$0
NEUTROGENA
(Tier
SHAMPOO
3)
$0
NEUTROGENA TRIPLE
(Tier
MOISTURE UV SHIELD
3)
$0
NIVEA MOISTURIZING
(Tier
BODY WASH
3)
$0
NIVEA MOISTURIZING
(Tier
BODY WASH 2 IN 1
3)
NIVEA TOUCH OF
$0
SMOOTHNESS
(Tier
MOISTURIZING BODY
3)
WASH
$0
NIVEA VISAGE GENTLE
(Tier
CLEANSING
3)
$0
(Tier
NO-STING SKIN-PREP
3)
$0
(Tier
OCUSOFT HAND SOAP
3)
$0
OCUSOFT LID SCRUB
(Tier
FOAMING
3)
$0
OCUSOFT LID SCRUB
(Tier
ORIGINAL
3)
$0
(Tier
OILATUM
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
RX/OTC; NT
RX/OTC; NT
MO; NT
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
101
Name of drug
PHACID
PROSHIELD FOAM &
SPRAY CLEANSER
PURPOSE BAR
PX CALAMINE
QC CALAMINE
RA BEAUTY BAR
RA CALAMINE LOTN
6.971%-6.971%
RA SALINE WOUND
WASH
SAFE WASH
SALINE WOUND WASH
SALJET
SALJET RINSE
SAYMAN LANOLIN
SAYMAN WITCH HAZEL
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO; NT
skin protectants, misc. liqd
NT
SM CALAMINE
MO; NT
SM CALAMINE
PHENOLATED
Calamine-Zinc
Oxide
Lotion;MO; NT
NT
STYGIENE STERILE
EYELID CLEANSER
MO; NT
Calamine-Zinc
Oxide
Lotion;MO; NT
NT
NT
NT
NT
RX/OTC; NT
TERSASEPTIC
GLYCERINE CLEANSING
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
TOPICLEAR
ULTRASWIM ULTRA
REPAIR
UNIVERSAL REMOVER
WIPES
URO-PREP PROTECTIVE
SKINWIPES
VANICREAM BAR
MO; NT
witch hazel-glycerin
MO; NT
NT
$0 MO; NT
(Tier
3)
NT
NT
Necessary
actions,
restrictions, or
limits on use
SUMMERS EVE NIGHTTIME
CLEANSING/SENSITIVE
SKIN
ULTRASWIM
NT
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
NT
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
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Name of drug
WOUND WASH SALINE
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
Name of drug
NT
permethrin aero xx 0.5 %
Rosacea Agents
FINACEA GEL
METROCREAM (Use
Metronidazole (Topical))
METROGEL (Use
Metronidazole (Topical))
METROLOTION (Use
Metronidazole (Topical))
metronidazole (topical)
MIRVASO
$0- MO
$6.60
(Tier
2)
NF MO
permethrin crea ex 5 %
NF MO
permethrin lotn ex 1 %
NF MO
PRONTO SHAM EX
0.33%-4% (Use PyrethrinsPiperonyl Butoxide)
$0- MO
$2.65
(Tier
1)
$0- PA; MO
$6.60
(Tier
2)
LYCELLE
malathion
nit remover
NIX CREME RINSE (Use
Permethrin)
OVIDE 0.5 % (Use
Malathion)
PYRETHINS/PIPERONYL
BUTOXIDE
pyrethrins-piperonyl
butoxide
RID (Use Permethrin)
Scabicides & Pediculicides
lindane lotn
permethrin liqd ex 1 %
$0$2.65
(Tier
1)
$0
(Tier
3)
$0$2.65
(Tier
1)
$0
(Tier
3)
MO
RID (Use PyrethrinsPiperonyl Butoxide)
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0$2.65
(Tier
1)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
NT
MO
MO; NT
MO; NT
NT
NF
$0 NT
(Tier
3)
$0 NT
(Tier
3)
NF NT
NF NT
Sunscreens
RX/OTC; NT
BULL FROG QUIK GEL
SPF 36
MO
BULL FROG QUIK GEL
SPF 50
RX/OTC; NT
BULL FROG QUIK GEL
SPORTSPF 36
NF MO; NT
BULL FROG QUIK GEL
SPORTSPRAY SPF 50
NF MO
BULL FROG SPF 36
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
BULL FROG WATER
(Tier
ARMOR SPORT QUIK
3)
GEL SPF 50
$0
BULL FROG WATER
(Tier
ARMOR SPORT QUIK
3)
SPRAY SPF 50
$0
NIVEA VISAGE EYE
(Tier
CONTOUR
3)
$0
PRESUN ULTRA/PARSOL (Tier
GEL 3%-5%-7.5%-6%
3)
$0
SHADE OIL FREE CLEAR (Tier
GELSPF 25
3)
$0
SOLBAR PF LIQUID/GEL (Tier
SPF30
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
Name of drug
GRANDPAS PINE TAR
SOAP
MO; NT
MG217 MEDICATED TAR
MO; NT
POLYTAR BAR
MO; NT
TARSUM
MO; NT
MO; NT
THERAPLEX T (Use Coal
Tar Extract)
coal tar extract sham 1 %
coal tar extract sham 1 %,
15 %
COAL TAR SOLN EX
CUTAR
ELTA LITE TAR
ELTA TAR
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
REGRANEX
NT
Necessary
actions,
restrictions, or
limits on use
NT
NT
NT
MO; NT
NF NT
Wound Care Products
Tar Products
BALNETAR LIQUIM
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0- MO
$6.60
(Tier
2)
DIAGNOSTIC PRODUCTS
Diagnostic Drugs
NT
GLUTOL
MO; NT
NT
MO; NT
NT
NT
$0 NT
(Tier
3)
Diagnostic Tests
$0
(Tier
3)
$0
CHEK-STIX COMBO PAK (Tier
URINALYSIS CONTROL
3)
$0
(Tier
CHEK-STIX CONTROL
3)
$0
CHEMSTRIP -10 WITH SG (Tier
3)
$0
(Tier
CHEMSTRIP 10 MD
3)
MO; NT
ALBUSTIX
MO; NT
MO; NT
MO; NT
MO; NT
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
CHEMSTRIP 2 GP
(Tier
STRIPS
3)
$0
CHEMSTRIP 2 LN STRIPS (Tier
3)
$0
(Tier
CHEMSTRIP 5 OB
3)
$0
(Tier
CHEMSTRIP 7
3)
$0
(Tier
CHEMSTRIP 9 STRIPS
3)
$0
(Tier
CHEMSTRIP UGK
3)
$0
(Tier
CHEMSTRIP-K
3)
$0
(Tier
CHEMSTRIP-MICRAL
3)
$0
(Tier
CLINISTIX
3)
$0
(Tier
CLINITEST
3)
$0
(Tier
CLINITEST REAGENT
3)
$0
(Tier
COMBISTIX
3)
$0
(Tier
CVS KETONE CARE
3)
$0
(Tier
DIASTIX
3)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO; NT
HEMA-COMBISTIX
MO; NT
KETO-DIASTIX
MO; NT
KETOCARE
MO; NT
KETONE TEST STRIPS
MO; NT
KETOSTIX
MO; NT
LABSTIX
MO; NT
MULTISTIX
MO; NT
MULTISTIX 10 SG
MO; NT
MULTISTIX 5
NT
MULTISTIX 7
NT
MULTISTIX 8 SG
MO; NT
MULTISTIX 9
MO; NT
MULTISTIX 9 SG
MO; NT
NITRATEST PAPER
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
105
Name of drug
NOVA MAX PLUS
KETONE TESTSTRIPS
PRECISION XTRA
PTS PANELS KETONE
TEST
RELION KETONE
RELION KETONE TEST
STRIPS
UNIVERSAL PH STRIPS
URISTIX
URISTIX 4
WFHC PH PAPER
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
SULFZIX
MO; NT
XIZFLUS
MO; NT
MO; NT
MO; NT
MO; NT
Nutritional Supplements
DEXATRIM MAX PACK
1MG-5.5UNIT-34MCG72MG-75MG-0.35MG70MG-45MG-0.263MG10MG-1.8MG-3.5MG0.3MG-3MCG-70MCG0.35MG-25MG-30MG
Necessary
actions,
restrictions, or
limits on use
RX/OTC; NT
RX/OTC; NT
PA; NT
$0
(Tier
3)
DIGESTIVE AIDS - Drugs to Treat Low Digestive
Enzymes
Digestive Enzymes
MO; NT
CREON
MO; NT
PANCREAZE
MO; NT
DIETARY PRODUCTS/DIETARY MANAGEMENT
PRODUCTS
Dietary Management Products
$0
(Tier
CEREFOLIN
3)
$0
folic acid-pyridoxine(Tier
cyancobalamin
3)
$0
(Tier
L-METHYL-MC
3)
$0
(Tier
METAFOLBIC
3)
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
MO; NT
MO; NT
MO; NT
$0- MO
$6.60
(Tier
2)
$0- MO
$6.60
(Tier
2)
DIURETICS - Drugs to Treat Heart, Circulation
Conditions and Blood Pressure
Carbonic Anhydrase Inhibitors
$0- MO
acetazolamide cp12 or 500 $2.65
(Tier
mg
1)
$0- MO
acetazolamide tabs or 250 $2.65
(Tier
mg
1)
DIAMOX (Use
NF MO
Acetazolamide)
MO; NT
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
106
Name of drug
methazolamide tabs or 25
mg, 50 mg
Diuretic Combinations
ALDACTAZIDE 25MG25MG (Use Spironolactone
& Hydrochlorothiazide)
amiloride &
hydrochlorothiazide
DYAZIDE (Use
Triamterene &
Hydrochlorothiazide)
MAXZIDE (Use
Triamterene &
Hydrochlorothiazide)
MAXZIDE-25 (Use
Triamterene &
Hydrochlorothiazide)
spironolactone &
hydrochlorothiazide
triamterene &
hydrochlorothiazide
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
furosemide soln or 10
mg/ml
MO
NF
$0- MO
$2.65
(Tier
1)
MO
NF
MO
NF
MO
NF
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
Loop Diuretics
$0- MO
bumetanide tabs or 0.5 mg, $2.65
(Tier
1 mg, 2 mg
1)
BUMEX (Use Bumetanide) NF MO
DEMADEX (Use
Torsemide)
Name of drug
NF MO
$0- MO
$2.65
furosemide soln ij 10 mg/ml (Tier
1)
furosemide tabs or 20 mg,
40 mg, 80 mg
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
LASIX (Use Furosemide)
NF MO
torsemide tabs or 10 mg,
100 mg, 20 mg, 5 mg
$0- MO
$2.65
(Tier
1)
Potassium Sparing Diuretics
ALDACTONE (Use
NF MO
Spironolactone)
$0- MO
$2.65
amiloride hcl
(Tier
1)
$0- MO
spironolactone tabs or 100 $2.65
(Tier
mg, 25 mg, 50 mg
1)
Thiazides and Thiazide-Like Diuretics
$0- MO
$2.65
chlorothiazide 500 mg
(Tier
1)
$0- MO
$2.65
chlorthalidone 25 mg, 50
(Tier
mg
1)
$0- MO
hydrochlorothiazide caps or $2.65
(Tier
12.5 mg
1)
$0- MO
hydrochlorothiazide tabs or $2.65
(Tier
12.5 mg, 25 mg, 50 mg
1)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
107
Name of drug
indapamide
metolazone
MICROZIDE (Use
Hydrochlorothiazide)
ZAROXOLYN (Use
Metolazone)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
FOSAMAX (Use
Alendronate Sodium)
MO
NF MO
NF MO
ENDOCRINE AND METABOLIC AGENTS MISC. - Drugs to Treat Bone Disease and
Regulate Hormones
Bone Density Regulators
$0- MO
$2.65
(Tier
1)
$0- QL(0.15 ea
$2.65 daily); MO
alendronate sodium tabs
(Tier
35 mg, 70 mg
1)
BONIVA SOLN IV 3
QL(0.04 ml
MG/3ML (Use Ibandronate NF daily); MO
Sodium)
BONIVA TABS OR 150 MG NF QL(0.036 ea
(Use Ibandronate Sodium)
daily); MO
$0- MO
$2.65
calcitonin (salmon)
(Tier
1)
$0- QL(0.09 ml
$6.60 daily)
FORTEO
(Tier
2)
$0- MO
$6.60
FORTICAL
(Tier
2)
alendronate sodium tabs
10 mg, 5 mg
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF QL(0.15 ea
daily); MO
$0- QL(0.04 ml
ibandronate sodium soln iv $2.65 daily); MO
(Tier
3 mg/3ml
1)
$0- QL(0.036 ea
ibandronate sodium tabs or $2.65 daily); MO
(Tier
150 mg
1)
$0- MO
$6.60
MIACALCIN IJ 200
(Tier
UNIT/ML
2)
MIACALCIN NA 200
MO
NF
UNIT/ACT (Use Calcitonin
(Salmon))
$0- PA; LA
$6.60
NATPARA
(Tier
2)
$0- QL(0.01 ml
$6.60 daily)
PROLIA
(Tier
2)
RECLAST (Use Zoledronic NF QL(0.28 ml
Acid)
daily)
$0- QL(0.243 ml
$6.60 daily)
XGEVA
(Tier
2)
$0$2.65
zoledronic acid conc 4
(Tier
mg/5ml
1)
$0- QL(0.28 ml
$2.65 daily)
zoledronic acid soln 5
(Tier
mg/100ml
1)
$0$2.65
zoledronic acid solr 4 mg
(Tier
1)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
108
Name of drug
ZOMETA CONC 4
MG/5ML (Use Zoledronic
Acid)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF
Corticotropin
H.P. ACTHAR
$0- PA; LA
$6.60
(Tier
2)
Fertility Regulators
$0chorionic gonadotropin solr $2.65
(Tier
im
1)
Growth Hormone Receptor Antagonists
$0- LA
$6.60
SOMAVERT
(Tier
2)
Growth Hormone Releasing Hormones (GHRH)
$0$6.60
EGRIFTA 2 MG
(Tier
2)
Growth Hormones
$0- PA
$6.60
GENOTROPIN 5 MG
(Tier
2)
$0- PA
GENOTROPIN MINIQUICK $6.60
(Tier
0.4 MG
2)
$0- PA
$6.60
HUMATROPE
(Tier
2)
$0- PA
$6.60
HUMATROPE COMBO
(Tier
PACK
2)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0NORDITROPIN FLEXPRO $6.60
10 MG/1.5ML, 5 MG/1.5ML (Tier
2)
$0$6.60
NUTROPIN AQ NUSPIN
(Tier
20
2)
$0$6.60
NUTROPIN AQ PEN 20
(Tier
MG/2ML
2)
$0$6.60
OMNITROPE SOLN 10
(Tier
MG/1.5ML, 5 MG/1.5ML
2)
$0$6.60
SEROSTIM 4 MG, 6 MG
(Tier
2)
$0$6.60
TEV-TROPIN
(Tier
2)
$0$6.60
ZOMACTON 5 MG
(Tier
2)
Hormone Receptor Modulators
EVISTA (Use Raloxifene
NF
HCl)
$0$2.65
raloxifene hcl
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
PA
PA
PA
PA
PA
PA
PA
QL(1 ea daily);
MO
QL(1 ea daily);
MO
Insulin-Like Growth Factors (Somatomedins)
$0- LA
$6.60
INCRELEX
(Tier
2)
LHRH/GnRH Agonist Analog Pituitary
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$6.60
LUPRON DEPOT-PED
(Tier
11.25 MG
2)
$0$6.60
LUPRON DEPOT-PED
11.25 MG, 15 MG, 7.5 MG (Tier
2)
$0LUPRON DEPOT-PED 30 $6.60
(Tier
MG
2)
$0$6.60
SYNAREL
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
3 Month Kit;
levocarnitine (metabolic
modifiers) tabs or 330 mg
LUMIZYME
MYALEPT
MO
MYOZYME
Metabolic Modifiers
$0calcitriol caps or 0.25 mcg, $2.65
(Tier
0.5 mcg
1)
$0$2.65
calcitriol soln or 1 mcg/ml
(Tier
1)
CARNITOR TABS OR 330
NF
MG (Use Levocarnitine
(Metabolic Modifiers))
$0$6.60
FABRAZYME 35 MG
(Tier
2)
$0$6.60
KUVAN PACK 100 MG,
(Tier
500 MG
2)
$0$6.60
KUVAN TBSO 100 MG
(Tier
2)
MO
NAGLAZYME
MO
ORFADIN
MO
paricalcitol caps or 1 mcg,
2 mcg, 4 mcg
LA
ROCALTROL (Use
Calcitriol)
SENSIPAR
VIMIZIM
LA
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
LA
LA
LA
LA
LA
MO
NF MO
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
ZEMPLAR CAPS OR 1
MCG, 2 MCG, 4 MCG (Use
Paricalcitol)
MO
NF
Posterior Pituitary Hormones
You can find information on what the symbols and abbreviations on this table mean by going to
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110
Name of drug
DDAVP (Use
Desmopressin Acetate
Refrigerated)
DDAVP (Use
Desmopressin Acetate
Spray)
DDAVP (Use
Desmopressin Acetate)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO
NF
MO
NF
NF MO
$0$2.65
desmopressin acetate
(Tier
refrigerated
1)
$0desmopressin acetate soln $2.65
(Tier
ij 4 mcg/ml
1)
$0$2.65
desmopressin acetate
(Tier
spray
1)
$0$2.65
desmopressin acetate
(Tier
spray refrigerated
1)
$0desmopressin acetate tabs $2.65
(Tier
or 0.1 mg, 0.2 mg
1)
MO
MO
MO
MO
MO
Prolactin Inhibitors
cabergoline
$0- MO
$2.65
(Tier
1)
Somatostatic Agents
octreotide acetate 100
mcg/ml, 1000 mcg/5ml,
200 mcg/ml, 50 mcg/ml
SANDOSTATIN 100
MCG/ML, 200 MCG/ML, 50
MCG/ML (Use Octreotide
Acetate)
$0$2.65
(Tier
1)
NF
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$6.60
SANDOSTATIN LAR
(Tier
DEPOT 20 MG, 30 MG
2)
$0$6.60
SIGNIFOR
(Tier
2)
$0$6.60
SIGNIFOR LAR 20 MG
(Tier
2)
$0SIGNIFOR LAR 40 MG, 60 $6.60
(Tier
MG
2)
$0$6.60
SOMATULINE DEPOT
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
LA
QL(0.11 ea
daily)
QL(0.036 ea
daily)
Vasopressin Receptor Antagonists
$0$6.60
SAMSCA
(Tier
2)
ESTROGENS - Hormone Replacement/Modifying
Drugs
Estrogen Combinations
ACTIVELLA (Use Estradiol
& Norethindrone Acetate)
NF AL; MO
$0- AL; MO
$2.65
(Tier
1)
$0- AL; MO
$2.65
estradiol-norgestimate
(Tier
1)
$0- AL; MO
$2.65
norethindrone acetateethinyl estradiol 5mcg-1mg (Tier
1)
estradiol & norethindrone
acetate
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111
Name of drug
PREMPHASE
PREMPRO
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
AL; MO
Estrogens
CLIMARA (Use Estradiol)
DELESTROGEN 10
MG/ML
DELESTROGEN 20
MG/ML, 40 MG/ML (Use
Estradiol Valerate)
NF AL; MO
$0- MO
$6.60
(Tier
2)
MO
NF
$0- MO
$6.60
DIVIGEL
(Tier
2)
estradiol ptwk td 0.025
$0- AL; MO
mg/24hr, 0.05 mg/24hr,
$2.65
0.06 mg/24hr, 0.075
mg/24hr, 0.1 mg/24hr, 37.5 (Tier
1)
mcg/24hr
$0- AL; MO
estradiol tabs or 0.5 mg, 1 $2.65
(Tier
mg, 2 mg
1)
$0- MO
estradiol valerate oil im 10 $2.65
mg/ml, 20 mg/ml, 40 mg/ml (Tier
1)
$0- AL; MO
$2.65
estropipate 0.75 mg, 1.5
(Tier
mg
1)
$0PREMARIN TABS OR 0.3 $6.60 AL; MO
MG, 0.45 MG, 0.625 MG,
(Tier
0.9 MG, 1.25 MG
2)
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
FLUOROQUINOLONES - Drugs to Treat Bacterial
Infections
Fluoroquinolones
CIPRO I.V.-IN D5W
200MG/100ML-5% (Use
Ciprofloxacin in D5W)
CIPRO I.V.-IN D5W
400MG/200ML-5% (Use
Ciprofloxacin in D5W)
CIPRO TABS 250 MG, 500
MG (Use Ciprofloxacin
HCl)
CIPRO XR (Use
Ciprofloxacin-Ciprofloxacin
HCl)
ciprofloxacin hcl tabs or
100 mg, 250 mg, 500 mg,
750 mg
ciprofloxacin in d5w
200mg/100ml-5%
ciprofloxacin in d5w
400mg/200ml-5%
ciprofloxacin soln iv 400
mg/40ml
ciprofloxacin-ciprofloxacin
hcl
LEVAQUIN SOLN IV
250MG/50ML-5%,
500MG/100ML-5% (Use
Levofloxacin in D5W)
LEVAQUIN SOLN IV
750MG/150ML-5% (Use
Levofloxacin in D5W)
NF
MO
NF
MO
NF
MO
NF
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
MO
MO
MO
MO
NF
MO
NF
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Health Net Cal MediConnect 2015 Drug List
112
Name of drug
LEVAQUIN SOLN OR 25
MG/ML (Use Levofloxacin)
LEVAQUIN TABS OR 250
MG, 500 MG, 750 MG (Use
Levofloxacin)
levofloxacin in d5w
250mg/50ml-5%,
500mg/100ml-5%
levofloxacin in d5w
750mg/150ml-5%
levofloxacin soln iv 25
mg/ml
levofloxacin soln or 25
mg/ml
levofloxacin tabs or 250
mg, 500 mg, 750 mg
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO
MO
$0$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
simethicone caps or 125
mg
simethicone chew or 125
mg
MO; NT
NF
NF MO; NT
MO; NT
NF
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
Gallstone Solubilizing Agents
ACTIGALL (Use Ursodiol)
NF
GASTROINTESTINAL AGENTS - MISC. Miscellaneous Gastrointestinal Drugs
Antiflatulents
GAS-X EXTRA
STRENGTH CHEW 125
MG (Use Simethicone)
MYLANTA GAS (Use
Simethicone)
MYLANTA GAS RELIEF
MAXIMUM STRENGTH
(Use Simethicone)
Name of drug
What
the
drug
will
cost
you
(tier
level)
chenodiol
URSO 250 (Use Ursodiol)
URSO FORTE (Use
Ursodiol)
ursodiol caps or 300 mg
ursodiol tabs or 250 mg,
500 mg
NF MO
$0- LA
$2.65
(Tier
1)
NF MO
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
Gastrointestinal Antiallergy Agents
$0- MO
$2.65
cromolyn sodium
(Tier
(mastocytosis)
1)
GASTROCROM (Use
MO
NF
Cromolyn Sodium
(Mastocytosis))
Gastrointestinal Stimulants
$0- MO
metoclopramide hcl soln or $2.65
(Tier
10 mg/10ml, 5 mg/5ml
1)
$0- MO
metoclopramide hcl tabs or $2.65
(Tier
10 mg, 5 mg
1)
REGLAN (Use
NF MO
Metoclopramide HCl)
Inflammatory Bowel Agents
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Health Net Cal MediConnect 2015 Drug List
113
Name of drug
APRISO
ASACOL HD
AZULFIDINE (Use
Sulfasalazine)
AZULFIDINE EN-TABS
(Use Sulfasalazine)
balsalazide disodium
CIMZIA
CIMZIA STARTER KIT
COLAZAL (Use
Balsalazide Disodium)
DELZICOL
DIPENTUM
ENTYVIO
mesalamine enem re
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
mesalamine w/ cleanser
MO
REMICADE
NF MO
ROWASA (Use
Mesalamine w/ Cleanser)
NF MO
$0- MO
$2.65
(Tier
1)
$0- PA
$6.60
(Tier
2)
$0- PA
$6.60
(Tier
2)
NF MO
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
MO
MO
PA
MO
sulfasalazine tabs or
sulfasalazine tbec or
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
PA
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
Intestinal Acidifiers
$0- MO
$2.65
lactulose (encephalopathy) (Tier
1)
Irritable Bowel Syndrome (IBS) Agents
$0- MO
$2.65
alosetron hcl
(Tier
1)
$0- MO
$6.60
LINZESS
(Tier
2)
$0- MO
$6.60
LOTRONEX (Use
(Tier
Alosetron HCl)
2)
Peripheral Opioid Receptor Antagonists
$0$6.60
RELISTOR KIT 12
(Tier
MG/0.6ML
2)
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114
Name of drug
RELISTOR SOLN 12
MG/0.6ML, 8 MG/0.4ML
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
Phosphate Binder Agents
$0- MO
calcium acetate (phosphate $2.65
(Tier
binder) caps
1)
$0- MO
$6.60
FOSRENOL
(Tier
2)
PHOSLO (Use Calcium
MO
NF
Acetate (Phosphate
Binder))
$0- MO
$6.60
RENVELA PACK 2.4 GM
(Tier
2)
$0- MO
$6.60
RENVELA TABS 800 MG
(Tier
2)
$0- MO
$6.60
SEVELAMER
(Tier
CARBONATE
2)
GENITOURINARY AGENTS - MISCELLANEOUS
- Miscellaneous Drugs to Treat Reproductive
Organs and Urinary System
Alkalinizers
$0- MO
potassium citrate
$2.65
(alkalinizer) 1080 mg, 540 (Tier
mg
1)
$0- MO
UROCIT-K 10 (Use
$6.60
Potassium Citrate
(Tier
(Alkalinizer))
2)
Name of drug
UROCIT-K 5 (Use
Potassium Citrate
(Alkalinizer))
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
MO
Genitourinary Irrigants
acetic acid ir 0.25 %
neomycin/polymyxin b gu
sodium chloride (gu
irrigant)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
Prostatic Hypertrophy Agents
alfuzosin hcl
AVODART (Use
Dutasteride)
dutasteride
finasteride tabs or
FLOMAX (Use Tamsulosin
HCl)
JALYN
PROSCAR (Use
Finasteride)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
MO
GL; MO
GL; MO
GL; MO
NF MO
$0- GL; MO
$6.60
(Tier
2)
NF GL; MO
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Name of drug
tamsulosin hcl
UROXATRAL (Use
Alfuzosin HCl)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
probenecid
NF MO
Urinary Analgesics
$0 MO; NT
phenazopyridine hcl tabs or (Tier
100 mg, 200 mg
3)
PYRIDIUM (Use
NF MO; NT
Phenazopyridine HCl)
colchicine w/ probenecid
Complement Inhibitors
CINRYZE
Gout Agents
allopurinol tabs or 100 mg
allopurinol tabs or 300 mg
COLCHICINE TABS OR
COLCRYS
ZYLOPRIM 100 MG (Use
Allopurinol)
ZYLOPRIM 300 MG (Use
Allopurinol)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
QL(8 ea daily);
MO
QL(2 ea daily);
MO
MO
Bradykinin B2 Receptor Antagonists
$0$6.60
FIRAZYR
(Tier
2)
BERINERT
$0- MO
$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
HEMATOLOGICAL AGENTS - MISC. - Drugs to
Treat Blood Disorders
GOUT AGENTS - Drugs to Treat Gout
Gout Agent Combinations
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
RUCONEST
$0$6.60
(Tier
2)
$0- LA
$6.60
(Tier
2)
$0$6.60
(Tier
2)
Hematorheologic Agents
pentoxifylline tbcr or
MO
$0- MO
$2.65
(Tier
1)
Plasma Kallikrein Inhibitors
MO
NF QL(8 ea daily);
MO
NF QL(2 ea daily);
MO
Uricosurics
KALBITOR
$0$6.60
(Tier
2)
Platelet Aggregation Inhibitors
$0- MO
$6.60
AGGRENOX
(Tier
2)
AGRYLIN (Use Anagrelide NF MO
HCl)
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
anagrelide hcl
(Tier
1)
$0$6.60
ASPIRIN/DIPYRIDAMOLE (Tier
2)
$0$6.60
BRILINTA
(Tier
2)
$0$2.65
cilostazol
(Tier
1)
$0$2.65
clopidogrel bisulfate 300
(Tier
mg
1)
$0$2.65
clopidogrel bisulfate 75 mg (Tier
1)
$0$2.65
dipyridamole tabs or 25
(Tier
mg, 50 mg, 75 mg
1)
$0$6.60
EFFIENT
(Tier
2)
PERSANTINE (Use
NF
Dipyridamole)
PLAVIX 300 MG (Use
NF
Clopidogrel Bisulfate)
PLAVIX 75 MG (Use
NF
Clopidogrel Bisulfate)
PLETAL (Use Cilostazol)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
ticlopidine hcl
MO
ZONTIVITY
MO
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
AL
MO
HEMATOPOIETIC AGENTS - Drugs to Treat
Blood Disorders
Agents for Gaucher Disease
MO
CERDELGA
CEREZYME
MO
ELELYSO
AL; MO
VPRIV
MO
ZAVESCA
AL; MO
MO
NF MO
$0- PA
$6.60
(Tier
2)
$0- LA
$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0- LA
$6.60
(Tier
2)
Agents for Sickle Cell Anemia
$0- MO
$6.60
DROXIA
(Tier
2)
Cobalamins
cyanocobalamin subl sl
1000 mcg
$0 MO; NT
(Tier
3)
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Name of drug
cyanocobalamin tabs or
250 mcg
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO; NT
NEUMEGA
Folic Acid/Folates
FA-8
FOLIC ACID CAPS OR 20
MG, 5 MG
folic acid tabs or 1 mg
folic acid tabs or 400 mcg,
800 mcg
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Hematopoietic Growth Factors
$0$6.60
ARANESP ALBUMIN
(Tier
FREE
2)
$0$6.60
EPOGEN
(Tier
2)
$0$6.60
GRANIX
(Tier
2)
$0$6.60
LEUKINE
(Tier
2)
$0$6.60
NEULASTA
(Tier
2)
$0$6.60
NEULASTA DELIVERY
(Tier
KIT
2)
NT
NEUPOGEN
NT
PROCRIT
RX/OTC; MO;
NT
MO; NT
PA
PA
PA
PA
PROMACTA 12.5 MG
PROMACTA 25 MG
PROMACTA 50 MG
PROMACTA 75 MG
ZARXIO
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA
PA
PA
QL(12 ea
daily); LA
QL(6 ea daily);
LA
QL(3 ea daily);
LA
QL(2 ea daily);
LA
PA
Hematopoietic Mixtures
PA
B-6 FOLIC ACID
PA
FOLGARD RX (Use Folic
Acid-Vitamin B6-Vitamin
B12)
FOLIC + B12
$0 NT
(Tier
3)
MO; NT
NF
$0 RX/OTC; MO;
(Tier NT
3)
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Health Net Cal MediConnect 2015 Drug List
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
folic acid-vitamin b6(Tier
vitamin b12
3)
$0
(Tier
FOLTRATE
3)
$0
(Tier
HEMOCYTE-F
3)
$0
(Tier
I.L.X. B-12
3)
$0
(Tier
iron combinations
3)
$0
(Tier
MTX SUPPORT
3)
$0
OPURITY B12/FOLIC
(Tier
ACID
3)
$0
(Tier
PRE-FOLIC
3)
$0
VITAMIN B12/FOLIC ACID (Tier
3)
Iron
FER-IN-SOL (Use Ferrous
Sulfate)
FERGON 240 MG (Use
Ferrous Gluconate)
ferrous fumarate tabs or
324 mg, 325 mg
FERROUS FUMARATE
TABS OR 90 MG
FERROUS GLUCONATE
225 MG
Necessary
actions,
restrictions, or
limits on use
MO; NT
RX/OTC; MO;
NT
RX/OTC; NT
RX/OTC; NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
NT
RX/OTC; MO;
NT
NF MO; NT
NF NT
$0 MO; NT
(Tier
3)
$0 NT
(Tier
3)
$0 NT
(Tier
3)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
ferrous gluconate 240 mg, (Tier
27 mg
3)
$0
ferrous sulfate dried tbcr
(Tier
160 mg
3)
$0
ferrous sulfate elix or 220
(Tier
mg/5ml
3)
$0
FERROUS SULFATE LIQD (Tier
OR 220 MG/5ML
3)
$0
ferrous sulfate soln or 15
(Tier
mg/ml
3)
$0
FERROUS SULFATE
(Tier
SYRP OR 300 MG/5ML
3)
$0
ferrous sulfate tabs or 325 (Tier
mg, 65 mg
3)
$0
ferrous sulfate tbcr or 50
(Tier
mg
3)
$0
FERROUS SULFATE
(Tier
TBEC OR 324 MG
3)
$0
ferrous sulfate tbec or 325 (Tier
mg
3)
HEMOCYTE (Use Ferrous
NF
Fumarate)
$0
IRON CHEWS PEDIATRIC (Tier
3)
$0
(Tier
IRON TABS 256 MG
3)
$0
(Tier
IRON TABS 28 MG
3)
Necessary
actions,
restrictions, or
limits on use
NT
NT
MO; NT
NT
MO; NT
NT
MO; NT
NT
MO; NT
NT
MO; NT
MO; NT
MO; NT
NT
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119
Name of drug
polysaccharide iron
complex 150 mg
PROFERRIN ES
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO; NT
Barbiturate Hypnotics
MO; NT
SLOW FE 160 MG (Use
Ferrous Sulfate Dried)
NF NT
SLOW RELEASE IRON
$0 NT
(Tier
3)
Stem Cell Mobilizers
MOZOBIL
$0$6.60
(Tier
2)
HEMOSTATICS - Drugs to Stop Bleeding/Treat
Blood Disorders
BUTISOL SODIUM
phenobarbital elix or 20
mg/5ml
phenobarbital soln or 20
mg/5ml
phenobarbital tabs or 100
mg, 15 mg, 16.2 mg, 30
mg, 32.4 mg, 60 mg, 64.8
mg, 97.2 mg
Hypnotics - Tricyclic Agents
Hemostatics - Systemic
AMICAR TABS 500 MG
aminocaproic acid tabs or
500 mg
CYKLOKAPRON (Use
Tranexamic Acid)
LYSTEDA (Use
Tranexamic Acid)
$0- MO
$6.60
(Tier
2)
$0- MO
$2.65
(Tier
1)
NF
NF MO
$0tranexamic acid soln iv 100 $2.65
(Tier
mg/ml
1)
$0- MO
$2.65
tranexamic acid tabs or
(Tier
650 mg
1)
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
SILENOR
Non-Barbiturate Hypnotics
AMBIEN 10 MG (Use
Zolpidem Tartrate)
AMBIEN 5 MG (Use
Zolpidem Tartrate)
AMBIEN CR 12.5 MG (Use
Zolpidem Tartrate)
AMBIEN CR 6.25 MG (Use
Zolpidem Tartrate)
HALCION (Use Triazolam)
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
AL; MO
AL; MO
AL; MO
$0- MO
$6.60
(Tier
2)
NF AL; QL(1 ea
daily); MO
NF AL; QL(2 ea
daily); MO
NF AL; QL(1 ea
daily); MO
NF AL; QL(2 ea
daily); MO
NF MO
RESTORIL (Use
Temazepam)
NF MO
SONATA (Use Zaleplon)
NF AL; MO
temazepam
$0- MO
$2.65
(Tier
1)
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
triazolam
(Tier
1)
$0$2.65
zaleplon
(Tier
1)
$0$2.65
zolpidem tartrate tabs 10
(Tier
mg
1)
$0$2.65
zolpidem tartrate tabs 5 mg (Tier
1)
$0zolpidem tartrate tbcr 12.5 $2.65
(Tier
mg
1)
$0zolpidem tartrate tbcr 6.25 $2.65
(Tier
mg
1)
Necessary
actions,
restrictions, or
limits on use
MO
ROZEREM
AL; MO
BELSOMRA 10 MG
BELSOMRA 15 MG, 20
MG
BELSOMRA 5 MG
Necessary
actions,
restrictions, or
limits on use
MO
LAXATIVES - Bowel Treatment Drugs
Bulk Laxatives
AL; QL(1 ea
daily); MO
AL; QL(2 ea
daily); MO
calcium polycarbophil
CITRUCEL FIBER
LAXATIVE (Use
Methylcellulose (Laxative))
CVS NATURAL FIBER
SUPPLEMENT
AL; QL(1 ea
daily); MO
AL; QL(2 ea
daily); MO
Orexin Receptor Antagonists
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
PA; QL(2 ea
daily); MO
PA; QL(1 ea
daily); MO
PA; QL(4 ea
daily); MO
Selective Melatonin Receptor Agonists
$0- PA
$6.60
HETLIOZ
(Tier
2)
EQL NATURAL FIBER
EVAC (Use Psyllium)
FIBERCON (Use Calcium
Polycarbophil)
HYDROCIL INSTANT
PACK
HYDROCIL INSTANT
POWD (Use Psyllium)
KONSYL PACK 100 %
KONSYL PACK 28.3 %,
60.3 %
KONSYL POWD 100 %
(Use Psyllium)
KONSYL POWD 60.3 %,
71.67 %
KONSYL-D
$0 MO; NT
(Tier
3)
MO; NT
NF
$0 NT
(Tier
3)
$0 NT
(Tier
3)
NF MO; NT
NF MO; NT
$0 MO; NT
(Tier
3)
NF MO; NT
$0 MO; NT
(Tier
3)
$0 NT
(Tier
3)
NF MO; NT
$0 NT
(Tier
3)
$0 MO; NT
(Tier
3)
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Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
METAMUCIL CAPS 0.52
NF MO; NT
GM (Use Psyllium)
$0 NT
METAMUCIL
(Tier
MULTIHEALTH FIBER
3)
55.46 %
METAMUCIL ORIGINAL
MO; NT
NF
TEXTURE 48.57 % (Use
Psyllium)
METAMUCIL POWD 48.57 NF MO; NT
% (Use Psyllium)
$0 NT
METAMUCIL SMOOTH
(Tier
TEXTUREFIBER SINGLES 3)
GOLYTELY 236GM22.74GM-5.86GM-2.97GM6.74GM (Use PEG 3350KCl-Sod Bicarb-Sod
Chloride-Sod Sulfate)
NULYTELY/FLAVOR
PACKS (Use PEG 3350Potassium Chloride-Sod
Bicarbonate-Sod Chloride)
methylcellulose (laxative)
powd 2 gm/10.2gm, 2
gm/19gm
peg 3350-potassium
chloride-sod bicarbonatesod chloride
$0
(Tier
3)
$0
psyllium caps 0.52 gm, 520 (Tier
mg
3)
$0
psyllium powd 100 %,
(Tier
48.57 %, 58.6 %, 95 %
3)
$0
psyllium powd 28.3 %, 30
%, 30.9 %, 33 %, 49 %, 68 (Tier
3)
%
$0
(Tier
UNIFIBER
3)
MO; NT
peg 3350-kcl-sod bicarbsod chloride-sod sulfate
MO; NT
SUPREP BOWEL PREP
MO; NT
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO
NF
MO
NF
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$6.60
(Tier
2)
Laxatives - Miscellaneous
NT
NT
Laxative Combinations
$0COLYTE-FLAVOR PACKS $6.60
227.1GM-21.5GM-5.53GM- (Tier
2.82GM-6.36GM
2)
COLYTE-FLAVOR PACKS
MO
240GM-22.72GM-5.84GM2.98GM-6.72GM (Use PEG NF
3350-KCl-Sod Bicarb-Sod
Chloride-Sod Sulfate)
$0
(Tier
3)
$0
FLEET LIQUID GLYCERIN (Tier
SUPPOSITORIES
3)
$0$2.65
lactulose
(Tier
1)
$0$2.65
polyethylene glycol 3350
(Tier
pack or
1)
$0$2.65
polyethylene glycol 3350
(Tier
powd or
1)
MO; NT
CEO-TWO
MO; NT
MO
RX/OTC; MO
RX/OTC; MO
Saline Laxatives
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122
Name of drug
MILK OF MAGNESIA
CONCENTRATE
PHILLIPS MILK OF
MAGNESIA CHEWABLE
PHILLIPS MILK OF
MAGNESIA
CONCENTRATED
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
NT
NT
Stimulant Laxatives
bisacodyl supp re 10 mg
bisacodyl tbec or 5 mg
DULCOLAX (Use
Bisacodyl)
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
NF MO; NT
$0
DULCOLAX BOWEL PREP (Tier
KIT
3)
EX-LAX TABS (Use
NF
Sennosides)
$0
(Tier
FLEET BISACODYL
3)
$0
sennosides tabs 15 mg, 8.6 (Tier
mg
3)
SENOKOT (Use
NF
Sennosides)
SENOKOT TO GO (Use
NF
Sennosides)
NT
COLACE (Use Docusate
Sodium)
COLACE CLEAR (Use
Docusate Sodium)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
NT
NT
MO; NT
LOCAL ANESTHETICS-Parenteral - Drugs for
Numbing
MO; NT
Local Anesthetics - Amides
MO; NT
MO; NT
MO; NT
Surfactant Laxatives
benzocaine-docusate
sodium
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
(Tier
docusate calcium
3)
$0
docusate sodium caps or
(Tier
100 mg, 250 mg, 50 mg
3)
$0
docusate sodium enem re (Tier
283 mg
3)
$0
docusate sodium liqd or
(Tier
150 mg/15ml, 50 mg/5ml
3)
$0
docusate sodium syrp or 60 (Tier
mg/15ml
3)
$0
docusate sodium tabs or
(Tier
100 mg
3)
$0
(Tier
DOCUSOL KIDS
3)
$0 MO; NT
(Tier
3)
NF MO; NT
NF MO; NT
$0- MO
lidocaine hcl (local anesth.) $2.65
(Tier
1 %, 2 %
1)
XYLOCAINE IJ 1 %, 2 %
MO
NF
(Use Lidocaine HCl (Local
Anesth.))
XYLOCAINE-MPF 1 %
MO
NF
(Use Lidocaine HCl (Local
Anesth.))
MACROLIDES - Drugs to Treat Bacterial
Infections
Azithromycin
$0- MO
$2.65
azithromycin solr iv 500 mg (Tier
1)
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
123
Name of drug
azithromycin susr or 100
mg/5ml, 200 mg/5ml
azithromycin tabs or 250
mg, 500 mg, 600 mg
ZITHROMAX SOLR IV 500
MG (Use Azithromycin)
ZITHROMAX SUSR OR
100 MG/5ML, 200 MG/5ML
(Use Azithromycin)
ZITHROMAX TABS OR
250 MG, 500 MG, 600 MG
(Use Azithromycin)
ZITHROMAX TRI-PAK
(Use Azithromycin)
ZITHROMAX Z-PAK (Use
Azithromycin)
Clarithromycin
BIAXIN (Use
Clarithromycin)
BIAXIN XL (Use
Clarithromycin)
BIAXIN XL PAC (Use
Clarithromycin)
clarithromycin susr or 125
mg/5ml, 250 mg/5ml
clarithromycin tabs or 250
mg, 500 mg
clarithromycin tb24 or 500
mg
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
NF MO
MO
NF
MO
NF
NF MO
NF MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0erythromycin base tabs 250 $2.65
(Tier
mg
1)
$0erythromycin base tabs 500 $2.65
(Tier
mg
1)
$0$2.65
erythromycin
(Tier
ethylsuccinate tabs or
1)
$0$2.65
erythromycin lactobionate
(Tier
1)
$0$2.65
erythromycin stearate
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(16 ea
daily); MO
QL(8 ea daily);
MO
QL(10 ea
daily); MO
500 MG;QL(8
ea daily)
QL(16 ea
daily); MO
Fidaxomicin
NF MO
DIFICID
NF MO
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
Erythromycins
$0- MO
$6.60
(Tier
2)
MEDICAL DEVICES
Bandages-Dressings-Tape
gauze pads 2" x 2"
$0- RX/OTC; MO
$2.65
(Tier
1)
Contraceptives
CONDOMS
$0
(Tier
3)
Misc. Devices
ALCOHOL PADS
$0- RX/OTC; MO
$6.60
(Tier
2)
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
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124
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
What
the
drug
will
cost
you
(tier
level)
Parenteral Therapy Supplies
$0- MO
INSULIN SYRINGES AND $6.60
(Tier
PEN NEEDLES
2)
AEROCHAMBER PLUS
FLOW-VU
$0
(Tier
3)
AEROCHAMBER PLUS
FLOW-VU/LARGE MASK
$0
(Tier
3)
AEROCHAMBER PLUS
FLOW-VU/MASK
$0
(Tier
3)
MEDICAL DEVICES AND SUPPLIES
Contraceptives
OMNIFLEX DIAPHRAGM
ORTHO DIAPHRAGM
ALL-FLEX/65MM
ORTHO DIAPHRAGM
ALL-FLEX/70MM
ORTHO DIAPHRAGM
ALL-FLEX/75MM
ORTHO DIAPHRAGM
ALL-FLEX/80MM
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
NT
NT
NT
NT
NT
$0
AEROCHAMBER PLUS
(Tier
FLOW-VU/MEDIUM MASK 3)
Respiratory Therapy Supplies
AEROCHAMBER MINI
AEROSOLCHAMBER
AEROCHAMBER MV
AEROCHAMBER PLUS
FLOW VU
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
AEROCHAMBER PLUS
FLOW-VU/SMALL MASK
$0
(Tier
3)
AEROCHAMBER Z-STAT
PLUS VALVED HOLDING
CHAMBER W/FLOW VU
$0
(Tier
3)
AEROCHAMBER Z-STAT
PLUS/FLOWSIGNAL
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
You can find information on what the symbols and abbreviations on this table mean by going to
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125
Name of drug
AEROCHAMBER Z-STAT
PLUS/LARGE MASK
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
AEROCHAMBER Z-STAT
PLUS/MEDIUM MASK
$0
(Tier
3)
AEROCHAMBER Z-STAT
PLUS/SMALL MASK
$0
(Tier
3)
$0
AEROCHAMBER/FLOWSI (Tier
GNAL
3)
$0
AEROVENT PLUS
(Tier
HOLDING
CHAMBER/COLLAPSIBLE 3)
AIRZONE PEAK FLOW
METER
ARIAL CHAMBER
ASSESS FULL RANGE
PEAK FLOW METER
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
$0 RX/OTC; MO;
(Tier NT
3)
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
ASSESS LOW RANGE
(Tier
PEAK FLOW METER
3)
$0
ASSESS PEAK FLOW
(Tier
METER FULL RANGE
3)
$0
ASSESS PEAK FLOW
(Tier
METER LOW RANGE
3)
$0
ASTHMA CHECK METER- (Tier
ZONE SYSTEM
3)
$0
(Tier
ASTHMAMENTOR
3)
BREATHERITE
$0
(Tier
3)
BREATHERITE
COLLAPSIBLEADULT
SPACER W/MASK
$0
(Tier
3)
BREATHERITE
COLLAPSIBLECHILD
SPACER W/MASK
$0
(Tier
3)
BREATHERITE
COLLAPSIBLEINFANT
SPACER W/MASK
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
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Name of drug
What
the
drug
will
cost
you
(tier
level)
BREATHERITE
COLLAPSIBLESMALL
CHILD SPACER W/MASK
$0
(Tier
3)
BREATHERITE
COLLAPSIBLESPACER
W/ NEONATE MASK
$0
(Tier
3)
BREATHERITE RIGID
SPACERW/MASK
$0
(Tier
3)
BREATHERITE W/LARGE
MASK
$0
(Tier
3)
BREATHERITE
W/MEDIUM MASK
$0
(Tier
3)
BREATHERITE W/SMALL
MASK
$0
(Tier
3)
E-Z SPACER
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
Name of drug
What
the
drug
will
cost
you
(tier
level)
E-Z SPACER THE BODY
GUARDS PACK
$0
(Tier
3)
EASIVENT
$0
(Tier
3)
EASIVENT/MASK-LARGE
$0
(Tier
3)
EASIVENT/MASKMEDIUM
$0
(Tier
3)
EASIVENT/MASK-SMALL
$0
(Tier
3)
FLEXICHAMBER
$0
(Tier
3)
INSPIRACHAMBER/ANTISTATIC
VALVED/MOUTHPIECE
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
You can find information on what the symbols and abbreviations on this table mean by going to
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Name of drug
What
the
drug
will
cost
you
(tier
level)
INSPIRACHAMBER/SOOT $0
HERMASK/INSPIRAMASK (Tier
3)
/MEDIUM
INSPIRACHAMBER/SOOT $0
HERMASK/INSPIRAMASK (Tier
3)
/SMALL
INSPIREASE DRUG
DELIVERYSYSTEM
LITEAIRE
MICROCHAMBER
MICROLIFE DIGITAL
PEAK FLOW METER
MICROSPACER
MINI WRIGHT AFS PEAK
FLOWMETER LOW
RANGE
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
$0 RX/OTC; MO;
(Tier NT
3)
Name of drug
MINI WRIGHT PEAK
FLOW METER
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
NESSI SPACER/LARGE
MASK
$0
(Tier
3)
NESSI
SPACER/MOUTHPIECE
$0
(Tier
3)
NESSI
SPACER/SMALL/MED
MASK
$0
(Tier
3)
OPTICHAMBER
ADVANTAGE
$0
(Tier
3)
OPTICHAMBER
ADVANTAGE/LARGE
MASK
$0
(Tier
3)
OPTICHAMBER
ADVANTAGE/MEDIUM
FACE MASK
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
128
Name of drug
What
the
drug
will
cost
you
(tier
level)
OPTICHAMBER
ADVANTAGE/SMALL
FACE MASK
$0
(Tier
3)
OPTICHAMBER
DIAMOND
$0
(Tier
3)
OPTICHAMBER
DIAMOND/LARGEFACE
MASK
$0
(Tier
3)
$0
OPTICHAMBER
DIAMOND/MEDIUM FACE (Tier
3)
MASK
OPTICHAMBER
DIAMOND/SMALLFACE
MASK
$0
(Tier
3)
OPTICHAMBER FACE
MASK/LARGE
$0
(Tier
3)
OPTICHAMBER FACE
MASK/MEDIUM
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
Name of drug
What
the
drug
will
cost
you
(tier
level)
OPTICHAMBER FACE
MASK/SMALL
$0
(Tier
3)
OPTIHALER
$0
(Tier
3)
OPTIHALER MDI DRUG
DELIVERY SYSTEM
$0
(Tier
3)
PEAK AIR PEAK FLOW
METERADULT/PEDIATRI
C
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
PEAK FLOW METER
PERSONAL BEST FULL
RANGE
PERSONAL BEST LOW
RANGE
PIKO 1 ELECTRONIC
POCKET CHAMBER
POCKET PEAK FLOW
METER
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
365 days
retail,1 ea per
365 days mail);
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
$0 RX/OTC; MO;
(Tier NT
3)
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
129
Name of drug
POCKET SPACER
POCKETPEAK PEAK
FLOW METER LOW
RANGE
POCKETPEAK PEAK
FLOW
METER/UNIVERSAL
RANGE
POCKETPEAK PEAK
FLOW
METER/UNIVERSAL
RANGE 50-720 LPM
RITEFLO
TRUZONE PEAK FLOW
METER
VALVED HOLDING
CHAMBER
VORTEX VALVED
HOLDING CHAMBER
WATCHHALER
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
$0 RX/OTC; MO;
(Tier NT
3)
$0 RX/OTC; MO;
(Tier NT
3)
$0 RX/OTC; MO;
(Tier NT
3)
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
$0 RX/OTC; MO;
(Tier NT
3)
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
QL(1 ea per
$0 365 days
(Tier retail,1 ea per
3) 365 days mail);
RX/OTC; MO;
NT
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MIGRAINE PRODUCTS - Drugs to Treat Migraine
Headaches
Migraine Products
D.H.E. 45 (Use
Dihydroergotamine
Mesylate)
dihydroergotamine
mesylate soln ij 1 mg/ml
ergotamine tartrate subl sl
MO
NF
$0- MO
$2.65
(Tier
1)
$0$2.65
(Tier
1)
Serotonin Agonists
$0- QL(0.27 ml
$6.60 daily); MO
ALSUMA
(Tier
2)
AMERGE (Use Naratriptan NF QL(0.3 ea
HCl)
daily); MO
IMITREX SOLN SC 6
QL(0.27 ml
NF daily); MO
MG/0.5ML (Use
Sumatriptan Succinate)
IMITREX STATDOSE
QL(0.14 ml
NF daily); MO
REFILL 4 MG/0.5ML (Use
Sumatriptan Succinate)
IMITREX STATDOSE
QL(0.27 ml
NF daily); MO
REFILL 6 MG/0.5ML (Use
Sumatriptan Succinate)
IMITREX STATDOSE
QL(0.14 ml
SYSTEM 4 MG/0.5ML (Use NF daily); MO
Sumatriptan Succinate)
IMITREX STATDOSE
QL(0.27 ml
SYSTEM 6 MG/0.5ML (Use NF daily); MO
Sumatriptan Succinate)
IMITREX TABS OR 100
QL(0.3 ea
NF daily); MO
MG (Use Sumatriptan
Succinate)
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
Health Net Cal MediConnect 2015 Drug List
130
Name of drug
IMITREX TABS OR 25 MG
(Use Sumatriptan
Succinate)
IMITREX TABS OR 50 MG
(Use Sumatriptan
Succinate)
MAXALT 10 MG (Use
Rizatriptan Benzoate)
MAXALT 5 MG (Use
Rizatriptan Benzoate)
MAXALT-MLT 10 MG (Use
Rizatriptan Benzoate)
MAXALT-MLT 5 MG (Use
Rizatriptan Benzoate)
naratriptan hcl
rizatriptan benzoate tabs
10 mg
rizatriptan benzoate tabs 5
mg
rizatriptan benzoate tbdp
10 mg
rizatriptan benzoate tbdp 5
mg
sumatriptan succinate soaj
sc 4 mg/0.5ml
sumatriptan succinate soaj
sc 6 mg/0.5ml
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
QL(0.9 ea
NF daily); MO
Name of drug
sumatriptan succinate soct
sc 4 mg/0.5ml
QL(0.6 ea
NF daily); MO
NF QL(0.4 ea
daily); MO
NF QL(0.8 ea
daily); MO
NF QL(0.4 ea
daily); MO
NF QL(0.8 ea
daily); MO
$0- QL(0.3 ea
$2.65 daily); MO
(Tier
1)
$0- QL(0.4 ea
$2.65 daily); MO
(Tier
1)
$0- QL(0.8 ea
$2.65 daily); MO
(Tier
1)
$0- QL(0.4 ea
$2.65 daily); MO
(Tier
1)
$0- QL(0.8 ea
$2.65 daily); MO
(Tier
1)
$0- QL(0.14 ml
$2.65 daily); MO
(Tier
1)
$0- QL(0.27 ml
$2.65 daily); MO
(Tier
1)
sumatriptan succinate soct
sc 6 mg/0.5ml
sumatriptan succinate soln
sc 6 mg/0.5ml
sumatriptan succinate tabs
or 100 mg
sumatriptan succinate tabs
or 25 mg
sumatriptan succinate tabs
or 50 mg
zolmitriptan tabs 2.5 mg
zolmitriptan tabs 5 mg
zolmitriptan tbdp 2.5 mg
zolmitriptan tbdp 5 mg
ZOMIG TABS OR 2.5 MG
(Use Zolmitriptan)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
QL(0.14 ml
daily); MO
QL(0.27 ml
daily); MO
QL(0.27 ml
daily); MO
QL(0.3 ea
daily); MO
QL(0.9 ea
daily); MO
QL(0.6 ea
daily); MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
QL(4 ea daily);
MO
QL(2 ea daily);
MO
NF QL(4 ea daily);
MO
You can find information on what the symbols and abbreviations on this table mean by going to
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131
Name of drug
ZOMIG TABS OR 5 MG
(Use Zolmitriptan)
ZOMIG ZMT 2.5 MG (Use
Zolmitriptan)
ZOMIG ZMT 5 MG (Use
Zolmitriptan)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF QL(2 ea daily);
MO
NF QL(4 ea daily);
MO
NF QL(2 ea daily);
MO
MINERALS & ELECTROLYTES
calcium carbonate-vitamin
d tabs 200unit-500mg,
500mg-200unit, 500mg500mg-200unit-200unit
$0 MO; NT
(Tier
3)
calcium citrate tabs or 200
mg, 950 mg
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
CALCIUM CITRATE TABS
OR 250 MG
Calcium
$0
(Tier
3)
$0
(Tier
CALCI-MIX
3)
$0
(Tier
CALCIONATE
3)
$0
CALCIUM & MAGNESIUM (Tier
3)
$0
calcium carbonate chew or (Tier
1250 mg
3)
$0
calcium carbonate tabs or
1250 mg, 500 mg, 600 mg, (Tier
3)
600mg
$0
calcium carbonate tabs or (Tier
1500 mg
3)
$0
calcium carbonate(Tier
cholecalciferol caps
3)
600mg-500unit
$0
calcium carbonate(Tier
cholecalciferol chew
3)
500mg-100unit
calcium carbonate-vitamin
$0
d tabs 125unit-250mg,
(Tier
125unit-500mg, 250mg3)
125unit, 500mg-125unit
Name of drug
What
the
drug
will
cost
you
(tier
level)
NT
CALCI-CHEW
MO; NT
MO; NT
NT
calcium citrate-vitamin d
250mg-200unit, 315mg200unit
calcium gluconate soln iv
10 %
CALCIUM GLUCONATE
TABS OR 500 MG
CALCIUM LACTATE 648
MG
NT
calcium tabs 600 mg
MO; NT
calcium w/ magnesium
500mg-250mg
NT
CALCIUM/VITAMIN D
NT
CALCIUM/VITAMIN D3
MO; NT
NT
CITRACAL/VITAMIN D
(Use Calcium CitrateVitamin D)
CORAL CALCIUM TABS
OR 500 MG
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
MO; NT
MO; NT
NT
MO; NT
NT
NT
MO; NT
MO; NT
MO; NT
NF
$0 NT
(Tier
3)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
132
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
EQL CALCIUM/VITAMIN D (Tier
3)
$0
(Tier
MAGNEBIND 200
3)
$0
(Tier
oyster shell
3)
Necessary
actions,
restrictions, or
limits on use
Name of drug
NT
ENFAMIL ENFALYTE
NT
lactated ringer's
MO; NT
Chloride
MEDI-LYTE
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0$2.65
(Tier
1)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
NT
$0- MO
$2.65
ammonium chloride soln iv (Tier
1)
Electrolyte Mixtures
CERALYTE 70 SOLN
60MEQ/L-70MEQ/L20MEQ/L-30MEQ/L,
70MEQ/L-20MEQ/L
CERASPORT EX1 SOLN
CERASPORT SOLN
4MEQ/L-18MEQ/L20MEQ/L-69MEQ/L,
4MEQ/L-18MEQ/L20MEQ/L-6MEQ/L
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
MO; NT
$0
(Tier
3)
$0$2.65
dextrose in lactated ringers (Tier
1)
$0dextrose w/ sodium
$2.65
chloride 0.45%-2.5%,
(Tier
0.45%-5%
1)
$0- MO
$2.65
dextrose w/ sodium
(Tier
chloride 0.9%-5%
1)
$0 MO; NT
(Tier
ENFALYTE
3)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
133
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO; NT
oral electrolytes soln
16meq/473ml21meq/473ml-9meq/473ml11gm/473ml, 18.8meq/l42.4meq/l-33.2meq/l4.8gm/l-18.8gm/l,
20meq/1000ml45meq/1000ml35meq/1000ml25gm/1000ml, 20meq/l20meq/l-45meq/l-45meq/l35meq/l-25gm/l, 20meq/l20meq/l-45meq/l-45meq/l35meq/l-35meq/l-30meq/l30meq/l-25gm/l-25gm/l,
20meq/l-20meq/l-45meq/l45meq/l-35meq/l-35meq/l30meq/l-30meq/l-5gm/l20gm/l, 20meq/l-45meq/l35meq/l-25gm/l, 20meq/l45meq/l-35meq/l-30meq/l25gm/l, 20meq/l-45meq/l$0
35meq/l-30meq/l-5gm/l(Tier
20gm/l, 20meq/l-45meq/l3)
35meq/l-30meq/l-5gm/l25gm/l, 20meq/l-45meq/l35meq/l-5gm/l-20gm/l,
20meq/l-45meq/l-35meq/l7.8mg/l-25gm, 20meq/l45meq/l-35meq/l-7.8mg/l25gm/l, 20meq/l-45meq/l35meq/l-7.8mg/l-25meq/l,
20meq/l-45meq/l-45meq/l35meq/l-5gm/l-20gm/l,
35meq/l-45meq/l-20meq/l20gm/l, 35meq/l-45meq/l20meq/l-25gm/l, 35meq/l45meq/l-20meq/l-30meq/l25gm/l, 35meq/l-45meq/l20meq/l-30meq/l-30gm/l,
35meq/l-45meq/l-20meq/l30meq/l-5gm/l-20gm/l,
35meq/l-45meq/l-20meq/l5gm/l-20gm/l, 35meq/l45meq/l-20meq/l-7.5mg/l25meq/l, 35meq/l-45meq/l-
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
20meq/l-7.8mg/l-25
oral electrolytes tabs
287mg-180mg-15mg
parenteral electrolytes
PEDIALYTE FREEZER
POPS (Use Oral
Electrolytes)
PEDIALYTE SOLN
20MEQ/L-45MEQ/L35MEQ/L-30MEQ/L25GM/L, 20MEQ/L45MEQ/L-35MEQ/L5GM/L-20GM/L (Use Oral
Electrolytes)
$0 NT
(Tier
3)
$0- B/D
$2.65
(Tier
1)
MO; NT
NF
MO; NT
NF
$0potassium chloride in
$2.65
dextrose & sodium chloride (Tier
0.45%-20meq/l-5%
1)
$0
(Tier
THERMOTABS
3)
Fluoride
$0
(Tier
FLORICAL CAPS
3)
$0
(Tier
MONOCAL
3)
Iodine Products
$0
(Tier
IODINE STRONG
3)
$0
POTASSIUM IODIDE
(Tier
TABS OR
3)
NT
MO; NT
MO; NT
MO; NT
NT
Magnesium
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
134
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
(Tier
MAG-TAB SR
3)
$0
(Tier
MAGINEX
3)
$0
(Tier
MAGINEX DS
3)
$0
MAGNESIUM CHLORIDE (Tier
HEXAHYDRATE
3)
$0
magnesium chloride tbcr or (Tier
535 mg, 64 mg
3)
$0
MAGNESIUM
(Tier
ELEMENTAL TABS 30 MG 3)
$0
MAGNESIUM
(Tier
GLUCONATE TABS OR
3)
250 MG, 500 MG, 550 MG
$0magnesium sulfate soln ij $2.65
(Tier
50 %
1)
$0
magnesium tabs 250 mg,
(Tier
250mg
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
NT
NT
NT
MO; NT
NT
NT
MO
NT
Potassium
K-TAB 10 MEQ (Use
Potassium Chloride)
K-TAB 8 MEQ
MICRO-K (Use Potassium
Chloride)
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
Sodium
Phosphate
PHOS-NAK POWDER
CONCENTRATE
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0potassium chloride cpcr or $2.65
(Tier
10 meq, 8 meq
1)
$0POTASSIUM CHLORIDE $2.65
(Tier
ER
1)
$0potassium chloride
$2.65
microencapsulated crystals (Tier
cr
1)
$0potassium chloride soln iv 2 $2.65
(Tier
meq/ml
1)
$0potassium chloride soln or $2.65
(Tier
10 %
1)
$0potassium chloride soln or $2.65
(Tier
20 %
1)
$0potassium chloride tbcr or $2.65
(Tier
10 meq, 8 meq
1)
$0 MO; NT
(Tier
3)
NF MO
$0- MO
$6.60
(Tier
2)
NF MO
$0$2.65
(Tier
1)
$0- MO
sodium chloride soln iv 0.9 $2.65
(Tier
%
1)
sodium chloride soln iv
0.45 %
Trace Minerals
chromium 200 mcg
$0 NT
(Tier
3)
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Health Net Cal MediConnect 2015 Drug List
135
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
chromium picolinate caps
(Tier
or 200 mcg
3)
$0
chromium picolinate tabs or (Tier
200 mcg
3)
$0
(Tier
MULTITRACE-4
3)
$0
SELENIUM SOLN IV 40
(Tier
MCG/ML
3)
$0
selenium tabs or 100 mcg (Tier
3)
$0
(Tier
selenium tabs or 50 mcg
3)
$0
trace minerals (cr-cu-mn(Tier
zn)
3)
Necessary
actions,
restrictions, or
limits on use
NT
zinc tabs or 50 mg
MO; NT
MO; NT
MO; NT
NT
MO; NT
NT
Zinc
$0
(Tier
3)
$0
(Tier
ZINC 15
3)
$0
zinc gluconate lozg mt 10
(Tier
mg
3)
$0
zinc gluconate tabs or 50
(Tier
mg
3)
$0
ZINC SULFATE SOLN IV 1 (Tier
MG/ML, 5 MG/ML
3)
$0
(Tier
zinc tabs or 25 mg
3)
Name of drug
MO; NT
ORAZINC
NT
NT
MO; NT
MO; NT
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MOUTH/THROAT/DENTAL AGENTS
Anesthetics Topical Oral
BABY ANBESOL (Use
Benzocaine (Dental))
BABY ORAJEL GEL (Use
Benzocaine (Dental))
NF NT
NF NT
$0
(Tier
3)
$0
benzocaine (dental) gel 7.5 (Tier
%
3)
$0
benzocaine (dental) pste
(Tier
20 %
3)
$0
benzocaine (dental) soln 20 (Tier
%
3)
HURRICAINE ONE (Use
NF
Benzocaine (Dental))
HURRICAINE SOLN (Use
NF
Benzocaine (Dental))
$0lidocaine hcl (mouth-throat) $2.65
(Tier
2%
1)
ORABASE (Use
NF
Benzocaine (Dental))
$0
(Tier
ZILACTIN
3)
NT
BABY ORAJEL LIQD
NT
MO; NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
MO
MO; NT
MO; NT
Anti-infectives - Throat
NT
$0 MO; NT
carbamide peroxide soln mt (Tier
3)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
136
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
clotrimazole lozg mt
(Tier
1)
$0$2.65
clotrimazole troc mt
(Tier
1)
$0
hydrogen peroxide (mouth- (Tier
throat)
3)
$0
hydrogen peroxide-benzyl (Tier
alcohol
3)
$0$2.65
nystatin (mouth-throat)
(Tier
1)
PEROXYL SOLN EX 1.5%NF
6% (Use Hydrogen
Peroxide-Benzyl Alcohol)
$0
(Tier
ULCEREASE
3)
Necessary
actions,
restrictions, or
limits on use
MO
AQUORAL
MO
cevimeline hcl
NT
EVOXAC (Use Cevimeline
HCl)
MO; NT
pilocarpine hcl (oral)
MO
SALAGEN (Use
Pilocarpine HCl (Oral))
PERIDEX (Use
Chlorhexidine Gluconate
(Mouth-Throat))
phenol (antiseptic) aers
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO
NF MO
$0- MO
$2.65
(Tier
1)
NF MO
MULTIVITAMINS
MO; NT
MO; NT
Antiseptics - Mouth/Throat
chlorhexidine gluconate
(mouth-throat)
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
MO
NF
$0 NT
(Tier
3)
B-Complex Vitamins
b-complex vitamins caps or
MO; NT
3.33mg-0.4mg-0.33mg0.66mcg-0.11mg, 60mg$0
60mg-3mg-5mg-20mg(Tier
3mg-1mcg-0.5mg, 60mg3)
60mg-5mg-20mg-3mg1mcg-3mg-0.5mg, 70mg100mg-1mg-10mg-2mg1.5mg-100mcg
b-complex vitamins inj ij
MO; NT
2mg/ml-100mg/ml-2mg/ml- $0
100mg/ml-2mg/ml, 2mg/ml- (Tier
3)
2%-100mg/ml-2mg/ml100mg/ml-2mg/ml
$0 MO; NT
b-complex vitamins soln ij
(Tier
2mg/ml-2%-100mg/ml3)
2mg/ml-100mg/ml-2mg/ml
Steroids - Mouth/Throat
triamcinolone acetonide
(mouth)
$0- MO
$2.65
(Tier
1)
Throat Products - Misc.
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Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
b-complex vitamins tabs or
MO; NT
0.1mg-20mg-2mg-5mcg3mg-1mg, 100mg-50mg40mg-10mg-20mg-5mg4.6mg-1mcg-5mg-1mg,
10mg-10mg-2mg-1.5mg0.2mg, 10mg-14mg25mcg-7mg-4.5mg, 15mg2mg-5mg-2mcg-2mg-2mg,
$0
30mg-50mg-50mg-50mg(Tier
50mg-50mg-50mcg-50mg3)
100mcg-50mcg-50mg,
3mg-10mg-20mg-3mg6mcg-2mg, 3mg-20mg3mg-10mg-6mcg-2mg,
3mg-3mg-20mg-20mg3mg-3mg-10mg-10mg6mcg-6mcg-2mg-2mg,
83mg-3mg-20mg-2mg5mcg-1mg
B-Complex w/ C
b complex w/ c caps
NT
10.2mg-10mg-15mg-50mg$0
5mg-300mg, 10mg-50mg10.2mg-15mg-5mg-300mg, (Tier
3)
10mg-50mg-10mg-15mg5mg-300mg, 15mg-10mg50mg-10mg-5mg-300mg
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
b complex w/ c tabs
NT
10.2mg-10.2mg-10mg10mg-50mg-50mg-15mg15mg-5mg-5mg-300mg300mg, 100mg-100mg25mg-20mg-6mg-15mcg100mg-5mcg-2mg-150mg,
100mg-100mg-5.5mg20mg-15mcg-25mg400mcg-5mcg-2mg-150mg,
100mg-10mg-20mg10mcg-15mg-5mg-500mg,
100mg-20mg-5.5mg15mcg-2mg-25mg-150mg400mcg-5mcg-150mg,
$0
10mg-10mg-15mg-50mg(Tier
5mg-300mg, 15mg3)
10.2mg-10mg-50mg-5mg300mg, 15mg-10mg-50mg10.2mg-5mg-300mg,
15mg-10mg-50mg-10.2mg6mcg-400mcg-5mg-300mg,
15mg-150mg-10mg-50mg10.2mg-5mg-300mg,
15mg-20mg-50mg-10mg10mcg-5mg-300mg, 15mg50mg-10.2mg-10mg-5mg300mg, 50mg-10.2mg10mg-15mg-5mg-300mg,
50mg-10mg-10mg-15mg5mg-300mg, 50mg-15mg10mg-10.2mg-5mg-300mg
B-Complex w/ Folic Acid
$0 MO; NT
(Tier
B-100 COMPLEX
3)
b-complex w/ c & folic acid
MO; NT
tabs 10mg-20mg-1.5mg$0
1mg-1.5mg-5mg-300mcg- (Tier
50mg-60mg, 20mg-1.5mg3)
10mg-1mg-1.5mg-5mg300mcg-50mg-60mg
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
138
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
b-complex w/ folic acid tabs
MO; NT
1.5mg-20mg-1.7mg-6mcg400mcg-2mg, 1.7mg10mg-6mcg-1.2mg-20mg0.4mg-2mg, 100mg100mg-100mg-100mcg400mcg-100mg, 100mg100mg-100mg-100mg10mcg-400mcg-100mcg100mg, 10mg-10mg-50mg$0
10mg-10mg-10mg-10mcg(Tier
10mg-400mcg-10mcg3)
10mg, 10mg-20mg-1.7mg6mcg-1.5mg-400mcg-2mg,
15mg-100mg-200mg17mg-60mcg-400mcg20mg, 30mg-20mg-50mg30mg-10mg-10mcg400mcg-8mg, 40mcg-1mg6mg-5mcg-3mg-2mcg19mcg, 50mg-50mg-50mg50mcg-50mg-400mcg50mcg-50mg
b-complex w/ folic acid tbcr
NT
100mg-100mg-100mg100mg-100mcg-400mcg100mcg-100mg, 125mg125mg-125mg-125mg$0
125mcg-125mg-125mg(Tier
400mcg-125mcg-125mg,
3)
50mg-50mg-50mg-50mg50mcg-0.4mg-50mcg50mg, 50mg-50mg-50mg50mg-50mcg-100mcg50mcg-50mg
$0 NT
(Tier
NERVO B-12 SL
3)
Ped MV w/ Fluoride
$0 MO; NT
pediatric vitamins acd w/
(Tier
fluoride
3)
Name of drug
MULTI-DELYN/IRON
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
NT
pediatric multiple vitamins
MO; NT
w/ iron soln 0.6mg/ml10mg/ml-5unit/ml-8mg/ml1500unit/ml-400unit/ml$0
0.5mg/ml-0.4mg/ml(Tier
35mg/ml, 1500unit/ml3)
10mg/ml-5unit/ml400unit/ml-8mg/ml0.6mg/ml-0.5mg/ml0.4mg/ml-35mg/ml
Ped Multi Vitamins w/Fl & FE
$0 MO; NT
ped multivitamins w/fl &
(Tier
iron
3)
TRI-VIT/FLUORIDE/IRON
$0 MO; NT
(Tier
3)
Pediatric Multiple Vitamins
$0 NT
(Tier
3)
$0 MO; NT
pediatric multiple vitamin w/ (Tier
c
3)
$0 NT
pediatric multiple vitamin w/ (Tier
extra c & fa
3)
EQL CHILDRENS
MULTIVITAMINS
Pediatric Vitamins
pediatric vitamins adc
$0 MO; NT
(Tier
3)
Prenatal Vitamins
ONE A DAY WOMENS
PRENATAL/DHA
$0 NT
(Tier
3)
Ped MV w/ Iron
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Health Net Cal MediConnect 2015 Drug List
139
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
PRENATAL FORMULA
NT
CAPS 35MG-30UNIT$0
4000UNIT-200MG-25MG(Tier
1.8MG-200MG-28MG3)
20MG-1.7MG-8MCG400UNIT-800MCG-2.6MG120MG
Specialty Vitamins Products
ULTRA MAN
ULTRA WOMAN
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
Vitamin Mixtures
cod liver oil caps 10 minim,
110mg-2664unit-1000mg100mg-200unit, 1250unit130unit, 1250unit133.33unit, 1250unit133unit, 1250unit-135unit,
200unit-4000unit, 20mg$0
35mg-1250unit-45mg(Tier
133.333unit, 34mg3)
1250unit-415mg-32mg135unit, 50mg-110mg250unit-110mg-100unit10unit, 52mg-2500unit600mg-52mg-270unit,
530mg-1250unit-130unit,
90mg-37mg-415mg-36mg1250unit-135unit
$0
COD LIVER OIL FOR KIDS (Tier
3)
COD LIVER OIL OIL
$0
4000UNIT/5ML(Tier
400UNIT/5ML,
3)
5000UNIT/5ML500UNIT/5ML
$0
(Tier
CVS COD LIVER OIL
3)
NT
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
NORWEGIAN COD LIVER (Tier
OIL
3)
$0
(Tier
QC COD LIVER OIL
3)
$0
(Tier
RA COD LIVER OIL
3)
vitamins a & d caps
10000unit-400unit,
$0
10000unit-5000unit,
1250unit-133unit, 1250unit- (Tier
3)
135unit, 5000unit-400unit,
700unit-400unit, 8000unit400unit
Necessary
actions,
restrictions, or
limits on use
RX/OTC; NT
RX/OTC; NT
RX/OTC; NT
MO; NT
Vitamins w/ Lipotropics
RX/OTC; NT
RX/OTC; NT
RX/OTC; NT
You can find information on what the symbols and abbreviations on this table mean by going to
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140
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
MO; NT
vitamins w/ lipotropics tabs
10000unit-10mg-18mg100unit-225mcg-10mg150mg-100mg-30mg10mg-25mg-25mg-50mg50mg-10mg-50mg-50mg200mcg-400unit-50mg400mcg-50mg-250mg,
100mg-100mg-100mg100mcg-100mg-100mcg100mcg-100mg, 100mg100mg-100mg-100mg100mg-100mg-100mcg100mg-100mcg-100mcg100mg, 100mg-100mg100mg-100mg-100mg100mg-100mg-100mcg100mcg-100mcg-100mg,
100mg-100mg-100mg100mg-100mg-100mg100mg-100mcg-100mg200mcg-100mcg-100mg,
$0
100mg-111.3mg-0.33mg(Tier
1.7mg-1.7mcg-0.33mg3)
111.3mg-3.3mg-0.33mg100mg, 100mg-12.5mg100mg-100mg-12.5mg12.5mg-100mg-100mcg100mcg-100mcg-100mg,
100mg-43.33mg-111.3mg0.33mg-1.7mg-1.7mcg0.33mg-111.3mg-3.3mg0.33mg-100mg, 200mg29mg-0.333mg-1.666mg3.33mg-111.333mg111.333mg-1mg1.666mcg-0.333mg100mg, 200mg-29mg0.33mg-1.67mg-3.33mg111.33mg-111.33mg-1mg1.67mcg-0.33mg-100mg,
200mg-29mg-0.34mg1.67mg-3.34mg-111mg111mg-1mg-1.67mcg0.34mg-100mg, 20mg50mg-30mg-10mg-10mcg-
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
30mg-8mg, 25mg-40mg20mg-3.4mg-20mg-12mcg3mg-20mg-400mcg30mcg-4mg-150mg, 25mg40mg-20mg-3.4mg-20mg12mcg-3mg-20mg-400mg30mcg-4mg, 266.
MUSCULOSKELETAL THERAPY AGENTS Drugs to Treat Spasms
Central Muscle Relaxants
$0- QL(8 ea daily);
$2.65 MO
baclofen tabs or 10 mg
(Tier
1)
$0- QL(4 ea daily);
$2.65 MO
baclofen tabs or 20 mg
(Tier
1)
$0- AL; MO
$2.65
carisoprodol tabs or 350
(Tier
mg
1)
$0- AL; MO
$2.65
chlorzoxazone
(Tier
1)
$0- AL; MO
cyclobenzaprine hcl tabs or $2.65
(Tier
10 mg, 5 mg
1)
$0- AL; MO
$2.65
metaxalone
(Tier
1)
$0- AL; MO
methocarbamol tabs or 500 $2.65
(Tier
mg, 750 mg
1)
PARAFON FORTE DSC
NF AL; MO
(Use Chlorzoxazone)
ROBAXIN TABS OR 500
NF AL; MO
MG (Use Methocarbamol)
You can find information on what the symbols and abbreviations on this table mean by going to
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141
Name of drug
ROBAXIN-750 (Use
Methocarbamol)
SKELAXIN (Use
Metaxalone)
SOMA 350 MG (Use
Carisoprodol)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF AL; MO
ENTSOL NASAL SPRAY
NF AL; MO
NF AL; MO
$0- MO
tizanidine hcl caps or 2 mg, $2.65
(Tier
4 mg, 6 mg
1)
$0- MO
tizanidine hcl tabs or 2 mg, $2.65
(Tier
4 mg
1)
ZANAFLEX (Use
NF MO
Tizanidine HCl)
Direct Muscle Relaxants
DANTRIUM (Use
Dantrolene Sodium)
Name of drug
NF MO
$0- MO
dantrolene sodium caps or $2.65
(Tier
100 mg, 25 mg, 50 mg
1)
NASAL AGENTS - SYSTEMIC AND TOPICAL Drugs to treat the Nose or Sinus
Nasal Agents - Misc.
$0 MO; NT
AFRIN PURESEA
(Tier
GENTLE MISTNASAL
3)
RINSE
$0 MO; NT
AFRIN PURESEA
MEDIUM STREAM NASAL (Tier
3)
RINSE
AFRIN PURESEA ULTRA- $0 MO; NT
(Tier
GENTLE MIST NASAL
3)
RINSE
$0 NT
(Tier
AYR NASAL DROPS
3)
$0 NT
ENTSOL HYPERTONIC
(Tier
NASAL IRRIGATION MIST 3)
ENTSOL NASAL WASH
GELONASAL
OCEAN NASAL SPRAY
(Use Saline)
PONARIS
saline gel na
saline soln na 0.65 %,
0.65%, 0.65%-0.002%
SALTAIRE
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
NT
NT
MO; NT
NF MO; NT
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
MO; NT
MO; NT
MO; NT
NT
Nasal Antiallergy
azelastine hcl 0.1 %
olopatadine hcl (nasal)
PATANASE (Use
Olopatadine HCl (Nasal))
Nasal Anticholinergics
ATROVENT (Use
Ipratropium Bromide
(Nasal))
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$6.60
(Tier
2)
MO
NF
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
142
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
ipratropium bromide (nasal) (Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
FLONASE (Use
Fluticasone Propionate
(Nasal))
flunisolide (nasal)
fluticasone propionate
(nasal)
RHINOCORT AQUA (Use
Budesonide (Nasal))
triamcinolone acetonide
(nasal)
$0- MO
$2.65
(Tier
1)
RX/OTC; MO
NF
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
Sympathomimetic Decongestants
$0
(Tier
BENZEDREX INHALER
3)
$0
ELIXSURE CONGESTION (Tier
3)
$0
NASAL DECONGESTANT (Tier
LIQD
3)
$0
NASAL DECONGESTANT (Tier
SYRP
3)
NEO-SYNEPHRINE 0.25
% (Use Phenylephrine HCl)
Necessary
actions,
restrictions, or
limits on use
NF MO; NT
$0 MO; NT
(Tier
3)
NEO-SYNEPHRINE COLD
MO; NT
NF
& SINUS MILD (Use
Phenylephrine HCl)
$0
NEO-SYNEPHRINE COLD (Tier MO; NT
& SINUS REGULAR
3)
NEO-SYNEPHRINE 0.5 %
Nasal Steroids
budesonide (nasal)
Name of drug
What
the
drug
will
cost
you
(tier
level)
MO
RX/OTC; MO
MO
RX/OTC; MO
NT
NT
MO; NT
$0 MO; NT
(Tier
3)
$0 MO; NT
pseudoephedrine hcl liqd or (Tier
15 mg/5ml
3)
$0 MO; NT
pseudoephedrine hcl tabs (Tier
or 30 mg, 60 mg
3)
SUDAFED (Use
NF MO; NT
Pseudoephedrine HCl)
SUDAFED CHILDRENS
MO; NT
NF
(Use Pseudoephedrine
HCl)
SUDAFED CONGESTION
MO; NT
NF
(Use Pseudoephedrine
HCl)
SUDAFED NASAL
MO; NT
DECONGESTANT
NF
MAXIMUM STRENGTH
(Use Pseudoephedrine
HCl)
$0 NT
SUDAFED PE
(Tier
CHILDRENS NASAL
3)
DECONGESTANT
phenylephrine hcl soln na
0.25 %
NEUROMUSCULAR AGENTS - Drugs to
Relax/Paralyze Muscles
NT
ALS Agents
RILUTEK (Use Riluzole)
NF MO
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143
Name of drug
riluzole
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
MCT OIL
Neuromuscular Blocking Agent - Neurotoxins
$0- PA
$6.60
BOTOX 200 UNIT
(Tier
2)
$0- PA
$6.60
XEOMIN
(Tier
2)
MICROLIPID
NUTRIENTS
LECITHIN
CONCENTRATE
Carbohydrates
dextrose soln iv 10 %
dextrose soln iv 5 %
GLUCOSE NURSETTE
(Use Glucose)
glucose soln 5 %
POLYCOSE
$0- B/D
$2.65
(Tier
1)
$0- MO; B/D
$2.65
(Tier
1)
NF NT
$0 NT
(Tier
3)
$0 NT
(Tier
3)
Lipids
fat emulsion 20 gm/100ml
LIPOSYN III
1.2GM/100ML10GM/100ML2.5GM/100ML
$0- B/D
$2.65
(Tier
1)
$0- B/D
$6.60
(Tier
2)
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
NT
MO; NT
Lipotropics
INOSITOL TABS OR 500
MG
lecithin caps or
$0 MO; NT
(Tier
3)
$0 MO; NT
(Tier
3)
$0 NT
(Tier
3)
Misc. Nutritional Substances
docosahexaenoic acid 200
mg
$0 MO; NT
(Tier
3)
NF MO; NT
EXPECTA LIPIL (Use
Docosahexaenoic Acid)
omega-3 fatty acids caps
NT
$0
180mg-120mg, 300mg,
(Tier
300mg-160mg-1000mg3)
100mg-5unit, 300mg772.5mg-90mg-180mg
omega-3 fatty acids caps
MO; NT
180mg-500mg-120mg,
27mg-244mg-500mg$0
89mg, 300mg-1000mg200mg, 300mg-200mg, 500 (Tier
3)
mg, 500mg, 500mg270mg-135mg, 500mg320mg-130mg, 90mg500mg-60mg
Proteins
ADD-INS COMPLETE
$0 NT
(Tier
3)
You can find information on what the symbols and abbreviations on this table mean by going to
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Health Net Cal MediConnect 2015 Drug List
144
Name of drug
amino acid infusion 15%
amino acids caps 130mg10mg-130mg-130mg
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
B/D
NT
amino acids tabs 100mgMO; NT
6.15mg-2.1mg-0.85mg1.95mg-0.55mg-2.3mg1.95mg-0.75mg-1.15mg0.6mg-3.65mg-0.65mg3.25mg-3.8mg-1.95mg1.7mg-0.7mg-1.05mg,
115.333mg-54.667mg21mg-33.333mg33.333mg-46.667mg14.167mg-46.667mg40mg-53.333mg18.167mg-41mg66.667mg-40mg30.667mg-17.333mg14mg, 115.3mg-54.7mg21mg-33.3mg-13.3mg33.3mg-63.3mg-14.2mg$0
46.7mg-40mg-53.3mg(Tier
18.2mg-41mg-66.7mg3)
40mg-30.7mg-17.3mg14mg, 1200mg-100mg,
18.33mg-200mg-33.33mg50mg-23.16mg-58.33mg18.33mg-75mg-108.33mg,
200mg-33.33mg-50mg23.16mg-18.33mg58.33mg-18.33mg-75mg108.33mg, 35mg-29.5mg24.667mg-4.833mg17.667mg-24.667mg12.5mg-24mg-19mg-36mg17.5mg-4.667mg-75mg15mg, 74mg-50mg-0.7mg77mg-1.4mg-72mg-64mg27mg-54mg-70mg-41mg17mg-109mg-7mg-27mg68mg-47mg-41mg-64mg
Name of drug
amino acids-protein
hydrolysate
AMINOSYN II 15% (Use
amino acid infusion)
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
NF B/D
$0
(Tier
3)
$0
(Tier
ARGIMENT AT
3)
$0
(Tier
arginine tabs 500 mg
3)
$0
COMPLEX MSUD AMINO (Tier
ACID BAR
3)
$0
(Tier
GLUTAMENT
3)
$0
(Tier
HEPAMENT
3)
$0
L-CARNITINE TABS OR
(Tier
250 MG
3)
$0
L-CITRULLINE CAPS OR (Tier
3)
$0
levocarnitine caps or 250
(Tier
mg
3)
$0
PHENYLADE AMINO ACID (Tier
3)
$0
PHENYLADE AMINO ACID (Tier
BLEND
3)
$0
PHENYLADE MTE AMINO (Tier
ACIDBLEND
3)
NT
ARGIMENT
NT
NT
MO; NT
NT
NT
NT
NT
MO; NT
MO; NT
NT
NT
You can find information on what the symbols and abbreviations on this table mean by going to
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145
Name of drug
PHENYLADE PHEBLOC
TABS
PHENYLADE40 DRINK
MIX
PHLEXY-10 CAPS
PROTEINEX
SOLVIL
SUPER-AMINO 1600
SYMPT-X G.I.
TRIAMINO
tyrosine tabs 500 mg
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
NT
NT
MO; NT
NT
MO; NT
NT
MO; NT
NT
Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
XPHE MAXAMUM PACK
NT
153MG-280MG-41MCG1114UNIT-29MCG13MCG-0.9MG-410MCG4.5MG-569MG-7.4MG9.2UNIT-18.5MCG65.5MCG-592MG-280MG350MG-2.9MG-40MG215MG-0.49MG-2.5MG1.6MCG-166UNIT-0.46MG- $0
246MCG-12.3MCG-0.8MG- (Tier
31MG, 153MG-280MG3)
41MCG-29MCG-13MCG0.9MG-410MCG-4.5MG569MG-7.4MG-9.2UNIT18.5MCG-65.5MCG592MG-280MG-350MG1114UNIT-2.9MG-40MG215MG-0.49MG-2.5MG1.6MCG-166UNIT-0.46MG246MCG-12.3MCG-0.8MG31MG
OPHTHALMIC AGENTS - Drugs to Treat the Eye
Artificial Tears and Lubricants
GENTEAL MILD TO
NF
MODERATE (Use
Hypromellose (Ophth))
$0
hypromellose (ophth) 0.3
(Tier
%, 3 mg/ml
3)
$0
(Tier
ISOPTO TEARS
3)
$0
(Tier
NUTRATEAR
3)
$0
(Tier
polyvinyl alcohol soln op
3)
$0
TEARS AGAIN NIGHT &
(Tier
DAY
3)
MO; NT
MO; NT
MO; NT
NT
MO; NT
NT
You can find information on what the symbols and abbreviations on this table mean by going to
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Name of drug
TGT LUBRICANT EYE
DROPS
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
Beta-blockers - Ophthalmic
BETAGAN (Use
NF
Levobunolol HCl)
$0$2.65
betaxolol hcl (ophth)
(Tier
1)
$0$2.65
carteolol hcl (ophth)
(Tier
1)
COSOPT (Use
NF
Dorzolamide HCl-Timolol
Maleate)
$0$2.65
dorzolamide hcl-timolol
(Tier
maleate
1)
$0$2.65
levobunolol hcl 0.5 %
(Tier
1)
$0$2.65
timolol maleate (ophth)
(Tier
1)
TIMOPTIC (Use Timolol
NF
Maleate (Ophth))
TIMOPTIC-XE (Use
NF
Timolol Maleate (Ophth))
Necessary
actions,
restrictions, or
limits on use
NT
MO
MO
MO
MO
MO
MO
MO
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$6.60
ISOPTO CARPINE (Use
(Tier
Pilocarpine HCl)
2)
$0$6.60
PHOSPHOLINE IODIDE
(Tier
2)
$0pilocarpine hcl soln op 1 %, $2.65
(Tier
2 %, 4 %
1)
Ophthalmic Adrenergic Agents
$0$6.60
ALPHAGAN P 0.1 %
(Tier
2)
ALPHAGAN P 0.15 % (Use NF
Brimonidine Tartrate)
$0$2.65
apraclonidine hcl
(Tier
1)
$0$2.65
brimonidine tartrate
(Tier
1)
IOPIDINE 0.5 % (Use
NF
Apraclonidine HCl)
MO
Ophthalmic Anti-infectives
MO
bacitracin-polymyxin b
(ophth)
Cycloplegic Mydriatics
cyclopentolate hcl soln op
1%
$0- MO
$2.65
(Tier
1)
Miotics
BLEPH-10 (Use
Sulfacetamide Sodium
(Ophth))
CILOXAN SOLN (Use
Ciprofloxacin HCl (Ophth))
Necessary
actions,
restrictions, or
limits on use
MO
MO
MO
MO
MO
MO
MO
$0- MO
$2.65
(Tier
1)
MO
NF
NF MO
You can find information on what the symbols and abbreviations on this table mean by going to
page viii.
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147
Name of drug
ciprofloxacin hcl (ophth)
erythromycin (ophth)
gatifloxacin (ophth)
gentamicin sulfate (ophth)
levofloxacin (ophth)
neomycin-bacitracin znpolymyxin
neomycin-polymyxingramicidin
OCUFLOX (Use Ofloxacin
(Ophth))
ofloxacin (ophth)
polymyxin b-trimethoprim
POLYTRIM (Use
Polymyxin B-Trimethoprim)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
sulfacetamide sodium
(ophth)
MO
tobramycin (ophth)
MO
TOBREX SOLN (Use
Tobramycin (Ophth))
MO
trifluridine soln op
MO
VIGAMOX
MO
VIROPTIC (Use
Trifluridine)
ZYMAXID (Use
Gatifloxacin (Ophth))
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
$6.60
(Tier
2)
NF MO
NF MO
Ophthalmic Decongestants
MO
NF MO
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
NF MO
naphazoline w/
pheniramine 0.025%-0.3%
NAPHCON-A (Use
Naphazoline w/
Pheniramine)
VISINE-LR
$0 MO; NT
(Tier
3)
MO; NT
NF
$0 NT
(Tier
3)
Ophthalmic Immunomodulators
$0- MO
$6.60
RESTASIS
(Tier
2)
Ophthalmic Local Anesthetics
You can find information on what the symbols and abbreviations on this table mean by going to
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Name of drug
proparacaine hcl soln op
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
sulfacetamide sodprednisolone
Ophthalmic Steroids
bacitracin-poly-neomycinhc
dexamethasone sodium
phosphate (ophth)
fluorometholone (ophth)
FML LIQUIFILM (Use
Fluorometholone (Ophth))
LOTEMAX OINT
MAXITROL (Use
Neomycin-PolymyDexameth)
neomycin-polymydexameth
OMNIPRED (Use
Prednisolone Acetate
(Ophth))
PRED FORTE (Use
Prednisolone Acetate
(Ophth))
prednisolone acetate
(ophth)
Name of drug
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
NF MO
$0- MO
$6.60
(Tier
2)
MO
NF
$0- MO
$2.65
(Tier
1)
MO
NF
TOBRADEX SUSP (Use
TobramycinDexamethasone)
tobramycindexamethasone
Ophthalmics - Misc.
ACULAR (Use Ketorolac
Tromethamine (Ophth))
ACULAR LS (Use
Ketorolac Tromethamine
(Ophth))
azelastine hcl (ophth)
AZOPT
bromfenac sodium (ophth)
cromolyn sodium (ophth)
MO
NF
$0- MO
$2.65
(Tier
1)
CYSTARAN
diclofenac sodium (ophth)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
MO
NF
$0- MO
$2.65
(Tier
1)
NF MO
MO
NF
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
MO
MO
Once daily
dosing;MO
MO
Limited to 60
ml per 28
days;QL(2.15
ml daily); LA
MO
You can find information on what the symbols and abbreviations on this table mean by going to
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149
Name of drug
dorzolamide hcl
ELESTAT (Use Epinastine
HCl (Ophth))
ENUCLENE
epinastine hcl (ophth)
EYE STREAM
flurbiprofen sodium
ILEVRO
ketorolac tromethamine
(ophth)
ketotifen fumarate (ophth)
MURO 128 OINT 5 % (Use
Sodium Chloride
Hypertonic)
MURO 128 SOLN 2 %
MURO 128 SOLN 5 %
(Use Sodium Chloride
Hypertonic)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
NEVANAC
NF MO
$0
(Tier
3)
$0$2.65
(Tier
1)
$0
(Tier
3)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0
(Tier
3)
Name of drug
MO; NT
MO
MO; NT
MO
MO
OCUFEN (Use Flurbiprofen
Sodium)
OPTIVAR (Use Azelastine
HCl (Ophth))
Necessary
actions,
restrictions, or
limits on use
MO
NF MO
NF MO
$0- MO
$6.60
PATADAY
(Tier
2)
$0 MO; NT
sodium chloride hypertonic (Tier
3)
TRUSOPT (Use
NF MO
Dorzolamide HCl)
ZADITOR (Use Ketotifen
NF MO; NT
Fumarate (Ophth))
Prostaglandins - Ophthalmic
BIMATOPROST
MO
latanoprost
MO; NT
LUMIGAN
MO; NT
NF
$0 MO; NT
(Tier
3)
MO; NT
NF
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
TRAVATAN Z
XALATAN (Use
Latanoprost)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
MO
MO
MO
MO
NF MO
OTIC AGENTS - Drugs to Treat the Ear
Otic Agents - Miscellaneous
You can find information on what the symbols and abbreviations on this table mean by going to
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150
Name of drug
acetic acid (otic)
acetic acid-aluminum
acetate
carbamide peroxide (otic)
DEBROX (Use Carbamide
Peroxide (Otic))
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
MO
hydrocortisone w/acetic
acid
MO
MO; NT
NF MO; NT
$0- MO
$2.65
(Tier
1)
Otic Combinations
$0 NT
(Tier
3)
$0- MO
$6.60
CIPRODEX
(Tier
2)
CORTISPORIN SOLN OT
MO
10000UNIT/ML-3.5MG/ML- NF
1% (Use NeomycinPolymyxin-HC (Otic))
$0- MO
$2.65
neomycin-polymyxin-hc
(Tier
(otic)
1)
boric acid in isopropyl
Otic Steroids
DERMOTIC (Use
Fluocinolone Acetonide
(Otic))
fluocinolone acetonide
(otic)
VOSOL HC (Use
Hydrocortisone w/Acetic
Acid)
Necessary
actions,
restrictions, or
limits on use
MO
MO
NF
OXYTOCICS - Drugs to Prevent/Control Uterine
Bleeding
Oxytocics
Otic Anti-infectives
ofloxacin (otic)
Name of drug
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
MO
NF
$0- MO
$2.65
(Tier
1)
$0- MO
methylergonovine maleate $2.65
(Tier
tabs or 0.2 mg
1)
PASSIVE IMMUNIZING AGENTS - Antibody
Drugs to Treat Low Immune System
Immune Serums
$0- B/D
$6.60
BIVIGAM
(Tier
2)
$0- B/D
$6.60
FLEBOGAMMA DIF 10 % (Tier
2)
$0- B/D
$6.60
GAMASTAN S/D
(Tier
2)
$0- B/D
$6.60
GAMMAGARD LIQUID
(Tier
2)
$0- B/D
$6.60
GAMMAKED
(Tier
2)
$0- B/D
$6.60
GAMUNEX-C
(Tier
2)
You can find information on what the symbols and abbreviations on this table mean by going to
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151
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$6.60
HIZENTRA
(Tier
2)
$0OCTAGAM 10 GM/100ML, $6.60
2 GM/20ML, 20
(Tier
GM/200ML, 5 GM/50ML
2)
$0$6.60
PRIVIGEN
(Tier
2)
$0$6.60
VARIZIG
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
B/D
B/D
B/D
Monoclonal Antibodies
SYNAGIS 50 MG/0.5ML
PENICILLINS - Drugs to Treat Bacterial Infections
Aminopenicillins
amoxicillin susr 125
mg/5ml, 200 mg/5ml, 250
mg/5ml, 400 mg/5ml
amoxicillin tabs 500 mg,
875 mg
Necessary
actions,
restrictions, or
limits on use
MO
MO
Natural Penicillins
$0$6.60
(Tier
2)
Passive Immunizing Agents - Combinations
$0$6.60
HYQVIA
(Tier
2)
amoxicillin caps 250 mg,
500 mg
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
ampicillin caps 250 mg,
(Tier
500 mg
1)
$0ampicillin sodium ij 1 gm, 2 $2.65
(Tier
gm
1)
$0$2.65
ampicillin sodium ij 125 mg (Tier
1)
$0$2.65
ampicillin sodium iv 10 gm (Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
BICILLIN L-A
penicillin g potassium 20
mu, 20000000 unit,
5000000 unit
penicillin v potassium
$0- MO
$6.60
(Tier
2)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
Penicillin Combinations
amoxicillin & pot
clavulanate
ampicillin & sulbactam
sodium ij 1gm-2gm
ampicillin & sulbactam
sodium iv 5gm-10gm
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
$0$2.65
(Tier
1)
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Name of drug
AUGMENTIN ES-600 (Use
Amoxicillin & Pot
Clavulanate)
AUGMENTIN SUSR
250MG/5ML-62.5MG/5ML
(Use Amoxicillin & Pot
Clavulanate)
AUGMENTIN TABS
500MG-125MG, 875MG125MG (Use Amoxicillin &
Pot Clavulanate)
AUGMENTIN XR (Use
Amoxicillin & Pot
Clavulanate)
BICILLIN C-R
300000UNIT/ML300000UNIT/ML
BICILLIN C-R
900000UNIT/2ML300000UNIT/2ML
piperacillin sodiumtazobactam sodium
UNASYN 1GM-2GM (Use
Ampicillin & Sulbactam
Sodium)
ZOSYN SOLN
0.5GM/100ML4GM/100ML-5%
ZOSYN SOLR 0.25GM2GM, 0.375GM-3GM,
0.5GM-4GM, 4.5GM-36GM
(Use Piperacillin SodiumTazobactam Sodium)
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
nafcillin sodium ij 1 gm, 10
gm
NF
MO
NF
nafcillin sodium ij 2 gm
MO
NF
oxacillin sodium 10 gm
MO
NF
$0- MO
$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
MO
NF
$0$6.60
(Tier
2)
oxacillin sodium 2 gm
Necessary
actions,
restrictions, or
limits on use
MO
MO
PHARMACEUTICAL ADJUVANTS
Liquid Vehicles
$0
CHERRY CONCENTRATE (Tier
SYRP
3)
$0
(Tier
CHERRY SYRUP
3)
$0
PROPYLENE GLYCOL
(Tier
SOLN EX
3)
$0
(Tier
RASPBERRY SYRUP
3)
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; MO;
NT
RX/OTC; NT
Pharmaceutical Excipients
KARAYA GUM GUM
NF
Penicillinase-Resistant Penicillins
$0- MO
$2.65
dicloxacillin sodium
(Tier
1)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0 RX/OTC; MO;
(Tier NT
3)
Semi Solid Vehicles
hydrophilic ointment
LANOLIN ANHYDROUS
$0 MO; NT
(Tier
3)
$0 RX/OTC; NT
(Tier
3)
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Name of drug
LANOLIN ANHYDROUSGRX
lanolin oint ex
What
the
drug
will
cost
you
(tier
level)
$0
(Tier
3)
$0
(Tier
3)
Necessary
actions,
restrictions, or
limits on use
RX/OTC; NT
acamprosate calcium
RX/OTC; NT
CAMPRAL (Use
Acamprosate Calcium)
PROGESTINS - Hormone Replacement/Modifying
Drugs
Progestins
$0$2.65
(Tier
1)
$0MEGACE ES (Use
$6.60
Megestrol Acetate
(Tier
(Appetite))
2)
$0$2.65
megestrol acetate
(Tier
(appetite)
1)
$0norethindrone acetate tabs $2.65
(Tier
or
1)
$0$2.65
progesterone micronized
(Tier
caps or 100 mg, 200 mg
1)
PROMETRIUM (Use
NF
Progesterone Micronized)
PROVERA (Use
NF
Medroxyprogesterone
Acetate)
Name of drug
MO
medroxyprogesterone
acetate
disulfiram tabs or 250 mg,
500 mg
XYREM
MO
MO
MO
MO
PSYCHOTHERAPEUTIC AND NEUROLOGICAL
AGENTS - MISC. - Drugs to Treat Mental and
Emotional Conditions
Agents for Chemical Dependency
Necessary
actions,
restrictions, or
limits on use
MO
NF MO
$0- MO
$2.65
(Tier
1)
Anti-Cataplectic Agents
AL; MO
AL; MO
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Antidementia Agents
ARICEPT (Use Donepezil
Hydrochloride)
ARICEPT ODT (Use
Donepezil Hydrochloride)
donepezil hydrochloride
$0- LA
$6.60
(Tier
2)
NF MO
NF MO
$0- MO
$2.65
(Tier
1)
MO
NF
EXELON CAPS OR 1.5
MG, 3 MG, 4.5 MG, 6 MG
(Use Rivastigmine Tartrate)
$0- MO
EXELON PT24 TD 13.3
MG/24HR, 4.6 MG/24HR, $6.60
(Tier
9.5 MG/24HR (Use
2)
Rivastigmine)
$0- MO
$2.65
galantamine hydrobromide (Tier
1)
$0- AL; MO
$2.65
memantine hcl soln 2
(Tier
mg/ml
1)
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154
Name of drug
memantine hcl tabs 10 mg,
5 mg
NAMENDA SOLN 10
MG/5ML (Use Memantine
HCl)
NAMENDA TABS 10 MG, 5
MG (Use Memantine HCl)
NAMENDA TITRATION
PAK (Use Memantine HCl)
NAMENDA XR 14 MG
NAMENDA XR 21 MG, 28
MG
NAMENDA XR 7 MG
NAMENDA XR TITRATION
PACK
RAZADYNE (Use
Galantamine
Hydrobromide)
RAZADYNE ER (Use
Galantamine
Hydrobromide)
rivastigmine
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
rivastigmine tartrate
AL; MO
MO
MO
QL(2 ea daily);
MO
QL(1 ea daily);
MO
QL(4 ea daily);
MO
MO
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Combination Psychotherapeutics
$0$2.65
chlordiazepoxide(Tier
amitriptyline
1)
$0$2.65
olanzapine-fluoxetine hcl
(Tier
1)
$0$2.65
perphenazine-amitriptyline (Tier
1)
SYMBYAX (Use
Olanzapine-Fluoxetine HCl) NF
Necessary
actions,
restrictions, or
limits on use
MO
AL; MO
MO
AL; MO
MO
Movement Disorder Drug Therapy
$0$2.65
tetrabenazine
(Tier
1)
$0- LA
$6.60
XENAZINE (Use
(Tier
Tetrabenazine)
2)
Multiple Sclerosis Agents
MO
AMPYRA
NF
MO
NF
$0- MO
$2.65
(Tier
1)
AUBAGIO
AVONEX
$0$6.60
(Tier
2)
$0- PA
$6.60
(Tier
2)
$0- PA
$6.60
(Tier
2)
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Name of drug
AVONEX PEN
BETASERON
COPAXONE 20 MG/ML
(Use Glatiramer Acetate)
COPAXONE 40 MG/ML
EXTAVIA
GILENYA
glatiramer acetate
LEMTRADA
PLEGRIDY
PLEGRIDY STARTER
PACK
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
PA
REBIF
PA
REBIF REBIDOSE
PA
REBIF REBIDOSE
TITRATIONPACK
PA
REBIF TITRATION PACK
PA
TECFIDERA
PA
TECFIDERA STARTER
PACK
PA
TYSABRI
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA
PA
PA
PA
PA
PA
PA
PA; LA
Premenstrual Dysphoric Disorder (PMDD) Agents
fluoxetine hcl (pmdd) cap
NF
10 mg, 20 mg
PA
Pseudobulbar Affect (PBA) Agents
$0- MO
$6.60
NUEDEXTA
(Tier
2)
PA
Psychotherapeutic and Neurological Agents $0- AL; MO
$2.65
ergoloid mesylates tabs or (Tier
1)
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156
Name of drug
ORAP (Use Pimozide)
pimozide
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
NICOTROL INHALER
MO
NICOTROL NS
Smoking Deterrents
bupropion hcl (smoking
deterrent)
CHANTIX
CHANTIX CONTINUING
MONTHPAK
NICODERM CQ (Use
Nicotine)
NICORETTE (Use Nicotine
Polacrilex)
NICORETTE MINI (Use
Nicotine Polacrilex)
NICORETTE STARTER
KIT (Use Nicotine
Polacrilex)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
QL(2 ea daily);
MO
PA; MO
PA; MO
NF MO; NT
NF PA; MO; NT
NF PA; MO; NT
PA; MO; NT
NF
$0
(Tier
3)
$0
nicotine polacrilex gum mt (Tier
2 mg, 4 mg
3)
$0
nicotine polacrilex lozg mt (Tier
2 mg, 4 mg
3)
$0
NICOTINE
(Tier
TRANSDERMAL SYSTEM
3)
Name of drug
MO; NT
nicotine
PA; MO; NT
PA; MO; NT
NT
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
ZYBAN (Use Bupropion
HCl (Smoking Deterrent))
Necessary
actions,
restrictions, or
limits on use
QL(17 ea
daily); MO
MO
NF QL(2 ea daily);
MO
Vasomotor Symptom Agents
BRISDELLE
$0- MO
$6.60
(Tier
2)
RESPIRATORY AGENTS - MISC. - Drugs to
Treat Lung Conditions
Alpha-Proteinase Inhibitor (Human)
$0- LA
$6.60
ARALAST NP 1000 MG
(Tier
2)
$0- LA
$6.60
PROLASTIN-C
(Tier
2)
$0- LA
$6.60
ZEMAIRA
(Tier
2)
Cystic Fibrosis Agents
$0- PA
KALYDECO PACK 50 MG, $6.60
(Tier
75 MG
2)
$0- PA; LA
$6.60
KALYDECO TABS 150 MG (Tier
2)
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157
Name of drug
ORKAMBI
PULMOZYME
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
PA
demeclocycline hcl
B/D
Pulmonary Fibrosis Agents
ESBRIET
OFEV
$0- PA; LA
$6.60
(Tier
2)
$0- PA; QL(2 ea
$6.60 daily); LA
(Tier
2)
SULFONAMIDES - Drugs to Treat Bacterial
Infections
Sulfonamides
sulfadiazine tabs or
$0- MO
$2.65
(Tier
1)
TETRACYCLINES - Drugs to Treat Bacterial
Infections
Tetracyclines
ADOXA PAK 1/100 (Use
Doxycycline
(Monohydrate))
ADOXA PAK 1/150 (Use
Doxycycline
(Monohydrate))
ADOXA PAK 2/100 (Use
Doxycycline
(Monohydrate))
ADOXA TABS 100 MG, 50
MG, 75 MG (Use
Doxycycline
(Monohydrate))
Name of drug
MO
NF
MO
NF
MO
NF
MO
NF
DORYX 150 MG (Use
Doxycycline Hyclate)
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
MO
NF MO
$0doxycycline (monohydrate) $2.65
caps 100 mg, 50 mg, 75
(Tier
mg
1)
$0doxycycline (monohydrate) $2.65
(Tier
susr 25 mg/5ml
1)
$0doxycycline (monohydrate) $2.65
tabs 100 mg, 150 mg, 50
(Tier
mg, 75 mg
1)
$0doxycycline hyclate caps or $2.65
(Tier
100 mg, 50 mg
1)
$0doxycycline hyclate solr iv $2.65
(Tier
100 mg
1)
$0doxycycline hyclate tabs or $2.65
(Tier
100 mg, 20 mg
1)
$0doxycycline hyclate tbec or $2.65
(Tier
150 mg
1)
MINOCIN CAPS OR 100
NF
MG, 50 MG, 75 MG (Use
Minocycline HCl)
$0minocycline hcl caps or 100 $2.65
(Tier
mg, 50 mg, 75 mg
1)
MO
MO
MO
MO
MO
MO
MO
MO
MO
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158
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0minocycline hcl tabs or 100 $2.65
(Tier
mg, 50 mg
1)
MONODOX (Use
NF
Doxycycline
(Monohydrate))
$0tetracycline hcl caps or 250 $2.65
(Tier
mg, 500 mg
1)
VIBRAMYCIN CAPS 100
NF
MG (Use Doxycycline
Hyclate)
VIBRAMYCIN SUSR 25
MG/5ML (Use Doxycycline NF
(Monohydrate))
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
SYNTHROID (Use
Levothyroxine Sodium)
MO
NF MO
Toxoid Combinations
MO
ADACEL
MO
BOOSTRIX
MO
Antithyroid Agents
propylthiouracil tabs or
Necessary
actions,
restrictions, or
limits on use
TOXOIDS
THYROID AGENTS - Drugs to Regulate Thyroid
Hormones
methimazole tabs or 10
mg, 5 mg
What
the
drug
will
cost
you
(tier
level)
$0- MO
$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
Thyroid Hormones
CYTOMEL (Use
NF MO
Liothyronine Sodium)
levothyroxine sodium tabs
MO
$0or 100 mcg, 112 mcg, 125
$2.65
mcg, 137 mcg, 150 mcg,
(Tier
175 mcg, 200 mcg, 25
1)
mcg, 300 mcg, 50 mcg, 75
mcg, 88 mcg
$0- MO
liothyronine sodium tabs or $2.65
(Tier
25 mcg, 5 mcg, 50 mcg
1)
DAPTACEL
DIPHTHERIA/TETANUS
TOXOIDS ADSORBED
PEDIATRIC
INFANRIX
TENIVAC
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED
ADULT
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Toxoids
TETANUS TOXOID
ADSORBED
$0- B/D
$6.60
(Tier
2)
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Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
ULCER DRUGS - Drugs to Treat Bowel, Intestine
and Stomach Conditions
Antispasmodics
BENTYL CAPS OR 10 MG
(Use Dicyclomine HCl)
BENTYL TABS OR 20 MG
(Use Dicyclomine HCl)
NF MO
NF MO
$0$2.65
dicyclomine hcl caps 10 mg (Tier
1)
$0$2.65
dicyclomine hcl tabs 20 mg (Tier
1)
$0$2.65
glycopyrrolate soln ij 0.2
(Tier
mg/ml
1)
$0$2.65
glycopyrrolate tabs or 1
(Tier
mg, 2 mg
1)
$0methscopolamine bromide $2.65
(Tier
tabs or 2.5 mg, 5 mg
1)
PAMINE (Use
Methscopolamine Bromide) NF
PAMINE FORTE (Use
Methscopolamine Bromide) NF
ROBINUL FORTE (Use
NF
Glycopyrrolate)
ROBINUL SOLN IJ 0.2
NF
MG/ML (Use
Glycopyrrolate)
ROBINUL TABS OR 1 MG NF
(Use Glycopyrrolate)
H-2 Antagonists
AXID CAPS 300 MG (Use
Nizatidine)
MO
MO
MO
MO
Name of drug
cimetidine tabs or 200 mg
cimetidine tabs or 300 mg,
400 mg, 800 mg
famotidine soln iv 20
mg/2ml, 200 mg/20ml, 40
mg/4ml
famotidine susr or 40
mg/5ml
famotidine tabs or 10 mg
famotidine tabs or 20 mg
MO
famotidine tabs or 40 mg
MO
nizatidine caps 150 mg,
300 mg
MO
MO
PEPCID 40 MG/5ML (Use
Famotidine)
MO
PEPCID AC CHEW
MO
PEPCID AC TABS (Use
Famotidine)
NF MO
ranitidine hcl caps or 150
mg, 300 mg
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0
(Tier
3)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
RX/OTC; MO
MO
MO
MO; NT
RX/OTC; MO
MO
MO
NF MO
$0 NT
(Tier
3)
NF MO; NT
$0- MO
$2.65
(Tier
1)
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0ranitidine hcl syrp or 15
$2.65
mg/ml, 150 mg/10ml, 75
(Tier
mg/5ml
1)
$0$2.65
ranitidine hcl tabs or 150
(Tier
mg
1)
$0$2.65
ranitidine hcl tabs or 300
(Tier
mg
1)
$0
ranitidine hcl tabs or 75 mg (Tier
3)
ZANTAC 75 (Use
NF
Ranitidine HCl)
ZANTAC SYRP OR 15
NF
MG/ML (Use Ranitidine
HCl)
ZANTAC TABS OR 150
NF
MG (Use Ranitidine HCl)
ZANTAC TABS OR 300
NF
MG (Use Ranitidine HCl)
Misc. Anti-Ulcer
CARAFATE TABS 1 GM
(Use Sucralfate)
sucralfate tabs or
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO
esomeprazole magnesium
40 mg
RX/OTC; MO
ESOMEPRAZOLE
STRONTIUM
MO
lansoprazole cpdr or 15 mg
MO; NT
lansoprazole cpdr or 30 mg
MO; NT
MO
NEXIUM CPDR 20 MG
RX/OTC; MO
NEXIUM CPDR 20 MG
(Use Esomeprazole
Magnesium)
MO
NF MO
$0- MO
$2.65
(Tier
1)
Proton Pump Inhibitors
$0- ST; MO
$6.60
DEXILANT
(Tier
2)
$0- ST; RX/OTC;
esomeprazole magnesium $2.65 MO
(Tier
20 mg
1)
NEXIUM CPDR 40 MG
NEXIUM CPDR 40 MG
(Use Esomeprazole
Magnesium)
NEXIUM PACK 10 MG, 2.5
MG, 20 MG, 40 MG, 5 MG
omeprazole cpdr or 10 mg,
20 mg, 40 mg
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
$0$2.65
(Tier
1)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$2.65
(Tier
1)
Necessary
actions,
restrictions, or
limits on use
ST; MO
ST
RX/OTC; MO
MO
ST; RX/OTC;
MO
ST; RX/OTC;
MO
ST; MO
ST; MO
ST; MO
MO
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0pantoprazole sodium solr iv $2.65
(Tier
40 mg
1)
$0pantoprazole sodium tbec $2.65
(Tier
or 20 mg, 40 mg
1)
PREVACID 15 MG (Use
NF
Lansoprazole)
PREVACID 30 MG (Use
NF
Lansoprazole)
PRILOSEC CPDR 10 MG,
NF
20 MG, 40 MG (Use
Omeprazole)
PROTONIX SOLR IV 40
NF
MG (Use Pantoprazole
Sodium)
PROTONIX TBEC OR 20
NF
MG, 40 MG (Use
Pantoprazole Sodium)
Necessary
actions,
restrictions, or
limits on use
MO
RX/OTC; MO
MO
MO
MO
Ulcer Drugs - Prostaglandins
CYTOTEC (Use
NF MO
Misoprostol)
$0- MO
$2.65
misoprostol tabs or 100
(Tier
mcg, 200 mcg
1)
Ulcer Therapy Combinations
$0- MO
$2.65
(Tier
1)
$0- MO
$6.60
OMECLAMOX-PAK
(Tier
2)
$0- RX/OTC; MO
$2.65
omeprazole-sodium
bicarbonate 20mg-1100mg (Tier
1)
amoxicillin-clarithromycin
w/ lansoprazole
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$2.65
omeprazole-sodium
bicarbonate 40mg-1100mg (Tier
1)
PREVPAC (Use
NF
Amoxicillin-Clarithromycin
w/ Lansoprazole)
ZEGERID CAPS 20MG1100MG (Use Omeprazole- NF
Sodium Bicarbonate)
ZEGERID CAPS 40MG1100MG (Use Omeprazole- NF
Sodium Bicarbonate)
$0$6.60
ZEGERID PACK 20MG(Tier
1680MG
2)
Necessary
actions,
restrictions, or
limits on use
MO
MO
RX/OTC; MO
MO
ST; MO
URINARY ANTI-INFECTIVES - Drugs to Treat
Bladder/Kidney Infections
Urinary Anti-infectives
HIPREX (Use
Methenamine Hippurate)
MACROBID (Use
Nitrofurantoin Monohyd
Macro)
MACRODANTIN 100 MG,
50 MG (Use Nitrofurantoin
Macrocrystal)
NF MO
MO
NF
AL; MO
NF
$0- MO
$2.65
methenamine hippurate
(Tier
1)
$0- AL; MO
nitrofurantoin macrocrystal $2.65
(Tier
caps or 100 mg, 50 mg
1)
$0- MO
$2.65
nitrofurantoin monohyd
(Tier
macro
1)
URINARY ANTISPASMODICS - Drugs to Treat
Miscellaneous Bladder Spasms
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Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Urinary Antispasmodic - Antimuscarinics
DETROL (Use Tolterodine
NF MO
Tartrate)
DETROL LA (Use
NF MO
Tolterodine Tartrate)
DITROPAN XL (Use
NF MO
Oxybutynin Chloride)
$0- MO
$2.65
oxybutynin chloride
(Tier
1)
SANCTURA (Use
NF MO
Trospium Chloride)
SANCTURA XR (Use
NF MO
Trospium Chloride)
$0- MO
$2.65
tolterodine tartrate
(Tier
1)
$0- MO
$2.65
trospium chloride
(Tier
1)
Urinary Antispasmodics - Cholinergic Agonists
$0- MO
$2.65
bethanechol chloride 10
(Tier
mg, 25 mg, 5 mg, 50 mg
1)
Urinary Antispasmodics - Direct Muscle Relaxants
$0- MO
$2.65
flavoxate hcl
(Tier
1)
VACCINES
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Mixed Vaccine Combinations
COMVAX
$0$6.60
(Tier
2)
Viral Vaccines
CERVARIX
ENGERIX-B SUSP IJ 10
MCG/0.5ML, 20 MCG/ML
GARDASIL
Bacterial Vaccines
ACTHIB
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0$6.60
MENACTRA
(Tier
2)
$0$6.60
MENOMUNE-A/C/Y/W-135 (Tier
2)
$0$6.60
MENVEO
(Tier
2)
$0$6.60
PEDVAX HIB
(Tier
2)
$0$6.60
TYPHIM VI
(Tier
2)
HAVRIX
$0$6.60
(Tier
2)
$0- B/D
$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
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163
Name of drug
IMOVAX RABIES
(H.D.C.V.)
IPOL INACTIVATED IPV
IXIARO
M-M-R II
PROQUAD
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
TWINRIX
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
Name of drug
B/D
VAQTA
VARIVAX
YF-VAX
ZOSTAVAX
What
the
drug
will
cost
you
(tier
level)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
Necessary
actions,
restrictions, or
limits on use
VAGINAL PRODUCTS - Drugs to Treat Vaginal
Infections and Low Hormones
B/D
B/D
Miscellaneous Vaginal Products
$0
benzocaine-resorcinol
(Tier
vaginal 2%-5%
3)
$0
(Tier
FEMINEASE
3)
$0
(Tier
TRIMO-SAN
3)
VAGISIL (Use Benzocaine- NF
Resorcinol Vaginal)
NT
NT
MO; NT
NT
Spermicides
ENCARE
nonoxynol-9
OPTIONS CONCEPTROL
VAGINAL
CONTRACEPTIVE
$0 NT
(Tier
3)
$0 MO; NT
(Tier
3)
$0 NT
(Tier
3)
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
OPTIONS GYNOL II
VAGINALCONTRACEPTIV (Tier
3)
E
$0
(Tier
SHUR-SEAL
3)
$0
VCF VAGINAL
(Tier
CONTRACEPTIVE FILM
3)
$0
VCF VAGINAL
(Tier
CONTRACEPTIVE FOAM
3)
Vaginal Anti-infectives
CLEOCIN CREA VA 2 %
(Use Clindamycin
Phosphate Vaginal)
clindamycin phosphate
vaginal
clotrimazole vaginal 1 %
GYNE-LOTRIMIN (Use
Clotrimazole Vaginal)
METROGEL-VAGINAL
(Use Metronidazole
Vaginal)
metronidazole vaginal
miconazole nitrate vaginal
supp 100 mg
TERAZOL 3 (Use
Terconazole Vaginal)
TERAZOL 7 (Use
Terconazole Vaginal)
Necessary
actions,
restrictions, or
limits on use
Name of drug
MO; NT
terconazole vaginal
NT
tioconazole vaginal
NT
What
the
drug
will
cost
you
(tier
level)
$0$2.65
(Tier
1)
$0
(Tier
3)
VAGISTAT-1 (Use
Tioconazole Vaginal)
NT
MO
NF
PREMARIN CREA VA
0.625 MG/GM
NT
NF NT
$0- MO
$2.65
(Tier
1)
$0- MO
$6.60
(Tier
2)
VASOPRESSORS - Drugs to Treat Heart and
Circulation Conditions
Anaphylaxis Therapy Agents
ADRENACLICK
MO
NF
AUVI-Q
$0- MO
$2.65
(Tier
1)
$0 MO; NT
(Tier
3)
NF MO
MO
Vaginal Estrogens
estradiol vaginal
$0- MO
$2.65
(Tier
1)
$0 MO; NT
(Tier
3)
NF MO; NT
Necessary
actions,
restrictions, or
limits on use
EPINEPHRINE SOAJ IJ
0.15 MG/0.15ML, 0.3
MG/0.3ML
EPIPEN 2-PAK
NF MO
EPIPEN-JR 2-PAK
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
$0$6.60
(Tier
2)
MO
MO
MO
MO
MO
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Name of drug
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
Vasopressors
dobutamine hcl
midodrine hcl
$0$2.65
(Tier
1)
$0- MO
$2.65
(Tier
1)
Oil Soluble Vitamins
BABY DDROPS (Use
Cholecalciferol)
DRISDOL (Use
Ergocalciferol)
ergocalciferol caps or
50000 unit
ergocalciferol soln or 8000
unit/ml
MEPHYTON
VITAMINS
A-25
Name of drug
$0 NT
(Tier
3)
NF NT
$0
BETA CAROTENE CAPS (Tier
OR 10000 UNIT
3)
$0
beta carotene caps or
(Tier
25000 unit
3)
$0
cholecalciferol caps or
(Tier
1000 unit, 2000 unit, 400
3)
unit, 5000 unit
$0
cholecalciferol liqd or 400
(Tier
unit/ml
3)
$0
cholecalciferol liqd or 400
(Tier
unt/0.03ml
3)
$0
cholecalciferol tabs or 1000 (Tier
unit, 2000 unit, 400 unit
3)
$0
cholecalciferol tabs or 5000 (Tier
unit
3)
D-VI-SOL (Use
NF
Cholecalciferol)
phytonadione tabs or 100
mcg
vitamin a caps 10000 unit
NT
VITAMIN A CAPS 25000
UNIT
MO; NT
vitamin a caps 8000 unit
MO; NT
VITAMIN A TABS
10000UNIT-1000UNIT
MO; NT
vitamin e caps or 100 unit
NT
vitamin e caps or 1000 unit
MO; NT
vitamin e liqd or 400
unit/15ml
NT
vitamin e soln or 15
unit/0.3ml
MO; NT
WHEAT GERM
What
the
drug
will
cost
you
(tier
level)
Necessary
actions,
restrictions, or
limits on use
NF MO; NT
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
$0
(Tier
3)
MO; NT
MO; NT
MO; NT
MO; NT
MO; NT
NT
NT
NT
NT
MO; NT
NT
MO; NT
RX/OTC; NT
Water Soluble Vitamins
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What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
AMINOBENZOATE
(Tier
POTASSIUM
3)
$0
ascorbic acid chew or 250 (Tier
mg, 250mg
3)
$0
ascorbic acid cpcr or 500
(Tier
mg
3)
$0
ascorbic acid soln ij 500
(Tier
mg/ml
3)
$0
ascorbic acid syrp or 500
(Tier
mg/5ml
3)
$0
ascorbic acid tabs or 100
(Tier
mg
3)
$0
ascorbic acid tabs or 250
(Tier
mg
3)
$0
ascorbic acid tbcr or 1000 (Tier
mg
3)
$0
ascorbic acid tbcr or 30mg- (Tier
500mg, 500 mg, 500mg
3)
$0
(Tier
biotin tabs or 300 mcg
3)
$0
biotin tabs or 5 mg, 5000
(Tier
mcg, 800 mcg
3)
$0
calcium ascorbate tabs or (Tier
3)
$0
niacin cpcr or 250 mg, 500 (Tier
mg
3)
$0
niacin tabs or 100 mg, 250 (Tier
mg, 50 mg, 500 mg
3)
Necessary
actions,
restrictions, or
limits on use
NT
MO; NT
MO; NT
MO; NT
MO; NT
NT
MO; NT
NT
MO; NT
MO; NT
What
the
drug
will
Name of drug
cost
you
(tier
level)
$0
niacin tbcr or 250 mg, 500 (Tier
mg, 750 mg
3)
$0
(Tier
NIACIN TR
3)
$0
niacinamide tabs or 100 mg (Tier
3)
$0
niacinamide tabs or 500 mg (Tier
3)
$0
pyridoxine hcl tabs or 100
(Tier
mg, 25 mg, 50 mg
3)
$0
(Tier
riboflavin tabs or 100 mg
3)
$0
riboflavin tabs or 25 mg, 50 (Tier
mg
3)
SLO-NIACIN 500 MG,750
NF
MG (Use Niacin)
$0
thiamine hcl tabs or 100
(Tier
mg, 50 mg
3)
$0
(Tier
thiamine mononitrate
3)
Necessary
actions,
restrictions, or
limits on use
MO; NT
MO; NT
NT
MO; NT
MO; NT
MO; NT
NT
MO; NT
MO; NT
NT
NT
NT
MO; NT
MO; NT
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167
Index
A & D ZINC OXIDE
98
A-25
166
A-MANTLE
98
abacavir sulfate
68
abacavir sulfate-lamivudinezidovudine
68
ABELCET
41
ABILIFY 1 MG/ML
67
ABILIFY 10 MG
67
ABILIFY 15 MG
67
ABILIFY 2 MG
67
ABILIFY 20 MG, 30 MG
67
ABILIFY 5 MG
67
ABILIFY 9.75 MG/1.3ML
67
ABILIFY DISCMELT 10 MG 66
ABILIFY DISCMELT 15 MG 66
ABILIFY MAINTENA
66
ABRAXANE
61
ABSORICA
87
acamprosate calcium
154
acarbose
33
ACCOLATE
21
ACCUPRIL
46
ACCURETIC
48
acebutolol hcl 200 mg, 400
mg
75
ACEON 4 MG
46
ACEON 8 MG
46
acetaminophen 100 mg/ml, 160
mg/5ml, 80 mg/0.8ml
7
acetaminophen 120 mg
8
acetaminophen 160 mg
7
acetaminophen 160 mg/5ml 7
acetaminophen 160 mg/5ml, 80
mg/2.5ml
7
acetaminophen 80 mg
7
acetaminophen 80 mg/0.8ml 8
acetaminophen w/ codeine
120mg/5ml-12mg/5ml
12
acetaminophen w/ codeine
300mg-15mg, 300mg-30mg,
300mg-60mg
12
acetaminophen-caffeinepyrilamine
7
acetazolamide 250 mg
106
acetazolamide 500 mg
106
acetic acid (otic)
151
acetic acid 0.25 %
115
acetic acid-aluminum
acetate
151
Index 1
acetylcysteine 10 %, 20 % 86
acitretin
90
ACNE MEDICATION
87
ACNE MEDICATION 10 87
ACNE-AID
98
ACTEMRA
4
ACTHIB
163
ACTIGALL
113
ACTIMMUNE
59
ACTIQ 1200 MCG, 1600 MCG,
400 MCG, 600 MCG, 800
MCG
8
ACTIQ 200 MCG
8
ACTIVELLA
111
ACTOPLUS MET
33
ACTOS 15 MG
36
ACTOS 30 MG, 45 MG
36
ACUICYN DAILY EYELID &
EYELASH CLEANSER
98
ACULAR
149
ACULAR LS
149
acyclovir 200 mg
72
acyclovir 200 mg/5ml
72
acyclovir 400 mg, 800 mg 72
acyclovir sodium 50 mg/ml 72
acyclovir sodium 500 mg 72
acyclovir topical
91
ADACEL
159
ADAGEN
76
ADALAT CC
76
adapalene 0.1 %
87
ADCIRCA
78
ADD-INS COMPLETE
144
ADDERALL XR
1
adefovir dipivoxil
71
ADIPEX-P
1
ADOXA 100 MG, 50 MG, 75
MG
158
ADOXA PAK 1/100
158
ADOXA PAK 1/150
158
ADOXA PAK 2/100
158
ADRENACLICK
165
ADULT ACNOMEL
87
ADVAIR DISKUS
22
ADVAIR HFA
22
ADVIL
4
ADVIL ALLERGY &
CONGESTION
84
ADVIL MIGRAINE
4
AEROCHAMBER MINI
AEROSOLCHAMBER
125
AEROCHAMBER MV
125
AEROCHAMBER PLUS FLOW
VU
125
AEROCHAMBER PLUS FLOWVU
125
AEROCHAMBER PLUS FLOWVU/LARGE MASK
125
AEROCHAMBER PLUS FLOWVU/MASK
125
AEROCHAMBER PLUS FLOWVU/MEDIUM MASK
125
AEROCHAMBER PLUS FLOWVU/SMALL MASK
125
AEROCHAMBER Z-STAT PLUS
VALVED HOLDING CHAMBER
W/FLOW VU
125
AEROCHAMBER Z-STAT
PLUS/FLOWSIGNAL
125
AEROCHAMBER Z-STAT
PLUS/LARGE MASK
126
AEROCHAMBER Z-STAT
PLUS/MEDIUM MASK
126
AEROCHAMBER Z-STAT
PLUS/SMALL MASK
126
AEROCHAMBER/FLOWSIGNAL
126
AEROSPAN
22
AEROVENT PLUS HOLDING
CHAMBER/COLLAPSIBLE 126
AFINITOR
57
AFINITOR DISPERZ
57
AFRIN PURESEA GENTLE
MISTNASAL RINSE
142
AFRIN PURESEA MEDIUM
STREAM NASAL RINSE 142
AFRIN PURESEA ULTRAGENTLE MIST NASAL
RINSE
142
AGGRENOX
116
AGRYLIN
116
AIRZONE PEAK FLOW
METER
126
ALBATUSSIN NN
85
ALBENZA
15
ALBUSTIX
104
albuterol sulfate 0.083 %, 0.5 %,
0.63 mg/3ml, 1.25 mg/3ml 22
albuterol sulfate 2 mg, 4 mg 22
albuterol sulfate 2 mg/5ml 22
albuterol sulfate 4 mg, 8 mg 22
alclometasone dipropionate 92
ALCOHOL PADS
124
ALDACTAZIDE 25MG25MG
107
ALDACTONE
107
ALDARA
96
alendronate sodium 10 mg, 5
mg
108
alendronate sodium 35 mg, 70
mg
108
ALER-DRYL
43
ALEVAZOL
88
ALEVE
4
alfuzosin hcl
115
ALIMTA 100 MG
53
ALIMTA 500 MG
53
ALINIA 500 MG
16
ALKERAN 2 MG
51
ALKERAN 50 MG
51
ALLI
1
allopurinol 100 mg
116
allopurinol 300 mg
116
ALMACONE
14
ALOE VESTA MULTI
PURPOSECLEANSING
99
alosetron hcl
114
ALPHA LIPOIC ACID 50 MG 2
ALPHA-LIPOIC ACID
2
alpha-lipoic acid (thioctic acid)
100 mg
2
ALPHAGAN P 0.1 %
147
ALPHAGAN P 0.15 %
147
alprazolam 0.25 mg, 0.5 mg, 1
mg, 2 mg
19
alprazolam 0.5 mg, 1 mg, 2 mg, 3
mg
19
ALSUMA
130
ALTACE
46
alum & mag hydrox-simethicone
200mg-25mg-200mg
14
alum & mag hydrox-simethicone
200mg/5ml-200mg/5ml20mg/5ml-20mg/5ml-200mg/5ml200mg/5ml, 200mg/5ml20mg/5ml-200mg/5ml,
400mg/5ml-400mg/5ml40mg/5ml-40mg/5ml-400mg/5ml400mg/5ml, 400mg/5ml40mg/5ml-400mg/5ml
15
alum & mag hydrox-simethicone
200mg/5ml-20mg/5ml200mg/5ml, 400mg/5ml40mg/5ml-400mg/5ml
14
ALUMINUM ACETATE
99
ALUMINUM HYDROXIDE 15
aluminum hydroxide
99
aluminum hydroxide-mag
trisil
15
aluminum sulfate & calcium
acetate
99
amantadine hcl 100 mg
62
amantadine hcl 50 mg/5ml 62
AMARYL 1 MG
38
AMARYL 2 MG
38
AMARYL 4 MG
38
AMBI COCOA BUTTER
CLEANSING
99
AMBI COMPLEXION
CLEANSING
99
AMBIEN 10 MG
120
AMBIEN 5 MG
120
AMBIEN CR 12.5 MG
120
AMBIEN CR 6.25 MG
120
AMBISOME
41
amcinonide
92
AMERGE
130
AMICAR 500 MG
120
amifostine crystalline
60
amikacin sulfate 1 gm/4ml, 500
mg/2ml
3
amiloride &
hydrochlorothiazide
107
amiloride hcl
107
amino acid infusion 15% 145
amino acids 100mg-6.15mg2.1mg-0.85mg-1.95mg-0.55mg2.3mg-1.95mg-0.75mg-1.15mg0.6mg-3.65mg-0.65mg-3.25mg3.8mg-1.95mg-1.7mg-0.7mg1.05mg, 115.333mg-54.667mg21mg-33.333mg-33.333mg46.667mg-14.167mg-46.667mg40mg-53.333mg-18.167mg41mg-66.667mg-40mg30.667mg-17.333mg-14mg,
115.3mg-54.7mg-21mg-33.3mg13.3mg-33.3mg-63.3mg-14.2mg46.7mg-40mg-53.3mg-18.2mg41mg-66.7mg-40mg-30.7mg17.3mg-14mg, 1200mg-100mg,
18.33mg-200mg-33.33mg-50mg23.16mg-58.33mg-18.33mg75mg-108.33mg, 200mg33.33mg-50mg-23.16mg18.33mg-58.33mg-18.33mg75mg-108.33mg, 35mg-29.5mg24.667mg-4.833mg-17.667mg24.667mg-12.5mg-24mg-19mg36mg-17.5mg-4.667mg-75mg15mg, 74mg-50mg-0.7mg-77mg1.4mg-72mg-64mg-27mg-54mg70mg-41mg-17mg-109mg-7mg27mg-68mg-47mg-41mg-64mg
145
amino acids 130mg-10mg130mg-130mg
145
amino acids-protein
hydrolysate
145
AMINOBENZOATE
POTASSIUM
167
aminocaproic acid 500 mg 120
aminophylline
23
aminosalicylic acid
51
AMINOSYN II 15% (Use amino
acid infusion)
145
amiodarone hcl 100 mg, 200 mg,
400 mg
20
amitriptyline hcl
32
amlodipine besylate 10 mg 76
amlodipine besylate 2.5 mg 76
amlodipine besylate 5 mg
76
amlodipine besylate-benazepril
hcl
48
ammonium chloride
133
amoxapine
32
amoxicillin & pot
clavulanate
152
amoxicillin 125 mg/5ml, 200
mg/5ml, 250 mg/5ml, 400
mg/5ml
152
Index 2
amoxicillin 250 mg, 500 mg 152
amoxicillin 500 mg, 875 mg 152
amoxicillin-clarithromycin w/
lansoprazole
162
amphetaminedextroamphetamine
1
amphotericin b 50 mg
41
ampicillin & sulbactam sodium
1gm-2gm
152
ampicillin & sulbactam sodium
5gm-10gm
152
ampicillin 250 mg, 500 mg 152
ampicillin sodium 1 gm, 2
gm
152
ampicillin sodium 10 gm
152
ampicillin sodium 125 mg 152
AMPYRA
155
ANADROL-50
13
ANAFRANIL
32
anagrelide hcl
117
ANAPROX
5
ANAPROX DS
5
anastrozole
55
ANCOBON
41
ANDRODERM
13
ANDROGEL
13
ANDROGEL PUMP
13
ANORO ELLIPTA
22
ANTARA 130 MG, 43 MG 44
ANTARA 30 MG
45
ANTARA 90 MG
45
ANTI-BACTERIAL HAND
LOTION
99
APOKYN
62
apraclonidine hcl
147
APRISO
114
APTIOM 200 MG
25
APTIOM 400 MG
25
APTIOM 600 MG
25
APTIOM 800 MG
25
APTIVUS 100 MG/ML
68
APTIVUS 250 MG
68
AQUANIL SKIN CLEANSER 99
AQUORAL
137
ARALAST NP 1000 MG
157
ARALEN
50
ARANESP ALBUMIN
FREE
118
ARAVA
7
Index 3
ARCALYST
4
argatroban 250 mg/2.5ml 24
ARGIMENT
145
ARGIMENT AT
145
arginine 500 mg
145
ARIAL CHAMBER
126
ARICEPT
154
ARICEPT ODT
154
ARIMIDEX
55
aripiprazole 1 mg/ml
67
aripiprazole 10 mg
67
aripiprazole 15 mg
67
aripiprazole 2 mg
67
aripiprazole 20 mg, 30 mg 67
aripiprazole 5 mg
67
ARIPIPRAZOLE ODT 10
MG
67
ARIPIPRAZOLE ODT 15
MG
67
ARISTOSPAN INTRAARTICULAR
83
ARIXTRA
24
ARNUITY ELLIPTA
22
AROMASIN
55
ARRANON
53
ARTHRICARE DOUBLE ICE
PAIN RELIEVING RUB
96
ARTHRICARE PAIN
RELIEVINGRUB
96
ARTHRICARE TRIPLE
MEDICATED PAIN RELIEVING
RUB
96
ARTHROTEC 50
5
ARTHROTEC 75
5
ARZERRA
54
ASACOL HD
114
ascorbic acid 100 mg
167
ascorbic acid 1000 mg 167
ascorbic acid 250 mg
167
ascorbic acid 250 mg,
250mg
167
ascorbic acid 30mg-500mg,
500 mg, 500mg
167
ascorbic acid 500 mg
167
ascorbic acid 500 mg/5ml 167
ascorbic acid 500 mg/ml 167
ASCRIPTIN
8
ASPIRIN 120 MG, 200 MG 8
aspirin 300 mg, 600 mg
8
aspirin 324 mg, 325 mg, 500 mg,
81 mg
8
aspirin 325 mg
8
aspirin 81 mg
8
aspirin buffered (cal carb-mag
carb-mag oxide)
8
ASPIRIN/DIPYRIDAMOLE 117
ASSESS FULL RANGE PEAK
FLOW METER
126
ASSESS LOW RANGE PEAK
FLOW METER
126
ASSESS PEAK FLOW METER
FULL RANGE
126
ASSESS PEAK FLOW METER
LOW RANGE
126
ASTAGRAF XL
73
ASTHMA CHECK METER-ZONE
SYSTEM
126
ASTHMAMENTOR
126
ATACAND
47
ATACAND HCT
48
atenolol & chlorthalidone
48
atenolol 100 mg, 25 mg, 50
mg
75
ATIVAN 0.5 MG, 1 MG, 2
MG
19
ATIVAN 2 MG/ML
19
ATIVAN 4 MG/ML
19
ATOPICLAIR
98
atorvastatin calcium
45
atovaquone
16
atovaquone-proguanil hcl 250mg100mg
50
ATRIPLA
68
ATROVENT
142
ATROVENT HFA
21
AUBAGIO
155
AUGMENTIN 250MG/5ML62.5MG/5ML
153
AUGMENTIN 500MG-125MG,
875MG-125MG
153
AUGMENTIN ES-600
153
AUGMENTIN XR
153
AURSTAT ANTI-ITCH
HYDROGEL
98
AUVI-Q
165
AVALIDE
48
AVANDIA 2 MG
36
AVANDIA 4 MG
36
AVANDIA 8 MG
36
AVAPRO
47
AVASTIN
54
AVEED
13
AVEENO ACTIVE NATURALS
PURE RENEWAL
SHAMPOO
99
AVEENO MOISTURIZING 99
AVEENO POSITIVELY
AGELESSDAILY EXFOLIATING
CLEANSER
99
AVEENO POSITIVELY
RADIANTCLEANSER
99
AVEENO SKIN RELIEF
SHOWER& BATH
91
AVEENO ULTRA-CALMING
CLEANSER
99
AVENOVA
99
AVODART
115
AVONEX
155
AVONEX PEN
156
AXID 300 MG
160
AXSAIN
97
AYR NASAL DROPS
142
azacitidine
53
AZACTAM
15
azathioprine 100 mg, 50 mg, 75
mg
73
azelastine hcl (ophth)
149
azelastine hcl 0.1 %
142
AZILECT
63
azithromycin 100 mg/5ml, 200
mg/5ml
124
azithromycin 250 mg, 500 mg,
600 mg
124
azithromycin 500 mg
123
AZOPT
149
aztreonam
15
AZULFIDINE
114
AZULFIDINE EN-TABS
114
b complex w/ c 10.2mg10.2mg-10mg-10mg-50mg50mg-15mg-15mg-5mg-5mg300mg-300mg, 100mg-100mg25mg-20mg-6mg-15mcg100mg-5mcg-2mg-150mg,
100mg-100mg-5.5mg-20mg15mcg-25mg-400mcg-5mcg2mg-150mg, 100mg-10mg20mg-10mcg-15mg-5mg500mg, 100mg-20mg-5.5mg15mcg-2mg-25mg-150mg400mcg-5mcg-150mg, 10mg10mg-15mg-50mg-5mg-300mg,
15mg-10.2mg-10mg-50mg5mg-300mg, 15mg-10mg50mg-10.2mg-5mg-300mg,
15mg-10mg-50mg-10.2mg6mcg-400mcg-5mg-300mg,
15mg-150mg-10mg-50mg10.2mg-5mg-300mg, 15mg20mg-50mg-10mg-10mcg-5mg300mg, 15mg-50mg-10.2mg10mg-5mg-300mg, 50mg10.2mg-10mg-15mg-5mg300mg, 50mg-10mg-10mg15mg-5mg-300mg, 50mg15mg-10mg-10.2mg-5mg300mg
138
b complex w/ c 10.2mg-10mg15mg-50mg-5mg-300mg,
10mg-50mg-10.2mg-15mg5mg-300mg, 10mg-50mg10mg-15mg-5mg-300mg,
15mg-10mg-50mg-10mg-5mg300mg
138
B-100 COMPLEX
138
B-6 FOLIC ACID
118
b-complex vitamins 0.1mg20mg-2mg-5mcg-3mg-1mg,
100mg-50mg-40mg-10mg20mg-5mg-4.6mg-1mcg-5mg1mg, 10mg-10mg-2mg-1.5mg0.2mg, 10mg-14mg-25mcg7mg-4.5mg, 15mg-2mg-5mg2mcg-2mg-2mg, 30mg-50mg50mg-50mg-50mg-50mg50mcg-50mg-100mcg-50mcg50mg, 3mg-10mg-20mg-3mg6mcg-2mg, 3mg-20mg-3mg10mg-6mcg-2mg, 3mg-3mg20mg-20mg-3mg-3mg-10mg10mg-6mcg-6mcg-2mg-2mg,
83mg-3mg-20mg-2mg-5mcg1mg
138
b-complex vitamins 2mg/ml100mg/ml-2mg/ml-100mg/ml2mg/ml, 2mg/ml-2%-100mg/ml2mg/ml-100mg/ml-2mg/ml 137
b-complex vitamins 2mg/ml-2%100mg/ml-2mg/ml-100mg/ml2mg/ml
137
b-complex vitamins 3.33mg0.4mg-0.33mg-0.66mcg-0.11mg,
60mg-60mg-3mg-5mg-20mg3mg-1mcg-0.5mg, 60mg-60mg5mg-20mg-3mg-1mcg-3mg0.5mg, 70mg-100mg-1mg-10mg2mg-1.5mg-100mcg
137
b-complex w/ c & folic acid 10mg20mg-1.5mg-1mg-1.5mg-5mg300mcg-50mg-60mg, 20mg1.5mg-10mg-1mg-1.5mg-5mg300mcg-50mg-60mg
138
b-complex w/ folic acid 1.5mg20mg-1.7mg-6mcg-400mcg-2mg,
1.7mg-10mg-6mcg-1.2mg-20mg0.4mg-2mg, 100mg-100mg100mg-100mcg-400mcg-100mg,
100mg-100mg-100mg-100mg10mcg-400mcg-100mcg-100mg,
10mg-10mg-50mg-10mg-10mg10mg-10mcg-10mg-400mcg10mcg-10mg, 10mg-20mg1.7mg-6mcg-1.5mg-400mcg2mg, 15mg-100mg-200mg-17mg60mcg-400mcg-20mg, 30mg20mg-50mg-30mg-10mg-10mcg400mcg-8mg, 40mcg-1mg-6mg5mcg-3mg-2mcg-19mcg, 50mg50mg-50mg-50mcg-50mg400mcg-50mcg-50mg
139
b-complex w/ folic acid 100mg100mg-100mg-100mg-100mcg400mcg-100mcg-100mg, 125mg125mg-125mg-125mg-125mcg125mg-125mg-400mcg-125mcg125mg, 50mg-50mg-50mg-50mg50mcg-0.4mg-50mcg-50mg,
50mg-50mg-50mg-50mg-50mcg100mcg-50mcg-50mg
139
BABY ANBESOL
136
BABY DDROPS
166
BABY ORAJEL
136
BACIGUENT
88
bacitracin (topical)
88
bacitracin zinc
88
bacitracin-poly-neomycin-hc
149
bacitracin-polymyxin b
88
Index 4
bacitracin-polymyxin b
(ophth)
147
baclofen 10 mg
141
baclofen 20 mg
141
BACTRIM
16
BACTRIM DS
16
BACTROBAN
88
BALNETAR LIQUIM
104
balsalazide disodium
114
BANZEL
25
BARACLUDE
71
BASIS ALL CLEAR
99
BASIS COMBINATION
99
BASIS EXTRA DRY
99
BASIS NORMAL/DRY
99
BASIS SENSITIVE SKIN
99
bath products 40%-40%-40%40%, 5%-5%-5%
91
BD GLUCOSE
35
BELEODAQ
57
BELSOMRA 10 MG
121
BELSOMRA 15 MG, 20
MG
121
BELSOMRA 5 MG
121
BELVIQ
1
BENADRYL
43
BENADRYL ALLERGY
43
BENADRYL ALLERGY &
COLD
85
BENADRYL ALLERGY &
SINUSHEADACHE
85
BENADRYL ALLERGY
CHILDRENS 12.5 MG
43
BENADRYL ALLERGY
CHILDRENS 12.5 MG/5ML 43
BENADRYL DYE-FREE
ALLERGYLIQUID-GELS
43
BENADRYL-D ALLERGY &
SINUS
85
benazepril &
hydrochlorothiazide
48
benazepril hcl 10 mg, 20 mg, 40
mg, 5 mg
46
BENLYSTA 120 MG
75
BENSULFOID
87
BENTYL 10 MG
160
BENTYL 20 MG
160
BENZACLIN
87
BENZACLIN WITH PUMP 87
BENZALKONIUM
CHLORIDE
68
Index 5
BENZAMYCIN
87
BENZEDREX INHALER 143
benzocaine (dental) 20 % 136
benzocaine (dental) 7.5
%
136
benzocaine-docusate
sodium
123
benzocaine-resorcinol vaginal
2%-5%
164
benzonatate 100 mg, 200
mg
84
benzoyl peroxide 5 %
87
benzoyl peroxideerythromycin
87
benztropine mesylate 0.5 mg, 1
mg, 2 mg
62
benztropine mesylate 1
mg/ml
62
BERINERT
116
BETA CAROTENE 10000
UNIT
166
beta carotene 25000 unit 166
BETAGAN
147
betamethasone dipropionate
(topical)
92
betamethasone dipropionate
augmented
92
betamethasone sod phosphate
& acetate
83
betamethasone valerate 0.1
%
92
betamethasone valerate 0.12
%
92
BETAPACE
76
BETAPACE AF
76
BETASERON
156
betaxolol hcl
75
betaxolol hcl (ophth)
147
bethanechol chloride 10 mg, 25
mg, 5 mg, 50 mg
163
BETHKIS
3
bexarotene
59
BIAXIN
124
BIAXIN XL
124
BIAXIN XL PAC
124
bicalutamide
55
BICILLIN C-R 300000UNIT/ML300000UNIT/ML
153
BICILLIN C-R
900000UNIT/2ML300000UNIT/2ML
153
BICILLIN L-A
152
BICNU
51
BIMATOPROST
150
BIOFLEXOR
96
biotin 300 mcg
167
biotin 5 mg, 5000 mcg, 800
mcg
167
BIPHENOX
7
bisacodyl 10 mg
123
bisacodyl 5 mg
123
bismuth subsalicylate 262
mg
39
bismuth subsalicylate 262
mg/15ml, 525 mg/15ml, 527
mg/30ml
39
bisoprolol &
hydrochlorothiazide
48
bisoprolol fumarate
75
BIVIGAM
151
bleomycin sulfate 15 unit
56
bleomycin sulfate 30 unit
56
BLEPH-10
147
BLINCYTO
54
BLUE-EMU SUPER
STRENGTH
97
BODI WHIRL OIL
91
BODY WASH & SHAMPOO 99
BONIVA 150 MG
108
BONIVA 3 MG/3ML
108
BOOSTRIX
159
boric acid in isopropyl
151
BOSULIF
57
BOTOX 200 UNIT
144
BREATHERITE
126
BREATHERITE
COLLAPSIBLEADULT SPACER
W/MASK
126
BREATHERITE
COLLAPSIBLECHILD SPACER
W/MASK
126
BREATHERITE
COLLAPSIBLEINFANT SPACER
W/MASK
126
BREATHERITE
COLLAPSIBLESMALL CHILD
SPACER W/MASK
127
BREATHERITE
COLLAPSIBLESPACER W/
NEONATE MASK
127
BREATHERITE RIGID
SPACERW/MASK
127
BREATHERITE W/LARGE
MASK
127
BREATHERITE W/MEDIUM
MASK
127
BREATHERITE W/SMALL
MASK
127
BREO ELLIPTA 25MCG/INH100MCG/INH, 25MCG/INH200MCG/INH
22
BREVICON-28
81
BRILINTA
117
brimonidine tartrate
147
BRINTELLIX 10 MG
31
BRINTELLIX 20 MG
31
BRINTELLIX 5 MG
31
BRISDELLE
157
bromfenac sodium (ophth) 149
bromocriptine mesylate 2.5
mg
63
bromocriptine mesylate 5 mg63
brompheniramine &
phenyleph
85
brompheniramine &
pseudoeph
85
BRONCOPECTOL
85
budesonide
83
budesonide (inhalation) 0.25
mg/2ml, 0.5 mg/2ml
22
budesonide (nasal)
143
BUFFERIN
8
BULL FROG QUIK GEL SPF
36
103
BULL FROG QUIK GEL SPF
50
103
BULL FROG QUIK GEL
SPORTSPF 36
103
BULL FROG QUIK GEL
SPORTSPRAY SPF 50
103
BULL FROG SPF 36
103
BULL FROG WATER ARMOR
SPORT QUIK GEL SPF 50 104
BULL FROG WATER ARMOR
SPORT QUIK SPRAY SPF
50
104
bumetanide 0.5 mg, 1 mg, 2
mg
107
BUMEX
107
BUPRENEX
12
buprenorphine hcl 0.3 mg/ml 13
buprenorphine hcl 2 mg
13
buprenorphine hcl 8 mg
13
buprenorphine hcl-naloxone hcl
dihydrate 2mg-0.5mg
13
buprenorphine hcl-naloxone hcl
dihydrate 8mg-2mg
13
bupropion hcl (smoking
deterrent)
157
bupropion hcl 100 mg
29
bupropion hcl 150 mg
29
bupropion hcl 150 mg, 200
mg
29
bupropion hcl 300 mg
29
bupropion hcl 75 mg
29
BURN SPRAY
98
buspirone hcl 10 mg, 15 mg, 30
mg, 5 mg, 7.5 mg
19
BUSULFEX
52
butalbital-aspirin-caffeine
w/cod
12
BUTISOL SODIUM
120
butorphanol tartrate 10
mg/ml
13
butorphanol tartrate 2
mg/ml
13
BYDUREON
36
BYETTA
36
cabergoline
111
CALAMINE
99
CALAMINE
PHENOLATED
99
CALAN
76
CALAN SR
76
CALCI-CHEW
132
CALCI-MIX
132
CALCIONATE
132
calcipotriene
90
calcitonin (salmon)
108
calcitriol 0.25 mcg, 0.5
mcg
110
calcitriol 1 mcg/ml
110
CALCIUM &
MAGNESIUM
132
calcium 600 mg
132
calcium acetate (phosphate
binder)
115
calcium ascorbate
167
calcium carbonate (antacid)
500 mg, 750 mg
15
calcium carbonate (antacid)
600 mg
15
calcium carbonate 1250
mg
132
calcium carbonate 1250 mg,
500 mg, 600 mg, 600mg 132
calcium carbonate 1500
mg
132
CALCIUM CARBONATE 648
MG
15
calcium carbonatecholecalciferol 500mg100unit
132
calcium carbonate-cholecalciferol
600mg-500unit
132
calcium carbonate-vitamin d
125unit-250mg, 125unit-500mg,
250mg-125unit, 500mg125unit
132
calcium carbonate-vitamin d
200unit-500mg, 500mg-200unit,
500mg-500mg-200unit-200unit
132
calcium citrate 200 mg, 950
mg
132
CALCIUM CITRATE 250
MG
132
calcium citrate-vitamin d 250mg200unit, 315mg-200unit
132
calcium gluconate 10 %
132
CALCIUM GLUCONATE 500
MG
132
CALCIUM LACTATE 648
MG
132
calcium polycarbophil
121
calcium w/ magnesium 500mg250mg
132
CALCIUM/VITAMIN D
132
CALCIUM/VITAMIN D3
132
CAMPRAL
154
CAMPTOSAR 100 MG/5ML, 40
MG/2ML
62
CAMPTOSAR 300
MG/15ML
62
CANCIDAS 50 MG
41
CANCIDAS 70 MG
41
candesartan cilexetil
47
candesartan cilexetilhydrochlorothiazide
49
CAPASTAT SULFATE
51
CAPRELSA
57
capsaicin in lidocaine vehicle97
captopril &
hydrochlorothiazide
49
captopril 100 mg, 12.5 mg, 25
mg, 50 mg
46
CARAC
90
CARAFATE 1 GM
161
carbamazepine 100 mg
25
carbamazepine 100 mg, 200 mg,
300 mg
25
carbamazepine 100 mg/5ml 25
carbamazepine 200 mg
25
carbamazepine 200 mg, 400
mg
26
carbamide peroxide
136
carbamide peroxide (otic) 151
Index 6
CARBATROL
26
carbidopa
62
carbidopa-levodopa
63
carbinoxamine maleate
43
carboplatin 150 mg/15ml, 600
mg/60ml
52
carboplatin 450 mg/45ml, 50
mg/5ml
52
CARDIZEM
76
CARDIZEM CD
76
CARDIZEM LA 180 MG, 240 MG,
300 MG, 360 MG, 420 MG 76
CARDURA
48
carisoprodol 350 mg
141
CARMOL
95
CARMOL 20
95
CARNITOR 330 MG
110
CARRAFOAM
99
carteolol hcl (ophth)
147
carvedilol
75
CASODEX
55
CATAFLAM
5
CATAPRES
48
CATAPRES-TTS-1
48
CATAPRES-TTS-2
48
CATAPRES-TTS-3
48
CAVILON NO STING
BARRIERFILM
99
CAYSTON
16
cefaclor 250 mg, 500 mg
79
cefadroxil
78
cefazolin sodium 1 gm, 10 gm,
500 mg
78
cefdinir
79
CEFEPIME 1 GM/50ML, 2
GM/100ML
80
cefepime hcl
80
cefixime 100 mg
79
cefixime 100 mg/5ml, 200
mg/5ml
79
cefixime 200 mg
79
cefixime 400 mg
79
cefotaxime sodium 1 gm, 10
gm
79
cefotaxime sodium 2 gm, 500
mg
79
cefpodoxime proxetil
79
cefprozil
79
ceftazidime 1 gm, 2 gm
79
ceftazidime 6 gm
79
Index 7
CEFTIN 125 MG/5ML
79
CEFTIN 250 MG, 500 MG 79
ceftriaxone sodium 1 gm 80
ceftriaxone sodium 10 gm 80
ceftriaxone sodium 2 gm 80
ceftriaxone sodium 250 mg80
ceftriaxone sodium 500 mg80
cefuroxime axetil
79
cefuroxime sodium 1.5 gm, 7.5
gm
79
cefuroxime sodium 750 mg79
CELEBREX
5
celecoxib
5
CELESTONE-SOLUSPAN 83
CELEXA 10 MG
30
CELEXA 20 MG
30
CELEXA 40 MG
30
CELLCEPT 200 MG/ML 73
CELLCEPT 250 MG
73
CELLCEPT 500 MG
74
CELLCEPT
INTRAVENOUS
73
CELONTIN
28
CENTANY
88
CEO-TWO
122
cephalexin 125 mg/5ml, 250
mg/5ml
79
cephalexin 250 mg, 500 mg,
750 mg
78
CERALYTE 70 60MEQ/L70MEQ/L-20MEQ/L-30MEQ/L,
70MEQ/L-20MEQ/L
133
CERASPORT 4MEQ/L18MEQ/L-20MEQ/L-69MEQ/L,
4MEQ/L-18MEQ/L-20MEQ/L6MEQ/L
133
CERASPORT EX1
133
CERDELGA
117
CEREBYX 100 MG
PE/2ML
28
CEREBYX 500 MG
PE/10ML
28
CEREFOLIN
106
CEREZYME
117
CERVARIX
163
CESAMET
41
CETAPHIL
ANTIBACTERIAL
68
CETAPHIL GENTLE
CLEANSER
99
CETAPHIL GENTLE
CLEANSING
99
cetirizine hcl 1 mg/ml
43
cetirizine hcl 1 mg/ml, 5
mg/5ml
43
cevimeline hcl
137
CHANTIX
157
CHANTIX CONTINUING
MONTHPAK
157
CHEK-STIX COMBO PAK
URINALYSIS CONTROL 104
CHEK-STIX CONTROL
104
CHEMSTRIP -10 WITH SG 104
CHEMSTRIP 10 MD
104
CHEMSTRIP 2 GP STRIPS105
CHEMSTRIP 2 LN STRIPS 105
CHEMSTRIP 5 OB
105
CHEMSTRIP 7
105
CHEMSTRIP 9 STRIPS
105
CHEMSTRIP UGK
105
CHEMSTRIP-K
105
CHEMSTRIP-MICRAL
105
chenodiol
113
CHERRY CONCENTRATE 153
CHERRY SYRUP
153
CHEW Q 100 MG
2
CHILDRENS MOTRIN 40
MG/ML
5
CHILDRENS MOTRIN 50 MG 5
CHILDRENS MOTRIN JUNIOR
STRENGTH
5
CHLOR-TRIMETON
42
chloramphenicol sodium
succinate
17
chlordiazepoxide-amitriptyline
155
chlorhexidine gluconate (mouththroat)
137
chloroquine phosphate 250 mg,
500 mg
50
chlorothiazide 500 mg
107
chlorpheniramine &
phenylephrine
85
chlorpheniramine & pseudoeph
15mg/5ml-1mg/5ml
85
chlorpheniramine maleate 2
mg/5ml
42
chlorpheniramine maleate 4
mg
42
chlorpheniramine w/ codeine 85
chlorpheniramine-phenylephrineacetaminophen 1mg/5ml160mg/5ml-2.5mg/5ml
85
chlorpromazine hcl 10 mg, 100
mg, 200 mg, 25 mg, 50 mg 66
chlorpromazine hcl 25 mg/ml 66
chlorpromazine hcl 50
mg/2ml
66
chlorthalidone 25 mg, 50
mg
107
chlorzoxazone
141
cholecalciferol 1000 unit, 2000
unit, 400 unit
166
cholecalciferol 1000 unit, 2000
unit, 400 unit, 5000 unit
166
cholecalciferol 400 unit/ml 166
cholecalciferol 400
unt/0.03ml
166
cholecalciferol 5000 unit
166
cholestyramine 4 gm
44
cholestyramine 4 gm/dose 44
cholestyramine light
44
choline fenofibrate
45
chorionic gonadotropin
109
chromium 200 mcg
135
chromium picolinate 200
mcg
136
ciclopirox 0.77 %
89
ciclopirox 1 %
89
ciclopirox 8 %
89
ciclopirox olamine
89
cidofovir
71
cilostazol
117
CILOXAN
147
cimetidine 200 mg
160
cimetidine 300 mg, 400 mg, 800
mg
160
CIMZIA
114
CIMZIA STARTER KIT
114
CINRYZE
116
CIPRO 250 MG, 500 MG 112
CIPRO I.V.-IN D5W
200MG/100ML-5%
112
CIPRO I.V.-IN D5W
400MG/200ML-5%
112
CIPRO XR
112
CIPRODEX
151
ciprofloxacin 400 mg/40ml 112
ciprofloxacin hcl (ophth)
148
ciprofloxacin hcl 100 mg, 250 mg,
500 mg, 750 mg
112
ciprofloxacin in d5w
200mg/100ml-5%
112
ciprofloxacin in d5w
400mg/200ml-5%
112
ciprofloxacin-ciprofloxacin
hcl
112
cisplatin
52
citalopram hydrobromide 10
mg
30
citalopram hydrobromide 10
mg/5ml
30
citalopram hydrobromide 20
mg
30
citalopram hydrobromide 40
mg
30
CITRACAL/VITAMIN D 132
CITRUCEL FIBER
LAXATIVE
121
cladribine
53
CLAFORAN 1 GM, 10 GM 80
CLAFORAN 2 GM, 500
MG
80
CLARINEX 5 MG
43
CLARINEX REDITABS 5
MG
43
clarithromycin 125 mg/5ml, 250
mg/5ml
124
clarithromycin 250 mg, 500
mg
124
clarithromycin 500 mg
124
clemastine fumarate 2.68
mg
43
CLEOCIN 150 MG, 300 MG, 75
MG
17
CLEOCIN 2 %
165
CLEOCIN IN D5W
17
CLEOCIN PHOSPHATE
300MG/50ML-5%,
600MG/50ML-5%,
900MG/50ML-5%
17
CLEOCIN PHOSPHATE 600
MG/4ML, 900 MG/6ML
17
CLEOCIN-T
87
CLIMARA
112
CLINDAGEL
87
clindamycin hcl 150 mg, 300
mg, 75 mg
17
clindamycin palmitate
hydrochloride
17
clindamycin phosphate
(topical)
87
clindamycin phosphate 150
mg/ml, 600 mg/4ml
17
clindamycin phosphate 150
mg/ml, 9000 mg/60ml
17
clindamycin phosphate 600
mg/4ml, 900 mg/6ml
17
clindamycin phosphate in
d5w
17
clindamycin phosphate
vaginal
165
clindamycin phosphate-benzoyl
peroxide
87
clindamycin phosphate-benzoyl
peroxide (refrigerate)
87
CLINISTIX
105
CLINITEST
105
CLINITEST REAGENT
105
clobetasol propionate
92
clobetasol propionate emollient
base
92
clobetasol propionate
emulsion
92
CLOBEX
92
CLOLAR
53
clomipramine hcl 25 mg, 50 mg,
75 mg
32
clonazepam 0.125 mg, 0.25 mg,
0.5 mg, 1 mg, 2 mg
25
clonazepam 0.5 mg
25
clonazepam 1 mg
25
clonazepam 2 mg
25
clonidine hcl (adhd)
1
clonidine hcl 0.1 mg, 0.2 mg, 0.3
mg
48
clonidine hcl 0.1 mg/24hr, 0.2
mg/24hr, 0.3 mg/24hr
48
clopidogrel bisulfate 300
mg
117
clopidogrel bisulfate 75 mg 117
clorazepate dipotassium
19
clotrimazole
137
clotrimazole (topical)
89
clotrimazole vaginal 1 %
165
clotrimazole w/
betamethasone
89
CLOVERINE SALVE
89
clozapine
65
CLOZAPINE ODT
65
CLOZARIL
65
COAL TAR
81
coal tar extract 1 %
104
coal tar extract 1 %, 15 % 104
COARTEM
50
Index 8
cod liver oil 10 minim, 110mg2664unit-1000mg-100mg200unit, 1250unit-130unit,
1250unit-133.33unit, 1250unit133unit, 1250unit-135unit,
200unit-4000unit, 20mg-35mg1250unit-45mg-133.333unit,
34mg-1250unit-415mg-32mg135unit, 50mg-110mg-250unit110mg-100unit-10unit, 52mg2500unit-600mg-52mg-270unit,
530mg-1250unit-130unit, 90mg37mg-415mg-36mg-1250unit135unit
140
COD LIVER OIL 4000UNIT/5ML400UNIT/5ML, 5000UNIT/5ML500UNIT/5ML
140
COD LIVER OIL FOR KIDS140
coenzyme q10 (ubidecarenone)
10 mg, 60 mg
2
coenzyme q10 (ubidecarenone)
150 mg, 30 mg
2
COENZYME Q10 25 MG
3
COENZYME Q10 60 MG
2
COGENTIN
62
COLACE
123
COLACE CLEAR
123
COLAZAL
114
COLCHICINE
116
colchicine w/ probenecid 116
COLCRYS
116
COLESTID
44
COLESTID FLAVORED 5
GM
44
colestipol hcl
44
colistimethate sodium
16
COLY-MYCIN M
16
COLYTE-FLAVOR PACKS
227.1GM-21.5GM-5.53GM2.82GM-6.36GM
122
COLYTE-FLAVOR PACKS
240GM-22.72GM-5.84GM2.98GM-6.72GM
122
COMBISTIX
105
COMBIVENT RESPIMAT
22
COMBIVIR
68
COMETRIQ
57
COMPLERA
68
COMPLEX MSUD AMINO ACID
BAR
145
COMTAN
62
COMVAX
163
CONCERTA 27 MG, 36 MG 2
Index 9
CONDOMS
124
CONDYLOX
96
CONTI CASTILE SOAP 99
CONTRAVE
1
COPAXONE
156
COPEGUS
71
CORAL CALCIUM 500
MG
132
CORDARONE
20
COREG
75
COREG CR
75
CORGARD
76
CORLANOR
78
CORTEF
83
CORTENEMA
14
cortisone acetate
83
CORTISPORIN
10000UNIT/ML-3.5MG/ML-1%
151
CORZIDE
49
COSENTYX
90
COSENTYX SENSOREADY
PEN
91
COSMEGEN
56
COSOPT
147
COUMADIN 1 MG, 10 MG, 2
MG, 2.5 MG, 3 MG, 4 MG, 5
MG, 6 MG, 7.5 MG
24
COZAAR
47
CREON
106
CRESEMBA 186 MG
42
CRESEMBA 372 MG
42
CRESTOR
45
CRIXIVAN
68
cromolyn sodium
21
cromolyn sodium
(mastocytosis)
113
cromolyn sodium (ophth) 149
CUBICIN
17
CUPRIMINE
73
CUTAR
104
CUTIVATE
93
CVS COD LIVER OIL
140
CVS GLUCOSE 4 GM
35
CVS HDYROCORTISONE
ACETATE
93
CVS KETONE CARE
105
CVS NATURAL FIBER
SUPPLEMENT
121
CVS SALINE WOUND
WASH
100
cyanocobalamin 1000 mcg 117
cyanocobalamin 250 mcg 118
cyclobenzaprine hcl 10 mg, 5
mg
141
cyclopentolate hcl 1 %
147
cyclophosphamide 25 mg, 50
mg
52
CYCLOSET
36
cyclosporine 100 mg, 25 mg 74
cyclosporine 50 mg/ml
74
cyclosporine modified (for
microemulsion) 100 mg, 25 mg,
50 mg
74
CYKLOKAPRON
120
CYMBALTA
31
cyproheptadine hcl 2 mg/5ml 44
cyproheptadine hcl 4 mg
44
CYRAMZA
54
CYSTARAN
149
cytarabine 100 mg/ml
53
cytarabine 20 mg/ml
53
CYTOMEL
159
CYTOTEC
162
CYTOVENE
71
D-VI-SOL
166
D.H.E. 45
130
dacarbazine 100 mg
59
dacarbazine 200 mg
59
DACOGEN
53
dakin's solution 0.25 %, 0.5
%
68
DALIRESP
21
danazol 100 mg, 200 mg, 50
mg
13
DANTRIUM
142
dantrolene sodium 100 mg, 25
mg, 50 mg
142
dapsone 100 mg, 25 mg
17
DAPTACEL
159
DARA
100
DARAPRIM
50
daunorubicin hcl
56
DAUNOXOME
56
DAYPRO
5
DDAVP
111
DEBROX
151
decitabine
53
DECON-A 2MG/5ML5MG/5ML
85
DEEP BLUE RELIEF
97
DELESTROGEN 10
MG/ML
112
DELESTROGEN 20 MG/ML, 40
MG/ML
112
DELZICOL
114
DEMADEX
107
demeclocycline hcl
158
DEMEROL 100 MG/ML, 50
MG/ML
8
DEMEROL 25 MG/ML
9
DEMSER
47
DENAVIR
91
DEPACON
28
DEPAKENE
29
DEPAKOTE
29
DEPAKOTE ER
29
DEPAKOTE SPRINKLES
29
DEPEN TITRATABS
73
DEPO-MEDROL 20 MG/ML 83
DEPO-MEDROL 40 MG/ML, 80
MG/ML
83
DEPO-PROVERA
55
DEPO-PROVERA
CONTRACEPTIVE
82
DERMA-SMOOTHE/FS
BODY
93
DERMA-SMOOTHE/FS
SCALP
93
DERMAGRAN
98
DERMAREST ROSACEA 98
dermatological products, misc.
0.17%-2.7%, 4%-2%-0.5% 98
DERMATOP
93
DERMAZINC BABY
91
DERMAZINC SCALP
91
DERMAZINC SPRAY
91
DERMOPLAST
97
DERMOPLAST PAIN
RELIEVINGSPRAY
97
DERMOTIC
151
desipramine hcl 10 mg, 100 mg,
150 mg, 25 mg, 50 mg, 75
mg
32
desloratadine 5 mg
43
desmopressin acetate 0.1 mg,
0.2 mg
111
desmopressin acetate 4
mcg/ml
111
desmopressin acetate
refrigerated
111
desmopressin acetate
spray
111
desmopressin acetate spray
refrigerated
111
DESOGEN
81
desogestrel & ethinyl
estradiol
81
desogestrel-ethinyl estradiol
(biphasic)
81
desonide
93
DESOWEN
93
desoximetasone 0.05 % 93
desoximetasone 0.25 % 93
DESOXYN
1
DESVENLAFAXINE ER 100
MG, 50 MG
31
DETROL
163
DETROL LA
163
DEX4 QUICK DISSOLVE
GLUCOSE
35
dexamethasone 0.5 mg, 0.75
mg, 1 mg, 1.5 mg, 2 mg, 4 mg,
6 mg
83
dexamethasone 0.5
mg/5ml
83
dexamethasone sodium
phosphate (ophth)
149
dexamethasone sodium
phosphate 10 mg/ml
83
dexamethasone sodium
phosphate 10 mg/ml, 120
mg/30ml
83
dexamethasone sodium
phosphate 100 mg/10ml, 20
mg/5ml, 4 mg/ml
83
DEXATRIM MAX 1MG5.5UNIT-34MCG-72MG-75MG0.35MG-70MG-45MG0.263MG-10MG-1.8MG-3.5MG0.3MG-3MCG-70MCG0.35MG-25MG-30MG
106
dexbrompheniramine &
pseudoephedrine
85
DEXEDRINE
1
DEXILANT
161
dexmethylphenidate hcl 10 mg,
2.5 mg, 5 mg
2
dexmethylphenidate hcl 15
mg
2
dexrazoxane
60
dextroamphetamine sulfate 10
mg, 15 mg, 5 mg
1
dextroamphetamine sulfate 10
mg, 5 mg
1
dextrose (diabetic use) 15
gm/38gm, 40 %
35
dextrose 10 %
144
dextrose 5 %
144
dextrose in lactated ringers 133
dextrose w/ sodium chloride
0.45%-2.5%, 0.45%-5%
133
dextrose w/ sodium chloride
0.9%-5%
133
DHS
100
DHS COLOR SAFE
SHAMPOO
100
DHS CONDITIONING
RINSE
100
DHS ZINC
91
DIABETA 1.25 MG
38
DIABETA 2.5 MG
38
DIABETA 5 MG
38
DIABETIDERM
CLEANSING
100
DIAMOX
106
DIASTAT ACUDIAL
25
DIASTAT PEDIATRIC
25
DIASTIX
105
diazepam 1 mg/ml
19
diazepam 10 mg, 2 mg, 5
mg
19
DIAZEPAM 10 MG, 2.5 MG, 20
MG
25
diazepam 5 mg/ml
19
DIBENZYLINE
47
diclofenac potassium
5
diclofenac sodium (actinic
keratoses)
90
diclofenac sodium (ophth) 149
diclofenac sodium 100 mg
5
diclofenac sodium 25 mg, 50 mg,
75 mg
5
diclofenac w/ misoprostol
5
dicloxacillin sodium
153
dicyclomine hcl 10 mg
160
dicyclomine hcl 20 mg
160
didanosine
68
diethylpropion hcl 25 mg
1
DIETHYLPROPION HCL 25
MG
1
diethylpropion hcl 75 mg
1
DIFFERIN 0.1 %
87
DIFICID
124
diflorasone diacetate
93
DIFLUCAN
42
Index 10
diflunisal
8
DIGOXIN 0.05 MG/ML
77
digoxin 0.125 mg, 0.25 mg, 125
mcg, 250 mcg
77
dihydroergotamine mesylate 1
mg/ml
130
DILANTIN-125
28
DILAUDID 1 MG/ML
9
DILAUDID 2 MG
9
DILAUDID 2 MG/ML
9
DILAUDID 4 MG
9
DILAUDID 8 MG
9
DILAUDID-HP 10 MG/ML
9
diltiazem hcl 120 mg, 180 mg,
240 mg
77
diltiazem hcl 120 mg, 30 mg, 60
mg, 90 mg
77
diltiazem hcl 120 mg, 60 mg, 90
mg
77
diltiazem hcl coated beads 76
diltiazem hcl extended release
beads
77
DIMETAPP COLD & ALLERGY
1MG/5ML-2.5MG/5ML
85
dimethicone-zinc oxide-vitamin avitamin d
100
DIOVAN
47
DIOVAN HCT
49
DIPENTUM
114
diphenhydramine hcl
(topical)
90
diphenhydramine hcl 12.5
mg
43
diphenhydramine hcl 12.5
mg/5ml
43
diphenhydramine hcl 12.5
mg/5ml, 25 mg/10ml, 50
mg/20ml
43
diphenhydramine hcl 25 mg 43
diphenhydramine hcl 50
mg/ml
43
diphenhydramine-phenylephrine
12.5mg/5ml-5mg/5ml
85
diphenhydramine-phenylephrine
25mg-10mg
85
diphenhydramine-phenylephrineacetaminophen 12.5mg-12.5mg325mg-325mg-5mg-5mg,
12.5mg-325mg-5mg
85
diphenhydramine-phenylephrineacetaminophen 12.5mg/5ml160mg/5ml-2.5mg/5ml
85
diphenhydraminepseudoephedrine-acetaminophen
85
Index 11
diphenhydramine-zinc acetate
0.1%-1%
90
diphenoxylate w/ atropine 39
DIPHTHERIA/TETANUS
TOXOIDS ADSORBED
PEDIATRIC
159
DIPROLENE
93
DIPROLENE AF
93
dipyridamole 25 mg, 50 mg, 75
mg
117
disopyramide phosphate 20
disulfiram 250 mg, 500
mg
154
DITROPAN XL
163
divalproex sodium
29
DIVIGEL
112
dobutamine hcl
166
DOCEFREZ
61
docetaxel 140 mg/7ml, 20
mg/ml, 80 mg/4ml
61
DOCETAXEL 160 MG/16ML,
20 MG/2ML, 200 MG/20ML, 80
MG/8ML
61
DOCETAXEL 20 MG/ML, 80
MG/4ML
61
docosahexaenoic acid 200
mg
144
docusate calcium
123
docusate sodium 100 mg 123
docusate sodium 100 mg, 250
mg, 50 mg
123
docusate sodium 150 mg/15ml,
50 mg/5ml
123
docusate sodium 283 mg 123
docusate sodium 60
mg/15ml
123
DOCUSOL KIDS
123
DOLOPHINE 10 MG
9
DOLOPHINE 5 MG
9
DOMEBORO 1347MG952MG
100
donepezil hydrochloride 154
DORYX 150 MG
158
dorzolamide hcl
150
dorzolamide hcl-timolol
maleate
147
DOVONEX
91
doxazosin mesylate
48
doxepin hcl 10 mg, 100 mg,
150 mg, 25 mg, 50 mg, 75
mg
33
doxepin hcl 10 mg/ml
33
DOXIL
56
doxorubicin hcl 10 mg
57
doxorubicin hcl 2 mg/ml
57
doxorubicin hcl 50 mg
57
doxorubicin hcl liposomal
56
doxycycline (monohydrate) 100
mg, 150 mg, 50 mg, 75 mg 158
doxycycline (monohydrate) 100
mg, 50 mg, 75 mg
158
doxycycline (monohydrate) 25
mg/5ml
158
doxycycline hyclate 100 mg 158
doxycycline hyclate 100 mg, 20
mg
158
doxycycline hyclate 100 mg, 50
mg
158
doxycycline hyclate 150 mg 158
DRISDOL
166
DRIXORAL
COLD/ALLERGY
85
dronabinol
41
drospirenone-ethinyl
estradiol
81
DROXIA
117
DUAC
87
DUETACT
33
DULCOLAX
123
DULCOLAX BOWEL PREP
KIT
123
DULERA
23
duloxetine hcl 20 mg, 30 mg, 60
mg
31
DUONEB
23
DUOPA
63
DURAGESIC 100 MCG/HR 9
DURAGESIC 12 MCG/HR
9
DURAGESIC 25 MCG/HR
9
DURAGESIC 50 MCG/HR
9
DURAGESIC 75 MCG/HR
9
dutasteride
115
DYAZIDE
107
dyphylline-guaifenesin
21
E-Z SPACER
127
E-Z SPACER THE BODY
GUARDS PACK
127
EASIVENT
127
EASIVENT/MASK-LARGE 127
EASIVENT/MASK-MEDIUM
127
EASIVENT/MASK-SMALL 127
EC-NAPROSYN
5
econazole nitrate
89
ECOTRIN MAXIMUM
STRENGTH
8
ECOTRIN REGULAR
STRENGTH
8
ED CHLORPED
42
ED CHLORPED D
85
EDURANT
68
EFFEXOR XR 150 MG
31
EFFEXOR XR 37.5 MG
31
EFFEXOR XR 75 MG
31
EFFIENT
117
EFUDEX
90
EGRIFTA 2 MG
109
ELDEPRYL
63
ELELYSO
117
ELESTAT
150
ELETONE
98
ELETONE TWINPACK
98
ELIDEL
96
ELIGARD
55
ELIQUIS
24
ELITEK
60
ELIXSURE CONGESTION 143
ELIXSURE FEVER/PAIN
8
ELLA
82
ELLENCE
57
ELOCON
93
ELOXATIN
52
ELTA CLEANSE FOAM
100
ELTA LITE TAR
104
ELTA TAR
104
EMCYT
55
EMEND 125 MG, 80 MG
41
EMEND 40 MG
41
EMLA
97
EMSAM
30
EMTRIVA
68
enalapril maleate &
hydrochlorothiazide
49
enalapril maleate 10 mg, 2.5 mg,
20 mg, 5 mg
46
ENBREL
7
ENBREL SURECLICK
7
ENCARE
164
ENFALYTE
133
ENFAMIL ENFALYTE
133
ENGERIX-B 10 MCG/0.5ML, 20
MCG/ML
163
enoxaparin sodium
24
entacapone
62
entecavir
71
ENTOCORT EC
83
ENTRESTO
78
ENTSOL HYPERTONIC
NASAL IRRIGATION
MIST
142
ENTSOL NASAL SPRAY 142
ENTSOL NASAL WASH 142
ENTYVIO
114
ENUCLENE
150
EPHEDRINE HCL
23
EPHEDRINE SULFATE 23
epinastine hcl (ophth)
150
EPINEPHRINE 0.15
MG/0.15ML, 0.3
MG/0.3ML
165
epinephrine hcl 0.1 mg/ml 23
EPIPEN 2-PAK
165
EPIPEN-JR 2-PAK
165
epirubicin hcl 200 mg/100ml, 50
mg/25ml
57
EPIVIR 10 MG/ML
68
EPIVIR 150 MG, 300 MG 68
EPIVIR HBV 100 MG
71
EPIVIR HBV 5 MG/ML
71
eplerenone
50
EPOGEN
118
eprosartan mesylate
47
EPZICOM
68
EQL CALCIUM/VITAMIN
D
133
EQL CHILDRENS
MULTIVITAMINS
139
EQL NATURAL FIBER 121
EQUETRO
64
ERAXIS 100 MG
41
ERBITUX
54
ergocalciferol 50000 unit 166
ergocalciferol 8000
unit/ml
166
ergoloid mesylates
156
ergotamine tartrate
130
ERIVEDGE
55
ERWINAZE
59
erythromycin (acne aid)
87
erythromycin (ophth)
148
erythromycin base 250
mg
124
erythromycin base 500 mg 124
erythromycin
ethylsuccinate
124
erythromycin lactobionate 124
erythromycin stearate
124
ESBRIET
158
escitalopram oxalate
30
esomeprazole magnesium 20
mg
161
esomeprazole magnesium 40
mg
161
ESOMEPRAZOLE
STRONTIUM
161
estradiol & norethindrone
acetate
111
estradiol 0.025 mg/24hr, 0.05
mg/24hr, 0.06 mg/24hr, 0.075
mg/24hr, 0.1 mg/24hr, 37.5
mcg/24hr
112
estradiol 0.5 mg, 1 mg, 2
mg
112
estradiol vaginal
165
estradiol valerate 10 mg/ml, 20
mg/ml, 40 mg/ml
112
estradiol-norgestimate
111
estropipate 0.75 mg, 1.5
mg
112
ethambutol hcl 100 mg, 400
mg
51
ethosuximide 250 mg
28
ethosuximide 250 mg/5ml 28
ethynodiol diacet & eth
estrad
81
ETHYOL
60
etodolac 200 mg, 300 mg
5
etodolac 400 mg, 500 mg
5
etodolac 400 mg, 500 mg, 600
mg
5
ETOPOPHOS
61
etoposide 1 gm/50ml, 100
mg/5ml
61
etoposide 500 mg/25ml
61
EVAC
121
EVISTA
109
EVOCLIN
87
EVOTAZ
68
EVOXAC
137
EX-LAX
123
EXELON 1.5 MG, 3 MG, 4.5 MG,
6 MG
154
EXELON 13.3 MG/24HR, 4.6
MG/24HR, 9.5 MG/24HR 154
exemestane
55
Index 12
EXJADE
40
EXPECTA LIPIL
144
EXTAVIA
156
EXTINA
89
EYE STREAM
150
FA-8
118
FABRAZYME 35 MG
110
famciclovir
72
famotidine 10 mg
160
famotidine 20 mg
160
famotidine 20 mg/2ml, 200
mg/20ml, 40 mg/4ml
160
famotidine 40 mg
160
famotidine 40 mg/5ml
160
FAMVIR
72
FANAPT
64
FARESTON
55
FARXIGA
38
FARYDAK
57
FASLODEX
55
fat emulsion 20 gm/100ml 144
FAZACLO
65
felbamate
28
FELBATOL
28
FELDENE
5
felodipine
77
FEMARA
55
FEMCON FE
81
FEMINEASE
164
fenofibrate 145 mg, 160 mg, 48
mg, 54 mg
45
fenofibrate micronized
45
fentanyl 100 mcg/hr
9
fentanyl 12 mcg/hr
9
fentanyl 25 mcg/hr
9
fentanyl 50 mcg/hr
9
fentanyl 75 mcg/hr
9
fentanyl citrate 1200 mcg, 1600
mcg, 400 mcg, 600 mcg, 800
mcg
9
fentanyl citrate 200 mcg
9
FER-IN-SOL
119
FERGON
119
FERRIPROX
40
ferrous fumarate 324 mg, 325
mg
119
FERROUS FUMARATE 90
MG
119
Index 13
FERROUS GLUCONATE 225
MG
119
ferrous gluconate 240 mg, 27
mg
119
ferrous sulfate 15 mg/ml 119
ferrous sulfate 220
mg/5ml
119
FERROUS SULFATE 220
MG/5ML
119
FERROUS SULFATE 300
MG/5ML
119
FERROUS SULFATE 324
MG
119
ferrous sulfate 325 mg
119
ferrous sulfate 325 mg, 65
mg
119
ferrous sulfate 50 mg
119
ferrous sulfate dried 160
mg
119
FETZIMA 120 MG, 40 MG, 80
MG
31
FETZIMA 20 MG
32
FETZIMA TITRATION
PACK
32
FEVERALL INFANTS
8
FIBERCON
121
FINACEA
103
finasteride
115
FIORINAL/CODEINE #3 12
FIRAZYR
116
FIRMAGON
55
FLAGYL
16
flavoxate hcl
163
FLEBOGAMMA DIF 10 %151
flecainide acetate 100 mg 20
flecainide acetate 150 mg 20
flecainide acetate 50 mg 20
FLECTOR
88
FLEET BISACODYL
123
FLEET LIQUID GLYCERIN
SUPPOSITORIES
122
FLEXICHAMBER
127
FLOMAX
115
FLONASE
143
FLORICAL
134
FLOVENT DISKUS 100
MCG/BLIST
22
FLOVENT DISKUS 250
MCG/BLIST
22
FLOVENT DISKUS 50
MCG/BLIST
22
FLOVENT HFA 110 MCG/ACT,
220 MCG/ACT
22
FLOVENT HFA 44
MCG/ACT
22
fluconazole 10 mg/ml, 40
mg/ml
42
fluconazole 100 mg, 150 mg, 200
mg, 50 mg
42
fluconazole in dextrose
42
fluconazole in nacl 200mg/100ml0.9%, 400mg/200ml-0.9% 42
flucytosine
41
FLUDARA
53
fludarabine phosphate 50
mg
53
fludrocortisone acetate
84
FLUMADINE
73
flunisolide (nasal)
143
fluocinolone acetonide
(otic)
151
fluocinolone acetonide 0.01
%
93
fluocinolone acetonide 0.01 %,
0.025 %
93
fluocinolone acetonide 0.025
%
93
fluocinonide 0.05 %
93
fluocinonide emulsified base 93
fluorometholone (ophth)
149
fluorouracil (topical)
90
FLUOROURACIL 0.5 %
90
fluorouracil 1 gm/20ml
53
fluorouracil 2.5 gm/50ml, 5
gm/100ml, 500 mg/10ml
53
fluoxetine hcl (PMDD) cap 10 mg,
20 mg
156
fluoxetine hcl 10 mg, 20 mg 30
fluoxetine hcl 10 mg, 20 mg, 40
mg
30
fluoxetine hcl 20 mg/5ml
30
fluoxetine hcl 90 mg
30
fluoxymesterone
13
fluphenazine decanoate
66
fluphenazine hcl 1 mg, 10 mg, 2.5
mg, 5 mg
66
fluphenazine hcl 2.5 mg/ml 66
fluphenazine hcl 5 mg/ml
66
flurbiprofen 100 mg, 50 mg
5
flurbiprofen sodium
150
flutamide
55
fluticasone propionate
(nasal)
143
fluticasone propionate 0.005
%
94
fluticasone propionate 0.05
%
94
fluvastatin sodium 20 mg, 40
mg
45
fluvoxamine maleate
30
FML LIQUIFILM
149
FOCALIN
2
FOCALIN XR 15 MG
2
FOLGARD RX
118
FOLIC + B12
118
folic acid 1 mg
118
FOLIC ACID 20 MG, 5 MG 118
folic acid 400 mcg, 800
mcg
118
folic acid-pyridoxinecyancobalamin
106
folic acid-vitamin b6-vitamin
b12
119
FOLOTYN
53
FOLTRATE
119
fondaparinux sodium
24
FORADIL AEROLIZER
23
FORFIVO XL
29
FORMULA 405 FACIAL &
BODYCLEANSING
100
FORMULA 405
MOISTURIZINGSOAP
100
FORTAMET 1000 MG
34
FORTAMET 500 MG
34
FORTAZ 1 GM, 2 GM
80
FORTAZ 6 GM
80
FORTEO
108
FORTICAL
108
FOSAMAX
108
fosinopril sodium
47
fosinopril sodium &
hydrochlorothiazide
49
fosphenytoin sodium 100 mg
pe/2ml
28
fosphenytoin sodium 500 mg
pe/10ml
28
FOSRENOL
115
FRAGMIN 10000 UNIT/ML,
12500 UNIT/0.5ML, 15000
UNIT/0.6ML, 18000 UNT/0.72ML,
2500 UNIT/0.2ML, 25000
UNIT/ML, 5000 UNIT/0.2ML,
7500 UNIT/0.3ML
24
FRAGMIN 95000
UNIT/3.8ML
24
FREE & CLEAR
100
FRESH'N FEMININE
DEODORANT
98
furosemide 10 mg/ml
107
furosemide 20 mg, 40 mg, 80
mg
107
FUSILEV
60
FUZEON
68
FYCOMPA 10 MG
24
FYCOMPA 12 MG
24
FYCOMPA 2 MG
24
FYCOMPA 4 MG
24
FYCOMPA 6 MG
24
FYCOMPA 8 MG
25
gabapentin 100 mg, 300 mg,
400 mg
26
gabapentin 250 mg/5ml
26
gabapentin 600 mg, 800
mg
26
GABITRIL 12 MG, 16 MG 28
GABITRIL 2 MG, 4 MG
28
galantamine
hydrobromide
154
GAMASTAN S/D
151
GAMMAGARD LIQUID 151
GAMMAKED
151
GAMUNEX-C
151
ganciclovir sodium
71
GARDASIL
163
GAS-X EXTRA STRENGTH
125 MG
113
GASTROCROM
113
gatifloxacin (ophth)
148
gauze pads 2" X 2"
124
GAZYVA
54
gelatin 650 mg
73
GELONASAL
142
GELUSIL 200MG-25MG200MG
15
GEMCITABINE
53
gemcitabine hcl 1 gm, 200
mg
53
gemcitabine hcl 2 gm
54
gemfibrozil
45
GEMZAR
54
GENOTROPIN 5 MG
109
GENOTROPIN MINIQUICK 0.4
MG
109
gentamicin in saline 0.9%0.8mg/ml
3
gentamicin in saline 0.9%1.2mg/ml, 0.9%-1.6mg/ml,
0.9%-1mg/ml
3
gentamicin sulfate (ophth) 148
gentamicin sulfate (topical) 88
gentamicin sulfate 10 mg/ml 3
gentamicin sulfate 40 mg/ml 3
GENTEAL MILD TO
MODERATE
146
GENTLE RAIN EXTRA
MILD
100
GENTLE RAIN SHAMPOO AND
SKIN CLEANSER
100
GENTLE SKIN CLEANSER100
GEODON 20 MG
64
GEODON 20 MG, 40 MG, 60
MG, 80 MG
64
GERI-SHAMPOO/SHEA
BUTTER
100
GERISILK BATH OIL
91
GILENYA
156
GILOTRIF
57
GILTUSS PED-C
85
glatiramer acetate
156
GLEEVEC
57
GLEOSTINE
52
glimepiride 1 mg
38
glimepiride 2 mg
38
glimepiride 4 mg
38
glipizide 10 mg
38
glipizide 2.5 mg
38
glipizide 5 mg
38
glipizide-metformin hcl 2.5mg250mg
33
glipizide-metformin hcl 2.5mg500mg, 5mg-500mg
33
GLUCAGEN HYPOKIT
35
glucagon (rdna)
35
GLUCOPHAGE 1000 MG 34
GLUCOPHAGE 500 MG
34
GLUCOPHAGE 850 MG
34
GLUCOPHAGE XR 500 MG 34
GLUCOPHAGE XR 750 MG 34
glucosamine sulfate 500 mg 3
glucosamine-chondroitin 200mg250mg
3
GLUCOSE 4 GM
35
glucose 5 %
144
GLUCOSE NURSETTE
144
GLUCOTROL 10 MG
38
GLUCOTROL 5 MG
38
GLUCOTROL XL 10 MG
38
GLUCOTROL XL 2.5 MG
38
Index 14
GLUCOTROL XL 5 MG
38
GLUCOVANCE 1.25MG250MG
33
GLUCOVANCE 2.5MG-500MG,
5MG-500MG
34
GLUMETZA 1000 MG
35
GLUMETZA 500 MG
35
GLUTAMENT
145
GLUTOL
104
glyburide 1.25 mg
39
glyburide 2.5 mg
39
glyburide 5 mg
39
glyburide micronized 1.5 mg 39
glyburide micronized 3 mg 39
glyburide micronized 6 mg 39
glyburide-metformin 1.25mg250mg
34
glyburide-metformin 2.5mg500mg, 5mg-500mg
34
GLYCERIN 99 %, 99.5 %
80
GLYCERINE
80
GLYCEROL FORMAL
81
glycopyrrolate 0.2 mg/ml 160
glycopyrrolate 1 mg, 2 mg 160
GLYNASE 1.5 MG
39
GLYNASE 3 MG
39
GLYNASE 6 MG
39
GLYSET
33
GNP CALAMINE
100
GNP CALAMINE
PHENOLATED
100
GNP GLUCOSE 4 GM
35
GNP QUICK DISSOLVE
GLUCOSE
35
GNP SALINE WOUND
WASH
100
GOLYTELY 236GM-22.74GM5.86GM-2.97GM-6.74GM 122
GRANDPAS BAKING SODA
SOAP
100
GRANDPAS INDIAN CORN
SOAP
100
GRANDPAS LOVE MY LOOFAH
SOAP
100
GRANDPAS OATMEAL
SOAP
100
GRANDPAS ORANGE
ESSENCE SOAP
100
GRANDPAS PATCHOULI
SOAP
100
GRANDPAS PINE TAR
SOAP
104
Index 15
GRANDPAS SHEA BUTTER
SOAP
100
GRANDPAS WITCH HAZEL
SOAP
100
granisetron hcl 1 mg
40
GRANIX
118
GRIS-PEG
41
griseofulvin microsize
41
griseofulvin ultramicrosize 41
guaifenesin-codeine
100mg/5ml-10mg/5ml
86
guanfacine hcl
48
guanfacine hcl (adhd)
1
guanidine hcl
50
GYNE-LOTRIMIN
165
H.P. ACTHAR
109
HALAVEN
61
HALCION
120
HALDOL
65
HALDOL DECANOATE
100
65
HALDOL DECANOATE 50 65
halobetasol propionate
94
haloperidol
65
haloperidol decanoate 100
mg/ml, 50 mg/ml
65
haloperidol lactate
65
HARVONI
71
HAVRIX
163
HEMA-COMBISTIX
105
HEMOCYTE
119
HEMOCYTE-F
119
HEPAMENT
145
heparin sodium (porcine) 24
HEPSERA
71
HERCEPTIN
54
HETLIOZ
121
HEXALEN
52
HIPREX
162
HIZENTRA
152
HM CALAMINE
101
HPR PLUS
98
HUMALOG
36
HUMALOG KWIKPEN
36
HUMALOG MIX 50/50
36
HUMALOG MIX 50/50
KWIKPEN
36
HUMALOG MIX 75/25
36
HUMALOG MIX 75/25
KWIKPEN
37
HUMATROPE
109
HUMATROPE COMBO
PACK
109
HUMIRA
4
HUMIRA PEDIATRIC CROHNS
DISEASE STARTER PACK 4
HUMIRA PEN
4
HUMIRA PEN-CROHNS
DISEASESTARTER
4
HUMIRA PEN-PSORIASIS
STARTER
4
HUMULIN 70/30
37
HUMULIN 70/30 KWIKPEN 37
HUMULIN 70/30 PEN
37
HUMULIN N
37
HUMULIN N KWIKPEN
37
HUMULIN N U-100 PEN
37
HUMULIN R
37
HUMULIN R U-500
(CONCENTRATED)
37
HURRICAINE
136
HURRICAINE ONE
136
HYCAMTIN
62
hydralazine hcl 10 mg, 100 mg,
25 mg, 50 mg
50
HYDREA
59
hydrochlorothiazide 12.5
mg
107
hydrochlorothiazide 12.5 mg, 25
mg, 50 mg
107
HYDROCIL INSTANT
121
hydrocodone polistirexchlorpheniramine polistirex 86
hydrocodone w/
homatropine
84
hydrocodone-acetaminophen
10mg-300mg, 5mg-300mg,
7.5mg-300mg
12
hydrocodone-acetaminophen
10mg-325mg, 5mg-325mg,
7.5mg-325mg
12
hydrocodone-acetaminophen
2.5mg/5ml-108mg/5ml,
5mg/10ml-217mg/10ml,
7.5mg/15ml-325mg/15ml
12
hydrocodone-ibuprofen
12
hydrocortisone (intrarectal) 14
hydrocortisone (rectal)
14
hydrocortisone (topical) 0.5
%
94
hydrocortisone (topical) 1 % 94
hydrocortisone (topical) 2.5
%
94
hydrocortisone 10 mg, 20 mg, 5
mg
83
hydrocortisone acetate
(topical)
94
hydrocortisone butyrate
94
hydrocortisone butyrate
hydrophilic lipo base
94
hydrocortisone sod
succinate
83
hydrocortisone valerate
94
hydrocortisone w/acetic
acid
151
hydrocortisone-aloe vera
94
hydrogen peroxide (mouththroat)
137
hydrogen peroxide-benzyl
alcohol
137
hydromorphone hcl 1 mg/ml 9
hydromorphone hcl 10 mg/ml, 2
mg/ml, 50 mg/5ml, 500
mg/50ml
9
hydromorphone hcl 2 mg
9
hydromorphone hcl 4 mg
9
hydromorphone hcl 8 mg
9
HYDROPEL
101
hydrophilic ointment
153
hydroxychloroquine sulfate 50
hydroxyurea
59
hydroxyzine hcl 10 mg, 25 mg, 50
mg
19
hydroxyzine hcl 10 mg/5ml 19
hydroxyzine hcl 25 mg/ml, 50
mg/ml
19
hydroxyzine pamoate 25 mg, 50
mg
19
HYLATOPIC PLUS
98
hypromellose (ophth) 0.3 %, 3
mg/ml
146
HYQVIA
152
HYSINGLA ER 100 MG, 120
MG
10
HYSINGLA ER 20 MG, 30 MG,
40 MG, 60 MG, 80 MG
10
HYVEE ADVANCED ANTACID
MAXIMUM STRENGTH
15
HYZAAR
49
I.L.X. B-12
119
ibandronate sodium 150
mg
108
ibandronate sodium 3
mg/3ml
108
IBRANCE
57
ibuprofen 100 mg
5
ibuprofen 100 mg/5ml
5
ibuprofen 200 mg
5
ibuprofen 40 mg/ml, 50
mg/1.25ml
5
ibuprofen 400 mg
6
ibuprofen 600 mg
6
ibuprofen 800 mg
6
ICLUSIG
58
IDAMYCIN PFS
57
idarubicin hcl
57
IFEX 1 GM
52
IFEX 3 GM
52
ifosfamide 1 gm
52
ifosfamide 1 gm/20ml, 3
gm/60ml
52
IFOSFAMIDE 3 GM
52
ILARIS
4
ILEVRO
150
IMBRUVICA
58
imipenem-cilastatin
17
imipramine hcl 10 mg, 25 mg,
50 mg
33
imipramine pamoate
33
imiquimod
96
IMITREX 100 MG
130
IMITREX 25 MG
131
IMITREX 50 MG
131
IMITREX 6 MG/0.5ML
130
IMITREX STATDOSE REFILL
4 MG/0.5ML
130
IMITREX STATDOSE REFILL
6 MG/0.5ML
130
IMITREX STATDOSE SYSTEM
4 MG/0.5ML
130
IMITREX STATDOSE SYSTEM
6 MG/0.5ML
130
IMOVAX RABIES
(H.D.C.V.)
164
IMURAN
74
INCIVEK
71
INCRELEX
109
INCRUSE ELLIPTA
21
indapamide
108
INDERAL LA
76
indomethacin 25 mg, 50 mg 6
indomethacin 75 mg
6
INFANRIX
159
INFANTS ADVIL
6
INLYTA
58
INOSITOL 500 MG
144
INSPIRACHAMBER/ANTISTATIC
VALVED/MOUTHPIECE 127
INSPIRACHAMBER/SOOTHER
MASK/INSPIRAMASK/MEDIUM
128
INSPIRACHAMBER/SOOTHER
MASK/INSPIRAMASK/SMALL
128
INSPIREASE DRUG
DELIVERYSYSTEM
128
INSPRA
50
INSULIN SYRINGES AND PEN
NEEDLES
125
INTELENCE 100 MG, 200
MG
69
INTELENCE 25 MG
69
INTRON A
59
INTRON A W/DILUENT
59
INTUNIV
1
INVANZ
17
INVEGA 1.5 MG
64
INVEGA 3 MG
64
INVEGA 6 MG
64
INVEGA 9 MG
64
INVEGA SUSTENNA
64
INVEGA TRINZA
64
INVIRASE
69
INVOKAMET 150MG-1000MG,
150MG-500MG, 50MG1000MG
34
INVOKAMET 50MG-500MG 34
INVOKANA
38
IODINE STRONG
134
IOPIDINE 0.5 %
147
IPECAC
40
IPOL INACTIVATED IPV 164
ipratropium bromide
21
ipratropium bromide (nasal) 143
ipratropium-albuterol
23
irbesartan
47
irbesartan-hydrochlorothiazide
49
IRESSA
58
irinotecan hcl 100 mg/5ml, 40
mg/2ml
62
irinotecan hcl 500 mg/25ml 62
IRON 256 MG
119
IRON 28 MG
119
IRON CHEWS PEDIATRIC 119
Index 16
iron combinations
119
irrigation solutions,
physiological
75
ISENTRESS 100 MG
69
ISENTRESS 25 MG
69
ISENTRESS 400 MG
69
isoniazid & rifampin
51
isoniazid 100 mg, 300 mg 51
ISOPTO CARPINE
147
ISOPTO TEARS
146
ISORDIL TITRADOSE 5 MG 18
isosorbide dinitrate 10 mg, 20
mg, 30 mg, 5 mg
18
isosorbide dinitrate 40 mg 18
isosorbide mononitrate 10 mg, 20
mg
18
isosorbide mononitrate 120 mg,
30 mg, 60 mg
18
isotretinoin 10 mg, 20 mg, 30 mg,
40 mg
87
ISTODAX
58
ITCH-X
97
itraconazole
42
ivermectin
15
IXEMPRA KIT
61
IXIARO
164
JADENU
40
JAKAFI
58
JALYN
115
JANUMET
34
JANUMET XR 100MG1000MG
34
JANUMET XR 50MG-1000MG,
50MG-500MG
34
JANUVIA
36
JARDIANCE 10 MG
38
JARDIANCE 25 MG
38
JENTADUETO
34
JEVTANA
61
JOHNSONS BABY BAR
101
JOHNSONS BUDDIES EASYGRIP SUDZING
101
JOHNSONS KIDS SUPER
SUDZER E-Z GRIP SOAP 101
JUXTAPID 10 MG
46
JUXTAPID 20 MG
46
JUXTAPID 30 MG
46
JUXTAPID 40 MG, 60 MG 46
JUXTAPID 5 MG
46
K-TAB 10 MEQ
135
Index 17
K-TAB 8 MEQ
135
KADCYLA
54
KADIAN 100 MG
10
KADIAN 20 MG, 30 MG, 50
MG, 60 MG, 80 MG
10
KALBITOR
116
KALETRA
69
KALYDECO 150 MG
157
KALYDECO 50 MG, 75
MG
157
KAPVAY
1
KARAYA GUM
153
KAYEXALATE
75
KAZANO
34
KEFLEX
79
KENALOG-10
83
KENALOG-40
83
KEPIVANCE
60
KEPPRA
26
KEPPRA XR
26
KERLONE
75
KETO-DIASTIX
105
KETOCARE
105
ketoconazole
42
ketoconazole (topical)
89
KETONE TEST STRIPS 105
ketoprofen 50 mg, 75 mg
6
ketorolac tromethamine
(ophth)
150
ketorolac tromethamine 15
mg/ml, 30 mg/ml
6
ketorolac tromethamine 30
mg/ml, 60 mg/2ml
6
KETOSTIX
105
ketotifen fumarate (ophth)150
KEYTRUDA
54
KHEDEZLA
32
KINERET
4
KLARON
88
KLONOPIN 0.5 MG
25
KLONOPIN 1 MG
25
KLONOPIN 2 MG
25
KOMBIGLYZE XR 2.5MG1000MG
34
KOMBIGLYZE XR 5MG1000MG, 5MG-500MG
34
KONSYL 100 %
121
KONSYL 28.3 %, 60.3 % 121
KONSYL 60.3 %, 71.67
%
121
KONSYL-D
121
KUVAN 100 MG
110
KUVAN 100 MG, 500 MG 110
KYNAMRO
44
L-CARNITINE 250 MG
145
L-CITRULLINE
145
L-METHYL-MC
106
labetalol hcl 100 mg, 200 mg, 300
mg
75
LABSTIX
105
LAC-HYDRIN
95
lactated ringer's
133
LACTIC ACID
80
lactic acid (ammonium lactate) 12
%
95
lactic acid (ammonium lactate) 5
%
95
LACTIC ACID RACEMIC
80
lactulose
122
lactulose (encephalopathy) 114
LAMICTAL 100 MG, 150 MG,
200 MG, 25 MG
26
LAMICTAL CHEWABLE
DISPERSIBLE
26
LAMICTAL XR
26
LAMICTAL XR 100 MG, 200 MG,
25 MG, 250 MG, 300 MG, 50
MG
26
LAMISIL 250 MG
41
LAMISIL AT
89
LAMISIL AT JOCK ITCH
89
lamivudine
69
lamivudine (hbv)
71
lamivudine-zidovudine
69
lamotrigine 100 mg, 150 mg, 200
mg, 25 mg
26
lamotrigine 100 mg, 200 mg, 25
mg, 250 mg, 300 mg, 50 mg 26
lamotrigine 25 mg, 5 mg
26
LANACANE
97
lanolin
154
lanolin (topical)
101
LANOLIN ANHYDROUS 153
LANOLIN ANHYDROUSGRX
154
LANOXIN 125 MCG, 250
MCG
77
LANOXIN 187.5 MCG, 62.5
MCG
78
lansoprazole 15 mg
161
lansoprazole 30 mg
161
LANTUS
37
LANTUS SOLOSTAR
37
LASIX
107
latanoprost
150
LATUDA 120 MG
64
LATUDA 20 MG
64
LATUDA 40 MG
64
LATUDA 60 MG
64
LATUDA 80 MG
64
LAZANDA 100 MCG/ACT 10
LAZANDA 400 MCG/ACT 10
LEADER QUICK DISSOLVE
GLUCOSE
35
lecithin
144
LECITHIN
CONCENTRATE
144
leflunomide 10 mg, 20 mg
7
LEMTRADA
156
LENVIMA 10MG DAILY
DOSE
58
LENVIMA 14MG DAILY
DOSE
58
LENVIMA 20MG DAILY
DOSE
58
LENVIMA 24MG DAILY
DOSE
58
LESCOL
45
LETAIRIS
78
letrozole
55
leucovorin calcium 10 mg, 15 mg,
25 mg, 5 mg
60
leucovorin calcium 100 mg, 200
mg, 350 mg
60
leucovorin calcium 50 mg, 500
mg
60
LEUKERAN
52
LEUKINE
118
leuprolide acetate
55
levalbuterol hcl 0.31 mg/3ml, 0.63
mg/3ml, 1.25 mg/0.5ml, 1.25
mg/3ml
23
LEVAQUIN 25 MG/ML
113
LEVAQUIN 250 MG, 500 MG,
750 MG
113
LEVAQUIN 250MG/50ML-5%,
500MG/100ML-5%
112
LEVAQUIN 750MG/150ML5%
112
LEVEMIR
37
LEVEMIR FLEXPEN
37
LEVEMIR FLEXTOUCH
37
levetiracetam 100 mg/ml, 500
mg/5ml
26
levetiracetam 1000 mg, 250
mg, 500 mg, 750 mg
26
LEVETIRACETAM
1000MG/100ML750MG/100ML,
1500MG/100ML540MG/100ML, 500MG/100ML820MG/100ML
26
levetiracetam 500 mg, 750
mg
26
levetiracetam 500 mg/5ml 26
levobunolol hcl 0.5 %
147
levocarnitine (metabolic
modifiers) 330 mg
110
levocarnitine 250 mg
145
levocetirizine
dihydrochloride
43
levofloxacin (ophth)
148
levofloxacin 25 mg/ml
113
levofloxacin 250 mg, 500 mg,
750 mg
113
levofloxacin in d5w
250mg/50ml-5%,
500mg/100ml-5%
113
levofloxacin in d5w
750mg/150ml-5%
113
LEVOLEUCOVORIN
60
levoleucovorin calcium
60
levonorgestrel & eth
estradiol
81
levonorgestrel (emergency oc)
0.75 mg
82
levonorgestrel (emergency oc)
1.5 mg
82
levonorgestrel-eth estradiol
(triphasic)
81
levonorgestrel-ethinyl estradiol
(91-day)
81
levothyroxine sodium 100 mcg,
112 mcg, 125 mcg, 137 mcg,
150 mcg, 175 mcg, 200 mcg,
25 mcg, 300 mcg, 50 mcg, 75
mcg, 88 mcg
159
LEXAPRO
30
LEXIVA
69
LEXUSS 210
86
lidocaine 5 %
97
lidocaine hcl (local anesth.) 1
%, 2 %
123
lidocaine hcl (mouth-throat) 2
%
136
lidocaine hcl 0.5 %
97
lidocaine hcl 2 %
97
lidocaine hcl 4 %
97
lidocaine-prilocaine
97
LIDODERM
97
LINCOCIN
18
lindane
103
linezolid 2 mg/ml
18
linezolid 600 mg
18
liniments & rubs 0.01%-5%-10%,
1.2%-2.6%-4.7%, 10%-0.025%15%
97
liniments & rubs 0.25%, 8%2%
97
LINZESS
114
liothyronine sodium 25 mcg, 5
mcg, 50 mcg
159
LIPITOR
45
LIPOSYN III 1.2GM/100ML10GM/100ML-2.5GM/100ML
144
LIPTRUZET
44
LIQ-10 50MG/5ML15UNIT/5ML
3
lisinopril &
hydrochlorothiazide
49
lisinopril 10 mg, 2.5 mg, 20 mg,
30 mg, 40 mg, 5 mg
47
LITEAIRE
128
lithium
63
lithium carbonate 150 mg, 300
mg, 600 mg
63
lithium carbonate 300 mg
63
lithium carbonate 300 mg, 450
mg
63
LITHIUM CARBONATE 600
MG
63
LITHOBID
63
LOBOB CONTACT LENS
WEARERS SOAP
101
LOCOID
94
LOCOID LIPOCREAM
94
LODOSYN
62
LOMOTIL
39
lomustine 10 mg
52
LOMUSTINE 100 MG, 40
MG
52
loperamide hcl 2 mg
39
LOPID
45
LOPRESSOR 100 MG, 50
MG
75
LOPRESSOR HCT
49
LOPROX
89
LOPROX SHAMPOO
89
Index 18
lorazepam 0.5 mg, 1 mg, 2
mg
20
lorazepam 2 mg/ml
20
lorazepam 2 mg/ml, 20
mg/10ml
20
lorazepam 4 mg/ml
20
losartan potassium
48
losartan potassium &
hydrochlorothiazide
49
LOSEASONIQUE
81
LOTEMAX
149
LOTENSIN
47
LOTENSIN HCT
49
LOTREL
49
LOTRISONE
89
LOTRONEX
114
lovastatin
45
LOVAZA
44
LOVENOX
24
LOWILA
101
loxapine succinate 10 mg, 25 mg,
5 mg, 50 mg
65
LUMIGAN
150
LUMIZYME
110
LUPRON DEPOT
55
LUPRON DEPOT-PED 11.25
MG
110
LUPRON DEPOT-PED 11.25
MG, 15 MG, 7.5 MG
110
LUPRON DEPOT-PED 30
MG
110
lutein 6 mg
3
LUVOX CR
30
LUXIQ
95
LYCELLE
103
LYNPARZA
58
LYRICA 100 MG
26
LYRICA 150 MG
26
LYRICA 20 MG/ML
27
LYRICA 200 MG
26
LYRICA 225 MG, 300 MG 27
LYRICA 25 MG
27
LYRICA 50 MG
27
LYRICA 75 MG
27
LYSODREN
56
LYSTEDA
120
M-M-R II
164
MAALOX
15
MACROBID
162
Index 19
MACRODANTIN 100 MG, 50
MG
162
mafenide acetate
92
MAG-TAB SR
135
MAGINEX
135
MAGINEX DS
135
MAGNEBIND 200
133
magnesium 250 mg,
250mg
135
magnesium chloride 535 mg,
64 mg
135
MAGNESIUM CHLORIDE
HEXAHYDRATE
135
MAGNESIUM ELEMENTAL 30
MG
135
MAGNESIUM GLUCONATE
250 MG, 500 MG, 550
MG
135
magnesium sulfate 50 % 135
MALARONE 250MG100MG
50
malathion
103
maprotiline hcl
29
MARINOL
41
MARPLAN
30
MATULANE
59
MAVIK
47
MAXALT 10 MG
131
MAXALT 5 MG
131
MAXALT-MLT 10 MG
131
MAXALT-MLT 5 MG
131
MAXIPIME 1 GM, 2 GM 80
MAXITROL
149
MAXZIDE
107
MAXZIDE-25
107
MCT OIL
144
meclizine hcl 12.5 mg, 25
mg
40
meclizine hcl 25 mg
40
MEDI-LYTE
133
MEDIPLAST
96
MEDROL 16 MG, 32 MG, 4
MG, 8 MG
84
MEDROL 2 MG
84
MEDROL DOSEPAK
84
medroxyprogesterone
acetate
154
medroxyprogesterone acetate
(contraceptive)
82
mefenamic acid
6
mefloquine hcl
50
MEGACE ES
154
MEGACE ORAL
56
megestrol acetate
(appetite)
154
megestrol acetate 20 mg, 40
mg
56
megestrol acetate 40 mg/ml, 400
mg/10ml
56
MEIJER CALAMINE
101
MEKINIST
58
meloxicam 15 mg, 7.5 mg
6
melphalan hcl
52
memantine hcl 10 mg, 5 mg155
memantine hcl 2 mg/ml
154
MENACTRA
163
MENOMUNE-A/C/Y/W-135
163
menthol (topical analgesic) 5
%
88
MENVEO
163
meperidine hcl 100 mg/ml, 50
mg/ml
10
meperidine hcl 25 mg/ml
10
meperidine hcl 50 mg/5ml 10
MEPHYTON
166
MEPRON
17
mercaptopurine
54
meropenem
17
MERREM
17
mesalamine
114
mesalamine w/ cleanser
114
mesna
60
MESNEX 100 MG/ML
60
MESNEX 400 MG
61
MESTINON 60 MG
50
MESTINON TIMESPAN
50
METADATE CD
2
METAFOLBIC
106
METAMUCIL 0.52 GM
122
METAMUCIL 48.57 %
122
METAMUCIL MULTIHEALTH
FIBER 55.46 %
122
METAMUCIL ORIGINAL
TEXTURE
122
METAMUCIL SMOOTH
TEXTUREFIBER SINGLES 122
metaxalone
141
metformin hcl 1000 mg
35
metformin hcl 1000 mg, 750
mg
35
metformin hcl 500 mg
35
metformin hcl 850 mg
35
methadone hcl 10 mg
10
methadone hcl 10 mg/5ml 10
methadone hcl 10 mg/ml
10
methadone hcl 5 mg
10
methadone hcl 5 mg/5ml
10
METHADOSE
10
METHADOSE SUGARFREE
10
methamphetamine hcl
1
methazolamide 25 mg, 50
mg
107
methenamine hippurate
162
methimazole 10 mg, 5 mg 159
methocarbamol 500 mg, 750
mg
141
methotrexate sodium 1 gm 54
methotrexate sodium 1 gm/40ml,
100 mg/4ml, 200 mg/8ml, 25
mg/ml, 250 mg/10ml, 50
mg/2ml
54
methotrexate sodium 10 mg, 15
mg, 2.5 mg, 5 mg, 7.5 mg
54
methoxsalen rapid
91
methscopolamine bromide 2.5
mg, 5 mg
160
methylcellulose (laxative) 2
gm/10.2gm, 2 gm/19gm
122
methyldopa &
hydrochlorothiazide
49
methylergonovine maleate 0.2
mg
151
methylphenidate hcl 10 mg, 20
mg, 30 mg, 40 mg, 50 mg, 60
mg
2
methylphenidate hcl 10 mg, 20
mg, 5 mg
2
methylphenidate hcl 20 mg, 27
mg, 36 mg
2
methylphenidate hcl 20 mg, 30
mg, 40 mg
2
methylphenidate hcl 27 mg, 36
mg
2
methylprednisolone 16 mg, 32
mg, 4 mg, 8 mg
84
methylprednisolone acetate 40
mg/ml, 80 mg/ml
84
methylprednisolone sod
succ
84
metoclopramide hcl 10 mg, 5
mg
113
metoclopramide hcl 10 mg/10ml,
5 mg/5ml
113
metolazone
108
metoprolol &
hydrochlorothiazide
49
metoprolol succinate
75
metoprolol tartrate 100 mg, 25
mg, 50 mg
75
METROCREAM
103
METROGEL
103
METROGEL-VAGINAL 165
METROLOTION
103
metronidazole (topical) 103
metronidazole 250 mg, 500
mg
16
metronidazole 375 mg
16
metronidazole in nacl
16
metronidazole vaginal
165
MEVACOR
45
mexiletine hcl
20
MG217 MEDICATED
TAR
104
MIACALCIN 200
UNIT/ACT
108
MIACALCIN 200
UNIT/ML
108
MICATIN
89
miconazole nitrate (topical) 89
miconazole nitrate vaginal 100
mg
165
MICRO-K
135
MICROCHAMBER
128
MICROLIFE DIGITAL PEAK
FLOW METER
128
MICROLIPID
144
MICROSPACER
128
MICROZIDE
108
midodrine hcl
166
MIDOL COMPLETE 500MG15MG-60MG
7
MIDOL MAXIMUM STRENGTH
MENSTRUAL
7
MIDOL MAXIMUM STRENGTH
MENSTRUAL FORMULA 7
MILK OF MAGNESIA
CONCENTRATE
123
MINI WRIGHT AFS PEAK
FLOWMETER LOW
RANGE
128
MINI WRIGHT PEAK FLOW
METER
128
MINIPRESS
48
MINOCIN 100 MG, 50 MG, 75
MG
158
minocycline hcl 100 mg, 50
mg
159
minocycline hcl 100 mg, 50 mg,
75 mg
158
minoxidil 10 mg, 2.5 mg
50
MIRAPEX
63
mirtazapine
29
MIRVASO
103
misoprostol 100 mcg, 200
mcg
162
mitomycin 20 mg, 40 mg, 5
mg
57
mitoxantrone hcl
57
MOBIC 15 MG, 7.5 MG
6
modafinil
2
MODICON
81
moexipril hcl
47
moexipril-hydrochlorothiazide
49
mometasone furoate
95
MONOCAL
134
MONODOX
159
montelukast sodium 10 mg 21
montelukast sodium 4 mg, 5
mg
21
morphine sulfate 0.5 mg/ml 10
morphine sulfate 1 mg/ml
10
morphine sulfate 10 mg/5ml 10
morphine sulfate 100 mg
10
morphine sulfate 100 mg, 200
mg, 30 mg, 60 mg
11
morphine sulfate 100 mg/5ml, 20
mg/ml
10
MORPHINE SULFATE 15
MG
11
morphine sulfate 15 mg
11
morphine sulfate 20 mg, 30 mg,
50 mg, 60 mg, 80 mg
10
morphine sulfate 20 mg/5ml 11
MORPHINE SULFATE 30
MG
11
MOSCO CALLUS/CORN
REMOVER
96
MOTRIN INFANTS
6
MOTRIN INFANTS DROPS 6
MOTRIN JUNIOR
STRENGTH
6
MOZOBIL
120
MS CONTIN 100 MG, 200 MG,
30 MG, 60 MG
11
MS CONTIN 15 MG
11
MS QUICK DISSOLVE
GLUCOSE
35
MTX SUPPORT
119
Index 20
MULTAQ
21
MULTI-DELYN/IRON
139
MULTISTIX
105
MULTISTIX 10 SG
105
MULTISTIX 5
105
MULTISTIX 7
105
MULTISTIX 8 SG
105
MULTISTIX 9
105
MULTISTIX 9 SG
105
MULTITRACE-4
136
mupirocin
88
mupirocin calcium (topical) 88
MURO 128 2 %
150
MURO 128 5 %
150
MUSTARGEN
52
MYALEPT
110
MYAMBUTOL
51
MYCAMINE
41
MYCOBUTIN
51
mycophenolate mofetil
74
mycophenolate sodium
74
MYFORTIC
74
MYLANTA 200MG/5ML20MG/5ML-200MG/5ML
15
MYLANTA DOUBLESTRENGTH
15
MYLANTA GAS
113
MYLANTA GAS RELIEF
MAXIMUM STRENGTH
113
MYOZYME
110
MYSOLINE
27
nabumetone
6
nadolol &
bendroflumethiazide
49
nadolol 20 mg, 40 mg, 80
mg
76
nafcillin sodium 1 gm, 10
gm
153
nafcillin sodium 2 gm
153
NAFTIN 2 %
89
NAGLAZYME
110
nalbuphine hcl 10 mg/ml, 20
mg/ml
13
naloxone hcl 1 mg/ml
40
naltrexone hcl
40
NAMENDA 10 MG, 5 MG 155
NAMENDA 10 MG/5ML
155
NAMENDA TITRATION
PAK
155
NAMENDA XR 14 MG
155
Index 21
NAMENDA XR 21 MG, 28
MG
155
NAMENDA XR 7 MG
155
NAMENDA XR TITRATION
PACK
155
naphazoline w/ pheniramine
0.025%-0.3%
148
NAPHCON-A
148
NAPROSYN
6
naproxen 250 mg, 375 mg, 500
mg
6
naproxen 375 mg, 500 mg 6
naproxen sodium 220 mg 6
naproxen sodium 275 mg, 550
mg
6
naratriptan hcl
131
NARDIL
30
NASAL
DECONGESTANT
143
NASALGUARD
98
nateglinide
37
NATPARA
108
NATURE DE FRANCE ALGOLI
SOAP
101
NATURE DE FRANCE ARGILE
BLANCHE SOAP
101
NATURE DE FRANCE
ARGIMIEL SOAP
101
NAVELBINE
61
NEBUPENT
16
nefazodone hcl
31
NEO-SYNEPHRINE 0.25
%
143
NEO-SYNEPHRINE 0.5
%
143
NEO-SYNEPHRINE COLD &
SINUS MILD
143
NEO-SYNEPHRINE COLD &
SINUS REGULAR
143
neomycin sulfate
3
neomycin-bacitracin znpolymyxin
148
neomycin-bacitracin-polymyxin
w/ lidocaine
88
neomycin-polymydexameth
149
neomycin-polymyxin-gramicidin
148
neomycin-polymyxin-hc
(otic)
151
neomycin/polymyxin b gu 115
NEORAL 100 MG, 25 MG 74
NEOSALUS
98
NEOSALUS CP
98
NERVO B-12 SL
139
NESINA
36
NESSI SPACER/LARGE
MASK
128
NESSI
SPACER/MOUTHPIECE 128
NESSI SPACER/SMALL/MED
MASK
128
NEULASTA
118
NEULASTA DELIVERY KIT118
NEUMEGA
118
NEUPOGEN
118
NEUPRO
63
NEURONTIN
27
NEUTROGENA ACNE
CLEANSING SOAP
101
NEUTROGENA CLEAN
REPLENISHING
101
NEUTROGENA FACIAL SOAP
ORIGINAL FORMULA
101
NEUTROGENA NATURALS
FACE& BODY
101
NEUTROGENA
SHAMPOO
101
NEUTROGENA TRIPLE
MOISTURE UV SHIELD
101
NEVANAC
150
nevirapine 100 mg
69
nevirapine 200 mg
69
nevirapine 400 mg
69
NEVIRAPINE 50 MG/5ML 69
NEW SKIN
98
NEXAFED SINUS PRESSURE
+PAIN
86
NEXAVAR
58
NEXIUM 10 MG, 2.5 MG, 20 MG,
40 MG, 5 MG
161
NEXIUM 20 MG
161
NEXIUM 40 MG
161
niacin (antihyperlipidemic) 46
niacin 100 mg, 250 mg, 50 mg,
500 mg
167
niacin 250 mg, 500 mg
167
niacin 250 mg, 500 mg, 750
mg
167
NIACIN TR
167
niacinamide 100 mg
167
niacinamide 500 mg
167
NIASPAN
46
nicardipine hcl 20 mg, 30 mg 77
NICODERM CQ
157
NICORETTE
157
NICORETTE MINI
157
NICORETTE STARTER
KIT
157
nicotine
157
nicotine polacrilex 2 mg, 4
mg
157
NICOTINE TRANSDERMAL
SYSTEM
157
NICOTROL INHALER
157
NICOTROL NS
157
nifedipine 30 mg, 60 mg, 90
mg
77
NILANDRON
56
nimodipine
77
NIRAVAM
20
nisoldipine 17 mg, 34 mg, 8.5
mg
77
nit remover
103
NITRATEST PAPER
105
NITRO-DUR 0.1 MG/HR, 0.2
MG/HR, 0.4 MG/HR, 0.6
MG/HR
18
nitrofurantoin macrocrystal 100
mg, 50 mg
162
nitrofurantoin monohyd
macro
162
nitroglycerin 0.1 mg/hr, 0.2 mg/hr,
0.4 mg/hr, 0.6 mg/hr
19
nitroglycerin 0.4 mg/spray 19
NITROGLYCERIN LINGUAL 18
NITROLINGUAL
PUMPSPRAY
19
NITROMIST
19
NITROSTAT
19
NIVATOPIC PLUS
98
NIVEA MOISTURIZING BODY
WASH
101
NIVEA MOISTURIZING BODY
WASH 2 IN 1
101
NIVEA TOUCH OF
SMOOTHNESS MOISTURIZING
BODY WASH
101
NIVEA VISAGE EYE
CONTOUR
104
NIVEA VISAGE GENTLE
CLEANSING
101
NIX CREME RINSE
103
nizatidine 150 mg, 300 mg 160
NIZORAL
89
NIZORAL A-D
89
NO-STING SKIN-PREP
101
NOBLE FORMULA 2 %
91
nonoxynol-9
164
NONYX
98
NOR-QD
83
NORDITROPIN FLEXPRO 10
MG/1.5ML, 5 MG/1.5ML 109
norelgestromin-ethinyl
estradiol
82
norethin acet & estrad-fe 75mg20mcg-1mg, 75mg-30mcg1.5mg
81
norethindrone & eth
estradiol
81
norethindrone & ethinyl
estradiol-fe 0.4mg-35mcg 81
norethindrone
(contraceptive)
83
norethindrone acet & eth
estra
81
norethindrone acetate
154
norethindrone acetate-ethinyl
estradiol 5mcg-1mg
111
norethindrone-eth estradiol
(triphasic)
81
norgestimate-ethinyl
estradiol
82
norgestimate-ethinyl estradiol
(triphasic)
82
norgestrel & ethinyl
estradiol
82
NORINYL 1+35
82
NORPACE
20
NORPRAMIN
33
nortriptyline hcl 10 mg, 25 mg,
50 mg, 75 mg
33
nortriptyline hcl 10 mg/5ml 33
NORVASC 10 MG
77
NORVASC 2.5 MG
77
NORVASC 5 MG
77
NORVIR
69
NORWEGIAN COD LIVER
OIL
140
NOVA MAX PLUS KETONE
TESTSTRIPS
106
NOXAFIL 100 MG
42
NOXAFIL 300 MG/16.7ML 42
NOXAFIL 40 MG/ML
42
NUEDEXTA
156
NULLO
73
NULOJIX
74
NULYTELY/FLAVOR
PACKS
122
NUTRATEAR
146
NUTROPIN AQ NUSPIN
20
109
NUTROPIN AQ PEN 20
MG/2ML
109
NUVARING
82
NYMALIZE
77
nystatin
41
nystatin (mouth-throat)
137
nystatin (topical)
89
nystatin-triamcinolone
89
OC8
98
OCEAN NASAL SPRAY
142
OCTAGAM 10 GM/100ML, 2
GM/20ML, 20 GM/200ML, 5
GM/50ML
152
octreotide acetate 100 mcg/ml,
1000 mcg/5ml, 200 mcg/ml, 50
mcg/ml
111
OCUFEN
150
OCUFLOX
148
OCUSOFT HAND SOAP 101
OCUSOFT LID SCRUB
FOAMING
101
OCUSOFT LID SCRUB
ORIGINAL
101
ODOMZO
55
OFEV
158
ofloxacin (ophth)
148
ofloxacin (otic)
151
OILATUM
101
olanzapine
65
olanzapine-fluoxetine hcl 155
olopatadine hcl (nasal)
142
OLUX
95
OLUX-E
95
OLYSIO
71
OMECLAMOX-PAK
162
omega-3 fatty acids 180mg120mg, 300mg, 300mg-160mg1000mg-100mg-5unit, 300mg772.5mg-90mg-180mg
144
omega-3 fatty acids 180mg500mg-120mg, 27mg-244mg500mg-89mg, 300mg-1000mg200mg, 300mg-200mg, 500 mg,
500mg, 500mg-270mg-135mg,
500mg-320mg-130mg, 90mg500mg-60mg
144
omega-3-acid ethyl esters 44
omeprazole 10 mg, 20 mg, 40
mg
161
omeprazole-sodium bicarbonate
20mg-1100mg
162
Index 22
omeprazole-sodium bicarbonate
40mg-1100mg
162
OMNIFLEX DIAPHRAGM 125
OMNIPRED
149
OMNITROPE 10 MG/1.5ML, 5
MG/1.5ML
109
ONCASPAR
59
ondansetron
40
ondansetron hcl 24 mg, 4 mg, 8
mg
40
ondansetron hcl 4 mg/2ml, 40
mg/20ml
40
ondansetron hcl 4 mg/5ml 40
ONE A DAY WOMENS
PRENATAL/DHA
139
ONFI
25
ONGLYZA
36
OPANA 10 MG
11
OPANA 5 MG
11
OPDIVO
54
OPSUMIT
78
OPTICHAMBER
ADVANTAGE
128
OPTICHAMBER
ADVANTAGE/LARGE
MASK
128
OPTICHAMBER
ADVANTAGE/MEDIUM FACE
MASK
128
OPTICHAMBER
ADVANTAGE/SMALL FACE
MASK
129
OPTICHAMBER DIAMOND129
OPTICHAMBER
DIAMOND/LARGEFACE
MASK
129
OPTICHAMBER
DIAMOND/MEDIUM FACE
MASK
129
OPTICHAMBER
DIAMOND/SMALLFACE
MASK
129
OPTICHAMBER FACE
MASK/LARGE
129
OPTICHAMBER FACE
MASK/MEDIUM
129
OPTICHAMBER FACE
MASK/SMALL
129
OPTIHALER
129
OPTIHALER MDI DRUG
DELIVERY SYSTEM
129
OPTIONS CONCEPTROL
VAGINAL
CONTRACEPTIVE
164
Index 23
OPTIONS GYNOL II
VAGINALCONTRACEPTIVE
165
OPTIVAR
150
OPURITY B12/FOLIC
ACID
119
ORABASE
136
oral electrolytes 16meq/473ml21meq/473ml-9meq/473ml11gm/473ml, 18.8meq/l42.4meq/l-33.2meq/l-4.8gm/l18.8gm/l, 20meq/1000ml45meq/1000ml-35meq/1000ml25gm/1000ml, 20meq/l20meq/l-45meq/l-45meq/l35meq/l-25gm/l, 20meq/l20meq/l-45meq/l-45meq/l35meq/l-35meq/l-30meq/l30meq/l-25gm/l-25gm/l,
20meq/l-20meq/l-45meq/l45meq/l-35meq/l-35meq/l30meq/l-30meq/l-5gm/l-20gm/l,
20meq/l-45meq/l-35meq/l25gm/l, 20meq/l-45meq/l35meq/l-30meq/l-25gm/l,
20meq/l-45meq/l-35meq/l30meq/l-5gm/l-20gm/l, 20meq/l45meq/l-35meq/l-30meq/l5gm/l-25gm/l, 20meq/l-45meq/l35meq/l-5gm/l-20gm/l, 20meq/l45meq/l-35meq/l-7.8mg/l-25gm,
20meq/l-45meq/l-35meq/l7.8mg/l-25gm/l, 20meq/l45meq/l-35meq/l-7.8mg/l25meq/l, 20meq/l-45meq/l45meq/l-35meq/l-5gm/l-20gm/l,
35meq/l-45meq/l-20meq/l20gm/l, 35meq/l-45meq/l20meq/l-25gm/l, 35meq/l45meq/l-20meq/l-30meq/l25gm/l, 35meq/l-45meq/l20meq/l-30meq/l-30gm/l,
35meq/l-45meq/l-20meq/l30meq/l-5gm/l-20gm/l, 35meq/l45meq/l-20meq/l-5gm/l-20gm/l,
35meq/l-45meq/l-20meq/l7.5mg/l-25meq/l, 35meq/l45meq/l-20meq/l-7.8mg/l-25
134
oral electrolytes 287mg-180mg15mg
134
ORAP
157
ORAPRED ODT
84
ORAZINC
136
ORENCIA
7
ORFADIN
110
ORKAMBI
158
ORTHO DIAPHRAGM ALLFLEX/65MM
125
ORTHO DIAPHRAGM ALLFLEX/70MM
125
ORTHO DIAPHRAGM ALLFLEX/75MM
125
ORTHO DIAPHRAGM ALLFLEX/80MM
125
ORTHO EVRA
82
ORTHO MICRONOR
83
ORTHO TRI-CYCLEN
82
ORTHO-CEPT
82
ORTHO-CYCLEN
82
ORTHO-NOVUM 1/35
82
ORTHO-NOVUM 7/7/7
82
OSENI 12.5MG-15MG
34
OSENI 12.5MG-30MG, 12.5MG45MG, 25MG-15MG, 25MG30MG, 25MG-45MG
34
OTEZLA
7
OTREXUP
4
OVIDE
103
oxacillin sodium 10 gm
153
oxacillin sodium 2 gm
153
oxaliplatin 100 mg, 50 mg
52
oxaliplatin 100 mg/20ml, 50
mg/10ml
52
OXANDRIN
13
oxandrolone 10 mg, 2.5 mg 13
oxaprozin
6
oxazepam
20
oxcarbazepine
27
OXSORALEN ULTRA
91
oxybutynin chloride
163
oxycodone hcl 100 mg/5ml, 20
mg/ml
11
oxycodone hcl 15 mg
11
oxycodone hcl 30 mg
11
oxycodone hcl 5 mg
11
oxycodone w/ acetaminophen
10mg-325mg, 2.5mg-325mg,
5mg-325mg, 7.5mg-325mg 12
oxycodone w/ acetaminophen
5mg/5ml-325mg/5ml
12
oxycodone-aspirin
12
oxymorphone hcl 10 mg
11
oxymorphone hcl 15 mg
11
oxymorphone hcl 5 mg
11
oxymorphone hcl 7.5 mg
11
oyster shell
133
P&S
91
paclitaxel 100 mg/16.7ml, 30
mg/5ml, 300 mg/50ml
61
paclitaxel 150 mg/25ml
61
paliperidone 1.5 mg
64
paliperidone 3 mg
64
paliperidone 6 mg
64
paliperidone 9 mg
64
PAMELOR
33
PAMINE
160
PAMINE FORTE
160
PANCREAZE
106
PANRETIN
90
PANTHODERM
95
pantoprazole sodium 20 mg, 40
mg
162
pantoprazole sodium 40
mg
162
papaya 5mg-5mg-3mg-2mg20mg
73
PARAFON FORTE DSC 141
parenteral electrolytes
134
paricalcitol 1 mcg, 2 mcg, 4
mcg
110
PARLODEL
63
PARNATE
30
paromomycin sulfate
3
paroxetine hcl
31
PATADAY
150
PATANASE
142
PAXIL 10 MG, 20 MG, 30 MG, 40
MG
31
PAXIL 10 MG/5ML
31
PAXIL CR
31
PEAK AIR PEAK FLOW
METERADULT/PEDIATRIC
129
PEAK FLOW METER
129
ped multivitamins w/fl &
iron
139
PEDI-WHIRL
CONCENTRATE
68
PEDIALYTE 20MEQ/L-45MEQ/L35MEQ/L-30MEQ/L-25GM/L,
20MEQ/L-45MEQ/L-35MEQ/L5GM/L-20GM/L
134
PEDIALYTE FREEZER
POPS
134
PEDIATEX TD
86
pediatric multiple vitamin w/
c
139
pediatric multiple vitamin w/
extra c & fa
139
pediatric multiple vitamins w/
iron 0.6mg/ml-10mg/ml5unit/ml-8mg/ml-1500unit/ml400unit/ml-0.5mg/ml-0.4mg/ml35mg/ml, 1500unit/ml-10mg/ml5unit/ml-400unit/ml-8mg/ml0.6mg/ml-0.5mg/ml-0.4mg/ml35mg/ml
139
pediatric vitamins acd w/
fluoride
139
pediatric vitamins adc
139
PEDVAX HIB
163
peg 3350-kcl-sod bicarb-sod
chloride-sod sulfate
122
peg 3350-potassium chloridesod bicarbonate-sod
chloride
122
PEG-INTRON
72
PEG-INTRON REDIPEN 72
PEG-INTRON REDIPEN PAK
4
72
PEGANONE
28
PEGASYS
72
PEGASYS PROCLICK
72
PEGINTRON
72
penicillin g potassium 20 mu,
20000000 unit, 5000000
unit
152
penicillin v potassium
152
PENLAC NAIL LACQUER 90
PENTAM 300
16
pentoxifylline
116
PEPCID
160
PEPCID AC
160
PEPTO BISMOL
39
PEPTO-BISMOL
39
PEPTO-BISMOL
INSTACOOL
39
PEPTO-BISMOL MAX
STRENGTH
39
PEPTO-BISMOL TO-GO 39
PERCODAN
12
PERIDEX
137
perindopril erbumine 2 mg 47
perindopril erbumine 4 mg 47
perindopril erbumine 8 mg 47
PERJETA
54
permethrin 0.5 %
103
permethrin 1 %
103
permethrin 5 %
103
PEROXYL 1.5%-6%
137
perphenazine 16 mg, 2 mg, 4 mg,
8 mg
66
perphenazine-amitriptyline 155
PERSANTINE
117
PERSONAL BEST FULL
RANGE
129
PERSONAL BEST LOW
RANGE
129
PETROLATUM
95
PHACID
102
phenazopyridine hcl 100 mg, 200
mg
116
phenelzine sulfate
30
phenobarbital 100 mg, 15 mg,
16.2 mg, 30 mg, 32.4 mg, 60 mg,
64.8 mg, 97.2 mg
120
phenobarbital 20 mg/5ml 120
phenol (antiseptic)
137
phenoxybenzamine hcl
47
phentermine hcl
1
PHENYLADE AMINO ACID145
PHENYLADE AMINO ACID
BLEND
145
PHENYLADE MTE AMINO
ACIDBLEND
145
PHENYLADE PHEBLOC 146
PHENYLADE40 DRINK
MIX
146
phenyleph-promethazine w/
cod
86
phenylephrine hcl 0.25 % 143
phenylephrine-shark liver oilglycerin-petrolatum
14
phenytoin 125 mg/5ml
28
phenytoin 50 mg
28
phenytoin sodium
28
phenytoin sodium extended 28
PHILLIPS MILK OF MAGNESIA
CHEWABLE
123
PHILLIPS MILK OF MAGNESIA
CONCENTRATED
123
PHLEXY-10
146
PHOS-NAK POWDER
CONCENTRATE
135
PHOSLO
115
PHOSPHOLINE IODIDE 147
PHYSIOSOL IRRIGATION PH
7.4
75
phytonadione 100 mcg
166
PICATO
90
PIKO 1 ELECTRONIC
129
Index 24
pilocarpine hcl (oral)
137
pilocarpine hcl 1 %, 2 %, 4
%
147
pimozide
157
pindolol
76
pioglitazone hcl 15 mg
36
pioglitazone hcl 30 mg, 45
mg
36
pioglitazone hcl-glimepiride 34
pioglitazone hcl-metformin
hcl
34
piperacillin sodium-tazobactam
sodium
153
piroxicam 10 mg, 20 mg
6
PLAN B ONE-STEP
82
PLAQUENIL
50
PLAVIX 300 MG
117
PLAVIX 75 MG
117
PLEGRIDY
156
PLEGRIDY STARTER
PACK
156
PLETAL
117
POCKET CHAMBER
129
POCKET PEAK FLOW
METER
129
POCKET SPACER
130
POCKETPEAK PEAK FLOW
METER LOW RANGE
130
POCKETPEAK PEAK FLOW
METER/UNIVERSAL
RANGE
130
POCKETPEAK PEAK FLOW
METER/UNIVERSAL RANGE 50720 LPM
130
podofilox
96
POLYCOSE
144
polyethylene glycol 3350 122
polymyxin b sulfate
18
polymyxin b-trimethoprim 148
polysaccharide iron complex 150
mg
120
POLYSPORIN
88
POLYTAR
104
POLYTRIM
148
polyvinyl alcohol
146
POMALYST
56
PONARIS
142
PONSTEL
7
potassium chloride 10 % 135
potassium chloride 10 meq, 8
meq
135
Index 25
potassium chloride 2
meq/ml
135
potassium chloride 20 % 135
POTASSIUM CHLORIDE
ER
135
potassium chloride in dextrose
& sodium chloride 0.45%20meq/l-5%
134
potassium chloride
microencapsulated crystals
cr
135
potassium citrate (alkalinizer)
1080 mg, 540 mg
115
POTASSIUM IODIDE
134
POTIGA 200 MG
27
POTIGA 300 MG
27
POTIGA 400 MG
27
POTIGA 50 MG
27
PRADAXA
24
PRALUENT 150 MG/ML 46
PRALUENT 75 MG/ML
46
pramipexole dihydrochloride
0.125 mg, 0.25 mg, 0.5 mg,
0.75 mg, 1 mg, 1.5 mg
63
pramoxine-camphor-zinc
acetate
97
PRANDIMET
34
PRANDIN 0.5 MG
37
PRANDIN 1 MG
37
PRANDIN 2 MG
37
PRAVACHOL
45
pravastatin sodium
45
prazosin hcl
48
PRE-FOLIC
119
PRECISION XTRA
106
PRECOSE
33
PRED FORTE
149
prednicarbate
95
prednisolone
84
prednisolone acetate
(ophth)
149
prednisolone sodium
phosphate 10 mg, 15 mg, 30
mg
84
prednisolone sodium
phosphate 15 mg/5ml, 5
mg/5ml, 6.7 mg/5ml
84
prednisone 1 mg, 10 mg, 2.5
mg, 20 mg, 5 mg, 50 mg 84
prednisone 5 mg/5ml
84
prednisone 5 mg/ml
84
PREMARIN 0.3 MG, 0.45 MG,
0.625 MG, 0.9 MG, 1.25
MG
112
PREMARIN 0.625 MG/GM 165
PREMPHASE
112
PREMPRO
112
PRENATAL FORMULA 35MG30UNIT-4000UNIT-200MG25MG-1.8MG-200MG-28MG20MG-1.7MG-8MCG-400UNIT800MCG-2.6MG-120MG 140
PRESUN ULTRA/PARSOL 3%5%-7.5%-6%
104
PREVACID 15 MG
162
PREVACID 30 MG
162
PREVPAC
162
PREZCOBIX
69
PREZISTA 100 MG/ML
69
PREZISTA 150 MG, 600 MG,
800 MG
69
PREZISTA 400 MG, 75 MG 69
PRIFTIN
51
PRILOSEC 10 MG, 20 MG, 40
MG
162
PRIMAQUINE PHOSPHATE 50
PRIMAXIN IV
17
primidone 250 mg, 50 mg
27
PRINIVIL
47
PRISTIQ
32
PRIVIGEN
152
PROAIR HFA
23
PROAIR RESPICLICK
23
probenecid
116
PROCARDIA XL
77
prochlorperazine
66
prochlorperazine edisylate 66
prochlorperazine maleate 10 mg,
5 mg
66
PROCRIT
118
PROCTOCORT 1 %
14
PROFERRIN ES
120
progesterone micronized 100 mg,
200 mg
154
PROGLYCEM
35
PROGRAF 0.5 MG, 1 MG, 5
MG
74
PROGRAF 5 MG/ML
74
PROLASTIN-C
157
PROLEUKIN
59
PROLIA
108
PROMACTA 12.5 MG
118
PROMACTA 25 MG
118
PROMACTA 50 MG
118
PROMACTA 75 MG
118
promethazine hcl 12.5 mg, 25
mg
44
promethazine hcl 12.5 mg, 25
mg, 50 mg
44
promethazine hcl 25 mg/ml, 50
mg/ml
44
promethazine hcl 6.25
mg/5ml
44
promethazine w/codeine
86
promethazine-dm
86
PROMETRIUM
154
PRONTO 0.33%-4%
103
propafenone hcl
20
proparacaine hcl
149
propranolol hcl 10 mg, 20 mg, 40
mg, 60 mg, 80 mg
76
propranolol hcl 120 mg, 160 mg,
60 mg, 80 mg
76
PROPYLENE GLYCOL
153
propylthiouracil
159
PROQUAD
164
PROSCAR
115
PROSHIELD FOAM & SPRAY
CLEANSER
102
PROTEINEX
146
PROTONIX 20 MG, 40 MG 162
PROTONIX 40 MG
162
PROTOPIC
96
protriptyline hcl
33
PROVENTIL HFA
23
PROVERA
154
PROVIGIL
2
PROZAC
31
PROZAC WEEKLY
31
PRUCLAIR
98
PRUMYX
98
pseudoephedrine hcl 15
mg/5ml
143
pseudoephedrine hcl 30 mg, 60
mg
143
pseudoephedrine-acetaminophen
86
pseudoephedrine-ibuprofen
100mg/5ml-15mg/5ml
86
psyllium 0.52 gm, 520 mg 122
psyllium 100 %, 48.57 %, 58.6 %,
95 %
122
psyllium 28.3 %, 30 %, 30.9 %,
33 %, 49 %, 68 %
122
PTS PANELS KETONE
TEST
106
PULMICORT 0.25 MG/2ML, 0.5
MG/2ML
22
PULMOZYME
158
PURINETHOL
54
PURIXAN
54
PURPOSE
102
PX CALAMINE
102
pyrazinamide
51
PYRETHINS/PIPERONYL
BUTOXIDE
103
pyrethrins-piperonyl
butoxide
103
PYRIDIUM
116
pyridostigmine bromide 180
mg
51
pyridostigmine bromide 60
mg
51
pyridoxine hcl 100 mg, 25 mg,
50 mg
167
pyrithione zinc 0.25 %
91
pyrithione zinc 2 %
91
QC CALAMINE
102
QC COD LIVER OIL
140
QSYMIA
1
QUALAQUIN
50
quetiapine fumarate
65
quinapril hcl
47
quinapril-hydrochlorothiazide
49
quinidine gluconate 324
mg
20
quinidine sulfate
20
quinine sulfate
50
QVAR
22
RA BEAUTY BAR
102
RA CALAMINE 6.971%6.971%
102
RA COD LIVER OIL
140
RA SALINE WOUND
WASH
102
RABAVERT
164
raloxifene hcl
109
ramipril
47
RANEXA
18
ranitidine hcl 15 mg/ml, 150
mg/10ml, 75 mg/5ml
161
ranitidine hcl 150 mg
161
ranitidine hcl 150 mg, 300
mg
160
ranitidine hcl 300 mg
161
ranitidine hcl 75 mg
161
RAPAMUNE 0.5 MG
74
RAPAMUNE 1 MG, 2 MG
74
RAPAMUNE 1 MG/ML
74
RASPBERRY SYRUP
153
RASUVO
4
RAZADYNE
155
RAZADYNE ER
155
REBETOL 200 MG
72
REBIF
156
REBIF REBIDOSE
156
REBIF REBIDOSE
TITRATIONPACK
156
REBIF TITRATION PACK 156
RECLAST
108
RECOMBIVAX HB
164
RECTIV
14
REGENECARE HA
97
REGIMEX
1
REGLAN
113
REGRANEX
104
RELENZA DISKHALER
73
RELION KETONE
106
RELION KETONE TEST
STRIPS
106
RELISTOR 12 MG/0.6ML 114
RELISTOR 12 MG/0.6ML, 8
MG/0.4ML
115
REMERON
29
REMERON SOLTAB
29
REMICADE
114
REMODULIN
78
RENVELA 2.4 GM
115
RENVELA 800 MG
115
repaglinide 0.5 mg
37
repaglinide 1 mg
37
repaglinide 2 mg
38
REQUIP
63
REQUIP XL
63
RESCRIPTOR
70
RESERPINE 0.1 MG, 0.25
MG
48
RESTASIS
148
RESTORIL
120
RETIN-A
88
Index 26
RETIN-A MICRO
88
RETIN-A MICRO PUMP 0.04 %,
0.1 %
88
RETROVIR
70
RETROVIR IV INFUSION 70
REVATIO 10 MG/12.5ML
78
REVATIO 20 MG
78
REVLIMID
73
REXULTI 0.25 MG
67
REXULTI 0.5 MG
67
REXULTI 1 MG
67
REXULTI 2 MG
67
REXULTI 3 MG, 4 MG
67
REYATAZ 150 MG, 200 MG, 300
MG
70
REYATAZ 50 MG
70
REZAMID
88
RHINOCORT AQUA
143
ribavirin (hepatitis c)
72
riboflavin 100 mg
167
riboflavin 25 mg, 50 mg
167
RID
103
RIDAURA
4
rifabutin
51
RIFADIN
51
rifampin 150 mg, 300 mg
51
rifampin 600 mg
51
RIFATER
51
RILUTEK
143
riluzole
144
rimantadine hydrochloride 73
RISPERDAL
64
RISPERDAL CONSTA 12.5
MG
65
RISPERDAL CONSTA 25
MG
65
RISPERDAL CONSTA 37.5 MG,
50 MG
65
RISPERDAL M-TAB
65
risperidone
65
RITALIN
2
RITALIN LA 20 MG, 30 MG, 40
MG
2
RITALIN LA 60 MG
2
RITALIN SR
2
RITEFLO
130
RITUXAN
55
rivastigmine
155
rivastigmine tartrate
155
Index 27
rizatriptan benzoate 10
mg
131
rizatriptan benzoate 5 mg 131
ROBAXIN 500 MG
141
ROBAXIN-750
142
ROBINUL 0.2 MG/ML
160
ROBINUL 1 MG
160
ROBINUL FORTE
160
ROCALTROL
110
ropinirole hydrochloride
63
ROTARIX
164
ROTATEQ
164
ROWASA
114
ROXICODONE 15 MG
11
ROXICODONE 30 MG
11
ROXICODONE 5 MG
11
ROZEREM
121
RUCONEST
116
RYMED
86
RYTARY
63
RYTHMOL
20
RYTHMOL SR
20
SABRIL
28
SAFE WASH
102
SALAGEN
137
saline
142
saline 0.65 %, 0.65%, 0.65%0.002%
142
SALINE WOUND WASH 102
SALJET
102
SALJET RINSE
102
SALTAIRE
142
SAMSCA
111
SANCTURA
163
SANCTURA XR
163
SANDIMMUNE 100 MG, 25
MG
74
SANDIMMUNE 100
MG/ML
74
SANDIMMUNE 50 MG/ML 74
SANDOSTATIN 100 MCG/ML,
200 MCG/ML, 50
MCG/ML
111
SANDOSTATIN LAR DEPOT
20 MG, 30 MG
111
SANTYL
96
SAPHRIS 10 MG
65
SAPHRIS 2.5 MG
65
SAPHRIS 5 MG
65
SAXENDA
1
SAYMAN LANOLIN
102
SAYMAN WITCH HAZEL 102
SEASONIQUE
82
SECTRAL
75
selegiline hcl
63
selenium 100 mcg
136
SELENIUM 40 MCG/ML
136
selenium 50 mcg
136
selenium sulfide 2.5 %
91
SELZENTRY
70
sennosides 15 mg, 8.6 mg 123
SENOKOT
123
SENOKOT TO GO
123
SENSIPAR
110
SEREVENT DISKUS
23
SEROQUEL
66
SEROSTIM 4 MG, 6 MG 109
sertraline hcl 100 mg, 25 mg, 50
mg
31
sertraline hcl 20 mg/ml
31
SEVELAMER
CARBONATE
115
SHADE OIL FREE CLEAR
GELSPF 25
104
SHUR-SEAL
165
SIGNIFOR
111
SIGNIFOR LAR 20 MG
111
SIGNIFOR LAR 40 MG, 60
MG
111
sildenafil citrate (pulmonary
hypertension)
78
SILENOR
120
SILVADENE
92
silver sulfadiazine
92
simethicone 125 mg
113
SIMPONI
4
SIMPONI ARIA
4
SIMULECT
74
simvastatin 10 mg
45
simvastatin 20 mg
45
simvastatin 40 mg
45
simvastatin 5 mg
45
simvastatin 80 mg
45
SINEMET
63
SINEMET CR
63
SINGULAIR 10 MG
21
SINGULAIR 4 MG, 5 MG
21
sirolimus
74
SIVEXTRO
18
SKELAXIN
142
skin protectants, misc.
102
SLO-NIACIN
167
SLOW FE 160 MG
120
SLOW RELEASE IRON
120
SM CALAMINE
102
SM CALAMINE
PHENOLATED
102
SM GLUCOSE 4 GM
35
SM IPECAC SYRUP
40
SM PAIN
RELIEF/MENTHOL
97
sodium chloride (gu
irrigant)
115
sodium chloride (inhalant) 86
sodium chloride 0.45 %
135
sodium chloride 0.9 %
135
sodium chloride hypertonic 150
SODIUM CHLORIDE/SODIUM
BICARBONATE
81
SODIUM CITRATE
DIHYDRATE
80
sodium polystyrene
sulfonate
75
sodium polystyrene sulfonate 15
gm/60ml
75
SOLARAZE
90
SOLARCAINE ALOE EXTRA
GEL
97
SOLARCAINE ALOE VERA 97
SOLBAR PF LIQUID/GEL
SPF30
104
SOLTAMOX
56
SOLU-CORTEF 100 MG, 250
MG, 500 MG
84
SOLU-CORTEF 1000 MG 84
SOLU-MEDROL 1000 MG, 125
MG, 40 MG
84
SOLVIL
146
SOMA 350 MG
142
SOMATULINE DEPOT
111
SOMAVERT
109
SONATA
120
SORIATANE
91
sotalol hcl
76
sotalol hcl (afib/afl)
76
Sotalol Hcl IV Soln
76
SOTYLIZE
76
SOVALDI
72
SPIRIVA HANDIHALER 21
SPIRIVA RESPIMAT 1.25
MCG/ACT
21
SPIRIVA RESPIMAT 2.5
MCG/ACT
21
spironolactone &
hydrochlorothiazide
107
spironolactone 100 mg, 25 mg,
50 mg
107
SPORANOX 100 MG
42
SPORANOX PULSEPAK 42
SPRYCEL
58
starch (topical)
14
STARLIX
38
stavudine
70
STAVZOR
29
STELARA
91
STIOLTO RESPIMAT
23
STIVARGA
58
STRATTERA
2
STRIBILD
70
STRIVERDI RESPIMAT 23
STROMECTOL
15
STYGIENE STERILE EYELID
CLEANSER
102
SUBSYS 100 MCG, 200
MCG
11
SUBSYS 1200 MCG, 1600
MCG
11
SUBSYS 400 MCG, 600 MCG,
800 MCG
11
sucralfate
161
SUDAFED
143
SUDAFED CHILDRENS 143
SUDAFED
CONGESTION
143
SUDAFED NASAL
DECONGESTANT MAXIMUM
STRENGTH
143
SUDAFED PE CHILDRENS
NASAL
DECONGESTANT
143
SUDAFED PE SEVERE COLD
MULTI-SYMPTOM
86
SULAR
77
sulfacetamide sodprednisolone
149
sulfacetamide sodium
(acne)
88
sulfacetamide sodium
(ophth)
148
sulfadiazine
158
sulfamethoxazole-trimethoprim
16
SULFAMYLON 5 %
92
sulfasalazine
114
SULFZIX
106
sulindac 150 mg, 200 mg
7
sumatriptan succinate 100
mg
131
sumatriptan succinate 25
mg
131
sumatriptan succinate 4
mg/0.5ml
131
sumatriptan succinate 50
mg
131
sumatriptan succinate 6
mg/0.5ml
131
SUMMERS EVE DEODORANT
SPRAY
98
SUMMERS EVE DEODORANT
SPRAY ULTRA
98
SUMMERS EVE NIGHT-TIME
CLEANSING/SENSITIVE
SKIN
102
SUPER E
96
SUPER E DAY
96
SUPER E EYE
96
SUPER E NIGHT
96
SUPER-AMINO 1600
146
SUPRAX 400 MG
80
SUPRAX 500 MG/5ML
80
SUPRENZA
1
SUPREP BOWEL PREP 122
SURMONTIL
33
SUSTIVA
70
SUTENT
58
SYLATRON
59
SYMBYAX
155
SYMLINPEN 120
33
SYMLINPEN 60
33
SYMPT-X G.I.
146
SYNAGIS 50 MG/0.5ML
152
SYNALAR
95
SYNAREL
110
SYNERCID
18
SYNRIBO
60
SYNTHROID
159
SYPRINE
73
TABLOID
54
tacrolimus (topical)
96
tacrolimus 0.5 mg, 1 mg, 5
mg
74
TAFINLAR
58
Index 28
TAMIFLU
73
tamoxifen citrate 10 mg, 20
mg
56
tamsulosin hcl
116
TARCEVA
58
TARGRETIN
60
TARSUM
104
TASIGNA
58
TASMAR
62
TAXOL
61
TAXOTERE
61
TAZORAC
91
TEARS AGAIN NIGHT &
DAY
146
TECFIDERA
156
TECFIDERA STARTER
PACK
156
TEFLARO 400 MG
80
TEGRETOL
27
TEGRETOL-XR 100 MG
27
TEGRETOL-XR 200 MG, 400
MG
27
TEKTURNA
50
TEKTURNA HCT
49
temazepam
120
TEMODAR
52
TEMOVATE
95
TEMOVATE E
95
TENEX
48
TENIVAC
159
TENORETIC 100
49
TENORETIC 50
49
TENORMIN
75
TERAZOL 3
165
TERAZOL 7
165
terazosin hcl
48
terbinafine hcl
42
terbinafine hcl (topical)
90
terbutaline sulfate 2.5 mg, 5
mg
23
terconazole vaginal
165
TERSASEPTIC GLYCERINE
CLEANSING
102
TESSALON PERLES
84
TESTIM
13
TESTOSTERONE 1 %, 25
MG/2.5GM, 50 MG/5GM
14
testosterone 25 mg/2.5gm, 50
mg/5gm
14
testosterone cypionate
13
Index 29
testosterone enanthate
14
TESTOSTERONE PUMP 14
TETANUS TOXOID
ADSORBED
159
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED 159
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED
ADULT
159
tetrabenazine
155
tetracycline hcl 250 mg, 500
mg
159
TEV-TROPIN
109
TEVETEN
48
TGT LUBRICANT EYE
DROPS
147
THALOMID
73
theophylline 100 mg, 200 mg,
300 mg, 450 mg
23
theophylline 400 mg, 600
mg
23
THERACYS
60
THERAPLEX T
104
THERMOTABS
134
thiamine hcl 100 mg, 50
mg
167
thiamine mononitrate
167
thioridazine hcl 10 mg, 100 mg,
25 mg, 50 mg
66
THIOTEPA
53
thiothixene
68
THYMOGLOBULIN
74
THYMOL
81
tiagabine hcl
28
TIAZAC
77
TICE BCG
60
ticlopidine hcl
117
TIGAN 100 MG/ML
40
TIKOSYN
21
timolol maleate (ophth) 147
TIMOPTIC
147
TIMOPTIC-XE
147
TINACTIN
90
TINACTIN JOCK ITCH
90
TINDAMAX
16
tinidazole 250 mg, 500 mg 16
tioconazole vaginal
165
TIVICAY
70
tizanidine hcl 2 mg, 4 mg 142
tizanidine hcl 2 mg, 4 mg, 6
mg
142
TOBI
3
TOBI PODHALER
3
TOBRADEX
149
tobramycin
3
tobramycin (ophth)
148
tobramycin sulfate 1.2 gm
4
tobramycin sulfate 1.2 gm/30ml,
40 mg/ml, 80 mg/2ml
3
tobramycin sulfate 10 mg/ml 3
tobramycindexamethasone
149
TOBREX
148
TOFRANIL-PM
33
tolazamide 250 mg
39
tolazamide 500 mg
39
tolbutamide
39
tolcapone
62
tolmetin sodium 200 mg
7
tolmetin sodium 400 mg
7
tolnaftate
90
tolterodine tartrate
163
TOPAMAX
27
TOPAMAX SPRINKLE
27
TOPICLEAR
102
topiramate 100 mg, 200 mg, 25
mg, 50 mg
27
topiramate 15 mg, 25 mg
27
topotecan hcl 4 mg
62
TOPOTECAN HCL 4
MG/4ML
62
TOPROL XL
75
TORISEL
58
torsemide 10 mg, 100 mg, 20 mg,
5 mg
107
TOTECT
61
TOUJEO SOLOSTAR
37
trace minerals (cr-cu-mnzn)
136
TRACLEER
78
TRADJENTA
36
tramadol hcl 100 mg
12
tramadol hcl 200 mg, 300
mg
12
tramadol hcl 50 mg
12
tramadol-acetaminophen
12
TRANDATE
75
trandolapril
47
tranexamic acid 100 mg/ml 120
tranexamic acid 650 mg
120
TRANSDERM-SCOP
40
TRANXENE T
20
tranylcypromine sulfate
30
TRAVATAN Z
150
trazodone hcl 100 mg, 150 mg,
300 mg, 50 mg
31
TREANDA
53
TRECATOR
51
TRELSTAR
56
TRELSTAR MIXJECT
56
tretinoin (chemotherapy)
60
tretinoin 0.01 %, 0.025 %
88
tretinoin 0.025 %, 0.05 %, 0.1
%
88
tretinoin microsphere
88
TRI-VIT/FLUORIDE/IRON 139
triamcinolone acetonide
(mouth)
137
triamcinolone acetonide
(nasal)
143
triamcinolone acetonide (topical)
0.025 %, 0.1 %
95
triamcinolone acetonide (topical)
0.025 %, 0.1 %, 0.5 %
95
TRIAMINIC COUGH & RUNNY
NOSE
43
TRIAMINO
146
triamterene &
hydrochlorothiazide
107
triazolam
121
TRICOR
45
trifluoperazine hcl
66
trifluridine
148
TRIGLIDE
45
trihexyphenidyl hcl
62
TRILEPTAL
27
TRILIPIX
45
trimethobenzamide hcl 100
mg/ml
41
trimethoprim
16
trimipramine maleate 100 mg, 25
mg, 50 mg
33
TRIMO-SAN
164
triprolidine & pseudoephedrine
0.938mg/ml-10mg/ml
86
triprolidine & pseudoephedrine
2.5mg-2.5mg-60mg-60mg,
2.5mg-60mg
86
TRISENOX
60
TRIUMEQ
70
TRIZIVIR
70
trospium chloride
163
TRUSOPT
150
TRUVADA
70
TRUZONE PEAK FLOW
METER
130
TUCKS
14
TUCKS ANTI-ITCH
95
TUDORZA PRESSAIR
21
TUMS
15
TUMS E-X 750
15
TUMS KIDS
15
TUMS LASTING
EFFECTS
15
TUMS SMOOTHIES
15
TUSNEL 2MG-15MG200MG
86
TUSSIONEX PENNKINETIC
EXTENDED RELEASE
86
TWINRIX
164
TYBOST
70
TYGACIL
17
TYKERB
59
TYLENOL CHILDRENS
8
TYLENOL CHILDRENS PLUS
COLD
86
TYLENOL CHILDRENS PLUS
COLD & ALLERGY
86
TYLENOL
CHILDRENS/FLAVORCREAT
OR
8
TYLENOL INFANTS 160
MG/5ML
8
TYLENOL INFANTS 80
MG/0.8ML
8
TYLENOL JR MELTAWAYS8
TYPHIM VI
163
tyrosine 500 mg
146
TYSABRI
156
TYVASO
78
TYVASO REFILL
78
TYVASO STARTER
78
TYZEKA
72
UCERIS 2 MG/ACT
14
ULCEREASE
137
ULTILET GLUCOSE
35
ULTRA DERM BATH OIL 91
ULTRA MAN
140
ULTRA MIDE 25
95
ULTRA WOMAN
140
ULTRACET
12
ULTRAM
12
ULTRAM ER 100 MG
12
ULTRAM ER 200 MG, 300
MG
12
ULTRASWIM
102
ULTRASWIM ULTRA
REPAIR
102
ULTRAVATE
95
UNASYN 1GM-2GM
153
UNDELENIC TINCTURE
90
UNIFIBER
122
UNIRETIC
49
UNIVASC
47
UNIVERSAL PH STRIPS 106
UNIVERSAL REMOVER
WIPES
102
urea 20 %
95
urea 25 %
95
URISTIX
106
URISTIX 4
106
URO-PREP PROTECTIVE
SKINWIPES
102
UROCIT-K 10
115
UROCIT-K 5
115
UROXATRAL
116
URSO 250
113
URSO FORTE
113
ursodiol 250 mg, 500 mg 113
ursodiol 300 mg
113
UVADEX
60
VAGISIL
164
VAGISTAT-1
165
valacyclovir hcl 1 gm, 1000 mg,
500 mg
72
VALCHLOR
90
VALCYTE 450 MG
71
valganciclovir hcl
71
VALIUM
20
valproate sodium 100 mg/ml, 500
mg/5ml
29
valproate sodium 250
mg/5ml
29
valproic acid
29
valsartan
48
valsartan-hydrochlorothiazide
49
VALSTAR
57
VALTREX
72
VALVED HOLDING
CHAMBER
130
VANCOCIN HCL
16
Index 30
vancomycin hcl 10 gm, 1000 mg,
5000 mg
16
vancomycin hcl 125 mg, 250
mg
16
vancomycin hcl 500 mg
16
VANCOMYCIN HCL IN
DEXTROSE
16
VANICREAM
102
VANTAS
56
VAQTA
164
VARIVAX
164
VARIZIG
152
VASCEPA
44
VASERETIC
49
VASOTEC
47
VCF VAGINAL
CONTRACEPTIVE FILM 165
VCF VAGINAL
CONTRACEPTIVE FOAM 165
VECTIBIX
55
VELCADE
59
venlafaxine hcl 100 mg
32
venlafaxine hcl 150 mg
32
venlafaxine hcl 25 mg
32
venlafaxine hcl 37.5 mg
32
venlafaxine hcl 50 mg
32
venlafaxine hcl 75 mg
32
VENLAFAXINE HCL ER
32
VENTAVIS
78
verapamil hcl 100 mg, 120 mg,
180 mg, 200 mg, 240 mg, 300
mg, 360 mg
77
verapamil hcl 120 mg, 180 mg,
240 mg
77
verapamil hcl 120 mg, 40 mg, 80
mg
77
VERELAN
77
VERELAN PM
77
VERSACLOZ
66
VFEND 200 MG, 50 MG
42
VFEND IV
42
VIBRAMYCIN 100 MG
159
VIBRAMYCIN 25 MG/5ML 159
VICKS BABYRUB
97
VICOPROFEN
12
VICTOZA
36
VICTRELIS
72
VIDAZA
54
VIDEX EC
70
VIDEXPEDIATRIC
70
Index 31
VIEKIRA PAK
72
VIGAMOX
148
VIIBRYD
31
VIIBRYD STARTER PACK 31
VIMIZIM
110
VIMPAT 10 MG/ML
27
VIMPAT 100 MG, 150 MG, 200
MG, 50 MG
27
VIMPAT 200 MG/20ML
27
vinblastine sulfate
61
vincristine sulfate
61
vinorelbine tartrate
61
VIRACEPT
70
VIRAMUNE 200 MG
70
VIRAMUNE 50 MG/5ML 70
VIRAMUNE XR 100 MG 70
VIRAMUNE XR 400 MG 70
VIRAZOLE
73
VIREAD 150 MG, 200 MG, 300
MG
70
VIREAD 250 MG
71
VIREAD 40 MG/GM
70
VIROPTIC
148
VISINE-LR
148
VISTARIL
19
VISTIDE
71
VITALINE COQ10/VITAMIN E
100MG-300UNIT
3
vitamin a 10000 unit
166
VITAMIN A 10000UNIT1000UNIT
166
VITAMIN A 25000 UNIT 166
vitamin a 8000 unit
166
VITAMIN B12/FOLIC
ACID
119
vitamin e (topical) 100
unit/5drop, 12000 unit, 20000
unit, 28000 unit, 28000
unit/29ml, 400 unit/ml, 4000
unit, 49000 unit/52ml, 933.333
unit/ml
96
vitamin e (topical) 1000 unit,
1500 unit/30gm, 30000
unit/60gm, 6000 unit
96
vitamin e 100 unit
166
vitamin e 1000 unit
166
vitamin e 15 unit/0.3ml
166
vitamin e 400 unit/15ml 166
vitamins a & d 10000unit-400unit,
10000unit-5000unit, 1250unit133unit, 1250unit-135unit,
5000unit-400unit, 700unit400unit, 8000unit-400unit 140
vitamins w/ lipotropics 10000unit10mg-18mg-100unit-225mcg10mg-150mg-100mg-30mg10mg-25mg-25mg-50mg-50mg10mg-50mg-50mg-200mcg400unit-50mg-400mcg-50mg250mg, 100mg-100mg-100mg100mcg-100mg-100mcg100mcg-100mg, 100mg-100mg100mg-100mg-100mg-100mg100mcg-100mg-100mcg100mcg-100mg, 100mg-100mg100mg-100mg-100mg-100mg100mg-100mcg-100mcg100mcg-100mg, 100mg-100mg100mg-100mg-100mg-100mg100mg-100mcg-100mg-200mcg100mcg-100mg, 100mg111.3mg-0.33mg-1.7mg-1.7mcg0.33mg-111.3mg-3.3mg-0.33mg100mg, 100mg-12.5mg-100mg100mg-12.5mg-12.5mg-100mg100mcg-100mcg-100mcg100mg, 100mg-43.33mg111.3mg-0.33mg-1.7mg-1.7mcg0.33mg-111.3mg-3.3mg-0.33mg100mg, 200mg-29mg-0.333mg1.666mg-3.33mg-111.333mg111.333mg-1mg-1.666mcg0.333mg-100mg, 200mg-29mg0.33mg-1.67mg-3.33mg111.33mg-111.33mg-1mg1.67mcg-0.33mg-100mg, 200mg29mg-0.34mg-1.67mg-3.34mg111mg-111mg-1mg-1.67mcg0.34mg-100mg, 20mg-50mg30mg-10mg-10mcg-30mg-8mg,
25mg-40mg-20mg-3.4mg-20mg12mcg-3mg-20mg-400mcg30mcg-4mg-150mg, 25mg-40mg20mg-3.4mg-20mg-12mcg-3mg20mg-400mg-30mcg-4mg,
266.
141
VITEKTA
71
VOGELXO
14
VOGELXO PUMP
14
VOLTAREN
88
VOLTAREN-XR
7
voriconazole 200 mg
42
voriconazole 200 mg, 50 mg 42
VORTEX VALVED HOLDING
CHAMBER
130
VOSOL HC
151
VOTRIENT
59
VPRIV
117
WALGREENS GLUCOSE 4
GM
35
warfarin sodium
24
WATCHHALER
130
water for irrigation, sterile
75
WELCHOL
44
WELLBUTRIN 100 MG
29
WELLBUTRIN 75 MG
29
WELLBUTRIN SR 100 MG 30
WELLBUTRIN SR 150 MG, 200
MG
30
WELLBUTRIN XL 150 MG 30
WELLBUTRIN XL 300 MG 30
WESTCORT
95
WFHC PH PAPER
106
WHEAT GERM
166
witch hazel-glycerin
102
WOUND WASH SALINE 103
XALATAN
150
XALKORI
59
XANAX
20
XANAX XR
20
XARELTO
24
XARELTO STARTER PACK 24
XELJANZ
4
XENAZINE
155
XEOMIN
144
XGEVA
108
XIFAXAN
16
XIZFLUS
106
XOLAIR
21
XOPENEX
23
XOPENEX CONCENTRATE 23
XPHE MAXAMUM 153MG280MG-41MCG-1114UNIT29MCG-13MCG-0.9MG410MCG-4.5MG-569MG7.4MG-9.2UNIT-18.5MCG65.5MCG-592MG-280MG350MG-2.9MG-40MG-215MG0.49MG-2.5MG-1.6MCG166UNIT-0.46MG-246MCG12.3MCG-0.8MG-31MG,
153MG-280MG-41MCG29MCG-13MCG-0.9MG410MCG-4.5MG-569MG7.4MG-9.2UNIT-18.5MCG65.5MCG-592MG-280MG350MG-1114UNIT-2.9MG40MG-215MG-0.49MG-2.5MG1.6MCG-166UNIT-0.46MG246MCG-12.3MCG-0.8MG31MG
146
XTANDI
56
XYLOCAINE 1 %, 2 %
123
XYLOCAINE 4 %
97
XYLOCAINE-MPF 1 % 123
XYREM
154
XYZAL
43
YASMIN 28
82
YAZ
82
YERVOY
55
YF-VAX
164
YODORA DEODORANT 98
YONDELIS
53
ZADITOR
150
zafirlukast
21
zaleplon
121
ZALTRAP
54
ZANAFLEX
142
ZANOSAR
53
ZANTAC 15 MG/ML
161
ZANTAC 150 MG
161
ZANTAC 300 MG
161
ZANTAC 75
161
ZARONTIN
28
ZAROXOLYN
108
ZARXIO
118
ZAVESCA
117
ZEBETA
76
ZEGERID 20MG1100MG
162
ZEGERID 20MG1680MG
162
ZEGERID 40MG-1100MG 162
ZELBORAF
59
ZEMAIRA
157
ZEMPLAR 1 MCG, 2 MCG, 4
MCG
110
ZERIT
71
ZESTORETIC
49
ZESTRIL
47
ZETIA
46
ZIAC
50
ZIAGEN 20 MG/ML
71
ZIAGEN 300 MG
71
zidovudine
71
ZILACTIN
136
ZINACEF 1.5 GM, 7.5 GM 79
ZINACEF 750 MG
79
ZINC 15
136
zinc 25 mg
136
zinc 50 mg
136
zinc gluconate 10 mg
136
zinc gluconate 50 mg
136
ZINC SULFATE 1 MG/ML, 5
MG/ML
136
ZINECARD
61
ziprasidone hcl
64
ZITHROMAX 100 MG/5ML, 200
MG/5ML
124
ZITHROMAX 250 MG, 500 MG,
600 MG
124
ZITHROMAX 500 MG
124
ZITHROMAX TRI-PAK
124
ZITHROMAX Z-PAK
124
ZOCOR 10 MG
45
ZOCOR 20 MG
46
ZOCOR 40 MG
46
ZOCOR 5 MG
46
ZOCOR 80 MG
46
ZOFRAN 4 MG, 8 MG
40
ZOFRAN 4 MG/5ML
40
ZOFRAN 40 MG/20ML
40
ZOFRAN ODT
40
ZOHYDRO ER 10 MG, 15 MG,
20 MG, 30 MG, 40 MG, 50
MG
12
ZOLADEX
56
zoledronic acid 4 mg
108
zoledronic acid 4 mg/5ml 108
zoledronic acid 5 mg/100ml 108
Index 32
ZOLINZA
59
zolmitriptan 2.5 mg
131
zolmitriptan 5 mg
131
ZOLOFT
31
zolpidem tartrate 10 mg
121
zolpidem tartrate 12.5 mg 121
zolpidem tartrate 5 mg
121
zolpidem tartrate 6.25 mg 121
ZOMACTON 5 MG
109
ZOMETA 4 MG/5ML
109
ZOMIG 2.5 MG
131
ZOMIG 5 MG
132
ZOMIG ZMT 2.5 MG
132
ZOMIG ZMT 5 MG
132
ZONEGRAN
28
zonisamide
28
ZONTIVITY
117
ZORTRESS
74
ZOSTAVAX
164
ZOSYN 0.25GM-2GM, 0.375GM3GM, 0.5GM-4GM, 4.5GM36GM
153
ZOSYN 0.5GM/100ML4GM/100ML-5%
153
ZOVIRAX 200 MG
72
ZOVIRAX 200 MG/5ML
72
ZOVIRAX 400 MG, 800 MG 73
ZOVIRAX 5 %
91
ZYBAN
157
ZYCLARA
96
ZYCLARA PUMP
96
ZYDELIG
59
ZYKADIA
59
ZYLOPRIM 100 MG
116
ZYLOPRIM 300 MG
116
ZYMAXID
148
ZYPREXA
66
ZYPREXA RELPREVV 210
MG
66
ZYPREXA ZYDIS
66
ZYTIGA
56
ZYVOX 100 MG/5ML
18
ZYVOX 2 MG/ML
18
ZYVOX 600 MG
18
Index 33
Ini-update ang listahan ng gamot na ito noong .
12/1/2015 Kung mayroon kayong mga katanungan,
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